Loss-of-function HDAC8 mutations cause a phenotypic spectrum of Cornelia de Lange syndrome-like features, ocular hypertelorism, large fontanelle and X-linked inheritance

Cornelia de Lange syndrome (CdLS) is a multisystem genetic disorder with distinct facies, growth failure, intellectual disability, distal limb anomalies, gastrointestinal and neurological disease. Mutations in NIPBL, encoding a cohesin regulatory protein, account for >80% of cases with typical facies. Mutations in the core cohesin complex proteins, encoded by the SMC1A, SMC3 and RAD21 genes, together account for ∼5% of subjects, often with atypical CdLS features. Recently, we identified mutations in the X-linked gene HDAC8 as the cause of a small number of CdLS cases. Here, we report a cohort of 38 individuals with an emerging spectrum of features caused by HDAC8 mutations. For several individuals, the diagnosis of CdLS was not considered prior to genomic testing. Most mutations identified are missense and de novo. Many cases are heterozygous females, each with marked skewing of X-inactivation in peripheral blood DNA. We also identified eight hemizygous males who are more severely affected. The craniofacial appearance caused by HDAC8 mutations overlaps that of typical CdLS but often displays delayed anterior fontanelle closure, ocular hypertelorism, hooding of the eyelids, a broader nose and dental anomalies, which may be useful discriminating features. HDAC8 encodes the lysine deacetylase for the cohesin subunit SMC3 and analysis of the functional consequences of the missense mutations indicates that all cause a loss of enzymatic function. These data demonstrate that loss-of-function mutations in HDAC8 cause a range of overlapping human developmental phenotypes, including a phenotypically distinct subgroup of CdLS.

Medical negligence and post traumatic stress disorder (PTSD)

Post traumatic stress disorder (PTSD) is well recognised as a consequence of natural and man-made disasters, accidents and assaults. An increasing number of plaintiffs making claims for compensation alleging medical negligence complain of the symptoms of PTSD. Medical accidents such as anaesthetic awareness and stillbirths may be claimed as stressors and relatives may allege PTSD as a psychological injury following witnessing the death or suffering of a loved one. A series of cases will be presented. Many cases are entirely genuine but increasing media publicity has alerted potential plaintiffs and their legal advisers to the symptoms of PTSD which make evaluation of symptoms difficult for psychiatric experts. Psychometric tests exist to screen PTSD but research has shown that they can be falsified and it would be unwise to rely on such tests.

Identifying oral lesions associated with crack cocaine use

Dental patients who smoke crack cocaine are at higher risk for HIV infection and other medical concerns including stroke, heart failure and pulmonary hemorrhage. Four cases are reported which illustrate oral ulcers caused by crack cocaine usage.

Autonomy through androgyny

The perception of contemporary nursing as being subordinate and subservient to medicine can be compared to the role of chloroform, which in its day served the purpose intended. However, like nursing, today's anesthetic agents require greater expertise to maximize their effectiveness. As nursing enters a new era in its struggle for autonomy, androgynous approaches promise increased independent thinking, action and self-esteem. Nurses possessing these qualities can address effectively, many of the challenges today's nursing practice poses.

Schizophreniform psychosis and adrenomyeloneuropathy

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