Polite Dissent

Tonight’s episode of House tried to hard to be edgy and ended up losing a coherent plot and any semblance of logical medical care along the way.

Abby is a seventeen year old high school senior who becomes unresponsive while on a school outing to the planetarium. Foamy red sputum drips from her mouth and her boyfriend reports that she’s not breathing; she is rushed to the hospital and admitted to House’s service.

Abby is found to have pulmonary edema (fluid build-up the lungs). The team understands this to mean that she has either a heart problem or a lung problem. Her drug screen was negative and her blood alcohol level was barely positive. Foreman suggests she may have developed heart disease from binge drinking. A C-13 pyruvate MRI is ordered (a test that looks at blood flow within the heart muscle itself). It doesn’t show the heart disease Foreman was looking for, but there appears to be something wrong with the mitral valve. Fungus is considered as a possibility, but the team decides a fastidious enteric bacteria infection is more likely (enteric bacteria are found in the human intestine, and fastidious means they are difficult to culture). A TEE (transesophageal echo — an echocardiogram performed from the inside of the throat which offers good views of the heart valves) is ordered to get a better look at the mitral valve. Under echocardiography, the valve appears normal, but during the test Abby develops an aortic dissection (a tear in the wall of the aorta), a life threatening emergency. She is rushed to emergency surgery where Taub and Thirteen manage to successfully resuscitate her.

The question now is how did Abby develop the aortic weakness which led to the dissection? A genetic defect is mentioned, but quickly dismissed with the aside that she is not Marfanoid (Marfan’s syndrome is known to cause aortic dissections — of course, there are other genetic defects besides Marfan’s). An allergic reaction is also suggested as a likely cause. Thirteen believes that a severe immune reaction could have led to the aortic weakness. She goes on to suggest that Abby may be allergic to her boyfriend’s semen. A quick test is performed but shows no reaction. However, during the test, Abby develops excruciating abdominal pain and is found to have blood in her urine. “Kidney failure,” screams Chase.

The differential diagnosis now consists of neuropathy (by which they mean syphilis, which can lead to a weakened aorta), a blood clot, insterstitial cystitis, or cancer. A full body scan is suggested, but, for the second week in a row, House mentions how much he hates them (a point on which we agree — of course, House’s opinion would carry more weight if they hadn’t already ordered five or six this season — and he wasn’t a fictional character). Out of other options, House agrees to the full body scan, which is negative. This being House, no test can go smoothly, and Abby starts to hallucinate during the study. This causes the team to reevaluate their differential, which now consists of a vascular disease (probably vasculitis from the way Foreman is talking) or an aneurysm. An MRA (an MRI that looks specifically at blood vessels) is ordered to find the aneurysm, but it also is negative. Foreman suggests a parasite found in the Middle East, but House shoots him down abruptly, saying it was too ridiculous to even consider.

Abby continues to hallucinate, but now has also started to have seizures. House convinces the team to try an experimental technology (conveniently available at that very hospital): cognitive pattern recognition. In a scene more at home on Fringe than House, the team see the image of her boyfriend playing baseball, then the universe, then an older man (“her late father” they surmise) from Abby’s brain. Unfortunately, this isn’t enough to build any sort of diagnosis. Grasping at straws, Thirteen suggests something may be wrong with the liver. Chase suggests she may have polycystic kidney disease (which really would have been seen on that full body scan he wanted). Foreman notices the MRI shows that her pineal gland is calcified (which is normal), but wonders if it may be hiding a tumor. A high powered MRI is ordered to check but is completely normal. House is at a loss until a conversation with Taub triggers his Eureka! moment. It turns out that Abby boyfriend’s father travels extensively, to the Middle East even, where he picked up the parasite that Foreman mentioned earlier, which he passed on to Abby in a drunken sexual encounter. The parasite itself died, but it left enough behind to cause a severe allergic reaction which is causing all of Abby’s problems (Cerebellar schistosomiasis hypersensitivity allergy). A quick brain surgery (to the remove the parasite, presumably) and she is fine physically. Emotionally…is a different story.

As usual, major complaints are in red, minor complaints are in blue, and nit-picking ones in green:

Schistosomiasis is infection by the liver fluke. It is endemic in much of the world, including the Middle East. So far so good, however:
1. It is the eggs of the fluke that illicit elicit a potent immune response. The fluke can cause an immune response itself, but not the level the eggs do (the level Abby demonstrated)
2. The body walls the offending agent off in a granuloma which absolutely should show up on a scan.
3. Schistosomiasis is not transmitted from person to person; it has a complex life-cycle and needs an intermediate host.

Coincidentally, just this past Thursday, NPR ran a segment on using a computer and pattern recognition to read human minds. Suffice it to say that the scene on House bore little in common with reality.

5cc of Adrenalin is a high dose. Even in emergencies, it is generally given in 1cc doses (though it will likely take more than a single dose). Plus, in the medical profession in the United States we call it “epinephrine,” half the OR staff wouldn’t know what you wanted if you asked for “adrenalin.”

Taub is suddenly a cardiac surgeon now? There’s a great deal of difference between a plastic surgeon and a cardiac surgeon. They only share one year of residency — the rest is completely different.

We’ve discussed this before, many times, and in great detail last week, but once more: blood in the urine is not a sign of kidney failure.

If the offending parasite’s body was so small it didn’t show up on a scan, how did they know where to operate to remove it?

Only in the hospital for a few minutes, Taub breaks HIPAA (Health Information Portablilty and Accountability Act, a Federal law which deals with, among other things, patient privacy) by telling Abby’s boyfriend about her medical condition. That’s a big fine for the hospital. $$$$ Nice going, Taub.

I know I often complain about the unrealistic time course of tests on the show, but this week’s deserves a special mention: fungal cultures are very slow growing — weeks, not days — so there’s no way they’d be negative so soon.
To my knowledge, there are no blood cultures for parasites. They are generally detected by O&P (ova and parasite) studies of the stool and blood smears.

She seized for just about a minute, yet in that time they managed to hook up a multi-lead EEG and record the waveforms. That’s damn impressive.
And can we stop the “OMG! If she has another seizure she’ll stroke out!” That’s unrealistic and insulting to people who actually have a seizure disorder.

The medical mystery was average — nothing we haven’t seen before: C. The final solution really didn’t make much sense. If they wanted her to have schistosomiasis, they should have given it to her in a way which could actually happen. If they wanted the edginess of sex with her boyfriend’s father, they should have just made her allergic to his semen, as was discussed earlier. Combining the two was a bad decision: D. The medicine had holes this week, though no more than usual, other than House giving up so fast. I give it a B. The soap opera was good, though not as strong as the last couple of weeks: B+.

The review of the previous episode of House
A list of all prior House reviews

The set-up was clever, but the medicine and final solution were sloppy and average, at best. The speed dating scene was worth it, though

Frankie is a 28 year old vegetarian (well, mostly vegetarian) who presents with a sudden case of severe coagulopathy (blood that won’t clot correctly — in Frankie’s case, her symptoms included facial bruising and bleeding gums). The initial thoughts include a congential thrombocytopenia (an inherited condition of low platelets), a toxic exposure, or a deficiency in clotting factors. House thinks the toxin exposure is the best option, and has the team search her apartment. Nothing is found in the search, but a conversation with a neighbor indicates that she has been exposed to rat poison (this is important because a common kind of rat poison is an anticoagulant and would explain her bleeding problem). Soon, Frankie complains of “muddy” urine, which the team takes to be a sign of kidney failure, meaning that rat poison was not the cause.

Looking at conditions which cause both a coagulopathy and kidney disease, the differential now includes hemolytic-uremic syndrome, Gaucher’s disease, Sjogrens syndrome (an autoimmune disease), and Haff disease (sudden development of rhabdomyolysis shortly after eating fish, thought to be related to some form of toxin). The latter seems the most likely and she is started on saline and mannitol (the suggested treatment for Haff disease is fluid and diuretics so these are reasonable choices). Chase still believes his suggestion of Sjogrens was the best, and reads over Frankie’s blog looking for clues. He sees one post mentioning decreased sexual arousal and he suspects this is due to vaginal dryness, a sign of Sjogrens. He wheels her into the x-ray suite to perform a sialogram (an x-ray of the salivary glands, because decreased saliva production is another sign of Sjogrens). He is unable to get the x-ray because she complains that it is uncomfortable to lie down. Chase recognizes this as a sign of valvular heart disease, and sure enough, an echocardiogram reveals severe problems with an unspecified mitral valve disorder (probably mitral valve regurgitation, as this has been associated with Sjogrens). Her condition is so bad that she will need an artificial mitral valve.

As she is being readied for surgery, Frankie develops severe right lower abdominal pain and vomiting. Emergency abdominal surgery reveals a burst appendix. Even worse, studies suggest that the appendix burst because it was full of cancerous cells — lymphoma — that has now spread throughout the body. The team tells her that it is too late for regular chemotherapy, but that she is a candidate for an experimental anti-lymphoma vaccine. Without it, she has maybe a year to live. She agrees and is started on the vaccinations. Everything goes well at first, but after the third dose she suffers a high fever. The suspicion is that the vaccine has triggered a severe immune response of some sort.

During a discussion of the case with Cuddy, the fact that Frankie is a night owl comes up in conversation because this is new for her. Until six months ago, she was up during the day instead of at night. According to the team, day-night reversal can be a sign of liver disease (true, to a point). A liver biopsy confirms that she has liver failure. What was initially thought to be lymphoma is now recognized as a granulomatous build up (inflammatory cells) related to the liver failure. Instead of a year to live, she is now given a few days.

Looking over her symptoms of fever, cell atypia, coagulopathy, liver disease, kidney disease, and heart disease, the team suspects some form of infection but can’t narrow it down any more than that (I don’t buy it: something inflammatory like an autoimmune disease could explain all the symptoms just as well). House orders her started on broad spectrum antibiotics. A later conversation with Wilson leads to his Eureka! moment. He realizes that in all her blogging, even the intensely personal stuff, she never mentioned her bowel movements. Direct questioning reveals that she had a change in bowel habits consistent with a malabsorption syndrome — in this case Whipple’s disease. A course of antibiotics and she’ll be fine (though she’ll still need the new mitral valve).

As usual, major complaints are in red, minor complaints are in blue, and nit-picking ones in green:

The writers don’t seem to understand kidney failure. It is – just as the name suggests – a failure of kidneys – that is: they don’t work any more. Instead of normal urine production there is a decreased or absent urine production. Dark urine is not a sign of kidney failure.
Dark urine is a common sign of a bleeding disorder, just like Frankie has. It would be more proof of rat poison exposure, not less.
Her kidney labs are normal, at least the creatinine is (arguably the most significant one), so she has no actual signs of kidney failure.

How did they miss severe liver failure on this patient? Liver labs should be drawn for every patient with an undiagnosed clotting problem,and it should have shown up on her other tests as well.

I don’t buy the whole “the lymphoma is too advanced for chemotherapy” argument. What tests have they done to show how widespread the cancer is? What treatments have they tried and failed?
The vaccine only works for follicular lymphoma, a rare type, and it doesn’t cure it, it just extends the time until the inevitable relapse this type of lymphoma always has.

Frankie has severe enough mitral valve disease to require a new valve sooner rather than later, yet no one heard a murmur on exam?

Other than a possible Vitamin K deficiency, what other signs of severe malabsorption does she show? None. Where’s the long history of weight loss (no way she wouldn’t have mentioned that on her blog), joint pain, fatigue, and fever?

Day night reversal is a sign of severe hepatic encephalopathy, which is seen is severe liver failure.

Her bleeding and bruising came on incredibly fast. I wouldn’t call it impossible, just very very very unlikely.

I find it sloppy work that no one asked about her bowel movements until House finally did. (It’s one of my “big four” questions I ask every patient). Especially in a patient they were considered hemolytic-uremic syndrome in.

If the team ever did a thorough admission exam and history, these shows would be lucky to last a half hour. How many diagnoses have they missed because of sloppy exam or poor history?

Another interesting medical mystery — better than most this season. It earns a B+. The final solution was a stretch. If her Whipple’s (and liver and kidney) had really been that bad, there would have been many signs along the way. I give it a C. The medicine had lots of holes this week, and the parts didn’t add up. It deserves no more than a C-. The soap opera was good. It was nice to a non-melancholy Chase again, and the House/Wilson scenes were well down. The speed dating was terrifically over the top. The soap opera earns a swofting A.

The review of the previous episode of House
A list of all prior House reviews

This week’s House Challenge scores have been posted

Elizabeth and raininthehills both had the week’s high score with 12 points.

Overall, TRad and Noether continue their dominance, with 82 and 80 points, respectively. Theta Sigma is third with 57 points, Corien retains fourth with 54 points, and The Erskine holds on to fifth with 52 points.

Click here to see the full scoreboard.

An atypical episode of House as it focused on a day in Dr. Cuddy’s life, moving every other character to the background. A change of pace, but a solid and enjoyable show nonetheless.

Cuddy gets up at five AM and starts the day with some yoga. Her daughter Rachel wakes up a little while later, sick, and Cuddy comforts her while getting ready for work. The nanny arrives, and then Lucas, who’d been up all night on a stakeout. He talks her into a quickie before work, but unfortunately he was a little premature in his efforts and she heads off to work unsatisfied.

Cuddy arrives at the hospital at eight and things are already going crazy.

House strolls up to discuss his patient he thought had resistant Staph, and who he wanted to treat by infecting him with malaria.

Cuddy walks off, telling House that she has to finish a proposal before an important 8:30 meeting and there’s a crisis in the pharmacy where some paperwork, and some ephedrine, is missing. Next, there’s a problem in surgery, where one of the surgeons is complaining because House has turned on the air conditioning. She gets the heat turned back on and heads to her meeting.

Meeting Cuddy in the hallway, House informs her that his patient now has boils and a large abscess.

Cuddy hears from the nanny that Rachel is still sick, only now she’s running a fever and vomiting. She finally makes it to her 8:30 appointment with the contract negotiator from AtlanticNet Insurance, the largest insurance company in the area. He and Cuddy have been arguing about a contract for eight months, and today Cuddy lays it all on the line. She agrees to capitated care, but wants a 12% increase in rates. He refuses. She tells him that this is the hospital’s final offer and he has until 3PM to agree, or she will make a public announcement that they are no longer accepting AtlanticNet, and why.

Thirteen and Taub report to House that their patient is now hallucinating and has a falling blood pressure and rising heart rate. They suspect congestive heart failure, but House disagrees, telling them that the patient has [elevator door shuts before we hear the answer].

On the way to the hospital board meeting, Cuddy has a run in with Dr. Thomas, the hospital’s Chief of Surgery. He is seething about House — upset primarily about the fact that he stole Chase back from the surgery department. She heads into the board meeting where the board makes it clear that Cuddy’s job is on the line if she can’t pull off the contract with AtlanticNet.

House skipped clinic again, so Cuddy fills in for him. The patient is an older man with metastatic cancer who wants a prescription for breast milk. He has heard that breast milk can help with his cancer, and wants a prescription so the insurance company will pay for it. She refuses, pointing out that even with a prescription the insurance company won’t pay for it. He accuses her of being in the pocket of the insurance company before insulting her and storming out.

Back at her office, Cuddy finds a lawyer waiting for her. He is representing Martin Acevedo, a man who had his thumb reattached after cutting it off with a saw. He is suing because he didn’t want the thumb reattached — he is poor and that was too expensive — but Chase went ahead and did the surgery anyway. When confronted Chase admits that he did sew the thumb back on even though that was not what the patient wanted because he felt that the reattachment was the best option for the patient medically.

A little while later, Cuddy meets with Gail, the pharmacy tech who stole the ephedrine. She tells Cuddy that it was to help her lose weight and asks Cuddy not to fire her. Cuddy takes a little pity on her and tells Gail that she has to fire her, but she won’t report her to the DEA. She grabs a quick unhealthy lunch from the cafeteria.

House is sitting in Cuddy’s office – in her chair – waiting for her. He tells her that his patient has renal cell cancer (kidney cancer) and he wants to treat with malaria in addition to chemotherapy.

Lucas swings by the office, bringing Cuddy a real lunch. He tells her that Rachel seems to be doing better — she is no longer running a fever — but she has developed a rash. Unfortunately, Lucas accidentally grabbed the nanny’s phone, and turned the ringer off on Cuddy’s phone at home, so there is no way to reach the nanny.

With Lucas’s help, Cuddy tracks down the CEO of AtlanticNet at lunch and confronts him about the contract. He blows her off, telling her he doesn’t care if her PR campaign makes him out to be a rich bastard, as long as he stays rich.

Back at the hospital she meets with the head of the pharmacy and discovers that a lot more ephedrine is missing from the hospital than previously suspected — $50,000 dollars worth — and the thefts have been going on for at least three years. She realizes that Gail has been lying to her and has been stealing the ephedrine to sell to a meth dealer (ephedrine can be used to make methamphetamine)

The negotiator from AtlanticNet returns and offers an 8% increase as their final offer. Cuddy declines, wanting the full 12%.

Now House’s patient has liver failure and needs a transplant.

Three o’clock arrives, and as there have been no new offers from AtlanticNet, Cuddy calls a staff meeting and informs the physicians that the hospital has terminated the contract with the insurer. This causes widespread disbelief and dismay among the staff, as many of them made much of their money from AtlanticNet patients.

Foreman arrives, telling Cuddy that they’ve found a liver, but now there’s another conflict. House wants Chase to do the surgery, but Thomas refuses to put him on the schedule. Foreman needs someone who outranks both House and Thomas to schedule the surgery.

Cuddy meets with Acevedo and his lawyer. She tells them that not only will the hospital fight the lawsuit tooth and nail, but that she wants Acevedo to pay the remaining bill for his care.

Next, Cuddy arrives at the surgical suite and breaks up a brawl between Drs. Chase and Thomas. She then returns to her office and confronts Gail, the recently fired pharmacy tech, about lying to her. Gail freely admits the theft and tells Cuddy she can’t do anything about it because she’ll lie to the DEA, telling them that she did it on House’s orders, and that House and Cuddy were having an affair. Frustrated, Cuddy walks out of her office, telling the staff that she quits. She sits quietly in her car for a few minutes until House arrives. He cheers her up, as only House can, by insulting her, but this is enough to get her to head back into the hospital.

Cuddy confronts Gail again, who once again brags of her theft and her plan to lie to the DEA. Luckily, Cuddy captured it all on one of Lucas’s hidden recording devices. The nanny calls and tells her that Rachel is doing fine. To complete the hat trick, the negotiator from Atlantic Net arrives and tells Cuddy that the insurer has agreed to her 12% proposal. Ecstatic, she informs the board and staff, who share her enthusiasm. Finally, she heads home to Lucas and Rachel after a long, exhausting day at work.

No significant medical complaints, and no grading this week either, as the episode didn’t give me much to work with in that regard. Just a few thoughts and comments:

Though I know nothing of its use in Staph infections or cancer patients, before the advent of penicillin, malaria was used a treatment for syphilis. The malaria gave the patients a high fever — high enough to kill off the syphilis germs — and malaria was curable with quinine.

On one hand, you could argue that Cuddy should have acceded to the patient’s wishes and given him a prescription for breast milk, since, as House said, “it might work.” However, I have to side with Cuddy on this one. First, she’s right: the insurance company will not pay for it, even with a prescription — they’ll consider it an experimental treatment. Second, it’s her signature on the prescription, and she should not write any prescription she is not comfortable signing. Finally, and she should have pushed this part harder, the breast milk is at best a shot in the dark — it’s wishful thinking — and by writing the prescription she would be confirming the patient’s false hope. She handled it well: she was upfront and truthful and told the patient she would not write the prescription. He didn’t like what she said, but he’s free to find a new physician.

Though it was mentioned briefly at the beginning, both Cuddy and the lawyer are glossing over the key fact that the treatment Mr. Acevedo received was not covered by the informed consent he signed. Chase may have done what he thought was best for the patient, but he did it through lying and dishonesty. Sure, Mr. Acevedo kept his thumb, and this will probably restrain the jury’s and judge’s enthusiasm for a large payout, but there is clear written evidence that Chase was deceitful in his treatment of the patient. The hospital’s insurance company will pay this off long before it sees a courtroom. And as for Chase, skipping informed consent or lying on it is a good way to lose a medical license.

Every place I’ve ever worked has a two people count the controlled substances in the pharmacy, just so situations like Gail’s can’t happen. And why does the hospital have so much ephedrine? It’s not that common a drug.

Anyone know what the rules in New Jersey are for surreptitiously recording a conversation? I know in Illinois it needs the consent of both parties involved, but I believe this is the exception, rather than the rule.

Consider this a non-scoring week for the House Challenge. Last week’s scores can be found here.

The review of the previous episode of House
A list of all prior House reviews

Big questions were answered, the science wasn’t that bad, but it still struck me as a surprisingly lifeless outing for the “Winter Finale” of Fringe.

The Plot: At an office building in Manhattan, the workers grouse about a series of small earthquakes the city has been experiencing. Suddenly, there is a larger tremor and one of the workers finds himself caught in the quake. He blacks out for a second and when he comes to, he is pinned by the rubble — and has four arms and four legs.

The Fringe team is called in to examine the office building. So far, no survivors have been found, but many dead bodies. The bodies aren’t normal, however, but each seems to be two separate people fused together. Walter hypothesizes that a “Quantum Tectonic Event” has caused a rip in space that caused the quake and fusion. A survivor is found upstairs: the worker from the opening scene. Walter converses with him while he is slowly dying and learns that the worker is from the alternate universe. Walter has a new theory: an office building from that universe has suddenly merged with the same office building from ours, killing all the inhabitants. Agent Dunham suspects this to be a deliberate act on the part of Newton (the leader of the team from the alternate universe that is trying to destroy ours).

Back at the lab, Walter realizes what has happened — and what will happen. Twenty-five years ago, he and William Bell sent a car to the alternate universe and a short time later, a car of equivalent mass from that universe appeared in ours, merged into a statue. Walter tells the team that a building from our universe will disappear within 35 hours. His only idea how to stop it is to use some of the abilities Dunham gained from Cortexiphan. He drags her and Peter to Jacksonville, where the original Cortexiphan experiments were carried out. He repeats the experiment on Dunham, but it has no effect this time. Belatedly he realizes that her abilities depends on fear, and Dunham no longer experiences fear, but channels it all into anger. Defeated, the three of them return to New York.

While they’ve been in Florida, small earthquakes have started in New York City, signaling that the calamity is impending. The scientists at Massive Dynamic are trying to find a pattern to the quakes, but Walter tells them there is no pattern to find. Instead, he suggests locating the building in New York City of identical mass to the one that appeared from the other universe. They are able to narrow the list down to 147 building, but the thirty-five hours is up. Concern over her failure and the likely loss of life scares Dunham, kick starting her spot-the-things-from-the-other-universe power. She is able to spot a building that weirdly glimmers, a sign that it is the one that is going to disappear. The team is able to identify the building and the authorities evacuate it just in time — with a massive inrush of air the entire building — basement, foundation, and all — disappears.

As the episode ends, Olivia and Peter are heading out for drinks, but when she looks at him, she realizes that he is glimmering too. Walter begs her not to tell Peter the truth.

1. Spellchecker
Manhattan was spelled wrong in the opening scene.

2. Island of Misfit Toys
If the building in Florida has been sealed for 25 years, why did it have toys from the Ice Age movies (’02, ‘06, and ‘09)?

3. Where’s Johnny? He Was Here Just a Minute Ago!
So did a child of identical mass to Peter get transported to the alternate universe when Walter brought Alterna-Peter here?

4. Glimmer Glimmer Glumpkin
If Olivia’s powers detect items from the other universe (that’s what Walter was testing in the classroom after all), why did the building from this universe glimmer?

5. Tick Tock
Why 35 hours? I’m guessing that’s how long it took for the car to appear.

6. Mass Effect
How are they going to be able to find the mass of the alternate universe building when it is merged with ours. Are they assuming it was identical to the one in our universe, just like their Nixon coins and double-decker cars are identical to ours?

7. There’s No Babble Like Good Babble
Quantum tectonic event. That is some grad-A prime of technobabble. It sounds impressive, but notice how none of the words really work together (or at least the two most important: tectonic and quantum. They’re pretty much contradictory — “quantum” suggest atomic or sub-atomic, while “tectonic” is very macro in its implications.)

I so wanted to like this episode with the Peter reveal (that we all knew anyway), but I couldn’t — it was dull. It wasn’t horrible, but an episode this big should be more fulfilling. The Fringe Doomsday Clock stays put.

Tags: television fringe quantum tectonic cortexiphan

The team in this week’s episode of House followed a more logical approach to the patient, but they were still hampered by bad medicine. But hey, an opossum!

Daryl is a 22 year-old college football player hoping to be spotted by pro scouts. In the middle of practice, he suddenly becomes uncontrollably violent. He grabs his opponent and drags him around by his helmet until it finally comes loose, and then he bashes himself in the face repeatedly with the helmet until he starts bleeding.

He is admitted to the hospital for evaluation, but has no memory of the incident. A head CT scan and a psychiatric evaluation — both obtained in the Emergency Room — were negative. House suspects Daryl’s symptoms are due to steroids, even though he tested clean in the Emergency Room. He believes he is on the “good stuff,” i.e. steroids that don’t show up on tests. The rest of the team suspects a pituitary adenoma (a tumor in the pituitary gland) caused by repeated head trauma. Tests for GnRH (gonadotropin releasing hormone, which controls the gonadotropins, which control the production of testosterone in men) are high, but a pituitary MRI is negative, which lends credence to House’s theory of steroid abuse. He tells the team to start Daryl on a somatostatin-analog (a medication which inhibits the pituitary gland) to block the effects of the elevated GnRH.

Daryl denies any use of steroids and begins to suffer a racing heart rate and chest pain. He has an episode of paroxysmal tachycardia (sudden onset of an abnormally fast heart rate) that requires cardioversion to return it to a normal rhythm (by definition “cardioversion” means returning the patient to a normal heart rhythm. This can be done chemically, such as with adenosine, or electrically). Taub reports that the cardiac symptoms do not fit the diagnosis of steroid abuse, so the team gives Daryl’s heart a further work-up including EKG and sestamibi scan (a test that looks at perfusion of the heart itself), but they are completely normal. The differential diagnosis now consists of a PFO (patent foramen ovale, a hole between the two sides of the heart) or hypertrophic cardiomyopathy (muscular thickening of the heart). House favors the latter and has the team put Daryl on a treadmill to stress him until he develops cardiac symptoms. Unfortunately (or fortunately, really), Daryl is in good enough shape that his heart rate never rises high enough to cause a problem. Going for “plan B”, House decides to chemically induce heart stress by injecting Daryl with a vasodilator (such as adenosine or dipyridamole — they mimic the effects of exercise on the heart). Before he injects the medication, however, he notices that the palms of Daryl’s hands are unusually white.

This new symptom causes the team to reassess their diagnosis. Taub thinks Daryl’s pale hands are due to Raynaud’s phenomenom (spasm of the smooth muscles around the small arteries of the fingers), which he thinks is caused by rheumatoid arthritis. Thirteen suspects that Daryl has plaques in his arteries, and these are breaking off and sending tiny clots blocking the arteries in his hands. Chase believes Daryl has Takayasu arteritis (inflammation of the aorta and other large arteries), and Foreman, ever the optimist, blames lymphoma. House likes the last two ideas the best, and tells Foreman to put Daryl on an ethanol drip. If he develops itchiness, it’s a sign of lymphoma, and if he loses his radial pulses, it’s a sign of Takayasu. Daryl develops itchiness while on the drip, so Foreman’s suspicion of lymphoma appears to be correct. Daryl is taken to surgery for a splenectomy, but during surgery Chase notices that his spleen is fine but his liver is inflamed.

Biopsies reveal no lymphoma and a non-specific liver inflammation. The new differential diagnosis includes polymyositis (a chronic inflammation of the muscles), Felty syndrome (rheumatoid arthritis + splenomegaly, which doesn’t fit at all), and viral hepatitis. Blood is drawn for further testing, but Foreman reports that the blood clotted almost immediately after being drawn. This suggests that Daryl has cryoglobulinemia (abnormal proteins in the blood that thicken with cold temperatures), brought on by football practice on cold days, and needs to be started on anticoagulants (blood thinners). This isn’t good enough for Daryl; he doesn’t want to miss his shot at the pros, so he leaves the hospital, promising to come back the next day. At the exhortation of Daryl’s mother, Foreman tags along to look after him — it was a good thing he did, too, as Daryl starts to experience shortness of breath and blurry vision. He is admitted back to the hospital. As the team begins to evaluate the new symptoms, Foreman admits that their really aren’t any new symptoms. He had dosed Daryl with nitrates (a class of blood pressure medication) to drop his blood pressure so he’d feel bad enough to want to come back to the hospital.

Looking over the chart, House notices that Daryl has only lost one pound during his stay in the hospital and he should have lost more. This lack-of-weight-loss could be due to steroid abuse, or paraneoplastic syndrome — only there’s been no evidence of cancer. The team performs blood test after blood test, and scan after scan, but can find no cancer. House then realizes that the cancer they are looking for is not inside the body, but outside. It turns out that Daryl has melanoma, a skin cancer hard to spot on African-Americans, and this cancer (or course) is causing paraneoplastic syndrome, which explains his symptoms.

(Here’s my take on what’s going on: you may have noticed during the episode that the team gave two different definitions of paraneoplastic syndrome. First, they described a situation where a cancer produces a hormone which can cause systemic effects: in this case, the melanoma is apparently producing GnRH which increased Daryl’s testosterone and gave the appearance and symptoms of steroid abuse including “roid rage,” weight gain, and probably the heart symptoms. Second, House describes paraneoplastic syndrome as a situation where the body is making antibodies against the cancer, and this produces the systemic effects. This would explain the kidney failure and liver inflammation. The apparent cryoglobulinemia may be an effect of the extra paraneoplastic antibodies, or cryoglobulinemia can occur with certain cancers. Both definitions of paraneoplastic syndrome are correct, but I’m not certain if a patient would ever experience both situations.)

I admit that I’m somewhat confused by House’s take on steroids. If Daryl was taking steroids, his GnRH should be suppressed — lower — not higher. Or is House suggesting that Daryl was receiving GnRH itself, or a synthetic substitute — and if that’s the case, the body generally downregulates GnRH receptors when GnRH levels are unusually high, actually leading to hypogonadism and less testosterone.

As usual, major complaints are in red, minor complaints are in blue, and nit-picking ones in green:

The clotting in cryoglobulinemia resolves at normal temperatures, so why would Daryl be clotting in the presumably warm hospital room. Did Princeton-Plainsboro not pay the electric bill?
Why didn’t he show abnormal clotting during surgery as most operating rooms are kept PDC (pretty damn cold).
Surely they drew blood before surgery, at least a blood type/transfusion panel, and should have notoiced the clotting then.
Blood thinners are not the recommended treatment for cryoglobulinemia.

Giving a patient enough of a nitrate to intentionally cause hypotension (low blood pressure) is dangerous. How did Foreman know he didn’t give too much? I’d also expect Daryl to develop a severe headache — the most common nitrate side effect – before any other symptoms.
I guess he learned it from House, who was trying to induce a cardiac event in a patient without even having him hooked up to any cardiac monitors.

Stress tests aren’t used to test for hypertophic cardiomyopathy, at least not as a first-, second-, or even third-line test. An EKG has already been obtained. A structural test, such as an echocardiogram or MRI is the next logical step. If needed, cardiac catheterization may also be performed.

Sorry Taub, steroid abuse can cause heart problems, including tachycardia.

Is there really a link between repeated trauma and pituitary adenoma, a type of cancer? I haven’t been able to find one, but then again, I’m not a neurologist or sports medicine specialist.
GnRH is released into the pituitary, not from it, so why would a pituitary cancer lead to “leaking” GnRH?

There is a condition known as the “lymphoma itch” that is a severe itching, primarily of the lower extremities. It is most commonly seen in Hodgkin’s lymphoma, but even then it only occurs in 10-25% of patients.
It is not associated with alcohol. A separate condition (severe aches and pains) can be worsened by alcohol intake in certain patients with lymphoma.

I don’t know it alcohol will really shut off blood flow in the radial arteries in patients with Takayasu’s arteritis, but who in the hell would thank that is a good idea. Personally, I like my hands to have full blood flow, thank you.

Return to full contact football a day after abdominal surgery, even a laparoscopic one? Nonsense.

Blood in the urine is really not a sign of kidney failure. It suggests that there is a problem with something farther along in the urinary system. This is especially true in patients on blood thinners, were urinary bleeding is more common – maybe from inserting the catheter in the first place.

Why would a melanoma secrete GnRH?

It is certainly possible to have rheumatoid disease with a negative rheumatoid factor.
Wasn’t Chase the one who shot down Taub’s suggestion of rheumatoid arthritis? So why would he later suggest Felty’s, which requires rheumatoid arthritis?

Paraneoplastic syndrome has become the lupus of this season.

I found the medical mystery interesting this week. Not great, but better than recent episodes. I give it a B+. The final solution clever (hidden melanoma in a black male), but too much of “Been there, got the T-Shirt” feeling (paraneoplastic, again, and a nearly impossible one at that). I give the solution a C-. Overall, the medicine was more driven this week, and followed a logical progression, but too much of it was questionable or downright wrong. Another C-. The soap opera was decent. I liked the Foreman and Foreman scenes, and the Wilson/House scenes were good, but I figures Lucas was the culprit fairly early on as Mark Michael Weston was listed as a guest star, but nowhere to be seen. I give the soap opera a B.

The House Challenge scores have been posted here.

The review of the previous episode of House
A list of all prior House reviews

Bunches of high scores this episode, thanks to this year’s ubiquitous diagnoses: paraneoplastic syndrome and “lymphoma.” TRad led this week with 18 points.

Overall, TRad and Noether increase their dominance, with 77 and 75 points, respectively. Theta Sigma stays in third with 57 points, and Corien retains fourth with 54 points. The Erskine holds on to fifth with 52 points.

Click here to see the full scoreboard.

Does Godwin’s Law apply to television shows? Actually, though the science was questionable, I thought the storyline was sufficiently creepy to be a good episode overall.

The Plot: At a wedding, the groom’s grandmother notices someone standing in the back who alarms her. As she moves to confront him, she starts gasping for breath, turns an ashen gray, and then collapses, dead. Soon, other members of her family start dying as well – fourteen total – and the Fringe team is called in. After examining the corpses, Walter and Peter declare that everyone has died of asphyxia (suffocation). Agent Dunham notices a tattoo on the grandmother’s arm that indicates she was a concentration camp survivor. Poking around the church, they find the groom, still alive, but gasping for air. He dies at their feet, bringing the death toll to fifteen.

At the lab, Walter starts his autopsy of one of the victims and notices that the blood is a deep blue (Prussian blue, perhaps?), indicating some form of toxin exposure. The team also realizes that everyone who died was a blood relative and a direct descendant of the grandmother. Re-examining the church, Peter finds a candle that is different from the others and brings it to Walter. A quick run through the lab equipment shows that the candle contains some sort of cyanide compound. Walter suspects the deaths at the wedding were an experiment by the murderer to see if his toxin would work, and predicts that he will strike again soon. Sure enough, in a similar episode, nine people die in a coffee shop. The connection this time is that they all have brown eyes.

Back at the lab, Walter has isolated the toxin and shows how it can be set up to target different proteins, depending on who the murderer wants to kill. He points out a carbon chain on the toxin that he claims in the creator’s “signature.” When Peter remarks that it looks like a seahorse, Walter realizes that the poison was created by his own father who had been a scientist in Berlin until fleeing in 1943 (his nickname was “seahorse”). He has kept his father’s formulas in some old German books, Peter sold them ten years ago when Walter was in the asylum. It all turns out to be a red herring though, as they are not connected to the mysterious murderer.

Meanwhile, Walter has managed to get a partial DNA profile of the killer from skin cells left on a fingerprint. He claims that it’s a bad sample though, because the telomeres are severely damaged, suggesting that the person must be at least one hundred years old. The FBI is able to track down the chemicals used in the making of the toxin, and get the killer’s address. They search the house (poorly), but find nothing, as their target is at that very moment escaping from his lab in the basement. Eventually, Agent Dunham finds the basement lab, but the killer has set a trap for them, with some of the toxin specifically targeted to Walter. Luckily, Dunham and Peter get Walter to medical care in time, and he survives. A clue (found by Dunham even) tells the team that the killer has his sights set on a World Tolerance conference going on in Boston. Peter, Dunham, and the FBI head over to the conference to look for the killer. Walter stays behind, mixing up something in the lab, and then he heads over to the conference himself. Peters spots the poison and he and Dunham are able to confiscate it before it can be activated – but they are interrupted by a horrible coughing sound and rush over to find the killer, disguised as a waiter, gasping for breath and dying. Walter has turned the tables on him and made a version of the poison specifically tuned to his DNA. As the episode ends, Peter and Walter are still puzzled how the murderer got his hands on Walter’s father’s research, not realizing that the killer was a Nazi scientist himself, somehow still alive sixty years later.

1. Stay on Target
According to Walter, the toxin binds to a particular protein, and this protein can be altered depending on who the target. Unfortunately, the Nazi scientist’s poor understanding of molecular biology has doomed more people than he realizes. For instance, there is no protein specific to brown eyes. Brown eyes simply have more melanin than other eye colors — but the other eye colors still contain melanin. Everyone in that coffee shop, including the Nazi, should have died. Similarly, there is no special protein in dark skin that sets them apart — people with darker skin simply have more melanin than lighter skinned people. Trying to kill off the darker skinned people would have killed everyone — well, except the albinos. Good job, Nazi scientist. Now the albinos rule the world.
Suddenly, in a virtual deus ex machina, the toxin can be programmed with a specific DNA — even though Walter made it point, repeatedly, to mention that it was created before DNA was understood.
Even if the poison could target DNA, how are you going to get that big of a molecule into the nucleus of the cell, let alone through the cell membrane?

2. Those Who Do Not Know History…
Walter is off on his history: the discovery of DNA predated the Nazis, not the other way around. DNA was discovered in the middle of the 19th century, well before the Third Reich. By the 1920s, there was strong evidence that DNA was involved in inheritance, with the first definitive experiment performed in 1943. Walter is probably thinking of Watson and Crick’s famous work on the structure of DNA, which was published in 1953.

3. Sure Hope He Never Testifies in Court
The signs Walter mentions — petechiae, bulging eyes — are seen in asphyxia caused by strangulation (they are related to increased venous pressure in the head from the compression of the blood vessels in the neck), not by asphyxia due to toxin inhalation.
Can the vitreous humor, a gel-like liquid, really swell?

4. How Dare You Kill People With My Dad’s Poison!
Walter was upset that the murderer was “perverting” his father’s work, but let’s not forget that his father’s work was a nasty chemical warfare agent.

5. It Is Impolite To Inquire As To A Telomere’s Age
Telomeres are special DNA sequences on the ends of chromosomes that keep it from breaking down or fraying. There has been some good research suggesting a link between aging and the break down of telomeres. Still, it’s a dubious stretch to tell someone’s age from looking at their telomeres.

6. Nasty Poison
Hydrogen cyanide can kill remarkably fast, depending on its concentration.

6. Comes With A Certificate of Authenticity
That seahorse “signature” is so incredibly bulky and large that it would interfere with the biological activity of the toxin. Plus, it’s bad planning because it provides an easy target to identify and develop an antibody against.

7. Two Puffs Four Times A Day
A nit-pick here, but the groom sure has poor inhaler technique (but then, so do many of my patients — and a quick Google search reveals that much of the internet has a similarly poor understanding.) The inhaler should be held an inch or two in front of the mouth, not actually in the mouth.

The science was quite questionable this week, but I thought the story did a good job keeping the suspense going — and the Nazi scientist was truly creepy — so it’s a wash and the Doomsday Clock stays at 11:58.

Tags: television fringe toxin nazi cyanide

This episode was better than last week’s pathos-fest, but it was still lacking in the medicine department.

Valerie is a 27 year-old ruthless business woman who experiences the sudden onset of severe bilateral ear pain. She is admitted to House’s team, even though he finds her case uninteresting, because she is “hot” and yet has an ugly husband. Chase suggests that due to a recent dietary change, Valerie may have a vitamin deficiency which is causing her symptoms. House thinks that her change in diet may have boosted her already elevated cholesterol, leading to blocked arteries, heart damage, and an arrhythmia (abnormal heart rhythm) which she experiences as ear pain. Testing shows no evidence of blocked arteries, but it does confirm an arrhythmia. The team plans to start her on unspecified “cardiac medications.”

An ex-coworker of Valerie’s appears in her room, drunk, and accuses her of having an affair with him and later poisoning him to cause him to lose his job. She denies these accusations and security escorts the man out. The male members of the team jump to her defense, but Thirteen thinks that Valerie is up to something. When the team discussed the situation with House, he suggests that she may have been poisoned with thyroid medication, which would rev-up her heart and cause the arrhythmia. House and Foreman want her started on beta-blockers (to block the effects of the thyroid medication), but Thirteen sneaks her off to the MRI suite. Her testing reveals that Valerie has no emotions and is by definition a psychopath. Confronted later, Valerie admits to everything Thirteen suspects. All that her co-worker said is true — she slept with him and then poisoned him. She also admits she only married her husband for his trust fund.

Taking both the heart and brain symptoms into account, the new differential diagnosis consists tertiary syphilis (late stage syphilis where mental symptoms are common), Wilson’s disease (a disease of copper metabolism), and Hashimoto’s thyroiditis (autoimmune inflammation of the thyroid gland). The first seems the most likely, so they start Valerie on penicillin. There is a heated discussion between Valerie and Thirteen, and when Thirteen reaches to turn over Valerie’s arm, she breaks it. Further testing reveals elevated BUN (blood urea nitrogen) and creatinine levels which suggest kidney failure, which would explain the brittle and easily-broken bones.

House now feels that the Valerie’s psychopathy is something she was born with, and not a symptom of her condition. Focusing on the heart and kidney symptoms, Foreman suggests that she has paraneoplastic syndrome, likely from a lymphoma. House orders full body radiation therapy. Thirteen wants to run some tests first, but Foreman shoots her down.

There are more confrontations between Valerie and Thirteen, with Thirteen’s “innocent” questions lead Valerie’s husband to realize she’s was having an affair, and Valerie reporting her to the medical board. Eventually, Thirteen is removed from direct patient contact with Valerie, but Cuddy explains is it because Thirteen does not deserve to have Valerie inflicted upon her.

Valerie starts bleeding heavily from her mouth due to esophageal varices (enlarged, bleeding esophageal veins related to liver disease). She is taken to the operating room for a TIPS procedure (transjugular intrahepatic portosystemic shunt) — placement of a stent which bypasses the liver, relieving the elevated blood pressure in the liver which lead to the varices. This new symptom causes the team to reevaluate their diagnosis, and this time they consider and discard amyloidosis and alpha-1 antitrypsin deficiency before settling on primary hepatic fibrosis (fibrosis of the liver not due to another disease). She is started on steroids and a search begins for a liver donor for transplant. Thirteen talks to Valerie’s sister and learns that she wasn’t always a psychopath — that started during her teen years. This suggests that the psychopathy is a symptom of her condition, and not something that can be overlooked. Thirteen and House realize that she must have Wilson’s disease, which is confirmed by looking at her fingernails which are blue. She is started on chelation therapy to remove the excess copper. By the end of the episode it seems to be working

Those of you who read comic books will know what I mean when I say that the medicine of this episode was the television equivalent of a Mark Millar comic: a bunch of dramatic set pieces connected by sketchy plotting and poor logic. Sudden ear pain (hand waving) It’s her heart! (hand waving) Oh no, kidney failure! (hand waving) It’s cancer! (hand waving) Now it’s liver failure (hand waving) Wilson’s disease and presto! Iit’s cured, and now the world is safe for democracy.

As usual, major complaints are in red, minor complaints are in blue, and nit-picking ones in green:

You do not treat a patient for cancer — be it radiation therapy or chemotherapy — without knowing what sort of cancer it is first. Different cancers have different treatments. Even if it is a B-Cell Lymphoma, there are over a dozen different cancers of that type, and only some are treated with radiation therapy. This seems to be a recurrent mistake this year.

Her kidney failure is so bad that her bones break that easily and she’s stopped producing urine and nobody noticed?
There’s no way it took that long before they checked her BUN/Creatinine. They would have been checked before running any cardiac artery testing to make sure her kidney could handle the dye.
Similar arguments for no one noticing her chronic liver disease bad enough to cause bleeding varices.

Wilson’s disease should have shown up on the MRI. You know, the one they used to dismiss the diagnosis of amyloidosis.

She sure improved from her fifteen years of Wilson’s disease improbably fast, especially her psychiatric symptoms.

A paraphrase:
Thirteen: If she has Wilson’s, why doesn’t she have Kayser-Fleischer rings?
House: Notice how I avoid answering — or even acknowledging — your question by distracting you with another symptom. Aren’t I (and by extension, the writers) clever?
(House could have just said that KF rings only occur in 2/3 of the patients with Wilson’s. Blue nails [azure lunula] are certainly seen in Wilson’s, but less commonly than KF rings).

Technically, Broca’s area is only on one side of the brain, it is not bilateral.

I suspect the fingernail polish under the pulse-ox (oxygen monitor) had already been wiped off – the monitors work a lot better that way.

The team never “ruled out” Wilson’s, they just focused on the tertiary syphilis instead.

The medical mystery was modestly interesting, but quickly forgotten and ear-pain was never again mentioned after the seven minute mark. It deserves a B. The final solution was a bit of a stretch, but actually fit fairly well (especially if you ignore the whole “chronic” aspect of the disease). It also earns a B. Overall, the medicine was spotty, with the team missing things an intern would have noticed. I give it a B-. The soap opera was light, but generally well done. I thought Olivia Wilde held up her end better than expected, but I’m surprised House never ran any sort of background check on his classmate. I give the soap opera a B.

The House Challenge scores have been posted here.

The review of the previous episode of House
A list of all prior House reviews

Higher scores this episode, thanks to some old friends including syphilis, paraneoplastic syndrome, and amyloidosis. Theta Sigma and The Erskine led the week with 18 points each.

Overall, TRad continues to lead with 59 points. Noether remains in second, but moved in closer with 58 points. Theta Sigma moved into third with 45 points, and Corien drops to fourth with 42 points. The Erskine and atg round up the top five (err, six) with 39 points.

Click here to see the full scoreboard.

Updated through Episode Ten, with Episode Eleven to come tomorrow (hopefully).

Click here to see the full scoreboard.

The plot of this episode of Fringe was, at best, so-so. They could have at least played up the “trapped in a building with a possible killer” angle. The science — and it’s generous calling it that — was painfully bad.

The Plot: In a large office building in Boston, a man walks into the office of a petroleum corporation, then drops dead, with his last breath spraying a fine mist of blood on all around him. Given the strange nature of the man’s death, the Fringe team is called in. Peter and Olivia arrive first and are interviewing bystanders. Walter, Broyles, and Astrid are on their way into the building, when one of the people exposed to the dead man’s blood comes walking toward the door, as fast as he can. Walter quickly shuts the door before the man can escape, and the man dies, spraying blood against the closed door. Fearful of an unknown contagious disease, the CDC is called in and the building quarantined — with Peter and Dunham still inside.

Some blood samples are obtained, and Walter takes them back to his lab. In the office building, the receptionist falls ill. Doing a little detective work, the team determines that the first dead man was a corporate spy from Dubai who was selling information on the peteroleum company’s competitors. The ill receptionist becomes frantic and violent. She scuffles with Peter, then jumps through a window, plummeting to the street below, dead. Unfortunately, Peter has been exposed to infected blood and now may be infected himself.

Inspecting the car of the corporate spy, the FBI and Center for Disease Control (CDC) find a core sample from 10 miles down that he was trying to sell. They also find the mysterious virus behind the outbreak contained within the core sample. Walter speculates it is 75,000 years old and was responsible for killing most of the mammals on Earth during the Ice Age (as opposed to the ice and cold). From this virus, Walter is able to concoct a test to determine who is infected and who isn’t. Walter believes that the virus has human-level intelligence and is purposefully acting to infect as many people as possible. He and Astrid enter the office building and test the staff. Most are not infected. Peter is showing signs of infection, but through sleight of hand, makes sure he has a negative test. The people who tested clean are escorted out of the building — except Peter. The guard at the door (a competent FBI agent at Fringe?) notices he has a nosebleed and keeps him in quarantine. In the end, eleven infected individuals remain in the building. Walter and Astrid also elect to stay.

Walter deduces that sulfur is a cure for the virus and relays the information to Dunham. Meanwhile, the CDC has called in the US Army to “take care of” the people remaining in the building. Dunham and Broyles ask for more time to synthesize Walter’s cure. Broyles suggests pumping the building full of Fentanyl gas (a strong narcotic) to knock everyone out and buy time. Dunham volunteers to enter the building and turn the HVAC back on. She scuffles with an infected Peter but succeeds in her mission. All the infected people are knocked out, Walter’s cure is made, and everyone (well, except for those already dead) survives.

It’s been a number of years since I’ve worked in a biochemistry or infectious disease lab, and I found the “science” in this episode totally appalling. I’m sure any actual infectious disease researcher or biochemist who watched the show had their television explode from the rays of frustration and hate their brains emitted. I’ll highlight a handful of items, but there are many more mistakes and plot holes that I didn’t have time to mention because I actually do have to get some sleep tonight.

1. I Give Him Credit For Trying
I applaud the bike messenger for attempting CPR (even if it was the 5 compression/1 breath technique that is not recommended anymore), but give it some time before you declare the guy dead. Ten compressions doesn’t cut it. At least continue the CPR until the EMTs arrive.

2. You Know What They Say About “Assume”
Walter believes the virus is transmitted by bodily fluids. How does he arrive at this conclusion? Certainly blood transmission seems probable, but how does he know about other bodily fluids? Is he surreptitiously testing saliva and semen?
He claims the virus is not airborne, or more people would be sick. How is he so sure about the incubation time? Maybe more people could be sick than he knows, they’re just not showing it yet. Sure, the bike messenger fell ill fast, but how do you know he was not exposed before (maybe the Dutch guy wasn’t patient zero), or maybe the messenger had a weakened immune system and succumbed faster than normal. Walter is making way too many assumptions.

3. Do You Even Know What You’re Testing For
There are way too many problems with Walter’s test.
Why the cheek swab? That’s used for DNA samples. Is he saying the virus can be found in the DNA of cheek cells?
Most viral tests look for antibodies against the virus — they’re a lot easier to develop. Of course, it usually takes several weeks for these antibodies to appear. There are some tests that look for the actual virus, but I don’t care how much of a genius Walter is, he couldn’t have cobbled one together so fast, or made enough of it to test the entire office building.
Most importantly, there was no prior testing to determine the false negative/false positive rate of Walter’s test. No test is 100% right all the time. They are risking everybody’s life on an unknown test.
Then Peter’s test was negative but he clearly was infected. We the viewers know he faked the test swab, but the characters don’t know that. Their first thought would have been: “Peter’s test was negative, but he has the disease. How many of these other people we let outside also had false negative tests?” And then they would have hustled them all back inside and left them there.

4. If Only My Labs In College Were This Easy
The scene in Walter’s lab was laughable.
No protective gear.
Isolating a virus in a test-tube using a centrifuge (and using it poorly) would never work. It’s not even close to being right.

5. Down In The Hole
Admittedly, I’m not a geologist, but how does 10 miles down equal 75,000 years. I would think it would be a lot more (years) than that.
The virus lived 75,000 years without a host — that’s impressive. Plus this virus can apparently be visualized without an electron microscope.

6. It’s A Gas
Fentanyl gas has been used at least once before to subdue a building full of people. In this case, it was a hostage situation in Russia with Chechnyan separatists. The Fentanyl didn’t work as well as expected and actually killed 117 hostages. In situations like that, it’s hard to control the inhaled dose — and Fentanyl can kill at the wrong dose. Plus, a fair number of people are allergic — fatally allergic — to narcotics.

7. Dire-Swine Flu?
Neuraminidase inhibitors are used to treat influenza viruses and … that’s about it. So this is a flu virus now

8. Eli Lilly Is Spinning In His Grave
In vivo does not equal in vitro. In other words, what works great in a test tube often doesn’t turn out to work so well in an actual living organism. If creating a new drug were as easy as Walter makes it out to be, we’d be neck deep in fancy new medications and the pharmaceutical companies wouldn’t be laying off people left and right.

9. Not So Smart, Is It?
If the virus really wanted to infect as many people as possible, why not infect the airplane instead of an office building? Those people would be in an airport and then other planes, not trapped in a building.

8. Nice Try, But…
The US Army is not authorized to act on US soil. National Guard, maybe.

9. Georgia On My Mind
I’m not sure of the actual powers of the CDC in a situation like this, but this seemed unrealistic to me. Their response was incredibly fast and a lot like a sledgehammer. I’m not saying the CDC isn’t fast — they are easily the best in the world at what they do — but they’re not that fast. And they actually do research, rather than just shoot people. Wait, was that a knock at the door?

I thought last week’s science was bad, but this was even worse. I have no choice but to move the Fringe Doomsday Clock forward two minutes to 11:58.

Tags: television fringe mutation virus infection cdc

Not the best episode of Fringe. The storyline was pretty cliche (the sheriff involved, really?) and the science was wrong, wrong, wrong.

The Plot: A state trooper picks up a young boy running away from home. A few minutes later, he looks over at his passenger and discovers that the boy has suddenly become horribly deformed. The trooper arrives at the station and he and two coworkers photograph the child and enter him into their database. They all mention that they’ve heard rumors of deformities such as this, but never actually seen one. Suddenly, a car pulls up and three adults, all as deformed as the child, enter the station and kill all the troopers, reclaiming the boy.

The Fringe team is called in because of the picture of the deformed boy. Looking through other files at the station, the team finds thirty years worth of similar reports, though no actual evidence, all centered on the nearby town of Edina. Deciding that it’s their next logical stop, the team heads over to Edina where they meet the local sheriff. He tells them he’s also heard stories of deformed people nearby, but never seen one. He also identified the sound the team has heard since entering the town as the “Edina Hum” – which he blames on turbines at a nearby military base. Strangely, the hum causes Walter to start singing nonsense words to Bizet’s Carmen.

As the team heads out of town back to their hotel, they are run off the road by a pick up truck. Dunham was knocked out by the crash but Peter stayed conscious. Walter is blissfully asleep in the back seat. The pickup that ran them off the road comes back and a deformed men gets out and starts shooting at the wrecked car. Peter gets off a couple of shots, and actually thinks he hits the shooter, before he gets back in his truck and drives away. Other federal agents arrive and inform the team that they’ve found an abandoned truck that matches their description. Peter spots a blood trail leading into the woods, and they find a dead man –- but he’s not deformed at all. The corpse is sent to Walter’s lab for autopsy.

Agent Broyles tells the team that the nearby Army base was once home to classified experiments known as “Project Elephant” back in the ‘70s. Meanwhile, in Walter’s lab, when the body bag is opened, the corpse has become deformed once again. Walter continues to sing Carmen and Astrid realizes that the song is really a mnemonic for “Harkness,” which Walter recognizes as the name of the campus’s law library. Furthermore, he remembers that he did work on “Project Elephant” –- which dealt with camouflage — and hid some papers in the library, which he and Astrid successfully recover.

Peter and Dunham are going through the county and federal records on the town of Edina and realize that several key files are missing. The census date shows the town population has only changed by deaths and a few births — no one has moved in or out of town in the past thirty years. The town sheriff calls to tell Dunham that he has located the owner of the truck and wants Peter and Dunham to join him at the subject’s house. They agree, unaware that the sheriff is setting a trap for them.

Walter tells Astrid that the people of Edina are all hopelessly deformed because they lived too close to the military experiment. However, in order to help the people of Edina, one of the scientists built a giant transmitter that sends out powerful EM waves which fool the eyes into thinking what they see looks normal. Thus, as long as the residents stay within Edina and range of the transmitters, their deformities are hidden. When they leave town, their deformities can be seen again. Walter and Astrid find the transmitter and shut it off, proving his theory, as all the deformities are suddenly clear. Across town, the sheriff is not particularly good at his ambush and loses a few men, but he ultimately gets the drop on Peter and Dunham. Luckily, one of the town’s residents – sick of all the death of innocents – steps up and shoots the sheriff, saving the team. In the end, the transmitter is left on for the residents and it is decided that no one outside of the Fringe team and the residents will learn the truth about Edina.

1. The Eyes Have It
The eye does not act as a transmitter, sending through whatever the eye sees to the brain as if it were a fiber-optic cable. Instead, the receptors in the retina at the back of the eye are triggered by certain specific wavelengths of light, and when they’re triggered, a nerve impulse is sent to the visual areas of the brain. No extraneous information is transmitted. If a wavelength is not visible, it’s not visible, end of story.
So the EM wave is a low enough frequency to be heard as a deep hum, but still manages to affect the eye?

2. Are You Still Rose or Am I Hitting on Susan?
For the sake of argument, let’s say that the EM camouflage does work. How would it remain constant from person, to person, time to time? I see Rose as beautiful brunette instead of a Troma look alike. Does the person next to me see the same Rose as I do? If I leave town and then come back, does she still look the same to me?

3. A Window To the Soul (Kinda)
A Johari window is a cognitive tool that compares how we see ourselves with how others see us. It looks into four areas of personality: Arena (known to others and known to self), Façade (known to self but unknown to others), Blind Spot (known to others but not known to self), and “Unknown.”

4. God, that hand! The window! The window!
This is another episode this season (the third, I think) that had some definite Lovecraftian overtones, in this case “The Shadow Over Innsmouth”, about an isolated town with a deformed populace and a hidden secret.

5. Not What I Expect To See In a Corpse
Frankly, I’d expect histolysis (tissue decay) to be present in any corpse, not just shapechangers.

6. A Generation Unexplained
A germline mutation would be inheritable, but it wouldn’t have a tremendous (really any visible) effect on those originally exposed to the mutagen. So Teddy would be visibly deformed, but if Walter is right, Rose shouldn’t be.

Painfully bad science this week, the Fringe Doomsday Clock advance to 11: 56 (ironically, the real Doomsday Clock was moved back a minute this week)

Tags: television fringe mutation camouflage science

This was a Fringe episode left over from Season One that had never been aired — and it wasn’t a particularly good episode, but better than some that were aired. There was at least one good plot twist.

The Plot: Lisa, a seventeen year old high school junior has been declared brain dead after a cerebral aneurysm. Her life support is shut off and she is declared officially dead before being wheeled into the operating room to harvest her organs for transplant. Once the operation has started, she suddenly sits up, alive, and screams out a series of code numbers. It turns out the code refers to a naval officer by the name of Andrew Rusk — and he has been reported missing. The Fringe team is called in to investigate.

Lisa denies ever having met Rusk, but when his name is mentioned, she speaks a phrase in Russian which translates to “my (or ‘little’) star.” Lisa has developed a fever and the doctors are watching her closely. Her mother tells Agent Dunham that she doesn’t want the team questioning Lisa anymore when Lisa suddenly screams from the bathroom — when looking in the mirror she has seen the image of Rusk standing behind her. Walter hypothesizes that Lisa’s aneurysm affected Broca’s area, a part of the brain which controls language — and according to Walter — also controls psychic ability.

A little while later, Lisa calls Agent Dunham, telling her that she still is still seeing Rusk. She is at a junkyard, because she saw the image of it in her mind. When the Fringe team finds her, she tells them that Rusk was shot there. Sure enough, a 9mm casing is found and a short time later, Rusk’s body is found. Lisa has a sudden seizure and is readmitted to the hospital.

Walter deduces that Rusk’s death and Lisa’s rebirth occurred simultaneously, and somehow this allowed her to pick up his memories. Lisa’s mother allows Lisa to be taken to Walter’s lab to purge the memories.

Meanwhile, Dunham finds out that Rusk used to call his wife the Russian phrase “my star.” She also finds out that he was exposed to high radiation doses in a shipboard accident and was given an experimental radiation inhibitor.

Back at the lab, Walter hooks Lisa up to an EEG, pumps her full of drugs, and the team discovers that she doesn’t just have some of Rusk’s memories — his entire consciousness is sharing her brain. Rusk’s personality emerges when the drugs put Lisa to sleep. He is able to give the team enough of a lead to track down his killer — a former Navy SEAL. When the suspect is questioned by the FBI he admits that he killed Rusk, but he did it because Rusk was a wife beater — Rusk’s wife hired him to kill her husband. He tells the team that he mentioned this fact to Rusk before shooting him.

Rusk is still in control of Lisa’s body, but by pretending to be Lisa, manages to sneak out of the lab. He goes to his house and grabs his gun. He confronts his wife, but she denies having anything to do with his murder. He ties her up and is getting ready to start a house fire when Peter arrives, with the rest of the team following a short time later. Peter talks to Lisa/Rusk enough to distract him so that Charlie can shoot him with a tranquilizer dart. Further testing in the lab reveals that only Lisa’s consciousness remains within her mind.

1. Breathe, Breathe In The Air. Since Lisa stopped breathing and died once the ventilator was stopped, why are they bagging her on the way to OR? (And if you want to argue that they are bagging her to provide oxygenated blood to her organs, then they also need to 1) give CPR, and 2) continue to bag her in the OR).

2. Infection Control, What’s That?
Lisa has enough of a fever to worry her doctor, but is discharged the next day — and immediately returns to school and church? Where lots of sick people are? (Assuming she goes to church on Sunday, it seems impossible for her to have made it back to school. By my calculation she would have been discharged late Friday at the earliest.).

3. Total Nit-Pick About Balloons
Hospitals are picky about which balloons are allowed. The ones is Lisa’s room are not allowed due to concerns about latex allergy.

4. I Wish All Surgeries Were That Easy
Abdominal surgeries, even on dead people, are not that easy. The renal artery is way in the back and all the intestines have to be moved out of the way before it can be reached.

5. Seize Her
That was one of the more unconvincing seizures I’ve ever seen.
Speaking of seizures, while I agree with the hospital doctor that in most cases the cause of seizures are never identified, I would not so cavalierly dismiss the idea that it was related to her aneurysm. She had a recent bleed in her brain, and blood is a very irritating substance — not to mention the swelling from the injury — which is enough to set off a seizure.

6. Too Many To Choose From
It was nice of Walter to put her on 100 mikes (micrograms) of a benzodiazepine, but it would help if he told Astrid which one to use. He typically has used Valium, but the doses he is giving fits Versed better.

7. Too Late To Matter
With a dose of 600-1000 REM, Rusk would have had the initial symptoms of radiation poisoning starting shortly after exposure (mostly nasty gastrointestinal ones). His bone marrow would be dead and he would require a bone marrow transplant to have any chance of survival (and for the record, only one person has ever survived that dose of radiation).
Once Rusk was removed from the reactor, he was no longer exposed to the radiation — and since he is not radioactive himself (radiation doesn’t work that way) — giving a radiation inhibitor at this point is useless, like closing the barn door after the horse has left. There is no radiation left to inhibit. The damage has already been done.

8. Quickdraw McGraw
Intramuscular medications (like the tranquilizer dart) do not take immediate effect. The medicine must be absorbed into the blood stream and spread throughout the body — or at least reach the brain) before it knocks the victim out.

9. Enough Already, George Michael
Scientifically-based faith (e.g. I have faith the sun will rise tomorrow) is a completely different concept than religious-based faith and the terms are not really interchangeable.

Since this is not a current episode, it’s not going to affect the Doomsday clock — which is a good thing for the show.

Tags: television fringe brain psychic possession

This episode seemed like it was trying to be a cross between House and Brotherhood. A novel approach, but the medicine suffered for it.

In a dark garage, a drug deal is going down between two groups of mobsters. When one of them gets antsy and starts flashing a gun around, another of the mobsters jumps him. In the struggle, the gun goes off and one of the combatants slumps to the ground. It turns out he wasn’t shot by the gun — he just collapsed.

A little while later, House is sewing up the Mickey the mobster’s forehead laceration. Being quick on the uptake, House realizes what line of work his patient is in. He suggests Mickey stay in the hospital for a work-up, but he declines. As Mickey and his partner leave the room, House slams his cane into the table and the sudden loud noise causes Mickey to collapse. He gets admitted to the hospital after all.

House presents the patient to the team as a “32 year-old man who recently developed loud-noise induced vertigo.” There is no medical history as Mickey does not want to share anything. Foreman suggests the cause must be in the ear or brain, and since a brain CT scan was negative, it must be in the ear. He suggests an acoustic neuroma (a tumor of the eighth cranial nerve, the nerve involved with hearing). An ABR is ordered to test for the neuroma (An ABR — or Auditory Brainstem Response — is a hearing test that looks specifically at the nerve component of hearing. If you’ve seen a hearing test done on a newborn in the hospital, you’ve seen one of these) . House announces that the diagnosis might be lidocaine or benzocaine toxicity, as both chemicals are commonly used to cut cocaine.

While the team runs the ABR, House talks to Mickey’s partner Eddie who swears that Mickey never touches the cocaine. The ABR is normal, but Mickey has a seizure during the test, which Foreman announces must be due to his elevated blood pressure. Mickey is started on a vasodilator (a blood pressure medication that works by dilating — opening wider — his blood vessels) and his blood pressure improves. The differential now consists of sick sinus syndrome (the heart’s “pacemaker” isn’t working right), carotid stenosis (narrowing of the carotid arteries), or toxin exposure. A carotid ultrasound (to look for the narrowing) is normal. Figuring the cause must be toxin exposure, the team discharges Mickey with the plan of trailing him back to his hideout, but he manages to ditch them.

Mickey is brought back to the hospital several hours later delirious with a high temperature. He is given antipyretics (fever reducing medicine, usually acetaminophen [Tylenol]) and “soft steroids” (basically, a specially engineered steroid with less side effects. Sounds nice, but doesn’t really apply in this case. Technobabble) The differential diagnosis now consists of an environmental exposure (but House figures Mickey wasn’t out of the hospital long enough to be re-exposed) or an infection. A lumbar puncture is performed and shows no sign of infection. Chase notices that despite it being a poorly performed lumbar puncture (and therefore qutie painful) , Mickey’s heart rate never budged when it should have shot up with the pain. Chase suspects Mickey has autonomic dysfunction, but House doesn’t think the symptoms match. He confronts Mickey who admits that he’s been taking a beta-blocker (a blood pressure medication that slows the heart rate) for his nerves.

Given the symptoms of vertigo and fever, and Mickey’s high stress occupation, the team decides he must have “excess adrenalin” and probably has a pheochromocytoma (a tumor that pumps out high levels of adrenalin and similar compounds). An MRI of the adrenal glands is negative, ruling this out. Once again, the team decides the cause must be environmental. Meanwhile, House had bugged Mickey’s room so he could learn more information about his background, but the bug never worked well. Eventually, he realizes that something is interfering with it and suspects that it’s another bug in the room. Sure enough, he finds a second bug and deduces that Mickey is an undercover cop. He reluctantly admits that House is right. Suddenly, Mickey experiences severe abdominal pain. Later, Chase reveals that he suffered a GI infarction (the blood supply to the bowel was cut off, causing some of the bowel to die. Like a heart attack, only of the bowel) of the superior mesenteric artery, and a foot of his bowel had to be removed.

Reviewing Mickey’s symptoms of vertigo, fever, and clotting (the high blood pressure is discounted because it is felt to be a rebound high pressure from skipping his medications), the team decides yet again that it must be an environmental exposure. Thirteen leans on Eddie who agrees to take her to the hideout. It turns out to be a dry cleaners, and she takes multiple samples — but they all turn out to be negative. Just as the team is stumped, Mickey starts coughing up blood. A VQ scan (ventilation-perfusion scan) of the lungs shows a pulmonary aneurysm (a bulge in the blood vessels in the lung), which Chase surgically repairs, but the next morning, three more have appeared. House and team decide this must be a fungal infection and start Mickey on antifungal medication, but it doesn’t seem to be working. Totally out of the blue, House deduces that Mickey has Hughes-Stovin Syndrome, an autoimmune disease. Unfortunately, by the time it’s reached this stage it is fatal and according to House, Mickey has but a few days — or hours — to live. House’s prediction is true, and Mickey dies in the arms of his wife a little while later.

Lots of errors this week, and several big ones, too. As usual, major complaints are in red, minor complaints are in blue, and nit-picking ones in green:

Hughes-Stovin Syndrome is not a good fit. True, once the aneurysms start rupturing the patients often die (but even then there are treatments that have been tried — sometimes successfully — and since when has House’s team just given up like that?)
The aneurysms do not appear overnight, but appear over time.
Hughes-Stovin Syndrome is associated with venous thrombosis — but the patient had an arterial thrombosis — a different animal all together.
There is a good chance the steroids given earlier would have helped the Hughes-Stovin Syndrome.

10-20% of pheochromocytomas occur occur outside the adrenal glands, so a negative adrenal MRI would not rule them out (especially in House’s world, where the uncommon is common).

The superior mesenteric artery is a major blood vessel and supplies much of the bowel with blood. A blockage in it would cause the patient to lose more than just a foot of bowel.

Despite having a diagnosis of “vertigo”, the patient didn’t really show much in the way of vertigo. Sure, vertigo can cause drop attacks (from extreme dizziness and loss of balance), but the patient never complained of any of those symptoms. The drop attacks looked more like those cataleptic goats.

It’s quite a jump in logic to decide that the high blood pressure caused the seizure. There’s so many other possible causes. For instance, Lidocaine toxicity — House’s suggested diagnosis — is well known for causing seizures.

Did I really see Foreman jam something in the mouth of seizing patient? In 2010? He’s a neurologist, he should know better.

Expect to see results from antifungal medication in a few hours? Nonsense. That would be fast for regular antibiotics, let alone antifungals which are slower (as I tell patients in the office, fungus grows slowly, so it dies slowly).

If Mickey took enough beta-blockers to not respond to pain, then he would have an extremely low heart rate, definitely below sixty and probably even lower.

Beta-blockers do not cause a noticeable rebound high blood pressure. Certainly not one high enough to cause a seizure.

A VQ scan is a logical approach to diagnosing coughing up blood (looking for a pulmonary embolus), but isn’t good at showing aneurysms. The image Chase showed was way too clear for a VQ scan (here’s what one really looks like; very fuzzy) — it was probably a CT.

Is Foreman really expecting inhaled Albuterol to fix what is clearly a systemic problem?

It was strange the way the writers were being very coy with medications this episode: “vasodilator,” “antipyretic,” and “soft steroid” rather than actually naming the drugs, like they always (or almost always) have before.

It was hard, but you’ll notice I made it through the entire review without resorting to a “Can’t Hardly Wait” pun.

The scene in the clinic (at least I assume it was the clinic) where House deduces the source of Mickey’s injury was well done, and very Holmesian.

The medical mystery was okay, but I question if the patient really had what they said he had — I give it a C. The final solution was a big stretch, and in shooting for pathos, they shortchanged the team. It gets a D. Overall, the medicine was more often than not, painful to watch: another D. The soap opera was quite good though (with this week’s theme seeming to be “deception”) and earns a solid A.

The House Challenge scores have been posted here.

The review of the previous episode of House
A list of all prior House reviews

Another low scoring episode. Austin Иосефович and Joe led the week with 5 points.

Overall, TRad continues his lead with 48 points. Noether remains second with 42 points. Corien is third with 34 points, atg is fourth with 33 points and Heidi is fifth with her 31 points.

Click here to see the full scoreboard.

I liked the plot of this week’s episode of Fringe — at least for the first two thirds (until Walter was captured, when it started going downhill) — but the “science” and “medicine” was ridiculous.

The Plot: Mysterious men break into a mental health facility and perform some sort of brain operation on one of the patients. They remove some sort of foreign tissue from his brain, but are disturbed before they can finish the operation, so the patient is left with part of his brain exposed. Strangely, the patient has also been completely cured of his schizophrenia.

The Fringe team is called in and it is clear that Walter is uncomfortable with being back in a mental health institution. The security tapes manage to capture the face of the intruders’ leader, and Olivia recognizes him instantly. It was one of the frozen heads that was stolen earlier in the season and belongs to a man named “Newton.”

Looking through the patient’s medical records, Walter finds reference to a mysterious psychiatrist by the name of “Paris.” Astrid can find no records of the mysterious doctor, but with Walter’s help, is able to track down some prescriptions he wrote. They find two other institutionalized patients with prescriptions from Dr. Paris. Visiting these patients, they find that they have also been recently miraculously cured of various psychiatric diseases and show evidence of recent brain surgery. Walter recognizes that one of the drugs they’ve been given is used to prevent tissue rejection in organ transplant patients. He then realizes that the patient’s brains had been used to store the tissue from someone else’s brain.

The team is informed that Walter’s old mental health records show that Dr. Paris visited him six times while he was in the asylum — visits which Walter does not remember. Peter check’s Walter’s scalp and, sure enough, there’s an old surgical scar. An MRI of Walter’s brain is obtained and it shows three missing sections of brain — missing sections that perfectly match the pieces implanted in the other patients. Someone has removed part of Walter’s hippocampus (important in memory storage) and placed it in other people’s brains. And now someone has taken these pieces back.

Meanwhile, Walter has been captured by the Newton and his cohorts. They hook him up through some sort of contraption to the missing pieces of his brain. Once the connection is made, Walter seems suddenly awake for the first time since the show began. Newton is able to get Walter to tell him how to make a door to the other universe. He then injects Walter with some sort of drug before high-tailing it just before Dunham and the rest of the team arrive. While Peter helps Walter, Olivia chases after the bad guys. She manages to shoot the driver of their van (who bleeds silver — one of the shapeshifters), and then the second man (regular blood). Newton is captured — but only for a moment — because he tells Dunham that Walter has been given a neurotoxin, and he’ll only tell her how to administer the antidote after he is allowed to escape. Dunham acquiesces and Walter survives, but she is chided by Newton for her “weakness.”

In a final flashback, we see that the mysterious Dr Paris was actually William Bell and Walter’s brain surgery was done — apparently with Walter’s consent — to remove the knowledge of how to open the cross-dimensional door from his brain and store it someplace “safe.”

1. Lost ‘em Again
That tracking chip didn’t last long, did it?

2. “Iä! Iä! Cthulhu Fhtagn!”
There were a couple of H.P. Lovecraft references this week (purposefully?)
Dr. West (as in Herbert West, Reanimator)
Dunwich Mental Health Facility (as in The Dunwich Horror)

3. Department of Redundancy Department
“Global destruction of biblical proportions.” That’s ridiculously redundant — global destruction, by definition, is of biblical proportions.

4. The AMA Does Not Do What You Seem To Think It Does
A common mistake, but an irritating one. The American Medical Association is really nothing more than a professional organization for doctors, like a union or lobbying group. It has no official sanction. It is not in charge of medical licensing, and keeps no “official list of doctors.” Depending on which source you use, only 15-30% of the physicians in this country are members of the AMA, so someone not being on their roster is no proof that they’re not a doctor or don’t exist. [I've blogged about this several times before, most recently here, in relation to the Beast and Dr. Mid-Nite.]

5. But I Asked For Infinite Refills
You cannot write an “indefinite prescription.” One-year, maximum.

6. I Reject Your Rejection
The four drugs listed on the patient records (Sirolimus, Muromonab CD3, Basiliximab, Azathioprine) are used to prevent rejection in organ transplant patients.
You would think that in their years in the asylum, at least one doctor or nurse would realize the drugs make no sense.

7. Bad Radiology
Those spots on the patients’ brain MRIs were way too big to be thought of as artifacts. The brain tissue was large enough that it would show up on multiple MRI slices (images).
No radiologist ever noticed the three holes in Walter’s brain before?

8. Respiratory Depression and Death
Tolerance or no, 50MG of Valium is one helluva dose. That’s two-and-one-half times the maximum daily dose of Valium.
Dr. West is either extremely trusting or extremely naïve to give that much Valium to Walter just on his say so, especially when it’s clear that Walter is not all there.

9. It’s Not a Two-Dimensional Jigsaw Puzzle
The brain is three-dimensional. The tissue cut out was three-dimension. It was inserted into people’s brains (crammed in, basically, because there was no “slot” to put it in), but somehow manages to show up on a two-dimensional MRI as a perfect fit, like a jigsaw puzzle piece. There was no way they could fit the extra piece in the brain so precisely at just the right point and at just the right angle for this to be true. [A similar problem occurred in the infamous autopsy scene in Identity Crisis #6, where Dr. Mid-Nite managed to find just the right slice to find perfect footprints in the brain.]

Good plot but goofy science cancel each other out. The Doomsday Clock stays at 11:55

Tags: television fringe brain schizophrenia door

This week’s episode of Fringe was fairly creepy, and the science wasn’t all that bad

The Plot: A boat from Hong Kong has run aground in the harbor and dozens of illegal Chinese immigrants have washed up on the shore, dead. It turns out it wasn’t the water or cold that killed them, but giant tentacled parasite worms lodged in their gastrointestinal tracts. The Fringe team is called in. One of the immigrants, Mai Lin, managed to survive. She tells the team that all her fellow immigrants were given a strange capsule to treat sea-sickness, but since she was raised in a fishing village and never got sea sick, she didn’t take it. The team suspects these capsules contained the larvae for the giant worms. She tearfully tells the team that her husband and daughter are on the next boat arriving in few days.

The immigrant smugglers are tied to a local Triad gang best known for smuggling and selling illegal drugs. The team initially surmises that the worms secrete some form of opiate, and this is why they’re being smuggled. After being bitten himself, Walter realizes that the worms produce a powerful immune boosting agent. Walter does some research and discovers that the worms are genetically modified Ancylostoma duodenale (hookworm), an intestinal parasite used in traditional Chinese medicine. The genetically modified versions make an immune boosting agent that is stored in their lymph glands.

Some financial documents tie a local woman to the one of the Triad’s front. She tells Agent Dunham that she has no knowledge of any illegal activity and only invested the money where her financial adviser suggested. Peter notices that her house has a surprising number of air filters and hermetically-sealed windows. Once the team learns about the immune-boosting aspect of the worm, they realize this woman knows more than she is telling. This time, Peter approaches her son who tells him that he has a rare immune deficiency. He receives a special monthly treatment of worm-powder delivered surgically, directly into his spleen.

Walter, with some reluctant help from Astrid, heads off to Chinatown to find a herbalist that sells Ancylostoma that is genetically similar to the giant worm. He finds several shops that sell the worms, and inadvertently discloses to one of the shop owners — the wrong one, of course — that he has a giant worm back at the lab. The Triad follow Astrid back to the lab, beat her up, and steal the parasite.

The ship carrying Mai Lin’s family is found and boarded, but it is too late — all the immigrants have already been carted off. Luckily, Peter is spying on the shop in Chinatown where they have been taken. He calls Agent Dunham then decides to do some investigating of his own. He breaks in to the shop and is in the process of freeing one of the immigrants when he is captured. The Triad and their crooked doctor are force feeding Peter one of the larva when the FBI team arrives, just in the nick of time. The villains are shot or captured, Peter is saved, the immigrants are taken to the hospital where they are treated, and everything ends happily.

(Oh, and Walter implanted a tracking chip in his neck.)

Overall, the science — what little there was of it — was passable this episode, so I just have a few nit-picks an observations:

1. As the Worm Turns
Nematodes such as Ancylostoma are too primitive an organism to have a lymphatic system. They don’t even have a circulatory system.
Admittedly, these are “genetically engineered” hookworms, and for a worm to grow as large as those shown, thanks to the square-cube law and other similar concepts, they would have to have some sort of circulatory system.
In the actual worms, the many-tentacled end is the tail, not the head.

2. Glad I Don’t Have to Take Them Out
Matt’s staples should have been removed long ago. He was 3 ½ weeks out from his surgery. By this far out, the incision is healed with 80-90% strength. Leaving in staples or stitches that long serves no purpose, is going to lead to train-track scarring, possible stitch abscesses, and skin-growth around the staples.
Open abdominal surgery is to be avoided whenever possible, especially in immune compromised individuals. Why not just inject the powder into the spleen?
Credit-Where-Credit-Is-Due Dept: That is where an incision for splenic surgery would be made.

3. High is Not Always Better
A high white blood count is a sign of infection (or leukemia, not the sign of a healthy immune system).

4. Ahhh, Just Right
I was starting to have concerns with Walter’s mention of “boosting the immune system” — a common alternative medicine/quackery claim. In reality, the human immune system is finely tuned: too little leaves you open for infection; too much and you get allergy problems and autoimmune disease. If all the alternative “medicine” boosted the immune system like it was claimed, we’d have an epidemic of autoimmune problems in this country. I’ll give the episode credit for having the medication be used by immune-compromised patients — a proper use.

5. What Does the FBI Teach These People?
Walter’s about as good an investigator as Olivia — that is, very bad. The logic of his whole “find a matching worm” plan had more holes than Swiss cheese (though this is Walter we’re talking about). For instance, who’s to say the various different herbalist shops didn’t all use the same importer of worms — which they probably did — so the worms from the various shops would be identical.
And Peter’s not any better. Why would he think breaking into a shop owned by the Triad — known for their brutality — would be a good idea at all?

5. Lions and Tigers and Bears, Oh My!
The song Walter was singing was “The Menagerie“, which was also mentioned in the first season (episode 16, Unleashed).

While there was some errors of scientific-concerned, most of them were minor and could be hand-waved area. Thus, for the second week in a row, there is a one-minute improvement on the Doomsday Clock.

Tags: television fringe parasite ancylostoma worm

Almost entirely a Wilson character episode, so the medicine was fairly straightforward, if surprisingly sloppy

Wilson is out hunting turkeys with Tucker, a friend who he helped defeat leukemia five years earlier. Tucker nearly shoots Wilson when his left arm becomes suddenly numb and paralyzed. Wilson has Tucker brought to the Princeton Plainsboro Hospital emergency room for evaluation. A head CT is negative, and the blood count is normal, which tells Wilson that Tucker has not had a recurrence of his cancer. Noticing a fever blister on the lip of Tucker’s girlfriend, Wilson diagnoses him with tranverse myelitis (inflammation of the spinal cord, it can have many causes, in this case the Herpes simplex virus passed from the fever blister). He admits him to the hospital for treatment with acyclovir (an antiviral drug). House chides Wilson for his diagnosis, telling him that Tucker has cancer. Wilson disagrees and they end up betting $100 on the final diagnosis.

Paying a visit to Tucker a little later, Wilson discovers that he now complains of tingling in his left foot in addition to the continuing numbness and paralysis of his left arm. Wilson sticks with his diagnosis of transverse myelitis, but adds a second antiviral — Ribavirin — to the therapy. There is no improvement, and in the meantime Tucker has developed a nasty cough that eventually devolves into a respiratory arrest (which he survives, or it would have been a very short episode).

Perplexed, Wilson enlists House’s team in reviewing the case. Cancer is suggested, as is a subdural hematoma (bleeding around the brain), bacterial infection, or fungal infection. Wilson agrees with the fungal infection, and suspects that Tucker has aspergillosis (infection by the Aspergillus fungus) including fungal balls (exactly what they sound like) in the lungs and spine. He declares that Tucker is too sick for tests and rushes him into surgery. Chase sees no Aspergillus, but instead finds “global lung damage” suggesting PCP (Pneumocystis carinii pneumonia, a fungal infection of the lungs).

House is watching the surgery beside Wilson, and points out that a PCP infection means that Tucker must have a weakened immune system (since healthy immune systems can easily defeat the Pneumocystis carinii). He states that Tucker must have HIV (the virus that causes AIDS), acquired SCID (Severe Combine Immune Deficiency), or cancer. He suggests that Wilson test for all three.

Sure enough, this round of testing shows cancer — more specifically ALL (Acute Lymphocytic Leukemia, also known as Acute Lymphoblastic Leukemia). This is not a recurrence of Tucker’s original leukemia, but a different one, possibly caused by the chemotherapy required to treat the initial cancer. ALL is fairly treatable, so Wilson starts Tucker on chemotherapy. Twenty-four hours later, there is no change in his condition, and Tucker is concerned he may be in the 10% of ALL cases that Wilson says do not respond to therapy. Wilson decides to double the dose of chemotherapy. It works, more or less. The high dose chemotherapy knocks out the ALL, but it also severely damages Tucker’s liver (the yellow eyes were a sign of jaundice). In fact, the liver damage is so bad that Tucker will die in twenty-four hours if not given a transplant. When it becomes apparent that no transplant is available, Tucker asks Wilson to donate part of his liver to him (he know that they have the same blood type). Wilson thinks on it, and drinks on it, but eventually acquiesces and Tucker receives part of his liver. After the operation, both are doing well and expected to recover fully.

House’s first patient had Popcorn Lung, and diverticulitis (from the popcorn kernels). The second, apparently, had a screw in his lung.

No deal-breaker errors this week, but worse than the last couple of episodes. Some real sloppiness in writing/editing/continuity as well. As usual, major complaints are in red, minor complaints are in blue, and nit-picking ones in green:

Wilson is being generous with his ALL prognosis of 90%. The remission rate of ALL in children is 95%. In adults, it is 60-80%, with patient have CNS disease (which Tucker does) having a worse prognosis.
Chemotherapy cures leukemia completely in twenty-four hours? Nonsense. That’s too soon to tell if it’s working at all. Best case scenario is usually remission in 4-6 weeks.

There is no surgeon — even Chase — who would operate on Tucker without at least getting a CT first to show where the suspected fungal ball is. You don’t just slice up the lung indiscriminately. If there were a fungal ball, it would have shown up on the CT, as would PCP severe enough to cause a respiratory arrest.

By my understanding, SCID is currently defined to be a genetic disease, not one acquired later in life. There are acquired immune deficiencies, some severe (most notably HIV), but they are not “SCID.”

I’m surprised none of Wilson’s original blood work showed the cells associated with ALL.

Not my area of expertise or interest, but would a patient with a history of two cancers (though admittedly, no liver cancer or liver metastases) be placed that high on the transplant list?

Left arm or right arm? The episode description and House referred to right arm paralysis, yet the patient was clearly paralyzed in the left arm. Wilson later mention left arm. This is just sloppy.

“PCP Pneumonia” is redundant. The second P stands for “Pneumonia.”

A real nit-pick here, but by the time a patient has PCP, it is considered AIDS, no longer just an HIV infection.

I enjoyed the scenes with Wilson and his other patients.

The medical mystery was routine (as far as House episodes go), but well constructed. I give it a B. The final solution was fairly obvious, but entirely logical: B+. Overall, the medicine was OK, but way too sloppy, and gets marked down to a B-. The soap opera was good, though I would have liked to see a little more of the team. B+.

The House Challenge scores have been posted here.

Last week’s House review
A list of all prior House reviews

Not a lot of high scoring this episode. A handful of 5s, 4s, 3s, and 2s.

Overall, TRad remains in the lead with 44 points. Noether is close behind in second with 42 points. Corien remains in third but closes the gap with 33 points, atg moves to fourth with 29 points and Heidi drops to fifth with her 28 points.

Click here to see the full scoreboard.

A so-so mystery, but an interesting patient on this week’s episode of House.

James Sidas was a brilliant physics prodigy who quit the field twelve years ago and now works as a deliveryman. While he is delivering some books one day, he develops a hand tremor and some confusion. He is admitted to House’s team at Princeton-Plainsboro Hospital, with the presenting complaints of ataxia (loss of coordination), anemia, and a mild cough. A CT scan was negative, as was a screen for toxin screen. The team’s initial differential diagnosis consists of West Nile Virus, hyperbilirubinemia (high bilirubin levels in the blood), meningitis, sickle cell anemia, or TTP (thrombotic thrombocytopenic purpura). The last one seems the most likely so House has his team check a blood smear and AdamTS13 antibodies. The blood smear shows schistocytes (fragmented red blood cells), a sign of TTP, so they decide to begin treatment. Usually, plasmapheresis is treatment of choice, but James is allergic to one of the components of the procedure, so instead they perform a splenectomy — a removal of his spleen. The surgery goes well, but while Chase is examining him afterward, James begins to show symptoms of a stroke. He is rushed to the cath lab, where the clot in the brain is removed by a special catheter, “blood flow is restored,” and there is no permanent brain damage.

The fact that James suffered a stroke after his spleen was removed suggests that he did not have TTP. The differential now consists of CNS vasculitis (inflammation of the blood vessels in the brain), DIC (disseminated intravascular coagulation), acquired pancytopenia (low white cells, red cells, and platelets), or a toxin exposure. The team reasons that the basic toxin screen only tests for a few toxins, and they need to test for more. Chase and Taub are sent to search James’s apartment, while Thirteen and Foreman run an expanded toxicity screen. The apartment shows signs of mice (and Taub suggests James may have Leptospirosis), and a hidden bottle of booze.

The team now suspects that James has liver failure, probably due to alcohol abuse. When confronted, James admits to having a shot of vodka each day after work, but denies being an alcoholic. The team proceeds with a liver biopsy, which is normal. The liver function tests show a slightly elevated albumin, but are otherwise normal. Thirteen now deduces that James has renal (kidney) failure, not liver failure. The reasons for the kidney failure could be rhabdomyolysis (muscle damage), multiple myeloma (cancer of the blood forming cells), polycystic kidney disease, or Goodpasture’s Syndrome (an autoimmune disease that affects the kidneys and lungs). Goodpasture’s seems the most likely, so James is started on unnamed “immunosuppresant drugs” and dialysis. After a Eureka! moment in a conversation with Wilson, House realizes that James has been abusing dextromethorphan (DXM, also known as the DM in “Robitussin DM”). He has been taking it to suppress his intelligence, and taking the alcohol along with it to make it work better. The chronic abuse of the drug has caused his symptoms.

With an aggressive regimen, the drug is cleared from James’s system and his natural intelligence once again emerges. Due to his brilliance, he finds it impossible to relate to his wife anymore, and she herself realizes that he is no longer “the man she married.” While Foreman is trying to explain the situation to James’s wife, he begins to complain that he can’t feel his legs. Foreman evaluates and finds that James has no feeling in his legs at all. The team half-heartedly throws out some ideas including vitamin B12 deficiency, bone marrow malignancy (i.e. cancer of the bone marrow), and lupus, but none of them fit well. House talks to James who admits he had been abusing the dextromethorphan because, while he was intelligent, he was extremely unhappy. He tried to commit suicide once by jumping off of a tall building, but he survived, just busting some ribs. It was while he was in the hospital recovering from these injuries that he was given some narcotic pain medication, and he enjoyed the way it made him feel dumb. After discharge, he sought out the dextromethorphan because it made him feel the same way. Hearing about the history of broken ribs, House realizes that in the suicide attempt, James injured his spleen, causing it to split into multiple smaller (accessory) spleens. Chase thought he removed the spleen, but he removed only one and James still has several more. His ultimate diagnosis is the same one he started with: TTP. Once the rest of the spleens are removed, his TTP will be under better control. He decides to go back on the dextromethorphan though because he’d rather be dumb and happy than intelligent and alone.

For the second week in a row, There were no major errors that jumped out at me in tonight’s episode. The team did their usual combination overlooking certain findings and overtesting/undertesting (diagnosing renal failure without checking renal labs, for instance). Once again, that’s not to say I have no complaints…As usual, minor complaints are in blue, nit-picking ones in green:

Surely before Chase operated on James, he got an abdominal CT scan to double check the anatomy, and surely he would have seen at least one extra spleen (or unexplained mass) on the scan.

If James’s problem had been due to the DXM abuse, which they said caused brain damage, then clearing the drug from his system would not have returned him to his baseline but would have left behind some permanent damage.

Liver biopsy is not performed that early in someone with liver failure. There is much you can discover with labs and CTs/ultrasounds before you go plunging a needle into the liver of someone who is low on platelets.

Did James have accessory spleens or splenosis? It sounds more like the latter to me, but this is not my area of expertise.

The “Otis Campbell” mnemonic is for seizures, not strokes.

I’m not an expert on street drugs, as shown in my review a few weeks ago, but the affects of DMX that House and James describe don’t match what I see in the literature. Unless they’re saying that James went around high and tripping all the time, which you’d think somebody would notice.

What’s the House team going to do when they encounter someone who actually knows how to close a vent?

So James has Thrombotic Thrombocytopenic Purpura without the thrombocytopenia or the purpura? (OK, they implied a low platelet count late in the episode when they mentioned pancytopenia, but that was the only mention. Purpura? Never mentioned).

Schistocytes can be seen in other conditions besides TTP. DIC, for instance.

The team just gives up when James can’t feel his legs? And this is House’s All Star team?

Whatever happened to the ADAMTS13 testing from the beginning of the show? Might it have remained unmentioned because it would have given the final solution away too early?

Convenient how it was mentioned in the beginning that James’s CT was “clear”, but it was never mentioned what the CT was of…

A few brief words about the soap opera: while I enjoyed the way Cuddy tricked House, I found most of the Cuddy/House/Lucas scenes to be excruciating. On the other hand, I appreciated the fact that both Chase and Taub (especially Chase) were shown to be more devious than previously suspected.

The medical mystery was pretty good this week, but more due to the patient than the mystery itself. I give it a B. The final solution made a certain amount of sense. Spleens can “multiply” after trauma, and there have been cases where doctors removed the largest thinking it was the only one. I give in another B. Overall, the medicine was fairly strong, and earns yet another B. The soap opera had a few good parts, but was weighed down by the House/Cuddy/Lucas scene earning a meager C.

Last week’s House review
A list of all prior House reviews

The House Challenge scores for episode five are up and available here.

House Challenge scores are up to date through Episode 8.
I also corrected the scores from Episode 5 where I forgot to count “paraneoplastic syndrome”

Overall, TRad remains in the lead with 44 points. Noether is close behind in second with 42 points. Corien is third with 29 points, Heidi is fourth with 28 points, and Theta Sigma rounds out the top five with 27 points.

Click here to see the full scoreboard.

A fairly light episode of Fringe, but an enjoyable one

The Plot:The Observer is patiently standing in front of a museum in Boston, taking notes, and spying on brunettes. After a few minutes, he finds the one he wants, grabs her, throws her in the back of a stolen car and drives off. Arriving at an out of town motel, he gags her and ties her to a chair, and then leaves.

With the Observer involved, the Fringe team is called in. The kidnap victim is identified as Christine Hollis, and seems to be an entirely normal young woman. They review the surveillance camera footage and realize that this is a different Observer than the one they first met. It turns out that the Observer accidentally left his notebook behind, so it’s turned over to the team; however, they are unable to decipher the code/language in the book. Astrid identifies over 1200 different symbols, without any repeats. Looking online, she discovers that one of the researchers at Massive Dynamics is also interested in the code. He has not been able to solve it either, but he has documented evidence of Observers at important historical events including the Boston Massacre, the beheading of Marie Antoinette, and the shooting of Archduke Ferdinand. Peter finds a drop of what appears to be blood in the Observer’s journal. Walter notes its orange cast and wonders if the Observer might not have hemophilia.

At a restaurant across town, a group of three Observers are meeting to discuss the actions of the rogue Observer, whom they call “August”. They mention a plane flight and imply that Christine is supposed to be dead, so they send an assassin after her.

August returns to the hotel room, unties Christine, and shows her the television news, which reports that the flight she had booked to Rome crashed en route with no survivors.

The labs tests come back and the drop in the journal wasn’t blood, but hot pepper sauce — and sauce from a particular hot pepper: the King Cobra Chili. Astrid is able to find the address of the individual who imported some last year, so Olivia and Peter head over to check it out. As luck would have it, the Observers’ assassin is there at the same time. There are some fisticuffs and Peter sustains a small wound, but the assassin escapes.

August meets with the other Observers. They tell him that Christine must be killed to set things right. This is not what he wants to hear. He manages to set up a meeting with Walter, asking for his help. All Walter can tell him is that he must somehow make Christine important to the Observers, so they won’t kill her.

August returns to the hotel room and unties Christine. He tells her that she must do exactly as he says. A short time later, the assassin appears at the hotel and in the ensuing battle, August is shot and critically wounded. Olivia and Peter arrive, and August gives his gun to Peter. Together, Peter and Olivia are able to kill the assassin. They find Christine and return her home.

The first Observer picks up August and drives him away from the hotel. As August lies dying in the back, he tells the other Observer that he had developed “feelings” for Christine, even loved her — and that is why he saved her. The first Observer tells August that she is safe now because she is responsible for the death of an Observer, and that makes her important.

Overall, the science — what little there was of it — was passable this episode, so I just have a few nit-picks an observations:

1. Hot, Hot, Hot
The King Cobra Chile is the hottest chile known to man, scoring 850,000 to 1,000,000 Scoville units. It is also known as the “ghost chile”, which should be familiar to you if you watch Man v. Food.

2. 15% Tip
Why would it be a surprise that the tip about August was called in from the same hotel? Would it really be a shock that one of the other guests, or an employee, saw him and phoned it in?

3. Color of Love
This is the first I’ve ever heard of hemophiliacs having orange blood, and I don’t buy it. Hemophilia affects the clotting of the blood, not the hemoglobin (which is what gives blood its red color), so why would the blood be a different color?

4. You Go That Way, I’ll Go This Way
I would not want to be Olivia’s insurance agent, and I hate for her to be my backup. Tonight she: 1) was easily distracted by the assassin, 2) nearly shot Peter, and 3) only avoided being shot by the assassin due to dumb luck and Peter.

A much better episode this week. The show does much better when they stick with the Pattern. There is a one-minute improvement on the Doomsday Clock.

Tags: television fringe observer hemophilia scoville

The mystery was fairly bland in this week’s episode of House, but the medicine was much better overall. Good bye Cameron. Don’t let the door hit you on the way out.

Hank, a successful porn star is admitted to Princeton Plainsboro Teaching Hospital after developing a severe headache and photophobia (sensitivity to light) while on set. House starts off by ordering a series of tests: an STD panel (to look for sexually transmitted diseases), a toxin screen (to look for common toxins), C-Reactive Protein (”CRP”, a measure of inflammation), ANA (antinuclear antibodies, to look for autoimmune diseases) and a lumbar puncture (to look for viral encephalitis). While the patient is having his spinal tap performed, he develops severe muscle spam and pain (tetany) in his arms. Foreman orders meperidine (Demerol, a strong pain medication).

About this time, House starts hitting up Taub and Thirteen for ideas, trying to lure them back on the team. Taub suggests that Hank must have a brain problem, such as a tumor or seizure. Foreman believes that Hank suffers from cerebral vasculitis (inflammation of the blood vessels in the brain). House agrees with Foreman’s assessment and starts the patient on steroids. He also orders a brain angiogram (an x-ray of the arteries in the brain), as well as an EEG and a nerve biopsy, just to be sure. Foreman convinces Chase to perform the angiogram, but he and Cameron suspect that the patient is suffering from Vitamin D deficiency, so instead of checking the angiogram, they decide to start Hank on light therapy and intravenous vitamin replacement. Unfortunately, while undergoing the light therapy, Hank develops a nosebleed and is found to have petechiae on his legs.

Hank is now diagnosed with disseminated intravascular coagulation (DIC, a weird, but very serious, condition, where the patient is both bleeding too much and clotting too much). Sepsis is suggested as a possible cause, but since he is showing none of the shock associated with sepsis, the idea is discarded. Bacteremia (bacteria in the blood) is suggested, but Cameron shoots it down suggesting instead Meningococcemia (meningococcal bacteria in the blood — really a subset of what Chase suggested). House concurs with Cameron’s diagnosis and Hank is started on heparin (a blood thinner, for the clots) and a broad spectrum antibiotic that covers meningococcus (but if you know which bacteria you’re treating, then you don’t need a broad spectrum antibiotic).

Hank does not improve and he starts to run a fever. Taub suggests that he might have an infection hidden away in his sinuses, where the antibiotics have difficulty reaching, so Chase performs sinus surgery to clear out the sinuses. Now Hank begins to complain of severe abdominal pain and Cameron discovers something on the exam (apparent ascites — fluid in the abdomen) that makes her diagnose liver failure. She suggests a Klatskin tumor (cancer of the bile duct), but it doesn’t quite fit the symptoms. Foreman suggests that Hank has sclerosing cholangitis (a disease that damages the bile ducts). House agrees and an ERCP (an endoscopic exam of the bile duct and pancreas) is ordered — surprisingly it shows a mass in the common bile duct that ends up being a large clump of worms. Hank apparently has strongyloides (”whipworm threadworm”), and is given mebendazole to kill the worms.

Once again, Hank’s condition dramatically worsens. He develops severe pulmonary edema (fluid build up in the lungs). Chase thinks it might be a combination of a hematological (blood) problem and cardiomyopathy (a heart problem). Foremen suspects Hank has lymphoma, with peritoneal carcinomatosis (malignant spread of cancer across the abdomen) and paraneoplastic syndrome explaining his symptoms. House sides with Foreman, and Hank is started on chemotherapy. A short time later, Hank’s condition takes another turn for the worse when he starts urinating blood. Next, his blood pressure and heart rate skyrocket, and he starts to bleed from his mouth. He then suffers a cardiac arrest, but the team is able to stabilize him.

The latest labs are back and show that Hank barely has any red blood cells, white blood cells, or platelets. The differential diagnosis now includes hypopituitarism (an underfunctioning pituitary gland), renal cell carcinoma (a type of kidney cancer), or aleukemic leukemia (a leukemia that is associated with low white blood counts instead of the normally high counts found in leukemia). House tells the team that the latter is the most likely and orders them to ablate (destroy) Hank’s bone marrow in anticipation of a bone marrow transplant. There is a lot of hemming and hawing about whether this is the right thing to do, since it could make Hank sicker or kill him, but at the last moment, Thirteen and Taub call in with the correct diagnosis: extraintestinal Crohn’s disease. According to them, Hank’s exceptionally clean childhood made him more likely to develop diseases such as Crohn’s, and the worms were actually helping him keep the disease in check. Once the worms were killed off, the Crohn’s flared up with a vengeance. With some methylprednisolone (steroids), Hank should get better — but the team wants to give him some worms again, just to make sure.

I found no massive errors in tonight’s episode. There was the usual: jumping randomly between unrelated diagnoses, bizarre test interpretation, and Chase being a specialist surgeon, but nothing horrible. Of course, that’s not to say I have no complaints (as if!). As usual, minor complaints are in blue, nit-picking ones in green:

Where exactly was the extraintestinal focus of the Crohn’s?

Why did he develop a headache and photophobia in the beginning? Was that the Crohn’s? Why did everything suddenly worsen when he got in the hospital? The steroids he was given for the vasculitis should have calmed down the Crohn’s.

The strongyloides worms may not have been the cause of his disease, but their blockage of the bile duct would still cause serious problems for the patient.

Again, no oncologist is going to start chemotherapy for cancer without a tissue diagnosis.

Special precautions are taken for patients who are neutropenic (dangerously low in white blood cells, and thus more susceptible to infection) including gowning and gloving everybody in contact with the patient. You do not roll them down the hospital’s common hallway without a mask and with the wife holding his hand.

The CRP should have been significantly elevated with the Crohn’s disease (and the cerebral vasculitis too).

While the ANA is generally strongly positive for certain types of autoimmune diseases, it is not found in every autoimmune condition (or even most autoimmune conditions), so a negative ANA does not mean there is no autoimmune disease (and positive ANAs in the absence of autoimmune pathology are also possible).

How about checking the vitamin D level — an easy thing to do — before treating the patient.

I noticed how they avoided actually saying the word “ascites” and instead chose a wordier explanation. Probably because of their problem pronouncing it last time.

Cameron shoots down Chase’s idea of bacteremia, but then suggests meningococcemia, a type of bacteremia. The same argument she used against Chase would go against her as well.

Why would you ablate the bone marrow without finding a donor first? (OK, maybe House was never planning on really following through with it, but why would the others go along?)

And now credit where credit is due:
The hygiene hypothesis is a legitimate and controversial scientific theory concerning the rise in asthma and allergy rates in industrialized nations. Some researchers link it to autoimmune diseases as well.
Helminthic therapy — treatment of disease using intentional infestation of parasitic worms — is being tested in a variety of diseases, including Crohn’s/
Shocking ventricular tachycardia, like Foreman did this episode, is the right treatment.

The mystery was okay, but seemed to get lost in the shuffle as the show progressed. I give it a B. The final solution was a stretch, especially when you look back at the original symptoms. It earns a C. Overall, the medicine was better that it has been the past few weeks and earns another B. The soap opera was decent as well. I enjoy Tab and Thirteen, so I’m fine with having them back, though I know many will disagree. The soap opera earns still another B.

Last week’s House review
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The House Challenge scores are now up to date here.

An incredibly mediocre show that didn’t meet a cliche it didn’t like (except, unfortunately, the psychic nosebleed). Sorry if the write up seems brief, but I’m really having a hard time caring about this show recently.

The Plot:The police are called for a kidnapping/hostage situation at the top of a parking garage where two guys are holding a teen hostage in a car. When the police arrive, they order the men out of the car. The duo get out of the car and then strange things begin to happen: one cop backs up and throws himself off the garage, while his partner shoots the other cops and then herself. The two guys get back in the car and drive off with the kid.

The Fringe team is called in to evaluate the case. Walter suspects that there is hypnotism of subliminal messages involved. The team heads to Massive Dynamic because the kidnapped boy is the son of one of their top aerospace researchers. By now, the two guys in the car have been identified as two local used car salesmen who had been upstanding citizens until now. The kidnappers and teen stop by a convenience store and ob it. A burly customer tries to intervene, but suddenly he is pouring scalding coffee over his head and the breaking the carafe over it. The cashier tries to shoot the men, but finds himself picking up a key and inserting it into an outlet and shocking himself unconscious.

Walter has been performing an autopsy on the cop who shot the other cops and deduces that it was not hypnosis, but instead mind control. He makes his deduction based on the fact that there are hematomas (pockets of leaked blood) on the surface of the brain, suggesting some mind/body conflict. He then infers — for no good or logical reason — that this mind control must be done via the cochlear (hearing) nerve.

A call comes in from the kidnappers demanding two million dollars. Meanwhile, Walter has concocted white noise headphones for the FBI troops to wear in the field which should block out any mind control. At an abandoned factory, the teen’s father hands over a briefcase of money to the kidnapper, who then runs into a nearby building. Agent Dunham follows. Meanwhile, Peter sees someone else running with the briefcase and follows, only to find the teen, Tyler, holding the briefcase. It turns out Tyler’s the one with mind control and the others were nothing but patsies. Unfortunately, Peter’s white noise headphones don’t protect him and Tyler orders him to drive the two of them out of town in the Bishop family roadster.

Peter tries to rebel, but Tyler forces him to drive the car as fast as it can go and plays chicken with a truck before Peter agrees to behave. A little while later, they are pulled over by a policeman. Tyler wants Peter to shoot the cop, but in the end, he lets Peter just knock him unconscious. Finally, Tyler and Peter arrive at his mother’s house (by way of a strip club), where Tyler finally gets to meet the goal of his quest — his mother. He believes that his father had driven her away and lied to him about her, but that turns out not to be the case, and when he learns she is married he has Peter pull out a gun and point it at her husband. Luckily, Agent Broyles arrives and shoots Tyler with a taser — but it’s a bad shot. Tyler has Peter shoot Broyles, and then he and Peter hop back in the family roadster and take off. Agent Dunham, Astrid and Walter are following close behind, and when they get near off, Walter activates the EMP device he has been working on. It knocks Tyler out for a split second, and that’s enough for Peter to realize what is going on and drive into a telephone pole. He survives with a mild concussion, but Tyler is knocked unconscious and captured.

1. Watching Too Many B-Movies, and Now I Need Some Popcorn
Walter’s original suggestions were nonsense. As Peter pointed out, hypnosis doesn’t work like that — and subliminal messages don’t work at all.

2. La La La! I Can’t Hear You!
Why go through all the elaborate set up of the white noise headphones instead of just using ear plugs?

3. Bleeding On The Brain
Hematomas don’t form with brain/body conflict. There are certainly medical conditions with conflict between mind and body — somatization comes to mind — but none of them cause hematomas. You could argue that the straining led to an increased blood pressure which popped the vessels, but high blood pressure related bleeds occur within the brain, not on the outside.
That was a surprisingly intact brain for someone who received a bullet at point black range.

4. On the AM Radio
Why amplify the brain waves — that should have been the team’s first realization that something wasn’t kosher — why not just make better sensors?
Amplifying the brain waves means that you are increasing the voltage within the brain itself, which is wonderful way of setting off a seizure.

5. It’s Better Than The 10% Cliche, But Just Barely
Brains are not computers. Whenever someone uses this analogy, it’s a safe bet that they don’t understand brains or computers
Having Tyler’s mother actually be a surrogate was a fairly clever twist — really the only one in an episode thick with clichés — but how does the doctor raise all five Tylers? Are they frozen until needed? Does he spend one day of the week with each one?

6. The Blind Leading the Blind
Geez, Olivia is a bad detective. She already knows Tyler’s mother died when he was young, and then can’t figure out why he’s looking at records of women who died in car crashes fourteen years before.

7. Crime And (Lack of) Punishment
Why would Tyler get off with just seeing some psychiatrists? That makes no sense at all, especially the way they explain it. He was directly involved in the murder of five people, the maiming of three others, and at least three attempted murders. He’s fifteen — old enough to be tried as an adult.

Why exactly am I still watching this show? I’m sure I have much better things to do.

Tags: television medicine fringe mind control hypnosis subliminal

This episode of House started well but collapsed under the weight of its ridiculous medicine in a surprisingly short period of time. The soap opera was well done and enjoyable, though

Jordan, a sixteen year-old girl, and her best friend bluff their way into a band’s post-concert party. The next morning when they are regaling their other friends with the details of the night (including alcohol, marijuana, and skinny dipping), her friends notice that Jordan’s ankles are very swollen. Seconds later, her fingers become swollen too, and then she collapses on the floor.

Admitted to Princeton-Plainsboro, House is convinced that Jordan has rhabdomyolysis (muscle damage, often caused by a crush injury. He thinks she injured herself climbing the fence to the pool to go skinny dipping). The rest of the team suggests that she may have a deep vein thrombosis (a blood clot), anaphylaxis (a life-threatening allergic reaction), or even a heart condition, but House maintains that Jordan must have rhabdomyolysis. Tests reveal that Jordan’s muscle enzymes are elevated (a sign of rhabdomyolysis), but the scans show no sign of the muscle injury House was suspecting.

House now looks over the labs and notices that Jordan has a low potassium. He has her air drum (like air guitar, only drumming), but she can only drum for a minute or two before her arms are too tired to lift. House states that this muscle weakness is a sign of low potassium, and since she would have had a low potassium the previous night as well, there was no way she had the muscle strength to climb the pool fence. In other words, he accused her of lying about what happened. Later, Jordan and her friend admit to Cameron and Chase that in reality, they only wanted to go to the party because their favorite comic book/movie writer Jeffrey Keener would be there. They then proceeded to stalk him for the next few hours (going where he went, eating what he ate, etc), before finally going to bed.

The differential now consists of an unknown food allergy, plus Cameron thinks that Jordan may be bulimic. They run a scan to look for a Mallory-Weiss tear (a rip in the esophagus seen in people who vomit frequently, like bulimics), and when they don’t find one, decide that she isn’t bulimic. As they finish the test, Jordan’s blood pressure drops suddenly and then she flatlines. Foreman starts CPR (good for him). Chase announces that Jordan has cardiac tamponade (the pericardial sac — the membrane around the heart — has become filled with so much fluid the heart can no longer beat correctly) and he plunges a needle into her chest to draw off the blood around the heart and relieve the problem. Somehow, this brief moment of tamponade has severely damaged (“constricted”) her heart, necessitating use of antiarrhythmic medications (drugs to prevent abnormal heart rhythms). Since Jordan’s blood pressure drop was sudden, House decides that this means she has an acute problem, not a chronic one. Therefore, the most likely diagnoses are toxin exposure or infection, but the team still needs to figure out which toxin or which infection.

Things continue to worsen for Jordan. She tells the team about stopping by Bruce Springsteen’s house and playing guitar with him . She is lying and does not even realize that she is doing it. Additionally, Foreman notices blood dripping from her ear and announces to her friend that bleeding in her brain is affecting her thalamus and this is causing her to lie. (When did he get an MRI to determine this? And why would bleeding in the thalamus — in the center of the brain — leak out the ear? Did she somehow rupture her eardrum too?)

The team reviews the videotapes from the hotel that night and discover that Jordan sneaked out of her room briefly in the middle of the night. They see her a few minutes later carrying Keener’s journal. He apparently left it in the restaurant and she went back to get it. They figure that she must have stopped by his room to return the journal and maybe something happened to her there. Chase and Cameron confront Keener in his hotel room — he shuts the door in their face. Cameron now suspects that Jordan was slipped some roofies (a slang term for Rohypnol, an alleged common date rape drug) and wants to start her on Flumazenil (a medication which reverses the effects of Rohypnol and similar drugs). When they return to the hospital, they find Foreman frantically working on Jordan. He tells them that she has been bleeding behind her kidneys and has required multiple units of blood. Cameron thinks it looks like a “toxic reaction.”

Cameron realizes that they must figure out what really happened to Jordan that night. Her plan is to give Jordan Amobarbital — i.e.truth serum — so they can discover the truth. Jordan is given the drug, and under questioning, admits that she went to Keener’s room where he invited her in and gave her Ecstasy — only it didn’t have the same effect on her that Ecstasy usually does — this pill made her sleepy. She then begins telling the team how Keener started to touch her. As her father gets more and more upset, Foreman points out that the scans indicate “increased periorbital blood flow” meaning that everything she just said is a lie.

Most of the action now shifts upstate, where Cuddy, House, and Wilson are at a medical conference. At one point, the team talks to Wilson and tells him that since Keener travels with his dog, Jordan may have come down with Rickettsia (not the name of an infection per se, but a genus of tick-borne bacteria that cause such diseases as typhus and rocky mountain spotted fever). A short time later, in the middle of an argument with Wilson, House has his Eureka! moment and calls the team. He announces that Jordan has Vibrio vulnificus, a not uncommon bacterial contaminant of the raw oysters Jordan ate. For most people, the bacteria present no problem (or mild nausea and vomiting), but Jordan also has hemochromatosis. According to House, this made her more susceptible to the contaminated oysters. The Vibrio infection explains her initial symptoms. Then the team, thinking she had bulimia, started her on iron-containing vitamins, which worsened the symptoms of the hemochromatosis (by causing iron overload), resulting in liver damage and bleeding. They gave her transfusions, which again worsened her symptoms (more iron overload). However, with the right diagnosis and some Cetazidime (an antibiotic for the Vibrio) and chelation (for the excess iron), she should be as good as new.

Tonight’s episode was rife with errors, far worse than usual. I did my best, but I’m sure some obvious one slipped by. As usual, major complaints are in red, minor in blue, nit-picking in green:

The truth serum idea was simply ridiculous. Amobarbital does not work like Cameron explained, and it is far from foolproof — for example, it’s easy to create false memories (and the questioner Cameron clearly had a preconceived belief of what happened to Jordan).
Telling truth from lies is not nearly as black and white and Foreman makes it seem. You can’t look at an fMRI report and definitively state “she was lying the entire time” like he did. But it sure would make police interrogations and court a lot easier if it worked as easily as Foreman implies.
Anyway, where is the fMRI? Jordan was in a bed in the center of the room. There was no MRI equipment in sight. Nothing to read the “increased blood flow” he mentions.

Cardiac tamponade or not, you don’t just plunge a needle and syringe blindly into the chest — you’re likely to do more harm than good. Yes, you can perform a needle pericardiocentesis, but it’s more involved than “plunge and pray.”
Why would 20 seconds of tamponade cause a permanent conduction problem in the heart?

A day or two of iron supplementation is not enough to cause that severe liver damage in a patient with hemochromatosis. And apparently it kicked in really fast, because it bled into her pericardial sac mere minutes after suggesting the diagnosis of bulimia, let alone giving her vitamins with iron.

Jordan’s symptoms do not match Vibrio at all. For starters, she has no gastrointestinal symptoms from what is essentially food poisoning.

When did Foreman get an MRI to determine that Jordan had “bleeding into her thalamus?” And why would bleeding in the thalamus — in the center of the brain — leak out the ear? Did she suffer head trauma which disrupted her ear canal and also ruptured her eardrum?)

Rhabdomyolysis can have other causes other that a direct muscle injury, so not seeing a specific injury on the scan means little (for example, many marathon runners end up with some rhabdomyolysis by the end of their race, but it’s not a single muscle, but most of them, so a scan would show nothing)

Not everyone with bulimia develops Mallory-Weiss tears, in fact, most don’t. So not seeing a tear does not mean she is not bulimic.

Edema is swelling of soft tissue. Effusion is the swelling of a joint. They are not the same thing and the terms should not be used interchangeably. A halfway decent physical exam, especially on someone as skinny as Jordan, should easily tell them apart.

Assuming Jordan did receive Rohypnol, the flumazenil, a benzodiazepine antidote, is a reasonable choice. But by the time Cameron would have given the drug to her, the rohypnol would have been long gone from her system.

Rickettsia is a genus of bacteria, not a specific disease.

Rhabdomyolysis is very hard on the kidney. I would think twice, and then a third time, before giving such a person IV contrast (also very hard on the kidneys).

I thought the medical mystery itself, and the confusion of the always changing history, was intriguing this week and deserves a B+. It goes downhill from there. The final solution did not fit the mystery at all — either solution — and earns a D-. The medicine overall was a complete mess, with scattershot diagnoses, ideas abandoned for sloppy reasons, and missing equipment. It earns a solid dismal F. The soap opera was a bright spot — especially all the scenes at the conference — and earns an A.

Last week’s House review
A list of all prior House reviews

The House Challenge scores are now up to date here.

Could have been a contender, but was KO’d by bad science and too many clichés

The Plot: A married man in Boston mysteriously turns to ash while waiting to spring an anniversary surprise on his wife. The Fringe team is called in to investigate. Broyles tells Dunham that he’s seen this before — there were five similar deaths several years ago at a hospital in Washington DC. He tells her he was contacted by an “Eastern European” man who provided a strange formula to him and indicated it was the solution to the deaths. Unfortunately, none of the FBI’s scientists could decipher the formula several more deaths occurred before they suddenly stopped — until now.

Dunham digs a little deeper and finds that the victim had recently been visiting his sick mother at a hospital. The Fringe team stakes out the hospital, trying to find a link between this hospital and the one four years ago in DC. They find a critical care nurse named Tomas Koslov who has worked at both institutions. Meanwhile, another ash-death has occurred on the in the hospital. A review of the hospital’s surveillance tapes show a strange being made entirely of shadow moving down the hall right before the death was discovered.

The team locates and searches Koslov’s apartment but discover he has abandoned it. They are able to find a fingerprint. When they run the fingerprint they find that their suspect is man by the name of Timur Vasaleiv who is wanted by both the CIA and the Russians because he stole something important from Russia. Broyles is told that the CIA will be taking over the case, but he decides to keep his team on it anyway. A contact at the Senate sends him Timur’s file. It turns out that his brother Aleks was a cosmonaut who returned comatose from a space mission, and it is his brother that Timur has stolen from a special Russian quarantine facility. He has been keeping him in various American hospitals while posing as an ICU nurse.

Walter has been working on the formula and realizes that it represents an organism that seems to feed on radiation. The hospital patients died because they all had been undergoing radiation treatment, and the husband died because he had been on a recent cross country flight (where he had been exposed to higher than normal levels of background radiation).

Timur returns to the hospital and takes his comatose brother out of the ICU and to a hotel. The shadow tries to emerge, but using a series of car batteries, Timur shocks his brother enough that the shadow retreats. He also knocks his brother into asystole (flatline), but after a few moments, a normal heartbeat returns.

Confident that Walter can crack the formula, Agent Broyles reaches out to Timur and offers his help. Timur is trying to decide whether to take Broyles assistance when he slowly turns to ash — the shadow is loose. The FBI arrives to find the comatose cosmonaut and the dead Timur. Peter thinks Walter can shock Aleks to make the shadow return, but Walter cannot read the equipment as it is all in Russian. When they hear a young girl scream from another motel room, Broyles takes unhesitating action and shoots Aleks in the head, killing him. The girl tells her mother that there was a shadow man in the room, but he disappeared. Later, when the CIA approaches Broyles to warn him off their case, they tell him that despite being shot in the head, Aleks returned to life, and they apparently sent him back into space.

1. Glow In the Dark
There is a major misunderstanding of radiation here. While the victims had all been recently exposed to radiation, but they were not radioactive themselves. There was no “high levels” of radiation for the shadow to detect, let alone feed off of.

2. Feed Me, Seymour
What had the shadow been feeding off of for the past four years, after DC but before the husband died?

3. I See You
There is no way a patient is going to sit for four years in a hospital ICU like Aleks apparently did.
ICU beds are incredibly expensive. The hospital billing department would have been on the phone to his insurance company as soon as he was admitted. No insurance? While they wouldn’t have kicked him out (unless he was medically stable and had a place to go), they would have been looking at the records very closely.
If someone is in a permanent coma, they would be transferred to a rehabilitation hospital or a nursing home as soon as they were medically stable. They wouldn’t keep them in a regular hospital ICU indefinitely.
How did he get him admitted to each new ICU? ICU transfers are very irregular unless one is going from a less-equipped hospital to a better-equipped one, and that doesn’t seem to be the case here.

4. Eleven Herbs and Spices
In my brief look at the formula, there seemed to be a number of carbon atoms with more than 4 bonds. I admit that Ionly had two years of Organic Chemistry, but that seems quite unlikely to me.

5. Blackjack
Your Osama Tezuka link for the day: the little girl was watching Kimba, the White Lion.

The plot line had potential, but was dragged down by too much bad science, reliance of clichés, and deep piles of nonsense they didn’t even try to explain away. The clock moves closer to midnight.

UPDATE: And I should mention that I’m already dreading next week’s show, just based on the preview, where they mention the completely debunked “most people only use 10% of their brain” myth as if it were fact.

Tags: television medicine fringe sleep coma ash formula radiation

The medical mystery was intriguing on this week’s House, but the medicine was shaky from the beginning, resulting in a rather pedestrian solution. Plenty of so-so soap opera, if you like that sort of thing.

The patient this week is Donny, a police officer with a deathwish. His father, grandfather, and great-grandfather all died at age 40 due to a sudden heart problem. He is convinced that he is going to die at forty as well, so he has started to take crazy chances at work, certain that he will be dead soon enough anyway. In his latest escapade, he fell 30 feet trying to jump from roof to roof after a parkour-ing thief and ended up with a concussion, a couple of broken bones, and a punctured lung. When Cameron hears about his family heart history she admits him for evaluation, to the dismay of House who thinks Donny’s family history nothing more than a coincidence.

The initial differential diagnosis for Donny, focusing on a suspected genetic heart condition, includes Marfan syndrome (an inherited disease of the connective tissue that can affect the aorta and heart valves), Brugada syndrome (an inherited abnormal heart rhythm), and familial hypercholesterolemia (an inherited condition that results in very high cholesterol and early heart attacks). Foreman orders some vague “genetic testing” in addition to an EKG, cardiac catheterization, and echocardiogram. All of the initial tests are normal, so Foreman and team proceed to run further genetic testing on the conveniently available remains of the patient’s father, grandfather, and great-grandfather. It is also discovered that Donny has a son he didn’t know about, so DNA is collected from him as well. Once again, all the tests are negative.

House decides it is time to send Donny home as there is no evidence of any disease. He and Chase tell the patient that he has the very rare (and completely fictional) condition known as Ortoli Syndrome, and that it can be successfully treated with the (fictional) drug Nabasynth. They give him a few breath mints as a placebo and send him on his way. Only it doesn’t work out so well. Donny collapses, dead, four hours later in the laundry room at his apartment complex.

Foreman has Donny’s body moved to Princeton Plainsboro so they can perform the postmortem. As he and House begin the autopsy, starting the Y incision, they notice the body is bleeding, which shouldn’t be happening in a corpse that old. Suddenly, Donny sits up and screams. It turns out he wasn’t dead after all — and no one noticed. He is readmitted to the hospital, and after a brief period of lucidity, becomes essentially unresponsive with a dangerously low blood pressure (though this is forgotten soon enough and he is awake for the rest of episode). The new differential diagnosis is tetrodotoxin exposure (the toxin from the fugu, of pufferfish), sick sinus syndrome (a condition where the heart’s natural pacemaker isn’t working right), or a sinoatrial block (another abnormal heart rhythm). House suggests the underlying problem may not be in the heart at all and recommends the team look elsewhere. Chase proposes some sort of metabolic disturbance and Foreman suggests an autoimmune disease (actually he suggests that the family suffers a “pre-disposition to an autoimmune disease”, but clearly they all had more than a mere disposition). He suggests anti-Ro antibodies (a marker for autoimmune disease) which can lead to heartblock. House concurs and Donny is started on steroids.

There is no improvement, in fact, Donny begins to complain of a severe headache that later becomes jaw pain and then a severe tooth pain. He finds a heavy surgical clamp, conveniently left in the room, and pulls his own tooth out. The team has the tooth evaluated by a dentist (using a specialist, for once) and it is normal. They now decide that Donny must have bone cancer with paraneoplastic syndrome. The inheritance is explained by Li Fraumeni syndrome (an inherited condition where patients have a high chance of developing cancer at an early age), which makes people more likely to develop bone cancer. A gamma scan (a bone scan to look for cancer) is performed but is normal — there is no bone cancer.

House now decides that the condition is a nerve problem and diagnoses Donny with hereditary sensory autonomic neuropathy, type I (an inherited degenerative nerve disorder). He is started on carbamazepine (an anti-seizure drug that can provide partial relief of pain in HSAN1). Almost immediately after starting the drug, Donny loses bowel control, so the team decides they once again have the wrong diagnosis. Autoimmune is suggested once more, but shot down. Wilson’s disease (an inherited disease of copper metabolism) is also suggested, but House notes Donny’s liver functions are normal. The counter suggestion is that his liver is so bad, the labs look normal, so they decide to go ahead and start him on the treatment for Wilson’s disease, penicillamine (rather than, you know, actually testing the liver). Later, while bantering with Cuddy, House has his Eureka! moment and deduces that Donny has a berry aneurysm slowly growing in the brain in just the right place to press against the part of the brain responsible for the heart. Some quick brain surgery and both Donny and his son survive to live a full life.

The medicine had some problems this week. As usual, major complaints are in red, minor in blue, nit-picking in green:

Berry aneurysms can be inherited, but 5 generations of patients with an aneurysm at the identical location in the brain — out of all the arteries in the brain — growing at an identical rate. If you buy that, I have some oceanfront property to sell you in Arizona.
Are the cardiac centers and tooth pain centers even near each other in the brain?

Cardiac catheterizations can have serious complications and they’re not undertaken lightly. I doubt any self respecting cardiologist — at least one who wants to keep her malpractice insurance rates somewhat affordable — would perform a cath on a healthy forty year old with no cardiac symptoms. EKG and Echocardiogram are probably overkill too, but at least they’re not invasive.

Bone Marrow DNA is “more pure?” DNA is DNA — it’s the same whatever cell you take it from. If the blood isn’t “pure enough” surely there are easier — and less painful — ways to get a sample than a bone marrow biopsy.

So this week, in addition to being the team leader and a neurologist (who missed an intracranial aneurysm — the bread and butter of his profession), Foreman is:
A pathologist
A cardiologist
A radiologist
A geneticist.

Sequencing the cardiac sodium channel, in a hospital lab, in a day. Right. See me about that property in Arizona. Even with modern equipment, gene sequencing is tricky, time consuming, and a specialized skill.

HSAN1 doesn’t fit the case at all.

For once, they don’t get a brain scan, and where is the solution? The brain.

At least run some simple tests before declaring it to be Wilson’s Disease.

Verbatim from my wife: “If I were House, I would just walk around the hospital having random conversations with people until I have my Eureka! moment and solve the case.”

I thought the medical mystery was very good this week, but the initial presentation and the Lazarus-like return; I give it an A-. The final solution was pedestrian, an incredible stretch of coincidence, and didn’t really fit all that well. I give it a D. The medicine overall was barely okay — not good, but not horribly bad — like a car accident where the car isn’t a total loss — and earns a C-. The soap opera was plentiful, but nothing spectacular. For the second week in a row, it earns a C.

Last week’s House review
A list of all prior House reviews

The House Challenge scores for episode five are up and available here.

A low scoring week, with the high score of 5 point for the episode. Bubbarum, Dana, Jamie II, jwsellers, Robb, and Theta Sigma all scored 5 points.

Overall, TRad remains in the lead with 23 points. Alex Davis stays in second with 19 points, but is now joined by Theta Sigma. Kevin Lighton drops to fourth with his 18 points and Elizabeth drops to fifth with 15.

Click here to see the full scoreboard.

The science, while a little sketchy, wasn’t half-bad in this episode of Fringe. Despite this, I found the story itself rather lackluster.

The Plot:In Seattle, Greg, a businessman, walks through his office, late for a meeting with his boss. As he moves through the office, he notices that everyone he sees has the heads of demons rather than their proper heads. When he enters the conference room, he sees that his boss is also a demon, so he bludgeons him to death with his briefcase. The co-workers who wrestle Greg to the ground notice that his eyes are cloudy and twitching.

The Fringe team is called to Seattle to evaluate the case. They interview Greg at the hospital and he tells them what he saw in the office. Suddenly, he begins thrashing wildly in bed, his hair turns completely white, and he collapses, dead. Walter assists that local medical examiner with the autopsy and determines that Greg died of “acute exhaustion.” He arranges for the body to be sent to his lab at Harvard for a more complete, Walter style, autopsy.

Talking with Greg’s wife, Dunham and Peter learn that he had a history of sleep walking, but it hadn’t been a problem for several months since visiting some specialists.

A second incident has occurred: a woman driving a mini-van told her husband she saw a monster and drove her car into an innocent cyclist. She died at the scene and was found to have the same white hair Greg did.

Back in his lab, Walter finds a microchip implanted in Greg’s midbrain. A quick look at the body of the second victim shows an incision on the neck suggesting she had the same operation. Broyles takes the microchip to Nina Sharp at Massive Dynamics who identifies it as a chip designed to work on the thalamus to promote sleep. She identifies its creator as a Dr. Nayak, also in Seattle.

Dunham and Peter pay Dr. Nayak a visit. He identifies both victims as patients of his who are taking part in a clinical study on the brain chip. He takes Dunham and Peter to his office only to finf there has been a break-in. Nayak’s office has been trashed and the computers containing all the patient data are missing.

Walter and Peter hypothesize that someone is using the chips as a rudimentary form of mind control. Meanwhile, in a dark room, we see shadowy someone access the clinic’s computers and select a patient — a waitress at a local Greek restaurant. Soon she begins hallucinating before attacking the chef and then collapsing, dead. Nayak identifies her as one of his patients as well.

Back on the east coast, Walter has been experimenting with the chip and discovers that it siphons the patient’s dreams away so that they never dream. The chips can also be used to place the patient in a dreaming state while awake. Finally, he discovers that whoever is on the receiving end of the chip gets an incredible high from the stolen dreams. Olivia realizes that they are looking for someone addicted to the dreams. A brief amount of detective works reveal that Dr. Nayak himself is the perpetrator. He has a dream-addicted dark side that is causing all the problems. They track him to his home just as he is using his machine to activate the chip in an airline pilot’s head. Dunham destroys the computer, saving the pilot (and his crew and passengers), but killing Dr. Nayak in the process.

Overall this week, I felt the science was not entirely implausible, a step up from the usual. So most of what follows are probably best regarded as “nit-picks”

1. Wherein I Make Some Concessions
I agree that exhaustion/stress can cause high cortisone levels and dehydration. For the sake of the story, I will also accept that it can cause sudden loss of hair pigment (a la Jean Valjean) and thyroid disorders. However, I am at a loss to explain how it can cause the sudden appearance of large patches of thickened flaking skin. Sure, dehydration and low thyroid can cause skin problems, but it is the entire skin, not just large discrete patches.

2. We Solve the Problem by Breaking the Space-Time Continuum
Let me get this straight: the brain chip is used to correct non-REM sleep disorders. It does this by siphoning off dreams. Now, dreams generally occur in REM sleep, which comes after non-REM sleep. So the chips fix the sleep by removing something that hasn’t even occurred yet.

3. Department of Redundancy Department
“Blood CBC” is hopelessly redundant. CBC stands for complete blood count, so a blood CBC is a blood complete blood count.
A CBC looks at the blood cells (white, red, platelets). It doesn’t look at hormones like thyroxine and cortisol, that’s a different test entirely.

4. OMG, n00b
Yes hackers steal passwords. They also mount DDOS attacks, but these are two separate things. Claiming the lack of DDOS attack means that a hacker couldn’t be involved means the FBI (or the Fringe writers) need much better forensic computer experts. (And what would a DDOS attack against a single clinic server accomplish, anyway?)

5. It’s Not Brain Surgery — Wait, Maybe It Is
The thalamus is located deep in the center of the brain. Any surgery to reach it, let alone implant a chip in it, is going to be a major undertaking — a hole in the skull needs to made after all — and wouldn’t be performed as an outpatient clinic procedure.
The thalamus is part of the diencephalon, making it forebrain, not midbrain.
And good luck getting the clinical trial approved by the IRB.

6. Your Suspicions Are Suspicious
Hearing that one of his employees was suspected, one would think that Dr. Nayak would have volunteered the information about his assistant being missing earlier in the day, rather than waiting until the end of it (or was that the effect of Hyde-Nayak?).

7. A Shot In The Dark
Peter, Dunham and the other FBI agent can’t find an on/off switch or a plug or a circuit breaker between the three of them? So the next logical step is shooting the server?

It’s the reverse of last week. This time, I found the science acceptable, but the story tepid — so they cancel out and the clock stays at 11:55

A list of all previous Fringe reviews is available here.

Tags: television medicine fringe sleep rem hacker adrenalin

High score for the week goes to Alex Davis and Linda Pollock both with 7 points.

Overall, TRad retains the lead with 23 points. Alex Davis moves to second with 19 points. Kevin Lighton drops to third with 18 points. Elizabeth remains in fourth with 15, and atg and Theta Sigma are tied for fifth with 14 points.

Click here to see the full scoreboard.

An exciting episode of Fringe that did a nice job advancing the overall plot. The action and suspense were well done, but the medicine was rather abysmal.

The Plot: A cryogenic storage facility is robbed and a truckload of frozen human heads is stolen. Four security officers are killed in the robbery — well, actually it’s three officers killed and one shape shifter. The Fringe team is called after the last corpse is found bleeding a silver colored liquid. While Walter inspects the corpse, Peter mentions that this is the third cryogenic facility robbed in the last week, and every time, only human heads are stolen.

Back at the lab, Walter has Agent Dunham drink a concoction of ground up flatworms to help restore her memory of her time on the parallel Earth. It seems to work as she begins to have brief flashbacks as the episode progresses.

Walter finishes the autopsy and discovers that the shape shifters’ blood is 47% mercury. He realizes that there was only trace mercury in the previous body they thought had been a shape shifter (the Nurse from the first episode), so that means the shape shifter who tried to kill Olivia is still out there.

Walter and Peter to hunt down Rebecca, the girl from the ESP video (first episode again), to see if she can still detect the shape shifters with her psychic powers. She tells them her powers faded a few years ago, but she agrees to repeat the experiment to see if her powers will return. She returns to the lab and is dosed with a variety of hallucinogens.

Meanwhile, Agent Dunham takes the device found on the dead shape shifter to the lab at Massive Dynamics. They tell her they can use the new device to repair the damaged device from the first shape shifter and will be able to generate an image of who he is disguised as now. They’ll have the results sent to Walter’s lab and Olivia’s phone.

Back at the lab, Dunam collapses and has an extended flashback to her time in the other universe. She remembers William Bell telling here that there is a war coming and he needs her to guard the gate between the two worlds. He tells her the shape shifters are looking for a certain person — a leader who can open the gate — and that’s why they’re after the frozen heads; one of them is the leader. Later, when Dunham is telling Nina Sharp of her recovered memories, Charlie calls to inform her that Nina is the shape shifter. She all but runs out of the building and encounters Charlie outside. Just then, her phone rings and sends her the results from the device that reveal that it is Charlie who is the shape shifter. There is a brutal fight, and at the end, Dunham shoots him, repeatedly. And then she learns that the other shape shifters have found their leader. This is what we call a downer ending.

1. The Worm Turns
Ah, the famed planarian experiments from the 1950s. A “scientist” trained some of the flatworms to run a maze. He then killed them and fed their remains to a second group of flatworms. This second batch of flatworms was found to be able to run the maze faster, suggested that they had gained the memories of the worms they ate. This experiment was actually featured in one of the greatest comic books of all time (Saga of the Swamp Thing #21 — “The Anatomy Lesson”). Trouble is, it’s not true. While the story of the experiment persists as a myth/urban legend, few actual scientists believe the results are valid. Over the intervening fifty years, no one has been able to duplicate the results despite repeated attempts. The current suspicion is that the positive results of the initial experiment were due to either observer bias (the tests weren’t double blinded), or the fact that the worms were following the slime trails left by the initial batch of worms.
Even if the experimental results were valid, why would that apply here? By drinking all the flatworms, shouldn’t Olivia have gained flatworm memories, not her own?

2. The Medicine Cabient
Salvia – a native Mexican plant with hallucinatory and dissociative properties. Currently legal in the U.S., but maybe not for long.
Phenothiazine - medically, it refers to a class of antipsychotic drugs derived from the chemical phenothiazine. The chemical itself isn’t really used in medicine, but is used as a dye, insecticide, and livestock dewormer.
Valium – a benzodiazepine. A relaxant and sedative. Addictive.

3. A Bad Resuscitation
How is turning Olivia’s head to the side going to open her airway?
Nitroglycerin relaxes blood vessels and drops the blood pressure. How’s that going to help Olivia?
30cc is a large amount of medication to give. If oral, that’s a shot-glass full of liquid to get down an unconscious person. If intravenous or intramuscular, that’s a hell of a lot to get in. Most IV or IM medications are 1cc or less.
I know I’ve mentioned this before several times (including a previous episode of Fringe), but despite what you’ve seen on Pulp Fiction, shooting adrenalin into the heart is a bad idea. It’s a blind stick and you could easily miss the heart, or worse, rupture one of the coronary arteries and cause a heart attack. There are other options for giving adrenalin: inject it into a blood vessel, or squirt it down the throat.

The story was good, but the medicine was bad, so it’s a wash and the Doomsday Clock stays at five ’til midnight

UPDATE: Oh look, I’ve made a Fringe landing page. It’s plain now, but I’ll fancy it up soon.

A good episode of House, with a nice turn by Thulsa Doom, full of many layers of moral dilemmas. Plus, if you ignore the scenes dealing with the heart, the medicine was pretty good.

Dibala, a brutal African dictator suspected of genocide, is in the United States to address the UN when he suddenly starts coughing up blood (or vomiting blood — it’s not entirely clear). He is admitted to House’s Foreman’s team at Princeton-Plainsboro for evaluation. The team’s initial differential diagnosis includes hemorrhagic ulcers of the lung, an assassination attempt using polonium (suggested by the dictator), and acid reflux. Foreman notices a bug bite on the patient’s hand and thinks he had has malaria. House, on the other hand, thinks the bump is not a bug bite but instead chloracne indicating dioxin poisoning (probably from an assassination attempt). Foreman goes with House’s idea and starts Dibala on Olestra (the same “fake fat” once used in no-fat potato chips. It is thought to increase fecal excretion of dioxin — i.e. it makes you poop more).

Dibala suffers a heart attack. He is started on oxygen, heparin (a blood thinner), and streptokinase (a “clot buster”). He survives, but since the heart is now involved and he has also developed a low grade fever, the team revisits their differential diagnosis. They now focus mostly on infectious causes including Lassa fever, Ebola, Marburg, and trypanosomiasis (African Sleeping Sickness). Once again, Foreman goes with House’s suggestion and starts the patient on ribavirin to treat Lassa fever. Dibala’s staff bring in an expatriate who has survived Lassa fever. They want to use her blood to help treat Dibala (they will presumably inject her antibodies — which would include antibodies against Lassa — into Dibala, providing him with passive immunity). Cuddy agrees over Cameron’s dissent.

Meanwhile, an opponent of Dibala has sneaked into the hospital and attempted to assassinate the dictator. The shots miss, but while evaluating Dibala, Chase notices a right eye hemorrhage. Further evaluation shows that an enlarged lymph node has blocked the retinal vein, leading to the bleeding into the eye. With lymph node involvement, the differential changes again and now consists of sarcoidosis, a Staph infection, and lymphoma. The lymphoma seems the most likely, so a biopsy is checked, but turns out to be completely normal. When Chase and Cameron tell Dibala the results of the test, it becomes clear that he is having problems with his short term memory. House suspects scleroderma is the cause, but Foreman suggests blastomycosis, a fungal infection (the argument here seems confusing to me: Chase says he agrees with Foreman, but then says he doesn’t think it is fungal). This time, Foreman sticks with his choice and starts Dibala on Amphotericin B, an antifungal medication. Cameron begins to have second thoughts that maybe it was scleroderma after all. Some blood tests are run which show that Dibala is positive for anticentromere antibodies (a test for scleroderma). As Foreman points out, it’s not a perfect test, but it does strongly suggest that scleroderma is the cause. Taking this into account, Foreman stops the Amphotericin and starts steroids to treat the scleroderma.

The next time we see Dibala, he is bleeding copiously from his mouth and nose. Chase is using a bronchoscope to look down into his lungs to find the source of the bleeding. He is able to cauterize one bleeding area, but another appears, and then another and another. It is too much for Dibala and his heart stops and he flatlines. Foreman calls for the paddles and the patient is shocked and shocked and shocked and shocked — all the while blood is pouring from his mouth and nose. It’s no use though, Dibala is dead.

After it’s all over, Foreman is mulling over the case and can’t decide what mistake he made. Was he too stubborn, or not stubborn enough? He wants to recheck some tests, but Dibala’s body is locked in the morgue. He discovers Chase visited the morgue earlier in the day and realizes that the blood tests for scleroderma did not come from Dibala at all, but from an elderly patient who died of the condition. Chase had purposefully misled Foreman so that Dibala would get the wrong treatment and die.

The medicine, for the most part (i.e. ignoring the cardiac scenes) was fairly sound. But, oh, those heart scenes dragged it down.As usual, major complaints are in red, minor in blue, nit-picking in green:

I’ve discussed shocking flat lines many times before — and I’m going to do it again — but with a twist: Dibali’s problem isn’t that his heart has stopped, it’s that’s he’s losing massive amounts of blood — which in turn is leading to the heart stopping. No amount of shocking (or anything) is going to restart the heart until the bleeding is stopped and blood replaced. It probably would not have been a bad idea to try some other maneuvers before declaring him dead (epinephrine or atropine, or CPR), but as I mentioned above, it wouldn’t have made a difference unless they stopped the hemorrhage first.

A recent bleeding problem (i.e. in the last six weeks) is a relative contraindication to the use of thrombolytic (clot busting) therapy. In another words, while not an absolute no-no, think twice before doing it. Dibala had some significant bleeding in his lungs just a day or two before — is using streptokinase really a good idea?
Regardless, you don’t give heparin with streptokinase (other thrombolytics, yes, just not streptokinase).
You’d think they’d use a newer thrombolytic at a cutting edge hospital like Princeton-Plainsboro.

You don’t give Amphotericin IV push — it’s too dangerous. Quoting the FDA: “rapid intravenous infusion has been associated with hypotension, hypokalemia, arrhythmias, and shock.”

The incubation period of malaria is at least seven days, usually longer. The mosquito bite mark should have gone away by then.
To be fair to Foreman, it’s quite a stretch for House to consider a single bump on the hand chloracne.

Anticentromere antibodies tend to occur in the more limited, milder forms of scleroderma. This should have given Foreman more reason for pause.

The mirror box is a relatively new technique for phantom limb pain, and while it does show promise, it doesn’t work that fast (it takes multiple treatments) or that completely.

The medical mystery was good this week — lots of unexplained bleeding usually is — though not terribly original. It earns a B+. The final solution generally fit the symptoms, and had a nice twist, so earns another B+. I have mixed feelings about the medicine overall. Most of it was quite good, but two scenes were particularly bad. I wish I could split the score, but I can’t (well, it is my site, so I guess I could — but I won’t), so I give the medicine a weak C. The soap opera was very good. There was House/Wilson, House/Neighbor, House/Foreman, Foreman/Thirteen, Chase/Cameron, Chase/Dibali, Cameron/Dibali, and of course, Foreman/Chase. It deserves an A.

Last week’s House review
A list of all prior House reviews

House Challenge scores have been posted. Pretty much everybody is tied for second this week.

High score for the week goes to TRad with 13 points with Elizabeth second with 12 points.

Overall, TRad is in the lead with 20 points. Kevin Lighton is second with 17 points, and Theta Sigma is third with 4 points. Tied for fourth with 13 points are atg and Elizabeth.

Click here to see the full scoreboard.

I found this the best episode of the season, so far, and one of the better ones overall. There were certainly scientific mistakes, but it was nice to see some of the “police procedural” scenes well done, fo once

The Plot:Officer Gillespie, a policeman in Philadelphia receives a mysterious phone call from the “Colonel” and is told to head to a nearby subway station and stop a man in a black trenchcoat with a black briefcase. When the officer spots the suspect and tries to grab the suitcase, he suddenly begins to crystalize. Gillespie screams in pain, then explodes, killing all around him

The Fringe Team is called in to evaluate the Philadelphia explosion because no evidence of any explosive material can be found. Poking around, Walter finds some crystallized parts of Office Gillespie, and realizes that it was the officer that exploded. He takes the bodies back to the lab for autopsy. As he pieces the crystallized officer back together, he finds needle marks between the toes — Gillespie had been injecting himself with some unknown medication.

Meanwhile, Peter takes the subway station surveillance tapes to one of his contacts, because the tapes all were strangely full of static. Peter’s friend is able to remove a little of the static but not much, so what led up to the explosion of Gillespie remains unclear. His friend speculates radio wave interference caused the static. Later, Peter and Dunham are talking to the officer’s widow when Dunham stumbles across a hidden case consisting of a syringe and a strange injectable medicine.

Across the country, Captain Burgess, once a military officer, now a suburban housewife, is seen injecting herself with the same medication. Later that day, the Colonel appears and tells her she is needed on a mission to Washington D.C. He provides her with airline tickets and hotel reservations.

Dunham and Peter discover that the Gillespie was part of an experimental medical program while he was stationed in Iraq. They travel to Iraq and track down one of the doctors who worked on the program, which was developed to produce an antidote to the chemical agent cyanogen chloride. The experiments weren’t very successful — only four out of 200 patients survived. Plus there was another unfortunate side effect: the serum turned the users into human bombs if they were exposed to a certain radio frequency.

Back in the United States, Broyles in charge of taskforce put together to capture Captain Burgess and the Colonel. They track her to a Metro station in Washington. Peter spots the Colonel and a brawl begins. Dunham is able to shut down the radio signal the Colonel had been sending just in time to stop Burgess before she exploded.

Back in FBI custody, the Colonel tells Broyles that he was trying to stop the “others” — who were planning a war and passing intelligence by a network of couriers. In the end, we see a courier hand a briefcase to the Observer, who opens it to reveal surveillance photos of Walter.

1. A Quick Summation
The idea of a person being turned into an explosive device is clever, but I just don’t see how it would work. Where would the energy of an explosion that powerful come from — even if the person were injecting a strange medication and turning to crystal? I just don’t think there are that many high-energy bonds to break in a human (particularly since the explosion left behind identifiable pieces). Admittedly, this is all “back of the envelope” math so I could be wrong, but color me suspicious.

2. Deus Ex EMP
Does an “EMP disabling device disable” EMPs, or is does it utilize EMPs to disable devices?
If the former, wouldn’t the EMP disabling device itself be disabled by an EMP?
If the latter, how did it know which device to disable or when to activate? It can’t be “always on”.
Regardless, if the device scrambles all radio waves, you wouldn’t be able to listen to the radio or talk on your cell phone inside the station.

3. Moses Supposed his Toeses are Roses
The webspace between the toes is used by addicts to inject drugs because the track marks are harder to find. It is commonly used by medical personnel who are addicted.
Captain Burgess’s injection was horrible as she has apparently never heard of sterile technique. There are nasty germs on the soles of the feet, why invite them into the body?

4. Just Like Detective Comics
Cyanogen chloride is a nasty chemical weapon. It acts as both an irritant (to the skin, mucous membranes, and respiratory tract) and a cyanide agent. Like most cyanide agents, it is quick acting (less than 10 minutes, usually). Treatment involves skin decontamination and use of cyanide antidotes.
With treatment, the chemical is cleared from the body quickly, there would be no need for continuing injections. And even if the soldiers were lied to about the serum, their own NBC training should have raised questions.

5. Video Killed the Radio Star
316 megahertz is technically UHF, not VHF, and falls in the band controlled by the government.

While there was questionable science this week, the episode score points by actually showing some detective work (though mostly by Peter, Dunham — as usual — stumbled into clues) and having an enjoyably suspenseful chase at the end. The Doomsday Clock gains a minute, and goes back to five ’til midnight.

This episode explores what happens when Foreman takes over the team after House quits. And the results are, frankly, dull. The House scenes were good, but the hospital scenes were uninspired. Even the usually humorous theme of “internet medicine is better than real medicine” couldn’t do much more than evoke a tired chuckle

Vince is a game programmer working on a virtual reality first person shooter. He has to drop out in the middle of a gaming session because he suddenly develops a severe burning pain in his hands. He is initially evaluated in the emergency room and told that his nerve conduction studies are normal (so no carpal tunnel) and his bloodwork is negative (which is quite a work-up for the ER). Instead of continuing to work this up as an outpatient, Vince is admitted to the hospital.

Currently, the team consists of Foreman, Taub, and Thirteen. Foreman has taken over the team because House has handed in his official resignation. Cuddy tells Foreman he has one chance to prove to her he can run the team. Looking at Vince’s case, the team suggests diabetic neuropathy (but his HbA1c, a blood sugar test, is normal), hypothyroidism (but no other symptoms match), or complex regional pain syndrome (a difficult to treat cause of chronic pain; previously called reflex sympathetic dystophy). The last one fits the symptoms the best so they plan on treating him with spinal stimulation. When they talk to Vince, he tells them that he has been doing research online and believes that he has mercury poisoning. To placate him, Thirteen draws a mercury level. It is mildly elevated, but nowhere near the toxic level. Nevertheless, Vince still believes that he has mercury poisoning and demands chelation therapy. Foreman steps up and draws the line, informing Vince that if doesn’t want to follow his doctor’s advice, he can do so elsewhere. Vince grudgingly agrees to the spinal stimulation.

The stimulation provides no improvement, and during the procedure, Vince develops a racing heart rate and flash pulmonary edema (the lungs quickly filling up with fluid). Further study demonstrates that Vince has a thickened left ventricle (part of the heart). Lyme disease and cocaine use are the new differential diagnosis. Lyme disease doesn’t quite fit, and Vince denies any cocaine use. Not entirely trusting him, Thirteen and Taub search his office. They find no cocaine, but seeing the realistic rendering of birds in his game, Thirteen suspects he has been in close contact with them and developed psittacosis (also known as “parrot fever,” a disease carried by birds than can be passed to humans). As the team is telling him about the disease, Vince mentions that he is suffering from priaprism — a persistant erection — for the past three hours. The priapism not only requires surgical correction (a shunt), but it also rules out psittacosis.

The new differential diagnosis consists of Guillain-Barre disease (an autoimmune disease of the nerves), thrombocytosis (a disease caused by too many platelets), or a brain tumor. Thirteen favors the tumor diagnosis, but Foreman presses ahead with thrombocytosis, despite Vince having a normal platelet count. He wants to start Vince on hydroxyurea (a medicine used to treat thrombocytosis). At this time, Foreman and Thirteen notice two other doctors — doctors that neither of them recognize — standing next to Vince’s bed. It turns out the other doctors came in response to Vince’s internet postings. Foreman reminds them that neither of them are credentialed to treat patients at Princeton Plainsboro Hospital. One doctor turns out to be a quack, but the other seconds Thirteen suspicion of brain tumor. Vince demands an MRI and Foreman agrees. When the MRI shows no sign of tumor, Vince is started on the hydroxyurea.

Instead of improving, Vince develops massively enlarged cervical (neck) lymph nodes. This should not happen in thrombocytosis. He is started on steroids, which bring down the swelling. Foreman suspects polyarteritis (an autoimmune disease of the arteries), but before the team can act they discover that Vince has posted all his symptoms online and is offering $25,000 to whoever can diagnose his condition. The diagnostic team is inundated with faxes, calls, and e-mails. They confront Vince and tell him that it will take way too long if they have to address every one of the online suggestions (samples include paraneoplastic syndrome, Graves disease, and demonic possession). Vince tells them that he thinks he has amyloidosis, since that’s what most of the people on his site are saying. Foreman agrees to biopsy one of his kidneys looking for amyloidosis, but only if Vince agrees to shut down his website and rescind his reward when the biopsy is negative. Of course, the biopsy is “suggestive” of amyloidosis, and Foreman starts him on dexamethasone (a steroid used, among other things, to treat amyloidosis).

The story isn’t over yet (clearly, as it is has only been 45 minutes), and a short time later Vince is running wild through the halls of the hospital, feverish and hallucinating. Antipyretics (fever reducing medicines such as Tylenol or Motrin) have no effect, so he is placed in a cooling bath. Foreman tells him that Light Chain Deposition Disease (the body overproduces the light chain — part of the antibody macromolecule — and it is deposited in various organs) is the most likely diagnosis, and he will require high dose chemotherapy for treatment. Wearily, Vince agrees. Just as the therapy is about to start, Foreman has his Aha! moment when he realizes that Vince’s fingers never became wrinkled in the bath. This is a sign of Fabry’s disease, a condition caused by the errant deposition of certain lipids throughout the body. His elation is short-lived, however, when he discovers Thirteen has already made the diagnosis and started treatment, based on an internet suggestion she read behind Foreman’s back.

As the episode ends, Foreman is officially put in charge of the team — what little team there is left. Taub has quit to take a surgical job and Foreman just fired Thirteen because he feels he can’t be both her boss and boyfriend. To further complicate matters, House has realized that difficult diagnostic situations are the only thing that keeps his mind off his leg pain and decides to come back to the hospital (after all, it was his suggestion of Fabry’s disease that Thirteen unknowingly used).

I found the medical aspect of the story to be rather uninteresting this week, but whether it was from the weak mystery or lack of House — or both — it’s hard to say. The medicine was haphazard, jumping from diagnosis to diagnosis and lacked the drive most episodes have. Still, there was some logic to it, just not much. Because there wasn’t much medicine, there isn’t much to criticize.

As usual, major complaints are in red, minor in blue, nit-picking in green:

I am concerned that the pathologist could not tell the lipid depositions of Fabry’s disease from the protein depositions of the LCDD and Amyloidosis.

The team couldn’t make up their minds whether to play hard with the diagnostic criteria (no joint pain, can’t be Lyme), or loose with them (sure, you can have thrombocytosis — a disease defined by elevated platelet counts — with normal platelet levels). A little consistency would be nice.

Shouldn’t abnormal lipid deposition in the nerves showed up on a nerve conduction study?

There was nothing about this patient’s initial presentation that required inpatient admission. Almost all the work-up, including the nerve conduction studies, should have been done as an outpatient.

While spinal stimulation seems to offer some relief in many patients with CRPS, it is does not work for everyone, and is generally not the first treatment tried.

The medical mystery was only modestly interesting, and never developed the “this guy is on the verge of dying” feeling that makes these shows interesting; I give it a C. The final solution was logical, and generally fit the symptoms so earns an B+. The medicine was stumbling, and seemed to arbitrarily ignore as many logical diagnoses as it focused it; at best, it was average: C. The soap opera, though predictable, was well done and also earns a B+.

Last week’s House review
A list of all prior House reviews

House Challenge scores have been posted. Pretty much everybody is tied for second this week.

High score for the week goes to Alex Davis with 12 points. Kevin Lighton is in second with 9 points. Bird Gal, Erin, and Kirsten are all tied for third with 8 points. As it is early in the season, these people also are leading the overall House Challenge.

Click here to see the full scoreboard.

More exciting than the last episode, but the “big surprise” was obvious barely halfway in. Charlie is seriously creepy though.

The Plot: A small town in Pennsylvania has had seven people disappear in the past four months. Peter talks Agent Broyles into letting the Fringe Team investigate because he feels it may be related to Agent Dunham’s disappearance. Walter discovers a strange thick blue liquid at the scene of the latest disappearance, and Dunham realizes that one townsman, Andre Hughes, a retired doctor, was at the scene of several of the disappearances.

Peter and Dunham question Hughes at his home. Olivia thinks she hears someone else in the home, but can’t find anyone. She does find a fairly extensive lab in the house. They bring Hughes down to the Boston FBI office for questioning. He answers their questions, but refuses to give a blood sample. Dunham discovers that Hughes’s wife and infant son died in childbirth nearly twenty years before.

Suspecting foul play, the team exhumes the bodies of Hughes’s wife and son. The wife’s body is brought to Walter’s lab for evaluation but there is no body in the son’s coffin. It looks like something chewed its way in — or out. A small tunnel is found leading out of the grave into the ground.

Walter’s autopsy reveals that the late Mrs. Hughes had lupus, which he claims made it impossible for her to be pregnant. Closer examination reveals that she had been pregnant as there is still a placenta present; however, closer examination of the placenta reveals human DNA plus something else, apparently scorpion and mole rat DNA. Walter hypothesizes that Hughes used his knowledge of biology and genetics to alter his son while he was still in the womb — to make it more likely that he would survive the pregnancy.

Peter and Dunham suspect Hughes’s mutated son is still alive and living in tunnels under the town. They search Hughes’s house once again and find the partially decomposing corpse of a dog hidden behind a wall in the basement. They also find a recent tunnel with a dead — and gnawed — human body. Just as Dunham is telling Peter what she found, something grabs her from behind. Peter chases after her and there is a claustrophobic fight in an underground tunnel between Dunham, Peter, and Hughes’s mutated son. Peter stabs it through the chest. It tries to escape, only to be crushed by car that falls into the collapsing tunnel.

As the episode ends, Peter and Walter head of to go fishing, while Olivia meets with a mysterious man at a bowling alley who seems to know more than he is telling about the strange symptoms she’s been having since her trip to the other world.

1. A Quick Summation
This episode of Fringe = 65% The Lurking Fear + 30% Tremors+ 5% The Big Lebowski

2. A Silver Platter
Has then ever been an episode of Fringe telegraphed more blatantly? Who didn’t realize who the killer was, once Hughes mentioned that wife and infant son died in childbirth? The episode could have been salvaged by a climactic ending, but it instead it was over faster than the big boss fight in Transformers 2.

3. My Arm is Tingling Therefore I Cannot Move It
Walter seems to be confusing a paralytic with an anesthetic. Numbness is the sign of an anesthetic; not being able to move is a sign of a paralytic. I can numb your hand with lidocaine, but you’ll still be able to move it. On the other hand, I can paralyze you with pancuronium and you’ll be unable to move, but still feel everything.

4. Where’s House When You Need Him?
While lupus makes becoming pregnant — and carrying the child to term — very difficult, it does not make it impossible.
I’m impressed that Walter can find a malar rash on the skin of a corpse 17 years dead.

5. Dig Them Up
Since when do they open exhumed caskets in the open air, in public?
I would have like to see the search warrant/court order for the exhumation Exactly what information did they have on Hughes? An extremely vague note that may possibly if-you-squinted-your-eyes-right suggest he might have something to do with the death of his wife? He was seen near 3 of 7 missing persons? He, according to his constitutional rights, refused to give blood? He has a chemistry set?

6. String Him Up
That was a time consuming and elaborate way to hang yourself. Why not just use your shirt? What was that wire rack anyway?

Bad medicine, an unoriginal story, and another chimera as the bad guy all add up to the Doomsday clock moving one minute closer to midnight

This was purely a character episode for House, and a pretty good one, at least until it became ridiculously sappy at the end — sappy enough to put a soap opera to shame. There wasn’t that much medicine, which is probably good, because this is a long enough review already.

The episode starts out with a montage of scenes of House locked in a room and undergoing Vicodin withdrawal. Not a very pleasant experience, but he comes through it unscathed.

Now that he has detoxed from the Vicodin, wants to check out of the clinic and resume his previous life. Dr. Nolan, the head psychiatrist of the clinic, confronts House and tells him that he is free to leave, but if he wants the letter of clearance he needs to regain his medical license, he’ll have to attend inpatient therapy. Dr. Nolan points out that it wasn’t the Vicodin that was causing his hallucination, but other deeper problems. Reluctantly, House allows himself to be admitted to Ward Six, the inpatient psychiatric unit.

Dr. Beasley is the young psychiatrist in charge of the unit. Point blank, House tells her that he’s only there until he gets the clearance letter he needs. He threatens to “turn the ward upside down” if he doesn’t get what he wants. He is shown his room and soon meets his roommate, Alvie, a manic depressive (in modern parlance: bipolar) who is in a full manic state because he doesn’t like to take his medications which “bring him down.” (Alvie is a pretty good example of someone who is manic. If anything, he’s more subdued than most manics I’ve encountered.) Alvie introduces him to the other patient including Annie (a mute), Hal (an anorexic), Jay (a claustrophobic) and Richter (a paranoid schizophrenic — probably because he was in all those Revenge of the Nerds movies). They all meet for the first group therapy session, which doesn’t go well, and House finds himself confined to a locked room as punishment.

House rejoins the rest of the patients when they’re outside playing basketball, and quickly turns their psychoses and neuroses against them in order to win the game. House goes back to the ward and encounters Lydia, the sister-in-law of Annie, playing the piano for her. About this time, the orderlies arrive to take him back to the locked room for his behavior on the basketball court.

This time, when House comes out of punishment, he leads a vocal patient rebellion until Dr. Nolan steps in. After things calm down, Steve, a new patient, joins the group. Steve believes that he is a superhero and goes by the name “Freedom Master.” House decides his best bet to get the clearance letter he needs is to find something incriminating on Dr. Nolan and blackmail him. He sends Alvie up to his office, but he can’t find anything. He sneaks a phone call to Wilson, but he refuses to help him.

Now House’s plan is to cooperate, or at least to fake it. He pretends to take his pills and is, to all appearances, getting better and more social. A third psychiatrist, Dr. Medina, wants House to provide a urine sample to prove he is taking his medication. House is ready, though, and has Hal waiting in one of the bathroom stalls to provide a sample. Sure enough, the sample shows evidence of psychiatric medication and Dr. Medina is satisfied.

A little while later, Dr. Medina strolls onto the Ward and confronts Steve about his delusions and the fact that he doesn’t really have superpowers. His extremely confrontational approach angers House, and he becomes even more concerned finding Steve medicated to the gills a short while later. Dr. Nolan steps in. He pulls House into his office and reveals that he knows House has been faking. He had only been getting sugar pills, so his urine should have been clean. Having a positive drug test was proof that he was faking.

Lydia visits later that day, bringing Annie’s old cello. House has Steve help her get the heavy instrument from the car, hoping it will bring back his old super-heroic feelings. Next, he decides that he and Steve should take a ride and he “borrows” Lydia’s car. He takes Steve to a nearby carnival where they have one of those “skydiving over a giant fan” rides (would that really work out in the open like that?). Both he and Steve have fun soaring, and it seems to bring Steve out of his funk — so much so that once again he believes that he has superpowers, and he jumps off the parking garage to prove it.

Steve survives his plummet, but just barely. He has a lacerated spleen and multiple bone fractures. Nolan confronts House and tells him that he is going to transfer him to another psychiatric facility. House is shocked by what happened to Steve and clearly feels guilty. He asks Nolan not to transfer him and promises to comply with his therapy.

House and Nolan start regular one-on-one counseling sessions. He is also started on an antidepressant (an SSRI — serotonin specific reuptake inhibitor. This is a class of antidepressant/antianxiety drug that includes Prozac, Paxil, Zoloft, Celexa, and Lexapro). Nolan takes him to a charity dinner so he can mingle and learn to trust people. Lydia is there, and the two of them have a good time lying and pulling pranks on the other attendees. At the end of the night, she kisses him. Nolan tells House that the night was a success because no one tattled on House’s lies, therefore he can trust other people– which seems a painful stretch of logic to me.

Lydia comes back to visit the next day, but the return of the severely injured and now catatonic Steve to the floor puts a damper on whatever may have happened between her and House. Nolan tells House he needs to apologize to Steve, but he can’t bring himself to do it.

Meanwhile, Dr. Beasley announces that there is going to be a talent show and wants everyone to participate. During group session, House receives an urgent note from Nolan. He meets him at the hospital where Nolan’s father lies in a coma. Nolan tells House that the doctors have told him there is no chance of recovery, but he wants a second opinion. House looks at the CT scans and tells Nolan that his father has had a catastrophic hemorrhagic stroke and agrees that there is no chance of recovery. After being confrontational at first, he pulls up a chair and sits by Nolan as he holds his father’s hands.

Returning to the ward, he finds Lydia by herself crying. One thing leads to another and they end up having mad passionate sex in the office. (Ask anyone: locked ward insane asylum love making is the best kind.) At the talent show, House ends up helping his roommate Alvie rap by stepping in and helping when he starts to stumble over words.

House finally finds the strength to apologize to Steve. He starts to wheel him to group therapy when he notices that Annie is looking down at a music box Steve is holding. He slows down and Steve hands the box to her. She accepts it and opens it.
“Thank you,” she says — the first words she has spoken in ten years.
“You’re welcome,” replies Steve. His first words since the accident.
(And this ridiculously maudlin moment is where all forward plot momentum was lost and along with it, most of the good feelings I had about the story).

Since she is no longer mute, Annie is discharged to an out of state rehabilitation facility. The rest of her family, including Lydia, is going with her. House gets a pass from the hospital and goes to confront Lydia. She tells him that she doesn’t want to leave, but she must because she doesn’t want to break up her family. Nearly broken, House returns to the psychiatric hospital where he encounters Dr. Nolan. Nolan offers to write him the clearance letter he needs — not out of pity — but because House has shown he can change: he cared enough about somebody else to get hurt, and he turned to Dr. Nolan for help when this happened, not Vicodin. The next day, House leaves the hospital and hops on a bus back to his old life.

Not much non-psychiatric medicine this episode, so no major complaints. Minor ones are in blue, nit-picking in green:

Confronting someone with a delusion as strong as Steve’s the way Dr. Medine did is not going to work. Logically, you would think that showing someone that their beliefs are wrong would break the delusion — but by definition, delusions aren’t logical. The mind is very facile and will find a way to keep the delusion despite the evidence. For instance, Steve might now say, “My powers didn’t work because no one was in danger. They only work if there is a lady in distress.” Dr. Medina should know this.
And if you do choose to confront him that way, you don’t do it in public.

Why on earth would you give oral Haldol (a strong anti-psychotic medication. Also a tranquilizer) to someone who’s agitated. First you’ve got to get them to swallow the pills, then you have to wait for them to take effect. It’s much faster just to use injectable Haldol.
And that brings up the ethical question of whether this is an appropriate use of Haldol (my answer: no).

A nitpick here, but House is shown to be receiving 15MG of an unnamed SSRI. It seemed that House was only taking a single pill, but no SSRI comes in that strength. It could be Lexapro, which comes in 10MG, and 15 is a common dose, but that would take a pill and a half

No medical mystery this week, so no grade for it or the final solution. The medicine overall was pretty good, at least until the miraculous cures in the end. I’ll give it a solid B. The soap opera was good — at leas the House part — because it wasn’t as maudlin as Annie, Steve, and Alvie. House’s soap opera gets an A- (everyone else gets a C).

A list of all prior House reviews

House Challenge scores have been posted. Pretty much everybody is tied for second this week.

Because there was little — if any — medical mystery this week, the scores were resoundingly low. The only real mystery was why was Annie mute, and why did a music box make her better — a music box that had been sitting on the shelf in the nurses station for who knows how long.

I did give 3 points for the diagnosis of “stroke” in Dr. Nolan’s father, giving it the weight of a clinic patient. Of course, only one participant even suggested stroke, so RGM is the leader with a whopping 3 points. Everyone else is tied for second with 0 points.

Click here to see the full scoreboard.

All in all, a rather unexciting way to start the season. Though, to give the writers credit, they are just starting what seem to be several intriguing plotlines.

The Plot: The episode starts out with head on collision between two cars: a silver one and a black one. A wounded man stumbles out the silver car and runs down the street. He hides in a nearby apartment building and kills man who tries to help him. He then uses a strange machine to change himself into an exact replica of man he killed.

The black car is identified as Agent Dunham’s, but she is nowhere to be found and the evidence suggests no one was in the car at all. Peter and Walter arrive on scene and find a junior FBI Agent Jessup in charge. Walter jimmies the lock of the car open and looks around. As he leaves the car, it suddenly turns on and Agent Dunham comes crashing through the windshield and onto the road. She is rushed to the ER in critical condition. The doctors do everything they can, but Olivia remains in a coma (or maybe brain dead, the writers can’t make up their mind). Later that night, Peter comes in to sit by her, and Dunham suddenly regains consciousness and shouts a line of Greek at him. She has no memory of what happened other than she met with someone somewhere and there is something important she has to do or everyone will suffer.

Peter, Walter, and Agent Jessup team up to track down the driver of the silver car who they determined was purposefully trying to hit her car. Finding a body that matches the driver of the car, only more decomposed than it should have been, they bring it to Walter’s lab for autopsy. The examination reminds Walter of an old experiment he did (what doesn’t?), and he plays a tape of an old ESP project. The subject of the experiment warns of a soldier from another world who has the ability to shapechange, just like the one they are facing now. Belatedly, Peter and Agent Jessup realize the soldier still means to kill Olivia, so they rush to the hospital. Meanwhile, the soldier has killed and taken the appearance of Dunham’s nurse; he tries to weasel some information from her, but when he is unsuccessful, he starts to suffocate her. A couple of bullets from Agent Jessup send the nurse running but Charlie manages to catch her. There are some more gunshots, and when Peter and Agent Jessup arrive, Agent Francis is standing over the nurse’s dead body. Agent Dunham is safe and the soldier from the other world is dead — but is that that what really happened?

1. They Canceled ER, Didn’t They?
A sloppy ER/hospital scene.
“Possible brain herniation” — that’s a secondary diagnosis. What’s causing the brain to herniate? She’s probably bleeding inside the skull from the trauma, which in turn forces the brain down.
Pupils non-reactive — but are they dilated or fixed?
Blood pressure 180/20. Can one really measure of diastolic pressure of 20, particularly in an ambulance? 160 is quite a wide pulse pressure.
Instead of telling the EMTs to “prep her” when she is coding, how about actually doing something about it — like starting CPR?

2. Brain Death or Coma?
Olivia’s sister implies they are going to take Olivia off life support in the morning. What life support is that? Her heart is beating and she is breathing on her own. This isn’t brain death; it’s a coma. There is nothing to stop.

3. It’s All Greek to Me
For the record, here’s what Agent Dunham said: Einai kalytero anthropo apo ton patera toy

4. Eye See You
You can hear the cardiac monitor speeding up, but yet her heart rate on the machine remains the same at 72, a normal reading. While a beta-blocker would lower the heart rate, her heart’s not going fast enough to need one — and you risk dropping the pulse too low.

5. Silent Lividity
A short time after a person dies, their red blood cells settle to the lower parts of the body since there is no longer a working heart to pump them around. This results is a purplish discoloration of the skin which is known as livor mortis, or lividity. It starts at about 1-2 hours, and reaches its maximum at 6-12 hours. It persists after that, but becomes masked by other changes of decomposition. So all it could really tell Agent Jessup was that the victim had been dead around 6-12 hours; nothing to indicate he couldn’t have been in a car accident the day before.

6. Unpalatable
I think they’re confusing the palates. The soldier seemed to be putting the nail-plate directly behind the teeth, which is the hard palate not the soft palate (which is father back in your mouth than you think: feel the roof of your mouth all the way back until it switches from hard to soft).

7. Her Father Wasn’t in Intelligence, Was He?
It takes Agent Jessup several hours after they learn that they are dealing with an enemy soldier to suddenly realize that he is still going to try to kill Agent Dunham? I see she has the making to be just as incompetent an investigator as Dunham herself was last season.

UPDATE: I forgot to mention the “cocktail” Walter mixed to help him sleep. Sleep, hell, that concoction would knock out an elephant! It contained Valium (diazepam, an antianxiety drug with strong muscle relaxant and sedative properties), Haldol (haloperidol, a classic antipsychotic drug which is also a strong tranquilizer), Seconal (secobarbital, a barbiturate and another strong sedative), and lorazepam (Ativan, another drug from the Valium class). Unless he has developed one heck of a tolerance for these drugs, Walter should have been asleep for the rest of the show, if not the entire season.

Though it introduced a new hero, as well as a spooky new villain, the episode was rather “meh”. The medicine was pretty bad, but I’ll give them credit for the typewriter scene, which was cool. The Fringe Doomsday Clock remains where it ended last season, five minutes ’til midnight.

Welcome to Polite Dissent, my medical/television/comic book blog.

For medical reviews of the television show House, this is the best place to start. Reviews of the new season will start on September 21st, with the first review posted a few hours after the season opener airs.

For medical review of comic books, stroll through the archives, or start here. A look back at the classic medical comics of the ’50s and ’60s can be found during my annual Flashback Weeks.

Finally, for some true stories of medical training, look here.

Season Six of House starts two weeks from today on September 21st, so it’s time to begin this year’s House challenge.

It’s free, it’s fun, it’s easy. Here’s how to play:

Make a list of ten conditions or diseases you think will show up on HOUSE. Be as specific as possible: no categories (like “cancer” or “autoimmune disease”), and no overly broad descriptions (“liver failure” or “cardiac arrest”, for instance). The list you make will last the remainder of the season — no addition, subtractions, or swaps. Put your list in the comments section.

Each week, your list will be compared against the show. Scoring is as follows:

1 point for a brief mention or one-liner.
3 points if the team actually tests for the condition.
3 points if your diagnosis is featured in a clinic scene (or other side plot).
5 points if the team treats the condition (or supposed condition).
12 points if it’s actually the correct final answer (or one of the answers) of the episode.
Please note: If your diagnosis is close, but not specific enough (for example “meningitis” when the team tests for “viral meningitis”) you will earn 1/3 the points.

Scores will be collated each week and a running total will be kept. Scores will be posted as soon as possible (my goal is by late night the day of the show, but it may take longer depending on how much real life intrudes). After the final episode of the season, a winner will be crowned!

To play the full season, your list must be posted in the comments section by 7pm (Central time) September 21st — the night the season starts. Later entries are accepted and will start accruing points the following week.

The spam filter likes to hold on to these lists, so if yours doesn’t appear right away, don’t panic. If it’s been at least six hours and it still hasn’t shown up, drop me a line and I’ll hunt it down.

Here are last year’s final scores.

To get things started, here is my list of ten predicted diagnoses for the upcoming season:

In addition to watching the television show Fringe, I also read the Fringe comic published by WildStorm. The comic takes place years before the show, and features two stories per issue — one a continuing story featuring scientists Walter Bishop and William Bell, and a second stand alone story. This post is about the continuing “Bishop and Bell” storyline, the third chapter in particular.

When we meet William Bell in the first issue of Fringe, it is 1970 and he is a twenty year old college student at Harvard. He meets up with Dr. Walter Bishop and becomes his lab assistant.

The next issue takes place at some undetermined point later. Dr Bishop and William Bell are still working in a lab at Harvard. There is reference to experiments the duo performed “last year.” William Bell is also referred to as “Dr. Bell” which suggests he has had time to complete not only his undergraduate degree, but also his doctorate. Depending on how much credit you want to give him for being a genius, that would make it 4 to 8 years later, so the story takes place sometime between 1974 and 1978.

Why is this important? Because the timing seemed off to me — and it turns out I was right:

Neurontin is the brand name of Gabapentin, a drug originally developed to prevent seizures. Gabapentin wasn’t discovered until 1973 and was an experimental drug for years after that, so it’s unlikely that the doctors would be able to get there hands on any. Even if their mysterious “Soap Company” benefactors somehow managed to obtain a supply of the medication, it wasn’t known as Neurontin until 1983.

I’ll also point out that injecting serotonin into the body is not a good idea. It doesn’t cross over from the blood to the brain well (which one assumes is where they want it), and it acts as a potent vasoconstrictor (causes the blood vessels to clamp closed) in the bloodstream. High levels of serotonin in the blood have been linked with fatal lung and heart conditions.

Injecting LSD into the body — probably not the best idea either, but for different reasons (mainly due it being a potent hallucinogen). Speaking of LSD, it’s the chemical structure the worker holding the clipboard is looking at in the second story in issue #3.

For episode 24, Theta Sigma and EmilyH (the second one) had the high score with 9 points.

The episodes with the highest scores were 22, 16, and 17.
The lowest scores were episodes 2, 3, and 9.

Full scores are available here.

A good season finale for Fringe. Lots of mysteries were tied up, or at least explained, but enough were left for next season to explore.

The Plot: Nina Sharp has been shot by David Robert Jones and is rushed into surgery. Agent Dunham and her team review the surveillance tapes and notices that Jones did something to Sharp’s bionic arm. After she recovers from surgery, she tells them that he stole an extremely powerful power cell that had been hidden there. Sharp tells Dunham that Jones was once an employee and protégé of William Bell, and he was fired for reasons she refuses to articulate. She goes on to tell Dunham that Jones is hunting for Bell so he can kill him. If Dunham can stop Jones, though, Nina will guarantee her a meeting with the elusive Bell. Nina goes on to explain that Bell is currently living in an alternate dimension, and Jones is trying to travel to that dimension to pursue him. Pulling all the “x-files” the FBI has, Dunham is able to come up with a pattern to the “Pattern” which points to Reiden Lake as the epicenter.

Meanwhile, Jones has set up a strange machine in a New York City street. It emits a high pitched whine, and then open a shimmering doorway into another dimension. A truck comes barreling through, but is cut in half when the unstable doorway closes. Jones later tries the same trick on a soccer field, but this time an unfortunate player is cut in half. He heads to Reiden Lake to try a third time.

Over in Massachusetts, Walter has gone missing. Peter tracks him to an old beach home the family owns. Digging through various boxes, Walter finds what the Observer sent him to locate: a machine that plugs dimensional holes. He and Peter head for Reiden Lake, because Walter tells Peter that’s where he opened the first doorway.

Dunham’s team meets up with the Bishops, and together they confront Jones. He has opened his doorway and is about to go through when Dunham shoots him, again and again. He shrugs off the bullets, explaining that while the radiation from the teleporter may be slowly killing him, in the meantime, it has made him more than human. He finally enters the doorway, but Peter uses Walter’s machine to shut the gate, cutting Jones in half and killing him.

As the episode ends, Walter stands tearfully over a grave labeled “Peter Bishop, 1978-1985″ — so the Peter we know must be the Peter from the alternate dimension. Olivia finds herself transported to the alternate world where she meets with William Bell in his office in one of the towers of the World Trade Center.

1. I’m As Shocked As You
The medicine in the emergency room scene was pretty spot on, so no complaints from me there.

2. It Keeps Going and Going and Going
I like the way Jones was being particularly careful with the energy cell, like it was on the verge of exploding. Meanwhile, Nina had just schlepped it around in her arm, swinging it this way and that, not careful at all.

3. Flight 19, Where Are You?
“The Pattern” works best when it is all fictional. Trying to work in the Bermuda Triangle just cheapens it for me — especially as all good skeptics know, there is no real mystery there at all.

4. A Little Dry
I’d expect more blood out of people cut in half.

5. You Must Learn To Govern Your Passions; They Will Be Your Undoing
There is little Leonard Nimoy can’t add a touch of class gravitas too — well, except this (and this).
Actually, I was expecting more from him. It sounded like he was on the verge of cracking himself up.

A good episode. I liked that it actually answered some questions, which was frankly more than I expected. Of course, there’s still a bunch left for next year. Anyway, it was a good episode — good enough to move the clock back to 11:55

A perfectly serviceable episode of House – for the middle of the season, anyway. As a season finale, it was a bit of a let down (until the last five minutes, that is).

Scott is a 20 year-old who has undergone surgery that cut his corpus callosum (the part of the brain that allows the left and right sides of the brain to communicate) to treat a seizure disorder. The seizures have resolved since the surgery, but he has subsequently developed Alien Hand Syndrome, where he has no control at all over his left hand and it seems to have a mind of its own. He is at a restaurant on a date, complaining of bland food, when his left hand starts throwing rolls at an obnoxious diner at another table. A fight ensues, and before the melee even starts, we notice blood dripping from his eye.

Scott is admitted to House’s service for evaluation of his bloody tears and loss of his sense of taste. The initial differential diagnosis includes autoimmune disease, nasolacrimal tumor, infection, or the common cold. House has Taub and Thirteen search Scott’s apartment and they find mold growing on the ceiling in his bathroom. They decide this is the cause of his symptoms and start him on anti-fungal medication. About this time, Scott has a fight with his girlfriend, his left hand slapping her, and she storms out. He tries to follow her out but finds that he cannot walk. The differential now consists of dehydration or a meningioma (the most common tumor of the central nervous system) — only it’s a special meningioma that is allowing the two sides of the brain to communicate again. Instead of running an MRI or CT scan to look for the tumor, they run a test to see if there is communication between the left and right brain. The test is negative, but House notices that Scott is shivering. He also detects an ammonia scent to his breath and sees a caput medusae on physical exam, all signs of liver failure. House suspects the liver failure is due to sarcoidosis and has the team perform a liver biopsy. While performing the biopsy, Thirteen sees splinter hemorrhages (a sign of trauma or tiny blood clots) under Scott’s fingernails. He then takes a sudden turn for the worse, vomiting blood while his oxygen saturation and blood pressure drop.

The team now decides that Scott has a clotting issue, and start him on heparin (a blood thinner). An echocardiogram is normal, so the heart isn’t the source of the clots. They’ve also run tests for Factor V Leiden, Protein C, and Protein S (all things that can cause a clotting disorder), but they’re also negative. Thirteen now recalls his mention of always being sweaty and wonders if that might be a symptom of whatever disease he has. Cancer is thought to be the most likely, particularly lymphoma or pancreatic cancer. House strongly suspects the latter, even when an MRI of the pancreas is normal. He has Chase perform a new test where scorpion toxin and infrared dye is painted on the pancreas and will light up any cancer cells. There isn’t any sign of cancer, but once again Scott starts to develop a dangerously low blood pressure. House now realizes that the clotting problem is caused by his heart throwing off clots, but only when he slips into an arrhythmia, which he does under stress (like surgery or a biopsy), or every now and then. Sure enough, Chase checks a transesophageal echocardiogram and finds an abnormal rhythm and clots in the left atrial appendage. The heart throwing clots explains most of Scott’s symptoms, but what explains the heart condition? The new differential includes rhabdomyolysis (muscle disease), Graves disease (an autoimmune disease that causes too much thyroid hormone to be produced), and Cushing’s Syndrome (a condition where the body makes too much cortisol, a steroid). The Cushing’s seems the most likely, and a dexamethasone suppression test is ordered. About this time, Scott’s girlfriend returns and points out that his left hand only seemed to get “agitated” when Scott’s deodorant was involved. It turns out to be a special deodorant that Scott has to special order. Taub checks on it, and sure enough, one of the ingredients has been shown in one case to cause a heart condition and therefore this is decided to be the cause of Scott’s problem. End of case. Taub also notes ironically that the chemical has been implicated in seizure disorders, and maybe Scott had not needed the surgery in the first place.

As usual, major complaints are in red, minor in blue, nit-picking in green:

Patient has neurological signs (loss of his sense of taste, inability to walk) and they even suspect a brain tumor, yet they never check a CT or MRI of the brain?

The liver failure, particularly the varices and caput medusae, developed way too quickly — or else they’ve been there for a while and the team did a piss-poor physical exam.

It caught my attention when the script was vague about propylene glycol causing “heart problems.” From what I can find, it can cause arrhythmia, particularly bradyarrhthmias (abnormally slow heart rates) and QRS abnormalities. I don’t see any connection between it and atrial fibrillation, the arrhythmia that would cause Scott’s symptoms (again, left unnamed in the script).

The patient is crashing in the OR and no one thinks to look at the cardiac monitors?

I was surprised how quickly the team accepted that propylene glycol caused his problems and just stopped there, other more likely causes left untested for.

While giving blood thinners to someone with a clotting disorder is a good idea, they might want to think twice about giving it to someone with bleeding esophageal varices (at least I assume he has them, that’s the only thing that fits and can explain the vomiting blood).

Chlorotoxin-based (scorpion venom) tumor paint has been used in animal models, but I’m not sure it’s been tested in humans yet. It seems like an extreme step to take though. One of the first things I was taught (and taught loudly) on my surgical rotation was “don’t mess with pancreas” — though the language was more colorful.

So a clot to the brain caused the lack of taste , but what caused the bloody tears?
And don’t tell me “subconjunctival hemorrhage,” that was an embarrassingly bad suggestion of Taub’s.

I like that the writers finally acknowledge that storylines are often built on single case reports (not that there’s necessarily anything wrong with that).

The medical mystery was mediocre, and they never explained one of the opening symptoms. His underlying condition (Alien Hand Syndrome) was more interesting that the mystery: C. The final diagnosis fit the symptoms, or at least the main ones, it just seemed the team accepted that the deodorant caused it too easily. I give it a B. The medicine overall was superficial and rushed, but not horrible. I give it a weak B. The soap opera was the highlight of the show, particularly the end scenes with Cuddy and Wilson and earns the show an A in this regard (though shouldn’t Cuddy have been mad that House lied to the clinic about sleeping with her, and not just yelled at him for discussing her sex-life?).

Last week’s House review
A list of all prior House reviews

For episode 23, Catesby had the high score with 12 points.

Overall, with just a single episode remaining, The Erskine retains a strong lead with 82 points. Ron remains in second with 72 points. Ash is in third with 71 points. Dogma-Central, Nekolux, and TRad are tied for fourth with 66 points.

Full scores are available here.

A rather unexciting episode of Fringe overall, despite several clever plot concepts. Definitely a “sum of the whole is less than the parts” week.

The Plot: A young woman is desperately trying to get to a hospital when she suddenly catches fire and explodes. Agent Dunham and her team are called in to investigate. Through dental records, they are able to identify her as Susan Pratt, a 29 year-old toll booth attendant. They search her apartment and find a large check made out by a mysterious lawyer, a lawyer whose office seems hurriedly deserted. Walter initially suspects spontaneous human combustion, and then deduces that Susan was a pyrokinetic (think Firestarter) who could not control her own powers.

Meanwhile, Agent Dunham is having recurrent hallucinations. Walter tells her that she is experiencing déjà vu, which he explains are visions of an alternate reality. The next time Dunham has one of the hallucinations, she investigates and discovers that in this reality, Susan had a twin sister Nancy. Sure enough, in our reality there is a twin sister too, and Olivia’s team rushes to Nancy’s apartment, but she has been kidnapped. Luckily, Peter has invented a machine that can pull sounds from an apartment window which was melted during the kidnapping. Uncovering the sound of a phone dialing, Olivia is able to trace a call made to Sanford Harris’ phone (if you can’t remember, Sanford Harris is the new a**hole boss at the FBI who took over earlier in the season). She and Charlie track Harris to a warehouse where he and the lawyer have locked up Nancy and are experimenting on her. In the final confrontation, Nancy is rescued and Harris burned alive by her pyrokinesis.

The episode ends with a variety of short scenes: Olivia confronts Walter about the experiments he and Walter Bell performed on her and other children, Nina visits Broyle to discuss the reappearance of the Observer, Walter discovers the missing original ZFT manifesto just as the Observer walks in and tells him it is time to go, and Nina is shot by masked men in her apartment building.

1. Walter’s Reality, Quite Different From My Reality
A myth is an unverified fact? I’m sure Zeus would be happy to know he’s factual, merely unverified.

2. Again and Again
That is an interesting explanation for déjà vu. Just saying.
Would Robert Frost approve?

3. Too Close a Look
There are so many things wrong with Peter’s electron microscope/Geiger counter/mp3 player. Here are just a few:
Electron microscope samples have to be specially prepared.
At electron microscope level, there would be so many natural grooves and bumps in the surface of the glass that it would have tremendous background noise. Even an LP or CD at that level of detail would have so many imperfections it would be hard to hear the actual sound.
A flash fried window captured that much sound?
Peter was somehow able to reproduce the sound perfectly down to the exact voices and tones of a dialing phone?

4. Irony
I had to laugh when Walter told Olivia she was a good investigator — she’s anything but. For instance, she missed the entire closet full of gray clothes and the check from a mysterious lawyer that all tie into the emotion spewing guy from episode 17.

5. Y Kant Olivia Read?
Olivia is a cornflake gal. Is that anything like a Cornflake Girl?

A plainly mediocre episode. Not bad enough to advance the clock, but not good enough to gain some time. (With just one episode left, it is extremely unlikely the Doomsday Clock will run out…this year at least. Fringe has been renewed, so I’ll continue the clock next year.)

I wanted to like this episode of House, I really did, but the absolutely horrible medical care just wouldn’t let me.

There is an accident during a ballet recital, and 21 year-old ballerina Penelope drops to floor, gasping for breath. She is admitted to House’s service and found to have lungs that “keep collapsing” despite the use of chest tubes. Supplemental oxygen can only raise her oxygen saturation to 60%. The team reports that there are no tumors is her lungs and no evidence of any lung punctures. There is also no bruising, trauma, or evidence of sexually transmitted diseases. Her white blood count and temperature are normal, ruling out pneumonia. House suggests a pulmonary contusion, but it is pointed out that her CT scan was normal. He then decides that she is dehydrated and this is masking her pneumonia, so he orders her started on intravenous fluids and antibiotics.

When Penelope fails to improve on the antibiotics, House wants to do a more invasive test to look for the pneumonia. He is told her lungs can’t tolerate a bronchoscopy, so House decides on a transtacheal aspiration. As always seems to be the case, there is a complication during the procedure. This time, her skin starts sloughing off — not just a little bit, but almost all of it. An autoimmune disease is suggested as a cause for the skin problem. House tells them that he is suspicious a liver tumor has caused the lung problem (by eroding into the lungs). Furthermore, he tells the team that her skin problems is toxic epidermal necrolysis — caused by the antibiotic they gave her.

An ultrasound shows a liver mass. The team can’t perform a standard liver biopsy because without her skin, she is at an increased risk of bleeding out. Instead, they go with a transjugular approach. They obtain the liver biopsy and it is negative for cancer, but she is knocked into the abnormal heart rhythm atrial fibrillation. Wilson suggests giving her metoprolol to lower the heart rate, but Foreman rather brusquely shoves the idea aside. The team has apparently decided that the atrial fibrillation must be caused by something within the heart itself, and want to get an MRI of the heart to get a closer look. Unfortunately, the very atrial fibrillation they are concerned about means that they would be unable to get good results from the scan (the heart would be beating too rapidly and irregularly to get a clear image). They decide to stop her heart, take the MRI, and then restart the heart. To prevent brain damage, there is a strict 3-minute deadline. Foreman thinks he sees something in the aorta, but by then the three minutes are up and the MRI is halted.

House agrees that Foreman saw something in the aorta. The differential now includes tumor, scar tissue, or abscess. Looking at Penelope’s boyfriend, House thinks he is spending so much time with her because he feels guilty, so House deduces that the boyfriend must have given her gonorrhea, which led to an abscess in her heart. The boyfriend is tested and sure enough, he has gonorrhea — only he got it from her and not the other way around. Meanwhile Penelope goes into septic shock and they can’t operate to remove the abscess until she’s stabilized. The team decides to give her dopamine (a medication used to raise the blood pressure in critically ill patients) in order to stabilize her. It works, and Chase is able to remove the heart abscess, but unfortunately the dopamine has cut off the blood flow to her hands and feet and they are turning black and starting to die (dopamine can cause occlusive vascular disease). Chase recommends that she has them amputated, but she refuses. After a fair amount of bickering among the team, Taub decides to go with the Hail Mary pass of injecting her with vasodilators to open the closed off blood vessels. Miraculously, it works and her hands and feet are saved.

House’s hallucination of Amber persists. He tells Wilson what is going on, in a round about way, and insists it must be sleep apnea — but he knows it isn’t, because the symptoms don’t fit at all. A sleep study is normal; no apnea. He has a blood test to look for infection, but it is negative as well. He decides the guilt he is feeling about causing the patient to develop TEN is a symptom of multiple sclerosis, but the tests for MS are all negative. He is down to two causes for the hallucinations: schizophrenia or his Vicodin use. He knows schizophrenia doesn’t really match, but he wants it to be that instead of the Vicodin. But eventually House realizes it must be the Vicodin causing his problems and asks Cuddy to help him go through the unpleasantness that is narcotic withdrawal, because she knows him best and won’t let him get away with anything.

As usual, major complaints are in red, minor in blue, nit-picking in green:

It’s not clear to me exactly what caused Penelope’s lung collapse that started the whole business. Was it the heart abscess? The show more or less implied it was, since the team felt that solved her problem, but I don’t know how a heart abscess would cause her lung(s) to repeatedly collapse.

They might have been able to raise her oxygen saturation above 60% if they took her off the nasal canula and used a proper oxygen mask instead.

In this episode, the writers are having a bad case “having your cake and eating it too” in terms of Penelope’s heart abscess. The abscess that is walled off, sealing the bacterial infection away from the rest of her body, making it much harder to detect and treat. However, despite being walled off, the abscess is able to:
Cause septic shock
Deflate the lungs

When we talk about dehydration hiding a pneumonia, we’re talking about the x-ray. An infiltrate (the sign that appears on x-ray showing a pneumonia) does not show up well in a dehydrated patient. Give them some IV fluids, repeat the x-ray, and boom — there’s the infiltrate. Dehydration does not mask the other symptoms he mentioned (temperature, white count — if anything, dehydration will falsely elevate the white count).

You cannot draw a “Vicodin level”. You can draw an acetaminophen (Tylenol, paracetamol) level, but not an hydrocodone level (the two drugs which make up Vicodin). Wilson could have been talking about high acetaminophen levels (which causes irreversible liver damage), but his tone and presentation suggested he was talking about the narcotic component.

The time course of toxic epidermal necrolysis makes it more likely the condition was caused by Penelope’s use of medication (say non-steroidal anti-inflammatory drugs for sore muscles from ballet) than by any antibiotics she received in the hospital.

Lack of overlying skin should not prevent a standard liver biopsy since it doesn’t decrease her blood’s ability to clot. (You could argue that it should be avoided because it would raise the risk of infection, and I’d buy that, but that’s not what they mentioned).

While I agree the heart monitor was showing a narrow complex tachycardia, it didn’t look like atrial fibrillation to me (way too regular a rhythm, for one).

Speaking of atrial fibrillation, I would have liked them to look a little harder at other causes (say thyroid) before immediately deciding it was something within her heart.

While metoprolol controls the rapid rate of the atrial fibrillation, it doesn’t covert it to a normal rhythm. There are other medications that can do that.
I’m not an electrophysiologist, but whenever I’ve seen someone’s heart stopped electrically, they’ve used internal leads, not external paddles.

A “negative ANA” does not magically rule out all autoimmune diseases. Plenty of people have an autoimmune disease without a positive ANA.

A transtracheal aspiration involves a needle, a tiny catheter, and saline. There is no knife — nothing needs to be cut!

Did they ever convert her out of a-fib, or is she still in it (or did removing the abscess clear that up)?

I assume they put her on a heart-lung machine during surgery, but it would have been nice to mention, since they made such a big deal out of stopping the heart earlier.

Eye protection in surgery, team.

The medical mystery was okay, or it would have been had they stayed with it (I’m still wondering what caused her lungs to collapse), so I’ll give it a B-. As I’ve mentioned above, the final diagnosis doesn’t really fit the presentation, or her complex of symptoms. It earns a D. The medicine overall? Well, take a look at the sheer length of this week’s list of concerns and tell me how it can earn anything other than an F. The soap opera was good, but I feel it could have been better. Still, I’ll give it a B+.

Last week’s House review
A list of all prior House reviews

UPDATED:
This week, Nekolux has the high score with 22 points.

Overall, with just two episodes remaining, The Erskine continues in the lead with 79 points. Ron is in second with 69 points. Ash and Dogma-Central are tied for third with 65 points, which leaves George to round out the top five with 64 points.

Full scores are available here.

They almost made it for a complete episode without screwing up the science…almost.

The Plot: Strange murders have been occurring in Boston, murders where the victim has their spinal column ripped open and have been drained of spinal fluid. Agent Dunham and her team are called in after the second murder. While examining the body, Walter finds traces of Treponema pallidum, the bacteria that causes syphilis — only it’s a variety of syphilis that has been extinct for decades. They trace the syphilis to the CDC who note that they recently sent a sample of that very syphilis to Lubov Pharmaceuticals. The CDC also mentions that the same research lab ordered RND-390, a component of the rapid skin growth bioweapon seen previously.

Olivia and her team raid the lab — only it’s not a real lab, just a split-level house in a residential area. They arrest a wheelchair-bound scientist named Boone and bring him in for questioning. He admits to working for the ZTF and having developed the rapid skin growth weapon, as well as playing a role in whatever is terrorizing the city now. He tells Dunham that he will help her, only they need to rescue his wife who was kidnapped by the ZTF to ensure he keeps working for them. Eventually, Boone admits that his wife is not a hostage, but has been dosed with a contagion that has turned her into the killer stalking the city. If Dunham and her team can capture his wife, he will concoct an antidote and then tell Dunham everything he knows about the ZTF.

Dunham, Peter, and Charlie capture the wife and brings her back to the lab where Walter and Boone have concocted an antidote. The cure is a success, unfortunately Boone died of a stroke while making it. He leaves a videotape for Dunham naming names. He doesn’t know much, but reveals to her that the money man behind ZTF is William Bell.

1. Free Samples
The CDC is a little free with their germ samples, aren’t they? Particularly the bioweapon ones.
And they know the lab is in a residential area, but don’t seem to think twice about it.

2. It Goes to Eleven
How does giving cerebral spinal fluid to his wife going to cause Boone to become paralyzed? If that’s the case, then everyone who ever had a spinal tap would be in a wheelchair.

3. FBwhat?
Astrid gets the “Only Agent Actually Investigating” Award for her finding-the-club-stamp moment.

4. Billy Squire
Taking too much spinal fluid is not going to cause a stroke; if anything, it’s going to cause a herniation (the brainstem is pushed downward over sharp bony prominences and damaged — and not in a good way). At the least, it’ll give him a nasty spinal headache.
Because it’s not a stroke, the medication tPA (tissue plasminogen activator, a “clot busting” drug) is not going to do any good. And even if it were a stroke, tPA is not necessarily a good idea. If it is a stroke caused by a clot, then tPA is indicated, but if it is a stroke caused by bleeding in the brain, then tPA will make it worse. There are very specific rules about giving tPA to minimize the risk of bad outcomes.
Regardless, you don’t stab someone in the neck with a syringe of the medication.

5. K.I.S.S.
Why inject the antidote into the spinal column at the cervical spine (neck level)? It’s a tough shot, and runs a risk of injuring the cord. Since the CSF circulates throughout the spinal column as a whole, injecting the medication at the lumbar level will have the same effect, only be easier and less risky.

Everything was going for this episode, and I was going to move the clock back again, but then they started talking about stroke and tPA and lost all benefits. The clock stays in place this week.

An episode of House with some decent medicine this week. There was also a bachelor party and House may be slowly going insane…

Seth Miller is a fourteen year old who has been deaf since he had meningitis at the age of four. He is a high school wrestler and is competing in a wrestling match when he suddenly screams and clutches his ears, where he is now hearing painfully loud explosions.

Seth is admitted to House’s team. Foreman immediately rules out “the usual suspects:” insomnia, migraines, and head trauma. House suggests it is temporal lobe epilepsy and sends Seth to the seizure lab where they try to induce a photosensitive seizure with flickering lights. He suffers no seizures, but loses the vision in one of his eyes. The team now suspects it is subclavian steal syndrome (blood that should go to the brain goes to the arm instead) and wants to perform an angiogram. House agrees, then has a conversation with himself and decides that Seth has optic neuritis. He interrupts before the angiogram can be performed and shows that Seth has neuropathy (he cannot feel the vibrations from the boombox in his hands, but can elsewhere in his body). The differential now includes increased intracranial pressure (ICP) from a brain tumor, or rhabdomyolysis (a muscle disease, in this case felt to be caused by losing too much weight for wrestling). House disagrees at first, but then changes his mind, deciding that Seth must have neurofibromatosis (neurofibromatosis, type 2 — i.e. NF2 — to be precise) tumor in his brain. An MRI is obtained and shows no tumor, but it does show a bulge in the wall of the fourth ventricle that was not present on an MRI from several years earlier. House thinks the bulge represents a tumor and has Chase perform a biopsy. House also has Chase install a cochlear implant while the patient is undergoing surgery.

Seth now develops a fever. The team suggests a post-operative reaction, an Arnold-Chiari malformation, pseudotumor cerebri, or Epstein barr virus. Foreman, who’s in charge now, favors that latter and starts Seth on ribavarin. Seth now develops urinary incontinence, which makes the team rethink their diagnoses. They suggest sarcoidosis, glomerulonephritis, and pheocromocytoma. House, after another conversation with himself, believes the problem to be heart related and wants a four-hour EKG on the patient. Foreman ultimately relents, but the heart study is normal. The team now suggests it may be Hashimoto’s Thyroiditis. House wants to continue studying the heart, but Foreman chooses to go with ordering a thyroid panel. House decides to induce an arrhythmia in the patient with some asthma medications, but when he arrives at the room to perform the dastardly deed, he discovers that Seth has pulled out his cochlear implant and in the process knocked himself into an arrhythmia, saving House the effort. Thrombocythemia is suggested as a possible diagnosis as is a pulmonary embolus. House tells Foreman that Seth is experiencing the Uthoff phenomenon, a sign of multiple sclerosis, and has him start him on interferon.

Everything goes well at first, and Seth is improving, but then he goes into “lung failure” and needs to be intubated and placed on a ventilator. This means multiple sclerosis is the wrong diagnosis. Eosinophilic pneumonitis is suggested. Hoarseness is a hallmark of this condition, so Foreman goes to check if Seth is hoarse. He is not, but while there, Foreman notices tobacco stained teeth and Seth admits to chewing tobacco in the past. This is enough to let Foreman know that Seth has sarcoidosis. When he was chewing, the immune suppression from the tobacco kept it in check, but now that he has stopped chewing, the sarcoidosis has flared up.

As usual, major complaints are in red, minor in blue, nit-picking in green. I didn’t really have any big complaints tonight, just blues and greens:

The medicine was fairly good, but also fairly superficial tonight. There was a great deal of jumping from half-hearted diagnosis to half-hearted diagnosis and abandoning previous diagnoses at the drop of a hat (you can have glomerulonephritis without brown urine, and eosinophilic pneumonitis without hoarseness). The whole heart arrhythmia thing was essentially a red herring and it didn’t affect the speed of the final diagnosis at all (now if they had gotten an echocardiogram, or at least a good look at the heart — which they usually do after an unexplained arrhythmia — they would have noticed granulomas and made the correct diagnosis earlier. Funny how they skipped that step this week.)

House’s prescription bottle read “Zolpidem” (i.e. Ambien, a reasonable choice for a sleeping medication), but then it said 200MG (the dose of zolpidem is 5-10MG. It doesn’t come in 200MG, after all, that’s twenty times the highest recommended dosage). The bottle also read “take three times a day.” Zolpidem is only to be taken at night. What’s the point of taking a sleep aid 3 times a day?

Seth must have been chewing an awful lot of tobacco to suppress his immune system enough to suppress the sarcoidosis.

How accurate are MRIs and CTs at determining ICP, particular the subtle increases seen in tonight’s episode? I thought the opening pressure of the lumbar puncture was the best way to determine ICP — though IANAN (I am not a neurologist).

Lung failure — not a common medical term at all. Respiratory failure would have been a better choice.
Why didn’t the sarcoid granulomas show up on the chest x-ray?

Not all seizures can be induced with flickering lights, only people with photosensitive seizures.

How can you tell is someone who is just extubated is hoarse? Intubating, extubating, and being on the ventilator can all cause hoarseness.

MRIs aren’t used to diagnose a broken nose.

The medical mystery itself was good this week and deserves a B. The final solution fit, but the tobacco-suppression was was quite a lucky coincidence; I give it another B. The medicine was pretty good, though the reasons to choose and discard diagnoses seemed more superficial (and incorrect) than usual. It earns a B-. The soap opera was excellent. I enjoyed the look at how House’s subconscious worked, and using Amber’s ghost to play that part was perfect. The bachelor party was well done too, I particularly liked how he held in it Wilson’s apartment. A.

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A low scoring episode this time, with Cheryl and FlowerPower tying for the high score with 6 points for the week.

Overall, The Erskine maitains the lead with 63 points, while DrBoy remains in second with with 57 points. Ash stays in third with 55 points, and Dogma-Central drops to fourth with 53 points. Ron moves into fifth with 52 points.

Full scores are available here.

A surprisingly enjoyable episode this week. The science mumbo-jumbo was kept to a minimum and storyline kept moving quickly along.

The Plot: A mother is pushing her daughter in a stroller through Grand Central Station singing a song about a circus elephant. As they wait by the tracks for the next subway, Olivia suddenly appears and pushes the mother in front of the oncoming train, killing her. Olivia suddenly wakes from her sleep with a start, realizing she had dreamed the whole thing — until she sees the report of the suicide on the morning news.

Olivia and her team go to New York to investigate the death, but the evidence — including a surveillance tape — point to suicide. Her husband, however, pleads to Olivia that his wife would not have committed suicide. Walter suggests that possibly Olivia somehow compelled the woman to jump.

Olivia decides not to go back to sleep. She takes caffeine pills and drinks cup of coffee after cup of coffee. She finds herself in a restaurant full of happy couples. Suddenly, one of the wives starts accusing her husband of philandering and stabs him repeatedly with a steak knife. Olivia is beside her, helping her drive the knife in. Again, Olivia wakes up with a start — she has dreamed of another death. Investigating at the restaurant where the stabbing took place, the owner tells her a blond man with a scar was sitting in the booth she had dreamed herself sitting in. Reviewing the tape of the New York suicide, a blond man with a scar was there as well.

A search of governmental databases reveals that the man in question is named Nick Lane and was once a resident of St Jude’s Mental Hospital, until he came into a sudden inheritance and checked himself out. He also seems to have been familiar with the mysterious ZTF manifesto. The staff psychiatrist describes him as “hyper-emotive” — someone whose mood influences those about him. Looking through the patient’s chart, Olivia discovers that he was treated with the experimental drug Cortexiphan — the same drug she was once treated with. Walter reveals that during the Cortexiphan experiments, children were paired to reduce their anxiety. He suggests that Olivia must have been paired with Nick and a mental bond developed that allows her to dream what he is seeing. Thanks to the Cortexiphan and his unstable mental state, Nick is broadcasting his emotions to those around him. When he felt suicidal, the mother picked up his emotions and committed suicide. When he felt abandoned, the wife picked up his feelings and stabbed her husband.

Walter places Olivia under hypnosis in an attempt to locate Nick. They are able to find Nick’s apartment, but not before he has lured a stripper there and caused her to commit suicide. By the time the team reaches his apartment, Nick is already gone. Exploring his place, they find an entire wall dedicated to the Pattern. About this time, news reaches them that Nick has been spotted. He has gone to the roof of a tall building nearby and is prepared to jump to his death. He’s not alone though, his emotions are spilling so much that there are about twenty other people on the roof with him, also ready to jump. Walter tells Olivia that because she was also treated with Cortexiphan, she will be immune to Nick’s powers. She climbs to the roof and confronts him. He remembers her from the experiment, but she doesn’t remember him. He hands her a gun and asks her to kill him. She shoots him in the knees instead — he collapses and it releases his hold on the others. He tells her regretfully that someday soon, she’ll wish she had killed him. As the episode ends, Walter is watching an old videotape of the Cortexiphan experiments — a tape featuring a very young Olivia.

Not too much science to dish on in tonight’s episode, so I’m just going to go stream of consciousness here.

1. Circus Circus
According to Wikipedia, Nellie the Elephant is a perfect song to sing in order to time CPR correctly.

2. The Count
For something that was supposedly not detecting any radiation, the Geiger counter was certainly clicking a fair amount.

3. Showtime
Walter wants to see Pippin, a musical about Charlemagne’s deformed son, Pippin the Hunchback. The song he is quoting is Corner of the Sky.

4. Stripper or Not
Continuity error: When the stripper is first shown looking in the mirror in Nick’s apartment, she is topless. When the scene flashes back to her, she’s suddenly wearing a bra (what can I say, I’m a guy — I notice these things.)

5. Torre! Torre! Torre!
Just for the record: Walter mentions Nick was using the Torre attack when playing chess. Who was he playing?

6. Clues?
Thanks to some recent articles on the clues in Fringe, I’m looking for them everywhere now. I saw the light pattern in the windows in Walter’s hotel, but now I’m wondering about the 7 of clubs shown prominently on Nick’s table.

7. Continuity
Nice to see the some of the threads begin to tie together — particularly the Cortexiphan and the ZTF manifesto (both from Episode 14)

8. The Wall
I would have loved to have time to study the Pattern wall in Nick’s apartment.

An enoyable episode this week, that restores some of my faith in the show. The Doomsday clock goes back to 11:56

This episode seemed to have potential — strange creature from lab released by animal rights activists that proceeds to terrorize the countryside. But then the bad science and awkward storyline kicked in.

The Plot: A group of animal activists break into a research lab and frees all the animals from their cages. They also release a particularly nasty creature hidden in the back of the lab. The monster shows its gratitude by promptly killing one of the activists and a scientist who tried to stop them. It then hunts down and kills the other activists as they are fleeing in an SUV.

Agent Dunham and her team are called in the next morning when the wrecked car and shredded bodies are found. One of the dead bodies is moved back to the lab where Walter performs and autopsy and finds a stinger of some sort buried in the body. He also finds hundreds of larval worms in the body, apparently implanted by the creature. Unfortunately, by this time Charlie has encountered the monster and been attacked. He survived, but has become implanted with the larvae as well.

Walter has deduced that the monster is a transgenic animal — composed of the genes and attributes of multiple species. He is worried that it may be based on his work because he experimented with transgenics years before. For once, the “science” turns out to be unrelated to his research.

Walter theorizes that the only way to kill the larvae inside of Charlie is to transfuse him with some of the monster’s blood so that the larvae will get confused and stop feeding on him. The team traps the monster in the sewers and kills it, but they collect enough blood to transfuse Charlie and save his life.

1. Worry Wart
After all the other episodes where the plot was based on Walter’s research, why is he suddenly worried about the morality of it. Plenty of people have died because of his work already this season.

2. Blue Genes
Transgenic animals have been used in research for years. They are animals that express genes from other sources, or express specially modified genes. Walter seemed to be talking about transgenics taken to a whole new level — plus he was confusing it with xenografting (transplanting parts from different animals) with his talk about rejection.

“Accelerated Darwinism”
A nonsense phrase and a particularly stupid one at that. The theory of evolution applies to natural selection, and the selection here was man-made, pretty much the opposite of natural..

3. Keep the Needle Away From Me
Astrid is told to draw 25cc of blood from Charlie and she sticks the needle in the belly? She might get some peritoneal fluid, but the big blood vessels are deep in the abdomen. Why not just draw blood from the arm like a normal person?

4. Lucky Shot
Where was the incendiary part of the incendiary 50 caliber rounds? And wouldn’t incendiary rounds have made it that much more difficult to get blood from it.

5. Ultra-Special
That was impressive resolution on that out of date ultrasound machine. Even more impressive was how the picture stayed perfectly still despite Walter waving the wand all over Charlie’s chest. (That last sentence should get some interesting Google searches)

6. The Belly of the Beast
So the idea was that by giving Charlie some of Mama Monster’s blood, the baby monsters would get confused (in that “can’t tell self versus non-self” way), and thus miraculously die off (cause of death? Confusion.) So how did the proteins on Mama’s blood cells get into Charlie’s peritoneal fluid so fast, if at all? Why not just inject an anti-parasitic into the peritoneal fluid, thus bypassing most of the side effects Charlie would suffer.

7. Random Thoughts
Apparently the monster has either blue curaçao or Windex for blood.
Johnathan Swift?
Clearly Walter missed Aliens when he was in the asylum or he would have known to look up.

Another week of bad science, and characters acting, well, out of character. The Fringe Doomsday Clock gains another minute and stands at 11:57 (meaning that all the gains from the good episodes before the break have been lost).

A mystery with potential, an interesting patient (in an annoying sort of way), and good soap opera all marred by very sloppy medicine (but at least they got the defibrillation right this time).

Doug is an environmental activist who starts the episode chained to a giant bulldozer. After being forced to leave, he stumbles around and discovers that he is unable to walk or even stand up. He sees a variety of specialists, but no one can cure him, so he is transferred to Princeton Plainsboro and admitted to House’s team.

Cameron tells the team that the “tox screen” is negative, and that there are no neurological, muscular, or cardiovascular abnormalities. House has Cameron perform a vestibular caloric test (irrigating cold water in the ear canal and monitoring any resulting nystagmus — eye twitching) to test his inner ear — the test is normal. Foreman suggests that Doug may have carotid atherosclerosis (hardening and narrowing of the carotid artery, leaving Doug at risk for stroke) worsened by stress. House orders a Holter monitor and a carotid doppler, both of which are normal. While performing the procedure, Cameron discovers that Doug has a serious case of the hiccups, and has had them on and off for a week. She realizes that his hiccups are somehow tied in to his condition. She suggests that he may have organophosphate poisoning from spending time protesting at commercial agricultural warehouses (organophosphates are commonly found in commercial insecticides). Taub counters that multiple sclerosis is a more likely diagnosis. House agrees and orders a lumbar puncture to test for the disease.

Cameron is having difficulty performing the spinal tap on Doug because he keeps moving when he hiccups. She gives him some chlorpromazine (better known as Thorazine, a potent antipsychotic which can be used to treat intractable hiccups). Then Foreman notices some swelling in his neck. At first, Cameron thinks it is torticollis (a severe muscle spasm) caused by the chlorpromazine, but House points out the neck is not just stiff but swollen. It also crunches when he touches it, a sign of crepitus, or air in the subcutaneous tissue. In this case, it comes from an “air leak between the lungs.” Sarcoidosis is suggested, but so is scleroderma, and House chooses to go with the latter, starting Doug on intravenous steroids.

Doug is lying in bed, wheezing (and this wheezing is never really mentioned or even addressed), when he develops a sudden excruciating pain in his left leg. The team decides it is likely osteomyelitis (infection of the bone) after deciding it is not a tumor, aneurysm, or metabolic bone disease. He is started on intravenous antibiotics and x-rays of the left leg are obtained. Surprise, surprise — the x-ray shows a fracture of his left femur. Cameron suggests it may be due to osteogenesis imperfecta (an inherited bone disease), but House is convinced it’s cancer. He wants to start Doug on chemotherapy. Meanwhile, Chase is surgically repairing the broken leg (because he’s an orthopedic surgeon this week), and Foreman asks him to obtain a bone biopsy at the same time. The biopsy is clear, showing no cancer. Unfortunately, Doug has bleeding problems after the surgery, with bleeding from the leg wound and purpura (a skin discoloration that is commonly seen in platelet disorders, vasculitis, and coagulation disorders) showing up on the other leg. Foreman orders 2 units of FFP (Fresh Frozen Plasma).

House is still convinced Doug has cancer and wants to proceed with total body irradiation. Instead Taub suggest that they give Doug Insulin-like Growth Factor, which should make the cancer grow larger, and thus they’ll be able to find exactly where it is. It should really come as no surprise that House agrees with this dangerous and unethical plan. About this time, Doug goes into pulseless ventricular tachycardia and needs several shocks to resuscitate him (and defibrillation is the right idea in this situation). An echocardiogram is normal, as is the troponin level (a blood test that is elevated after a heart attack). House and the team are stumped, stymied, and stuck. They have no idea what is happening to Doug. House decides to implant a defibrillator while they try and deduce what is going on. Then he his has his weekly Eureka! moment talking to Wilson. Despite being fervently anti-commercial-florist, Doug broke down once and bought his wife some roses after missing their anniversary. He caught sporotrichosis (a fungal infection) from those roses, and that’s what’s caused his problems.

As usual, major complaints are in red, minor in blue, nit-picking in green:

There are hundreds, if not thousands, of different kinds of cancer. Different types of cancer require different types of chemotherapy. What works for one cancer may not work for other cancers. There is no generic “chemotherapy” that treats every cancer — you need to know what type of cancer you are treating.

Similarly, total body irradiation only works on certain cancers — the blood and lymphatic cancers, primarily.

How exactly did the sporotrichosis make Doug unable to walk and start this entire situation? Are they suggesting he had a sportrichosis-related meningitis (a known, albeit rare, possibility), that didn’t have any affect on his mental status? They probably should have gone ahead with the lumbar puncture.

Cameron announces that Doug is free from cardiovascular disease, yet is quickly testing for carotid atherosclerosis — a cardiovascular disease.

A Holter monitor is a portable heart monitor that patients wear so that their heart rhythm can be recorded while they go about their normal daily business. It would be redundant in the hospital where all of House’s patients are already hooked up to heart monitors.

If Doug is bleeding out so much that he’s weak and fainting, a transfusion of blood might be a good idea in addition to the fresh frozen plasma.

Pulmonary sporotrichosis (from inhaled fungus) is a distinctly different form of the disease than cutaneous sporotrichosis (from superficial penetrating trauma), which is what House is describing.

His femur is broken, but everyone is focusing on and looking at his calf.

I’m suspicious that defibrillating ventricular tachycardia would be enough to raise the troponin level, at least a little bit. (From what I can find, the jury is still out on this: studies suggest defibrillating atrial arrhythmias doesn’t do much to the troponin, but multiple shocks in ventricular tachycardias do affect it).

The medical mystery itself was good again this week and deserves a B+. The final solution almost fit, but should not have been as significant a puzzle as House’s team made it, I give it a B-. The medicine was very sloppy, and even the smallest amount of research would have shown that “generic” chemotherapy was wrong. The medicine earns a D, and that’s probably generous. The soap opera was good, with Cuddy, Wilson, and Cameron/Chase all having their moments. I give it a B+.

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For Episode 20, DrBoy had the high score with 15 points.

Overall, The Erskine holds on to the lead with 58 points, while DrBoy makes a strong push and ends up in second with 54 point. Ash and Dogma-Central are tied for third with 52 points. Harvey rounds out the top five with 50 points.

Full scores are available here.

Big spoilers in the write up of this week’s episode of House, so don’t read it until you’ve watched the show. Overall, the medicine was good, though I would have liked to have seen more of it.

This was really an episode with a split personality. Half the episode was spent on Kutner, and only half was spent on the patient (or in this case patients) of the week. While Kutner certainly deserved the time he received, I think the medical mystery got short shrift as it had some really nice twists and turns that would have benefited from receiving more time.

Eddie is dying of lung cancer related heart failure, and is under hospice care at home. Sensing his time is near, he asks to be alone with his wife Charlotte to give her a final goodbye. In the midst of their tearful farewell, Charlotte suddenly begins gasping and struggling to breathe before collapsing. Shocked, Eddie struggles to sits up and calls out for help.

Charlotte is admitted to House’s team for evaluation of her acute respiratory failure. Her history is unremarkable except for a trip to Hawaii six months ago with her sister. Foreman suggests she may have contracted melioidosis (a tropical disease that was the culprit in episode nine) there, but the idea is dismissed in favor of Taub’s suggestion of varicella zoster (the virus that causes chicken pox; it can cause a nasty pneumonia if contracted as an adult). House wants her started on acyclovir (an antiviral drug that’s good against varicella), but she refuses treatment because she wants to be with her husband. She reports that he seemed to get better when she became sick, so it appears she will be able to spend more time with him before he dies. Taub solves the problem by wheeling her husband’s bed into her room so they can stay together.

Charlotte gets better with treatment, but Eddie starts to decline again. A short time later, Taub is called to the bedside when Charlotte starts gasping for breath. The respiratory technician tells him that her oxygen saturation is normal and it doesn’t appear to be her airway. Her lungs are normal on exam, and her heart rate, though rapid, is regular. Once again, Eddie gets better when he sees Charlotte sick. Her cardiac enzymes were normal, so that makes a heart problem unlikely. House rules out a mitochondrial disease because the vision is normal. The team then suggests a metabolic disease causing acidosis or polyserositis. House likes the latter suggestion, so starts Charlotte on indomethacin (a potent anti-inflammatory drug).

Unfortunately, Charlotte doesn’t improve on the indomethacin. Eddie, on the other hand, continues to show subtle signs of improvement. Deciding that polyserositis was the wrong diagnosis, Taub considers then quickly discards Wegener’s Granulomatosis (a disease that commonly affects the lungs and kidneys), Byssinossis (“cotton worker’s lungs” or “brown lungs” — a lung disease caused by a bacteria that lives in cotton), and mitral valve stenosis. House decides that there is only one likely diagnosis, so heads to Charlotte and Eddie’s room and confronts her. He tells her that since Eddie is improving while he is worried about her, she is faking being sick so that he will continue to improve. Grudgingly, she admits that House is correct, then she screams, complaining of left leg pain. House is doubtful, but when he examines the leg he sees muscle atrophy and petechiae, he realizes that something is truly wrong with her.

Multiple sclerosis seems a likely diagnosis, so she is sent to get an MRI of the brain to look for the telltale signs of the disease. She passes out while undergoing the procedure and is found to have a ruptured spleen. While Chase is performing an emergency splenectomy, Taub wants him to look for signs of rheumatoid arthritis. He doesn’t find any, but he does find that her liver is scarred, so whatever she has is getting worse. The team discusses and discards the diagnoses of autoimmune hepatitis and amyloidosis. House suggests alpha-1 antritrypsin deficiency (an inherited disease that attacks the liver and lungs) and orders the appropriate test (AAT). Eddie has an echocardiogram which shows he still has very severe heart failure with only a few days, at most, to live. Meanwhile, Taub has a conversation with Charlotte where she tells him that if she dies before Eddie, she would like him to get her heart for transplant. A short time later she is found seizing on the floor — she had broken into the crash cart and injected herself with all the medication she could find. She is resuscitated, but her liver has taken more damage from the drugs and she only has about 24 hours left to live. In the meantime, the AAT test has come back normal. Thirteen now suggests that Charlotte may have myelofibrosis (a disorder of the bone marrow), but mentions that the test for it takes longer than Charlotte has to live. House’s first idea is to lie to the transplant committee and say that Charlotte has myelofibrosis so she can get a liver transplant. But then he has a more devious idea. He wants Eddie to give Charlotte a partial liver transplant. Of course, a partial transplant won’t help Charlotte for long, but House understands this. He also knows that Eddie is so sick it is unlikely he will survive the surgery and will almost certainly die on the operating table, thus leaving an entire liver to transplant into Charlotte. House convinces Cameron, the “incurable romantic,” to discuss this with Eddie. He agrees to the surgery, fully realizing that he will die during the surgery, and understanding that he is dying so that his wife can receive his liver and survive.

Cameron tells House that Eddie has agreed to his plans, but she also mentions that she noticed nodules on his hands and suspects his heart failure may be caused by something other than lung cancer. House investigates and sure enough, Cameron was right. Eddie doesn’t have lung cancer, but instead a fungal infection (blastomycosis) that caused lung nodules that were mistaken for cancer, and then caused his heart failure. It is a curable disease, but Eddie is having none of it and refuses treatment — he wants to die for Charlotte so she can have his liver. Across the hospital, Charlotte is doing worse. Her fever is spiking and the lumbar puncture shows bunches of white cells (a sign of infection). Taub mentions that she is “infected everywhere.” Still unsure of her diagnosis, the team considers sarcoidosis and scleroderma. Taub then makes a comment about guilt and love, and House has his Eureka! moment of the week. It turns out that Charlotte was lying about her trip to Hawaii. She really snuck off the Rio with some other guy, and while there she contracted visceral leishmaniasis (a nasty parasitic infection of the organs, i.e. the viscera). She is started on antimony for treatment and a transplant is arranged, but it is tool late and Charlotte dies with Eddie by her side.

I don’t have any huge medical complaints this week, other than the ethics of the partial (wink, wink) liver transplant — I’m surprised Cameron agreed to go along with it. Sure, she’s the romantic, but she also been shown to have the strongest sense of ethics.

As usual, major complaints are in red, minor in blue, nit-picking in green:

Why did she improve on the acyclovir if her symptoms were caused by leishmaniasis?

House was discarding diagnosis left and right for incorrect reasons. For example:
No vision problems, can’t be mitochondrial. Wrong!
Normal thyroid, can’t be autoimmune hepatitis.Wrong!

Severe blastomycosis (like that causing heart failure — a rare situation) needs a stronger medication than Itraconazole.

It would be easier to diagnose rheumatoid arthritis with blood tests than a splenic biopsy.

It doesn’t take 48 hours to test for myelofibrosis.

Most of the suggested diagnoses fit the case better than usual this week (though most still required quite a bit of stretching); on the other hand, they also skipped over a bunch of possible causes — more than usual — probably due to lack of time.

I thought the scenes relating to Kutner were well done. His death seemed very abstract at first as it occurred off camera and the way they just showed the his legs and trunk through the doorway lent it an air of unreality. I liked the way they showed how the situation affected each character, and everyone reacted differently, though ultimately within character.

I’m sorry to see Kal Penn leave the show. He should be proud though: between playing Kutner, Kumar, and appearing in the last Superman movie, he’s completed this nerd doctor’s trifecta.

With the eminent thespian Meatloaf playing Eddie (who shares a name with the character he played in the Rocky Horror Picture Show), I hope you know how hard it was for me not to make any Bat Out of Hell Jokes in tonight’s write up.

Well, just one: Kutner may be gone, but Taub and Thirteen are still around and Two Out of Three Ain’t Bad.

The medical mystery was good, though would have benefited from the full time, not just the half it got. It deserves an A-. The medicine was sketchy in places, but fit the symptoms better than usual and earns a B. The final solution was clever and (mostly) logical, and earns another B. The soap opera was the star of this episode, and was very good. I give it an A.

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