If it’s happening in Cincinnati, it is happening everywhere. All the young doctors are being hired by hospital systems at better pay than private practices can afford. When I asked the CEO at one Cincinnati hospital about the trend, he explained: “We like to have referrals available for our primary care physicians.” Sounds nice, but I don’t believe it.

Hospital outpatient facilities have been reaping the benefits of site-of-service differential payments for years. Under the current Centers for Medicare/Medicaid Services payment scales, identical services are reimbursed at extraordinarily higher rates – differentials amounting to, on average, approximately 360% of Medicare’s payment for the same mix of services when they are performed in a physician’s office – if they are delivered at off-campus hospital outpatient departments rather than independent doctors’ offices. Technically, these outpatient departments can be an office that has been bought by the hospital and proximity is not an issue. Many off-campus hospital outpatient departments in my area are as far away as 35 miles, some in strip malls no less!

That situation may soon change, though. The CMS has proposed eliminating the site-of-service differentials for hospital outpatient services. The proposal is being aggressively opposed by hospital lobbyists and has even inspired lawsuits because it would blow the lid off the extraordinary payment differential available to hospital outpatient departments (“Proposed site-neutral payment policy sets the stage for battle royale between CMS, hospitals,” Modern Healthcare, July 26, 2018).

It’s a change that’s long overdue.

In the period from 2001 to 2017, Medicare Part B payments to physicians increased only 6%, while Medicare’s index of inflation measuring the cost of running a medical practice increased 30%. After adjustment for inflation in practice costs, physician pay has declined 19%, thus failing to match increases in office overhead costs. In that same 17-year period, Medicare hospital payments increased roughly 50%, including average annual increases of 2.6% for inpatient services and 2.5% per year for outpatient services. Hospitals have thus received payment increases more than eightfold greater than payment adjustments to physicians in the period from 2001 to 2017!

I think we have found the secret sauce!

Obviously, some of this largesse was spread over the recruitment of physicians, buying offices, and creating of secret sauce clinics. Hospital purchases of private offices and physician employment at hospitals soared to nearly 33%.

But much went to the hospital’s bottom line.

Hospitals have enjoyed 28 annual year-over-year increases in payments for services rendered in hospital outpatient facilities.

Many of these hospital systems claim to make no extra money using the hospital outpatient system. If so, eliminating the site-of-service differential will not affect them. We will see.

I think the elimination of the site-of-service differential will have profound impacts on office medicine. While the AMA is asking that the savings (several billion over 10 years) be funneled back into the office setting to correct past underpayments, just the correction of the distortion will benefit office practice. The recruitment of new physicians by hospitals, and the practice-buying binge, appear to have subsided. Expect many of these satellites to close, and their employed physicians, young and old, to be coming back into the job market. Expect Medicare beneficiaries to pay lower copays and deductibles.

Corrections of distortions like the site-of-service differential empower patients and independent physicians. Thank the AMA for exposing the unfairness and allowing the CMS to act. You may not know it, but the American Medical Association puts together a tremendous – some would say overwhelming – amount of research together on topics of importance to physicians. Some of this is fascinating. I direct you to the AMA’s Report 4 of the Council on Medical Service (I-18)

This report lays it all out, and explains what has happened.

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at [email protected].

If it’s happening in Cincinnati, it is happening everywhere. All the young doctors are being hired by hospital systems at better pay than private practices can afford. When I asked the CEO at one Cincinnati hospital about the trend, he explained: “We like to have referrals available for our primary care physicians.” Sounds nice, but I don’t believe it.

Hospital outpatient facilities have been reaping the benefits of site-of-service differential payments for years. Under the current Centers for Medicare/Medicaid Services payment scales, identical services are reimbursed at extraordinarily higher rates – differentials amounting to, on average, approximately 360% of Medicare’s payment for the same mix of services when they are performed in a physician’s office – if they are delivered at off-campus hospital outpatient departments rather than independent doctors’ offices. Technically, these outpatient departments can be an office that has been bought by the hospital and proximity is not an issue. Many off-campus hospital outpatient departments in my area are as far away as 35 miles, some in strip malls no less!

That situation may soon change, though. The CMS has proposed eliminating the site-of-service differentials for hospital outpatient services. The proposal is being aggressively opposed by hospital lobbyists and has even inspired lawsuits because it would blow the lid off the extraordinary payment differential available to hospital outpatient departments (“Proposed site-neutral payment policy sets the stage for battle royale between CMS, hospitals,” Modern Healthcare, July 26, 2018).

It’s a change that’s long overdue.

In the period from 2001 to 2017, Medicare Part B payments to physicians increased only 6%, while Medicare’s index of inflation measuring the cost of running a medical practice increased 30%. After adjustment for inflation in practice costs, physician pay has declined 19%, thus failing to match increases in office overhead costs. In that same 17-year period, Medicare hospital payments increased roughly 50%, including average annual increases of 2.6% for inpatient services and 2.5% per year for outpatient services. Hospitals have thus received payment increases more than eightfold greater than payment adjustments to physicians in the period from 2001 to 2017!

I think we have found the secret sauce!

Obviously, some of this largesse was spread over the recruitment of physicians, buying offices, and creating of secret sauce clinics. Hospital purchases of private offices and physician employment at hospitals soared to nearly 33%.

But much went to the hospital’s bottom line.

Hospitals have enjoyed 28 annual year-over-year increases in payments for services rendered in hospital outpatient facilities.

Many of these hospital systems claim to make no extra money using the hospital outpatient system. If so, eliminating the site-of-service differential will not affect them. We will see.

I think the elimination of the site-of-service differential will have profound impacts on office medicine. While the AMA is asking that the savings (several billion over 10 years) be funneled back into the office setting to correct past underpayments, just the correction of the distortion will benefit office practice. The recruitment of new physicians by hospitals, and the practice-buying binge, appear to have subsided. Expect many of these satellites to close, and their employed physicians, young and old, to be coming back into the job market. Expect Medicare beneficiaries to pay lower copays and deductibles.

Corrections of distortions like the site-of-service differential empower patients and independent physicians. Thank the AMA for exposing the unfairness and allowing the CMS to act. You may not know it, but the American Medical Association puts together a tremendous – some would say overwhelming – amount of research together on topics of importance to physicians. Some of this is fascinating. I direct you to the AMA’s Report 4 of the Council on Medical Service (I-18)

This report lays it all out, and explains what has happened.

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at [email protected].

If it’s happening in Cincinnati, it is happening everywhere. All the young doctors are being hired by hospital systems at better pay than private practices can afford. When I asked the CEO at one Cincinnati hospital about the trend, he explained: “We like to have referrals available for our primary care physicians.” Sounds nice, but I don’t believe it.

Hospital outpatient facilities have been reaping the benefits of site-of-service differential payments for years. Under the current Centers for Medicare/Medicaid Services payment scales, identical services are reimbursed at extraordinarily higher rates – differentials amounting to, on average, approximately 360% of Medicare’s payment for the same mix of services when they are performed in a physician’s office – if they are delivered at off-campus hospital outpatient departments rather than independent doctors’ offices. Technically, these outpatient departments can be an office that has been bought by the hospital and proximity is not an issue. Many off-campus hospital outpatient departments in my area are as far away as 35 miles, some in strip malls no less!

That situation may soon change, though. The CMS has proposed eliminating the site-of-service differentials for hospital outpatient services. The proposal is being aggressively opposed by hospital lobbyists and has even inspired lawsuits because it would blow the lid off the extraordinary payment differential available to hospital outpatient departments (“Proposed site-neutral payment policy sets the stage for battle royale between CMS, hospitals,” Modern Healthcare, July 26, 2018).

It’s a change that’s long overdue.

In the period from 2001 to 2017, Medicare Part B payments to physicians increased only 6%, while Medicare’s index of inflation measuring the cost of running a medical practice increased 30%. After adjustment for inflation in practice costs, physician pay has declined 19%, thus failing to match increases in office overhead costs. In that same 17-year period, Medicare hospital payments increased roughly 50%, including average annual increases of 2.6% for inpatient services and 2.5% per year for outpatient services. Hospitals have thus received payment increases more than eightfold greater than payment adjustments to physicians in the period from 2001 to 2017!

I think we have found the secret sauce!

Obviously, some of this largesse was spread over the recruitment of physicians, buying offices, and creating of secret sauce clinics. Hospital purchases of private offices and physician employment at hospitals soared to nearly 33%.

But much went to the hospital’s bottom line.

Hospitals have enjoyed 28 annual year-over-year increases in payments for services rendered in hospital outpatient facilities.

Many of these hospital systems claim to make no extra money using the hospital outpatient system. If so, eliminating the site-of-service differential will not affect them. We will see.

I think the elimination of the site-of-service differential will have profound impacts on office medicine. While the AMA is asking that the savings (several billion over 10 years) be funneled back into the office setting to correct past underpayments, just the correction of the distortion will benefit office practice. The recruitment of new physicians by hospitals, and the practice-buying binge, appear to have subsided. Expect many of these satellites to close, and their employed physicians, young and old, to be coming back into the job market. Expect Medicare beneficiaries to pay lower copays and deductibles.

Corrections of distortions like the site-of-service differential empower patients and independent physicians. Thank the AMA for exposing the unfairness and allowing the CMS to act. You may not know it, but the American Medical Association puts together a tremendous – some would say overwhelming – amount of research together on topics of importance to physicians. Some of this is fascinating. I direct you to the AMA’s Report 4 of the Council on Medical Service (I-18)

This report lays it all out, and explains what has happened.

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at [email protected].

SAN FRANCISCO – Nearly half of all childhood-onset SLE occurs in patients born during the winter months, Simone Appenzeller, MD, PhD, reported at an international congress on systemic lupus erythematosus.

Bruce Jancin/MDedge News

She presented a cross-sectional study of 760 consecutive SLE patients seen in a university lupus clinic and 700 healthy controls. Ninety-eight of the lupus patients had childhood-onset disease that began no later than age 16 years, while 662 had adult-onset SLE.

Southeastern Brazil, where the study was conducted, features a mostly subtropical climate with relatively mild winters. Because it is in the southern hemisphere, winter lasts from June 21 to September 21, while spring runs from September 22 to December 20.

Forty-six percent of subjects with childhood-onset SLE were born in winter, 17% in spring, another 17% in summer, and just over 19% in autumn, according to Dr. Appenzeller, a rheumatologist at the University of Campinas (Brazil).

In contrast, the occurrence of adult-onset SLE showed no variation by birth month or season.

The birth disparity between childhood- and adult-onset SLE was greatest in August, the depth of Brazilian winter, when 15.3% of all subjects with childhood-onset SLE were born, compared with 9% of adult-onset SLE patients and 8% of healthy controls.

The explanation for the increased likelihood of patients with childhood-onset SLE to be born in the winter months probably involves a gene-environment interaction, Dr. Appenzeller said. The most likely environmental factors are low seasonal maternal vitamin D levels and/or exposure to winter respiratory infections. The existence of a genetic component to the birth month disparity is suggested by another study by the Brazilian investigators in which they determined that the prevalence of SLE in both the first- and second-degree relatives of individuals with childhood-onset SLE was significantly higher than in patients with adult-onset disease.

Dr. Appenzeller reported having no financial conflicts regarding her study, funded by the Brazilian National Council for Scientific and Technological Development and other noncommercial research organizations.

[email protected]

SAN FRANCISCO – Nearly half of all childhood-onset SLE occurs in patients born during the winter months, Simone Appenzeller, MD, PhD, reported at an international congress on systemic lupus erythematosus.

Bruce Jancin/MDedge News

She presented a cross-sectional study of 760 consecutive SLE patients seen in a university lupus clinic and 700 healthy controls. Ninety-eight of the lupus patients had childhood-onset disease that began no later than age 16 years, while 662 had adult-onset SLE.

Southeastern Brazil, where the study was conducted, features a mostly subtropical climate with relatively mild winters. Because it is in the southern hemisphere, winter lasts from June 21 to September 21, while spring runs from September 22 to December 20.

Forty-six percent of subjects with childhood-onset SLE were born in winter, 17% in spring, another 17% in summer, and just over 19% in autumn, according to Dr. Appenzeller, a rheumatologist at the University of Campinas (Brazil).

In contrast, the occurrence of adult-onset SLE showed no variation by birth month or season.

The birth disparity between childhood- and adult-onset SLE was greatest in August, the depth of Brazilian winter, when 15.3% of all subjects with childhood-onset SLE were born, compared with 9% of adult-onset SLE patients and 8% of healthy controls.

The explanation for the increased likelihood of patients with childhood-onset SLE to be born in the winter months probably involves a gene-environment interaction, Dr. Appenzeller said. The most likely environmental factors are low seasonal maternal vitamin D levels and/or exposure to winter respiratory infections. The existence of a genetic component to the birth month disparity is suggested by another study by the Brazilian investigators in which they determined that the prevalence of SLE in both the first- and second-degree relatives of individuals with childhood-onset SLE was significantly higher than in patients with adult-onset disease.

Dr. Appenzeller reported having no financial conflicts regarding her study, funded by the Brazilian National Council for Scientific and Technological Development and other noncommercial research organizations.

[email protected]

SAN FRANCISCO – Nearly half of all childhood-onset SLE occurs in patients born during the winter months, Simone Appenzeller, MD, PhD, reported at an international congress on systemic lupus erythematosus.

Bruce Jancin/MDedge News

She presented a cross-sectional study of 760 consecutive SLE patients seen in a university lupus clinic and 700 healthy controls. Ninety-eight of the lupus patients had childhood-onset disease that began no later than age 16 years, while 662 had adult-onset SLE.

Southeastern Brazil, where the study was conducted, features a mostly subtropical climate with relatively mild winters. Because it is in the southern hemisphere, winter lasts from June 21 to September 21, while spring runs from September 22 to December 20.

Forty-six percent of subjects with childhood-onset SLE were born in winter, 17% in spring, another 17% in summer, and just over 19% in autumn, according to Dr. Appenzeller, a rheumatologist at the University of Campinas (Brazil).

In contrast, the occurrence of adult-onset SLE showed no variation by birth month or season.

The birth disparity between childhood- and adult-onset SLE was greatest in August, the depth of Brazilian winter, when 15.3% of all subjects with childhood-onset SLE were born, compared with 9% of adult-onset SLE patients and 8% of healthy controls.

The explanation for the increased likelihood of patients with childhood-onset SLE to be born in the winter months probably involves a gene-environment interaction, Dr. Appenzeller said. The most likely environmental factors are low seasonal maternal vitamin D levels and/or exposure to winter respiratory infections. The existence of a genetic component to the birth month disparity is suggested by another study by the Brazilian investigators in which they determined that the prevalence of SLE in both the first- and second-degree relatives of individuals with childhood-onset SLE was significantly higher than in patients with adult-onset disease.

Dr. Appenzeller reported having no financial conflicts regarding her study, funded by the Brazilian National Council for Scientific and Technological Development and other noncommercial research organizations.

[email protected]

Hurray! We’re getting a version update of our electronic medical record (EMR) this month. Of course, I might be overplaying my excitement here: EMR updates are emotionally closest to a trip to the dentist – usually turn out fine, but hardly worth circling on the calendar.

copyright BrianAJackson/Thinkstock

Like a good dental cleaning however, these updates can be beneficial. Although uncomfortable, EMR redesigned menus and shortcuts can help – once you’re used to them. It typically doesn’t take long for most of us to learn the “improvements” so we’re at least not worse off. It is also a good time to update customized features. I try to use updates as an opportunity to refresh SmartPhrases, update order preferences, or rearrange my desktop to be more efficient.

Given how much my quality of life depends upon my EMR skills, it’s a shame I don’t make an effort to work on it more often. Really, why wait to make improvements just once a year? Why not get better every day?

This idea of continuous improvement is a popular meme in the self-improvement community right now. Instead of working on goals or adjusting your routine episodically, set an intention to get better, just a little, daily. Sometimes it’s described as the 1% model. The idea is that improving your habits or work flow by 1% each day will yield compound benefits with time. It is an aggregation of marginal gains with a surprising payout. For example, daily 1% improvements would mean you are 37 times more effective by the end of a year. Now, I don’t believe this mathematical model is necessarily accurate or even necessary. But the concept that a little development done daily yields lasting improvement seems to be true.

The corollary, that if you got a little worse each day, you’d be much worse off at the end of a year, is also reasonable. That’s how most health problems set in: continuous and insidious aggregation of bad choices. Why then not use that same principle for good instead?

The Japanese thought of this idea a generation ago. Applied to manufacturing, they called it Kaizen, “continuous improvement.” It was a managerial principle that reminded people to look for opportunities to improve, just a little, wherever they were in the process and to do so each day. It led to remarkable reductions in waste and became a key to their economic success.

Opportunities for relentless improvement abound in our work too. For example, when you write an order or work up a diagnosis, rather than just enter it, you might save it as a panel. When you find yourself using the same word or phrase, save it to your dictionary to pull it up with minimal keystrokes. When you research a difficult disease you’ve not seen lately, save the diagnostic questions as a template so you can pull it up in real time the next time it walks in. When you set up your procedure tray, place items so they can be picked up efficiently and moved out of the way quickly. No matter how good your setup or template is today, you can find a tiny improvement that would make it a little better tomorrow. And you’ll reap gains from that day forward.

I don’t expect this EMR update will have much impact on my quality of life. It will however be a reminder that like flossing, improvements are best done daily. You and your dentist will thank me someday.
 

Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].

Hurray! We’re getting a version update of our electronic medical record (EMR) this month. Of course, I might be overplaying my excitement here: EMR updates are emotionally closest to a trip to the dentist – usually turn out fine, but hardly worth circling on the calendar.

copyright BrianAJackson/Thinkstock

Like a good dental cleaning however, these updates can be beneficial. Although uncomfortable, EMR redesigned menus and shortcuts can help – once you’re used to them. It typically doesn’t take long for most of us to learn the “improvements” so we’re at least not worse off. It is also a good time to update customized features. I try to use updates as an opportunity to refresh SmartPhrases, update order preferences, or rearrange my desktop to be more efficient.

Given how much my quality of life depends upon my EMR skills, it’s a shame I don’t make an effort to work on it more often. Really, why wait to make improvements just once a year? Why not get better every day?

This idea of continuous improvement is a popular meme in the self-improvement community right now. Instead of working on goals or adjusting your routine episodically, set an intention to get better, just a little, daily. Sometimes it’s described as the 1% model. The idea is that improving your habits or work flow by 1% each day will yield compound benefits with time. It is an aggregation of marginal gains with a surprising payout. For example, daily 1% improvements would mean you are 37 times more effective by the end of a year. Now, I don’t believe this mathematical model is necessarily accurate or even necessary. But the concept that a little development done daily yields lasting improvement seems to be true.

The corollary, that if you got a little worse each day, you’d be much worse off at the end of a year, is also reasonable. That’s how most health problems set in: continuous and insidious aggregation of bad choices. Why then not use that same principle for good instead?

The Japanese thought of this idea a generation ago. Applied to manufacturing, they called it Kaizen, “continuous improvement.” It was a managerial principle that reminded people to look for opportunities to improve, just a little, wherever they were in the process and to do so each day. It led to remarkable reductions in waste and became a key to their economic success.

Opportunities for relentless improvement abound in our work too. For example, when you write an order or work up a diagnosis, rather than just enter it, you might save it as a panel. When you find yourself using the same word or phrase, save it to your dictionary to pull it up with minimal keystrokes. When you research a difficult disease you’ve not seen lately, save the diagnostic questions as a template so you can pull it up in real time the next time it walks in. When you set up your procedure tray, place items so they can be picked up efficiently and moved out of the way quickly. No matter how good your setup or template is today, you can find a tiny improvement that would make it a little better tomorrow. And you’ll reap gains from that day forward.

I don’t expect this EMR update will have much impact on my quality of life. It will however be a reminder that like flossing, improvements are best done daily. You and your dentist will thank me someday.
 

Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].

Hurray! We’re getting a version update of our electronic medical record (EMR) this month. Of course, I might be overplaying my excitement here: EMR updates are emotionally closest to a trip to the dentist – usually turn out fine, but hardly worth circling on the calendar.

copyright BrianAJackson/Thinkstock

Like a good dental cleaning however, these updates can be beneficial. Although uncomfortable, EMR redesigned menus and shortcuts can help – once you’re used to them. It typically doesn’t take long for most of us to learn the “improvements” so we’re at least not worse off. It is also a good time to update customized features. I try to use updates as an opportunity to refresh SmartPhrases, update order preferences, or rearrange my desktop to be more efficient.

Given how much my quality of life depends upon my EMR skills, it’s a shame I don’t make an effort to work on it more often. Really, why wait to make improvements just once a year? Why not get better every day?

This idea of continuous improvement is a popular meme in the self-improvement community right now. Instead of working on goals or adjusting your routine episodically, set an intention to get better, just a little, daily. Sometimes it’s described as the 1% model. The idea is that improving your habits or work flow by 1% each day will yield compound benefits with time. It is an aggregation of marginal gains with a surprising payout. For example, daily 1% improvements would mean you are 37 times more effective by the end of a year. Now, I don’t believe this mathematical model is necessarily accurate or even necessary. But the concept that a little development done daily yields lasting improvement seems to be true.

The corollary, that if you got a little worse each day, you’d be much worse off at the end of a year, is also reasonable. That’s how most health problems set in: continuous and insidious aggregation of bad choices. Why then not use that same principle for good instead?

The Japanese thought of this idea a generation ago. Applied to manufacturing, they called it Kaizen, “continuous improvement.” It was a managerial principle that reminded people to look for opportunities to improve, just a little, wherever they were in the process and to do so each day. It led to remarkable reductions in waste and became a key to their economic success.

Opportunities for relentless improvement abound in our work too. For example, when you write an order or work up a diagnosis, rather than just enter it, you might save it as a panel. When you find yourself using the same word or phrase, save it to your dictionary to pull it up with minimal keystrokes. When you research a difficult disease you’ve not seen lately, save the diagnostic questions as a template so you can pull it up in real time the next time it walks in. When you set up your procedure tray, place items so they can be picked up efficiently and moved out of the way quickly. No matter how good your setup or template is today, you can find a tiny improvement that would make it a little better tomorrow. And you’ll reap gains from that day forward.

I don’t expect this EMR update will have much impact on my quality of life. It will however be a reminder that like flossing, improvements are best done daily. You and your dentist will thank me someday.
 

Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].

Benign tumors consisting of glomus cells may be subdivided into two types: glomus tumors and glomuvenous malformations or glomangiomas. Glomus cells are modified smooth muscle cells that normally line the Sucquet-Hoyer canal, an arteriovenous fistula that is involved in temperature regulation in the digits.

In adults, solitary glomus tumors are more common and are sporadically inherited. Upper extremities are often affected. In women, lesions more frequently occur on the fingers (especially nail beds). Glomus tumors are firm subcutaneous nodules, often skin colored or bluish in color. Subungual tumors tend to appear bluish under the nail plate. Lesions are extremely tender or painful, with worse pain upon palpation. Occasionally, nontender lesions can be seen.

In children, multiple nontender lesions are called glomangiomas or glomuvenous malformations. They may be sporadic or can be inherited in an autosomal dominant fashion due to a mutation in glomulin on chromosome 1p21-p22. Multiple lesions may be scattered or grouped, often in a segmental distribution. Congenital lesions tend to be large, blue-purple in color with a cobblestone appearance. They are more superficial than venous malformations.

Histologically, a proliferation of blood vessels surrounded by glomus cells is seen. Glomus cells appear as monotonous cells with a dense, round nucleus and abundant pink cytoplasm. Glomus cells can also be appreciated single-filing through pale stroma, resembling strings of black pearls. Glomus cells stain positive for smooth muscle actin and vimentin.

The painful tumor differential diagnosis has been described in the literature by the mnemonic “LEND AN EGG:” leiomyoma, eccrine spiradenoma, neuroma, dermatofibroma, angiolipoma, neurilemmoma, endometrioma, glomus tumor, and granular cell tumor.

The malignant counterpart is glomangiosarcoma, which is a rare tumor. These lesions are often large and deeply located on the extremities. Histologically, sarcomatous areas are mixed with areas of benign glomus tumor.

Surgical excision is the treatment of choice for solitary glomus tumors to provide pain relief. Subungual tumors are more challenging due to their small size, but may be excised as well. Glomuvenous malformations may require different treatment modalities, such as surgery and laser, due to their larger size.

This case and photo were submitted by Dr. Bilu Martin.

Dr. Bilu Martin is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Fla. More diagnostic cases are available at www.mdedge.com/dermatology. To submit a case for possible publication, send an email to [email protected].

Benign tumors consisting of glomus cells may be subdivided into two types: glomus tumors and glomuvenous malformations or glomangiomas. Glomus cells are modified smooth muscle cells that normally line the Sucquet-Hoyer canal, an arteriovenous fistula that is involved in temperature regulation in the digits.

In adults, solitary glomus tumors are more common and are sporadically inherited. Upper extremities are often affected. In women, lesions more frequently occur on the fingers (especially nail beds). Glomus tumors are firm subcutaneous nodules, often skin colored or bluish in color. Subungual tumors tend to appear bluish under the nail plate. Lesions are extremely tender or painful, with worse pain upon palpation. Occasionally, nontender lesions can be seen.

In children, multiple nontender lesions are called glomangiomas or glomuvenous malformations. They may be sporadic or can be inherited in an autosomal dominant fashion due to a mutation in glomulin on chromosome 1p21-p22. Multiple lesions may be scattered or grouped, often in a segmental distribution. Congenital lesions tend to be large, blue-purple in color with a cobblestone appearance. They are more superficial than venous malformations.

Histologically, a proliferation of blood vessels surrounded by glomus cells is seen. Glomus cells appear as monotonous cells with a dense, round nucleus and abundant pink cytoplasm. Glomus cells can also be appreciated single-filing through pale stroma, resembling strings of black pearls. Glomus cells stain positive for smooth muscle actin and vimentin.

The painful tumor differential diagnosis has been described in the literature by the mnemonic “LEND AN EGG:” leiomyoma, eccrine spiradenoma, neuroma, dermatofibroma, angiolipoma, neurilemmoma, endometrioma, glomus tumor, and granular cell tumor.

The malignant counterpart is glomangiosarcoma, which is a rare tumor. These lesions are often large and deeply located on the extremities. Histologically, sarcomatous areas are mixed with areas of benign glomus tumor.

Surgical excision is the treatment of choice for solitary glomus tumors to provide pain relief. Subungual tumors are more challenging due to their small size, but may be excised as well. Glomuvenous malformations may require different treatment modalities, such as surgery and laser, due to their larger size.

This case and photo were submitted by Dr. Bilu Martin.

Dr. Bilu Martin is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Fla. More diagnostic cases are available at www.mdedge.com/dermatology. To submit a case for possible publication, send an email to [email protected].

Benign tumors consisting of glomus cells may be subdivided into two types: glomus tumors and glomuvenous malformations or glomangiomas. Glomus cells are modified smooth muscle cells that normally line the Sucquet-Hoyer canal, an arteriovenous fistula that is involved in temperature regulation in the digits.

In adults, solitary glomus tumors are more common and are sporadically inherited. Upper extremities are often affected. In women, lesions more frequently occur on the fingers (especially nail beds). Glomus tumors are firm subcutaneous nodules, often skin colored or bluish in color. Subungual tumors tend to appear bluish under the nail plate. Lesions are extremely tender or painful, with worse pain upon palpation. Occasionally, nontender lesions can be seen.

In children, multiple nontender lesions are called glomangiomas or glomuvenous malformations. They may be sporadic or can be inherited in an autosomal dominant fashion due to a mutation in glomulin on chromosome 1p21-p22. Multiple lesions may be scattered or grouped, often in a segmental distribution. Congenital lesions tend to be large, blue-purple in color with a cobblestone appearance. They are more superficial than venous malformations.

Histologically, a proliferation of blood vessels surrounded by glomus cells is seen. Glomus cells appear as monotonous cells with a dense, round nucleus and abundant pink cytoplasm. Glomus cells can also be appreciated single-filing through pale stroma, resembling strings of black pearls. Glomus cells stain positive for smooth muscle actin and vimentin.

The painful tumor differential diagnosis has been described in the literature by the mnemonic “LEND AN EGG:” leiomyoma, eccrine spiradenoma, neuroma, dermatofibroma, angiolipoma, neurilemmoma, endometrioma, glomus tumor, and granular cell tumor.

The malignant counterpart is glomangiosarcoma, which is a rare tumor. These lesions are often large and deeply located on the extremities. Histologically, sarcomatous areas are mixed with areas of benign glomus tumor.

Surgical excision is the treatment of choice for solitary glomus tumors to provide pain relief. Subungual tumors are more challenging due to their small size, but may be excised as well. Glomuvenous malformations may require different treatment modalities, such as surgery and laser, due to their larger size.

This case and photo were submitted by Dr. Bilu Martin.

Dr. Bilu Martin is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Fla. More diagnostic cases are available at www.mdedge.com/dermatology. To submit a case for possible publication, send an email to [email protected].

Background: As frequency of imaging studies increases, and those studies become more advanced, incidental findings on imaging are a growing concern. Incidentalomas can lead to anxiety for patients, increased testing, and possible interventions such as biopsies. Current literature does not provide adequate guidance for providers to discuss the risks of incidentalomas with patients, nor are there clear methods described to manage incidentalomas when discovered.

Limitations included variations in how primary study authors defined a positive result and in imaging protocols. Although the authors of this study used primary data extracted from the individual studies in the systematic reviews, they did not analyze the primary studies for inclusion based on methods.

Bottom line: This study provides guidance to clinicians regarding counseling patients on the risks of incidentalomas and how to manage those incidental findings.

Citation: O’Sullivan JW et al. Prevalence and outcomes of incidental imaging findings: umbrella review. BMJ. 2018 Jun 18. doi: 10.1136/bmj.k2387.

Dr. Witt is an assistant professor of medicine in the division of hospital medicine at Emory University, Atlanta.

Background: As frequency of imaging studies increases, and those studies become more advanced, incidental findings on imaging are a growing concern. Incidentalomas can lead to anxiety for patients, increased testing, and possible interventions such as biopsies. Current literature does not provide adequate guidance for providers to discuss the risks of incidentalomas with patients, nor are there clear methods described to manage incidentalomas when discovered.

Limitations included variations in how primary study authors defined a positive result and in imaging protocols. Although the authors of this study used primary data extracted from the individual studies in the systematic reviews, they did not analyze the primary studies for inclusion based on methods.

Bottom line: This study provides guidance to clinicians regarding counseling patients on the risks of incidentalomas and how to manage those incidental findings.

Citation: O’Sullivan JW et al. Prevalence and outcomes of incidental imaging findings: umbrella review. BMJ. 2018 Jun 18. doi: 10.1136/bmj.k2387.

Dr. Witt is an assistant professor of medicine in the division of hospital medicine at Emory University, Atlanta.

Background: As frequency of imaging studies increases, and those studies become more advanced, incidental findings on imaging are a growing concern. Incidentalomas can lead to anxiety for patients, increased testing, and possible interventions such as biopsies. Current literature does not provide adequate guidance for providers to discuss the risks of incidentalomas with patients, nor are there clear methods described to manage incidentalomas when discovered.

Limitations included variations in how primary study authors defined a positive result and in imaging protocols. Although the authors of this study used primary data extracted from the individual studies in the systematic reviews, they did not analyze the primary studies for inclusion based on methods.

Bottom line: This study provides guidance to clinicians regarding counseling patients on the risks of incidentalomas and how to manage those incidental findings.

Citation: O’Sullivan JW et al. Prevalence and outcomes of incidental imaging findings: umbrella review. BMJ. 2018 Jun 18. doi: 10.1136/bmj.k2387.

Dr. Witt is an assistant professor of medicine in the division of hospital medicine at Emory University, Atlanta.

SAN FRANCISCO – Falls figured prominently in the elevated fracture risk of SLE patients in a Dutch prospective longitudinal study, Irene E.M. Bultink, MD, PhD, reported at an international congress on systemic lupus erythematosus.

Bruce Jancin/MDedge News

“I think we should focus on fall risk and fall events in lupus. I think that’s a neglected area,” according to Dr. Bultink, a rheumatologist at the University of Amsterdam.

Contrary to the conventional wisdom, in her study, cumulative corticosteroid dose, average daily dosage, and bone loss were not significantly related to fracture risk in these SLE patients. That’s because Dr. Bultink and her fellow rheumatologists took steps to mitigate steroid-induced bone loss.

“We know steroids are very important for bone loss in lupus, but we demonstrated in our long-term follow-up study that it’s very dose dependent. If you use steroids below 7.5 mg daily and you protect your patient with calcium and vitamin D and, if possible, with bisphosphonates, the bone loss is restricted. I think fracture risk in lupus is more related to fall risk and fall incidence than to bone loss and steroid use. That’s what we demonstrated in our study,” she said in an interview.

“Unfortunately, until now, no studies on fall risk and fall events in lupus have been published. It’s not investigated very well. I think that fall risk in lupus patients might be greatly increased, compared to healthy controls,” Dr. Bultink added.

The study included 145 Dutch SLE patients with a mean age of 41 years at baseline. Ninety percent were women; 69% were white. Bone mineral density measurements by dual x-ray bone densitometry and x-rays of the lumbar and thoracic spine were obtained at entry and again after a median of 5 years.

Forty-two incident fractures occurred during a median of 7.2 years of follow-up. This equated to an incidence rate of 2.2 peripheral and 2.0 vertebral fractures per 100 person-years, rates double those in the Dutch general population.

In a logistic regression analysis, white ethnicity was independently associated with a 13.2-fold increased risk of fractures overall. Postmenopausal status conferred a fourfold increased risk. Older age was another important determinant. And patients with a prior stroke were at 15.5-fold greater risk of peripheral fractures.

“The prior stroke subgroup is especially vulnerable. In an earlier population-based study using data from the U.K. we also demonstrated that fractures happened more frequently in SLE patients who had already suffered a stroke (Osteoporos Int. 2014 Apr;25[4]:1275-83). So those are patients who are at very high risk for falling and fractures. But I think there are many reasons why patients with SLE would have an elevated fall risk. They have fatigue. They have muscle weakness, which might be due to vitamin D deficiency or prednisone use or inactivity. And they often have balance problems due to neuropathy or medication,” the rheumatologist observed.

She reported having no financial conflicts regarding her study, carried out free of commercial support.

[email protected]

SAN FRANCISCO – Falls figured prominently in the elevated fracture risk of SLE patients in a Dutch prospective longitudinal study, Irene E.M. Bultink, MD, PhD, reported at an international congress on systemic lupus erythematosus.

Bruce Jancin/MDedge News

“I think we should focus on fall risk and fall events in lupus. I think that’s a neglected area,” according to Dr. Bultink, a rheumatologist at the University of Amsterdam.

Contrary to the conventional wisdom, in her study, cumulative corticosteroid dose, average daily dosage, and bone loss were not significantly related to fracture risk in these SLE patients. That’s because Dr. Bultink and her fellow rheumatologists took steps to mitigate steroid-induced bone loss.

“We know steroids are very important for bone loss in lupus, but we demonstrated in our long-term follow-up study that it’s very dose dependent. If you use steroids below 7.5 mg daily and you protect your patient with calcium and vitamin D and, if possible, with bisphosphonates, the bone loss is restricted. I think fracture risk in lupus is more related to fall risk and fall incidence than to bone loss and steroid use. That’s what we demonstrated in our study,” she said in an interview.

“Unfortunately, until now, no studies on fall risk and fall events in lupus have been published. It’s not investigated very well. I think that fall risk in lupus patients might be greatly increased, compared to healthy controls,” Dr. Bultink added.

The study included 145 Dutch SLE patients with a mean age of 41 years at baseline. Ninety percent were women; 69% were white. Bone mineral density measurements by dual x-ray bone densitometry and x-rays of the lumbar and thoracic spine were obtained at entry and again after a median of 5 years.

Forty-two incident fractures occurred during a median of 7.2 years of follow-up. This equated to an incidence rate of 2.2 peripheral and 2.0 vertebral fractures per 100 person-years, rates double those in the Dutch general population.

In a logistic regression analysis, white ethnicity was independently associated with a 13.2-fold increased risk of fractures overall. Postmenopausal status conferred a fourfold increased risk. Older age was another important determinant. And patients with a prior stroke were at 15.5-fold greater risk of peripheral fractures.

“The prior stroke subgroup is especially vulnerable. In an earlier population-based study using data from the U.K. we also demonstrated that fractures happened more frequently in SLE patients who had already suffered a stroke (Osteoporos Int. 2014 Apr;25[4]:1275-83). So those are patients who are at very high risk for falling and fractures. But I think there are many reasons why patients with SLE would have an elevated fall risk. They have fatigue. They have muscle weakness, which might be due to vitamin D deficiency or prednisone use or inactivity. And they often have balance problems due to neuropathy or medication,” the rheumatologist observed.

She reported having no financial conflicts regarding her study, carried out free of commercial support.

[email protected]

SAN FRANCISCO – Falls figured prominently in the elevated fracture risk of SLE patients in a Dutch prospective longitudinal study, Irene E.M. Bultink, MD, PhD, reported at an international congress on systemic lupus erythematosus.

Bruce Jancin/MDedge News

“I think we should focus on fall risk and fall events in lupus. I think that’s a neglected area,” according to Dr. Bultink, a rheumatologist at the University of Amsterdam.

Contrary to the conventional wisdom, in her study, cumulative corticosteroid dose, average daily dosage, and bone loss were not significantly related to fracture risk in these SLE patients. That’s because Dr. Bultink and her fellow rheumatologists took steps to mitigate steroid-induced bone loss.

“We know steroids are very important for bone loss in lupus, but we demonstrated in our long-term follow-up study that it’s very dose dependent. If you use steroids below 7.5 mg daily and you protect your patient with calcium and vitamin D and, if possible, with bisphosphonates, the bone loss is restricted. I think fracture risk in lupus is more related to fall risk and fall incidence than to bone loss and steroid use. That’s what we demonstrated in our study,” she said in an interview.

“Unfortunately, until now, no studies on fall risk and fall events in lupus have been published. It’s not investigated very well. I think that fall risk in lupus patients might be greatly increased, compared to healthy controls,” Dr. Bultink added.

The study included 145 Dutch SLE patients with a mean age of 41 years at baseline. Ninety percent were women; 69% were white. Bone mineral density measurements by dual x-ray bone densitometry and x-rays of the lumbar and thoracic spine were obtained at entry and again after a median of 5 years.

Forty-two incident fractures occurred during a median of 7.2 years of follow-up. This equated to an incidence rate of 2.2 peripheral and 2.0 vertebral fractures per 100 person-years, rates double those in the Dutch general population.

In a logistic regression analysis, white ethnicity was independently associated with a 13.2-fold increased risk of fractures overall. Postmenopausal status conferred a fourfold increased risk. Older age was another important determinant. And patients with a prior stroke were at 15.5-fold greater risk of peripheral fractures.

“The prior stroke subgroup is especially vulnerable. In an earlier population-based study using data from the U.K. we also demonstrated that fractures happened more frequently in SLE patients who had already suffered a stroke (Osteoporos Int. 2014 Apr;25[4]:1275-83). So those are patients who are at very high risk for falling and fractures. But I think there are many reasons why patients with SLE would have an elevated fall risk. They have fatigue. They have muscle weakness, which might be due to vitamin D deficiency or prednisone use or inactivity. And they often have balance problems due to neuropathy or medication,” the rheumatologist observed.

She reported having no financial conflicts regarding her study, carried out free of commercial support.

[email protected]