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.
Peripheral artery disease (PAD) is a strong predictor of cardiovascular morbidity and mortality yet it is under-recognised and undertreated. General practitioners (GPs) are best positioned to detect patients with PAD. This article investigates awareness of PAD by GPs; the prevalence of screening for PAD and tools used for screening and diagnosis, in particular the ankle-brachial index (ABI); and the barriers to PAD screening and measurement of the ABI in the general practice setting. A cross-sectional survey of primary care practitioners was conducted between September 2011 and March 2012. A mail-out survey was distributed to 1120 GPs practising in Queensland, Australia: 287 (26%) responded; 61% of GPs reported screening for PAD; 58% of GPs reported 'never' measuring the ABI; and 70% reported using arterial duplex ultrasound as their first-line diagnostic tool. Equipment availability, time constraints and lack of training and skills were identified as the most significant barriers to screening and ABI testing. In conclusion, there are deficits in the utilisation of guideline recommendations relating to PAD screening and diagnosis by Australian GPs. Our data suggest that earlier detection of PAD may be achieved through GP education combined with increased access to ABI equipment or the availability of a more time-efficient test.
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