Prospective Study of a Self-Report Type A Scale and Risk of Coronary Heart Disease
Test of the MMPI-2 Type A Scale
Background—Several methods exist by which to assess type A behavior (TAB). Although the videotaped clinical interview is regarded as the “gold standard,” self-report measures have also proved useful in assessing TAB in large population studies. The purpose of this study was to examine prospectively the relationship of TAB to risk of coronary heart disease (CHD) incidence with the use of the revised Minnesota Multiphasic Personality Inventory (MMPI-2) Type A Scale. To the best of our knowledge, this is the first test of this scale in the context of predicting CHD incidence.
Methods and Results—The study was performed in the VA Normative Aging Study, an ongoing cohort of older (mean age, 61 years) community-dwelling men. A total of 1305 men who were free of diagnosed CHD in 1986 completed the MMPI-2 Type A Scale. During an average 7.0 years of follow-up, 110 cases of incident CHD occurred. Compared with men in the lowest quartile of type A scores, men in the highest quartile had multivariate adjusted relative risks of 2.86 (95% CI, 1.19 to 6.89; P for trend=0.016) for combined CHD death and nonfatal myocardial infarction (MI) and 2.30 (95% CI, 1.32 to 4.01; P for trend=0.001) for combined CHD death/nonfatal MI plus angina pectoris. The relationship of TAB to CHD was independent of measures of anger and cynicism.
Conclusions—The MMPI-2 Type A Scale predicts CHD incidence. Further research is warranted to examine the correlation, if any, between this scale and the videotaped clinical interview.
Research on TAB peaked during the 1980s, accompanied by high levels of enthusiasm for the screening and diagnosis of this behavior pattern and psychosocial interventions aimed at modifying the risk of CHD.1 However, conflicting evidence on the relationship between TAB and CHD in epidemiological studies2 3 4 has led some observers to question the clinical utility of identifying this behavior pattern.5 6 7
Part of the reason for the conflicting evidence linking TAB to coronary risk may be the differences in methods used by researchers to identify this behavior pattern. Broadly, 2 approaches exist for diagnosing the type A pattern: the structured interview approach (also known as VCE8,9) and various self-report questionnaire-based approaches, such as the JAS,10 the Framingham Type A Scale,11 and the Bortner Scale.12 The advantage of the VCE approach is that it provides a situation in which TAB may be directly observed. As formulated by Friedman,13 TAB is an action-emotion complex that requires an environmental challenge to serve as the trigger for expression. The overt manifestations of the behavior pattern include a free-floating but well-rationalized hostility, hyperaggressiveness, and a sense of time urgency. Visual cues to TAB, such as hurried speech and hostile facial expressions, are most likely to be caught during the VCE. By contrast, self-report assessments of TAB are unlikely to capture these aspects of behavior, which are often beyond a subject’s awareness. It is notable, therefore, that epidemiological studies reporting no association between TAB and CHD2 3 4 have tended to use questionnaire-based approaches, whereas interview-based approaches have continued to report an association.14 15 16 17 18
The conflicting results of studies based on self-reported assessment of TAB may occur in part because existing questionnaires inquire about some but not all of the components of this action-emotion complex.19 For example, the JAS (a commonly used self-report instrument in previous US studies2,3) includes subscales for hard-driving competitiveness, speed and impatience, and job involvement. However, the instrument does not contain many items regarding hostility or aggressiveness. Another commonly used questionnaire, the Framingham Type A Scale,11 assesses an individual’s sense of time urgency, competitive drive, and perceptions of job pressures but not the level of hostility (which is measured by a separate scale). Thus, different questionnaires have tended to emphasize different components of the TAB pattern.
In contrast to earlier scales such as the JAS, the MMPI-2 Type A Scale incorporates a broader set of components that have been identified as being potentially “toxic”: hostility, competitiveness, and time urgency. It is possible that it is the combination of the above components, rather than any one in isolation,20 that increases coronary risk, so a global assessment of TAB (such as provided by the MMPI-2 scale) might provide a better prediction of CHD. Therefore, the purpose of the present study was to examine prospectively the ability of the MMPI-2 Type A Scale to predict CHD incidence. To the best of our knowledge, this is the first report of the use of the MMPI-2 Type A Scale in the context of predicting CHD incidence in a cohort of disease-free individuals.
The study was carried out in the Normative Aging Study, which is a longitudinal study of aging established by the Veterans Administration in 1961.21 The study cohort consists of 2280 community-dwelling men from the greater Boston area who were 21 to 80 years of age at the time of entry. Volunteers were screened at entry according to health criteria20 and were free of known chronic medical conditions (including diabetes mellitus) at the start of follow-up.
Assessment of TAB
In 1986, the MMPI-222 was administered by mail to all active cohort members (n=1881). Of the 1550 men who responded (82.4% response rate), complete and valid questionnaire data were available for 94% (n=1459). We excluded 154 men with preexisting CHD (angina pectoris or history of MI), resulting in a study population of 1305 men. The mean age of the study population was 61.8 years (SD, 8.3 years; range, 40 to 90 years).
TAB was assessed prospectively, ie, before the onset of coronary heart disease. The MMPI-2 Type A Scale is made up of 19 items that require true or false responses to questions about time urgency, competitiveness, and hostile attitudes (see the “Appendix”). High scorers on the type A scale are described as hard-driving, fast-moving, and work-oriented individuals who frequently become impatient, irritable, and annoyed. The scale was developed from the MMPI Restandardization Project involving a national, representative sample of 2600 subjects (1138 men and 1462 women).23 Butcher et al23 developed the scale from a multistep process involving the rational identification of content areas (independent rater selection of items from the total MMPI pool and expert consensus on selection of items) and statistical verification of item-to-scale membership. The type A scale has excellent 9-day test-retest reliability (r=0.82) and internal consistency reliability (Cronbach’s α=0.72) in men.23 Responses to the scale have been validated against spousal ratings of behavior. Specific behaviors described by spouses of high-TAB men include having temper tantrums; acting bossy; arguing over minor things; and being irritable, angry, and tense.23 Responses to the type A scale were categorized a priori into 4 approximately equally sized groups on the basis of the distribution of scores in this population: 0 to 4 (24.5%), 5 to 7 (29.1%), 8 to 10 (23.8%), and ≥11 (22.7%).
Assessment of Anger, Cynicism, and Hostility
From the MMPI-2, we also assessed levels of anger and cynicism, both of which have been reported previously to be correlated with TAB, to predict the risk of CHD.24 25 26 27 The MMPI-2 Anger Content Scale is made up of 16 items that require true or false responses to questions about expression or control of anger. It has high test-retest reliability (r=0.85) and internal consistency reliability (Cronbach’s α=0.76) in men.23 This scale has been shown previously to predict a 2- to 3-fold increased risk of CHD incidence in this cohort.25 High scores on the scale suggest anger-control problems. These individuals report being irritable and hotheaded and sometimes feeling like swearing or smashing things. Individual items on the MMPI-2 anger scale are quite similar to those of other scales, like the Spielberger Anger Expression Scale,28 which measures aspects of anger such as frequency of the expression of anger directed at other people or objects (Anger-Out Subscale) and the extent to which a person works to control the experience and expression of anger (Anger-Control Subscale). Responses to the anger subscale were categorized a priori into 3 levels on the basis of the distribution of scores in this population: 0 or 1, 2 to 4, and 5 to 14.
The MMPI-2 Cynicism Scale comprises 23 items that inquire about misanthropic beliefs. The scale also has excellent test-retest reliability (r=0.80) and internal consistency reliability (Cronbach’s α=0.86).23 Individuals who score high on this scale expect hidden, negative motives behind the acts of others, eg. believing that most people are honest simply because they fear being caught. These individuals are likely to hold negative attitudes toward those close to them, including fellow workers, family, and friends.22 Items on the cynicism scale overlap with many of the questions that make up the 50-item Ho Scale,29 which some have suggested measures “cynical hostility.”30 Because the Ho Scale has been linked to CHD incidence in some studies, some researchers have claimed that it taps into the toxic core of TAB.31 32 33
Finally, we examined 3 additional subscales in the original MMPI related to hostility and aggression.27 These subscales—“hostile affect” (5 items), “hostile attribution” (12 items), and “aggressive responding” (9 items)—were developed by Barefoot et al27 from a subset of the Ho Scale items and have been demonstrated to predict CHD incidence and all-cause mortality.27 Hostile affect measures the negative emotions associated with social relationships, and high scores reflect anger, impatience, and loathing when dealing with others. Hostile attribution measures the tendency to interpret the behavior of others as intended to harm the respondent, and high scores reflect suspicion, paranoia, and fear of threat to the self. Aggressive responding measures the respondent’s tendency to use anger and aggression as instrumental responses to problems or to endorse these behaviors as reasonable and justified.27
Measurement of Other Cardiovascular Risk Factors
Every 3 to 5 years, participants in the Normative Aging Study are assessed by physical examination, updating of medical history, and measurement of a variety of biochemical values, including serum cholesterol. Cigarette smoking status (current, former, or never) is ascertained by a trained interviewer. Current smokers are defined as men who smoke ≥1 cigarette per day. Weight and height are measured with the participants wearing only socks and underpants. Body mass index (weight/height2) is then calculated. Blood pressure is measured by an examining physician with a standard mercury sphygmomanometer with a 14-cm cuff. With the subject seated, systolic blood pressure and fifth-phase diastolic blood pressures are measured in each arm to the nearest 2 mm Hg. The average systolic and diastolic blood pressures in both arms were used in analyses. Only 8 individuals in the study population were receiving oral hypoglycemic agents or insulin.
Assessment of Morbidity and Mortality
The average length of follow-up in the present study was 7.0 years (SD, 2.3 years). The present study includes all confirmed CHD end points (angina pectoris, myocardial infarction, fatal CHD) that occurred during the average 7 years of follow-up. Individuals were censored either at the time of developing a coronary end point (or death) or from the time of their most recent follow-up visit.
A medical history was obtained from each participant at his regular follow-up visit every 3 to 5 years. The hospital records were obtained for every report of a possible CHD event and reviewed by a board-certified cardiologist (P.S.V.). The criteria for myocardial infarction and angina pectoris were those used in the Framingham Heart Study.34 MI was diagnosed only when documented by unequivocal ECG changes (ie, pathological Q waves), by a diagnostic elevation of serum enzymes (serum glutamic–oxalacetic transaminase and lactic dehydrogenase) together with chest discomfort consistent with MI, or by autopsy. Angina pectoris was diagnosed when the subject reported recurrent chest discomfort lasting up to 15 minutes, which was distinctly related to exertion and relieved by rest or nitroglycerin.
Death from CHD was designated when a death certificate (coded according to the eighth revision of the International Classification of Diseases35) indicated an underlying cause of death coded to rubric 410 through 414. The medical records in each instance of CHD death were reviewed by a board-certified cardiologist (P.S.V.) to ensure accurate coding. Most deaths occurring in this cohort are notified through next of kin or postal authorities. Every year, birthday cards have been mailed to participants in the cohort, at which point news of a participant’s death is likely to be reported to the investigators by the next of kin. Additional opportunities to ascertain the vital status of participants occur when supplemental questionnaires are mailed to participants approximately annually. Finally, we routinely search the state vital records and the records of the Department of Veterans Affairs to find deaths that may have gone unreported. Thus, our ascertainment of fatal events is both systematic and comprehensive.
We ran proportional hazards models using SAS36 to estimate the relative risks of CHD according to different levels of type A score, controlling for a range of potential confounding variables ascertained in 1986, including age (years), body mass index (kg/m2), smoking status (never, former, current), systolic and diastolic blood pressure (mm Hg), serum cholesterol level (mg/dL), family history of heart disease (yes/no), and whether the participant drank ≥2 drinks of alcohol per day (yes/no). The multivariate probability value for linear trend in the relative risk was estimated by entering the type A score as a continuous variable in the regression models.
The mean Type A score among 1305 subjects was 7.48 (SD, 3.72; range, 0 to 18). These numbers are quite comparable to the national male norms (mean, 8.08; SD, 3.68) reported in the MMPI Restandardization Project.37 Differences were noted in the distribution of coronary risk factors by level of type A score (Table 1⇓). Individuals with higher type A scores had higher average body mass index and were more likely to report a family history of heart disease. They were also more likely to be current smokers and more likely to consume ≥2 drinks of alcohol per day, although these differences were not statistically significant. There were no statistically significant differences in the distribution of other cardiovascular disease risk factors, including mean systolic or diastolic blood pressure or serum cholesterol level. All potential confounding variables were adjusted for in proportional hazards models.
During the follow-up period, 110 new coronary events occurred in the 1305 men: 30 incident cases of nonfatal MI, 20 cases of fatal CHD, and 60 cases of angina pectoris. Men with higher type A scores had increased risks of total CHD and combined CHD/angina pectoris (Table 2⇓). In multivariate proportional hazards models, men who scored ≥11 on the type A scale were at about 2.9 times the risk of combined CHD death and nonfatal MI (multivariate P for trend=0.02) and 2.3 times the risk of combined CHD death/nonfatal MI plus angina pectoris (multivariate P for trend=0.001) compared with men in the lowest-score (0 to 4) group.
Overall type A score was moderately to strongly correlated with anger (r=0.71) and cynicism scores (r=0.59) and hostile affect (r=0.71), hostile attribution (r=0.53), and aggressive responding (r=0.62) (Table 3⇓). We have previously reported that high scores on the MMPI-2 Anger Scale predict CHD risk in this cohort.25 The multivariate relative risks of a 1.0-SD increase in the MMPI-2 Anger Scale were 1.27 (95% CI, 0.83 to 1.95) for combined CHD death/nonfatal MI and 1.27 (95% CI, 1.06 to 1.52) for combined CHD death/nonfatal MI plus angina. To evaluate if TAB is a risk factor for CHD independently of anger, we included both sets of scales in multivariate proportional hazards models (Table 4⇓). In these analyses, anger scores were categorized into 3 levels—0 or 1, 2 to 4, and 5 to 14—as described in a previous report.25 Comparison of the relative risk estimates in Table 4⇓ with those in Table 2⇑ indicates that the point estimates of the associations between TAB and CHD end points were moderately attenuated after simultaneous adjustment for the MMPI-2 anger score. Although neither of the relative risk estimates was statistically significant, men in the highest category of type A score were at 2.4 times the risk of combined CHD death/nonfatal MI and 1.7 times the risk of combined CHD death/nonfatal MI plus angina. The relative risk estimates for anger similarly suggested elevated CHD incidence after adjusting for TAB (Table 4⇓). We also examined the associations of TAB to CHD within strata of anger scores (data not shown in the tables). Responses to the MMPI-2 Anger Scale were stratified into high (scores of ≥5) and low (<5). Among men with low levels of anger, TAB was associated with increased risks of CHD: the multivariate relative risks of a 1.0-SD increase in type A score were 2.04 (95% CI, 1.27 to 3.29) for combined CHD death/nonfatal MI and 1.75 (95% CI, 1.24 to 2.46) for all end points combined. Among men with high levels of anger, TAB did not appear to add further predictive ability. The multivariate risks of a 1.0-SD increase in type A score were 1.04 (95% CI, 0.64 to 1.70) for combined CHD death/nonfatal MI and 1.09 (95% CI, 0.79 to 1.50) for all end points combined.
When we examined TAB and CHD risk after simultaneously adjusting for MMPI-2 cynicism scores, the multivariate relative risks for TAB became somewhat stronger (Table 4⇑). By comparison, no relationship was evident between cynicism score and risk of CHD (Table 4⇑).
Finally, we examined the relationships of the 3 Ho subscales to CHD risk in 2 sets of models: unadjusted (model 1) and adjusted (model 2) for type A scores (Table 5⇓). In models unadjusted for type A scores, hostile attribution and aggressive responding were both associated with increased CHD risk. A 1.0-SD increase in hostile attribution and aggressive responding were associated with relative risks of combined CHD death/nonfatal MI of 1.29 (95% CI, 1.10 to 1.67) and 1.41 (95% CI, 1.04 to 1.90), respectively. However, when we adjusted simultaneously for TAB, none of the Ho subscales was associated with CHD (Table 5⇓). By contrast, TAB remained statistically significantly associated with CHD risk. Thus, the MMPI-2 Type A Scale appeared to predict CHD incidence independently of anger, cynicism, and hostility.
The first large-scale prospective epidemiological demonstration of the link between TAB and CHD incidence emerged from the Western Collaborative Group Study in 1975.38 Two other confirmatory studies of CHD incidence followed: the Framingham Heart Study11 and the French-Belgian Cooperative Group Study.39 On the basis of the evidence available at the time, a National Institutes of Health panel concluded in 1981 that TAB was an independent risk factor for CHD.40 In studies published before 1985, the most commonly used instrument to measure TAB was the JAS.10 The JAS yielded a continuous score indicating overall TAB and scores for 3 components of TAB, which were called “speed and impatience,” “job involvement,” and “hard-driving competitiveness.”10 In the Normative Aging Study, the JAS was administered to all active participants in 1982. The correlations of JAS scales to MMPI-2 Type A Scores ranged from modest to poor: 0.12 to job involvement; 0.22 to hard-driving competitiveness, 0.46 to speed and impatience, and 0.36 to the overall score. Thus, earlier type A studies that used JAS are not strictly comparable to the present study, because the different measurement scales were clearly tapping different dimensions of the construct. In the Normative Aging Study cohort, no relationship was found between any of the JAS scales and risk of CHD. The multivariate relative risks of combined CHD death/nonfatal MI for a 1.0-SD increase in score were 0.88 (95% CI, 0.70 to 1.11) for the overall JAS score, 0.96 (95% CI, 0.77 to 1.20) for hard-driving competitiveness, 0.85 (95% CI, 0.67 to 1.06) for job involvement, and 0.86 (95% CI, 0.69 to 1.09) for speed and impatience.
Beginning in the 1980s, research began to focus on attempts to identify the toxic components of TAB. From these efforts, hostility (especially as measured by the MMPI Ho Scale) emerged as the leading candidate for the toxic core of TAB.31 32 33 Unfortunately, a series of more recent follow-up studies has failed to corroborate an association between hostility scores and CHD incidence.41 42 43 44 The conflicting state of the evidence has led some observers to call for the abandonment of the type A concept.5 6 7 But rather than abandon the concept altogether, researchers need to search for the sources of disagreement between studies and determine whether the problem lies in the concept itself or in the methods used to measure it. In 1987, a review of the 83 studies of TAB found that standardized interview approaches to measuring TAB yielded more consistent associations with CHD than questionnaire-based approaches,45 perhaps because self-report questionnaires miss important visual cues to the diagnosis of TAB and/or because interview approaches provide a more global assessment of the action-emotion complex. In the present study, we have demonstrated the ability of a hitherto-untested questionnaire instrument (the MMPI-2 Type A Scale) to predict CHD incidence. The MMPI-2 Type A Scale provides a global score based on 3 apparently critical aspects of TAB: time urgency, competitiveness, and hostility. It may be the confluence of these behavior styles, rather than any one aspect alone, that increases risk of CHD.20 This may in turn explain the inconsistency of previous findings with questionnaires that included measures of some but not all components of TAB. On the basis of the findings of the present study, we concur with Matthews46 that “the occurrence of some failures to replicate does not justify abandoning the concept”.
An important limitation of the present study is its lack of generalizability to younger populations, to women, and to ethnic minorities. Further studies are warranted to replicate our findings in other populations. In particular, evidence from the MMPI Restandardization Project suggests that the MMPI-2 Type A Scale may not be as reliable in women.23 Additional research is needed to establish the correlation, if any, between the MMPI-2 Type A Scale and responses to structured interview assessments of TAB. Despite the limitations of self-report assessments of TAB, the identification of a valid questionnaire with the ability to predict CHD risk remains of considerable clinical interest. Although the VCE is considered the gold standard in the diagnosis of TAB, this approach is time-consuming and requires training in skills to identify nonverbal cues.8 9 In prospective epidemiological study settings involving large numbers of subjects, questionnaire-based approaches still have a place.
The clinical effectiveness of intervening on TAB has been demonstrated in controlled trials aimed at secondary prevention of cardiac events.47 48 A meta-analysis by Nunes et al49 of 18 controlled studies of the effect of psychological treatment of TAB found that psychological treatment aimed at reducing TAB led to a significant reduction in type A scores and a 50% reduction in coronary events up to 3 years. If our findings can be confirmed in further studies, they may suggest the utility of this questionnaire-based approach to identifying coronary-prone behavior for the purposes of research and intervention.
Selected Abbreviations and Acronyms
|CHD||=||coronary heart disease|
|Ho Scale||=||Cook-Medley Hostility Scale|
|JAS||=||Jenkins Activity Survey|
|MMPI-2||=||Minnesota Multiphasic Personality Inventory (revised)|
|TAB||=||type A behavior|
|VCE||=||videotaped clinical examination|
Items on the MMPI-2 Type A Scale, Anger Scale, and Cynicism Scale
Type A Scale (19 Items)
1. When people do me wrong, I feel I should pay them back if I can, just for the principle of the thing.
2. It makes me impatient to have people ask my advice or otherwise interrupt me when I am working on something important.
3. I resent having anyone trick me so cleverly that I have to admit I was fooled.
4. I have at times stood in the way of people who were trying to do something, not because it amounted to much but because of the principle of the thing.
5. I easily become impatient with people.
6. I have often found people jealous of my good ideas, just because they had not thought of them first.
7. I have at times had to be rough with people who were rude or annoying.
8. There are certain people whom I dislike so much that I am inwardly pleased when they are catching it for something they have done.
9. It makes me nervous to have to wait.
10. I am often inclined to go out of my way to win a point with someone who has opposed me.
11. I am often sorry because I am so irritable and grouchy.
12. I am usually very direct with people I am trying to correct or improve.
13. I often become very irritable with people when they interrupt my work.
14. Others tell me I eat too fast.
15. At movies, restaurants, or sporting events, I hate to have to stand in line.
16. I work very long hours even though my job doesn’t require this.
17. I get very irritable when people I depend on don’t get their work done on time.
18. I work best when I have a definite deadline.
19. I always have too little time to get things done.
Anger Scale (16 Items)
1. At times I feel like swearing.
2. At times I feel like smashing things.
3. Often I can’t understand why I have been so irritable and grouchy.
4. At times I feel like picking a fistfight with someone.
5. I easily become impatient with people.
6. I am often said to be hotheaded.
7. I am often so annoyed when someone tries to get ahead of me in a line of people that I speak to that person about it.
8. I have at times had to be rough with people who were rude or annoying.
9. I am often sorry because I am so irritable and grouchy.
10. It makes me angry to have people hurry me.
11. I am very stubborn.
12. Sometimes I get so angry and upset, I don’t know what comes over me.
13. I have gotten angry and broken furniture or dishes when I was drinking.
14. I have become so angry with someone that I felt as if I would explode.
15. I’ve been so angry at times that I’ve hurt someone in a physical fight.
16. I almost never lose self-control.
Cynicism Scale (23 Items)
1. I have often had to take orders from someone who did not know as much as I did.
2. I think a great many people exaggerate their misfortunes in order to gain the sympathy and help of others.
3. It takes a lot of argument to convince most people of the truth.
4. I think most people would lie to get ahead.
5. Most people are honest chiefly because they are afraid of getting caught.
6. Most people will use somewhat unfair means to gain profit or an advantage rather than to lose it.
7. I often wonder what hidden reason another person may have for doing something nice for me.
8. My way of doing things is apt to be misunderstood by others.
9. It is safer to trust nobody.
10. Most people make friends because friends are likely to be useful to them.
11. The person who provides temptation by leaving valuable property unprotected is about as much to blame for its theft as the one who steals it.
12. I think nearly anyone would tell a lie to keep out of trouble.
13. Most people inwardly dislike putting themselves out to help other people.
14. I tend to be on my guard with people who are somewhat more friendly than I had expected.
15. I have often met people who were supposed to be experts who were no better than I.
16. People generally demand more respect for their own rights than they are willing to allow for others.
17. I have often found people jealous of my good ideas, just because they had not thought of them first.
18. Most people will use somewhat unfair means to get ahead in life.
19. The future is too uncertain for a person to make serious plans.
20. People have often misunderstood my intentions when I was trying to put them right and be helpful.
21. I have frequently worked under people who seem to have things arranged so that they get credit for good work but are able to pass off mistakes onto those under them.
22. A large number of people are guilty of bad sexual conduct.
23. Most men are unfaithful to their wives now and then.
This study was supported by grants HL-45089 and AG-02287 and by the Health Services Research and Development Service of the Department of Veterans Affairs. Dr Kawachi is supported by a Career Development Award from the National Heart, Lung, and Blood Institute. Dr Sparrow is an associate research career scientist at the Medical Research Service of the Department of Veterans Affairs.
- Received January 29, 1998.
- Revision received March 20, 1998.
- Accepted March 26, 1998.
- Copyright © 1998 by American Heart Association
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