Polite Dissent

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Why would a melanoma secrete GnRH?

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

Paraneoplastic syndrome has become the lupus of this season.

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

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

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

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

Click here to see the full scoreboard.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

This week’s Fringe cipher was: FATHER.
A list of all previous Fringe reviews is available here.
Karl has much more to say. And he’s still talking about it a week later.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Click here to see the full scoreboard.

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

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

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

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

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

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

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

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

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

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

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

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

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

This week’s Fringe cipher was: MUTATE.
A list of all previous Fringe reviews is available here.
Karl has much more to say.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

A list of all previous Fringe reviews is available here.
As always, Karl has more to say.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Click here to see the full scoreboard.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

This week’s Fringe cipher was: HIDDEN.
A list of all previous Fringe reviews is available here.
Karl has much more to say.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

I enjoyed the scenes with Wilson and his other patients.

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

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

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

Click here to see the full scoreboard.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Click here to see the full scoreboard.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

This week’s Fringe cipher was: ARRIVE.
A list of all previous Fringe reviews is available here.
Karl has much more to say.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

It’s time for three more case studies to determine if you’d be a good doctor in a super-hero world. So put on your thinking caps and your diagnostic head mirrors and see if you can make the correct diagnosis.

The previous case studies and a bit more an explanation can be found at Dr. Scott’s Case Studies of Comic Book Medicine

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

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

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

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

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

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

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

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

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

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

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

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

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

HSAN1 doesn’t fit the case at all.

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

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

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

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

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

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

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

Click here to see the full scoreboard.

An interesting premise initially on this week’s episode of House, but a slight episode over all. It was in many ways a rehash of House vs God, only not as clever

Jack Randall is the son of a billionaire. He has been sick for over a week with worsening abdominal pain, fever, dehydration, diarrhea, and weight loss. He has seen a variety of doctors, the last who prescribed intravenous antibiotics for a presumed case of Clostridium dificile (i.e. “C. diff” — a cause of severe antibiotic-related diarrhea). When it became clear that Jack did not have C. diff and was not improving, his father brought him to Princeton-Plainboro Hospital demanding that he be seen by House. Cuddy, as always, acquiesced (she has become the Neville Chamberlain of hospital administrators. Didn’t she used to have a backbone?)

House wants the team to start over from the beginning with the history and physical. While performing the physical exam, Cameron feels a left-sided abdominal mass. This is confirmed by an x-ray and revealed to be a fecal impaction (a big hard ball of poop) revealing that Jack is severely constipated. This is a new finding, as previous x-rays were normal. The team decides that this represents toxic megacolon due to Hirschprung’s Disease (a congenital condition caused by missing nerves in one section of the intestine). They want to perform a barium enema and colon biopsy to confirm. Jack feels much better after the procedure and disimpaction and is laughing and joking. Suddenly he begins staring straight ahead and then breaks into a convulsive seizure. Foreman gives him some diazepam (Valium — among its other uses, it is good at stopping seizures). An examination of the eyes reveals swollen optic discs, a sign of intracranial hypertension. Foreman orders furosemide (Lasix – a diuretic, i.e. “water pill”) and then orders more diazepam and then some phenytoin (Dilantin — another seizure medication). He is worried that Jack’s intracranial pressure will get so high the brain will herniate, so he rushes him into surgery where Chase drills burr holes in the skull to relieve the pressure.

Jack is looking a little better after the operation, but the team notices that he is building up fluid in his brain and abdomen again. Closely examining the head CT, Foreman notices an irregularity in the way the fluid is building up and finds this suspicious for early brain cancer. House concurs. A biopsy is taken, but it is negative. Now House suspects that Jack has adenocarcinoma (cancer) of the stomach, and this is what is causing his symptoms. Jack has another bad seizure, but this time with a normal intracranial pressure. The team gives him some diazepam to stop the seizure and proceeds with the scope — but there is no sign of gastrointestinal cancer either. In the meantime, Jack has fallen into a coma. Chase suggests the cause may be infection caused by an antibiotic resistant germ, but all the cultures have been negative. Cameron suggests that Jack may be having abdominal epilepsy — in other words, he has seizures, but they show up as severe stomach pain, and this then in turn led to his other symptoms. House agrees and Jack is started on gabapentin (Neurontin, an anti-seizure drug). An EEG (brainwave) evaluation is started but reveals no seizure like activity. However, Cameron notices that Jack has developed a rash all over (and I mean all over) his body.

The differential diagnosis of Jack’s condition now includes an allergic reaction to his medications, autoimmune disease (lupus and vasculitis), or polyarteritis nodosa (another type of autoimmune disease). House considers starting Jack on Prednisone to treat the polyarteritis, but when Cameron tells him that the rash is also on the genitals, he deduces that Jack has Degos disease, an incurable terminal disease caused by inflammation and blockage of small and medium sized blood vessels. House breaks the news to Jack’s father and lets him know that Jack has less than a day left to live. Jack’s father decides to invest all his assets in extremely risky ventures, knowing he will lose everything. He has decided that by doing so well in business, he has tempted fate and his family is suffering. Therefore, if he is ruined financially, his karma will even out and Jack will improve. House mocks him, but doesn’t stop him (and apparently makes some money on it). As the financial papers are signed, Jack has a cardiac arrest and flatlines. The team is able to resuscitate him, but it’s touch and go. Talking with Wilson a short time later, House has one of his patented aha! moments and realizes that Jack does not have Degos, but has Primary Antiphospholipid Syndrome. They give him some heparin and immunoglobulin and he miraculously recovers.

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

I’m no neurosurgeon, but I don’t think you just whip out your trusty Ryobi cordless and drill a burr hole like that.
At the very least, clean the skin first — I don’t want any nasty skin bacteria pushed into brain which is what you are drilling into.
Also, a sudden drop in an increased intracranial pressure is likely to cause a brain herniation — the very thing they were trying to avoid.

This is the second episode of the season (and we’re only four episodes into the season) where the misdiagnosis of the patient was made by biopsy.

While writing the script for the classic film noir The Big Sleep, the screenwriters couldn’t figure out who murdered the chauffer. They called up Raymond Chandler, who wrote the original book, and ultimately he admitted the plot was so complex that he didn’t know either. I think this happens in House a lot when the writers get lost in their own plot. Case in point — the seizures: First they suggest the increased intracranial pressure is causing the seizures (could happen). Then they suggest electrolyte imbalances could cause the seizures (could happen) — but if the latter is the case, then what caused the increased intracranial pressure in the first place?
The team kept referring to the abdominal fluid returning or recurring. What did they do to remove it in the first place?

Furosemide is, at best, a second-line agent for treating increased intracranial pressure. If you’re going to use a diuretic, acetazolamide is the best choice. Mannitol is a good choice as well.
Cameron’s suggestion of intubation and hyperventilation was another good option.

Phenytoin 500MG is not an unreasonable dose to break a seizure in patient who weighs 60-80 pounds.
I notice Cameron only ended up giving 50MG. Was this a continuity error in the script, or willful disobedience on her part? And 50MG would be an appropriate dose for an 6-10 pound child, way too little for this kid.

If your patient with C.diff is a previously healthy kid, with no recent antibiotic use, and no record of C.diff exposure, and he requires oxygen, then your C.diff case does not have C.diff.

I defy anyone to get a good fundoscopic exam on a seizing patient in the middle of a brightly lit room. Can’t be done.

You’d think after six years, Jennifer Morrison would know how to pronounce ascites.

Labs don’t run extra blood tests without an order. Especially tests that require prep, like fasting before a cholesterol test.
Here is another example of the writer’s trying to have it both ways. If the lab ran the tests, then there would be a computer file with results, not just a single piece of paper. But if Chase ran the test himself so there was not a full computer record, then who ran the extra tests?

I thought the medical mystery was interesting this week and deserves a B. The final solution fit fairly well, though I think Degos fit better. I give it another B. The medicine overall was average, though there were some positive signs — like the team actually performing a history and physical. I give it a C+. The soap opera was okay. Nothing great, but nothing out of character either. It earns a C.

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

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

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

Click here to see the full scoreboard.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Click here to see the full scoreboard.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

A list of all prior House reviews

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

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

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

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

Here are last year’s final scores.

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

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

Full scores are available here.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Full scores are available here.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Eye protection in surgery, team.

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

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

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

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

Full scores are available here.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

MRIs aren’t used to diagnose a broken nose.

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

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

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

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

Full scores are available here.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Full scores are available here.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

For Episode 18, Ben Tan and DrBoy had the high scores with 12 points.

For Episode 19, selkie had the high score with 16 points.

Overall, The Erskine takes over the lead with 54 points, Dogma-Central remains at 51 points which drops him to second. Ash in in third with 49 points, with Harvey right behind in fourth with 48 points. Tied for fifth are Erin A. and George, with 46 points each.

Full scores are available here.

An interesting concept felled by extremely poor medicine on this week’s episode of House.

Lee is a roofer who ends up in the ER after a bicycle accident. He has suffered head trauma and appears to be brain dead, so the ER physician is ready to call the organ transplant team. Luckily, House is in the bed next to Lee after a minor motorcycle accident. He recognizes that Lee is showing purposeful eye movement so he cannot be brain dead. He realizes that lee is suffering from Locked-In Syndrome. Lee is able to communicate with House by blinking his eyes in response to yes or no questions. The hospital doctor believes that Lee’s brain damage was caused by the crash, but House suspects it was the other way around: Lee’s crash was caused by the brain damage (and Lee’s memory seems to back this up when he sees the car door but is unable to work the brakes on his bike to stop in time to avoid the collision). House’s initial differential diagnosis is fairly general and consists of stroke, cancer, or infection. The rest of his team (excepting Taub) shows up at the ER. Foreman suggests a basilar artery stroke, Kutner suggests cardiovascular disease, and Thirteen suggests a tumor. House thinks Thirteen’s idea has the most merit so he forges a set of orders for the patient to get an MRI.

The MRI is normal, though House imagines he can see a lesion in the central pons. He continues to believe that Lee has a tumor with an associated paraneoplastic syndrome. The hospital doctor disagrees and has diagnosed Lee with an infection of his central nervous system and so has him on antiviral medication (apparently suspecting a herpes, varicella, or CMV infection). The medications don’t work and Lee suffers a seizure. House reports that Lee needs plasmapheresis. Lee’s wife believes him and has Lee transferred to Princeton Plainsboro Hospital . Once there, the team discovers that he has blood in his urine. Thirteen suggests Marchiafava-Bignami Disease (a rare, progressive neurological disease seen in alcoholics). House decides that a brain biopsy is the key to discovering what the underlying disease is. In the middle of the biopsy, Lee loses his ability to blink — which was his only way of communicating. It’s not clear to the team why Lee can no longer blink — or even if he is still alive or brain dead. The worsening symptoms could be caused by a botched biopsy, brain swelling caused by the procedure, or it could be from an as of yet undetermined cause. The differential now includes Epstein-Barr virus, malaria, picornavirus or rotavirus.

Taub suggests using a brain computer interface to allow Lee to communicate. It takes some time and coaching (and pleading) by Taub, but Lee is eventually able to answer yes or no questions with the interface. While interviewing Lee about travel, his wife tells the team he had recently been in St Louis, but Lee tells House “no” to this. It turns out he lied to his wife, and was not out of town at all. At first, House thinks some hanky panky may have been going on (meaning that neurosyphilis would be a possible diagnosis), but he later learns that Lee was staying at a friend’s basement while he was cranking out resumes and applying for jobs because his roofing business was having financial troubles. The team also learns that he had been moonlighting as janitor for a local factory that made rechargeable batteries. Kutner and Taub search the factory and find cadmium dust, suggesting that Lee may have heavy metal poisoning. He is started on chelation therapy.

The chelation therapy does not seem to be working, and Lee has been frequently complaining (to himself, since no one else can hear him) of eye pain. Thirteen takes a close look with fluorescein dye (an orange dye that fluoresces green under black light if there is corneal damage) and diagnoses him with ulcerative keratitis. To House, this means that Lee either has an infection like varicella (the virus that causes chicken pox and shingles), or an autoimmune disease like Behçets Disease. Neither condition really fits well, so Cameron recommends that he perform a lumbar puncture (i.e. a spinal tap) and let the results guide his treatment. As the team is explaining the lumbar puncture procedure to Lee, he suffers a cardiac arrest. The team manages to successfully resuscitate him, but now he complains of an itching foot. To House, this mean that Lee has liver failure. When reminded that Lee’s liver enzymes are normal, he tells them that they had been high, but as the liver failure became worse and the liver died off, the levels dropped and now appear normal. He now believes that it is the liver failure which is causing the locked-in syndrome. Sclerosing Cholangitis (an autoimmune disease of the bile ducts and liver) is the team’s main diagnosis. They are preparing to perform a liver biopsy when Kutner realizes that Thirteen developed a rash where her skin had come in contact with Lee’s urine. Therefore there must be something infectious in his urine that caused her rash and Lee’s symptoms — and the likely cause is Leptospirosis. Sure enough, there were rats positive for leptospirosis in his friend’s basement. He caught the disease from them which caused his liver failure which then caused his locked in syndrome. Antibiotic treatment is started and Lee is able to move a finger again.

The concept of a patient who could only communicate with yes/no answers was clever, but the medicine was very sloppy this week.

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

How did the liver failure affect just the one tiny portion of the brain to cause the locked-in syndrome? Why wouldn’t it affect the rest of the brain?

For the 1,732nd time: Don’t shock a flatline.
A recent study suggests bad habits learned from television medical dramas are a major reason medical students and residents are having trouble intubating patients correctly. I hate to think what that means for treating cardiac arrests…

Why was House suggesting that Lee needed plasmapherisis? It is used for treatment is certain cancers, but these are blood cancers, and nothing that fit Lee’s scenario.

It is true that in people with advanced liver failure the liver enzymes do seemingly return to normal levels. But by then, other symptoms of liver failure have been long evident. None of which Lee showed.

Liver failure can cause pruritius (itching) because of the elevated bilirubin. But it wouldn’t show up as just one foot — and the bilirubin level would be markedly elevated on the liver function test (but you notice the team only mentioned the “liver enzymes” were not elevated. Bilirubin in not a liver enzyme, though it part of the same common liver test).

Locked-In Syndrome takes a very long time to improve (not just a few days), and that’s even if the patient gets better and most don’t (actually, most die within 4 months of diagnosis).

Leptospirosis causes uveitis, not keratisis, which wouldn’t show up on fluoroscein staining.

Liver failure that advanced would probably require a liver transplant, not a few days of antibiotics.

The medical mystery was very clever, though it seemed a little too conveniently clever for its own good, still I’ll give it an A-. The final solution was an incredible stretch and earns a D. The medicine was scarcely better and earns a C-. The soap opera was only average. Taub was mildly interesting, and neither House nor Wilson seemed to have their heart in their scenes. C.

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

Tonight’s House is a repeat episode of the sixth episode of this season: Joy.

Full recap can be found here.

I thought this would be a good episode of House — the last couple have been pretty good — but I was mistaken. It was surprisingly boring and the medicine was hap-hazard and illogical as well.

Morgan, a thirty-five year-old nursing home nurse comes to see House in the hospital clinic complaining of frequent colds and feeling rundown. As she is asking for some tests to be run, she suffers a tonic-clonic seizure and becomes incontinent of green urine. House decides to admit her.

The team’s initial differential diagnosis consists of infection (especially Pseudomonas) or toxin exposure. House sends Taub and Kutner to search Morgan’s office where they find a bottle of methylthionium chloride (better known as “methylene blue“), a medication that can cause green urine. Taub suspects that she has Munchausen’s Syndrome and has been faking her symptoms. Rather than admit that Taub was right, House sends him off on a fool’s errand.

House now goes to see the Morgan and pretends to induce a photosensitivite seizure. He catches her faking a seizure and she realizes it. She admits that her symptoms were fake, but insists that she is really sick. She knows that she is sick because Debbie the nursing home cat came to sleep beside her. Debbie has a reputation for only sleeping next to people who are dying, so now Morgan is certain that she is at death’s door. House is unimpressed, but then she collapses outside his office, wheezing. Foreman declares that she has bronchospasm, which both House and Foreman agree cannot be faked.

The differential now consists of bronchitis, emphysema, or visceral larva migrans (infection with intestinal worms from the cat). House suspects the latter and has the team perform a bronchoscopy (looking down the lungs with a flexible fiberoptic camera) to find any worms. The test is negative, and so now the team considers acid reflux, allergic asthma, or a panic attack. House thinks the allergy idea is the most likely, so orders a methacholine challenge (a test which provokes asthma is the patient is asthmatic). The challenge test is negative, so Cuddy tells House the he has to discharge Morgan. He takes her out to the smoking area to talk about the dissolution of her marriage and death of her step-son. While there, he notices a rash and she begins to wheeze again. He has another nearby doctor diagnose her with bronchospasm then wheels her back into the hospital. He thinks she has Churg-Strauss Syndrome (a type of vasculitis more common in people with asthma) so starts her on steroids. Morgan now develops brown urine, but there is no evidence of kidney failure, liver failure, an intestinal fistula (an abnormal connection between the intestine and bladder), or blood in the urine. Foreman suggests that the urine only looks brown because it still has traces of green dye and something is making it purple, and purple + green = brown. House thinks this means she may have a Strep bovis infection from colon cancer (about 15% of colon cancers have a concurrent S. bovis infection. The exact relationship between the two is unclear). The team reminds him that her colonoscopy was normal. He orders a pill-cam (capsule endoscopy), which is also negative for cancer.

Kutner suggest that Morgan may have a skin cancer which has spread to her colon. House has him check her over for melanomas. He finds no skin cancers, but does find prominent spider veins on her back which weren’t there before. House now determines that she has Cushing’s Syndrome (Cushing’s is caused by elevated levels of cortisol in the body. This is most commonly caused by high levels of ACTH, a chemical that tells the body to make more cortisol. ACTH-secreting tumors can most commonly be found in the pituitary gland — part of the brain — or the adrenal glands near the kidneys. House is trying to determine which is the source of the ACTH.) An MRI is negative for a tumor in the adrenals or brain, and blood levels of ACTH are equivocal, so House wants Chase to sample the blood from within her brain to see if there are high levels of ACTH there. The surgery is completed, and Morgan is found to have slightly elevated levels of ACTH in her brain. Incidentally, she also suffered a cardiac arrest while in the operating room. House decides that the cause of her Cushing’s Syndrome is an ACTH secreting tumor in the pituitary. The symptoms can be controlled with medication, but surgery can correct the problem permanently. Chase tries to dissuade her from the surgery, but she decides to have it anyway.

About this time, House has his Eureka! moment of the week when the cat comes in to his office and plops down on his laptop. He realizes that Debbie likes warm places to sleep, so she lay down with patient with fever or those on a heating blanket. She chose to sleep next to Morgan because she was giving off heat due to a carcinoid tumor hiding in her appendix. House is able to stop the brain surgery in time — and presumably Morgan has her appendix and tumor removed.

A very blah episode of House. Basically a weak copy of the themes of House versus God, with much less exciting medicine. The best part was Taub’s side story, and that — like a car crash — was painful to watch but you couldn’t look away. Poor guy.

This episode did inspire me to develop Scott’s Sign: If the cardiac arrest occurs off-camera, it’s not going to be a good show.

Their really weren’t any huge medical errors this week, but there was a great deal of confusing medicine, leaps of logic, and poorly explained reasoning. Since I didn’t have any major complaints this week, I’ll just go with minor complaints in blue and nit-picking in green:

It always amuses me when House, a show about a physician which prides itself on finding the most obscure presentation of a particular disease, limits itself to only looking for the most common causes a condition knowing it must be one of them (in this case, it was Cushing’s Syndrome having to be from an ACTH-secreting tumor in either the brain or adrenals. Sure, they’re the most common, but many other more obscure causes are known and this show thrives on obscure.)

All her MRIs and CT scans and no one ordered a scan of the abdomen, which would have found the tumor.

The purple urine/Strep bovis infection is quite a stretch. Strep bovis is one of the possible culprits in PUBS (Purple Urine Bag Syndrome — a condition seen in catheterized patients), but the evidence is far from convincing.

House seemed to be saying the Cushing’s explained the brown urine (which, incidentally, I can find no information on), but the team also told him they tested for every cause of brown urine, which would presumably include Cushing’s. So did they test or not?

Labyrinthitis is only very rarely treated with antibiotics. It is not treated with the Dix-Halpike maneuver either — Benign Positional Paroxysmal Vertigo is (though, admittedly, they do have similar presentations)

The medical mystery wasn’t given a chance to be interesting, so only earns a B-. The final solution was slightly clever, but relies on too many missed opportunities earlier, so earns a B. While there was nothing hair-rendingly bad about the medicine this week, there was nothing remotely commendable either, and so it is awarded a strictly average C. The soap opera was disappointing as well. The Taub scenes were painfully good, but the rest was just goofy. I give it another B-.

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

For Episode 16, there was six-way tie for first for the week, with Dean, Karl Withakay, Nicki, promiscuous peach, Staci, and teatime all scoring 8 points.

For Episode 17, there was a four-way tie, with Kevin Lighton, Noether, The Erskine, and Theta Sigma all scoring 9 points.

Overall, Dogma-Central takes a decisive lead with 51 points. The Erskine is in second with 47 points. In third is Sconibulus with 45 points. Ash and Ron tie for fourth with 44 points.

Full scores are available here.

A good episode of House with a fascinating premise and some good soap opera and social moments. The medicine was average, but didn’t hurt the episode much.

Nick Greenwald is a successful book editor who, while at a party launching his star author’s latest book, finds himself blurting out truth after uncomfortable truth to those around him. He then develops a nosebleed and collapses.

Nick is admitted to House’s service where the team notes that he reminds them of the classic case of Phineas Gage (a railroad worker who suffered personality changes after a spike was driven through his brain). Nick is showing signs of frontal lobe disinhibition, but there is no sign of a frontal lobe tumor as his head MRI is negative. Thirteen suggests that there may be a tumor hidden in the nasal cavity, but a nasopharyngoscope shows nothing. Next, an fMRI (functional MRI — an MRI that looks at blood flow within the brain) is obtained and reveals an abnormal area in the cingulate gyrus. Thirteen remarks that it’s too near the brainstem to biopsy, then Foreman mentions that it might be neurosarcoidosis (sarcoidosis which affects the central nervous system). Steroids are started to treat the presumed sarcoidosis.

Nick suddenly becomes very short of breath. Foreman states that it’s not his heart because the EKG is normal, so it must be kidney failure, and starts him on dialysis.

The differential now includes systemic sclerosis and chronic lymphocytic leukemia (both of which are quickly dismissed), as well as diabetes, and some sort of “congenital genetic disorder.” Foreman points out that there are too many genetic disorders to test for them all. House has Taub run a glucose tolerance test to check for diabetes, and has Kutner check Nick’s daughter for peripheral nerve damage because she suffers from some ill-defined neurological disorder and he thinks the condition might be inherited. The peripheral nerve test is normal, and Taub reports that the glucose tolerance test was completely normal and never above 120 for the entire night. House now wants to check the thyroid, but before the test can be ordered, Nick develops a fever, coughing, and pulmonary edema. Kutner orders 200MG of furosemide (a diuretic) and 2MG of morphine (primarily a pain killer, it also helps with pulmonary edema).

With Nick’s temperature at 103° (39C), the team now considers infection as the likely cause of his symptoms. Foreman mentions Staph aureus, tuberculosis, and strongyloides (threadworm). Kutner determines that a stray dog is living with Nick’s family and he and House suspect that Nick has developed Weil’s Disease (leptospirosis — an infection caused by the Leptospira genus of bacteria). He is started on doxycycline (an antibiotic) and his condition improves. Kutner and Foreman tell him that while the infection is cured, his brain damage and disinhibition are going to be permanent. Nick wants surgery to remove the damaged area, but they tell him it is too risky. He talks to House, who apparently sees some of himself in Nick, and talks Chase into getting his boss — a neurosurgeon — to perform the surgery. Initially, the surgery seems successful, but then it quickly becomes clear that Nick still blurts out whatever crosses his mind. That’s not all though, as his temperature starts falling dangerously low and he develops unstable ventricular tachycardia (and this is the right time to use the paddles). The arrhythmia is corrected and an echocardiogram is obtained, but shows no structural heart damage. Nick continues to have an abnormal temperature. The differential diagnosis now leans toward cancer, but Foreman rather cavalierly dismisses the idea. He orders a full body scan. This shows a small abdominal aneurysm (dismissed as an incidental finding), a cyst in the pleura (the membrane surrounding the lungs — also dismissed as an incidental finding), and a density in the liver. Foreman suspects this density represnts an ateriovenous malformation (AVM) and that multiple AVMs would explain the patient’s condition. He wants to go forward with angiography with embolization (a test to find and then block off the AVMs).

House is in New York with Wilson, but the team is texting him to keep in touch. In the middle of a conversation about Wilson’s guilt over his schizophrenic brother, House has his Eureka! moment. The glucose tolerance test that was normal should not have been normal because Nick was on steroids, which raise a person’s blood sugar. The fact that it did not rise, combined with the cyst — which is really a fibroma — in the pleura means that Nick has Doege-Potter Syndrome (a fibrous tumor that secretes insulin-like compounds and causes low blood sugar; Kutner mentions human growth hormone, but other similar chemicals can also be secreted). Nick has also developed an autoimmune reaction to the tumor, and his immune system has gone into overdrive and attacked his own body (brain, kidney, heart in this case). Removing the tumor should solve his problems — the medical ones at least.

They’re really weren’t any huge medical errors this week, just the usual hodge-podge of symptoms and diagnoses that really don’t fit. The worst was Foreman’s clueless statement about cancer, so that gets the prize this week. Well, there was also that one scene, but I’ve already spent enough space talking about it.

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

A normal PSA, normal colonoscopy, and normal blood count absolutely do not rule out cancer. Admittedly, colon cancer and prostate cancer are the most common cancers in a man Nick’s age, but there are plenty of other cancers out there (plus there are concerns about how reliable the PSA test actually is).

Diabetes doesn’t really fit his symptoms at all — other than the kidney disease. Of course, it was just an excuse to run the glucose tolerance test.
Speaking of the glucose tolerance test, the patient needs to be fasting, and it doesn’t take 12 hours to run.
It’s true that the steroids should have raised Nick’s sugars, but even a normal patient whose blood sugar didn’t rise above 120 after a hefty glucose load would be unusual.

Brain damage and peripheral nerve damage are two different things. It’s more common to have one without the other than both together.

If Nick’s kidneys are shot and he requires dialysis (a very important fact that was never mentioned again in the show; the dialysis that is, not the kidneys), then even 200MG of Lasix is not going to have any effect.

An MRI of the brain should have shown any nasal cavity tumor, especially one that was eroding into the brain.

Too many genetic disorders to test for them all? But they tested for them all in at least two previous episodes.

House doesn’t like full body scans? Then why does the team order them so regularly.

A cyst is hollow, a fibroma is solid. A scan should be able to tell the difference.

I thought the medical mystery was good this week, it was interesting not only from a medical perspective, but also fascinating from a social perspective. It made me wonder what horrible secrets I might spill. I give it an A. The solution was fairly logical, even if it did require two diagnoses (Doege-Potter + autoimmune). It earns a B+. The medicine was average for the show and I give it a C; it might have scored higher had that one scene been clearer. The soap opera was the best part of the episode. There were good House/Wilson and House/Taub interactions (the squash racket was great), and the patient’s social interactions were like a car crash: painful, but impossible to look away. The soap opera earns a solid A.

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

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

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.

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

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.)

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.

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.

A much better episode of House this week. While it wasn’t quite up to the standards of the first two seasons, there were definite that classic House was trying to break through.

Sarah is a 29 year old teacher of special needs children who suddenly begins to cough up blood during class and then collapses. She is admitted to the hospital under House’s care. The team’s initial differential diagnosis includes ulcer, leukemia, von Willebrand’s disease (a blood clotting disorder), or a thoracic tumor. House agrees with Foreman that the problem is likely within the patient’s blood and orders a bleeding time test. The test is abnormal, showing that her blood is not clotting correcting. A check of her clotting factors is normal, but her platelets turn up abnormal. The differential diagnosis now includes lymphoma and ITP (idiopathic thrombocytopenic purpura), with the latter being more likely. House elects to start her on methotrexate (which really isn’t a recommended treatment for ITP), but he also wants to treat her with total body irradiation (which is also not a recommended treatment for ITP, only it can have even nastier side effects than methrotrexate). In actuality, House has no intention of using the radiation but is just trying to test Cameron’s limits. She calls his bluff and allows the procedure, so now House and his team pretend have to pretend to use it. In the meantime, the methotrexate has shown no benefit, so House doubles the dose and adds Prednisone (a steroid, and the actual recommended treatment for treating ITP). During the (fake) radiation treatment, Sarah mentions that she has to pee. When she tries to get off the table, she collapses and is found to be pulseless. Thirteen and Taub rapidly pull out the defibrillator and shock her back into a normal rhythm.

The team meets again to discuss the latest findings. Tests, including a transthoracic echocardigram and a bubble test, show no structural defects of Sarah’s heart. Thirteen suggests a high vagal tone from urinating may have caused her to develop an arrhythmia and collapse. The rest of the team half-heartedly suggest heavy metal poisoning, toxin exposure, drug use, or alcohol use. Thirteen then mentions cold agglutinin disease, which seem to fit the case. House wants to put Sarah in an ice bath to test the diagnosis, but Cameron wants him to test some of the blood first. Reluctantly House agrees. The blood clots when exposed to the cold, confirming the presence of cold agglutinins, so Sarah is put into a three minute ice bath. The test, though uncomfortable, is normal (so while she may have some cold agglutinins — and most people do at various levels — she doesn’t have the disease; but please note this is not the recommended way to diagnose the condition).

House now decides that Sarah’s offhand story of transposing the digits of her room number, combined with her need to urinate during the radiation treatment, are signs of a brain lesion — a left hippocampal lesion to be precise. He thinks it is most likely multiple sclerosis (MS), and wants to perform a brain biopsy to confirm his diagnosis. Kutner thinks she has a pancreatic tumor and wants to perform an ERCP instead, but House wins — sort of. Cameron won’t let him go through with a brain biopsy, wanting an MRI first. Reluctantly, House orders the MRI, but it is normal, so Sarah doesn’t have MS. Kutner performs his ERCP and it is normal, but Sarah starts to have problems breathing during the test. She is found to have pleural effusions (fluid build up around the lungs), which are drained (off camera). House now decides that Sarah has equine encephalitis, a mosquito-borne disease caused by a picornavirus (there are actually several types of equine encephalitis, but none that I can find are caused by a picornavirus), which is causing conduction problems in her brain. He wants to test nerve conduction tests along the surface of her brain. This, of course, requires removing the top of her skull and thus needs approval from Cameron. She declines. Meanwhile, Kutner now thinks that she has a lymphoma of her spleen and wants to perform a splenectomy (surgically remove the spleen). House has Thirteen and Foreman search the classroom for evidence of encephalitis, but they turn up nothing significant. Nevertheless, Cameron allows him to perform the nerve conduction study and even assists. The test is going smoothly until Kutner tattles by calling Cuddy. She demands to speak with House and is placed on speakerphone. In the background, her baby Rachel is crying, and the sound is annoying Sarah quite a bit. Her reaction is paradoxical, though, in that her blood pressure drops while she is annoyed (it should rise). The team ends the test and puts her skull back together. House is puzzled and cannot figure out what is going on with Sarah. Puzzled, that is, until Cuddy and Rachel stop by. The baby spits up on House which leads him to start a monologue about evolution which leads him to have his Eureka! moment and diagnose Sarah with a PDA (patent ductus arteriosus).

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

Even though the PDA may not have been open when the heart was scanned, the fact that the duct still existed (it should have withered away) should have been evident.
Why would only the left part of her brain been affected?

Apparently no one in the hospital likes to run CT scans or MRIs (this week anyway). Most of the diagnoses mentioned (MS, lymphoma, tumor) would have shown up and not required brain biopsy, ERCP, etc.

A blood test for cold agglutinins is not simply a “cool the blood and see if it clots” test, but a test to see how much it clots.
An ice bath is by no stretch of the imagination a good test for cold agglutinin disease, if they have it, you’ve just done the patient a major disservice as systemic clotting is not a good thing.

ITP, by definition, has low platelet numbers — which were never mentioned, just abnormal looking platelets (though her red blood cells should have looked chewed up as well).
MTX is not a treatment for ITP. It has been investigated, and continues to be investigated, but hasn’t shown a lot of promise. IV steroids are first line.

There seems to be confusion among the team about heart attacks (myocardial infarctions) and cardiac arrest. The terms are not synonymous.
Shocking a pulseless patient? How about — at least — some CPR first, if not checking the rhythm before shocking?

If I were the doctors I would have taken a closer look at the vitals during the test. Her resting oxygen saturation was 97% — on oxygen. That’s not normal. Nor is a heart rate of 116 , even though they called it “normal”. It didn’t change at all during her ice bath, when it should have shot up. Sure, I know the fancy vital sign machine was just there as a prop, but at least put in a little effort to make it authentic, prop people.

It would have been nice if they had run labs on the fluid they pulled out of the effusion. It would have helped to rule out cancer and pancreatic disease at least.

On another note, parent/baby bonding is often delayed in adoption situations and post-adoption depression in common, so what Cuddy was feeling was fairly normal. I’m glad to see she did not give up Rachel because of it.

The medical mystery started out weak (coughing up blood? That’s it?), but got better earns a B. The final solution was a stretch, but at least it fits more symptoms and seems more logical than usual and thus deserves a B+. The medicine had too much jumping from diagnosis to diagnosis while overlooking the most common and useful testing, so can’t really be considered anything more than average: C. The soap opera was subdued this week, but that felt appropriate, and earns a B.

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

This episode of Fringe introduced a new antagonist as well as new protagonist/hostage, and also features some spectacularly bad medical science

The Plot: Agent Dunham had been kidnapped at the end of the previous episode. As this episode begins, she is strapped down to a gurney by her captors and ends up on the receiving end of a spinal tap. We manage to catch a glimpse of one of her abductors: Agent Loeb (from episode 7). Dunham manages to escape, and in the process steals some suspicious looking test tubes.

Dunham calls in reinforcements, but the FBI agents who show up subdue and tranquilize her. It turns out that there is an internal affairs investigation into the FBI “Fringe” office, and it is being headed up by an investigator who bears a grudge against Agent Dunham. Tranquilizing her was his way of letting her know who is boss.

Meanwhile, a world-famous immunologist is lectur