1ba4108317f9930ed8a5b8b87ea9d3a9 pmc_34770489.pdf 93e08c9d5825eae662bc4636b890771097f4d84c pmc_34770489.pdf b7ec133aa812bcf39964885901e605d485d60b2c6b767f60f7bb8ada49a84140 pmc_34770489.pdf Title: Detection of Sleep-Disordered Breathing in Patients with Spinal Cord Injury Using a Smartphone Subject: Patients with spinal cord injury (SCI) have an increased risk of sleep-disordered breathing (SDB), which can lead to serious comorbidities and impact patients’ recovery and quality of life. However, sleep tests are rarely performed on SCI patients, given their multiple health needs and the cost and complexity of diagnostic equipment. The objective of this study was to use a novel smartphone system as a simple non-invasive tool to monitor SDB in SCI patients. We recorded pulse oximetry, acoustic, and accelerometer data using a smartphone during overnight tests in 19 SCI patients and 19 able-bodied controls. Then, we analyzed these signals with automatic algorithms to detect desaturation, apnea, and hypopnea events and monitor sleep position. The apnea–hypopnea index (AHI) was significantly higher in SCI patients than controls (25 15 vs. 9 7, p < 0.001). We found that 63% of SCI patients had moderate-to-severe SDB (AHI 15) in contrast to 21% of control subjects. Most SCI patients slept predominantly in supine position, but an increased occurrence of events in supine position was only observed for eight patients. This study highlights the problem of SDB in SCI and provides simple cost-effective sleep monitoring tools to facilitate the detection, understanding, and management of SDB in SCI patients. Keywords: spinal cord injury; sleep-disordered breathing; sleep apnea; sleep position; smartphone; biomedical signal processing; mHealth; monitoring Author: Yolanda Castillo-Escario, Hatice Kumru, Ignasi Ferrer-Lluis, Joan Vidal and Raimon Jané Creator: LaTeX with hyperref Producer: pdfTeX-1.40.21 CreationDate: Fri Oct 29 05:53:20 2021 CEST ModDate: Fri Oct 29 06:04:49 2021 CEST Tagged: no UserProperties: no Suspects: no Form: none JavaScript: no Pages: 19 Encrypted: no Page size: 595.276 x 841.89 pts (A4) Page rot: 0 File size: 13624885 bytes Optimized: no PDF version: 1.7 name type encoding emb sub uni object ID ------------------------------------ ----------------- ---------------- --- --- --- --------- GULDYU+VnURWPalladioL Type 1 Custom yes yes no 10 0 LLGUJI+URWPalladioL-Ital Type 1 Custom yes yes no 15 0 PNRHIX+URWPalladioL-Bold Type 1 Custom yes yes no 20 0 SNNPJZ+URWPalladioL-Roma Type 1 Custom yes yes no 24 0 LFLYLN+CMSY10 Type 1 Builtin yes yes no 28 0 BTFGED+VnURWPalladioL-Bold Type 1 Custom yes yes no 32 0 RVSEMT+TimesNewRomanPS-BoldItalicMT Type 1C WinAnsi yes yes no 40 0 MCBCCI+SourceSansRoman-Regular Type 1C Custom yes yes no 62 0 MCBCCM+SourceSansRoman.613wght Type 1C Custom yes yes no 66 0 MCBCCO+SourceSansRoman-Bold Type 1C Custom yes yes no 70 0 ARLQUR+EURM10 Type 1 Builtin yes yes no 105 0 Jhove (Rel. 1.22.1, 2019-04-17) Date: 2023-10-21 02:41:03 CEST RepresentationInformation: pmc_34770489.pdf ReportingModule: PDF-hul, Rel. 1.12.1 (2019-04-17) LastModified: 2023-03-31 12:06:12 CEST Size: 13624885 Format: PDF Version: 1.7 Status: Well-Formed and valid SignatureMatches: PDF-hul MIMEtype: application/pdf PDFMetadata: Objects: 470 FreeObjects: 11 IncrementalUpdates: 0 DocumentCatalog: PageLayout: SinglePage PageMode: UseNone Outlines: Item: Title: Introduction Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@262b2c86 Item: Title: Materials and Methods Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@371a67ec Children: Item: Title: Participants Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@5ed828d Item: Title: Data Acquisition System and Experimental Setup Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@50d0686 Item: Title: Signal Processing and Analysis Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@7a3d45bd Children: Item: Title: SpO2 Analysis Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@1e7c7811 Item: Title: Apnea and Hypopnea Detection Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@77ec78b9 Item: Title: Sleep Position Monitoring Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@1a3869f4 Item: Title: Oral vs. Nasal Breathing Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@a38d7a3 Item: Title: Statistical Analysis Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@77f99a05 Item: Title: Results Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@63440df3 Children: Item: Title: SpO2 Measures Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@3aeaafa6 Item: Title: Apneas and Hypopneas Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@76a3e297 Item: Title: Sleep Position Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@4d3167f4 Item: Title: Oral Breathing Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@ed9d034 Item: Title: Correlation with Age, BMI, and Injury Characteristics Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@6121c9d6 Item: Title: Discussion Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@87f383f Item: Title: Patents Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@4eb7f003 Item: Title: References Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@eafc191 Info: Title: Detection of Sleep-Disordered Breathing in Patients with Spinal Cord Injury Using a Smartphone Author: Yolanda Castillo-Escario, Hatice Kumru, Ignasi Ferrer-Lluis, Joan Vidal and Raimon Jané Subject: Patients with spinal cord injury (SCI) have an increased risk of sleep-disordered breathing (SDB), which can lead to serious comorbidities and impact patients’ recovery and quality of life. However, sleep tests are rarely performed on SCI patients, given their multiple health needs and the cost and complexity of diagnostic equipment. The objective of this study was to use a novel smartphone system as a simple non-invasive tool to monitor SDB in SCI patients. We recorded pulse oximetry, acoustic, and accelerometer data using a smartphone during overnight tests in 19 SCI patients and 19 able-bodied controls. Then, we analyzed these signals with automatic algorithms to detect desaturation, apnea, and hypopnea events and monitor sleep position. The apnea hypopnea index (AHI) was significantly higher in SCI patients than controls (25 15 vs. 9 7, p < 0.001). We found that 63% of SCI patients had moderate-to-severe SDB (AHI 15) in contrast to 21% of control subjects. Most SCI patients slept predominantly in supine position, but an increased occurrence of events in supine position was only observed for eight patients. This study highlights the problem of SDB in SCI and provides simple cost-effective sleep monitoring tools to facilitate the detection, understanding, and management of SDB in SCI patients. Keywords: spinal cord injury; sleep-disordered breathing; sleep apnea; sleep position; smartphone; biomedical signal processing; mHealth; monitoring Creator: LaTeX with hyperref Producer: pdfTeX-1.40.21 CreationDate: Fri Oct 29 05:53:20 CEST 2021 ModDate: Fri Oct 29 06:04:49 CEST 2021 ID: 0x266d44e9714ff370c918e88a7f1be42f, 0x266d44e9714ff370c918e88a7f1be42f Filters: FilterPipeline: FlateDecode Fonts: Type1: Font: BaseFont: BTFGED+VnURWPalladioL-Bold FontSubset: true FirstChar: 178 LastChar: 178 FontDescriptor: FontName: BTFGED+VnURWPalladioL-Bold Flags: Symbolic FontBBox: -152, -301, 1000, 935 FontFile: true EncodingDictionary: Differences: true Font: BaseFont: PNRHIX+URWPalladioL-Bold FontSubset: true FirstChar: 3 LastChar: 121 FontDescriptor: FontName: PNRHIX+URWPalladioL-Bold Flags: Symbolic FontBBox: -152, -301, 1000, 935 FontFile: true EncodingDictionary: Differences: true Font: BaseFont: SNNPJZ+URWPalladioL-Roma FontSubset: true FirstChar: 2 LastChar: 252 FontDescriptor: FontName: SNNPJZ+URWPalladioL-Roma Flags: Symbolic FontBBox: -166, -283, 1021, 943 FontFile: true EncodingDictionary: Differences: true Font: BaseFont: ARLQUR+EURM10 FontSubset: true FirstChar: 18 LastChar: 18 FontDescriptor: FontName: ARLQUR+EURM10 Flags: Symbolic FontBBox: -32, -243, 1060, 720 FontFile: true Font: BaseFont: GULDYU+VnURWPalladioL FontSubset: true FirstChar: 160 LastChar: 243 FontDescriptor: FontName: GULDYU+VnURWPalladioL Flags: Symbolic FontBBox: -166, -283, 1021, 943 FontFile: true EncodingDictionary: Differences: true Font: BaseFont: LFLYLN+CMSY10 FontSubset: true FirstChar: 0 LastChar: 21 FontDescriptor: FontName: LFLYLN+CMSY10 Flags: Symbolic FontBBox: -29, -960, 1116, 775 FontFile: true Font: BaseFont: LLGUJI+URWPalladioL-Ital FontSubset: true FirstChar: 43 LastChar: 122 FontDescriptor: FontName: LLGUJI+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, 153, 795 Annotation: Subtype: Link Rect: 515, 759, 560, 795 Annotation: Subtype: Link Rect: 172, 659, 183, 673 Annotation: Subtype: Link Rect: 277, 659, 288, 673 Annotation: Subtype: Link Rect: 396, 659, 407, 673 Annotation: Subtype: Link Rect: 478, 659, 489, 673 Annotation: Subtype: Link Rect: 133, 647, 144, 661 Annotation: Subtype: Link Rect: 106, 346, 154, 355 Annotation: Subtype: Link Rect: 35, 334, 121, 343 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: 395, 206, 402, 215 ActionDest: 168 Annotation: Subtype: Link Rect: 416, 143, 423, 152 ActionDest: 168 Annotation: Subtype: Link Rect: 199, 105, 206, 114 ActionDest: 168 Annotation: Subtype: Link Rect: 207, 105, 214, 114 ActionDest: 168 Annotation: Subtype: Link Rect: 113, 17, 241, 28 Annotation: Subtype: Link Rect: 408, 17, 558, 28 Annotation: Subtype: Link Rect: 35, 423, 87, 442 Page: Sequence: 2 Annotations: Annotation: Subtype: Link Rect: 541, 737, 548, 746 ActionDest: 168 Annotation: Subtype: Link Rect: 549, 737, 556, 746 ActionDest: 168 Annotation: Subtype: Link Rect: 428, 712, 435, 721 ActionDest: 168 Annotation: Subtype: Link Rect: 199, 661, 206, 670 ActionDest: 168 Annotation: Subtype: Link Rect: 209, 661, 221, 670 ActionDest: 168 Annotation: Subtype: Link Rect: 336, 649, 343, 658 ActionDest: 168 Annotation: Subtype: Link Rect: 344, 649, 356, 658 ActionDest: 168 Annotation: Subtype: Link Rect: 389, 649, 401, 658 ActionDest: 168 Annotation: Subtype: Link Rect: 404, 649, 416, 658 ActionDest: 168 Annotation: Subtype: Link Rect: 314, 636, 321, 645 ActionDest: 168 Annotation: Subtype: Link Rect: 544, 636, 556, 645 ActionDest: 168 Annotation: Subtype: Link Rect: 461, 598, 473, 608 ActionDest: 168 Annotation: Subtype: Link Rect: 345, 548, 357, 557 ActionDest: 168 Annotation: Subtype: Link Rect: 355, 523, 366, 532 ActionDest: 168 Annotation: Subtype: Link Rect: 445, 498, 452, 507 ActionDest: 168 Annotation: Subtype: Link Rect: 452, 498, 464, 507 ActionDest: 168 Annotation: Subtype: Link Rect: 241, 473, 253, 482 ActionDest: 171 Annotation: Subtype: Link Rect: 315, 448, 327, 457 ActionDest: 168 Annotation: Subtype: Link Rect: 517, 372, 529, 382 ActionDest: 171 Annotation: Subtype: Link Rect: 300, 360, 312, 369 ActionDest: 171 Annotation: Subtype: Link Rect: 409, 360, 421, 369 ActionDest: 171 Annotation: Subtype: Link Rect: 484, 348, 496, 356 ActionDest: 171 Annotation: Subtype: Link Rect: 306, 335, 318, 344 ActionDest: 171 Annotation: Subtype: Link Rect: 496, 310, 508, 319 ActionDest: 171 Annotation: Subtype: Link Rect: 523, 247, 535, 256 ActionDest: 168 Annotation: Subtype: Link Rect: 387, 197, 399, 206 ActionDest: 171 Annotation: Subtype: Link Rect: 447, 172, 459, 181 ActionDest: 168 Annotation: Subtype: Link Rect: 459, 172, 471, 181 ActionDest: 171 Annotation: Subtype: Link Rect: 332, 159, 344, 168 ActionDest: 168 Annotation: Subtype: Link Rect: 474, 159, 486, 168 ActionDest: 168 Annotation: Subtype: Link Rect: 486, 159, 498, 168 ActionDest: 171 Annotation: Subtype: Link Rect: 501, 159, 513, 168 ActionDest: 171 Annotation: Subtype: Link Rect: 264, 147, 276, 156 ActionDest: 168 Annotation: Subtype: Link Rect: 277, 147, 289, 156 ActionDest: 171 Annotation: Subtype: Link Rect: 489, 134, 496, 143 ActionDest: 168 Annotation: Subtype: Link Rect: 465, 96, 477, 105 ActionDest: 168 Annotation: Subtype: Link Rect: 477, 96, 489, 105 ActionDest: 168 Annotation: Subtype: Link Rect: 278, 71, 285, 80 ActionDest: 168 Annotation: Subtype: Link Rect: 286, 71, 298, 80 ActionDest: 168 Annotation: Subtype: Link Rect: 298, 71, 310, 80 ActionDest: 168 Annotation: Subtype: Link Rect: 311, 71, 323, 80 ActionDest: 171 Page: Sequence: 3 Annotations: Annotation: Subtype: Link Rect: 544, 710, 556, 719 ActionDest: 171 Annotation: Subtype: Link Rect: 302, 685, 314, 694 ActionDest: 171 Annotation: Subtype: Link Rect: 317, 685, 329, 694 ActionDest: 171 Annotation: Subtype: Link Rect: 428, 634, 440, 643 ActionDest: 171 Annotation: Subtype: Link Rect: 441, 634, 453, 643 ActionDest: 171 Annotation: Subtype: Link Rect: 315, 609, 327, 618 ActionDest: 171 Annotation: Subtype: Link Rect: 327, 609, 339, 618 ActionDest: 171 Annotation: Subtype: Link Rect: 523, 597, 535, 606 ActionDest: 171 Annotation: Subtype: Link Rect: 535, 597, 547, 606 ActionDest: 171 Annotation: Subtype: Link Rect: 245, 534, 257, 543 ActionDest: 171 Annotation: Subtype: Link Rect: 260, 534, 272, 543 ActionDest: 171 Annotation: Subtype: Link Rect: 345, 354, 352, 366 ActionDest: 85 Annotation: Subtype: Link Rect: 474, 319, 486, 328 ActionDest: 171 Page: Sequence: 4 Annotations: Annotation: Subtype: Link Rect: 518, 333, 530, 342 ActionDest: 171 Annotation: Subtype: Link Rect: 533, 333, 545, 342 ActionDest: 171 Annotation: Subtype: Link Rect: 514, 308, 526, 317 ActionDest: 171 Annotation: Subtype: Link Rect: 517, 268, 524, 280 ActionDest: 88 Annotation: Subtype: Link Rect: 330, 258, 342, 267 ActionDest: 171 Annotation: Subtype: Link Rect: 420, 218, 427, 230 ActionDest: 88 Annotation: Subtype: Link Rect: 229, 82, 241, 91 ActionDest: 171 Page: Sequence: 5 Annotations: Annotation: Subtype: Link Rect: 544, 83, 556, 92 ActionDest: 171 Page: Sequence: 6 Annotations: Annotation: Subtype: Link Rect: 339, 685, 351, 694 ActionDest: 171 Annotation: Subtype: Link Rect: 448, 647, 460, 656 ActionDest: 171 Annotation: Subtype: Link Rect: 348, 609, 360, 618 ActionDest: 171 Annotation: Subtype: Link Rect: 360, 609, 372, 618 ActionDest: 174 Annotation: Subtype: Link Rect: 282, 559, 294, 568 ActionDest: 171 Annotation: Subtype: Link Rect: 294, 559, 306, 568 ActionDest: 174 Annotation: Subtype: Link Rect: 543, 459, 555, 468 ActionDest: 171 Annotation: Subtype: Link Rect: 309, 408, 321, 417 ActionDest: 171 Annotation: Subtype: Link Rect: 378, 346, 390, 355 ActionDest: 171 Annotation: Subtype: Link Rect: 256, 308, 268, 317 ActionDest: 174 Annotation: Subtype: Link Rect: 180, 182, 192, 191 ActionDest: 171 Annotation: Subtype: Link Rect: 193, 182, 205, 191 ActionDest: 171 Annotation: Subtype: Link Rect: 325, 170, 337, 179 ActionDest: 171 Annotation: Subtype: Link Rect: 510, 82, 522, 91 ActionDest: 171 Annotation: Subtype: Link Rect: 522, 82, 534, 91 ActionDest: 171 Page: Sequence: 7 Annotations: Annotation: Subtype: Link Rect: 366, 710, 378, 719 ActionDest: 171 Annotation: Subtype: Link Rect: 212, 534, 224, 543 ActionDest: 171 Annotation: Subtype: Link Rect: 247, 433, 259, 442 ActionDest: 171 Annotation: Subtype: Link Rect: 466, 370, 478, 380 ActionDest: 171 Annotation: Subtype: Link Rect: 336, 320, 348, 329 ActionDest: 171 Annotation: Subtype: Link Rect: 343, 267, 357, 279 ActionDest: 88 Annotation: Subtype: Link Rect: 387, 129, 394, 141 ActionDest: 109 Annotation: Subtype: Link Rect: 266, 104, 273, 116 ActionDest: 109 Page: Sequence: 8 Annotations: Annotation: Subtype: Link Rect: 213, 291, 220, 303 ActionDest: 109 Annotation: Subtype: Link Rect: 492, 291, 499, 303 ActionDest: 109 Annotation: Subtype: Link Rect: 265, 241, 272, 253 ActionDest: 109 Annotation: Subtype: Link Rect: 294, 228, 301, 241 ActionDest: 109 Annotation: Subtype: Link Rect: 208, 128, 215, 140 ActionDest: 112 Page: Sequence: 9 Annotations: Annotation: Subtype: Link Rect: 214, 479, 221, 491 ActionDest: 109 Annotation: Subtype: Link Rect: 394, 417, 401, 429 ActionDest: 112 Annotation: Subtype: Link Rect: 435, 417, 442, 429 ActionDest: 109 Annotation: Subtype: Link Rect: 299, 366, 306, 378 ActionDest: 112 Annotation: Subtype: Link Rect: 551, 124, 558, 136 ActionDest: 109 Annotation: Subtype: Link Rect: 197, 111, 204, 123 ActionDest: 112 Annotation: Subtype: Link Rect: 502, 111, 509, 123 ActionDest: 109 Annotation: Subtype: Link Rect: 543, 111, 550, 123 ActionDest: 112 Annotation: Subtype: Link Rect: 195, 74, 202, 86 ActionDest: 109 Annotation: Subtype: Link Rect: 236, 74, 243, 86 ActionDest: 112 Page: Sequence: 10 Annotations: Annotation: Subtype: Link Rect: 232, 691, 239, 703 ActionDest: 130 Annotation: Subtype: Link Rect: 209, 666, 216, 678 ActionDest: 130 Annotation: Subtype: Link Rect: 317, 616, 324, 628 ActionDest: 130 Page: Sequence: 11 Annotations: Annotation: Subtype: Link Rect: 218, 732, 225, 744 ActionDest: 130 Annotation: Subtype: Link Rect: 269, 694, 276, 706 ActionDest: 130 Annotation: Subtype: Link Rect: 497, 682, 504, 694 ActionDest: 130 Annotation: Subtype: Link Rect: 256, 632, 263, 644 ActionDest: 130 Annotation: Subtype: Link Rect: 199, 607, 206, 619 ActionDest: 130 Annotation: Subtype: Link Rect: 517, 594, 524, 606 ActionDest: 130 Annotation: Subtype: Link Rect: 385, 581, 392, 594 ActionDest: 130 Annotation: Subtype: Link Rect: 478, 569, 485, 581 ActionDest: 130 Annotation: Subtype: Link Rect: 331, 456, 338, 468 ActionDest: 109 Annotation: Subtype: Link Rect: 371, 456, 377, 468 ActionDest: 112 Annotation: Subtype: Link Rect: 197, 292, 204, 304 ActionDest: 145 Annotation: Subtype: Link Rect: 544, 267, 551, 279 ActionDest: 145 Annotation: Subtype: Link Rect: 467, 204, 474, 216 ActionDest: 145 Annotation: Subtype: Link Rect: 385, 129, 392, 141 ActionDest: 145 Annotation: Subtype: Link Rect: 221, 66, 228, 78 ActionDest: 145 Page: Sequence: 12 Annotations: Annotation: Subtype: Link Rect: 543, 254, 555, 263 ActionDest: 174 Annotation: Subtype: Link Rect: 380, 204, 387, 213 ActionDest: 168 Annotation: Subtype: Link Rect: 272, 166, 279, 175 ActionDest: 168 Annotation: Subtype: Link Rect: 280, 166, 287, 175 ActionDest: 168 Annotation: Subtype: Link Rect: 287, 166, 299, 175 ActionDest: 168 Annotation: Subtype: Link Rect: 300, 166, 312, 175 ActionDest: 171 Annotation: Subtype: Link Rect: 283, 154, 295, 163 ActionDest: 168 Annotation: Subtype: Link Rect: 195, 141, 207, 150 ActionDest: 168 Annotation: Subtype: Link Rect: 441, 91, 453, 100 ActionDest: 168 Page: Sequence: 13 Annotations: Annotation: Subtype: Link Rect: 190, 722, 202, 731 ActionDest: 171 Annotation: Subtype: Link Rect: 203, 722, 215, 731 ActionDest: 171 Annotation: Subtype: Link Rect: 215, 722, 227, 731 ActionDest: 171 Annotation: Subtype: Link Rect: 228, 710, 240, 719 ActionDest: 171 Annotation: Subtype: Link Rect: 240, 710, 252, 719 ActionDest: 174 Annotation: Subtype: Link Rect: 499, 607, 506, 619 ActionDest: 109 Annotation: Subtype: Link Rect: 415, 544, 422, 556 ActionDest: 112 Annotation: Subtype: Link Rect: 373, 521, 385, 530 ActionDest: 168 Annotation: Subtype: Link Rect: 253, 481, 260, 493 ActionDest: 109 Annotation: Subtype: Link Rect: 328, 393, 335, 405 ActionDest: 109 Annotation: Subtype: Link Rect: 204, 358, 216, 367 ActionDest: 174 Annotation: Subtype: Link Rect: 545, 308, 556, 317 ActionDest: 171 Annotation: Subtype: Link Rect: 462, 268, 469, 280 ActionDest: 109 Annotation: Subtype: Link Rect: 506, 268, 513, 280 ActionDest: 112 Annotation: Subtype: Link Rect: 374, 233, 386, 242 ActionDest: 174 Annotation: Subtype: Link Rect: 386, 233, 398, 242 ActionDest: 174 Annotation: Subtype: Link Rect: 258, 208, 270, 217 ActionDest: 174 Annotation: Subtype: Link Rect: 271, 208, 283, 217 ActionDest: 174 Annotation: Subtype: Link Rect: 544, 195, 556, 204 ActionDest: 174 Annotation: Subtype: Link Rect: 221, 157, 233, 166 ActionDest: 174 Page: Sequence: 14 Annotations: Annotation: Subtype: Link Rect: 409, 720, 416, 732 ActionDest: 145 Annotation: Subtype: Link Rect: 482, 672, 494, 681 ActionDest: 168 Annotation: Subtype: Link Rect: 316, 647, 323, 656 ActionDest: 168 Annotation: Subtype: Link Rect: 317, 634, 329, 643 ActionDest: 168 Annotation: Subtype: Link Rect: 330, 634, 342, 643 ActionDest: 174 Annotation: Subtype: Link Rect: 342, 634, 354, 643 ActionDest: 174 Annotation: Subtype: Link Rect: 405, 634, 417, 643 ActionDest: 168 Annotation: Subtype: Link Rect: 417, 634, 429, 643 ActionDest: 171 Annotation: Subtype: Link Rect: 430, 634, 442, 643 ActionDest: 174 Annotation: Subtype: Link Rect: 222, 622, 234, 631 ActionDest: 168 Annotation: Subtype: Link Rect: 234, 622, 246, 631 ActionDest: 174 Annotation: Subtype: Link Rect: 284, 609, 291, 618 ActionDest: 168 Annotation: Subtype: Link Rect: 291, 609, 303, 618 ActionDest: 168 Annotation: Subtype: Link Rect: 458, 572, 470, 581 ActionDest: 174 Annotation: Subtype: Link Rect: 251, 481, 258, 493 ActionDest: 145 Annotation: Subtype: Link Rect: 310, 456, 317, 468 ActionDest: 145 Annotation: Subtype: Link Rect: 473, 421, 480, 430 ActionDest: 168 Annotation: Subtype: Link Rect: 461, 408, 473, 417 ActionDest: 171 Annotation: Subtype: Link Rect: 474, 408, 486, 417 ActionDest: 171 Annotation: Subtype: Link Rect: 486, 409, 498, 417 ActionDest: 174 Annotation: Subtype: Link Rect: 404, 396, 415, 405 ActionDest: 168 Annotation: Subtype: Link Rect: 419, 396, 431, 405 ActionDest: 168 Annotation: Subtype: Link Rect: 431, 396, 443, 405 ActionDest: 174 Annotation: Subtype: Link Rect: 444, 396, 456, 405 ActionDest: 174 Annotation: Subtype: Link Rect: 360, 371, 371, 380 ActionDest: 171 Annotation: Subtype: Link Rect: 480, 371, 492, 380 ActionDest: 171 Annotation: Subtype: Link Rect: 474, 358, 486, 367 ActionDest: 168 Annotation: Subtype: Link Rect: 486, 358, 498, 367 ActionDest: 171 Annotation: Subtype: Link Rect: 499, 358, 511, 367 ActionDest: 174 Annotation: Subtype: Link Rect: 289, 245, 301, 254 ActionDest: 174 Annotation: Subtype: Link Rect: 458, 195, 470, 204 ActionDest: 171 Annotation: Subtype: Link Rect: 475, 130, 482, 142 ActionDest: 130 Page: Sequence: 15 Annotations: Annotation: Subtype: Link Rect: 299, 660, 311, 669 ActionDest: 168 Annotation: Subtype: Link Rect: 287, 619, 294, 631 ActionDest: 130 Annotation: Subtype: Link Rect: 244, 569, 251, 581 ActionDest: 130 Annotation: Subtype: Link Rect: 500, 569, 507, 581 ActionDest: 130 Annotation: Subtype: Link Rect: 313, 421, 325, 430 ActionDest: 174 Annotation: Subtype: Link Rect: 246, 346, 258, 355 ActionDest: 168 Annotation: Subtype: Link Rect: 472, 120, 484, 129 ActionDest: 171 Annotation: Subtype: Link Rect: 485, 120, 497, 129 ActionDest: 171 Annotation: Subtype: Link Rect: 202, 82, 214, 91 ActionDest: 171 Annotation: Subtype: Link Rect: 296, 69, 308, 79 ActionDest: 171 Page: Sequence: 16 Annotations: Annotation: Subtype: Link Rect: 232, 697, 244, 706 ActionDest: 171 Page: Sequence: 17 Annotations: Annotation: Subtype: Link Rect: 135, 414, 172, 424 Annotation: Subtype: Link Rect: 140, 391, 178, 401 Annotation: Subtype: Link Rect: 184, 391, 220, 401 Annotation: Subtype: Link Rect: 168, 367, 205, 378 Annotation: Subtype: Link Rect: 211, 367, 247, 378 Annotation: Subtype: Link Rect: 468, 344, 505, 355 Annotation: Subtype: Link Rect: 59, 321, 97, 332 Annotation: Subtype: Link Rect: 59, 298, 97, 309 Annotation: Subtype: Link Rect: 95, 264, 133, 274 Annotation: Subtype: Link Rect: 198, 240, 236, 251 Annotation: Subtype: Link Rect: 371, 217, 408, 228 Annotation: Subtype: Link Rect: 360, 194, 398, 205 Annotation: Subtype: Link Rect: 256, 171, 293, 182 Annotation: Subtype: Link Rect: 215, 148, 253, 159 Annotation: Subtype: Link Rect: 208, 125, 246, 136 Annotation: Subtype: Link Rect: 452, 102, 489, 113 Annotation: Subtype: Link Rect: 208, 80, 245, 90 Annotation: Subtype: Link Rect: 131, 57, 169, 67 Page: Sequence: 18 Annotations: Annotation: Subtype: Link Rect: 122, 722, 160, 732 Annotation: Subtype: Link Rect: 260, 686, 298, 697 Annotation: Subtype: Link Rect: 305, 663, 342, 674 Annotation: Subtype: Link Rect: 192, 640, 230, 651 Annotation: Subtype: Link Rect: 134, 607, 171, 617 Annotation: Subtype: Link Rect: 478, 583, 516, 594 Annotation: Subtype: Link Rect: 478, 560, 516, 571 Annotation: Subtype: Link Rect: 159, 526, 196, 536 Annotation: Subtype: Link Rect: 374, 502, 412, 513 Annotation: Subtype: Link Rect: 353, 479, 390, 490 Annotation: Subtype: Link Rect: 383, 456, 420, 467 Annotation: Subtype: Link Rect: 109, 423, 146, 433 Annotation: Subtype: Link Rect: 251, 399, 289, 410 Annotation: Subtype: Link Rect: 386, 376, 423, 387 Annotation: Subtype: Link Rect: 429, 376, 465, 387 Annotation: Subtype: Link Rect: 59, 354, 97, 364 Annotation: Subtype: Link Rect: 103, 354, 139, 364 Annotation: Subtype: Link Rect: 154, 319, 191, 329 Annotation: Subtype: Link Rect: 420, 295, 457, 306 Annotation: Subtype: Link Rect: 59, 262, 97, 272 Annotation: Subtype: Link Rect: 409, 238, 447, 249 Annotation: Subtype: Link Rect: 302, 215, 339, 226 Annotation: Subtype: Link Rect: 462, 192, 499, 203 Annotation: Subtype: Link Rect: 239, 169, 276, 180 Annotation: Subtype: Link Rect: 456, 111, 493, 122 Annotation: Subtype: Link Rect: 519, 100, 556, 111 Annotation: Subtype: Link Rect: 235, 77, 272, 88 Page: Sequence: 19 Annotations: Annotation: Subtype: Link Rect: 259, 721, 297, 732 Annotation: Subtype: Link Rect: 198, 663, 235, 674 Annotation: Subtype: Link Rect: 254, 640, 292, 651 Annotation: Subtype: Link Rect: 284, 594, 322, 605 Annotation: Subtype: Link Rect: 177, 560, 214, 571 Annotation: Subtype: Link Rect: 218, 537, 256, 548 Annotation: Subtype: Link Rect: 240, 514, 278, 525 Annotation: Subtype: Link Rect: 277, 468, 315, 479 Annotation: Subtype: Link Rect: 175, 445, 213, 456 Annotation: Subtype: Link Rect: 439, 422, 476, 433 Annotation: Subtype: Link Rect: 227, 399, 264, 410 Annotation: Subtype: Link Rect: 188, 376, 226, 387 Annotation: Subtype: Link Rect: 153, 342, 190, 352 Annotation: Subtype: Link Rect: 59, 308, 97, 318 Checksum: 0da9a7e5 Type: CRC32 Checksum: 1ba4108317f9930ed8a5b8b87ea9d3a9 Type: MD5 Checksum: 93e08c9d5825eae662bc4636b890771097f4d84c Type: SHA-1