IntroductionWhat I cannot create, I do not understand. Richard Feynman Regulation of cell adhesion through cell-matrix or cell-cell interaction is a critical step in various physiologic processes, such as cell migration and anchoring during development of the blood-forming organs, recruitment of cells into sites of inflammation, and aggregation and adhesion of platelets. Integrins are cell surface receptors composed of type I heterodimeric transmembrane proteins, formed by a combination of 18 ␣-subunits and 8 -subunits. Twenty-four integrins have been identified so far. 1 In blood cells, integrins are usually in a resting (inactive) state with low affinity for their ligands; they can quickly switch to an activated, high-affinity state in response to agonists, such as proteases or adenine nucleotides, a process often referred to as inside-out activation or inside-out signaling. [1][2][3][4][5] Disruption of integrin function causes several hematologic diseases. For example, loss of integrin-␣IIb3 (GPIIb-IIIa), the most abundant platelet integrin, causes Glanzmann thrombasthenia, a hereditary hemorrhagic disorder. [6][7][8][9] In the early 1990s, investigators also identified Glanzmann thrombasthenia patients whose platelet ␣IIb3, although expressed in normal amount, cannot be activated by agonists because of mutations in the 3 cytoplasmic domain. 10,11 These mutations, although not fully explained until the recent understanding of talin and kindlin function in integrin regulation, provided important early insight indicating that integrins were regulated from inside-out (reviewed in the last section).Similarly, a subset of integrins, such as 2-integrins and ␣4-integrins, are expressed in leukocytes and mediate their adhesion to endothelium during various stages of extravasation during inflammatory responses. Loss of integrin-2 (CD18) expression causes leukocyte adhesion deficiency I (LAD I), a disease characterized by recurrent infections. 12 Certain patients with LAD symptoms have normal levels of 2-integrins combined with a bleeding diathesis. These patients' leukocytes are defective in 2-and 1-integrin activation, whereas their platelets also exhibit defects in activation of ␣IIb3; this variant is termed LAD III, or Lad1v. [13][14][15][16] The defective integrin activation in these LAD patients is caused by kindlin-3 mutations. [13][14][15]17 Some groups have also suggested the name of integrin activation deficiency disease for these conditions. 14 Furthermore, Kindler syndrome, a skin blistering disease, is the result of defective 1-integrin activation caused by kindlin-1 mutations. 18,19 As proteins involved in multiple biologic processes and located at the cell surface, integrins are also readily accessible therapeutic targets. For example, inhibitors of integrin-␣IIb3 are currently used in the prevention and treatment of arterial thrombosis in the acute settings of percutaneous coronary intervention. 20 Other integrin-blocking agents against ␣4 are currently used for multiple sclerosis and Croh...