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Objectives: To determine whether undertriage affects the outcome for patients requiring direct admission to the intensive care unit (ICU) from the emergency department due to a medical condition. To identify factors associated with undertriage., Material and Methods: Retrospective review of patients treated in 2018 for medical emergencies requiring direct admission to the ICU from the emergency department. The cases were classified in 2 groups according to the assigned triage level. Underestimation was defined as a triage level of III or more. Independent variables were demographic and epidemiologic data and indicators of severity recorded in the emergency department. The main outcome was 30-day mortality. Secondary outcomes were in-hospital mortality, prolonged ICU stay, and prolonged hospital stay., Results: We included 470 patients with a median age of 68 years (first-third quartile range, 57-78 years); 61.1% were men, and 151 (32.1%) were undertriaged. Factors directly related to undertriage according to odds ratios (ORs) were age (OR = 1.017; 95% CI, 1.003-1.032), Quick Sequential Organ Failure Assessment score of 0 or 1 (OR = 1.761; 95% CI, 1.038-2.988), ratio of oxygen saturation to fraction of inspired oxygen greater than 300 (OR = 2.447; 95% CI, 1.418-4.223), a diagnosis of infection (OR = 5.003, 95% CI 2.727-9.188) whether respiratory (OR = 3.993, 95% CI 1.919-8.310) or other (OR = 1.980, 95% CI, 1.036-3.785) versus a diagnosis of cardiovascular disease. Factors inversely related to undertriage were admission during the afternoon (OR = 0.512, 95% CI, 0.306-0.856) and ambulance transfer (OR = 0.373; 95% CI, 0.232-0.600). Ninety patients (19.1%) died within 30 days. Undertriage was not related to 30-day mortality or the other outcomes analyzed., Conclusion: Undertriage was not associated with a worse outcome in patients requiring direct admission to the ICU for a medical emergency. The factors we found to be associated with undertriage, such as patient age and time of day admitted, merit special attention given that these factors should not be affecting the triage process.

Objectives: To develop a risk model to predict 30-day mortality after emergency department treatment for COVID-19., Material and Methods: Observational retrospective cohort study including 2511 patients with COVID-19 who came to our emergency department between March 1 and April 30, 2020. We analyzed variables with Kaplan Meier survival and Cox regression analyses., Results: All-cause mortality was 8% at 30 days. Independent variables associated with higher risk of mortality were age over 50 years, a Barthel index score less than 90, altered mental status, the ratio of arterial oxygen saturation to the fraction of inspired oxygen (SaO2/FIO2), abnormal lung sounds, platelet concentration less than 100 000/mm3, a C-reactive protein concentration of 5 mg/dL or higher, and a glomerular filtration rate less than 45 mL/min. Each independent predictor was assigned 1 point in the score except age, which was assigned 2 points. Risk was distributed in 3 levels: low risk (score of 4 points or less), intermediate risk (5 to 6 points), and high risk (7 points or above). Thirty-day risk of mortality was 1.7% for patients who scored in the low-risk category, 28.2% for patients with an intermediate risk score, and 67.3% for those with a high risk score., Conclusion: This mortality risk stratification tool for patients with COVID-19 could be useful for managing the course of disease and assigning health care resources in the emergency department.

Objectives: To analyze emergency department (ED) revisits from patients discharged with possible coronavirus disease 2019 (COVID-19)., Material and Methods: Retrospective observational study of consecutive patients who came to the ED over a period of 2 months and were diagnosed with possible COVID-19. We analyzed clinical and epidemiologic variables, treatments given in the ED, discharge destination, need to revisit, and reasons for revisits. Patients who did or did not revisit were compared, and factors associated with revisits were explored., Results: The 2378 patients included had a mean age of 57 years; 49% were women. Of the 925 patients (39%) discharged, 170 (20.5%) revisited the ED, mainly for persistence or progression of symptoms. Sixty-six (38.8%) were hospitalized. Odds ratios (ORs) for the following factors showed an association with revisits: history of rheumatologic disease (OR, 2.97; 95% CI, 1.10-7.99; P = .03), digestive symptoms (OR, 1.73; 95% CI, 1.14-2.63; P = .01), respiratory rate over 20 breaths per minute (OR, 1.03; 95% CI, 1.0-1.06; P = .05), and corticosteroid therapy given in the ED (OR, 7.78; 95% CI, 1.77-14.21, P = .01). Factors associated with hospitalization after revisits were age over 48 years (OR, 2.57; 95% CI, 1 42-4.67; P = .002) and fever (OR, 4.73; 95% CI, 1.99-11.27; P = .001)., Conclusion: Patients under the age of 48 years without comorbidity and with normal vitals can be discharged from the ED without fear of complications. A history of rheumatologic disease, fever, digestive symptoms, and a respiratory rate over 20 breaths per minute, or a need for corticosteroid therapy were independently associated with revisits. Fever and age over 48 years were associated with a need for hospitalization.

Objectives: To analyze clinical data and electrocardiographic (ECG) findings obtained during the initial evaluation of patients with nontraumatic chest pain (NTCP). To explore associations between these findings and the initial and final diagnoses of acute coronary syndrome (ACS). To assess which variables initially over- or underestimate risk ACS., Material and Methods: Consecutive patients with NTCP attended in a chest pain unit during the 10-year period of 2008-2017 were included if the suspected and discharge diagnoses of interest (ACS or non-ACS) had been recorded. Thirtythree independent variables (demographic, 2; cardiovascular, 5; chest pain, 22; ECG, 4). We included all variables in models to calculate crude and adjusted odds ratios (ORs) between each independent variable and the initial and final diagnoses. The adjusted ORs were compared to determine whether the initial and final diagnoses of ACS differed significantly in relation to the variables., Results: A total of 34 552 patient visits were attended. The ORs for the 33 variables were significantly associated with initial and final NTCP classification as ACS or non-ACS, and in many cases the association was confirmed by the adjusted ORs. The adjusted ORs for 19 variables were significantly different in their relation to the initial and final diagnoses of ACS: 10 overpredicted the probability of the diagnosis and 9 underpredicted it., Conclusion: The variables traditionally used to warn of ACS in emergency patients with NTCP identify individuals likely to be initially and finally diagnosed with ACS. However, some of these variables overestimate or underestimate the risk of a final ACS diagnosis. Emergency medicine physicians should be aware of variables associated with underestimation of risk.

Chronic obstructive pulmonary disease (COPD) is the second leading cause of emergency department (ED) admissions to hospital, and nearly a third of patients with acute exacerbation (AE) of COPD are re-admitted to hospital within 28 days after discharge. It has been suggested that nearly a third of COPD admissions could be avoided through the implementation of evidence-based care interventions. A COPD discharge bundle is a set of evidence-based practices, aimed at improving patient outcomes after discharge from AE COPD; body of evidence supports the usefulness of discharge care bundles after AE of COPD, although there is a lack of consensus of what interventions should be implemented. On the other hand, the implementation of those interventions also involves different challenges. Important care gaps remain regarding discharge care bundles for patients with acute exacerbation of COPD discharged from EDs There is an urgent need for investigations to guide future implementation of care bundles for those patients discharged from EDs., Competing Interests: The authors declare no conflicts of interest.

Objectives: To study the relation between nursing staff demographics and experience and their assignment of triage level in the emergency department., Material and Methods: One-year retrospective observational study in the triage area of a tertiary care urban university hospital that applies the Andorran-Spanish triage model. Variables studied were age, gender, nursing experience, triage experience, shift, usual level of emergency work the nurse undertakes, number of triage decisions made, and percentage of patients assigned to each level., Results: Fifty nurses (5 men, 45 women) with a mean (SD) age of 45 (9) years triaged 67 803 patients during the year. Nurses classified more patients in level 5 on the morning shift (7.9%) than on the afternoon shift (5.5%) (P=.003). The difference in the rate of level-5 triage classification became significant when nurses were older (β = 0.092, P=.037) and experience was greater (β = 0.103, P=.017). The number of triages recorded by a nurse was significantly and directly related to the percentage of patients assigned to level 3 (β = 0.003, P=.006) and inversely related to the percentages assigned to level 4 (β = -0.002, P=.008) and level 5 (β = -0.001, P=.017)., Conclusion: We found that triage level assignments were related to age, experience, shift, and total number of patients triaged by a nurse.

Objective: To validate a triage flowchart to rule out acute coronary syndrome (ACS) in chest pain patients attending the emergency department (ED)., Methods: An observational cohort study of consecutive patients. In all cases, a previously derived five-step triage flowchart (age ≤ 40 years, absence of diabetes, not previously known coronary artery disease, non-oppressive and non-retrosternal pain) was applied. Patients meeting all five discriminators were grouped as 'five-step triage non-ACS', the rest as 'five-step triage ACS'. The same strategy was used with a four-step model (without age ≤ 40 years). After ED study and 1-month follow-up, patients were definitively classified as 'true ACS' or 'true non-ACS'. Validity indexes and receiver operating characteristics curves were calculated., Results: 4231 patients were included: 918 (21.7%) were 'true ACS', 3303 (78.1%) 'true non-ACS'; 10 (0.2%) were lost to follow-up. The five-step triage flowchart classified 4000 (94.8%) as 'triage ACS' and 221 (5.2%) as 'triage non-ACS'; none of the latter was 'true ACS'. The four-step model classified 3194 (75.6%) as 'triage ACS' and 1027 (24.4%) as 'triage non-ACS'. A 'true ACS' was seen in 26 patients from the latter group. Accordingly, five-step triage flowchart specificity and positive predictive value (PPV) to rule out ACS were 100% (95% CI 100% to 100%). For the four-step model specificity and PPV were 97% (95% CI 96% to 98%)., Conclusion: The five-step triage flowchart identifies chest pain patients without an ACS. However, only 5% of these patients meet these five criteria. A simpler model allows greater patient inclusion but a higher risk of misclassification of true ACS.

Aim: To determine predictors of frequent chest pain unit (CPU) users and to identify characteristics and outcomes of their CPU visits., Patients and Methods: Observational prospective case-control study. Frequent CPU user was defined by 3 or more CPU visits within the study year. A control patient and a control visit were randomly selected for each case patient and case visit. Demographic, clinical, and outcome variables were collected from medical record and phone interview performed in a 30-day interval. A multivariate logistic regression analysis was used to identify frequent CPU users' predictors., Results: Of 1934 patients presenting during the year, 80 (4.1%) met the definition for case patient. They accounted for 352 (13%) of 2709 CPU visits. Sixty-seven (83.7%) case patients and 71 (88.7%) control patients were contacted. The final predictors were the following: Karnofsky Performance Scale of 70 or lesser (odds ratio [OR], 5.24 [95% confidence interval {CI}, 1.71-16.06]), previous hospitalization (OR, 3.76 [95% CI, 1.49-9.49]), previously known coronary artery disease (OR, 3.72 [95% CI, 1.32-10.52]), and symptoms of depression (OR, 2.98 [95% CI, 1.14-7.78]). Case visits were more likely at night (OR, 2.41 [95% CI, 1.64- 3.52]), generated more diagnostic uncertainty (OR, 2.39 [95% CI, 1.71-3.35]), but did not increase the need of hospital admission., Conclusions: Frequent CPU user is associated with previously known coronary artery disease, previous hospitalization, impaired performance status, and presence of symptoms of depression. They are more likely to arrive on CPU at night and generate more diagnostic uncertainty.

Aim: The aim of the study was to establish a triage flowchart to rule out acute coronary syndrome (ACS) among patients with chest pain (CP) arriving on an Emergency Department (ED)., Patients and Method: This prospective observational study included 1000 consecutive patients with CP arriving on an ED CP unit. Demographic and clinical characteristics along with vital signs were recorded as independent variables. After CP unit protocol completion and 1-month follow-up, patients were classified as (dependent variable) (1) true non-ACS (all noncoronary patients at the first visit that kept this condition when called 1 month later) or (2) true ACS (all the remaining patients). Relationship among variables was assessed by multiple logistic regression analysis. A triage flowchart was obtained from significant variables and applied to patients with CP who were then grouped in "triage non-ACS" and "triage ACS." Validity indexes to exclude ACS for triage flowchart were measured., Results: Variables significantly associated with non-ACS and included in the triage flowchart were age <40 years (odds ratio 3.61, 95% CI 1.63-7.99), absence of diabetes (2.74, 1.53-4.88), no previously known coronary artery disease (5.46, 3.42-8.71), nonoppressive pain (10.63, 6.04-18.70), and nonretrosternal pain (5.16, 2.82-9.42). For the triage flowchart, both specificity and positive predictive value to rule out ACS were 100%., Conclusions: The triage flowchart is able to accurately identify patients with CP not having an ACS. It may help triage nurses make quick decisions on who should be immediately seen and who could safely wait when delays in medical attention are unavoidable. Prospective validation is needed.

Background and Objective: Blood pressure (BP) fluctuations may contribute to the development of target organ damage in essential hypertension. However, a possible relationship with left ventricular hypertrophy (LVH) is controversial. The aim of the present study was to analyze the association between BP variability, defined through different instrument measures, and LVH in a group of essential hypertensive patients., Patients and Method: Forty-three untreated hypertensive patients were studied. BP variability was evaluated by using both non-invasive, beat-to-beat finger 24-hour monitoring (Portapres) and discontinuous oscillometric ambulatory blood pressure monitoring (ABPM). All patients underwent echocardiography in order to detect the presence or absence of LVH., Results: Thirty out of 43 patients studied (70%) exhibited LVH. Office [167.7 (19.5) versus 156.7 (14.9) mmHg; p = 0.032], 24-hour ambulatory [146.6 (15.7) versus 131.9 (15.1) mmHg; p = 0.003] and 24-hour continuous finger [147.5 (21.3) versus 135.7 (14.2) mmHg; p = 0.046] systolic BP were significantly higher in patients with LVH with respect to those without cardiac hypertrophy. No differences were observed in terms of nocturnal BP fall, ABPM 24-h standard deviation of BP or continuous finger BP variability estimates., Conclusion: Left ventricular hypertrophy is mainly correlated with the severity of systolic BP elevation, but not with BP variability, neither long-term nor short-term.

Background: An association between midlife blood pressure levels and late-life cognitive impairment has been reported. Hypertension is one of the most important factors related to the presence of cerebral white matter lesions, which is a prognostic factor for the development of cognitive impairment. Studies have shown a relationship between white matter lesions and cognitive decline in elderly hypertensive patients. The aim of the present study was to evaluate cognitive function in asymptomatic middle-aged hypertensive patients according to the presence or absence of white matter lesions., Methods: Sixty never-treated essential hypertensive patients (38 men, 22 women), aged 50 to 60 years (mean age, 54.4 +/- 3.8 years), without clinical evidence of target organ damage, were studied. All patients underwent brain magnetic resonance imaging to establish the presence or absence of white matter lesions, using the Rotterdam criteria. Cognitive function was evaluated by a neuropsychologic test battery measuring attention, memory, intelligence, anxiety, and depression., Results: Twenty-three hypertensive patients (38%) were found to have white matter lesions on brain resonance. These patients exhibited a significantly worse performance on digit span forward, a standardized measure of attention than hypertensives without white matter lesions (4.86 +/- 1.14 v 5.51 +/- 0.97; P =.027). Hypertensive patients with white matter lesions showed no differences on both visual and logical memory tests when compared with patients without lesions., Conclusions: We conclude that the presence of silent cerebral white matter lesions in middle-aged hypertensive patients is associated with a mild decline in basic attention.

Background and Objective: Emergency department (ED) overcrowding has been increasing over the last years. The aims are to define ED overcrowding, and to determine and quantify which factors explain it., Patients and Method: For 3 consecutive weeks throughout 3 years (2000-2002), we recorded every 3-hour period, the arrivals, the occupancy rate (OR) of patients in ED, in first aid area (FAA), and in observation area (OA) according to the reason for their stay. The data was subjected to multiple logistic regression analysis including as a dependent variable non overcrowding/overcrowding for each area (ED, FAA, and OA). Overcrowding was defined as an OR >= 100%. Models from the three areas were calculated according to goodness of fit and were discriminated by ROC methodology. Models were set up after randomizing data in two groups: selection set (88% of data) and validation set (12% of data)., Results: Variables associated with overcrowding in the ED model were OR of patients waiting for test results, for a bed going to be left, to find a bed, for test performed out of ED, and for outcome. In the FAA model, they were OR of patients being seen, and waiting for test results. Finally, in the OA model they were OR of patients waiting for a bed going to be left, to find a bed, for test performed out of ED, and for outcome. For all models sensitivity and specificity were greater than 85%, with a ROC area greater than 0.97. We did not find any relationship between number of arrivals and overcrowding for none model. Results were corroborated on the validation data set., Conclusions: Patients remaining in the ED due to factors related to both hospital (waiting for a bed going to be left, or to find a bed), and ED itself (waiting for outcome) are the main reason for ED overcrowding.

Background: The goal of this study was to evaluate the relative association of several components of blood pressure (BP), as measured in the office and by ambulatory monitoring (ABPM), with clinically useful indicators of target organ damage and cardiovascular events (CE) in essential hypertensive patients., Patients and Method: We retrospectively included 390 hypertensives (55% men; mean age: 56 years) between 1989 and 1998. All them had a baseline office BP measurement and a valid 24-hour ABPM record, both performed while the patient was free of antihypertensive therapy. Estimates of target organ damage included electrocardiographic indexes of left ventricular hypertrophy (Cornell and Sokolow-Lyon), serum creatinine, 24-hour urine protein excretion and creatinine clearance. Multiple linear regression and logistic regression analyses were used to evaluate the relationship between BP and target organ damage or CE., Results: Forty-nine patients had CE (26 stroke, 18 myocardial infarction and 5 both). The BP parameter correlating better with cardiovascular events was office pulse pressure (multivariate odds ratio: 1.03; CI 95%: 1.00-1.05; p = 0.0095). Nevertheless, cardiac growth indexes correlated better with ABPM measurements. In fact, Cornell index correlated with night-time systolic BP (standardized regression coefficient beta: 0.260; p < 0.001) and Sokolow-Lyon index correlated with day-time systolic BP ( beta: 0.257; p < 0.001). Creatinine clearance inversely correlated with night-time pulse pressure ( beta: 0.122; p = 0.017) while proteinuria correlated better with 24-hour systolic BP ( beta: 0.390; p < 0.001)., Conclusions: Whereas office BP (especially pulse pressure) is associated with the development of CE, ABPM estimates show a better association with target organ damage, especially systolic and pulse pressures.

Background: It has been proposed that concentric left ventricular hypertrophy (LVH) is related to a worse degree of target organ damage in hypertensives with this feature than in those without. Moreover, the presence of cerebral white matter lesions (WMLs) is considered to be an early marker of brain damage in essential hypertension. The aim of this study was to assess the association between the presence of silent WMLs and left ventricular mass and geometry in middle-aged individuals with hypertension that had never been treated., Methods: A total of 62 patients (39 men, 23 women, aged 50 to 60 years, mean age 54.4 +/- 3.2 years) with never-treated essential hypertension and without clinical evidence of target organ damage were studied. All patients underwent brain magnetic resonance imaging and were classified into two groups according to the presence or absence of WMLs. Echocardiography measuring posterior wall thickness (PWT), interventricular septum thickness (IVST) and left ventricular end-diastolic diameter (LVEDD) was also performed. Left ventricular mass index (LVMI) was calculated using the Penn convention criteria, and relative wall thickness ratio (RWT) was estimated by the standard formula: 2 x PWT/LVEDD., Results: Hypertensive patients with WMLs exhibited significantly higher PWT, IVST, LVMI, and RWT when compared with hypertensive patients without WMLs. In addition, 23 of 26 hypertensive patients with WMLs showed echocardiographic criteria for LVH that was significantly higher than that observed in hypertensive patients without WMLs (21 of 36; P = .01). Concentric hypertrophy (LVH and RWT > or = 0.45) was present in 14 hypertensive patients with WMLs and in only four patients without WMLs (P = .002)., Conclusion: There is a close association between cerebral WMLs and concentric LVH in asymptomatic middle-aged hypertensive patients, independent of blood pressure values.

Objective: Age, hypertension, diabetes mellitus and a history of cardiovascular disease are the most important factors related to the presence of cerebral white matter lesions (WML), which are a common finding in elderly people. This study investigates which factors related to hypertension per se are associated with the presence of WML in asymptomatic, middle-aged, never-treated essential hypertensive patients., Methods: A total of 66 untreated essential hypertensive patients of both genders, aged 50-60 years, with neither diabetes mellitus nor evidence of cardiovascular disease, were studied. Hypertensive patients were classified into two groups according to the presence or absence of WML in brain magnetic resonance imaging (MRI)., Results: A total of 39 (59.1%) hypertensives showed no WML in brain MRI, and 27 (40.9%) exhibited the presence of WML. Compared with hypertensives without WML, patients with WML showed significantly higher values of both office and 24 h ambulatory blood pressure monitoring (ABPM) systolic, diastolic, mean and pulse pressure. No differences were observed in either the nocturnal fall of blood pressure, or in blood pressure variability, assessed by 24 h standard deviation, among hypertensives with WML. In contrast, the nocturnal decline of heart rate was significantly blunted in patients with WML, compared with those without WML., Conclusions: Cerebral white matter lesions are a common finding in asymptomatic middle-aged essential hypertensives. The severity of blood pressure elevation seems to be the most important factor related to the presence of WML. Neither the circadian rhythm nor the long-term variability of blood pressure were related to WML.

It has been reported that both the DD genotype of the angiotensin converting enzyme (ACE) gene and the presence of cerebral white matter lesions (WML) may represent risk factors for the development of stroke. The present study investigates a possible association between 3 different genetic polymorphisms of the renin-angiotensin system and the presence of WML in 60 never-treated essential hypertensive patients (36 men, 24 women), aged 50 to 60 years, without clinical evidence of target organ damage. All patients underwent brain magnetic resonance imaging to establish the presence or absence of WML. The insertion/deletion (I/D) ACE gene, the M235T angiotensinogen (AGT) gene, and the A1166C angiotensin II type 1 receptor gene polymorphisms were determined by standard polymerase chain reaction. Twenty-five hypertensive patients (41.6%) were found to have WML on brain magnetic resonance imaging. No significant association between the M235T angiotensinogen or A1166C angiotensin II type 1 receptor genotypes and the presence of WML was found. However, the frequency of the DD genotype in patients with WML (64%) was significantly higher than that observed in patients without WML (28.6%; P=0.022). The DD genotype odds ratio for the presence of WML was 4.44 (95% confidence interval: 1.48 to 13.3). Likewise, the proportion of the D allele in patients with WML (74%) was significantly higher (P=0.014) than that observed in patients without WML (51.4%). We conclude that the presence of the DD genotype and/or the D allele of the ACE gene may be a predisposing factor for developing WML in essential hypertensive patients. However, because of the small sample size, these results require confirmation in a larger study.

The case of a 36-year-old chronic alcoholic patient who came to the hospital for presenting general bad shape, arthromyalgia and jaundice and who developed severe hepatitis with an extreme elevation in the transaminase levels following the consumption of therapeutic doses of paracetamol (3 g/day for 4 days). The possibility of other causes of hepatitis were duly discarded. Liver biopsy showed confluent centrolobular necrosis compatible with the diagnosis of toxic hepatitis. The patient was discharged from hospital in stable condition and with a slight alteration in the transaminase levels. Recognizing hepatotoxicity by paracetamol in alcoholics is simple if the clinical history, the marked transaminase elevation and the history of paracetamol intake are adequately evaluated. Lower doses of paracetamol or even avoidance of this drug is recommended in circumstances in which the toxicity of the drug may be potentiated by chronic alcohol consumption or by the lack of appetite associated with deficient alimentation.

Background: Urgent medical claim from recluse population shows some special traits due to firstly, the reclusion situation itself and the high prevalence of certain diseases in this population, as the infections ones, such as HIV infection, hepatitis B and tuberculosis. Moreover, emergency rooms constitute for this patients, a common previous admission place. Thus, a high and a complex medical care claim must be expected from this population in hospital emergency rooms., Methods: Consultations from ill prisoners examined in emergency room of Hospital Clinic Internal Medicine department during 1993, were checked: Age, sex, date, time of visit, serology and HIV risk factor, stage infection among positive HIV subjects, cause of complaint. age o symptomatology, number and the kind of complementary examinations done, the consulting time, the diagnosis and its link to the HIV infections, the consulting recurrence, and its relation with the initial cause, and the patient final destiny., Results: 394 patients, from 598 who consulted, were visited (1.8% total consultings). The mean age was 32.4 years and 92% were men. A 68% (268 patients) realized that had HIV infection, and among these, a 37% (99 patients) were AIDS. The most frequent cause of complaint were related to respiratory, digestive, neurologic and non foci fever, which caused the higher number of admissions. The tuberculosis diagnosis was done in 39 patients (9.9%). Sixty wine patients discharged from hospital on first examination came again one or more times to the emergency room because of the same complaint. The number of complementary examinations done was 1,370 (a mean of 2.4 per visit), and were significantly higher among the HIV patients than in negative or unknown (p < 0.001). The overall admissions average was 37%, which increased to 71% among patients visited repeatedly. The HIV recluse patients required admission in the 46.3% of visits, and the HIV negative ones, in the 20.6% (p < 0.001). The duration of the visit among the patients that were discharged was 4 hours and 54 minutes., Conclusion: Recluse population generates an important urgent medical care claim. The number of admissions among this population is elevated and higher than the respective to the general one, related to the age. This high number of consulting, the increased number of admissions and the complex assistance (high number of complementary examinations that often requires high technology, and the repetitive urgent visits, etc.), are caused, mainly by the high prevalence of HIV infections among this population.

Tracheobronchomegaly, also known as Mounier-Kühn's Syndrome, is characterized by market dilation of the trachea and main bronchi and has been reported in association with several conditions, particularly connective tissue disease. The pathogenesis and clinical signs of light chain deposition disease are similar to those of light chain amyloidosis, in which these chains are deposited as amorphous material lacking the tinctorial features of the amyloid. We present a case involving both entities, an association that has not been previously reported, and we review the main characteristics of both diseases.