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Efficacy of Dressing by Aloe Vera Gel on Healing and Pain among Burned Patients

Ahmed Mahmoud Walash, Om Elhana Kamel Abo Shehata, Abeer El-Said Hassan El-Sol*

Assistant Professor of Medical-Surgical Nursing, Faculty of Nursing, Menoufia University, Egypt

Abstract: Aloe Vera gel plays an important role in managing burn by rapid healing process, it increases growth factors, by collagen and proteoglycan synthesis, also it contains many important components as nutrients, vitamins, antioxidants, antimicrobial, anti-inflammatory and Magnesium lactate has anti-itching and analgesic effect by inhibiting histamine-decarboxylase which controls pain level and promoting wound healing furthermore reduction of duration of patient hospitalization. The aim of the study; this study aimed to evaluate the efficacy of dressing by Aloe Vera gel versus conventional dressing on the healing process and pain among burned patients. Subjects & Method; design: Quasi-experimental research design was utilized to achieve the aim of the study. Research setting: The current study was conducted at burn unit and burn out patient's clinic of Shebin El-Kom Teaching Hospital, Menoufia Governorate- Egypt. Subjects; a purposive sample of 50 patients; they were divided into two equal groups 25 patients in each as follows: 1-The study group (I): dressing by Aloe Vera gel 2- The control group (II): dressing by conventional dressing or routine hospital. Tools: two tools were utilized to collect the necessary data. Tool one: interview questionnaire sheet; divided into four parts: Part one: Sociodemographic and medical data; Part two: Bio-physiological measurements (Vital signs; Patient’s Knowledge about nutrition and Laboratory investigations); Part three: Burn characters (parameters); as total body surface area (TBSA); degree of burn; presence of wound oozing; eschar (dry, black necrotic tissue); burn odor; wound redness and swelling, healing process and burn complication. Part four: Photographs. They were taken by researchers to evaluate the healing process at the beginning of the treatment, then every week until complete healing occurred. Tool two: Visual analogue pain scale. The results: most patients in study group hadn't characters of wound infection after one week of Aloe Vera gel dressing application (fourth assessment); moreover during fifth and sixth assessment all patients in the study group were free from symptoms of wound infection, while 48% in the control group had characters of wound infection by last two assessments. The rapid healing process occurred, decreased level of pain and length of hospitalization stay among the study group after dressing application by Aloe Vera gel than the control group. Conclusion: Depending on the present study results, it can be concluded that Aloe Vera gel promoted wound healing of first and second degree of burns better than traditional dressing in management methods, it also reduces pain level so lesser length of patient hospitalization stay. Recommendation: Based on the previous researches and the current study results, the researchers recommended that; use Aloe Vera gel in a dressing of the burned patient especially second unhealed or delayed. Apply research on a large number of patients with more times for follow up.

Keywords: Aloe Vera gel, burn, dressing, pain level, healing process, length of hospital stay

Received August 19, 2019; Revised September 26, 2019; Accepted October 21, 2019

Citation: Ahmed Mahmoud Walash, Om Elhana Kamel Abo Shehata, Abeer El-Said Hassan El-Sol, Efficacy of Dressing by Aloe Vera Gel on Healing and Pain among Burned Patients. American Journal of Nursing Research, 7 (6). 1028-1040. January 2019. doi:10.12691/ajnr-7-6-17

1. Introduction

A burn is a significant and increasing global as well as local health mortality & morbidity problem. It's caused by heat, chemicals, electricity, sunlight or radiation. Incidence of burn is a major health problem, which estimated 180 000 deaths per year [1,2].

Burn is the fourth cause of injuries after motor accidents, falling, and violence. Moreover, 90% of burn happens in the developing world due to overcrowding and an unsafe cooking situation [3,4]. Technological advances decrease the incidence and severity of burn injuries, and enhance medical care of burn injuries, so survival rates increase [5,6,7].

In Egypt, according to a statistical report, the prevalence of some 100,000 people burned yearly, and only a few manage to afford the care needed to survive, according to the AhlMasr Foundation. The mortality rate of burned victims in Egypt is considered 37%, while in other countries the average of 5%. Moreover, most of these victims who survive facing problems to carry their daily activities due to their physical disfigurement and physiological trauma [8].

Recognizing the type of burn is necessary because interventions must be appropriately tailored to the underlying cause. There are many types of burns thermal, chemical, electrical and radiation burns. Thermal burns can be further classified according to skin depth and percentage of the total body burned area, the thermal type may be due to contact, flame, heat, and scalding. Accurate documentation of the burn location and measurement of involved surface area is important for treatment and transfer decisions [9].

The depth of injury depends on the strength or concentration of the burn agent and duration of these agent contacts with the skin. To map the area of the burn and assess its size, the practitioner needs to be able to differentiate between various depths of injury. The depth of the burn is classified into superficial partial-thickness injuries, deep partial-thickness injuries and full-thickness injuries [10,11,12].

The complexity of burn management requires an integrated multidisciplinary approach. Nurses play a vital role in caring and supporting patients through the seven phases of burn care. Accurate knowledge of the pathophysiology and epidemiology of burn injuries is necessary to ensure appropriate specialist nursing care. Only through such specialist management can best outcomes for these patients be achieved [11].

The main aim of burn care is to restore function, maximize the patient’s abilities and promote physical, psychological and emotional recovery. Wound care involves local wound care as well as systemic measures. Promote wound healing by debridement or removal of necrotic tissue; wound cleansing, and dressings that promote a moist wound environment. Systemic treatments by using antibiotics to control infection and optimizing nutritional status [13,14].

Wound healing involves a complex process of cellular interactions coordinated by cytokines and growth factors leading to restoration of tissue integrity. Normal wound healing is characterized by three phases: inflammation, proliferation, and maturation (remodeling). This can be affected by local and systemic factors [15,16,17].

Aloe Vera is also known as Barbados or Curaçao Aloe has been used in traditional and folk medicines for thousands of years to treat and cure a variety of wound as burn [18,19].

Aloe Vera gel has been used in managing burn for many years. Aloe Vera gel has been stated that; rapidly healing by increased growth factors as collagen and proteoglycan synthesis, it has many important components as nutrients, vitamins, antioxidants, antimicrobial, anti-inflammatory and Magnesium lactate has anti-itching and analgesic effect by inhibiting histamine-decarboxylase which controls pain level and promoting wound healing furthermore reduced length of hospitalization [20,21,22].

Significance of the Study

Annually admitted into Shebin El-Kom Teaching Hospital, Menoufia Governorate- Egypt; about 1200 of burned case from all ages and different degree of burn[23]. For many years; Aloe Vera gel has been used in burn injuries as topical healing therapy with anti-microbial properties. Aloe Vera gel is a natural herbal with rarer toxic effect and inexpensive remedies. Many researchers have reported that; it had the effect on pain control and wonderful healing support for burning patients; so the researchers used it in dressing of first and second degree of burn.

1.2. Aim of the Study

This study aimed to evaluate the efficacy of dressing by Aloe Vera gel versus conventional dressing on the healing process and pain among burned patients.

1.3. Research Hypothesis

The following research hypotheses are formulated in an attempt to achieve the aim of the study:

1- Dressing by Aloe Vera gel in Study group (group I); will be decrease level of the patient's pain, and faster healing process than whom have conventional dressing (control group II).

2- Dressing by Aloe Vera gel in the study group (group I); will be decrease the length of hospitalization stay and wound infection if compared with the control group.

3- There will be change of knowledge about nutrition for burning patients in the study group after intervention compared with control group (II).

2. Subjects & Method

Research design: Quasi-experimental research design was utilized to achieve the aim of the study.

Research setting: The current study was conducted at burn units and burn out patient's clinic of Shebin El-Kom Teaching Hospital, at Shebin El-Kom district, Menoufia Governorate- Egypt.

Sample: A convenient sample of 50 patients who admitted to burn units for burn management, agree to participate in the study and fulfill the inclusion criteria. The study subjects were divided randomly and alternatively into two equal groups 25 patients in each as follows: 1-The study group (I): received Aloe Vera gel is dressing 2- The control group (II): received routine hospital dressing.

• Inclusion criteria: a) Adult patients from sexes, b) Total Body surface area (TBSA) < 30%, c) 1st and 2nd degree of burn

• Exclusion criteria the cases had diseases as renal, hepatic, cardiac, diabetic and malnourished.

Sample size: Based on a previous literature by (Shahzad and Ahmed, 2013) [24], with a power of the study, 90% and a confidence level, 95%,the calculated sample size for this randomized controlled clinical trial study rendered 50 subjects which were divided into two groups after doing randomization so each group consists of 25 patients.

Tools for data collection: two tools were utilized by the researchers to achieve the aim of the study and to collect the necessary data.

Tool I: Interview questionnaire sheet; divided into four parts:

Part one: Sociodemographic and medical data: This tool developed by the researcher to assess socio-demographic and medical data, theywere age, sex, level of education, occupation, monthly income; marital statusand length of patient stay.

Part two: bio- physiological measurements:

A-Vital signs: Measurement of patient's vital signs as body temperature, pulse, respiratory rate and arterial blood pressure.

B-Patient’s Knowledge about nutrition: It was adapted from Abdel –Aziz, GS. (2008)[25], to assess patient’s knowledge regarding nutrition. It included 5 questions about the nutrition for burned patients as diet components; increasing important nutrient intake, especially protein, iron and vitamin intake, the main source for each nutrient, limit intake of carbohydrates and fats finally; the relation between nutrition and wound healing and infection. Each question has three alternatives scores.

Correct and complete answer given a score of three.

Correct and incomplete answer given a score of two.

Incorrect answer given a score of one.

C- Laboratory investigations: It included total serum protein, albumin, hemoglobin, hematocrit, red blood count, white blood count, and blood glucose.

Part three: Burn characters (parameters): It was adapted from Gad, NRA. (2002) [26]. This part included, the place of accident; causative agent; total body surface area (TBSA); degree of burn; presence of wound oozing; eschar (dry, black necrotic tissue); burn odor; wound redness and swelling, healing process and burn complication as Bacteriological wound infection; culture will be done.

Part four:Photographs: They were taken by researchers to evaluate the healing process at the beginning of the treatment then every week until complete healing occurred.

Tool II: Visual analogue pain scale (VAS): It was developed byBain, Kuwahata, Raymod and Foster (2005)[27], to rate the patients accroding to level of pain intensity. The measurement was from zero to ten in which: 0 = no pain, 1-3, mild pain, 4-6 = moderate pain, 7- 10 = sever pain

Pilot study: A total of 10% of the sample was included in the pilot study in order to assess the feasibility and the clarity of the tools and determine the needed time to answer the questions. Based on its result changes were carried out. Pilot study revealed the average length of time needed to complete the structured interview schedule. It carried out prior to data collection on 10% of the subjects (5) patients. They were excluded from the study.

Validity: Before starting, the data collection tools were translated into Arabic and tested for its content validity by a group of experts in the medical-surgical nursing and burn specialist to ascertain relevance, completeness, coverage of the content and clarity of the questions. The required modification was carried out accordingly. Then back translation was done in English to ensure translation accuracy.

Reliability of the tool (I): Each question in each study tool will be tested for reliability. This will be done by asking each question twice so as to compare the consistency of answers produced for the same questions by the same respondent. Accordingly, the necessary adjustment will be carried out. Chronbach’s alpha was practical for the reliability of the questionnaire and was established to be 0.84 for Part one.

Reliability of the tool (II): Reliability was tested using a test retest method and a person correlation coefficient formula was used. The period between each test was two weeks. It was 0.97 for the tool (I), and 99 for tool (II). Boonstra, et al. tested the reliability of tool II and found that the test retest reliability was 0.84 [28].

Formal approval: An approved permit was obtained from the administrative authorities of Shebin El-Kom Teaching Hospital to conduct the study in the burn unit and burn out patients after clarification of the study aim.

Ethical consideration: Written consent was obtained from the patients after clarification of the study aim for participants before the start of the study. Privacy and confidentiality were assured through coding the data.

Fieldwork:

Interviewing and assessment phase: Data collection for this study was carried out from the first off before conducting the study, permission was obtained from administrative personnel of Shebin El-Kom Teaching Hospital. The data collection period started from the beginning of February to the end of August. Data collection was carried out in three phases: assessment phase, implementation phase, and evaluation phase.

Assessment phase: The aim of this phase is to collect baseline assessment of social and medical data for patients with burn using the tool (I). Interview questionnaire sheet.Tool (II): Visual analogue pain scale.

Planning phase: The researcher goes through extensive literature to design the plan for the interventions. Also, preparing the Aloe Vera gel that the researcher will use for the burn healing. Individualized plan for patients was developed based on the finding of the assessment. The goals, priority of care, and expected outcome criteria were formulated and taking first into considerations.

Implementation phase: The obtained information used as the baseline assessment (pretest), then the researchers identify the patients burn degree through assessing site, calculate total body surfase area, degree and depth of burn; method of treatment and burn complication, also pain level assessed by visual analogue pain scale first and every week along period of wound healing; also laboratory parameters as total serum protein, albumin, hemoglobin, red blood count, white blood count, and blood glucose. The researchers used the wound healing sheet to evaluate the healing process of burn wound. The exudation of wound is observed for amount, color and odor weekly along period of healing to evaluate the healing process of burn wound.

The nursing care included assessing the wound and wound dressing using the aseptic technique of preparing the needed equipment and wear the sterile gloves to clean the wound with normal saline, remove the dead tissues and eschar them clean with normal saline and gentle dry, then apply Aloe Vera gel on wound and leave wound open (open dressing); in some cases the researchers put layer from Vaseline Petrolatum Gauze to prevent irritation of burned area or covered with sterile dressing (closed dressing) as prescribed. Wound dressing was performed as prescribed. The researchers have taken six assessments for both groups as follows:

• First assessment: Pre-interventions

• Second assessment: Post 1 after dressing by 3 days

• Third assessment: Post 2 after dressing by one week

• Fourth assessment: Post 3 after dressing by two weeks

• Fifth assessment: Post 4 after dressing by 4 weeks

• Sixth assessment: Post 5 last dressing.

The evaluation phase "Post-test": In this phase, the wound was evaluated for the healing process. The evaluation was done for all patients using all tools except tool one weekly along period of healing. The comparisons between study and control groups were done by using the proper statistical analysis.

• Human rights and ethical considerations: An official permission was taken from the authoritative personal in the hospital. The researchers introduced themselves to the patients who met the inclusion criteria and informed them about the aim of the current study in order to obtain their acceptance to share in this study. Written consent was obtained from them. Confidentiality and anonymity of them were assured through coding the data.

Statistical methodology: The data collected were tabulated & analyzed by SPSS (statistical package for the social science software) statistical package version 20 on IBM compatible computer.

Two types of statistics were done:

1) Descriptive statistics: They were expressed as mean and standard deviation (X+SD) for quantitative data or number and percentage (No & %) for qualitative data.

2) Analytic statistics:

1- Pearson Chi-square test (χ²) & Fisher`s Exact Test: It is the test of significance used to study the association between two qualitative variables.

2- Student t- test: is a test of significance used for comparison between two independent groups of normally distributed quantitative variables.

3- Repeated measures ANOVA test: is a test of significance used for comparison between more than two related groups of normally distributed quantitative variables.

P-value of 0.05 was used to determine significance regarding:

• P-value > 0.05 to be statistically insignificant.

• P-value ≤ 0.05 to be statistically significant.

• P-value ≤ 0.001 to be highly statistically significant.

3. Results

Table 1: Comparing the two groups (study and control) in relation to socio-demographic characteristics, these groups were comparable and no statistically significant differences were noted; in other words, they can be considered homogeneous.

Table 2: this table revealed that; there were no statistically significant differences between both groups regarding burn characters except dressing frequency, there was highly significant differences regarding dressing frequency between both groups (study and control group) in post interventions P (<0.001). Hypothesis 1 was supported by the data.

Figure 1: this figure showed that; about 56% and 76% respectively from studying groups showed incorrect knowledge about nutrition for burned patient, immediately after the health education and continued to be high at the following evaluation sessions about 68% of the study group had correct and complete knowledge about nutrition for the burning patient while 56% of the control group had incorrect and incomplete knowledge, with highly statistically significant differences p<0.001). Hypothesis 3 was supported by the data.

Table 3: this table illustrated that; most of cases in study group had characters of wound infection during the first three assessment; this was supported by first assessment of wound swap culture; while 88% from them in fourth assessment and all study group hadn't characters of wound infection during the last three assessments; this supported by second assessment of wound swap culture; with highly statistical significant differences among the six assessment in the same group; regarding to control group; relatively constant percentage had characters of wound infections during the first three assessments, and 52% from them hadn't characters of wound infection during the last three assessments; there were highly statistically significant differences between both groups in last two assessments. Hypothesis 2 was supported by the data

Table 4: this table showed that; there was no statistically significant difference between both groups during first measurement of all vital signs, but there was highly statistically significant difference between both groups during second and third measurements of vital signs except in systolic blood pressure and diastolic blood pressure; wherever presence of highly statistical significant difference among three assessments in study group; while presence of statistically significant difference only in pulse and respiratory rate measurement in control group during the three measurements.

Table 5: this table represented that; there was no statistically significant difference between both groups during first and second assessment of all laboratory investigations except of the white blood cells (WBCs) account in the second measurement; while there was statistically significant difference between both groups during third assessment in laboratory investigations except blood glucose and albumin level; however there was statistically significant difference among three measurements for both groups.

Figure 2: this figure showed that; most of cases from both groups had bad healing process during the first three assessments, with no statistically significant difference between them; but all study groups had a good healing process during the last two assessments, with no change in the control group; there was a statistically significant difference between both groups. Hypothesis 1 was supported by the data.

Figure 3: this figure exposed that; most of cases from both groups had a moderate level of pain (4-6) in pre-intervention; while post intervention in second assessment 56% from study group had mild pain and in third assessment 64% from study group had mild pain and 36% hadn’t pain; but still 68% of the control group had moderate level of pain during third assessment. There was statistically significant difference between both groups. Hypothesis 1 was supported by the data.

Figure 4: this figure illustrated that; after intervention most of the study group had a lower length of hospital stay (2 weeks) than control group (3 weeks). Hypothesis 2 was supported by the data.

Photographs: They were taken by researchers to evaluate the healing process at the beginning of the treatment then every week until complete healing occurred

Table 1. Distribution of demographic characteristics of the study and control groups

Table 2. Distribution of patients` burn characters/ assessment among the studied groups pre intervention and frequency of dressing pre & post interventions

Figure 1. Patient`s knowledge about nutrition among studied groups pre-post interventions

Table 3. Characters of wound infection among studied groups pre-post interventions

Table 4. Comparisons between patients of both groups regarding to physiological parameters at different intervals

Table 5. Laboratory investigations of the studied groups' pre-post interventions

Figure 2. Healing process among studied groups' pre-post interventions

Figure 3. Visual Analogue Scale (level of pain) among studying groups' pre-post interventions

Figure 4. Length of hospital stay among the studied groups

Photographs

4. Discussion

Aloe Vera is a natural plant, which used as traditional and herbal medicine for many years. Aloe Vera gel has many components, which are very necessary for promoting rapidly burn healing, reducing pain sensation that; leading to lesser burned patient admission period if compared with other conservative methods of dressing. The present study aimed to investigate the efficacy of dressing by Aloe Vera gel versus conventional dressing on the healing process and pain among burned patients.

4.1. Regarding to Socio-demographic Characteristics

The present study revealed that; the majority of subjects in both groups were illiterate married female; their mean age was 36.08 ± 10.27 & 33.80 ±8. 98 respectively; and there was no statistically significant differences between study and control groups related to socio-demographic data, this result was supported Varaei (2017) [29], who reported that; there was no statistically significant difference between all cases because they had similar characteristics. The researcher explained that; the subjects, both groups were homogenous.

4.2. In Relation to Burn Assessment

The current study documented that; most of cases in both samples had first and second degree of burn, means of burn percentage were 19.28±4.8 & 18.28±3.7 respectively; they burned at home by the fire, with no statistically significant differences between both groups related to burn characters, there were in line with Muhammad, N s., & Naheed, A. (2013) [30], they said that; there was no statistically significant difference between both sample regards to total body surface area and type of burn injury, furthermore in the study group after application of a dressing of Aloe Vera gel the dressing frequency reduced from daily to every 3 days while still daily dressing among control group; this result agreed with Muhammad, N s., &Naheed, A. (2013) [30], they reported that; after 5 days of Aloe Vera dressing application, layers of skin started into growth so the cases needed dressing every several days, with highly statistically significant differences between both groups with regards to this item. The researcher explained that Aloe Vera contains compounds that; had properties shorten the recovery time of burns' wounds so wide frequency between dressing.

4.3. Regards to Patient`s Knowledge about Nutrition

The present study showed that; the majority of subjects in both groups had incorrect and incomplete knowledge about nutrition for burning patients during pre-interventions; however, during the second assessment after intervention most of study group improved their level of knowledge; which reflected the researcher role as a nursing educator; while more than half of the control group had incorrect and incomplete knowledge about this item. This result agreed with Shaban, et al (2017), [31]; they said that; improvement of knowledge occurred in most of the study group during the post- intervention to a better level than the poor level in pre-intervention. The researcher explained that; one of the nursing responsibilities toward the patients is educating them about their conditions reduce its morbidity and mortality.

4.4. As Regards to the Characters of Wound Infection

The existing study approved that; most of cases in study group hadn't characters of wound infection as swelling, bad odor, oozing secretion after one week of Aloe Vera gel dressing application (fourth assessment); additional during fifth and sixth assessment all study group were free from symptoms of wound infection, while still 48% from control group had characters of wound infection by last two assessment, these results supported by Varaei; (2017) [29], who documented that; the study sample than control was excluded from indicators of infection by antimicrobial effect of Aloe Vera gel. With highly statistical significant differences between both groups regarding to this point and among assessment pre and post-interventions for study group only. The researcher explained that; Aloe Vera gel had antibacterial, antifungal and antiviral effects so signs of infection disappeared after application of it.

4.5. Regarding to Vital Signs Measurements

The present study reported that; presence of elevation in body temperature among study group during pre- intervention (first measurement), it is known that presence of positive relationship among increased temperature and pulse rate and respiratory rate due to vasodilatation by fever, elevated body temperature one indicator of burn wound infection plus previous other wound symptoms, by absence of characters of wound infection during post intervention (2nd and 3rd measurements) they improved to normal range these agreed with Davies and Maconochie, (2009) [32] & Dahag; et al (2018) [33], they reported that; pyrexia is sign of infection and other vital signs changed to above normal by it. With highly statistically significant differences between both groups in regards to vital signs and among measurements during pre and post-interventions for study group only. The researcher explained that; Aloe Vera gel had antibacterial, antifungal and antiviral effects so signs of infection disappeared after application of it.

4.6. In Relation to Laboratory Investigations

The existing study approved that; the majority of both groups had abnormal of laboratory investigations during first assessment; but the improvement happened in laboratory investigations for all cases in studied group during third assessment; while about 9 cases from control group still below normal, this result in line with Sen, et al (2019) [34] & Badica, (2013) [35], they said that; after burn incidence by a week hemoglobin level and red blood cells decreased due to losses by burn; while white blood cells elevated due to wound infection after damage of first defense against infection; furthermore albumin level decreased within the first two days after burn injury; finally all these improved with the time by medical intervention. With highly statistically significant differences between both groups and among three assessments related to laboratory investigation except glucose level. The researcher explained that; hemoglobin level and red blood cells decreased due to loss during dressing, the level of albumin decreased by blister formation and white blood cells elevated due to wound infection, all studied groups improved their investigations by blood transfusion and nutritional correction.

4.7. Regarding to the Healing Process, Pain Level and Length of Hospital Stay

The current study reported that; incidence of good healing process for burn, decreased levels of pain and length of hospitalization stay among studied group during post dressing application of Aloe Vera gel than the control group, these results supported by Muhammad Muhammad, N s.,& Naheed, A. (2013) [30], Varaei; (2017) [29] & Athavale et al (2017) [36]; they documented that; reduction happened in a burned surface area by rapidly rate of wound healing with decreased intensity of pain sensation and period of admission in studying group than conventional group. The researcher rationalized that; Aloe Vera has many important elements as nutrients, vitamins, antioxidants, antimicrobial, anti-inflammatory and Magnesium lactate has anti-itching and analgesic effect by inhibiting histamine-decarboxylase which controls the pain level promoting wound healing and reduction of duration of patient hospitalization.

5. Conclusion

Depending on the present study results; it can be concluded that Aloe Vera gel promoted wound healing of first and second degree of burns better than traditional dressing in management methods, it also reduced pain level so decreased length of patient hospitalization statement.

6. Recommendation

Based on the previous researches and the current study results, the researchers recommended that; use Aloe Vera gel in a dressing of the burned patient especially second unhealed or delayed. Apply research on a large number of patients with more times for follow up.

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