bluuebunny/crossref_metadata_2025_split huggingface dataset:
952-P: Improving Glycemic Management of Patients with Type 2 Diabetes in Acute Geriatric Care by Using a Basal Insulin Algorithm Incorporated into a Workflow and Decision Support System
Authors: LIBISELLER ANGELA , LICHTENEGGER KATHARINA M. , KOPANZ JULIA , CAMPO ANTONELLA DE , WIESINGER TATJANA , WEIDINGER LISA , LAUBREITER LISA , SCHIPPINGER WALTER , TRUSKALLER THOMAS , LACKNER BETTINA C. , BECK PETER , HÖLL BERNHARD , PIEBER THOMAS R. 
Published: June 2019

Introduction: Glycemic management can be complex in elderly patients despite of multimorbidity and polypharmacy. International guidelines recommend individualizing therapy goals by using easy to handle basal insulin regimen with low hypoglycemia risk. An algorithm for basal insulin therapy (including basal-plus) based on the individual’s health status was developed and incorporated into GlucoTab®. This tablet-based workflow and decision support system provides suggestions for insulin therapy, blood glucose (BG) management and offers workflow support by visualization of open tasks. The study objective was to investigate efficacy and safety of the GlucoTab® system in patients at an acute geriatric hospital.
Methods: A randomized controlled trial was performed in 58 patients with type 2 diabetes aged ≥ 65 years. Patients in the intervention group (IG) (n=31) were treated according to GlucoTab® basal insulin algorithm, patients in the control group (CG) (n=27) received diabetes therapy according to physician’s prescription electronically documented in GlucoTab®.
Results: Patients of both groups (sex: IG=65% vs. CG=63% females, age: 78±6 vs. 76±6 years, BMI: 29±6 vs. 30±6 kg/m2 and HbA1c: 56±10 vs. 61±13 mmol/mol) were attributed an individual health status: 74% moderate and 26% good health. The percentage of fasting BG (FBG) values within health-dependent FBG target range was 59±33% vs. 51±31%. BG values below, within, and above health dependent target range occurred in 4%, 75% and 22% vs. 1%, 75% and 25%, respectively. In both groups no severe hypoglycemic event &lt;40 mg/dl was observed. The number of BG values in the ranges 40 to 69 mg/dl was 3 vs. 2, respectively. Mean FBG was 142±49 vs. 150±38 mg/dl and mean daily BG was 195±74 vs. 201±46 mg/dl.
Conclusion: The GlucoTab® basal insulin algorithm supported an efficacious and safe glycemic management in patients with type 2 diabetes in acute geriatric care.

Disclosure
A. Libiseller: None. K.M. Lichtenegger: None. J. Kopanz: None. A. de Campo: Advisory Panel; Self; Sanofi-Aventis. T. Wiesinger: Other Relationship; Self; Bristol-Myers Squibb Company. L. Weidinger: None. L. Laubreiter: None. W. Schippinger: None. T. Truskaller: None. B.C. Lackner: None. P. Beck: Employee; Self; decide Clinical Software GmbH. Stock/Shareholder; Self; decide Clinical Software GmbH. B. Höll: Employee; Self; decide Clinical Software GmbH. T.R. Pieber: Advisory Panel; Self; ADOCIA, Arecor Limited, AstraZeneca, Novo Nordisk A/S, Sanofi. Speaker's Bureau; Self; Novo Nordisk A/S.

Funding
Austrian Research Promotion Agency (FFG844737)
957-P: Differences in Glucose Level between Left Arm and Right Arm Using Continuous Glucose Monitors
Authors: KIM NICOLE , PHAM KEVIN , SHEK ALLEN , LIM JEREMY J. , SHAH SACHIN A. 
Published: June 2019

Background: Continuous glucose monitoring (CGM) is an emerging technology that provides real-time interstitial glucose levels through a sensor with a thin filament inserted under the skin. It is customary for patients to rotate sensor application sites between arms to minimize skin irritation. However, the degree of inter-arm differences with CGM technology remains unknown.
Materials and Methods: Self-proclaimed right-handed (n=5) and left-handed (n=5) subjects, regardless of concurrent comorbidities, were enrolled for CGM. A FreeStyle Libre Pro Flash Glucose Monitoring System sensor was simultaneously placed on each arm for all subjects. The sensors were worn for a maximum of 14 days with measurements taken every 15 minutes. Muscle mass and body fat analysis was conducted using a multi-frequency segmental body composition analyzer. Glucose levels from the right and left arms were time-matched with the first 12 hours eliminated from analysis.
Results: A total of 9830 paired glucose levels were included for analysis. Glucose levels were outside the euglycemic range (70-140 mg/dL) for 14.5% of the time in the right arm compared to 20.0% in the left arm (P&lt;0.001). The glucose level in the right arm was higher than the left arm in 67% (range 46 - 98%) of the measurements (P&lt;0.001). The absolute difference in glucose level between the right and left arms was &gt;10 mg/dL, &gt;20 mg/dL, and &gt;30 mg/dL, for 19.4%, 3.4%, and 0.32% of the time, respectively. The mean glucose level in the right arm was higher than the left arm by 3.75 mg/dL [SD, 8.51 mg/dL] in right-handed subjects, and by 3.84 mg/dL [SD, 7.09 mg/dL] in left-handed subjects (P=0.54).
Conclusion: Time in euglycemic range could significantly differ based on arm selection when using a CGM. While the absolute difference in glucose levels between arms appears small, this degree of variability would have significant implications for clinical trial design using CGM technology. Arm dominance does not explain the inter-arm glucose level discordance.

Disclosure
N. Kim: None. K. Pham: None. A. Shek: None. J.J. Lim: Employee; Self; Genentech, Inc. Stock/Shareholder; Self; F. Hoffmann-La Roche Ltd. S.A. Shah: None.

Funding
University of the Pacific
962-P: Continuous Glucose Monitor Readings Lag Interstitial Glucose by Several Minutes
Authors: MCCLATCHEY PENN MASON , MCCLAIN ETHAN S. , WILLIAMS IAN M. , GREGORY JUSTIN M. , CLIFFEL DAVID , WASSERMAN DAVID 
Published: June 2019

Objective: Continuous glucose monitor (CGM) measured glucose lags blood glucose by several minutes, and this delay is usually attributed to the latency of interstitial fluid. However, independent findings suggest that interstitial glucose dispersion is near-immediate. This study seeks to determine the physiological locus of CGM latency.
Methods: Current was measured at 1 Hz in Dexcom G4 CGMs using a CHI 1440 potentiostat. CGMs were exposed to varying glucose levels in vitro to define sensor kinetics. Next, CGMs were implanted in mice, and sensor vs. blood glucose responses were measured following an intravenous glucose challenge. Finally, dispersion of a fluorescent glucose analogue (2-NBDG) into the CGM micro-environment was observed in vivo using intravital microscopy. Tissue deposited on sensors and non-CGM implanted subcutaneous fat were then collected for histological analysis.
Results: The CGM time constant in vitro was 51±3 seconds. In vivo, CGMs took 24±7 minutes to reach a local maximum in maximum current following intravenous injection of glucose. 2-NBDG took 21±7 minutes to reach maximum fluorescence near the sensor, vs. 6±6 minutes in subcutaneous fat (p=0.0011). Collagen was increased in sensor deposits relative to non-CGM implanted subcutaneous fat (p=0.0018), and collagen content was correlated with 2-NBDG latency (R=0.96, p=0.0004).
Conclusions: Interstitial glucose responds to changes in blood glucose within seconds, whereas the glucose levels seen by a CGM are delayed by several minutes due to fibrous encapsulation. A CGM that avoids encapsulation could approximate real-time blood glucose measurements. Additionally, these data raise the possibility that fibrosis underlies insulin resistance by creating a biophysical impediment to the interstitial dispersion of glucose.

Disclosure
P.M. McClatchey: None. E.S. McClain: None. I.M. Williams: None. J.M. Gregory: Consultant; Self; InClinica. D. Cliffel: None. D. Wasserman: None.

Funding
National Institutes of Health (DK059637, DK054902, DK050277, T32DK101003, F32DK120104); American Heart Association
963-P: Impact of Exercise on Glycemia among Users of Flash Glucose Monitoring
Authors: COVINGTON KENDALL , JANGAM SUJIT , DUNN TIMOTHY 
Published: June 2019

Real-world data gathered from flash glucose monitoring (FreeStyle LibreTM system) can be used to examine the impact of exercise on time in hypoglycemia, euglycemia, and hyperglycemia. De-identified data from 623 users who recorded 29,280 exercise notes were analyzed, all having notes spanning at least 10 days and more than 25% of days with notes. Glucose time in ranges during night time (11P-8A) and fasting levels (7A-8A) following exercise days and non-exercise days were evaluated. Nights following exercise had an average of 119.2 min/night above 180 mg/dL vs. 137.0 min/night without exercise (p &lt; .001), a difference of 17.8 min/night. There was a median difference of 11.3 fewer minutes in hyperglycemia on exercise nights, with minimal increase in time in hypoglycemia (1.2 min). Days with exercise had an average fasting glucose the next day of 137 + 59 mg/dL compared to fasting levels of 140 + 59 mg/dL without (p &lt; .001). More exercise days had fasting glucose below 70 mg/dL (8.2% vs. 6.4%), but fewer were above 180 mg/dL (19.5% vs. 25.4%). While days with exercise are associated with increased time in hypoglycemia, users saw a greater reduction in hyperglycemia. Flash glucose monitoring can help identify pre-exercise levels and trends which can be used to assist patients in improving time-in-range without increasing nighttime hypoglycemia.

Disclosure
K. Covington: Employee; Self; Abbott Laboratories. S. Jangam: Employee; Self; Abbott Laboratories. Employee; Spouse/Partner; Abbott Laboratories. T. Dunn: Employee; Self; Abbott Laboratories.

Funding
Abbott Diabetes Care
967-P: Association between Visit-to-Visit Blood Pressure Variability and Blood Glucose Control, a Retrospective Analysis of Three Population-Based Cohorts of Diabetic Patients
Authors: ZHANG SHUO , XIE LI , ZHANG WEITUO , QIAN BIYUN 
Published: June 2019

Background: Relationship between blood pressure (BP) and blood glucose control is still unsure. This study aimed to find whether visit-to-visit variability (VVV) of BP could be an independent risk factor for blood glucose control.
Methods: A retrospective analysis was conducted in 95254 Chinese primary care diabetic patients from Oct. 2014 to Nov. 2018 with repeated measurements of BP and fasting plasma glucose (FPG) every 3 months, including 3 cohorts: Putuo District diabetes cohort (PTD, N=43590), Xuhui District diabetes cohort (XHD, N=45451) and Changning District diabetes cohort (CND, N=6213). The VVV of systolic blood pressure (SBP) was evaluated by average successive difference (ASD), and glucose control was evaluated by “FPG well-controlled proportion” (FPG≤7mmol/L as “well-controlled”), over 16 follow-ups. Logistic regression was used to explore the association of SBP ASD and FPG well-controlled proportion. The full model adjusted the baseline characteristics considering age, gender, BMI, exercise, medication and diet. Model was built in PTD and validated in the other 2 cohorts.
Results: Patients in PTD can be divided into 3 groups by VVV of SBP, which were “stable,” “fluctuating” and “highly fluctuating” groups. With “stable” group as reference, higher VVV of SBP was associated with lower FPG well-controlled proportion. In PTD, “fluctuating” group, OR: 1.18, 95% CI: 1.13-1.24; “highly fluctuating” group, OR: 1.42, 95% CI: 1.35-1.49. Results were consistent in the 2 validated cohorts and ORs for the “highly fluctuating” group were 2.37, 95% CI: 2.23-2.52 and 1.34, 95% CI: 1.15-1.56. In the whole population (N =95254), “highly fluctuating” group was associated with the worst blood glucose control with OR: 1.67, 95% CI: 1.62-1.73.
Conclusion: High VVV of SBP could be an independent risk factor for blood glucose control, which suggests extra surveillance for those with highly fluctuating SBP.

Disclosure
S. Zhang: None. L. Xie: None. W. Zhang: None. B. Qian: None.
973-P: The Feasibility of Continuous Glucose Monitoring in Youth with Type 2 Diabetes Mellitus: A Pilot Study
Authors: LAROCHE ALLISON , UTZSCHNEIDER KRISTINA , PIHOKER CATHERINE 
Published: June 2019

Background: Continuous glucose monitoring (CGM) systems are increasing in use among youth with type 1 diabetes; however, the feasibility of wearing an unblinded, real-time CGM has not been studied in youth with type 2 diabetes. The aims of this study are to evaluate the feasibility of CGM and to explore its effects on lifestyle behaviors and glycemic control among youth with type 2 diabetes.
Methods: Youth ages 12-19 years (n=17) with type 2 diabetes participated in a prospective cohort intervention study with Dexcom G6 CGM. For baseline data, participants wore a blinded CGM for the 1st week and unblinded CGM for the 2nd and 6th weeks. Glycemic and metabolic measures (glucose, insulin, c-peptide, hemoglobin A1C, fructosamine, 1,5 anhydroglucitol, lipids), 24-hour food recalls, and Youth Eating Disorder Questionnaires (YEDE-Q) were collected at baseline and conclusion of study.
Results: Eight participants have completed the study to date (4F/4M, mean age 15.7 years, BMI mean 32.6 kg/m2); data on metabolic measures, food recall, YEDE-Q are pending. See Table 1.
Conclusion: Based on this pilot study, CGM use among youth with type 2 diabetes is feasible and acceptable. Larger studies of longer duration are needed to demonstrate whether real-time CGM can improve glycemic control and lifestyle behaviors in this population.

Disclosure
A. LaRoche: None. K. Utzschneider: Consultant; Self; Novo Nordisk Inc. C. Pihoker: None.

Funding
National Institutes of Health (DK007247)
98-LB: Efficacy and Clinical Considerations of Flash Glucose Monitoring among Canadian Adults with Diabetes
Authors: JAZDAREHEE ARIA , KAPELUTO JORDANNA E. , PAWLOWSKA MONIKA , PAWLOWSKA MONIKA , MACKENZIE-FEDER JESSICA , SCHROEDER BENJAMIN , WHITE ADAM 
Published: June 2019

The FreeStyle Libre flash glucose monitoring (FGM) system was introduced in Canada in 2017. FGM incorporates aspects of conventional blood glucose testing and continuous glucose monitoring (CGM). The FreeStyle Libre utilizes a sensor placed on the upper arm to test interstitial glucose levels every fifteen minutes and may be used to obtain a ‘flash’ (real-time) reading. The FreeStyle Libre system is less costly than CGM and may help overcome common barriers to conventional glucose testing, including pain, needle aversion, and inconvenience, but at present there is no public coverage for the product available in Canada. In this study, we investigated the continuation rate of FGM use in patients provided complimentary FreeStyle Libre starter packs, consisting of one reader and two 14-day sensors, and the impact of continued use on glycemic control. More than half (21/40) continued to use the system beyond the trial period. The mean A1C of patients who continued using FGM decreased by 1.14% at three months, compared to an increase of 0.17% in those who did not (p=0.038). Despite small sample size, there was also a trend of decreased basal and bolus insulin requirements in patients continuing use. These results show benefit and support the implementation of public coverage because greater adherence of self-monitoring of blood glucose results in improved glycemic control which ultimately reduces the risk of long-term diabetes associated complications and healthcare costs.

Disclosure
A. Jazdarehee: None. J.E. Kapeluto: None. M. Pawlowska: None. J. MacKenzie-Feder: None. B. Schroeder: Advisory Panel; Self; Abbott, Boehringer Ingelheim Pharmaceuticals, Inc., Janssen Pharmaceuticals, Inc., LifeScan Canada, Natesto, Sanofi-Aventis. Speaker’s Bureau; Self; AstraZeneca, Eli Lilly and Company, Merck & Co., Inc., Novo Nordisk Inc. A. White: Advisory Panel; Self; Abbott, AstraZeneca, Boehringer Ingelheim Pharmaceuticals, Inc., Janssen Pharmaceuticals, Inc., Lilly Diabetes, Novo Nordisk Inc., Sanofi. Speaker’s Bureau; Self; Merck & Co., Inc. Other Relationship; Self; Diabetes Canada.
994-P: Effects of Dulaglutide and Trelagliptin on ß-Cell Function after One Year in Patients with Type 2 Diabetes: DUET-Beta Extension Study
Authors: KONDO YOSHINOBU , SATOH SHINOBU , TERAUCHI YASUO 
Published: June 2019

Studies on glucagon-like peptide 1 receptor agonists (GLP-1-RA) and dipeptidyl peptidase-4 inhibitors (DPP-4-I) have suggested positive effects on beta-cells. However, direct comparison between weekly GLP-1-RA: dulaglutide (Dula) and weekly DPP-4-I: trelagliptin (Trela) effects on beta-cell function is not known. Thus, we compared the effects of Dula and Trela on beta-cell function in patients with type 2 diabetes (T2D) in an open-label, parallel-group, randomized controlled 24-week trial, with an additional 28 weeks of extension follow-up. Beta-cell function and insulin resistance were assessed by HOMA2-%β and HOMA2-IR, respectively. Body composition was also assessed by the bioelectrical impedance method. Fifty metformin ± basal insulin-treated patients with type 2 diabetes (T2D) were randomized to Dula 0.75 mg/week or Trela 100 mg/week. Forty-eight patients entered the 28-weeks extension study and continued their allocated therapy. Forty-six completed (Dula: n = 23, Trela: n = 23) the 52-week exposure and were included in the analysis. HOMA2-%β was higher in the Dula group than in the Trela group throughout the 52 weeks (24 weeks: Dula: +50.6 ± 9.9% vs. Trela: +7.5 ± 9.5%, p = 0.003; 52 weeks: Dula: +54.5 ± 8.7% vs. Trela: +3.0 ± 8.7%, p &lt;0.001). HOMA2-IR was not significantly different between both groups (24 weeks: Dula: -0.29 ± 0.50 vs. Trela: -0.19 ± 0.50, p = 0.88; 52 weeks: Dula: +0.79 ± 0.52 vs. Trela: +0.45 ± 0.52, p = 0.64). At 52 weeks, HbA1c had a larger decrease with the Dula group (Dula: -0.52 ± 0.11%, Trela: -0.13 ± 0.12%, p = 0.02). Body fat mass was reduced more in the Dula group than the Trela group (52 weeks: Dula: -1.5 ± 0.3 kg vs. Trela: +0.4 ± 0.3 kg, p &lt;0.001). However, Dula patients did not have a reduction in skeletal muscle mass (52 weeks: 0.0 ± 0.3 kg, p = 0.94).
In conclusion, Dula increased HOMA2-%β level more than Trela over the 52 weeks, without a significant change in HOMA2-IR level. Dula reduced body fat mass without skeletal muscle mass loss.

Disclosure
Y. Kondo: None. S. Satoh: None. Y. Terauchi: Advisory Panel; Self; AstraZeneca, Daiichi Sankyo Company, Limited, Eli Lilly and Company, Merck Sharp & Dohme Corp., Mitsubishi Tanabe Pharma Corporation, Novo Nordisk A/S, Sanofi. Research Support; Self; Daiichi Sankyo Company, Limited, Eli Lilly and Company, Merck Sharp & Dohme Corp., Novartis Pharmaceuticals Corporation, Novo Nordisk A/S, Ono Pharmaceutical Co., Ltd., Sanofi, Shionogi & Co., Ltd., Sumitomo Dainippon Pharma Co., Ltd. Speaker's Bureau; Self; Astellas Pharma Inc., AstraZeneca, Bayer Yakuhin, Ltd., Daiichi Sankyo Company, Limited, Eli Lilly and Company, Merck Sharp & Dohme Corp., Mitsubishi Tanabe Pharma Corporation, Novartis Pharmaceuticals Corporation, Novo Nordisk A/S, Ono Pharmaceutical Co., Ltd., Sanofi, Sanwa Kagaku Kenkyusho, Shionogi & Co., Ltd., Sumitomo Dainippon Pharma Co., Ltd.
998-P: Efficacy and Safety of Semaglutide by Baseline BMI in SUSTAIN 1-5 and 7
Authors: VILJOEN ADIE , FRIAS JUAN P. , GONDOLF THEIS , HANSEN OLUF , WIJAYASINGHE NELUN , UNGER JEFF 
Published: June 2019

Semaglutide, a once-weekly glucagon-like peptide-1 analog for type 2 diabetes, showed significant, clinically meaningful reductions in HbA1c and body weight in the SUSTAIN clinical trial program. Higher body mass index (BMI) at baseline (BL) was associated with greater weight loss during semaglutide therapy. This post hoc analysis evaluated change in HbA1c by BL BMI (&lt;25, 25-&lt;30, 30-&lt;35 and ≥35 kg/m2) for semaglutide vs. comparators by trial for SUSTAIN 1-5 and 7. Safety data were pooled and analyzed stratified by trial. Reductions in mean HbA1c (%) from BL were greater in all BMI subgroups with semaglutide vs. comparators (Figure). There were no significant interactions between treatment and BMI, indicating a consistent effect of semaglutide vs. comparator on change in HbA1c across BMI subgroups. In all treatment arms, adverse events (AEs) occurred in a similar proportion of subjects across BMI subgroups. Gastrointestinal AEs were higher with semaglutide, but decreased with increasing BL BMI, vs. comparators (semaglutide: &lt;25 kg/m2=48.8%, 25-&lt;30 kg/m2=43.0%, 30-&lt;35 kg/m2=39.4% and ≥35 kg/m2 =39.3% vs. comparators range: 21.2-28.9%). Premature treatment discontinuation due to AEs was higher in all BMI subgroups with semaglutide vs. comparators (5.6-15.3% vs. 2.3-8.3%).
In conclusion, the efficacy of semaglutide in lowering HbA1c does not appear to be influenced by BL BMI. Semaglutide had an acceptable safety profile in all BMI subgroups.

Disclosure
A. Viljoen: Advisory Panel; Self; NAPP Pharmaceuticals Limited. Research Support; Self; Eli Lilly and Company, Sanofi-Aventis. Speaker's Bureau; Self; AstraZeneca, Boehringer Ingelheim Pharmaceuticals, Inc., Novo Nordisk A/S. J.P. Frias: Advisory Panel; Self; Becton, Dickinson and Company, Eli Lilly and Company, Gilead Sciences, Inc., Sanofi. Consultant; Self; Echosens, Genentech, Inc., Johnson & Johnson Diabetes Institute, Novo Nordisk Inc., Zafgen, Inc. Research Support; Self; AbbVie Inc., Akcea Therapeutics, Allergan, Amgen Inc., AstraZeneca, Bayer US, Boehringer Ingelheim Pharmaceuticals, Inc., Bristol-Myers Squibb Company, Cirius Therapeutics, Elcelyx Therapeutics, Inc., Eli Lilly and Company, Enanta Pharmaceuticals, Inc., GENFIT, Intarcia Therapeutics, Inc., Intercept Pharmaceuticals, Inc., Ionis Pharmaceuticals, Inc., Janssen Pharmaceuticals, Inc., Merck & Co., Inc., NGM Biopharmaceuticals, Novartis Pharmaceuticals Corporation, Novo Nordisk A/S, Oramed Pharmaceuticals, Pfizer Inc., Sanofi, TaiwanJ Pharmaceuticals Co., Ltd., Theracos, Inc. Speaker's Bureau; Self; Merck & Co., Inc., Sanofi. T. Gondolf: Employee; Spouse/Partner; Chr. Hansen Holding A/S. Employee; Self; Novo Nordisk A/S. O. Hansen: Employee; Self; Novo Nordisk A/S. N. Wijayasinghe: None. J. Unger: Advisory Panel; Self; Abbott Laboratories, Novo Nordisk Inc. Speaker's Bureau; Self; Janssen Pharmaceuticals, Inc.

Funding
Novo Nordisk A/S
The hidden cause of chronic finger pain: Glomus Tumor – A Case Report
Authors: Bordianu Anca ,   Bagdasar-Arseni Emergency Hospital, Plastic and Reconstructive Department, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania,   Anca Bordianu, MD, PhD, Department of Plastic and Reconstructive Surgery, “Bagdasar-Arseni” Emergency Hospital Bucharest, 10-12 Berceni Road, District 4, 41914, Bucharest, Romania Tel.: +40740-231 424; E-mail: anca.bordianu@gmail.com, Zamfirescu Dragos ,   Zetta Clinic, Plastic and Reconstructive Surgery Department, Bucharest, Romania
Published: June 2019

Glomus tumors are frequently associated with pain, tenderness and cold sensitivity.
We report the diagnosis and successful surgical management of a case of a classic glomus tumor in a young woman.
The clinical diagnosis was made on the basis of medical history and MRI findings. The lesion was excised via a dorsolateral subungual approach, leading to the complete resolution of symptoms. Histology confirmed the lesion to be a glomus tumor.
Glomus tumors are painful subungual lesions. They produce a throbbing or lancinating local discomfort, cold-sensitivity, and severe pain following minor trauma. The diagnosis is confirmed by histology, but the clinical diagnosis is highly suggestive. Complete excision will usually relieve pain. Recurrence is common following incomplete resection.