1d16d81fc422666577866eeafd2c918d 290569.pdf 76c002e4e8ac1dd1619d826d0fd28286edb442d5 290569.pdf 9387e95fb5096d31b0df86f365e0b65d7f5b0bd2f287ea2860ab5b30ad4b1cdc 290569.pdf Title: New Generation Pulse Modulation in Holmium:YAG Lasers: A Systematic Review of the Literature and Meta-Analysis Subject: (1) Background: New pulse modulation (PM) technologies in Holmium:YAG lasers are available for urinary stone treatment, but little is known about them. We aim to systematically evaluate the published evidence in terms of their lithotripsy performance. (2) Methods: A systematic electronic search was performed (MEDLINE, Scopus, and Cochrane databases). We included all relevant publications, including randomized controlled trials, non-randomized comparative and non-comparative studies, and in-vitro studies investigating Holmium:YAG lithotripsy performance employing any new PM. (3) Results: Initial search yielded 203 studies; 24 studies were included after selection: 15 in-vitro, 9 in-vivo. 10 In-vitro compared Moses with regular PM, 1 compared Quanta’s, 1 Dornier MedTech’s, 2 Moses with super Thulium Fiber Laser, and 1 compared Moses with Quanta PMs. Six out of seven comparative studies found a statistically significant difference in favor of new-generation PM technologies in terms of operative time and five out of six in fragmentation time; two studies evaluated retropulsion, both in favor of new-generation PM. There were no statistically significant differences regarding stone-free rate, lasing and operative time, and complications between Moses and regular PM when data were meta-analyzed. (4) Conclusions: Moses PM seems to have better lithotripsy performance than regular modes in in-vitro studies, but there are still some doubts about its in-vivo results. Little is known about the other PMs. Although some results favor Quanta PMs, further studies are needed. Keywords: holmium; laser; urinary stones; pulse modulation Author: Antoni Sánchez-Puy, Alejandra Bravo-Balado, Pietro Diana, Michael Baboudjian, Alberto Piana, Irene Girón, Andrés K. Kanashiro, Oriol Angerri, Pablo Contreras, Brian H. Eisner, Josep Balañà, Francisco M. Sánchez-Martín, Félix Millán, Joan Palou and Esteban Emiliani Creator: LaTeX with hyperref Producer: pdfTeX-1.40.21 CreationDate: Tue Jun 7 11:15:37 2022 CEST ModDate: Tue Jun 7 11:45:17 2022 CEST Custom Metadata: no Metadata Stream: no 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: 1107058 bytes Optimized: no PDF version: 1.7 name type encoding emb sub uni object ID ------------------------------------ ----------------- ---------------- --- --- --- --------- RREXSY+VnURWPalladioL Type 1 Custom yes yes no 10 0 NMPHMD+URWPalladioL-Bold Type 1 Custom yes yes no 15 0 SKBVSV+URWPalladioL-Roma Type 1 Custom yes yes no 20 0 WMPUZR+URWPalladioL-Ital Type 1 Custom yes yes no 24 0 JUXSQN+VnURWPalladioL-Bold Type 1 Custom yes yes no 28 0 XPUSBJ+TimesNewRomanPS-BoldItalicMT Type 1C WinAnsi yes yes no 46 0 BSDWLC+TimesNewRomanPSMT Type 1C WinAnsi yes yes no 49 0 BIDDXY+CMSY10 Type 1 Builtin yes yes no 71 0 OLDMNK+TimesNewRoman CID TrueType Identity-H yes yes yes 86 0 OLDLLI+PalatinoLinotype,Bold TrueType WinAnsi yes yes no 92 0 OLDLLK+PalatinoLinotype TrueType WinAnsi yes yes no 95 0 OLDLLM+PalatinoLinotype,Italic TrueType WinAnsi yes yes no 98 0 OLDMBM+PalatinoLinotype,BoldItalic TrueType WinAnsi yes yes no 101 0 OLDMLK+Arial CID TrueType Identity-H yes yes yes 104 0 FHBIAZ+EURB7 Type 1 Builtin yes yes no 117 0 OVNEXW+EURM10 Type 1 Builtin yes yes no 133 0 LJRCOY+EURB5 Type 1 Builtin yes yes no 137 0 WBVKDJ+URWPalladioL-BoldItal Type 1 Custom yes yes no 141 0 OLDLLI+PalatinoLinotype,Bold TrueType WinAnsi yes yes no 160 0 OLDLLJ+PalatinoLinotype CID TrueType Identity-H yes yes yes 163 0 OLDLLK+PalatinoLinotype TrueType WinAnsi yes yes no 169 0 OLDLLM+PalatinoLinotype,Italic TrueType WinAnsi yes yes no 172 0 OLDMBM+PalatinoLinotype,BoldItalic TrueType WinAnsi yes yes no 175 0 OLDLLI+PalatinoLinotype,Bold TrueType WinAnsi yes yes no 188 0 OLDLLJ+PalatinoLinotype CID TrueType Identity-H yes yes yes 191 0 OLDLLK+PalatinoLinotype TrueType WinAnsi yes yes no 197 0 OLDLLM+PalatinoLinotype,Italic TrueType WinAnsi yes yes no 200 0 OLDLLI+PalatinoLinotype,Bold TrueType WinAnsi yes yes no 218 0 OLDLLJ+PalatinoLinotype CID TrueType Identity-H yes yes yes 221 0 OLDLLK+PalatinoLinotype TrueType WinAnsi yes yes no 227 0 OLDLLM+PalatinoLinotype,Italic TrueType WinAnsi yes yes no 230 0 OLDLLI+PalatinoLinotype,Bold TrueType WinAnsi yes yes no 245 0 OLDLLJ+PalatinoLinotype CID TrueType Identity-H yes yes yes 248 0 OLDLLK+PalatinoLinotype TrueType WinAnsi yes yes no 254 0 OLDLLM+PalatinoLinotype,Italic TrueType WinAnsi yes yes no 257 0 Jhove (Rel. 1.28.0, 2023-05-18) Date: 2024-04-17 02:47:27 CEST RepresentationInformation: 290569.pdf ReportingModule: PDF-hul, Rel. 1.12.4 (2023-03-16) LastModified: 2024-04-16 12:41:30 CEST Size: 1107058 Format: PDF Version: 1.7 Status: Well-Formed and valid SignatureMatches: PDF-hul MIMEtype: application/pdf PDFMetadata: Objects: 542 FreeObjects: 1 IncrementalUpdates: 0 DocumentCatalog: PageLayout: SinglePage PageMode: UseNone Outlines: Item: Title: Introduction Destination: section.1 Item: Title: Objectives Destination: section.2 Item: Title: Evidence Acquisition Destination: section.3 Children: Item: Title: Protocol Destination: subsection.3.1 Item: Title: Search Strategy Destination: subsection.3.2 Item: Title: Eligibility Criteria Destination: subsection.3.3 Item: Title: Study Selection Destination: subsection.3.4 Item: Title: Data Extraction Destination: subsection.3.5 Item: Title: Assessment of Risk of Bias of Included Studies Destination: subsection.3.6 Item: Title: Meta-Analyses for In-Vivo Studies Destination: subsection.3.7 Item: Title: Results Destination: section.4 Children: Item: Title: Literature Search and Inclusion Studies Destination: subsection.4.1 Item: Title: Description of the Studies Destination: subsection.4.2 Children: Item: Title: In-Vitro Studies Destination: subsubsection.4.2.1 Item: Title: In-Vivo Studies Destination: subsubsection.4.2.2 Item: Title: Risk of Bias of Included Studies Destination: subsection.4.3 Item: Title: Meta-Analyses Destination: subsection.4.4 Item: Title: Discussion Destination: section.5 Item: Title: Conclusions Destination: section.6 Item: Title: References Destination: section.6 Info: Title: New Generation Pulse Modulation in Holmium:YAG Lasers: A Systematic Review of the Literature and Meta-Analysis Author: Antoni Sánchez-Puy, Alejandra Bravo-Balado, Pietro Diana, Michael Baboudjian, Alberto Piana, Irene Girón, Andrés K. Kanashiro, Oriol Angerri, Pablo Contreras, Brian H. Eisner, Josep Balañà, Francisco M. Sánchez-Martín, Félix Millán, Joan Palou and Esteban Emiliani Subject: (1) Background: New pulse modulation (PM) technologies in Holmium:YAG lasers are available for urinary stone treatment, but little is known about them. We aim to systematically evaluate the published evidence in terms of their lithotripsy performance. (2) Methods: A systematic electronic search was performed (MEDLINE, Scopus, and Cochrane databases). We included all relevant publications, including randomized controlled trials, non-randomized comparative and non-comparative studies, and in-vitro studies investigating Holmium:YAG lithotripsy performance employing any new PM. (3) Results: Initial search yielded 203 studies; 24 studies were included after selection: 15 in-vitro, 9 in-vivo. 10 In-vitro compared Moses with regular PM, 1 compared Quanta’s, 1 Dornier MedTech’s, 2 Moses with super Thulium Fiber Laser, and 1 compared Moses with Quanta PMs. Six out of seven comparative studies found a statistically significant difference in favor of new-generation PM technologies in terms of operative time and five out of six in fragmentation time; two studies evaluated retropulsion, both in favor of new-generation PM. There were no statistically significant differences regarding stone-free rate, lasing and operative time, and complications between Moses and regular PM when data were meta-analyzed. (4) Conclusions: Moses PM seems to have better lithotripsy performance than regular modes in in-vitro studies, but there are still some doubts about its in-vivo results. Little is known about the other PMs. Although some results favor Quanta PMs, further studies are needed. Keywords: holmium; laser; urinary stones; pulse modulation Creator: LaTeX with hyperref Producer: pdfTeX-1.40.21 CreationDate: Tue Jun 07 11:15:37 CEST 2022 ModDate: Tue Jun 07 11:45:17 CEST 2022 ID: 0x909dedab23bb3409c83850973eb8ac2e, 0x909dedab23bb3409c83850973eb8ac2e Filters: FilterPipeline: FlateDecode Fonts: Type1: Font: BaseFont: SKBVSV+URWPalladioL-Roma FontSubset: true FirstChar: 2 LastChar: 248 FontDescriptor: FontName: SKBVSV+URWPalladioL-Roma Flags: Symbolic FontBBox: -166, -283, 1021, 943 FontFile: true EncodingDictionary: Differences: true Font: BaseFont: FHBIAZ+EURB7 FontSubset: true FirstChar: 22 LastChar: 22 FontDescriptor: FontName: FHBIAZ+EURB7 Flags: Symbolic FontBBox: -1, -247, 1316, 723 FontFile: 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: BIDDXY+CMSY10 FontSubset: true FirstChar: 0 LastChar: 21 FontDescriptor: FontName: BIDDXY+CMSY10 Flags: Symbolic FontBBox: -29, -960, 1116, 775 FontFile: true Font: BaseFont: WMPUZR+URWPalladioL-Ital FontSubset: true FirstChar: 40 LastChar: 121 FontDescriptor: FontName: WMPUZR+URWPalladioL-Ital Flags: Symbolic FontBBox: -170, -305, 1010, 941 FontFile: true EncodingDictionary: Differences: true Font: BaseFont: LJRCOY+EURB5 FontSubset: true FirstChar: 22 LastChar: 22 FontDescriptor: FontName: LJRCOY+EURB5 Flags: Symbolic FontBBox: 70, -247, 1471, 723 FontFile: true Font: BaseFont: RREXSY+VnURWPalladioL FontSubset: true FirstChar: 161 LastChar: 226 FontDescriptor: FontName: RREXSY+VnURWPalladioL Flags: Symbolic FontBBox: -166, -283, 1021, 943 FontFile: true EncodingDictionary: Differences: true Font: BaseFont: JUXSQN+VnURWPalladioL-Bold FontSubset: true FirstChar: 160 LastChar: 226 FontDescriptor: FontName: JUXSQN+VnURWPalladioL-Bold Flags: Symbolic FontBBox: -152, -301, 1000, 935 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: NMPHMD+URWPalladioL-Bold FontSubset: true FirstChar: 2 LastChar: 241 FontDescriptor: FontName: NMPHMD+URWPalladioL-Bold Flags: Symbolic FontBBox: -152, -301, 1000, 935 FontFile: true EncodingDictionary: Differences: true Pages: Page: Sequence: 1 Annotations: Annotation: Subtype: Link Rect: 54, 323, 152, 332 Annotation: Subtype: Link Rect: 34, 311, 75, 320 Annotation: Subtype: Link Rect: 34, 164, 96, 186 Annotation: Subtype: Link Rect: 126, 90, 154, 99 Annotation: Subtype: Link Rect: 34, 78, 147, 87 Annotation: Subtype: Link Rect: 34, 756, 176, 792 Annotation: Subtype: Link Rect: 515, 756, 560, 792 Annotation: Subtype: Link Rect: 456, 660, 467, 674 Annotation: Subtype: Link Rect: 539, 660, 550, 674 Annotation: Subtype: Link Rect: 276, 648, 287, 662 Annotation: Subtype: Link Rect: 426, 118, 433, 127 ActionDest: 269 Annotation: Subtype: Link Rect: 433, 118, 440, 127 ActionDest: 269 Annotation: Subtype: Link Rect: 541, 80, 548, 89 ActionDest: 269 Annotation: Subtype: Link Rect: 548, 80, 555, 89 ActionDest: 269 Annotation: Subtype: Link Rect: 374, 67, 381, 76 ActionDest: 269 Annotation: Subtype: Link Rect: 384, 68, 391, 76 ActionDest: 269 Annotation: Subtype: Link Rect: 130, 17, 267, 28 Annotation: Subtype: Link Rect: 424, 17, 560, 28 Annotation: Subtype: Link Rect: 34, 444, 87, 463 Page: Sequence: 2 Annotations: Annotation: Subtype: Link Rect: 344, 735, 351, 744 ActionDest: 269 Annotation: Subtype: Link Rect: 352, 735, 359, 744 ActionDest: 269 Annotation: Subtype: Link Rect: 204, 723, 215, 732 ActionDest: 269 Annotation: Subtype: Link Rect: 216, 723, 228, 732 ActionDest: 269 Annotation: Subtype: Link Rect: 511, 723, 523, 732 ActionDest: 269 Annotation: Subtype: Link Rect: 524, 723, 536, 732 ActionDest: 269 Annotation: Subtype: Link Rect: 504, 635, 516, 644 ActionDest: 269 Annotation: Subtype: Link Rect: 223, 509, 235, 519 ActionDest: 272 Annotation: Subtype: Link Rect: 207, 484, 219, 493 ActionDest: 272 Annotation: Subtype: Link Rect: 544, 434, 556, 443 ActionDest: 272 Annotation: Subtype: Link Rect: 218, 384, 230, 393 ActionDest: 272 Annotation: Subtype: Link Rect: 231, 384, 243, 393 ActionDest: 272 Page: Sequence: 3 Annotations: Annotation: Subtype: Link Rect: 461, 310, 468, 322 ActionDest: 78 Page: Sequence: 4 Annotations: Annotation: Subtype: Link Rect: 220, 455, 232, 464 ActionDest: 272 Annotation: Subtype: Link Rect: 373, 442, 385, 451 ActionDest: 272 Annotation: Subtype: Link Rect: 397, 86, 404, 98 ActionDest: 78 Page: Sequence: 5 Annotations: Annotation: Subtype: Link Rect: 219, 723, 226, 732 ActionDest: 130 Annotation: Subtype: Link Rect: 246, 723, 253, 732 ActionDest: 145 Annotation: Subtype: Link Rect: 213, 656, 220, 668 ActionDest: 130 Annotation: Subtype: Link Rect: 213, 571, 225, 580 ActionDest: 272 Annotation: Subtype: Link Rect: 310, 571, 322, 580 ActionDest: 272 Annotation: Subtype: Link Rect: 192, 558, 204, 568 ActionDest: 272 Annotation: Subtype: Link Rect: 526, 533, 538, 542 ActionDest: 272 Annotation: Subtype: Link Rect: 260, 508, 272, 517 ActionDest: 272 Annotation: Subtype: Link Rect: 227, 471, 234, 480 ActionDest: 269 Annotation: Subtype: Link Rect: 234, 471, 246, 480 ActionDest: 272 Annotation: Subtype: Link Rect: 247, 471, 259, 480 ActionDest: 272 Annotation: Subtype: Link Rect: 193, 458, 205, 467 ActionDest: 272 Annotation: Subtype: Link Rect: 494, 445, 506, 455 ActionDest: 272 Annotation: Subtype: Link Rect: 293, 395, 305, 404 ActionDest: 272 Annotation: Subtype: Link Rect: 305, 395, 317, 404 ActionDest: 272 Annotation: Subtype: Link Rect: 318, 395, 330, 404 ActionDest: 272 Annotation: Subtype: Link Rect: 239, 383, 251, 392 ActionDest: 272 Annotation: Subtype: Link Rect: 253, 333, 264, 342 ActionDest: 272 Annotation: Subtype: Link Rect: 228, 295, 240, 304 ActionDest: 272 Annotation: Subtype: Link Rect: 397, 220, 408, 229 ActionDest: 272 Annotation: Subtype: Link Rect: 282, 207, 294, 216 ActionDest: 272 Annotation: Subtype: Link Rect: 369, 207, 381, 216 ActionDest: 272 Annotation: Subtype: Link Rect: 518, 169, 530, 178 ActionDest: 272 Annotation: Subtype: Link Rect: 240, 157, 252, 166 ActionDest: 272 Annotation: Subtype: Link Rect: 231, 132, 243, 141 ActionDest: 272 Page: Sequence: 6 Annotations: Annotation: Subtype: Link Rect: 63, 418, 72, 425 ActionDest: 272 Annotation: Subtype: Link Rect: 63, 342, 72, 349 ActionDest: 272 Annotation: Subtype: Link Rect: 63, 237, 72, 244 ActionDest: 272 Annotation: Subtype: Link Rect: 63, 157, 72, 164 ActionDest: 272 Page: Sequence: 7 Annotations: Annotation: Subtype: Link Rect: 63, 388, 72, 395 ActionDest: 272 Annotation: Subtype: Link Rect: 63, 286, 72, 293 ActionDest: 272 Annotation: Subtype: Link Rect: 63, 217, 72, 224 ActionDest: 272 Annotation: Subtype: Link Rect: 65, 143, 70, 150 ActionDest: 269 Page: Sequence: 8 Annotations: Annotation: Subtype: Link Rect: 63, 412, 72, 419 ActionDest: 272 Annotation: Subtype: Link Rect: 63, 328, 72, 335 ActionDest: 272 Annotation: Subtype: Link Rect: 63, 228, 72, 235 ActionDest: 272 Page: Sequence: 9 Annotations: Annotation: Subtype: Link Rect: 63, 379, 72, 386 ActionDest: 272 Annotation: Subtype: Link Rect: 63, 272, 72, 278 ActionDest: 272 Annotation: Subtype: Link Rect: 63, 158, 72, 165 ActionDest: 272 Page: Sequence: 10 Annotations: Annotation: Subtype: Link Rect: 63, 404, 72, 411 ActionDest: 272 Annotation: Subtype: Link Rect: 55, 216, 62, 222 ActionDest: 272 Annotation: Subtype: Link Rect: 55, 170, 62, 175 ActionDest: 272 Annotation: Subtype: Link Rect: 55, 127, 62, 133 ActionDest: 272 Annotation: Subtype: Link Rect: 55, 94, 62, 99 ActionDest: 272 Page: Sequence: 11 Annotations: Annotation: Subtype: Link Rect: 55, 408, 62, 414 ActionDest: 272 Annotation: Subtype: Link Rect: 55, 363, 62, 369 ActionDest: 272 Annotation: Subtype: Link Rect: 55, 315, 62, 320 ActionDest: 272 Annotation: Subtype: Link Rect: 55, 252, 62, 257 ActionDest: 272 Annotation: Subtype: Link Rect: 55, 226, 62, 232 ActionDest: 275 Page: Sequence: 12 Annotations: Annotation: Subtype: Link Rect: 338, 743, 350, 752 ActionDest: 272 Annotation: Subtype: Link Rect: 231, 718, 243, 727 ActionDest: 272 Annotation: Subtype: Link Rect: 516, 693, 528, 702 ActionDest: 272 Annotation: Subtype: Link Rect: 373, 668, 385, 677 ActionDest: 272 Annotation: Subtype: Link Rect: 545, 656, 557, 665 ActionDest: 272 Annotation: Subtype: Link Rect: 378, 618, 389, 627 ActionDest: 272 Annotation: Subtype: Link Rect: 545, 593, 557, 602 ActionDest: 272 Annotation: Subtype: Link Rect: 499, 357, 511, 367 ActionDest: 272 Annotation: Subtype: Link Rect: 376, 251, 388, 260 ActionDest: 272 Annotation: Subtype: Link Rect: 533, 207, 545, 217 ActionDest: 272 Annotation: Subtype: Link Rect: 544, 157, 556, 166 ActionDest: 272 Page: Sequence: 13 Annotations: Annotation: Subtype: Link Rect: 511, 647, 523, 656 ActionDest: 272 Annotation: Subtype: Link Rect: 262, 597, 274, 606 ActionDest: 275 Annotation: Subtype: Link Rect: 504, 544, 511, 556 ActionDest: 145 Annotation: Subtype: Link Rect: 349, 534, 361, 543 ActionDest: 272 Annotation: Subtype: Link Rect: 544, 509, 556, 518 ActionDest: 272 Annotation: Subtype: Link Rect: 199, 430, 206, 443 ActionDest: 152 Annotation: Subtype: Link Rect: 240, 270, 251, 279 ActionDest: 272 Annotation: Subtype: Link Rect: 251, 270, 262, 279 ActionDest: 272 Annotation: Subtype: Link Rect: 262, 270, 273, 279 ActionDest: 272 Annotation: Subtype: Link Rect: 274, 270, 285, 279 ActionDest: 272 Annotation: Subtype: Link Rect: 320, 233, 326, 245 ActionDest: 152 Annotation: Subtype: Link Rect: 240, 84, 251, 92 ActionDest: 272 Annotation: Subtype: Link Rect: 251, 84, 262, 92 ActionDest: 272 Annotation: Subtype: Link Rect: 262, 84, 273, 92 ActionDest: 272 Page: Sequence: 14 Annotations: Annotation: Subtype: Link Rect: 320, 722, 326, 734 ActionDest: 206 Annotation: Subtype: Link Rect: 271, 581, 282, 589 ActionDest: 272 Annotation: Subtype: Link Rect: 282, 581, 293, 589 ActionDest: 272 Annotation: Subtype: Link Rect: 365, 543, 372, 555 ActionDest: 206 Annotation: Subtype: Link Rect: 299, 378, 310, 387 ActionDest: 272 Annotation: Subtype: Link Rect: 310, 378, 321, 387 ActionDest: 272 Annotation: Subtype: Link Rect: 322, 378, 333, 387 ActionDest: 272 Annotation: Subtype: Link Rect: 333, 378, 344, 387 ActionDest: 272 Annotation: Subtype: Link Rect: 373, 242, 385, 251 ActionDest: 275 Annotation: Subtype: Link Rect: 544, 229, 556, 238 ActionDest: 272 Annotation: Subtype: Link Rect: 439, 204, 451, 213 ActionDest: 275 Annotation: Subtype: Link Rect: 545, 204, 557, 213 ActionDest: 272 Annotation: Subtype: Link Rect: 194, 91, 206, 100 ActionDest: 275 Annotation: Subtype: Link Rect: 209, 91, 221, 100 ActionDest: 275 Annotation: Subtype: Link Rect: 451, 79, 463, 88 ActionDest: 275 Annotation: Subtype: Link Rect: 464, 79, 476, 88 ActionDest: 275 Annotation: Subtype: Link Rect: 285, 66, 296, 75 ActionDest: 275 Page: Sequence: 15 Annotations: Annotation: Subtype: Link Rect: 235, 725, 247, 734 ActionDest: 275 Annotation: Subtype: Link Rect: 400, 700, 412, 709 ActionDest: 272 Annotation: Subtype: Link Rect: 460, 700, 472, 709 ActionDest: 272 Annotation: Subtype: Link Rect: 540, 700, 552, 709 ActionDest: 272 Annotation: Subtype: Link Rect: 327, 675, 339, 684 ActionDest: 272 Annotation: Subtype: Link Rect: 339, 675, 351, 684 ActionDest: 272 Annotation: Subtype: Link Rect: 545, 675, 557, 684 ActionDest: 272 Annotation: Subtype: Link Rect: 544, 649, 556, 659 ActionDest: 272 Annotation: Subtype: Link Rect: 373, 612, 385, 621 ActionDest: 272 Annotation: Subtype: Link Rect: 343, 599, 355, 608 ActionDest: 272 Annotation: Subtype: Link Rect: 240, 562, 252, 571 ActionDest: 275 Annotation: Subtype: Link Rect: 228, 512, 240, 521 ActionDest: 272 Annotation: Subtype: Link Rect: 228, 436, 240, 445 ActionDest: 272 Annotation: Subtype: Link Rect: 387, 386, 399, 395 ActionDest: 272 Annotation: Subtype: Link Rect: 284, 311, 296, 320 ActionDest: 275 Annotation: Subtype: Link Rect: 238, 273, 250, 282 ActionDest: 272 Annotation: Subtype: Link Rect: 545, 160, 557, 169 ActionDest: 275 Page: Sequence: 16 Annotations: Annotation: Subtype: Link Rect: 544, 725, 556, 734 ActionDest: 275 Annotation: Subtype: Link Rect: 284, 712, 296, 721 ActionDest: 272 Annotation: Subtype: Link Rect: 455, 624, 467, 633 ActionDest: 275 Annotation: Subtype: Link Rect: 221, 549, 233, 558 ActionDest: 275 Annotation: Subtype: Link Rect: 503, 549, 515, 558 ActionDest: 275 Annotation: Subtype: Link Rect: 314, 524, 326, 533 ActionDest: 275 Annotation: Subtype: Link Rect: 287, 511, 299, 521 ActionDest: 275 Annotation: Subtype: Link Rect: 210, 499, 222, 508 ActionDest: 272 Annotation: Subtype: Link Rect: 222, 499, 234, 508 ActionDest: 272 Annotation: Subtype: Link Rect: 417, 474, 429, 483 ActionDest: 275 Annotation: Subtype: Link Rect: 459, 449, 471, 458 ActionDest: 275 Annotation: Subtype: Link Rect: 544, 411, 556, 420 ActionDest: 275 Annotation: Subtype: Link Rect: 447, 398, 459, 408 ActionDest: 272 Page: Sequence: 17 Annotations: Annotation: Subtype: Link Rect: 488, 737, 500, 746 ActionDest: 275 Annotation: Subtype: Link Rect: 59, 354, 96, 364 Annotation: Subtype: Link Rect: 102, 354, 138, 364 Annotation: Subtype: Link Rect: 374, 330, 412, 341 Annotation: Subtype: Link Rect: 59, 308, 96, 318 Annotation: Subtype: Link Rect: 102, 308, 138, 318 Annotation: Subtype: Link Rect: 59, 285, 96, 295 Annotation: Subtype: Link Rect: 102, 285, 138, 295 Annotation: Subtype: Link Rect: 338, 261, 376, 272 Annotation: Subtype: Link Rect: 219, 239, 257, 249 Annotation: Subtype: Link Rect: 263, 239, 299, 249 Annotation: Subtype: Link Rect: 343, 215, 380, 226 Annotation: Subtype: Link Rect: 519, 192, 557, 203 Annotation: Subtype: Link Rect: 59, 182, 95, 192 Annotation: Subtype: Link Rect: 436, 169, 473, 180 Annotation: Subtype: Link Rect: 374, 146, 412, 157 Annotation: Subtype: Link Rect: 418, 146, 454, 157 Annotation: Subtype: Link Rect: 384, 123, 421, 134 Annotation: Subtype: Link Rect: 495, 100, 533, 111 Annotation: Subtype: Link Rect: 86, 67, 124, 77 Page: Sequence: 18 Annotations: Annotation: Subtype: Link Rect: 470, 735, 508, 746 Annotation: Subtype: Link Rect: 514, 735, 550, 746 Annotation: Subtype: Link Rect: 303, 712, 340, 723 Annotation: Subtype: Link Rect: 168, 678, 206, 689 Annotation: Subtype: Link Rect: 212, 678, 248, 689 Annotation: Subtype: Link Rect: 408, 654, 446, 665 Annotation: Subtype: Link Rect: 431, 631, 469, 642 Annotation: Subtype: Link Rect: 384, 585, 421, 596 Annotation: Subtype: Link Rect: 428, 585, 464, 596 Annotation: Subtype: Link Rect: 170, 563, 207, 573 Annotation: Subtype: Link Rect: 214, 563, 250, 573 Annotation: Subtype: Link Rect: 405, 539, 443, 550 Annotation: Subtype: Link Rect: 449, 539, 485, 550 Annotation: Subtype: Link Rect: 442, 517, 480, 527 Annotation: Subtype: Link Rect: 486, 517, 522, 527 Annotation: Subtype: Link Rect: 325, 493, 363, 504 Annotation: Subtype: Link Rect: 410, 470, 447, 481 Annotation: Subtype: Link Rect: 59, 448, 96, 458 Annotation: Subtype: Link Rect: 407, 424, 444, 435 Annotation: Subtype: Link Rect: 356, 401, 393, 412 Annotation: Subtype: Link Rect: 59, 368, 96, 378 Annotation: Subtype: Link Rect: 109, 333, 146, 343 Annotation: Subtype: Link Rect: 152, 333, 188, 343 Annotation: Subtype: Link Rect: 351, 298, 388, 309 Annotation: Subtype: Link Rect: 395, 298, 431, 309 Annotation: Subtype: Link Rect: 519, 275, 557, 286 Annotation: Subtype: Link Rect: 59, 264, 95, 274 Annotation: Subtype: Link Rect: 122, 230, 159, 240 Annotation: Subtype: Link Rect: 86, 195, 124, 205 Annotation: Subtype: Link Rect: 130, 195, 166, 205 Annotation: Subtype: Link Rect: 475, 171, 513, 182 Annotation: Subtype: Link Rect: 193, 137, 231, 148 Annotation: Subtype: Link Rect: 401, 102, 439, 113 Annotation: Subtype: Link Rect: 458, 79, 495, 90 Page: Sequence: 19 Annotations: Annotation: Subtype: Link Rect: 369, 712, 407, 723 Annotation: Subtype: Link Rect: 240, 701, 509, 712 Annotation: Subtype: Link Rect: 277, 678, 560, 689 Annotation: Subtype: Link Rect: 56, 667, 97, 677 Annotation: Subtype: Link Rect: 463, 643, 500, 654 Annotation: Subtype: Link Rect: 507, 643, 543, 654 Annotation: Subtype: Link Rect: 342, 620, 380, 631 Annotation: Subtype: Link Rect: 386, 620, 422, 631 Annotation: Subtype: Link Rect: 59, 586, 96, 596 Annotation: Subtype: Link Rect: 102, 586, 138, 596 Annotation: Subtype: Link Rect: 316, 563, 353, 573 Annotation: Subtype: Link Rect: 275, 539, 312, 550 Annotation: Subtype: Link Rect: 109, 517, 146, 527 Annotation: Subtype: Link Rect: 398, 493, 436, 504 Annotation: Subtype: Link Rect: 59, 460, 96, 470 Annotation: Subtype: Link Rect: 59, 402, 96, 412 Annotation: Subtype: Link Rect: 292, 378, 330, 389 Annotation: Subtype: Link Rect: 336, 378, 372, 389 Annotation: Subtype: Link Rect: 127, 355, 164, 366 Annotation: Subtype: Link Rect: 170, 355, 206, 366 Annotation: Subtype: Link Rect: 194, 333, 231, 343 Annotation: Subtype: Link Rect: 237, 333, 274, 343 Annotation: Subtype: Link Rect: 267, 309, 304, 320 Annotation: Subtype: Link Rect: 472, 286, 510, 297 Annotation: Subtype: Link Rect: 431, 263, 468, 274 Annotation: Subtype: Link Rect: 458, 217, 495, 228 Annotation: Subtype: Link Rect: 198, 194, 236, 205 Annotation: Subtype: Link Rect: 325, 171, 363, 182 Checksum: 4259ae8f Type: CRC32 Checksum: 1d16d81fc422666577866eeafd2c918d Type: MD5 Checksum: 76c002e4e8ac1dd1619d826d0fd28286edb442d5 Type: SHA-1 Checksum: 9387e95fb5096d31b0df86f365e0b65d7f5b0bd2f287ea2860ab5b30ad4b1cdc Type: SHA-256