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More recently, the variability of baseline UFC calculated from four 24-hour urine samples collected over 2 weeks was evaluated in patients with persistent/recurrent or de novo Cushing's disease.
Of note, patients with mild degrees of cortisol excess were not included in the study; in addition, UFC was analyzed at 3 different laboratories (16).
Patients with CS with at least one normal UFC or LNSF have been observed in other series (14).
The limitation of these studies was the long time interval of serial measurement of either UFC or LNSF and/or nonsimultaneous and nonconsecutive collection of urine and saliva.
The introduction of salivary cortisol as a first line test for CS (4, 5, 7, 8), irrespective of whether patients are investigated on an inpatient or an outpatient basis (8, 9) has allowed the study of hypothalamic-pituitary-adrenal axis response patterns without the need of repeated blood or urinary samples.The area under the receiver-operating characteristic curves for LNSF was 0.999 (95% credible interval [CI] 0.990–1.00) and for UFC was 0.928 (95% CI 0.809–0.987).The ratio between areas under the curve was 0.928 (95% CI 0.810–0.988), indicating better performance of LNSF than UFC in diagnosing CS.Two recent meta-analyses support the use of LNSF for screening and diagnosis of CS (10, 11).Studies using receiver-operating characteristic (ROC) curves have addressed the comparison of LNSF with traditional tests in a large population of CS and obese subjects.