Gender and CV Risk
|Whang et al. (2009)|
|Nurses’ Health Study Cohort: 63,469 women without previous coronary heart disease/stroke in 1992||Association between depression and CHD and SCD in women; outcome: CHD/SCD; exposure: depression||Depression: Mental Health Index (MHI-5) < 53||CHD: HR 1.49 (1.11-2.00, for MHI-5 score < 53|
SCD: HR 2.33 (1.47-3.70
|Shanmugasegaram et al. (2012)|
|Systematic review and meta-analysis: 8 studies; n = 2072; 24.6% female||To examine whether women with CAD experience greater prevalence of major depression than men with CAD||Depression||Pooled analysis, women vs men: OR 1.77 (1.21-2.58), P < 0.1|
|Meijer et al. (2013)|
Doyle et al. (2015)
|Systematic review and meta-analysis: 16 studies, 10,175 patients; age 56-65, mean age 61, 28% female||Association between post-MI depression and prognosis||Depression (after MI)||Pooled analyses: all-cause mortality HR 1.32 (1.26-1.38); CV events HR 1.19 (1.14-1.24).|
Men, all-cause mortality: HR 1.38 (1.30-1.47).
Women, all-cause mortality: HR 1.22 (1.14-1.31)
|Xu et al. (2015)|
|VIRGO study: 3572 AMI patients; 2397 female, ages 18-55||Sex difference in perceived stress in young and middle-aged patients presenting with AMI||Moderate perceived stress||Adjusted mean difference in 1-month recovery associated with sex and baseline perceived stress: angina-related QOL Beta −3.50 (−5.68 to −1.33); SF-12 MCS score Beta −1.96 (−2.96 to −0.96)|
|Nyberg et al. (2013)|
|Systematic review and meta-analysis: 8 studies; n = 47,045; mean age 45.1, 29.2% female||Association between job strain and traditional risk factors of heart disease||Job strain||Age and sex adjusted: diabetes OR 1.35 (1.15-1.57), smoking OR 1.23 (1.16-1.3), physical inactivity OR 1.43 (1.36-1.51), obesity OR 1.19 (1.11-1.28), Framingham risk score ≥ 20 OR 1.19 (1.08-1.31)|
|Kivimaki et al. (2006)|
|Systematic review and meta-analysis: 14 studies; 83,014 employees||Association between work stress, as indicated by job strain, effort-reward imbalance, and organisational injustice, with RR of CHD||Job strain, organisational injustice, effort-reward imbalance||Sex-adjusted RR of CHD for high job strain: 1.43 (1.15-1.84).|
Sex-adjusted RR of CHD for higher organisational injustice: 1.62 (1.24-2.1).
Sex-adjusted RR of CHD for effort-reward imbalance: RR 2.52 (1.63-3.90)
|Torquati et al. (2018)|
|Systematic review and meta-analysis: 21 studies; 173,010 participants||Association between shiftwork and CVD||Shift work||CVD events: effect size (OR) 1.17 (1.09-1.25), I2 = 67.0%|
|Kang et al. (2012)|
|Systematic review and meta-analysis: 11 studies, 15,923 participants, age 20-65, mean age 52.6, 22.6% female||Association between long work hours and CVD||Long/overtime work hours vs regular||CVD: OR 1.37 (1.11-1.70)|
|Kilpi et al. (2015)|
|Population-based registry: adults aged 40-60, Finland 1995-2007; n = 302,885, 49.9% female||Association between living arrangements and MI incidence and fatality||Living arrangement: marital partner, cohabitation, living with others, living alone||HR for MI, reference married: men: cohabitation 1.34 (1.20-1.49), living with others 1.42 (1.29-1.56), living alone 1.49 (1.39-1.60); women: cohabitation 1.30 (1.03-1.65), living with others 1.60 (1.33-1.93), living alone 1.45 (1.26-1.66).|
HR for MI first-day fatality, reference married: men: cohabitation 1.35 (1.14-1.60), living with others 2.35 (2.02-2.74), living alone 2.22 (1.99-2.49); women: cohabitation 1.82 (1.25-2.65), living with others 1.76 (1.30-2.37), living alone 1.35 (1.09-1.67).
HR for MI long-term fatality, reference married: men: cohabitation 1.23 (1-1.51), living with others 2.46 (2.05-2.95), living alone 2.05 (1.80-2.34); women: cohabitation 2.21 (1.42-3.44), living with others 1.95 (1.41-2.70), living alone 1.26 (1-1.59)
|Ikeda et al. (2008)|
|Prospective cohort study: 1990-2004, 90,987 Japanese, age 40-69, 47,594 female||Impact of living arrangements on the incidence of CHD and mortality as well as all-cause mortality||Living arrangements||Men: HR for CHD incidence (reference spouse): alone 1.23 (0.74-2.02), spouse + parent 0.90 (0.54-1.5), spouse + child 1.06 (0.83-1.35), spouse + child + parent 1.04 (0.76-1.41), child 0.84 (0.52-1.37), child + parent 1.17 (0.63-2.16); HR for CHD mortality (reference spouse): alone 1.43 (0.73-2.81), spouse + parent 0.57 (0.23-1.42), spouse + child 1.11 (0.79-1.57), spouse + child+ parent 1.01 (0.63-1.62), child 1.54 (0.86-2.76), child + parent 0.81 (0.25-2.65).|
Women: HR for CHD incidence (reference spouse): alone 1.77 (0.92-3.39), spouse + parent 3.03 (1.36-6.75), spouse + child 2.11 (1.33-3.35), spouse + child + parent 2 (1.1-3.94), child 2 (1.16-3.43), child + parent 1.17 (0.27-4.98); HR for CHD mortality (reference spouse): alone 2.72 (1.37-5.38), spouse + parent 1.45 (0.42-4.97), spouse + child 1.26 (0.69-2.30), spouse + child + parent 1 (0.36-2.79), child 1.85 (0.95-3.62), child + parent 2.73 (0.78-9.51)
|Backholer et al. (2016)|
|Systematic review and meta-analysis: 116 studies, >22 million individuals, 35% female||Estimate of the sex differences in the RRs of SES on the risk of incident CHD, stroke, and CVD in the general population||Education, deprivation, occupation, income||CHD: education RR: women 1.66 (1.46-1.88), men 1.30 (1.15-1.48);|
area deprivation RR: women 1.83 (1.61-2.07), men 1.5 (1.38-1.63);
occupation RR: women 1.59 (1.28-1.97), men 1.50 (1.25-1.80);
income RR: women 2.48 (1.53-4), men 2.01 (1.47-2.74).
CVD: education RR: women 1.66 (1.43-1.92), men 1.42 (1.25-1.63);
area deprivation RR: women 1.75 (1.55-1.98), men 1.60 (1.45-1.76);
occupation RR: women 1.80 (1.51-2.40), men 1.74 (1.38-2.20);
income RR: women 1.46 (1.43-1.50), men 1.36 (1.34-1.39).
|Tang et al. (2015)|
|Systematic review and meta analysis: 10 studies; n = 981-8152; 34%-74% female||Association between SSS and the odds of CAD, hypertension, diabetes, obesity, and dyslipidemia||Low vs high SSS: an individual’s perception of his or her own position in the social and socioeconomic hierarchy||ORs:|
CAD 1.82 (1.10-2.99), hypertension 1.88 (1.27- 2.79), diabetes 1.90 (1.25-2.87), dyslipidemia 3.68 (2.03-6.64), obesity 1.57 (0.95-2.59);
Male: hypertension 1.57 (1.03-2.38), diabetes, 1.99 (1.40-2.84), obesity 1.02 (0.76-1.37);
Female: hypertension 1.77 (1.27-2.49), diabetes 2.14 (1.34-3.42), obesity 1.66 (0.88-3.13).
Meta regression comparing females vs males: not significant.
|Rosengren et al. (2019)|
|Large-scale prospective cohort study: the PURE study: 367 urban communities, 302 rural communities, 20 countries, age 35-70; n = 17,241; 53.6% female||Association between education, household wealth, and CVD mortality||Education (low vs high level)||Major CV events: high-income countries HR 1.23 (0.96-1.58), middle-income countries HR 1.59 (1.42-1.78), low-income countries HR 2.23 (1.79-2.77).|
CV mortality: high-income countries HR 1.50 (1.14-1.98), middle-income countries HR 1.80 (1.58-2.06), low-income countries HR 2.76 (2.29-3.31).
No sex-stratified results provided.
|Gender score (all dimensions)|
|Pelletier et al. (2016)|
|GENESIS-PRAXY, a prospective observational cohort study: n = 909; 2009-2013, age 18-55, 30% female||Associations between gender and sex with recurrent ACS and MACE (eg, ACS, cardiac mortality, revascularisation) over 12 months in patients with ACS||Gender score: household primary earner, personal income, number of hours per week spent doing housework, level of stress at home, Bem Sex-Role Inventory masculinity score, Bem Sex-Role Inventory femininity score||Hypertension OR 1.85 (1.04-3.29), diabetes OR 2.07 (1.00-2.39), depressive symptoms OR 2.68 (1.61-4.44), anxious symptoms OR 3.62 (2.17-6.01), recurrent ACS OR 4.50 (1.05-19.27)|
|Azizi et al. (2020)|
|CCHS database: cycle 2014; n = 63,522; 55.27% female||Association between a gender index created from a composite measure of gender-related factors and biological sex in predicting CVH||Gender score: household size, perceived life stress, education level, sense of belonging to community, marital status, income||CANHEART score: CVH Beta −0.43 (−0.51 to −0.36)|
- Johnson J.L.
- Greaves L.
- Repta R.
- Johnson J.L.
- Greaves L.
- Repta R.
- Johnson J.L.
- Greaves L.
- Repta R.
- Johnson J.L.
- Greaves L.
- Repta R.
Noncommunicable diseases: a priority for women’s health and development.
- Shaw L.J.
- Bairey Merz C.N.
- Bittner V.
- et al.
Gender—A Modifier of Established Cardiovascular Risk Factors
Physical activity and obesity
Sex- and Gender-Based Analysis Approaches
What Is Needed
- •Create sex disaggregated data for traditional and nontraditional risk factors.
- •Understand the intersectionality between sex and gender.
- •Formulate a standardised method to measure gender.
- Global, regional, and national age-sex-specific mortality for 282 causes of death in 195 countries and territories 1980-2017: a systematic analysis for the Global Burden of Disease Study 2017.Lancet. 2018; 392: 1736-1788
- Delayed care and mortality among women and men with myocardial infarction.J Am Heart Assoc. 2017; 6e005968
- Gender-specific ambulance priority and delays to primary percutaneous coronary intervention: a consequence of the patients’ presentation or the management at the emergency medical communications center?.Am Heart J. 2013; 166: 839-845
- Sex bias in referral of women to outpatient cardiac rehabilitation? A meta-analysis.Eur J Prev Cardiol. 2015; 22: 423-441
- Women’s participation in cardiovascular clinical trials from 2010 to 2017.Circulation. 2020; 141: 540-548
- Sex-specific determinants of coronary artery disease and atherosclerotic risk factors: estrogen and beyond.Can J Cardiol. 2020; 36: 706-711
- Performance of prognostic risk scores in heart failure patients: do sex differences exist?.Can J Cardiol. 2020; 36: 45-53
- Moving toward sex-specific cardiovascular risk estimation.Can J Cardiol. 2020; 36: 13-15
- Sex-specific considerations in guidelines generation and application.Can J Cardiol. 2019; 35: 598-605
- The effects of oestrogens and their receptors on cardiometabolic health.Nat Rev Endocrinol. 2017; 13: 352
- Does age at natural menopause affect mortality from ischemic heart disease?.J Clin Epidemiol. 1997; 50: 475-479
- A comparative study of lipid profile and oestradiol in pre-and post-menopausal women.J Clin Diagn Res. 2013; 7: 1596
- Effects of conjugated equine estrogen in postmenopausal women with hysterectomy: the Women’s Health Initiative randomized controlled trial.JAMA. 2004; 291: 1701-1712
- Cardiovascular Health After Maternal Placental Syndromes (CHAMPS): population-based retrospective cohort study.Lancet. 2005; 366: 1797-1803
- Polycystic ovary syndrome and early-onset preeclampsia: reproductive manifestations of increased cardiovascular risk.Menopause. 2010; 17: 990-996
- Reporting sex, gender, or both in clinical research?.JAMA. 2016; 316: 1863-1864
- Gender matters in biological research and medical practice.J Am Coll Cardiol. 2016; 67: 136-138
- Sex, gender and health research.(Available at:)Accessed April 2, 2021)
- Sex- versus gender-related characteristics: which predicts outcome after acute coronary syndrome in the young?.J Am Coll Cardiol. 2016; 67: 127-135
- Sex and gender: modifiers of health, disease, and medicine.Lancet. 2020; 396: 565-582
- Better science with sex and gender: a primer for health research.Women’s Health Research Network, Vancouver2007 (Available at:)https://bccewh.bc.ca/wp-content/uploads/2012/05/2007_BetterSciencewithSexandGenderPrimerforHealthResearch.pdf(Accessed April 2, 2021)
- Methods for prospectively incorporating gender into health sciences research.J Clin Epidemiol. 2020; 129: 191-197
- Psychosocial perspectives in cardiovascular disease.Eur J Prev Cardiol. 2017; 24: 108-115
- Stress and cardiovascular disease: an update on current knowledge.Annu Rev Public Health. 2013; 34: 337-354
- Sex differences in perceived stress and early recovery in young and middle-aged patients with acute myocardial infarction.Circulation. 2015; 131: 614-623
- Pre-existing depression predicts survival in cardiovascular disease and cancer.J Epidemiol Community Health. 2018; 72: 617-622
- Why is depression more common among women than among men?.Lancet Psychiatry. 2017; 4: 146-158
- Depression and cardiovascular disease: a clinical review.Eur Heart J. 2014; 35: 1365-1372
- Ischaemic heart disease in women: are there sex differences in pathophysiology and risk factors? Position paper from the Working Group on Coronary Pathophysiology and Microcirculation of the European Society of Cardiology.Cardiovasc Res. 2011; 90: 9-17
- Depression and risk of sudden cardiac death and coronary heart disease in women: results from the Nurses’ Health Study.J Am Coll Cardiol. 2009; 53: 950-958
- Combining psychosocial data to improve prediction of cardiovascular disease risk factors and events: the National Heart, Lung, and Blood Institute–sponsored Women’s Ischemia Syndrome Evaluation study.Psychosom Med. 2012; 74: 263-270
- Greater daily psychosocial stress exposure is associated with increased norepinephrine-induced vasoconstriction in young adults.J Am Heart Assoc. 2020; 9e015697
- Better science with sex and gender: facilitating the use of a sex and gender-based analysis in health research.Int J Equity Health. 2009; 8: 14
- A composite measure of gender and its association with risk factors in patients with premature acute coronary syndrome.Psychosom Med. 2015; 77: 517-526
- Job strain and cardiovascular disease risk factors: meta-analysis of individual-participant data from 47,000 men and women.PLoS One. 2013; 8e67323
- Work stress as a risk factor for cardiovascular disease.Curr Cardiol Rep. 2015; 17: 630
- Shift work and the risk of cardiovascular disease. A systematic review and meta-analysis including dose-response relationship.Scand J Work Environ Health. 2018; 44: 229-238
- Long working hours and cardiovascular disease: a meta-analysis of epidemiologic studies.J Occup Environ Med. 2012; 54: 532-537
- Stress on and off the job as related to sex and occupational status in white-collar workers.J Organ Behav. 1989; 10: 321-346
- Stress hormones in health and illness: the roles of work and gender.Psychoneuroendocrinology. 2005; 30: 1017-1021
- Applying social support research: Theoretical problems and future directions.J Soc Issues. 1985; 41: 5-28
- Addressing social determinants of health in the care of patients with heart failure: a scientific statement from the American Heart Association.Circulation. 2020; 141: e841-e863
- Marital stress worsens prognosis in women with coronary heart disease: the Stockholm Female Coronary Risk Study.JAMA. 2000; 284: 3008-3014
- Living arrangement and coronary heart disease: the JPHC study.Heart. 2009; 95: 577-583
- Living arrangements as determinants of myocardial infarction incidence and survival: a prospective register study of over 300,000 Finnish men and women.Soc Sci Med. 2015; 133: 93-100
- Sex differences in the relationship between socioeconomic status and cardiovascular disease: a systematic review and meta-analysis.J Epidemiol Community Health. 2017; 71: 550-557
- Association between subjective social status and cardiovascular disease and cardiovascular risk factors: a systematic review and meta-analysis.BMJ Open. 2016; 6e010137
- Noncommunicable diseases: a priority for women’s health and development.(Available at:)Accessed April 2, 2021)
- Importance of socioeconomic status as a predictor of cardiovascular outcome and costs of care in women with suspected myocardial ischemia. Results from the National Institutes of Health, National Heart, Lung and Blood Institute–sponsored Women’s Ischemia Syndrome Evaluation (WISE).J Womens Health. 2008; 17: 1081-1092
- Clinical advances in sex- and gender-informed medicine to improve the health of all: a review.JAMA Intern Med. 2020; 180: 574-583
- Coronary heart disease in the Framingham study.Am J Public Health Nations Health. 1957; 47: 4-24
- The Framingham Heart Study and the epidemiology of cardiovascular disease: a historical perspective.Lancet. 2014; 383: 999-1008
- Coronary artery calcium scores and risk for cardiovascular events in women classified as “low risk” based on Framingham risk score: the Multi-Ethnic Study Of Atherosclerosis (MESA).Arch Intern Med. 2007; 167: 2437-2442
- Sex differences in risk factors for myocardial infarction: cohort study of UK Biobank participants.BMJ. 2018; 363: k4247
- Mechanistic pathways of sex differences in cardiovascular disease.Physiol Rev. 2017; 97: 1-37
- Emergence of sex differences in prevalence of high systolic blood pressure: analysis of a longitudinal adolescent cohort.Circulation. 2006; 114: 2663-2670
- Heart disease and stroke statistics—2018 update: a report from the American Heart Association.Circulation. 2018; 137: e67-492
- Sex differences in blood pressure trajectories over the life course.JAMA Cardiol. 2020; 5: 19-26
- Sex-specific differences in hypertension and associated cardiovascular disease.Nat Rev Nephrol. 2018; 14: 185-201
- Gender differences in the association between socioeconomic status and hypertension in France: a cross-sectional analysis of the Constances cohort.PLoS One. 2020; 15e0231878
- Cigarette smoking as a risk factor for coronary heart disease in women compared with men: a systematic review and meta-analysis of prospective cohort studies.Lancet. 2011; 378: 1297-1305
- Smoking prevalence and attributable disease burden in 195 countries and territories 1990-2015: a systematic analysis from the Global Burden of Disease Study 2015.Lancet. 2017; 389: 1885-1906
- Smoking and risk of myocardial infarction in women and men: longitudinal population study.BMJ. 1998; 316: 1043
- Cigarette smoking among adults—United States 2006.MMWR Morb Mortal Wkly Rep. 2007; 56: 1157
- Smoking, quitting, and the risk of cardiovascular disease among women and men in the Asia-Pacific region.Int J Epidemiol. 2005; 34: 1036-1045
- Do smoking habits differ between women and men in contemporary Western populations? Evidence from half a million people in the UK Biobank study.BMJ Open. 2014; 4e005663
- Association of leisure-time physical activity with total and cause-specific mortality: a pooled analysis of nearly a half million adults in the Asia Cohort Consortium.Int J Epidemiol. 2018; 47: 771-779
- Leisure time physical activity and mortality: a detailed pooled analysis of the dose-response relationship.JAMA Intern Med. 2015; 175: 959-967
- Sustained physical activity, not weight loss, associated with improved survival in coronary heart disease.J Am Coll Cardiol. 2018; 71: 1094-1101
- Physical activity and incident cardiovascular disease in women: is the relation modified by level of global cardiovascular risk?.J Am Heart Assoc. 2018; 7e008234
- Physical activity and risk for cardiovascular events in diabetic women.Ann Intern Med. 2001; 134: 96-105
- Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study.Lancet. 2004; 364: 937-952
- Worldwide trends in insufficient physical activity from 2001 to 2016: a pooled analysis of 358 population-based surveys with 1.9 million participants.Lancet Glob Health. 2018; 6: e1077-e1086
- Comprehensive primary prevention of cardiovascular disease in women.Clin Cardiol. 2017; 40: 832-838
- Twelve-year follow-up of American women’s awareness of cardiovascular disease risk and barriers to heart health.Circulation Cardiovasc Qual Outcomes. 2010; 3: 120-127
- Associations of diabetes mellitus with total life expectancy and life expectancy with and without cardiovascular disease.Arch Intern Med. 2007; 167: 1145-1151
- Impact of impaired fasting glucose on cardiovascular disease: the Framingham Heart Study.J Am Coll Cardiol. 2008; 51: 264-270
- Sex disparities in treatment of cardiac risk factors in patients with type 2 diabetes.Diabetes Care. 2005; 28: 514-520
- Gender disparities in blood pressure control and cardiovascular care in a national sample of ambulatory care visits.Hypertension. 2008; 51: 1149-1155
- Physical activity and cardiovascular health: lessons learned from epidemiological studies across age, gender, and race/ethnicity.Circulation. 2010; 122: 743-752
- Trends in adult body-mass index in 200 countries from 1975 to 2014: a pooled analysis of 1698 population-based measurement studies with 19.2 million participants.Lancet. 2016; 387: 1377-1396
- Gender specific differences in left ventricular adaptation to obesity and hypertension.J Hum Hypertens. 1998; 12: 685-691
- Sex differences in cardiovascular pathophysiology: why women are overrepresented in heart failure with preserved ejection fraction.Circulation. 2018; 138: 198-205
- Sex-specific relevance of diabetes to occlusive vascular and other mortality: a collaborative meta-analysis of individual data from 980 793 adults from 68 prospective studies.Lancet Diabetes Endocrinol. 2018; 6: 538-546
- Sex differences in the cardiovascular consequences of diabetes mellitus: a scientific statement from the American Heart Association.Circulation. 2015; 132: 2424-2447
- Excess psychosocial burden in women with diabetes and premature acute coronary syndrome.Diabet Med. 2017; 34: 1568-1574
- Sex and gender differences in body composition, lipid metabolism, and glucose regulation.in: Neigh G. Mitzelfelt M. Sex Differences in Physiology. Academic Press, 2016: 145-165
- Sex differences in lipid profiles and treatment utilization among young adults with acute myocardial infarction: results from the VIRGO study.Am Heart J. 2017; 183: 74-84
- Gender diagnosticity: a new bayesian approach to gender-related individual differences.J Pers Soc Psychol. 1990; 59: 1051-1065
- Measuring gender when you don’t have a gender measure: constructing a gender index using survey data.Int J Equity Health. 2016; 15: 82
- Conducting gender-based analysis of existing databases when self-reported gender data are unavailable: the GENDER Index in a working population.Can J Public Health. 2020; : 1-14
- Twenty-five years after the Bem Sex-Role Inventory: a reassessment and new issues regarding classification variability.Meas Eval Couns Dev. 2001; 34: 39-55
- Measurement of masculine and feminine sex role identities as independent dimensions.J Consult Clin Psychol. 1976; 44: 183
- The measurement of psychological androgyny.J Consult Clin Psychol. 1974; 42: 155
- Sex and gender analysis improves science and engineering.Nature. 2019; 575: 137-146
- Psychological androgyny: a review of the research.Couns Psychol. 1987; 15: 471-513
- Sex and gender factors and the cardiovascular health of canadians.Can J Cardiol. 2020; 36: S21
- Sex and gender differences and biases in artificial intelligence for biomedicine and healthcare.NPJ Digit Med. 2020; 3: 1-11
- Gender and sex differences in prevalence of major depression in coronary artery disease patients: a meta-analysis.Maturitas. 2012; 73: 305-311
- Adjusted prognostic association of depression following myocardial infarction with mortality and cardiovascular events: individual patient data meta-analysis.Br J Psychiatry. 2013; 203: 90-102
- Systematic review and individual patient data meta-analysis of sex differences in depression and prognosis in persons with myocardial infarction: a MINDMAPS study.Psychosom Med. 2015; 77: 419-428
- Work stress in the etiology of coronary heart disease: a meta-analysis.Scand J Work Environ Health. 2006; 32: 431-442
- Socioeconomic status and risk of cardiovascular disease in 20 low-income, middle-income, and high-income countries: the Prospective Urban Rural Epidemiologic (PURE) study.Lancet Glob Health. 2019; 7: e748-e760
Raparelli VR, Norris CM, Bender U, et al. The Gender Outcomes International Group: To Further Well-Being Development (GOING-FWD) methodology on identification and inclusion of gender factors in retrospective cohort studies [preprint]. Research Square rs-51246.
- Gender Outcomes International Group: To Further Well-Being Development (GOING-FWD).(Available at:)Accessed April 2, 2021)
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