7229ce5ed15332bd53964a459e74709b pmc_33066107.pdf 4dd586ca640264539e2ff4df56cfd3c85818588b pmc_33066107.pdf ae6d341617eba59c9569319368a8b81234fa369065028a53f28c145ed4299129 pmc_33066107.pdf Title: Effects of Bifidobacterium animalis Subsp. lactis (BPL1) Supplementation in Children and Adolescents with Prader–Willi Syndrome: A Randomized Crossover Trial Subject: Prader–Willi syndrome (PWS) is a rare genetic disorder characterized by a wide range of clinical manifestations, including obesity, hyperphagia, and behavioral problems. Bifidobacterium animalis subsp. lactis strain BPL1 has been shown to improve central adiposity in adults with simple obesity. To evaluate BPL1's effects in children with PWS, we performed a randomized crossover trial among 39 patients (mean age 10.4 years). Participants were randomized to placebo–BPL1 (n = 19) or BPL1–placebo (n = 20) sequences and underwent a 12-week period with placebo/BPL1 treatments, a 12-week washout period, and a 12-week period with the crossover treatment. Thirty-five subjects completed the study. The main outcome was changes in adiposity, measured by dual-energy X-ray absorptiometry. Secondary outcomes included lipid and glucose metabolism, hyperphagia, and mental health symptoms. Generalized linear modeling was applied to assess differences between treatments. While BPL1 did not modify total fat mass compared to placebo, BPL1 decreased abdominal adiposity in a subgroup of patients older than 4.5 years (n = 28). BPL1 improved fasting insulin concentration and insulin sensitivity. Furthermore, we observed modest improvements in some mental health symptoms. A follow-up trial with a longer treatment period is warranted to determine whether BPL1 supplementation can provide a long-term therapeutic approach for children with PWS (ClinicalTrials.gov NCT03548480). Keywords: obesity; Prader–Willi syndrome; insulin sensitivity; hyperphagia; gut microbiota; probiotic supplementation; mental health Author: Montse Amat-Bou, Sonika Garcia-Ribera, Eric Climent, Irene Piquer-Garcia, Raquel Corripio, David Sanchez-Infantes, Laia Villalta, Maria Elias, Josep C. Jiménez-Chillarón, Empar Chenoll, Daniel Ramón, Lourdes Ibañez, Marta Ramon-Krauel and Carles Lerin Creator: LaTeX with hyperref package Producer: pdfTeX-1.40.18 CreationDate: Fri Oct 16 03:31:09 2020 CEST ModDate: Fri Oct 16 03:36:36 2020 CEST Tagged: no UserProperties: no Suspects: no Form: none JavaScript: no Pages: 15 Encrypted: no Page size: 595.276 x 841.89 pts (A4) Page rot: 0 File size: 765128 bytes Optimized: no PDF version: 1.7 name type encoding emb sub uni object ID ------------------------------------ ----------------- ---------------- --- --- --- --------- HJOMHV+VnURWPalladioL-Bold Type 1 Custom yes yes no 10 0 HCRKXL+VnURWPalladioL Type 1 Custom yes yes no 15 0 PXKYNV+URWPalladioL-Ital Type 1 Custom yes yes no 19 0 GGDSVM+URWPalladioL-Bold Type 1 Custom yes yes no 24 0 UCEZQU+Rpxb Type 1 Builtin yes yes no 28 0 KFUGCW+URWPalladioL-BoldItal Type 1 Custom yes yes no 32 0 GILQNP+URWPalladioL-Roma Type 1 Custom yes yes no 36 0 GJQQCT+Rpxr Type 1 Builtin yes yes no 40 0 HCUIQB+Pxsy Type 1 Builtin yes yes no 44 0 HGMNRX+TimesNewRomanPS-BoldItalicMT Type 1C WinAnsi yes yes no 52 0 MCBCCI+SourceSansRoman-Regular Type 1C Custom yes yes no 74 0 MCBCCM+SourceSansRoman.613wght Type 1C Custom yes yes no 78 0 MCBCCO+SourceSansRoman-Bold Type 1C Custom yes yes no 82 0 TGMEOR+Rpcxr Type 1 Builtin yes yes no 95 0 FECLBO+Calibri,Bold CID TrueType Identity-H yes yes yes 112 0 FECLDO+Calibri CID TrueType Identity-H yes yes yes 118 0 FECIOE+PalatinoLinotype TrueType WinAnsi yes yes no 124 0 FECIOG+PalatinoLinotype,Italic TrueType WinAnsi yes yes no 127 0 FECIPH+PalatinoLinotype,Bold TrueType WinAnsi yes yes no 130 0 FECJOF+TimesNewRoman CID TrueType Identity-H yes yes yes 133 0 GBLQZB+Rpxi Type 1 Builtin yes yes no 142 0 FECIOD+PalatinoLinotype CID TrueType Identity-H yes yes yes 153 0 FECIOE+PalatinoLinotype TrueType WinAnsi yes yes no 159 0 FECIOG+PalatinoLinotype,Italic TrueType WinAnsi yes yes no 162 0 FECIPH+PalatinoLinotype,Bold TrueType WinAnsi yes yes no 165 0 FECJEH+PalatinoLinotype,BoldItalic TrueType WinAnsi yes yes no 168 0 FECJOF+TimesNewRoman CID TrueType Identity-H yes yes yes 171 0 ZRZGVF+Pxbsy Type 1 Builtin yes yes no 180 0 Jhove (Rel. 1.22.1, 2019-04-17) Date: 2023-09-15 02:36:29 CEST RepresentationInformation: pmc_33066107.pdf ReportingModule: PDF-hul, Rel. 1.12.1 (2019-04-17) LastModified: 2020-11-16 03:38:36 CET Size: 765128 Format: PDF Version: 1.7 Status: Well-Formed and valid SignatureMatches: PDF-hul MIMEtype: application/pdf PDFMetadata: Objects: 406 FreeObjects: 1 IncrementalUpdates: 0 DocumentCatalog: PageLayout: SinglePage PageMode: UseNone Outlines: Item: Title: Introduction Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@44c8afef Item: Title: Materials and Methods Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@7b69c6ba Children: Item: Title: Study Design Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@46daef40 Item: Title: Study Participants Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@12f41634 Item: Title: Intervention Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@13c27452 Item: Title: Randomization Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@262b2c86 Item: Title: Outcomes Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@371a67ec Item: Title: Subgroup Analyses Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@5ed828d Item: Title: Gut Microbiota Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@50d0686 Item: Title: Statistical Analysis Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@7a3d45bd Item: Title: Results Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@1e7c7811 Children: Item: Title: Study Participants Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@77ec78b9 Item: Title: Effects of BPL1 Probiotic Supplementation on Gut Microbiota Composition Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@1a3869f4 Item: Title: Effects of BPL1 Probiotic Supplementation on Adiposity Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@a38d7a3 Item: Title: Effects of BPL1 Probiotic Supplementation on Hyperphagia, Lipid Profile, and Glucose Homeostasis Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@77f99a05 Item: Title: Effects of BPL1 Probiotic Supplementation on Mental Health Problems Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@63440df3 Item: Title: Adverse Events Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@3aeaafa6 Item: Title: Discussion Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@76a3e297 Item: Title: References Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@4d3167f4 Info: Title: Effects of Bifidobacterium animalis Subsp. lactis (BPL1) Supplementation in Children and Adolescents with Prader Willi Syndrome: A Randomized Crossover Trial Author: Montse Amat-Bou, Sonika Garcia-Ribera, Eric Climent, Irene Piquer-Garcia, Raquel Corripio, David Sanchez-Infantes, Laia Villalta, Maria Elias, Josep C. Jiménez-Chillarón, Empar Chenoll, Daniel Ramón, Lourdes Ibañez, Marta Ramon-Krauel and Carles Lerin Subject: Prader Willi syndrome (PWS) is a rare genetic disorder characterized by a wide range of clinical manifestations, including obesity, hyperphagia, and behavioral problems. Bifidobacterium animalis subsp. lactis strain BPL1 has been shown to improve central adiposity in adults with simple obesity. To evaluate BPL1's effects in children with PWS, we performed a randomized crossover trial among 39 patients (mean age 10.4 years). Participants were randomized to placebo BPL1 (n = 19) or BPL1 placebo (n = 20) sequences and underwent a 12-week period with placebo/BPL1 treatments, a 12-week washout period, and a 12-week period with the crossover treatment. Thirty-five subjects completed the study. The main outcome was changes in adiposity, measured by dual-energy X-ray absorptiometry. Secondary outcomes included lipid and glucose metabolism, hyperphagia, and mental health symptoms. Generalized linear modeling was applied to assess differences between treatments. While BPL1 did not modify total fat mass compared to placebo, BPL1 decreased abdominal adiposity in a subgroup of patients older than 4.5 years (n = 28). BPL1 improved fasting insulin concentration and insulin sensitivity. Furthermore, we observed modest improvements in some mental health symptoms. A follow-up trial with a longer treatment period is warranted to determine whether BPL1 supplementation can provide a long-term therapeutic approach for children with PWS (ClinicalTrials.gov NCT03548480). Keywords: obesity; Prader Willi syndrome; insulin sensitivity; hyperphagia; gut microbiota; probiotic supplementation; mental health Creator: LaTeX with hyperref package Producer: pdfTeX-1.40.18 CreationDate: Fri Oct 16 03:31:09 CEST 2020 ModDate: Fri Oct 16 03:36:36 CEST 2020 ID: 0x82b82b084753b3fa3cb7de04884704f3, 0x82b82b084753b3fa3cb7de04884704f3 Filters: FilterPipeline: FlateDecode Fonts: Type1: Font: BaseFont: KFUGCW+URWPalladioL-BoldItal FontSubset: true FirstChar: 2 LastChar: 117 FontDescriptor: FontName: KFUGCW+URWPalladioL-BoldItal Flags: Symbolic FontBBox: -170, -300, 1073, 935 FontFile: true EncodingDictionary: Differences: true Font: BaseFont: PXKYNV+URWPalladioL-Ital FontSubset: true FirstChar: 2 LastChar: 122 FontDescriptor: FontName: PXKYNV+URWPalladioL-Ital Flags: Symbolic FontBBox: -170, -305, 1010, 941 FontFile: true EncodingDictionary: Differences: true Font: BaseFont: GILQNP+URWPalladioL-Roma FontSubset: true FirstChar: 2 LastChar: 252 FontDescriptor: FontName: GILQNP+URWPalladioL-Roma Flags: Symbolic FontBBox: -166, -283, 1021, 943 FontFile: true EncodingDictionary: Differences: true Font: BaseFont: ZRZGVF+Pxbsy FontSubset: true FirstChar: 0 LastChar: 0 FontDescriptor: FontName: ZRZGVF+Pxbsy Flags: Symbolic FontBBox: 5, -978, 1382, 913 FontFile: true Font: BaseFont: GGDSVM+URWPalladioL-Bold FontSubset: true FirstChar: 3 LastChar: 241 FontDescriptor: FontName: GGDSVM+URWPalladioL-Bold Flags: Symbolic FontBBox: -152, -301, 1000, 935 FontFile: true EncodingDictionary: Differences: true Font: BaseFont: GJQQCT+Rpxr FontSubset: true FirstChar: 11 LastChar: 61 FontDescriptor: FontName: GJQQCT+Rpxr Flags: Symbolic FontBBox: -40, -283, 904, 728 FontFile: true Font: BaseFont: HJOMHV+VnURWPalladioL-Bold FontSubset: true FirstChar: 178 LastChar: 226 FontDescriptor: FontName: HJOMHV+VnURWPalladioL-Bold Flags: Symbolic FontBBox: -152, -301, 1000, 935 FontFile: true EncodingDictionary: Differences: true Font: BaseFont: HCUIQB+Pxsy FontSubset: true FirstChar: 0 LastChar: 48 FontDescriptor: FontName: HCUIQB+Pxsy Flags: Symbolic FontBBox: -21, -994, 1292, 912 FontFile: true Font: BaseFont: UCEZQU+Rpxb FontSubset: true FirstChar: 11 LastChar: 62 FontDescriptor: FontName: UCEZQU+Rpxb Flags: Symbolic FontBBox: -57, -266, 932, 729 FontFile: true Font: BaseFont: GBLQZB+Rpxi FontSubset: true FirstChar: 11 LastChar: 11 FontDescriptor: FontName: GBLQZB+Rpxi Flags: Symbolic FontBBox: -162, -280, 856, 733 FontFile: true Font: BaseFont: HCRKXL+VnURWPalladioL FontSubset: true FirstChar: 129 LastChar: 226 FontDescriptor: FontName: HCRKXL+VnURWPalladioL Flags: Symbolic FontBBox: -166, -283, 1021, 943 FontFile: true EncodingDictionary: Differences: true Font: BaseFont: TGMEOR+Rpcxr FontSubset: true FirstChar: 169 LastChar: 174 FontDescriptor: FontName: TGMEOR+Rpcxr Flags: Symbolic FontBBox: -212, -286, 1344, 973 FontFile: true Pages: Page: Sequence: 1 Annotations: Annotation: Subtype: Link Rect: 75, 757, 210, 793 Annotation: Subtype: Link Rect: 474, 757, 519, 793 Annotation: Subtype: Link Rect: 283, 607, 294, 621 Annotation: Subtype: Link Rect: 293, 594, 304, 607 Annotation: Subtype: Link Rect: 475, 594, 486, 607 Annotation: Subtype: Link Rect: 185, 583, 196, 594 Annotation: Subtype: Link Rect: 292, 583, 303, 594 Annotation: Subtype: Link Rect: 174, 38, 246, 50 Annotation: Subtype: Link Rect: 398, 38, 519, 50 Annotation: Subtype: Link Rect: 466, 357, 518, 376 Page: Sequence: 2 Annotations: Annotation: Subtype: Link Rect: 122, 696, 129, 705 ActionDest: 197 Annotation: Subtype: Link Rect: 275, 683, 282, 692 ActionDest: 197 Annotation: Subtype: Link Rect: 285, 683, 292, 692 ActionDest: 197 Annotation: Subtype: Link Rect: 298, 669, 305, 678 ActionDest: 197 Annotation: Subtype: Link Rect: 306, 669, 313, 678 ActionDest: 197 Annotation: Subtype: Link Rect: 118, 642, 125, 651 ActionDest: 197 Annotation: Subtype: Link Rect: 126, 642, 133, 651 ActionDest: 197 Annotation: Subtype: Link Rect: 245, 628, 251, 638 ActionDest: 197 Annotation: Subtype: Link Rect: 149, 574, 156, 584 ActionDest: 197 Annotation: Subtype: Link Rect: 157, 574, 164, 584 ActionDest: 197 Annotation: Subtype: Link Rect: 508, 574, 515, 584 ActionDest: 197 Annotation: Subtype: Link Rect: 422, 561, 429, 570 ActionDest: 197 Annotation: Subtype: Link Rect: 174, 520, 181, 529 ActionDest: 197 Annotation: Subtype: Link Rect: 181, 520, 193, 529 ActionDest: 197 Annotation: Subtype: Link Rect: 121, 507, 133, 516 ActionDest: 197 Annotation: Subtype: Link Rect: 136, 507, 148, 516 ActionDest: 197 Annotation: Subtype: Link Rect: 123, 480, 135, 489 ActionDest: 197 Annotation: Subtype: Link Rect: 138, 480, 150, 489 ActionDest: 197 Annotation: Subtype: Link Rect: 427, 466, 439, 475 ActionDest: 200 Annotation: Subtype: Link Rect: 383, 453, 395, 462 ActionDest: 200 Annotation: Subtype: Link Rect: 426, 439, 438, 448 ActionDest: 197 Annotation: Subtype: Link Rect: 439, 439, 451, 448 ActionDest: 200 Annotation: Subtype: Link Rect: 351, 426, 363, 435 ActionDest: 200 Annotation: Subtype: Link Rect: 365, 426, 377, 435 ActionDest: 200 Annotation: Subtype: Link Rect: 172, 385, 184, 394 ActionDest: 200 Annotation: Subtype: Link Rect: 125, 358, 137, 367 ActionDest: 200 Annotation: Subtype: Link Rect: 338, 345, 350, 354 ActionDest: 200 Annotation: Subtype: Link Rect: 153, 318, 165, 327 ActionDest: 200 Page: Sequence: 3 Annotations: Annotation: Subtype: Link Rect: 75, 726, 287, 738 Page: Sequence: 4 Annotations: Annotation: Subtype: Link Rect: 503, 669, 515, 678 ActionDest: 200 Annotation: Subtype: Link Rect: 312, 615, 324, 624 ActionDest: 200 Annotation: Subtype: Link Rect: 321, 601, 333, 611 ActionDest: 200 Annotation: Subtype: Link Rect: 120, 588, 132, 597 ActionDest: 200 Annotation: Subtype: Link Rect: 420, 466, 432, 475 ActionDest: 200 Annotation: Subtype: Link Rect: 124, 383, 131, 392 ActionDest: 197 Annotation: Subtype: Link Rect: 299, 369, 306, 379 ActionDest: 197 Annotation: Subtype: Link Rect: 401, 288, 408, 298 ActionDest: 197 Annotation: Subtype: Link Rect: 409, 289, 421, 298 ActionDest: 200 Annotation: Subtype: Link Rect: 123, 205, 135, 214 ActionDest: 200 Annotation: Subtype: Link Rect: 293, 165, 305, 174 ActionDest: 200 Annotation: Subtype: Link Rect: 233, 151, 245, 160 ActionDest: 200 Annotation: Subtype: Link Rect: 403, 124, 415, 133 ActionDest: 200 Page: Sequence: 5 Annotations: Annotation: Subtype: Link Rect: 193, 729, 205, 738 ActionDest: 200 Annotation: Subtype: Link Rect: 359, 347, 366, 359 ActionDest: 102 Annotation: Subtype: Link Rect: 216, 226, 223, 238 ActionDest: 102 Annotation: Subtype: Link Rect: 375, 212, 382, 224 ActionDest: 102 Annotation: Subtype: Link Rect: 177, 131, 184, 143 ActionDest: 102 Page: Sequence: 6 Page: Sequence: 7 Annotations: Annotation: Subtype: Link Rect: 482, 707, 489, 719 ActionDest: 139 Annotation: Subtype: Link Rect: 285, 666, 292, 678 ActionDest: 139 Annotation: Subtype: Link Rect: 221, 612, 228, 624 ActionDest: 139 Annotation: Subtype: Link Rect: 156, 173, 163, 185 ActionDest: 177 Annotation: Subtype: Link Rect: 190, 146, 197, 158 ActionDest: 177 Page: Sequence: 8 Annotations: Annotation: Subtype: Link Rect: 447, 480, 454, 492 ActionDest: 177 Annotation: Subtype: Link Rect: 508, 467, 515, 479 ActionDest: 177 Annotation: Subtype: Link Rect: 203, 440, 210, 452 ActionDest: 177 Page: Sequence: 9 Annotations: Annotation: Subtype: Link Rect: 351, 616, 358, 628 ActionDest: 184 Annotation: Subtype: Link Rect: 508, 575, 515, 587 ActionDest: 184 Annotation: Subtype: Link Rect: 211, 293, 218, 302 ActionDest: 197 Page: Sequence: 10 Annotations: Annotation: Subtype: Link Rect: 315, 710, 327, 719 ActionDest: 197 Annotation: Subtype: Link Rect: 330, 709, 342, 719 ActionDest: 197 Annotation: Subtype: Link Rect: 342, 709, 354, 719 ActionDest: 200 Annotation: Subtype: Link Rect: 476, 683, 488, 692 ActionDest: 197 Annotation: Subtype: Link Rect: 491, 682, 503, 692 ActionDest: 197 Annotation: Subtype: Link Rect: 503, 682, 515, 692 ActionDest: 200 Annotation: Subtype: Link Rect: 453, 561, 460, 570 ActionDest: 197 Annotation: Subtype: Link Rect: 185, 520, 197, 529 ActionDest: 203 Annotation: Subtype: Link Rect: 200, 520, 212, 529 ActionDest: 203 Annotation: Subtype: Link Rect: 403, 507, 415, 516 ActionDest: 197 Annotation: Subtype: Link Rect: 313, 493, 325, 502 ActionDest: 197 Annotation: Subtype: Link Rect: 156, 466, 168, 475 ActionDest: 197 Annotation: Subtype: Link Rect: 503, 426, 515, 435 ActionDest: 203 Annotation: Subtype: Link Rect: 133, 399, 145, 408 ActionDest: 197 Annotation: Subtype: Link Rect: 203, 372, 215, 381 ActionDest: 200 Annotation: Subtype: Link Rect: 216, 372, 228, 381 ActionDest: 203 Annotation: Subtype: Link Rect: 231, 372, 243, 381 ActionDest: 203 Annotation: Subtype: Link Rect: 161, 277, 173, 286 ActionDest: 200 Annotation: Subtype: Link Rect: 174, 277, 186, 286 ActionDest: 203 Annotation: Subtype: Link Rect: 186, 277, 198, 286 ActionDest: 203 Annotation: Subtype: Link Rect: 198, 264, 210, 273 ActionDest: 197 Annotation: Subtype: Link Rect: 210, 264, 222, 273 ActionDest: 203 Annotation: Subtype: Link Rect: 491, 264, 503, 273 ActionDest: 203 Annotation: Subtype: Link Rect: 503, 264, 515, 273 ActionDest: 203 Annotation: Subtype: Link Rect: 274, 250, 286, 259 ActionDest: 197 Annotation: Subtype: Link Rect: 108, 169, 120, 178 ActionDest: 203 Annotation: Subtype: Link Rect: 347, 142, 359, 151 ActionDest: 203 Annotation: Subtype: Link Rect: 279, 115, 291, 124 ActionDest: 203 Annotation: Subtype: Link Rect: 291, 115, 303, 124 ActionDest: 203 Page: Sequence: 11 Annotations: Annotation: Subtype: Link Rect: 289, 729, 301, 738 ActionDest: 197 Annotation: Subtype: Link Rect: 304, 729, 316, 738 ActionDest: 197 Annotation: Subtype: Link Rect: 169, 648, 176, 657 ActionDest: 197 Annotation: Subtype: Link Rect: 176, 648, 183, 657 ActionDest: 197 Annotation: Subtype: Link Rect: 184, 648, 196, 657 ActionDest: 203 Annotation: Subtype: Link Rect: 468, 634, 475, 644 ActionDest: 197 Annotation: Subtype: Link Rect: 331, 245, 518, 256 Page: Sequence: 12 Page: Sequence: 13 Annotations: Annotation: Subtype: Link Rect: 100, 652, 137, 662 Annotation: Subtype: Link Rect: 178, 614, 216, 624 Annotation: Subtype: Link Rect: 211, 575, 248, 585 Annotation: Subtype: Link Rect: 255, 575, 291, 585 Annotation: Subtype: Link Rect: 213, 549, 251, 559 Annotation: Subtype: Link Rect: 257, 549, 293, 559 Annotation: Subtype: Link Rect: 145, 510, 182, 520 Annotation: Subtype: Link Rect: 189, 510, 225, 520 Annotation: Subtype: Link Rect: 366, 484, 402, 495 Annotation: Subtype: Link Rect: 159, 446, 196, 456 Annotation: Subtype: Link Rect: 241, 407, 279, 417 Annotation: Subtype: Link Rect: 100, 368, 137, 378 Annotation: Subtype: Link Rect: 154, 330, 192, 340 Annotation: Subtype: Link Rect: 440, 290, 476, 301 Annotation: Subtype: Link Rect: 482, 290, 516, 301 Annotation: Subtype: Link Rect: 100, 265, 137, 275 Annotation: Subtype: Link Rect: 100, 226, 137, 236 Annotation: Subtype: Link Rect: 143, 226, 179, 236 Annotation: Subtype: Link Rect: 411, 188, 448, 198 Annotation: Subtype: Link Rect: 454, 188, 491, 198 Annotation: Subtype: Link Rect: 225, 136, 263, 146 Annotation: Subtype: Link Rect: 269, 136, 305, 146 Annotation: Subtype: Link Rect: 352, 84, 390, 94 Annotation: Subtype: Link Rect: 396, 84, 432, 94 Page: Sequence: 14 Annotations: Annotation: Subtype: Link Rect: 181, 702, 219, 712 Annotation: Subtype: Link Rect: 225, 702, 261, 712 Annotation: Subtype: Link Rect: 346, 675, 384, 686 Annotation: Subtype: Link Rect: 390, 675, 426, 686 Annotation: Subtype: Link Rect: 221, 638, 258, 648 Annotation: Subtype: Link Rect: 145, 599, 182, 609 Annotation: Subtype: Link Rect: 479, 559, 516, 570 Annotation: Subtype: Link Rect: 100, 547, 136, 557 Annotation: Subtype: Link Rect: 478, 521, 516, 531 Annotation: Subtype: Link Rect: 100, 508, 136, 519 Annotation: Subtype: Link Rect: 299, 469, 461, 480 Annotation: Subtype: Link Rect: 253, 417, 290, 428 Annotation: Subtype: Link Rect: 297, 417, 333, 428 Annotation: Subtype: Link Rect: 470, 391, 519, 402 Annotation: Subtype: Link Rect: 97, 378, 263, 389 Annotation: Subtype: Link Rect: 100, 341, 137, 351 Annotation: Subtype: Link Rect: 325, 301, 362, 312 Annotation: Subtype: Link Rect: 360, 276, 397, 286 Annotation: Subtype: Link Rect: 221, 237, 258, 247 Annotation: Subtype: Link Rect: 176, 212, 214, 222 Annotation: Subtype: Link Rect: 122, 186, 160, 196 Annotation: Subtype: Link Rect: 259, 159, 297, 170 Annotation: Subtype: Link Rect: 479, 120, 516, 131 Annotation: Subtype: Link Rect: 100, 108, 136, 118 Annotation: Subtype: Link Rect: 248, 69, 285, 80 Annotation: Subtype: Link Rect: 292, 69, 328, 80 Page: Sequence: 15 Annotations: Annotation: Subtype: Link Rect: 168, 715, 205, 725 Annotation: Subtype: Link Rect: 211, 715, 247, 725 Annotation: Subtype: Link Rect: 100, 676, 137, 686 Annotation: Subtype: Link Rect: 136, 638, 174, 648 Annotation: Subtype: Link Rect: 314, 611, 352, 622 Annotation: Subtype: Link Rect: 293, 586, 331, 596 Annotation: Subtype: Link Rect: 433, 546, 470, 557 Annotation: Subtype: Link Rect: 145, 508, 183, 519 Annotation: Subtype: Link Rect: 100, 457, 137, 467 Annotation: Subtype: Link Rect: 430, 366, 467, 376 Annotation: Subtype: Link Rect: 474, 366, 510, 376 Annotation: Subtype: Link Rect: 159, 341, 196, 351 Annotation: Subtype: Link Rect: 202, 341, 238, 351 Annotation: Subtype: Link Rect: 246, 315, 283, 325 Annotation: Subtype: Link Rect: 289, 315, 325, 325 Annotation: Subtype: Link Rect: 76, 273, 166, 304 Annotation: Subtype: Link Rect: 234, 267, 407, 278 Checksum: 0a1f9558 Type: CRC32 Checksum: 7229ce5ed15332bd53964a459e74709b Type: MD5 Checksum: 4dd586ca640264539e2ff4df56cfd3c85818588b Type: SHA-1