PULMONOLOGY CARDIOLOGY PEDIATRIC PULMONOLOGY SLEEP MEDICINE AFib is on the rise in COPD patients ODYSSEY trial supports PCSK9 use to Maternal vaccination for RSV was Insomnia is linked with epileptic hospitalized for exacerbation // 11 reduce M1 and M2 risk // 21 found to protect neonates // 28 seizure frequency // 39 VOL. 14 • NO. 6 • JUNE 2019 Smoking rates Undiagnosed remain steady OSA can double among the poor cardiovascular BY ANDREW D. BOWSER MDedge News risk after hile an increasing number of U.S. citizens are saying no to cigarettes, current smok- surgery Wing rates are holding steady among people who face multiple forms of socioeconomic or health-related disadvantages, a recent study shows. The odds of current smoking, versus never smoking, declined significantly during 2008- 2017 for individuals with none of six disadvan- Dr. Matthew T.V. Chan and tages tied to cigarette use, including disability, colleagues stated, “General unemployment, poverty, low education, psy- anesthetics, sedatives, and chological distress, and heavy alcohol intake, postoperative analgesics are according to researchers. potent respiratory depressants Individuals with one or two of those disad- that relax the upper airway vantages have also been cutting back, the data dilator muscles and impair suggest. But, by contrast, odds of current versus ventilatory response to never smoking did not significantly change for hypoxemia and hypercapnia.” those with three or more disadvantages, accord- Courtesy Dr. Matthew T.V. Chan Matthew T.V. Courtesy Dr. ing to Adam M. Leventhal, PhD, of the Univer- sity of Southern California, Los Angeles, and BY BIANCA NOGRADY patients to postoperative cardiovascular compli- coinvestigators. MDedge News cations,” said researchers who conducted the The “How this pattern can inform a cohesive poli- Postoperative vascular complications in unrec- cy agenda is unknown, but it is clear from these nrecognized severe obstructive sleep apnea ognised Obstructive Sleep apnoea (POSA) study findings that the crux of the recently expanding is a risk factor for cardiovascular compli- (NCT01494181). tobacco-related health disparity problem in the Ucations after major noncardiac surgery, They undertook a prospective observational Smoking // continued on page 7 according to a study published in JAMA. cohort study involving 1,218 patients undergo- The findings indicate that perioperative mis- ing major noncardiac surgery, who were already INSIDE HIGHLIGHT management of obstructive sleep apnea can considered at high risk of postoperative cardio- NEWS FROM CHEST lead to serious medical consequences. “Gen- vascular events – having, for example, a history Envisioning the eral anesthetics, sedatives, and postoperative of coronary artery disease, stroke, diabetes, or analgesics are potent respiratory depressants renal impairment. However, none had a prior INSPIRATION: future: The CHEST that relax the upper airway dilator muscles and diagnosis of obstructive sleep apnea. Environmental Pacing the Future impair ventilatory response to hypoxemia and Preoperative sleep monitoring revealed that Scan hypercapnia. Each of these events exacerbates two-thirds of the cohort had unrecognized and Page 44 [obstructive sleep apnea] and may predispose OSA // continued on page 6 Rosemont, IL 60018 IL Rosemont, Lebanon Jct. KY Jct. Lebanon Suite 280 Suite Permit No. 384 No. Permit PAID 10255 W Higgins Road, Higgins W 10255 U.S. Postage U.S. CHANGE SERVICE REQUESTED SERVICE CHANGE Presorted Standard Presorted CHEST PHYSICIAN CHEST Register Today chestmeeting.chestnet.org NEWS Employed physicians now outnumber independents BY ALICIA GALLEGOS survey from the American Medical employed, compared with 46% of percentage points over the same peri- MDedge News Association. doctors who were self-employed that od, according to the study published The AMA’s annual Physician year. The number of employed phy- May 6 on the AMA website. or the first time, employed Practice Benchmark Survey, which sicians has risen 6 percentage points Younger physicians and women physicians outnumber indepen- queried 3,500 doctors, showed that since 2012, while the number of doctors were more likely to be em- Fdent physicians, according to a 47% of all physicians in 2018 were self-employed doctors has fallen by 7 ployed than their counterparts. Nearly 4 • JUNE 2019 • CHEST PHYSICIAN 70% of physicians under age 40 years cian-owned practices in 2018 either 42% who were employees. employed physicians (57%). were employees in 2018, compared as an owner, employee, or contrac- Surgical subspecialists had the A majority of doctors still work in with 38% of physicians 55 years and tor, a decrease from 60% in 2012. highest share of owners (65%) fol- small practices, the analysis found. older, the study found. About 35% of Male physicians were more likely lowed by obstetrician-gynecologists In 2018, 57% of physicians worked physicians worked either directly for a to be practice owners than female (54%) and internal medicine subspe- in practices with 10 or fewer phy- hospital or in a practice at least partly physicians. Among female doctors, cialists (52%). Emergency physicians sicians versus 61% in 2012. How- owned by a hospital in 2018, up from 58% were employees, compared had the lowest share of owners (26%) ever, fewer physicians work in solo 29% in 2012. with 34% who were practice owners, and the highest share of independent practice. Between 2012 and 2018 More than half of physicians while 52% of men physicians were contractors (27%). Family physicians, the percentage of physicians in solo surveyed (54%) worked in physi- practice owners, compared with meanwhile, had the highest share of practice fell from 18% in 2012 to 15% in 2018. The AMA’s Physician Practice Benchmark Survey is a nationally representative survey of post-resi- dency physicians who provide at least 20 hours of patient care per week, are not employed by the federal gov- ernment, and practice in one of the 50 states or the District of Columbia. The 2018 survey was conducted in September 2018, and the final data included 3,500 physicians. [email protected] VIEW ON THE NEWS Michael E. Nelson, MD, FCCP, comments: Today one hears of physician early retire- ment and burnout, and now data that reveal that most doctors are choosing employment over ownership. With the hyperbolic expansion of ad- ministrative tasks related to government oversight, the institution of the electronic records, the ever-increasing cost of overhead, among many other pressures, it is not difficult to understand why physicians choose not to “own” a practice. If one transfers those headaches to someone else, the practice of medicine should be sim- plified. But as an employee, physicians are often judged more by their Press-Ganey score than how well they practice medicine. There is also a crowd of corporate clerks whose job it is to count things and tell you why you are not doing your job cor- rectly or efficiently, while knowing nothing of what your job entails. In addition, most employment contracts con- tain a “termination without cause” clause that allows the employer to fire you without giving you a reason. I believe owning a practice may be less frightening. MDEDGE.COM/CHESTPHYSICIAN • JUNE 2019 • 5 NEWS FROM CHEST // 40 Sedation amplies OSA risk // continued from page 1 untreated obstructive sleep apnea, “Despite a substantial decrease in PULMONARY PERSPECTIVES®// 50 including 11.2% with severe ob- ODI [oxygen desaturation index] structive sleep apnea. with oxygen therapy in patients with At 30 days after surgery, patients OSA during the first 3 postoperative CHEST PHYSICIAN with obstructive sleep apnea had a nights, supplemental oxygen did IS ONLINE 49% higher risk of the primary out- not modify the association between CHEST Physician is available at David A. Schulman, MD, come of myocardial injury, cardiac OSA and postoperative cardiovascu- chestphysician.org. FCCP, is Medical Editor in death, heart failure, thromboem- lar event,” wrote Matthew T.V. Chan, Chief of CHEST Physician. bolism, atrial fibrillation, or stroke, MD, of Chinese University of Hong compared with those without ob- Kong, Prince of Wales Hospital, and structive sleep apnea. coauthors. However, this association was Given that the events were as- largely due to a significant 2.23-fold sociated with longer durations of higher risk among patients with se- severe oxyhemoglobin desaturation, American College of Chest CHEST Physician, the newspaper of the American vere obstructive sleep apnea, while more aggressive interventions such Physicians (CHEST) College of Chest Physicians, provides cutting-edge those with only moderate or mild as positive airway pressure or oral EDITOR IN CHIEF reports from clinical meetings, FDA coverage, clinical David A. Schulman, MD, FCCP trial results, expert commentary, and reporting on the sleep apnea did not show a signifi- appliances may be required, they business and politics of chest medicine. Each issue also cant increased risk of cardiovascular noted. PRESIDENT provides material exclusive to CHEST members. Content Clayton Cowl, MD, FCCP for CHEST Physician is provided by Frontline Medical complications. “However, high-level evidence EXECUTIVE VICE PRESIDENT & CEO Communications Inc. Content for News From Chest is Patients in this study with severe demonstrating the effect of these Robert Musacchio provided by the American College of Chest Physicians. PUBLISHER, CHEST® JOURNAL The statements and opinions expressed in CHEST obstructive sleep apnea had