A pilot retrospective study of a physician-directed and genomics-based model for precision lifestyle medicine.

Precision lifestyle medicine is a relatively new field in primary care, based on the hypothesis that genetic predispositions influence an individual's response to specific interventions such as diet, exercise, and prescription medications. Despite the increase in commercially available genomic testing, few studies have investigated effects of a physician-directed program to optimize chronic disease using genomics-based precision medicine. We performed an pilot, observational cohort study to evaluate effects of the Wild Health program, a physician and health coach service offering genomics-based lifestyle and medical interventions, on biomarkers indicative of chronic disease. 871 patients underwent genomic testing, biomarker testing, and ongoing health coaching after initial medical consultation by a physician. Improvements in several clinically relevant out-of-range biomarkers at baseline were identified in a large proportion of patients treated through lifestyle intervention without the use of prescription medication. Notably, normalization of several biomarkers associated with chronic disease occurred in 47.5% (hemoglobin A1c [HbA1c]), 33.3% (low density lipoprotein particle number [LDL-P]), and 33.2% (C-reactive protein [CRP]). However, due to the inherent limitations of our observational study design and use of retrospective data, ongoing work will be crucial for continuing to shed light on the effectiveness of physician-led, genomics-based lifestyle coaching programs. Future studies would benefit from implementing a randomized controlled study design, tracking specific interventions, and evaluating physiological data, such as BMI.

Investigation of polyethylene terephthalate (PET) drinking bottles as marine reservoirs for fecal bacteria and phytoplankton.

Polyethylene terephthalate (PET) is frequently used in the food and beverage industry and therefore contributes greatly to plastic marine debris. The fecal pollution indicator bacteria Enterococcus is used for marine water contamination assessments and is regularly found in storm water discharge. In order to examine if PET drinking bottles act as refuges for Enterococcus, a study was conducted within euhaline tidal waters of Wrightsville Beach, NC, USA via the deployment of bottle floats positioned nearby two stormwater outfall pipes. Bottles were retrieved weekly to assess the accumulation of fecal bacteria and phytoplankton. Each bottle was analyzed for the presence of Enterococcus on plastic surfaces and within water inside the bottle. Abundance of Enterococcus and planktonic chlorophyll α was found to be significantly greater in association with PET bottles versus the surrounding waters. Bottles were observed to act as reservoirs for both Enterococcus and phytoplankton with concentrations well above the state, federal, and WHO standards.

Successful mitigation of stormwater-driven nutrient, fecal bacteria and suspended solids loading in a recreational beach community.

Marine and estuarine waterways adjacent to urban areas are often the final recipient of polluted stormwater runoff. Microbial degradation of coastal water quality is a direct threat to human health through fecal contamination of bathing waters and shellfish, as well as distressing local economies through the loss of waterways to commercial (shellfishing) and recreational use. In coastal waters reduction of nitrogen loading is a key strategy for prevention of noxious and toxic algal blooms. Best management practices (BMPs) can be successful tools for mitigating such pollutants in runoff, but BMPs must be tailored to individual situations for maximum effectiveness. This study examines the efficacy of a set of BMPs installed in the coastal resort Town of Wrightsville Beach, North Carolina, USA. The BMPs targeted the highly-impervious (90%+) drainage area of two stormwater outfall pipes emptying into recreationally used Banks Channel. Mitigation measures included replacement of impervious pavement with pervious concrete and construction of an infiltration chamber in the parking lot of a local recreational seaside club. Significant reductions were achieved in total stormwater discharge (62%), as well as loading of the fecal indicator bacteria Enterococcus (76%) and total nitrogen (TN - 87% decrease). Additionally, there were reductions in loading of total phosphorous (TP) and total suspended solids (TSS) to estuarine waters following BMP installment. The set of BMPs applied here have wide management applicability to coastal ecosystems, as well as freshwater riparian areas characterized by sandy, porous soils.

Tracing nutrient pollution from industrialized animal production in a large coastal watershed.

One of the highest concentrations of swine and poultry concentrated animal feeding operations (CAFOs) in North America is located on the Coastal Plain of North Carolina, in which the Cape Fear River basin is located. The CAFOs produce vast amounts of manure causing loading of nutrients and other pollutants to receiving waters. With the Cape Fear River basin vulnerable to nutrient pollution, as are many other watersheds with CAFOs, δ13C and δ15N stable isotopic signatures were identified from water samples collected within the Northeast Cape Fear, Black, and lower Cape Fear River watersheds to trace nutrient sources and their distribution downstream. The spatial and temporal variability of nutrients and isotopic signatures were also identified to understand water quality impacts of animal waste spraying season and proximity to CAFOs. Our results showed that significantly enriched δ15N signatures characterized sites in close proximity to CAFOs as well as point-source wastewater discharge areas, while the opposite was true for an unimpacted control stream and two estuarine sites. Additionally, the impacted sites yielded significantly (p < 0.05) higher nitrate concentrations than control and estuarine sites. Statistical analyses demonstrated that nitrate concentrations were positively correlated with heavier δ15N signatures, suggesting that animal waste, as well as human wastewater, are relatively more important sources of N to this large watershed than fertilizers from traditional row crop agriculture. Our results also suggested that during appropriate hydrological conditions CAFO-derived N can be detected many kilometers downstream from freshwater sources areas to the estuary.

Waste nutrients from U.S. animal feeding operations: Regulations are inconsistent across states and inadequately assess nutrient export risk.

Livestock production in the United States has been transformed over the past several decades, largely as a result of widespread development of industrial-scale mass production facilities, termed Animal Feeding Operations (AFOs). These facilities generate massive amounts of animal waste that can concentrate in small areas. Animal wastes from AFOs have led to high levels of nutrients and other pollutants in nearby surface waters, as well as groundwater. The environmental problems associated with these disposal practices have led to federal and state modifications to the rules and regulations governing waste practices. We summarize the federal guidelines for AFO nutrient management, focusing on swine, and compare the regulations of four AFO-rich states in different regions of the USA. Furthermore, we discuss inconsistencies among regulations and regulatory gaps, and identify issues with waste nutrient management practices that lead to environmental degradation in watersheds hosting AFOs. Finally, we address these shortcomings and the need to implement policy updates that would alleviate some of these environmental and human concerns.

Transesophageal Echocardiography During Cardiopulmonary Resuscitation Is Associated With Shorter Compression Pauses Compared With Transthoracic Echocardiography.

STUDY OBJECTIVE: Point-of-care ultrasonography provides diagnostic information in addition to visual pulse checks during cardiopulmonary resuscitation (CPR). The most commonly used modality, transthoracic echocardiography, has unfortunately been repeatedly associated with prolonged pauses in chest compressions, which correlate with worsened neurologic outcomes. Unlike transthoracic echocardiography, transesophageal echocardiography does not require cessation of compressions for adequate imaging and provides the diagnostic benefit of point-of-care ultrasonography. To assess a benefit of transesophageal echocardiography, we compare the duration of chest compression pauses between transesophageal echocardiography, transthoracic echocardiography, and manual pulse checks on video recordings of cardiac arrest resuscitations. METHODS: We analyzed 139 pulse check CPR pauses among 25 patients during cardiac arrest. RESULTS: Transesophageal echocardiography provided the shortest mean pulse check duration (9 seconds [95% confidence interval {CI} 5 to 12 seconds]). Mean pulse check duration with transthoracic echocardiography was 19 seconds (95% CI 16 to 22 seconds), and it was 11 seconds (95% CI 8 to 14 seconds) with manual checks. Intraclass correlation coefficient between abstractors for a portion of individual and average times was 0.99 and 0.99, respectively (P<.001 for both). CONCLUSION: Our study suggests that pulse check times with transesophageal echocardiography are shorter versus with transthoracic echocardiography for ED point-of-care ultrasonography during cardiac arrest resuscitations, and further emphasizes the need for careful attention to compression pause duration when using transthoracic echocardiography for point-of-care ultrasonography during ED cardiac arrest resuscitations.

Downstream Effects of Upstream Causes.

The United States Environmental Protection Agency considers nutrient pollution in stream ecosystems one of the U.S.' most pressing environmental challenges. But limited independent replicates, lack of experimental randomization, and space- and time-varying confounding handicap causal inference on effects of nutrient pollution. In this paper the causal g-methods are extended to allow for exposures to vary in time and space in order to assess the effects of nutrient pollution on chlorophyll a - a proxy for algal production. Publicly available data from North Carolina's Cape Fear River and a simulation study are used to show how causal effects of upstream nutrient concentrations on downstream chlorophyll a levels may be estimated from typical water quality monitoring data. Estimates obtained from the parametric g-formula, a marginal structural model, and a structural nested model indicate that chlorophyll a concentrations at Lock and Dam 1 were influenced by nitrate concentrations measured 86 to 109 km upstream, an area where four major industrial and municipal point sources discharge wastewater.

Does the Addition of M-Mode to B-Mode Ultrasound Increase the Accuracy of Identification of Lung Sliding in Traumatic Pneumothoraces?

OBJECTIVES: It is unknown whether the addition of M-mode to B-mode ultrasound (US) has any effect on the overall accuracy of interpretation of lung sliding in the evaluation of a pneumothorax by emergency physicians. This study aimed to determine what effect, if any, this addition has on US interpretation by emergency physicians of varying training levels. METHODS: One hundred forty emergency physicians were randomized via online software to receive a quiz with B-mode clips alone or B-mode with corresponding M-mode images and asked to identify the presence or absence of lung sliding. RESULTS: The sensitivity, specificity, and accuracy of the diagnosis of lung sliding with and without M-mode US were compared. Overall, the sensitivities, specificities, and accuracies of B-mode + M-mode US versus B-mode US alone were 93.1% and 93.2% (P = .8), 96.0% and 89.8% (P < .0001), and 91.5% and 94.5% (P = .0091), respectively. A subgroup analysis showed that in those providers with fewer than 250 total US scans done previously, M-mode US increased accuracy from 88.2% (95% confidence interval, 86.2%-90.2%) to 94.4% (92.8%-96.0%; P = .001) and increased the specificity from 87.0% (84.5%-89.5%) to 97.2% (95.4%-99.0%; P < .0001) compared with B-mode US alone. There was no statistically significant difference observed in the sensitivity, specificity, and accuracy of B-mode + M-mode US compared with B-mode US alone in those with more than 250 scans. CONCLUSIONS: The addition of M-mode images to B-mode clips aids in the accurate diagnosis of lung sliding by emergency physicians. The subgroup analysis showed that the benefit of M-mode US disappears after emergency physicians have performed more than 250 US examinations.

Season matters when sampling streams for swine CAFO waste pollution impacts.

Concentrated (or confined) animal feed operations (CAFOs) are the principal means of livestock production in the United States, and such facilities pollute nearby waterways because of their waste management practices; CAFO waste is pumped from the confinement structure into a cesspit and sprayed on a field. Stocking Head Creek is located in eastern North Carolina, a state with >9,000,000 head of swine confined in CAFOs. This watershed contains 40 swine CAFOs; stream water quality was investigated at seven sites during 2016, with five sampling dates in early spring and five in summer. Geometric mean fecal coliform counts were in the thousands/100 mL at five sites in spring and all seven sites in summer. Excessive nitrate pollution was widespread with concentrations up to >11.0 mg N/L. Seasonality played an important role in pollutant concentrations. In North Carolina, spraying animal waste on adjoining fields is permissible from March 1 through September 30. Seasonal data showed significantly higher (p < 0.01) concentrations of conductivity, nitrate, total nitrogen, total organic carbon, and fecal bacteria in summer as opposed to early spring. Thus, sampling performed only in winter-early spring would significantly underestimate impacts from swine CAFO spray fields on nearby waterways.

Transesophageal Echocardiography: Guidelines for Point-of-Care Applications in Cardiac Arrest Resuscitation.

Cardiac arrest is one of the most challenging patient presentations managed by emergency care providers, and echocardiography can be instrumental in the diagnosis, prognosis, and treatment guidance in these critically ill patients. Transesophageal echocardiography has many advantages over transthoracic echocardiography in a cardiac arrest resuscitation. As transesophageal echocardiography is implemented more widely at the point of care during cardiac arrest resuscitations, guidelines are needed to assist emergency providers in acquiring the equipment and skills necessary to successfully incorporate it into the management of cardiac arrest victims.

Micro-zooplankton grazing as a means of fecal bacteria removal in stormwater BMPs.

A priority for environmental managers is control of stormwater runoff pollution, especially fecal microbial pollution. This research was designed to determine if fecal bacterial grazing by micro-zooplankton is a significant control on fecal bacteria in aquatic best management practices (BMPs); if grazing differs between a wet detention pond and a constructed wetland; and if environmental factors enhance grazing. Both 3-day grazing tests and 24-h dilution assays were used to determine grazing differences between the two types of BMP. Micro-zooplankton grazing was a stronger bacteria removal mechanism in stormwater wetlands rich in aquatic vegetation compared to a standard wet detention pond, although grazing was important in detention ponds as well. Our experiments indicated that the majority of grazers that fed on fecal bacteria were <20 µm in size. Grazing rates were positively correlated with fecal coliform abundance and increased water temperatures. Enumeration of grazers demonstrated that protozoans were significantly more abundant among wetland vegetation than in open water, and open wetland waters contained more flagellates and dinoflagellates than open wet detention pond waters. Grazing on fecal bacteria in BMPs is enhanced by aquatic vegetation, and grazing in aquatic BMPs in warmer climates should be greater than in cooler climates.

Medical expulsive therapy use in emergency department patients diagnosed with ureteral stones.

OBJECTIVE: Recent studies have clarified the role of alpha-blockers, such as tamsulosin, for patients diagnosed with ureteral stones <10mm not requiring an urgent intervention. Prior studies have reported low rates of use of MET by emergency physicians. We sought to describe patterns of alpha-blocker use and to determine factors associated with utilization in patients diagnosed with ureterolithiasis in the ED. METHODS: We used data from a randomized trial of CT scan vs. ultrasound in participants with suspected urolithiasis enrolled at 15 EDs between October 2011 and February 2013. The use of medical expulsive therapy was identified by the prescription of an alpha-blocker, calcium channel blocker, or steroid at the ED visit. The prevalence of alpha-blocker use in participants with ureteral stones on imaging was calculated, and multivariable models were used to examine risk factors for utilization. RESULTS: Of the 524 participants who were identified with a ureteral stone on CT scan and discharged from the ED, 375 (71.4%) received an alpha-blocker, and 2 (<1%) received a steroid. There was no significant difference in alpha-blocker use for participants based on stone size or location. However, there was a 3.6-fold difference in alpha-blocker use between the lowest and highest use ED sites. In the multivariable analysis, ED site was independently associated with utilization of alpha-blockers. CONCLUSIONS: Alpha-blockers were prescribed in more than two-thirds of patients with a distal ureteral stone on imaging, a much higher prevalence than previously reported. There was substantial variability in alpha-blocker use based on ED site.

Development and Implementation of a Comprehensive, Multidisciplinary Emergency Department Extracorporeal Membrane Oxygenation Program.

Despite advances in the medical and surgical management of cardiovascular disease, greater than 350,000 patients experience out-of-hospital cardiac arrest in the United States annually, with only a 12% neurologically favorable survival rate. Of these patients, 23% have an initial shockable rhythm of ventricular fibrillation/pulseless ventricular tachycardia (VF/VT), a marker of high probability of acute coronary ischemia (80%) as the precipitating factor. However, few patients (22%) will experience return of spontaneous circulation and sufficient hemodynamic stability to undergo cardiac catheterization and revascularization. Previous case series and observational studies have demonstrated the successful application of intra-arrest extracorporeal life support, including to out-of-hospital cardiac arrest victims, with a neurologically favorable survival rate of up to 53%. For patients with refractory cardiac arrest, strategies are needed to bridge them from out-of-hospital cardiac arrest to the catheterization laboratory and revascularization. To address this gap, we expanded our ICU and perioperative extracorporeal membrane oxygenation (ECMO) program to the emergency department (ED) to reach this cohort of patients to improve survival. In this report, we illustrate our process and initial experience of developing a multidisciplinary team for rapid deployment of ED ECMO as a template for institutions interested in building their own ED ECMO programs.

Practice characteristics of Emergency Department extracorporeal cardiopulmonary resuscitation (eCPR) programs in the United States: The current state of the art of Emergency Department extracorporeal membrane oxygenation (ED ECMO).

PURPOSE: To characterize the current scope and practices of centers performing extracorporeal cardiopulmonary resuscitation (eCPR) on the undifferentiated patient with cardiac arrest in the emergency department. METHODS: We contacted all US centers in January 2016 that had submitted adult eCPR cases to the Extracorporeal Life Support Organization (ELSO) registry and surveyed them, querying for programs that had performed eCPR in the Emergency Department (ED ECMO). Our objective was to characterize the following domains of ED ECMO practice: program characteristics, patient selection, devices and techniques, and personnel. RESULTS: Among 99 centers queried, 70 responded. Among these, 36 centers performed ED ECMO. Nearly 93% of programs are based at academic/teaching hospitals. 65% of programs are less than 5 years old, and 60% of programs perform ≤3 cases per year. Most programs (90%) had inpatient eCPR or salvage ECMO programs prior to starting ED ECMO programs. The majority of programs do not have formal inclusion and exclusion criteria. Most programs preferentially obtain vascular access via the percutaneous route (70%) and many (40%) use mechanical CPR during cannulation. The most commonly used console is the Maquet Rotaflow(®). Cannulation is most often performed by cardiothoracic (CT) surgery, and nearly all programs (>85%) involve CT surgeons, perfusionists, and pharmacists. CONCLUSIONS: Over a third of centers that submitted adult eCPR cases to ELSO have performed ED ECMO. These programs are largely based at academic hospitals, new, and have low volumes. They do not have many formal inclusion or exclusion criteria, and devices and techniques are variable.

Emergency physician-performed transesophageal echocardiography for extracorporeal life support vascular cannula placement.

INTRODUCTION: There is growing interest and application of extracorporeal membrane oxygenation (ECMO) as a life-saving procedure for out-of-hospital cardiac arrest (OHCA), also called extracorporeal life support (ECLS). Extracorporeal membrane oxygenation cannulation with ongoing chest compressions is challenging, and transesophageal echocardiography (TEE) is an invaluable tool with which to guide ECMO wire guidance and cannula positioning. METHODS: We describe our protocol for TEE guidance by emergency physicians in our hospital. RESULTS: Of our first 12 cases of ECLS, 10 have had TEE guidance by an emergency physician with successful placement and without complication or need for repositioning. Emergency physician-performed TEE for ECLS vascular cannula placement has been both feasible and useful in our experience and warrants further study.

Assessing hog lagoon waste contamination in the Cape Fear Watershed using Bacteroidetes 16S rRNA gene pyrosequencing.

Hog lagoons can be major sources of waste and nutrient contamination to watersheds adjacent to pig farms. Fecal source tracking methods targeting Bacteroidetes 16S rRNA genes in pig fecal matter may underestimate or fail to detect hog lagoon contamination in riverine environments. In order to detect hog lagoon wastewater contamination in the Cape Fear Watershed, where a large number of hog farms are present, we conducted pyrosequencing analyses of Bacteroidetes 16S rRNA genes in hog lagoon waste and identified new hog lagoon-specific marker sequences. Additional pyrosequencing analyses of Bacteroidetes 16S rRNA genes were conducted with surface water samples collected at 4 sites during 5 months in the Cape Fear Watershed. Using an operational taxonomic unit (OTU) identity cutoff value of 97 %, these newly identified hog lagoon markers were found in 3 of the river samples, while only 1 sample contained the pig fecal marker. In the sample containing the pig fecal marker, there was a relatively high percentage (14.1 %) of the hog lagoon markers and a low pig fecal marker relative abundance of 0.4 % in the Bacteroidetes 16S rRNA gene sequences. This suggests that hog lagoon contamination must be somewhat significant in order for pig fecal markers to be detected, and low levels of hog lagoon contamination cannot be detected targeting only pig-specific fecal markers. Thus, new hog lagoon markers have a better detection capacity for lagoon waste contamination, and in conjunction with a pig fecal marker, provide a more comprehensive and accurate detection of hog lagoon waste contamination in susceptible watersheds.

Diagnosis of appendicitis by bedside ultrasound in the ED.

BACKGROUND: Computed tomography (CT) has largely become standard of care for diagnosing appendicitis at the expense of increased patient radiation exposure, cost, and time to surgical intervention. To date, there are very limited data on the accuracy of bedside ultrasound (BUS) for the diagnosis of appendicitis in adults. OBJECTIVE: The objective of this study is to evaluate test characteristics of BUS for diagnosis of acute appendicitis in the emergency department. METHODS: Data were prospectively collected on 97 cases of suspected appendicitis, which had BUS performed by trained residents with attending supervision between August 2011 and November 2013. All BUS interpretation and additional diagnostic imaging were left to the discretion of the physician or surgical consultants. A blinded ultrasound fellowship-trained physician reviewed all images after clinical treatment. Bedside ultrasound findings and patient outcomes were reported. RESULTS: A total of 97 adult cases underwent diagnostic ultrasound scans for suspected appendicitis. Of 97 cases, 34 had acute appendicitis by surgery/pathology report. Twenty-four BUS were positive for acute appendicitis and 11 were nondiagnostic. Of 24 positive ultrasounds, 23 had appendicitis on pathology report. There was 1 false-positive result, yielding a sensitivity of 67.65% (95% confidence limits, 49.5%-82.6%) and a specificity of 98.41% (95% confidence limits, 91.4%-99.7%). Of 23 positive BUS, 12 cases went to the Operating Room without an abdominal CT yielding a 12% reduction in CT utilization. If all positive BUS went to the OR without a CT scan, this would yield a 24% reduction in CT utilization. CONCLUSIONS: Bedside ultrasound may be an appropriate initial test to evaluate patients with suspected acute appendicitis in the emergency department.

The role of ultrasound in the emergency department evaluation of the acutely painful pediatric hip.

Children presenting with hip pain or a limp are a diagnostic challenge for the clinician. The differential diagnosis is extensive, and the workup can be broad. This review focuses on differentiating between transient synovitis and septic arthritis of the hip. The role of bedside ultrasound in the clinical evaluation of these patients is addressed, including the technique and appropriate indications for bedside ultrasound of the hip in the emergency department.

First "glass" education: telementored cardiac ultrasonography using Google Glass- a pilot study.

OBJECTIVES: The objective of this study was to determine the feasibility of telementored instruction in bedside ultrasonography (US) using Google Glass. The authors sought to examine whether first-time US users could obtain adequate parasternal long axis (PSLA) views to approximate ejection fraction (EF) using Google Glass telementoring. METHODS: This was a prospective, randomized, single-blinded study. Eighteen second-year medical students were randomized into three groups and tasked with obtaining PSLA cardiac imaging. Group A received real-time telementored education through Google Glass via Google Hangout from a remotely located expert. Group B received bedside education from the same expert. Group C represented the control and received no instruction. Each subject was given 3 minutes to obtain a best PSLA cardiac imaging using a portable GE Vscan. Image clips obtained by each subject were stored. A second expert, blinded to instructional mode, evaluated images for adequacy and assigned an image quality rating on a 0 to 10 scale. RESULTS: Group A was able to obtain adequate images six out of six times (100%) with a median image quality rating of 7.5 (interquartile range [IQR] = 6 to 10) out of 10. Group B was also able to obtain adequate views six out of six times (100%), with a median image quality rating of 8 (IQR = 7 to 9). Group C was able to obtain adequate views one out of six times (17%), with a median image quality of 0 (IQR = 0 to 2). There were no statistically significant differences between Group A and Group B in the achievement of adequate images for E-point septal separation measurement or in image quality. CONCLUSIONS: In this pilot/feasibility study, novice US users were able to obtain adequate imaging to determine a healthy patient's EF through telementored education using Google Glass. These preliminary data suggest telementoring as an adequate means of medical education in bedside US. This conclusion will need to be validated with larger, more powerful studies including evaluation of pathologic findings and varying body habitus among models.

Ultrasonography versus computed tomography for suspected nephrolithiasis.

BACKGROUND: There is a lack of consensus about whether the initial imaging method for patients with suspected nephrolithiasis should be computed tomography (CT) or ultrasonography. METHODS: In this multicenter, pragmatic, comparative effectiveness trial, we randomly assigned patients 18 to 76 years of age who presented to the emergency department with suspected nephrolithiasis to undergo initial diagnostic ultrasonography performed by an emergency physician (point-of-care ultrasonography), ultrasonography performed by a radiologist (radiology ultrasonography), or abdominal CT. Subsequent management, including additional imaging, was at the discretion of the physician. We compared the three groups with respect to the 30-day incidence of high-risk diagnoses with complications that could be related to missed or delayed diagnosis and the 6-month cumulative radiation exposure. Secondary outcomes were serious adverse events, related serious adverse events (deemed attributable to study participation), pain (assessed on an 11-point visual-analogue scale, with higher scores indicating more severe pain), return emergency department visits, hospitalizations, and diagnostic accuracy. RESULTS: A total of 2759 patients underwent randomization: 908 to point-of-care ultrasonography, 893 to radiology ultrasonography, and 958 to CT. The incidence of high-risk diagnoses with complications in the first 30 days was low (0.4%) and did not vary according to imaging method. The mean 6-month cumulative radiation exposure was significantly lower in the ultrasonography groups than in the CT group (P<0.001). Serious adverse events occurred in 12.4% of the patients assigned to point-of-care ultrasonography, 10.8% of those assigned to radiology ultrasonography, and 11.2% of those assigned to CT (P=0.50). Related adverse events were infrequent (incidence, 0.4%) and similar across groups. By 7 days, the average pain score was 2.0 in each group (P=0.84). Return emergency department visits, hospitalizations, and diagnostic accuracy did not differ significantly among the groups. CONCLUSIONS: Initial ultrasonography was associated with lower cumulative radiation exposure than initial CT, without significant differences in high-risk diagnoses with complications, serious adverse events, pain scores, return emergency department visits, or hospitalizations. (Funded by the Agency for Healthcare Research and Quality.).