Background In this study, we aimed to evaluate the effects of tocilizumab in adult patients admitted to hospital with COVID-19 with both hypoxia and systemic inflammation. Methods This randomised, controlled, open-label, platform trial (Randomised Evaluation of COVID-19 Therapy [RECOVERY]), is assessing several possible treatments in patients hospitalised with COVID-19 in the UK. Those trial participants with hypoxia (oxygen saturation <92% on air or requiring oxygen therapy) and evidence of systemic inflammation (C-reactive protein ≥75 mg/L) were eligible for random assignment in a 1:1 ratio to usual standard of care alone versus usual standard of care plus tocilizumab at a dose of 400 mg–800 mg (depending on weight) given intravenously. A second dose could be given 12–24 h later if the patient's condition had not improved. The primary outcome was 28-day mortality, assessed in the intention-to-treat population. The trial is registered with ISRCTN (50189673) and ClinicalTrials.gov ( NCT04381936 ). Findings Between April 23, 2020, and Jan 24, 2021, 4116 adults of 21 550 patients enrolled into the RECOVERY trial were included in the assessment of tocilizumab, including 3385 (82%) patients receiving systemic corticosteroids. Overall, 621 (31%) of the 2022 patients allocated tocilizumab and 729 (35%) of the 2094 patients allocated to usual care died within 28 days (rate ratio 0·85; 95% CI 0·76–0·94; p=0·0028). Consistent results were seen in all prespecified subgroups of patients, including those receiving systemic corticosteroids. Patients allocated to tocilizumab were more likely to be discharged from hospital within 28 days (57% vs 50%; rate ratio 1·22; 1·12–1·33; p<0·0001). Among those not receiving invasive mechanical ventilation at baseline, patients allocated tocilizumab were less likely to reach the composite endpoint of invasive mechanical ventilation or death (35% vs 42%; risk ratio 0·84; 95% CI 0·77–0·92; p<0·0001). Interpretation In hospitalised COVID-19 patients with hypoxia and systemic inflammation, tocilizumab improved survival and other clinical outcomes. These benefits were seen regardless of the amount of respiratory support and were additional to the benefits of systemic corticosteroids. Funding UK Research and Innovation (Medical Research Council) and National Institute of Health Research.

No abstract

No abstract

No abstract

A 13-year-old boy was referred to cardiology for evaluation of intermittent exertional breathlessness. Previous respiratory investigations had revealed normal lung function and no evidence of asthma on exercise spirometry. There was no past medical history of note. Cardiorespiratory examination was unremarkable except for a soft ejection systolic murmur at the lower left sternal border. ECG showed sinus rhythm and normal P-wave morphology and QRS axis, with a T-wave inversion in leads III and aVF. Chest radiograph demonstrated normal cardiothoracic ratio, but the heart was noted to be globular in shape (Figure 1).Transthoracic echocardiography revealed the presence of a large, thin-walled aneurysmal structure in continuity with the free wall of the right atrium, discrete from the caval veins ( Figure 2). There was mild tricuspid regurgitation, with a Doppler velocity of 2.1 m/s. Both ventricles were of normal size and function. To further characterize this cardiac abnormality, the patient was referred for cardiac magnetic resonance (CMR) imaging. Cine imaging using a balanced steady-state free precession sequence showed a noncontractile, smooth-walled, right atrial appendage aneurysm (RAAA) extending anterior to the body of the right atrium ( Figure 3A and 3B and Movie I of the online-only Data Supplement). The aneurysm had a broad-based pyramidal shape and was partially separated from the main atrial chamber by a membrane (total indexed right atrial volume 118 mL/m 2 at end-ventricular systole). There was mild distortion of the right ventricular (RV) inlet, but no significant compression. No intracavity thrombus was identified. The pulmonary arteries were unobstructed and of normal caliber. There was a small pericardial effusion.The patient subsequently underwent exercise tolerance testing, managing 12 minutes and 15 seconds on the standard Bruce protocol and achieving a workload of 13.8 metabolic equivalents. The test was stopped because of dyspnea, with no ST-segment changes detected. A 1-week cardiac rhythm monitor revealed no evidence of arrhythmia. On review in the outpatient clinic, the patient had symptomatically improved. He was therefore commenced on aspirin for thromboembolic prophylaxis and managed conservatively with annual imaging surveillance. During the next 2 years the patient was asymptomatic, with no significant change in the size of the RAAA on transthoracic echocardiography. However, repeat CMR imaging performed 3 years after the initial scan revealed a marked increase in the size of the aneurysm that was disproportionate to somatic growth (total indexed right atrial volume increased to 151 mL/m 2 ) ( Figure 3C and 3D). In addition, there was evidence of clear compression of the RV inlet by the RAAA (Movie II of the online-only Data Supplement), with flattening of the tricuspid annulus during ventricular diastole. Although the patient remained well, in view of the increase in relative size of the RAAA and associated RV inlet diastolic displacement, the patient was referred for surgical res...