Secondary sclerosing cholangitis after COVID-19 pneumonia: a report of two cases and review of the literature.

Secondary sclerosing cholangitis in critically ill patients (SC-CIP) is a rare disease characterized by chronic cholestasis. The underlying pathophysiology of SC-CIP is not fully understood, and prognosis in severe cases remains poor with liver transplantation remaining the only curative treatment option. There is a growing amount of literature describing patients with chronic cholangiopathy after COVID-19 infection. The vast majority of the patients described in these reports were male and had a poor outcome. While the exact percentage of patients with COVID-19-related SC-CIP cannot be estimated accurately due to a lack of larger studies, an increase in patients with long-term complications of chronic cholestatic liver disease after severe COVID19-pneumonia can be expected in the upcoming years. Treatment options remain limited and further research is needed to improve the dismal prognosis of SC-CIP. Here, we present the cases of two patients who developed SC-CIP after prolonged intensive care unit stay due to severe COVID-19 pneumonia. Both patients required invasive ventilation for 31 and 141 days, respectively, as well as extra-corporal membrane oxygenation for 23 and 87 days. The patients suffered from jaundice and severe pruritus, and typical features of SC-CIP were present by MRCP and ERC. Repeated removal of biliary casts resulted in some alleviation of their clinical symptoms, but cholestasis parameters remain elevated. Furthermore, an increased liver stiffness was indicative of advanced fibrosis in both patients. In addition to these two case reports, we provide a concise review of the literature of SC-CIP after COVID-19 infection and discuss risk factors, treatment options and prognosis.

Zoonotic Coronaviruses Regeneration of Capto™ Core 700 resin through high throughput and laboratory scale studies and impact on production of a SARS-CoV-2 vaccine candidate

Summary Coronaviruses (CoVs) are important pathogens for humans and vertebrate animals. These viruses can infect the respiratory, gastrointestinal, hepatic and central nervous system of humans, livestock, birds, bats and other wild animals. The CoVs have frequently crossed species barriers and some have emerged as important human pathogens. Bats are well adapted anatomically and physiologically to CoVs. During the twenty-first century, the world has witnessed two pandemics of coronaviruses (SARSCoV and SARS-CoV-2) and fatal sporadic outbreaks due to the emerging Middle East respiratory syndrome-CoV. Most of the coronaviruses are transmitted through respiratory droplets during coughing or sneezing. Transmission through the ocular surface is also possible. Animal CoVs have been known since the late 1930s. Various diagnostic tests are available for the detection of coronaviruses infection which is mainly based on antigen detection or specific antibody detection. During the development of a SARS-CoV-2 vaccine candidate, at the height of the COVID-19 pandemic, raw materials shortages, including chromatography resins, necessitated the determination of a cleaning in place (CIP) strategy for a multimodal core-shell resin both rapidly and efficiently. Here, we describe the deployment of high throughput (HT) techniques to screen CIP conditions for cleaning Capto? Core 700 resin exposed to clarified cell culture harvest of a SARS-CoV-2 vaccine candidate produced in Vero adherent cell culture. The best performing conditions, comprised of 30% n-propanol and ≥0.75 N NaOH, were deployed in cycling experiments, completed with miniature chromatography columns, to demonstrate their effectiveness. The success of the CIP strategy was ultimately verified at the laboratory scale. Here, its impact was assessed across the entire purification process which also included an ultrafiltration/diafiltration step. It is shown that the implementation of the CIP strategy enabled the re-use of the Capto Core 700 resin for up to ten cycles without any negative impact on the purified product. Hence, the strategic combination of HT and laboratory-scale experiments can lead rapidly to robust CIP procedures, even for a challenging to clean resin, and thus help to overcome supply shortages. This article is protected by copyright. All rights reserved

Regeneration of Capto Core 700 resin through high throughput and laboratory scale studies and impact on production of a SARS-CoV-2 vaccine candidate.

During the development of a SARS-CoV-2 vaccine candidate, at the height of the COVID-19 pandemic, raw materials shortages, including chromatography resins, necessitated the determination of a cleaning in place (CIP) strategy for a multimodal core-shell resin both rapidly and efficiently. Here, the deployment of high throughput (HT) techniques to screen CIP conditions for cleaning Capto Core 700 resin exposed to clarified cell culture harvest (CCCH) of a SARS-CoV-2 vaccine candidate produced in Vero adherent cell culture are described. The best performing conditions, comprised of 30% n-propanol and ≥0.75 N NaOH, were deployed in cycling experiments, completed with miniature chromatography columns, to demonstrate their effectiveness. The success of the CIP strategy was ultimately verified at the laboratory scale. Here, its impact was assessed across the entire purification process which also included an ultrafiltration/diafiltration step. It is shown that the implementation of the CIP strategy enabled the re-use of the Capto Core 700 resin for up to 10 cycles without any negative impact on the purified product. Hence, the strategic combination of HT and laboratory-scale experiments can lead rapidly to robust CIP procedures, even for a challenging to clean resin, and thus help to overcome supply shortages.

What Does Cross-Industry-Production Bring Under COVID-19? A Multi-Methodological Study

The COVID-19 pandemic has led to shutdowns of myriad factories, resulting in extreme scarce production capacity and disruptions of supply chains. Many manufacturing firms around the world struggle to ramp up their production capacity to mitigate the negative impact of the pandemic. We adopt a multimethodological approach to examine the impacts of cross-industry production (CIP) on supply chains and society. First, we provide evidence of CIP of personal and protective equipment (PPE), including CIP's business model, CIP in real-world practice, and the global supply chain of PPE by collecting public organizational data. Second, we confirm the importance of CIP and its beneficial impacts on brand value and society by conducting statistical tests and analyses. Third, we propose a framework of CIP implementation from the perspectives of firms and governments. Finally, we conduct real-world case studies to illustrate the framework of CIP. We find that CIP in pandemic time can significantly increase capacity to tens or even thousands of times of normal capacity in a short period, which can enhance firms’brand values and profiles and improve their social impacts and benefits. We provide managerial insights and guidance to firms with potential CIP capability and governments in fighting the COVID-19 pandemic. IEEE

Migratory birds as the vehicle of transmission of multi drug resistant extended spectrum ß lactamase producing Escherichia fergusonii, an emerging zoonotic pathogen.

The acquisition of multi-drug resistance (MDR) genes by pathogenic bacterial bugs and their dispersal to different food webs has become a silent pandemic. The multiplied use of different antibacterial therapeutics during COVID-19 pandemic has accelerated the process among emerging pathogens. Wild migratory birds play an important role in the spread of MDR pathogens and MDR gene flow due to the consumption of contaminated food and water. Escherichia fergusonii is an emerging pathogen of family Enterobacteriaceae and commonly causes disease in human and animals. The present study focused on the isolation of E. fergusonii from blood, saliva, and intestine of selected migratory birds of the Hazara Division. The sensitivity of isolated strains was assessed against ten different antibiotics. The isolation frequency of E. fergusonii was 69%. In blood samples, a high rate of resistance was observed against ceftriaxone (80%) followed by ampicillin (76%) whereas, in oral and intestinal samples, ceftriaxone resistant strains were 56% and 57% while ampicillin resistance was 49% and 52% respectively. The overall ceftriaxone and ampicillin-resistant cases in all three sample sources were 71% and 65% respectively. In comparison to oral and intestinal samples, high numbers of ceftriaxone-resistant strains were isolated from the blood of mallard while ampicillin-resistant strains were observed in blood samples of cattle egrets. 16S rRNA-based confirmed strains of E. fergusonii were processed for detection of CTX-M and TEM-1 gene through Polymerase chain reaction (PCR) after DNA extraction. Hundred percent ceftriaxone resistant isolates possessed CTX-M and all ampicillin-resistant strains harbored TEM-1 genes. Amplified products were sequenced by using the Sanger sequencing method and the resulted sequences were checked for similarity in the nucleotide Database through the BLAST program. TEM-1 gene showed 99% and the CTX-M gene showed 98% similar sequences in the Database. The 16S rRNA sequence and nucleotide sequences for TEM-1 and CTX-M genes were submitted to Gene Bank with accession numbers LC521304, LC521306, LC521307 respectively. We posit to combat MDR gene flow among the bacterial pathogens across different geographical locations, regular surveillance of new zoonotic pathogens must be conducted.

Functional assessment of miR­1291 in colon cancer cells.

miR­1291 exerts an anti­tumor effect in a subset of human carcinomas, including pancreatic cancer. However, its role in colorectal cancer (CRC) is largely unknown. In the present study, the expression and effect of miR­1291 in CRC cells was investigated. It was identified that miR­1291 significantly suppressed the proliferation, invasion, cell mobility and colony formation of CRC cells. Additionally, miR­1291 induced cell apoptosis. A luciferase reporter assay revealed that miR­1291 directly bound the 3'­untranslated region sequence of doublecortin­like kinase 1 (DCLK1). miR­1291 also suppressed DCLK1 mRNA and protein expression in HCT116 cells that expressed DCLK1. Furthermore, miR­1291 suppressed cancer stem cell markers BMI1 and CD133, and inhibited sphere formation. The inhibitory effects on sphere formation, invasion and mobility in HCT116 cells were also explored and verified using DCLK1 siRNAs. Furthermore, miR­1291 induced CDK inhibitors p21WAF1/CIP1 and p27KIP1 in three CRC cell lines, and the overexpression of DCLK1 in HCT116 cells led to a decrease of p21WAF1/CIP1 and p27KIP1. Intravenous administration of miR­1291 loaded on the super carbonate apatite delivery system significantly inhibited tumor growth in the DLD­1 xenograft mouse model. Additionally, the resultant tumors exhibited significant upregulation of the p21WAF1/CIP1 and p27KIP1 protein with treatment of miR­1291. Taken together, the results indicated that miR­1291 served an anti­tumor effect by modulating multiple functions, including cancer stemness and cell cycle regulation. The current data suggested that miR­1291 may be a promising nucleic acid medicine against CRC.

Kinetics of Bilirubin and Ammonia Elimination during Hemadsorption Therapy in Secondary Sclerosing Cholangitis Following ECMO Therapy and Severe COVID-19.

In critically ill patients, liver dysfunction often results in coagulopathy and encephalopathy and is associated with high mortality. Extracorporeal clearance of hepatotoxic metabolites, including bilirubin and ammonia, aims to attenuate further hepatocyte damage and liver injury, resulting in decreased mortality. The efficacy of hemadsorption combined with conventional hemodialysis to eliminate bilirubin and ammonia to support the liver's excretory function in acute liver injury has been described previously. However, the optimal use of liver support systems in chronic liver dysfunction due to secondary sclerosing cholangitis in critically ill patients (SSC-CIP) has not been defined yet. We herein describe the kinetics of successful bilirubin and ammonia elimination by hemadsorption in a patient with SSC-CIP after extracorporeal membrane oxygenation (ECMO) therapy for severe acute respiratory distress syndrome (ARDS) in a patient with coronavirus disease 2019 (COVID-19). During the course of the disease, the patient developed laboratory signs of liver injury during ECMO therapy before clinically detectable jaundice or elevated bilirubin levels. A diagnosis of SSC-CIP was confirmed by endoscopic retrograde cholangiopancreatography (ERCP) based on intraductal filling defects in the intrahepatic bile ducts due to biliary casts. The patient showed stable elevations of bilirubin and ammonia levels thereafter, but presented with progressive nausea, vomiting, weakness, and exhaustion. Based on these laboratory findings, hemadsorption was combined with hemodialysis treatment and successfully eliminated bilirubin and ammonia. Moreover, direct comparison revealed that ammonia is more efficiently eliminated by hemadsorption than bilirubin levels. Clinical symptoms of nausea, vomiting, weakness, and exhaustion improved. In summary, bilirubin and ammonia were successfully eliminated by hemadsorption combined with hemodialysis treatment in SSC-CIP following ECMO therapy and severe COVID-19. This observation is particularly relevant since it has been reported that a considerable subset of critically ill patients with COVID-19 suffer from liver dysfunction associated with high mortality.

Forecasting COVID-19 recovered cases with Artificial Neural Networks to enable designing an effective blood supply chain.

This study introduces a forecasting model to help design an effective blood supply chain mechanism for tackling the COVID-19 pandemic. In doing so, first, the number of people recovered from COVID-19 is forecasted using the Artificial Neural Networks (ANNs) to determine potential donors for convalescent (immune) plasma (CIP) treatment of COVID-19. This is performed explicitly to show the applicability of ANNs in forecasting the daily number of patients recovered from COVID-19. Second, the ANNs-based approach is further applied to the data from Italy to confirm its robustness in other geographical contexts. Finally, to evaluate its forecasting accuracy, the proposed Multi-Layer Perceptron (MLP) approach is compared with other traditional models, including Autoregressive Integrated Moving Average (ARIMA), Long Short-term Memory (LSTM), and Nonlinear Autoregressive Network with Exogenous Inputs (NARX). Compared to the ARIMA, LSTM, and NARX, the MLP-based model is found to perform better in forecasting the number of people recovered from COVID-19. Overall, the findings suggest that the proposed model is robust and can be widely applied in other parts of the world in forecasting the patients recovered from COVID-19.

High Rate of Gastrointestinal Bleeding in Patients with Secondary Sclerosing Cholangitis in Critically Ill Patients (SC-CIP).

Secondary sclerosing cholangitis in critically ill patients (SC-CIP) is a rare cholestatic liver disease triggered by long-term intensive care treatment. The aim of this study was to evaluate the frequency and characteristics of gastrointestinal bleeding in SC-CIP. Patients with diagnosed SC-CIP were retrospectively identified and compared to a control group of patients with cardiac surgery and intensive care treatment but without the development of SC-CIP. Fifty-three patients with SC-CIP and 19 controls were included in the study. The frequency of gastrointestinal bleeding was 30% in SC-CIP (16 patients) and 5% in the control group (1 patient) (p = 0.03). Bleeding occured in the mean 13 months after admission to an intensive care unit in SC-CIP, three patients (19%) suffered bleeding during intensive care treatment. Three SC-CIP patients (19%) had cirrhosis at the time of bleeding, five (31%) had splenomegaly, and four (25%) received oral anticoagulation. In SC-CIP, 13 bleedings were identified in the upper gastrointestinal tract, two in the lower, and one remained unknown. The most common reasons for bleeding were gastroduodenal ulcers. In total, 80% of patients needed blood units, and one death due to bleeding occurred in SC-CIP. In conclusion, gastrointestinal bleeding is a frequent complication in patients with SC-CIP. Whether the liver disease itself or cofactors cause the susceptibility for bleeding remains unclear.

Clinical and neurophysiological characterization of muscular weakness in severe COVID-19.

OBJECTIVE: To report clinical and electroneuromyographic (ENMG) characteristics of patients affected by severe COVID-19 infection, evaluated for muscular weakness. MATERIALS AND METHODS: ENMGs performed for evaluation of diffuse weakness in patients who could not be discharged from semi-intensive care COVID unit because of difficulties in ventilation weaning were reviewed. Patients with severe COVID-19 infection who had undergone endotracheal intubation and able to co-operate were considered. ENMG protocol was focused on neurophysiological items that excluded or confirmed critical illness polyneuropathy (CIP), myopathy (CIM), or polyneuromyopathy (CIPM). Standardized clinical evaluation was performed using Medical Research Council (MRC) sum score. RESULTS: Eight patients were included in the study. All presented known risk factors for intensive care unit-acquired weakness (ICU-AW), and none of them had history of underlying neuromuscular disorders. ENMG findings were normal in two patients, while only two patients had an altered MRC sum score (< 48). Neuromuscular involvement was diagnosed in 6/8 patients (75%): 2 had CIP, 1 had possible CIM, 1 had CIPM, while 1 patient, with clinically evident weakness but equivocal ENMG findings, was classified as ICU-AW. Finally, 1 patient was diagnosed with acute demyelinating neuropathy. Patients with neuromuscular involvement were those with longer intubation duration and higher levels of IL-6 at admission. CONCLUSION: Neuromuscular complications are frequent in severe COVID-19 and cannot be excluded by MRC sum scores above 48. Standardized ENMG is helpful in guiding diagnosis when clinical evaluation is not reliable or possible. Elevated IL-6 at admission may be a predictor biomarker of ICU-AW in COVID-19.