Community Acquired Pneumonia Alsalama

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Community Acquired Pneumonia:

Community Acquired Pneumonia 7/10/2012 1

Dr Amr Badreldin Hamdy, MD FCCP:

Dr Amr Badreldin Hamdy , MD FCCP Prof Pulmonary Medicine Banha University, EGYPT 7/10/2012 2

Pulmonary Consultant:

Pulmonary Consultant Ibn Nafees Medical Centre ABU DHABI 7/10/2012 3

Objectives:

Objectives Define CAP. Prevalence of CAP. Etiology of CAP. Diagnosis of CAP. Treatment of CAP. Prophylaxis of CAP. 7/10/2012 4

Definition:

Definition 7/10/2012 5

Definition of Pneumonia:

Definition of Pneumonia Pneumonia is an infection of the alveolar space, with accumulation of inflammatory cells and secretions in the alveoli, resulting in impaired gas exchange. 7/10/2012 6

Definition of CAP:

Definition of CAP Community-acquired pneumonia (CAP) is defined as an acute infection of the lung parenchyma accompanied by symptoms of acute illness, which is not acquired in hospitals or other long-term care facilities. - Clin . infect Dis. 2000;31:347-82 7/10/2012 7

Definition cont’d:

Definition cont’d … an acute infection of the pulmonary parenchyma that is associated with some symptoms of acute infection, accompanied by the presence of an acute infiltrate on a chest radiograph, or auscultatory findings consistent with pneumonia, in a patient not hospitalized or residing in a long term care facility for > 14 days before onset of symptoms. Bartlett. Clin Infect Dis 2000;31:347-82 .

Incidence:

Incidence 7/10/2012 9

Incidence:

Incidence Pneumonia is the third most common cause of death among infectious diseases in the world. Lopez & Murray; Nat. Med 4:1241 (1998). Each year, three to four million patients die from pneumonia, a large proportion of whom are children or elderly people. The mortality of CAP is low in outpatients, and rises in hospitalized patients. 7/10/2012 10

Incidence:

Incidence 7/10/2012 11

CAP – Age wise Incidence:

CAP – Age wise Incidence

CAP – Age wise Mortality:

CAP – Age wise Mortality

CAP Co-morbidities:

CAP Co-morbidities 7/10/2012 14

Pneumonias – Classification:

Pneumonias – Classification Nosocomial Pneumonias

Morbid Anatomist’s Classification:

Morbid Anatomist’s Classification Lobar pneumonia Segmental pneumonia Bronchopneumonia 7/10/2012 amr badreldin hamdy MD FCCP 16

Empiricist’s Classification:

Empiricist’s Classification Community-acquired pneumonia Hospital-acquired pneumonia Aspiration pneumonia Immune-compromised host pneumonia 7/10/2012 amr badreldin hamdy MD FCCP 17

Behaviorist’s Classification:

Behaviorist’s Classification Easy pneumonia (responds to initial treatment) Difficult pneumonia (fails to do so). 7/10/2012 amr badreldin hamdy MD FCCP 18

What are the Risk Factors for CAP?:

What are the Risk Factors for CAP?

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Age Obesity(Exercise is protective) Smoking Asthma and COPD Immune-suppression; HIV Institutionalization, Old age homes etc. Dementia ID Clinics 1998;12:723 . Am J Med 1994;96:313

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7/10/2012 21 When To Suspect Which Bug…..

CAP – The Pathogens Involved:

CAP – The Pathogens Involved 40-60% - No causative agent identified 2-5% - Two are more agents identified

Failure To Identify Etiology:

Failure To Identify Etiology A large number of patients have no definite etiology. This may be due to: Prior treatment with antibiotics. Presence of unusual pathogens that go unrecognized e.g. C. burnetti , fungi. Presence of a non-infectious mimic of CAP. Presence of pathogens that are currently not identified or recognized. 7/10/2012 amr badreldin hamdy MD FCCP 23

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Diagnosis of CAP:

Diagnosis of CAP 7/10/2012 29

Diagnosis:

Diagnosis Prompt and accurate diagnosis of CAP is important, since it is the only acute respiratory tract infection in which delayed antibiotic treatment has been associated with increased risk of death. -JAMA 1997;278:2080-4 7/10/2012 30

Diagnosis:

Diagnosis History and physical examination Image study Laboratory -based approach Invasive procedures 7/10/2012 31

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7/10/2012 32

DD of CAP:

DD of CAP

History and Physical Examination:

History and Physical Examination 7/10/2012 34 -Ann Intern Med. 2003;138:109-118

Alternative Causes of Pneumonic Symptoms:

Alternative Causes of Pneumonic Symptoms Cough (asthma, bronchial carcinoma, chronic bronchitis, parenchyma eosinophils) lung disease, ACE inhibitors). Purulent sputum (asthma e.g. eosinophils). Hemoptysis (pulmonary infarction, bronchial carcinoma). Wheeze (airway disease, bronchial carcinoma). 7/10/2012 amr badreldin hamdy MD FCCP 35

Continued:

Continued Pleural chest pain (pulmonary infarction). Breathlessness (airway disease, parenchyma lung disease, pulmonary vascular disease). Fever (inflammatory diseases, e.g. autoimmune disease) 7/10/2012 amr badreldin hamdy MD FCCP 36

Continued:

Continued Radiographic shadowing (pulmonary edema, parenchyma lung disease, bronchial carcinoma, pulmonary infarction, pulmonary hemorrhage). Peripheral blood leukocytosis (asthma, steroid therapy, eosinophilia). 7/10/2012 amr badreldin hamdy MD FCCP 37

What Are The Criteria Of Severe Pneumonia?:

What Are The Criteria Of Severe Pneumonia? 7/10/2012 38

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7/10/2012 39

Chest Imaging:

Chest Imaging 7/10/2012 40

The Value Of The CXR:

The Value Of The CXR Differentiating pneumonia from other conditions that may mimic it. May suggest specific etiologies or conditions, e.g. lung abscess, TB. Can identify co-existing conditions such as bronchial obstruction, pleural effusion. Evaluating the severity of illness by identifying multi-lobar involvement. 7/10/2012 amr badreldin hamdy MD FCCP 41

Potential Causes Of A False Negative CXR:

Potential Causes Of A False Negative CXR Early course of the disease. Dehydration . Neutropenia (because of inability to generate an acute reaction). 7/10/2012 amr badreldin hamdy MD FCCP 42

Focal Opacity:

Focal Opacity S. pneumoniae . H. influenzae . M. pneumoniae . Legionella . Chlamydia pneumonia. S. aureus . M. tuberculosis. 7/10/2012 amr badreldin hamdy MD FCCP 43

Interstitial/Miliary Pattern:

Interstitial/ Miliary Pattern Viruses. M. pneumonia. M. tuberculosis. Pathogenic fungi e.g. H. capsulatum , Coccidioides immitis , Blastomyces dermatidis . 7/10/2012 amr badreldin hamdy MD FCCP 44

Cavitation:

Cavitation Anaerobes. M. tuberculosis. Pathogenic fungi. Gram-negative bacilli. S. aureus . 7/10/2012 amr badreldin hamdy MD FCCP 45

Hilar Adenopathy With Or Without Segmental Or Interstitial Infiltrate:

Hilar Adenopathy With Or Without Segmental Or Interstitial Infiltrate Epstein-Barr virus. Tularemia. Chlamydia psittaci . Pathogenic fungi. Atypical rubella. 7/10/2012 amr badreldin hamdy MD FCCP 46

Normal Chest X-Ray:

Normal Chest X-Ray 7/10/2012 47

Lobar Consolidation:

Lobar Consolidation 7/10/2012 48

LLL Pneumonia:

LLL Pneumonia 7/10/2012 49

RUL and LLL Pneumonia:

RUL and LLL Pneumonia 7/10/2012 50

PA and Lateral Views:

PA and Lateral Views RML RML

Right UL Pneumonia (S. Pneumonia):

Right UL Pneumonia (S. Pneumonia)

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Right middle lobe pneumonia 7/10/2012 53

Right ML Lobar Pneumonia (Pneumococcal):

Right ML Lobar Pneumonia (Pneumococcal) 7/10/2012 54

RLL Pneumonia in emphysema lung:

RLL Pneumonia in emphysema lung

Lobar versus Segmental :

Lobar versus Segmental RML ( Early) Segmental

Lobar Pneumonia:

Lobar Pneumonia Bilateral Multi lobar LUL

Bronchopneumonia:

Bronchopneumonia 7/10/2012 58

Staphylococci abscesses:

Staphylococci abscesses

Special forms of Consolidation:

Special forms of Consolidation Lingular Pneuematocele

Round Pneumonic Consolidation:

Round Pneumonic Consolidation RUL RLL & LLL

Round Pneumonia (S Pneumonia):

Round Pneumonia (S Pneumonia) 7/10/2012 62

CAT Round Pneumonia:

CAT Round Pneumonia 7/10/2012 63

Right UL Pneumonia:

Right UL Pneumonia 7/10/2012 64

Right UL Pneumonia CT:

Right UL Pneumonia CT 7/10/2012 65

Right LL Bronchopenumonia (Patchy Consolidation):

Right LL Bronchopenumonia (Patchy Consolidation) 7/10/2012 66

Atypical pneumonia:

Atypical pneumonia 7/10/2012 67

Mycoplasma Pneumonia:

Mycoplasma Pneumonia 7/10/2012 68

Value of Sputum Examination:

Value of Sputum Examination 7/10/2012 69

Bartlett-criteria:

Bartlett-criteria Requires a high proportion of leukocytes and a low proportion of squamous cells in the sputum. Bartlett et al. (2000); Infect Dis 31:422. Non purulent sputum should not be used for cultures and therefore rejected. Should contain less than 10 epithelial cells and more than 25 neutrophils per low-power field. 7/10/2012 70

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Reliable microbiologic diagnosis can be established in only 20% of all cases. Felmingham et al (2000); J Antimicrob Chemother , 50(S 1):25. 7/10/2012 71

Gram’s Stain of Sputum:

Gram’s Stain of Sputum Efficiency of test S. pneumoniae H. influenza Sensitivity 57 % 82 % Specificity 97 % 99 % Pos itive Predictive Value 95 % 93 % Negative Predictive Value 71 % 96 % Good sputum samples is obtained only from 39% 83% show only one predominant organism

Limitation Of Gram’s Stain:

Limitation Of Gram’s Stain Not all patients can produce a sample. Interpretation is observer dependent. Atypical pathogens cannot be seen. A positive result for pneumococcus is poorly predictive of the ability to recover that organism from a sputum or blood culture. 7/10/2012 amr badreldin hamdy MD FCCP 73

Failure To Identify Etiology:

Failure To Identify Etiology A large number of patients have no definite etiology. This may be due to: Prior treatment with antibiotics. Presence of unusual pathogens that go unrecognized e.g. C. burnetti , fungi. Presence of a non-infectious mimic of CAP. Presence of pathogens that are currently not identified or recognized. 7/10/2012 amr badreldin hamdy MD FCCP 74

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S. Pneumonia diplococci:

S. Pneumonia diplococci

Invasive Procedures:

Invasive Procedures Bronchoscopy Upper airway flora contamination Protected specimen brush (PSB) Pathogen yield rate: 13~48% Bronchoalveolar lavage (BAL) Pathogen yield rate: 12~30% - Thorax 2002; 57:267-271 7/10/2012 77

Blood Culture:

Blood Culture 7/10/2012 78

Pathogens Retrieved from Blood Culture:

Pathogens Retrieved from Blood Culture

What Are The Criteria For Hospital Admission?:

What Are The Criteria For Hospital Admission?

Criteria For Admission:

Criteria For Admission 7/10/2012 81

Treatment:

Treatment 7/10/2012 82

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Objective 2 Objective 1 Avoid emergence of multidrug resistant microorganisms Immediate Rx. of patients with serious sepsis The Therapy Conundrum

Principles For Antimicrobial Use:

Principles For Antimicrobial Use

Criteria For Selection Of Antimicrobial Agents:

Criteria For Selection Of Antimicrobial Agents Most likely pathogens Clinical experience In vitro activity Patient tolerance Epidemiologic setting Exposures Prevalence of drug resistance among respiratory tract pathogens. 7/10/2012 amr badreldin hamdy MD FCCP 86

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Initial antibiotic selection in the acute care setting is always empiric (versus pathogen-directed). Antibiotic selection begins with categorizing the patient with regard to severity and site of care (outpatient, hospital ward, intensive care unit).

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3. For outpatient therapy, antibiotics with activity against drug resistant S. pneumoniae are necessary only in patients at risk, based on comorbidities and recurrent (within three months) antibiotic use. 4. For inpatient therapy, activity against drug resistant S. pneumoniae is always provided.

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5. All antibiotic regimens should ensure activity against atypical pathogens. 6. Activity against enteric gram- ve pathogens, Pseudomonas, S. aureus , and anaerobes is reserved for patients at increased risk. 7. Consider drug allergy history and pregnancy status.

The Importance of Empirical Antibiotic Treatment:

The Importance of Empirical Antibiotic Treatment Despite the improvement in diagnostic methods, some cases of CAP ( may be up to 30%) can ’ t isolate a specific pathogen. -Thorax 2002; 57:267-271 The availability of diagnostic methods - Chest 2001; 120:2021-2034 7/10/2012 90

Practical Approach To Assess Severity of CAP:

Practical Approach To Assess Severity of CAP 7/10/2012 amr badreldin hamdy MD FCCP 91

Immediately Available Criteria:

Immediately Available Criteria Increasing age. Co-morbid illness, addiction. Respiratory rate more than 30 per min. Diastolic blood pressure less than 60 Torr and systolic BP less than 90 Torr. Cyanosis. 7/10/2012 amr badreldin hamdy MD FCCP 92

Criteria Available Soon After Admission:

Criteria Available Soon After Admission Leukocyte count less than 4000 or more than 20 000 cell/mm3. Blood urea more than 19.6 mg/dl. Acidosis. Bilateral lung shadowing. 7/10/2012 amr badreldin hamdy MD FCCP 93

Criteria Available Later:

Criteria Available Later Bacteremia. Abnormal liver functions. Hypo-albuminemia. Progressive radiographic shadowing. 7/10/2012 amr badreldin hamdy MD FCCP 94

Pneumonia Severity Index:

Pneumonia Severity Index

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Who Should be Hospitalized?:

Who Should be Hospitalized? Class I and II Usually do not require hospitalization Class III May require brief hospitalization Class IV and V Usually do require hospitalization Severity of CAP with poor prognosis RR > 30; PaO 2 /FiO2 < 250, or PO 2 < 60 on room air Need for mechanical ventilation; Multi lobar involvement Hypotension; Need for vasopressors Oliguria; Altered mental status

CURB 65:

CURB 65

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7/10/2012 102

Choice Of Therapy:

Choice Of Therapy 7/10/2012 amr badreldin hamdy MD FCCP 103

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The major variables that influence the spectrum of etiologic agents and the initial approach to therapy are: The severity of illness at initial presentation. The presence of co-existing illness. Presence of identified clinical risk factors for drug-resistant and unusual pathogens 7/10/2012 amr badreldin hamdy MD FCCP 104

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Empirical Treatment for Out-Patient:

Empirical Treatment for Out-Patient Macrolide ( clarithromycin or azithromycin for H. influenzae ) Fluoroquinolones Doxycycline Amoxicillin- clavulanate 2nd generation cephalosporin -Chest 2001; 120:2021-2034 7/10/2012 107

Empirical treatment for In-patient (General Ward):

Empirical treatment for In-patient (General Ward) 3rd generation cephalosporin plus a macrolide or doxycycline Antipneumococcal fluoroquinolones Betalactam -beta- lactamase inhibitor plus a macrolide or doxycycline -N Engl J Med 2002; 347:2039-45 7/10/2012 108

Switch Therapy:

Switch Therapy Or step-down therapy, refers to the use of the same drug first intravenously and then orally . 7/10/2012 amr badreldin hamdy MD FCCP 109

Advantages Of Early Switching:

Advantages Of Early Switching Shorter hospital stay. Cost savings in drugs, nursing time, and IV solutions. Fewer hospital related complications e.g. phlebitis, falls. Greater patient satisfaction . 7/10/2012 amr badreldin hamdy MD FCCP 110

Continued:

Continued 5. Avoidance of IV line complications. 6. Lower cost of oral agents. 7. Oral administration facilitates discharge. 7/10/2012 amr badreldin hamdy MD FCCP 111

:

Rapid switch therapy is believed to be successful in pneumonia treatment because the lung is highly vascular , permitting the achievement of adequate levels of the antibiotic at the site of infection, the lung and the macrophages. 7/10/2012 amr badreldin hamdy MD FCCP 112

Continued:

Continued If antibiotic penetration into the infected lung is expected to be poor for a particular patient e.g. presence of lung abscess, necrotizing pneumonia or empyema , then switch therapy is not recommended . 7/10/2012 amr badreldin hamdy MD FCCP 113

Sequential Therapy:

Sequential Therapy This refers to the use of an intravenous antibiotic therapy followed by oral therapy with a drug from another antibiotic class. 7/10/2012 amr badreldin hamdy MD FCCP 114

Duration Of Therapy:

Duration Of Therapy Because the natural course of treatment response, antibiotic therapy should not be changed within the first 72 hours, unless there is marked clinical deterioration, or if bacteriologic data necessitate a change. 7/10/2012 amr badreldin hamdy MD FCCP 115

Treatment Failure:

Treatment Failure It is defined as lack of clinical improvement after 72 hours of treatment or worsening of the clinical situation. 7/10/2012 116

Lack of response or deterioration :

Lack of response or deterioration Host factors Elderly Immunosuppressed Bacteraemia Chronic illness Diabetes Alcoholism Second nosocomial pneumonia Misdiagnosis Pulmonary embolus CCF Pulmonary haemorrhage Pulmonary vasculitis BOOP Acute interstitial pneumonitis Eosinophilic pneumonia Hypersensitivity pneumonitis Local factors Effusion/ empyema Abscess

Management of Poor Responders:

Management of Poor Responders Consider non-infectious illnesses Consider less common pathogens Consider serologic testing Broaden antibiotic therapy Consider bronchoscopy

How Best to Win the War?:

How Best to Win the War? Early antibiotic administration within 4-6 hours Empiric antibiotic Rx. as per guidelines (IDSA / ATS) PORT – PSI scoring and classification of cases Early hospitalization in Class IV and V Change Abx. as per pathogen & sensitivity pattern Decrease smoking cessation - advice / counseling Arterial oxygenation assessment in the first 24 h Blood culture collection in the first 24 h prior to Abx. Pneumococcal & Influenza vaccination; Smoking X

When Can The Patient be Discharged?:

When Can The Patient be Discharged? 7/10/2012 120 -N Engl J Med 2002; 347:2039-45

Mortality of CAP – Based on Pathogen :

Mortality of CAP – Based on Pathogen P. aeruginosa - 61.0 % K. pneumoniae - 35.7 % S. aureus - 31.8 % Legionella - 14.7 % S. pneumoniae - 12.0 % C. pneumoniae - 9.8 % H. influenza - 7.4 %

Strategies for Prevention of CAP:

Strategies for Prevention of CAP Cessation of smoking Influenza Vaccine ( Flu shot – Oct through Feb) It offers 90% protection and reduces mortality by 80% Pneumococcal Vaccine ( Pneumonia shot ) It protects against 23 types of Pneumococci 70% of us have Pneumococci in our RT It is not 100% protective but reduces mortality Age 19-64 with co morbidity of high for pneumonia Above 65 all must get it even without high risk Starting first dose of antibiotic within 4h & O 2 status

The Influenza Vaccine:

The Influenza Vaccine The influenza vaccine (the ‘flu shot’) is offered during the ‘flu season’, which is October through March. Studies have shown the flu vaccine can be up to 90% effective in preventing flu in healthy adults, but may be less effective in elderly or chronically ill persons. The good news is up to 80% of deaths from the flu could be prevented with a flu shot. 7/10/2012 123

The Pneumococcal Vaccine:

The Pneumococcal Vaccine The pneumococcal vaccine (the ‘pneumonia shot’) protects against 23 types of pneumococcal bacteria. Researchers know the vaccine is not 100% effective in preventing pneumonia, but they’ve found that if you are vaccinated you are less likely to die from pneumonia. 7/10/2012 124 If you are between 19 and 64 years of age, you may need to have the pneumonia shot if you have a medical condition which puts you at a higher risk of getting pneumonia.

The Pneumococcal Vaccine:

The Pneumococcal Vaccine Everyone age 65 or older should have one lifetime dose of the pneumonia shot. However, if you received the pneumonia shot before the age of 65, you need to wait at least 5 years before you get the ‘after 65’ pneumonia shot. 7/10/2012 125

Vaccination for Prevention of CAP:

Vaccination for Prevention of CAP 7/10/2012 126

Complications:

Complications

Complications:

Complications Hypotension and septic shock 3-5% pleural effusion ; clear fluid + pus cells 1% empyema thoracis pus in the pleural space Lung abscess – destruction of lung - CSLD Single (aspiration) anaerobes, Pseudomonas Multiple (metastatic) Staphylococcus aureus Septicemia –brain abscess, liver abscess Multiple pyemic abscesses Organizing pneumonia Bronchiectasis

Pneumonia Consolidation and Abscess:

Pneumonia Consolidation and Abscess 7/10/2012 129

Pus Filled Cavity:

Pus Filled Cavity 7/10/2012 130

Complications of Pneumonia:

Complications of Pneumonia Empyema Lung Abcess

Lung Abscess:

Lung Abscess 7/10/2012 132

Empyema:

Empyema 7/10/2012 133

Empyema:

Empyema 7/10/2012 134

Empyema:

Empyema Empyema CT Empyema

Empyema:

Empyema

Emerging Threats:

Emerging Threats Community Acquired Methicillin - Resistant S aureusl Avian influenza. 7/10/2012 137

Recurrent Pneumonia:

Recurrent Pneumonia

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Elderly patients. Smokers . Chronic pulmonary disease. Impairment of local host defense (e.g. bronchial obstruction, localized or diffuse bronchiectasis )

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Impairment of general immunity (e.g. denutrition , IV drug abuse, alcoholism, cirrhosis chronic renal failure, nephrotic syndrome chronic heart failure, chronic humoral deficiency such as Ig quantitative or qualitative abnormalities, asplenia , sickle-cell disease, neutrophils , underlying cancer or hematologic malignancy, HIV infections and other T-cell deficiencies).

Conclusion:

Conclusion

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References:

References

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Mintz ML (2006): Disorders of the Respiratory Tract . Humana Press. Seaton A el al (2000): Crofton and Douglas’s Respiratory Diseases , 5 th edition. Blackwell Science. Mason RJ et al (2010): Murray & Nadel’s Textbook of Respiratory Medicine , 5 th edition. Saunders Elsevier.

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I hope I was not boring !!!!! 7/10/2012 145

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