HOUSE: Flawed Identity

** SPOILER ALERT **

Sophia is a factory supervisor who collapses at work and ends up at Princeton-Plainsboro Medical Center. Hmmm...she looks kinda young. Sophia is actually 16 and living on her own - she is a legally emancipated teenager. With both parents deceased the courts recognized her as an adult, giving her personal responsibility and legal authority to make her own decisions. Sophia is found to have acute promyelocytic leukemia and needs a bone marrow transplant from a sibling or parent in order to have the best chance for survival.

There are just a few unresolved problems:

• Sophia's parents are not dead
• Sophia is responsible for her sole sibling's death
• Sophia is not who she says she is, she is an identity thief

It seems 'Sophia' ran away from home out of guilt for her brother's accidental death. She fabricated (embezzled) a new identity and wanted to start over with a clean slate. (Funny...we never learn her real name?!?)

By now most of you are familiar with the serious identity theft problem that threatens every person in this country.

[A quick digression: I love watching the commercials with that CEO blurting out his social security number to boast about his anti-hacker software. How long before he gets burned?]

Anyway, do you know about Medical Identity Theft (MIT)? It is an enormous, underpublicized crisis that is compromising our entire health care system. MIT occurs when someone ineligible for health insurance uses another person's health card for doctor's visits, hospitalizations, prescription drugs, and other medical benefits.

Sophia may have been involved in MIT. Her factory job may not have provided comprehensive health care benefits. The 'real' Sophia's parents [still alive!] would probably need emergency hospitalization when they received the 'Explanation of Benefits' (EOB) from their health insurer - including a $250,000 bill for bone marrow transplantation. Fortunately, Sophia confessed by the end of the program and her real mother and father (still alive!) arrived at her bedside - hopefully with photo IDs.

According to the most recent government statistics approximately 3% of all identity theft cases involve MIT. That's over 250,000 victims per year and countless millions in illegal claims. With traditional identity theft stolen credit cards eventually get canceled and bogus charges are forgiven. Your credit rating remains bruised for awhile as you try to reconcile your accounts. When MIT happens the consequences are far more severe and far more enduring! Huge costs are quickly incurred and everybody ends up paying for the fraudulent claim (insurance premiums, local taxes, higher copays, etc.) Even worse, the victim's computerized medical records are permanently corrupted. Depending on circumstances, it would be very hard to acquire life insurance if your records say you have acute promyelocytic leukemia!

Just like a erroneous credit card charge, if you discover an incorrect billing statement regarding a family member you should fight it, fight it, and fight some more! If you know that the EOB is wrong alert your insurer to the possibility of Medical Identity Theft.

Related Topics:

• WebMD Video: A Less Toxic Bone Marrow Transplant
• The Identity Theft You Haven't Heard of...Yet

HOUSE: Simulated Surgery, Real Deceit

A young man named Nozick ("no sick"... get it?) suffers from agoraphobia (fear of public places) and collapses at home. He resists emergency responders who want to transport him to the hospital for evaluation. House's former fellow, Cameron, knows the patient and she recruits the team to help establish a diagnosis right inside Nozick's bedroom.

As usual, the guest star patient quickly decompensates and emergency surgery is needed. Anxious Nozick adamantly refuses to leave his bedroom. House announces a clever scheme: Let the patient consent to surgery that will be performed in his own house but, once asleep, transfer the anesthetized patient to Princeton-Plainsboro Medical Center for the exploratory procedure. Following surgery, drag Nozick back to his own bed before he wakes up.

You got a problem with that?

It is a different twist on sham surgery. Yeah, you read right - sham surgery. It's real medical terminology. Tell the patient you are going to perform a procedure on them, take them to the O.R., put them to sleep, apply a dressing and take them back to recovery.

Sham surgery and other sham treatments populate the medical literature. They demonstrate the power of placebo therapy to gauge treatment efficacy in randomized clinical research. For example, does removal of frayed knee cartilage improve long-term knee comfort? A study is designed where half of the patients receive knee arthroscopy with damaged cartilage removal while the other half merely receive peek-a-boo arthroscopy. The patients themselves are blinded as to which procedure(s) they received, and both have stitches and swelling after surgery. Six months later, surprise, both groups share similar statistics regarding comfort and function.

Just a thought; would phony 'gastric banding' lead to progressive weight loss simply because the patient believed their stomach was 50 percent smaller and thereafter were satisfied with smaller portions?

Faking surgery is more complex and more risky than swallowing a sugar pill.

Many medical ethicists claim that the routine use of invasive sham procedures is unethical and should only be reserved for special occasions where no alternative exists. They claim that research volunteers cannot render a valid consent because if they knew beforehand that they were going to receive the sham procedure they would never agree to undergo the procedure. The ethics of medical practice can also be applied to fictional medical dramas. As seen in House Episode 507 - 'Itch', there is no way Nozick would agree to undergo exploratory surgery if it meant leaving his home. That is where House's approach went astray and nobody intervened. Things went badly for the patient up until the end of the show when House opened Nozick's abdomen without anesthesia to remove some old bullet fragments.

Once again, I ask myself in horror, "Does anybody ever sign consent forms on House? Does it really matter?"

Related Topics:

• What is a Phobia?
• WebMD Video: How Do Placebos Work?

HOUSE: Asleep at the Wheel

Ready for a surprise? I actually enjoyed watching most of this week's House [Episode 506 "Joy"] because it taught me several things I had not previously known.

Jerry is a busy single father who experiences unusual neurologic attacks wherein extended periods of his day disappear as if they never happened. Time warp. Jerry and his single daughter live a spartan, isolated life: work and school. They do not socialize. In fact, they hardly relate to each other.

It doesn't take the team at Princeton-Plainsboro to establish that Jerry is a narcoleptic sleep walker. During attacks Jerry is a cocaine abuser, which only further aggravates his sleep disorder.

Chicken meets egg: Did the cocaine cause the narcolepsy that led to the sleepwalking (to buy more cocaine)? Much of the program tries to unravel that mystery until Jerry begins to perspire blood and goes into renal failure. House puts the pieces together and diagnoses Familial Mediterranean Fever (FMF). Jerry and his daughter are from the Middle East, a region where FMF cases congregate. The responsible genetic defect in FMF resides in chromosome 16 and it is passed along in an autosomal recessive inheritance pattern. Parents can be affected or carriers. Jerry is a widower and the cause of his wife's death was not mentioned. Jerry's only daughter apparently inherited the disease as well.

Now for the good part. House recognized that Jerry and his daughter exhibited anhedonia. Ever hear that word before? See the letters 'hedo' as in hedonism? These two bland, boring people found no joy is life whatsoever. Anhedonia is linked to various chemical imbalances in the brain as seen in depression, schizophrenia and drug addiction. Aha! The cocaine! Wait, don't take the bait! Jerry's daughter was not abusing cocaine. In their particular circumstance it was their Familial Mediterranean Fever that was responsible for their flattened mood.

House prescribed colchicine and melphalan to delay disease progression and inhibit additional complications that await FMF patients down the road. At the end of the program everyone was smiling - not really. Remember, this is House - not Full House!

Related Topics:

• Who Uses and Abuses Drugs and Alcohol?
• Why Sleepwalkers Need Regular Sleep

HOUSE: Time Is Running Out

This week's episode opens with Thirteen enjoying a late night lesbian tryst complete with alcohol and ecstasy. Sounds pretty irresponsible for an on-call physician, especially one who is enrolled in a high-profile fellowship. The party ends abruptly when her partner Spencer (nice androgynous name) collapses. Thirteen brings the woman to the Princeton-Plainsboro emergency department for a complete workup.

Spencer experiences seizures, dehydration, chronic sleep deficiency, cardiac arrest, skin numbness. Each new symptom jump starts a fresh diagnosis and another invasive procedure - each of which triggers a more serious complication. Does the formula sound familiar? Meanwhile, Thirteen has to withstand the harsh judgment of her team members regarding her risky behaviors. It appears that both women are spiraling out of control.

House and others believe that Spencer has a fatal smooth muscle proliferation called Lymphangioleiomyomatosis (abbreviated LAM). Thirteen is told to notify Spencer of the bad news. Hmmm...a women dying from Huntington's Chorea counseling a former sex partner about certain death from LAM.

How strange! Spencer does not cry upon hearing such the tragic information. A-Ha! House deduces that Spencer does not have LAM (despite a confirmatory lung biopsy...darn those pesky plot details!) House bundles it all together as Sjögren's syndrome (SS), an autoimmune disorder characterized by loss of watery gland secretion (saliva, lacrimal, etc.) Activated lymphocytes attack the patient's own glands.

House based the diagnosis of Sjögren's on Spencer's failure to cry. Screenwriter whims notwithstanding, medical truth must prevail! I can think of three obvious flaws. For starters, Spencer appeared a bit young for Sjögren's. Next, SS most often accompanies mixed connective tissue inflammatory disorders like rheumatoid arthritis. Having reviewed Spencer's bedroom gymnastics (hello, TiVo!) I can attest that her joints were very flexible. Hospital closeup scenes of Spencer's hands revealed no joint swelling typical for rheumatoid arthritis. Finally, SS initially attacks the microscopic tear glands - leading to subnormal maintenance tear moisture content. The large lacrimal gland can still flood the eyes following a noxious exposure like tear gas or after psychomotor stimulation such as crying.

So, lo and behold, Spencer is not going to die anytime soon. At the same time, Thirteen's demise continues right on schedule. Is Thirteen crying for help or simply maintaining control over her choices? Is she trying to cram-in as much fun now as possible or has she embraced these self-destructive gestures so as to die before the Huntington's takes over?

Related Topics:

• Grey's Anatomy Raises Health Awareness
• Sjögren's Syndrome

HOUSE: Pins and Needles

It's a good thing Fox aired 'Birthmarks' after the Olympics. There were many offensive concepts in this week's fictional medical drama specifically relating to Chinese culture. Do you think Chinese parents insert needles into their infant children's skulls? Excuse me, I'm getting ahead of myself.

Magnetism was the central theme: House's attraction to Wilson, House's polarization from his father, and the adopted Nicole's transcontinental search to be drawn closer to her birth family back in China. Nicole is a drug abuser and smokes like a chimney. It appears much of her hospitalization is related to problems with different forms of iron.

At one point House's team suspects genetically-impaired iron metabolism - maybe hemachromatosis. (Medical geek point: House wanted to know if Nicole's birth parents had bronze skin as a sign of a systemic iron disorder. House was a bit rusty with the facts. The bronze skin discoloration from iron overload is not melanin; it is accumulated granules of hemosiderin and hematoidin - a breakdown product from iron-rich blood).

Later in the story it is revealed that Nicole's biologic parents inserted metallic pins into her soft infant skull in an effort to kill her in compliance with China's one-child per family population control policy. Nice... wouldn't a blanket have been sufficient? Apparently this parental shish-kabob approach to family planning backfired. Those intracranial pins turned into some kind of mega-acupuncture with the needle tips stimulating the pleasure/addiction centers of Nicole's developing brain. Small detail, but most acupuncturists that I know apply their needles (or a therapeutic staple) to the earlobe to promote smoking cessation.

Enough! By this time the entire plot was as difficult to consume as a mercury-laced, rat-stuffed dim sum washed down with a glass of contaminated Chinese milk. How did Nicole travel from America to China and get past the airport security metal detectors?!? "Excuse me, ma'am, but would you please remove your head?"

Still stuck on the magnetism theme, had Nicole undergone the planned MRI she would be in deep trouble. MRI, magnetic resonance imaging, relies on powerfully energized magnetic fields that would turn those pins into lethal projectiles. Magnetic items are never allowed into the MRI suite but surprises do happen. Some women experience 'tingling, burning hair' during an MRI scanning procedure. Guess what? Many hairsprays contain small quantities of elemental iron that cause this uncomfortable phenomenon.

By the end of the show the team tells Nicole that all of her problems will disappear once those nasty needles are removed. I don't think they nailed it. Postsurgical scarring in her traumatized brain tissue (reactive gliosis) may actually make things worse over time. Again and again I try to hammer-home the importance of never making overly optimistic promises to surgical patients. Give things time... at least until the next episode.

I'm done with this. My head hurts!

Related Topics:

• WebMD Video: Relief From Pain With Accupuncture
• WebMD Video: Smaller MRI - A Better Alternative for Some

HOUSE: Finding It Hard to Swallow?

The guest star patient for this episode of House, M.D. (Adverse Events) had a bezoar. There! A top-line spoiler!

I suppose if you've never previously heard about a bezoar the climactic diagnostic surprise remains intact.

Portrait artist Brandon is struggling financially and participates in new drug clinical research to pay his bills. Unfortunately he was actively enrolled in three simultaneous medication trials: an anticoagulant, an immune modulator, and an antacid. Brandon's art suffers because of drug-related visual changes.

Despite hemodialysis Brandon has recurrent bouts of drug toxicity. Even a slow drug taper failed to control a serious heart arrhythmia. He also displays hypersexual aggression and his hair changes color. Problems progress as if the medicines were never discontinued.

In the end, all of Brandon's problems do trace back to adverse interactions between those three experimental medicines. The antacid slowed Brandon's intestinal motility and a clump of undigested matter collected in his gut. Supposedly, many swallowed pills got trapped in the 'hair ball' (yep, lay terminology for a bezoar!) So, even when Brandon stopped taking the pills his bezoar continued to leech drugs into his digestive system. Yecchhh!

The cast members took their turns disparaging clinical trials. In all fairness, the current system is among the world's safest and most rigorously enforced, but we need to do better identifying unscrupulous researchers, indifferent medical journal publishers and dishonest corporate decision-makers. There was no mention of Phases I-IV which prioritize drug safety long before efficacy is analyzed. Truth be told, most new drugs never make it out of Phase II (human safety).

While we are on the subject of truth-telling, much of the dramatic subplots in this episode focused on issues of honesty. Brandon nearly died because he failed to disclose his failure as an artist to his girlfriend and he covered that lie by choosing not to disclose his unauthorized entry into three different drug trials. Surgery yielded a football-sized bezoar and Brandon fully recovered - enabling him to begin formulating his apologies. He can start with the hospital cashier. Nobody explained how unemployed Brandon will pay the bill for his week-long hospitalization!

Related Topics:

• Clinical Trials for Newborn Surgeries
• Can Drug Clinical Trials Be Trusted?

Related Topics:

HOUSE: What's Worse Than Rejection?

I have received several comments recently that I should devote less space to plot synopsis and more text to specific medical issues that arise (erupt) during an episode of House,M.D.

It appears that I picked a great week to skip the plot synopsis because this week's episode ("Not Cancer") was already spinning out of control during the first segment.

Most viewers probably want to know: Can I acquire an organ donor's illnesses? The answer is a definite 'Yes'. If a donor has the corneal condition keratoconus (extreme irregular astigmatism) and the corneas are harvested for transplantation, the recipient will have keratoconus. It happens! Not only can transplant recipients develop the same illnesses that were present in the donor, the transplantation itself can generate some new ones. Let me explain.

Infected organs that are transplanted can quickly spread the infection elsewhere in the recipients body. Fortunately, today's rigorous organ screening procedures greatly limit this possibility. Typically, only healthy dead people (an oxymoron?) and healthy living people are acceptable donors.

A scriptwriting oversight deserves clarification. There are different types of transplantations: solid organ (heart, liver, etc.), tissue (tendons, corneas, skin), and bone marrow. They made a big deal that math professor Apple's cornea transplant was safer because the cornea has no blood vessels. That statement is meaningless. In the past cornea recipients contracted rabies from deceased donors. Somebody forgot to tell the morgue staff, "Don't harvest any donor tissue on this corpse!" Today that does not happen - end of story.

Solid organ transplantation requires extensive immunosuppression in the recipient to prevent the recipient's immune system from fighting the stranger's tissue, thereby causing organ rejection. You can see the problem here: profound immunosuppression makes the recipient highly vulnerable to opportunistic infections. Cytomegalovirus (CMV) is one such example. Most organ recipients with no prior CMV exposure take antiviral drugs after transplantation to prevent CMV infection.

Powerful immunosuppressive drugs can also cause problems. Individuals who contract Epstein-Barr virus infection (same bug that causes mononucleosis) while immunosuppressed may develop a lymphoma-type condition that is controlled, not by chemotherapy, but by reducing the level of immunosuppression.

Yep, organ transplantation is serious business. Besides hoping for a good tissue match and healthy acceptance of the new organ, transplant patients have to deal with the challenges of a compromised immune system, unexpected dangerous infections, and other complications that threaten the survival of both the transplanted organ as well as the life of its recipient. Having said that, organ transplantation means hope for a new life.

Hey, don't forget to become an organ donor - and notify your loved ones of your decision. Over half of all folks needing an organ transplantation die without getting it.

One final thought. Livers and kidneys aside, like an unwanted organ, Wilson continues to reject House!

Related Topics:

• Living With an Organ Transplant
• Donating Organs and Tissue: Giving the Gift of Life