The Application of Advanced Bone Imaging Technologies in Sports Medicine.

Until recently, the evaluation of bone health and fracture risk through imaging has been limited to dual-energy X-ray absorptiometry (DXA) and plain radiographs, with a limited application in the athletic population. Several novel imaging technologies are now available for the clinical assessment of bone health, including bone injury risk and healing progression, with a potential for use in sports medicine. Among these imaging modalities is high-resolution peripheral quantitative computed tomography (HR-pQCT) which is a promising technology that has been developed to examine the bone microarchitecture in both cortical and trabecular bone at peripheral anatomical sites. Technologies that do not expose patients to ionizing radiation are optimal, particularly for athletes who may require frequent imaging. One such alternative is diagnostic ultrasound, which is preferable due to its low cost and lack of radiation exposure. Furthermore, ultrasound, which has not been a common imaging modality for monitoring fracture healing, has been shown to potentially demonstrate earlier signs of union compared to conventional radiographs, including callus mineralization and density at the healing site. Through the use of conventional magnetic resonance imaging (MRI), finite element analysis (FEA) can be used to simulate the structural and mechanical properties of bone. On the other hand, the ultrashort echo time (UTE) MRI can evaluate cortical bone quality by detecting water bound to the organic bone matrix and free water, providing important information about bone porosity. Several novel bone imaging techniques originally developed for osteoporosis assessment have great potential to be utilized to improve the standard of care in bone fracture risk assessment and healing in sports medicine with much greater precision and less adverse radiation exposure.

Trends of Chronic Liver Disease in a Tertiary Care Centre in the Eastern Part of India: A Retrospective Study.

AIM OF THE STUDY: To assess the relationship between the severity of liver cirrhosis and its outcomes based on laboratory parameters, Child-Turcotte-Pugh (CTP) score, and upper gastrointestinal (UGI) endoscopy findings. BACKGROUND:  Cirrhosis is the end stage of chronic liver disease (CLD) and is characterised by progressive liver fibrosis and distortion of the liver architecture. It is a major cause of morbidity and mortality all over the world. Cirrhosis is compensated in the initial stages and later progresses to the decompensated stage with various complications. The CTP scoring system predicts mortality in patients with cirrhosis. MATERIALS AND METHODS: This retrospective study was done in the Department of Medicine and Gastroenterology of Tata Main Hospital (TMH), Jamshedpur, Jharkhand, India. It was conducted over a period of two years between 1 January 2019 and 31 December 2020, on 150 confirmed cases of cirrhosis. RESULTS: The most common age group was 41-60 years (86, 57.33%) and the mean age ± standard deviation (SD) for all patients was 49.82 ± 11.63 years. In a total of 150 CLD cases, males were 96 (64%). The most common cause of CLD was alcohol (76, 50.67%). Based on presenting symptoms, most CLD patients presented with generalized weakness (144, 96.00%). The most common signs were icterus (68, 45.33%) and ascites (44, 29.33%). Most patients belonged to CTP class A (77, 51.33%), followed by CTP class B (44, 29.33%) and class C (29, 19.34%). The most common UGI endoscopy finding was portal hypertensive gastropathy (mild or severe) (135, 75%). Total deaths were 24 (16.00%), with 17 deaths (70.83%) in patients belonging to CTP class C. CONCLUSION: CLD is a common entity in eastern India with male preponderance and affects mostly people of the middle age group. Alcohol intake is a major cause of CLD, followed by non-alcoholic fatty liver disease and chronic hepatitis B and C. A significant rise in morbidity and mortality due to alcoholic liver disease (ALD) was observed in the study and needs urgent social and medical intervention. The incidence of ALD in our study was 50.67%.

Evolution of single-lead ECG for STEMI detection using a deep learning approach.

BACKGROUND: While ST-Elevation Myocardial Infarction (STEMI) door-to-balloon times are often below 90 min, symptom to door times remain long at 2.5-h, due at least in part to a delay in diagnosis. OBJECTIVES: To develop and validate a machine learning-guided algorithm which uses a single­lead electrocardiogram (ECG) for STEMI detection to speed diagnosis. METHODS: Data was extracted from the Latin America Telemedicine Infarct Network (LATIN), a population-based Acute Myocardial Infarction (AMI) program that provides care to patients in Brazil, Colombia, Mexico, and Argentina through telemedicine. SAMPLE: the first dataset was comprised of 8511 ECGs that were used for various machine learning experiments to test our Deep Learning approach for STEMI diagnosis. The second dataset of 2542 confirmed STEMI diagnosis EKG records, including specific ischemic heart wall information (anterior, inferior, and lateral), was derived from the previous dataset to test the STEMI localization model. Preprocessing: Detection of QRS complexes by wavelet system, segmentation of each EKG record into individual heartbeats with fixed window of 0.4 s to the left and 0.9 s to the right of main. Training & Testing: 90% and 10% of the total dataset, respectively, were used for both models. CLASSIFICATION: two 1-D convolutional neural networks were implemented, two classes were considered for first models (STEMI/Not-STEMI) and three classes for the second model (Anterior/Inferior/Lateral) each corresponding to the heart wall affected. These individual probabilities were aggregated to generate the final label for each model. RESULTS: The single­lead ECG strategy was able to provide an accuracy of 90.5% for STEMI detection with Lead V2, which also yielded the best results overall among individual leads. STEMI Localization model provided promising results for anterior and inferior wall STEMIs but remained suboptimal for Lateral STEMI. CONCLUSIONS: An Artificial Intelligence-enhanced single­lead ECG is a promising screening tool. This technology provides an autonomous and accurate STEMI diagnostic alternative that can be incorporated into wearable devices, potentially providing patients reliable means to seek treatment early and offers the potential to thereby improve STEMI outcomes in the long run.

Chronic Workload, Subjective Arm Health, and Throwing Injury in High School Baseball Players: 3-Year Retrospective Pilot Study.

BACKGROUND: Baseball workloads are monitored by pitch counts, appearances, innings per appearance, ball velocity, and distance, whereas current workload standards neglect throws made during nongame situations. The association between total workloads, subjective measures, and injury in baseball is poorly understood. The question remains whether baseball athletes are at higher risk of injury by throwing more often or if they generate injury resilience when appropriately transitioned into the higher demands of throwing. HYPOTHESIS: Increased chronic load, along with subjective arm health measures, are related to decreased injury risk. STUDY DESIGN: Clinical research. LEVEL OF EVIDENCE: Level 3. METHODS: A total of 49 male baseball players (age 17.9 ± 0.4 years, height 181.8 ± 6.8 cm, body mass 80.6 ± 9.1 kg) competing at the varsity high school level were included in this 3-year retrospective data analysis from 2016 to 2019. Players wore the motusTHROW sleeve and sensor during all throwing activities. RESULTS: A total of 898,492 throws and 9455 athletic exposures were captured with the motusTHROW sensors. There were 24 injuries recorded throughout the 3-year analysis, with 11 throwing-related and 13 non-throwing related injuries. Results of the 1-way analysis of variance found chronic load was significantly related to throwing-injury occurrence (P < 0.01). Six of the throwing-related injuries occurred when athletes had a chronic load greater than 11.3, marking 75th percentile across all observations. There was a relationship between arm health and throwing arm-related injury occurrence (P < 0.01). Higher chronic load was associated with increased throwing-related injuries even when adjusted for arm health (P = 0.01). Specifically, injuries were more likely to occur in pitchers (either as a combination player or pitcher only) with a chronic load greater than 9.2. CONCLUSION: This study revealed a significant relationship between chronic load, subjective arm health, and throwing-related injury in varsity high school baseball players. Contrary to our hypothesis, increased chronic load was associated with increased injury risk. However, subjective arm health measures remain a relevant factor in assessing injury risk. Normative data for this population also provide key information around positional demands along with overall demands of the sport during the competitive season and off-season.

Impact of a telemedicine-guided, population-based, STEMI network on reperfusion strategy, efficiency, and outcomes: Impact of telemedicine on STEMI management.

AIMS: A telemedicine-guided strategy increases the access to and efficiency of ST-elevation myocardial infarction (STEMI) networks resulting in increased access to, and reduced disparities in, acute myocardial infarction (AMI) care between rural and urban areas. METHODS AND RESULTS: The Latin America Telemedicine Infarct Network (LATIN) was developed for poor and remote regions in Brazil and Colombia that lacked coordinated AMI systems of care. It strategically connects small clinics and primary care health centres (spokes) to hubs with 24/7 percutaneous coronary intervention (PCI) capability. Experts at three remote sites provide urgent electrocardiogram (ECG) diagnosis and tele-consultation for the entire network. Data from the busiest LATIN site, the Santa Marcelina Hospital in Sao Paolo, Brazil, were compared with health statistics from Sistema Unico de Saude (Brazilian Public Health System - SUS). A total of 192 centres were networked using standardised and guideline-based protocols for AMI care. Overall, 313,897 patients were remotely screened, 3,572 AMI diagnosed (1.1%), and 1,636 AMI urgently reperfused (45.8%), mainly by primary PCI (n=1,351; 83%). CONCLUSIONS: In conclusion, a comparison between a pre-LATIN cohort from SUS (1,015) and a LATIN cohort from Santa Marcelina Hospital (1,247) revealed increased reperfusion with PCI (65.52% vs 75.2%), increased cost ($2,037.12 vs $2,246.40, p<0.005), a statistically significant reduction in PCI mortality (8.5% vs 4.3% p<0.01) and a non-significant reduction in mortality overall amongst all treatment pathways (9.69% vs 9.43%, p=0.931).

Getting paralysed after COVID: Guillain-Barre syndrome.

Neurological involvement after coronavirus disease (COVID-19) pneumonias is common and occurs in almost one-third of the patients. The commonest neurological symptoms are ageusia, anosmia, headache, nausea, vomiting, dizziness, and myalgia. Guillain-Barre syndrome (GBS) is a rare manifestation of severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) infection; whereas the common neurological manifestations of the SARS-CoV-2 infection occur with the onset of the respiratory symptoms and may be due to the direct invasion of the nervous system by the virus, GBS in COVID-19 follows a time lag of 1-4 weeks and may be attributable to the immune mechanism of molecular mimicry. Here we report a case of GBS in a patient of COVID-19 which occurred on the 22nd day after the onset of the disease. The patient recovered completely and went home walking.

A Rare Case of Caroli's Syndrome.

Caroli's syndrome is a rare autosomal recessive congenital disorder of the biliary tree characterized by intrahepatic bile duct dilation and hepatic fibrosis. Very few cases have been encountered in routine day-to-day practice. The patients usually present with features of cholangitis such as pain abdomen and jaundice. They may also present with features of chronic liver disease and portal hypertension. Very rarely, they may develop cholangiocarcinoma and present with jaundice, weight loss, and abdominal mass or ascites. Here, we report one such case of a young female who presented to us with features of cholangitis with sepsis and encephalopathy, which was finally diagnosed as Caroli's syndrome. The aim of presenting this case is to learn that even patients with common symptoms of pain abdomen and jaundice may be harboring some rare congenital disease like Caroli's syndrome, as in our case.

STEMI telemedicine for 100 million lives.

BACKGROUND: Developing countries struggle to diagnose and treat ST-segment elevation myocardial infarction (STEMI) patients in a timely manner, and subsequent outcomes are suboptimal. METHODS: The Latin America Telemedicine Network (LATIN) functioned between 2013 to present in four countries-Brazil, Colombia, Mexico, and Argentina. A Hub and Spoke platform was developed to expand access to >100 million population for STEMI care. Patients were triaged at spokes that included small clinics and primary health care centers in remote South American locations. Three telemedicine command sites provided immediate 24/7 electrocardiogram diagnosis and teleconsultation of the STEMI process at 355 centers in four countries. RESULTS: LATIN Spokes (n = 313) screened up to 30,000 patients per month, and a total of 780,234 patients over the study period. Telemedicine experts diagnosed 8395 (1·1%) with STEMI, of which a total of 3872 (46·1%) were urgently treated at 47 Hubs. A total of 3015 patients (78%) were reperfused with percutaneous coronary intervention. Time-to-telemedicine diagnosis averaged 3·5 min. Average door-to-balloon time improved from 120 to 48 min during the study period and overall STEMI mortality was 5·2%. INTERPRETATION: Telemedicine transcends boundaries and enables access to millions of patients for STEMI care. With this initiative, LATIN has created a template for reducing disparities in STEMI management between developed and developing countries.

Seattle Angina Pectoris Questionnaire and Canadian Cardiovascular Society Angina Categories in the Assessment of Total Coronary Atherosclerotic Burden.

The patient reported angina measurement with the Seattle Angina Questionnaire (SAQ) has shown to have prognostic implications and became an endpoint in clinical trials. Our objective was to study physician-reported and SAQ severity with the total coronary atherosclerotic burden as assessed by 4 angiographic scores. We prospectively analyzed data of consecutive patients scheduled for coronary angiography or percutaneous coronary intervention. The Canadian Cardiovascular Society (CCS) angina categories was used as physician-reported angina. SAQ domains were categorized as severe (0 to 24), moderate 25 to 75 and mild angina (>75). All angina assessments were done before coronary angiography. Gensini, Syntax, Friesinger, and Sullivan angiographic scores were used for total atherosclerotic burden quantification: 261 patients were included in the present analysis. The median age was 66.0 (59.0 to 71.8) years, 53.6% were male and 43.7% had diabetes. The median SYNTAX score was 6.0 (0 to 18.0). The worse the symptoms of CCS categories, the more severe was the atherosclerotic burden in all angiographic scores: SYNTAX (p = 0.01); Gensini (p <0.01); Friesinger (p = 0.02) and Sullivan (p = 0.03). Conversely, SAQ domains were not able to discriminate the severity of CAD in any of the scores. The only exception was the severe SAQ quality of life that had worse Gensini score than the mild SAQ quality of life (p = 0.04). In conclusion, CCS angina categories are related to the total atherosclerotic burden in coronary angiography, by all angiographic scores. SAQ domains should be used as a measure of patient functionality and quality of life but not as a measure of CAD severity.

Meta-Analysis of Gender Disparities in In-hospital Care and Outcomes in Patients with ST-Segment Elevation Myocardial Infarction.

Gender disparities in ST-segment elevation myocardial infarction (STEMI) outcomes continue to be reported worldwide; however, the magnitude of this gap remains unknown. To evaluate gender-based discrepancies in clinical outcomes and identify the primary driving factors a global meta-analysis was performed. Studies were selected if they included all comers with STEMI, reported gender specific patient characteristics, treatments, and outcomes, according to the registered PROSPERO protocol: CRD42020161469. A total of 56 studies (705,098 patients, 31% females) were included. Females were older, had more comorbidities and received less antiplatelet therapy and primary percutaneous coronary intervention (PCI). Females experienced significantly longer delays to first medical contact (mean difference 42.5 min) and door-to-balloon time (mean difference 4.9 min). In-hospital, females had increased rates of mortality (odds ratio [OR] 1.91, 95% confidence interval [CI] 1.84 to 1.99, p <0.00001), repeat myocardial infarction (MI) (OR 1.25, 95% CI 1.00 to 1.56, p=0.05), stroke (OR 1.67, 95% CI 1.27 to 2.20, p <0.001), and major bleeding (OR 1.82, 95% CI 1.56 to 2.12, p <0.00001) compared with males. Older age at presentation was the primary driver of excess mortality in females, although other factors including lower rates of primary PCI and aspirin usage, and longer door-to-balloon times contributed. In contrast, excess rates of repeat MI and stroke in females appeared to be driven, at least in part, by lower use of primary PCI and P2Y12 inhibitors, respectively. In conclusion, despite improvements in STEMI care, women continue to have in-hospital rates of mortality, repeat MI, stroke, and major bleeding up to 2-fold higher than men. Gender disparities in in-hospital outcomes can largely be explained by age differences at presentation but comorbidities, delays to care and suboptimal treatment experienced by women may contribute to the gender gap.

Cluster of climatic and pollutant characteristics increases admissions for acute myocardial infarction: Analysis of 30,423 patients in the metropolitan area of Sao Paulo.

BACKGROUND: The impact of simultaneous adverse climate conditions in the risk of myocardial infarction (MI) was not tested before. The aim of the present study was to investigate the impact of the combination of climate and air pollution features in the number of admissions and mortality due to acute myocardial infarction in 39 municipalities of São Paulo from 2012 to 2015. METHODS: Data about MI admissions were obtained from the Brazilian public health system (DataSUS). Daily information on weather were accessed from the Meteorological Database for Teaching and Research. Additionally, daily information on air pollution were obtained from the Environmental Company of the State of São Paulo. A hierarchical cluster analysis was applied for temperature, rainfall patterns, relative air humidity, nitrogen dioxide, particulate matter 2.5 and particulate matter 10. MI admissions and in-hospital mortality were compared among the clusters. RESULTS: Data analysis produced 3 clusters: High temperature variation-Low humidity-high pollution (n=218 days); Intermediate temperature variation/high humidity/intermediate pollution (n=751 days) and low temperature variation/intermediate humidity-low pollution (n=123 days). All environmental variables were significantly different among clusters. The combination of high temperature variation, dry weather and high pollution resulted in a significant 9% increase in hospital admissions for MI [30.5 (IQR 25.0-36.0)]; patients/day; P<0.01). The differences in weather and pollution did not have impact on in-hospital mortality (P=0.88). CONCLUSION: The combination of atmospheric conditions with high temperature variation, lower temperature, dryer weather and increased inhalable particles was associated with a marked increase of hospital admissions due to MI.

Multi-organ dysfunction following honeybee bite-A rare entity.

Honeybee bites have been known to cause localized allergic reactions and anaphylaxis but systemic toxic reactions leading to multiorgan dysfunction is very rare. Serious complications like acute renal failure, acute myocardial infarction (Kounis syndrome) and even death have been reported as the complication of honeybee bite. Herein, we report a case of multiorgan dysfunction following honeybee bite, which was complicated with acute kidney injury, thrombocytopenia, bradycardia, keratitis, and deranged liver function along with localized allergic reaction and pain.

Resource and Infrastructure-Appropriate Management of ST-Segment Elevation Myocardial Infarction in Low- and Middle-Income Countries.

The 143 low- and middle-income countries (LMICs) of the world constitute 80% of the world's population or roughly 5.86 billion people with much variation in geography, culture, literacy, financial resources, access to health care, insurance penetration, and healthcare regulation. Unfortunately, their burden of cardiovascular disease in general and acute ST-segment-elevation myocardial infarction (STEMI) in particular is increasing at an unprecedented rate. Compounding the problem, outcomes remain suboptimal because of a lack of awareness and a severe paucity of resources. Guideline-based treatment has dramatically improved the outcomes of STEMI in high-income countries. However, no such focused recommendations exist for LMICs, and the unique challenges in LMICs make directly implementing Western guidelines unfeasible. Thus, structured solutions tailored to their individual, local needs, and resources are a vital need. With this in mind, a multicountry collaboration of investigators interested in LMIC STEMI care have tried to create a consensus document that extracts transferable elements from Western guidelines and couples them with local realities gathered from expert experience. It outlines general operating principles for LMICs focused best practices and is intended to create the broad outlines of implementable, resource-appropriate paradigms for management of STEMI in LMICs. Although this document is focused primarily on governments and organizations involved with improvement in STEMI care in LMICs, it also provides some specific targeted information for the frontline clinicians to allow standardized care pathways and improved outcomes.

The Effect of Inflammation on Bone.

Bone remodeling is the continual process to renew the adult skeleton through the sequential action of osteoblasts and osteoclasts. Nuclear factor RANK, an osteoclast receptor, and its ligand RANKL, expressed on the surface of osteoblasts, result in coordinated control of bone remodeling. Inflammation, a feature of illness and injury, plays a distinct role in skewing this process toward resorption. It does so via the interaction of inflammatory mediators and their related peptides with osteoblasts and osteoclasts, as well as other immune cells, to alter the expression of RANK and RANKL. Such chemical mediators include TNFα, glucocorticoids, histamine, bradykinin, PGE2, systemic RANKL from immune cells, and interleukins 1 and 6. Conditions, such as periodontal disease and alveolar bone erosion, aseptic prosthetic loosening, rheumatoid arthritis, and some sports related injuries are characterized by the result of this process. A thorough understanding of bone response to injury and disease, and ability to detect such biomarkers, as well as imaging to identify early structural and mechanical property changes in bone architecture, is important in improving management and outcomes of bone related pathology. While gut health and vitamin and mineral availability appear vitally important, nutraceuticals also have an impact on bone health. To date most pharmaceutical intervention targets inflammatory cytokines, although strategies to favorably alter inflammation induced bone pathology are currently limited. Further research is required in this field to advance early detection and treatments.

Relationship between workload and throwing injury in varsity baseball players.

OBJECTIVES: In this study we describe the first analysis of the relationship between acute-to-chronic valgus workload ratio (ACVR) and injury in baseball. DESIGN: Observational study. SETTING: Competitive, team sport. PARTICIPANTS: Eighteen, elite male baseball players (aged 17.0 ±â€¯0.7 year, height 185 ±â€¯5.7 cm, and mass 85.2 ±â€¯7.6 kg) competing at the varsity level participated in this six-month study. Each player wore the motusTHROW™ sleeve and sensor during pre-season training and the entire 2017 regular season. MAIN OUTCOME MEASURES: ACVR and injury. RESULTS: Overall there were a total of ten injuries recorded throughout the 2017 season amongst those wearing the sleeves, including six throwing-related injuries. Over 159 days of throwing, a total of 171,703 throws, and 1307 exposures were captured with the motusTHROW™ sensors. Five of the six throwing-related injuries occurred when athletes had an ACVR greater than 1.27, which marks the 75th percentile across all observations. Results from logistic regression suggested that ACVR was significantly related to injury occurrence (p < .05). This resulted in an odds ratio of 15.2 and a risk ratio of 14.9, meaning that ACVR ratios above 1.27 were 14.9 times more likely to result in injury than ACVR ratios below 1.27. CONCLUSIONS: Logistic regression reveals a significant relationship between ACVR and injury occurrence such that high ACVRs may increase injury risk.

Protocol of the China ST-segment elevation myocardial infarction (STEMI) Care Project (CSCAP): a 10-year project to improve quality of care by building up a regional STEMI care network.

INTRODUCTION: Successful ST-segment elevation myocardial infarction (STEMI) management is time-sensitive and is based on prompt reperfusion mainly to reduce patient mortality. It has evolved from a single hospital care to an integrated regional network approach over the last decades. This prospective study, named the China STEMI Care Project (CSCAP), aims to show how implementation of different types of integrated regional STEMI care networks can improve the reperfusion treatment rate, shorten the total duration of myocardial ischaemia and lead to mortality reduction step by step. METHODS AND ANALYSIS: The CSCAP is a prospective, multicentre registry study of three phases. A total of 18 provinces, 4 municipalities and 2 autonomous regions in China were included. Patients who meet the third universal definition of myocardial infarction and the Chinese STEMI diagnosis and treatment guidelines are enrolled. Phase 1 (CSCAP-1) focuses on the in-hospital process optimisation of primary percutaneous coronary intervention (PPCI) hospitals, phase 2 (CSCAP-2) focuses on the PPCI hospital-based regional STEMI care network construction together with emergency medical services and adjacent non-PPCI hospitals, while phase 3 (CSCAP-3) focuses on the whole-city STEMI care network construction by promoting chest pain centre accreditation. Systematic data collection, key performance index assessment and subsequent improvement are implemented throughout the project to continuously improve the quality of STEMI care. ETHICS AND DISSEMINATION: The study has been reviewed and approved by the Ethics Committee of Peking University First Hospital. Ranking reports of quality of care will be generated available to all participant affiliations. Results will be disseminated via peer-reviewed scientific journals and presentations at congresses. TRIAL REGISTRATION NUMBER: NCT03821012.

Ordering of Diagnostic Imaging by Physical Therapists: A 5-Year Retrospective Practice Analysis.

BACKGROUND: Significant progress has been made in implementing direct access. As more therapists transition into direct access roles, it seems prudent to consider how additional resources common to other first-contact providers might impact patient care. OBJECTIVES: Direct referral for diagnostic imaging by physical therapists is relatively rare in the civilian setting and little has been published on the subject. The primary objective of this study was to examine the appropriateness of diagnostic imaging studies referred by civilian physical therapists at an academic medical center. Secondary objectives were to track reimbursement data and overall use rates. DESIGN: This was a single-center, retrospective practice analysis of 10 physical therapists over a period of nearly 5 years. METHODS: The electronic medical record was reviewed for each patient who had an imaging referral placed by a physical therapist. Relevant clinical exam findings and patient history were provided to a radiologist who then applied the American College of Radiology Appropriateness Criteria to determine appropriateness. Reimbursement data and therapist use rates were also evaluated. RESULTS: Of the 108 total imaging studies, 91% were considered appropriate. Overall, use rates per direct access evaluation were 9% for plain film x-rays and 4% for advanced imaging. Reimbursement was 100%. LIMITATIONS: This study was limited to 10 physical therapists at 1 practice location. Appropriateness was evaluated by 1 radiologist. The educational background of referring therapists was not evaluated. CONCLUSIONS: Physical therapists demonstrated appropriate use of diagnostic imaging in the vast majority of cases (91%). They were judicious in their use of imaging, and there were no issues with reimbursement. These findings could be useful for physical therapists interested in acquiring diagnostic imaging referral privileges.