Peter A E Sillevis Smitt

Erasmus MC, Rotterdam, South Holland, Netherlands

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Publications (121)566.96 Total impact

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    ABSTRACT: To determine sensitivity and specificity of a standardized recombinant cell-based indirect immunofluorescence assay (RC-IFA) for anti-Tr antibodies in comparison to a reference procedure. Delta/Notch-like epidermal growth factor-related receptor (DNER) was expressed in HEK293 and used as a substrate for RC-IFA. HEK293 control cells expressing CDR2/Yo and CDR2L as well as mock-transfected HEK293 cells were used as controls. Serum samples from 38 patients with anti-Tr antibodies (33 with paraneoplastic cerebellar degeneration [PCD] and Hodgkin lymphoma), 66 patients with anti-Tr-negative PCD, 53 patients with Hodgkin lymphoma without neurologic symptoms, 40 patients with rheumatic diseases, and 42 healthy blood donors were tested for anti-DNER reactivity in the RC-IFA. In addition, RC-IFA results were compared to those from a commercial tissue-based IFA using monkey cerebellum. Using the RC-IFA, anti-DNER was detected in all anti-Tr-positive patients but in none of the controls (sensitivity 100%, 95% confidence interval [CI] 92.8%-100%; specificity 100%, 95% CI 98.7%-100%). In comparison, anti-Tr was not detected in 4 samples with low-titer autoantibodies using the commercial tissue-based assay. Preadsorption of sera with either recombinant full-length DNER or its extracellular domain selectively abolished anti-Tr reactivity. Anti-Tr antibodies bind to the extracellular domain of DNER and can be detected by RC-IFA using HEK293 cells expressing the recombinant receptor. The new method performs better than a frequently used commercial tissue-based indirect immunofluorescence assay (IFA) in samples with low-titer antibodies. This study provides Class II evidence that RC-IFA accurately detects anti-Tr as compared to conventional IFA.
    04/2015; 2(2):e68. DOI:10.1212/NXI.0000000000000068
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    ABSTRACT: Multiple sclerosis (MScl) frequently remits during 3rd trimester of pregnancy but exacerbates in the first postpartum period. In this context, we investigated protein identification, its abundance and its change in urine related to these two periods. Using mass spectrometry (LTQ Orbitrap), we identified 1699 tryptic peptides (related to 402 proteins) in urine from 31 MScl and 8 control at these two periods. Pregnancy related peptides were significantly elevated (p<0.01) in MScl patients compared to controls (Analysis 1; 531 peptides in MScl and 36 peptides in controls higher abundant in the 3rd trimester compared to postpartum). When comparing the longitudinal differences (Analysis 2), we identified 43 (related to 35 proteins) MScl disease associated peptides (p<0.01) with increased or decreased difference ratio in MScl compared to controls. The most discriminative peptides identified were trefoil factor 3 and lysosomal associated membrane protein-2. Both proteins have a role in the innate immune system. Three proteins with a significant decreased ratio were plasma glutamate carboxypeptidase, Ig mu chain C region, osteoclast associated immune like receptor. Our results indicate that the protein expression pattern in urine of MScl patients contains information about remote CNS and brain disease processes.
    Journal of Proteome Research 03/2015; 14(5). DOI:10.1021/pr501162w · 5.00 Impact Factor
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    ABSTRACT: Increased levels of pregnancy zone protein (PZP) were found in the serum of persons who later developed Alzheimer's disease (AD) in comparison to controls who remained dementia free. We suggested that this increase is due to brain derived PZP entering the blood stream during the early phase of the disease. Here we investigate the possible involvement of PZP in human AD pathogenesis. We observed increased PZP immunoreactivity in AD postmortem brain cortex compared to non-demented controls. In the AD cortex, PZP immunoreactivity localized to microglial cells that interacted with senile plaques and was occasionally observed in neurons. Our data link the finding of elevated serum PZP levels with the characteristic AD pathology and identify PZP as a novel component in AD.
    Journal of Alzheimer's disease: JAD 03/2015; 46(1). DOI:10.3233/JAD-131628 · 4.15 Impact Factor
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    ABSTRACT: Causal genetic changes in oligodendrogliomas (OD) with 1p/19q co-deletion include mutations in IDH1, IDH2, CIC, FUBP1, TERT promoter and NOTCH1. However, it is generally assumed that more somatic mutations are required for tumorigenesis. This study aimed to establish whether genes mutated at low frequency can be involved in OD initiation and/or progression. We performed whole-genome sequencing on three anaplastic ODs with 1p/19q co-deletion. To estimate mutation frequency, we performed targeted resequencing on an additional 39 ODs. Whole-genome sequencing identified a total of 55 coding mutations (range 8-32 mutations per tumor), including known abnormalities in IDH1, IDH2, CIC and FUBP1. We also identified mutations in genes, most of which were previously not implicated in ODs. Targeted resequencing on 39 additional ODs confirmed that these genes are mutated at low frequency. Most of the mutations identified were predicted to have a deleterious functional effect. Functional analysis on a subset of these genes (e.g. NTN4 and MAGEH1) showed that the mutation affects the subcellular localization of the protein (n = 2/12). In addition, HOG cells stably expressing mutant GDI1 or XPO7 showed altered cell proliferation compared to those expressing wildtype constructs. Similarly, HOG cells expressing mutant SASH3 or GDI1 showed altered migration. The significantly higher rate of predicted deleterious mutations, the changes in subcellular localization and the effects on proliferation and/or migration indicate that many of these genes functionally may contribute to gliomagenesis and/or progression. These low-frequency genes and their affected pathways may provide new treatment targets for this tumor type.
    Journal of Neuro-Oncology 02/2015; 122(3). DOI:10.1007/s11060-015-1741-1 · 2.79 Impact Factor
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    ABSTRACT: We treated patients with newly diagnosed and large low-grade oligodendroglial tumors with upfront procarbazine, CCNU and vincristine (PCV) in order to delay radiotherapy. Patients were treated with PCV for a maximum of 6 cycles. The response to treatment was defined according to the RANO criteria; in addition change over time of mean tumor diameters (growth kinetics) was calculated. Thirty-two patients were treated between 1998 and 2006, 18 of which were diagnosed with 1p/19q co-deleted tumors. Median follow-up duration was 8 years (range 0.5-13 years). The median overall survival (mOS) was 120 months and the median progression-free survival (mPFS) was 46 months. Growth kinetics showed an ongoing decrease of the mean tumor diameter after completion of chemotherapy, during a median time of 35 months, but an increase of the mean tumor diameter did not herald progression as detected by RANO criteria. 1p/19q co-deletion was associated with a significant increase in OS (mOS 83 months versus not reached for codeleted tumors; p = 0.003)) and PFS (mPFS 35 months versus 67 months for codeleted tumors; p = 0.024). Patients with combined 1p/19q loss had a 10 year PFS of 34 % and the radiotherapy in these patients was postponed for a median period of more than 6 years. This long-term follow-up study indicates that upfront PCV chemotherapy is associated with long PFS and OS and delays radiotherapy for a considerable period of time in patients with low-grade oligodendroglial tumors, in particular with combined 1p/19q loss.
    Journal of Neuro-Oncology 10/2014; 16(suppl 5). DOI:10.1007/s11060-014-1641-9 · 2.79 Impact Factor
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    ABSTRACT: Validated biomarkers for patients suffering from gliomas are urgently needed for standardizing measurements of the effects of treatment in daily clinical practice and trials. Circulating body fluids offer easily accessible sources for such markers. This review highlights various categories of tumor-associated circulating biomarkers identified in blood and cerebrospinal fluid of glioma patients, including circulating tumor cells, exosomes, nucleic acids, proteins, and oncometabolites. The validation and potential clinical utility of these biomarkers is briefly discussed. Although many candidate circulating protein biomarkers were reported, none of these have reached the required validation to be introduced for clinical practice. Recent developments in tracing circulating tumor cells and their derivatives as exosomes and circulating nuclear acids may become more successful in providing useful biomarkers. It is to be expected that current technical developments will contribute to the finding and validation of circulating biomarkers.
    Neuro-Oncology 09/2014; DOI:10.1093/neuonc/nou207 · 5.29 Impact Factor
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    ABSTRACT: INTRODUCTION: To assess the effects of bevacizumab (BEV) in recurrent GBMs, a three-arm randomized phase II study was initiated (the BELOB trial) comparing BEV monotherapy, CCNU monotherapy and BEV + CCNU combinationtherapy. Primary endpoint was 9 months OS and was 38% [25,51], 43% [29,57] and 59% [43,72] in the BEV, lomustine and combination arms respectively. The BELOB trial results therefore provide evidence for clinical efficacy of BEV, at least in a recurrent GBM setting and when given in combination with lomustine. However, not all patients in this trial appeared to benefit equally from the combination treatment. In this study, we therefore aimed to identify patients that benefit from BEV. METHODS: RNA expression profiling was performed using DASL (Illumina, n = 118) and RNA sequencing (n = 78) of samples. RESULTS: The DASL and RNA-seq platform both show a high concordance between technical and biological replicates and with expression profiling on snap frozen tissue samples. Sample assignment to one of seven ‘intrinsic glioma subtypes’ (IGS; molecular subtypes of glioma based on similarities in gene-expression profiles [PMID: 19920198]) was also highly similar between the different platforms. Analysis of BELOB samples shows that most are assigned to poor prognostic subtypes (IGS-18 "EGFR-amplified, classical" n = 73 and IGS-23 "mesenchymal" n = 28). Nine patients were assigned to prognostically more favourable subtypes (IGS-9 and IGS-17), but these do not explain the more favourable outcome in the BEV + CCNU arm. Patients with tumors assigned to IGS-18 show benefit from combined treatment with bevacizumab + CCNU. In contrast, tumors assigned to IGS-23 may have worse performance in this arm, though patient numbers are small. CONCLUSIONS: DASL and RNA-seq perform well on RNA isolated from FFPE tissues stored (up to 20 years) in paraffin. Specific molecular subtypes of recurrent GBM show benefit from BEV + CCNU treatment.
    Neuro-Oncology 07/2014; 16 Suppl 3(suppl 5):iii8-iii9. DOI:10.1093/neuonc/nou206.29 · 5.29 Impact Factor
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    ABSTRACT: Late diagnosis of lung cancer is still the main reason for high mortality rates in lung cancer. Lung cancer is a heterogeneous disease which induces an immune response to different tumor antigens. Several methods for searching autoantibodies have been described that are based on known purified antigen panels. The aim of our study is to find evidence that parts of the antigen-binding-domain of antibodies are shared among lung cancer patients. This was investigated by a novel approach based on sequencing antigen-binding-fragments (Fab) of immunoglobulins using proteomic techniques without the need of previously known antigen panels. From serum of 93 participants of the NELSON trial IgG was isolated and subsequently digested into Fab and Fc. Fab was purified from the digested mixture by SDS-PAGE. The Fab containing gel-bands were excised, tryptic digested and measured on a nano-LC-Orbitrap-Mass-spectrometry system. Multivariate analysis of the mass spectrometry data by linear canonical discriminant analysis combined with stepwise logistic regression resulted in a 12-antibody-peptide model which was able to distinguish lung cancer patients from controls in a high risk population with a sensitivity of 84% and specificity of 90%. With our Fab-purification combined Orbitrap-mass-spectrometry approach, we found peptides from the variable-parts of antibodies which are shared among lung cancer patients.
    PLoS ONE 05/2014; 9(5):e96029. DOI:10.1371/journal.pone.0096029 · 3.23 Impact Factor
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    ABSTRACT: Over the last decade multiple autoantigens located on the plasma membrane of neurons have been identified. Neuronal surface antigens include molecules directly involved in neurotransmission and excitability. Binding of the antibody to the antigen may directly alter the target protein's function, resulting in neurological disorders. The often striking reversibility of symptoms following early aggressive immunotherapy supports a pathogenic role for autoantibodies to neuronal surface antigens. In order to better understand and treat these neurologic disorders it is important to gain insight in the underlying mechanisms of antibody pathogenicity. In this review we discuss the clinical, circumstantial, in vitro and in vivo evidence for neuronal surface antibody pathogenicity and the possible underlying cellular and molecular mechanisms. This review shows that antibodies to neuronal surface antigens are often directed at conformational epitopes located in the extracellular domain of the antigen. The conformation of the epitope can be affected by specific posttranslational modifications. This may explain the distinct clinical phenotypes that are seen in patients with antibodies to antigens that are expressed throughout the brain. Furthermore, it is likely that there is a heterogeneous antibody population, consisting of different IgG subtypes and directed at multiple epitopes located in an immunogenic region. Binding of these antibodies may result in different pathophysiological mechanisms occurring in the same patient, together contributing to the clinical syndrome. Unravelling the predominant mechanism in each distinct antigen could provide clues for therapeutic interventions.
    Autoimmunity reviews 11/2013; 13(3). DOI:10.1016/j.autrev.2013.10.016 · 7.10 Impact Factor
  • Journal of the Neurological Sciences 10/2013; 333:e657. DOI:10.1016/j.jns.2013.07.2278 · 2.26 Impact Factor
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    ABSTRACT: The long-term follow-up results from the EORTC-26951 trial showed that the addition of PCV after radiotherapy increases survival in anaplastic oligodendrogliomas/oligoastrocytomas (AOD/AOA). However, some patients appeared to benefit more from PCV treatment than others. We performed genome-wide methylation profiling of 115 samples included in the EORTC-26951 trial and extracted the CpG island hypermethylated phenotype (CIMP) and MGMT promoter-methylation (MGMT-STP27) status. We first demonstrate that methylation profiling can be performed on archival tissues with a performance that is similar to snap frozen tissue samples. We then performed methylation profiling on EORTC-26951 clinical trial samples. Univariate analysis indicated that CIMP+ or MGMT-STP27 methylated tumors had an improved survival compared to CIMP- and/or MGMT-STP27 unmethylated tumors (median overall survival (OS) 1.05 v. 6.46 years and 1.06 v. 3.8 years, both P<0.0001 for CIMP and MGMT-STP27 status respectively). Multivariable analysis indicates that CIMP and MGMT-STP27 are significant prognostic factors for survival in presence of age, sex performance score and review diagnosis in the model. CIMP+ and MGMT-STP27 methylated tumors showed a clear benefit from adjuvant PCV chemotherapy: the median OS of CIMP+ samples in the RT and RT-PCV arms was 3.27 and 9.51 years respectively P=0.0033; for MGMT-STP27 methylated samples it was 1.98 and 8.65 years. There was no such benefit for CIMP- or MGMT-STP27 unmethylated tumors. MGMT-STP27 status remained significant in an interaction test (P=0.003). Statistical analysis of microarrays (SAM) identified 259 novel CpGs associated with treatment response. MGMT-STP27 may be used to guide treatment decisions in this tumor type.
    Clinical Cancer Research 08/2013; 19(19). DOI:10.1158/1078-0432.CCR-13-1157 · 8.19 Impact Factor
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    ABSTRACT: Subacute cerebellar degeneration associated with metabotropic glutamate receptor type 1 (mGluR1) autoantibodies is an uncommon syndrome known to be part of the spectrum of paraneoplastic cerebellar degenerations associated with neuronal autoantibodies. We describe a patient with prostate adenocarcinoma who developed a subacute cerebellar ataxia. Autoantibodies specific to mGluR1 were detected in patient's serum and cerebrospinal fluid (CSF). Immunohistochemistry analyses of patient's prostate adenocarcinoma revealed abundant mGluR1 expression in luminal acinar epithelial cells and binding of patient's IgGs to tumoral mGluR1. These findings suggest that cerebellar degeneration associated with mGluR1 antibodies can be a paraneoplastic accompaniment of prostate adenocarcinoma.
    Journal of neuroimmunology 08/2013; DOI:10.1016/j.jneuroim.2013.07.015 · 2.79 Impact Factor
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    ABSTRACT: We have explored proteins related to mild cognitive impairment (MCI). The serum proteome of 35 amnestic MCI patients and 35 cognitively healthy persons was investigated by LC MS. We identified 108 differentially expressed peptides between MCI patients and controls, belonging to 39 proteins. Eight proteins were selected for further investigation by quantitative protein measurements using a MRM assay; apolipoprotein E, carboxypeptidase N subunit 2, complement factor B (CFAB), galectin-3 binding protein (LG3BP), lumican, serum amyloid A-4 protein (SAA4), serum amyloid P-component, and sex hormone binding globulin. Results of the quantitative protein measurements showed significantly decreased levels of carboxypeptidase N subunit 2, CFAB, LG3BP, SAA4, and serum amyloid P-component in serum from amnestic MCI patients compared with cognitive healthy controls (two-sided t-test; p < 0.05). Apolipoprotein E and lumican showed no significant difference in protein levels, sex hormone binding globulin could not be quantified since the MRM assay did not reach the required sensitivity. A model based on the three most significantly decreased proteins (CFAB, LG3BP, and SAA4) showed a sensitivity and specificity of 73 and 66%, respectively, for the initial sample set. A small external validation set yielded 77% sensitivity and 75% specificity.
    Proteomics 08/2013; 13(16). DOI:10.1002/pmic.201200190 · 3.97 Impact Factor
  • Cancer Research 04/2013; 73(8 Supplement):3142-3142. DOI:10.1158/1538-7445.AM2013-3142 · 9.28 Impact Factor
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    ABSTRACT: Multi-parametric flow cytometry was used to study lymphocyte subsets and dendritic cells in paired blood and CSF samples from 11 newly diagnosed patients with progressive anti-Hu antibody associated paraneoplastic neurological syndromes (Hu-PNS), 9 patients with other inflammatory neurologic disorders (IND), and 12 patients with other non-inflammatory neurologic disorders (OND). Hu-PNS patients had elevated numbers of regulatory T cells, central memory T cells, class-switched B cells and dendritic cells in their CSF. These findings support the hypothesis that the immune system is locally activated in Hu-PNS, and suggests common etiological pathways between Hu-PNS and other inflammatory central nervous system disorders.
    Journal of neuroimmunology 04/2013; 258(1-2). DOI:10.1016/j.jneuroim.2013.02.006 · 2.79 Impact Factor
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    ABSTRACT: Recent studies have indicated a prognostic role for genome-wide methylation in gliomas: Tumors that show an overall increase in DNA methylation at CpG sites (CIMP+; CpG island methylator phenotype) have a more favorable prognosis than CIMP- gliomas. Here, we have determined whether methylation profiling can identify more and clinically relevant molecular subtypes of glioma by performing genome-wide methylation profiling on 138 glial brain tumors of all histological diagnosis. Hopach (Hierarchical ordered partitioning and collapsing hybrid) clustering using the 1,000 most variable CpGs identified three distinct glioma subtypes (C+1p19q , C+wt , and C-) and one adult brain subtype. All "C+1p19q " and "C+wt " tumors were CIMP+ whereas most (50/54) "C-" tumors were CIMP-. The C- subtype gliomas contained many glioblastomas and all pilocytic astrocytomas. 1p19q LOH was frequent in the C+1p19q subtype. Other genetic changes (IDH1 mutation and EGFR amplification) and gene-expression based molecular subtypes also segregated in distinct methylation subtypes, demonstrating that these subtypes are also genetically distinct. Each subtype was associated with its own prognosis: median survival for C-, C+1p19q , and C+wt tumors was 1.18, 5.00, and 2.62 years, respectively. The prognostic value of these methylation subtypes was validated on an external dataset from the TCGA. Analysis of recurrences of 14 primary tumors samples indicates that shifts between some C+wt and C+1p/19q tumors can occur between the primary and recurrent tumor, but CIMP status remained stable. Our data demonstrate that methylation profiling identifies at least three prognostically relevant subtypes of glioma that can aid diagnosis and potentially guide treatment for patients. © 2013 Wiley Periodicals, Inc.
    Genes Chromosomes and Cancer 04/2013; 52(7). DOI:10.1002/gcc.22062 · 3.84 Impact Factor
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    ABSTRACT: Paraneoplastic neurological syndromes (PNS) are devastating neurological disorders secondary to cancer, associated with onconeural autoantibodies. Such antibodies are directed against neuronal antigens aberrantly expressed by the tumor. The detection of onconeural antibodies in a patient is extremely important in diagnosing a neurological syndrome as paraneoplastic (70% is not yet known to have cancer) and in directing the search for the underlying neoplasm. At present six onconeural antibodies are considered 'well characterized' and recognize the antigens HuD, CDR62 (Yo), amphiphysin, CRMP-5 (CV2), NOVA-1 (Ri), and Ma2. The gold standard of detection is the characteristic immunohistochemical staining pattern on brain tissue sections combined with confirmation by immunoblotting using recombinant purified proteins. Since all six onconeural antibodies are usually analyzed simultaneously and objective cut-off values for these analyses are warranted, we developed a multiplex assay based on Luminex technology. Reaction of serial dilutions of six onconeural standard sera with microsphere-bound antigens showed lower limits of detection than with Western blotting. Using the six standard sera at a dilution of 1:200, the average within-run coefficient of variation (CV) was 4% (range 1.9 - 7.3%). The average between-run within-day CV was 5.1% (range 2.9 - 6.7%) while the average between-day CV was 8.1% (range 2.8 - 11.6%). The shelf-life of the antigen coupled microspheres was at least two months. The sensitivity of the multiplex assay ranged from 83% (Ri) to 100% (Yo, amphiphysin, CV2) and the specificity from 96% (CV2) to 100% (Ri). In conclusion, Luminex-based multiplex serology is highly reproducible with high sensitivity and specificity for the detection of onconeural antibodies. Convential immunoblotting for diagnosis of onconeural antibodies in the setting of a routine laboratory may be replaced by this novel, robust technology.
    Journal of immunological methods 03/2013; 391(1-2). DOI:10.1016/j.jim.2013.02.017 · 2.01 Impact Factor
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    ABSTRACT: We compared data acquired on an LTQ-Orbitrap MS used in a typical shotgun proteomics setting (optimized for protein identification) with data from a quadrupole ion trap MS operated in the MRM mode. Six relative abundant proteins were quantified in identical sets of serum and CSF samples by the following methods; a qual/quant method with and without use of internal standards and a quantitative method (MRM with use of internal standards). Comparison of these methods with an antibody-based method in CSF samples showed good linearity for both methods (R2 of 0.961 and 0.971 for the qual/quant method with use of internal standards and the quantitative method, respectively). Besides its better linearity, the quantitative method was also more reproducible with lower CVs for all samples. Next to these comparisons we also explored why a qual/quant approach had typically a lower reproducibility compared to MRM analyses. We observed that modified peptides, or peptides with a cysteine or a methionine, yielded a significant increase in CV. Furthermore, a positive correlation was found between the length of the peptide and the CV. We conclude that qual/quant is an alternative for the quantification of abundant proteins and that the use of internal standards in qual/quant could be advantageous. Furthermore, the ongoing development in MS techniques increases the possibilities of qual/quant in protein quantification.
    Journal of Proteome Research 03/2013; 12(4). DOI:10.1021/pr301221f · 5.00 Impact Factor
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    ABSTRACT: Cytomegalovirus (CMV)-carrying individuals have significantly higher levels of effector memory and late memory T lymphocytes in their blood than non-carriers. To date, it is well recognized that the central nervous system is subjected to active immunosurveillance, as evidenced by the presence of central memory T cells in cerebrospinal fluid (CSF) of healthy individuals. In order to investigate whether levels of effector memory and late memory T cells were also increased in the CSF of CMV-carrying individuals, we characterized CD4(+) and CD8(+) T-cell subsets in CSF and blood of both groups. Effector memory and late memory T cells were only rarely seen in CSF, which was similar in CMV carriers and non-carriers. In conclusion, there was no demonstrable difference in the numbers of CSF effector memory and late memory T cells between CMV seronegative and CMV seropositive individuals. © 2013 International Clinical Cytometry Society.
    Cytometry Part B Clinical Cytometry 02/2013; 84(4). DOI:10.1002/cyto.b.21073 · 2.28 Impact Factor
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    ABSTRACT: This chapter contains sections titled: Introduction Forward-genetics in orthoreoviruses Reovirus/cell interactions Reverse-genetics in orthoreoviruses Reovirus as an oncolytic agent Conclusion References
    Reverse Genetics of RNA Viruses, Edited by Anne Bridgen, 01/2013: pages 289-317; Wiley-Blackwell., ISBN: 978-0-470-97965-5

Publication Stats

3k Citations
566.96 Total Impact Points


  • 1996–2015
    • Erasmus MC
      • • Department of Neurology
      • • Department of Pathology
      • • Daniel den Hoed Centre
      Rotterdam, South Holland, Netherlands
  • 2005–2013
    • Erasmus Universiteit Rotterdam
      • • Department of Neurology
      • • Department of Pediatric Urology
      Rotterdam, South Holland, Netherlands
    • GGD Zuid-Holland Zuid
      Dordt, South Holland, Netherlands
  • 2011
    • University of Groningen
      Groningen, Groningen, Netherlands
  • 2009
    • Leiden University Medical Centre
      Leyden, South Holland, Netherlands
  • 2008–2009
    • Leiden University
      Leyden, South Holland, Netherlands
  • 2006
    • Reinier de Graaf Groep
      Delft, South Holland, Netherlands
  • 2002
    • Hogeschool Arnhem and Nijmegen
      Arnheim, Gelderland, Netherlands
  • 1992–1993
    • Academisch Medisch Centrum Universiteit van Amsterdam
      • Department of Neurology
      Amsterdamo, North Holland, Netherlands
    • Academic Medical Center (AMC)
      Amsterdamo, North Holland, Netherlands
  • 1971–1990
    • University of Amsterdam
      • Department of Neurology
      Amsterdam, North Holland, Netherlands