Main Outcome Measure: Incident MI.Results: Of 8845 patients included, 1673 received a TNF inhibitor for at least 2 months (TNF inhibitor cohort), 2097 were TNF inhibitor naive and received other systemic agents or phototherapy (oral/phototherapy cohort), and 5075 were not treated with TNF inhibitors, other systemic therapies, or phototherapy (topical cohort). The median duration of follow-up was 4.3 years (interquartile range, 2.9, 5.5 years), and the median duration of TNF inhibitor therapy was 685 days (interquartile range, 215, 1312 days). After adjusting for MI risk factors, the TNF inhibitor cohort had a significantly lower hazard of MI compared with the topical cohort (adjusted hazard ratio, 0.50; 95% CI, 0.32-0.79). The incidence of MI in the TNF inhibitor, oral/phototherapy, and topical cohorts were 3.05, 3.85, and 6.73 per 1000 patientyears, respectively.Conclusions: Use of TNF inhibitors for psoriasis was associated with a significant reduction in MI risk and incident rate compared with treatment with topical agents. Use of TNF inhibitors for psoriasis was associated with a non-statistically significant lower MI incident rate compared with treatment with oral agents/phototherapy.

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Objective The emergency department (ED) is an inherently high-risk setting. Early death after an ED evaluation is a rare and devastating outcome which the understanding of can potentially help improve patient care and outcomes. Using administrative data from an integrated health system, we describe characteristics and predictors of patients who experience 7-day death after ED discharge. Methods Administrative data from 12 hospitals were used to identify death after discharge in adults age 18 or older within 7 days of ED presentation from 1/1/07 to 12/31/08. Patients who were non members of the health system, in hospice care, or seen at out of network EDs were excluded. Predictors of 7-day post-discharge death were identified using multivariable logistic regression. Results The study cohort contained a total of 475,829 members with 728,312 discharges from Kaiser Permanente Southern California (KPSC) EDs in 2007 and 2008. Death within 7 days of discharge occurred in 357 cases (0.05%). Increasing age, male gender, and number of pre-existing co-morbidities were associated with increased risk of death. The top 3 primary discharge diagnoses predictive of 7-day death after discharge include non-infectious lung disease (OR 7.1, 95% CI 2.9-17.4), renal disease (OR 5.6, 95% CI 2.2-14.2), and ischemic heart disease (OR 3.8, 95%CI 1.0-13.6). Conclusions Our study suggests that 50 in 100,000 patients in the U.S. die within 7-days after discharge from an emergency department. Our study is the first to identify potentially “high risk” discharge diagnoses in patients who suffer a short-term death after discharge.

Background: Data on the rate of positive penicillin skin test (PenST) results over time in large populations are rare. The factors that influence positive PenST results are incompletely understood.Objectives: We sought to correlate demographic variables to the rate of positive PenST results over time in a large group of patients with a history of penicillin allergy. Methods:Results from the first test for all patients tested for penicillin allergy in the Kaiser Permanente Health Care Program in San Diego County, CA, between 1995 and 2007 are reported. All patients were tested with penicillin, penicilloyl-poly-lysine, penilloate, penicilloate, and amoxicillin.Results: There were 255 positive PenST results in 3469 individuals. The rate of positive PenST results declined from >10% to <5% during the 13 years studied. The positive PenST result rate could be accounted for by the year of testing (R 2 = 0.56; p = 0.003) without any significant contribution from the patient's age or the time since reaction (TSR). If the TSR was ≤13 years, the relative risk of a positive PenST result was 2.1 (95% confidence interval = 1.6-2.8). If the study subject's age was ≤38 years, the relative risk of a positive PenST result was 2.1 (95% confidence interval = 1.6-2.7). Females reported higher rates of penicillin allergy history than males did (11% compared with 6.6%; p < 0.0001), but there were no significant sex differences in the rate of positive PenST results.Conclusions: There has been a steady decline in the proportion of positive PenST results between 1995 and 2007, independent of study subject age and TSR. Increasing age and increasing TSR were associated with a lower rate of positive PenST results. Eric Macy, MD, (top, left) is an Allergist in the