Anesthesia E-ssential

AANA Anesthesia E-ssential, July 18, 2019

Vital Signs

President Brydges Represents AANA on Bipartisan Policy Center Surprise Billing Panel

A panel of healthcare experts organized by the Bipartisan Policy Center met on July 17 in Washington, D.C., to discuss surprise medical bills, a growing concern targeted by Congress for corrective legislative action. The panel, including AANA President Garry Brydges, PhD, DNP, MBA, ACNP-BC, CRNA, FAAN, examined the impact of surprise billing and discussed approaches to solving the problem.

“It was an honor to be invited to participate on the panel,” said Brydges. “The AANA believes it is critically important to address the underlying causes of surprise billing, such as insurance plans engaging in discrimination against providers based on their licensure or certification.”

CRNAs, acting within the scope of their license or certification under applicable state laws or regulations, have long faced harmful discrimination with respect to participation in health plans, thus forcing them to become out-of-network providers. Such discrimination may exacerbate surprise billing, impair consumer choice, reduce competition, and affect healthcare costs.

During the panel, Brydges recommended that Congress direct the Centers for Medicare & Medicaid Services to use its authority to consistently and stringently enforce the federal provider nondiscrimination law that applies to all health plans and ensure that qualified licensed healthcare professionals are paid the same rate for the same service. In 2010, Congress passed this provision in the Patient Protection and Affordable Care Act, which prohibits health plans from discriminating against qualified licensed healthcare professionals, such as CRNAs, solely on the basis of their licensure. Unfortunately, health plans are continuing to discriminate against providers because the federal government does not actively enforce this provision of law.

The Bipartisan Policy Center is a D.C.-based think tank that actively fosters bipartisanship by combining the best ideas from both parties to promote health, security, and opportunity for all Americans. In addition to the AANA, other organizations represented on the surprise billing panel included USC-Brookings Schaeffer Initiative for Health Policy; Center on Health Insurance Reforms, Georgetown University Health Policy Institute; American Economic Institute; Blue Cross Blue Shield Association; American Hospital Association.

Surprise Medical Bills Presentation

President Brydges on Surprise Medical Billing Panel

Surprise Billing Panel

Surprise Billing Panel, Listening

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Agenda, Background Materials, Live Stream Info Available for Annual Business Meeting

The 2019 Annual Business Meeting of the AANA will take place on Saturday, August 10, 2019 at 1:15 p.m. in the Hyatt Regency Chicago hotel. This meeting will be live streamed for viewing by members who cannot attend.

See agenda, background materials and live stream information. (Requires Member Log in)

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Hot Topics

Deadline Extended! Council on Accreditation (COA) Seeking Nominations for Director Opening

The COA is seeking nominations for a University Administrator Director. Candidates must be available to attend three-day COA meetings, typically held in January, May and October. The term of office is three years, beginning Fall 2019 through Fall 2022. The elected candidate then would be eligible to be considered for reelection to a second three-year term. The deadline to apply has been extended to July 22, 2019. For position criteria and application requirements, please visit
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2017 QPP Data Now Available on Physician Compare

The public profiles for clinicians on Physician Compare were updated with 2017 Quality Payment Program (QPP) Performance information. Details about the Physician Compare website can be accessed here. The profiles of CRNAs who were MIPS-eligible and reported data as individual practitioners or in groups also will be displayed on public profiles. More detailed information will be available when the Downloadable Database files for 2017 data are released. If you have questions about the 2017 QPP Performance Information, contact
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Future of Nursing 2020-2030: Agendas for Upcoming Town Halls in Philadelphia and Seattle Now Available

The Committee on the Future of Nursing 2020-2030 is holding regional meetings to hear from you. The committee is interested in your insights on how to advance the profession of nursing to help our nation create a culture of health, reduce health disparities, and improve the health and well-being of the U.S. population in the 21st century.

We have gathered two more groups of speakers for the Philadelphia and Seattle town hall meetings. Learn more about them below.

View the Philadelphia Agenda, Seattle Agenda.
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Message from President Garry Brydges Regarding Follow-up on Special Meeting Request

Dear Colleagues,

On April 16, 2019, the AANA received a formal request from 200+ members representing 25 states to hold a Special Meeting for the purposes of allowing members to vote on the replacement for the vacancy in the FY2019 President-elect position. Members also requested that this meeting occur during the August 10, 2019 AANA Business Meeting to be held in Chicago, Ill.  On April 17, 2019, the AANA Board of Directors held a conference call to discuss the FY2019 President-elect vacancy and decided to schedule an Advisory Vote to allow all eligible voting members to vote on their selection for the new FY2019 President-elect. Since the AANA Bylaws authorize the Board to fill any vacancy on the Board, the Board unanimously decided that following the outcome of the Advisory Vote by the membership, the Board would accept the candidate who receives the most votes in the Advisory Vote and appoint him or her to the Board.

According to the AANA Bylaws, a Special Meeting can only be called to discuss a specific agenda item. The topic of the meeting cannot be changed once the request has been submitted. Therefore, since the AANA Board has agreed to hold an Advisory Vote for all eligible voting members and has committed to appointing the winner, the specified reason for requesting the Special Meeting has been fulfilled. Upon discussion with Erik Rauch, CRNA, the member who coordinated the request for the Special Meeting, both parties concur that the meeting is no longer needed.

As your Board of Directors, we were pleased to select the candidate chosen by the membership to fill the President-elect position for the remainder of FY2019 and then ascend to the position of FY2020 AANA President.

Garry Brydges, PhD, DNP, MBA, ACNP-BC, CRNA, FAAN
AANA President

Statement from Erik Rauch, CRNA, coordinator of the request for a Special meeting
As outlined above, I was the coordinator of a Petition for AANA Special Meeting and Special Election regarding selecting a replacement for the vacancy in the FY2019 President-Elect/FY2020 President position. This petition had more than 1,000 signatures in support of this request. I applaud the AANA Board of Directors for proactively responding to the voice of the membership and agreeing to hold an Advisory Vote to allow participation and input from all eligible voting members.

Furthermore, I wish to thank the AANA Board of Directors for their commitment to filling the FY2019 President-elect vacancy with the candidate chosen by the AANA members through the Advisory Vote. Since the agenda topic of our request for a Special Meeting will be met, I concur that there is no longer a need for a special meeting of the membership. I believe I can speak for many members when I say that we look forward to gathering on August 10 at the AANA Business Meeting to discuss the business of the association and provide further input to the Board on various topics of mutual interest.
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Enrich Your Clinical Skills and Obtain Additional Class A CE Credits with Your Selection of Pre-Congress Workshops

The Pre-Congress Workshops take place Friday, August 9, at the AANA Congress in Chicago. The workshops are:
  • 2019 Peer Assistance and Wellness Workshop Program - Full Day; 7.25 Class A CE Credits
  • Ultrasound-Based Acute and Chronic Pain Procedural Workshop - there is a morning and an afternoon session to choose from; 4.00 Class A CE Credits
  • Ultrasound-Guided Peripheral Nerve Blocks: A Focused Review and Clinical Applications - Full Day; 7.25 Class A CE Credits
  • Obstetrical Regional Anesthesia - A Focused Review and Clinical Applications - Full Day; 7.25 Class A CE Credits
  • Fundamentals in Perioperative Transesophageal Echocardiogram (TEE) Workshop - there is a morning and an afternoon session to choose from; 4.00 Class A CE Credits
Learn more and register now.
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NewsMaker: CRNA Andy Biegner to Supervise Pain Management Fellowship Program

According to Michigan's Fox-TV 47, Andy Biegner, CRNA, FAAPM, USN(ret), will supervise the new University of South Florida College of Nursing Pain Management Fellowship Program at Hillsdale Hospital in Hillsdale, Mich. The fellowship allows for additional days and hours of service to be offered to the local community.

"We seek to improve our patients' quality of life through minimally invasive techniques," Biegner said. "We want our patients to return to their everyday lives free of the chronic pain that may have become their normal in the previous months or even years." Learn more.
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Meetings and Workshops

Annual Congress Product Theater Preview
Clinical Considerations in Neuromuscular Blockade Management

On Sunday, August 11 at 12:00 p.m., speaker J. Dru Riddle, PhD, DNP, CRNA, will address the clinical considerations in neuromuscular blockage management during one of AANA's Product Theaters at the AANA 2019 Annual Congress. Learning objectives include:
  • Understanding the importance of monitoring neuromuscular blockade and recovery.
  • Reviewing clinical data for neuromuscular blockade management.

Stay tuned with updates via and the AANA Meetings app for room assignments.

Presented by: Merck

Merck is pleased to sponsor this program to provide information consistent with FDA guidelines. This program is not an accredited CME program and is not designed to meet any training and/or educational requirements. This medical education program for U.S. healthcare professionals and healthcare business professionals only. The speaker for this program is speaking on behalf of Merck.
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Annual Congress Product Theater Preview
Promoting Medication Safety

Medication safety was recently discussed at the Anesthesia Patient Safety Foundation Conference. This presentation will further explore continued opportunities for anesthesia providers to promote patient safety through the use of safe medication practice.

  • Mark Warner, MD, President, APSF
  • Bernadette Henrichs, PhD, CRNA, CCRN
  • Lynn Reede, DNP, MBA, CRNA, FNAP
Monday, August 12: 12-1 p.m.
Location: Crystal Ball C, West Tower, Lobby Level, Hyatt Regency Chicago
(Lunch is provided.)

Space is limited and pre-registration is required. Registrants will receive an email and will need to bring the email to the Fresenius Kabi booth (#840) to obtain a ticket for the product theater program. The ticket will provide entrance to the program and lunch.

Presented by:

Fresenius Kabi logo
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AANA Member Benefits

Coming Soon: A Premier Event!
AANA Learn ERAS® Webinar Series Explores Opioid Alternatives

In the first of its kind, the AANA is hosting a live webinar series concerning the various aspects of Enhanced Recovery After Surgery® (ERAS) protocols. CRNAs can advocate for patients by educating themselves and other healthcare providers about the importance of ERAS.

The knowledge to drive change.

This unique webinar series will empower you to champion ERAS protocols for your facility. You’ll hear directly from experts in your field and walk away with tips and insights for engaging your team and implementing and measuring an ERAS pathway. You’ll be armed with the knowledge you need to reduce the need for opioids, improve patient outcomes and reduce costs. No doubt you’ll have questions—and there will be time to ask them at the end of each webinar.

You can help solve the opioid crisis.

CRNAs are pain management experts who are uniquely qualified to help solve this problem using ERAS protocols. Be sure to attend the ERAS webinar series and become a change agent for your healthcare organization. Sign-up Today!

Learning outcomes for the webinar series.

Series details and dates:

Webinar 1: View from 30,000 feet: Why should I embrace enhanced recovery?
Speaker: Lynn Reede, DNP, MBA, CRNA, FNAP
Live webinar date: Wednesday, July 31, 2019 from 7:00 PM - 8:00 PM CDT

Webinar 2: Integrating multimodal pain management techniques into my practice
Speaker: Josh Newman, MSN, CRNA
Live webinar date: September 25, 2019

Webinar 3: Metrics to assess your enhanced recovery program for continued improvement and team engagement
Speaker(s): Carol Schmidt, MS, CRNA
Live webinar date: October 30, 2019

Webinar 4: Lessons learned: Meet the interprofessional team
Speaker: Laura Ardizzone, DNP, CRNA, DCC; Kara Douglas, MS, BSN, CRNA; and Josh Magnuson, MS, CRNA
Live webinar date: December 4, 2019

Recognition: Supported by Pacira.

Pacira logo
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Certified Registered Nurse Anesthetist: Memorial Health System, Springfield, Illinois

This position embodies the Memorial Health System Performance Excellence Standards of Safety, Courtesy, Quality, and Efficiency that support our mission, vision and values. Our CRNAs administer general, regional, and MAC anesthesia to patients of all ages and any ASA status. The CRNAs work in a collaborative team environment with 50 CRNAs, 21 Anesthesiologists and 12 Anesthesia Techs to assist with room turnover and stocking. The CRNAs serve as Clinical Instructors for SIUE and Millikin/Decatur Nurse Anesthesia programs.

Due to our continued growth, Memorial Medical Center has multiple needs for Certified Registered Nurse Anesthetists. Positions are available full time in the Main OR, CVOR or as a split 50/50 between Main OR and CVOR. Learn more.
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Professor/Associate Professor of Anesthesiology: Barry University, Hollywood, Florida

Barry University, College of Nursing and Health Sciences, entry-level DNP in Anesthesiology Program, is seeking a full-time faculty member for the Hollywood classroom with travel to four (4) other geographical classroom sites. This position also would involve teaching didactic courses in the Post-Master’s Doctor of Nursing Practice (DNP) with a Specialization in Anesthesiology. Both programs utilize innovative curricula through technology-mediated synchronous and asynchronous instruction. The entry-level DNP Program is a full-time, 36-month intensive residency program with students located in five geographical locations. The locations are Ocala, Orlando, Tampa, West Palm and South Florida. Faculty must be flexible to teach from all locations as needed but primarily the South Florida location.

The Post Master's DNP with a Specialization in Anesthesiology is a 24-month, part-time completion DNP program utilizing blended distance learning. The Post Master's DNP Program requires synchronous webinars, scholarly project advising, and face-to-face meetings with students. Some administrative responsibilities are also expected with this role. Learn more.
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CRNA: Envision Physician Services, New London, Connecticut

Envision Physician Services has an exciting new opportunity for qualified CRNAs to join our team in New London, CT! This is a full-time opportunity to join the well-established group of 11 physicians and over 20 CRNAs. We also will consider part-time candidates who will commit to 24 hours per week. The practice covers Lawrence Memorial Hospital in New London as well as 2 surgery centers in the region. The New London area is located on the coast in Southeastern Connecticut and is centrally located between Boston and New York City.

For more information about these opportunities, please contact Jenny Wimsatt, Senior Clinical Recruiter at W: 615.695.1771 C: 954.383.7256 or email Looking forward to connecting with you! Learn more.
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How Does Your Career Grow?

Are you looking to further your career? CRNA Careers is a valuable resource to help you both in your job search and with your career advancement. It's more than a job board. CRNA Careers is where those searching for fulfillment, opportunity, and challenges go to find helpful career tips, search for jobs, and upload anonymous resumes to be found by recruiters and employers.

Here's how to grow your career on CRNA Careers:

  • Seek and find the best jobs in your industry.
  • Set up job alerts to be notified when the jobs you're looking for are posted on the site.
  • Upload your anonymous resume and allow employers to contact you.
  • Access career resources and job searching tips and tools.

Growing your career requires regular care and cultivation. CRNA Careers has the tools to move your career toward your goals. Learn more today!


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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.

Best Neuraxial Technique for Hip and Knee Arthroplasty Is Spinal Anesthesia

As evidence mounts that neuraxial anesthesia is superior to general anesthesia for joint replacement surgery, researchers are starting to look at which of the neuraxial approaches is optimal. The answer, based on a large single-site study, is spinal anesthesia. Investigators at Weill Cornell Medical College in New York City retrospectively identified 40,852 patients who underwent hip or knee arthroplasty under epidural, spinal, or combined spinal and epidural (CSE) anesthesia between 2005 and 2014. The results indicated that spinal anesthesia significantly reduced the odds for prolonged hospital length of stay and markedly lowered the chances of cardiac, pulmonary, gastrointestinal, and thromboembolic complications compared with CSE. The rate of postoperative complications with epidural anesthesia, meanwhile, was on par with that observed with CSE. "With this growing evidence, and in the absence of data suggesting that neuraxial is worse than general, the results of our study promote the transition from a practice that currently is still largely dominated by a general anesthetic approach in joint arthroplasties in the United States," said lead investigator Stavros Memtsoudis, MD, PhD, a Weill Cornell professor of anesthesiology and public policy and research.

From "Best Neuraxial Technique for Hip and Knee Arthroplasty Is Spinal Anesthesia"
Anesthesiology News (07/16/19) Kronemyer, Bob

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Studies Find Desmetramadol Comparable to Tramadol Minus Metabolic Issues

New evidence indicates that desmetramadol, which is being explored as an analgesic, is as safe and efficient as tramadol but lacks its metabolic drawbacks. The data come from two randomized controlled trials, both of which compared desmetramadol and tramadol. The difference was that one study included paroxetine, a cytochrome P450 (CYP) inhibitor, while the other focused on tramadol without CYP inhibition. The findings revealed that "cytochrome inhibition causes significant reduction in tramadol metabolites and markedly reduces analgesia, whereas cytochrome inhibition has no effect on desmetramadol analgesia," reports researcher Lynn Webster, a past president of the American Academy of Pain Medicine. The importance, he adds, is that as much as 10 percent of the overall population are poor metabolizers—meaning that tramadol is basically ineffective for them. For people who metabolize super fast, meanwhile, tramadol prescriptions could include unsafe levels of active metabolite. "Eliminating the metabolic problems associated with tramadol may yield a more consistent analgesic profile of a drug that has less abuse potential than Schedule II analgesics," Webster remarked. "Hence, desmetramadol could be an option for treating pain that has formally been limited to drugs with greater abuse potential."

From "Studies Find Desmetramadol Comparable to Tramadol Minus Metabolic Issues"
Pain Medicine News (07/15/19) Kronemyer, Bob

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Oral Sedation Satisfactory for Patients Undergoing Cataract Surgery

According to a new study, patients undergoing cataract surgery are equally satisfied whether they receive oral or intravenous (IV) sedation for the process. Researchers at Boston Medical College compared patient satisfaction on postoperative day one in 85 individuals assigned to preoperative care consisting of oral triazolam with IV placebo or IV midazolam with oral placebo. Mean satisfaction scores ranged between 3.75 and 6 in the oral sedation group and between 4 and 6 in the IV group, with the difference meeting the prespecified margin for non-inferiority. Satisfaction with the surgeon and anesthesia provider—secondary outcomes—were comparable between the groups. However, intraoperative complications were more common in the oral group, as was the need for supplemental IV sedation.

From "Oral Sedation Satisfactory for Patients Undergoing Cataract Surgery"
Speciality Medical Dialogues (07/14/19) Baranwal, Medha

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Transforaminal Epidural Steroid Injections May Improve Cervical Radiculopathy Pain

Researchers undertook a systematic review and meta-analysis in an effort to assess the value of fluoroscopically guided cervical transforaminal epidural steroid injection (CTFESI) in suppressing cervical radiculopathy pain. It is thought that CTFESI may provide relief to this patient population by flooding the intervertebral foramen and nearby nerve root with potent corticosteroids. In all, 17 studies were included in the qualitative synthesis and eight were included in the meta-analysis. The primary endpoint was at least a 50 percent decline in pain from baseline to follow-up at four weeks, as reported by the patient. Functional improvements in cervical radicular pain were observed in several studies; however, the tools used to gauge these effects were inconsistent across the board and the evidence overall was very low in quality, based on the GRADE system. For example, none of the 17 studies included an internal comparison group that met the authors' criteria—including patients receiving placebo, sham procedures, and standard treatments. While encouraging, therefore, the researchers say the findings should be interpreted with these and other shortcomings in mind. "Determining the ideal concentration and volume of injectate for CTFESI will require high-quality head-to-head [randomized controlled trials] as single-group observational studies cannot provide these answers," noted the authors, who published their work in Pain Medicine.

From "Transforaminal Epidural Steroid Injections May Improve Cervical Radiculopathy Pain"
Clinical Pain Advisor (07/12/19) Rothbard, Gary

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Study: NSAID, Opioid Combo Better for Post-Surgery Pain Than Just Opioids

Researchers at New York University Hospital for Joints Diseases are adding to the body of work that argues that pairing nonsteroidal anti-inflammatory drugs with opioids is better for postoperative pain than opioids only. Led by Kamali Thompson, the team worked with 40 patients having shoulder surgery, randomly assigning some to take Percocet 5/325 mg alone. The remaining study participants received a 10-count rescue prescription of the Percocet, to be used only if 600 mg of ibuprofen did not satisfactorily quell their pain. According to the investigators, the group that took both ibuprofen and Percocet needed significantly fewer opioids. "It is possible to alleviate postoperative pain with lower amounts of opioids than are currently being prescribed," Thompson insisted. "The public health crisis of opioid abuse requires an immediate solution beginning with the reduction of post-operative narcotics distribution." The researchers presented the findings at the recent annual meeting for the American Orthopedic Society of Sports Medicine.

From "Study: NSAID, Opioid Combo Better for Post-Surgery Pain Than Just Opioids"
United Press International (07/12/19) Dyson, Tauren

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An Alternative Route to Anesthesia-Induced Anaphylaxis

Scientists in Paris believe that immunoglobulin G (IgG) may explain mysterious cases of anaphylaxis triggered by anesthetic agents. Anaphylactic response is mediated in humans by IgE, but as many as a fifth of cases of drug-induced anaphylaxis do not detect reactivity. Researchers suspect that IgG can be implicated as well in this dangerous and potentially fatal condition, but it had only been documented in animals until now. The team asked surgical centers in the Paris area to gather blood samples from patients who suffered an anaphylactic episode after receiving a neuromuscular blocking agent (NMBA). Multiple samples were taken for each of the 86 individuals in the study: at 30 minutes and two hours after symptom onset and at six to eight weeks after the incident. The samples were screened for both IgE- and IgG-mediated anti-NMBA reactivity, the level of which was shown to correlate with the severity of anaphylaxis. Researchers also discovered that severe cases were also possible without an obvious IgE-mediated response. Blood samples with IgG-mediated response, they noted, were characterized by neutrophil activation and raised levels of platelet activating factor, a protein secreted by neutrophils upon IgG activation. At the same time, IgG antibodies isolated from samples were able to activate cultured healthy human neutrophils in the presence of the NMBA. The findings explain "why there are some people who have recurring anaphylactic reactions and yet the usual markers of anaphylaxis that we look for ... are not found," said University of Toronto clinical immunologist Peter Vada, who was not involved in the study. Meanwhile, lead researcher Pierre Bruhns, an immunologist at the Pasteur Institute, acknowledged that knowing the biological mechanism behind an acute anaphylactic attack would not change treatment. However, he said, a positive IgG result—as opposed to simply a negative IgE result—might inform future treatments and help to avoid antigen re-exposure.

From "An Alternative Route to Anesthesia-Induced Anaphylaxis"
The Scientist (07/10/19) Williams, Ruth

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News summaries © copyright 2019 SmithBucklin

Anesthesia E-ssential is an executive summary of noteworthy articles of interest to nurse anesthetists. It is distributed weekly to AANA members.

Anesthesia E-ssential is for informational purposes, and its contents should not be interpreted as endorsements, standards of care, or position statements of the American Association of Nurse Anesthetists.

If you are interested in advertising in Anesthesia E-ssential contact HealthCom Media at 215-489-7000.

For more information on AANA and Anesthesia E-ssential, contact:

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Park Ridge, IL 60068
Phone: (855) 526-2262 (toll-free)/(847) 692-7050
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Attn: Cathy Hodson
E–ssential Editor
July 18, 2019
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