From the Editors.

It will take years before we can understand and measure the full toll that the COVID-19 pandemic has taken on our health systems. Of the many reverberations from the pandemic, one of the most concerning implications is an increase in the rates of preventable harm. Four years of unprecedented demand on healthcare services combined with health human resource shortages and clinician burnout have pushed our systems to the brink - and are impacting our capacity to improve or even maintain standards of care.

From the Editors.

There is no doubt that 2023 was a very difficult year for many Canadians, as well as people across the world. War caused massive upheaval globally, inflation continued to impose financial hardship on families and our health systems experienced another brutal respiratory season while still in recovery from the COVID-19 pandemic. Unfortunately, the year ahead is likely to bring more political and economic uncertainty, although we hope it also brings with it some opportunities for our health system, including the use of artificial intelligence (AI), research advancements and system transformation initiatives.

From the Editors.

Some of us may recall a time in healthcare when it seemed that the summer months were a bit quieter, providing an opportunity to catch our breath before the onslaught of fall and the ramp-up to flu season. Yet, with the increasing demand on our health systems, the sense of downtime has all but disappeared. This may suggest that we collectively have less time available for review, reflection and learning - all of which are critical elements for improvement and transformation. As an editorial team, our contribution is to continue synthesizing and presenting leading practices and innovative concepts to our readers, enabling them to access knowledge and ideas more easily. It is how we can help build capacity in our system to deliver better healthcare at a time when renewal is needed more than ever.

From the Editors.

As we consider the current pressures on healthcare, the options for where to focus our policy and leadership efforts are numerous and, at times, overwhelming. From health human resources capacity to access to mental health and preventative care to intermittent closures of emergency departments - the outlook is alarming. To help make sense of the situation, our Healthcare Quarterly (HQ) editorial team carefully considers a few areas to focus on in each edition. Over the past few issues, we have highlighted the importance of health equity and the challenges faced by different populations in gaining access to appropriate care and support. We continue to welcome submissions on this topic as we start to shift our focus toward other system priorities, including the mental health crisis in Canada. We are currently exploring a special focus edition on this long-neglected area of the health system and will be inviting submissions on this topic over the coming months.

From the Editors.

The recent winter months were particularly brutal for the healthcare system and its patients as we grappled with an onslaught of infectious diseases, healthcare backlogs and critical shortages of health human resources. We subsequently watched as Canada's federal and provincial leaders sought agreement on additional investments for several of our most precarious sectors, including long-term care, primary care and mental healthcare. Spring 2023 offers some optimism in that we will have new resources to make much-needed improvements to our depleted health sectors and services. While we can anticipate ongoing tensions as to how these investments will be used and how political leaders are held accountable, our healthcare leaders are gearing up to increase capacity and shore up our systems.

Shadows and Light: An Interview with Heather Patterson.

The editors of Healthcare Quarterly (HQ) recently had the opportunity to speak with Heather Patterson - emergency physician, photographer and author of the recently released book Shadows and Light (Patterson 2022). Through the photographs she took at Calgary-area hospitals during the height of the COVID-19 pandemic, Patterson created a poignant record of how the pandemic affected hospital staff, patients and their families. The book has struck a chord with many Canadians as it offers both an honest appraisal of the dreadful toll of the pandemic while also demonstrating the grace and compassion of healthcare workers.

From the Editors.

As we launch into 2023, the third year of the COVID-19 pandemic, the state of Canadian healthcare remains deeply concerning. Over the fall and winter months, our systems have experienced crippling levels of hospitalizations due to waves of infectious diseases, including influenza, respiratory syncytial virus infection and COVID-19. We have been particularly distressed by the impact to paediatric care, the insufficient capacity in mental health services and the continued strain on our healthcare workforce as well as on patients and families.

Lessons from the COVID-19 Pandemic for Long-Term Care: Where Do We Go Next?

Even before the COVID-19 pandemic, I would often hear colleagues who are intimately familiar with our health and social care system remark that they would never allow themselves or those closest to them to end up in long-term care. Sadly, the conversation often progressed to an acknowledgment that more desirable alternatives to long-term care for the most part lie outside our publicly supported care system and are only accessible to those with the means. And then we had the pandemic. For too many it turned what was often dreary and uninspiring care into a modern hell - so awful that two Canadian provinces called in the military to restore care in their worst-hit homes (Howlett 2021). There can be no doubt that the challenges that we face in providing dignified, respectful care to all our seniors have been decades in the making. It would be wrong to simply blame the long-term care homes, and it would be a travesty to lay the blame on individual care providers. On the contrary, those working in long-term care have continued to do their best, against the odds. In the early stages of the pandemic, they were not given the support that they deserved, and many paid a high personal price for their service.

From the Editors.

It would be a vast understatement to say that our healthcare systems are facing extraordinary pressure. The COVID-19 pandemic has pushed our people and our systems to their limits. We observe with trepidation that the current state of healthcare has not looked more precarious at any time in recent memory. Patients and families are feeling it. Providers, clinicians and leaders in the system are feeling it. And all of us recognize that it will take incredible political will and system-wide commitment to make the changes that are needed to renew and strengthen our front-line teams, structures and capacity. As editors for Healthcare Quarterly (HQ), we see the opportunity to contribute to the daunting task ahead by shining a light on leading practices and lessons learned from implementing change across Canada and beyond. Our commitment is to continue to showcase healthcare leadership in all forms and share opportunities for post-pandemic recovery and the future of healthcare.

From the Editors.

Although we do not yet know how or when the story of COVID-19 ends, Canadians are welcoming the summer of 2022 with the anticipation of the first prolonged period of near normalcy in two-and-a-half years. This sense of renewal coincides with the start of our roles as the new co-editors-in-chief of Healthcare Quarterly (HQ). Building on HQ's 25 years of excellence in sharing leading practices in health services delivery and policy, we are looking forward to taking the journal in new directions. Although both of us of have had long careers in healthcare and have experienced many cycles of change, this particular point in time feels different. Despite the devastating aftermath of this global pandemic, the disruption comes with an extraordinary level of opportunity. It is in thinking about the future state that we have embraced our new leadership roles with HQ.

The effectiveness of home-based phototherapy for vitiligo: A systematic review of randomised controlled trials.

BACKGROUND: Vitiligo may be treated with hospital-based phototherapy, but this requires long-term frequent appointments. Self-treatment using home-based phototherapy is a convenient alternative, which may improve adherence and results, but evidence is limited, and so it is not routinely recommended. This systematic review aims to assess the effectiveness and safety of home-based phototherapy for vitiligo. METHODOLOGY: Searches were conducted on Medline, Scopus and The Cochrane Library for randomised controlled trials comparing home-based phototherapy with institution-based phototherapy or placebo/no phototherapy for vitiligo. The primary outcome was treatment effectiveness. CASP criteria were used for quality assessment. Data were synthesised in a meta-analysis where appropriate. RESULTS: Three studies (195 participants) were included: two compared home-based with institution-based phototherapy, and one compared home-based phototherapy with placebo. Studies were of mixed quality. Therapy regimes varied across studies. Findings on effectiveness were contradictory across studies with variable rates of repigmentation. There was no significant difference in repigmentation rates between the groups, although adherence to treatment schedules was significantly better in home-based groups. Adverse effects were significantly higher in home-based groups. No long-term data were reported on maintenance of treatment benefits. CONCLUSIONS: Although adherence to treatment was significantly better with home-based phototherapy, data were insufficient to form conclusions on effectiveness. Home-based phototherapy had a significantly higher risk of adverse effects, making it difficult to recommend in clinical practice. However, as it offers logistical advantages for patients, its effectiveness alongside additional safety measures should be explored further in large-scale, good-quality RCTs, with standardised outcome measures, including patient-reported outcomes.

Resetting the Future of Healthcare Leadership.

There is no doubt that the events of the past two years will leave an indelible mark on human history. The tragic loss of so many lives during the COVID-19 pandemic, the long-term health and psychological impacts for many more and the economic and societal changes will reverberate for years to come. While the pandemic is not yet over, we are starting to appreciate how different our new future looks and feels. It is within this context that Longwoods Publishing and the Canadian College of Health Leaders (CCHL) have collaborated, for the first time, in a shared reflection on the future of leadership in Canada's healthcare system.

Leadership Perspective: Addressing Canada's Opioid Crisis - Reducing the Harm of Leadership.

While the COVID-19 pandemic has been the major focus for healthcare leaders since early 2020, the opioid crisis has been growing in the background. Confronting this emerging problem will require new thinking. Guest editors Anne Wojtak and Neil Stuart spoke with Scott Elliott, executive director, and Patrick McDougall, director of Knowledge Translation and Evaluation, at the Dr. Peter AIDS Foundation in Vancouver to gain their insights into how leaders can respond effectively.

Leadership Perspective: Partnering with Patients to Co-Design Healthcare Systems.

The ability to partner with patients to design healthcare systems is an increasingly critical skill for healthcare leaders. Guest editors Anne Wojtak and Neil Stuart spoke with Vincent Dumez, co-director of the Montreal-based Centre of Excellence on Partnership with Patients and the Public, to gain an understanding of what true patient partnership looks like and how healthcare system design can be transformed.

The P681H mutation in the Spike glycoprotein confers Type I interferon resistance in the SARS-CoV-2 alpha (B.1.1.7) variant

Variants of concern (VOCs) of severe acute respiratory syndrome coronavirus type-2 (SARS-CoV-2) threaten the global response to the COVID-19 pandemic. The alpha (B.1.1.7) variant appeared in the UK became dominant in Europe and North America in early 2021. The Spike glycoprotein of alpha has acquired a number mutations including the P681H mutation in the polybasic cleavage site that has been suggested to enhance Spike cleavage. Here, we show that the alpha Spike protein confers a level of resistance to the effects of interferon-{beta} (IFN{beta}) in lung epithelial cells. This correlates with resistance to restriction mediated by interferon-induced transmembrane protein-2 (IFITM2) and a pronounced infection enhancement by IFITM3. Furthermore, the P681H mutation is necessary for comparative resistance to IFN{beta} in a molecularly cloned SARS-CoV-2 encoding alpha Spike. Overall, we suggest that in addition to adaptive immune escape, mutations associated with VOCs also confer replication advantage through adaptation to resist innate immunity.

Antibody longevity and cross-neutralizing activity following SARS-CoV-2 wave 1 and B.1.1.7 infections

As SARS-CoV-2 variants continue to emerge globally, a major challenge for COVID-19 vaccination is the generation of a durable antibody response with cross-neutralizing activity against both current and newly emerging viral variants. Cross-neutralizing activity against major variants of concern (B.1.1.7, P.1 and B.1.351) has been observed following vaccination, albeit at a reduced potency, but whether vaccines based on the Spike glycoprotein of these viral variants will produce a superior cross-neutralizing antibody response has not been fully investigated. Here, we used sera from individuals infected in wave 1 in the UK to study the long-term cross-neutralization up to 10 months post onset of symptoms (POS), as well as sera from individuals infected with the B.1.1.7 variant to compare cross-neutralizing activity profiles. We show that neutralizing antibodies with cross-neutralizing activity can be detected from wave 1 up to 10 months POS. Although neutralization of B.1.1.7 and B.1.351 is lower, the difference in neutralization potency decreases at later timepoints suggesting continued antibody maturation and improved tolerance to Spike mutations. Interestingly, we found that B.1.1.7 infection also generates a cross-neutralizing antibody response, which, although still less potent against B.1.351, can neutralize parental wave 1 virus to a similar degree as B.1.1.7. These findings have implications for the optimization of vaccines that protect against newly emerging viral variants.

Necrotic Ulceration of the Hand Case Review: Think Beyond Infection.

Neutrophilic dermatosis of the dorsal hands is a rare neutrophilic dermatosis that can be associated with inflammatory bowel disease, rheumatoid arthritis, and underlying malignancies. The occurrence of trauma as an initiating factor and its early features of pain and inflammation followed by blistering or ulceration mean that it can be mistaken for necrotizing infection. Neutrophilic dermatosis of the dorsal hands should be considered in all patients who present with such features confined to the back of the hands, particularly those with negative microbiological results or lack of response to antibiotic therapy. A case review design was used to analyze the presentation of a woman aged 65 years in the United Kingdom, seeking care for a painful rash on the hand in the emergency department that was subsequently diagnosed as neutrophilic dermatosis of the dorsal hands. Emergency clinician awareness of neutrophilic dermatosis of the dorsal hands as a rare differential diagnosis for patients presenting with necrotic ulceration may prevent unnecessary antibiotic therapy and surgical intervention.

The immediate effects of winter storms and power outages on multiple health outcomes and the time windows of vulnerability.

BACKGROUND: While most prior research has focused on extreme heat, few assessed the immediate health effects of winter storms and associated power outages (PO), although severe storms have become more frequent. This study evaluates the joint and independent health effects of winter storms and PO, snow versus ice-storm, effects by time window (peak timing, winter/transitional months) and the impacts on critical care indicators including numbers of comorbidity, procedure, length of stay and cost. METHODS: We use distributed lag nonlinear models to assess the impacts of winter storm/PO on hospitalizations due to cardiovascular, lower respiratory diseases (LRD), respiratory infections, food/water-borne diseases (FWBD) and injuries in New York State on 0-6 lag days following storm/PO compared with non-storm/non-PO periods (references), while controlling for time-varying factors and PM2.5. The storm-related hospitalizations are described by time window. We also calculate changes in critical care indicators between the storm/PO and control periods. RESULTS: We found the joint effects of storm/PO are the strongest (risk ratios (RR) range: 1.01-1.90), followed by that of storm alone (1.02-1.39), but not during PO alone. Ice storms have stronger impacts (RRs: 1.04-3.15) than snowstorms (RRs: 1.03-2.21). The storm/PO-health associations, which occur immediately, and some last a whole week, are stronger in FWBD, October/November, and peak between 3:00-8:00 p.m. Comorbidity and medical costs significantly increase after storm/PO. CONCLUSION: Winter storms increase multiple diseases, comorbidity and medical costs, especially when accompanied by PO or ice storms. Early warnings and prevention may be critical in the transitional months and afternoon rush hours.

Environmental Sustainability Must Be on Our Agenda for Healthcare.

I am increasingly alarmed by climate change and environmental degradation. Many of you share my concerns, no doubt. I worry that we are not dealing with these issues in a manner that promises meaningful or timely results, and I believe we must reorder our priorities. There is also a fundamental unfairness that runs through what is happening. Environmental harm compounds existing inequities within and among our communities, inequities between richer and poorer nations and, most insidiously, generational inequity - deferring the consequences of our inaction to a future generation. Adding to these concerns is the realization that in my own professional field, healthcare, we have given little thought to the sector's role in and responsibility for environmental sustainability. To date, these issues have not been part of the mainstream healthcare conversation.

Estimates of the rate of infection and asymptomatic COVID-19 disease in a population sample from SE England

BackgroundUnderstanding of the true asymptomatic rate of infection of SARS-CoV-2 is currently limited, as is understanding of the population-based seroprevalence after the first wave of COVID-19 within the UK. The majority of data thus far come from hospitalised patients, with little focus on general population cases, or their symptoms. MethodsWe undertook enzyme linked immunosorbent assay characterisation of IgM and IgG responses against SARS-CoV-2 spike glycoprotein and nucleocapsid protein of 431 unselected general-population participants of the TwinsUK cohort from South-East England, aged 19-86 (median age 48; 85% female). 382 participants completed prospective logging of 14 COVID-19 related symptoms via the COVID Symptom Study App, allowing consideration of serology alongside individual symptoms, and a predictive algorithm for estimated COVID-19 previously modelled on PCR positive individuals from a dataset of over 2 million. FindingsWe demonstrated a seroprevalence of 12% (51participants of 431). Of 48 seropositive individuals with full symptom data, nine (19%) were fully asymptomatic, and 16 (27%) were asymptomatic for core COVID-19 symptoms: fever, cough or anosmia. Specificity of anosmia for seropositivity was 95%, compared to 88% for fever cough and anosmia combined. 34 individuals in the cohort were predicted to be Covid-19 positive using the App algorithm, and of those, 18 (52%) were seropositive. InterpretationSeroprevalence amongst adults from London and South-East England was 12%, and 19% of seropositive individuals with prospective symptom logging were fully asymptomatic throughout the study. Anosmia demonstrated the highest symptom specificity for SARS-CoV-2 antibody response. FundingNIHR BRC, CDRF, ZOE global LTD, RST-UKRI/MRC