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.

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Introduction Intestinal strictures are a known complication of Crohn's disease (CD) and may be inflammatory (in part), fibrostenotic or post-operative (anastomotic). Treatment options include a combination of medical, endoscopic or surgical interventions. We performed a retrospective analysis of our radiological assessment and endoscopic management of CD related strictures. Methods A retrospective review of adult patients who underwent balloon dilatation of CD related strictures by a single endoscopist at our institution. All patients underwent MR enterography prior to endoscopic assessment. Where necessary strictures were dilated under fluoroscopic screening. Endoscopic success was defined as the ability to traverse the stricture endoscopically after dilatation. Clinical success was defined as improvement in patients symptoms at follow-up. Complications, need for escalation of medical therapy, further dilatation or surgical intervention were recorded. Results A total of 56 dilatations were performed in 30 patients (range 1e5). Mean age was 47.5 years. 16 were females. Mean duration of disease was 209 months (range 14e444). Mean follow-up was 29.5 months (range 1e135). 27/30 (90%) had at least one previous CD surgical resection (range 0e6, mean 1.96 per patient). The site of the strictures were ileo-colonic in 21/30 (70%), colonic 3/30 (10%), gastro-duodenal 3/30 (10%), ileo-rectal 2/30 (7%) and ileal pouch stricture in 1/30 (3%). Stricture lengths at MRE were 6 cm, a length deemed significant as this is the length of the colonoscopic balloons. At MRE 17 (57%) of strictures were deemed to have an inflammatory component and 13 (43%) fibrostenotic. There was correlation between MRE and endoscopic findings of the nature of the stricturing (inflammatory vs fibrostenotic) in 26/30 (87%) of cases. Fluoroscopic screening was used in 21/30 (70%) of cases. Dilatation endoscopically successful in 27/30 (90%) cases and clinically successful in 26/30 (87%) of cases. No dilatation was performed in one case due to technical difficulties and this patient ultimately required surgical resection. Fourteen patients (47%) required repeated dilatations for symptom recurrence (range 2e5 dilatations). 17 patients (57%) had an escalation of their medical therapy after dilatation. A total of 5/30 (17%) ultimately required elective surgery for symptom recurrence. Conclusion MRE enterographic assessment of CD related strictures correlates well with endoscopic findings. Fluoroscopic screening facilitates safe and effective dilatation of CD related strictures which, together with optimising medical therapy, can reduce the need for surgical intervention.