Bridging the Gap for Children With Compound Health Challenges: An Intervention Protocol

Background: During the last decades, there is a major shift in the panorama of diseases in children and adolescents. More children are referred to the specialized health care services due to less specific symptoms and more complex health challenges. These children are particularly difficult to care for in a “single-disease” oriented system. Our objective was to develop an alternative and more holistic approach better tailored to the complex needs of these children. Method: The target patient population is children between 6 and 13 years with three or more referrals including both the pediatric department and the mental health services. Furthermore, to be included in the project, the child's actual complaints needed to be clinically considered as an unclear or compound condition in need of an alternative approach. This paper describes the process of developing an intervention where a complementary professional team meets the patient and his/her family altogether for 2.5 h. The consultation focus on clarifying the complex symptomatology and on problem solving. The bio-psycho-social model is applied, emphasizing the patient's story as told on the whiteboard. In the dynamic processes of development, piloting, evaluating, and adjusting the components, feed-back from the patients, their families, professional team members, and external team coaches is important. The professional teams include pediatricians, psychologists and physiotherapists. Achieving the transformation from a logistic oriented team where members act separately toward a real complementary team, seems to be a success factor. Discussion: Composing multi-disciplinary and complementary teams was an essential part of the re-designed intervention. Team interaction transforming the professionals from working as a logistic team to act as a complementary team, was one of the important requirements in the process. When re-designing the specialist health service, it is mandatory to anchor all changes among employees as well as the hospital leadership. In addition, it is important to include patient experiences in the process of improvement. Evaluation of long-term outcomes is needed to investigate possible benefits from the new intervention.publishedVersio

Plasma levels of guanylins are reduced in patients with Crohn’s disease

Background: Guanylin (GN) and uroguanylin (UGN) are endogenous ligands for the intestinal receptor guanylate cyclase C (GC-C), an important regulator of intestinal fluid homeostasis. Gene expression and protein levels of GN are suppressed in inflamed intestinal tissue from patients with inflammatory bowel disease (IBD), but knowledge about plasma levels of guanylins in these conditions is sparse. We aimed to investigate the fasting plasma levels of the prohormones proGN and proUGN in patients with Crohn’s Disease (CD) and relate these to levels found in persons with other diarrheal conditions, as well as persons with normal bowel habits. Methods: Plasma from patients with CD, patients with Familial GUCY2C Diarrheal Disease (FGDS), diarrhea-predominant irritable bowel syndrome (IBS-D) and healthy controls (HC) was analyzed using ELISA assays. Results: Significantly lower fasting plasma levels of proguanylins were found in CD and FGDS patients, compared to HC. In CD patients, plasma proGN levels correlated negatively with Harvey Bradshaw Index and with number of stools/24 h. Conclusion: Our data indicate that diarrhea may be a determinant for levels of proGN in plasma, and should be further explored in studies of different diarrheal disorders.acceptedVersio

Clinical and molecular effects of guanylate cyclase C-activation

We studied a large Norwegian family who had been affected by chronic diarrhoea and other symptoms from the digestive tract throughout several generations. Our genetic studies showed that family members with diarrhoea shared markers on the short arm of chromosome 12. In this part of the genome we discovered a new genetic variant in GUCY2C. This variant was present in 32 family members with diarrhoea, but not in the healthy family members. We performed functional assays of the GUCY2C variant in a cell-model. These studies showed that the genetic variant encodes an increased activity of guanylate cyclase C (GC-C), a protein known to be involved in infectious diarrhoea. Apart from diarrhoea many family members had also experienced acute intestinal obstructions and/or inflammatory bowel disease (IBD) categorized as Crohn’s disease (CD). To our knowledge the constellation of symptoms experienced by our patients had not been reported previously and we assumed that we were dealing with a new disorder. We called this disorder Familial GUCY2C diarrhoea syndrome (FGDS). The publication in 2012 of our research constituted the first report of a human disorder caused by a change in the GUCY2C gene. The further work on this thesis aimed at discovering factors involved in the pathogenesis of FGDS with a main focus on its link to IBD. In parallel with our project multinational case-control studies were charting the genetic basis for IBD, and by 2015 more than 200 genetic associations had been identified. While GUCY2C has not been flagged by these population-based studies we hypothesised that common genetic variants within the GC-C pathway may still contribute to the risk of developing IBD. Rather than assessing single genes, we tested whether an aggregation of genes within the GC-C pathway was associated with IBD. For this analysis we used genetic association statistics made publicly available from the largest IBD case-control studies. The GC-C gene list did indeed show significant enrichment of association in IBD. We then looked at common IBD genetic risk variants in FGDS patients and found that genetic variants in the NOD2 gene distinguished FGDS patients affected by IBD from those not developing IBD. NOD2 encodes a protein involved in sensing and removal of bacteria in the intestinal wall. We studied which genes were differentially expressed in the distal small bowel of FGDS compared to healthy controls as well as patients with CD. Down regulation of metallothionein genes was found in FGDS patients regardless of concomitant IBD when compared to healthy but not when compared to CD. Metallothioneins may serve as signal transducers in the interplay between the human host and its resident bacteria (microbiota). Paucity of these antioxidant proteins may perturb epithelial sensing and clearance of microbes and has been reported in IBD. We hypothesised that GUCY2C related changes of the gut hydration could also impact on its bacterial composition. Using sequencing of the 16S ribosomal RNA gene we analysed the microbial composition in stool from adult FGDS patients, related and unrelated healthy controls as well as patients with IBD. Overall microbiota composition of FGDS patients was different from the other groups, but similar between healthy relatives and unrelated healthy controls. The microbiota of the FGDS patients displayed increased abundance of Enterobacteriaceae and loss of Faecalibacterium, findings that may have a pro-inflammatory potential and are found in IBD. In conclusion we here identified activating mutations of the GUCY2C gene as the cause of familial diarrhoea and defined a new disorder, Familial GUCY2C diarrhoea syndrome. Our work indicates that genetic testing for mutations in GUCY2C should be considered in patients presenting with early onset secretory diarrhoea. Apart from diarrhoea we also highlighted clinical complications potentially linked to hyperactivation of GUCY2C, such as IBD, intestinal obstruction and dysfunctional gut peristalsis. Our subsequent studies suggested that GUCY2C is involved in the crosstalk between the gut mucosa and the adjacent microbiota, providing a potential clue to the link between GUCY2C and IBD

Clinical and molecular effects of guanylate cyclase C-activation

We studied a large Norwegian family who had been affected by chronic diarrhoea and other symptoms from the digestive tract throughout several generations. Our genetic studies showed that family members with diarrhoea shared markers on the short arm of chromosome 12. In this part of the genome we discovered a new genetic variant in GUCY2C. This variant was present in 32 family members with diarrhoea, but not in the healthy family members. We performed functional assays of the GUCY2C variant in a cell-model. These studies showed that the genetic variant encodes an increased activity of guanylate cyclase C (GC-C), a protein known to be involved in infectious diarrhoea. Apart from diarrhoea many family members had also experienced acute intestinal obstructions and/or inflammatory bowel disease (IBD) categorized as Crohn’s disease (CD). To our knowledge the constellation of symptoms experienced by our patients had not been reported previously and we assumed that we were dealing with a new disorder. We called this disorder Familial GUCY2C diarrhoea syndrome (FGDS). The publication in 2012 of our research constituted the first report of a human disorder caused by a change in the GUCY2C gene. The further work on this thesis aimed at discovering factors involved in the pathogenesis of FGDS with a main focus on its link to IBD. In parallel with our project multinational case-control studies were charting the genetic basis for IBD, and by 2015 more than 200 genetic associations had been identified. While GUCY2C has not been flagged by these population-based studies we hypothesised that common genetic variants within the GC-C pathway may still contribute to the risk of developing IBD. Rather than assessing single genes, we tested whether an aggregation of genes within the GC-C pathway was associated with IBD. For this analysis we used genetic association statistics made publicly available from the largest IBD case-control studies. The GC-C gene list did indeed show significant enrichment of association in IBD. We then looked at common IBD genetic risk variants in FGDS patients and found that genetic variants in the NOD2 gene distinguished FGDS patients affected by IBD from those not developing IBD. NOD2 encodes a protein involved in sensing and removal of bacteria in the intestinal wall. We studied which genes were differentially expressed in the distal small bowel of FGDS compared to healthy controls as well as patients with CD. Down regulation of metallothionein genes was found in FGDS patients regardless of concomitant IBD when compared to healthy but not when compared to CD. Metallothioneins may serve as signal transducers in the interplay between the human host and its resident bacteria (microbiota). Paucity of these antioxidant proteins may perturb epithelial sensing and clearance of microbes and has been reported in IBD. We hypothesised that GUCY2C related changes of the gut hydration could also impact on its bacterial composition. Using sequencing of the 16S ribosomal RNA gene we analysed the microbial composition in stool from adult FGDS patients, related and unrelated healthy controls as well as patients with IBD. Overall microbiota composition of FGDS patients was different from the other groups, but similar between healthy relatives and unrelated healthy controls. The microbiota of the FGDS patients displayed increased abundance of Enterobacteriaceae and loss of Faecalibacterium, findings that may have a pro-inflammatory potential and are found in IBD. In conclusion we here identified activating mutations of the GUCY2C gene as the cause of familial diarrhoea and defined a new disorder, Familial GUCY2C diarrhoea syndrome. Our work indicates that genetic testing for mutations in GUCY2C should be considered in patients presenting with early onset secretory diarrhoea. Apart from diarrhoea we also highlighted clinical complications potentially linked to hyperactivation of GUCY2C, such as IBD, intestinal obstruction and dysfunctional gut peristalsis. Our subsequent studies suggested that GUCY2C is involved in the crosstalk between the gut mucosa and the adjacent microbiota, providing a potential clue to the link between GUCY2C and IBD

Bridging the Gap for Children With Compound Health Challenges: An Intervention Protocol

Background: During the last decades, there is a major shift in the panorama of diseases in children and adolescents. More children are referred to the specialized health care services due to less specific symptoms and more complex health challenges. These children are particularly difficult to care for in a “single-disease” oriented system. Our objective was to develop an alternative and more holistic approach better tailored to the complex needs of these children. Method: The target patient population is children between 6 and 13 years with three or more referrals including both the pediatric department and the mental health services. Furthermore, to be included in the project, the child's actual complaints needed to be clinically considered as an unclear or compound condition in need of an alternative approach. This paper describes the process of developing an intervention where a complementary professional team meets the patient and his/her family altogether for 2.5 h. The consultation focus on clarifying the complex symptomatology and on problem solving. The bio-psycho-social model is applied, emphasizing the patient's story as told on the whiteboard. In the dynamic processes of development, piloting, evaluating, and adjusting the components, feed-back from the patients, their families, professional team members, and external team coaches is important. The professional teams include pediatricians, psychologists and physiotherapists. Achieving the transformation from a logistic oriented team where members act separately toward a real complementary team, seems to be a success factor. Discussion: Composing multi-disciplinary and complementary teams was an essential part of the re-designed intervention. Team interaction transforming the professionals from working as a logistic team to act as a complementary team, was one of the important requirements in the process. When re-designing the specialist health service, it is mandatory to anchor all changes among employees as well as the hospital leadership. In addition, it is important to include patient experiences in the process of improvement. Evaluation of long-term outcomes is needed to investigate possible benefits from the new intervention

Colonic Mucosal Epigenome and Microbiome Development in Children and Adolescents

Epigenetic and microbiome changes during pediatric development have been implicated as important elements in the developmental origins of inflammatory bowel diseases (IBDs) including Crohn’s disease (CD) and ulcerative colitis (UC), which are linked to early onset colorectal cancer (CRC). Colonic mucosal samples from 22 control children between 3.5 and 17.5 years of age were studied by Infinium HumanMethylation450 BeadChips and, in 10 cases, by 454 pyrosequencing of the bacterial 16S rRNA gene. Intercalating age-specific DNA methylation and microbiome changes were identified, which may have significant translational relevance in the developmental origins of IBD and CRC

Plasma levels of guanylins are reduced in patients with Crohn’s disease

Background: Guanylin (GN) and uroguanylin (UGN) are endogenous ligands for the intestinal receptor guanylate cyclase C (GC-C), an important regulator of intestinal fluid homeostasis. Gene expression and protein levels of GN are suppressed in inflamed intestinal tissue from patients with inflammatory bowel disease (IBD), but knowledge about plasma levels of guanylins in these conditions is sparse. We aimed to investigate the fasting plasma levels of the prohormones proGN and proUGN in patients with Crohn’s Disease (CD) and relate these to levels found in persons with other diarrheal conditions, as well as persons with normal bowel habits. Methods: Plasma from patients with CD, patients with Familial GUCY2C Diarrheal Disease (FGDS), diarrhea-predominant irritable bowel syndrome (IBS-D) and healthy controls (HC) was analyzed using ELISA assays. Results: Significantly lower fasting plasma levels of proguanylins were found in CD and FGDS patients, compared to HC. In CD patients, plasma proGN levels correlated negatively with Harvey Bradshaw Index and with number of stools/24 h. Conclusion: Our data indicate that diarrhea may be a determinant for levels of proGN in plasma, and should be further explored in studies of different diarrheal disorders

Familial Diarrhea Syndrome Caused by an Activating GUCY2C Mutation

BACKGROUND Familial diarrhea disorders are, in most cases, severe and caused by recessive mutations. We describe the cause of a novel dominant disease in 32 members of a Norwegian family. The affected members have chronic diarrhea that is of early onset, is relatively mild, and is associated with increased susceptibility to inflammatory bowel disease, small-bowel obstruction, and esophagitis. METHODS We used linkage analysis, based on arrays with single-nucleotide polymorphisms, to identify a candidate region on chromosome 12 and then sequenced GUCY2C, encoding guanylate cyclase C (GC-C), an intestinal receptor for bacterial heat-stable enterotoxins. We performed exome sequencing of the entire candidate region from three affected family members, to exclude the possibility that mutations in genes other than GUCY2C could cause or contribute to susceptibility to the disease. We carried out functional studies of mutant GC-C using HEK293T cells. RESULTS We identified a heterozygous missense mutation (c.2519G -> T) in GUCY2C in all affected family members and observed no other rare variants in the exons of genes in the candidate region. Exposure of the mutant receptor to its ligands resulted in markedly increased production of cyclic guanosine monophosphate (cGMP). This may cause hyperactivation of the cystic fibrosis transmembrane regulator (CFTR), leading to increased chloride and water secretion from the enterocytes, and may thus explain the chronic diarrhea in the affected family members. CONCLUSIONS Increased GC-C signaling disturbs normal bowel function and appears to have a proinflammatory effect, either through increased chloride secretion or additional effects of elevated cellular cGMP. Further investigation of the relevance of genetic variants affecting the GC-C-CFTR pathway to conditions such as Crohn's disease is warranted. (Funded by Helse Vest Western Norway Regional Health Authority] and the Department of Science and Technology, Government of India.