February 28, 2013
For Medicare Payment Fix, AANA Urges Greater Use of APRNs, Focuses on Anesthesia-Specific Issues
In repealing and reforming the annual cycle of Medicare “sustainable growth rate” (SGR) Part B funding formula cuts, Congress should enact legislation making more effective use of CRNAs and other advanced practice registered nurses, said the AANA in a Feb. 25 letter to two House health committee chairs. The letter from AANA President Janice Izlar, CRNA, DNAP, also expressed caution about hinging too much payment on quality measures, given that anesthesia is very safe and has not been contributed to Medicare cost growth.
“As the Institute of Medicine has recommended, improving access to high-quality healthcare while reducing its costs demands greater use of Advanced Practice Registered Nurses (APRNs) such as Certified Registered Nurse Anesthetists (CRNAs) and eliminating policy barriers that impair patient access to them,” the letter stated. Further, “because the incidences of complications or mortality in anesthesia are so rare, and because those measures that do exist are quality measures but not necessarily of anesthesia, we would have significant reservations about applying a system of risk and reward to performance in anesthesia payment, and about ranking anesthesia providers accordingly. We would have similar significant reservations about hinging a substantial share of Medicare anesthesia payment to such a risk and reward system.”
being circulated by the House Energy & Commerce and Ways & Means Committees Republicans would repeal the annual cycle of huge Medicare Part B “sustainable growth rate” (SGR) funding formula cuts, and replace it with a fee for service system with lower base payments for Part B services and larger payment incentives for meeting quality measures and efficiency goals. To read the AANA’s comment letter, log in to the member side of the AANA website
- AANA Recognition Awards Nominations Due March 15
- AANA Student Writing Contest Deadline is April 1
- Anesthesia College Bowl Deadline is April 15
- CRNAs Needed for College Bowl Challenge Team
- Nominees Sought for AANA Education Committee Student Excellence Award
- Candidates Sought for Student Representative to the Education Committee
- Join us for Exciting AANA Workshops Being Offered in April, May and June!
- AANALearn® Offers Six New CE Courses
- AANA Foundation Issues Call for Researchers
- Apply Now for Scholarships, Fellowships, Grants and More -- Applications Now Available Online
- Calling all Performers: Talent Application Deadline is April 1, 2013
- AANA Professional Practice Manual Documents go Public
- AANA Drug Shortage Survey
- Upcoming Scope of Practice Focus Group Sessions
- AORN Soliciting Open Comments
- Call for Comment-First Draft of the Standards for Accreditation of Post-Graduate Fellowship
Healthcare HeadlinesHealthcare Headlines is for informational purposes, and its content should not be interpreted as endorsements, standards of care, or position statements of the American Association of Nurse Anesthetists.
Inside the Association
AANA Recognition Awards Nominations Due March 15
Nominations are being sought for the following awards, which are presented during the Annual Meeting: the Agatha Hodgins Award for Outstanding Accomplishment, the Helen Lamb Outstanding Educator Award, the Alice Magaw Outstanding Clinical Practitioner Award, the Ira P. Gunn Award, the Clinical Instructor of the Year Award, the Didactic Instructor of the Year Award, and the Program Director of the Year Award. For information, visit the AANA website at www.aana.com/awards
AANA Student Writing Contest Deadline is April 1
Each year, the AANA Education Department accepts Student Writing Contest papers between January 1 and April 1. Only students are eligible to enter the contest. For a complete set of contest rules, click here
. All manuscripts and related documents must be submitted via email to the AANA Education Department at firstname.lastname@example.org
by the deadline of April 1.
Anesthesia College Bowl Deadline is April 15
Each school is encouraged to submit one student to be selected at random for participation in the 24th Annual Anesthesia College Bowl, which will be held during the 2013 AANA Annual Meeting. Applications can be obtained from your program director, through the AANA Education Department at email@example.com
on the AANA website.
CRNAs Needed for College Bowl Challenge Team
Deadline: April 15, 2013
The Annual Anesthesia College Bowl at the AANA Annual Meeting will once again be the site of a stirring contest between the 2013 Student Champion Team and a CRNA Challenge Team. Don’t be afraid to show off your brainpower and volunteer to be on the CRNA Challenge Team! Contact the Education Department for an application at firstname.lastname@example.org
Nominees Sought AANA Education Committee Student Excellence Award
Deadline: May 15, 2013
The Education Committee will present a Student Excellence Award at the AANA Annual Meeting during the Student Luncheon. The recipient will be a student nominated by their program administrator who demonstrates excellence in at least one of three areas: Leadership, Scholarship, or Service. Submission must be a narrative of no more than 1,000 words from the program administrator that includes specific details on how the nominated student demonstrates excellence in an area related to leadership, scholarship, or service. Click here
for a complete set of rules and guidelines. The nomination must be submitted via email to the AANA Education Department at email@example.com
by May 15.
Candidates Sought for Student Representative to the Education Committee
Students who wish to run for the position of Student Representative to the AANA Education Committee can obtain a Campaign Packet from the AANA Education Department at firstname.lastname@example.org
. Packets are also available here
on the AANA website. The application must be submitted by June 1, 2013
Join us for Exciting AANA Workshops Being Offered in April, May and June!
- In conjunction with the Mid-Year Assembly, boost your business savvy by attending the highly successful Business of Anesthesia Conference, April 13, 2013, at the Crystal Gateway Marriott in Arlington, VA. Here is what past participants have to say about this valuable conference: “Excellent, best money ever spent at an AANA meeting” “Excellent content” “Great speakers.” Register for the Business of Anesthesia Conference.
- On May 1, 2013, Essentials of Obstetric Analgesia/Anesthesia Workshop will be held in the AANA Foundation Learning Center in Park Ridge, IL. This workshop addresses clinical applications of obstetric analgesia/anesthesia. Lecture format will cover normal and abnormal physiology of pregnancy, pharmacology, and techniques plus case presentations will enhance lecture material.
- Immediately following the above workshop, the Spinal and Epidural workshop will be held on May 2-4, 2013, also at our AANA Foundation Learning Center. Discussion includes pertinent anatomic knowledge necessary for performing spinal and epidural anesthesia, comparisons of the differences and similarities between spinal and epidural anesthesia, review of the clinical use of various local anesthetic and adjunct drugs for spinal anesthesia. “Hands-on” sessions will be offered for attendees to put into practice what they have learned. Register for the OB and Spinal/Epidural Workshops
- Exciting revisions have been made to the Jack Neary Advanced Pain Management Workshop to better serve our members and to respond to requests by past attendees! We are now offering a series of workshops all focusing on various aspects of importance to the pain practitioner. Each workshop can be registered for separately, but the biggest impact comes from taking them all together as a training plan. We are now offering:
- AANA Physical Assessment for APRNs Workshop – May 3, 2013
- AANA Jack Neary Advanced Pain Management I Workshop – May 4-5, 2013
- AANA Jack Neary Advanced Pain Management II Workshop – May 6-7, 2013
- Neuroanatomy Prosection Workshop – May 8, 2013
- Sign in as member at www.aana.com to access the registration form.
- June 1-2, 2013, join us at the beautiful Grand America hotel in Salt Lake City, Utah, for the Comprehensive Ultrasound Guided Peripheral Nerve Block and Vascular Access Workshop. Watch the AANA website at www.aana.com for more information as it becomes available!
- Space is limited for all these workshops so register early!
AANALearn® Offers Six New CE Courses
The AANA presents the Wellness and Chemical Dependency in the Nurse Anesthesia Profession courses–6 modules designed specifically for nurse anesthetists. Each module can be purchased separately in AANALearn
® and will provide 1 CE credit upon completion. Each course will increase awareness and knowledge for CRNAs of the need to be healthy and well, with helpful information, resources, and references related to health, stress, and chemical dependency. All AANALearn
® courses are available 24/7 with discounted pricing for AANA members. Credits transfer to the transcript file within the same day. Now is the time to consider completing the CE credits required for recertification in 2013! Check out the catalogs now at www.aanalearn.com
AANA Foundation Issues Call for Researchers
The AANA Foundation is exploring research opportunities regarding a closed claim insurance study. The Foundation is currently selecting CRNAs to collect and analyze data regarding insurance claims. If you would like to participate in this study, please complete this application
and send it to email@example.com
with the subject line "Closed Claims."
Apply Now for Scholarships, Fellowships, Grants, and More – Applications Now Available Online
The AANA Foundation is proud to continue its history of funding research and education to advance the science of anesthesia. Scholarships, fellowships, grants and awards with April 1 and May 1 deadlines are listed below. Applications are currently available on the AANA Foundation website at www.aanafoundation.com
April 1 Deadlines
Nurse Anesthesia Student Scholarships
Scholarships are available to all nurse anesthesia students currently enrolled in an accredited nurse anesthesia program. Students must be in good standing within the attended program and meet the specific scholarship requirements outlined in the application. Scholarships start at $1,000.
“State of the Science” – Oral Poster Presentation
An opportunity for CRNAs and nurse anesthesia students to present their research findings and innovative educational approaches through an oral presentation at the AANA Annual Meeting. Research, literature reviews, and innovative, creative techniques in anesthesia are appropriate topics. A $1,000 award accompanies presentation.
Dean Hayden Student Research Scholarship – Awarded up to $5,000.
Doctoral and Post Doctoral Fellowship Opportunities
- Post Doctoral Fellowship Funding will be awarded to CRNAs who, having been awarded the doctorate, are actively involved in the development of a research program. The goal of this program is to support nurse anesthetists who evidence a strong commitment to nurse anesthesia and are seeking to develop a research program. Awarded up to $60,000.
- Doctoral Fellowship Supports CRNAs actively engaged in doctoral studies that evidence a strong commitment to research. Recipients possess the vision to impact the health care system as a doctorally-prepared CRNA. Awarded at $10,000.
- Florida Association of Nurse Anesthetists Practice and Research Doctoral Fellowship – Maximum of $3,000 award.
- Kay Wagner Pennsylvania Association of Nurse Anesthetists Practice and Research Doctoral Fellowship – Clinical Doctorate and Research Doctorate – Maximum of $5,000 award each.
- Lorraine D. Dankowski Doctoral Fellowship - Maximum of $10,000 award.
- NBCRNA Fellowship for the Advancement of Patient Safety Through Enhancing Provider Quality – Project must address the value of certification or recertification in the advancement of patient safety through enhancing provider quality. Maximum of $10,000 award.
- Palmer Carrier, CRNA Scholarship Applicants must be currently enrolled in a doctorate degree program at a nationally accredited university to enhance their professional development as a leader in research. Awarded at $5,000.
May 1 Deadlines
“State of the Science” – General Poster Presentation
An opportunity for CRNAs and nurse anesthesia students to present their research findings and innovative educational approaches through a poster presentation at the AANA Annual Meeting. Research, literature reviews, and innovative, creative techniques in anesthesia are appropriate topics.
General research grants are awarded to AANA member CRNAs in good standing. Research funding priorities change annually. Please refer to the research priorities on the proposal application for more information. Funding varies.
If you have any questions, please contact the AANA Foundation at (847) 655-1170 or firstname.lastname@example.org.
Calling all Performers: Talent Application Deadline is April 1, 2013
Mark your calendar and plan to attend a fabulous and fun event on Monday, Aug. 12, 2013 at the AANA Annual Meeting: Vegas – The Stars Come Out At Night. Even better… YOU can help make the night a huge success. If you have a talent you’d like to share, submit a Talent Application today. Visit our event webpage
to learn more about the event and access the application. Share the stage with our emcee Kenan Thompson from Saturday Night Live and other CRNAs and students who will be showcasing their talent and creativity, competing for fabulous prizes, and supporting the AANA Foundation’s mission of advancing the science of anesthesia through education and research. Contact Luanne Irvin at (847) 655-1173 or email@example.com
with any questions.
AANA Professional Practice Manual Documents go Public
The Professional Practice Manual has been placed on the AANA Professional Practice page
and will also be available on the AANA Member Professional Practice page.
AANA Drug Shortage Survey
The AANA’s Professional Practice Division is conducting a survey of nurse anesthetists to gauge how drug shortages have impacted CRNAs in the past year. This follow up survey to one conducted in September 2011 was launched on Feb. 15, 2013, and will close at midnight March 3, 2013. The aggregate survey report will be published on the AANA’s website.
Upcoming Scope of Practice Focus Group Sessions
The AANA Practice Committee and Professional Practice Division staff are in the process of revising the Scope of Practice document. A series of focus group sessions will be conducted to hear from a variety of stakeholders who are interested in and affected by nurse anesthesia scope of practice issues. The first focus group session took place at the 2013 Assembly of School Faculty Meeting in February. Additional focus sessions will occur at the 2013 Mid-Year Assembly Meeting in April.
AORN Soliciting Open Comments
The Association of Perioperative Registered Nurses (AORN) is accepting public comments on Recommended Practices for Care of Patients Undergoing Pneumatic Tourniquet-Assisted Procedures through March 10, 2013. To access this document and submit comments see: http://www.aorn.org/Secondary.aspx?id=24169
Call for Comment-First Draft of the Standards for Accreditation of Post-Graduate Fellowship
The Council on Accreditation of Nurse Anesthesia Educational Programs (COA) has issued a Call for Comments on the first draft of the Standards for Accreditation of Post-Graduate Fellowships, which were approved for distribution following its January 2013 meeting. The comment period will be open through Monday, April 1, 2013.
Please take time to review the current draft and submit comments by visiting the COA’s website at http://home.coa.us.com.
You can also comment via email to firstname.lastname@example.org
, using the subject line, “Comments- Fellowship Standards.” Thank you for your input and your support of nurse anesthesia education. Contact the COA at email@example.com
with any questions.
Chronic Pain Can Be Limited by Anesthesia Choice
Researcher Michael Andreae, MD, and his associate, Doerthe Andreae, MD, conducted a meta-analysis of 23 trials that compared the use of local or regional anesthesia technology with conventional treatment of pain. They found that, for some procedures, the administration of local or regional anesthesia prior to major surgery may help prevent long-term pain for patients at five to six months postoperatively. Patients who underwent surgery for breast cancer were less likely to experience pain at five or six months postoperatively if they had received a paravertebral block; while thoracotomy patients have a lower likelihood of chronic pain at six months if treated with regional anesthesia, instead of conventional pain control. Arthur Atchabahain, MD, of the Department of Anesthesiology at New York University Langone Medical Center, who was not involved with the study, said the review "is extremely important in that it clearly demonstrates that chronic pain is reduced when regional anesthesia and analgesia are used." He added that "a next step might be to evaluated possible long-term benefits from other modalities of acute postoperative pain control." Andreae noted that as only studies of adults were included in the meta-analysis, he would like to assess chronic pain in children after surgery and would like to expand his findings with another meta-analysis that would assess postoperative pain control following other types of surgical procedures.
From "Chronic Pain Can Be Limited by Anesthesia Choice"
General Surgery News (02/01/13) Vol. 41 McNamara, Damian
Epidural Analgesia May Provide Best Form of Pain Relief for Colorectal Surgery Patients
A study published in the March issue of Anesthesiology directly compares epidural analgesia (EA) and continuous wound infiltration (CWI) of local anesthetics in a randomized, double-blind controlled trial of patients undergoing colorectal surgery. A team of anesthesia providers from the University Hospital of Clermont-Ferrand in France sought to determine whether CWI was a valid alternative to EA for providing effective postoperative analgesia that allows for earlier mobilization, which is a critical part of fast-track anesthesia and surgery programs. The study found that "EA was the superior choice after colorectal surgery," according to lead author Emmanuel Futier, MD, with patients experiencing better pain relief, faster functional recovery, and shorter hospital stays than CWI patients. The findings support the idea that the higher cost and complexity of EA are justifiable since it provides the best form of pain relief for these patients.
From "Epidural Analgesia May Provide Best Form of Pain Relief for Colorectal Surgery Patients"
Steroid Injection May Lead to Worse Outcomes in Patients With Spinal Stenosis
While steroid injections are commonly used to treat spinal stenosis—a narrowing of the spinal canal that leads to back and leg pain, among other problems—new research suggests that epidural steroid injections (ESI) may actually be detrimental to these patients over the long term. Led by Dr. Kris Radcliff of Thomas Jefferson University in Philadelphia, researchers analyzed data from the large-scale Spine Outcomes Research Trial (SPORT). They compared outcomes for 69 patients who received ESI against outcomes for 207 patients who did not, finding markedly less improvement in the ESI group at four years' follow-up—regardless of whether or not the patient eventually had surgery. Moreover, among patients who did receive surgical treatment, the procedure took longer for ESI patients, and their hospital stays were extended by roughly one day compared to non-ESI surgical patients. Reporting in the Feb. 15 issue of Spine, Radcliff and colleagues speculate that ESI injections may actually exacerbate the spinal narrowing or spinal nerve impingement.
From "Steroid Injection May Lead to Worse Outcomes in Patients With Spinal Stenosis"
Science Daily (02/19/2013)
Effect of Preoperative Intravenous Methocarbamol and Intravenous Acetaminophen on Opioid Use After Primary Total Hip and Knee Replacement
Researchers in Florida conducted a retrospective study of total hip and knee replacement patients administered different perioperative pain protocols. One cohort of 150 patients was treated with a 2008 pain protocol, while a second cohort with a like number of patients was treated under a 2011 protocol. The 2011 group, instead of swallowing oral analgesics as part of the preoperative regimen, received intravenous methocarbamol and intravenous acetaminophen prior to surgery. A comparison of outcomes from the two study groups observed improved patient care in the 2011 cohort, as measured by overall opioid consumption following the procedure, pain scores, progression of physical therapy, and hospital discharge times. The investigators ruled out individual surgeon practice patterns as a cause for the differences and attributed the improvement with the 2011 pain protocol at least in part to the switch from oral analgesics to IV acetaminophen and IV methocarbamol. The next step, they conclude, is to conduct a prospective, randomized clinical trial of hip and knee replacement patients who are given the two drugs for 48 hours following surgery.
From "Effect of Preoperative Intravenous Methocarbamol and Intravenous Acetaminophen on Opioid Use After Primary Total Hip and Knee Replacement"
Orthopedics (02/13) Vol. 36, No. 2, P. 25 Looke, Thomas D.; Kluth, Cameron T.
Open Hernia Repair With General Anesthesia Found Less Safe in Study
Open surgery with general anesthesia is the most common approach in the United States for inguinal hernia repair, but new research suggests that better outcomes can be had with local anesthesia. Led by Aaron Rickles, MD, of the University of Rochester, investigators analyzed 71,126 hernia repairs performed between 2005 and 2010. Their findings show that using local anesthesia is safer than general anesthesia not only in open surgery but in laparoscopic procedures as well. Despite the study's limitations—including its reliance on administrative data and its observational nature—it is the first major "real-world" account of the superior safety of laparoscopic hernia repair compared to open repair with general anesthesia. Rickles presented the research at the 2012 Clinical Congress of the American College of Surgeons.
From "Open Hernia Repair With General Anesthesia Found Less Safe in Study"
General Surgery News (02/01/13) Vol. 41 Frangou, Christina
Two 'Lows' Better Than Three for Anesthesia Outcomes
A recent study led by Ankit Maheshwari, MD, an anesthesia resident at Cleveland Clinic, suggests that patients who experience a "double low" of blood pressure and brain function during cardiac surgery are not at greater risk for perioperative death. The finding is contrary to previous research suggesting that a "triple low" of mean arterial pressure (MAP) and low bispectral index (BIS; Covidien) values during low minimum alveolar concentration (MAC) is a strong predictor of mortality in non-cardiac patients. Maheshwari and his colleagues grouped 3,445 patients into categories based on time-weighted BIS and MAP scores but were forced to leave out MAC fraction, as technical reasons made the information unavailable for the targeted patient population. The analysis revealed no significant associations between the four BIS-MAP exposure groups and the reference group with respect to either in-hospital morbidity and mortality or 30-day mortality. Maheshwari noted that the inability to include MAC fraction in the analysis meant that researchers were unable to identify those patients who had low BIS and low MAC, a group that tends to be sensitive to volatile anesthesia and to have especially poor outcomes.
From "Two 'Lows' Better Than Three for Anesthesia Outcomes"
Anesthesiology News (02/01/13) Vol. 39, No. 2 Vlessides, Michael
Ketamine and Atropine for Pediatric Sedation: A Prospective Double-Blind Randomized Controlled Trial
Researchers have found that atropine added to ketamine can significantly reduce hypersalivation in children undergoing surgery. In addition, the drug combination does not appear to have any adverse effects on the procedure duration or success rate. In the study, 200 patients aged two to 15 years were divided randomly into two groups treated by ketamine. One group received excessive intravenous atropine in addition to the ketamine, while the second group received distilled water as a placebo. The researchers note that the mean procedure and sedation time between the two groups were not significantly different. None of the children experienced apnea or laryngospasm during the sedation process.
From "Ketamine and Atropine for Pediatric Sedation: A Prospective Double-Blind Randomized Controlled Trial"
Pediatric Emergency Care (02/13) Vol. 29, No. 2, P. 136 Asadi, Payman; Ghafouri, Hamed-Basir; Yasinzadeh, Mohammadreza; et al.
Study: Emergency Anesthesia Alerts Occur Most Often With Infants
As reported in Anesthesia-Analgesia, researchers at the Mayo Clinic analyzed the characteristics of an electronic visual paging system to see how often emergency anesthesia situations occurred in adults and children. Of more than 258,000 anesthetics performed over a period of nearly five years, a total of 370 emergency pages were recorded. The investigators found that infants had the highest instance of emergency pages and that such alerts were uncommon in children older than two. Respiratory or airway events in children and hemodynamic cases were identified, meanwhile, as the most frequent causes of emergency alerts.
From "Study: Emergency Anesthesia Alerts Occur Most Often With Infants"
Becker's ASC Review (02/13) Linder, Heather
Simple Measures to Promote Sleep Can Reduce Delirium in Intensive Care Patients
Clinicians from The Johns Hopkins Hospital set out to determine if they could mitigate cases of delirium—which can slow down patient recovery—by taking simple steps to promote sleep. Lack of sleep is known to cause delirium, and the hospital environment often is not conducive to a good night of rest due to the level of activity taking place at all hours. The Johns Hopkins investigators introduced changes in the intensive care unit in three phases, first turning off televisions and lights at night, reducing interruptions by staff for dosing and other procedures, curbing overhead pages, and minimizing unnecessary equipment alarms. The second stage involved offering patients eye masks, ear plugs, and serene music; while the final phase centered around discouraging sleep aids that cause delirium. "Each patient was evaluated twice a day for delirium using the Confusion Assessment Method for the ICU (CAM-ICU), a widely used delirium screening tool," said Biren Kamdar, MD, MBA, MHS. "After 13 weeks, during which all of the interventions had been in place, we saw a substantial reduction in patient delirium compared to the baseline group." The group reported their findings online in Critical Care M
edicine ahead of publication in the journal's March issue.
From "Simple Measures to Promote Sleep Can Reduce Delirium in Intensive Care Patients"
FDA Warns on Codeine Use for Children
Children who have had their tonsils or adenoids removed should not receive codeine for their pain, as the medication can cause death, according to the Food and Drug Administration (FDA). The agency says that it will require all codeine-containing products to carry a boxed warning instructing doctors not to use the medication in children. The FDA has received reports of 13 deaths, occurring between 1969 to 2012, among children who had surgery and received codeine-containing drugs afterward. Most of these deaths took place after surgery to remove tonsils and adenoids in children who had sleep apnea. Some children rapidly metabolized the codeine, which caused their livers to convert it into life-threatening amounts of morphine. Growing evidence shows that ibuprofen may be used safely after surgery.
From "FDA Warns on Codeine Use for Children"
Wall Street Journal (02/21/13) P. A2 Dooren, Jennifer Corbett
Georgia Rushes Through Executions Before Lethal Injection Drugs Expire
Efforts to block procurement of the necessary drugs for capital punishment are grinding the process to a halt in the United States, with Georgia being the latest to experience problems with its protocol. Corrections officials there are moving quickly on executions, in a bid to complete scheduled lethal injections before the state's inventory of pentobarbital expires on March 1. Andrew Allen Cook on Feb. 21 became the first death row inmate executed since a shortage of the anesthetic sodium thiopental forced Georgia to switch from a three-drug lethal injection cocktail to a single dose of pentobarbital. Now, state officials are scrambling to carry out the death sentence against Warren Hill—who won a stay of execution when it was discovered that pentobarbital was being ordered for lethal injections without a doctor's prescription—before the March 1 deadline. After that date, Georgia will still have 94 inmates on death row but no clear means by which to execute them. Stores of pentobarbital have become scarce as suppliers in Europe have restricted distribution of the drug in order to keep it from being used for executions. As a result, some of the 33 states that still have the death penalty have had to get creative to acquire lethal injection drugs—some turning to suppliers in India or unlicensed providers and others using compounding pharmacies.
From "Georgia Rushes Through Executions Before Lethal Injection Drugs Expire"
Guardian (United Kingdom) (02/21/13) Pilkington, Ed