Neurotherapeutics

Spinocerebellar ataxia type 3 (SCA3) is most common subtype of autosomal dominant spinocerebellar ataxia worldwide and the most prevalent CAG expansion disorder in the east Asian population, but disease-modifying therapies remain unavailable. SCA3 is caused by the accumulation of polyglutamine- (polyQ-) expanded mutant ataxin-3 (mAtxn3), while the wild-type ataxin-3 (wtAtxn3) plays an important cellular role. Thus, allele-selective clearance of mAtxn3 without affecting wtAtxn3 is highly desired for SCA3 treatment. To achieve this goal, we tested previously reported compounds that have been shown to selectively degrade the Huntingtons disease causing mutant HTT protein by tethering the expanded polyQ to the autophagosome protein LC3. Here, we demonstrated that two of these compounds, AN2 and GW5074, selectively reduced both soluble and aggregated mAtxn3 with expanded polyQ (84Q), but not wtAtxn3, in both cellular and mouse models of SCA3. Mechanistically, both compounds lowered mAtxn3 by enhancing its autophagic degradation without obvious activation of global autophagy. At the molecular level, both compounds increased mAtxn3-LC3 interaction and colocalization to enhance the allele-selectively autophagic degradation of mAtxn3. Phenotypically, both compounds rescued cell viability and ATP content of SCA3 cellular models. In SCA3 patient pluripotent stem cells (iPSCs) derived cortical neurons, both compounds allele-selectively reduced mAtxn3 and partially rescued neurite shortening. Importantly, in a well-established SCA3 transgenic mouse model (MJD84.2), intracerebroventricular, intraperitoneal, and oral administration allele-selectively reduced mAtxn3 in multiple brain regions and rescued motor function deficits. Oral dosing achieved nanomolar cerebellar exposure and showed no overt liver, kidney, or glial toxicity over 28 days. Analyses of 1303 Chinese patients with SCA3 and ATXN3 constructs of different polyglutamine lengths further supported the compounds polyQ length-dependent activity with relative sparing of normal-length ataxin-3. Together, these findings provide preclinical proof of concept that utilizing orally available small molecule compounds to allele-selectively enhance mAtxn3 autophagic degradation for SCA3 treatment. One-sentence summarySmall-molecule autophagosome-tethering compounds selectively lower mutant ataxin-3 through an LC3- and autophagy-dependent mechanism and improve disease-related phenotypes in preclinical models of SCA3.

NOS1AP is a genetically validated driver of tau pathology in Alzheimer's disease (AD), yet the NOS1AP-tau interaction itself has remained pharmacologically untargeted. We report CAPTOR-1, a first-in-class small molecule that disrupts this interaction by binding a pocket in the N-terminal region of NOS1AP (residues 1-126). A drug-resistant NOS1AP Y16A/F42A variant that retained tau binding but exhibited a 78-fold reduction in CAPTOR-1 affinity provides genetic evidence supporting an on-target mechanism. In human iPSC-derived neurons, CAPTOR-1 dose-dependently reduces endogenous NOS1AP-tau association, tau seeding activity, and pathogenic tau phosphorylation, phenocopying genetic NOS1AP knockdown; these effects extend to neurons from patients with sporadic AD. Orally dosed CAPTOR-1 crosses the blood-brain barrier and engages NOS1AP in brain dose-dependently. Chronic oral dosing rescues pathology, synaptic function, and memory in a tauopathy model (PS19) and an amyloidosis model (APP/PS1), sparing wild-type littermates in both. This work establishes pharmacological disruption of the NOS1AP-tau interaction as a viable, disease-modifying strategy for AD and positions CAPTOR-1 as a biomarker-ready chemical probe (pTau217, neurofilament light) for translational studies.

Background: Huntington's disease (HD) is an inherited neurodegenerative disorder primarily associated with motor and psychiatric manifestations. No disease-modifying treatment currently exists, with vesicular monoamine transporter type-2 inhibitors (VMAT2i's) being the only FDA-approved therapy for motor features in HD. Previous studies evaluated the antichorea effects of VMAT2i's but did not address its effects on non-choreiform features. Objectives: This study aimed to characterize the effect of VMAT2i's on hyperkinetic, hypokinetic and total hypokinetic subscores of the UHDRS motor assessment in patients with motor-manifest HD from the Enroll-HD research platform. Methods: Data from 622 participants were analyzed. Linear mixed effects models were constructed to compare the rates of change of choreiform and non-choreiform motor scores before and after the initiation of a VMAT2i. We calculated and plotted the direction, magnitude and significance of VMAT2i administration on the rates of change of motor subscores. A similar analysis was performed investigating the effect of antipsychotic medications on motor subscales in HD. Results: VMAT2i's reversed progression of hyperkinesis but significantly increased the rates of change in the hypokinetic and total hypokinetic subscores. Antipsychotics also displayed efficacy in reversing progression of chorea but did not significantly influence progression of hypokinesis. Conclusions: The initiation of VMAT2i's was associated with an improvement in hyperkinesis but was associated with worsening of other motor features of HD. Hypokinesis increases progressively in HD and is correlated with functional impairment and global decline. Therefore, the use of VMAT2i's to treat motor features in HD should be a nuanced decision, considering its multipronged impact.

TBR1 haploinsufficiency causes a neurodevelopmental disorder associated with intellectual disability and autistic features, but the therapeutic potential of postnatal gene replacement remains incompletely defined. Here, we evaluated adeno associated virus (AAV) mediated human TBR1 replacement in Tbr1 haploinsufficient mice. A single retroorbital injection of AAV.PHP.eB expressing human TBR1 under the human synapsin promoter was administered at postnatal day 3 at a dose of 2 E11 vector genomes. Compared with control vector treated mutants, treated mice exhibited increased TBR1 protein abundance and TBR1, CTIP2, and parvalbumin positive cell counts in selected brain regions. Treatment improved sociability, social transmission of food preference, and buried food seeking. Electroencephalographic (EEG) recordings showed attenuation of elevated relative theta power and improved theta suppression and gamma enhancement during social interaction. However, anterior commissure abnormalities persisted, correction of other EEG abnormalities was incomplete, and sleep wake proportions showed no significant treatment improvement. These findings demonstrate that neonatal TBR1 replacement improves selected behavioral and electrophysiological outcomes despite persistent anatomical abnormalities. These findings support further development of gene replacement for TBR1 haploinsufficiency and highlight EEG measures as candidate biomarkers for monitoring treatment response.

Magnetic Resonance guided High Intensity Focused Ultrasound (MRgHIFU) has been demonstrated to be a safe and effective minimally invasive therapy for essential tremor (ET). However, it is not clear whether older adults ([&ge;]70 years old) or individuals with comorbidities exhibit similar safety and efficacy. This IRB approved project collected EPIC EMR data on patients that underwent MRgHIFU at Parkview Regional Medical Center from January 2023 to November 2025. 68 patients were assessed for tremor severity using Clinical Rating Scale for Tremor (CRST), quality of life using Quality of life in ET Questionnaire (QUEST), and safety profile via reported post-procedure side effects. CRST and QUEST scores improved up to 1 year from baseline in our patient cohort and efficacies in older ([&ge;]70 years of age) and younger (<70 years of age) patients up to 3 months post MRgHIFU were not statistically different. Effects of comorbidities on CRST or QUEST scores improvements were all transient or did not affect endpoints. Older patients showed fewer total side effects at 3 months (1.17 (95% CI: 0.47-1.87) vs 0.21 (95% CI: -0.09-0.51), p=0.017) as did patients with pulmonary disease at 1 month (1.9 (95% CI: 1.6-2.2) vs 1.1 (95% CI: 0.9-1.3), p=0.036) while patients with family history of tremor showed more side effects at day 1 (1.5 (95% CI: 0.8-2.2) vs 2.5 (95% CI: 2.1-2.9), p=0.025). Age and comorbidities were not detected to adversely affect safety or efficacy following MRgHIFU in ET patients.

Neuroinflammation is increasingly recognized as a determinant of dopaminergic neuron vulnerability in Parkinson's disease, yet the receptor-level mechanisms linking microglia to disease progression remain incompletely defined. We investigated whether microglial P2Y12 receptor (P2Y12R) signalling drives neurodegeneration in experimental Parkinsonism and assessed its pharmacological tractability. Tamoxifen-inducible microglia-specific P2ry12 deletion was examined in acute and subchronic MPTP models, with receptor deletion induced before or during disease progression. Neurodegeneration, neuroinflammation, neurochemistry, and motor function were evaluated, and novel P2Y12R antagonists identified by structure-based virtual screening were characterized in vitro and following central administration in vivo. Inducible microglia-specific P2Y12R deletion reduced nigrostriatal dopaminergic neuron loss, preserved dopamine synthesis, attenuated acute and sustained neuroinflammatory responses, and improved parkinsonian motor deficits without affecting survival. Importantly, delayed receptor deletion during ongoing neurodegeneration remained protective, indicating that P2Y12R contributes to disease progression. Two novel antagonists exhibited functional P2Y12R inhibition in vitro, and central administration of the most promising candidate recapitulated the neuroprotective phenotype observed following genetic receptor deletion. These findings identify microglial P2Y12R as a therapeutically relevant regulator of neuroinflammation and dopaminergic vulnerability and provide complementary genetic and pharmacological proof-of-concept for targeting central P2Y12R in Parkinsonism.

Background: Although opioids are frequently prescribed for refractory chronic neuropathic pain, few data are available on baseline factors that may identify individuals more likely to respond and inform individually tailored practice. Methods: This was a post hoc, exploratory analysis of individual-level data from a placebo-controlled trial of methadone for chronic neuropathic pain (NCT05235191). Baseline clinical, psychological, psychophysical and radiological variables were tested for association with 30% or more pain reduction in the methadone group. The correlation between expectation of improvement and pain reduction was examined in both groups. Results: Of the 81 participants completing the 8-week follow-up, 28 (70%) on methadone and 14 (34.1%) on placebo achieved 30% or more pain reduction. In the methadone group, responders had higher baseline expectation of improvement (median 100 [80-100] vs. 55 [50-81]; p=0.004), which correlated moderately with percentage pain reduction (rs=0.508; p<0.001). Neither finding was observed in the placebo group (p=0.211 and p=0.161, respectively), although the correlation did not differ significantly between groups (p for interaction=0.728). Other clinical, sociodemographic, psychological and psychophysical variables were not associated with response. In the subsample with peripheral neuropathic pain and structural MRI (n=37), lower left precentral cortex volume was associated with response to methadone (p=0.041), and lower right paracentral volume with response to placebo (p=0.003). Conclusions: Baseline expectation may influence treatment outcomes, supporting its inclusion as a covariate to improve the precision of treatment effect estimates in trials, and its use in clinical practice to help tailor treatment to individual patients. These exploratory findings require confirmation in larger studies.

Background: Temporary 60-day percutaneous peripheral nerve stimulation (PNS) can relieve pain in refractory occipital neuralgia (ON), but whether it alters acute healthcare utilization relative to the natural trajectory of the disease is unknown, because prior studies have lacked a concurrent comparator. Methods: We performed a secondary analysis of prospectively collected data from a tertiary interventional pain center. Adults with medically refractory ON (primary diagnosis occipital neuralgia, ICD-10-CM M54.81) who underwent 60-day occipital PNS (n = 42) were compared with concurrent patients who were clinically eligible for PNS but were denied insurance authorization and continued optimized non-PNS management (usual care; n = 63). Headache-related emergency department (ED) encounters - index (occipital neuralgia) and non-index (other headache/facial-pain diagnoses) - were ascertained over the 12 months before and after the treatment window via the electronic record and the statewide health information exchange. Patients were 1:1 propensity-matched on a priori confounders (age, sex, baseline total headache-related ED utilization, HIT-6, and baseline headache-medication use). The primary analysis was a difference-in-differences (DiD) comparison of the change in headache-related ED utilization, reported as the additive difference (Hodges-Lehmann estimate, distribution-free 95% CI) and, alongside, as a multiplicative rate ratio (RR). Results: Thirty-six matched pairs were well balanced. Baseline headache-related ED utilization was nearly identical between matched groups (6.3 vs. 6.2 visits/year). Over the following year, PNS patients' utilization fell to 2.5 while usual-care patients' rose to 6.9. The DiD was 5.0 fewer headache-related ED visits per patient (95% CI 3.0-6.0; p < 0.001), corresponding to a rate ratio of 0.36 (95% CI 0.27-0.48; p < 0.001). Results were consistent in the full sample, in covariate-adjusted models, and after excluding controls denied for incomplete conservative-therapy trials. The effect was driven by non-index headache visits. Conclusions: Relative to a concurrent, matched usual-care cohort whose headache related ED utilization rose over time, 60-day occipital PNS was associated with a substantial reduction in acute-care use, strengthening the case for a role of PNS on healthcare utilization in refractory ON.

Huntington&'s disease (HD) is characterized by progressive accumulation of mutant huntingtin (mHTT), neurodegeneration and motor dysfunction. Increasing evidence implicates impaired glymphatic function and loss of perivascular aquaporin 4 (AQP4) polarization in HD, suggesting that defective brain waste clearance may contribute to disease pathogenesis. Whether restoration of AQP4&-mediated glymphatic transport can ameliorate HD pathology remains unknown. We tested whether genetic restoration of AQP4 improves glymphatic function and HD&-associated phenotypes in heterozygous zQ175 knock-in mice. At 2 months of age, premanifest zQ175 mice received a single retro-orbital injection of BBB-penetrant AAV9&-PHP.eB encoding the AQP4 (M1 isoform). Glymphatic transport was assessed by intracisternal injection of fluorescent BSA 647 and quantification of parenchymal influx and drainage to the deep cervical lymph nodes. Perivascular AQP4 localization, mHTT aggregation, gliosis, DARPP32 immunoreactivity, CSF neurofilament light chain (NfL) and total Tau, structural brain volumes by 11.7T MRI, and motor behavior were assessed longitudinally through 12 months of age. AAV9&-PHP.eB&-AQP4 produced widespread brain expression and restored perivascular AQP4 localization in the striatum and cortex of zQ175 mice. AQP4 overexpression significantly increased glymphatic tracer influx into brain parenchyma and BSA-647 drainage to the deep cervical lymph nodes. At 12 months, AQP4 restoration reduced CSF NfL and total Tau concentrations, mHTT aggregate number and mean aggregate size, and striatal Iba1 positive microglia and GFAP-positive astrocytes (P < 0.05). AQP4 overexpression also preserved striatal DARPP32 immunoreactivity and significantly attenuated striatal atrophy measured by MRI. Female zQ175 mice showed improved balance-beam performance and locomotor activity, while effects on motor performance in males did not reach statistical significance. AQP4 overexpression attenuated body-weight loss in both sexes. No detectable structural, behavioral or body-weight abnormalities were observed following sustained AQP4 overexpression in wild-type mice. In summary, restoration of AQP4 enhances glymphatic transport and is associated with reduced proteopathic, neuroinflammatory and neurodegenerative phenotypes in zQ175 HD mice. These findings provide proof-of-concept that impaired glymphatic function is a modifiable component of HD pathology and support AQP4&-mediated restoration of brain waste clearance pathways as a potential disease-modifying therapeutic strategy.

Background. CNM-Au8, a catalytic nanocrystalline gold suspension, is proposed to support neuronal bioenergetics, but its effect on chronic lesion evolution in multiple sclerosis (MS) has not been reported. Objectives. To evaluate the effect of CNM-Au8 on chronic lesion tissue expansion (CLTE). Results. In this exploratory post hoc analysis of the VISIONARY randomised placebo-controlled trial, CLTE was quantified from serial FLAIR MRI. Fifty-five participants were included (CNM-Au8, n=40; placebo, n=15). Compared with placebo, CNM-Au8 was associated with lower lesion expansion rate (p=0.001; Cliffs =-0.58) and volume (p<0.001; Cliffs =-0.65). Conclusions. CNM-Au8 treatment was associated with substantially reduced chronic lesion tissue expansion.

We have examined how ibogaine may enhance synaptic plasticity and neural repair. Extracellular efflux analysis showed that ibogaine (3, 10 or 30 M) produced a rapid (<5 minutes) and concentration-dependent suppression of mitochondrial function and glycolysis in mouse cortical neurons. Cell-based imaging demonstrated this metabolic inhibition was preceded by an elevation of the mitochondrial membrane potential and followed by increased mitochondrial reactive oxygen species levels. Like ibogaine, which blocks potassium channels, mitochondrial Kv1.3 channel (mitoKv1.3) inhibitors produce concordant changes over a similar timeframe. Following treatment with ibogaine (3, 10 or 30 M) for 4 hours, a marked concentration-dependent rebound of energy production occurred 20 hours later suggestive of metabolic preconditioning. Indeed, proteomic profiling showed that oral ibogaine (100 mg/kg) administration to female mice produced changes in spinal cord protein abundance indicative of increasing metabolic stress from 0.25-24 hours that resolved by 72 hours. This was accompanied by activation, inhibition and reactivation of synaptic plasticity and neural repair signaling pathways at 0.25, 4-24 and 72 hours, respectively. Hence, by inducing transient metabolic stress, ibogaine may re-open a neurodevelopmental window characterized by enhanced synaptic plasticity and neural repair. Ibogaine binds with high affinity to the sigma-2 receptor. Like mitoKv1-3 inhibitors and sigma-2 receptor ligands, ibogaine transiently elevated AMP-activated protein kinase (0.25 hours) and temporally suppressed mechanistic target of rapamycin and lipid synthesis pathways (0.25-24 hours) implicated in enhanced synaptic plasticity and neural repair. These findings suggest ibogaine rewires and repairs neural circuits by a metabolic preconditioning mechanism, perhaps involving mitoKv1.3 and the sigma-2 receptor.

Non-pharmacological adjuncts are needed for chronic non-cancer pain in patients receiving long-term opioid therapy. Music listening may reduce pain, but most previous trials have used passive controls, limiting attribution of effects specifically to music. In this open-label, parallel- group, proof-of-concept randomized controlled trial, adults with chronic non-cancer pain receiving long-term opioid therapy were randomized 1:1 to four weeks of daily home-based music or audiobook listening. Analgesic outcomes included pain intensity, responder rates, quantity of pain relief, and multidimensional pain assessment; secondary outcomes included mood, quality of life, global impression of change, and safety. Of 70 participants entering the run-in period, 56 were randomized (28 per group). Adjusting for baseline pain intensity in a linear mixed-effects model, the between-group difference at end of treatment was -1.26 NRS points (95% CI -1.98 to -0.55; p<0.001; d=-0.70), favoring music. A [&ge;]30% pain-reduction criterion was met by 21.4% of participants in the music group and none in the audiobook group (p=0.023). An exploratory between-group difference in pain intensity favoring music was also observed at follow-up. Other analgesic and secondary outcomes showed no significant between-group differences, although exploratory within-group improvements in mood and health-related quality of life were observed with music. Both groups reported overall improvement in global perceived change, with ratings numerically favoring music. No intervention-related harms were observed. These findings support an analgesic benefit of music beyond the structured listening experience shared with the active comparator. Daily self-administered music listening may represent a feasible, low-cost adjunct for chronic non-cancer pain in patients receiving long-term opioid therapy.

Background and Objectives Huntington's disease is a rare neurodegenerative disease in which optimizing clinical trial design is essential. Although baseline characteristics are known to predict disease progression, the statistical efficiency gains achievable by formally integrating prognostic predictions into trial analyses have not been systematically quantified. We aimed to benchmark prognostic modeling approaches, quantify the trial efficiency gains from prognostic covariate adjustment, and deliver a ready-to-deploy framework for immediate implementation. Methods: We developed a two-step modeling pipeline using longitudinal Enroll-HD natural history data (NCT01574053) to train nine machine learning algorithms to predict disease progression across five UHDRS endpoints. For this, we used 16 predictive baseline covariates representing stage of disease (baseline score levels), disease specific (CAP, CAG length), demographics and co-medication use that could be quantified in one clinical visit. For Total Function Capacity (TFC), frequently used as a primary endpoint in clinical trials, we also devised a minimal prognostic model based on 6 covariates. Model performance was tested using the placebo arm of the GENERATION HD1 phase 3 trial (NCT03761849). Results: Models were trained on 16,398 Enroll-HD participants and tested on 260 participants from the GENERATION HD1 placebo arm. Models that take into account nonlinear relationships between the covariates showed no performance advantage over linear-based models on the test set. For TFC, a minimal six-covariate linear prognostic model performed on par with the full 16-feature model. Adjusting for the prognostic score increased the signal-to-noise ratio across different trial visits by 8-18%, raising statistical power from 80% to up to 90% at a fixed sample size, or, equivalently, reducing required sample size by 15-28% compared to unadjusted analyses (no covariate adjustment). Compared to routinely used covariate adjustments (including baseline score, age, CAG repeat length, and CAP score), adjusting for a prognostic score consistently delivered meaningful additional efficiency gains. Discussion: Prognostic covariate adjustment using a simple six-covariate linear score derived from a single baseline visit yields meaningful gains in statistical power for HD clinical trials, while remaining fully embedded within standard, regulator-accepted analysis frameworks. This approach offers a practical and immediately deployable tool to improve trial design.

Genetic loss-of-function (LoF) variants in SCN2A, a gene encoding the voltage-gated sodium channel Nav1.2, have been identified as one of the foremost monogenic causes of autism spectrum disorder (ASD). ASD encompasses a broad spectrum of behavioral phenotypes, with impaired sociability as a core characteristic. We have established Scn2a-deficient mice (Scn2agt/gt) to model Scn2a-related ASD and found that this model recapitulates social impairment, exhibiting severe social deficits. Scn2agt/gt mice exhibit neuronal hyperexcitability and a marked global reduction in potassium channel expression, which plays a crucial role in maintaining the resting membrane potential and repolarizing neurons after an action potential. Among these downregulated potassium channels, potassium voltage-gated channel subfamily A member 1 (Kv1.1) was one of the most affected. To explore whether Kv1.1 could be a potential therapeutic target in SCN2A-related ASD, we evaluated the in vivo efficacy of a genetic construct driven by the CaMKII promoter that allows for exogenous expression of human Kv1.1 (hKv1.1) in principal neurons. In Scn2agt/gt mice, we found that hKv1.1 expression normalizes neuronal hyperexcitability. Importantly, doxycycline-induced hKv1.1 expression enhances sociability in Scn2a-deficient mice without influencing social behavior in wild-type mice, and this effect was reversed upon doxycycline withdrawal. Overall, we demonstrate the successful use of an inducible AAV-mediated gene delivery system to supplement hKv1.1 expression to mitigate neuronal hyperexcitability and ameliorate social impairments in a mouse model of SCN2A-related ASD. These findings highlight the contribution of Kv1.1 to SCN2A-associated pathophysiology and its potential as a therapeutic target for severe social deficits.

Background: More than 90% of rare diseases lack an approved therapy, partly reflecting economic barriers in developing treatments for small patient populations. A common bottleneck is costly and resource-intensive hit-to-lead prioritization. Congenital contractures of the limbs and face, hypotonia, and developmental delay (CLIFAHDD) is an ultra-rare neurodevelopmental disease often caused by de novo gain-of-function variants in the sodium leak channel NALCN, with no approved treatments. Methods: We developed a cost and resource-efficient, AI-enabled translational drug discovery framework integrating phenotypic high-throughput screening (HTS), structural biology foundation models for hit-to-lead prioritization, and orthogonal experimental validation. We applied this framework for drug repurposing to identify NALCN inhibitors as therapeutic candidates for CLIFAHDD. We screened ~1,200 approved drugs using a fluorescence-based membrane potential assay in doxycycline-inducible HEK293 cells stably expressing the NALCN channelosome. Boltz-2 modeling predicted binding affinity and mode to prioritize hits. Lead repurposing candidates were selected by a multidisciplinary expert review panel. Lead candidates were evaluated using patch-clamp electrophysiology in HEK293 cells expressing wild-type or CLIFAHDD-associated NALCN variants, primary mouse hippocampal neurons, and a C. elegans NALCN gain-of-function model. Results: HTS identified 11 candidate NALCN inhibitors. Boltz-2 prioritized candidates based on predicted binding affinity and predicted binding within the NALCN pore, consistent with a direct pore-blocking mechanism. Aprepitant emerged as the lead candidate after multidisciplinary evaluation based on its predicted mechanism, pharmacologic properties, blood-brain barrier penetration, established safety profile, and regulatory approval in children and adults. Patch-clamp electrophysiology confirmed partial inhibition of NALCN-mediated sodium leak currents in HEK293 cells (IC50;=2.22 M), with comparable potency against Cav3.1 (IC50=1.63 M). In primary mouse hippocampal neurons, aprepitant reduced sodium leak currents, hyperpolarized resting membrane potential, and decreased spontaneous firing. Aprepitant rescued hyperlocomotor and dystonic phenotypes in a C. elegans gain-of-function NALCN model. There was notable concordance between AI-predicted hits, phenotypic screening hits, and experimental validation. Conclusion: These findings identify aprepitant as a lead therapeutic candidate for CLIFAHDD, and establish an AI-enabled translational drug discovery framework integrating phenotypic screening, structural modeling, and experimental validation for NALCN channelopathies. This scalable and resource-conscious strategy may accelerate hit-to-lead prioritization and drug discovery for rare and ultra-rare diseases lacking effective therapies.

Loss-of-function mutations in the GATOR1 complex (NPRL2, NPRL3, and DEPDC5) are among the most common genetic causes of epilepsy. These mutations impair amino acid-dependent regulation of mTORC1 and cause hyperactive signaling, neuronal hyperexcitability, astrocytic metabolic remodeling, seizures, and early mortality. Here, we report the development of antisense oligonucleotides (ASOs) targeting RAPTOR, an mTORC1 scaffolding subunit, to correct pathological mTORC1 hyperactivity caused by defective upstream regulation. RAPTOR-targeted ASO treatment reduced RAPTOR expression in mouse and human systems and dampened mTORC1 signaling in GATOR1-deficient models. ASO-mediated RAPTOR reduction rescued neuronal hyperexcitability, corrected astrocytic mitochondrial dysfunction, and suppressed spontaneous seizures in vivo. A single treatment significantly extended longevity across neuronal and astrocytic models of GATOR1 deficiency. Collectively, these findings establish RAPTOR-targeted ASOs as a mechanism-based therapeutic approach that durably corrects cellular and circuit-level consequences of GATOR1 deficiency. By tuning RAPTOR abundance, this strategy provides a therapeutic framework for mTORC1-driven epilepsies and related diseases.

Background: Parkinson's disease is a progressive neurodegenerative condition, often associated with motor complications, neuropsychiatric symptoms, and increased care costs in advanced stages. Neuromodulation, especially deep brain stimulation, represents a therapeutic alternative for selected patients. Objective: To characterize the clinical, epidemiological, therapeutic, and economic profile of patients with Parkinson's disease followed at a tertiary center and to estimate the proportion of individuals eligible for neuromodulation. Methods: A cross-sectional descriptive study included 4,060 patients with idiopathic Parkinson disease followed from January 2022 to December 2025. Demographic data, clinical characteristics, functional scales, therapeutic regimen, eligibility criteria for neuromodulation, and cost-effectiveness estimates were analyzed. Comparisons with data from the literature were performed using appropriate statistical tests, considering a significance of p<0.05. Results: The sample was predominantly male, with a median age of 69 years, and a median time of evolution of 8 years. Motor complications occurred in 58.4% of the patients, a frequency higher than that described in general populations. In all, 893 patients were considered eligible for neuromodulation, corresponding to 22.0% of the sample. The economic analysis estimated a reduction in annual costs after neuromodulation, with an average saving of R$ 8,247 per patient/year and an incremental cost-effectiveness ratio of R$ 46,505 per QALY. Conclusion: The study population presented a clinical profile compatible with advanced Parkinson's disease, a high frequency of motor complications and a significant proportion of patients potentially eligible for neuromodulation. The data suggest a possible clinical and economic benefit of the structured incorporation of this therapeutic strategy.

Neuropathic pain involves spinal microglial activation and metabolic changes.Forsythoside B (FB) has anti-inflammatory effects, but its role in neuropathic pain and microglial glycolysis remains unclear. We investigated the effects and mechanisms of FB in mice with chronic constriction injury (CCI) and in LPS-stimulated BV2 microglia.FB reduced mechanical allodynia and thermal hyperalgesia in CCI mice. FB also reduced the spinal levels of HIF-1, HK2, PKM2, LDHA, and CD86. It decreased the proportion of IBA1+/CD86+ cells and the levels of IL-1{beta}, IL-6, and TNF-. In LPS20 stimulated BV2 microglia, FB reduced glycolysis-related proteins, proinflammatory markers, and cytokine release. FB also reduced glycolytic activity and partly restored basal mitochondrial respiration. FB did not change Hif1a mRNA levels. However, it Manuscript Click here to access/download;Manuscript;Manuscript.docx increased HIF-1 ubiquitination and promoted its proteasome-dependent degradation. HIF-1 overexpression partly reversed the effects of FB on glycolytic enzymes, CD86 expression, and proinflammatory cytokine production. Immunoprecipitation followed by mass spectrometry and UbiBrowser analysis identified USP7 as a candidate HIF27 1-associated deubiquitinase. Molecular docking and cellular thermal shift assays supported a possible interaction between FB and USP7. FB reduced the association between USP7 and HIF-1. USP7 knockdown produced effects similar to those of FB on HIF-1 ubiquitination and downstream glycolytic and inflammatory responses.Overall, FB alleviated neuropathic pain and reduced proinflammatory microglial responses. These effects may involve the promotion of HIF-1 degradation through modulation of the USP7-HIF-1 regulatory axis.

Huntington disease (HD) is a fatal, neurodegenerative disorder driven by a CAG trinucleotide repeat expansion in the huntingtin (HTT) gene, resulting in neuronal toxicity and brain atrophy, initially in the most vulnerable brain region striatum and expanding to the cortex and other brain regions along disease progression. While cell-autonomous mechanisms within neurons have been extensively characterized, how brain waste clearance pathways at the brain's borders change during disease progression remains poorly understood. In this study, we investigated the structural and functional adaptations of border-associated macrophages (BAMs) in the zQ175DN knock-in mouse model of HD. Immunohistochemical analysis revealed an age-dependent, selective reduction in the CD206 Lyve1 subset of leptomeningeal BAMs in 16-month-old zQ175DN mice, which tightly correlated with a profound impairment in cerebrospinal fluid (CSF) flow velocity and perivascular influx. To determine whether BAMs actively drives this CSF flow, we selectively depleted these populations of macrophages in 10-month-old zQ175DN mice via intracerebroventricular (i.c.v.) injection of clodronate liposomes (CLO). Chemical ablation of BAMs significantly exacerbated global CSF dynamic impairment, indicted by decreasing CSF fluorescent tracer distribution across perivascular parenchymal channels. Crucially, this CSF flow failure resulted in a marked accumulation of extranuclear mutant huntingtin (mHTT) aggregates in the zQ175DN HD mouse brain, while intranuclear inclusions were not significantly altered. Furthermore, BAMs depletion did not alter microglial or astrocytic gliosis in the brain, demonstrating that the exacerbation of mHTT load is a byproduct of brain waste clearance dysfunction. Together, our results indicate that BAMs are non-redundant regulators of CSF flow dynamics at the brain borders, offering a unique non-neuronal therapeutic target to combat HD.

Background: To determine the crude and age-adjusted point prevalence of motor neuron disease (MND) and its phenotypes (classical amyotrophic lateral sclerosis [ALS], primary lateral sclerosis [PLS] and progressive muscular atrophy [PMA]) using a comprehensive multi-source case ascertainment strategy. Methods: Cross-sectional population-based study with a prevalence date of 1 January 2025. Cases were identified through five complementary regional data sources and confirmed by clinical review against the revised El Escorial and Gold Coast criteria. Cases were classified by phenotype as ALS, PLS or PMA. The reference population was the population aged 15 years or older in Valencian Community (n=4,433,999). Crude prevalence was calculated per 100,000 with 95% Poisson confidence intervals; age-adjusted rates were obtained by direct standardisation to the 2013 European Standard Population. Results: A total of 374 confirmed MND cases were identified. The overall crude prevalence of MND was 8.43 per 100,000 (95% CI: 7.60-9.29) and the age-adjusted prevalence was 7.85 per 100,000 (95% CI: 7.05-8.65). By phenotype, ALS accounted for 325 cases (86.9%; crude prevalence 7.33 per 100,000), PLS for 26 (7.0%; 0.59 per 100,000) and PMA for 23 (6.1%; 0.52 per 100,000). Prevalence was consistent across provinces. Mean age was 65.9 years, the male-to-female ratio was 1.37:1, and 83.4% were receiving riluzole. Conclusions: This is the first comprehensive, multi-source population-based estimate of MND prevalence and its subtypes in the Valencian Community. The estimate is higher than the previous single-unit figure and consistent with recent European data, underscoring the value of multi-source ascertainment.