Anesthesia E-ssential June 30, 2014

 
Anesthesia E-ssential

June 30, 2014

 

Vital Signs

New Video Answers Malpractice Insurance Questions for Employed CRNAs
AANA President Dennis Bless, CRNA, MS, interviews Director of AANA Insurance Services John Fetcho, CPCU, ARM, in an informative video that answers questions employed CRNAs may have about the agency’s new supplemental malpractice insurance product.
 
In the video, Fetcho explains how supplemental malpractice insurance puts CRNAs in control of their own interests and professional reputation should they become involved in a claim. CRNAs who rely exclusively on their employer or facility for malpractice insurance may have little or no say in how a claim is handled on their behalf.
 
With AANA Insurance Services’ supplemental malpractice insurance, employed CRNAs have an attorney dedicated solely to their interests and protection that goes with them should they change jobs. The numerous benefits of a supplemental insurance plan are spelled out in clear, concise language in this informative video.
 
New graduates and CRNAs within their first two years of practice receive a discount on the already low premium.
 
To learn more, log in to view the Supplemental Malpractice Insurance video: http://www.aana.com/insurance/Pages/Supplemental-Malpractice-Insurance-Toolkit.aspx
 
 

 

The Pulse

 
  • COA Now Accrediting CRNA Fellowships
  • The Joint Commission Issues New Sentinel Event Alert: Preventing Infection from the Misuse of Vials
  • AANA Electronic Medical Record Survey Summary
  • Beware of Hotel Pirates in Orlando
  • NAAC Ambassador Program
  • Additional Member Discounts on AANALearn through July 31, 2014
 
Professional Practice
  • Outbreaks Show Need to Double Check Injection Knowledge, Practices
  • Open Comment Period for AORN Recommended Practices for Surgical Attire 
  • Orlando – The Stars Come Out Again: Another Chance to Become a Star
  • New Fellowship Deadline Dates
  • Donate Now for Annual Congress Recognition
 
  • COA Establishes "Frequently Asked Questions" Webpage
 
  • Meet Your Educational Needs
  • There's Still Time to Save $50 on Your Registration for the 2014 Nurse Anesthesia Annual Congress
  • Registration is Open for the Jack Neary Pain Management Workshops
  • Save the Date for the AANA's Fall Leadership Academy
  • Essentials of Obstretric Analgesia/Anesthesia Workshop
 
 

Healthcare Headlines

Healthcare 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
 
COA Now Accrediting CRNA Fellowships
At its May 2014 meeting, the Council on Accreditation of Nurse Anesthesia Educational Programs (COA) granted accreditation to the Hamline University Post-Graduate Advanced Pain Management Fellowship.  This is the first fellowship accredited by the COA.
 
In January 2014 the COA established Standards for Accreditation of Post Graduate CRNA Fellowships (SPGF). CRNA fellowships will provide advanced educational opportunities for CRNAs to advance their practice and the nurse anesthesia profession. The Fellowship Standards support fellowship offerings in areas of specialty practice such as pediatrics, obstetrics, and pain management or in nonclinical concentrations such as leadership or government affairs.
 
The accreditation process for fellowships is a non-onerous process that includes a post-graduate fellowship assessment prepared by the fellowship to demonstrate compliance with the SPGF and a virtual onsite review by the Fellowship Review Committee. Accreditation may be offered for onetime fellowships, or continuous/intermittent fellowships. Fellowships may be designed to be conducted face-to-face and/or via distance education. Individuals interested in establishing a COA accredited fellowship are encouraged to contact the COA at accreditation@coa.us.com or 847-655-1160.
 
 
The Joint Commission Issues New Sentinel Event Alert: Preventing Infection from the Misuse of Vials
In a Sentinel Event Alert issued June 16, "Preventing Infection from the Misuse of Vials," The Joint Commission describes factors that contribute to the misuse of vials and offers strategies to curb the problem.  The Sentinel Event Alert states that “a significant contributing factor to the misuse of vials is the lack of adherence to safe infection control practices and to aseptic techniques within health care organizations.”  The document provides recommendations and potential strategies that can be used to help prevent the misuse of vials, including resources from the One & Only Campaign.  Download the Sentinel Event Alert in its entirety here.
 
 
AANA Electronic Medical Record Survey Summary
The AANA disseminated an Electronic Medical Record Survey to CRNAs and Chief CRNAs in February. Fifty-four percent (n=2,226) of CRNA respondents indicated that they are using electronic medical records to document elements of anesthesia care. The top three challenges of transitioning from paper to electronic records reported by all respondents included identifying and correcting inconsistencies within a record, software incompatibility, and insufficient staff training. Approximately 20 percent of those surveyed indicated that they did not experience any challenges during their transition. Access the complete survey report.
 
 
Beware of Hotel Pirates in Orlando
AANA has been notified that  hotel—or room—pirates have been reaching out to exhibitors attempting to have them book their hotel rooms outside of the AANA 2014 Nurse Anesthesia Annual Congress room block. Hotel pirates will contact a convention goer—using lists obtained by perusing Web or social networks—and promise better room rates than those advertised. Pirates will call, email, or even create official-looking websites to fool people. After the victim has given his/her credit card information, they’ll find that either they won’t have a hotel room, or the one provided will not be up to par with what group attendees are getting through the room block. Housing pirates are particularly prevalent in major meetings cities like Orlando.
In order to protect themselves, AANA members can take the following precautions:
  • Visit www.aana.com/naac for all meeting needs.
  • Don’t give out credit card information to anyone claiming to be with AANA unless they personally know the staff member. Members can always hang up and call AANA directly to verify who they were talking to.
Should you receive a call or email, please let AANA meetings staff know by calling (847) 655-8797 or emailing meetings@aana.com.
 
 
Be an Ambassador
Have you attended several AANA Annual Meetings and have an interest in an opportunity to share your insights to a successful meeting experience? Follow this link to more information on the new Ambassador Program to help new attendees feel welcome by providing networking advice, or assist in planning an AANA Annual Congress itinerary. 
 
 

Additional Member Discounts on AANALearn through July, 31, 2014
AANA’s online continuing education resource, AANALearn, is featuring the entire Clinical Topics catalog at an additional 30 percent discount for AANA Members now through July 31:
 
Click here for more information.
 
 
 

  

Professional Practice

 
Outbreaks Show Need to Double Check Injection Knowledge, Practices
You might be thinking, “Really? Is a refresher on injection safety needed? I know how to give safe injections!” The truth is that many healthcare providers make mistakes or simply do not know the right injection safety basics. CDC has seen outbreak after outbreak related to healthcare providers not following safe injection practice standards as outlined in CDC guidelines. 
 
Recently, the CDC and the Safe Injection Practices Coalition (SIPC) released an injection safety toolkit geared specifically for toward busy healthcare providers. This free toolkit features an audio PowerPoint, a training video, printed materials, and more! With this information, all providers can refresh their injection safety knowledge and help keep patients safe from unnecessary harm.
 
The bottom line is this: unsafe injection practices place patients at unnecessary risk for exposures to hepatitis B, hepatitis C, HIV, and assorted bacterial infections. Poor practices also put your licenses, accreditation status, and ability to work at risk. We urge all providers to use this information and share it with your colleagues.
 
 
Open Comment Period for AORN Recommended Practices for Surgical Attire
The Association of periOperative Registered Nurses (AORN) is holding an open comment period on Recommended Practices for Surgical Attire. These recommended practices provide guidance for surgical attire including scrub attire, shoes, jewelry, head coverings, and masks worn in the semi-restricted and restricted areas of the perioperative practice setting. This document also provides guidance for personal items such as stethoscopes, backpacks, briefcases, cell phones, and tablets. The comment period closes on July 20, 2014. View the document and submit comments through AORN’s website.
 
 
 

  
 
Orlando – The Stars Come Out Again: Another Chance to Become a Star
Tickets are now on sale for the AANA Foundation fundraiser, Orlando – The Stars Come Out Again, scheduled for Sunday, Sept. 14, 2014. Purchase your ticket when you register for the AANA 2014 Nurse Anesthesia Annual Congress.
 
It’s not too late to apply to be a STAR! You could win a fabulous grand prize—a one-week stay in a three-bedroom penthouse in Sint Maarten. Submit a Talent Application by July 7, 2014. Click here to visit the event webpage, learn more about the event, and access the application.
 
If you have any questions, please contact Luanne Irvin at the AANA Foundation at (847) 655-1173 or lirvin@aana.com.
 
 
New Fellowship Deadline Dates
Nov. 1, 2014, is the new deadline date for FY15 fellowships. Applications will be available after Sept. 1, 2014, on the AANA Foundation website at www.aanafoundation.com
 
Doctoral and Post-Doctoral Fellowship Opportunities – November 1 Deadline
 
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 show evidence of 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 who demonstrate a strong commitment to research. Recipients possess the vision to impact the healthcare system as a doctorally-prepared CRNA. Awarded up to $10,000.
 
Florida Association of Nurse Anesthetists Practice and Research Doctoral Fellowship – Maximum of $3,000 awarded.
 
Kay Wagner Pennsylvania Association of Nurse Anesthetists Practice and Research Doctoral Fellowship – Clinical Doctorate and Research Doctorate – Maximum of $5,000 awarded each.
 
Lorraine D. Dankowski Doctoral Fellowship – Maximum of $10,000 awarded.
 
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 up to $5,000.
 
If you have any questions, please contact the AANA Foundation at (847) 655-1170 or foundation@aana.com.
 
 
Donate Today for Annual Congress Recognition
Thank you to all AANA members who have supported the AANA Foundation in Fiscal Year 2014. Your support is so important in advancing nurse anesthesia education and research. 
 
If you haven’t made your donation yet, please do so by July 1, 2014, to be included in the AANA Foundation’s FY14 Annual Report (donations of $100 or more will be included). Click here to access the Foundation’s secure donation page. 
 
Again, thank you for your support!
 
 
 

 
 
COA Establishes "Frequently Asked Questions" Webpage
Visit the COA’s website to view its new Frequently Asked Questions page. This page was designed to be a dynamic space for addressing current topics in nurse anesthesia accreditation. Current FAQs include the rationale for establishing a minimum total case number requirement of 600 cases rather than proposed 650 cases in the first draft of the Practice Doctorate Standards. The FAQs also include the rational for requiring a minimum number of clinical hours. Both requirements are effective for master’s and doctoral nurse anesthesia programs beginning January 1, 2015. Please contact the COA at accreditation@coa.us.com with any questions you would like to see on the FAQs page.
 
 
 

 
 
Meet Your Educational Needs
AANA has meetings and workshops designed to meet your educational needs. Click here to find out more.
 
 
There’s Still Time to Save $50 on Your Registration for the 2014 Nurse Anesthesia Annual Congress
Orlando has something for everyone. Join us in Orlando for the AANA 2014 Nurse Anesthesia Annual Congress. The Annual Congress brings together thought leaders in the fields of quality, patient safety, and satisfaction to discuss best outcomes through evidence-based practice and quality improvement programs. Register today.
 
 
Registration is Open for the Jack Neary Pain Management Workshops
Interventional pain management demands critical assessment and knowledge to provide proper and precise treatment interventions. Register today for the Jack Neary Pain Management Workshops, Oct. 10-15 in Rosemont, Ill.
 
 
Save the Date for the AANA’s Fall Leadership Academy
Mark your calendars for AANA’s Fall Leadership Academy. The Fall Leadership Academy will be held Nov. 7-9 in Rosemont, Ill. Registration opens in July.
 
 
Essentials of Obstetric Analgesia/Anesthesia Workshop
AANA's Essentials of Obstetric Analgesia/Anesthesia Workshop will address normal and abnormal physiology of pregnancy as well as pharmacology and current techniques in this specialty. Register today.
 
 

  
 
 
CRNA - Cedar Valley Medical Specialists, P.C
Waterloo, IA
Excellent opportunity for a CRNA to join an established group of Anesthesiologists within Cedar Valley Medical Specialists, P.C., in Waterloo, Iowa.
 
Read more about this position (hyperlink):
http://www.crnacareers.com/jobdetails.asp?jobid=2099
 
Visit the CRNA Career Center
 
 

 
 
 
 
Regional Anesthesia Use for Hip-Fracture Surgery Not Associated With Lower Risk of Death
New research finds that administering an epidural instead of using general anesthesia may allow hip repair patients to leave the hospital a little sooner; however, the choice of technique does not impact their mortality risk. There is a push for greater use of regional anesthesia in this type of surgery based on its potential to reduce postoperative complications, according to the study published in the Journal of the American Medical Association. University of Pennsylvania researchers considered 56,729 adults aged 50 or older who had surgery to repair a hip fracture in New York state hospitals between July 2004 and December 2011. Of the study population, 72 percent underwent general anesthesia and 28 percent received epidural, or spinal, anesthesia. While there was no statistically significant difference between the two groups in terms of deaths within 30 days of the operation, patients who had regional anesthesia were discharged from the hospital about half a day sooner than those in the general anesthesia group.
 
From "Regional Anesthesia Use for Hip-Fracture Surgery Not Associated With Lower Risk of Death"
News-Medical (06/25/14)
 
 
 
Waking Up During Surgery Not Tied to PTSD
Based on a small-scale study out of Finland, patients who remain awake during anesthesia and surgery are no more likely than other patients to suffer from posttraumatic stress disorder (PTSD) or other psychosocial problems. Anesthesia & Analgesia published the research, which centered around nine documented cases of "intraoperative awareness" with recall of events that took place in the operating theater. The patients were evaluated for PTSD, anxiety, depression, and other psychiatric disorders a median of 17.2 years after their episodes of awareness. The results, compared against nine patients who had similar quality of life and other traits but who did not experience intraoperative awareness, found no evidence of PTSD in any of the patients who had been awake during a surgery. In fact, there was no significant difference at all in long-term psychosocial outcomes for the two groups. Because the phenomenon is so rare, it has been difficult to learn more about intraoperative awareness; but the few studies done have suggested a correlation between it and PTSD. The new research, although reassuring, does not take that possibility off the table. "We emphasize that it is of utmost importance to try to prevent intraoperative awareness, and when recognized, potentially traumatized individuals should be offered support according to evidence-based guidelines," write the team at the Centre for Military Medicine in Helsinki.
 
From "Waking Up During Surgery Not Tied to PTSD"
Psych Central (06/23/14) Nauert, Rick
 
 
 
Some Fear Children Being Put at Risk by Oxycodone Uptick
Medical experts are warning against the increased use of oxycodone in children, since it could lead to painkiller dependence later in life. Children as young as three have been put on the powerful drug. Statistics from Symphony Health Solutions show that prescriptions of oxycodone rose 34 percent in Massachusetts from May 2011 to April 2014, outpacing the 27 percent uptick in the general population. There was an increase from 11,637 to 15,606 in oxycodone prescriptions for specialties that included child psychiatry and pediatric surgery. Total opioid prescriptions, however, fell in pediatrics, from 62,133 in the first year to 60,749 by the third year. "From my perspective, it's not the right thing to do to prescribe opiates to children, especially to children with chronic pain," said Dr. Jane Ballantyne, a University of Washington professor of anesthesiology and pain medicine. "Their brain can change very easily and does change when it's exposed to drugs. It sets them up with really problematic dependence, even as they become adults." Dr. Karen Fauman, a critical care pediatrician at Tufts Medical Center, said that doctors have been trying to move away from using codeine, and many believe that oxycodone is a more predictable and "safer" drug.
 
From "Some Fear Children Being Put at Risk by Oxycodone Uptick"
Boston Herald (06/23/14) Stout, Matt
 
 
 
Preop Medication Compliance Better With Instruction Combo
According to an article published in the July issue of Anesthesiology, patients did a better job of complying with their preoperative medication regimen when given verbal guidance along with a simple, standardized instruction sheet. The form listed all medications that patients were to take on the day of surgery, those they should not take, and those that could be taken if necessary. Each category, respectively, was marked with brightly colored go, stop, and yield signs. Of 519 control patients who were given traditional preoperative medication instructions and 531 patients who received the instruction sheet combined with verbal instructions, 60 percent of the former group followed the instructions compared to 74 percent of the latter group. The study authors concluded that the use of a standardized sheet can help patient follow directions better. Lead researcher Thomas Vetter, MD, MPH, noted the lack of consistency in delivering medication instructions ahead of an operation. "Our effort to enhance patients' understanding of medication use before surgery is important and can increase patient satisfaction by more actively engaging them in their own health care," said Vetter, who is with the University of Alabama's anesthesia department.
 
From "Preop Medication Compliance Better With Instruction Combo"
Medscape (06/20/14) Frellick, Marcia
 
 
 
Ether or? Nitrous or Nerve Block for Labor
New findings indicate that nitrous oxide (N2O) may be a viable alternative during childbirth when an epidural block is contraindicated or simply not wanted. The researchers conducted a retrospective study of more than 6,000 women who gave birth at the University of California, San Francisco Medical Center between 2007 and 2012. They determined that 14 percent of the women opted to use N2O for pain control—although, of this group, 42 percent also received an epidural injection. It was found that use of N2O did not have a significant impact on the neonates' admission to intensive care, nor on their five-minute Apgar score or on the likelihood that the mother would experience complications. Melissa Rosenstein, MD, a clinical fellow in the Division of Maternal-Fetal Medicine at UCSF, noted that one of N2O's positives is that a woman is not committed to the treatment and can elect to halt it and receive an epidural instead, or simply focus on her breathing. Additionally, N2O does not block the mother's urge to push and can thus be used during the second phase of labor. Rosenstein noted that while the use of N2O is common in Canada and Europe, it is relatively uncommon in the United States; so the findings were released in order to spread awareness of this alternative to epidural blocks.
 
From "Ether or? Nitrous or Nerve Block for Labor"
Anesthesiology News (06/01/14) Vol. 40, No. 6 Raj, Ajai
 
 
 
Study: Opioid-Induced Constipation May Be Vastly Underreported
New research shows that individuals whose chronic noncancer pain is treated with opioids suffer from constipation far more often than is reported by this patient group. Led by N. Nick Knezevic, MD, PhD, director of anesthesiology research at the University of Illinois, the study evaluated 608 chronic noncancer pain patients who were taking opioids and 568 who were taking nonopioid pain medications. Another 572 people randomly plucked from the general Chicago population served as a control group. Nearly a quarter of the opioid patients experienced constipation—compared to just 11.3 percent of those not on narcotics and 9.4 percent in the control group—but only 39 percent of them self-reported the condition. The investigators found that those who had constipation took significantly higher doses of opioids, and they noted an inverse correlation between the opioid dose and the number of bowel movements that patients had each week. While 80 percent of constipated individuals from the other study groups had less constipation after using bulking agents, fiber, stimulants, and stool softeners, only 40 percent of the opioid patients experienced similar relief through these interventions.
 
From "Study: Opioid-Induced Constipation May Be Vastly Underreported"
Pain Medicine News (06/01/2014) Vol. 12, No. 6 Frei, Rosemary
 
 
 
Pre-Surgery Routines Might Be Doing More Harm Than Good for Patients
Mayo Clinic researchers are challenging long-accepted standards for surgery, such as fasting before and after an abdominal procedure and taking IV painkillers as part of recovery. Dr. Robert Cima, who chairs the clinic's surgical safety and quality committee, says there is little scientific basis for today's protocols, which he suggests may even be working against patients' well-being. "A lot of the things we've done in the past don't add up to patient benefit," Cima argues. "We should be trying to get the patient back to being who they were beforehand—starting to eat real food, getting up, walking around, avoiding systemic narcotics." This kind of approach, however, demands tightly coordinated patient care among anesthesia providers, nurses, residents, and all other members of a surgical team. A standard of integrated care likely will not abolish the traditional protocols; more likely, Cima says, it will mean learning to balance the old with the new. "But clearly," he concludes, "you're better off not disturbing the person, and letting their bodies do what they normally do."
 
From "Pre-Surgery Routines Might Be Doing More Harm Than Good for Patients"
PRI's The World (06/22/14) Wernick, Adam
 
 
 
Subconjunctival Lidocaine Lessens Rate of Endophthalmitis After Intravitreal Injection
Research has discovered that when given subconjunctivally as anesthesia, lidocaine's antibacterial properties may lower the rate of endophthalmitis following intravitreal injections. As part of a retrospective chart review, the investigators analyzed more than 15,000 intravitreal injections that were delivered either as a 2 percent lidocaine/0.1 percent methylparaben preparation by itself or in conjunction with other types of anesthesia. For the 6,853 injections where the lidocaine preparation was administered beforehand, there were no cases of endophthalmitis; but there were eight cases among the 8,189 injections that were given along with other anesthetics. Looking at the bactericidal effects of lidocaine, the researchers documented significant reductions in colony-forming units of Staphylococcus aureus, Staphylococcus epidermidis, and Streptococcus viridans. "[Antibacterial] properties of lidocaine may augment the antibacterial effects of povidone-iodine and offer an alternative to topical antibiotics in the setting of emerging microbial resistance and rising health care cost," the researchers concluded.
 
From "Subconjunctival Lidocaine Lessens Rate of Endophthalmitis After Intravitreal Injection"
Healio (06/13/2014)
 
 
 
Anesthesiologists Identify Top 5 Practices That Could Be Avoided
Researchers from the University of Pennsylvania School of Medicine's anesthesiology department spearheaded an effort to identify the most common—but least necessary—perioperative procedures. The findings, published in JAMA Internal Medicine, are based on responses from polled anesthesia providers. Survey participants were asked to identify common surgical procedures that they believe should be challenged. Responses were restricted to preoperative and intraoperative procedures that might be tied to increased costs or poorer-quality care, that have little to no benefits for the patient, and that could easily be ended in practice; postoperative and pain services were not included. The top five activities singled out included administration of blood in young healthy patients with no ongoing blood loss; baseline laboratory studies in healthy patients without significant systemic disease, when blood loss during surgery is expected to be minimal; baseline cardiac testing or cardiac stress test in stable asymptomatic patients with known cardiac disease who are scheduled for low- or moderate-risk noncardiac surgery; routine administration of intravenous fluids for replacement of blood or other fluids without appropriate indications; and the routine use of pulmonary artery catheter for cardiac surgery in patients with a low risk of blood pressure complications. The recommendations were submitted to the American Board of Internal Medicine Foundation's "Choosing Wisely" campaign, which aims to help healthcare providers make high-quality, cost-effective treatment decisions.
 
From "Anesthesiologists Identify Top 5 Practices That Could Be Avoided"
Medical Xpress (06/16/14)
 
 
 
Effort Seeks to Reduce Ear-Tube Surgeries for Small Children
About 667,000 children undergo surgery each year to have ear tubes inserted, but a new set of guidelines could help reduce unnecessary procedures. The American Academy of Otolaryngology—Head and Neck Surgery Foundation last year issued the guidelines, which state that children with recurrent ear infections should only receive ear tubes, also known as tympanostomy tubes, if middle-ear fluid is present in at least one ear at the time of inspection. Children also may be candidates for the implantation if they have persistent fluid buildup in the middle ear of both ears for at least three months, with or without an ear infection. Doctors and parents also want to avoid surgery due to concerns about the use of general anesthesia in young children. One study, published recently in Neuropsychopharmacology, found that children under one year old who received general anesthesia had problems with short-term memory years later. Researchers are looking into devices that would allow the use of alternatives in ear-tube procedures. A new device, called a hummingbird, may let doctors make the incision in the ear drum and insert the tube at the same time, using nitrous oxide instead of general anesthesia.
 
From "Effort Seeks to Reduce Ear-Tube Surgeries for Small Children"
Wall Street Journal (06/17/14) P. D1 Reddy, Sumathi
 
 
 
New Block Technique Improves Total Knee Outcomes
Research out of Virginia Mason Medical Center in Seattle suggests that patients undergoing total knee replacement recover faster and with less need for opioids when a nerve block technique targeting the adductor canal of the mid-thigh is used. According to the study, patients administered a ropivacaine solution through a catheter in the adductor canal did not experience temporary weakness in their legs and reported less pain than those who received a nerve block in the area near the femoral nerve. David Auyong, MD, one of the researchers, said the use of this block technique appears to improve clinical outcomes and patient safety while reducing the length of hospital stays. He added that it would now be used as part of standard practice for knee replacement surgery at the medical center.
 
From "New Block Technique Improves Total Knee Outcomes"
Outpatient Surgery (06/03/14) Burger, Jim
 
 
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