Deux types de problématiques différentes peuvent motiver l'approche structurale d'une macromolécule. Soit la fonction de cette macromolécule est inconnue et l'on détermine sa structure afin de mieux connaître sa fonction ; cette démarche était l'un des défis du développement de la génomique structurale. Soit la fonction est connue et la structure va permettre de comprendre comment cette molécule remplit son rôle biologique.<br />Durant ma thèse, j'ai eu l'occasion de pouvoir aborder deux projets structuraux très différents, qui correspondent à ces deux approches de biologie structurale. C'est pourquoi mon manuscrit décrit ces deux projets dont la démarche scientifique est différente et complémentaire pour ma formation en biologie structurale. <br />Dans un premier temps, je décrirai les résultats obtenus sur le projet PAB0955, débuté en stage de DEA et poursuivi pendant les deux premières années de ma thèse. Ce projet avait pour objectif de déterminer la fonction de la protéine d'après sa structure. La protéine PAB0955 est de fonction biologique inconnue, elle hydrolyse le GTP et elle n'a pas de proche homologue dont la structure est connue. La démarche scientifique de ce projet a été de déterminer la structure de cette protéine, puis d'analyser sa structure en la comparant de manière systématique à l'ensemble des protéines ATPases et GTPases. Notre étude a été conduite dans l'objectif extraire un maximum d'information fonctionnelle à partir des données structurales.<br />Dans une deuxième partie, je décrirai notre étude sur des protéines du système immunitaire humain débuté en troisième année de thèse. Nous nous sommes intéressés à des molécules impliquées dans la reconnaissance d'antigène : le récepteur du lymphocyte T (TCR) et la molécule du complexe majeur d'histocompatibilité (CMH). L'objectif de ce projet est de comprendre comment un complexe antigène-CMH sélectionne un répertoire de lymphocyte T spécifique. L'objectif étant de déterminer le lien entre les caractéristiques structurales d'un complexe antigène-CMH et la diversité et la fréquence des lymphocytes T activés par ce complexe. En résumé corréler les observations structurales avec les données immunologiques dont nous disposons. En déterminant les bases structurales du caractère antigénique d'un peptide présenté par une molécule CMH nous pourrons, à plus long terme, produire des peptides efficaces dans le cadre d'une vaccination

Von Willebrand factor (VWF) is a multimeric glycoprotein that critically supports platelet aggregation in hemostasis. Disordered VWF function causes both thrombotic and bleeding disorders, and genetic defects in VWF are responsible for von Willebrand’s disease (VWD), the most common inherited bleeding disorder in humans. Very large VWF multimers exhibit the greatest thrombogenic activity, which is attenuated by ADAMTS13 cleavage in the A2 domain. A2 cleavage is regulated by mechanical force, and pathologically high shear forces are known to enhance proteolysis and cause bleeding in patients. Enhanced cleavage is also described in patients with VWD 2A mutations. In contrast, VWF A2 is stabilized against cleavage by a calcium binding site within A2. Single molecule studies have demonstrated that mechanical unfolding is required for A2 cleavage to expose the scissile bond. In this dissertation, we aim to better understand the mechanosensitivity of A2 cleavage by characterizing the force sensitivity of A2 unfolding and refolding. We first characterized the interaction between VWF A2 and calcium using bulk isothermal calorimetry and thermal denaturation assays. In parallel, we used single molecule optical tweezers to characterize A2 unfolding and refolding. Calcium was found to bind A2 with high affinity, stabilize A2 against thermal denaturation, and enhance domain refolding. In contrast, we found that VWD 2A mutations destabilize the A2 domain against thermal denaturation. R1597W, the most common VWD 2A mutation, lies within the calcium binding loop and exhibited diminished calcium stabilization against thermal denaturation. Using optical tweezers, we found that R1597W also diminished A2 refolding. R1597W refolding in the presence of calcium was similar to that of wild-type A2 in the absence of calcium, suggesting that loss of calcium stabilization contributes to the disease mechanism of R1597W. Other VWD 2A mutations lying outside the calcium binding loop also destabilized A2, but retained calcium mediated stabilization. These studies provide a better understanding of VWD 2A pathophysiology and offer structural insights into A2 unfolding and refolding pathways. By exploring the role of mechanical force in regulating VWF cleavage, this work moves towards a better understanding of how hydrodynamic forces within the vasculature regulate VWF function in hemostasis and thrombosis.

Access to abstract permanently restricted to Ball State community only / Access to thesis permanently restricted to Ball State community only / School of Physical Education, Sport, and Exercise Science

Access to abstract permanently restricted to Ball State community only / Access to thesis permanently restricted to Ball State community only / School of Physical Education, Sport, and Exercise Science

Access to abstract permanently restricted to Ball State community only / Access to thesis permanently restricted to Ball State community only / School of Physical Education, Sport, and Exercise Science

Although the etiology of diabetic nephropathy is still uncertain, proteinuria due to podocyte injury and loss (podocytopenia) are early features of the disease. Significant increases in thromboxane A2 (TXA2) production as well as expression of its receptor in animal models of diabetic nephropathy led to the hypothesis that TXA2 acting via its thromboxane-prostanoid (TP) receptor induces podocytopenia resulting in proteinuria. Systemic infusion of a TP antagonist demonstrated an important role of TXA2/TP signalling in our model of streptozotocin induced type-1 diabetic nephropathy by reducing kidney damage including proteinuria. Podocyte specific TP overexpressing mice did not demonstrate more pathologic or dynamic kidney damage than non-transgenic mice in STZ-induced diabetic nephropathy. Further assessment of the TP transgene functionality in this mice line is necessary to validate those results. Whereas the importance of TXA2/TP signalling is undeniable in diabetic nephropathy, it appears that podocyte TP receptors might not be directly targeted.

Die Verfütterung von Fetten mit mehrfach ungesättigter Fettsäuren (PUFA) stellt seit Jahren eine nebenwirkungsfreie Alternative in der Behandlung atopischer Erkrankungen wie der Caninen Atopischen Dermatitis (CAD) dar. Zahlreiche Studien belegen die antiinflammatorische Wirkung der PUFA und die damit verbundene Besserung der klinischen Symptomatik. Diese antiinflammatorische Wirkung kommt auf molekularer Ebene zustande, indem die supplementierten Fettsäuren die Eigenschaften zellulärer Membranen verändern, intrazelluläre Signalwege und Enzyme beeinflussen sowie die Expression verschiedener Gene modulieren. Die cytosolische Phospholipase A2 (cPLA2) stellt eines der Schlüsselenzyme im Rahmen der Synthese proinflammatorischer Eikosanoide dar, die allergische Symptome wie Juckreiz und Hautrötungen bedingen. Sie spaltet bevorzugt Arachidonsäure (AA) aus der sn2-Position membranständiger Phospholipide ab und stellt somit das Substrat für die Synthese von Entzündungsmediatoren wie Prostaglandinen, Leukotrienen und Thromboxanen zur Verfügung. Peroxisomen-Proliferator-aktivierte Rezeptoren (PPAR) gehören zur Großfamilie der Kernrezeptoren. Besonders die Isoform PPARγ ist an der Regulation der Expression verschiedener proinflammatorischer Proteine beteiligt, wie z.B. der Cyclooxygenase (COX). PUFA gehören zu den natürlichen Liganden dieser Rezeptoren, was die Vermutung nahe legt, dass zumindest ein Teil der Wirkungen über die Beeinflussung dieser Rezeptoren vermittelt wird. Über die Beeinflussung der Expression des cPLA2-Gens durch PPAR existieren zurzeit noch keine Erkenntnisse. Mastzellen spielen eine zentrale Rolle im Rahmen der Pathogenese allergischer Erkrankungen. Auf einen allergenen Stimulus hin sind sie in der Lage, präformierte (z.B. Histamin) und de novo synthetisierte Entzündungsmediatoren (z.B. Eikosanoide) freizusetzen und damit die für allergische Erkrankungen typischen Symptome hervorzurufen. Das Ziel der vorliegenden Arbeit war es, an einer caninen Mastozytomzelllinie (C2) die zeitabhängigen Effekte der Supplementierung des Zellkulturmediums mit jeweils 20 μM n3- PUFA (α-Linolensäure LE, C18:3n3; Eikosapentaensäure EPA, C20:5n3) und n6-PUFA (Linolsäure LA, C18:2n6; Arachidonsäure AA, C20:4n6) auf das Wachstum, das zelluläre Fettsäurenmuster, die Histaminfreisetzung, die Aktivität und Expression der cPLA2 sowie die Expression von PPARγ zu untersuchen. Vergleichend wurden die C2 auch im Grundmedium kultiviert. Zur Untersuchung des Einflusses der PUFA auf das Wachstum der Zellen erfolgte die Kultivierung über einen Zeitraum von 8 Tagen. Um die zeitabhängigen Effekte feststellen zu können, wurden die Zellen 6 h, 48 h bzw. 6 Tage in den entsprechenden Medien bzw. dem Grundmedium kultiviert und danach die folgenden Verfahren angewendet. – Bestimmung des zellulären Fettsäurenmusters mittels Gaschromatographie (GC) – Bestimmung der Histaminfreisetzung mit Hochleistungsflüssigkeitschromatographie (HPLC) – Bestimmung der Aktivität der cPLA2 über Messung der freigesetzten [3H]Arachidonsäure – Bestimmung der Expression der cPLA2 und des PPARγ mittels Western Blot. Die Ergebnisse zeigen, dass die Fettsäuren-Supplementierung keinerlei Auswirkung auf das Zellwachstum hat. Sie führt aber zur Anreicherung der jeweils angebotenen Fettsäure sowie ihrer Elongations- und Desaturierungsprodukte. Die Effekte auf die spontane und auch auf die Mastoparan-stimulierte Histaminfreisetzung waren zeitabhängig sehr unterschiedlich. Die Zugabe der Fettsäuren hatte auf die spontane cPLA2-Aktivität der Zellen nur bei längerer Kultivierungsdauer (6 d) einen Einfluss, wobei es zu einer Minderung der Aktivität nach PUFA- Gabe kam. Im Gegensatz dazu zeigten die Mastoparan-stimulierten C2 nur nach 6- stündiger Kultivierung eine signifikante Erhöhung der cPLA2-Aktivität in den mit den n6-FS supplementierten Medien. Die cPLA2-Expression war in ihrer Höhe von der Kultivierungsdauer abhängig. Nach 6 h zeigten die PUFA-supplementierten C2 eine im Vergleich zum Grundmedium gesteigerte Expression, unabhängig von der Art der zugesetzten Fettsäure. Nach 48 h war die Expression in den C20-PUFA-supplementierten C2 deutlich erhöht, während sie nach 6-tägiger Kultivierung in den mit C20-PUFA angereicherten Medien signifikant reduziert war. Der fehlende Zusammenhang zwischen der Aktivität des Enzyms und der Höhe der cPLA2-Expression lassen auf eine unterschiedliche Regulation dieser beiden Parameter schließen. Die PPARγ-Expression verhielt sich, besonders nach 48-stündiger und 6- tägiger Kultivierung, umgekehrt zur cPLA2-Expression. Dabei deutet das annähernd gegensätzliche Verhalten von cPLA2 und PPARγ nach 48 h und 6 d auf eine mögliche Beteiligung des Kernrezeptors an der Regulation der cPLA2-Expression hin. Aus den vorliegenden Untersuchungen geht somit deutlich hervor, dass die C2 mit der cPLA2 und dem PPARγ zwei bedeutende Regulatoren von Entzündungsprozessen exprimieren und somit als Modell zur Erforschung der Pathogenese der CAD geeignet sind.

Masters Research - Masters of Medical Science / The goal of this thesis is to report on research that explored the role of cow’s milk protein in children with chronic functional constipation. The research consisted of a systematic review of the literature, two clinical crossover trials, and a qualitative exploration of the lived experience of following a milk-free diet. Chapter 1 provides the introduction to both allergy and constipation, and the relationship between the two. Causes of constipation can be organic or functional (1). Organic causes of constipation occur in relation to a primary disease classification such as endocrine or metabolic disorders, neurologic disorders, anatomic malformation, collagen vascular disease and some drugs (for example, opiates). Chronic functional constipation is defined as having one bowel motion every three to 15 days (2) and is characterised by painful bowel movements or strain in defecation, hard stools with increased diameter or pellets, and occurs with or without soiling (3). This functional constipation is defined as chronic when it persists for greater than two weeks (4). Chapter 2 details the methods used in searching the literature for evidence for a role of cow’s milk consumption in chronic functional constipation in children from 1980 to 2006. This was published as a systematic review. The literature surrounding cow’s milk and constipation was found to be limited. None of the studies previously conducted were population-based or structured to provide evidence-based evaluation or treatment guidelines at either the general practitioner or paediatric specialist level. The strongest evidence found was a double blind randomised control trial conducted by Iacono and colleagues (3). The research study by Iacono and colleagues (3) provides evidence of an association between cow’s milk and constipation. The following research questions were developed from the systematic review: 1. Can the results of the Iacono and colleagues study of children with chronic functional constipation that respond to the replacement of cow’s milk protein with soy be replicated in the Australian setting? 2. Does cow’s milk β casein A1 cause constipation in children with chronic functional constipation? 3. What are the immunological and biochemical mechanisms underlying chronic functional constipation that respond to the removal of cow’s milk protein in children? 4. What factors affect the feasibility of parents administering a cow’s milk protein free diet to their children? The four questions were addressed by two different dietary crossover trials and a qualitative study. Chapter 3 describes the participants recruited and the methods used for the crossover trials investigating milk protein and paediatric chronic functional constipation including details of the primary outcome measure (number of bowel motions during a two-week trial period) and secondary outcome measures (biochemical, immunological and faecal analysis). Chapter 4 describes the results of Trial 1, which replicated the Iacono and colleagues study in the Australian setting, investigating the effects of soy and cow’s milk β-casein A1 in children with chronic functional constipation. One hundred percent of participants experienced resolution of their constipation during the soy milk condition compared with 68% experiencing resolution during the soy milk condition in the Iacono and colleagues study (n=65). Thirteen participants were recruited to Trial 1. Nine participants returned constipation diaries for the study period. The mean (SD) number of stools for each of the conditions was: baseline, 5.1 (1.4); cow’s milk 9.9 (4.4); washout 13.0 (5.2); and soy milk 15.1 (5.0). The differences between the three dietary conditions were statistically significant, p=0.03. The results confirmed the hypothesis that children in the Australian setting with chronic functional constipation unresponsive to the usual treatments, respond to the removal of cow’s milk protein from the diet. Chapter 5 describes the results of Trial 2, the double blind crossover trial comparing the effects of cow’s milk β-casein A1 and cow’s milk β-casein A2 in children with chronic functional constipation. Thirty-nine participants were recruited to Trial 2 and 26 participants returned constipation diaries for the trial period. Unlike the soy result, the cow’s milk β casein A2 did not give 100% resolution of constipation, in fact, the percentage resolution was almost identical to the cow’s milk β casein A1 result. The fact that some children responded during the cow’s milk casein A1 condition in both trials could be caused by a threshold effect, given it was likely that participants were consuming less cow’s milk protein during the trial (400 mL with elimination of all other sources of cow’s milk protein) than on their pre-trial diet. Resolution with both the cow’s milk β casein A1 and cow’s milk β casein A2 conditions suggests that these children are able to tolerate some cow’s milk protein before the symptom of constipation occurs. This could be a food intolerance type reaction or there is some other component in cow’s milk that is causing the problem in these children. Chapter 6 describes a qualitative study of the feasibility for mothers to administer a cow’s milk protein free diet to their children. The experiences of mothers following a cow’s milk protein free diet to assist in the management of chronic functional constipation in children were reported. A number of themes were identified that are useful to health professionals educating families. Mothers found the removal of cow’s milk protein from the diets of their children challenging but persevered due to the potential benefit to their children. Many mothers planned to continue post study with a modified approach to the cow’s milk protein free diet by allowing some cow’s milk protein in the diet to make the diet more acceptable to the family but not as much as the pre-trial diet. These experiences provide health professionals with valuable insights and ideas to assist their patients to manage a cow’s milk protein free diet. Chapter 7 discusses all aspects of the research including any limitations. The results of Trial 1 confirmed the hypothesis that children in the Australian settling with chronic functional constipation unresponsive to the usual treatments respond to the removal of cow’s milk protein from the diet. Therefore, cow’s milk protein is involved in the aetiology of constipation in these children. All the study participants demonstrated an absence or low level of normal gut flora, which may affect bowel regularity. Further research into species present and absent may provide further explanations to the lack of bowel regularity in these children. The immunological and biochemical mechanisms underlying chronic functional constipation that respond to the removal of cow’s milk protein requires further investigation. Although the number of statistically significant variables between the conditions was low, there was a high degree of abnormality. Further investigations are needed, including research into food intolerance reactions that affect the nerve endings in the bowel. The results in Trial 1 and Trial 2 are suggestive of an involvement of blood factors including platelets and monocytes. Other children may have a chronic Streptococcus A infection which may be contributing to constipation as well as to liver function abnormalities. Liver function abnormalities were observed for some participants in both trials, independent of milk condition. The extent to which the research questions have been answered is evaluated in Chapter 7, which includes the conclusions and recommendations of this research. In brief, the findings were: • Children with chronic functional constipation that is unresponsive to the traditional treatments should trial a cow’s milk protein free diet for at least two weeks to determine whether this may resolve the constipation. During this period, the numbers and form of bowel motions should be recorded and results compared to a one week record collected prior to commencing the cow’s milk protein free diet. • Due to the complicated nature of a cow’s milk protein free diet, especially the number of processed foods which contain hidden cow’s milk protein, consultation with a dietitian is essential for implementation of this diet. The dietitian should consider educating the patient’s family, both parents and siblings, to ensure the best outcome in terms of acceptance and compliance of the diet, and provide adequate resources. • If this dietary modification is successful for the child and alleviates constipation, consultation with a dietitian is recommended to determine the amount tolerated and nutritional adequacy of the diet. Soy milk is recommended as a substitute for cow’s milk and a probiotic needs to be prescribed to assist with the normalisation of gut flora. • Education of health professionals such as general practitioners, paediatricians, and paediatric continence nurses, regarding a cow’s milk protein free diet for chronic functional constipation, is essential to support the child and his/her family and integral to the success of this strategy. The findings of this research will be published in the scientific literature and as conference presentations. It is hoped that these findings will assist in the management of children with chronic functional constipation unresponsive to the traditional treatments.

Masters Research - Masters of Medical Science / The goal of this thesis is to report on research that explored the role of cow’s milk protein in children with chronic functional constipation. The research consisted of a systematic review of the literature, two clinical crossover trials, and a qualitative exploration of the lived experience of following a milk-free diet. Chapter 1 provides the introduction to both allergy and constipation, and the relationship between the two. Causes of constipation can be organic or functional (1). Organic causes of constipation occur in relation to a primary disease classification such as endocrine or metabolic disorders, neurologic disorders, anatomic malformation, collagen vascular disease and some drugs (for example, opiates). Chronic functional constipation is defined as having one bowel motion every three to 15 days (2) and is characterised by painful bowel movements or strain in defecation, hard stools with increased diameter or pellets, and occurs with or without soiling (3). This functional constipation is defined as chronic when it persists for greater than two weeks (4). Chapter 2 details the methods used in searching the literature for evidence for a role of cow’s milk consumption in chronic functional constipation in children from 1980 to 2006. This was published as a systematic review. The literature surrounding cow’s milk and constipation was found to be limited. None of the studies previously conducted were population-based or structured to provide evidence-based evaluation or treatment guidelines at either the general practitioner or paediatric specialist level. The strongest evidence found was a double blind randomised control trial conducted by Iacono and colleagues (3). The research study by Iacono and colleagues (3) provides evidence of an association between cow’s milk and constipation. The following research questions were developed from the systematic review: 1. Can the results of the Iacono and colleagues study of children with chronic functional constipation that respond to the replacement of cow’s milk protein with soy be replicated in the Australian setting? 2. Does cow’s milk β casein A1 cause constipation in children with chronic functional constipation? 3. What are the immunological and biochemical mechanisms underlying chronic functional constipation that respond to the removal of cow’s milk protein in children? 4. What factors affect the feasibility of parents administering a cow’s milk protein free diet to their children? The four questions were addressed by two different dietary crossover trials and a qualitative study. Chapter 3 describes the participants recruited and the methods used for the crossover trials investigating milk protein and paediatric chronic functional constipation including details of the primary outcome measure (number of bowel motions during a two-week trial period) and secondary outcome measures (biochemical, immunological and faecal analysis). Chapter 4 describes the results of Trial 1, which replicated the Iacono and colleagues study in the Australian setting, investigating the effects of soy and cow’s milk β-casein A1 in children with chronic functional constipation. One hundred percent of participants experienced resolution of their constipation during the soy milk condition compared with 68% experiencing resolution during the soy milk condition in the Iacono and colleagues study (n=65). Thirteen participants were recruited to Trial 1. Nine participants returned constipation diaries for the study period. The mean (SD) number of stools for each of the conditions was: baseline, 5.1 (1.4); cow’s milk 9.9 (4.4); washout 13.0 (5.2); and soy milk 15.1 (5.0). The differences between the three dietary conditions were statistically significant, p=0.03. The results confirmed the hypothesis that children in the Australian setting with chronic functional constipation unresponsive to the usual treatments, respond to the removal of cow’s milk protein from the diet. Chapter 5 describes the results of Trial 2, the double blind crossover trial comparing the effects of cow’s milk β-casein A1 and cow’s milk β-casein A2 in children with chronic functional constipation. Thirty-nine participants were recruited to Trial 2 and 26 participants returned constipation diaries for the trial period. Unlike the soy result, the cow’s milk β casein A2 did not give 100% resolution of constipation, in fact, the percentage resolution was almost identical to the cow’s milk β casein A1 result. The fact that some children responded during the cow’s milk casein A1 condition in both trials could be caused by a threshold effect, given it was likely that participants were consuming less cow’s milk protein during the trial (400 mL with elimination of all other sources of cow’s milk protein) than on their pre-trial diet. Resolution with both the cow’s milk β casein A1 and cow’s milk β casein A2 conditions suggests that these children are able to tolerate some cow’s milk protein before the symptom of constipation occurs. This could be a food intolerance type reaction or there is some other component in cow’s milk that is causing the problem in these children. Chapter 6 describes a qualitative study of the feasibility for mothers to administer a cow’s milk protein free diet to their children. The experiences of mothers following a cow’s milk protein free diet to assist in the management of chronic functional constipation in children were reported. A number of themes were identified that are useful to health professionals educating families. Mothers found the removal of cow’s milk protein from the diets of their children challenging but persevered due to the potential benefit to their children. Many mothers planned to continue post study with a modified approach to the cow’s milk protein free diet by allowing some cow’s milk protein in the diet to make the diet more acceptable to the family but not as much as the pre-trial diet. These experiences provide health professionals with valuable insights and ideas to assist their patients to manage a cow’s milk protein free diet. Chapter 7 discusses all aspects of the research including any limitations. The results of Trial 1 confirmed the hypothesis that children in the Australian settling with chronic functional constipation unresponsive to the usual treatments respond to the removal of cow’s milk protein from the diet. Therefore, cow’s milk protein is involved in the aetiology of constipation in these children. All the study participants demonstrated an absence or low level of normal gut flora, which may affect bowel regularity. Further research into species present and absent may provide further explanations to the lack of bowel regularity in these children. The immunological and biochemical mechanisms underlying chronic functional constipation that respond to the removal of cow’s milk protein requires further investigation. Although the number of statistically significant variables between the conditions was low, there was a high degree of abnormality. Further investigations are needed, including research into food intolerance reactions that affect the nerve endings in the bowel. The results in Trial 1 and Trial 2 are suggestive of an involvement of blood factors including platelets and monocytes. Other children may have a chronic Streptococcus A infection which may be contributing to constipation as well as to liver function abnormalities. Liver function abnormalities were observed for some participants in both trials, independent of milk condition. The extent to which the research questions have been answered is evaluated in Chapter 7, which includes the conclusions and recommendations of this research. In brief, the findings were: • Children with chronic functional constipation that is unresponsive to the traditional treatments should trial a cow’s milk protein free diet for at least two weeks to determine whether this may resolve the constipation. During this period, the numbers and form of bowel motions should be recorded and results compared to a one week record collected prior to commencing the cow’s milk protein free diet. • Due to the complicated nature of a cow’s milk protein free diet, especially the number of processed foods which contain hidden cow’s milk protein, consultation with a dietitian is essential for implementation of this diet. The dietitian should consider educating the patient’s family, both parents and siblings, to ensure the best outcome in terms of acceptance and compliance of the diet, and provide adequate resources. • If this dietary modification is successful for the child and alleviates constipation, consultation with a dietitian is recommended to determine the amount tolerated and nutritional adequacy of the diet. Soy milk is recommended as a substitute for cow’s milk and a probiotic needs to be prescribed to assist with the normalisation of gut flora. • Education of health professionals such as general practitioners, paediatricians, and paediatric continence nurses, regarding a cow’s milk protein free diet for chronic functional constipation, is essential to support the child and his/her family and integral to the success of this strategy. The findings of this research will be published in the scientific literature and as conference presentations. It is hoped that these findings will assist in the management of children with chronic functional constipation unresponsive to the traditional treatments.

Diss. (sammanfattning) Stockholm : Karolinska institutet, 2006. / Härtill 4 uppsatser.