A Comparison of Outflow Properties in AGN Dwarfs vs. Star Forming Dwarfs

Feedback likely plays a crucial role in resolving discrepancies between observed and theoretical predictions of dwarf galaxy properties. Stellar feedback was once believed to be sufficient to explain these discrepancies, but it has thus far failed to fully reconcile theory and observations. The recent discovery of energetic galaxy-wide outflows in dwarf galaxies hosting Active Galactic Nuclei (AGN) suggests that AGN feedback may have a larger role in the evolution of dwarf galaxies than previously suspected. In order to assess the relative importance of stellar versus AGN feedback in these galaxies, we perform a detailed Keck/KCWI optical integral field spectroscopic study of a sample of low-redshift star-forming (SF) dwarf galaxies that show outflows in ionized gas in their SDSS spectra. We characterize the outflows and compare them to observations of AGN-driven outflows in dwarfs. We find that SF dwarfs have outflow components that have comparable widths (W$_{80}$) to those of outflows in AGN dwarfs, but are much less blue-shifted, indicating that SF dwarfs have significantly slower outflows than their AGN counterparts. The outflows in SF dwarfs are spatially resolved and significantly more extended than those in AGN dwarfs. The mass loss rates, momentum and energy rates of SF-driven outflows are much lower than those of AGN-driven outflows. Our results indicate that AGN feedback in the form of gas outflows may play an important role in dwarf galaxies and should be considered along with SF feedback in models of dwarf galaxy evolution.Comment: 27 pages, 25 figures, Accepted for publication in Ap

Nuclear Activity in the Low Metallicity Dwarf Galaxy SDSS J0944-0038: A Glimpse into the Primordial Universe

Local low metallicity dwarf galaxies are relics of the early universe and hold clues into the origins of supermassive black holes (SMBHs). In recent work, coronal lines have been used to unveil a population of candidate accreting black holes in dwarf galaxies with gas phase metallicities and stellar masses well below the host galaxies of any previously known AGNs. Using MUSE/VLT observations, we report the detection of [Fe X] $\lambda$6374 coronal line emission and a broad H$\alpha$ line in the nucleus of SDSS J094401.87$-$003832.1, a nearby ($z=0.0049$) metal poor dwarf galaxy at least fifty times less massive than the LMC. The [Fe X] $\lambda$6374 emission is compact and centered on the brightest nuclear source, with a spatial extent of $\approx$100 pc. The [Fe X] luminosity is $\approx 10^{37}$ erg s$^{-1}$, within the range seen in previously identified AGNs in the dwarf galaxy population. This line has never been observed in gas ionized by hot stars. While it can be produced in supernova ejecta, the [Fe X] flux from SDSS J094401.87$-$003832.1 has persisted over the ~19 year time period between the SDSS and MUSE observations, ruling out supernovae as the origin for the emission. The FWHM of the broad component of the H$\alpha$ line is $446 \pm 17$ km s$^{-1}$ and its luminosity is $\approx 1.5\times10^{38}$ erg s$^{-1}$, lower than the broad line luminosities of previously identified low mass broad line AGNs. These observations, together with previously reported multi-wavelength observations, can most plausibly be explained by the presence of an accreting intermediate mass black hole in a primordial galaxy analog. However, we cannot rule out the possibility that current stellar population models of metal poor stars significantly under-predict the stellar ionizing photon flux, and that metal poor stars can produce an extreme ionizing spectrum similar to that produced by AGNs.Comment: 12 pages, 5 figures, 1 table, submitted to ApJL. Comments welcom

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570

A Comparison of Outflow Properties in AGN Dwarfs versus Star-forming Dwarfs

Feedback likely plays a crucial role in resolving discrepancies between observations and theoretical predictions of dwarf galaxy properties. Stellar feedback was once believed to be sufficient to explain these discrepancies, but it has thus far failed to fully reconcile theory and observations. The recent discovery of energetic galaxy-wide outflows in dwarf galaxies hosting active galactic nuclei (AGNs) suggests that AGN feedback may have a larger role in the evolution of dwarf galaxies than previously suspected. In order to assess the relative importance of stellar versus AGN feedback in these galaxies, we perform a detailed Keck/KCWI optical integral field spectroscopic study of a sample of low-redshift star-forming (SF) dwarf galaxies that show outflows in ionized gas in their Sloan Digital Sky Survey spectra. We characterize the outflows and compare them to observations of AGN-driven outflows in dwarfs. We find that SF dwarfs have outflow components that have comparable widths ( W _80 ) to those of outflows in AGN dwarfs, but are much less blueshifted, indicating that SF dwarfs have significantly slower outflows than their AGN counterparts. Outflows in SF dwarfs are spatially resolved and significantly more extended than those in AGN dwarfs. The mass-loss, momentum, and energy rates of star-formation-driven outflows are much lower than those of AGN-driven outflows. Our results indicate that AGN feedback in the form of gas outflows may play an important role in dwarf galaxies and should be considered along with SF feedback in models of dwarf galaxy evolution

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Evaluation of a quality improvement intervention to reduce anastomotic leak following right colectomy (EAGLE): pragmatic, batched stepped-wedge, cluster-randomized trial in 64 countries

Background Anastomotic leak affects 8 per cent of patients after right colectomy with a 10-fold increased risk of postoperative death. The EAGLE study aimed to develop and test whether an international, standardized quality improvement intervention could reduce anastomotic leaks. Methods The internationally intended protocol, iteratively co-developed by a multistage Delphi process, comprised an online educational module introducing risk stratification, an intraoperative checklist, and harmonized surgical techniques. Clusters (hospital teams) were randomized to one of three arms with varied sequences of intervention/data collection by a derived stepped-wedge batch design (at least 18 hospital teams per batch). Patients were blinded to the study allocation. Low- and middle-income country enrolment was encouraged. The primary outcome (assessed by intention to treat) was anastomotic leak rate, and subgroup analyses by module completion (at least 80 per cent of surgeons, high engagement; less than 50 per cent, low engagement) were preplanned. Results A total 355 hospital teams registered, with 332 from 64 countries (39.2 per cent low and middle income) included in the final analysis. The online modules were completed by half of the surgeons (2143 of 4411). The primary analysis included 3039 of the 3268 patients recruited (206 patients had no anastomosis and 23 were lost to follow-up), with anastomotic leaks arising before and after the intervention in 10.1 and 9.6 per cent respectively (adjusted OR 0.87, 95 per cent c.i. 0.59 to 1.30; P = 0.498). The proportion of surgeons completing the educational modules was an influence: the leak rate decreased from 12.2 per cent (61 of 500) before intervention to 5.1 per cent (24 of 473) after intervention in high-engagement centres (adjusted OR 0.36, 0.20 to 0.64; P < 0.001), but this was not observed in low-engagement hospitals (8.3 per cent (59 of 714) and 13.8 per cent (61 of 443) respectively; adjusted OR 2.09, 1.31 to 3.31). Conclusion Completion of globally available digital training by engaged teams can alter anastomotic leak rates. Registration number: NCT04270721 (http://www.clinicaltrials.gov)