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Introduction: Neurology wait times - from referral to consultation - continue to grow, leading to various adverse effects on patient outcomes. Key elements of virtual care can be leveraged to improve efficiency. This study examines the implementation of a novel virtual care model - Virtual Rapid Access Clinics - at the Neurology Centre of Toronto. The model employs a patient-centred care workflow, involving multidisciplinary staff and online administrative tools that are synthesized to expedite care and maintain quality., Methods: Virtual Rapid Access Clinic efficacy was studied by determining average wait times and patient throughput, calculated from anonymous data that was extracted from the clinic patient database (n  =  1542). Comparative analysis focused on new patient consultations during the 12-month periods prior to (pre-Virtual Rapid Access Clinic, n  =  456) and following (post-Virtual Rapid Access Clinic, n  =  1086) Virtual Rapid Access Clinic implementation., Results: After Virtual Rapid Access Clinic implementation, there was a mean 15-day wait time reduction, and a monthly average 52-patient increase in patient throughput. Wait time reductions and increased patient throughput were observed in all three Virtual Rapid Access Clinic sub-clinics - epilepsy, headache and concussion. Respectively, average wait times reduced significantly by 26.4 and 18.9 days and insignificantly by 1.1 days; monthly average patient throughputs increased by 235%, 95% and 161%., Discussion: These findings demonstrated that the Virtual Rapid Access Clinic model of care is effective at reducing patient wait times and increasing patient throughput. While the Virtual Rapid Access Clinic presents a feasible model both during and after pandemic restrictions, further research exploring its scalability in other care contexts, potential changes in care quality and efficiency outside of pandemic restrictions must be performed., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: A small body of evidence suggests medical cannabis may facilitate wound healing, but the exact mechanism of this effect is unclear., Purpose: This case report describes a patient with a pressure injury (PI) who received cannabis oil treatment for pain management and sleep improvement., Methods: A 37-year-old woman with multiminicore disease, scoliosis, short-chain acyl-CoA dehydrogenase deficiency, and epilepsy presented to the Neurology Centre of Toronto with chronic pain and sleep disturbance, including difficulty initiating and maintaining sleep. She also had a 5-year history of a PI between her right iliac crest and right rib cage that had progressively worsened. The patient received a medical cannabis oil protocol that used a combination of cannabidiol and tetrahydrocannabinol., Results: Cannabis oil was effective in treating pain and sleep difficulties. Unexpectedly, during the first 2 weeks of treatment, the PI started to heal and was almost completely closed at the 2-month follow-up., Conclusion: Although it is unknown if the observed healing of this refractory PI was indirectly or directly related to the cannabidiol and tetrahydrocannabinol treatment, the potential relationships among pain, sleep disturbance, cannabis treatment, and healing should be explored.

Background: Intense pulsed light therapy (IPL) decreases facial erythema and telangiectasias associated with rosacea. Topical skin care products decrease facial erythema by the action of active ingredients and masking effects., Objectives: To assess the efficacy and tolerability of combining a topical skin care regimen (TSCR) comprised of a multifunctional three-in-one facial cream and a mineral-based brush-on SPF50 powder sunscreen with a single IPL treatment for treating mild-to-severe facial redness associated with rosacea., Methods: Twenty female subjects with Fitzpatrick skin types I-III received TSCR monotherapy for 12 weeks. At that time, subjects received a single IPL treatment and continued TSCR for 6 additional weeks. Subjects were evaluated at Baseline and at Weeks 4, 8, 12, and 18., Results: Using a 7-point redness scale, the overall mean (SD) redness score significantly improved from 3.05 (0.97) at baseline to 2.05 (0.76) at Week 18 (P < 0.01). There was a decrease in investigator-rated erythema from baseline (bare skin) to Week 12 (bare skin, before IPL) when TSCR was used as monotherapy which did not achieve significance (P = 0.12). Most subjects (80%) were satisfied or Very satisfied with the TSCR at Week 18. All subjects (100%) agreed that it improved their baseline skin redness and most (85%) would recommend TSCR to others. TSCR was well-tolerated with no significant changes in skin dryness, scaling, or itching. Mild burning occurred immediately following the IPL treatment at Week 12., Conclusion: TSCR in combination with a single IPL treatment produced a significant improvement in overall facial redness in patients with rosacea. Longer-term treatment with TSCR may produce continued improvement., (© 2019 Wiley Periodicals, Inc.)

Background: A number of epidermal and papillary dermal skin conditions can be treated safely and effectively with fractional photothermolysis (FP)., Objective: We sought to evaluate the effectiveness of FP with a 1550-nm fractionated erbium-doped fiber laser for the treatment of facial actinic keratoses (AKs)., Methods: Fourteen men, ages 59 to 79 years, underwent 5 laser treatments (2- to 4-week intervals) at an energy fluence of 20 to 70 mJ and treatment level of 11 (8-10 passes), corresponding to 32% to 40% surface area coverage. AK counts and photographs were taken at baseline, before each treatment, and at 1-, 3-, and 6-month follow-ups after the last treatment. Biopsies were performed at baseline and at the 3-month follow-up. The clinical improvement of the actinic lesions was evaluated by a dermatologist using digital photography and lesion counts at all 3 follow-up visits., Results: The AK count for each patient was reduced on average by 73.1% (67.5%-77.7%) at the 1-month, 66.2% (60.0%-71.5%) at the 3-month, and 55.6% (43.9%-64.8%) at the 6-month follow-up visit. Excluding two cases, all biopsy specimens (baseline and at the 3-month follow-up) were positive for histologic features of AK and/or squamous cell carcinoma., Limitations: This study is limited by a small number of patients; therefore further clinical studies are warranted., Conclusions: FP decreases the number of clinical AKs; however, posttreatment biopsy specimens indicate the histologic persistence of AKs (epidermal tumors). FP is not an adequate single-treatment modality for AKs., (Copyright © 2011 American Academy of Dermatology, Inc. Published by Mosby, Inc. All rights reserved.)

Background: Melasma on the face is difficult to treat and is often refractory to multiple treatment modalities., Objectives: To investigate the safety and efficacy of fractional photothermolysis (FP) for the treatment of melasma and to determine recurrence rates with this treatment method., Materials and Methods: Eight female patients (Fitzpatrick skin type II-IV) with clinically diagnosed melasma on the face were treated using FP (1,550 nm Fraxel SR laser). Two to seven treatments were performed at 3- to 8-week intervals. Treatment levels ranged from 3 to 10, corresponding to 9% to 29% surface area coverage (8-10 passes per treatment). Energies used ranged from 6 to 40 mJ. Physician and patient assessments were recorded at each visit and at a follow-up visit 7 to 36 months (mean 13.5 months) after the last treatment session., Results: At the last treatment, assessments revealed greater than 50% clinical improvement in melasma in five of eight patients. Follow-up assessments by the evaluating physician revealed sustained efficacy in five patients. Recurrence was reported in three patients. No significant adverse effects were noted., Conclusions: FP is a safe and effective treatment for refractory melasma, with long-term remission.

Background: Nonablative fractional photothermolysis has revolutionized the way we treat a number of common skin conditions with laser technology., Objective: A comprehensive guide is needed for clinicians using this technology to treat specific skin conditions in various skin types., Materials and Methods: Recommendations were made from a recent round table discussion among experienced physicians and a review of recent literature findings., Results: Optimal laser parameters are dependent on patient skin type and condition. We recommended guidelines for the successful treatment of several common skin conditions on and off the face using nonablative fractional photothermolysis. Specific conditions were dyschromia, rhytides, acne scars, surgical scars, melasma, and striae distensae., Conclusions: We developed reproducible guidelines to most effectively treat a variety of skin types and conditions using nonablative fractional photothermolysis. Future large, multicenter trials are indicated for further optimization of treatment parameters.

Background: Desmoplastic trichoepithelioma (DTE) is an uncommon adnexal tumor usually found on the face of young women., Objective: We sought to describe the clinical and histologic characteristics of DTE and discuss management strategies for these tumors., Methods: We conducted a retrospective case series and review of the literature., Results: A series of 17 cases of DTE is reported. Of our patients, 82% were female and half of all these cases occurred on the cheek. Unlike previous reports, the patients in our study were slightly older, with 53% older than 51 years and 71% between the ages of 31 and 60 years at the time of surgery (mean age 49 years, median age 52 years, range 14-81 years). Approximately 38% of the tumors had been present for 1 to 2 years before presentation. The average size of the tumors at the time of surgery was 0.8 x 0.6 cm. All cases were treated with Mohs micrographic surgery. To date, none of the tumors have recurred., Limitations: This is a small case series. The referral patterns of our predominantly Mohs micrographic surgery clinic might further bias this study., Conclusion: DTE is a benign tumor that has a predilection for the face. With its rapid growth, aggressive histologic features that may be confused with basal cell carcinoma, and tendency to arise in cosmetically and functionally sensitive areas, these tumors should be removed in a manner that assures clear surgical margins, such as Mohs micrographic surgery.

Arthropod bites remain a major cause of patient morbidity. These bites can cause local or systemic effects that may be infectious or inflammatory in nature. Arthropods, notably insects and arachnids, are vectors of potentially serious ailments including malaria, West Nile virus, dengue, and Lyme disease. Measures to curtail the impact of insect bites are important in the worldwide public health effort to safely protect patients and prevent the spread of disease. The history of insect repellent (IR) lends insight into some of the current scientific strategies behind newer products. Active ingredients of currently available IRs include N,N-diethyl-3-methylbenzamide (DEET), botanicals, citronella, and, the newest agent, picaridin. Currently, the Environmental Protection Agency's registered IR ingredients approved for application to the skin include DEET, picaridin, MGK-326, MGK-264, IR3535, oil of citronella, and oil of lemon eucalyptus. DEET has reigned as the most efficacious and broadly used IR for the last 6 decades, with a strong safety record and excellent protection against ticks, mosquitoes, and other arthropods. Newer agents, like picaridin and natural products such as oil of lemon eucalyptus are becoming increasingly popular because of their low toxicity, comparable efficacy, and customer approval. Various characteristics and individual product advantages may lead physicians to recommend one agent over another.

Background: There has been no previously published study on skin cancers on the scalp of women., Objectives: To better elucidate the characteristics of skin cancers that develop on the female scalp., Methods: A retrospective review of 13,885 biopsy-proven skin cancers treated by Mohs micrographic surgery was performed. We identified 197 tumors on the scalp of women. Demographic features and tumor characteristics were compiled and analyzed., Results: The average age of women with scalp tumors was 61.8 +/- 16.9, which was significantly lower than that of men with scalp tumors. The age followed a bimodal distribution with peaks in the fifth and eighth decades. Overall, 77% of female scalp tumors were basal cell carcinomas (BCCs), 17% were squamous cell carcinomas (SCCs), and 6% were a variety of other tumors. This contrasts with men in whom 53% of tumors were squamous cell carcinomas. Basal cell carcinomas were significantly more common in women under age 50., Conclusion: Skin cancers of the female scalp tend to be basal cell carcinomas, many of which occur at a relatively young age as compared to other skin cancers. The exact role of ultraviolet radiation in the development of some of these tumors is unclear.

From October 1981 to September 1984, the authors conducted a three-year longitudinal study of diarrhea among infants and toddlers attending day care centers in Maricopa County, Arizona. In the third year of study, they evaluated the effects on diarrhea rates of staff training without external monitoring and of active surveillance conducted throughout the study. From 21 study day care centers, they randomly selected 10 ("intervention day care centers") to receive staff training in procedures to reduce transmission of infectious diarrhea. Continuing active surveillance in the 10 intervention and 11 control day care centers found no difference between diarrhea rates in intervention day care centers in the pre- and posttraining years and no difference between diarrhea rates in the two groups of centers either before or after the training intervention. Biweekly family-based surveys during the two months after training also demonstrated no difference between infant-toddler diarrhea rates in intervention and control day care centers. These surveys found the 21 study day care centers to have significantly higher diarrhea rates than did day care homes or households not using day care, but significantly lower rates than day care centers not included in the active surveillance. Continuous surveillance without training was associated with a significant decrease in diarrheal illness during the course of longitudinal study. One-time staff training without subsequent monitoring did not result in additional decreases and did not lower day care center diarrhea rates to the levels observed in day care homes and households not using day care.