Aims Cardiovascular diseases (CVDs) increase mortality risk from coronavirus infection (COVID-19). There are also concerns that the pandemic has affected supply and demand of acute cardiovascular care. We estimated excess mortality in specific CVDs, both ‘direct’, through infection, and ‘indirect’, through changes in healthcare. Methods and results We used (i) national mortality data for England and Wales to investigate trends in non-COVID-19 and CVD excess deaths; (ii) routine data from hospitals in England (n = 2), Italy (n = 1), and China (n = 5) to assess indirect pandemic effects on referral, diagnosis, and treatment services for CVD; and (iii) population-based electronic health records from 3 862 012 individuals in England to investigate pre- and post-COVID-19 mortality for people with incident and prevalent CVD. We incorporated pre-COVID-19 risk (by age, sex, and comorbidities), estimated population COVID-19 prevalence, and estimated relative risk (RR) of mortality in those with CVD and COVID-19 compared with CVD and non-infected (RR: 1.2, 1.5, 2.0, and 3.0). Mortality data suggest indirect effects on CVD will be delayed rather than contemporaneous (peak RR 1.14). CVD service activity decreased by 60–100% compared with pre-pandemic levels in eight hospitals across China, Italy, and England. In China, activity remained below pre-COVID-19 levels for 2–3 months even after easing lockdown and is still reduced in Italy and England. For total CVD (incident and prevalent), at 10% COVID-19 prevalence, we estimated direct impact of 31 205 and 62 410 excess deaths in England (RR 1.5 and 2.0, respectively), and indirect effect of 49 932 to 99 865 deaths. Conclusion Supply and demand for CVD services have dramatically reduced across countries with potential for substantial, but avoidable, excess mortality during and after the pandemic.

Surgery Following bony realignment and posterior fixation, the ISP probe (Codman, Depuy Synthes, Leeds, UK) was tunnelled through skin into the wound cavity. Under the operating microscope, the dura was opened one level below the injury. The ISP probe was inserted through the durotomy and placed on the spinal cord surface (Fig. 1A) Data collection Neurological examinations were done pre-operatively (day of injury) and at 9-12 months. Whole spine CT and MRI were done on admission and another CT within 48hours of surgery to check probe and screw position. We collected the following: patient age, AIS grade pre-operatively and at 9-12 months, level of injury, ISP and SCPP.Statistics Data were analysed using exact asymptotic logistic regression (LogXact 11, Cytel, Cambridge MA, USA). Neurological outcome was AIS grade at follow-up vs. pre-operative, binarised as improved vs. non-improved. We first assessed each factor individually. A forward stepwise method was then used to construct multi-variate models. RESULTSThere were 45 patients with average age 41 years (range 19-70) and male:female ratio 4:1.53% patients had cervical (C2-C7), 22% upper thoracic (T1-T6), 7% lower thoracic (T7-T10) and 18% conus medullaris (T11-L2) injuries. Pre-operative AIS grade was A in 67%patients, B in 20 % and C in 13%. For details see Supplementary Multivariate analysis was used to determine whether AIS grade on admission, injury level, patient age, mean ISP and mean SCPP are independent predictors of improvement by at least one AIS grade. We produced two models. In one model, age, AIS grade on admission and ISP were independent predictors of AIS improvement (P<0.05). Increase in ISP by 10 mmHg reduced the chance of AIS grade improvement about five times. In the other model, age, AIS grade on admission and SCPP were independent predictors of AIS improvement (P<0.05). Increase in SCPP by 10mmHg increased the chance of AIS grade improvement about 2.7 times. Due to collinearity, ISP and SCPP were not predictors in the same model.For details see Supplementary Table 3. DISCUSSIONOur key finding is that injury site ISP and SCPP, monitored during the first few days after TSCI, predict neurological improvement at 9-12 months. Mean ISP <10 mmHg and mean SCPP >90 mmHg are associated with the best recovery. In multivariate analysis, elevated ISP or low SCPP is a significant risk factor independent of AIS grade on admission and patient age. Limitations of the study include the small number of patients and use of the AIS as the only outcome measure. Ultimately, a randomised, controlled trial is required to determine whether interventions that reduce ISP or increase SCPP improve neurological outcome after TSCI. ACKNOWLEDGMENTS

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