Hematology DirectorHarinder S. Juneja, M.D.
Director of the Division of Hematology
The University of Texas Health Science Center at Houston
Medical School Department of Internal Medicine
6431 Fannin, MSB 5.016
Houston, Texas 77030
- Sickle cell anemia: Approximately 20 years ago, I started to supervise care of patients with sickle cell anemia at the UT-Hermann Hospital and as a result of our special interests, the patient population of sickle cell patients in our clinics has increased. We have been able to use the availability of these patients to participate in clinical studies in sickle cell anemia. We participated in two multicenter clinical studies funded by a drug company (CytRX, Inc.) to evaluate the effectiveness of FLOCOR, a polymer which inhibits cell-cell attachments between the RBCs. Unfortunately on analysis of the completed Phase III study, the drug was found to have hepatotoxicity and studies have been halted by the drug company. However, the drug was found to be beneficial in a subgroup of patients with sickle cell disease having pain crisis. A study sponsored by ICAGEN to study their drug in SCA patients was also completed.
Role of adenosine in pathophysiology of sickle cell anemia is being studied currently, in collaboration with Dr. Yang Xia, Department of Biochemistry, UT Medical School at Houston.
- Stem Cell therapy: I am an active participant in stem cell therapy for patients with acute cerebrovascular accidents and myocardial infarction in collaboration with Dr. Sean Savitz, Department of Neurology, UT Medical School and Texas Heart Institute investigators lead by Dr. J.T. Willerson, respectively.
- Bone marrow stromal cells and leukemic/myeloma cell interactions: In the past we have reported on the effect of steroid hormones on bone marrow fibroblasts and shown that the response to corticosteriods or dexamethasone is paradoxical in marrow fibroblasts from patients with aplastic anemia compared to normal marrow fibroblasts. Also functional abnormalities were noted in marrow fibroblasts from aplastic anemia patients. These studies were published in Experimental Hematology in 1984 and 1985. The observation in the laboratory that growth of leukemic cells from a patient were supported by bone marrow stromal cells changed the direction of the research on stromal cells towards interaction between leukemic cells, and bone marrow stromal cells. We have shown that the bone marrow stromal cells can provide growth support to malignant lymphoblasts of human origin. It was noted during these studies leukemic cells adhere to the stromal cells. Work in our laboratory and that of others showed that V-CAM-1 and its ligand VLA4 are important in adherence between leukemic cells and bone marrow stromal cells. In addition it was shown that the integrin VLA4 and V-CAM-1 were involved in an early phase of heterotypic adhesion within the first 10-15 minutes while an as yet undefined mechanism was responsible for further increase in adherence between initial phase and subsequent increase in adherence. (Blood 85:168-178, 1995). Also, CD45 was found to be an adhesion protein involved in adhesion of murine leukemic cells to marrow stromal cells (Leuk Res 29:805-15, 1998). Adhesion of leukemic cells was also reported to decrease apoptotic cell death in a human MSC-chronic lymphocytic leukemia ex-vivo model (Hematology 5(6):463-473, 2001).
Most recently, we have studied changes in transcripts in the bone marrow stromal cells on contact with myeloma cell membrane. Using differential display and RT-PCR, we have found that approximately 141 transcripts were either up or downregulated when bone marrow stromal cells came in contact with myeloma cell membrane. Twenty of these up or downregulated transcripts were converted to DNAs by RTPCR and sequenced. On comparison to the sequencing in the DNA banks we found that in addition to one of the previously described upregulated transcripts i.e., IL-6, gp130, the cotransducer for IL-6 receptor superfamily was also upregulated. We further showed that the upregulation of IL-6 and gp130 transcripts occurs co-coordinately. However, the upregulation of gp130 transcripts occurs in the presence of cycloheximide suggesting that the IL-6 secretion is not responsible for upregulation of gp130. In addition, we observed that cycloheximide increases basal IL-6 and gp130 transcripts levels in the bone marrow stromal cells. In addition, cycloheximide caused superinduction of gp130 and IL-6 transcripts in the presence of myeloma cell membranes. (J. Interferon and Cytokine Research 21:157-166, 2001). The paracrine secretion of IL-6 by bone marrow stromal cells is considered to be an important mechanism of in-vivo myeloma cell growth. Interruption of signals that would decrease the secretion of IL-6 and alter expression gp130 may be useful in treatment of patients with multiple myeloma. Currently, we are examining cell-adhesion mediated upregulation of TIMP-1 transcripts in marrow stromal cells. This work is not being actively pursued at present.
- Atherosclerosis: I was a co-investigator (15% effort) in the ARIC (Atherosclerosis Risk In Communities) project between 1997-1999 and have continued as a collaborator on the project to date. The project is an NIH funded prospective study to identify risk factors for atherosclerosis utilizing three representative communities in the United States. I have served as a member of the Laboratory Committee of this project over the last five years. I have participated in the activities of the Central Coagulation Laboratory, which is based in the Hematology Division at UTHSC at Houston. Several papers on predictive value of coagulation factors and endothelial cell markers in relationship to incident coronary disease, heart peripheral arterial disease and cerebral vascular disease have been published. The major platelet integrin glycoprotein IIb/IIIa plays an important role in platelet aggregation and acute thrombus formation at the site of vascular injury. The ARIC cohort was utilized to determine whether PIA2 allele is a potential genetic risk factor for incident coronary heart disease and whether it is linked to platelet hyperaggregability. This prospective population-based study indicated that healthy individuals carrying PIA2 allele do not have an increased risk for coronary heart disease. (Circulation 102:1901-1905, 2000). Similarly, the role of soluble thrombomodulin was evaluated in peripheral arterial disease, incident coronary disease and symptomless carotid artery atherosclerosis. Thrombomodulin is integral membrane glycoprotein that has a major role in vasoprotection. In the study published in the Lancet (353:1729-1734, 1999), using the cohort case and control groups, it was found that soluble thrombomodulin showed a strong, graded, inverse association with incident coronary heart disease (p 0.005). The adjusted rate ratio of the highest quintile of soluble thrombomodulin compared with the lowest was 0.29 (95% CI 0.15-0.57). The association with carotid atherosclerosis, however, tended to be positive, especially among white participants (odds ratio 2.94 [1.15-7.51] for highest vs. lowest quintile). Thus, a high concentration of soluble thrombomodulin may be associated with a decrease in risk of coronary heart disease. A case-control designed study evaluating the cross-sectional association of soluble thrombomodulin with mild peripheral artery disease was reported in Atherosclerosis 157:309-314, 2001. This study confirmed the observation of interaction between thrombomodulin and factor VIII coagulant activity. Among white participants, a subgroup with highest factor VIII:C levels present and the lowest quintile of soluble thrombobulin had significantly high risk for PAD. These data further support a role for thrombomodulin-protein C pathway in atherosclerosis. Whether thrombomodulin as a risk factor in coronary artery disease was further examined by studying thrombomodulin ALA 455 Val polymorphism and the risk of coronary heart disease. (Circulation 103:1386-1389, 2001). When the relative risk was determined according to race, the AV/VV genotype group increased the CHD risk in blacks by 4.44 fold after adjustment for age and sex and by 6.1 fold when adjusted for other CHD risk factors. In contrast, AV/VV genotypes were not significantly associated with CHD risk in whites. The mechanism of this increase risk in blacks is unclear. It is not the concentration of thrombomodulin but some other interactions that are likely to be responsible for the association of higher relative risk for blacks with a AV/VV genotype. This is the first report that identifies a risk factor for coronary heart disease specifically limited to the black population, given the prospective nature of these case-control studies. These observations on thrombomodulin and the variances of thrombomodulin in coronary heart disease atherosclerosis and several vascular diseases significantly advance our understanding of atherosclerosis. Further analysis of ARIC data is in progress.
- Therapy of marrow failure: In 1987 we reported the use of etiocholanolone as therapy for aplastic anemia with a response rate of 42%. In the past few years we have attempted to develop etiocholanedione, an oral hemopoietic stimulator, for the treatment of aplastic anemia and myelodysplasias. Currently two protocols are open for treatment of aplastic anemia. The first therapy uses intramuscular etiocholanolone along with testosterone and cyclosporin in patients who have failed ATG treatment. Over the last two years we have enrolled only two patients. The protocol is a salvage protocol as marrow transplantation and ATG + cyclosporin are effective treatment for aplastic anemia. The second study is a Phase I study for etiocholanedione which is converted in vivo to etiocholanolone. Phase I dose escalation studies have been done, however, the drug company in collaboration with which this protocol is being done, had difficulty in assaying the serum levels of etiocholanolone and etiocholanedione. This protocol is on hold until the company can set up their assays adequately and provide data on samples already collected.
We published a paper on the use of low dose ARA-C in the 5 q- syndrome in the American Journal of Hematology in 1994 showing that low dose cytosine arabinoside is able to induce clinical remissions of durable for up to 1.5 to 2 yrs in these patients.
Currently we are actively looking at large granular lymphocytosis as a cause of cytopenias in the patient population at MDACC, Houston, TX.
- Juneja, H.S., and Weiner, R.: Presence of the Philadelphia chromosome in pokeweed mitogen stimulated lymphocytes during the chronic phase of chronic granulocytic leukemia. Cancer Genetics and Cytogenetics 4:39-44, 1981.
- Juneja, H.S., Williams, W.C., Minguell, J.J., Bessman, J.D., Weiss, G.B., Gardner, F.H.: Growth of human malignant micromegakaryocytes in vitro. Exp. Hematol. 10:404-412, 1982.
- Juneja, H.S., Gardner, F.H., Minguell J.J., Helmer, R.E., III.: Abnormal marrow fibroblasts in aplastic anemia. Exp. Hematol. 12:221-230, 1984.
- Juneja, H.S., Gardner, F.H.: Functionally abnormal marrow stromal cells in aplastic anemia. Exp. Hematol. 13:194-199, 1985.
- Gallardo, R.L., Juneja, H.S., Gardner, F.H.: Normal human bone marrow fibroblasts induce clonal growth of malignant lymphoblasts of human origin. Int. J. Cell Cloning 3:169-175, 1985.
- Lett-Brown, M.A., Juneja, H.S.: Basophil function in patients with chronic myelogenous leukemia. Brit. J. Haematol. 62:621-626, 1985.
- Juneja, H.S, Ramsey K., Rajaraman S., Elder, F.: Role of marrow stromal cells in establishment of a transformed B lymphoid cell line from a normal human subject. Leukemia Research 10:1209-1219, 1986.
- Gardner, F.H., Juneja, H.S.: Androstane therapy to treat aplastic anemia in adults: An uncontrolled pilot study. Brit. J. Haematol. 65:295-300, 1987.
- Juneja, H.S., Rajaraman, S., Alperin, J.A., Bainton, D.F.: Auer-rod like inclusions in prolymphocytic leukemia: Acta Haematologica 77:115-119, 1987.
- Juneja, H.S., Elder, F.F.B., Rajaraman, S.: Acute monoblastic leukemia with a single chromosomal rearrangement involving breakpoints on chromosomes 8 and 16. 46XX, t (8;16) (p11; p13): Acta Haematologica 78:1-5, 1987.
- Mamlock, R., Juneja, H.S., Elder, F.F.B., Haggard, M.E., Schmalsteig, F., Goldman, A.S.: Neutropenia and defective chemotaxis associated with binuclear, tetraploid myeloid-monocytic leukocytes. J. Pediatrics 111(4):555-558, 1987.
- Juneja, H.S., Elder, F.F.B., Gardner, F.H.: Abnormality of platelet size and T-lymphocyte proliferation in an autosomal recessive form of dyskeratosis congenital. Eur. J. Haematol. 39:306-310, 1987.
- Juneja, H.S., Lee, S.: In vivo and in vitro association between leukemic cells and marrow stromal cells: a murine model. Leuk. Res. 12:631-636, 1988.
- Rakusan, T.A., Juneja, H.S. and Fleischman, W.R., Jr.: Inhibition of hemopoietic colony formation by human cytomegalovirus in vitro. J. Inf. Disease 159:127-130, 1989.
- Lett-Brown, M.A., Robinson, L., Juneja, H.S., and Grant, J.A.: Purification of human basophils: Their response to Anti-IgE. J. Immunological Methods 117:163-167, 1989.
- Juneja, H.S., Lee, S., Gardner, F.H.: Human long-term bone marrow cultures in aplastic anemia. Int. J. Cell Cloning 7:129-135, 1989.
- Juneja, H.S., Schmalsteig, F.C., Rajaraman, S., Lee, S.: Heterotypic adherence between murine leukemia/lymphoma cells and marrow stromal cells involves a recognition mechanism with galactylosyl and mannosyl specificities. Exp. Hematol. 20:405-411, 1992.
- Juneja, H.S., Rajaraman, S., Gay, R.E., Gay, S., and Schmalsteig, F.C.: Characterization of heterotypic adherence between transformed human lymphoblastic cells and marrow stromal cells: VCAM-1 is a ligand for one of the leukemia cell adhesion proteins. Exp. Hematol. 20:1263-70, 1992.
- Juneja, H.S., Schmalsteig, F.C., Lee, S., Chen, J.: Vascular cell adhesion molecule-1 and VLA-4 are obligatory adhesion proteins in the heterotypic adherence between human leukemia/lymphoma cells and marrow stromal cells. Exp. Hematol. 21:444-450, 1993.
- Jenkins, V.K., Juneja, H.S., Lee, S., and Perry, R.R.: Effects of diflubenzuron and clanfenur on mouse bone marrow cells. Investigational New Drugs 11:279-289, 1993.
- Juneja, H.S., Jodhani, M., Gardner, F.H., Trevarthen, D., and Schottstedt M.: Low-dose ARA-C consistently induces hematologic responses in the clinical 5q- syndrome. Am. J. of Hematol. 46:338-342, 1994.
- Patrick, C.W., Juneja, H.S., Lee, S., Schmalstieg, F.C., and McIntire, L.V.: Heterotypic adherence between human B-lymphoblastic and pre-B-lymphoblastic cells and marrow stromal cells is a biphasic even: Integrin very late antigen-4-α mediates only the early phase of the heterotypic adhesion. Blood 85:(1)168-178, 1995.
- Juneja, H.S., Harvey, W.H., Brasher, W.K., and Thompson, E.B.: Successful in vitro purging of leukemic blasts from marrow by cortivazol, a pyrazolosteroid: A preclinical study for autologous transplantation in acute lymphoblastic leukemia and non-Hodgkin’s lymphoma. Leukemia 9:1771-1778, 1995.
- Juneja, H .S., Shulman, E., Reed, K., McIntire. L.V., Natarajan, M.: Pathophysiology and management of the sickle cell pain crisis. Lancet 346:1408-1411, 1995.
- Patrick, C.W., Smith, T.W., McIntire, L.V., and Juneja, H.S.: Invited Review: Cellular interactions among marrow stromal and normal/neoplastic Pre-B- and B- lymphoblastic cells. Leukemia Lymphoma 22:(3-4)205-219, 1996.
- Juneja, H.S., Schmalsteig, F.C., Lee, S., Chen, J.: CD45 partially mediates heterotypic adhesion between murine leukemia/lymphoma cell line L5178Y and marrow stromal cells. Leukemia Research 22(9):805-815, 1998.
- Pivalizza, E.G., Tjia, I.M., Juneja, H.S., Cohen, A.M., and Duke, Jr., J.H.: Elective splenectomy in an anemic Jehovah’s Witness patient with cirrhosis. Anesth. & Analg. 87:529-530, 1998.
- Salomaa, V., Matei, C., Aleksic, N., Sansores-Garcia, L., Folsom, A.R., Juneja, H.S., Chambless, L.E., and Wu, K.K.: Soluble thrombomodulin as a predictor of incident coronary heart disease and symptomless carotid artery atherosclerosis in the Atherosclerosis Risk in Communities (ARIC) Study: a case-cohort study. Lancet 353:1729-1734, 1999.
- Aleksic, N., Juneja, H.S., Folsom, A.R., Ahn, C., Boerwinkle, E., Chambless, L.E., and Wu, K.K. Platelet PLA2 allelle and incidence of coronary heart disease: Results from the atherosclerosis risk in communities (ARIC). Circulation 102:1901-1905, 2000.
- Lee, S., Van, N.T., Vachhani, N.B., Uthman, M., Keating, M.J., and Juneja, H.S. Adhesion of B-cell chronic lymphocytic leukemia cells to marrow stromal cells is mediated by a4b1 but not ba L2 integrin: MSC also prevent apoptosis of B-CLL cells. Hematology 5(6):463-473, 2000.
- Juneja, H.S., Lee, S., Thomazy, V., Shipley, G., and Davies, P.J.A.: Acute activation of gp130 gene expression in bone marrow stromal cells by contact with myeloma-derived lymphoblastic cell line ARH77 cell membranes. J. Interferon and Cytokine Research 21:157-166, 2001.
- Saloma, V., Matei, C., Aleksic, N., Sansores-Garcia, L., Folsom, A.R., Juneja, H., Park, E., Wu, K.K. Cross-sectional association of soluble thrombomodulin with peripheral artery disease; the ARIC study. Atherosclerosis 157(2):309-314, 2001.
- Wu, K.K., Aleksic, N., Ahn, C., Boerwinkle, E., Folsom, A.R., Juneja, H.S. Thrombomodulin ALA 455 VAL polymorphism and risk of coronary heart disease. Circulation 103(10):1386-1389, 2001.
- Folsom, A.R., Aleksic, N., Park, E., Salomaa, V., Juneja,H., Wu, K.K.: Prospective study of fibrinolytic factors and incident coronary heart disease: The Atherosclerosis Risk in Communities (ARIC)Study. Arterioscler. Thromb. Vasc. Biol. 21(4):611-617, 2001.
- Folsom, A.R., Aleksic, N. Catellier, D., Juneja, H.S., Wu, K.K.: C-reactive protein and incident coronary heart disease in the Atherosclerosis Risk In Communities (ARIC) study. Am. Heart J. 144(2):233-238, 2002.
- Aleksic, N., Ahn, C., Wang, Y.W., Juneja,H., Folsom, A.R.,Boerwinkle, E., Wu, K.K.: Factor XIIIA Val34Leu polymorphism does not predict risk of coronary heart disease: The Atherosclerosis Risk in Communities (ARIC) Study. Arterioscler. Thromb. Vasc. Biol. 22(2):348-352, 2002.
- Wu, K.K., Aleksic, N., Ballantyne, C.M., Ahn, C., Juneja,H., Boerwinkle, E.: Interaction between soluable thrombomodulin and intracellular adhesion molecule-1 in predicting risk of coronary heart disease. Circulation 107(13):1729-1732, 2003.
- Shtivelband, M.I., Juneja, H.S., Lee, S., Wu, K.K.: Aspirin and salicylate inhibit colon cancer medium- and VEGF-induced endothelial tube formation: correlation with suppression of cyclooxygenase-2 expression. J. Thromb. & Haem. 1(10):2225-2233, 2003.
- Faustinella, F., Orlander, P.R., Colletti, L.A., Juneja, H.S., Perkowski, L.C.: Medical students’ performance in the IV year exit exam: effect of clinical reasoning exercises, self-observation on tape, and faculty feedback on clinical skills. JIAMSE 14:42-45, 2004.
- Faustinella, F., Orlander, P.R., Colletti, L.A., Juneja, H.S., Perkowski, L.C.: Remediation strategies and students’ clinical performance. Medical Teacher 26(7) 664-665, 2004.
- Gupta, A., Gupta, S., Juneja, H.S.: Man with worsening dyspnea, epistaxis, and a distended abdomen. Consultant 45(14)1587-1590, 2005.
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