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Open Educational Resources (OER) in higher education cannot be put into practice without considering institutional contexts, which differ not only globally but also within the same country. Each institutional context provides educators with opportunities or limitations where Open Educational Practices (OEP) and OER for teaching and learning are involved. As part of a broader research project, and as a follow-up to national perspectives, an international comparison was conducted, based on institutional cases of nine different higher education systems (Australia, Canada, China, Germany, Japan, South Africa, South Korea, Spain, Turkey). Aspects regarding the availability of infrastructure and institutional policies for OER, as well as the existence of measures directed at OER quality assurance and at the promotion of the development and use of OER were covered. The resulting theoretical contribution sheds light on an international comparative view of OER and points towards country-specific trends, as well as differences among institutions. These aspects could provide an impetus for the development of institutional guidelines and measures. In line with international literature on the topic, recommendations are derived to promote/ enhance the use of OER in teaching and learning in higher education at the institutional level.

When driving at night, flickering automobile LED tail lights can appear as multiple images. The perception of a flickering source of light was therefore studied during rapid eye movements (saccades) of 20–40° amplitude in an otherwise dark room (<1 lux). The temporal modulation appeared as a spatial pattern known as a ‘phantom array’ during the saccade. The appearance of the pattern enabled the discrimination of flicker from steady light at frequencies that in 11 observers averaged 1.98 kHz. At a frequency of 120 Hz, the intrasaccadic pattern was perceptible when the contrast of the flicker exceeded 10%. It is possible that intrasaccadic stimulation interferes with ocular motor control. [ABSTRACT FROM AUTHOR]

Suboptimal antiretroviral adherence is associated with poorer HIV outcomes. Psychosocial factors, including life stress, depression and coping, may influence adherence behavior. This prospective investigation sought to examine the impact of life stress (acute life events, chronic stress, and perceived stress), depression, and coping style on adherence to HIV treatment regimes over time. Participants were 87 treatment-seeking HIV-infected individuals recruited from an urban HIV clinic. They completed clinician-administered interviews and self-report questionnaires at baseline and 3-month follow-up. Acute life events and chronic stress prospectively predicted decreases in treatment adherence more strongly among individuals in a major depressive episode ( n = 21) compared to non-depressed individuals ( n = 66). Coping style did not appear to be the mechanism by which life stress influenced adherence among depressed HIV-infected individuals. These findings demonstrate that life stress has toxic effects for depressed individuals and suggest that treatment adherence interventions with depressed individuals could be enhanced via development of stress management skills. [ABSTRACT FROM AUTHOR]

Background and Purpose: No longitudinal study on sensory processing in children with fragile X syndrome (FXS) exists. This study examined developmental trajectories and correlates of sensory processing from infancy through preschool years in 13 boys with FXS. Method: Participants were assessed using observational and parentreport measures 2-6 times between 9 and 54 months of age. Results: Over time, an increasing proportion of boys displayed sensory processing that differed significantly from test norms. Observational measures were more sensitive than parent-reports early in infancy. Age and developmental quotient significantly predicted levels of hyporesponsiveness; there was a trend for hyperresponsiveness to increase with age. Baseline physiological and biological measures were not predictive. Conclusions: Sensory processing problems are observable early and grow increasingly problematic from infancy through the preschool ages. Early identification and intervention may attenuate long-term difficulties for children with FXS. [ABSTRACT FROM AUTHOR]

Objective. African American children exposed to multiple social risk factors during early childhood often experience academic difficulties, so identification of protective factors is important. Design. Academic and school behavior trajectories from kindergarten through third grade were studied among 75 African American children who have been followed prospectively since infancy to test hypothesized protective factors: quality of home and child care environments during early childhood, child language and social skills at entry to kindergarten, and school characteristics. Results. Children exposed to multiple risks in early childhood showed lower levels of academic and social-emotional skills from kindergarten through third grade. Parenting mediated the association with risk. Children's language skills, parenting, and child care quality serve as protective factors in acquisition of mathematics skills and reduction in problem behaviors during the first 4 years of primary school for African American children facing multiple risks. Attending a school with a higher proportion of children from low-income families might predict increasing numbers of problem behaviors over time. Conclusions. Exposure to social risk in early childhood negatively predicted academic achievement and adjustment during early elementary school for African American children, in part through associations between exposure to social risk and less responsive and stimulating parenting. Furthermore, the negative associations between risk and academic outcomes were substantially weaker when children had more responsive and sensitive parents or child care providers or entered school with stronger language skills. [ABSTRACT FROM AUTHOR]

This study utilized retrospective video analysis to distinguish sensory-motor patterns in infants with fragile X syndrome (FXS) (n = 11) from other infants [i.e., autism (n = 11), other developmental delay (n = 10), typical (n = 11)] at 9-12 months of age. Measures of development, autistic features, and FMRP were assessed at the time of entry into the study. Home videos collected from families were edited and coded with previously validated procedures. Findings revealed a pattern of sensory-motor features (e.g., repetitive leg movements, posturing, less sophistication/repetitive use of objects) associated with FXS, and suggest these infants were most similar to the group of infants with other developmental delays, irrespective of co-existing autistic symptoms later in life. Infant sensory-motor features in the FXS group were more predictive of an early developmental milestone (i.e., age walking) than later, more broad, developmental outcomes, or FMRP. Implications for early identification and differential diagnosis are discussed. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Otitis media with effusion (OME) is a common health care problem for children. The purpose of this study was to examine factors that place children at risk for OME such as age, type of child care, number of people in the household, and smoking in the household. METHODS: Eighty-six African American children, enrolled in center-based child care in infancy, entered the study at a mean age of 8.2 months and were followed prospectively until 48 months of age. Ear status was documented biweekly using pneumatic otoscopy and tympanometry. Data on risk factors were collected every 6 months. RESULTS: Results indicated that children had a marked decrease in the proportion of time with OME between 6 and 48 months. The rate of OME decline was faster in the first 2.5 years than in subsequent years. Children in center-based child care showed a slightly slower rate of decline than did children in non-center-based care. Longitudinal analysis indicated that the age of the child and the number of other children in the household were significant predictors of OME. For each additional child under 12 years of age in the home, there was a 2% increase in the proportion of time with OME. CONCLUSION: While attendance in group child care predicted a risk for OME, children's age and the number of other children in the household were still contributing risk factors for OME. [ABSTRACT FROM AUTHOR]

Recognition that the available evidence does not support arbitrary time limits for the second stage of labor has led to reconsideration of the influence of maternal bearing down efforts on fetal/newborn status as well as on maternal pelvic structural integrity. The evidence that the duration of 'active' pushing is associated with fetal acidosis and denervation injury to maternal perineal musculature has contributed to the delineation of at least two phases during second stage, an early phase of continued fetal descent, and a phase of 'active' pushing. The basis for the recommendation that the early phase of passive descent be prolonged and the phase of active pushing shortened by strategies to achieve effective, but non-detrimental pushing efforts is reviewed. The rational includes an emphasis on the obstetric factors that are optimal for birth and conducive to efficient maternal bearing down. Explicit assessment of these obstetric factors and observation of maternal behavior, particularly evidence of an involuntary urge to push, should be coupled with the use of maternal positions that will promote fetal descent as well as reduce maternal pain. The use of epidural analgesia for pain relief can also be accompanied by these same principles, although further research is needed to verify the strategies of 'delayed pushing' and maintenance of pain relief along with a reconceptualization of the second stage of labor. [ABSTRACT FROM AUTHOR]

In the United States, state governments play a central role in determining the extent to which midwives can provide care to women and babies. State laws and regulations establish midwives' scope of practice, set licensure requirements, and frequently determine their ability to get paid and obtain access to health care facilities. For certified nurse-midwives (CNMs), state regulation has evolved from a haphazard patchwork of highly variable regulatory models into a fairly uniform set of rules and requirements from one state to the next. For direct entry midwives (DEMs), there is much less uniformity, with some states outlawing practice by any midwife who is not a CNM, whereas other states have established rigorous standards and requirements for the licensure of DEMs. This article provides a broad overview of these state regulatory variables for both CNMs and DEMs, and explores issues and options that both state regulators and midwives should consider when developing or amending state laws and regulations governing their practice. In particular, the role of the state in regulating the practice of the certified midwife (CM) is examined in the context of existing regulatory frameworks for CNMs and DEMs. [ABSTRACT FROM AUTHOR]

There is growing interest in the development of transient, multiphysics models for nuclear reactors and analysis of uncertainties in those models. Reduced-order models (ROMs) provide a computationally cheaper alternative to compute uncertainties. However, the application of ROMs to transient systems remains a challenging task. Here, a 1-D, twogroup, time-dependent, diffusion model was used to explore the potential of three different ROMs: the intrusive POD-Galerkin and DMD-Galerkin methods and the purely datadriven DMD. For the problem studied, POD-Galerkin exhibited by far the best accuracy and was selected for further application to uncertainty propagation. Perturbations were introduced to the initial condition and to the cross-section data. A greedy-POD sampling procedure was used to construct a reduced space that captured much of the variation in the uncertain these parameters. Results indicate that relatively few samples of the uncertain parameters are needed to produce a basis for POD-Galerkin that leads to distributions of the quantities of interest that match well with those obtained from the full-order model using brute-force, forward sampling.

Until recently, reactor transient problems were exclusively solved by approximate deterministic methods. The increase in available computing power made it feasible to approach the transient analyses with time-dependent Monte Carlo methods. These methods offer the first-principle solution to the space-time evolution of reactor power by explicitly tracking prompt neutrons, precursors of delayed neutrons and delayed neutrons in time and space. Nevertheless, a very significant computing cost is associated with such methods. The general benefits of the Monte Carlo approach may be retained at a reduced computing cost by applying a hybrid stochastic-deterministic computing scheme. Among such schemes are those based on the fission matrix and the response matrix formalisms. These schemes aim at estimating a variant of the Greens function during a Monte Carlo transport calculation, which is later used to formulate a deterministic approach to solving a space-time dependent problem. In this contribution, we provide an overview of the time-dependent response matrix method, which describes a system by a set of response functions. We have recently suggested an approach where the functions are determined during a Monte Carlo criticality calculation and are then used to deterministically solve the space-time behaviour of the system. Here, we compare the time-dependent response matrix solution with the transient fission matrix and the time-dependent Monte Carlo solutions for a control rod movement problem in a mini-core reactor geometry. The response matrix formalism results in a set of loosely connected equations which offers favourable scaling properties compared to the methods based on the fission matrix formalism.

An improved computational model of the University of Wisconsin Nuclear Reactor (UWNR) was developed to support the benchmark evaluation of recent data acquired during an experimental campaign conducted at UWNR. Previous efforts led to a scripted UWNR model for automated generation of MCNP6 and Serpent inputs. This capability was extended to SCALE/KENO. All three tools were used to evaluate a variety of zero-power, fresh-critical configurations, and the results agreed well. The MCNP6 model was extended to support shuffling the core configuration, which allows the modeling of burnup for evaluation of depleted critical configurations. The MCNP6 model successfully predicts core reactivity over time, after accounting for the initial reactivity bias. The inclusion of SCALE/KENO input generation enables sensitivity and uncertainty analyses using the TSUNAMI and Sampler modules of SCALE. A preliminary uncertainty analysis was performed with TSUNAMI for nuclear data uncertainties while direct perturbation calculations were performed using MCNP6 for geometry and material uncertainties, which helped to identify model parameters with the largest effect on the eigenvalue. A transient UWNR transport Model in Mammoth/Rattlesnake is under development to simulate the transient experiments. The existing MCNP6 and Serpent models are used to provide the CAD file for meshing and homogenized cross-sections. In conclusion, the evaluation of UWNR benchmark data provides increased confidence in various states of the UWNR computational model and will provide a unique model for use by other analysts.

The relationships between aspects of mother-infant interaction and both communication and cognitive skills at 1 year of age were examined in 92 African American dyads, of whom 64 (70%) fell below the poverty line. Ratings of warmth, sensitivity, responsiveness, encouragement of initiative, stimulation, and elaborativeness during a semistructured play interaction were correlated with measures of global cognition, expressive and receptive communication, and communication use. The overall quality of the home environment and maternal ratings of stimulation and elaborativeness were the most consistent correlates of infant communication measures. Relationships were stronger in middle-income than lower-income dyads. These results support the linkage of didactic and functional aspects of maternal behavior to cognitive and communication skills at 1 year of age for African American infants. [ABSTRACT FROM AUTHOR]

Presented is a short, computational study on the potential use of multichambered fission detectors for in-core, neutron spectroscopy. Motivated by the development of very small fission chambers at CEA in France and at Kansas State University in the U.S., it was assumed in this preliminary analysis that devices can be made small enough to avoid flux perturbations and that uncertainties related to measurements can be ignored. It was hypothesized that a sufficient number of chambers with unique reactants can act as a real-time, foilactivation experiment. An unfolding scheme based on maximizing (Shannon) entropy was used to produce a flux spectrum from detector signals that requires no prior information. To test the method, integral, detector responses were generated for singleisotope detectors of various Th, U, Np, Pu, Am, and Cs isotopes using a simplified, pressurized-water reactor spectrum and fluxweighted, microscopic, fission cross sections, in the WIMS-69 multigroup format. An unfolded spectrum was found from subsets of these responses that had a maximum entropy while reproducing the responses considered and summing to one (that is, they were normalized). Several nuclide subsets were studied, and, as expected, the results indicate inclusion of more nuclides leads to better spectra but with diminishing improvements, with the best-case spectrum having an average, relative, group-wise error of approximately 51%. Furthermore, spectra found from minimum-norm and Tihkonov-regularization inversion were of lower quality than the maximum entropy solutions. Finally, the addition of thermal-neutron filters (here, Cd and Gd) provided substantial improvement over unshielded responses alone. The results, as a whole, suggest that in-core, neutron spectroscopy is at least marginally feasible.

Advancements in nuclear reactor core modeling and computational capability have encouraged further development of in-core neutron sensors. Measurement of the neutron-flux distribution within the reactor core provides a more complete understanding of the operating conditions in the reactor than typical ex-core sensors. Micro-Pocket Fission Detectors have been developed and tested previously but have been limited to single-node operation and have utilized highly specialized designs. The development of a widely deployable, multi-node Micro-Pocket Fission Detector assembly will enhance nuclear research capabilities. A modular, four-node Micro-Pocket Fission Detector array was designed, fabricated, and tested at Kansas State University. The array was constructed from materials that do not significantly perturb the neutron flux in the reactor core. All four sensor nodes were equally spaced axially in the array to span the fuel-region of the reactor core. The array was filled with neon gas, serving as an ionization medium in the small cavities of the Micro-Pocket Fission Detectors. The modular design of the instrument facilitates the testing and deployment of numerous sensor arrays. The unified design drastically improved device ruggedness and simplified construction from previous designs. Five 8-mm penetrations in the upper grid plate of the Kansas State University TRIGA Mk. II research nuclear reactor were utilized to deploy the array between fuel elements in the core. The Micro-Pocket Fission Detector array was coupled to an electronic support system which has been specially developed to support pulse-mode operation. The Micro-Pocket Fission Detector array composed of four sensors was used to monitor local neutron flux at a constant reactor power of 100 kWth at different axial locations simultaneously. The array was positioned at five different radial locations within the core to emulate the deployment of multiple arrays and develop a 2-dimensional measurement of neutron flux in the reactor core.

OBJETIVO: A tuberculose é uma das maiores causas de mortalidade no mundo, porém seus efeitos econômicos são pouco conhecidos. O objetivo do estudo foi o de estimar os custos do tratamento e prevenção da tuberculose para o sistema de saúde (público e privado) e para as famílias. MÉTODOS: O estudo foi realizado no município de Salvador, BA, em 1999. Os dados para estimação dos custos para o sistema de saúde foram coletados nas secretarias de saúde, centros de saúde e em uma entidade filantrópica. Os custos públicos e privados foram estimados pela metodologia da contabilidade de custos. Os dados de custos para as famílias foram coletados por meio de questionários e incluem despesas com transporte, alimentação e outros, bem como as perdas de renda associadas à doença. RESULTADOS: O custo médio para tratamento de um caso novo de tuberculose foi de aproximadamente R$186,00 (US$103); para o tratamento de um paciente multiresistente o custo foi 27 vezes mais alto. Os custos para o serviço público corresponderam a 65% em internações, 32% em tratamento e apenas 3% em prevenção. As famílias comprometeram cerca de 33% da sua renda com despesas relacionadas a tuberculose. CONCLUSÕES: Apesar do fato das famílias não terem que pagar por medicamentos e tratamento, dado que este serviço é oferecido pelo Estado, os custos familiares ligados a perda de rendimentos devido a doença foram muito elevados. A proporção utilizada em prevenção pelo serviço público é pequena. Um maior investimento em campanhas de prevenção poderia não somente diminuir o número de casos, mas também, levar a um diagnósticos precoce, diminuindo os custos associados à hospitalização. A falta de um sistema integrado de custos não permite a visualização dos custos nos diversos setores.

Abstract Background Mapping from health status measures onto generic preference-based measures is becoming a common solution when health state utility values are not directly available for economic evaluation. However the accuracy and reliability of the models employed is largely untested, and there is little evidence of their suitability in patient datasets. This paper examines whether mapping approaches are reliable and accurate in terms of their predictions for a large and varied UK patient dataset. Methods SF-36 dimension scores are mapped onto the EQ-5D index using a number of different model specifications. The predicted EQ-5D scores for subsets of the sample are compared across inpatient and outpatient settings and medical conditions. This paper compares the results to those obtained from existing mapping functions. Results The model including SF-36 dimensions, squared and interaction terms estimated using random effects GLS has the most accurate predictions of all models estimated here and existing mapping functions as indicated by MAE (0.127) and MSE (0.030). Mean absolute error in predictions by EQ-5D utility range increases with severity for our models (0.085 to 0.34) and for existing mapping functions (0.123 to 0.272). Conclusion Our results suggest that models mapping the SF-36 onto the EQ-5D have similar predictions across inpatient and outpatient setting and medical conditions. However, the models overpredict for more severe EQ-5D states; this problem is also present in the existing mapping functions.

Abstract Background Welding fume has been categorized as "possibly carcinogenic" to humans. Our objectives were to characterize the lung response to carcinogenic and non-carcinogenic metal-containing welding fumes and to determine if these fumes caused increased lung tumorigenicity in A/J mice, a lung tumor susceptible strain. We exposed male A/J and C57BL/6J, a lung tumor resistant strain, by pharyngeal aspiration four times (once every 3 days) to 85 μg of gas metal arc-mild steel (GMA-MS), GMA-stainless steel (SS), or manual metal arc-SS (MMA-SS) fume, or to 25.5 μg soluble hexavalent chromium (S-Cr). Shams were exposed to saline vehicle. Bronchoalveolar lavage (BAL) was done at 2, 7, and 28 days post-exposure. For the lung tumor study, gross tumor counts and histopathological changes were assessed in A/J mice at 48 and 78 weeks post-exposure. Results BAL revealed notable strain-dependent differences with regards to the degree and resolution of the inflammatory response after exposure to the fumes. At 48 weeks, carcinogenic metal-containing GMA-SS fume caused the greatest increase in tumor multiplicity and incidence, but this was not different from sham. By 78 weeks, tumor incidence in the GMA-SS group versus sham approached significance (p = 0.057). A significant increase in perivascular/peribronchial lymphoid infiltrates for the GMA-SS group versus sham and an increased persistence of this fume in lung cells compared to the other welding fumes was found. Conclusion The increased persistence of GMA-SS fume in combination with its metal composition may trigger a chronic, but mild, inflammatory state in the lung possibly enhancing tumorigenesis in this susceptible mouse strain.

Abstract Background Squamous cell carcinoma (SCC) of the skin is the most aggressive form of non-melanoma skin cancer (NMSC), and is the single most commonly diagnosed cancer in the U.S., with over one million new cases reported each year. Recent studies have revealed an oncogenic role of activated signal transducer and activator of transcription 3 (Stat3) in many human tumors, especially in those of epithelial origin, including skin SCC. Stat3 is a mediator of numerous growth factor and cytokine signaling pathways, all of which activate it through phosphorylation of tyrosine 705. Results To further address the role of Stat3 in skin SCC tumorigenesis, we have analyzed a panel of human skin-derived cell lines ranging from normal human epidermal keratinocytes (NHEK), to non-tumorigenic transformed skin cells (HaCaT), to highly tumorigenic cells (SRB1-m7 and SRB12-p9) and observed a positive correlation between Stat3 phosphorylation and SCC malignancy. We next determined the role of Stat3 activity in cell proliferation and viability under serum-free culture conditions. This was accomplished by suppressing Stat3 activity in the SRB12-p9 cells through stable expression of a dominant negative acting form of Stat3β, which contains a tyrosine 705 to phenylalanine mutation (S3DN). The S3DN cells behaved similar to parental SRB12-p9 cells when cultured in optimal growth conditions, in the presence of 10% fetal calf serum. However, unlike the SRB12-p9 cells, S3DN cells underwent apoptotic cell death when cultured in serum-free medium (SFM). This was evidenced by multiple criteria, including accumulation of sub-G1 particles, induced PARP cleavage, and acquisition of the characteristic morphological changes associated with apoptosis. Conclusion This study provides direct evidence for a role for Stat3 in maintaining cell survival in the conditions of exogenous growth factor deprivation produced by culture in SFM. We also propose that delivery of the S3DN gene or protein to tumor cells could induce apoptosis and/or sensitize those cells to the apoptotic effects of cancer therapeutic agents, raising the possibility of using S3DN as an adjunct for treatment of skin SCC.

Abstract Background The aim of the study was to develop a menopause-specific, preference-based health-related quality-of-life (HRQoL) index reflecting both menopausal symptoms and potential side-effects of Hormone Replacement Therapy (HRT). Methods The study had three phases: the development of a health state classification, a prospective valuation survey and the estimation of a model to interpolate HRQoL indices for all remaining health states as defined by the classification. A menopausal health state classification was developed with seven dimensions: hot flushes, aching joints/muscles, anxious/frightened feelings, breast tenderness, bleeding, vaginal dryness and undesirable androgenic signs. Each dimension contains between three and five levels and defines a total of 6,075 health states. A sample of 96 health states was selected for the valuation survey. These states were valued by a sample of 229 women aged 45 to 60, randomly selected from 6 general practice lists in Sheffield, UK. Respondents were asked to complete a time trade-off (TTO) task for nine health states, resulting in an average of 16.5 values for each health state. Results Mean health states valued range from 0.48 to 0.98 (where 1.0 is full health and zero is for states regarded as equivalent to death). Symptoms, as described by the classification system, can be rank-ordered in terms of their impact (from high to low) on menopausal HRQoL as follows: aching joints and muscles, bleeding, breast tenderness, anxious or frightened feelings, vaginal dryness, androgenic signs. Hot flushes did not significantly contribute to model fit. The preferred model produced a mean absolute error of 0.053, but suffered from bias at both ends of the scale. Conclusion This article presents an attempt to directly value a condition specific health state classification. The overall fit was disappointing, but the results demonstrate that menopausal symptoms are perceived by patients to have a significant impact on utility. The overall effect is modest compared to the more generic health state descriptions such as the EQ-5D. The resultant algorithm generates a preference-based index that can be used economic evaluation and that reflects the impact of this condition.

Abstract Background Influenza vaccination policy for elderly people in Britain has changed twice since 1997 to increase protection against influenza but there is no information available on how this has affected vaccine uptake, and socioeconomic variation therein, among people aged over 74 years. Methods Vaccination information for 1997–2000 was collected directly from general practices taking part in a MRC-funded Trial of the Assessment and Management of Older People in the Community. This was linked to information collected during assessments carried out as part of the Trial. Regression modelling was used to assess relative probabilities (as relative risks, RR) of having vaccination according to year, gender, age, area and individual socioeconomic characteristics. Results Out of 106 potential practices, 73 provided sufficient information to be included in the analysis. Uptake was 48% (95% CI 45%, 55%) in 1997 and did not increase substantially until 2000 when the uptake was a third higher at 63% (50%, 66%). Vaccination uptake was lower among women than men (RR 0.9), people aged 85 or more compared to people aged under 80 (RR 0.9), those in the most deprived areas (RR 0.8) compared to the least deprived, and was relatively high for those in owner-occupied homes with central heating compared to other non-supported housing (RR for remainder = 0.9). This pattern did not change over the years studied. Conclusions Increased uptake in 2000 may have resulted from the additional financial resources given to practices; it was not at the expense of more disadvantaged socioeconomic groups but nor did they benefit disproportionately.

Abstract Background Appropriate information flow is crucial to the care of patients, particularly at the interface between primary and secondary care. Communication problems can result from inadequate organisation and training, There is a major expectation that information and communication technologies may offer solutions, but little reliable evidence. This paper reports the design and performance of a multi-centre randomised controlled trial (RCT), unparalleled in telemedicine research in either scale or range of outcomes. The study investigated the effectiveness and cost implications in rural and inner-city settings of using videoconferencing to perform joint tele-consultations as an alternative to general practitioner referral to the hospital specialist in the outpatient clinic. Methods Joint tele-consultation services were established in both the Royal Free Hampstead NHS Trust in inner London, and the Royal Shrewsbury Hospitals Trust, in Shropshire. All the patients who gave consent to participate were randomised either to joint tele-consultation or to a routine outpatients appointment. The principal outcome measures included the frequency of decision by the specialist to offer a follow-up outpatient appointment, patient satisfaction (Ware Specific Questionnaire), wellbeing (SF12) and enablement (PEI), numbers of tests, investigations, procedures and treatments. Results A total of 134 general practitioners operating from 29 practices participated in the trial, referring a total of 3170 patients to 20 specialists in ENT medicine, general medicine (including endocrinology, and rheumatology), gastroenterology, orthopaedics, neurology and urology. Of these, 2094 patients consented to participate in the study and were correctly randomised. There was a 91% response rate to the initial assessment questionnaires, and analysis showed equivalence for all key characteristics between the treatment and control groups. Conclusion We have designed and performed a major multi-centre trial of teleconsultations in two contrasting centres. Many problems were overcome to enable the trial to be carried out, with a considerable development and learning phase. A lengthier development phase might have enabled us to improve the patient selection criteria, but there is a window of opportunity for these developments, and we believe that our approach was appropriate, allowing the evaluation of the technology before its widespread implementation.