A critical examination of R v Collins and the pregnant woman's right to refuse treatment

In this thesis I aim to provide a balanced, unbiased analysis of the materno-fetal conflict as expressed by the caesarean section scenario. A second aim is to examine the legal balance of the woman's rights against the fetus' and to determine whether the law could be altered to increase its protection of the fetus without unacceptably infringing the woman's rights. In R v Collins, the Court of Appeal has strongly affirmed the right of the competent pregnant woman to refuse consent to medical treatment regardless of any detrimental effect either to herself or her fetus. Likewise, Re MB holds that the interests of the fetus have no bearing on the woman’s right to self-determination. However, despite its powerful affirmation of the primacy of autonomy I show that the Court of Appeal has left significant leeway for the concerned physician - or judge - to circumvent the woman's decision by finding her temporarily incompetent. The subjective nature of the current competence assessment tests and the use of temporary factors - such as pain, drugs and labour itself - allows backdoor paternalism. The failure of the courts to assess the public policy implications of the situation, and the obvious judicial sympathy for the fetus, suggest that the legal balance may be weighted too heavily in favour of the woman. However, analysis of statute law, common law and government publications suggests that society would not support the protection of the fetus at the expense of the woman. This is confirmed by European human rights law. Likewise, I argue that the moral value of the fetus is insufficient to allow it to trump the woman's rights. Finally, I argue that neither criminal nor tort liability are justified in trying to protect the fetus against the woman’s refusal of consent to treatment

Replication characteristics of herpes simplex virus type-1 (HSV-1) recombinants in 3 types of tissue cultures

A complication in the analysis of the role of ICP34.5 gene in the herpes simplex virus type-1 (HSV-1) lifecycle is the presence of overlapping antisense gene, open reading frame P (ORF P), which is also deleted in HSV-1 ICP34.5 negative mutants. A HSV-1 wild type strain (17+) ICP34.5/ORF P deletion mutant (1716) is totally avirulent in animal models and impaired in a number of in vitro functions: replication in 3T6 cells; and replication and shutoff of cellular protein synthesis in SK-N-SH cells. To attribute characteristics of 1716 to each of these two genes (ICP34.5 or ORF P), a number of HSV-1 recombinant viruses that express ICP34.5 and ORF P independently were constructed, purified and characterized. The parent of these recombinants is 1716 and they are (so called): 1622, expressing ICP34.5; 1624/24.5, expressing ORF P; and 1625, expressing both ICP34.5 and ORF P in separate loci. Using homologous recombination in cell culture, the recombinants were constructed and their DNA were analyzed by Southern-blotting. Expression of ICP34.5 and ORF P from the recombinants was checked by Western-blotting. Using cell culture, titration and plaque assay techniques, replication kinetics of the recombinants were compared with 17+ and 1716 in 3 cell lines, BHK, 3T6, and SK-N-SH. The results showed that (i) ICP34.5 restored the ability to replicate and prevent host shutoff similar to wild type in SK-N-SH cells; (ii) ICP34.5 restored the replication phenotype to near wild type levels in 3T6 cells; and (iii) ORF P expression had no effect on the replication of these mutants. The characteristics of 1716 is obviously due to the lack of ICP34.5 and ORF P has no role in the characteristics studied. Thus, the function of ORF P still has to be determined

Consent to medical treatment and the competent adult

In this thesis I analyse the concept of consent to medical treatment. I explore its ethical basis in autonomy and examine how other principles and ethical approaches might interact with the rules derived from autonomy. I then situate the relevant ethical obligations within the context f the healthcare professional-patient relationship which subsequently allows me to develop a textured model of consent. The model is predicated on the theory that consent is a secondary right, derivative on the underlying right which it controls. By giving or withholding consent, the autonomous person determines who may justifiably infringe the primary right. Importantly, however, the context of the professional-patent relationship highlights the relevance of consent, not just as permission, but also as agreement. I subsequently utilise the model of consent to analyse the current law, which is found to be deficient. I explore the conceptual difficulties of the split regulation between the torts of battery and negligence. I examine the current standard of disclosure and conclude that while it seems to be moving towards more autonomy respecting prudent patient standard, the courts may still be affording expert witnesses too much say in determining which risks should be disclosed. Most importantly I expose the thin and unsatisfactory conception of autonomy that appears to ground the current legal approach. Some of the common law’s deficiencies lie in tort law’s focus on the outcome rather than the process of the interaction between healthcare professional and the patient. There are three responses to these deficiencies. The common law could be allowed to continue its piecemeal development. The deficiencies of the common law could be patched up by developing professional regulation, or new legislation could be drafted to deal specifically with consent to medical treatment. If there is a genuine commitment to patient autonomy and patient centred care then I submit that legislation is justified

Xba I Site Loss Mutants and Deletion/Duplication Variants of Herpes Simplex Virus Type 1: Isolation, Characterization and Recombination Studies

The aim of this project was to isolate a herpes simplex virus type 1 Glasgow strain 17 genome lacking all four Xba I restriction enzyme sites and to use the sites as non-selected markers to study intratypic HSV recombination. However, a large part of the work involved the analysis of variant genomes which were identified during the isolation of Xba I site negative viruses. The parent virus used in these studies was the variant X2, from which the 0.07 map unit (m.u.) and 0.29 m.u. Xba I sites had been removed by selection enrichment (Brown et al., 1984). The remaining two Xba I sites were deleted as follows s the Xba I site at 0.45 m.u. , which lies within the gene (UL 33) encoding a predicted polypeptide of 14,000 molecular weight (mol. wt.), was removed by selection enrichment; while the Xba I site at 0.29 m.u., which lies within the gene (UL22) encoding the essential glycoprotein H (Buckmaster et al., 1984), was removed by site-directed mutagenesis. The variant devoid of Xba I sites (1702) shows normal growth characteristics in vitro and its polypeptide profile is indistinguishable from wild-type virus apart from the absence of the thymidine kinase (tk) polypeptide, a feature which is believed to be unrelated to the loss of the Xba I sites. During in vitro latency experiments, Cook and Brown (1987) isolated a variant of X2 containing a novel Xba I site at 0.74 m.u. This virus was used in intratypic recombination experiments with wild-type strain 17 to generate a HSV-1 strain 17 variant (1708) containing a fifth Xba I site, thus increasing the number of non-selectable markers between this virus (5) and 1702 (0). Different temperature-sensitive (ts) lesions were introduced into 1702 and 1708 as selectable markers. A time-course of recombination was carried out at the permissive temperature and the appearance of non-ts recombinants assayed at the non-pemissive temperature. Recombination was first detected at 4 h post infection, following the onset of DNA replication, and rapidly increased to 15% by 24 h post infection. The distribution of the non-selectable markers, ie. the Xba I sites, in ts+ recombinant molecules was analyzed. From the experimental results a number of conclusions were drawn: (i) there was an increase in the complexity or number of crossovers in recombinants arising at later time-points, confirming the previous hypothesis of Ritchie et al. (1977) that both parental and progeny molecules take part in HSV recombination; (ii) in ts+ recombinants, recombination was very high outwith the selected recombination region, suggesting that correct alignment of genomes plays an important role in determining the overall but not the relative rate of recombination; and (iii) due to the large distance between the Xba I sites, little can be determined about recombinational hotspots. The HSV-1 genome consists of two unique sequences - the long unique (UL) and the short unique (US) - flanked by inverted repeat elements known as the internal repeats (IRL/IRS) and the terminal repeats (TRL/TRS). During the isolation of 1702, a variant (1703) was isolated which has a deletion of approximately 5x10e6 mol. wt. in the UL and IRL regions of its genome, such that one copy of the immediate-early (IE) gene 1 and two unique open reading frames coding for predicted polypeptides of 20,000 mol. wt. and 22,000 mol. wt. (UL55 and UL56) are deleted. The variant 1703 synthesizes reduced levels of VmwIE110, the product of IE gene 1, and under immediate-early conditions apparently fails to synthesize VmwIE63, at both the polypeptide and RNA levels, despite there being no apparent deletion in the coding or controlling regions of the IE2 (VmwIE63) gene. 1703 also fails to synthesize the thymidine kinase polypeptide, although this is unrelated to either the deletion or the failure to synthesize VmwIE63. The variant 1703 exhibits normal growth characteristics in vitro. During the analysis of eighty plaque isolates from one recombination experiment, fourteen variants with rearrangements around the long repeats were detected. Of these, eleven have extensive variation (up to 0.4x10e6 mol. wt.) in the size of the long repeats outwith the 'a' sequence. The remaining three variants have large scale deletion or duplication of both unique and repeat sequences

Prevalence of HCV NS3 pre-treatment resistance associated amino acid variants within a Scottish cohort

Background: Protease inhibitors (PI) including boceprevir, telaprevir and simeprevir have revolutionised HCV genotype 1 treatment since their introduction. A number of pre-treatment resistance associated amino acid variants (RAVs) and polymorphisms have been associated with reduced response to treatment. Objectives: We measured the prevalence of RAVs/polymorphisms in a PI treatment-naïve HCV genotype 1 Scottish cohort using Sanger sequencing. Study design: Chronically infected, treatment-naïve, HCV genotype 1 patients (n = 146) attending NHS Greater Glasgow and Clyde clinics were investigated for RAVs/polymorphisms to the PIs boceprevir, telaprevir and simeprevir. The NS3/4A region was amplified by nested polymerase chain reaction. The 1.4 kb amplified product was sequenced using an ABI 3710XL DNA sequencer. Sequence analysis was performed using web-based ReCall (beta 2.10). Amino acid positions 36, 41, 43, 54, 55, 80, 109, 122, 155, 156, 168 and 170 were analysed for RAVs/polymorphisms. Results: Overall, 23.29% (34/146) of patients had an RAV or polymorphism detected. Overall, 13.69% (20/146) of patients had HCV virus that contained the Q8 K polymorphism. Other RAVs detected were: V36 M 0.70% (1/146), V36L 0.70% (1/146), T54S 6.85% (10/146), V55A 3.42% (5/146) and V/I170A 0.68% (1/146). Four patients had dual combinations of mutations (T54S + V36L; T54S + V55A and 2 patients with T54S + Q80K). Conclusions: Q80K was the most prevalent baseline polymorphism detected in the Scottish cohort. Simeprevir treatment is not recommended in patients infected with the Q80K genotype 1a variant. This highlights the need for baseline sequencing prior to administration of this drug in this population

Obesity alters oestrogen metabolism and contributes to pulmonary arterial hypertension

Obesity is a common comorbidity for pulmonary arterial hypertension (PAH). Additionally, oestrogen and its metabolites are risk factors for the development of PAH. Visceral adipose tissue (VAT) is a major site of oestrogen production; however, the influence of obesity-induced changes in oestrogen synthesis and metabolism on the development of PAH is unclear. To address this we investigated the effects of inhibiting oestrogen synthesis and metabolism on the development of pulmonary hypertension (PH) in male and female obese mice. We depleted endogenous oestrogen in leptin deficient (ob/ob) mice with the oestrogen inhibitor anastrozole (ANA) and determined the effects on the development of PH, plasma oestradiol and urinary 16α-hydroxyestrone (16αOHE1). Oestrogen metabolism through CYP1B1 was inhibited with 2,2',4,6'-tetramethoxystilbene (TMS). Ob/ob mice spontaneously develop PH, pulmonary vascular remodelling and increased reactive oxygen species (ROS) production in the lung; these effects were attenuated by ANA. Oestradiol levels were decreased in obese male mice; however, VAT CYP1B1 and 16αOHE1 levels were increased. TMS also attenuated PH in male ob/ob mice. Intra-thoracic fat from ob/ob mice and VAT conditioned media produce 16αOHE1 and can contribute to oxidative stress; effects that are attenuated by both ANA and TMS. Obesity can induce PH and changes in oestrogen metabolism, resulting in increased production of 16αOHE1 from VAT that contributes to oxidative stress. Oestrogen inhibitors are now in clinical trials for PAH. This study has translational consequences as it suggests that oestrogen inhibitors may be especially beneficial in treating obese individuals with PA

Seoul Virus Associated with Pet Rats, Scotland, UK, 2019.

We describe a case of hemorrhagic fever with renal syndrome caused by Seoul virus in a woman in Scotland, UK. Whole-genome sequencing showed the virus belonged to a lineage characterized by recent international expansion, probably driven by trade in pet rats

Identification of GSK3186899/DDD853651 as a Preclinical Development Candidate for the Treatment of Visceral Leishmaniasis

The leishmaniases are diseases that affect millions of people across the world, in particular visceral leishmaniasis (VL) which is fatal unless treated. Current standard of care for VL suffers from multiple issues and there is a limited pipeline of new candidate drugs. As such, there is a clear unmet medical need to identify new treatments. This paper describes the optimization of a phenotypic hit against Leishmania donovani, the major causative organism of VL. The key challenges were to balance solubility and metabolic stability while maintaining potency. Herein, strategies to address these shortcomings and enhance efficacy are discussed, culminating in the discovery of preclinical development candidate GSK3186899/DDD853651 (<b>1</b>) for VL

Reconciling autonomy and beneficence in treatment decision-making for animal patients

This article explores how the concept of consent to medical treatment applies in the veterinary context, and aims to evaluate normative justifications for owner consent to treatment of animal patients. We trace the evolution of the test for valid consent in human health decision-making, against a backdrop of increased recognition of the importance of patient rights and a gradual judicial espousal of a doctrine of informed consent grounded in a particular understanding of autonomy. We argue that, notwithstanding the adoption of a similar discourse of informed consent in professional veterinary codes, notions of autonomy and informed consent are not easily transferrable to the veterinary medicine context, given inter alia the tripartite relationship between veterinary professional, owner and animal patient. We suggest that a more appropriate, albeit inexact, analogy may be drawn with paediatric practice which is premised on a similarly tripartite relationship and where decisions must be reached in the best interests of the child. However, acknowledging the legal status of animals as property and how consent to veterinary treatment is predicated on the animal owner’s willingness and ability to pay, we propose that the appropriate response is for veterinary professionals generally to accept the client’s choice, provided this is informed. Yet such client autonomy must be limited where animal welfare concerns exist, so that beneficence continues to play an important role in the veterinary context. We suggest that this ‘middle road’ should be reflected in professional veterinary guidance