Anesthesia E-ssential

AANA Anesthesia E-ssential

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Be Sure to Vote in the AANA 2017 Election!
Voting ends May 23 at noon CDT

The AANA 2017 election, which started on April 25, will continue until May 23 – 12 noon CDT. For more information, visit the AANA Election Center (member login and password required.)

To vote online, visit Direct Vote and enter your member number and the election passcode provided to you by SBS. If you do not have your election login information, click on the “Email me my login information?” link on the login page and enter the email address on file with AANA, and your election login information will be emailed to you. SBS can be reached by phone at (952) 974-2339 (Monday through Friday, 8 a.m. to 5 p.m. CDT) or by email at If it’s more convenient, please feel free to contact or, and they will ask SBS to re-send you your voting credentials.

Board Candidates Video Speeches Board candidates’ speeches presented at the April Mid-Year Assembly are available on the Election Center page.
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Hot Topics

AANA Nominees Selected for CMS MACRA Episode-Based Cost Measures Clinical Subcommittees

The four nominees that the AANA submitted for the Centers for Medicare & Medicaid Services (CMS) MACRA Episode-Based Cost Measures Clinical Subcommittees—John Hitchens, CRNA; Juan Quintana, DNAP, MSHSA, CRNA; Michael MacKinnon, MSN, FNP-C, CRNA; and Bob Gauvin, MS, CRNA—have been selected to participate on four clinical subcommittees. CMS has contracted with Acumen, LLC, to develop care episode and patient condition groups for use in cost measures to meet the requirements of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). These subcommittees will be responsible for refining episode triggers from the draft list of episode groups posted by CMS in December 2016 and will recommend what services should be included in episode costs. These episode-based cost measures will be reported on provider claims that will be used to attribute patients and episodes to clinicians as part of the cost performance category. Therefore, it is vital that episode-based cost measures account for the true cost of furnishing anesthesia care services.
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Last Chance to Request to Serve on an AANA FY18 Committee
Applications Due Today, Monday, May 15

Positions are available on AANA committees for CRNAs and student registered nurse anesthetists. Check out the committee page on the AANA website to read about the various opportunities. You'll find instructions and the Committee Request Submission form.  Deadline for submission of a committee request is today, May 15, 2017. Please note: If you currently serve on a fiscal year 2017 committee, you must reapply for fiscal year 2018.
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SRNA DualEnroll Coming Soon

Program administrators, have you ever wished you didn’t have to enroll new students with the AANA and NBCRNA separately—on two different sites with two different logins? Soon you’ll be able to cut the time it takes to enroll students in half! How? AANA and NBCRNA are joining forces to bring nurse anesthesia program administrators a single portal to enroll students with both organizations, with one form and one login. SRNA DualEnroll will be available at the end of May 2017. Watch your email inbox for details.
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New AANA Journal Article Offers Solutions to Integrate Infection Control and Anesthesia Safety Measures

The AANA Journal article, "Infection Control and Patient Safety: What Is Desirable and What Is Possible During Anesthesia?," discusses the controversies that arise when anesthesia professionals integrate both essential infection control measures and anesthesia safety practices, and offers potential solutions to optimize patient safety. Specifically it offers recommendations for preparation and testing of laryngoscope blades and handles, hand hygiene during active cases, and drug preparation among other important topics. Online Content Practice News April 2017.
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Notice of CMS Participation Status in MIPS

Beginning in late April 2017, Medicare Administrative Contractors (MACs) will send clinical group practices and individual clinicians a Participation Letter notifying them whether they will be included in the Merit-based Incentive Payment System (MIPS) Program. The Participation Letter includes an attachment indicating which clinicians under the group Tax Payer Identification Number (TIN) will have to report to MIPS based on the MAC's review of clinicians Medicare Part B reimbursement claims. Clinicians who bill more than $30,000 in Medicare Part B service or who provide care to more than 100 Part B beneficiaries in the 2017 performance year are strongly encouraged to participate in the MIPS Program to avoid a 4 percent reduction in their Medicare 2019 reimbursements. For more information on these letters, please go to the FAQs page, and visit the QPP website for more information on the MIPS Program. For more announcements about MIPS under the Quality Payment Program, please visit the AANA Quality-Reimbursement webpage.
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New Online CE Courses Now Available on AANA Learn®

The following course is now available on AANA Learn:

AANA Journal Course No. 37, Part 1: A Tour of Autonomic Reflex Activity Relevant to Clinical Practice

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HVO Needs CRNA Volunteers in Rwanda

Nurse anesthetists with at least 2-3 years’ experience are needed to volunteer at the University of Rwanda College of Medicine and Health Sciences. Volunteers are needed June 19-30, 2017, and July 31-August 25, 2017. For more information contact Kim Rodgers at
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New MIPS Calculator and Advanced APM Fact Sheets

New fact sheets are now available featuring a Merit-based Incentive Payment System (MIPs) Composite Scoring and Payment Adjustments calculator and the essential elements of Advanced Alternative Payment Models for the Medicare 2017 performance year/2019 payment year. The MIPS_Composite_Score_ Fact_Sheet covers participation requirements for MIPS-eligible CRNAs who are not reporting measures for the Advancing Care Information performance category. The fact sheet also describes how to calculate one’s Quality and Improvement Activities performance categories scores as well as how to determine one’s final MIPS Composite Score. The Advanced APM Fact Sheet includes information on how Qualified Participant (QP) status is determined, the Medicare 2017 QP and Partial QP threshold requirements, and the dates when QP status determinations are made. The fact sheets are located and can be accessed on the AANA Quality-Reimbursement webpage.
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Take a Look at the AANA Member Advantage Program for Exclusive Benefits

The AANA Member Advantage Program was designed to foster unique business relationships with companies that offer high-quality products and services to AANA members such as life/health insurance, credit cards, and more. As AANA members, CRNAs and student nurse anesthetists can take advantage of special promotions, discounted products, and customized service from these highly regarded companies. Visit AANA Member Advantage Program. Questions or comments about the AANA Member Advantage Program can be sent to
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Duke University Postdoctoral Fellowship Program in Health Services Research

Join Duke's experienced investigators for a unique one- to two-year postdoctoral training program focused on health services research relevant to CRNAs. Postdoctoral appointment is for one year beginning in fall of 2017 with potential for a second year. Stipends are provided for the fellowship. Application deadline is April 15, 2017. Read the announcement. For more information about this opportunity, visit the Duke University School of Nursing Postdoc Website to access the application form and possible research topics. For more information about additional opportunities, please go to the AANA Research.
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Correction to May Issue of NewsBulletin

In the May issue of the AANA NewsBulletin, the “Discoveries of Distinction” article on page 37 by Victoria Goode, PhD, CRNA, was listed under an incorrect title. The correct title is “A Patient Safety Dilemma: Obesity in the Surgical Patient.” We apologize for the error.
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Professional Practice

Joint Commission Accreditation Surveys Focus on Malignant Hyperthermia Preparedness

Being prepared for a malignant hyperthermia (MH) crisis is essential to anesthesia practice. The Joint Commission and the Centers for Medicare & Medicaid Services (CMS) state surveyors are reportedly increasing scrutiny of this area during facility surveys. Anesthesia staff should be able to answer surveyor questions regarding recognizing MH symptoms, appropriately responding to symptoms, and the location and availability of medications and supplies to treat MH. If those supplies are not nearby, make sure you know the time it will take to obtain them. The surveyors will want to know how you will access the cart in an emergent situation and ensure that the supplies are available in a timeframe that will not compromise patient safety. To prepare for surveys and an MH emergency, it is highly recommended to train staff at all affected locations, conduct realistic drills on how to effectively respond to an MH crisis, and complete relevant risk assessments. For more information, please see the AANA’s Position Statement, Malignant Hyperthermia Crisis Preparedness and Treatment.
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CDC Updates SSI Guidelines

The Centers for Disease Control and Prevention (CDC) has updated its guidelines on the prevention of surgical site infections (SSIs). Recommendations cover areas such as antimicrobial prophylaxis, normothermia, oxygenation, glycemic control, and antiseptic prophylaxis. Read the guidelines.
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Joint Commission Deletes Requirement for Licensed Independent Practitioner Concurrence with the Anesthesia Plan

As part of a review to modernize and streamline its standards, The Joint Commission (TJC) has eliminated the requirement for a licensed independent practitioner (LIP) to concur with the anesthesia plan. TJC stated that it deleted this requirement because this is a clinical care process that is determined by the organization. In addition, this is covered under another standard that requires planning the patient’s care based on needs identified by patient assessment. The concurrence requirement has already been eliminated from the hospital program, and will, effective July 1, 2017, be eliminated from the critical access hospital, ambulatory care, and office-based surgery programs. The AANA is pleased that TJC has deleted this unnecessary and burdensome requirement. For more information on this requirement and other requirements deleted from TJC’s accreditation programs, please see Standards and Elements of Performance Deletions Related to EP Review Phase 111 and Standards and Elements of Performance Deletions for Hospital.
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Meetings and Workshops

12th Annual AANA Wellness Fun 5K Walk/Run

Going to #AANA2017? Join us Sept. 12 for a 5K walk/run benefiting CRNA research! Take in views of the Puget Sound, Seattle skyline, and mountains.
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Visit to view or place job postings
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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.

Obese Have Less Respiratory Insufficiency Than Nonobese During Endoscopy

Surgical teams are especially watchful of obese patients due to a perceived higher threat of complications tied to anesthesia, but new evidence suggests clinicians may be misguided in this focus. In the surprising discovery, researchers found that heavier people actually presented a lower risk of at least one such complication—respiratory insufficiency (RI)—than nonobese people. The 18 obese patients enrolled in the study spent significantly less time with low minute ventilation, a measure of RI, compared to the 43 normal-weight participants, both before and after endoscopic surgery. Investigators from the University of Vermont College of Medicine say the findings suggest that patients of any size should be closely monitored during procedural sedation. Rather than reducing sedative use across the board for potentially at-risk populations, study lead Michael Oberding, MD, believes the better approach is to use real-time sedative dosing through respiratory volume monitors (RVMs) that continuously check for RI. Widespread use of RVMs, he concluded, would allow clinicians to invest their energy in preventing rather than treating RI—which, in turn, promises to enhance patient safety, reduce staffing needs, and curtail healthcare costs.

From "Obese Have Less Respiratory Insufficiency Than Nonobese During Endoscopy"
Anesthesiology News (05/11/17) Covey, Ethan

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Preop Opioid Use Linked to Worse Spine Surgery Outcomes

A new study published in the Journal of Neurosurgery links poorer outcomes after lumbar fusion surgery to preoperative use of opioids. The prospective investigation involved 93 patients with similar demographic and surgical characteristics, 60 of whom used prescription opioids before their procedures. At 12-month followup, those in the opioid cohort had significantly more low back pain, greater disability, and lower SF-36 Physical Component Summary scores than did nonusers. "In general, we found that the patients all got better whether they used opioids or not, but there was a statistically significant difference in the amount of improvement based on whether they used opioids preoperatively or not," explained lead investigator Alan Villavicencio, MD. "This is the first study that has demonstrated this association in a homogeneous population of patients, which should be studied further to confirm these conclusions." He also said the evidence supports the argument for multimodal strategies or other pain management approaches to reduce patient consumption of opioids.

From "Preop Opioid Use Linked to Worse Spine Surgery Outcomes"
Medscape (05/10/17) Melville, Nancy A.

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Risk of Acute Myocardial Infarction With NSAIDs in Real World Use

The results of a new study indicate that all NSAIDs, including naproxen, are associated with a higher risk of acute myocardial infarction. The systematic review was followed by an individual patient data meta-analysis, using studies from Canadian and European health care databases. Based on 61,460 cases of acute myocardial infarction in a cohort of 446,763 individuals, the researchers found that taking any dose of NSAIDs for one week, one month, or longer than one month was associated with a heightened risk of myocardial infarction. The probability of increased myocardial infarction risk with one to seven days of use was 92% for celecoxib; 97% for ibuprofen; and 99% for diclofenac, naproxen, and rofecoxib. A higher risk of myocardial infarction was noted for higher doses of NSAIDs; however, the risks for use beyond a month did not appear to exceed those linked to shorter durations of use. The researchers recommend that "given that the onset of risk of acute myocardial infarction occurred in the first week and appeared greatest in the first month of treatment with higher doses, prescribers should consider weighing the risks and benefits of NSAIDs before instituting treatment, particularly for higher doses."

From "Risk of Acute Myocardial Infarction With NSAIDs in Real World Use"
BMJ (05/09/17) Bally, Michèle; Dendukuri, Nandini; Rich, Benjamin; et al.

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In Endovascular Therapy for Stroke, Monitored Anesthesia Is Safe, Effective

New research has demonstrated the safety and efficacy of monitored anesthesia care (MAC) for endovascular therapy (ET) in patients with acute posterior circulation stroke. A team from the University of Pittsburgh Medical Center compared MAC—which has a perceived risk of complications from possible patient movement—and intubation under general anesthesia (GA)—which could drop blood pressure—in this setting. The retrospective case-control study identified 215 patients with posterior circulation strokes at two academic institutions, but eliminated 39 who required emergent intubation. Of the remaining 176 patients, 63 underwent MAC and 113 received GA. Analysis of clinical and angiographic endpoints in 61 matched pairs found no significant disparity between the two cohorts in terms of 90-day Rankin Scale scores, reperfusion success rate, parenchymal hematomas, wire perforation, good outcome, or 90-day mortality. Reporting in JAMA Neurology, the researchers conclude that "MAC is feasible and appears to be as safe and effective as GA" for ET for posterior circulation stroke, although a randomized clinical trial is needed to confirm the finding.

From "In Endovascular Therapy for Stroke, Monitored Anesthesia Is Safe, Effective"
Neurology Advisor (05/08/17) Aymes, Shannon

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Watching Movies Can Replace General Anesthesia for Kids With Cancer Having Radiotherapy

Pediatric cancer patients typically must be put under to keep them immobile during radiotherapy, but Belgian researchers believe that showing movies instead can spare them the risks of general anesthesia. Projecting a film on the inside of a radiotherapy machine not only reduces anxiety, they report, it also quickens the treatment process and saves money. The study involved 12 children aged 1.5–6 years old, half of whom underwent treatment before a video projector was installed in the radiotherapy machine at one university hospital and half of whom were treated afterward. General anesthesia was required for 83 percent of children's treatments before the video option was made available, but that number fell to just 33 percent after the projector was put in place. Also, because patients were more cooperative and no time had to be carved out for anesthesia preparation, the start-to-finish time for the entire procedure was whittled down to 15–20 minutes from 1 hour or more previously.

From "Watching Movies Can Replace General Anesthesia for Kids With Cancer Having Radiotherapy"
ScienceDaily (05/08/17)

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Alcohol Could Inspire Next Generation of Pain-Meds

Research out of the University of Greenwich suggests that alcohol has an analgesic effect and could lay the foundation for the next generation of pain medications. The study, involving more than 400 participants, showed how elevating blood alcohol content to a level of 0.08 percent slightly boosts an individual's threshold for pain and lowers pain intensity scores by a moderate to large margin. "We found robust evidence that alcohol is an effective painkiller," confirmed lead investigator Trevor Thompson. "Consuming around four units of alcohol—about two pints of beer or medium glasses of wine—resulted in a 24 percent drop in people's pain ratings." He and his colleagues still are unsure exactly how alcohol suppresses pain. One possibility is that it affects the same nerve receptors as ketamine and other analgesics, while another line of thought suggests an indirect relationship whereby alcohol eases pain by reducing anxiety—which could explain why many chronic pain patients also abuse alcohol. "I hope that future work will help us understand the ways in which alcohol can provide pain relief," Thompson said. "This will inform the development of future medication that is both more effective and safer than what we have at the moment."

From "Alcohol Could Inspire Next Generation of Pain-Meds"
Morning Advertiser (05/08/2017) Townshend, Georgina

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Clobazam for Low Back Pain

Benzodiazepines have not garnered a large following as a pain management strategy despite their analgesic properties, but researchers are taking a closer look at clobazam for low back pain. The class is often bypassed for pain due to associated sedative side effects, but clobazam is less sedating than other benzodiazepines. A new crossover study compared outcomes in 49 adults with chronic low back pain, who were treated with clobazam or the active placebo tolterodine in separate sessions buffered by a washout period of at least one week. Participants scored their pain intensity at baseline and then every 30 minutes for two hours after drug administration. The results indicated that clobazam produced greater relief from low back pain than tolterodine, but only in the supine position. Reporting in the European Journal of Pain, the investigators stress that additional research is required before clear treatment recommendations can be made.

From "Clobazam for Low Back Pain"
Clinical Pain Advisor (05/05/17) Rodriguez, Tori

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Is the Baby in Pain? Brain Scans Can Tell

Premature babies often are subject to painful procedures, from heel pricks to tube insertions. While medical personnel now understand that early assumptions about newborns not feeling pain are untrue, they continue to be undertreated for it. Not only is dosage a trouble area when analgesics are used, but some of these drugs are inappropriate for infants in any amount. Babies also are unable to communicate whether or not a pain intervention is working, but researchers from the University of Oxford say they have discovered a workaround for that obstacle: a pain-related brain wave signal that responds to analgesics and could be used to gauge their effectiveness. Using electroencephalography (EEG), they found that painful and painless procedures produced markedly different brain-wave patterns in 18 healthy, full-term babies. The pattern of pain response was repeated in 12 pre-term neonates, who did not react to heel pricking when their feet were anesthetized. “We can now objectively measure pain-related brain activity and determine whether different pain-relieving drugs effectively reduce pain during essential medical procedures,” said Oxford pediatric neuroscientist Rebeccah Slater. The research is published in Science Translational Medicine.

From "Is the Baby in Pain? Brain Scans Can Tell"
Scientific American (05/04/17) Costandi, Moheb

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New Pain Protocol Cut Time to Treatment in Sickle Cell Kids

Canadian researchers studied time to first analgesia in 107 pediatric sickle cell patients who presented with vaso-occlusive crisis at a single Montreal hospital. The chart review included 56 children during a six-month period before the facility changed its pain protocol in an effort to deliver relief faster and 51 children during a six-month period after the switch. In the first leg of the investigation, from January-June 2014, oral morphine was received a mean 95 minutes after patient registration—far longer than the 60 minutes maximum recommended for optimum quality of care. In the second phase, from January-June 2016, intranasal fentanyl was administered a mean 49 minutes after registration, for an improvement of 46 minutes. "There are several goals of treating a sickle cell patient with a pain crisis. The first goal is obviously to control the pain," noted study lead Yves Pastore, MD, who co-directs the institution's sickle cell disease program. "Since intranasal fentanyl acts very quickly, it was reasonable to hypothesize that it might control a pain crisis more efficiently, and reduce hospitalization."

From "New Pain Protocol Cut Time to Treatment in Sickle Cell Kids"
MedPage Today (05/01/17)

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Perioperative Epidural Analgesia Is Not Associated With Increased Survival From Renal Cell Cancer, But Overall Survival May Be Improved

Researchers studied a possible correlation between perioperative epidural and survival rates in patients undergoing surgical excision of localized renal cell carcinoma (RCC). Their retrospective chart review examined data for 438 Cleveland Clinic patients who had the procedure between 1994 and 2008, stratified according to whether they received systemic or epidural analgesia. Using multivariable Cox regression analysis, the investigators determined that administering an epidural during surgical resection of localized RCC significantly improved overall survival but had a negligible effect on cancer-specific survival. Prospective studies could help characterize these associations and help pinpoint the underlying mechanisms, they reported in the Canadian Journal of Anaesthesia.

From "Perioperative Epidural Analgesia Is Not Associated With Increased Survival From Renal Cell Cancer, But Overall Survival May Be Improved"
UroToday (04/27/2017)

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FDA approves label changes for general anesthetic and sedation drugs used in young children

FDA reports that it has approved previously announced label changes regarding the use of general anesthetic and sedation drugs in young children. The revisions include a new warning stating that exposure to the drugs for lengthy periods of time or over multiple surgeries or procedures may negatively affect brain development in children younger than age three. New information has also been added to the sections of the labels about pregnancy and pediatric use to describe studies in young animals and pregnant animals. The research has showed that exposure to general anesthetic and sedation drugs for more than three hours can cause widespread loss of nerve cells in the developing brain. Studies in young animals indicated these changes led to long-term negative effects on the animals' behavior or learning.

From "FDA approves label changes for general anesthetic and sedation drugs used in young children"
FDA MedWatch (04/27/17)

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Dexamethasone Versus Standard Treatment for Postoperative Nausea and Vomiting in Gastrointestinal Surgery

A U.K. study focused on the efficacy of dexamethasone, a corticosteroid, for prevention of postoperative nausea and vomiting (PONV) in people undergoing small or large bowel surgery. The DREAMS trial enrolled 1,350 adult patients from 45 hospitals, roughly half of whom were randomized to standard care. The remaining participants also receive a single intravenous dose of dexamethasone during anesthesia induction. Vomiting within 24 hours—the primary outcome—occurred in 25.5 percent of patients in the intervention group and 33 percent of patients in the control group. Only 39.3 percent of the dexamethasone patients requested additional postoperative antiemetics, meanwhile, compared with 51.9 percent of patients who received routine care only. The supplemental corticosteroid appeared to reduce the incidence of PONV and the need for rescue antiemetics without increasing the incidence of complications.

From "Dexamethasone Versus Standard Treatment for Postoperative Nausea and Vomiting in Gastrointestinal Surgery"
BMJ (04/18/17) Vol. 357 Bartlett, D.; Berkman, L.; Bodenham-Chilton, H.; et al.

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

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Attn: Linda Lacey
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May 15, 2017
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