From www.bloodjournal.org by guest on June 18, 2017. For personal use only. Signal Transduction and the Regulation of Actin Conformation During Myeloid Maturation: Studies in HL60 Cells By Ronald L. Sham, Charles H. Packman, Camille N. Abboud, and Marshall A. Lichtman Maturation of human myeloid cells is associated with quantitative and qualitative changes in protein kinase C (PKC) and increases in N-formyl-L-methionyl-L-leucyl-L-phenylalanine (FMLP) receptors, actin, and actin regulatory proteins. We have studied the actin responses and cell shape changes caused by FMLP and its second messenger pathways in HLW cells undergoing neutrophilic maturation. In uninduced cells, the PKC activators 12-0-tetradecanoyl phorbol-13-acetate (TPA), bryostatin, and 1-oleyl-2-acetylglycerol (OAG) resulted in 15% t o 30% decreases in F-actin, whereas FMLP had no effect. lonomycin had no effect on actin but did cause a 10-fold increase in intracellular calcium. Cells grown for 24 hours in 1% dimethyl sulfoxide (DMSO) acquired the ability to polymerize actin in response t o FMLP and ionomycin. TPA continued t o cause a decrease in F-actin at 24 hours, but caused an increase in F-actin at 48 t o 72 hours of maturation. The PKC inhibitor 1-5-isoquinolinesulfonyl P-methylpiperazine (H7) partially blockedthe F-actin increase caused by TPA in induced cells, but had no effect on the decrease in F-actin caused by TPA in uninduced cells or the increase in F-actin seen in FMLP-treated neutrophils. F-actin rich pseudopods developed following TPA or FMLP stimulation of induced HLW cells; in uninduced cells neither agent caused pseudopod formation but TPA caused a dramatic loss of surface ruffles. The ability of FMLP and ionomycin t o elicit a neutrophil-like actin response in HLW cells within 24 hours after DMSO treatment shows that the actin regulatory mechanism is mature by that time. The inability of ionomycin to increase F-actin in uninduced cells supports the view that calcium increases alone are insufficient for actin polymerization. The longer maturation time required for HLW cells t o develop an actin polymerization response t o TPA compared with FMLP, coupled with the inability of H7 to block the FMLP-mediated F-actin increase in neutrophils, suggests that the F-actin increase caused by FMLP is not mediated solely by PKC. Lastly, the TPA-induced F-actin decrease and shape changes in uninduced HL60 cells, and the longer time required for a ”mature” responset o TPA, may reflect immaturity in the PKC isoenzyme pattern rather than immaturity of the actin regulatory mechanism. 8 1991by The American Society of Hematology. M use this information to assess the role of calcium and PKC in FMLP-mediated actin responses. ATURATION OF human promyelocytic leukemia (HMO) cells can be induced with a variety of physiologic and pharmacologic agentslg and may proceed along monocytic or neutrophilic pathways depending on the inducing agent used. The acquisition of a more mature phenotype is assessed by morphologic, immunocytochemical, physiologic, or functional studies. One of the several capabilities of the normal mature neutrophil, chemotaxis, develops in HMO cells after they are induced to mature by exposure to dimethyl sulfoxide The number of chemotactic receptors for N-formyl-L-methionyl-L-leucylL-phenylalanine (FMLP)’ and the actin content6 increase as HL60 cells mature. Chemotaxis is related to actin function because cell motility requires reversible polymerThe ization of actin when chemotactic stimuli are biochemical pathways regulating actin polymerization are not fully characterized but are known to be affected by the two second messenger pathways, calcium9-” and protein kinase C (PKC).9,12 PKC is a calcium and phospholipid-dependent intracellular enzyme that modulates many cellular responses and undergoes both qualitative and quantitative changes with HL60 cell maturation.” This enzyme is activated by 12-0tetradecanoyl phorbol-13-acetate (TPA),14 1-oleyl-2-acetylglycerol (OAG), and bryostatin,” and inhibited by sphin(H7),16 gosine, 1-5-isoquinolinesulfonyl2-methylpiperazine and stauro~porine.’~ The calcium second messenger pathway can be examined using calcium ionophores such as A23187 and ionomycin.’o.’8 We have studied the effects of PKC activators, ionomycin, and FMLP on actin polymerization in HMO cells during their neutrophilic maturation. The purpose of this study was twofold: (1) to evaluate the actin responses caused by activation of the different second messenger pathways throughout neutrophilic maturation and (2) to Blood, Vol77, No 2 (January 15). 1991: pp 363-370 MATERIALS AND METHODS Preparation of cells. A neutrophilic variant of the HL60 cell linet9was grown in RPMI medium containing 10% fetal calf serum (FCS). The cultures were initiated at 2 X lo5 cellslmL and incubated at 37°C in air with 5% CO,. A final concentration of 1% DMSO was added to the incubation when appropriate. Paired samples of induced and uninduced cells were examined at desired points in their maturation. Cell morphology was assessed using Wright’s stain. Neutrophils from normal volunteers were isolated using dextran sedimentation followed by Ficoll-Hypaque centrifugation. Activation of cells. “PA, FMLP (Sigma Chemical Corp, St Louis, MO), bryostatin (kindly provided by W. Stratford May, Baltimore, MD), OAG, and ionomycin (Calbiochem, San Diego, CA) were stored in DMSO at -20°C. For use, they were thawed and diluted in phosphate-buffered saline (PBS) so that 10 pL added to 1 mL of cell suspension achieved the desired final concentration. H7 (Seikagaku America Corp, St Petersburg, FL) was refrigerated in pH 4.0 distilled water and used directly from the stock solution. All experimentswere performed at 37T, except for the neutrophil studies performed at room temperature. H7 was From the Departments of Medicine and of Bwphysics, University of Rochester Medical Center, Rochester, hY Submitted March 23,1990; accepted September 19,1990. Supported in part by Public Health Service (PHS) Grant POI HL18208-15and PHS Training Grant HL 07152. Address reprint requests to Ronald L. Sham, MD, Hematologv Unit, Rochester General Hospital, 1425 Portland Ave, Rochester, NyI4621. The publication costs of this article were &frayed in part by page charge payment. This article must therefore be hereby marked “advertisement” in accordance with I8 U.S.C. section 1734 solely to indicate thisfact. 0 I991 by The American Society of Hematology. 0006-4971l91l7702-om4$3.00/0 363 From www.bloodjournal.org by guest on June 18, 2017. For personal use only. SHAM ET AL 364 added 15 minutes before the addition of TPA, FMLP, and bryostatin. Aliquots of the cell suspension containing 1 x lo6 cells/200 pL were removed before and at appropriate times after the addition of activating agents and inhibitors, and placed into 1 mL ice-cold 3.2% paraformaldehyde and refrigerated for 48 hours to permeabilize the cells. Flow cyfomeoy. Cells were prepared for flow cytometry using previously described methods: Cells were washed with PBS containing 0.1% bovine serum albumin (BSA) and incubated in the dark with 0.1 mL (0.7 pmol/L) of the F-actin-specific probe, 7-nitrobenz-2-oxa-diazole (NBD) phallacidin (Molecular Probes Inc, Eugene, OR), for 45 minutes. The cells were rewashed and filtered through 53 pm nylon mesh. The final volume of 0.5 mL contained about 1 x lo6cells. The F-actin content of cells was measured on an EPICS Profile flow cytometer (Coulter Corp, Hialeah, FL). A 15-mW laser was used for fluorescence excitation at 488-nm and green fluorescence was measured at 525-nm as was forward angle light scatter. The log green fluorescence was converted to a relative linear scale and plotted against time. A total of 20,000 cells was collected for each measurement. Fluorescent microscopy. Rhodamine phalloidin, 10 p1 (Molecular Probes), was added to 150-pL aliquots of permeabilized cells and incubated in the dark for 45 minutes. The cells were then washed with PBS/O.l% BSA and cytospin preparations were made. The cell preparations were studied with fluorescent microscopy and representative cells were photographed. __.. *-.. Scanning electron microscopy. Aliquots of fresh cell samples taken at appropriate time points were pipetted into 1%glutaraldehyde in Sorensen's phosphate buffer and fixed for 1 hour. Cells were then rinsed with Sorensen's buffer and attached to poly-Llysinexoated mica chips. They were postfixed in 1% osmium tetroxide for 1hour and rinsed again. Samples were dehydrated in a graded ethanol series and critical point dried. Cells were coated with gold palladium and observed with a JEOL T330A (JEOL U S A Inc, Peabody, MA) scanning electron microscope. Measurement of cytoplasmic free calcium. HL60 cells were loaded with the calcium-sensitive fluorescent probe fura-2-AM (fura-2-tetraacetomethoxyester) (Molecular Probes), using previously described methods?' A suspension of 5 x lo6HL60 cells/mL in Hanks Balanced Salt Solution (HBSS) was incubated at 37°C for 10 minutes in a shaking water bath. The cells were diluted sixfold and incubated for 20 minutes. This suspension was further diluted fivefold, centrifuged at 25% for 10 minutes, and resuspended at 2 X lo6 cells/mL in HBSS containing 1 mmol/L calcium and 1 m m o m magnesium for the calcium determinations. Fura-2 fluorescence was monitored continuously with a SPEX Fluorolog photofluorimeter (SPEX Industries, Edison, NJ) using dual exitation monochromators. The intracellular ionized free calcium concentration was determined as follows: Ca? = k (R - R,,,&(Rmm- R). R is the ratio of emission intensities at 505 nm on excitation at 340 and 380 nm. R,,,, was obtained by inducing cell lysis with 0.1% Triton, which exposed the fura-2 to 1mmol/L external calcium, and R,,,,, was determined at zero calcium upon addition of 6.25 mmol/L - Control A --t- TPA * TPA+H7 1.21.1 - B __..e-Control .. 1.1 OAG12.5uM OAG25uM OAG50uM 1.04 0.8 0.9 0.7 . I . I . I -15 -10 -5 0 . I 5 . I 10 . * 15 C 1.3 .-..*... --)- Control Bryostatin 1.1 :I 0.7 . , . , . , . , . , 0.7 0 2 4 6 8 1 0 1 2 0 2 4 6 8 10 Time (min) Fig 1. Uninduced HL60 cells were used for these experiments. Samples were taken at the indicated times for determination of F-actin content by flow cytometry. The conditionsfor each set of experiments were as follows. (A) Effect of TPA on F-actin content. Cells were incubated with or without H7 200 pmol/Lfor 15 minutes. TPA (100 nmol/L) (or buffer)was added et time = 0. TPA resulted in a 20% decrease in F-actin content. H7 had no effect on the TPA-induced decrease in F-actin. Resultsshown are the mean of three experiments 5 SE. (B) Effect of OAG on F-actin content. OAG (12.5 pmollL, 25 pmol/L. and 50 pmol/L) (or buffer) was added at time = 0. OAG resulted in a dose-dependent decrease in F-actin. Results are the mean of four experiments ?SE. (C) Effect of bryostatin on F-actin content. Bryostatin (10 nmol/L) (or buffer) was added at time = 0. Bryostatinresultedin a 20% decrease in F-actin content. Resultsshown are the mean of three experiments 2 SE. (D) Effect of ionomycin on F-actin content. lonomycin (400nmol/L) (or buffer) was added at time = 0. lonomycin did not change the F-actin content of uninduced cells. Results shown are the mean of nine experiments SE. * From www.bloodjournal.org by guest on June 18, 2017. For personal use only. REGULATiON OF ACTIN CONFORMATION IN HL60 CELLS ethyleneglycol-bis-(9-amino-ethylether) N,N'-tetra-acetic acid (EGTA) to the lysed cellular suspension at pH 8.5. k is the product, kd x (FJF,), where kd is the effective dissociation constant of fura-2 for calcium (224 nmol/L), F, is the 380-nm excitation signal in the absence of calcium, and F, is the 380-nm excitation signal in the presence of calcium. RESULTS Effects of PKC activators,FMLP, and ionomycin on F-actin content and cell shape in HL60 cells. To determine the effects of the two second messenger pathways on actin polymerization in HL60 cells, PKC activators, ionomycin, and FMLP were studied. TPA (Fig 1A) and OAG (Fig 1B) caused dose-dependent decreases in F-actin in uninduced HL.60 cells within 5 minutes. TPA (100 nmol/L) and OAG (50 pmol/L) caused a maximal effect with a 15% to 30% decrease in F-actin. Bryostatin (10 nmol/L) resulted in a similar rapid decrease in F-actin content (Fig 1C). The inactive phorbol ester, 4 a phorbol, had no effect on HL.60 cell F-actin content (not shown). Fluorescence microscopy using rhodamine phalloidin staining showed minimal differences in fluorescence between control and TPA-treated cells. However, scanning electron microscopy of TPAtreated HL60 cells showed rounding and a dramatic and consistent loss of the surface villi and ruffles when compared with control cells (Fig 2). This change was detectable at 1 minute, coincident with the decrease in F-actin. Ionomycin (400 nmol/L) caused no change in uninduced HL60 cell F-actin content (Fig lD), despite a 10-fold increase in intracellular calcium (see below). FMLP (1 Fig 2. Effect of TPA and FMLP on F-actin distribution and cell shape in u n i n d u d HL60 cells. TPA (100 nmol/L) and 1 pmol/L FMLP were added to HL60 cells and samples were taken at 1 minute and preparedfor fluorascent microscopy and scanning electron microscopy. (A and D) show small surface projections on resting cells. (B and E) show rounding and the loss of surface features following TPA treatment. (C and F) show no detectable change from resting cells with FMLP treatment. 365 pmol/L) did not alter the F-actin content (not shown) or the cell surface features of uninduced HL60 cells (Fig 2). Effects of maturation on the FMLP, lonomycin, and PKC activator response. Mature neutrophils are known to have enhanced chemotaxis when compared with immature cells. The effects of the two second messenger pathways on actin polymerization in mature neutrophilic cells were evaluated using the same methodology as above. HL60 cells were induced to mature by culturing them in 1% DMSO for 4 days. Comparison of induced and uninduced cells using light microscopy of Wright's-stained samples showed cytoplasmic maturation characterized by inconspicuous primary granules, the formation of secondary granules, and a decrease in cell size. Nuclear maturation was characterized by a decrease in nuclear size, loss of nucleoli, and some nuclear segmentation. The actin polymerization responses of HL.60 cells matured with 1% DMSO for 4 days were studied as follows: Addition of 1 pmol/L FMLP to matured HL60 cells resulted in a 50% increase in F-actin content by 1 minute with a return to baseline within 10 minutes (Fig 3A). TPA (100 nmol/L) (Fig 3B) caused a 35% increase in F-actin. Bryostatin (10 nmol/L) (Fig 3C) caused a 15% increase in F-actin. Ionomycin (400 nmol/L) (Fig 3D) caused a 30% increase in F-actin content by 30 to 60 seconds with a return to the baseline within 10 minutes. Scanning electron microscopy of FMLP- and TPAtreated mature HMO cells showed one or multiple pseudopods. Fluorescent microscopy with rhodamine phalloidin From www.bloodjournal.org by guest on June 18, 2017. For personal use only. -'a;i . I B 1.51.41.3- ____ *.--Control -f- Bryostatin - ---e-Control lonomycin From www.bloodjournal.org by guest on June 18, 2017. For personal use only. REGULATION OF ACTIN CONFORMATION IN HL60 CELLS 367 rb Fig 4. Effect of TPA and FMLP on F-actin distribution and cell shape in induced HL80 cells (following 48 to 72 hours of 1% DMSO indudon). TPA (100 nmol/L) and 1pmol/L FMLPwere added t o HUrOcells, and samples were taken at 1minute and preparedfor fluomcent mkmscopy and scanning electron microscopy. (A and D) show small rutface projections on resting cells. (e and E) show pseudopod formation following TPA treatment with marked concentration of F-actin in pseudopods. (C and F) show similar responsesfollowing FMLP treatment. strated increase in F-actin content (Fig 3A). The decrease in F-actin content observed in uninduced cells treated with TPA (Fig 1A) or bryostatin (not shown) was not inhibited by pretreatment with H7. Neutrophils were also used to assess the role of PKC in FMLP-induced actin polymerization. Neutrophils isolated from normal volunteers were treated with 1 nmol/L FMLP following preincubation with H7.The increase in F-actin content seen after FMLP application was not inhibited by H7 in doses ranging from 12.5 pmoVL to 200 pmol/L (Fig 1.61 7). DISCUSSION 0.9 l 0 2 4 . 6 8 o10 Time (min) Flg 5. Effect of DMSO induction thne on the F - d n mpome to FMLP In HL60 cells. HUW) celh were cultured in the pmsence of 1% DMSO and experiments were performed after 0,24,48, and 72 hours of culture. FMLP (1 ~ o l / L was ) added at time = 0 minutes and samples were a n a m as above (mean of two experiments; muklple other experiments confirmed this finding). The day 0 cells had no change in F-actin content in response to FMLP. After 24 hours of DMSO incubation, the cells displayed a 25.h increase in F-actinwithin 1 minute of FMLP addition. A more pronounced increase in F-actin day 1; (4) day 2; was seen at 48 hours and 72 hours. ( 4 3 day 0; (-0-1 (-A-1 day 3. These experiments ~ evaluate the regulation of actin conformation in HL60 cells undergoing neutrophilic maturation. Total cellular actin content increases twofold as HL60 cells mature over several days and reflects new protein synthesis: Throughout maturation an equilibrium exists between G- and F-actin and the G:Fratio of approximately 2 1 is similar in induced and uninduced HL60 cells?' The actin changes we measured occur within minutes, and result from shifts in G- to F-actin. These processes involve the interaction between actin-regulatory proteins and cellsignaling pathways. One of the more important physiologic pathways is initiated at the FMLP receptor. The biochemical events which follow FMLP receptor occupancy are not From www.bloodjournal.org by guest on June 18, 2017. For personal use only. SHAM ET AL 368 0.” , ,0 2 4 6 a 10 Time (min) Fig 6. Effect of DMSO induction time on the F-actin response to TPA in HL60 cells. HL60 cells were cultured in the presence of 1% DMSO and experiments were performed after 0,24,48, and 72 hours of culture. TPA (100 nmol/L) was added at time = 0 minutes and samples were analyzed as above (mean of two experiments; multiple other experiments confirmed this finding). The day 0 cells exhibited a 20% decrease in F-actin content in response to TPA. At 24 hours of DMSO incubation, there was only a 10% decrease in F-actin content in response to TPA addition. By 48 hours of maturation a small F-actin increase was observed in response to TPA. By 72 hours of maturation the cells exhibited a 20% increase in F-actin after TPA addition. Symbols for days 0 through 3 are the same as in Fig 5. fully characterized but are known to result in activation of the phosphotidylinositol pathway with subsequent PKC activation and calcium mobilization.” These two second messenger systems were studied and compared with FMLP to determine their relative roles in actin polymerization responses. Uninduced HL60 cells treated with TPA showed an immediate decrease in F-actin content and dramatic changes in cell shape and surface features. This effect is presumably mediated by PKC because several dissimilar PKC activators cause a similar F-actin decrease. Uninduced HL60 cells treated with either ionomycin or FMLP exhibited no change in F-actin content. The analysis of the actin polymerization responses as HL60 cells mature helps to define the relationship between the FMLP receptor, second messenger pathways, and actin-regulatory proteins. Within 24 hours of maturation, HL60 cells have acquired the ability to increase F-actin in response to both ionomycin and FMLP. In contrast, TPA continued to result in a decrease in F-actin at 24 hours. The 24-hour maturation time required for an actin response to FMLP probably reflects time required to synthesize FMLP receptors. FMLP receptors are few in number in uninduced cells: and in other studies maturation of HL60 cells parallels the ability to respond to chemoattractant stimuli.43z’Similarly, quantitative changes in actin-regulatory proteins occur with maturation?’ Gelsolin and actin-binding protein, for example, increase threefold within 24 hours of HL60 cell maturation?’ The 24-hour maturation time required for an actin response to ionomycin may in part reflect synthesis of calcium-dependent actin-regulatory proteins. This explanation is favored be- cause ionomycin caused a dramatic increase in intracellular calcium in uninduced cells and in those matured for 24 hours, yet actin polymerization occurred only in the matured cells. It is also possible that qualitative changes in actin-regulatory proteins occur during HL60 cell maturation. As an example, the characteristics of actin-gelsolin complexes vary depending on the state of activation of neutrophils.” Nonetheless, qualitative or quantitative changes in actin-regulatory proteins alone could not account for the persistent decrease in F-actin in response to TPA at 24 hours of maturation because the cells are capable of exhibiting a “mature” response to ionomycin and FMLP within 24 hours of maturation. This discrepancy raises the possibility that maturation-associated changes in PKC could account for the observed TPA results. The quantity, isoenzyme pattern, and cellular localization of PKC change with maturation of HL60 cell^''^^ and may be causally linked to changes in functional abilities of cells. An immature PKC isoenzyme pattern in uninduced cells could account for the decrease in F-actin in response to TPA in these cells. In matured HMO cells, the TPAinduced F-actin response is qualitatively similar to that of normal blood neutrophils.9326The role of PKC in this process is supported by similar changes in F-actin mediated by chemically dissimilar PKC activators. Furthermore, H7 partially inhibited the TPA-induced actin polymerization in the matured cells. The failure of H7 to inhibit the actin decrease in uninduced cells may be a manifestation of an immature PKC isoenzyme pattern and the associated differences in kinetics and substrate specificities of the various isotypes.” PKC (Y and PKC p are the predominant isotypes in uninduced HL60 cells. DMSO-induced maturation results in at least a twofold increase in both isotypes within 48 hours.I3 Also, PKC y, which is barely detectable in uninduced HL60 cells, increases significantly following matur- 1.2 1.1 0.9 -15 -10 -5 0 5 Time (min) Fig 7. Effect of H7 on FMLP-induced F-actin increase in mature neutrophils. Neutrophils were incubated with or without H7 (100 pmol/L) for 15 minutes. FMLP (1 nmol/L) (or buffer) was added at time = 0 minutes. Samples were taken at the indicated times for determinationof F-actin content by flow cytometry. FMLP resulted in a 40% increase in F-actin content. H7 (100 pmol/L) did not inhibit the FMLP response. The results shown are the mean of four experiments Control; (4-) FMLP; (-A-), FMLP H7. &SE. (---0---) + From www.bloodjournal.org by guest on June 18, 2017. For personal use only. REGULATION OF ACTIN CONFORMATION IN HL60 CELLS 369 ation.I3 The changes in actin responses to PKC activators during HL60 cell maturation may be a function of PKC evolution. In neutrophils, the roles of the two second messenger pathways in actin polymerization have been studied and compared with FMLP.9Calcium ionophores can cause actin polymerization in neutrophils, yet FMLP-induced actin polymerization still occurs when intracellular calcium fluxes are inhibited."." Several investigators have shown that increases in intracellular calcium are not necessary to initiate actin polymerization.28A new observation, in fact, suggests that increases in intracellular calcium caused by electropermeabilization of neutrophils in calcium containing buffer causes actin depolymerization." Our experiments in uninduced HL60 cells provide further evidence that a calcium increase alone is not sufficient for actin polymerization because ionomycin causes an increase in intracellular calcium in uninduced HL60 cells without associated actin polymerization. Similarly, the role of PKC in the FMLP-mediated actin polymerization response has been studied. In blood neutro- phils, TPA and FMLP result in different changes in shape and cytoplasmic streaming,29suggesting different effects on the cytoskeletal apparatus. Quantitative differences in phosphorylation stimulated by TPA and FMLP in neutrophils have been described:' and it has been postulated that 'ITA and FMLP activate different forms of PKC. H7 blocks neutrophil oxidative burst and degranulation induced by TPA, but not that induced by FMLP?' We have also found that H7 is unable to inhibit FMLP-induced actin polymerization in normal neutrophils. These data together with the time course analysis of the actin polymerization response in maturing HL60 cells suggest that neither activation of PKC nor increases in intracellular calcium caused by FMLP entirely account for actin polymerization in neutrophilic cells. ACKNOWLEDGMENT The authors thank Rachel Goss, Maureen Kempski, and Carol Kirch for expert technical assistance, and Karen Balta and Linda Piedemonte for preparing the manuscript. REFERENCES 1. 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For personal use only. 1991 77: 363-370 Signal transduction and the regulation of actin conformation during myeloid maturation: studies in HL60 cells RL Sham, CH Packman, CN Abboud and MA Lichtman Updated information and services can be found at: http://www.bloodjournal.org/content/77/2/363.full.html Articles on similar topics can be found in the following Blood collections Information about reproducing this article in parts or in its entirety may be found online at: http://www.bloodjournal.org/site/misc/rights.xhtml#repub_requests Information about ordering reprints may be found online at: http://www.bloodjournal.org/site/misc/rights.xhtml#reprints Information about subscriptions and ASH membership may be found online at: http://www.bloodjournal.org/site/subscriptions/index.xhtml Blood (print ISSN 0006-4971, online ISSN 1528-0020), is published weekly by the American Society of Hematology, 2021 L St, NW, Suite 900, Washington DC 20036. 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