810 Abstracts

ingestions, this study provides robust evidence for causation.Utilizing the Granger causality analysis, the authors give quan-titative evidence showing that a significant medical problem isonly going to get worse without proper efforts to ensure medi-cation stewardship and safety.

, TIME TO TREATMENT WITH INTRAVENOUS TIS-SUE PLASMINOGEN ACTIVATOR AND OUTCOMEFROM ACUTE ISCHEMIC STROKE. Saver J, Fonarow G,Smith E, et al. JAMA 2013;309:2480–8.

Typically limited to a usage window of 4.5 h after onset ofsymptoms, tissue-type plasminogen activator (tPA) has provento be beneficial in the treatment of acute stroke.

This study aimed to assess the extent to which onset to treat-ment time (OTT), influenced overall outcome. There were58,353 patients who received tPA for acute stroke included inthe study and placed into three sub-groups: OTT of 0–90 min(5404 patients), 91–190 min (45,029 patients), and 181–270minutes (7920 patients).

Data showed that improved outcomes were independentlylinked to OTT. For every 15-min-faster interval of treatment,mortality was less likely to occur (odds ratio [OR], 0.96; 95%confidence interval [CI] 0.95–0.98); symptomatic intracranialhemorrhage was less likely to occur (OR 0.96; 95% CI 0.95–0.98); independence in ambulation at discharge was more likelyto occur (OR 1.04; 95% CI 1.03–1.05), and discharge to homewas more likely to occur (OR 1.03; 95% CI 1.02–1.04).

As such, patients in the 0–90-min treatment window had de-creased mortality, improved independent ambulation, decreasedintracranial hemorrhage rates, and increased frequency of dis-charge to home than those patients who received tPA from91–180 min or 181–270 min.

[Marc Quinlan, MD

Denver Health Medical Center, Denver, CO]

Comment: Put simply, time is of the essence. Creatingstreamlined regimens for patients presenting with stroke-likesymptoms seems to be more important than ever. Decreasinghurdles to tPA management is key in decreasing OTT, thus, itis not surprising that more and more hospitals are embracingstroke protocols to expedite this process and limit time-consum-ing obstacles.

, HISTORY OF KIDNEY STONES AND THE RISK OFCORONARY HEART DISEASE. Ferraro P, Taylor E, EisnerB, et al. JAMA 2013;310:408–15.

In 1972, a report noted an increased incidence of nephroli-thiasis with survivors of myocardial infarction (MI), comparedto the general population.

To further examine this outcome, this prospective observa-tional study sought to assess the association between nephroli-thiasis and coronary heart disease (CHD). The study enrolled196,357 women and 45,748 men, from the United States.

Three large cohort populations were used; the Health Profes-sionals Follow-Up Study (HPFS) and the Nurses’ Health Study I(NHS) and NHS II. An initial survey, followed by biennial ques-tionnaires, inquired about a history of nephrolithiasis. Patientswere also asked specific questions about CHD (defined as fatalor nonfatal MI or coronary revascularization).

Multiple subgroup analyses were also included: race, region,family history, smoking status, body mass index (BMI), diabe-tes, hypertension, gout, hyperlipidemia, and pharmaceuticaluse.

Of the nearly quarter million participants in the study, 19,678reported a history of nephrolithiasis. After a 24-year follow-upfor men and an 18-year follow-up in women, 16,838 cases ofCHD occurred.

After considering other covariates, women with a history ofnephrolithiasis were at a modest, but statistically significant,risk for CHD. Incident rates (IR), hazard ratios (HR), and con-fidence intervals (CI) for NHS I and NHS II, respectively, were:IR 754 vs. 514 per 100,000 person-years/HR 1.18, 95%CI 1.08–1.28; IR 144 vs. 55 per 100,000 person-years/HR 1.48, 95% CI1.23–1.78. There was no similar association between nephroli-thiasis and CHD inmen, HPFS results: IR 1355 vs. 1022 per 100000 person-years, multivariable HR 1.06, 95% CI 0.99–1.13.

[Marc Quinlan, MD

Denver Health Medical Center, Denver, CO]

Comment: CHD is a multi-factorial disease process. Accord-ingly, this study found an association between nephrolithiasisand CHD in the female population. When evaluating CHDrisk factors with patients, it is important to assess/address diet,BMI, blood pressure, and other more controllable factors todecrease the overall risk of CHD.

, THE IMPACT OF MARIJUANA USE ON GLUCOSE,INSULIN, AND INSULIN RESISTANCE AMONGUNITED STATESADULTS. Penner E, Buettner H,MittlemanM. Am J Med 2013;126:583–9.

Marijuana use is increasingly common in the United States,but the effect of chronic use is not well understood. Previousstudies report that marijuana use is not only associated withan acute increase in caloric intake, but also, albeit odd, lowerbody mass indexes.

This cross-sectional study aimed to better address the impactof habitual marijuana use on fasting glucose levels, insulinlevels, and insulin resistance.

The study enlisted 4657 participants from the NationalHealth and Nutrition Examination Survey (NHANES) whonoted marijuana intake and also provided fasting blood samples.Of those included, 579 were current marijuana users and 1975were prior users.

Results of the study showed that current marijuana use wasassociated with 16% lower fasting insulin levels (95% confi-dence interval [CI] �26 to �6); 17% lower homeostasis modelassessment of insulin resistance (HOMA-IR) (95% CI �27 to�6); 1.63 mg/dL higher high-density lipoprotein cholesterollevels (95% CI 0.23–3.04); as well as a significant decrease inwaist circumference in multivariable adjusted models.

[Marc Quinlan, MD

Denver Health Medical Center, Denver, CO]

Comment:Although this study focuses on some of the poten-tial benefits of habitual marijuana use, the medical practitionershould also weigh the potential risks of marijuana ingestionwhen providing information to their patients.