Health Science, Technology and Innovation Policy (ST&I/H): an update for debate. / Política de Ciência, Tecnologia e Inovação em Saúde (CT&I/S): uma atualização para debate.

The text presents an updated proposal for a Health Science, Technology and Innovation Policy in Brazil, following the huge political turmoil in the country since 2019 and the COVID-19 pandemic since 2020. The proposal is presented in five sections: Scientific Research; Productive Innovation; Health Technology Assessment and Incorporation; Intellectual Property in Health; New challenges posed by the Pandemic. The authors take part in the Advisory Committee in Science, Technology and Innovation of the Brazilian Association of Collective Health.

O texto contém uma proposta atualizada de política de Ciência, Tecnologia e Inovação em Saúde no Brasil e a pertinência da atualização decorre do desastre nas atividades nesse terreno verificadas no país desde o início do atual governo federal em 2019, bem como dos desafios colocados pela emergência da pandemia COVID-19 desde 2020. Ele está organizado em cinco seções, a saber: Pesquisa em Saúde; Inovação Produtiva; Avaliação e Incorporação de Tecnologias em Saúde; Propriedade Intelectual em Saúde; Novos desafios colocados pela Pandemia. Os autores fazem parte do Comitê de Assessoramento em Ciência, Tecnologia e Inovação da Abrasco.

VitalSeer: The development of a contactless sensing technology based on a user-centric data-driven clinical approach.

The COVID-19 pandemic presented challenges to the healthcare system while catalyzing the adoption of virtual care. The need for remote assessment and real-time monitoring of physiological vital signs has driven towards a need for virtual care solutions. This paper presents the outcome of a multidisciplinary collaboration to ensure clinical usability of a remote contactless sensing technology, VitalSeer, and to help close gaps between emerging technologies and clinical practice. The paper describes the user-centric data-driven clinical approach to address the needs as identified by clinical experts through the iterative and agile development cycle. It highlights findings from preliminary studies to validate proof-of-concept VitalSeer's adoptability, accessibility and usability. The studies on volunteers demonstrated the accuracy of VitalSeer's heart rate model at a low MAE of 0.74 (bpm) and a RMSE of 1.2 bpm, below the threshold of clinical grade contact-based sensors. The paper concludes with a discussion on the technology implications in emergency medicine and community care.

Information and Communication Technology Use for Alleviation of Disability Onset in Socially Isolated Older Adults: A Longitudinal Cohort Study.

INTRODUCTION: Delaying the onset of disability is important for maintaining independence and quality of life in community-dwelling older adults. Given that social isolation is a significant risk factor for disability, effective means associated with social isolation are needed to alleviate disability. Although information and communication technology (ICT) may be a reasonable measure considering the recent social contexts due to the coronavirus disease 2019 pandemic, further insights are required. This study aimed to investigate whether ICT use can alleviate the onset of disability in community-dwelling older adults with and without social isolation. METHODS: This longitudinal cohort study on 4,346 community-dwelling independent Japanese older adults (mean age, 73.5 ± 5.3 years) was conducted between 2017 and 2018. Participants were classified into four groups based on social isolation (the condition where two or more of the following measures were met: domestic isolation, less social contact, and social disengagement) and ICT users (those who had recently used a computer or a smartphone) and followed up to assess disability incidence for 24 months after baseline assessments. Cox proportional-hazards regression models were used to identify the effect of social isolation and ICT use on the risk of disability onset by adjusting for age, sex, education history, number of medications, eye disease, level of annual income, Mini-Mental State Examination, Geriatric Depression Scale 15, and gait speed. RESULTS: The group comprised nonsocial isolation and ICT users (44.7%), social isolation and ICT users (5.4%), nonsocial isolation and ICT nonusers (41.7%), and social isolation and ICT nonusers (8.2%). At the follow-up, 2.2%, 2.4%, 5.5%, and 12.4% of the participants in the above order developed disability (p < 0.01). Cox regression models revealed a significantly higher risk of disability onset in the social isolation and ICT nonusers group than in the social isolation and ICT users group (HR = 2.939; 95% confidence interval (CI) 1.029-8.397; p = 0.044). In the subgroup analysis stratified by social isolation, ICT use significantly reduced the risk of disability onset in the socially isolated group (HR = 0.320; 95% CI 0.109-0.943; p = 0.039), although the same association was not observed in the nonsocially isolated group (HR = 0.845; 95% CI 0.565-1.264; p = 0.411). CONCLUSION: ICT use can alleviate the onset of disability in socially isolated older adults in a community setting. Considering ICT-applied methods for alleviating disability is beneficial for older adults in social isolation.

From concept to delivery: a yeast-expressed recombinant protein-based COVID-19 vaccine technology suitable for global access.

INTRODUCTION: The development of a yeast-expressed recombinant protein-based vaccine technology co-developed with LMIC vaccine producers and suitable as a COVID-19 vaccine for global access is described. The proof-of-concept for developing a SARS-CoV-2 spike protein receptor-binding domain (RBD) antigen as a yeast-derived recombinant protein vaccine technology is described. AREAS COVERED: Genetic Engineering: The strategy is presented for the design and genetic modification used during cloning and expression in the yeast system. Process and Assay Development: A summary is presented of how a scalable, reproducible, and robust production process for the recombinant protein COVID-19 vaccine antigen was developed. Formulation and Pre-clinical Strategy: We report on the pre-clinical and formulation strategy used for the proof-of-concept evaluation of the SARS-CoV-2 RBD vaccine antigen. Technology Transfer and Partnerships: The process used for the technology transfer and co-development with LMIC vaccine producers is described. Clinical Development and Delivery: The approach used by LMIC developers to establish the industrial process, clinical development, and deployment is described. EXPERT OPINION: Highlighted is an alternative model for developing new vaccines for emerging infectious diseases of pandemic importance starting with an academic institution directly transferring their technology to LMIC vaccine producers without the involvement of multinational pharma companies.

Critical Care 1950 to 2022: Evolution of Medicine, Nursing, Technology, and Design.

Critical care units-designed for concentrated and specialized care-came from multiple parallel advances in medical, surgical, and nursing techniques and training taking advantage of new therapeutic technologies. Regulatory requirements and government policy impacted design and practice. After WWII, medical practice and education promoted further specialization. Hospitals offered newer, more extreme, and specialized surgeries and anesthesia enabled more complex procedures. ICUs developed in the 1950s, providing a recovery room's level of observation and specialized nursing to serve the critically ill, whether medical or surgical.

Rapid screening of benzyl dodecyl dimethyl ammonium bromide co-metabolic degrading bacteria based on NIR hyperspectral imaging technology.

As a typical disinfectant, the use of benzyl dodecyl dimethyl ammonium bromide (BDAB) has dramatically increased since the emergence of SARS-CoV-2, posing a threat to environmental balance and human health. Screening BDAB co-metabolic degrading bacteria is required for efficient microbial degradation. Conventional methods for screening co-metabolic degrading bacteria are laborious and time-consuming, especially when the number of strains is large. This study aimed to develop a novel method for the rapid screening of BDAB co-metabolic degrading bacteria from the cultured solid medium using near-infrared hyperspectral imaging (NIR-HSI) technology. Based on NIR spectra, the concentration of BDAB in the solid medium can be well predicted by partial least squares regression (PLSR) models, non-destructively and rapidly, with Rc2 > 0.872 and Rcv2 > 0.870. The results show that the predicted BDAB concentrations decrease after degrading bacteria utilization, comparing with the regions where no degrading bacteria grew. The proposed method was applied to directly identify the BDAB co-metabolic degrading bacteria cultured on the solid medium, and two kinds of co-metabolic degrading bacteria RQR-1 and BDAB-1 were correctly identified. This method provides a high-efficiency method for screening BDAB co-metabolic degrading bacteria from a large number of bacteria.

The Role of Advanced Technologies against COVID-19: Prevention, Detection, and Treatments.

Concurrent with the global outbreak of COVID-19, the race began among scientists to generate effective therapeutics for the treatment of COVID-19. In this regard, advanced technology such as nanotechnology, cell-based therapies, tissue engineering and regenerative medicine, nerve stimulation and artificial intelligence (AI) are attractive because they can offer new solutions for the prevention, diagnosis and treatment of COVID-19. Nanotechnology can design rapid and specific tests with high sensitivity for detecting infection and synthases new drugs and vaccines based on nanomaterials to directly deliver the intended antiviral agent to the desired site in the body and also provide new surfaces that do not allow virus adhesion. Mesenchymal stem cells and exosomes secreted from them apply in regenerative medicine and regulate inflammatory responses. Cell therapy and tissue engineering are combined to repair or substitute damaged tissues or cells. Tissue engineering using biomaterials, cells, and signaling molecules can develop new therapeutic and diagnostic platforms and help scientists fight viral diseases. Nerve stimulation technology can augment body's natural ability to modulate the inflammatory response and inhibit pro-inflammatory cytokines and consequently suppress cytokine storm. People can access free online health counseling services through AI and it helps very fast for screening and diagnosis of COVID-19 patients. This study is aimed first to give brief information about COVID-19 and the epidemiology of the disease. After that, we highlight important developments in the field of advanced technologies relevant to the prevention, detection, and treatment of the current pandemic.

Clinical characteristics of the host DNA-removed metagenomic next-generation sequencing technology for detecting SARS-CoV-2, revealing host local immune signaling and assisting genomic epidemiology.

Background: Metagenomic next-generation sequencing (mNGS) technology has been central in detecting infectious diseases and helping to simultaneously reveal the complex interplay between invaders and their hosts immune response characteristics. However, it needs to be rigorously assessed for clinical utility. The present study is the first to evaluate the clinical characteristics of the host DNA-removed mNGS technology for detecting SARS-CoV-2, revealing host local immune signaling and assisting genomic epidemiology. Methods: 46 swab specimens collected from COVID-19 patients were assayed by two approved commercial RT-qPCR kits and mNGS. The evolutionary tree of SARS-CoV-2 was plotted using FigTree directly from one sample. The workflow of removing the host and retaining the host was compared to investigate the influence of host DNA removal on the performances of mNGS. Functional enrichment analysis of DEGs and xCell score were used to explore the characteristics of host local immune signaling. Results: The detection rate of mNGS achieved 92.9% (26/28) for 28 samples with a Ct value ≤ 35 and 81.1% (30/37) for all 46 samples. The genome coverage of SARS-CoV-2 could reach up to 98.9% when the Ct value is about 20 in swab samples. Removing the host could enhance the sensitivity of mNGS for detecting SARS-CoV-2 from the swab sample but does not affect the species abundance of microbes RNA. Improving the sequencing depth did not show a positive effect on improving the detection sensitivity of SARS-CoV-2. Cell type enrichment scores found multiple immune cell types were differentially expressed between patients with high and low viral load. Conclusions: The host DNA-removed mNGS has great potential utility and superior performance on comprehensive identification of SARS-CoV-2 and rapid traceability, revealing the microbiome's transcriptional profiles and host immune responses.

Inflammatory profile of convalescent plasma to treat COVID: Impact of amotosalen/UVA pathogen reduction technology.

Blood products in therapeutic transfusion are now commonly acknowledged to contain biologically active constituents during the processes of preparation. In the midst of a worldwide COVID-19 pandemic, preliminary evidence suggests that convalescent plasma may lessen the severity of COVID-19 if administered early in the disease, particularly in patients with profound B-cell lymphopenia and prolonged COVID-19 symptoms. This study examined the influence of photochemical Pathogen Reduction Treatment (PRT) using amotosalen-HCl and UVA light in comparison with untreated control convalescent plasma (n= 72 - paired samples) - cFFP, regarding soluble inflammatory factors: sCD40L, IFN-alpha, IFN-beta, IFN-gamma, IL-1 beta, IL-6, IL-8, IL-10, IL-18, TNF-alpha and ex-vivo inflammatory bioactivity on endothelial cells. We didn't observe significant modulation of the majority of inflammatory soluble factors (8 of 10 molecules tested) pre- or post-PRT. We noted that IL-8 concentrations were significantly decreased in cFFP with PRT, whereas the IL-18 concentration was increased by PRT. In contrast, endothelial cell release of IL-6 was similar whether cFFP was pre-treated with or without PRT. Expression of CD54 and CD31 in the presence of cFFP were similar to control levels, and both were significant decreased in when cFFP had been pre-treated by PRT. It will be interesting to continue investigations of IL-18 and IL-8, and the physiopathological effect of PRT- treated convalescent plasma and in clinical trials. But overall, it appears that cFFP post-PRT were not excessively pro-inflammatory. Further research, including a careful clinical evaluation of CCP-treated patients, will be required to thoroughly define the clinical relevance of these findings.

CT medical image segmentation algorithm based on deep learning technology.

For the problems of blurred edges, uneven background distribution, and many noise interferences in medical image segmentation, we proposed a medical image segmentation algorithm based on deep neural network technology, which adopts a similar U-Net backbone structure and includes two parts: encoding and decoding. Firstly, the images are passed through the encoder path with residual and convolutional structures for image feature information extraction. We added the attention mechanism module to the network jump connection to address the problems of redundant network channel dimensions and low spatial perception of complex lesions. Finally, the medical image segmentation results are obtained using the decoder path with residual and convolutional structures. To verify the validity of the model in this paper, we conducted the corresponding comparative experimental analysis, and the experimental results show that the DICE and IOU of the proposed model are 0.7826, 0.9683, 0.8904, 0.8069, and 0.9462, 0.9537 for DRIVE, ISIC2018 and COVID-19 CT datasets, respectively. The segmentation accuracy is effectively improved for medical images with complex shapes and adhesions between lesions and normal tissues.

Technologies and social services. An overview of technology use by users of social services.

Information and communication technologies have significantly transformed the way advanced societies interact, produce, deliver services and consume resources. All walks of life are now touched by these technologies. However, compared to other areas of society, digital penetration is much lower in the development of and access to social services. The main objective of this paper was to find out what technological devices are used, how they are used and the way citizens interact with public bodies using technology to deliver social services. This has been part of a wider project on innovation in social services using participative methodologies centred on the development of local Hubs. The findings reveal a digital divide in technology-enabled access to social services that excludes the very people most in need of benefits and support.

Microneedle technology for potential SARS-CoV-2 vaccine delivery.

INTRODUCTION: Microneedle fabrication was conceptualized in the 1970s as devices for painless transdermal drug delivery. The last two decades have seen considerable research and financial investment in this area with SARS-CoV-2 and other vaccines catalyzing their application to in vivo intradermal vaccine delivery. Microneedle arrays have been fabricated in different shapes, geometries, formats, and out of different materials. AREAS COVERED: The recent pandemic has offered microneedle platforms the opportunity to be employed as a vehicle for SARS-CoV-2 vaccine administration. Various modes of vaccination delivery and the potential of microneedle array-based vaccines will be presented, with a specific focus placed on recent SARS-CoV-2 research. The advantages of microneedle-based vaccine administration, in addition to the major hurdles to their en masse implementation, will be examined. EXPERT OPINION: Considering the widely acknowledged disadvantages of current vaccine delivery, such as anxiety, pain, and the requirement for professional administration, a large shift in this research sphere is imminent. The SARS-CoV-2 pandemic has catalyzed the development of alternate vaccination platforms, working to avoid the requirement for mass vaccination centers. As microneedle vaccine patches are transitioning through clinical study phases, research will be required to prepare this technology for a more mass production environment.

The era of technology in healthcare: an evaluation of telerehabilitation on patient outcomes-a systematic review and meta-analysis protocol.

BACKGROUND: The World Health Organization announced the outbreak of the Coronavirus disease as a global pandemic on March 11, 2020. Since then, rapid implementation of telehealth approaches into the healthcare system have been evident. The pandemic has drastically impacted the lives of many around the globe and has detrimentally affected our healthcare systems, specifically with the delivery of healthcare. This has had many implications on rehabilitation services such as, occupational therapy, physiotherapy, and speech therapy. The delivery of mental health services remotely may be referred to as teletherapy, telemental health, telepsychiatry, and telepsychology. Telerehabilitation has become a necessity over the course of the pandemic due to safety concerns with COVID-19 transmission. The primary aim of this systematic review protocol is to evaluate the literature on the effect of telerehabilitation on patient outcomes and propose directives for future research based on the evidence reviewed. METHODS: A systematic review and meta-analysis will be conducted to examine the literature on the effect of telerehabilitation on patient outcomes following the Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) guidelines (PRISMA, 2015). The systematic review will use the following databases to examine the literature on telerehabilitation and patient outcomes: APA PsychINFO, Embase (Ovid), MEDLINE (Ovid), CINAHL, and Scopus. DISCUSSION: The utilization of telerehabilitation and similar telehealth treatments has increased throughout the COVID-19 pandemic. However, much is still unclear regarding the effectiveness of these methods in the delivery and service of healthcare, and their effect on health outcomes. This review will identify and address the knowledge gaps in the literature, which will provide further directions for future research. TRIAL REGISTRATION: This systematic review has been registered with PROSPERO under registration number CRD42022297849.

Teaching after the pandemic: The role of technostress and organizational support on intentions to adopt remote teaching technologies.

The ongoing COVID-19 pandemic has led to several changes in academic teaching practices. Although educational digital technologies have been crucial during the initial phases of the pandemic, their forced adoption has led to negative consequences. In the present study, we aimed to integrate the Technology Acceptance Model theoretical framework (Davis, 1989) by exploring the effects of some possible factors that influence the willingness to adopt digital learning tools in the future when the pandemic is over. Among them, technostress was considered one of the external factors that could have adversely affected digital teaching technology adoption in the future. In contrast, the perception of technical support offered by the university was considered a potential protective factor. A total of 463 Italian university faculty completed an online questionnaire at the end of the first semester (a.y. 2020-21). The frequency of distance teaching technologies usage behavior was measured objectively by extracting teachers' activities from the University's e-learning databases. Key findings indicated that distance teaching technologies' frequency of use increased technostress, which in turn negatively impacted the perception of ease of use. The latter influences - both directly and indirectly through perceived usefulness - the intentions to adopt distance learning tools after the pandemic. Organizational support negatively predicted technostress. Implications to help public institutions develop functional strategies to cope with the technological changes brought by the pandemic are discussed.

The APPLE Tree programme: Active Prevention in People at risk of dementia through Lifestyle, bEhaviour change and Technology to build REsiliEnce-randomised controlled trial.

BACKGROUND: Large-scale trials of multidomain interventions show that modifying lifestyle and psychological risk factors can slow cognitive decline. We aim to determine if a lower intensity, personally tailored secondary dementia prevention programme for older people with subjective or mild objective memory decline, informed by behaviour change theory, reduces cognitive decline over 2 years. METHODS: A multi-site, single-blind randomised controlled trial recruiting 704 older adults at high dementia risk due to mild cognitive impairment (MCI) or subjective cognitive decline (SCD). Participants are randomised using 1:1 allocation ratio to the APPLE Tree intervention versus control arm (dementia prevention information), stratified by site. The intervention explores and implements strategies to promote healthy lifestyle, increase pleasurable activities and social connections and improve long-term condition self-management. Two facilitators trained and supervised by a clinical psychologist deliver ten, 1-h group video call sessions over 6 months (approximately every fortnight), video-call 'tea breaks' (less structured, facilitated social sessions) in intervening weeks and individual goal-setting phone calls every 2 weeks. From 6 to 12 months, participants meet monthly for 'tea breaks', with those not attending receiving monthly goal-setting phone calls. Participants receive a food delivery, pedometer and website access to cognitive training and information about lifestyle modification. Follow-ups for all outcome measures are at 12 and 24 months. The primary outcome is cognition (Neuropsychological Test Battery (NTB) score) at 24 months. Secondary outcomes are quality of life, cost per quality-adjusted life year (QALY) and wellbeing and lifestyle factors the intervention targets (diet, vascular risk, body weight, activity, sleep, anxiety, depression, social networks and loneliness, alcohol intake and smoking). Participants from purposively selected sites participate in qualitative process evaluation interviews, which will be analysed using thematic analytic methods. DISCUSSION: If effective, the intervention design, involving remote delivery and non-clinical facilitators, would facilitate intervention roll-out to older people with memory concerns. TRIAL REGISTRATION: ISRCTN17325135 . Registration date 27 November 2019.

Pasos Hacia La Salud II: study protocol for a randomized controlled trial of a theory- and technology-enhanced physical activity intervention for Latina women, compared to the original intervention.

BACKGROUND: Latinas are at increased risk for many lifestyle-related chronic diseases and are one of the least physically active populations in the US Innovative strategies are needed to help Latinas achieve the health benefits associated with physical activity (PA). This manuscript describes the study protocol of the Pasos Hacia La Salud II Study, which builds upon our previous research to test an enhanced individually-tailored, text-message and website-delivered, Spanish-language intervention (enhanced intervention), in comparison to the original web-based Pasos Hacia La Salud Intervention (original intervention). METHODS: Sedentary Latinas between the ages of 18-65 will be recruited and will complete an orientation and baseline assessments. Participants will be subsequently randomized to the original intervention, or the Enhanced Intervention, which has greater targeting of theoretical constructs such as self-efficacy, enjoyment, and social support, and which uses text messages and more dynamic and refined website features to encourage increased website use. Using a linear mixed effects regression model, we will simultaneously estimate the intervention effects on mean accelerometer-measured hours/week of moderate-to-vigorous PA (MVPA) at 6, 12, 18, and 24 months, with a subject-specific intercept (intent-to-treat sample). Change in self-reported MVPA, measured via the 7-day Physical Activity Recall, will be assessed as a secondary outcome using a similar model. We will investigate potential mediators of the intervention effect using a multiple mediation approach, and potential moderators by evaluating potential interactions. As an exploratory outcome, we will study the differences (among both study arms) in cost, in US dollars, per minute increases in weekly mean MVPA. DISCUSSION: The original Pasos PA intervention showed efficacy in helping Latinas increase PA; we expect the Enhanced Intervention to help a larger proportion of participants to increase and maintain their PA long term. This web- and text-based enhanced intervention could have great reach and dissemination potential, which could be capitalized on in the future to help to advance health equity. Adaptations made in response to the COVID-19 pandemic are also described in this manuscript. TRIAL REGISTRATION: Clinical Trial Number: NCT03491592 . First posted April 9, 2018.

Beyond the Museum Walls: The Pandemic and the Prototypes Exhibit at the Conservatoire National des Arts et Métiers.

This article looks at the consequences of the health crisis for France's field of culture and its response since the first French lockdown from March to May 2020 and the second one between October 2020 and May 2021. One exhibition that had to close the day after it had just opened was Prototypes: From Experimentation to Innovation. The exhibition's organizers (the museum staff and a network to safeguard national scientific and technical heritage) quickly turned to technological tools to find alternative ways of reaching the public during the crisis: online and traveling exhibitions. Moving the exhibition online was successful; however, a review of the exhibition shows that to truly reach their audience, museum exhibits need to be seen in person.

Implementation of Blockchain Technology Could Increase Equity and Transparency in Organ Transplantation: A Narrative Review of an Emergent Tool.

In the last few years, innovative technology and health care digitalization played a major role in all medical fields and a great effort worldwide to manage this large amount of data, in terms of security and digital privacy has been made by different national health systems. Blockchain technology, a peer-to-peer distributed database without centralized authority, initially applied to Bitcoin protocol, soon gained popularity, thanks to its distributed immutable nature in several non-medical fields. Therefore, the aim of the present review (PROSPERO N° CRD42022316661) is to establish a putative future role of blockchain and distribution ledger technology (DLT) in the organ transplantation field and its role to overcome inequalities. Preoperative assessment of the deceased donor, supranational crossover programs with the international waitlist databases, and reduction of black-market donations and counterfeit drugs are some of the possible applications of DLT, thanks to its distributed, efficient, secure, trackable, and immutable nature to reduce inequalities and discrimination.

Telemedicine technologies and applications in the era of COVID-19 pandemic: A systematic review.

INTRODUCTION: Telemedicine services saw substantial surges in their use during the COVID-19 pandemic due to the lockdowns and characteristics of the pandemic. Therefore, the authors aimed to systematically review the telemedicine services provided during the COVID-19 pandemic and their potential applications. METHODS: The authors searched PubMed, Scopus, and Cochrane databases on September 14, 2021. Then, the retrieved records underwent two-step title/abstract and full-text screening processes, and the eligible articles were included for qualitative synthesis. RESULTS: The review of studies demonstrated that the telephone is listed 38 times, making it the most common technology used in telemedicine. Video conferencing is also mentioned in 29 articles, as well as other technologies: Mobile-health (n = 15), Virtual reality (n = 7). According to the findings of the present study, Tele-follow-up (n = 24), Tele-consulting (n = 20), Virtual visits (20), and Tele-monitoring (n = 18) were the most widely used telemedicine applications. CONCLUSION: Telemedicine has been an effective approach to COVID-19 management. Telemedicine technology is going to play a key role in the future of health medicine, patient consultation, and many other extended applications of health care in remote rural locations.