Virtual urgent care is here to stay: driving toward safe, equitable, and sustainable integration within emergency medicine.

BACKGROUND: Virtual care in Canada rapidly expanded during the COVID-19 pandemic in a low-rules environment in response to pressing needs for ongoing access to care amid public health restrictions. Emergency medicine specialists now face the challenge of advising on which virtual urgent care services ought to remain as part of comprehensive emergency care. Consideration must be given to safe, quality, and appropriate care as well as issues of equitable access, public demand, and sustainability (financial and otherwise). The aim of this project was to summarize current literature and expert opinion and formulate recommendations on the path forward for virtual care in emergency medicine. METHODS: We formed a working group of emergency medicine physicians from across Canada working in a variety of practice settings. The virtual care working group conducted a scoping review of the literature and met monthly to discuss themes and develop recommendations. The final recommendations were circulated to stakeholders for input and subsequently presented at the 2023 Canadian Association of Emergency Physicians (CAEP) Academic Symposium for discussion, feedback, and refinement. RESULTS: The working group developed and reached unanimity on nine recommendations addressing the themes of system design, equity and accessibility, quality and patient safety, education and curriculum, financial models, and sustainability of virtual urgent care services in Canada. CONCLUSION: Virtual urgent care has become an established service in the Canadian health care system. Emergency medicine specialists are uniquely suited to provide leadership and guidance on the optimal delivery of these services to enhance and complement emergency care in Canada.

RéSUMé: CONTEXTE: Les soins virtuels au Canada ont rapidement pris de l'ampleur pendant la pandémie de COVID-19 dans un environnement où les règles sont peu strictes, en réponse aux besoins urgents d'accès continu aux soins dans un contexte de restrictions en santé publique. Les spécialistes de la médecine d'urgence sont maintenant confrontés au défi de conseiller sur les services de soins d'urgence virtuels qui devraient rester dans le cadre des soins d'urgence complets. Il faut tenir compte des soins sécuritaires, de qualité et appropriés, ainsi que des questions d'accès équitable, de la demande publique et de la durabilité (financière et autre). L'objectif de ce projet était de résumer la littérature actuelle et l'opinion d'experts et de formuler des recommandations sur la voie à suivre pour les soins virtuels en médecine d'urgence. MéTHODES: Nous avons formé un groupe de travail composé de médecins urgentistes de partout au Canada qui travaillent dans divers milieux de pratique. Le groupe de travail sur les soins virtuels a effectué un examen de la portée de la documentation et s'est réuni chaque mois pour discuter des thèmes et formuler des recommandations. Les recommandations finales ont été distribuées aux intervenants pour obtenir leurs commentaires, puis présentées au symposium universitaire 2023 de l'Association canadienne des médecins d'urgence (ACMU) pour discussion, rétroaction et perfectionnement. RéSULTATS: Le groupe de travail a élaboré et atteint l'unanimité sur neuf recommandations portant sur les thèmes de la conception du système, de l'équité et de l'accessibilité, de la qualité et de la sécurité des patients, de l'éducation et des programmes, des modèles financiers et de la viabilité des services virtuels de soins d'urgence au Canada. CONCLUSION : Les soins d'urgence virtuels sont devenus un service établi dans le système de santé canadien. Les spécialistes en médecine d'urgence sont particulièrement bien placés pour fournir un leadership et des conseils sur la prestation optimale de ces services afin d'améliorer et de compléter les soins d'urgence au Canada.

Differential Activation and Functional Plasticity of Multimodal Areas Associated with Acquired Musical Skill.

Training of a musical skill is known to produce a distributed neural representation of the ability to perceive music and perform musical tasks. In the present study we tested the hypothesis that the audiovisual perception of music involves a wider activation of multimodal sensory and sensorimotor structures in the brain, including those containing mirror neurons. We mapped the activation of brain areas during passive listening and viewing of the first 40 s of "Ode to Joy" being played on the piano by an expert pianist. To do this we performed brain functional magnetic resonance imaging during the presentation of 6 different stimulus contrasts pertaining to that musical melody in a pseudo-randomized order. Group data analysis in musically trained and untrained adults showed robust activation in broadly distributed occipitotemporal, parietal and frontal areas in trained subjects and much restricted activation in untrained subjects. A visual stimulus contrast focusing on the visual motion percept of moving fingers on piano keys revealed selective bilateral activation of a locus corresponding to the V5/MT area, which was significantly more pronounced in trained subjects and showed partial linear dependence on the duration of training on the left side. Quantitative analysis of individual brain volumes confirmed a significantly greater and wider spread of activation in trained compared to untrained subjects. These findings support the view that audiovisual perception of music and musical gestures in trained musicians involves an expanded and widely distributed neural representation formed due to experience-dependent plasticity.

A qualitative study of the feasibility and acceptability of a smoking cessation program for people living with HIV and emotional dysregulation.

Despite high rates of co-occurring tobacco use and anxiety among persons living with HIV, evidence-based interventions for these individuals are limited. An existing cognitive-behavioral treatment protocol for smoking cessation and anxiety (Norton, P. J., & Barrera, T. L. (2012). Transdiagnostic versus diagnosis-specific CBT for anxiety disorders: A preliminary randomized controlled noninferiority trial. Depression and Anxiety, 29(10), 874-882. https://doi.org/10.1002/da.21974) was modified to address transdiagnostic constructs, such as anxiety sensitivity, distress tolerance, and depressive symptomatology (Labbe, A. K., Wilner, J. G., Kosiba, J. D., Gonzalez, A., Smits, J. A., Zvolensky, M. J., … O'Cleirigh, C. (2017). Demonstration of an Integrated Treatment for Smoking Cessation and Anxiety Symptoms in People with HIV: A Clinical Case Study. Cognitive and Behavioral Practice, 24(2), 200-214. https://doi.org/10.1016/j.cbpra.2016.03.009). This study examines the feasibility and acceptability of the intervention as determined from qualitative data from structured exit interviews from 10 participants who completed treatment. Results demonstrated that participants were very motivated to quit smoking and enrolled in the program for health-related reasons and to be able to quit. Participants found nearly all the treatment components to be useful for reaching their smoking cessation goal and in managing emotional dysregulation. Last, all participants stated that they would strongly recommend the treatment program. This qualitative study provides initial evidence for the feasibility and acceptability of a modified smoking cessation treatment protocol for HIV+ individuals with anxiety and emotional dysregulation. Future research will focus on evaluating the efficacy of the protocol in a full-scale randomized controlled trial, as well as working to collect qualitative data from participants who discontinue treatment to better understand reasons for treatment attrition.

Modulation of theta/alpha frequency profiles of slow auditory-evoked responses in the songbird zebra finch.

Spatiotemporal patterns of forebrain neural activity associated with auditory perception of biologically relevant complex acoustic stimuli can be conveniently studied in the songbird zebra finch. Here we present a time-frequency analysis of averaged slow auditory-evoked potentials (sAEPs) obtained at electrode locations overlying the main song control nucleus, high vocal center. Gabor spectrograms of these sAEPs show a prolonged response time course consisting of unimodal frequency peaks in the theta/alpha range (4-17 Hz). There is a stimulus-dependent modulation of the duration of the response and of the total number of its constituent frequency peaks, an effect that is bilateral in 75% of the birds and lateralized to the left side in the remaining 25%. Since the state of alertness of birds modulates these parameters along a similar continuum, these findings suggest that modulation of sAEP frequency profile may be dependent on attentional mechanisms. The presence and modulation of neurobiologically ubiquitous dominant frequency components also implicate the possible role of induced cerebral neuronal circuit oscillations in songbird auditory perception.

Development and adult phase plasticity of syllable repetitions in the birdsong of captive zebra finches (Taeniopygia guttata).

Oscines learn their birdsongs from tutors. The authors found that a small fraction (approximately 7%) of captive male zebra finches (Taeniopygia guttata) produce variant acoustic birdsong profiles consisting of repetitions of single song syllables at high frequencies. Juvenile offspring of nonrepeaters can selectively learn the syntactic rule or habit of repeating syllables from repeaters. Adult tutored syllable repeaters, unlike spontaneous repeaters, undergo a form of song plasticity involving progressive reduction of the mean number and variance of repeated syllables as a function of long-term exposure to nonrepeater songs without altering the number or sequence of syllables within motifs. These findings suggest that aspects of song syntax or temporal frame can be acquired independently of song syllable or spectral content, and plasticity involving restorative alteration of acquired variant temporal frames can occur after the closure of the critical period for song learning.

Reduction of female-directed song motifs induced by repeated singing in laboratory-bred zebra finches.

Songbirds such as zebra finches show a remarkable degree of neural plasticity associated with the motor act of singing. Here we show that in adult male zebra finches repeated female-directed singing episodes are associated with a change in subsequent singing behavior involving a progressive long-lasting decline in the number of song motifs sung. This reduction in song motif production cannot be completely explained by the circadian rhythm, declining motivation or neuromuscular exhaustion. Paired song induction sessions reveal that the time course of motif reduction during repeated singing can be best explained by the cumulative effect of reduction produced by each singing episode. These results suggest that song production in zebra finches is prone to a form of rapid behavioral adaptation.

Transient speech compromise following sublabial transsphenoidal surgery: a case report and findings of a small preliminary study.

Sublabial transsphenoidal surgical removal of pituitary tumors is a common procedure with minimal complications. Although many investigators have reported oral sensory compromises following surgery, none has reported any postoperative compromise in speaking ability. In this article, we describe the case of a 33-year-old woman who developed transient but severe speech symptoms after she underwent sublabial transsphenoidal surgery. This case prompted us to undertake a brief retrospective analysis of our experience with this procedure in other patients, which revealed that speech compromise is far more common than heretofore realized.

Stuttering induced by theophylline.

We retrospectively evaluated three fluent asthmatic children who developed speech dysfluency following administration of theophylline. The dysfluency ceased in all three, following discontinuation of the medication. The medication was re-instituted in two patients, prompting return of dysfluency. It is unknown whether the patients had characteristics of "acquired stuttering" or "developmental stuttering." We urge appropriate testing should this complication again occur. This might then provide pharmacologic information regarding stuttering.

A model of the phonatory response time of stutterers and fluent speakers to frequency-modulated tones.

Stutterers and fluent speakers tracked frequency-modulated tones by humming. The response time (RT) to the first corrective change in fundamental frequency in response to linear ramps of increasing and decreasing frequency was measured. The results demonstrate that RT is a function of the stimulus ramp velocity. A model of this dependency is provided which consists of parameters of threshold frequency and a fixed time delay. The estimated threshold frequency for the fluent speakers is 2.029 Hz with 95% confidence interval: (1.70 Hz, 2.35 Hz) whereas that of the stutterers is 3.937 Hz (3.28 Hz, 4.60 Hz). These threshold frequencies are significantly different (p < 0.0001). This implies that stutterers are slower to respond to changes in frequency than are fluent speakers. The fixed time delays for the two groups are not significantly different. This means that it is possible for the stutterers to respond as fast as the fluent speakers (i.e., their basic "reflexes" are the same); however, they spend more time in the detection of the change in a tracking signal. This supports the model of the stuttered event as being triggered by an instability in a multiloop speech motor control system.

Neurologic aspects of spasmodic dysphonia.

We discuss the etiology of 100 spasmodic dysphonia patients. Seventy-one patients had underlying essential tremor, 25 had Meige's syndrome, 12 were hypothyroid, and 27 had either a functional disturbance or focal dystonia. Six patients had intermittent breathy dysphonia. A large corpus of spasmodic dysphonia patients have organic neurolaryngeal disease.

Physician referral patterns for stutterers.

Many children who stutter initially seek guidance from their pediatricians. Pediatricians often do not refer stutterers for speech therapy. We present a brief analysis of pediatricians' views regarding stuttering, as well as their exposure to patients who stutter. We present a practical approach to children who stutter.