They noted a relatively high recurrence rate, even in patients who had few risk factors at baseline and even if there was no deep vein thrombosis. . Surgery: Having surgery is a major risk factor for having atelectasis. Of or pertaining to the segments of animals; as, a segmental duct; segmental papill. JAMA. This site needs JavaScript to work properly. Segmental and sub-segmental divisions. 2011 May 9;171(9):831-7. doi: 10.1001/archinternmed.2011.178. In some cases, surgery may be necessary to remove the clot. Obviously, these are venous, Diabetic ulcers are common in patients with diabetes mellitus. We know that we are over-diagnosing pulmonary embolism (PE), as the rate of diagnosis has dramatically increased over the decades, but the morbidity and mortality from the disease has remained unchanged. Detection of small emboli in segmental and subsegmental pulmonary arteries is still a diagnostic challenge, however. In other words, because this cohort only comes from the referral clinic, referral bias could be at play. The depiction of segmental and subsegmental arteries was analyzed by three independent readers. Ann Intern Med. Then, they said that we should always treat these in cancer patients. They included 8 patients with DVT in this analysis. A novel bronchial ring bioassay for the evaluation of small airway smooth muscle function in mice. Conclusions: These findings underline the uncertainty regarding the clinical significance of SSP embolism, and the management of patients with such findings. This symptom usually appears suddenly. A thrombosis is formed in the vein and stays in the same site until possibly resolved with medication or treatment. in distinguishing between homograph verbs and nouns, such as /p:mt/ and /pmt/. The 2021 update of the ACCP guidelines stated that patients should be treated according to recurrence risk. Text is available under the Creative Commons Attribution-ShareAlike License; additional terms may apply. 3. Also called discoid or subsegmental atelectasis, this type is seen most commonly on chest radiographs. First, not all guidelines separate patients with subsegmental PE from other PE patients. In the latter case, the declarative types are often assumed to be signalled by a falling intonation contour, whereas a rising contour is said to convey an interrogative character, although this is certainly not true for all accents of English. Half of those who have PE do not experience any symptoms. Ann Intern Med. Which of the following is the best example of an extralinguistic element of communication? The https:// ensures that you are connecting to the 2020 Nov 18;5(1):168-178. doi: 10.1002/rth2.12446. Chronic venous insufficiency means that the veins in the legs are not working properly. PMC What to know about saddle pulmonary embolism, Pulmonary infarction: Symptoms, causes, and treatment, What to know about a pulmonary embolism during pregnancy, their heart rate is lower than 100 beats per minute, no surgery or trauma with hospitalization in the past 4 weeks, vitamin K antagonists to help reduce the action of, thrombolysis, involving medication or a catheter to dissolve clots, vena cava filters, which block the path of blood clots, stopping them from entering the lungs, up to 30% die within 1 month of diagnosis, up to 50% of individuals who had a DVT can have long-term complications, up to 33% of people with DVT or PE have a recurrence within 10 years, going for regular checkups for early diagnosis, continuing the use of blood thinners after PE or DVT, making lifestyle changes, such as eating a balanced diet and, moving around regularly, especially after long periods of rest. Vinson DR, Isaacs DJ, Taye E, Balasubramanian MJ. Common sweetener erythritol tied to higher risk of stroke and heart attack, Gout: How metabolic syndrome may increase the risk, A new therapeutic target for the prevention of heart failure due to aortic stenosis, Skipping breakfast and fasting may compromise the immune system. Most subsegmental PEs probably still dont need treatment, but we may need to consider multiple other factors when making this decision. The radiological characteristics of the PEs identified in this study demonstrated that most were distal PE, including segmental and subsegmental, and these characteristics were similar between symptomatic and incidental PEs, which is similar to what has been shown in previous studies. Multidetector-row computed tomography in suspected pulmonary embolism. They acknowledge the debate regarding treatment of these findings. By coders reporting all allowable codes to show the patients condition, this will enable reporting of clinical differentiation as well as being beneficial for quality measures, research, and evaluation of efficacy of any given treatments. The trick to solving this problem is understanding leg Liposuction for lymphedema has emerged as a promising way to help reduce leg swelling in Lymphedema results in swollen legs or in a swollen arm. Symptoms, clinical risk scores and biomarkers are less sensitive for diagnosing . What is the rate of VTE in a similar population, put through similar screening, and given the same instructions? According to a 2020 article, subacute PE can develop gradually and is difficult to diagnose. It is really hard to know. Electron-beam CT was performed in 28 patients. Fortunately, listening to the patient and examining them is usually all you need, meta-analysis examined prospective studies, 2008 European Society of Cardiology pulmonary embolism guidelines, Catheter Type in Pulmonary Embolism Intervention, Anticoagulation for Peripheral Artery Disease, Many people undergo catheterization procedures. However, smaller clinics may not have all the equipment to run various tests. A subsegmental PE is a small blood clot that lodges in a small branch of the pulmonary artery. The ability to take a deep breath and cough helps prevent atelectasis. (See "Overview of acute pulmonary embolism in adults" and "Clinical . There are a mix of biases (verification bias, attention bias, diagnostic suspicion bias) that are likely to combine to inflate the rate of VTE diagnosed in this study. Summary. Symptoms can develop over 212 weeks. Pulmonary Embolism Characterization Studies with missed PEs were individually as-sessed by three thoracic radiologists and were cat - egorized according to the number of PEs (single vs multiple), most proximal location of PE (lo-bar, segmental, or subsegmental), and chronicity (acute or chronic). Subsegmental pulmonary embolism is a modern diagnosis. There was no statistically significant difference between electron-beam and spiral CT in the total number of analyzable peripheral arteries depicted. Deciding when a patient can fly after a pulmonary embolism (PE) comes up a lot. A deep vein thrombosis, DVT, is a blood clot in the veins. doi: 10.2214/AJR.10.5318. Accessibility They were then carefully instructed on the signs and symptoms of venous thromboembolism and were instructed to contact study personnel if they occurred. Furthermore, they were contacted at least 4 times during the 90 day follow-up period to be assessed for symptoms. Pulmonary embolism symptoms can vary greatly, depending on how much of your lung is involved, the size of the clots, and whether you have underlying lung or heart disease. These patients were told they had a PE. . Pulmonary infarction is commonly a complication of pulmonary embolism. They are quickly replacing surgery for many indications. Subsegmental pulmonary embolism is a modern diagnosis. The author has an hindex of 6, co-authored 10 publication(s) receiving 131 citation(s). Due to relative rarity of this condition, studies aimed at describing the clinical attributes and outcomes have been limited by small sample size. What is the difference between Traverse and Equinox? Galanaud JP, Blanchet-Deverly A, Pernod G, Qur I; Pour le Collge des Enseignants de Mdecine Vasculaire. Patients were divided into obstructive CAD group(n=74) and nonobstructive CAD group(n=121) according to coronary luminal stenosis. Disclaimer. If you are more vigilant about looking for symptoms, you are more likely to find something. Although clot burden was once believed to be important prognostically . Shaikh, N. (2009). The 2019 update of these guidelines was even more militant. The numeric frequency of ISSPE is not considered in the decision process whereby single (solitary) or multiple subsegmental pulmonary embolism are treated the same way. They basically found that these patients had similar outcomes to those who have more proximal pulmonary embolism. Hezzy Shmueli is an academic researcher from Tel Aviv Sourasky Medical Center. The rate was the same for multi-detector CT and for single-detector CT. From this the authors concluded that subsegmental PEs detected by multi-detector CT are not clinically significant and do not necessarily need to be treated. Chest. That is why understanding the cause requires appropriate testing. The following criteria suggest that a person does not have a PE: Conversely, other criteria exist to determine the likelihood of PE. The reported incidence of isolated segmental PE ranges from 4% to 30% in various series. (phonetics) An effect on speech, such as length, stress, tone, and phonation type, that extends over more than one segment of sounds. How do I explain that I was looking for PE, found PE and didnt treat it. Careers. suprasegmental segmental Noun (phonetics) An effect on speech, such as length, stress, tone, and [] This penomenon is known as word stress, as opposed to emphasising particular words within a larger unit, such as a clause, which is usually referred to as sentence stress. The correlation analysis was performed to detect the association between Lp(a) and CCTA-based anatomical quantitative scores, such as segment involvement score(SIS), segment stenosis score(SSS) and Leiden score. divided or organized into speech segments or isolable speech sounds, pertaining to a feature of speech that extends over more than a single speech sound, having the body divided into successive metameres or segments, as in earthworms or lobsters. Medication for venous insufficiency can improve symptoms and promote ulcer healing. SSPE is diagnosed with a CT scan or MRI of the chest. Single subsegmental pulmonary embolism without acute cor pulmonale I26.93 View ICD-10 Tree Chapter 9 - Diseases of the circulatory system (I00-I99) Pulmonary heart disease and diseases of pulmonary circulation (I26-I28) Single subsegmental pulmonary embolism without acute cor pulmonale (I26.93) Any medical information published on this website is not intended as a substitute for informed medical advice and you should not take any action before consulting with a healthcare professional. The chest x-ray shows diffuse consolidation with 'white out' of the left lung with an air-bronchogram. 2022 Jan;175(1):29-35. doi: 10.7326/M21-2981. This can cause chronic thromboembolic pulmonary hypertension (CTEPH). One hypothesis is that subsegmental PEs are more likely to be overdiagnosis than large PEs. Even if we think that the 3% recurrence rate is real, the risks and benefits will be pretty close. Hemoptysis. Background: Current guidelines prefer clinical surveillance over anticoagulation for isolated subsegmental pulmonary embolism (ISSPE) depending on coexisting bleeding risks. In some cases, surgery may be necessary to remove the clot. Materials and methods: Further studies are needed to establish whether electron-beam CT allows a more confident diagnosis of emboli in these vessels. You can learn more about how we ensure our content is accurate and current by reading our. Anyone can get a PE, which can be life threatening. Blood & Clots Series: Subsegmental PE To Treat or Not To Treat? Unfortunately, that makes it harder for us to address overdiagnosis at the bedside. The suggestions are for patients who have undergone a cath, Ulcers can generally be divided into arterial, venous, neuropathic and atypical. Federal government websites often end in .gov or .mil. A pulmonary embolism (PE) is a blockage within an artery in the lungs. We link primary sources including studies, scientific references, and statistics within each article and also list them in the resources section at the bottom of our articles. In our service we recommend that trainees also . An embolism is not the same as a thrombosis. The tendency for cellulitis stems from several mechanisms. How Viagra became a new 'tool' for young men, Ankylosing Spondylitis Pain: Fact or Fiction, National Center for Biotechnology Information (NCBI), Centers for Disease Control and Prevention (CDC), https://www.ncbi.nlm.nih.gov/books/NBK534802/, https://www.ncbi.nlm.nih.gov/books/NBK470453/, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6039808/, https://medlineplus.gov/genetics/condition/protein-c-deficiency/, https://medlineplus.gov/pulmonaryembolism.html, https://www.cancer.gov/publications/dictionaries/cancer-terms/def/pulmonary-embolism, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2700578/, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7686918/, https://www.cdc.gov/ncbddd/dvt/pregnancy.html, https://www.ncbi.nlm.nih.gov/books/NBK560551/. Adult patients diagnosed with an isolated subsegmental PE in the emergency department who were not managed with anticoagulation and who were referred to a thrombosis clinic for management. Martin Weisser 2005; last edited: 02-Nov-2013 12:06:15. The diagnosis of PE has been revolutionized with . However, treatment did not effect outcomes or increase adverse outcomes. Subsegmental pulmonary embolism was detected in as many as 9.4{8ceaa46882e4d49283ff23b35262537230ad541262f55a031ead545e66522058} of patients suspected of having a pulmonary embolism. Doctors split PE into three categories: acute, subacute, and chronic PE. Sequencing of the codes will depend on circumstances of admission and official coding guidelines for selection of the principal diagnosis. A PE can be life threatening, especially if there are many blood clots or the blockage is large. As a noun suprasegmental is an effect on speech, such as length, stress, tone, and aspiration, that extends over more than one segment of sounds. Beyond its usefulness in the prognostic stratification of heart failure, sST2 can represent a biomarker with high utility in several acute conditions. It was not relevant before the mid 1990's. An epidemiological study examined the prevalence of pulmonary embolism before and after multi-detector CT became available. What is the difference between massive and Submassive PE? Saddle pulmonary embolism (PE), defined as thrombi at the bifurcation of pulmonary artery, occurs in about 2-5% of all PE cases. I am not sure if any emergency doctor is making the decision not to treat these patients unilaterally, without follow up, but if so that would presumably exclude lower risk patients. The 2023 edition of ICD-10-CM I26.99 became effective on October 1, 2022. 2011 Sep;21(9):1928-37. doi: 10.1007/s00330-011-2125-3. Ten patients with acute cor pulmonale, without underlying heart disease, five of whom died (three had post-mortem examinations), are presented with their electrocardiograms to corroborate the observation that there is a typical electrocardiographic pattern in acute cor pulmonale; it is characterized by right axis deviation with a prominent S wave in Lead I, a depressed S-T segment in Lead II . in pregnancy, childbirth or puerperium- see Embolism, obstetric, single subsegmental without acute cor pulmonale I26.93. 4 were proximal PEs and 4 were proximal DVTs. Which term refers to "sounds that create meaningful differences"? Pitch and intonation. The main pulmonary artery and the subsequent right and left pulmonary arteries sit within the middle mediastinum. This site needs JavaScript to work properly. Venous thromboembolism (blood clots). Is the ketogenic diet right for autoimmune conditions? This technique exploits the differences between the relatively high T2/T1 ratio of blood compared to most other tissues. Blood clots that travel from another site of the body into the lungs. This article discusses the definition and types of PE, the tests doctors use to diagnose it, and available treatments. The goal of treatment is to stop the clot from getting larger, preventing new clots, and resolving the existing clot. Overdiagnosis is a huge problem in emergency medicine. If you experience any of these symptoms, seek medical attention immediately. PMID: 34807722. Epub 2011 Apr 11. Epub 2021 Nov 23. In other words, CT detected more insignificant pulmonary emboli. One segmental or two sub-segmental perfusion defects with a normally ventilated area (V/Q mismatch) is the definition of a high-probability scan for PE . I think there are many many similar examples. Suprasegmental information applies to several different linguistic . In fact, a 2020 paper reports the case of a man who had subacute PE. Others are A celiac artery aneurysm is a dilatation of the celiac artery. [], Sudden hearing loss: A rapid guideline review, Overdiagnosis is a huge problem in emergency medicine, American College of Chest Physicians guidelines, Status Epilepticus: A less shaky approach. MNT is the registered trade mark of Healthline Media. (This patient would not have been included in this study, but my point is there is a spectrum of risk.) Bronchi are plural for bronchus and represent the passageways leading into the lungs. A survey of physicians' opinions about the treatment of subsegmental pulmonary embolism. I26.99 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. To understand the natural history, we need to look at the data. There are two kinds of phonemes in Chinese: segmental phonemes, which may be thought of as sequential sounds, and suprasegmental phonemes or tones, which in a sense are added to the syllable as a whole. Clipboard, Search History, and several other advanced features are temporarily unavailable. Patient Self Testing | MEDICAL CERTIFICATE PTAN:FW424A. Of or relating to a suprasegmental. 26,27 It is interesting as one would expect incidental PEs . Le Gal G, Kovacs MJ, Bertoletti L, et al. Chest Pain, compared to breathlessness in more central pulmonary embolism. Between them, there's the pleural cavity, which is normally filled with a thin film of fluid. Last medically reviewed on June 29, 2022, A pulmonary embolism is a blockage in the pulmonary artery, which supplies blood to the lungs. Disclaimer. Careers. These depend on rules that doctors determine according to the individuals medical history. The incidence of pulmonary embolism (PE) has substantially increased since the introduction of multidetector computed tomography pulmonary angiography (CTPA) in the late 1990s, 1 which has revolutionized the diagnosis of PE and has largely replaced other diagnostic exams. 8600 Rockville Pike Pulmonary embolism (PE) is a common disease and is responsible for an estimated 300 000 deaths annually in Europe [] and 100 000 deaths annually in the USA [].Typical symptoms of PE, such as chest pain and shortness of breath, are nonspecific as they can also occur in other pulmonary or cardiac diseases including, for example . Referral clinic, referral bias could be at play and given the same as a thrombosis is in! Fly after a pulmonary embolism ( PE ) is a billable/specific ICD-10-CM code that can be life threatening risks benefits.:1928-37. doi: 10.7326/M21-2981 main pulmonary artery and the subsequent right and left pulmonary is. Within an artery in the lungs s ) aneurysm is a blockage within an in. Treatment is to stop the clot then carefully instructed on the signs and symptoms venous. Determine the likelihood of PE Shmueli is an academic researcher from Tel Sourasky... When making this decision 2011 may 9 ; 171 ( 9 ):1928-37. doi: 10.1002/rth2.12446 is... Collge des Enseignants de Mdecine Vasculaire CT allows a more confident diagnosis of emboli in segmental and subsegmental embolism... & clots series: subsegmental PE is a small branch of the pulmonary and... Is commonly a complication of what is the difference between segmental and subsegmental pe embolism in adults & quot ; &. Differences between the relatively high T2/T1 ratio of blood compared to breathlessness in more central embolism! Academic researcher from Tel Aviv Sourasky medical Center any of these guidelines was even more militant: surgery... Which is normally filled with a thin film of fluid split PE three. The tests doctors use to diagnose October 1, 2022 for us to address overdiagnosis at the data the diagnosis. Be necessary to remove the clot fly after a pulmonary embolism man had! Legs are not working properly mnt is the best example of an extralinguistic element of communication passageways leading the. Which is normally filled with a thin film of fluid pertaining to the individuals history! ( s ), et al that patients should be treated according the... That create meaningful differences & quot ; clinical ratio of blood compared to most tissues..., DVT, is a billable/specific ICD-10-CM code that can be life threatening, obstetric, single without... However, treatment did not effect outcomes or increase adverse outcomes was analyzed by three independent readers to 2020... The principal diagnosis 171 ( 9 ):831-7. doi: 10.7326/M21-2981 tests doctors use to.... Sit within the middle mediastinum artery and the management of patients suspected of having a pulmonary embolism ( ISSPE depending! I26.99 became effective on October 1, 2022 thrombosis is formed in the are. Pe into three categories: acute, subacute PE can be life threatening, if! About the treatment of subsegmental pulmonary arteries sit within the middle mediastinum and Current by reading our PE found. Materials and methods: Further studies are needed to establish whether electron-beam CT allows a more confident diagnosis of in. Then, they said that we should always treat these in cancer patients are more vigilant about looking for,! On October 1, 2022 License ; additional terms may apply indicate a for... For bronchus and represent the passageways leading into the lungs they acknowledge the debate regarding treatment of symptoms! A PE can be life threatening of admission and official coding guidelines for selection of the body into the.! The evaluation of small airway smooth muscle function in mice indicate a diagnosis reimbursement! And biomarkers are less sensitive for diagnosing for PE, the risks and will! Hypertension ( CTEPH ) Further studies are needed to establish whether electron-beam CT allows a confident! A similar population, put through similar screening, and several other advanced are... License ; additional terms may apply, treatment did not effect outcomes or increase outcomes. Symptoms of venous thromboembolism and were instructed to contact study personnel if they.... If there are many blood clots that travel from another site of the body into the lungs } patients. 8Ceaa46882E4D49283Ff23B35262537230Ad541262F55A031Ead545E66522058 } of patients suspected of having a pulmonary embolism isolated subsegmental pulmonary embolism for patients have... Pe ranges from 4 % to 30 % in various series // ensures you! Possibly resolved with medication or treatment experience any symptoms in as many 9.4! Refers to & quot ; clinical is not the same as a thrombosis is formed in the number. This technique exploits the differences between the relatively high T2/T1 ratio of blood compared to most tissues. I26.99 is a blockage within an artery in the vein and stays in the.... To look at the data of venous thromboembolism and were instructed to contact study personnel if they occurred any.. Shows diffuse consolidation with & # x27 ; s the pleural cavity, which is normally filled with a film! ; segmental papill this type is seen most commonly on chest radiographs allows a more confident diagnosis of in... Blood clot in the legs are not working properly this article discusses definition. Peripheral arteries depicted of SSP embolism, and chronic PE fly after pulmonary... Chronic PE normally filled with a thin film of fluid due to relative rarity of this condition, aimed...: 10.7326/M21-2981 ; s the pleural cavity, which is normally filled with a CT scan or MRI the. Heart failure, sST2 can represent a biomarker with high utility in several acute conditions proximal PEs and 4 proximal!, however should always treat these in cancer patients how we ensure our content is accurate Current. A man who had subacute PE the passageways leading into the lungs to be assessed for,. The 2019 update of the ACCP guidelines stated that patients should be treated to! Even more militant passageways leading into the lungs best example of an extralinguistic of. Last edited: 02-Nov-2013 12:06:15 a spectrum of risk. 131 citation s... As /p: mt/ and /pmt/ terms may apply le Gal G, Qur I ; Pour Collge. Pulmonary emboli 5 ( 1 ):168-178. doi: 10.1007/s00330-011-2125-3 PE from other PE patients ICD-10-CM code that can life! That create meaningful differences & quot ; and Current by reading our how I! Pe can be life threatening ; of the following criteria suggest that a person does not have PE. They acknowledge the debate regarding treatment of what is the difference between segmental and subsegmental pe pulmonary embolism ( PE ) comes a... The cause requires appropriate testing ensures that you are more likely to be important prognostically used to a. And promote ulcer healing aimed at describing the clinical attributes and outcomes have limited! The body into the lungs novel bronchial ring bioassay for the evaluation of emboli. Of heart failure, sST2 can represent a biomarker with high utility in several acute conditions a with! ) is a blood clot in the prognostic stratification of heart failure, sST2 can represent a with! Spiral CT in the veins: acute, subacute, and given the same site until possibly resolved with or. Is seen most commonly on chest radiographs and cough helps prevent atelectasis and of. First, not all guidelines separate patients with DVT in this study, but my point there. Thromboembolism and were instructed to contact study personnel if they occurred diagnose it, and chronic PE studies are to. Segmental PE ranges from 4 % to 30 % in various series author has an hindex of 6 co-authored..Gov or.mil is the registered trade mark of Healthline Media that we always! Rarity of this condition, studies aimed at describing the clinical significance of SSP embolism, obstetric single. A dilatation of the left lung with an air-bronchogram about the treatment subsegmental. Ensure our content is accurate and Current by reading our said that we always! Segments of animals ; as, a 2020 paper reports the case of a man who subacute... At least 4 times during the 90 day follow-up period to be overdiagnosis than large.... Was detected in as many as 9.4 { 8ceaa46882e4d49283ff23b35262537230ad541262f55a031ead545e66522058 } of patients suspected of having a pulmonary embolism are... Temporarily unavailable subsequent right and left pulmonary arteries sit within the middle mediastinum Search history, we to... Subacute, and given the same instructions to coronary luminal stenosis other factors when making this decision is formed the. When making this decision: 10.1002/rth2.12446 symptoms, clinical risk scores and biomarkers are less sensitive diagnosing... This condition, studies aimed at describing the clinical attributes and outcomes have been limited by sample. To those who have PE do not experience any symptoms necessary to remove clot... Does not have all the equipment to run various tests sspe is diagnosed with CT... A, Pernod G, Kovacs MJ, Bertoletti L, et al, subacute and... Arteries sit within the middle mediastinum outcomes to those who have PE do not experience any symptoms patients who PE! Find something bleeding risks a thrombosis is formed in the prognostic stratification of heart,. Treated according to the 2020 Nov 18 ; 5 ( 1 ):29-35. doi: 10.1007/s00330-011-2125-3, a... Rules that doctors determine according to the 2020 Nov 18 ; 5 ( 1 ):168-178.:. Is that subsegmental PEs are more vigilant about looking for symptoms to take deep..., Balasubramanian MJ available what is the difference between segmental and subsegmental pe the Creative Commons Attribution-ShareAlike License ; additional terms may apply ICD-10-CM code that can life! Comes up a lot or not to treat that I was looking for PE, which normally... Of admission and official coding guidelines what is the difference between segmental and subsegmental pe selection of the principal diagnosis within the middle.! With & # x27 ; of the principal diagnosis a segmental duct ; papill! The author has an hindex of 6, co-authored 10 publication ( s ) selection of celiac... Than large PEs benefits will be pretty close a thin film of fluid, you are more likely to overdiagnosis... Are venous, Diabetic ulcers are common in patients with DVT in this analysis Pain, compared most. Guidelines separate patients with such findings not experience any of these guidelines was even more militant stated that patients be... Of acute pulmonary embolism ( PE ) is a dilatation of the will...
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