Trial of Sodium Phenylbutyrate-Taurursodiol for Amyotrophic Lateral Sclerosis.

BACKGROUND: Sodium phenylbutyrate and taurursodiol have been found to reduce neuronal death in experimental models. The efficacy and safety of a combination of the two compounds in persons with amyotrophic lateral sclerosis (ALS) are not known. METHODS: In this multicenter, randomized, double-blind trial, we enrolled participants with definite ALS who had had an onset of symptoms within the previous 18 months. Participants were randomly assigned in a 2:1 ratio to receive sodium phenylbutyrate-taurursodiol (3 g of sodium phenylbutyrate and 1 g of taurursodiol, administered once a day for 3 weeks and then twice a day) or placebo. The primary outcome was the rate of decline in the total score on the Amyotrophic Lateral Sclerosis Functional Rating Scale-Revised (ALSFRS-R; range, 0 to 48, with higher scores indicating better function) through 24 weeks. Secondary outcomes were the rates of decline in isometric muscle strength, plasma phosphorylated axonal neurofilament H subunit levels, and the slow vital capacity; the time to death, tracheostomy, or permanent ventilation; and the time to death, tracheostomy, permanent ventilation, or hospitalization. RESULTS: A total of 177 persons with ALS were screened for eligibility, and 137 were randomly assigned to receive sodium phenylbutyrate-taurursodiol (89 participants) or placebo (48 participants). In a modified intention-to-treat analysis, the mean rate of change in the ALSFRS-R score was -1.24 points per month with the active drug and -1.66 points per month with placebo (difference, 0.42 points per month; 95% confidence interval, 0.03 to 0.81; P = 0.03). Secondary outcomes did not differ significantly between the two groups. Adverse events with the active drug were mainly gastrointestinal. CONCLUSIONS: Sodium phenylbutyrate-taurursodiol resulted in slower functional decline than placebo as measured by the ALSFRS-R score over a period of 24 weeks. Secondary outcomes were not significantly different between the two groups. Longer and larger trials are necessary to evaluate the efficacy and safety of sodium phenylbutyrate-taurursodiol in persons with ALS. (Funded by Amylyx Pharmaceuticals and others; CENTAUR ClinicalTrials.gov number, NCT03127514.).

Titan in a Test Tube: Organic Co-crystals and Implications for Titan Mineralogy.

In this Account, we highlight recent work in the developing field of mineralogy of Saturn's moon Titan, focusing on binary co-crystals of small organic molecules. Titan has a massive inventory of organic molecules on its surface that are formed via photochemistry in the atmosphere and likely processing on the surface as well. Physical processes both in the atmosphere and on the surface can lead to molecules interacting at cryogenic temperatures. Recent laboratory work has demonstrated that co-crystals between two or more molecules can form under these conditions. In the organic-rich environment of Titan, such co-crystals are naturally occurring minerals and a critical area of research to understand the physical, chemical, and possibly even biological and prebiotic processes occurring in this alien world.With a future NASA mission, Dragonfly, slated to land on Titan in the next decade, much work is needed to understand organic mineralogy in order to properly interpret the data from this and past Titan missions, such as Cassini-Huygens. By cataloging Titan minerals and their properties, we can begin to connect these behaviors to large-scale surface features observed on Titan (labyrinth terrain, lake evaporites, karst, dunes, etc.), and possible processes leading to their formation (erosion, deposition, etc.). To date, seven co-crystals (aside from clathrates and hydrates) have been experimentally reported to form under Titan-relevant conditions, with an eighth predicted by theoretical modeling. This Account will summarize the formation and properties of these cryominerals and discuss the implications for surface processes on Titan. Enhanced thermal expansion and decreased crystal size, for example, may lead to fracturing and/or more rapid erosion of co-crystal-based deposits; density changes upon co-crystal formation may also play a role in organic diagenesis and metamorphism on Titan. Some cryominerals with stability only under certain conditions may preserve the evidence of Titan's history, such as cryovolcanic activity, ethane fluvial/pluvial exposure, and outgassing of CO2 from the interior of the moon.In this Account, we will also highlight areas of future work, such as the characterization of pure molecular solids and the search for ternary (and more complex) co-crystals. We note that on Titan, organic chemistry dominates, which gives a unique opportunity for chemists to play an even more significant role in planetary science discoveries and likewise in discoveries motivated by planetary science to inform fundamental organic and physical chemistry research.

Effect of sodium phenylbutyrate/taurursodiol on tracheostomy/ventilation-free survival and hospitalisation in amyotrophic lateral sclerosis: long-term results from the CENTAUR trial.

BACKGROUND: Coformulated sodium phenylbutyrate/taurursodiol (PB/TURSO) was shown to prolong survival and slow functional decline in amyotrophic lateral sclerosis (ALS). OBJECTIVE: Determine whether PB/TURSO prolonged tracheostomy/ventilation-free survival and/or reduced first hospitalisation in participants with ALS in the CENTAUR trial. METHODS: Adults with El Escorial Definite ALS ≤18 months from symptom onset were randomised to PB/ TURSO or placebo for 6 months. Those completing randomised treatment could enrol in an open-label extension (OLE) phase and receive PB/TURSO for ≤30 months. Times to the following individual or combined key events were compared in the originally randomised treatment groups over a period spanning trial start through July 2020 (longest postrandomisation follow-up, 35 months): death, tracheostomy, permanent assisted ventilation (PAV) and first hospitalisation. RESULTS: Risk of any key event was 47% lower in those originally randomised to PB/TURSO (n=87) versus placebo (n=48, 71% of whom received delayed-start PB/TURSO in the OLE phase) (HR=0.53; 95% CI 0.35 to 0.81; p=0.003). Risks of death or tracheostomy/PAV (HR=0.51; 95% CI 0.32 to 0.84; p=0.007) and first hospitalisation (HR=0.56; 95% CI 0.34 to 0.95; p=0.03) were also decreased in those originally randomised to PB/TURSO. CONCLUSIONS: Early PB/TURSO prolonged tracheostomy/PAV-free survival and delayed first hospitalisation in ALS. TRIAL REGISTRATION NUMBER: NCT03127514; NCT03488524.

Long-term survival of participants in the CENTAUR trial of sodium phenylbutyrate-taurursodiol in amyotrophic lateral sclerosis.

An orally administered, fixed-dose coformulation of sodium phenylbutyrate-taurursodiol (PB-TURSO) significantly slowed functional decline in a randomized, placebo-controlled, phase 2 trial in ALS (CENTAUR). Herein we report results of a long-term survival analysis of participants in CENTAUR. In CENTAUR, adults with ALS were randomized 2:1 to PB-TURSO or placebo. Participants completing the 6-month (24-week) randomized phase were eligible to receive PB-TURSO in the open-label extension. An all-cause mortality analysis (35-month maximum follow-up post-randomization) incorporated all randomized participants. Participants and site investigators were blinded to treatment assignments through the duration of follow-up of this analysis. Vital status was obtained for 135 of 137 participants originally randomized in CENTAUR. Median overall survival was 25.0 months among participants originally randomized to PB-TURSO and 18.5 months among those originally randomized to placebo (hazard ratio, 0.56; 95% confidence interval, 0.34-0.92; P = .023). Initiation of PB-TURSO treatment at baseline resulted in a 6.5-month longer median survival as compared with placebo. Combined with results from CENTAUR, these results suggest that PB-TURSO has both functional and survival benefits in ALS.

Long-term safety and efficacy of eculizumab in generalized myasthenia gravis.

INTRODUCTION: Eculizumab is effective and well tolerated in patients with antiacetylcholine receptor antibody-positive refractory generalized myasthenia gravis (gMG; REGAIN; NCT01997229). We report an interim analysis of an open-label extension of REGAIN, evaluating eculizumab's long-term safety and efficacy. METHODS: Eculizumab (1,200 mg every 2 weeks for 22.7 months [median]) was administered to 117 patients. RESULTS: The safety profile of eculizumab was consistent with REGAIN; no cases of meningococcal infection were reported during the interim analysis period. Myasthenia gravis exacerbation rate was reduced by 75% from the year before REGAIN (P < 0.0001). Improvements with eculizumab in activities of daily living, muscle strength, functional ability, and quality of life in REGAIN were maintained through 3 years; 56% of patients achieved minimal manifestations or pharmacological remission. Patients who had received placebo during REGAIN experienced rapid and sustained improvements during open-label eculizumab (P < 0.0001). DISCUSSION: These findings provide evidence for the long-term safety and sustained efficacy of eculizumab for refractory gMG. Muscle Nerve 2019.

Raman Signatures and Thermal Expansivity of Acetylene Clathrate Hydrate.

The vibrational signatures for the υ2 C≡C and υ1 symmetric C-H stretches of acetylene in cubic structure I clathrate, synthesized under ambient pressure, are reported for the first time. The most diagnostic features are at 1966 for υ2 and 3353 cm-1 for υ1, respectively, and are assigned to acetylene trapped in the large 51262 cages. In addition, the υ2 mode for acetylene occupying the small 512 cages is observed at 1972.5 cm-1, a red shift of 1.5 cm-1 from its gas phase frequency. Unit cell parameters and thermal expansion coefficients are determined via powder X-ray diffraction between 195 and 225 K and are found to be in good correlation with previous single crystal data at 143 K. The calculated density for acetylene clathrate is also reported, with values ranging from 0.985 g/cm3 at 195 K to 0.976 g/cm3 at 225 K. These results are relevant for spectral detection of acetylene-containing compounds on planetary bodies, as well as providing additional insights on the thermal behavior and physical properties of acetylene clathrate.

Humoral factors in ALS patients during disease progression.

BACKGROUND: Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease affecting upper and lower motor neurons in the CNS and leading to paralysis and death. There are currently no effective treatments for ALS due to the complexity and heterogeneity of factors involved in motor neuron degeneration. A complex of interrelated effectors have been identified in ALS, yet systemic factors indicating and/or reflecting pathological disease developments are uncertain. The purpose of the study was to identify humoral effectors as potential biomarkers during disease progression. METHODS: Thirteen clinically definite ALS patients and seven non-neurological controls enrolled in the study. Peripheral blood samples were obtained from each ALS patient and control at two visits separated by 6 months. The Revised ALS Functional Rating Scale (ALSFRS-R) was used to evaluate overall ALS-patient functional status at each visit. Eleven humoral factors were analyzed in sera. Cytokine levels (GM-CSF, IL-1ß, IL-2, IL-4, IL-5, IL-6, IL-8, IL-10, and TNF-α) were determined using the Bio-Rad Bio-Plex® Luminex 200 multiplex assay system. Nitrite, a breakdown product of NO, was quantified using a Griess Reagent System. Glutathione (GSH) concentrations were measured using a Glutathione Fluorometric Assay Kit. RESULTS: ALS patients had ALSFRS-R scores of 30.5 ± 1.9 on their first visit and 27.3 ± 2.7 on the second visit, indicating slight disease progression. Serum multiplex cytokine panels revealed statistically significant changes in IL-2, IL-5, IL-6, and IL-8 levels in ALS patients depending on disease status at each visit. Nitrite serum levels trended upwards in ALS patients while serum GSH concentrations were drastically decreased in sera from ALS patients versus controls at both visits. CONCLUSIONS: Our results demonstrated a systemic pro-inflammatory state and impaired antioxidant system in ALS patients during disease progression. Increased levels of pro-inflammatory IL-6, IL-8, and nitrite and significantly decreased endogenous antioxidant GSH levels could identify these humoral constituents as systemic biomarkers for ALS. However, systemic changes in IL-2, IL-5, and IL-6 levels determined between visits in ALS patients might indicate adaptive immune system responses dependent on current disease stage. These novel findings, showing dynamic changes in humoral effectors during disease progression, could be important for development of an effective treatment for ALS.

Propyne: Determination of Physical Properties and Unit Cell Parameters under Titan-Relevant Conditions.

With its large size, dense atmosphere, methane-based hydrological-like cycle, and diverse surface features, the Saturnian moon Titan is one of the most unique of the outer Solar System satellites. Study of the photochemically produced molecules in Titan's atmosphere is critical in order to understand the mechanics of the atmosphere and, by extension, the interactions between atmosphere, surface, and subsurface water ocean. One example is propyne vapor, a photochemically produced species in Titan's upper atmosphere expected to condense in Titan's stratosphere at lower altitudes. Propyne may also be a trace species in Titan's stratospheric co-condensed ice clouds detected by the Cassini Composite InfraRed Spectrometer. Bulk structural characterization of propyne ice is currently incomplete and is lacking in published laboratory Raman spectra and X-ray diffraction data. Here, we present a laboratory characterization of propyne ice, including the first published X-ray diffraction and Raman spectroscopy results for propyne ice.

Experimental Characterization of the Pyridine:Acetylene Co-crystal and Implications for Titan's Surface.

Titan, Saturn's largest moon, has a plethora of organic compounds in the atmosphere and on the surface that interact with each other. Cryominerals such as co-crystals may influence the geologic processes and chemical composition of Titan's surface, which in turn informs our understanding of how Titan may have evolved, how the surface is continuing to change, and the extent of Titan's habitability. Previous works have shown that a pyridine:acetylene (1:1) co-crystal forms under specific temperatures and experimental conditions; however, this has not yet been demonstrated under Titan-relevant conditions. Our work here demonstrates that the pyridine:acetylene co-crystal is stable from 90 K, Titan's average surface temperature, up to 180 K under an atmosphere of N2. In particular, the co-crystal forms via liquid-solid interactions within minutes upon mixing of the constituents at 150 K, as evidenced by distinct, new Raman bands and band shifts. X-ray diffraction (XRD) results indicate moderate anisotropic thermal expansion (about 0.5-1.1%) along the three principal axes between 90-150 K. Additionally, the co-crystal is detectable after being exposed to liquid ethane, implying stability in a residual ethane "wetting" scenario on Titan. These results suggest that the pyridine:acetylene co-crystal could form in specific geologic contexts on Titan that allow for warm environments in which liquid pyridine could persist, and as such, this cryomineral may preserve the evidence of impact, cryovolcanism, or subsurface transport in surface materials.

Low-Temperature Specific Heat Capacity of Water-Ammonia Mixtures Down to the Eutectic.

Robust thermodynamic data are essential for the development of geodynamic and geochemical models of ocean worlds. The water-ammonia system is of interest in the study of ocean worlds due to its purported abundance in the outer solar system, geological implications, and potential importance for origins of life. In support of developing new equations of state, we conducted 1 bar specific heat capacity measurements (Cp) using a differential scanning calorimeter (DSC) at low temperatures (184-314 K) and low mass fractions of ammonia (5.2-26.9 wt %) to provide novel data in the parameter space most relevant for planetary studies. This is the first known set of data with sufficient fidelity to investigate the trend of specific heat capacity with respect to temperature. The obtained Cp in the liquid phase domain above the liquidus generally increases with temperature. Deviations of our data from the currently adopted equation of state by Tillner-Roth and Friend[Tillner-Roth R.; Friend D. G.J. Phys. Chem. Ref. Data1998, 27, 63-96]. are generally negative (ranging from +1 to -10%) and larger at lower temperatures. This result suggests that suppression of the critical behavior of supercooled water (rapid increase in specific heat with decreasing temperature) by ammonia starts at a smaller concentration than that set by Tillner-Roth and Friend.[Tillner-Roth R.; Friend D. G.J. Phys. Chem. Ref. Data1998, 27, 63-96]. Cp measurements of the liquid were also obtained in the partial melting domain between the eutectic and liquidus. This novel data set will be useful in future investigations of conditions where such partial melt may exist, such as the ice shell-ocean boundary or the interiors of ocean worlds that may contain relatively large proportions of dissolved ammonia.

Reply to the 'Comment on Cage occupancy of methane clathrate hydrates in the ternary H2O-NH3-CH4 system' by S. Alavi and J. Ripmeester, Chem. Commun., 2022, 58, DOI: 10.1039/D1CC06526B.

Our recent Communication suggested that ammonia in aqueous solution may preferentially destabilize large cages in methane clathrate hydrates. A Comment favored ammonia incorporation instead, but it did not accurately describe our proposed mechanism and relied primarily on studies conducted in different chemical systems and/or which used other preparation methods.

X-linked dominant scapuloperoneal myopathy is due to a mutation in the gene encoding four-and-a-half-LIM protein 1.

Scapuloperoneal (SP) syndrome encompasses heterogeneous neuromuscular disorders characterized by weakness in the shoulder-girdle and peroneal muscles. In a large Italian-American pedigree with dominant SP myopathy (SPM) previously linked to chromosome 12q, we have mapped the disease to Xq26, and, in all of the affected individuals, we identified a missense change (c.365G-->C) in the FHL1 gene encoding four-and-a-half-LIM protein 1 (FHL1). The mutation substitutes a serine for a conserved trypophan at amino acid 122 in the second LIM domain of the protein. Western blot analyses of muscle extracts revealed FHL1 loss that paralleled disease severity. FHL1 and an isoform, FHL1C, are highly expressed in skeletal muscle and may contribute to stability of sarcomeres and sarcolemma, myofibrillary assembly, and transcriptional regulation. This is the first report, to our knowledge, of X-linked dominant SP myopathy and the first human mutation in FHL1.

Cage occupancy of methane clathrate hydrates in the ternary H2O-NH3-CH4 system.

The incorporation of ammonia inside methane clathrate hydrate is of great interest to the hydrate chemistry community. We investigated the phase behavior of methane clathrate formed from aqueous ammonia solution. Ammonia's presence decreases methane occupancy in the large cages, without definitive Raman spectroscopic evidence for its incorporation inside the structure.

An Open-Label, Prospective Study Evaluating the Clinical and Immunological Effects of Higher Dose Granulocyte Colony-Stimulating Factor in ALS.

OBJECTIVE: We evaluated the safety and tolerability of higher-dose granulocyte colony-stimulating factor (G-CSF) in patients with amyotrophic lateral sclerosis. In addition, rates of disease progression and serum G-CSF levels and other immunological and hematological markers were measured. METHODS: Three patients with advanced amyotrophic lateral sclerosis were treated with G-CSF subcutaneously at 5 µg/kg twice daily for 5 consecutive days monthly for 4-12 months. Patients were monitored for adverse effects, and disease progression was assessed with ALSFRS-R and other measures. RESULTS: Patients tolerated higher-dose G-CSF well with no serious adverse events. Adverse effects were mild to moderate with musculoskeletal pain and malaise being most often reported. No significant change in the rate of disease progression was noted for ALSFRS-R or other measures. Bone marrow progenitor cells were rapidly mobilized for a duration of approximately 9 days with transient and variable effect on cytokines. CONCLUSIONS: Higher-dose G-CSF was well tolerated in this cohort with no apparent effect on disease progression up to 1 year.

Clinical Effects of the Self-administered Subcutaneous Complement Inhibitor Zilucoplan in Patients With Moderate to Severe Generalized Myasthenia Gravis: Results of a Phase 2 Randomized, Double-Blind, Placebo-Controlled, Multicenter Clinical Trial.

Importance: Many patients with generalized myasthenia gravis (gMG) have substantial clinical disability, persistent disease burden, and adverse effects attributable to chronic immunosuppression. Therefore, there is a significant need for targeted, well-tolerated therapies with the potential to improve disease control and enhance quality of life. Objective: To evaluate the clinical effects of zilucoplan, a subcutaneously (SC) self-administered macrocyclic peptide inhibitor of complement component 5, in a broad population of patients with moderate to severe gMG. Design, Setting, and Participants: This randomized, double-blind, placebo-controlled phase 2 clinical trial at 25 study sites across North America recruited participants between December 2017 and August 2018. Fifty-seven patients were screened, of whom 12 did not meet inclusion criteria and 1 was lost to follow-up after randomization but before receiving study drug, resulting in a total of 44 acetylcholine receptor autoantibody (AChR-Ab)-positive patients with gMG with baseline Quantitative Myasthenia Gravis (QMG) scores of at least 12, regardless of treatment history. Interventions: Patients were randomized 1:1:1 to a daily SC self-injection of placebo, 0.1-mg/kg zilucoplan, or 0.3-mg/kg zilucoplan for 12 weeks. Main Outcomes and Measures: The primary and key secondary end points were the change from baseline to week 12 in QMG and MG Activities of Daily Living scores, respectively. Significance testing was prespecified at a 1-sided α of .10. Safety and tolerability were also assessed. Results: The study of 44 patients was well balanced across the 3 treatment arms with respect to key demographic and disease-specific variables. The mean age of patients across all 3 treatment groups ranged from 45.5 to 54.6 years and most patients were white (average proportions across 3 treatment groups: 78.6%-86.7%). Clinically meaningful and statistically significant improvements in primary and key secondary efficacy end points were observed. Zilucoplan at a dose of 0.3 mg/kg SC daily resulted in a mean reduction from baseline of 6.0 points in the QMG score (placebo-corrected change, -2.8; P = .05) and 3.4 points in the MG Activities of Daily Living score (placebo-corrected change, -2.3; P = .04). Clinically meaningful and statistically significant improvements were also observed in other secondary end points, the MG Composite and MG Quality-of-Life scores. Outcomes for the 0.1-mg/kg SC daily dose were also statistically significant but slower in onset and less pronounced than with the 0.3-mg/kg dose. Rescue therapy (intravenous immunoglobulin or plasma exchange) was required in 3 of 15, 1 of 15, and 0 of 14 participants in the placebo, 0.1-mg/kg zilucoplan, and 0.3-mg/kg zilucoplan arms, respectively. Zilucoplan was observed to have a favorable safety and tolerability profile. Conclusions and Relevance: Zilucoplan yielded rapid, meaningful, and sustained improvements over 12 weeks in a broad population of patients with moderate to severe AChR-Ab-positive gMG. Near-complete complement inhibition appeared superior to submaximal inhibition. The observed safety and tolerability profile of zilucoplan was favorable. Trial Registration: ClinicalTrials.gov Identifier: NCT03315130.

Mitochondrial myopathy of childhood associated with mitochondrial DNA depletion and a homozygous mutation (T77M) in the TK2 gene.

BACKGROUND: The mitochondrial DNA depletion syndrome is an autosomal recessive disorder of infancy or childhood characterized by decreased mitochondrial DNA copy number in affected tissues. Mutations in 2 genes involved in deoxyribonucleotide metabolism, the deoxyguanosine kinase gene (DGK) and the thymidine kinase 2 gene (TK2), have been related to this syndrome. OBJECTIVE: To describe 3 siblings with the myopathic form of mitochondrial DNA depletion syndrome and a homozygous mutation in the TK2 gene. PATIENTS AND METHODS: These children developed normally until 12 to 16 months of age, when they started showing difficulty walking, which rapidly progressed to severe limb weakness. They died of respiratory failure between the ages of 23 and 40 months. Histochemical and biochemical studies of respiratory chain complexes were performed in muscle biopsy specimens. The whole coding region of the TK2 gene was sequenced. RESULTS: Muscle biopsy showed ragged-red cytochrome-c oxidase-negative fibers. All affected siblings had markedly decreased activities of respiratory chain complexes. Southern blot analysis showed severe reduction of the mitochondrial DNA-nuclear DNA ratio in muscle biopsy specimens from all patients, indicating 80% to 90% mitochondrial DNA depletion. Sequencing of the TK2 gene showed a homozygous C-->T transition at nucleotide 228 in exon 5, which changes a threonine to a methionine at position 77 (T77M). CONCLUSIONS: These results document the importance of screening the TK2 gene in patients with myopathic mitochondrial DNA depletion syndrome and confirm that exon 5 is a "hot spot" for TK2 mutations.

Mitochondrial diseases.

Since the first reports of disorders associated with mitochondrial DNA (mtDNA) defects more than a decade ago, the small mtDNA circle has been a Pandora's box of pathogenic mutations associated with human diseases. The "morbidity map" of mtDNA has gone from one point mutation and a few deletions in 1988 to more than 110 point mutations as of September, 2001. Nuclear DNA defects affecting mitochondrial function and mtDNA replication and integrity have also been identified in the past few years and more are expected. As a result, human "mitochondrial" diseases have evolved beyond the novelty diagnoses of a decade ago into an important area of medicine, and thus, the diagnostic principles of these disorders ought to be familiar to the clinician. In this article, the authors, we summarize the principles of mitochondrial genetics and discuss the common phenotypes, general diagnostic approach, and possible therapeutic venues for these fascinating disorders.

Navajo neurohepatopathy is caused by a mutation in the MPV17 gene.

Navajo neurohepatopathy (NNH) is an autosomal recessive disease that is prevalent among Navajo children in the southwestern United States. The major clinical features are hepatopathy, peripheral neuropathy, corneal anesthesia and scarring, acral mutilation, cerebral leukoencephalopathy, failure to thrive, and recurrent metabolic acidosis with intercurrent infections. Infantile, childhood, and classic forms of NNH have been described. Mitochondrial DNA (mtDNA) depletion was detected in the livers of two patients, suggesting a primary defect in mtDNA maintenance. Homozygosity mapping of two families with NNH suggested linkage to chromosome 2p24. This locus includes the MPV17 gene, which, when mutated, causes a hepatocerebral form of mtDNA depletion. Sequencing of the MPV17 gene in six patients with NNH from five families revealed the homozygous R50Q mutation described elsewhere. Identification of a single missense mutation in patients with NNH confirms that the disease is probably due to a founder effect and extends the phenotypic spectrum associated with MPV17 mutations.