Jeffrey A. Kline
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Facial Expression as a Diagnostic Tool for Pulmonary Embolism
Jeffrey Kline studies blood clots, the people they affect, and the providers who care for those people. His diagnostic research interests focus on human affect analysis, pretest probability, and novel breath-based instruments to reduce medical imaging. His human treatment research includes randomized trials of fibrinolysis and inhaled nitric oxide to reduce heart damage from blood clots in the lungs. He derived and validated a decision rule to help emergency physicians reduce unnecessary diagnostic tests for low-risk patients with symptoms of blood clots in the lungs.
Dr. Kline’s current work focuses on using the human face as a diagnostic instrument to further help doctors make informed decisions about diagnostic testing for blood clots. His laboratory work focuses on mechanisms and treatment of acute pulmonary hypertension from pulmonary embolism (PE), animal models of pulmonary embolism, and a nanoparticle-delivered enzyme, plasmin, to promote clot lysis without increasing risk. He helped set up an advanced hospital treatment program to treat patients with severe PE, and he also created and runs a clinic specifically to allow patients diagnosed with blood clots in the emergency department to treat themselves at home, rather than in the hospital.
Dr. Kline’s work using the human face as a diagnostic instrument is another example of how IUPUI’s faculty members are TRANSLATING their RESEARCH INTO PRACTICE.
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Item Leukocyte Expression of Heme Oxygenase-1 [hmox1] Varies Inversely with Severity of Tricuspid Regurgitation in Acute Pulmonary Embolism.(Elsevier, 2015-10) Kline, Jeffrey A.; Steuerwald, Nury M.; Watts, John A.; Courtney, Mark; Bonkovsky, Herbert L.; Department of Emergency Medicine, IU School of MedicineObjective: Pulmonary embolism (PE) can cause intracardiac hemolysis and increased plasma hemoglobin and arginase-1, which can worsen pulmonary vasoconstriction. We test the hypothesis that patients with PE that causes tricuspid regurgitation (TR), indicative of higher pulmonary arterial pressures, have decreased leukocyte expression of hmox-1 compared with patients with PE and no TR and patients without PE. Design: Prospective, noninterventional study. Patients: Normotensive patients with suspected PE (n=87) who underwent CT pulmonary angiography and transthoracic Doppler-echocardiography. Measurements: Significant TR was defined as a jet velocity > 2.7m/s. Leukocyte expression of hmox-1, haptoglobin, haptoglobin related gene, the haptoglobin receptor, CD163 and cox-2 genes were assessed by quantitative rtPCR, and the hmox-1 promoter was examined for the −413 A→T SNP and GT repeat polymorphisms. Results: Of the 44 (50%) with PE+, 22 had TR+, and their mean pulmonary vascular occlusion (39±32%) did not differ significantly from patients who were TR− (28±26%, P=0.15). Patients with PE+ and TR+ had significantly lower expression of hmox-1 and haptoglobin genes than patients without PE+ and no TR. Expression of hmox-1 varied inversely with TR velocity (r2=0.45, P<0.001) for PE+ (n=22) but not patients without PE. Hmox-1 expression did not vary significantly with genotype. Cox-2 did not differ between groups and had no correlation with TR. Conclusions: Severity of TR varied inversely with hmox-1 expression, suggesting that hmox-1 expression affects pulmonary vascular reactivity after PE.Item Comparison of Four Bleeding Risk Scores to Identify Rivaroxaban-treated Patients With Venous Thromboembolism at Low Risk for Major Bleeding(Wiley, 2016-02) Kline, Jeffrey A.; Jimenez, David; Courtney, Mark; Ianus, Juliana; Cao, Lynn; Lensing, Anthonie W. A.; Prins, Martin H.; Wells, Philip S.; Department of Chemistry & Chemical Biology, School of ScienceObjectives Outpatient treatment of acute venous thromboembolism (VTE) requires the selection of patients with a low risk of bleeding during the first few weeks of anticoagulation. The accuracy of four systems, originally derived for predicting bleeding in VTE treated with vitamin K antagonists (VKAs), was assessed in VTE patients treated with rivaroxaban. Methods All patients treated with rivaroxaban in the multinational EINSTEIN deep vein thrombosis (DVT) and pulmonary embolism (PE) trials were included. Major bleeding was defined as ≥2 g/dL drop in hemoglobin or ≥2-unit blood transfusion, bleeding in critical area, or bleeding contributing to death. The authors examined the incidence of major bleeding in patients with low-risk assignment by the systems of Ruiz-Gimenez et al. (score = 0 to 1), Beyth et al. (score = 0), Kuijer et al. (score = 0), and Landefeld and Goldman. (score = 0). For clinical relevance, the definition of low risk for all scores except Kuijer includes all patients < 65 years with no prior bleeding history and no comorbid conditions (current cancer, renal insufficiency, diabetes mellitus, anemia, prior stroke, or myocardial infarction). Results A total of 4,130 patients (1,731 with DVT only, 2,399 with PE with or without DVT) were treated with rivaroxaban for a mean (±SD) duration of 207.6 (±95.9) days. Major bleeding occurred in 1.0% (40 of 4,130; 95% confidence interval [CI] = 0.7% to 1.3%) overall. Rates of major bleeding for low-risk patients during the entire treatment period were similar: Ruiz-Gimenez et al., 12 of 2,622 (0.5%; 95% CI = 0.2% to 0.8%); Beyth et al., nine of 2,249 (0.4%; 95% CI = 0.2% to 0.8%); Kuijer et al., four of 1,186 (0.3%; 95% CI = 0.1% to 0.9%); and Landefeld and Goldman, 11 of 2,407 (0.5%; 95% CI = 0.2% to 0.8%). At 30 days, major bleed rates for low-risk patients were as follows: Ruiz-Gimenez et al., five of 2,622 (0.2%; 95% CI = 0.1% to 0.4%); Beyth et al., five of 2,249 (0.2%; 95% CI = 0.1% to 0.5%); Kuijer et al., three of 1,186 (0.3%; 95% CI = 0.1% to 0.7%); and Landefeld and Goldman, seven of 2,407 (0.3%; 95% CI = 0.1% to 0.6%). No low-risk patient had a fatal bleed. Conclusions Four scoring systems that use criteria obtained in routine clinical practice, derived to predict low bleeding risk with VKA treatment for VTE, identified patients with less than a 1% risk of major bleeding during full-course treatment with rivaroxaban.Item High Intensity Interval Training Benefits Right Heart Function in a Rat Model of Pulmonary Arterial Hypertension(Office of the Vice Chancellor for Research, 2016-04-08) Troutman, Ashley; Brown, Mary Beth; Johnson, Breann; Neves, Evandro; Fisher, Amanda; Graber, Jeremy; Gladish, Brett; Presson, Robert; Petrache, Irina; Kline, Jeff; Lahm, TimPulmonary Arterial Hypertension (PAH) is a disease of progressive remodeling in pulmonary arteries that elevates pulmonary pressures and eventually leads to right ventricular (RV) failure and death. The purpose of this study was to examine the benefit and detriment of high intensity interval training (HIIT) to the RV in a monocrotaline (MCT) PAH rat model. It is hypothesized that HIIT will improve indicators of RV function without increasing myocardial inflammation or apoptosis. Male Sprague Dawley rats were injected with either MCT (40 mg/kg, n=14)) to induce mild PAH or saline for healthy controls (CON, n=9). A subgroup of MCT (n= 8) and CON rats (n=6) performed a 6 week treadmill HIIT program 5x/week using short bouts of alternating high intensity (2 min, 85-90%VO2max) and low intensity (3 min, ~30%VO2max) running for 30 min/session. Histochemistry/immunohistochemistry was performed on cryofixed or formalin-fixed/paraffin-embedded RV sections to assess indicators of inflammation (CD45+ cells), apoptosis (TUNEL), fibrosis (trichrome) and was imaged using epifluorescence or brightfield microscopy. Image quantification was performed using ImageJ. For the HIIT rats, a reduction in MCTinduced RV hypertrophy was observed, as measured echocardiographically, and by the calculated ratio of RV mass relative to LV+Septum mass. RV function was better preserved for HIIT vs. sedentary MCT, as indicated by stroke volume and cardiac index (cardiac output normalized by body weight) in echocardiography. MCT-induced RV fibrosis as measured by trichrome staining was lower for HIIT, also indicating a healthier myocardium. HIIT did not prompt greater counts per field of CD45+ cells and TUNEL+ cells in HIIT vs. sedentary MCT RV myocardium. In conclusion, in the monocrotaline rat model of PAH, HIIT appears to be a beneficial exercise approach that improves RV function without exacerbating RV inflammation or apoptosis. Future work will examine effects in other PAH models and ultimately in patients with disease.Item Findings from 12-lead electrocardiography that predict circulatory shock from pulmonary embolism: systematic review and meta-analysis(Wiley, 2015-10) Shopp, Jacob D.; Stewart, Lauren K.; Emmet, Thomas W.; Kline, Jeffrey A.; Department of Emergency Medicine, IU School of MedicineObjectives Treatment guidelines for acute pulmonary embolism (PE) recommend risk stratifying patients to assess PE severity, as those at higher risk should be considered for therapy in addition to standard anticoagulation to prevent right ventricular (RV) failure, which can cause hemodynamic collapse. The hypothesis was that 12-lead electrocardiography (ECG) can aid in this determination. The objective of this study was to measure the prognostic value of specific ECG findings (the Daniel score, which includes heart rate > 100 beats/min, presence of the S1Q3T3 pattern, incomplete and complete right bundle branch block [RBBB], and T-wave inversion in leads V1–V4, plus ST elevation in lead aVR and atrial fibrillation suggestive of RV strain from acute pulmonary hypertension), in patients with acute PE. Methods Studies were identified by a structured search of MEDLINE, PubMed, EMBASE, the Cochrane library, Google Scholar, Scopus, and bibliographies in October 2014. Case reports, non-English papers, and those that lacked either patient outcomes or ECG findings were excluded. Papers with evidence of a predefined reference standard for PE and the results of 12-lead ECG, stratified by outcome (hemodynamic collapse, defined as circulatory shock requiring vasopressors or mechanical ventilation, or in hospital or death within 30 days) were included. Papers were assessed for selection and publication bias. The authors also assessed heterogeneity (I2) and calculated the odds ratios (OR) for each ECG sign from the random effects model if I2 > 24% and fixed effects if I2 < 25%. Funnel plots were used to examine for publication bias. Results Forty-five full-length studies of 8,209 patients were analyzed. The most frequent ECG signs found in patients with acute PE were tachycardia (38%), T-wave inversion in lead V1 (38%), and ST elevation in lead aVR (36%). Ten studies with 3,007 patients were included for full analysis. Six ECG findings (heart rate > 100 beats/min, S1Q3T3, complete RBBB, inverted T waves in V1–V4, ST elevation in aVR, and atrial fibrillation) had likelihood and ORs with lower-limit 95% confidence intervals above unity, suggesting them to be significant predictors of hemodynamic collapse and 30-day mortality. OR data showed no evidence of publication bias, but the proportions of patients with hemodynamic collapse or death and S1Q3T3 and RBBB tended to be higher in smaller studies. Patients who were outcome-negative had a significantly lower mean ± SD Daniel score (2.6 ± 1.5) than patients with hemodynamic collapse (5.9 ± 3.9; p = 0.039, ANOVA with Dunnett's post hoc), but not patients with all-cause 30-day mortality (4.9 ± 3.3; p = 0.12). Conclusions This systematic review and meta-analysis revealed 10 studies, including 3,007 patients with acute PE, that demonstrate that six findings of RV strain on 12-lead ECG (heart rate > 100 beats/min, S1Q3T3, complete RBBB, inverted T waves in V1–V4, ST elevation in aVR, and atrial fibrillation) are associated with increased risk of circulatory shock and death.Item Investigating Skeletal Muscle Metabolic Adaptations underlying Aerobic Fitness Gains following High Intensity Interval Training in a Rat Model of Pulmonary Arterial Hypertension(Office of the Vice Chancellor for Research, 2016-04-08) Talley, Mary; Troutman, Ashley; Neves, Evandro; Fisher, Amanda; Graber, Jeremy; Gladish, Brett; Presson, Robert; Petrache, Irina; Kline, Jeff; Lahm, TimRationale: In patients with pulmonary arterial hypertension (PAH) a shift from oxidative to a less efficient non-oxidative (glycolytic) metabolism in skeletal muscle is believed to contribute to the reduced exercise tolerance hallmark of the disease. As seen for other cardiopulmonary diseases, exercise training (ExT) may ameliorate this “glycolytic switch” in PAH and improve exercise capacity. Previous studies in this lab showed an improved metabolic profile of skeletal muscle in PAH rats following an ExT protocol of continuous running at moderate relative intensity, 60 minutes at 75% of maximal aerobic capacity (VO2 Max). This study tests the hypothesis in a PAH rat model that HIIT will also result in preserved aerobic capacity and attenuation of skeletal muscle glycolytic shift. Methods: Male Sprague-Dawley rats received either monocrotaline (MCT, 40 mg/kg) to induce mild PAH (n= 14), or saline, for healthy controls (n=9). After 2 wks, a 6 wkprogram of treadmill HIIT was initiated for a subset of PAH (n= 8) and healthy controls (n=6). The 30 min HIIT sessions alternated between 2 minutes at 85% VO2 max and 3 minutes at ~30% VO2 max. VO2 max was assessed at baseline, and in pre-training and post-training via analysis of expired gases. Preliminary results: MCT-induced decrement in VO2 max was attenuated by HIIT (p<0.05). Soleus muscle hypertrophy (soleus mass relative to body mass) tended to be higher (p=0.07) in HIIT vs. SED MCT. Membrane glucose transporter Glut-1, a marker of glycolytic metabolism, was evaluated in soleus cryosections with immunofluorescent staining and abundance was similar between sedentary and HIIT MCT rats (p>0.05). Western blotting of soleus homogenates for cytochromes I-V of the electron transport chain (OXPHOS), and for PGC1α, a potent stimulus for mitochondrial biogenesis, is being performed at present to further investigate potential training-induced adaptations in skeletal muscle metabolismItem Comparison of isoflurane and α-chloralose in an anesthetized swine model of acute pulmonary embolism producing right ventricular dysfunction(American Association for Laboratory Animal Science, 2015-02) Beam, Daren M.; Neto-Neves, Evandro M.; Stubblefield, William B.; Alves, Nathan J.; Tune, Johnathan D.; Kline, Jeffrey A.; Department of Emergency Medicine, IU School of MedicinePulmonary embolism (PE) is a leading cause of sudden cardiac death, and a model is needed for testing potential treatments. In developing a model, we compared the hemodynamic effects of isoflurane and α-chloralose in an acute swine model of PE because the choice of anesthesia will likely affect the cardiovascular responses of an animal to PE. At baseline, swine that received α-chloralose (n = 6) had a lower heart rate and cardiac output and higher SpO2, end-tidal CO2, and mean arterial pressure than did those given isoflurane (n = 9). After PE induction, swine given α-chloralose compared with isoflurane exhibited a lower heart rate (63 ± 10 compared with 116 ± 15 bpm) and peripheral arterial pressure (52 ± 12 compared with 61 ± 12 mm Hg); higher SpO2 (98% ± 3% compared with 95% ± 1%), end-tidal CO2 (35 ± 4 compared with 32 ± 5), and systolic blood pressure (121 ± 8 compared with 104 ± 20 mm Hg); and equivalent right ventricular:left ventricular ratios (1.32 ± 0.50 compared with 1.23 ± 0.19) and troponin I mean values (0.09 ± 0.07 ng/mL compared with 0.09 ± 0.06 ng/mL). Isoflurane was associated with widely variable fibrinogen and activated partial thromboplastin time. Intraexperiment mortality was 0 of 6 animals for α-chloralose and 2 of 9 swine for isoflurane. All swine anesthetized with α-chloralose survived with sustained pulmonary hypertension, RV-dilation-associated cardiac injury without the confounding vasodilatory or coagulatory effects of isoflurane. These data demonstrate the physiologic advantages of α-chloralose over isoflurane for anesthesia in a swine model of severe submassive PE.Item Development, validation, and comparison of four methods to simultaneously quantify L-arginine, citrulline, and ornithine in human plasma using hydrophilic interaction liquid chromatography and electrospray tandem mass spectrometry(Elsevier, 2015-11) Lai, Xianyin; Kline, Jeffrey A.; Wang, Mu; Department of Biochemistry and Molecular Biology, IU School of MedicineTo understand the role of l-arginine depletion in impaired nitric oxide synthesis in disease, it is important to simultaneously quantify arginine, citrulline, and ornithine in the plasma. Because the three amino acids are endogenous analytes, true blank matrix for them is not available. It is necessary and valuable to compare the performance of different approaches due to lack of regulatory clarity for validation. A two-step sample preparation method using methanol as protein precipitation reagent was developed in this study is used for sample preparation. Because true blank matrix for endogenous analytes is not available, water as blank matrix, 1% BSA in PBS as blank matrix, surrogate analyte, and background subtraction were designed to establish successful quantification methods. Four methods to simultaneously quantify arginine, citrulline, and ornithine in human plasma using hydrophilic interaction liquid chromatography and electrospray tandem mass spectrometry were developed, validated, and compared. The developed two-step sample preparation method using methanol as protein precipitation reagent in this study needs less time and provides higher recovery comparing with other approaches. Three of the four methods, water as blank matrix, 1% BSA in PBS as blank matrix, and surrogate analyte, have been successful in fulfilling all the criteria, while background subtraction has failed. Results of the measured concentrations in 97 human plasma samples using the three methods show that the difference between any two methods or among the three methods presents 100% of samples with less than 20% for all the three amino acids and majority of them are under 10%. The developed two-step sample preparation method using methanol as protein precipitation reagent is simple and convenient. Three of the four methods are fully validated and the validation is successful. The BSA functioned effectively as a blank matrix for these three amino acids, considering cost, data quality, matrix similarity, and practicality.Item Variable Resistance to Plasminogen Activator Initiated Fibrinolysis for Intermediate-Risk Pulmonary Embolism.(PLOS, 2016) Stubblefield, William B.; Alves, Nathan J.; Rondina, Matthew T.; Kline, Jeffrey A.; Department of Emergency Medicine, IU School of MedicineBackground: We examine the clinical significance and biomarkers of tissue plasminogen activator (tPA)-catalyzed clot lysis time (CLT) in patients with intermediate-risk pulmonary embolism (PE). Methods: Platelet-poor, citrated plasma was obtained from patients with PE. Healthy age- and sex-matched patients served as disease-negative controls. Fibrinogen, α2-antiplasmin, plasminogen, thrombin activatable fibrinolysis inhibitor (TAFI), plasminogen activator Inhibitor 1 (PAI-1), thrombin time and D-dimer were quantified. Clotting was induced using CaCl2, tissue factor, and phospholipid. Lysis was induced using 60 ng/mL tPA. Time to 50% clot lysis (CLT) was assessed by both thromboelastography (TEG) and turbidimetry (A405). Results: Compared with disease-negative controls, patients with PE exhibited significantly longer mean CLT on TEG (+2,580 seconds, 95% CI 1,380 to 3,720 sec). Patients with PE and a short CLT who were treated with tenecteplase had increased risk of bleeding, whereas those with long CLT had significantly worse exercise tolerance and psychometric testing for quality of life at 3 months. A multivariate stepwise removal regression model selected PAI-1 and TAFI as predictive biomarkers of CLT. Conclusion: The CLT from TEG predicted increased risk of bleeding and clinical failure with tenecteplase treatment for intermediate-risk PE. Plasmatic PAI-1 and TAFI were independent predictors of CLT.Item Derivation of a screening tool to identify patients with right ventricular dysfunction or tricuspid regurgitation after negative computerized tomographic pulmonary angiography of the chest(University of Chicago Press Journals, 2015-03) Kline, Jeffrey A.; Russell, Frances M.; Lahm, Tim; Mastouri, Ronald A.; Department of Medicine, IU School of MedicineMany dyspneic patients who undergo computerized tomographic pulmonary angiography (CTPA) for presumed acute pulmonary embolism (PE) have no identified cause for their dyspnea yet have persistent symptoms, leading to more CTPA scanning. Right ventricular (RV) dysfunction or overload can signal treatable causes of dyspnea. We report the rate of isolated RV dysfunction or overload after negative CTPA and derive a clinical decision rule (CDR). We performed secondary analysis of a multicenter study of diagnostic accuracy for PE. Inclusion required persistent dyspnea and no PE. Echocardiography was ordered at clinician discretion. A characterization of isolated RV dysfunction or overload required normal left ventricular function and RV hypokinesis, or estimated RV systolic pressure of at least 40 mmHg. The CDR was derived from bivariate analysis of 97 candidate variables, followed by multivariate logistic regression. Of 647 patients, 431 had no PE and persistent dyspnea, and 184 (43%) of these 431 had echocardiography ordered. Of these, 64 patients (35% [95% confidence interval (CI): 28%-42%]) had isolated RV dysfunction or overload, and these patients were significantly more likely to have a repeat CTPA within 90 days (P = .02, [Formula: see text] test). From univariate analysis, 4 variables predicted isolated RV dysfunction: complete right bundle branch block, normal CTPA scan, active malignancy, and CTPA with infiltrate, the last negatively. Logistic regression found only normal CTPA scanning significant. The final rule (persistent dyspnea + normal CTPA scan) had a positive predictive value of 53% (95% CI: 37%-69%). We conclude that a simple CDR consisting of persistent dyspnea plus a normal CTPA scan predicts a high probability of isolated RV dysfunction or overload on echocardiography.Item Contribution of fibrinolysis to the physical component summary of the SF-36 after acute submassive pulmonary embolism(Springer US, 2015-08) Stewart, Lauren K.; Peitz, Geoffrey W.; Nordenholz, Kristen E.; Courtney, D. Mark; Kabrhel, Christopher; Jones, Alan E.; Rondina, Matthew T.; Diercks, Deborah B.; Klinger, James R.; Kline, Jeffrey A.; Department of Emergency Medicine, School of MedicineAcute pulmonary embolism (PE) can diminish patient quality of life (QoL). The objective was to test whether treatment with tenecteplase has an independent effect on a measurement that reflects QoL in patients with submassive PE. This was a secondary analysis of an 8-center, prospective randomized controlled trial, utilizing multivariate regression to control for predefined predictors of worsened QoL including: age, active malignancy, history of PE or deep venous thrombosis (DVT), recurrent PE or DVT, chronic obstructive pulmonary disease and heart failure. QoL was measured with the physical component summary (PCS) of the SF-36. Analysis included 76 patients (37 randomized to tenecteplase, 39 to placebo). Multivariate regression yielded an equation f(8, 67), P<0.001, with R2 = 0.303. Obesity had the largest effect on PCS (β = −8.6, P<0.001), with tenecteplase second (β = 4.73, P = 0.056). After controlling for all interactions, tenecteplase increased the PCS by +5.37 points (P = 0.027). In patients without any of the defined comorbidities, the coefficient on the tenecteplase variable was not significant (−0.835, P = 0.777). In patients with submassive PE, obesity had the greatest influence on QoL, followed by use of fibrinolysis. Fibrinolysis had a marginal independent effect on patient QoL after controlling for comorbidities, but was not significant in patients without comorbid conditions.