Association of State Recreational Marijuana Laws with Adolescent Marijuana Use

908 Comments: This was an impressive study that demonstrated body temperature in the emergency department as a strong predictor of mortality in patients with severe sepsis and septic shock. Contrary to common perception, patients with fever actually had a lower mortality. While it is tempting to attribute this relationship to faster recognition and initiation of treatment, this association persisted even after adjusting for sepsis bundle completion time. While fever is helpful in identifying infected patients, it may offer other physiologic benefits in sepsis, and it is important to recognize that its absence may indicate a worse prognosis. , ASSOCIATION OF STATE RECREATIONAL MARIJUANA LAWS WITH ADOLESCENT MARIJUANA USE. Cerda M, Wall M, Tianshu F, et al. JAMA Pediatr 2017;17(2):142-148 The recent legalization of recreational marijuana in states such as Washington and Colorado has led to considerable debate about potential unintended consequences. Although recreational marijuana legalization (RML) is applicable to only adults, there are concerns that adolescent use will increase as a result of increased availability, advertising and a general acceptance of marijuana as non-risky. Numerous studies have attempted to understand the effects of this legislative change on adolescent marijuana use, but none have evaluated adolescents’ perception of marijuana in addition to their usage of marijuana. Data was collected from 2010 to 2015 using The Monitoring the Future (MTF) study, an annual national cross-sectional survey of 8th, 10th & 12th graders. Survey data from Colorado and Washington were compared to the 45 contiguous states that had not yet legalized recreational marijuana use. Using a multistage random sampling design, 253,902 students provided data on marijuana use and perception. Of these students, 2,982 were from Colorado and 5,509 students were from Washington. The primary outcomes for the study were perceived harmfulness of marijuana and marijuana use within the preceding 30 days. Survey results before recreational marijuana legalization in Colorado and Washington were compared to post-legalization results. Interestingly, results between Washington and Colorado varied. In Washington, there was a significant decrease in perceived harmfulness of marijuana in 8th & 10th graders post-RML (14.2% and 16.1% decrease, respectively) when compared to non-RML states (4.9% and 7.2% decrease, respectively). Moreover, there was a significant increase in the usage of marijuana in 8th & 10th graders in Washington (2.0 and 4.1% increase, respectively) when compared to non-RML states which showed decreased usage (-1.3% and -0.9%, respectively) following RML. In Colorado, there was no change in perceived harmfulness of marijuana or usage of marijuana following RML. Additionally, there was no difference in usage or perceived risk of marijuana in 12th graders in both Washington and Colorado. The authors suggest that the changes seen in Washington post-RML can be attributed to reduced stigma surrounding marijuana use as well as increased availability of marijuana to adolescents. The absence of change in perceived harmfulness and usage in Colorado may be secondary to an already lower perceived risk and to an already higher marijuana usage pre-

Abstracts RML, likely because of a well-established legal medical marijuana industry. [Alexa Camarena-Michel, MD Denver Health Medical Center, Denver, CO] Comments: This study does demonstrate a change in perceived harmfulness and usage among Washington 8th & 10th graders, but fails to replicate these findings in Colorado. It is possible that this study was not powered to detect a change in Colorado perception and usage because the study surveyed half the amount of Colorado students when compared to Washington students. This data does suggest that states considering recreational marijuana legalization ought to consider concomitant investment in adolescent substance use education and prevention programs. , INCREASED TIME TO INITIAL ANTIMICROBIAL ADMINISTRATION IS ASSOCIATED WITH PROGRESSION TO SEPTIC SHOCK IN SEVERE SEPSIS PATIENTS. Whiles BB, Deis AS, Simpson SQ. Crit Care Med 2017;45(4):623-629 Despite advancements in management of severe sepsis and septic shock, these conditions continue to be a significant cause of morbidity and mortality. While many studies have demonstrated that early antibiotics are associated with decreased mortality in patients with severe sepsis and septic shock, there are no studies to date that evaluate whether initiation of antibiotics within 24 hours can prevent progression of severe sepsis to septic shock. This was a retrospective cohort study that took place at a large urban academic medical center. Participants were greater than 18 years of age who received antimicrobials within 24 hours of emergency department (ED) triage time and were admitted for severe sepsis or septic shock. Time from ED triage to initiation of first antimicrobial as well as to initiation of broad-spectrum antimicrobials was recorded. Patients requiring vasopressors within 3 hours of initial presentation were excluded and progression to septic shock, defined by administration of vasopressors greater than 3 hours following ED triage time, was the primary outcome measure. Chi-square analysis was used to compare those patients that progressed to septic shock to those that did not. A total of 3,929 patients were included in the analysis. Of these patients, 984 (25.0%) progressed to septic shock during their hospitalization. Overall in-hospital mortality was 12.8%. Not surprisingly, septic shock patients were found to have longer length of stays (LOS) as well as increased mortality compared to patients that did not develop septic shock (30.8% vs 7.0%). The median time to initial antimicrobial administration overall was 2.95 hours (interquartile range [IQR] = 1.67-5.26). In patients who ultimately progressed to septic shock, median time to initial antimicrobial initiation was 3.77 hours, whereas those without progression to septic shock received antimicrobials at a median time of 2.76 hours. In-hospital mortality was associated with increased time to initial antimicrobial administration. Notably, the majority of patients received a broad-spectrum antimicrobial as their first antimicrobial. In this study, the risk of progression from severe sepsis to septic shock increased by 8.0% for every hour delay in initiation