Financial toxicity in allogeneic haematopoietic stem cell transplant patients from a social determinants of health perspective

PURPOSE

Financial toxicity (FT) refers to the subjective perception of financial distress resulting from objective economic strain due to illness, exerting a detrimental influence on health outcomes. This study aimed to describe FT among allogeneic haematopoietic stem cell transplant (allo-HSCT) recipients within a public health framework, employing a social determinants of health approach.

METHODS

A multi-centre cross-sectional study involving adult allo-HSCT patients was conducted across three public hospitals in Madrid. FT was assessed using a validated COST scale (range 0-44; lower scores indicating higher FT). Patient-administered paper/online questionnaires were utilized to collect data on sociodemographic, socioeconomic, clinical, and healthcare access variables. Descriptive, non-parametric univariate statistical analysis and multiple linear regression models were performed.

RESULTS

Sixty-six patients, with a mean age: 52.5 years (SD: 11.5), 50% women, 28.7% displaced to Madrid for HSCT, and 71.4% lacking financial support were included. The median FT score was 20 points (IQR 12-27.25). Independent factors associated with higher FT included being females (Coef = -3.26; p = 0.079), perceived income loss after HSCT (Coef = -6.81; p < 0.001) and a monthly household income of ≤1000 € compared to 1001-2500€ (Coef = 8.29; p = 0.005) or >2500 € (Coef = 15.75; p < 0.001).

CONCLUSIONS

Despite the limited sample size, our findings underscore the presence of financial toxicity among allo-HSCT patients, shaped by social determinants of health. Recognizing and addressing FT within the HSCT process is essential to mitigate social inequalities in health.

Evaluation of convalescent plasma versus standard of care for the treatment of COVID-19 in hospitalized patients: study protocol for a phase 2 randomized, open-label, controlled, multicenter trial

BACKGROUND

COVID-19 is a respiratory disease caused by a novel coronavirus (SARS-CoV-2) and causes substantial morbidity and mortality. At the time this clinical trial was planned, there were no available vaccine or therapeutic agents with proven efficacy, but the severity of the condition prompted the use of several pharmacological and non-pharmacological interventions. It has long been hypothesized that the use of convalescent plasma (CP) from infected patients who have developed an effective immune response is likely to be an option for the treatment of patients with a variety of severe acute respiratory infections (SARI) of viral etiology. The aim of this study is to assess the efficacy and safety of convalescent plasma in adult patients with severe COVID-19 pneumonia.

METHODS/DESIGN

The ConPlas-19 study is a multicenter, randomized, open-label controlled trial. The study has been planned to include 278 adult patients hospitalized with severe COVID-19 infection not requiring mechanical ventilation (invasive or non-invasive). Subjects are randomly assigned in a 1:1 ratio (139 per treatment arm), stratified by center, to receive intravenously administered CP (single infusion) plus SOC or SOC alone, and are to be followed for 30 days. The primary endpoint of the study is the proportion of patients that progress to category 5, 6, or 7 (on the 7-point ordinal scale proposed by the WHO) at day 15. Interim analyses for efficacy and/or futility will be conducted once 20%, 40%, and 60% of the planned sample size are enrolled and complete D15 assessment.

DISCUSSION

This clinical trial is designed to evaluate the efficacy and safety of passive immunotherapy with convalescent plasma for the treatment of adult patients hospitalized with COVID-19. The results of this study are expected to contribute to establishing the potential place of CP in the therapeutics for a new viral disease.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04345523 . Registered on 30 March, 2020. First posted date: April 14, 2020.

Double-blind, randomized, controlled, trial to assess the efficacy of allogenic mesenchymal stromal cells in patients with acute respiratory distress syndrome due to COVID-19 (COVID-AT): A structured summary of a study protocol for a randomised controlled trial

Objectives

1. To assess the efficacy of Mesenchymal Stromal Cells (MSC) versus a control arm as described in the primary endpoint.

2. To evaluate the effects of MSC on the secondary efficacy endpoints.

3. To evaluate the safety and tolerability profiles of MSC.

4. To study soluble and cellular biomarkers that might be involved in the course of the disease and the response to the investigational product.

Trial design

A double-blind, randomized, controlled, trial to evaluate the efficacy and safety of MSC intravenous administration in patients with COVID-induced Acute Respiratory Distress Syndrome (ARDS) compared to a control arm.

Participants

The trial is being conducted at a third level hospital, Hospital Universitario Puerta de Hierro, in Majadahonda, Madrid (Spain).

Inclusion criteria

1. Informed consent prior to performing study procedures (witnessed oral consent with written consent by representatives will be accepted to avoid paper handling). Written consent by patient or representatives will be obtained whenever possible.

2. Adult patients ≥18 years of age at the time of enrolment.

3. Laboratory-confirmed SARS-CoV-2 infection as determined by Polymerase Chain Reaction (PCR), in oropharyngeal swabs or any other relevant specimen obtained during the course of the disease. Alternative tests (e.g., rapid antigen tests) are also acceptable as laboratory confirmation if their specificity has been accepted by the Sponsor.

4. Moderate to severe ARDS (PaO2/FiO2 ratio equal or less than 200 mmHg) for less than 96 hours at the time of randomization.

5. Patients requiring invasive ventilation are eligible within 72 hours from intubation.

6. Eligible for ICU admission, according to the clinical team.

Exclusion criteria

1. Imminent and unavoidable progression to death within 24 hours, irrespective of the provision of treatments (in the opinion of the clinical team).

2. “Do Not Attempt Resuscitation” order in place.

3. Any end-stage organ disease or condition, which in the investigator’s opinion, makes the patient an unsuitable candidate for treatment.

4. History of a moderate/severe lung disorder requiring home-based oxygen therapy.

5. Patient requiring Extracorporeal Membrane Oxygenation (ECMO), haemodialysis or hemofiltration at the time of treatment administration.

6. Current diagnosis of pulmonary embolism.

7. Active neoplasm, except carcinoma in situ or basalioma.

8. Known allergy to the products involved in the allogeneic MSC production process.

9. Current pregnancy or lactation (women with childbearing potential should have a negative pregnancy test result at the time of study enrolment).

10. Current participation in a clinical trial with an experimental treatment for COVID-19 (the use of any off-label medicine according to local treatment protocols is not an exclusion criteria).

11. Any circumstances that in the investigator’s opinion compromises the patient’s ability to participate in the clinical trial.

Intervention and comparator

- Experimental treatment arm: Allogeneic MSC (approximately 1 x 10⁶ cells/kg).

- Control arm: placebo solution (same composition as the experimental treatment, without the MSC).

One single intravenous dose of the assigned treatment will be administered on Day 0 of the study.

All trial participants will receive standard of care (SOC). In the context of the current worldwide pandemic, SOC can include medicines that are being used in clinical practice (e.g. lopinavir/ritonavir; hydroxy/chloroquine, tocilizumab, etc.), as well as those authorised for COVID (e.g., remdesivir).

Main outcomes

Primary endpoint:

Change in the PaO2/FiO2 ratio from baseline to day 7 of treatment administration, or to the last available PaO2/FiO2 ratio if death occurs before day 7.

Secondary endpoints:

- All-cause mortality on days 7, 14, and 28 after treatment.

- PaO2/FiO2 ratio at baseline and days 2, 4, 7, 14 and 28 after treatment.

- Oxygen saturation (by standardized measurement) at baseline, daily until day 14, and on day 28 after treatment.

- Time to PaO2/FiO2 ratio greater than 200 mmHg.

- Subjects’ clinical status on the WHO 7-point ordinal scale at baseline, daily until day 14, and on day 28 after treatment.

- Time to an improvement of one category from admission on the WHO 7-point ordinal scale.

- Percentage of patients that worsen at least one category on the WHO 7-point ordinal scale.

- Percentage of patients that improve at least one category (maintained 48h) on the WHO 7-point ordinal scale.

- Sequential Organ Failure Assessment (SOFA) scale at baseline and days 2, 4, 7, 14 and 28 after treatment.

- Duration of hospitalization (days).

- Duration of ICU stay (days).

- Oxygen therapy-free days in the first 28 days after treatment.

- Duration of supplemental oxygen.

- Incidence of and duration of non-invasive and invasive mechanical ventilation in the first 28 days after treatment.

- Mechanical ventilation-free days in the first 28 days after treatment.

- Ventilation parameters.

- Incidence of new onset pulmonary fibrosis at 3 and 12 months after treatment, based on CT scan and pulmonary function tests.

- Survival at 3 and 12 months.

- Cumulative incidence of Serious Adverse events (SAEs) and Grade 3 and 4 Adverse Events (AEs).

- Cumulative incidence of Adverse Drug Reactions (ADR) in the experimental treatment arm.

- Cumulative incidence of AEs of special interest.

- Levels of analytical markers (C-Reactive Protein, lymphocyte and neutrophil counts, lymphocyte subpopulations, LDH, ferritin, D-dimer, coagulation tests and cytokines...) at baseline and days 2, 4, 7, 14 and 28 after treatment.

- Other soluble and cellular biomarkers that might be involved in the course of the disease and the response to MSC.

Randomisation

The assignment to treatment will be carried out randomly and blinded, with a 1:1 allocation. Randomization will be done through a centralized system embedded in the electronic Case Report Form (CRF).

Blinding (masking)

To ensure blinding, treatments will be prepared for administration at the Cell Production Unit and the administration of the treatment will be masked, not allowing the identification of the Investigational Medicinal Product (IMP).

Numbers to be randomised (sample size)

A total of 20 participants are planned to be randomized, 10 to each treatment group.

Trial Status

Protocol version: 1.2, dated October 14th, 2020

Start of recruitment: 01/10/2020

End of recruitment (estimated): December 2020.

Trial registration

EudraCT Number: 2020-002193-27, registered on July 14^th, 2020.

NCT number: NCT04615429, registered on November 4^th, 2020.

Full protocol

The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-020-04964-1.