R.Paul Consulting
R.Paul Consulting

2024 Blog Entries


An often overlooked subject in the field of nuclear cardiology are non-responders to vasodilatory stress agents, specifically A2A receptor agonists. In fact, a JNM article from June '2022 stated "The prevalence of non-response (NR) to regadenoson (Reg), which is one potential mechanism for false negative stress myocardial perfusion imaging (MPI), is unknown."

In this study, using CZT SPECT derived myocardial flow reserves (MFR), after separating the findings out of 269 patients (eg., ischemia, infarct, etc.) they were left with 186. Out of that group, 5 (~3%) patients had unexplainably low MFR's of <1.2  in the absence of extensive coronary disease or known microvascular disease, as well as confirmed caffeine cessation, suggesting a lack of response to regadenoson.

This begs a few questions: what serology based tests could be used to pre-screen patients A2A cardiac receptor expression, or should there be consideration for a cartridge based test similar to Abbott's CLIA waived i-Stat?

And lastly, could this lack of response to A2A agonists suggest an underlying disease known to involve A2A receptors (eg., Parkinsons, Alzheimers, Depression)?


In past blogs I mentioned a Jeffry A. Siegel dispelling the 70 year old hypothesis (Linear No-Threshold Hypothesis) in 2017 via the Journal of Nuclear Medicine that exposure to medical radiation could increase ones risk of cancer. In fact, he suggested that efforts to lower dose exposure in medical imaging ultimately harm patients and it more likely helps prevent it (radiation hormesis).

MIT has a very informative YouTube Video further emphasizing there aren't enough high quality studies such that one side cannot disprove the other.

More and more websites are offering substantive evidence warranting the need for a high quality 'end-game' scientific study.

The consensus thus far weighs in favor of a controversial complete overhaul which some argue "would likely result in the elimination of many government jobs and significantly reduce the budget of the federal and state regulatory agencies."



Gibbins Advisors, a Healthcare advisory firm, reports concerning trends of increasing Healthcare related bankruptcies.

Below are some key takeaways:
1. Healthcare Bankruptcy filings* in 2023 totaled 79 cases, which is over 3 times the level seen in 2021 and over 1.7 times the level in 2022.
2. 2023 saw the return of large cases with liabilities over $100 million, with 28 filings in 2023 compared to just 7 in 2022, and 8 in 2021.
3. While the number of Healthcare Bankruptcy filings* increased across six consecutive quarters through Q3 2023, there was a decline from Q3 to Q4 2023. This will be monitored in 2024 to identify if Q4 2023 is indicative of a trend.
4. Consistent with previous trends, in 2023 Senior Care and Pharmaceutical subsectors comprised almost half of the total Healthcare Bankruptcy filings*.
5. Hospital bankruptcies in 2023 were at their highest level since 2019, with 12 hospital filings† compared to just 11 hospital filings across the prior 3 years combined (2020-2022).

Gibbins Healthcare Bankruptcies
Adobe Acrobat document [1.7 MB]



We've all heard of student loan forgiveness. Is medical debt forgiveness now the new norm?



Despite the Tc99m-PYP shortage, our clinics are still routinely performing amyloidosis scans with Tc99m-HMDP, allowing us to screen specifically for Transthyretin ATTR, a rare disease that's often underdiagnosed.

Here we have an 83 year old Caucasian male with a history of paroxysmal atrial fibrillation, and severe left-ventricular hypertrophy despite well controlled blood-pressure. To rule out cardiac amyloidosis, a Tc99m-HMDP scan was performed.

Patient was found to have an HCL ratio of 1.6, and a Grade III visual score, both strongly suggesting the scan to be positive for TTR amyloidosis.

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