Talk:Cushing's syndrome

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This article was the subject of a Wiki Education Foundation-supported course assignment, between 13 January 2020 and 27 April 2020. Further details are available on the course page. Student editor(s): IanConstantine.

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Merging is wrong

Cushing's Disease and Cushing's Syndrome are two different entities. So they should be separate. I would suggest to unmerge. Thanks -- Abhijeet Safai (talk) 09:55, 22 February 2013 (UTC)

Imaging in ectopic Cushing's syndrome

doi:10.1210/JC.2015-1589 - various modalities discussed. JFW | T@lk 18:01, 12 July 2015 (UTC)

Endocrine society guideline

doi:10.1210/jc.2015-1818 JFW | T@lk 08:35, 3 August 2015 (UTC)

Lancet seminar

doi:10.1016/S0140-6736(14)61375-1 JFW | T@lk 17:02, 1 September 2015 (UTC)

Diagnosis?

No diagnosis section...Jobonki (talk) 16:39, 4 September 2016 (UTC)

Feel free to find some good sources and add that section. Doc James (talk · contribs · email) 16:42, 4 September 2016 (UTC)

Text

Extended content

Visibly obvious Cushing’s syndrome is associated with 83% of the patients in older peer reviewed medical literature that have been described as either abusing corticosteroids or having a corticosteroid addiction, which would now be more correctly described as having a corticosteroid use disorder. Newer peer reviewed medical literature uses the term Factitious Cushing’s Syndrome to characterize what used to be termed abuse and by definition the correlation is 100% with a 0.7% incidence having no supporting underlying medical condition, however, the more modern literature fails to address the concept of medically prescribed addiction where the DSM V criteria of a Corticosteroid Use Disorder is met while having an active prescription for an underlying medical condition. References

Removed a mass of old primary sources. Editor needs to read WP:MEDRS Doc James (talk · contribs · email) 08:21, 6 September 2016 (UTC)

Images used might be illegal

The immages used are sourced from a journal article. While the article may be open content, this does not mean that the immages may be copied. This is even more true given that the pictures in the original article were published under strict consent forms that may or, and this far more likely, may not have allowed publication in a third source. The consent forms are not publicized, so the obvious thing to assume is that consent is **not** given! — Preceding unsigned comment added by 62.58.236.32 (talk) 05:25, 12 October 2016 (UTC)

Glucose homeostasis

Reviewed: doi:10.1210/er.2016-1105 JFW | T@lk 18:53, 12 June 2017 (UTC)

External links modified

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Fluticasone ad at the top of this page

Why is there an ad for Fluticasone at the top of the page with an unverified picture of someone who supposedly took it and had relief of symptoms? Wikipedia is supposed to be ad free. After four attempts to remove this ad unsuccessfully I end up here discussing something that should be obvious to everyone. Advertisements for anything, including drugs,have no place in a wiki page. — Preceding unsigned comment added by 2600:1003:B11D:8018:93A:E38F:D82A:9741 (talk) 23:13, 25 March 2018 (UTC)

I don't understand why you think the image is an advertisement. Wikipedia should describe the results of drugs and the image is showing an adverse effect of from the use of a drug. How does showing this adverse effect advertise the drug anyway? And why do you call it an unverified picture? It is referenced to a peer-reviewed medical journal. What greater verification do you expect? ChemNerd (talk) 17:17, 26 March 2018 (UTC)

Inconsistent first sentence

Hi,

The opening sentence of the article reads "Cushing's syndrome is a collection of signs and symptoms due to prolonged exposure to cortisol." which is consistent with the its inline citations. However, this proposition is clearly contradicted later in the article; Cushing's syndrome can also be caused by glucocorticoid medications that mimic the physiological effects of cortisol while not being, well, cortisol. The sentence is thus inaccurate.

Since inline citations are not required for the lead section, and since the detailed explanation of CS etiology (endogenous vs. medication-induced CS) is clearly delineated in the article body, I propose the first paragraph be rewritten as e.g. "Cushing's syndrome is a collection of signs and symptoms caused by prolonged exposure to cortisol or other glucocorticoids." or "... cortisol or glucocorticoid medications." and the current inline citations be removed.

Kind regards, -J Jay Hodec (talk) 21:48, 16 April 2019 (UTC)

Muddle, and potential muddle, between Cushing’s Syndrome and Cushing’s Disease is a bit of a theme - within the article as it stands, and as a thread through the article’s history. Unless I’m misunderstanding something, the point being made here is the same issue turning up again. The sooner we can deal with it, so the article ceases to prompt controversy or puzzlement about this, the better.

But I’m not sure the proposed amendment is the way to do it. The opening sentence as it stands is clear and, for what it’s worth, accurate. (The Syndrome is a collection of signs and symptoms, and the common feature which those signs and symptoms share is that they arise from prolonged exposure to cortisol.) The snag, the weakness of the sentence, is tht it’s apt to be misunderstood: as saying tht that’s the *only* thing that causes them, they arise *only* from exposure to cortisol. It doesn’t say that, but it’s easily misread and gives that impression.

The proposed change avoids the misunderstanding - but loses the crispness and clarity of the sentence. It kind-of risks substituting *no* understanding for *mis*understanding! And that is sooo not what u want at the start of a lede!

To me, the better route is to clarify by amplifying, immediately but in a separate following sentence. (Or two, actually.) And to use the opportunity to tackle the Syndrome / Disease muddle up-front and head-on.

How about

   Cushing's syndrome is a collection of signs and symptoms which arise from prolonged exposure to cortisol.  Cushing’s Disease is a condition which causes a raised level of cortisol in the body, and so causes Cushing’s syndrome.  The syndrome itself can also be [? is often? source?] caused instead by medication such as prednisone.

- SquisherDa (talk) 13:42, 17 April 2019 (UTC)

Cushing's disease is generally defined as a subcategory of CS caused specifically by excess ACTH release. The syndrome encompasses, at least as set forth in the article, CD, ACTH-independent CS, and the medication-induced condition. I'm noticing that sources are a bit divided as to the precise definitions also, however, since the article defines medication-induced CS within the scope of "Cushing's syndrome", the wording of the first sentence should be changed to reflect article content. If we wish to distinguish exogeneous CS from endogeneous CS "proper" (as some sources do), the distinction should likewise be made in the article text.

I went ahead and checked how the term is defined in a dozen sources chosen at random (definition excerpts below). You'll notice that there's an interesting pattern; scientific sources tend to point out that CS is caused by *any* glucocorticoid excess (whether endogenous cortisol or exogenous glucocorticoids) while non-scientific sources fail to make the distinction. However, here's the crucial point; glucocorticoids=/=cortisol, and failing to point that out leads to an inaccurate definition. I understand why you would simplify the thing for the general public on a health information website, however, as far as I know, Wikipedia should strive for greater accuracy instead of greater comprehensibility.

   *"Cushing’s syndrome is a rare disorder resulting from prolonged exposure to excess glucocorticoids." - S. T. Sharma (2015)
   *"Cushing syndrome is caused by prolonged exposure to high circulating levels of cortisol. The most common cause of cushingoid features is iatrogenic corticosteroid use [...] There are two main etiologies of Cushing syndrome: endogenous hypercortisolism and exogenous hypercortisolism. Exogenous hypercortisolism, the most common cause of Cushing syndrome, is mostly iatrogenic and results from the prolonged use of glucocorticoids. Endogenous Cushing Syndrome results from excessive production of cortisol by adrenal glands and can be ACTH-dependent and ACTH-independent." - C. S. Hammad, G. Singh (2019)
   *"Cushing’s Syndrome results from chronic exposure to excessive circulating levels of glucocorticoids." - A. Juszczak, P. Sulentic, A. Grossman (2017)
   *"Endogenous pathologic hypercortisolism, or Cushing’s syndrome ..." L. K. Nieman (2015)
   *"Cushing’s syndrome (CS) is the state of hypercortisolism that results from endogenous or exogenous glucocorticoid excess." J. M. Pappachan, et al. (2017)
   *"Cushing's syndrome, or chronic hypercortisolism, is a severe endocrine disease due to the prolonged exposure to glucocorticoid excess" - A. M. Isidori, et al. (2015)

   *"Cushing syndrome occurs when your body is exposed to high levels of the hormone cortisol for a long time. Cushing syndrome, sometimes called hypercortisolism, may be caused by the use of oral corticosteroid medication. The condition can also occur when your body makes too much cortisol on its own. [...] Excess levels of the hormone cortisol are responsible for Cushing syndrome. [...] Cushing syndrome can develop from a cause outside of your body (exogenous Cushing syndrome)." - Mayo Clinic
   *"Cushing’s syndrome is a disorder that occurs when your body makes too much of the hormone cortisol over a long period of time. [...] Endogenous Cushing’s syndrome is rare. “Endogenous” means something inside your body is causing the disorder rather than something outside your body, such as medicine. [...] People who take medicines called glucocorticoids, which are similar to cortisol, also can develop Cushing’s syndrome." - National Institute of Diabetes and Digestive and Kidney Diseases
   *"Cushing syndrome occurs due to abnormally high levels of the hormone cortisol. This can happen for a variety of reasons. The most common cause is overuse of corticosteroid medications." - Healthline
   *"You can get Cushing's syndrome when there’s too much cortisol in your body for too long. Cortisol comes from your adrenal glands, which sit on top of your kidneys. The most common cause is related to medications called glucocorticoids, also commonly known as steroids or prednisone." - WebMD
   *"Cushing syndrome is a rare endocrine disorder caused by abnormally excessive amounts of the hormone cortisol. Many people develop Cushing syndrome as a result of exogenous, long-term administration of a cortisol-like drug therapy [...] Cushing syndrome can also be due to endogenous causes; approximately 70% of Cushing syndrome is the result of Cushing disease." - National Organization for Rare Disorders
   *"Cushing's syndrome is a condition caused by having too much of a hormone called cortisol in your body. [...] Cushing's syndrome is uncommon. It mostly affects people who have been taking steroid medicine, especially steroid tablets, for a long time. Steroids contain a man-made version of cortisol. Very rarely, it can be caused by the body producing too much cortisol." - NHS

I think the wiki article should use the wider definition which also appears to be the preferred definition in scientific literature.

Sincerely, -J Jay Hodec (talk) 10:07, 18 April 2019 (UTC)

Mmm - looking at the references U’ve pulled together there, I’m seeing more clearly why U want to get the exogenous syndrome more up-front and into the first sentence.

I want to make changes too, of course.

And that’s not the only thing we agree on! Ur observation tht Wikipedia should strive for greater accuracy seems to me entirely right, and absolutely central. In fact I’d suggest this particular article is mainly important for its value to refugees from the non-scientific sources U point to: because yes, that is a really *very* interesting pattern; and u’d really think, for example, tht the Mayo Clinic would do a bit better than that! </rant>

I also agree with Ur view tht the wider, scientific definition is the more encyclopaedic - so tht where endogenous CS is caused by CD, but exogenous-CS cases are not CD cases.

I might attach greater priority than I think U do, though, to greater comprehensibility. I hesitate to settle for “instead”! I’d try really hard to get *both*.

In that connection, Ur plan to drop citations out of the lede is also obviously good.

And should we drop the reference to “signs and symptoms”? The distinction doesn’t seem helpful here - signs aren’t much involved where CS is concerned - if I understand the distinction correctly? (My impression is tht signs are abnormalities tht declare the condition even to people without medical knowledge: make the diagnosis obvious, in the way tht a bent limb can declare a fracture. In this sense, there aren’t going to be many signs of an endocrine disorder - whether or not iatrogenic!)

How about refocusing the opening sentence - on the distinction itself? That way, our reader / refugee gets the distinction clear, as a rather necessary preliminary; and the sentence functions naturally to introduce a pair of following sentences which handle the details:

  Cushing's syndrome is a collection of symptoms which can arise from an endocrine disorder, or, more often, as a side-effect of medication.  Cushing’s Disease is a rare condition which causes a raised level of cortisol in the body, resulting in endogenous Cushing’s syndrome.  The syndrome itself is more often exogenous - caused by prolonged use of glucocorticoid medication such as prednisone.

- SquisherDa (talk) 20:52, 19 April 2019 (UTC)

Attesting from my own personal experience, I usually use Wikipedia as a semi-scientific framework to get a feel for a subject before building upon that knowledge; individual scientific articles often do not give a good enough overview of a subject to give a reader the basis for initial comprehension. Wikipedia, in contrast, often offers a comprehensive initial aggregate of relevant scholarly information to help you get started on a deeper dive on a subject. That's why "pop-sci" inconsistencies in wiki articles really throw me off and "grind my gears" since you have to go back and compare sources to figure out where the inconsistency lies.

Regarding "Signs and symptoms"; I much prefer to use the terms "Presentation" and "Features" since the former are as you have pointed out a bit murky. "Symptoms" generally refers to disease features that are internal/subjective (pain, fatigue, nausea, tingling, numbness, etc.) while "signs" refers to objective/observable features, and particularly those that are observed during medical examination (e.g. abnormal heart/lung sounds, abnormal lab/radiological findings, a palpable lump, abnormal gait, tremor, etc.). The terms are often used interchangeably, however, and the "Signs and symptoms" phrasing is generally preferred on wiki ... In this case, I think there are plenty outwardly/objective signs of disease, even if not immediately suggestive of the cause to casual observers.

I generally agree with your formulation, however, there are some inaccuracies in your phrasing, namely that exogenous disorder could still be tentatively defined as an endocrine disorder as it still affects the "endocrine mechanisms" at the target receptor end. Furthermore, CD is a subset of endogenous CS, and not all endogenous CS is CD.

I'm gonna go ahead an just rewrite the Causes section and the first sentence so that we can get a feel for the situation as it stands and we can then discuss it further.

Kind regards, -J Jay Hodec (talk) 11:53, 20 April 2019 (UTC)

This "causes a raised level of cortisol in the body" is not really accurate. It is a result of a high cortisol level.

For medical articles we references the lead.

How common the condition is is discussed in the 4 paragraph of the lead and in the infobox. We do not need to state how common it is as we give the numbers. Doc James (talk · contribs · email) 19:45, 20 April 2019 (UTC)

Definition

The NIH says "Cushing's syndrome is a hormonal disorder caused by prolonged exposure of the body's tissues to high levels of the hormone cortisol"[1]

This can reasonably be summarized as "due to prolonged exposure to glucocorticoids such as cortisol."

I agree with the usefulness of mentioning glucocorticoids and have added that to the first sentence. Doc James (talk · contribs · email) 19:49, 20 April 2019 (UTC)

Etiology

We try to use English not Latin / Greek. The English word is cause. We use easier to understand language per WP:MEDMOS.

There is no NEED for 7 references here.[2] Expecially not two reference that are the same. It is not that controversial. Doc James (talk · contribs · email) 19:31, 20 April 2019 (UTC)

Regarding NIH/NEMDIS's definition see discussion above (I found your version acceptable and did not contest it).

To address the two sections I actually reversed to my version ... Though I generally understand the utility of avoiding jargon, I think @DocJames's drive for plain English goes a bit too far. Just as an off-point, "cause" comes from Latin ("causare"), but is just as much an English word as "etiology". Admittedly, etiology is a more "advanced" word, however, I don't see the point in reducing everything down to a second grade English level, especially when it comes at the cost of accurate language ("cause" and "etiology" are not synonyms, please, see context). I've noticed multiple times that your simplifications made sections less precise and more ambiguous. From a scholarly standpoint this is quite problematic. I've tried to find the guideline that directs medical editors towards the plainest of English but cannot find it, even in the WP:MEDMOS you've referenced (anyway, I thought that's what Simple English wiki is for).

I may have accidentally inserted a source twice (my bad). However, as already mentioned, the handful of references was intended to establish a trend to bolster the "glucocorticoids" definition since no secondary source for a meta-definition of CS can be found.

I've already addressed the reason for re-inserting "... or the dose can be adjusted downward to limit Cushing's symptoms."

Kind regards, -J Jay Hodec (talk) 21:02, 20 April 2019 (UTC)

We are not writing for graduate students. We can barely get our content down to a grade 12 reading level at the best of times. MEDMOS says "The lead of an article, if not the entire article, should be written as simply as possible without introducing errors or ambiguity." Doc James (talk · contribs · email) 04:21, 22 April 2019 (UTC)

"If due to medications, these can often be slowly stopped or decreased." → " If due to medications, these can often be slowly stopped, or, if the medication is needed to treat an ongoing chronic condition, the dose can sometimes be reduced to minimize Cushing's symptoms." Emphasis on the fact that it is not always possible to completely avoid CS if no alternative exists and that it may be necessary to balance exogenous CS against underlying disorder. Note that reducing the dose is not mentioned in the originally cited source (I reinserted the needed source). If you leave "stopped or decreased" while removing the source, the "decreased" may be removed as unsourced in the future.

"The cause of Cushing's syndrome include all reasons for increased glucocorticoid levels leading to a diseased state." → "Cushing's syndrome may be defined broadly as disease resulting from any cause of increased glucocorticoid levels, whether due to medication or internal processes." Your version makes the sentence nonsensical when contrasted to the following one. (i.e. "Some sources however do not consider the glucocorticoid medication-induced condition as "Cushing's syndrome" proper, instead using the term "Cushingoid" to describe the medication's side effects which mimic the endogenous condition.") I rephrased the sentence to remove "etiology" while preserving the intended meaning. Emphasis on the fact that not all sources define endogenous CS as CS (important in context of definitions that regard cortisol exposure as sole possible cause; future editors may challenge the definition without this clarification/disclaimer). I did not restore the sources since that was a minor point of contention.

Kind regards, -J Jay Hodec (talk) 15:50, 21 April 2019 (UTC)

Yah the original source sort did not cover it as clearly.

"If Cushing’s syndrome is caused by glucocorticoid medicine taken to treat another disorder, your health care provider will slowly and carefully decrease your dose and give you another medication so that your body can go back to making its own cortisol. However, if you need to continue taking the glucocorticoid, your health care provider will closely monitor you and treat symptoms that might develop, such as high blood sugar, high cholesterol levels, bone thinning, or osteoporosis"

Have condensed it to "Cushing's syndrome may result from any cause of increased glucocorticoid levels"

Doc James (talk · contribs · email) 04:18, 22 April 2019 (UTC)

Alright ... Your new condensed version is better than previous one, but still quite a bit off (when read together with following sentence). However, I really don't wanna argue about this anymore, so I leave it up to (potential) other editors to decide.

Take care. -J Jay Hodec (talk) 17:32, 22 April 2019 (UTC)

Genetics behind Cushing

Please, can someone add some information about the genetics behind this syndrome? Now is quite known that there are some relevant mutations in PRKACA gene. Reviewed: https://advances.sciencemag.org/content/7/8/eabd4176.full — Preceding unsigned comment added by Aldhairmedico (talk • contribs) 01:39, 9 March 2021 (UTC)