The Decline of Small Practice in Colorectal Surgery: Practice Consolidation From 2015-2022

INTRODUCTION

Physicians have gravitated toward larger group practice arrangements in recent years. However, consolidation trends in colorectal surgery have yet to be well described. Our objective was to assess current trends in practice consolidation within colorectal surgery and evaluate underlying demographic trends including age, gender, and geography.

METHODS

We performed a retrospective cross-sectional study using the Center for Medicare Services National Downloadable File from 2015 to 2022. Colorectal surgeons were categorized by practice size and by region, gender, and age.

RESULTS

From 2015 to 2022, the number of colorectal surgeons in the United States increased from 1369 to 1621 (+18.4%), while the practices with which they were affiliated remained relatively stable (693-721, +4.0%). The proportion of colorectal surgeons in groups of 1-2 members fell from 18.9% to 10.7%. Conversely, those in groups of 500+ members grew from 26.5% to 45.2% (linear trend P < 0.001). The midwest region demonstrated the highest degree of consolidation. Affiliations with group practices of 500+ members saw large increases from both female and male surgeons (+148.9% and +86.9%, respectively). New surgeons joining the field since 2015 overwhelmingly practice in larger groups (5.3% in groups of 1-2, 50.1% in groups of 500+).

CONCLUSIONS

Colorectal surgeons are shifting toward larger practice affiliations. Although this change is happening across all demographic groups, it appears unevenly distributed across geography, gender, and age. New surgeons are preferentially joining large group practices.

Occurrence of Escherichia coli O157:H7 in diverse farm environments

In the United States, foodborne outbreaks of Escherichia coli O157:H7 illness have often been linked to the consumption of contaminated, undercooked ground beef. However, the occurrence of E. coli O157:H7 has also been reported in other farm animals. The objective of this study was to evaluate the occurrence of E. coli O157:H7 on diverse farm types and from a variety of farm samples. Rectal swabs (n=1686) and environmental samples (n=576) were collected from 16 farms in five states over 24 months and analyzed for the presence of E. coli O157:H7. Overall, E. coli O157:H7 was found in 3.6% of beef cattle, 3.4% of dairy cattle, 0.9% of chicken, 7.5% of turkey, and 8.9% of swine samples. The pathogen was isolated sporadically from each of the environmental sample types. Of particular concern was the isolation of E. coli O157:H7 from fresh feed samples, indicating a potential vector for transmission. The data from this study indicate a high occurrence of E. coli O157:H7 on swine and turkey farms. This unexpected result suggests that more research on the occurrence of E. coli O157:H7 on these types of farms is required in order to better understand potential reservoirs of pathogenic E. coli.

Genetic characterization of a diverse Escherichia coli O157:H7 population from a variety of farm environments

Many of the current studies on the genetic diversity of Escherichia coli O157:H7 have focused on pathogenic clinical, veterinary, or food isolates. These studies did not explore the diversity of the larger population in the farm environment. Research on selected farm isolates address this wider diversity but have typically been limited to a specific geographic locale or farm type, thus giving limited insight into the greater diversity across geographic regions and varied environments. The objective of this study was to evaluate a diverse population of E. coli O157:H7 collected from a variety of locations and farm environments. Eighty-eight isolates were collected from four farm types (swine, dairy, beef, and poultry) across the southeastern and western United States. Eighteen farms were sampled every 3 months over a period of 24 months. Isolates were analyzed by ribotyping and pulsed field gel electrophoresis (PFGE). Real-time PCR was used to determine the presence or absence of key pathogenic genes (stx1, stx2, and eae). The data indicate a significant amount of genetic diversity, however, ribotype analysis revealed meaningful clusters within the larger population. These groupings were consistent with PFGE analysis. Most of these isolates were clustered by location (i.e. from the same state or region) or farm type. Of the isolates in these clusters, most did not contain pathogenic genes. Of notable interest is a single group in which the majority of isolates, collected from four of the five states sampled, contained at least one stx gene and the eae gene suggesting the existence of a specific pathogenic cluster. These data suggest that, while there is notable diversity within the broader E. coli O157:H7 population, pathogenic isolates may be limited to a subset of strains within the population.

Osmotic dehydration of apple slices using a sucrose/CaCl2 combination to control spoilage caused by Botrytis cinerea, Colletotrichum acutatum, and Penicillium expansum

The efficacy of sucrose combined with CaCl2 during osmotic dehydration (OD) was tested for the control of Botrytis cinerea, Colletotrichum acutatum, and Penicillium expansum growth on lightly processed apple slices. The objective of this work was to determine whether the addition of CaCl2 in the osmotic solutions would limit the proliferation of fungal decay organisms. Slices were submitted to OD for 1 h at 25 degrees C in solutions containing 5 to 65% sucrose. Calcium chloride was added to a similar set of sucrose solutions at 0 to 8%. Control slices were made of untreated slices, and slices were processed in water. The mass ratio of the slices did not vary when fruit pieces were processed in solutions containing 5 to 65% sucrose. These slices showed a high susceptibility to spoilage compared to the control slices not submitted to OD: a significant twofold and 60% increase in decay area caused by B. cinerea and P. expansum, respectively, was observed when slices were processed in 50% sucrose/0% CaCl2; C. acutatum showed a significant 50% increase in decay area when slices were processed in 20% sucrose/0% CaCl2. Calcium uptake was significantly increased when slices were processed in CaCl2 solutions, and the highest Ca content was observed when processed in 8% CaCl2, reaching 40 times that of the control slices processed in water. Calcium-treated slices were less susceptible to spoilage by all three pathogens, and the most effective combination in reducing apple slice spoilage was 20 to 30% sucrose combined with 2% CaCl2.

Antimicrobial activity of essential oils from plants against selected pathogenic and saprophytic microorganisms

The beneficial health effects of extracts from many types of plants that are used as seasoning agents in foods and beverages have been claimed for centuries. The purpose of this study was to examine the effectiveness of selected herb and spice essential oils for control of growth and survival of microorganisms. Inhibition of growth was tested by the paper disc agar diffusion method. Antibiotic susceptibility discs were used as control. Minimum lethal concentration (MLC) was determined by the tube dilution method. Essential oils from anise, angelica, basil, carrot, celery, cardamom, coriander, dill weed, fennel, oregano, parsley, and rosemary were evaluated. Inhibition ranged from complete with oregano to no inhibition with carrot oil for each of the test strains that included: Listeria monocytogenes, Staphylococcus aureus, Escherichia coli O:157:H7, Yersinia enterocolitica, Pseudomonas aeruginosa, Lactobacillus plantarum, Aspergillus niger, Geotrichum, and Rhodotorula. Oregano essential oil showed the greatest inhibition (zone, > or = 70 to 80 mm) (MLC, approximately 8 ppm). Coriander and basil were also highly inhibitory (MLC, approximately 25 to 50 ppm) to E. coli O:157:H7 and to the other bacteria and fungi tested. Anise oil was not particularly inhibitory to bacteria (inhibition zone, approximately 25 mm); however, anise oil was highly inhibitory to molds. Because some of the herbal and spice essential oils are highly inhibitory to selected pathogenic and spoilage microorganisms, they may provide alternatives and supplements to conventional antimicrobial additives in foods.