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Ince LM, Barnoud C, Lutes LK, Pick R, Wang C, Sinturel F, Chen CS, de Juan A, Weber J, Holtkamp SJ, Hergenhan SM, Geddes-McAlister J, Ebner S, Fontannaz P, Meyer B, Vono M, Jemelin S, Dibner C, Siegrist CA, Meissner F, Graw F, Scheiermann C. Influence of circadian clocks on adaptive immunity and vaccination responses. Nat Commun 2023; 14:476. [PMID: 36717561 PMCID: PMC9885059 DOI: 10.1038/s41467-023-35979-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 01/11/2023] [Indexed: 02/01/2023] Open
Abstract
The adaptive immune response is under circadian control, yet, why adaptive immune reactions continue to exhibit circadian changes over long periods of time is unknown. Using a combination of experimental and mathematical modeling approaches, we show here that dendritic cells migrate from the skin to the draining lymph node in a time-of-day-dependent manner, which provides an enhanced likelihood for functional interactions with T cells. Rhythmic expression of TNF in the draining lymph node enhances BMAL1-controlled ICAM-1 expression in high endothelial venules, resulting in lymphocyte infiltration and lymph node expansion. Lymph node cellularity continues to be different for weeks after the initial time-of-day-dependent challenge, which governs the immune response to vaccinations directed against Hepatitis A virus as well as SARS-CoV-2. In this work, we present a mechanistic understanding of the time-of-day dependent development and maintenance of an adaptive immune response, providing a strategy for using time-of-day to optimize vaccination regimes.
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Affiliation(s)
- Louise Madeleine Ince
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Division of Pharmacology & Toxicology, College of Pharmacy, University of Texas at Austin, Austin, TX, USA
| | - Coline Barnoud
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Lydia Kay Lutes
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Robert Pick
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Chen Wang
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Flore Sinturel
- Department of Medicine, Division of Endocrinology, Diabetes, Nutrition and Patient Education, Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Department of Cell Physiology and Metabolism, Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Diabetes Center, Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Institute of Genetics and Genomics of Geneva (iGE3), University of Geneva, Geneva, Switzerland
| | - Chien-Sin Chen
- Walter-Brendel-Centre of Experimental Medicine, Ludwig-Maximilians-University Munich, BioMedical Centre, Planegg-Martinsried, Germany
| | - Alba de Juan
- Walter-Brendel-Centre of Experimental Medicine, Ludwig-Maximilians-University Munich, BioMedical Centre, Planegg-Martinsried, Germany
| | - Jasmin Weber
- Walter-Brendel-Centre of Experimental Medicine, Ludwig-Maximilians-University Munich, BioMedical Centre, Planegg-Martinsried, Germany
| | - Stephan J Holtkamp
- Walter-Brendel-Centre of Experimental Medicine, Ludwig-Maximilians-University Munich, BioMedical Centre, Planegg-Martinsried, Germany
| | - Sophia Martina Hergenhan
- Walter-Brendel-Centre of Experimental Medicine, Ludwig-Maximilians-University Munich, BioMedical Centre, Planegg-Martinsried, Germany
| | - Jennifer Geddes-McAlister
- Experimental Systems Immunology, Max Planck Institute of Biochemistry, Martinsried, Germany.,Department of Molecular and Cellular Biology, University of Guelph, Guelph, Ontario, Canada
| | - Stefan Ebner
- Experimental Systems Immunology, Max Planck Institute of Biochemistry, Martinsried, Germany.,Systems Immunology and Proteomics, Institute of Innate Immunity, Medical Faculty, University of Bonn, Bonn, Germany
| | - Paola Fontannaz
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland.,World Health Organization Collaborating Center for Vaccine Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Benjamin Meyer
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland.,World Health Organization Collaborating Center for Vaccine Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Maria Vono
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland.,World Health Organization Collaborating Center for Vaccine Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Stéphane Jemelin
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Charna Dibner
- Department of Medicine, Division of Endocrinology, Diabetes, Nutrition and Patient Education, Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Department of Cell Physiology and Metabolism, Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Diabetes Center, Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Institute of Genetics and Genomics of Geneva (iGE3), University of Geneva, Geneva, Switzerland
| | - Claire-Anne Siegrist
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland.,World Health Organization Collaborating Center for Vaccine Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Felix Meissner
- Experimental Systems Immunology, Max Planck Institute of Biochemistry, Martinsried, Germany.,Systems Immunology and Proteomics, Institute of Innate Immunity, Medical Faculty, University of Bonn, Bonn, Germany
| | - Frederik Graw
- BioQuant - Center for Quantitative Biology, Heidelberg University, Heidelberg, Germany.,Interdisciplinary Center for Scientific Computing, Heidelberg University, Heidelberg, Germany
| | - Christoph Scheiermann
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland. .,Institute of Genetics and Genomics of Geneva (iGE3), University of Geneva, Geneva, Switzerland. .,Walter-Brendel-Centre of Experimental Medicine, Ludwig-Maximilians-University Munich, BioMedical Centre, Planegg-Martinsried, Germany. .,Geneva Centre for Inflammation Research, Faculty of Medicine, University of Geneva, Geneva, Switzerland.
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Wang C, Barnoud C, Kizil B, Scheiermann C. 44P Dendritic cells direct circadian anti-tumor immune responses. Ann Oncol 2022. [DOI: 10.1016/j.annonc.2022.07.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Abstract
The immune system is highly time-of-day dependent. Pioneering studies in the 1960s were the first to identify immune responses to be under a circadian control. Only in the last decade, however, have the molecular factors governing circadian immune rhythms been identified. These studies have revealed a highly complex picture of the interconnectivity of rhythmicity within immune cells with that of their environment. Here, we provide a global overview of the circadian immune system, focusing on recent advances in the rapidly expanding field of circadian immunology.
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Affiliation(s)
- Chen Wang
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Lydia Kay Lutes
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Coline Barnoud
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Christoph Scheiermann
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Biomedical Center (BMC), Institute for Cardiovascular Physiology and Pathophysiology, Walter Brendel Center for Experimental Medicine (WBex), Ludwig-Maximilians-Universität München, Planegg-Martinsried, Germany
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Wang C, Barnoud C, Kizil B, Scheiermann C. Dendritic Cells Direct Circadian Anti‐Tumor Immune Response. FASEB J 2022. [DOI: 10.1096/fasebj.2022.36.s1.r2866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Chen Wang
- Pathology and ImmunologyUniversity of GenevaGeneva
| | | | - Burak Kizil
- Pathology and ImmunologyUniversity of GenevaGeneva
| | - Christoph Scheiermann
- Pathology and ImmunologyUniversity of GenevaGeneva
- Walter‐Brendel‐Centre of Experimental MedicineLudwig‐Maximilians‐University MunichMunich
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Barnoud C, Wang C, Ince LM, Scheiermann C. Time‐of‐Day Influence on Central Nervous System Autoimmunity. FASEB J 2022. [DOI: 10.1096/fasebj.2022.36.s1.r2860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
| | - Chen Wang
- Pathology and ImmunologyUniversity of GenevaGeneva
| | | | - Christoph Scheiermann
- Pathology and ImmunologyUniversity of GenevaGeneva
- Walter‐Brendel‐Centre of Experimental MedicineLudwig‐Maximilians‐University MunichMunich
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Barnoud C, Ince LM, Lutes LK, Pick R, Wang C, Jemelin S, Scheiermann C. Benefit of Circadian Clocks in Adaptive Immunity And Vaccination Responses. FASEB J 2022. [PMCID: PMC9347973 DOI: 10.1096/fasebj.2022.36.s1.r2867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
| | | | | | - Robert Pick
- Pathology and ImmunologyUniversity of GenevaGeneva
| | - Chen Wang
- Pathology and ImmunologyUniversity of GenevaGeneva
| | | | - Christoph Scheiermann
- Pathology and ImmunologyUniversity of GenevaGeneva
- Walter‐Brendel‐Centre of Experimental MedicineLudwig‐Maximilians‐University MunichMunich
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Affiliation(s)
- Coline Barnoud
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Chen Wang
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Christoph Scheiermann
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland.
- Walter-Brendel-Centre of Experimental Medicine, BioMedical Centre, Ludwig-Maximilians-University München, Planegg-Martinsried, München, Germany.
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Holtkamp SJ, Ince LM, Barnoud C, Schmitt MT, Sinturel F, Pilorz V, Pick R, Jemelin S, Mühlstädt M, Boehncke WH, Weber J, Laubender D, Philippou-Massier J, Chen CS, Holtermann L, Vestweber D, Sperandio M, Schraml BU, Halin C, Dibner C, Oster H, Renkawitz J, Scheiermann C. Circadian clocks guide dendritic cells into skin lymphatics. Nat Immunol 2021; 22:1375-1381. [PMID: 34663979 PMCID: PMC8553624 DOI: 10.1038/s41590-021-01040-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 08/31/2021] [Indexed: 12/11/2022]
Abstract
Migration of leukocytes from the skin to lymph nodes (LNs) via afferent lymphatic vessels (LVs) is pivotal for adaptive immune responses1,2. Circadian rhythms have emerged as important regulators of leukocyte trafficking to LNs via the blood3,4. Here, we demonstrate that dendritic cells (DCs) have a circadian migration pattern into LVs, which peaks during the rest phase in mice. This migration pattern is determined by rhythmic gradients in the expression of the chemokine CCL21 and of adhesion molecules in both mice and humans. Chronopharmacological targeting of the involved factors abrogates circadian migration of DCs. We identify cell-intrinsic circadian oscillations in skin lymphatic endothelial cells (LECs) and DCs that cogovern these rhythms, as their genetic disruption in either cell type ablates circadian trafficking. These observations indicate that circadian clocks control the infiltration of DCs into skin lymphatics, a process that is essential for many adaptive immune responses and relevant for vaccination and immunotherapies.
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Affiliation(s)
- Stephan J Holtkamp
- Biomedical Center (BMC), Institute for Cardiovascular Physiology and Pathophysiology, Walter Brendel Center for Experimental Medicine (WBex), Faculty of Medicine, Ludwig-Maximilians-Universität Munich, Planegg-Martinsried, Germany
| | - Louise M Ince
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Coline Barnoud
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Madeleine T Schmitt
- Biomedical Center (BMC), Institute for Cardiovascular Physiology and Pathophysiology, Walter Brendel Center for Experimental Medicine (WBex), Faculty of Medicine, Ludwig-Maximilians-Universität Munich, Planegg-Martinsried, Germany
- Laboratory 'Cell Biology of the Immune System', Biomedical Center (BMC), Institute for Cardiovascular Physiology and Pathophysiology, Walter Brendel Center for Experimental Medicine (WBex), Faculty of Medicine, Ludwig-Maximilians-Universität Munich, Planegg-Martinsried, Germany
| | - Flore Sinturel
- Department of Medicine, Division of Endocrinology, Diabetes, Nutrition and Patient Education, University Hospitals of Geneva, Geneva, Switzerland
- Department of Cell Physiology and Metabolism, University of Geneva, Geneva, Switzerland
- Diabetes Center, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Institute of Genetics and Genomics of Geneva (iGE3), University of Geneva, Geneva, Switzerland
| | - Violetta Pilorz
- Institute of Neurobiology, University of Lübeck, Lübeck, Germany
| | - Robert Pick
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Stéphane Jemelin
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Michael Mühlstädt
- Division of Dermatology and Venereology, Department of Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - Wolf-Henning Boehncke
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Division of Dermatology and Venereology, Department of Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - Jasmin Weber
- Biomedical Center (BMC), Institute for Cardiovascular Physiology and Pathophysiology, Walter Brendel Center for Experimental Medicine (WBex), Faculty of Medicine, Ludwig-Maximilians-Universität Munich, Planegg-Martinsried, Germany
| | | | - Julia Philippou-Massier
- Laboratory for Functional Genome Analysis, Gene Center Munich, Ludwig-Maximilians-Universität Munich, Munich, Germany
| | - Chien-Sin Chen
- Biomedical Center (BMC), Institute for Cardiovascular Physiology and Pathophysiology, Walter Brendel Center for Experimental Medicine (WBex), Faculty of Medicine, Ludwig-Maximilians-Universität Munich, Planegg-Martinsried, Germany
| | - Leonie Holtermann
- Department of Vascular Cell Biology, Max Planck Institute for Molecular Biomedicine, Münster, Germany
| | - Dietmar Vestweber
- Department of Vascular Cell Biology, Max Planck Institute for Molecular Biomedicine, Münster, Germany
| | - Markus Sperandio
- Biomedical Center (BMC), Institute for Cardiovascular Physiology and Pathophysiology, Walter Brendel Center for Experimental Medicine (WBex), Faculty of Medicine, Ludwig-Maximilians-Universität Munich, Planegg-Martinsried, Germany
| | - Barbara U Schraml
- Biomedical Center (BMC), Institute for Cardiovascular Physiology and Pathophysiology, Walter Brendel Center for Experimental Medicine (WBex), Faculty of Medicine, Ludwig-Maximilians-Universität Munich, Planegg-Martinsried, Germany
| | - Cornelia Halin
- Institute of Pharmaceutical Sciences, ETH Zurich, Zurich, Switzerland
| | - Charna Dibner
- Department of Medicine, Division of Endocrinology, Diabetes, Nutrition and Patient Education, University Hospitals of Geneva, Geneva, Switzerland
- Department of Cell Physiology and Metabolism, University of Geneva, Geneva, Switzerland
- Diabetes Center, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Institute of Genetics and Genomics of Geneva (iGE3), University of Geneva, Geneva, Switzerland
| | - Henrik Oster
- Institute of Neurobiology, University of Lübeck, Lübeck, Germany
| | - Jörg Renkawitz
- Biomedical Center (BMC), Institute for Cardiovascular Physiology and Pathophysiology, Walter Brendel Center for Experimental Medicine (WBex), Faculty of Medicine, Ludwig-Maximilians-Universität Munich, Planegg-Martinsried, Germany
- Laboratory 'Cell Biology of the Immune System', Biomedical Center (BMC), Institute for Cardiovascular Physiology and Pathophysiology, Walter Brendel Center for Experimental Medicine (WBex), Faculty of Medicine, Ludwig-Maximilians-Universität Munich, Planegg-Martinsried, Germany
| | - Christoph Scheiermann
- Biomedical Center (BMC), Institute for Cardiovascular Physiology and Pathophysiology, Walter Brendel Center for Experimental Medicine (WBex), Faculty of Medicine, Ludwig-Maximilians-Universität Munich, Planegg-Martinsried, Germany.
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland.
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Chen CS, Weber J, Holtkamp SJ, Ince LM, de Juan A, Wang C, Lutes L, Barnoud C, Kizil B, Hergenhan SM, Salvermoser J, Lasch M, Deindl E, Schraml B, Baumjohann D, Scheiermann C. Loss of direct adrenergic innervation after peripheral nerve injury causes lymph node expansion through IFN-γ. J Exp Med 2021; 218:e20202377. [PMID: 34086056 PMCID: PMC8185988 DOI: 10.1084/jem.20202377] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 02/19/2021] [Accepted: 05/03/2021] [Indexed: 11/04/2022] Open
Abstract
Peripheral nerve injury can cause debilitating disease and immune cell-mediated destruction of the affected nerve. While the focus has been on the nerve-regenerative response, the effect of loss of innervation on lymph node function is unclear. Here, we show that the popliteal lymph node (popLN) receives direct neural input from the sciatic nerve and that sciatic denervation causes lymph node expansion. Loss of sympathetic, adrenergic tone induces the expression of IFN-γ in LN CD8 T cells, which is responsible for LN expansion. Surgery-induced IFN-γ expression and expansion can be rescued by β2 adrenergic receptor agonists but not sensory nerve agonists. These data demonstrate the mechanisms governing the pro-inflammatory effect of loss of direct adrenergic input on lymph node function.
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Affiliation(s)
- Chien-Sin Chen
- Biomedical Center, Institute of Cardiovascular Physiology and Pathophysiology, Faculty of Medicine, Ludwig-Maximillians-Universität München, Planegg-Martinsried, Germany
| | - Jasmin Weber
- Biomedical Center, Institute of Cardiovascular Physiology and Pathophysiology, Faculty of Medicine, Ludwig-Maximillians-Universität München, Planegg-Martinsried, Germany
| | - Stephan Jonas Holtkamp
- Biomedical Center, Institute of Cardiovascular Physiology and Pathophysiology, Faculty of Medicine, Ludwig-Maximillians-Universität München, Planegg-Martinsried, Germany
| | - Louise Madeleine Ince
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Alba de Juan
- Biomedical Center, Institute of Cardiovascular Physiology and Pathophysiology, Faculty of Medicine, Ludwig-Maximillians-Universität München, Planegg-Martinsried, Germany
| | - Chen Wang
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Lydia Lutes
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Coline Barnoud
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Burak Kizil
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Sophia Martina Hergenhan
- Biomedical Center, Institute of Cardiovascular Physiology and Pathophysiology, Faculty of Medicine, Ludwig-Maximillians-Universität München, Planegg-Martinsried, Germany
| | - Johanna Salvermoser
- Biomedical Center, Institute of Cardiovascular Physiology and Pathophysiology, Faculty of Medicine, Ludwig-Maximillians-Universität München, Planegg-Martinsried, Germany
| | - Manuel Lasch
- Biomedical Center, Institute of Cardiovascular Physiology and Pathophysiology, Faculty of Medicine, Ludwig-Maximillians-Universität München, Planegg-Martinsried, Germany
- Walter-Brendel-Centre of Experimental Medicine, University Hospital, Ludwig-Maximillians-Universität München, Munich, Germany
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital, Ludwig-Maximillians-Universität München, Munich, Germany
| | - Elisabeth Deindl
- Biomedical Center, Institute of Cardiovascular Physiology and Pathophysiology, Faculty of Medicine, Ludwig-Maximillians-Universität München, Planegg-Martinsried, Germany
- Walter-Brendel-Centre of Experimental Medicine, University Hospital, Ludwig-Maximillians-Universität München, Munich, Germany
| | - Barbara Schraml
- Biomedical Center, Institute of Cardiovascular Physiology and Pathophysiology, Faculty of Medicine, Ludwig-Maximillians-Universität München, Planegg-Martinsried, Germany
| | - Dirk Baumjohann
- Institute for Immunology, Biomedical Center, Faculty of Medicine, Ludwig-Maximillians-Universität München, Planegg-Martinsried, Germany
- Medical Clinic III for Oncology, Hematology, Immuno-Oncology and Rheumatology, University Hospital Bonn, University of Bonn, Bonn, Germany
| | - Christoph Scheiermann
- Biomedical Center, Institute of Cardiovascular Physiology and Pathophysiology, Faculty of Medicine, Ludwig-Maximillians-Universität München, Planegg-Martinsried, Germany
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
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