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  • Print publication year: 2019
  • Online publication date: December 2018

Chapter 5 - Hypothalamic–Pituitary–Adrenal Cortex Axis

de Kloet, E R, Joëls, M & Holsboer, F. (2005). Stress and the brain: from adaptation to disease. Nat Rev Neurosci 6, 463475.
Kadmiel, M & Cidlowski, J A. (2013). Glucocorticoid receptor signaling in health and disease. Trends Pharmacol Sci 34, 518530.
Lacroix, A, Feelders, R A, Stratakis, C A & Nieman, L K. (2015). Cushing’s syndrome. Lancet 386, 913927.
Loriaux, D L. (2017). Diagnosis and differential diagnosis of Cushing’s syndrome. New Engl J Med 376, 14511459.
Oster, H, Challet, E, Ott, V et al. (2017). The functional and clinical significance of the 24-h rhythm of circulating glucocorticoids. Endocr Rev 38, 345.
Quax, R A, Manenschijn, L, Koper, J W et al. (2013). Glucocorticoid sensitivity in health and disease. Nat Rev Endocr 9, 670686.
Ramamoorthy, S & Cidlowski, J A. (2013). Exploring the molecular mechanisms of glucocorticoid receptor action from sensitivity to resistance. Endocr Dev 24, 4156.
Rodriguez, A C I, Epel, E S, White, M L, Standen, E C, Seckl, J R & Tomiyama, A J. (2015). Hypothalamic-pituitary-adrenal axis dysregulation and cortisol activity in obesity: a systematic review. Psychoneuroendocr 62, 301318.
Abelson, J L & Liberzon, I. (1999). Dose response of adrenocorticotropin and cortisol to the CCK-B agonist pentagastrin. Neuropsychopharmacol 21, 485494.
Agha, A, Phillips, J, O’Kelly, P, Tormey, W & Thompson, C J. (2005). The natural history of post-traumatic hypopituitarism: implications for assessment and treatment. Am J Med 118, 1416.e1–1416.e7.
Andela, C D, van Haalen, F M, Ragnarsson, O et al. (2015). Cushing’s syndrome causes irreversible effects on the human brain: a systematic review of structural and functional magnetic resonance imaging studies. Europ J Endocr 173, R1R14.
Asa, S L & Ezzat, S. (2002). The pathogenesis of pituitary tumours. Nat Rev Cancer 2, 836849.
Bachelot, A, Chakhtoura, Z, Plu-Bureau, G et al. (2012). Influence of hormonal control on LH pulsatility and secretion in women with classical congenital adrenal hyperplasia. Europ J Endocr 167, 499505.
Bachelot, A, Grouthier, V, Courtillot, C, Dulon, J & Touraine, P. (2017). Congenital adrenal hyperplasia due to 21-hydroxylase deficiency: update on the management of adult patients and prenatal treatment. Europ J Endocr 176, R167R181.
Benedict, C, Hallschmid, M, Scheibner, J et al. (2005). Gut protein uptake and mechanisms of meal-induced cortisol release. J Clin Endocr Metab 90, 16921696.
Berardelli, R, Karamouzis, I, Marinazzo, E et al. (2010). Effect of acute and prolonged mineralocorticoid receptor blockade on spontaneous and stimulated hypothalamic–pituitary–adrenal axis in humans. Europ J Endocr 162, 10671074.
Berardelli, R, Karamouzis, I, D’Angelo, V et al. (2013). Role of mineralocorticoid receptors on the hypothalamus–pituitary–adrenal axis in humans. Endocr 43, 5158.
Berga, S L, Daniels, T L & Giles, D E. (1997). Women with functional hypothalamic amenorrhea but not other forms of anovulation display amplified cortisol concentrations. Fert Steril 67, 10241030.
Berga, S L. (2016). Social determinants of infertility: beyond the obvious. Fert Steril 105, 14591460.
Berthon, B S, MacDonald-Wicks, L K & Wood, L G. (2014). A systematic review of the effect of oral glucocorticoids on energy intake, appetite, and body weight in humans. Nutr Res 34, 179190.
Besser, G M & Thorner, M O. (2002). Comprehensive Clinical Endocrinology, 3rd Edition (St Louis, MO: Mosby).
Betterlie, C & Morlin, L. (2011). Autoimmune Addison’s disease. Endocr Dev 20, 161172.
Bierer, L M, Ivanov, I, Carpenter, D M et al. (2015). White matter abnormalities in gulf war veterans with posttraumatic stress disorder: a pilot study. Psychoneuroendocr 51, 567576.
Boonen, E, Vervenne, H, Meersseman, P et al. (2013). Reduced cortisol metabolism during critical illness. New Eng J Med 368, 14771488.
Bose, M, Oliván, B & Laferrére, B. (2009). Stress and obesity: the role of the hypothalamic–pituitary–adrenal axis in metabolic disease. Curr Opin Endocr Diabetes Obes 16, 340346.
Bresson, J L, Clavequin, M C, Fellmann, D & Bugnon, C. (1985). Anatomical and ontogenetic studies of the human paraventriculo-infundibular corticoliberin system. Neurosci 14, 10771090.
Brown, E S & Chandler, P A. (2001). Mood and cognitive changes during systemic corticosteroid therapy. Primary Care Comp J Clin Psych 3, 1721.
Bruera, E, Roca, E, Cedaro, L, Carraro, S & Chacon, R. (1985). Action of oral methylprednisolone in terminal cancer patients: a prospective randomized double-blind study. Cancer Treat Rep 69, 751754.
Cao-Lei, L, Suwansirikul, S, Jutavijittum, P, Mériaux, SB, Turner, JD Muller, CP. (2013). Glucocorticoid receptor gene expression and promoter CpG modifications throughout the human brain. J Psych Res 47, 15971607.
Castro, M, Elias, L L K, Elias, P C L & Moreira, A C. (2003). A dose–response study of salivary cortisol after dexamethasone suppression test in Cushing’s disease and its potential use in the differential diagnosis of Cushing’s syndrome. Clin Endocr 59, 800805.
Chriguer, R S, Elias, L L K, da Silva, I M, Jr., Vieira, J G H, Moreira, A C & de Castro, M. (2005). Glucocorticoid sensitivity in young healthy individuals: in vitro and in vivo studies. J Clin Endocr Metab 90, 59785984.
Chrousos, G P, Torpy, D J & Gold, P W. (1998). Interactions between the hypothalamic-pituitary-adrenal axis and the female reproductive system: clinical implications. Ann Intern Med 129, 229240.
Cohan, P. (2014). Pasireotide and mifepristone: new options in the medical management of Cushing’s disease. Endocr Pract 20, 8493.
Cohan, P, Wang, C, McArthur, D L et al. (2005). Acute secondary adrenal insufficiency after traumatic brain injury: a prospective study. Crit Care Med 33, 23582366.
Cohrs, S, Röher, C, Jordan, W et al. (2006). The atypical antipsychotics olanzapine and quetiapine, but not haloperidol, reduce ACTH and cortisol secretion in healthy subjects. Psychopharmacol 185, 1118.
de Kloet, E R, Joëls, M & Holsboer, F. (2005). Stress and the brain: from adaptation to disease. Nat Rev Neurosci 6, 463475.
El-Maouche, D, Arlt, W & Merke, D P. (2017). Congenital adrenal hyperplasia. Lancet 390, 21942210.
Faghih, R T, Dahleh, M A, Adler, G K, Klerman, E B & Brown, E N. (2014). Deconvolution of serum cortisol levels by using compressed sensing. PLoS ONE 9, e85204.
Fleseriu, M, Biller, B M K, Findling, J W, Molitch, M E, Schteingart, D E & Gross, C on behalf of the SEISMIC Study Investigators. (2012). Mifepristone, a glucocorticoid receptor antagonist, produces clinical and metabolic benefits in patients with Cushing’s syndrome. J Clin Endocr Metab 97, 20392049.
Garin, M C, Burns, C M, Kaul, S & Cappola, A R. (2013). The human experience with ghrelin administration. J Clin Endocr Metab 98, 18261837.
Gibbison, B, Spiga, F, Walker, J J et al. (2015). Dynamic pituitary-adrenal interactions in response to cardiac surgery. Crit Care Med 43, 791800.
Gil-Lozano, M, Pérez-Tilve, D, Alvarez-Crespo, M et al. (2010). GLP-1(7–36)-amide and exendin-4 stimulate the HPA axis in rodents and humans. Endocr 151, 26292640.
Giraldi, F P, Moro, M & Cavagnini, F. (2003). Gender-related differences in the presentation and course of Cushing’s disease. J Clin Endocr Metab 88, 15541558.
Goletiani, N V, Siegel, A J, Lukas, S E & Hudson, J I. (2015). The effects of smoked nicotine on measures of subjective states and hypothalamic–pituitary–adrenal axis hormones in women during the follicular and luteal phases of the menstrual cycle. J Addict Med 9, 195203.
González-Cabrera, J, Fernández-Prada, M, Iribar-Ibabe, C & Peinado, J M. (2014). Acute and chronic stress increase salivary cortisol: a study in the real-life setting of a national examination undertaken by medical graduates. Stress 17, 149156.
Hall, B S, Moda, R N & Liston, C. (2015). Glucocorticoid mechanisms of functional connectivity changes in stress-related neuropsychiatric disorders. Neurobiol Stress 1, 174183.
Hardy, J R, Rees, E, Ling, J et al. (2001). A prospective survey of the use of dexamethasone on a palliative care unit. Palliat Med 15, 38.
Heaney, AP & Melmed, S. (2004). Molecular targets in pituitary tumours. Nature Rev Cancer 4, 285295.
Henley, D E, Leendertz, J A, Russell, G M et al. (2009). Development of an automated blood sampling system for use in humans. J Med Eng Technol 33, 199208.
Hollanders, J L, van der Voorn, B, Kieviet, N et al. (2017). Glucocorticoids in neonatal hair: a reflection of intra-uterine glucocorticoid regulation? Endocr Connections 6, 667675.
Hook, V, Funkelstein, L, Lu, D, Bark, S, Wegrzyn, J & Hwang, S-R. (2008). Proteases for processing proneuropeptides into peptide neurotransmitters and hormones. Ann Revs Pharmacol Toxicol 48, 393423.
Ivars, K, Nelson, N, Theodorsson, A, Theodorsson, E, Ström, J O & Mörelius, E. (2017). Development of salivary cortisol circadian rhythm in preterm infants. PLOS One 12, e0182685.
Jackson, R V, Grice, J E, Hockings, G I & Torpy, D J. (1995). Naloxone-induced ACTH release: mechanism of action in humans. Clin Endocr 43, 423424.
Jessop, D S, Dallman, M F, Fleming, D & Lightman, S L. (2001). Resistance to glucocorticoid feedback in obesity. J Clin Endocr Metab 86, 41094114.
Judd, L L, Schettler, P J, Brown, E S et al. (2014). Adverse consequences of glucocorticoid medication: psychological, cognitive, and behavioral effects. Am J Psych 171, 10451051.
Kadmiel, M & Cidlowski, J A. (2013). Glucocorticoid receptor signaling in health and disease. Trends Pharmacol Sci 34, 518530.
Kalafatakis, K, Russell, G M, Zarros, A &. Lightman, S L. (2016). Temporal control of glucocorticoid neurodynamics and its relevance for brain homeostasis, neuropathology and glucocorticoid-based therapeutics. Neurosci Biobehav Rev 61, 1225.
Kowal, B F, Turco, J & Nangia, A K. (2006). Addison’s disease presenting as male infertility. Fert Steril 85, 1059.e1-e3.
Krolewski, D M, Medina, A, Kerman, I A et al. (2010). Expression patterns of corticotropin-releasing factor, arginine vasopressin, histidine decarboxylase, melanin-concentrating hormone, and orexin genes in the human hypothalamus. J Comp Neurol 518, 45914611.
Lacroix, A, Feelders, R A, Stratakis, C A & Nieman, L K. (2015). Cushing’s syndrome. Lancet 386, 913927.
Lado-Abeal, J, Rodriguez-Arnao, J, Newell-Price, J D C et al. (1998). Menstrual abnormalities in women with Cushing’s disease are correlated with hypercortisolemia rather than raised circulating androgen levels. J Clin Endocr Metab 83, 30833088
Lamberts, S W J, Verleun, T, Oosterom, R, de Jong, F & Hackeng, W H L. (1984). Corticotropin-releasing factor (ovine) and vasopressin exert a synergistic effect on adrenocorticotropin release in man. J Clin Endocr Metab 58:298303.
Lightman, S L & Conway-Campbell, B L. (2010). The crucial role of pulsatile activity of the HPA axis for continuous dynamic equilibration. Nat Rev Neurosci 11, 710718.
Liston, C, McEwen, B S & Casey, B J. (2009). Psychosocial stress reversibly disrupts prefrontal processing and attentional control. Proc Nat Acad Sci USA 106, 912917.
Locatelli, V, Bresciani, E, Tamiazzo, L & Torsello, A. (2010). Central nervous system-acting drugs influencing hypothalamic-pituitary-adrenal axis function. Endocr Dev 17, 108120.
López, J F, Palkovits, M, Arató, M, Mansour, A, Akil, U & Watson, S J. (1992). Localization and quantification of pro-opiomelanocortin mRNA and glucocorticoid receptor mRNA in pituitaries of suicide victims. Neuroendocr 56, 491501.
Loriaux, D L. (2017). Diagnosis and differential diagnosis of Cushing’s Syndrome. New Engl J Med 376, 14511459.
Luton, J-P, Thieblot, P, Valcke, J-C, Mahoudeau, J A & Bricaire, H. (1977). Reversible gonadotropin deficiency in male Cushing’s disease. J Clin Endocr Metab 45, 488495.
McKeage, K. (2013). Pasireotide: a review of its use in Cushing’s disease. Drugs 73, 563574.
Meyer, J S & Novak, M A. (2012). Minireview: Hair cortisol: a novel biomarker of hypothalamic-pituitary-adrenocortical activity. Endocr 153, 41204127.
Mihály, E, Fekete, C, Lechan, R M & Liposits, Z. (2002). Corticotropin-releasing hormone-synthesizing neurons of the human hypothalamus receive neuropeptide Y-immunoreactive innervation from neurons residing primarily outside the infundibular nucleus. J Comp Neurol 446, 235243.
Miller, G E, Chen, E & Zhou, E S. (2007). If it goes up, must it come down? Chronic stress and the hypothalamic-pituitary-adrenocortical axis in humans. Psychol Bull 133, 2545.
Miranda, H, Gore, R J, Boyer, J, Nobrega, S & Punnett, L. (2015). Health behaviors and overweight in nursing home employees: contribution of workplace stressors and implications for worksite health promotion. Sci World J 2015, Article ID 915359.
Misra, M & Klibanski, A. (2014). Endocrine consequences of anorexia nervosa. Lancet Diabetes Endocr 2, 581592.
Munro, V, Tugwell, B, Doucette, S, Clarke, D B, Lacroix, A & Imran, S A. (2016). Recovery of adrenal function after chronic secondary adrenal insufficiency in patients with hypopituitarism. Clin Endocr 85, 216222.
Nicolaides, N C, Kino, T, Chrousos, G P & Charmandari, E. (2014). Primary generalized glucocorticoid resistance, or Chrousos syndrome.
Nicolaides, N C, Lamprokostopoulou, A, Sertedaki, A & Charmandari, E. (2016). Recent advances in the molecular mechanisms causing primary generalized glucocorticoid resistance. Hormones 15, 2334.
Oster, H, Challet, E, Ott, V et al. (2017). The functional and clinical significance of the 24-h rhythm of circulating glucocorticoids. Endocr Rev 38, 345.
Pasquali, R, Cantobelli, S, Casimirri, F et al. (1993). The hypothalamic–pituitary–adrenal axis in obese women with different patterns of body fat distribution. J Clin Endocr Metab 77, 341346.
Pasquali, R, Anconetani, B, Chattat, R et al. (1996). Hypothalamic–pituitary–adrenal axis activity and its relationship to the autonomic nervous system in women with visceral and subcutaneous obesity: effects of the corticotropin-releasing factor/arginine-vasopressin test and of stress. Metabolism 45, 351356.
Pasquali, R, Biscotti, D, Spinucci, G et al. (1998). Pulsatile secretion of ACTH and cortisol in premenopausal women: effect of obesity and body fat distribution. Clin Endocr 48, 603612.
Pasquali, R, Gagliardi, L, Vicennati, V et al. (1999). ACTH and cortisol response to combined corticotropin releasing hormone-arginine vasopressin stimulation in obese males and its relationship to body weight, fat distribution and parameters of the metabolic syndrome. Int J Obesity 23, 419424.
Pasquali, R, Vicennati, V, Cacciari, M & Pagotto, U. (2006). The hypothalamic-pituitary-adrenal axis activity in obesity and the metabolic syndrome. Anns NY Acad Sci 1083, 111128.
Perlman, W R, Webster, M J, Herman, M M, Kleinman, J E & Weickert, C S. (2007). Age-related differences in glucocorticoid receptor mRNA levels in the human brain. Neurobiol Aging 28, 447458.
Potter, G D M, Skene, D J, Arendt, J, Cade, J E, Grant, P J & Hardie, L J. (2016). Circadian rhythm and sleep disruption: causes, metabolic consequences, and countermeasures. Endocr Rev 37, 584608.
Prokai, D & Berga, S L. (2016). Neuroprotection via reduction in stress: altered menstrual patterns as a marker for stress and implications for long-term neurologic health in women. Int J Mol Sci 17, 2147.
Quax, R A, Manenschijn, L, Koper, J W et al. (2013). Glucocorticoid sensitivity in health and disease. Nat Rev Endocr 9, 670686.
Raab, C, Weidmann, E, Schmidt, A et al. (1999). The effects of interleukin-2 treatment on endothelin and the activation of the hypothalamic–pituitary–adrenal axis. Clin Endocr 50, 3744.
Raadsheer, F C, Sluiter, A A, Ravid, R, Tilders, F J H & Swaab, D F. (1993). Localization of corticotropin-releasing hormone (CRH) neurons in the paraventricular nucleus of the human hypothalamus: age-dependent colocalization with vasopressin. Brain Res 615, 5062.
Rasmussen, S A, Rosebush, P I, Smyth, H S & Mazurek, M F. (2015). Cushing disease presenting as primary psychiatric illness: a case report and literature review. J Psychiatric Prac 21, 449457.
Reichman, D E, White, P C, New, M I & Rosenwaks, Z. (2014). Fertility in patients with congenital adrenal hyperplasia. Fert Steril 101, 301309.
Rittmaster, RS, Cutler, GB Jr., Gold, P W et al. (1987). The relationship of saline-induced changes in vasopressin secretion to basal and corticotropin-releasing hormone-stimulated adrenocorticotropin and cortisol secretion in man. J Clin Endocr Metab 64, 371376.
Rodriguez, A C I, Epel, E S, White, M L, Standen, E C, Seckl, J R & Tomiyama, A J. (2015). Hypothalamic–pituitary–adrenal axis dysregulation and cortisol activity in obesity: a systematic review. Psychoneuroendocr 62, 301318.
Roelfsema, F, Aoun, P & Veldhuis, J D. (2016). Pulsatile cortisol feedback on ACTH secretion is mediated by the glucocorticoid receptor and modulated by gender. J Clin Endocr Metab 101, 40944102.
Roelfsema, F, Yang, R J, Olson, T P, Joyner, M J, Takahashi, P Y & Veldhuis, J D. (2017). Enhanced coupling within gonadotropic and adrenocorticotropic axes by moderate exercise in healthy men. J Clin Endocr Metab 102, 24822490.
Rohleder, N, Beulen, S E, Chen, E, Wolf, J M & Kirschbaum, C. (2007). Stress on the floor: the cortisol stress response to social-evaluative threat in competitive ballroom dancers. Pers Soc Psychol Bull 33, 6984.
Ross, I L, Levitt, N S, Blom, D J & Haarburger, D. (2014). Male and female hypogonadism are highly prevalent in South Africans with Addison’s disease. Horm Metab Res 46, 691696.
Russell, G M, Henley, D E, Leendertz, J et al. (2010). Rapid glucocorticoid receptor-mediated inhibition of hypothalamic–pituitary–adrenal ultradian activity in healthy males. J Neurosci 30, 61066115.
Saketos, M, Sharma, N & Santoro, N F. (1993). Suppression of the hypothalamic-pituitary-ovarian axis in normal women by glucocorticoids. Biol Reprod 49, 12701276.
Salehi, F, Kovacs, K, Scheithauer, B W, Pfeifer, E A & Cusimano, M. (2007). Histologic study of the human pituitary gland in acute traumatic brain injury. Brain injury 21, 651656.
Sarlos, S & Inder, W J. (2013). Selective use of the insulin tolerance test to diagnose hypopituitarism. Int Med J 43, 8993.
Scheer, F A J L, Hilton, M F, Mantzoros, C S & Shea, S A. (2009). Adverse metabolic and cardiovascular consequences of circadian misalignment. Proc Nat Acad Sci USA 106, 44534458.
Schneiderman, N, Ironson, G S & Siegel, S D. (2005). Stress and health: psychological, behavioral, and biological determinants. Ann Rev Clin Psychol 1, 607628.
Schorr, M & Miller, K K. (2017). The endocrine manifestations of anorexia nervosa: mechanisms and management. Nat Rev Endocr 13, 174186.
Starkman, M N, Schteingart, D E & Schork, M A. (1986). Cushing’s syndrome after treatment: changes in cortisol and ACTH levels, and amelioration of the depressive syndrome. Psych Res 19, 177188.
Starkman, M N. (2013). Neuropsychiatric findings in Cushing syndrome and exogenous glucocorticoid administration. Endocr Metab Clin N Amer 42, 477488.
Stimson, R H, Mohd-Shukri, N A, Bolton, J L, Andrew, R, Reynolds, R M & Walker, B R. (2014). The postprandial rise in plasma cortisol in men is mediated by macronutrient-specific stimulation of adrenal and extra-adrenal cortisol production. J Clin Endocr Metab 99, 160168.
Swinburn, C R, Wakefield, J M, Newman, P S & Jones, P W. (1988). Evidence of prednisolone induced mood change (‘steroid euphoria’) in patients with chronic obstructive airways disease. Brit J Clin Pharmacol 26, 709713.
Tennant, F, Shannon, J A, Nork, J G, Sagherian, A & Berman, M. (1991). Abnormal adrenal gland metabolism in opioid addicts: implications for clinical treatment. J Psychoactive drugs 23, 135149.
Trifonova, S T, Gantenbein, M, Turner, J D & Muller, C P. (2013). The use of saliva for assessment of cortisol pulsatile secretion by deconvolution analysis. Psychoneuroendocr 38, 10901101.
van der Klaauw, A A, Keogh, J M, Henning, E et al. (2013). High protein intake stimulates postprandial GLP1 and PYY release. Obesity 21, 16021607.
van Honk, J & Pruessner, J C. (2010). Psychoneuroendocrine imaging: a special issue of psychoneuroendocrinology. Psychoneuroendocr 35, 14.
Veldhuis, J D, Lizarralde, G & Iranmanesh, A. (1992). Divergent effects of short term glucocorticoid excess on the gonadotropic and somatotropic axes in normal men. J Clin Endocr Metab 74, 96102.
Veldhuis, J D, Roelfsema, F, Iranmanesh, A, Carroll, B J, Keenan, D M & Pincus, S M. (2009). Basal, pulsatile, entropic (patterned), and spiky (staccato-like) properties of ACTH secretion: impact of age, gender, and body mass index. J Clin Endocr Metab 94, 40454052.
Wang, S-S, Kamphuis, W, Huitinga, I, Zhou, J-N & Swaab, D F. (2008). Gene expression analysis in the human hypothalamus in depression by laser microdissection and real-time PCR: the presence of multiple receptor imbalances. Mol Psych 13, 786799.
Watson, S J, Lopez, J F, Young, E A, Vale, W, Rivier, J & Akil, H. (1987). Effects of low dose ovine corticotropin-releasing hormone in humans: endocrine relationships and β-endorphin/γ-lipotropin responses. J Clin Endocr Metab 66, 1015.
Wester, V L & van Rossum, E F C. (2015). Clinical applications of cortisol measurements in hair. Europ J Endocr 173, M1M10.
Whirledge, S & Cidlowski, J A. (2017). Glucocorticoids and reproduction: traffic control on the road to reproduction. Trends Endocr Metab 28, 399415.
Yedinak, C G, Hopkins, S, Williams, J, Ibrahim, A, Cetas, J S & Fleseriu, M. (2017). Medical therapy with pasireotide in recurrent Cushing’s disease: experience of patients treated for at least 1 year at a single center. Front Endocr 8, Article # 35.
Yip, C-E, Stewart, S A, Imran, F et al. (2013). Role of morning basal serum cortisol in assessment of hypothalamic pituitary-adrenal axis. Clin Invest Med 36, E216E222.
Zampetti, B, Grossrubatscher, E, Ciaramella, B D, Boccardi, E & Loli, P. (2016). Bilateral inferior petrosal sinus sampling. Endocr Connect 5, R12R25.