Polite Dissent

House shows some heart in tonight’s episode, unfortunately, he seems to have left his brain at home.

A teenager presents to the Princeton-Plainsboro Hospital clinic complaining of some difficulty breathing. All she wants is an inhaler for her “asthma” but House correctly recognizes that she is homeless and the man with her isn’t really her father. What really piques his interest is when she starts bleeding from her ear. He mentions that this is a sign of a skull fracture, but can find no fracture — or any other cause of the bleeding — so he admits her to his service. The team’s initial diagnoses focus on her homelessness and consist of drug use, malnutrition, or HIV. Chase goes further and suggests she may have a squamous cell cancer of the middle ear with paraneoplastic syndrome, while Taub, backed by Adams, suggests a possible cerebral (brain) infection, probably pneumococcus. House agrees with Taub and Adams and starts “Jane Doe” on ceftriaxone (a potent antibiotic).

Adams and Park check out Doe’s school — where she is doing quite well — and also check out her address on record with the school, which is a foreclosed home she has fixed up. Looking around the house, Adams finds a few beers and some mold. She now suspects Doe has a fungal infection and starts her on fluconazole (an antifungal medication). Upset that the team went behind her back digging into her history, Doe tries to leave, but collapses as soon as she gets out of bed, complaining that she “can’t feel her legs” (her symptoms are later identified as paralysis, which is different from the paresthesia she was complaining of).

Looking over her symptoms of ear bleeding, problems breathing, and lower extremity paralysis, the team’s new differential diagnosis is transverse myelitis, endocarditis with septic emboli, or the fairly vague “vasculitis” (inflammation of the blood vessels). House goes with the vague and starts the patient on steroids to treat the presumed vasculitis. Initially, she is doing better on the steroids, but then things quickly go to hell. Her estranged mother shows up, identifying the patient as Callie, and in the middle of the confrontation, Callie begins coughing up blood. Different diagnoses are considered based on where the blood may be coming from (respiratory or gastrointestinal source). Chase suggests she has a sinusitis and a bleeding disorder, and Adams suggests Zollinger-Ellison syndrome (a condition where the patient has a tumor which secretes gastrin, which causes the stomach to pump out too much acid). House thinks Adams has the better idea and orders an EGD (upper endoscopy), which reveals bleeding ulcers in the esophagus; unfortunately, this doesn’t fit any of the diagnoses discussed. The team now considers the diagnoses of HPV (human papilloma virus), alcohol-induced esophagitis, or a berry aneurysm of the brain. House thinks it is the aneurysm and wants a quick cerebral angiogram followed by surgery before the aneurysm has a chance to rupture, which would rapidly kill her. Adams favors the alcohol theory — Callie does admit drinking an occasional beer — and Callie’s mother agrees with Adams and decides to forgo the angiogram and surgery. Callie seems to be doing well and is actually talking with her mother when she suddenly falls unconscious. Coudl she have had a berry aneurysm which burst? Was House right? She is rushed to the OR suite for the cerebral angiogram, but no aneurysm is detected. Her blood pressure begins to plummet and the team buys time with some pressors (medications that increase blood pressure), but still don’t know what is wrong her. Brainstorming, Adams first suggests cancer, then recalls hearing about a trip Callie took to Florida two years before and wonders is she may have contracted dengue or cholera. House (rightfully) scoffs at those, then after learning Callie went swimming in a freshwater canal while in Florida, correctly diagnoses her with ascariasis (a parasitic worm infection). After Callie is treated, she sneaks out of the hospital to be on her own again, still unwilling to trust her mother. (I’m assuming she snuck off to the Disney Channel, where she was able to find a much happier family).

As usual, major complaints are in red (red caduceus), modest complaints are in blue (blue Vicodin), and nit-picking ones in green (green pencils):

House dismisses Adams suggestions of dengue and cholera by pointing out the two year gap between exposure and symptoms, but then diagnoses ascariasis, which has precisely the same problem. The worms would not have sat quiescent for two years, not when they had their preferred environment, no matter what the fancy graphics at the end showed.
I’ll grant that ascariasis can cause pulmonary symptoms and gastrointestinal symptoms (because the worms travel intestines to liver to liver blood flow to lungs, then up the trachea, and swallowed back down to the intestines). Ears (and even if they could get to the ears, how were they causing bleeding? Drilling a hole?)? Brain (and yet not be visible on CT scan)?

Ears should not bleed. House looked in Callie’s ear and said it was normal. I would expect him to see a bleeding source (such as a scratch, cyst, infection, etc) in the canal, or a hole in the tympanic membrane which would let blood from deeper in the ear out into the canal. He mentioned neither of these – so how could there be blood?
Other than Chase’s mention of squamous cell cancer of the ear, none of the diagnoses mentioned are going to cause ear bleeding, particularly ear bleeding that looks normal on exam. For example, Zollinger-Ellison? How is a gastrin-secreting tumor going to cause ear bleeding? Callie only has four symptoms, and Adams still skips one in her diagnosis

Taub’s phrasing “cerebral infection” was a odd. He seems to be suggesting meningitis — for which pneumoccocus is a common cause and ceftriaxone a good choice of medication — but that doesn’t fit with Adams comment about lack of fever. You would expect a fever — and meningeal signs — with meningitis. They could possibly be referring to a brain abscess, but that would have shown up on the CT, and pneumococcus (and thus the choice of ceftriaxone) much less common.

No vaccine is 100% protective, and Callie could still get pneumococcus even after being immunized. Plus, the vaccine only covers a handful of different pneumococcus serotypes (admittedly the most common), and she could have been infected with one of the serotypes not covered by the vaccine.
Why would Adams, who doesn’t believe much of what Callie says, believe a shot record to be true? Callie likely forged or lied on her school shot records. It’s not like her parents really signed it.

When Callie stands up and collapses to the floor, she complains she can’t feel her legs (paresthesia). That’s different that an inability to move her legs (paralysis). It’s possible she has both and can’t move or feel her legs, but then the most common complaint would be that she couldn’t move her legs, not that she couldn’t feel them.

PPH is in for some tough times. In the past two weeks, they’ve let two patients escape– two they should have been watching closely. Last week, a patient with Alzheimer’s (known to be elopement risks), and this week, a minor left AMA, a minor with a history of running away.

I found the medical mystery to be more interesting than usual this week, because the symptoms were quite disparate. I give it B. The final solution was a let down, because it couldn’t really explain half the symptoms (and the most interesting half at that); it deserves no more than a D. The medicine was very sloppy this week, with many of the diagnoses not explaining all the symptoms — and there were only three or four symptoms to work with. I give it a C-. The soap opera was adequate and average. There were a couple of nice scenes, and Wilson got a few good lines, but it really wasn’t anything above average: C.

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This week’s House Challenge scores have been posted.

This week, Roxana wins with 9 points. Harvey, Little apple, rileyjo, Rouge Rogue, Silvina and TheJester were second with 8 points.

Overall, James H retains the lead with 46 points. Dr. R moves back up to second with 44 points. Nextsundayad and Roxana are tied for third with 42 points. wkmaier is fifth with 40 points. If you have 35 or more points, then you are in the top 10%.

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An average episode of Fringe that had too much bad science (and math) for me to truly enjoy. I guess we need some mediocre weeks to let us enjoy the good ones.

The Plot: Emily is a teenager who occasionally catches glimpses of someone’s pending death. She quickly sketches the scene she sees in her sketchbook, rips out the page, and then hands it to the victim. She’s essentially Cassandra, and her warnings of imminent death do no good to the victim. They do bring her to the attention of the Fringe Team, especially Olivia, who is still coming to terms with the Observer who told her that she had to die.

Emily gives the Fringe Team a sketch she made showing numerous victims amid piles of rubble. The image is centered on one particular man. The team is able to figure out who he is via his bus pass. Walter hypnotizes Emily (using the standard red and green lights) to gain more information and learns that the disaster will take place at a courthouse. Olivia and Lincoln learn that the man in question recently lost custody of his children in a divorce proceedings. They track him down to a local courthouse and the FBI finds a large bomb in the bed of his pickup truck. They are able to block the radio detonator, but he threatens them with a small bomb he is wearing. Olivia is able to talk him into surrendering and no one is killed. For once, Emily’s prediction does not come true.

When Olivia calls Emily to thank for her help, she learns that she is missing. Olivia tracks her down to a pond-side bench at a park she was fond of. Emily has foreseen her own death and has come to her favorite spot to die, which she does, quietly, in the arms of her father.

Later in the evening, Nina Sharp comes over to Olivia’s apartment to check on her. Olivia complains about the migraines she’s been having (the ones caused by Nina’s secret injections), so Nina promises to send over some “new medicine” the next day.

1. Math Must Be Different in Spain
The math Olivia and Broyles use on the Spanish Flu doesn’t add up. If the last case was 1919, then 91 years later is 2010, not 2012 (or even 2011, when the episode was undoubtedly filmed). Unless they are suggesting that 1 and 2 year-old do not make antibodies, which would contradict years of immunization and vaccine research.

2. Billy Squier
An “overload of electrical energy in her brain was just too much” is not the definition of stroke; it’s the definition of a seizure. A stroke is what I like to call a “plumbing problem” – the required blood cannot get to the brain either due to a blockage (embolic stroke) or bleeding out (hemorrhagic stroke). A problem with the brain’s electrical system would be a stroke, at least in the sense Olivia is describing.
Neither of these would account for the bloody nose, so I’m going to count that as a psychic nosebleed.

3. Scan Acquired
I’m amazed Walter could get such an accurate reading from the occipital lobe when he had no sensors anywhere near it.
Theta-1 waves are said to occur during voluntary motion and REM sleep, though the exact definition of a theta-1 wave varies.
Theta-1 waves originate in the hippocampus, a part of the brain which is nowhere near the occipital lobe.
Since blood carries oxygen, it would be hard to get increased oxygen without increased blood. And since when does an EEG measure either?

4. Radio Free Albemuth
Now I’m no radio-specialist or electrician, but is it really that easy to jam a specific frequency? How did they know they weren’t going to set off the bomb by accident?
Was it wise to send Peter and Lincoln, not trained in demolitions, it to help the bomb squad? Particularly in regards to Peter, he’s one of a kind and is it really worth risking him?

5. Must Be Those Ceramic Wires and Electrodes
So the bomb Albert was wearing had not detectable metal in it? Really?

6. Oh By The Way
When are the Fringe Team finally going learn that they need to sit down and have a long debriefing session with Peter. How many times has he recognized something they didn’t or knew more than they did? Just off the top of my head: shapeshifter’s memory banks, David Robert Jones, and the Observers. I’m sure I’m missing a few others.

While there was nothing specifically wrong with this episode (other than the questionable science and math), it just didn’t gel particular well, with the attempt at pathos at the end being a more than a little over-the-top. The Fringe Doomsday Clock heads back towards midnight.

This week’s Fringe cipher was: MARCH.
A list of all previous Fringe reviews is available here.
Karl should soon have more to say over at his blog, providing he’s not partying too hard on his vacation.

Tags: television fringe precognition bomb hypnosis

An unfortunately average episode of House where the most interesting question is left unanswered.

Andres is a man with early onset Alzheimer’s disease. He is being evaluated for possible inclusion in a drug study when he develops bloody vomiting. He is admitted to Princeton-Plainsboro Hospital and assigned to House’s service. The team’s initial thought is that the patient has a gastrointestinal bleed which is causing the bloody emesis. An EGD (upper endoscopy) is performed and it shows a Mallory-Weiss tear (a rip in the esophagus of those who vomit frequently or forcefully), but that is a consequence of vomiting, not a cause. Andres is also noted to have elevated liver enzymes, and the diagnoses of gallbladder disease and steatohepatitis (fatty liver) are mentioned. House favors the latter and decides to start the patient on statins (a class of cholesterol drug as high cholesterol is almost always seen with steatohepatitis) and double check the liver (initially a biopsy, but overruled by Foreman to an ultrasound examination), but before they can perform the testing, Andres becomes more violent that ever, punching his wife, and requires sedation. At this time, the team also notices bloody urine. The differential diagnosis now consists of rhabdomyolysis (severe sudden muscle damage) and TTP (thrombotic thrombocytopenic purpura). House thinks TTP fits best, and orders Andres started on plasmapheresis.

Overnight, Andres elopes (the medical term for a patient, especially a demented one, who leaves the hospital). In the middle of a snowstorm, the team tracks him down to an old soccer field, but by the time they find him, he is hypothermic and pulseless. CPR is started, because, as Chase reminds Adams, they’re not dead until they’re warm and dead (sudden hypothermia can sometimes be protective of a patient, though this is more common in children than in adults, so it’s medical tradition not to declare someone dead until they’re back to normal temperature). Andres is brought back to the hospital, sent to the ICU, and started on extracorporeal warming of his blood. As he warms up, his brain function returns, then his heart. He’s initially in ventricular fibrillation, but he returns to a normal rhythm after some amiodarone (a medication used to suppress heart arrhythmias) and defibrillation. Unfortunately, he seems to have lost his ability to speak English and now only murmurs in Portuguese, his native language. He also develops a fever, but is this a symptom of his original admitting disease, or a consequence of being hypothermic? Looking over Andres’ symptoms, House sticks with the diagnosis of TTP and wants to resume plasmapherises. Foreman, instead, favors a viral infection that has spread to the brain to cause encephalitis. House relents, and has the patient started on interferon.

Andres is not doing any better. He falls back into ventricular fibrillation and this time requires three shocks to correct (apparently they neglected the amiodarone this time around). Foreman maintains it is a viral infection of the brain, such as encephalitis or meningitis, while House now favors toxin exposure. This week, it is Foreman who has the Eureka! moment while talking with some hospital donors. Seeing a flower bouquet still looking fresh despite being over a week old, he recalls that aspirin in the water can prolong the life of cut flowers, and this leads him to diagnose the patient with Reye’s syndrome. Some corticosteroids and Andres is back to normal (well, as normal as someone with early onset Alzheimer’s can be.)

Meanwhile, Wilson is treating a patient with a bladder infection (which he apparently diagnoses by palpating her neck). In the course of his discussion with her, he learns that she and her husband are self-proclaimed “asexuals”, completely disinterested in sex. House finds this head to believe and wagers $100 that he’ll find a medical cause for the lack of sex. He runs tests on the patient’s blood, but everything is normal. He eventually lures the husband in for an exam and discovers a pituitary tumor (a “macroprolactinoma“) that is suppressing the normal sexual urges. With some treatment, the high levels prolactin can be treated and the patient’s symptoms (in this case his nonexistent sex drive) corrected.

As usual, major complaints are in red (red caduceus), modest complaints are in blue (blue Vicodin), and nit-picking ones in green (green pencils):

Pet peeve here: Defibrillation does not “shock the heart back into rhythm.” The shock from defibrillation momentarily stops the conduction of the arrhythmia, allowing (hopefully) a normal rhythm to take over. The shock itself does not “jump start” the heart or start the normal rhythm, it just stops the bad rhythm — an important distinction.

TTP (thrombotic thrombocytopenic purpura) -– none of three parts (the T, T, or P) fits. There was no mention of low platelets (though other lab abnormalities were mentioned), no clotting, and no purpura. (In fact, there was no mention of rash at all, and rash is almost always seen in Reye’s).

In regards to his symptoms, Reye’s syndrome is quite a stretch with few of Andres symptoms matching well, but then again, Reye’s in adults is quite a stretch in-and-of-itself.

Symptoms of death in the hypothermic do not resolve that predictably (“Ah, 93 degrees, must be time for the ventricular fibrillation”), and frankly, the patient usually remains dead.

Interferon is not a treatment for encephalitis or meningitis.

Cortciosteroids are used in Reye’s to treat swelling of the brain — something they never bothered to look for, despite the more-than-expected behavioral changes.

Third episode so far this season where there is debate whether societally atypical behaviors are symptoms or not. Charity, paranoia, and now aggression.

Before starting statins in a patient with elevated liver enzymes, I’d want to make sure the cholesterol is indeed high and require treatment, as the statins themselves can elevate liver functions.

While there is debate over the use of “chemical restraints” (sedation in aggressive patients), diazepam is unusual for a first line agent. Haldol seems the more common choice. On the other hand, diazepam can be more easily reversed if something goes wrong.

The medical mystery this week was OK, but not great — but that still makes it better than most episodes this season. The big mystery was why Andres developed Alzheimer’s so young, but answering that was outside the scope of the episode. I give the medical mystery a C+. The final solution kind of more or less fit, if you ignored the usual time course of Reye’s Syndrome. I give it another C+. The medicine was uninspiring this week, with diagnoses thrown around that could be easily tested, but never were. Plus Foreman, a neurologist, was using meningitis and encephalitis interchangeably. I give the overall medicine a C. The soap opera was enjoyable this week from the pathos (Chase), to the humorous (the yellow cards, Park and her “tapping”), to the unethical (House and Wilson). It deserves an A-. (Bonus points for the Spider-Man allusion. And what manga was House reading when first talking to Wilson? Maybe someone should tell him they’re read right-to-left, not left-to-right.)

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The second cat-and-mouse Fringe episode in a row, and the second good one in a row. Coincidence?

The Plot: Fauxlivia and otherLee arrive at the warehouse they learned about at the end of last episode, and find David Robert Jones waiting for them inside. He makes a not-so-subtle threat by killing one of his own shapeshifters, and then surrenders himself to them and asks to be taken to their leader.

At Fringe HQ, Peter recognizes Jones as the man he thought he killed, and watches alternaBroyles’ interrogation of him. Peter even does a little interrogation of his own, a situation that seems to unnerve Jones, even though he doesn’t recognize Peter. Jones asks for a certain hard drive hidden by the shapeshifter Brandon, and when it does not arrive in time, kills an ER full of people. He then demands to be released or he will kill more innocents. Walternate agrees, and the team has just enough time to slip a tracker into Jones so he will be easy to follow. They track him to a crowed public plaza but it is clear he knows he is being watched. He grabs a package from a nearby trash bin containing a thermos and a stack of money. He starts handing out the money to passersby and drinks from the thermos. All the money has trackers identical to his, and the liquid in the thermos knocks out his tracker, so he is able to escape when dozens of extra subjects show up on Fringe’s trackers, but he no longer does.

Looking over the information contained on the hard drive Jones wanted, the Fringe team finds dozens of satellite geographical pictures. Peter realizes Jones is looking for Amphilicite, a rare but potentially very dangerous mineral. They determine one particular quarry is the most likely spot for the mineral so they race to beat Jones there. At first, they believe they’ve beaten him to the punch, but then they realize the satellite pictures are from our universe, not the alternate one. Jones has crossed over and is harvesting the mineral from our side. Peter and Agent Lee cross back to our universe and join the rest of the Fringe Team in trying to capture Jones. As usual, Jones is one stop ahead of the team and is able to escape back to the alternate universe with nearly a hundred pounds of the Amphilicite.

Meanwhile, Walternate’s wife Elizabeth has arrived in our universe to talk Walter into helping Peter, and ultimately, he agrees.

Walternate helms an emergency meeting between both Fringe teams as they realize they have to work together to stop Jones.

As the episode ends, Jones is communicating a secret partner about phase two of their plans, a phase that has to do with a certain unnamed “her.” The final shot of the episode reveals his partner to be Nina Sharp.

1. Bad Feng Shui
I’ve never known an Emergency Room with only one entrance. There are usually a half dozen or more. Strange and dangerous things can happen in ERs and you need lots of room for people to rush in, or out.

2. Spares, Just In Case
Are there just extra guns laying around in Fringe division vehicles?

3. Continui-what?
How many of the previous adventures have the various Fringe teams not experienced?
Nobody recognized Jones.
Walter’s comments about no sign of forgives makes me think he never received the eponymous white tulip.

4. Big Bang Dune
Mentat Astrid seemed less Mentat-like and more Sheldon like this episode.

5. What is the RDA of Amphilicite?
Has Amphilicite been mentioned in the show before? I can’t find any mention of it in my notes so I’m just wondering.

6. A Little Too Trusting
Once again, everyone is way too trusting knowing there are shapeshifters all around. Walternate is even suggesting that Fringe team is compromised, but doesn’t check if the person he’s telling is the real alternaBroyles (probably not, but I wouldn’t put it past the writers to try and pull a fast one).

Another good episode. As always, David Robert Jones makes an excellent villain. The Fringe Doomsday Clock retreats a minute to 11:52

Tags: television fringe shapeshifter walternate jones! amphilicite

A good episode of Fringe — one of the best of the season. It occurs to me that the “espionage” episodes of Fringe have been some of the best of the last two seasons, probably because — thanks to the shapeshifters — Fringe can pull of paranoia better than any other show.

The Plot: Peter Bishop has decided that he needs to get home to his universe, and in order to do so, he needs to recreate The Machine. He can’t do this without Walter’s help, but Walter still wants nothing to do with him. Peter heads over to talk with Olivia in an attempt to convince her to get Broyles let Peter cross the bridge over into the other universe and talk with Walternate. Instead, Olivia tells Peter where to find Walter’s original dimension-crossing device. She and Peter and Agent Lee take the device to the Orpheum theater — where Olivia’s cortexiphan team crossed over at the end of season two — and Peter and Lee cross over. The plan is for this Agent Lee to pretend to be that Agent Lee and bluff their way onto Liberty Island. The plan works at first, but Peter and Lee end up captured by Fauxlivia and otherLee. As they are being transported to Fringe HQ for questioning, an attempt is made on their life by one of the Fringe agents. Lee is ultimately recaptured, but Peter escapes.

Lee tells Fauxlivia and otherLee that his team suspects Walternate is behind the new shapeshifters. Since they have some concerns of their own, Fauxlivia and otherLee decide to check out his story.

Meanwhile, Peter has headed to Tarrytown, New York, where Walternate’s wife, his other-other-universe mother, lives. She recognizes who he is and gets him in to see Walternate. Peter and Walternate have a tense meeting where Peter accuses him of not only being unrepentantly evil, but also being behind the new shapeshifter attacks. All the while they’re talking, Walternate is building some sort of handheld weapon. Walternate calls his chief scientist Brandon in to vouch for him, then shoots Brandon in the face with his weapon. It turns out that Brandon had been replaced by a shapeshifter several weeks before and Walternate suspected. He asks Peter to cross back over and tell the other Fringe team that he is not behind the shapeshifters.

Across town, Fauxlivia and otherLee’s investigation has not confirmed Lee’s story, but hasn’t contradicted it either. They ask Broyles for more time to finish their investigation and he reluctantly agrees. Then, once they’re out of the room, he calls a third party to let them know Fauxlivia and otherLee will soon arrive. The person he calls? David Robert Jones, the main villain from way back in season one.

As the episode ends, a wounded Observer appears to Olivia. He warns her that in all the futures he’s seen, she has to die. Then, like Batman, he disappears.

1. Your Heart Is Full of Unwashed Socks
Just a few episodes after going out of his way to help the Fringe team with their shapeshifter problem, Peter’s suddenly become frighteningly cold. “Who care if two universes die, especially a universe where I have friends, as long as I get home?” That’s a rather abrupt change for Peter.

2. Cephalgia
Olivia still has the headache Nina’s covert treatment gave her at the end of the previous episode.

3. Into the Valley of Death / Rode the Six Hundred
Either otherLee was making a bad joke of an allusion, of 2. Cephalgia “>The Charge of the Light Brigade is quite different in the other universe.

4. Reichenbach Falls
The “bad guy” Peter was so non-chalant about cutting in half and killing? That’s the same David Robert Jones that Broyles was calling at the end of the show (and incidentally, he made a damn good Moriarty in the recent movie Sherlock Holmes: A Game of Shadows).

A good episode, even missing the monster-of-the-week (or maybe because of that). The Fringe Doomsday Clock retreats a minute to 11:5511:53

Tags: television fringe shapeshifter walternate jones!

What started out as an intriguing courtroom thriller ended up a barely mediocre episode of House

Tommy is a forty year-old prosecutor who develops sudden severe chest pain in the middle of a court case. He is admitted to the hospital where a heart attack and anxiety are ruled out — with no clear cause of chest pain remaining, he is admitted to House’s service. The team’s initial differential diagnosis includes shingles, asthma-induced pneumothorax (a collapsed lung) or poisoning (particularly chlorine poisoning). House thinks poisoning seems the most likely, so has the team alkalinize the urine, and then interview his wife and search the house. No poisons turn up in the search, but Park and Adams find a hidden bunker filled with guns. Now Chase and Adams think that this is a sign of paranoia, but Park doesn’t think he’s paranoid. Taub, wisely, sits this one out. The new differential diagnosis consists of cocaine abuse, Fahr’s disease, or atrial fibrillation due to hyperthyroidism or sleep apnea. House has all the suggestions checked, but everything comes back negative.

Park notices a bleeding sore on Tommy’s leg, which he tells he didn’t know about. He starts running a fever as well. The team thinks tuberculosis is possibility, as is systemic sclerosis (better known as scleroderma, an autoimmune disease). House decides to go with Taub’s suggestion of sclerosis; he orders a skin biopsy and starts Tommy on enoxaparin (a blood thinner). The treatment doesn’t help and Tommy starts having hallucinations and suffers a psychotic break. Park thinks he has an infection like tularemia and Adams thinks he has GAD autoimmunity. Chase thinks all of the patient’s symptoms are psychiatric or self induced. House favors Adams, and starts Tommy on immunoglobulin and corticosteroids. Tommy continues to get worse with his fever getting higher. Adams wants to up the steroid dose, but this time House agrees with Park and has Tommy checked for a number of infectious diseases, including sporotrichosis and meningococcemia.

Without warning, Tommy goes into anaphylactic shock. Chase performs a tracheotomy, but it doesn’t help because the airway blockage is below the cricothyroid membrane. There are some tense moments (as least I assume they were tense, all we got was a commercial break), but Chase and Taub manage to open the airway and get him hooked up to a ventilator. The team is at a loss for a cause when Park suggests that Tommy’s symptoms are the result of squamous cell carcinoma (a type of skin cancer) along with paraneoplastic syndrome. The team is getting ready to obtain a skin biopsy when House has one of his Eureka! moments and realizes that Tommy has severe diphtheria. One of the classic symptoms of the disease is a pseudomembrane which blocks the airway, and this explains the respiratory arrest. His other symptoms have also been associated with the disease, albeit very rarely. Some antitoxin, and he should be as good as new (though still paranoid).

As usual, major complaints are in red (red caduceus), modest complaints are in blue (blue Vicodin), and nit-picking ones in green (green pencils):

A patient with non-cardiac non-anxiety chest pain is not a big mystery; they’re a dime a dozen. Once the patient’s chest pain is determined to be non-cardiac, there’s no reason to admit the patient (unless something life threatening is going on, which is not the case with Tommy – at least at this point). The rest of the work-up can be done as an outpatient.
There are many common causes of chest pain that are non-cardiac and non-anxiety (gastrointestinal and musculoskeletal are common, for starters). An ER of that size would see at least a dozen such patients a day. There is no reason House would be intrigued by such a pedestrian complaint.

Notice how, for once, House held off starting broad spectrum antibiotics (or any antibiotics) and waited for tests to come back first – only because if he had given the antibiotics earlier the case would have been solved too quickly. Acting out of character in order to advance the plot is not the sign of a well written mystery.

Do they intend to biopsy the entire chest looking for this squamous cell cancer, or is there a suspicious lesion on the chest just asking to be biopsied – and if that’s the case, why didn’t someone spot it or mention it sooner?

Severe enough diphtheria to cause fever, pseudomembrane formation, skin lesions, chest pain, and hallucinations, but somehow there are no upper respiratory symptoms or swollen lymph nodes?

Giving someone Xanax and noting no chest pain, even when lying to the patient, does not rule out anxiety. For instance, what if they only have anxiety in high-stress situations like a courtroom? What does giving them Xanax in the artificial surroundings of the hospital accomplish?

It was not anaphylaxis, it was respiratory distress/arrest. They are not synonymous. You’d think the team would notice there were no other symptoms of anaphylaxis.

The main symptoms of Fahr’s syndrome are disorders of movement, none of which the patient had.

Once the airway blockage has been cleared, why is Tommy on a ventilator? There was never any indication or any reason given why he was unable to breath for himself.

Someone with a bad infection may worsen on corticosteroids, but giving someone with GAD autoimmunity antibiotics is not going to kill them.

If the EKG was normal and the cardiac enzymes were normal, why proceed with a cardiac catheterization?

Schizoid and schizophrenia are not the same thing.

As I mentioned above, the medical mystery this week was routine, boring even. Chest pain is exceedingly common and this case would not pique House’s interest. I give it a D. The final solution fit, but really only if you accepted the fact that the doctors on the team are idiots and borderline incompetent. I give it a C. The medicine diagnoses seemed more random than logical with many of them fitting the patient poorly, if at all. And did I mention House acting out of character? I give it a weak D The soap opera was better this week with all three storylines (Foreman, Park, House/Wilson) clicking. I give it a B+.

The review of the previous episode of House
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This week’s House Challenge scores have been posted.

This week, Akshay R, James H, and Kevin Lighton won with 8 points. Roxanna was fourth with 7 points.

Overall, James H takes over the lead with 39 points. Dr. R drops to second with his 37 points. Yerkietand mbrigdan are tied for third with and has 35 points. Roxanna moves into fifth with 32 points. If you have 29 or more points, then you are in the top 10%.

Click here to see the full scoreboard.

A promising episode derailed by a story decision more suited to Grey’s Anatomy or Chicago Hope than House. The B storyline was better.

Two cases this week: the team tackled the case of a moody teenager, while House looked into the death of a four year old boy.

The team takes on the case of Iris, a fourteen year-old girl who was admitted to the hospital with an idiopathic anaphylactic reaction. The first thoughts are hereditary angiodema (a genetic condition leading to swelling of the face and airways), systemic mastocytosis, pheochromocytoma (a tumor that secretes stress hormones, like adrenalin), or an anaphylactoid reaction to opioids. They start out by checking a catecholamine panel (high in cases of pheochromocytoma) and an expanded opioid screen. Taub learns that Iris’s mother has been secretly slipping diazepam (Valium) to her daughter to calm her down, telling her they were vitamin pills. When Iris suddenly begins throwing up, the team starts to rethink their diagnoses. A quick exam reveals some mild abdominal pain and breast tenderness. They run a pregnancy test, even though she insists that she’s never had sex. About this time, she develops numbness in both arms. The pregnancy test comes back positive, explaining away many of the symptoms. To work up the paresthesia (numbness), the team considers the possibilities of a cerebral tumor, vasculitis (inflammation of the blood vessels), multiple sclerosis, or HIV-related mononeuritis mutiplex. The tumor and HIV seem the most likely, so a blood test and MRI are ordered, but both are negative.

In the meantime, Iris’s paresthesia has resolved, but she now has bruises on her upper arm. The team investigates the possibility of clotting disorders such as thromobocytopenia (low platelet count), vitamin K deficiency, or scurvy (severe vitamin C deficiency). The tests for these conditions are negative, but a search of her room at home turns up a hidden stash of love letters and hardcore pornography. When confronted, Iris admits to having a boyfriend and reports that the porn is his. She also explains that he snuck into the hospital and beat her the night before, explaining the bruises. In the middle of the conversation, she develops a sudden attack of tunnel vision, which resolves spontaneously. Chase suggests a TIA (transient ischemic attack — a “mini-stroke”) and an MRA is ordered. House, stopping by, has a moment of inspiration and tells Iris her boyfriend was hit by a car. She angrily tells House that he’s lying because she is the boyfriend. It turns out that she has dissociative identity disorder (multiple personality disorder, to the layperson), and the boyfriend is just one of her personalities. Hypnosis reveals the trauma that split the personalities was the car accident when she was two that killed her father. Snips of memory from that accident (strawberries, an eight ball) caused her initial allergic symptoms — in one personality at least. It seems each personality was exhibiting different symptoms, and that’s why they would come and go so quickly. When she develops severe vaginal bleeding, the team realizes that she still has an unexplained medical ailment. They find that the symptoms that are consistent across all three personalities are the pregnancy, the high blood pressure, and the vaginal bleeding. Bearing this into account, the differential now consists of preeclampsia or an ectopic pregnancy (a pregnancy outside the uterus), but an ultrasound reveals no embryo. She is ultimately diagnosed with choriocarcinoma, a cancer of the placenta (or rarely, very rarely, a choriocarcinoma can be found in other reproductive tissue).

Meanwhile, House is obsessed with discovering the cause of death of a four year-old who died five years before of an unexplained kidney disease. Berger’s disease is suggested initially but when House learns that the lungs were also involved, he considers lupus and Wegener’s granulomatosis, but those avenues of inquiring prove pointless. Next he focuses on heavy metal poisoning, particularly arsenic, lead, and mercury, but his tests are negative. In the end, after a confrontation with the dead boy’s grandfather, mother, and mother’s new-husband — combined with an earlier comment from the boy’s father said — House realize that the boy had been partially deaf and was suffering from Alport syndrome, a genetic condition affecting kidneys and hearing.

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

As far as I was concerned, the episode was going along fairly well, but then lost all momentum and semblance of coherence when the diagnosis of dissociative identity disorder (DID) was introduced. It introduced more questions and generating more handwaving than it solved. For example:
What trauma caused the boyfriend personality?
Nobody noticed Iris’s changes in personality? Not just no one at home (explained away by the Valium), but no one at the hospital noticed a change in personality with a change in symptoms?
Iris’s main personality was aware of the boyfriend much more than she should have been if it were a true case of DID.
DID in young patients is not unheard of, but very rare. But a two year old? You can’t blame the Valium for Mom missing a decade of symptoms unless she started Iris on Valium as a toddler.

Three positive HCG tests and no one ran a quantitive test (tells how much HCG there is. Can be helpful in dating the pregnancy, or discovering if something else, like a choriocarcinoma, is going on), or checked an ultrasound for dating. How far along the pregnancy is is an important topic, especially when considering preeclampsia, ectopic pregnancy, or even morning sickness.

I don’t think pregnancy is a “symptom” of a condition. A positive HCG test may be, but that’s not what they were discussing during the differential. They also forgot to mention all the symptoms they explained away by blaming that same pregnancy (vomiting, abdominal pain, breast tenderness, abnormal periods).

Another House episode this season overcome by real world events, in this case the recent news that the most famous of all multiple personality cases, Sybil, was faked – casting doubt (more doubt, anyway) on many of the more extreme DID cases.

A patient taking diazepam would not have a “clean tox screen,” she would be positive for benzodiazepines.

An expanded opioid screen is not better at telling if a person is on opioids or not, it just shows which opioid they are taking. If the initial tox screen was negative for opioids, then the expanded screen would be too.

It was more of a symmetrical neuritis than a mononeuritis multiplex.

For the second week in a row, Park suggests the most ridiculous diagnosis: scurvy. Really? Easy bleeding, sure, but no other symptoms match.

Like most of this season’s episode, this week’s medical mystery was mildy interesting, but little more. I give it a C+. The final solutions to both medical mysteries fit, at least better than usual. They earn a B+. The A-storyline had sloppy medicine, and that was before they added in the multiple personality aspect. The B-storyline was better, but not enough to save the episode. I give it a D+ (the plus is from the B-storyline). The soap opera wasn’t compelling this week. How many times can we see Foreman stew over where to draw the line with House, and how many times can Wilson ineffectually hem and haw. It was particularly hard to accept the hard ass Foreman this week after we say him sharing a beer with House at an out-of-town boxing match last week. The soap opera earns a C-.

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

This week’s House Challenge scores have been posted.

This week, yarnpiggy leads the way with 13 points. Cyndi, Karatesocks, Nextsundayad, and Synth tie for second with 6 points.

Overall, Dr. R retains the lead with 37 points. Yerkiet is still in second and has 35 points. mbrigdan is third with 32 points. James H is fourth with 31 points, and Alex51 is fifth with 30 points. If you have 26 or more points, then you are in the top 10%.

N.B.: This week’s scores also contain the two corrections from last week’s scoring.

Click here to see the full scoreboard.

A disappointing episode of Fringe. The writing was choppy and the science sloppy; it felt only half finished.

The Plot: Olivia wakes up at night with a bad migraine. She heads to a pharmacy to refill her prescription and on the way home she passes an all-night diner where Agent Lee is sitting; it seems he has bad insomnia since joining the Fringe Team.

Across town, a man is heading home late at night and has the strange sensation he is being followed. Just as he makes it to the front door of his apartment building he is attacked. When the police arrive a few minutes later, they find him dead, and white as a sheet – drained of all pigment. Unsurprisingly, the Fringe Team is called in. Walter suggests the victim may have been scared to deat,h and Agent Lee finds blood on some broken glass, evidence of their mystery suspect. The blood is identified as belonging to an infant who died 22 years ago. Visiting the hospital where the baby was born, the team learns the baby had an unknown genetic condition, and didn’t really die, but instead was kidnapped by a company known as Cyprox, an old subsidiary of Massive Dynamic. Olivia visits Nina Sharp who admits Cyprox performed genetic experimentation on Eugene (what the baby was named), but insists the experimentation saved his life. He disappeared after a lab fire ten years before and they had assumed he died.

Meanwhile, another body has been found at another apartment complex. The building is locked down and the lights shut off. Walter has determined that Eugene can be seen under ultraviolet light and so groups of FBI agents search the building with UV lights and dogs. Olivia falls in a hole and Eugene rescues her, but then runs off. The team continues to search the building, but calls it off after there is no more sign of Eugene. They do find his hidden apartment and lab in the basement. Olivia speculates that Eugene just wants to be seen. A short time later, Eugene, now looking normal, enters the elevator at the apartment complex and has a short conversation with Julie, the object of his infatuation. As she leaves the elevator and the doors close, Eugene collapses to the floor, twitches, and dies.

Later that night, Olivia is getting ready to head out to the all-night diner to meet up with Agent Lee when she is knocked out by a gas pumped into her apartment. Two men enter her apartment, disable the security cameras, and inject her with a red medication. They mention that she’ll be out for a couple of hours, and wake with a massive headache. As they leave the room, we see Nina Sharp standing by, supervising the entire operation.

1. Not Quite Thirty Minutes Or Less
It takes more than 4 days to get genetic testing done, especially if so many “experts” are involved.

2. Let’s Digitize The Tests We Didn’t Perform
I realize this may or may-not or may-sometimes be our universe, but hospitals don’t keep DNA databases. And even if they did, why would it be online when the episode made the point of explicitly mentioning that all the hospital records from that era were on paper?

3. It’s A Hard Knock Life
Did Baby Boy Bryant didn’t have any parents? (The name is what you’d expect in a hospital file; all newborns are “baby-boy-mothers-lastname” or “baby-girl-mothers-lastname”).

4. Sorry Jean Valjean
A person’s hair turning white from a sudden fright is a myth. At most, theoretically, you could change the color of any hair that is newly growing, but the color of hair that’s already emerged from the follicles cannot be changed (excluding Clairol and Just for Men, of course).
What exactly was the pigment drained through? The pores? Capillaries? What?
More importantly, if Eugene is pigmentless, how does he see? The retinas require pigment to function.

5. Unclear On the Concept
I’m unclear how Eugene stealing other people’s pigment was returning himself to his original condition, since he was born without any pigment.

6. Ennui
In this entire episode, the Fringe Team accomplished nothing. Seriously: if they had not become involved, Eugene would have talked to Julie and died, just like he did after they became involved. They saved no lives; they prevented no crimes. There’s nothing quite like watching the characters of a TV show so completely not matter.

7. Mischief Managed
No octopus or chameleon can mimic that complicated an environment. They “blend in”, they don’t disappear. It’s camouflage, not the One Ring.

8. Spotting Scorpions
Why not bring in decent sized UV lights rather than those dinky little flashlight ones? It would be very easy to miss someone with one of those, especially the way they were haphazardly swinging them around. The ones we use in our office are easily four times the size of those, light, and portable.

The plot was too sloppy, let alone the science, for this to be considered a good episode, let alone the advertised mid-season finale. The Fringe Doomsday Clock gains two minutes to midnight.

Tags: television fringe time pigment ultraviolet

A disappointing episode, as the ones that try to make a broad point (this time: all parents screw up) usually are. There were a few clever moments — who am I kidding, there was one, maybe two clever moments, and the rest was rushing from one imagined crisis to the next

Ben is a teenager working, quite ineptly, as a clown at a kid’s birthday party. After an altercation with one of the kids and their father, he develops the sudden paralysis of an arm and a leg and is admitted to House’s service with a diagnosis of TIA (Transient Ischemic Attack, i.e. a “mini-stroke.”) The team is puzzled why a healthy teenager would have such a condition. The initial concerns are drug use or endocarditis (an infection of the heart valves). A transesophageal echocardiogram is ordered — it shows no heart valve problems, but it does reveal a thickened pericardium (the membranous sack that surrounds the heart). The differential now includes syphilitic vasculitis, histoplasmosis, or Sjögren’s syndrome. The tests for the first two were negative, so House orders Ben started on immunosuppressants to treat the Sjögren’s.

While Taub sets up the medication, Ben develops a bloody nose, then a bloody cough. Taub reports that Ben’s platelet count is low and suggests DIC (disseminated intravascular coagulation). Park reports a low red blood cell count and suggests a retropeitoneal bleed (bleeding into the tissues behind the abdominal cavity). Adams reports few white blood cells and suggests an infection. House notes that the entire blood count (platelets, red cells, and white cells) is low and reports that Ben has aplastic anemia (a condition where the bone marrow stops production of any kind of blood cell). He has Ben started on platelet transfusions and orders bone marrow testing on Ben and his relatives to prepare for a bone marrow transplant. A short time later, Ben complains of back pain and his blood pressure drops. It turns out that he is having an allergic reaction to the platelet transfusion. House orders a more specific kind of platelet transfusion so there will be less chance of a reaction. Ben suddenly starts gasping for breath and after a perfunctory physical exam, Taub announces that he has a pleural effusion (fluid building up around the lungs). A chest tube is placed, but rather than returning blood, it drains an transudate (which to me looked more like an exudate), which Park takes to mean our old friend liver failure is back. The team now has a prolonged and mostly pointless argument about whether the liver failure is due to a failure of protein synthesis or high ammonia levels. House suggests feeding Ben a high protein diet to purposefully worsen the liver, and his symptoms (heart failure or coma) will let the team know which problem he had (because this is so much quicker and easier than running a ten-minute blood test).

Of course, things quickly go from bad to worse. Ben’s left eye starts bulging out and needs steroid injections to resolve. The team now suggests angioneurotic edema, anasarca, or Burkitt’s lymphoma. House suspects that later is the most likely, so starts Ben on chemotherapy. While receiving his therapy, Ben crashes and develops multiple organ failure. The team initially suggests multiple aneurysms or cholesterol emboli as potential causes. But then Ben’s estranged and in-fact-thought-dead father stops by, and House recognizes the abnormal gait of someone with tabes dorsalis, a sign of syphilis. This causes him to realize that the father sexually abused Ben as a youngster and infected him with syphilis, which is what caused his current symptoms — well, that plus the antibiotics causing a Jarish-Herxheimer reaction (severe symptoms caused by multitudes of bacteria dying off and releasing toxins into the bloodstream).

This week’s episode was particularly weak in differential diagnoses. After the first round, they quite trying, and the newer diagnoses just explained the latest symptom and not the previous ones, so the original admitting symptoms were usually left unexplained. As always, major complaints are in red, modest complaints are in blue, and nit-picking ones in green:

Once again, House is starting chemotherapy on a patient without even confirming the patient has cancer, let alone what type he has. There is no generic chemotherapy; it is specially tailored to the specific cancer.

A few simple blood tests would determine the likely cause of the liver failure, though it is quite possible if not very likely to have poor synthesis and high ammonia livers. Despite what House says, it would be quicker too than feeding the poor patient protein and waiting for it to be processed by the liver and have an effect.

Worst diagnosis of the episode: retroperitoneal bleed. How does that even come close to explaining the TIA symptoms?

A pleural effusion is not “bleeding into the lung.” It is bleeding around the lung, a not unsubtle difference.

I have my doubts that the syphilis tests (likely an RPR or VDRL) would be negative in Ben’s case. Those tests are known for their false positives, not false negatives.

If Ben’s white count is so low as to suggest aplastic anemia, why was he not placed under neutropenic precautions?

The effusion should have been clear, not cloudy (and I’d expect it to be a little bloody as a result of the brutal chest tube placement as well).

This week’s medical mystery was a little interesting, but not terribly compelling. I give it a C. The more I think about the final solution, the less it makes sense. Ben had latent syphilis that suddenly, in the space of a minute, exploded into neuro- or at least cardiosyphilis? Really? And the Jarish-Herxheimer symptoms are a poor match as well. It earns a D. The medicine was poor as well, and was more reactive than actually thought out. I give it a C-. The soap opera, at least among the patient and his family, and among the team was interesting, though Taub surely knows that House cares nothing for his daughters’ well-being. The House/Wilson/Foreman aspect, though at times amusing, just reminded me of what a sad defeated man Wilson really is. I give the soap opera a B.

The review of the previous episode of House
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This week’s House Challenge scores have been posted.

A high scoring week as a bunch of people had syphilis as a choice. Dr. R was first with 15 points. Seven different players had 14 points , and more had 13 and 12 points.

Dr. R takes the lead with 33 points. Yerkiet makes a surge into second with 32 points. mbrigdan is third with 31 points and SMEL drops to fourth with 27 points. Alex51, brism19, and 4287 are tied for fifth with 25 points. If you have 21 or more points, then you are in the top 10%.

Click here to see the full scoreboard.

An enjoyable episode of Fringe, but then, episodes featuring time travel usually are. (What would have made it even better would have been if the crew had managed to place a red Swingline stapler in Raymond’s house.)

The Plot: A series of strange time-related events have appeared around Boston. They all seem to relate to events that happened four years before. An apartment complex suddenly shows signs of fire damage, but the fire happened four years ago and the damage was long since repaired. A five year-old girl is reverted back to infancy. A freight train appears on a track abandoned four years before.

The Fringe Team is called in and brings along Peter, suspecting that the time effects are somehow the result of him reappearing in our universe. Mapping the disturbances, the team is able to discover that the effects seem to originate from one particular block. Soon, they are able to identify the specific house, but it is surrounded by a time bubble that will disintegrate anyone who enters it. Walter builds a portable Faraday cage that Peter is able to use to enter the house.

Inside the house are Raymond and his wife Kate. He is an electrical engineer and his wife is a theoretical physicist – or was, as she now suffers from severe Alzheimer’s disease. Raymond has used her notes on time to build a machine responsible for creating the time bubble surrounding the house. He brings the time in the house back four years, before Kate’s Alzheimer’s kicks in. Currently, his machine isn’t quite finished because Kate hasn’t finished her time equations, so it only works for a handful of minutes. That’s enough for him to bring her back to work on finishing the equations so the time bubble can become permanent. When Peter arrives, he confronts Raymond about the side effects of the machine, including the imminent deaths of hundreds of people in an underwater transit tunnel. Raymond agrees to shut off the machine, planning on building it again later. He knows that Kate has finished the equations so his next machine should be work perfectly – only, instead of writing down the finished equations, Kate blotted out all her previous work so Raymond can never build the machine again.

As the episode ends, Peter tells Broyles that his appearance in this universe provided the spark Raymond’s machine needed to work – this makes Peter think that he has appeared in the wrong universe.

1. Better Than Sylvia Brown
Peter is able to recognize that something is “growing geometrically” from just a single event?

2. Sure Natural Radiation is Good, but Organic Radiation is Much Better
Despite what Peter says, neutron radiation does occur naturally. (I’d go into a more thorough debunking of Fringe radiation here, but Karl’s always been better at that than me, so I’ll just link to him earlier than usual.)

3. The Fools-Gold Spiral
Fibonacci’s sequence creates something very close to the Golden Spiral, but it’s not quite the same thing. (A true Golden Spiral has a growth factor of phi. The Fibonacci sequence approaches this, but never quite reaches it.)

4. Time Keeps Flowing Like a River
Apparently, time is an electromagnetic wave and can be blocked by a Faraday cage (but walkie-talkies cannot be blocked by time bubbles or Faraday cages. Seriously, at that point Peter was so close to Olivia, why not just pop his head out of the bubble and talk to her?)

5. Steady Hands
Apparently Walter and Peter can both hand draw perfect Golden Spirals without mechanical aid. Must be genetic.

6. Caged Rat
Faraday cages consist of fine metal mesh which block out certain wavelengths of electromagnetic waves depending on the size of the mesh. Whatever Peter was wearing wasn’t a Faraday cage.

7. Ahead of Its Time
How long has Walter’s house been abandoned, because that look’s like a recent model flat screen TV.

8. Old Friends
This is the third episode Burlap Bear has been mentioned in. (Previous episodes 1-16 “Unleashed”, 3-07 “The Abducted.”)
The airplane in the old house looks like the one Peter bought after arriving from his universe into ours (episode 3-15 “Subject 13.”).

9. Gratuitous Product Placement
Sprint for the win.

A somewhat cliched story, but an enjoyable hour nonetheless (plus it’s always enjoyable to see Stephen Root). The Fringe Doomsday Clock retreats a minute, returning to 11:52

Tags: television fringe time peter stephen root

Chase and Taub are back on the team this week, which makes the episode much easier to watch (because the medicine sure isn’t helping)

Bob Harris, small town businessman and philanthropist collapses while in flagrante delicto with the local beauty queen. He has her bring him to the hospital where he is diagnosed with ventricular fibrillation, though there is no other sign of heart disease. He initially claims he was at his desk when the attack happened, but later admits to the affair when confronted with the evidence (fresh rug burns on his knees). The team decides to run an exercise test to see if another attack will occur. Initially, they get no results, but when Chase adds an emotional component to the stress, Bob collapses with a seizure. The team’s initial differential diagnosis is viral myocarditis, Brugada syndrome (an inherited abnormal heart rhythm), or pheochromocytoma. House suggests photic epilepsy (more commonly called “photosensitive epilepsy” — seizures brought on by flashing lights), but an EEG is negative, so he goes back to Park’s suggestion of a pheochromocytoma. While Chase and Adams run tests for the tumor, Park and Taub check out the seedy motel where Bob had his tryst. The pheochromocytoma tests are negative, but the patient now has a large mass on the right-side of his neck. Park and Taub find an abundance of pathogenic material at the hotel, including traces of fusobacterium necrophorum, which confirms House’s suspicion that the patient has Lemierre’s syndrome (an infected thrombophlebitis of the neck). The patient is started on Augmentin (amoxicillin + clavanulate) and surgery to remove the infected clot is scheduled. However, the surgery reveals no clot, but an enlarged lymph node. Adams suggests lymphoma. Chase obtains a biopsy and the patient’s vital signs plummet. Adams checks his eyes and notes yellow sclera, indicating liver failure to her.

With the new symptoms, the team formulates a new differential diagnosis. Lymphoma has been ruled out because the biopsy was negative. Alcoholism and withdrawal is suggested, but House is sure Bob still has an infection of some sort. He wants to use high doses of broad spectrum antibiotics to kill whatever infection it is. Adams is concerned that his plan will kill the patient’s already compromised liver. Chase suggests a liver transplant, and then the antibiotics. Since time is short, a partial liver transplant from a living donor is suggested. Most of the population of Bob’s small town come to the hospital to be see if they would be good donors for the liver transplant. Most leave after Bob confesses a number of sins, from cheating on his wife to ripping off customers at his car repair shop to stealing scholarship money. None of the remaining townspeople are good matches for his liver. House wants another CT of the liver, and surprisingly, this one shows that the liver is healing.

The team now suspects Bob is having an allergic reaction of some sort. He reacts strongly against the wheat sample, though he has no history of wheat allergy and blood tests don’t confirm the allergy. A latex allergy is considered but tests were also negative for that. Bob’s allergic reaction worsens, with large strips of his skin now tearing off. The team diagnoses Stevens-Johnson’s Syndrome and report that there’s nothing they can do as, according to the team, most medications exacerbate the confession. Not comfortable with leaving the patient alone, Chase sits besides him during the night. Bob tells Chase he has one last confession to make: he tells Chase he is a murderer, having killed his business partner and several others. This is over the top enough for Chase to realize that a large part of the problem is in the brain, with the patient confessing to crimes he has never committed. A brain scan shows an aneurysm. Taking this along with his other symptoms, House recognizes that Bob has Kawasaki’s syndrome, an autoimmune disease (in this case apparently induced by carpet cleaning chemicals Bob was exposed to through the rug burns). After treatment, Bob is feeling good enough to start lying to his wife.

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

A patient with a suspected systemic infection is not going to be a candidate for a liver transplant.

House’s team was bizarrely satisfied with the diagnosis of Stevens-Johnson syndrome (SJS), and never explored the all important question of what set it off?
Looked more like toxic epidermal necrolysis (TEN) than SJS to me, though admittedly most subspecialists consider TEN a very severe type of SJS.
The hallmark of SJS is the involvement of mucous membranes, none of which were involved in this patient (at least the ones we could see).
Corticosteroids haven’t been implicated in SJS, though they have rarely in TEN. In fact, they are one of the main treatments of the condition.
Narcotic pain medications are not known to cause SJS or TEN, so there was no reason to withhold them from the patient.

A lymph node biopsy, especially for something like lymphoma, takes the entire node, not just a little bit of juice from it.

Augmentin/Amoxicillin + clanulate is not the proper antibiotic for Lemierre’s syndrome.
Scanning the neck (CT scan or ultrasound) to evaluate the clot — or at least to make sure it exists – is recommended before surgery.
Patient was missing the pharyngeal/peritonsillar signs and symptoms seen before Lemierre’s.

Park complains about the length of time it takes to get culture results back (a valid point), yet she is the one who supplied the surprisingly fast results from the hotel room.

There was no good reason (other than to advance the plot, so make that no good medical reason) to repeat a CT scan of the liver so soon after the first.

You don’t confirm skin allergy test results with blood results. The skins tests are generally more definitive.

This week’s medical mystery was moderately intriguing, admittedly mostly because of its illicitness. I give it a B+. The final solution fit, but was quite a stretch, about average for the last few seasons of House. It earns a C. The medicine started out decent, but rapidly degraded. The treatment of SJS was nearly medieval. And why did it take the team so long to realize his confessions were a symptom? They were quick to consider altruism a symptom just two episodes ago. I give the medicine a grade of C-. The soap opera was much better this week — and most of that is due to the return of Chase and Taub. It’s good to have them back. 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.

This week, Fred had the high score with 13 points. Jinksb, SMEL, and wkmaier all tied for second with 12 points. Dr. R was in fifth with 10 points.

There was significant change in the overall standings this week. SMEL moves into first with 25 points. 4287, Harvey, and wkmaier are tied for second with 22 points. FlowerPower is in fifth with 21 points. If you have 18 or more points, then you are in the top 10%.

Click here to see the full scoreboard.

The writers should have taken the extra week they had off from the World Series and used it to tighten up the lousy science in this episode of Fringe.

The Plot: Peter has a meeting with Walter but it doesn’t go well, with NuFringe’s Walter not being as confident or comfortable as the Walter Peter new.

Meanwhile, the single remaining Shapeshifter 2.0 is back, this time tracking down a former Massive Dynamic scientist, who she locates and kidnaps at gunpoint. She needs his expertise in “cellular replication” in order to permanently fix what’s wrong with her body. She spins a sob story about being a melanoma patient in remission and he agrees to help her. At the lab she has set up, he injects her with some of his serum and she loses control of her shapeshifting and takes on the appearance of his wife. Now the scientist realizes something bad is going on and tries to kill her by making a toxic serum. She stops him and forces him to make the correct serum.

Agent Lee pulls Olivia in on the scientist’s case because he realizes it involves a shapeshifter. They aren’t making much progress until Peter volunteers his help. He is able to analyze the data disk the team recovered from the dead shapeshifter in episode 1 and use it to track the remaining shapeshifter and the scientist to her lab.

The Fringe team arrives at the lab just as the scientist finishes the new serum. The shapeshifter grabs it and sprints for the roof. Olivia follows but is told by an injured agent that the shapeshifter jumped off the roof into the harbor. Of course — and everyone saw it coming — the injured agent wasn’t really an agent but instead the shapeshifter who, once again, manages to escape. As the episode ends, she pulls out an old typewriter — like those used in previous seasons to communicate with the alternate dimension – and makes contact with her mysterious boss.

Peter has a second meeting with Walter. This one goes better, at first, until Walter denies Peter, telling him that he is nothing more than temptation that must be avoided.

1. Knitting the Raveled Sleave of Care
Sodium thiopental (i.e sodium pentathol, “truth serum”) is a barbiturate and can be used as an inducer of anesthetic. Using it to induce sleep, however, is a little better than Michael Jackson doing the same with Propofol, but not by much. Adrenalin may counteract some of the effects of the thiopental, but isn’t by any means a sure counteragent.

2. Phantom Itch
“Copied genetic data of healthy cells…and used it to replace the damaged ones.” The DNA of cancer cells is abnormal, so that makes a little sense, but Nina also mentioned using the process for people with amputations, and there’s no abnormal DNA in amputated cells; it’s just missing.

3. This Week, in NüFringe
We learned that Nina was a foster mother to Olivia and her sister after their mother died

4. Pluck the Heartstrings
Stage IV melanoma is melanoma with distant spread. The prognosis is dismal and there are no good treatments.

5. Larry, Darryl, and Darryl
Newhart gas station in Vermont — really?

6. Some Restrictions Apply
Restriction enzymes cut DNA strands into smaller pieces (of course, it’s DNA in the lab, not DNA still bound up in chromosomes and all the associated molecules). It would lead to massive cell death, in which case internal hemorrhaging is the least of your worries.

7. Inherited versus Acquired
Despite what Peter says, copying DNA – and even every molecule — exactly won’t duplicate a person. For a quick example, say I lost an eye in a barfight – that’s not going to be reflected in my DNA or molecules – so an identical copy of my genetic material is still going to leave the shapeshifter easy to spot.

8. Sherlock She’s Not
Olivia is smart enough to spot a smudge of grease under a victim’s fingernails, but not enough of a detective to see through the shapeshifter’s clumsy masquerade as Agent Warrick?

This episode didn’t do much for me, from the clumsy understandings of genetics to the worthlessness of Olivia’s vaunted detective skills. The Fringe Doomsday Clock advances one minute towards midnight.

Tags: television fringe shapeshifter peter dna

House acted like a real bastard in tonight’s episode. If you like that, then you’ll probably enjoy it. If you enjoy coherent medicine or decent mysteries, then you’d better just skip it

Local businessman Thad Barton is cleaning up his yard when he suddenly develops micropsia (a condition where everything appears small or far away). He is admitted to House’s service. The initial differential diagnosis includes JBE (Japanese B encephalitis, a vaccine-preventable disease), central serous retinopathy, atropine poisoning, or thyrotoxicosis (high levels of thyroid hormones in the blood causing hyperthyroid symptoms). House decides the latter is the most likely, and is just about to start the patient on PTU (propylthiouracil, a drug used to treat hyperthyroidism) when Barton reports he is no longer seeing things appear small, but now things are appearing larger than they should. To House, this suggests that Barton has Alice in Wonderland Syndrome, which House explains as a type of atypical migraine.

A short time later, Barton develops severe respiratory distress and hemoptysis. Angiography reveals a hemorrhagic site in his left lower lobe. The differential diagnosis now consists of hyperviscosity syndrome (blood that is thicker than normal), Factor V Leiden deficiency (a genetic condition that causes blood to clot more easily), or myelodysplasia. House tells the team to give Barton activated protein C. According to the team, it will cause a life threatening reaction if he has either Leiden or myelodysplasia (but a different life threatening reaction in each case); House realizes this and wants to give it so they can figure out which diagnosis Barton has. However, instead of the expected life threatening complications, he develops a brief episode of itching. Adams now proposes that Barton has cancer caused by HTLV-1 infection, which his late wife also had and it caused her lymphoma. House agrees with her theory and starts the patient on radiation therapy. Unfortunately, during his first radiation treatment, he develops chest tightness and a rising heart rate. Adams thinks he’s having a heart attack, but the troponin (a blood test for heart attacks) and EKG are equivocal (meaning “maybe yes, maybe no”). House wants an echocardiogram on the patient (to look for areas of abnormal heart wall motion, a sign of a past heart attack), but the patient’s heart is beating too rapidly for the test. Adams is able to get a cardiac catheterization which is normal. The team next proceeds to look at an EP study (electrophysiology study, a test of the electrical “wiring” of the heart), but Barton’s blood oxygenation suddenly drops in the middle of the test for no reason.

House consults a neurologist who suggests the patient has normal pressure hydrocephalus. Park disagrees and thinks the symptoms suggest autonomic dysregulation. She wants to do a tilt table test to prove her diagnosis, but the other neurologist tells her that the patient will slip into a coma if he has normal pressure hydrocephalus. Park proceeds with the test anyway, and Barton falls into a coma. House considers this a fluke and never thought the patient had normal pressure hydrocephalus. He now wonders if the patient might have hepatic encephalopathy, but a liver biopsy is normal. His team suggests Eastern equine encephalitis or loa loa disease, but a glance at an orthopedic x-ray gives House his Eureka! moment of the week. He diagnoses the patient with hyperviscosity syndrome caused by the increased number of antibodies in his blood because of his rheumatoid arthritis. A quick plasmapheresis treatment and the patient miraculously wakes up.

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

Another episode where the team goes straight to treating cancer with radiation therapy, without ever confirming the patient has cancer, let alone what type of cancer it is. The situation is even worse in this episode as no HTLV-1 related condition is treated with radiotherapy.

Similarly, House plans on treating the patient with PTU, despite having no proof the patient actually is hyperthyroid – an easy test to check. PTU is not a benign drug.

So, the patients tachycardia makes getting an echocardiogram impossible (reasonable, if the heart is beating too fast, then it’s damn near impossible to get a good reading on the echo), but yet they are still able to perform a cardiac catheterization, where the same issue would apply – even more so because it is an invasive test with definitive risks, unlike echocardiography.
Apparently no one thought to give a medicine to correct the tachycardia.

Lots of handwaving* with this episode:
What caused the oxygen desaturization? (frantic handwaving – thick blood!)
What caused the heart attack> (more handwaving – thick blood!)
What caused the coma? What did it have to do with the tilt table. And why did it miraculously correct with plasmapheresis?
*My term for when the writers try to distract you so you never notice the patient’s symptoms don’t match the diagnosis.

A migraine is just one possible cause of Alice in Wonderland syndrome; there are others.

House is right to belittle Andrews suggestion of normal pressure hydrocephalus – it doesn’t fit the case at all. But then again, Park’s suggestion is no better.

Ironically, between the time this episode was filmed and broadcast, Xigris (Activated Protein C) has been withdrawn from the market.

This week’s medical mystery was modestly interesting, at least compared to last episode. I give it a B. The final solution fit, but was blindingly obvious — at least it would have been, had the writers been playing fair. Holding out the fact that the patient had rheumatoid arthritis — much different than your standard degenerative arthritis — was clearly intentional. The fact that they had to hide this fact that should have been provided from the very beginning shows that they knew how weak the mystery was. I give it a B for realism, but knock it down to a D for cheating. The medicine this week bad. Missing repeated clots and bleeds. Dropping inconvenient symptoms. Radiating the patient. I give it a D+. Without more Wilson, the soap opera never rose above average: C.

The review of the previous episode of House
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This week’s House Challenge scores have been posted.

This week, 4287, FlowerPower, and SMEL had the high score with 12 points. Yep, that’s about it.

Overall, Yerkiet stays in the lead with 20 points while Harvey and jwsellers remain tied for second with 18 points. Nextsundayad is tied for fourth with 4287 with 17 points. If have 13 or more points, you are in the top 10%.

Click here to see the full scoreboard.

An average, at best, episode of House tonight. You’ll notice I throw around that phrase a lot tonight: “Average, at best.”

Benjamin, a once rich man who now gives all of his money away, collapses after leaving a million dollar donation to a job skills clinic. He is admitted to House’s team, mostly, House admits, because he is rich. Park is unimpressed with the case and feels Benjamin was just dehydrated. She is even more unimpressed when Dr. Adams, the doctor House got fired from the prison clinic, joins the team. Adams suggests cardiomyopathy as a possible cause. An echocardiogram is checked and it shows nothing wrong with the heart. Along the way, a head CT is checked to rule out a subdural hemorrhage, though it was never mentioned in the differential (pay attention, this will become important later). Park suspects Benjamin’s extreme altruism is a symptom of neurological disease, but Adams disagrees. An electromyogram is tested (because apparently muscle tone goes along with charitable impulses), but it is also normal. Just as he is ready to be discharged, Benjamin complains of feeling “funny” and develops tachycardia (an unnaturally rapid heart rate) that is corrected with the administration of adenosine.

The differential diagnosis now consists of long QT syndrome (an inherited heart condition that can lead to life-threatening arrhythmias) and Whipple’s disease (an intestinal malabsorption syndrome). While undergoing another cardiac test, Benjamin develops severe hand tremors (ridiculously severe — I thought he was having a tonic-clonic seizure. And, though mentioned repeatedly, these tremors were never seen again.) With symptoms of arrhythmia, fainting, muscle tremors and (possibly) mental status changes, the differential diagnosis now consists of drug abuse, polyarteritis nodosa, or echovirus infection. The latter seems the most likely, so Benjamin is started on pleconaril, an antiviral active against echoviruses.

House thinks Benjamin is cured, but then he hears that his patient has volunteered to donate a kidney to one of Wilson’s patients. To House, this means that Benjamin’s condition has not improved and it must not have been echovirus. Whipple’s disease now seems the most likely cause, but all the tests including EGD and DNA testing are negative.

With no proof of anything seriously wrong, Benjamin is wheeled into surgery, but his heart rate spikes and blood pressure drops so the surgery is called off. The team now considers a spider-bite (no specific spider species is mentioned) or LCDD (light chain deposition disease), and Adams wants him started on blood thinners for the tachycardia. Foreman shows up and accuses House of doping the patient with some drug to cause his symptoms, but House denies it — to Foreman, anyway — he admits it to the rest of the team.

Back to the symptoms of arrhythmia, tremor, and mental changes, the team now suggests Graves disease, or some other form of “thyroid disease,” Coxsackie B virus or porphyria. (Why weren’t these mentioned in the original differential diagnoses for the same symptoms? They should have been.) The patient is started on hematin to treat the presumed porphyria. Meanwhile, House has his Eureka! moment of the week when discussing the case with Wilson. It seems Benjamin has Plummer’s Disease — a single thyroid nodule that has managed to pump out enough thyroid hormone to cause behavioral symptoms and syncope, but yet remain undetectable in thyroid tests. Benjamin’s condition worsened when he received iodine based contrast for the head CT, which caused thyrotoxicosis (high levels of thyroid hormones in the blood causing hyperthyroid symptoms). After surgical removal of the nodule, Benjamin is back to normal, losing most, if not all, of his altruistic feelings along the way.

I already mentioned some of my concerns above: the miraculous untestable thyroid nodule that causes personality changes, the poorly explained need for EMG testing , and the only mentioned after-the-fact need for a head CT though it was useful for nothing on the differential diagnosis. Here are a handful more (as usual, major complaints are in red, modest complaints are in blue, and nit-picking ones in green):

In referring to the diagnosis of Whipple’s disease at one point, Adams states that it should have improved since the patient had already been on antibiotics.
No, the patient was on an antiviral, not an antibiotic (which is antibacterial). Frankly, that’s a mistake a first year medical student wouldn’t make.
Even if she had been right, Whipple’s takes a year of antibiotics to treat. Do you really think a day or two is going to make that much difference?

I know I’ve mentioned it before, but this episode really highlighted how poorly this show actually understands what a differential diagnosis is, despite it being a major part of every episode. When creating a differential diagnosis, you list every possible diagnosis that could explain the patient’s symptoms, then you run tests or elucidate a better history so the long list can be narrowed down to a shorter one and then finally to the correct diagnosis. If you’re introducing entirely new diagnoses for the same symptoms, then you’re doing it wrong.

Tachycardia simply means an elevated heart rate. There are many causes of tachycardia, but it seems that Benjamin has SVT, since it responds to adenosine. This is not a rhythm that requires blood thinners.

Whipple’s disease is one of the main diagnoses? Really? Where’s the abdominal and bowel symptoms you’d expect? In other words, throw out all the half-dozen expected symptoms and shoe horn in several one-in-a-million-cases symptoms. I know this happens every week on House, but this episode was particularly egregious.
Repeat with spider-bite, echovirus, polyarteritis, porphyria, and most of the other diagnoses mentioned this week.

This week’s medical mystery was nothing special. In the 100+ episodes of House, how many times has collapse been the initial mystery? A dozen? Two dozen? I know they lampshaded it, but that still doesn’t change the fact that the mystery was average, at best: C-. The final solution was quite a stretch requiring several unlikely coincidences: a nodule strong enough to cause personality changes, but not be detectable? check! An unneeded test that fits no suggested diagnosis that worsened the symptoms? check! The final diagnosis earns another C-. The medicine this week was poor. Zebras were chased left and right while ignoring more likely more common diagnoses. I give it a D. The soap opera had some good moments this week, but for most of the show was barely above average with a B-.

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

This week’s House Challenge scores have been posted.

This week, Ash88 had the high score with 8 points. Ender2003 was second with 7. Cyndi, Harvey, rileyjo, and Silvina all tied for third with 6 points.

Overall, Yerkiet stays in the lead with 20 points. Harvey and jwsellers are tied for second with 18 points. Nextsundayad drops to fourth with 17 points. mbrigdan and Ash88 are in fifth with 16 points. If you scored 13 points or higher, you are in the top 10%.

Click here to see the full scoreboard.

A fairly light episode that clarifies some parts of NüFringe, particularly the Cortexiphan trials. Plus, the full return of Peter.

The Plot: Olivia is awakened one morning by a strange blue energy apparition. She notices that the apparition draws metal objects nearer, but she misses the strange effect it has on the flow of time. She is burned on the arm when she comes into contact with it.

Olivia reports what happened to Walter at his lab, and he sends her and Astrid back to the apartment to get some more readings. Watching over the video link from back at the lab, Walter witnesses another materialization of the apparition, only he sees the events before they actually occur. Talking with Olivia later, Walter tells her that the phenomenon reminded him of one of her fellow Cortexiphan subjects, a boy who had the ability to astral project, but also had some magnetism-related side effects. Olivia looks over the Cortexiphan trial notes, now held by Nina Sharp over at Maxiumum Dynamics. From these notes, they learn the subject’s name, Cameron James, and where to find him.

Olivia and Walter head to New York City to talk to Cameron, but he isn’t at his apartment when they arrive; they’re told by a nosy neighbor that he’ll be back in the morning. She and Walter get rooms a hotel, but Walter freaks out with an attack of mysophobia and the two of them end up enjoying late night rootbeer floats at a nearby restaurant. While there, the apparition manifests again, bigger than before, and doesn’t fade away until it disrupts traffic and is hit by a car.

The next morning, Olivia manages to track down Cameron, but he insists he has nothing to do with the strange occurrences. While talking with him in his apartment building’s lobby, the phenomenon occurs again, but Cameron is able to drive it away using what little remains of his Cortexiphan powers (side effects, at this point really). Walter devises a plan to use Cameron’s abilities and a large chunk of New York’s power grid to destroy the apparition once and for all. The energy apparition appears again, and Walter’s plan seems to be working – but then Olivia sees the face and body of Peter materialize in the energy. She stops Cameron and the apparition disappears – but then Peter suddenly surfaces at Reiden Lake and is rescued by two fisherman. A short time later, the Fringe Team arrives at the hospital where Peter is taken. Broyles is understandably concerned that this unknown person knows so much about Fringe personnel and history. Olivia walks into Peter’s room and he is clearly delighted to see her, but she still has no memory of him.

1. Fallout, Boy?
A rad is an all but abandoned scientific unit that measures absorbed radiation. There is a lot of math in figuring out equivalent doses, depending among other things on the material involved, but two rads is roughly the same dose of radiation from twenty chest x-rays, a CT of the brain, or a third of a CT scan of the chest.

2. Needed Better Career Counseling
If Cameron becomes magnetic when anxious, then why drive a truck for a living? There’s a great deal of metal in vehicles, and you’d think driving a truck in big city traffic would get quite anxious.

3. Amalgamated
Dental fillings aren’t particularly magnetic. By the time Cameron was generating enough of a magnetic field to affect the fillings, surely there’d be a noticeable effect on the silverware and probaly the pots and pans in the kitchen as well, if not more.

4. NüFringe Revelations
Changes over past Fringe Continuity:
The ethical fallout from the Cortexiphan trials has not occurred in NüFringe. Knows nothing of any of the other Cortexiphan .
Olivia has shown no Cortexiphan related powers as an adult.
Nina and Walter have quite an antagonistic relationship while Nina and Olivia seem to share a more maternal/child bond.
Walter mentions that his wife Elizabeth committed suicide after the death of “our Peter” — suggesting that she died before Walter crossed over to get the alternate Peter.

5. What’s In A Name?
“Cameron James” — really? Why not also have Spielberg Steven, Polanski Roman, or (for an almost believable name) Lucas George?

A fairly shallow episode, plot-wise, but I enjoyed the new Cortexiphan revelations and the return of Peter — in an almost logical manner, at least from a Fringe point of view — so the Fringe Doomsday Clock will move back one minute to 11:52.

Tags: television fringe cortexiphan peter astral projection reiden lake

Hopefully not too many of you found yourself watching Terra Nova instead of House because of the ALCS running late tonight.

Tonight’s episode of House featured House’s return to Princeton Plainsboro Hospital to work under Foreman, the new Dean of Medicine. The social aspects of the episode was good, and the mystery intriguing, but the follow through lacked some luster.

Foreman, now Dean of Medicine at Princeton-Plainsboro Hospital, has arranged for House to get a conditional release from prison. The conditions are fairly simple: House is to break no further laws, is under Foreman’s direction, and is only to be at his apartment or at the hospital. (Or at least, those are all the conditions we know about now…)

Foreman has arranged for House’s release because of a difficult medical case. A young college student was killed in a motorcycle crash and his lungs were donated. Just as the transplant surgeons were ready to implant them into the new patient, the lungs went bad, showing signs of increasing airway resistance. The lungs were then placed in a pristine plexiglass box (seriously, no blood? No fluids?) hooked up to a ventilator. House has twelve hours to find out what’s wrong with the lungs and fix them so that they can still be transplanted. To help him out, he’s given the services of Park, a resident who punched her Neurology attending after he copped a feel.

House and Park meet with the transplant team. Their initial diagnosis is ARDS (acute respiratory distress syndrome), which House discounts as there is no exudates. He suggests ehrlichiosis, but that’s already been tested for and treated, and then suggests cocaine. While the patient’s drug screen was negative, House feels the cocaine ingestion was too recent to have made detectable metabolites in the urine. He and Park search the victim’s bedroom at his parent’s house, but find no evidence of drug use. They do find a new pair of glasses and an admission from the victim’s father that his son had headaches, leading House to a new diagnosis of brain tumor. He and Park get the body from the morgue with the plan of getting an MRI. House notices a bulge in the arm, and now thinks that instead of a brain tumor, the victim had rhabdomyosarcoma (A malignant muscle cancer) and paraneoplastic syndrome.

However, reality — such as it is on this show — is unkind to House. The MRI reveals no tumors, and what he thought was a muscle mass was a clot caused by the intravenous plasma the victim had received in the emergency room. House now suspects that something in the unit of plasma the victim received caused whatever is happening in the lungs. The trouble is that each unit of plasma is made up of donations from a number of donors — twenty-five is the number House throws around. He has six hours to find something in the history of those twenty-five donors that will explain the lungs. Possibilities include peanut allergy, dengue fever, FMF (Familial Mediterranean Fever), malaria, acute alcohol intoxication, or lead poisoning. The latter seems the most likely so he starts chelation therapy on the lungs. At first, they seem to be improving, but then things take a turn for the worse. Park and Foreman are able to correct the vasospasm in the lungs, but not before the right middle lobe dies. House is undeterred; he looks at the dead lobe as some tissue he gets to biopsy for the right answer.

Considering what conditions might cause chelation to go poorly, House considers and discards the diagnoses of sarcoidosis, heavy metal poisoning, and asbestosis before settling on the diagnosis of hemosiderosis (a type of iron overload). Park stains the lung tissue for iron, but instead of the expected metal, she finds white blood cells. To House, this suggests an infection hiding in the lung cells, likely brucellosis. He starts the lungs on antibiotics and IVIG (intravenous immunoglobulin). The treatment doesn’t help, and in fact seems to make the lungs worse. Desperate for ideas, House looks to Park and the transplant surgeon for ideas, but all they can suggest are IgA Nephropathy and lupus. House has his eventual Eureka! moment watching one of the wards celebrate a nurses birthday with cake and candles and realizes that the patient had eosinophilic pneumonitis, and the cigar smoke he was exposed to the night of his death caused his lungs to shut down. The lungs are given radiation treatment and this cures the problem, allowing the lungs to be transplanted.

The medicine was extremely disjointed this episode, jumping almost randomly from diagnosis to diagnosis. Some of this was due to the nature of the patient: lungs in a box, but part of it seemed to be a return to the usual poorly thought out differential diagnosis of prior House episodes. As usual, major complaints are in red, modest complaints are in blue, and nit-picking ones in green:

I admit it’s out of my field, but keeping the lungs alive in a pristine clean box — no blood, no fluids, no drainage, no mess — seemed unrealistic.

Not a medical question per se, but how did House, a convicted felon, manage to retain his medical license?

Radiation for eosinophilic pneumonitis, even in this “every minute counts” scenario? Ridiculous. Radiation therapy, even if it would work for this condition, takes time — more than a single treatment — and has its own set of side effects (radiation pneumonitis, for instance). Why not stick with the corticosteroids, since a transplant patient is likely going to need them for some time?

Would a patient with active angina be a candidate for a lung transplant?

Nitrates don’t cause renal insufficiency.

An iron-stain of the lung tissue incidentally reveals high white cells, but no one follows through with a simple H&E stain to show what types of white cells they are.

I would expect the patient to have an elevated WBC, particularly elevated eosinophils.

The patient had severe enough EP to cause a life threatening reaction to cigar smoke, but had never had symptoms before? Surely he’d been around tobacco smoke before…

This week’s medical mystery offered an intriguing premise, but it failed to live to it’s full potential. Just like last week, I give it the mystery a A-. The final solution was unsatisfying, even if it was more or less almost nearly logical. I give it a C+. Unlike last week’s logical progression of medical diagnoses, this week seemed particularly haphazard, and this was a case where a consistent logical approach would have been extremely important. It earns a weak C. I enjoyed the soap opera this week, particularly the scenes with Foreman (but lose the ’stache), Park, and especially Wilson. I give it an 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.

A decent monster-of-the-week episode of Fringe. There was a little advancement on the Peter end of things, plus a little more history of NüFringe continuity, but still a just slightly better than average episode.

The Plot: An aggressive neurotoxic fungus has been discovered in an old tunnel in Boston. By the time the Fringe Team has been called in, it has killed two twelve year-old boys. The extremely decomposed bodies of the two victims explode in a rain of spores. Walter understands what it happening and contains the explosion just in time. The medical examiners in the morgue aren’t so lucky, though, and die when the second corpse explodes. That brings the total dead to three four. A dead homeless man is found in another tunnel, bringing the total to four five. The fungus is spreading throughout the old tunnels underneath Boston.

The team has discovered a third young boy, Aaron, who was in the first tunnel. Walter learns that Aaron and the fungus have sort of psychic bond. When the FBI tries to kill the fungus it, it affects Aaron. Broyles gives Walter two hours to sever the psychic link, but he is unable to. Luckily, at just the right moment, he learns the fungus is more dependent on the boy that the other way round. He convinces Aaron to let go of the psychic bond, and that allows the Fringe Team to destroy the fungus, yet leaves Aaron unharmed.

After the fungus has been dealt with, Walter and Olivia realize that they’ve both been seeing images of a mysterious man — Peter. Walter sees and hears him through visual and auditory hallucinations, while Olivia sees him in her dreams.

1. More Of A Retcon Than A Reboot
We finally learn the fates of the Peters in the NüFringe continuity, and it’s not all that different from the original continuity. Walter’s Peter died young of an illness, just like what originally happened. Similarly, Walter crossed the barrier between dimensions to rescue a sick alt-Peter. Only, when returning to our world, after falling into the icy lake, Peter died. I guess there was no Observer to rescue them this time.

2. I Was Hoping For A Nosebleed
Interesting “psychic bond” from the fungus:
Tinfoil hats offer no protection (despite numerous independent studies showing otherwise)
It can link to a kid at a lab in Harvard, but not to itself in a Boston morgue, which should be closer.

3. I’m Guessing There’s No OSHA in NüFringe
Whose bright idea was it to send the Fringe Team into the tunnel, any of the three times, without protective gear?The first time, all they knew was that something was in there that could cause rapid decay — but that’s reason enough to be protected. The second and third time it was known what was in there and what it was capable of doing, yet no one thought to wear protective equipment (despite wearing it in the morgue). A little foresight would have prevented Agent Lee from getting trapped.

4. There’s No Percentage In That
What sort of reading is a respiratory rate of 89%. Respiratory rate is a number, not a percentage, and the there is wide variation in what is normal – from person to person, and within the same person from minute to minute. I suspect they meant oxygen saturation (which is a percentage score), not respiratory rate.

5. Leave The Carotid Alone
Just like a shot of adrenalin to the heart is a bad idea – no matter what Pulp Fiction says – a shot of epinephrine (another name for adrenalin) into the carotid artery is just as bad. Just put in the IV, it’ll get there nearly as fast and without the risk.
Walter has some of the worse syringe skills I’ve ever seen – not what you’d expect from a self experimenting junkie. Hideously poor sterile technique as well.

6. I’d Rather A Bottle In Front Of Me
The tools that Walter was using were the proper tools for a frontal lobotomy — at least the “from behind the eye” style that was popular for a brief time (a very brief time, thankfully).

Another episode that was neither good nor bad enough to move the Doomsday Clock. The fungus was suitably creepy, but the lack of common sense shown by the agents time and time again hurt the chances of moving the clock.

Tags: television fringe fungus cordyceps psychic

Watching the Cardinals/Phillies game. Come back tomorrow.

The first episode of what is likely to be the final season of House is off to a good start. The constraints of practicing medicine in prison focus the usually superficial medicine on the show down to its core elements.

After last season’s finale, House is now in prison for driving his car into Cuddy’s house and then fleeing the country for three months. In a meeting before the parole board, House is informed that due to prison overcrowding, he is due to be released in five days, as long as he can stay out of trouble. What follows is a week in the life of Gregory House, prisoner.

As the week start, we see him in line to receive his daily medication. He’s there not only to receive his Vicodin, but also to make sure his sociopathic roommate takes his medications. He also passes one of his painkillers as a “tax” to the head of the jail’s neo-Nazi gang.

Nick, a fellow prisoner, asks House for some medical advice, but House blows him off. Later in the day, when House is doing his rounds as a janitor, he is in the clinic when the doctors are examining Nick. Noting the joint pain and fever, Dr. Adams is prescribing ceftriaxone for a suspected case of gonorrhea. House jumps in, telling her it isn’t gonorrhea and suggests his thinning eyebrows suggest that Nick has lupus. Dr. Adams points out that he doesn’t have the classic malar rash so it can’t be lupus.

The next day, House checks out Nick himself and finds a rash (which he never describes, so it could be any kind of rash) on his left thigh, but Dr. Adams is unimpressed. Later that day, being jostled into a wall breaks Nick’s arm. Bones that break so easily don’t fit with lupus, so House realizes that cannot be the right diagnosis. During his janitor rounds, he discussed the case with Dr. Adams again. Viral syndrome and MRSA infection (antibiotic resistant Staph infection) are mentioned but quickly discarded. Knowing that Nick is a smoker, House now suspects that he has metastasic lung cancer (lung cancer which has spread to the bones, and bones with cancer break easier than normal bones), but it will take a couple days until an x-ray is available. This doesn’t sit well with House. Through an exceedingly thoroughly lung exam, including auscultation and percussion, he is able to convince Dr Adams that Nick has some sore of lung mass. She doesn’t have access to any stat labs or x-rays, so she decides to run an old fashioned bleeding time test (patients with cancer have blood that clots too easily, so she suspects his wound will clot sooner than expected), but instead of clotting, Nick bleeds profusely from his wound.

By the next day, an x-ray has been obtained but it shows a lipoma (a benign fatty lump) rather than a tumor. Dr. Adams suspects a toxin, but she is caught sharing patient information with House and no longer allowed to discuss cases with him. Later in the day, Nick comes to talk to House again. House tries to blow him off, but in the middle of it, Nick collapses in anaphylactic shock. Luckily, House has a convenient ballpoint pen to perform an emergency tracheotomy and save the patient’s life. House’s suspicions are pointing toward some sort of allergy, probably a food allergy, at this point.

On his final day, House has his Eureka! moment when he sees a prisoner drinking a hot cup of coffee. He realizes that Nick has mastocystosis, which caused an anaphylactic attack when he drank hot coffee. House wants to give some aspirin to Nick in an attempt to induce an anaphylactic attack, which would prove the mastocytosis, but Dr. Adams supervisor won’t allow it. A short while later, House intentionally enrages the neo-Nazis in order to get himself beat up so he would get sent to the clinic (whether the riot that followed was part of his plan or not). Once in the clinic, though he threatened with the loss of his parole, he gets Nick to drink the aspirin. As House is dragged away, despite drinking the aspirin, Nick remains symptom free.

When last we see House, he is locked up in the solitary wing of the prison. A meal tray arrives, along with a note that says, “You were right.”

Non-medical comments:
It was nice to see House act Holmes-ian again — identifying and explaining Adams by her shoes, scarf, locket, etc.
I always knew Urkel would end up in prison.

I don’t have that much negative to say about the medicine this week. I liked the idea of having to make a diagnosis with limited resources, and I think the writers pulled it off better this time than previous attempts (like on the plane). The medicine was relatively logical this time with not many curve balls and zebras thrown in just for sake of it. As usual, major complaints are in red, modest complaints are in blue, and nit-picking ones in green:

There are better blood tests from Mastocytosis than House lets on; for instance, a bone marrow biopsy is a good test. Now that Nick has been stabilized, this is not a situation that needs emergent treatment. He can wait the few days required for definitive testing.
ASA has been known to induce mast cell degranulation – and subsequent anaphylaxis – in patients with mastocytosis, but it’s not reliable enough to use a diagnostic test. A positive test would suggest mastocysotis (or an aspirin allergy), but a negative test wouldn’t rule out the diagnosis.

You can’t differentiate a lipoma on an x-ray. You could see that there were no lung masses, but at best an x-ray would suggest a soft tissue mass. You’d need a CT scan or something similar to identify it as a lipoma.
If it were a lipoma, that would be a tissue mass, not a lung mass, so would not have affected the lung exam. The lung beneath it would still percuss as hollow, not solid.

House specifically asked his friend for his pen, but why? He didn’t use it in his firestarting routine. He seems to only have needed it so he could use it to perform a tracheostomy later.

Bleeding time test is a test primarily for platelet function. I don’t know if it’s ever been tested or is appropriate in cancer patients.

Was Nick’s broken arm/elbow ever treated?

This week’s medical mystery was a little vague and general at first, but picked up as the episode progressed. It would have been a two-minute clinic quickie in previous seasons, but it fit the prison milieu perfectly; I give it an A-. The final solution, though a stretch, fit the scenario and earns a B+. The medicine followed a logical progression for once, and the constraints of being in prison helped rather than hurt. It earns a B. Even though the players were new — except House — the soap opera was well done and earns a B+.

A list of all prior House reviews

This week’s House Challenge scores have been posted.

The scoring this season starts out with a bang, thank to the mention of some old favorites like lupus and MRSA.

As of Week 1, Yerkietleads with 18 points. jwsellers and Nextsundayad are in second with 15 points. Rounding out the top five, mbrigdan is in fourth with 12 points, and Sean McBride is in fifth with 7 points. If you scored 6 points or higher, you are in the top 10%.

Click here to see the full scoreboard.

There were enough twists in this episode to redeem an otherwise straightforward hunt-the-serial-killer storyline. Sure, we all knew what was going to happen by the end (turning on his double, amnesia, etc.), but the concept of using an alternate universe analogue as essentially a human bloodhound for himself was clever.

The Plot: Olivia is called in by Broyles to work on a serial killer case, only it turns out it’s a case in the alternate universe and Fauxlivia has asked for their help.

After five years of chasing the murderer, alternate-Fringe have finally learned
his identity, only now they can’t find him. Their solution is to have Olivia cross over with the killer’s double from our universe, hoping he can point out what they might have missed. As it turns out, the killer’s double is a forensic psychiatrist and he is happy to help the FBI on a profiling case, not realizing the true identity of the killer, and the team keeps the secret of the two universes from him. He’s no dummy though, and quickly spots pictures and belongings in the killer’s house that he knows he owns as well, and the Olivias have no choice but to tell him the truth about the second universe.

Word comes down from alternate-Broyles that the killer had kidnapped another victim. While the team deals with this information, the profiler escapes, believing he can track down and stop his other self. Acting like a competent detective for once, Olivia is able to track their whereabouts to an old family farm.

Meanwhile, the killer’s double interrupts his other self in the middle of a murder and tries to help him see the error of his way, but the killer sucker punches him, and soon the double is strapped to a chair and pumped full of sodium pentathol while the killer uses a machine to drain the happy memories from his brain. The Fringe team arrives in time to rescue the victims, and Fauxlivia saves Olivia’s life by shooting the killer when he drew a gun on her. In the end, the killer is dead and his double returns safely to our world –luckily his memories of his time in the alternate universe were drained by the killer’s machine so the secret is safe.

And Walter covers every reflective surface in his lab so he can’t see Peter – and it works – only he can still hear him.

1. Ch-Ch-Ch-Changes
Post-Peter continuity in the Alternate Universe:
Fauxlivia is still with Frank (which makes sense, as there was no Peter to get pregnant by)
Alternate Broyles is still around (which doesn’t make as much sense, since his helping Olivia escape cost him his life, and not Peter)
Meat is readily available now.

2. Led Astray
Multi lead EEG display in the killer’s lab, but there was only one EEG lead, at best.

3. To Tell the Truth
Sodium pentathol is not that powerful a “truth serum,” at the high doses needed to make people with holes-drilled-in-their-head feel comfortable enough to talk that freely to a strange person, they’d either be dead or completely sedated.

4. High Fidelity
As much as Olivia was shown to be a good detective this episode, the alternate-Fringe team was horrible. Did it never occur to them that the killer’s double would see something in the killer’s house to clue him in to the truth? I figured it was going to be a problem the moment they announced their plan.

5. High Fidelity
I liked Walter’s recreation of the classic Maxell ad.

6. Reading Too Much Into It.
The tractor license plate numbers recalled by Olivia were entirely different in the spoken versus closed caption version.

An average track down the serial killer plot helped along by some clever Fringe twists. Still it was neither good enough to loose time from the Doomsday Clock, nor bad enough to advance it.

Tags: television fringe fauxlivia alternate universe serial killer

Terra Nova = The Unteleported Man + Mastodonia + (a little bit of) Earth 2

A fairly slow moving episode, designed to let us learn the new Fringe Division status quo and introduce a new character or two. Plus maybe some recurring villains

The Plot: The episode, and the season, starts with two brief vignettes: A verbal sparring match between Olivia and Fauxlivia as they trade Fringe Division case files, and a conversation between two Observers where they discuss the fact that Peter Bishop, or at least part of him, is still around. The senior Observer admonishes his junior counterpart that he needs to take care of Peter once and for all.

The episode proper starts with FBI Agent Lincoln Lee swinging by to pick up his partner, perpetually tardy family man Robert Danzig. Later, the pair is pursuing an arms dealer but split up when he disappears in a maze-like basement complex. Lee manages to catch the dealer, but when he goes to look for Robert he finds him dead with a strange translucently skinned man standing over the dead body. Robert face has a similarly translucent appearance. Lee gives chase but the strange man escapes by jumping through the window (windows, really).

Fringe Division is called in to examine Robert’s death. Olivia talks with Lee, telling him her division is taking over the case, but won’t give him any more information. Lee won’t take no for an answer, and manages to track Olivia back to Walter’s lab where he demands more answers. A call from Fringe Division HQ comes in, alerting the team to a new body. Lee invites himself along. This time the victim is a female, but she has the same partially translucent look as Robert had. Lee manages to find a witness who has a photo of the killer, a translucently skinned man. Reluctantly, Olivia informs Lee that there have been other similar killings before Robert. She takes him to a morgue at Fringe HQ where there are dozens of dead bodies – all from the last three days, Broyles informs them. Broyles mentions that they have not been able to find any common link between the victims. Lee tells Broyles that Robert had Crohn’s disease and took iron pills, and wonders if that may be the missing connection. Walter looks into Lee’s idea and finds that neither Crohn’s nor iron is the link, but “heavy metal poisoning” is. He also mentions that the victims’ blood seems to have been cleansed of all the expected excess heavy metals.

Meanwhile, in a dingy lab, the translucent man takes a vial of neon liquid, draws it up in a syringe, and injects it into his arm. We see a flush of mercury under one of his fingernails, which then loosens. He pulls the nail off, and seems quite pleased by whatever just happened.

Back at Walter’s lab, Agent Lee makes another connection: all the killings have been close to one of four commuter rail stations. Teams of FBI agents stake out the stations and sure enough, one team sees the translucent man and gives chase. Olivia and Lee arrive just in time to find both agents down: one dead and one wounded. Lee stays to help the wounded agent while Olivia takes off after the translucent man. She finds him in his lab, burning his notes. There is a scuffle, and in the end she shoots him, repeatedly. This takes care of the bad guys, right? Wrong. The wounded agent informs Lee that there was more than one translucent man – and the other one stole his pistol. Lee goes off looking for the missing perpetrator and finds him hiding around the corner. Lee is able to shoot him before the translucent can get a shot off.

An autopsy of the translucent men back at Walter’s lab reveals some tech similar to that used by the shapeshifters from the previous two seasons. To Walter, this is proof that they are part of a scheme by Walternate. Olivia takes the suspicious tech to the Liberty Island dimensional bridge and hands it over to Fauxlivia, who says she’ll “look into it.” Agent Lee tags along as well, learning more of Fringe Division’s secrets.

The episode ends with a few more brief vignettes: a third translucent “man” is seen, only this one looks just like the female second victim. An Observer shows up outside Walter’s lab with his machine, the one designed to erase someone from history. He turns it on, but appears to think better of it, and switches it off. Finally, Walter sees Peter’s reflection in his television set, and it is clear that he is spooked by the fact that he keeps seeing this person who he does not recognize.

1. Lesson One: Never Partner with Olivia
Which partner is Olivia referring to when she told Lee about her dead partner? Agent Scott? Charlie?

2. Is She Reading Ahead in the Script?
Why evidence did Olivia have that the translucent men were shapeshifters, other than the suspicious tech? I bring this up because she referred to them that way when talking to Fauxlivia but had she seen one change, or appear in someone else’s shape? The only shapeshfiting I recall was the female translucent “man”, and we saw that after the Liberty Island hand off.

3. Is this FRINGE or HOUSE?
Walter is making quite a reach with his statement blaming heavy metal poisoning. First, bear in mind that there are dozens of heavy metals (from a medical point of view, pretty much every metal with toxicity is considered a “heavy metal”) and they each can cause different symptoms. Sure, everything he mentions can be associated with heavy metal poisoning, but only in very very rare cases. Yes, some heavy metal poisonings can cause hair loss. But it is an extremely unusual cause of hair loss and there would be many other more telling symptoms of heavy metal poisoning. Genetics, sadly, is by far the most common cause of hair loss (trust me on this one: personal experience). Similarly, some heavy metal toxicities can cause kidney disease, but there are many more common causes — high blood pressure or diabetes, for instance. High lead levels can cause gout (saturnine gout), but this once again is a very rare cause. I’ve probably seen several hundred gout cases, and never yet seen one associated with lead toxicity. Most gout is caused by bad genes, and poor diet is the second most common cause. Crohn’s is not associated with heavy metal poisoning either (but in this case, I assume it was the iron Agent Danzig was taking that Walter was referring to, not the Crohn’s itself).

4. One Way Street
If the translucent man was injecting into a vein, the chemical was flowing the wrong direction, but maybe it was an artery…

5. Be Careful Around the Thirteenth One
I’m pretty sure the secret to being a good FBI Fringe Agent is just to keep an eye on every warehouse in town. Damn villains are always using those warehouses.

6. Put On a Jacket
I suspect Walter’s prominent mention of John le Carre’s novel The Spy Who Came in from the Cold is a hint at things to come, but its exact significance escapes me, unless he is similar suggesting intricate plots within plots within plots in the Fringe world (which, like the era of le Carre’s book, is in a Cold War — this time between the two dimensions).

7. Flashpoint
I’m sure the timing is just coincidental, but this Fringe reboot is reminding me an awful lot of the current Nu52 reboot at DC Comics. If Olivia starts wearing red lingerie or sleeping around, I’ll become extremely concerned (of course, this is Fringe after all — maybe it’s Walter who’ll wear the red lingerie).

A fairly slow episode, but it was clearly designed to introduce the new status quo and stir up some plot elements for later in the season. The Fringe Doomsday Clock remains where it ended last season at five seven minutes to midnight. (Or Doosmday Clock, if you prefer.)

Tags: television fringe observer shapeshifter lincoln lee

Continuing the character biographies from the 2008 Fringe Convention Exclusive comic. Here’s four more, including a couple characters who’ve died (more or less):

Back in the summer of 2008, before the first season of Fringe, special “Fringe Convention Exclusive” comics were published and available at the summer comic book conventions. These contained a brief comic story, mostly an ad for the upcoming Fringe comic, but they also contained biographical pages for each of the major characters. These pages contain some interesting personal details that — to my knowledge — have never been mentioned on the show.

Here’s the first four, I’ll post the other four later today (click on the thumbnail for the full image):

Season Eight of House starts in three weeks, on October 3rd, 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.

To play the full season, your list must be posted in the comments section by 7pm (Central time) October 3rd — the night the season starts. Later entries are accepted and will start accruing points the following week.

Last season’s final standings can be found here.

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.

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

The final episode of an unsatisfying season of House was — appropriately enough — unsatisfying. The story, both medical and soap opera, had potential, but it was like everyone gave up two-thirds of the way through.

Afsoun Hamidi, a famous performance artist, is in the middle of an exhibition when she collapses. She is admitted to House’s team at Princeton Plainsboro with arrhythmia, a high hematocrit (too many red blood cells), and “inconsistent RR variability” (a measure of the difference between heart beats). Foreman also thinks that she is crazy and he wants to do a functional MRI to confirm this, but House shoots him down. Other possible diagnoses are an allergic reaction to the paint thinner used in the performance art, or carbon monoxide poisoning from a nearby space heater. House favors the latter and has Afsoun placed in a hyperbaric chamber. Once inside, she becomes sick and vomits. Thirteen suspects infection, but House has caught on to the fact that Afsoun is secretly videotaping everything to make a new piece of performance art.

Chase informs House that Afsoun had a pancreatic cyst that he drained. According to House, the differential now consists of a Coxsackie B viral infection. He also orders a CT scan to check for gallstones — not that he thinks Afsoun has gallstones — but because he’s giving Foreman a chance to scan the lungs to prove his own theory: that pain thinner fumes are the culprit (not that House thinks Foreman is right — he just wants to be there when he’s proven wrong). Sure enough, the CT of the lungs is negative. During the procedure, Afsoun becomes dizzy, pale, diaphoretic (sweaty), tachycardic (elevated heart rate), and hypotensive (low blood pressure). This leads the team to suspect internal bleeding. A colonoscopy is negative and an abdominal ultrasound is also negative. Foreman becomes suspicious and discovers evidence that Afsoun has been secretly blood doping (injecting herself with her own blood) to manufacture symptoms. He also learns that she has been researching Greg House. All to make a more compelling piece of art.

House confronts Afsoun and she admits her deception. But then she tells him that she is really sick, and challenges him to find here true diagnosis. She tells him that she may make up some symptoms, or hide others — but that’s all part of the game. Much to his team’s dismay, House decides to play along. He starts by ordering blood cultures. When Thirteen and Chase are drawing the blood, Afsoun complains of nausea and back pain. A quick physical exam reveals Grey Turner’s sign (bruising of the flanks — indicative of a particularly nasty pancreatitis). Meanwhile, taking a look at Afsoun’s past exhibitions, House has concluded that she has something fatal. A CT scan of the brain shows a mass. House tells her that he’s won the game: she has primary CNS lymphoma with paraneoplastic syndrome. She confirms that House is right.

A little later, House sees that Afsoun is still in the hospital. He asks why, and she mentions that she’s waiting for the nurse to bring her something for her eczema, which seems to have been worsened because of the paint thinner. Looking at the rash, House realizes that it is not eczema. He also realizes that his previous diagnosis was wrong: Afsoun actually has Wegener’s granulomatosis. She is offered radiation therapy and/or steroids for treatment. She initially declines the radiation therapy for fear of mental decline, but is ultimately convinced by Thirteen and her assistant to go for the radiation treatment — and that life may be more important than art.

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

As mentioned numerous times before: it’s irresponsible and unprofessional to treat cancer without a definitive biopsy. It’s one thing to accept that from House, but from another doctor at another hospital?

Radiation is not a first-line therapy for Wegener’s granulomatosis. It’s not even a second- or third-line therapy.

Pallor, diaphoresis, tachycardia, hypotension are all signs of an acute anemia (i.e. blood loss) – which they then tried to explain away as a return to her normal state from the increased hematocrit from blood doping. Nonsense. First, the return to her normal state would be a gradual process, not an acute one, so would not trigger these symptoms. Second, her normal state whould be normocythemic (normal blood counts) not anemic (and certainly not acutely anemic), so that explanation doesn’t pass the common sense test.

“Arrythmia” is a vague term. It’s something you’d find in a general review of a topic (such as “Symptoms associated with blood doping”). A doctor of the caliber of House or his team (or frankly any competent cardiologist or generalist) would be specific about what type of arrhythmia it is. Tachycardia? Bradycardia? PSVT? PVCs? WPW? Afib? VFib? Vtach? Torsades? Each has different causes and different treatments.

Once again, a good physical exam on admission would have found several symptoms earlier: the bruising and the rash. A really good physical exam would have found the injection marks.

There are causes of pancreatic cysts other than acute pancreatitis.

A simple blood test can easily confirm carbon monoxide poisoning.
If it was carbon monoxide poisoning, why wasn’t anyone else at the gallery, at least her assistant, also having symptoms? At least headaches?

Coxsackie B virus doesn’t fit her symptoms at all.

If you’re suspecting internal bleeding, why not perform a quick CT — especially since she’s already in the CT machine?

This week’s medical mystery was moderately interesting, but didn’t sustain interest even after it became a game (not that it mattered, since despite threats, she didn’t lie about any symptoms). I give it a B-. The final solution was unimpressive and earns a C. The medicine was superficial and sloppy, and was driven by the plot, not the other way around. It deserves a measly C-. The soap opera was fair, but could have been so much better. The flash forward sequences held a lot of promise — promise that was never really fulfilled. I give it a B.

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

The final scores for this season’s House Challenge have been posted. Thanks to all who played.

Tags: television medicine house art carbon monoxide lymphoma wegener’s granulomatosis

The final week of the challenge, and seven people chose the correct diagnosis. There were several “almost correct” diagnoses that also scored points. For this week, Bhetti leads with 13 points, and Adriana, Akshay, Amr, JenJen, Joe, and Mac all scored 12 points.

Overall, Jamie Pt finished the season at #1, and even padded the lead a little. Here’s the top 10 overall:

If you scored 55 or more points, then you finished in the top 10%. Congratulations!

Click here to see the full scoreboard.

A cleverly set up episode of House, with an interesting medical mystery — though the medical conclusion was less satisfying.

I

Darrien, a friend of Thirteen from prison, knocks on her door late at night. She’s been stabbed in the belly and wants Thirteen to fix her up while promising not to take her to the hospital. Thirteen reluctantly agrees and carefully explores Darrien’s wound, declaring that the bowel is fine, however the liver has been nicked — but has clotted off, so blood loss should not be an issue. However, when she’s rechecking Darrien’s vitals, she discovers that there is no detectable blood pressure or pulse in her left arm, though her right arm is fine. Thirteen calls Chase and has him bring a portable ultrasound machine from the hospital because she is worried the patient may have an aortic arch aneurysm. The ultrasound shows no aneurysm, and Chase wonders if Darrien may have clotted off the blood supply to the left arm. They take a close look at the arm blood vessels vessels and and find some sort of mass in the axilla (arm pit), possibly a lipoma (a fatty lump) that is pinching off the blood flow to the arm. They stick a needle in the mass to drain it, but instead of fat, they drain syringe after syringe of blood. Chase suspects the excess bleeding may be a result of the patient’s drug use, her hepatitis C, or exposure to toxins. Thirteen believes that Darrien depleted all her clotting factors dealing with the stab wound, so has none left for the cyst in the arm. She sends Chase out to pick up some IV clotting factor.

While Chase is gone, Darrien begins to hallucinate. This is a sign that she there may be bleeding in her brain. Thirteen wants to give more clotting factor while Chase wants to take Darrien to the hospital. After a brief scuffle, Chase wins and they take Darrien to Princeton Plainsboro, but she falls unconscious along the way. Once there, they obtain a head CT, which shows no bleeding in the brain. Puzzled, they call House who points out that they’re making assumptions about how long Darrien has been abusing drugs and had hepatitis C. Looking back through newspaper records, Thirteen is able to discover that Darrien has had hepatitis for no more than three years, but because she received chronic hepatitis C treatments with interferon while she was in jail, her presentation must have made it appear she had it longer. Thirteen and Chase finally deduce that in addition to the hepatitis C, Darrien must have had a second infection with the parasite Entamoeba. The amoeba had formed an abscess in her liver and thus when her liver was injured in the stabbing, it released the parasite back into her bloodstream which led to her other symptoms. Thirteen and Chase give Darrien some metronidazole and she comes out of her coma.

II

Meanwhile, House has discovered that all the rats given the experimental drug he’s been using have died of cancer. He CTs his leg and finds some suspicious masses. House then decides to remove his tumors himself, but it turns out to be more difficult than he anticipated. He is forced to call Cuddy for help and she takes him to Princeton Plainboro where he eventually requires surgery.

III
Taub has been sleeping with the one of the nurses and she is now pregnant. He is unsure how to proceed, so he and Taub head to strip bar, where Taub ultimately finds himself thrown out and then nearly shot as a stalker.

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

This is another one of those episodes where the final diagnosis doesn’t really explain all the symptoms. The excess bleeding in the arm cyst – and was that a cyst or a lipoma or what? – was that caused by “depletion of clotting factors” (however unlikely that may be) or by the amoebas. The hallucinations and the coma, was that the amoebas again? You can certainly get amoeba problems in the brain, but not so quickly after exposure.

Thirteen is way off about hepatitis C. Chronic is defined as 6 months, not 10 years (or even three years). Interferon is given for chronic infections, but is also given more commonly for acute infections as well now.

Sure, hallucinations could be a sign of bleeding in the brain – through there should be other noticeable neurological signs as well – but what about being caused by blood loss? Darrien may not have signs of internal bleeding, but Thirteen has no idea how much blood she lost before she showed up at her apartment.

Lipomas aren’t full of liquid fat, they’re full of solid fat, so they’re nothing you can drain with a syringe. They’re quite…chunky.

If Thirteen knew Darrien had hepatitis C, she should probably have washed off all the blood dripping from that one hand.

Intravenous clotting factors aren’t something you can just call into the neighborhood pharmacy and pick up. Institutional use only.

This week’s medical mystery was interesting — first the bleeding patient lurching down the hall — and the reveal of the lack of blood flow in the left arm. I give it an A-. The final solution, while clever, didn’t really fit the symptoms well: C-. The medicine was sloppy, some of which I can explain away as apartment-based-emergency-medicine, but you can’t excuse poor basic medical knowledge. It earns another C-. The soap opera was good on many levels this week, from House/Wilson and House/Cuddy (and House/Rachel) to Chase/Thirteen and especially Taub/Foreman. I give it an A.

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

The penultimate House Challenge scores for the season have been posted.

A very low scoring week. Cyndi, Gleb, and Steve led with 4 points. Seven other people earned 1 point. Everyone else got nada.

Overall, Jamie Pt remains in the lead with 72 points. Gleb leaps into second with 67 points. Corien and Forny drop to third with 66 points each. Tippi falls to fifth with 65 points. If your score is 54 points or higher, you are in the top 10%.

Click here to see the full scoreboard.

Thanks to Foreman mentioning a handful of common condition, almost everyone scored at least 1 point this week. No particularly high scorers though.

Joe Giliberti and zkeramid won this week with 7 points. Corien was in third with 6 points, and Gaut and Indyfrick took fourth with 5 points.

Overall, Jamie Pt remains in the lead with 72 points. Corien and Forny have vaulted into a tie for second with 66 points each. Tippi falls to fourth with 65 points. Gary and Kirsten are tied for fifth with 64 points. If your score is 54 points or higher, you are in the top 10%.

Click here to see the full scoreboard.

The season finale for this season of Fringe, answering a lot of questions, but leaving a few more…

Peter awakens in the middle of a fringe event in the dystopic future of 2026. He sustains some mild injuries and is taken to Fringe Medical for evaluation. He quickly forgets any connection to 2011 and as far as he knows, he is 47 year-old Fringe Agent Peter Bishop. As far as the future of 2016 is concerned, things started to go bad back in 2011 when Peter used the machine to destroy the alternate universe and save ours. It turns out that the two universes needed each other to survive, so without the alternate universe, our universe is breaking down. There have been other changes as well: Peter and Olivia are married, and Olivia is now the head of Fringe Division. Astrid is a Fringe field agent, as is Olivia’s niece Ella, all grown up. Broyles is a U.S. Senator. And Walter is locked away in a maximum security prison, a pariah to all, blamed for the impending and inevitable destruction of our world.

Working within the chaos of the future is a terrorist group know as the End-of-Days who are, as their name suggests, trying to end the world a little faster. They do this by using special gadgets that exacerbate the universe’s breakdown. These neat little gadgets are being supplied by Walternate — it seems he crossed universes fifteen years ago, and ended up trapped in ours when his universe was destroyed. He has been plotting his revenge since. He lures Peter to their old summer house, and then shows up in New York and shoots and kills Olivia. About this time, Walter works out that the giant wormhole in Central Park is not only a wormhole through time, but is what he must have used to send the pieces of the machine back in time. You see, Walter is the “First People” and he is the one who is responsible for the pieces of the machine ending up scattered back in time. He also realizes that he can use the time-wormhole to reach back to Peter in 2011 and bring him forward in time to 2026 so he can see what happened to the world. Forewarned, Peter can then make the proper decision once in the machine back in 2011. Which is how the Peter of 2011 ended up in 2026 at the end of the previous episode.

Back in our time, Peter uses the machine to link both universes at the Liberty Island facility, actually bringing Walternate, Fauxlivia, badBrandon and their team over to our universe, so that they can work together to fix the problem. In middle of his explanation, Peter suddenly fades away and no once seems to notice. Outside the facility, a group of Observers have gathered to, well, observe, and they mention that since Peter has now served his purpose, there is no need for him to exist.

1. In the Beginning…
I noticed it was a new Fringe opening tonight, or at least the fringe science terms were new ones. Ominously, the last two words were “water” and “hope.”

2. I Need Sustenance
Apparently, in the future, all wine comes from boxes, and steaks from cans. Cans which must be kept frozen – which kind of defeats the purposed of canned food.

3. Bad Medicine
Apparently Fringe Medical has forgotten that a c-collar is supposed to immobilize the neck.
I meant to mention this last week, but it was even worse this week: that was a horrible job of applying steri-strips to Peter’s facial wounds. Gonna leave scars.

4. It Is By Will Alone I Set My Mind In Motion
I used to make fun of alternate Astrid by calling her a Mentat, but was had an honest to god Mentat in this episode with Brad Dourif as “Moreau” (a name with a good mad science lineage).

5. Alphabet Soup
I’m familiar with Alpha, Beta, and Gamma radiation. Delta and epsilon radiation have been described as well. And Kappa radiation is apparently associated with time travel. So what’s the story with Zeta, Eta, Theta and Iota radiation?

6. Alphabet Soup
The images of the vortex in the Thames looked suspiciously identical to the scenes from the execrable second Fantastic Four movie: The Rise of the Silver Surfer.

7. Chicken, Egg, Both, neither?
So we end up with one of those great science fiction paradoxes: no one actually designed or created the machine. The modern Fringe teams found the pieces and instructions and built it, and the future Fringe team sent it back in time — but no one actually built the original parts. Much like no one actually wrote the poems of William Ashbless or Lallafa (to name two other similar classic science-fiction time paradoxes).

8. Final Question
If Peter never existed, why did Walter cross universes in the first place?

I liked this episode. Sure, it was filled with cliches, but they were classic cliches, and done well. The Fringe Doomsday Clock moves back another minute.

Tags: television fringe machine telekinesis sam weiss

A nice week, with quite a few scores of 10 or higher, and even more earning 5 points.

EverybodyLies wins this week with a score of 13 points, followed closely by Barak with 12 points. Markcb and TRad came in third with 11 points.

Overall, Jamie Ptremains in the lead with 70 points. Gary and Tippi are still tied for second with 64 points. Gleb moves up to fourth with 63 points, and Forny is in fifth with 62 points. If your score is 51 points or higher, you are in the top 10%.

Click here to see the full scoreboard.

Not a showy or spectacular episode of Fringe, but a solidly entertaining one that significantly advances the über-plot and sends the two universes into crisis.

The Plot: Over in the alternate universe, Walternate and evilBrandon have devised a method of turning on “the machine” using DNA extracted from Fauxlivia’s child. There plan has not gone unnoticed, however, as the machine is emitting enough abnormal signals to set off the highest alert for the Fringe Team. They arrive on site at Liberty Island, but are sent home by Walternate. It’s enough for Fauxlivia to realize that Walternate has turned on his doomsday device and she confronts him about it. He lectures her about ethics, and then sends her on her way. Fauxlivia decides that Peter is the only one who can stop Walternate’s plan (or maybe she just wants him with her in the surviving universe), so she sneaks onto Liberty Island. She confronts evilBrandon and has him show her how to cross over into our universe (because apparently she forgot how she did it last time). He gives her a canister to use — but it doesn’t work (faulty? Or was evilBrandon lying?) — and she is captured and locked up in one of the cells used earlier in the season to house the real Olivia.

In our world, Nina frantically calls Agent Broyles to inform him that our version of “the machine” has turned on all by itself. Walter realizes that this means that Walternate must have turned on his machine, which caused the one in our universe to switch because of “quantum entanglement”. Peter decides that because the machine is keyed to him, he has the best chance of switching if off. Unfortunately, as he tries to touch the machine, it sends him crashing across the room, unconscious. As the episode ends, he remains comatose.

Because of the activation of the machine (or machines), strange things have been happening in our universe. A dimensional vortex appears and destroys a large swath of farmland, including two ranchers and large herd of sheep. There’s radio interference and swarms of locusts. A strange aurora appears in the skies at night.

Sam, the strange bowling alley proprietor who has some connection to the First People, realizes something bad is going on. He disappears and Olivia spends most of the episode trying to track him down, only to have him show up on her doorstep at the end telling her he needs to see “the machine”.

1. Cat’s Cradle
Henry may have received half his chromosomes from his father, but they’re not the identical chromosomes. Crossovers and recombination occur during meiosis resulting in unique chromosomes.
And if 23 chromosomes were all that mattered, Walternate and Peter should have 23 similar ones as well.

2. Use Your Head
Closed head injury with unconsciousness and it’s a “possible concussion?” No, that’s definitely a concussion, though there may be some other injuries as well. It’s no surprise the MRI didn’t show anything, and concussion-related imaging studies are usually negative. Now, Peter may have been unconscious before he hit the ground, but he still would have had a concussion, just on top of whatever machine-related injury he suffered.
What does an echocardiogram have to do with electrical injury to the heart. An EKG would be a better choice since it detects the changing electrical fields within the heart.

3. Alternotes
The Dodgers are still in Brooklyn and still play at Ebbets Field, and the Expos are still a team.

A solid episode. Nothing showy, but it really felt like the overall plot was advancing. For another week, the Fringe Doomsday Clock stays where it is.

Tags: television fringe machine concussion fauxlivia

Master’s swan song. It’s a pity this episode couldn’t have worked up better medicine for her to go out on.

Kendall is a sixteen year-old sailing prodigy who is just a few days away from leaving on a record breaking around-the-world sail when she collapses on deck. She is admitted to House’s team for evaluation. The initial differential diagnosis consists of dehydration, a seizure, or back trauma that injured her adrenal glands causing an adrenal crisis. House likes the adrenal idea so orders cortisol levels checked on Kendall every fifteen minutes for four hours. M³ and Thirteen decide to speed up the process by putting Kendall on a treadmill. While being stressed on the treadmill, her hand turned blue, requiring vasodilators to correct. This leads to a new differential diagnosis of cardiomyopathy due to mercury poisoning, Raynaud’s disease, or a cereberal vasospasm. The team decides to test the latter by infusing Kendall’s basilar artery with a calcium channel blocker. The test is (apparently) negative, but Foreman incidentally notices a calcified pineal gland. Thirteen declares that this solves the diagnosis and she is started on hormone therapy and scheduled for discharge.

When next we see Kendall, she is in an OR receiving a sympathectomy. Apparently she collapsed in the hospital parking lot and was readmitted. Her symptoms were thought to be a hypertensive crisis caused by overstimulation of the kidneys. Thus a surgery is being performed to remove that stimulation. Unfortunately, Kendall develops severe hypotension (low blood pressure) during surgery, suggesting the current diagnosis is wrong. The latest differential diagnosis consists of Wegener’s granulomatosis, dehydration, or sarcoidosis. House favors the Wegener’s idea and the patient is started on immune suppressants. Several hours later, watching House and Wilson’s latest escapades, M³ has her own Eureka! moments and deduces that Kendall must have caught Salmonella enteritis from some bad poultry and the infection is now hiding in the bone. She finds a tender area in the left upper arm that seems to support her decision. However, an MRI scan reveals no infection, but a bone tumor — a lymphoid sarcoma. Amputation is recommended as definitive treatment, but Kendall refuses to go through with it until after her sail around the world. When her parents acquiesce to her desires, M³ becomes extremely frustrated. Hearing some of the history of House’s injury from Wilson, she decides to take a play out of Stacy’s book. M³ gives Kendall a medication that causes a cardiac event, when she is rushed to the OR, incapacitated, M³ has Kendall’s parents sign a consent for the amputation. When all is said and done, Kendall’s arm is removed and her life is saved, but at the cost of her dream.

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

I have to admit that I am very puzzled by two aspects of the medicine this episode. So puzzled I’m not sure if they’re right and I missed it, or they are utterly wrong:
First, the calcified pineal gland. I’m not aware that this finding means anything significant, other than possibly a poor sense of direction. It’s not a rare finding and can be seen in 10% of adolescents. There’s nothing about it that requires any hormone therapy. I suspect they meant pituitary gland.
Second, I’m unfamiliar with lymphoid sarcoma. Searches only reveal a few hits, and nothing that remotely matches this case. Could they have meant lymphosarcoma, a cancer of the lymphoid tissues? While this can, rarely, occur in bone it doesn’t fit the history or treatment. Frankly, osteosarcoma seems the best fit.

This is another episode where the dots don’t connect well at all. So Kendall has a bone tumor of her arm — how did that cause her collapse on the boat? Did this tumor somehow cause the calcification of the pineal (cough cough) gland, which itself somehow led to the collapse (and the pericarditis, and the blue hand)?

You can have a seizure without head trauma. Most people with seizures have never suffered a head trauma.

Why would they diagnose a hypertensive crisis when they made a big deal of Kendall having normal blood pressure and pulse earlier in the episode when they discounted dehydration.

Scott’s Second Law of House: When the writers are vague about the treatment (“hormones,” “immune suppressants”) instead of giving the actual name of the medication, the medicine is almost always fishy.

I’m confused about the medical school timeline. M³ finishes medical school on one day, and starts internship the next (presumably July 1st, the traditional starting day). No graduation? What if she didn’t turn in her procedure book, was there enough time to stop her from starting her internship? And why is she choosing an internship the last day of school — it should have been decided in March during Match Day, where very hard-to-break contracts are signed.

It would be exceedingly rare for Salmonella to cause a bone infection in a healthy adolescent with a normal immune system.

This week’s medical mystery was rather dull — someone fainting. Nothing particularly special there. At best, this earns a C-. The final solution, while full of drama, didn’t answer the underlying mystery. It earns a meager D. The medicine was sloppy, confusing, and probably plain wrong. I’ll give it a D, just because I’m not entirely certain enough about what’s actually going on to give it the F it likely deserves (even with the Violet Beauregarde reference). The soap opera was good, and it was nice to see a fun Wilson/House feud (and seeing Wilson win). I give it an A.

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Walter and William Bell, with the help of Peter and Astrid, decide it’s finally time to separate Olivia and William Bell’s souls. To do this, they need to enter her — frequently rotoscoped — mind.

The Plot: Walter and company try to move William Bell’s soul out of Olivia and into a brain dead body “borrowed” from the medical school, but their experiment is a failure. A short time later, Bellivia suffers a a significant seizure that requires emergency medical treatment. At this point, Bell and Walter realize that the situation with Olivia is becoming worse and they only have twenty-four hours to get Bell into a new body or Olivia’s soul will disappear. They decide to take massive doses of hallucinogens (hence the episode’s title) and enter Olivia’s mind to bring her real personality to the forefront. As for Bell’s soul, they propose to move it into a specially constructed computer.

Entering Olivia’s mind, Peter and Walter find themselves on a crowded New York City street. The World Trade Center towers can be seen, and a flash of light from an upper floor tells them that Olivia is there. About this time, the crowd turns ugly and starts to chase Peter and Walter. They arrive at the tower and are met by Nina Sharp, who tries to throw them down an elevator shaft. They throw her down instead and make it up to the office where they expect to find Olivia but instead find William Bell – and now becomes animated, reminiscent of those rotoscoped Charles Schwab broker ads. Looking out the window, angry crowds have arrived at the tower. The trio rush to the roof and are attacked by zombies in lab coats (just go with the flow here). Luckily, there is a zeppelin moored to the roof and Peter, Walter, and Bell escape in the airship.

Peter tells them to head to Jacksonville because that is where Olivia must be hiding. Along the way, someone sabotages the zeppelin’s fuel lines. Peter heads to the engine room, finding it locked and chained. He opens it and is attacked by the man who had been locked inside. The man fires a flare gun through the wall of the airship, grabs a parachute and jumps out. Unfortunately, Walter is too near the opening and is sucked out, falling to his death – only he awakens back in the real world, kicked out of Olivia’s mind.

Bell and Peter arrive in Jacksonville and head not to the child care center, but to the local military base (no, not Army base, it is clearly labeled “military base”). They manage to find the house Olivia is taking refuge in – the house she was living it just before the Cortexiphan experiments. Peter finds Olivia, but quickly realizes it isn’t the real Olivia because there is something wrong with her eyes. Instead, it is the six year-old Olivia in the background who is the real Olivia. Bell, Peter, and young Olivia run out of the house because the angry crowd has arrived. Peter saves Olivia from being hit by a car, but is struck himself, and like Walter, ends up back in the real world. Now only Olivia and Bell remain. Just as the mob advances on them, Olivia finally takes control and tells the crowd – which is made up of her lifetime of fears – to stop. Bell congratulates her and gives her a message to pass on to Walter, then disappears.

Back in our world, Olivia wakes up, in complete control of her body again. Walter and Astrid try to download Bell’s soul into a computer but fail. Olivia passes on Bell’s message to Walter, letting him know that Bell never expected the computer-download trick to work – he expected to die – and he was never good at good-byes. When Peter shows her a sketch of the man locked in the zeppelin, Olivia matter-of-factly informs him that he’s the man who’s going to kill her.

I’m just going to focus my attention on the real world aspects of this episode, so I can avoid the inevitable “it’s all a dream” argument.

1. Status
25 minutes of seizure activity puts Olivia right at the cusp of status epilepticus, and also puts her into the likely brain damage category.
Lorazepam (brand name: Ativan) is a good first-line agent for treatment of a prolonged seizure. 4mg is the correct dose.
Phenytoin (brand name: Dilantin) is a reasonable second agent (another dose of Lorazepam would be another option), but not as a drip, at least initially. A loading dose needs to be given before the drip is started or the medication will take too long to have any effect. As an aside, Phenytoin can cause some anemia, but this is a chronic problem and in no way should affect emergency treatment.

2. Zapped
It looked like Olivia was having some sort of ventricular tachycardia on the monitor, and if the patient is unstable, then defibrillation (shocking) is the recommended treatment.
However, 360 joules is not the recommended starting level. 200J is first, then 300J, then finally 360J.

3. Don’t Worry, It’s a Loaner
The medical school’s not just going to loan out a brain-dead body (a corpse slated for anatomy class, perhaps, but they were clear this was a brain dead patient), and why would a medical school have posession of such a patient anyway? A hospital would — and they’re not going to loan him out either.
Apparently it’s important that just the lower half of his body is chilled.

4. The Candyman Can
Walter’s 2000 grams of LSD is enough to make between 4 million and 20 million standard doses of the hallucinogen (depending on what you consider a standard dose), or about 29,000 lethal doses (and that’s probably an underestimation).
► UPDATE: Oops, I misheard. Walter said 2000 milligrams, not 2000 grams — so that means he made only 4,000 to 20,000 doses of LSD.

5. Now I Feel Old
I dealt with the “synch the brains’ electrical activities” way back in my review of the very first episode of Fringe.

6. Just Wondering
What OS does a soul-containing computer run?

A decent episode of Fringe, but nothing extraordinary. I found the animated sequences rather offputting (if you’re going to use them, use them for the entire in-the-mind sequence). At the end I also wondered, story-wise, what this several week diversion with Walter’s soul actually accomplished. The Fringe Doomsday Clock remains unchanged.

Tags: television fringe lsd brain seizure

Thirteen’s back, at least for now. While she and House play with potato guns in New York, the rest of the team encounters a patient — make that patients — ready for their own A&E show. Overall, one of the better episode of the season.

While House is off picking up Thirteen from jail — where she has been for the past six months — and whisking her away to a chili cook-off and potato gun contest in Schenectady, the rest of the team remains at the hospital. The guys are looking forward to a few days of vacation, but M³ manages to dredge up a case for them.

A thirty-six year old male science teacher who has been coughing up blood, and also suffering headache, chills, and chest pain, is admitted to House’s service. The ER has already ruled out pneumonia, bronchitis, and lung cancer. The initial diagnosis is epistaxis — nose bleeds (the blood drips down the back of the nose into the throat and then is coughed back up) — but while the patient has had nosebleeds in the past, he hasn’t had any recently. Chase then suggests that he may have a Serratia infection, which can produce a red pigment which may be mistaken for blood, but the patient is clearly coughing up blood. Toxic exposure was also suggested as a diagnosis and a search of the patient’s house turns up a home straight out of Hoarders. Taub suggests the hoarding may be a symptom of a brain injury or Alzheimer’s, but Foreman thinks the patient may have caught the fungal infection Aspergillosis from the moldy food in the house. Blood cultures, as well as a psychiatric consult, are ordered, but everything turns up normal.

Despite being in the hospital, the patient’s condition worsens. His chest pain is worse and his blood oxygenation is dropping. Carbon monoxide poisoning is suggested, and this time Chase and M³ head out to the patient’s house. They find no carbon monoxide, but they do find his wife hiding under a blanket. It turns out she is the hoarder, and he just goes along with it. They also find some raccoon droppings and become suspicious of Q fever (a bacterial infection carried by certain animals). Both the patient and his wife are started on the antibiotic doxycycline.

The patient improved markedly, but his wife does not and actually suffers a heart attack. When the team discusses possible diagnoses, there is debate about whether or not her hoarding is symptom of some other underlying condition. An MRI is ordered to get a good look at her brain, and Chase and M³ head back to the house to look for a potential hydrogen sulfide exposure. There are only normal amounts of hydrogen sulfide, but hidden in the back of the bedroom closet, M³ finds an old set of baby clothes. The team now adds infertility to the list of symptoms and rush to check hormone studies et al on both patients. Thirteen jumps in and points out in her oblique way that hidden baby clothes may represent something other than infertility. Making the logical jump, M³ deduces that the wife has suffered miscarriages, and this and the other symptoms leads her to a diagnosis of Ehlers-Danlos syndrome (an inherited disorder affecting collagen, which can lead to all kinds of problems). To sum up: Ehlers-Danlos led to her miscarriages, and the hoarding was a psychological response to that. The hoarding led to the exposure to raccoon droppings which led to the Q fever.

Not too many medical issues tonight (as is usually the case when the patient only makes up half the episode). As usual, major complaints are in red, modest complaints are in blue, and nit-picking ones in green:

The carbon monoxide diagnosis doesn’t make sense. They said the carbon monoxide exposure was improving his lung function (and it explained why he got worse in the hospital: no more CO) – but improving it from what? Even if they were right, there would still be some underlying condition causing his symptoms.

Aspergillosis would have shown up on a chest CT or x-ray — studies the ER would have performed to “rule out” pneumonia, bronchitis, and lung cancer.

Ehlers-Danlos is associated with multiple heart and blood vessel diseases, mostly valve defects and aneurysms, but a heart attack isn’t a common symptom. There have only been a handful of cases studied, and even in those cases there’s debate over whether the Ehlers-Danlos played a part or not.

Q fever can be carried by raccoons, but they aren’t a common carrier. Admittedly, it does fit the symptoms a little better than most of their other transmissible diseases.

Infertility? I agree with Thirteen that miscarriage was much more likely. People buy baby clothes when they’re pregnant, not when they’re trying to get pregnant.

M³ is being misleading when she suggests the symptoms of Ehlers-Danlos can be controlled. It’s true, but only in a limited way. A successful pregnancy is still highly unlikely.

Admittedly I’m not up on my hoarding, but why wouldn’t they have had power, water, and gas? He had a job and could presumably pay bills.

This week’s medical mystery started off rather routine: coughing up blood shows up in every other episode after all. It deserves no more than a solidly average C. The final solutions fit the symptoms surprisingly well, so I give them an A-. The medicine was brief, but reasonable: B. The soap opera was good in all three aspects: House/Thirteen, Taub/Wife, M³/the rest of the team. I give it an A.

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A few people scored high this week, a few scored low, and most didn’t score at all. For episode 18, Laura wins with 13 points, followed closely by Crystal and Fred13, both with 12 points.

Overall the top standings, and points, remain completely unchanged: Jamie Ptremains in the lead with 64 points. Gary and Tippi are tied for second with 58 points. Corien is fourth with 53 points, and Fran and atg are in fifth with 52 points. If your score is 43 points or higher, you are in the top 10%.

Click here to see the full scoreboard.

I watched the pilot episode of Body of Proof last night. It’s the new hour long drama on ABC starring Dana Delaney as Megan Hunt, a neurosurgeon turned medical examiner.

Let’s be honest, there was no way I wasn’t going to watch it, because:
1. It stars Dana Delaney
2. It’s a medical police procedural
3. It stars Dana Delaney

So how was it? Fair. I think many of the problems were due to it being the pilot episode and will hopefully be better in later episodes. I’ll give the show at least another chance or two (did I mention Dana Delaney?).

More thoughts:

The show was trying way too hard to tug the heartstrings and most of the attempts at pathos were clumsy at best, painful at worst. That whole speech at the end about not knowing the patient because she didn’t know about a tattoo or old arm fracture? Ridiculous.

If the victim suffered anaphylactic shock then her airway would have closed off — meaning she would not have drowned when she fell in the water (she’d still be dead, just not drowned. That would have made for a better hook anyway: a dry drowning).

You can’t match Amoxicillin like that; it’s a common and relatively simple chemical. At best, they’d be able to tell that the victim had been exposed to Amoxicillin from the same manufacturer, or even possibly the same batch, as the one in the house – leaving lots of reasonable doubt – but they wouldn’t be able to pinpoint it that specifically.

The best attorney in Philadelphia is going to let police search his house without a warrant? Nonsense.

I don’t care if they’re old friends or not, giving Dana Delaney the lawyer’s name was a huge ethical no-no (not to mention a costly HIPAA violation). If he’s even just a halfway decent lawyer, it won’t take him long to figure out who provided her with the data. (She was seen in public having lunch with the lawyer’s Urologist and later that day accused the lawyer of murder, using the private knowledge of his vasectomy as proof. Hello, Urologist, meet big lawsuit and federal fine. $$$$)

If you don’t check electrolytes on someone suspected of having died from heat stroke, you shouldn’t be working in the medical examiners office.

The plot relied too heavily on coincidences, such as:
There’s only one attorney who had a vasectomy in an entire firm of lawyers.
There’s only one Urologist he would have gone to for the procedure, never mind that most general surgeons and family practitioners do it as well. It’s a simple twenty minute procedure with a low complication rate, not the sort of thing you’d need “the best” for.
The victim had a true anaphylactic allergy to penicillin, and not just a rash or some stomach upset or diarrhea (as the vast majority of most people who claim an allergy to penicillin actually have).

I did think it was clever that the murderer was able to deduce the penicillin allergy based on the fact the victim was on Erythromycin for Strep throat.

Neurosurgeon who can’t operate any more due to a hand nerve injury from a car accident? Megan Hunt must be Dr Strange.

I’m sure I’ll add more thoughts as they occur to me later. This was a show chock full of Fridge Logic.

Back to the alternate universe to deal with Fauxlivia’s pregnancy. This episode had its share of “fringe” science and medicine and was clearly written to advance advanced the overall plot before the season ends. It was nice to see Agents Lee and Charlie finally getting a clue.

The Plot: Fauxlivia and her mother at the obstetrician, where Faux is being tested for viral propagated eclampsia (VPE), a disease which usually proves fatal to mother and child. Faux is at high risk for the disease because her sister Rachel had it.

After she gets home from the doctor, Faux is tasered and kidnapped and brought to one of those warehouse-turned-into-an-operating-room that television dramas love so much. Both she and the fetus are injected with a number of medications.

Agents Lee and Charlie take off to find Fauxlivia, but her implanted tracker – a big government secret – has been removed. Mentat Astrid points them in the direction of a suspicious car that’s been seen a lot near Faux’s apartment, which leads Lee and Charlie to cab driver Henry, from earlier in the season. He has nothing to do with the kidnapping, but he tells enough to the agents that they finally begin to realize the truth about the Olivia/Fauxlivia switch. Lee ultimately talks to Walternate about the situation, and he admits the switch, and also tells Lee that that Fauxlivia is carrying his grandson.

Back in the warehouse/OR, the medical team keeps feeding Fauxlivia sedatives and painkillers. They continue with their treatments, and it is soon obvious that somehow managed to advance her pregnancy, to that point that Faux now appears to be full term.
Resourceful as ever, Faux manages to escape from the facility and finds herself lost in Chinatown. She gets a call to Agent Lee, and he — with the assistance of Henry — manage to arrive just as she is going into labor. Henry delivers the child, and — miraculously — the treatments Fauxlivia received not only advanced her pregnancy, but managed to protect mother and child from VPE. As the episode ends, Walter stops by to visit Fauxlivia and his grandchild, and we learn that he and alternate-Brandon are somehow connected to the kidnapping.

1. That Is A Weird Shaped Baby
NURSE: “Abdominal circumference 160, head circumference 170, biparietal diameter 40”
I can’t speak for the accuracy of those numbers since they never mention the units involved (though I would guess millimeters), and we don’t know how “far along” Fauxlivias pregnancy was. However, I will note that the biparietal diameter is a measurement of the head circumference at its widest point so should not be less than the head circumference, particularly that much less.

2. Might As Well Stop Testing At That Point
If you’re testing your patient for wakefulness by checking her pupils and you have to tell her to stop moving, it’s a good indication that she’s awake.

3. They Really Didn’t Plan Very Well
If you’re so intent on sedating your patient, then putting a Foley catheter in place would make more sense that escorting her to the bathroom, especially if you’re on a strict timeline.

4. Building Blocks
I covered this in one of the first Fringe episodes, but all that mass for the baby to grow has to come from somewhere. That’s why mothers “eat for two.” The pregnancy timeline may have changed, but the baby’s requirements haven’t. Fauxlivia simply cannot support the pregnancy advancing that fast.

5. True Blood
Assuming that use the same units we do, then a hemoglobin of 6.7 is not borderline, it’s very low. Transfusing units of plasma won’t do a thing to correct it, because by definition plasma does not contain any red blood cells (and therefore hemoglobin). Twelve units is a helluva lot of fluid too.

6. HELLP
Eclampsia is a real condition, also known by its older name: toxemia of pregnancy. It generally doesn’t tend to occur until fairly late in the pregnancy and the definitive treatment is delivery. It is not viral.
VPE, as presented here, is a puzzle. Being viral suggests it is contagious, yet no mention is made of that face. There is a suggestion of a genetic link as well in that Fauxlivia’s risk is very high because her sister had it – yet clearly her mother never had it.
80% is weird risk number; it’s not something that usually shows up in biology, unless maybe it’s a genetic condition with variable penetrance. Which wouldn’t explain the viral part.

7. More Poor Planning
Pills take time to work, they don’t take effect instantaneously. Sublingual tablets are the fastest oral medication, but even they take some time.
All that advanced medicine and they don’t give her pain medication via injection? Not to mention that it’s hard to make sedated people swallow.

8. Alternotes
Apparently Typhoid is a still a risk as their are posters advising people to get their typhoid immunizations (which do really exist, they are just not used routinely in this county).
West Wing, season 12.
Opus the Pea-Hen, instead of Opus the Penguin (from Bloom County, and then Outland and then Opus). And apparently Berkeley Breathed is still writing newspaper comic there, rather than writing children’s books that turn into movies that bomb.
Coppola directed Taxi Driver instead of Scorsese.

An episode clearly designed to advance the uber-plot, and full of bizarre medicine and science, but still enjoyable. The Fringe Doomdsday Clock stays put.

Tags: television fringe fauxlivia pregnant eclampsia

UPDATE: It turns out the Opus the Peahen strip was actually written and drawn by Berkeley Breathed, so kudos to Fringe for pulling that off. Here’s a link to the full comic.

The episode started good, but went off the rails quickly, then slammed into a brick wall with the ending. And monster trucks.

After a pair of boys accidentally set a homeless man’s arm on fire, he notes that his charred skin smells like licorice and then he collapses, unconscious. He is admitted to the hospital and then to House’s team because House finds the symptom of dysosmia (an altered sense of smell) intriguing. It is noted that the differential diagnosis of dysosmia is extensive, covering everything from environmental factors to early degenerative brain disease. House has the patient started on prednisone while having the team check out the park where he was living. The prednisone does nothing to alleviate his symptoms — the dysosmia continues. The search of the park turned up the patient’s backpack, which contains a syringe and several vials. The patient swears the vials are just vitamins he’s been giving himself, but the team is understandably suspicious of drug use. He refuses to divulge his name, but his backpack also contains several paperback books with the name Danny Jenkins in them, so the team decides that must be who he is. Danny suddenly starts complaining of stomach pain and his stained gown and sheets provide ample evidence of gastrointestinal bleeding. It turns out that the vials in his bag were vitamins, and his urine drug screen was clean. However, a drug test of his hair shows heroin use within the past five months. This leads most of the team and House to diagnose Danny’s symptoms as a result of hypervitaminosis A and snorting heroin (the high levels of vitamin A caused the gastrointestinal bleeding while the drug snorting caused the altered sense of smell). M³ disagrees, concerned that they may be overlooking a bowel obstruction. To appease her, House lets her x-ray his abdomen. There is no obstruction, but there are thirteen small sharp-edged masses within the walls of his colon. They don’t look like cancer, and parasite studies have been negative, so House suspects a fungal infection. He orders Danny started on amphotericin B, an anti-fungal medication. He also orders a colonoscopy which reveals thirteen small pieces of bone. M³ thinks he may have pica, but Danny admits that he ate the bone purposefully because sometimes one of the local chefs will give him actual food to eat if he acts like a carnival geek.

Danny now develops severe tunnel vision, telling the team that it’s like he’s looking up from the bottom of a well. With this new symptom, and disregarding the gastrointestinal symptoms of being a result of his bone eating, the differential diagnosis is now Western Equine Encephalitis (a mosquito-borne viral disease), or Foster Kennedy Syndrome due to a meningioma or plasmacytoma pressing on some of the cranial nerves. House favors the latter and an MRI is ordered. Danny becomes ill while in the MRI machine, but the team discounts it, explaining it away as a result of a panic attack from claustrophobia (and apparently they were correct). The MRI reveals two dark spots in his parietal lobe. They could be something he was born with, a sign of an old injury, or House suspects it is a sign that Danny has schizophrenia. Danny is started on Clozapine to treat the suspected schizophrenia, but doesn’t get better. As usual — on House at least — his condition worsens and now he complains of severe burning pain in his non-burned arm. This time the team suspects a regional pain disorder due to some as-yet-undiagnosed genetic disorder. House mentions that there are dozens of possibilities, but Parkinson’s, Huntington’s, and cortical basal ganglionic degeneration are name checked. Testing for them all would take too long, so he wants the team to track down Danny’s family and see if any of them have similar problems. They succeed in tracking down Danny Jenkin’s father, but unfortunately it turns out the real Danny Jenkins died of a drug overdose three months ago, meaning whoever their patient really is, he’s not Danny Jenkins.

House questions faux-Danny, but he still won’t give his real name. During their conversation, House notices that faux-Danny is exhibiting cerebellar ataxia, which narrows down the list of genetic maladies to one: early onset Parkinson’s disease. He has Danny started on levodopa, a Parkinson’s drug, and orders a DNA test for Parkinson’s. Later when faux-Danny is talking to M³, he complains of dizziness and then goes into cardiac arrest. He survives, but now has a “dilated and failing heart.” House is perplexed to the reason faux-Danny’s condition has steadily worsened since arriving at the hospital — much quicker than one would expect. He ultimately deduces that it is due to the healthy vegetarian diet faux-Danny has been getting at the hospital — better than anything he got while homeless. He realizes that he has Adult Refsum Disease, a genetic condition where his body cannot, according to House, break down the chlorophyll in plants. He is placed on plasmapheresis to remove the buildup of the toxic chemicals, and should improve by just carefully watching his diet.

For a better take on a doctor’s regret at saving the life of a serial killer, I strongly suggest the manga Monster, by Naoki Urasawa.

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

Refsum disease comes from having the particular genetic disorder and eating a diet high in dairy and beef — not vegetables (admittedly, the cattle get phytanic acid from eating plants, but we humans get it from them. We can’t get enough from plants to matter).
Regardless, the symptoms of Refsum Disease do not fit Danny’s presentation or symptoms.

Cerebellar Ataxia is not one of the movement disorders associated with Parkinson’s disease. It is associated with a host of other genetic diseases however.

Intestinal obstruction could explain the abdominal pain, and possibly the rectal bleeding, but M³’s idea was to tie all his symptoms together into one diagnosis. How does a bowel obstruction explain the dysosmia?

Clozapine is not a first-line agent to treat schizophrenia. It is very effective, but it has some all-too-common nasty and potentially fatal side effects that require regular testing, so it’s not something you’d give a homeless man.

How does running a genetic test in a hospital get the patient’s DNA entered in a national FBI DNA database? That’s a pretty significant violation of current privacy laws — the patient has not been convicted, or even accused, of committing any crime. Not to mention, the DNA testing for Parkinson’s and law enforcement DNA databases are quite different.

I mentioned this recently is a previous episode, but here it is again: levodopa is not given by itself. It is always used in combination with carbidopa to minimize the common side effects.

Though “polyneuropathy” was mentioned as a symptom, technically the patient only exhibited mononeuropathy – only his left arm was affected.

I can find a single study suggesting that help with certain aspects of hypervitaminosis A in rats, but nothing about it in actual humans.

Giving Zinc to someone with dysosmia is not a good idea, as zinc has a high chance of screwing up the sense of smell itself.

This week’s medical mystery started off well and managed to keep the mystery going through most of the episode. I give it an A. The final solution doesn’t fit the symptoms, or the purported cause. I give it a D-. The medicine was better than last week, but not better than average: it gets a C. The soap opera was stupid — you don’t have a greencard wedding by having everyone know upfront it’s fake. Unbelievable, even for House. I did like the monster truck, and bonus points for the Superman II quote. Still, the soap opera aspect earns a mere C-.

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

This week’s House Challenge scores have been posted.

Gary and Udabac led this week with 6 points.

Overall, Jamie Ptremains in the lead with 64 points. Gary and Tippi move into a tie for second with 58 points. Corien drops to fourth with 53 points. Fran and atg are in fifth with 52 points. If your score is 43 points or higher, you are in the top 10%.

Click here to see the full scoreboard.

I apologize for the delay in posting this week’s Fringe episode evaluation. An unexpected confluence of sick kids and accident-prone family members led to multiple trips to the doctor and a general gumming up of the works.

This week was good because we got to see our universe’s version of Agent Lee, but bad for about everything else. Poor science, unnecessarily creepy soap opera, and a continuing of the trend toward predestination and away from science spelled doom for this episode.

The Plot: This episode takes up shortly after last episode ended, with William Bell’s soul in control of Olivia’s body. Together, s/he and Walter are trying to find another body for the permanent housing of Bell’s soul. At one point, they even consider putting Bell’s soul in Gene the cow.

Meanwhile, the Fringe Team is called to investigate the case of a pair who committed suicide together by plunging of a tall building. The man died, but the woman walked away with minimal injuries. Another FBI agent appears – our universe’s version of Lincoln Lee – and tells the team that he’s been tracking this woman for months. Her name was Dana Gray and she was shot and killed along with the rest of her family in a home invasion eighteen months ago, but her body disappeared from the morgue. Since then, she has been witnessed walking away from at least four double suicides.

The tem first hypothesizes that she is a “soul vampire,” using the souls of the suicides to prolong her life. Later, after discovering that she is working at a suicide hotline and is their best employee, personally saving nearly forty people, the team suspects that she is instead trying to hitchhike on the soul of someone else who is dying. At one point, a suicidal man tells her that he has placed a bomb on a train, and tells her specifically where. She decides to catch that train and sit in the specific seat, so that either/or she’ll be blown to little bitty pieces, or there will be more souls to catch a ride with. Regardless, the Fringe Team is able to figure out where she is and stop the train. She escapes with the bomb. She drops it in a field and runs away – but not far enough, as she’s found shortly after the bomb explodes – dead.

1. 22 Grams
Remember the end of V: The Final Battle where Elizabeth, the magical hybrid girl, saves the day with her strange mystical powers? While that ending may have tied off all the appropriate plot strings, it left no one satisfied. I fear Fringe is going that route since they seem to replacing most of the science (even the bad science) with talks of “fate” and such similar mystic concepts for the couple of episodes.

2. Nice Sine Waves
Bellivia (I’ll go with Karl’s portmanteau here, it was better than my own concoction of “Olivilliam”) was wearing at least a dozen EEG electrodes, so there should have been at least that many tracings, not just two. Each particular electrode just measures the summed electrical activity detected at its particular location by showing a flat line (neutral activity), an upward deflection (electrical activity toward the electrode) or a downward one (electrical activity away from the electrode). Since each electrode, and the EEG as a whole, just detects summed activity, it is impossible to split out two components, as seen in the episode.

3. It’s Electric, Boogie Woogie Woogie
EEGs detect electrical activity in the brain. This is entirely different that actually reading someone’s thoughts.

4. There Is Nothing Like a Broad
Yes, it is true that electromagnetism plays a role in biology. However, Bell and Walter so grossly overspimplify, overgeneralize, and mangle their description of its actual role to render their entire description meaningless.
If Dana’s molecules want to remain attached to each other, why has she not died long ago of some sort of nasty clot, such as a pulmonary embolism, heart attack, or stroke. If you prefer to remain at the purely molecular level, she’d still be dead. For example, she would have died from status epilepticus from all her neurotransmitter molecules adhering together and permanently sticking to their receptors.
Ions play an important role in the body’s cellular processes. Many pathways exist to remove these excess ions. If these pathways are overwhelmed by too many ions, then bad things happen, such as lethal heart rhythms that occur with hypercalcemia or hyperkalemia (too many calcium- and potassium-ions, respectively).

Too much talk of “fate” and “destiny” and too much bad science. The Fringe Doomsday Clock moves a minute closer to midnight.

Tags: television fringe olivia william bell electromagnetism

I am out of town at C2E2 so this week’s Fringe Review won’t be up until Sunday evening. Karl should have his up on time…probably.

Frankly, a bad episode. The medicine was incredibly sloppy with imaginary tests and key symptoms that appeared and disappeared at random. The soap opera aspect was better, but still not enough to redeem the episode.

At a rodeo, a bull rider — coincidentally named Lane — finishes a successful eight second ride, and is standing, celebrating, when he spaces out for a second. Unfortunately, this is just enough time for a bull to knock him down and trample him. He is admitted to the hospital and House’s service. According to Foreman, there are two concerns: first, Lane has a ruptured diaphragm, cracked sternum, broken nose and partial hearing loss attributable to the bull injury; and second, some sort of neurological disorder along with fever and muscle weakness. M³ suggests the hearing loss may be related to an inner ear disorder and not the rodeo injury. She wants to test calorics and an ENG (electronystagmogram). The tests are normal, but House tells them this is because Lane is a bull rider with better-than-average balance. He says they need a better test, which they concoct, but it is normal as well (though surely his muscle weakness have affected this test).

Lane now develops bloody sputum. Chase suggests a salivary gland tumor, while Taub suggests a gastrointestinal bleed. Both are tested for, and both tests are negative, though now Lane suddenly shows yellow sclera (a sign of jaundice, and thus a problem in the liver). An x-ray suggests a mass in the liver, but it is hard to tell for certain with the various pieces of hardware (from his previous rodeo injuries) in the way. To get a better look at the mass, they surgically examine the liver, but no mass can be found. House suggests a tapeworm or tapeworm cyst, but the team tells him they’ve tested for it. House points out the intermittently swollen lymph nodes (which the team appears to have overlooked, but how House knows since he’s never laid eyes on the patient isn’t clear), which M³ interprets to mean infection, probably of the brain, given his neurological symptoms. Due to his head injury (but isn’t it an old injury, not a recent one?), she doesn’t think a spinal tap is a good idea because it might cause a herniation, so House tells the team to proceed with a ventricular puncture (getting cerebrospinal fluid from the brain itself) — which ends up being normal. However, during the procedure, Lane develops respiratory distress. They try to intubate him, but the airway is blocked, so they end up giving him a tracheotomy. During the procedure they also realize that Lane has extremely smelly feet. House suggests that these may be a sign of diabetes, athlete’s foot, or gangrene. He then points out that a fungal infection of the feet may have allowed infection to enter the body causing abscesses to form. The team thinks the heart and brain are likely places to look for these abscesses.

A heart MRI is obtained, but shows no abnormalities. A head CT is the next step, but to get a good one would require removing the titanium plate in Lane’s skull, a risky idea. To prove the need for the surgery, House proves to the team that Lane does not have hearing loss, but is instead having multiple brief absence seizures. This convinces them of the need go ahead with the CT, which is, of course, normal. House now decides that they need to take another look at the heart. He suggests increasing the pressure on the heart and aorta by ramping up the blood pressure until it is dangerously high. If the aorta ruptures, then it is a sign of a Bartonella infection and he is right. He points out that it is better for an aortic rupture to happen on an operating room table than a bull ring, and the team ultimately agrees. Cuddy confronts him, but backs down, and the test proceeds. Lane’s chest is cracked and his heart and aorta monitored while his blood pressure is increased. Soon enough, an aortic leak (then a full spray) is detected, proving that House is right. With deft surgical skills (especially important since the suture is several sizes too large), Chase is able to repair the aorta and Lane will live another day.

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

This is the sloppiest (medical) writing I have seen in a House episode in a long time, if not ever. Of the three presenting symptoms, two are never mentioned again and the third isonly brought up by House again 2/3 of the way through the show.
Fever is mentioned as one of the presenting complaints, but is never mentioned again through the entire show – even when infection is suspected later on. On every other episode this season, we’ve been assured that fever=infection.
He is clearly having some sort of seizure on the bull ring. House is aware of this fact. Yet the team ignores this important symptom until House brings it up again.

High blood pressure doesn’t just affect the heart, it affects every other organ system as well. The brain, kidneys, and liver are particularly vulnerable and we already know that Lane is having trouble with two of those. This is just another way to say that increase-the-blood-pressure-until-he-explodes idea was very, very wrong.

Bartonella is not an opportunistic skin infection that would work its way into the body through tears in the skin of the feet. Bartonella is transmitted through an arthropod bite vector, or in the case of cat scratch fever, a cat bite or scratch from a cat infected by an arthropod bite.

A gastrointestinal bleed is not going to give you bloody sputum, but then nor is a salivary gland tumor (it might give you bloody saliva, which is different).

The ENG and caloric testing checks the function of the inner ear, not the patient’s balance per se. Lane may have great balance, but a screwed up inner ear would still show up on these tests.

A good physical exam would have detected those nasty feet long before surgery.

An abscess large enough to cause recurrent seizures over the course of several days is not going to show up on CT scan?

His respiratory distress and airway blockage miraculously healed?

This week’s medical mystery was actually interesting, if only they’d only stayed with it rather than chasing every new symptom. It earns a B. The final solution, I guess, kinda, sorta, almost fit if you ignored all the reasons it didn’t make sense or fit the symptoms. I give it a C-. The medicine was incredibly sloppy on every level, a real disappointment. I give it a generous F. The soap opera was the only interesting part, but even that felt a little flat: B.

This week’s House Challenge score have been posted.

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

Chritoph led this week with 5 points. KingKha, Legault, and steve a were second with 4 points.

Overall, the top five standing and points are unchanged. Jamie Pt resumes the lead with 64 points, followed by Corien and Tippi both in second with 53 points. George and atg are right behind with 52 points. If your score is 43 points or higher, you are in the top 10%.

Click here to see the full scoreboard.

A rather uninspired episode of Fringe this week. The lighter-than-air thievery concept had some legs, but unfortunately got short shrift because of the focus on the Fringe über-plot.

The Plot: A scientist inadvertently discovers that by alloying two very dense elements, osmium and lutetium, he can create a lighter than air compound. He injects this new compound into willing volunteers so that they can steal some more osmium and lutetium. There is a method to the scientist’s scheme: his son has a form of muscular dystrophy that has left him in a wheelchair and the scientist sees his new discovery as a way of giving his son a more normal life. The accomplices he has recruited also have muscular dystrophy and he offers them a chance of leaving their wheelchairs behind as well. Unfortunately, his experiments have their problems, and most of his subjects end of dead. One is shot while robbing a metal depository and almost floats away — that’s when the Fringe Team is called in.

Walter finds himself unable to figure out precisely what is going on because everything he sees defies the laws of physics. The Fringe Team figures out, more or less, what the scientist is up to and where he’ll strike next. Then, in a rather anticlimactic end to this particular storyline, he is captured in the act of stealing meteorites (a source of lutetium) from a local museum.

The scientist/metal thief storyline may take up the most minutes in the episode, but the main story is really about the members of the Fringe Team themselves.
Peter and Olivia are disgustingly couple-ish (a thought that should give their boss Broyles serious pause).
Walter realizes the fact that the osmium/lutetium alloy works despite breaking the laws of physics is proof the universe is breaking down.
Peter comes clean to Olivia about his experiments on the shapeshifter memory disks – and how he obtained them.
Walter suspects that William Bell was able to carry out his plan utilizing a soul magnet – a device that will call his soul back to Earth to inhabit the body a previously prepared subject. When Walter activates the magnet, Bell’s soul possesses Olivia.

1. 4 8 15 16 23 42
So Hurley got off the island…and ended up at Massive Dynamic

2. Where’s Watson?
I would’ve expected a scientist named Crick (”Krick” in the closed captioning) to be a biologist or chemist.

3. The roaming charges must be astronomical
The soul magnet can call Walter Bell’s soul across from the other universe?

4. Osmium Jones
I seem to remember Osmium being mentioned on the show before, in one of the earliest episodes (”Arrival” — the one with the subterranean torpedo). That projective was eventually identified as iridium, which gives Karl’s theory a nice “completing the circle” feel.

5. Comic Book Fans Will Get the Allusion
I’m willing to accept the osmium/lutetium alloy was lighter than air because “the universes are breaking down” (this is Fringe’s version of Superboy punching the wall, isn’t it?), but injecting a metallic sludge into someone’s body is a quick way to kill them (gumming up the arteries, veins, heart valves, etc) — no matter what the new laws of physics say.

6. Cognitive Dissonance
Walter makes a big deal about how he can’t abide the breakdown in the laws of physics, and then in his next breath he talks about summoning a soul.

7. 1 Table QID PO
Os is not only the symbol for osmium, but is also a medical term (from Latin) for “opening” “mouth” or “door”.

Not a bad episode, just a very slight one. There’s simply not enough here to move the Fringe Doomsday Clock either way.

An…interesting…episode with two patients: a depressed teen-age boy with a bleeding problem, and Cuddy. There were some clever moments (for instance, now I really want to see Hugh Laurie’s take on the emcee from Cabaret), but ultimately the medicine had too many mistakes and required too much handwaving to work

I. Ryan
Ryan is a 16 year-old adolescent who is admitted to the hospital after spitting up blood during a pick-up basketball game. His pulmonary and GI work-ups were negative, so he is admitted to House’s team for evaluation. Initial concerns include vasculitis (blood vessel inflammation), bronchiectasis (chronic airway damage and scarring), inhaled particles, or angiodysplasia (abnormal blood vessels in the gastrointestinal tract). House favors the latter, so he has the patient swallow a special camera to look for angiodysplasia. The study is negative. Meanwhile, Taub confronts Ryan about cutting, given the healing cuts on his abdomen. Ryan denies the cutting, telling Taub the wounds are from a skateboarding injury. Taub then points out that Ryan has many of the signs and symptoms of depression, which Ryan ultimately admits to. He also admits to smoking marijuana, which Taub thinks may have been contaminated with lead or formaldehyde, leading to the Ryan’s symptoms. A lead level is checked (and apparently normal, as it is never mentioned again).

Ryan now has developed some red spots — small hemorrhages — in his eyes. This is his second bleeding-related symptom, so the team now considers an acquired coagulopathy or a Staph infection. House thinks the infection is more likely, so Ryan is started on Nafcillin (a good anti-Staph antibiotic). Despite the new treatment, Ryan’s symptoms worsen. He starts seeing blood in his urine, and a subsequent kidney scan reveals a mass of some sort. The differential diagnosis now consists of antiphospholipid syndrome or a heroin-induced nephropathy (kidney damage caused by heroin use). To House, the first seems the more logical choice, so Ryan is started on plasmapheresis. Taub and Foreman search Ryan’s home and find no illegal drugs, but do find that he has defaced his yearbook with threats to kill half his class. The two return to the hospital when they learn Ryan’s right arm has gone numb. Foreman now suspects that instead of a bleeding problem, Ryan actually has a clotting problem. He gets an angiogram of the brain and sure enough, it shows a clot. Ryan is started on Streptokinase (a thrombolytic, or “clot busting” drug), but doesn’t improve. The team decides to proceed with an embolectomy — advancing a catheter into the arteries of the brain to remove the clot — but the clot disintegrates in the middle of the procedure just as Foreman reaches it. To complicate the situation, Taub has found videos of Ryan’s that show him detonating pipe bombs while making threatening comments. He is unsure who in authority, if anyone, he should tell.

Ryan continues to get worse. Out of nowhere, he’s now in a coma, on a mechanical ventilator, and his liver is failing. Because House is obsessing over Cuddy, the team is on their own and looking at such diagnoses as AIP (acute intermittent porphyria) and fucosidosis (an inherited enzyme deficiency) before settling on type II citrullinemia (another enzyme deficiency — in the case of type II citrullinemia, almost entirely exclusive to Japanese patients). They start him on sodium benzoate to treat the suspected high ammonia levels (which would be easy to test for, hint, hint). Across the hospital, House is having a conversation with Cuddy when he has his Eureka! moment. He realized that Ryan has a Staph abscess, and while the antibiotics given earlier treated the bacteria in the blood, they did not reach the ones still protected in the abscess. Taub takes it a step further and realizes that the likely source of the abscess is the pipe bombs Ryan had been making, and the cuts on his abdomen are shrapnel wounds, not skateboarding injuries. Some PVC fragments got in his body, picking up Staph along the way, and developed into abscesses. Apparently these abscesses now are somehow breaking apart, and sending septic clots throughout the body, causing all Ryan’s other symptoms. After some surgery to open the abscesses and remove the shrapnel, and loads more antibiotics, Ryan should be good as new — physically.

II. Cuddy
Out of the blue one morning, Cuddy sees blood in her urine. Next thing that morning, she has a cystoscopy performed, which shows nothing abnormal. She proceeds to a renal (kidney) ultrasound — performed by Wilson (who is apparently an ultrasound tech and radiologist in addition to being the New Jersey’s top oncologist) – which shows a mass in her kidney. A biopsy of the mass is obtained, but it is inconclusive. Further radiology shows enhancing lesions in her lungs, which makes everyone suspicious for metastasized renal cancer. Now she definitely needs a surgical biopsy. The mass is removed and turns out to be a benign oncocytoma. The masses in her lungs? Those were an allergic reaction the antibiotics she was on. All’s well that end’s well — physically.

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

Except for a rare condition or two that combine clotting and bleeding (DIC — disseminated intravascular coagulation, comes to mind), clotting disorders and bleeding disorders are distinct entities and very different (and you’ll notice they never tested for DIC or anything similar). Bleeding disorders do not present as clotting disorders and vice versa.

Streptokinase is a first generation thrombolytic — in a cutting edge hospital, why would Foreman choose to use it instead of a newer agent, especially when he is a Neurologist and should know streptokinase has been shown not to be beneficial (and thus not approved) for use in strokes.
Contraindications to the use of streptokinase include recent bleeding problems. Ryan has a condition which has caused at least three unexplained bleeding episodes, and now they want to give him a drug which will likely cause him to bleed more? It’s not an absolute contraindication, just a relative one, but still, they should have at least mentioned it, or gone straight to the embolectomy.
If streptokinase doesn’t work, you don’t just “increase the dose.”

Taub is correct that most PVC — unless specially treated — will not show up on x-ray or CT scan. However, the abscesses themselves still should.
The PVC would, however, show up on ultrasound.

I’m unclear how the abscess is breaking apart enough to cause clots elsewhere in the body. If it is walled off enough to prevent antibiotics from reaching it, it shouldn’t be breaking up into the blood stream.

Cuddy’s sleeping pill label read “Zolpidem, 200MG.” Zolpidem is better known as Ambien — the maximum dose of which is 10MG. She is taking twenty times the maximum dose (and no, it doesn’t come in 200mg capsules — only in 5 and 10MG pills).

Antiphospholipid Syndrome is a clotting disorder, not a bleeding disorder.

For the first time all season, they never checked blood cultures?

Ryan is so depressed he’s playing pick-up basketball games?

Plasmapheresis is not the first-line treatment for antiphospholipid syndrome.

This week’s medical mystery started a little bland, but picked up speed, but then they started throwing everything at it (out of nowhere a coma! And liver failure!). I give it a B-. The final solution was a stretch and the writers are trying to have it both ways: the abscesses are walled off and protected from the body, but no they’re causing problems in the body — everywhere! I give it a C-. The medicine was sloppy (confusing a clotting and a bleeding disorder?) and conveniently neglected tests they’ve run in every other single episode. It also earns a C-. The soap opera was certainly inventive, which I give them credit for. It also advanced the overall plot, which I appreciate. I give it a B+.

This week’s House Challenge scores have been posted.

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

A good medical mystery on this week’s House, but the final diagnosis didn’t really fit. There were lots of little plot holes, too (M³ notices the condition of his hands, but his wife doesn’t?)

Bert takes the clean-up jobs no one else wants: crime scenes, septic tanks, mold removal. As the episode start, he is cleaning up copious amounts of blood at a murder scene. Of course, his wife doesn’t know this; she thinks he is still a real-estate developer. At their anniversary dinner, he breaks out in a sudden rash and starts struggling to breathe. He is admitted to the hospital under Dr. House’s service. House points out that the patient seems to having an allergic reaction, but has tested negative to “all known allergens.” Once the team learns what Bert really does, they realize he has been exposed to countless pathogens and toxins. The initial thoughts are either a fungal infection or a bacterial infection. House suspects the latter and has the patient started on antibiotics.

A search of Bert’s office turns up some illicit Vicodin as well as numerous cleaning compounds. The team now believes he has boric acid exposure and wants to decontaminate him. As they are explaining their suspicions to him, he suddenly spikes a high fever that require cooling blankets to bring down, and then only to 102º. The autopsy from the crime scene he was cleaning up showed no infectious agents, so a blood borne disease is ruled out. Foreman suggests a more common disease may be the cause so meningococcemia (a common type of bacterial meningitis) becomes the chief suspect, so a lumbar puncture (spinal tap) is checked. The results show no bacteria, but an elevated number of white cells. When they go to check on the patient, he is complaining of numbness and paralysis of the legs. The covers are dramatically thrown back to reveal cold blue discolored feet.

Circulation is restored to Bert’s legs (though how is never mentioned). The lumbar puncture tests do not suggest meningococcemia, but fit a viral meningitis better. M³ points out that they also fit serum sickness. House agrees with her, so the antibiotics are stopped and corticosteroids started. The rash resolves, but now Bert develops bilateral conjunctivitis — and more concerning — starts to hallucinate. The team debates whether Bert’s original disease has moved to the brain, or have the steroids caused the hallucinations? The differential diagnosis now includes Familial Mediterranean Fever or a systemic fungal infection. The initial fungal cultures were negative, but M³ points out that the saline used in cultures can sometimes inhibit fungal growth, so new cultures are drawn avoiding saline. Bert is started on a strong antifungal therapy.

Bert’s condition continues to worsen. His fever is back, and now he has lost his hearing. There is concern for Tumor Necrosis Factor syndrome, a brain tumor, or a viral infection. The tumor is the most concerning, so an MRI is ordered. Unfortunately, while getting the MRI, Bert has a seizure. He consequently develops severe kidney failure requiring dialysis and falls into a coma. House wants to start chemotherapy and radiation therapy for a suspected brain tumor. In the meantime, Bert’s rash has returned. The inciting factor seems to be exposure to cold (open windows at the crime scene, air conditioning in the MRI room) leading to a thought of cold urticaria (hives caused by exposure to cold). House finally deduces that Bert has a rare inherited condition known as Muckle-Wells Syndrome. Starting him on rilonacept should help with his condition, unfortunately, the diagnosis has arrived too late and Bert has flatlined and cannot be resuscitated.

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

Only superficially does Muckle-Wells Syndrome (MWS) fit. It is a recurrent episodic disease, so Bert should have experienced episodes of joint pains and fevers several times before — starting in his teens, if not earlier. Like many genetic syndromes, there is gradual onset of symptoms. For example, both the hearing loss and kidney failure are gradual not sudden (and again, start in the teens).
It’s an autosomal dominant disease, so one of his parents should have had similar symptoms.
He lives in New Jersey – you can’t tell me he’s never been exposed to the cold before.
Foreman shows shock at diagnosis a disease with only a few thousand reported cases in the United States, but in previous weeks has shown no shock when the team (not infrequently) diagnoses conditions with only a handful of recorded cases — ever.

The patient clots off arteries to both legs, which requires some sort of correction (surgical? medical?) and this is blown off and never mentioned again. This is a very significant and concerning symptom, and should have resulted in a full work-up all by itself — not just abandoned nonchalantly.
If I were a patient and having symptoms in my legs, I would remove the blankets and take a look myself.

Most clinicians check a CT scan before performing an LP (to make sure there is nothing that could cause a herniation when the LP is performed) – but then if they got a CT then when they were supposed to, they wouldn’t have needed a (cold) MRI later…

Part of the danger of fever is not just how high the temperature goes, but how fast the temperature changes. This also includes how fast the fever drops – you don’t want to drop the temperature too fast.

There is no way to test for “all known allergens” — there are thousands, if not millions, of things people are allergic to. Then a few scenes later they mention that they didn’t test for Vicodin allergy, though narcotics are common causes of allergies (so much for “all known allergens”).

The CSF showed a high white count, which was never really followed up on. Presumably, this is linked to the MWS, but I see no mention of it in a quick perusal of the literature.

MWS is a type of CAPS, the two are not synonymous.

Fungal cultures are slow growing and take a long time to come back negative (generally 2 weeks).

Before starting chemotherapy and radiation therapy, it helps to know which kind of cancer it is, because different cancers (even different brain tumors) require different therapies.

Kudos to Chase and M³ for treating the flatline properly. No defibrillation, just CPR and medication.

This week’s medical mystery was the first truly intriguing one in several episodes. It deserves an A-. The final solution was quite a stretch, even if you assume the team never took a good personal or family medical history. It earns a D. The medicine was decent — if you ignore the team skipping the CT and blowing off the clots, which were both quite important. I can;t give it anything higher than a C-. The soap opera was OK. Foreman and Taub, and Chase and M3 were good. Wilson was pretty good. But House and Cuddy had no spark or interest whatsoever. I give it a C.

This week’s House Challenge scores have been posted.

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

I though last week was low scoring, but this week is even worse.

karatesocks was the best this week with 4 points. There were about a dozen people tied for second with 3 points.

Overall, the top three remain unchanged with Tippi, Corien, and atg take first through third place, with 53 points, 52 points, and 51 points, respectively. Jamie Pt stays in fourth, but moves a point closer with 50 points. Gary and Gleb are tied for fifth with 49 points. If your score is 42 points or higher, you are in the top 10%.

Click here to see the full scoreboard.

Another Fringe episode that flashes back to 1980s, this time revealing the events occuring a few months after Peter was brought over. A solid episode that — like most good Fringe episodes — answers some important questions, but poses several more

The Plot: A young Peter Bishop, convinced that he doesn’t belong in our world, heads out over the ice-covered Reiden Lake. He ties himself to a cement block and starts smashing the block against the ice, wanting to get back to the “other world at the bottom of the lake.” Elizabeth Bishop arrives just in time to see him plunge through the ice. She dives in and brings him back to the surface.

Meanwhile, Walter is working with the Cortexiphan children in Florida, trying to get them to cross-over into the other universe, but having no success. After the ice escapade, Elizabeth is understandably worried and arrives at the daycare center with Peter in tow. We learn it’s been six months since Walter brought Peter across from the other universe, and for the past two months, Peter has been vocal that he does not belong here, and that Walter and Elizabeth are not his real parents. Walter tells his wife that he cannot personally cross over to return Peter, like he did before, because the universes are too unstable. Instead, he tells her, the Cortexiphan children should be able to cross-over and return Peter. He asks her to give him a little more time.

At her house, young Olivia has stayed up reading well past her bed time. Her step-father grabs the book and starts yelling and threatening her. In a blink, she finds herself teleported to an open field elsewhere, and then a second later, she teleports back home to the less-than-tender care of her step-father. The next morning at the daycare, she has a black eye, but assures everyone that she “fell.” Walter also notices her drawing a picture of a blimp and realizes that she has managed to cross-over into the other universe. He deduces that moving between universes must only occur when she is exposed to extreme emotions. In the lab, he tries joy, exhaustion, anger, and loneliness, but none of these work. He finally decides that fear must be the answer — not just fear alone, but a combination of love and fear, like what her step-father brings out in her. To prove his point, Walter stages a murder scene with one of Olivia’s friends pretending to be dead. He sure gets a reaction: Olivia sets the room on fire with pyrokinesis and then runs away.

Hearing the sirens rush by, Elizabeth is concerned that something must have happened at Walter’s work (so this has probably happened before). She and Peter arrive to find a small fire being put out, and learn that Olivia has gone missing. Elizabeth leaves Peter in the hallway while she goes to speak to Walter. Looking through Olivia’s notebook, Peter finds a picture of a field of tulips. He decides he knows where Olivia is, and heads off to find her.

We flash across to the alternate universe now, where Walternate and alt-Elizabeth are not handling the disappearance of Peter well. Walter has become quite the alcoholic and their marriage is strained to the breaking point. Rather than staying home to try and repair his relationship with his wife, Walter returns to work at Bishop Dynamic in Florida

Back in our universe, Peter finds Olivia just where he thought she’d be in the tulip field. They talk for a while and she admits that her black eye is from her step-father. He urges her to tell Walter the truth. When they arrive back at the daycare center, Olivia draws a new picture in her journal, then, when she is told her step-father is coming to pick her up, she decides to follow Peter’s advice and talk to Walter. She barges in his office and blurts out that her step-father has been hitting her and that was what led to cross-over into the alternate universe. Only it turns out – and I didn’t see this coming at all – that she just crossed-over again and told all this to Walternate instead of our Walter. This is how he learned of our universe and discovered what happened to Peter.

As the real Walter hands Olivia off to her step-father, he lets him know in no uncertain terms that he has his eye on Olivia and will report to social services if anything untoward happens to her. Later, talking to Elizabeth, Peter seems resigned to the fact that he is fated to remain in our universe.

1. I Would Love to Visit That Toystore — I Bet They Still Have the Original Micronauts.
There were quite a few anachronisms in that toy store. The one that caught my eye was the shelf full of the Battlestar Galactica board games (1978 – my best friend in elementary school had this – we combined it with his Snoopy Come Home game to make Battlestar: Snoopy Come Home) and the G.I. Joe playsets (1982, if not later). Still, it’s closer than having Ice Age toys in a 1980s daycare like they had the first time.

2. Alternotes
Over there:
Walternate is “safety czar” in his world (the term czar has been used for Presidential political appointees since FDR) and develop the Star Wars missile defense program.
Bishop Dynamic, instead of Massive Dynamic.

3. Appealing Question
I still wonder whatever happened to the alternate William Bell? Or Nina Sharp? They’re the only Alternates we have yet to see — or even hear about.

4. Purposeful or Simply Inept
When Walter threatened Olivia’s step-father (rather ineffectually, it seemed to me), was he really trying to protect Olivia, or was he trying to goad her step-father into abusing her again.

Minor historical accuracies aside, I thought this was a very good episode, and I did not see that twist at the end coming at all — but it fit and did not feel cheap. If there is any downside to this episode, it’s that it required a solid footing in Fringe mythology and not would be tough to understand as a first-time viewer. Regardless, this episode was good enough for the Fringe Doomsday Clock to gain another minute. (For the record, this is the furthest back the clock has ever been — I had to make a new graphic.)

Tags: television fringe olivia peter sortexiphan

A multilayered episode with multiple flashbacks and fictionalizations telling (despite what the title says) at least three stories: 1) a patient with shortness of breath, 2)why House is on the outs with Cuddy and what he does to fix it, and 3) why the fifth-grade girl has the black eye.

Not as good as Three Stories, one of the best episodes ever, this was a mostly entertaining though incredibly hard to believe episode. (At some point though, that fifth-grade teacher has got to learn when to draw the line, no matter what her kids say.) And did I mention the medicine was pretty poor?

Since this is a medical review blog, I’m going to focus on the patient:

A college student is admitted for severe cough and shortness of breath. The initial diagnosis was acute bronchitis, but cultures and sputum studies were negative. He was admitted to House’s team and his symptoms continue to worsen, with the patient developing hemoptysis (coughing up blood). The thought now was that the patient had a drug–resistant infection and he was started on oxygen, pulmonary suction, and bronchidilators (medicines like Albuterol). His symptoms continue to worsen and he coughs up a handful of lung tissue. The differential diagnosis now includes primary squamous carcinoma (the second most common lung cancer, unlikely because the FOB –fiberoptic bronchoscopy –was negative), infection (unlikely because he’s been on broad spectrum antibiotics), ruptured amebic liver abscess (unlikely because liver function tests are normal), or toxin exposure. Personally, House favors a diagnosis of sarcoidosis. He orders the team to carry out a thorascopic lung biopsy and run a C-ANCA test.

A CT shows no evidence of sarcoidosis or foreign bodies in the lung. Furthermore, the biopsy is negative for sarcoidosis, and the C-ANCA is also negative. Nevertheless, House wants to start the patient on corticosteroids and methotrexate. Later, Foreman calls too tell him that a PET scan was also checked and showed no sarcoidosis. House suggests this was because the therapy was working, but Foreman tells him that the therapy was never started. He also informs him that the patient is worsening as his lung his collapsing. House insists that Foreman start the treatment for sarcoidosis. Later, while being lectured by an elementary school principal, he sees a poster on her wall for The Princess and the Pea, giving him his weekly Eureka! moment. He deduces that the patient has inhaled a small piece of food — too small to be seen on CT scan — and this is what is causing his problems. He is scheduled for an exploratory surgery.

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

A pea-sized foreign body will show up on a CT scan. I’ve seen them pick up things smaller than that (1-2mm nodules, for instance).
You could also, successfully to my mind, argue that a foreign body that small is not likely to cause the severe symptoms that the patient has. For instance, why would it lead to coughing up lung tissue? (Unless it was the piece of lung containing the foreign body — and then you’d never be able to find the foreign body).

A “diagnosis of exclusion” refers to a condition for which there are no reliable tests. Because of this, other diagnoses must be ruled out first (i.e. excluded). If those tests are all negative, then the patient must have the remaining condition — the diagnosis of exclusion. To put it another way, to make the diagnosis, you have to rule everything else out. (A common example would be irritable bowel syndrome. There are no good tests for it, so other gastrointestinal conditions with similar symptoms are looked at first. If those results are negative, then the patient is likely to have irritable bowel syndrome). I mention this all to point out that Sarcoid is not a diagnosis of exclusion. House has ordered tests for it (admittedly, an incorrect test) so it is, by definition, not a diagnosis of exclusion.

C-ANCA is a test for Wegener’s Granulomatosis, not sarcoid.

Negative sputum and blood cultures do not rule out an acute bronchitis. Acute bronchitis is only bacterial 10-15% of the time, so 85-90% of the time the cultures are going to be negative, no matter what. Furthermore, even if it is bacterial, it’s tricky to obtain a good sputum culture and bronchitis is rarely — if ever — bacteremic so blood cultures are of no use.

If a patient is admitted with low O₂ sats, then he needs to be started on oxygen right away; there no reason to wait until he gets even worse.

The medical mystery this week was background story material, and it showed. Nothing exciting there: D. The final solution was unlikely, unless they have the world’s wost radiologists using CT scanners from the 1970s at Princeton Plainsboro. I give it a D-. The medicine was very sloppy, more expensive than usual, and incorrect: another D-. I’m of two minds about the soap opera. On one hand, it was fun to watch, but on the other hand, it didn’t add anything new. House acts like a dick to Cuddy? Tell us something we don’t know. I also found it hard to believe that House would be able get away with all he did in the classroom scenes. It was too over the top. Overall, I give the soap opera and non-medical storylines a weak C+.

This week’s House Challenge scores have been posted.

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

A relatively low scoring week, though a lot of people scored points.

Harvey was top this week with 6 points. Too many people to name came in second with 5 points.

Overall, Tippi takes the lead with 53 points. Corien moves to second with 52 points. atg is in third with 51 points. Jamie Pt drops to fourth with 49 points. Gary, Gleb, and Harvey are all tied for fifth with 48 points. If your score is 42 points or higher, you are in the top 10%.

Click here to see the full scoreboard.

A fairly predictable episode of Fringe tonight. The uberplot was advanced nicely, but this week’s action just felt shallow.

The Plot: Strange things are happening at the Rosencrantz apartment building. Half the residents have moved out over the strange goings on. Still, that doesn’t stop the couple in 7B from hosting a party. Unfortunately, the party is pretty much a disaster as their balcony becomes immaterial at one point, sending six people plunging to their deaths. The Fringe Team is called in and quickly realizes the building is somehow a weak spot between the two universes. Walter is worried that a vortex will appear at the site, destroying most of Brooklyn. He sends Peter and Olivia with a bevy of equipment to monitor the building. Meanwhile, he starts researching the amber jello first seen in Episode 3 (”The Ghost Network”) which is what the alternate universe uses to seal vortexes.

Monitoring the building – except when they’re having French fries in a nearby pub – Peter and Olivia quickly realize that whatever disturbance is going on, it is centered on Apartment 6B. They bust down the door and find an elderly widow talking to the “ghost” of her husband — except Peter can’t see the ghost, only Olivia and the widow can. Walter suspects that it’s not a ghost at all, but she is somehow seeing the alternate of her husband from the other universe – a sign a vortex is imminent. Walter proceeds with his amber plan, and even gets Broyles and his superiors to sign off on it.

Peter and Olivia don’t want to risk using the amber. They deduce that while the husband died in this universe, the wife must have died in the other universe. The combined grief of the remaining spouses is what is causing the universes to meld at that point.

Another episode of instability occurs, more intense than the last. Walter believes the time has come to deploy the amber. The building is evacuated – except for the widow in 6B who refuses to leave. The amber canister is emplaced and ready to release the gas. Peter and Olivia convince Broyles to give them a few minutes to talk to the widow. They figure if they can convince her to let go of the past, the vortex will seal on its own. When they arrive in the apartment this time, the breach is string enough that even Peter can see the ghost. Even the people outside the building can see the telltale glimmer in the window of the apartment. The widow refuses to let go, insisting that it is her husband. Now she can hear the “ghost” speak and he tells her how much he misses her – then he tells her how much their daughters miss her as well. In this universe, the widow and her husband never had children, so this makes her realize that it is not her husband, and she drops the connection. The vortex immediately subsides, just as Broyles was ready to release the amber gas. The world is saved – for now.

In a brief coda set in the other universe, Fauxlivia and Lincoln are puzzled when a high class disturbance set at the same apartment building in their universe abruptly stops for no reason.

1. Never Bet Against the House
The odds of flipping a coin and getting heads ten times in a row is 1 in 1024

2. Put Your Dread Pleasures More Into Command Than To Entreaty.
With a building named the Rosencrantz, Apartment 2B would have been a more apropos choice.

3. Apparently He Plays Dice with Emotions
“Spooky action at a distance” is an Einstein quote regarding quantum entanglement, but it was a quote disparaging it, not supporting it.

4. Did You Really Expect That to Work
Why did Broyles even ask Peter and Olivia to agree to evacuate when he ordered – he knew they weren’t going to listen. They haven’t yet.

5. Give It Some Distance
I’m unclear why separating the grieving widow and widower wouldn’t work in stopping — or at least slowing — the vortex. It was their proximity that started it, and surely there have been other alternate universe grieving couples before without incident.

While their weren’t really any significant errors or plot problems this week, it simply wasn’t a strong enough episode to improve the Doomsday Clock.

Tags: television fringe apartment ghost amber

A below average episode of House with more-unrealistic-than-usual medicine and a more-unrealistic-than-usual final solution. At least Wilson was back this week.

Nadia is a waitress in her mid-thirties who has perfect memory — she never forgets anything, or anyone. One day at work, she suddenly collapses, both her legs paralyzed. Though it is just a temporary paralysis, she is admitted to House’s team for work-up. In addition to the episode of paralysis, she is also noted to have elevated CK (creatine kinase, a muscle protein) levels. There is debate among the team about her perfect memory, and whether that’s a symptom or not. An MRI of her brain was negative for stroke or tumor (notice how carefully that was phrased: not a negative study overall, but just negative for those two specific diagnoses). The initial diagnostic suggestions include toxin exposure, botulism, or alcoholism. Half the team is sent to look over her house, while the other half performs a thorough physical exam (which they should really do for every patient anyway). The search of her house turns an empty bottle of laxatives, so Taub suggests magnesium poisoning. House discounts that suggestion. Noting that the patient is constipated, he asks her how many times she’s stumbled or fallen over the past several years. As he suspected, she is falling more now than she used to, and he diagnoses her with early onset Parkinson’s disease and starts her on levodopa.

Nadia’s sister Elena stops by to visit and it is clear there is some unresolved issues between them. Nadia’s heart rate skyrockets — a wide complex tachycardia (an elevated heart rate that originates in the ventricles. This can degenerate into fatal arrhythmias like ventricular fibrillation so defibrillation can be appropriate). The cardiac symptoms mean that the diagnosis of Parkinson’s was wrong, so now the team throws out the ideas of elevated catecholamines (stress hormones such as adrenalin. High levels can occur with a pheochromocytoma), or long QT syndrome (an inherited heart condition that can lead to life-threatening arrhythmias) worsened by the stress of her sister’s visit. Under House’s suggestion, the team performs a cardiac stress test on Nadia using a fight with her sister as the stressor. The test is positive and she is started on beta blockers (a medication that lowers the blood pressure and slows the heart rate).

Chase now notices that Nadia has ammonia breath, which suggests kidney failure. This new information means the team needs to rethink their diagnoses again, and this time they come up with amyloidosis or an autoimmune disease (with Guillain-Barre, myositis, multiple sclerosis, polyarteritis nodosa, and SLE getting a shout out). She is started on steroids to treat the autoimmune disease and dialysis for the kidney failure. Things continue to deteriorate and Nadia develops shortness of breath and hives. It is determined that she is having a severe allergic reaction to the dialysis. Unfortunately, without dialysis, she’ll soon die. A kidney transplant is possible, but the waiting list is too long. Instead, the team decides to approach Elena who agrees to donate a kidney. The surgery is quickly performed and seems to go well at first, but then Nadia suffers a seizure while in the recovery room. And then the autoimmune tests all come back negative, so the suspected diagnosis was wrong. Now the differential diagnosis consists of acute porphyria or Factor V Leiden mutation (a condition that causes blood to clot more easily). House favors the latter, and Nadia is started on the blood thinner Heparin. Even with this treatment, Nadia is not doing any better, and is actually getting worse. She now has some uncontrollable movement of her left hand (chorea). Foreman suggests getting an MRI to look for a brain hemorrhage, but House wants a peripheral blood smear for acanthocytes (abnormally shaped red blood cells). Later, he comes in the room to talk to Nadia. He points out that she has obsessive compulsive disorder (OCD). Furthermore, he informs her that this and her other symptoms are due to a rare genetic condition known as McLeod’s Syndrome. Unfortunately, it is not curable, but it is controllable. After House leaves, Chase gives her a prescription for an SSRI ( — the class of drugs that includes Prozac, Zoloft, Paxil, Lexapro, and others) telling her that it will help with her OCD. As the episode end, she decides to try the medication in order to live a more normal life.

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

I don’t care if the donor was her sister, there’s no way that Nadia is going to get a kidney transplant without a firm diagnosis.

McLeod syndrome is an x-linked disorder. This means it is almost exclusively a male disease. Women with the affected gene are carriers, with mild symptoms at worst – however, their have a handful of cases of more severely affected women (felt to be due to unequal inactivation of the x chromosomes) but only one exhibited any symptoms near the level of disease Nadia was showing. Surely a good family history (she has that great memory after all) would turn up some siblings/cousins/uncles with neurological problems.

Nadia seems to have OCPD (obsessive compulsive personality disorder) more than OCD. Her symptoms seem more OCPD-like and ego syntonic than I would expect with OCD (and I consider it cheating for the writers to not even suggest such a major clue until the very end the way they did).
While people with hyperthymesia have been said to have some OCD-like characteristics, I’ve never seen it mentioned that they actually have OCD itself.

CK from the heart can easily be distinguished from CK from skeletal muscles or other sources.

McLeod’s will show up on an MRI, but then it’s not a “tumor” or “stroke” so I guess they didn’t look for it.

Before starting a blood thinner such as heparin you need some proof of blood clots, even if it’s just an elevated lab value (such as troponin or d-dimer). I guess you could argue that the elevated CK could have been CK-MB (the heart form of creatine kinase, and an elevated level can represent a heart attack) but then the heparin should have been started at the very beginning of the episode.

Levodopa is really never administered by itself anymore for Parkinson’s (too many side effects). It is prescribed in a combination form with carbidopa.

She was allergic to the hemodialysis, what about peritoneal dialysis?

Taub was always shown to be a plastic surgeon. Now he’s a pathologist too?

The medical mystery this week was barely intriguing and only got a little better as the episode went on. This is House, so you knew the hyperthymesia had to be a symptom: I give it aC. The final solution was a stretch, even by House standards. I give it a C-. The medicine was very sloppy and the sudden transplant was too much to believe: D+. The soap opera was pretty good, I liked that we saw more Wilson, and the Taub/Foreman pairing is always fun (I also liked the call back to video game episode); it earns a B+.

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

Though nobody came up with McLeod’s Syndrome, it was a high scoring week with multiple common autoimmune disease mentioned by name. I also went back and corrected any previous mistakes in scoring that were brought to my attention or that I noticed myself.

brism19 and Eli top this week with 16 points. Silvina comes in third with 15 points, followed by atg and Karatesocks in fourth with 13 points.

Overall, Jamie Pt takes the lead with 49 points. Tippi is in second with 48 points. Corien stays in third with 47 points. atg is in fourth with 46 points and Fran rounds out the top five with 44 points. If your score is 40 points or higher, you are in the top 10%.

Click here to see the full scoreboard.

It’s nice to have Fringe back in the alternate universe. This was a good episode, creepy for sure, and one that definitely changes the status quo

The Plot: Fauxlivia picks up her boyfriend Frank at the Empire State Building airship station. At the bar at the dock, two men – one of them a scientist named Silva — make small talk. Silva distracts his conversational partner, then switches their drinks. A short time later, the victim of the switched drink is violently retching in the bathroom as beetles eat their way out through his skin. Silva collects a couple of these beetles and nonchalantly strolls out.

The Fringe Team is called to the airship station for investigation of a “spontaneous bug eruption.” No insect data base they have can identify the beetles, and the team finds only a single live specimen.

Back at the Department of Defense, experiments continue on the chemical they extracted from Olivia (i.e. cortexiphan). After receiving a second injection, one patient develops telekinetic abilities — for a short time anyway, until he collapses in pain, apparently killed by the cortexiphan. Walter mentions that all the other patients in the experiment died. Alternate Brandon points out that the patient who developed telekinesis was the youngest of the patients, and he wants to try the cortexiphan on children. Walternate draws the line and tells him absolutely no experimenting on children.

Fauxlivia and Charlie arrive at an insect lab asking for assistance. Mona, the lab tech, recognizes Charlie from when he was initially infected with spiders and is clearly quite smitten. She eventually recognizes the bug as Mansonium boogliosis, the “Skelter beetle”. It was an obligate sheep parasite – not the use of “was” — the beetle died out 10 years ago, shortly after all the sheep did.

In his lab, Silva dissects the bugs he collected, but the results are clearly not what he was looking for. Next we see him at a local diner, ordering the same dinner as the man next to him. A short time later, when this guy dies, eaten by beetles, Silva is nearby collecting the insects.

The Fringe Team determines that the initial bug eruption seems to be an isolated case and not an outbreak. They put a “Fringe Alert” on television asking for help identifying the insect. They get a call from a scientist who used to work with Dr Silva, who was using the skelter bugs to develop an avian flu vaccine. Fauxlivia’s boyfriend Frank, through use of his CDC connections, is able to get more details on Dr Silva. He also identifies the equipment Silva would need to start his own laboratory. Agent Lincoln tracks a shipment of these supplies to a warehouse in Brooklyn. Lincoln and Fauxlivia investigate the warehouse — it appears deserted, but they suspect someone is in there with them. Soon, Lincoln is locked in a walk-in freezer and Fauxlivia crashes through the rotten floor of the warehouse and is captured by Silva. He gives her some water to drink that apparently contained some beetle eggs. Lincoln frees himself from the freezer and calls in a backup team. Silva is captured. Frank arrives and Fauxlivia is transported to the hospital. Frank is all ready to inject her with a potent anti-parasitic when it turns out that Fauxlivia is not infected at all, but pregnant. Dr Silva had infected himself and became the final victim of the beetles.

Poor Frank, he had asked Olivia to marry him, but now she is pregnant with a child that is clearly not his. He walks out of her room and moves out of their house. As the episode ends, Walternate arrives to comfort Fauxlivia, reminding her that she is the mother-to-be of his grandchild.

1. Hopefully, There Is No Alternate Jenny McCarthy
Jonas Salk was the researcher who developed the best known polio vaccine. His vaccine used a killed polio virus, and thus did not have the risk of wild-type reversion (infection with an active polio virus) that can sometimes occur with a live virus vaccine. I’m unsure of why Silva would suggest Salk had killed people in pursuit of his vaccine as this simply is not true. Experiments with the Sabin vaccine (a live virus vaccine) did end up with some patients contracting polio and dying, but this had nothing to do with Salk. There was also the so-called Cutter Incident where a batch of the Salk vaccine was contaminated with live polio virus, which did result in some deaths – but this had nothing to do with Salk himself.
Louis Pasteur was a French scientist from the 19th century. Every time you drink milk and don’t die, you owe it to him (assuming your drinking pasteurized milk – if it’s raw milk, then good luck to you and say hello to Brucellosis for me). He was an early vaccine researcher. He certainly took risks – all vaccine researchers did back then – but again I know of no deaths directly attributable to Pasteur and his vaccine work.
Of course it could be that Silva was right and the alternate Pasteur and Salk did kill patients in their research.

2. Alternotes
Over there:
All sheep died off 10 years gao.
Apparently all of Boston has been amber-ified.
Airship still dock at the empire state building.
An Avian Flu outbreak in the last ten years has killed millions.
Samuel Clemens is not routinely referred to by the more common (here at least) “mark Twain”

3. Oh The Humanity
In our world, the Empire State Building was originally designed to have a airship dock and terminal as well. The plan was scrapped after a few months when it was discovered the updrafts caused by the building itself made mooring an airship dangerous.

4. Somewhere, Vincent Bugliosi Is Upset
Though the closed captioning referred to the beetle as “Mahnsonium boogliosis,” to me it is clear that this should be “Mansonium boogliosis” as it a definite reference to Charles Manson, who is famously associated with the phrase Helter Skelter (as in the Beatle’s song and the source of the name “skelter beetle”).

5. The Beetles!
Coleoptera is the largest order of insects; it’s the beetle order. Archostemata is the smallest suborder of beetles. They are relatively rare and fairly primitive – similar in many ways to fossil beetles.

6. I Call Lab Shenanigans
Plasmids are a form of DNA molecule used by some bacteria, so I’m not sure how helpful they would be in a virus lab.
The way they mentioned the liquid nitrogen (all that fancy equipment then plain old “liquid nitrogen”) you just knew it was going to come into play later.

7. Bad Romance
Convenient that other universe ambulances carry portable ultrasound machines. It’s also convenient that Frank turned the machine not on Faulivia’s stomach area — the most likely place the eggs would be and found high in the abdomen — but on her pelvic area (and it did appear to be a fairly accurate ultrasound for a six-week pregnancy).

8. Fluke, Beetle, What’s the Difference?
Metrifonate is a real drug. It is an organophosphate acetylcholinesterase inhibitor and has been used to treat schistosomiasis (an infection by parasitic flukes — not close to an insect infestation at all). It is no longer available commercially in our universe, but apparently it still is over there. And apparently, there must be schistosomiasis problems in Texas over there, since Frank had it in his bag.

A solidly creepy episode that also managed to advance the überplot. I’m sad to see Frank go, but at least he acquitted himself well this episode — unlike Lincoln (locked in a freezer?). The Fringe Doomsday Clock moves back one minute to 11:54.

Tags: television fringe beetles fauxlivia pregnant

Cuddy’s mother is back in an episode of House that was more soap opera than medicine — and yet, no Wilson.

Cuddy, her mother Arlene, and sister Julia are shopping for dresses when her mother complains of an irregular heart rate. When Cuddy detects atrial fibrillation she has Arlene admitted to the hospital. While there is some hypertension (high blood pressure) and borderline macrocytic anemia (anemia with abnormally large red blood cells), there is nothing that particularly alarms House. Her treadmill test comes back normal, so he plans on discharging her. She bombards him with fifteen years worth of minor symptoms such as dizziness, diarrhea, constipation, rashes, and joint pain, so he decides to keep her in the hospital to appease her. He sends a team to search her apartment and — in addition to finding some in flagrante delicto photos — they also find a bottle of Mexican herbal medicine. Since these are often high in lead, Arlene is started on chelation therapy for possible lead poisoning.

House feels that hypochondria explains most of Arlene’s symptoms and gives her placebo pills to prove his point. When she finds out, she fires him from the case. Cuddy convinces House to stay on “behind the scenes” while Dr. Kaufman, the head of Internal Medicine, takes over. Soon, Arlene’s atrial fibrillation starts up again and Dr. Kaufman suggests cardioversion (using medications or electrical shocks to return the heart to a normal rhythm; in this case Kaufman is clearly referring to electrical cardioversion because it is painful if one is awake during the procedure — which was apparently never carried out, or if it was, it failed). Looking over her symptoms, the team suspects leukemia, which is the same thing that Dr. Kaufman suspects and is testing for. House berates them for their suggestion, insisting that Arlene has thiamine deficiency, which he blames on her likely alcoholism. Cuddy confronts her mother about her drinking, but she denies being an alcoholic, so Cuddy tricks her into taking thiamine pills.

Arlene now begins to run a fever which rules out thiamine deficiency. Taub suggests an autoimmune disease such as SLE (lupus) — which again is the same thing Dr. Kaufman diagnosed and he has already started her on prednisone. Foreman suggests endocarditis (an infection of the heart valves) and House agrees. If it is endocarditis, then the prednisone will make the condition worse because it suppresses the immune system. With the assistance of Cuddy, they switch out the prednisone for an antibiotic without Dr. Kaufman knowing.

Unfortunately, Arlene now develops an allergic reaction to the antibiotic with wheezing, shortness of breath, and pruritus (itching). Cuddy switches the antibiotic back to prednisone and the allergic symptoms resolve, but the atrial fibrillation and fever return. House now suspects Arlene has a fungal endocarditis and wants to start Amphotericin B, a particularly nasty antifungal. The team balks as there are many potential pitfalls when using Amphotericin, especially if carried out covertly. Despite being threatened by House, M³ works up the nerve to tell Dr. Kaufman what’s been going on behind his back and he is livid. Arlene is also furious and demands to be transferred to another hospital. After a discussion with House about how she never stands up to her mother, Cuddy confronts her and tells her that while the care may be friendlier at another hospital, but she’ll die there. It works and Arlene decides to stay at Princeton-Plainsboro.

As Arlene is being wheeled back to her room, she makes a comment that shows she misunderstood one of House’s clearly sarcastic comments. House quickly confirms that she is unable to detect sarcasm which suggests a problem with her right parahippocampal gyrus (a part of the brain used to decipher social context, such as sarcasm). Since the neurological symptoms started before the fever, it makes the diagnosis of endocarditis less likely. Instead, House returns to heavy metal poisoning. No lead this time, but cobalt, from a worn hip replacement. He confirms this by exposing the muscle around the implant which is discolored from the toxicity. Arlene is started again on chelation therapy and given a new hip.

This episode had a number of abbreviations mentioned without much context to figure them out:
M&M: Morbidity and mortality conferences are held by departments and hospitals to review and evaluate cases with bad patient outcomes.
DDX: Differential diagnosis
AOA: Alpha omega alpha, a national honor society for medical students

Not that much actual medicine this week, so not as much to criticize. Surprisingly, for yet another week, I found nothing I considered a major error. There were the usual jumping to unsupported diagnosis errors, but nothing that made me cringe too bad.

As usual, major complaints are in red (none this week), more minor complaints are in blue, and nit-picking ones in green:

A treadmill test will tell you if there is ischemic heart disease — which atrial fibrillation can cause, and can sometimes be caused by — but won’t help much in Arlene’s case. The key tests are to figure out why she is in atrial fibrillation. Only one test, thyroid, was mentioned and only in a discussion of outpatient care. Also, it would extremely difficult, if not impossible, to interpret a treadmill test on someone in atrial fibrillation.

That much hip muscle damage, but no significant hip pain? It should at least be worse than her other joints, and should have prevented her from performing a treadmill test.

I see many case reports of cobalt toxicity from hip replacement and cardiomyopathy and heart failure, but no mentions of atrial fibrillation.

If she had fungal endocarditis, why did her symptoms improve on the antibiotics? (Same question, just replace “fungal endocarditis” with “cobalt poisoning”)

House seems decidedly unconcerned about her atrial fibrillation. “It may get better on its own, or it may not…” If she’s in chronic atrial fibrillation, she’s probably going to need anticoagulation (blood thinning medication).

Low cobalt levels can lead to B12 deficiency which can lead to macrocytic anemia. Elevated cobalt levels lead to polycythemia — too many red blood cells — the opposite of anemia.

Yes, going against a patient’s DNR has been viewed as assault in certain cases, but M³ wasn’t initiating treatment, just running some tests. I doubt this would violate the DNR (tests of one sort or another have to be run on all patients), and she did perform the testing under House’s implied suggestion, even if it wasn’t verbal. No prosecutor would touch the case.

The medical mystery this week was only interesting because of who the patient was, not due to the mystery itself: C-. The final solution was logical — and well documented — and fit many of her symptoms. I give it a B+ The medicine was sparse, but above average. It earns a B. The soap opera was good, but was severely lacking in Wilson. For that, I can only give it a weak B.

This week’s House Challenge scores have been posted.

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

Jamie Pt wins this week with 14 points. Forny, Kirsten, and Mosaad all tied for second with 9 points.

Overall, Sapramiska takes the lead with 39 points. Jamie Pt and Tippi are tied for second with 37 points. Corien moves up to third with 36 points and Forny and Fran round out the top five (or six, actually) with 34 points. If your score is 30 points or higher, you are in the top 10%.

Click here to see the full scoreboard.

An average episode of Fringe — nothing outstanding, but nothing horrible — with a couple of strange choices for plot explanation.

The Plot: Dr. Blake, a prominent scientist receives a package in the mail on his birthday. When he opens it, there is a cloth doll inside. He pulls the string on her back and she laughs and then releases a cloud of blue powder at him. After inhaling the powder, he collapses in excruciating pain, all the bones in his body fracturing and disintegrating. The Fringe Team is called in to investigate. They discover the doll and bring it back to Walter’s lab for analysis. After a bit of investigation Walter learns that it is a biological weapon used to dissolve the victims’s bones.

Olivia and Peter check out post office surveillance and identify who sent the package to the scientist. He turns out to be a decorated former marine. They search his house and find a case of the bioweapon in the basement – but with three canisters missing. One had been used against Dr. Blake, leaving two unaccounted for. The marine shows up and is pursued, but he is hit by a car and ends up in a coma. They track down his ex-wife who tells the team that after getting out of the marines, he had been doing some consultant work on bioweapons. He blamed his wife’s miscarriage on the bioweapon experiments and swore to kill Dr. Blake — who was in charge of the project.

Walter mentions that he has a way to get information from the comatose marine. He mentions Simon, another child in the cortexiphan experiments who was dropped from the project after he developed the unsettling ability to read minds. Olivia, Peter, and Walter track down Simon, and Olivia eventually convinces him to come to the hospital to read the marine’s mind. He is able to pick up certain words and phrases, though much of it seems to be a grocery list.

Broyles calls on Nina Sharp and her contacts to find out more about the bioweapon project the marine was working on. It turns out that three ex-marines worked on “Project Jellyfish” and all three of their wives suffered miscarriages – which they blamed on their work with the project. Meanwhile, a second bioweapon attack has occurred, killing three executives from the defense contractor that ran the bioweapon project. A search of pay records show that in addition to pay, the first marine was given a three acre farm not far from town.

The Fringe Team searches the farm and finds evidence that the two remaining marines are planning to launch a large attack with the remaining bioweapon canister. Thanks to notes conveniently left behind and some of the information gathered by Simon, the team deduces that they are going to target a congressman who was once an army general. The place of attack is a fundraiser at the local art museum. Simon and Olivia arrive at the fundraiser and locate and take out one of the marines, but he doesn’t have the bioweapon on him. They search the crowd and manage to kill the second marine just before he activates the weapon.

The mystery of the week solved, the episode ends on two related vignettes:
Nina realizes that the books on the First People, supposedly written by different writers in different languages, actually were written by Sam, the mysterious bowling alley owner we haven’t seen since last season. He tells Nina the First People machine will destroy one universe and save one universe – it all depends on which Olivia Peter chooses.
Simon hands Olivia a note of what he read from Peter’s mind. It tells her that he still has feelings for Fauxlivia.

1. No Star Trek Novelizations?
William Bell has an interesting choice in books: In the Wake of Chaos; The Second Ring of Power; Gödel, Escher, Bach: An Eternal Golden Braid; an old edition of Cell and Molecular Biology; and finally, one of Dr. Spock’s baby books (clearly a nod to Leonard Nimoy’s best known role).

2. He’s a Genius?
Hey look! I’ve found the delivery device for the unknown bioweapon. We have no idea if our biohazard suits will be effective. Why don’t I pull the trigger again to see what happens? Brilliant idea, Peter.

3. When in Glasgow
The marine is suffering brain swelling — common after a head injury. This has increased the intracranial pressure around the brain, and that in turn is forcing the brain farther down into the skull, causing a herniation. These are particularly nasty and the doctor is right about his poor prognosis.
Still, he’s having some remarkably coherent thoughts for someone whose brain has all but shut down.
Apparently HIPAA doesn’t apply if the Fringe Team wants information.

4. Pathogenicity
What exactly is a DNA Pathogen? Is it a piece of DNA that acts as a pathogen (like certain viruses), or a pathogen that targets DNA? And what does it have to do with causing a miscarriage?
Why not just say the marine developed damage to his DNA during the experiments and this was passed along to his child rather that trying for technobabble?
Seven months is surprisingly late for a complete lack of bones to finally be noticed.

5. Way, Way Off
Despite what Walter says, the vast majority of animals don’t have bones. 95% of animal species don’t have bones, and when you look at the number of total animals — as opposed to species — the percentage is even higher.

6. Forty Acres and a Mule
How convenient that the marine was paid with a farm just outside of town. ? This is not the 18th century — who pays in farms anymore? Why not just say his parents left him a small farm outside of town; sounds more believable that way.

7. Those Who Do Not Know History
Didn’t we already have the bioweapon at the elite public gathering storyline?

An average episode. Nothing bad enough to advance the countdown, but nothing redeeming enough to reverse it. The Doomsday Countdown Clock stays at 11:56 11:55.

Tags: television fringe dna bioweapon telepathy

At a trivia night Friday night then an early 5K run Saturday morning. Will get the full review posted soon as I can, probably later afternoon/early evening Saturday.

A decently entertaining episode of Fringe. While it had some good moments, it seemed to be more about setting up the storylines to follow.

In a hangar at a remote military installation, Massive Dynamic scientists have built the First People’s machine but cannot get it to work at all. However, when Peter enters the hangar, the machine suddenly turns on and he develops a nosebleed.

The following day, multiple tests are run on Peter at Massive Dynamic trying to figure out why the machine reacted to him, but other than an elevated heart rate (and an unmentioned elevated blood pressure), the tests were all normal.

About this time, the dead body of a shapeshifter turns up. The victim’s name is mentioned in Fauxlivia’s notes. This suggests to Agents Broyles and Dunham that there is a mole in the agency. A lie detector test is run on everyone who had access to Fauxlivia’s notes, but no spies turn up. Peter then suggests they test Dr. Falcon, the head of the machine project, but he has left work early. The team arrives at his house to find him dead, another shapeshifter.

When Walter examines Falcon’s body, he finds some human blood under the fingernails, which suggests that he tried to fight off his attacker. The blood leads initially to Massive Dynamic chief scientist Brandon, but it’s just a dead end and Brandon is innocent (of this, at least).

Across town, another shapeshifter is running for her life, but in the process of changing identities is fatally shot — and the killer is revealed to be Peter.

Meanwhile Olivia manages to break Fauxlivia’s code and identifies the fifth, and apparently final, shapeshifter. Peter is already there, trying to kill him, but this one is doing a good job of fighting back. Just then Walter arrives — he has found Peter’s notes and tracked him down. This distracts the shapeshifter long enough for Peter to kill him and extract the memory disc from its lower back. Peter is convinced one of the shapeshifters must know more about the machine. Peter and Walter quickly leave so when the rest of the Fringe Team arrives they just find a dead shapeshifter.

Later on, Walter tells Peter that he thinks that Peter’s encounter with the machine changed him and somehow “weaponized” him.

1. Fauxlivia For The Win
Wish I could take credit for this one, but it all goes back to io9.

2. Back and Bloody
Nice to see the psychic nosebleed returning to network television.

3. Racing Heart
Generally speaking, there are two types of tachycardia, narrow and wide (this refers to the width of the QRS complex, the largest waveforms on an EKG). Narrow tachycardias originate in the atria, the upper half of the heart, whereas wide tachycardias originate in the ventricles. Ventricular tachycardias tend to be much more dangerous and can degenerate into a fatal arryhthmia. On the other hand, atrial tachycardias are not usually as serious, which is why Dr Falcon wasn’t worried when he saw Peter’s was narrow.

4. You look down and see a tortoise, Leon. It’s crawling toward you…
I was getting a definite Blade Runner vibe from Brandon’s lie detector, which I suspect was intentional — hunting for shapefshifters can’t be all that different from hunting for replicants.
I suspect Brandon’s machine is looking for microexpressions, which allegedly allow a skilled interviewer to know whether someone is lying (the show Lie to Me is based on this premise).

5. Mavis Beacon<