<clinical_study>
  <!-- This xml conforms to an XML Schema at:
    https://clinicaltrials.gov/ct2/html/images/info/public.xsd -->
  <required_header>
    <download_date>ClinicalTrials.gov processed this data on September 20, 2023</download_date>
    <link_text>Link to the current ClinicalTrials.gov record.</link_text>
    <url>https://clinicaltrials.gov/ct2/show/NCT04412382</url>
  </required_header>
  <id_info>
    <org_study_id>NETS IN COVID-19</org_study_id>
    <nct_id>NCT04412382</nct_id>
  </id_info>
  <brief_title>Covid-19: Possible Role of Neutrophil Extracellular Traps</brief_title>
  <acronym>NETSINCOVID</acronym>
  <official_title>Covid-19: Possible Role of Neutrophil Extracellular Traps</official_title>
  <sponsors>
    <lead_sponsor>
      <agency>Azienda Ospedaliera Universitaria Integrata Verona</agency>
      <agency_class>Other</agency_class>
    </lead_sponsor>
  </sponsors>
  <source>Azienda Ospedaliera Universitaria Integrata Verona</source>
  <oversight_info>
    <has_dmc>Yes</has_dmc>
    <is_fda_regulated_drug>No</is_fda_regulated_drug>
    <is_fda_regulated_device>No</is_fda_regulated_device>
  </oversight_info>
  <brief_summary>
    <textblock>
      The process by which neutrophils expel DNA together with various proteins to the outside,&#xD;
      forming a network structure called Neutrophil Extracellular Traps (NETs) constitutes a&#xD;
      particular cell death that involves the destruction of the nuclear membrane before the&#xD;
      plasmatic one. This process is called NETosis and differs from other known forms of cell&#xD;
      death, such as necrosis and apoptosis.&#xD;
&#xD;
      This process, however, if exaggerated, brings local or systemic damage. Viruses are known for&#xD;
      their ability to evade the body's immune response. Only recently has it been seen that they&#xD;
      can act as triggers for NETosis process.&#xD;
&#xD;
      In fact, many viruses can stimulate neutrophils to produce NETs. Virus-induced NETs can begin&#xD;
      to circulate in an uncontrolled manner, leading to an extreme systemic response of the body&#xD;
      with the production of immunocomplexes, cytokines, Interferon I etc.&#xD;
&#xD;
      To date, there are no data in the literature on the role of NETs in Covid-19 infection, a&#xD;
      viral infection that leads to highly lethal interstitial pneumonia and for which there is&#xD;
      currently no vaccine or specific therapy.&#xD;
&#xD;
      Advanced forms of Covid-19 are often characterized by hyperinflammation (&quot;cytokine storm&quot;)&#xD;
      with the development of an ARDS-like condition. Furthermore, reports of micro and macro&#xD;
      thrombotic phenomena such as microangiopathy, pulmonary embolism (which has led to a careful&#xD;
      evaluation procedure for antithrombotic prophylaxis and/or coagulation in Covid-19 patients)&#xD;
      are increasingly frequent.&#xD;
&#xD;
      The primary objective of the study is to understand if NETs can be implicated in the response&#xD;
      to Covid-19 and by which mechanisms. Concrete therapeutic proposals could derive from the&#xD;
      knowledge and enhancement of this form of innate immunity.&#xD;
&#xD;
      To do this, it will be necessary to evaluate the activity of NETosis in Covid-19 patients and&#xD;
      evaluate whether the clinical course of the disease (worsening vs healing) determines the&#xD;
      degree of NETosis activity. Therefore, the association between mortality from&#xD;
      Covid-19/survival and NETs activity will be studied.&#xD;
&#xD;
      Secondary objectives concern the possibility of studying the associations among NETosis&#xD;
      markers and blood inflammation markers and among NETosis markers and the onset of peripheral&#xD;
      or deep vein thrombosis.&#xD;
&#xD;
      Finally, the possibility that the plasma deriving from Covid-19 patients could trigger the&#xD;
      NETosis process in vitro will be evaluated.&#xD;
    </textblock>
  </brief_summary>
  <detailed_description>
    <textblock>
      The process by which neutrophils expel DNA together with various proteins to the outside,&#xD;
      forming a network structure called Neutrophil Extracellular Traps (NETs) constitutes a&#xD;
      particular cell death that involves the destruction of the nuclear membrane before the&#xD;
      plasmatic one. This process is called NETosis and differs from other known forms of cell&#xD;
      death, such as necrosis and apoptosis.&#xD;
&#xD;
      Neutrophil death by NETs ejection (NETosis) was first described in 2004 by Brinkman.&#xD;
&#xD;
      NETs,as indicated by the word itself, represent a sort of network composed of DNA fibers,&#xD;
      histones and proteins derived from the neutrophil granules, whose main function is to trap&#xD;
      pathogens (mainly bacteria and fungi).This process is related to the innate immunity.&#xD;
&#xD;
      However, this process, if activated in an exaggerated way, implies itself local or systemic&#xD;
      damage.&#xD;
&#xD;
      The DNA expelled during this process is a double stranded DNA, a dsDNA subtype. The dsDNA,&#xD;
      which represents a fraction of the DNA available in the circulation (cell free DNA - cfDNA),&#xD;
      originates from various processes of cell death, and is therefore correlated with the degree&#xD;
      of tissue damage. It is present only in small quantities in healthy subjects.&#xD;
&#xD;
      It is important to underline how during the NETosis process the cellular redox state is&#xD;
      altered, leading to an excess production of oxygen free radicals (Reactive Oxygen Species,&#xD;
      ROS) and to the activation of the enzyme NADPH oxidase. The formation of NETs, and therefore&#xD;
      the process of NETosis, were initially studied in the context of bacterial infections, but&#xD;
      subsequently their role became increasingly clear in other conditions such as cancer,&#xD;
      autoimmune diseases, lung diseases, atherosclerosis and venous thromboembolic disease.&#xD;
&#xD;
      In particular, NETosis seems to play an important role in all conditions characterized by&#xD;
      venous and arterial thrombosis, as numerous evidences have confirmed.&#xD;
&#xD;
      NETosis has also been documented at the microvascular level, such as in vasculitis,&#xD;
      thrombotic microangiopathies such as Moschowitz syndrome.&#xD;
&#xD;
      Viruses are known for their ability to evade the body's immune response. Recently it has been&#xD;
      seen that they too can act as triggers of NETosis processes.&#xD;
&#xD;
      In fact, many viruses can stimulate neutrophils to produce NETs. Different responses of&#xD;
      neutrophils have been seen, from classical NETosis, to the production of antiviral agents or&#xD;
      even to the switch to apoptosis.&#xD;
&#xD;
      Virus-induced NETs (therefore complexes of dsDNA, histones, granular proteins) can begin to&#xD;
      circulate in an uncontrolled way, leading to an extreme systemic response of the body with&#xD;
      the production of immune complexes, cytokines, Interferon I etc.&#xD;
&#xD;
      NETosis appears to be closely linked to the inflammatory response. For example, it is known&#xD;
      that in the neutrophilic granulocyte the PAD4 protein is present in the nucleus, it&#xD;
      decondensates the chromatin and favors the formation of the NETs. On the other hand, NETs&#xD;
      increase in patients with acute respiratory distress syndrome (ARDS) as observed in studies&#xD;
      about bronchoalveolar lavage fluid, as well as in patients with acute respiratory failure&#xD;
      during COPD exacerbation.&#xD;
&#xD;
      It is therefore clear that virus-induced NETosis acts as a double-edged sword: if on one hand&#xD;
      there is the mechanical entrapment of the virus, on the other the inflammatory and&#xD;
      immunological reaction triggered by the release of the NETs can be harmful itself.&#xD;
&#xD;
      To date, there are few data in the literature on the role of NETs in Covid-19 infection, a&#xD;
      viral infection that can lead to highly lethal interstitial pneumonia and for which there is&#xD;
      no vaccine or specific therapy today. Advanced forms of Covid-19 are often characterized by&#xD;
      hyperinflammation (&quot;cytokine storm&quot;) with the development of an ARDS-like condition.&#xD;
      Furthermore, reports of micro and macro thrombotic phenomena such as microangiopathy,&#xD;
      pulmonary embolism (which has led to a careful evaluation procedure for antithrombotic&#xD;
      prophylaxis and / or coagulation in Covid-19 patients) are increasingly frequent.&#xD;
&#xD;
      OBJECTIVE OF THE STUDY The primary objective of the study is to understand if NETs can be&#xD;
      implicated in the response to Covid-19 and by which mechanisms. Concrete therapeutic&#xD;
      proposals could derive from the knowledge and enhancement of this form of innate immunity.&#xD;
&#xD;
      To do this, it will be necessary to evaluate the activity of NETosis in Covid-19 patients and&#xD;
      evaluate whether the clinical course of the disease (worsening vs healing) determines the&#xD;
      degree of NETosi activity. Therefore, the association between mortality from&#xD;
      Covid-19/survival and NETs activity will be studied.&#xD;
&#xD;
      Secondary objectives concern the possibility of studying the various associations among&#xD;
      NETosis markers and biohumoral indices of inflammation and among NETosi markers and the onset&#xD;
      of peripheral or deep vein thrombosis.&#xD;
&#xD;
      Finally, the possibility that the plasma from Covid-19 patients could trigger the NETosis&#xD;
      process in vitro will be evaluated.&#xD;
&#xD;
      PLANNED PROCEDURES and COLLECTED INFORMATION Medical examination: (blood pressure, heart rate&#xD;
      and SpO2, which will allow to evaluate the precise PaO2 / FiO2 ratio).&#xD;
&#xD;
      As in normal clinical practice, Covid-19 patients will undergo venous sampling for the&#xD;
      determination of blood count, creatinine, lipid profile, PCR, D-dimer, LDH, liver function&#xD;
      indices and blood glucose.&#xD;
&#xD;
      Precise medical history will be drawn up for each subject. Patients will&#xD;
      undergo:electrocardiogram and chest x-ray and, in selected cases, chest CT scan, depending on&#xD;
      their clinical need.&#xD;
&#xD;
      They will also undergo venous echo-color Doppler lower limbs examination. A complete analysis&#xD;
      of the venous axes will not be necessary. NETosis markers (Cf-DNA. MPO-DNA, Cit-H3) and the&#xD;
      cytokines IL-6 and IL-1β will be analyzed from the subjects' plasma.&#xD;
&#xD;
      Spittle sample (or bronchoalveolar fluid if necessary for diagnostic-therapeutic purposes)&#xD;
      will be collected and the detection of NETs at electron microscopy will be assessed.&#xD;
&#xD;
      Informed consent will be requested.&#xD;
&#xD;
      CALCULATION OF THE SAMPLE The sample size was defined on the basis of the number of&#xD;
      admissions for Covid-19 in the months of March-April 2020 and on the decrease in numbers in&#xD;
      the current period.&#xD;
&#xD;
      100 subjects (50 patients and 50 controls) are expected to be enrolled.&#xD;
&#xD;
      STATISTICAL ANALYSIS Hypothetical statistical analysis: the data will be collected through&#xD;
      descriptive statistics. The estimates will be accompanied by appropriate 95% confidence&#xD;
      intervals. The level of statistical significance is set at 5%. The statistical program Stata&#xD;
      14.2 will be used. Planned test: t-test and Mann-Whitney test. Correlations will be evaluated&#xD;
      through Pearson or Spearman coefficients. Furthermore, Kaplan-Meier analyzes will be carried&#xD;
      out with the use of Log-Rank test and Cox regression for survival analysis.&#xD;
    </textblock>
  </detailed_description>
  <overall_status>Unknown status</overall_status>
  <last_known_status>Recruiting</last_known_status>
  <start_date type="Actual">June 1, 2020</start_date>
  <completion_date type="Anticipated">December 31, 2021</completion_date>
  <primary_completion_date type="Anticipated">December 31, 2020</primary_completion_date>
  <study_type>Observational [Patient Registry]</study_type>
  <has_expanded_access>No</has_expanded_access>
  <study_design_info>
    <observational_model>Case-Control</observational_model>
    <time_perspective>Prospective</time_perspective>
  </study_design_info>
  <target_duration>1 Year</target_duration>
  <primary_outcome>
    <measure>NETOSIS AND MORTALITY</measure>
    <time_frame>1 year</time_frame>
    <description>correlation among plasma levels of NETosis markers and Covid-19 mortality</description>
  </primary_outcome>
  <primary_outcome>
    <measure>NETOSIS AND DCOVID-19 SEVERITY</measure>
    <time_frame>1 year</time_frame>
    <description>correlation among plasma levels of NETosis markers and disease severity (that is duration of hospitalization in days and any need for passage to intensive care with non-invasive ventilation or intubation);</description>
  </primary_outcome>
  <secondary_outcome>
    <measure>NETOSIS AND INFLAMMATION</measure>
    <time_frame>1 year</time_frame>
    <description>correlation among plasma levels of NETosis markers and clinical inflammation biomarkers (white blood cells, PCR IL-6-IL-1β)</description>
  </secondary_outcome>
  <secondary_outcome>
    <measure>NETOSIS AND VENOUS THROMBOSIS</measure>
    <time_frame>1 year</time_frame>
    <description>correlation among plasma levels of NETosis markers and the onset of deep vein thrombosis and / or the increase in D-dimer values.</description>
  </secondary_outcome>
  <number_of_groups>2</number_of_groups>
  <enrollment type="Anticipated">100</enrollment>
  <condition>Covid-19</condition>
  <arm_group>
    <arm_group_label>covid-19</arm_group_label>
    <description>Study population: Covid-19 patients aged ≥ 18 years admitted to the Covid sections of the Verona University Hospital. Based on the ongoing epidemic emergency and the lack of specific therapy, we believe that to date this should be the only INCLUSION CRITERION.</description>
  </arm_group>
  <arm_group>
    <arm_group_label>control</arm_group_label>
    <description>Control group: medical doctors and nurses working in the University Hospital of Verona without known autoimmune diseases nor cancer.</description>
  </arm_group>
  <intervention>
    <intervention_type>Diagnostic Test</intervention_type>
    <intervention_name>NETosis markers</intervention_name>
    <description>NETosis markers (Cf-DNA. MPO-DNA, Cit-H3) and the cytokines IL-6 and IL-1β will be analyzed from the subjects' plasma.&#xD;
Spittle sample (or bronchoalveolar fluid if necessary for diagnostic-therapeutic purposes) will be collected and the detection of NETs at electron microscopy will be assessed.</description>
    <arm_group_label>control</arm_group_label>
    <arm_group_label>covid-19</arm_group_label>
  </intervention>
  <biospec_retention>Samples Without DNA</biospec_retention>
  <biospec_descr>
    <textblock>
      serum&#xD;
    </textblock>
  </biospec_descr>
  <eligibility>
    <study_pop>
      <textblock>
        Study population: Covid-19 patients aged ≥ 18 years admitted to the Covid sections of the&#xD;
        Verona University Hospital.&#xD;
&#xD;
        Control group: medical doctors and nurses worìking in the University Hospital of Verona.&#xD;
      </textblock>
    </study_pop>
    <sampling_method>Non-Probability Sample</sampling_method>
    <criteria>
      <textblock>
        -  Covid-19 patients aged ≥ 18 years admitted to the Covid sections of the Verona&#xD;
             University Hospital.&#xD;
&#xD;
          -  Control group: medical doctors and nurses working in the University Hospital of&#xD;
             Verona.&#xD;
&#xD;
        Exclusion Criteria:&#xD;
&#xD;
          -  age &lt;18 years;&#xD;
&#xD;
          -  pregnancy;&#xD;
&#xD;
          -  known autoimmune diseases.&#xD;
&#xD;
        For the control group:&#xD;
&#xD;
        - positivity to Covid-19 swabs and / or the presence of IgM and IgG antibodies&#xD;
        (sierological picture known from the samples taken by the Health surveillance System of the&#xD;
        hospital).&#xD;
      </textblock>
    </criteria>
    <gender>All</gender>
    <minimum_age>18 Years</minimum_age>
    <maximum_age>N/A</maximum_age>
    <healthy_volunteers>Accepts Healthy Volunteers</healthy_volunteers>
  </eligibility>
  <overall_official>
    <last_name>DOMENICO GIRELLI, MD-PhD</last_name>
    <role>Study Chair</role>
    <affiliation>Universita di Verona</affiliation>
  </overall_official>
  <overall_contact>
    <last_name>CHIARA MOZZINI, MD-PhD</last_name>
    <phone>+39 0458124262</phone>
    <email>chiara.mozzini@univr.it</email>
  </overall_contact>
  <overall_contact_backup>
    <last_name>DOMENICO GIRELLI, MD-PhD</last_name>
    <phone>+39 0458124262</phone>
    <email>domenico.girelli@univr.it</email>
  </overall_contact_backup>
  <location>
    <facility>
      <name>Univeristy of Verona</name>
      <address>
        <city>Verona</city>
        <zip>37136</zip>
        <country>Italy</country>
      </address>
    </facility>
    <status>Recruiting</status>
    <contact>
      <last_name>chiara mozzini, MD PhD</last_name>
      <phone>+390458124262</phone>
    </contact>
  </location>
  <location_countries>
    <country>Italy</country>
  </location_countries>
  <reference>
    <citation>Mozzini C, Girelli D. The role of Neutrophil Extracellular Traps in Covid-19: Only an hypothesis or a potential new field of research? Thromb Res. 2020 Jul;191:26-27. doi: 10.1016/j.thromres.2020.04.031. Epub 2020 Apr 27. No abstract available.</citation>
    <PMID>32360977</PMID>
  </reference>
  <verification_date>July 2020</verification_date>
  <study_first_submitted>May 26, 2020</study_first_submitted>
  <study_first_submitted_qc>May 31, 2020</study_first_submitted_qc>
  <study_first_posted type="Actual">June 2, 2020</study_first_posted>
  <last_update_submitted>July 7, 2020</last_update_submitted>
  <last_update_submitted_qc>July 7, 2020</last_update_submitted_qc>
  <last_update_posted type="Actual">July 8, 2020</last_update_posted>
  <responsible_party>
    <responsible_party_type>Principal Investigator</responsible_party_type>
    <investigator_affiliation>Azienda Ospedaliera Universitaria Integrata Verona</investigator_affiliation>
    <investigator_full_name>Chiara Mozzini</investigator_full_name>
    <investigator_title>Principal Investigator</investigator_title>
  </responsible_party>
  <keyword>Covid-19</keyword>
  <keyword>neutrophil extracellular traps</keyword>
  <condition_browse>
    <!-- CAUTION:  The following MeSH terms are assigned with an imperfect algorithm            -->
    <mesh_term>COVID-19</mesh_term>
  </condition_browse>
  <patient_data>
    <sharing_ipd>Yes</sharing_ipd>
    <ipd_description>study protocol and results</ipd_description>
    <ipd_info_type>Study Protocol</ipd_info_type>
    <ipd_info_type>Statistical Analysis Plan (SAP)</ipd_info_type>
    <ipd_time_frame>end 2020</ipd_time_frame>
    <ipd_access_criteria>mail contact</ipd_access_criteria>
  </patient_data>
  <!-- Results have not yet been posted for this study                                          -->
</clinical_study>


download date: ClinicalTrials.gov processed this data on September 20, 2023
link text: Link to the current ClinicalTrials.gov record.
url: https://clinicaltrials.gov/ct2/show/NCT04412382
org study id: NETS IN COVID-19
nct id: NCT04412382
lead sponsor: 
has dmc: Yes
is fda regulated drug: No
is fda regulated device: No
The process by which neutrophils expel DNA together with various proteins to the outside,
      forming a network structure called Neutrophil Extracellular Traps (NETs) constitutes a
      particular cell death that involves the destruction of the nuclear membrane before the
      plasmatic one. This process is called NETosis and differs from other known forms of cell
      death, such as necrosis and apoptosis.

      This process, however, if exaggerated, brings local or systemic damage. Viruses are known for
      their ability to evade the body's immune response. Only recently has it been seen that they
      can act as triggers for NETosis process.

      In fact, many viruses can stimulate neutrophils to produce NETs. Virus-induced NETs can begin
      to circulate in an uncontrolled manner, leading to an extreme systemic response of the body
      with the production of immunocomplexes, cytokines, Interferon I etc.

      To date, there are no data in the literature on the role of NETs in Covid-19 infection, a
      viral infection that leads to highly lethal interstitial pneumonia and for which there is
      currently no vaccine or specific therapy.

      Advanced forms of Covid-19 are often characterized by hyperinflammation ("cytokine storm")
      with the development of an ARDS-like condition. Furthermore, reports of micro and macro
      thrombotic phenomena such as microangiopathy, pulmonary embolism (which has led to a careful
      evaluation procedure for antithrombotic prophylaxis and/or coagulation in Covid-19 patients)
      are increasingly frequent.

      The primary objective of the study is to understand if NETs can be implicated in the response
      to Covid-19 and by which mechanisms. Concrete therapeutic proposals could derive from the
      knowledge and enhancement of this form of innate immunity.

      To do this, it will be necessary to evaluate the activity of NETosis in Covid-19 patients and
      evaluate whether the clinical course of the disease (worsening vs healing) determines the
      degree of NETosis activity. Therefore, the association between mortality from
      Covid-19/survival and NETs activity will be studied.

      Secondary objectives concern the possibility of studying the associations among NETosis
      markers and blood inflammation markers and among NETosis markers and the onset of peripheral
      or deep vein thrombosis.

      Finally, the possibility that the plasma deriving from Covid-19 patients could trigger the
      NETosis process in vitro will be evaluated.
The process by which neutrophils expel DNA together with various proteins to the outside,
      forming a network structure called Neutrophil Extracellular Traps (NETs) constitutes a
      particular cell death that involves the destruction of the nuclear membrane before the
      plasmatic one. This process is called NETosis and differs from other known forms of cell
      death, such as necrosis and apoptosis.

      Neutrophil death by NETs ejection (NETosis) was first described in 2004 by Brinkman.

      NETs,as indicated by the word itself, represent a sort of network composed of DNA fibers,
      histones and proteins derived from the neutrophil granules, whose main function is to trap
      pathogens (mainly bacteria and fungi).This process is related to the innate immunity.

      However, this process, if activated in an exaggerated way, implies itself local or systemic
      damage.

      The DNA expelled during this process is a double stranded DNA, a dsDNA subtype. The dsDNA,
      which represents a fraction of the DNA available in the circulation (cell free DNA - cfDNA),
      originates from various processes of cell death, and is therefore correlated with the degree
      of tissue damage. It is present only in small quantities in healthy subjects.

      It is important to underline how during the NETosis process the cellular redox state is
      altered, leading to an excess production of oxygen free radicals (Reactive Oxygen Species,
      ROS) and to the activation of the enzyme NADPH oxidase. The formation of NETs, and therefore
      the process of NETosis, were initially studied in the context of bacterial infections, but
      subsequently their role became increasingly clear in other conditions such as cancer,
      autoimmune diseases, lung diseases, atherosclerosis and venous thromboembolic disease.

      In particular, NETosis seems to play an important role in all conditions characterized by
      venous and arterial thrombosis, as numerous evidences have confirmed.

      NETosis has also been documented at the microvascular level, such as in vasculitis,
      thrombotic microangiopathies such as Moschowitz syndrome.

      Viruses are known for their ability to evade the body's immune response. Recently it has been
      seen that they too can act as triggers of NETosis processes.

      In fact, many viruses can stimulate neutrophils to produce NETs. Different responses of
      neutrophils have been seen, from classical NETosis, to the production of antiviral agents or
      even to the switch to apoptosis.

      Virus-induced NETs (therefore complexes of dsDNA, histones, granular proteins) can begin to
      circulate in an uncontrolled way, leading to an extreme systemic response of the body with
      the production of immune complexes, cytokines, Interferon I etc.

      NETosis appears to be closely linked to the inflammatory response. For example, it is known
      that in the neutrophilic granulocyte the PAD4 protein is present in the nucleus, it
      decondensates the chromatin and favors the formation of the NETs. On the other hand, NETs
      increase in patients with acute respiratory distress syndrome (ARDS) as observed in studies
      about bronchoalveolar lavage fluid, as well as in patients with acute respiratory failure
      during COPD exacerbation.

      It is therefore clear that virus-induced NETosis acts as a double-edged sword: if on one hand
      there is the mechanical entrapment of the virus, on the other the inflammatory and
      immunological reaction triggered by the release of the NETs can be harmful itself.

      To date, there are few data in the literature on the role of NETs in Covid-19 infection, a
      viral infection that can lead to highly lethal interstitial pneumonia and for which there is
      no vaccine or specific therapy today. Advanced forms of Covid-19 are often characterized by
      hyperinflammation ("cytokine storm") with the development of an ARDS-like condition.
      Furthermore, reports of micro and macro thrombotic phenomena such as microangiopathy,
      pulmonary embolism (which has led to a careful evaluation procedure for antithrombotic
      prophylaxis and / or coagulation in Covid-19 patients) are increasingly frequent.

      OBJECTIVE OF THE STUDY The primary objective of the study is to understand if NETs can be
      implicated in the response to Covid-19 and by which mechanisms. Concrete therapeutic
      proposals could derive from the knowledge and enhancement of this form of innate immunity.

      To do this, it will be necessary to evaluate the activity of NETosis in Covid-19 patients and
      evaluate whether the clinical course of the disease (worsening vs healing) determines the
      degree of NETosi activity. Therefore, the association between mortality from
      Covid-19/survival and NETs activity will be studied.

      Secondary objectives concern the possibility of studying the various associations among
      NETosis markers and biohumoral indices of inflammation and among NETosi markers and the onset
      of peripheral or deep vein thrombosis.

      Finally, the possibility that the plasma from Covid-19 patients could trigger the NETosis
      process in vitro will be evaluated.

      PLANNED PROCEDURES and COLLECTED INFORMATION Medical examination: (blood pressure, heart rate
      and SpO2, which will allow to evaluate the precise PaO2 / FiO2 ratio).

      As in normal clinical practice, Covid-19 patients will undergo venous sampling for the
      determination of blood count, creatinine, lipid profile, PCR, D-dimer, LDH, liver function
      indices and blood glucose.

      Precise medical history will be drawn up for each subject. Patients will
      undergo:electrocardiogram and chest x-ray and, in selected cases, chest CT scan, depending on
      their clinical need.

      They will also undergo venous echo-color Doppler lower limbs examination. A complete analysis
      of the venous axes will not be necessary. NETosis markers (Cf-DNA. MPO-DNA, Cit-H3) and the
      cytokines IL-6 and IL-1β will be analyzed from the subjects' plasma.

      Spittle sample (or bronchoalveolar fluid if necessary for diagnostic-therapeutic purposes)
      will be collected and the detection of NETs at electron microscopy will be assessed.

      Informed consent will be requested.

      CALCULATION OF THE SAMPLE The sample size was defined on the basis of the number of
      admissions for Covid-19 in the months of March-April 2020 and on the decrease in numbers in
      the current period.

      100 subjects (50 patients and 50 controls) are expected to be enrolled.

      STATISTICAL ANALYSIS Hypothetical statistical analysis: the data will be collected through
      descriptive statistics. The estimates will be accompanied by appropriate 95% confidence
      intervals. The level of statistical significance is set at 5%. The statistical program Stata
      14.2 will be used. Planned test: t-test and Mann-Whitney test. Correlations will be evaluated
      through Pearson or Spearman coefficients. Furthermore, Kaplan-Meier analyzes will be carried
      out with the use of Log-Rank test and Cox regression for survival analysis.
observational model: Case-Control
time perspective: Prospective
measure: NETOSIS AND MORTALITY
time frame: 1 year
description: correlation among plasma levels of NETosis markers and Covid-19 mortality
measure: NETOSIS AND DCOVID-19 SEVERITY
time frame: 1 year
description: correlation among plasma levels of NETosis markers and disease severity (that is duration of hospitalization in days and any need for passage to intensive care with non-invasive ventilation or intubation);
measure: NETOSIS AND INFLAMMATION
time frame: 1 year
description: correlation among plasma levels of NETosis markers and clinical inflammation biomarkers (white blood cells, PCR IL-6-IL-1β)
measure: NETOSIS AND VENOUS THROMBOSIS
time frame: 1 year
description: correlation among plasma levels of NETosis markers and the onset of deep vein thrombosis and / or the increase in D-dimer values.
arm group label: covid-19
description: Study population: Covid-19 patients aged ≥ 18 years admitted to the Covid sections of the Verona University Hospital. Based on the ongoing epidemic emergency and the lack of specific therapy, we believe that to date this should be the only INCLUSION CRITERION.
arm group label: control
description: Control group: medical doctors and nurses working in the University Hospital of Verona without known autoimmune diseases nor cancer.
intervention type: Diagnostic Test
intervention name: NETosis markers
description: NETosis markers (Cf-DNA. MPO-DNA, Cit-H3) and the cytokines IL-6 and IL-1β will be analyzed from the subjects' plasma.
Spittle sample (or bronchoalveolar fluid if necessary for diagnostic-therapeutic purposes) will be collected and the detection of NETs at electron microscopy will be assessed.
arm group label: control
arm group label: covid-19
serum
study pop: 
sampling method: Non-Probability Sample
criteria: 
gender: All
minimum age: 18 Years
maximum age: N/A
healthy volunteers: Accepts Healthy Volunteers
last name: DOMENICO GIRELLI, MD-PhD
role: Study Chair
affiliation: Universita di Verona
last name: CHIARA MOZZINI, MD-PhD
phone: +39 0458124262
email: chiara.mozzini@univr.it
last name: DOMENICO GIRELLI, MD-PhD
phone: +39 0458124262
email: domenico.girelli@univr.it
facility: 
status: Recruiting
contact: 
country: Italy
citation: Mozzini C, Girelli D. The role of Neutrophil Extracellular Traps in Covid-19: Only an hypothesis or a potential new field of research? Thromb Res. 2020 Jul;191:26-27. doi: 10.1016/j.thromres.2020.04.031. Epub 2020 Apr 27. No abstract available.
PMID: 32360977
responsible party type: Principal Investigator
investigator affiliation: Azienda Ospedaliera Universitaria Integrata Verona
investigator full name: Chiara Mozzini
investigator title: Principal Investigator
mesh term: COVID-19
sharing ipd: Yes
ipd description: study protocol and results
ipd info type: Study Protocol
ipd info type: Statistical Analysis Plan (SAP)
ipd time frame: end 2020
ipd access criteria: mail contact