Simplifying informed consent as a universal precaution.

One barrier to participating in clinical research is that patients with low literacy skills (1 in 5 US adults) may struggle to understand the informed consent document (ICD). Writing consents using health literacy and plain language guidelines including simplified syntax and semantics can increase understandability and facilitate inclusivity of research populations with literacy challenges. Our study aim was to evaluate a simplified ICD for understandability while considering factors known to relate to comprehension (reading skills and working memory). We performed an on-line survey of 192 adults ages 18-77 in Georgia. Participants performed significantly better on the simplified ICD test. We built an additional model with all version x measure interactions (i.e., age, sex, race, urbanicity, GMVT, WM). This model did not significantly improve model fit, F < 1.00, suggesting that individual differences did not moderate the effect of simplification. Our findings suggest that using plain language and simplified syntax and semantics in ICD as a universal precaution may reduce cognitive reading burden for adults regardless of differences in reading skill or working memory. Increasing understandability in ICD may help improve targets for clinical trial enrollment.

Proximal Junctional Degeneration and Failure Modes: A Novel Classification and Clinical Implications.

STUDY DESIGN: Case-control study. OBJECTIVE: To introduce a classification system that will include the major types of degenerative changes and failures related to the proximal junction, and to determine the clinical course and characteristics for the different types of proximal junctional degeneration (PJD). SUMMARY OF BACKGROUND DATA: Proximal junctional kyphosis (PJK) and failures are well recognized after adult spinal fusion, however, a standardized classification is lacking. METHODS: The proposed system identified four different patterns of PJD: Type 1 (multi-level symmetrical collapse), Type 2 (Single adjacent level collapse), Type 3 (fracture) and Type 4 (spondylolisthesis). A single center database was reviewed from 2018 to 2021. Patients ≥18 years of age, who underwent posterior spinal fusion of ≥3 levels with an upper instrumented vertebral level between T8-L2, and a follow-up of ≥2 years were included. Radiographic measurements, revision surgery and time to revision were the primary outcomes. RESULTS: 150 patients were included with a mean age of 65.1 (±9.8) years and a mean follow-up of 3.2 (±1) years. 69 patients (46%) developed significant degenerative changes in the proximal junction, and were classified accordingly. 20 (13%) were Type 1, 17 (11%) were Type 2, 22 (15%) were Type 3 and 10 (7%) were Type 4. Type 3 had a significantly shorter time to revision with a mean of 0.9 (±0.9) years. Types 3 and 4 had greater preoperative sagittal vertical axis, and Types 1 and 3 had greater final follow-up lumbar lordosis. Bone density measured by Hounsfield units showed lower measurements for Type 3. Types 1 and 4 had lower rates of developing PJK. Type 1 had the lowest revision rate with 40% (types 2, 3 and 4 were 77%, 73% and 80%, respectively, P=0.045). CONCLUSION: This novel classification system defines different modes of degeneration and failures at the proximal junction, and future studies with larger sample sizes are needed for validation. LEVEL OF EVIDENCE: 3.

Enhanced Photostability and Photoactivity of Ruthenium Polypyridyl-Based Photocatalysts by Covalently Anchoring Onto Reduced Graphene Oxide.

Recentstudies toward finding more efficient ruthenium metalloligands for photocatalysis applications have shown that the derivatives of the linear [Ru(dqp)2]2+ (dqp: 2,6-di(quinolin-8-yl)-pyridine) complexes hold significant promise due to their extended emission lifetime in the µs time scale while retaining comparable redox potential, extinction coefficients, and absorption profile in the visible region to [Ru(bpy)3]2+ (bpy: 2,2'-bipyridine) and [Ru(tpy)2]2+ (tpy: 2,2':6',2″-terpyridine) complexes. Nevertheless, its photostability in aqueous solution needs to be improved for its widespread use in photocatalysis. Carbon-based supports have arisen as potential solutions for improving photostability and photocatalytic activity, yet their effect greatly depends on the interaction of the metal complex with the support. Herein, we present a strategy for obtaining Ru-polypyridyl complexes covalently linked to aminated reduced graphene oxide (rGO) to generate novel materials with long-term photostability and increased photoactivity. Specifically, the hybrid Ru(dqp)@rGO system has shown excellent photostable behavior during 24 h of continual irradiation, with an enhancement of 10 and 15% of photocatalytic dye degradation in comparison with [Ru(dqp)2]2+ and Ru(tpy)@rGO, respectively, as well as remarkable recyclability. The presented strategy corroborates the potential of [Ru(dqp)2]2+ as an interesting photoactive molecule to produce more advantageous light-active materials by covalent attachment onto carbon-based supports.

SHARP risk score: A predictor of poor outcomes in adults admitted for emergency general surgery: A prospective cohort study.

PURPOSE: Post-operative complications following emergency abdominal surgery are associated with significant morbidity and mortality. Despite the knowledge of prognostic factors associated with poor surgical outcomes; few have described risks of poor outcomes based on admission information in acute surgical setting. We aimed to derive a simple, point-of-care risk scale that predicts adults with increased risk of poor outcomes. METHODS: We used data from an international multi-centre prospective cohort study. The effect of characteristics; age, hypoalbuminaemia, anaemia, renal insufficiency and polypharmacy on 90-day mortality was examined using fully adjusted multivariable models. For our secondary outcome we aimed to test whether these characteristics could be combined to predict poor outcomes in adults undergoing emergency general surgery. Subsequently, the impact of incremental increase in derived SHARP score on outcomes was assessed. RESULTS: The cohort consisted of 419 adult patients between the ages of 16-94 years (median 52; IQR(39) consecutively admitted to five emergency general surgical units across the United Kingdom and one in Ghent, Belgium. In fully adjusted models the aforementioned characteristics; were associated with 90-day mortality. SHARP score was associated with higher odds of mortality in adults who underwent emergency general surgery, with a SHARP score of five also being associated with an increased length of hospital stay. CONCLUSIONS: SHARP risk score is a simple prognostic tool, using point-of-care information to predict poor outcomes in patients undergoing emergency general surgery. This information may be used to improve management plans and aid clinicians in delivering more person-centred care. Further validation studies are required to prove its utility.

The Prognostic and Discriminatory Utility of the Clinical Frailty Scale and Modified Frailty Index Compared to Age.

Background: There is no consensus on the optimal method for the assessment of frailty. We compared the prognostic utility of two approaches (modified Frailty Index [mFI], Clinical Frailty Scale [CFS]) in older adults (≥65 years) hospitalised with COVID-19 versus age. Methods: We used a test and validation cohort that enrolled participants hospitalised with COVID-19 between 27 February and 30 June 2020. Multivariable mixed-effects logistic modelling was undertaken, with 28-day mortality as the primary outcome. Nested models were compared between a base model, age and frailty assessments using likelihood ratio testing (LRT) and an area under the receiver operating curves (AUROC). Results: The primary cohort enrolled 998 participants from 13 centres. The median age was 80 (range:65−101), 453 (45%) were female, and 377 (37.8%) died within 28 days. The sample was replicated in a validation cohort of two additional centres (n = 672) with similar characteristics. In the primary cohort, both mFI and CFS were associated with mortality in the base models. There was improved precision when fitting CFS to the base model +mFI (LRT = 25.87, p < 0.001); however, there was no improvement when fitting mFI to the base model +CFS (LRT = 1.99, p = 0.16). AUROC suggested increased discrimination when fitting CFS compared to age (p = 0.02) and age +mFI (p = 0.03). In contrast, the mFI offered no improved discrimination in any comparison (p > 0.05). Similar findings were seen in the validation cohort. Conclusions: These observations suggest the CFS has superior prognostic value to mFI in predicting mortality following COVID-19. Our data do not support the use of the mFI as a tool to aid clinical decision-making and prognosis.

Leveraging a multidimensional linguistic analysis of constructed responses produced by college readers.

The goal of this study was to assess the relationships between computational approaches to analyzing constructed responses made during reading and individual differences in the foundational skills of reading in college readers. We also explored if these relationships were consistent across texts and samples collected at different institutions and texts. The study made use of archival data that involved college participants who produced typed constructed responses under thinking aloud instructions reading history and science texts. They also took assessments of vocabulary knowledge and proficiency in comprehension. The protocols were analyzed to assess two different ways to determine their cohesion. One approach involved assessing how readers established connections with themselves (i.e., to other constructed responses they produced). The other approach involved assessing connections between the constructed responses and the texts that were read. Additionally, the comparisons were made by assessing both lexical (i.e., word matching) and semantic (i.e., high dimensional semantic spaces) comparisons. The result showed that both approaches for analyzing cohesion and making the comparisons were correlated with vocabulary knowledge and comprehension proficiency. The implications of the results for theory and practice are discussed.

Comparison between first and second wave of COVID-19 outbreak in older people: the COPE multicentre European observational cohort study.

BACKGROUND: Effective shielding measures and virus mutations have progressively modified the disease between the waves, likewise healthcare systems have adapted to the outbreak. Our aim was to compare clinical outcomes for older people with COVID-19 in Wave 1 (W1) and Wave 2 (W2). METHODS: All data, including the Clinical Frailty Scale (CFS), were collected for COVID-19 consecutive patients, aged ≥65, from 13 hospitals, in W1 (February-June 2020) and W2 (October 2020-March 2021). The primary outcome was mortality (time to mortality and 28-day mortality). Data were analysed with multilevel Cox proportional hazards, linear and logistic regression models, adjusted for wave baseline demographic and clinical characteristics. RESULTS: Data from 611 people admitted in W2 were added to and compared with data collected during W1 (N = 1340). Patients admitted in W2 were of similar age, median (interquartile range), W2 = 79 (73-84); W1 = 80 (74-86); had a greater proportion of men (59.4% vs. 53.0%); had lower 28-day mortality (29.1% vs. 40.0%), compared to W1. For combined W1-W2 sample, W2 was independently associated with improved survival: time-to-mortality adjusted hazard ratio (aHR) = 0.78 [95% confidence interval (CI) 0.65-0.93], 28-day mortality adjusted odds ratio = 0.80 (95% CI 0.62-1.03). W2 was associated with increased length of hospital stay aHR = 0.69 (95% CI 0.59-0.81). Patients in W2 were less frail, CFS [adjusted mean difference (aMD) = -0.50, 95% CI -0.81, -0.18], as well as presented with lower C-reactive protein (aMD = -22.52, 95% CI -32.00, -13.04). CONCLUSIONS: COVID-19 older adults in W2 were less likely to die than during W1. Patients presented to hospital during W2 were less frail and with lower disease severity and less likely to have renal decline.

Frailty is associated with poor mental health 1 year after hospitalisation with COVID-19.

BACKGROUND: Frailty is associated with long-term physical deterioration after COVID-19. Mental health recovery has been less well investigated. Early studies have shown minimal effect from the virus, although studies have not focused on whether people living with frailty may have different psychiatric outcomes. We aimed to examine the effect of living with frailty on mental health outcomes one year after hospital with COVID-19. METHODS: We undertook a multicentre cross-sectional study of people admitted with COVID-19. We assessed quality of life (ICECAP-O and MRC), psychiatric symptoms including: generalised anxiety (GAD-7), depression (Patient Health Questionnaire-9), and trauma (Trauma Screening Questionnaire). Frailty was measured using the Clinical Frailty Scale (CFS). We used a multivariable mixed-effects logistic and linear regression to examine the adjusted odds ratio (aOR) and adjusted mean difference (aMD). RESULTS: From eight hospitals 224 participants consented. Median follow-up time from admission 358 days (IQR 153-418), mean age 63.8 (SD = 13.7), 34.8% female (n = 78), and 43.7% living with frailty (n = 98 CFS 4-8). People living with frailty were significantly more likely to have symptoms of anxiety aOR = 5.72 (95% CI 1.71-19.13), depression aOR = 2.52 (95% CI 1.59-14.91), post-traumatic stress disorder aMD = 1.16 (95% CI 0.47, 1.85), and worse quality of life aMD = 1.06 (95% CI 0.76-1.36). LIMITATIONS: Patient-rated symptoms were captured rather than formal mental health diagnoses. CFS has not been validated in under 65-year-olds. CONCLUSIONS: Living with frailty is associated with significant psychiatric morbidity and reduced wellbeing one year after COVID-19 hospital admission. We recommend clinical follow-up after COVID-19 for people living with frailty should include a psychiatric assessment.

A new stoma for an older person-An association with quality of life and physical function: A systematic review.

BACKGROUND: Older people are more likely to have a stoma postabdominal surgery than younger people. Few studies have examined the effect of a stoma on older people. The aim of this review was to explore the effect of a stoma on functional independence of an older person. We explored secondary outcomes of poststoma formation length of hospital stay, quality of life and factors affecting stroma independence. METHODS: An exploratory systematic review was developed by our multidisciplinary group including an expert patient, colorectal surgeon, stoma nurse, physiotherapist, geriatrician, and methodologist. Four databases were searched including studies with participants 60 years old or older, who had undergone abdominal surgery for any pathology resulting in an abdominal stoma. RESULTS: We identified 857 studies, of which we included 25 in the final review incorporating 6972 participants (average age 67.4 years). There was a strong association between presence of stoma and (1) worse physical function (standardized MD = 0.7; 95% CI 0.21-1.19; I2  = 95) and (2) worse quality of life (standardized MD = 1.61; 95% CI 0.5-2.72, I2  = 98). The same effect was seen in fecal ostomy and urinary diversion. Few studies measured stoma independence and only one examined factors affecting this. No studies examined length of stay. CONCLUSIONS: Stoma have a negative association with the physical function and quality of life of older people. Future studies should focus on identifying modifiable factors that may affect physical function, quality of life, and stoma independence.

Progress in Development of Photocatalytic Processes for Synthesis of Fuels and Organic Compounds under Outdoor Solar Light.

With photovoltaics becoming a mature, commercially feasible technology, society is willing to allocate resources for developing and deploying new technologies based on using solar light. Analysis of projects supported by the European Commission in the past decade indicates exponential growth of funding to photocatalytic (PC) and photoelectrocatalytic (PEC) technologies that aim either at technology readiness levels (TRLs) TRL 1-3 or TRL > 3, with more than 75 Mio€ allocated from the year 2019 onward. This review provides a summary of PC and PEC processes for the synthesis of bulk commodities such as solvents and fuels, as well as chemicals for niche applications. An overview of photoreactors for photocatalysis on a larger scale is provided. The review rounds off with the summary of reactions performed at lab scale under natural outdoor solar light to illustrate conceptual opportunities offered by solar-driven chemistry beyond the reduction of CO2 and water splitting. The authors offer their vision of the impact of this area of research on society and the economy.

Prognostic value of estimated glomerular filtration rate in hospitalised older patients (over 65) with COVID-19: a multicentre, European, observational cohort study.

BACKGROUND: The reduced renal function has prognostic significance in COVID-19 and it has been linked to mortality in the general population. Reduced renal function is prevalent in older age and thus we set out to better understand its effect on mortality. METHODS: Patient clinical and demographic data was taken from the COVID-19 in Older People (COPE) study during two periods (February-June 2020 and October 2020-March 2021, respectively). Kidney function on admission was measured using estimated glomerular filtration rate (eGFR). The primary outcomes were time to mortality and 28-day mortality. Secondary outcome was length of hospital stay. Data were analysed with multilevel Cox proportional hazards regression, and multilevel logistic regression and adjusted for individual patient clinical and demographic characteristics. RESULTS: One thousand eight hundred two patients (55.0% male; median [IQR] 80 [73-86] years) were included in the study. 28-day mortality was 42.3% (n = 742). 48% (n = 801) had evidence of renal impairment on admission. Using a time-to-event analysis, reduced renal function was associated with increased in-hospital mortality (compared to eGFR ≥ 60 [Stage 1&2]): eGFR 45-59 [Stage 3a] aHR = 1.26 (95%CI 1.02-1.55); eGFR 30-44 [Stage 3b] aHR = 1.41 (95%CI 1.14-1.73); eGFR 1-29 [Stage 4&5] aHR = 1.42 (95%CI 1.13-1.80). In the co-primary outcome of 28-day mortality, mortality was associated with: Stage 3a adjusted odds ratio (aOR) = 1.18 (95%CI 0.88-1.58), Stage 3b aOR = 1.40 (95%CI 1.03-1.89); and Stage 4&5 aOR = 1.65 (95%CI 1.16-2.35). CONCLUSION: eGFR on admission is a good independent predictor of mortality in hospitalised older patients with COVID-19 population. We found evidence of a dose-response between reduced renal function and increased mortality.

Implementing the SNIS recommendations for neurointerventional emergent care in the setting of COVID-19: impact on stroke metrics and patient outcomes.

BACKGROUND: It is not clear whether the COVID-19 pandemic and subsequent Society of Neurointerventional Surgery (SNIS) recommendations affected hospital stroke metrics. METHODS: This retrospective cohort study compared stroke patients admitted to a comprehensive stroke center during the COVID-19 pandemic April 1 2020 to June 30 2020 (COVID-19) to patients admitted April 1 2019 to June 30 2019. We examined stroke admission volume and acute stroke treatment use. RESULTS: There were 637 stroke admissions, 52% in 2019 and 48% during COVID-19, with similar median admissions per day (4 vs 3, P=0.21). The proportion of admissions by stroke type was comparable (ischemic, P=0.69; hemorrhagic, P=0.39; transient ischemic stroke, P=0.10). Acute stroke treatment was similar in 2019 to COVID-19: tPA prior to arrival (18% vs, 18%, P=0.89), tPA treatment on arrival (6% vs 7%, P=0.85), and endovascular therapy (endovascular therapy (ET), 22% vs 25%, P=0.54). The door to needle time was also similar, P=0.12, however, the median time from arrival to groin puncture was significantly longer during COVID-19 (38 vs 43 min, P=0.002). A significantly higher proportion of patients receiving ET were intubated during COVID-19 due to SNIS guideline implementation (45% vs 96%, P<0.0001). There were no differences by study period in discharge mRS, P=0.84 or TICI score, P=0.26. CONCLUSIONS: The COVID-19 pandemic did not significantly affect stroke admission volume or acute stroke treatment utilization. Outcomes were not affected by implementing SNIS guidelines. Although there was a statistical increase in time to groin puncture for ET, it was not clinically meaningful. These results suggest hospitals managing patients efficiently can implement practices in response to COVID-19 without impacting outcomes.

Multiple house occupancy is associated with mortality in hospitalized patients with COVID-19.

BACKGROUND: In response to the COVID-19 pandemic, many countries mandated staying at home to reduce transmission. This study examined the association between living arrangements (house occupancy numbers) and outcomes in COVID-19. METHODS: Study population was drawn from the COPE study, a multicentre cohort study. House occupancy was defined as: living alone; living with one other person; living with multiple other people; or living in a nursing/residential home. Outcomes were time from admission to mortality and discharge (Cox regression), and Day 28 mortality (logistic regression) analyses were adjusted for key comorbidities and covariates including admission: age, sex, smoking, heart failure, admission C-reactive protein (CRP), chronic obstructive pulmonary disease, estimated glomerular filtration rate, frailty and others. RESULTS: A total of 1584 patients were included from 13 hospitals across UK and Italy: 676 (42.7%) were female, 907 (57.3%) were male, median age was 74 years (range: 19-101). At 28 days, 502 (31.7%) had died. Median admission CRP was 67, 82, 79.5 and 83 mg/l for those living alone, with someone else, in a house of multiple occupancy and in a nursing/residential home, respectively. Compared to living alone, living with anyone was associated with increased mortality: within a couple [adjusted hazard ratios (aHR) = 1.39, 95% confidence intervals (CI) 1.09-1.77, P = 0.007]; living in a house of multiple occupancy (aHR = 1.67, 95% CI 1.17-2.38, P = 0.005); and living in a residential home (aHR = 1.36, 95% CI 1.03-1.80, P = 0.031). CONCLUSION: For patients hospitalized with COVID-19, those living with one or more people had an increased association with mortality, they also exhibited higher CRP indicating increased disease severity suggesting they delayed seeking care.

A redescription of the poorly known Central American toad Inciliustacanensis (Anura, Bufonidae), with a summary of its biology and conservation status.

Based on examination of most of the existing museum specimens of the rare bufonid frog Inciliustacanensis, we present a redescription and new diagnosis for this species. The species is limited to small region of the Pacific chain of volcanoes in southeastern Chiapas, Mexico, and adjacent areas of Guatemala. The species has not been observed in the wild since 1984 and may have been reduced or eliminated by regional epidemics of chytridiomycosis.

ResumenBasándonos en la revisión de la mayoría de los especímenes de museo existentes del raro sapo bufónido Inciliustacanensis, presentamos una redescripción y una nueva diagnosis para esta especie. La especie se limita a una pequeña región de la cadena de volcanes del Pacífico en el sureste de Chiapas, México, y áreas adyacentes de Guatemala. La especie no se ha observado en la naturaleza desde 1984 y puede haber sido reducida o eliminada por epidemias regionales de quitridiomicosis.

Association of Postoperative Clinical Outcomes With Sarcopenia, Frailty, and Nutritional Status in Older Patients With Colorectal Cancer: Protocol for a Prospective Cohort Study.

BACKGROUND: Older patients account for a significant proportion of patients undergoing colorectal cancer surgery and are vulnerable to a number of preoperative risk factors that are not often present in younger patients. Further, three preoperative risk factors that are more prevalent in older adults include frailty, sarcopenia, and malnutrition. Although each of these has been studied in isolation, there is little information on the interplay between them in older surgical patients. A particular area of increasing interest is the use of urine metabolomics for the objective evaluation of dietary profiles and malnutrition. OBJECTIVE: Herein, we describe the design, cohort, and standard operating procedures of a planned prospective study of older surgical patients undergoing colorectal cancer resection across multiple institutions in the United Kingdom. The objectives are to determine the association between clinical outcomes and frailty, nutritional status, and sarcopenia. METHODS: The procedures will include serial frailty evaluations (Clinical Frailty Scale and Groningen Frailty Indicator), functional assessments (hand grip strength and 4-meter walk test), muscle mass evaluations via computerized tomography morphometric analysis, and the evaluation of nutritional status via the analysis of urinary dietary biomarkers. The primary feasibility outcome is the estimation of the incidence rate of postoperative complications, and the primary clinical outcome is the association between the presence of postoperative complications and frailty, sarcopenia, and nutritional status. The secondary outcome measures are the length of hospital stay, 30-day hospital readmission rate, and mortality rate at days 30 and 90. RESULTS: Our study was approved by the National Health Service Research Ethics Committee (reference number: 19/WA/0190) via the Integrated Research Application System (project ID: 231694) prior to subject recruitment. Cardiff University is acting as the study sponsor. Our study is financially supported through an external, peer-reviewed grant from the British Geriatrics Society and internal funding resources from Cardiff University. The results will be disseminated through peer-review publications, social media, and conference proceedings. CONCLUSIONS: As frailty, sarcopenia, and malnutrition are all areas of common derangement in the older surgical population, prospectively studying these risk factors in concert will allow for the analysis of their interplay as well as the development of predictive models for those at risk of commonly tracked surgical complications and outcomes. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/16846.

Materials Matter: An Exploration of Text Complexity and Its Effects on Middle School Readers' Comprehension Processing.

Purpose Complex features of science texts present idiosyncratic challenges for middle grade readers, especially in a post-Common Core educational world where students' learning is dependent on understanding informational text. The primary aim of this study was to explore how middle school readers process science texts and whether such comprehension processes differed due to features of complexity in two science texts. Method Thirty 7th grade students read two science texts with different profiles of text complexity in a think-aloud task. Think-aloud protocols were coded for six comprehension processes: connecting inferences, elaborative inferences, evaluative comments, metacognitive comments, and associations. We analyzed the quantity and type of comprehension processes generated across both texts in order to explore how features of text complexity contributed to the comprehension processes students produced while reading. Results Students made significantly more elaborative and connecting inferences when reading a text with deep cohesion, simple syntax, and concrete words, while students made more evaluative comments, paraphrases, and metacognitive comments when reading a text with referential cohesion, complex syntax, and abstract words. Conclusions The current study provides exploratory evidence for features of text complexity affecting the type of comprehension processes middle school readers generate while reading science texts. Accordingly, science classroom texts and materials can be evaluated for word, sentence, and passage features of text complexity in order to encourage deep level comprehension of middle school readers.

The role of C-reactive protein as a prognostic marker in COVID-19.

BACKGROUND: C-reactive protein (CRP) is a non-specific acute phase reactant elevated in infection or inflammation. Higher levels indicate more severe infection and have been used as an indicator of COVID-19 disease severity. However, the evidence for CRP as a prognostic marker is yet to be determined. The aim of this study is to examine the CRP response in patients hospitalized with COVID-19 and to determine the utility of CRP on admission for predicting inpatient mortality. METHODS: Data were collected between 27 February and 10 June 2020, incorporating two cohorts: the COPE (COVID-19 in Older People) study of 1564 adult patients with a diagnosis of COVID-19 admitted to 11 hospital sites (test cohort) and a later validation cohort of 271 patients. Admission CRP was investigated, and finite mixture models were fit to assess the likely underlying distribution. Further, different prognostic thresholds of CRP were analysed in a time-to-mortality Cox regression to determine a cut-off. Bootstrapping was used to compare model performance [Harrell's C statistic and Akaike information criterion (AIC)]. RESULTS: The test and validation cohort distribution of CRP was not affected by age, and mixture models indicated a bimodal distribution. A threshold cut-off of CRP ≥40 mg/L performed well to predict mortality (and performed similarly to treating CRP as a linear variable). CONCLUSIONS: The distributional characteristics of CRP indicated an optimal cut-off of ≥40 mg/L was associated with mortality. This threshold may assist clinicians in using CRP as an early trigger for enhanced observation, treatment decisions and advanced care planning.