ffcbc51798dda09948505fce596850c5 pmc_34834935.pdf a1e9945bc9399667d412d7c9ea309dcc9e05337b pmc_34834935.pdf 3796788200fe5c0d7e5f8c887989bd908d8d433e537eedc7fa637895587f4035 pmc_34834935.pdf Title: PICO Questions and DELPHI Methodology for the Management of Venous Thromboembolism Associated with COVID-19 Subject: Patients with coronavirus disease 2019 (COVID-19) have a higher risk of venous thromboembolic disease (VTE) than patients with other infectious or inflammatory diseases, both as macrothrombosis (pulmonar embolism and deep vein thrombosis) or microthrombosis. However, the use of anticoagulation in this scenario remains controversial. This is a project that used DELPHI methodology to answer PICO questions related to anticoagulation in patients with COVID-19. The objective was to reach a consensus among multidisciplinary VTE experts providing answers to those PICO questions. Seven PICO questions regarding patients with COVID-19 responded with a broad consensus: 1. It is recommended to avoid pharmacological thromboprophylaxis in most COVID-19 patients not requiring hospital admission; 2. In most hospitalized patients for COVID-19 who are receiving oral anticoagulants before admission, it is recommended to replace them by low molecular weight heparin (LMWH) at therapeutic doses; 3. Thromboprophylaxis with LMWH at standard doses is suggested for COVID-19 patients admitted to a conventional hospital ward; 4. Standard-doses thromboprophylaxis with LMWH is recommended for COVID-19 patients requiring admission to Intensive Care Unit; 5. It is recommended not to determine D-Dimer levels routinely in COVID-19 hospitalized patients to select those in whom VTE should be suspected, or as a part of the diagnostic algorithm to rule out or confirm a VTE event; 6. It is recommended to discontinue pharmacological thromboprophylaxis at discharge in most patients hospitalized for COVID-19; 7. It is recommended to withdraw anticoagulant treatment after 3 months in most patients with a VTE event associated with COVID-19. The combination of PICO questions and DELPHI methodology provides a consensus on different recommendations for anticoagulation management in patients with COVID-19. Keywords: venous thromboembolic disease; COVID-19; coronavirus; pulmonary embolism; deep vein thrombosis; anticoagulation Author: Antoni Riera-Mestre, Luis Jara-Palomares, Ramón Lecumberri, Javier Trujillo-Santos, Enric Grau, Angeles Blanco-Molina, Ana Piera Carbonell, Sonia Jiménez, Manuel Frías Vargas, Mari Paz Fuset, Sergi Bellmunt-Montoya, Manuel Monreal, David Jiménez and on behalf of the COVILAX Project Creator: LaTeX with hyperref Producer: pdfTeX-1.40.21 CreationDate: Fri Oct 22 09:38:18 2021 CEST ModDate: Fri Oct 22 09:56:41 2021 CEST Custom Metadata: no Metadata Stream: no Tagged: no UserProperties: no Suspects: no Form: none JavaScript: no Pages: 12 Encrypted: no Page size: 595.276 x 841.89 pts (A4) Page rot: 0 File size: 299778 bytes Optimized: no PDF version: 1.7 name type encoding emb sub uni object ID ------------------------------------ ----------------- ---------------- --- --- --- --------- IYDCBB+VnURWPalladioL Type 1 Custom yes yes no 10 0 YLEKOH+URWPalladioL-Ital Type 1 Custom yes yes no 15 0 OCTPIL+URWPalladioL-Bold Type 1 Custom yes yes no 20 0 HNIEDX+URWPalladioL-Roma Type 1 Custom yes yes no 24 0 XWOCXD+VnURWPalladioL-Bold Type 1 Custom yes yes no 28 0 HOWKDX+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 OVNEXW+EURM10 Type 1 Builtin yes yes no 84 0 HCPSKZ+CMSY10 Type 1 Builtin yes yes no 91 0 Jhove (Rel. 1.28.0, 2023-05-18) Date: 2024-10-02 03:38:03 CEST RepresentationInformation: pmc_34834935.pdf ReportingModule: PDF-hul, Rel. 1.12.4 (2023-03-16) LastModified: 2023-03-31 12:06:22 CEST Size: 299778 Format: PDF Version: 1.7 Status: Well-Formed and valid SignatureMatches: PDF-hul MIMEtype: application/pdf PDFMetadata: Objects: 317 FreeObjects: 1 IncrementalUpdates: 0 DocumentCatalog: PageLayout: SinglePage PageMode: UseNone Outlines: Item: Title: Introduction Destination: section.1 Item: Title: Materials and Methods Destination: section.2 Item: Title: Results Destination: section.3 Children: Item: Title: Domain 1: Thromboprophylaxis in COVID-19 Patients Not Requiring Hospital Admission Destination: subsection.3.1 Item: Title: Domain 2: Thromboprophylaxis in Hospitalized COVID-19 Patients Destination: subsection.3.2 Children: Item: Title: PICO 2: In Hospitalized Patients for COVID-19 Who Were Receiving Anticoagulation with Oral Anticoagulants Prior to Admission, Should We Substitute Them with LMWH? Destination: subsubsection.3.2.1 Item: Title: PICO 3: What Is the Optimal Dose of LMWH for Most COVID-19 Patients Admitted to a Conventional Hospital Ward? Destination: subsubsection.3.2.2 Item: Title: PICO 4: What Is the Optimal Dose of LMWH for Most COVID-19 Patients Admitted to an Intensive Care Unit (ICU)? Destination: subsubsection.3.2.3 Item: Title: Domain 3: Diagnosis and Treatment Guide of VTE in COVID-19 Hospitalized Patients Destination: subsection.3.3 Item: Title: Domain 4: Follow-Up after Discharge of Patients Admitted for COVID-19 with and without a Vte Event Destination: subsection.3.4 Children: Item: Title: PICO 6. Which Patients without COVID-19-Associated VTE Should Receive Extended Standard-Doses Thromboprophylaxis after Hospital Discharge? Destination: subsubsection.3.4.1 Item: Title: PICO 7. Which Is the Optimal Duration of Anticoagulant Treatment for Patients with COVID-19-Associated VTE? Destination: subsubsection.3.4.2 Item: Title: Discussion Destination: section.4 Item: Title: References Destination: section.4 Info: Title: PICO Questions and DELPHI Methodology for the Management of Venous Thromboembolism Associated with COVID-19 Author: Antoni Riera-Mestre, Luis Jara-Palomares, Ramón Lecumberri, Javier Trujillo-Santos, Enric Grau, Angeles Blanco-Molina, Ana Piera Carbonell, Sonia Jiménez, Manuel Frías Vargas, Mari Paz Fuset, Sergi Bellmunt-Montoya, Manuel Monreal, David Jiménez and on behalf of the COVILAX Project Subject: Patients with coronavirus disease 2019 (COVID-19) have a higher risk of venous thromboembolic disease (VTE) than patients with other infectious or inflammatory diseases, both as macrothrombosis (pulmonar embolism and deep vein thrombosis) or microthrombosis. However, the use of anticoagulation in this scenario remains controversial. This is a project that used DELPHI methodology to answer PICO questions related to anticoagulation in patients with COVID-19. The objective was to reach a consensus among multidisciplinary VTE experts providing answers to those PICO questions. Seven PICO questions regarding patients with COVID-19 responded with a broad consensus: 1. It is recommended to avoid pharmacological thromboprophylaxis in most COVID-19 patients not requiring hospital admission; 2. In most hospitalized patients for COVID-19 who are receiving oral anticoagulants before admission, it is recommended to replace them by low molecular weight heparin (LMWH) at therapeutic doses; 3. Thromboprophylaxis with LMWH at standard doses is suggested for COVID-19 patients admitted to a conventional hospital ward; 4. Standard-doses thromboprophylaxis with LMWH is recommended for COVID-19 patients requiring admission to Intensive Care Unit; 5. It is recommended not to determine D-Dimer levels routinely in COVID-19 hospitalized patients to select those in whom VTE should be suspected, or as a part of the diagnostic algorithm to rule out or confirm a VTE event; 6. It is recommended to discontinue pharmacological thromboprophylaxis at discharge in most patients hospitalized for COVID-19; 7. It is recommended to withdraw anticoagulant treatment after 3 months in most patients with a VTE event associated with COVID-19. The combination of PICO questions and DELPHI methodology provides a consensus on different recommendations for anticoagulation management in patients with COVID-19. Keywords: venous thromboembolic disease; COVID-19; coronavirus; pulmonary embolism; deep vein thrombosis; anticoagulation Creator: LaTeX with hyperref Producer: pdfTeX-1.40.21 CreationDate: Fri Oct 22 09:38:18 CEST 2021 ModDate: Fri Oct 22 09:56:41 CEST 2021 ID: 0xd439575f0fb23dde072c792c89d28745, 0xd439575f0fb23dde072c792c89d28745 Filters: FilterPipeline: FlateDecode Fonts: Type1: Font: BaseFont: OCTPIL+URWPalladioL-Bold FontSubset: true FirstChar: 2 LastChar: 134 FontDescriptor: FontName: OCTPIL+URWPalladioL-Bold Flags: Symbolic FontBBox: -152, -301, 1000, 935 FontFile: true EncodingDictionary: Differences: true Font: BaseFont: OVNEXW+EURM10 FontSubset: true FirstChar: 22 LastChar: 22 FontDescriptor: FontName: OVNEXW+EURM10 Flags: Symbolic FontBBox: -32, -243, 1060, 720 FontFile: true Font: BaseFont: HNIEDX+URWPalladioL-Roma FontSubset: true FirstChar: 2 LastChar: 252 FontDescriptor: FontName: HNIEDX+URWPalladioL-Roma Flags: Symbolic FontBBox: -166, -283, 1021, 943 FontFile: true EncodingDictionary: Differences: true Font: BaseFont: IYDCBB+VnURWPalladioL FontSubset: true FirstChar: 129 LastChar: 243 FontDescriptor: FontName: IYDCBB+VnURWPalladioL Flags: Symbolic FontBBox: -166, -283, 1021, 943 FontFile: true EncodingDictionary: Differences: true Font: BaseFont: HCPSKZ+CMSY10 FontSubset: true FirstChar: 2 LastChar: 21 FontDescriptor: FontName: HCPSKZ+CMSY10 Flags: Symbolic FontBBox: -29, -960, 1116, 775 FontFile: true Font: BaseFont: XWOCXD+VnURWPalladioL-Bold FontSubset: true FirstChar: 178 LastChar: 226 FontDescriptor: FontName: XWOCXD+VnURWPalladioL-Bold Flags: Symbolic FontBBox: -152, -301, 1000, 935 FontFile: true EncodingDictionary: Differences: true Font: BaseFont: YLEKOH+URWPalladioL-Ital FontSubset: true FirstChar: 45 LastChar: 122 FontDescriptor: FontName: YLEKOH+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, 147, 795 Annotation: Subtype: Link Rect: 515, 759, 560, 795 Annotation: Subtype: Link Rect: 148, 643, 159, 656 Annotation: Subtype: Link Rect: 266, 643, 277, 656 Annotation: Subtype: Link Rect: 381, 643, 392, 656 Annotation: Subtype: Link Rect: 506, 643, 517, 656 Annotation: Subtype: Link Rect: 321, 630, 332, 644 Annotation: Subtype: Link Rect: 262, 618, 273, 631 Annotation: Subtype: Link Rect: 370, 618, 381, 631 Annotation: Subtype: Link Rect: 480, 618, 491, 631 Annotation: Subtype: Link Rect: 142, 371, 154, 379 Annotation: Subtype: Link Rect: 35, 358, 148, 367 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: 112, 17, 241, 28 Annotation: Subtype: Link Rect: 409, 17, 558, 28 Annotation: Subtype: Link Rect: 35, 494, 87, 513 Page: Sequence: 2 Annotations: Annotation: Subtype: Link Rect: 430, 517, 437, 526 ActionDest: 107 Annotation: Subtype: Link Rect: 438, 517, 445, 526 ActionDest: 107 Annotation: Subtype: Link Rect: 539, 492, 546, 501 ActionDest: 107 Annotation: Subtype: Link Rect: 549, 492, 556, 501 ActionDest: 110 Annotation: Subtype: Link Rect: 295, 454, 302, 463 ActionDest: 107 Annotation: Subtype: Link Rect: 303, 454, 310, 463 ActionDest: 107 Annotation: Subtype: Link Rect: 311, 454, 318, 463 ActionDest: 110 Annotation: Subtype: Link Rect: 276, 404, 283, 413 ActionDest: 107 Annotation: Subtype: Link Rect: 283, 404, 290, 413 ActionDest: 110 Annotation: Subtype: Link Rect: 314, 366, 321, 375 ActionDest: 110 Annotation: Subtype: Link Rect: 324, 366, 336, 375 ActionDest: 110 Annotation: Subtype: Link Rect: 341, 152, 353, 161 ActionDest: 110 Annotation: Subtype: Link Rect: 353, 152, 365, 161 ActionDest: 110 Annotation: Subtype: Link Rect: 217, 127, 229, 136 ActionDest: 110 Annotation: Subtype: Link Rect: 229, 115, 241, 124 ActionDest: 110 Annotation: Subtype: Link Rect: 244, 115, 256, 124 ActionDest: 110 Page: Sequence: 3 Annotations: Annotation: Subtype: Link Rect: 210, 682, 337, 694 Annotation: Subtype: Link Rect: 368, 660, 380, 669 ActionDest: 110 Annotation: Subtype: Link Rect: 453, 581, 460, 593 ActionDest: 81 Annotation: Subtype: Link Rect: 250, 521, 262, 530 ActionDest: 110 Annotation: Subtype: Link Rect: 264, 521, 276, 530 ActionDest: 110 Annotation: Subtype: Link Rect: 284, 496, 296, 505 ActionDest: 110 Annotation: Subtype: Link Rect: 236, 481, 243, 493 ActionDest: 81 Page: Sequence: 4 Annotations: Annotation: Subtype: Link Rect: 505, 155, 512, 167 ActionDest: 88 Page: Sequence: 5 Annotations: Annotation: Subtype: Link Rect: 343, 539, 355, 548 ActionDest: 110 Annotation: Subtype: Link Rect: 228, 461, 235, 473 ActionDest: 88 Annotation: Subtype: Link Rect: 409, 452, 416, 461 ActionDest: 107 Annotation: Subtype: Link Rect: 417, 452, 429, 461 ActionDest: 110 Annotation: Subtype: Link Rect: 487, 315, 499, 323 ActionDest: 110 Annotation: Subtype: Link Rect: 191, 289, 203, 298 ActionDest: 110 Annotation: Subtype: Link Rect: 203, 289, 215, 298 ActionDest: 110 Annotation: Subtype: Link Rect: 461, 277, 468, 286 ActionDest: 110 Annotation: Subtype: Link Rect: 468, 277, 475, 286 ActionDest: 110 Annotation: Subtype: Link Rect: 370, 176, 382, 185 ActionDest: 110 Page: Sequence: 6 Annotations: Annotation: Subtype: Link Rect: 213, 735, 225, 744 ActionDest: 110 Annotation: Subtype: Link Rect: 225, 735, 237, 744 ActionDest: 110 Annotation: Subtype: Link Rect: 313, 672, 325, 681 ActionDest: 110 Annotation: Subtype: Link Rect: 280, 609, 292, 618 ActionDest: 110 Annotation: Subtype: Link Rect: 334, 396, 345, 405 ActionDest: 114 Annotation: Subtype: Link Rect: 243, 283, 255, 292 ActionDest: 110 Annotation: Subtype: Link Rect: 255, 283, 267, 292 ActionDest: 114 Annotation: Subtype: Link Rect: 461, 170, 473, 179 ActionDest: 114 Page: Sequence: 7 Annotations: Annotation: Subtype: Link Rect: 483, 672, 495, 681 ActionDest: 110 Annotation: Subtype: Link Rect: 361, 597, 373, 606 ActionDest: 114 Annotation: Subtype: Link Rect: 276, 521, 288, 530 ActionDest: 114 Annotation: Subtype: Link Rect: 466, 471, 478, 480 ActionDest: 114 Annotation: Subtype: Link Rect: 298, 408, 310, 417 ActionDest: 114 Annotation: Subtype: Link Rect: 396, 259, 403, 268 ActionDest: 107 Annotation: Subtype: Link Rect: 404, 259, 416, 268 ActionDest: 114 Annotation: Subtype: Link Rect: 234, 234, 241, 243 ActionDest: 107 Annotation: Subtype: Link Rect: 242, 234, 254, 243 ActionDest: 114 Annotation: Subtype: Link Rect: 254, 234, 266, 243 ActionDest: 114 Annotation: Subtype: Link Rect: 269, 234, 281, 243 ActionDest: 114 Annotation: Subtype: Link Rect: 487, 196, 494, 205 ActionDest: 107 Annotation: Subtype: Link Rect: 494, 196, 501, 205 ActionDest: 110 Annotation: Subtype: Link Rect: 502, 196, 514, 205 ActionDest: 114 Annotation: Subtype: Link Rect: 514, 196, 526, 205 ActionDest: 114 Annotation: Subtype: Link Rect: 298, 146, 310, 155 ActionDest: 110 Annotation: Subtype: Link Rect: 311, 146, 323, 155 ActionDest: 114 Annotation: Subtype: Link Rect: 354, 121, 361, 130 ActionDest: 107 Annotation: Subtype: Link Rect: 362, 121, 374, 130 ActionDest: 114 Annotation: Subtype: Link Rect: 376, 121, 388, 130 ActionDest: 114 Page: Sequence: 8 Annotations: Annotation: Subtype: Link Rect: 517, 645, 524, 657 ActionDest: 88 Annotation: Subtype: Link Rect: 264, 585, 271, 594 ActionDest: 110 Annotation: Subtype: Link Rect: 272, 584, 279, 594 ActionDest: 110 Annotation: Subtype: Link Rect: 376, 534, 388, 543 ActionDest: 114 Annotation: Subtype: Link Rect: 291, 509, 303, 518 ActionDest: 114 Annotation: Subtype: Link Rect: 550, 482, 557, 493 ActionDest: 88 Annotation: Subtype: Link Rect: 182, 459, 189, 468 ActionDest: 107 Annotation: Subtype: Link Rect: 189, 459, 201, 468 ActionDest: 110 Annotation: Subtype: Link Rect: 202, 459, 214, 468 ActionDest: 114 Annotation: Subtype: Link Rect: 541, 310, 548, 319 ActionDest: 110 Annotation: Subtype: Link Rect: 549, 310, 556, 319 ActionDest: 110 Annotation: Subtype: Link Rect: 230, 285, 237, 294 ActionDest: 110 Annotation: Subtype: Link Rect: 238, 285, 245, 294 ActionDest: 110 Annotation: Subtype: Link Rect: 245, 260, 252, 269 ActionDest: 110 Annotation: Subtype: Link Rect: 253, 260, 260, 269 ActionDest: 110 Annotation: Subtype: Link Rect: 260, 260, 272, 269 ActionDest: 114 Annotation: Subtype: Link Rect: 450, 247, 457, 256 ActionDest: 110 Annotation: Subtype: Link Rect: 458, 247, 465, 256 ActionDest: 110 Annotation: Subtype: Link Rect: 444, 210, 451, 219 ActionDest: 107 Annotation: Subtype: Link Rect: 452, 210, 458, 219 ActionDest: 107 Annotation: Subtype: Link Rect: 459, 210, 471, 219 ActionDest: 114 Page: Sequence: 9 Annotations: Annotation: Subtype: Link Rect: 539, 697, 546, 706 ActionDest: 107 Annotation: Subtype: Link Rect: 549, 697, 556, 706 ActionDest: 110 Annotation: Subtype: Link Rect: 330, 634, 342, 643 ActionDest: 114 Annotation: Subtype: Link Rect: 363, 584, 375, 593 ActionDest: 110 Annotation: Subtype: Link Rect: 375, 584, 387, 593 ActionDest: 114 Annotation: Subtype: Link Rect: 390, 584, 402, 593 ActionDest: 114 Annotation: Subtype: Link Rect: 206, 547, 213, 556 ActionDest: 107 Annotation: Subtype: Link Rect: 214, 546, 221, 556 ActionDest: 107 Annotation: Subtype: Link Rect: 531, 484, 543, 493 ActionDest: 110 Annotation: Subtype: Link Rect: 544, 484, 556, 493 ActionDest: 114 Annotation: Subtype: Link Rect: 316, 446, 328, 455 ActionDest: 110 Annotation: Subtype: Link Rect: 532, 421, 544, 430 ActionDest: 114 Annotation: Subtype: Link Rect: 300, 383, 312, 392 ActionDest: 110 Annotation: Subtype: Link Rect: 277, 358, 289, 367 ActionDest: 110 Annotation: Subtype: Link Rect: 292, 358, 304, 367 ActionDest: 114 Annotation: Subtype: Link Rect: 300, 320, 312, 330 ActionDest: 110 Annotation: Subtype: Link Rect: 315, 321, 327, 330 ActionDest: 114 Annotation: Subtype: Link Rect: 531, 283, 543, 292 ActionDest: 114 Annotation: Subtype: Link Rect: 544, 283, 556, 292 ActionDest: 114 Annotation: Subtype: Link Rect: 520, 233, 532, 242 ActionDest: 114 Annotation: Subtype: Link Rect: 452, 182, 464, 192 ActionDest: 114 Page: Sequence: 10 Annotations: Annotation: Subtype: Link Rect: 517, 722, 524, 731 ActionDest: 110 Annotation: Subtype: Link Rect: 524, 722, 531, 731 ActionDest: 110 Annotation: Subtype: Link Rect: 544, 710, 556, 719 ActionDest: 110 Annotation: Subtype: Link Rect: 379, 672, 391, 681 ActionDest: 110 Annotation: Subtype: Link Rect: 220, 158, 258, 169 Annotation: Subtype: Link Rect: 331, 135, 369, 146 Annotation: Subtype: Link Rect: 59, 101, 97, 111 Annotation: Subtype: Link Rect: 103, 101, 139, 111 Page: Sequence: 11 Annotations: Annotation: Subtype: Link Rect: 180, 699, 218, 709 Annotation: Subtype: Link Rect: 210, 664, 248, 674 Annotation: Subtype: Link Rect: 305, 641, 342, 651 Annotation: Subtype: Link Rect: 406, 594, 444, 605 Annotation: Subtype: Link Rect: 519, 571, 557, 582 Annotation: Subtype: Link Rect: 59, 561, 95, 571 Annotation: Subtype: Link Rect: 320, 537, 357, 548 Annotation: Subtype: Link Rect: 227, 502, 265, 513 Annotation: Subtype: Link Rect: 95, 469, 133, 479 Annotation: Subtype: Link Rect: 139, 469, 175, 479 Annotation: Subtype: Link Rect: 287, 445, 324, 456 Annotation: Subtype: Link Rect: 331, 445, 367, 456 Annotation: Subtype: Link Rect: 104, 423, 141, 433 Annotation: Subtype: Link Rect: 193, 387, 231, 398 Annotation: Subtype: Link Rect: 237, 387, 273, 398 Annotation: Subtype: Link Rect: 489, 364, 526, 375 Annotation: Subtype: Link Rect: 59, 331, 97, 341 Annotation: Subtype: Link Rect: 363, 295, 400, 306 Annotation: Subtype: Link Rect: 361, 284, 560, 295 Annotation: Subtype: Link Rect: 489, 249, 527, 260 Annotation: Subtype: Link Rect: 406, 238, 443, 249 Annotation: Subtype: Link Rect: 297, 215, 335, 226 Annotation: Subtype: Link Rect: 122, 169, 160, 180 Annotation: Subtype: Link Rect: 429, 123, 466, 134 Annotation: Subtype: Link Rect: 202, 89, 239, 99 Annotation: Subtype: Link Rect: 266, 65, 303, 76 Page: Sequence: 12 Annotations: Annotation: Subtype: Link Rect: 514, 721, 551, 732 Annotation: Subtype: Link Rect: 536, 698, 560, 709 Annotation: Subtype: Link Rect: 56, 686, 293, 697 Annotation: Subtype: Link Rect: 245, 663, 283, 674 Annotation: Subtype: Link Rect: 289, 663, 325, 674 Annotation: Subtype: Link Rect: 332, 629, 370, 640 Annotation: Subtype: Link Rect: 387, 594, 424, 605 Annotation: Subtype: Link Rect: 430, 594, 466, 605 Annotation: Subtype: Link Rect: 131, 572, 169, 582 Annotation: Subtype: Link Rect: 175, 572, 211, 582 Annotation: Subtype: Link Rect: 121, 526, 159, 536 Annotation: Subtype: Link Rect: 355, 502, 392, 513 Annotation: Subtype: Link Rect: 398, 502, 434, 513 Annotation: Subtype: Link Rect: 136, 469, 173, 479 Annotation: Subtype: Link Rect: 223, 433, 261, 444 Annotation: Subtype: Link Rect: 267, 433, 303, 444 Annotation: Subtype: Link Rect: 256, 399, 293, 410 Annotation: Subtype: Link Rect: 299, 399, 335, 410 Annotation: Subtype: Link Rect: 381, 364, 418, 375 Annotation: Subtype: Link Rect: 131, 331, 169, 341 Annotation: Subtype: Link Rect: 175, 331, 211, 341 Annotation: Subtype: Link Rect: 344, 307, 382, 318 Annotation: Subtype: Link Rect: 104, 285, 141, 295 Annotation: Subtype: Link Rect: 131, 250, 169, 260 Annotation: Subtype: Link Rect: 167, 215, 205, 226 Checksum: 37f3f9d3 Type: CRC32 Checksum: ffcbc51798dda09948505fce596850c5 Type: MD5 Checksum: a1e9945bc9399667d412d7c9ea309dcc9e05337b Type: SHA-1 Checksum: 3796788200fe5c0d7e5f8c887989bd908d8d433e537eedc7fa637895587f4035 Type: SHA-256