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Prion Protein Mutation Database

Gly114Val

Allele count in gnomAD control population: 0

Cases in literature: 26

Penetrance: Incomplete/variable

Clinical presentation:

26 symptomatic and asymptomatic cases are reported in the literature to date. Of which 10 exhibited the disease phenotype and 16 are asymptomatic at time of reporting (see Table of Cases below). Seven cases are Met/Val129 heterozygote and 18 are Met/Met129 homozygotes (genotype at codon 129 for one case is not known) – where the in-phase allele is reported (n = 18), all cases are Gly114Val in cis with methionine at codon 129. The mean age of onset (n = 10) is 33.7 years (range 20 to 75 years, SD 16.5) and mean clinical duration-to-death (n = 6) is 38 months (range 24 to 60 months, SD 15.9).

The table below shows a summary of age of onset and clinical duration-to-death data, with survival analysis (Kaplan-Meier curves). Download Kaplan-Meier tables here.

AGE OF ONSET
Mutation Without censored data Survival curve including censored data
Mean+/-SD (years) n Median IQR Range n
Gly114Val 33.7 +/- 16.5 10 31.5 22-36 20-75 10
 
CLINICAL DURATION-TO-DEATH
Mutation Without censored data Survival curve including censored data
Mean+/-SD (years) n Median IQR Range n
Gly114Val 38 +/- 15.9 6 48 24-48 24-60 7

Figure: Kaplan-Meier curves for Gly114Val age of onset and clinical duration-to-death. The Kaplan-Meier curve is shown as a solid line and the 95% confidence limits are shown as dotted lines. In clinical duration graph b) censored data is shown as open circles.

a) Gly114Val-Met129 Age of Onset

b) Gly114Val-Met129 Clinical Duration to Death

The clinical course in mutant Gly114Val-Met129 is marked by behavioural change, progressive dementia, extrapyramidal features and myoclonus, and is phenotypically associated with CJD. In one Polish patient, generalised ataxia was also noted. Beside one South Indian gentleman, who presented aged 75 years, onset is early between 22 and 45 years of age. The 16 asymptomatic carriers ranged in age from 12 to 61 years at time of reporting (age of one asymptomatic carrier is not known), four of which, are older than the mean age of onset for this mutant, suggesting incomplete or variable penetrance that is not yet well characterised.

Table of Cases

Case reportCountry of originNumber of DNA-confirmed Gly114Val patientsDetails of kindred and family members studiedGenderAge at onsetDuration of illness (months)Genotype at polymorphic sitesPresentation and other clinical details
Rodriguez MM 2005 [1]Uruguay6Six members of family shown to harbour Gly114Val mutant, of which three where asymptomatic (III-7, III-9 and IV-5) and three manifest the disease phenotype (III-14, III-19 and IV 2). This family has a further two clinically affected but not genotyped members (II-1 and III-16).
The father of III-7, III-9, III-14 and III-19 (case II-8) did not carry the mutation and is it hypothesised that their mother II-6 (deceased without suggestive symptomology, age at death not given) was an asymptomatic carrier. Asymptomatic Gly114Val members III-7 and III-9 were aged 45 and 44 years, respectively at time of report.
4 F
2 M
22-2724-484 Met/Val129 (in cis allele not known)

2 Met/Met129
Presentation of disease in this family included neuropsychiatric disturbance (mood and personality), followed by dementia associated with Parkinsonism, pyramidal signs, myoclonus and mild cerebellar signs
No post-mortem was performed for any member of this family, although frontal lobe biopsy data is available. No multicentric plaques were noted.
Ye J 2008 [2]China4Second family worldwide to be described with this mutation. The index case (III-4) and the son of her cousin (IV-2) were genetically confirmed. The daughter of III-4 (case IV-10) and mother of IV-2 (case III-1) were asymptomatic carriers of mutant Gly114Val and were aged 22 and 61, respectively.3 F
1 M
45 (III-4)
32 (IV-2)
24 (III-4)

Alive 24 months from onset (IV-2)
4 Met/Met129Clinical features of index case, III-4, similar to sporadic CJD including progressive neuropsychiatric symptoms, dementia, myoclonus and pyramidal signs. Cerebellar signs were observed late but became marked.
Liu Z 2010 [3]

*See note below regarding discrepancies between this paper and that of Ye J 2008.
China11 (15)A re-report of the proband’s neuropathology (brain biopsy) and further analysis of the Han Chinese family reported by Ye J 2008. Cases III-4 (proband), IV-2, IV-10 and III-1 reported previously by Ye J 2008. This paper finds a further 11 asymptomatic members harbouring the Gly114Val mutant, who range in age from 12 to 41 years.6 F
5 M
n/an/a10 Met/Met129
1 Met/Val129 (case IV-14 and not known which is the in cis allele)
Glu219Lys in cases IV-1 and IV-5 (in cis allele not known). Others were Glu219Glu.
n/a
Beck JA 2010 [4]India (1)
Turkey (1)
275-year-old South Indian gentleman had no relevant family history of neurological disease.

No clinical information for Turkish female patient given.
1 F
1 M
34 (F)
75 (M)
Not reportedMet/Val129 (in cis allele not reported)75-year-old South Indian gentleman presented with excessive fatigue, perceived left-sided weakness and sensory disturbances of his feet. He rapidly deteriorated and experienced recurrent falls. Second patients was a 34-year-old Turkish lady – no further clinical details given
Cali I 2018 (first reported in abstract form in Mikhail F 2015) [5-6]Poland1Polish-American gentleman. Patient’s father (III-B) died at age 34 with a similar phenotype and “autopsy proven CJD”, no genetic analysis available. Apart from proband’s father (III-B) no other family member over four generations known to have a neurological disorder. Genetic testing undertaken in five asymptomatic family members – 81-year-old paternal grandmother (II-E), three of the father’s siblings aged between 40 and 59 (III-C/D/E) and the proband’s sister (IV-B) – showed that none harboured the Gly114Val mutant**.M2460Met/Met129Progressive dementia, aphasia and ataxia
Margolesky J 2018 [7]US1Proband is African American. Proband’s mother and father, aged 51 and 49, respectively, are alive and well. Her brother aged 23 is well. Her paternal and maternal grandparents reached their ninth decades f life without neurodegenerative disease. Genetic testing was only undertaken in the proband and no further family members were tested.F20Alive (duration of clinical course to date not given)Not reportedPresented with involuntary movements and cognitive decline.
Cousyn L 2019 [8]France1No known family history. Proband’s brother dies aged 25 years from a limb-girdle dystrophy; his parents both 74 years old and his maternal half-sister were neurologically intact.M3648Met/Met129Developed attention deficit leading to difficulties in work as a computer engineer. Memory loss and spatial and temporal disorientation then developed and worsened rapidly.

In the column of DNA-confirmed cases, the number in brackets represents the total number of cases contained within the report. They may not have all be counted due to cases being reported in a previous publication, the details of which will be given in the table. F, female; M, male. * This is the same family described by Ye J 2008, yet there is no reference to this paper in this report and data is presented as the first report of this family. The authors of these two papers are affiliated with the same hospital. It is of note that in the Ye J 2008 paper the proband was known to have been deceased at age 47, however, this same proband is reported contemporaneously here with no indication that she is in fact deceased. Although, the Liu Z 2010 paper identifies further asymptomatic Gly114Val members of the family, there are inconsistencies between these two papers. In Ye J 2008, the asymptomatic carrier daughter of proband (case IV-10) is said to be 22 years of age and Met/Met129 homozygous. In this paper, the age of the proband’s daughter (same IV-10 individual) is given as 17 years, and we are told she is Met/Val129 heterozygous. The original reporting of this case as Met/Met129 is the one taken into account. Furthermore, age of asymptomatic Gly114Val case, III-1 (mother of patient IV-2), was given as 61 years in Je Y 2008, and is given as 60 years in the Lui Z 2010 paper. Patient IV-2 was reported by Ye J 2008 as being 34, his age is still given as 34 in this paper. Asymptomatic carriers IV-4 and IV-5 are sisters (not twins) and are both reported as being aged 31 years. **Since the paternal grandmother (II-E) was Val/Val129 and the Gly114Val variant is allelic with Met129, the paternal grandfather would be predicted to have a Met/Val129 genotype and be a silent carrier of Gly114Val in cis with Met129 – he died without dementia aged 84 years. However, surprisingly, the genotype of the proband’s aunt (III-E) was Met/Val129 but with a normal Met129 allele. Therefore, it is suggested that either the mutation has arisen de novo in the paternal grandfather’s germline or a non-paternity event has skewed the genetics of this family.

Neurological examination and clinical investigations

  Rodriguez MM 2005 [1] Ye J 2008 [2] Beck JA 2010 [4] Cali I 2018 [5] Margolesky J 2018 [7] Cousyn L 2019 [8]
  III-14 III-19 IV-2 III-4 IV-2 Proband Proband Proband
Gender M F F F M M M F M
Age on onset (years) 27 22 22 45 32 75 24 20 36
Clinical duration to death (months) 24 24 48 24 Alive Not reported 60 Alive 48
Examination findings Corticospinal syndrome, hyperreflexia with bilateral Babinski signs, marked extrapyramidal syndrome, myoclonus and incontinence. Frontal signs. Corticospinal syndrome, hyperreflexia (plantars flexor), bilateral extrapyramidal syndrome, frontal signs, myoclonus and incontinence. Mild cerebellar signs. Marked extrapyramidal syndrome, myoclonus Corticospinal dysfunction, generalised hyperreflexia and bilateral Babinski signs, extrapyramidal signa, myoclonus. No cerebellar signs. Extrapyramidal syndrome, left-sided extensor plantar response and positive palmomental reflexes predominant on the right. Asymmetric akinetic rigid syndrome, broken pursuit eye movements, myoclonic jerks and mild apraxia Extrapyramidal syndrome with cogwheel rigidity, stooped posture and reduced arm swing, generalised ataxia and myoclonus Facial and limb myoclonic jerks, asymmetric action and postural tremor (affecting left > right arm), slow gait and decreased arm swing. Extrapyramidal syndrome, hyperreflexia and myoclonus.
Neuropsychological deficits Panic attacks, visual hallucinations, apathy and self-neglect Hallucinations, indifference, apathy, asomatognosia, dementia. Folstein score 12 months from onset 17/30 Puerility, progressive dyspraxia, tendency to mutism and restlessness. Insomnia. Generalised dementia, emotional lability, severe apathy and insomnia Progressive memory impairment and insomnia leading to inability to work. MMSE score 17/30. Cognition well preserved Progressive cognitive decline with language impairment and loss of motor skills leading to three car accidents, withdrawal and agraphia. MMSE 20/30 Paucity of spontaneous speech output, bradyphrenia, incongruent smiling facial expression, emotional lability Dysexecutive syndrome and impaired episodic memory with spatial disorientation suggestive of hippocampal dysfunction
CSF 14-3-3 protein Not performed Not performed Not performed Negative Not performed Negative Negative Not performed Negative
(total tau was increased)
EEG Diffuse cerebral damage Background 5-6 Hz activity, bilateral sporadic medium amplitude spike discharges Background activity with a theta rhythm at 6-7 Hz Background 5-6 Hz activity Not performed Not performed Grade 2 dysrhythmia Diffuse delta frequency slowing Diffuse theta activity
MR brain Not performed Moderate diffuse encephalic atrophy Diffuse cerebral atrophy Moderate diffuse atrophy. Hyperintensities on DWI in caudate nucleus, putamen and periventricular regions No obvious abnormalities on MR brain including DWI Hyperintensities in putamen and caudate nuclei bilaterally Left greater than right cortical atrophy in addition to restricted diffusion within the cortical ribbon on DWI Signal hyperintensities in the cortex and striatum bilaterally on DWI Hyperintensities of the parieto-occipital cortex on DWI associated with reduced apparent diffusion coefficient
Neuropathology Moderate spongiform change, neuronal loss, gliosis and the absence of amyloid plaque deposits, however, synaptic PrPSc deposits were seen. Not performed Not performed Neuronal loss and spongiform change, with synaptic PrP staining on immunohistochemical analysis. Not performed Not performed Diffuse spongiform degeneration with PrP plaque-like collections in basal ganglia, thalamus and cerebellar molecular layer. Not performed Moderate spongiosis, moderate gliosis. Diffuse synaptic PrP staining on immunohistochemical analysis.
Codon 129 (in cis allele) Met/Val129 (not reported) Met/Val129 (not reported) Met/Met129 (Met) Met/Met129 (Met) Met/Met129 (Met) Met/Val129
(not reported)
Met/Met129
(Met)
Not reported Met/Met129 (Met)

Genetic analysis:

c.341G>T leading to GGT-to-GTT change at codon 114, resulting in Gly114Val missense mutation.

Neuropathological studies:

Case III-14 from Rodriguez MM 20051: Moderate spongiform change, neuronal loss, gliosis and the absence of amyloid plaque deposits. PrP immunoreactivity of the synaptic type was found.

Case III-4 from Yen J 20082 (also reported in Liu Z 20103): Neuronal loss and spongiform change was seen. Deposits of PrPSc were restricted mostly to the neuronal cytoplasm, and no obvious PrPSc deposits were observed in extracellular areas. No tau pathology was seen. Three PK-resistant PrPSc bands ranging from 21 to 27 kDa were detected with predominance of monoglycosylated PrPSc (type 1).

Proband from Cali I 20185: Widespread spongiform degeneration and gliosis were most severe in the frontal, temporal and parietal cortices, and least severe in the occipital lobe and hippocampus. Severe spongiform degeneration was also present with the putamen but no globus pallidus, and within the medial nuclei of thalamus but not the lateral thalamus. The midbrain, cerebellum, pons and medulla were also free from spongiosis. Immunohistochemistry reveals fine diffuse PrP staining and occasionally larger granules within the cerebral cortex and neostriatum, as well as plaque-like (globular) PrP deposits in the putamen and cerebellum. There was intense astrogliosis in the frontal and temporal lobes.

Molecular typing of proteinase K-resistant PrP revealed a mixture of type 1 (21 kDa) and type 2 (19 kDa) conformations with only two, rather than the usual three PrPSc glycoforms5. The brain homogenate lacked the high molecular weight diglycosylated band, exhibiting only prominent monoglycosylated, and less prominent unglycosylated bands. Interestingly, a similar pattern has been reported for Pro105Ser9, CJD-associated Thr183Ala10 and Val180Ile11. Intracerebral inoculation of patient brain homogenate to CJD-susceptible transgenic mice that express human PrP-Met129 did not develop clinical or pathological signs of prion disease after nearly 700 days of observation, therefore displaying a lack of transmissibility.

Proband from Cousyn L 20198: Moderate spongiosis in most cortical areas, the caudate nucleus and the thalamus. The hippocampus was spared, contrasting with severe impairment of the entorhinal cortex. There was no confluence of the vacuoles, and gliosis was moderate. Diffuse synaptic labelling of PrP was noted by immunohistochemistry.

Structure-based protein function annotation:

Glycine 114 is located in the hydrophobic region of the N-terminal domain of PrP, participates in the highly conserved palindromic sequence, aa 113-AGAAAAGA-120 aa, and directly participates in the formation of the PrPC-PrPSc complex that leads to propagation of PrPSc, thereby, supporting the pathogenicity of the Gly114Val mutant12.

The hydrophobic region (residues 112-134, see Architecture of PrP) has a predicted high propensity for -sheet secondary structure13, thought to undergo significant structural transition following prion infection – as antibodies directed toward mouse PrP residues 90-120 detect PrPC but not PrPSc 14 – and is proposed to be involved in PrPc-PrPSc interaction, as a misfolding initiation site that effects prion propagation12,15. Indeed, cells transfected with a PrP transgene that expresses mutant PrP with a deletion of the AGAAAAGA palindrome (residues 114-121) cannot be infected with PrPSc 16, indicating the necessity of the palindrome for conformational conversion of PrPC to PrPSc. When synthesised as peptides, the PrP region comprising amino acid residues 109-122 and 106-126 has a high intrinsic ability to polymerise into amyloid-like fibrils in vitro17-18, with the internal palindromic AGAAAAGA sequence displaying the highest tendency to form amyloid18. Furthermore, peptides that include the AGAAAAGA region antagonise the in vitro conversion of PrPC to PrPSc in a cell-free conversion model, again underlining the importance of these amino acids in the PrPC-PrPSc interaction and subsequent prion propagation19-20.

In addition to the amyloidogenic palindrome, the hydrophobic core itself is glycine rich, arranged in GXXXG motifs; a frequent motif in transmembrane -helices that is reported to stabilise helix-helix associations and permit close packing of transmembrane domains21. The glycine residues in this region show perfect conservation across all mammalian species identified to date22-23. Relatively conservative amino acid substitutions of the glycine residues in this region (Gly119, Gly123, Gly126, Gly131) have been shown to diminish prion propagation and infectivity – reinforcing, the importance of the hydrophobic region in conversion of PrPC to PrPSc 24. Mouse homologue of the pathogenic Gly114Val mutation (mouse numbering: Gly113Val), leads to the formation of an altered prion strain characterised by decreased protease resistance but a higher degree of neurotoxicity25. Furthermore, the most neurotoxic deletion mutant in mice, as determined by the relative amount of wild-type expression required to rescue the phenotype, involves deletion of the hydrophobic region, however, these PrPC mutants do not form PrPSc 26-28.

Mouse homologue mutant Gly113Val, as expected, does not have an effect on the global structure, stability or dynamics of native monomeric mouse PrP29, but it has been shown to accelerate misfolding and aggregation relative to wild-type mouse PrP by inducing structure in the palindromic region29 which appears to be the site for inter-molecular association in PrP oligomers12,16,29. Valine is hydrophobic and being a C-branched residue like isoleucine and threonine, it is known to be preferentially found in -sheet structures30.

Therefore, it is possible that mutant Gly114Val, in a similar mechanism to mutant Ala117Val enhances -sheet formation in the amyloidogenic palindrome, that drives PrPSc conversion.

In silico Pathogenicity predictions:

Pon-P2 (independent)31:

  • Probability of pathogenicity: 0.672
  • Standard error: 0.062
  • Prediction: Unknown

Revel (ensemble)32:

  • Score: 0.781
  • Prediction: Pathogenic

A stringent REVEL score threshold of 0.75 is applied, above which the variant is classified as pathogenic.

References:

  1. Rodriguez MM, Peoc’h K, Haik S et al. A novel mutation (G114V) in the prion protein gene in a family with inherited prion disease. Neurology 2005; 64(8): 1455-1457. (PMID: 15851745)
  2. Ye J, Han J, Shi Q et al. Human prion disease with a G114V mutation and epidemiological studies in a Chinese family: a case series. Journal of Medical Case Reports 2008; 2: 331. (PMID: 18925969)
  3. Liu Z, Jia L, Piao Y et al. Creutzfeldt-Jakob disease with PRNP G114V mutation in a Chinese family. Acta Neurologica Scandinavica 2010; 121(6): 377-383. (PMID: 20028338)
  4. Beck JA, Poulter M, Campbell TA et al. PRNP allelic series from 19 years of prion protein gene sequencing at the MRC Prion Unit. Human Mutation 2010; 31(7): E1551-1563. (PMID: 20583301)
  5. Cali I, Mikhail F, Qin K et al. Impaired transmissibility of atypical prions from genetic CJD G114V. Neurology Genetics 2018; 4(4): e253. (PMID: 30109268)
  6. Mikhail F, Busch C, Norstrom E et al. Characterisation of the first American case of familial prion disease due to the PRNP-Gly114Val mutation (P4.103). Neurology 2015; 84(Supplement 14).
  7. Margolesky J and Saporta M. Twenty-year old African American woman with prion disease associated with the G114V PRNP variant. Neurology Genetics 2018; 4(2): e229. (PMID: 29577079)
  8. Cousyn L, Grabli D, Seilhean D et al. First European case of Creutzfeldt-Jakob disease with a PRNP G114V mutation. Cortex 2019; 117: 407-413. (PMID: 30266397)
  9. Tunnell E, Wollman R, Mallik S et al. A novel PRNP-P105L mutation associated with atypical prion disease and a rare PrPSc conformation. Neurology 2008; 71(18): 1431-1438. (PMID: 18955686)
  10. Grasbon-Frodl E, Lorenz H, Mann U et al. Loss of glycosylation associated with the T183A mutation in human prion disease. Acta Neuropathologica 2004; 108(6): 476-484. (PMID: 15558291)
  11. Chasseigneaux S, Haik S, Laffont-Proust I et al. V180I mutation of the prion protein gene associated with atypical PrPSc glycosylation. Neuroscience Letters 2006; 408(3): 165-169. (PMID: 17029785)
  12. Norstrom EM and Mastrianno JA. The AGAAAAGA palindrome in PrP is required to generate a productive PrPSc-PrPC complex that leads to prion propagation. Journal of Biological Chemistry 2005; 280(29): 27236-27243. (PMID: 15917252)
  13. Zhang J and Zhang Y. Molecular dynamic studies on 3D structures of the hydrophobic region PrP (109-136). Acta Biochemica et Biophysica Sinica 2013; 45(6): 509-519. (PMID: 23563221)
  14. Peretz D, Williamson RA, Matsunaga Y et al. A conformational transition at the N-terminus of the prion protein features in formation of the scrapie isoform. Journal of Molecular Biology 1997; 273(3): 614-622. (PMID: 9356250)
  15. Abskharon R, Wang F, Wohlkonig A et al. Structural evidence for the critical role of the prion protein hydrophobic region in forming an infectious prion. PLOS Pathogens 2019; 15(12): e1008139. (PMID: 31815959)
  16. Hölscher C, Delius H, Bürke A. Overexpression of nonconvertible PrPc delta114-121 in scpraie-infected mouse neuroblastoma cells leads to trans-dominant inhibition of wild-type PrP(Sc) accumulation. Journal of Virology 1998; 72(2): 1153-1159. (PMID: 9445012)
  17. Forloni G, Angeretti N, Chiesa R et al. Neurotoxicity of a prion protein fragment. Nature 1993; 362(6420): 543-546. (PMID: 8464494)
  18. Gasset M, Baldwin MA, Lloyd DH et al. Predicted alpha-helical regions of the prion protein when synthesised as peptides form amyloid. Proceedings of the National Academy of Sciences USA 1992; 89(22): 10940-10944. (PMID: 1438300)
  19. Brown DR. Prion Protein Peptides: Optimal Toxicity and Peptide Blockade of Toxicity. Molecular and Cellular Neuroscience 2000; 15(1): 66-78. (PMID: 10662506)
  20. Chabry J, Priola SA, Wehrly K et al. Species-independent Inhibition of Abnormal Prion Protein (PrP) Formation by a Peptide Containing a Conserved PrP Sequence. Journal of Virology 1999; 73(8): 6245-6250. (PMID: 10400714)
  21. Russ WP and Engelman DM. The GXXXG motif: a framework for transmembrane helix-helix association. Journal of Molecular Biology 2000; 296(3): 911-919. (PMID: 10677291)
  22. Wopfner F, Weidenhöfer G, Schneider R et al. Analysis of 27 mammalian and 9 avian PrPs reveals high conservation of flexible regions of the prion protein. Journal of Molecular Biology 1999; 289(5): 1163-1178. (PMID: 10373359)
  23. van Rheede T, Smolenaars MMW, Madsen O, de Jong WW. Molecular Evolution of the Mammalian Prion Protein. Molecular Biology and Evolution 2003; 20(1): 111-121. (PMID: 12519913)
  24. Harrison CF, Lawson VA, Coleman BM et al. Conservation of a glycine-rich region in the prion protein is required for uptake of prion infectivity. Journal of Biological Chemistry 2010; 285(26): 20213-20223. (PMID: 20356832)
  25. Coleman BM, Harrison CF, Guo B et al. Pathogenic mutations within the hydrophobic domain of the prion protein lead to the formation of protease-sensitive prion species with increased lethality. Journal of Virology 2014; 88(5): 2690-2703. (PMID: 24352465)
  26. Evans EGB and Millhauser GL. Copper- and Zinc-Promoted Interdomain Structure in the Prion Protein: A mechanism for Autoinhibition of the Neurotoxic N-terminus. Progress in Molecular Biology and Translational Science 2017; 150: 35-56. (PMID: 28838668)
  27. Baumann F, Tolnay M, Brabeck C et al. Lethal recessive myelin toxicity of prion protein lacking its central domain. The EMBO Journal 2007; 26: 538-547.
  28. Li A, Christensen HM, Stewart LR et al. Neonatal lethality in transgenic mice expressing prion protein with a deletion of residues 105-125. The EMBO Journal 2007; 26: 548-558.
  29. Sabareesan AT and Udgaonkar JB. Pathogenic Mutations within the Disordered Palindromic Region of the Prion Protein Induce Structure Therein and Accelerate the Formation of Misfolded Oligomers. Journal of Molecular Biology 2016; 428: 3935-3947.
  30. Betts MJ and Russell RB. Amino acid properties and consequences of substitutions. In Bioinformatics for Geneticists. Barnes MR, Gray IC eds. Wiley 2003.
  31. Niroula A, Urolagin S, Vihinen M. PON-P2: Prediction Method for Fast and Reliable Identification of Harmful Variants. PLoS One 2015; 10(2): e0117380. (PMID: 25647319)
  32. Ioannidis NM, Rothstein JH, Pejaver V et al. REVEL: An Ensemble Method for Predicting the Pathogenicity of Rare Missense Variants. American Journal of Human Genetics 2016; 99(4): 877-885. (PMID: 27666373)