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Aims Ca2+ waves are thought to be important in the aetiology of ventricular tachyarrhythmias. There have been conflicting results regarding whether flecainide reduces Ca2+ waves in isolated cardiomyocytes. We sought to confirm whether flecainide inhibits waves in the intact cardiomyocyte and to elucidate the mechanism. Methods and results We imaged spontaneous sarcoplasmic reticulum (SR) Ca2+ release events in healthy adult rat cardiomyocytes. Variation in stimulation frequency was used to produce Ca2+ sparks or waves. Spark frequency, wave frequency, and wave velocity were reduced by flecainide in the absence of a reduction of SR Ca2+ content. Inhibition of I Na via alternative pharmacological agents (tetrodotoxin, propafenone, or lidocaine) produced similar changes. To assess the contribution of I Na to spark and wave production, voltage clamping was used to activate contraction from holding potentials of −80 or −40 mV. This confirmed that reducing Na+ influx during myocyte stimulation is sufficient to reduce waves and that flecainide only causes Ca2+ wave reduction when I Na is active. It was found that Na+/Ca2+-exchanger (NCX)-mediated Ca2+ efflux was significantly enhanced by flecainide and that the effects of flecainide on wave frequency could be reversed by reducing [Na+]o, suggesting an important downstream role for NCX function. Conclusion Flecainide reduces spark and wave frequency in the intact rat cardiomyocyte at therapeutically relevant concentrations but the mechanism involves I Na reduction rather than direct ryanodine receptor (RyR2) inhibition. Reduced I Na results in increased Ca2+ efflux via NCX across the sarcolemma, reducing Ca2+ concentration in the vicinity of the RyR2.

The potential of sodium fluoride to affect spermatogenesis in the rat was assessed by intratesticular injection. Experimental rats' left testis was injected with sodium fluoride (50, 175 and 250 ppm) in vehicle (0.9% physiological saline); control testes were injected with vehicle. The right testis served as a non-injected control. Testicular tissues collected ‘at’ and ‘distal to’ the injection site and from the non-injected control testes were evaluated microscopically 24 hr and 1, 2 and 3 wk post-injection. Testicular tissues obtained at and distal to the injection site in all fluoride-injected groups resembled tissues collected from corresponding areas in the controls. Seminiferous tubule damage observed in both the vehicle-injected control testes and the fluoride-injected testes but not in the non-injected testes was attributed to injection trauma. Polymorphonuclear leucocyte infiltration was observed 24 hr post injection only at the injection site in the vehicle- and fluoride-injected groups. Leydig cells were unaffected. Leucocyte infiltration with seminiferous tubule damage was not considered to be a fluoride treatment-related effect because it was observed in both vehicle- and fluoride-injected testes. The results demonstrate that spermatogenesis in the rat is not adversely affected by direct exposure to fluoride at levels 200 times greater than those under normal conditions.

Neurons exhibiting reduced nicotinamide adenine dinucleotide phosphate-diaphorase activity (NADPHd) were quantified at 500 μm rostrocaudal intervals in spinal trigeminal nucleus (Vsp) of adenalectomized (ADX), ADX + corticosterone, and sham-ADX rats 6–12 days after surgery. NADPHd neurons were found predominantly in Vsp subnucleus caudalis (Vc) and in dorsomedial subnucleus oralis. ADX significantly increased the number of NADPHd neurons in superficial laminae of Vc, an effect reversed by chronic corticosterone replacement. ADX effects on NADPHd in superficial laminae of Vc but not in deep laminae of Vc or in the periobex region of Vsp paralleled previously observed sites of ADX enhancement of noxious stimulus-induced Fos-like immunoreactivity. The results indicate that chronic changes in adrenal steroid status regulate NADPHd, a mechanism that may both derive from changes in nitric oxide synthase expression and influence the processing of nociceptive information by central trigeminal neurons.

The pyrazolone dye Orange B was given by gavage to pregnant Osborne- Mendel rats throughout gestation. Dose levels of 0, 15, 30, 100, 200, 400, or 700 mglkg body weight were given daily. On gestation day 20, the females were killed and cesarean sections were performed. Feed consumption and maternal weight gain were not affected. No dose-related changes were seen in maternal clinical findings, implantations, fetal viability, or fetal size (weight and length). No compound-related effects were seen in sternebral development. No dose- related effect was seen in the incidence of skeletal variations in fetuses or in the number of litters containing fetuses with skeletal variations. Skeletal development, as measured by the average number of ossified vertebrae, was similar in all groups. No compound-related effects were seen in soft-tissue development.

This paper focuses on enabling multi-robot teams to cooperatively perform tasks without the use of radio or acoustic communication. One key to more effective cooperative interaction in a multi-robot team is the ability to understand the behavior and intent of other robots. This is similar to the honey bee “waggle dance” in which a bee can communicate the orientation and distance of a food source. In this similar manner, our heterogenous multi-robot team uses a specific behavior to indicate the location of mine-like objects (MLOs). Observed teammate action sequences can be learned to perform behavior recognition and task-assignment in the absence of communication. We apply Conditional Random Fields (CRFs) to perform behavior recognition as an approach to task monitoring in the absence of communication in a challenging underwater environment. In order to demonstrate the use of behavior recognition of an Autonomous Underwater Vehicle (AUV) in a cooperative task, we use trajectory based techniques for model generation and behavior discrimination in experiments using simulated scenario data. Results are presented demonstrating heterogenous teammate cooperation between an AUV and an Autonomous Surface Vehicle (ASV) using behavior recognition rather than radio or acoustic communication in a mine clearing task.

Despite the chronic exposure of the US population to fluoridated drinking water since the 1940s, existing studies have been judged inadequate to determine any potential reproductive or developmental hazard. This study was conducted to determine the effects of sodium fluoride (NaF) on foetal development. Sperm-positive female rats were given 0, 10, 25, 100, 175 or 250 ppm NaF daily throughout gestation. They were dosed by drinking water to mimic human exposure to fluoridated water. No dose-related behavioural changes or maternal clinical signs were noted. Fluid consumption by females in the 175- and 250-ppm groups was significantly less than that of the control females. Because of this decreased fluid consumption, the daily amount of NaF ingested (0, 1.4, 3.9, 15.6, 24.7 and 25.1 mg/kg body weight) was less than expected at the two high levels. Feed consumption decreased significantly at 250 ppm, and body weights of pregnant females reflected feed consumption trends. The mean number of viable foetuses per female in all treated groups was similar to that of the control group. The significant decrease in the mean number of implants per litter in the 250-ppm group is probably linked to the lower mean number of corpora lutea in this group. The occurrence of in utero deaths was similar in the control and treated groups. Foetal growth (in terms of foetal body weight and crown-rump length) was not affected by NaF, despite the fact that the dams in the 250-ppm group ate significantly less feed and drank significantly less fluid. There was no dose-related increase in the number of external anomalies in foetuses due to NaF ingestion. At the doses given, NaF had no effect on the development of specific bones, including sternebrae. A significant increase was seen in the average number of foetuses with three or more skeletal variations in the 250-ppm group; the number of litters with foetuses with three or more skeletal variations was increased in the 250-ppm group also, but the increase was not significant. There was no dose-related effect of NaF on the incidence of soft tissue variations.

This paper develops an analytic model of the macroscopic dynamics of the liquid encapsulated Czochralski (LEC) GaAs growth process together with a series of system identification experiments that confirm the validity of the model for control system design and analysis. The model combines the meniscus dynamics with a low-order model of the thermal dynamics of the process. the effective heat transfer coefficients used in the model are determined from a steady-state finite-element model of the process. The identification experiments confirm that the model gives accurate predictions of the dominant process dynamics and high frequency phase characteristics. Although the model gain at high frequencies is less accurate, the error can be identified and accommodated in the control system design and analysis process.

In a joint venture between The Family Journal and the Human Rights Committee of the Ameriuan Counseling Associatlon, a group of counseling professioIls joined together, using a roundtable format to discuss gender -related issues. The followinzg material is based on a transcription of their discus.si(m, zwhch took place in Minneapolis, Minnesota, on April 25, 1994, at the annual convention of the Ameriwan Cumnselin

According to recent studies, large numbers of children and adolescents with serious emotional or behavioral disorders receive either no mental health treatment or treatment inappropriate to their needs. In this article the authors examine the problem of unnecessary hospitalization and the inadequacy of community-based systems. They discuss the barriers that impede improved mental health service systems for children and their families and present the Child and Adolescent Service System Program (CASSP) “system of care” model as an alternative. Last, counseling and development's role in promoting and fostering positive changes in the mental health system serving children and adolescents is discussed.

The design, testing, and mission execution of a network of autonomous underwater vehicles (AUV) is a difficult process. The design of low-level controllers requires high-fidelity hydrodynamic models for simulation, but the testing of a large network of AUVs with high-order models is computationally challenging. Also, efficiency is achieved when developers can reuse components already implemented and tested by others in the community. An integrated development system is discussed where the Robot Operating System (ROS) is used to interface a number of individual systems that could not natively communicate. The system integrates the low-level controller simulation, mission planning, and mission execution processes. Most importantly, ROS was integrated with the Mission Oriented Operating Suite (MOOS), which allowed for the use of both ROS and MOOS applications within the same robotic platform via the MOOS/ROS Bridge application. Also, the 3D globe mapping program, NASA WorldWind, was interfaced to ROS via rosjava. The target AUV for the ROS implementation was the GTRI Yellowfin, which was developed for multiple AUV collaborative missions.

laboratory studies. 2. B/L subcostal (roof top) incision. 3. Completely mobilize the liver. 4. Carefully evaluate for evidence of metastatic disease by palpation and intraoperative ultrasound of liver including the caudate lobe, subhilar and retroduodenal area. 5. Examine all peritoneal surfaces. 6. Perform cholecystectomy by top-down technique. 7. Perform a complete Kocher maneuver. 8. Dissect the porta hepatis including the following: Circumferential dissection of the portal vein and hepatic ●

This procedure is performed for patients requiring long-term access for peritoneal dialysis. This chapter describes indications, essential steps, variations, and complications of this procedure. It provides a detailed template operative note for the procedure.

FD&C Red No. 3 (erythrosine) is a commonly used food additive. As part of a series of studies on the potential fetal developmental effects of food colors, FD&C Red No. 3 was administered by gavage to pregnant Osborne-Mendel rats at daily dose levels of 15, 30, 100, 200, 400, or 800 mg/kg on days 0-19 of gestation. Control animals were given distilled water by gavage. On gestation day 20, the animals were euthanized and cesarean sections were performed. During the entire treatment period, feed consumption by the animals given 400 mg/kg doses was increased significantly; the increases in the animals given 30 or 800 mg/kg were of borderline significance. The only significant increase in maternal weight gain, on days 0-7 in the animals given 30 mg/kg, was considered a random occurrence. No dose-related changes were seen in maternal clinical findings, implantations, fetal viability, or fetal size (weight and length). No fetal terata were seen, and neither skeletal nor visceral development was affected. FD&C Red No. 3 was neither fetotoxic nor teratogenic at 800 mg/kg when given by gavage.

As part of our research for the ARL MAST CTA (Collaborative Technology Alliance) [1], we present an integrated architecture that facilitates the design of microautonomous robot platforms and missions, starting from initial design conception to actual deployment. The framework consists of four major components: design tools, mission-specification system (MissionLab), case-based reasoning system (CBR Expert), and a simulation environment (USARSim). The designer begins by using design tools to generate a space of missions, taking broad mission-specific objectives into account. For example, in a multi-robot reconnaissance task, the parameters varied include the number of robots used, mobility capabilities (e.g. maximum speeds), and sensor capabilities. The design tools are used to intelligently carve out the space of all possible parameter combinations to produce a smaller set of mission configurations. Quantitative assessment of this design space is then performed in simulation to determine which particular configuration would yield an effective team before actual deployment. MissionLab, a mission-specification platform, is used to incorporate the input parameters, generate the underlying robot missions, and control the robots in simulation. It also provides logging mechanisms to measure a range of quantitative performance metrics, such as mission completion rates, resource utilization, and time to completion, which are then used to determine the best configuration for a particular mission. These metrics can also provide guidance for the refinement of the entire design process. Finally, a case-based reasoning system allows users to maximize successful deployment of the robots by retrieving proven configurations and determine the robot capabilities necessary for success in a particular mission.

This paper describes ongoing research by Georgia Tech into the challenges of tasking and controlling heterogonous teams of unmanned vehicles in mixed indoor/outdoor reconnaissance scenarios. We outline the tools and techniques necessary for an operator to specify, execute, and monitor such missions. The mission specification framework used for the purposes of intelligence gathering during mission execution are first demonstrated in simulations involving a team of a single autonomous rotorcraft and three ground-based robotic platforms. Preliminary results including robotic hardware in the loop are also provided.

The vision for the Micro Autonomous Systems Technologies MAST program is to develop autonomous, multifunctional, collaborative ensembles of agile, mobile microsystems to enhance tactical situational awareness in urban and complex terrain for small unit operations. Central to this vision is the ability to have multiple, heterogeneous autonomous assets to function as a single cohesive unit, that is adaptable, responsive to human commands and resilient to adversarial conditions. This paper represents an effort to develop a simulation environment for studying control, sensing, communication, perception, and planning methodologies and algorithms.

In 1982, the Food and Drug Administration (FDA) issued guidelines for testing the effects of direct food additives and color additives on developing embryos and for longer monitoring during several generations. In 1984, an FDA task force began a review of testing procedures for reproductive and developmental toxicity. The Developmental Toxicity Committee was formed specifically to evaluate the current guidelines and to propose revisions. As part of the evaluation, a two-part questionnaire was devised and sent to about 800 members of the Teratology Society and the Reproductive and Developmental Toxicity Specialty Section of the Society of Toxicology. The questionnaire included questions on multigeneration reproduction and developmental toxicity. A total of 132 responses (16.5%) were received, and they are discussed in detail in this report. The responses to the multigeneration reproduction questions were concerned with the optimum number of generations and litters, reduction of litter size for standardization, selection of offspring to produce the next generation, parameters to be measured, indices to be calculated, length of premating exposure, additional protocols, and microscopic examination of the offspring. Responses to the developmental toxicity questions were concerned with dose levels, diet variations, route of administration, examination of the offspring, and control of bias.

Background Data on longterm outcomes after liver transplantation with partial grafts are limited. We compared 10-year outcomes for liver transplant patients who received whole grafts (WLT), split grafts from deceased donors (SLT), and partial grafts from living donors (LDLT). Study Design We conducted a single-center analysis of 2,988 liver transplantations performed between August 1993 and May 2006 with median followup of 5 years. Graft types included 2,717 whole-liver, 181 split-liver, and 90 living-donor partial livers. Split-liver grafts included 109 left lateral and 72 extended right partial livers. Living-donor grafts included 49 left lateral and 41 right partial livers. Results The 10-year patient survivals for WLT, SLT, and LDLT were 72%, 69%, and 83%, respectively (p=0.11), and those for graft survival were 62%, 55%, and 65%, respectively (p=0.088). There were differences in outcomes between adults and children when compared separately by graft types. In adults, 10-year patient survival was significantly lower for split extended right liver graft compared with adult whole liver and living-donor right liver graft (57% versus 72% versus 75%, respectively, p=0.03). Graft survival for adults was similar for all graft types. Retransplantation, recipient age older than 60 years, donor age older than 45 years, split extended right liver graft, and cold ischemia time>10 hours were predictors of diminished patient survival outcomes. In children, the 10-year patient and graft survivals were similar for all graft types. Conclusions Longterm graft survival rates in both adults and children for segmental grafts from deceased and living donors are comparable with those in whole organ liver transplantation. In adults, patient survival was lower for split compared with whole grafts when used in retransplantations and in critically ill recipients. Split graft-to-recipient matching is crucial for optimal organ allocation and best use of a scarce and precious resource.

Androstenedione, an anabolic steroid used to enhance athletic performance, was administered in corn oil by gastric intubation once daily in the morning to nonpregnant female rats at a dose of 5 or 60 mg/kg/day, beginning two weeks before mating and continuing through gestation day (GD) 19. On GD 20, the distribution of androstenedione and other steroid metabolites was investigated in the maternal plasma and target organs, including brain and liver. The concentration of estradiol in plasma approached a statistically significant increase after treatment as compared with the controls, whereas the levels of androstenedione, testosterone and progesterone were not significantly different from the controls. In the liver, the concentrations of androstenedione and estradiol only were increased in a dose-related manner. None of these steroids was detectable in the brain. Androstenedione treatment also produced changes in the level of selected free fatty acids (FFAs) in the maternal blood, brain, liver and fetal brain. The concentrations of palmitic acid (16:0) and stearic acid (18:0) in the plasma were not significantly different between the controls and treated rats. However, oleic acid (18:1), linoleic acid (18:2) and docosahexaenoic acid (DHA, 22:6) were 17.94 +/- 2.06 microg/ml, 24.23 +/- 2.42 microg/ml and 4.08 +/- 0.53 microg/ml, respectively, in the controls, and none of these fatty acids was detectable in the treated plasma. On the other hand, palmitic, stearic, oleic, linoleic and DHA were present in both control and treated livers. Among the FFAs in liver, linoleic and DHA were increased 87% and 169%, respectively, over controls. Palmitic, stearic and oleic acids were not significantly affected by the 60 mg/kg treatment. These were present in both control maternal and fetal brains, whereas linoleic acid was found only in fetal brain control. DHA was present only in the control maternal brain (0.02 +/- 0.02 microg/mg protein) and fetal brain (0.24 +/- 0.15 microg/mg protein). The results indicated that androstenedione exhibits significantly different effects on the FFA composition among target organs during pregnancy.

The extensive media coverage of the 2008 subprime crisis, both domestically and abroad, drives home the crucial role that the financial services industry plays for not only individual Americans, but for U.S. national security. This is recognized in the 2006 U.S. National Security Strategy that designates as a priority the "pressing for open markets, financial stability, and deeper integration of the world economy." This tenet of the National Security Strategy recognizes there is a direct link between our financial services industry and the nation's ability to engage across the globe in every area of national power to include military force projection, international diplomatic activities, economic aid, and humanitarian aid. Because of this correlation, any threat to the vitality, stability and confidence of the financial services industry ultimately affects U.S. national security. This assessment concludes that the U.S. financial services industry is not an industry in permanent decline. Though currently mired in a financial cycle downturn, the financial services industry will recover as the U.S. government takes action to preserve this tenet of our national security. This process should follow the Treasury Secretary's proposed Blueprint for a Modernized Financial Regulatory Structure as the way ahead for restructuring the government's regulatory oversight. Such an innovative and proactive approach will lead the U.S. financial services industry to recovery, restore confidence in the financial sector, and maintain a key component of U.S. national security.

The principle of parent-professional collaboration in responding to the needs of seriously emotionally disturbed children has been articulated in both policy and program guidelines. Research suggests that parents have not yet been integrated into the system of care for their children. This article reviews parents' concerns about their interactions with professionals and analyzes factors that may impede an improved relationship between the two groups. It suggests that a feminist/empowerment conceptualization of practice with parents of seriously emotionally disturbed children may be conducive to the attainment of full parent involvement in the system of care.

Since the 19509s, intense scrutiny of the siting for critical facilities (nuclear power plants, dams, nuclear waste repositories, etc.) has spurred detailed field investigations of faults located at or near proposed facility sites. Over the past three decades, hundreds of reports on seismic risk and surface fault hazards have been produced based on a traditional interpretation of faults observed in natural or man-made exposures. Alternative interpretations for some of these faults may be appropriate in light of two phenomena which have received comparatively little attention: 1) new faulting, and 2) attenuation of fault displacement during an earthquake. Failure to consider these basic phenomena may have undermined the foundation for many of the Quaternary fault studies and derivative earthquake hazard assessments produced in the last three decades. Recognition of these phenomena will have potentially important impacts on virtually every branch of earthquake hazard assessment, including estimates of earthquake recurrence intervals, earthquake magnitudes, maximum single-event displacement, surface faulting hazard, and dating of fault movements.

Phosphorylation of ion channels plays an important role in the regulation of cardiac function, but signaling mechanisms controlling dephosphorylation are not well understood. We have tested the hypothesis that p 21 -activated kinase-1 (Pak1), a serine–threonine protein kinase regulated by Ras-related small G proteins, regulates sinoatrial node (SAN) ion channel activity through a mechanism involving protein phosphatase 2A. We report a novel role of Pak1-mediated signaling in attenuating isoproterenol-induced enhancement of L-type Ca 2+ current ( I CaL ) and delayed rectifier potassium current ( I K ) in guinea pig SAN pacemaker cells. We demonstrate that in guinea pig SAN: (1) there is abundant expression of endogenous Pak1 in pacemaker cells; (2) expression of constitutively active Pak1 depresses isoproterenol-induced upregulation of I CaL and I K ; (3) inhibition of protein phosphatase 2A increases the enhancement of I K and I CaL by isoproterenol in Ad-Pak1–infected cells; (4) protein phosphatase 2A coimmunoprecipitates with endogenous Pak1 in SAN tissue; and (5) expression of constitutively active Pak1 suppresses the chronotropic action of isoproterenol on pacemaker activity of intact SAN preparations. In conclusion, our data demonstrate that a Pak1 signaling pathway exists in cardiac pacemaker cells and that this novel pathway plays a role in the regulation of ion channel activity.

Zearalenone (ZE), an estrogenic mycotoxin produced by Fusarium graminearum or F. roseum, is one of the most common contaminants of cereal grains world-wide. The objective of this study was to determine the effects of ZE on in utero development of rats. Pregnant female Charles River Sprague-Dawley rats were gavaged once daily with ZE (in corn oil) at doses of 0, 1, 2, 4, or 8 mg/kg body weight on gestation days (GD) 6-19. All females survived to cesarean section on GD 20. At cesarean section, reproductive and developmental parameters were measured and blood was taken for hormone analysis. Dose-related decreases were seen in maternal feed consumption and body weight gain in all treated groups. Delayed fetal development was linked to maternal toxicity. Fetal body weight was significantly decreased in both sexes in all treated groups. ZE retarded skeletal ossification at 4 and 8 mg/kg. Fetal anogenital index (anogenital distance normalized for body weight) was increased in all treated groups, indicating an androgenic effect of ZE during fetal development. Fetal viability was significantly decreased at 8 mg/kg; significant decreases were observed in number of viable fetuses, and number of litters totally resorbed. At 4 and 8 mg/kg, maternal liver-body weight ratios were significantly increased and organ-brain weight ratios for weights of liver, heart, spleen, kidneys, and ovaries were significantly decreased. Gonadotropins (LH, FSH, and prolactin) and sex steroids (progesterone and estradiol) were analyzed from the blood serum obtained at cesarean section. LH in the 0, 1, 2, and 4 mg/kg groups showed minimal variation, and slightly increased at 8 mg/kg. FSH was decreased in the 1, 2, and 4 mg/kg groups, but the level at 8 mg/kg was slightly higher than the control level. Prolactin level was not affected at 1 mg/kg, slightly increased at 2 and 4 mg/kg, and significantly increased at 8 mg/kg. Progesterone was decreased at 2, 4, and 8 mg/kg and the decreases were significant at 2 and 4 mg/kg. Estradiol level was not affected at 1mg/kg, but dose-related decreases were observed at 2, 4, and 8 mg/kg. Only the 8 mg/kg level of estradiol was significantly decreased. In summary, ZE was maternally toxic and fetotoxic but not teratogenic. The increased anogenital distance observed in male and female fetuses was considered a hormonal change rather than a teratologic response. The increased anogenital distance indicated an androgenic effect. Based on the dose-related maternal and fetal toxicity in all treated groups, the NOEL for reproductive and teratogenic effects was less than 1 mg/kg.

Autonomous outdoor navigation requires the ability to discriminate among different types of terrain. A non-trivial problem is to manage the robot’s speed based on terrain roughness. This paper presents a speed control system for a robotic platform traveling over natural terrain. This system is based on the view of a line-scanning laser of the area just in front of the platform. Analysis of range data for roughness produced by the laser over different terrains is examined. An algorithm for managing speed through different terrain has been tested on real outdoor surfaces producing excellent performance.

Background In the out-of-hospital setting, when emergency medical services (EMS) providers respond to a 9-1-1 call and encounter a patient who wishes to refuse medical treatment and/or transport to the hospital, the EMS providers must ensure the patient possesses medical decision-making capacity and obtain an informed refusal. In the city of Cleveland, Ohio, Cleveland EMS completes a nontransport worksheet that prompts the paramedics to evaluate specific patient characteristics that can influence medical decision-making capacity and then discuss the risks of refusing with the patient. Cleveland EMS then contacts an online medical command (OLMC) physician to authorize the refusal. OLMC calls are recorded for review. Objectives To assess the ability of EMS to determine medical decision-making capacity and obtain an informed refusal of transport. Methods This study was a retrospective review of a cohort of recorded OLMC refusal calls and of the accompanying written documentation by Cleveland EMS. The completeness of the verbal communication between the paramedic and OLMC physician and the written documentation on the nontransport worksheet were measured as surrogate markers of the adequacy of determining medical decision-making capacity and obtaining an informed refusal. Results One hundred thirty-seven OLMC calls for patient-initiated refusals were reviewed. Vital signs and alertness/orientation were verbally communicated more than 83% of the time. The presence of head injury, presence of alcohol or drug intoxication, and presence of hypoglycemia were verbally communicated less than 31% of the time. Verbal communication stating that the risks of refusing had been discussed with the patient occurred 44.5% of the time. The written documentation of the refusal encounter was more complete, exceeding 95% for vital signs and alertness/orientation, and exceeding 80% for the remaining patient characteristics. The rate of written documentation that the risks of refusing had been discussed with the patient was 48.7%. Discrepancies between the verbal and written paramedic reports were clinically insignificant. Conclusions Paramedic and OLMC physician communication for patients refusing out-of-hospital medical treatment and/or transport is inadequate in the Cleveland EMS system. A written nontransport worksheet improves documentation of the refusal encounter but does not ensure that every patient who refuses possesses medical decision-making capacity and the capacity to provide an informed refusal.