Nasacort AQ Steroid Nasal Spray NOW Available OTC!

Sanofi announced in 2013 that the FDA had approved Nasacort steroid nasal spray to be made available over-the-counter (OTC) starting sometime spring 2014.

Well... It's now available for about $20. Here's where you can get it on Amazon.com.

Nasacort is a steroid nasal spray used to treat allergies in patients starting from the age of 2 years old. It is similar to prescription steroid nasal sprays like flonase, nasonex, etc. It is also the very first steroid nasal spray made OTC in the United States which can be both a blessing as well as a curse.

Why?

With Nasacort going OTC which will certainly make it more convenient for patients, I also anticipate that the other prescription steroid nasal sprays including flonase, nasonex, qnasl, zetonna, veramyst, etc will become much harder to prescribe due to insurance requiring patients to use OTC Nasacort first. Worst case, insurance may even simply stop paying for the prescription steroid nasal sprays.

After all, this is exactly what happened with prescription reflux and anti-histamine medications.

Source:
FDA Approves Sanofi's Nasacort(R) Allergy 24HR for Over-the-Counter Use. Wall Street Journal 10/11/13

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Chin Strap May Help with Snoring

There is a relatively simple (and cheap) device that may help some people who snore called a chin strap. This lowly, humble, and low-tech device may benefit patients who typically snore when:

1) Lays on back, but not on side
2) Mouth-breathes when sleeping (but suffers no nasal obstruction)
3) Does not suffer from severe obstructive sleep apnea
4) Appears to be "slack-jawed" when sleeping (chin pushed back relative to upper jaw creating a pseudo-overjet dental appearance)

How (or more importantly why) does this device work?

When a person sleeps who also mouth-breathes AND has a chin that falls backwards, it also causes the tongue to fall back against the back wall of the throat causing a partial narrowing. It also causes the overall throat diameter to decrease causing the throat mucosa to loosen creating the perfect environment for snore production: a partially narrow airway resulting in negative pressure due to increased respiratory effort which triggers any loose mucosa to vibrate causing a snore sound.

A chin strap can be used to force the mouth closed into a more normal position (chin in normal forward position with teeth in normal occlusion). By preventing the chin from falling backward, it would prevent the tongue from falling backward. By preventing the tongue from falling backward, the partial airway narrowing could be avoided. By preventing the airway from narrowing, the throat mucosa would be more taught and less prone to vibrate as well as prevent increased respiratory effort and a "negative" pressure environment.

Where can you get one? There's a whole bunch that can be purchased on Amazon.com.

So there you have it... Of course, keep in mind that the chin-strap will NOT work for everybody as the snore production could be due to other factors unrelated to the chin, tongue, mouth position.

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What Does a Kiss Look Like from INSIDE the Mouth? [VIDEO]

Image from Wikipedia

A kiss is beautiful to behold and even better to give/receive... but it may be a matter of perspective, because what a kiss looks like from the inside is downright disconcerting. Check out this YouTube video...

On that note, I'm curious to know what kind of camera was used given it must have been tiny, and focus was unusually good given the varying focal length.

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Man Sues ENT for Wrongful Tracheostomy

Image from ParaMedicine101

In December 2012, a West Virginia man suffered angioedema causing tongue swelling due to a not uncommon reaction from lisinopril. Presumably due to airway concern from the tongue swelling, an urgent tracheostomy (cutting a hole in the throat) was performed.

The patient later filed suit against the ENT who performed the tracheostomy stating that it was unnecessary as the tongue swelling was getting better. [link]

Although a tracheostomy is not always performed for tongue swelling due to angioedema, it also is not unusual to do so, mainly because the alternative outcome is airway loss and death. It is a judgement call on the physicians who are caring for a patient with angioedema whether close monitoring alone is sufficient versus performing a tracheostomy. If the tongue swelling is large enough to cause some airway obstruction, no physician or ENT would ever question the need for a tracheostomy, regardless of whether the swelling "might" be getting better or not.

If one waited until the airway became critical before performing a tracheostomy, the risk of death and complications become MUCH larger. As such, a tracheostomy is performed well before there's any chance of airway loss. (Intubation is not recommended or at times even possible as the act of trying to intubate may trigger airway loss.)

Indeed, the patient who is suing the ENT may not be alive today to sue the ENT if it weren't for the tracheostomy. Instead, it would be the family who would be suing the ENT for wrongful death for NOT doing a tracheostomy.

Check out this lawsuit where an ENT did NOT perform a tracheostomy for airway swelling resulting in death. Here's another lawsuit for similar though under more convoluted circumstances.

Source:
Clay Co. man says doctors performed unnecessary tracheostomy. West Virginia Record. 1/29/14

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New Incisionless Device to Correct Reflux by Medigus

A new trans-oral incisionless device to surgically treat reflux was announced by Medigus, an Israeli company, called the "SRS system." It is a competitor to two other incisionless devices currently available: Stretta (Mederi Therapeutics) and Esophyx (Endogastric Solutions).

Common to all incisionless devices is the fact that the procedure is performed using an endoscope introduced through the mouth threaded down into the stomach. At this point, the technique used by the devices to tighten the valve separating the esophagus and stomach varies.

With Stretta (first on the market), radiofrequency energy is used to induce scarring of the valve causing it to constrict.

With Esophyx (next to market), a 270 degree 2-3cm fundoplication is performed by manipulating the esophago-gastric tissue in a rotating twisting manner and anchoring in place using 12 or more full-thickness polypropylene fasteners.

With SRS, the stomach is folded up against the esophagus and anchored in place using a few staplers. Watch the video below to see how this system works.

The technique that is best for a given patient will vary based on surgeon's comfort and experience with the device as well as unique patient variables. As such, no technique is perfect or applicable to everybody. Also, only time will tell if this or any other incisonless technique provides long-term reflux relief with minimal risk and side effects.

Ask your GI or general surgery specialist on what option is best for you.

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Surgeon's Point-of-View (POV) Video Recording

Learning how to video record vivid, stable, high-def, and focussed shots from my (surgeon's) point-of-view has not been an easy endeavor due to technology limitations, though things do appear to be slowly improving. There have been pros and cons with most video-recording systems to date which I have summarized below. The "perfect" video-recording system has yet to be developed which must include all these elements:

• Wearable on headlight or glasses
• Camera located between the eyes that is maneuverable to adjust recording angle
• Head-up view to see what is being recorded real-time
• Manual white balance adjustment

• Manual exposure adjustment (bright lights used in surgery often confuse auto-exposure settings which result in washed-out pictures)

• Auto-focussing with adjustable zoom

• VERY good image stabilization

• HD video-recording

General Problems with Head-Mounted Video Recordings

The problem with current head mounted video-recording systems including Google Glass are several-fold. First of all, no matter how good you think you are staying still, there are constant micro-motions/tremors which produce unusable erratic videos. This annoying camera movement becomes even more pronounced when using cameras with longer focal lengths which is why most head-mounted camera systems come with a fixed, wide-angle lens which unfortunately takes away from the narrow-angle, focussed shot a surgeon would like recorded.

Also, the smaller and lighter the camera, the more inferior the optics resulting in poor video quality (compared to high-resolution, 3CCD, HD recordings which is what the surgeon's want).

These short-comings are common with all head-mounted video-recording systems. Unfortunately, there are even more problems depending the camera.

Google Glass (or any eyeglass side-mounted camera)

Typically, when a surgeon operates, the surgical field (green) is a certain distance from the his/her face. When in a comfortable position, wearing any type of head-mounted camera system located on the side like Google Glass unfortunately ends up video-recording a point that is above and to the side (purple) of what is actually desired.

In order to compensate the vertical offset, either the surgeon has to flex the head more or move the eyeglass down towards the lip.

To adjust the horizontal offset, the surgeon would have to turn and move the head to one side such that the camera has a more direct line shot into the surgical field... but that would mean the surgeon would be operating off-centered, almost looking over one shoulder.

Although doable, this is far from perfect or comfortable.

Central Head-Mounted Video Camera Systems

There ARE video-recording cameras that contain a camera that can be placed centrally over the forehead or between the eyes including Luxtec and SurgeonCam which are mounted on the headlight and PivotHead glasses (among others) where the camera is built into the frame between the eyes.

The headlight mounted systems'  camera angle can be adjusted to provide a more precise POV recording, but the general disadvantages of body-worn cameras still apply with constant erratic motion and wide-angle shots that do not specifically focus in on the surgical field.

The PivotHead glasses do provide perfect central shots, but still suffer from a vertical offset (orange) which cannot be adjusted like the headlight mounted systems.

Overhead Mounted Camera Systems

For the same reason the best photos are obtained by cameras fixed to a tripod, the best videos are often obtained by cameras fixed into position by a stationary object.

One object cameras can be attached to are overhead fixtures.. specifically the operating room lights.

Such cameras are attached typically to the light-handle of such overhead operating room lights which are directed down into the surgical field. Such systems provide excellent focussed, stable, high-quality video-recordings with one BIG disadvantage. The surgeon's head keeps getting in the way.

Also, the light-handle is positioned for optimal lighting of the surgical field... not optimal framing for capturing good videos.

Bed-Mounted Camera Systems

Using a Thompson Laparoscopic Retractor System, the video camera can be attached to one of the articulating arms and adjusted sterilely as needed. Using this retractor system can allow the camera to be positioned independently of the overhead operating room lights and to be as close to the surgical field as necessary.

The video is limited by how good the camera is that is attached. The best one I've been able to find is the Sony HXR-MC1 which incorporates a large-sized lipstick camera that is attached to a controller where manual controls for focus, zoom, white balance, exposure, etc can be made. Other than the built-in LCD screen, there are included plugs (Component, RCA, and with adapter S-Video) that allow what the camera is recording to be thrown up onto a large screen.

Other wireless video lipstick cameras are now being produced, but lack manual controls to adjust zoom, white balance, and exposure. Some offer real-time video display so it may be just a matter of time before all other manual controls found with the Sony HXR-MC1 become more widely available.

The main disadvantage with this setup is that the setup itself can get in the way of the surgeon.

Conclusion

So there you have it... No perfect surgical POV video system yet... Maybe in the next few years if technology keeps moving the way it is.

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