Controlled release of glial-derived neurotrophic factor from fibrin matrices containing an affinity-based delivery system

This research evaluated the controlled release of glial-derived neurotrophic factor (GDNF) from an affinity-based delivery system (ABDS) as potential treatment for peripheral nerve injury. The ABDS consisted of a bidomain peptide containing a transglutaminase substrate, allowing crosslinking into fibrin matrices, and a heparin-binding domain based on the antithrombin-III heparin-binding domain, heparin, and GDNF, which was sequestered based on its heparin-binding affinity. The objective of this research was to determine the release rate and biological activity of GDNF released from the ABDS in vitro. The ratio of peptide to heparin was found to modulate the rate of GDNF release. The biological activity of GDNF released from the ABDS was assayed using chick dorsal root ganglia (DRGs) neurite extension. Neurite extension was equivalent for fibrin matrices containing the ABDS for all concentrations of GDNF tested versus DRGs grown with GDNF in the media. Furthermore, neurite extension was enhanced in fibrin matrices containing 100 ng/mL of GDNF with the ABDS versus matrices with GDNF at a simliar dose but no ABDS. These results suggest that GDNF can be retained and released in a biologically activity form from the ABDS, and thus this approach may prove useful for the treatment of peripheral nerve injury.     

Development of rationally designed affinity-based drug delivery systems

Many drug delivery systems have been developed to provide sustained release of proteins in vivo. However, the ability to predict and control the rate of release from delivery systems is still a challenge. Toward this goal, we screened a random drug-binding peptide library (12 amino acids) to identify peptides of varying (i.e. low, moderate, and high) affinity for a model polysaccharide drug (heparin). Peptide domains of varying affinity for heparin identified from the library were synthesized using standard solid phase chemistry. A mathematical model of drug release from a biomaterial scaffold containing drug-binding peptide domains identified from the library was developed. This model describes the binding kinetics of drugs to the peptides, the diffusion of free drug, and the kinetics of enzymatic matrix degradation. The effect of the ratio of binding sites to drug, the effect of varying the binding kinetics and the rate of enzymatic matrix degradation on the rate of drug release was examined. The in vitro release of the model drug from scaffold containing the peptide drug-binding domains was measured. The ability of this system to deliver and modulate the biological activity of protein drugs was also assessed using nerve growth factor (NGF) in a chick dorsal root ganglia (DRG) neurite extension model. These studies demonstrate that our rational approach to drug delivery system design can be used to control drug release from tissue-engineered scaffolds and may be useful for promoting tissue regeneration in vivo.     

Rationally designed peptides for controlled release of nerve growth factor from fibrin matrices

The purpose of this research was to identify peptide sequences with varying affinity for nerve growth factor (NGF) and use them in the rational design of affinity-based drug delivery systems. A phage display library (12 amino acid random peptide sequence) was screened against NGF-conjugated chromatography resin three times and fractions containing phage of varying affinity were eluted by decreasing the pH of the eluent. These phages were isolated, amplified; then their DNA was purified and sequenced to determine the identity of the random peptide domain. Consensus peptides based on these sequences were synthesized and screened for their ability to bind NGF and release it at different rates from fibrin matrices. The ability of fibrin matrices containing these peptides and NGF to deliver to biologically active NGF was tested using a chick dorsal root ganglia model. A mathematical model was developed to further understand how the affinity of a peptide can modulate release of NGF and to aid in design optimization for the delivery system. The peptides identified in this study were determined to have varying affinities for NGF suggesting that this approach can serve as a model for tailoring the affinity of a drug delivery system for a target protein drug.     

Heparin-Binding-Affinity-Based Delivery Systems Releasing Nerve Growth Factor Enhance Sciatic Nerve Regeneration

The controlled delivery of nerve growth factor (NGF) to the peripheral nervous system has been shown to enhance nerve regeneration following injury, although the effect of release rate has not been previously studied with an affinity-based delivery system (DS). The goal of this research was to determine if the binding site affinity of the DS affected nerve regeneration in vivo using nerve guidance conduits (NGCs) in a 13-mm rat sciatic nerve defect. These DSs consisted of bi-domain peptides that varied in heparin-binding affinity, heparin and NGF, which binds to heparin with moderate affinity. Eight experimental groups were evaluated consisting of NGF with DS, control groups excluding one or more components of the DS within silicone conduits and nerve isografts. Nerves were harvested 6 weeks after treatment for analysis by histomorphometry. These DSs with NGF resulted in a higher frequency of nerve regeneration compared to control groups and were similar to the nerve isograft group in measures of nerve fiber density and percent neural tissue, but not in total nerve fiber count. In addition, these DSs with NGF contained a significantly greater percentage of larger diameter nerve fibers, suggesting more mature regenerating nerve content. While there were no differences in nerve regeneration due to varying peptide affinity with these DSs, their use with NGF enhanced peripheral nerve regeneration through a NGC across a critical nerve gap.     

A laminin and nerve growth factor-laden three-dimensional scaffold for enhanced neurite extension.

Agarose hydrogel scaffolds were engineered to stimulate and guide neuronal process extension in three dimensions in vitro. The extracellular matrix (ECM) protein laminin (LN) was covalently coupled to agarose hydrogel using the bifunctional cross-linking reagent 1,19- carbonyldiimidazole (CDI). Compared to unmodified agarose gels, LN-modified agarose gels significantly enhanced neurite extension from three-dimensionally (3D) cultured embryonic day 9 (E9) chick dorsal root ganglia (DRGs), and PC 12 cells. After incubation of DRGs or PC 12 cells with YIGSR peptide or integrin beta1 antibody respectively, the neurite outgrowth promoting effects in LN-modified agarose gels were significantly decreased or abolished. These results indicate that DRG/PC 12 cell neurite outgrowth promoting effect of LN-modified agarose gels involves receptors for YIGSR/integrin beta1 subunits respectively. 1,2-bis(10, 12-tricosadiynoyl)-sn-glycero-3-phosphocholine (DC(8,9)PC)-based lipid microcylinders were loaded with nerve growth factor (NGF), and embedded into agarose hydrogels. The resulting trophic factor gradients stimulated directional neurite extension from DRGs in agarose hydrogels. A PC 12 cell-based bioassay demonstrated that NGF-loaded lipid microcylinders can release physiologically relevant amounts of NGF for at least 7 days in vitro. Agarose hydrogel scaffolds may find application as biosynthetic 3D bridges that promote regeneration across severed nerve gaps.     

Gene therapy vectors with enhanced transfection based on hydrogels modified with affinity peptides

Regenerative strategies for damaged tissue aim to present biochemical cues that recruit and direct progenitor cell migration and differentiation. Hydrogels capable of localized gene delivery are being developed to provide a support for tissue growth, and as a versatile method to induce the expression of inductive proteins; however, the duration, level, and localization of expression is often insufficient for regeneration. We thus investigated the modification of hydrogels with affinity peptides to enhance vector retention and increase transfection within the matrix. PEG hydrogels were modified with lysine-based repeats (K4, K8), which retained approximately 25% more vector than control peptides. Transfection increased 5- to 15-fold with K8 and K4 respectively, over the RDG control peptide. K8- and K4-modified hydrogels bound similar quantities of vector, yet the vector dissociation rate was reduced for K8, suggesting excessive binding that limited transfection. These hydrogels were subsequently applied to an in vitro co-culture model to induce NGF expression and promote neurite outgrowth. K4-modified hydrogels promoted maximal neurite outgrowth, likely due to retention of both the vector and the NGF. Thus, hydrogels modified with affinity peptides enhanced vector retention and increased gene delivery, and these hydrogels may provide a versatile scaffold for numerous regenerative medicine applications.     

Controlled release of nerve growth factor from fibrin gel

Nerve growth factor (NGF) is known to promote the axonal regeneration in injured nerve system. Delivery of NGF for a long period in a controlled manner may enhance the regeneration efficacy. In this study, we investigated whether NGF can be released from fibrin gel for a long period in a controlled manner. We also investigated whether sustained delivery of NGF using fibrin gel can enhance the efficacy of NGF in vitro. The addition of heparin to fibrin gel decreased the rate of NGF release from the fibrin gel. As the concentrations of thrombin and fibrinogen in fibrin gel increased, the NGF release rate decreased significantly, and the initial release burst decreased. NGF was released for up to 14 days in vitro. The bioactivity of NGF released from fibrin gel was assessed by morphological changes of pheochromocytoma (PC12) cells cultured in the presence of NGF-containing fibrin gel. NGF released from fibrin gel exhibited significantly higher degrees of PC12 cell viability and differentiation than NGF added in a free form daily into the culture medium. This study demonstrates that fibrin gel can release NGF in a sustained, controlled manner and in a bioactive form.     

Release characteristics and bioactivity of gelatin-tricalcium phosphate membranes covalently immobilized with nerve growth factors

The gelatin-tricalcium phosphate membranes were cross-linking with low concentration glutaraldehyde solution (GTG). This material has good mechanical property, biocompatibility, and is feasible for surgical manipulation. For axonal regeneration, nerve growth factors (NGF) were immobilized onto the composite (GTG) with carbodiimide. The purpose of this study was to evaluate the release characteristics and bioactivity of NGF after covalent immobilization onto the GTG membranes (GEN). NGF immobilized onto and released from the composite was quantified using ELISA method. PC 12 cells were cultured on the GTG and GEN composites. Cell survival, cytotoxicity, and cellular activity were evaluated by total protein content, LDH activity, and MTT assay respectively. Neurite outgrowth assay was used to evaluate the biological activity of NGF released from GEN composite. From ELISA measurement, the releasing curve for NGF showing two distinctive parts with different slopes indicated that NGF were released from the composite in diffusion-controlled mechanism and degradation-controlled mechanism respectively. While culturing with PC 12 cells, LDH leakage results implied that whether GTG composite cross-linked with NGF or not showed little cytotoxicity. The total protein content and cellular activity of PC 12 cells were lower on GTG and GEN membranes than control group. However, 56%+/-3.98 of PC 12 cells showed significant neurite outgrowth on GEN membranes which was statistically higher than GTG without NGF immobilization. In addition, sustained release of bioactive NGF for two months had been demonstrated by neurite outgrowth assay. From these experiments, it can be concluded that the technique used in the present study is capable of immobilizing NGF onto GTG membranes covalently and remaining the bioactivity of NGF. Therefore, GEN composite can be materials for sustained release of bioactive NGF and a candidate for future therapeutic application in nerve repair.     

Nerve growth factor expression by PLG-mediated lipofection

Biomaterials capable of efficient gene delivery provide a fundamental tool for basic and applied research models, such as promoting neural regeneration. We developed a system for the encapsulation and sustained release of plasmid DNA complexed with a cationic lipid and investigated their efficacy using in vitro models of neurite outgrowth. Sustained lipoplex release was obtained for up to 50 days, with rates controlled by the fabrication conditions. Released lipoplexes retained their activity, transfecting 48.2+/-8.3% of NIH3T3 cells with luciferase activity of 3.97x10(7)RLU/mg. Expression of nerve growth factor (NGF) was employed in two models of neurite outgrowth: PC12 and primary dorsal root ganglia (DRG) co-culture. Polymer-mediated lipofection of PC12 produced bioactive NGF, eliciting robust neurite outgrowth. An EGFP/NGF dual-expression vector identified transfected cells (GFP-positive) while neurite outgrowth verified NGF secretion. A co-culture model examined the ability of NGF secretion by an accessory cell population to stimulate DRG neurite outgrowth. Polymer-mediated transfection of HEK293T with an NGF-encoding plasmid induced outgrowth by DRG neurons. This system could be fabricated as implants or nerve guidance conduits to support cellular and tissue regeneration. Combining this physical support with the ability to locally express neurotrophic factors will potentiate regeneration in nerve injury and disease models.     

Impact of co-incorporating laminin peptide dopants and neurotrophic growth factors on conducting polymer properties

Conductive neural interfaces tailored for cell interaction by incorporation of bioactive factors are hypothesized to produce superior neuroprostheses with improved charge transfer capabilities. This study examined the effect of entrapping nerve growth factor (NGF) within the conducting polymer poly(ethylene dioxythiophene) (PEDOT) during electrodeposition to create a polymer capable of stimulating neurite outgrowth from proximal neural tissue. NGF entrapment was performed on polymers doped with laminin peptides DEDEDYFQRYLI and DCDPGYIGSR and, additionally, a conventional dopant, paratoluene sulphonate (pTS). All polymer coatings were analysed for a range of physical, electrical and mechanical properties, with the biological activity of ligands examined using a PC12 neurite outgrowth assay. NGF was successfully entrapped in PEDOT during electrodeposition and was shown to produce a softer interface than conventional conducting polymers and films without the NGF modification. However, it was found that the use of a peptide dopant combined with NGF entrapment resulted in polymers with diminished electrical and mechanical stability. Entrapped NGF was determined to be biologically active, with PEDOT/pTS/NGF producing neurite outgrowth comparable with control films where NGF was supplied via the medium. Future studies will determine the effect of typical neural prosthetic stimulation regimes on the release of neurotrophins and subsequent cell response.     

Silk fibroin matrices for the controlled release of nerve growth factor (NGF)

Nerve conduits (NC) for peripheral nerve repair should guide the sprouting axons and physically protect the axonal cone from any damage. The NC should also degrade after completion of its function to obviate the need of subsequent explanation and should optionally be suitable for controlled drug release of embedded growth factors to enhance nerve regeneration. Silk fibroin (SF) is a biocompatible and slowly biodegradable biomaterial with excellent mechanical properties that could meet the above stated requirements. SF material (films) supported the adherence and metabolic activity of PC12 cells, and, in combination with nerve growth factor (NGF), supported neurite outgrowth during PC12 cell differentiation. NGF-loaded SF-NC were prepared from aqueous solutions of NGF and SF (20%, w/w), which were air-dried or freeze-dried (freezing at -20 or -196 degrees C) in suitable molds. NGF release from the three differently prepared SF-NC was prolonged over at least 3 weeks, but the total amount released depended on the drying procedure of the NC. The potency of released NGF was retained within all formulations. Control experiments with differently dried NGF-lactose solutions did not evidence marked protein aggregation (SEC, HPLC), loss of ELISA-reactivity or PC12 cell bioactivity. This study encourages the further exploitation of SF-NC for growth factor delivery and evaluation in peripheral nerve repair.     

小鼠NGF基因真核表达载体的构建及其在NIH3T3细胞中的表达

目的 :构建小鼠 β NGF基因真核表达载体并观察其稳定转染的NIH 3T3细胞系中NGF的表达情况。方法 :用基因重组技术 ,将小鼠 β NGF的成熟cDNA序列及其前导序列 ,克隆到真核表达载体 pcDNA3.1+中 ,用限制性内切酶酶切鉴定重组体。利用脂质体FuGENETM6方法 ,转染NIH 3T3细胞。转染后 72h ,用G4 18筛选阳性克隆并培养至 2 0d。对阳性克隆培养上清中NGF的表达用Westernblot分析并观察该上清中NGF对PC12细胞突起生长的作用。结果 :β NGF基因在NIH 3T3细胞中获得表达。阳性克隆培养上清能促进PC12细胞突起生长。结论 :重组真核表达载体 pcDNA3.1+/NGF构建成功 ,NGF蛋白在NIH 3T3细胞中表达 ,并具有良好的生物学活性 ,为进一步开展NGF基因治疗神经系统疾病奠定了基础     

Neurite outgrowth from PC12 cells is enhanced by an inhibitor of mechanical channels

GsMTx4, a peptide inhibitor for mechanosensitive ion channels (MSCs), promoted neurite outgrowth from PC12 cells in the presence of NGF in a dose-dependent manner between 5 and 100 μM peptide. Enhanced neurite growth required >12 h of peptide exposure in cells grown with NGF. Adsorption of GsMTx4 to serum proteins in the media lowered the free peptide concentration of 100 μM to a free concentration of 5 μM, a concentration shown to completely inhibit MSCs in the patch clamp assay. Outside-out patches from PC12 cells grown in NGF had mechanically activated cation channels that were reversibly inhibited by GsMTx4. These results are similar to those observed by Gomez and co-workers [4] in Xenopus spinal cord. The inhibition of mechanosensitive channels by GsMTx4 may be a useful approach to accelerate regeneration of neurons in neurodegenerative diseases and spinal cord injury.     

Patterned PLG substrates for localized DNA delivery and directed neurite extension

Tissue engineering strategies that enable nerve regeneration will require methods that can promote and direct neurite extension across the lesion. In this report, we investigate an in vitro combinatorial approach to directed neurite outgrowth using gene delivery from topographically patterned substrates, which can induce expression of neurotrophic factors to promote neurite extension and direct the extending neurites. Poly(lactide-co-glycolide) (PLG), which has been used to fabricate conduits or bridges for regeneration, was compression molded to create channels with 100, 150, and 250 microm widths. DNA complexes were immobilized to the PLG, and cells cultured on the substrate were transfected with efficiencies dependent on channel width and DNA amount. A co-culture model consisting of primary neurons and accessory cells was employed to investigate neurite outgrowth within the channels. Localized secretion of nerve growth factor (NGF) by the accessory cells promoted neuron survival and neurite extension. Neurons cultured in channels with NGF expression exhibited longer primary neurites than in the absence of channels. Neurons cultured in smaller width PLG microchannels exhibited a greater degree of directionality and less secondary sprouting than larger channels. Finally, surface immobilization allowed for the delivery of distinct plasmids from each channel, which may enable channels to be tailored for specific nerve tracts. This approach demonstrates the ability to combine gene delivery with physical guidance, and can be tailored to target specific axonal populations with varying neurotrophic factor requirements.     

Neurotrophin-eluting hydrogel coatings for neural stimulating electrodes

Improved sensory and motor prostheses for the central nervous system will require large numbers of electrodes with low electrical thresholds for neural excitation. With the eventual goal of reducing stimulation thresholds, we have investigated the use of biodegradable, neurotrophin-eluting hydrogels (i.e., poly(ethylene glycol)-poly(lactic acid), PEGPLA) as a means of attracting neurites to the surface of stimulating electrodes. PEGPLA hydrogels with release rates ranging from 1.5 to 3 weeks were synthesized. These hydrogels were applied to multielectrode arrays with sputtered iridium oxide charge-injection sites. The coatings had little impact on the iridium oxide electrochemical properties, including charge storage capacity, impedance, and voltage transients during current pulsing. Additionally, we quantitatively examined the ability of neurotrophin-eluting, PEGPLA hydrogels to promote neurite extension in vitro using a PC12 cell culture model. Hydrogels released neurotrophin (nerve growth factor, NGF) for at least 1 week, with neurite extension near that of an NGF positive control and much higher than extension seen from sham, bovine serum albumin-releasing boluses, and a negative control. These results show that neurotrophin-eluting hydrogels can be applied to multielectrode arrays, and suggest a method to improve neuron-electrode proximity, which could result in lowered electrical stimulation thresholds. Reduced thresholds support the creation of smaller electrode structures and high density electrode prostheses, greatly enhancing prosthesis control and function.     

Mouse saliva prevents the beta-nerve growth factor-dependent neurite formation in PC-12 cells

A highly sensitive and specific competitive beta-nerve growth factor radioimmunoassay (beta NGF-RIA) was utilized to determine the beta NGF levels in epinephrine-provoked saliva of adult male and female Swiss-Webster mice. Saliva beta NGF levels in males were higher than in females. In order to assess the immunoreactive material measured in the RIA as biologically active beta NGF, saliva of male and female mice was examined for the neurite outgrowth responsiveness both in the rat pheochromocytoma tumor cell line (PC-12) and 8-day-old chick embryo dorsal root sensory ganglion (DRG) bioassay systems. At concentrations (based on the RIA values) sufficient to saturate both high and low affinity beta NGF-receptors (100 ng and above), saliva of both male and female mice did not elicit neurite outgrowth in the PC-12 bioassay system. In contrast, similar concentrations of saliva stimulated extensive neurites in the DRG bioassay system. When serum of aggression-provoked male mice (which also contained high serum beta NGF levels as indicated by the RIA) was tested, both the PC-12 and DRG bioassay systems readily responded with neurite extension. In the PC-12 bioassay system, saliva of both sexes stimulated cell proliferation and cell aggregation, but not cell substratum-adhesion. Addition of saliva also prevented the cell substratum adhesion and the formation of neurites induced by purified submandibular gland (SMG)-beta NGF. Epidermal growth factor (EGF), a potent mitogen present in mouse saliva, did not prevent the neurite outgrowth induced by the purified SMG-beta NGF. In summary, the results suggest that saliva of adult male and female mice may contain biologically interfering substances for beta NGF-dependent neurite formation in the PC-12 bioassay system.     

Impact of cell type and density on nerve growth factor distribution and bioactivity in 3-dimensional collagen gel cultures

Local delivery of protein agents is potentially important in many tissue engineering systems. In this report, we evaluate an experimental system for measuring the rate of nerve growth factor (NGF) transport and biological activity within a 3-dimensional, tissue-like environment. Fetal brain cells or PC12 cells were suspended throughout collagen gel cultures; controlled-release matrices were used to control the spatial and temporal pattern of NGF release. Experimentally measured concentration profiles were compared to profiles predicted by a mathematical model encompassing diffusion and first-order elimination. Our results suggest that NGF moves through gels by diffusion while being eliminated at a rate that depends on cell density. Since diffusion and elimination also govern protein transport in brain tissue, the collagen gel serves as a model system that replicates the main features of transport in the brain and, therefore, can be used to identify new strategies that enhance NGF distribution in the central nervous system. As an example of the utility of this biophysical model, we demonstrate that implantation of multiple controlled-release matrices can broaden NGF distribution in gel cultures; this broadening was accompanied by a significant increase in cellular biological activity. This approach may be useful in customizing NGF distribution throughout degenerating or damaged central nervous system tissue while minimizing toxicity to surrounding healthy tissue.     

Lysine-based polycation:heparin coacervate for controlled protein delivery

Polycations have good potential as carriers of proteins and genetic material. However, poor control over the release rate and safety issues currently limit their use as delivery vehicles. Here we introduce a new lysine-based polycation, poly(ethylene lysinylaspartate diglyceride) (PELD), which exhibits high cytocompatibility. PELD self-assembles with the biological polyanion heparin into a coacervate that incorporates proteins with high loading efficiency. Coacervates of varying surface charge were obtained by simple alteration of the PELD:heparin ratio and resulted in diverse release profiles of the model protein bovine serum albumin. Therefore, coacervate charge represents a direct means of control over release rate and duration. The PELD coacervate also rapidly adsorbed onto a porous polymeric scaffold, demonstrating potential use in tissue engineering applications. This coacervate represents a safe and tunable protein delivery system for biomedical applications.     

Chondroitin sulfate-binding peptides block chondroitin 6-sulfate inhibition of cortical neurite growth

Chondroitin sulfate (CS) expression is increased in the glial scar following spinal cord injury demonstrating the importance understanding the role of CS in the central nervous system (CNS). There have been conflicting studies on the effects of the most abundant types of CS, chondroitin 4-sulfate (C4S) and chondroitin 6-sulfate (C6S), found in the CNS. In this study, the effects of C4S and C6S on rat embryonic day 18 cortical neurons were investigated. C4S had no effect on neuron behavior whereas C6S inhibited neurite outgrowth at higher concentrations (>10 μg/ml). Two C6S-binding peptides (C6S-1 and C6S-2) were tested for their ability to block the inhibitory activity of C6S on neurite outgrowth. Neurons cultured with C6S and C6S-binding peptide at higher peptide concentrations had neurite lengths similar to neurons cultured without C6S. Therefore, the C6S-binding peptides were effective at blocking the inhibitory activity of C6S. The C6S-1 peptide had a higher binding affinity than the C6S-2 peptide and was consequently more effective at blocking C6S inhibition of neurite growth. To date, this is the first study to employ an alternative strategy from enzymatic digestion of CS chains to increase neurite outgrowth. These studies warrant further investigation of the use of C6S-binding peptides to increase nerve regeneration following spinal cord injury.     

Heparin-immobilized biodegradable scaffolds for local and sustained release of angiogenic growth factor

Heparin-immobilized porous biodegradable scaffolds were fabricated to release basic fibroblast growth factor (bFGF) in a sustained manner. Heparin was covalently conjugated onto the surface of macroporous PLGA scaffolds fabricated by a gas-foaming/salt-leaching method. Sustained release of bFGF was successfully achieved for over 20 days due to high affinity of bFGF onto the immobilized heparin. It appears that bFGF release rate was regulated by the specific interaction between bFGF and heparin. The bFGF fraction released from the scaffolds maintained its bioactivity, as judged from determining the proliferation extent of human umbilical vein endothelial cells (HUVECs) in vitro. When heparin-immobilized scaffolds loaded with bFGF were implanted subcutaneously in vivo, they effectively induced the formation of blood vessels in the vicinity of the implant site. This study demonstrated that local and sustained delivery of angiogenic growth factor for tissue regeneration could be achieved by surface modification of porous scaffolds with heparin.