Interrelationship between mitosis and endomitosis in cultures of human megakaryocyte progenitor cells [published erratum appears in Blood 1987 May;69(5):1547]

Sera from dogs rendered aplastic by total-body irradiation stimulate human bone marrow megakaryocyte progenitors to form megakaryocyte colonies in plasma clot cultures. In this investigation, we evaluated the effects of varying concentrations of such sera on both the mitotic and endomitotic phases of human megakaryocyte development in vitro. When low concentrations of aplastic canine sera (2.5% to 5.0% [vol/vol]) were added to cultures of human peripheral blood mononuclear cells in place of normal AB serum, megakaryocyte colony formation was augmented fivefold, cell numbers per colony increased approximately 2.5- fold, and the geometric mean megakaryocyte ploidy almost doubled. Further increasing the aplastic canine serum concentration from 10% to 30% (vol/vol) stimulated no additional colony formation. However, there was a further augmentation of cell numbers per colony associated with a progressive decrease in the mean megakaryocyte ploidy. Megakaryocyte cultures were harvested after 7, 12, 15, and 19 days of incubation, and these demonstrated that the lower mean ploidy values found at the higher concentrations of aplastic canine serum did not result from delayed endoreduplication. At all aplastic serum concentrations evaluated, there existed a strong correlation between nuclear ploidy and cell diameter. We conclude that both the mitotic and endomitotic events in human megakaryocytopoiesis may be influenced by a factor or factors present in aplastic canine serum. At lower in vitro concentrations, such sera stimulate both mitosis and endomitosis, which promotes the development of megakaryocyte colonies composed of larger cells with a higher mean ploidy. With increasing aplastic serum concentrations, colony formation plateaus and mitosis is favored over endomitosis. This results in colonies composed of more numerous but smaller megakaryocytes with a lower mean ploidy. Our data suggest that the size and extent of polyploidization that can be achieved by a developing megakaryocyte may be influenced by the mitotic prior history of its immediate precursor cell.     

Combining counterflow centrifugal elutriation and glycoprotein Ib-dependent purification of human megakaryocytes: efficacy and selectivity

To estimate the efficacy of human megakaryocyte purification techniques, mixtures of known numbers of megakaryocytes with a known ploidy range and of bone marrow or peripheral blood mononuclear cells were made. These artificial bone marrow samples were submitted to either a counterflow centrifugal elutriation or Percoll density separation followed by the glycoprotein Ib-dependent agglutination procedure. Also crude bone marrow samples were submitted to counterflow centrifugal elutriation directly followed by a glycoprotein Ib-dependent agglutination. The counterflow centrifugal elutriation resulted in a mean megakaryocyte recovery of 81% (mean 81% +/- 2.3). Purification by glycoprotein Ib-dependent agglutination after either a Percoll density separation or counterflow centrifugal elutriation resulted in a recovery of 61% (mean 61% +/- 15%) and 81% (mean 81% +/- 6) respectively. Purity of the resulting material was 87% (mean 87% +/- 11) and 83% (mean 83% +/- 5) respectively. The various isolation procedures did not affect the ploidy distribution of megakaryocytes greater than or equal to 8N. Counterflow centrifugal elutriation was preferred as the preparing step before glycoprotein Ib-dependent agglutination because of the lower variability in recovery and purity of megakaryocyte populations. When large numbers of rather pure and mature megakaryocytes are required, counterflow centrifugal elutriation followed by the glycoprotein Ib-dependent agglutination is a relatively simple method to purify human megakaryocytes without an appreciable loss in ploidy class greater than or equal to 8N.     

Measurement of megakaryocyte frequency and ploidy distribution in unfractionated murine bone marrow

Measurement of megakaryocyte frequency, ploidy distribution, and maturation stage have been complicated by the low frequency of megakaryocytes in either bone marrow or spleen. Due to harsh labeling conditions, previous studies utilizing flow cytometry have not quantified cell recovery or megakaryocyte frequency. We have modified our two-color fluorescence-activated cytometric technique in order to identify megakaryocytes in unfractionated murine bone marrow with a fluoresceinated cell surface immunologic probe (heterologous polyclonal platelet antiserum) and to selectively measure megakaryocyte DNA content with propidium iodide using isosmolar conditions. Under these conditions, total nucleated cell recovery from unfractionated normal murine bone marrow, after all preparative procedures, averaged 68.0% +/- 5.0% (SD) with 93.5% +/- 2.0% DNA staining efficiency. Mean megakaryocyte frequency (n = 30) was 0.14% +/- 0.04%. Using both our previously described gating technique with single parameter analysis and our modified dual parameter technique, the modal megakaryocyte ploidy class was 16N. Low ploidy megakaryocytes, 2N and 4N, constituted 9.8% and 10.8%, respectively, of the total megakaryocyte population. Analysis of the megakaryocyte population with respect to cell surface fluorescence intensity demonstrated that the dimly fluorescent population contained an increased proportion of lower ploidy class cells (2N + 4N + 8N) compared with brightly fluorescent cells, which contained an increased proportion of higher ploidy cells (16N + 32N). Our modifications of the two-color technique yielded improved recovery of total nucleated bone marrow cells from unfractionated bone marrow and provided more precise measurements of megakaryocyte frequency and ploidy than previously available.     

Induction of cytotoxicity in resting human T lymphocytes bound to tumor cells by antibody heteroconjugates.

An in vitro model for peripheral human T-cell activation and resultant tumor cell killing is described. Cytotoxic T lymphocytes may be generated from resting lymphocytes by incubation of human peripheral blood mononuclear cells for 3 days with the anti-CD3 monoclonal antibody OKT3. Cytotoxicity in peripheral blood mononuclear cells can also be induced by adding an anti-target-OKT3 antibody conjugate and 10% (vol/vol) fetal calf serum to the culture medium. Conjugate activation of T cells was almost completely blocked, however, when 20% (vol/vol) human serum was added to the medium. Conjugate-mediated peripheral blood mononuclear cells activation was restored to some extent by the addition of melanoma target cells to the culture and was markedly enhanced by a second conjugate containing anti-target cell and anti-CD28 antibody. Monoclonal antibody 9.3 (anti-CD28) provides a progression signal in T-lymphocyte activation when used in combination with anti-CD3. Thus, presentation by the tumor target cells of anti-CD3 and anti-CD28 to resting human lymphocytes causes T-cell activation, which is independent of monocytes, proceeds in the presence of human serum, and results in tumor cell killing.     

Cloning of murine megakaryocyte progenitor cells in a fibrin clot culture system

A fibrin clot culture system was applied to the cloning of mouse megakaryocyte colony-forming cells (CFU-Meg). The culture medium in this new method consists of Iscove's minimal essential medium containing fetal bovine serum, bovine fibrinogen, bovine thrombin, and pokeweed mitogen-stimulated mouse spleen cell-conditioned medium (PWM-SCM). CFU-Meg colony frequency with 10% PWM-SCM was maximal on days 5-6 of culture. Plating efficiencies averaged 36.1 +/- 3.9 and 51.9 +/- 6.0 per 1.5 X 10(5) BDF1 bone marrow cells and 1.0 X 10(6) spleen cells, respectively. The addition of bovine serum albumin to the culture medium had no effect on the efficiency of megakaryocyte colony growth in this culture system. This simplified and reproducible culture system supported not only the growth of colonies composed of megakaryocytes in "synchronous maturation," but also so-called "heterogenous" megakaryocyte colonies composed of cells in all stages of maturation.     

The effect of partially purified thrombopoietin on guinea pig megakaryocyte ploidy in vitro

Enriched populations of guinea pig bone marrow megakaryocytes were prepared by density gradient and velocity centrifugation and maintained in liquid cultures for 24 or 48 h. The resulting megakaryocyte preparations were of 86.1% +/- 5.5% purity. After 24 or 48 h in liquid culture, recovery of viable cells was 77% +/- 11% or 83% +/- 13%, respectively. Megakaryocyte cultures were supplemented with 100-200 micrograms/ml of either a lectin-fractionated preparation of thrombopoietin (TPO) from the plasma of thrombocytopenic rabbits or an identically prepared protein fraction from non-thrombocytopenic animals. Addition of TPO resulted in a significant increase (p less than 0.05) in both the proportion and total numbers of 32N megakaryocytes and a significant decrease (p less than 0.05) in the relative frequency of 8N megakaryocytes. In most experiments, a decrease in the total number of 8N megakaryocytes also was noted. These results indicate that partially purified TPO is able to increase the ploidy (DNA levels) of megakaryocytes in vitro.     

Modest stimulatory effect of recombinant human GM-CSF on colony growth from peripheral blood human megakaryocyte progenitor cells

Recombinant human granulocyte-macrophage colony-stimulating factor (rGM-CSF) has been previously demonstrated to stimulate colony formation from human myeloid, erythroid, and multipotential stem cells. In this investigation, we evaluated the effects of rGM-CSF on colony growth by human megakaryocyte progenitors (CFU-Meg). rGM-CSF was tested at concentrations of 0.1-100 U/ml in plasma clot cultures of adherent-depleted normal peripheral blood mononuclear cells. Control cultures were concurrently prepared containing either no stimulator or megakaryocyte colony-stimulating factor (Meg-CSF) partially purified from aplastic canine serum. rGM-CSF increased megakaryocyte colony numbers from a baseline of 4.3 +/- 1.4 (+/- SEM) in the unstimulated cultures to a maximum of 21.0 +/- 5.3 colonies at an rGM-CSF concentration of 1.0 U/ml. Corresponding megakaryocytic colony size increased from 4.4 to 8.3 cells/colony. Further increasing the rGM-CSF concentration resulted in decreasing megakaryocyte colony growth, reaching 6.8 +/- 2.9 colonies at 100 U/ml. The maximum number of megakaryocyte colonies stimulated by rGM-CSF was only 23.3% of that achieved in the control cultures containing optimal concentrations of serum-derived Meg-CSF protein (2.0 mg/ml). Megakaryocyte colonies stimulated by rGM-CSF consisted of predominantly low ploidy cells approximately equally distributed in 2N, 4N, and 8N ploidy classes. There was no increase in ploidy with any rGM-CSF concentration. These data indicate that rGM-CSF has modest activity in stimulating human megakaryocyte colony growth that is substantially less than that present in serum-derived Meg-CSF. rGM-CSF appears to primarily affect the early mitotic phase of megakaryocyte colony development with little influence on megakaryocyte endoreduplication.     

Cord blood is better than bone marrow for generating megakaryocytic progenitor cells

Thrombocytopenia remains an important problem for patients post high-dose chemotherapy and hematopoietic stem cell transplantation. The study of megakaryocytes, the direct precursors of platelets, has been hampered by their relatively low frequency in hematopoietic tissues. In an attempt to obtain a large number of functional megakaryocytic cells, we established a serum-free culture system to grow megakaryocytic progenitor cells derived from normal human bone marrow (BM) and cord blood (CB). Highly purified (purity >95%) CD34+ cells were obtained using magnetic cell sorting (MACS) followed by fluorescence activated cell sorting (FACS). The cells were cultured in a serum-free culture system for 3 weeks in the presence of a single dose of MGDF (50 ng/mL). On days 0, 5, 8, 12, 14, 18, and 21 of culture, the cellularity and morphology were examined. Megakaryocytic cells were monitored by detecting the expression of GPIIIa (CD61), GPIIb/IIIa (CD41) and GPIb (CD42b), and the distribution of megakaryocyte (MK) ploidy was analyzed by two-color flow cytometry. MGDF alone induced maximal nucleated cell expansion at day 14, resulting in a 38.20+/-10.47-fold increase in cell number for CB and a 5.08+/-1.30-fold increase in cell number for BM. On day 14 of the culture, the percentage of CD41-/CD14- cells derived from CB reached 73.54%+/-6.01% giving an absolute number of CD41+/CD14- cells of 27.25+/-2.23 x 10(4)/mL (27,250-fold increase), whilst the percentage of CD41+/CD14- cells derived from BM was only 29.21%+/-5.63% with an absolute number of 1.36+/-0.26 x 10(4)/mL (680-fold increase). Increased expression of GPIIIa occurred the earliest in culture, followed by GPIIb/IIIa, and then GPIb. The majority (81.6%-92.6%) of megakaryocytes (CD41+ cells) on day 14 of culture were 2N, although we did detect some 4N, 8N and greater ploidy cells. In conclusion, CD34+ cells stimulated by MGDF alone generated highly enriched MK progenitor cells at day 14 of serum-free culture. CB stem and progenitor cells have a greater proliferative response to MGDF alone than those derived from BM and may, therefore, prove to be a better source of cells for MK expansion.     

Effects of thrombopoietin on the proliferation and differentiation of primitive and mature haemopoietic progenitor cells in cord blood

Thrombopoietin (TPO) is considered to be the primary growth factor for regulating megakaryopoiesis and thrombopoiesis. In this study we investigated the in vitro effect of TPO on relatively immature and mature CD34⁺ progenitor cells in cord blood. Cells were cultured in both liquid and semi-solid cultures containing 50 ng/ml TPO. The CD34⁺/CD45RA⁻ and CD34⁺/CD38⁻ subfractions in cord blood were both enriched for megakaryocyte progenitors as determined in a semisolid CFU-meg assay. Progenitor cells derived from the CD34⁺/CD45RA⁻ and CD34⁺/CD38⁻ subfractions showed high proliferative capacity in liquid cultures. We observed a mean 19-fold expansion of the total CD34⁺ cell fraction, whereas in the CD34⁺/CD45RA⁻ and CD34⁺/CD38⁻ subfractions the mean expansion was 23- and 50-fold respectively. The expansion of the immature progenitor cell subfractions resulted in a highly purified megakaryocyte suspension containing > 80% megakaryocytes after 14 d in culture. However, these expanded megakaryocytes remained in a diploid (2N) and tetraploid (4N) state. Maturation could not be further induced by low concentration of TPO (0.1 ng/ml). The majority of the cells were 2N (80%) and 4N (15%) and only 5% of the cells had a ploidy of more than 4N. These results indicate that megakaryocyte progenitor cells in cord blood residing in the immature stem cell fraction exhibit a high proliferative capacity when cultured in the presence of TPO as the single growth factor, without maturation to hyperploid megakaryocytes.     

Immunofluorescent identification of human megakaryocyte colonies using an antiplatelet glycoprotein antiserum

The development of a satisfactory in vitro assay system for human megakaryocyte colony forming progenitor cells has been delayed by the lack of a suitable marker for cells of human megakaryocyte lineage. For this purpose we raised an antiserum directed against a purified human platelet glycoprotein preparation. In conjunction with indirect immunofluorescent staining of human bone marrow, this antiserum labeled only platelets, megakaryocytes, and an infrequent population of small mononuclear cells. These small mononuclear cells, not otherwise identifiable as members of the megakaryocyte series, constituted 22.9% of the total fluorescein positive nucleated bone marrow cells. This antiserum was also used to label colonies cultured from human peripheral blood mononuclear cells using a modified plasma clot technique. A mean of 123 fluorescein-labeled colonies were cloned per 10(6) mononuclear cells cultured. Granulocyte-macrophage and erythroid burst colonies did not label using this method. No augmentation of colony numbers was found with varying concentrations of erythropoietin, human embryonic kidney cell conditioned media (a source of thrombopoietin), or media conditioned by a human T lymphoblast cell line (a source of both colony stimulating and burst promoting activities). Immunofluorescent labeling for platelet glycoproteins is a convenient phenotypic marker for cells of human megakaryocyte lineage useful in the study of in vitro human megakaryocytopoiesis.     

The significance of megakaryocyte size

Normal guinea pig and human megakaryocytes in suspension were measured with an optical micrometer. The range of megakaryocyte diameters in both species was from 10 to about 65 micrometer. Approximately 20%-25% of megakaryocytes were smaLler than 20 micrometer in diameter and were mostly missed in past studies. However, virtually the entire population of megakaryocytes was larger than all but a very small percent of the other marrow cells. This size range and the existence of a visual threshold size between the megakaryocytes and nonmegakaryocytes were confirmed by flow cytometric analysis of fresh unfixed cells. On human bone marrow smears there was some flattening of all cell types, but the megakaryocytes were consistently at least minimally greater in size than almost all the nonmegakaryocytes. Normal marrow cells greater than 20 micrometer in diameter were always megakaryocytes. Cells 14-20 micrometer were still noticeably larger than the general marrow population; thus easily found, they could be examined for specific morphological criteria. Size, therefore, is a useful first criterion for the identification of megakaryocytes. The larger sizes of megakaryocytes were related to their greater DNA content per cell (polyploidy) compared to nonmegakaryocytes. The relationship between megakaryocyte size, ploidy, and maturation was examined by the simultaneous measurement for the first time of each of these parameters in the same cell. Maturation was quantitated by the new scheme based on the progressive changes in megakaryocytes nuclear configuration. Within each maturation stage the mean cell volume of guinea pig megakaryocytes doubled with each ploidy doubling. Within each ploidy group, the sizes of megakaryocytes increased with maturation stage. However, maturation and polyploidization appear to be linked; the data showed that 80% of the low ploidy (4N-8N) megakaryocytes were immature and that 95% of the platelet-shedding megakaryocytes were 16N-32N.     

Expression of major blood group antigens on human erythroid cells in a two phase liquid culture system

In order to examine the sequential expression of major blood group antigens on human erythroblasts, a selective two phase liquid culture system for erythroid progenitors was established. After mononuclear cells obtained from peripheral blood were cultured in the presence of phytohemagglutinin stimulated-leukocyte conditioned medium (PHA-LCM) for 7 days (the first phase), nonphagocytic cells were recultured under hypoxic culture conditions containing 30% fetal calf serum, 1% bovine serum albumin, 300 micrograms/mL transferrin and 2 U/mL recombinant erythropoietin (the second phase). Mature (orthochromatic) erythroblasts were observed on day 4 of the second phase, and reached 57.1 +/- 3.1% of total cells on day 8, followed by the appearance of denucleated red cells, equivalent to mature red cells in peripheral blood. Hemoglobin contents reached the level of 16.8 +/- 0.7 micrograms/10(6) cells on day 8. Flow cytometric analyses revealed that, on day 3 of the second phase, cells became blood type M-positive, corresponding to the maturation of erythroid cells. Regarding the expression of ABH blood group antigens, a small number of blood type H- positive cells were initially detected on day 0 of the second phase, while blood type A-positive cells, which essentially were not observed on day 0, increased gradually corresponding to the extent of erythroid maturation. In the present system, Lewis and P1 blood group antigens were expressed at day 5 of the second phase, although autologous plasma was required to determine the expression of Lewis blood group antigens. This culture system is beneficial for studies on normal and abnormal human red cell membranes, because the erythroid progenitors in human peripheral blood were used, and a reasonable number of erythroid cells (0.5 to 1.5 x 10(7] was obtained with good maturation.     

Culture of isolated bovine megakaryocytes on reconstituted basement membrane matrix leads to proplatelet process formation

We have enriched for bovine megakaryocytes and identified a culture system that may provide an in vitro model for platelet formation. Mature megakaryocytes with an unusually high ploidy distribution were obtained after differential centrifugation and velocity sedimentation of bone marrow cells through gradients of bovine serum albumin (BSA). The cell membranes of isolated megakaryocytes and megakaryocytes in vivo stained with antisera to human platelets and human platelet membrane GPIIIa. The microenvironment of bovine megakaryocytes in vivo was investigated using antibodies to types I and IV collagen and laminin. In an attempt to duplicate the microenvironment in vitro, bovine megakaryocytes were cultured on a reconstituted basement membrane matrix (Matrigel). The cells adhered to the gel, extended radial lamellipodia, and occasionally formed lengthy pseudopodia. Ultrastructural examination of these cells showed widening and coalescence of the megakaryocyte demarcation membranes (DMS), and inclusion of platelet granules, thin filaments, and microtubules in the processes. Very few DMS vesicles were present distally in the processes. The culture of megakaryocytes on a reconstituted basement membrane may closely model the in vivo megakaryocyte microenvironment and allow the study of thrombocytopoiesis in vitro.     

Megakaryocytic development in liquid cultures of cryopreserved leukocyte stem cell concentrates from chronic myelogenous leukemia patients

The proliferation and differentiation of human megakaryocytes in liquid culture has been obtained using cryopreserved light-density blood cell concentrates from chronic myelogenous leukemia (CML) patients. A large number of megakaryocytes, representing 20%-60% of total cells cultured, developed after 12-14 days in liquid cultures supplemented with human plasma, while fetal calf serum supported the development of cells of the megakaryocytic lineage poorly. Ploidy studies showed the presence of 8N and 16N cells in human plasma-supplemented cultures while very few cells with DNA content greater than 4N were found in those supplemented with fetal calf serum. Using the FACS IV cytofluorometer, 1-2 X 10(6) megakaryocytes/h were sorted after immunolabeling of the human plasma-cultured cells with a monoclonal antibody reacting against the platelet glycoprotein complex IIb-IIIa. Thus, cryopreserved CML blood stem cell concentrates seem to offer a reproducible source of human megakaryocytes that retain their capacity to proliferate and differentiate in liquid cultures. These megakaryocytes can be used for the study of platelet glycoprotein biosynthesis as well as the regulation of megakaryocytopoiesis.     

Studies of an improved rhesus hematopoietic progenitor cell assay.

We have improved Rhesus monkey marrow cell growth in semisolid media by means of substituting supplemented calf serum for fetal bovine serum. The cloning efficiency of light-density marrow cells separated on 60% Percoll was 126 (+/- 54)/10(5) (n = 12, +/- SD), and for light-density peripheral blood cells 60 (+/- 46)/10(6) (n = 11). Thirty-five percent of the colonies were multilineage, whereas the remainder were unilineage colonies composed of erythrocytes, megakaryocytes, and neutrophilic or monocytic granulocytes. Unilineage megakaryocyte colonies comprised 12% of the total marrow progenitor cells. The [3H]TdR suicide index of marrow progenitor cells was 47% +/- 9% (n = 12). This progenitor cell assay should prove useful in preclinical studies of the effect of recombinant hematopoietic growth factors on the number and cycling status of Rhesus hematopoietic progenitor cells.     

Hypersensitivity of megakaryocyte progenitors to thrombopoietin in essential thrombocythemia.

Essential thrombocythemia (ET) is a clonal myeloproliferative disorder characterized by an elevation of platelets in peripheral blood and excessive proliferation of megakaryocytes in bone marrow. The pathological mechanisms for the elevation of megakaryocytes and platelets in ET remain unclear. To study the hypersensitivity of megakaryocyte progenitors to thrombopoietin (TPO), a 9-year-old girl, diagnosed with ET, underwent dose-response experiments with recombinant human TPO, using her bone marrow non-adherent mononuclear cells and CD34 positive cells. Spontaneous colony-forming unit-megakaryocytes (CFU-Meg) were observed in serum-deprived cultures of non-adherent mononuclear cells, whereas they disappeared in cultures of CD34 positive cells. The patient's CFU-Meg showed maximal growth at concentrations of TPO lower than those for normal children. Dose-response curves demonstrated a 50-80 fold increase in sensitivity of the patient's CFU-Meg to TPO. We observed hypersensitivity of megakaryocyte progenitors to TPO in a child with ET. Our results suggest that spontaneous CFU-Meg formation in patients with ET may be due to hypersensitivity to TPO.     

Cyclooxygenase-2 expression is induced during human megakaryopoiesis and characterizes newly formed platelets

Cyclooxygenase (COX)-1 or -2 and prostaglandin (PG) synthases catalyze the formation of various PGs and thromboxane (TX) A(2). We have investigated the expression and activity of COX-1 and -2 during human megakaryocytopoiesis. We analyzed megakaryocytes from bone marrow biopsies and derived from thrombopoietin-treated CD34(+) hemopoietic progenitor cells in culture. Platelets were obtained from healthy donors and patients with high platelet regeneration because of immune thrombocytopenia or peripheral blood stem cell transplantation. By immunocytochemistry, COX-1 was observed in CD34(+) cells and in megakaryocytes at each stage of maturation, whereas COX-2 was induced after 6 days of culture, and remained detectable in mature megakaryocytes. CD34(+) cells synthesized more PGE(2) than TXB(2) (214 +/- 50 vs. 30 +/- 10 pg/10(6) cells), whereas the reverse was true in mature megakaryocytes (TXB(2) 8,440 +/- 2,500 vs. PGE(2) 906 +/- 161 pg/10(6) cells). By immunostaining, COX-2 was observed in <10% of circulating platelets from healthy controls, whereas up to 60% of COX-2-positive platelets were found in patients. A selective COX-2 inhibitor reduced platelet production of both PGE(2) and TXB(2) to a significantly greater extent in patients than in healthy subjects. Finally, we found that COX-2 and the inducible PGE-synthase were coexpressed in mature megakaryocytes and in platelets. We conclude that both COX-isoforms contribute to prostanoid formation during human megakaryocytopoiesis and that COX-2-derived PGE(2) and TXA(2) may play an unrecognized role in inflammatory and hemostatic responses in clinical syndromes associated with high platelet turnover.