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Papadopoulou A, Pfister A, Tsagkas C, Gaetano L, Sellathurai S, D'Souza M, Cerdá-Fuertes N, Gugleta K, Descoteaux M, Chakravarty MM, Fuhr P, Kappos L, Granziera C, Magon S, Sprenger T, Hardmeier M. Visual evoked potentials in multiple sclerosis: P100 latency and visual pathway damage including the lateral geniculate nucleus. Clin Neurophysiol 2024; 161:122-132. [PMID: 38461596 DOI: 10.1016/j.clinph.2024.02.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 02/11/2024] [Accepted: 02/13/2024] [Indexed: 03/12/2024]
Abstract
OBJECTIVE To explore associations of the main component (P100) of visual evoked potentials (VEP) to pre- and postchiasmatic damage in multiple sclerosis (MS). METHODS 31 patients (median EDSS: 2.5), 13 with previous optic neuritis (ON), and 31 healthy controls had VEP, optical coherence tomography and magnetic resonance imaging. We tested associations of P100-latency to the peripapillary retinal nerve fiber layer (pRNFL), ganglion cell/inner plexiform layers (GCIPL), lateral geniculate nucleus volume (LGN), white matter lesions of the optic radiations (OR-WML), fractional anisotropy of non-lesional optic radiations (NAOR-FA), and to the mean thickness of primary visual cortex (V1). Effect sizes are given as marginal R2 (mR2). RESULTS P100-latency, pRNFL, GCIPL and LGN in patients differed from controls. Within patients, P100-latency was significantly associated with GCIPL (mR2 = 0.26), and less strongly with OR-WML (mR2 = 0.17), NAOR-FA (mR2 = 0.13) and pRNFL (mR2 = 0.08). In multivariate analysis, GCIPL and NAOR-FA remained significantly associated with P100-latency (mR2 = 0.41). In ON-patients, P100-latency was significantly associated with LGN volume (mR2 = -0.56). CONCLUSIONS P100-latency is affected by anterior and posterior visual pathway damage. In ON-patients, damage at the synapse-level (LGN) may additionally contribute to latency delay. SIGNIFICANCE Our findings corroborate post-chiasmatic contributions to the VEP-signal, which may relate to distinct pathophysiological mechanisms in MS.
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Affiliation(s)
- Athina Papadopoulou
- Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland; Department of Clinical Research, University of Basel, Switzerland; Translational Imaging in Neurology (ThINK) Basel, Department of Biomedical Engineering, University of Basel, Basel, Switzerland; Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel and University of Basel, Basel, Switzerland
| | - Armanda Pfister
- Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Charidimos Tsagkas
- Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland; Translational Imaging in Neurology (ThINK) Basel, Department of Biomedical Engineering, University of Basel, Basel, Switzerland; Translational Neuroradiology Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health (NIH), Bethesda, MD, USA
| | | | - Shaumiya Sellathurai
- Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland; Department of Clinical Research, University of Basel, Switzerland; Translational Imaging in Neurology (ThINK) Basel, Department of Biomedical Engineering, University of Basel, Basel, Switzerland; Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel and University of Basel, Basel, Switzerland
| | - Marcus D'Souza
- Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland; Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel and University of Basel, Basel, Switzerland; Neurostatus AG, University Hospital of Basel, Basel, Switzerland
| | - Nuria Cerdá-Fuertes
- Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland; Department of Clinical Research, University of Basel, Switzerland; Translational Imaging in Neurology (ThINK) Basel, Department of Biomedical Engineering, University of Basel, Basel, Switzerland; Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel and University of Basel, Basel, Switzerland; Neurostatus AG, University Hospital of Basel, Basel, Switzerland
| | - Konstantin Gugleta
- University Eye Clinic Basel, University Hospital Basel and University of Basel, Basel, Switzerland
| | | | - Mallar M Chakravarty
- Douglas Mental Health University Institute, Departments of Psychiatry and Biomedical Engineering (M.M.C.), McGill University, Montreal, University of Sherbrooke (M.D.), Canada
| | - Peter Fuhr
- Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland; Department of Clinical Research, University of Basel, Switzerland
| | - Ludwig Kappos
- Department of Clinical Research, University of Basel, Switzerland; Translational Imaging in Neurology (ThINK) Basel, Department of Biomedical Engineering, University of Basel, Basel, Switzerland; Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel and University of Basel, Basel, Switzerland
| | - Cristina Granziera
- Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland; Translational Imaging in Neurology (ThINK) Basel, Department of Biomedical Engineering, University of Basel, Basel, Switzerland; Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel and University of Basel, Basel, Switzerland
| | - Stefano Magon
- Pharma Research and Early Development, Neuroscience and Rare Diseases Roche Innovation Center Basel, F. Hoffmann-La Roche Ltd., Basel, Switzerland
| | | | - Martin Hardmeier
- Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland.
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Willems E, Schepers M, Piccart E, Wolfs E, Hellings N, Ait-Tihyaty M, Vanmierlo T. The sphingosine-1-phosphate receptor 1 modulator ponesimod repairs cuprizone-induced demyelination and induces oligodendrocyte differentiation. FASEB J 2024; 38:e23413. [PMID: 38243760 DOI: 10.1096/fj.202301557rr] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 12/20/2023] [Accepted: 12/26/2023] [Indexed: 01/21/2024]
Abstract
Sphingosine-1-phosphate receptor (S1PR) modulators are clinically used to treat relapse-remitting multiple sclerosis (MS) and the early phase of progressive MS when inflammation still prevails. In the periphery, S1PR modulators prevent lymphocyte egress from lymph nodes, hence hampering neuroinflammation. Recent findings suggest a role for S1PR modulation in remyelination. As the Giα-coupled S1P1 subtype is the most prominently expressed S1PR in oligodendrocyte precursor cells (OPCs), selective modulation (functional antagonism) of S1P1 may have direct effects on OPC functionality. We hypothesized that functional antagonism of S1P1 by ponesimod induces remyelination by boosting OPC differentiation. In the cuprizone mouse model of demyelination, we found ponesimod to decrease the latency time of visual evoked potentials compared to vehicle conditions, which is indicative of functional remyelination. In addition, the Y maze spontaneous alternations test revealed that ponesimod reversed cuprizone-induced working memory deficits. Myelin basic protein (MBP) immunohistochemistry and transmission electron microscopy of the corpus callosum revealed an increase in myelination upon ponesimod treatment. Moreover, treatment with ponesimod alone or in combination with A971432, an S1P5 monoselective modulator, significantly increased primary mouse OPC differentiation based on O4 immunocytochemistry. In conclusion, S1P1 functional antagonism by ponesimod increases remyelination in the cuprizone model of demyelination and significantly increases OPC differentiation in vitro.
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Affiliation(s)
- Emily Willems
- Department of Neuroscience, Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
- Department Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University, Maastricht, Netherlands
| | - Melissa Schepers
- Department of Neuroscience, Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
- Department Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University, Maastricht, Netherlands
- University MS Center (UMSC) Hasselt-Pelt, Hasselt, Belgium
| | - Elisabeth Piccart
- Department of Neuroscience, Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | - Esther Wolfs
- Department of Cardio and Organ Systems, Biomedical Research Institute, Hasselt University, Diepenbeek, Belgium
| | - Niels Hellings
- University MS Center (UMSC) Hasselt-Pelt, Hasselt, Belgium
- Department of Immunology and Infection, Biomedical Research Institute, Hasselt University, Diepenbeek, Belgium
| | | | - Tim Vanmierlo
- Department of Neuroscience, Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
- Department Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University, Maastricht, Netherlands
- University MS Center (UMSC) Hasselt-Pelt, Hasselt, Belgium
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3
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Kipp M. How to Use the Cuprizone Model to Study De- and Remyelination. Int J Mol Sci 2024; 25:1445. [PMID: 38338724 PMCID: PMC10855335 DOI: 10.3390/ijms25031445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 01/19/2024] [Accepted: 01/22/2024] [Indexed: 02/12/2024] Open
Abstract
Multiple sclerosis (MS) is an autoimmune and inflammatory disorder affecting the central nervous system whose cause is still largely unknown. Oligodendrocyte degeneration results in demyelination of axons, which can eventually be repaired by a mechanism called remyelination. Prevention of demyelination and the pharmacological support of remyelination are two promising strategies to ameliorate disease progression in MS patients. The cuprizone model is commonly employed to investigate oligodendrocyte degeneration mechanisms or to explore remyelination pathways. During the last decades, several different protocols have been applied, and all have their pros and cons. This article intends to offer guidance for conducting pre-clinical trials using the cuprizone model in mice, focusing on discovering new treatment approaches to prevent oligodendrocyte degeneration or enhance remyelination.
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Affiliation(s)
- Markus Kipp
- Rostock University Medical Center, Institute of Anatomy, 18057 Rostock, Germany
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4
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Packer D, Fresenko EE, Harrington EP. Remyelination in animal models of multiple sclerosis: finding the elusive grail of regeneration. Front Mol Neurosci 2023; 16:1207007. [PMID: 37448959 PMCID: PMC10338073 DOI: 10.3389/fnmol.2023.1207007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 06/09/2023] [Indexed: 07/18/2023] Open
Abstract
Remyelination biology and the therapeutic potential of restoring myelin sheaths to prevent neurodegeneration and disability in multiple sclerosis (MS) has made considerable gains over the past decade with many regeneration strategies undergoing tested in MS clinical trials. Animal models used to investigate oligodendroglial responses and regeneration of myelin vary considerably in the mechanism of demyelination, involvement of inflammatory cells, neurodegeneration and capacity for remyelination. The investigation of remyelination in the context of aging and an inflammatory environment are of considerable interest for the potential translation to progressive multiple sclerosis. Here we review how remyelination is assessed in mouse models of demyelination, differences and advantages of these models, therapeutic strategies that have emerged and current pro-remyelination clinical trials.
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5
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Mey GM, DeSilva TM. Utility of the visual system to monitor neurodegeneration in multiple sclerosis. Front Mol Neurosci 2023; 16:1125115. [PMID: 37063369 PMCID: PMC10090562 DOI: 10.3389/fnmol.2023.1125115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 03/14/2023] [Indexed: 03/31/2023] Open
Abstract
Neurodegeneration occurs early in the multiple sclerosis (MS) disease course and is an important driver of permanent disability. Current immunomodulatory therapies do not directly target neuronal health; thus, there is a critical need to develop neuroprotective strategies in MS. Outcome measures in clinical trials primarily evaluate disease activity and clinical disability scores rather than measures of neurodegeneration. The visual system provides a noninvasive correlate of brain atrophy and neuronal function through structural and functional exams. Furthermore, optic nerve axons and their respective neuronal cell bodies in the retina, in addition to their synaptic input to the thalamus, provide a distinct anatomy to investigate neurodegenerative processes. This review discusses the utility of the visual system as an early output measure of neurodegeneration in MS as well as an important platform to evaluate neuroprotective strategies in preclinical models.
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Affiliation(s)
| | - Tara M. DeSilva
- Department of Neurosciences, Cleveland Clinic, Cleveland, OH, United States
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6
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Clawson ED, Radecki DZ, Samanta J. Immunofluorescence assay for demyelination, remyelination, and proliferation in an acute cuprizone mouse model. STAR Protoc 2023; 4:102072. [PMID: 36853716 PMCID: PMC9918794 DOI: 10.1016/j.xpro.2023.102072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 12/16/2022] [Accepted: 01/09/2023] [Indexed: 01/31/2023] Open
Abstract
Here, we present a protocol to assess demyelination in the corpus callosum of an acute cuprizone mouse model, which is routinely used to induce demyelination for studying myelin regeneration in the rodent brain. We describe the tracing of neural stem cells via intraperitoneal injection of tamoxifen into adult Gli1CreERT2;Ai9 mice and the induction of demyelination with cuprizone diet. We also detail EdU administration, cryosectioning of the mouse brain, EdU labeling, and immunofluorescence staining to examine proliferation and myelination. For complete details on the use and execution of this protocol, please refer to Radecki et al. (2020).1.
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Affiliation(s)
- Elizabeth D Clawson
- Department of Comparative Biosciences, University of Wisconsin-Madison, Madison, WI 53706, USA; Molecular and Cellular Pharmacology Program, University of Wisconsin-Madison, Madison, WI 53706, USA; Stem Cell and Regenerative Medicine Center, University of Wisconsin-Madison, Madison, WI 53706, USA.
| | - Daniel Z Radecki
- Department of Comparative Biosciences, University of Wisconsin-Madison, Madison, WI 53706, USA; Stem Cell and Regenerative Medicine Center, University of Wisconsin-Madison, Madison, WI 53706, USA
| | - Jayshree Samanta
- Department of Comparative Biosciences, University of Wisconsin-Madison, Madison, WI 53706, USA; Molecular and Cellular Pharmacology Program, University of Wisconsin-Madison, Madison, WI 53706, USA; Stem Cell and Regenerative Medicine Center, University of Wisconsin-Madison, Madison, WI 53706, USA.
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7
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Schepers M, Paes D, Tiane A, Rombaut B, Piccart E, van Veggel L, Gervois P, Wolfs E, Lambrichts I, Brullo C, Bruno O, Fedele E, Ricciarelli R, Ffrench-Constant C, Bechler ME, van Schaik P, Baron W, Lefevere E, Wasner K, Grünewald A, Verfaillie C, Baeten P, Broux B, Wieringa P, Hellings N, Prickaerts J, Vanmierlo T. Selective PDE4 subtype inhibition provides new opportunities to intervene in neuroinflammatory versus myelin damaging hallmarks of multiple sclerosis. Brain Behav Immun 2023; 109:1-22. [PMID: 36584795 DOI: 10.1016/j.bbi.2022.12.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 12/17/2022] [Accepted: 12/24/2022] [Indexed: 12/29/2022] Open
Abstract
Multiple sclerosis (MS) is a chronic autoimmune disease of the central nervous system (CNS) characterized by focal inflammatory lesions and prominent demyelination. Even though the currently available therapies are effective in treating the initial stages of disease, they are unable to halt or reverse disease progression into the chronic progressive stage. Thus far, no repair-inducing treatments are available for progressive MS patients. Hence, there is an urgent need for the development of new therapeutic strategies either targeting the destructive immunological demyelination or boosting endogenous repair mechanisms. Using in vitro, ex vivo, and in vivo models, we demonstrate that selective inhibition of phosphodiesterase 4 (PDE4), a family of enzymes that hydrolyzes and inactivates cyclic adenosine monophosphate (cAMP), reduces inflammation and promotes myelin repair. More specifically, we segregated the myelination-promoting and anti-inflammatory effects into a PDE4D- and PDE4B-dependent process respectively. We show that inhibition of PDE4D boosts oligodendrocyte progenitor cells (OPC) differentiation and enhances (re)myelination of both murine OPCs and human iPSC-derived OPCs. In addition, PDE4D inhibition promotes in vivo remyelination in the cuprizone model, which is accompanied by improved spatial memory and reduced visual evoked potential latency times. We further identified that PDE4B-specific inhibition exerts anti-inflammatory effects since it lowers in vitro monocytic nitric oxide (NO) production and improves in vivo neurological scores during the early phase of experimental autoimmune encephalomyelitis (EAE). In contrast to the pan PDE4 inhibitor roflumilast, the therapeutic dose of both the PDE4B-specific inhibitor A33 and the PDE4D-specific inhibitor Gebr32a did not trigger emesis-like side effects in rodents. Finally, we report distinct PDE4D isoform expression patterns in human area postrema neurons and human oligodendroglia lineage cells. Using the CRISPR-Cas9 system, we confirmed that pde4d1/2 and pde4d6 are the key targets to induce OPC differentiation. Collectively, these data demonstrate that gene specific PDE4 inhibitors have potential as novel therapeutic agents for targeting the distinct disease processes of MS.
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Affiliation(s)
- Melissa Schepers
- Department of Neuroscience, Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium; Department Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University, Maastricht, Netherlands; University MS Center (UMSC) Hasselt-Pelt, Hasselt, Belgium
| | - Dean Paes
- Department of Neuroscience, Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium; Department Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University, Maastricht, Netherlands
| | - Assia Tiane
- Department of Neuroscience, Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium; Department Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University, Maastricht, Netherlands; University MS Center (UMSC) Hasselt-Pelt, Hasselt, Belgium
| | - Ben Rombaut
- Department of Neuroscience, Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium; Department Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University, Maastricht, Netherlands
| | - Elisabeth Piccart
- Department of Neuroscience, Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | - Lieve van Veggel
- Department of Neuroscience, Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium; Department Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University, Maastricht, Netherlands; University MS Center (UMSC) Hasselt-Pelt, Hasselt, Belgium
| | - Pascal Gervois
- Department of Cardio and Organ Systems, Biomedical Research Institute, Hasselt University, Diepenbeek, Belgium
| | - Esther Wolfs
- Department of Cardio and Organ Systems, Biomedical Research Institute, Hasselt University, Diepenbeek, Belgium
| | - Ivo Lambrichts
- Department of Cardio and Organ Systems, Biomedical Research Institute, Hasselt University, Diepenbeek, Belgium
| | - Chiara Brullo
- Department of Pharmacy, Section of Medicinal Chemistry, University of Genoa, Genova, Italy
| | - Olga Bruno
- Department of Pharmacy, Section of Medicinal Chemistry, University of Genoa, Genova, Italy
| | - Ernesto Fedele
- Department of Pharmacy, Section of Pharmacology and Toxicology, University of Genova, Genova, Italy; IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Roberta Ricciarelli
- IRCCS Ospedale Policlinico San Martino, Genova, Italy; Department of Experimental Medicine, Section of General Pathology, University of Genova, Genova, Italy
| | - Charles Ffrench-Constant
- MRC Centre for Regenerative Medicine and MS Society Edinburgh Centre, Edinburgh bioQuarter, University of Edinburgh, Edinburgh, UK
| | - Marie E Bechler
- Department of Cell and Developmental Biology, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Pauline van Schaik
- Department of Biomedical Sciences of Cells and Systems, Section Molecular Neurobiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Wia Baron
- Department of Biomedical Sciences of Cells and Systems, Section Molecular Neurobiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Evy Lefevere
- Rewind Therapeutics NV, Gaston Geenslaan 2, B-3001, Leuven, Belgium
| | - Kobi Wasner
- Luxembourg Centre for Systems Biomedicine, University of Luxembourg, Esch-sur-Alzette, Luxembourg
| | - Anne Grünewald
- Luxembourg Centre for Systems Biomedicine, University of Luxembourg, Esch-sur-Alzette, Luxembourg
| | - Catherine Verfaillie
- Stem Cell Institute, Department of Development and Regeneration, KU Leuven, Belgium
| | - Paulien Baeten
- University MS Center (UMSC) Hasselt-Pelt, Hasselt, Belgium; Department of Immunology and Infection, Biomedical Research Institute, Hasselt University, Diepenbeek, Belgium
| | - Bieke Broux
- University MS Center (UMSC) Hasselt-Pelt, Hasselt, Belgium; Department of Immunology and Infection, Biomedical Research Institute, Hasselt University, Diepenbeek, Belgium
| | - Paul Wieringa
- MERLN Institute for Technology-Inspired Regenerative Medicine, Complex Tissue Regeneration department, Maastricht University, Maastricht, the Netherlands
| | - Niels Hellings
- University MS Center (UMSC) Hasselt-Pelt, Hasselt, Belgium; Department of Immunology and Infection, Biomedical Research Institute, Hasselt University, Diepenbeek, Belgium
| | - Jos Prickaerts
- Department Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University, Maastricht, Netherlands
| | - Tim Vanmierlo
- Department of Neuroscience, Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium; Department Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University, Maastricht, Netherlands; University MS Center (UMSC) Hasselt-Pelt, Hasselt, Belgium.
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