Embedded protostellar disks around (sub-)solar protostars. I. Disk structure and evolution

We perform a comparative numerical hydrodynamics study of embedded protostellar disks formed as a result of the gravitational collapse of cloud cores of distinct mass (M_cl=0.2--1.7 M_sun) and ratio of rotational to gravitational energy (\beta=0.0028--0.023). An increase in M_cl and/or \beta leads to the formation of protostellar disks that are more susceptible to gravitational instability. Disk fragmentation occurs in most models but its effect is often limited to the very early stage, with the fragments being either dispersed or driven onto the forming star during tens of orbital periods. Only cloud cores with high enough M_cl or \beta may eventually form wide-separation binary/multiple systems with low mass ratios and brown dwarf or sub-solar mass companions. It is feasible that such systems may eventually break up, giving birth to rogue brown dwarfs. Protostellar disks of {\it equal} age formed from cloud cores of greater mass (but equal \beta) are generally denser, hotter, larger, and more massive. On the other hand, protostellar disks formed from cloud cores of higher \beta (but equal M_cl) are generally thinner and colder but larger and more massive. In all models, the difference between the irradiation temperature and midplane temperature \triangle T is small, except for the innermost regions of young disks, dense fragments, and disk's outer edge where \triangle T is negative and may reach a factor of two or even more. Gravitationally unstable, embedded disks show radial pulsations, the amplitude of which increases along the line of increasing M_cl and \beta but tends to diminish as the envelope clears. We find that single stars with a disk-to-star mass ratio of order unity can be formed only from high-\beta cloud cores, but such massive disks are unstable and quickly fragment into binary/multiple systems.Comment: Accepted for publication in the astrophysical Journa

Embedded protostellar disks around (sub-)solar stars. II. Disk masses, sizes, densities, temperatures and the planet formation perspective

We present basic properties of protostellar disks in the embedded phase of star formation (EPSF), which is difficult to probe observationally using available observational facilities. We use numerical hydrodynamics simulations of cloud core collapse and focus on disks formed around stars in the 0.03-1.0 Msun mass range. Our obtained disk masses scale near-linearly with the stellar mass. The mean and median disk masses in the Class 0 and I phases (M_{d,C0}^{mean}=0.12 Msun, M_{d,C0}^{mdn}=0.09 Msun and M_{d,CI}^{mean}=0.18 Msun, M_{d,CI}^{mdn}=0.15 Msun, respectively) are greater than those inferred from observations by (at least) a factor of 2--3. We demonstrate that this disagreement may (in part) be caused by the optically thick inner regions of protostellar disks, which do not contribute to millimeter dust flux. We find that disk masses and surface densities start to systematically exceed that of the minimum mass solar nebular for objects with stellar mass as low as M_st=0.05-0.1 Msun. Concurrently, disk radii start to grow beyond 100 AU, making gravitational fragmentation in the disk outer regions possible. Large disk masses, surface densities, and sizes suggest that giant planets may start forming as early as in the EPSF, either by means of core accretion (inner disk regions) or direct gravitational instability (outer disk regions), thus breaking a longstanding stereotype that the planet formation process begins in the Class II phase.Comment: accepted for publication by the Astrophysical

Self-Assessment Framework for Corporate Environmental Sustainability in the Era of Digitalization

The shift towards a climate-neutral economy will affect businesses in the upcoming decades. Companies will need to increase their transformation towards environmentally sustainable businesses in the following years, in which digitalization might be a practical enabler to accelerate this transformation. However, as a starting point, companies require knowledge of their current sustainability performance to manage this transition and need a method that provides the necessary information. The use of self-assessment tools is a widely acknowledged method for such processes. Nevertheless, there is a lack of self-assessment tools that integrate sustainability and digitalization perspectives to overcome different organizational barriers. This paper focuses on how managers can be supported in planning their transformations by interlinking sustainability and digitization. Our objective is to enable the managers of companies to assess their current state in terms of corporate environmental sustainability and to explore their policies, information systems, and actions to support their transformation towards sustainable and digital businesses. A self-assessment tool based on a rapid questionnaire is presented after reviewing and synthesizing different approaches, including maturity modeling, sustainability reporting, and digital assessment tools. The self-assessment tool is improved upon evaluation by industry experts and the framework is tested on a case company.</jats:p

Laparoscopy in management of appendicitis in high-, middle-, and low-income countries: a multicenter, prospective, cohort study.

BACKGROUND: Appendicitis is the most common abdominal surgical emergency worldwide. Differences between high- and low-income settings in the availability of laparoscopic appendectomy, alternative management choices, and outcomes are poorly described. The aim was to identify variation in surgical management and outcomes of appendicitis within low-, middle-, and high-Human Development Index (HDI) countries worldwide. METHODS: This is a multicenter, international prospective cohort study. Consecutive sampling of patients undergoing emergency appendectomy over 6 months was conducted. Follow-up lasted 30 days. RESULTS: 4546 patients from 52 countries underwent appendectomy (2499 high-, 1540 middle-, and 507 low-HDI groups). Surgical site infection (SSI) rates were higher in low-HDI (OR 2.57, 95% CI 1.33-4.99, p = 0.005) but not middle-HDI countries (OR 1.38, 95% CI 0.76-2.52, p = 0.291), compared with high-HDI countries after adjustment. A laparoscopic approach was common in high-HDI countries (1693/2499, 67.7%), but infrequent in low-HDI (41/507, 8.1%) and middle-HDI (132/1540, 8.6%) groups. After accounting for case-mix, laparoscopy was still associated with fewer overall complications (OR 0.55, 95% CI 0.42-0.71, p < 0.001) and SSIs (OR 0.22, 95% CI 0.14-0.33, p < 0.001). In propensity-score matched groups within low-/middle-HDI countries, laparoscopy was still associated with fewer overall complications (OR 0.23 95% CI 0.11-0.44) and SSI (OR 0.21 95% CI 0.09-0.45). CONCLUSION: A laparoscopic approach is associated with better outcomes and availability appears to differ by country HDI. Despite the profound clinical, operational, and financial barriers to its widespread introduction, laparoscopy could significantly improve outcomes for patients in low-resource environments. TRIAL REGISTRATION: NCT02179112

Global economic burden of unmet surgical need for appendicitis

Background: There is a substantial gap in provision of adequate surgical care in many low-and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis. Methods: Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism. Results: Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and$73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and$75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality. Conclusion: For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially

Pooled analysis of WHO Surgical Safety Checklist use and mortality after emergency laparotomy

Background The World Health Organization (WHO) Surgical Safety Checklist has fostered safe practice for 10 years, yet its place in emergency surgery has not been assessed on a global scale. The aim of this study was to evaluate reported checklist use in emergency settings and examine the relationship with perioperative mortality in patients who had emergency laparotomy. Methods In two multinational cohort studies, adults undergoing emergency laparotomy were compared with those having elective gastrointestinal surgery. Relationships between reported checklist use and mortality were determined using multivariable logistic regression and bootstrapped simulation. Results Of 12 296 patients included from 76 countries, 4843 underwent emergency laparotomy. After adjusting for patient and disease factors, checklist use before emergency laparotomy was more common in countries with a high Human Development Index (HDI) (2455 of 2741, 89.6 per cent) compared with that in countries with a middle (753 of 1242, 60.6 per cent; odds ratio (OR) 0.17, 95 per cent c.i. 0.14 to 0.21, P <0001) or low (363 of 860, 422 per cent; OR 008, 007 to 010, P <0.001) HDI. Checklist use was less common in elective surgery than for emergency laparotomy in high-HDI countries (risk difference -94 (95 per cent c.i. -11.9 to -6.9) per cent; P <0001), but the relationship was reversed in low-HDI countries (+121 (+7.0 to +173) per cent; P <0001). In multivariable models, checklist use was associated with a lower 30-day perioperative mortality (OR 0.60, 0.50 to 073; P <0.001). The greatest absolute benefit was seen for emergency surgery in low- and middle-HDI countries. Conclusion Checklist use in emergency laparotomy was associated with a significantly lower perioperative mortality rate. Checklist use in low-HDI countries was half that in high-HDI countries.Peer reviewe

Mortality of emergency abdominal surgery in high-, middle- and low-income countries

Background: Surgical mortality data are collected routinely in high-income countries, yet virtually no low- or middle-income countries have outcome surveillance in place. The aim was prospectively to collect worldwide mortality data following emergency abdominal surgery, comparing findings across countries with a low, middle or high Human Development Index (HDI). Methods: This was a prospective, multicentre, cohort study. Self-selected hospitals performing emergency surgery submitted prespecified data for consecutive patients from at least one 2-week interval during July to December 2014. Postoperative mortality was analysed by hierarchical multivariable logistic regression. Results: Data were obtained for 10 745 patients from 357 centres in 58 countries; 6538 were from high-, 2889 from middle- and 1318 from low-HDI settings. The overall mortality rate was 1⋅6 per cent at 24 h (high 1⋅1 per cent, middle 1⋅9 per cent, low 3⋅4 per cent; P < 0⋅001), increasing to 5⋅4 per cent by 30 days (high 4⋅5 per cent, middle 6⋅0 per cent, low 8⋅6 per cent; P < 0⋅001). Of the 578 patients who died, 404 (69⋅9 per cent) did so between 24 h and 30 days following surgery (high 74⋅2 per cent, middle 68⋅8 per cent, low 60⋅5 per cent). After adjustment, 30-day mortality remained higher in middle-income (odds ratio (OR) 2⋅78, 95 per cent c.i. 1⋅84 to 4⋅20) and low-income (OR 2⋅97, 1⋅84 to 4⋅81) countries. Surgical safety checklist use was less frequent in low- and middle-income countries, but when used was associated with reduced mortality at 30 days. Conclusion: Mortality is three times higher in low- compared with high-HDI countries even when adjusted for prognostic factors. Patient safety factors may have an important role. Registration number: NCT02179112 (http://www.clinicaltrials.gov)

Global variation in anastomosis and end colostomy formation following left-sided colorectal resection

Background End colostomy rates following colorectal resection vary across institutions in high-income settings, being influenced by patient, disease, surgeon and system factors. This study aimed to assess global variation in end colostomy rates after left-sided colorectal resection. Methods This study comprised an analysis of GlobalSurg-1 and -2 international, prospective, observational cohort studies (2014, 2016), including consecutive adult patients undergoing elective or emergency left-sided colorectal resection within discrete 2-week windows. Countries were grouped into high-, middle- and low-income tertiles according to the United Nations Human Development Index (HDI). Factors associated with colostomy formation versus primary anastomosis were explored using a multilevel, multivariable logistic regression model. Results In total, 1635 patients from 242 hospitals in 57 countries undergoing left-sided colorectal resection were included: 113 (6·9 per cent) from low-HDI, 254 (15·5 per cent) from middle-HDI and 1268 (77·6 per cent) from high-HDI countries. There was a higher proportion of patients with perforated disease (57·5, 40·9 and 35·4 per cent; P < 0·001) and subsequent use of end colostomy (52·2, 24·8 and 18·9 per cent; P < 0·001) in low- compared with middle- and high-HDI settings. The association with colostomy use in low-HDI settings persisted (odds ratio (OR) 3·20, 95 per cent c.i. 1·35 to 7·57; P = 0·008) after risk adjustment for malignant disease (OR 2·34, 1·65 to 3·32; P < 0·001), emergency surgery (OR 4·08, 2·73 to 6·10; P < 0·001), time to operation at least 48 h (OR 1·99, 1·28 to 3·09; P = 0·002) and disease perforation (OR 4·00, 2·81 to 5·69; P < 0·001). Conclusion Global differences existed in the proportion of patients receiving end stomas after left-sided colorectal resection based on income, which went beyond case mix alone