f846a431e36727209bae5687a15a5c8a pmc_34679404.pdf ba43decda916fcb7e7fae8243a2d9d84149a835d pmc_34679404.pdf 8ab9da2bcc01b4df4960b1436d64392c2623bd74e4865657b5d80698ee378748 pmc_34679404.pdf Title: Can the Addition of Maintenance Electroconvulsive Therapy to Pharmacotherapy Improve Relapse Prevention in Severe Major Depressive Disorder? A Randomized Controlled Trial Subject: Few systematic evaluations have been performed of the efficacy of electroconvulsive therapy (ECT) as a relapse prevention strategy in major depressive disorder (MDD). This is a single-blind, multicenter, randomized controlled trial to compare the efficacy and tolerability of pharmacotherapy plus maintenance ECT (M-Pharm/ECT) versus pharmacotherapy alone (M-Pharm) in the prevention of MDD relapse. Subjects with MDD who had remitted with bilateral acute ECT (n = 37) were randomly assigned to receive M-Pharm/ECT (n = 19, 14 treatments) or M-Pharm (n = 18) for nine months. The subjects were followed up for 15 months. The main outcome was relapse of depression, defined as a score of 18 or more on the Hamilton Depression Rating Scale. At nine months, 35% of the subjects treated with M-Pharm/ECT relapsed as compared with 61% of the patients treated with M-Pharm. No statistically significant differences between groups were indicated by either Kaplan–Meier or Cox proportional hazards regression analyses. The subjects without psychotic features were at higher risk of relapse. There were no statistically significant differences in the MMSE scores of the two groups at the end of the study. Further studies are needed to better define the indications for M-ECT in order to improve its efficacy as a relapse prevention strategy. Keywords: electroconvulsive therapy; major depressive disorder; prevention; relapse; recurrence; maintenance Author: Erika Martínez-Amorós, Narcís Cardoner, Verònica Gálvez, Aida de Arriba-Arnau, Virginia Soria, Diego J. Palao, José M. Menchón and Mikel Urretavizcaya Creator: LaTeX with hyperref Producer: pdfTeX-1.40.21 CreationDate: Fri Oct 15 09:42:41 2021 CEST ModDate: Fri Oct 15 09:52:23 2021 CEST Custom Metadata: no Metadata Stream: no 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: 1976587 bytes Optimized: no PDF version: 1.7 name type encoding emb sub uni object ID ------------------------------------ ----------------- ---------------- --- --- --- --------- CMFVHJ+VnURWPalladioL Type 1 Custom yes yes no 10 0 XYCQVQ+URWPalladioL-Ital Type 1 Custom yes yes no 15 0 BEJMCB+URWPalladioL-Bold Type 1 Custom yes yes no 20 0 NRROMB+URWPalladioL-Roma Type 1 Custom yes yes no 24 0 DFJPUL+VnURWPalladioL-Bold Type 1 Custom yes yes no 28 0 SLUQMQ+TimesNewRomanPS-BoldItalicMT Type 1C WinAnsi yes yes no 36 0 MCBCCI+SourceSansRoman-Regular Type 1C Custom yes yes no 58 0 MCBCCM+SourceSansRoman.613wght Type 1C Custom yes yes no 62 0 MCBCCO+SourceSansRoman-Bold Type 1C Custom yes yes no 66 0 FJBUXO+CMSY10 Type 1 Builtin yes yes no 78 0 JLZORU+EURM10 Type 1 Builtin yes yes no 85 0 WBVKDJ+URWPalladioL-BoldItal Type 1 Custom yes yes no 89 0 Jhove (Rel. 1.28.0, 2023-05-18) Date: 2024-10-02 03:38:44 CEST RepresentationInformation: pmc_34679404.pdf ReportingModule: PDF-hul, Rel. 1.12.4 (2023-03-16) LastModified: 2023-03-31 12:05:53 CEST Size: 1976587 Format: PDF Version: 1.7 Status: Well-Formed and valid SignatureMatches: PDF-hul MIMEtype: application/pdf PDFMetadata: Objects: 351 FreeObjects: 1 IncrementalUpdates: 0 DocumentCatalog: PageLayout: SinglePage PageMode: UseNone Outlines: Item: Title: Introduction Destination: section.1 Item: Title: Materials and Methods Destination: section.2 Children: Item: Title: Study Design and Recruitment Destination: subsection.2.1 Item: Title: Subjects Destination: subsection.2.2 Item: Title: Intervention/Treatment Destination: subsection.2.3 Children: Item: Title: M-ECT Destination: subsubsection.2.3.1 Item: Title: Pharmacotherapy Destination: subsubsection.2.3.2 Item: Title: Variables and Measures Destination: subsection.2.4 Item: Title: Statistics Destination: subsection.2.5 Item: Title: Sample Size Destination: subsection.2.6 Item: Title: Dropout from Statistical Analysis Destination: subsection.2.7 Item: Title: Results Destination: section.3 Children: Item: Title: Subject Disposition Destination: subsection.3.1 Item: Title: Study Sample Characteristics Destination: subsection.3.2 Item: Title: Efficacy Results Destination: subsection.3.3 Children: Item: Title: Relapse in the Intention-to-Treat Sample at Nine Months Destination: subsubsection.3.3.1 Item: Title: Relapses at the End of the Study (at 15 Months) Destination: subsubsection.3.3.2 Item: Title: Changes in Clinical Scales (HDRS-21 and CGI-S) Destination: subsection.3.4 Item: Title: Adverse Events and Cognitive Function Destination: subsection.3.5 Item: Title: Discussion Destination: section.4 Item: Title: Conclusions Destination: section.5 Item: Title: References Destination: section.5 Info: Title: Can the Addition of Maintenance Electroconvulsive Therapy to Pharmacotherapy Improve Relapse Prevention in Severe Major Depressive Disorder? A Randomized Controlled Trial Author: Erika Martínez-Amorós, Narcís Cardoner, Verònica Gálvez, Aida de Arriba-Arnau, Virginia Soria, Diego J. Palao, José M. Menchón and Mikel Urretavizcaya Subject: Few systematic evaluations have been performed of the efficacy of electroconvulsive therapy (ECT) as a relapse prevention strategy in major depressive disorder (MDD). This is a single-blind, multicenter, randomized controlled trial to compare the efficacy and tolerability of pharmacotherapy plus maintenance ECT (M-Pharm/ECT) versus pharmacotherapy alone (M-Pharm) in the prevention of MDD relapse. Subjects with MDD who had remitted with bilateral acute ECT (n = 37) were randomly assigned to receive M-Pharm/ECT (n = 19, 14 treatments) or M-Pharm (n = 18) for nine months. The subjects were followed up for 15 months. The main outcome was relapse of depression, defined as a score of 18 or more on the Hamilton Depression Rating Scale. At nine months, 35% of the subjects treated with M-Pharm/ECT relapsed as compared with 61% of the patients treated with M-Pharm. No statistically significant differences between groups were indicated by either Kaplan Meier or Cox proportional hazards regression analyses. The subjects without psychotic features were at higher risk of relapse. There were no statistically significant differences in the MMSE scores of the two groups at the end of the study. Further studies are needed to better define the indications for M-ECT in order to improve its efficacy as a relapse prevention strategy. Keywords: electroconvulsive therapy; major depressive disorder; prevention; relapse; recurrence; maintenance Creator: LaTeX with hyperref Producer: pdfTeX-1.40.21 CreationDate: Fri Oct 15 09:42:41 CEST 2021 ModDate: Fri Oct 15 09:52:23 CEST 2021 ID: 0x04a17cc61d6b74ad558f5310b4bd9942, 0x04a17cc61d6b74ad558f5310b4bd9942 Filters: FilterPipeline: FlateDecode Fonts: Type1: Font: BaseFont: BEJMCB+URWPalladioL-Bold FontSubset: true FirstChar: 3 LastChar: 150 FontDescriptor: FontName: BEJMCB+URWPalladioL-Bold Flags: Symbolic FontBBox: -152, -301, 1000, 935 FontFile: true EncodingDictionary: Differences: true Font: BaseFont: JLZORU+EURM10 FontSubset: true FirstChar: 31 LastChar: 31 FontDescriptor: FontName: JLZORU+EURM10 Flags: Symbolic FontBBox: -32, -243, 1060, 720 FontFile: true Font: BaseFont: NRROMB+URWPalladioL-Roma FontSubset: true FirstChar: 2 LastChar: 248 FontDescriptor: FontName: NRROMB+URWPalladioL-Roma Flags: Symbolic FontBBox: -166, -283, 1021, 943 FontFile: true EncodingDictionary: Differences: true Font: BaseFont: WBVKDJ+URWPalladioL-BoldItal FontSubset: true FirstChar: 112 LastChar: 112 FontDescriptor: FontName: WBVKDJ+URWPalladioL-BoldItal Flags: Symbolic FontBBox: -170, -300, 1073, 935 FontFile: true EncodingDictionary: Differences: true Font: BaseFont: CMFVHJ+VnURWPalladioL FontSubset: true FirstChar: 129 LastChar: 226 FontDescriptor: FontName: CMFVHJ+VnURWPalladioL Flags: Symbolic FontBBox: -166, -283, 1021, 943 FontFile: true EncodingDictionary: Differences: true Font: BaseFont: DFJPUL+VnURWPalladioL-Bold FontSubset: true FirstChar: 161 LastChar: 226 FontDescriptor: FontName: DFJPUL+VnURWPalladioL-Bold Flags: Symbolic FontBBox: -152, -301, 1000, 935 FontFile: true EncodingDictionary: Differences: true Font: BaseFont: FJBUXO+CMSY10 FontSubset: true FirstChar: 6 LastChar: 20 FontDescriptor: FontName: FJBUXO+CMSY10 Flags: Symbolic FontBBox: -29, -960, 1116, 775 FontFile: true Font: BaseFont: XYCQVQ+URWPalladioL-Ital FontSubset: true FirstChar: 2 LastChar: 241 FontDescriptor: FontName: XYCQVQ+URWPalladioL-Ital Flags: Symbolic FontBBox: -170, -305, 1010, 941 FontFile: true EncodingDictionary: Differences: true Pages: Page: Sequence: 1 Annotations: Annotation: Subtype: Link Rect: 35, 759, 174, 795 Annotation: Subtype: Link Rect: 515, 759, 560, 795 Annotation: Subtype: Link Rect: 162, 642, 173, 654 Annotation: Subtype: Link Rect: 489, 642, 500, 654 Annotation: Subtype: Link Rect: 118, 628, 129, 642 Annotation: Subtype: Link Rect: 54, 358, 154, 367 Annotation: Subtype: Link Rect: 35, 348, 89, 355 Annotation: Subtype: Link Rect: 35, 162, 97, 184 Annotation: Subtype: Link Rect: 153, 89, 154, 98 Annotation: Subtype: Link Rect: 35, 77, 147, 86 Annotation: Subtype: Link Rect: 221, 185, 228, 194 ActionDest: 130 Annotation: Subtype: Link Rect: 231, 185, 238, 194 ActionDest: 130 Annotation: Subtype: Link Rect: 448, 160, 455, 169 ActionDest: 130 Annotation: Subtype: Link Rect: 424, 135, 431, 144 ActionDest: 130 Annotation: Subtype: Link Rect: 388, 97, 395, 106 ActionDest: 130 Annotation: Subtype: Link Rect: 398, 97, 405, 106 ActionDest: 130 Annotation: Subtype: Link Rect: 528, 97, 535, 106 ActionDest: 130 Annotation: Subtype: Link Rect: 536, 97, 543, 106 ActionDest: 130 Annotation: Subtype: Link Rect: 277, 85, 289, 94 ActionDest: 130 Annotation: Subtype: Link Rect: 121, 17, 273, 28 Annotation: Subtype: Link Rect: 406, 17, 558, 28 Annotation: Subtype: Link Rect: 35, 494, 87, 513 Page: Sequence: 2 Annotations: Annotation: Subtype: Link Rect: 387, 737, 394, 746 ActionDest: 130 Annotation: Subtype: Link Rect: 292, 661, 303, 670 ActionDest: 130 Annotation: Subtype: Link Rect: 307, 661, 318, 670 ActionDest: 130 Annotation: Subtype: Link Rect: 382, 661, 394, 670 ActionDest: 130 Annotation: Subtype: Link Rect: 397, 661, 409, 670 ActionDest: 130 Annotation: Subtype: Link Rect: 529, 624, 541, 633 ActionDest: 133 Annotation: Subtype: Link Rect: 544, 624, 556, 633 ActionDest: 133 Annotation: Subtype: Link Rect: 471, 599, 483, 608 ActionDest: 133 Annotation: Subtype: Link Rect: 229, 561, 236, 570 ActionDest: 130 Annotation: Subtype: Link Rect: 237, 561, 249, 570 ActionDest: 133 Annotation: Subtype: Link Rect: 328, 536, 340, 545 ActionDest: 133 Annotation: Subtype: Link Rect: 348, 511, 360, 520 ActionDest: 133 Annotation: Subtype: Link Rect: 353, 498, 365, 507 ActionDest: 130 Annotation: Subtype: Link Rect: 366, 498, 378, 507 ActionDest: 133 Annotation: Subtype: Link Rect: 479, 485, 491, 495 ActionDest: 133 Annotation: Subtype: Link Rect: 335, 461, 347, 469 ActionDest: 130 Annotation: Subtype: Link Rect: 347, 461, 359, 469 ActionDest: 130 Annotation: Subtype: Link Rect: 359, 461, 371, 469 ActionDest: 130 Annotation: Subtype: Link Rect: 372, 460, 384, 469 ActionDest: 133 Annotation: Subtype: Link Rect: 457, 356, 560, 368 Annotation: Subtype: Link Rect: 260, 126, 272, 136 ActionDest: 133 Annotation: Subtype: Link Rect: 429, 89, 436, 98 ActionDest: 130 Annotation: Subtype: Link Rect: 206, 76, 218, 85 ActionDest: 133 Annotation: Subtype: Link Rect: 494, 64, 506, 73 ActionDest: 133 Annotation: Subtype: Link Rect: 507, 64, 519, 73 ActionDest: 133 Page: Sequence: 3 Annotations: Annotation: Subtype: Link Rect: 279, 735, 290, 744 ActionDest: 133 Annotation: Subtype: Link Rect: 297, 570, 309, 579 ActionDest: 133 Annotation: Subtype: Link Rect: 196, 329, 203, 341 ActionDest: 82 Page: Sequence: 4 Annotations: Annotation: Subtype: Link Rect: 232, 559, 244, 568 ActionDest: 133 Annotation: Subtype: Link Rect: 245, 559, 257, 568 ActionDest: 133 Annotation: Subtype: Link Rect: 242, 546, 254, 555 ActionDest: 133 Annotation: Subtype: Link Rect: 268, 534, 280, 543 ActionDest: 133 Annotation: Subtype: Link Rect: 331, 521, 343, 530 ActionDest: 133 Annotation: Subtype: Link Rect: 361, 509, 373, 518 ActionDest: 133 Annotation: Subtype: Link Rect: 326, 484, 338, 492 ActionDest: 133 Annotation: Subtype: Link Rect: 330, 471, 342, 480 ActionDest: 133 Annotation: Subtype: Link Rect: 448, 458, 460, 467 ActionDest: 133 Annotation: Subtype: Link Rect: 470, 458, 482, 467 ActionDest: 133 Page: Sequence: 5 Annotations: Annotation: Subtype: Link Rect: 259, 534, 271, 543 ActionDest: 133 Annotation: Subtype: Link Rect: 298, 316, 305, 328 ActionDest: 99 Annotation: Subtype: Link Rect: 553, 193, 560, 202 ActionDest: 82 Page: Sequence: 6 Annotations: Annotation: Subtype: Link Rect: 428, 694, 435, 706 ActionDest: 105 Annotation: Subtype: Link Rect: 374, 105, 381, 117 ActionDest: 105 Page: Sequence: 7 Annotations: Annotation: Subtype: Link Rect: 352, 71, 360, 83 ActionDest: 111 Page: Sequence: 8 Annotations: Annotation: Subtype: Link Rect: 418, 669, 425, 681 ActionDest: 111 Annotation: Subtype: Link Rect: 336, 217, 343, 229 ActionDest: 111 Page: Sequence: 9 Annotations: Annotation: Subtype: Link Rect: 480, 704, 487, 716 ActionDest: 114 Annotation: Subtype: Link Rect: 553, 679, 560, 691 ActionDest: 114 Annotation: Subtype: Link Rect: 216, 666, 223, 678 ActionDest: 114 Annotation: Subtype: Link Rect: 411, 654, 418, 666 ActionDest: 114 Annotation: Subtype: Link Rect: 445, 629, 452, 641 ActionDest: 114 Page: Sequence: 10 Annotations: Annotation: Subtype: Link Rect: 237, 720, 243, 732 ActionDest: 82 Annotation: Subtype: Link Rect: 287, 707, 294, 719 ActionDest: 120 Annotation: Subtype: Link Rect: 454, 682, 461, 694 ActionDest: 120 Annotation: Subtype: Link Rect: 426, 317, 438, 326 ActionDest: 130 Annotation: Subtype: Link Rect: 439, 317, 451, 326 ActionDest: 136 Annotation: Subtype: Link Rect: 258, 217, 270, 226 ActionDest: 130 Annotation: Subtype: Link Rect: 270, 217, 282, 226 ActionDest: 130 Annotation: Subtype: Link Rect: 247, 192, 259, 201 ActionDest: 130 Annotation: Subtype: Link Rect: 368, 142, 380, 151 ActionDest: 136 Annotation: Subtype: Link Rect: 423, 104, 435, 113 ActionDest: 130 Annotation: Subtype: Link Rect: 442, 79, 454, 88 ActionDest: 130 Page: Sequence: 11 Annotations: Annotation: Subtype: Link Rect: 262, 722, 274, 731 ActionDest: 130 Annotation: Subtype: Link Rect: 544, 710, 556, 719 ActionDest: 130 Annotation: Subtype: Link Rect: 221, 597, 233, 606 ActionDest: 130 Annotation: Subtype: Link Rect: 222, 584, 234, 593 ActionDest: 130 Annotation: Subtype: Link Rect: 379, 509, 391, 518 ActionDest: 130 Annotation: Subtype: Link Rect: 391, 509, 403, 518 ActionDest: 136 Annotation: Subtype: Link Rect: 270, 471, 282, 480 ActionDest: 136 Annotation: Subtype: Link Rect: 382, 433, 394, 443 ActionDest: 136 Annotation: Subtype: Link Rect: 394, 433, 406, 443 ActionDest: 136 Annotation: Subtype: Link Rect: 507, 421, 514, 430 ActionDest: 130 Annotation: Subtype: Link Rect: 515, 421, 522, 430 ActionDest: 130 Annotation: Subtype: Link Rect: 543, 296, 555, 304 ActionDest: 130 Annotation: Subtype: Link Rect: 512, 258, 524, 267 ActionDest: 130 Annotation: Subtype: Link Rect: 362, 195, 374, 204 ActionDest: 130 Annotation: Subtype: Link Rect: 374, 195, 386, 204 ActionDest: 130 Annotation: Subtype: Link Rect: 387, 195, 399, 204 ActionDest: 130 Annotation: Subtype: Link Rect: 545, 132, 557, 141 ActionDest: 130 Annotation: Subtype: Link Rect: 215, 107, 227, 116 ActionDest: 130 Annotation: Subtype: Link Rect: 426, 107, 438, 116 ActionDest: 130 Page: Sequence: 12 Annotations: Annotation: Subtype: Link Rect: 489, 735, 501, 744 ActionDest: 130 Annotation: Subtype: Link Rect: 244, 722, 256, 731 ActionDest: 130 Annotation: Subtype: Link Rect: 424, 710, 436, 719 ActionDest: 136 Annotation: Subtype: Link Rect: 495, 659, 502, 669 ActionDest: 130 Annotation: Subtype: Link Rect: 502, 659, 514, 669 ActionDest: 136 Annotation: Subtype: Link Rect: 303, 458, 315, 467 ActionDest: 130 Annotation: Subtype: Link Rect: 316, 458, 328, 467 ActionDest: 130 Annotation: Subtype: Link Rect: 424, 357, 560, 368 Annotation: Subtype: Link Rect: 166, 345, 285, 356 Page: Sequence: 13 Annotations: Annotation: Subtype: Link Rect: 222, 626, 259, 637 Annotation: Subtype: Link Rect: 295, 603, 560, 614 Annotation: Subtype: Link Rect: 56, 592, 331, 603 Annotation: Subtype: Link Rect: 300, 569, 337, 580 Annotation: Subtype: Link Rect: 344, 569, 380, 580 Annotation: Subtype: Link Rect: 95, 546, 133, 557 Annotation: Subtype: Link Rect: 109, 523, 146, 533 Annotation: Subtype: Link Rect: 475, 511, 513, 522 Annotation: Subtype: Link Rect: 519, 511, 555, 522 Annotation: Subtype: Link Rect: 440, 499, 477, 510 Annotation: Subtype: Link Rect: 319, 465, 357, 476 Annotation: Subtype: Link Rect: 59, 420, 97, 430 Annotation: Subtype: Link Rect: 145, 385, 182, 395 Annotation: Subtype: Link Rect: 353, 350, 391, 361 Annotation: Subtype: Link Rect: 122, 316, 160, 326 Annotation: Subtype: Link Rect: 519, 304, 557, 315 Annotation: Subtype: Link Rect: 59, 293, 95, 303 Annotation: Subtype: Link Rect: 442, 269, 480, 280 Annotation: Subtype: Link Rect: 158, 247, 196, 257 Annotation: Subtype: Link Rect: 202, 247, 238, 257 Annotation: Subtype: Link Rect: 347, 223, 385, 234 Annotation: Subtype: Link Rect: 391, 223, 427, 234 Annotation: Subtype: Link Rect: 363, 200, 401, 211 Annotation: Subtype: Link Rect: 407, 200, 443, 211 Annotation: Subtype: Link Rect: 191, 178, 228, 188 Annotation: Subtype: Link Rect: 235, 178, 271, 188 Annotation: Subtype: Link Rect: 82, 144, 119, 154 Annotation: Subtype: Link Rect: 126, 144, 162, 154 Annotation: Subtype: Link Rect: 520, 120, 557, 131 Annotation: Subtype: Link Rect: 59, 109, 95, 119 Annotation: Subtype: Link Rect: 426, 85, 464, 96 Page: Sequence: 14 Annotations: Annotation: Subtype: Link Rect: 146, 710, 184, 720 Annotation: Subtype: Link Rect: 95, 676, 131, 686 Annotation: Subtype: Link Rect: 315, 640, 352, 651 Annotation: Subtype: Link Rect: 358, 640, 394, 651 Annotation: Subtype: Link Rect: 358, 617, 521, 628 Annotation: Subtype: Link Rect: 95, 584, 133, 594 Annotation: Subtype: Link Rect: 139, 584, 175, 594 Annotation: Subtype: Link Rect: 379, 560, 416, 571 Annotation: Subtype: Link Rect: 422, 560, 458, 571 Annotation: Subtype: Link Rect: 131, 515, 169, 525 Annotation: Subtype: Link Rect: 175, 515, 211, 525 Annotation: Subtype: Link Rect: 540, 479, 560, 490 Annotation: Subtype: Link Rect: 56, 468, 227, 479 Annotation: Subtype: Link Rect: 419, 456, 457, 467 Annotation: Subtype: Link Rect: 463, 456, 499, 467 Annotation: Subtype: Link Rect: 519, 445, 557, 456 Annotation: Subtype: Link Rect: 59, 434, 95, 444 Annotation: Subtype: Link Rect: 172, 399, 210, 410 Annotation: Subtype: Link Rect: 216, 399, 252, 410 Annotation: Subtype: Link Rect: 195, 341, 232, 352 Annotation: Subtype: Link Rect: 238, 341, 274, 352 Annotation: Subtype: Link Rect: 122, 319, 158, 329 Annotation: Subtype: Link Rect: 417, 284, 454, 295 Annotation: Subtype: Link Rect: 155, 204, 192, 214 Annotation: Subtype: Link Rect: 198, 204, 234, 214 Annotation: Subtype: Link Rect: 86, 169, 123, 180 Annotation: Subtype: Link Rect: 130, 169, 166, 180 Annotation: Subtype: Link Rect: 249, 146, 286, 157 Annotation: Subtype: Link Rect: 253, 88, 290, 99 Annotation: Subtype: Link Rect: 297, 88, 333, 99 Page: Sequence: 15 Annotations: Annotation: Subtype: Link Rect: 235, 710, 273, 720 Annotation: Subtype: Link Rect: 108, 676, 146, 686 Annotation: Subtype: Link Rect: 59, 641, 97, 651 Annotation: Subtype: Link Rect: 103, 641, 139, 651 Annotation: Subtype: Link Rect: 437, 617, 474, 628 Annotation: Subtype: Link Rect: 480, 617, 516, 628 Annotation: Subtype: Link Rect: 82, 584, 119, 594 Annotation: Subtype: Link Rect: 126, 584, 162, 594 Annotation: Subtype: Link Rect: 212, 549, 249, 559 Annotation: Subtype: Link Rect: 256, 549, 292, 559 Annotation: Subtype: Link Rect: 86, 515, 123, 525 Annotation: Subtype: Link Rect: 130, 515, 166, 525 Checksum: 539f7fd9 Type: CRC32 Checksum: f846a431e36727209bae5687a15a5c8a Type: MD5 Checksum: ba43decda916fcb7e7fae8243a2d9d84149a835d Type: SHA-1 Checksum: 8ab9da2bcc01b4df4960b1436d64392c2623bd74e4865657b5d80698ee378748 Type: SHA-256