Journal of Pediatric Psychology, Vol. 27, No. 7, 2002, pp. 565-573
© 2002 Society of Pediatric Psychology
Aggression and Cardiovascular Response in Children
University of Miami School of Medicine
All correspondence should be sent to Alan Delamater, Department of Pediatrics, University of Miami School of Medicine, P.O. Box 016820, Miami, Florida 33101. E-mail: adelamater{at}med.miami.edu.
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Abstract |
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Objective: To examine cardiovascular response as a function of children's aggression after controlling for the effects of known risk factors.
Method: Participants were 140 children in second, fourth, and sixth grades. Teachers completed the Matthews Youth Test for Health, a measure that includes questions pertaining to children's aggression. Measures of blood pressure and heart rate were obtained during baseline, academic quiz, and recovery.
Results: Increasing age and body mass index were associated with increased cardiovascular responses. Aggressive children exhibited higher heart rates at baseline and lower heart rate reactivity. Aggressive children with a positive parent history of hypertension exhibited the greatest cardiovascular response.
Conclusions: These results provide further support for the identification of behavioral factors that increase cardiovascular risk in children.
Key words: children; cardiovascular response; aggression.
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Introduction |
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Coronary heart disease (CHD) remains the major cause of mortality of adults in the United States (Centers for Disease Control and Prevention, 1999
). Investigation of modifiable risk
factors contributing to the development of this disease remains a high
priority for behavioral medicine research. Childhood risk factors, including
elevated blood pressure levels, parental history of hypertension, obesity, and
the Type A behavior pattern, have been identified that predict cardiovascular
disease in adulthood (Berenson et al.,
1989; Keltikangas-Jarvinen & Raikkonen, 1989). Studies in
adults have determined that hostility is a significant independent predictor
of coronary heart disease, but few studies have examined this issue in
children. Since behavioral risk factors such as hostility are amenable to
intervention, early identification of such characteristics is imperative.
Research findings indicate that elevated blood pressure in childhood is
predictive of essential hypertension in adulthood
(Becket, Rosner, Roche, & Guo,
1992; Webber, Cresanta, Voors,
& Berenson, 1983). Cross-sectional pediatric studies have
demonstrated that elevated blood pressure is associated with greater left
ventricular mass (LVM) in childhood (Janz,
Burns, & Mahoney, 1995; Trieber et al., 1993), which is also a
significant predictor of cardiovascular complications in adulthood
(Casale et al., 1986).
Prospective studies with children have shown that baseline levels of
cardiovascular functioning, such as resting blood pressure levels
(Urbina et al., 1995) and
cardiovascular reactivity to acute laboratory stressors
(Murdison et al., 1998;
Papavassiliou, Treiber, Strong, Malpass,
& Davis, 1996), are independent predictors of future left
ventricular mass. The importance of identifying these potential risk factors
in childhood is highlighted by longitudinal studies that have demonstrated the
stability of blood pressure levels up to a 40-year period
(Becket et al., 1992;
Matthews, Woodall, & Stoney,
1990). This stability in blood pressure has been demonstrated in
resting blood pressure levels (Becket et
al., 1992) and blood pressure in response to a stressor
(Matthews et al., 1990;
Matthews, Rakaczky, Stoney, & Manuck,
1987; McAnn & Matthews, 1988;
Treiber et al., 1994).
Consistency in cardiovascular response has also been exhibited across a
variety of laboratory stressors (Musante
et al., 1994).
Type A behavior, another cardiovascular risk factor, has historically been
characterized by impatience, hostility, aggression, a sense of time urgency,
competitiveness, and high aspirations for achievement
(Friedman & Rosenman,
1959). Type A behavior in children has been associated with higher
systolic blood pressure levels, greater systolic blood pressure reactivity to
tasks, significantly greater heart rate levels, heart rate reactivity to
tasks, and heart rate variability during rest
(Lawler, Allen, Critcher, & Standard,
1981). This relationship may be affected by parent history of
hypertension. For example, McCann and Matthews
(1988) found that Type A
children with a hypertensive parent exhibited greater diastolic blood pressure
responses during behavioral stress; however, this relationship was not evident
in Type A children without a hypertensive parent.
Studies indicate that anger and hostility are the key components in the
relationship between Type A behavior and cardiovascular response
(Matthews & Haynes, 1986;
Siegel, 1984). Components of
hostility include suspiciousness, feelings of anger, and a general disregard
for social rules and norms (Smith &
Frohm, 1985). Hostility in children and adolescents has been shown
to be relatively stable over time (Woodall
& Matthews, 1993), thereby magnifying the importance of
investigating the relationship between hostility and cardiovascular risk in
children.
A number of studies have examined the relationship between hostility and
cardiovascular risk with adult samples, but relatively few studies have
examined this in youths (e.g., Miller,
Smith, Turner, Guijarro, & Hallet, 1996;
Suls & Wan, 1993). McCann
and Matthews (1988)
demonstrated that adolescents who scored high in potential for hostility
exhibited increased systolic and diastolic blood pressure responses to
behavioral stressors. In another study, parental report of increased
delinquency in children was significantly correlated with increased blood
pressure in a sample of boys at risk for disruptive behavior disorders
(Pine et al., 1996).
Various measures have attempted to capture the cognitive, behavioral, and
affective aspects of hostility. An extensive review of measures of anger,
hostility, and aggression for use with children is available in the literature
(Furlong & Smith, 1994).
However, reliable and valid measures of hostility for children are limited
(Treiber et al., 1989). A
behavioral measure of the Type A construct, designed specifically for
children, is the Matthews Youth Test for Health (MYTH;
Matthews & Angulo, 1980),
which includes characteristics related to hostility. The MYTH is composed of
two subscales: Competitiveness and Impatience/Aggression. By definition, the
aggression items of the Impatience/Aggression subscale of the MYTH appear to
be most related to the construct of hostility.
This study investigated children's cardiovascular (CV) responses to an acute laboratory stressor. The effects of known correlates of CV responses, such as age, gender, body mass index (BMI), and parent history of hypertension, were examined. The primary objective of this study was to examine cardiovascular responses in children as a function of their aggression after controlling for these known correlates of CV response. The relationships between known correlates of CV response and aggression were also investigated to determine if these variables interacted to produce greater levels of CV response. We expected that the presence of known risk factors would be related to increased CV response, as measured by systolic blood pressure (SBP), diastolic blood pressure (DBP), and heart rate (HR). In addition, we expected that higher aggression scores would be related to increased CV response, especially among those with parental history of hypertension.
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Method |
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Participants
One hundred fifty-nine children participated in the study. Analyses could not be conducted on 19 of these participants due to missing items on the teacher-completed measure of children's aggression. Therefore, most analyses were conducted on the 140 children with complete data regarding the aggression measure and CV responses. Analyses involving BMI utilized a slightly smaller sample since this information was missing for an additional 14 subjects. The participants were Caucasian children (61 boys, 79 girls), ages 7 to 13 years old (M = 9.48, SD = 1.66). Children were in second (n = 45), fourth (n = 53), and sixth (n = 42) grades. Based on the Four Factor Index of Social Status (Hollingshead, 1975
), the
socioeconomic status (SES) of participants ranged from lower to upper class,
with the majority of participants falling within the middle-class range. The
distribution of SES was as follows: upper class (3%), middle to upper class
(25%), middle class (35%), middle to lower class (28%), and lower class
(9%).
Measures
Cardiovascular Response. Blood pressure and heart rate were
measured with a Vita-Stat 900-D automated monitor. Children's SBP, DBP, and HR
were evaluated during an adaptation phase (5 minutes), a first baseline (5
minutes), a math and information quiz (7 minutes), and a second baseline (5
minutes). Three measurements of these CV responses were obtained during each
phase. Mean values of these responses were calculated for each phase of
measurement. CV reactivity scores were calculated by subtracting the mean
values during the baseline from the mean values during the quiz.
Aggression. The MYTH (Matthews
& Angulo, 1980) is a teacher-rated measure of the behavioral
components of the Type A construct and is composed of two factor analytically
derived scales: Competitiveness and Impatience/Aggression. Previous research
has indicated that reliability for the MYTH is acceptable, with test-retest
reliability correlations equal to .82 for the competitiveness factor and .79
for the impatience/aggression factor
(Matthews & Angulo, 1980).
In addition, internal consistency for the competitiveness factor (
=
.89) and the impatience/aggression factor ( = .88) are both adequate
(Matthews & Angulo, 1980).
Validity of the MYTH was documented in a study in which children classified as
Type A were more competitive, aggressive, and impatient in a test setting
compared with children classified as Type B
(Matthews & Angulo, 1980).
Although the MYTH does not measure hostility specifically, four aggression
items on the Impatience/Aggression subscale are related to the construct of
hostility: (1) it takes a lot to get this child angry at his or her peers; (2)
this child get irritated easily; (3) this child likes to argue or debate; (4)
this child tends to get into fights. As more recent research has identified
hostility as the cardio-toxic component of Type A behavior
(Matthews & Haynes, 1986),
hypotheses for this study utilized the sum of the four agression items on the
impatience/aggression factor of the MYTH (i.e., rather than the factor scores
or the total MYTH score). A test of internal consistency was performed on
these four items for the purposes of this study, indicating adequate internal
consistency ( = .75).
Procedure
The following procedures were approved by the institutional review board
for human subjects. A letter describing the study, a parental consent form,
and a child assent form were sent home to parents of all children in the
second, fourth, and sixth grades of four urban schools. After consent forms
were received by the teachers, a senior undergraduate research assistant
conducted telephone interviews with parents of these children regarding
parents' hypertension status (medication usage). Children were rated by their
teachers on the MYTH, which provided a measure of children's tendencies toward
aggression. During school hours, children were brought to a private room
within the school nurse's suite to complete study procedures. Each child's
height and weight were measured using a Detecto Medical Scale (Webb City, MO).
The quiz contained 20 questions, administered via audiotape, and consisted of
items culled from the Arithmetic and Information subtests of the Weschler
Intelligence Scale for Children-Revised (WISC-R; Weschler, 1974) and the
Mathematics and General Information subtests of the Peabody Individual
Achievement Test (PIAT; Dunn &
Markwardt, 1970). Items were selected for each grade in order to
approximate the 50% difficulty level. The mean number correct of the 20 items
administered to all of the children in the study indicated that the items were
of moderate difficulty. The mean number correct for grades 2, 4, and 6 were
8.25, 11.85, and 9.83, respectively. Measures of SBP, DBP, and HR were
obtained at 1-minute intervals during adaptation (5 minutes), baseline (5
minutes), mild stress (7-minute math and information quiz), and recovery (5
minutes) conditions.
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Results |
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Descriptive Analyses
Means and standard deviations by gender and grade are listed for CV responses across all phases of the study (see Table I). In this sample, 14% of the children exhibited SBPs (mm/Hg, millimeters mercury) at baseline and 25% exhibited DBPs (mm/Hg) at baseline that were greater than the 95th percentile, as identified by the Report of the Second Task Force on Blood Pressure Control in Children (1987
). The mean BMI for this
sample was 17.7 (SD = 3.23). Seven percent of this sample exhibited
BMIs greater than the 95th percentile, as compared to standardized percentile
curves of BMI for children and adolescents
(Hammer, Kraemer, Wilson, Ritter, &
Dombusch, 1991). Twenty-three percent of the children in the study
had parents with a positive history of hypertension (74% no parent history of
hypertension; 3% missing data).
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Validity Check of Laboratory Stressor
In order to determine if the academic quiz did indeed increase CV arousal,
repeated measures ANOVAs were conducted to investigate changes in children's
CV responses over time (i.e., baseline one, quiz, baseline two). Significant
within subjects effects were noted for SBP, F(3, 399) = 33.013,
p < .001; DBP, F(3, 399) = 33.465, p < .001;
and HR, F(3, 399) = 33.080, p < .001. Post-hoc analyses
indicated that there were significant differences between phases of
measurement for each form of CV response (see
Table II for means and standard
deviations). Since measurements during the adaptation phase were utilized to
facilitate adjustment to the novel experimental situation, findings regarding
responses during this phase were not considered.
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Overall, increases in CV response were noted from baseline one to the quiz and decreases in cardiovascular responses were noted from the quiz to baseline two. SBP (mm/Hg) increased from baseline one to the quiz (t[139] = -9.197, p < .001) and decreased from the quiz to baseline two (t[139] = -10.465, p < .001). DBP (mm/Hg) increased from baseline one to the quiz (t[139] = -11.414, p < .001) and decreased from the quiz to baseline two (t[139] = -8.549, p < .001). In addition, HR, as indicated in beats per minute (bpm), increased from baseline one to the quiz (t[139] = -6.693, p < .001) and decreased from the quiz to baseline two (t[139] = -4.415, p < .001). There was no difference between baseline one and baseline two for SBP (t[139] = .109, p = ns); however, for both DBP (t[139] = -3.293, p < .001) and HR (t[139] = -2.131, p < .05), baseline two was significantly greater than baseline one. Mean increases from baseline one to the quiz were 6.06 mm/Hg, 6.85 mm/Hg, and 3.82 bpm for SBP, DBP, and HR, respectively.
Effects of Known Correlates of CV Response
Hierarchical multiple regression analyses were performed in which CV
responses were first analyzed as a function of age, gender, BMI, parental
history of hypertension in the first step, and aggression in the second step.
Examination of individual beta weights in the first step of the regressions
performed (see Table III)
indicated that parental hypertension did not offer any unique contribution to
the variance explained. Girls exhibited greater DBP during the quiz than boys.
Children with greater BMI exhibited increased SBP at baseline, SBP during the
quiz, DBP at baseline, DBP during the quiz, and HR at baseline. Children with
greater BMI exhibited decreased HR reactivity. As children's ages increased,
they demonstrated increased SBP and DBP at both baseline and during the quiz.
Older children also exhibited lower HR during baseline and quiz relative to
younger children.
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Unique Effects of Aggression on CV Response
Children's scores on aggression items explained an additional 3.9% of the
variance in children's heart rate at baseline (t = 2.33, p
< .05) and an additional 3.9% of the variance in children's heart rate
reactivity (t = -2.29, p < .05), indicating higher heart
rates at baseline and lower heart rate reactivity. These items did not account
for unique variance in any of the other CV measures.
Table IV lists the beta weights
for aggression items across CV responses.
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Interactions with Aggression
A series of ANOVAs were conducted to investigate potential interactions
between children's aggressiveness and other variables (i.e., grade, gender,
parent history of hypertension) on CV measures. For analyses of CV responses
during the quiz, ANCOVAs were utilized to control for baseline levels of SBP,
DBP, and HR. A median split on the aggression items of the MYTH was performed
to classify children as either high aggressiveness or low aggressiveness for
these analyses. Prior to completion of the ANOVAs and ANCOVAs, analyses were
conducted to ensure that highly aggressive individuals were not primarily
older and male. A t test that compared the high and low
aggressiveness groups on age confirmed that there was no relationship between
these groups and age (t[138] = -1.81, p = ns). A
chi-square analysis that compared the aggressiveness groups by gender
confirmed that there was no relationship between these groups and gender
(
2[1] = .046, p = ns).
Aggression and Grade Interactions. In 3 x 2 ANOVAs analyzing the effects of grade and aggression, children in higher grades exhibited increased SBP at baseline, F(2, 139) = 11.77, p < .001, increased DBP at baseline, F(2, 139) = 13.39, p < .001, and decreased heart rate at baseline, F(2, 139) = 8.02, p < .001. Fisher's LSD indicated that children in second grade demonstrated significantly lower SBP and DBP than children in fourth and sixth grades. Children in sixth grade had significantly lower HR than children in second and fourth grades. A 3 x 2 ANCOVA, controlling for baseline SBP, indicated that children in higher grades also exhibited increased SBP during the quiz, F(2, 139) = 4.55, p < .01. Fisher's LSD indicated that children in sixth grade exhibited higher SBP during the quiz than children in second and fourth grades. No interaction effects were noted between grade and aggression.
Aggression and Gender Interactions. In 2 x 2 ANOVAs investigating the effects of gender and aggression, girls exhibited higher DBP at baseline, F(1, 139) = 4.014, p < .05, than boys. A significant interaction between gender and aggression was noted, F(1, 139) = 4.42, p < .05, with heart rate reactivity being greater for nonaggressive males than aggressive males (t[59] = 2.72, p < .01), whereas no differences in heart rate reactivity were noted between nonaggressive and aggressive females (t[77] = .00, p = ns). ANCOVAs did not reveal any significant differences between genders during the quiz, after controlling for baseline cardiovascular responses. Analyses of SBP and DBP reactivity did not reveal significant interactions.
Aggression and Parent History Interactions. In 2 x 2 ANOVAs analyzing the effects of aggression and parent history of hypertension, significant interactions were obtained between aggression and parent history of hypertension on SBP at baseline, F(1, 134) = 3.65, p < .05, and DBP at baseline, F(1, 134) = 5.59, p < .05, indicating that aggressive children who had a positive parent history of hypertension had higher SBP and DBP at baseline, whereas nonaggressive children with a positive parent history of hypertension exhibited the lowest cardiovascular responses. As shown in Figure 1 aggressive children with a positive parent history of hypertension exhibit significantly higher DBP at baseline than nonaggressive children with a positive parent history of hypertension (t[30] = -7.74, p < .05); however, no other significant simple effects were noted. ANCOVAs did not reveal any significant differences between these groups during the quiz, after controlling for baseline cardiovascular responses.
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Discussion |
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This study investigated children's CV responses to an acute laboratory stressor, an academic quiz of moderate difficulty. CV responses at the various stages of the study indicated that the quiz was affective at increasing children's CV arousal. One goal of this study was to replicate previous studies that have identified correlates of CV response in children. Consistent with previous findings (Lauer, Connor, Leaverton, Reiter, & Clarke, 1975
;
Matthews & Stoney, 1988;
Voors, Webber, & Berenson,
1978), age and BMI were associated with higher cardiovascular
responses. These findings indicated that at baseline and quiz, increases in
age were associated with greater SBP and DBP and lower HR. Also congruent with
previous findings, increases in BMI were associated with higher SBP and DBP at
both baseline and quiz. This is consistent with previous research indicating
that obesity in childhood is related to elevations in blood pressure (e.g.,
Ferrannini, Haffner, Mitchell, &
Stern, 1991).
The primary goal of this study was to determine if children's aggression
explained additional variance in children's CV responses after controlling for
the effects of known correlates of CV response. The results indicated that
aggressive children did in fact exhibit increased heart rate at baseline as
compared to their nonaggressive counterparts. Although aggression/anger is
only one component of Type A behavior, these results are consistent with past
research suggesting that Type A behavior in male children is associated with a
higher mean heart rate (Lawler et al.,
1981). Similarly, Dembroski and his colleagues have demonstrated
that Type A college students show greater heart rate variability at rest
(Dembroski, MacDougall, & Shields,
1977; Dembroski, MacDougall,
Shields, Petitto, & Lushene, 1978).
Aggressive children also displayed lower heart rate reactivity. These
results may be due to a ceiling effect from higher heart rate levels at
baseline. However, these results might also be interpreted in light of
research that has demonstrated that chronic aggression or conduct problems in
children and adolescents are associated with lower autonomic activity
(Borkovec, 1970;
Delamater & Lahey, 1983;
Fox & Lippert, 1963;
Siddle, Nicol, & Foggitt,
1973). Some of the variability in autonomic response in this
sample may be explained by research that has suggested that autonomic
reactivity in children at-risk for conduct problems is moderated by children's
anxiety levels (Delamater & Lahey,
1983; Harden, Pihl, Vitaro,
Gendreau, & Tremblay, 1995). Harden et al. found that
nonanxious disruptive boys who were also physically aggressive were
electrodermally underaroused during cognitive stress, whereas anxious
disruptive boys exhibited increased electrodermal activity, cardiac
reactivity, and muscle tension.
This study also aimed to further clarify the relationship between aggression and known correlates of CV response in children by determining if interactions between these risk factors led to increased CV response. A significant gender by aggression interaction was found in which nonaggressive boys exhibited greater heart rate reactivity than aggressive boys. Once again, this finding is consistent with the findings relating autonomic underarousal to conduct problems in children; however, the reason why this relationship was found to be more salient in boys than girls is unclear.
Consistent with hypotheses, a significant interaction between parent
history of hypertension and aggressiveness was obtained, whereby aggressive
children with a positive parent history of hypertension exhibited elevated SBP
and DBP. These results are consistent with past research studies that have
found clear associations between parental hypertension and CV responses
(Lawler et al., 1998;
Musante, Treiber, Strong, & Levy,
1990). McCann and Matthews
(1988) also demonstrated that
the relationship between parental hypertension and CV response is more
pronounced in children who exhibit Type A behavior, of which anger/aggression
is a component. It was unexpected that nonaggressive children with a positive
parent history would exhibit lower CV responses than nonaggressive children
with a negative parent history. However, some studies have suggested that the
relationship between family history and CV reactivity may be affected by
gender and personality characteristics, such as defensiveness
(Shapiro, Goldstein, & Jamner,
1995).
These findings should be interpreted in light of the fact that parental hypertension status was based on a telephone conversation in which the parent reported whether either of the child's parents was taking medication for hypertension. Since these reports were not verified by physician records, some parents' self-report of negative histories may reflect the fact that they have not seen a physician in several years and are unaware of their hypertension status. Therefore, false negatives may be inaccurately driving the DBP of the negative parent history group upward, contributing to the unexpected findings.
Although this study provided an indicator of the unique effects of anger/aggression on children's CV response, other important components of hostility, such as suspiciousness, cynicism, and a disregard for societal rules and norms, were not assessed. Future researchers examining the effects of hostility on CV response in children should attempt to assess all aspects of hostility, including its cognitive, affective, and behavioral components, using various measurement approaches (e.g., behavioral observation, self-report rating scales) and multiple informants (e.g., child, parent, teacher).
Another potential limitation of this study concerns the type of stressor
utilized. Suls and Wan (1993)
found that when research studies used interpersonal stressors that evoked
feelings of mistrust, hostile interpersonal style was predictive of
cardiovascular responses. This study utilized a traditional laboratory
stressor, an academic quiz of moderate difficulty. Cardiovascular reactivity
data indicated that the quiz was effective at increasing cardiovascular
arousal. Also, a differential response in heart rate reactivity was obtained
based on children's aggressiveness; however, it is conceivable that more
substantial findings would have been achieved if an interpersonal stressor had
been used.
A growing body of literature suggests that the relationship between CV
response and hostility varies across ethnic groups. This study was limited by
the fact that the sample consisted of only Caucasian children. Recent research
has demonstrated that children's hostility may be predictive of cardiovascular
reactivity in African American children, but not in Caucasian children
(Gump, Matthews, & Raikkonen,
1999). Differences in cardiovascular responses across ethnic
groups were also demonstrated in a study that found that African American
males under high levels of stress and who experienced suppressed hostility had
the highest blood pressure levels compared to all other groups
(Harburg et al., 1995). These
findings suggest that future research regarding the relationship between
cardiovascular response and hostility utilize ethnically diverse samples.
Overall, this study provides further support for the identification of behavioral factors that increase cardiovascular risk in children. The current results suggest that aggressive children exhibit increased HR at baseline and decreased HR reactivity. Aggressive children with a hypertensive parent exhibit higher SBP and DBP at baseline. In addition, greater BMI in children was associated with increased CV response throughout all phases of the study. These results provide further support for the role of obesity and aggression as modifiable risk factors for coronary heart disease. Interventions to address both obesity and aggression in children may be helpful in reducing risk for the development of coronary heart disease.
Received October 5, 2000; revision received May 10, 2001; accepted November 14, 2001
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