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long-term structured physical activity program reduced the risk of major mobility disability in individuals with compromised lower extremity functioning. 1 Our recent article reported prespecified secondary cognitive outcomes. The trial was not designed to test the effect of changes in cardiorespiratory fitness on cognition, as implied by ˙ O2 was not included in Dr Poulin and colleagues. Testing of V the LIFE study because in our pilot study, we found that maximal exercise testing was not well tolerated and the data were of little value for exercise prescription.2 We disagree with Poulin and colleagues’ assertions about our definition of moderate-intensity physical activity. The LIFE study defined moderate-intensity exercise in terms of ratings of perceived exertion with a prescribed target of 13 (somewhat hard) and using accelerometry (>760 counts/min). Ratings of perceived exertion have been used in numerous randomized clinical trials of physical activity in older adults and use of these ratings is generally accepted as a valid indicator of exercise intensity.3 The American College of Sports Medicine and the American Heart Association have acknowledged that defining aerobic exercise intensity in absolute terms (eg, target ˙ O2max) with older adults can be heart rate derived from V problematic due to high levels of heterogeneity (ie, low levels of fitness, compromised functioning).4 Recent evidence suggests that moderate-intensity activity for a population aged 70 to 77 years corresponds to 669 to 4048 counts/min depending on sex and fitness level, highlighting the importance of tailoring thresholds for older adults.5 Thus, our definition of moderate-intensity physical activity based on accelerometer counts is consistent with published data, especially because our sample was older (mean age, 78.9 years), sedentary, and had physical function limitations. Poulin and colleagues state that the exercise sessions were unsupervised and adherence was self-reported. The intervention involved 2 center-based sessions/week and 3 days/week of home-based physical activity. The centerbased sessions were supervised and adherence was closely monitored. Each center-based session included an average of 36 minutes of walking as well as strength, balance, and flexibility training for a total of 60 minutes. Based on accelerometry data in a subsample of LIFE participants, we found that the mean counts/minute were 1555 for men and 1237 for women each session and the ratings of perceived exertion were within target.6 In addition, averaged across follow-up, accelerometry data indicated that the physical activity group engaged in 213 minutes/week of moderateintensity activity.1 Although it is possible that participants did not engage in a sufficient dose of physical activity to generate changes in cognitive functioning, the precise dose-response relationship between physical activity and cognition is not well understood, despite Poulin and colleagues’ suggestion that the intensity was too light and sessions too short. Interventionists used a variety of techniques to motivate participants to exercise at the prescribed intensity, and higher 416

intensity exercise would not have been feasible without jeopardizing participant safety and adherence. The LIFE study realistically tested the effect of a longterm, multimodal physical activity program on cognitive outcomes in older adults who were sedentary, deconditioned, and had physical limitations. Jeffrey A. Katula, PhD, MA Timothy Church, MD, PhD, MPH Kaycee M. Sink, MD, MAS Author Affiliations: Department of Health and Exercise Science, Wake Forest University, Winston Salem, North Carolina (Katula); Pennington Biomedical Research Center, Baton Rouge, Louisiana (Church); Section on Gerontology and Geriatric Medicine, Wake Forest School of Medicine, Winston Salem, North Carolina (Sink). Corresponding Author: Kaycee M. Sink, MD, MAS, Sticht Center on Aging, Section on Gerontology and Geriatric Medicine, Wake Forest School of Medicine, One Medical Center Boulevard, Winston Salem, NC 27157 ([email protected]). Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Sink reported receiving grants from the National Institute on Aging and Navidea. No other disclosures were reported. 1. Pahor M, Guralnik JM, Ambrosius WT, et al; LIFE study investigators. Effect of structured physical activity on prevention of major mobility disability in older adults: the LIFE study randomized clinical trial. JAMA. 2014;311(23): 2387-2396. 2. Church TS, Gill TM, Newman AB, Blair SN, Earnest CP, Pahor M. Maximal fitness testing in sedentary elderly at substantial risk of disability: LIFE-P study experience. J Aging Phys Act. 2008;16(4):408-415. 3. Chodzko-Zajko WJ, Proctor DN, Fiatarone Singh MA, et al; American College of Sports Medicine. American College of Sports Medicine position stand: exercise and physical activity for older adults. Med Sci Sports Exerc. 2009;41(7): 1510-1530. 4. Nelson ME, Rejeski WJ, Blair SN, et al. Physical activity and public health in older adults: recommendation from the American College of Sports Medicine and the American Heart Association. Med Sci Sports Exerc. 2007;39(8): 1435-1445. 5. Zisko N, Carlsen T, Salvesen Ø, et al. New relative intensity ambulatory accelerometer thresholds for elderly men and women: the Generation 100 study. BMC Geriatr. 2015;15(1):97. 6. Rejeski WJ, Axtell R, Fielding R, et al; LIFE Study Investigator Group. Promoting physical activity for elders with compromised function: the Lifestyle Interventions and Independence for Elders (LIFE) study physical activity intervention. Clin Interv Aging. 2013;8:1119-1131.

Epinephrine Administration and Pediatric In-Hospital Cardiac Arrest To the Editor The study by Dr Andersen and colleagues1 found an association between delayed administration of epinephrine and poorer survival rates after in-hospital pediatric cardiac arrest. There are at least 3 possible scenarios for delivering epinephrine: the patient might already have a functioning c annula or central line, venous access might be attempted during resuscitation, or epinephrine might be delivered by intraosseous injection. Epinephrine can be given quickly and reliably by intraosseous injection, but clinicians could preferentially attempt intravenous administration first. We wonder whether the reason for delay in epinephrine administration was related to unsuccessful attempts at ve-

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nous access leading to delayed intraosseous injection. If this were the case, intraosseous administration might be overrepresented in the group with delay. It would be informative to analyze whether a greater proportion of the subgroup who received epinephrine after 5 minutes had intraosseous administration. Future studies might then be warranted to investigate whether attempts at venous access should be omitted altogether in cardiac arrest and for epinephrine to be administered promptly through the intraosseous route. Alison Poulton, MD, MA, MBBChir Frank Chen, MBChB Ralph Nanan, DrMedHabil, FRACP Author Affiliations: Sydney Medical School Nepean, University of Sydney, Sydney, Australia (Poulton, Nanan); Nepean Hospital, Sydney, Australia (Chen). Corresponding Author: Frank Chen, MBChB, Children’s Hospital at Westmead, Locked Bag 4001, Westmead, Australia 2145 ([email protected]). Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Poulton reported receiving personal fees and nonfinancial support from Shire; and owning shares in GlaxoSmithKline. Dr Nanan reported being the medical director of Vascular Access Technologies; and having a pending patent application for a portable automated cannulation insertion device. No other disclosures were reported. 1. Andersen LW, Berg KM, Saindon BZ, et al; American Heart Association Get With the Guidelines–Resuscitation Investigators. Time to epinephrine and survival after pediatric in-hospital cardiac arrest. JAMA. 2015;314(8):802-810.

Marriage Equality Act and Changes to Health Insurance Coverage To the Editor Using data from the American Community Survey (ACS), Dr Gonzales1 analyzed the association between implementation of the Marriage Equality Act for same-sex couples in New York and their health insurance coverage. There are a few problems with the analysis. First, as the US Census Bureau reports,2,3 ACS data on samesex adults are subject to substantial error, including failing to identify many lesbian, gay, and bisexual adults (LGB; including all those not currently living with a partner) and misclassifying a significant number of opposite-sex couples as samesex couples. Second, Gonzales assumed that opposite-sex couples provide the counterfactual for what would have happened to same-sex couples in the absence of marriage expansion in New York. However, unlike same-sex adults, who are often seeking marriage, the marriage rate for opposite-sex couples is decreasing over time.4 Third, Gonzales made a number of errors in his empirical work, including treating each member of the couple as an independent observation, which would lead to an overestimation of the precision of his estimates, and failing to control for significant differences between the same-sex and opposite-sex couples in his sample that could bias his estimates, including differences in educational attainment and residence in New York City. Sharon K. Long, PhD

In Reply We do not have data on whether the first epinephrine bolus was administered by an intravenous or intraosseous injection. The variable we used for assessment of epinephrine administration included both intravenous and intraosseous administration but did not distinguish between the two. Similarly, we did not have reliable and consistent data on whether the patient already had functioning vascular access at the time of the cardiac arrest. We agree with the assessment by Dr Poulton and colleagues that obtaining intravenous or intraosseous access could have led to a delay in epinephrine administration and welcome future research to assess the potential benefits of rapid intraosseous access in this patient population.

Author Affiliation: Urban Institute, Health Policy Center, Washington, DC. Corresponding Author: Sharon K. Long, PhD, Urban Institute, 2100 M St NW, Washington, DC 20027 ([email protected]). Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. 1. Gonzales G. Association of the New York State Marriage Equality Act with changes in health insurance coverage. JAMA. 2015;314(7): 727-728. 2. US Census Bureau. Same-sex couple households: American community survey briefs. https://www.census.gov/prod/2011pubs/acsbr10-03.pdf. Accessed October 12, 2015. 3. US Census Bureau. Matching survey data with administrative records to evaluate reports of same-sex married couple households. https://www.census .gov/hhes/samesex/files/Kreider-Lofquist-Working-Paper.pdf. Accessed October 12, 2015.

Lars W. Andersen, MD Katherine M. Berg, MD Michael W. Donnino, MD

4. Population Reference Bureau. US economic and social trends since 2000. http://www.prb.org/pdf10/65.1unitedstates.pdf. Accessed October 12, 2015.

Author Affiliations: Department of Anesthesiology, Aarhus University Hospital, Aarhus, Denmark (Andersen); Division of Pulmonary and Critical Care Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts (Berg); Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts (Donnino).

In Reply Dr Long is concerned about the measurement of same-sex couples in the ACS. Sexual orientation is not directly ascertained in the ACS. Same-sex couples are identified when the primary respondent identifies a cohabiting person in the household of the same sex as a husband, wife or unmarried partner, missing single LGB adults, same-sex couples not cohabiting together, and same-sex couples choosing not to disclose their relationship, which may bias the results. The findings should not be generalized to all LGB adults or same-sex couples.

Corresponding Author: Michael W. Donnino, MD, Beth Israel Deaconess Medical Center, 1 Deaconess Rd, W/CC 2, Boston, MA 02215 ([email protected]). Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Donnino reported being a paid consultant for the American Heart Association. No other disclosures were reported. jama.com

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Epinephrine Administration and Pediatric In-Hospital Cardiac Arrest--Reply.

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