Polite Dissent

As part of her rehabilitation, Poison Ivy offers to cook you a meal. Do you:

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The 100th episode of House. Too bad it was so absolutely mediocre with an unlikable patient.

Of course, this also makes it my 100th House review*. Sure the first reviews were just a paragraph or two, but they quickly evolved into the behemoth you see before you now. While it’s certainly true that the quality of the show has suffered some over the past few seasons, it still remains the best medical show, if not best show outright, on television.

Dana Miller is assisting a chef in teaching a cooking class when she becomes short of breath and starts to cough. She discovers that her lips are blue and realizes she has cyanosis. She complains of pain in her chest and back and diagnoses herself with a spontaneous pneumothorax before collapsing on the floor. She is rushed to the hospital and admitted to House’s service, primarily based on her name and reputation. It turns out that Dana is a rock star in the world of the cancer research, and said to be on the cusp of finding a cure for retinoblastoma. The team is sorely disappointed when she tells them that she gave up her career in medicine eight months ago after uterine surgery because she realized it wasn’t making her happy. She now devotes her time only to activities that she fully enjoys.

There is no clear cause for Dana’s pneumothorax. Foreman points out that there is no history of COPD (chronic obstructive pulmonary disease, i.e. emphysema) and no history of tobacco use or recent scuba diving. The initial differential diagnosis consists of cystic fibrosis, lung cancer, or an undiagnosed asthma. She is started on steroids to treat the suspected asthma and a CT scan of her lungs is obtained to look for evidence of hyperinflation (a sign of asthma). The CT scan is normal, making asthma less likely. Taub suggests that lingering damage from the central line from her surgery might explain the lung problem (and I couldn’t help but notice that instead of just stating she had “surgery,” he was very specific about which surgery she had. Hmmm. Wonder if this will be important later?). Kutner notes increased interstitial markings on the CT scan — which apparently everyone else missed — which means that Dana might have pulmonary fibrosis. A biopsy is ordered. When Taub is explaining the test to her, she starts to complain of left-sided abdominal pain. After a quick exam, Taub tells her she has bleeding into her abdominal cavity and withdraws a syringe of blood to prove it. (FYI: She asks if she has ascites, the build up of fluid in the abdomen).

In addition to her lung problem, Dana now has a liver problem — or problems — as well. Not only is her liver bleeding into her abdominal cavity, but they also work in the fact that she has liver failure. Foreman suggests a liver granuloma as a possible cause, and Thirteen goes one step farther and suggests blastomycosis as the cause of the granuloma. A biopsy is obtained, but the test for blastomycosis is negative. Dana starts to complain of itching, which she blames on the liver failure (the high bilirubin levels that occur in liver failure can definitely lead to very bad itching). As she sleeps, she continues to scratch, and in fact scratches hard enough that she scratches through her skull into her brain. Luckily, Taub is able to repair the skin damage (having a plastic surgeon on the team is sure handy) and announces that she has suffered no brain damage.

The differential now consists of psychogenic itching, meningitis, encephalitis, multiple sclerosis, or a brain tumor. An MRI of the brain is obtained and is negative. House now suspects that Dana has polyneuropathy and wants to shock the affected areas to “reboot” the nerves. As Taub is about to start the treatment, she begins to experience a shocking sensation — which he identifies as Lhermitte’s sign. According to the team, this can be suggestive of Behçets Disease, Vitamin B12 deficiency, a demyelinating disease, or a spinal hemangioma. An MRI is ordered to look for a hemangioma. It turns up what appears to be not just a single hemangioma, but hemangiomas in the spine, lungs, and pericardium (the sac surrounding the heart). The thought now is that she has metastatic mesothelioma (a lung cancer most commonly associated with asbestos exposure), but House is perplexed that these same lesions did not show up on the chest CT two days before. Wilson is called in to biopsy one of the lung lesions, but he is unable to perform the procedure as the lesion starts bleeding profusely, which should not happen if it is mesothelioma. He suggests she might have arteriovenous malformations (AVMs) due to schistosomiasis (a parasitic infection acquired from bathing or swimming in contaminated water), but the team counters that she shows signs of Gorham’s Disease or Kasabach-Merritt Syndrome. The brainstorming is interrupted when Dana suffers cardiac tamponade (blood fills the pericardial sac, compressing the heart and not allowing it to beat correctly). Kutner inserts a needle (read: jams a needle blindly) into her chest to relieve the tamponade, only now she is bleeding copiously through her ears, nose and eyes.

Later, Taub informs House that they are giving Dana multiple units of platelets and FFP (fresh frozen plasma) but they cannot control her bleeding. House suggests embolization — blocking off the bleeding blood vessels. He wants them to start with the ones in her lungs. He then proceeds to run into Cuddy, where in the midst of a crasser than normal conversation, he has his Eureka! moment. He reveals that Dana is bleeding so heavily because it she is menstruating. He announces that as a result of her uterine surgery she has developed endometrosis, and it is these abnormal clusters of endometrial tissues throughout her body that are doing the bleeding.

Thirteen begins to have frontal headaches. Foreman is concerned that it may be related to the experimental Huntington’s drug, but she blows it off, telling him that she has been taking the drug or the placebo for weeks now, and nothing has changed recently (Right? Right? Wink wink.) House then brings her lack of peripheral vision to Foreman’s attention. He tests her himself and finds that House is right. He confesses the truth that he switched the drugs to her, and obtains an MRI of her brain. It reveals a tumor in the optic chiasm. Within a day or so, she becomes totally blind. House and Foreman give her a directed radiation treatment to the tumor, and it regresses and Thirteen’s sight is restored. As the episode ends, Foreman confesses what he did to the drug company running the trial. He is kicked off the trial, but gets to keep his license. On the other hand, Thirteen’s data, now considered dirty, is excluded from the trial and so is the evidence that the drug may cause tumors.

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

I had pretty much given up on even mentioning the errors in the procedures the team performs, but this week two scenes were so bad that they bear special mention.
First, Taub drawing the blood from the abdomen. He did just about everything wrong. No protection for him. God forbid he sterilize or at least clean the patient first (congratulations Taub, you just gave her a staph infection of the abdomen). You need to use a z-track technique or the higher pressure in the abdomen will push the fluid out the needle track. That 20- or 40-cc syringe was way too small to draw off any appreciable amount of fluid. I have seen multiple liters pulled off a single patient (though admittedly, those patients looked pregnant).
I have similar complaints in regards to Kutner’s technique for pericardiocentesis. Worst was when he overhand jabbed the needle blindly into her left chest. That is NOT the way to perform a pericardiocentesis. He likely gave her a second pneumothorax, not to mention injured the heart or sheared off a coronary artery. The trick is to drain off the fluid without killing the patient in the process.

There have been documented cases of endometrosis being spread due to surgery, however, in all these cases the patients had endometriosis before surgery, and it was that endometriosis that was spread, not normal endometrial tissue that became endometriosis.
My biggest problem with the endrometriosis solution is the time course. Remember your high school health class. The endometrium takes 3 -3½ weeks to slowly build up in thickness before sloughing off to start the menstrual cycle. Endometrial tissue does not go from nothing to suddenly-detectable-everywhere one day before the cycle starts. If she that much endometriosis to cause all the symptoms she had, there would have been plenty of evidence on the first CT.
Why had she been symptom free the previous 7 months?

Bronchoscopy and bronchoalveolar lavage are the preferred initial steps in diagnosing pulmonary fibrosis. It’s true that they are not as good as an open biopsy, but the risk pf complications are significantly less.

There are many fungi that fluoresce under black light and it is a fun way to diagnose ringworm, but it is not the recommended method of diagnosing blastomycosis. In fact, I didn’t find the technique mentioned in any of the main texts on the subject.

Wow, Thirteen had an incredibly fast growing tumor, didn’t she?
I was amazed at how fast the writers were able to turn it around from “Foreman screwed up” to “Those evil drug companies!”

“House was right” about the hemangioma? I though Taub was the one who brought it up.

I don’t know too many oncologists who do their own lung biopsies.

What explains the liver failure?

Other than the comic-book style shocking visuals, why was Dana bleeding from her ears, nose and eyes? Did she have endometriosis there too (a first), or was the pressure of the bleeding so much it split her skull?

The medical mystery was fair this week. It started out small, but built up over the course of the episode and earns a B. Though I had problems with the final diagnosis medically, I thought it was clever and with a little tweaking could have fir perfectly so deserves another B. The medicine was average again: very superficial with little follow through. It earns a C. The soap opera was good, if understated. I liked the book-ending Wilson scenes, and the House/Cuddy scenes were fun, if a little out of character for her (though she did explain she had been dragged down to his level). I give the soap opera a B.

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

*OK, technically it’s my 101st House review as I re-reviewed one of the earlier episodes. One of these days, when I have time, I plan to go back and do the same for the other early episodes.

Comic book writers have a tendency to try to tie everything together in a neat little package. Depending on your point of view, this can be a good or exasperating (I tend towards the former). I find it particularly interesting when writers take this approach when dealing with comic book medicine. A good example is what I like to call the “Venom Family Tree.” In it, we see 60+ years of comic book continuity linked by the drug Venom.

NOTES:
1. Miraclo is the pill that gives Hourman his power and was first mentioned in Adventure Comics #48 (March 1940). In JSA All-Stars #5 (Nov 2003), Hourman II revealed that he had made a new non-addictive version of Miraclo that worked via a skin patch. In JSA Classified #17-18 (November 2006), it was revealed that Venom was based on Miraclo.

2. Venom is an addictive super-steroid that was first mentioned in Legends of the Dark Knight #16 (March 1991). Side note: it wasn’t called Venom at that time — that was the name of the storyline. It is best known for giving the super-villain Bane his power. There have been at least a second- and third-generation of Venom, each more powerful and more addictive than the last.

3. Decahydrabolin, better known as Steroid A39, is the drug that gave the current Dr. Mid-Nite his powers. In Doctor Mid-Nite #1 (1999), he mentions that it is a derivative of Venom.

4. Slappers are a transdermal version of Venom that appeared in Batman Beyond, so are undoubtedly non-canon.

5. Nandrolone is a real-world anabolic steroid. In Nightwing #114 (January 2006) it was mentioned as a precursor of Venom.

I’m pretty sure I’m missing a few more Venom derivatives, but I’ll fill them in as I run across them again. Some day, when I have way too much time on my hands and I’m feeling masochistic, I’ll take on the Super Soldier Serum family tree.

From week to week, it seems to vary: Agent Dunham is shown as either very competent or very lucky, and this was an episode favoring luck over skill. Despite that, I thought it was one of the better episodes of Fringe.

The Plot: A passenger on an airline flight notices a sudden nosebleed. He goes to the restroom, checks himself out in the mirror, and then runs a test on his saliva. When the results comes back positive, he is mortified. He rushes out and tries to convince the stewardess and steward that unless he was given some sedatives immediately, everyone on the flight will die. This, unsurprisingly, does not sit well with them. He retreats back to the bathroom where he transforms into a giant porcupine-sasquatch that proceeds to attack the other passengers and terrorize the plane, which shortly crashes into a field.

Agent Dunham and her team are called in to examine the wreckage of the crashed flight. The porcupine-man’s body is found and taken to Bishop’s lab. The good doctor finds “evidence of an extradural hematoma, probable epistaxis” and a glass disc embedded in the victim’s hand (similar to the disc found in the Jell-O Bus episode).

Agent Dunham looks through the passenger manifest and by using Agent Scott’s memories is able to identify the victim. She also identifies a suspicious person among his contacts, Daniel Hicks. When Hicks is brought in for questioning, his nose begins to bleed just like the original victim’s. Before he succumbs, Dunham is able to get a name out of Hicks: “Conrad.” Luckily, Dr. Bishop is there and orders the man be sedated and brought to his lab where he is placed in medically induced coma to slow the transformation. Bishop recognizes that a designer virus is to blame, and is able to concoct a antidote — but isn’t completely sure it will work.

Broyles tells Dunham that Conrad is a mysterious developer of biological weapons that law enforcement agencies have been trying to capture for years. As coincidence would have it, he is due to arrive in Chicago any day now to complete an arms deal for the virus in question.

Seeking information, Agent Dunham goes back into the isolation tank to delve into Agent Scott’s memories. Scott sees her there — though he shouldn’t be able to — and tells her that he was a deep cover agent for the NSA trying to catch Conrad. The two victims of the virus were also deep cover agents. He tells her to trust Hicks.

Dunham orders Hicks to be brought out of his coma and given the antidote. Through an undetectable two-way radio, he is going to guide her through an arms deal with Conrad. She and Peter Bishop fly to Chicago and manage to bluff their way into a meeting with Conrad’s men. Everything goes well until the antidote stops working and Hicks starts to transform again. Bishop has to sedate him to keep him alive. Peter does some fancy verbal footwork, but eventually their deception is exposed. No worries though, because they are able to summon the nearby FBI agents rescue them as well as capture Conrad.

As the episode ends, Dunham goes back in the tank a final time to say goodbye to Agent Scott.

1. Identity Issues
If the victim’s DNA was “completely rewritten,” (Peter’s words) how were they able to identify him through his blood?

2. I Swear, It’s For My Attention Deficit Disorder
I wonder how much dextroamphetamine 30cc is, since Dr. Bishop doesn’t give a concentration. 30cc is a hell of a lot of fluid to inject into somebody — it would hurt like hell, if you were able to get it all in (for reference, 30cc is a shot-glass full of liquid; a usual injection is less than 1cc).

3. Viral Nosebleed Zen
Even if the victim has a bleed around their brain (the “extradural hematoma”), it wouldn’t be able to leak out into the nose unless the skull was also fractured. (FYI: “Epistaxis” is fancy medical talk for “nosebleed”).

4. I Think Walter’s Lab is the Second Level of the Inferno
If I were Walter and autopsying a mysterious porcupine-sasquatch, I would be wearing a mask at the very least.
Walter has the equipment to keep someone safely in a medically induced coma in his lab?
Midazolam is better known as Versed, and is a short acting intravenous sedative from the same family as Valium.

5. The Return of Some Old Favorites
Once again, conservation of mass is an issue. Where did the matter to make all those spines and increased muscles come from?
And I’m not even going to mention the retained-memories from John Scott scenes — well, other than this.

Despite the isolation tank scenes and the return of Massive Dynamic, I enjoyed the episode more than I expected. I thought the arms deal in particular was handled well and gave off a palpable feeling of suspense. I’m giving Fringe a bit of a respite, and moving my Fringe Doomsday Clock back a little: the clock is now showing 11:56.

When we took the cats to the vet last weekend for their annual vaccinations, this poster for National Pet Wellness Month caught my eye. But then again, it contains two of my interests combine it one: it’s a cat wearing a head mirror dammit (and wearing it incorrectly at that). So of course, I decided it required a blog post.

Sorry for the late scores, but social obligations stole most of my free time over the past week.

This episode, Gerritt scored the most points with 15, while both Staci and tina earned 12 points.

Overall, Ash takes the lead with 42 points and Sable Hope drops to second with 40 points. Dogma-Central remains in third with 37 points. The Erskine rejoins the top scorers with 34 points, and Sconibulus and JockM tie for fifth with 33 points.

(The two people with missing points from last week had their scores updated as well)

Full scores are available here.

Before Superman perfected his “keep the heart beating with heat vision” technique, it appears he experimented with other resuscitation methods including this one, which he used to restart Professor Hamilton’s heart in Action Comics #667.

This technique seems to involve rubbing the chest very fast and…um…OK, I actually have no idea what Superman’s trying to accomplish here. But it sure seems to work — maybe it will show up in the next revision of ACLS.

Actually, I think that Superman’s powers would work against him in a resuscitation situation:
1. Super strength: It’s be too easy for him to apply a little too much pressure and crush the ribcage.
2. Super speed: He’d have the tendency to compress the heart too fast. CPR requires steady measured beats. With his speed, he’d essentially be mimicking ventricular tachycardia, if not downright ventricular fibrillation.

So if you’re down for the count and a super-hero shows up, you better pray it’s Batman and not Superman — I bet he’s got a Bat-AED in that belt of his.

Detective Comics #693 “Systemic Shock”
Chuck Dixon, writer
Staz Johnson, penciler
Published January 1996

I hope everyone looked at the Arkham Asylum Employment Application, because this scene follows immediately from that image and gives you good reason not to trust Poison Ivy’s cooking (like that isn’t common sense).

Psychiatrist #1: And you grew these greens on the grounds?
Poison Ivy: And strictly organic, doctor.
Psychiatrist #1: I love fresh radishes.
Psychiatrist #2: Um…they’re tangier than I’m used to.
Psychiatrist #1: Mmf…Chmmf…They’ve got a real bite to them. Almost like–
Psychiatrist #2: FFT! [choking sound]
Psychiatrist #1: WFFT! [choking sound]

Jack in the Pulpit (Arisaema triphyllum) is a common forest plant in the western half of the United States. It is well known for its unique flower that looks like a preacher standing in a pulpit (hence its name).

Native Americans used Jack in the Pulpit as a food source, but they were careful only to consume the plant once it was dried or cooked. The raw plant is extremely irritating to the mucous membranes of the mouth and throat. It contains calcium oxalate crystals — which are extremely irritating to the tissues of the mouth causing swelling and a burning pain. Mild mouth or throat irritation is the most common, but there have allegedly been cases where consumption of the raw plant has led to a severe swelling of the throat, causing the victim to asphyxiate (which is what seems to be happening here. Poison Ivy seems to have found an uncommonly potent variety). If swallowed, the plant can also be extremely irritating to the stomach, causing nausea, vomiting, and severe abdominal pain; it is said to have caused deaths in this manner as well. According to my most reliable medical botany text, human deaths from Jack in the Pulpit are just rumored; there have been no confirmed deaths from eating the plant.

There are a couple problems with Poison Ivy’s plan (besides her lucking into finding an extremely toxic variety of the plant): While eating raw Jack in the Pulpit causes irritation of the mouth, gums, and throat, the irritation is on the inside of the mouth. The cheeks won’t swell up like a puffer-fish. Pushing a narrow straw through the lips won’t help anyway because –
1) It’s the throat swelling that’s cutting off the airway, not the lips.
2) The straw is too narrow for good air exchange (which seems to be a common comic book theme).

The second good episode of Fringe in a row. Maybe my Doomsday Clock threat is working

The Plot:The episode starts with Mr. Jones, the enigmatic villain who escaped from a German prison several episodes ago through the use of Dr. Bishop’s teleport machine. He was shoved in a decompression chamber the minute he arrived, and now he finally emerges 2 weeks later. Everything should be fine, but he notices a distinct tremor of his hands.

Meanwhile, a newspaper vendor in the city dies in a particularly gruesome way. In a matter of seconds, his skin grows over his eyes, nose, and mouth and he suffocates to death. On first hearing about the case, Bishop suspects ceramides were involved. Agent Dunham, on her part, suspects that Mr. Jones is behind the death and is determined to find him.

One of the junior FBI agents determines that Jones’ late lawyer had access to a warehouse in Texas that, after years of lying dormant, had its power switched back on the same day Jones escaped from prison. Broyles is just about to order a raid on the warehouse when Mr. Jones turns himself in to the FBI at the Boston office. He refuses to speak to anyone but Agent Dunham.

For once making sense, new head honcho Harris refuses to let Dunham talk to Jones, telling her that doing so would be giving in to a terrorist’s demands. Instead he sends Dunham on the raid on the Texas warehouse. The raid turns up evidence that Jones had been there, and when one of the FBI agents (coincidentally, the same one who located the warehouse in the first place) dies of the same weird condition, the team knows Jones is responsible for the strange disease.

Dunham and Peter Bishop track down the manifesto of the ZTF, the group Jones is associated with. It tells of a coming war between two realities with only one surviving. By now, Dr. Bishop has discovered that the strange disease is caused by toxin absorbed through the skin that causes hyperactivity of the “protein responsible for scar tissue.”

Back in Boston, Jones refuses to talk to Harris, but does give him a list of supplies he requires. Dunham returns from Texas and meets with Jones. She hands him the supplies he requested and he promptly uses them to make an anti-surveillance device so no one can overhear their conversation. He admits that he is responsible for the two deaths, but tells her he wants to prevent any more. Before giving her anymore information, he tells her that she must take the key he brought with him and take it to an abandoned amusement part. Once there, she finds what appears to be a box of old children’s games. A note tells her that she must pass the “first test” — mentally turn off all the lights in a box — with her mind alone before Jones will tell her anything else.

Dunham tries the test, fails, and is convinced it is nothing but a game Jones is playing. She confronts him again, and he tells her it is not a game, but reality. He then tells her that she is special because she received treatment with the drug Cortexiphan. It turns out that this is a drug designed by Massive Dynamics — by Dr. Bell himself in fact — which is supposed to “remove limitations” from the mind. During their conversation, Jones collapses, suffering from after effects of teleportation; effects which are hinted at, but never explained. He is rushed to Bishop’s lab where Dr. Bishop manages to resuscitate him. Dunham has Peter Bishop rewire the light board so it looks like she passed the test. Jones relents and tells her the location of a bomb containing the compound that causes the disease. The FBI rushes there to find that the bomb is wired with an array of lights, just like the “test” Dunham was given. The only way to defuse the bomb is turn out all the lights without touching the device. Olivia decides she has to try and manages to mentally turn off all the lights with just seconds to spare.

Afterward, when she goes to talk with Jones, she discovers he has escaped the hospital where he was transferred by punching an enormous hole in the wall. The words “You Pass” are scrawled on the wall. Meanwhile, Walter has been reading the ZTF manifesto and discovers that its typewritten pages exactly match the print produced by his old typewriter.

1. Would a Fat-Free Diet Help?
Ceramides are lipid molecules common in cell membranes. As Walter says, they play a role in cell differentiation. On the other hand, he’s mostly wrong when he also mentions cell growth. Ceramides don’t seem to play a role in overactive cell growth — just the opposite actually — they appear to inhibit cell growth. (And being a lipid – a fatty molecule — it has nothing to do with the scar tissue protein implicated later).

2. Not Quite Far Enough
Performing her emergency tracheotomy, Agent Dunham successfully cut through the skin, but neglected to actually cut into the trachea — the key part of the procedure. She just slid the tube into the loose tissue in front of the trachea — though it ended up being a moot point.

3. Rescue Me
Unexplained bradycardia. An EKG is a good call.
They confused cardiac arrest (the heart stopping) and heart attack (lack of blood flow to the heart causing damage). Nitroglycerin is good for a heart attack, but won’t do any good for a cardiac arrest.
50cc is not enough saline to resuscitate anyone; it’s only about 1 ½ shot glasses of salt water. A normal resuscitation required liters of fluid. Though to be fair, Walter orders the saline and never states why; it is Peter who tells us it is for resuscitation, and he might not know what he’s talking about.

4. Lying or Stupid?
Mr Jones didn’t tell Olivia “where or when” the bomb was going to go off? He may have neglected the where, but he certainly told us the when — 16 hours.

5. Elementary, My Dear Watson
Some interesting choices for the movies and book mentioned in this episode. I’m suspicious they may be clues, or at least hints.
The Land of Laughs. I actually have the book in my library (but not the edition shown). A very good book. Among other themes, it deals with reality versus fantasy. Since they explicitly singled out the book by name, I suspect it’s important. I’ll have to reread it.
Charade. Good movie. Cary Grant, Audrey Hepburn. Deals with people who aren’t what they seem. Good guys are bad guys and bad guys are good guys.
Rear Window, the only Jimmy Stewart/Grace Kelly movie. A classic Hitchcock suspense thriller.

There were hokey aspects (Dunham’s psychic powers, alternate realities) and questionable medicine, but there was enough cleverness in this week’s plot to allow me to overlook them. I particularly liked the manifesto and the twist that the bomb had to be deactivated just like the test she only beat by cheating. I’m moving back the clock another minute, and the Doomsday Clock now stands at 11:55. (Of course, now we have to wait until April for new episodes, and I will have forgotten all the clues and the show will have lost all its building momentum.)

With the upcoming film, Warner Brothers has been busy preparing an avalanche of Watchmen merchandise. Among the t-shirts, action figures, mugs, video games, mad-libs, thongs, and pogs, these little beauties almost slipped by unnoticed. Which is a shame, because nothing says “I Love You” better than a Watchmen Valentine.

This episode of House started off great with an intriguing medical mystery, but over the course of an hour it degenerated into a barely mediocre episode.

Daniel Bresson is a burned out alcoholic priest currently working at a small inner city church. After he shuts the sanctuary for the night, he retires to his dingy one-room apartment and proceeds to drink and smoke the night away. A few drinks later, he hears a knock on the door and angrily gets up to answer it, only to discover that waiting at the door for him is Jesus, stigmata present, floating a foot of the ground. The next time we see Daniel he is at the Princeton Plainsboro ER. Cameron has decided he is probably just suffering from alcohol abuse or exhaustion, and is surprised when House decides to take the case and admit the patient. It turns out that House doesn’t think Daniel has anything significantly wrong with him either, he is just looking for a “fake patient” to prove a point to Foreman and Thirteen.

After informing his team about Daniel’s admission, House suggests psychomotor epilepsy (an older term for temporal lobe epilepsy, particularly the complex partial seizure variety), atropine toxicity, or a frontal lobe tumor as possible causes of the hallucination. Taub suspects it was the alcohol. House orders an EEG, a head CT, and a search of Daniel’s apartment. The EEG and CT are normal. The apartment search takes a while to finally get started, but reveals nothing as well. While performing the tests, Taub and Kutner learn that Daniel has been transferred around different churches across the nation because a teenager once accused him of “inappropriate contact.” Daniel swears he is innocent, but Taub thinks he is lying and suggests that his symptoms may be caused by syphilis.

As Kutner and Taub get ready to discharge the patient — as they could find nothing wrong with him — he mentions that he is feeling nauseated and his left foot is numb. Examining the foot, Kutner discovers that one of Daniel’s toes has turned black and fallen off. House now suggests leprosy, ergotism, or carbon monoxide poisoning. He seems to favor the latter and orders a carbon monoxide blood level, as well as starting Daniel in a hyperbaric chamber. While in the chamber, he begins to feel a crushing chest pain and the team is suspicious he may have had a heart attack, but the EKG is normal. House proposes that Daniel may have a clotting disorder and orders what seems to be an entire body angiogram to look for clots. None are seen, but the team discovers that Daniel has large areas of his body that are entirely numb. Daniel also takes this moment to mention that he has become blind in his right eye. House now believes his problem to be a neurological one. Autoimmune is mentioned (particularly Guillain-Barre) as a possible diagnosis, as are tumors and infection. House then dives into a metaphor about Duran Duran as his way of suggesting that the problem probably lies in the patient’s spleen. He orders a spleen biopsy. The results are normal, except for “insignificant traces of minor bugs.” One of these bugs turns out to be Pneumocystis, which is only seen in patients with a compromised immune system. The team suspect AIDS. Daniel refuses an HIV test, informing the doctors that he knows he cannot have AIDS as he does not have any of the risk factors. After some arguments among the team, House decides to start him on HIV therapy regardless.

As Kutner is hanging the medicine, Daniel’s condition begins to deteriorate. His blood pressure climbs, he begins to feel flushed, and a rash breaks out on his chest. The differential now consists of a reaction to the HIV medication, hyper IgE syndrome, another genetic syndrome, or cerebral microtumors (tumors too small to show up on standard scans). Genetic testing is ordered to look for the cause of his symptoms. House has his weekly Eureka! moment while talking with Wilson. He realizes that the hallucination that brought Daniel to the hospital in the first place was alcohol induced — and after excluding that, the remaining symptoms lead him to conclude that Daniel is suffering from Wiskott-Aldrich Syndrome, an inherited disease.

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

This is the first episode in quite a while where House himself is suggesting most of the differential diagnoses — and he’s not very good at it (at least in this episode). The vast majority of his diagnoses — including the final one — require tremendous leaps of logic and the ability to gloss over inconvenient symptoms that don’t fit.

Taub can rule out pneumonia, pleurisy and an embolus just by fluoroscope? The pneumonia I can accept, but pleurisy doesn’t show up on a scan like that, and how could he rule out a clot since they only rarely show up on x-rays, and Kutner hadn’t even started injecting the dye yet?

If the patient had low white count, I wouldn’t think of the spleen first thing, or even second or third. There are other more likely causes that don’t require a risky and likely uninformative spleen biopsy.

Traces of other diseases (&ldquomild bugs”) can be found in the spleen? Really, how is that? And they can be easily tested? (Unless they are somehow referring to antibody memory cells.)
Now, assuming for a moment Thirteen is correct, Pneumocystis is a very common germ. Pretty much everyone has come in contact with it and their immune system has easily fought it off. (It only becomes a problem in people with low immune systems.) Bear in mind that even these healthy people would show “insignificant traces” of a minor bug so the test tells us nothing, certainly not that the patient has AIDS

Is House suggesting the team test for every genetic disorder?

Non-medical nitpicks:
They move the priest back to the same city as his alleged victim?
Foreman’s job hunt — even with a letter of recommendation — didn’t go so well last time. That’s why he ended up working under House again.

The medical mystery was good. It started off well, even if it was a fake out, and maintained interest through the episode. It earns a B+. The final diagnosis was quite a stretch, Wiskott-Aldrich appearing suddenly in 29 year-old who had been previously healthy? Maybe a family history would have been a nice thing to obtain. I give the solution a C-. The same for the medicine (C-) which required too much coincidence and skipping over symptoms. The soap opera was good on every front and deserves an A-.

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

With the 2009 NASCAR season just starting¹, I thought it was about time to finally get around to looking at the NASCAR Heroes Free Comic Day issue² from last year.

The story takes place shortly after the third issue of the comic³, but the scene shifts from the race track to a movie set. It’s the best issue of the series yet, probably because the racetrack is left behind⁴ — but with a slightly different ending, it could have been even better.

The director of the Zoom Speedster movie is in trouble. He has gone through three different lead actors because the set is haunted by a headless ghost — and not just any ghost, but the ghost of a racecar driver. In desperation, the director calls Jimmy Dash and asks him to play the role of Zoom Speedster. Dash agrees and when he asks why the previous stars quit, the director and his staff claim to have no idea.

The first day on the set goes well even though Dash encounters the ghost. His friends are scared, but Dash tells them that he doesn’t believe in ghosts. The next day, the ghost kidnaps the lead actress and in order to rescue her, Dash has to race him. It’s an eye pleasing — if unrealistic race — including vertical loops, flaming rings, alligators, and games of chicken at over 150 miles per hour⁵. In the end, Dash wins and the ghost mysteriously disappears. It’s not a happy ending though, as Dash is fired from the movie for wrecking the set.

The story is set up an awful lot like an episode of Scooby Doo, and there are many of the familiar characters and situations: a confident skeptical hero, cowardly friends, a mysterious ghost, and authority figures who know more than they’re letting on. There’s an important part of Scooby Doo that the writers of this story forgot though: the reveal at the end. That was always the best part of Scooby Doo.

As far as I can tell, this was the last issue of the comic distributed through standard comic retail channels. There have been two more issues released by Starbridge Media Group — and available at their site — but they don’t appear to have had distribution through Diamond⁶. Issue #4 appears to be this same comic with a slightly different cover, and issue #5 purports to start a new story arc⁷.

Previous NASCAR posts: Review of NASCAR Heroes #1 Review of NASCAR Heroes #2 Review of NASCAR Heroes #3 A History of Comics and NASCAR

Recently, I’ve been reading through DC’s Doc Savage comic book series from the late ’80s. It features the titular hero brought forward into modern times and having his usual world-spanning adventures. As to be expected from a character who got his start in the pulp magazines of the ’30s and ’40s, the stories are chock full of improbable — if not downright impossible — science (or should that be Science!). Since I’m a fan of the old pulps, I’m willing to accept these in the spirit of the times.

Sometimes, though, I run across a scene where the science is just a little too mad…

So…the “magnetic ray” exerts a force on the iron in the blood (I can buy that), but this somehow causes the pulse to race, the blood pressure to skyrocket, and then the heart to explode. I’d be interested to know how the hemoglobin in the red blood cells has that powerful an affect on the heart, since normally it exerts exactly zero influence on it. I can’t even conceive of a mechanism how this would work. A racing heart could certainly raise the blood pressure, but other severe problems would occur (severe sudden heart failure, a fatal arrhythmia, a stroke, or a heart attack) long before the heart exploded. This is another example of trying to explain things too much — they should have just left it at “magnetic ray.”

Of course, I do appreciate the fact that I get to add another entry to my “Things Which Cause Nose Bleeds in Comic Books” list.

As the Sunlight Rising storyline begins, Doc Savage decides to use his science (Science!) skills to resurrect his dead wife. Here, two of his companions discuss the plans.

Unfortunately for Doc, he’s basing his resurrection plans on an untruth. It’s a myth that the hair and fingernails grow after you die. While they may appear to grow, what is really happening that the skin next to them is dehydrating and shrinking, giving the illusion of growth.

Doc proceeds with his planned resurrection, but his equipment is stolen by the villains who use it to resurrect his more-or-less archenemy, John Sunlight.

This week, Ron scored the most points with 8, with Asphault, Harvey, and promiscuouspeach eacg scoring 6 points.

Overall, Ash remains in the lead with 43 points with Sable Hope closely behind with 41 points. Dogma-Central remains in third with 40 points. Ron and Sconibulus tie for fourth with 36 points.

Full scores are available here.

From Action Comics #175 (December 1952) comes this Superman public service ad about UNICEF (the United Nations Children’s Fund), one of the more common subjects of PSAs not only in DC comics, but those of other publishers as well.

Thanks to this ad, I think I’ve developed a new phobia: Superman flying down and exposing all of my little white lies. I can see it now, walking down the street with the Polite-Wife, and thinking I’ve just dodged a conversational landmine when suddenly Superman swoops in with a, “That’s not quite true Scott, in reality, you didn’t even notice that your wife got a new haircut.” Gee thanks, Superman. Can I just charge the flowers and dinner to you?

This public service ad ran in a variety of December 1952 DC comics. The script was written by DC’s PSA-king Jack Schiff with art by frequent collaborator Win Mortimer.

Despite the barely above average medicine, I enjoyed this episode of House. Probably because it focused more on House himself than on Foreteen.

Jackson is a teenager born with genetic mosaicism whose parents have chosen to raise him as a male. He is playing on the school’s basketball team and he has just made the winning basket when he collapses to the ground with severe abdominal pain. He is later admitted to House’s service for treatment of this “chronic pelvic pain”. An issue is that his parents have never told him about his underlying genetic condition and have been giving him testosterone shots under the fiction that they are vitamins. They don’t want House or his team to tell him the truth, a situation that doesn’t sit well with some of the team, particularly Thirteen.

The team’s initial differential includes dehydration, congenital adrenal hyperplasia, PMDS (Persistent Mullerian Duct Syndrome), a blind uterus, or problems from the surgical reconstruction of his penis. House wants to perform a urethroscopy, but the parents want an MRI to look for a blind uterus. House gives into their suggestion and an MRI is ordered. The results are negative, so Jackson is prepared for the urethroscopy. As they start the procedure he starts to complain of chest pain and shortness of breath. Thirteen only hears muffled heart sounds on exam and notices jugular venous distention. He appears to be in cardiac tamponade so she jabs a syringe blindly into his chest to remove the extra fluid from around the heart.

The team’s second attempt at a differential diagnosis only yields the generalities of “drugs, toxins or infection.” Then autoimmune disease related to the testosterone injections is mentioned, especially polyarteritis or SLE (lupus). House has the team start Jackson on corticosteroids for the suspected autoimmune condition and finasteride to block the effects of the testosterone. (It’s not made clear at this point, but the testosterone injections are stopped as well). As Thirteen is administering the medicine, she notices red palms on Jackson. She takes this to mean that 1) he has does not have an autoimmune disease, and 2) his liver and kidneys are failing. Blood tests back this up (her second point, at least).

The third version of a differential diagnosis contains amyloidosis or drug/alcohol abuse due to depression. A search of his room yields some dismal and morbid poetry that Thirteen takes as proof that Jackson is depressed. She feels this depression is related to his sexual identity issues and wants his parents to tell him the truth, but his mother refuses. Meanwhile, Taub finds evidence of toxoplasmosis on Jackson’s water bottle, so infection is a possibility as well. He is started on pyrimethamine to treat the suspected toxoplasmosis. His parents ask that his testosterone be restarted as well. When Thirteen is injecting the medicine into Jackson, she confesses that it isn’t a vitamin shot like he’d been told — though she doesn’t tell him what it is, just tells him to ask his parents. This triggers a showdown with her and the parents in Cuddy’s office. Cuddy backs Thirteen, but lets her know it is for Jackson’s sake, not her own. When told the truth, Jackson understandably becomes angry and refuses to speak with his parents anymore. Thirteen comes back in to talk with him and lets him know about finding the poem. He tells her it was for a class assignment (”write a poem in the style of Sylvia Plath”), and was not about his feeling at all. He tells her that he doesn’t feel depressed — or at least he didn’t until his parents told him the truth about his genetics. He becomes suddenly nauseated and begins to vomit blood.

Jackson is found to have a gastric fistula due to necrotizing pancreatitis. Thirteen suggests Zollinger-Ellison Syndrome, but Taub believes it is systemic scleroderma. Foreman decides to treat the possible Zollinger-Ellison first and if that doesn’t work, then to treat the scleroderma. He and the rest of the team know that sclerodema is more likely, but also has a worse outcome, so they are treating the Zollinger Ellison and hoping for the best. It doesn’t work, so Jackson is started on anti-inflammatory medication to treat the scleroderma. The next morning, Foreman tells Thirteen that it is having some effect as Jackson’s liver enzymes are improving. Through some convoluted logic, they deduce that this means it cannot be sclerodema since he is getting better too fast. About this time, House reappears on the scene, hears about the case and instantly makes the diagnosis: it all started with dehydration; that’s what caused the collapse. The ER gave him some IV fluids, but because of his use if energy drinks (which apparently also caused his abdominal pain), his kidneys were slow to respond. When Jackson was then given the contrast for the MRI, the already dehydration/energy drink-strained kidneys could not filter the contrast fast enough so it cycled throughout the body, causing problems wherever it went. It was this contrast that caused the heart disease, the liver failure, the kidney failure, and the pancreatitis.

Methadone is a potent narcotic, and has more respiratory depression than more common narcotics, but it’s not that life threatening. Particularly in a patient with such a heavy previous use of narcotics.

I did like House’s realization that he can’t be the brilliant diagnostician he wants to be if he’s not in pain.

Mosaicism occurs when one person has two genetically distinct lines of cells. Some of their cells have one set of genes, and the other cells have a different set. Mosaicism generally occurs early in development, often from a mutation or nondisjunction. In Jackson’s case, one cell line is genotypically male (XY) and the other female (XX). This is a known, but rare, cause of intersexuality.

As usual, minor complaints are in blue, and nit-picking in green. My main complaint this week, the red one, I’d characterize as a “moderate” complaints — more than minor, but less than major. It’s theoretically possible, but extremely unlikely.

Intravenous contrast can certainly cause renal problems, my kidneys are proof of that. Contrast material can cause acute renal failure (contrast-induced nephropathy). There have also been isolated cases of pancreatitis and pericardial effusion thought to be linked to contrast material, but the patients involved all had significant other co-morbidities (such as AIDS). For Jackson to have had such problems with contrast, his kidneys must have been in bad shape, which should have shown up on simple blood tests — blood tests which radiologists are maniacal about ordering and avoiding the use of contrast if they looks even a little off.
I guess this sort of complication is what happens when you act as your own radiologist.
And seriously, how many energy drinks was this kid downing to cause these problems?

Notice how vague the writers were being when treating the scleroderma: repeatedly using the term “anti-inflammatories” instead of naming a specific drug. This is usually a sign that they’re trying to skirt around a known plot inconsistency.
Such as the fact the anti-inflammatory that they’d use would likely be a corticosteroid, the same type of drug they gave Jackson for a suspected autoimmune condition in the first half of the show. In fact, scleroderma is an autoimmune condition.

I like how psychic the team can be. Thirteen automatically knows it’s an exudate causing Jackson’s tamponade instead of the more common (and seen just two episodes ago) blood.
That’s incredibly fast for an exudate to form.
Blindly jamming a needle in the chest is still not a good idea. It wouldn’t take that much longer the properly position it, and just a little more time to attach it to a cardiac monitor.

Finasteride is not approved for use in children. It blocks the breakdown of testosterone into dihydrotestosterone (DHT), which I guess might help if it is the DHT causing the lupus reaction and not the testosterone itself. Otherwise, you’ve just made things worse by increasing the levels of testosterone.

Toxoplasmosis is a common parasitic disease, but does not typically cause problems in people with healthy immune systems. It is a worry in patients with compromised immune systems and in pregnant patients, because it is one of the diseases that can be passed from mother to fetus.
Symptoms don’t match at all.
Pyrimethamine is not used alone to treat toxoplasmosis. It is given with a sulfonamide.

I suspect a pelvic U/S would be a better choice than MRI when looking for a blind uterus, but then you’d avoid that whole contrast material concept.

Several hours of pelvic pain is not chronic.

The medical mystery was good. The mosaicism was a red herring in terms of the mystery itself — though it did add to the family dynamics issues. I give the mystery a B+. The final diagnosis was logical, but would have required a perfect storm of events to occur. I give it a B. The medicine overall remained haphazard, but at least it was more focused than previous weeks (except for the toxoplasmosis, that came out of left field), and earns a C+. The soap opera was fairly good, both the “House is happy” and “Mother avoids the issue” aspects. I give it a B.

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

I’m going to the hockey game tonight, so I thought I’d look for a good hockey-themed comic book cover to post, but there really aren’t that many. There are couple of Wayne Gretzky issues of sports personality comics from the 1990s, and then there’s Spider-Man PSA comic “Skating on Thin Ice” that I’ve written about before, but that’s about it. This cover from Strange Sports Stories #5 is the best of the bunch by far. If a Skeletor-wannabe for goalie isn’t enough, how about playing hockey on an ice floe going over a waterfall? Now I really want to read this story.

Now, it’s not made clear in the comic if the MGH itself was exposed to gamma radiation, or if it was the mutant it was extracted from that was exposed to gamma radiation, but I favor the latter scenario because it would be a lot more fun. As if having a mutant super-power wasn’t enough, now you’d have gamma powers too. Imagine a Hulked-out Angel, Nightcrawler, or Beast…or Emma Frost.

I like the idea of stacking super-powers, and I’m surprised it hasn’t been addressed more often than the occasional Elseworlds*. (Of course, it does have its potential downside, like this)

*Some hero or other always seems to have a Green Lantern ring in addition to their own powers in those.

Flash did a version of stacking powers when he used Johnny Quick’s speed mantra in addition to his own speed powers in the Terminal Velocity storyline (my favorite Flash story ever).

This scene raises a good question: how do you close the wounds of a man with invulnerable skin?

As I see it, there are several options:

Scene from Superman/Wonder Woman: Whom Gods Destroy, a mostly forgotten Elseworlds series from 1997 by Chris Claremont and Dusty Abell