f5a67992357b13ab3c20e1323b8c3f5e pmc_9566538.pdf 3d8275e5f353b8ad22090f9241ef7d16b1ad26c6 pmc_9566538.pdf 3856fb7ab0d96a44bd453339e3fbe1be8aa146f3fddb350981fef00b72bec294 pmc_9566538.pdf Title: Deaths of Despair: A Scoping Review on the Social Determinants of Drug Overdose, Alcohol-Related Liver Disease and Suicide Subject: Background: There is a lack of consensus on the social determinants of Deaths of Despair (DoD), i.e., an increase in mortality attributed to drug overdose, alcohol-related liver disease, and suicide in the United States (USA) during recent years. The objective of this study was to review the scientific literature on DoD with the purpose of identifying relevant social determinants and inequalities related to these mortality trends. Methods: Scoping review focusing on the period 2015–2022 based on PubMed search. Articles were selected according to the following inclusion criteria: published between 1 January 2000 and 31 October 2021; including empirical data; analyzed DoD including the three causes defined by Case and Deaton; analyzed at least one social determinant; written in English; and studied DoD in the USA context only. Studies were excluded if they only analyzed adolescent populations. We synthesized our findings in a narrative report specifically addressing DoD by economic conditions, occupational hazards, educational level, geographical setting, and race/ethnicity. Results: Seventeen studies were included. Overall, findings identify a progressive increase in deaths attributable to suicide, drug overdose, and alcohol-related liver disease in the USA in the last two decades. The literature concerning DoD and social determinants is relatively scarce and some determinants have been barely studied. However different, however, large inequalities have been identified in the manner in which the causes of death embedded in the concept of DoD affect different subpopulations, particularly African American, and Hispanic populations, but blue collar-whites are also significantly impacted. Low socioeconomic position and education levels and working in jobs with high insecurity, unemployment, and living in rural areas were identified as the most relevant social determinants of DoD. Conclusions: There is a need for further research on the structural and intermediate social determinants of DoD and social mechanisms. Intersectional and systemic approaches are needed to better understand and tackle DoD and related inequalities. Keywords: death of despair; public health; social determinants of health; health inequalities Author: Elisabet Beseran, Juan M. Pericàs, Lucinda Cash-Gibson, Meritxell Ventura-Cots, Keshia M. Pollack Porter and Joan Benach Creator: LaTeX with hyperref Producer: pdfTeX-1.40.21 CreationDate: Fri Sep 30 04:36:13 2022 CEST ModDate: Fri Sep 30 04:41:21 2022 CEST Tagged: no UserProperties: no Suspects: no Form: none JavaScript: no Pages: 18 Encrypted: no Page size: 595.276 x 841.89 pts (A4) Page rot: 0 File size: 541322 bytes Optimized: no PDF version: 1.7 name type encoding emb sub uni object ID ------------------------------------ ----------------- ---------------- --- --- --- --------- WNWTFR+VnURWPalladioL-Bold Type 1 Custom yes yes no 10 0 PAPUPC+VnURWPalladioL Type 1 Custom yes yes no 15 0 IEKUYL+URWPalladioL-Bold Type 1 Custom yes yes no 19 0 NYAGJX+URWPalladioL-Roma Type 1 Custom yes yes no 24 0 TKEFGN+URWPalladioL-Ital Type 1 Custom yes yes no 28 0 LWQXII+TimesNewRomanPS-BoldItalicMT Type 1C WinAnsi yes yes no 46 0 IRWHZX+TimesNewRomanPSMT Type 1C WinAnsi yes yes no 49 0 KIOPHP+PalatinoLinotype,Bold TrueType WinAnsi yes yes no 82 0 KIOPIB+PalatinoLinotype TrueType WinAnsi yes yes no 85 0 KIOPID+PalatinoLinotype,Italic TrueType WinAnsi yes yes no 88 0 Jhove (Rel. 1.22.1, 2019-04-17) Date: 2023-01-13 02:31:03 CET RepresentationInformation: pmc_9566538.pdf ReportingModule: PDF-hul, Rel. 1.12.1 (2019-04-17) LastModified: 2022-10-27 02:17:13 CEST Size: 541322 Format: PDF Version: 1.7 Status: Well-Formed and valid SignatureMatches: PDF-hul MIMEtype: application/pdf PDFMetadata: Objects: 440 FreeObjects: 1 IncrementalUpdates: 0 DocumentCatalog: PageLayout: SinglePage PageMode: UseNone Outlines: Item: Title: Introduction Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@4923ab24 Item: Title: Materials and Methods Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@44c8afef Children: Item: Title: Search Strategy Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@7b69c6ba Item: Title: Inclusion and Exclusion Criteria Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@46daef40 Item: Title: Data Extraction Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@12f41634 Item: Title: Definitions Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@13c27452 Item: Title: Results Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@262b2c86 Children: Item: Title: Economic Conditions Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@371a67ec Item: Title: Occupational Hazards Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@5ed828d Item: Title: Education Level Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@50d0686 Item: Title: Geographical Settings Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@7a3d45bd Item: Title: Ethnicity/Race Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@1e7c7811 Item: Title: Discussion Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@77ec78b9 Item: Title: Conclusions Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@1a3869f4 Item: Title: References Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@a38d7a3 Info: Title: Deaths of Despair: A Scoping Review on the Social Determinants of Drug Overdose, Alcohol-Related Liver Disease and Suicide Author: Elisabet Beseran, Juan M. Pericàs, Lucinda Cash-Gibson, Meritxell Ventura-Cots, Keshia M. Pollack Porter and Joan Benach Subject: Background: There is a lack of consensus on the social determinants of Deaths of Despair (DoD), i.e., an increase in mortality attributed to drug overdose, alcohol-related liver disease, and suicide in the United States (USA) during recent years. The objective of this study was to review the scientific literature on DoD with the purpose of identifying relevant social determinants and inequalities related to these mortality trends. Methods: Scoping review focusing on the period 2015 2022 based on PubMed search. Articles were selected according to the following inclusion criteria: published between 1 January 2000 and 31 October 2021; including empirical data; analyzed DoD including the three causes defined by Case and Deaton; analyzed at least one social determinant; written in English; and studied DoD in the USA context only. Studies were excluded if they only analyzed adolescent populations. We synthesized our findings in a narrative report specifically addressing DoD by economic conditions, occupational hazards, educational level, geographical setting, and race/ethnicity. Results: Seventeen studies were included. Overall, findings identify a progressive increase in deaths attributable to suicide, drug overdose, and alcohol-related liver disease in the USA in the last two decades. The literature concerning DoD and social determinants is relatively scarce and some determinants have been barely studied. However different, however, large inequalities have been identified in the manner in which the causes of death embedded in the concept of DoD affect different subpopulations, particularly African American, and Hispanic populations, but blue collar-whites are also significantly impacted. Low socioeconomic position and education levels and working in jobs with high insecurity, unemployment, and living in rural areas were identified as the most relevant social determinants of DoD. Conclusions: There is a need for further research on the structural and intermediate social determinants of DoD and social mechanisms. Intersectional and systemic approaches are needed to better understand and tackle DoD and related inequalities. Keywords: death of despair; public health; social determinants of health; health inequalities Creator: LaTeX with hyperref Producer: pdfTeX-1.40.21 CreationDate: Fri Sep 30 04:36:13 CEST 2022 ModDate: Fri Sep 30 04:41:21 CEST 2022 ID: 0x9cd42fdc637b6b32e8f553d98ee265dd, 0x9cd42fdc637b6b32e8f553d98ee265dd Filters: FilterPipeline: FlateDecode Fonts: Type1: Font: BaseFont: IEKUYL+URWPalladioL-Bold FontSubset: true FirstChar: 3 LastChar: 121 FontDescriptor: FontName: IEKUYL+URWPalladioL-Bold Flags: Symbolic FontBBox: -152, -301, 1000, 935 FontFile: true EncodingDictionary: Differences: true Font: BaseFont: NYAGJX+URWPalladioL-Roma FontSubset: true FirstChar: 2 LastChar: 248 FontDescriptor: FontName: NYAGJX+URWPalladioL-Roma Flags: Symbolic FontBBox: -166, -283, 1021, 943 FontFile: true EncodingDictionary: Differences: true Font: BaseFont: WNWTFR+VnURWPalladioL-Bold FontSubset: true FirstChar: 160 LastChar: 160 FontDescriptor: FontName: WNWTFR+VnURWPalladioL-Bold Flags: Symbolic FontBBox: -152, -301, 1000, 935 FontFile: true EncodingDictionary: Differences: true Font: BaseFont: TKEFGN+URWPalladioL-Ital FontSubset: true FirstChar: 2 LastChar: 150 FontDescriptor: FontName: TKEFGN+URWPalladioL-Ital Flags: Symbolic FontBBox: -170, -305, 1010, 941 FontFile: true EncodingDictionary: Differences: true Font: BaseFont: PAPUPC+VnURWPalladioL FontSubset: true FirstChar: 160 LastChar: 226 FontDescriptor: FontName: PAPUPC+VnURWPalladioL Flags: Symbolic FontBBox: -166, -283, 1021, 943 FontFile: true EncodingDictionary: Differences: true Pages: Page: Sequence: 1 Annotations: Annotation: Subtype: Link Rect: 34, 323, 152, 332 Annotation: Subtype: Link Rect: 34, 311, 86, 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, 180, 792 Annotation: Subtype: Link Rect: 515, 756, 560, 792 Annotation: Subtype: Link Rect: 336, 661, 347, 674 Annotation: Subtype: Link Rect: 327, 98, 334, 107 ActionDest: 129 Annotation: Subtype: Link Rect: 205, 17, 354, 28 Annotation: Subtype: Link Rect: 416, 17, 560, 28 Annotation: Subtype: Link Rect: 34, 432, 87, 451 Page: Sequence: 2 Annotations: Annotation: Subtype: Link Rect: 314, 723, 321, 732 ActionDest: 129 Annotation: Subtype: Link Rect: 414, 698, 421, 707 ActionDest: 129 Annotation: Subtype: Link Rect: 530, 685, 536, 694 ActionDest: 129 Annotation: Subtype: Link Rect: 416, 673, 423, 682 ActionDest: 129 Annotation: Subtype: Link Rect: 432, 660, 439, 669 ActionDest: 129 Annotation: Subtype: Link Rect: 439, 635, 446, 644 ActionDest: 129 Annotation: Subtype: Link Rect: 424, 610, 431, 619 ActionDest: 129 Annotation: Subtype: Link Rect: 354, 547, 361, 556 ActionDest: 129 Annotation: Subtype: Link Rect: 188, 484, 195, 493 ActionDest: 129 Annotation: Subtype: Link Rect: 467, 391, 474, 401 ActionDest: 129 Annotation: Subtype: Link Rect: 469, 336, 476, 345 ActionDest: 129 Annotation: Subtype: Link Rect: 490, 311, 497, 320 ActionDest: 129 Annotation: Subtype: Link Rect: 411, 286, 423, 295 ActionDest: 129 Annotation: Subtype: Link Rect: 379, 249, 391, 257 ActionDest: 129 Annotation: Subtype: Link Rect: 394, 248, 406, 257 ActionDest: 129 Annotation: Subtype: Link Rect: 444, 123, 451, 132 ActionDest: 129 Annotation: Subtype: Link Rect: 390, 98, 402, 107 ActionDest: 129 Page: Sequence: 3 Annotations: Annotation: Subtype: Link Rect: 423, 607, 430, 616 ActionDest: 129 Annotation: Subtype: Link Rect: 431, 607, 438, 616 ActionDest: 129 Annotation: Subtype: Link Rect: 261, 544, 268, 553 ActionDest: 129 Annotation: Subtype: Link Rect: 391, 531, 398, 540 ActionDest: 129 Annotation: Subtype: Link Rect: 398, 531, 410, 540 ActionDest: 129 Annotation: Subtype: Link Rect: 413, 531, 425, 540 ActionDest: 129 Annotation: Subtype: Link Rect: 549, 255, 556, 264 ActionDest: 129 Annotation: Subtype: Link Rect: 549, 230, 556, 238 ActionDest: 129 Annotation: Subtype: Link Rect: 544, 217, 556, 226 ActionDest: 129 Annotation: Subtype: Link Rect: 222, 192, 234, 201 ActionDest: 129 Annotation: Subtype: Link Rect: 254, 167, 266, 176 ActionDest: 129 Annotation: Subtype: Link Rect: 416, 154, 428, 163 ActionDest: 129 Annotation: Subtype: Link Rect: 499, 113, 506, 125 ActionDest: 74 Page: Sequence: 4 Annotations: Annotation: Subtype: Link Rect: 493, 374, 499, 383 ActionDest: 129 Annotation: Subtype: Link Rect: 269, 362, 281, 371 ActionDest: 129 Annotation: Subtype: Link Rect: 281, 362, 293, 371 ActionDest: 129 Annotation: Subtype: Link Rect: 215, 349, 222, 358 ActionDest: 129 Annotation: Subtype: Link Rect: 222, 349, 229, 358 ActionDest: 129 Annotation: Subtype: Link Rect: 230, 349, 241, 358 ActionDest: 129 Annotation: Subtype: Link Rect: 244, 349, 256, 358 ActionDest: 129 Annotation: Subtype: Link Rect: 256, 349, 268, 358 ActionDest: 129 Annotation: Subtype: Link Rect: 268, 349, 280, 358 ActionDest: 129 Annotation: Subtype: Link Rect: 283, 349, 295, 358 ActionDest: 132 Annotation: Subtype: Link Rect: 389, 337, 396, 346 ActionDest: 129 Annotation: Subtype: Link Rect: 396, 337, 403, 346 ActionDest: 129 Annotation: Subtype: Link Rect: 404, 337, 415, 346 ActionDest: 129 Annotation: Subtype: Link Rect: 418, 337, 430, 346 ActionDest: 129 Annotation: Subtype: Link Rect: 430, 337, 442, 346 ActionDest: 129 Annotation: Subtype: Link Rect: 442, 337, 454, 346 ActionDest: 129 Annotation: Subtype: Link Rect: 454, 337, 466, 346 ActionDest: 129 Annotation: Subtype: Link Rect: 466, 337, 478, 346 ActionDest: 129 Annotation: Subtype: Link Rect: 479, 337, 490, 346 ActionDest: 132 Annotation: Subtype: Link Rect: 491, 337, 502, 346 ActionDest: 132 Annotation: Subtype: Link Rect: 503, 337, 514, 346 ActionDest: 132 Annotation: Subtype: Link Rect: 515, 337, 526, 346 ActionDest: 132 Annotation: Subtype: Link Rect: 363, 324, 375, 333 ActionDest: 129 Annotation: Subtype: Link Rect: 375, 324, 387, 333 ActionDest: 129 Annotation: Subtype: Link Rect: 388, 324, 400, 333 ActionDest: 129 Annotation: Subtype: Link Rect: 400, 324, 412, 333 ActionDest: 132 Annotation: Subtype: Link Rect: 413, 324, 425, 333 ActionDest: 132 Annotation: Subtype: Link Rect: 420, 287, 432, 296 ActionDest: 129 Annotation: Subtype: Link Rect: 433, 286, 445, 296 ActionDest: 129 Annotation: Subtype: Link Rect: 445, 286, 457, 296 ActionDest: 132 Annotation: Subtype: Link Rect: 258, 274, 265, 283 ActionDest: 129 Annotation: Subtype: Link Rect: 266, 274, 278, 283 ActionDest: 129 Annotation: Subtype: Link Rect: 278, 274, 290, 283 ActionDest: 129 Annotation: Subtype: Link Rect: 291, 274, 303, 283 ActionDest: 129 Annotation: Subtype: Link Rect: 303, 274, 315, 283 ActionDest: 129 Annotation: Subtype: Link Rect: 316, 274, 328, 283 ActionDest: 129 Annotation: Subtype: Link Rect: 328, 274, 340, 283 ActionDest: 129 Annotation: Subtype: Link Rect: 344, 274, 355, 283 ActionDest: 132 Annotation: Subtype: Link Rect: 356, 274, 368, 283 ActionDest: 132 Annotation: Subtype: Link Rect: 369, 274, 381, 283 ActionDest: 132 Annotation: Subtype: Link Rect: 473, 274, 480, 283 ActionDest: 129 Annotation: Subtype: Link Rect: 403, 249, 415, 258 ActionDest: 129 Annotation: Subtype: Link Rect: 416, 249, 428, 258 ActionDest: 129 Annotation: Subtype: Link Rect: 428, 249, 440, 258 ActionDest: 129 Annotation: Subtype: Link Rect: 441, 249, 453, 258 ActionDest: 132 Annotation: Subtype: Link Rect: 251, 211, 258, 220 ActionDest: 129 Annotation: Subtype: Link Rect: 259, 211, 271, 220 ActionDest: 129 Annotation: Subtype: Link Rect: 274, 211, 286, 220 ActionDest: 129 Annotation: Subtype: Link Rect: 286, 211, 298, 220 ActionDest: 129 Annotation: Subtype: Link Rect: 298, 211, 310, 220 ActionDest: 132 Annotation: Subtype: Link Rect: 234, 186, 241, 195 ActionDest: 95 Annotation: Subtype: Link Rect: 317, 148, 329, 157 ActionDest: 129 Annotation: Subtype: Link Rect: 544, 98, 556, 107 ActionDest: 129 Page: Sequence: 5 Annotations: Annotation: Subtype: Link Rect: 72, 577, 78, 585 ActionDest: 129 Annotation: Subtype: Link Rect: 65, 374, 75, 381 ActionDest: 129 Annotation: Subtype: Link Rect: 65, 166, 75, 173 ActionDest: 129 Page: Sequence: 6 Annotations: Annotation: Subtype: Link Rect: 56, 596, 66, 604 ActionDest: 129 Annotation: Subtype: Link Rect: 56, 464, 66, 471 ActionDest: 129 Annotation: Subtype: Link Rect: 65, 355, 75, 362 ActionDest: 129 Annotation: Subtype: Link Rect: 65, 184, 75, 192 ActionDest: 132 Page: Sequence: 7 Annotations: Annotation: Subtype: Link Rect: 278, 710, 290, 719 ActionDest: 129 Annotation: Subtype: Link Rect: 544, 685, 556, 694 ActionDest: 129 Annotation: Subtype: Link Rect: 426, 635, 438, 644 ActionDest: 129 Annotation: Subtype: Link Rect: 413, 597, 420, 606 ActionDest: 129 Annotation: Subtype: Link Rect: 424, 547, 431, 556 ActionDest: 129 Annotation: Subtype: Link Rect: 206, 509, 218, 519 ActionDest: 129 Annotation: Subtype: Link Rect: 182, 396, 194, 405 ActionDest: 129 Annotation: Subtype: Link Rect: 194, 396, 206, 405 ActionDest: 129 Annotation: Subtype: Link Rect: 207, 396, 219, 405 ActionDest: 129 Annotation: Subtype: Link Rect: 219, 396, 231, 405 ActionDest: 132 Annotation: Subtype: Link Rect: 234, 396, 246, 405 ActionDest: 132 Annotation: Subtype: Link Rect: 391, 384, 403, 393 ActionDest: 129 Annotation: Subtype: Link Rect: 190, 371, 197, 380 ActionDest: 104 Annotation: Subtype: Link Rect: 61, 204, 71, 212 ActionDest: 132 Page: Sequence: 8 Annotations: Annotation: Subtype: Link Rect: 61, 610, 71, 618 ActionDest: 132 Annotation: Subtype: Link Rect: 52, 454, 62, 462 ActionDest: 132 Annotation: Subtype: Link Rect: 52, 251, 62, 258 ActionDest: 129 Page: Sequence: 9 Annotations: Annotation: Subtype: Link Rect: 52, 582, 62, 590 ActionDest: 129 Annotation: Subtype: Link Rect: 61, 364, 71, 372 ActionDest: 132 Annotation: Subtype: Link Rect: 52, 161, 62, 168 ActionDest: 129 Page: Sequence: 10 Annotations: Annotation: Subtype: Link Rect: 347, 723, 359, 732 ActionDest: 129 Annotation: Subtype: Link Rect: 522, 698, 534, 707 ActionDest: 129 Annotation: Subtype: Link Rect: 218, 673, 230, 682 ActionDest: 132 Annotation: Subtype: Link Rect: 468, 660, 480, 669 ActionDest: 132 Annotation: Subtype: Link Rect: 221, 610, 233, 619 ActionDest: 132 Annotation: Subtype: Link Rect: 258, 597, 270, 606 ActionDest: 129 Annotation: Subtype: Link Rect: 319, 535, 331, 544 ActionDest: 129 Annotation: Subtype: Link Rect: 321, 459, 333, 468 ActionDest: 132 Annotation: Subtype: Link Rect: 325, 422, 337, 431 ActionDest: 132 Annotation: Subtype: Link Rect: 314, 396, 326, 406 ActionDest: 129 Annotation: Subtype: Link Rect: 344, 334, 355, 343 ActionDest: 132 Annotation: Subtype: Link Rect: 241, 271, 253, 280 ActionDest: 132 Annotation: Subtype: Link Rect: 248, 170, 255, 179 ActionDest: 129 Annotation: Subtype: Link Rect: 255, 170, 267, 179 ActionDest: 129 Annotation: Subtype: Link Rect: 268, 170, 280, 179 ActionDest: 129 Annotation: Subtype: Link Rect: 280, 170, 292, 179 ActionDest: 132 Annotation: Subtype: Link Rect: 351, 155, 358, 167 ActionDest: 114 Annotation: Subtype: Link Rect: 423, 158, 435, 167 ActionDest: 129 Annotation: Subtype: Link Rect: 435, 158, 447, 167 ActionDest: 129 Annotation: Subtype: Link Rect: 510, 142, 517, 154 ActionDest: 95 Page: Sequence: 11 Annotations: Annotation: Subtype: Link Rect: 54, 568, 60, 576 ActionDest: 129 Annotation: Subtype: Link Rect: 52, 379, 62, 386 ActionDest: 129 Annotation: Subtype: Link Rect: 52, 213, 62, 220 ActionDest: 129 Page: Sequence: 12 Annotations: Annotation: Subtype: Link Rect: 52, 568, 62, 576 ActionDest: 132 Annotation: Subtype: Link Rect: 241, 418, 248, 427 ActionDest: 129 Annotation: Subtype: Link Rect: 485, 405, 497, 414 ActionDest: 129 Annotation: Subtype: Link Rect: 503, 368, 515, 377 ActionDest: 129 Annotation: Subtype: Link Rect: 200, 330, 212, 339 ActionDest: 129 Annotation: Subtype: Link Rect: 280, 292, 292, 301 ActionDest: 129 Annotation: Subtype: Link Rect: 407, 267, 419, 276 ActionDest: 129 Annotation: Subtype: Link Rect: 332, 230, 344, 239 ActionDest: 129 Annotation: Subtype: Link Rect: 294, 192, 306, 201 ActionDest: 129 Annotation: Subtype: Link Rect: 307, 192, 319, 201 ActionDest: 132 Annotation: Subtype: Link Rect: 391, 104, 403, 113 ActionDest: 129 Annotation: Subtype: Link Rect: 403, 104, 415, 113 ActionDest: 129 Annotation: Subtype: Link Rect: 416, 104, 428, 113 ActionDest: 132 Annotation: Subtype: Link Rect: 224, 91, 231, 101 ActionDest: 117 Page: Sequence: 13 Annotations: Annotation: Subtype: Link Rect: 59, 606, 69, 613 ActionDest: 129 Annotation: Subtype: Link Rect: 52, 402, 62, 410 ActionDest: 129 Annotation: Subtype: Link Rect: 61, 208, 71, 216 ActionDest: 129 Annotation: Subtype: Link Rect: 494, 90, 506, 99 ActionDest: 129 Page: Sequence: 14 Annotations: Annotation: Subtype: Link Rect: 194, 698, 206, 707 ActionDest: 129 Annotation: Subtype: Link Rect: 276, 660, 288, 669 ActionDest: 129 Annotation: Subtype: Link Rect: 200, 610, 212, 619 ActionDest: 129 Annotation: Subtype: Link Rect: 199, 572, 211, 581 ActionDest: 129 Annotation: Subtype: Link Rect: 544, 560, 556, 569 ActionDest: 129 Annotation: Subtype: Link Rect: 316, 509, 328, 519 ActionDest: 129 Annotation: Subtype: Link Rect: 306, 409, 313, 418 ActionDest: 129 Annotation: Subtype: Link Rect: 507, 409, 519, 418 ActionDest: 129 Annotation: Subtype: Link Rect: 519, 409, 531, 418 ActionDest: 129 Annotation: Subtype: Link Rect: 531, 409, 543, 418 ActionDest: 129 Annotation: Subtype: Link Rect: 544, 409, 556, 418 ActionDest: 132 Annotation: Subtype: Link Rect: 198, 384, 205, 393 ActionDest: 129 Annotation: Subtype: Link Rect: 205, 384, 217, 393 ActionDest: 129 Annotation: Subtype: Link Rect: 218, 384, 230, 393 ActionDest: 129 Annotation: Subtype: Link Rect: 450, 371, 462, 380 ActionDest: 129 Annotation: Subtype: Link Rect: 465, 371, 477, 380 ActionDest: 129 Annotation: Subtype: Link Rect: 477, 371, 489, 380 ActionDest: 129 Annotation: Subtype: Link Rect: 490, 371, 501, 380 ActionDest: 132 Annotation: Subtype: Link Rect: 511, 358, 523, 368 ActionDest: 129 Annotation: Subtype: Link Rect: 524, 358, 536, 368 ActionDest: 129 Annotation: Subtype: Link Rect: 400, 333, 412, 342 ActionDest: 129 Annotation: Subtype: Link Rect: 548, 145, 555, 154 ActionDest: 129 Page: Sequence: 15 Annotations: Annotation: Subtype: Link Rect: 467, 622, 479, 631 ActionDest: 129 Annotation: Subtype: Link Rect: 213, 597, 225, 606 ActionDest: 132 Annotation: Subtype: Link Rect: 197, 572, 209, 581 ActionDest: 132 Annotation: Subtype: Link Rect: 210, 572, 222, 581 ActionDest: 132 Annotation: Subtype: Link Rect: 222, 572, 234, 581 ActionDest: 132 Annotation: Subtype: Link Rect: 420, 560, 432, 569 ActionDest: 132 Annotation: Subtype: Link Rect: 433, 560, 445, 569 ActionDest: 132 Annotation: Subtype: Link Rect: 430, 522, 441, 531 ActionDest: 129 Annotation: Subtype: Link Rect: 360, 484, 372, 493 ActionDest: 132 Annotation: Subtype: Link Rect: 375, 484, 387, 493 ActionDest: 132 Annotation: Subtype: Link Rect: 438, 434, 450, 443 ActionDest: 132 Annotation: Subtype: Link Rect: 201, 371, 213, 380 ActionDest: 132 Annotation: Subtype: Link Rect: 292, 359, 304, 368 ActionDest: 132 Annotation: Subtype: Link Rect: 367, 346, 379, 355 ActionDest: 132 Annotation: Subtype: Link Rect: 380, 346, 392, 355 ActionDest: 132 Annotation: Subtype: Link Rect: 325, 309, 337, 318 ActionDest: 132 Annotation: Subtype: Link Rect: 374, 271, 386, 280 ActionDest: 132 Annotation: Subtype: Link Rect: 498, 258, 510, 267 ActionDest: 132 Annotation: Subtype: Link Rect: 346, 196, 358, 205 ActionDest: 132 Annotation: Subtype: Link Rect: 213, 146, 225, 154 ActionDest: 129 Annotation: Subtype: Link Rect: 499, 83, 511, 92 ActionDest: 132 Annotation: Subtype: Link Rect: 512, 83, 523, 92 ActionDest: 132 Page: Sequence: 16 Annotations: Annotation: Subtype: Link Rect: 544, 723, 556, 732 ActionDest: 132 Annotation: Subtype: Link Rect: 373, 647, 385, 657 ActionDest: 132 Annotation: Subtype: Link Rect: 439, 610, 451, 619 ActionDest: 132 Annotation: Subtype: Link Rect: 452, 610, 464, 619 ActionDest: 132 Annotation: Subtype: Link Rect: 251, 396, 263, 405 ActionDest: 132 Annotation: Subtype: Link Rect: 480, 308, 492, 317 ActionDest: 132 Page: Sequence: 17 Annotations: Annotation: Subtype: Link Rect: 253, 707, 290, 718 Annotation: Subtype: Link Rect: 297, 707, 333, 718 Annotation: Subtype: Link Rect: 59, 673, 96, 684 Annotation: Subtype: Link Rect: 102, 673, 138, 684 Annotation: Subtype: Link Rect: 235, 650, 273, 661 Annotation: Subtype: Link Rect: 279, 650, 315, 661 Annotation: Subtype: Link Rect: 56, 626, 299, 638 Annotation: Subtype: Link Rect: 367, 592, 404, 603 Annotation: Subtype: Link Rect: 478, 580, 515, 591 Annotation: Subtype: Link Rect: 521, 580, 557, 591 Annotation: Subtype: Link Rect: 440, 569, 477, 580 Annotation: Subtype: Link Rect: 502, 546, 540, 557 Annotation: Subtype: Link Rect: 438, 523, 476, 534 Annotation: Subtype: Link Rect: 487, 511, 524, 522 Annotation: Subtype: Link Rect: 59, 489, 96, 499 Annotation: Subtype: Link Rect: 291, 477, 560, 488 Annotation: Subtype: Link Rect: 59, 443, 95, 453 Annotation: Subtype: Link Rect: 430, 419, 468, 430 Annotation: Subtype: Link Rect: 474, 419, 510, 430 Annotation: Subtype: Link Rect: 186, 396, 223, 407 Annotation: Subtype: Link Rect: 229, 396, 265, 407 Annotation: Subtype: Link Rect: 104, 374, 141, 384 Annotation: Subtype: Link Rect: 147, 374, 183, 384 Annotation: Subtype: Link Rect: 59, 351, 96, 361 Annotation: Subtype: Link Rect: 59, 328, 96, 338 Annotation: Subtype: Link Rect: 131, 294, 168, 304 Annotation: Subtype: Link Rect: 174, 270, 212, 281 Annotation: Subtype: Link Rect: 444, 247, 481, 258 Annotation: Subtype: Link Rect: 239, 224, 276, 235 Annotation: Subtype: Link Rect: 59, 202, 96, 212 Annotation: Subtype: Link Rect: 335, 178, 372, 189 Annotation: Subtype: Link Rect: 378, 178, 414, 189 Annotation: Subtype: Link Rect: 377, 155, 414, 166 Annotation: Subtype: Link Rect: 420, 155, 456, 166 Annotation: Subtype: Link Rect: 207, 110, 245, 120 Annotation: Subtype: Link Rect: 251, 110, 287, 120 Annotation: Subtype: Link Rect: 216, 86, 253, 97 Annotation: Subtype: Link Rect: 385, 63, 422, 74 Page: Sequence: 18 Annotations: Annotation: Subtype: Link Rect: 248, 722, 286, 733 Annotation: Subtype: Link Rect: 352, 699, 389, 710 Annotation: Subtype: Link Rect: 419, 676, 456, 687 Annotation: Subtype: Link Rect: 59, 653, 96, 664 Annotation: Subtype: Link Rect: 327, 629, 364, 640 Annotation: Subtype: Link Rect: 370, 629, 406, 640 Annotation: Subtype: Link Rect: 257, 595, 294, 606 Annotation: Subtype: Link Rect: 300, 595, 336, 606 Annotation: Subtype: Link Rect: 412, 572, 449, 583 Annotation: Subtype: Link Rect: 456, 572, 492, 583 Annotation: Subtype: Link Rect: 227, 549, 264, 560 Annotation: Subtype: Link Rect: 237, 526, 275, 537 Annotation: Subtype: Link Rect: 153, 504, 190, 514 Annotation: Subtype: Link Rect: 157, 481, 194, 491 Annotation: Subtype: Link Rect: 59, 458, 96, 468 Annotation: Subtype: Link Rect: 430, 434, 467, 445 Annotation: Subtype: Link Rect: 409, 411, 447, 422 Annotation: Subtype: Link Rect: 453, 411, 489, 422 Annotation: Subtype: Link Rect: 253, 388, 290, 399 Annotation: Subtype: Link Rect: 296, 388, 332, 399 Annotation: Subtype: Link Rect: 472, 376, 510, 387 Annotation: Subtype: Link Rect: 516, 376, 552, 387 Annotation: Subtype: Link Rect: 59, 354, 96, 364 Annotation: Subtype: Link Rect: 104, 331, 141, 341 Annotation: Subtype: Link Rect: 162, 308, 199, 318 Annotation: Subtype: Link Rect: 502, 284, 539, 295 Annotation: Subtype: Link Rect: 408, 261, 446, 272 Annotation: Subtype: Link Rect: 257, 238, 294, 249 Annotation: Subtype: Link Rect: 254, 204, 291, 215 Annotation: Subtype: Link Rect: 415, 158, 453, 169 Annotation: Subtype: Link Rect: 459, 158, 495, 169 Annotation: Subtype: Link Rect: 256, 135, 293, 146 Annotation: Subtype: Link Rect: 479, 112, 516, 123 Annotation: Subtype: Link Rect: 521, 112, 557, 123 Checksum: 2c843cc0 Type: CRC32 Checksum: f5a67992357b13ab3c20e1323b8c3f5e Type: MD5 Checksum: 3d8275e5f353b8ad22090f9241ef7d16b1ad26c6 Type: SHA-1