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Sly syndrome

Mucopolysaccharidosis Type VII or Sly syndrome (named after its discoverer William Sly in 1969) is also sometimes called MPS. The defective gene lies on chromosome 7. MPS is transmitted as an autosomal recessive trait. more...

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It is an extremely rare inherited metabolic disorder characterized by a deficiency of the enzyme β-glucuronidase, a lysosomal enzyme. Sly syndrome belongs to a group of disorders known as the mucopolysaccharidoses, which are lysosomal storage diseases. In Sly syndrome, the deficiency in β-glucuronidase leads to the accumulation of certain complex carbohydrates (mucopolysaccharides) in many tissues and organs of the body.

The symptoms of Sly syndrome are similar to those of Hurler syndrome (MPS I). The symptoms include:

  • in the head, neck, and face: coarse (Hurler-like) facies and macrocephaly, frontal prominence, premature closure of sagittal lambdoid sutures, and J-shaped sella turcica
  • in the eyes: corneal opacity and iris colobmata
  • in the nose: anteverted nostrils and a depressed nostril bridge
  • in the mouth and oral areas: prominent alveolar processes and cleft palate
  • in the thorax: usually pectus carinatum or exacavatum and oar-shaped ribs; also a protruding abdomen and inguinal or umbilical hernia
  • in the extremities: talipes, an underdeveloped ilium, aseptic necrosis of femoral head, and shortness of tubular bones occurs
  • in the spine: kyphosis or scoliosis and hook-like deformities in thoracic and lumbar vertebrate
  • in the bones: dysotosis multiplex

In addition recurrent pulmonary infections occur. Hepatomegaly occurs in the gastrointestinal system. Splenomegaly occurs in the hematopoietic system. Inborn mucopolysaccharide metabolic disorders due to β-glucuronidase deficiency with granular inclusions in granulocytes occurs in the biochemical and metabolic systems. Growth and motor skills are affected, and mental retardation also occurs.

MPS type VII occurs in only 1:250,000 people.

Mucopolysaccahridosis Type VII is also known as β-glucurondinase deficiency, β-glucurondinase deficiency mucopolysaccahridosis, GUSB deficiency, mucopolysaccahride storage disease VII, MCA, and MR.

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Effect of inspiratory flow pattern and inspiratory to expiratory ratio on nonlinear elastic behavior in patients with acute lung injury
From American Journal of Respiratory and Critical Care Medicine, 3/1/03 by Edibam, Cyrus

Ventilatory modes employing different inspiratory flow patterns and inspiratory to expiratory ratios may alter lung strain in acute lung injury patients. To determine whether variations in lung strain existed between pressure-controlled, volume-controlled, and pressure-controlled inverse ratio modes of ventilation, we randomly applied each for 30 minutes in 18 acute lung injury patients, keeping tidal volume, respiratory rate, fractional inspired oxygen, and total positive end-expiratory pressure constant. After each mode, a multiple linear regression analysis of dynamic airway pressure and airflow was performed with a volume-dependent single compartment model of the equation of motion, and an index of nonlinear elastic behavior was calculated. In five additional patients, concurrent dynamic computerized axial tomography scanning at juxtadiaphragmatic and subcarinal levels was added. Although static mechanics, oxygenation, and hemodynamics were no different between pressure-controlled, volume-controlled, and pressure-controlled inverse ratio ventilation, we found significant differences in nonlinear behavior. This was least with pressure-controlled followed by volume-controlled ventilation, and pressure-controlled inverse ratio ventilation had the greatest nonlinear elastic behavior. Dynamic computerized axial tomography analysis revealed more overinflated units in the left subcarinal slice with pressure-controlled inverse ratio ventilation. Ventilator flow pattern and inspiratory to expiratory ratio independently influence lung strain in acute lung injury; however, further studies are needed to determine the biologic significance.

Keywords: acute respiratory distress syndrome; respiratory mechanics; nonlinear behavior, lung strain

Acute lung injury (ALI) results in an increase in the work of breathing and impairment of gas exchange that usually requires mechanical ventilation. However, the pathophysiology of ALI includes surfactant dysfunction, increased lung weight, and airspace collapse and consolidation, which predispose the lung to ventilation-induced lung injury (1). For example, mortality in patients with ALI is reduced by using small tidal volume (VT) ventilation (2), and protective ventilatory strategies using positive end-expiratory pressure (PEEP), recruitment maneuvers, surfactant replacement therapy, and varying VT may also reduce ventilation-induced lung injury (1). In general, these strategies aim to reduce ventilation-- induced lung injury by reducing sheer stress or lung strain (3).

The quasistatic volume-pressure curve and the static distending pressure of the respiratory system (plateau pressure [Pplat]) are the most commonly used measures of lung strain. However, the dynamic elastic distending pressure, which is composed of the static pressure, and the viscoelastic pressure will better reflect the volume-pressure relationships and end-- inspiratory pressure strain that are applied to the distal airspaces during mechanical ventilation (4, 5). The viscoelastic pressure is, in turn, composed of tissue viscance and the effects of time constant inequalities within the lung (6), which can lead to regional flow maldistribution.

When VT, PEEP, and inspiratory to expiratory ratio are constant compared with volume-controlled ventilation, pressure-controlled ventilation does not improve oxygenation or lower Pplat (7-9). In addition, when VT and total PEEP (PEEPtot) are constant, the inverse ratio ventilation at an inspiratory to expiratory ratio of 2:1 compared with 1:2 does not improve oxygenation or Pplat (7-10). However, the different inspiratory flow patterns and different inspiratory to expiratory ratios may alter the viscoelastic component of lung strain by altering the buildup of tissue resistance or the distribution of ventilation. Variation in the extent of nonlinear dynamic elastic volume-pressure behavior of the respiratory system will reflect the differences in viscoelastic strain between modes. To examine these issues, we used a volume-dependent single-compartment model to examine the extent of nonlinear dynamic volume-pressure relationships in 18 patients with ALT randomly receiving pressure-- controlled ventilation at an inspiratory to expiratory ratio of 1:2 and 2:1 (pressure-controlled inverse ratio ventilation) and volume-controlled ventilation at an inspiratory to expiratory ratio of 1:2 with PEEPtot, VT, and respiratory rate constant. To examine whether heterogeneity of regional ventilation contributed to differences in nonlinear volume-pressure behavior when these three modes of ventilation were applied, dynamic computerized axial tomography (CT) scans and dynamic volume-pressure relationships were examined in an additional five ALI patients.

METHODS

The local ethics committee approval for the study was granted (#26/ 97 and #94/01), and written informed consent was obtained from the patient's next of kin. Inclusion criteria were ALl as defined by the American European Consensus Conference criteria (11) and mechanical ventilation. Exclusion criteria were late ALI (greater than 5 days from onset), hemodynamic instability, and anticipated intolerance of transient PEEP removal. Demographic data (sex, height, and weight), Acute Physiology and Chronic Health Evaluation II score, etiologic factors, baseline ventilator settings, as set by the attending clinician before this study, and lung injury score (12) were recorded at inclusion.

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Cyrus Edibam, Albert J. Rutten, Daniel V. Collins, and Andrew D. Bersten

Department of Critical Care Medicine, Flinders Medical Centre, Bedford Park, South Australia

(Received in original form December 21, 2000; accepted in final form November 12, 2002)

Supported by the National Health and Medical Research Council (grant #980451).

Correspondence and requests for reprints should be addressed to Andrew D. Bersten, Department of Critical Care Medicine, Flinders Medical Centre, Bedford Park, South Australia, 5042. E-mail: andrew.bersten@flinders.edu.au

This article has an online supplement, which is accessible from this issue's table of contents online at www.atsjournals.org

Am J Respir Crit Care Med Vol 167. pp 702-707, 2003

DOI: 10.1164/rccm.2012110

Internet address: www.atsjournals.org

Copyright American Thoracic Society Mar 1, 2003
Provided by ProQuest Information and Learning Company. All rights Reserved

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