Orthostatic hypotension as the initial presentation of disseminated cryptococcosis in a kidney transplant recipient.

Background: Solid organ transplant recipients are immunocompromised and at risk for invasive viral, fungal, and bacterial pathogens. Cryptococcus neoformans is the third most common invasive fungal infection in transplant recipients, and the clinical presentation of Cryptococcus neoformans infection can vary widely. Cryptococcal disease can affect the brain, lungs, skin, or vasculature, and it is frequently disseminated. Meningitis typically presents with fever, headache, and altered mental status. Solid organ transplant recipients with cryptococcosis tend to have poorer outcomes than HIV patients with cryptococcosis. Case presentation: In this case report, we describe the case of a 69 year-old man with a past medical history of a deceased donor kidney transplant who presented with severe orthostatic hypotension and was found to have disseminated cryptococcosis. Conclusions: This case report emphasizes the importance of broadening the differential diagnosis in transplant recipients who present with non-specific chief concerns. Availability of data and materials: No datasets were used in the preparing of this manuscript. All patient information comes from the electronic health record and authors personal care of this patient.

Photoacoustic monitoring of angiogenesis predicts response to therapy in healing wounds.

Chronic wounds are a major health problem that cause the medical infrastructure billions of dollars every year. Chronic wounds are often difficult to heal and cause significant discomfort. Although wound specialists have numerous therapeutic modalities at their disposal, tools that could three dimensional-map wound bed physiology and guide therapy do not exist. Visual cues are the current standard but are limited to surface assessment; clinicians rely on experience to predict response to therapy. Photoacoustic (PA) ultrasound (US) is a non-invasive, hybrid imaging modality that can solve these major limitations. PA relies on the contrast generated by haemoglobin in blood which allows it to map local angiogenesis, tissue perfusion and oxygen saturation-all critical parameters for wound healing. This work evaluates the use of PA-US to monitor angiogenesis and stratify patients responding versus not-responding to therapy. We imaged 19 patients with 22 wounds once a week for at least 3 weeks. Our findings suggest that PA imaging directly visualises angiogenesis. Patients responding to therapy showed clear signs of angiogenesis and an increased rate of PA increase (p = 0.002). These responders had a significant and negative correlation between PA intensity and wound size. Hypertension was correlated to impaired angiogenesis in non-responsive patients. The rate of PA increase and hence the rate of angiogenesis was able to predict healing times within 30 days from the start of monitoring (power = 88%, alpha = 0.05). This early response detection system could help inform management and treatment strategies while improving outcomes and reducing costs.

Microglial reduction of colony stimulating factor-1 receptor expression is sufficient to confer adult onset leukodystrophy.

Adult onset leukoencephalopathy with axonal spheroids and pigmented glia (ALSP) is a dementia resulting from dominantly inherited CSF1R inactivating mutations. The Csf1r+/- mouse mimics ALSP symptoms and pathology. Csf1r is mainly expressed in microglia, but also in cortical layer V neurons that are gradually lost in Csf1r+/- mice with age. We therefore examined whether microglial or neuronal Csf1r loss caused neurodegeneration in Csf1r+/- mice. The behavioral deficits, pathologies and elevation of Csf2 expression contributing to disease, previously described in the Csf1r+/- ALSP mouse, were reproduced by microglial deletion (MCsf1rhet mice), but not by neural deletion. Furthermore, increased Csf2 expression by callosal astrocytes, oligodendrocytes, and microglia was observed in Csf1r+/- mice and, in MCsf1rhet mice, the densities of these three cell types were increased in supraventricular patches displaying activated microglia, an early site of disease pathology. These data confirm that ALSP is a primary microgliopathy and inform future therapeutic and experimental approaches.

Low Thyroid Function in Nonalcoholic Fatty Liver Disease Is an Independent Predictor of All-Cause and Cardiovascular Mortality.

INTRODUCTION: Higher levels of thyroid-stimulating hormone (TSH) in the euthyroid state can negatively affect the metabolic health, including nonalcoholic fatty liver disease (NAFLD). We studied the effect of TSH levels in the setting of normal levels of thyroid hormone on all-cause and cause-specific mortality stratified by NAFLD status. METHODS: The National Health and Nutrition Examination Survey (NHANES) III from 1988 to 1994 and NHANES III-linked mortality data through 2015 were used. NAFLD was defined as ultrasonographically diagnosed hepatic steatosis without coexisting liver diseases. Subclinical hypothyroidism was defined as a TSH level over 4.5 mIU/L and "low-normal" thyroid function as higher TSH level (2.5-4.5 mIU/L) within the euthyroid reference range. The Cox proportional hazard model analyzed the all-cause mortality and cause-specific mortality. RESULTS: In a multivariate logistic regression analysis, individuals with low thyroid function demonstrated an association with NAFLD in a dose-dependent manner. During a median follow-up of 23 years, low thyroid function was associated with increased all-cause mortality only in the univariate model. Low thyroid function was associated with a higher risk for all-cause mortality in individuals with NAFLD and not in those without NAFLD. Furthermore, low thyroid function was associated with a higher risk for cardiovascular mortality in the entire population and among those with NAFLD but demonstrated no association with the non-NAFLD group. DISCUSSION: In this large nationally representative sample of American adults, low thyroid function was associated with NAFLD and a predictor of higher risk for all-cause and cardiovascular mortality in individuals with NAFLD.

Diet quality and its association with nonalcoholic fatty liver disease and all-cause and cause-specific mortality.

BACKGROUND & AIMS: Healthy diet has been recommended for nonalcoholic fatty liver disease (NAFLD), although it is not clear whether improving diet quality can prevent mortality. We aim to assess the impact of quality of diet on NAFLD and mortality in subjects with and without NAFLD. METHODS: We performed cohort study using the Third National Health and Nutrition Examination Survey from 1988 to 1994 and linked mortality data through 2015. We used the Healthy Eating Index (HEI) scores to define diet quality, with higher HEI scores (Q4) indicating better adherence to dietary recommendations. NAFLD was defined as ultrasonographic hepatic steatosis. RESULTS: Multivariate analysis showed that subjects with higher diet quality were inversely associated with NAFLD in a dose-dependent manner. During the median follow-up of 23 years, having a higher diet quality was associated with reduction in risk of all-cause mortality in the age, sex, Race/ethnicity-adjusted hazard ratio (HR) (Q4, HR: 0.60, 95% CI: 0.52-0.68) and the multivariate model (Q4, HR: 0.81, 95% CI: 0.71-0.92). Higher diet quality was associated with a lower risk for all-cause mortality in subjects without NAFLD; however, this protective association with diet quality was not noted in those with NAFLD. Furthermore, a high diet quality was associated with a lower risk for cancer-related mortality in the total population and among those without NAFLD. This association was not noted in those with NAFLD. CONCLUSIONS: High diet quality was inversely associated with NAFLD and was positively associated with a lower risk for cancer-related and all-cause mortality in those without NAFLD.

The molecular determinants of R-roscovitine block of hERG channels.

Human ether-à-go-go-related gene (Kv11.1, or hERG) is a potassium channel that conducts the delayed rectifier potassium current (IKr) during the repolarization phase of cardiac action potentials. hERG channels have a larger pore than other K+channels and can trap many unintended drugs, often resulting in acquired LQTS (aLQTS). R-roscovitine is a cyclin-dependent kinase (CDK) inhibitor that induces apoptosis in colorectal, breast, prostate, multiple myeloma, other cancer cell lines, and tumor xenografts, in micromolar concentrations. It is well tolerated in phase II clinical trials. R-roscovitine inhibits open hERG channels but does not become trapped in the pore. Two-electrode voltage clamp recordings from Xenopus oocytes expressing wild-type (WT) or hERG pore mutant channels (T623A, S624A, Y652A, F656A) demonstrated that compared to WT hERG, T623A, Y652A, and F656A inhibition by 200 µM R-roscovitine was ~ 48%, 29%, and 73% weaker, respectively. In contrast, S624A hERG was inhibited more potently than WT hERG, with a ~ 34% stronger inhibition. These findings were further supported by the IC50 values, which were increased for T623A, Y652A and F656A (by ~5.5, 2.75, and 42 fold respectively) and reduced 1.3 fold for the S624A mutant. Our data suggest that while T623, Y652, and F656 are critical for R-roscovitine-mediated inhibition, S624 may not be. Docking studies further support our findings. Thus, R-roscovitine's relatively unique features, coupled with its tolerance in clinical trials, could guide future drug screens.

Treatment of inoperable hepatocellular carcinoma with immunotherapy.

In the USA, mortality associated with hepatocellular carcinoma (HCC) continues to rise. Globally, HCC is the third most common cause of cancer-related death. In early stages of HCC, hepatic resection or liver transplantation are the preferred treatment options with a high probability of recurrence-free postoperative course. However, ineffective screening of chronic liver diseases in high-risk populations, poor linkage to care and suboptimal HCC surveillance has led to increasing rates of late-stage HCC at clinical presentation or diagnosis amenable only to palliative and experimental treatment options. Our case is a 66-year-old man with chronic hepatitis C virus infection complicated by cirrhosis and inoperable HCC which was non-responsive to selective intrahepatic trans-arterial chemoembolisation by interventional radiology. Therefore, he was treated with nivolumab immunotherapy and demonstrated normalisation of previously elevated alpha-fetoprotein levels suggestive of at least a partial response to immunotherapy. No adverse events related to nivolumab immunotherapy were encountered.

Kratom-Induced Cholestatic Liver Injury and Its Conservative Management.

Drug-induced liver injury (DILI) is a common cause of hepatotoxicity associated with prescription-based and over-the-counter exposure to medications and herbal supplements. Use of unapproved and inadequately tested herbal supplements can cause DILI. Therefore, thorough history-taking on exposure to herbal supplements must be an integral part of clinical evaluation of DILI. Kratom is an herbal supplement or remedy that has been known for its analgesic effects and has also been used for self-treatment of opiate withdrawals. A 52-year-old man was seen for evaluation of yellow discoloration of the eyes and skin. He reported taking kratom for right shoulder strain for at least a couple of months. On workup, his total bilirubin was noted to be 23.2 mg/dL, which peaked at 28.9 mg/dL. He was noted to have mild elevation of aspartate aminotransferase, alanine aminotransferase, and alkaline phosphatase. Extensive laboratory tests were ordered and known causes of chronic liver disease ruled out. Magnetic resonance imaging of the abdomen was unremarkable without stigmata of portal hypertension or signs of chronic liver disease. He demonstrated no evidence of coagulopathy or hepatic encephalopathy during his illness. He underwent liver biopsy, which demonstrated histologic evidence of acute cholestatic hepatitis highly suspicious of DILI. He was advised to avoid kratom or other herbal supplements in future and prescribed ursodeoxycholic acid with significant improvement in his liver chemistries. Kratom is associated with significant liver enzymes derangements leading to DILI. Kratom is not approved for use in the United States and should be avoided.

Low-Normal Thyroid Function Is Associated With Advanced Fibrosis Among Adults in the United States.

The pathogenetic pathways leading to increasing prevalence of advanced fibrosis in the setting of nonalcoholic fatty liver disease (NAFLD) and resulting in higher rates of liver-related and cardiovascular morbidity and mortality in the United States are multifactorial.1 The negative health impact of "low-normal" thyroid function, which is defined as a higher level of thyroid-stimulating hormone (TSH) within the euthyroid reference range, may be comparable with overt and subclinical hypothyroidism.2-4 We reported a strong association between biopsy-proven advanced fibrosis in NAFLD with increasing TSH levels in a dose-dependent manner even within the euthyroid reference range.5 To generalize our findings across all ethnicities, we examined the association of both low-normal thyroid function and subclinical hypothyroidism with advanced fibrosis in the US general population.

The impact of computerized provider order entry on emergency department flow.

OBJECTIVES: Computerized provider order entry (CPOE) has been established as a method to improve patient safety by avoiding medication errors; however, its effect on emergency department (ED) flow remains undefined. We examined the impact of CPOE implementation on three measures of ED throughput: wait time (WT), length of stay (LOS), and the proportion of patients that left without being seen (LWBS). METHODS: We conducted a retrospective cohort study of all ED patients of 18 years and older presenting to London Health Sciences Centre during July and August 2013 and 2014, before and after implementation of a CPOE system. The three primary variables were compared between time periods. Subgroup analyses were also conducted within each Canadian Triage and Acuity Scale (CTAS) level (1-5) individually, as well as for admitted patients only. RESULTS: A significant increase in WT of 5 minutes (p=0.036) and LOS of 10 minutes (p=0.001), and an increase in LWBS from 7.2% to 8.1% (p=0.002) was seen after CPOE implementation. Admitted patients' LOS increased by 63 minutes (p<0.001), the WT of CTAS 3 and 5 patients increased by 6 minutes (p=0.001) and 39 minutes (p=0.005), and LWBS proportion increased significantly for CTAS 3-5 patients, from 24.3% to 42.0% (p<0.001) for CTAS 5 patients specifically. CONCLUSIONS: CPOE implementation detrimentally impacted all patient flow throughput measures that we examined. The most striking clinically relevant result was the increase in LOS of 63 minutes for admitted patients. This raises the question as to whether the potential detrimental effects to patient safety of CPOE implementation outweigh its benefits.

Reliability of the Canadian Triage and Acuity Scale: interrater and intrarater agreement from a community and an academic emergency department.

OBJECTIVES: The Canadian Triage and Acuity Scale (CTAS) is a five-level triage tool that is used to help prioritize the order in which emergency department (ED) patients should be seen. The objectives of this study were to determine the interrater and intrarater agreement of the 2008 CTAS guideline revisions by triage nurses and to compare agreement between triage nurses working in a small community ED and an academic ED. METHODS: Seventy-eight triage nurses assigned CTAS scores and free-text presenting complaints for 10 paper-based case scenarios. For five scenarios, the CTAS score should have remained unchanged from previous guidelines, whereas the other five scenarios should have been triaged differently based on the 2008 CTAS first-order modifiers. Thirty-three participants repeated the questionnaire 90 days later, and intrarater agreement was measured. RESULTS: There was a higher level of agreement (κ  =  0.73; 95% CI 0.68-0.79) for the five case scenarios, which relied on the older 2004 guidelines compared to the scenarios where the 2008 guidelines would have suggested a different triage level (κ  =  0.50; 95% CI 0.42-0.59). For the 10 case scenarios analyzed, the free-text presenting complaints matched the Canadian Emergency Department Information System (CEDIS) list 90.1% of the time (κ  =  0.80; 95% CI 0.76-0.84). CONCLUSION: The reliability of CTAS scoring by academic and community ED nurses was relatively good; however, the application of the 2008 CTAS revisions appears less reliable than the 2004 CTAS guidelines. These results may be useful to develop educational materials to strengthen reliability and validity for triage scoring using the 2008 CTAS guideline revisions.

Implementing an obstetric triage acuity scale: interrater reliability and patient flow analysis.

A 5-category Obstetric Triage Acuity Scale (OTAS) was developed with a comprehensive set of obstetrical determinants. The objectives of this study were as follows: (1) to test the interrater reliability of OTAS and (2) to determine the distribution of patient acuity and flow by OTAS level. To test the interrater reliability, 110 triage charts were used to generate vignettes and the consistency of the OTAS level assigned by 8 triage nurses was measured. OTAS performed with substantial (Kappa, 0.61 - 0.77, OTAS 1-4) and near perfect correlation (0.87, OTAS 5). To assess patient flow, the times to primary and secondary health care provider assessments and lengths of stay stratified by acuity were abstracted from the patient management system. Two-thirds of triage visits were low acuity (OTAS 4, 5). There was a decrease in length of stay (median [interquartile range], minutes) as acuity decreased from OTAS 1 (120.0 [156.0] minutes) to OTAS 3 (75.0 [120.8]). The major contributor to length of stay was time to secondary health care provider assessment and this did not change with acuity. The percentage of patients admitted to the antenatal or birthing unit decreased from 80% (OTAS 1) to 12% (OTAS 5). OTAS provides a reliable assessment of acuity and its implementation has allowed for triaging of obstetric patients based on acuity, and a more in-depth assessment of the patient flow. By standardizing assessment, OTAS allows for opportunities to improve performance and make comparisons of patient care and flow across organizations.

Methicillin-resistant Staphylococcus aureus in skin and soft tissue infections presenting to the Emergency Department of a Canadian Academic Health Care Center.

OBJECTIVES: This study aimed to estimate the city-wide prevalence of methicillin-resistant Staphylococcus aureus (MRSA) in patients (≥18 years old) presenting with skin and soft tissue infections (SSTIs) to the emergency departments (EDs) of a Canadian Academic Health Care Center. Secondary objectives were to identify demographic and clinical variables associated with MRSA, and determine MRSA antimicrobial susceptibilities and genotypes. METHODS: This prospective observational study was conducted over 2 months. Participants completed a Health and Lifestyle Questionnaire. Cultures of the infection site, nares, and throat were obtained and MRSA isolates were confirmed by polymerase chain reaction. Patient characteristics were summarized using descriptive statistics and MRSA prevalence and 95% confidence intervals were estimated using standard equations. Backwards stepwise multivariate logistic regression models determined predictor variables independently associated with MRSA colonization or infection. RESULTS: Of 205 patients, 35 (17.1%) were infected or colonized with MRSA. Seventy-eight (38.0%) of the infection site cultures grew S. aureus of which 27 (34.6%) were MRSA. Incarceration, known exposure to MRSA and involvement in competitive sports were significant predictors of MRSA SSTIs. Antimicrobial susceptibility among MRSA isolates was trimethoprim/sulfamethoxazole, vancomycin, gentamicin, and linezolid 100%, clindamycin 75%, ciprofloxacin 59.3%, and erythromycin 7.4%. Sixty-nine percent of MRSA cases fit the clinical definition of community associated; subsequently 77% were confirmed as CMRSA 10, a recognized community-acquired MRSA. CONCLUSION: Community-acquired -MRSA is a significant pathogen of SSTIs in EDs of a Canadian teaching center. MRSA should be considered when initiating empiric antibiotic therapy, particularly in patients with risk factors.

Triage tool inter-rater reliability: a comparison of live versus paper case scenarios.

BACKGROUND: Published studies of triage scale inter-rater reliability assessment have been conducted mostly using paper case scenarios. OBJECTIVE: To determine if this method of inter-rater reliability assessment generated significantly different measures from those generated from live triage cases. METHODS: This was a multicenter, prospective, observational cohort study of a population-based random sample of patients triaged at 2 emergency departments during a period of 4 months. All patients presenting to the emergency department within the study periods were simultaneously and independently triaged using a 5-level triage acuity scale by 2 to 3 research triage nurses blinded to each other's assessment and to the study objective. After 6 months, the same nurses were asked to assign triage scores to paper case scenarios of the same patients that they had each previously triaged. RESULTS: Each of the 9 research nurses triaged approximately 90 cases. The inter-rater reliabilities as measured by an intraclass correlation coefficient were 0.9 (95% CI = 0.87 to 93) for the live triage assessments and 0.76 (95% CI = 0.73 to 0.79) for the paper case scenarios. The mean triage score assigned to the live cases was significantly less than that assigned to the paper-based cases (3.17; 95% CI = 3.08 to 3.26) (p < 0.001). CONCLUSIONS: There is moderate to high agreement between live cases and paper case scenarios, and the inter-rater reliabilities, although significantly different, are acceptable in both cases. It is impossible to determine which triage setting provides a more accurate triage score but paper case scenarios generally receive lower triage scores than live cases.

Predictive validity comparison of two five-level triage acuity scales.

INTRODUCTION: Each of the two most commonly used five-level triage tools in North America, the Emergency Severity Index and the Canadian Triage and Acuity Scale have been used as a measure of emergency department resource utilization in addition to acuity. In both cases, it is believed that patients triaged as having a higher level of acuity require a greater number of emergency department resources. We compared the ability of each tool to predict the emergency department resources for each emergency department visit and associated hospital admission and in-hospital mortality rates. METHODS: This is an observational, cohort study of a population-based random sample of patients triaged at two emergency departments over a 4-month period. Correlational analyses were performed to examine the relationship between the triage assessment and: (i) resource utilization, (ii) hospital admission, and (iii) in-hospital mortality. RESULTS: From 486 patients, analyses revealed the greatest correlation was between Emergency Severity Index and diagnostic resources [-0.54 (95% confidence intervals: -0.58, -0.50)] and the poorest correlation was between Canadian Triage and Acuity Scale and mortality [-0.16 (95% confidence intervals: -0.20, -0.12)]. No statistically significant differences (P<0.005) were observed between each tool 's ability to predict any of the outcomes measured. CONCLUSION: No statistically significant difference was observed in the ability of Emergency Severity Index v. 3 and Canadian Triage and Acuity Scale to predict emergency department resource utilization or immediate patient outcomes. This ability is, at best, only moderate indicating that other, more accurate tools than measures of triage acuity are required for this purpose.

Anaphylactoid reaction to recombinant tissue plasminogen activator.

Anaphylactoid reaction to recombinant tissue plasminogen activator for the thrombolytic treatment of acute ischemic stroke is an uncommon complication. An increased risk of anaphylaxis may be found in patients concomitantly being treated with angiotensin-converting enzyme inhibitors, as illustrated by this case report describing a patient who experienced an urticaric rash, hypotension, tachycardia, orolingual angioedema, and airway obstruction following intravenous administration of alteplase. Possible pharmacologic interactions resulting in excessive serum bradykinin and subsequent systemic hypersensitivity responses are discussed.

Predictive validity of the triage risk screening tool for elderly patients in a Canadian emergency department.

PURPOSE: We sought to externally evaluate the predictive validity of the Triage Risk Screening Tool (TRST) for elderly patients in a Canadian setting. METHODS: A prospective, observational cohort study of a convenience sample of patients more than 64 years old was assessed using the TRST before discharge. The composite outcome of any emergency department (ED) revisit, hospital admission, or long-term care placement at 30 and 120 days was measured. Likelihood ratios (LRs) and 95% confidence intervals (CIs) were calculated. MAIN FINDINGS: Of 218 patients screened, 120 patients were enrolled. At 30 and 120 days, the positive LRs were 1.4 (95% CI, 0.9-2.0) and 1.4 (95% CI, 1.0-1.9), respectively. The negative LRs were 0.7 (95% CI, 0.4-1.3) and 0.7 (95% CI, 0.4-1.0), respectively. CONCLUSION: The TRST cannot be used as a single diagnostic test to predict whether Canadian ED elders will have an ED revisit, hospital admission, or long-term care placement at 30 or 120 days.

Identification of root causes for emergency diagnostic imaging delays at three Canadian hospitals.

BACKGROUND: Diagnostic imaging of patients in the emergency department offers numerous opportunities for delay. In an era of ED overcrowding, it is important to identify causes of delay in caring for patients to minimize patient length of stay in the emergency department. OBJECTIVES: This study was intended to: (1) identify each of the steps involved in completing emergency diagnostic imaging investigations; (2) identify points of delay in the process; (3) identify the root causes for delay; and (4) perform a barrier analysis to provide insight into the contribution of the work environment and existing processes to delays. METHODS: This prospective, cross-sectional, modified time-in-motion study was conducted simultaneously at 3 urban emergency departments of a Canadian academic center over a 3-week period. Turnaround and process event times were recorded and a log transformation was performed to normalize the time data. Analysis of variance was used to examine individual time intervals between sites. Root cause and barrier analyses were conducted on the summary data. RESULTS: Analysis of 2297 cases revealed the mean turnaround time for one site was 50 minutes and significantly greater (P < .05) than the means of the other 2 sites (approximately 33 and 37 minutes, respectively). Root cause analysis identified 3 root causes of delay: (1) processing of radiograph request order by registered nurse; (2) transport times; and (3) radiology suite location. Barrier analysis indicated that current practices are responsible for the first 2 causes of delay. CONCLUSION: Both radiology and emergency department staffing considerations and workload contribute to delays in turnaround times of diagnostic imaging investigations.

Coded Chief Complaints--automated analysis of free-text complaints.

OBJECTIVES: To describe a new chief-complaint categorization schema, the development of a computer text-parsing algorithm to automatically classify free-text chief complaints into this schema, and use of these coded chief complaints to describe the case mix of a community emergency department (ED). METHODS: Coded Chief Complaints for Emergency Department Systems (CCC-EDS) is a new and untested schema of 228 chief complaints, grouped within dimensions of type and system. A computerized text-parsing algorithm for automatically reading and classifying free-text chief complaints into 1 of these 228 coded chief complaints was developed by using a consecutive derivation sample of 46,602 patients who presented to a community teaching-hospital ED in 2004. Descriptive statistics included frequency of patients presenting with the 228 coded chief complaints; percentage of free-text complaints not categorizable by the CCC-EDS; and admission rate, age, and gender differences by chief complaint. RESULTS: In the derivation sample, the text-parsing algorithm classified 87.5% of 45,329 ED visits with non-null free-text chief complaints into 1 of 194 coded chief complaints. The text-parsing algorithm successfully classified 87.3% of the free-text chief complaints in a validation sample. The five most common coded chief complaints were Abdominal Pain (3,734 visits), Fever (2,234), Chest Pain (2,183), Breathing Difficulty (2,030), and Cuts-Lacerations (2,028). CONCLUSIONS: The CCC-EDS is a new comprehensive, granular, and useful classification schema for categorizing chief complaints in an ED. A CCC-EDS text-parsing algorithm successfully classified the majority of free-text chief complaints from an ED computer log. These coded chief complaints were used to describe the case mix of a community teaching-hospital ED.