94c934081caa11728b8f15e62352f296  sfae191.pdf
56dc13801f1f027a34c064f979bf178579216b20  sfae191.pdf
437c74b1dec64d6c86aea864e733487176f0e8551c9121f40a6ea4fa47bb09d3  sfae191.pdf

Title:           Vertebral fractures in patients with CKD and the general population: a call for diagnosis and action
Subject:         DOI: 10.1093/ckj/sfae191 Clinical Kidney Journal, 17, 8, 09-07-2024. Abstract: Vertebral fractures (VFs) are the most common osteoporotic fractures in the general population, and they have been associated with high mortality, decreased quality of life, and high risk of subsequent fractures, especially when recent, multiple, or severe. Currently, VF diagnosis and classification determine fracture risk and the most appropriate anti-osteoporotic treatment. However, VFs are clearly underdiagnosed, especially in patients with chronic kidney disease (CKD), and CKD-associated osteoporosis has been disregarded until recently. VFs are associated with higher morbidity and mortality, and their prevalence and incidence differ depending on the grade of renal dysfunction (CKD G1–G5) and/or the type of renal replacement therapy (dialysis or transplantation). In addition to classical risk factors [such as higher age, female sex, reduced bone mineral density, diabetes and steroid use], various other factors have been associated with an increased risk of VFs in CKD, including CKD grade, haemodialysis vintage, time since renal transplantation, low or high intact parathyroid hormone and phosphate levels, and/or vitamin D and K1 deficiencies. Importantly, several clinical societies have recently modified their algorithms according to the fracture risk classification (including the presence of VFs) and determined the most appropriate anti-osteoporotic treatment for the general population. However, there are no specific guidelines addressing this topic in patients with CKD despite an important paradigm shift regarding the prognostic value of bone mineral density in 2017 after the publication of the CKD-Mineral and Bone Disorder Kidney Disease: Improving Global Outcomes guidelines. A proactive attitude towards diagnosis, treatment, and research is proposed to avoid therapeutic nihilism.
Keywords:        chronic kidney disease, dialysis, kidney transplant, risk factors, vertebral fracture
Author:          Gifre Laia, Massó Elisabet, Fusaro Maria, Haarhaus Mathias, Ureña Pablo, Cozzolino Mario, Mazzaferro Sandro, Calabia Jordi, Peris Pilar, Bover Jordi
Creator:         OUP
Producer:        Acrobat Distiller 10.0.0 (Windows)
CreationDate:    Sat Jul 27 03:58:01 2024 CEST
ModDate:         Sat Jul 27 03:58:35 2024 CEST
Custom Metadata: yes
Metadata Stream: yes
Tagged:          yes
UserProperties:  no
Suspects:        no
Form:            none
JavaScript:      no
Pages:           14
Encrypted:       no
Page size:       612.284 x 790.866 pts
Page rot:        0
File size:       1053921 bytes
Optimized:       yes
PDF version:     1.3


name                                 type              encoding         emb sub uni object ID
------------------------------------ ----------------- ---------------- --- --- --- ---------
KANNNM+CaeciliaLTStd-Bold            Type 1C           Custom           yes yes yes   2935  0
KAOAFM+CaeciliaLTStd-Heavy           Type 1C           WinAnsi          yes yes no    2940  0
KANNNJ+CaeciliaLTStd-Italic          Type 1C           WinAnsi          yes yes no    2943  0
KANNNL+CaeciliaLTStd-Roman           Type 1C           Custom           yes yes yes   2946  0
KANNNK+dummy-space                   Type 1C           WinAnsi          yes yes no    2951  0
KAOBEH+RMTMI                         Type 1C           Custom           yes yes yes    650  0
KAOBEI+MTSY                          Type 1C           Custom           yes yes yes    655  0
KAOLGH+ArialMT                       Type 1C           MacRoman         yes yes no      79  0
KAOLGI+Arial-BoldMT                  Type 1C           WinAnsi          yes yes no      82  0
KAONBO+TimesNewRomanPSMT             Type 1C           Custom           yes yes yes    660  0


Jhove (Rel. 1.28.0, 2023-05-18)
 Date: 2025-06-24 02:46:18 CEST
 RepresentationInformation: sfae191.pdf
  ReportingModule: PDF-hul, Rel. 1.12.4 (2023-03-16)
  LastModified: 2025-06-23 18:59:07 CEST
  Size: 1053921
  Format: PDF
  Version: 1.3
  Status: Well-Formed, but not valid
  SignatureMatches:
   PDF-hul
  ErrorMessage: Invalid indirect destination - referenced object 'bib96-b' cannot be found
   ID: PDF-HUL-149
  ErrorMessage: Invalid indirect destination - referenced object 'bib98-b' cannot be found
   ID: PDF-HUL-149
  ErrorMessage: Invalid indirect destination - referenced object 'bib99-b' cannot be found
   ID: PDF-HUL-149
  ErrorMessage: Invalid indirect destination - referenced object 'bib97-b' cannot be found
   ID: PDF-HUL-149
  ErrorMessage: edu.harvard.hul.ois.jhove.module.pdf.PdfInvalidException: Invalid indirect destination - referenced object 'bib99-b' cannot be found
   ID: PDF-HUL-122
   Offset: 776151
  ErrorMessage: edu.harvard.hul.ois.jhove.module.pdf.PdfInvalidException: Invalid indirect destination - referenced object 'bib96-b' cannot be found
   ID: PDF-HUL-122
   Offset: 776151
  ErrorMessage: edu.harvard.hul.ois.jhove.module.pdf.PdfInvalidException: Invalid indirect destination - referenced object 'bib97-b' cannot be found
   ID: PDF-HUL-122
   Offset: 776151
  ErrorMessage: edu.harvard.hul.ois.jhove.module.pdf.PdfInvalidException: Invalid indirect destination - referenced object 'bib98-b' cannot be found
   ID: PDF-HUL-122
   Offset: 776151
  MIMEtype: application/pdf
  Profile: Linearized PDF, Tagged PDF
  PDFMetadata: 
   Objects: 3022
   FreeObjects: 1
   IncrementalUpdates: 1
   DocumentCatalog: 
    ViewerPreferences: 
     HideToolbar: false
     HideMenubar: false
     HideWindowUI: false
     FitWindow: false
     CenterWindow: false
     DisplayDocTitle: true
     NonFullScreenPageMode: UseNone
     Direction: L2R
     ViewArea: CropBox
     ViewClip: CropBox
     PrintArea: CropBox
     PageClip: CropBox
    PageLayout: OneColumn
    PageMode: UseOutlines
    Language: English
    Outlines: 
     Item: 
      Title: INTRODUCTION
      Destination: section*.2
     Item: 
      Title: DIAGNOSTIC CRITERIA
      Destination: section*.4
     Item: 
      Title: EPIDEMIOLOGY
      Destination: section*.6
     Item: 
      Title: General population
      Destination: section*.8
     Item: 
      Title: CKD
      Destination: section*.12
     Item: 
      Title: VERTEBRAL FRACTURE AS A RISK BIOMARKER
      Destination: section*.26
     Item: 
      Title: Subsequent fractures
      Destination: section*.28
     Item: 
      Title: Morbidity
      Destination: section*.30
     Item: 
      Title: Mortality
      Destination: section*.32
     Item: 
      Title: SCREENING STRATEGY AND FRACTURE RISK CLASSIFICATION
      Destination: section*.34
     Item: 
      Title: CONCLUSIONS
      Destination: section*.36
     Item: 
      Title: FUNDING
      Destination: section*.38
     Item: 
      Title: DATA AVAILABILITY STATEMENT
      Destination: section*.40
     Item: 
      Title: CONFLICT OF INTEREST STATEMENT
      Destination: section*.42
     Item: 
      Title: REFERENCES
      Destination: section*.44
   Info: 
    Title: Vertebral fractures in patients with CKD and the general population: a call for diagnosis and action
    Author: Gifre Laia, Massó Elisabet, Fusaro Maria, Haarhaus Mathias, Ureña Pablo, Cozzolino Mario, Mazzaferro Sandro, Calabia Jordi, Peris Pilar, Bover Jordi
    Subject: DOI: 10.1093/ckj/sfae191 Clinical Kidney Journal, 17, 8, 09-07-2024. Abstract: Vertebral fractures (VFs) are the most common osteoporotic fractures in the general population, and they have been associated with high mortality, decreased quality of life, and high risk of subsequent fractures, especially when recent, multiple, or severe. Currently, VF diagnosis and classification determine fracture risk and the most appropriate anti-osteoporotic treatment. However, VFs are clearly underdiagnosed, especially in patients with chronic kidney disease (CKD), and CKD-associated osteoporosis has been disregarded until recently. VFs are associated with higher morbidity and mortality, and their prevalence and incidence differ depending on the grade of renal dysfunction (CKD G1–G5) and/or the type of renal replacement therapy (dialysis or transplantation). In addition to classical risk factors [such as higher age, female sex, reduced bone mineral density, diabetes and steroid use], various other factors have been associated with an increased risk of VFs in CKD, including CKD grade, haemodialysis vintage, time since renal transplantation, low or high intact parathyroid hormone and phosphate levels, and/or vitamin D and K1 deficiencies. Importantly, several clinical societies have recently modified their algorithms according to the fracture risk classification (including the presence of VFs) and determined the most appropriate anti-osteoporotic treatment for the general population. However, there are no specific guidelines addressing this topic in patients with CKD despite an important paradigm shift regarding the prognostic value of bone mineral density in 2017 after the publication of the CKD-Mineral and Bone Disorder Kidney Disease: Improving Global Outcomes guidelines. A proactive attitude towards diagnosis, treatment, and research is proposed to avoid therapeutic nihilism.
    Keywords: chronic kidney disease, dialysis, kidney transplant, risk factors, vertebral fracture
    Creator: OUP
    Producer: Acrobat Distiller 10.0.0 (Windows)
    CreationDate: Sat Jul 27 04:28:01 CEST 2024
    ModDate: Sat Jul 27 04:28:35 CEST 2024
   ID: 0x3ae636aa72d0ba87f9ec97cb6c6710d0, 0x6e8e0f5fb53b9db5df5cb10924ad85c0
   Filters: 
    FilterPipeline: FlateDecode
    FilterPipeline: DCTDecode
   Images: 
    Image: 
     NisoImageMetadata: 
      FormatName: image/jpg
      CompressionScheme: JPEG
      ImageWidth: 143
      ImageHeight: 151
      ColorSpace: CMYK
      BitsPerSample: 8
      BitsPerSampleUnit: integer
    Image: 
     NisoImageMetadata: 
      FormatName: image/jpg
      CompressionScheme: JPEG
      ImageWidth: 945
      ImageHeight: 668
      ColorSpace: black is zero
      BitsPerSample: 8
      BitsPerSampleUnit: integer
    Image: 
     NisoImageMetadata: 
      FormatName: image/png
      ImageWidth: 20
      ImageHeight: 12
      ColorSpace: RGB
      BitsPerSample: 8
      BitsPerSampleUnit: integer
     Filter: FlateDecode
    Image: 
     NisoImageMetadata: 
      FormatName: image/png
      ImageWidth: 388
      ImageHeight: 221
      BitsPerSample: 8
      BitsPerSampleUnit: integer
     Filter: FlateDecode
    Image: 
     NisoImageMetadata: 
      FormatName: image/png
      ImageWidth: 53
      ImageHeight: 100
      BitsPerSample: 8
      BitsPerSampleUnit: integer
     Filter: FlateDecode
    Image: 
     NisoImageMetadata: 
      FormatName: image/png
      ImageWidth: 311
      ImageHeight: 123
      BitsPerSample: 8
      BitsPerSampleUnit: integer
     Filter: FlateDecode
    Image: 
     NisoImageMetadata: 
      FormatName: image/png
      ImageWidth: 339
      ImageHeight: 146
      BitsPerSample: 8
      BitsPerSampleUnit: integer
     Filter: FlateDecode
    Image: 
     NisoImageMetadata: 
      FormatName: image/png
      ImageWidth: 336
      ImageHeight: 42
      BitsPerSample: 8
      BitsPerSampleUnit: integer
     Filter: FlateDecode
    Image: 
     NisoImageMetadata: 
      FormatName: image/png
      ImageWidth: 311
      ImageHeight: 165
      BitsPerSample: 8
      BitsPerSampleUnit: integer
     Filter: FlateDecode
    Image: 
     NisoImageMetadata: 
      FormatName: image/png
      ImageWidth: 56
      ImageHeight: 25
      BitsPerSample: 8
      BitsPerSampleUnit: integer
     Filter: FlateDecode
    Image: 
     NisoImageMetadata: 
      FormatName: image/png
      ImageWidth: 339
      ImageHeight: 123
      BitsPerSample: 8
      BitsPerSampleUnit: integer
     Filter: FlateDecode
    Image: 
     NisoImageMetadata: 
      FormatName: image/png
      ImageWidth: 335
      ImageHeight: 5
      BitsPerSample: 8
      BitsPerSampleUnit: integer
     Filter: FlateDecode
    Image: 
     NisoImageMetadata: 
      FormatName: image/png
      ImageWidth: 13
      ImageHeight: 37
      BitsPerSample: 8
      BitsPerSampleUnit: integer
     Filter: FlateDecode
    Image: 
     NisoImageMetadata: 
      FormatName: image/png
      ImageWidth: 307
      ImageHeight: 47
      BitsPerSample: 8
      BitsPerSampleUnit: integer
     Filter: FlateDecode
    Image: 
     NisoImageMetadata: 
      FormatName: image/png
      ImageWidth: 6
      ImageHeight: 59
      BitsPerSample: 8
      BitsPerSampleUnit: integer
     Filter: FlateDecode
    Image: 
     NisoImageMetadata: 
      FormatName: image/png
      ImageWidth: 335
      ImageHeight: 100
      BitsPerSample: 8
      BitsPerSampleUnit: integer
     Filter: FlateDecode
    Image: 
     NisoImageMetadata: 
      FormatName: image/png
      ImageWidth: 13
      ImageHeight: 47
      BitsPerSample: 8
      BitsPerSampleUnit: integer
     Filter: FlateDecode
    Image: 
     NisoImageMetadata: 
      FormatName: image/png
      ImageWidth: 314
      ImageHeight: 100
      BitsPerSample: 8
      BitsPerSampleUnit: integer
     Filter: FlateDecode
    Image: 
     NisoImageMetadata: 
      FormatName: image/png
      ImageWidth: 301
      ImageHeight: 12
      BitsPerSample: 8
      BitsPerSampleUnit: integer
     Filter: FlateDecode
    Image: 
     NisoImageMetadata: 
      FormatName: image/png
      ImageWidth: 4
      ImageHeight: 100
      BitsPerSample: 8
      BitsPerSampleUnit: integer
     Filter: FlateDecode
    Image: 
     NisoImageMetadata: 
      FormatName: image/png
      ImageWidth: 6
      ImageHeight: 42
      ColorSpace: RGB
      BitsPerSample: 8
      BitsPerSampleUnit: integer
     Filter: FlateDecode
    Image: 
     NisoImageMetadata: 
      FormatName: image/png
      ImageWidth: 24
      ImageHeight: 42
      BitsPerSample: 8
      BitsPerSampleUnit: integer
     Filter: FlateDecode
    Image: 
     NisoImageMetadata: 
      FormatName: image/png
      ImageWidth: 12
      ImageHeight: 57
      BitsPerSample: 8
      BitsPerSampleUnit: integer
     Filter: FlateDecode
    Image: 
     NisoImageMetadata: 
      FormatName: image/png
      ImageWidth: 25
      ImageHeight: 119
      BitsPerSample: 8
      BitsPerSampleUnit: integer
     Filter: FlateDecode
    Image: 
     NisoImageMetadata: 
      FormatName: image/png
      ImageWidth: 357
      ImageHeight: 52
      BitsPerSample: 8
      BitsPerSampleUnit: integer
     Filter: FlateDecode
    Image: 
     NisoImageMetadata: 
      FormatName: image/png
      ImageWidth: 24
      ImageHeight: 11
      BitsPerSample: 8
      BitsPerSampleUnit: integer
     Filter: FlateDecode
    Image: 
     NisoImageMetadata: 
      FormatName: image/png
      ImageWidth: 421
      ImageHeight: 78
      BitsPerSample: 8
      BitsPerSampleUnit: integer
     Filter: FlateDecode
    Image: 
     NisoImageMetadata: 
      FormatName: image/png
      ImageWidth: 421
      ImageHeight: 57
      BitsPerSample: 8
      BitsPerSampleUnit: integer
     Filter: FlateDecode
    Image: 
     NisoImageMetadata: 
      FormatName: image/png
      ImageWidth: 380
      ImageHeight: 59
      BitsPerSample: 8
      BitsPerSampleUnit: integer
     Filter: FlateDecode
    Image: 
     NisoImageMetadata: 
      FormatName: image/png
      ImageWidth: 319
      ImageHeight: 93
      BitsPerSample: 8
      BitsPerSampleUnit: integer
     Filter: FlateDecode
    Image: 
     NisoImageMetadata: 
      FormatName: image/png
      ImageWidth: 380
      ImageHeight: 111
      BitsPerSample: 8
      BitsPerSampleUnit: integer
     Filter: FlateDecode
    Image: 
     NisoImageMetadata: 
      FormatName: image/png
      ImageWidth: 24
      ImageHeight: 111
      BitsPerSample: 8
      BitsPerSampleUnit: integer
     Filter: FlateDecode
    Image: 
     NisoImageMetadata: 
      FormatName: image/png
      ImageWidth: 319
      ImageHeight: 120
      BitsPerSample: 8
      BitsPerSampleUnit: integer
     Filter: FlateDecode
    Image: 
     NisoImageMetadata: 
      FormatName: image/png
      ImageWidth: 388
      ImageHeight: 25
      BitsPerSample: 8
      BitsPerSampleUnit: integer
     Filter: FlateDecode
    Image: 
     NisoImageMetadata: 
      FormatName: image/png
      ImageWidth: 388
      ImageHeight: 123
      BitsPerSample: 8
      BitsPerSampleUnit: integer
     Filter: FlateDecode
    Image: 
     NisoImageMetadata: 
      FormatName: image/png
      ImageWidth: 56
      ImageHeight: 123
      BitsPerSample: 8
      BitsPerSampleUnit: integer
     Filter: FlateDecode
    Image: 
     NisoImageMetadata: 
      FormatName: image/png
      ImageWidth: 53
      ImageHeight: 5
      BitsPerSample: 8
      BitsPerSampleUnit: integer
     Filter: FlateDecode
    Image: 
     NisoImageMetadata: 
      FormatName: image/png
      ImageWidth: 339
      ImageHeight: 119
      BitsPerSample: 8
      BitsPerSampleUnit: integer
     Filter: FlateDecode
    Image: 
     NisoImageMetadata: 
      FormatName: image/png
      ImageWidth: 56
      ImageHeight: 119
      BitsPerSample: 8
      BitsPerSampleUnit: integer
     Filter: FlateDecode
    Image: 
     NisoImageMetadata: 
      FormatName: image/png
      ImageWidth: 454
      ImageHeight: 287
      BitsPerSample: 8
      BitsPerSampleUnit: integer
     Filter: FlateDecode
    Image: 
     NisoImageMetadata: 
      FormatName: image/png
      ImageWidth: 100
      ImageHeight: 142
      BitsPerSample: 8
      BitsPerSampleUnit: integer
     Filter: FlateDecode
    Image: 
     NisoImageMetadata: 
      FormatName: image/png
      ImageWidth: 364
      ImageHeight: 169
      BitsPerSample: 8
      BitsPerSampleUnit: integer
     Filter: FlateDecode
    Image: 
     NisoImageMetadata: 
      FormatName: image/png
      ImageWidth: 364
      ImageHeight: 119
      BitsPerSample: 8
      BitsPerSampleUnit: integer
     Filter: FlateDecode
    Image: 
     NisoImageMetadata: 
      FormatName: image/png
      ImageWidth: 364
      ImageHeight: 120
      BitsPerSample: 8
      BitsPerSampleUnit: integer
     Filter: FlateDecode
    Image: 
     NisoImageMetadata: 
      FormatName: image/png
      ImageWidth: 307
      ImageHeight: 179
      BitsPerSample: 8
      BitsPerSampleUnit: integer
     Filter: FlateDecode
    Image: 
     NisoImageMetadata: 
      FormatName: image/png
      ImageWidth: 348
      ImageHeight: 259
      BitsPerSample: 8
      BitsPerSampleUnit: integer
     Filter: FlateDecode
    Image: 
     NisoImageMetadata: 
      FormatName: image/png
      ImageWidth: 431
      ImageHeight: 193
      BitsPerSample: 8
      BitsPerSampleUnit: integer
     Filter: FlateDecode
    Image: 
     NisoImageMetadata: 
      FormatName: image/png
      ImageWidth: 13
      ImageHeight: 224
      BitsPerSample: 8
      BitsPerSampleUnit: integer
     Filter: FlateDecode
    Image: 
     NisoImageMetadata: 
      FormatName: image/png
      ImageWidth: 53
      ImageHeight: 188
      BitsPerSample: 8
      BitsPerSampleUnit: integer
     Filter: FlateDecode
    Image: 
     NisoImageMetadata: 
      FormatName: image/png
      ImageWidth: 421
      ImageHeight: 167
      BitsPerSample: 8
      BitsPerSampleUnit: integer
     Filter: FlateDecode
    Image: 
     NisoImageMetadata: 
      FormatName: image/png
      ImageWidth: 39
      ImageHeight: 287
      BitsPerSample: 8
      BitsPerSampleUnit: integer
     Filter: FlateDecode
   Fonts: 
    Type1: 
     Font: 
      BaseFont: KANNNL+CaeciliaLTStd-Roman
      FontSubset: true
      FirstChar: 2
      LastChar: 250
      FontDescriptor: 
       FontName: KANNNL+CaeciliaLTStd-Roman
       Flags: Serif, Symbolic
       FontBBox: -167, -270, 1136, 926
       FontFile3: true
      EncodingDictionary: 
       Differences: true
      ToUnicode: true
     Font: 
      BaseFont: KAOLGI+Arial-BoldMT
      FontSubset: true
      FirstChar: 32
      LastChar: 121
      FontDescriptor: 
       FontName: KAOLGI+Arial-BoldMT
       Flags: Nonsymbolic
       FontBBox: -628, -376, 2000, 1010
       FontFile3: true
      Encoding: WinAnsiEncoding
     Font: 
      BaseFont: KAONBO+TimesNewRomanPSMT
      FontSubset: true
      FirstChar: 2
      LastChar: 3
      FontDescriptor: 
       FontName: KAONBO+TimesNewRomanPSMT
       Flags: Symbolic
       FontBBox: 17, 90, 543, 572
       FontFile3: true
      EncodingDictionary: 
       Differences: true
      ToUnicode: true
     Font: 
      BaseFont: KANNNK+dummy-space
      FontSubset: true
      FirstChar: 32
      LastChar: 32
      FontDescriptor: 
       FontName: KANNNK+dummy-space
       Flags: Nonsymbolic
       FontBBox: 0, 0, 0, 0
       FontFile3: true
      Encoding: WinAnsiEncoding
     Font: 
      BaseFont: KANNNM+CaeciliaLTStd-Bold
      FontSubset: true
      FirstChar: 2
      LastChar: 121
      FontDescriptor: 
       FontName: KANNNM+CaeciliaLTStd-Bold
       Flags: Serif, Symbolic, ForceBold
       FontBBox: -166, -273, 1141, 938
       FontFile3: true
      EncodingDictionary: 
       Differences: true
      ToUnicode: true
     Font: 
      BaseFont: KAOBEH+RMTMI
      FontSubset: true
      FirstChar: 60
      LastChar: 62
      FontDescriptor: 
       FontName: KAOBEH+RMTMI
       Flags: Symbolic, Italic
       FontBBox: 0, -213, 987, 680
       FontFile3: true
      EncodingDictionary: 
       Differences: true
      ToUnicode: true
     Font: 
      BaseFont: KAOAFM+CaeciliaLTStd-Heavy
      FontSubset: true
      FirstChar: 48
      LastChar: 89
      FontDescriptor: 
       FontName: KAOAFM+CaeciliaLTStd-Heavy
       Flags: Nonsymbolic, ForceBold
       FontBBox: -170, -277, 1146, 970
       FontFile3: true
      Encoding: WinAnsiEncoding
     Font: 
      BaseFont: KANNNJ+CaeciliaLTStd-Italic
      FontSubset: true
      FirstChar: 40
      LastChar: 241
      FontDescriptor: 
       FontName: KANNNJ+CaeciliaLTStd-Italic
       Flags: Serif, Nonsymbolic, Italic
       FontBBox: -166, -270, 1053, 915
       FontFile3: true
      Encoding: WinAnsiEncoding
     Font: 
      BaseFont: KAOBEI+MTSY
      FontSubset: true
      FirstChar: 2
      LastChar: 215
      FontDescriptor: 
       FontName: KAOBEI+MTSY
       Flags: Symbolic
       FontBBox: 0, -954, 1043, 796
       FontFile3: true
      EncodingDictionary: 
       Differences: true
      ToUnicode: true
     Font: 
      BaseFont: KAOLGH+ArialMT
      FontSubset: true
      FirstChar: 32
      LastChar: 208
      FontDescriptor: 
       FontName: KAOLGH+ArialMT
       Flags: Nonsymbolic
       FontBBox: -665, -325, 2000, 1006
       FontFile3: true
      Encoding: MacRomanEncoding
   XMP: <x:xmpmeta xmlns:x="adobe:ns:meta/" x:xmptk="XMP Core 5.1.2">
   <rdf:RDF xmlns:rdf="http://www.w3.org/1999/02/22-rdf-syntax-ns#">
      <rdf:Description rdf:about=""
            xmlns:xmp="http://ns.adobe.com/xap/1.0/">
         <xmp:CreateDate>2024-07-27T07:28:01+05:30</xmp:CreateDate>
         <xmp:ModifyDate>2024-07-27T07:28:35+05:30</xmp:ModifyDate>
         <xmp:MetadataDate>2024-07-27T07:28:35+05:30</xmp:MetadataDate>
         <xmp:CreatorTool>OUP</xmp:CreatorTool>
      </rdf:Description>
      <rdf:Description rdf:about=""
            xmlns:pdf="http://ns.adobe.com/pdf/1.3/">
         <pdf:Producer>Acrobat Distiller 10.0.0 (Windows)</pdf:Producer>
         <pdf:Keywords>chronic kidney disease, dialysis, kidney transplant, risk factors, vertebral fracture</pdf:Keywords>
      </rdf:Description>
      <rdf:Description rdf:about=""
            xmlns:jav="http://www.niso.org/schemas/jav/1.0/">
         <jav:journal_article_version>VoR</jav:journal_article_version>
      </rdf:Description>
      <rdf:Description rdf:about=""
            xmlns:pdfx="http://ns.adobe.com/pdfx/1.3/">
         <pdfx:doi>10.1093/ckj/sfae191</pdfx:doi>
      </rdf:Description>
      <rdf:Description rdf:about=""
            xmlns:prism="http://prismstandard.org/namespaces/basic/3.0/">
         <prism:issn>2048-8513</prism:issn>
         <prism:publicationName>Clinical Kidney Journal</prism:publicationName>
         <prism:aggregationType>journal</prism:aggregationType>
         <prism:volume>17</prism:volume>
         <prism:doi>10.1093/ckj/sfae191</prism:doi>
         <prism:url>https://doi.org/10.1093/ckj/sfae191</prism:url>
         <prism:copyright>© The Author(s) 2024. Published by Oxford University Press on behalf of the ERA. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (https://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com</prism:copyright>
      </rdf:Description>
      <rdf:Description rdf:about=""
            xmlns:dc="http://purl.org/dc/elements/1.1/">
         <dc:rightsHolder>All Rights Reserved</dc:rightsHolder>
         <dc:format>application/pdf</dc:format>
         <dc:identifier>doi:10.1093/ckj/sfae191</dc:identifier>
         <dc:rights>
            <rdf:Alt>
               <rdf:li xml:lang="x-default">© The Author(s) 2024. Published by Oxford University Press on behalf of the ERA. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (https://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com</rdf:li>
            </rdf:Alt>
         </dc:rights>
         <dc:contributor>
            <rdf:Seq>
               <rdf:li>Gifre Laia</rdf:li>
               <rdf:li>Massó Elisabet</rdf:li>
               <rdf:li>Fusaro Maria</rdf:li>
               <rdf:li>Haarhaus Mathias</rdf:li>
               <rdf:li>Ureña Pablo</rdf:li>
               <rdf:li>Cozzolino Mario</rdf:li>
               <rdf:li>Mazzaferro Sandro</rdf:li>
               <rdf:li>Calabia Jordi</rdf:li>
               <rdf:li>Peris Pilar</rdf:li>
               <rdf:li>Bover Jordi</rdf:li>
            </rdf:Seq>
         </dc:contributor>
         <dc:publisher>
            <rdf:Bag>
               <rdf:li>Oxford University Press</rdf:li>
            </rdf:Bag>
         </dc:publisher>
         <dc:description>
            <rdf:Alt>
               <rdf:li xml:lang="x-default">DOI: 10.1093/ckj/sfae191 Clinical Kidney Journal, 17, 8, 09-07-2024. Abstract: Vertebral fractures (VFs) are the most common osteoporotic fractures in the general population, and they have been associated with high mortality, decreased quality of life, and high risk of subsequent fractures, especially when recent, multiple, or severe. Currently, VF diagnosis and classification determine fracture risk and the most appropriate anti-osteoporotic treatment. However, VFs are clearly underdiagnosed, especially in patients with chronic kidney disease (CKD), and CKD-associated osteoporosis has been disregarded until recently. VFs are associated with higher morbidity and mortality, and their prevalence and incidence differ depending on the grade of renal dysfunction (CKD G1&amp;#x2013;G5) and/or the type of renal replacement therapy (dialysis or transplantation). In addition to classical risk factors &amp;#x005B;such as higher age, female sex, reduced bone mineral density, diabetes and steroid use&amp;#x005D;, various other factors have been associated with an increased risk of VFs in CKD, including CKD grade, haemodialysis vintage, time since renal transplantation, low or high intact parathyroid hormone and phosphate levels, and/or vitamin D and K1 deficiencies. Importantly, several clinical societies have recently modified their algorithms according to the fracture risk classification (including the presence of VFs) and determined the most appropriate anti-osteoporotic treatment for the general population. However, there are no specific guidelines addressing this topic in patients with CKD despite an important paradigm shift regarding the prognostic value of bone mineral density in 2017 after the publication of the CKD-Mineral and Bone Disorder Kidney Disease: Improving Global Outcomes guidelines. A proactive attitude towards diagnosis, treatment, and research is proposed to avoid therapeutic nihilism.</rdf:li>
            </rdf:Alt>
         </dc:description>
         <dc:subject>
            <rdf:Bag>
               <rdf:li>chronic kidney disease</rdf:li>
               <rdf:li>dialysis</rdf:li>
               <rdf:li>kidney transplant</rdf:li>
               <rdf:li>risk factors</rdf:li>
               <rdf:li>vertebral fracture</rdf:li>
            </rdf:Bag>
         </dc:subject>
         <dc:title>
            <rdf:Alt>
               <rdf:li xml:lang="x-default">Vertebral fractures in patients with CKD and the general population: a call for diagnosis and action</rdf:li>
            </rdf:Alt>
         </dc:title>
         <dc:creator>
            <rdf:Seq>
               <rdf:li>Gifre Laia, Massó Elisabet, Fusaro Maria, Haarhaus Mathias, Ureña Pablo, Cozzolino Mario, Mazzaferro Sandro, Calabia Jordi, Peris Pilar, Bover Jordi</rdf:li>
            </rdf:Seq>
         </dc:creator>
      </rdf:Description>
      <rdf:Description rdf:about=""
            xmlns:xmpMM="http://ns.adobe.com/xap/1.0/mm/">
         <xmpMM:DocumentID>uuid:31adbbc9-492f-3ebf-bf10-5f7c6235fc30</xmpMM:DocumentID>
         <xmpMM:InstanceID>uuid:05ad7c44-120c-4eb1-b5ac-bf4c90811a28</xmpMM:InstanceID>
      </rdf:Description>
      <rdf:Description rdf:about=""
            xmlns:xmpRights="http://ns.adobe.com/xap/1.0/rights/">
         <xmpRights:Marked>True</xmpRights:Marked>
      </rdf:Description>
   </rdf:RDF>
</x:xmpmeta>
   Pages: 
    Page: 
     Label: 1
     Annotations: 
      Annotation: 
       Subtype: Link
       Rect: 62, 683, 116, 694
      Annotation: 
       Subtype: Link
       Rect: 314, 709, 426, 719
      Annotation: 
       Subtype: Link
       Rect: 125, 543, 139, 560
      Annotation: 
       Subtype: Link
       Rect: 137, 549, 144, 561
       Destination: 2918
      Annotation: 
       Subtype: Link
       Rect: 243, 549, 250, 561
       Destination: 2918
      Annotation: 
       Subtype: Link
       Rect: 340, 543, 354, 560
      Annotation: 
       Subtype: Link
       Rect: 352, 549, 359, 561
       Destination: 2918
      Annotation: 
       Subtype: Link
       Rect: 483, 543, 497, 560
      Annotation: 
       Subtype: Link
       Rect: 495, 549, 502, 561
       Destination: 2918
      Annotation: 
       Subtype: Link
       Rect: 503, 549, 510, 561
       Destination: 2918
      Annotation: 
       Subtype: Link
       Rect: 138, 531, 145, 543
       Destination: 2918
      Annotation: 
       Subtype: Link
       Rect: 146, 531, 153, 543
       Destination: 2918
      Annotation: 
       Subtype: Link
       Rect: 264, 525, 278, 542
      Annotation: 
       Subtype: Link
       Rect: 276, 531, 283, 543
       Destination: 2918
      Annotation: 
       Subtype: Link
       Rect: 411, 525, 425, 542
      Annotation: 
       Subtype: Link
       Rect: 423, 531, 430, 543
       Destination: 2918
      Annotation: 
       Subtype: Link
       Rect: 515, 531, 527, 543
       Destination: 2918
      Annotation: 
       Subtype: Link
       Rect: 125, 513, 137, 525
       Destination: 2918
      Annotation: 
       Subtype: Link
       Rect: 239, 513, 246, 525
       Destination: 2918
      Annotation: 
       Subtype: Link
       Rect: 184, 317, 285, 326
      Annotation: 
       Subtype: Link
       Rect: 218, 71, 374, 80
      Annotation: 
       Subtype: Link
       Rect: 435, 61, 537, 71
     Thumb: true
    Page: 
     Label: 2
     Annotations: 
      Annotation: 
       Subtype: Link
       Rect: 100, 593, 106, 603
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 148, 561, 154, 572
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 156, 561, 162, 572
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 141, 551, 147, 561
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 149, 551, 155, 561
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 65, 519, 72, 530
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 177, 509, 183, 519
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 199, 498, 205, 509
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 125, 435, 131, 446
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 65, 425, 76, 435
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 188, 404, 198, 414
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 138, 278, 148, 288
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 151, 278, 161, 288
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 90, 236, 100, 246
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 242, 215, 252, 225
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 254, 215, 264, 225
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 240, 183, 250, 194
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 208, 131, 218, 141
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 244, 110, 255, 120
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 431, 610, 441, 620
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 334, 578, 344, 589
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 346, 578, 356, 589
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 524, 557, 535, 568
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 535, 494, 545, 505
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 356, 410, 366, 421
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 539, 349, 545, 359
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 487, 233, 493, 244
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 495, 233, 505, 244
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 523, 212, 534, 223
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 497, 191, 504, 202
       Destination: 38
      Annotation: 
       Subtype: Link
       Rect: 508, 191, 515, 202
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 359, 160, 365, 170
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 367, 160, 373, 170
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 316, 128, 323, 139
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 464, 86, 474, 97
       Destination: 423
     Thumb: true
    Page: 
     Label: 3
     Annotations: 
      Annotation: 
       Subtype: Link
       Rect: 276, 467, 282, 476
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 123, 394, 129, 404
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 133, 394, 139, 404
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 169, 278, 175, 289
       Destination: 71
      Annotation: 
       Subtype: Link
       Rect: 84, 163, 94, 173
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 262, 44, 268, 55
       Destination: 227
      Annotation: 
       Subtype: Link
       Rect: 271, 44, 281, 55
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 283, 44, 293, 55
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 414, 394, 425, 404
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 459, 362, 470, 373
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 472, 362, 483, 373
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 415, 331, 425, 341
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 335, 299, 342, 310
       Destination: 266
      Annotation: 
       Subtype: Link
       Rect: 345, 299, 355, 310
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 358, 299, 368, 310
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 370, 299, 380, 310
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 476, 278, 486, 289
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 488, 278, 498, 289
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 415, 257, 425, 268
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 441, 170, 452, 181
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 416, 128, 427, 139
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 372, 107, 379, 118
       Destination: 227
      Annotation: 
       Subtype: Link
       Rect: 451, 97, 462, 107
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 464, 97, 474, 107
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 417, 76, 428, 86
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 430, 76, 440, 86
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 460, 55, 470, 65
       Destination: 476
     Thumb: true
    Page: 
     Label: 4
     Annotations: 
      Annotation: 
       Subtype: Link
       Rect: 124, 336, 134, 347
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 136, 336, 146, 347
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 157, 315, 168, 326
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 83, 305, 94, 315
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 152, 210, 159, 221
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 161, 137, 167, 147
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 169, 137, 180, 147
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 182, 137, 192, 147
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 194, 137, 204, 147
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 206, 137, 216, 147
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 218, 137, 229, 147
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 189, 74, 199, 84
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 425, 336, 435, 347
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 437, 336, 447, 347
       Destination: 532
      Annotation: 
       Subtype: Link
       Rect: 420, 315, 430, 326
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 432, 315, 443, 326
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 444, 315, 455, 326
       Destination: 532
      Annotation: 
       Subtype: Link
       Rect: 489, 284, 496, 294
       Destination: 266
      Annotation: 
       Subtype: Link
       Rect: 336, 273, 347, 284
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 535, 252, 545, 263
       Destination: 532
      Annotation: 
       Subtype: Link
       Rect: 432, 231, 442, 242
       Destination: 532
      Annotation: 
       Subtype: Link
       Rect: 363, 221, 373, 231
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 469, 210, 479, 221
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 482, 210, 493, 221
       Destination: 532
      Annotation: 
       Subtype: Link
       Rect: 496, 210, 506, 221
       Destination: 532
      Annotation: 
       Subtype: Link
       Rect: 338, 189, 349, 200
       Destination: 532
      Annotation: 
       Subtype: Link
       Rect: 350, 189, 361, 200
       Destination: 532
      Annotation: 
       Subtype: Link
       Rect: 515, 168, 526, 179
       Destination: 532
      Annotation: 
       Subtype: Link
       Rect: 507, 116, 514, 126
       Destination: 227
     Thumb: true
    Page: 
     Label: 5
     Annotations: 
      Annotation: 
       Subtype: Link
       Rect: 172, 667, 182, 677
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 163, 648, 173, 658
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 168, 628, 177, 638
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 246, 608, 256, 618
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 190, 598, 203, 608
       Destination: 592
      Annotation: 
       Subtype: Link
       Rect: 156, 578, 166, 588
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 181, 558, 191, 568
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 276, 526, 285, 535
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 226, 516, 236, 526
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 368, 516, 374, 526
       Destination: 227
      Annotation: 
       Subtype: Link
       Rect: 255, 500, 265, 510
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 221, 490, 231, 500
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 258, 480, 268, 490
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 215, 460, 225, 470
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 252, 434, 262, 444
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 233, 423, 243, 433
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 251, 413, 260, 423
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 228, 383, 237, 393
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 243, 373, 253, 383
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 222, 363, 231, 373
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 216, 297, 222, 307
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 225, 297, 231, 307
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 234, 297, 240, 307
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 243, 297, 253, 307
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 259, 170, 270, 181
       Destination: 532
      Annotation: 
       Subtype: Link
       Rect: 113, 118, 124, 128
       Destination: 532
      Annotation: 
       Subtype: Link
       Rect: 236, 76, 246, 86
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 247, 76, 258, 86
       Destination: 532
      Annotation: 
       Subtype: Link
       Rect: 283, 55, 293, 65
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 499, 276, 510, 286
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 512, 276, 522, 286
       Destination: 532
      Annotation: 
       Subtype: Link
       Rect: 347, 234, 353, 244
       Destination: 266
      Annotation: 
       Subtype: Link
       Rect: 462, 192, 473, 202
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 476, 192, 486, 202
       Destination: 532
      Annotation: 
       Subtype: Link
       Rect: 475, 171, 486, 181
       Destination: 532
      Annotation: 
       Subtype: Link
       Rect: 466, 150, 473, 160
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 452, 129, 458, 139
       Destination: 423
     Thumb: true
    Page: 
     Label: 6
     Annotations: 
      Annotation: 
       Subtype: Link
       Rect: 161, 667, 171, 677
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 230, 658, 239, 667
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 220, 628, 230, 638
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 163, 598, 173, 608
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 111, 578, 121, 588
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 244, 545, 254, 555
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 251, 535, 261, 545
       Destination: 532
      Annotation: 
       Subtype: Link
       Rect: 237, 506, 247, 516
       Destination: 532
      Annotation: 
       Subtype: Link
       Rect: 341, 516, 347, 526
       Destination: 266
      Annotation: 
       Subtype: Link
       Rect: 237, 486, 247, 496
       Destination: 532
      Annotation: 
       Subtype: Link
       Rect: 211, 130, 221, 141
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 223, 130, 233, 141
       Destination: 532
      Annotation: 
       Subtype: Link
       Rect: 65, 88, 76, 99
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 194, 78, 205, 88
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 335, 109, 346, 120
       Destination: 532
      Annotation: 
       Subtype: Link
       Rect: 388, 78, 398, 88
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 400, 78, 410, 88
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 412, 78, 423, 88
       Destination: 532
      Annotation: 
       Subtype: Link
       Rect: 446, 57, 457, 67
       Destination: 476
     Thumb: true
    Page: 
     Label: 7
     Annotations: 
      Annotation: 
       Subtype: Link
       Rect: 146, 717, 156, 727
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 118, 706, 128, 717
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 95, 664, 105, 675
       Destination: 532
      Annotation: 
       Subtype: Link
       Rect: 225, 654, 236, 664
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 263, 622, 273, 633
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 270, 580, 280, 591
       Destination: 532
      Annotation: 
       Subtype: Link
       Rect: 283, 580, 293, 591
       Destination: 532
      Annotation: 
       Subtype: Link
       Rect: 167, 528, 177, 538
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 95, 507, 106, 517
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 81, 486, 92, 496
       Destination: 532
      Annotation: 
       Subtype: Link
       Rect: 255, 423, 266, 433
       Destination: 532
      Annotation: 
       Subtype: Link
       Rect: 227, 402, 238, 412
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 240, 402, 250, 412
       Destination: 532
      Annotation: 
       Subtype: Link
       Rect: 180, 349, 191, 360
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 152, 328, 162, 339
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 220, 297, 230, 307
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 233, 297, 243, 307
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 245, 297, 256, 307
       Destination: 532
      Annotation: 
       Subtype: Link
       Rect: 136, 286, 146, 297
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 130, 213, 140, 223
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 119, 171, 129, 181
       Destination: 532
      Annotation: 
       Subtype: Link
       Rect: 103, 139, 113, 150
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 100, 129, 110, 139
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 114, 76, 125, 86
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 334, 654, 344, 664
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 439, 643, 449, 654
       Destination: 532
      Annotation: 
       Subtype: Link
       Rect: 316, 622, 326, 633
       Destination: 532
      Annotation: 
       Subtype: Link
       Rect: 466, 559, 476, 570
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 395, 528, 405, 538
       Destination: 532
      Annotation: 
       Subtype: Link
       Rect: 316, 507, 326, 517
       Destination: 532
      Annotation: 
       Subtype: Link
       Rect: 468, 465, 478, 475
       Destination: 532
      Annotation: 
       Subtype: Link
       Rect: 480, 465, 491, 475
       Destination: 532
      Annotation: 
       Subtype: Link
       Rect: 316, 433, 326, 444
       Destination: 532
      Annotation: 
       Subtype: Link
       Rect: 349, 391, 359, 402
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 348, 381, 358, 391
       Destination: 532
      Annotation: 
       Subtype: Link
       Rect: 451, 349, 461, 360
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 336, 297, 342, 307
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 384, 276, 394, 286
       Destination: 532
      Annotation: 
       Subtype: Link
       Rect: 460, 213, 470, 223
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 411, 181, 421, 192
       Destination: 532
      Annotation: 
       Subtype: Link
       Rect: 423, 181, 433, 192
       Destination: 532
      Annotation: 
       Subtype: Link
       Rect: 516, 86, 527, 97
       Destination: 532
      Annotation: 
       Subtype: Link
       Rect: 436, 65, 446, 76
       Destination: 532
      Annotation: 
       Subtype: Link
       Rect: 524, 55, 534, 65
       Destination: 532
     Thumb: true
    Page: 
     Label: 8
     Annotations: 
      Annotation: 
       Subtype: Link
       Rect: 132, 675, 142, 685
       Destination: 532
      Annotation: 
       Subtype: Link
       Rect: 202, 675, 213, 685
       Destination: 592
      Annotation: 
       Subtype: Link
       Rect: 136, 601, 142, 612
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 144, 601, 155, 612
       Destination: 592
      Annotation: 
       Subtype: Link
       Rect: 156, 601, 167, 612
       Destination: 592
      Annotation: 
       Subtype: Link
       Rect: 211, 580, 217, 591
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 139, 538, 145, 549
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 148, 538, 154, 549
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 237, 517, 243, 528
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 65, 507, 72, 517
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 167, 454, 174, 465
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 157, 402, 163, 412
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 133, 381, 140, 391
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 248, 339, 259, 349
       Destination: 532
      Annotation: 
       Subtype: Link
       Rect: 161, 286, 172, 297
       Destination: 592
      Annotation: 
       Subtype: Link
       Rect: 162, 223, 172, 234
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 191, 170, 201, 181
       Destination: 532
      Annotation: 
       Subtype: Link
       Rect: 85, 139, 95, 149
       Destination: 532
      Annotation: 
       Subtype: Link
       Rect: 236, 118, 246, 128
       Destination: 532
      Annotation: 
       Subtype: Link
       Rect: 148, 97, 154, 107
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 156, 97, 166, 107
       Destination: 532
      Annotation: 
       Subtype: Link
       Rect: 116, 55, 122, 65
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 535, 675, 545, 685
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 439, 643, 449, 654
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 479, 622, 490, 633
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 316, 580, 327, 591
       Destination: 592
      Annotation: 
       Subtype: Link
       Rect: 535, 570, 545, 580
       Destination: 592
      Annotation: 
       Subtype: Link
       Rect: 535, 485, 545, 496
       Destination: 592
      Annotation: 
       Subtype: Link
       Rect: 387, 422, 398, 433
       Destination: 592
      Annotation: 
       Subtype: Link
       Rect: 351, 370, 361, 380
       Destination: 592
      Annotation: 
       Subtype: Link
       Rect: 447, 338, 458, 349
       Destination: 592
      Annotation: 
       Subtype: Link
       Rect: 449, 296, 459, 307
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 353, 223, 364, 233
       Destination: 592
      Annotation: 
       Subtype: Link
       Rect: 420, 191, 426, 202
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 475, 170, 482, 181
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 316, 139, 327, 149
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 535, 86, 545, 97
       Destination: 476
     Thumb: true
    Page: 
     Label: 9
     Annotations: 
      Annotation: 
       Subtype: Link
       Rect: 322, 667, 327, 677
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 391, 510, 401, 520
       Destination: 592
      Annotation: 
       Subtype: Link
       Rect: 121, 424, 127, 434
       Destination: 372
      Annotation: 
       Subtype: Link
       Rect: 360, 388, 370, 398
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 121, 302, 127, 312
       Destination: 372
      Annotation: 
       Subtype: Link
       Rect: 345, 272, 358, 282
       Destination: 592
      Annotation: 
       Subtype: Link
       Rect: 316, 108, 322, 118
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 325, 108, 335, 118
       Destination: 592
     Thumb: true
    Page: 
     Label: 10
     Annotations: 
      Annotation: 
       Subtype: Link
       Rect: 241, 717, 247, 727
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 250, 717, 265, 727
       Destination: 592
      Annotation: 
       Subtype: Link
       Rect: 155, 591, 162, 601
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 164, 591, 174, 601
       Destination: 592
      Annotation: 
       Subtype: Link
       Rect: 144, 570, 155, 580
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 284, 570, 294, 580
       Destination: 592
      Annotation: 
       Subtype: Link
       Rect: 85, 559, 91, 570
       Destination: 372
      Annotation: 
       Subtype: Link
       Rect: 150, 496, 156, 507
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 158, 496, 168, 507
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 170, 496, 180, 507
       Destination: 592
      Annotation: 
       Subtype: Link
       Rect: 182, 496, 197, 507
       Destination: 592
      Annotation: 
       Subtype: Link
       Rect: 144, 433, 154, 444
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 115, 402, 125, 412
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 143, 349, 153, 360
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 177, 297, 183, 307
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 186, 297, 196, 307
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 198, 297, 209, 307
       Destination: 532
      Annotation: 
       Subtype: Link
       Rect: 211, 297, 226, 307
       Destination: 592
      Annotation: 
       Subtype: Link
       Rect: 228, 297, 242, 307
       Destination: 592
      Annotation: 
       Subtype: Link
       Rect: 144, 286, 154, 297
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 156, 286, 170, 297
       Destination: 592
      Annotation: 
       Subtype: Link
       Rect: 172, 286, 187, 297
       Destination: 592
      Annotation: 
       Subtype: Link
       Rect: 82, 255, 92, 265
       Destination: 532
      Annotation: 
       Subtype: Link
       Rect: 239, 192, 250, 202
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 253, 192, 267, 202
       Destination: 592
      Annotation: 
       Subtype: Link
       Rect: 286, 181, 297, 192
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 63, 171, 78, 181
       Destination: 592
      Annotation: 
       Subtype: Link
       Rect: 96, 139, 111, 150
       Destination: 592
      Annotation: 
       Subtype: Link
       Rect: 113, 139, 127, 150
       Destination: 592
      Annotation: 
       Subtype: Link
       Rect: 282, 129, 297, 139
       Destination: 592
      Annotation: 
       Subtype: Link
       Rect: 63, 118, 78, 129
       Destination: 592
      Annotation: 
       Subtype: Link
       Rect: 106, 76, 116, 87
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 517, 633, 523, 643
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 525, 633, 535, 643
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 537, 633, 548, 643
       Destination: 592
      Annotation: 
       Subtype: Link
       Rect: 314, 622, 329, 633
       Destination: 592
      Annotation: 
       Subtype: Link
       Rect: 452, 570, 463, 580
       Destination: 423
      Annotation: 
       Subtype: Link
       Rect: 433, 549, 443, 559
       Destination: 476
      Annotation: 
       Subtype: Link
       Rect: 445, 549, 460, 559
       Destination: 592
     Thumb: true
    Page: 
     Label: 11
     Annotations: 
      Annotation: 
       Subtype: Link
       Rect: 62, 620, 70, 630
       Destination: 1
      Annotation: 
       Subtype: Link
       Rect: 51, 587, 298, 610
      Annotation: 
       Subtype: Link
       Rect: 62, 578, 70, 588
       Destination: 1
      Annotation: 
       Subtype: Link
       Rect: 141, 557, 281, 567
      Annotation: 
       Subtype: Link
       Rect: 62, 546, 70, 557
       Destination: 1
      Annotation: 
       Subtype: Link
       Rect: 62, 526, 70, 536
       Destination: 1
      Annotation: 
       Subtype: Link
       Rect: 51, 472, 298, 495
      Annotation: 
       Subtype: Link
       Rect: 62, 463, 70, 473
       Destination: 1
      Annotation: 
       Subtype: Link
       Rect: 51, 430, 298, 453
      Annotation: 
       Subtype: Link
       Rect: 62, 421, 70, 431
       Destination: 1
      Annotation: 
       Subtype: Link
       Rect: 51, 389, 298, 412
      Annotation: 
       Subtype: Link
       Rect: 62, 379, 70, 390
       Destination: 1
      Annotation: 
       Subtype: Link
       Rect: 51, 336, 298, 359
      Annotation: 
       Subtype: Link
       Rect: 62, 327, 70, 337
       Destination: 1
      Annotation: 
       Subtype: Link
       Rect: 82, 274, 232, 285
      Annotation: 
       Subtype: Link
       Rect: 62, 264, 70, 275
       Destination: 1
      Annotation: 
       Subtype: Link
       Rect: 51, 232, 298, 255
      Annotation: 
       Subtype: Link
       Rect: 62, 222, 74, 233
       Destination: 1
      Annotation: 
       Subtype: Link
       Rect: 51, 200, 298, 223
      Annotation: 
       Subtype: Link
       Rect: 62, 191, 74, 201
       Destination: 1
      Annotation: 
       Subtype: Link
       Rect: 51, 148, 298, 171
      Annotation: 
       Subtype: Link
       Rect: 62, 138, 74, 149
       Destination: 1
      Annotation: 
       Subtype: Link
       Rect: 51, 96, 298, 119
      Annotation: 
       Subtype: Link
       Rect: 62, 86, 74, 97
       Destination: 1
      Annotation: 
       Subtype: Link
       Rect: 62, 55, 74, 65
       Destination: 1
      Annotation: 
       Subtype: Link
       Rect: 332, 684, 569, 707
      Annotation: 
       Subtype: Link
       Rect: 313, 675, 325, 685
       Destination: 1
      Annotation: 
       Subtype: Link
       Rect: 332, 642, 569, 665
      Annotation: 
       Subtype: Link
       Rect: 313, 633, 325, 643
       Destination: 1
      Annotation: 
       Subtype: Link
       Rect: 391, 601, 542, 612
      Annotation: 
       Subtype: Link
       Rect: 313, 591, 325, 602
       Destination: 1
      Annotation: 
       Subtype: Link
       Rect: 332, 559, 569, 582
      Annotation: 
       Subtype: Link
       Rect: 313, 549, 325, 560
       Destination: 1
      Annotation: 
       Subtype: Link
       Rect: 332, 496, 569, 519
      Annotation: 
       Subtype: Link
       Rect: 313, 486, 325, 497
       Destination: 1
      Annotation: 
       Subtype: Link
       Rect: 332, 433, 569, 456
      Annotation: 
       Subtype: Link
       Rect: 313, 424, 325, 434
       Destination: 1
      Annotation: 
       Subtype: Link
       Rect: 332, 370, 569, 393
      Annotation: 
       Subtype: Link
       Rect: 313, 361, 325, 371
       Destination: 1
      Annotation: 
       Subtype: Link
       Rect: 333, 329, 469, 340
      Annotation: 
       Subtype: Link
       Rect: 313, 319, 325, 330
       Destination: 1
      Annotation: 
       Subtype: Link
       Rect: 313, 298, 325, 309
       Destination: 1
      Annotation: 
       Subtype: Link
       Rect: 332, 245, 569, 268
      Annotation: 
       Subtype: Link
       Rect: 313, 235, 325, 246
       Destination: 1
      Annotation: 
       Subtype: Link
       Rect: 333, 194, 493, 204
      Annotation: 
       Subtype: Link
       Rect: 313, 183, 325, 194
       Destination: 1
      Annotation: 
       Subtype: Link
       Rect: 333, 141, 484, 152
      Annotation: 
       Subtype: Link
       Rect: 313, 131, 325, 141
       Destination: 38
      Annotation: 
       Subtype: Link
       Rect: 333, 78, 486, 89
      Annotation: 
       Subtype: Link
       Rect: 313, 68, 325, 79
       Destination: 38
      Annotation: 
       Subtype: Link
       Rect: 357, 47, 487, 58
     Thumb: true
    Page: 
     Label: 12
     Annotations: 
      Annotation: 
       Subtype: Link
       Rect: 63, 717, 75, 727
       Destination: 38
      Annotation: 
       Subtype: Link
       Rect: 52, 674, 299, 697
      Annotation: 
       Subtype: Link
       Rect: 63, 664, 75, 675
       Destination: 38
      Annotation: 
       Subtype: Link
       Rect: 52, 621, 299, 644
      Annotation: 
       Subtype: Link
       Rect: 63, 612, 75, 622
       Destination: 38
      Annotation: 
       Subtype: Link
       Rect: 141, 581, 289, 591
      Annotation: 
       Subtype: Link
       Rect: 63, 570, 75, 581
       Destination: 38
      Annotation: 
       Subtype: Link
       Rect: 142, 539, 295, 549
      Annotation: 
       Subtype: Link
       Rect: 63, 528, 75, 539
       Destination: 38
      Annotation: 
       Subtype: Link
       Rect: 52, 464, 299, 487
      Annotation: 
       Subtype: Link
       Rect: 63, 455, 75, 466
       Destination: 38
      Annotation: 
       Subtype: Link
       Rect: 52, 412, 299, 435
      Annotation: 
       Subtype: Link
       Rect: 63, 403, 75, 413
       Destination: 38
      Annotation: 
       Subtype: Link
       Rect: 52, 370, 299, 393
      Annotation: 
       Subtype: Link
       Rect: 63, 361, 75, 371
       Destination: 38
      Annotation: 
       Subtype: Link
       Rect: 63, 330, 75, 340
       Destination: 38
      Annotation: 
       Subtype: Link
       Rect: 83, 288, 238, 298
      Annotation: 
       Subtype: Link
       Rect: 63, 277, 75, 288
       Destination: 38
      Annotation: 
       Subtype: Link
       Rect: 137, 246, 297, 256
      Annotation: 
       Subtype: Link
       Rect: 63, 235, 75, 246
       Destination: 38
      Annotation: 
       Subtype: Link
       Rect: 52, 193, 299, 216
      Annotation: 
       Subtype: Link
       Rect: 63, 183, 75, 194
       Destination: 38
      Annotation: 
       Subtype: Link
       Rect: 52, 130, 299, 153
      Annotation: 
       Subtype: Link
       Rect: 63, 120, 75, 131
       Destination: 38
      Annotation: 
       Subtype: Link
       Rect: 52, 77, 299, 100
      Annotation: 
       Subtype: Link
       Rect: 63, 68, 75, 79
       Destination: 38
      Annotation: 
       Subtype: Link
       Rect: 314, 685, 326, 696
       Destination: 38
      Annotation: 
       Subtype: Link
       Rect: 333, 653, 570, 676
      Annotation: 
       Subtype: Link
       Rect: 314, 643, 326, 654
       Destination: 38
      Annotation: 
       Subtype: Link
       Rect: 333, 600, 570, 623
      Annotation: 
       Subtype: Link
       Rect: 314, 591, 326, 602
       Destination: 38
      Annotation: 
       Subtype: Link
       Rect: 334, 560, 457, 570
      Annotation: 
       Subtype: Link
       Rect: 314, 549, 326, 560
       Destination: 38
      Annotation: 
       Subtype: Link
       Rect: 334, 518, 457, 528
      Annotation: 
       Subtype: Link
       Rect: 314, 507, 326, 518
       Destination: 71
      Annotation: 
       Subtype: Link
       Rect: 333, 464, 570, 487
      Annotation: 
       Subtype: Link
       Rect: 314, 455, 326, 466
       Destination: 71
      Annotation: 
       Subtype: Link
       Rect: 333, 412, 570, 435
      Annotation: 
       Subtype: Link
       Rect: 314, 403, 326, 413
       Destination: 71
      Annotation: 
       Subtype: Link
       Rect: 334, 361, 489, 371
      Annotation: 
       Subtype: Link
       Rect: 314, 350, 326, 361
       Destination: 71
      Annotation: 
       Subtype: Link
       Rect: 334, 319, 494, 330
      Annotation: 
       Subtype: Link
       Rect: 314, 309, 326, 319
       Destination: 71
      Annotation: 
       Subtype: Link
       Rect: 388, 267, 519, 277
      Annotation: 
       Subtype: Link
       Rect: 314, 256, 326, 267
       Destination: 71
      Annotation: 
       Subtype: Link
       Rect: 333, 224, 570, 247
      Annotation: 
       Subtype: Link
       Rect: 314, 214, 326, 225
       Destination: 71
      Annotation: 
       Subtype: Link
       Rect: 333, 172, 570, 195
      Annotation: 
       Subtype: Link
       Rect: 314, 162, 326, 173
       Destination: 71
      Annotation: 
       Subtype: Link
       Rect: 333, 130, 570, 153
      Annotation: 
       Subtype: Link
       Rect: 314, 120, 326, 131
       Destination: 71
      Annotation: 
       Subtype: Link
       Rect: 388, 99, 515, 110
      Annotation: 
       Subtype: Link
       Rect: 314, 89, 326, 99
       Destination: 71
      Annotation: 
       Subtype: Link
       Rect: 333, 57, 570, 80
     Thumb: true
    Page: 
     Label: 13
     Annotations: 
      Annotation: 
       Subtype: Link
       Rect: 62, 717, 74, 727
       Destination: 71
      Annotation: 
       Subtype: Link
       Rect: 141, 685, 293, 696
      Annotation: 
       Subtype: Link
       Rect: 62, 675, 74, 685
       Destination: 71
      Annotation: 
       Subtype: Link
       Rect: 145, 643, 270, 654
      Annotation: 
       Subtype: Link
       Rect: 62, 633, 74, 643
       Destination: 71
      Annotation: 
       Subtype: Link
       Rect: 51, 600, 298, 623
      Annotation: 
       Subtype: Link
       Rect: 62, 591, 74, 602
       Destination: 71
      Annotation: 
       Subtype: Link
       Rect: 51, 548, 299, 571
      Annotation: 
       Subtype: Link
       Rect: 62, 539, 74, 549
       Destination: 71
      Annotation: 
       Subtype: Link
       Rect: 168, 518, 297, 528
      Annotation: 
       Subtype: Link
       Rect: 62, 507, 74, 518
       Destination: 71
      Annotation: 
       Subtype: Link
       Rect: 51, 475, 298, 498
      Annotation: 
       Subtype: Link
       Rect: 62, 465, 74, 476
       Destination: 71
      Annotation: 
       Subtype: Link
       Rect: 51, 433, 298, 456
      Annotation: 
       Subtype: Link
       Rect: 62, 424, 74, 434
       Destination: 227
      Annotation: 
       Subtype: Link
       Rect: 82, 392, 241, 403
      Annotation: 
       Subtype: Link
       Rect: 62, 382, 74, 392
       Destination: 227
      Annotation: 
       Subtype: Link
       Rect: 82, 309, 238, 319
      Annotation: 
       Subtype: Link
       Rect: 62, 298, 74, 309
       Destination: 266
      Annotation: 
       Subtype: Link
       Rect: 51, 255, 298, 278
      Annotation: 
       Subtype: Link
       Rect: 62, 246, 74, 256
       Destination: 266
      Annotation: 
       Subtype: Link
       Rect: 51, 203, 298, 226
      Annotation: 
       Subtype: Link
       Rect: 62, 194, 74, 204
       Destination: 287
      Annotation: 
       Subtype: Link
       Rect: 51, 151, 298, 174
      Annotation: 
       Subtype: Link
       Rect: 62, 141, 74, 152
       Destination: 287
      Annotation: 
       Subtype: Link
       Rect: 82, 99, 238, 110
      Annotation: 
       Subtype: Link
       Rect: 62, 89, 74, 99
       Destination: 287
      Annotation: 
       Subtype: Link
       Rect: 136, 58, 288, 68
      Annotation: 
       Subtype: Link
       Rect: 313, 717, 325, 727
       Destination: 287
      Annotation: 
       Subtype: Link
       Rect: 332, 684, 569, 707
      Annotation: 
       Subtype: Link
       Rect: 313, 675, 325, 685
       Destination: 287
      Annotation: 
       Subtype: Link
       Rect: 332, 632, 569, 655
      Annotation: 
       Subtype: Link
       Rect: 313, 622, 325, 633
       Destination: 287
      Annotation: 
       Subtype: Link
       Rect: 345, 601, 465, 612
      Annotation: 
       Subtype: Link
       Rect: 313, 591, 325, 602
       Destination: 287
      Annotation: 
       Subtype: Link
       Rect: 332, 559, 569, 582
      Annotation: 
       Subtype: Link
       Rect: 313, 549, 325, 560
       Destination: 287
      Annotation: 
       Subtype: Link
       Rect: 333, 518, 468, 528
      Annotation: 
       Subtype: Link
       Rect: 313, 507, 325, 518
       Destination: 287
      Annotation: 
       Subtype: Link
       Rect: 332, 475, 569, 498
      Annotation: 
       Subtype: Link
       Rect: 313, 465, 325, 476
       Destination: 287
      Annotation: 
       Subtype: Link
       Rect: 332, 423, 569, 446
      Annotation: 
       Subtype: Link
       Rect: 313, 413, 325, 424
       Destination: 287
      Annotation: 
       Subtype: Link
       Rect: 332, 370, 569, 393
      Annotation: 
       Subtype: Link
       Rect: 313, 361, 325, 371
       Destination: 287
      Annotation: 
       Subtype: Link
       Rect: 332, 329, 569, 351
      Annotation: 
       Subtype: Link
       Rect: 313, 319, 325, 330
       Destination: 287
      Annotation: 
       Subtype: Link
       Rect: 332, 276, 569, 299
      Annotation: 
       Subtype: Link
       Rect: 313, 267, 325, 277
       Destination: 287
      Annotation: 
       Subtype: Link
       Rect: 332, 213, 569, 236
      Annotation: 
       Subtype: Link
       Rect: 313, 204, 325, 215
       Destination: 287
      Annotation: 
       Subtype: Link
       Rect: 332, 172, 569, 195
      Annotation: 
       Subtype: Link
       Rect: 313, 162, 325, 173
       Destination: 287
      Annotation: 
       Subtype: Link
       Rect: 391, 152, 547, 162
      Annotation: 
       Subtype: Link
       Rect: 313, 141, 325, 152
       Destination: 287
      Annotation: 
       Subtype: Link
       Rect: 333, 110, 489, 120
      Annotation: 
       Subtype: Link
       Rect: 313, 99, 325, 110
       Destination: 333
      Annotation: 
       Subtype: Link
       Rect: 332, 57, 569, 80
     Thumb: true
    Page: 
     Label: 14
     Annotations: 
      Annotation: 
       Subtype: Link
       Rect: 63, 716, 75, 726
       Destination: 333
      Annotation: 
       Subtype: Link
       Rect: 52, 683, 299, 706
      Annotation: 
       Subtype: Link
       Rect: 63, 674, 75, 685
       Destination: 333
      Annotation: 
       Subtype: Link
       Rect: 52, 642, 299, 665
      Annotation: 
       Subtype: Link
       Rect: 63, 632, 75, 643
       Destination: 333
      Annotation: 
       Subtype: Link
       Rect: 141, 611, 297, 622
      Annotation: 
       Subtype: Link
       Rect: 63, 601, 75, 611
       Destination: 333
      Annotation: 
       Subtype: Link
       Rect: 141, 580, 294, 590
      Annotation: 
       Subtype: Link
       Rect: 63, 569, 75, 580
       Destination: 333
      Annotation: 
       Subtype: Link
       Rect: 83, 538, 217, 549
      Annotation: 
       Subtype: Link
       Rect: 63, 528, 75, 538
       Destination: 333
      Annotation: 
       Subtype: Link
       Rect: 52, 474, 299, 497
      Annotation: 
       Subtype: Link
       Rect: 63, 465, 75, 475
       Destination: 333
      Annotation: 
       Subtype: Link
       Rect: 83, 433, 243, 444
      Annotation: 
       Subtype: Link
       Rect: 63, 423, 75, 433
       Destination: 333
      Annotation: 
       Subtype: Link
       Rect: 52, 391, 299, 414
      Annotation: 
       Subtype: Link
       Rect: 63, 381, 75, 392
       Destination: 333
      Annotation: 
       Subtype: Link
       Rect: 52, 338, 299, 361
      Annotation: 
       Subtype: Link
       Rect: 63, 329, 75, 339
       Destination: 333
      Annotation: 
       Subtype: Link
       Rect: 52, 286, 299, 309
      Annotation: 
       Subtype: Link
       Rect: 63, 277, 75, 287
       Destination: 372
      Annotation: 
       Subtype: Link
       Rect: 52, 234, 299, 257
      Annotation: 
       Subtype: Link
       Rect: 63, 224, 75, 235
       Destination: null
      Annotation: 
       Subtype: Link
       Rect: 95, 193, 254, 203
      Annotation: 
       Subtype: Link
       Rect: 63, 182, 75, 193
       Destination: null
      Annotation: 
       Subtype: Link
       Rect: 52, 140, 299, 163
      Annotation: 
       Subtype: Link
       Rect: 63, 130, 75, 141
       Destination: null
      Annotation: 
       Subtype: Link
       Rect: 52, 77, 299, 100
      Annotation: 
       Subtype: Link
       Rect: 314, 717, 326, 727
       Destination: null
      Annotation: 
       Subtype: Link
       Rect: 346, 685, 496, 696
      Annotation: 
       Subtype: Link
       Rect: 314, 675, 330, 685
       Destination: 382
      Annotation: 
       Subtype: Link
       Rect: 314, 643, 330, 654
       Destination: 372
      Annotation: 
       Subtype: Link
       Rect: 333, 600, 570, 623
      Annotation: 
       Subtype: Link
       Rect: 314, 591, 330, 602
       Destination: 382
      Annotation: 
       Subtype: Link
       Rect: 333, 559, 570, 582
      Annotation: 
       Subtype: Link
       Rect: 314, 549, 330, 560
       Destination: 382
      Annotation: 
       Subtype: Link
       Rect: 333, 517, 570, 540
      Annotation: 
       Subtype: Link
       Rect: 314, 507, 330, 518
       Destination: 382
      Annotation: 
       Subtype: Link
       Rect: 333, 475, 570, 498
      Annotation: 
       Subtype: Link
       Rect: 314, 465, 330, 476
       Destination: 382
      Annotation: 
       Subtype: Link
       Rect: 314, 413, 330, 424
       Destination: 382
      Annotation: 
       Subtype: Link
       Rect: 333, 381, 570, 404
      Annotation: 
       Subtype: Link
       Rect: 314, 371, 330, 382
       Destination: 382
      Annotation: 
       Subtype: Link
       Rect: 333, 339, 570, 362
      Annotation: 
       Subtype: Link
       Rect: 314, 330, 330, 340
       Destination: 382
      Annotation: 
       Subtype: Link
       Rect: 333, 287, 570, 310
      Annotation: 
       Subtype: Link
       Rect: 314, 277, 330, 288
       Destination: 382
      Annotation: 
       Subtype: Link
       Rect: 333, 234, 570, 257
      Annotation: 
       Subtype: Link
       Rect: 314, 225, 330, 235
       Destination: 382
      Annotation: 
       Subtype: Link
       Rect: 333, 182, 570, 205
      Annotation: 
       Subtype: Link
       Rect: 314, 173, 330, 183
       Destination: 382
      Annotation: 
       Subtype: Link
       Rect: 333, 140, 570, 163
      Annotation: 
       Subtype: Link
       Rect: 314, 131, 330, 141
       Destination: 227
      Annotation: 
       Subtype: Link
       Rect: 333, 77, 570, 100
      Annotation: 
       Subtype: Link
       Rect: 218, 37, 375, 46
      Annotation: 
       Subtype: Link
       Rect: 436, 27, 538, 37
     Thumb: true
  Checksum: 2ab4fc28
   Type: CRC32
  Checksum: 94c934081caa11728b8f15e62352f296
   Type: MD5
  Checksum: 56dc13801f1f027a34c064f979bf178579216b20
   Type: SHA-1
  Checksum: 437c74b1dec64d6c86aea864e733487176f0e8551c9121f40a6ea4fa47bb09d3
   Type: SHA-256