Background: Academic centers' and professional societies' top leadership representation and professional societies' award recipients remain disparate by gender in many fields. Little is known regarding leadership representation and recognition within pulmonary, critical care, and sleep medicine (PCCM), which has similar to 22% women physicians. We sought to understand the landscape of female PCCM leaders. Methods: We abstracted gender of fellowship program directors (PDs), Department of Medicine (DOM) Chairs and Division Chiefs from academic medical centers with PCCM fellowship programs from 2018 and for comparison 2008. We abstracted leadership and recognition award recipients within four PCCM professional societies from 2013 to 2018 (American Thoracic Society [ATS], American Academy of Sleep Medicine [AASM], American College of Chest Physicians [CHEST], and Society of Critical Care Medicine [SCCM]). Results: In 2018, 29% of PCCM PD, 15% of PCCM Division Chiefs, and 15% of DOM Chairs were women. There were significantly more female PDs in 2018 (29%) compared with 2008 (16%, p = 0.04). On average, 25% of society presidents were women, with 28% of PCCM societal awards going to women, with significant difference between societies (p = 0.04). Each society differed in average distribution of female board members over the 6-year period: ATS 38%, AASM 35%, CHEST 18%, and SCCM 44% (p < 0.001). Conclusion: PCCM leadership and societal recognition are disparate by gender with few women holding top leadership roles and receiving societal recognition. Fortunately, the distribution notably is starting to reflect the specialty's demographics. Understanding why these inequalities exist will be essential to achieving gender parity in PCCM.

TYPE: Abstract Publication TOPIC: Obstructive Lung Diseases PURPOSE: To highlight how constrictive bronchiolitis is a rare obstructive lung disease associated with paraneoplastic autoimmune multi-organ syndrome (PAMS). METHODS: A 35 year old man with non-Hodgkin follicular lymphoma and PAMS presents with dyspnea. He was diagnosed with lymphoma and PAMS nine months prior. He completed chemoradiation therapy and was doing well until one month prior when he developed dyspnea. Dyspnea progressively worsened over the next month, so he sought medical care. Further work up was obtained. RESULTS: Pulmonary function testing (PFT) showed very severe, irreversible airflow obstruction (FEV1 11%) with marked air trapping (RV 370%). Chest computerized tomography (CT) revealed air trapping with bronchial wall thickening and bronchiectasis. CONCLUSIONS: Given his constellation of symptoms, CT findings, and pulmonary function abnormalities, he was diagnosed with constrictive bronchiolitis. He was initiated on fluticasone, azithromycin, and montelukast (FAM) therapy along with systemic corticosteroids and plasma exchange. His dyspnea improved with this regimen, and he was discharged home. CLINICAL IMPLICATIONS: PAMS is a rare paraneoplastic syndrome commonly associated with non-Hodgkin lymphoma, chronic lymphocytic lymphoma, and Castleman disease. Clinical presentation varies with possible mucocutaneous, muscle, and lung involvement. Lung involvement can manifest as constrictive bronchiolitis - a dreaded complication with high mortality. Diagnosis of constrictive bronchiolitis is suggested by respiratory symptoms, irreversible airflow obstruction on PFT, and air trapping on CT. Treatment is limited with scant data to identify an ideal agent. If present, treat an underlying disease process and consider systemic corticosteroids, macrolide antibiotics, and immunosuppressive medications. Despite treatment, disease progression commonly occurs leading to respiratory failure and death. DISCLOSURE: No significant relationships. KEYWORDS: Constrictive bronchiolitis, Paraneoplastic autoimmune multi-organ syndrome, PAMS

Adaptive servo-ventilation (ASV) is a PAP modality prescribed for central sleep apnea (CSA). A safety notice was issued in 2015 for patients with congestive heart failure (CHF; ejection fraction [EF] ≤ 45%) and CSA treated with ASV based on the SERVE-HF study that found a 2.5% absolute increased risk of annual cardiovascular mortality in CHF-CSA patients on ASV compared to controls. Physicians were advised to discontinue ASV in these patients. This project was designed to evaluate the long-term mortality for CHF-CSA patients prescribed ASV. After IRB approval, retrospective chart review was performed for CHF-CSA patients started on ASV 2006 -2015 at Mayo Clinic Arizona. Of 305 patients prescribed ASV, 23 patients were identified with an EF ≤ 45% and CSA (defined by an apnea-hypopnea index [AHI] ≥ 15/hour with > 50% central events). Mean age was 81 ± 11 years (96% male). Mean EF was 32.6 ± 13%. Mean AHI was 51 ± 20/hour with a CAI of 34 ± 18/hour. Mean follow-up from initial sleep evaluation was 3 ± 0.5 years. 16 (70%) have died (Mean EF 31 ± 10% and AHI 51 ± 20)). Causes of death were CHF(6), cancer (2), and unknown (8). Two were on ASV at time of death, 1 had stopped ASV, and ASV status was unknown in the rest. Of the 7 survivors, 1 elected to convert to CPAP after the safety notice, 2 remained on ASV, and 4 had no follow-up but were on ASV at last contact. Mean EF for those alive was 37 ± 16% and AHI 48 ± 21. Our study shows a high mortality rate of 70% for patients with EF ≤ 45% and CSA prescribed ASV. Given the small number of patients, absence of a control group, and high age of our cohort, it is unclear whether ASV use was associated with death in our cohort.

Iron deficiency occurs in approximately 51% of patients following bariatric surgery. Iron deficiency is a risk factor for restless legs syndrome/Willis Ekbom Disease (RLS/WED); yet this disease has not been systematically studied in the bariatric surgery population. Our objectives were to prospectively analyze presence and severity level of RLS/WED in patients before and after undergoing bariatric surgery for weight loss. Consecutive adult patients scheduled for bariatric surgery for treatment of obesity between October 2014 and February 2016 were enrolled. Subjects completed validated questionnaires to assess presence and severity of RLS/WED (Cambridge-Hopkins Questionnaire 13 and International Restless Legs Syndrome Study Group Rating Scale (IRLS)) during baseline and follow-up visits. In 101 total subjects, 79% were females. Mean body mass index was 45.65 (SD +/- 7.7). Baseline RLS/WED was present in 21% of patients with a mean IRLS score of 15 (SD +/- 9.0). Three months following surgery, an additional 17% of subjects who presented for followup had developed RLS/WED (8/47); at 6 months an additional 8.8% (3/34); and at 12 months an additional 27% (3/11) had developed RLS/WED. Pre-surgical hemoglobin was below 12.0 g/dL in 8% (7/91). At baseline, 32% (32/101) of subjects were on a proton pump inhibitor and 39% (40/101) were on an antidepressant. Sleep studies were performed in 50% of patients (50/101) and 84% were diagnosed with obstructive sleep apnea. Of the 37 subjects who underwent in-lab polysomnography, mean periodic limb movement index was 20.47/h (SD +/- 34.5). Bariatric surgery patients may be at higher risk for RLS/WED than the general population and their disease may be unrecognized. Long-term follow-up to identify new or worsening cases will be important, particularly given high risk of iron deficiency in this population. Routine screening for RLS/WED should be considered in bariatric surgery patients.

Bilevel positive airway pressure with back up rate (BPAP-ST) is the most common ventilation mode in neuromuscular disease patients. The role of Average Volume Assured Pressure Support (AVAPS) has not been established. Our aim was to compare ventilatory and sleep parameters and patient preference of BPAP-ST vs AVAPS. We implemented a sequential titration protocol of BPAP-ST followed by AVAPS during polysomnography in 10 patients (all had known or suspected ALS) and retrospectively reviewed their data. Patients (50% female) averaged 66 years(± 6 SD) with maximal predicted inspiratory and expiratory pressures, and vital capacity of 46% (± 17), 36% (± 23), and 65% (± 25) respectively. At optimal titration of each device, average tidal volumes were 93.2 ml (± 61) higher on AVAPS with transcutaneous CO2 0.7 mmHg (± 2.9) higher on BPAP-ST. Average respiratory rate was 2.8 bpm (± 5) higher while nadir NREM SaO2 was 4.7% (± 8) lower on BPAP-ST with no difference in REM (0 ± 2). Tidal volumes tolerated by patients on AVAPS were 47ml (± 55) lower than those recommended per the manufacturer’s reference table (8ml/kg). The average apnea-hypopnea index was 2.9 events/hour(± 10) higher on BPAP-ST. Sleep efficiency was on average 0.7% (± 18) higher on BPAP-ST. None of the ventilatory or sleep parameters differed significantly (p> 0.05) between BPAP-ST and AVAPS. A majority of the patients preferred BPAP-ST (70%). BPAP-ST and AVAPS provided equivalent ventilator and sleep parameters during polysomnography in a neuromuscular disease patient cohort while these patients tended to prefer BPAP-ST.

Chemical input to the deep sea from hydrothermal systems is a globally distributed phenomenon. Hydrothermal discharge is one of the primary mechanisms by which the Earth’s interior processes manifest themselves at the Earth’s surface, and it provides a source of energy for autotrophic processes by microbes that are too deep to capitalize on sunlight. Much is known about the water-column signature of this discharge from high-temperature mid-ocean Ridge (MOR) environments and their neighboring low-temperature counterparts. Hydrothermal discharge farther away from the ridge, however, has garnered less attention, owing in part to the difficulty in finding this style of venting, which eludes methods of detection that work well for high-temperature ‘black smoker’-type venting. Here we present a case study of the plume from one such ‘invisible’ off-axis environment, The Lost City, with an emphasis on the dissolved volatile content of the hydrothermal plume. Serpentinization and abiotic organic synthesis generate significant concentrations of H2 and CH4 in vent fluid, but these species are unevenly transported to the overlying plume, which itself appears to be a composite of two different sources. A concentrated vent cluster on the talus slope channels fluid through at least eight chimneys, producing a water-column plume with the highest observed concentrations of CH4 in the field. In contrast, a saddle in the topography leading up to a carbonate cap hosts broadly distributed, nearly invisible venting apparent only in its water-column signals of redox potential and dissolved gas content, including the highest observed plume H2. After normalizing H2 and CH4 to the 3He background-corrected anomaly (3HeΔ) to account for mixing and relative amount of mantle input, it appears that, while a minimum of 60% of CH4 is transported out of the system, greater than 90% of the H2 is consumed in the subsurface prior to venting. The exception to this pattern occurs in the plume originating from the area dubbed Chaff Beach, in which somewhat more than 10% of the original H2 remains, indicating that this otherwise unremarkable plume, and others like it, may represent a significant source of H2 to the deep sea.

Phase separation at mid‐ocean ridge hydrothermal systems is a widely distributed frequently occurring process. It is highly sensitive to dynamic subsurface pressure and temperature conditions and has a significant impact on chloride concentrations of hydrothermal fluid. Although vapor phases produced by phase separation are observed in a variety of hydrothermal settings, observation of conjugate brines that must be produced concurrently are more rare and the fate of subsurface brines is still not well understood. Here we use an array of in situ chloride sensors deployed at the Main Endeavor Field on the Juan de Fuca Ridge in the wake of a magmatic event to monitor the behavior of hydrothermal vent effluent with high temporal resolution. Our results provide evidence of near‐critical chloride depleted fluids within the crust up to 486 m beneath the seafloor. We estimate that a brine reservoir stored beneath the Main Endeavor Field is constrained to temperatures between 131°C and 326°C for chloride concentrations ranging from 6 to 25 Wt.% NaCl, respectively. Our data suggest that subsurface fluids and circulation pathways vary widely over spatial scales on the order of meters. Under these circumstances, simultaneous measurements of multiple fluid parameters at a high temporal resolution are essential to understanding subsurface hydrothermal processes associated with magmatic events.

Based on the results of petrological studies of four complexes in the vicinity of the regional faults of the Yenisey Ridge it can be shown that a Neoproterozoic medium-pressure metamorphism at c. 850 Ma overprinted regionally metamorphosed andalusite-bearing rocks of low pressures. The medium-pressure metamorphism was characterized by (1) the development of deformational structures and kyanitebearing blastomylonites after andalusite-bearing rocks; (2) insignificant observed thickness of the zone of mediumpressure metamorphism (from 2.5 to 6-8 km), which was localized in the vicinity of the overthrusts; (3) a low geothermal gradient during metamorphism (from 1-7 to 12°C/km); and (4) a gradual increase in lithostatic pressure towards the thrust faults. These specific features are typical of collision metamorphism during overthrusting of continental blocks and are evidence of nearly isothermal loading in accordance with the transient emplacement of thrust sheet. The proposed model for tectono-metamorphic evolution of the study areas within a framework of crustal thickening at high thrusting rates and subsequent rapid tectonic exhumation, explain these features associated with this tectonic phenomenon. The data obtained allowed us to consider a medium-pressure rocks as a product of collision metamorphism, which were formed both by thrusting of rock blocks from Siberian craton onto the Yenisey Ridge in the zones of regional deep faults and by opposite movements in the zone of splay faults of higher orders. Volatiles in the Loki’s Castle and Jan Mayen vent fields of the ultra-slow spreading Knipovich and Mohns Ridges M.D. LILLEY*, R.B. PEDERSEN, I.H. THORSETH, J.E. LUPTON E.J. OLSON, G.L. FRÜH-GREEN AND T. BAUMBERGER School of Oceanography, University of Washington, Seattle, WA 98195, USA (*correspondence: lilley@u.washington.edu) Centre for Geobiology, University of Bergen, 5007 Bergen, Norway (rolf.pedersen@geo.uib.no) NOAA Pacific Marine Environmental Laboratory, Newport, OR 97365 USA (john.e.lupton@noaa.gov) ETH Zurich, Department of Earth Sciences, 8092 Zurich, Switzerland (frueh-green@erdw.ethz.ch)

A unique dataset from paired low- and high-temperature vents at 9°50′N East Pacific Rise provides insight into the microbiological activity in low-temperature diffuse fluids. The stable carbon isotopic composition of CH4 and CO2 in 9°50′N hydrothermal fluids indicates microbial methane production, perhaps coupled with microbial methane consumption. Diffuse fluids are depleted in 13C by ∼10‰ in values of δ13C of CH4, and by ∼0.55‰ in values of δ13C of CO2, relative to the values of the high-temperature source fluid (δ13C of CH4=−20.1±1.2‰, δ13C of CO2=−4.08±0.15‰). Mixing of seawater or thermogenic sources cannot account for the depletions in 13C of both CH4 and CO2 at diffuse vents relative to adjacent high-temperature vents. The substrate utilization and 13C fractionation associated with the microbiological processes of methanogenesis and methane oxidation can explain observed steady-state CH4 and CO2 concentrations and carbon isotopic compositions. A mass-isotope numerical box model of these paired vent systems is consistent with the hypothesis that microbial methane cycling is active at diffuse vents at 9°50′N. The detectable 13C modification of fluid geochemistry by microbial metabolisms may provide a useful tool for detecting active methanogenesis.

The ability to continuously monitor chemical properties of hydrothermal vent effluents for extended periods of time is essential to understanding dynamic processes responsible for the temporally variable nature of mid-ocean ridge hydrothermal systems. Although instruments do exist for some parameters, there has been no sensor capable of measuring the chloride concentration, an indicator of possible phase separation, on a real-time and long-term basis. In this article, we discuss the construction of a novel instrument which measures solution resistance as a proxy for chloride concentration. The sensor consists of four gold electrodes embedded in a cylindrical ZrO2 ceramic housing. It has been successfully deployed in several high temperature vents at the Main Endeavour Field (MEF) on the Juan de Fuca ridge in the NE Pacific, and calibrated under simulated hydrothermal conditions ranging up to 380°C and 300bar. The in situ data clearly demonstrate a tidal influence on the effluent from some high temperature vents possibly relating to a subsurface mixing process involving non-seawater end-members. Non-tidal changes are used to constrain the sequence and type of controls operating on fluids circulating within the subsurface.

We report here the first compositional data for fluids from the Sea Cliff hydrothermal field, northern Gorda Ridge, collected in 2000, 2002, and 2004. An unusual aspect of this site is its location ∼2.6 km east of the axis of spreading, leading to speculation since its discovery in 1988 that this may be an “older” hydrothermal field, as it occurs on crust that the spreading rate would predict to be ∼100,000 years old. Our results suggest this hydrothermal system is being driven by subsurface magma, as evidenced by (1) elevated 3He/heat ratios, (2) relatively high concentrations of He, and (3) chloride contents less than seawater in the hydrothermal fluids. The measured fluid temperatures were ≤308°C, but we infer they were >400°C at depth. In spite of these elevated temperatures, the fluids exiting from these vents are clear, a consequence of extremely low transition metal concentrations. We attribute the low transition metal contents to loss of these metals below the seafloor, most likely as a result of the slightly elevated pH of the fluids. Neither the fluid compositions nor the setting provides evidence that buried sediments and/or organic matter are responsible for raising the fluid pH. Our favored explanation for the elevated pH is that calcite, deposited as a vein‐filling mineral at this site, perhaps when it was closer to the axis and a hydrothermal downflow zone, is currently being dissolved by the hydrothermal fluids. This hypothesis is supported by our geochemical modeling results that suggest the fluids are close to saturation with calcite at in situ conditions. Elevated fluid pH is observed at a number of hydrothermal sites on the global mid‐ocean ridge system, and the reason for this has not been well understood. Dissolution of previously deposited calcite may be a heretofore unrecognized mechanism that can explain these observations. Finally, our data suggest the compositions of these fluids are unchanged from 2002 to 2004 and are consistent with water column observations first made at this site in 1985. We therefore interpret the Sea Cliff site to be another hydrothermal area marked by long‐term stability in fluid compositions and temperatures.

The composition and temperature of vent fluids sampled from the active hydrothermal system in Escanaba Trough, Gorda Ridge in 2000 and 2002 remain unchanged from the only time this field was previously sampled, in 1988. ODP Leg 169 drilled nine bore holes at this site in 1996, some within meters of the vents, yet this disturbance has not impacted the measured compositions or temperatures of the fluids exiting at the seafloor. The fluids have maximum measured temperatures of 218°C and contain ∼20% more chloride than local ambient seawater. Our interpretation is that the fluid compositions are generated by supercritical phase separation of seawater, with much of the water-rock reaction occurring within the ∼400m thick sedimentary section that overlies the basalt at this site. The ODP drilling results provide information on the mineralogy and composition of materials below the seafloor, as well as direct constraints not typically available on the physical conditions occurring below the seafloor hydrothermal system. Calculations utilizing geochemical modeling software suggest the fluids are close to saturation with a suite of minerals found subsurface, suggesting equilibrium between the fluids and substrate. These results provide an explanation for why the fluids have remained chemically stable for 14 yrs. The pore water data from drilling suggest that the hydrology and chemistry of the hydrothermal system are much more complex within the sediment cover than would be expected from the surface manifestations of the hydrothermal system. While the pore waters have chloride contents both greater and less than the local seawater, only fluids with higher chloride contents vent at the seafloor. Our calculations suggest that at the current conditions the “brines” (fluids with chlorinity greater than seawater) are actually less dense than the “vapors” (fluids with chlorinity less than seawater). These density relationships may provide an explanation for why the “brines” are now venting preferentially to the “vapors,” a situation opposite to what is usually observed or inferred.

The serpentinite-hosted Lost City hydrothermal field is a remarkable submarine ecosystem in which geological, chemical, and biological processes are intimately interlinked. Reactions between seawater and upper mantle peridotite produce methane- and hydrogen-rich fluids, with temperatures ranging from <40° to 90°C at pH 9 to 11, and carbonate chimneys 30 to 60 meters tall. A low diversity of microorganisms related to methane-cycling Archaea thrive in the warm porous interiors of the edifices. Macrofaunal communities show a degree of species diversity at least as high as that of black smoker vent sites along the Mid-Atlantic Ridge, but they lack the high biomasses of chemosynthetic organisms that are typical of volcanically driven systems.