Significance of intravenous immunoglobulins to the neonate born of a mother with idiopathic thrombopenic purpura

High dose gammaglobulin therapy for pregnant women with idiopathic thrombocytopenic purpura may be suitable for both mother and foetus during pregnancy. A newborn with severe thrombocytopenia secondary to maternal illness, was treated successfully by intravenous gammaglobulin, without toxicity. In such a case, we believe the platelet count is not the only criterion for starting immunoglobulin therapy.     

Evaluation of platelet function in postsplenectomy thrombocytosis

The usually transient post-splenectomy thrombocytosis has no well defined effect on the development of thromboembolism. We studied 14 patients submitted to splenectomy for different causes: portal vein thrombosis (PVT), idiopathic thrombocytopenia purpura (ITP) and lymphoma. The mean platelet count in PVT patients was significantly higher than in all other subjects. In PVT group we demonstrated various alterations in platelet aggregation curves and a frequent increase of platelet 5-HT levels. In effect, we noted that all the PVT patients showed a myeloproliferative disease (MPD) before the surgical procedure. We therefore conclude that the increased incidence of thromboembolism in the patients who underwent splenectomy is probably caused by a preexisting MPD rather than the post-splenectomy thrombocytosis.     

Severe thrombocytopenia in Epstein-Barr virus-induced mononucleosis.

Severe thrombocytopenia is a rare complication of Epstein-Barr virus-induced infectious mononucleosis. We evaluated the clinical and laboratory data from seven patients seen between 1976 and 1985 whose lowest platelet counts varied from 3 to 25 x 10(9) per liter. Five of the seven patients were initially thought to have either acute leukemia or idiopathic thrombocytopenic purpura; eventually, however, primary Epstein-Barr virus infections were confirmed in all patients. Two of six patients tested had antiplatelet antibodies during the acute phase of their illnesses. Eight additional patients with acute disease who had only mild thrombocytopenia (94 to 144 x 10(9) per liter) were also tested for platelet antibodies with negative results. Steroid therapy was administered to three patients and platelet transfusions to one. All seven patients recovered with no serious hemorrhagic sequelae.     

High dose gammaglobulin therapy in adults with idiopathic thrombocytopenic purpura (ITP). Clinical effects

This study of the effect of high-dose intravenous gammaglobulins with one or two courses of therapy in 18 adults with idiopathic thrombocytopenia purpura showed a platelet rise in thirteen patients. The highest response rates were seen in splenectomized adults. In chronic patients the response was transient only. If therapy was effective, increased values of platelet-associated IgG were reduced, while shortened platelet survival times were prolonged. There was no influence of high-dose gammaglobulins on platelet function. different 7S-preparations such as beta-propiolactone modified Ig, pH 4 treated Ig and reduced and alkylated Ig have comparable effects.     

Increased factor VIII/vWf levels in patients with reduced platelet number

Factor VIII/von Willebrand factor (VIII/vWf) related properties were studied in twenty six patients with thrombocytopenia. Fifteen patients were affected by idiopathic thrombocytopenic purpura (ITP) and 11 patients by thrombocytopenia of a different nature or non-ITP (n-ITP). All patients showed an enhancement of platelet associated IgG (PAIgG). A significant increase of factor VIII ristocetin cofactor (VIII R: RCoF) and factor VIII related antigen (VIII R:Ag) was found in ITP patients while normal values were observed for factor VIII coagulant (VIII:C). All factor VIII/vWf components, on the contrary, were increased in n-ITP group with a prevalence of VIII R:RCoF as observed in ITP group even though with lower mean values. Multimeric analysis of VIII/vWf demonstrated a higher concentration of all multimeric components, with major representation of higher molecular weight multimers (HMWM) in patients of both groups. Two patients were studied before and after improvement in platelet count. A decrease of vWf related properties (VIII R:RCoF and VIII R:Ag) concomitant with the increase in platelet count was found. In n-ITP patients a statistical correlation between VIII R:RCoF and PAIgG was also observed while no correlation was found between other factor VIII/vWf components and PAIgG both in ITP and n-ITP patients.     

Polymorphisms in Canine Platelet Glycoproteins Identify Potential Platelet Antigens

Human alloimmune thrombocytopenic conditions caused by exposure to a platelet-specific alloantigen include neonatal alloimmune thrombocytopenia, posttransfusion purpura, and platelet transfusion refractoriness. More than 30 platelet-specific alloantigens have been defined in the human platelet antigen (HPA) system; however, there is no previous information on canine platelet-specific alloantigens. Using the HPA system as a model, we evaluated the canine ITGB3, ITGA2B, and GP1BB genes encoding GPIIIa (β₃), GPIIb (α_IIb), and GPIbβ, respectively, which account for 21 of 27 HPA, to determine whether amino acid polymorphisms are present in the orthologous canine genes. A secondary objective was to perform a pilot study to assess possible association between specific alleles of these proteins and a diagnosis of idiopathic thrombocytopenic purpura (ITP) in dogs. By using genomic DNA from dogs of various breeds with and without ITP, sequencing of PCR products encompassing all coding regions and exon–intron boundaries for these 3 genes revealed 4 single-nucleotide polymorphisms in ITGA2B resulting in amino acid polymorphisms in the canine genome, 3 previously reported and 1 newly identified (Gly[GGG]/Arg[AGG] at amino acid position 576 of ITGA2B. Of 16 possible ITGA2B protein alleles resulting from unique combinations of the 4 polymorphic amino acids, 5 different protein isoforms were present in homozygous dogs and explain all of the genotype combinations in heterozygous dogs. There was no amino acid polymorphism or protein isoform that was specific for a particular breed or for the diagnosis of ITP.Abbreviations: HPA, human platelet antigen; ITP, idiopathic thrombocytopenic purpura; PTR, platelet transfusion refractoriness; SNP, single-nucleotide polymorphismHuman alloimmune thrombocytopenic conditions caused by exposure to a platelet-specific alloantigen, through pregnancy or transfusion, include neonatal alloimmune thrombocytopenia, posttransfusion purpura, and platelet transfusion refractoriness (PTR). More than 30 platelet-specific alloantigens have been defined in the human platelet antigen (HPA) system, with 12 alloantigens grouped into 6 biallelic systems (HPA1 through HPA5 and HPA15) in which alloantibodies against both the common (designated ‘a’) and rare (designated ‘b’) alleles have been identified.^5,12 For the remaining 21 platelet alloantigens (HPA6bw through HPA14bw and HPA16bw through HPA27bw), only antibodies against the rare allele (designated ‘bw’) have been detected. Although HPA traditionally were defined by using immune sera, the molecular basis of these antigens has now been characterized.^5,12 The HPA reside in platelet membrane glycoproteins, the most common being GPIIIa, which accounts for 14 HPA. In all but one (HPA14bw), the platelet alloantigens are defined by a single amino-acid substitution caused by a single-nucleotide polymorphism (SNP) in the gene encoding the relevant membrane glycoprotein.^5,12 The Platelet Nomenclature Committee, which includes members of both the International Society of Blood Transfusion and the International Society of Thrombosis and Haemostasis, has set guidelines for defining new platelet antigens, which include: 1) determining the genetic basis of the alloantigen by genomic DNA sequence analysis, and 2) demonstrating an association between the genetic mutation and the reactivity of alloantibodies with the allelic forms of the protein.¹² For patients suspected of having alloimmune thrombocytopenia, well-defined platelet genotyping methods and serologic assays for the detection of platelet antibodies are available to guide case management.In contrast to the well-characterized HPA system and wealth of information on alloimmune thrombocytopenic conditions in humans, there is no information on canine platelet-specific alloantigens in the literature. However, early serologic studies using antiHPA1a alloantiserum resulted in direct immunoprecipitation of a 90-kDa protein from canine platelets, suggesting that the antigenic determinant for HPA1a has been conserved between humans and dogs.¹⁰ Neonatal alloimmune thrombocytopenia has not yet been documented in dogs, and there is a single case report of suspected posttransfusion purpura in a dog with hemophilia A, in which severe thrombocytopenia was noted 1 to 2 wk after transfusion (cryoprecipitate, fresh whole blood), with an increased amount of platelet surface-associated IgG and rapid resolution (less than 1 wk) of the thrombocytopenia.³⁰ PTR, however, has been well documented in dogs for more than 25 y, because this species has been used as an experimental model to evaluate a variety of methods of preventing platelet alloimmunization.^21-23 The occurrence of platelet alloimmunization in dogs receiving platelets from dog leukocyte antigen-identical littermates indicates that nondog leukocyte antigen immunizing platelet antigens, perhaps platelet-specific antigens, are responsible for the development of PTR.²¹Using the HPA system as a model, our main objective in this study was to evaluate the canine ITGB3, ITGA2B, and GP1BB genes encoding the GPIIIa (β₃), GPIIb (α_IIb), and GPIbβ, respectively, proteins that account for 21 of 27 HPA, to determine whether there are amino acid polymorphisms that could define canine platelet-specific alloantigens. A secondary objective was to perform a pilot study to assess the possible association between canine platelet antigen protein alleles or single amino acid substitutions and primary immune-mediated thrombocytopenia, also referred to as idiopathic thrombocytopenic purpura (ITP), in dogs. The identification of a canine platelet antigen system would improve our understanding of the molecular basis of alloimmune thrombocytopenic conditions in dogs and help guide effective platelet transfusion support of these critical patients.     

Mechanism of action, development and clinical experience of recombinant FVIIa

Recombinant FVIIa has been developed for treatment of bleedings in hemophilia patients with inhibitors, and has been found to induce hemostasis even during major surgery such as major orthopedic surgery. Recombinant FVIIa is being produced in BHK cell cultures and has been shown to be very similar to plasma-derived FVIIa. The use of rFVIIa in hemophilia treatment is a new concept of treatment and is based on the low affinity binding of FVIIa to the surface of thrombin activated platelets demonstrated in a cell-based in vitro model. By the administration of pharmacological doses of exogenous rFVIIa the thrombin generation on the platelet surface at the site of injury is enhanced independently of the presence of FVIII/FIX. As a result of the increased and rapid thrombin formation, a tight fibrin hemostatic plug is being formed. A tight fibrin structure has been found to be more resistant to fibrinolytic degradation thereby helping to maintain hemostasis. The general mechanism of action of pharmacological doses of rFVIIa shown to induce hemostasis not only in hemophilia, but also in patients with platelet defects, and with profuse bleedings triggered by extensive surgery or trauma, may very well be the capacity of generating a tight fibrin hemostatic plug through the increased thrombin generation. Such a fibrin plug will help to resist the overwhelming mostly local release of fibrinolytic activity triggered by the vast tissue damage occurring in extensive trauma. A release of fibrinlytic activity locally has also been demonstrated to occur in the gastrointestinal tract as well as during profuse postpartum bleedings. Pharmacological doses of rFVIIa have in fact, also been shown to induce hemostasis in such cases.     

Prostacyclin degradation in patients with quantitative platelet disorders

Plasma prostacyclin (PGI2) degradation rates were measured at 1, 5, 15 and 30 min in a group of patients with platelet quantitative disorders of various pathogeneses, including 13 with thrombocytosis, 16 with thrombocytopenia from impaired production in the bone marrow, 11 with thrombocytopenia from peripheral destruction, and 28 normal, healthy persons. Patients with thrombocytosis had a low PGI2 degradation rate, whereas patients with thrombocytopenia due to impaired production had a high PGI2 degradation rate. Of the patients with thrombocytopenia caused by peripheral destruction, six with idiopathic thrombocytopenia purpura (ITP) had a slow PGI2 degradation in contrast to five with systemic lupus erythematosus (SLE) - four concurrently had cryoglobulinemia - who had a rapid PGI2 degradation. The findings suggest that: (1) a platelet-derived substance in the human plasma may have a PGI2 stabilising activity; (2) presence of cryoglobulin or immune complex in plasma may interfere with PGI2 stability.     

妊娠合并血小板减少136例临床研究

目的：探讨妊娠合并血小板减少的原因及围生期处理方法。方法：回顾性分析2005年10月-2011年4月产科分娩的136例妊娠合并血小板减少患者临床资料。结果：妊娠合并血小板减少的主要原因有妊娠相关性血小板减少症（PAT）79例（58．09％）、妊娠期高血压疾病（PIH）21例（15．44％）、特发性血小板减少性紫癜（ITP）18例（13．24％）、妊娠期肝内胆汁瘀积症（ICP）16例（11．76％）;阴道分娩52例,剖宫产84例;产后出血16例,产褥感染1例。结论：多种原因可以导致妊娠妇女血小板减少。PAT是最常见类型。治疗采用针对病因治疗的基础上给予糖皮质激素、丙种球蛋白、输血小板等综合治疗。分娩方式视血小板多少及有无产科指征而定。     

In vivo gene amplification in non-cancerous cells: cholinesterase genes and oncogenes amplify in thrombocytopenia associated with lupus erythematosus.

The ACHE and BCHE genes, encoding the acetylcholine hydrolysing enzymes acetylcholinesterase (ACHE) and butyrylcholinesterase (BCHE), co-amplify with several oncogenes in leukemic patients with platelet deficiency (thrombocytopenia). This and other experiments implicated ACHE and BCHE in the development of bone marrow megakaryocytes, the progenitors of platelets. Therefore, we wished to find out whether cholinesterase gene amplification would also occur in non-cancerous platelet disorders and, if so, whether oncogenes would amplify in such cases as well. The autoimmune disease systemic lupus erythematosus (SLE) presents an appropriate model system for this issue, since patients with SLE may suffer from thrombocytopenia resistant to most treatment modalities. Here, we report a 40-80-fold amplification of genomic sequences from the ACHE and BCHE genes as well as the C-raf, V-sis and C-fes/fps oncogenes in peripheral blood cells from an SLE patient with severe thrombocytopenia. PvuII restriction analysis and DNA blot hybridization of the amplified ACHE and BCHE sequences demonstrated apparent aberrations in both genes, suggesting that malfunctioning of modified, partially amplified cholinesterase genes may be involved in the etiology of thrombocytopenia associated with SLE. These observations imply that cholinergic mechanisms regulate megakaryocytopoiesis, shed new light on the diverse hematologic findings characteristic of SLE, and may become valuable as diagnostic, treatment and prognostic tools in the follow-up of patients suffering from thrombocytopenia associated with SLE. Furthermore, these findings reinforce the notion that cholinesterase gene amplifications are causally related with platelet abnormalities in multiple hemopoietic disorders.     

Severe Acquired Idiopathic Thrombocytopenia in a Female Cynomolgus Macaque (Macaca fascicularis)

A 4-y-old female cynomolgus macaque presented for veterinary evaluation prior to placement in a preclinical study showed markedly low platelet counts that continued to decrease over time. Physical examination over the next several days showed areas of pale red discoloration in forelimbs, anterior thorax, and inguinal area and multifocal pinpoint areas of erythema or scabs. An area of dark red discoloration approximately 2 cm in diameter on the dorsal surface of the tongue was discovered on day 9. The macaque was euthanized, and histopathologic evaluation showed multifocal, ulcerative or erosive, hemorrhagic, lymphohistiocytic and neutrophilic glossitis and tonsillitis. The lesions on the tongue were associated with opportunistic fungi consistent with Candida albicans. The bone marrow showed megakaryocytic hyperplasia. There was no evidence of increased consumption of platelets, sequestration of platelets, or bone marrow suppression. The monkey was serologically negative for simian retrovirus, SIV, and simian T-lymphotropic virus. In light of cases reported in humans, immune-mediated destruction of platelets due to autoantibodies secondary to Candida albicans infection was considered. However, we were unable to detect antiplatelet antibodies on the platelet surface or in serum to support this etiology; therefore idiopathic thrombocytopenia was diagnosed. To our knowledge, this case represents the second reported observation of acquired thrombocytopenia in a nonhuman primate and the first reported observation in a cynomolgus macaque.Abbreviations: SVV, simian varicella virusDrug-induced thrombocytopenia is a serious but relatively common clinical condition, because numerous drugs have been associated with development of DIT. The diagnosis of drug-induced thrombocytopenia is usually made after the exclusion of all other possible causes, such as infectious agents and artifactual decreases due to clumping of platelets in vitro (pseudothrombocytopenia), and the establishment of a temporal relationship between the administration of a drug and the development of thrombocytopenia. Consequently, scientists involved with preclinical studies in NHP need to be aware of nondrug-related cases of unexplained marked thrombocytopenia like the one we describe in this case report because they may confound a drug-related effect.     

Determination of antiplatelet antibodies on the surface of platelets by direct radioimmune method in patients with different types of immune thrombocytopenia

Direct radioimmune assay (RIA) have been developed for detection of antibodies associated wild platelet membrane. Platelets from 12 patients with idiopathic thrombocytopenic purpura (ITP) and 27 patients with chronic lymphocytic leukemia (CLL) (platelet count (100,000 in 1 microliters) have been tested. Antibodies on platelets surface have been detected in all 12 patients with ITP and in 21 patients with CLL. In 6 CLL patients the number of immunoglobulins associated with platelets surface does not increase control level. It is possible, that in some CLL patients development of thrombocytopenia is mediated not only by platelet associated antibodies but by other mechanisms, one of which can be linked with the depression of megakaryocytes growth in bone marrow. Direct RIA for measurement of antibodies on platelet surface detect antiplatelet antibodies with higher frequency than indirect enzyme-linked-immunosorbent-assay (ELISA), developed earlier for assessment of antiplatelet antibodies in serum. Increase of platelet count in CLL patients after steroid and cytostatic treatment correlated with the decrease of platelet surface associated antibodies.     

Differential effects of prostacyclin and prostaglandin E1 on bronchoconstriction and thrombocytopenia during collagen and arachidonate infusions and anaphylactic shock in the guinea-pig

The antagonism by prostacyclin (PGI2) and prostaglandin E1 (PGE1) of bronchoconstriction induced by serotonin (5HT), collagen, arachidonic acid (AA) and anaphylaxis, as well as of thrombocytopenia was studied in the guinea-pig. Under conditions where PGE1 prevented bronchoconstriction by 5HT, by collagen or by AA better than the accompanying thrombocytopenia, PGI2 was a selective antagonist of bronchoconstriction due to collagen, but failed to interfere with that due to 5HT or to AA. Collagen-induced bronchoconstriction in the guinea-pig is platelet-dependent, being inhibited by immune platelet depletion, whereas that due to AA is platelet-independent. PGI2 blocks bronchoconstriction by collagen, because it prevents the platelet activation, and fails to interfere with bronchoconstriction by AA, even though it reduces the accompanying thrombocytopenia, because the role of platelets is negligible. PGE1 and PGI2 failed to interfere with thrombocytopenia or with bronchoconstriction of anaphylactic shock, and were inactive even when the acute bronchial effect was suppressed by anti-histamine treatment. Anaphylactic thrombocytopenia is beyond the control of agents which stimulate the cyclic AMP system, and involves specific mechanism which are not stimulated in platelet-rich plasma.     

The Effect of Factor VIII Deficiencies and Replacement and Bypass Therapies on Thrombus Formation under Venous Flow Conditions in Microfluidic and Computational Models

Clinical evidence suggests that individuals with factor VIII (FVIII) deficiency (hemophilia A) are protected against venous thrombosis, but treatment with recombinant proteins can increase their risk for thrombosis. In this study we examined the dynamics of thrombus formation in individuals with hemophilia A and their response to replacement and bypass therapies under venous flow conditions. Fibrin and platelet accumulation were measured in microfluidic flow assays on a TF-rich surface at a shear rate of 100 s⁻¹. Thrombin generation was calculated with a computational spatial-temporal model of thrombus formation. Mild FVIII deficiencies (5–30% normal levels) could support fibrin fiber formation, while severe (<1%) and moderate (1–5%) deficiencies could not. Based on these experimental observations, computational calculations estimate an average thrombin concentration of ∼10 nM is necessary to support fibrin formation under flow. There was no difference in fibrin formation between severe and moderate deficiencies, but platelet aggregate size was significantly larger for moderate deficiencies. Computational calculations estimate that the local thrombin concentration in moderate deficiencies is high enough to induce platelet activation (>1 nM), but too low to support fibrin formation (<10 nM). In the absence of platelets, fibrin formation was not supported even at normal FVIII levels, suggesting platelet adhesion is necessary for fibrin formation. Individuals treated by replacement therapy, recombinant FVIII, showed normalized fibrin formation. Individuals treated with bypass therapy, recombinant FVIIa, had a reduced lag time in fibrin formation, as well as elevated fibrin accumulation compared to healthy controls. Treatment of rFVIIa, but not rFVIII, resulted in significant changes in fibrin dynamics that could lead to a prothrombotic state.     

利奈唑胺对肾功能不全G~+感染患者血小板减少的相关性研究

目的:分析利奈唑胺对肾功能不全G+患者血小板减少的关系。方法:回顾性分析92例应用利奈唑胺治疗的革兰阳性球菌感染患者的临床资料,根据是否伴有肾功能不全分为肾功能不全组(33例),正常组(59例),检测用药前、用药后血小板计数,观察停药后血小板计数恢复正常时间及不良反应发生情况。结果:肾功能不全组治疗后血小板计数显著低于治疗前及正常组(P0.01),正常组治疗前、后血小板计数比较无统计学意义(P0.05);肾功能不全组血小板减少发生率高于正常组(P0.05);停药后正常组血小板恢复正常时间短于肾功能不全组(P0.01);肾功能不全组血红蛋白下降率高于正常组(P0.05),其余不良反应发生率比较差异无统计学意义(P0.05)。结论:感染患者肾功能可影响利奈唑胺所致血小板减少发生率,肾功能不全患者在应用利奈唑胺时应定期监测血小板计数。     

A New Ibuprofen Derivative Inhibits Platelet Aggregation and ROS Mediated Platelet Apoptosis

Thrombocytopenia is a serious issue connected with the pathogenesis of several human diseases including chronic inflammation, arthritis, Alzheimer''s disease, cardiovascular diseases (CVDs) and other oxidative stress-associated pathologies. The indiscriminate use of antibiotics and other biological drugs are reported to result in thrombocytopenia, which is often neglected during the treatment regime. In addition, augmented oxidative stress induced by drugs and pathological conditions has also been shown to induce thrombocytopenia, which seems to be the most obvious consequence of elevated rate of platelet apoptosis. Thus, blocking oxidative stress-induced platelet apoptosis would be of prime importance in order to negotiate thrombocytopenia and associated human pathologies. The current study presents the synthesis and platelet protective nature of novel ibuprofen derivatives. The potent anti-oxidant ibuprofen derivative 4f was selected for the study and the platelet protective efficacy and platelet aggregation inhibitory property has been demonstrated. The compound 4f dose dependently mitigates the oxidative stress-induced platelet apoptosis in both platelet rich plasma and washed platelets. The platelet protective nature of compound 4f was determined by assessing various apoptotic markers such as ROS generation, cytosolic Ca²⁺ levels, PS externalization, cytochrome C translocation, Caspase activation, mitochondrial membrane depolarization, cytotoxicity, LDH leakage and tyrosine phosphorylation of cytosolic proteins. Furthermore, compound 4f dose dependently ameliorated agonist induced platelet aggregation. Therefore, compound 4f can be estimated as a potential candidate in the treatment regime of pathological disorders associated with platelet activation and apoptosis. In addition, compound 4f can be used as an auxiliary therapeutic agent in pathologies associated with thrombocytopenia.     

Chronic immune thrombocytopenic purpura in hemophilia A.

Chronic immune thrombocytopenic purpura resistant to steroid therapy occurred in a 30-year-old patient with severe hemophilia A. This association has recently been reported in other patients, and a possible relation to the acquired immune deficiency syndrome (AIDS) has been suggested. Although this patient had been treated with factor VIII concentrate for 4 years, the proportions of helper and suppressor T cells were normal, and there was no evidence of AIDS. An uncomplicated splenectomy gave excellent results. All patients with hemophilia should have their platelet counts monitored closely and should report any unusual pattern of bleeding.     

Human megakaryocytopoiesis--normal and abnormal.

Regulation of megakaryocyte and platelet production remains poorly understood. In culture system two separate activities are needed for maximum production of megakaryocyte progenitors: promotor of clonal expansion and promoter of maturation, other growth factors and cells also contribute to regulation of megakaryocytopoiesis. Increased proliferation of megakaryocytes is observed in myeloproliferative disorders and idiopathic thrombocytopenic purpura, and decreased proliferation is found in aplastic anaemia and hypomegakaryocytic thrombocytopenia. Dysmegakaryocytopoiesis is present in myelodysplastic syndromes and acute leukaemia, and a proliferation of immature megakaryocytes in acute megakaryoblastic leukaemia. Increased understanding of human megakaryocytopoiesis is beginning to help in rational clinical management.     

Heparin-associated thrombocytopenia: low frequency in 104 patients treated with heparin of intestinal mucosal origin.

A prospective study of 104 patients receiving heparin obtained from porcine intestinal mucosa for 4 or more days was conducted to determine the frequency of associated significant thrombocytopenia (platelet count less than 100 x 10(9)/I on 2 consecutive days). No episodes of significant thrombocytopenia were identified in the 13 patients receiving heparin by continuous intravenous infusion for a mean of 8.0 days or in the 38 patients receiving heparin subcutaneously for a mean of 9.9 days. In 1 of the 26 patients receiving heparin as intermittent intravenous boluses for a mean of 8.2 days significant thrombocytopenia developed; this patient had laboratory evidence of disseminated intravascular coagulation. In none of the 17 patients receiving uninterrupted heparin therapy for 4 or more days by more than one route of administration but for less than 4 days by any single route did significant heparin-associated thrombocytopenia develop. Of the 104 patients 13 had one or more platelet counts of less than 150 x 10(9)/I, but in most it was not possible to definitely relate the thrombocytopenia to the heparin therapy. Platelets in normal platelet-rich plasma did not aggregate when heparin and serum from patients with thrombocytopenia were added. The frequency of heparin-associated thrombocytopenia noted in this study was considerably lower than that reported previously.     

Misfolding of vWF to Pathologically Disordered Conformations Impacts the Severity of von Willebrand Disease

The primary hemostatic von Willebrand factor (vWF) functions to sequester platelets from rheological blood flow and mediates their adhesion to damaged subendothelium at sites of vascular injury. We have surveyed the effect of 16 disease-causing mutations identified in patients diagnosed with the bleeding diathesis disorder, von Willebrand disease (vWD), on the structure and rheology of vWF A1 domain adhesiveness to the platelet GPIbα receptor. These mutations have a dynamic phenotypical range of bleeding from lack of platelet adhesion to severe thrombocytopenia. Using new rheological tools in combination with classical thermodynamic, biophysical, and spectroscopic metrics, we establish a high propensity of the A1 domain to misfold to pathological molten globule conformations that differentially alter the strength of platelet adhesion under shear flow. Rheodynamic analysis establishes a quantitative rank order between shear-rate-dependent platelet-translocation pause times that linearly correlate with clinically reported measures of patient platelet counts and the severity of thrombocytopenia. These results suggest that specific secondary structure elements remaining in these pathological conformations of the A1 domain regulate GPIbα binding and the strength of vWF-platelet interactions, which affects the vWD functional phenotype and the severity of thrombocytopenia.