And It's About Time There Was Some Support For Cushing's!
Relevant Information and News Items
Salivary Cortisol, New Diagnostic Test
Creatine May Limit Brain Damage
Cushing's Syndrome News Article
Cushing's: Thin-Skinned Patient Gets Relief
A 61-year-old patient undergoes surgery to remove a tumor from his pituitary gland. Small incisions are made on the inside of the nose and underneath the upper lip, and microscopic technology is used.
Friday, November 03, 2000
But There's Still a Lot Left to Learn About Supplement's Possible Side Effects
By Elaine Zablocki
WebMD Medical News
Reviewed by Dr. Jacqueline Brooks
Nov. 2, 2000 -- The dietary supplement creatine is widely used by athletes to increase muscle mass and performance. Now a new study, conducted in animals, suggests that it may also protect against damage due to brain injury in people.
"Professional quarterbacks in the NFL sustain many concussions, with less damage than we might expect," senior author Stephen W. Scheff, PhD, tells WebMD. "That could be because they're taking creatine." Scheff is professor of anatomy and neurobiology at the University of Kentucky School of Medicine and associate director of basic research at the Sanders-Brown Center on Aging, both in Lexington.
In this study, published in the November issue of The Annals of Neurology, researchers fed rats and mice a diet high in creatine, and then simulated a concussion. They found that rats who ate a creatine diet for four weeks had a 50% reduction in brain damage, compared to rats on a normal diet. Mice who received three days of creatine pretreatment had a 21% decline in damaged cells, while those who received five days of creatine pretreatment had a 36% decline.
This doesn't mean you should eat creatine ahead of time before having a concussion, because concussions obviously aren't planned. But because these animal studies show creatine works by increasing energy production in the part of the brain cells responsible for generating the body's energy, called the mitochondria, it may be possible to find a substance that has a similar effect if taken soon after a concussion or brain injury. Scheff and other researchers have looked at several substances and are now conducting tests on one promising possibility.
Just as important, creatine may be valuable in several diseases where mitochondrial dysfunction plays a role. According to Sinclair Smith, ScD, many previous studies have indicated that creatine has the capacity to protect nerves. These reports have shown that it has good results in Lou Gehrig's disease (also known as amyotrophic lateral sclerosis, or ALS) and multiple sclerosis among others, he tells WebMD. Smith is an assistant professor of physiology in the occupational therapy department at Temple University School of Medicine in Philadelphia.
He believes creatine could potentially assist in treatment of diseases involving nerves and muscle. "I don't expect it will be a cure, but it may slow the disease process. Future research needs to focus on how creatine works in humans, and how it works in conjunction with other treatments. This is a hot area right now."
Head injuries predispose people to early onset of Alzheimer's disease, though no one knows why. This suggests creatine might also possibly slow Alzheimer's progression, Scheff speculates. "We don't know if it will stave off the disease, but it might be worth investigating."
However, since creatine is a nutritional supplement, it isn't regulated by the FDA, and it hasn't been tested for safety in human beings. At the same time, lots of athletes are taking it, and lots of health food stores are selling it.
Last May, the Blue Cross and Blue Shield Association released a statement warning about potential negative consequences of creatine. Although there have been no formal studies, observers say it may be linked to cramps, diarrhea, nausea, dizziness, high blood pressure, and liver and kidney problems.
But Scheff says creatine is an inexpensive substance with no known side effects. "Three grams of creatine per day is a maintenance dose," he says. "I buy it at the local grocery store before I go skiing."
Edward J. Kasarskis, MD, PhD, agrees creatine may play a valuable role in fighting diseases of the nervous system. When mice with ALS are fed creatine, they live longer, he tells WebMD. Now studies are planned to test creatine in humans with ALS. Meanwhile, since creatine is readily available, many of these patients are already taking it on their own.
"When people are faced with a desperate disease that has no effective treatment, they don't worry about side effects. They're eager to try something that may prolong life. We don't encourage them; we don't discourage them. Is creatine safe and effective for this condition? We don't know," says Kasarskis, a professor of neurology at the University of Kentucky's Chandler Medical Center and a member of the Amyotrophic Lateral Sclerosis Association's Subcommittee on Gulf War Veterans and Amyotrophic Lateral Sclerosis.
© 2000 WebMD Corporation. All rights reserved
The July 25th, 2000 issue of Woman's World magazine has two articles about cortisol.
One is using dietary means to control (page 16).
The other, on page 30, is "Boost your memory" and gives information about cortisol being released when we're stressed.
The principle researcher for salivary cortisols is Hershel Raff at the University of Wisconsin. His e-mail address is hraff@post.its.mcw.edu He is a research scientist, not a doctor. You can contact him directly for ordering info.
Salivary Cortisol: A Screening Technique
By: Dr. Hershel Raff
Cushing's syndrome - endogenous hypercortisolism - is characterized by a loss of circadian rhythmicity. In normal patients, cortisol levels peak in the early morning hours and decrease to substantially lower levels at night. Rather than the normal decrease in late evening cortisol, patients with Cushing's syndrome of any cause fail to decrease cortisol secretion in the late evening. Therefore, the measurement of elevated late evening cortisol is helpful in the diagnosis of Cushing's syndrome. Obtaining a late night, unstressed plasma cortisol is virtually impossible in most clinical practices. Salivary cortisol is in equilibrium with the free, biologically active portion of cortisol in the plasma. Therefore, if one obtains a saliva sample in patients at bedtime in their homes under unstressed conditions, one can make the diagnosis of endogenous hypercortisolism.
A simple way to sample saliva is by using a Salivette made by the Sarstedt Company (Newton, NC). This device consists of a cotton tube and plastic tubes. The patient only has to chew the cotton tube for 2-3 minutes and place it in the plastic tube. The tube is then transported to our lab for analysis.
Late-evening salivary cortisol is not intended to replace the current standard screening test - measurement of a 24 hr urine free cortisol. However, the salivary cortisol test can be extremely useful for patients suspected of having intermittent Cushing's syndrome. Due to the convenience of sample collection, the patient can sample saliva several evenings in a row. In fact, our clinical endocrinologists routinely order 2-3 consecutive late-evening salivary cortisol samples.
Our research (Raff H, Raff JL, Findling JW. 1998 Late-Night Salivary Cortisol as a Screening Test for Cushing's Syndrome.J Clin Endocrinol Metab. 83:2681-2686) has shown that the combination of late-evening salivary cortisol and urine free cortisol is very accurate in diagnosing Cushing's syndrome in most patients. Doctors can obtain a kit by contacting ACL Client Services at 1-800-877-7016.Editor's Note: Dr. Hershel Raff, Ph.D. is a Professor of Medicine and Physiology at the Medical College of Wisconsin's Endocrine Research Laboratory at St. Luke's Medical Center in Milwaukee, Wisconsin.
More on Salivary Cortisol from NIH
By Susan Whiteman
Special to The Washington Post
Tuesday, October 19, 1999; Page Z16
My mother is getting old. Sixty-three is not exactly ancient--for doctors specializing in geriatrics it's downright juvenile. Active, vivacious and slim, she hit her sixties running. But a few years later, she started a downhill slide.
At first it was just two or three health problems. Her orthopedic surgeon assured her that the pains in her back and hips were due to arthritis. The most frustrating problem was her fragile skin that never seemed to heal.
"I'm so careful, but look!" she would cry. After minor brushes against doorjambs or kitchen cabinets, her skin would crack and a piece the size of a penny could slide off, like the skin atop pudding. Even the brush of her infant granddaughter's fingernail would tear her skin as if it were wet tissue paper. "I'm starting to think I'll have to be quarantined away in some nice soft, pillowy space, kind of like the 'Bubble Boy'," she said, trying to maintain her sense of humor.
Angry red and purple splotches peppered her arms and hands. One doctor asked if maybe, perhaps, she was being a bit vain; he'd seen similar skin changes in other older people. Five board-certified dermatologists came up with the rather anticlimactic diagnosis of aging-related "purpura," a medical term analogous to "rash" and just as nonspecific.
"Why can't they figure out what is wrong with you?" I had asked, exasperated. My mind returned repeatedly to my medical training. Could it be a reaction to years of exposure to the sun? A disease of connective tissue? Cancer?
Then the dam broke. Mom was flooded with a torrent of health problems. Her internist told her that her cholesterol was too high and, while he was at it, her blood pressure was elevated enough to require medication. Dad said she seemed depressed at times, but with the myriad health problems plaguing her, wouldn't anyone? She became forgetful. Her legs felt heavy and tired after just a little walking. As a psychiatrist, I suggested that antidepressant medication might help with her feelings of fatigue and pain, at least until her doctors uncovered a cause or a cure for her afflictions.
After a year of seeking help for her problems, Mom was exasperated with doctors. Besides making her rounds to the five dermatologists and the orthopedic surgeon, she had visited internists, neurologists and an endocrinologist. Even plastic surgery to tighten up her chin had not been successful; the swelling in her face never did subside.
Mom had always cut a slender figure but now her jacket buttons strained to meet their buttonholes. Her abdomen enlarged to the point where she felt it was throwing her off balance. We wondered about the weight she had gained, but she was like a vacuum cleaner around food. "The kids didn't finish their dinner?" she would note, eyebrows raised. "Don't bother saving the rest of that dessert," she'd add, "or that one--I'll take care of it."
Dressing in a lavender lace and satin dress she had bought a few months earlier for my sister's wedding, she battled with the zipper over the expanse of her upper back. Turning to the side to survey the problem in the mirror, she was chagrined to see what looked like a "dowager's hump." With a dispirited sigh, she said, "Maybe the doctors are right. Maybe I am just getting old."
Mom patiently completed medical test after test. One showed that her bone density was so poor that she was in danger of fracture--so much for 25 years of estrogen pills to combat osteoporosis. Her bones, like her skin and her muscles, seemed to be dissolving.
As another year dragged by, Mom slumped with weakness and exhaustion. To her, the aisles of the grocery store seemed to stretch for miles. Shopping malls might as well have been Mount McKinley. Mom cried in frustration over each new skin injury. Her back pain tortured her sleep. She wondered how much longer she would be around--if she even wanted to be around. Mom had always been the glue holding our family together; the thought that we might lose her slammed into our minds.
In a flashback to medical school, the chairman of medicine, transcendent with his long bleached coat and winter white hair, had bellowed repeatedly, "LISTEN, listen to your patient, for he will tell you what is wrong, often tell you the diagnosis." My mother felt that most of her physicians dealt with her in a perfunctory way, that they weren't really listening. Unreasonable time restrictions under which physicians must work in the managed care environment contributed to this. Managed carelessness results.
For a fresh look, we took her to the Mayo Clinic in Rochester, Minn. Within five minutes, the internist asked her if she had been taking steroid hormones. She hadn't.
The Mayo doctor explained the possible causes of her body's excess secretion of steroids, known as Cushing's syndrome. This occurred, of course, only after carefully examining her "buffalo hump "--a medical term for a fat pad that develops on the upper back and is a distinctive characteristic of Cushing's syndrome. Oh, so it wasn't just age--although the gray haze of ageism had prejudiced and blinded her hometown doctors.
At Mayo, an MRI scan of my mother's head pointed to a benign tumor of the pituitary gland as the cause of her gush of steroid hormones, called corticosteroids. These are potent hormones that affect every part of the body, from skin and bones to brain and brawn. The one-centimeter tumor , nestled at the base of her brain, was the source of all that had plagued her. The constellation of signs and symptoms had been there, right under our noses. Actually, the tumor on her pituitary was, anatomically speaking, right behind hers.
The gradual changes in my mother, her myriad symptoms and advancing age had engendered misinterpretations by those other doctors. Her buffalo hump (I cringe to mention this abominable term in the same sentence as my mother) was small. Her osteoporosis--oh well, estrogen supplements can't work for everyone. Her steroid-soaked skin--age and the Florida sun.
Our oversized cerebrums are very good at concocting explanations. One day, sunlight had offered me a gentle hint to my mother's condition, highlighting the peach fuzz on her face, another sign of steroid hormone excess. The illumination was lost on me, though. The fleeting, barely conscious observation was instantly filed away to some backwater convolution of my cortex, tabbed to "age"--finding, I'm sure, an even deeper recess when cross-referenced to "mother." I had completely forgotten the peach fuzz, this clinical sign, until a diagnosis became available to hang it on.
The Mayo doctors recommended surgery to remove the tumor . The night before the operation, my phone rang. It was Mom, sounding tired and defeated. "I'm sorry to call so late; I wanted to wait until Dad went back to his hotel." With a sigh, she continued, "I feel so weak; I really don't think I'm going to survive this surgery." She sounded very sad and very sure. I took her concerns very seriously. Sometimes people have an eerie intuition about when they are going to die. As a psychiatrist, I also knew that the depression caused by the Cushing's disease was casting a pall on her outlook.
"Try to think positively," I implored. "The girls are really looking forward to your visit on Katie's birthday."
In a brave voice, she said, "I love you all."
The next day at work, I waited. And waited, glancing at the phone every few minutes for the call promised by my father. I knew the three-hour operation should be finished around noon. As that hour passed, I could feel my face becoming flushed. My mind churned through all the things that could have gone wrong: a stroke, heart failure, too much anesthesia for her weakened state. I left work early and hurried home.
I called Mayo and was promptly put through to the recovery room where my father, sounding upbeat, said, "She just arrived here; the surgery started late but she came through it well. She's awake but still groggy." My wise and wonderful husband, noticing my bleary-eyed agitation and then relief suggested, "Why don't you go up there? I bet you could still catch a flight this afternoon." This was no small offer. I thought that leaving him alone for more than a day with our three small daughters, aged 4 and under, was just too much to ask.
"Just go!" he said. "You probably should have flown up yesterday." He handed me the phone--an airline reservation agent rattled off departure times. In two hours, I was jetting toward Rochester.
My mother was up and around within a day, although with an even more swollen face, an odd purple bruise in the shape of a Fu Manchu mustache, and a very stuffy, gauze-packed nose. But these were very temporary.
My mother's body is now slender and her skin has healed. She is off all medication except that required to rebuild her bones. She has regained the strength needed to pick up her toddling grandchildren and the energy required for the perpetual commotion of her older grandchildren. Older, in this case, refers to the 3-, 4-, and 5-year-olds. Age is indeed in the eye of the beholder. My mother has a bright future ahead of her--I think she would agree with Walt Whitman:
Youth, large, lusty, loving--youth full of grace, force, fascination,
Do you know that Old Age may come after you with equal grace, force, fascination?
Resources
Susan Whiteman is a psychiatrist living in Bethesda
The Washington Post
Tuesday, June 30, 1998; Page Z19
By Jay Siwek, M.D.
Q: I have recently been diagnosed with Cushing's syndrome. My family knew something was wrong with me because of how drastically my appearance had changed over the past year or so.
I went to my doctor and specifically asked to be tested for a hormonal problem. Lo and behold, the tests were markedly abnormal. I also learned that I had developed high blood pressure and diabetes due to Cushing's syndrome.
I am now waiting to learn what's causing this problem, and what treatment I need. What I'd like to know is why this condition didn't show up during a physical exam and blood tests last year. How serious is it? Can it recur after treatment?
A: Cushing's syndrome, named for pioneering U.S. neurosurgeon Harvey Williams Cushing (1869-1939), is actually several diseases grouped under one name.
Because Cushing's can be difficult to recognize, it can cause damage throughout your body before it is detected, and because it can stem from any of several causes, treatment depends on your underlying conditions.
In all cases, the ailment stems from an overproduction of cortisol, or hydrocortisone, a hormone made in your adrenal glands.
In normal amounts, cortisol is essential for healthy function. It helps your body respond to stress, inflammation and illness.
Too much cortisol can lead to a variety of problems, including weight gain, high blood pressure, weakness, fatigue and swelling. You can develop osteoporosis and be prone to fractures. You can develop bruising, irritability, depression and even confusion. In women, menstrual periods can become infrequent or stop. Some women also develop acne and increased hair growth.
The appearance of people with Cushing's can change dramatically. They gain weight in a characteristic pattern, with fatty tissue accumulating particularly in the face, between the shoulder blades and in the abdomen.
Another characteristic feature is the development of stretch marks, usually across the abdomen. Unlike the stretch marks that might accompany pregnancy or weight gain from other causes, those in Cushing's patients can sometimes have a distinctive purplish color.
In addition to these physical changes, Cushing's is caused by adrenal tumors, you'll need surgery; if you have pituitary problems, treatment options include surgery, radiation and medications.
