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Objectives The purpose of this study was to assess the follow-up of patients with vaccinia-associated myocarditis. Background With the threat of biological warfare, the U.S. Department of Defense resumed a program for widespread smallpox vaccinations on December 13, 2002. One-year afterwards, there has been a significant increase in the occurrence of myocarditis and pericarditis among those vaccinated. Methods Cases were identified through sentinel reporting to military headquarters, systematic surveillance, and spontaneous reports. Results A total of 540,824 military personnel were vaccinated with a New York City Board of Health strain of vaccinia from December 2002 through December 2003. Of these, 67 developed myopericarditis at 10.4 ± 3.6 days after vaccination. The ST-segment elevation was noted in 57%, mean troponin on admission was 11.3± 22.7 ng/dl, and peak cardiac enzymes were noted within 8 h of presentation. On follow-up of 64 patients (96%) at a mean of 32 ± 16 weeks, all patients had objective normalization of echocardiography, electrocardiography, laboratory testing, graded exercise testing, and functional status; 8 (13%) reported atypical, non-limiting persistent chest discomfort. Conclusions Post-vaccinial myopericarditis should be considered in patients with chest pain within 30 days after smallpox vaccination. Normalization of echocardiography, electrocardiography, and treadmill testing is expected, and nearly all patients have resolution of chest pain on follow-up.

Echocardiography is an essential tool in the evaluation of patients with cardiac emergencies and chest trauma. The objective of our study was to establish the feasibility and diagnostic accuracy of a portable satellite transmission system in the assessment of cardiac emergencies for the real-time support of mass casualty and humanitarian relief efforts. Twelve patients with various degrees of cardiac structural disease identified by conventional inhospital transthoracic echocardiography were transported to a remote portable field hospital where transthoracic echocardiography was performed with a handheld echocardiographic device. Images were then relayed by a commercial satellite to a level III trauma center where they were interpreted in real time by a cardiologist. Remote studies were recorded at the field hospital before satellite transmission and again on download at the receiving facility. The remotely acquired studies before and after satellite transmission were compared with each other and subsequently compared with conventional hospital transthoracic echocardiograms for technical quality and diagnostic accuracy using a blinded, single-reader, side-by-side comparison. Excellent agreement was found between the recorded field-site and satellite-transmitted images with an overall average of 95% concordance. When the field data acquired with the handheld device and satellite transmission were compared with conventional inhospital echocardiography, a high degree of agreement was demonstrated in overall technical quality (83%) and assessments of left ventricular ejection fraction (100%), pericardial effusion (100%), and left ventricular size (92%). This study demonstrates the feasibility and diagnostic accuracy of remote, real-time echocardiography using satellite transmission for mass casualty triage or humanitarian relief efforts.

Objectives: Focused assessment with sonography in trauma (FAST) can define life-threatening injuries in austere settings with remote real-time review by experienced physicians. This study evaluates vest-mounted microwave, satellite, and LifeLink communications technology for image clarity and diagnostic accuracy during remote transmission of FAST examinations. Methods: Using a SonoSite, FAST was obtained on three patients with pericardial and intraperitoneal effusions and two control subjects in a remotely located U.S. Army Combat Support Hospital. A miniature vestmounted video transmitter attached to the SonoSite sent wireless ultrasound video 20 m to a receiving antenna. The signal was then transferred over VSAT satellite systems at 512 kilobaud per second (kbps), INMARSAT satellite systems at 64 kbps, and over LifeLink on a moving ambulance through a metropolitan wireless traffic‐management network. Clarity and absence or presence of effusions were recorded by 15 staff emergency physicians. Results: Average sensitivity, specificity, and accuracy were 87% (95% confidence interval [CI] ¼ 79% to 95%), 85% (95% CI ¼ 81% to 89%), and 86% (95% CI ¼ 82% to 90%) for the Premier WirelessVest;98%(95%CI ¼97%to99%),83%(95%CI ¼75% to 91%), and 86% (95% CI ¼ 82% to 90%) for VSAT; 95% (95% CI ¼ 94% to 96%), 70% (95% CI ¼ 58% to 82%), and 75% (95% CI ¼ 70% to 80%) for INMARSAT; and 82% (95% CI ¼ 73% to 91%), 83% (95% CI ¼ 74% to 92%), and 82% (95% CI ¼ 78% to 86%) for LifeLink with clarity of 3.0 (95% CI ¼ 2.7 to 3.3), 2.9 (95% CI ¼ 2.6 to 3.2), 1.3 (95% CI ¼ 1.2 to 1.4), and 2.1 (95% CI ¼ 1.8 to 2.4), respectively. Conclusions: Accuracy correlated with clarity. Roaming vest transmission of FAST provides interpretable, diagnostic imagery at the distances used in this study. VSAT provided the best clarity and diagnostic value with the lighter, more portable INMARSAT serving a lesser role for remote clinical interpretation. LifeLink performed well, and further infrastructure improvements may increase clarity and accuracy. Key words: ultrasound; FAST; telemedicine; prehospital; satellite; VSAT; INMARSAT; LifeLink. ACADEMIC EMERGENCY MEDICINE 2003; 10:1411‐1414.

Echocardiography is a key diagnostic tool in evaluating patients with cardiac emergencies and chest trauma. The lack of qualified real-time interpretation limits its use by emergency first responders. Early diagnosis of cardiac emergencies has the potential to facilitate triage and medical intervention to improve outcomes. We investigated the feasibility of remote, real-time interpretation of echocardiograms during patient transport. Echocardiograms using a hand-carried ultrasound device were transmitted from an ambulance in transit to a tertiary care facility using a distributed mobile local area network. Transmitted studies were reviewed by a cardiologist for ability to interpret predefined features. Transmission quality and reliability were assessed. Echocardiographic images were successfully transmitted greater than 88% of transport time. The evaluation of left-ventricular size and function, and presence of pericardial effusion were greater than 90% concordant, but only 66% of all echocardiographic features were concordant. Most transmission losses were brief (≤10 seconds) with little impact on interpretability. Wireless infrastructures in metropolitan areas provide the ability for real-time transmission of echocardiograms during patient transport of adequate quality for accurate interpretation. (J Am Soc Echocardiogr 2003;16:197-201.)

As military operations become smaller and more remote and as humanitarian missions increase, ultrasound technology is emerging as a valuable asset for defining injuries in austere settings. This study evaluated the feasibility of focused abdominal sonography for trauma (FAST) examinations in a field environment with real-time images sent wireless to an antenna and over satellite.Using a 6-lb SonoSite portable ultrasound device with battery pack, FAST examinations were performed on a healthy volunteer, transferred wireless at distances of 1,000 and 1,500 feet from the receiving antenna using a vest-mounted microwave transmitter, and then redirected over satellite (INMARSAT) to a remote hospital for review by emergency physicians, and a radiologist.Real-time wireless transmissions at 1,500 feet reliably yielded images without quality or interpretability drop compared with those recorded digitally at the examination site. A 32% reduction in image quality and interpretability was seen with still images and a 42% reduction was noted with cine loops using INMARSAT. The authors did not find the upper distance limit of the wireless transmitter used.This study suggests 1) that remote FAST examinations are plausible for prehospital care and triage using new-generation portable ultrasound units, 2) that line-of-sight transmission of FAST examinations when compared with on-site images results in no degradation in image quality or interpretability at distances used, 3) that ranges greater than 1,500 feet are feasible for interpretable examinations and therefore line-of-site mass casualty or field triage sites, and 4) that real-time INMARSAT transmission of FAST examinations at 64 kbps may serve a limited role for remote clinical interpretation.

Coronary flow response to low-dose (5 and 10 micrograms/kg/min) dobutamine infusion was used to assess myocardial viability at the time of cardiac catheterization in 13 patients (age, 60 +/- 11 years) with recent myocardial infarction. Echocardiographic improvement in regional wall motion performed 4 to 6 weeks after discharge was used as the marker for viability. Viable patients demonstrated a 2-fold increase in flow from baseline (p < 0.001) during intravenous infusion. In contrast, patients without viability demonstrated no increase in flow. The coronary flow response to dobutamine measured at the time of catheterization shows promise in identifying viable myocardium in postinfarction patients.

Background . The presence of ascending aortic atheroma is a known risk for systemic emboli or early saphenous vein graft failure if unrecognized at the time of cardiopulmonary bypass. Methods . This study prospectively compared intraoperative omniplane transesophageal echocardiography (TEE) and epiaortic ultrasound (EAU) images in 22 patients (6 women, 16 men, age 66 ± 8 years) before surgical manipulation of the ascending aorta. Atheroma lesion severity was scored: 1=normal, 2=nonprotruding intimal thickening (> 2 mm), 3=atheroma less than 4 mm ± Ca++, 4=atheroma greater than or equal to 4 mm ± Ca++, and 5=any size mobile or ulcerated lesion ± Ca++. The ascending aorta between the aortic valve and innominate artery was divided into proximal, middle, and distal segments. A total of 66 segments were evaluated. Results . Although the overall agreement of scores between procedures was 75.8%, significantly more lesions were identified by EAU (15) than by TEE (5) ( p Conclusions . Although atheromatous lesions were identified in the ascending aorta by both ultrasound modalities, the results suggest that intraoperative EAU may have an advantage over TEE for surgeons assessing target sites for surgical procedures involving the ascending aorta.

Right ventricular endomyocardial biopsy has been the traditional gold standard for determining cardiac transplant rejection. Although endomyocardial biopsy has proved useful in guiding rejection therapy, this procedure is not without risk. The objective of the present study was to determine whether a noninvasive method for assessing cardiac diastolic function would be of value in predicting biopsy scores. Doppler echocardiographic indices of left ventricular function were compared with biopsy scores in 43 studies from 23 patients (age 50 +/- 8 years). The average time from transplant to echocardiographic study was 1.5 years. Standard clinical indices of diastolic function failed to predict biopsy results. The A-Ar interval, evaluated in 36 studies, was found to significantly decrease (p0.003) with increasing biopsy scores. Preliminary results suggest that this echocardiographic parameter may prove useful in predicting biopsy results.

Postoperative atrial fibrillation following cardiothoracic surgery is common and frequently managed with intravenous (IV) amiodarone. Phlebitis is the most common complication with peripheral infusion of this agent. Current practice guidelines for peripheral IV administration of2 mg/mL amiodarone were established to reduce the risk of phlebitis. The present study examines the incidence of phlebitis in a postoperative patient population given current dose recommendations. A total of 273 patient charts were reviewed. The incidence of phlebitis in patients given IV amiodarone (n = 36) was 13.9% (95% confidence interval, 2.6-25.2%; p = 0.001). Logistic regression analysis with backward elimination of other therapeutic risk factors suggests that the odds ratio for phlebitis using current dose regimens without IV filters is 19-fold greater than baseline risk in this population. Phlebitis remains a significant complication associated with peripheral infusion of amiodarone within recommended dosing limits.

Kawasaki disease is the most common cause of pediatric ischemic heart disease in the world, but it is unusual in adults. We present a case of Kawasaki disease in a young adult. This 20-year-old man presented with angina. Coronary angiography revealed aneurysmal obstructive lesions consistent with remote Kawasaki disease. The patient underwent coronary artery bypass grafting with arterial conduits. Postoperative echocardiography was normal and stress myocardial perfusion imaging showed no ischemia. He remained asymptomatic 12 months after surgery. There is controversy regarding optimal therapy, choice of conduit, treatment of proximal aneurysms, and surveillance in adults with Kawasaki disease.

Focused assessment with sonography in trauma (FAST) can define life-threatening injuries in austere settings with remote real-time review by experienced physicians. This study evaluates vest-mounted microwave, satellite, and LifeLink communications technology for image clarity and diagnostic accuracy during remote transmission of FAST examinations.Using a SonoSite, FAST was obtained on three patients with pericardial and intraperitoneal effusions and two control subjects in a remotely located U.S. Army Combat Support Hospital. A miniature vest-mounted video transmitter attached to the SonoSite sent wireless ultrasound video 20 m to a receiving antenna. The signal was then transferred over VSAT satellite systems at 512 kilobaud per second (kbps), INMARSAT satellite systems at 64 kbps, and over LifeLink on a moving ambulance through a metropolitan wireless traffic-management network. Clarity and absence or presence of effusions were recorded by 15 staff emergency physicians.Average sensitivity, specificity, and accuracy were 87% (95% confidence interval [CI]=79% to 95%), 85% (95% CI=81% to 89%), and 86% (95% CI=82% to 90%) for the Premier Wireless Vest; 98% (95% CI=97% to 99%), 83% (95% CI=75% to 91%), and 86% (95% CI=82% to 90%) for VSAT; 95% (95% CI=94% to 96%), 70% (95% CI=58% to 82%), and 75% (95% CI=70% to 80%) for INMARSAT; and 82% (95% CI=73% to 91%), 83% (95% CI=74% to 92%), and 82% (95% CI=78% to 86%) for LifeLink with clarity of 3.0 (95% CI=2.7 to 3.3), 2.9 (95% CI=2.6 to 3.2), 1.3 (95% CI=1.2 to 1.4), and 2.1 (95% CI=1.8 to 2.4), respectively.Accuracy correlated with clarity. Roaming vest transmission of FAST provides interpretable, diagnostic imagery at the distances used in this study. VSAT provided the best clarity and diagnostic value with the lighter, more portable INMARSAT serving a lesser role for remote clinical interpretation. LifeLink performed well, and further infrastructure improvements may increase clarity and accuracy.

Minimal information currently exists on how clinicians should approach the evaluation of the young patient with exertional dyspnea. The objective of this study was to determine the frequency of specific diseases and the most useful tests to establish the diagnosis in an active duty military population presenting with exertional dyspnea.A total of 105 active duty military patients with complaints of exertional dyspnea and 69 active duty military asymptomatic controls were evaluated at a pulmonary disease clinic at an Army tertiary care center. All patients and controls underwent a standard evaluation that included history, physical examination, chest radiography (CXR), arterial blood gas testing, laboratory testing, full pulmonary function testing (PFT), inspiratory and expiratory pressure determinations, methacholine challenge testing, cardiopulmonary exercise testing, electrocardiography, and echocardiography.Obstructive lung disease was found in 52% of patients (35% with exercise-induced asthma and 12% with asthma), 10% had vocal cord dysfunction, and 14% had other diagnoses. Twenty-four percent of patients had no specific diagnosis. Methacholine challenge testing yielded a positive diagnosis in 41% of patients and spirometry in 16%. Other pulmonary tests were of limited value, with abnormal values of 11.4% for full PFT, 2.9% for arterial blood gas testing, and 0.4% for CXR. Laboratory evaluation yielded positive results in less than 5% of patients, and cardiac evaluation was normal in all patients.Various forms of obstructive lung disease and vocal cord dysfunction were the most common findings in this group. The routine use of spirometry and bronchoprovocation testing is warranted, but other tests, such as full PFT, CXR, and cardiac and laboratory evaluations, have limited diagnostic value in this population.