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Giles JB, Martinez KL, Steiner HE, Klein A, Ooi A, Pryor J, Sweitzer N, Fuchs D, Karnes JH. Association of Metal Cations with the Anti-PF4/Heparin Antibody Response in Heparin-Induced Thrombocytopenia. Cardiovasc Toxicol 2024; 24:968-981. [PMID: 39017812 DOI: 10.1007/s12012-024-09895-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Accepted: 07/08/2024] [Indexed: 07/18/2024]
Abstract
Heparin-induced thrombocytopenia (HIT) is an antibody-mediated immune response against complexes of heparin and platelet factor 4 (PF4). The electrostatic interaction between heparin and PF4 is critical for the anti-PF4/heparin antibody response seen in HIT. The binding of metal cations to heparin induces conformational changes and charge neutralization of the heparin molecule, and cation-heparin binding can modulate the specificity and affinity for heparin-binding partners. However, the effects of metal cation binding to heparin in the context of anti-PF4/heparin antibody response have not been determined. Here, we utilized inductively coupled plasma mass spectrometry (ICP-MS) to quantify 16 metal cations in patient plasma and tested for correlation with anti-PF4/heparin IgG levels and platelet count after clinical suspicion of HIT in a cohort of heparin-treated patients. The average age of the cohort (n = 32) was 60.53 (SD = 14.31) years old, had a mean anti-PF4/heparin antibody optical density [OD405] of 0.93 (SD = 1.21) units, and was primarily female (n = 23). Patients with positive anti-PF4/heparin antibody test results (OD405 ≥ 0.5 units) were younger, had increased weight and BMI, and were more likely to have a positive serotonin release assay (SRA) result compared to antibody-negative patients. We observed statistical differences between antibody-positive and -negative groups for sodium and aluminum and significant correlations of anti-PF4/heparin antibody levels with sodium and silver. While differences in sodium concentrations were associated with antibody-positive status and correlated with antibody levels, no replication was performed. Additional studies are warranted to confirm our observed association, including in vitro binding studies and larger observational cohorts.
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Affiliation(s)
- Jason B Giles
- Lifecourse Epidemiology of Adiposity and Diabetes (LEAD) Center, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Kiana L Martinez
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, 1295 N Martin AVE, Tucson, AZ, 85721, USA
| | - Heidi E Steiner
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, 1295 N Martin AVE, Tucson, AZ, 85721, USA
| | - Andrew Klein
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, 1295 N Martin AVE, Tucson, AZ, 85721, USA
| | - Aikseng Ooi
- Department of Pharmacology and Toxicology, University of Arizona College of Pharmacy, Tucson, AZ, USA
| | - Julie Pryor
- Banner University Medical Center-Tucson, Tucson, AZ, USA
| | - Nancy Sweitzer
- John T Milliken Department of Internal Medicine, Washington University School of Medicine, St Louis, MO, USA
| | - Deborah Fuchs
- Banner University Medical Center-Tucson, Tucson, AZ, USA
| | - Jason H Karnes
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, 1295 N Martin AVE, Tucson, AZ, 85721, USA.
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA.
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Giles JB, Martinez KL, Steiner HE, Klein A, Ooi A, Pryor J, Sweitzer N, Fuchs D, Karnes JH. Association of Metal Cations with the Anti-PF4/Heparin Antibody Response in Heparin-Induced Thrombocytopenia. RESEARCH SQUARE 2024:rs.3.rs-4385055. [PMID: 38798628 PMCID: PMC11118685 DOI: 10.21203/rs.3.rs-4385055/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Abstract
Heparin-induced thrombocytopenia (HIT) is an antibody-mediated immune response against complexes of heparin and platelet factor 4 (PF4). The electrostatic interaction between heparin and PF4 is critical for the anti-PF4/heparin antibody response seen in HIT. The binding of metal cations to heparin induces conformational changes and charge neutralization of the heparin molecule, and cation-heparin binding can modulate the specificity and affinity for heparin-binding partners. However, the effects of metal cation binding to heparin in the context of anti-PF4/heparin antibody response have not been determined. Here, we utilized inductively coupled plasma mass spectrometry (ICP-MS) to quantify 16 metal cations in patient plasma and tested for correlation with anti-PF4/heparin IgG levels and platelet count after clinical suspicion of HIT in a cohort of heparin-treated patients. The average age of the cohort (n = 32) was 60.53 (SD = 14.31) years old, had a mean anti-PF4/heparin antibody optical density [OD405] of 0.93 (SD = 1.21) units and was primarily female (n = 23). Patients with positive anti-PF4/heparin antibody test results (OD405 ≥ 0.5 units) were younger, had increased weight and BMI, and were more likely to have a positive serotonin release assay (SRA) result compared to antibody negative patients. We observed statistical differences between antibody positive and negative groups for sodium and aluminum and significant correlations of anti-PF4/heparin antibody levels with sodium and silver. While differences in sodium concentrations were associated with antibody positive status and correlated with antibody levels, no replication was performed. Additional studies are warranted to confirm our observed association, including in vitro binding studies and larger observational cohorts.
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Pombal R, Silva L, Ferreira D. Genetic Predisposition to Vaccine-Induced Immune Thrombotic Thrombocytopenia: is there a Family Link? Eur J Case Rep Intern Med 2024; 11:004546. [PMID: 38846670 PMCID: PMC11152221 DOI: 10.12890/2024_004546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Accepted: 04/22/2024] [Indexed: 06/09/2024] Open
Abstract
Background Vaccine-induced immune thrombotic thrombocytopenia (VITT) is a rare life-threatening thrombotic reaction to COVID-19 vaccines. Case description Two young male first cousins, with a family history of idiopathic thrombocytopenic purpura, developed VITT after the Ad26.COV2.S vaccine. Both had a favourable clinical and analytical outcome. We investigated the genetic factors that could be associated with a genetic predisposition to VITT. Conclusions There are no published cases where the VITT patients were relatives. The genetic study did not reveal any likely pathogenic variants, although the prevalent polymorphism c.497A>G (p.(His166Arg)) in the FCGR2A gene was found in a homozygous state. More studies are required to better understand VITT's pathophysiology and any underlying genetic predispositions. LEARNING POINTS Vaccine-induced immune thrombotic thrombocytopenia (VITT), a rare but life-threatening disease, emerged with COVID-19 vaccines.The genetic analyses revealed the FCGR2A gene in a homozygous state.These cases may raise new questions about a family predisposition to VITT.
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Affiliation(s)
- Rita Pombal
- Immunohemotherapy Department, Unidade Local de Saúde Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - Luciana Silva
- Internal Medicine Department, Unidade Local de Saúde Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - David Ferreira
- Immunohemotherapy Department, Unidade Local de Saúde Gaia/Espinho, Vila Nova de Gaia, Portugal
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Karnes JH, Rollin J, Giles JB, Martinez KL, Steiner HE, Shaffer CM, Momozawa Y, Inai C, Bombin A, Shi M, Mosley JD, Stanaway I, Selleng K, Thiele T, Mushiroda T, Pouplard C, Heddle NM, Kubo M, Phillips EJ, Warkentin TE, Gruel Y, Greinacher A, Roden DM. ABO O blood group as a risk factor for platelet reactivity in heparin-induced thrombocytopenia. Blood 2022; 140:274-284. [PMID: 35377938 PMCID: PMC9305089 DOI: 10.1182/blood.2021014240] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 03/08/2022] [Indexed: 11/20/2022] Open
Abstract
Heparin-induced thrombocytopenia (HIT) is an unpredictable, potentially catastrophic adverse effect resulting from an immune response to platelet factor 4 (PF4)/heparin complexes. We performed a genome-wide association study (GWAS) with positive functional assay as the outcome in a large discovery cohort of patients divided into 3 groups: (1) functional assay-positive cases (n = 1269), (2) antibody-positive (functional assay-negative) controls (n = 1131), and (3) antibody-negative controls (n = 1766). Significant associations (α = 5 × 10-8) were investigated in a replication cohort (α = 0.05) of functional assay-confirmed HIT cases (n = 177), antibody-positive (function assay-negative) controls (n = 258), and antibody-negative controls (n = 351). We observed a strong association for positive functional assay with increasing PF4/heparin immunoglobulin-G (IgG) level (odds ratio [OR], 16.53; 95% confidence interval [CI], 13.83-19.74; P = 1.51 × 10-209) and female sex (OR, 1.15; 95% CI, 1.01-1.32; P = .034). The rs8176719 C insertion variant in ABO was significantly associated with positive functional assay status in the discovery cohort (frequency = 0.41; OR, 0.751; 95% CI, 0.682-0.828; P = 7.80 × 10-9) and in the replication cohort (OR, 0.467; 95% CI, 0.228-0.954; P = .0367). The rs8176719 C insertion, which encodes all non-O blood group alleles, had a protective effect, indicating that the rs8176719 C deletion and the O blood group were risk factors for HIT (O blood group OR, 1.42; 95% CI, 1.26-1.61; P = 3.09 × 10-8). Meta-analyses indicated that the ABO association was independent of PF4/heparin IgG levels and was stronger when functional assay-positive cases were compared with antibody-positive (functional assay-negative) controls than with antibody-negative controls. Sequencing and fine-mapping of ABO demonstrated that rs8176719 was the causal single nucleotide polymorphism (SNP). Our results clarify the biology underlying HIT pathogenesis with ramifications for prediction and may have important implications for related conditions, such as vaccine-induced thrombotic thrombocytopenia.
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Affiliation(s)
- Jason H Karnes
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, AZ
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
| | - Jerome Rollin
- Regional University Hospital Centre Tours, Department of Hemostasis, Tours, France
- University of Tours, EA7501 GICC, Tours, France
| | - Jason B Giles
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, AZ
| | - Kiana L Martinez
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, AZ
| | - Heidi E Steiner
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, AZ
| | | | - Yukihide Momozawa
- RIKEN Center for Integrative Medical Sciences (IMS), Yokohama, Kanagawa, Japan
| | - Chihiro Inai
- RIKEN Center for Integrative Medical Sciences (IMS), Yokohama, Kanagawa, Japan
| | - Andrei Bombin
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Mingjian Shi
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
| | - Jonathan D Mosley
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Ian Stanaway
- Department of Medicine, Kidney Research Institute, University of Washington, Seattle, WA
| | - Kathleen Selleng
- Institute of Immunology and Transfusion Medicine, University of Greifswald, Greifswald, Germany
| | - Thomas Thiele
- Institute of Immunology and Transfusion Medicine, University of Greifswald, Greifswald, Germany
| | - Taisei Mushiroda
- RIKEN Center for Integrative Medical Sciences (IMS), Yokohama, Kanagawa, Japan
| | - Claire Pouplard
- Regional University Hospital Centre Tours, Department of Hemostasis, Tours, France
- University of Tours, EA7501 GICC, Tours, France
| | - Nancy M Heddle
- Department of Medicine, McMaster University, Hamilton, ON, Canada; and
| | - Michiaki Kubo
- RIKEN Center for Integrative Medical Sciences (IMS), Yokohama, Kanagawa, Japan
| | - Elizabeth J Phillips
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Department of Pharmacology, Vanderbilt University Medical Center, Nashville, TN
| | | | - Yves Gruel
- Regional University Hospital Centre Tours, Department of Hemostasis, Tours, France
- University of Tours, EA7501 GICC, Tours, France
| | - Andreas Greinacher
- Institute of Immunology and Transfusion Medicine, University of Greifswald, Greifswald, Germany
| | - Dan M Roden
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Department of Pharmacology, Vanderbilt University Medical Center, Nashville, TN
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Miller E, Norwood C, Giles JB, Huddart R, Karnes JH, Whirl-Carrillo M, Klein TE. PharmGKB summary: heparin-induced thrombocytopenia pathway, adverse drug reaction. Pharmacogenet Genomics 2022; 32:117-124. [PMID: 35102073 PMCID: PMC8988468 DOI: 10.1097/fpc.0000000000000465] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Elise Miller
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, Arizona
| | - Charles Norwood
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, Arizona
| | - Jason B. Giles
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, Arizona
| | - Rachel Huddart
- Department of Biomedical Data Science, Stanford University, Stanford, CA
| | - Jason H. Karnes
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, Arizona
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
| | | | - Teri E. Klein
- Department of Biomedical Data Science, Stanford University, Stanford, CA
- Department of Biomedical Informatics Research, Stanford University, Stanford, CA
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Giles JB, Miller EC, Steiner HE, Karnes JH. Elucidation of Cellular Contributions to Heparin-Induced Thrombocytopenia Using Omic Approaches. Front Pharmacol 2022; 12:812830. [PMID: 35126147 PMCID: PMC8814424 DOI: 10.3389/fphar.2021.812830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 12/31/2021] [Indexed: 11/23/2022] Open
Abstract
Heparin-induced thrombocytopenia (HIT) is an unpredictable, complex, immune-mediated adverse drug reaction associated with a high mortality. Despite decades of research into HIT, fundamental knowledge gaps persist regarding HIT likely due to the complex and unusual nature of the HIT immune response. Such knowledge gaps include the identity of a HIT immunogen, the intrinsic roles of various cell types and their interactions, and the molecular basis that distinguishes pathogenic and non-pathogenic PF4/heparin antibodies. While a key feature of HIT, thrombocytopenia, implicates platelets as a seminal cell fragment in HIT pathogenesis, strong evidence exists for critical roles of multiple cell types. The rise in omic technologies over the last decade has resulted in a number of agnostic, whole system approaches for biological research that may be especially informative for complex phenotypes. Applying multi-omics techniques to HIT has the potential to bring new insights into HIT pathophysiology and identify biomarkers with clinical utility. In this review, we review the clinical, immunological, and molecular features of HIT with emphasis on key cell types and their roles. We then address the applicability of several omic techniques underutilized in HIT, which have the potential to fill knowledge gaps related to HIT biology.
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Affiliation(s)
- Jason B. Giles
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, AZ, United States
| | - Elise C. Miller
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, AZ, United States
| | - Heidi E. Steiner
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, AZ, United States
| | - Jason H. Karnes
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, AZ, United States,Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, United States,*Correspondence: Jason H. Karnes,
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Banerjee AK. Molecular fingerprinting by single cell clone analysis in adverse drug reaction (ADR) assessment. Curr Drug Saf 2021; 17:1-6. [PMID: 34315383 DOI: 10.2174/1574886316666210727150415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 05/06/2021] [Accepted: 06/07/2021] [Indexed: 11/22/2022]
Abstract
Causality assessment for idiosyncratic ADRs mainly relies on epidemiology, signal detection and less often on proven or plausible mechanistic evidence of the drug at a cellular or organ level. Distinct clones of cells can exist within organs of individual patients, some conferring susceptibility to well recognised adverse drug reactions (ADRs). Recent advances in molecular biology has allowed the development of single cell clonal techniques, including single cell RNA sequencing (scRNA-seq) to molecularly fingerprint ADRs and distinguish between distinct clones of cells within organs in individuals, which may confer differing susceptibilities to ADRs. ScRNA-seq permits molecular fingerprinting of some serious ADRs, mainly in the skin, through identification of directly expressed genes (DEG) of interest within specific clones. Overexpressed DEGs provides an opportunity for targeted treatment strategies to be developed. scRNA-seq could be applied to a number of other ADRs involving tissues that can be biopsied/sampled (including skin, liver, kidney, blood, stem cells) as well as providing a molecular basis for rapid screening of potential therapeutic candidates, which may not otherwise be predictable from class of toxicity/organ involvement. . A framework for putative assessment for ADRs using scRNA-seq is proposed as well as speculating on potential regulatory implications for pharmacovigilance and drug development. Molecular fingerprinting of ADRs using scRNA-seq may allow better targeting for enhanced pharmacovigilance and risk minimisation measures for medicines with appropriate benefit risk profiles, although cost-effectiveness and other factors, such as frequency/severity of individual ADRs and population differences will still be relevant.
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Affiliation(s)
- Anjan K Banerjee
- Consultant Pharmaceutical Physician and CEO, Medical Safety Solutions Ltd, Courtfield House, 21 Church Street, Market Deeping, Cambs PE6 8AN , United Kingdom
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Pattanaik S, Jain A, Ahluwalia J. Evolving Role of Pharmacogenetic Biomarkers to Predict Drug-Induced Hematological Disorders. Ther Drug Monit 2021; 43:201-220. [PMID: 33235023 DOI: 10.1097/ftd.0000000000000842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 09/21/2020] [Indexed: 11/26/2022]
Abstract
ABSTRACT Drug-induced hematological disorders constitute up to 30% of all blood dyscrasias seen in the clinic. Hematologic toxicity from drugs may range from life-threatening marrow aplasia, agranulocytosis, hemolysis, thrombosis to mild leukopenia, and thrombocytopenia. Pathophysiologic mechanisms underlying these disorders vary from an extension of the pharmacological effect of the drug to idiosyncratic and immune-mediated reactions. Predicting these reactions is often difficult, and this makes clinical decision-making challenging. Evidence supporting the role of pharmacogenomics in the management of these disorders in clinical practice is rapidly evolving. Despite the Clinical Pharmacology Implementation Consortium and Pharmacogenomics Knowledge Base recommendations, few tests have been incorporated into routine practice. This review aims to provide a comprehensive summary of the various drugs which are implicated for the hematological adverse events, their underlying mechanisms, and the current evidence and practical recommendations to incorporate pharmacogenomic testing in clinical care for predicting these disorders.
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Affiliation(s)
| | - Arihant Jain
- Internal Medicine, Hematology and Bone Marrow Transplantation, and
| | - Jasmina Ahluwalia
- Hematology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Individual variation in unfractionated heparin dosing after pediatric cardiac surgery. Sci Rep 2020; 10:19438. [PMID: 33173059 PMCID: PMC7655810 DOI: 10.1038/s41598-020-76547-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 10/29/2020] [Indexed: 11/24/2022] Open
Abstract
We aimed to identify attributing factors to the interindividual variabilities of the infusion rates in unfractionated heparin therapy. We included patients who required unfractionated heparin therapy to achieve the target APTT after cardiac surgery between May 2014 and February 2018. Fifty-nine patients were included, of whom 8 underwent Blalock-Taussig shunt; 27, Glenn procedure; 19, Fontan procedure; 3, mechanical valve replacement; and 2, Rastelli procedure. Previously reported variables that influenced the response to unfractionated heparin treatment were initially compared, which included age; weight; sex; type of surgery; platelet count; fibrinogen, antithrombin III, total protein, albumin, alanine transaminase, and creatinine levels; and use of fresh frozen plasma. The type of surgical procedure was found to be significantly associated with the differences in heparin infusion rate (P = 0.00073). Subsequently, the variance explained by these factors was estimated through a selection based on the minimum Akaike information criterion value; models constructed by various combinations of the surgery types were compared. The model including the Blalock-Taussig shunt, Glenn procedure, and mechanical valve replacement showed the highest summed variance explained (29.1%). More than 70% of the interindividual variability in initial heparin maintenance dosing was unexplained.
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Gautam I, Storad Z, Filipiak L, Huss C, Meikle CK, Worth RG, Wuescher LM. From Classical to Unconventional: The Immune Receptors Facilitating Platelet Responses to Infection and Inflammation. BIOLOGY 2020; 9:E343. [PMID: 33092021 PMCID: PMC7589078 DOI: 10.3390/biology9100343] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 10/06/2020] [Accepted: 10/15/2020] [Indexed: 12/14/2022]
Abstract
Platelets have long been recognized for their role in maintaining the balance between hemostasis and thrombosis. While their contributions to blood clotting have been well established, it has been increasingly evident that their roles extend to both innate and adaptive immune functions during infection and inflammation. In this comprehensive review, we describe the various ways in which platelets interact with different microbes and elicit immune responses either directly, or through modulation of leukocyte behaviors.
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Affiliation(s)
| | | | | | | | | | | | - Leah M. Wuescher
- Department of Medical Microbiology and Immunology, University of Toledo College of Medicine and Life Sciences, Toledo, OH 43614, USA; (I.G.); (Z.S.); (L.F.); (C.H.); (C.K.M.); (R.G.W.)
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