Development of non-invasive imaging biomarkers sensitive to microstructural organization is crucial for deepening our understanding of mechanisms underlying neurodegenerative processes such as aging and further improving early diagnosis and monitoring of neurodegenerative disease such as Alzheimer’s disease (AD) and amnestic mild cognitive impairment (MCI). The diffusional kurtosis imaging (DKI) is an extension of conventional diffusion tensor imaging. It is hypothesized that DKI will provide complementary information to conventional diffusivity metrics in a new dimension that will more comprehensively capture microstructural changes in anisotropic white matter tracts and particularly in relatively isotropic tissues such as gray matter during neurodegenerative processing of aging, MCI and AD and probably improve the early diagnosis of the diseases. Firstly, DKI method and a white-matter model that provided metrics of explicit neurobiological interpretations were applied on healthy participants. In white matter tracts, age-related degenerations appeared to be broadly driven by axonal loss. Demyelination may also be a major driving mechanism, although confined to the anterior brain. In terms of deep gray matter, higher mean kurtosis (MK) and fractional anisotropy (FA) in the globus pallidus, substantia nigra, and red nucleus reflected higher microstructural complexity and directionality compared with the putamen, caudate nucleus, and thalamus. In particular, unique age-related positive correlations for FA, MK, and radial kurtosis (KR) in the putamen opposite to those in other regions were observed. Secondly, to verify the speculation that iron deposition could be one probable underlying mechanism driving changes in microstructure, another advance MRI technique of quantitative susceptibility mapping (QSM) was also used in healthy participants. Significant age-related increases of iron were observed in the putamen, red nucleus, substantia nigra, and caudate nucleus. Putamen exhibited the highest rate of iron accumulation with aging, which was nearly twice of the rates in substantia nigra and caudate nucleus. Significant positive correlations between susceptibility value and diffusion measurements were observed for FA and MK in the putamen as well as FA in the red nucleus. Thirdly, whether DKI metrics could serve as imaging biomarkers to indicate the severity of cognitive deficiency for AD and MCI was investigated. In AD, significantly increased diffusivity and decreased kurtosis parameters were observed in both white and gray matter of the parietal and occipital lobes as compared to MCI. Significantly decreased FA was also observed in the white matter of these lobes in AD. With the exception of FA and KR, all the other five DKI metrics exhibited significant correlations with mini-mental state examination score in both white and gray matter. Lastly, DKI metrics were compared against volumetry for diagnosis of AD and MCI. In AD vs. aMCI, although no significant difference of either FA or MD was observed in white matter tracts, it is encouraging to note that MK captured loss of microstructural complexity in the superior longitudinal fasciculus and internal capsule. MK in the putamen showed the highest power that outperformed volume of the hippocampus for discriminating AD from normal. Besides, FA in the putamen showed the second highest power for discriminating aMCI from normal. / published_or_final_version / Diagnostic Radiology / Doctoral / Doctor of Philosophy

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Copper is an extremely toxic metal in biological systems and thus, its availability to the system, must be effectively and efficiently controlled. Copper is vital for life, as it is essential for critical enzymes in biological systems. It is free copper in the biological systems that is toxic, as free copper induces free radical generation, which disrupts lipid membranes, interacts with DNA causing mutations, and eventually leads to cell death. Wilson’s disease is a inherited copper disease, which results in hepatolenticular disease. Copper is unable to be excreted, and thus accumulates, eventually spilling over into the bloodstream from the liver, and “poisons” the patient. The Wilson’s disease patient leads a short life, due to neurological and hepatological problems. There is no cure for Wilson’s disease, only chelation therapy using potent chelators such as penicillamine and EDTA. Zinc, in high doses, can be used to compete with copper absorption. This has proved to be the only successful therapy at present. This study investigates the possible use of melatonin as a copper binder/chelator. Melatonin has been shown to interact with copper in vitro. By binding/chelating to copper, melatonin may inhibit copper-induced free radical generation, and thus prevent copper from interacting with DNA to cause mutations and act as a cytotoxin. In vivo studies on copper (2mg/kg) administered for 2-weeks and 6-weeks were carried out on Wistar rats. The potential of melatonin (12mg/kg) to prevent copper-induced cellular damage was investigated. The results indicate that melatonin does not protect the lipid membranes from copper-induced lipid peroxidation. In vitro investigations using 1mM, 5mM and 10mM copper and 5mM melatonin, show that melatonin prevents copper-induced lipid peroxidation at a copper concentration of 1mM (p<0.001). The 5mM and 10mM copper induces less lipid peroxidation, compared to the 1mM copper. It has been reported that metal ions, antioxidants and chelating agents can influence peroxide decomposition during the assay. Melatonin (5mM) administration does not significantly prevent copper-induced lipid peroxidation at 5mM and 10mM copper. It is possible that due to melatonin’s relatively low concentration, it is unable to inhibit lipid peroxidation induced by the copper. The chemical nature of the interaction between melatonin and copper was also investigated, using NMR, IR and electrochemistry techniques. The NMR and IR techniques show that melatonin coordinates with Cu²⁺ and not Cu¹⁺, at the carbonyl group of melatonin. The electrochemistry experiments using cyclic voltammetry and adsorptive stripping voltammetry, show that melatonin forms a strong bond with Cu¹⁺. Cu²⁺ prefers binding to oxygen, and that is clearly seen in the NMR and IR. Cu¹⁺ prefers binding to nitrogen and then oxygen, and this is seen in the electrochemistry, as Cu¹⁺ is forced to bind through one of the nitrogens on the melatonin. Previously, it has been shown that melatonin binds/chelates with Cu²⁺. Histochemical investigations show that copper administration for 2-weeks and 6-weeks, causes extensive mitochondrial damage in liver and kidney’s proximal convoluted tubule epithelium cells. Melatonin (12mg/kg) co-administration with copper for 2-weeks and 6-weeks did not significantly protect the mitochondria from copper-induced damage. Copper-specific stains (rhodanine, silver sulphide and rubeanic acid) were used to stain liver, brain and kidney tissue samples. Rhodanine and silver sulphide were equally sensitive in staining copper in the 2-week samples, but not at all in the 6-week samples. This could not be explained. Rubeanic acid was ineffective in all samples tested. Thus, it appears that specific copper stains cannot be used in making a definitive diagnosis in cases of copper overload, and that specific copper stains do not always correlate with a high concentration of copper present in tissues. Pineal organ culture was used to determine the effect of copper administration on pineal indole synthesis. Exogenous (³H) tryptophan was administered to the pineal organ cultures, and the level of (³H) pineal indoles synthesised, were measured. Pineals from 2-week and 6-week copper/melatonin treated animals exhibited paradoxical 5- methoxytryptophol (ML) levels, as compared to the 2-week and 6-week copper treated animals. The 2-week copper/melatonin administered animals, showed a decrease in the ML level (p<0.01), and the copper/melatonin administered for 6-weeks, showed an increase in the ML levels (p<0.01). This indicates that melatonin interacts with the HIOMT enzyme. Pineals from 6-week copper/melatonin treated animals, as compared to the 6-week copper treated animals, showed an increase in N-acetylserotonin levels. This indicates that melatonin prevents the inhibition of the NAT enzyme. The final experiment was to determine in vitro, the effect of Cu²⁺ and Cu¹⁺ administration, on mitochondrial electron transport chain. Rat liver homogenate was incubated with and solutions of Cu²⁺ (10mM) and Cu¹⁺ (10mM) and melatonin (10mM). Cu²⁺ administration caused an inhibition of the electron transport at t=0 and t=60, whereas Cu¹⁺ administration at t=0 caused an inhibition of electron transport, but at t=60, Cu¹⁺ administration stimulated electron transport. Melatonin administered with Cu²⁺, resulted in an inhibition of the electron transport chain at t=0 and t=60. The findings of this study indicate that melatonin might have a potentially beneficial effect in copper overloading, by binding/chelating copper.

Parkinson’s disease, one of the most common neurodegenerative disorders associated with ageing, is characterised by abnormal and profound loss of nigrostriatal dopaminergic neurons. The cause of Parkinson’s disease is unknown, but epidemiological studies suggest an association with pesticides and other environmental toxins, and biochemical studies implicate oxidative damage and mitochondrial impairment, particularly at the level of complex I enzyme. Recently, rotenone, a commonly used organic pesticide and a classical inhibitor of mitochondrial complex I has been reported to reproduce the specific features of Parkinson’s disease in rodents. The mitochondrial respiratory chain is one of the most important sites of reactive oxygen species production under physiological conditions. Toxic free radicals have been implicated in a variety of neurodegenerative diseases as well as ageing itself. Melatonin, a secretory product of the pineal gland is a multifaceted free radical scavenger and natural antioxidant. In the present study, the neuroprotective effects of melatonin against the environmental neurotoxin, rotenone was investigated. Initial studies showed that inhibition of mitochondrial complex I enzyme by rotenone induced superoxide radical generation. Melatonin, administered to the rat in vivo and in vitro was able to offer neuroprotection by curtailing the production of superoxide radicals induced by rotenone. Mitochondria, being the major target of rotenone, the effects of melatonin were investigated at the mitochondrial level. Melatonin was able to increase the electron transport chain activity thus preventing the respiratory inhibition by rotenone. The pineal hormone also counteracted the action of rotenone on complex I enzyme. These results suggest melatonin’s ability to potentially limit the free radical generation and thereby modulate the mitochondrial functions. The detection and measurement of lipid peroxidation is the evidence most frequently cited to support the involvement of free radical reactions in toxicology and in human disease. Melatonin also offered significant protection in vivo and in vitro against rotenone induced lipid peroxidation. Since iron plays a major role in oxidative damage and in the progression of Parkinson’s disease, the effect of melatonin on both rotenone and iron induced lipid peroxidation was investigated, the results of which show that melatonin affords protection and this was suggested to be due to its interaction with the rotenone-iron complex that might have formed. Electrochemical studies were further used to characterise the interactions between melatonin, rotenone and iron (III). Melatonin was shown to bind with iron and thus reducing their toxicity. Histological studies were undertaken to assess the effects of melatonin on rotenone induced toxicity on the dopaminergic neurons in the rat brain. Rotenone treated brains showed extensive neuronal damage whereas with melatonin less damage was observed. Rotenone induces apoptosis via reactive oxygen species production and apoptotic cell death has been identified in PD brains. Furthermore, the apoptotic cell death was detected and quantified by the TUNEL staining. Rotenone treated sections showed signs of apoptosis whereas with melatonin, less apoptotic damage was observed. The findings of this study indicate that the neurohormone, melatonin may protect against rotenone-induced neurodegeneration. Since melatonin production falls substantially during ageing, the loss of this antioxidant is theorized to be instrumental in the degenerative processes associated with advanced age. Considering how devastating diseases such as Parkinson’s disease, are to a patient and the patient’s families, the discovery of protective agents are a matter of urgency. Further investigations using the pesticide model will help to determine the involvement of environmental exposure in the pathogenesis of human diseases as well as to test therapeutic strategies for the treatment of such diseases.

The hippocampus, located in the medial temporal lobe, is an important region of the brain responsible for the formation of memory. Thus, any agent that induces stress in this area has detrimental effects and could lead to various types of dementia. Such agents include the neurotoxin, Quinolinic acid. Quinolinic acid (QUIN) is a neurotoxic metabolite of the tryptophan-kynurenine pathway and is an endogenous glutamate agonist that selectively injures and kills vulnerable neurons via the activation of the NMDA class of excitatory amino acid receptors. Estrogen is a female hormone that is responsible for reproduction. However, in the last decade estrogen has been shown to exhibit a wide range of actions on the brain, including neuroprotection. Estrogen has been shown to exhibit intrinsic antioxidant activity and protects cultured neurons against oxidative cell death. This is achieved by estrogen’s ability to scavenge free radicals, which is dependent on the presence of the hydroxyl group at the C3 position on the A ring of the steroid molecule. Numerous studies have shown that estrogen protects neurons against various toxic substances and may play a role in delaying the onset of neurodegenerative diseases, such as Alzheimer’s disease. Neuronal damage due to oxidative stress has been implicated in several neurodegenerative disorders. The detection and measurement of lipid peroxidation is the evidence most frequently cited to support the involvement of free radical reactions in toxicology and in human disease. The study aims to elucidate and further characterise the mechanism behind estrogen’s neuroprotection, using QUIN as a model of neurotoxicity. Initial studies confirm estrogen’s ability to scavenge potent free radicals. In addition, the results show that estrogen forms an interaction with iron (II) and also acts at the NMDA receptor as an agonist. Both mechanisms reduce the ability of QUIN to cause damage to neurons, since QUIN-induced toxicity is dependent on the activation of the NMDA receptor and the formation of a complex with iron (II) to induce lipid peroxidation. Heat shock proteins, especially Hsp 70 play a role in cytoprotection by capturing denatured proteins and facilitating the refolding of these proteins once the stress has been relieved. Estrogen has been shown to increase the level of expression of Hsp70, both inducible and cognate forms of the protein. This suggests that estrogen helps to protect against cellular protein damage induced by any form of stress the cell may encounter. The discovery of neuroprotective agents, such as estrogen, is becoming important as accumulating evidence indicates a protective role in vivo. Thus further research may favour the use of these agents in the treatment of several neurodegenerative disorders. Considering how devastating diseases, such as Alzheimer’s disease, are to a patient and the patient’s families, the discovery of new protective agents are a matter of urgency.

An increasing number of studies show that nutritional antioxidants such as vitamin E and polyphenols are capable of blocking neuronal death in vitro and may have therapeutic properties in animal models of neurodegenerative diseases including Alzheimer’s and Parkinson’s diseases. In the present study, the neuroprotective ability of one such polyphenolic antioxidant, curcumin, was investigated. Curcumin is the yellow curry spice derived from turmeric, and is widely used as a dietary component and herbal medicine in India. Most neurological disorders are postulated to have an oxidative or excitototoxic basis. Thus the effects of curcumin on oxidative stress in the rat brain were investigated. Curcumin, administered to the rat in vivo and in vitro, was able to exert protective effects on oxidative damage in the brain, induced by cyanide, a mitochondrial inhibitor. Curcumin also offered protection against quinolinic acid induced lipid peroxidation, and this protection was extended to lipid peroxidation induced by metals such as lead and cadmium in the rat brain. Experiments conducted on the pineal gland revealed an increased production of the neuroprotective hormone melatonin in presence of curcumin in vivo. The hippocampus is functionally related to vital behaviour and intellectual activities and is known to be a primary target for neuronal degeneration in the brains of patients with Alzheimer’s disease. Histological studies were undertaken to assess the effects of curcumin on lead induced toxicity on the rat hippocampus, the results of which show that curcumin affords significant protection to the hippocampus of the lead treated rats. This study also sought to elucidate possible mechanisms by which curcumin exerts its neuroprotective capabilities. Curcumin was found to inhibit the action of cyanide on the mitochondrial electron transport chain, one of the most common sources of free radicals. Electrochemical, UV/VIS and Infrared spectroscopy were used to characterise interactions between curcumin and the metals lead, cadmium, iron (II) and iron (III). Curcumin was shown to directly chelate these metals with the formation and isolation of two new curcumin complexes with lead, and one complex each with cadmium and iron (III). These results suggest chelation of toxic metals as a mechanism of neuroprotection afforded by curcumin. The need for neuroprotective agents is urgent considering the rapid rise in the elderly population and the proportionate increase in neurological disorders. The findings of this study indicate that curcumin, a well-established dietary antioxidant, is capable of playing a bigger role in neuroprotection, which needs to be further explored and exploited.

No description available.

Thesis (PhD)--Stellenbosch University, 2015. / ENGLISH ABSTRACT: Parkinson’s disease (PD) is a progressive and debilitating neurodegenerative disorder, characterized by a distinct motor phenotype and the selective loss of dopaminergic neurons in the substantia nigra. While the etiology of PD is not fully understood, it is thought to involve a combination of different genetic, cellular and environmental factors that independently or concurrently contribute to neurodegeneration. To date, several PD-causing genes have been identified, and investigations of their function have provided novel insights into the pathobiology of disease. Particularly interesting among the known PD genes is parkin, mutations in which are the most common genetic cause of early onset PD. Parkin is an E3 ligase that ubiquitinates protein substrates and targets such substrates for degradation via the ubiquitin proteasome system (UPS). Therefore, the loss of parkin may result in the deleterious accumulation or dysregulation of parkin substrates and neurotoxicity. Parkin’s enzymatic activity has also been implicated in the maintenance of mitochondrial health, and mitochondrial dysfunction is commonly reported in cellular and animal models of parkin deficiency. This study aimed to investigate parkin and its role in PD on various levels. Initially, genetic screening approaches were used to assess the contribution of parkin mutations to PD in a group of 229 South African patients. It was concluded that parkin mutations are rare in the South African PD population, being present in only seven (3.1%) patients in the study group. Interestingly, this study identified two of only three Black African PD patients with mutations in a known PD-causing gene to date. The low frequency of known PD genes raises the interesting possibility that the unique South African ethnic groups may harbor mutations in novel PD-causing genes. Although many parkin-interacting proteins have been identified in the literature, it is anticipated that novel, pathologically-relevant parkin substrates remain to be discovered. Hence, this study used a yeast two-hybrid (Y2H) approach to identify novel parkin interactions. This yielded 29 putative parkin interactors, of which four, namely ATPAF1, SEPT9, actin and 14-3-3η, were prioritized for verification by co-localization and co-immunoprecipitation experiments. Interestingly, two of the parkin interactors (ATPAF1 and SEPT9) were found to accumulate in the absence of parkin, supporting their role as authentic parkin substrates. The identification of these two intriguing proteins implicates parkin in the regulation of mitochondrial ATP synthase assembly and septin filament dynamics, which may be of significant relevance to our understanding of processes underlying neurodegeneration. Moreover, it was aimed to assess various markers of mitochondrial function in a parkin-deficient cellular model, as previous studies had reported conflicting results regarding mitochondrial impairments in patient-derived cells with parkin mutations. Hence, dermal fibroblasts were obtained from PD patients with homozygous parkin mutations, after which cell growth and viability, mitochondrial membrane potential, respiratory rates and the integrity of the mitochondrial network were assessed. Surprisingly, it was found that cell growth was significantly higher in the parkin-mutant fibroblasts compared to wild-type controls fibroblasts under basal conditions (p=0.0001), while exhibiting a greater inhibition of cell growth in the presence of the mitochondrial toxin CCCP (p=0.0013). Furthermore, whereas the mitochondrial networks of patient-derived fibroblasts were more fragmented than controls (p=0.0306), it was found that mitochondrial respiratory rates were paradoxically higher in the patients (p=0.0355). These unanticipated findings are suggestive of a compensatory response to the absence of parkin. The parkin-deficient cellular model was also used in a pilot study of the functional effects of vitamin K2 treatment, which has recently been identified as a promising PD therapeutic modality. It was found that treatment with vitamin K2 resulted in more interconnected mitochondrial networks (p=0.0001) and enhanced respiratory rates (p=0.0459) in both parkin-mutant and wild-type control cells. While these results need to be studied further, it suggests that vitamin K2 supplementation may be of use as a general promoter of mitochondrial integrity and function. In conclusion, this dissertation highlights some novel interactions of the parkin protein and some interesting phenotypes of parkin deficiency. It is hoped that further investigation of parkin and its role in PD will, ultimately, aid in the development of therapeutic strategies to treat this debilitating and poorly-understood disorder. / AFRIKAANSE OPSOMMING: Parkinson se siekte (PS) is 'n progressiewe en aftakelende neurodegeneratiewe kondisie, wat gekarakteriseer word deur 'n kenmerkende bewegingsfenotipe en die selektiewe afsterwing van dopaminergiese neurone in die substantia nigra. Terwyl die etiologie van PS nie ten volle verstaan is nie, behels dit waarskynlik 'n kombinasie van verskillende genetiese, sellulêre en omgewings-faktore wat onafhanklik of gelyktydig lei tot senuwee-afsterwing. Tot op hede is daar al verskeie PS-veroorsakende gene geïdentifiseer, en die bestudering van hul funksie het nuwe insigte in die patobiologie van hierdie siekte verskaf. Onder meer hierdie PS gene is parkin van besondere belang, aangesien mutasies in parkin die mees algemene genetiese oorsaak van vroeë-aanvang PS is. Parkin is 'n E3 ligase-ensiem wat proteïen substrate ubiquitineer en teiken vir degradasie via die ubiquitien proteasoomstelsel (UPS). Dus kan die verlies van parkin lei tot die beskadigende opeenhoping of wanregulasie van parkin substrate en senuwee-afsterwing. Parkin se ensiematiese aktiwiteit is ook betrokke by die instandhouding van mitokondriale gesondheid, en mitokondriale afwykings word dikwels gerapporteer in sellulêre en diermodelle van parkin tekort. Hierdie studie het gepoog om parkin en sy rol in PS op verskillende vlakke te ondersoek. Aanvanklik is genetiese siftingsbenaderinge gebruik om die bydrae van parkin mutasies tot PS in 'n groep van 229 Suid-Afrikaanse pasiënte te evalueer. Die gevolgtrekking is bereik dat parkin mutasies skaars is in die Suid-Afrikaanse PS bevolking, aangesien dit teenwoordig is in net sewe (3.1%) pasiënte in die studie groep. Interessant genoeg, hierdie studie het twee van slegs drie gevalle van Swart Afrika-pasiënte met mutasies in 'n bekende PS geen to op datum geïdentifiseer. Die lae frekwensie van bekende PS gene versterk die stimulerende moontlikheid dat die unieke Suid-Afrikaanse sub-populasies dalk mutasies in nuwe PS-veroorsakende gene mag koester. Alhoewel baie parkin proteïen-interaksies reeds in die literatuur geïdentifiseer is, word daar verwag dat nuwe, patologies-relevante parkin substrate nog wag om ontdek te word. Dus het hierdie studie 'n gis twee-hibried (G2H) benadering gebruik om nuwe parkin interaksies te identifiseer. Hierdie het 29 vermeende parkin interaktors opgelewer, waarvan vier, naamlik ATPAF1, SEPT9, aktien en 14-3-3η, geprioritiseer is vir verifikasie deur mede-lokalisering en mede-immunopresipitasie eksperimente. Interessant genoeg, daar is gevind dat twee van die parkin interaktors (ATPAF1 en SEPT9) ophoop in die afwesigheid van parkin, wat hul rol as werklike parkin substrate ondersteun. Die identifisering van hierdie twee interessante proteïene impliseer parkin in die regulering van mitokondriale ATP sintase vervaardiging en septienfilament dinamika, wat moontlik van beduidende belang is vir ons begrip van die onderliggende prosesse wat senuwee-afsterwing veroorsaak. Verder is daar daarop gemik om verskeie aanwysigings van mitokondriale funksie in 'n parkin-gebrekkige sellulêre model te evalueer, aangesien vorige studies teenstrydige resultate rapporteer rakende mitokondriale afwykings in pasiënt-selle met parkin mutasies. Dus is daar dermale fibroblaste verkry van PS pasiënte met homosigotiese parkin mutasies, waarna sel-groei en lewensvatbaarheid, mitokondriale membraanpotensiaal, respiratoriese tempo en die integriteit van die mitokondriale netwerk geëvalueer is. Daar is verbasend gevind dat sel-groei aansienlik hoër is die parkin-mutante fibroblaste in vergelyking met wilde-tipe kontrole fibroblaste onder basale kondisies (p=0.0001), terwyl hulle 'n groter inhibisie van sel-groei in die teenwoordigheid van die mitokondriale toksien CCCP ondergaan (p=0.0013). Verder, terwyl die mitokondriale netwerke van pasiënt fibroblaste meer gefragmenteer is as die van kontroles (p=0.0306), is daar gevind dat mitokondriale respiratoriese tempo’s, paradoksaal-gewys, hoër is in die pasiënte (p=0.0355). Hierdie onverwagte bevindinge is suggestief van die aanskakeling van 'n vergoedende respons-proses in die afwesigheid van parkin. Die parkin-gebrekkige sellulêre model is ook gebruik in 'n voorlopige studie van die funksionele effekte van vitamiene K2 behandeling, wat onlangs geïdentifiseer is as 'n belowende terapeutiese moontlikheid vir PS. Daar is gevind dat sel-behandeling met vitamiene K2 lei tot meer geïnterkonnekteerde mitokondriale netwerke (p=0.0001) en verbeterde respiratoriese fuksie (p=0.0459) in beide parkin-mutante en wilde-tipe kontrole selle. Terwyl hierdie resultate verder bestudeer sal moet word, dui dit daarop dat vitamiene K2-aanvulling moontlik gebruik kan word as 'n algehele promotor van mitochondriale integriteit en funksie. Ten slotte, hierdie verhandeling beklemtoon ‘n paar nuwe interaksies van die parkin proteïen en 'n paar interessante fenotipes van parkin tekort. Daar word gehoop dat verdere ondersoek van parkin en parkin se rol in PS sal, uiteindelik, steun in die ontwikkeling van terapeutiese strategieë om hierdie aftakelende en swak-verstaande wanorde beter te behandel.

published_or_final_version / Anatomy / Doctoral / Doctor of Philosophy