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Ortigoza MB, Yoon H, Goldfeld KS, Troxel AB, Daily JP, Wu Y, Li Y, Wu D, Cobb GF, Baptiste G, O'Keeffe M, Corpuz MO, Ostrosky-Zeichner L, Amin A, Zacharioudakis IM, Jayaweera DT, Wu Y, Philley JV, Devine MS, Desruisseaux MS, Santin AD, Anjan S, Mathew R, Patel B, Nigo M, Upadhyay R, Kupferman T, Dentino AN, Nanchal R, Merlo CA, Hager DN, Chandran K, Lai JR, Rivera J, Bikash CR, Lasso G, Hilbert TP, Paroder M, Asencio AA, Liu M, Petkova E, Bragat A, Shaker R, McPherson DD, Sacco RL, Keller MJ, Grudzen CR, Hochman JS, Pirofski LA, Parameswaran L, Corcoran AT, Rohatgi A, Wronska MW, Wu X, Srinivasan R, Deng FM, Filardo TD, Pendse J, Blaser SB, Whyte O, Gallagher JM, Thomas OE, Ramos D, Sturm-Reganato CL, Fong CC, Daus IM, Payoen AG, Chiofolo JT, Friedman MT, Wu DW, Jacobson JL, Schneider JG, Sarwar UN, Wang HE, Huebinger RM, Dronavalli G, Bai Y, Grimes CZ, Eldin KW, Umana VE, Martin JG, Heath TR, Bello FO, Ransford DL, Laurent-Rolle M, Shenoi SV, Akide-Ndunge OB, Thapa B, Peterson JL, Knauf K, Patel SU, Cheney LL, Tormey CA, Hendrickson JE. Efficacy and Safety of COVID-19 Convalescent Plasma in Hospitalized Patients: A Randomized Clinical Trial. JAMA Intern Med 2022; 182:115-126. [PMID: 34901997 PMCID: PMC8669605 DOI: 10.1001/jamainternmed.2021.6850] [Citation(s) in RCA: 52] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
IMPORTANCE There is clinical equipoise for COVID-19 convalescent plasma (CCP) use in patients hospitalized with COVID-19. OBJECTIVE To determine the safety and efficacy of CCP compared with placebo in hospitalized patients with COVID-19 receiving noninvasive supplemental oxygen. DESIGN, SETTING, AND PARTICIPANTS CONTAIN COVID-19, a randomized, double-blind, placebo-controlled trial of CCP in hospitalized adults with COVID-19, was conducted at 21 US hospitals from April 17, 2020, to March 15, 2021. The trial enrolled 941 participants who were hospitalized for 3 or less days or presented 7 or less days after symptom onset and required noninvasive oxygen supplementation. INTERVENTIONS A unit of approximately 250 mL of CCP or equivalent volume of placebo (normal saline). MAIN OUTCOMES AND MEASURES The primary outcome was participant scores on the 11-point World Health Organization (WHO) Ordinal Scale for Clinical Improvement on day 14 after randomization; the secondary outcome was WHO scores determined on day 28. Subgroups were analyzed with respect to age, baseline WHO score, concomitant medications, symptom duration, CCP SARS-CoV-2 titer, baseline SARS-CoV-2 serostatus, and enrollment quarter. Outcomes were analyzed using a bayesian proportional cumulative odds model. Efficacy of CCP was defined as a cumulative adjusted odds ratio (cOR) less than 1 and a clinically meaningful effect as cOR less than 0.8. RESULTS Of 941 participants randomized (473 to placebo and 468 to CCP), 556 were men (59.1%); median age was 63 years (IQR, 52-73); 373 (39.6%) were Hispanic and 132 (14.0%) were non-Hispanic Black. The cOR for the primary outcome adjusted for site, baseline risk, WHO score, age, sex, and symptom duration was 0.94 (95% credible interval [CrI], 0.75-1.18) with posterior probability (P[cOR<1] = 72%); the cOR for the secondary adjusted outcome was 0.92 (95% CrI, 0.74-1.16; P[cOR<1] = 76%). Exploratory subgroup analyses suggested heterogeneity of treatment effect: at day 28, cORs were 0.72 (95% CrI, 0.46-1.13; P[cOR<1] = 93%) for participants enrolled in April-June 2020 and 0.65 (95% CrI, 0.41 to 1.02; P[cOR<1] = 97%) for those not receiving remdesivir and not receiving corticosteroids at randomization. Median CCP SARS-CoV-2 neutralizing titer used in April to June 2020 was 1:175 (IQR, 76-379). Any adverse events (excluding transfusion reactions) were reported for 39 (8.2%) placebo recipients and 44 (9.4%) CCP recipients (P = .57). Transfusion reactions occurred in 2 (0.4) placebo recipients and 8 (1.7) CCP recipients (P = .06). CONCLUSIONS AND RELEVANCE In this trial, CCP did not meet the prespecified primary and secondary outcomes for CCP efficacy. However, high-titer CCP may have benefited participants early in the pandemic when remdesivir and corticosteroids were not in use. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04364737.
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Affiliation(s)
- Mila B Ortigoza
- Division of Infectious Disease, Department of Medicine, NYU Grossman School of Medicine, New York, New York.,Department of Microbiology, NYU Grossman School of Medicine, New York, New York
| | - Hyunah Yoon
- Division of Infectious Disease, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York
| | - Keith S Goldfeld
- Department of Population Health, NYU Grossman School of Medicine, New York, New York
| | - Andrea B Troxel
- Department of Population Health, NYU Grossman School of Medicine, New York, New York
| | - Johanna P Daily
- Division of Infectious Disease, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York.,Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, New York
| | - Yinxiang Wu
- Department of Population Health, NYU Grossman School of Medicine, New York, New York
| | - Yi Li
- Department of Population Health, NYU Grossman School of Medicine, New York, New York
| | - Danni Wu
- Department of Population Health, NYU Grossman School of Medicine, New York, New York
| | - Gia F Cobb
- Department of Medicine, NYU Grossman School of Medicine, New York, New York
| | - Gillian Baptiste
- Department of Surgery, NYU Grossman School of Medicine, New York, New York
| | - Mary O'Keeffe
- Department of Medicine, NYU Long Island School of Medicine, Mineola, New York
| | - Marilou O Corpuz
- Division of Infectious Disease, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York
| | - Luis Ostrosky-Zeichner
- Division of Infectious Disease, Department of Internal Medicine, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston
| | - Amee Amin
- Department of Emergency Medicine, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston
| | - Ioannis M Zacharioudakis
- Division of Infectious Disease, Department of Medicine, NYU Grossman School of Medicine, New York, New York
| | - Dushyantha T Jayaweera
- Division of Infectious Disease, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida.,Miami Clinical and Translational Science Institute, University of Miami Miller School of Medicine Miami, Florida
| | - Yanyun Wu
- Department of Pathology, University of Miami Miller School of Medicine, Miami, Florida
| | - Julie V Philley
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, The University of Texas Health Science Center at Tyler, UTHealth East Texas, Tyler
| | - Megan S Devine
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, The University of Texas Health Science Center at Tyler, UTHealth East Texas, Tyler
| | - Mahalia S Desruisseaux
- Section of Infectious Diseases, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Alessandro D Santin
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut
| | - Shweta Anjan
- Division of Infectious Disease, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Reeba Mathew
- Division of Critical Care, Department of Internal Medicine, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston
| | - Bela Patel
- Division of Critical Care, Department of Internal Medicine, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston
| | - Masayuki Nigo
- Division of Infectious Disease, Department of Internal Medicine, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston
| | - Rabi Upadhyay
- Department of Medicine, NYU Grossman School of Medicine, New York, New York.,Laura and Isaac Perlmutter Cancer Center, NYU Grossman School of Medicine, New York, New York
| | - Tania Kupferman
- Division of Infectious Disease, Department of Medicine, NYU Grossman School of Medicine, New York, New York
| | - Andrew N Dentino
- Department of Internal Medicine, The University of Texas Rio Grande Valley, Edinburg
| | - Rahul Nanchal
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee
| | - Christian A Merlo
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - David N Hager
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Kartik Chandran
- Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, New York
| | - Jonathan R Lai
- Department of Biochemistry, Albert Einstein College of Medicine, Bronx, New York
| | - Johanna Rivera
- Division of Infectious Disease, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York.,Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, New York
| | - Chowdhury R Bikash
- Department of Biochemistry, Albert Einstein College of Medicine, Bronx, New York
| | - Gorka Lasso
- Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, New York
| | - Timothy P Hilbert
- Department of Pathology, NYU Grossman School of Medicine, New York, New York
| | - Monika Paroder
- Department of Pathology, Albert Einstein College of Medicine, Bronx, New York
| | - Andrea A Asencio
- Division of Infectious Disease, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York
| | - Mengling Liu
- Department of Population Health, NYU Grossman School of Medicine, New York, New York.,Department of Environmental Health, NYU Grossman School of Medicine, New York, New York
| | - Eva Petkova
- Department of Population Health, NYU Grossman School of Medicine, New York, New York.,Department of Child and Adolescent Psychiatry, NYU Grossman School of Medicine, New York.,Nathan S. Kline Institute for Psychiatric Research, Orangeburg, New York
| | - Alexander Bragat
- Clinical Research Information Technology and Informatics, NYU Grossman School of Medicine, New York, New York
| | - Reza Shaker
- Clinical and Translational Science Institute of Southern Wisconsin, Medical College of Wisconsin Milwaukee
| | - David D McPherson
- Center for Clinical and Translational Sciences, Division of Cardiovascular Medicine, Department of Internal Medicine, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston
| | - Ralph L Sacco
- Miami Clinical and Translational Science Institute, University of Miami Miller School of Medicine Miami, Florida
| | - Marla J Keller
- Division of Infectious Disease, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York.,Harold and Muriel Block Institute for Clinical and Translational Research, Albert Einstein College of Medicine and Montefiore Medical Center Bronx, New York
| | - Corita R Grudzen
- Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, New York.,NYC Health and Hospitals Corporation Clinical and Translational Science Institute, NYU Grossman School of Medicine, New York, New York
| | - Judith S Hochman
- NYC Health and Hospitals Corporation Clinical and Translational Science Institute, NYU Grossman School of Medicine, New York, New York.,Leon H. Charney Division of Cardiology, Department of Medicine, NYU Grossman School of Medicine, New York, New York
| | - Liise-Anne Pirofski
- Division of Infectious Disease, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York.,Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, New York
| | | | - Lalitha Parameswaran
- Division of Infectious Disease, Department of Medicine, NYU Grossman School of Medicine, New York, New York
| | - Anthony T Corcoran
- Department of Urology, NYU Long Island School of Medicine, Mineola, New York
| | - Abhinav Rohatgi
- Department of Medicine, NYU Long Island School of Medicine, Mineola, New York
| | - Marta W Wronska
- Department of Medicine, NYU Long Island School of Medicine, Mineola, New York
| | - Xinyuan Wu
- Department of Medicine, NYU Grossman School of Medicine, New York, New York
| | - Ranjini Srinivasan
- Department of Pediatrics, NYU Grossman School of Medicine, New York, New York
| | - Fang-Ming Deng
- Department of Pathology, NYU Grossman School of Medicine, New York, New York
| | - Thomas D Filardo
- Division of Infectious Disease, Department of Medicine, NYU Grossman School of Medicine, New York, New York
| | - Jay Pendse
- Department of Medicine, NYU Grossman School of Medicine, New York, New York
| | - Simone B Blaser
- Department of Medicine, NYU Grossman School of Medicine, New York, New York
| | - Olga Whyte
- Department of Medicine, NYU Grossman School of Medicine, New York, New York
| | | | - Ololade E Thomas
- Department of Medicine, NYU Grossman School of Medicine, New York, New York
| | - Danibel Ramos
- Department of Medicine, NYU Grossman School of Medicine, New York, New York
| | | | - Charlotte C Fong
- Department of Medicine, NYU Grossman School of Medicine, New York, New York
| | - Ivy M Daus
- Department of Medicine, NYU Grossman School of Medicine, New York, New York
| | | | - Joseph T Chiofolo
- Department of Pathology, NYU Long Island School of Medicine, Mineola, New York
| | - Mark T Friedman
- Department of Pathology, NYU Long Island School of Medicine, Mineola, New York
| | - Ding Wen Wu
- Department of Pathology, NYU Grossman School of Medicine, New York, New York
| | - Jessica L Jacobson
- Department of Pathology, NYU Grossman School of Medicine, New York, New York
| | - Jeffrey G Schneider
- Department of Medicine, NYU Long Island School of Medicine, Mineola, New York
| | - Uzma N Sarwar
- Division of Infectious Disease, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York.,Pfizer Vaccine Clinical Research and Development, Pfizer Inc, Pearl River, New York
| | - Henry E Wang
- Department of Emergency Medicine, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston.,Department of Emergency Medicine, The Ohio State University, Ohio
| | - Ryan M Huebinger
- Department of Emergency Medicine, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston
| | - Goutham Dronavalli
- Division of Critical Care, Department of Internal Medicine, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston
| | - Yu Bai
- Department of Pathology and Laboratory Medicine, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston
| | - Carolyn Z Grimes
- Division of Infectious Disease, Department of Internal Medicine, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston
| | - Karen W Eldin
- Department of Pathology and Laboratory Medicine, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston
| | - Virginia E Umana
- Division of Infectious Disease, Department of Internal Medicine, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston
| | - Jessica G Martin
- Department of Internal Medicine, The University of Texas Rio Grande Valley, Edinburg
| | - Timothy R Heath
- Department of Internal Medicine, The University of Texas Rio Grande Valley, Edinburg
| | - Fatimah O Bello
- Department of Internal Medicine, The University of Texas Rio Grande Valley, Edinburg
| | - Daru Lane Ransford
- Miami Clinical and Translational Science Institute, University of Miami Miller School of Medicine Miami, Florida
| | - Maudry Laurent-Rolle
- Section of Infectious Diseases, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Sheela V Shenoi
- Section of Infectious Diseases, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Oscar Bate Akide-Ndunge
- Section of Infectious Diseases, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Bipin Thapa
- Department of Medicine, Medical College of Wisconsin, Milwaukee
| | - Jennifer L Peterson
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee
| | - Kelly Knauf
- Clinical and Translational Science Institute of Southern Wisconsin, Medical College of Wisconsin Milwaukee
| | - Shivani U Patel
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Laura L Cheney
- Division of Infectious Disease, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York
| | - Christopher A Tormey
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Jeanne E Hendrickson
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, Connecticut.,Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut
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6
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Vorland CJ, Brown AW, Dawson JA, Dickinson SL, Golzarri-Arroyo L, Hannon BA, Heo M, Heymsfield SB, Jayawardene WP, Kahathuduwa CN, Keith SW, Oakes JM, Tekwe CD, Thabane L, Allison DB. Errors in the implementation, analysis, and reporting of randomization within obesity and nutrition research: a guide to their avoidance. Int J Obes (Lond) 2021; 45:2335-2346. [PMID: 34326476 PMCID: PMC8528702 DOI: 10.1038/s41366-021-00909-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 06/26/2021] [Accepted: 07/06/2021] [Indexed: 02/06/2023]
Abstract
Randomization is an important tool used to establish causal inferences in studies designed to further our understanding of questions related to obesity and nutrition. To take advantage of the inferences afforded by randomization, scientific standards must be upheld during the planning, execution, analysis, and reporting of such studies. We discuss ten errors in randomized experiments from real-world examples from the literature and outline best practices for their avoidance. These ten errors include: representing nonrandom allocation as random, failing to adequately conceal allocation, not accounting for changing allocation ratios, replacing subjects in nonrandom ways, failing to account for non-independence, drawing inferences by comparing statistical significance from within-group comparisons instead of between-groups, pooling data and breaking the randomized design, failing to account for missing data, failing to report sufficient information to understand study methods, and failing to frame the causal question as testing the randomized assignment per se. We hope that these examples will aid researchers, reviewers, journal editors, and other readers to endeavor to a high standard of scientific rigor in randomized experiments within obesity and nutrition research.
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Affiliation(s)
- Colby J Vorland
- Department of Applied Health Science, Indiana University School of Public Health-Bloomington, Bloomington, IN, USA.
| | - Andrew W Brown
- Department of Applied Health Science, Indiana University School of Public Health-Bloomington, Bloomington, IN, USA
| | - John A Dawson
- Department of Nutritional Sciences, Texas Tech University, Lubbock, TX, USA
| | - Stephanie L Dickinson
- Department of Epidemiology and Biostatistics, Indiana University School of Public Health-Bloomington, Bloomington, IN, USA
| | - Lilian Golzarri-Arroyo
- Department of Epidemiology and Biostatistics, Indiana University School of Public Health-Bloomington, Bloomington, IN, USA
| | - Bridget A Hannon
- Division of Nutritional Sciences, University of Illinois at Urbana-Champaign, Urbana, IL, USA
| | - Moonseong Heo
- Department of Public Health Sciences, Clemson University, Clemson, SC, USA
| | - Steven B Heymsfield
- Pennington Biomedical Research Center, Louisiana State University, Baton Rouge, LA, USA
| | - Wasantha P Jayawardene
- Department of Applied Health Science, Indiana University School of Public Health-Bloomington, Bloomington, IN, USA
| | - Chanaka N Kahathuduwa
- Department of Psychiatry, School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Scott W Keith
- Department of Pharmacology and Experimental Therapeutics, Division of Biostatistics, Thomas Jefferson University, Philadelphia, PA, USA
| | - J Michael Oakes
- Department of Epidemiology, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Carmen D Tekwe
- Department of Epidemiology and Biostatistics, Indiana University School of Public Health-Bloomington, Bloomington, IN, USA
| | - Lehana Thabane
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - David B Allison
- Department of Epidemiology and Biostatistics, Indiana University School of Public Health-Bloomington, Bloomington, IN, USA.
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