Clinical impact of genomic testing in patients with suspected monogenic kidney disease.

PURPOSE: To determine the diagnostic yield and clinical impact of exome sequencing (ES) in patients with suspected monogenic kidney disease. METHODS: We performed clinically accredited singleton ES in a prospectively ascertained cohort of 204 patients assessed in multidisciplinary renal genetics clinics at four tertiary hospitals in Melbourne, Australia. RESULTS: ES identified a molecular diagnosis in 80 (39%) patients, encompassing 35 distinct genetic disorders. Younger age at presentation was independently associated with an ES diagnosis (p < 0.001). Of those diagnosed, 31/80 (39%) had a change in their clinical diagnosis. ES diagnosis was considered to have contributed to management in 47/80 (59%), including negating the need for diagnostic renal biopsy in 10/80 (13%), changing surveillance in 35/80 (44%), and changing the treatment plan in 16/80 (20%). In cases with no change to management in the proband, the ES result had implications for the management of family members in 26/33 (79%). Cascade testing was subsequently offered to 40/80 families (50%). CONCLUSION: In this pragmatic pediatric and adult cohort with suspected monogenic kidney disease, ES had high diagnostic and clinical utility. Our findings, including predictors of positive diagnosis, can be used to guide clinical practice and health service design.

Functional Communication Training for Multiple Reinforcers: an Evaluation of Isolated Control Following a Synthesized Context.

We evaluated the effectiveness of teaching 2 functionally and topographically dissimilar communication responses within the same sessions following a functional analysis with a synthesized contingency. We also conducted stimulus-control probes to determine the extent to which communication responses and problem behavior occurred when each contingency was presented in isolation. The child in the current study acquired communicative responses for both reinforcers, and problem behavior decreased during functional communication training (FCT). Further, relevant communication responses occurred in the respective stimulus-control probes. Results are discussed in terms of implications for research and practice regarding methods for conducting FCT following functional analyses with synthesized contingencies.

Nucleophilic reactions between thiols and a tobacco specific nitrosamine metabolite, 4-hydroxy-1-(3-pyridyl)-1-butanone.

4-Hydroxy-1-(3-pyridyl)-1-butanone (HPB) is a metabolite of the tobacco specific nitrosamines, 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK) and N'-nitrosonornicotine (NNN). HPB is also a breakdown product of covalently bound pyridyloxobutyl adducts resulting from NNK and NNN exposure. HPB released from DNA or hemoglobin has been used as an important dosimeter of tobacco specific nitrosamine exposure in a variety of studies. This compound is not reactive with cellular nucleophiles under biological conditions. We have discovered that HPB reacts with nucleophiles under acidic conditions to form cyclic tetrahydrofuranyl reaction products. Dithiothreitol, 2-mercaptoethanol, and N-acetylcysteine all reacted with HPB under these reaction conditions. In addition, reactions were observed with buffer chemicals such as 4-(2-hydroxyethyl)-1-piperazineethanesulfonic acid and tris(hydroxymethyl)aminomethane. The resulting cyclic adducts were unstable at room temperature. Their half-lives were significantly longer under neutral conditions than under acidic conditions. NMR studies established that the cyclic form of HPB, 2-hydroxy-2-(3-pyridyl)-2,3,4,5-THF, is present at significant concentrations in acidic solutions. The observation of this cyclic compound suggests that the reaction with nucleophiles may occur via a cyclic oxonium ion intermediate. This reaction was significant in our biological samples; there was up to 40% conversion of [5-(3)H]HPB to cyclic DTT-derived compounds when acidic DNA repair reactions containing [5-(3)H]pyridyloxobutylated DNA were stored overnight at -20 degrees C. Therefore, long-term storage of acid hydrolysates of pyridyloxobutylated DNA or protein for the analysis of HPB-releasing adducts could result in an underestimation of HPB-releasing adduct in those samples. In addition, these observations provide a mild synthetic method to prepare large quantities of cyclic 2-(3-pyridyl)-2,3,4,5-THF adducts predicted to result from pyridyloxobutylation of important cellular nucleophiles as a result of NNK and/or NNN exposure.