calcium by sodium citrate used as an anticoagulant with blood collection. However, protein-S dimerization occurs at concentrations far above the plasma concentration: "at 17 M, the associated product is principally a dimer." 2 Inspection of Figure 5 of the paper by Pauls et al 2 indicates that, at the free protein-S concentration present in plasma (ϳ 150 nM), protein S is principally a monomer.In spite of this, Dr Mann believes that inhibitory protein-S dimers are present at the start of our experiments, and that slow depolymerization of these dimers after recalcification of plasma invalidated our conclusions. 1 We refuted this possibility by recalcifying the plasma 15 minutes before initiation of thrombin generation with tissue factor/phospholipid. This provided ample time for the Ca 2ϩ -induced conformational changes of vitamin-K-dependent proteins to occur, and for depolymerization of protein-S dimers if present. Figure 1 shows that after "pre"-recalcification of plasma the activated protein C (APC)-independent inhibitory effect of protein S on thrombin generation prevailed.The endogenous thrombin potentials (ETPs) determined in the absence of functional protein S were similar without and with preincubation of plasma with CaCl 2 (Figure 1). In the presence of protein S (Figure 1 open symbols), the ETP determined in plasma preincubated with CaCl 2 (521 nM thrombin min) was even lower than the ETP of plasma that was not preincubated with CaCl 2 (659 nM thrombin min). Protein S decreased the ETP in freshly recalcified citrated plasma by 30%, compared with 40% when plasma was preincubated with CaCl 2 , and thus became an even better inhibitor of thrombin generation. Moreover, if protein-S dimers in citrated plasma had caused the observed phenomena, the inhibitory effect of protein S on thrombin generation would have been abrogated at high phospholipid concentrations. 2 However, increasing phospholipid concentrations did not affect the anticoagulant potential of protein S in plasma. 1 This demonstrates that the inhibition of thrombin formation by protein S in plasma is not due to competition for phospholipid binding sites.Dr Mann raised an important point regarding the effect of the thrombin substrate on thrombin generation. Indeed, it has been shown that the measured ETP increases with increasing substrate concentrations, 5 likely due to the fact that the substrate protects thrombin against inhibition by antithrombins. However, it should be emphasized that only free thrombin (ie, thrombin that is not occupied by substrate) will be available for feedback reactions. Surprisingly, when the free-thrombin concentrations present in plasma were calculated using the Michaelis-Menten constant (K m ) and substrate concentrations, superimposable thrombin generation curves (free thrombin versus time) were obtained. 5 This indicates that the generation of thrombin hardly depends on the action of thrombin but that another component is rate limiting, namely factor Xa, 6 and that the presence of the substrate has virtually no ...