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.

Auditory streaming refers to the perceptual parsing of acoustic sequences into "streams", which makes it possible for a listener to follow the sounds from a given source amidst other sounds. Streaming is currently regarded as an important function of the auditory system in both humans and animals, crucial for survival in environments that typically contain multiple sound sources. This article reviews recent findings concerning the possible neural mechanisms behind this perceptual phenomenon at the level of the auditory cortex. The first part is devoted to intra-cortical recordings, which provide insight into the neural "micromechanisms" of auditory streaming in the primary auditory cortex (A1). In the second part, recent results obtained using functional magnetic resonance imaging (fMRI) and magnetoencephalography (MEG) in humans, which suggest a contribution from cortical areas other than A1, are presented. Overall, the findings concur to demonstrate that many important features of sequential streaming can be explained relatively simply based on neural responses in the auditory cortex.

Wilson EC, Melcher JR, Micheyl C, Gutschalk A, Oxenham AJ. Cortical fMRI activation to sequences of tones alternating in frequency: relationship to perceived rate and streaming. J Neurophysiol 97: 2230-2238, 2007. First published January 10, 2007 doi:10.1152/jn.00788.2006. Human listeners were functionally imaged while reporting their perception of sequences of alternating-frequency tone bursts separated by 0, 1/8, 1, or 20 semitones. Our goal was to determine whether functional magnetic resonance imaging (fMRI) activation of auditory cortex changes with frequency separation in a manner predictable from the perceived rate of the stimulus. At the null and small separations, the tones were generally heard as a single stream with a perceived rate equal to the physical tone presentation rate. fMRI activation in auditory cortex was appreciably phasic, showing prominent peaks at the sequence onset and offset. At larger-frequency separations, the higher-and lower-frequency tones perceptually separated into two streams, each with a rate equal to half the overall tone presentation rate. Under those conditions, fMRI activation in auditory cortex was more sustained throughout the sequence duration and was larger in magnitude and extent. Phasic to sustained changes in fMRI activation with changes in frequency separation and perceived rate are comparable to, and consistent with, those produced by changes in the physical rate of a sequence and are far greater than the effects produced by changing other physical stimulus variables, such as sound level or bandwidth. We suggest that the neural activity underlying the changes in fMRI activation with frequency separation contribute to the coding of the co-occurring changes in perceived rate and perceptual organization of the sound sequences into auditory streams.

The brain continuously disentangles competing sounds, such as two people speaking, and assigns them to distinct streams. Neural mechanisms have been proposed for streaming based on gross spectral differences between sounds, but not for streaming based on other nonspectral features. Here, human listeners were presented with sequences of harmonic complex tones that had identical spectral envelopes, and unresolved spectral fine structure, but one of two fundamental frequencies ( f 0 ) and pitches. As the f 0 difference between tones increased, listeners perceived the tones as being segregated into two streams (one stream for each f 0 ) and cortical activity measured with functional magnetic resonance imaging and magnetoencephalography increased. This trend was seen in primary cortex of Heschl's gyrus and in surrounding nonprimary areas. The results strongly resemble those for pure tones. Both the present and pure tone results may reflect neuronal forward suppression that diminishes as one or more features of successive sounds become increasingly different. We hypothesize that feature-specific forward suppression subserves streaming based on diverse perceptual cues and results in explicit neural representations for auditory streams within auditory cortex.

Perceptual integration of vibrotactile and auditory sinusoidal tone pulses was studied in detection experiments as a function of stimulation frequency. Vibrotactile stimuli were delivered through a single channel vibrator to the left middle fingertip. Auditory stimuli were presented diotically through headphones in a background of 50 dB sound pressure level broadband noise. Detection performance for combined auditory-tactile presentations was measured using stimulus levels that yielded 63% to 77% correct unimodal performance. In Experiment 1, the vibrotactile stimulus was 250 Hz and the auditory stimulus varied between 125 and 2000 Hz. In Experiment 2, the auditory stimulus was 250 Hz and the tactile stimulus varied between 50 and 400 Hz. In Experiment 3, the auditory and tactile stimuli were always equal in frequency and ranged from 50 to 400 Hz. The highest rates of detection for the combined-modality stimulus were obtained when stimulating frequencies in the two modalities were equal or closely spaced (and within the Pacinian range). Combined-modality detection for closely spaced frequencies was generally consistent with an algebraic sum model of perceptual integration; wider-frequency spacings were generally better fit by a Pythagorean sum model. Thus, perceptual integration of auditory and tactile stimuli at near-threshold levels appears to depend both on absolute frequency and relative frequency of stimulation within each modality.