Glucagon does not directly stimulate pituitary secretion of ACTH, GH or copeptin

Glucagon is best known for its contribution to glucose regulation through activation of the glucagon receptor (GCGR), primarily located in the liver. However, glucagon's impact on other organs may also contribute to its potent effects in health and disease. Given that glucagon-based medicine is entering the arena of anti-obesity drugs, elucidating extrahepatic actions of glucagon are of increased importance. It has been reported that glucagon may stimulate secretion of arginine-vasopressin (AVP)/copeptin, growth hormone (GH) and adrenocorticotrophic hormone (ACTH) from the pituitary gland. Nevertheless, the mechanisms and whether GCGR is present in human pituitary are unknown. In this study we found that intravenous administration of 0.2 mg glucagon to 14 healthy subjects was not associated with increases in plasma concentrations of copeptin, GH, ACTH or cortisol over a 120-min period. GCGR immunoreactivity was present in the anterior pituitary but not in cells containing GH or ACTH. Collectively, glucagon may not directly stimulate secretion of GH, ACTH or AVP/copeptin in humans but may instead be involved in yet unidentified pituitary functions.

Evidence of Hypothalamic-Pituitary-Adrenal and -Gonadal Dysfunction in Cocaine-Addicted Men

INTRODUCTION

Regular cocaine use has been associated with hormonal dysfunction including hypogonadism, which can lead to fatigue, reduced stamina, sexual dysfunction, and impaired quality of life. However, cocaine's endocrine effects are largely under-reported in the scientific addiction literature and, in many cases, are not addressed within treatment services. The low profile of these adverse effects might be attributable to a lack of awareness and linkage with cocaine use, such that they are recognized only when an acute/emergency problem arises.

METHODS

We assessed endocrine diurnal function (adrenocorticotrophic hormone [ACTH], cortisol, and testosterone) in 26 healthy and 27 cocaine-dependent men and examined changes in hormone levels in response to a single 40 mg dose of the noradrenaline re-uptake inhibitor atomoxetine in a double-blind, placebo-controlled experimental medicine study.

RESULTS

When compared with healthy controls, diurnal and atomoxetine-induced changes in ACTH and cortisol showed greater variability in cocaine-dependent men. Interestingly, despite an exaggerated rise in ACTH following atomoxetine, an attenuated cortisol response was observed, and one-third of cocaine-dependent men had subnormal testosterone levels.

CONCLUSION

Our findings point to a potential disconnection between the pituitary and adrenal responses in cocaine-dependent men, a higher rate of hypogonadism, and a pressing need for more research into the endocrine effects of cocaine and their clinical implications.

Stress and psoriasis: Exploring the link through the prism of hypothalamo-pituitary-adrenal axis and inflammation

BACKGROUND

Psoriasis is an immune-mediated, chronic inflammatory disease affecting mainly the skin. Chronic stress leads to the blunted hypothalamic-pituitary-adrenal axis (HPA) that might induce pro-inflammatory conditions. Hence, we assessed the blood levels of the HPA hormones and interleukin-17 (IL-17) and the effect of stress and emotional distress to understand the link between stress and psoriasis better.

METHODS

This cross-sectional study included 45 patients with psoriasis and 45 age and gender-matched apparently healthy volunteers (n = 45). IL-17, cortisol, and adrenocorticotrophic hormone (ACTH) levels were assessed in both groups. Psoriasis Area Severity Index (PASI) was used to assess disease severity. Presumptive Stressful Life Events scale [PSLE], Perceived Stress scale [PSS] and Daily Hassles and Uplifts Scale [DHUS] scoring were used to assess stress levels and emotional distress.

RESULTS

Patients with psoriasis had higher levels of IL-17 and ACTH and lower levels of cortisol, as compared to controls. Stress scores (PSS, PSLE & DHUS) were significantly elevated in cases, as compared to the controls. IL-17, ACTH and stress scores showed a significant positive correlation with one another and a significant negative correlation with cortisol levels. They also showed a significant positive correlation with PASI, while cortisol levels showed a significant negative correlation.

CONCLUSION

Psoriasis patients having high ACTH, IL-17 and stress scores had lower levels of cortisol, indicating a dysregulated HPA axis with the pro-inflammatory state. This might lead to exacerbation of psoriatic flares, which needs investigation in further prospective studies.

[Acupoint compatibility effect and mechanism of Shenmen (HT7) and Sanyinjiao (SP6) in improving daytime fatigue and sleepiness of insomnia]

OBJECTIVE

To observe the acupoint compatibility effect of Shenmen (HT7) and Sanyinjiao (SP6) in improving daytime fatigue and sleepiness of insomnia, and its mechanism in regulating hypothalamic-pituitary-adrenal (HPA) axis and suprachiasmatic nucleus-pineal gland-melatonin (SCN-PG-MT) system.

METHODS

Ninety patients with insomnia were randomly divided into HT7, SP6 and HT7-SP6 (HT7 plus SP6) groups, with 30 cases in each group. Electroacupuncture (EA,5 Hz/25 Hz) was applied to HT7, SP6 or HT7-SP6 in each group for 30 min. The EA treatment was conducted once daily, 5 days a week for 2 weeks. Before and after treatment, the Pittsburgh Sleep Quality Index (PSQI) and Epworth Sleepiness Scale (ESS) were observed, separately. The contents of serum adrenocorticotrophic hormone (ACTH), cortisol (CS) and melatonin (MT) were detected by ELISA.

RESULTS

Compared with before treatment, the sleep quality, sleep time, sleep efficiency, sleep disturbance, daytime dysfunction scores and total score of PSQI in the three groups after treatment were decreased (P<0.05), the time to fall asleep score of PSQI and total score of ESS were decreased in the SP6 and HT7-SP6 groups (P<0.05). After treatment, the sleep quality, time to fall asleep, sleep efficiency, daytime dysfunction scores, total score of PSQI and total score of ESS in the HT7-SP6 group were lower than those in the HT7 group (P<0.05), the sleep quality, sleep efficiency and total score of PSQI in the SP6 group were lower than those in the HT7 group (P<0.05). Compared with before treatment, the serum ACTH and CS levels in the three groups were decreased (P<0.05), and the serum MT levels in the SP6 and HT7-SP6 groups were increased (P<0.05). After treatment, the ACTH and CS levels in the HT7-SP6 group were lower than those in the HT7 group (P<0.05), and the serum MT levels in the SP6 and HT7-SP6 groups were higher than that in the HT7 group (P<0.05).

CONCLUSION

The compatibility of HT7 and SP6 has a synergism effect on the improvement of night sleep quality and daytime fatigue and sleepiness of insomnia patients, the mechanism may be related with its function in down-regulating the serum ACTH and CS levels and increasing the serum MT content. SP6 has a better effect than HT7, and plays a major role in acupoint compatibility.

Revalidation of inferior petrosal sinus sampling: the latest results from a single-center experience

Cushing's disease (CD), which manifests as excess cortisol secretion, is caused by adrenocorticotrophic hormone (ACTH)-secreting pituitary adenomas. Such adenomas are occasionally difficult to identify on magnetic resonance imaging (MRI), and thorough endocrinological examination may be required to detect them. Inferior petrosal sinus (IPS) sampling (IPSS) has been the gold standard test for distinguishing CD from ectopic ACTH syndrome (EAS). However, IPSS is an invasive procedure, and proper catheterization is occasionally challenging due to anatomical variations. Thus, there have been ongoing debates regarding the necessity of this procedure. Here, we present our recent IPSS data derived from the analysis of 65 patients who were referred to us for possible CD between April 2018 and December 2020 after undergoing meticulous endocrinological testing. Even with detailed MRI, no obvious lesions were identified in 19 patients. IPSS performed on these 19 individuals identified an IPS-to-peripheral ACTH gradient in 15 of them. The four patients who lacked this gradient were subjected to a classical algorithm using concurrently measured prolactin levels, the results of which were consistent with their ultimately confirmed diagnoses: two true-positive and two true-negative diagnoses. These findings support the validity of the algorithm and demonstrate that the prolactin-adjusted IPS-to-peripheral ACTH ratio can improve the differentiation between CD and EAS. We had no false-negative results, but three patients were false-positive. Consequently, those three patients in which no apparent tumor was clarified during surgery could not have any endocrinological improvement postoperatively.

Clinical manifestations and epilepsy treatment in Japanese patients with pathogenic CDKL5 variants

OBJECTIVE

Patients with pathogenic cyclin-dependent kinase-like-5 gene (CDKL5) variants are designated CDKL5 deficiency disorder (CDD). This study aimed to delineate the clinical characteristics of Japanese patients with CDD and elucidate possible appropriate treatments.

METHODS

We recruited patients with pathogenic or likely pathogenic CDKL5 variants from a cohort of approximately 1,100 Japanese patients with developmental and epileptic encephalopathies, who underwent genetic analysis. We retrospectively reviewed clinical, electroencephalogram, neuroimaging, and genetic information.

RESULTS

We identified 29 patients (21 females, eight males). All patients showed severe developmental delay, especially in males. Involuntary movements were observed in 15 patients. No antiepileptic drugs (AEDs) achieved seizure freedom by monotherapy. AEDs achieving ≥ 50% reduction in seizure frequency were sodium valproate in two patients, vigabatrin in one, and lamotrigine in one. Seizure aggravation was observed during the use of lamotrigine, potassium bromide, and levetiracetam. Adrenocorticotrophic hormone (ACTH) was the most effective treatment. The ketogenic diet (KD), corpus callosotomy and vagus nerve stimulation did not improve seizure frequency in most patients, but KD was remarkably effective in one. The degree of brain atrophy on magnetic resonance imaging (MRI) reflected disease severity. Compared with females, males had lower levels of attained motor development and more severe cerebral atrophy on MRI.

CONCLUSION

Our patients showed more severe global developmental delay than those in previous studies and had intractable epilepsy, likely because previous studies had lower numbers of males. Further studies are needed to investigate appropriate therapy for CDD, such as AED polytherapy or combination treatment involving ACTH, KD, and AEDs.

Invasive Crooke cell adenoma in a patient with diffuse large B-cell lymphoma

Crooke cell adenoma (CCA) is an aggressive corticotroph subtype of pituitary adenoma often with cyclically elevated blood adrenocorticotropic hormone (ACTH), which preoperative diagnosis is challenging especially in the context of a functionally silent invasive tumor and a history of high-stage malignancy such as diffuse large B-cell lymphoma (DLBCL). Here, we report the first case of invasive CCA in a patient with DLBCL. A 71 year-old previously healthy man was recently diagnosed with DLBCL that was treated with CHOP-R chemotherapy. Within one week of completing his first cycle of chemotherapy, he had a frontal headache that progressed to right-sided proptosis. Cranial MRI showed a heterogeneously enhancing mass with invasion into the sellar and suprasellar compartment, compression of the optic chiasm, as well as extension into the clivus, bilateral cavernous sinuses, and the prepontine cistern. He underwent a partial resection for the pituitary tumor debulking. Pathological examination revealed CCA with invasion into the adjacent tissue. The patient had no history of Cushing disease or syndrome, but his blood ACTH was found to be elevated on the operation day. Our present case and literature review suggest that comorbidity of CCA or ACTH-producing adenoma and B-cell lymphoma deserves awareness in our clinical practice, as these two diseases and/or their therapies may interact substantially. CAA should be considered in the major differential diagnosis for an invasive sellar tumor, even without blood ACTH elevation and/or with a history of malignant lymphoma.

[Moxibustion improved gastric ulcer by reducing contents of corticotrophin-releasing hormone and adrenocorticotropic hormone in serum and hypothalamus-pituitary tissues in rats with stress-induced gastric ulcer]

OBJECTIVE

To observe the effect of moxibustion of "Zhongwan" (CV12) and "Zusanli" (ST36) on histopathological changes of the gastric mucosa and contents of corticotropin-releasing hormone(CRH) and adrenocorticotrophic hormone(ACTH) in the serum, hypothalamus and pituitary tissues in rats with stress-induced gastric ulcer(SGU), so as to reveal its mechanisms underlying improvement of SGU.

METHODS

A total of 28 male SD rats were randomly divided into blank control, model, moxibustion, and medication groups, with 7 rats in each group. The SGU model was established by water immersion restraint stress for 3 h. Moxibustion was applied to "Zhongwan"(CV12) and bilateral "Zusanli" (ST36) for 20 min, once a day for 5 days, and rats of the medication group were treated by gavage of Omeprazole enteric-coated tablets (0.2 mg/kg) once a day for 5 days. The gastric mucosal damage index (ulcer index, UI) was measured to assess the injury severity according to Guth's me-thods. Histopathological changes of the gastric mucosa were determined by H．E. staining. The contents of CRH in serum and hypothalamus and ACTH in serum and pituitary gland tissue were assayed by using ELISA.

RESULTS

Outcomes of H．E. staining showed gastric mucosal epithelia defect, disordered arrangement of glands, obvious mucosal hyperemia and edema, exudation of a large number of red blood cells, swelling of mucosal cells with necrosis of nuclei in the model group. These situations were relatively milder in the moxibustion and medication groups. After modeling, the UI, and the contents of CRH in the serum and hypotha-lamus, and ACTH in the serum and pituitary tissue were significantly increased in comparison with the blank control group (P<0.01). Following the intervention, the UI, and contents of CRH in the serum and hypothalamus, and ACTH in the serum and pituitary were all down-regulated in both medication and moxibustion groups relevant to the model group (P<0.05, P<0.01). The therapeutic effect of moxibustion was notably superior to that of medication in down-regulating serum CRH and ACTH (P<0.05). No significant differences were found between the medication and moxibustin interventions in lowering the UI, hypothalamic CRH and pituitary ACTH levels (P>0.05)．.

CONCLUSION

Moxibustion can relieve gastric mucosal injury induced by stress in water immersion restraint stress rats, which may be associated with its effects in down-regulating the levels of CRH and ACTH in se-rum, hypothalamus and pituitary tissues (inhibition of activities of hypothalamic-pituitary-adrenocortical axis)．.

[De novo NFκB2 gene mutation associated common variable immunodeficiency]

Objective: To investigate the clinical, immunological, and molecular manifestations of nuclear factor kappa-B subunit 2 (NFκB2) gene mutation associated common variable immunodeficiency (CVID) . Methods: A 14-month-old boy diagnosed with NFκB2-mutated CVID was admitted into Children's Hospital of Chongqing Medical University in December 2015. The clinical manifestations, biochemical tests, immunological function, molecular features, treatment, and follow-up of the patient were analyzed. The Chinese and PUBMED databases were searched with the key words "NFκB2" and "immune deficiency" and related literatures were reviewed. Results: The patient had 4 episodes of pneumonias and one otitis media since the age of 6 months. The serum immunoglobulin levels were IgG 2.73 g/L, IgA<0.07 g/L, and IgM 0.12 g/L. The percentage of peripheral lymphocyte subsets demonstrated increased CD3(+)T lymphocyte (81.8%), increased CD4(+) naïve T cell (39.1%), normal B cell (14.1%), low switched memory B and plasmablast B (respectively 0.1% and 0), and lightly diminished natural killer(NK) cell (4.13%). Within the peripheral CD4(+)T cells, the percentage of regulatory T cells (1.49% (control 4.08%)), T follicular helper (3.66% (control 11.0%)), and T helper 17 (9.65% (control 15.7%)) were decreased, while the percentage of T helper 2 (60.9% (control 46.5%)) was elevated. T lymphocyte proliferative response and T cell receptor repertoire diversity were normal. NK-cell cytotoxic activity was impaired. The whole-exome sequencing harbored a de novo heterozygous nonsense mutation in exon 22 (c.2557C>T; p. Arg853X) in the C-terminus of NF-κB2. The western blotting confirmed the decreased expression of NF-κB2 (p52) protein. The patient received intravenous immunoglobulin infusion monthly (400-600 mg/kg), followed by improvement of pulmonary infection. After searching the databases, a total of 28 cases (1 Chinese and 27 non-Chinese) were identified. There were 12 cases of nonsense mutation (5 were gain-of-function mutation), and 8 cases of missense and frameshift mutations, respectively. The main clinical manifestation was respiratory infection, followed by autoimmune diseases such as alopecia and trachyonychia. Fifteen cases developed adrenocorticotrophic hormone (ACTH) deficiency. Conclusions: NF-κB2 signaling pathway played an important role in T and B lymphocyte differentiation, and NK-cell cytotoxic activity. NFκB2 mutation should be considered in cases with recurrent infections, hypogammaglobulinemia, and decreased memory B cells and plasma cells, especially when combined with ACTH deficiency.

Long-Term Effect of Cranial Radiotherapy on Pituitary-Hypothalamus Area in Childhood Acute Lymphoblastic Leukemia Survivors

Survival rates of childhood cancer have improved markedly, and today more than 80 % of those diagnosed with a pediatric malignancy will become 5-year survivors. Nevertheless, survivors exposed to cranial radiotherapy (CRT) are at particularly high risk for long-term morbidity, such as endocrine insufficiencies, metabolic complications, and cardiovascular morbidity. Deficiencies of one or more anterior pituitary hormones have been described following therapeutic CRT for primary brain tumors, nasopharyngeal tumors, and following prophylactic CRT for childhood acute lymphoblastic leukemia (ALL). Studies have consistently shown a strong correlation between the total radiation dose and the development of pituitary deficits. Further, age at treatment and also time since treatment has strong implications on pituitary hormone deficiencies. There is evidence that the hypothalamus is more radiosensitive than the pituitary and is damaged by lower doses of CRT. With doses of CRT <50 Gy, the primary site of radiation damage is the hypothalamus and this usually causes isolated GH deficiency (GHD). Higher doses (>50 Gy) may produce direct anterior pituitary damage, which contributes to multiple pituitary deficiencies. The large group of ALL survivors treated with CRT in the 70–80-ties has now reached adulthood, and these survivors were treated mainly with 24 Gy, and the vast majority of these patients suffer from GHD. Further, after long-term follow-up, insufficiencies in prolactin (PRL) and thyroid stimulating hormone (TSH) have also been reported and a proportion of these patients were also adrenocoticotrophic hormone (ACTH) deficient. CRT to the hypothalamus causes neuroendocrine dysfunction, which means that the choice of GH test is crucial for the diagnosis of GHD.

Neurotherapeutic Strategies for Multiple Sclerosis

Multiple sclerosis (MS) is the most common disabling neurologic disease of young adults. There are now 16 US Food and Drug Administration (FDA)-approved disease-modifying therapies for MS as well as a cohort of other agents commonly used in practice when conventional therapies prove inadequate. This article discusses approved FDA therapies as well as commonly used practice-based therapies for MS, as well as those therapies that can be used in patients attempting to become pregnant, or in patients with an established pregnancy, who require concomitant treatment secondary to recalcitrant disease activity.

A Case of Paraneoplastic Cushing Syndrome Presenting as Hyperglycemic Hyperosmolar Nonketotic Syndrome

Carcinoid tumors are neuroendocrine tumors that mainly arise in the gastrointestinal tract, lungs, and bronchi. Bronchopulmonary carcinoids have been associated with Cushing syndrome, which results from ectopic adrenocorticotrophic hormone (ACTH) secretion. We report the case of a 65-year-old man, a colonel in the US Air Force, with metastatic bronchopulmonary carcinoid tumors treated on a clinical trial who was hospitalized for complaints of increasing thirst, polydipsia, polyuria, weakness, and visual changes. Decompensated hyperglycemia suggested a diagnosis of hyperglycemic hyperosmolar nonketotic syndrome (HHNS). Additional findings, which included hypokalemia, hypernatremia, hypertension, metabolic alkalosis, moon facies, and striae, raised a red flag for an ectopic ACTH syndrome. Elevated ACTH levels confirmed Cushing syndrome. Treatment with a fluid replacement and insulin drip resulted in immediate symptomatic improvement. Cushing syndrome should be considered in carcinoid patients with physical stigmata such as moon facies and striae. HHNS may be the presenting clinical feature in patients with impaired glucose metabolism.

Clinical Practice Guideline for Management of Primary Aldosteronism: What is New in the 2016 Update?

Primary Aldosteronism is the single most common cause of secondary hypertension and is associated with increased target organ injury. The Endocrine Society has recently released the updated Clinical Practice Guideline for Primary Aldosteronism entitled “The Management of Primary Aldosteronism: Case Detection, Diagnosis, and Treatment: An Endocrine Society Clinical Practice Guideline”. We review the updated Clinical Practice Guideline, highlighting the new recommendations and the implications that they may have in clinical practice. The recognition by the Endocrine Society’s Task Force that Primary Aldosteronism is a public health issue and that the population at risk for screening should be significantly expanded will surely have an impact in the clinical practice which hopefully will translate in better detection, diagnosis and treatment of patients with Primary Aldosteronism.

A very rare case of Cushing's disease for cesarean section: What the anesthesiololgist needs to know

Cushing's syndrome is uncommon in pregnancy, and Cushing's disease being the cause for this syndrome is still rare. We had the opportunity to manage such a patient admitted for cesarean section. Here, we describe the evaluation of a patient with Cushing's syndrome in pregnancy along with its anesthetic implications. By describing this case, we intend to emphasize the role of the anaesthesiologist as a peri operative physician.

Adrenocorticotrophic hormone causes an increase in cortisol, but not parathyroid hormone, in dogs

Dogs with spontaneous disorders of glucocorticoid production often have marked disturbances in calcium homeostasis. For example, hypercalcaemia is frequently observed in dogs with hypoadrenocorticism and secondary hyperparathyroidism is a common feature of canine hyperadrenocorticism. The mechanism(s) by which glucocorticoids modulate calcium homeostasis in dogs remains ill-defined. The hypothesis of this study is that a marked increase in serum cortisol concentrations would lead to an immediate negative calcium balance state which would drive a compensatory increase in parathyroid hormone (PTH) concentrations. This hypothesis was investigated by measuring serum cortisol and plasma PTH concentration in 19 dogs before and after administration of adrenocorticotrophic (ACTH) hormone. Post ACTH administration, there was a significant increase in serum cortisol, but not PTH, concentrations. The results of this study do not support the hypothesis that an increase in endogenous glucocorticoids influences calcium balance sufficiently to cause an immediate, compensatory increase in parathyroid hormone concentration.

Effects of cranial electrotherapy stimulation on preoperative anxiety, pain and endocrine response

OBJECTIVES

Cranial electrotherapy stimulation (CES) is used as a treatment for depression and anxiety, and as an adjunctive intervention for pain management. This prospective study investigated whether CES could decrease preoperative anxiety, the injection pain of rocuronium, postoperative pain and stress hormone levels.

METHODS

Female patients undergoing thyroidectomy were randomly assigned to two groups, to receive either no pretreatment (control group) or CES pretreatment. Anxiety score, withdrawal response on rocuronium injection, and pain scores at 1, 4, 12 and 24 h post surgery were evaluated. Adrenocorticotrophic hormone (ACTH), cortisol and glucose levels were measured. Patients were blinded to the treatment condition.

RESULTS

Fifty patients entered the study (n = 25 per group). Anxiety score and withdrawal responses during rocuronium injection were significantly reduced in the CES group compared with the control group. Pain score was significantly lower in the CES group than in the control group, 1 h and 4 h post surgery. There were no significant differences in ACTH, cortisol and glucose levels.

CONCLUSIONS

CES pretreatment appears to reduce the level of preoperative anxiety, injection pain of rocuronium and postoperative pain. However, CES pretreatment did not affect stress hormone responses.

Cushing's Disease: Sustained remission in five cases induced by medical therapy with the dopamine agonist cabergoline

We report five cases of Cushing's disease where the patients were given a therapeutic trial of cabergoline. Morning serum cortisol, adrenocorticotrophic hormone (ACTH), and sleeping cortisol concentrations were significantly raised. Magnetic resonance imaging (MRI) scans revealed pituitary microadenomas in 3 patients but were normal in the others. Ectopic ACTH production was excluded in the 2 patients with normal MRI scans. All were given a therapeutic trial of cabergoline (1 mg daily). Four patients responded with a prompt fall in serum cortisol levels and had a sustained clinical and biochemical remission for 378, 44, 28 and 14 days, respectively. One patient failed to respond. In conclusion, we suggest that all patients with Cushing's disease should undergo a therapeutic trial of cabergoline. Responders can then be prepared for surgery or, if needed, treated medically in the long term.

Adrenocorticotrophic hormone secreting pheochromocytoma

We report a rare case of pheochromocytoma of the adrenal gland presenting as Cushing syndrome. A 30 year old woman presented with pain in the left loin and classical Cushingoid features. She was a diabetic and hypertensive on treatment. Magnetic resonance imaging of the abdomen revealed a 3.5×3 cm mass in the left adrenal gland. Urine analysis revealed an elevated 24 hr urinary cortisol level. Clinical diagnosis was Cushing syndrome due to functioning left adrenal tumor, and hence left adrenalectomy was performed laparoscopically. Histopathological examination revealed adrenal pheochromocytoma. Immunohistochemical analysis of the tumor was positive for adrenocorticotrophic hormone and chromogranin.