Abstract
Objective
Coronary artery disease (CAD) constitutes a significant health hazard in middle-aged individuals in Saudi Arabia. We sought to assess the level of knowledge of cardiovascular risk factors and describe the perception of coronary intervention among the general population in the city of Jeddah in the western part of Saudi Arabia.
Methods
A cross-sectional study was conducted in the city of Jeddah during the period from April 2019 to September 1, 2019, by using a structured online questionnaire to assess the participants’ awareness of risk factors for CAD and coronary intervention. The survey included questions about socio-demographic data, risk factors of cardiovascular diseases, symptoms of heart attack, knowledge of coronary catheterizations, as well as resources of knowledge about coronary heart disease.
Results
The study included 984 participants. The majority of the participants had university diplomas (78.1%). Only 38.5 % were healthcare workers. Dyslipidemia and smoking were identified by 70.5% and 66.7%, respectively, as a recognized risk factor for CAD. Diabetes was mentioned by 32.1%. Participants without CAD risk factors had a significantly lower level of knowledge regarding the strong association between diabetes mellitus (DM) II and CAD (p-value=0.02). Healthcare professionals had a significantly lower level of knowledge regarding cardiac catheterization as compared to non-healthcare professionals. A higher percentage of healthcare professionals would agree to have cardiac catheterization if indicated (p-value=0.003). Awareness campaigns were the most common source of information for the public.
Conclusion
The current level of knowledge of CAD in the western part of Saudi Arabia is fair. National awareness campaigns are required to improve the level of healthcare education.
Keywords: coronary artery diseases, cardiac catheterization, awareness, cardiovascular disease, survey, knowledge, perception
Introduction
Cardiovascular diseases (CVDs) are considered the leading cause of morbidity and mortality globally. They are regarded as the primary cause of extended hospital stays and increased healthcare costs [1-5]. More people die annually from CVDs than from any other cause. An estimated 17.9 million people died from CVDs in 2016, representing 31% of all global deaths. Of these deaths, 85% were due to heart attacks and stroke. Over three-quarters of CVD deaths take place in low and middle-income countries. Based on epidemiological data, cardiovascular diseases will remain the leading cause of mortality and morbidity throughout the next decade [2-7]. The mean age for developing CAD in the Middle East is 10 years younger than the mean age of their western counterparts [2-8]. The prevalence of CAD risk factors among Saudi patients with established CAD is alarming; however, many of these are modifiable risk factors [9-11]. In Saudi Arabia, despite the widespread availability of hospitals with a catheterization laboratory, there are fewer patients treated with a primary percutaneous intervention [12]. The baseline knowledge about CVD among the general population has a significant public impact in developing targeted educational programs [13]. Knowledge of CVDs, its symptoms, and its risk factors have been studied worldwide in various populations [14]. Nevertheless, there is a scarcity of data in Saudi Arabia on the perception of the Saudi public of coronary artery disease (CAD) and coronary catheterization. Therefore, this study aims to examine the level of knowledge and perception of the public towards coronary artery disease and its treatment in an attempt to generate educational programs to reduce the CVDs burden.
Materials and methods
This was a cross-sectional study conducted at King Saud bin Abdulaziz University for Health Sciences in Jeddah, Saudi Arabia, during the period from April 2019 to September 1, 2019. This was achieved through voluntary participation in an online survey questionnaire that was constructed in the Arabic language. Participants were asked to distribute the survey to their friends and relatives.
The sample size was calculated assuming that we are targeting a sample from only the city of Jeddah, which has an estimated total population of four million inhabitants, with a 99% confidence level and a 5% margin of error; the sample size was determined to be 665 respondents. All volunteer participants who were able to complete the online survey were included. Participants younger than 18 years of age and who could not or did not complete the survey were excluded. The questionnaire was adapted and modified from a previous survey by Almalki et al. [15]. We collected sociodemographic characteristics, assessments of awareness of CAD risk factors, coronary angiography, and CAD treatment. Socioeconomic variables were participants’ age, sex, nationality, marital status, employment, education, and income. Family and personal medical histories, such as diabetes mellitus (DM), hypertension, and dyslipidemia (high cholesterol or triglycerides levels) were collected as well. Awareness of CAD risk factors was assessed through yes or no questions asking whether or not the participants believed certain factors were considered risk factors for CAD. The survey also included questions on symptoms of a heart attack, information about cardiac catheterization, and resources of information about coronary artery disease (See Table 1 for complete survey questions). The study was conducted following the Declaration of Helsinki. It received ethical approval from the Institutional Review Board of King Abdullah International Medical Research Center.
Table 1. Survey questions.
Translated from the Arabic language
| Socio-demographics Section | |
| Age | |
| 18 to 25 | |
| 26 to 35 | |
| 36 to 45 | |
| 46 to 55 | |
| 56 to 65 | |
| Above 65 | |
| Gender | |
| Male | |
| Female | |
| Marital Status | |
| Married | |
| Unmarried | |
| Level of education | |
| Diploma or university | |
| High school or less | |
| Health care worker | |
| Yes | |
| No | |
| Smoker | |
| Yes | |
| No | |
| Medical and surgical history | |
| Diabetes mellitus | |
| Yes | |
| No | |
| Hypertension | |
| Yes | |
| No | |
| Dyslipidemia | |
| Yes | |
| No | |
| Chronic kidney disease | |
| Yes | |
| No | |
| Cardiac disease | |
| Yes | |
| No | |
| History of cardiac cath | |
| Yes | |
| No | |
| History of open-heart surgery | |
| Yes | |
| No | |
| Knowledge about heart attack | |
| Have you heard of the term “heart attack” before? | |
| Yes | |
| No | |
| Do you know the difference between a heart attack and a cardiac arrest? | |
| Yes | |
| No | |
| Can a person live normally after a heart attack? | |
| Yes | |
| No | |
| Do females have more heart attacks than males? | |
| Yes | |
| No | |
| If someone has a heart attack, does he/she need to go to the hospital by himself/herself and not wait for an ambulance? | |
| Yes | |
| No | |
| Can a heart attack happen to someone younger than 30 years old? | |
| Yes | |
| No | |
| Which of the following is a risk factor of coronary artery disease? (You may choose more than one) | |
| Diabetes | |
| Hypertension | |
| Dyslipidemia | |
| Smoking | |
| Overweight | |
| Aging | |
| Sedentary Lifestyle | |
| Unhealthy diet | |
| Genetics | |
| Anger | |
| Do not know | |
| Which of the following is a symptom of a heart attack? (You may choose more than one) | |
| Chest pain | |
| Shortness of breath | |
| Jaw or arm pain | |
| Nausea and vomiting | |
| Pins and needles sensation in the chest | |
| Palpitations | |
| Sweating | |
| Dizziness | |
| Do not know | |
| Which of the following is a coronary artery disease diagnostic method? (You may choose more than one) | |
| History and physical exam | |
| Blood tests | |
| Imaging | |
| Stress test | |
| Cardiac catheterization | |
| Heart biopsy | |
| ECG | |
| Do not know | |
| Which of the following is a treatment of coronary artery disease? (You may choose more than one) | |
| Anticoagulants | |
| Thrombolytics | |
| Vasodilators | |
| Medications to decrease blood pressure | |
| Medications to decrease heart rate | |
| Medications to decrease lipids | |
| Cardiac catheterization | |
| Open-heart surgery | |
| Do not know | |
| Knowledge of cardiac catheterization | |
| Do you know the difference between diagnostic and therapeutic catheterization? | |
| Yes | |
| No | |
| Who does the cardiac catheterization? | |
| Any doctor | |
| Cardiac surgeon | |
| Interventional cardiologist | |
| Do not know | |
| Is contrast used in cardiac catheterization? | |
| Yes | |
| No | |
| Do not know | |
| What is the access used in cardiac catheterization? | |
| Arm or thigh vessels | |
| Mouth | |
| Directly through the skin to the heart | |
| Do not know | |
| Can a cardiac catheterization be a one-day procedure? | |
| Yes | |
| No | |
| Do not know | |
| Can a stent be inserted using catheterization? | |
| Yes | |
| No | |
| Do not know | |
| Source of information | |
| Which of the following is your source of information about coronary artery disease? (You may choose more than one) | |
| Doctors | |
| Internet | |
| Media and social media | |
| Campaigns | |
| Books | |
| Patients with cardiac disease |
Statistical analysis
The results of this survey are mainly descriptive of the perception and knowledge of CAD and cardiac catheterization in a contemporary sample from Jeddah, Saudi Arabia. In this survey, data were reported mostly in the form of frequencies and the percentage of respondents. Categorical variables were analyzed by χ2 (chi-square) or Fisher's exact test as appropriate. The Kruskal-Wallis test was used for ordinal variables. Statistical analysis was performed using the Fisher exact test to evaluate the significance of some of the survey results. Values of p < 0.05 were considered significant. All statistical analysis and assessment of the model’s performance were conducted using the R-Software, version 3.3.0 (R Project for Statistical Computing, Vienna, Austria) [16].
Results
There were 984 responders to the study survey. The participants were well-educated and relatively young. There were 54.5% females. The majority had university diplomas or higher (78.1%). Two-thirds of the participants were younger than 45 years of age. The prevalence of CAD risk factors among the study group was low; 9.6% had type two diabetes, 9.2 % had hypertension, 7.7% had dyslipidemia, and 18.2 % were smokers. Only 3.9% of the study group had CAD; 38.5% of the cohorts were health care workers (Table 2).
Table 2. Respondents demographics (total number of respondents=984).
| Variable | Frequency (%) |
| Age (Years) | |
| 18 to 25 | 253 (25.7) |
| 26 to 35 | 198 (20.1) |
| 36 to 45 | 227 (23.1) |
| 46 to 55 | 190 (19.3) |
| 56 to 65 | 103 (10.5) |
| Above 65 | 13 (1.3) |
| Gender | |
| Male | 447 (45.4) |
| Female | 537 (54.6) |
| Marital Status | |
| Married | 678 (68.9) |
| Unmarried | 306 (31.1) |
| Educational Level | |
| Diploma or University | 769 (78.2) |
| Health Care Worker | |
| Yes | 379 (38.5) |
| No | 605 (61.5) |
| History of Smoking | |
| Yes | 180 (18.3) |
| No | 804 (81.7) |
| History of Diabetes Mellitus | |
| Yes | 94 (9.6) |
| No | 890 (90.4) |
| History of Hypertension | |
| Yes | 90 (9.2) |
| No | 894 (90.8) |
| History of Chronic Kidney Disease | |
| Yes | 3 (0.3) |
| No | 981 (99.7) |
| History of Dyslipidemia | |
| Yes | 76 (7.7) |
| No | 908 (92.3) |
| History of Cardiac Disease | |
| Yes | 38 (3.9) |
| No | 946 (96.1) |
| History of Cardiac Cath | |
| Yes | 48 (4.9) |
| No | 936 (95.1) |
| History of Open-Heart Surgery | |
| Yes | 5 (0.5) |
| No | 979 (99.5) |
The following responses to the questions on heart attack were obtained; 92.2% had heard of the term. Most participants (almost 82%) were able to differentiate between heart attack and cardiac arrest. Three-quarters mentioned that patients who suffered a heart attack could live normally. Almost two-thirds of the participants would not wait for emergency services arrival and would immediately drive themselves to the nearest hospital if they suffered a heart attack. Nearly three-quarters of the participants (72%) believed that a heart attack could occur in a person younger than the age of 30 (Table 3).
Table 3. General questions about heart attack.
| Response | Frequency | Percent | |
| Heard of heart attack before | No | 76 | 7.7 |
| Yes | 908 | 92.2 | |
| Knows the difference between heart attack and cardiac arrest | No | 181 | 18.3 |
| Yes | 803 | 81.6 | |
| Can a person live normally after a heart attack | No | 258 | 26.2 |
| Yes | 726 | 73.7 | |
| Females have more heart attacks than males | No | 293 | 29.7 |
| Yes | 176 | 17.8 | |
| Don’t know | 515 | 52.3 | |
| Should go to the hospital and not wait for an ambulance when experiencing a heart attack | No | 169 | 17.1 |
| Yes | 598 | 60.7 | |
| Don’t know | 214 | 21.7 | |
| Heart attack could happen in people younger than 30 years old | No | 57 | 5.7 |
| Yes | 710 | 72.1 | |
| Don’t know | 217 | 22.0 |
Responses to the coronary artery disease risk factors were as follows: 70.5% of the participants agreed that dyslipidemia is a risk factor for coronary artery disease, followed by smoking (66.7%), while diabetes was recognized by only 32.22% of the respondents. Five percent of the participants did not know CAD risk factors, as shown in Figure 1.
Figure 1. Responses to risk factors of coronary artery disease.
The participants’ perception of the symptoms of a heart attack is shown in Figure 2. Of the responders, 74.3% revealed that chest pain or heaviness is a common symptom of a heart attack, followed by dyspnea (59.1%), loss of consciousness (59.1%), sweating (39.4%), palpitations (34%), and jaw pain (36.2%). Other associated symptoms like nausea and vomiting were mentioned. Only 13% of responders did not know the common symptoms of a heart attack.
Figure 2. Responses to symptoms of a heart attack.
Figure 3 shows the perception of the diagnostic tests by the participants. Sixty-four percent mentioned that an electrocardiogram is the best test, followed by a stress test, imaging, and coronary angiography. Fifty-six percent of the cohort agreed that cardiac catheterization and coronary intervention are the best treatment for CAD, followed by anticoagulants (51.8%) and then thrombolytics (44.9) while only 17.2% were unaware of any treatment options (Figure 4).
Figure 3. Responses to the diagnosis of coronary artery disease.
Figure 4. Responses to the treatment of coronary artery disease.
Thirty percent were able to know the difference between diagnostic and therapeutic catheterization. Out of the 984 participants, 47.3% thought that cardiac catheterization is performed by a cardiac surgeon and 16.5% thought that it is done by an interventional cardiologist. Contrast use during the procedure was mentioned by 61.7%. Catheterization access was reported to be the arm or thigh blood vessels by 60.8%. Five percent thought it is done through the chest wall directly into the heart and 3.4% thought it was through the mouth. The majority of the participants (78.3%) would agree to have a cardiac catheterization if needed while 4.5% did not agree and 17.0% were ambivalent about whether to accept or not (Table 4).
Table 4. Responses to questions on cardiac catheterization.
| Response | Frequency, (%) | |
| Knows the difference between diagnostic and therapeutic catheterization | No | 684 (69.5%) |
| Yes | 300 (30.4%) | |
| Who does the catheterization | Any doctor | 58 (5.8%) |
| cardiac surgeon | 466 (47.3%) | |
| Interventional cardiologist | 163 (16.5%) | |
| Don't know | 297 (30.1%) | |
| Use of contrast in the catheterization | No | 102 (10.3%) |
| Yes | 274 (27.8%) | |
| Don’t know | 608 (61.7%) | |
| What is the access of the catheterization | Arm or thigh vessels | 599 (60.8%) |
| Mouth | 34 (3.4%) | |
| Directly through to the heart | 50 (5.0%) | |
| Don't know | 301 (30.5%) | |
| Can a catheterization be a one-day procedure | No | 310 (31.5%) |
| Yes | 385 (39.1%) | |
| Don’t know | 289 (29.3%) | |
| Can stent be inserted using a catheterization | No | 29 (2.9%) |
| Yes | 613 (62.2%) | |
| Don’t know | 342 (34.7%) | |
| Would you agree on a catheterization if needed? | No | 45 (4.5%) |
| Yes | 771 (78.3%) | |
| Don’t know | 168 (17.0%) |
We attempted to assess the difference in perception of cardiac disease risk factors and symptoms between respondents who had at least one cardiac risk factor (diabetes, hypertension, dyslipidemia, or smoking) as compared to respondents who had no cardiac risk factors. It was counterintuitive to notice that more participants who had CAD risk factors had poor knowledge of heart attack symptoms, as shown in Table 5. Interestingly, when assessing common cardiac risk factors, there were no differences between the two groups except that respondents who had no cardiac risk factors were less likely to think that diabetes is a recognized risk factor for cardiac disease (p-value=0.012). When we evaluated the knowledge of respondents on the most common cardiac symptoms, there were no differences except in nausea and vomiting. Respondents who had at least one cardiac risk factor were more likely to consider nausea and vomiting as a symptom of cardiac disease (p-value= 0.002) (Table 5).
Table 5. Comparison of responders with at least one risk factor with those who have none.
*p-value at level of significance <0.05
| Participants Who Have At Least 1 Cardiac Risk Factor | Yes, n= 357 (%) | No, n= 626 (%) | Total, n=984 (%) | P-value | |
| Risk Factors | |||||
| Diabetes is a Risk Factor | 131 (36.7%) | 185 (29.6%) | 316 (32.1%) | <0.05* | |
| Hypertension is a Risk Factor | 232 (65%) | 374 (59.7%) | 606 (61.6%) | 0.1 | |
| Dyslipidemia is a Risk Factor | 263 (73.7%) | 440 (70.3%) | 703 (71.5%) | 0.26 | |
| Age is a Risk Factor | 126 (35.3%) | 244 (39%) | 370 (37.6%) | 0.25 | |
| Overweight is a Risk Factor | 229 (64.1%) | 389 (62.1%) | 618 (62.9%) | 0.53 | |
| Smoking is a Risk Factor | 252 (70.6%) | 413 (66.1%) | 665 (67.7%) | 0.15 | |
| Sedentary Lifestyle is a Risk Factor | 173 (48.5%) | 282 (45%) | 455 (46.3%) | 0.3 | |
| Unhealthy Diet is a Risk Factor | 94 (26.4%) | 175 (28%) | 269 (27.4%) | 0.6 | |
| Genetics is a Risk Factor | 82 (23%) | 153 (24.4%) | 235 (23.9%) | 0.6 | |
| Anger is a Risk Factor | 156 (43.7%) | 240 (38.3%) | 396 (40.3%) | 0.09 | |
| Symptoms | |||||
| Chest Pain | 267 (74.8%) | 474 (75.7%) | 741 (75.4%) | 0.7 | |
| Dizziness | 119 (33.3%) | 209 (33.4%) | 328 (33.4%) | 0.9 | |
| Nausea and Vomiting | 84 (23.5%) | 99 (15.8%) | 183 (18.6%) | <0.05* | |
| Pain in the Jaw or Arm | 136 (38.1%) | 225 (35.9%) | 361 (36.7%) | 0.5 | |
| Palpitations | 114 (31.9%) | 225 (36%) | 339 (34.5%) | 0.2 | |
| Pins and Needles in the Chest | 202 (56.6%) | 357 (57%) | 559 (56.9%) | 0.9 | |
| Shortness of Breath | 207 (58%) | 382 (61%) | 589 (59.9%) | 0.4 | |
| Sweating | 154 (43.1%) | 239 (38.2%) | 393 (40%) | 0.1 | |
Because almost 40% of the respondents were health care workers, we sought to determine whether they have a better knowledge of coronary catheterization as compared to the general public. Table 6 demonstrates the responses to the questions with regard to coronary catheterizations. Non-healthcare workers had better knowledge on several points. Health care workers had a higher rate of choosing the “Do not Know” answer (Table 6). Additionally, more healthcare professionals will agree to have a cardiac catheterization if indicated (p-value= 0.005).
Table 6. Cath knowledge by being a health care worker or not.
*p-value at level of significance <0.05
| Health Care Worker | Yes, n= 379 (%) | No, n= 605 (%) | Total, n=984 (%) | p-value | |
| Heard of Cardiac Cath | 365 (96.3%) | 581 (96%) | 946 (96%) | 0.8 | |
| Knows the difference between diagnostic and therapeutic cath | 89 (23.5%) | 211 (34.9%) | 300 (30.5%) | <0.05* | |
| Who does the cath | |||||
| Any Doctor | 23 (6.1%) | 35 (5.8%) | 58 (5.9%) | 0.5 | |
| Cardiac Surgeon | 181 (47.8%) | 285 (47.1%) | 466 (47.4%) | ||
| Interventional Cardiology | 55 (14.5%) | 108 (17.9%) | 163 (16.6%) | ||
| Don’t know | 120 (31.7%) | 177 (29.3%) | 297 (30.2 %) | ||
| Use of contrast during a cardiac cath | |||||
| Yes | 98 (25.9%) | 176 (29.1%) | 274 (27.8%) | <0.05* | |
| Don’t know | 252 (66.5%) | 356 (58.8%) | 608 (61.8%) | ||
| Use of imaging during a cardiac cath | |||||
| Yes | 141 (37.2%) | 254 (42%) | 395 (40.1%) | 0.054 | |
| Don’t know | 217 (57.3%) | 302 (49.9%) | 519 (52.7%) | ||
| Cath can be done as a day case | |||||
| Yes | 127 (33.5%) | 258 (42.6%) | 385 (39,1%) | <0.05* | |
| Don’t know | 114 (30.1%) | 175 (28.9%) | 289 (29.4%) | ||
| Coronary Stent can be inserted during an angiogram | |||||
| Yes | 210 (55.4%) | 403 (66.6 %) | 613 (62.3%) | <0.05* | |
| Don’t know | 114 (30.1%) | 175 (28.9%) | 289 (29.4%) | ||
| Will you agree to have angiogram if needed | |||||
| Yes | 296 (78.1%) | 475 (78.5%) | 771 (78.4%) | <0.05* | |
| Don’t know | 56 (14.8) | 112 (18.5%) | 168 (17.1%) |
Finally, participants were required to choose the source of information about CAD and cardiac catheterization. Fifty-three point five percent received their knowledge from health awareness campaigns while only 6.9% received their information from books, as shown in Figure 5.
Figure 5. Source of coronary artery disease knowledge.
Discussion
The young population of Saudi Arabia is undergoing significant economic changes that have translated into the adoption of a Western dietary lifestyle that has led to a significant increase in the burden of cardiovascular diseases [17]. However, adequate baseline knowledge of CAD risk factors is lacking. Improved public awareness is associated with greater personal awareness and increased actions to lower CVD risk [18]. Knowledge related to heart disease has been associated with health promotion behaviors [19-20]. The study demonstrated fair knowledge of CAD risk factors and the role of coronary catheterization.
The majority of participants with or without CAD risk factors assumed that DM is the least likely to lead to the development of CAD. Participants without risk factors had significantly lower knowledge of the association between DM and CAD (p-value= <0.05). In contrast, many have recognized that dyslipidemia, hypertension, and smoking are risks for developing CAD. The study demonstrated poor knowledge of heart attack symptoms among patients with risk factors for CAD. While healthcare workers are more likely to accept undergoing coronary catheterization when required, they, had lower knowledge of aspects of cardiac catheterization as compared to non-healthcare professionals. Awareness campaigns seemed to be the most favorable source of information when learning about coronary heart disease and coronary catheterization among the population studied.
Almalki et al., in a recent study from Jeddah, reported a deficient level of awareness of CAD risk factors, DM, smoking, and lack of physical activity were identified by only 12%, 26%, and 39% of participants, respectively [15].
De Oliveira et al., in a small study, showed that patients were perplexed in differentiating between therapeutic and diagnostic coronary angiograms. They have reported heightened fear and anxiety among patients who had coronary catheterization; this was attributed to a lack of adequate knowledge of the procedure [21].
On the other hand, Tait et al., in a study that included 151 patients who underwent a pre-catheterization educational program, reported an improved understanding of the procedure, which resulted in better patient experience [22]. It is clear that educational programs are needed to spread knowledge and enhance the public awareness of the risk factors of CAD and its treatment in order to be effective in reducing the overwhelming burden of this devastating disease.
Limitations
The present study has many limitations: voluntary self-reporting of risk factors, lack of questioner validation, and high response from the younger age group with a high level of education, which might not be representative of the entire social spectrum. All these factors limit the generalizability of the survey.
Conclusions
CAD disease is a significant health issue globally. Prevention can be achieved through the better control of the risk factors of atherosclerosis. Improved public knowledge will favorably contribute to the adoption of a better lifestyle that lessens the burden of CAD. Our study showed an explicit limited knowledge of CAD risk factors, symptoms, methods of diagnosis, and treatment among the Western population of Saudi Arabia. Additionally, it showed a lack of proper awareness of the role of coronary angiography and coronary interventions. Decision-makers in the Kingdom of Saudi Arabia are required to enhance public awareness through campaigns and screening programs.
The content published in Cureus is the result of clinical experience and/or research by independent individuals or organizations. Cureus is not responsible for the scientific accuracy or reliability of data or conclusions published herein. All content published within Cureus is intended only for educational, research and reference purposes. Additionally, articles published within Cureus should not be deemed a suitable substitute for the advice of a qualified health care professional. Do not disregard or avoid professional medical advice due to content published within Cureus.
The authors have declared that no competing interests exist.
Human Ethics
Consent was obtained by all participants in this study. King Abdullah International Research Center issued approval H-01-R-005. The study was approved by King Abdullah International Research Center; it met all required conditions
Animal Ethics
Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue.
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