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[45]                                                                                                                                                                                                                                            AJDHS.COM 

 

 

Available online at ajdhs.com 

Asian Journal of Dental and Health Sciences 
Open Access to Dental and Medical Research 

Copyright  © 2024 The  Author(s): This is an open-access article distributed under the terms of the CC BY-NC 4.0 
which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided 

the original author and source are credited  

 

 

The Challenges of Chronic Wound Care and Management 
Pallav Dave * 

Regulatory Compliance Analyst, Louisville, KY, 40223, USA 

Article Info: 
_____________________________________________ 
Article History: 

Received   03 January 2024   
Reviewed 20 February 2024 
Accepted   04 March 2024 
Published 15 March 2024 

_____________________________________________ 
Cite this article as:  

Dave P, The Challenges of Chronic Wound Care and 
Management, Asian Journal of Dental and Health 
Sciences. 2024; 4(1):45-50 

DOI: http://dx.doi.org/10.22270/ajdhs.v4i1.70       

_____________________________________________ 

*Address for Correspondence:   

Pallav Dave, Regulatory Compliance Analyst, 
Louisville, KY, 40223, USA 

Abstract 
_________________________________________________________________________________________________________________ 

Chronic wounds are a significant healthcare challenge across the world. They affect approximately 
2.21 per 1000 people making them a prevalent challenge that needs to be addressed. The prevalence 
of these wounds is also growing as the population ages. Various underlying factors such as medical 
conditions, poor nutrition, diabetes, vascular disease, arterial disease, prolonged pressure, 
neuropathy, chronic venous insufficiency, and being overweight or obese are contributing to the 
increasing prevalence of chronic wounds. Addressing chronic wounds is vital. They are a significant 
healthcare burden that affects the overall quality of life and contributes to the loss of function. 
Chronic wounds are also painful, which makes them a difficult experience for patients. With the 
increasing morbidity and mortality attributed to chronic wounds, it is important to ensure 
treatment interventions are effective to achieve positive outcomes. However, achieving positive 
outcomes is a challenge because of the existing challenges that impede proper wound care and 
management. Identifying the challenges that make it difficult to manage chronic wounds effectively 
is vital to ensure positive outcomes in management. The aim of this review is to identify the 
challenges that affect chronic wound care and management.   

Keywords: chronic wounds, ulcers, wound care, wound management, treatment interventions 

 

Introduction 

Chronic wounds refer to wounds that do not progress through 
the normal healing process as other wounds. As a result, they 
remain open for longer periods of time. These wounds are a 
significant challenge to healthcare systems affecting about 2.21 
people per 1000 across the world.1 In the US alone, chronic 
wounds affect more than 2.5% of the population or 10.5 million 
people.2 The incidence of chronic wounds is increasing. In the 
US, about 1% of the population has an active or healed venous 
ulcer.3 Pressure sores are also a significant burden to the 
population. Another one million of the 30 million people who 
live with diabetes develop an ulcer every year.3 The burden of 
these wounds is projected to increase in the coming years as the 
aging population increases. Elderly people tend to be 
disproportionately affected by chronic wounds.2,4 Factors such 
as underlying medical conditions, poor nutrition, increased risk 
of falls, and the likelihood of undergoing surgery can explain 
why this population is disproportionately affected.5 In the 
general population, chronic wounds can be attributed to a 
number of factors. Some of these factors include diabetes, 
vascular disease, arterial disease, prolonged pressure, 
neuropathy, chronic venous insufficiency, and being overweight 
or obese.4,6   

Addressing the burden of chronic wounds is vital. They are a 
significant health burden that contributes significantly to lower 
quality of life and inability to perform daily functions.7 
Individuals with chronic wounds are prone to infections with a 
recurrence rate of up to 70% making it even more difficult for 
patients.4 Another feature of these wounds is inflammation 
which means they cause a great deal of pain to the affected 
patients. Chronic wounds also contribute to the morbidity and 

mortality burden. According to Jupiter et al.8 a diabetic ulcer is 
associated with 40% mortality rate five years after its 
occurrence. Chronic wounds also contribute significantly to 
disabilities. 85% of all amputations are attributed to ulcers 
while diabetic ulcers contribute to 75% of all lower limb 
amputations.9 The high morbidity and mortality rates 
attributed to chronic wounds despite the therapeutic 
interventions that are available for managing these wounds 
explain why they are a significant health burden. Chronic 
wounds are also attributed to a significant financial burden.10 

The difficulty in treating them, the high recurrence rate, and the 
persistent infections are some of the factors that contribute 
significantly to the financial burden of treating chronic wounds. 
Identifying the challenges attributed to chronic wound care and 
management is vital to their management. By identifying these 
challenges, it becomes easier to put interventions in place that 
can improve patient health outcomes.   

The aim of this review is to provide an overview of the 
challenges that are encountered in the care of chronic wounds. 
The review begins by providing a brief overview of chronic 
wounds including their classification and pathophysiology. It 
goes ahead to discuss the challenges that are encountered in the 
management of these wounds before providing a brief overview 
of measures that can be taken to ensure success is achieved 
when it comes to chronic wound care and management.  

Classification of Chronic Wounds 

Classifying chronic wounds is vital for the provision of adequate 
care. Classifying these wounds allows for adequate care and 
treatment interventions.11 Chronic wounds are mainly 
classified in three main ways. They include vascular ulcers, 
diabetic ulcers, and pressure ulcers.4   

                     Open Access                                                                                                                                                                                                           Review Article                                                                           

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Pallav Dave                                                                                                                                  Asian Journal of Dental and Health Sciences. 2024; 4(1):45-50 

[46]                                                                                                                                                                                                                                            AJDHS.COM 

Vascular ulcers 

Vascular ulcers can either occur as venous or arterial ulcers. 
Venous ulcers are the most common type of presenting 
wound.12 They result from chronic venous insufficiency or 
venous hypertension and mostly occur in the lower extremity.6 

Venous ulcers typically present as shallow wounds and 
normally occur following venous reflux or obstruction.13 

Venous ulcers can be attributed to a number of risk factors. 
Some of these risk factors are venous disease, old age, obesity, 
heart disease, arterial disease, insufficiency of the superficial, 
perforating, or deep veins of the legs, and deep venous 
thrombosis.13,14 Arterial ulcers emerge because of impaired 
tissue perfusion more so the reduced supply of blood to the 
lower limb.13 Reduced perfusion leads to ischemia or reduced 
blood flow making it hard to deliver nutrients which leads to 
the death of body tissue.15 It is this reduced blood flow and 
subsequent death of the body tissue that leads to the 
occurrence of an ulcer. Arterial ulcers occur on the distal 
extremities and present as deep wounds where the tendon or 
bone is exposed.16 Arterial ulcers are mostly attributed to 
atherosclerotic disease.17 Other risk factors that cause arterial 
ulcers include diabetes, vasculitis, thromboangiitis, 
hypertension, smoking, advanced age, obesity, and 
hyperlipidaemia. 15-17  

Diabetic ulcers  

Diabetic foot ulcers mostly affect people who are living with 
type 2 diabetes. Diabetic ulcers mainly occur when diabetes is 
not well controlled. In the US, diabetic foot ulcers affect an 
average of 1.6 million people annually.18 Several factors 
increase the risk of developing diabetic ulcers. They include 
peripheral neuropathy, arterial insufficiency, poor glycemic 
control, foot deformities, calluses, lack of proper foot care, and 
poor circulation.15,16, 19,20 Patients with peripheral neuropathy 
are particularly at a high risk of developing diabetic foot ulcers. 
This is because they have reduced sensory awareness because 
of sensory neuropathy. As a result of this reduced sensory 
awareness, they are less likely to feel pressure, heat, or injury.21 
In normal people, sensory awareness leads to pain and 
discomfort. However, when it is reduced, pain and discomfort 
go unnoticed for a long time which increases the risk of 
developing an injury or formation of an ulcer. This explains why 
peripheral neuropathy is a significant risk factor for diabetic 
foot ulcers. Diabetic ulcers develop in three stages. In the first 
stage, a callus is formed because of neuropathy. Neuropathy 
normally affects the nerves interfering with sensations and 
causing their impairment.22 The impairment of nerves results 
in what is known as sensory neuropathy. Sensory neuropathy 
leads to loss of senses and contributes to ongoing trauma.19 
Neuropathy can also occur as motor neuropathy. Motor 
neuropathy causes damage to motor nerves.19 It also affects the 
ability of an individual to coordinate movements which leads to 
physical deformity of the foot, hammerhead toes and claws, and 
Charcot’s foot.22 Neuropathy also presents as autonomic 
neuropathy. Autonomic neuropathy causes the deportation in 
functions of the sebaceous and sweat glands in the foot.22 As a 
result, it makes the skin around the foot dry making it easier to 
form fissures. A combination of these factors and the 
continuous trauma to the callus is what results in subcutaneous 
hemorrhage and eventually the development of an ulcer.21,23  

Diabetic ulcer is also attributed to severe atherosclerosis. 
Atherosclerosis develops when the basement membranes of 
capillaries thicken leading to vascular compromise.19 
Inadequate blood flow makes the wound heal slowly which 
leads to necrosis and gangrene.22  

 

 

Pressure ulcers 

Chronic wound ulcers are also classified as pressure ulcers 
(PUs). Pressure ulcers occur when there is prolonged pressure 
over a bony prominence normally lasting 2 to 6 hours.4 The 
sustained pressure or compression of the soft tissues makes it 
difficult for the tissue to get the needed blood flow (ischemia) 
resulting in tissue death (necrosis) or damage.24,4 There are 
four mechanisms that result in PUs. One is sustained high 
interphase pressure, loss of elasticity in aged skin, the friction 
that leads to superficial erosions and blisters, and excess skin 
moisture because of exposure to fluids such as urine, sweat, 
wound drainage, and fecal matter over a prolonged period of 
time.16 Pressure ulcers are attributed to several risk factors. Key 
among these factors is limited mobility.16 Limited mobility or 
impaired sensation increases the risk of developing PUs 
because of the difficulty the tissue has in getting the needed 
blood flow.24 Basically, individuals who have limited mobility 
are likely to experience reduced blood flow to the tissue. 
Individuals who are at risk include those who are sedated, and 
frail, those who have undergone surgery and are not able to 
move, and those with spinal cord injuries.24 Other risk factors 
that contribute to the development of PUs are skin changes that 
occur naturally with age, cognitive impairment, lower extremity 
edema, rheumatoid arthritis, and diabetes.4,16 Skin changes that 
occur with age increase the risk of developing PUs because of 
the thinning of the epidermis and dermis.  

Challenges in the Care and Management of 
Chronic Wounds  

Addressing chronic wounds is vital because of the burden they 
cause in healthcare systems. However, addressing chronic 
wounds is not easy. Despite the advances that have been made 
in managing chronic wounds, the challenges of proper wound 
care and management still remain. Various challenges 
contribute to poor wound healing leading to chronic wounds. 
To understand these factors, it is important to understand how 
a wound heals. Wound healing occurs in four phases. They are 
hemostasis, inflammation, proliferation, and remodelling.4 

Hemostasis is the first phase and it occurs after the injury.4 The 
main characteristics of this phase are vasoconstriction and 
blood clotting.25 Vasoconstriction and clotting play a critical 
role in preventing blood loss. They also play a crucial role in 
providing the provisional matrix for cell migration into the 
wound a process known as chemotaxis. Chemotaxis marks the 
beginning of the inflammatory phase. The inflammatory phase 
is the second phase. The stage normally lasts about seven days.4 
In this stage, phagocytic cells such as neutrophils, macrophages, 
and lymphocytes help in the healing process.4 Neutrophils help 
to clear the invading microbes and cellular debris from the 
wound area. It does this by releasing reactive oxygen species 
(ROS) and protases which helps to prevent contamination by 
bacteria and clear cellular debris.26 Macrophages are additional 
cells that help in the healing process. Macrophages are formed 
when blood monocytes arrive at the site of the wound and 
differentiate. Macrophages help in wound healing by removing 
bacteria and nonviable tissue. They release cytokines which 
facilitates an inflammatory response. Cytokines recruit and 
activate leukocytes, fibroblasts, keratinocytes, and endothelial 
cells that help to repair damaged blood vessels and promote 
tissue regeneration.26 The proliferation phase does not occur at 
a particular time and overlaps with the inflammatory phase. 
Tissue granulation is one of the characteristics of this phase.4 It 
also involves the formation of new blood vessels a process 
known as angiogenesis and epithelialization with fibroblasts 
and epithelial cells occurring at this stage. These cells play a 
crucial role in supporting capillary growth, helping in collagen 
formation, and formation of granulation tissue over the site of 
the wound. Re-epithelialization occurs when epithelial cells 
migrate from the wound periphery and adjacent edges of the 



Pallav Dave                                                                                                                                  Asian Journal of Dental and Health Sciences. 2024; 4(1):45-50 

[47]                                                                                                                                                                                                                                            AJDHS.COM 

wound.4,26 A thin superficial layer of epithelial cells is laid down 
over the wound before a more durable layer is laid over time. 
The remodelling phase occurs once the wound has closed. The 
duration of this phase varies but starts at around three weeks 
and can last up to 1 year.4,27  

Unlike other wounds, chronic wounds do not heal in a normal 
and timely manner. According to Wallace et al.27 wounds take an 
average of 4 to 6 weeks to heal. However, for chronic wounds, 
the process takes longer and they are even likely to reoccur 
after a certain period of time. In most instances, these wounds 
stall at the inflammation phase.4 Some of the common 
characteristics of chronic wounds are the excess presence of 
cytokines, proteases, ROS, and senescent cells. Chronic wounds 
can be attributed to a number of factors. They include bacterial 
colonization, impaired collagen production, altered cellular 
response, ischemia, reperfusion injury and hypoxia.27 Chronic 
wounds also occur when failure to achieve complete re-
epithelialization happens.4 

An additional factor that affects healing is bacterial biofilm. 
Bacterial biofilm occurs in up to 90% of these wounds.1 Vestby 
et al.28 define bacterial biofilm as membranous tissue that is 
created by a bacteria community that is attached to the wound 
bed. As a result, they are polymicrobial in nature. Bacteria 
biofilm occurs as a result of disruptions that occur in the skin 
microenvironment.29,30 They affect the wound healing process 
because they cause slow tissue repair and make the wounds 
non-responsive to treatment by making it difficult for 
antibiotics to penetrate the wound.31  

Several underlying factors can contribute to impaired wound 
healing. Some of these factors are the presence of chronic 
conditions such as diabetes, comorbidities, poor nutrition, 
smoking, and local factors such as tissue edema, oxygenation, 
dehydration, pressure, and infection.26,27,32 Systematic factors 
such as age, stress and obesity, can also affect the wound healing 
process.26  

Addressing the factors that contribute to impaired wound 
healing is vital to achieving positive outcomes. However, this 
still remains a challenge with a large proportion of the 
population continuing to suffer from wounds. Access and 
delivery of care are still a significant barrier that makes it 
difficult to manage chronic wounds.32 In most cases, chronic 
wounds are not given specialized care because they are not 
considered an actual disease.5 The care is fragmented with 
different healthcare providers using different treatment 
strategies based on their experiences and views.33 One 
challenge posed by fragmented care is the lack of coordination 
and poor communication among care providers. The end result 
of this is poor quality of care and poor patient outcomes. Taking 
a multidisciplinary approach can help to address the 
fragmentation and improve care outcomes. Research 
documents the importance of a multidisciplinary approach in 
managing chronic wounds because of their complex 
nature.4,5,7,34,35 Mahmoud and Gould,5 recommend establishing 
a center of excellence that can promote a multidisciplinary 
approach to chronic wound healing. Having a center of 
excellence can also ensure there are systematic care protocols 
in place to ensure standard wound care. Sen,6 recommends 
using different care professionals in the management of chronic 
wounds. For instance, physical therapists can use different 
treatment regimens including edema management, 
debridement, positioning, and mobility improvement to 
improve care outcomes for patients with chronic wounds.6 
Occupational therapists, on the other hand, can improve 
outcomes for wound care using treatment regimens such as 
edema management, positioning, wheelchair management, and 
toileting programs. Therefore, employing a multidisciplinary 
approach can lead to positive outcomes and improve patient 
outcomes.  

Chronic Wound Care and Management 

Although managing chronic wounds is a complex process, 
positive outcomes are possible with proper treatment regimens 
and management techniques. An assessment of the wound and 
the patient should be done to ascertain the underlying areas of 
concern before any type of treatment is commenced. Frykberg 
and Banks,4 recommend an assessment to identify any 
underlying areas of concern that need to be addressed to ensure 
favorable outcomes are attained.  

After assessing the patient and identifying all underlying areas 
of concern, a holistic approach to managing the patient should 
be taken to ensure positive outcomes. Healthcare providers 
should not focus on the wound alone. Instead, they should focus 
on the patient as a whole including addressing all the 
underlying comorbidities and the factors associated with the 
wound.34 Without addressing the underlying factors and 
comorbidities, it becomes difficult to achieve positive outcomes 
because they contribute to the likelihood of developing chronic 
wounds. For instance, nutrition is one of the factors that is 
constantly mentioned as affecting wound healing.36 Without 
proper nutrition support, positive outcomes of chronic wounds 
are less likely to be achieved.37 For diabetic patients, it is 
important to control for hyperglycemia and manage 
neuropathy.4 In patients that have pressure ulcers, there is a 
need to optimize patient mobility and redistribute the pressure 
to prevent friction.34 Applying compression for patients with 
venous ulcers to improve blood flow is also necessary.38 
Therefore, employing a holistic approach and management for 
patients with chronic wounds other than treating the wound 
alone is likely to lead to positive outcomes.  

After conducting a wound assessment and all the necessary 
interventions, wound bed preparation should begin. Wound 
bed preparation is crucial in chronic wound management 
because it accelerates endogenous healing and ensures the 
therapeutic measures applied are effective.34,39 Using the 
Tissue, Infection/Inflammation, Moisture imbalance, Epithelial 
edge advancement (TIME) concept can optimize wound bed 
preparation and lead to positive outcomes.4 Each component 
should be taken it account to improve the likelihood of positive 
wound care.  

Debridement is one of the most critical components of wound 
care. It helps to accelerate the healing process which explains 
why it is a critical component of care.4 Debridement entails the 
removal of non-viable wound components and tissue.3 It also 
includes the removal of necrotic tissue, biofilm, and slough. 
Necrotic tissue and biofilm are known to impair the healing 
process by prolonging the inflammation phase of wound 
healing.40 Debridement can be done in various ways with the 
most common methods being surgical, ultrasonic, 
hydrosurgical, mechanical, and autolytic debridement.41,34 
Surgical debridement also known as sharp debridement is a 
common method of debridement and is considered the most 
effective.41,42 It is done using scalpels, curettes, scissors, or 
tissue nippers. A topic, local, or general anesthesia may also be 
applied. Effective debridement is considered vital in chronic 
wound care. If debridement is not done as expected, it can slow 
wound healing significantly.  

Another important aspect that should be considered is 
offloading. Offloading is mainly applied in treating diabetic foot 
ulcers and is done to reduce mechanical stress on the wound.43 

Offloading is considered a standard for care for diabetic ulcers 
and is known to lead to successful outcomes.4,44, 45Reducing 
pressure from wounds helps to accelerate the healing process. 
In diabetic ulcers, total contact cast (TCC) is regarded as the 
gold standard for offloading because it enhances pressure 
redistribution.46,47 TCC is also considered instrumental because 
can help to reduce edema.46 



Pallav Dave                                                                                                                                  Asian Journal of Dental and Health Sciences. 2024; 4(1):45-50 

[48]                                                                                                                                                                                                                                            AJDHS.COM 

An additional aspect of chronic wound management that should 
be considered is infection control. According to Eriksson et al.3 

it is important to assume all chronic wounds are infected with 
bacteria to provide the necessary level of care that is needed. 
Assessing whether the wound is infected is vital. This can be 
done by carrying out a swab on the wound to determine if there 
is a presence of bacteria that can hinder healing.3 However, 
although swabs are considered important, it is vital to note that 
not all bacteria hinder healing. As a result, routine swab on all 
chronic wounds is not recommended.34 To know which wounds 
to conduct a swab on, clinical diagnosis is recommended.34 
Diagnosis can be done using quantitative biopsy.34 Using 
appropriate method to conduct biopsy is vital ensure safety and 
an accurate diagnosis. After diagnosing whether the wound is 
infected, infection control can begin. Various measures are 
recommended in infection control of infected wounds. The first 
is using cleansing agents and topical antimicrobials that can aid 
in healing.40 Different agents can be used to cleanse wounds 
including normal saline or tap water and dilute vinegar 0.5% 
acetic acid.40 Topical antimicrobials are considered vital in the 
management of chronic wounds and are preferred over 
systematic antimicrobials. They are used for treating wounds 
that are superficially infected. They are considered vital in 
managing these wounds because they directly target the 
bacteria.40 The Food and Drug Administration (FDA) 
recommends minocycline and gentamycin for topical treatment 
but caution needs to be applied because of the high risk of 
developing antimicrobial resistance.40 As such, Eriksson et al. 
recommend limiting treatment using topic antimicrobials to 
two weeks to prevent resistance.  

Dressing is also a vital part of wound care. According to 
Eriksson et al.3 wound dressings perform different functions in 
wound care and this should be considered when selecting the 
appropriate dressing. For instance, some dressings are for 
protection while others are for managing moisture. Some 
dressings help with pain management while others help with 
offloading. Choosing the appropriate dressing is vital in aiding 
with wound healing. For instance, moisture-retentive dressings 
help to balance moisture by absorbing moisture while still 
keeping the wound moist.40,48,49 Examples of moisture-retentive 
therapies that can used in wound dressing are hydrofibers, 
acrylics, alginates, hydrocolloids, films, and micronized collagen 
among others.3,4,50 All these dressings have different advantages 
and disadvantages and this should be taken into account when 
providing care.  

Other advanced therapies can also be considered in the care and 
management of chronic wounds. Examples of such therapies 
include negative pressure wound therapy, hyperbaric oxygen 
therapy, bioengineered therapies, acellular therapies, and stem 
cell therapies.4,51,52,53 All these therapies have been shown to 
have different levels of success when it comes to the 
management of chronic wounds. Choosing the right type of 
therapy depending on the wound being treated and the 
underlying needs of the patient is what determines the level of 
success that will be achieved in treating chronic wounds. 
Therefore, it is imperative for healthcare professionals involved 
in chronic wound management and care to select the right type 
of therapy to ensure success and positive outcomes are 
achieved.  

Strengths and Limitations of the Review 

Findings from this review offer a comprehensive discussion on 
chronic wound care and management. It includes challenges 
that are experienced in chronic wound care and various 
management/treatment approaches that can be used to achieve 
positive outcomes. Understanding the challenges healthcare 
providers face in the management of chronic wounds can help 
to identify appropriate strategies that can be used to enhance 

positive clinical outcomes. Chronic wounds still remain a 
prevalent challenge and as the population ages, the problem is 
not likely to go away soon. Therefore, it is imperative to 
understand the challenges encountered in the care and 
management of chronic wounds and different 
treatment/management strategies that can be applied to 
increase the likelihood of positive outcomes and a better quality 
of life.   

This review has some limitations. It does not follow a rigorous 
data extraction process and only includes articles that the 
author considers appropriate to inform this research. 
Determining the quality of sources included in this review was 
also difficult because a quality assessment was not done.  

Conclusion 

Managing chronic wounds is still a significant challenge. 
Despite advances in interventions to treat these wounds, they 
pose a significant challenge to healthcare systems around the 
world. The difficulty of managing chronic wounds stems from 
their complexity. Underlying factors such as diabetes, poor 
nutrition, comorbidities, infection, tissue edema, and pressure 
contribute to the complexity of managing chronic wounds. 
Addressing these factors is vital in achieving positive outcomes 
when it comes to treatment of chronic wounds. Addressing 
these factors requires a multidisciplinary approach that 
involves different healthcare professionals. It also requires a 
holistic approach to care that ensures the underlying factors 
that are contributing to impaired wound healing are addressed. 
Underlying factors that contribute to impaired wound healing 
can be addressed by conducting patient and wound 
assessments. After conducting a wound assessment wound bed 
preparation should commence.  Other crucial management 
strategies that should be applied to enhance wound healing are 
debridement, offloading, infection control, and proper dressing. 
Advanced therapies such as hyperbaric oxygen therapy and 
negative pressure wound therapy should be applied as 
appropriate. 

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Pallav Dave                                                                                                                                  Asian Journal of Dental and Health Sciences. 2024; 4(1):45-50 

[49]                                                                                                                                                                                                                                            AJDHS.COM 

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