Pneumonia is an infection of the lungs. The air sacs in the lungs (called alveoli) fill up with pus and other fluid, which makes it hard for oxygen to reach the bloodstream. Someone with pneumonia may have a fever, cough, or trouble breathing.

1. Mukesh sah, MD,JI
Virgen Milagrosa University Foundation

3. Introduction
Pneumonia is the leading killer of children, causing
an estimated 1.9 million deaths worldwide under
the age of 5 years.
Pneumonia is an inflammation of the parenchyma
of the lungs.
In developed countries, the diagnosis is usually
made on the basis of radiographic findings.
The WHO has defined pneumonia solely on the
basis of clinical findings obtained by visual
inspection and counting the respiratory rate, for
developing countries.
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5. Important notes??
Lobar pneumonia describes "typical" pneumonia localized
to one or more lobes of the lung in which the affected lobe
or lobes are completely consolidated.
Bronchopneumoniarefers to inflammation of the lung that
is centered in the bronchioles and leads to the production
of a mucopurulent exudate that obstructs some of these
small airways and causes patchy consolidation of the
adjacent lobules.
Interstitial pneumonitis refers to inflammation of the
interstitium, which is composed of the walls of the alveoli,
the alveolar sacs and ducts, and the bronchioles. Interstitial
pneumonitis is characteristic of acute viral infections, but
also may be a chronic process.
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6. Defense mechanism
Lower airways and secretions are sterile as a result of a
multicomponent cleansing system.
Airway contaminants are caught in the mucus secreted by
the goblet cells.
Cilia on epithelial surfaces, composing the ciliary elevator
system, beat synchronously to move particles upward
toward the central airways and into the throat, where they
are swallowed or expectorated.
Polymorphonuclearneutrophils from the blood and tissue
macrophages ingest and kill microorganisms.
IgA secreted into the upper airway fluid protects against
invasive infections and facilitates viral neutralization.
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7. Epidemiology
Pneumonia is a substantial cause of morbidity and mortality
in childhood throughout the world, Immunizations have
had a great impact on the incidence of
pneumonia caused by pertussis, diphtheria, measles, Hib,
and S. pneumoniae.
Where used, bacille Calmette-Guérin (BCG) for tuberculosis
also has had a significant impact.
More than 4 million deaths each year in developing
countries are due to acute respiratory tract infections.
The incidence of pneumonia is more than 10-fold higher
and the number of childhood-related deaths due to
pneumonia ≈2000-fold higher, in developing than in
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developed countries.

8. Rudan et al. Bull World Health Org 2008;86:408-41; Theodoratou et al. in press
• New episodes each year globally in children 1 mo – 5 y (year 2000):
– ~156 million according to WHO clinical definition (~50 million X-ray positive)
• 12–15% are severe episodes requiring hospitalisation: (~20 million cases)
• CFR for community-acquired pneumonia ~1%; for severe pneumonia ~7–10%
• Number of deaths globally: 1,575,000
– 350,000 in neonatal period and 1,225,000 in children 1 mo – 5 y
PNEUMONIA: BURDEN
BIO/SYN/0022/11
Slide with courtesy from Prof. I. Rudan

9. 1. Figure from Black et al. Lancet 2010;375:1969-87; 2. O’Brien et al. Lancet 2009;374:893-902
Approximately one in every
five deaths is attributed to
pneumonia
ALL-CAUSE PNEUMONIA MORTALITY IN CHILDREN
S. pneumoniae causes around
11% of all deaths in children
aged 1–59 months2
Of all pneumococcal deaths in
this period2…
90% from pneumonia
7% from meningitis
3% from serious non-
pneumonia, non-meningitis
clinical syndromes
BIO/SYN/0022/11
Slide with courtesy from Prof. I. Rudan

10. Risk factors
Risk factors for lower respiratory
include:
gastroesophageal reflux,
• tract infections
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neurologic impairment (aspiration),
immunocompromised states,
anatomic abnormalities of the respiratory
residence in residential care facilities for
handicapped children, and
tract,
• hospitalization, especially in an ICU or requiring
invasive procedures.

11. Etiology
Although most cases of pneumonia are
caused by microorganisms,(infectious)
noninfectious causes include:
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aspiration of food or gastric acid,
foreign bodies,
hydrocarbons, and lipoid substances,
hypersensitivity reactions, and
drug- or radiation-induced pneumonitis.

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The infectious agents that commonly cause
community-acquired pneumonia vary by age
The most common causes are RSV in infants ,
respiratory viruses (RSV, parain-fluenza viruses,
influenza viruses, adenoviruses) in children younger
than 5 years old, and
M. pneumoniae and S. pneumoniae in children older
than age 5.
M. pneumoniae and C. pneumoniae are the principal
causes of atypical pneumonia.
Additional agents occasionally or rarely cause
pneumonia as hospital-acquired pneumonia, as
zoonotic infections, in endemic areas, or among
immunocompromised persons.
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13. Etiology
Streptococcus pneumoniae, Haemophilus influenzae (type b,* nontypable)
AGE GROUP FREQUENT PATHOGENS (IN ORDER OF FREQUENCY)
Neonates (<3 wk)
Group B streptococcus, Escherichia coli, other gram-negative bacilli,
3 wk-3 mo
Respiratory syncytial virus, other respiratory viruses (parainfluenza viruses,
influenza viruses, adenovirus), S. pneumoniae, H. influenzae (type b,*
nontypable); if patient is afebrile, consider Chlamydia trachomatis
4 mo-4 yr
Respiratory syncytial virus, other respiratory viruses (parainfluenza viruses,
influenza viruses, adenovirus), S. pneumoniae, H. influenzae (type b,*
nontypable), Mycoplasma pneumoniae, group A streptococcus
≥5 yr
M. pneumoniae, S. pneumoniae, Chlamydophila pneumoniae, H. influenzae
(type b,* nontypable), influenza viruses, adenovirus, other respiratory
viruses, Legionella pneumophila

14. • Causes of pneumonia in immunocompromised
persons include:
gram-negative enteric bacteria,
mycobacteria (M. avium complex),
fungi (aspergillosis, histoplasmosis),
viruses (CMV), and
Pneumocystis jirovecii (carinii).
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• Pneumonia in patients with cystic fibrosis
caused by:
S. aureus in infancy and
usually is
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• P. aeruginosa or Burkholderia cepacia in older patients.

15. Pathogenesis
The lower respiratory tract is normally kept sterile
physiologic defense mechanisms, including
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mucociliary clearance, the properties of normal
secretions such as secretory immunoglobulinA
(IgA), and clearing of the airway by coughing.
Immunologic defense mechanisms of the lung that
limit invasion by pathogenic organisms include
macrophages that are present in alveoli and
bronchioles, secretory IgA, and other
immunoglobulins.
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16.  Viral pneumonia usually results from spread of
infection along the airways, accompanied by direct
injury of the respiratory epithelium, which results in
airway obstruction from swelling, abnormal
secretions, and cellular debris.
 M. pneumoniae attaches to the respiratory
epithelium, inhibits ciliary action, and leads to cellular
destruction and an inflammatory response in the
submucosa.

17. S. pneumoniae produces local edema that aids in
the proliferation of organisms and their spread into
adjacent portions of lung, often resulting in the
characteristic focal lobar involvement.
S. aureus pneumonia manifests in confluent
bronchopneumonia, which is often unilateral and
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characterized by the presence of extensive areas
hemorrhagic necrosis and irregular areas of
cavitation of the lung parenchyma, resulting in
pneumatoceles, empyema, or, at
times, bronchopulmonary fistulas.
of

18. CLINICAL MANIFESTATIONS
Age is a determinant in the clinical manifestations of pneumonia.
Neonates may have fever only with subtle or no physical findings of
pneumonia.
The typical clinical patterns of viral and bacterial pneumonias
usually differ between older infants and children, although the
distinction is not always clear for a particular patient.
Fever, chills,
tachypnea,
cough,
malaise,
pleuritic chest pain,
retractions, and
apprehension, because of difficulty breathing or shortness of
breath.
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19.  Any patient presenting with cough and difficult or
rapid breathing should be considered as a case of
pneumonia.

20. Neonates
 Neonates present with tachypnea, and signs of
respiratory distress such as grunting, flaring and
retractions.
 Fever and cough may be absent; however
hypothermia and temperature instability may
observed.
 Nonspecific complaints, such as irritability or
feeding may be the presenting symptoms
 Cyanosis may be present in severe cases
 Chlamydia trachomatis pneumonia should
be
poor
be
considered in infants aged 2– 4 wks and is often
associated with conjunctivitis.

21. Infants
 After the first month of life, cough is the most common
presenting symptom.
 Infants may have a history of antecedent upper
respiratory symptoms.
 Depending upon the degree of illness, tachypnea,
grunting, and retractions may be noted.
 Vomiting, poor feeding, and irritability are also common.
 Infants with bacterial pneumonia often are febrile, but
those with viral or atypical pneumonia may have
lowgrade fever or could be afebrile.
 Wheezing or noisy breathing. Wheeze suggests a viral
cause.

22. Toddlers and Preschool Children
 A history of antecedent upper respiratory illness is
common.
 Cough is the most common presenting symptom.
 The presence and degree of fever is dependent
upon the organism involved.
 Vomiting, particularly post-tussive, may be present.
 Chest pain may be observed with inflammation of or
near the pleura.
 Abdominal pain or tenderness is often seen in
children with lower lobe pneumonia.

23. Older Children and Adolescents
Atypical organisms, such as Mycoplasma are
common in this age group.
In addition to the symptoms observed in younger
children, adolescents may have other constitutional
symptoms, such as headache, pleuritic chest
pain, and vague abdominal pain.
Headache, fever and myalgia are associated with M.
pneumoniae.
Vomiting, diarrhea, pharyngitis, and otalgia/otitis are
also common symptoms.
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24. Assess for Contributing Etiology
Contact with
Possibility of
Possibility of
person(s) having respiratory infection
foreign body aspiration
primary aspiration
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 Stools consistent with malabsorption
fibrosis)
Sinusitis
Asthma
Growth and nutritional status
Dysmorphic syndromes
Neuromuscular weakness
Cardiac failure
(may suggest cystic
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25. Pneumonia History
Age
Presence of cough,
difficulty breathing,
shortness of breath, chest pain
Fever
Recent upper respiratory tract infections
Associated symptoms
Duration of symptoms
Immunizations status
TB exposure
Maternal Chlamydia,
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Group B Strep status during
Choking episodes
Previous episodes
Previous antibiotics
pregnancy
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26. Pneumonia Severity Assessment

27.  There is no validated criteria for severity assessment
in children >5 years.
 In this age group, pneumonia is considered
the following features (of severe respiratory
are present.
o Respiratory rate >30/min
o Chest wall retraction
o Use of accessory muscles of respiration
o Altered sensorium
severe if
distress)

28. CXR:
Chest radiographs are not needed routinely in all children with
suspected pneumonia.
Specific indications include:
1. When the diagnosis is in doubt (bronchiolitis, asthma, developmental
malformation, foreign body inhalation, aspiration pneumonia etc.)
2.Asymmetrical findings on chest examination
3. Suspected complications of pneumonia (pleural
effusion, empyema, lung abscess etc.)
4. Known case of recurrent chest infection (asthma,cystic
fibrosis, immunodeficiency etc.)
5. Severe and very severe pneumonia
Findings to be looked for in chest radiograph include:
 Parenchymal infiltrates (evidence of consolidation)
 Features of atypical pneumonia (bilateral streaky infiltrate)
 Presence of pneumatocele
 Any evidence of foreign body inhalation
 Pleural spaces for pneumothorax, effusion

29. Arterial blood gas (ABG):
The indications are:
1. Severe and very severe pneumonia
2. Hypoxemia on pulse oxymetry (SpO2
oxygen), cyanosis
3. Shock
<94% on 40%

30. Other Investigations in Hospitalized
Patients
 Hemogram with total and differential leukocyte count
 Serum electrolytes and renal function test
 Blood culture: These are positive in 10%–20% of children with
pneumonia
 Other diagnostic investigations:
In atypical pneumonia: Serology—
RSV, Mycoplasma, Chlamydia
CMV serology (if suspected like immune-compromised and
TORCH group of infection)
 Atypical H1N1 (swine flu) testing during epidemics
CSF (if feasible) in case of
 i. Newborns
 ii. Infants presenting with altered sensorium
 iii. Seizures

31. The indications for hospitalization are:
Age <2 months
Severe and very severe pneumonia (as per WHO
definition)
Signs of shock
Hypoxemia (requirement for supplemental oxygen)
Moderate to severe malnutrition because it increases
risk of mortality
Recurrent chest infection (cardiopulmonary
disease, anatomical defects in airway, neurological
disease)
Immunocompromised state
Not accepting orally, dehydration, vomiting
No response or increased severity (treatment failure)
appropriate oral antibiotic therapy
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 Family unable to provide appropriate care at home.

32. Philippine Academy of Pediatric Pulmonologists,
Inc.2012

33. Baseline Stabilization
 A-B-C
 Resuscitation if required as per the Pediatric Assessment Triangle and
Primary Assessment
 O2 inhalation by nasal prongs, at flow rate 1–5 l/min (depending on age) if
child has lower chest wall indrawing or SpO2 ≤92%.
 First dose of antibiotic as early as possible; preferably after obtaining a
sample for blood culture. However, administration of the first dose should not
be delayed for this.
 Hydration (intravenous or nasogastric tube feed)
i. If child is accepting orally well—allow orally (ad libitum)
ii. If not accepting well orally (but feeding not contraindicated)—Nasogastric
or orogastric feed can be started
iii. Start 0.45 Saline in 5% dextrose as 2/3rd to 3/4th maintenance if there is
respiratory distress (where feed cannot be started) or underlying dehydration
or ongoing losses through vomiting etc.
 Treatment of other emergent co-morbidities
i. Hypoglycemia
ii. Electrolyte imbalance

34. Antibiotic Treatment
The choice of first-line antibiotic therapy is guided by:
 Age of the child
Severity of pneumonia
Associated clinical features suggesting specific etiology
e.g. pustules suggesting Staphylococcal infection
Immune-suppressed or immunocompromised state (such
as post-measles state)
Underlying chronic lung disease e.g. cystic fibrosis
Radiographic pointers towards a specific etiology
(necrotizing pneumonia, pneumatoceles suggest
Staphylococcal infection, parahilar streaky infiltrates are
more common in atypical pneumonia.)
Presence of complication such as
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pneumothorax/empyema.

35. • The WBC count with viral pneumonias is often
normal or mildly elevated, with a
predominance of lymphocytes,
whereas with bacterial pneumonias the WBC
count is elevated (>20,000/mm3) with a
predominance of neutrophils.
Mild eosinophilia is characteristic of infant C.
trachomatis pneumonia.
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36. • Blood cultures should be performed to
attempt to diagnose a bacterial cause of
pneumonia.
Blood cultures are positive in 10% to 20% of
bacterial pneumonia and are considered to be
confirmatory of the cause of pneumonia if
positive for a recognized respiratory pathogen.
Urinary antigen tests are useful for L.
pneumophila (legionnaires' disease).
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37. • A pneumolysin-based PCR test for pneumococcus is
available at some centers and may aid in the diagnosis
of pneumococcal pneumonia.
CMV and enterovirus can be cultured from the
nasopharynx, urine, or bronchoalveolar lavage fluid.
M. pneumoniae should be suspected if cold agglutinins
are present in peripheral blood samples; this may be
confirmed by Mycoplasma IgM or more specifically
PCR.
The diagnosis of M. tuberculosis is established by TSTs
and analysis of sputum or gastric aspirates by culture,
antigen detection, or PCR.
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38. • When there is effusion or empyema,
performing a thoracentesis to obtain pleural
fluid can be diagnostic and therapeutic.

39. • The need to establish an etiologic diagnosis of pneumonia
is greater for patients who are:
ill enough to require hospitalization,
immunocompromised patients (persons with HIV infection,
cancer or transplant therapies, congenital
immunodeficiencies),
patients with recurrent pneumonia, or
patients with pneumonia unresponsive to empirical
therapy.
For these patients, bronchoscopy with bronchoalveolar
lavage and brush mucosal biopsy, needle aspiration of the
lung, and open lung biopsy are methods of obtaining
material for microbiologic diagnosis.
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40. DIFFERENTIAL DIAGNOSIS
The various types of pneumonia-lobarpneumonia,
bronchopneumonia, interstitial and alveolar pneumonias-need to
be differentiated on the basis of radiologic or pathologic diagnosis.
Pneumonia must be differentiated from other acute lung diseases,
including:
lung edema caused by heart failure,
allergic pneumonitis, and
aspiration, and
autoimmune diseases, such as rheumatoid disease and systemic
lupus erythematosus.
Radiographically, pneumonia must be differentiated from lung
trauma and contusion, hemorrhage, foreign body obstruction, and
irritation from subdiaphragmatic inflammation.
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41. TREATMENT
Therapy for pneumonia includes :
supportive and specific treatment.
The appropriate treatment plan depends on the degree of
illness, complications, and knowledge of the infectious
agent or of the agent that is likely causing the pneumonia.
Age, severity of the illness, complications noted on the
chest radiograph, degree of respiratory distress, and ability
of the family to care for the child and to assess the
progression of the symptoms all must be taken into
consideration in the choice of ambulatory treatment over
hospitalization.
Most cases of pneumonia in healthy children can be
managed on an outpatient basis.
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42. • Although viruses cause most community-acquired pneumonias in
young children, in most situations experts recommend empirical
treatment for the most probable treatable causes.
Treatment recommendations are based on the age of the child,
severity of the pneumonia, and antimicrobial activity of agents
against the expected pathogens that cause pneumonia at different
ages.
High-dose amoxicillin is used as a first-line agent for children with
uncomplicated community-acquired pneumonia. third-generation
cephalosporins and macrolide antibiotics such as azithromycin are
acceptable alternatives. Combination therapy (ampicillin and either
gentamicin or cefotaxime) is typically used in the initial treatment
of newborns and young infants.
Hospitalized patients can also usually be treated with ampicillin.
The choice of agent and dosing may vary based on local resistance
rates. In areas where resistance is very high, a third-generation
cephalosporin might be indicated instead. Older children, in
addition, may receive a macrolide to cover for atypical infections.
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43. • Pneumonia caused by S. pneumoniae presents a
problem because of increasing antibiotic
resistance.
In contrast to pneumococcal meningitis,
presumed pneumococcal pneumonia can be
treated with high-dose penicillin or cephalosporin
therapy, even with high-level penicillin resistance.
Vancomycin can be used if the isolate shows
high-level resistance and the patient is severely
ill.
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44. • Empirical antibiotic treatment is sufficient for management
of pneumonia in children, unless there is an exceptional
need to know the pathogen to guide management.
Such exceptional situations include:
lack of response to empirical therapy,
unusually severe presentations,
nosocomial pneumonia, and
immunocompromised children susceptible to infections
with opportunistic pathogens.
Infants 4 to 18 weeks old with afebrile pneumonia most
likely have infection with C. trachomatis, and erythromycin
is the recommended treatment.
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45. Antimicrobial Therapy for Pneumonia Caused by Specific Pathogens*
Pathogen Recommended Treatment Alternative Treatment
Streptococcus pneumoniae† Ceftriaxone, cefotaxime, penicillin
G, or penicillin V
Cefuroxime axetil, erythromycin, or
vancomycin
Group A streptococcus Penicillin G Cefuroxime, cefuroxime axetil, or
erythromycin
Group B streptococcus Penicillin G
Haemophilus influenzae type b Ceftriaxone, cefotaxime, amoxicillin,
or ampicillin
Cefuroxime or cefuroxime axetil
Mycoplasma pneumoniae Erythromycin, azithromycin, or
clarithromycin
Doxycycline (if >9 years old) or a
respiratory fluoroquinolone (if ≥18 years
old)‡
Gram-negative aerobic bacilli
(except Pseudomonas aeruginosa)
Cefotaxime (or ceftriaxone) with or
without an aminoglycoside§
Piperacillin-tazobactam plus an
aminoglycoside§
P. aeruginosa Ceftazidime with or without an
aminoglycoside§
Piperacillin-tazobactam plus an
aminoglycoside§
Staphylococcus aureus Nafcillin or oxacillin Vancomycin
Chlamydophila pneumoniae Erythromycin, azithromycin, or
clarithromycin
Doxycycline(if >9 years old) or a
respiratory fluoroquinolone (if ≥18 years
old)‡
Chlamydia trachomatis (afebrile
pneumonia in infants)
Erythromycin, azithromycin, or
clarithromycin
TMP-SMZ
Herpes simplex virus Acyclovir

46. COMPLICATIONS
Pleural effusion
Empyema
Parapneumonic effusions
Lung abscess
Pneumothorax
Pneumatocele
Delayed Resolution
Respiratory Failure
Metastatic Septic lesions
Activation of latent TB
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47. PROGNOSIS
Most children recover from pneumonia rapidly and
completely.
The radiographic abnormalities may take 6 to 8 weeks
to return to normal.
In a few children, pneumonia may persist longer than 1
month or may be recurrent. In such cases, the
possibility of underlying disease must be investigated
further, such as with TST, sweat chloride determination
for cystic fibrosis, serum immunoglobulin and IgG
subclass determinations, bronchoscopy to identify
anatomic abnormalities or foreign body, and barium
swallow for gastroesophageal reflux.
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48. PREVENTION
Immunizations have had a great impact on reducing the incidence
of vaccine-preventable causes of pneumonia.
Zinc supplementation
RSV infections can be reduced in severity by use of palivizumab .
Reducing the length of mechanical ventilation and using antibiotic
treatment only when necessary can reduce ventilator-associated
pneumonias.
Hand washing before and after every patient contact and use of
gloves for invasive procedures are important measures to prevent
nosocomial transmission of infections.
Hospital staff with respiratory illnesses or who are carriers of
certain organisms, such as methicillin-resistant S. aureus, should
use masks or be reassigned to non-patient care duties.
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