The new england journal of medicine n engl j med 370;9 nejm.org february 27, 2014 882 a substantial gradient in alcohol intake accord- ing to nut consumption could overcome the as- sumption for a strong unmeasured confounder in the array-approach sensitivity analysis (Table S6 in the Supplementary Appendix), which ac- counted for a maximal difference in prevalence of 40 percentage points between participants who ate nuts seven or more times per week and those who never ate nuts. Factors such as income level and the pattern of nut consumption (e.g., socially related con- sumption) should have been studied and, further- more, adjusted for in the models. Eran Kopel, M.D., M.P.H. Shaye Kivity, M.D. Yechezkel Sidi, M.D. Chaim Sheba Medical Center Tel Hashomer, Israel eran.kopel@mail.huji.ac.il No potential conflict of interest relevant to this letter was re- ported. 1. Stringhini S, Sabia S, Shipley M, et al. Association of socio- economic position with health behaviors and mortality. JAMA 2010;303:1159-66. DOI: 10.1056/NEJMc1315777 The authors and a colleague reply: We agree with Elin that nuts are rich in magnesium, a fact that may contribute to the observed inverse asso- ciation between nut consumption and total mor- tality. We performed an additional analysis ad- justing for total magnesium intake and found similar results. Hazard ratios for death among participants who ate nuts seven or more times per week, as compared with those who did not eat nuts, were 0.79 in the cohort of women (95% confidence interval [CI], 0.69 to 0.91), 0.81 in the cohort of men (95% CI, 0.73 to 0.90), and 0.80 in the pooled cohort (95% CI, 0.74 to 0.87). As suggested by Kopel et al., we performed an additional analysis adjusting for alcohol intake as a continuous variable and found similar re- sults. Hazard ratios for death among participants who ate nuts seven or more times per week, as compared with those who did not eat nuts, were 0.78 in the cohort of women (95% CI, 0.68 to 0.90), 0.78 in the cohort of men (95% CI, 0.71 to 0.87), and 0.78 in the pooled cohort (95% CI, 0.72 to 0.85). Although socioeconomic status is related to mortality, the study participants, being nurses and health professionals, are relatively homogeneous. Ying Bao, M.D., Sc.D. Bernard A. Rosner, Ph.D. Brigham and Women’s Hospital Boston, MA ying.bao@channing.harvard.edu Charles S. Fuchs, M.D., M.P.H. Dana–Farber Cancer Institute Boston, MA Dr. Rosner reports no potential conflict of interest relevant to this letter. Since publication of their article, Drs. Bao and Fuchs report no further potential conflict of interest. DOI: 10.1056/NEJMc1315777 Laryngeal Mask Airway in Medical Emergencies To the Editor: In their Video in Clinical Medi- cine, Lighthall et al. (Nov. 14 issue) 1 illuminate the utility of the laryngeal mask airway (LMA) in airway management during cardiopulmonary ar- rest. However, the existing data supporting the emergency application of this and other supra- glottic airway devices (e.g., the laryngeal tube) are limited and conflicting. Lighthall et al. state that LMA placement is usually successful on the first attempt, but a meta-analysis showed that the success rate for prehospital LMA insertion was only 85%. 2 Numerous observational studies have not shown reliable differences in outcomes for cardiopulmonary arrest between the use of supraglottic airway devices and tracheal intuba- tion, and the use of any advanced airway device has not been shown to be superior to bag-and- mask ventilation alone. 3-5 The most effective ap- proach to airway management probably varies according to the characteristics of the patients, the clinical circumstances, and the airway expe- rience and skills of the rescuer. Prospective, con- trolled trials would help to clarify the best ap- proaches to emergency airway management, particularly during cardiopulmonary arrest. Henry E. Wang, M.D. University of Alabama School of Medicine Birmingham, AL Clifton W. Callaway, M.D., Ph.D. University of Pittsburgh School of Medicine Pittsburgh, PA Jasmeet Soar, M.B. Southmead Hospital Bristol, United Kingdom jasmeetsoar@icloud.com The New England Journal of Medicine Downloaded from nejm.org by UNSPECIFIED UNSPECIFIED on February 26, 2014. For personal use only. No other uses without permission. Copyright © 2014 Massachusetts Medical Society. All rights reserved.