I assessed the accuracy of two clinical prediction rules, the d-dimer blood test and point of care ultrasound for diagnosing lower limb deep vein thrombosis. Emergency physicians were trained in ultrasound and prospectively scanned emergency department patients with suspected deep vein thrombosis. Accuracy of the Wells and AMUSE rules and the ultrasound result was compared to radiology-performed ultrasound and a 90-day clinical outcome. Univariate and multivariate analyses were performed assessing which factors were associated with the outcome. The sensitivity and specificity of the Wells score for the clinical outcome was 85.7% and 68.5%; the AMUSE score 85.7% and 54.4%. Ultrasound had a sensitivity of 91.7% and specificity of 91.7% for radiology-diagnosed thrombus and 78.6% and 95.0% for clinical outcome. The odds ratio of a positive outcome with a positive ultrasound was 65.1. After receiving the ultrasound training program, emergency physicians were unable to demonstrate sufficient accuracy to replace current diagnostic strategies.

Platelets are crucial for prevention of blood loss after vessel injury. Platelet adhesion to disrupted vessel walls is mediated by receptors such as the GPIb-IX-V complex that binds von Willebrand factor and the collagen-binding integrin α2β1. Also cross-linking of platelets, mediated by αIIbβ3 that binds to fibrinogen, results in platelet aggregation that further contributes to hemostasis. Platelets are also important pathophysiologically because of their role in thrombus formation following atherosclerotic plaque rupture. Pharmacological treatments aimed to prevent such events include use of platelet inhibitors such as acetylsalicylic acid (ASA) and clopidogrel. Despite the presence of several different platelet function assays, no one has so far been considered useful for clinical evaluation of the effect of anti-platelet treatment. The aim of this thesis was to evaluate possible applications in experimental as well as in clinical research for a platelet adhesion assay performed during static conditions. In principle, platelets in plasma are allowed to attach to protein coated microplates. Adhered platelets are then detected by induction of an enzymatic reaction followed by spectrophotometric measurements of the developed product. Our results show that the platelet adhesion assay is able to detect experimentally induced activation as well as inhibition of platelets. The assay also seems useful for investigation of synergistically induced platelet activation, especially when the coated surface consists of albumin. This is exemplified by the combination of lysophosphatidic acid and adrenaline, which induced a synergistically increased platelet adhesion to albumin that was dependent on αIIbβ3-receptors and on the secretion of ADP. Furthermore, secretion of ADP as well as TXA2 seems to contribute to several adhesive reactions investigated with this assay. The dependence on secretion, together with results showing that adhesion to collagen and fibrinogen is dependent on α2β1- and αIIbβ3-receptors respectively, indicate that the adhesive interactions occurring in the assay is in accordance with the general knowledge about platelet function. Regarding clinical applications, we found that platelet adhesion was increased for patients with essential thrombocythemia (ET) compared to controls. This is in line with the in vivo function of ET-platelets since a common complication for ET-patients is thrombosis. Furthermore, the assay was able to detect effects of treatment with clopidogrel in patients with unstable angina. To some extent it also measured the effects of ASA-treatment. In conclusion, our results suggest that the assay is suitable for experimental research and that further studies should be performed aimed at developing the assay into a clinically useful device.

Deficiency of antithrombin caused by mutations affecting the gene encoding this key anticoagulant (SERPINC1) significantly increases the risk of thrombosis. We aim to identify new mechanisms involved in antithrombin deficiency. Using molecular, cellular and biochemical methods, we studied 29 patients with antithrombin deficiency without SERPINC1 mutation, a family study, three case-control studies including 2,980 patients and 3,996 controls, and two patients with congenital disorder of glycosylation (CDG). We identified the first mutation affecting the SERPINC1 promoter causing antithrombin deficiency. We confirmed the low genetic variability of SERPINC1 and its minor role on the heritability of antithrombin. Genome wide association studies and silencing experiments identified the first modulating gene of antithrombin, LARGE. We diagnosed a patient with CDG based on his antithrombin deficiency. Finally, we described a new disorder with identical biochemical features than CDGs, but only thrombosis, which is caused by a single mutation in PMM2 and concomitant alcohol consumption. / La deficiencia de antitrombina causada por mutaciones en el gen SERPINC1 incrementa el riesgo trombótico. Nuestro objetivo fue identificar nuevos mecanismos implicados en la deficiencia de este anticoagulante. Empleando metodología molecular, celular y bioquímica estudiamos 29 pacientes con deficiencia de antitrombina sin mutaciones en SERPINC1, un estudio familiar, tres estudios caso-control (2,980 pacientes/3,996 controles) y dos pacientes con trastornos congénitos de glicosilación (CDG). Identificamos la primera mutación en el promotor de SERPINC1 que causa deficiencia de antitrombina. Confirmamos la baja variabilidad genética en SERPINC1 y su escasa influencia en la heredabilidad de antitrombina. Un GWAS y experimentos de silenciamiento mostraron que LARGE es el primer gen modulador de antitrombina. Diagnosticamos un CDG por la deficiencia de antitrombina de un paciente con trombosis recurrente y descubrimos nuevo desorden con patrón bioquímico similar al CDG pero solo con trombosis que es causado por una sola mutación en PMM2 y consumo de alcohol.

Thrombosis is initiated by platelets and leads to cardio-, cerebro-, and peripheral vascular disease, the leading causes of morbidity and mortality in the western world. Antiplatelet drugs have improved clinical outcomes for thrombosis patients. However, their expanded use is limited by hemorrhage at high concentrations and sub-therapeutic activity at lower doses. Thus, development of new antiplatelet agents with improved safety and efficacy is a medical priority. VWF is a multimeric plasma glycoprotein that plays a critical role in platelet-mediated thrombus formation and presents an attractive target for antiplatelet therapy. To this end, I have isolated and characterized aptamer molecules that bind to VWF with high affinity and have shown that some of these aptamer molecules could inhibit platelet activation/aggregation in vitro and in vivo. Furthermore, I designed antidote molecules that can reverse the effects of the aptamer molecules, restoring platelet function quickly and effectively. This project has yielded the first antidote controlled antiplatelet agent and may lead to significant improvements in thrombosis therapy. Thrombin is a plasma protein that plays a critical role in thrombosis. Currently, available antithrombin agents are efficacious in preventing coagulation but do not significantly affect platelet activation and aggregation, both essential components of thrombus formation. Therefore, I tested two aptamer molecules that bind to mutually exclusive exosites on thrombin and, when used together, synergistically inhibit both coagulation and platelet activation. I demonstrated that this method could potentially lead to the development of effective antithrombotic therapies. With an ever-increasing number of people taking multiple medications, the need to safely administer drugs and limit unintended side effects has never been greater. Antidote control remains the most direct means to counteract acute side effects of drugs but unfortunately it has been challenging and cost prohibitive to generate antidotes for most therapeutic agents. Therefore, I described the development of a set of antidote molecules that are capable of counteracting the effects of an entire class of therapeutic agents, i.e. aptamers, including those that I generated against VWF. I demonstrated that protein and polymer-based molecules that capture oligonucleotides can reverse the activity of aptamers in vitro and in vivo. / Dissertation

Native heart valves that have limited functionality due to cardiovascular disease or congenital birth defects are commonly replaced by prosthetic heart valves. Bileaflet mechanical heart valves (BMHV) are the most commonly implanted valve design due to their long-term durability. However, their unnatural hemodynamics promote thrombosis and thromboembolic events. Clinical reports and in vitro experiments suggest that the thrombogenic complications in bileaflet valves are related to the stress imposed on blood by the valves during the closing phase. Additionally, animal and clinical studies have shown that BMHV in the aortic position demonstrate reduced failure rates compared to identical valves in the mitral position. The present study aimed to investigate the leakage, hinge, and near hinge flow fields of two BMHV under simulated physiologic aortic flow conditions and to compare these results with previous findings in the mitral position to better understand how the implant location influences the valve performance and the subsequent risk of blood damage. Two and three-component Laser Doppler Velocimetry techniques were used to quantify the velocity and turbulent shear stress fields in both the hinge and the upstream leakage flow regions. The study focused on the 23 mm St. Jude Medical Regent (SJM) and the 23 mm CarboMedics (CM) valves. Although they were tested under similar physiologic conditions, shape and location of the leakage jets were dependent on valve design. Nevertheless, turbulent shear stress levels recorded within all jets were well above the threshold shear stress for the onset of blood cell damage. Within the hinge region, the flow fields were complex and unsteady. The angulated hinge recess of the CM valve appeared to promote blood damage while the streamlined geometry of the SJM valve contributed to better washout of the hinge region. Animations of the velocity flow fields are given in QuickTime or MPEG format. Comparison of the present findings with previously published results for the mitral position suggests that the superior clinical results of the mechanical valves in the aortic position may be due to less severe leakage flow upon valve closure as well as to enhanced hinge washout during the forward flow phase.

In this work, it is of interest to study the effects of thrombocytosis and microvascular anastomosis to that of vascular thrombosis. Here the splenectomy is used to the experimental subjects to have caused thrombocytosis first and later have the microvascular anastomsis on the divided vessel. Observations on different variables which may be related to vascular thrombosis are obtained during the three stages of the experiments, there are pre-splenectomy, post-splenectomy but before vascular division, and after the vascular anastomsis. These variables include platelet number, RBC count, Nitric oxide(nitrite and nitrate), femoral artery perfusion unit, hematocrit, reticulated-platelet number, and activated-platelets(p-selectin, CD62p). The experimental units are divided into thrombocysis group and control group. Basic statistical analysis are performed first to see the differences between the two groups for the above mentioned variables, and later try to use the profile analysis in multivariate analysis to understand the changes of these variables in different stages as well as their possible relationships with the cause of vascular thrombosis. Finally, classical regression and robust regression analysis for finding outliers are also used to see whether certain characteristics of those outliers have something to do with vascular thrombosis.

Arterial thrombus forms from the capture and accumulation of circulating platelets on a stenosis. As the thrombus grows, the lumen becomes further stenotic producing very high shear rates as the blood velocities increase through the narrowed cross-section. This study explores the molecular binding conditions that may occur under these pathologic shear conditions where circulating platelets must adhere quickly and with strong bonds. Platelets binding in an arterial stenosis of >75% are subject to drag forces exceeding 10,000 pN. This force can be balanced by 100 simultaneous GPIb-vWFA1 bonds of 100 pN each. The number and density of GPIb on platelets is sufficiently high; however, platelet capture under high shear would require the density of A1 receptors to be increased to over 416 per square micron. A computational model is used to determine platelet capture as a function of shear rate, surface receptor density, surface contact and kinetic binding rate. A1 density could be increased by a combination of vWF events of: i) plasma vWF attach to the thrombus surface and elongate under shear; ii) the elongated vWF strands create a net with 3-D pockets; and iii) additional vWF is released from mural platelets by activation under shear. With all three events, A1 density matches the existing high GPIbα densities to provide sufficient multivalency for capture at 100,000 s-1 with greater than 170 bonds per platelet. If the on-rate is greater than 108 M-1s-1, then a platelet could be captured within 15 microseconds, the amount of time available to form bonds before the platelet is swept away. This mechanism of platelet capture allows for the rapid platelet accumulation in atherothombosis seen clinically and in high shear experiments.

Atherosclerosis is the number one cause of death in the United States and one of the most common treatments is the implantation of a stent. In order to eliminate the two most common complications - restenosis and thrombosis - a novel covered stent is investigated. A covered stent membrane should be able to undergo large stretch, prevent restenosis, and be relatively non-thrombogenic. Polyvinyl alcohol (PVA) cryogels are examined as a candidate material for covered stent membranes. Mechanical testing included uniaxial tensile testing, puncture testing, and the fabrication and expansion of PVA cryogel covered stents. Uniaxial testing showed PVA cryogels to have sufficient ultimate stretch which was similar to bare metal stents during deployment. Puncture testing revealed that PVA cryogels are not likely to puncture in vivo. No tears were seen in the PVA cryogel membrane after expansion of the covered stents. Finite element analysis was used to determine a PVA cryogel membrane's effect on artery wall stress. PVA cryogel covered stents reduced both artery wall stress and tissue prolapse when compared to equivalent uncovered stents. Migration assays were used to determine if PVA cryogels are able to block the smooth muscle cell migration seen during restenosis. PVA cryogels significantly reduced cellular migration in modified Boyden chambers - suggesting that they would be able to prevent restenosis in vivo. Thrombogenicity was tested in vitro with a gravity-fed flow loop using porcine blood and in vivo with a sheep model. PVA cryogels were found to be less thrombogenic than polyester controls with the flow loop system. The sheep study demonstrated the feasibility of implanting PVA cryogel covered stents and good early patency. After explantation, the PVA cryogel membranes were intact - providing in vivo evidence for the durability of PVA cryogel covered stents. Overall, this work provides evidence that covered stents made with PVA cryogels are a feasible device in terms of their mechanics, ability to prevent restenosis, and low thrombogenicity. This work represents a major advancement in the development of PVA cryogel covered stents and provides necessary safety and feasibility data for future clinical trials.

Placental vessels and the umbilical circulatory network function to carry oxygen and nutrients to the fetus. It is at this level that placental lesions such as villitis, obliterative vasculopathy, and thrombotic vasculopathy have been observed in association with fetal inflammatory response syndrome (FIRS) and cerebral palsy. We used human umbilical vein endothelial cells (HUVECs) as a model to study the regulation of inflammation and thrombosis in fetal vessels by microbial products. In this thesis we measured interleukin-8 (IL-8) and tissue factor (TF) expression by HUVECs treated with lipopolysaccharide (LPS), poly (I:C) (PIC), and peptidoglycan (PG). Our results show a profound induction of IL-8 by PIC, a TLR-3 ligand. We also show a moderate induction of tissue factor expression in PIC-treated HUVECs. These results show that HUVECs are exquisitely sensitive to PIC and suggests an important role for viral infection in umbilical vessel inflammation. We additionally treated HUVECs with dexamethasone (DEX), an anti-inflammatory steroid, and melatonin (MT), a pineal gland product with immunomodulatory and anti-oxidant properties. DEX reduced the level of both IL-8 and TF expression in PIC-treated cells. MT, however, further enhanced IL-8 expression in PIC-treated cells. Our results indicate a potential role for glucocorticoid therapy in reducing placental vessel inflammation and thrombosis. Thus, intervention with GC in pregnancies with FIRS may reduce the severity of placental lesions associated with cerebral palsy.

A number of clinical, in vitro and computational studies have shown the potential for thromboembolic complications in bileaflet mechanical heart valves (BMHV), primarily due to the complex and unsteady flows in the valve hinges. These studies have focused on quantitative and qualitative parameters such as velocity magnitude, turbulent shear stresses, vortex formation and platelet activation to identify potential for blood damage. However, experimental characterization of the whole flow fields within the valve hinges has not yet been conducted. This information can be utilized to investigate instantaneous damage to blood elements and also to validate numerical studies focusing on the hinge’s complex fluid dynamics. The objective of this study was therefore to develop a high-resolution imaging system to characterize the flow fields and global velocity maps in a BMHV hinge. Subsequently, the present study investigated the effect of hinge gap width on flow fields in a St. Jude Medical BMHV. The results from this study suggest that the BMHV hinge design is a delicate balance between reduction of fluid shear stresses and areas of flow stasis during leakage flow, and needs to be optimized to ensure minimal thromboembolic complications. Overall, the current study demonstrates the ability of high-resolution Micro Particle Image Velocimetry to assess the fluid flow fields within the hinges of bileaflet mechanical heart valves, which can be extended to investigate micro-scale flow domains in critical regions of other cardiovascular devices to assess their blood damage potential.