A Coagulação Intravascular Disseminada (CID) é uma síndrome caracterizada pela ativação sistêmica da coagulação sanguínea, levando à trombose microvascular difusa e podendo comprometer a função de múltiplos órgãos. O acelerado consumo de plaquetas e fatores de coagulação pode, no entanto, dar origem a um estado de hipocoagulabilidade, o que confere à CID uma característica paradoxal na qual o excesso de coagulação pode causar uma diátese hemorrágica. Doenças que levam à Síndrome de Resposta Inflamatória Sistêmica (SIRS) estão entre os principais gatilhos da CID. A pancreatite é uma dessas doenças. O maior desafio para o médico veterinário é diagnosticar a CID na fase precoce, silenciosa e de hipercoagulabilidade, visto que os testes laboratoriais de rotina, como contagem de plaquetas, tempo de protrombina (TP) e tempo de tromboplastina parcial ativada (TTPA), detectam apenas o estado de hipocoaguabilidade, que se estabelece na fase mais avançada da síndrome. Nesse contexto ganham importância os analisadores tromboelastográficos, equipamentos que avaliam a coagulação em sangue total e que, ao menos em tese, podem informar a velocidade de formação do coágulo, a força máxima que ele atinge e os padrões de sua dissolução. Este estudo é o primeiro realizado em cães com o aparelho ReoRox G2 (MediRox), uma da marcas disponíveis no mercado. Limites de referência para as variáveis do aparelho foram definidos a partir da análise do sangue de 49 animais clinicamente saudáveis para três tipos de reação: acelerada com fator tecidual (TF), acelerada com TF e um antagonista de agregação plaquetária (abciximab) e apenas com sangue recalcificado. Em seguida, foram comparados a esse intervalo de referência os valores obtidos pela análise tromboelastográfica do sangue de seis pacientes com pancreatite recém-diagnosticada. Nos três tipos de reação pelo menos 50% dos pacientes do Grupo Pancreatite apresentaram alterações sugestivas de hipercoagulabilidade. A variável MAXELAST (força máxima do coágulo) foi a que esteve alterada com mais frequência entre os animais doentes. Não houve alteração nos marcadores de velocidade de fibrinólise. Estudos prospectivos que associem outras variáveis de trombose, protocolos de tratamento e prognóstico de pacientes com doenças subjacentes que predisponham à CID são necessários para que se possa afirmar que o traçado obtido pela tromboelastografia realmente representa um estado de hipercoagulabilidade in vivo em pacientes com pancreatite. / Disseminated Intravascular Coagulation (DIC) is a syndrome characterized by systemic activation of blood clotting, leading to diffuse microvascular thrombosis and may compromise multiple organ function. The accelerated consumption of platelets and coagulation factors may, however, originate a state of hypocoagulability, which gives the DIC a paradoxical characteristic in which excess coagulation can lead to a hemorrhagic diathesis. Diseases which cause Systemic Inflammatory Response Syndrome (SIRS) are among the major triggers of DIC, including pancreatitis. The greatest challenge for veterinarians is to diagnose DIC in the early, silent and hypercoagulable phase, since routine laboratory tests, such as platelet count, prothrombin time (PT) and activated partial thromboplastin time (APTT), detect only the state of hypocoagulability, which occurs in the most advanced stage of the syndrome. In this context, thromboelastography analyzers stand out. They are equipment which evaluate coagulation in whole blood and, at least in theory, inform the speed of clot formation, its maximum force and how it dissolves. This is the first study performed in dogs with the ReoRox G2 (MediRox), one of the brands available in the market. Limits of reference were defined from blood analysis of 49 healthy animals for three reaction types: accelerated with tissue factor (TF), accelerated with TF and a platelet aggregation antagonist (abciximab) and with only recalcified blood. Next, values obtained by blood thromboelastographic analysis of six patients with newly diagnosed pancreatitis were compared to this reference range. In all three types of reactions, at least 50% of patients in the Pancreatitis Group presented alterations suggestive of hypercoagulability. The variable MAXELAST (maximum clot strength) was the one that was most frequently altered among ill animals. There was no change in fibrinolysis rate markers. Prospective studies associating other thrombosis variables, treatment protocols, and prognosis of patients with underlying diseases predisposing to DIC are necessary to confirm that the pathway obtained by thromboelastography actually represents a state of hypercoaguability in vivo in patients with pancreatitis.

Les néoplasies myéloprolifératives (NMP) sont des maladies hématologiques acquises de la cellule souche hématopoiétique (CSH) caractérisées par une prolifération accrue de cellules sanguines. Une mutation activatrice de la protéine JAK2 (JAK2V617F) a été identifiée chez plus de 50% des patients. La survenue de thromboses au niveau artériel et veineux constitue une des principales complications au cours de ces maladies. Au cours d’un premier axe de travail, nous avons souhaité étudier les conséquences sur la physiopathologie de la thrombose de la présence de la mutation JAK2V617F dans les cellules endothéliales (CE). Utilisant deux approches complémentaires, in vitro avec l’utilisation de cellules endothéliales veineuses, et in vivo avec l’utilisation d’un modèle murin permettant la présence de la mutation JAK2V617F dans le compartiment endothélial, nous avons démontré que la présence de CE JAKV617F favorisait la survenue de thrombose. Cette augmentation de la survenue de thrombose était médiée par une augmentation de l’adhésion des leucocytes au niveau des CE JAK2V617F, secondaire à une augmentation d’expression de P-Sélectine à leur surface. Ce travail a permis de mettre en évidence un nouveau mécanisme de la physiopathologie de la thrombose au cours des NMP JAK2V617F. Au cours d’un second axe de travail, nous avons étudié les polynucléaires neutrophiles (PNN) et le phénomène de NETose (formation de neutrophil extracellular traps ou NET) au cours des NMP. Nous avons démontré que la formation de NET était augmentée dans une cohorte de patients avec NMP, tout comme des marqueurs indirects de NETose (ADN plasmatique, MPO-ADN plasmatique). Nous avons mis en évidence que les taux de MPO-ADN plasmatique étaient plus élevés chez les patients avec antécédents de thrombose par rapport aux patients sans. Nous avons confirmé ces résultats à l’aide de deux modèles murins différents dans lesquels nous avons également retrouvé une formation de NET augmentée. Nous avons mis en évidence que cette formation de NET participait à la physiopathologie de la thrombose, l’administration de DNAse entraînant une réduction de la survenue de thrombose. Enfin, nous avons démontré que les plaquettes JAK2V617F stimulaient la production de NET par les PNN JAK2V617F, suggérant une collaboration de ces deux types cellulaires au cours de la physiopathologie de la thrombose des NMP. / Myeloproliferative neoplasms (MPN) are acquired hematologic diseases of the hematopoietic stem cell (HSC) characterized by blood cell proliferation. An activating mutation of the protein JAK2 (JAK2V617F) has been identified in more than 50% of patients. The occurrence of arterial and venous thrombosis is one of the main complications during these diseases. We first studied the consequences of the presence of the JAK2V617F mutation in endothelial cells (EC) on the physiopathology of thrombosis. We used two complementary approaches, in vitro with the use of human venous endothelial cells, and in vivo with the use of a mouse model allowing the presence of the JAK2V617F mutation only in the endothelial compartment: the PDGFb-iCreERT2;JAK2V617F/WT model. We first observed that PDGFbiCreERT2; JAK2V617F/WT mice displayed a higher propensity for thrombosis. This increased thrombus formation was mediated by an increased leukocyte adhesion in presence of JAK2V617F EC, secondary to an increase in P-Selectin expression at their surface. This work made it possible to highlight a new mechanism of the physiopathology of thrombosis during JAK2V617F MPN. Then we studied neutrophils and the phenomenon of NETosis (formation of neutrophil extracellular traps or NET) during MPN. We demonstrated that NET formation was increased in a cohort of patients with MPN, such as indirect markers of NETosis (plasmatic DNA and MPO-DNA). We found that plasma MPO-DNA levels were higher in patients with a history of thrombosis compared to patients without. We confirmed these results using two different mouse models in which we also found increased NET formation. We found that NET formation was involved in the physiopathology of thrombosis, as DNAse administration resulted in a reduction of thrombosis occurrence. Finally, we demonstrated that JAK2V617F platelets stimulated NET formation by JAK2V617F neutrophils, suggesting collaboration of these two cell types during the physiopathology of thrombosis during MPN.

Santana, ANC. Estudo da trombose microvascular em biópsias pulmonares de pacientes com Granulomatose de Wegener. [tese]. São Paulo: Faculdade de Medicina, Universidade de São Paulo; 2008. A granulomatose de Wegener (GW) é associada com eventos trombo-embólicos. Neste trabalho, quantificamos os trombos em artérias pulmonares de pequeno/médio calibre de pacientes com GW (n:24), comparando com um grupo Controle normal (n:16). O resultado mostrou que a área total das artérias no grupo GW foi similar a do grupo Controle. Já a área do trombo foi significativamente maior no grupo GW em relação ao Controle. Em contrapartida, a área livre do lúmen do vaso foi significativamente menor no grupo GW em comparação ao Controle. Concluindo, este estudo demonstra uma obstrução da microcirculação pulmonar na GW, sugerindo um papel da trombose in situ na fisiopatologia desta doença / Wegeners granulomatosis (GW) is associated with thromboembolic events. In this work, we quantified the thrombus in small/medium-sized pulmonary arteries of patients with GW (n:24) compared to normal controls (n:16). The results showed that the GW and control arteries were similar regarding total area. The thrombus area was significantly increased in GW compared to controls; in contrast, the free lumen area was significantly decreased in GW compared to controls. In summary, this study shows obstruction of microvascular bed in GW, suggesting a possible role of thrombosis in situ in pathophysiology of this vasculitis

La maladie veineuse thromboembolique (MVTE) est un problème de santé publique (plus de 100000 cas par an en France). Elle regroupe deux entités cliniques : la thrombose veineuse profonde (TVP) des membres inférieurs et l’embolie pulmonaire (EP). La TVP correspond à la formation inadaptée d’un thrombus veineux (appelé aussi caillot sanguin) dans les veines profondes (poplitées, fémorales, iliaques). Un thrombus est principalement constitué de globules rouges et de plaquettes dans un réseau de fibrine. La complication majeure d’une TVP est la survenue d’une EP, c’est-à-dire que le thrombus s’est détaché de la paroi veineuse, ou s’est fragmenté, et est entraîné par la circulation sanguine jusqu’à une artère pulmonaire. Cette complication a un taux de mortalité assez élevée autour de 10000 à 20000 cas mortels par an en France. La survenue d’une TVP est multifactorielle associant des facteurs génétiques et acquis pouvant être répartis en trois catégories : la stase veineuse, l’altération de la paroi d’une veine et une hypercoagulabilité. En analysant la structure du thrombus, notre projet vise à identifier le facteur principal responsable de la TVP et à évaluer le risque d’EP. Pour caractériser sa structure, nous disposons de deux modes d’imagerie acoustique : l’échographie et l’élastographie (carte de dureté). Nous proposons d’extraire des descripteurs de ces images acoustiques par deux approches, l’une basée sur les ondelettes (le scattering operator) et l’autre sur les statistiques d’ordre supérieur (les multicorrélations). Ces descripteurs sont ensuite analysées par diverses techniques de classification (analyse en composantes principales, k-moyennes, classification spectrale) pour retrouver la cause principale des TVP ou la présence d’EP. / Venous thromboembolism (VTE) is an important public health issue (over 100000 individuals in France per year). VTE is a combination of a deep venous thrombosis (DVT) and a pulmonary embolism (PE). DVT is an inappropriate formation of a thrombus (also called blood clot) in one of the deep veins of the body, usually in the leg (popliteal, femoral, iliac). There are mainly three components in a thrombus: platelets, red blood cells and a mesh of fibrins. The main complication of a DVT is a pulmonary embolism (PE) which occurs when a thrombus breaks loose and travels to the lungs. PE affects an estimated 10000 - 20 000 individuals just in France per year. Three physiopathological mechanisms cancontribute, isolated or combined, to the development of a DVT: venous stasis, endothelial injury and hypercoagulability. Our project is aiming to relate the thrombus structure, its main triggering factor and the risk of a PE. To characterize the thrombus structure, we are collecting ultrasonography (echogenicity) and elastography (stiffness) of human thrombus. We propose to extract features from these to kind of ultrasound images using two approaches: one basedon wavelets (the scattering operator) and another based on high order statistics (multicorrelations). Then, the obtained features are analysed using several classification technics (principal component analysis, k-means, spectral clustering) to find the main cause of the DVT or the presence of PE.

Es wurde ein zweistufiger, indirekter enzymatischer Assay (Fibrinolytische-Kapazität, FC) in zwei Varianten (basal, aktiviert) vorgestellt, der summarisch Störungen der Fibrinolyse erfasst, da in ihn die Gesamtaktivität der Aktivatoren und Inhibitoren des Plasmas einfließt. In der ersten Stufe wird Plasma Urokinase zugeführt, welche mit Plasminogenaktivatorinhibitoren interagiert. Die noch freie Urokinase aktiviert Plasminogen zu Plasmin. Die plasmatischen Antiplasmine, hauptsächlich alpha 2-Antiplasmin, werden oxidativ mit Taurin-Chloramin inaktiviert. Schließlich wird die resultierende Plasminmenge mit einem chromogenen Substrat quantifiziert. In einer zweiten Variante wird die kontaktphasenabhängige Fibrinolyse vorher sehr potent mit Dextransulfat stimuliert. Zur Validierung wurde der Einfluss von PAI-1, Fibrinogen und Plasminogen untersucht. Störgrößen wie Antioxidantien, parenterale Antikoagulantien, Phenprocoumon, Aprotinin, Tranexamsäure, Thrombozyten und Bilirubin wurden ebenfalls untersucht. Zusätzlich wurde der Test anhand eines Normal-, Thrombose- und Schwangerenkollektives sowie zweier kleiner Kollektive (Schwangere und Patienten unter oraler Antikoagulation) im Zeitverlauf untersucht. Beide FC-Varianten bilden dabei die prothrombotischen Faktoren unterschiedlich ab. In der Regressionsanalyse reagiert die basale FC eher auf Veränderungen der PAI-1- und Plasminogenkonzentrationen, die aktivierte FC eher auf Plasminogen und Thrombose. Thrombose wird durch die aktivierte FC besser als durch die basale FC diagnostiziert (beta-Koeffizienten für Thrombose -0,12 vs. -0,26, Zusammenhangsmaß Eta² von FC und Thrombose 5,6% vs. 9,9%, Entscheidungsgrenze (Cut-Off) für Thrombose 33,0% vs. 66,2% für basale bzw. aktivierte FC). Beide FC-Varianten besitzen ähnliche Sensitivität, Spezifität, prädiktive Werte und relative Risikos für Thrombose bei FC-Werten unterhalb der Entscheidungsgrenze. Die Thromboseerkennbarkeit ist für beide Varianten gleichwertig bei einer Übereinstimmung untereinander von 61,3% (Cohen-Kappa-Koeffizient). Bei der Abklärung einer akuten Thrombose ist dieser Fibrinolyse-Globaltest in der Lage, Ursachen innerhalb des fibrinolytischen Systems zu erkennen. / A two-step indirect enzymatic assay (fibrinolytic capacity, FC) was presented in two variations (basal, activated) detecting the total fibrinolytic disturbances by its ability to assess the entire plasmatic activity of activators and inhibitors. In the first step urokinase is added to plasma, which interacts with plasminogen-activator-inhibitors. The remaining urokinase activated plasminogen to plasmin. The plasmatic antiplasmines, mainly alpha 2-antiplasmine were oxidative inhibited with taurine-chloramine. Finally the resulting amount of plasmin was quantified using a chromogenic substrate. In a second variation the contact-phase fibrinolysis was highly stimulated with dextran-sulfate. The influence of PAI-1, fibrinogen and plasminogen were analysed including disturbing substances such as antioxidants, parenteral anticoagulants, phenprocoumon, aprotinine, tranexamic acid, platelets and bilirubine. In addition, validation was performed including healthy individuals, patients with thrombosis and pregnant women and two small cohorts (pregnant women and patients under oral anticoagulation) over time. The prothrombotic factors were differently represented by the two FC-variations. In the regression analysis the basal FC reacted predominantly to alterations in the concentration of PAI-1 and plasminogen. In contrast the activated FC was more likely affected by plasminogen and thrombosis. The activated FC was more sensitive in the detection of thrombosis than the basal FC (with a beta-coefficient for thrombosis -0,12 vs. -0,26, a coefficient of strength of association eta² from FC with thrombosis 5,6% vs. 9,9% and a cut-off for thrombosis 33,0% vs. 66,2% for basal and activated FC respectively). Below these cut-offs both FC-variations had equal sensitivity, specificity, predictive values and relative risks in the detection of thrombosis by FC-values. The ability to detect thrombosis were equally with a correspondence of 61,3% (Cohen-Kappa-coefficient). This fibrinolytic global-test is able to identify the underlying cause within the fibrinolytic system for the a clarification of acute thrombosis.

Despite the currently recommended dual antiplatelet treatment (DAT) with aspirin and P2Y12 inhibition in patients with coronary artery disease (CAD) there is a risk of adverse clinical outcome. Pharmacodynamic (PD) poor response to clopidogrel occurs in ~ 30% of clopidogrel-treated patients and is associated with an increased risk of recurrent thrombotic events. The aims of this thesis were to compare the PD and pharmacokinetic effects of clopidogrel 600 mg loading dose (LD)/ 75 mg standard maintenance dose (MD) with the novel P2Y12 inhibitor prasugrel 60 mg LD/10 mg MD, in 110 patients with CAD. The mechanisms behind clopidogrel poor response were investigated by assessing the pharmacodynamics after adding clopidogrel active metabolite (AM) and genotyping for variation in CYP-genes involved in thienopyridine metabolism. In another study, we compared the on-clopidogrel platelet reactivity of patients with stent thrombosis (ST) (n=48) or myocardial infarction (MI) (n=30) while on DAT and their matched controls (n=50 + 28). Prasugrel achieved a faster and greater P2Y12-mediated platelet inhibition than clopidogrel measured with light transmission aggregometry, VASP and VerifyNow® P2Y12. Prasugrel’s greater platelet inhibition was associated with higher exposure of AM. The addition of clopidogrel AM led to maximal platelet inhibition in all subjects, suggesting that prasugrel’s greater antiplatelet effect was related to more efficient AM generation compared to that of clopidogrel. Lower levels of AM as well as less platelet inhibition were seen in clopidogrel-treated patients with reduced-metabolizer genotype CYP2C19 compared to those with normal genotype. Patients with ST while on DAT showed higher on-clopidogrel platelet reactivity compared to matched stented controls. Patients with spontaneous MI after stenting did not. In conclusion, these results showed a high rate PD poor response to a high bolus dose of clopidogrel because of a partly genetically caused lower generation of AM which could be overcome by prasugrel treatment. In patients after coronary stenting, clopidogrel poor response was related to ST but not to spontaneous MI, illustrating difficulties in optimizing treatment with clopidogrel based on platelet function or genetic testing in individual patients.

Over seven million Americans suffer from Chronic Venous Insufficiency (CVI), a painful and debilitating disease that affects the superficial and deep veins of the legs. Problems associated with CVI include varicose veins, bleeding, ulcerations, severe swelling, deep vein thrombosis, and pulmonary embolism, which may lead to death. The presence of CVI results from damaged (incompetent) one-way vein valves in leg veins. These valves normally allow forward flow of blood to the heart, and prevent blood from pooling at the feet. However, incompetent valves allow reflux of blood, causing clinical problems. There are few effective clinical therapies for treating CVI. Vein valve transplantation is a surgical option for treatment. However, it is often difficult to find suitable donor valves. Very few prosthetic valves developed in the past have demonstrated sufficient clinical or mechanical functionality. Persistent problems include thrombus formation, leaking valves, and valves that do not open at physiologic pressure gradient. The primary objective of this research was to develop a clinically relevant functional prosthetic vein valve. The novel prosthetic valve is flexible, biocompatible, has low thrombogenecity, and is easy to manufacture. It was designed to address well-defined consumer needs and functional design requirements. The valve was required to 1) withstand 300 mmHg of backpressure with leakage less than 1.0 mL/min, 2) open with a pressure gradient less than 5 mmHg, and 3) meet criteria 1 and 2 after 500,000 cycles of operation. The valve met these design requirements in bench testing. The valve can open with a pressure gradient of 2.6 0.7 mmHg, and can withstand 300 mmHg with leakage less than 0.5 mL/min. The valve remained functional after opening and closing over 500,000 times. The valve presented in this research is operationally functional, and is a potential solution for treating venous incompetence in CVI patients.

A mathematical model of blood coagulation under defined flow conditions, initiated and modulated by spatially discrete regions of surface bound tissue factor (TF) and thrombomodulin (TM), respectively, is presented. The model incorporates fluid phase and surface-associated reactions of the extrinsic, intrinsic, and common pathways, as well as three inhibitory pathways. The spatially heterogeneous model is formulated by finite element method, and an effective prothrombotic zone, which quantifies the spatial propagation of thrombin generation is defined. Characteristic features of coagulation are simulated under physiologic conditions, and the behavior of the system in response to perturbations in TF and TM surface densities, TF site dimensions, and wall shear rate is explored. The major findings of these studies include: (i) The model system responds in an 'all-or-none', threshold-like manner to changes in model parameters. (ii) It was found that prothrombotic effects may extend significantly beyond the dimensions of the spatially discrete site of TF expression in both axial and radial directions. (iii) The relationship between the length of the effective prothrombotic zone and the interval distance between tandem sites of TF expression dictate the net response of the system. Additive prothrombotic effects of sub-clinical lesions as well as suppressive antithrombotic effects of intervening TM-containing regions were observed. Secondly, the computational model is applied to calculate an individualized, systems-based metric of clotting potential for 210 pre-menopausal women in the Leiden Thrombophilia Study (LETS). The simulated variable was found to be a highly predictive parameter for deep venous thrombosis risk.

Atherothrombosis can induce acute myocardial infarction and stroke by progressive stenosis of a blood vessel lumen to full occlusion. The goal of this research is to determine what shear rates are pertinent to an occluding blood vessel, the rate of thrombus growth relative to wall shear rates, and to develop a predictive model for estimating length of time to thrombus occlusion for a given atherosclerotic lesion. Computational studies of severely stenotic idealized vessels were performed to investigate the wall shear rates that may exist. The study shows that maximum shear rates in severe short stenoses were found to exceed 250,000 1/s (9,500 dynes/cm2). We utilize an in vitro experiment consisting of blood flow through a collagen coated stenosis to study the rate of thrombus growth. Growth is monitored through light microscopy and a camera. Computational fluid dynamics are used to determine shear rates along the thrombus surface as it grows. We found a strong positive correlation between thrombus growth rates and shear rates up to 6,000 1/s after a log-log transformation (r=0.85, p<0.0001). Growth rates at pathologic shear rates were typically 2-4 times greater than for physiologic shear rates below 400 s-1. To determine whether transport or kinetic binding limits the rate of thrombus growth, a computational model of platelet transport was developed. The model allows for thrombus growth by occluding computational cells. We show that thrombus is transport rate-limited for shear rates below 6,000 1/s, while it is more likely to be kinetic rate-limited for higher shear rates. Predictions of occlusion times based on the model demonstrate that increases in stenosis severity results in decreased time to occlusion.

In order to simulate cellular blood, a coarse-grained spectrin-link (SL) red blood cell (RBC) membrane model is coupled with a lattice-Boltzmann (LB) based suspension solver. The LB method resolves the hydrodynamics governed by the Navier--Stokes equations while the SL method accurately models the deformation of RBCs under numerous configurations. This method has been parallelized using Message Passing Interface (MPI) protocols for the simulation of dense suspensions of RBCs characteristic of whole blood on world-class computing resources. Simulations were performed to study rheological effects in unbounded shear using the Lees-Edwards boundary condition with good agreement with rotational viscometer results from literature. The particle-phase normal-stress tensor was analyzed and demonstrated a change in sign of the particle-phase pressure from low to high shear rates due to RBCs transitioning from a compressive state to a tensile state in the flow direction. Non-Newtonian effects such as viscosity shear thinning were observed for shear rates ranging from 14-440 inverse seconds as well as the strong dependence on hematocrit at low shear rates. An increase in membrane bending energy was shown to be an important factor for determining the average orientation of RBCs, which ultimately affects the suspension viscosity. The shear stress on platelets was observed to be higher than the average shear stress in blood, which emphasizes the importance of modeling platelets as finite particles. Hagen-Poiseuille flow simulations were performed in rigid vessels for investigating the change in cell-depleted layer thickness with shear rate, the Fåhraeus-Linqvist effect, and the process of platelet margination. The process of platelet margination was shown to be sensitive to platelet shape. Specifically, it is shown that lower aspect ratio particles migrate more rapidly than thin disks. Margination rate is shown to increase with hematocrit, due to the larger number of RBC-platelet interactions, and with the increase in suspending fluid viscosity.