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f,s6parnue maBH 15-17, 24 ng..Davidson's Principles and Practice of iledicil6,r, 23rd edition

Edited by Stuart H. Flalston, lan D. Penman,

l,r3AATEnbCKAg rPynnA Mark W.J. Strachan, Richard P. Hobson
Davidson's Principles and Practice of Medicine,
TTFOOTAP-Me,qua>
23rd edition (Selected chapters 1S-'tT,24)
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[ory6ure crpenKil yKa3brBa]or ABuxeHl4e 6eAHofi KucnopoAoM KpoBu Yepe3 npaBble

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-eH'uraldeu€ wouHetrxogosclqs c re@coQudrHrr€oH eeder, runelnBdxoc rsHros el{Hatresodll u rr.rHeHutreoc
-etr€ rorruetnced rudorox',(eeruQcoQudruueouetru erlselIeffi sedeh ursu.(xwu oJo)3ohr{dJ)er€ euHetres
or,(ndrruudguQouln ruxdetroc BHr,rcouw v eHlaL>^E -odu roresuheuoego urclrtr erirHhos€rcf, 'lrw€)rarfi
un€rr.{>reroxr,(trxew ruHoHlrVeoo erqHhede[oII']rr rur ur ruHtraooo c u€rsconueea rer{eedgo u rcJl4sros
-newuruQ uxnsoHlr€our r r4NIqH<I[e[IrEd€[ u] uirJcroJ Jl,Inolrl/{olrtrdex 4rrtr'xex 6run 001-0S olfo)o ^&rul.[
eeriog J uerscohrueea rol,(eedgo u lror-rd wrswrdu rolenu (rsrulounouVd€)) etrdu)ouN u)rer)I
trou y'rruHnr-Z ) lsHelrrradxprdu nruelteruQ arqsoH
-ur)V'(g 'g 'g'1 'cud) irJcoHHehdeh3u r€Juoorrou eUdeyonur erHotrBdyoC I
euauaorc.(go Lt la'rer,'Lrur:alrt -7 r,u/'.*dgo u roletrErsoo
tundguQour r xr{Hvecoc sode^oxde3 rs[r,rHBdJ r/'reh
Br4r0uo14814O
l7 0 BAJOl.lAl|eUO ]t UUnOIVHV rVHqtfVHO]r|hXHAO
 28 . KAPAl,lOnOrU9
Jlexr,rr B 6opo3AKax cr.vpanu aKTuHa. Kpoue roro,
x xaxloft ceAtuofi MoneKyne aKTprHa rrpr,rKperrneH
er{e oAr.rH MoneKynrrpHruZ xouueKc
(puc. 1.5, l-).
- TponoHr{H
Bo npeux @asu nrlaro uoHbr K€urbur,rs BxoA_f,r B
KJrerKy u srrcro6oxralorcrr r,r3 capKonna3Marl,IqecKo-
ro perr4KyJryua. Ouu cBr3brBarorcrr c rpo[oHr4HoM,
rITo npuBoAlrr K B3al,rMo4eficrnr.rrc MoJreKyn aKTI{Ha
u Mtio3uHa r,I llx cKoJIbxeHr,IIO OTHOCI,ITeIbHO Apyr
rpyra. B pe:ylrrare ororo capKoMep yKopaqr,rBaercfl
u npoucxoAr.rT coKpalueHl4e MbIIIIeqHOTO BOJIOKHa.
Cu;ra coxparqeHr,u cepAeqHorl nrrurqtr, lrJrrr LrHorporr-
HOCTb, perynnpyercs BxoA_f,uluM roKoM r,roHoB KMbur{rr
IIEPE3 MEAJ'IEHHbIE KUUIbUI'ICBbIE KAHIUIbI.
CrENErrr, 4O
xoropoft capKoMep Moxer yKopairuBarbc.f,, onpeAe-
nrler yAapHuft o6reu xery.qorrKa. Marcr.rua.nrnoe
coKparueHr,re Ha6lrcAaerc fl. npv BBeAeHlru MoulHbrx
r{HoTporrHblx neKapcTBeHHbIx npelapaToB unu Bo Bpe-
Mq 3Harrr.rMbrx @usuvecxrax Hatpy3oK. B ro xe BpeMr
pacuupeHr.re KaMep cepAua, Koropoe Ha6nrcAaercs lpu
cepAe.IHoll HeAOCTaTOqHOCTI{, CB-g3aHO CO CKOJTbXeHI,I-
eu ltuo$r,r6plrJr;l I,I coceAHl,rx KJ'reroK rro orHorrreHlrro
Apyr K.4pyry, a He c yAnr{IreHr,reM capKoMepa.
I HarpufiyperraqecKue nenrr4u
KapAnouuorllrrbr ceKperr,rp),ror nenrlrrhr, Koropbre
oKa3brBarcr ryMopanbHoe BrprflHue Ha cocyAr,rcryro
cr{creMy u norrKr.r. flpeacepanl.;,fi tarpurt,yperu-
.recrlrft nenru4 (Atrial Natriuretic Peptide ANp)
- B HI,rx B ne6olrruou KoJIL{qecrBe xJrI{ orcyrcrBylor.
rrpeAcraBJ'rfler co60ft frerrrr{A, roropuri cocror{T
us 28 auunoKr4cJror r.r coAepxlrr aMr,rHoKr.rcJrorHoe
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3brBaer cHr,rxeHr.re apreppranbHoro AaBJreHrlq (AI),
a raKxe Aaer Auyperlrqecxurl e@@exr, cnoco6crryx
BbIBeAeHuro Boabr 14 Harpvfl, rroqKaMr{. ANP sHcno-
6oxraercs KapAr.{oMr,roq vr aMla npe.ucep4uft B orBer
Ha r{x pacrf,xeH}re. Mosrosorl narpurlyperu.recruri
rlerlrlrA (Brain Natriuretic Peptide
- BNP), roroptrfi
6rr,r nepnonaqzurbHo BbIAeJIeH I,I3 3KcrpaKToB roJroB-
Horo Mo3ra Bylllbv, flpe.IlcraBJrger co6oft lolunelrrl4.q,
c flpu uapacraHrlIr coflporr{BneHr,rrr B apr eputx etu 6ta-
cocroxulrafi us 32 auusoKlrcJror. BNP cexperupyercfl
KAPAPIOMIIOUIITAMId XENYAOIIKOB B OTBCT HA PACT,S)KE-
Hlae, HailpilMep,
fl pr,r cep4evHoft HeIocrarorrHocrl,t.
BNP roxe oKa3hrBaer MoqeroHHoe Aericrsue. Henpu-
IIvtst4H
- @epuenr, xoropuft lpucyrcrByer B KpoBrl r.r
nupa6arrrnaercq noqKaMu ,r ;1pytuvrtr man.f,r\,ru. OH
paculenJrrrerANP, BNP r4 Apyrue 6elrra u nplr sroM
Aeficrnyer raK Ba3oKoHcrpr{KTop. Henpu.uusun xmx-
ercs roqxofi flpr4JroxeH]r.f, neKapcrBeHHhrx cpeAcrB y
naulreHToB c cepgevuofi HeAocrarorIHocrblo.
I Kpoaoo6paqexrae
Be4Hax Klrcnopo4oM KpoBb lr3 nepxneri u suxnerl
noJrbrx BeH nocrynaer a fIfI, 3areM nepeMeruaercrr B
fIX, roropurl, n cnorc oqepe.qb, nlr6pacunaer ee B
neroqHyro aprepurc. Kport npoxoArrr ro neroqHbrM
apTepurlM B Ka[]IJlnqpbr, rAe HacblluaeTc.q Kucnopo,{oM
qepes zurbBeon.rrpHo-Kanr,Lalrpulro ueu6paHy, a 3areM
nocryflaer rro JrerorrHbrM BeHaM s JIII. I,Is "IIII xpoal
nonaAaer n JIX, xoropuft nrr6pacrruaer ee B aopry
(cu. prc. 1.1). Bo npeux coKparueHr.rq xe:ry4ovron (cu-
cro:ru) rpr{Kycnr,rAanrHrrri xlanaH B rrpaBbrx orAenax
cepAua Mr,rrpaaluurl rcnarraH B reBbrx orlenax cepArla
r.r
3aKphrrbr, a K,ranaH reroqHor? aprgpvr4 u aoprirnb-
nlul roranan orKpbITbI. Bo npeua Ar{acronbr KJIa[aH
rero.rHori apreplau lr aoprzurbHhlfi sauan 3aKpblTbt,
a o6a AB-xnataHa orKpbrrbr. B conorymrocrtr grr{
rlpeacepAHbre u xenyAorrKoBble co6ntrns cocraBr.rlror
cep4evHurZ ql{KJr, Bo BpeMfl Koroporo flpogcxoAur
HaloJrHeHr{e KaMep cepArla KpoBbro u ee alt6poc npu
KaxroM cepAeqHoM coKpatueHur{. I,Ig cepaua KpoBb
npoxoAr,rT rro KpyrrHbrM ueHTpiurbHbrM sJracrrrsHhrM
apTepr4qM B apTepr{r.r Mbrrrru, a 3aTeM B pe3r.{cTr.rBHbre
cocyAbr lr B r.{Tore B KanrrJrnrrpHoe pycflo, r.rle rpoucxo-
Aur o6uen nl,rrareJlbHhlMr,r BeIIIecrBaMIl, IarcJIopoAoM u
npoAyKTaMr{ uera6o:urslra Mexgy KpoBbro Lr rKaHflMr{.
IJ,eurpa,rrHue aprepuvt, TaKlae KaK aopra, cocrorlT
lper,{MyIIIecrBeHHo I,r3 3Jracrn.recxofi coeAunurenrnott
TKaHr4, a UraAKoMbrruerrHble KJreTKu npe.[cTaBneH],r
B lroueHr r{3rHaHr,rfl KpoB}I r.r3 cepArla aopra, creHKI4
xoropofi AocrarotrHo noAarJruBbre, pacmupflerc.f, ,
qro6rr sNrecrurr o6telr KpoBlr, a gnacrl,IqecKaflorgLalra
o6ecnequsaer rro44epxanrae A,{ pr KpoBoroKa rrocJre
npeKpauleHr.rrr cepAerrHoro coKpatueHug. Oro nasrrsa-
ercr s$@exroM pe3epByapa (or Heu. windkesselefekt),
6raro4apx KoropoMy He rrpo[cxo.qr.rr qpe3MepHoro
noBbruleHus cucroJrllqecKoro A,4 u nonAepxr.rBaercfl
Auacronr,rqecroe A.{, B pe3ynbrare qero cHuxaercrr
rlocrHarpy3Ka lr coxpaHflercx uep@y3u.s MuoKapAa.
ronpurrrHbre s$@exru lrcrre3aror, qro na6lrcA aercs. y
Iroxl{Jlbrx [aur4eHToB r,r y nauueHToB c sa6oresanl4_fir.{H
noqeK Ha rro3AHrrx cra4lz.flx. Huxe no aprepuanbHoMy
.{epeBy ponb rnaAKoMHtxeqHbrx KJreToK cocyAoB no-
cTeneHHo Bo3pacTaeT BIIJ'IOTb AO Harrala pe3r'rcTeHTHblx
aprepuoJr. Bce cocyau anocsr cnor7 sKJra,u B crrcreMHoe
cocyal{cToe conpoTl{BneHl{e, oAHaKO BzuIa"4 pe3I{CTr,rB-
HhIx cocyAoB (glrauerpou 50-200 r'axu) uau6oluunrl.
.(axe ue6olbrrrrle H3MeH eHvrs. pa!.ryca raKnx cocyAoB
oKa3blBaroT 3aMeTHOe Bnl.IflHl.ae Ha KpOBOTOK, rIpUqeM
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xrirHHeaodlr€,rreulrexc s o)qrror BcJrtrosodu' (taW) -urosd u €Irtrdac r^rerretrro nrirseu ) reds€os grirHsoH B
ru@edrowoJ BuHcHuHosed-oHluH.rel,rl u (1;) ruQ -es rcreemrqso[ 'XU eu codgrsa u €fitrdec hruretrro '
-udronor rendetotqulrox'ruQedrohlor rEHUorotu rarrssudu ) redseos 4rsrHeoHos roreexuHc :JodogoeH -
-orrllBd 'elrftdec I,uIJieelrdererpx xex eu)er 'rsdfvafiodu rororEsuarad rurngoc exo[Iirs ndII 'YV orr{Hexr{H, e
orqHxolrc oorfog xE) €ffor 'oJoHqrog urercofl.( r.ilru ,(lrtosqrewrnuHreH r,r XtI oLt ucodgrra orlrnamqselrd x xI
xrr,rsoffc^( xnndorer,(gnre s rqHeHrourirs quirg r^{ronr rnvosudu ore 'rcreB)Kr{Hc Bfitrdec I^I€IIetrro wrqsor x -
'wrQefu outrduxox€ rr pD{rerx 4ontr (dr aouerdo ruQefu u8od) )orudu erc,(d olorclrtr(coc oroHhoJerr urco)mo t\y
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-onoges xrqrcutrfJoc-oHhetrdao u)urcoHJu]ry ytrfi s [sodx ?roHooHos E)orudil ou4Homrqsoil ) rlrtrosudx 'B
exotrs rwads os ruHersE[' oJoHtrfdJudrr{na er4Hox b
rqt/\lorct4c -rrHJ 'l'l 'rguJ s oHorseJctredu xex 'Efrtrdec xBlfetrro Y
[01cilr^co3 xrqseu u xrsaedu s E)orogod) rr4HoHel{[u erersu,(ead OJ
-0Hhoudoc ur4Hus0ueuccu lctilor0l l s rBtroxcuodu uuHexrstr udu 4nuetned)oc xrsHhotrdec '(t
rqrorceh u [!'ecodgrqs oJoHhotrdac runeuewe14 -e
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na6nro.uaercrr orrc'roHeHpre snercpuqecrofi ocu cepAua.

Snexrpoxapgrorpa$nn Peno:rapusauuq npoucxoAr4T MeAneHHee r4 pacnpo-
9Kf ncuonr3yercq anq oueHKlI cepAerlHoro pI4TMa c'rpaHrrercrr or snr{KapAa K sHAoKapAy. Peno:r-spusaqra-fl
I4 npoBoAr4MOeTV rI flBnfleTCS OAHITM I,13 OCHOBHbIX Me- upeAcepluri He Bbr3brBaer cr,rHaJra, roropurZ MoxHo
To.qoB ArzarHocrr{Kr4 vrlnteMl,tr:a n uu@apxra M}roKapAa :aSuxcuponarb Ha noBepxHocrnori OKl, TorAa KaK
( 14 M). (Draslrororu.recKarr ocHoBa I Kf peruru3yercrr rpu peflon.spr{3auur{ xenyAovxon o6pasyercr sy6eu 7.
cJreAyrour.rM o6pasou: B xoAe 3neKrpuqecKorl Aeno- HHrepnal Q- T npetcrauaer o6qyro fipo.rloJrxrlrenb-
nfl,pv3alg:zvt Mr{oKapAa Bo3H}rKaer He6olrurorl Au- HOCTb Aefl OI_fl pl13a\Un n penonqpr.r3auuu xenyAorrKoB.
nomnrrfi ToK, Koropbrft uoxxo:a@urcuponarb c no-
MOTTIbIO HeCKOnbKIIX flap SneKTpO.[OB, yCTaHOBJTeHHbTX Snexrpoxap4uorpa0re
Ha rroBepxHocru reJla. 9ru cramamr ycurwlBatorcfl., rt
nor) {eHHaq 9Kf gHsoAr,rrcrr Ha neqarb u-ru oro6pa- OnerrporapauorpaMMy B 1 2 orneAenlrsx (ra6,r. 1 2) .

xaercfl Ha AucrrJree (puc. L6). IIpu cr.rHycoBoM plrrMe 3arrr{cbrBaror c rroMorrlbro l0 e:rexrpo.uoB, Korophre
n CA-ysne flpoucxo.rlr4r neilonxpv3aryzt rtpen.cepI.uit, HaKraAbrBarorcrr Ha rpyAHyro rcrerriy u KoHeqHocrrr
B pe3ynbrare vero @oprr.rnpyerc.fl :y6eu P. BorHa Ae- (no o.[Hor,ry sneKrpoAy Ha pyKax r{ Horax u rrecrb
nonqpu3aur4u Me.uJreHHo rrpoxo,{rrr vepe: AB-y:er, 3neKrpoAoB na uepeAHeft creHKe rpy4nori rurerxu).
roroprttl cJrr,rrrrKoM lran, vro6rr lpr{Becrr4 K Aeflors- Kpolre roro, gJIeKTpoAbr, Koropble pacfionaralorcg Ha
pu3agr, Koropyo MoxHo 6ruro 6u sa@urcuponarr renofi p).Ke, npaBoft pyre lr resorl Hore, coeAr{HeHbr
c noBepxHocrl,I TeJIa. ,{a,ree flpolrcxoAur aKTuBauu.s c rleHTpiurbHori repnauHa.nbro, Bbrcryfiarcueri B Kaqe-
n) {Ka fuca, ero sergell r,I BonoKoH flypxunle, vro crBe AoloJrHlrTeJrbHoro Br{pTyurJrbHoro 3neKTpoAa B
nplIBoAI4T K .4enOJIflpI{3aUI{U MI{OKapAa XenyAOTIKOB
ueHrpe rpyaHori KJrerKra (enexrpo4 ua npaaoft uore
u o6pasonauuro KoMrrJreKca QRSHa OKl. Mlrure.rHaq Irrpaer poJrb 3a3eMleuux). 9Kf n 12 orseletusx
MaccaxenyroqKoB HaMHoro 6omure, .reM upeAcepAurl, lpe.ucraBnrrer co6ori 3arrucb, cAenaHH)'ro c noMourbro
nogroMyKoMruerc QRS6oJ'rbrre, venr sy6eq P. I,lnrep- flap, vlJtu na6opon, raKr{x 3JreKTpo.rIoB. Bu.ue:rarcr rpu
Ban Mexly HarrzuroM zy6ua P Ir HaqzuroM KoMnJreKca rpylrrbr orne4enrarZ : Tpr,r AByxnonrocHbrx orBeAeHr4q
QRS ua:unaercrr r.rHTepB atov, P - R u n sHa.ruremHorz or KoHegHocretT, rpn oAHoIIoJIIocHrIx orBeAeHI4rI c
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 34 . KAPAHOTOfI9

Pacu:npeHuure
Pasuepu cep4rla MoxHo oueHr{rb [yreM cpaBHeHr,rfl
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oTHOrXeHr,re IIIIpI,IHbI cep.4lla K IU.IpIIHe lerorrHblx
Yeerrqexxurfi
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qacTHocTr.r JIX, uln BhrrroToM B rroJrocTr,r nepr{Kap.{a,
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yrna
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cepAua oKa3brBaroTcq HopMiurbHbrMr4.
Puc. 1.9. PenrreHorpauMa opraHoB rpyAHofi KnerKn y naqu- Aularaqurc
orAeJrbHbrx KaMep cepAua MoxHo Ar{a-
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crbo. OrMeqaerc, pacuJnpeHue reBoro npeAcepAue n eur6y-
ceprqa (puc. 1.9).
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. fiutaragut JIfI npuno4r4r K BbrcryflaHr,rrc ero
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or rpyAr.{Hbr r,r pacuupeHr{e }Tna Kapr4Hbr (6u$yp-
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. lunatagux flpaBoro npeflcep.[t4s Bbr3brBaer pacuu-
peHr,re lparoft lpaHuubr cepArla B cropoHy nlrxneri
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lpf,MneHr4e resoft rpaHr,ruhr cep.qqa.
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poB neBoro xenyAoHKa u pacuJ[peHileM BOCxOA,lqefi aopTbt HOrO OTAena aopTbr, rrocKoJrbKy B nepeAHe_3aAneft
lpoeKur,ru srlr tr3MeHeHua uoryr 6rrrb cKpbrrbr reHbro
Ha peHrreHorpaor4s B 3aAHe-[epeAHeri npoeKrluu, IIO3BOHOqH}IKA.
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fraqueHT otpaH[qeH B ABI,IXeHVqX, OAHaKO IIpI,I STOM BbrsBlrrb rrpt43HaKr,r 3acro.s r{ oreKa (clr. puc. 1.27), ay
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 36 . KAPAl4orIOruq
xenyAoqeK (pacur,tpexHurfi )
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(co crpyerl peryprraraqrara)
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crpyKryp cepBqa B qerbtpexKaMepHofi npoexquu.
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K 6onee cJroxHbrM MeroAaM orHocsrc.f,: TpexMep_
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4onr,udola ,fi^rdoQ {rogoc rerraerctredl 'f,9l4
o soJHeLIfrBu ^( Huluud€ xrssoxhotr^rex orurus
-eud x urcesudu rexotrAi 'qut?oHsnruxo aoudaezndl.
'f.llue-er r(ltennuxelrt ou rolsxllHtos
4uv'ttudeuxer osrcHr4rrqrog '( I g'1 'cnd) ruuetrx,{g
-eos r rotroxs ltrsHdorgou c ,tr1ua-er r{meu uvtHes,
-oslcelrll(c Johc E€ rcreusrlxdelI'ou rl 4ororcucedr
-3x€ Bcreuxcrttrct yurdexlrxel 'tqua-at w€rufixalN .
'1141 lrru uuYdexwxet 4oaore,('4oxtrdac
-tredu erarraseud reuarserss. yulrutudyvouetr reHdorg
- o1' (eocxarl.rrwo) x[)cehurroJ)e xrqnnenedsetrx
-adu) rorcucedrcxe xrqsoxhotr {rex ntrkt xrssolfE,(
'xrsHtrdectredr oruHesorDrl,rHeos x rntrogudu uulles
-udnrouetr eHroa reHhoHurg'orufirrfnurc or,{soH
-uhr?roxer€) uH resro s oJcgh'xzxnotrfuex g uru
rrrrHeHratreoc-gy'xrutrdactredu s EJeho oJo)cehuu
-o.lx€ uulreeudnrouetr goHH€rHoxc erursr,(eed s
re€x,rHoos yuVdelwxe 1' ow€nuowowso arutamnsoll .
'uuVdetax
-Br €rr0l,IHexew xlilHgonco udr rcrolrlretrIqg
'soHr,rr^{Eroxerp) xrrlflo{.(durdxdun
u €fitrdoc r.rlrfiegdeHHu Ho)cehr{rExr^ruc hrosrctredcou
.roegllnpIlre&( ee qrJoHsI.IDB ru)oehl,IJulrnulc e'4uuern
-€dxoc xrsHhsVdoc fuorceh reumsHer,ff egdeH o.reffioretr
-xrftrg qJcoHsuJ)B l4oruercuc 4onadau rjoHsuruJaJes
rcrer{durr{red erorcen rffHHesrcgoc ore u '€wII4d sror
-utros )€) ra,{arc4etr ree,{ 4naoc.{HuJ'(V' 1 'cnd 'ruc)
rsd,fu;r,(dlc eutlrYosodu ersHHesodueurer,rfieuc eeden
uufiu€r4druouotr go)Jahudryere rsHuos ruHetrxox
-odu edan ou so)hotr,(rex u 4utrdecVedu wrtresur>ru
BeHqrerBso[ercox rutroxcfiodu I^reJ€t'ure,(-y3 eu
woYrdeed lntuxcerrudrxere rcreexcr(re€ rillrfi ]rrsHhetr
r9 . vh?d3c vwll4d ct4H3m^dvH
-dec eltdong 'BrrEdec dnercnc oilmrtrosodr )oilrol
-es[,redJee'4unrolcoc xrDrceh]rJoro.r,uu e.r,eJ,srdeed
s JorExuHeos oHhrlgo Btrtrdec eru,r,rd runemddell
'rurEdsxllltudg d.uftrurt s 09 eeHa,tr
-
Ir,rHelrrcd>{oc )osHhoEdec e.rorc€h E'I,Iutrds)llxet r,edsJc
-J,esJooc /fufHr,rw s 00I oerog rlrHslrr€d>roc )(Isl{hetrdec
BroJcBh oJn 'qJe.t,llhc olnrudg 'e)rorH rsHedlowccud
endolox 'utrtrdoc elr.r,ud 4unsmfdeu sotrfls osJcex
-onlr .r,e[sJ,cem[C'Bfitrdec rnHexudou uusJ,cJfclo
udu rautreerdnrouetr urm r,t.r,cowu[osodu gunemfdeH
3€-€I{ q,ts)tr,IHeog elo{u,r rftort oH 'Bntrdec BuH"selrog?s
oron&irx(dm erneuurodu {rogoJ rorniuerctredu or,cer'
BIrEdec elt.r,ud runemfdell'en.r,ud oloxcer,rd.r:rere
oJe lrrurl,rHemdduH Bcnotr;rsy €Irtrdec uurrtudy
uhUdec Enrutd Ht,tHom^dPH
'r{HEI,rX eSrtehex
u urcone€s}{xlils eunemr,.{r,{ aodo.toxen onesod
-ufucnonreVodu omsg orqrcoHhoJurtotreH 4onr'etrdec
Holrexrr c aorHerrnBu,{ eenan oH I^IoI'(ruuerrxolrco
erilHhehorr I4 er,ucehlJorodseH' rulrxeQuu'wluogru€
nBHnercuc'eusenerogodx) 4IaueuxoIrco goJorceh
rJo)ocrqs oHahrrHedJo arcHodrc^{ xlDIEr eI{HoHel tudu
eoxodlrm eeffog 'fur(dx,firorelr u,firromurog ou vI,IH
-am€dgoosodx runer,eurego Brr[' il oH'so)hotrfrox
rrxe,{fu sud rLYoxqror eH rsrneneneenvedu earcuodrc6
'r{rdoe una otuderde olfirnorer g'exho[r(rex rfimi{xdeg
vuv evvdo)tredu s orsrHHersoHErc^( 'urotuux eeden
ssodx roresur'uxedeu
qyn ualc4ofuc6'wrsHsureldou
I/I nrsr{er{durH€rrrN}1
rcrerrar xrenfrc xrsdoroxeH
a 4ndorox 'e>torott orelnot,{ducqrr(u ecocult vltu
BJocBH o.ronxagodrHerr oJosoxurod orqrnowor c
codgna 4nunetrdec loresutrtacf uarc{odlcd ur6
'Bl,IHeheff 4oJCOHXOhI
-eos xr4Jr{dtr uraslcJr(cro r,rdu I4uuuder gonr,odcoflrotr
esrcahe:r s rcqresoeqrorcu rfuow qyn sorHelrttuu
xrsdoroxaH 6 'erutrduxoux nosc,{dlrs udu dexuduuH
' Btrd€: o llr lrlurexedou xoltured go oHirrpurrHerou
udu urconr.orercoVaH Eounatrdec rl,IHeher oJoHslror
-ugoHurocos oronnodcoxredx egrcenux g srrHenudu
oHxow Esrc{rofuc,{ erxer o)c{EJ '(61VA
- act^ag $lssv
n 1
n n4u a1) so)hotr^rex r,rxxda[?ou 4o)cohr,rHaxen
uurcrlodrc,( rcirJBso0irroucu r.(rolr sfitrdo c or.rIIBr r^4
-nerucnedr tradeu euere oronr,orr(xelrodu asrcenux s
'ouer'ltuefu o soHerdo xu)cdonoV oarcerrr,urox fxqroxc
-olf ')KIt nwrcdapgou noxcahn rDxaw oeucpofiaqg
62 . KAPAI4OJIOTh9

pq Txaus,
E L-J HaxoAtu{atc, A
B pespaKrepHoM.
nepuoAe

1 Cnnycoeuti punu 2 fl pexgeapeueHusrft nunyruc 3 lloeropusrfi exog aos6yxgeurn TaxnxapguR

Prac. 1.31. MexaHugu re-entry. lloaropHurri BXoA Bo36yxgeHhe (re-entry) Moxer npou3oirunpvHatvvtttA AByx anbrepHaruBHbtx
nyreri npoBe4eHue c pa3ntaqHbtMta npoBoAa.Lp4Mr4 cBoficrBaMu, HanpnMep raKhx, KaK arpiloBeHTpt4KyrlrpHutfi ysel n AononHurerb-
Hbtfi nyrb npoBegeHrg tanu o6nacrb HopMarbHofi rKaHV tA r4uJeMh3r/poBaHHaq o6nacrb. ['lpu srou nyru A uegreHHo npoBoAt4T
Bo36yxAeHue u 6btcrpo BoccraHaBrr4Baercr, TorAa KaK nyrb 5 6urcrpo npoBoAr/r Bo36yxgeHue I BoccraHaBrvlBaercs MeMeHHo.
(1)Ilpra cuHycoBoM pr4rMe Kaxgbtf uMnynbc npoxo4r4r no o6or4M nyrffM nepeg BxoAoM B o6u.tt4fi At4cranbHbrtl .nyrb.(2) Ecru nyru
BoccraHaBruBaprcr c pa3Hofi cKopocrbro, npexgeBpeMeHHbrf uMnyflbc Moxer npofiTt4 no nyru A, e ro BpeMfl KaK npoBeAeHue
no nyrr E 6yger HeBo3MoxHo. (3) floxa npexgeBpeMeHHbri uMnynbc il36ilparenbHo ABtaxerc, no nyru A, nyru 5 raoxer eoc-
craHoBi4Tbcr. flocne eroro ilMnynbc Moxer 6brrb perporpalHo npoBe4eH BBepx no nyru E c o6pa3oBaHueM 3aMKHyroro KoHrypa
ilnil KoHrypa re-entry. (4) ero rrloxer npuBecru K pa3Bhrr4ro raxhKapAnil, Koropac 6yfler npogonxarbcc Ao rex nop, noKa KoHryp
He 6y4er npepBaH BcJreAcrBue u3MeHeHilfl cKopocrr4 npoBe4eHus r4fir4 oreKrpuqecxoft genornpv3aqvu

Epa,uurap.uu-fl Moxer 6brrb cBf,3aHa co cHI,IxeHI,IeM Hrrfl pvrua Hocrrr rrpexouruuir xapaKrep u ua eKf n
aBroMarr43Ma cA-ysna mr{ HapyrrreHrreM npoBeAeHr{rr froKoe u3MeHeHHfl oTcyrcrByror, cneAyer [orr blTaTbcrl
uepes AB-yoer. Ecnil clrHycoBbrft plrrM craHoBr,rrcr saourcupoaarb n aroJ'r oru.{ecrr.{ii pr4TM c troM oxlb}o
cJrr4rrrKoM Me.4JreHHbrM, poJrb BoAI,ITeI-fl pI,ITMa MOXeT clrorrHoro MoHHTopr4posaHraq 3Kf unr4 pef r4crpaTopa
B3srb Ha ce6fl Apyrofi oTAen flpoBoArrruerz c]rcTeMbr, O Kl, arruoupyeMoro rrauneHroM.
xoroprrft pacnonoxeH .4rlcrzurbHee. Tarure pr{TMbr Ha-
3bIBaIOTCTI 3aMerUaIOIUr{MI4 I,r MOIyr no3nUXarr n AB- fle.{eHHe
y3Jre, B nyrxe luca (ysnonori pr,rru) u-nn B xenyAorlKzx
(uguorenrpuryrapuuft puru). Oco6enuocrr4 orAerrbHbrx HapyueHuii pnrua
cepArla
o6cyxnarcrcq Hnxe. Jle.{eutae 3aBVcvr or npl,IpoAbr
apvrultr4, o6utue npl{Hur,rn br reqeH r,rfl o6cyxnarcrcq
n Aa,rlueilurlx pa3trenax
Mnorr,re HapyrxeHr{f, pr.rrMa nporeKalor 6eccr,ru-
ITOMH O, OAH aKO ycTorirruBa.f, T AXVrKap AVts. O6bI.IHO I GuxycoBae aprrmuc
corrpoBoxAaercrr rrarueHHbrM cepAue6ueuuelr, ro.no- Cuuyconoft apuruueir Ha3bIBaIor IluKruqecKoe
BOKpyXeHr.reM, ArlrcKoMoopToM B rpyALr r4Jrr{ o.{brrrrKoft . I,I3MeHeHI,Ie qacrorbr cepAerrHbrx corparueHHft go
BupaxeuHa fl. Taxr4Kapl,ur TaroKe Moxer [prrBecrr,r K BpeMrr AbrxaHr,lf c ee yBelnqeHr{eM Bo BpeMfl BAoxa }r
c[HKorIiIJIbHoMy cocroflHuro, rrocKoJlbry npu rucoroft yr{eHbrrreH}reM Bo BpeMrr BbrAoxa. Cnnyconaa apur-
qacrore cepAerrHbrx corpaulenuft MpIoKapA He Moxer Murfl, HOpMiL'IbHOe I,I MOXeT 6Hrr ,UOSOIIHO
coKparrlarbc s. wwr paccna6nflrrc.s AonxHHu o6pasolr.
- 'rBreHUe
nrrpaxeHnofi y Aereft . Orclrcrnue sroro HopMiL'IbHoro
EpaguxapAr,ls o6br.rHo Bbr3brBaer cr{MrrroMbr, xapaK- u3MeHeHrarr qacrorbr cep.(eqHbrx coKpaureHr,uZ npu AhI-
TepHbre Ar-tr Hr,r3Koro cepAeqHoro Bbr6poca, Brcrrroqarr xaHvlil il nplat43MeHeHllu noroxeHu-s rera uoxer 6rmr
noBbrrxeHHyro yroMJrseMocTb, orqyuleHr{e AypHoTbI I,I npLI3HaKoM Alla6eru.recrori Heripouaruu, nopzDKeHurl
o6MopoKr,r. Brrpaxenna s 6palurap4vrfl vut4 raxlrKap- Bererarr{BHoft uepnuofi cr4creMbr y [auueHToB c sa6o-
Alrfl Moryr clpoBorlr4poBaTb BHe3arrlryro cMepTb r4rII4 JreBaHr{rrMr,r nepu$epuvecKr4x HepBoB I4nI4 ycl{neHueM
ocraHoBKy cepAe.ruoft AerrreJrbHocrr,r. roHyca clrMnaruqecrol7 HepnHoli cncreurr. Crnnyconar
aprffv,l,z.fl. He rpe6yer reqeHurr.

I Cnnycoaas 6paAuxapAnq
Ha6rrcAaerc;{ y 3AopoBux moaerl B cocrorrHra}r
flepnoouepeAHbrM lrccJre4oBaHr,reM .fl BJrfl ercfl craH-
rroKol t rBrrflercfl. qacrori naxorxoft y c[oprcMeHoB.
AaprHiur OKI s 12 orseAeHuqx, Koropir.fl Bo MHorr,x
cryr{asx [o3Bor.seT [ocTaBr{Tb Ir,rarHo3. Ecnu naplrue-
Heroropue flaroJroruqecKue npuquHbr crrHycoBofi
f hUdacVodu tAu\lvvvlAdgvq tcy{erc}odpu euel 14
oJoeoc^Hr,tc eyEoHelco 'ur,rUdexr,rUedg ugeoc^Hr,1c 'rqcyouur,loy erqeouel ,tqclouu
-y\oy an)cehiluotye erquUdecVedu'eylrud oJoeoc^Hilc rquoudeu rcHuue 'rcrirvredronudevodrveue uuhedrculad
4oeocen-77 radu
4ouuen[uou'ennedlonuud 14onerqdaduaH eg '@ue,{ oioeoc^r{rlc r4rcogeuc rrrodUnr,tc) euer{ oJoeoclHuc unbrufi$cuf .Zg.t .cua
urUdexuEedg reaoc,{xu3
at{rrd Woeoue^ radu c>reuuwoy I
a'edorrrrfi{urcoutrdexodl.lere oJoHHrorco[ ruIIEr r^rrrHhu[ur )'(gg' 1' rigur) et^rlmd urNrunem,(des uruIsu
-HErrrr rlt ncsreaogedro[ rexoht soJHeurleu LIJcuh -r,zneud rcrar(eude.Lxedex u ure,{-y3 Uevfirom],1r uuu
'(39'1 'cnd) (ure,( oroaoc^{nuc rrxrvHeHer reu r{NrirHsr,ruedene.ratr,woeodgue ouar I
u)soHurco uuu eYe;xoug-yf, )le.{arcr(cro so)hotr^r - aorc,(go er4H€sero gue aonue!'' IeEorr xrsmxou .,( rc
-exutfl4 4u[decEedu irJcoHsurxB xrsdorox nNeds os -.r.eurrefucg oJecs efflEh oH 'etcedeog ltogorr a sr^(uxran
' e f,eu utru u utrdexuVed g' uuy dexuxer g elnoruxlrH€os -€os IexoI^I erei( orogocr{nuc urcogerc lalodYrur3
nxcer'lrtror.rdou 3r - elr nxodorugo ra runexfdxosoroJ
rsu,(rcudu'eltuaugefitrdec eonnetreni( rctrconro
eII€,{ oJosoc,(ur,rc nrcogerc ewodtrHr4c wruHe[srodu '6 '
I [ ' rger s oH€ru)ou )B) 'ruHieseIloge€ oJoHsoHco we
. -uHarsrodu quirg rexoN etrJoHr{ on ,truHenorle^{gedr
UO reHclrer{e/clodeg
eUeroug-gy . (eue,4
oioeoclHilc as vuYde>l.uxer reaoc,&ru3 '.{r,.firulr s 002 <rrsJurcor I
uilUdeyilxer rerUdec ereouerco) eUeyoug-VC . lexox elulrd Wosoc.(Hr.rc r.rdu gu.tratnedxoo xrirHhoEdec
-Uedu ceHcuenercrodeg . r,uide>4tUedg reeoc{lr3 . BroJceh rxer(dres 4oxcanueuQ rJoHsLrJHerHra rl,,'leds
os Hevorrr xrrtrorofl xrsgodotre A 'r4rsoHHer redeg radu
-r(nrc urahxerscru uxeHcr,rdu ortngo ;fffi;:i I u xrulyeed xlqHirraHolllowe' exe,(dJ€H I]to)cohue
-uQ udu urcoHsuue rlro)cehureuwuc WerrHehuues1'
crcoHhorELcouoH
(srcuuole-g) ena ra o nc.( g
o o Hhrir g o y vy de>rvxe r ru a o c,( u r,l 3
ueuneUde3 .
rcredBuedu ersureetcde,>ey . '
st4hoHy r
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eolucxoroedrl
. e_)oeed1
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snildeyuxet reeoclnug x
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(uruleuedee'ulrcyolnE eoedrrour-1 . lrl{lr) oehr.rHur>r c Ueuydexufudg rloaoc,{nuc g eflor
'rsdotuougouedUe-fl) uur.ldarouu-1 .
rcredeuadu etsweercderey . (eueI o.JoeocIHilc
-,(durcucdeu f 4ottuuotcotf uuv 4elnoildraautrr.rled c
Br4HeuEBE oJoH t4l-cogeuo r'rodUlrac) er-reI sorHeufie[ A '(Jlt (,'I-9'0) enlruodre evHetrass s/s
-redenrdr{ue oilHomtceour o-toeoc{ul,rc orauoxedog . rcre,(eslroucu rr{Heher ee 6r1fr,141tr4 rweda os odrco
exfuuex rercohr4lercoliof,
r eUdeyon,r ordeSu4 . qre) uHoo s rexon vt\ryul:.er syodu u lt ux c ehI,IH rlrfl
uuUderuitsdg resoc{nug
) yvVde\ilYudg reaoc.&ru3 'rcre,(gedr en enner,er
tnUdeyuxer u unUdexnUedg vuY dexvYed g rlroao c,{nv c ur4He her NoHhroru niu c
SoaocIuuc nsnudu atqdoroxaH .6t'I ehxugel ! -ceg udg '61'l 'trgpr s rrHercuhedeu uutrdexufudg
e9 . vhudSc vnll4d Bl4HSmIdVH
64 . KAPAI4OJIOFU9

rlacrHocrlt, npI,I Hiu[I4r{uu c[oHTaHHOit 6pailuxapauu,
conpoBox.qarculeft cs HenpurITHbIMLI CUMIITOMaMII,
ranu npu 6pagl,IKapAr4r{ c KJII,IHI{rIeCKI4MI4 [pOrIBneH]rrI-
Mu, KOTOpafl BbI3BaHa JIeKapCTBeHHbIMII npeflapaTaMrr,
Heo6xolHMbr M.vr 4J.fl. npelorBpau elj.vls. TaxvapurM.uit .
flpegcepauafl crllMynflul,Ifl Moxer npeAorBparl,Irb
3rrlr3oAbr (DfI. Ore rrpoKapAl{ocruMy lrflrJus, yMeHb-
IIIaeT Cr{MnTOMbI, HO He BIUTIeT Ha nporHo3, u frpu
6ecculrrrorrrHoM TeqeHuu sa6orenaHur{ He IroKa3aHa.
I JlpeAcepAHas excrpacrcronffi
flpegcep4nas gKcrpacucrortaq o6rr.rHo rlporeKaer
6eccnulrouHo, oAHaKo prHorAa Moxer Bo3HI{Karb
oxlyrueHr{e npolyueHHoro rfiu CJILIIITKOM CI4IIbHOTO
cepAeqHoro coKpaqeHl,Is. Ha 9Kf (puc. 1.33) pe-
rr,rcTpr4pyroTcf, npexAeBpeMeHHble, Ho B ocTiulbHoM
HopMiutbHble KoMIIJIeKcU QRS. 3y6uu P, rpe4rue-
crByrouue [pelcepAHbrM 3KcTpacucroJraM, BI4.4HbI He
BcerAa lr r4Meror ApyrFo uop$olorurc, TaK KaK [peA-
cep4kls, aKrlrBupyrorcr 143 Apyroro o.rara nos6yxreHuq.
B 6omruuucrBe cnyraeB rlpelcep,{Harl gKcrpacucron[q
He BJreqer 3a co6orl raxrax-;ur6o nocreAcrnrafi, oAHaKo
CII4IUKOM IIACTbIE TIPEACEP.IIHbIE 9KCTPACI{CTONbI MOIYT
6nrr rpegnecrHlrKoM (DfI. Jle,{euue rpe6yercx
Haqa.ira
TOJTbKO B peAKL{X CJIy{a.f,X, Ho npu BbIpaxeHHhIx xiIJIO-
6ax uoxno rlcloJlb3oBarr B-aapeHo6noKaropbl.
! Ilpe4cep4Hae raxrKapgue
flpe.qcepAH a fl. T axvrKap ilvr Moxer 6 rtrt upor n -
JreHI{eM IloBbrlrreHHoro aBToMaru3Ma npetrce p]],vh,
flopaxeHr{rr CA-ysna uJI}I roKcuqecKoro Aeftcrsus
,{rrroKcr{Ha. Oua npeAcraBr.fler co6oft rax}IKapAI{Io c
y3KrrMr{ KoMrrJreKcaMI,I Q RS u gy6uauu P usMeHeHHoIU
uop$ororuu. flpu srrcoroft qacrore corparqeuuft
npe.ucep.uuft AB-npose.[eH]re Moxer 6loruponarrcx.
fI p egc epn H a fl. T axvKap lkr.a M oxer orBeil arb H a re -
pa[Hro 0 - alpexo6,roKaropaMl{, Koropble cHl{xalor aB-
TOMarlr3M ; TaKXe .[rS reqeHljg Mofyr r{cnonb3oBarbcq
aHrr4aplrrMl{qecKl{e npenaparbl Knacca I unra III
(cu. ra6l. 1.30). Xenytoqxosrlll orBer rIpI4 6prcrpoft
npe.rlcepAH ort raxurap4Iall MoxHo KoHrponupoBarb
npenaparaMu, 6lonapytoulrrMll rIpoBeAeHpIe uo AB -
y:ny. [:rx ycrpaHeHl{fl orlaroB gKront{qecKofi axrran-
Hocrlr Moxer 6rrrr nrrno.nHeHa Karereptat a6txt1ut,
Koropyo cneAyer paccMarplrBarb y rIauI{eHToB c peuu-
Ar,rBupyrcuerl npe4cep.uuoft raxuxapAuett n ra.{ecrge
zulbTepHaTr{Bbr aHTYapvTMI4qecKI{M llpellapaTaM.

Prac. 1.33. flpegcepgHar oKcrpacucronns: 1,2 n 5-fi rou-
nneKcbr eBlnrorc, HopM€InbHbrM ct4HycoBbrM pr4TMoM, 3, 4 n 6-fi
KoMnfleKcbr npeAcraBnnor co6ofi npe4cepgHbte sKcrpacu-
crorbr, KoMnrexcur QPS no Sopue raKue xe, KaK npta ct4Hy-
coBoM pr4rMe, a sy6qu P uuetor u3MeHeHHylo $opuy (nnorpa
egAa eUgUt'rtUt)
ill
W Tpeneranue upeAcep.uuft BcerAa cl€Ayer nono3peBarb
Prac. 1.34. TpeneraHue npegcepguft. [1pn o4noepeueHuoli
perucTpaLlur4 sneKrpoKapAuorpaMMbr B HecKorbKt4x orBeAe-
Hr4ex Br4EHo rpeneraHhe npegcepgufi c xoe$$uqreHroM npo-
Be4eHrls 4:1. Bornur rpeneraHilg per[crpt4py]orcn ToflbKo
oraegeHunx ll n lll
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Moxer na6:rrcaauc g qacrorHo - 3aBncvMas. 6loxaAa
Ileqenne
AB-yuoaax pequnpoKHarl Taxr4KapAlrfl He BcerAa
rpe6yer reseHu.f,. Teu ue MeHee napoKcll3M Moxer
6urr rynupoBaH MaccaxeM Kaporl'IrHoto cttryca r4ttvt
npoBeAeHI,Ieu npo6rr Balrcalrnrr. B 6oluuuHcrne
cnyqaeB cunyconrrti pI,IrM Moxer 6rrrr noccraHoBJreH
BBeAeHr{eM aAeHo3I{Ha (3-12 ltr 6rrcrpo, B Bo3pac-
Taroxlrlx Ao3ax Ao flpeKpalIlenfifl, TaxlaKap!.uu) uttu
BepanaMI{JIa (5 ur n reveHue I ltuH). Tarcr<e Bo3MoxHo
n/n nneAeuue B-a4peHo6noKaropoB LIJII,I $terauuurao .
B pe4rcax cnyrasx rrpll Trlxenblx HapyrlreHl,Isx reMoAu-
HaMI{KI{ AIs KytIUpOBAI{Idfl' TiXI{KapAI{I/t XCIOJIb3yIOT
snercpuqecKylo Kap.4l{oBepcl4lo.
Y naquesroB c peul{.(I{Bl{pylouefi HXT uau6olee
e$OercrunHuM MeroAoM JrerreHI,IrI rIBJLflercrI KarerepH€rfl
a6txttut, Koropafl ycrpaHqer HXT 6onee qeuz9l%
cny{aeB. B ra.Iecrse zulbrepHarl/tBbl Bo3MoxeH npo-
Qurarruuecxrali npueu B-agpeuo6loKaropoB, Bepa-
rraMr4lla utuSlexaunwaa BHyrpb, oAHaKo npI,I 3ToM
raur.reHTbr (.raue Bcero sro nl{Ira MoJroAoro nospacra)
BbrHyxIeHbI ArIlrTeJIbHO npl4HlrMaTb neKapcTBeHHyIo
3To Tepanurc. Taxoe JleqeHue Moxer 6rnr conpxxeHo c
- orrpeAeneHHrrrr,ta npo6leMaMl{ y xeHrII}rH, rlocKonbKy
Bo BpeMfl 6epeueHHocrra o6srqno cneAyer [s6erarr
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72 C KAPAIAONOTT'

TaxlIKapAI,Iu npaKTuiIecKI'I HlIqeM He oTJllrqaeTcfl oT

AB-ysronofi pequnpoKHoft raxuxapAnn (puc. I .39, A).
Ileqenue
TaxurapAI,ts uoxer 6rrrs KynupoBaHa c rIoMoIIIbIo
Maccaxa KaporlrrHor o cvrnyca utnrn/n nreAeuux a'ue-
Ho3I,IHa. flpu paswrruu OfI uoxer Bo3HlIKarb onacHoe
rroBbrrlreHlIe qacrorbl xenyAoqKoBrrx corpaulenuft ,
nocKonbKy .uononHl,ITeJlrurrft nyrr JII'IuIeH orpaHu -
qr,rBaloluux qacrory cnoftcrs AB-ygra (prac. 1.39' f)'
,{aHuoe cocro-aHlae I,I3BecrHo xar
(DII c 6ucrpuu
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flp[Becrr,I K KoJUIaIIcy, o6uopory I'I Aaxe cuepru. Ta-
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o6rrqHo npI,I HeM rpe6yercx npoBeAeHI'Ie snelopuqe-
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Tepanueft nepnoft.nlruuu y naulreHroB c cltMrlToMa-
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cepAeqHblM nu6pocou nplr cI'IHycoBoM coKpaIIIeHIllI,
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H.rrrbcr rrpn cuH,qpoMe Bo;rt$a-flapxrlncoHa-yarira,
rrocKonbKy 6noKr.rp),ror flpoBeaeHr{e no AorroJrH}rrenb-
HbrM nyrrrM.flpelaparrr Aasnori rpynnbr He AoJrxHbr
ucloJrb3oBarbcq y naqueHToB c rrepeHeceHHlru IrIM,
nocKonbKy oHlr yBenr,rq uBaroT pr4cK Bo3Hr,I KHOBeHI{,I
uapyureHufi pr{rMa cepnua.
Onexauung"
O@@ernrneH rnfl. upo@u,raxrr,rrra <DlI. Kponae
roro, n/n
BBeAeHue @.nexauHu4al, Moxer l{cronb3o-
Barbc.s 4lx @apuaxonorpuecKori rapnnonep cvrr rrpu
(DlI lpoaonxr{reJrbHocrbro MeHee 24 v. flocro.nlry
S,'rexauuug o cnoco6eu nrr3brBarb MeAJIeHHoe rpenera-
Hr{e npeAcep.urari c napa4oKczurbHo slrcoxofi .{acrorori
xenyAoqKoBbrx coKpaueuuri, ero cneAyer Ha3Haqarb
BMecre c npeflaparauu, 6,roxupyrctur,rMr,r npoBeAeHr{e
noAB-ysly, raKr,rMlr rar B-agpeuo6noraroplr,
B ueJrrrx
KoHTponfl :a .Iacrorori xenyAorrKoBtrx corpaulerurii.
llponaQenou
flpona$euoH raKxe o6,raAaer nexoroplruu cnofi -
crBaMr,r B-agpeHo6noKaropoB (lpenaparrr II x;racca).
Onncanrr gnaqllMble JIeKapcrBeHHbIe Bsauuo4etlcrnur
c .ultroKcr{Holr, rap@apuuoM r4 uuMerpr/Ir,1HoM.
I flp._eFp_qru lLyacc_a _
[aHryro rpynny cocraBJrrror aHraroH]rcru B-a4pe-
Hopeuerrropon (B-agpeHo6loraropn). 9ru rpena-
parbr cHr4xaror cKopocrb Aerron rplr3aquu r CA-y:le
r,r Bbr3brBaror orHocr{TeJmnyrc 6.norary [poBeAe Hr,rq
a AB-ysle, nogroMy r4x MoxHo r{c[oJrb3oBarb nrfl
KoHTponrr ga .racrororl fl pr{ Tpeflerauuu upe4cep4ufi
u @II. B-Agpeao6noKaropbr raroKe MoxHo Ha3Hatrarb
arx npo$ra-rraKruKrl XT u HXT. Onn cHuxaror Bo3-
6y4urrocrt MuoKapAa Lr prrcK apr,rrMltvecKori cuepru
y naur4eHroB c I4EC u cepaeqHorl HeAocraroqHocrbro.
H ecen e n u BH H e P - a ApeH o6n o Karo p bt
Eloxupyror xar B,-, rax u Br-agpeHopeuerrropbr.
C 6:roxa,uoli pr-aapenopeuerrropoB cBs3aHo pa3Btr-
TI4e raKr,rx no6oqnrrx eQ@exron, xar 6pouxocrra3M Ir
uepz@epuuecKa-f, Ba3oKoHcrpr,rKrlz.f, . flponpaHolon
flBrrfler c fl Hec eJreKTr{BHuu B - aap eHo6l oxaropolr u
noaBepraercs 3Harrurerbuouy e@@exry [epBoro npo-
xoxreHr4f, qepe3 neqeHb. Cle4onare:muo, e0$errun-
HyIO.403y npu [pr4eMe BHyfpb rrpeAcKa3arb cJroxHo, H
neqeHr.{e cneAyer HaquHarb c ge6olrruoli [o3br c.uzLrlb-
nefturuu rlrrpoBaHr4eM. flpyrrarr.ru ueceJreKT]rBHbrMH
ee
npeIIapaTaMI'I flBlrfltoTgfl Ha,UOJIOn r,r KapBe.rlHnon.
KapguoceneKru BH ile p- agpenofinoKaropbt
.{eftcrnyrcr DraBHbrM o6pasou na B,-a4peuope-
uenTophr B MiloKapAe H oTHoclrTeJrbHo xopouo nepe-
Hocsrc.s. flpuuepauu KapAr,roceJreKrlrBHbrx p-aape-
no6roxaropoB rrBJlflrorcrr 6uconponol u MeroflponoJr.
Coranon
flpelcrauxer co6ofi parleMlrrrecKyro cMecb .(Byx
u3oMepoB, o6:raAarculnx HeceJrer(ruBHBrMlr p-aapeno-
6roxlrpyrcquNlu csoficrnauu (npeuMyrrlecrBeHHo
l-cora.nol) u aKTlrBHocrbro npelaparon III KJracca
(npeuuyrqecrBeHHo d-cora-rron).
Moxer Bhr3brBarb raxr,rKap4r,rn Tuna <<rupygr>.
I lpenaparu lll Knacca
flpenaparu KJracca III yrenzvuBaror rrpoAoJrxu-
renrnocm $a3bl n raro IIoreHuI{ruIa Aeftcreul. u,TaK}IM
o6pasou, yAnuHqror pe$paxrepnuft ndilroa. grn
npelaparbr oqeHb sS@errunnu 4lx npo$u;raKrr,rKpr
rlpeAcep.aHbrx u xeryAoqKoBhrx raxuaprlTMr,rri. Ouu
yBenlur,rBaror rrpoAoDKrlTenbHocrb uurepaata Q- T
Ir MOryT npeApacnoJraraTb K pa3BrrTprro TaxvKapI.krkt
Tr.rla <(nlrpygTr> u XT, oco6enno flpu]gratrutq{ulr Apyrnx
rrpeApacnonararorqux @arropon pucxa (u'1. ra6n " I . 26).
lusonupauug r.r
Hocrbro npenaparoB KJracca
cora.nol o6naAaror HeKoroporZ arrran-
III, o4naxo ocHoBHbrM
ilpenapaToM B gTOM KJraCCe flBIrseTCfl aMproIapoH, qTo
o6cyxgeuo Hr,rxe.
Auuogapou
Xors aN.{r.{ oAapoH p accM arpuBaerc.f, rrper,rMyue -
crBeHHo KaK npenapar IIIruracca, oH TaroKe o6na,{aer
csor7crsal{u EpenaparoB I, II u IV rcraccon. Auuo-
AapoH B HacTostuee BpeMrr, rro-Blr.qr4MoMy, sB]Ifl,eTCs
caMhrM e@$errunHrrM [penaparoM Arrr neqeHt4fl. rra-
poKclr3Mzurbuofi $opusr OfI. On rapre rrclonb3yercJr
4rrx npo$ruaKrr{Kr{ srrr,r3o.qoB peuul}rnupyloqeft XT,
oco6enno y [aqueHToB co cHr,rxennofi $ynxquerl
JIX u c r,rMrrrraHrr,rpoBaHHbrM KapAr{oBeprepoM-Ae -
@r,r6pu.nlxroporr,r (4,,rx npeAorBparqeHr,rfl HeaAeKBar-
nrrx cpa6arrrsaHuir ycrpofi crra). Auuo4apon rlMeer
oqeHb AJrr.rrenrnurl uepuo4 nonyBbrBeAeHr,H lrs rxaHeft
(25-110 AHeri). 9acro r{cnoJrb3yercrr cxeMa tft wm
nepopiurbHoro HacbrrrleHut Eltt dl'lcrporo Aocrr,rxeHr4rr
repaneBTuqecKr{x KoHqeHrpaywir, B TKaH.sx. .{eft crnue
npenapaTa MOXOT !.nldTb9fl B TerIeHr.re HeCKOJIbKIIX
HC.IICNb VJIV MECIUEB NOCJIE TIPEKPAXIEH}I.'I ICqCHI,IS.
flo6o,{HHe a00erru Bo3HHKaror rracro (Ao l/3 tauu-
erroe). vHoroq Hc-reHH br H nore HuHiurbHo cepbe3Hbr.
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euueersdedg avddeynxetreeorr,oUluexUe;_.1 0u
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rcroildugu.rHr{ }r Norroweyvdltilr4fr rcrol(dlrtrnarou
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oHlrrrerr,rheHr eHr,rsoHe["e rsrxeeeg .sreregen re^{[erc
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rranenerarradu oJe 4orurce 4roHirruLrxHodg c ao.lnenlreu
.,(,{ltoreou' lrt0€ucoxttodg ilr€slqelqs Jexow HusoHeyv
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c Butrdactredrr er,rHerexedr xB) xrDeJ ,elr[dec elt.r,nd Bccenr iilsredeueA[I NU
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Itonqnedeuradeu zdu oJh ,Irrter c utytac a rcsruaogedr 'nrosodefoune c Hetroxr (.pad .natnfi1 .nesod]rdJc
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84 o KAPAHOTIOFI4f,

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Bxecepge.ruue npogBneHun Orexrpnvecruft pasprA HaHoclITcrI cpa3y rlocJre
:y6qa R, [ocKonbKy rIpI,I HaHeceHuI{ Bo BpeMfl pe-
. Orcyrcreile annerhra, . HapyueHue qBeroBoro
pBora rorspr43auuu xenyAoqKon (Ha sy6eu 7) oH Moxer
ToLlrHora, spexnn (xcanroncran)
. cnpoBorluposarr OX. flpn npuueHeHl{I{ pa3prlAoB
AilapeF
sHcoxoft MoxrHocrla ltaqueHTbl Moryt orMeqam 6olr
Kapguanuxue nporBreHut n rpyaHori creHKe nocne npoueAypbl, rlo3roMy IrJIa-
. Spagrarapgnn . npeAcepAHae raxilKapAnc HoByro KapAr{oBepcr4ro uerecoo6pasno Haql{Harb c
. l1oruronxaq (c nepeuernori 6roraAoti) pa3pflga 6o,ree nr.rsxofi uorunocrra, cocraBJlrlrcIuefo
sKCTpaC/CTOrlrlr r xT oKoJro 50 Ax, u lrcnoJlb3oBarr 6ortrruylo MoulHocrb
. XeryAoqxoeas lurewrtaun . <DX
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npu ueo6xoArrMocrrl [oBTopHbIx HaHeceHuft pa3prlAa.
pilTMa r xelyAotrKoBbrx
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@opuuponarure HapyrrreHuit purllr.a. Ar.rrcfl qepe3 BHyrpeHHroro rrpeMHyro, noAl[rcquqHylo
u,ru 6eApeHHyro BeHy 14 rro3lruproHr4pyerc.f, B BepxylrKe
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npepBarb opraHr{3oBannrrii p}rrM, rarofi rax (Dfl 3Kl nuanu npaBrlnbHbre rulrpoKrre roururercu QR,S,
ulu XT. Orerrpuvecruri ror npepblBaer apurMrrto \I Ha[oM]rHarouue [o @opue 6nora4y resoli HoxKH
Bbr3brBaer roporrur7 [eptloA acvcrollvrv,
3a KoropbrM rryrKa luca. KaxroMy KoMrrneKcy HenocpelcrBeHHo
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co6ururi.
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flouylaquoHHarr crpareruLe, HailpaBneHa Ha Mo-
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[.! naxrraxu nureuuqecxoi 6oneeH],r cepAqa
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y 65 -leruero MyxrruHbr co cpeaHurra AA | 50 / 90 MM pr.
cr., xoroprrrl Kyprrr Ir crpaAaer caxapHbrM 4ua6etou,
c coorHolleHnen o6urero xoJlecreplrHa r,r xoJrecrepr,r-
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Creuoxapgnn
CregorapAptg cr{MrrroMoKoMnJreKc, o6ycloa-
- npexoAqruefi
leHnlrfi HaJrr,rqr{eM I,rlue Mur4 M]roKapna,
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(ra6r. 1.38).
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(snlqncap uraUda (uuUde>ronerc reur,ou) Yl
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cru ITIEC. B cnqgr,r c sruM rrauueHraM, KoropbrM Moxer
6rrrr norasaHa peBacKyn flpvr3agfl,, peKoMeHAyercrr
npoBeAeHr{e Harpy3orlHbrx recroB c nnsya,rrasaqlretf .
Alropuru no o6cJre,uosanvfio vI reqeHllrc nauueHToB
co cra6u:rtnorl creHorap4uefrtpune1en Ha puc. 1.55.
B nepayro ovepegl ueo6xonrrMo rrpoBecru npo6y c @u-
su'{ecxorZ narpysrofi , Koropa.q AoJDKHa BbrrorH.rrrbcfl
no craHAaprHoMy nporoKony Ha 6eronori .qopoxKe
lrJlu BeJroSproMeTpe c KoHTpOneM 3a CepAeqHbrM plrr-
MoM, ypoBHeu An u o6u1uu cocroflHtreM rraur{eHTa.
fopusoHralbHas. vrv KocoHr,rcxoAq[Iarr Aenpeccus
cerMeHTa ST6onee I uu cnuAerenbcrByer o6 uure-
uuu (puc. 1.56). KocoBocxorrnua.s .uenpeccux SZ
MeHee cuequ$uvua, sacro perprcrpr.{pyerc.s y 3aopo-
BbIx JrI{u, Tecr Moxer 6rrrr loxnofloJloxl[TeJrbHbrM
CoorsercrseHHo, [pI{ nrrcoroft rruHra.recxori ne-
AaHHbrx o6 urueulru Mr.roKapAa npta npoBeaeHr{r{ npo-
6rr c Szsuuecxort uarpy3Korl noKa3ana Aa-[*refiuraq
Br43yuurr.rsaulrn (n
vacruocrz, nep$y3lroHHafl currH -
turpa$ux vnu crpecc-oxoKapArlorp a$ufl .
Mr{oKapAa
fle$exru nep$ysuu, BbrqBJrfl eMbre npu $usu.recrorl
Harpy3Ke r{ oTcyTcTByroruue B cocTo.aHr.ru froKoq,
cBrrlereJrbcrByror o npexo4xuleli r{ureM}ru Mr4oKapAa
(pnc. 1.58). llpra eroM croriKlre Ae0exru nep@ysuu,
Ha6lrcAaeubre B o6e @asrr uccleAoBaH:zs., o6uquo
cBr{AereJrbcrByror o nepeHeceHHotr I,IM. Als uoA-
rBepxreHus rlaJrurrvs lr.ttu orcyrcrsux IdBC y na-
IIT4eHTOB C IIOAO3peHLIeM Ha CTeHOKapAI,IT BCe rlarUe
r{cnoJrb3yercx KT-ropoHaporpa@ua. flannurl Merol
IIo3BoJI_f, eT yroqHuTb Ar,rarHo3, froMoraeT oflpeAenr{Tb
orrTI,IMZUrbHOe lerreHue I,1 u36exaTb Heo6xoAuruocrr.r
Karerepr43arluu cepAua y nar{ueHroB 6e: I,IBC ruru c
He3HaqI,ITeJIbHhIMlI KJIITIHI,IqOCKL{Mu npo.gBIeHVIflM]l4
3a6oreBaHu.f, (crra. pr,rc. L55).
Koponapoauruorpa@u.r{ rto3Borqer nonyqr.rrb
no4po6nyo aHaroMr,Frecryro ltr@opl.raulrrc o crefle-
Hr.r Ir xapaKrepe nopaxeHr4.f, KopoHapHhrx aprepnir
(cm. pnc. l.l5). Oua o6H.rHo BbrflonH_serc.f, B cnf{a-
{x,KorAa ruraHlrpyeTcfl KopoHapHoe rx},HTr{poBaHlre
lr.nu 9KB.
fleqexre
lI"
flcleerrt4fl upo6,reutr u o6cyxgeuux o6pasa xu3Hr,r Ir
Me,{uIII4HcKpIx BMeIIrareJIbcrB, Koroprre uoryr 6rrrl
r{crIoJIb3oBaHhI AJrq o6ner.reHu.g clrMlroMoB u yn],.q'-
Ta6nuqa 1.41. Crparr,rSrlKaque pncKa
i npn cra6rluxofi crexoxap4nu*

y naql{eHTOB, flony{arctu}rx AI{roKcI{H, a TaIOKe IIp}r Bstcoxufi pucx Husxrafi pucx

runeprpo@uu JIX, 6loxa"qe HoxeK n) {Ka luca utu llocrunSaprrnar creHoKapAile llpegcxasyerr,tan creHoKap.qilF
cr,rHApoMe Bolr@a-IIapKLrHcoHa-Y afira. Ypooeut npr Qrsuvecrux HarpyoKax
TonepaHTHocru r $u:uuecKtrM Harpy3KaM r{ creneHb lhoxar nepenocutilocrb XopoLuar nepeHocuMocrb
r{3MeHeHr4rr cerMeHra HarpysoK
^17(puc. 1.57) n xou6unaur,ru c Qr,tsnvecxrx HarpysoK
Suenrecxr,tx
TPYTI,IM}I KJII{HI{qECKI,IMI,I,{AHHbIMI,I UTPAIOT BII)I(HYIO llweuns npil Harpy3Kax lzlLuerlrn ronbKo npil
poJlb B BbITIBneHpIII nlrq c BbrcoKI,tM pr{cKoM cepAeqHo- nn3xori rrreucusxocl,,r Harpy3Kax eurcoxori
cocylr.rcrbrx sa6oresaH[ri (ra6,r. 1 .4 I ). Terra He MeHee THTEHC14BHOCTI4

y 3Haqurerbnoft .racrr4 nautreHroB c I,IEC npu flpoBe- llopaxenre crsora reeoil Ogno- rlrEByxcocyAr4croe
Aenur.r upo6rr c Ou3u.recKori narpysroft ne o6napyxra- xoponapuorT aprepvn t4tt nopaxeHile
Baerc.s usN{eHeHufi ua EKI nnu srr{ u3MeHeHurr Moryr TpexcocyA/cToe nopa)(eHL1e

6rrrr HeAocroBepHr,rMrr. flpuuunofi eroro uoxer 6urr CHilxeHHac SyHxqran flX Coxpannar QyHxqun flX
HeBo3MoxHocrb AocrI{xeHI,Lfl aAeKBarnofi qacrorbl * llaquexrur Mor1rr
orHocr4Tbcg K npoMexyrovnofi Kareropnr4
cepAeqHblx coKparueHuit screAcrsue orpaHr4rreHlrrr p!4cKa.
 lcvrdoH v{orHer4dee srrsg roxo}"1 /S elHovlJec cnccedueU 'I,IH0I4X OSrCehe) uH
selnsUoxcosocov ieVdevovtvl t4t4v{am[ 9o re[ercsuer qrrursoll oHHesJSerII/(c u rnnetrx.(Irgee ]Ir€ ilJres€ud
- I
-eUuec exver oHhrcgo -lS El-HolrJec rrccedueU relngUoxct4x rfiow prr.conHedes,{ eru{eV[du u sorHeulreu euneru(96
-ooov g leUdexoraw ililv{amil 9o re[ercsuaraUltec our'tsgo 'etrdexourt orunetrxedsou,fttoltrar,udgoeu x Ilturnrtros
/S -
erHalrrac urccaduaU rBHcueJ"HoeildoJ
rloxcanuenQ udu 19 elHenJec
- V :eve{dleu
uuccedueE tsUrg '99'1 'cn6 -Ildu '<,Mrcudu 4tsnr,etrdec 4omtrogeH)> or€ - uvfr
-duxoner,c udrcudu gnllxe) otn'toleJerou r{xqrox3ou
'u:er(dres wdoQ xeca roIBJegeI,I IqrHeI.{rIB[ andoJo)eH
'xe1' 4ercoxxow€os xrxcer'ueuQ oII'IHehI,IHBfu o rol
-,{arcgocouc orcuh uI,IH€seIrogBe o e}rHeraercvedu eox
-strrlsedueH u urotedl'(Jy'1 'rgur) eeonrodu rrHem
./r ^lr l.
uusedlodeuodoy-Dl oH e '(eEdaoran rar,telQdau nailHoueUoduo c ur$edrouuor seHcneHoead-oHrt4HJeu\ uur uu$ed:nrunhc seHHo[e
-,t$Oeu 'ura$edlorauderoxe) 4enheeuueleile c eorcer-ccadrc euuefaeodu oHeee)ou 'euc,{d o:or-rdeuodov euuaxedou scraerilI ex,{
xrqdoroy r( 'rilel.raraheg 'quderde xrqndeuodoy chHaxedou oJoHHeusurce eened ee9 eorFlauheu I nruanndu oouogueH wrndo:ue
r4rruuelt'xeye,{d.Leu xu>rcer,uenQ udu 4etnoreruHeoe'unUdevoHero foHcur4gerc tsvlHohau u vl)t4rcoHJenU nrudoltty'99'}'c}ld
r,rilheeradsu,{vceead +
u rQed"ior,uHeodeuodox
roHsiloesHvl 90
coduoe sredrowcce6
silueder
seHqljeHuJHeilJ.HV
tluueder €oeoHlBt4U
guueder O xrqHsilJ.eHdorcue qtcoH
4OxCer,urxeuu$odu
uelcer'raoleUu$odg coduoe s.uame6 -xoneo€ sredroncce4
I
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euxaxBdou euuexedou [OYCOhtlYlOmh ]eH
eor.reraotldrcA6 eoxerarxldrcaoeg
uu$edroruueodeuodoy
rraQed:owor ueuderoeulroy
l
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foH
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e!t i 2,raraUde>rouerc eoHJer4U f tcHEngohO
i ,raa.,. o-,orrorldreu nuuaueeodu o coduoe sredroncce6
I '
rau$ed:oraUdexoxe il ilv-LolDt foHUIdJ
uu$edroue:rued raraHeUeeodu o coduoe sredroncce6
xcr4HeUeero ZI s lyecilhedrcu.Jed u ueodv tceiluEHv
dtowco u eeeuweue dogg
ercuuerhauc ruhers ulcuoy '
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 KAPAHO,lOTUC

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rpyAHbre oraegenun). Ha enexrpoxap4uorpaMMe B noKoe
12 oreegeHurx orMeqaprc, nr4ub Mr4HnMaflbHbte il3MeHeHufl
f
sy6qa B npoeKLl4t4 HuxHe-6oxoeoil crenxu. flocre 3 rlran
xogu6ut Ha 6eroeoft AopoxKe BbtflBreercn orqernuBafl roph-
3oHTarrbHar Aenpeccufl cerMeHTa Sf a oree4eHurx Vo ra Vu (Ha
uso6paxerurx cneBa HanpaBo). l-lpra eurnorneHHoil a 4anu-
nefiueu KopoHapoaHruorpa$uu o6HapyxeHo Kpr4r[eecKoe
TpexcocyAr4croe nopaxeHile
f Ta6nnqa 1.42. PexoneHAaqt4r4 Ane naqlrexroB co
g! cta6unuxoicreHoKapgxei
. Orxa3 or KypeHun
r Cxrxexue Maccbr rera
. PeryrrpHure Qnervecxne HarpyaKr4 (noaeenur HarpyoKt4, He
npeBbruJapqile ypoBHfl, npil KoropoM Bo3HuKaer AucKoM-
Sopr e rpy4noi KnerKe; raKre Harpy3Kt4 voryr cnoco6creo-
Barb pa3Bul4ro KoJrnarepanbHbrx cocy4oa)
. Orxae or rnxeJrbrx HenpilBbtttHbtx HarpygoK t4 r4HTeHcuBHbtx
ynpaxnenuil nocle o6ulunoTo npueMa ntnLrl vnv B oHeHb
xonoAHyp noroAy
. nepe4 BbrnorHeHileM Harpy3Kt4, Koropaq Moxer BbBBarb cre-
HoKapAillo, ucnorbgoBaHile HilTparoB cy6luurealuuo
flpnHquuu JrerreHlr.s cneflyrou[e.
. Truare.rmra.s orIeHKa crerreHlr n rs)Kecrv flopa:Ke-
rrutaprepuit.
. Brrssren[e @axropon pucKa r,r ux KoppeKuus.
. Pexouengarluu rro flpeKparrleHr,rro KypeHr,rrr.
. llcnorrsosaHr.re MeAuKanreHrosHoft Tepailvrv DJts
KOHTpOJIS 3a CI,IMITOMaMI,I.
. BrrssreHue naqlreHToB BbrcoKoro pucKa Ms
qEHI,t.f, B UCJIqX YBENHqEHUg NPOAOJDIA{TCJIbHOCTI,I
XII3HI,I.
Bce nauuenrbr co creHoKap.uueft 4orurcmr noJrytrarb
aHrr{arperaHTrryro repalurc. Bceu naqnenraM AoJDrcrbr
B
\
Prc, 1.58. flepSyeraoHHar cqunrurpaSun MroKapAa, AeMoH-
t4uJeM u o nepegHefi creHKu neBoro
crpr4pyor.t1af, npexo4e r{yro
xenygoqKa. l4so6paxexur npe4craBnepr co6oi nonepevHute
cpe3br reBoro xenyAoqKa. flpr cquxrnrpaQuu e noxoe (cleaa)
oTMeqaeTcg paBHoMepHoe HaKonIeHue MeqeHHoro TexHeq[eM-
99m ("'Tc) rerpoSocuuxa, uso6paxeHun HanoMuHapr
Konbqa. Bo epeur Suonvecroil Harpy3Kt4 creneHb 3axBara
rexHequr cHnxaerce, oco6enxo no nepe4Her,t crexxe (yrasaHo
crperrauu), a cpe3bt BbtrnrAer KaK nonyMecrLlur (cnpaaa)
6rrrr Hasna.reHbr HLI3KpIe .t[o3br arrerllJlca;luuulonorl
KlrcJrorbr (Acuuplruar) (75 ur) Ha HeonpeAeJreHHo
AoJrroe BpeM.rr (n Poccurlcxofi @e.uepaqlru cyrqecrByer
TepMr,rH <<rroxr,r3HeHH or> . IIp utte u. p e d.), nocKonbKy
-
sro cHr,DKaer pr,rcK Bo3Hr{KHoBeHr{rrI4M. 3$$errur-
uoft alrrepuarusoit sBnflercfl KJrolruorpet (75 wr/
cyr), ero MoxHo lrcrloJlb3oBarb B cnyqa.f,x, KorAa
arleryrrcanuuuJroBarr Kracnora (Acnupunr) Bbr3brBaer
Alrcrreflclrrc uJrut 4pyrve no6o.rHrre sS$erru. Kpoue
TOIO, BCeM naupreHTaM cneAyeT Ha3HarraTb cTaTI{Hbr
(aaxe npu HopM€L'rbHoM ypoBHe xo-necrepuua).
I AxrraxrrHanbHa, neKapcrBeHHae
rre- I repanre
Ile.nr auruanrun al*rorl T eparruu 3aKrroqaerc.fl
B KOHTpOne 3a CI,TMITOMaMV C r,rC[OJIb3OBaHI{eM
cxeM bI T ep afrltv, KoTop afl flBJIg,eT c fl MaKCI,I ManbHO
upocroft Lr He Bbr3brBaer uo6oqHux e$@exros. flnr
Hdore)org .(xrroxcoll'etrd€)oult uJcoHgocouc IJoH utcagudu texort goredJ,LrH ellHeHelltlldu eouurorcog Y
-srraruredxoc u [! ruuexzHc rehc Ee etrodolrolil s Btr 'rrrHeherr rcoJotrrolExrotrodu enoQ uu rcr,eumqnevur( o
-dexofln srcongedlou rotemsHal L( rsrudeuedu urg oHHeuorcorr eHo oHhrlgo oxeHtro'aoredrun wdoQ I
xrirHsrBdodeu ltorxeQQ€ wlilHhogou ntlsHdorxedex Y
eoueHut xtqeonncruex ndoEvoug rororrsr qffog reHsolrol 'sdr.{ua sreltuHl{du oHxol i
'rodorexougouedfi'e-g|
(rur,(c ae*d7 rrrr'I{ I JI I Og-Od r€drusonolt erugdoc
-oer u (rrxr^,(c a ueed E rlt 97-61) red;,uttuYeYprgdocoeu
rqHeNJo nodtrnuc rE) Halcesou rxeQQe goxul'hll4
'I,IHohau a .{lteurogeren r(nronaurxe rcreerdos[otl
utrur uufrde>loHerc niel,IHeugrtrdc,(' ettll.;ud urtrugemr(d
4ndorox 'esudefiurrofuun ro ollh]Ilruo g '(nxrr{c a I
-eH r{NrqHruuo rcoJer[o{Itffsrodu'uromoxlld e.lxeQQe
eeed y rw g- y ) ruuef'xogoscrls oJoHHeIItrow )oJelfger e
ruruseed urcoHxoruoos €e-era oxeed qrrHexro soqlreH
xrrnsnexx^,(g uuu (rfc/tw 61-g) 4ednrcurr etrus s L
ndorexorgouedry-fl 'l(gad'nawndy -'r,(c/lt 61
enrzdetrur:odrran runeneltudu rer,c ee lftr.lurcotr srng u
rorrs?rcoc euoroduocug eto[ runnemedeed onslrelt
rexow rxeQQe gl,urehurseueder 4nnsrerurorotrodu
-Irsr?rr ur4Iredatreo go)c&tl{ccod a) r,{c/rl^t SI-S ou
oerrog 'uxodol^,rgo xrurr-,(rc xu>rtred a 14 oII4HoroIrI4J -
nonoduocug uwd t-flcf ttrt 002-0S otr rl{Ho["xogoscrls
or.{xltorurlruc'srog or,(nsoro: Joleholrtxs nrxeQQe ,
oJoHHoutseni€e
roroduolent 'deltudues] rxl(c a eed 1
erilHho gou e' ]svs.rc\4aY orqJcoHqlraruxrotrodu 4ox I
sruwuHr4du oHxol I orsdorov 'rqredeuedu erlHsulxor
-r,odox rcrorr(euderxedex unudeltrarrodrug wrudoQ o
-ecoutrdex qresooqrolcll ooHqlrorl/tJhotttrodu larur€ c
erirHqrusJHl,IIrg[3'tsltorunlrc sreaoduttosoduc .tbxol^l 4
u€Esc s'4udo;de xrsHdeHodo> sodorxelodouedtre
redorox'r1oxe^{fuuu tsoxcenueuQ vedeu slrdefiurrodl
-25.1 ntrexorg erasrcEotrcs sotr,(coc xrsHduHodox
-uH irrul^tuHudu uxcerrrarxuruQodu qresotrHeno)ed
rrrprc flrrg,fu,{cr{ uitolt rsdorexougouedtre-El elsn o
rer(trerc e)ol€r v'IurHe[fIB[I 'HkttN t-Z er{Heher s qllog B
- sur)ereceH r4) c ehrrJadoel' exnn rclotutrx^(cgo
rernefuc,( osnrsgo u uutrduxonerc so[,fuc]rdu rr,tresod t
aodorexorgouedtre-$ ruxeQQe euHhogou I,I Bsrc4osJ
-uu,tx rlfr'osete)ox (rxlt ggg eilM 00€) )orerger etrI4s -
'Hor rrc€ lroHqrruuxHodg c uoureurleu I w€Bxcoxnodg
awrvt (eeoYf ttr{ 00r) ruosodee oronnesoducotr etrus (
sresodufiogoduc rfuolt lrHo o)EHtro '€trdexoulru urcoH g eHrldafiurrodrun eltrenet^tudr eoHqrEsJHutgta a
-gocolc rlroHslreJ,uredxoc u [!'Eunelredxoc xrsHnetr o
'vfifireJleuvvoeea goudeuodox renc B0 l^lovodorcl4) Btr
-
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-dexoult eltrexg€Hc Jol€mhr{r,{ Isredll{H 'oJor enod)
trcougedlou rol€[IqHeltr( tsdoruxorgouedry-5J 'rcJeemqHer {.{ atrodorcn>I s etrdexorlw qJcoHqedrou
Edoexougouedty-f, orer' erersrr(ood s 'I{)El(drenrcou u uxer{druntredu
Bvrlr,ax.ule,x rehc ee ulrVdexonerc udu rxeQQ€ rolutr
'rl,treds eender.es s rrlsJcrlotr rsredrull '[t't 'trgeJ s rsHetresudu ersdorox 'lntdoQ
oJoHqlforul,atr rsrudruH qrl4huH0uH oHxol^t' rutrdexoH xrqHHasrcdu)or o)qlro)cen re.(srcot[^(J'Irouderd€
-erc r€HhoH yxJ,jeBrIsy woNorunnc wfiflolBtrBllgoedu u Hos ar.rHedumced reslil0lils 'sots,,(coc ,(dfuerr{xc.{nr
}Irca 'Hosur)eeH IHaI,IIIBU €trJo) 'IqcEh elqunoH EH orz{xtre[r uH onnesrctradcouen roilarcgetr ISJsfuLIH
'nrcoHrc€h g 'gosrsdedeu xrlsocuh-8-g olqrfionou 3
qJexegel{ oHxor r oJoJ€ oH 'runBxrqgudu orurtaseud x HEdtuH
' unYrctu dYu fi>tces ed <Irc o rrxow
eredruroxot,,l eUugdocoeu
h O l.-g Huw OZI-17 tendoQ etsusuedodel -eos sredror{cced ra,{trerc 'ul.,rtunournuc ee rrodrnox
EredrtaHilE eUrgdocoer oJoHhorErootr shrrrcotr rerllos€ou oH soredeuedu xfstr
h g-Z HAVI OZI-gi tsndoQ atsusuedodeg rulrEHr.rgrrox Hrrg'rusrclietr oronnesodu.rnorodu
rsredruH I{[u soruHe) xrlsoufiqrr€x rlrot4 HoJurH€
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h tZ oi h e-L tsndoS etsusueudeVcHedl rolrlrsEgotr urcol/llutroxgoen udu olr{Hehelr ) I^Ieree
u'sodoruxorgouedtre-g| u (o)Ved rclor,{esroucu
Hnr'r OOS-OO Hulr 0f-, _111-1 tsndoQ etsusuexx,(g
vlvuedel 4oaorderc earcehu>I a rr'tedg eotrtroJc€H g)
_|-H (ffg) enudalrarrodutu ltdoQ xlilHqreflJHurg,(c c
Hr4!\ 0e-0f Hr/v! B-t tswdoQ ercnewetruttgl(3
roreHlrh€H o{r{ueder oHHouluYedl 'uur(dr €LI 4oHtro
erxeSSe ucou eua$Se ogr,rrr- go)u) uJcoHsur>teQQe gemsrog srrilreresexo['
-quoruxuoUodg wi(wucxeyl oHhorgrcoVen rweds eerflrorceH s o)€Htro 'goJ€duu
soredrl,tH -edu xrcr{Hegrcduxer uur(dr qrru rirHegotlltroucr{
xndorovan unarcleU crcoxcuarrull'e7l ehxugel ! srng r,ftolnu ulrtrdexonerc rI{HohoII u uxurxemr@odu
/6 . fiEdsc vv{rHd 14t4H3mAdvH ul4H3hlu HunhHhdu
 HapacraHr4f cepAeqHoft HeAocraroqHocrn. .[pyrunau
Ta6nuqa 1.44, Enoxaropu KanbqfieBbx KaHaroB'
i ucnoJrb3yeMble Ang lleqeHun cTeHoKapAHl4 HexeJraTeJIbHbIMI4 e$$errarvru qBrf,Iorcfl flepuoepu-
qecKlle oreK[, rl{rlepeMl,tg KoxI4 JIUIIa, rOnOBHa.g 6onb
Ilpenapar fioaa Oco6exxocru
u ronoBoKpyxenue (ra6n' 1.44).
HrasegrnraH 5-20 r',rr 3 pasa Moxet eut3uteatu
a cyrru* BblpaxeHHylo raxilKappillo
Am u aarop u Ka fl ueBb,x Ka H afl oB
Huxapgunnu 2G40 ur Moxer estsutearb MeHee Bblpa-
Huxopan4ul flB:rsercs e.{LIHcrBeHHbrM npenapa-
3 pasa e cyrxur xeHHoe cHuxeHile Harpy3Kt'1
Ha Mr4oKapA, reu gPYrue 6ro- TOM B 9TOM KJIaCCe, XOrOprrfi B HacToslqee BpeMs Ao-
KaTopbr Kanblll4eBblx KaHaIl0B cTyrreH AJIS KJIITHI{IIeCKOTO npI'IMeHeHI',Iq. Huxoparurut
(s Aoge 10-30 Mr 2 pa3a B cyrKll sHyrpr) AeftcrByer
Aumogunnu 2,5-.10rr,tr/cyr Ylurpa4nrarerunoegeficreue
KaK Ba3OAllJIaTarop I{ BJII,UeT KaK Ha apTepu}I' TaK I{
Bepanaram 4G€0 rr,rr9acro autsuteaer 3anopbl, Ha BeHbI. flpenuytqecrBoM rlpelapara ,IBnrlercq To,
3 paea a cyrxu. o6nagaer BaKHblMr'! aHrhaphr- qTo oH He BbI3bIBaeT rIpI'IBbIKaHUr, XapaKTepHoro AJI-fl
MtaqecKuMt4 ceoicreai,4rl
HI'ITPATOB.
lumraeev 6G-120 ur l1o aurnaprrunlecxrv
3 pasa e cyrxra. ceoficreall cxopeH c Antaronucrb, lf- KaHanoB
BepanaMrnoM

. Cyu4ecrayror reKapcrBeHHble
QopMbl 3aMepeHHoro BblcBo-
6oxgerran, Koropbte MoxHo npuHnMantl nnu 2 paea a cyrxu.
KiurbuueBblx KaH€UIOB Ar{rlIAponHpI'IAI'IHOBOrO pfl Aa,
TaKr,re KaK HuoeAIaru.rs u aMJIOAI{IIIrH, MOryT BbI3bIBaTb
pe$lexropuylo raxuKapilvfio, vtx nyque Bcero IIc-
rroJrbsoBarb B KoM6I{HaIIUU C l3-aIpeHo6roKaropaMl'r.
Hanpotun, BepanaMI,IJI vr lvn'rva3eM HyxHo npu-
MEHflTb B KAIIECTBE MOHOTEPAIIUII, IOCKOJIbKY OH}I
yrHeraror rrpoBo.ulMocrr no CA- ra AB-yary u Moryr
nHelraarr 6pa,qI,IKapAr'Im.,Il,aunne npelaparrr oco6eu-
HO HeO6XO.(I{ Mbr npu ]f,aJfil.g.vrvt npoT]rBonoK azalJ.uit
K Ha3HaqeHLIrc 0-a.UpeHo6noKaropon.
KaJIbUI4e BbIX KaHaJIOB CH I4XaIOT COKpaTLIrenbHyIo
cfloco6Hocrb MlIOKapAa, [oSroMy y [au]IeHroB co
cHr4xeHHofi @ynruuerl JIX ux cneAyer npuMeHrlrb
c ocropoxHocTblo I43-3a BO3MOXHOTO pa3BIdTI,{q Vn r
I KoH'rpoJreM
Pnc. 1.59. gpecxoxuoe KopoHapHoe BMeuarerbcrBo. l-lpo-
BOAHT4K 3aBOArr eepe3 nyqeByp (r,lnra 6egpenHyrc) aprepuo e
KopoHapHbre aprep[u nog peHrreHoBcKl4M KoHrponeu (1).
llocne sroro ronxufi 6aruoHHutil Karerep npoAB[raor no npo-
BOAHT4Ky B CreHO3l4pOBaHHyro KopoHapHyp aprepu0 t4 pa3Ay-
aaor 6arroH MF AuflaraLluu creHo3a (2). l-locne ycrpaHeHrfl
creHo3a B ero Mecre o6blgHo ycraHaBnt4Balor creHT Ane coxpa-
HeHne npoxoAr4Mocrt4 aprepuu (3) (nor*reHr,tn cM. B reKcre)
Hna6pagun flBlrsercfl. nepBbIM npelaparoM 3Toro
Krracca. On srrsrrsaer 6pa,quxapAl'Ilo 3a cqer Bg;zuuvrs,
Ha r{oHHbIe KaHiuIbI c}IHycoBoro ysla' flpenapar He
Bru-seT Ha coKpaTI.{TeJIbrryIo cloco6HocTb MI'IOKapAa }I,
lo-BrI,4rIMoMy, 6e:onacen y [auI4eHToB c cep4evnoft
HeAOCTarOqHocrbIo.
Pauonaeuu
.{auuuft npelapar uuru6npyer [ocryIIneHLIe Ha-
Tpus BHyrpb uraAKoMhIIIreqHbIx r.[eroK KopoHapHblx
aprepnfi I,I BTopurIHo nosAeficrsyer na ralrrlraenrrft
ToK r{ cocyAncrrrfi ToHyc, yl[eHblIrafl cI'IMnroMBI cre-
Eloraroprt
HoKapAuu.
I Her'ieAuxar,reHrosHue MeroAH neqexffi
ipecxoxnoe KopoHapHoe BuewarenbcrBo
flpn rIKB ronxraft rpoBoAHI,IK saBoAllrcrl qepe3
creHo3 xopouapnotl apr epvtl fl o,{ peHTreHoBcKI'IM
I,I rro HeMy flpoucxoAl'ITycranosKa 6aJUIoHa
neo6xoAlarraoro pa3Mepa, roropufi 3areM pa3AyBalor
.urq paclllupeHl{rl npocBeTa apTepl,Iu B 3OHe CyXeHI4rI
(prac. 1.59). PasaVnasue 6a:lr,tor.a Moxer coqerarbcfl
c pacKpbITI{eM KopoHapHoro creHTa, roropuft upe4-
craBnfler co60ft Meta-rulu'{ecxuft xapxac, B HeKoropbx
cn) raqx norprrruft neKapcrBeHHbIMI{ npenaparaMl4 c
anrunporu@eparl4BHblMll cBofi crBaMu. Koponapuuft
CTEHT IOMOTAET MAKCI'IMIIJIbHO YBENI4qI4Tb I,I COXPAHI4Tb
pac[]rpeHHrul npocrer creHo3l,IpoBaHHoro cocyAa.
Pynrnuax uuMaHTaIIlH creHToB B creHo3I'IpoBaHHbIe
cocylbl cHI,DKaer KaK qacrory oc, pbD( ocnoxHeuIaft, tax
pI qacToTy Bo3HI,IKHOBeHI,ITI KJII',IHI',IqeCKI{ 3HaIII'IMOTO
pecreHo3a (pnc. 1.60).
 eiJ{arc oJoHdEHOdO)edrHU U[hBrHeuuv\l4 eucou e)oro8 >IE) xI{)Br'4uueaeroges xfimoltg.tcrr(uoc xrIHxEs
euHeueoHelccos aoHuou g i(vtnexuedrc OJ
d oJoHclrpv\dox - ]6.uhvtte]fl- lr eroro uVd€) oJoHHollnnesdeJ,Hu euqllo
€x0 woeognodr 4tsxxeueouc[go'uuuoxuoueu oeQeU >Ie
g 'soooHetrc uuroroQdow Jo JrJllaut edelt 4omsrog a
pru{dx screcuaUeduo e}ntceuuot4JHe 4oxr'uedeu udu - e
B8r3irreJB[el tg exeucr( q.r,coHrrodeg ]r IltHHeHXOIrSo
:nrdarde 4oudenodor {oeedu snEo{lrvvo cedrco - V :osrc 'e
-qr€,remov{s aoudenodov aouxovcedn aounuedeg'09'}'c.'ld )JvId']dilHesodurH,{m exEY UIUI4 B)h oJoHITo eme
qI
rreaogedlou rexon (luerc 4rsudunodoxedrrtu negod
-r,lrHurflrnu rng ltrsdorox'sotHeurt€u gg1-9 f, oudev't u
-udu celt 9 elrHehoJ s 4urnolexlneou) uutrde)oHerc 3
Br,rfi4ned'u['fcoc oJoHH€sod[€oHerc edrewuutr xum x
-qrogeH udu ogur rlrnaxudou o:onnesoduHurlqlrB) -
Y
I,rrM
oJoHHe)KKod[ 'ereg€utr oronduxec uut ultettvdu
IqH36U)OX OHHo9OCO IiIrHeJS'l toeedgo I^IIDISI'erHerc
Y
I
s eoHerced u HI^tI{rHlI otraeerudeuur rotemedaro[edu
EE
u rurtsdxou eLI roroluslqwns oHHellfiev[ (recxu'lmoruu
n
utnt ctvtuttoduc lex eluel) tsredeuedu ersnauredeQ
0
-uroduurHe xuH s elilne,{esroucu :eeonerced xclrd
ro€)c,rHc emqrog etne I'.Ier,r.rlsdxou wlqHHosrcdexar c
aorHorc euuenel tttd g'€resoodrr vllf;:re LevrrY gotitrou
eenog ilhl4rcotr,{doledeuo rerrossou €rHerc Ylalrel
-HBTIII III oJh 'Itet c oHB€trgc or€ 'oHrrodeg 'ueouerced
xcud reexlrHc oHHegrceln.(c eunesoduluer3 'cen €
ouHeher s rcreeaflseed 'orrltgedu xE) 'u firnlql,u xrl)trerrJ
flutrBdeQl4lrodu u I,IJrr 4o)cehl,IJculr€ nel4Herehoc u
Heusorc,{go €oHarced 'seen,(rc t/I oY rerlrtrErtoc xI
orodorox eroJceh '€osorced rcrerusr g)h x[eI'{HaH -
-xou3o nusHHehodcro l,rlrs.Lcuh eoroglr€H'soehduc
oAOl s rcrauhedJos 'e[dexotltl eeodxeu aodexduw
xrirHq[oursrcsdn rHsodr{ rtIHellrlsou pIuHesoHSo €H
rcre[durcoHJel,Itr eodorox'€trdexoul'u ouHa[xads
4
-ou eoHq[orI{hEH€eH'ol^Hesodl/IrHr(m eosdenodox '1
eosnedrcxe rcsreaogadro[ rexow runeaodurHerc E
o,ronr,etrfen xreMlrc xlsdoJo)eH a o)eHtro 'ErHerc HUII Y
werll sluHed,r,c,( oxxolt oJcuh oIII€oIIDDIO
-ErHurflrNI,I o
'd,ftolodu o4g-7 a oudexlrdu urEoxct'todu ra (utlderde
4onduuodox Eel,Itrxoccra[' srce or) Iqfl I4rHI,l e.r,fxcor
oJoHtrogotrc uru egltofu lteunesodultdoQ uueraorc,(
-go rr,r€orrx)g'etrdexollx vteunelrxedsou wumol](tr
Y
-erco[ c plsres 4oflo)og oJo ]rIfI,I 'ogtcqroJ€meng t(
iloolr.rrHroulils Itodorox eg'u[,(coc rl4€olrr>D{o YJLoIBII
vt
-sB g)h I,IwruHel{xorco ultlqdrco I4hlrIHsoHcO
'rnnesodurHdm oJoHdeH L
If
-odox effcou upltrdB)oHorc wospltrI4fled c sorHel{fieu
-
,{ ulrueder. EoHslIr€ulflfetr esrcehex g rcrer{esuoucu
-l
orc€h rrlrHeho[ Vorew I]to)€I 'xrudarde xrcHdeHodox
xuwuc s u xB) 'ex )er sruHedrc,( oHxolI xeur,(m
xrsHder{odo) s rseoHer3 'Iaunexedolr Norcl Vfcoc
-x,(s[ }Ilr}I -oHtro I,Id[ rrrerHlroulss g)h I loHsoHco g
'urcoNe€suxtss reemhr{rr( en on 'ultel.'rloJ,ulrtl4c e€ q
KrodrHo) oremodox qHeho qhllJcotr rorlfoseor orceh -
g)h geH['d€)oHerc 4oH<IIMgerc 03 sorHounBu A
66 . vhudSc vl lrl4d 1414H:ImAdvH gt4Hf hsu Hu]4hHudu
100 . KAPAHOnOffii

caxapHblft A%a6er I4 3a6oneBaHur nepraSep I{qecKI'Ix .florolnntelbHoe np]IMeHeHI'Ie cI'IJIbHbIx ulerru6u-

ropon rporra6oquToB, TaKI',IX KaK aHTaroHHCTbI peuenTo-
aprepuft. Bepoxruocrb xopouero pe3yJlbrara HI{xe
npr,r cJroxHbrx, npoTrlxeHHbIX, 3KCUeHTpI4r{HbIX H
pi Yzv tz (uour4uorpen, rpacyrpen ram ruxarpelop)
pac- s xoM6uHallvrv c acilvpvHoM I{ renapl'IHoM' ynylruaer
KZUIbULIHI{pOBaHHbIX fiop axeHvgx) npI'I CTeHO3aX,
noJroxeHHblx B Mecre usru6a vrvl B l43BvIToM cocyAe' racxoau [IKB.
A TAICKC 3AXBATbIBAIOUII'IX BETBI4 COCYAA I'IJIPI IMEIOIUUX
rrpH3HaKI,I areporPou6osa.
Aoproxo po H aP Hoe wY Hr u Po Ba H u e
ylacrKoB
.IInq uryHrl{poBaHl4s creHo3r{poBaHHblx
KopoHapHbx aprepuft uoryr 6rrrr ucnolr3oBaHbl BHy-
TpeHHfls rpy.[Haf, aprepl'Ifl, nyIeBa,I aprepl'Is rulu cer-
MeHr noaKoxHofi seHu nauuenra (pnc' I '61 )' O6uvxo
aoproKopoHapHoe IIryHTlIpoBaHI'Ie noApa3yMeBaer
cepbe3Hylo Onepauurc B ycnoBusx lIcKyccrBeHHOrO
rponoo6paueHvIfl, Ho B HeKoropblx cnfla'Ix IxyHT
Moxer 6urr ycranoBJleH Ha pa6orarcueM cepAue'
flocleonepauuoHHa.s cMeprHocrb cocraBnfler rlpu-
6nngr,rrelrrr o |5% : y [au]IeHToB Irox]IJloro Bo3pacra'
co cHlrxeHHoft Spaxuneft nu6poca JIX u cepresuotZ
cofiyrcrByloulefi narolorueti (uanpruep, noue'rHofi
HeAocraroqHoctro) pvcKr BIIIIIe.
aprepue AnrunosHue 6orut He peuu'[]rBl{pylor npI'IMepHo y
90% tauuettroB rrepe3 1 roA uocle aoproKopoHapHoro
LUyxr us rrryHTI,IpoBaHI,{q, o.uHaKo uyrb MeHee 60% \a\uerrtos
He I,IcrIbIThIBaIor cI,IMrlToMoB Ha npouDKeHI'Il,r 5 ler
noAKOXHOi4
BEHbI
u
6olee nocle onepaullu. Pasttss' nocreonepauuoHHafl
creHoKapALIs o6u'ruo o6yc.loBJleHa HeAocraror{Hocrblo
TpaHcIrJIaHTara BcJIeACTBI',Ie rexHllqecxlrx cloxnocrefi
BO BpeMfl onepaul4l',I r{nl'{ HapyIleHI{eM AI',ICTZIJIbHOTO

KpoBoroKa I,I3 - 3a Iropax e}l.vlfl lr4cr aJIbHOTO pycJra'

Pnc. 1.61. AoproropoHapHoe uyHrt4poBanue: A aprepuu c
- rrryHTOB, [OSrOMy oAI'IH I43 STUX [peflapaToB AOJIXeH
cyxeHHblM unn cTeHo3t4poBaHHblM npocBeroM tuyHTl4poBaHbl
c noMollbto rpaHcnnaHTara n3 noAKoxHofi eeHut, no4ull4Toro
Kaopre, unu c noMou1bro exyrpeHHefi rpygxoil aprepun; 6 -
Mynbrucn[panbHafl KoMnborepHae rourorpaQnn cepAqa c
rpexurepnofi peKoHcrpyKLlt4eil.
'nogroxHofi
[lpogeuoHcrpt4p-oBaHbl txyHrbl
rai 6onuuof eenur (5l"lB) x npaeofi ropoHapHofi
ipr"pr, (l-lKA), aereu rynoro Kpat (BTK) ra guaroxaruxoi
rbrri, Eri) ,a uryHr ua aHyrpenHefi rpygHofi 1P19.pv1v1 (Br{ x
-
nepegneil nncxoAnu-lefi apreprara (l"lHA)
flo:Anufi peullrl4B creHoKapAlII'I Moxer 6Hrr csRgaH
c nporpeccupoBaHueM 3a6oresaHl'Iq s KopoHapHblx
ap-
TepI,Igx I4JII'I C AereHepaTI'IBHbIMII I{3MeHeHI',LMlI IIryH-
ron. Hepe: l0ler nocle orrepauull [poxoAI'IMbI MeHee
50% seHosHrx uyl{roB. IIpu srou aprep[anbHble IuyH-
rbr xapaKTepx3ylorcfl ropa:lo rryIlrreft npoxoAllMocrblo
B Aonrocpoqnoti nepcnerrnne, 6olee 80% uauuapulx
rrryHroB npoxoAl{Mbl cnycrrl 10 ner. 9ro npunelo x
TOMy, qTo MHOrI'Ie xupyprt4 cTiull,t paccMaTp[BaTb Bo-
npoc o [poBeAeHuI{ no:troti peBacKynfp}r3auul'I Bo
BpeMq aoproKopoHapHoro IxyHr vrpoBanns" V a\erut-
czurlululoBarl KlIcJIora (Acnupnrt') (75- 1 50 iur/cyr),
r.r KJlonurorp ett (7 5 ut / cyr) ylyvruator npoxoAl'IMocrb
6rrrr nagnaqeH Ha HeonpeAeneHHo AoJIroe BpeMs'
IrlxrencusHarl il,IfionufluleMl,IqecKrls repanl{f, 3aMe.U-
Jrser npotpeccl4poBaHl'Ie sa6oresaHuq B KopoHapHblx
apTepl{qx u uryHTax I'I cHI4Xaer rlacToTy cepAeqHo-
cocyAr,Icrblx co6uruft. Y nauuesroB, Koropbre [po-
aonxalor KypI{Tb rIocJIe lIIyHTI4pOBaHrI-f, , orMerralorcs
3HaqurerbHo 6olee nrrcoxiu qacrora oc:roxnenraft u
 -8H )trrl,rEr r orr4trd?)oHerc '(otrHolflodr) oruvdexoue.rc 'ndolr xr(eU eeuog rseeunxoQ
-coQuureedr ufcoHshrve euHomtqaou lel 4tsl'leuueUedug *
or,imoildu c cadroduodr xrsg vrtrvt or,{mxrEnsos erss
-dau g roresrseuH 4eutrduxoHoJo EoHqlrvrge r:oH' I ll4 rcHBd
H OrHtrdSxOHSrC Or,{nqrr,rgBrCeH JeehOIIflS {tndorox r4J.cerlgo I quog eufucoU
'(rued 4or ercet,,t e eU,(coc
'Hnrtdar gnndenodox
Ertdrc6
or€ - lrodEsuc -uouhedeuo'rvrew erauefxedeog
4ouUAd:) uvrbreQrT euueeodurulm
rrodUHilc IrqHduHodox f rqdrcg 'EUdevor4ri! auHeE eoudBuodovor BilHoHxouco '
-xedeou eoHelQQnlt -doe eowedrcve erlldb'
'(qt't 'rgur) ur^rer rorrrrur{c
ut4HoHxouco
Hr u,DrJor c sorueulreu ,{ lneh 'omrqs e€ed 7 a ru,rrou rer g (rc>elnc) orce6 oxEe6 euxcenruouodee;.1
eHHaheJ s qrcon.rdelrc (6y'1 'rgurNO) (SJJ ere)m or
Bccerx oJoHlrrBHor{IDHr{Q AI UIM III rutrduoHarc)
rauZ c/hBe,4dsu^vceeed
rou Z ot4+or,ora o/oz eilHohor I o/oOZ-Ol uerdoreog
4eutrduxoueJo gorrexm c sorHoLIfIBU,t eenelt eH wel
'sotr(coc xsHsrudererrox nuluusled udx uutrde)oHerc eUor; cot/',r g nuUdevouerc
ot4Hohot E 0/06l onHohol E o/o1z-gl ErUuhod
soNorttnuc Irrconnexedrsg euHemsHelr{r{ eoHHerHouc
Bcre€trorffgeH oJcuh,{>rsroxcou'ooltrodu sJulreVeduo oloqed
UoH ZL-g qaHV 9-Z x eruainedeeog
oHhoJ rorlflloseol] eH Iql^lorull{Id)'ol\t eeHol I roBrserc
-oc nufleeudrr,(xcesad uuslcrr{cro udu qrcoweeslrx edeHouherc e
uuueersgedu crbor
-rqs rrHrormlru uunexBdou norcu[rbocxefu wondum
rlenE g-9 h ge-ZI -suelaxuoUodl
-go rr X1 ulrrrxHfQcuE gorerrrr lrdu 'autodtrcyl' g96
3OrO9 rerrsuJroc qrconoBsl,Ixlqs rrHrerurru xII .eUdevort,r
rEurrxu,(Q 4ounedxoc lr uunexedou lrorcutr {cocoHtro
o/oOl o/oZ udeSuy
'
rd1 'XIf lrnfixufQcutr urcoHHexedlss u 4udetde o/og'l> o/o9'O> croOtrden3
xrsHHaxedou elrcuh ro rlrcr4se€ JgI4 ndu eonrodll euxesodruxr(m
eoHrodll
eoudeHodorordoy Syh luderudy
I uuxeeodurxAm
'S?'I 'lrgur s oHetrosudx mresodurHr(m oron o:oxdenodorordoe ta e€rcqueremaws oJoH I
-deHodov o.roxxovcadt erxaueed3'gr' l etfiugel
-dusodoxordoe u g)h ellueuaed3 'rar g uunexcrrodu I
€H sorHeulrerr ol\t.{. lten earog rc<Irehol lro rexont
oHhrslgo elqdoro)' runomr(deu eIqHsuu.IHJo) oIqHHeN
eodorox'4utrxn(@ xsHsurI.IHJo) ruHe)IC,IHc oJoHqtfer i
-edsoxred) rcrorusr4s€pd aorHel{fieu %08-0E A' %g-I
-vttr kral'1,lvx rrHuourro 'cel I 9 ol,IHeher s rol^{dl,Iccefuad
rerrseJcoc erqufcHu oJoHHo]rrrEdeuoudeu )cu d' Yutt
ercedeoe -eHxolr3o 3u)cohl,IJo[odseH rcrolBrsBlqs orceh
10 axvel- B 'r4ilHesouogee xillnor(erclluoc eucilh 14 Xg' 'yudarde reHr^fu rrHHedr[Hs ruselr I
nuiluI$curU ilrcoxsf 'EoUIcm xcHHexEdou Es-Lcohr4uov ro qcerpsotquoucu uurr(m earcehe) s xFldoro) r( 'sorHe
J.tlct4spg BsJ_ccuorBmol,'le Eoxcl,4' t4treel3qLIoigmong
c xtcHHee
-u[eu r( exorer B 'I.{ulledeuo otr I^Iorcer nrirHho€^fu€H
-uec '!4rcoHrder\c il ft4HoHxorJco ercilh vlerHenilueeI c tqHox
-cduoc oH' Eor,\o-LUv't4c sr4r-remqHar',/,( ucsrugoU ro{Blioeeou
r^rrqHqneJHxorou c r/,trlr xv lrutrxu,(Q lteusem,(den
euHeeodurHlm aoxdexodovordoe u exnrceuuoltJH! o c soJHourIEU l( oHrer rB€ eerogl{€H L{rco^eEsuxlqs
eyleot t4ottu,{d.l e fudoQr',toxcrU x eu e euHomrqsolI' uude rde ty'oaoxnotr {re)oKan 4entredau
'evmrqUo vev xrveJ-' r4J-coHholprcoUou r4oHr'eUdec Eov',Jor-urlt4c I,IrCeh r^40HirruNr,rc)od[ fileuHehSlfsos 3 I lel,IHoxBdou
o{rHotrscou v rrceeudu rfuon eUdevourvr r,trh>ir,{$ r4ovcehilu wrqrcutr{cocx,(ev c uru 'uudetde 4onduuodox goaedu
-orceuE il r4rcoHhnrcgue gilHoHov\eil vrorcBdeoe c orcHHeeusc
eUdevouvr rt.z'wamluutnaeed ildu :cr4Hauecodu enxr'uuury . u uudetde gemoregr,rJo' (' pad' nawndll
-'ruffir[oxJr.tH
rleuUderouerc oc 4eUoru xrqu!4xou xece gcra rrHtrode[
-er,edrce ^
- w?rHoHr{c) uudaldu goso)hotr{re)oKeh{
o-Lceh
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" l1o: Thygesen K., Alpert J.S., Jaffe A.S. et al. Fourth univer-
sal definition of myocardial infarction // European Heart
Journal. 201 9. Vol. 40. P. 237-269.
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I,luorAa I4M nporeraer 6e3 LrII,IHI,IqecKHx npoxn'leuutl.
Bosl,{oxHo 6ucrpoe HacrylneHl,Ie sHesanHol; cMeprl4
BcJreAcrBHe @X lrnu acreroltvrvr, qro rlacro npouc-
xo,rlr4T B TeileHue rlepBoro qaca flocre uaura$ecraqlru
ranSapxra. Ecnu uauueHT ocraercfl xI,IB rIocJIe 3Tolo
KpururrecKoro cocrorlHlr-n, B.tIzL'IbHeIilIeM BeporlTHocrb
xr,r3Heyrpoxarcuux Hapylrenufi pI,ITMa coxpaHrlercrl,
Ho yMeHb[Iaercq c Kax,qbIM rracoM. O'{eHr BaxHo,
qro6rr naIrI{eHTbI IIoH}rMaJ'II{, rrro orKraablaarr o6pa-
IIIeHrre 3a IIOMOIIIbIO B Cnyqae noqBreHuq cuMrIToMoB
Herb3q. OcloxneHurl Moryr Bo3HHKarb npl{ Bcex
@opuax ocrporo KopoHapHoro curuIpoMa, oAHaKo B
coBpeMeHHyIo 3py HeMeAneHHofi u,ru panuefi ropo-
Hapuoft peBacIryJIfl pl43auun oH H crzl,'I u na6rloAamcs
pexe. OrgelbHble ociIoxHeHI,I-s ocrporo KopoHapHoro
cuHrpoMa I{ I{x JIeqeHI,Ie o6cyx.uarcTcq HHxe.
 'amrrs rqHucr{uo I4IrIqg oHgodtrOrl eeIIOg
UO. o
lrJcoHhorEr3otreH 4oHhetrdec ol4Hehelr u B)I,IrcoHJSI{x/ EUevoug-BV . CoX .
'HrcoHhorErco[eH r-{oHhetrdec 4ofuco uunurun udu ror (r,tufieewe>ou rund 4teuduu B
-€)LrH6os orqrcourrodea ty'emqlrog c WI{ 6l,IHel{xorco feHxuH t/!t4 radr ouuegoco) -^vradrHeeoilUt4 t4teHuedoxc4 . -
eurddtr ecg 'nio€oHJodu l^rl,xoru c rcre,{dttzllocce Lr urEdewUedg reeocluu3 . -LX . s
silUdevilxBJ- reuUdecUedg . XO . x
etrdexoux ur4Holrxedaou woxdumgo 9o re.(ar,csreretr
ewodUxuc woxdeuodov vuodrco f g
-usc oHhlqgo qrcoHhorercoVeu rennaVdac rzdr,c6
radu erirrud cuHamAdeH otqrceh'Og'l ehuugel E -I
etcoHhotetcoaeH aeHhaildac 6edno
rxdeQuy '(a/a rw Z'l-9'0) Huuodru Heh€Hc€H qrlqg
'4uderde xnn rexolt eun,firc Nor€ s igunemr{duuxlrxSehr4l leH}rtroneJ <I
-dunodox urafieeudrrfxcused xrrefi s (t y7-9 xlsadeu tult4 ut4:aoroxuJ uusrcr,{cro udu rr{HehelI re,tgedr
er{Hohor a) ruQufu oulreodenodo>t wvr+ted €HBoE)oIr eH uHo o)uHtro 'yuvde;uYedq <IrBxuHsos rexow ox
t4
'cuellrogwodr nenronrqg oHmeucr( nsg xsdorox ,( -xe1'ruueder runruvrl{.leo)I4rHe El{utroxgooH IfO
'r,{erHol4fleil Neos I^tur€ c rrersc g 'otutrdexoxor3 ilras€ rcuremorrHedxoc lrdl]'lrrcoHhoJercotroH lltoHhetrde3
yyluel.ieu vr LDrrrrcoHJulltr 4otrluxell['eH l{ugrcJr(cro udu
;
-rqs roxohr ooHorc IIo)eJ uudatde Iltor€ aH4eoceg s '1
u[dexoultr oJoHgocoucoHo]rx Ltur,ulrc-H ud11'uuderdu rjoHarar>raQQ€eH iruirg rexol I uuttedet ee u 'tltcoH '
-hoJerrotroH 4oaoxr'otrrfiraxosor tlonnexedns u)ceh
IroHHesrsc-.lxduQuu eouerc $ilHhoruJco ncrerrredxoc -
oilxcehlrrurrogr rodr oilsmeuc,{ en rfuoltcen -urvll,t>, urru 4efflolexodr.,( ltoxunelrdu susg re*onr
'orr.ruedg.r H
ttdoruxougonedtru uttu Huc)oJuV B J LorYYtaY
'sorHeuneu BgrJHlrrrrqrrog A'clr€urogwodr HaHIror 11 6' - F) ,
oHhrirgo udogna [wurudeuedu xrufiufruc xul{dn g
-rirs rrirg wrsdorox 'sorHeufieu %OS i rcreer'edrcs t4
' uncdasouV dux renneniedseosc BI IutroxgoeH I,nularuH
rutrdexonerc renrxduQHr{Jcoll'uttfiueudrr,{xcused
-uvoruoJ ralrrunem,(dBlJ vrltrfi .evHoroullJ c }rl4Hurehoc
4ondunodox gonuefucxe n ra[fiecsr.(ufuirox 4oHHoIr U
a 4unetnedxoc xrssoxhotr{rex erorceh t2toxocrsa udu
-uzg 4roHqrerdoeud.r/firs <rJcoHxon€os sredrowccud
o)EHtrO 'uutrudat goHxourooH ra,{gedr eH 'outlsudu
re^trelrc uxrrrEHutroneJ xrl{Homr(den xrsHHaxedlsg
)€) 'u Ueuwrude gerfirtroxadn oJecs e[[Eh oH'4otcul,
raru elrodtrnuc oJoserog rcoJelnolrHudxoc uunuren
lrll'oyray UO '(trXI4 ,{xsoHurc,( renotrxe) r,ruleder
udg'aorratrogltodr sodoJ,uefied-€III/qII xlqsoHl,l rlro)cahr{nurdenuru goxcenuQuIleuc u tsLIHuaotrerccu
-eloduoxurr sodorexorg or4Hetr3ss a/a onueuxou oJo)3ehr{JorroueuQodrxer€ el4Hetrosodu oueedgoocer
nronodtrnuc Nrirserog rrcwr,rrnolrHedxoc u J)e €H
- on fl orHeufiett efyd rl'urdewc 4onr,etsdec HoHrreeeHs
unrlll{eHel^t6l,t I,INI,DIoohl{r r€HI4tr o IllurHalIfruII' gellfle€
nodor)utrodu irJrqg pr soxhotr,(uex uullxsfQ ruu
-udrrr(xcesed c uuQedrouJHeoduHodox rauneVesodu -am,(den eHsrcvercs rcsrugugeed rexow ewodVnrEc
NoHqrereJerrroeeg o coduos Hefuoncced srng nexrotr nondenodox lrodrco udu unllHerlcereuuoxed neeQ
xug.{ r{ttoleou 'exJud oJorocrls euu,{fu ) rcrrSoHJo rlreds oa rlunrndu xrssoxhoVftrex el{h}rlrcH 'y1O
' axe^(fu en 4oxcer,ueuQ &roHquunuHuw udtt utnt eo)orr
eeg sorHeufieu ,( ,ftrroso>IeJ Heh]IJolrguu 'IqHegodttw
g HutrdexoHelc rsu,(Jcudu roilduailVufied ev[odtrHlrc
-usead oHnewedseosc u oHmeuct uuts'g ersdorox
orondenodox orodrco ercou xqdorox,('rsrHeufiell '(n gy xnade[ errHoher s) XO 4enued c sorHoutluu ,(
untdevoHetc euvufiad eourodlf irH€nx urceuc u vtrud tgrsaoc,{nlrc qu{soH
-Erccos rerros6ou uulrctruudguQetr rBHHen adaeoa3
'edorrr,{wn.lcortrdexodrxere o.Ionnenedg 'sfflol,[or BB>tc:g^LlfiuYaw eH€08)o retr{g I,u{ )E) 'otot
ru[IBrHBUrN}r re)cehr{rxuruQodu Br rutroxgoeH NBr otr xumoruglrJou 'sorHenfieu zrdewc 4ouurrudu 4on
-Heufitu nlDrBI' rtvtro::cttce NoI,IU{s€€d llrlqHttuoeHs -aoHco rcre€Juhc u 'dunolrnetc s JoIetrEUou arsdorox
eresedn r(xsroxcou'EHcuuo eerog'uulrB0plrexor 'sorHeprfi€u o4g1-g f,ucteeauaeudy6']r]rr reurlz)ou]IJ
r,u4n)eddo) Honnerrredueosc'Exlqfto'wtuutnrogeago
4entredeu 6114 r,rdu Eu[norcxlHeos'Etre)oug-gy'edor
oJoHrBsxetrE ltar,(u,fit{lnluglzw ) Hotresc qJrlg rexow
-r[r{l rurcoutrduxodrxer€ oJoHHaI leda exaouercr{ go
ptultwrdu )crrd 'rr{HeheH€ oJo)cohurconrodu }r oJo)o
coduos sledrorrcced re^trerrc Istre)org-gy I]toHlrox
-ehurruHutrolareJ rorenu es n derxudex 4ulnrtroxedu
urM r4Herrerc II rsYBxo[g-gv ar4sJctrercs ruHemtrfx,{
oJo)cohr{Hr4rx eer,,ftrc g'uuueder 4onuoue,(Qdaued
rrcon seeh.[trc esroHumirrog s oxeHtro '(gg'1 'rgur)
woluodtrnuc WrsHdeHodox rrursdrco c sorHeufieu f
ercox rcrernedrc^{ orceh r{ daJ,xudex r4utnrtroxadu
rcroresusrud orcun erl['dec eltrud runem.,(de11
JLrcoH oHhrqgo redo.r,ox'rttr€xorg-gy lteuruaeed
rcqrllHxolrco Jexon r{)Herc taeHx]IH etrdu)ouv'l efiildec eNMd auHemideH
90t . vhudSc vi,url4d t4t4HSmAdvH g14H3h3u Hut4hHt4du
106 . KAPAl4OIOrl4q
llepuxap4nr
flepurap4ur pasBprBaercrr rorbKo rrocJre LIM u
oco6enno .{acro Ha6rroI,aercs. sa 2-e u 3-u cytxu.
flaur,renr rroxer orMerrnb [oqBleHue 6olerl unoro xa-
paKTepa, xorrl ee JloKilJrlr3arrus Moxer 6rrrr upexHell;
6orr sasrlcltT or noJroxeHvrflTera I{ Moxer Hapacrarb
nprl BAoxe r4,-rlr Bo3HpIKaer roJIbKo Bo BpeMrI Hero. flpu
aycKynbTauur{ MoxeT BbrcnyulrBarbcf, rrryM TpeHI,IrI
flepr,rKapAa. B xaqecrse o6es6orprnarorueft repanl4l/t
cneAyeT I,IcIIoJIb3OBaTb OrrUOr{AHbre aHaIbreTI4KI,l.
HIIBC r{ rJrroKoKoprprKor{Abr Moryr rroBhrrrrarb pr{cK
@opnuponaHrfl aHeBpu3MhI I4 pa3pblBa MI,IoKapAa B
paHHeM BOCCTaHOBI,ITeJIbHOM rIepUO.Ile, IOSTOMy LIX
rrprrMeHeHr{rr cneAyer r,rs6erarr.
Cungpou flpeccrrcpa
CnHApou .{pecclepa xapaKrepu3yercq croftroft
rurxopagxoft, [eplrKapAr{roM }r IrneBpI,IToM I,I o6ycror-
JIeH, IIO-BLIII,IMOMy, ayIOI,IMMyHHbIMI,I HapyIIIeHVIgMl4.
CuN{nro}rrr so3H?IKaIor cnycrrl HecKonbKo HeAeJIb I,IJrLr
AUDKe MecflueB flocJre I,IM u.racro ilpoxo.u.f,T B TeqeHlre
HecKoJrbKr{x AHeri. flpu a.nr4TeJrbHbrx r4rrr,r BbrpDKeHHbD(
cl{MlrroMax Moxer norpe6oBarbcfl Tepafll{fl BbIcoKI{MI{
.rlo3aMlr a\ervrrcuruuulonorl Kr{cJrorbr (Acuupuna'),
HIIBC vuru rax,e rJrroKoKoprrrKolr.[oB.
Paspua nanunflrpHbtx Mbtuq
Pasprm nanruuxpHbrx MbrrIJu o6uuuo nporBJrrrerc.f,
oTeKoM JIerK[X I,r pa3BI,rTI,IeM I]rOKa 143-34 BHe3alHO
sogHux[efi rsxenor7 uurpa-nruoft HeAocraroqHo-
cru. flpu ayc KyJrbraurar,r o 6rr.rHo BbrcJryrur{Barorcrr
naHcr,rcroJrlrqecrurZ ruyru r.r III ros cepAua, oAHaKo y
lauueHToB c rqxerorZ N,rurpa;rruoft ne.(ocraroqHocrbro
[ryrll Moxer 6rrrr ruxuir,t l{nu orcyrcrBoBarb. .{uaruos
noArBepxlaercrr npu 3xoKapAr{orpa$utt; Moxer rro-
rpe6onarrc.a 3KcrpeHHoe npore3r,rpoBaHr,re KrralaHa.
9acro Bcrpeqaercg MeHee BbrpiDKeHHas MprrpiurbHa-f,
He.uocraroqHocrb, Koropax o6ycronreHa 4uc@ynr-
\ueitnanuruspHbrx Mbrrrru r{ Moxer npoxo4r{Tb caMo-
CTO'ITEJIbHO.
Paspua MexxeflyAolKoBoit neperopo4Ku
Paspun Me)oKenyAorrxonoft lepercpo4Krr o6rr.rHo
xapaKTepr43yercs BHe3anHbrM HapylxeH[eM reMoArr-
HaMI,IKTI I4 npOrIBnrIeTCrI HOBbIM LI TpOMKI'IM [aHCI{-
cToJIuqecKI{M IIIyMOM, npOBO.UqUIUMCfl BAOJTb npaBOrO
Kpaq rpyArlHbr, rro3ToMy ero 6rrnaer rpyAHo ornl,rrrr,rrb
or ocrpoft uurpamnofi He,qocraroqHocrr{. Pasprrn
Me)oKenyAoqrosoft neperopoAKr,r [pr,rBoAr{T x c6pocy
KpoBlr cJreBa HarrpaBo qepe3 sogHprnxr,rrl 4e@ert, vto,
KaK npaBr{Jro, npr{BoAr,rr K pa3Br,rrr{ro ocrpoft npaBo-
xeryAoitKoBofi HeAocraroqHocrr,r, a He oreKa JIerKI,Ix.
.fua no4rnepxAeHl.{s .4l{arHo3a rIoKa3aHbI Aonflnep-
gxoKapAr,rorp a$un v. Karereplr3arlu-f, npaBbrx or4enoB
cep.[ua. CocrosHue rpe6yer gKcrpeHHoro xl{pyprll-
qecKoro JleqeHr{fl, rrp}r orcyrcrBl{pl Koroporo o6rr.rHo
Hacryrraer nera-n*mrti l{cxoA.
Paspua cBofioAHofi creHKu fleBoro )Keny4oqKa
Paspun cno6oAHott creHKI{ JIX trroxer BhI3Barb
TaMIIOHaAy CepAUa I,1 qaCTO IpI{BOALIT K neTaJIbHOMy
lrcxoAy, xoTrr nplr HeloJrHoM pa3pbrBe r.rHorAa Bo3-
MOXHa rrO,4UepXr{BaIOUa.q Teparlvrfl. .Ilo BbIIroJrHeH}r-n
3KCTpeHHOTO XUpyprUqeCKOrO BMerrrareJrbcrBa.
eu6onnn
Ha sHroxapAe B Mecre cBexero HeKpo3a MI,IoKap.{a
vacro o6pasyrorc.a'rpolr6rr, qro Moxer rIpI,IBecrI,I K cI{-
creMHbrM ou6oluxu, TaIGTM KaK I,IHcynbr vurut HIITeMI{rr
KoHeqHocreri. Moryr pasBuBarbc.s BeHo:nrre rpou6o-
srr u TOJIA, oAHaKo ua @oue upo$u:rax'ruqecKoro
lplrMeHeHr{r aHT}rKoaryn rHToB r,r paHuefi Mo6rarnsa-
ql,Irr oHrr critJ'ru BcrpeqaTbcrl pexe.
Pe ru o4e n u po B a Hu e xe flyAoq Ko B
PeuorerupoBaHr{e xenyAorrKoB npeAcraBrqer
co6ofi Bo3MoxHoe ocJroxHeHr4e ocrporo rpaHcMy-
pilnbHoro I,IM, xoropoe o6ycnoueHo r,rcroHrreHueM r.r
pacrsxeHueu un@apxrnoro cerMeHTa. Oro [prIBoA]IT
K yBenuqeHuro HanpsxeHLIrI cTeHKI4 c nporpeccllpro-
urefi Au:rara\uefi u rraneprpo$rer7 coxpaHHoro MI{o-
rap4a (peuoAeJrr{poBaHrre xenyAoqKon) (prac, 1.64).
flo rvrepe pacur{peHr,{rr pa6ora xelygoqKa craHoBl{rc-f,
MeHee eS$exrunuorl u uoxer pa3Br,rrbcfl cepAeqHafl
HeAocraroqHocrr. PacrulrpeHr{e soHu uu$apKTa rrpo-
prcxo,4r{T B TeqeHr{e HecKoJIbKI{x ilp.eitu He.EeJIb, TorAa
KaK peMoAeJrr,rpoBaHl4e xeny.4orlKoB MoxeT 3aHrITb
ro.uu. I4Hru6r.rropbr AII@
ra aHraroHr,rcrbr MlrHepzL'ro-
peqenTopoB yMeHbrrraror rro3AHee pe-
KOpTr,rKOr{,UHbrX
MoAenI,IpoBaHI4e xenyAoqKoB I/t Molyt [pe.{oTBpaT}ITb
pa3BI,ITHe cepAe.IHoll HeAocraroqHocrl,I.
Aneapusna cep4ua
Anenpu:ua cepAua pa3BlrBaercrr rryuueptoy l0%
rarl[eHToB c VM u oco6eHHo qacro Bcrperr aer afl. ilpv
coxpaHfl roueft cs orKnrosuu uHSapxr- csssaHHor?
aprepvu. Oc-noxnenu.fl Mu aHeBpu3Mbr rrBJrrrrorcrr cep-
AeqHarI HeAocTaToqHocTb, xeJIyAorIKoBbIe HapylleHurr
-og-eH['edeu r4dx xE) Eneds or a "n-ln xrr4HetresJo JS' BrHelarJe, rrottrou rcree[orugeH oHsrreheHosder
xtsHtr(dr xl4)qro)ceH uIruI I,'toHVo s rcroreglrx^duugo erHonrJec r roHqrer ruc)odu ae g uuderdu gondenodox
rr4HeHen€rl tr{I4 Noso)og-entredeu udl'u.lxdeQuu 4ouuddx uueormrxo ud11 JS'ErHoNJoc olrHomel^lc rcJe
nrvvtulaleml,z^ eHoe ) I4)el{ttg eoroqueH etqdolo> 'xrun -rrs6 oHhrirgo eH r^rer{HeH3lreu wunued wrirn€J
J)e
-etresro s rsHtrr,rs oJecs emndr_1;6 eH rprHoHelrrtl4 'sonorrrhu4c BcxulfiorrHe dxoc uttu xutuorddualrEufied
'(99'1 'cnd) A E\gie uusrcr,tcro udu y eng,(e ut4l,vrceH udll utrtl etoHJevtr WoHcreH udu ounegoco
tstr^JulruIte eunexnnc eodoro)oH rcqretrorlrguH rexow '1;tr6 rutrudrcrared rendorsou Jeer rpr or{Hehgu€ oorn
e)rc{er NI4 }rdu 'J elrgft, rr{HeHer 16rr r,r JS' BrHolatJec -srog'HuHeHeI^r€u xlql^tuheHt I,rxcahurcoHJ€lrtr qrefitu
rracceduatr rcloildudrculed ounrsgo l,ttor€ udu 1y6 eH v[kr 4onyreltdoH quqg Joxon J)e r€Htroxcl4
e H' W
14,fttoHsreutrdu)otrH€9,(c u[u uvfr detoHer3 florHeulrer t /I wonnecenedeu eened udttutrvt
goHirrlrg€JcoH ) u{trosudu orr, 'edelreud oJem<rHellt ucul exn(u xexoH rqtrB)ougvtrhrilrc:a lrdu unentr{drue
^'W121
Etr,(coc rlroorrfx)ro rBHrou ulrlr Btr{coc oronqrudrcur quqg rexow rulteraduderHlr ee o)eHVo 'xrl,IHe[es
-ex rl{tollr))o reHhl4rSer, rutroxclrodx Js1 ErHewJec -Lo Zl s J)e renrdetrne.lc .leed.ru BwodtrHr,rc oJoH
ur res,tsou eeg exodtrnuc nondenodox xodrco ud11 -deuodox orodrco e)urcoHJuutr g srrod oilru,,fteg
'l,11YYuJ,us:tUd
uuQedrcnfldexodtvoue
lrxodc su4Hefro orsrcoHrrodes rlrornqrog oHhorerc
-otr c rorrroseor (E9'1 'cud) J)O uH Br{HeHer^r€u
elqHqrerBsoYe[cou erf)el 'rrulJuuo0u ) Js' erHor {Jec
uuHemedssos ercoll rcrennudxoc ]r soxnotr,(rax otqHquerHew{drcxu t4 otcHdoredogey
uufiesudrroued lreunenen€r.r €Hersorcfgo redorox
'Itrqr tutroxgoeH n3Jerrsr utrJoHu
'J e\gft yvcdesHu reuxuH0os uuarctrercoxg 'Q eng(a
oH'olqrcoHrdelntc u HuneHxottco gororJuh IIto)ocrls c
weunusodundoQ c aordeQuu ruonqred,{lrcnufu udu
- oxexrduoc 14qy rslteudaenu euseruft{ eoxcenltd(dry
u 'y e[9.{e rrft{rI,rrrrne Ner4Hemqxelu( ltufflor,{trerJox c 'unQedroratrdexoxe xrsHHetr ur,rH€soHco BH rrs€Jc
(ucu1 arr,.{u 4osros E['E)org rerrDrnHeoa enadeua mru)
eorueufi''u)rerx UoH[1{fu aoHerdo enrrefu onerrned
BH Btrtrdec
raner eunexr(grirs eoHhrilgoen xreMrc xrsd
89't-gg't'crd eu xrqHHeueBrcEedu'xuuneEaero ZL s r,rne$l
-vredroufdevodrveue c qrnxeedc relUeuc Ivr,rwBunU oluuefi -oroxeH B n J)O BHJS eJHarlJac rulrBseu€ r€)yrorc
'eehccaw uur4 cueUen oyquoycar eeden 'r,rxroril goH['l(fu rulrecqrfu ruHqrec)otru dett vcrc
!l uuUel.c p '4axU xr,r>r
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- I
E uuEerc 'ri{uuyr xr,ryquoycoH or4Hohor e reeufucen
I - u rogltodr xrqHhoHercudu eranusodul^rdoQ'elrlud
oJece elneh g ruUerc oyeuUo '4ouruueed crcg t axom ewyled.r
-onUdevodrveue pH fr4HoHovrer rvuvreurU srcodol3'nl'rrsr
(so>lt oU{uax etaHeeoduuaVonad) eEdel
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- -rqetqe eUdevonru rxde$uu 4rsusuedlncuedl'soxr,oUrtrex
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rqUfunuune et4HexuHc eoHHeueJ.cou l(,,st4xauxedeou
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156 . KAPAllOrlOFl49

i Ta6nuqa 1.94. OruononaqecKne Qaxropu raxSexquoxnoro exgoxapgrra*

flaroreu exgoxapgur Sngoxapgur y ruq, Sxgoxapgnr npore3upoBaHHoro

HaruBHoro ynorpe6nnrcqux [HreK- KnanaHa
KnanaHa quoHHbre HapKoTl4Kr4
(n = 87) (n = 84 paxnui (n = '15) nosguufi (n = 72)

Cra$unoxoxxra '124 (44Yo) 60 (69%) 10 (67%) 33 (46%)

Staph. aureus 106 (38%) 60 (6e%) 3 (20o/ol 15 (21o/o)

Koaryraeorierarueuure craSuroxoxxu 18 (6%) 0 7 (47Yol 18 (25o/ol

Crpenroxoxxu 86 (31%) 7 (9Yo) 0 25 (350/o)

Crpenroroxxu norrocru pra 59 (21o/ol 3 (3olo) 0 19 (26yo)

,lpyrre (ue eHrepoxoxxr) 27 ('t0Yol 4 (s%ol 0 6 (8%)

Enterococcus spp. 2't (9oh) 2 (2yol 1 (lYol 5 (t%,l
Fpynna HACEK 12 (4yo) 0 0 1(1%)
flonn6arrepuaaurarurxpoQnopa 6(2o/ol 8 (e%) 0 1 (1Yo)

fipyrue 6arrepuu 12(4Yo) 4(5o/ol 0 &(3%)

Fpu6ur (1%) 3 2(2oO 0 0

Orpuqarenuxan reMoKynbrypa 16 (6%) 4 (5o/ol 4 (27Vo) 5 (7Vo)

Ilpuuevaxue. l-pynna HACEK

- Haemophilus
Aggregatibacter actinomycetemcomitans,
aphrophilus (a nacroauqee BpeM, r43Becrea rax Aggregatibacter aphrophilus),
Cardiobacterium hominis, Eikenella corroden u Kingella kingae.
- llo: Moreillon P., Que Y.A. lnfective endocarditis // Lancet.2004. Vol. 363. P. 139-149.

cra@r4JroKoKKrl , raKfie KaK Staph. epidermidis, Koropbre
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raMnulrH (1 ur/xr 2pasa B cyrKrl r/n) c roppexuneft
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.{o3br Ha ocHoBaHr,rr{ KoHrreHTparI un alrrr w6uorr{KoB.
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-
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nopoAoM KpoBb nocrynaer u3 npaBoro npeAcepflufl yepe3 orKpbtroe oBaflbHoe oKHo B neBoe npeAcepAhe, noroM g reeuril
xenyAoqeK h aopry. BenogHas KpoBb t43 eepxHefi nonofi eenur (o6osHaveHa cuHr4M tlBeroM) c uarrcrparbHbtM KpoBoroKoM
nocrynaer B npaBoe npeAcepAue, a 3areM, qacrueHo cMeunBaf,cb c nacurr.qenHofi KucnopoAoM rpoauo (o6osnaqeHa
e[oneroBbtM
qeerou), B npaBbltl xenyEoqeK n nero'tHyto aprepfio. Cocygncrar cerb rerKr4x xapaKrepu3yercf, BbtcoKr4M conporylBreHileM,
-
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Koropble BblnonHrllor caou Qynxquu B ocHoBHoM nocae poxAeHur (nanpnuep, B noqKu I rhue,{Hurfi rparr) nocrynaer MeHbue
xpoeu, 6oraroi xrcnopogola; E npra pox4eHhlt nerKue pacnpaBnnrorcg nocrynapu.l4M Bo3AyxoM, t4 conpor[BneHue reroqHbtx
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cocyAoB naAaer; TaKilM o6pa3oM, KpoBb HatltaHaer nocrynarb B rerKhe I Bo3Bpaqaercs B reBoe nperqcepAr4e.
,QaaneHrae B reBoM
npeAcepAul4 noAHnMaerce BbluJe AaBreHilq B npaBoM npeAcepAur4, 14 KnanaH oB€IIbHoTo oKHa 3aKpbtBaercn. llynovHute aprep[u
u eeHosliutil nporoK 3aKpblBaprcfl. B nocnegyot4ile HecKorbKo gHefi nog Bnt4cH[eM ropMoHaflbHbtx ueuer.rennfi (e oco6eHtocru
npocrarnaHAnnoe) sarputeaercfl aprepuanbuurfi nporox u nepeueeK aoprbt pacu[psercq. flB reroqHa, eena (no: Adapted
from Drews U. Colour atlas of embryology. Stuttgart: Georg Thieme, '1995)-

MeqaTbcrr 3ana3,rlblBaHl,re rTynbcoBolz BonHbI Ha HUXHI{X

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xr,D{Jerr sotrfcoc lreranexudou c utrtt (omrcO eYedrer
udu xex) uuderde goHhoJoII NocoHerc wnrexrr o
I{HHErohoc s rlxVodoredeu 4otoxr'otr(Ire)ol(eht erxeQ
-etr neugJctreuc ncJerrsr oHhrlgo €oHel4n ercedeog
oremdurc geretr A 'nxtrodoredeu tloaoxr,otr(re)IoKel I
rxeQetr ra.(srcJ-,(cudu onnawedsoHtro ex)Er 'X11. ro
rutroxro yudatde rEHhoJeIr B 'XII ro orunen ledeg
erdoe godorox lrdu 'qudal.;de xrsHsredrclrJel{ rurtut
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-udu rgorcun eerroglleH xrsHHetrxodosoH A '(ousren
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-odx.ildx gom<rrog s reuudrcou ssodx rto[odorcrx
yElP^Yeg B[rox 'xrenr(rc s ro€x{Heog 'efitrdec IltotlJolr
-oJeil yrrqHHeruorc.,(go' toHeplll 4Isutredruefl
-edegr rqworuuur4c r eoHerh [rcHcuedrHeh
I
'ratlqHxor tooseH vcu,IsoHuJc ore
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164 .
nporor
uenbHoft KpoBlI - sa 40vo I',I CXOAHOe
yBerl4qeHl',Ie cep- I OrxpuruM aprepuanuxuil
,[eqHoro Bbl6poca. B csssu c 3rI4M npu 6epeuennocru O6H'IHo aprepllanbHuft nporor 3aKpblBaercfl
y xeHIuI,IH C Bpox.[eHHbIM [opoKoM CepAua MOXer pox[eHl'I-f,, oAHaKO rlpu IaHHOM [OpoKe
BCKOpe nocJle
uorrr*u"" pf,r rpo6neM (ra6l' ' I 0 I )' Teu He MeHee
1
pa3Bvrrufl. groro He rlpoucxoAllr' Orrpuruft apre-
MHorI,Ie rlautaeHTKI'I, y Koropblx 6Hro srrnoJlHeHo pua-nrnrrft flporoK B psre cJlyraeB conpoBox'Ilaercg
IITI,JUI4ATI{BHOE JIEqCHI'IE I'IJII{ JIEIIEHI4E
HE NPOBO'IPUIOCb pa3B]11Tvlfl I'I qalqe BCTpeqaeTc'I
ApyrI,IMlI aHoMzurllnMll
BoBce, xopouo flepeHocttr 6epeueunocrr' 6epeueu- y xeHuILIH.
Hocrb oco6eHHo onacHa npI'I Hzuluquu cocrogHr{ft'
conpoBox/Iarcuplxcfl uI'IaHo3oM lrrta rsxerofi JII' llaroSusuonorun
Y xeHuun c cungpouou ArZ3eHMeHrepa MarepI'IHcKuuI
.II,o roro xar lerKI'Ie
HaqllHarcr SyuxultoHupoBarb'
cMeprHocrb cocraBJlf,er 6otree 50Vo' BHy-
6olrruag qacrb KpoBI'I ug leroqnoft aprepvvr Bo
qepee ap:repualrnrtft
c Bpox- rpnyrpo6noM flepl{oAe flotra.Ilaer
Ta6nur.{a 1.101. BepeueHHocrb y xextl4uH
AeHnblMll nopoKaMu ceprqqa ,rpor*u uopry (o,'r.puc. 1.90)' Haruque $yHxquoHI'I-
apTepI'Ia,IbHOrO [pOTOKa IIoCne
poXJIeHIlt'I
pyrcluerc
. flopoxu c Qopuupoaaxneu o6crpyxt'1uu nroxo nepeHo-
csrcq u accoqt4l4poBaHbl co 3Haq''lrerbHoil
qacroroi ocnox- [p]IBoAI,Ir K HeflpepblBnouy c6pocy KpoBI'I lI3 aoprbr
B aopre
Heunit u cMepTHocrbro Y MarePLl B reroqHylo aprepllrc, [ocKonbKy AaBneHl{e
. nnoxo []pu O6seu
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o6t-
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cneqilarbHoM KoHcynbrilpoBaHilil Ao 3aqariln
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. flopoxu nocne xupypruvecxoi roppexquu: naqheHrKl4 yBenuqeHllrc
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aprepuu, vro B AuulbHeftueu nplrnoAl'IT K
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r fieru naqxeHroB c BpoxAeHHblM nopoKoM Bo3pacre
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6utlr nopoxu neBbx orAenoB cepAqa rITo I'IHofAa BbI3bIBaer
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lpolpeccupyouee noBpexAeHl{e cocyAoB JIeIKIIX'

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cTBOBaTb B reqeHue MHOrr'lxJIeT, O.UHaKO
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nporoKe Moxer sa6lroAarrcrl 3a,4epxKa
rna. Kar npaBI4JIo' orpaHplleHl4fi xugHeAesrenbHocrl'I
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B MIA,UEHIIECKOM BO3PACTE HE BO3HI{KAET'
HeAOCTa-
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xoropuft ryque Bcero Bblcnyul'IBaercs Bo BTopoM

uexpe6epse cneBa rIoA xrro'Iuueft (puc' l'92); rpoue
TOIO,qacro flaJlbrll'Ipyercf, ,upoxaH}Ie rpyAnoft rcuerrut'
Hanolnenrae nynbca YBerI'HeHo'
flpu peHrreHororl'IqecKoM I'IccneAoBaHI4I'I Moxer
6rrtr srtqBreHo pacIJrI'IpeHI'Ie JleroqHoft aprepuu' Ha
9Kf uaro:ro['IqecKux Ll3uenenuft o6lluuo He o6uapy-
xfiBaercr. flpu yneluveH[H conporI4BJIeHu'I B cocyAtx
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rIoBbI-
c
lrarbcs.[o rex IIop' [oKa He cpaBH',Iercfl AaBJIeHI'IeM
Prc. 1.92. Orrputrutfi aprepuanuHutil nporoK' Hart,t'rue coeAu-
HeHuq MexAy aoproi n rero'tlioft aprepraeil co
c6Pocora xPoan Baopre I4nI,1 He rIpeBbIcI{T ero' flocle 3roro HalpaBne-
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xenyAoqeK; Ifl - reroqHae aprepue; l-l[1 - npaaoe npeg-
pa3Bl,IBaercs cLIHApoM Afigeuuenrepa' IIIW B cepAue
cepAr,te; flX - nPaautil xenyAoeeK
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' HrcoHhor€JcotreH rloaoxnotrftrexoser eusrctrorcs Br,rHeHutreoc Lrrcergo s reuxraneos rsrdoe
eunexi(3
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0
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r
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EUHeeOilOUCCU
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166 o KAPAl4OrIOrnfl

uosr. XupypruqecKarl KoppeKlrl{r peKoMeHAyercrl

Prac. 1,03. MarHurHo-pesoHaHcHae rouorpaQun npu KoapKra-
qr4u aoprbr. OrueqaercR pe3Koe cyxeH[e B HaYafle Hucxogc-
qefi aopru cpa3y nocne Ayru aoprbt (crpenra A). Xopoulo
pa3Bilrbr Koflnarepanil; Bt4AHbl KpynHa, BHyrpeHHsF rpyAHas
apreprl (crpenxa E) ra necronuxo rraexpe6epxurx aprepnfi
(crpenxa B). Heo6urvno, qro B AaHHoM cnyqae raxxe Ha6rp-
Aaercfl KoapKraqnn 6proruHoil aoprut (crpenra l-.)
BO BCeX CJIy{arIX, 3a I CK,'IrcqeHI{eM caMblx JIeTKI'IX.
Ecru ona BhInoJIHeHa B.uocraroqHo paHHeM Bo3pac-
re, crofixoft rI{rIepreH3I,IV yilaercfl Ias6exarr. V ua-
ulreHToB, onepl4poBaHHblx B no3.[HeM AercKoM I{JII4
Bo B3pocnoM Bo3pacre, AI qacro coxpaH.aercq I'uIu
Bo3HlrKaer BHoBb n 6onee nosAHuIU [epl4oA. flo uepe
pocra pe6euKa creHo3 Moxer peuflAl{Br{poBarb, AJI-,I
ycrpaHeHu-fl ero Moryr 6lrrr srrnorurenrr 6ar,ronnaq
AI1.JTATaIIIA I{ B HeKOTOpbIX Cny{asx cTeHrI'tpoBaHI{e.
Kpoue roro, creHTI,IpoBaHI{e Moxer 6lrrs octtosHrtl\,l
reqeHr{eM. OAHospeIueHHoe Hzurlaql{e ABycrBopqaroro
aoprilJrbHoro KIIafIaHa, IITO BcTpeqaercr 6olee veu y
50% tautettroB, Moxer IrpiasoAurl K rlporpeccl{pylo-
ueMy aopTiurbHoMy cTeHo3y LIf,II,I He.{OCTaTOqHOCTI{ lI
raroKe rpe6yer AJIlrreJIbHoro na6moAenIa.fl .
I Aeoerr uq<npe4ggpnnotr lgpergpg4{I
Ae@err Mexrpenceplnofi neper6poAKu flBrfler cfl'
oAHr{M r.rg nau6onee qacrblx BpoxreHHblx nopoKoB
cepAua u n 2 pazaqarue Bo3HuKaer y xenruun. Eolr-
rrrr,rHcrBo Ae0erros MexrrpeAcep4uoti leperopoAKr{
npeAcraBrrlrcr co6ot7 Aeoertrr ruta o st ium se c un dum,
npl.{ KoTopblx BoBJIeKaeTcq oBzulbHafl qMKa, coor-
BercrBylouar oBzulbHoMy oKHy Bo BHyrp[]Tpo6Hou
repro.ue (c r'r. pnc. 1 . 90). Ae$errrt ruta ostium p rimum
flBrrsror cfl. pesynbraroM Ae$erra [peAcepAHo -xeJly-
Ao.rxosor? nepercpoAKl4 I{ co}Ieralorcs c HiuII4rIueM
pacnlerneHHoro Ml4TpanbHoro KlranaHa (pacrqen:reu-
Harr nepeAHrlx craopra).

(ri
llatoreneg
flocrorsxy HopMaJIbHbIft IIX rBlrs,ercfl 6olee
nn noAarJII{BbrM, veu JIX, npl{ orKpbIToM oBaJIbHoM
oKHe Bo3Hr{Kaer c6poc KpoBLI us JIII n fIfI, a 3areM
n fIX u JreroqHble apreplau (prac. 1.94). B pesylrrare
Sroro npaBhle oTAeJrbr cep.{qa }r JleroqHble apTepIIIj
rrocrerreHHo pacrrJr,rpf rorcr. fle$err uexlpeAcepAuoft
neperopoAKl,I rIHorAa ocJloxHrlercs JII u o6paruslu
c6pocotr.r KpoBI,I, oAHaKo 3To Bcrpeqaercrl pexe I4, KaK
IrpaBI4rIO, BO3HI'IKaeT IlO3AHee, rreM flpu Apyrux TI{[ax
c6poca [ryHTa cneBa Ha[paBo.

Prac. 1.94. Ae$err MexnpeAcepAHoi neperopogxn. C6poc Knunuqecxas KapruHa

KpoBn qepe3 4e$errMexnpeAcepAHofi neperopogru (yrasaH
crpenxofi) cfleBa HanpaBo. LUyt',l eosHuraer h3-3a yBenuqeHilq Y 6olruuncrna Aereti nopoK He colpoBoxraercrl
cKopocrr4 noroKa qepe3 KnanaH neroqnofi aprepuu B pe3ynb- HI4KAKPIMI'I CI{MITOMAMLI HA IPOT'IXEHI4I4 MHOTI4X
rare c6poca cneBa HanpaBo u 6onsuoro ygapHoro o6teua. Jrer, r{ ero qacro o6napyxlrnalor rlpu pyrI.IHHoM
l'lnorHocru reHh nponopLlt4oHarlbHa cKopocrt4 KpoBoroKa. KJrlrHr,rqecKoM ocMorpevnv flpvr peurreHorpaslru
JIX reeuil xenyAoqeK; flA nero,{Han aprepnn; fl['l
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r3rerrsr [xtrodoredeu 4oso)ho['^[exxel^t rxeQefi' rloxcenurdr(drlx .roL(ged.r trlxeQetr elD{€I'soxuHelldu
xIl)cohI,IHI4Ifi I,II,IHPsoHco 3H ilreHtoltced onxon xra
14 'r,rruumqrog oHhoreJcotr roIEsIiIg orcur' '(g'1:9'1
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.OI}IHEhEII )oroeodx t]nnr'orer xrsdoJ'ox
rlrrirHl^roJcl,IC JOeIIIIiISedX
radu' ttxtrodoredeu tlonVdecVeduxelt n.lxeQefl
,{wo nguru deuo ) I4 I^lrl4He€8)oilosl4rodu rcrorrrgr
uaodx codgc 4I*r.redgo ra llf relrexrl'Jy rcr,auauaeed euHahou
etrJo)'seBh,{rc NoI,IHehoIIfl ,uet,' 4umodox qHeho €arc
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nau6olee .racrori Qoprvroft KapAuoMr{on aruu, za6o -
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vnvr ItpyruMvryracrKaMla cepAua. Cyulecrnyer oco6utl
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ureHue nCB r rr"rrr,,,if3i.,BupaKeHHocru yrpeHHero
uue uacu) cqr{TaeTcrl AuafHocTI{qecKI,I 3HaqL{MOfi, a
BCJII{qI'IHA EE }I3MCHEHI4'I IIO3BOJI,SET B ONPEAENEHHOII
creneHr{ cyllrrb o rrrxecr}r 3a6oreBaHl,Ls (puc. 2.20).
flpu nocrauoBKe Ar4arHo3a Moxer 6blrr qe:recoo6pas-
HO npoBeAeHue flpo6Hofi Tepailvu rnIoKoKopTpIKoI{-
4aur.r (Hanpuruep, 30 ur/cyr B reqeHr.Ie 2se!,), npo6a
cqr,rraercq rroJroxr,rreJrbHorl B cnyqae AeMoHcrpauuu
y:ryrueuufi ru6o O{DB,, nu6o fICB.
HepeAro narrrreHTbr, y Korophlx cuMnroMbl cBI,{Ae-
TeJrbcrByroT o Hiuluql,Iu 6poHxraalsuoft acTMbI, I{MeIor
HOpMZUrbHbre [oKa3aTeJru oyuKII,Ifi JIeIKI,IX. B raXUX
cvrya]JJxflx Nrs noATBepxAeHlr.[ AI{arHo3a Moxer 6blrb
qelecoo6pa3Ha .ueMoHcrpaul4rl rrlneppeaKrLrBHocTI,I
.ubrxarenbHbrx uyrerl B xoAe npoBoKalll{onuux lpo6
(c r"r. p u c. 2. 1 7 ). f uneppeaKrl{BHocrb AbIxareJIbHbIx
nyreri xapaxrepr{3yeTcrl BhIcoKoIu [porHocTurlecKoll
IIeHHOCTbTO OTpr{UaTenbHOrO pe3yJrbraTa, oAHaKo
rroJroxureJrbHbre pe3ynbTaTbr Moryr Ha6nrc.(aTbcf, I,I
rrpr{ .qpyrux 3a6oneBaHuxx (nanpunaep, rrpu XOEJI,
6pouxoerrasax u MB). llcuonreosaHl,Ie Harpy3oqHblx
TecToB noJIe3HO, KOrAa ClIMnTOMbI [peI,IMyIIIeCTBeHHO
cBrr3aHbr c @Lr3u.recKofi Harpysxoft (puc. 2.21).
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ro rur ororxuoV ro %08 oeHof! ercrsuendop.l ('EOO ograu g3g) xroueu uubtu,(6
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(oueUer e eed 7 -euc oer-cohev s ulnonou tlodo>tc
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Iouuce ponruenxuodg tsex uuodrnov uxeod4 '02'Z ehuugel !
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uEJo)'dewuduun) aouerurH? xufflofu(srcresrooc rusrc eprHe)Kr,rrcov quqg oHxrotr ruHehell oIsroII 'lruuuder
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udu oHxes oHHegoro' Yuueaauoget auHehor xulfiol€ru u u H a ha u r^4a u an ev e o H e n ou
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xulnuemVfixi' eodou e$ ou Hoflxr.odu lfrodlJ
'soeerx€oxHodg axurconrera['
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eH€errou qJlqg
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rirH€sodu€[[I{rBa I4IrIiIg' 4ontroe 4OHqrEI,IxHOdg ven orh 'or eH sreslil€uxd raxo,t Irneredrsru@nu uxur.rfi,
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-o g3€ rr{Hoherf r,[rJoJEdrc ox HtI{Heme d Yntrig.udu ultrf Jexon or<r€uuc uxuodg orosuddx I{H6oIIDD{o udu on
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xrqHoBd o ouafiultdo@Hl,I e)olEr B 'rHHetrx1(godll aIqH 'usodx 4oxcer,udeQudetr uvtruQoHlaeoe ex)€r €
-hoH ,e) 'goworunuc xrlHsoHro xuxer urSol IIlheHe '(aotruodarcoxurdo:oxonru eenud oremseMuou eH
'vrtellHelreucos u uNEI lorunuc r(trxsw u0rsconue€s 'oronsrog oroffcodes .{ ,-trdurt 0, eeHen en) xrlfu
' yuueaar ogeo r<trodrldu el,IHeHcrqgo eolfloleslsudoh xlgHirrorBxlql s. Y]/rlJereuSos oJoH<IruQonueoe neror
-cu,(ffreufler su4seJcovedu owutroxgoeH'I {eLIHes -€€E)OU NrirHHesCO) rCOJetrtOIBrSr'(o*4.{) eX^['eos
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'4erreda xu u gorHeufi€u oJelrrgo rnsod( runedel^uer,r oIqI[oNo[ 3 O9I,Ir Xeroer
gHfrlolB){(udlo'ogJ,rodes' WeHHBser
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222 . flYIlbMOHOflOfYl9
Ta6nuqa 2.21. EpoxxnarbHar acrMa Bo BpeMt
6epenneaxocru
o KrlHuqecKoe reqeHue: y xeHulilH c xoporxo KoHTponilpye-
voti 6ponxraaruHori acrMori, KaK npaBilno, orN,,le,lalorcc
ronpilqrHbre rcxo4sr 6epeveHHocrr. SepeMeHHocrb y
xeHU.I4H c 6onee T9xeloti 6ponxualuHori acTr,,roil Moxer
cnpoBor,lupoBaTb yxyAueHile KoHrpon9 il np,4BecTil K yBenu-
qeHrlto Marep!4HcKori il HeoHaranbHof ga6oneBaeMocrr'l
r cxBaTKl4 ]4 poAbr: ] 907o cilMnroMbr orcrrcrBy]or
. AaHHbre no 6e3onacHocru: 6naronpilFTlrurri npoQralu y
pr-aroxrcroe, 14HTanrqiloHHbrx rnroKoKopruKor4Aoe (t/l-KC),
reooilnnilHoB, npeAHil3onoHa Enr npileMa BHyrpb ,4
Kpor\,roHoB
o Axraroxucrur neixorpuexoBbrx peqenropoB Ar9 npueMa
BHyrpb: AoKaSaTenbcTBa Bperqa Mq nnoAa oTcyrcTBytoT, t4
xeHu.lilHaM, y Koropbtx paHee, Ao 6eperr,tennocru, 6unr npo-
AeMOHCrprlpoBaHbr 3HaLrLrMbre ynyHuJeHilg KoHTponq HaI
6porixraanuuoil acruori ra Qone npuueueHilc ororo Macca
npenaparoB, He cneAyer npeKpaularb r4x npueM
. fnoKoKopfl4KocrepolrAbr: xeHu-lilHaM, nonyHarculilM noA-
Aepx/Barculyro repanro npeAHrl3oloHoM e gose 6olee
7 ,5 ur/cyt, cnegyer Ha3Haearb rr4poKoprr4soH no 1 00 Mr
3-4 pasa B cyrKil Bo BpeMc cxBaroqHoro nepiloAa poAoB
r npocrarnaHAux F2o r',roxer Bbr3brBarb 6ponxocnaeu u
EOIXeH rCnOrbsOBaTbCn C npegeluHor,r ocTopoxHocrbto
. fpygxoe BcKapMnxBaHxe: npilMeHFTb neKapcrBeHHbte npe-
naparbr KaK o6ur.rro
. HexoxrponupyeMEu 6poxxuanuxan acrMa cBfloaHa c
uarepr (Heyxporr,tr',tan peora, Al-,
ocloxHeHr4sMr4 co cropoHbt
npeSKnaMncrc, BaTilHarbHoe KpoBoTeqeH'le, oc,loxHeHHble
cxsarxu) il nro4a (sagepxxa exyrpuyrpo6uoro pocra ,t
Hil3Kac MaCCa rena npn poxfleHilil, npexAeBpeMeHHbte poEbt,
yBerryeHr4e nepruaraluHoi cMeprHocl4, runoKct4g
uoaopoxgerrsrx)
nocreJrbHoro 6ersfl.. {o uacrorulero npeueHra 6luro
TpyAHO npoAeMoHcTpl4poBarb yJryr{[reHr4e KoHTpoJrfl
Ha,u 6poHxuarbHori acrMorl nocne raKnx Mep. y MHorr{x
laurreHToB Bbrf BrrreTcs ceHcll6lt[Lt3au.vfl K HecKoJIb-
KHM ITOBCeMeCTHO paclpocrpaHeHHbrM aSpoaJrJrepre-
HaM, B CB.fl3yr C STHM CTpaTerr{fl rro [peAyrrpexAeHrrro
I{X BO3.tIeIiCTBnfl B 3HaqllTenbHorl cTeleHI.{ flB]/rfleTcs.
TpyAHoBbInonHlrMoIl. Meponpuarvs, tro cHnxeHrrro
Bo3Aeft crBr,rfl aHTr{reHoB rpu6or Moryr rrpr4MeH.sTbcn
nplll olpeAeneHHbrx o6cro{TenbcTBax. TaroKe cnetryeT
I.I36eraTb npuMeHeHu-f, JreKapcTBeHHbrx CpeACTB, Ko-
TOpbIe MOryT C[pOBOU]IpOBaTb BO3HpIKHOBeHT49 LUrur
yxyArxeHr4e TerreHu.s 6ponxr.ra-uruorz acTMhr. orrag or
KypeHuq oco6eHHo Ba)KeH, TaK KaK KypeHI.Ie He ronb-
KO CTI{Myn}rpyeT CeHCr,I6unr,r3aIIuIo, Ho rr Bbr3brBaeT B
AbrxaTeJlbHbrx nylrlx oTHocr,rTeJrbHylo pe3rrcTeHTHocTb
K rn roKoKopTtr Ko l,utaM.
Oco6essocrr.r reqeHurr 6pouxualruorl acrMbr Bo
BpeMrr 6eperreuHocrr,r rrprrBe.rleH br B r a6 il. 2.24.
Crynentarutrt noqxoA K fleqeHun
6pouxuantHoil acrubt
Cw.puc.2.22.
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Cryneru : ennsogutecKoe nphMeHeHy,e
1
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uH ran
qn X aro H U CT O B
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uux ycrpoficrB, ,r rrpu r{x au6ope cJre,{yer pyKoBoA-
CTBOBaTbCTI npeAnoqTeHylflMvr IIa\veHTa I{ ero yMeHI4-
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r{Hriurrrrop ocraercrr nau6olee urupoKo Ha3HairaeMbrM
rr{rroM ycrpolicrna (pvc. 2.23).
flaqr,renralr c rrHrepMlrrrlrpl,rorqerl 6poHxniurbHoft
acrMori (cuurroutr orMeqarorcs pexe I pa3a B He-
Aenro Ha [porrlxeHul,I 3 uec, r,r na6lrc.qaercg MeHee
AByx HoirHbrx srlr3oAoB n uecxq) o6lr.rHo AocraroqHo
Ha3HaqeHr4rr uHrzurfl ur.roHuux xoporrft erU crByroxlrlx
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ruu rep6yra-
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Oegeparlura.
- Ifpuueu. ped.) to rpe6ooauuro. Teru
He MeHee MHorr{e 6o-nsnrre (n ux npavu) uelooue-
Hr,rBalor rnKecrb sa6orenaHuq. Hanu.r[e B aHaMHe3e
TrlxeJloro o6ocrpeHlrs yKa3brBaer na neo6xoAuMocrb
yBeruqeHuq o6reua repar.uu (nepexoga Ha oAHy
cryneHb nnepx) [Ha ocuooaHlrr{ rrocJreAHek nepcwu
peKoMeHAarlufi <,Ilo6anrr.afl uHutryrarlrBa rro 6opr6e
c acrMorl (the Global Initiative for Asthma
- GINA)>
(20 19) He peKoMeHAyercrr r4cnoJrb3oBarb KoporKo-
4erlcrnyrorqr4e aroHr,rcru B, - a4pe HopeuenropoB B
MoHopexr,rMe. Xor.fl roporxo4erlcrByrouue aroHlrcrbr
0r-aApeHopeqerropon o6ecreqr{Baror KparKocpoqHoe
o6rer.IeHue cI{MrIToMoB acrMbl, oHrr He 3allll{ulalor
or pa3Buru.fl o6ocrpeHufi, a perynspHoe yurv qacroe
r{clloJlb3oBaHr,re rroBbrruaer p}IcK pa3Bvrrvs. o6ocrpe -
ur,rfi. B cBr3r,r c 3Tr,rM BceM B3pocJrbrM r{ no,4pocrKaM c
acnrori pexoMeHIyercfl Ha3HaqeHr,re HIKC s xa.recrse
KoHTponlrpyroqeri repanlru c lrcronb3oBaHlreM KoM-
6ul,i.at\uu < I,I IKC- @opMorepoJr )> no norpe6Hocrr,r.
CryneHr 1 uo norpe6uocu{ Ha3HaqeHlre xou6lr-
-
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I4IKC B Hr,r3Krlx Ao3ax BcrKr,rft pas, xorla Bo3Hr.rKaer
lorpe6Hocrb B r,rcrroJrb3oBaHrlrrKoporKoAerlcrnyroulux
aroHr,rcroB Fr-a,upeuopeuerrropoB (GINA, 20 19, www.
ginasthma.org). Ilpuuev. ped.]
-
Cryneru 2: naqano perynfrpHort npeBeHThBHofr repannn
.{oroluurelbHo K r,rHr€usquoHHblM pr-arouuctau,
npr,rHr{MaeMbrM pexr,rMe no rpe6onauu}o, perynflpHyro
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'natvndll 'rrrHaHor rudu oronnur.(d rrY rcJofu(trHer{ rcqresogedrou ilJor r soxrlnsrrl,Id1$ /( K,ox 'u.r,edeuedu
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BeHTr4nr.rpyeMorl uMr.I Aonl,r, rraToJror[qecKr{x r{3MeHe-
HI,rrZ He o6Hapyxr.rBaercrr. EcJrr,r B 6pouxoerraruqecKHx
nollocTf,x coAep)o{Tc.s 6onbruoe KoruqecTBo MoKpoTbr,
HaA o6nacTsMr4 nopaxeHl.tr{ MoxHo BbrcJryruaTb MHo-
xecrBeHHhre rpy6ne uaxHbre xpr{[br. Arenerrag c ga-
croIlHbIM ceKpeToM, 6rorurplroUr{M rrpoKcr,rManbHbrft
6poHx, Moxer npr{Becrr{ K JroKiurbHoMy ocna6neH}Ilo
AbrxaTeJIbHbIx uIyMoB, B To BpeM.f, KaK B 3anyueHHblx
cnyqa-f,x sa6oresaHne Moxer npuBoArrrb K py6uoBbrM
Puc. 2.N. Kounuorepnar roMorpaMMa npu 6ponxoexrasax.
O6urpHure yqacrKr4 pacurpeHue 6ponxoe c yronqeHHbtMt4
creHKaMil (yxasaHu crpenrarrlu) B HltxHr4x Aonsx o6oux neruux
I,I3MeHeHr4-f,M, HaA KoropbIMI,I Bblcnylxl{Baercs 6pou-
BaxHbrM ocJroxHeHr{eu 6ponxoeKTa3oB (le.reuue
onlrcaHo uac.204).
I MeroAH rccneAoaaxffi
floulruo o6br.rHbrx nos6yAureleft pecnuparop-
uux uu@exrlufi , 5axrepuoJrorr{qecKoe }rccJreAoBaHr{e
MoKporbr Moxer BbrrrBr,rrb Pseudomonas aeruginosa u
Staphylococcus aureus, rpu6u (nanpuuep, Aspergrllus)
u pa3Jlr,rlrHbre Br,rlbr MlrKo6arrepurl. .{lx o6ecneueuux
4orxHoIT reparuu unoexqr4r, BbrSBaHHor; pe3ucreHr-
HhrMrr MprKpoopraHr{3MaMlr, Heo6xoAr.{Mo qacToe
BeAe H He Kyn brypaJr bH srx rccleno'nannft .
He6onrurrae 6poHxosrra3br o6brqHo He Br,rrHbr nplr
o6sopnorl peHrrenorpa$urr opraHoB rpyAHorl merxu.
Ha nogAnux craAlrqx 3a6oreBaHuq Moryr Bu3yiuur3lr-
poBaTbcrr yronueHHhre cTeHKr,r .{bIxaTeJIbHbIx HyreIT,
KI'ICTO3HbIe 6pOnXOeXrarUqeCKI4e nOJIOCTI{ r,r CB.f, 3aH-
HbIe c HI,IMI,I y{acrKu yILIIorHeHlrq reroqHoft TKaHI,I
t4Jrlr areJreKTasa.KT qsr.sercs 6onee qlBcrBurerbHbrM
MeTOAOM, nO3BOJI_[rOrUr4M BbUrBJLrrTb ytOJrXIeHHbIe, pac-
ur,rpeHHbre AbrxareJrbHbre nyru (plc. 2.29).
Y naquenroB c noAo3peHr,reM Ha cr.rHApoM Ar,rc-
$yHrqrar,r pecHr4rqaroro grrr4TeJrr{rr Moxer 6rnr nrrnol-
HeHo cKplrHlrHroBoe r{ccJreAoBaHlre. C ero noMotrlbro
ollpe,ueJlgloT BpeMq, 3a Koropoe MrIneHbKI,IItr uapI,IK
caxapurHa, rroMeuleHHbrfi n nepe.qnue orlenbr rronocrr,r
HOCA, .4OCTIIIHET IJIOTKII, IAE NAUUEHT MOXET OIIIYTI,ITb
ero BKyc. 3ro npeua He.{onxHo npeBhrruarb 20 v.uu,
o.uHaKo y narlr{eHToB c .urEc$yuxqlreft pecHurvaroro
or.yrreIrvg. 3Tor rloKa3areJlb 3HaqI,ITerbHo 6onrme.
9acrory 6wenug. pecHurleK TaIoKe MoxHo orleHr,rrb B
6uoncufisux o6pa3uax, B3srbrx r,r3 cJrr{3}rcrorl o6o-
JrorrKr,r noca. CrpyrrypHbre aHoMzulu[ pecHHrIeK ycra-
HaBrlrBaror c noMoulbro 3JreKTpoHHot? ulrrpocxouuu.
I fleqenne
Y naquenroB c orpaHurreHr4eM cKopocrr,r Bo3,{yr[-
Horo rroroKa neo6xo.{ralro npI{MeHeHI{e I,rHriuurrltroH-
nux 6pouxoAr,rnararopoB r,r rnroKoKoprr4Kor4,qoB A.rtfl
ynln{ueHr,rq [poxoAr.rMocTl,I AblxaTeJlbnsx nyreri.
Ousuorcpanun
flauuenrau cJreAyer rloKa3arb, KaK BbrnoJrH flrorcg,
perynrrpHbre exe4HeBHbre @zsuorepafleBTtrqecK]re
npoueAypbr A.n.s o6reFreHr,r.f, ApeHaxa ras6rrrxa 6poH-
xlranbHoro ceKpera. flpu nparnrbHoM BbrrroJrHeHLII,I
gTor MeroA uMeer 6omuroe 3HaqeHr,re KaKAns WeHb-
IIIeHI4g KaITUH r4 MOKpOTbr, TaK LI Anq npe.4oTBparUeHr,rrr
rHtrosl,Idu J,)eootr glD{cahr4reHeJ 'eHaJ oJoHHetr g}rfr
-Br^{I^r
0002 eorrog oHerrsoHBrJ,{ rHor^ton 4lrf[rorcEH
eH rrox 'g7sIV BJJ"eIJrlsb rDr.rdewv r4 rquodsa rloH
-deae3 uufimr,(uou s edorrr^Jed olonnedgltewcnudr
oJoHEotrI4Ircusoxr(m uHet tleufiurr(w Htorsuh oarogueH
')oJ,alr){ xrrHqreureruu€ r(nudglntelt eedeh rqtros u I,Iro3
euneluelredeu eH Jeruus no ilnlodorrrfued wlsnnudg
- nrelr c nefu nrlHco trflficu go).,fi r
r]tgr eesrle€ H' elrl-lgre>r
^r
orondorx )orreg re[dutrox gndorox '1 rsr,tocoltrodx
oherlr NoHHvIil.l[, eH oJoHHoxorouced '€gat 4uner,ft,r
arurcn(eed s rcreeguseed gW 'soreuse,{ rcraenedrcs
axed etne lr rvnetrxoxcuodu oJo)cHe)rlrdQu trrarun'edc
egegedrcoducud ru:oroJell er€ e[irHol I oJoHr ruH
'xrsHHetrxodosI,rx 00SZ €H I oro)o orqrcone€sorogec r,r
)asoueh SZeH I esrcqreu,rooH rjororceh 'vusesofrerc
-eH I^to[]rJ r tlqHsuocelted-ogltocorr(e c rsced IltoH['I4o
-exodso llurr,{ xeuneseuoges I luxcehureHoJ I IIqHqITET
-eQ wnunenedrcoduced eerroglreH rcrerItsr flW
ul4Jouol4trleuuue I eeHeJoreu'eyruoioj
eoUilhcrsoxl{1711
' elrHehuHr eomqrrog rorer^ru e)rc{Br
uutrxddrcgo
4oHqrEr.rxHodg eunener u €)HrsoHJB LlY yylF^He d' KLLH
-roJcoc xur€ olrHehet u rt>tutxemtQodu oilnreorayu
srutrosodu oHxes oHrjehrqsoedh' unfueQnra 4oneerfx
-deg,{r 4roxr,uedeu rr Emorrrxox 'udox ercou esrJretr
a ror,(drarorgetr oJcuh rrceD€oxHodg,$sroxco11
eyrryBulrsodu
' ruIqnrruduoJslrg oHiIroJ
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IloHsucHeJHyr rttrrroHettvdu u d,{trefiodu xr,rxcehurseu
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xur,(dv A'nrcoHhorercotroH rjroHqfeJ€xrirtr oruruseud
x rlrtrogudu oHEeox rarz oned lr 'flI tr u rrirerr{u€ oJ
-olenuanced uutuH,(Q wounem,(dus c oHeorsc urce
'derxedux glllnoilduccedrodu reewu er.{Husoroget
eoHrodu
'^(dew uorury'edx xex rorusufuerucced'uutrxeQuu
lrode.{gdeead xumex,&rc '}{oxer s uutrxi(fucetr soruno
oru[rxeeed uH€effog xul^rdoQ xufror^ducaedrodu ud11
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'r [oJolroHeJrged lrrqugoltlrnegderHra
rellrerHroulqt'exnodg oronnexedou uzfirr.{xdlrtt
rqr^reJcr,rc rufiEsurogr^r€ r€Hxo)cedr, rcsreaogedlou
rexon xneMlrc xMrexil s rrox 'yuueaeuoge0 esoHco
s geffluxeu 'uulrxeQnr,r er{Hohor en rez(duread orcsn
xe€En€oxHodg udu eqnexdexosod;'(uxunueurQan
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elnrerxer-$ oJoHXroHJeHv)vLHe BlrHetress a a oguu
/
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vr{Hehorr yufi!' uuueeotrerro o}r r^roxcoh}rJorouderxeg
tzdu otdnnerstrIqg'q.LcoHqrerrasrrgfl eH rcsreduuo
EHxroE lr lroHxoffo eerog rcrusonurc rr.ruedbro)trr
- ovlgvltHe' (lrxr,oreu HoH goHJaH ut) so u o ru op n a s4
I HI^IetrI4a r{I^IrqHhI.{IrtBd
urconrcen g 'uhre)horBu uy{
-IsHq[erefrr4drowudr I{ 14I^te))o)oruQerc eHus€rirs
wrrrxeQHu n?Hhudors e['Jo) 'firrHroueH Jeesrqg orc€h
soworuNllc eunanedrcr( e'Iqcd,$ eIqHsIreJI,rLry eellog
u rqeots e?Drocrirs eerog rcroilgedr xun rftr oH 'IISOX
trIrHeher ndu rcror,(eirrroucu orh 'ex or rcrorrrsr
ulnueredeued[ unlqHirffer4derxuguure unrqHqrenr,rruo
unieeen€oxnodg c sorHer.rfieu esrcHr.rmqro 9 yv[,
6UUedltoyutougnfiv
'rswnrefuodu gouanrxe@Qe
l rftr NeI,IHohEHt I^trlHqrul^Iullylt^t yxJ.,erJrsr oth'l,txt (c g
ueed 7 uraru g I -g Jenrsurcoc sorHer.rfien esrcHumirrog
IrIftr oH 'rqrod)om ploNerretrIqs Bsrcohl{Iro) ro JBc}IsBe
d,(trefiodu xn{cehr4JseuederoueuQ eJorcuh H qrcoH
-auelvrll yeHqrBl^Iuruo' uxl,IHxer elqnr.ureud rsuuaog
-oduo srrsg rrHxroV'^JHauIrBu u,rtroxtrou edogudu uxr
rIo)e) 'srure[edro rirgoJh oJor rftr u 'xrsnflrog etrrd
.{ rsrodxor r o{uHetresrqs roruJor^iou '(deuuu@-neuerx)
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-sroruxlqv s rfl,rHeffs€tr oJoHqrerl{xorou EuIJeyEoJ B]dl
I excert),{nunltres ol,(HHrorcou en xn(u xrqHqreJuxrqtr
a ouHersetr eumoresr,rhr4read 'rsdogudl 'armex l^uon
-nlrrdene udu Heretrf quqg Jexow Ho etrfxro 'lroxudr
,&rodorc a 'xexuodg xrsHHedr,rmcud s rcoJefrrrtroxeH
'uredxec orlrHexnstrodu reerol,{ou (urr>run oJoHqror
-exHtr oJoHsrrJJg Exr{HxoJ) r4Nexotrrss uwrsHHesodr4c
-doQ ultutnoiltrofrou o xotrs graxog,{r1 'xrirHsrurco
amlqg rcro€srltuxo rro[ rel^rie.{dunedtr l,rlodorox
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ufirxeQHr4 r-{oHhoJerroxuodg aotroeuu€ xrsHdorsou
238 o flVIlbMOHOrlOfUg

A Hopua 6 Myxoarcqu4oe
[lpocaer
AblxaTenbHblx+
nyrefi

Anuxaauxan
noBepxHocTb

3N]4TETIl/A,1bHAg
KNETKA

SagaruHaq
noBepxHocTb

pr-a,qpexopeqenrop
f,d
Prac. 2.30. Myxoencqrago3: ocHoBHbte HapyuJeHun B onurefluu rerK[x. A
- reH MyKoBr4cr.lt4Ao3a (MBTP) Koghpyer xnopHblil KaHiIn
(1) anuxaruroi (ornocnr4eficfl K npocBery nporora) MeM6paHbr onurer[aflbHbrx KneroK Bo3AyxoHocHbtx AbtxarerbHbtx nyreil.
B noprvre sror KaHafl KoHrponhpyercq quKnuyecKuM aAeHo3r4HMoHOsOCQarOM (qAMO) u OnOCpeAOBaHHO - CTt4MyIaMn Or
B-agpenopeqenropoB I npeAcraBnqer co6ofi oAyrH rr3 HecKorbKr4x anuKanbHbrx r,loHHbrx KaHanoB, onpeAeasou.lux Kort4qecrBo ,l
cocraB KoMnoHeHToB xr4AKocrfi, noKpbtBaoqef AbrxareJlbHbre nyru. Hoprr,raabHbre KaHarbr, no ecefi Br,t4t4Mocrtt, hHru6upytor
cocegHile gn[Ter[EurbHbte Harp[eBbte KaHalbt (2) 5 reHa MyKo-
- npu MyKoBr4cqnAo3e u3-3a ogHoro ilrtt4 HecKortbKt4x AeQeKroB
Br4ct-14Ao3a HapyuJaercg t4ru norHocrblo r4cqe3aer Qyxrqrar ororo xnopHoro KaH€Ira (3). 3ro BeAer K cHhxeHuto ceKpeLluta xnopa
u yrpare uHrh6tapoBaHnfl Harp[eBbtx KaHafloB c r436btro,{Hofi pe3op6Lluefi narprr (4), a raKxe AerilAparaqtau Bbtcrrnapu.lero
EbtxarerbHbte nyrn onurenun. O6pasyoqaecf, aHoMarbHa, xnAKocrb, noKpbrBaoqac AbtxarenbHbte nyru, npe4pacnoraraer
K pa3Bnrro rHQexqnn qepe3 MexaHh3Mbr, Bce eqe nonHocrbn HeflcHbre Ha cero4HqtxHufi AeHb

K yBenurreHr,rrc coAepxaHlrfl r4oHoB HaTpvts. lI xnopa
B IIOTe r{ rroBbrrlraeT o6paTHoe BcacbrBaHlte HaTpLrfl 11
BoAbr r43 errvrerrvfl. AbrxareJlbHblx [yrell (ptac, 2.30).
Otrocure:mH,'ro Aen{Aparaul{rc,ublxareJlbHblx nyreli
cquraroT npeApacnonararcrur,IM $amoporrr .unfl pa3-
Brrr us xpoHr,rqe c Ko it 6 arr epualrs ofi uuo e xquu u
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pyrueHr4fl B Snr,rTeJrul{ KHlreqHVKa, noAxenyAotlHolz
xerre3e, fleqeHr{ r{ rroJroBbrx uyrrx (cu. uuxe).
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NEPI{OA AETCTBA, OAHAKO C HAq,LIIOM 1IHTEHCIIBHOTO
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yBennllnnagb, IIO9TOMy BO MHOIIIX pa3BLtTbIX CTpaHax
ceriqac 6olrure B3pocJrbrx, crpa.[arcuux MB, veu
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Bcero craBr{n}I Ha ocHoBaHr{I4 KJrr{Hr{qecKori Kapr?IHbI
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TBepxIaJrr4 c noMolrlblo I,IccJIeAoBaHI,If SneKTpoJn4ToB
B noTe r{ reHoTrrnr{poBaHr{eM. o4naxo npavn qacTo He
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3a6oneBaHu.f,, Lr rro3AHflq [ocraHoBKaArrarHo3a BeJra K
xyArrrr{M rrcxoAaM. B nacrosuee BpeM.f, HeoHarzulbHblft
cKpr{H}rHr MB, ocnonaHHbIIZ Ha ypoBHe I4MMyHope-
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o6pa:uon rpoBr{ HoBopoXqeHHbIx B Be.nuro6puraxuu
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cHu3r4Tb 3aAepxKy nocTaHoBKI,I AI,IarHo3a I,I yny{ruI{Tb
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uu@uquponatu Staph. aureus, oAHaKo Bo B3pocnoM
BO3paCTe IbrXareJIbHbIe rIyTpI MHOTUX naUUeHTOB
KonoHrr3r,rpytor cfl. P. a e rugi no s a, S t e no t ro p hom on a s
m a lt o p h i I i a unll .{pyr}rM I,I rpaMorpl4uareJlbHblMll
nruroqKaMr.r. Perlra4nnupyrcuue o6ocrpeHux B pa3-
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aeoiluncusovlw udu so,
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or
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. lloxrrori Bo3pacr . 3arpqsHeHile Bo3Ayxa
BH)fip14 nOMelqeHrlr/
un$uquponaHHbrx Strep. pneumoniae, a y HeKoropbrx
6o.lnnrx uoxer Ha6rroAarrc.f, KpoBoxapKaHbe. O.unlrtlr
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Xorx pasluuHbre Mr{KpoopraHu3Mbr qacro Bbr3br-
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KapTr,tHy, Bo3MoxHo cAeJraTb npeAnonoxeHue o Be-
tlt lr
eS porITHoM nos6yAllrere Ha ocHoBaHr,rr,r KrlrHuqecKl,Ix
oco6ennocreri sa6oresaunx. Mycoplasma pneumoniae
Puc. 2.31. flpu orpacxe MoKporbr no l-pauy Br4AHbr rpaMnono- 6olee pacnpocrpaHeHa cpe.ur,r Mono.ubrxrrcAerl u peAro
xuTerrbHbre AunnoKoKKl4, xapaKTepucTr4Kr4 KoTopbrx cooTBeT- BcTpeqaeTcq y floxr,rJrbrx rrauLIeHToB, B To BpeMrI KaK
crByror Streptococcus pneumoniae (yrasanur crpenrarrrra) u;a$eru1ul Haemop hilus in Jl uenzae qar\e na6rrogaerc.f,
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Merogu uccfleqoBaHue Ta6nuqa 2,38, O6cnegoBaHile npu exe6onuHn,{xofi

3aAa.ral.ru uccJreAoBaHlrri, roroprre o6o6ueuH a
i nHeBMOHxl,l

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lofi BfI c:reAyer flpoBotrr,rrb pqr Mr4Kpo6uorona.recKrax o FelaolulaqecKafl aHeMilq ocnoxHeHile nHeBMoHt4t4, Bbt3BaH-
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feuoxynurypa
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. lloloxrreluHbre pe3yrbTarbr y 50%o naqileHroa c Mycoplasma
l-agosHi cocraB apreplanumoi rpoar
. Ileiaepcor npur SaO, uenee 93% vnv npv eurpaxeugoi
Tsxecril KnilHilqecKilx nponaleHuil, vro6ut oqeHrru creneHb
BeHTiln9qhoHHori ne4ocrarovuocrv vnv aqrgosa

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O6pasqu MoKporbr
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Moea
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rKaHb frpaqeHa n 3aMeHeHa Sn6posnofi rKaHbp c rpaHyfleMa-
ro3HbrM BocnareHheM, Koropoe xapaKrepu3yercfl HarilqueM
6onuLuoro Korr4qecrBa MaKpoQaroB 14 T[raHrcKt4x MHorosAep-
Hbrx KneroK (6erar crpelra). B qexrpanuHorl o6nacru AaHHoro
nonn 3peHtae Ha6nogaercn xageoeHurfi HeKpo3 (vepHar
crpenra). (J1o6esno npeAocraBneHo E-poM William Wallace,
Department of Pathology, Royal Infirmary of Edinburgh)
Puc. 2.36. llepeuvnuri ry6epryres fleTKux. (1) pacnpocrpaxe-
nue rH$erquu or nepBui{Horo oqaTa K nrauearravecrrM y3naM
KopHfl nerKoro u cpe4ocreHhn c SopuupoBaHueM
"nepBur.t-
noro ry6epxyne3Horo KoMnaeKca", M9 KOTOpOTO e 6Onuur4H-
cTBe cny9aeB xapaKTepHo cnoHTaHHOe CaMOCTOgTenbHOe
3aK[BneHue. (2) HenocpegcrBeHHoe pacnpocrpaHeHue nep-
Br4qHoro oqara nporpeccrpyor4ui ry6epxyle3 ,rerKlx.
-
(3) PacnpocrpaHeHre ranQerqrar Ha nneBpy
- ry6epxyresHsrfi
nneBpr4r u nneBpanbHbrri eurnor. (4) l-enaarorenHoe pacnpo-
crpaHeHt,te: He3HaqnrerbHoTo Koflilqecraa ry6epxynesnurx
nanoqeK ry6epxynesHa.n uHQexqur rerK[x, xocrefi, no.{ex,
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ToM qucre nlrlr@aruuecKr,rx y3Jrax, cepo3Hblx o6oloq-
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Tecr.
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cno6oxlenuu y- r,rnrep$epoHa ( Int e rferon -y Re le a s i ng
Assay
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JrareHrHbrM TE. Eclra sru penapafiBHbre flpoqeccbr
ues@@erruBHbr, pa3BlrBaercfl nporpeccupyrorqufi
nepnlrunrrrl TE (pnc. 2.36). Pacvetmul pucx nos-
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pasnururc TB, o6o6rqenrr n ra6,'r. 2.45, a ecrecrBeHHoe
TerreHue TB-un$exuur{ [peAcraBJreuo n ra6,r. 2.46.
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I Hlllill"t*t'
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flo4 uepnu.rHbrMrr Sopuarr,rlr TE lonuuaror r,rH-
@exrlraro y paHee Her,rn$zuprpoBaHHbrx naqraenron (c
orprruareJrbHorZ ry6epryluHonoft npo6ori). Y nexoro-
prrx 6onrHlrx sa6oresaHlre nporeKaer c @e6pnnrnorl
TeMneparypori rela Lr caMocroqreJrbHo Kynlrpyercfl, a
BblpilxeHHhre KJIIIHI,IqeCKHe nporlBneHllf, BO3HI,TKaIOT
TOJIbKO npu pa3Br.rTilu peaKt\tlkr runeprryBcTBr.rTeJrb-
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noJroBlrHbr naur{eHToB c a6Aonaltralrnrnr TB. O6rr.rHo
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cHI{XeHI4e MaCChI TeJ'Ia, a TaKXe MOXeT IIiL{b[]IpOBaTb-
o6pasosaHrre B rrpaBori noAssAoilruofi o6:racrr. .{o
c.a
30% ctytaes flporrBJ'rrrrorca xapruHoft ocrporo xo{Bora.
IIpu Y3I,I lrnu KT MoxHo o6uapyxrrr ),roJrrrleHr{e
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ronroll Kl,lrrrKrr Bbrfl Brfl rorcs cyxeHlre, yKoporreHue
u 4e@oprrlauvs. Kullte,ulrlaKa c BoBJreqeHr{eM flpeuMy-
u.IecrBeHHo c:renorl Kr{rrrKlr. fluaruocru xa c'rpoprrcrr
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o6pasuos, nony{eHHbrx B xo.ue -1116o xoronocKorr}r}r,
lu6o ulrruJranaporoMr4ra. OcnosHoe 3a6orenanue,
c KoropbrM cne4yer npoBoAr4rb ar.r$$epeHunanbHyro
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- coxpaH.f,Tbcrl HeBponou,rqecKlre nocneAcrnus. Knu-
neplrroHlrr xapaKTepr43yercr 6omro
B3Ayrr,reM xr,rBora,
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flBrrfliorcs. MHoxecrBeHHue 6errre 6yropxra. Ha SoHe
uu-nuapnori $opuu sa6o,reBaHuq qacro nprlc),rcrByror
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roropori o6uapyxr.rBarorcrr rpaHyneMbr. B ernrurqnrrx
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ru.{ecxoft xeJrr}4(tr.
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u nporlBneHlu o6stuHo pa3BrlBarorcrr [ocrerreHHo, Ha-
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fIonruuo ltneBpanbHoro Bbrrrora, corryrcrByroqee
lopaxeHr4e JrerKr{x Bcrpeqaerc.s oqeHb pe4ro. llprE
o6eux $oprraax sa6olenanurr Bcrpeqarorcrr napaAoK-
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oreKn. flepurapaualumuZ Bbrnor corrpo Boxlaercrr
pacuupeHl,IeM rpaHuu orHocurelruoft rynocrr,r cep.Uua
u urapoo6pa3HbrM yBenr{rreHr.reM cepAua, IIo AaHHrIM
peHTreHorpa$lru opraHor rpy4uorl KJrerKLr, a raraKe
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nepr{KapAr{roM cBrr3brBaror panuuri III ros cepArla u
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u{rrecKoro }r 3xoKapArrorpa$uvecroro uccneilosauuit.
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JreHHocrlr AlrarHo3a Moxer 6urr nponeAeHa orKpblTarl
1uor.cv.fl. rrepr.rKapAa. E ruro nporeM oHcrprrpoBaHo,
.{ro Ao6asreHrre K nporunory6epryresuofi Tepanr{r,r
rnroKoKoprr{Kor{AoB rroMoraer npu o6eux @opuax
flopaxeHr,r.s nepr.rKapAa. .
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Hau6oree saxHofi @opuofi TE uenrparruoft
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6ucrpo flprrBo.qrrr K JrerilrrbHoMy r{cxoAy. [axe npu
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JreqeHue,uassoft @opuu sa6oresarrus onlrcaHbr
r,r B
coorBercrByroueM pa3AeJre.
Tydepxynea Kocreil u cycraBoB
Halr6oree .racrofi roxanu:auueft TE xocreft snrg-
ercq [o3BoHovHrar (6oresur florra), roropaa o6rrvHo
rlpof,BJrflercfl xpoHuqecroft 6omto B crruHe r.r, KaK
lpaBIL,IO, nOpiDKaeT HU)KHr{e rpyAHbre r,r rrofl cHr,rrrHbre
no3BoHKrr (cna. prac. 2.38). Hu$ercIuouHrrri npouecc
Harrr,rHaercrl c Ar{cuura (nocua,renux Mexrro3BoHKo-
BOrO.{rrcKa), a 3areM pacnpocTpaHqeTcs BAorb cBrI3oK
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Maulrrc no3BoHKoB c nocne.{yorquu @opuupoBaHu-
eu ru$osa. 9acro Bo3HlrKaror uapanepre6pzurbHbre
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suu) a6cueccoM B naxogor)r o1stacru. KT u-rrra MPT
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v rrput ueo6xoAlur,rocrrr orKpbrroro xlrpyprurlrecKoro
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a, gBItfltOT Cfl 3IOKarreCTBeHnrre uOSOO6 -
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r l-lpor,/ureFiure eogur xerygxa- (ucnoaueyercn .raule y Aereil)
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. ly'ccreAoBaHue xugxocrei (cnrHHor',rosroeoti, acqnruvecxoti,
nreeparuuoi, nepilKap4ranbHoil, cycraenoil): AilarHocruee-
cKaq gHaqilMocru o6ur.rHo oqeHb Ht4gKa
. Euoncun rxanu (us yeacrKa nopaxeurn): npu Ar4cceMuHr4po-
aaHnux $opraax BosMoxHo r4ccregoBaHile xocrnoro raoora /
neqeHil
fluarxocrurecKue recrbr
r T-nurr,rQourroB aHrlrreHauu lrprxo6axrepuft [pr,rBo-
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Hori r16o rareuruorT nHQexqnu
. Oxpacxa no l-{mro-Hurucery:
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. Meropur avnlnSrxaqur (pacuLupeHran noleri epenrs urxpo-
cxona) ryxrenroBbrx Kr4clor
. KyabrypanbHuril verog:
- Ha nrorHbrx n/rarerbHbrx cpeAax (IeBeHlurar7ra-l,4euceua,
Muggn6pyxa);
- xrlgKile nilrarerbHbre cpegur (ranpmvep, MGIT--)
. [heBpanbHa, xilAKocrb: r4ccre4oBaHue
arqeH0Sr/HAe3a[,4ilHa3bt
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npenaparaM/ (o6urvno ra6rogaercn vepes 5-10 gHera)
Tpaguquoxxure uccnegoBaHlrs KpoBr4
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la6oparopHure noKagarer!4 $ytxquu neteHr
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paHH14M yrpoM).
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MGIT uHAuKaropHan npo6rapxa 4rre onpegeneHxt
-
pocra lauxo6arcrepuil.
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KaprI,IHa npu peHrreHorpaSuu oprauon rpyAHorl Krrer-
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RIF (onpe.ueJreHr{e AHK, ocHoBaHHoe Ha MeroAax
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rrneBprurbHoft , nepurap4ualrfofi , crrr{HHoMo3roBorl
u acr\vrrriqe cxoti xlrAroc r ri Lt, T aKr M o6pa3oM, M oxer
rroMoqb B noATBepxAeHr.{r4 flpeAnoJraraeMoro Ar,ra-
urosa TE.
B npucyrcr suw BLIH - us@exuur,r lrccJreAoBaHr,re
MOKpOTbI MOXeT OCTaBaTbCS tIOre3HbIM, TaK KaK O6brrr-
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$opu sa6oleBaHnfl.. flpone4exrae recra Ha Hiurlrqrae
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262 . IIYIIbMOHOJ!Of1I|,

KyJr e3HbrM 14 M UKO6aKre pvfl.Mlvr.. B nyrpuxoxnHe Ileqenne noA Henocpe4crBeHHbtu

npo6u TaKxe Moryr 6brrb noxHoorpr{UareJrbHbrMH B
ycnoBr,rfl x rrMMyHocynpec cvil vnv reHepanr430BaHHorz
TE-rau@exquu.
C nououlr,rc IGRA MoxHo onpeAenrrrb BbrcBo-
6oxneuue y-raHrep@epoua T-rulu$our{raMr4 B orBer
na sosAeftcrBr{e raKr,rx aHTr,rreHoB, KaK paHHuIl ce-
rperopnrrft aHrr4reH-Mr.rueHl-6 (ESAT) ullr 6elor
Kynbrypanbuoro @ulrrpara-10 (MBP), Koropbre
3aKoArrpoBaHbr B reHax, cneuu$u.rHbrx n,rfl MET, u
He ,rBJ'l-srorcfl o6ruuMu c EUX lrnu onflopryHncrtt-
rIecKI,iMx MlrKo6aKrepuxuu (pttc. 2.42). IGRA 6onee
crteuu$t,rqHbr, qeM BFryrprrKoxHbre [po6br, u yno6Hee c
TorIKu 3peHuf ,rloru{crrrKr{, TaK KaK oHu rpe6ytor oAgo-
KpaTHOTO uCCr'IeAOBaHrrq KpOBU, a He AByX Br43I.{TOB B
KJrr{Hr{Ky. B Benr,lxo6p ur alauu peKoMeHryercs Aaorl -
Hafl crparerufl B BVA.^ npoBeAeHriq TST c flocneAyro-
rqur,{ IGRA. TST ocraerc.fl orrrr,rMilrrurrlr nrr6oporvr
y Aererl, B ro BpeMrr rar IGRA npeAcraBnfler co6ori
flpeAnoqrprre:rr,nr,tfi Bapr{aHT Anfl Ju4u c BI4rI.
Ovnqeuusre
T-rnuQoqurur
Ha6fl,oAeHueM
Husxaq npr{BepxeHHocrb repanuv r.lasHrrrt
-
@axrop yrJruHeHvrs. TeqeHr,rfl 3a5oreBalanfl, pr4cKa pe-
uufllrBa r,r Bo3HuKHoBeHuq JleKapcrBeHHofi ycrorirvuao-
cru. JlerreHue noA HenocpeAcrBeHHLIM Ha6nroAeHueM
(Direct Observation of Treatment DOT) BKrrroqaer
-
KoHTponb 3a repanueri 3 pasa s HeAerro Arrr ynfrmeHr4Jr
rrpr{BepxeHHocrrl JreqeHuro. DOT cra-rro BzrxHorl crpa-
rerr4eft KoHrpon.rr 3a 3a6oJreBaHueM B 6eAnrrx crpanax.
B Berulxo6pvraHuvr. oHa peKoMeHryercfl B Hacrorrulee
BpeMfl fIauHeHTaM, y KoTopbrx npr{BepxeHHocTb Te-
patw cqr{Taror MiuroBepoqruorl: 6esAor\,rHbre Jrro.ur{ r{
6polqru, ylorpe6.rrxmxrue rL,rKoroJrb r,rJrr,r HapKorrrKr,r,
6olrnr,re rqxer bI M I4 rlcuxI,tqecKl,IMu sa6orena lg.:,z.flMr4
u raurreHTbr, y KoTopbrx B aHaMHe3e oTcytcTByeT rrplr-
BepxeHHocTb JreqeHuro.
Ty1epxynes u Bupyc uwwyHbryefuu4ura
qenoBeKa / cungpou flpuofipeTeHHoro
nMMyHOAeQuqura
IIpu co,ueftcrapru nporpaMMaM, Koropbre BKJrroqaror
BbrqBreHue r{ JrerreHr,re TE n BI49, flppr3Harorc.f, Tec-

@ [-{enuran
Hbre B3ar{MocBrr3u Mexry BI49 u TE, n qacrHocr}r, B
crpauax A$pr.rKr.r, rrptrJrerarcxlue r Caxape, npn groM
noreHur{zlJl o6orax sa6orenauuft nperocxo,urr Bo3Mox-

I
14xr<y6aqur lAtry6atya
HOCTU SOUIOB 3ApaBOOXpaHeHr4rr B 6eAHbrX pecypcaMlr
crpaHax. PerouenAyercrl, qro6hl Bce [aqueHTrr c TE
B np!,rcyrcTBl4r4 B npucyrcTBr4r4 npottrnu o6cneAoBaHr,re Ha Bl4q-r,rH$exqnrc. Ha6nro-
aHTllreHoB, cnequ- aHTUTeHOB, Cnequ-
$rvrurx gm M6T $uvrurx 4rn MET traercfl. BbrcoKarr cMeprHocrb, u TB xmxercq seAyxIeIU

T
Burceo6oxgexue Bsrceo6oxgexue
t rpuvuuofr cMeprr,r cpeApr [au]reHroB c BI,19. llonnoe
o6clrr4euue ero [poqBleH uh u re\eHufl rrpe.qcraBJreHo
na c. 316.
yuxrepQepoxa yuxrepQepoxa
!
I
+
.luxrepQepox HaAocaAovxaq xuA-
t Ty6ep xynes, BbleBaHH bt rt
c
aosdygureaeu
neKapcTBeflHoit ycTortqu BocTbi,o
cB9SbtBaerc, c aHTu- KOCrb yEareerce
TeflaMr B ocHoBaHuu l/t KolilqecTBo TB, nusnanHHfi sos6yAr{reJreM c .nexapcrneHHoft
ryxox ELISPOT ^ltanrepQepoxa ycrolTql4Bocrbro, oflpeAerrlerc.f, Ha ocHoBaHlav Ha-
u3MepreTc9
c nouoquo ELISA Jtutlt4s. y 6arrepuu ycrorlqr4Bocrra x lrc6ouy nperra-
J
Ilogcvei raneru pary rrepBoro pfl.ta. TB, urrsnauHHit so:6yAr4reneM
co MHoxecTseHHofi neKapcTBeHHorl ycroftvuaocrbro,
Puc. 2.42. llprHqranur npoBeAeHre recroB, ocHoBaHHbtx Ha olpeAenqeTcf Ha ocHoBa}t]Il{ pe3r4cTeHTHOCTlr nO
eurceo6oxgenrara y-raHrepQepona (IGRA). O6paseq nra6o (A) rpar7neri Mepe K pra$aunraquHy Ir r,r3oHr,ra3r4.qy B [pr,r-
oqr4qeHHux T-ruuSoquroe (fecr T-SPOT.TB), ru6o (E) qenu- c),rcrBr{u rur,r B orc}TcrBr.re JreKapcrsennori ycrorluu-
uofi xpoeu flecr QuantiFERON-TB Gold) npoxogr,rr nnry6a- Bocru K Apyrr.rM npeflaparau. flo uo6a;lr,HorZ oueHKe,
r{r4to B np[cyrcrBr4u aHrilTeHoB, cneqrQnvHutx p4a Mycobac-
terium tuberculosis (MET). Burcao6oxgenrae y-ranrepQepoHa 3,37o cttytaeB BIrepBbIe ycraHoBneHuoro TE n 20Vo
KnerKaMu u3Mepntor c noMou.lbro QeplaeHr-censaHHoro hMMy- cn) {aeB y rrau}IeHToB, paHee floJly{aBrx}Ix Tepalltlro,
Hocop6eHrHoro aHan4sa (ELISA). (ELISPOT gepueHr-cen- xapaKrepr,r3o Batrprcb TE, arrsnannrru aos6y4r,rreJreM
saHHurfi urrrrvryHocop6eHrHurfi
-
aualug KaneflbHbtM uerogou) co MHoxecrnennorl JreKapcrBeHHoft ycroftvunocrbro.
otr xrrHquog xuHtro ,{ rletn,(xerorrs ro re,(duqdus
enurdux BuxcohuHI,IrX 'gntr IIm,I eteHlareH€ s gJ c
'Igool4Ho)ongeHu'Iqc€lxeoxuodg'lg6yxex'xlDt.lar
uhiruHsserogue l4wl4)cehunodx unl{xer c'erulruQetr
-on.{ltnur oJoHsr xurrtolol lu oH 'goJueufleu rotddutt
-uQuu uttufu rot.(dlleunoro>t (wn1m'Jr[ c)eru] Io)
Urvurreuder)ugo)Ilw renolrxa) aoVus xnl,(dv ox
-qro)coH eeHal I eH I lel '(mt/xorerx 0S 00HeI [ - r61J
osrcohr,rro)) t-rUS rl4Huserogue xeltdoQ xlilrexrr
ndu rsHecuuo omodox - tanwD'W e)\erul\o) oJoH
-ureuderxego)fiN ]rlrerl,Isurctredrr - tlnder,xegoxulll
xI,DBr eu elilHrcestrz oxodlrm erqI^lEJ 'I,IHE)J ept)Jrw
I,I Exo)' lsro.{ erxoenureQltur' oplxJotr rcJol€rersos
ccelodu 4r{)cohltJolforutr s oHhIqgO '(99'7 'ltgur)
(<<enunr.ruute,> lttoguvudet elqneeh€H€ogo orcen) etredc
4etuorux,{dxo s ol4f[ol€rugo'4uderxBgoxl4lI IstrI'rs
era.r,(dtr la qr€srlelils rr(ron exssoreh 6uHegeuo9ut
Btahvo$Hu ceHquendorYegoY14url
Eevcoht4rcIHfudouuo
'rr,rH€serfoge€ BsLI['fi tled )cud t^znnnemrssou oHHodev{^
14 r{rcoHilrurer unsodr( eluocrlg eollog rolewu elqHlllrog
errHirreu{xorox-hl4 g'sotrfloxurdoro)orlru €I I€I4[o9
-erew vr{Hamlqsorr ltoHurluulnwQnd orouneaeisa euoQ
€H 4or rr4heHt I,DIoohI,IHI{ID{ IrorIlaoHBJc ltedorox'q'rcog
-horerrotreH rBsox,IHhehoutrBH B?)cer'uuurr;r9r(c ncre
-enu xr{H r{ otr, 'orrxontos u 'vutledaI BII?heH oIICOU
sdoxcs rorcdultd oHHetrtDKoeH eIiIHiIIroq endoroxell
'goxl4msl,'I4df) [, u estert uuuoxcodxrar,t r'rnurursr,{eed
ul^tlqH<rroruxorou c sorHol,Ifisu I uerrodes eelroq
troxcu IrsHqII"re['rorudnlt('ruHeher xulno{utu(Irou
eu 'xrsnsrog o/gz eYoJ I ellHeher s 'u[oJ Z I leHtrodc s
I^tIqH€BdeE rCreerco gxeeN urauoxcodxuN pIuHesoHSO
BH +Ightr gI c rHeI,tII?u rI,IHeheIr IEUATCT^{Cr,O udg
'plrcoH<rrerusrcs,(h I1toHHearcd€xer nlodrxeuc luqgnur
-ol"eHe rcrol^eradelxudex oHhrslgo u ron E ellHeher s rc
-roresl4se€d sosl4trI,Ified srceh rernqrog 'esutrffIod xcud
grirrDKeg€ueH u (o69 eauew) 4omsrogeu rer(a.lceln{3
'sorHer4rrcrr EsrcHl,Imqlrog .( sretr[xo m.{trerc uuueder
-oI,INI{x rrllHemdesee oroHmeucr( ercou 6r4Hehelrel4
eoHrodu I
'nIIiIHHonedaq I4IM
(6gg euarctrercs'dal,tuduun) norultuQefloH,{Nwlr
3 r/'r?rrur rcsu{tross €H)Kffotr eH uHo 'eccellcg€ oJoH
-rcev{ r,rH€sodlrwdoQ otrlrs a 4]rHoHxouco Hl^lr€hflfc
rlr,uqHhuHutre rcrer(euderxedux u euceuoeeg yflg
'lroxcud nrD{ocns c flurxurfdtr u gaJetr en enesodur
-nerado eno 'orfl{sudu xex 'ots€og oH 'Kilrenedxoogedtre
4arcoH)Kor {ooa I{ I{rcol/{eEselro9u€ ro I,lrcoNptcplse€ a
e9Z r tgtAt3r-c]4C roHquSrvxlcu HhHvs3tfogve 3lqHHot4hvSoHH
edrtl^,r nrecs og uHlrur€ed uull€HufrxBs e)urplrou rntedg
eerfirorcBH g 'HL{rI)es xHsoH exrogedeed BI ll'Itroxgo
-eu l,I 'Iqsuhodosl{rodu xrqlrcodes I urconalfixeQQe
ae ou oIiIHHEtr o)eHtro 'BruJHtlHeN oroneer,$rdegrfu
errcuh r ror s 'geretr .{ runeaerogee wdoQ xrsHHegod
-r{Hur reccuV }flanetnudsrotredu s ry'ouaurxeQQ€ roleJ
-rar,c yflg 'olqrcoHHoJosdxrtu I^4o)oclqs roBtrErgo u
onxoxudrr(ns rcrutross eHO 'gI surod[
4oHulrxes
rlonnenefucoduced 4oI lec Y)LeYUIR 's1rcq 'q eu ItEI^l
-eer,r(rou '€HI4IDIBa ruHHelrg€rco restrx - X|1g
tctHulueg
'emrrs eme
- olqrcosl{h4orc,{ rlorinealcdexer rloxod
-I{Irr 3 gJ ro € ')oclqs 'orslcoturr4orc,( gonnsercduxer
rjoHHesrcexoHlI oc ltereuavfgeos oJoHHBsersa'91
ro HJroHqIrErer sneaod6 'sorud€rredrr xlrrodoE earog
u xrirHhuc)or eelrog'xrsnaurxeQ@e aeueltlel{Hesoc
-qrorr3l{ o I4l,Iueder 4onlraruftr roilgefu Hrorutrfgoos
ral,€'rltHehelf qrooHxol/{eos BH BdJoNceH'u' gocdr(ced
xrlHHehuHudJo xrugorcr{ s oHHegoco 'urrxolfc €xptlc
-oHJBI{tr oJA 'olqrsoaun4orcr( 4onneurcdu)or c gI
er,rHesolD{uHcos s trEIfis euturcoHa'tqdor:eQ nneucun
-adatt yg' 7' trgur g'xlqHHesodufiuQuu-1r14g utredc
e)IcIBr e 'uuHeher li{oHrefl)eYeeH oJe udu 'urcoutcen
a 'g1 eeeulteHu s xulflolel^Iu 'Itur ufedc rsHeHudJcodu
-ced eerogueu urelutr(geou ettuuefi''trxudQy u uuey
gousredruafl 'eeoIo3 oJoxcraso3 xunufuc xumeltg a
I{JcoHHogoJo s'retcud'olstcoaun4orc-{ 4ouuearcdex
-er r3oHHesrcoxoHl I oc l lereruVr(geoa oronueaena 'g1
srcoHHeHefu coduceg'olqrcosuh4orc,{ Utonnetrcdexer
yroxodum c gI rolewu 'otsJ.coatln4orcr( tJonnearcdux
-er IIoHHesJcexoHN oo I lereuaffgeou lntlsnneaelta '91
) qerlotltt ob L' 6 olro)O 'Btrrd oJodors fJedeuedu ,(noHHo
-ulrxes,Hlr fnontro x edew 4em<IHeI I ou ra egouonux fnt
-oHtroseuodu rfitogotrx oHillrerllHllouotr'^trflte[Hocu
u ,ftrufiuultetpud x adert 4eugedx ou rllHeserogeo YU
-eruE (geoa trcoaur'4orc,( JoIeWlIHolr otsrcoaur,Uorc,(
ty'oxxetrcdexer 4oxodu[ c gI voII 'olsJ3osnl,4orc,(
4oxuearcdexer IloHHesrcexoHl I oc wererutr(geot
oJoHHBseIqs 'gI ro urdelu( getroff 000 06I 'r tl\Z g
(cet.'{ g eedeF, eveen l4l4uovcodvt4v'l
rqrercu^ead orsHqua!4xouou) unueneu srcorlenrxeQQeeg .
gilueder reneeu,{>rdegfuoeilrodu relnou(ercemUedg o
orsrcoenntlorc{ 4ouueercdexeu c eot'{v\elm eneUedeg r
guodrHov oJetnexautrEH euercrlcrg .
eslcohev oJovehH eercVedc etsHuaercdaey r
ercUedc xtqHHeucdevau E)rEExol-{ r
!
-eos ellno{,{ercaosouc lqdorv eO' tg' Z el![,.vge L
264 . IIYIIbMOHOTIOTU9

Ta6nnqa 2.55. Opraxocnequguvecxue onnopryHr-

i cru{ecK}re unxo6axrepuanuxue nxSexquu
3a6oneeaHuR opraHoB AbrxaHnfl ,

.[ero.{rrte
Bbr3BaHHbre rpu6aMn
. M. xenopi '. MAK Eorrrul.rHcrso rpv 6oa, c KoropblMr,r cra,,rKr,rBarorcfl
t M. kansasii M. abscessus (npu MB) n rc.rlr1, flBnfl torcfl 6e:npenu sr na u ca npo$uraMr4, oaHa-
, M. malmoense Ko npr4 onpe.rleneHHrrx o6croqrerrbcrBax ( rlir'r. 2. 5(r)
Il urrrQarurecxue ysnur HeKoropbre Br4,u,br Moryr Bbr3brBarb 3a6oneBaHl,rq,
r.rH$ruupya rKaH14 qerroBeKa, [poBour{pyq noBpex-
a M. fortuitum
'MAK
. M. malmoense a M. chelonei
/r,a Io u r4 e zun e p rr,rqec Kr4 e peaKur{r{ u lu tupa6 arbrBaq
ToKc14Hbr. n,rs o6osHar{eHr{, 6o,resula, errssaHHoil
Mcrxue rxatu / xoxa rpu6ronofr Hu 6exUuefr , npr4MeHfl ror repMr4H <<Mr4Ko3,>.
. M. Leprae . M. marinum J.57 nepeuucneHbr 3a6oneBaaufl,, cBfl3aHHbre c
B'r'rr6."r .
, M. ulcerans (pacnpocrpa- . M. forluitum r.ru@uqnponaH14eM rrpeacraBrrre tavu pon a Aspergi I I us.
ueua a A$prxe, Ceeepuoi t M, chelonae
Aacrpaluu 14 lOro-Bocro,{-
I furneprraqecKuf 6poxxoneroqHbtf
nofi Aeru)
I acneprunre3
,{uccetrruuupoaaxnare
A-nlepruvecxnft 6pouxorero.rHHft acrreprranne3
. MAK (Btult-accoqr4r4poBaH- o M. fortuitum o6ycnoBneH peaxqueri DrleprryBcrBllf, eJrbHocrlr, pa3-
Hure) c M. chelonae nnnaroulerlcrr B creHKe AhrxareJlbHbrx rr),Terl B orBer
. M. haemophilum . EUX
o M. Genavense
Ha npopacraroulre cnopbr rpu6a. 3a6o:resaHr,re Moxer
ocJroxHrrrb rerreHue 6poHxraalrnor1 acrMbr u MB u
. MAK wuxo6axrepnaluxsrfi xouuexc Mycobacterium
avium
- M. scrofulaceum, M. intracellulare n M. avium
ctllrraercrr orHorl rl3 flpuqr.rH rerorrHolZ go3I4Ho0I4nI4I{.
- PacupocrpaHeHHocrb iunep[HecKoro 6poHxoneroq-
arpeccuBHoro TeqeHuf, c o6pa3oBaHr,reM IIoJIocTeIT I4 Horo acrrepfl,r,rne3a cocraBJurer npu6lusuretsuo l-2%
y3noB y Apyrux. PenrreHolorr4qecKr4e npoqBJreHurr rpu 6poHxrnanbHoft acrMe Ir 5-10% - rpu MB. Pag-
MorlT 6brrb cxo.qHbr c K[accuqecKr.rM TB, oAHaKo y JrrrrrHbre rerixouurapHbre aHrr.rreHbr qeroBeKa ( H LA)
naqr{eHToB c 6poHxo3Kra3aM}r olnopTyHucTr{qecKag
UHOeKIIlIq Moxer 6urr npeAcraBJreHa orraraMr{ B Ta6nuqa 2.56. Oaxropur,
Hl{xHr{x oTAenax JrerKHx. Hau6olee qacTo BcTpeqa- i K pa3BUTl,$O ea6Onesaxmi
rpu6amu
nerKlx, Bbr3BaHHbrx

rcuuecq Mr{KpoopraHpr3Mbr BKJirroqator M. kansasii,

Cucreuxure Qaxropur
M. malmoense, M. xenopi u M. abscessus, o.4HaKo AJrrr
srux ao:6yg vrr e rrefi. xapaKrepHbr reorpa@uvecxue . 3noxa,iecteeHHbteonyxo,nh . frloKoKopl4Kor4Abr,Ltt4To-
pa3nvrqvs.. M. abscessus u M. fortuitum 6ucrpo pa- cucTeMbr KpoBeTBopeHug ToKcrgecKue xilMt4oTepa-
. Blzll neBTrqecKue npenaparbt,
cTyT, oAHaKO 6onb[rr.rHcrBo M]rKo6a xr epuir AeJraroT . Caxapuuril gra6er 6uororuqecrue npenaparbt
gro Me.qneHHo. Pa:pa6arblBarorcfl ArrarHocruqecKrre . XpoHt4.iecK[fi al]KoTo.r'lngM t4 Apyrile
cucreMbl, Ilo3BoJlflrorur{e non} {arb 6olee 6ucrpuli . flyreeas repanue ilMMyHogenpeccaHrbt
oTBeT rrpu uccJleaoBaHr4r{, B ToM rll4cne AHK-3OHAbr,
Mecrxure $axropu
BbrcoKosooeKTlrBHaf, xr.rAKocrHarr xpoMarorpaolrfl ,
III{P-pecrplrrrruoHnlrrl $epuexruuir a:aalus (PRA)
. noBpex4eHue xaHefi npil HaTHoilTenbHoM t4r'lr4 HeKporrge-
cKoM npoqecce
v aHaJrrl3 rrocJreAoBareJrbHocTr{ reHa 165 pn6ocouHoft o l4graeseHue xopvalsuoi 6arrepuaruuoi vrxpoQaopur
pn6oHyrureuHoBofi KrrcJrorbr. 3a r,rcx.nro.reHr{eM Br4JIa BcnencrBue repanilu asru6uoruxauu
M. kansasii, uccJreAoBaHr{e neKapcrBeuuoft qyBcrBu-
TeIbHOCTr,r Ang [porHo3vrpoBaHvlg oTBeTa Ha JreqeH]Ie
o6br.rHo neun@opuarlrBHo. B Benuro6p vr aHvrv c ny -
qau sa6oresaHrnrl, nos6y4l4TeJurMr.r Koropblx rlBnqrorcr
i
o AnnepMgecKurfi 6ponxolerovnurrl acneprulles (acrlaaruve-
3TI{ MLrKpOOpraHI'I3MhI, He [O,UIeXaT penopTtrpoBaHulo cKa, rerogHaq eosrnoQnlur)
B MecrHbre oprauu o6qecrBeHHoro 3ApaBooxpaHeHtrrr, . SxsorexHuri amepruvecxrfi arbBeorrr $spergillus clavatus)
TaK KaK OHU O6H.rHO He nepeAaroTcrl oT qenoBeKa K r BxyrprnorocrHafi acnepmnnoMa
qeJroBeKy, xor.s npu MB uuercrcs. TaK:ae AaHHbre B . lzlisagilaHuril acneprunneo rerk!4x
. XpoHr4,{ecKilri u nogocrpuril acneprurreg refxtax
orHollreHlrlr M. abscessus.
adehr ou e 'I4xhouogo gorcll€urc .(xnerc olftrsodeH
<rJusrrirs oHxol^t I) olqlloNou c LIHYBTo 4ennud t4olt
-ec BH 'rrmrdauce douc xrsv{eexntrs ruHurcedodu u
BLIH€treco oJoHxoI Ieos EIltr rusolfc,{ ersnrruduorurg
rorptr€o3 'exnodg runetrxedso[ olrcou un'r '91 xex
'Uraneaerogee xlrxer ercott rcoumaBtco'r'rtcoro11
ewouuuJdeuce seHhoHuao
' eI4HehoII u .{>urlcomeutr rorrrrxorc,(
Ir lrnlgJc€h rcrolrrsr eH ItuHesoroge€ eIqHHeIrcI4h
- adel' eerrr,t.ldeuce I1rlHsuo€sHu.{rou l,t oen[{Jdeuc€
4rsudrr,(trou'xuxolr eenrurdeuce gumot,{dusodguQ
Urorcenunodx'xIDUor 6em,"urdeucu 4rsueoHdeaux &u'r:c
(ue;q1o1 3g11',(6olotqolc1Y1
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OTAeneH OT CTeHKI nOIOCTI4 "BO3AytlHblM norlyMecqqeM,
(yxasaH crpenrofi)
nporpeccupoBaHr.rrr pocra rpu6aoHa B KoHeqHoM urore
npoBiurr,rBaeTcrr B rroJrocTb, sopuupyr <,rpu6Horl
roropufi Moxer 6urr o6HapyxeH flprr Br.r3yalr{3r4py-
rour[x MeroAax LrccJreAoBaHlr s (puc. 2.44).
OAuuoquue acneprl4nnoMbr qacro 6eccunnrou-
Hbr, oAHaKo oHlI MoryT npI{BoAI,ITb KBO3HI,IKHOBeHI{IO
MHoxecrBa Hecneuu$uqecKl,Ix clIM[ToMoB, HalpI,IMep
3aTOpMOXeHHOCTTT rr CHrrXeHr.rrO MaCCbr TetA) A TarOKe
Moryr crarb nprlrruHoft peuuAuBr,rpyrcuero KpoBo-
xapKaHbs, Koropoe MoxeT cTaTb xu3HeylpoxaroullrM.
Tluu.rxa-s peHTreHonoruqecKafl KaprnHa He-
H3MeHHO COnpOBOXAaeTCTI TOBbIIITeHI'IeM ypOBHq
cbrBoporoqHbrx rpeuurrrunor/IgG r A. fumigatus.
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unu o6uapyrrraBaror cKyAHbre @parueuru ru$ u, xax
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KynbrypiubHoro MeroAa. Menee veu y
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Hocrb[plr Koxurx npo6ax c sKc'rpaKraMuA.fumigatus.
lpyrue Hr{reBrrAHbre rpu6u pe.4Ko Moryr BhI3bIBarb
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npoMexyrorrHbrM srarroM flepeA orrepaqueri lr-nlr npe-
MeHHO yrlreHbmuTb KpoBoxapKaHbe npu HeBo3Mox-
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auSorepuquHa B) vepes ycraHoBJreHHlrft n rolocru
Karerep, oAHaKo Aassurl MeroA peAKo r4cflonb3yercrr
n Beluxo6pr,rraHvrv.
Xponuuecxuil xaaepuosHuil acnepruflfles
nerKux u xpoHnqecKuit Qu6po3npy,o4urt
acneprnflne3 nerKux
Krunlr.recKxe flpofl BJreHI4rI xpoHl{qecKoro KaBep-
KpoBoxapKaHbeM I4JII{ 6e: uero), rrorepro Maccbr reJra,
aHopeKcr{rc }r yToMn_f,eMocTb Ha IIpoTrIxeHr{I,I MecflueB
r{ Jrer c conyrcrByrouleft rurxopaArorl, HouHstMI{ [o-
TAMI{ I4 NOBbIIXEHHbIMI'I YPOBHqMU MAPKEPOB BOCNANC-
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ToJrcrocreHHbrMr{ rIorocrsMl4 (npeuuyruecrBeHHo
B BepxyrxKax lerrrax), JreroqHbIMI{ uuQumrparauu
rr yronrueHr,reM rrneBpbr (owc. 2.45). Kax u B Apyrux
CJI}^{AflX, AI,IAIHOCTI,IKA OCHOBbIBAETC'I HA COqETAHI4II
pe3ynbraroB peHTreHonoruqecKr{x u narouopQoloru-
qec nx uccJregonaHnfi , BbIAeneHI,Iq lpn6a, nolryuenHo-
ro r43Abrxarel*rux nyretl Marepuiula, u o6uapyxenna
IgG rAsperyilftzs o cuaoporxe rpousTeparru o6rrvno
urap)>,
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pr,rKoHa3ona. I4:leqeHue Bo3MoxHo peAKo, sau6olee
qacroll xapruuoti flBIrflercfl xpoH[rrecKoe reqeHue c
pe\r4nvBaMu v peMljcct flMI,I, a raroKe rrocrelreHHblM
yxyArxeHr{eM. XupyprrvecKoe BMerrrareJrbcrBo qpeBaro
ocJIoxHeHI{gMr{, LI efo cne.uyer ug6erarl. Y unorrax
naqlreHToB pa3BuBaeTc_[ acTeHldfr, ]r oH]r HyxIaloTcf B
Hyrpr,rrrrBHofi noA.[epxre. cleayer us6erarb rrpr{MeHe-
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xpoHr,rqecKofo KaBepHo3Horo acneprvilte3a JIerKI,{x
rrpor4cxoAr,rr AecrpyKrlr4Jr nerKoro c r{cxo4orrr n @u6pos,
u, cJreAoBaTeJIbHo, TaKoe rlaToJloruqecKoe cocrosHue
MoxHo orHecru K xpoHurrecKol,ry @u6poslpfouleMy
acnepru.Jure3y nerKr4x.
H o gy n n p n u ir a c n ep r u n n ee
OopuuponaHr4e o.[Horo rtrru 6o:ree ysroB r{BJrrrercrr
MeHee pacnpocrpaHeHHbrM nporrBneHr,reu lrH$erqlrlr,
nu3nanHofi Aspergillus. flolruuo paKa nerKoro, Ho-
4ylrpHufi ac[epfl,rffre3 Moxer rrMr,rr]rpoBarr TE, uo
o6paaonauue noJrocrr,r HexapaKrepHo. Kplrlrororxos
r,1 KoKur,rrr{orrroMuKo3 uoryr 6urr rpuuuuor7 o6pa-
3oBaHuq y3noB B 3H,[eMr{qHbrx no Aannorl uu$erquu
peruoHax.
llogocrpurt uHBasuBHbtil acneprnnneg
flo.uocrpufi uHBa3HBHbrft acneprlune3 paHee
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rrecKafl Ir peHTreHonorurqecKas KapruHa 3a6oreBaHr,rs
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sore,{ xumsrog euhl'IrEH osderxudex dgl) udu
'4l4HelrSorq€u u )em $1'ralseqcuey\'ollueC
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ar,rnoxedou eoneerrurdeuce eoHqruuxnodgoexedl nnrahscal,u{uou vrtcHmAUeoe, ee nntnor'ex,(dxo n 4ottouuu'l
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s qmtroxcuodu rexont eranenudrcoducud eoHI^loJcI'Ic -oHtll EcreBUststqs unHamedeed o-tovoctqe uuQedlotilor 4ouder
-orqul'{ov r,tdu '(4oruedlc oxeeex[) oJo)Jou oJoeeu !4vm^x
€ 'oJoxJer wer.xdeQuu r lteeogltodr x lravosudu - 9
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rqHodorc oc IqI IoJITNI'tc elqsoH rcrolrrsroll 'extred
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creHKLr,4speryillus (ralaxrouaunau lr B- 1, 3 -rnrcraH)
B KpoBlr r.rJrr,r xlrlKocru EAJI r.r lHK Asperyillus no-
cpeAcrBoM [onuMepa3Horl qenHori peaKu]ur. flrarxos
qacro craBrIT Ha ocHoBaHI,II,I KoM6r,rHaur{u [pI,I3HaKoB
(ra6n. 2.60).
Ileqenne u npo$uflaKrnKa
HnsaglrnHrrrl acneprulJre3 JrerK]rx xapaKTepr,r -
3yercrl BbIcoKlrM ypoBHeM rerturbHocru, oco6enHo
lrpu no3AHo HaqaroM Jreqeuuu. flpeuaparoM ru6opa
flBnflercfl Bopr,rKoxa3ol. flpenaparbr BToporo p.sAa
Ta6nuqa 2.60. Kpurepnu BeporrHoro AlarHo3a
i tafloa3]rBHoro acneprmnne3a nerK[xt
@axropur xo3euHa
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@arropor, nporr{Borpra6ronax repauurr BbrcoKr.{Mr,r Ao- et al. Revised definitions of invasive fungal disease from the
3aMra JrlrnruHoro au@orepvrlvrHa B uru nosaxoHa3oJra European Organisation for Research and Treatment of
Cancer/Mycoses Study Group // Clin. lnfect. Dis. 2008.
(sroporl pql), a raroKe HeKpsKroMLrs. Vol.46. P. 1813-1821.
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nepetrucneHHhre flBJreHrlx o6yc:roueHbr paKoM JrerKo-
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Al{criurbHblx $alanr, BeAytuee K }tserurleHl4lo KptrBI,I3-
nrr Horrerl u $.rryxryaqrau ux Jroxa.
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AeJroB 6onrure6epqonorl, lralo6epuonoft , nyrerori
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(ra6n.2.64)
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MeJrKoKrreroqHbrM paKoM JrerKoro. fi,lnepxalrqileMus.
Moxer yKa3brBarb Ha pa3pytxeHue rocrerl Bcne,rlcrBlre
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i nporB,tenuf, paKa [erKoro
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ruo6ou rr,rfle paKa JrerKoro.
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6oresaHr,rs.
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Pax nerxoro npuro4nr x $opMtrpoBaHr,rrc uprpoKo-
ro crreKTpa peHTreHoJrornqecKl,Ix [p]I3HaKOB, na6lrc-
AaeMbIx npu IICCJIeAOBaHI,IU opIaHoB IpyAHofi rcrrerKr,r :
or AoJreBoro areneKra3a (crr.r, pr,rc. 2.5) lo o6reuHux
o6paoonanurl, nunora r,rJrr,r AecrpyKrlur,r [opilKeHHbrx
Meracra3aMr,r pe6ep (pr,lc. 2.49). KT cneayer npoBoAlrrb
na paHneft cra4ur,r o6cne,{oBaHr{_s, [ocKoJrbKy c rloMo-
rrlbro AaHHoro MeTO.4a MO)rGrO BbIrrBLrTb paclpocTpaHe-
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a raraKe KT uoxer rroMoqb [p]r rrJraHr,rpoBaHrrrr,r npo-
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xoxnoft 6uor.cuuno,q KoHrpoJreu KT.
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en urox.(uo n.lconsregudouo .{xnefro }tcesodu rerr
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rc4etnuUoxeu 'yrHe)r foHhoJorr uc{emseuc e nuhle$Hu go
'orUed eu4edr 'r4ur4 clcouou olHquedeeuu e nuox^uo etaHer
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Heserqs qJ.rcg rexoy\ ox)E.t. eeryouary 'exHodg oroHquBut
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Ycranoaneune craqn h ga1one BaHnn Anfl on peqeneH ue cBlrIeTeJrbcTByIouI.rMI,l O paCnpOCTpaHeHI{I{ OlyxoJII,I B

TaKTnKh neqeHnq
CxroHuocrb MeJrKoKleroilHoro paKa nerKoro
paHHeMy MeTacTa3I4poBaHI{IO IpL{BOAI,IT K TOMy, qro
nauueHTaM, KaK rrpaBuJ[o, He noAxoAI{T TaKTI'IKa
xfipypruqecKoro BMeIIrareJIbcrBa. flplr neltelroxle-
TOIIHOM PAKE NETKOIO NEqEHI,IE
paclpocrpaHenHocrlr sa6oJreBaHllfl , rosroMy Heo6xo-
sru opraHbr..(anHrre o pa3Mepe onyxonl{ I,I Meracra-
K 3lrpoBaHlrlr B n[MoaTI,IqeCKI4e y3JIbI I,1 Apyr[e opraHbl
corocTaBrqloTcfl. Nlfl oTHeceHI4S 60lrHoro x o,quofi
r{3 ceMr{ ctaI'vir 3a6oIeBaHI,Ig, KOTOpbIe Olpe.4enflIoT
orrrl,lMuurbHhlft nlan BeAeHI,Ifl I,l [porHo3 B KaxIOM
}I NPOTHO3 3ABI,IC'IT OT KoHKperHoM cJryrlae (puc. 2. 5 I ). Aff orBera Ha Boflpoc,
,rBJr.rrroTcs irr,I @ynxqulr 4uxarenbHoft crrcTeMbl I,I Cep.It-

AprMo TUIaTenbHoe ycTaHoBJIeHI,Ie CTaAUU npoqecca. Ha ua AocTaTotIHo cocTosTeJIbHbIMI,I Ar-fl OCyIIecTBJIeHI{f,

paHHr,rx 3Tanax AI,IafHocTtrYJt l[s
Bblfl BreHu-f, orryxoJlu arpeccr,rBHofi TaKTuKU reqeHI4JI, Tpe6yeTCrI AeTiLJIbHOe
pr ee M e crHoro pac npocTp a}Ie}{I.Ifl , l4Irl4 MeracTa3l4poBa - o6creAoBaHue.
Hr{s ucnorrb3yercrl KT. O6pasubr prl.fl, I,IccreAoBaHI{q
u3 )tsenuqeHHbrx BepxHI,Ix MeAI,IaCTI'IHa-nrnrrx ltltu@a-
Ileqenue
TuqecKI,Ix y3noB Moryr 6rrrr nolyleHhl c rloMorlblo XupyprrvecKarl pe3ei<qufi Hecer caMble 6oluur're
6ponxocronura c EBUS vrv Merr4acrlanocronuu. 06- HaAexlbr Ha AoJrrocpoqHylo BbIxI,IBaeMOCTb, OAHaKO
pa3rlbr 1I3 HI/DKHI'IX MeAI{aCTI'IHMbHbIX Jll4Msarruecrcax HeKOTOpbre 6olrurre, flony{}IBllrre paA[IKaJrbHyIo
y3noB Moryr 6Htr ngsrlt qepe3 creHKy rlrrxreBoAa c nyqeByro LI xI4MI,IOTepaIr[IO, TaIOKe AOCTI{IaIOT .UnI4-
rrpr,rMeHeHr,reM 3HAocKoluqecKoro yJIbTpa3ByKOBOfO TeJrbHofi peMr{ccI4I,I vrvr ilgreqvrBaloTcrl. Eonee'IeN'I
o6opyAoraulrs. Kort6ttxaquq KT tl IIOT Bcero reJla y75vo cttyuaeB repalluq B uerrlx frrroto
I,I3[eseHI'1s
(cru. pltc. 2.6) rulrpoxo lrcrloJlb3yercfl Ms Bbrflwrerlrag. HeBO3MOXHa rU6O nenpueMJleMa I,I3-3a O6UUpHOTO
cKpbrrblx, no uera6olnqecKlr aKTI{BHbIx Meracra3oB. MeracrrBupo BaP.vIs. vuwl co[yrcrBylouux sa6orenaHulz.
KT rolonrr, paAuoHyKJIIuHas ocreocq uururpaSmt, Tarue [auueHTbl o6ecnequnalorcfl rI EulJll,Iarlrnuotl
Y3I4 neqeHu u 6uoncurl KocrHoro Mo3ra o6rlrHo r,r our}rMuurbHorl cuMnroMar[qecKoll repanueri. 06-
rIpI{MeHTIIOTCfl y TIaqUeHTOB C KJII'IHI'IqeCKHMI'I, reMa- JIeMaTb CI,IMTITOMbI MOXeT ny{eBaS TepaIII,Ifl, a B He-
ToltoruqecKr4uvr uJrvr 6raoxraN{ra.{ecKl,IMl4 nph3HaKaMu, KOTOpbIX CJryrraqx u xuMl,IoTepall4s.

Cragnn onyxoneBoro npoqecca Pacnpocrpaxexue e numQaruqecKue y3rlbl

NO N1 N2 N3
(Her) il4ncuaareparuxute (l4ncurareparuxute (Korrpaaareparunute
xopxr nerxoro) MeAUaCTITH€InbHble unu xaAxroquqxste)
ranra 6raSypxaquoxxute)

T1a (< l ctvt) rA1(92%)

T1b (>1 to <2 ct,t) rA2 (83%)

Tl c (>2 to <3 ctvt) lA3 (77Yo) ilB (53%) ilrA (36%) ilrB (26%)

T2a (>3 to <4 cu) rB (68%)

T2b (>4 cu to <5 cv) [A (60%)

T3 (>5 ctt) ilB (53%)

ilrB (26%) ilc (13%)
T4 (>7 o,r ltnu npopacraHue B cepAqe, cocygbt, llli (36%)
nuqeBoA, 6ur$ypxaqurc rpaxeu u r.g.)

M1a Meracragur a nerrr4x / sstnor

rvA (10%)
M1 b Ogranornuril gKcrparopaK€InbHbtil Meracra3

M1c MHoxecrBeHHbre rvB (0%)

SKgrparopaKanbHbe Melacra3bl

Prac. 2.51. Cragus onyxoneBoro npoqecca a4 nf,rvnerHnfl BbrxlBaeMocrb npu HeMenKoKneroqHoM paKe nerKoro. B ra6nuqe
noKa3aHa B3auMocBe3b Mexgy pacnpocrpaHeHHocrbo onyxonn (pasrr,teporvr, cocrotHueM nuu$arrvecxt4x y3noB Meracra3[po- I
aaHneu) u nporHo3oM (% eurxueaeuocl4 qepe3 5 rer gnn xaxgoil xruH[,recxofi cragrara). (OcHoeaHo Ha cBeAeH[rx u3 Detter-
beck F.C., Boffa D.J., Kim A.W., Tanoue T. The eighth edition lung cancer stage classification // Chest. 2017. Vol. 151. P. 193-203)
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peaKrrlrrl B creHKzx uurbBeor u 6poHxuol. Pacnpoc'rpa-
HeHHbIe cnln{al4 AaHHorl raroloruu BKrloqalor JIerKoe
@epuepa u nerKoe rrrl,Iueno4a..{pyrue nplaMepbl npeA-
craBJreHhr B Ta6n. 2.81 . lfl He sBn-sercrl ucKrIoqI4TeJIb-

a npr{ 6uoncuu BbrrrBrqrorcs capKouAonoAo6nrre Ta6nnr{a 2,81. Hexoropure ga6onenarlm nerKrx,

rpaHyneMbr. .{uaruos Moxer 6rrrl noArsepx.qeH c i Bbr3HBaembre opraxnvecxoi nunrrc
noMorrlbro cleqr{aJrbHbrx r.rccJreAoBanufi $yuxquu 3a6oneeaHre hcro.{Hr4x Axrurex/eeqecrao
rraNr0ouuros.
Ierxoe llperoe ceno, Saccharopolyspora
I nHeBMOKOHl4O3br
Mexee pacnpocrpaHeHHbre Sepvepa- coroN/a, 3anrecHe- rectivigula (paaee
Benoe 3epHo HaauteaeMaq Mlcro-
I polyspora faeni).
Aspergillus fumigatus
TepuuHou <(cuAepo3)> o6ogxa.IarcT pa3Burr{e
Ao6pora.IecrBeHHoro rrHeBMoKoHI{o3a, BbI3BaHHoro Ierxoe excxpel,,remur llrrvuu cuteoporovHute
oKc,rIoM xene3a, y cBaprur,rKoB r,r Aplrr,rx pa60vux xe- nruqeBoAa. nruq,6emu v 6enru
nepbF
regolurefi Horo npor{3BoAcrna. Eaplrros N{oxer Ha6rlo-
Aarbcfl y pa6ouux, cB.f, 3aHHbrx c o6pa6orro h 6aput, a ferxoe 3anrecHeeeruril Aspergillus clavatus

craHHo3 c pa$lruupoBaHr,reM oJroBa. <(leMarr.{roBoe>>

nilBoBapa. conoA
-
JrerKoe Bo3HIrKaer y pa6ornuroB rrraxr no Ao6rr.Ie Ierroe Curp c nrecenu,o Aspergillus clavatus.
xe:resHoli pyAbl I{ HarloMuHaer cI4nI,IKo3, Ho c oKpa- cbrpoBapa. Penicillium casei

rrrr{BaHr{eM JrerKoro B KpacnHft user. Y nonuponuruxon Ierxoe xreHo- Kopa mera nocre Cryptostroma corticale
6pu:urraanroB Moxer pa3Br,rBarbcrl :a6olenauue, cnx- BOrO L!Kypu-[.4Ka. XpaHeHt4t

3aHHoe c nogAericrspreM TflxeJIbIx MeraJ'LIIoB, Koropoe Ierxoe florocru np6urx PoqFusarium.

roxoxe na o6brlrrryro r,rHTepcrl/ruuanbHylo nHeBMoHLIIo, caxcoQouucra. EyxoBbrx PoA Penicillium.
oAHaKo npr{ naroMop@ororuvecKoM r,rccJre,uoBaH}rr{ r4HcrpyMeHroB PogCladospoium
BbrflBrfleTcg. nlraHToKjreroqHafl r,rHTepcTlIuI{arbHafl Er.tcc/Hos TexcrilruHaq Xlonox, reH, neHbKo-
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firporeuuurri (nanprarr,tep, nocJte oneparilBHoro BMeuarerb-
3a6onen alun nneBpbt crBa Ha rpy4Hofi MerKe ilrr 6noncnul lu6o noepexgeHue
creHxr rpyguorZ xlerxr
fheopur, rureBpzlJrbHbrfi nblnor, eMnlreMa n sa6o-
reBauus. rurcBpbl, cBfl3aHnHe c nosAeftcrnueu ac6ecra, sa6oresaHuirrerK[x u cBrr:au c 6olee ntrlcorori cuepr-
6ruu upe4craBJreHbl Bbrrlre. Hocrbro (pxc. 2.71).
Eclra ngauruocBfl 3b MexIy AbrxareJrbHbrMpr [yr.sMrl
Ir nneBpiurbnorl uolocrblo npra cflag.eHrvr rerKoro
rrcqe3aeT u He nofBnfleTcg BHOBb, TO [HeBMOTOpaKC
flnenuoropaKc H:tflrrqtre BosAyxa rurenpalruoft
-
IIOJrOCTr,I, KOTOpOe MOXeT BO3HI,IKHyrr
B o6o3Haqaercq KaK 3aKpbrruft (puc. 2.12. A). Cpegnee
BHe3anso rur6o AaBneHr.re B nneBpiurbHorl uolocru ocTaeTcq oTpr.{_
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soft cresxra (ra6l. 2.90). flepnuuuuft cnonranHrrfi cKoJrbKlrx g.wefi wtu HeAerb, a uHQexqzu [p]r .qaH-
[HeBMOTOpaKC BO3HI,IKaeT y [au]IeHTOB, He UMeIOtqUX HoM cocro{nuu 6rrsarcT Heqacro. flepeuuclenuue
B aHaMHe3e sa6oresaHr4lU JrerKl,rx. Kypenre, sHcoKr,IIt xapaKTepucTuKlr He coB[aAaIoT C nporIBneHI{rrMII
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y narlrreHToB c Hitr[qtreM paHee flpeArrrecTByrouxx AepeBoM r,r nneBpiurbuorl uonocrrrc (pnc. 2.72, B).
flpuuepou [ocneAHero c-rryxrar 6ponxon neapalursrrt
a
s
400 cBrrrq, xoropur7 Moxer crroco6crnonarr paclpocrpa-
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0 10 20 30 40 50 60 70 80 90
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3aqun B cBe3r4 c nHeBMoropaKcou e 6onunuqu Benuro6pura_
rrHeBMoropaxcou. B ruenpa.nrnorl rroJrocrr,r flocrerreH-
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nepBuqHoro cnoH_
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Ho HaKarurllBaercq 6omlxoe KoJII{qecrBo Bo3Ayxa, .qaB-
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uuog 4orcenurudeeuu eened goHHersurctradu srcoHxorolosrlrodu g
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rource r4rsr-rsuedeeuu rlNr-rHodo.r.cor-rUo ccre
-phen-Lo xrqdorov I 'eorHeilheu xrquilxou ,{ ercedeoe ruogou
-ueuQ r,tocxedoror'rseHu I lu[ir[ogeH c soJHeulrerr A
E qrBhollycrr oHsrDre u AYva e qrenil euJece -Le,iueuc A1
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acilvpa\kru HaMHoro HI{xe, n rt},r o6rr.ruo rpe6yercr
flepnuuurul nHeBMoropaKc, rrpu roropou xparl ycraHoBKa rpy6xu uexpe6epuoro ApeHaxa vr r,a-
JrerKoro Jrexur Ha paccrosHr.rlr MeHee 2 cu or rpyl-
gofi creurra u naur{eHT He r{crrblTblBaer oAbIIrrKr{, 6rrcresue B ycnoBuqx craulroHapa, oco6euuo nr{uaM
craprle 50 ler c AbrxareJrbHofi ueAocraroqHocrbro.
o6uqno paspe[raercs 6es nN4eurareJrbcrB. Y uono.(rrx
flpu nanpxxeHHoM nHeBMoropaKce HeMe.ureHHoe
raul{eHToB c yMepeHHhlu u 6olruurM crroHTaHHbIM
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rroJrocrb Moxer.qaBarb nperraeHnrul sQ$exr r4 Bo3-
xopouo nepeHocuMyro zubrepHarr{By ycrauonxe rpy6-
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K]IETKLI.
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O.uraxo nropuunru7 rrHeBMoropaKc y [aur{eHToB co
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Cueuleune cpegouetua u/unu I
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npouu$oprvll,IpoBarb r4x o pr{cKax Bo3Hr,rKHoBeHr,rrr rro-
Puc.2.73. fleqeHrae cnoHraHHoro nHeBMoropaKca. (1) [o ycra-
BTopHoro rlHeBMoropa xca. 3assru s.4aft nraurou rocle
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- f.rIo6arbHtul IrHLIqlIar[Ba rro 6pouxu-
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chrcnic Obstructive Lung Disease
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cr,rHoBr,rre II rpyrl{x Bocniull{TeJlsnrrx sa6oreBaHusx
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crpl4pyer o6r.uupHoe ycuneHfie, coorBercrByror.qee cuHoBury
(6enure o6racrr4, orMeqeHHure crpenxofi) o6oilx sanqcrufi,
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uexQaraxroabrx cycraBoB npaeoil pyxu. (14s nuHHoro apxuBa
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AInAPATA
Ta6auqa 3.5, Cocronuur, BbrflBneeMbre c noMolqblo
a Ocreouexpos
a FarororrR r,4exno3BoHKoBoro AilcKa
t VqermeHre HepBHoro KopeuKa
a Kovnpeccnn cnilHHoro Mogra
a CreHog cnilHHo[,4o3roBoTo KaHana
a Cencrc
a KoranrexcxurrZ penaoralururri 6oreaoil cr4HApoM
a 3roxa,{ecraeHHoe sa6oneaaHile
a llepeloraur
a llarororilq MeHilcKa
a CilHoeilr
t Caxporreur u oHTe3r4Tbr
a Bocnaarreluuri H,tuogur
a Paepure epaqareluuoti r,rarxerur, 6ypcrr u reHocr,lHoBrlr
.IIJIS nO.UaBJ'reHI{g CI{rHaJIa OT XI{pa, TaKI{e KaK KOpOTKaJ
IIOCJIeAOBaTeJIbHOCTb <<I,IHBepCI4rI-BOCCTaHOBIeHUe)
c KoporKrrM BpeMeHeM r,rHBepclru (TI) (Short Tat
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oueHKe BocrrzL'rlrTeJrbHoro 3a6on eBaHVs.. Koxrpacr
HbIe flpenaparbr, Hanp]rMep raAonrrH]rfi, lroryr npn
MeHflTbCg Anf rroBbrrxeHu_f, qyBcTBr{TeJrbHocTu IIpr
o6Hapyz<euuu eposurl lr cr.rHoBr.rroB.
I Ynurpaseyroeoe uccnefloeaxre
Y3I4 uoxer npvMewffbcrB AuarHocrr{Ke cr.rHoB}rri
qe cKoft noK€urvaar\vu rrcpytapTr{Kynfl pHbx nopaxe uurT
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npu BHyTprrcycTaBHbrx LrHBeKuusx noA KoHrponen
y3I4. y3I4 o6,raAaer 6onrurerl qyBcrBlrreJrbHocrbro
r pauueri AHarHocrlIKe cI{HoB}ITa tto cpaBHeHulo I
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lleHue vycvrneHl,1le KpoBoToKa B cllHoBpruurbHoft 060
peXI{Me SHepreTUrIeCKOIO,(OIIIJIepOBCKO|(
JIOTIKU B
KapTr{poBaHuf (onuuf, AocTyrrHarr s 6orslIluHcrnr
coBpeMeHHbrx yJrbrpa3ByKoBbrx ail[aparor) (puc. 3.8)
KounuprepHa, roMorpa$Hs
KT ucno-nrsyercx nu6opoirHo npu uccJreAoBaHrrr
lauueHToB c sa6o.nenaHra.f,ruu xocrerl lr cycraaon. K!
Moxer I{clloJlb3oBarbc.f, , KorAa Heo6xoAunro onpeAe
Jrrrrb crpoeHue cKeJrera, flprr oueHKe xanrqu@uqupo
BaHHbrx nopaxenurl (crEHgpou xopoHoBaHHoro sy6a)
xorua MPT nporlmonoKa3aHo, rrJrrr rrpu o6creAosaH[l
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o6xoApttr,t AJI-fl MoHtIropI{Hra rpu repaflrfii EMAPII t't

Axanugur KpoBt4
I O6qufi aHarr3 KpoBlt
I[pu nocnarurerbHblx peBMarI,rlIecKI,D(
flx qacro Bcrperralorcrl rr3MeHeHr{rl s o6qel,I ar:.anu3e
necneuu$u're-
KpoBr,I, Koropble, KaK npaBl4Jro, Hocqr
cxrafi xapaxrep. flpuuepbl BKrloqalor ueftrpo@ramlrc
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creft, n roM qI4cJIe lpu 6olesHu lle4xera, uoqe'IHofi
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xapaKTepHarl KapTLrHa, KoTopas [oMoraeT IIocraBI{Tb
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ercfl KoHIIeHTpauI{fl Irao.Iesofi KI{cJIorbI B cblBoporKe,
o.rIHaKo HopMzL'IbHag KOHIIeHTpaUI4-,I He rrcKllloqaer
ll,IarHo3a, oco6enno so BpeMrI ocrporo [placryla, KorAa
KoHueH'rpauuq yparoB BpeMeHHo cHl{xaercrl. Toqno
TaK xe [oBbllreHHoe co,{epxaHr{e N,Io'renofi KI'IcJIorbI

I{ KJIIIHI{qECKU 3HAIII,IMbIM IP}I3HAKOM AKT?IBHbIX BOC-
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peBMarur{ecKl{e npelaparbl (EMAPII), ltlu 6astlcnrre
npenaparbr, Moryr oKa3blBarb roKcuqecxoe nosAeft-
crBr{e Ha Koctttltfi Mo3t, noSToMy rlpllt l{x [pI,IMeHeHI'II4
seo6xoAntnl peryl-apHufi uoHlrroplrHr o6uero analraga
KpoBr{. flpu o6cne.uoBaHr{I,I no roBoAy peBMarI{lIecKI'Ix
:a6oresaHull [oJIe3HbI AorIoJrHI4TeJIbHbIe recrbl, Ko-
ropbre BKrloqalor upruofi anruuo6yluttoslril lect
(npxrr.ryro peaKIII4Io Kyu6ca), xoroplrtl Moxer yKa-
3brBarb Ha BHyrpllcocyAucruti reMoJIlI3 npu CKB, u
TecT c r{cno,lb3oBaHl{eM pa3Be.ueHHoro sna qero'rHol?
ra,uroKlr (ulu raAmu Paccela. Ilpuuea. ped.),atax-
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xe OFrxuuoHuulbHoe IrccJIe.IIoBaHue Ha no.['IaHo'rHrrll
B cbrBoporKe caMo no ce6e He flo3Bollrler rlocraBl4Tb
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cleu[6u.rn],I, qeM COO. I,Icr,uoqeHl4e cocraBJrflIor
ayror4MMyHHrre :a6oresaHu.f, coq5uH[Tenurofi TKaHU
(Hanpuuep, CKB u CCA), npu o6ocrpeHl4r{ Koropblx
gToM
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He Ha aKTlIBHocrb ocHoBnoro sa6oreBaHvtfl, ar^avH-
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celcuca. OueHxa aKTlIBHocrI,I rpearun$ocSornuasst
B cbrBoporKe uelecoo6pasHa B Ar'IarHocrI4Ke Muorlarlrl
yrJtv v.uo3vr4 Ho cuerluQurrHocrb u qyBcrBureJlbHocrb
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aHTr4KOaryISHT. cvrryawrflx ('ra6"u. 3. 7).

I Sroxl,turqecxufi aHanrs xpoer I l4uruyxonorrqecrue uccneAoeaxffi

Pyru H u rul 6 floxuNlu.{ e cxuit artattu3 KpoBIl rlo - B AuarnocruKe peBMarl{qecrux sa6or esaHuil lru.u-
Ka3aH npl{ uera6o.luaqecxrax sa6oleBaHl,Irlx rocrnoft poKo l{clonb3}'Iorc.[ uccJle.uoBaHl4fl Ha a]'TOaHTVTera.
TKaHr{, N,tlture.rHoll lraroJroful4, noAarPe, a raICKe He- Pe:y.ltrarrr mo6oro recra cJleAyer L{Hrepnperl{poBarb

Ta6nur{a 3.6. Tnnraquure 6uoxnuuqecxue Hapyuet[e (e cuteoporre xpoara) npra pa3nlqxux ea6oneeaxusx onopHo-
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Kaaur{r,lfi OocSarur lJ{O nTf OPO23 25(OH)D

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OcreovarRqnrnpn[e$rar-lrareBuraM,4HaD NranraJ NrnraJ 1 t1 NranraJ .tJ

N .f., t N raru 1 tt N ranra J

Iepeuvrurri n4nepnaparilpeo3 trlt Nranal Nranrat t1 Nranr,rt Nranr,rl

flpruesanun, N HopMa; oAHa cTpenKa noBbtuleHue ufl4 cHuxeHue; ABe cTpenKu BblpEDKeHHoe noBbluJeHue nnu
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g[1 u,,vtcHeetc,iceue u u',levLree'{ c vd (qHilre_Lc,r4rcoHrcehr**;ffi
^rr*.uesodu fi JJTlX'firJi:ffi :;u:
o/o'Uw1evsv ura$odrcuU uEHhoffile[\ r
o
-rqs ErorcPh ruulvcee + rueou!\ {lgHeuouuBuco6
' ^" "'^a^^ ol4Hcorcog
4rexuraorewsad ccra :."'rsffi fi :lI
ltdu 'uuugorco3 'g'g ehuugel
*"*"**XL."X1"":H"""'l?'#1"'f
-Buatslqs xlqdorov
udu tst4HvEotrJrocu
r e0 . vrvdvuuv ojoHq ulrvJnsu-oHdouo xcHHvsauogve
-;;eQ
332 . PEBMATO'IOTUR }1 3A6O'IEBAHI49 ONOPHO-ABUTATENbHOTO ANNAPATA

Ta6nuqa 3.9. Cocrocxun, npu Koropblx BbleBrlnlor Cocrocrnt, accoql4rpoBaHHble c

Ta6nrar{a 3.10.
R aHTnHyKneapHule aHttaTena* i Hanxq}leM aHr]rTen K oKcTparulpyeMoMy sAepHoMy
aHTXreHy
Cocrosxue BePonruan uacro-
(unuext/ Accotlunpoearxue
ta eutngnexur, % Arrnrena
100
HasBaH[e) ga6oaeaaxur
CKB
Anrrrera K qeHrpoMepaM floxartasoeaHHaq xoxnar Qopt,la
CCA 60-80 CC! (vyecrer,rreflbHocrb 600/o,
cneqra$nrnoctu 9B%)
-
Crangpov LJJerpeua 40-70 -
norilMr1o3t4T 30-80 Anrrrem K rilcroHy flexapcreeHuo-t4HAytll4poBaHH€le
,[epvarolarosur t4lil KpacHae eonvaHra (80%)
CueuaxHure ga6oreeaHrc 100
Anlrrena x Jo-1 l-lolrlallogur, ,[M mn
coegilH[renbHoil txaau
(nacl,t4ur-rPHK- norili,4t403l,'1T nepeKpecrHa,
-(20-300/"),
AyrourvvynHuttT Tenarrlr 100 cururerasa) QoPua CC!
accotll,414poBaHHble c l/1HTepcTl.4l-lt1-
PA 30-50 arbHblvt ga6oregaHLaeM rerxilx
Ayrouuuynaoesa6oresaHheqrroergnoil 3G'50 AHrarera x La (arrrrena x Cr,rngpov Lllerpexa (60%).
xene3br ss-B) cKB (20-60%)
Kone6rerccauJ,4-
3roxaqecraeFlFluterioaoo6pasoeatrn
poKoN/ Ailana30He
AHrurelax Claeu.lanuoeaa6olleBaHile
pr,r6oHyxaeonporeuny coeAilHhrerbHofirxauu(100%).
lzln$er<qraouuute ga6oreeaH[aq Kole6lercs e ur- (airnr-BNP) CKB (25-50%), o6utqHo e
poKoM EilanaSoHe coqeraHilil c arrurelauu x Sm

t AHA e HusKoM rrrrpe Moryr Bcrpeqarbcq y rogefi, xe AHrrrera x Ro (anrrrera x CKB (35-60%), cBF3aHO c
ilMeoqhx ayrouMMyHHbtx ga6oneeaxuil, 6eg sexutx Krlt4xl,l- SS-A) QorovYacrenrerlbHocrbro,
qecKux nocneAcreuil, oco6erHo B noxurloM Bo3pacre. rpou6oquroneHrei ra nogocrpoil
xoxnoil eonqaHxoli.
Anrurela r eKcrpafl.IpyeMoMy flAepHoMy aHTlrreHy Aururera x Ro y laarePu cBR3aHbt
c pa3BklTrleM HeosaraluHotT
(OHA/ENA-cKpLIH) elue oAHH MeroA AuarHocrl4-
- BorgaHKL4 r,r epoxgeHuotTt
Klr ayTor{MMyHHbIx 3a6oleBaHufi coeAunurenbHoli 6roxagofi cepAqa.
TKAHI'I, B TOM qT{CJIE HEKOTOPbIX OCIOXUEXUfi CKB, Cranlpora IJJerpena (40-80%)
oAHaKO rIyBCTBrrTeJrbHOCTb rI CllequouqHocTb MeTo.[a
Asrrrera x lra$$YsHar CC.[ (15%)
Hr,r3Kre (ra6,r. 3.10). Hanpuuep, ralare MapKepbl, KaK PHK-norruepase
aHrrrreJra x Sm-anrureuy [aurureuy Cuura (Smith)],
Asrrrera x Sm-aHrureny CKB (1ffi0%), cBflsaHo c
KOTOpbre rralqe accoufiflpylorcrl c [opaxeHl4eM IIoqeK,
sa6oneeaHuei,i noqex
o6uapyxranalorcrl y MeHbIIrI,IHcrBa nauueHTos c CKB.
Anrurena K Ro-aHTLIreHy, BbIflBJIfleMbIe rrpu CKB t't Arrrrera x Scl-70 ,QraSQysnan CCA (15%),
accoqu4upoBaHHaR c 6olee
cr,rHApoMe lllerpena (n coueraurau c aHrvrenaMr{ K Tfl XeIbrM nopaKeHileM opraHoB,
la-axrureny), uoryr nonnuarbcf, y naqueHron c $oro- BrntoLraq rerogxuui Qr6poa
qyBcrBurenbnoft roxnoft cblrlblo I{ np}I raKoM peAKoM
sa6oresaHr,r[, KaK BpoxqeHHa.fi 6roxara cepAlra. AHTI'I- pr-muxonporenuy 1 (prGf t ;. Ouu tuoryr nprcyrcrBo-
rela x pu6orryrueolporel{Hy Bcrpeqalorcrl npu CKB, a Barb npl{ CKB u apyrux ayroLrMMyHHbIx 3a6oneBaHuqx
TaroKe rrprr cMeruannlx sa6oJIeBaHI,IrD( coeAururrelrHoft C OC.IIHIITEJIbHOI1 TKAHI{ I{'IBJIfl IOTC'I KIIOIIC BbIM H B

TKaHlr, KOrAa COCyXIeCTByIOT [pUSUaxU cKB, MI{O3I{Ta A[arHocrr,rKe aHTuoocoonuru.{Horo cI{HApoMa.

u CCA. Aururera K rorlol,I3oMepase (rarcre Ha3bI-I
saelroft Scl-70) Bcrpeqalorcrl upu 4aQQysHott Sopue
CCA, rorAa KaK aHTuueHTpoMepHbIe anrure.na 6olee
cneuu0uqsrt An-f, .[oKiulu3osaHHoii Oopuu CCA.
Awu$ocQonunnAH*e aHTurefla
Arrru6oc6oJrr{nl,IAHble cBrI3bIBaIorc{ c
aHTI,ITeJIa
prr.{oM @ocSonrauugcBf,3brBalouux 6elxon, Ho HaI'I-
6onee zurunuilecKu 3HarrI,IMbIMu rIBJIrIIorc-fl aHTI{TeJIa K
Axruxeilrpo$rnbHbe
uxronna3MaTut{ecKle aHT[Tera
AHruneftrpoQl{JrbHble IIIrroIUra3MarI{qecK}Ie aHTHTe-
Jra (AHUA) npe.ucraBJrllor co6oIl ayroaHrllreJla KJIacca
IgG x rounoHeHraM uHTorrJIa3MbI netirpoQulor, lrc-
nonb3yroTcf B AuarHocTI{Ke u MoHuTopI,IHre cl4creM-
Hbrx BacKynl{ron. flpu uuuyuo$lyopecueHrHoM aHa-
JII{3e BbUIeJTflIOT ABa OCHOBHbIX TI,Ina CSe'reHI'Is AHUA:
EJJanodu IrrJoHdeIIoHoxB€'trI,IHegeIIog€0 €oHNBHB
ror?tr /(€oHJuHV eerogu€H x hoIL){
^woHrrodos
xrqHHeu xuvcohl4Ht4n elHoho
'l I'€ 'lf93r s IqH€0€)d IiIHLIhud[ OISHXOI^I0OS
erlr,(d[' (VUO1) rudrde 4tuoehl{reroutru I^{IqHsruH
-aaor gnndrtrr{xurdeoruro }I yuf, 'rudlde 4l,rxcohl4r
-uac'rudrd e Ur>r)ehlavrercudx rcrolrrsr erudrde
-oHor r orodrco uwer.ur.udu prnlslHxes eelroql{BH
lildrduoHotA Utqdrcg
EIPdEUUU OIOHq UOIEI t4SU
-oHdouo [ilHesouogue uilHausBodU
'goIrJLI HfImIsY{
gonnexudou orrlnru,(v{urc €H rosro s I^{uH€ger
-o) xrqHrsrosoxoclqs IiIU,fucLIdu r3el{morydoraoll .
iwta;cqe[ solruuIlHerou xrsHHenledsoxludx
c)errrrwo) IirlHHesoeuHurdoen 4rsuQdortnrou.
i(errxoroa oron
-homrqw runelnedxoc) wtnYmmdguQ renueruouc .
:ef,eudt rBxcehl{JcoHJELItr rcro
-rrfsltgs xrsdoJ,ox udu '€luooun oJoHlIIIeJLIIrBuSos u
IeuJ€Iroutredu r(trosou ou ul,IHusotrorcgo
vrvr:,;arJovtN UoI
udu qrcosuefi rerlrsurctredu wrQefuouluofuxeIr6
u14SEdJo14r^roduoue
'unttudeuo 4or,ndx
-ro otrox g pltrl{ nierodJ,Ho) htl,DIcehurolronellned trou
exrcer.r( oronnexedou sI4 srutrosodfl reftrerc olllcuollg
xrr,rnexudou xlilsoJBho udg'uuleeLIIrBdaHI,Iv[aE 0e9
rorearsregedgo II IlelleeJceHu IltoHrcew ['ou (ltlt 3) ud.t
-ow€utr oJom<Ilfog IqUJI{ olqlTlowolI c l{rcox goHmoVEs
-for rugadr su r,{dag I,IHe)r naeedg6 'llunrll"I^[oeJco
ID{urcoHJEr{[ xlrlrefl s o)Ved rcru[osodu I{HE)I 4oH
-rro) tr{Juolrg'elaHesosedgooaon ooHHearcehe)oro
urrur ccotrodu glilHilrewlreucos- oHHoutrxe@nu grxc
-ar,unodx en rElilredeo[ou radu 'ulr@ofucutroerco 4ou
-hehou'soccefiodrr xIsHsl{refusm{Qnu exlrucoxreratr a
'dolurdueu' LlnlqHsurel^tdoQuuen rcroleslq0B)o IqrceJ
alqHslltusHueH €trJo) 'xrBr.rfttc xer s oH€o€)ott I,IH€)J
HoHf,co) ll1ll1lxuor g euHevosodll 'vttrxrtovg elsHdorsou
rol,(ecroucH eftoHu oI,IHehoIr BH I {orosro ue Krofunox
rLI''xrrlHusetrog€0 xlilHhemrsw-oHgdaH I,I xlilHhemlqn
rrqftrrdors H xsHr,usdeu o oruneltdoQuu teeY ewudat"
-eN oloHrjrt3uoHg weuHuso[offccu v'tIDIc0hr,LIo[orcrLI c
HTIHeLJhoJ s arnesumedxo eo)oahl,Inrxorcruon&rtrl7
'12 ;q rorieu.-ouJr,r HLrJUolIg rL'E eroel^l oremr.rftruen
0E€ . vrvdvLtw oJoHqr3rvJhsu-oHdouo t4l,lHvs3uogve
runenr.ou( nrtr BtrJoHI,l 'atrodudu 4aosc ou (lttsuorzm
ulrl,r) luslcururu qrrsg rexow .rlreoulu r(xquoxcoll 'E*
-erceH€ goHrcer I Vou l,rxo) esdesd 4omsrogen eadr
I rfdeg r<rImIsW 4oHtrfisoJqretr uru {tos€IilxedrsJ,r
rteeedgo onnrsgo 'v{oJI{oolII I NrlHqreruItzucos H [08
-BrroI,IH , gorHoI,IfIB[ I,Il{H€sotrercgo udu srod otdlxg
raefuu ttmlsv{ Bl,Icloug 'Ilmlqv'l u ioholr 'nrrrna-t-
uIrI,I lDIroIrJocoH IlDlholrogo 4oJcI'I0I{rc'xl,t)Jer'IDxcE
'dewuduen :geHsxl )ilqHHoxedou rl,Icuol4g eI U{trOxggf,
eJ,[rr{xces oJoHI{orJ[c u€oHJ?lI[ rI,IHetrXdeSfiOU rff'
'0oHJeI,Itr re€hoIIDIcI,I eH r,ersur(eed grlHqrerBnl,Idrc cn
-BHVo' Bsr,ltul,lle el,:.utdex vetcohI,IHI4ID{ Bff ox'lcruhff,?
xeJ s oHHogoco 'luudoJfr 4rsxr,ocng ex rlragedeoEfl
radu rcrerrutouns Ll[derde UroHhocus wlctloug 'IrE
-ercaH€ UtoHrcex[ wol,IH€sooqffoucu c lrlerod,rHox llatr
-oxr(seedJsrr( You. vtril (euoxcodlde oJor€hqroJu IiII
soJ,HendfucHl,I xlqHhlqgo olqrflonou c) uuuoxcodri
udu senftrou quilg Joxow lrtrexl lftedgg 'I.{urDIeOil
4onureude,rxego)I4x['l,tlJoHlcet' g'BccofiodlI oJoHqI:[
-ril?ucos - oHHoI,ITHoQHI,I oJoxcehl,IHodx ruserrourxr
)ffrffefi s )ohorogo xrlHqr"usoHl,Ic rucuol,Ig qrEV rex(x
orr4rrur{doQHu oldsneretroduo ('pad 'nawnd11 - 'xor
-I,IHI.rtrHor) noJusoH[coHar I{IM l^torufudeoson }iit'IE
-qrerrrrulrcoa rupD{Sehl,IHodx c gorHel,Itl€u Btrrd A
'
goHBxr Yvtxuoug rrrerHlro[rr
€0oHJuuV rl.IHe['xdesrtrott rJlfr etedeuua oJoHqr€ra'I
-us['-oHdouo xruHpserog€€ xlqHHoretredlIo udII
'ruHereucos tlnexeHel,tdu uwrrxcanuQurlerrrs
Y)Lo{BTI'IV PIHEWOI.rIINO, I,IUIBSI,IDU I{IIOIST€XOU AFIII
-srrcHor,Irr>tu,tQ u gC PrHeI lolnlnox sneeo&( 4nrocng
'g)3 r{rcoHs[rxB I4uHemoHJO g Uer,uQufieuc eeHett
iJ uJHaruelfilntox sHesodz( 4ID€IIH '(y'7'cttd'nc) tm
-ecxelruNo, nvtrsHHdnlmu eJHenelrunox rl,lHgslqers:t
eusJc[ercs gXJ I,IJcoHsI{J)u 4o)oclqs wereressl
-ou rcrerrrsr €J BJHexleruno) sHesod( 4]DIEHH
rHereuufloy I
'aeodgttQ woHhoJolr tI g)f, 'y4 'uxuxnomtil
xnlH€serogs€ )trqHqraJI,IIISucoa'(6149 ltn4 I,IurDIaQHIr
gonsreuderxeg) xrurrxoQHl,I'xruH€so€edgooaon :aur
-HesJcoh?xolr€'uHoheu xrl{HuserogBo xIsHHrttr{uo.Iie
udu rcqre[orrgen rdrort rsrulsr.(eed elqHqrorlDKouou
'souarrl(xcus I,tuHemoHro u ttwltnnuSulrouc rorolruu
oH BrrorlrrH€
ur6 '(eeulcure lr flrlrddeQoorcr'deluudu
-en) ruexreg ltrrfd[ u ooetrLlc)odouolral,In ) Irer]lrl{B
4ox.r,ogedna c (VfIHv-u) uur gnudeerx,{rurdau x
'(gUa) g oeenlrelodu x IreJI{rHP 4oxlogedrsa 4rux
-ueraorcfgo' (V[1HV-[) uur 4I,DIcoh]IrBI^[EeIflroJr{n
B14Hf usBodu
334 . PEBMATOflOTU9 14 3AEOTIEBAHMf, onoPHo-ABHTATETIbHOTO AnnAPATA

I hccnegoBaHue
i Ta6nraqa 3.11. llpuvuuul ocrporo MoHoaprpura
B clyrae ocrpo Bo3HpIKIIrero MoHoaprpllra He-
9acrure o6xoAuuu noceB KpoBI,I v aclrupawIfl cllHoBllrulbHofi
. lloAarpa xlrAKocTlr u3 nopilxeHHoro cycTaBa c MuKpocKorlllefi
. FceeAonoAarpa ' CnA
Ma3Ka, oKpalIreHHoro no lpauy, a ralol(e B nonrplr3o-
' [lcA
r TpaBMa ' PearrileHuti aprpilr BaHHoM cBere Ans o6napyxeHlas KpHcr€IJLIIoB Moqe-
. l-eMaprpoo ' eHreponar/eecxri aprpur soft Kr,rcrorrr urvt Kurbwte.nnpo@ocQara rvffilIpara.
Menee qacrute
flpn nogospenvlt Ha cerlrllqecKllfi aprpnr KpyrIHbIx
cycTaBoB peKoMeHAyeTcrI apTpocKonuqecKoe npo-
.PA 'TE MbIBAHI{C.
. lOtzlA . Ieixos"
. FunaeHrHuril BilnnoHoAy- Yponnu CPE u COg nosHuralorctr nplr cenrl'Iqe-
'. Fouoxoxxosar raHOexqrn cKoM, KpI'ICTUUUII{qeCKOM I'I peaKII{BHOM apTp}ITe, lI ]IX
lrpHurri cuuoerr Ocreovrelur*
. ly'HopoAuoe relo onpeAeneHr.Ie uoxer 6urp qelecoo6pasHo.ur.fi oueHKI'I

. Y gerefr refixog e@@errunnocrx npoBo.4uuoft repanuu. Co4epxaure

ocreoMuenur Morfr npotBrlnTbce
t4
MOHOapTpr4ToM.
BoBIeqeHurI B BocflaJrprrenbHbrri npoqecc Apyr]rx
cycTaBoB, cKopocTb pa3BvtTvtfl ct{MrlroMoB, BO3paCT
lr rroJr flaUr{eHra. floAarpa qaue nopaxaer nepBbIIZ
rrnrocHeoanaHroBblll (II(D) cycraB, B ro BpeMrI KaK
lceBAorloAarpa, Koropas MoxeT 6rrtr xapaxrepHblM
lpr43HaKoM 6Olegxlr orJroxeHrls KpllcrannoB AI'I-
rr{ApaTa n[pooocoaTa Krulbul4q, MoxeT rlopaxaTb
cycTaBbr pyK/3aucTbe, roJleHocronHbIIz, KoJreHHbIft
r4nr,r ra3o6eApeuurtft cycraBbl. O'IeHl 6rrcrpoe Ha-
.Iano (6-12 q) nanoAnr Ha MbIcJIb o KpI'IcrzuuII'Iqe-
cKoM apTpI{Te, cerrrl4qecxufi aprpuT pa3BI'IBaeTCS
MelJreHHee r,r npoAonxaer rlporpeccllpoBarb IIplI
orcyrcrBllll r eq eHllf . f e rr,raprp os,
Bcne.ucrBr{e rpaBMbI, O6bI.{HO npof Br.gerc.f,
rrrr,rM BHyTpI{CyCTaBHbIM BbIIOTOM npI,I OTCyTCTBI{I{
fl eplrapTpIKyJIrIpHOrO OTeKa r{JII{ I,I3MeHeHI{I1 KOXHOTO
noKpoBa HaA nopaxeHHblM CyCTaBOM. flUrUeUrurtft
Br{nnoHoAyrxpuruT cI{HoBI,IT TaKXe fIporIBJIrIeTCrI
oreKoM clrHoBrra-nbHoft o60ro'rru r.r
IIOTOM, HO pa3BI,IBaercrI rocrerleHHo. PeaKTuBHbIfi
aprpr.rr B 6onbluuHcrBe cJlyqaeB accouuupyercrl c
Kr4rrrerrHofi unr{ ypofeHl,Ira;rrnotl uHoeruueft , Tor.ua
KaK IrHTepKyppeHTHbIe ga6olenaHra-f,, o6e3BoxuBa-
}JI,e I4ILLI XupypruqecKoe BMeIIraTeJIbcrBo qBlrflioT c fl
Tp rr rre p aM Ir p a3Bll.tkr fl, M I.{ Kp O Kp lI C Tarrl u q e c Ko ro
aprpr,rra. PA pe4xo [porlBnsercs flopaxeHueM o.llHo-
ro cycraBa, B To BpeMs xar fIcA'raue re6rcrupyer
K;rr{Hr{qecKoft xapruuoft MoHoaprpI,ITa. Ocreoaprpur
ryrorloABt{xHocrblo
Moxer rporrBrrlTbcs 6omlo I,r
oAHoro cycraBa, Ho pa3Bl,IBaerc.f, uocrelenHo.
3HAKI,I BOCNZUI'ITEJIbHOTO OTEKA CYCTABA, KAK IIPABI{JIO,
oTcyrcrByloT, 3a I,ICKJTIOqeHUeM TeX CnyqaeB, KorAa
apTpr.rr ocroxHseTc fl. KpvcTannlrHAyul4pOBaHHbIM
BOCIIAJlEHI,IEM.
Naoqesoli KI{cJIorbI B cblBoporKe Moxer 6lrrl uosu-
rrreHo npfi noAarpe, Ho HopMiulbnsItZ yponeub He I'Ic-
KJlroqaer Ar{arHo3. flpra na.nr,rvul4 lrceBAonoAarpbl He-
o6xoAuuo ucKIIIoqI4Tb nepnu.ruu[runepflaparllpeo3.
I Ileqexne
flpu nogosp er^vlyt Ha celcllc cneAyer He3aMeAnI'I -
reJrbHo (4o nolylennq pe3yrbraroB rroceBa) Haqarb
n/r nnegeuue artru6uoruror (clr. ra6l' 3.50). BHy-
TplrcycTaBHafl I,IH6eKUU' rnIoKoKopTI4KOlIAOB MOXeT
paccMarpllBarbcfl cflycrq 48 v nplt ycnoBl,Iu orpllua-
TeJrbHoro noceBa cl,IHoBuiurbHoft xurxocru. Ecttu y
IaIII{eHTa UMeercfl BblcoKaf, Bepo.flTHOCrr arrlnra'IHofi
nnQexuunflB, vro rpe6yer g.ltl{renbHoro I4JI}I cneq[-
p cr
a3BI{BIIrIftft zulbHoro KynbTI,IBI,IpOBaHnfl, To B TaKI4X CI{TyaUx,{X
6orl- flrroKoKoprl4Kollrbl npuMeHflrbcfl He AoJIxHbI' B npo-
TIBHOM Cry{ae reqeHl,Ie AoJDKHO 6rnr nanparaeHo Ha
ycrpaHeHl4e ocHoBHoft nplrvuHbl.
60lHuuM BbI-
Oror repunn lrcnonmyercfl. Mfl otrvcaHlafl Bocla-
Jrr{TeJrbHoro npoqecca, flopilKaloItlero nstr r'uu 6olee
cycTaBoB I4III'I CyCTaBHbD( rpynu. Bosuox<nble np[lII{HbI
leperrr4creHu n ra6,r. 3.12.
I Kn[x[,{ecraq xapruxa
OrnraqurenrHblMl{ npI,I3HaKaMIl BocrraJlureJlbHoro
apTpr{Ta sBJrflioTcfl yTpeHHSfl CKOBaHHOCTb U l/XyA-
IIIEHI,IC CI'IMIITOMOB rrpra OTCYTCTB}III ABI'ITATEITTTOft
aKTLIBHOCTI,I, a TaIOKe OTeK CI,IHOBIIa-nrnofi o6oIo'{KI',I
flpu- ra 6onegnennocrb [pu nzlJlbnau[u. BrrqBreHI'Ie Klu-
HuqecKlrx upoauenuft co cropoHbl Apyrux opraHoB
u cr,rcTeM MoxeT noMoqb B AuarHocTuKe cycTaBHoro
3. 13). Ha[6oree sa)GIbIM]r Ho3oJIoruI-
cungpoua (ra6,r.
qecKlrMr{ Sopuauu, Koropble cne4yer paccMarp}IBarb
 'urudrde oJosoxxox
evb?doxur.r sevcor.ilrev.'leed auteuoualle$nuu
'V[4O{
-oJuofu cmox il (Ueretr .() VZOI oroHdrlrf)uJd€Llrox
fnHnalaac'uuhrc$u7 'exbbdoxuy
'(91 neuudrrodtroed o)odum etrl 'xeuouled u) orHoII
(4rereuruderc)
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336oPEBMATo,Iorhg}tSAEo,IEBAHI49onoPHo.ABurATEnbHoroAnnAPATA

puc. 3..10. 3axoHouepHocrh nopaKeHue cycraBoB npu pa3nhqHbtx Qopruax nonuaprpnra. A npu peBMaroilAHoM aprp[re
-
14 npoKcuMarbHbtx uexsalaHroBblx cycraBoB
pyK u nnoc-
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- pyK, 3Hre3ilcoB t4 KpynHblx cycraBoB' Bogtrloxen
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XeHIlte KpynHblx CyCTaBOB Ht{XHt{x rOne'IHoCreIi C I

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mr rocreft, ttpll ocreofleH]I[ ]r y HeKorlopbD( [aIPIeHToB

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338 . PEBMATOTIoTHfl u 3A6OrlEBAHi49 OnoPHO-ABUTATETIbHOTo AnnAPATA

I lle.rexne
i AonxHo 6urs nanpaBneHo Ha ycrpaHeHlle
JIe.reHIae
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. Tqxeraq ocreol/4ansqt1g

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340 . PEBMATOIOTI49 14 3AEOTEBAHTIq OflOPHO-ABHTATETIbHOTO AflnAPATA

Ta6nuqa 3.19. Tpeeoxxbre cr4mnroubr, yKa3brBap-
i qlre Ha Bo3Moxlryx, naTororurc no3BoHoqHl,tKa
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.uHJIOJrrrCTe3 MOXer BbI3bIBaTb 6Om A CrLrHe, KOTOpaS

ocra6eearor4an nocre orgbrxa o6rrvHo ycu,,ulBaercrl B rloJloxeHuu cros u npu xo.qr6e.

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nocneonepaulloHHoM rlepuo,{e Ha rro3BoHoqHr{Ke r{
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. llporpeccnpypltlile HeBponorr'lqecKL4e ctaMnro[,4bt / r,tutuieqHae BeluecrB Ha MacJrrHorl ocHoBe.
arpoQrn
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B clyuae ocrpoft 6oru s cllrHe BcJre.rlcrBr{e Mexa-
Ta6nnqa 3.20. KnunuqecKne npoeBrreHtlf, Kopeu-
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i xoaofi 6onu
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. flapecreouc c reM xe pacnpeAeneHr4eN/, qro Lr 6oreeofi ,IBUTb CTeHO3 CIr{HHOMO3TOBOTO KAr{AJIA, CAaBIIeHUe
cr/HApoN/ cII]rHHoro Mo3ra r,uru HepBHoro KopelrrKa, a raKxe
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orHgpova) peHTreHoJroruqecKue cHr{MKr,r uoryr 6rrrl noJIe3HbI y
. MoropHure, ceHcopHbre npil3HaKr ilrrv r,{3MeHeHLlfl peSrercoa
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Cungpou KoHcKoro xBocra Meracrarr{qecxoe sa6oreBaHpre cneAyer paccMorperb

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o r,rccJreAoBaHl4rl, Koropbre Moryr norpe6oaatlca, BKJITo-
ForepR ToHyca aHanbHoro cQnHrcrepa ilnLr HeIepxaHile Kana
r r{aror p},rr4Hurrft 6uoxul,r[.recxuft u o6wuit aHzLrrr{3br
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crrlrHe Lr aHturpr3 Ha npocraroclequQuvecrutti aHTI{reH
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rlyBcrBl4TenbHocru, raHure.{Horl cra6ocrbro v acvM- I fleqexne
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ce.rlanurlHoro r{Jrr{ 6eApeusoro HepBa uoryr 6urr Tu[a BaxHyro poJrb rrrpaer o6yreuue. C yuerolr ca-
loJroxr{reJrbHbrMrr. Ilpuuepuo y 70% laulreHroB Mopa3pelllanuleroc.f, xapaKTepa [pI{cTy[oB BaxHo
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342 . PEBMATOIOTUT U SAEOrlEBAHl4c OflOPHO-ABIrATEIbHOrO AnflAPATA

Ta6nuqa 3,22. O6uextuBHbre nptaanaKt,t, Bbtioltne- Ta6nrar{a 3.23. Ilpuvraxur 6oneeoro c}tnApoMa
i Mble npla 6onesoi, cl4HApoMe B nreqeBoM cycraoe B TOKTCBOM

llopaxeuue epaqarersxoi MaHxerbt lt cy6axpouuanuxutx Ipuvuxa 6onu flaxnure ocMorpa

crpyKryp
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- Oreegeuue: HaAocrHas MbruJqa (uanpuuep, TpaBMarilee- KOM.

- Bpaqeure Hapyxy: no4ocrHag Mbulqa, MaJtat Kpyrnag crufi loxoru reHHtacr/cra lz'lppaAilaqhq e 5oru, esrssaHHaF
MbruJtla ilru caqgaHFruri c CnA MbluJr"lbFpaS- conpoTt4BreHiler,4
- Bpaqenre BHfrpb: noponaroqHafl Mbrtt.tqa eureeur) rn6arcnu aKr!4BHOMy pa3ril-
npeAnneeb9 6aHrto sanscrun
Axporuualuxo-xnovnrxurfi cycrae
Meguarunuril onilKoHAr4- Meguarunurr,r 6ore3rennocr
Eoru npu norHoM orBegeHhil u npilBeAeHru (npn nogteue rilrnre,leaoil rocril SnilKOHEilnUT HaA HaAr/brqen-
pyxu enepeg Ha 90') (nanpruep, rpaBMar,lee- KOM.

Teuguxur geyrnaeoi MHUqbr (gnuxraa ronoexa) cxuil lororu rolu@rcr.a IrlppaAuaqnn 5oru, eurgeaHHaq
ilru cassaHHurfi c CnA B MbtLlJLlbt- conpoTilBneHreM
. EoresHeHHocru na.q uex6yroproeoti 6oposgofi nreqeeotl eHresur) crtt6atenn arrrenolay cru6a-
KOCTt4 npeAnneqbfl Ht4lo 3an9cTbt
r Eolu, BbBBaHHaq conporilBneHileM arrueHoi cynulau'nvi
3angcrbg ulu cru6anu0 rorrR Sypcrr lorreeoro floKreBofi 6oregHeHHuri
orpocrKa (Hanpuvep, oTpocToK
noAarpa, PA mr ruSex . OTEK

3a6oreeaHhe quouHurri, xax npu TE)

aKpoMualbHo-
KnrcgilqHOrO
cycraBa TlrKor,rloB r{ peryJurpHbrx MarITHrIKoBbIx }.IIpil{(treHLL
Nrs, Modwrn3arluu [rreqeBoro cycraBa. .II,.nx uomtor
Texgunur Bbr3AopoBJreHr{fl Moxer norpe6onarrcs, Ao 2 neT. IIp
geyrnaeofi T'IXEIOM TEqEHI'T}II,{.JIVI rIPIl HAJWIqVruI IOCTOflHHb]
Mbttutlbr
CI{MIITOMOB BO3MOXHO XLIpypIUqeCKOe IeqeHUe -
pacrrrxeHue cycTaBa pr MaHulynquuu IIoA HapKo3oM

I Eonu s noxreeoirr cycraee

Hau6olee paclpocrpaHeHHblMll [prFIrIHaMvI flBlrl
rorc.f, noBTopHbre rpaBMhr, Bbr3brBarorur{e JIarepiIrIbHbI
gnlrKoHAprJrr4r (:rorors reHHl{cl{cra) u lreAuamurt
onlrKoH.[r4Jrr{r (rorom ronl@ucra) (ra6,r. 3.23). Cnl
BKrIOqa.f, ncopplaTuqecKoe nopaxeHl{e, Moryr I{Me'l
cxo.rlHbre cuMrrroMbr (cyxoxulrHufi suresur). Jlevt
HLIe 3al[rcqaeTcfl B CO6nrcAeHI'IU peXUMa IIOKO.f,, npl
MEHEHI4}I AHIUIETCTI{KOB I'I MECTHbIX I4III,I CTICTEMHb
6oreeoro cuHApoMa B nreqeBoM cycraBe.
Prac. 3.12. flpuvuHur
Yqacrxh Han6onee uHTeHcr4BHofi 6onu orpaueHbr reMHbrM
HIIBC. Ilplr orcy,rcrauu s@@erra lroryr norpe6oBarl
crr MecrHbre r,rH6eKur{r4 rnroKoKopTr{rou4on. Eypcl
Morrlbro rpupo3BaKyaqprr4 Kzurbur,IHaToB noA KoHTponeM JToKTeBOTO CyCraBa raKxe Moxer 6rrrr creAcrsfle
Y3I4. IIpu pa3pbrBix BparuarenbHofi MaHxerbr flneqa y rroBTopHbrx rpaBM, K qr4cJry Apyrr4x np[!rr{H oTHocrrTC
nrrrl Monoxe 40 ner Bo3MoxHa norrHas.xupypMqecKaq un$exuuu lr noAarpa.
KoppeKrlrafl , y no)(}lrrbD( JrroAeft pesylrrar 6Hsaer N,reHee
6rarorpuxruHft . AAresuBHhrrl Karrcynur rur€qa (<<3a- I Eonu B nyqe3anecrHou 14 Apyrffi
MOpOxeHHOe nneqo>) conpoBoxnaeTcf, 6orbro u Bbr- I CycraBax Krcrer pyK
paxeHHhIM otpaHurIeHLIeM IIoAbeMa plKr r,r BHelIHeIT Boresoft Kficrw wn 3alrflcrbl
cr.{H.upoM B cycraB ax
poraur.rr4 rrJreireBoro cycraBa. oro sa6oresaHlre qacro KaK [paBr4rro,Hoc]rr lIoKa-rIbHbIIl xapaKTep, 3a I{cKr'IK
accoqr{upyeTcf, c caxapHrru Aua6erou I{ KopeIIrKoBbIM qeHr,reM 6oma n nepBoM rurcrHo-3aflqcrHoM clcr?Br
curulpoMoM rneftnoro orAena no3BoHoqHI,IKa. JIerIeHI,Ie xoroprul qarue nopaxaercfl. rl,pv OA u-nr.r fIcA. Xor
ua pauueft crail]1I/' 3aKrroqaercs s o6e:6orvlBaHvlvl, I4HTeHCT{BHOCTb 6OnH MaKCLIMZL'IbHa.g y OCHOBaHX
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oJoHHeno) urcoHxdoso[ 4eHtrodou vJ.jceugo s qrog
'yu) wfln/ s xo€ffu EH xlilHdal^leedh o}Isrctrercs' orrr{
-edu xE) 'xutfioruxl.IHoos '(Erer oJoaod[x flodtrHl,Ic
'rHHHYHor' uaeeure) xeunexedou lntlsHdnr.(xeHlared
urfi €)LIHHOIOXtrEH I,D{ErSC WOUneXedOU UnUS0IqA qII<Ig
rexo^ BHerro) xulroVro xuntredeu s qrog '(gf't 'rgur)
rsdfuJrtdrc gounexedou I4JcBIrgo s rcre,{eflIru)ou o)
-reh 4eHExr xrsHaelcr(coro)o ,IllHexsdou udu urog
'uHelro) eu u 'edtreg xruHexllstr udu reexlrntos BHo
eeMIrc wor6 s 'esetcr(c oronuedEegoeur fiunexedou
udu srog srusodr4utrEddu rexon oHeIIo) g '(eruue;1
sneerog) erudfiroxoarco oJar[oIE) acced uuu €xcllH
-elnr esgdeed eusrctreffcs roexl,rHcoa oHhlilgo '(oI<rog
IloHqrr43 rcrelnor?trxogoduoc' oHelrox sJ,r(Hroeed
orirrcoH[o[ <IJcoHgoco[ceH reHlr€eoua) eae.lcr{c or
-oHHouo) wer,IHesuHulff€o c ruHHeeruc 'srog 'eW,'J
eH rirHecr,r[o orodorox urcoHl{egooo 'VO BJLIYUIIY
osuJ,cr{c NoHHorIo) s el^{odtrHuc oJoaeffog 40nunudu
rJorceh aerrogueH ercedsos flolfl4xou u woHtredc g
aserc^c ultoHltelfo)t fquog
'Uer3o xrlHmotrEstrou
xun[edeu xlr]DKr{H 14 xl,IHxdes rpleeJ,He 'edtreg rsIlmrsrt
Xerflrtrosradu JuHutrHor '.{rrrsfu ordaoxeu urceHJo oH
-xorar fxeu g utntedYeguJcelrgo s Bl^tod['nuc oroaerog
14vrbHar ta]'{rqHNer rqxemedvo uluog {oHst4cHorHu aauogt4PH
lt>lrceh1 'euerdae oJomcuog t4rcet go e il aeercr(c uloxxedUag
-oee1 IevrodUnuc oJoseuog tquunudu etsxrrodeg '81'8 'r14d
eeBrclc
o:ouHadUagoeer
o14HBsorro9ee oromsuog rucdlg
0?0 . vrvdvuuv oJoHqu3lvJt4su-oHdouo 1414HVsf UOEVe
ltenur,udu ltlqHHeH?dJcoduced eosew y'(eunexedou
eoxcerruruudocll rehollD{s'v[J sil,IhoID{CU OnI{EOX9O
-eu) euaeuQnlrc ro qresodranuedaQQllr re,fterc (t(xeu
u llrog) euurc^{c o,ronnedtregosur oII4JoIrorBL['B)I,IHhoH
-os0o[ Effetrro o.rosofircedx-oHhl,IHcBou r'runexedou
udu srog sresoduutrBddla rexont e)oler qJc€rgo fue g
'
ft 7' E' u gul.) soHe.Ido xrannedr(tts xrl,IH€sorogee udu
ors[og rJoHHexafuo rcrorrsr ogLIIr I^IOTUCd(9 ltrunsrar
-des 'rfiIerdou ^firtomsrog x rranerruedxudu xe.r,celt s
Isfrmrcn rltoHhl4troJr 4eHtrodc worpreeure/woruxutrner
ueraorcr(go 'orugedu )€) 'euaJ,dea oJomsrog ltodtr
-Hr4c goserog 'rII4troJIr I4IM ererdeg oromsuog <IroEIIgO
en rorugrseu)r( etrJoHlr 'edtreg a u[og eu rcrol&rex ersd
-orox 'rqrHeunel '(E 1 'g 'cucl) eaerc,(c oronneUo) III|H
edtreg srcergo or,&rqredarurentredeu 'frlrtrorr a 4eutIe
-kfieddv 4onnexudrss oHHrorcoren c i(xuu a oxogfnr
rcreeln{tno onnrsgo eaerc.(c ltonuedvagoser s ilrog
'rlrcpu gonuexced
l -ox l{rceugo 4toHHo['BII s ]tueercader u rI,IHoNeHo
osrls,,ft, iuxr(d vunexouou ro rucusut 4odorox erau
-etrsror 'xoJ-(c rneds eoHhoH s oHhrlgo IrBrrIoIe)
-uHros 'tttog:('pad 'naurnd11 'vuodtrsprc 4IqHqIreH
-
-udr 4rsn<reudex) ereuex oJoHrcruee ltodtrnu3 .
'8C lrIII,I L)'9)eH
-godr( eH so)medo) lteunexedou c rureuor,(xuYed .
'Btrorox ausrclJetreos uH resro a tluderde
xrqHirrBrr4Jr,rtr ruIrrudJcHoxooBs :oH4ed wodflrtl3 .
'ltnunuQuleuc
yxJteyltrer eH r roruNl,Ic gnunefi' '(en4ermsre)Hl.{o
rtorumttc) ruollqlrBu I {umqlrog I,IHoYer ) wrsJ,€)Kxdu
c r{Jc}Dr xu[.(v s 4orexo vrrT[rekrsef 4ouden<r,{ udu
rcBErllorBsr.{utlcf, 'vsJ.yilecu rilhelflItrodu BIIetrro
oJoHqrurcr{tr nrconxdesou 4oaeMu sroVs rcJeutr
-olrgeH <IIro9 nEHsHSHerHI'I ooIIO9I{UH I,II4HBSoTO9E€
ltore ud11 'rrrSIDr Btlilrex oJOIliIrOg rreregu:eed
oJo)rodo) lr (u.tcru BnsIrPu oJOlIqIrOg rIrOregI'IJ
-eud oronnurtr) I<IrrmrqN urerllrtrosro voIJH.vI]fi 4vll
-rxoxdc €Iar,rrruJ€rs rsHexedou eueeday atr erlrsoH
-r{coHeJ Nemorddu€one,r.c udg'I4J^Io) ilruHul^lou€H
rorpHl4h€H eHrrreHa ersdolox'senqlrgu qrcoHH?s
-o)c rBHHod.l.( rcraetrotlrguH orc€h'4Iarrxox,{c
rranellxadsoll rIJcBIrgo s IqHesoeurE)or o)rah
qrcoHHeH0onog u qro g'sofislrBu 4au eteguJ€ed utrut
geroJ€gr,rJc rurruorop(c r,eexedou :rI{soHI.{coHoJ .
'xdd 4ercru xesurcr{c s eNodtrHuc
oJoserog oII,IHesoH)uHoos ) xumrtroslrdu'sunltdu
xr,rJ,(dtr Yrd
rer{sJcelfldc'sogBlcr(c runexudou oratllwoll
'urclD{ r(Hodorc ordseh-fir s o)olur 3 'utcogxdasou oJe
HmH3U860dU
344 . PEBMATOTOT]4g 14 3A6O'IEBAHh' ONOPHO-ABNTATEJIbHOTO ANNAPATA

Ta6nuqa 3.24, Ilpuuuxut 6onesoro cltHApoMa e raeo6eApenHou cycraBe

IIospexfleHle 6onc flaxuue ocMorpa

OHresur cpeAHei RrogrvHofi Bepxunn JtarepaJrbHae vacru 6egpa, ycr- SoresHeHHocru HaA 6onbuilM BeprenoM
t\,4btL1lr-lbt nexa Ha nopa-
rll.4BaeTcff B noroxeHl4l4
xeuuoil cropoHe B HoqHoe BPe[,4t

6ypo,rr 6onuuoro Beprena lzlgerruvua onucaHuo BbluJe TlAeutuqlut onucaHuto Bblue

TeHgnnrr MbluJqbt, nPI4BoArqetl
6eApo (o6ur,{Fto oHre3r4r nPn CnA
hlr4 TpaBMa, cBR3aHHaC CO CnOprou)
Bepxnnn BHyrpeHHefl vacrs 6egPa Eoneeneusocru nag o6lacrurc nptaKpenneHufl cp(o-
xhnue Mbtult-lbt, npraeogSrqefi 6egpo.
6oru, eogFtuxapu.las npil conporl4BneHilil aKrhBHoMy
npueegenurc 6egPa

CeAaflaqno-sroAn,ltiuril eHreorr/ flrograqsr, ycunr4Baerc9 B noJtoxeHuu Solegnexuocru HaA BblcrynoM ceAanhqHoft Kocrt4
6ypcrar cvlrye

6onu e vegutalbHbtx orAerax naxoaoi SoresHenHocru Ha4 cuvSusou.

CuuQusur (uoxer uraurrPoearu
o6racu, Moxer pacnpocrpaHtrbcs Ha sHresnre npnvoi r.,lutLLltlut (CnA) 6oru ycilnilBa-
[1pra
BHyrpilcycraBHoe nopaxeHile
BHyrpeHHoro tanta BepxHtoro lacru 6e4pa ercg np!4 cKpyqilBaHuu rynoBillLla / artuaaqnn npa-
6e4pa)
rvroi lautuqut c pyxorZ, xaxognqeicn Ha cnu$rse

Ta6nraqa 3,25. Iloxantxbrc npuqHHbl 6onesoro cxHApoMa B Ko'eHHoM cycraBe

lloapexAenne Eonu fiaxxute ocMorpa

SoresHeHHafl nynbcupyloqae npunpoocrb HaA
o6lacrun HaAKoJteHHuKa

floeepxnocruuttZ n r nY6oxtrtu llepegnsn noBepxHocrb KoreHHoro Soleenennocru KnepeAil or (noaepxnoctrutft

rn$panarennnPHuti 6YPcttt cycraBa, uuxe o6lacru HaAKoneHHilKa 6ypcrar) raau ea (rry6oxrail 6ypcur) cyxoxmueu
HaAKOneHHUKa.
r/ 04HApoM xl4poBoro Tena
Solu npr norHoM cru6anuvi

BepxHrn MeAI4aJtbHa; noBepxHocrb EonegHernocru (+ orex) uag eepxuefi vegnaruroi

6onsLue6epqoeoil xocru noBepxHocrbo roJleHkl

llopaxeHrae MeAuanbHofi BepxHnr l/eAilanbHaq noBepxHocrb IorarilgoaaHHac 6oresHeHHocrs HaA BepxHeil

KorflareparbHoi cessxh (HanPrueP, 6onuue6epqoeoti xocru uegualunofi noBepxHocrbrc rolleHr'
erresur) Eors, gut3eaHHaq BaJtbrycHblM HanpsxeHueM npu
qacTur{Ho corHyroM KoneHe

Eonesneurocru t4 oreK B o6lacru nogxolenuoil

Kucra nogronennoi nutxu (xucra
9MK14
6eixepa)
llepeAusn BepxHct noBepxHocrb SoresHeHHocru Hag 6YrPucrocrurc
6onuue6epqoeoi xocrn 6onur.ue6epqoeoil xocrr

OcreoxoHgpnr ceRsox flepegHnr BePxHte noBepxHocrb Ha6rrcgaercr y nogpocrKoB.

HaEKoJreHHhKa (6oreeHu 6onuLue6epqoeoil xocru 6onu npu conportlBneH!4tl aKrilBHoMy paern6auurc
KOJ]EHA
Ocry4a-[JJrarrepa

Harpy3Ke. Eorl s rIoArapaHHoM cycraBe (nplr rex

cycTaBa paclpocTpaHeHa cpeAl4 noApocTKOB I'I MOXeT
6nrr pesylrraroM ocreoxoH,4pl{Ta cycraBHoro xprlua xe raxxe ycvrvBaercfl' rlpu HoureHI{I4
naToJloru.ax)
I,UII,I CBS3KI,I. cuuurourr Boc[iulrlTeJrbHoro apTplara c
TflXecTefi.
xapaKrepHblM [oqBreHI'IeM oreKa (PA, fIcA, CPPD,
Eonu B roreHocronHoM 14 APYrux aprpl4T I'Inu floAarpa) 'Iacro yxyAuralorc's B floKoe'
cycraBax crynHefi ,flaunlte Ho3oJloruqecrue SoptvIrt uoryr 6urr cBrl3a-
Eom n roJleHocrorlHou (ru6uoralapuotvt) cycraBe HbI C TEHOCUHOB}ITOM MbIIXU 3AAHHX OTAEJIOB CTOTIbI
BCJTeACTBI,Ie oA Unu ocreoxoHApzulbHoro
aeoeKTa (uaro6epuoBoir vr,r4 saAHefi 6olrrue6epuosoli).
ouyuaeTcrl MexIy JIoAblxKaMI{ V ycvnvBaercfl. trpr4 Eors s o6nacrll fl.rlToqHofi KocrI'I o6blrrHo Bo3HI'IKaer
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'eovdehurcuh 'eou'l s rqHa0E).( IqHLIhI.{dII 'gosoroJ YeH )/(d eNo<ttroll H
-ocorcum) ersuderueede;_1 I,II{HBtrecI{du 'muxsxeur(J,3 oII oNeqtrou udr 'rtruc
(ec,(dreoxe BI{HOXOTfOIT EU B€SBTCS 'rnnentr(dJu0 re€slqilql]ru JHe
@uleeuuoxltltt '91 'ddeg-eut4ercug
-I.IfIBx xlqdoro) udII'eJ-vrtoutN vruv I,IplrBuor{n aI{hr{Ir€H
' rouorouuQerc' sue5uuped cldue'exArcedv'c^dheou
w np upop) ersucuendeueg -elo^or-uh';.,y9) enucldug €H reEsrirs€)r{ fimlsw xrIHqIrBNI4C)OdU SJCO9eTJ
nuhxa6xyl xntrxeu x]4vcehuHnrv evHeho I
tsredgu$ t4 t9Ht4-LEt! o 'HuHesarogB€
nrE{eoUrag r lgUuo>ttttdoxoxottl-.1 .
llrJOxIUo eeOdyOH Hl4Eto) e xlqHr rercilc xr{JoHI I I [oHHAIISrOdU v[lt)3eh]IQlIIIeuS
edoore$ rcdolulgt/rHr1 r 9uo.lollff o -eH ECJebrsr aosdoll 'I4l,IttxH,(Q V rs]fl4x 4OHhOmIqvi
lqHr,tcvor
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/ tqrPdBugdu oFHHesrcdEveu' eemo{e)}rH€os'I4rcogErc 4o[I9o e]rHeIfi^mo eoHsl4r
(rernuueed) uuQodrcrE 6PHhomte[\ o
-)eqg^c .rrehr{IfeEd oHxeg 'nteHr{hl4du I^lIiIH€ed ou
qJ€x4HEOs I,(JOII qrCOgBII, 14 q[O9 HBHhemIqIN
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6r4hUUe!,'iOA-LCO o luhuSelt r
' rl,Icoedlrwo)otr tsE)cehnJdkdrax ts3qJBs
eHilI4Hd€v 1lahra$efit r leeEul4doQcoooill,\
ur4rllor4ripygul4-l
r .Luhr$ef . -ogedrou rexol/\I soworxltl,Ic lluHeHEdxoc fldu 'xI4H
(tL BeBU.l) auvcshut ogelonl t,egvltru 8otrl4o)r{Jdo)o)o{lrJ uI lrufl)eqHu u] lrIHrJeI^l
c r4r,rHgrehoc a ua,(90 dogrou IIIqH<I[usedu reBJoI lou
EHoct4ffiV cH0auog r ooedilrdeul4J .
eoedilrouLl-.1 . orJBh '4eJ3O) XIqSOHJOIITU I4I IB)SOTOJ IYXoW S[OX.(UO
E.rHilm^y nodUHilC o
reHHeHeeIIog ]rclelrrcf{rrqs ul4nerql.|Bl] ndu'urcoH
enuuudxoErg
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hHev-L 4oH xrirHser r rellHemoH c oHStrsJ or€) IqHI4TIHOX JOI€redlC
-c uer4Hr4uooc ut4Heeouogee I,I
oJecs atfleh 'Iier3o) xlqseHcolltu AI III uwe)souor
6rlHOrCe!4I\ r olgHH{v\v\l4o.r^e orlridfi r
UhovdeC o .l-ileoilY"lol.endof . florelr roreeJurorrJud oHhrlgo I'I 'usdeH oJoHHesmotr
t4l/\Bl4H0holtfrg C l"ileOil|l\ o l-l40ol'1hlk'lUOll o -ou 4osre8 J^d)os rlHu)r HoH€odqI,Io hlerlHers€dsEd
ordHnuserqs'qrox.(uo olfHHesrcahuxodgor Iltogoc re
olqHCUoll,rueUCOg
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hmHrI xHHquBnucxodu xrcogeuo !l
o{qHem}I] l lto)cehl,Ircglr) 63Jelflfar exxBr IquoJc rlell?u
enodUnnc oJosauog nHnhr4du 'g7'e efit,tugel !
r^4
omcljog' oHHasrsJesroos worIrIII4 L\eY v snq o A xry I D q
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rJr(xf dH HnoJ Je r{ x' H rH€oHI^lHIro Il'sotrHEoelrx,(H -ehedrf,rr orJBh EgBJc^c oJosoJHereQeucotru oJosdeu
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u,xox EHo aBh/trJ lraaHf,rar:nu s :hl4g tr?holrr)Is'xtr nielIHOrBUcos nililHsuI)u c rIIHerr[€l_I 'hle)ud€m WIqH
-[TDreoHH )OsHr(dHs H sordBuedu xHHHaslrdsxeu -dolredw ou Bgiltrox )E) Bel^leuslilSltuo orc€h '4etcox
)(FrHhHrrEd r{ril{aHe}riudu Hdu qJ,sxHH€ofl e)olBr ilJo}ll xtqsaHrorllu ul^lu)souoJ trou BBhleulfl,(ruo'agsYox
IHeOHlrr H TruBUOHI^I 'llHIrrIIBXOar}O H HI{meHrrIIr?X udu srog rcrlrcoHro I lrl{Helrsrodu w}rxcehuHl'Ir, )
-daux: HoHHexudFIg EomxrrB€'uxetruoxltldoxox 'oHhr4drowwr4c rqHexedo[ oHhrlgo Iqserc,(, elqgoJHBr
-drfJ HHudaL xeHHelDrorco {rI9 rexon B}IJ?UO}IN -uQeucottruyd I{dLI' 6}llruxox.,(c eso trlrrlxu I lorucorH€
TBHqTBnHJXOdII 'SIIHr OJ-Z HO)OrOs XlqHhemlqw uru Norr,rHr{trHeJ c EHe€BgC quilg JaXOI I 'qrCOHXdeSOU
(q[og
orHQodrs H rHeoHI{ [rqHqlrau.IrBucos qresElqs Joxon ol&rgerc,(c odnnorru o{olHtr€e retlolBsuJEdrE€
rroJoxrrs 3l{Helrgedroud aonr.orrsgel4' oII4QOdl,Cntr 'EJ,r,rrarH€ eHrIhI4dU OU YUJ HdU Sre)HHtOS reXOI^l
ollfirnamrsn JoIBrBIroLmed[ aIcudoos xotrororu s uwI rjo)rrJu trou crog e)K)eI 'aotruo)urdo)o)o{n 4l4lrxe
esrcraY s ruHBflalrogB€ rolgetr I'I oeHI^leHB 4IqH4ONoC -<rHr4 xrqHrSSr r aII3OU U l1lAI9O 4O)JtsI^l ]I]IHemOH HdU
urrqHHer[oJHo'eHeJoxIIfJ rl{Helruo)BH uHealIog o eo)oil s gohrorllnuc aI4HehJeugo oHxowtos ul4lletllflX
dolruduus 'lrurerro]ut eHHhI{dIr 4oxoah}Ilrogurol I o rol Xo)Er s H ')o€.{dJeH xtqHdewtedh htorerslr,(eed susg
-l(slcsreretrfisc LDIel(fueH elrcolr I{Jodotr(c u exe,(fuen raxow or(i'erullll3eQ oJoHHesmo['ou eusJctralrsfl
9?0 r vrvdvuuv oloHqElvJHEv-oHdouo t4l4Hvs3uogve 44H3U8tsodU
346 . PEBMATOIOTU9 1,l 3A6OrlEBAHt49 OnoPHO-ABl4rArEnbHoro AnnAPATA

BaHlIeM, B qacTHocTLI C OnyxoJrflMH TIOJIOBbIX Xelle3. JrerreHl4fl Heo6xoAttua ruareJlbHzrfl oueHKa nauuel{Ta D
(Du gu xa,rruoe o6cre.[oBaHl{e AoJrxHo noArBepAI{Tb ueJroM. fLran re.IeHu.s Ao-ureH 6rrrb uHrrrBu.uyaJlbHbu
HaL[Uque, xapaKTep I{ cTerleHb BblpaxeHHocrl4 MbI- r,r opI4eHTI.{poBaHHbIM Ha [aq]IeHTa. B re'IeHI'Iu AoJDf,-
pilSII[tIHbIX CneryIiuIF
rrerrHol1 cna6ocrl{, oueH}rBaeMoIi xonuqecrneHHo rlo Hbr y{acTBoBaTb rIpeAcTaBI'ITeJrU
(0),qo uocreft, npI,I groM oHo AoJDKHo 6rrrr couacoBaHo E
rxKiure MRC
- or orcytcrBrlr MbIIIreqHoIl cunH IpLIHTITO KaK naUUeHTOM, TaK I{ BCeM}I BOBJIeqeHHbIMII
nonnori N{suue.rHoll cu:ru (5).
y{acrH}IKaMu. Tapre Heo6xoAIarvro yrl{TbrBarb:
I lla6oparopxue uccnenoeaxm . rpe6onanux K aKTlIBHocrI'I naul4eHTa lI
3aHHhIe c npo$eccuoHzulbHblMl4 norpe6nocrruu x
UeJILI' cBfl-

IrlccneAonanrle AoJDKHo Brrrroqarr 6uoxraMn'IecKllft

u o6ruuft aua:u{sbl KpoBI,I, ouenry COO, yponua CPE,
aKruBHocrl{ rpearun@oc@oruuasu, coAepxaHl4fl
25(OH) BrIraMI,IHa D n cunoporKe, ypoBH-fi fITf,
ponorurrecKr4e I,IccneAoBaHI{fl Ha napBoB}rpyc' BI{pycbI
renarrara B u C, BI49 u crperIToKoKKoByIo raH@exquro,
enerrpo$opeg 6erxos cbIBoporKI'I lI Moqu, AIIO s
cbrBoporKe KpoBI{, lIccJIeAoBaHr{x ua AHA/OHA, PO,
KoMIUTeMeHT I,IayroaHTl{Tela, cleura$lrvHble.[/'Iq Muo-
:ura (nanpuMep, aHrllre;ra x Jo-1). .{lr nocranonxra
o6uqno rpe6ytorca luortcus Mrrure'rHoft
.urarHo3a
TKaHI,I (nopaxeunyro MbIIluy onpe.{eJlslor c IIoMouIbIo
oco6ennocrrlMl,I .uocyta ;
. ga6ole-
Sarropu pllcKa, Koropble Moryr BJII'IrIrr na
ce- BAHI{E;
. BOCIpTISTI{e LI OCBeAOMJIeHHOCTb IIaUUeHTa O CBOeM
cocTogHl,tu;
. lpe[apaTbl I4 CrpaTeru[ [peoAone-
JreKapcrBeHHble
HwI, Koropble yxe 6ruu onPo6onanu;
' conytcrByloque sa6oresar.vs,il rlx reqeHl4e;
. AOCTynHocTb, CToI,IMOCTb I',I MlTepI',IzuIbHo-TexHI',I-
qecKoe o6ecne'{eHlae coorBercrBylouux BMeIIIa-
TEJIbCTB.

MPT) u enerrpouraorpa$ur. flepnonavalrnuft crpu- Cnaqana HyxHo ucnpo6onarb caMble npocrhle I{

HI{Hr 3JIoKaqecrBeH HbIx noroo6pa:o r,aHuil o6H'IHo 6esonacHlte BMellrareJlbcrsa. CUN'InroMbI lI npofl BJIe-
BKJIIoqaer KT oprauor rpy4Hori KJIeTKrI' 6pourxoli HLIq Moryt MeH,ITbc.s co BpeMeHeM, [ogTOMy rr]IaH JIe-
.reHu, 6om[HHcrBa naqlrenron rpe6yer peryJlrpHoro
rroJrocrlr I4 Ta3a, TaIoKe uoryr 6urr qerecoo6pasHrr
3HAOCKOrIfiqecKoe I{ccne.IIoBaH}Ie BepxHI',Ix OTAeJIOB nepecMorpa u KoppeKlluu.
xenyAotIHO-KI{UIeqHoro rpaKTa I,t KoJIOHOCKOII4TI' Ocnonnrre BMeIIrareJIbcrBa, Koropble cneAyer pac-
cMarpl{Barb Anf, Bcex naulleHroB c sa6oresaHtlqMll
I
I
fleqexue olopHo-ABLIrareJIbHOrO aflflapara, flepequcneHbl B
Jle.reHue onpeAenqercx nprvuuoii, Ho y Bcex raull- ra6n. 3.27 . Cyuecmyor ralaKe.{pyt[e HeMeAI{KaMeH-
eHToB c MbIIIIeqHbIM :a6o-nenagueM [oJIoxr'ITeJIbHbIM
TaSnraqa 3.27. Bapuaxrbl neqeHue peoMarfiqecxllx
e$$errona o6la4arcr @usuorepanl4r{ I'I nocrerleHHo i aa6oneaarui
Bo3pacTaloluue Harpy3KI4 AJI,I MaKCuMiUrbHOro BoccTa-
OcHosxure BMeuJarenbcrBa
HoBreHI,Iq NrsrureqHoft Oyrruu, fl ocJre IgmupoBaHI'IrI
BOCIIZUIUTeJIbHOTO [pouecca. . O6yqenile t VueruLuexue ue6laronpu-
. AepO6uOe KOHAI4|1I4OHI4- tTHblX MeXaHilqeCKvlX
poBaHile QarroPoe
06ulme npilHuilnbt neqeHiltl . VrpenleHue uutruq t Pacruupenue peurarerunoil
. llpOCtte aHartbTeTilKl4 aKruBHocTt4
. SMAPI] lloExoAqu]a' o6yeu
JIe.IeHIae peBMaroJloruqecK[x sa6olenanuti onpe- .' CHuxeuue Maccbl reJta nprl
\ersercs. ocHoBHbIM AlIarHo3oM. Ornaxo HeKoropble oxupeHrl/1
acrreKTbl flBlrfliorcfl. o6ruuuu AnrI MHort{x :a6oresa-
uuit, unuxe o6cyxlalorcs o6urue upuuuunrt. IJerut flpyrue BapuaHrbl
neqeHr{fl: . Apyrue o6ee6olueaoque . Oileilorepanilq
. ran$opur,rpoBarb Iraur{eHToB o sa6olenanr'rra; npenaparbl - Tenlo, xonog, Bcno[,4ora-
. KoHTpoJII,Iponatr 60lr, ecJIlI oHa 6ecnoxour; - HI1BC aryrpu rerbHble cpegcrBa,
. onruMr,r3lrpoBarb HapyIxeHHyIo Ovuxuurc; - Mecrnute npenaparbl npncnoco6leunr
. uoAu0uuupoBarb reqeHl,Ie 6olesuu, ecJII{ 3To Bo3- - Onroraguute aHallbreru'lKl4 t XilpyprilqecKoe reqeHile

MOXHO;
- AvurpunruluH ' Crparernn, HanpaBneHHac
. LI JIeq[ITb collytcTBylouyn naronoruIrc.
Bblf,BilsTb
- f a6anewuu/npera6aluu Ha pa3Bilrue cal'4onoMoll-ll4
. Me6nute ilH'beKqut4 npeoAOneHu' rpyglOCreit
14

Oru uena B3a[MocBs3aHbr, I{ ycflex s oA}roft o6- rroKoKoprl4Kol.4AoB Fa6l 3 28)

racru qacro npLIHoCIIT [OJIb3y n gpyroll. .[nx ycnexa
-on FI€ardO'esurcft trxa(dreed 4onurerurtr sJeJegol'{
rrateds os eorr xlsHqlroseuoduou
rairarc o)eHtrO 'enc
xrIH<rrarglrexeH euH€sodrawdoQ rolemedsrovodrr
arc{er e '4euux.l xrqngerc,(coro)o H uoszlc'(c xIqH
qruh
-naxedou fxxdanTou ra,(xer(dreud or,fi+reweds
-aucogo rr{.rovu soseJ,c,(c llulrecxuQ rrtr IcHI4m
' trvrre Lvoflrge ed rx e
Q Q e 4IitH€ orou oH<IITBHTIH
erorr
rotegl4lrl/lcr( llor'ede HuIrIBhar c unrI4HemOHJO I'IWI<IH
-qrarudesotr umrqnneodlcns u BrHoI'tIIErr I{el{Hehfgo
c 4unauxedu,( xraxcer,raeuQ eunereno3'xuae'r'c'(c
xrsHHexedorr g I]tuHexustr er,losgo otunadumced ror
-,{alcgocouc gunernredu,( rvc)elruNo) enunelogedeed
erqHhulr€Ed'rrxe,(druu 4oxcer,ueuQ urSoHsllcHerHrl
rcgeraolrH€dxoc udu etredc IitoHVoa 4onrdoQltox
'yroruel s Al,lHexl,Istr I4ullutusl4'L)e re,{arcgocouc ra
rrmlsn el,IHalrgelrcced reesrqerqa ruuuderodtrul
'IltuH€gorog€e xlDlcohllrul^rged etrrd
r.rdu golntoJ,unl,Ic eI4HerLIeIrgo eoHHeI Iedt lrur'eucego
u IlmIsI I eI4HeIIgeIICCed Sregrqersa r'{ror{ Yvls'LJqeY
-toa elrHmeHs eIqHsIIrExoIr erar,(dtr u IiIHHus anaouuQ
-ed€u 'ltotrqlr oo Iqraxeu 'euHesedJoc ooHrcal I
oneu6
'lIrcoHheHo) 4ounexudou I^{omKo[ol
-osurodu 'eHodolc en urcofu eraneso€q[o[cla i'firuuc lt
edVeg 'unerox 'unu,(r,c eH,$e,(fuen oilndets( sI}IeuHc
rexon redorox 'esmotrorr UtorJrlr't I^{ororor eu raa-{go
Iernoildueuldolte elIHesoeilroucu lol,celt lnter'oged
BH rt,rHesoV,{dogo olutreru€['B :roleholrora uurerefuc
erari(dfi' ']IHI,IH ,(rxelt lrnerugdarHra ultraxrodox c
4nuarrxudud xrxcanueuQ €lI oJerflrorcoc'4ulrueo
gcxelruIrto) uxrogedeed u uldouc sotrfis xIqHJ)eJHo)
Jo Eerro nueurxoQQ€ qrrlg r,fuo141 'Horradrde c
sorHa[rIBU ,{ rqnoruruac qu{mtr/(x.l( rexo}rl I'IHE)I eIqH
-suJcfroroxo mflr sa.l:,(c pu*raroxadeou uH s)effueH
rcrernoudoJeou remrnduoJurgeH I'I rendanead6
soserCrtc erutnee
' IqocEN IioHrso) udarou olr{Hartron
-ee I4 I'IHUXI IJOHICO) I{ISOHIOIrU OtUneftUfes'{ '(vl
-ongedeltd x rarcegfldu rfuov'r uno ltodorox udtt 'e€
-odouoerco udu rsHx€s goxe^{fuuu c rltrarxudu6
'tawenegderHu HI lfimilroq c wALYr,e€ alqHcrarl{ffi
lten'egurc.{c oronnexudou fimlqhl nagarruedx,( rffi
rjunerrxedud uc)el,lrfilox sodoraou Nosrcehurro)
WurnqttogeH c rlrrrHee olqrcuh ilrutsoaodu onqrettlrr'
-ouredg 'erudrde woxcanunodx udu eucesoHsed u
oII{ttEHI,Itrdoo)'olurluenolrduodu',tflac ol,fitnemtslt
ztE . tsllH3hilu lculfflHl,tdu 3[tnEO
.Loremh.&fl(' ornfiel:z[:arrasHl4 I'I eI^IodtrHI'Ic oJosorog
qtcoHsucHarHl4 rolemqHelt( axoter fimlsv[ rHHeIflr
-ed),{ rnnesxudud arxcenueuQ olilHqlre)off
rfi' '
'rauenardeurar u I{JcoHhor€rcoveH
Eour'etrdec goxcenrauodx'eLegevf, otoudgxec'ruu
-adrrxo delntudueH'4Ianuaerogee xratnotdsrcJ'{xoc
ruHeher olulremr,-fir,t ra ,&rc rslfl4c l{I Iel[Iolesurs€H
-Erccos .toiler,cgocorc'araaJ,ssdnolwc roremr'du'(
r,rHO'I4I,IIr?€ vIfivffesl,lla rarconnexudrss u ewodYHI'Ic
oJoselrog I,IJcoHsI,IcHorHI'I oIIaHerc'Inc'{lqonnelt
-edeo.Iro[ x urceslrdu rrfuort t^loxugodee rurrneg '
'ur4HeH
-xedM sotrus o)qro)ceH ilr€sotrHoNo)ed onxo141
'IstrHul'{o) gonsrraQoduoJoHl l uurcei.,f'
udll uctcrtruurcerilco orecg emhrfir u rIH)KBg qHeho
oro)m s exxdelftrou'ltillISJ ly'ocs qlfioNou B€)cehI'{J
-orroxucu u emrendgo 'YZ64 )ex r,rnlrx?r'uwrI'IH€s
-errogB€ I4Nl,rxoer'nnodx c soxr,cod[ou r'r 4ere[ rrf
'htrO lrVd udu deluadues
'xrsucodeg r{ xrl,IH€sorog€€ xu)cehuHodx xra;onlt
udu
I oneedgoocerefi e)oI€J on 'r^aeretr r( xrllHeserogee udu
oHxes ole 'Blgeltfteu enr(xeuo IIITI4 B)I'IHHegrcVod
ccefiodu s euHehersos oHrcel/ll-( xrufi€,fuI'I3 xrsdorox
-eu g'ltwedrodu xrsHderolilrno) xlqnsflt)udelul4
runeneltudu pI I4I {€rHeurletl c pvll,rlr^e€ xrsgouu'(d'I
runevasodu'sor€udeluw xlqHHeso)uttgfuo rI'tHoII
I^losrt
- gercotredu' nuuetrxr(cgo oronqre.(VvrtrvYlru
-tredcou rcqr[Vosodu rexon enuer,,(gg'ouararxeQQe
I{)CohI{NOHOT€ lt oHcelrotog osrcstlloremeNs eoxeJ,
xore udu 'e[otldeu NoHHelretrro s u eucuh hlor s
' olr.rHohelr urconHexde
gudu meuHemndr,( nersorc'{
-go quqg oHhurcuh rexon rxeQQe oH 'IqHcr erlHo)
Ia yg r'rdu errcl'lh ] IoJ s 'ered
otr eH IqI I€HHEXoW 'Vd
-uuu€ oJoH<IlrerEJusV-oHdouo xr[neselroge€ xI'IJoHhl
udu umomou 4o)3HI'{nUtreN euH€€€)o eH lcredleo
qruotlHc ,r tstfltx elqHHesrcgoc s ,(deg sruued)'{ 'uI4rI
-e€utrI4r?sHll srcoHHexedlqa I4 Hlfog qrcoHsl'rcHorHl4
qrl,ImsHel^I,{ IiIH9OSOIC NOr'edS N]Ir[BheII J eJ)erHo)
I er{hulreH I,I qrcoHHgaodraltdo@uq' troxoll srllmhdrr'(
rexox eunendgo )€) )€r 'o0ourodu u rauHehelr 'uI4HEg
-otrercgo I IonutroxgoeH 'Yuuerouogee xu ederxedex o
rsHegodflndoQnu rrng lsrrxrotr €trJo3s FIrHer'I[€lI
'
o14Hoh/(9o
rHeilx eeedgo st4hvaddov t4 ol4Hoh^90
'rruHeserog€o I,IJce)Krr u edaJ,xedex.ro rucuste xrsd
-orox dogrsa 'tslHel4dBg elqHtorHol lE)I4troI l H elqH0or
348.PEBMAToflor}t']43AEo,lEBAHl4gonoPHo.ABMrATE,lbHoroAnnAPATA
ryT r,lcnoJlb3oBaTbcrl B relleHl{e An}ITeIbHOro BpeMeHH
Nrfl cra6vnvr3awll4 I,I npeAoTBpalIeHI',LI I436bITO'{HbIX
[aTororuilecKl,Ix ABI,IXeHI'Ift ' K ]IX qI{cJIy oTHOC',ITCfl
Ar4HaMrTqecK[e KI4CTeBbIe [IuHbI, OpTe3bI AI-fl KOneHHO-
ro cycraBa, a ralaKe T-o6pasuue noJIocKIa pm cra6u-
JrH3auI4I,I roJleHocrollHoro cycraBa. Opre:lt 3aqacrylo
npor.I3Bo.IlflTcflkrHEuB:zgyuIJIbHo Ha 3aKa3 t,t s oco6eH-
HOCTI4 IOAXOAqTAJIS IAUUEHTOB C BbIPAXEHHbIMI'I
[PI4-
3HaKaMI{ ]2i]HBaltl,1lI.v3at\vrt4, y KOrOpbIx xupypruIqec Koe
reqeHue conpqxeHo c BbIcoKr'IMr{ plIcKaMI',I pA3BVIT[{,I
ocloxnenufi.
BcuouorareJlbHble npucnoco6leHr{fl [oBbIIJraIor
caMooueHlry naqlleHTa u o6ecne'IuBalor He3aBI{clI-
Mocrb B rloBceAHeBnoti xrnsHI'I. Tllura'rHrrllu [p]rMe-
paMr,r npl4cfloco6reHuft sBrqlorcfl : npI{noAH,IToe cr{.u,e-
Hbe )'Hl,tra3a, 6o:ree errcoKllilt cryl, yAJII'IHeHHrIe py'rKu
Ha KpaHax, .uylxeBaq xa6fina sN{ecro BaHHbI' croJloBbre
pyqKaMra v yNruHeHHbIe 3axBarbl
npu6oprt croncrblMl,I
Mg HarflltrBaHl,Irl KoJrroroK lI HocKoB. Kolrrrercnaq
oueHKa c ocr o fl:akrfl !I peKoMeH.II,a guu p e a6wturoJloro B
e@Serr
MaKcI{MiIJIbHo yBenuqfiBalor repafleBTl'rtlecxufi
(cu. ra6,r. 3.27).
Crpaterur, na[paBJIeHHar Ha pa3BI{TI{e caMonoMollu
r{ npeoAoneHr{e rpyAlrocrefi, uouoraer flaulleHraM n] {-
trre cnpaBn rbcfl14 npucnoca6llrBurbcg, K cocro'IHlllo
xpoHuilecKoft 6olrE u yrpa'{eHHoft TpyAocnoco6xocrr'r'
Ha ruo6oft
.[aHuas crpareru{q Moxer [pI'IHocI{rb rlonrsy
cra;;vlt, no oco6enno y naulleHToB c HeI'I3reqI'IMbtMI'I
sa6oresaHlrqMlr, Koropble flepenpo6onalu Bce Ao-
crynHble BapplaHTbuleileHufl. I-{elr saxlrcqaerc'I B
rou, uto6u IroBbIcI{Tb ypoBeHb caMoIroMoI!}I rlyreM
caMocrorlTeJllnofi orlenxra I4 perlreHl4rl npo6leu, uro6sr
fraulleHTbl MOIJIT{ pacrlo3HaBarb HeraTI{BHbIe, Ho IIO-
TeHulIiuIbHo uorua0uqupyeMble oco6ennocu{ cBoero
HaclpoeHr{rl (crpecc, pa3oqapoBaHhe, fHeB Lrnv HI{3Kag
caMooueHKa) lr no:roxeuru (@tl:uuecKoro' coql{aJlb-
noro, QrnHancororo). B AalrnefiureM oHI'I trloryr 6urr
ycTpaHeHbl nyteM I'I3MeHeHl'l-g oTHOIIJeHI',LI K HI',IM I'I
rIoBeAeHI,Ifl, KaK IroKa3aHo g ra6.n. 3.28.
V.Iacrue cyflpyra luru [aprHepa Bo B3aI'IMHoft no-
craHoBKe ueleft Moxer ynytlmurb uacrpoft' Taxre
noAxoAbl llacro flB,Jlfl]0TC[ SJIeMeHTOM fpyllrloBblx
o6yuarorurax saHlruf4 u npuMeHrllorc.a B K,'II'IHI'IKaX
JreqeHl{fl xpoHl{qecKoit 6ottu, Ho Moryr norpe6onarr
6o:ree Qopnaa-rrnoro [oAxoAa Bpaqa c oKa3aHI'IeM
flcl{xoJloruqecrofi [oA,qePxKIa.
HnqnsulyarbHble MexruculIIrJII'IHapHbIe rloAxoAbr
Heo6xoAr,rulr Ans flallueHron c IOHA u ApyruMll xpo-
Hr4qecKI,IMI4.IIetcxuN,ru sa6oneBaHu-fl MI'I B 3aBI'IcI'IMocrI'1
or Bo3pacra I,I [cuxororuqecxofi 3penocrll. flcuxolo-
I
Crpareruf,' HanpaBnexHaf, Ha pa3-
Ta6nraqa 3,28.
BITIe caMonoMol{}l }l npeoAoreHue TpyAHocTe}t
, ilorav, TexHvlKl4 penaKcaqilr4 MF cHuxeHilfl crpecca
. [z1s6erau/e HeraruBHblx cnrya4nit mn aosgeicreuti, eutgutea-
yBenuqeHue geficreut't, npl4Hocqqux qyBcrBo
rou-1.4x crpecc, t4
yAOBnerBopeHilF
. qerqx
t/H$opMilpoBaHl4e nauu4eHTa u o6cyxgeHne c H'1M B
il3MeHeHI4F ycraHoBoK t4 mrnnpoB na 6olegxu
. CHuxenue ilnu npeAorBpauleHl4e HeaAanrneHoro 6oreeoro
noBeAeHrlR
. OopMt4poBaHue o6paeoa il Mero,qoB orBreqeHilfl or 6oln
. PacurpeHre coql4arbHblx KoHTaKroB ra 6olee eSSerrnaHoe
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rcrotususeed xun.( onnauaJcolf '*(d gercrx uoselcr(c
xrsaoruuru@xen xIqHiIrErcI,Itr u xrssoJHeru@xen xIqH
-qrulrucxodr xlDq[oxcoH I,IIM oJoHtro qr,corx.(uudu u
irrcoHHeso)c '<roq rcro{€snsoed 'r,er gy olro)o ercud
-e os s xlrJddtr ,( xex rflads or s 'rol(srcr(cro Iqworuwuc
sorHor,rneu xrqdoroxen ,1 '8t't 'rgur s IqHB€Bxou VO
rslnrdo@ 4onneHedrcoduced 4ore rxu.l,cuderxedey
' ultreuranr.rdl ul turr{dE
EH€sorqs quqg rexow vo c EJHoLIrIUU -{ UrOg OJh 'Nor
o qJI,IHT TOU OHX€S rfiqOreou 'tlrttrutttroJ,coc ultur-(dtr c
362 o PEBMATOJIOTI49 t4 3AEOflEBAHl49 OflOPHO-AB14rATEnbHOrO AnnApATA
Puc, 3.19. PeHrreHororuqecKue npoeBneHu, npn ocreoap-
rpure KoreHHoro cycraBa. A pacnpocrpaHeHHbtfi ocreoap-
rpilr c npaKrrqecKh -
nonHoft noreperi cycraBHori r4enu. [1opa-
xeuur o6a orAena cycraBa, Ha6no4aerce cKnepo3 cy6xoH-
4paruHori Kocrr4. 5 HagKoreHHo-6egpenHufi cycraB B ropu-
-
eonraauHofi npoeKquu y naq[eHra c rlxerbtM ocreoxoH4po-
sou. Ha6nro4aercr noqrh norHa, noreps cycraenori uJeilA v
6oroeoe cMeu.leHue HaAKoneHHtaKa
Prc. 3.20. Tunil,{Hae eapycHan geQopMaqufl KoneHHoro cycra-
Ba, BO3HnKapU.lafi B pe3ynbTaTe BbtpaKeHHoro ocTeoapTpnTa
MeAtaanbHoro (aHyrpeHHero) 6oruue6epqoao-6egpenHoro
coqIeHeHhS
aJrbHoe (nHyrpeuuee. Ilpuueu. ped.) 6eApenuo-
-
6omrue6epqoBoe corureHeHlrll, Ho no Mepe nporpec-
cr{poBaHr,H npouecc paclpocTpaH_fleTcfl Ha Becb cycTaB
(puc. 3.19). On lroxer 6rrrr rasollrpoBaHHbrM rlnr.r
BcTpeqaeTcrr B paMKax reHepurJrpr3oBaHHoro y3eJrKoBoro
OA. Eo-uuuuHcrBo rrauueHroB rrMeror ABycropoHHee
cl{MMerprrrlHoe nopaKeH}re. Y }tyx.IuH TpaBMa rracro
flBrrsercs.6oree saxHrru @axropoM ptrcKa r,r Moxer
flpr,rBecTr,r K pa3Br,rTr{ro oAHocTopoHnero oA.
Bom o6sr.rHo JroKzurr,r3yercrr BAoJrb nepeAHeli ull,r
nHl,rpeHxerl floBepxHocrtr KoJreHHoro cycraBa c pac-
rrpocrpaHeHraeM Ha BepxHroro rperb ro:reHu. Eonr lpn
lopaxeHrrr,r 6e4peuHo-na,qKorreHH[KoBoro coqreHe-
HI{'I, KaK rrpaBItrIIO,yCz.JIVtBaeTCS npu nOAbeMe I{ cflycKe
no JlecrHr{ue rulu xoAr6e no HaKJroHHoft rulocrocru.
Eom nAom sa4neft rroBepxHocrlr KoJreHHoro cycraBa
yKa3brBaeT Ha Bo3MoxHoe HzLI[que KXcTbI IIOAKOJIeH-
Hoft f,MKr.r (xracru Eeftrepa). flaqueHr Moxer r,rcrrbr-
rbrBarb crroxHocrr4 u 4rcxou$ofi npn gnurelrHorl
xogr6e, BcraBaHI{}I co cryJla, [pI{ HaKJIoHax BHII3 I,I
Brrepe.4, a raroKe B corHyroM cocrorrHur,r (uaupuuep,
rrpu [oca,qKe n anrouo6u:m).
flpn ocuorpe MoxHo BhurBr.rrb cneAyronlr4e nptr-
3HAKI,I.
. ArrrarnaqecKa.s noxoAKa (xpouora) c yr!{eHbrrreHr.r-
eM BpeMeHr.r Harpy3Kr4 Ha nopaxeHHbrri cycraB.
. Bapycuaa (puc. 3.20)
Irnr4 pexe B€urbrycHar ufutu
QuxcuponanHaq crr46are rrblaas. Ae$opMarlrlq.
. BonegHennocrb cycraBa nfulu oKoJrocycraBHbrx
rxaneft [rropuvnoe BocrruureH]re rycltrorl ilanKr4 vI
oHTe3orrarurr ueAualrsoft cB.s3Ku (crra. ra6,r. 3.25),
Bbr3brBarorlr{e 6one3HeHHocTb Me,{rrzuruoft nonepx-
Hocrr{ nepxHerl rperu 6olrure6epqonor7 xocru].
. Cla6ocru u arpo$ux qerbrpexmaBori urnuuu 6eA-
pa.
. OrpaHu.renue $ynxqura ctuia:ans. u pasru6attut t
cycraBe c BbrpaxeHHofi xpenuraqueft .
. Ore.rHocrr cycraBa.
Ornoxenue Kpr.rcriurnoB Krurbuus nrapo$oc@ara
p,vttvtpara (KIIOA) B cor{eraHr,ru c OA rolennoro
cycraBa Bcrperraercfl AoBoJIbHo qacro. 9ro uoxer
npr,rBoIrrTb K pasnururo 6onee BbrpaKeHHofo Bocrriurr4-
TeJIbHoro KoMnoHeHTa (puruguocru, nunor), a raloKe
K ocrpbrM rrptrcq/naM cr,rHoBr{Ta (ncer4ono4arpa), vro
Moxer nplrBecrr{ x 6olee crpeMr.rreJrbHoMy peHTreHo-
rorlHecKoMy u KruHuqecKoMy nporpeccupoBaHr{ro.
I Ocreoaprpo3 ra3o6e4peHHoro cycraBa
IIpu OA raso6enpeHnoro cycraBa qalue Bcero no-
paxaercfl BepxHsrr [oBepxHocTb cycraBHoro xpf,rua ro-

slorox€og e)NoIEr 6rox'uam url4 IqII,IHCTOI UTCUII9o
s TEHHBaoEHITB)or 'suog rclerrsl NeuHeffarodu
vrrrHhlrrl]rl 'VO oJoHHesoel4lrudeHe.r xuxrted s. uuvt
onnesodurotlr <rJ€x,IHeos rexow Bx4HhoHos€ott VO
'Q7'g 'twd) eeerutrHotrc oJoHhrrHcrou ]I oJoHllelrt
orHrlrseud x rtrosudu 'ex4HnoHogeou Isretrro UrIsH
-hHHCrO[ r,r 4rqHgem reuxedou oJecs otflEh vo
evuHhoHossou I]4drdeoerca
@xuedrc remuor) eoeerc,(c xsudeerQ
-oue eodervcoerco r (t,t>tuedrc euruot) EovHoeeou uar xsedv
r^3 ,{rxeu',t eercHBdrcodu
xnuUedeu eu rsruQoerco "'nC tt
oJoHhoHo8eouxel,r vrarxexr{c c eeuuuHouc t4lcHt4em'Pvl4H
-hoHoeeou erndrdeoerco e)rlcoHJet4UoHaJrHed'ZZ'e'oud
(y) rsrcrx n (g) mu$oarco
aneaedx'(93) eodeuxc 4nusuedUuoxglc' (g) u uetn 4oxserclc
urcer' 4anxdea auxex(c es anxenuxe eJ.u1ed96 'eeerc{c olou
-Haduego€a Eeodrdeoerco ertnrronJeuUoHelr{ed' t7'e'3ud
:;: . lltdJ-dVO313O
'ESUJ3IC
o.ronnedtre goeEJ VO Ner,rnesodplccedrodu wrsdrc
-rqg oerog c rer(dureddox otdrurdueu auneduxo
'rranexedou enodorc EH l{rcoHhoHo) el,IHehodo*{ .
:EdYe9
uutrcrod 4orrxddeu udu 4unexrstr auHer'uHufuo
'oil{fi?wdoQetr orr(uvlreregurc oilnueaoducxuQ .
iuudetde 4onnedtreg rlulrecsr.(u Yurlaelr
I -etreduo EJcoN eoHillredorer'r{xeu s qrcoHHoHoelrog .
lxrranerrus[ xuffd[ udu
qJcoHHeH€erog vI euluel.tvtnefuo rcsrugrou rrfuoII
uusrctrorcoils'€selcr(c oronned[egocer YO )eHo
-udu Ulr<Hsrer,lrsrc&(n eerogueh u 4uuued 4IqI [uc
- es€r3l{c ltrouuedtregoo€r s uJoH t10rr(u:oc uult
-erod 4eunedrfirs rwedg os ellHohl{Hefuo u qrrog .
ifimrsrt xIiIHhLItroJr u udtr
-eg rsttruIsn 4oaerlxednren oIuQodl,e ]I eJcop€fc .
:A)troxou or^)cehllJlfPrHe .
:,DI?H€
-udu euluor,{trorc qrusrlqs oHxolll edlowco ud11
'eDrE oJoaoffou rflruads os srog qr€s€rss rexow HumHex
,( edtreg rr,IHel'esro eI{HohI{H€dJo 'oJor erlody 'eaerc
-,{c oronnerox y6 Iadu I4 )B) 'ex emteJ, rfiHolll(deH
erqHqreHor{mu,(Q l^toran g 'urco) 4ouuedreg efu,(g
oJomqrog erucd,(g Nonr,udors o ro^arcqlrorevusc
rarore.rdes Numqrog !'BH olqrcoHHeH€olrog c'ogodorc
4ronuexedou BH exer ul{Hoxoro[ s rcrurflol€sullrl4cL
'edVeg urcoxxdeaou 4oaoxog qlrotrs qffog 'qHeIroJ UIM
oHero) s exed'udtreg srcorrxdegou o{r(HslrederereHtrod
-err 'i(trutroJl a Uieralreutreddu 4ouuelntedeu c 'rucergo
I^{osoxe[ s rBnnexedrsg oHqIIElatI,Icx€laI 'srog reunexed
-ro r3sr?trollfg€H raXOW 'rBxreh oellog I,InrI,IHeHeNeI,I
t{nll)lcehlrJoronefined u I{H€I^IoJIrI^Iuc r(Yxert YIdlrYU
-addox eserc,{c orounedVegoe€r }II,IHoxBdou ud1
'I4rJo) gonnadtreg
IDrsoroJ raulre*ror,rdo 4oseco wounemddes rcre€trx
-osoduoc o)Ved entledx r.r eomodu tlnnrrlrduolurg
oHquerucoHro reonll ol,IHsserogeg'vo nrqsoxffeef
htrqHHESoouredene,r c rcrez(dlrnfioccB oHhrlgo ra der
-xedex 4uunodorc,{s[ u{coH 'sulnuex I NoHsoHco s
rcrouhedrcs urtdoQ wuuefil'Irrc€h 4oxsredruefi ee t
eoHHoxsdrqs eerog 'ltlcox uroxuedtrag nxsoroJ erflrdx
eunamfdeed eoHqlru)or BcroetroIlrg€tt yg (weuuedr
-fna) nonsrufune[ ltonnenefucoduced eenelt ud11
'derxedex Uqaunod
-orcoHtro rr{coH ol4HBseuogBo elrEr€ ltenned e11
'( 17'E 'cltd) lrvtlresetrogee eonrodu
reemE&-( edelr t^loHsrerl,IhuHo s oJh 'qrcoHxdegou
oilaoxog-enxdes uH BccaltodIr lteunenedlcoduced
wufflorftrercoll wlqHxol/lloos 3 I4tco) Eonuedtreg rxaor
364 . PEBMATOIOTIfl H 3AEOTIEBAH]49 OIOPHO-ABUTATETIbHOTO AflflAPATA
yppe.I.va\vs 6oru a pyry, ,rroAlruy r4 Hory Bcne.[crB]Ie
cAaBJreHlr-f, HepBHbrx KoperxKoB. Bo:m o6uqno ocJla-
6esaer B rroKoe r{ ycr{Jrr{Baercs nplr AsLIxeHu[. flpu
$usuxalrnolr o6cleAon alg.lalr ilvanasoH AsL{xeHuIl
Moxer 6rrrn orpaur{qeH, xapaKTepHo crJlax}rBaHue
roqcHr,ItrHoro JropAo3a. B c,ryrae pa3BrTvlg oclloxHe-
ttuit s Blrre cyxeHl{q c[uHHoMo3roBoro KaHiuIa ltlt]I
c I.aB reHvl fl. HepBHbrx Kope rrrKoB M oryT BblrlBrqrbcfl
rroJroxlrreJrbuurZ cuunrou Jlacera (noruenue 6olu
npr{ ilpoBeAenrau rpo6sr c no.[HsrueM Brrupxl,uexnoft
noru ), noJIoxIaTeJIbuuI? recr HarrlxeHlIs 6e4peuuoro
HepBa, a raroKe HapyItreHI{rI qyBcTBrrreJIbHocTI,I, CI,IJ'IbI
u pe$rercon B HHxHI,IX KoHerrHocrsx.
I Paxnnfi Ae6pr ocreoaprpr{ra
B peAxux cnyqaqx rlInI4tIHbIe cI,IMnroMbI I{ npu-
3HaKr{ OA uoryr nposB[flrbcq B Bo3pacre Ao 45 ner.
B 6omurlrncrBe cJr) {aeB nopuDKaerc.tr oAlrH cycraB rr
lpocnexlrBaeTcrr qeTKas cBfl3b c [peAlIrecTByroulefi
rpanuofi. Teu He MeHee nplr paHHeM ae6rore OA c
BOBreqeHLIeM HeTI,IrrIqHbIX CyCTaBOB BO3MOXHbI I,1
6onee peAxrae nplrqr{Hbr, flpraBoAflrrlrle K pa3Burl{rc
sa6onesaHur (ra6n. 3.39). Eoresur Kaurtra-Eera
npe4craBnser co6orZ pe.rlKyro Oopr*ry OA, xoropax
Bcrpeqaercs y.{erefi B HeKoropbrx peruoHax Kurat,
KaK npaBr.rJro, B Bo3pacTe or 7 Ao 13 ner. orr.roror}{s
npouecca ocraercs Ao KoHua ne scHofi, uo x Saxropalr
prrcKa rrpe.{nonoxnTeJrbHo orHocflr Ae0uulrr ceJIeHa
u rpu6roroe 3aprDKeHlre 3epHoBbrx Kynbryp, [poAyIIu-
pyrouux Mr4KoToKclrHbr.
! OposuaHbrf ocreoaprpr,tr
nraquoft rpynnbr [aulreHroB c OA cycranoB pyK, AnrI
Koropblx xapaKTepHbr AnlrrenbHoe reqeHl,Ie, 6olee
i Ta6nuqa 3.39. flpuruxur paHxero ocreoaprpfiTa
Moxoapruxyrnpxuril
. npeAuecreyoulag TpaBMa, roKarbHan secra6nluHocru
Onuroaprlrxynnpxuril rnu nonnapruxynrpxurfi
. tOtz'lA
. Mera6oruqecKAe vflA oHAoKpr4HHbre ga6oneeaHilq
- Fevoxpolaroe
- OxpoHos
-Arpoveralrn
. CnorluroennSrsaprar Alcnnagvt+
. llogAHhrl aeacxyrnpgsrra uexpoo
. Heeponarilqecxnil cycraa
. frflcrHbrx cycTaBoB npH reMoxpoMaTo3e Lrnu Hapyrle-
6one3ru Karuuna-Eexa
BbrpaxeHHbre npI,r3HaKI4 BocfluleH]Ifl, !IaCTO C yTpa-
tofi rpy.uocuoco6Hocrll, L MeHee 6laronpnnrHuft
nporHo3 rro cpaBHeHr,rrc c y3enKonuu OA. Otru.ru-
TeJrbHbre [p]r3HaK}r BKIIoqaIoT [pe[MyIIIeCTBeHHOe
nopaxeHlre npoKclrMiururrx uexSilJraHroBblx cy-
craBoB, cy6xoHapa-nbHbre spo3[rrt Ha peHTreHoBcKI,Ix
cHuMKax, aHK[IIO3 HeKOTOpbIX nOpAKeHHbIX CyCTaBOB
orcyrcrBr,re cBfl3lr c OA lpyrofi roraat,tsallrlr. He
r,r
BloJrHe scHo, qBrqercfl ntv eposunurrft OA orAelr-
noft nosororr,rqecroft Qopuoft r,urlr pa3BlrBaercc
BcJreAcrBlre nporpeccupoBanua OA cycraBoB BepxHID(
xogeqnocrefi.
PeHrreHorpa@nx nopaxeHHoro cycraBa qacro BbI-
qBr.f,eT o\LIH VnV HeCKOnbKO TI{[nqHblX npLI3HaKOB
OA (crvr. pnc. 3. I ll*3.22). flounuo rraarnocru.recxofi
ueHHocTI{, pe HTreHoBcKl{qF cHrlMKr{ rro3BoJI
'Ilor
oueHlrrb BbrpaxeHHocTb cTpyKTypHrtx u3nteHeHull,
IITO TIPI{HI,IMAETCfl BO BHI{MAHI,IE NPU PACCMOTPE-
Hrlrr Bonpoca o flpore3r{poBaHr{u cycraBa. ftpll OA
raso6e.[peHHoro cycraBa rroKa3aHa Br{3yanI.{3aIII,Ifl
cycraBa B nepe.[He-3aAsefi npoeKu]I]I 6es gecosoll
Harpy3Kr.r Ha cycraB. PenrreHorpa$urc KoJIeHHoro
cycraBa npoBoAqr B nepenHe-3aAseff [poeKur{H B
troJroxeHrrr{ crorl Arfl oueHKu cocroqHufl 6eApeHHo-
6orsure6epqoBoro xprIUIa, a raKxe B ropI,I3oHTiuIb-
Hofi npoerqw r.pr4 corHyroM KoJreHe Anrr oueHKr4
r opaxeHlrfl 6egpeHuo - u a.[KoJreHHoro coruleHeHH,
cycraBa. Cyxenue Mex.ql{cKoBoro npocrpaHcrBa L
ocreoSurlr npu OA no3BoHoqHuKa xopo[o BbItrB-
rrrrorcq ua o6lr.{Hol{ peHTreHoBcxou cuuure. llpu
IIOAO3peHlrU Ha CAaBJIeHUe HepBHOTO KoperrrKa IrJrI4
cTeHo3 cn14HHOMO3TOBOTO KaHaJ'Ia CneAyer npOBeCTr4
MPT nossoHorrHlrKa.
Pe:ylrrarlr 6uoxr{N{u.recKoro u o6ruero aHuulu3a
KpoBra, lrccneAoBaHvtfl. Ha ayroaHTl,ITena o6rr.rHo n
rrpeAenax HopMbr, xorq OA Moxer coflpoBoxrarbc,
yMepeHHbrM rroBbrrreHlreu ocrpoQasoBbrx rroKa3a-
re.neri. Acnupupon aHHag c[HoBlruurbHafl xuAKocrr
rycTaq, BrI3KarI u coAepxr{T MMoe KolluqecTBo KreToK.
flpu paHHeu.ue6rore OA rpe6yercrr AonorHI,IreJIb-
Hoe o6c.reAoBaHr{e B coorBercrBl4lr c npeArloJlarae-
MbrMrr [putruHaMr4. PeHrrenorpa@ur nopaxeHHorc
cycraBa Moxer Bbr.sBuTb TLIruirHbIe [pr{3HaKr{ .u4c-
rrJla3I4I.{ t{nu aBaCKynrIpHOrO HeKpO3a, paC[UpeHI4€
cycranuoti uenu [p?1 aKpoMerar-rpll4, MHoxecrBeHHbIe
KHCTbr, XOHApOKiUrbUrrHO3 U nOpaXeHUq [.SCTHO-34-
Hr.re apxuTeKTypbr [pI,I HeBponaruqecKlrx cycraBax.
- Halox VO Hdu IsHsHDoQQ€ IsJorcIDI HtosoHodl{Irul'rJ
HHrDratHH arlHsurcfcudr-fug 'strol I oE raunexrrodu
en erxarpQe aunonedxoc uresodudrcHone[odlr EsBrO
-ir oronnaro) VO r,rdu celt E olslrx€) Noreade.tHl4
c solruoxurdo)o)ollil olllHetress .(wonserc,{cudr,ftrg
ou rHHBsotrelrcStr oH'4lguueNedsoxredx oHhlqgo
rxaQQe 'usulc.(c oJoHJcruee-oHrcu[ I VO ]Ir{Hehelr
Hdu sor^rorur{u3 K,IHehJeIIgo 6lftr rcroil$Irollcu e)oI€J
e 'esurcl(c oJoHHeIIo) VO uI,IHoheIr udu IsnararxeQQe
golrxoxurdo)o)ollfJ lrlln)eqHrt ennaelc,(cudr.&rg
],l]4hyeclH}l olqH st[5i5ridr(-s
' runenewudu oJoxcehI,IHI4Ifi
o:ossur,{d rIItr IsHesodudril.r.ledue eH e)ou I,IHO oH
'yg udu ultodtrnHc orosellog Ifi{Hehalr Nosrcvedc HrsH
-aurxeQQeo)ocns 63rolsrrsr elqdorox'sosdeH elcod
,{dorxuQ x euarprrHe eulroileurudrgeu rsnerogudeed
umsrg 'BumqrfogeH otprrreneltradu xI4 ou E€eg r€Hqlrer
-e€€)oV on' nlrrehtoluwuc lrhtlqxer(durodrgox oxoru
c sorHoHflEr ,( rcroileqro[ol{ etrJoHI{ 'nnl'uguredu u
HI{rHauBgBJ 'ltutm.l,uudlfiI Ie xux 'gledeuodu elr>tel
' IlxI{roJqreHB olqHtr}Iol4uo eIqHqIII4 3 rcsluao g edlou
r",fu olat etrrogl4'Irw€xllroJqlruH€ lrwlqHxoltc ]Ilrlr hlolron
-urenedEu c s,r,uuodunugluox onmeuc,{ oI{xoI^I xll lluog
rlonrruc udu u'roneJorlud€rr v'teh'IqusltrxeQQe eerog
oHqueJprheHe H.redeuodu llre 'f,gIIH rlaudu 4ltusred
-odeu sredrolrcced ro,{trerc ao}toruruIa3 uunenedxoc
udg'uuuflue cue>turvf u agUH oJoHrceru ouHersugotr
wrsueedgoocerefi srlsg rexo^ e)IoIBr I,lrcI,DI ]r egercr{c
oJoHHerro)vO udil 'rox€rerled€u qrllh€HteH re.{trerc
tldg
delt xqseourer rex.rtrenioH lIJcoHsuueQtpeeu
erHohou eovceh[JouovEwdeo
'er{HohJergo eonnaweda qrutr
rexow eVJoHI,I (Btrolfox vYItrelfreJ- NeuHesoeqroucu c
'delruduen) ruuedeloueuQ ruHJceIN'€setc,{c oloHHe[
-ox VO udu lqHsr,rrxeQQe runrtr,(nrrarcoduenodrxere
renxovcodr, u el,tH€slqlrBx,(orl.r oln' ouu€€xo g -r,(c.lo en rdroltcen 'u delxedex gnlturedgoeH rlrcoH
elHeheu eoHeorHenevlueweH
' Iqnourwuc qrI,IhJoIIgo oHr'rarcun rft olt lrron wrger'od
-ox.,( 4eulecHexr rox c sa.(go ruxcohutreuordo enoler
e'urcodr olrHusoeqroltcu'qrcoHgulxg r€Hilr€ada.lnu
'sedgo retflorl{dr4EHrdolru eserc,(c orounedtregoeur
rrL-H oJoHHerro) VO ud11 'rsfimnw Iltossrrrxedlsrar,
axxaruadx,{ EH B}rHeHxedu,( rsHeelrolr oHHogoro
esuDir oroHHeroxVO rd1 '(17'E 'rgurnc) rxerp@e
UFTIflL?rJot(oLfou rol€tr e){olel'lgeuedoJ,oueuQ reeltun
-xdu axr:er"{ eoHsrlrxu xrsdorox exrogedeed g'wrtl
-emrrdrri anHgodee H eumorrmedxd enncxerruxoy
99€ . IlldLdO:IICO
ror(erctlcro
eoeercAc oHav\ee ou 4rahedeuo guU guHehhHed.Lo etstrl.cedeog
'rpeVoll xrsuuxou ,{ eeerc^c o-toHnedVegoeer iluu oJoHHouov
eudrdeoerco ildu urcoHUr[reeHu tsndoS {ouoxul or4H0h0t
eor.rer,1oieooe uvcoht4t{oHov€ eoeerclc eHov\pe cBHuoU
-
eeen,(uc eUsd e eeBrc^c uuh)tttlS
sr4HorJeoHprccoe cuU ehHeheu eouenrxeQ$e orceh h goH
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flpu ovaronux geSerrax xpflua B pe3yJrbrare rpaBMbr
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JreHr{s xp.sua.

I Hyrpr,rqeeilxr _ Kpu crann ilq ecKtlt 14 aprp r4r

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OA roreunoro cycrana. .{aHHbre paHloMr,r3r,rpoBaHHbx
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nenu o6rer.rurr 6olr B KoJreHHoM cycraBe @a3*5%)
rro cpaBHeHlrn c ruaue6o.
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o6pasa xn3Hr4, cJreAyer paccMorperb Bo3MoxHocrb
xupypruqecKoro JreqeHlrrr. Onepaqza lo
uomrorl saMe-
He cycraBa Ha ceroAHfl rrrHuil EeHr sar,fl,ercs Ha[6oree
pacnpocrpaHeHHorl xupyprw ecxoft nporleayporl npra
OA. Oxa Moxer rr3MeHlrrb KarlecrBo xrr3Hl{lroAefi c
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leHIIt4, no AaHHbIM peHTIeHOJrOrfi TIeCKOIO I4CCneAO -
BaHlz,s.. He cle4yer npoBoAr.rrb onepaur4ro ua pauueri
cra4t4u OA, o4naxo BzDKHo paccMorperb Bo3MoxHocrb
ee npoBeAeHr{rr Ao nofl BJreHr4rr $ynxquouaJrbHbrx
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AeHrreM cycraron (ra6ri. 3.41). Kpucra,rnn uoryr 6rrrr
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r4Jrr4 AorroJrHr4TeJrbHbrM (xax npu 6one3Hr{.qenoH}rpoBa-
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(ptrc. 3.23). Heo6xoAurrla rocrarorrHarr KoHr{eHTpaurarr
xr{Mr{qecKnx BerqecrB (lpo4lrron r4oHHoro o6rraena)
B coqeraHlrlr c p,uc6atrr.coM TKaHeBrrx @axropon,
Koropbre peryJrr{pyror @opuuponauue ueHTpoB Kpr.r-
cratrnv3arJuv r4 pocr KprlcraruroB. Bocnanure.nurui
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cxoti HepanHoMepHocrl{ }r BbrcoKoM orpl,ruareJrbHoM
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i xeHt e KpltcrarnoB B coeglHntenuxofi rxaxu

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o 3aMeHe cycTaBa. l-1rpo$ocQara Kanbqile Ocrpar nceagonoAarpa.
Jluur y ne6olturoit \acru rarlr4eHToB OA npo- Anrnqpar. Xporrrecxa.n nrpoQocQaman
apTponaT14r.
rpeccupyer Ao rarorl creneHlr, Korna rpe6yercx uonHar
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qacrbrM noKa3aHueM x,4annori npoqelype. y 95% KaluqrHos
flaur{eHToB u 6olee, nepeHecrx}rx 3aMeHy cycraBa, Heqacro
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. uJr4nbr pacrerril / unnur XpotrvecxrarZ MoHoaprpur,
vopcxux exei TeHoct4HoBt4T
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-daretr oJh 'I,ImE)r'ou IqJorcpDI I^{osehollr rauledxcxe
aHHOxr,rH, B}LeefrofirgeH aorHer,rfiefl yg6 twen aouog
'urudlde uvccutnadu
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u rcrorfeedgo E/7;ex rwads or s '{rotfiulr c reeufucou
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orn'qrr(gxdehtrou oNutroxgooH, rsdJetrou yutusted
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!uvu, uopenpogyxrur, [lyruyrulraeaqur Cnrree

xupHaq pur6a, cy6npogyxrur nypnHoB de novo i Ta6nnqa 3.42. flpuvnnur rnnepypuKeMlrx lr noAarpbr

Yuexuuenue BbrBeAeHr,rfl noqKaMu

l-lypranur, no.ryn.oqr. I Sngorennure nyprrr, I r c
c nuqefr (-400 r,rrlcyrxra) lloaurLuexxaqpea6cop6qr4q lexapcreeHHbrenpenaparbr
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I ArKoTorb (AcnrpraHa)
rranoxcaxnax
I
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(-1200 ur) t Milero- n rrvSonporuSe- . HacreAcraeFlHbre naroron4r
parr4BHbre sa6o,leeaHr1q - CrHpou fleu.ia-Harzena
Yonxoavon,{ecx}re
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nrpoQoc$arcuHrerasur 1
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(-800 ur/cyrxu) (-400 ur/24 raca) Eoleeuu HaKonrreHilt
milKoreHa

Pxc.3.24. Mera6onugM MoqeBof Kucrorbr. floragaHur ocHoe- " O6utqxo reHeruqecKu AerepMuHupoBaxo (crr,r. a rexcre).
Hbre nyru o6pa3oBaHun 14 BbrBeAeHufi lroqeaofi Kuclorbr, a Ilpuueraxue. HPRT
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llpeAnoraraercfl, qro cBrr3b Mexry OA ra uoAarport
onocpelyeTcfl cHr,rxeHr4eM ypoBH.f, npoTeourr,rKaHa r{
Apyrr{x cy6cranuuri, unru6upyroullrx o6pasoBaHlre
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coeAI,IHeHUeM XOpeOaTeTO3a. BpOXIeHHyTO flpuqr,rHy
cneAyeT 3arroAo3plrTb nplr HiL'rr{qul{ ApyIHx KJII{HI4-
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paHHeM BO3paCTe B COqeTaHI{I{ C IIOJIOXI,ITeJIbHbIM Ce-
Mefi HhrM aHaMHe3oM. T.pKe.[a.s r[nepypr.{KeM[s Moxer
TaIOKe BO3HI,IKaTb y IIaIIUeHTOB C TeMaTOJIOTUqeCKLIMH
r,r ApyrnMr,r $opuauu oHKoJroruqecxux sa6ore BaHlair
ua $oHe xr,rMr,rorepanr{r4, BcJreAcrBrre yc?rneHHoro
pacnaAa nypr4HoBbrx ocHoBaHr4ft (rusuc - cun4porvr ),
9ro pegxo npr{BoAr.rr K pa3Br{T}rro noAarpbr, Ho Moxer
6rnr npnvuuoft ocrporo noBpexIeHr4x nouer (OfIII)
(rrrovexuc.rrorl ue@ponar uu. IIp uuea.
- p e d.) .

Y se6omuofi qacru 6omnrrx noAarporl 6oaesnr

pa3Br,rBaerc.f, BcrreAcrBr{e r,r36brrorrHori npoAyKu}ru
MoqeBoll Kuclorrr. Mexanl,r3Mbl I{3yrIeHbI lrr'Ioxo, 3a uc-
K'IIorIeHfieM cJryqaea uyrauuft B reHax, perynupyouux
Mera6onu3M rypr{Ha (rn6,r. 3.42). Cun.upou Jleua-
Hallena (Hacre4crneHHoe 3a6oneBaHr{e, xapaKTepr,r-
3yroueecfl yBenI,IrIeHI.teM cI,rHTe3a Nao.Iegoft KI,IcJIorbI
yAereri.
- Ilpuuea. ped.) tatrerca Soprraoft roAarpbr,
HacneAyeMofi no X-cqenJreHHoMy peqeccrrBHoMy
TlrIIy, corpoBoxlaercfl :a,uepxxori nc[xoMoropHoro
I Knuxnqecxas xapruxa __
Klaccuqecxarr KapruHa c ocrpbrM MoHoaprpurou I
mrccue$araHroBoro cycraBa Ha6nroAaercs 6oree r{eM
s 50% cryuaea (puc. 3.25). B nocniurr{renbHbrft npouecc
MOIIT BOBJreKaTbC.' n.ItpyrHe CyCTaRbr TOJTeHOCTOn-
-
Hbre KoJIeHHbIe, a TaIoKe cpeAHflq qacTb cTofIbI, 3anq-
r,r
crbe, JroKTeBbre r,r MeJrKHe cycraBbr p),K. Ocenoft cxeler
r{ KpynHbre npoKcr,rMzrJrbHbre cycTaBhr nopaxaroTc.f,
pe.rlKo. Tnn[.rHrre flpogBJreHr,rf, BK]rroqaror:
qr.EEF[Frs uIrH rJqJesodulrlrQnu',(ccelt rcodfiemodx
'a,ftieg rErarrls 'trcqJnrsetrq,€ra rfuolt ung 'aoxree.(
xF[ilMorensad ro xu Joah]IIrJo orn '(97'g 'cud) .reatt
Urrrag rda,t[u lscl(Qo1 'rsHusoxed 4oumd oxrl4seo 3H
w Jourt u xyvlrfl.rxoxfc xrs gomfirxe' xegetc,{c xgseuolr
'panarnrredu 'x^(d 4elcnr 'goflqreu xmcorrxdesou rcsH
-qrarzguJtrSd en orl{nersroll xu ) ruflHotrHar Ircro€tr
-o{rgeH'ul^recr((por xnxo?slqo?H'tsrtdoQ gouqrftrsedu
-on sox[oer( xlstrdesr Heranegoeedgo c xrHe)r xlDIJtrI^l
u xesercr(c a I'csJ?alqtr?rX.Lo rfuolu rsrrer,cud;
'(g;'g'rgur) sordrclrdu
xrsdrco ro euhl,Imo g 'uner{orttltrnc uvuurru(xoJolrrs
t4rcoHht4cvoJ. eilHexogen oe'qreeilhl4ueeA xl4
oHHouolcou ra (rlc4r,',t gg) euouttdAuotiue lceoU oilveilH c-Leh
-ereer relUeu3 eooreQQe xqHhogou rlovcttd t,'ltqwomtqeou
c he6ec e oqrcosxodorco c c-Legoecuoucl4 relUouc Ht/h
-r4xrJov 14
CEUH 't4oilheeiluugon tleuHed u eouilovhrdovovo{u-l
r4euhle+uu 4oneerclclrdr,{ne 4otnol^Eoucou c silhediluce
eueraora$Se aouogileH xeufucrdu xqdrco udu :olHehe[J r
rlorcoHh0Hov
xuHxdee rceerc,{c ucroiexedou etne;,'uneufucndu ltntqdlco
oH E 'r4tl\Bv\orul\t4c ,11/\l4vcehuHodx r nnecr{Qor rvlteH
-HoHeouog c 'r4oHht4ut4l-B c1lc9 loxotl'l exurdev 6e)cohl,lHl4lf)
erudrdeoerco eroQ eu scraeeileeBd
orcen edreUog '(ggy) xer,ou ilHeouog 4orcer'uuodx r eox
-lued{lrU st4HeHet,"lt4du ailsrcUaucs BdlPUou cpHL/dore gcre
-pUorugeH sortrarhe! xtqurxou l4l-ceh {emquog ,{ :uu.touourg
ercedeoa urout4xou a ed.reUog 'Er'e ,t roerf
S rfiow rvu,fucudu atsfucg 'ltorufudu ltnnaurxeed u (tot
rrroruodUsnc vltqseuog wtqHHax
-edrqe il 4ovlerude 'uro)eJ"o c Beerc,{c oloeolueueSalcotuu
oJoedau rndrde 4nrcanrd:eUou 4rsdrc6 'edtUog 'SZ'6 'c!ld
t treH
{ irscen euH
690 . IlldIdV l4l4YC3ht4UWICl4dY
LNIDISohI'IHOdX C '40.rderc '4ourruuuloH qrrlg rexoH
gotrorr xHlr[xou ,( lqfuetrou esr'rrdex rexcehl'IH]Ilrx
'Hdrutrou gouc,{Qor
4oxcer,unodx urltrBrc o[ ouHugoduccefuodu orxKowoos
e)oI€r'erradrde o.ro>rcor.ufuetrou orod'lco ulqerrrfu cladu
unrqHHearcoxoHlI roletr€drc andoro)'4enltexudt(
-deuu.r goner(durofuHo)eH 3 sorHel'Ifiuu 6 'xeaercz(c
xtsHHaxedou fl 4LIHem,{deH xrsHslruHourIxH,(Q H
4lrneltdoQetr xrsHHexedlss I leuJ,I{sted l lrsHxoweog
'ruueaeroge€ Nol,IHesoduccedlodu wramotr(treffcou
c BtroJ I el,IHaher s EcreEsuflged suvuled 4nadeu
soehrftIc esrcHl4mqrog s o)BHtro 'JoIr o)qroxceH trc
-srurVodu roxow [oudeu 4rsuurfu cuduxevu xur-(dtr
,( xex rln[eds or s 'qlurr(lcutt eH uVJox]IH rexon
nr{HeserogBe sI,IWIrIed sorHel,Ifi€u xndoroxen 6
'o)tred rcJe€trollrquH
gosurcr{.c xu>Iil[o)ceH er.ilroxedou eoHHenledsoHtrO
'(uderrradl osrcehex a le,(arcgeV u,tgpudu 4rsedeu
'rfitovul.ttrug-ou 'eft 't3ouV oxsroxcoH s I lorEsde'r,nu
c sosercr(c xurr(d[ rI,IHoxPdOX AUHOHUIOOCUdU) XUIU
xrsHdercerx xrsl Ie€sIq€?H )?r nel4Jrlsted c eserc1(c or
o - oHtro Neh aorog elaHaxedo[ rcme[ollrg?H xI'IJ^dtr ?['rd
O)irro)ceH rceerlole)Krotrodu'ruueaorogee
or{HehoJ eoxJor oelrog Joleslqcnuo IqrHeI{[e[ aLIJOHIAI
^'4eHtr
. 'rilnorllnuc olqHtroxc Jolewu orqdoro)'u)r€nrelr>I
gonxoxtrort rl,IHoli?ucos orofuco um,I Bu'IsoHI'IcoHer
'urncd,(g 4onur.dzx 4o>IcehllHl,Irr;r rcqrrrgrodu o)orcr
-Jehrarfl ritoHxoxtrox NeI4HeIrBrcos wIqHHoI,ITDoQHI'I)
Norr4rrorrrofi' ltouadrdu xlDIcehuJuec c sIl{trosodu
oniutroxgoeH ^(vurconreutr oI^,(HsIrEI4rIuedeQQu['' moa
-e.rc,tc wrlHHexedou trPH I,D(ox ol,IHemlfirom vY[e BJ
-Jolnrdgrrou oHhlilgo'uaVoxodu u^{rcradu xex o.ror edelt
o11 '(o,rouxerox 'daluaduen) eaur,c,b orosu.(dx uusex
-udou udu oHHogoco '4udulleY exeY il eLIHUJoI^lotreH
'BxYedoxur rlHxol^t€og 'Noserc,tc treH 4owerud€ LI
r^ro)oJo ltgHdeuedex 3 erl,IsoHltc oronnexedrss BHI'Ir
-dex rexcer,uHulrx rcrauslrseed errdrcl4du rnedu og
'goH['rI-9
el,IHehor s euHemedeedoln{ec ooroeh}IH}rIDI .
llalosercr(c
}Ixo) )cerg ]I orultedeuur 'xelo rlnuuexBdlva .
ir(aercfc zfutonnexedou ) ullHesoHco r
-ndu rrem4erult udu Yx;.;eesuruct redorox 'tro9 .
lurog 4oltaea
-rqrnlcu ogl,Ir-efto) eu olftrqrrurc oilrlec )B) I,Ihl€r
-Hel,rrrelr otrftnreeglscurto orcuh'srog oilm4eHill'I'Ic .
-nedr,{tradu u erqHhoH s elfleh 'goNo.LuNtL eurus
-eed eernoilduccedrodu 'n 9-Z ol,IHeher s 'eofuclsg .
370 . PEBMATOIOTUC il SAEOrlEBAHhq OnOPHO-ABUTATEflbHOTO
f 6uru uyrHori
Puc. 3.26, flo4xoxHurfi roQyc c 6eaurun Kpr4cranraMu MoHo-
rugpara ypara Harpuc. [1o4arpa, Bbr3BaHHar nphMeHeHueM
AnypeTuKoB, y naq[eHra c npeAuecrByrorJ.[4M y3enKoBblM
ocTeoapTpr4roM
r upo$un.
Pnc,3,27, Sposuu Ha SoHe xpoHr4qecKoro noAarp[qecKoro
aprp[ra. LlJraMnoeaHHuE (,,6yxra llynaopra") gpo3t4t4 (crpen-
xu) npu AecrpyKrr4BHoM aprp[re, nopaKatoqeM nepeurfi nnoc-
HeQanaHroBbrfi cycraB
MecrHyro Bocn€urr4reJrbHyro peaKur,rro c 3prrTeMorl u
HarHoeHueM B oTcyTcTBr{e BTopuqHoft }I}roerquu.
ToSycu, KaK npaBprno, sBJrqrorcfl npr{3HaKoM .unl{-
reJrbHo reKyllleft noAarpbr, Ho r{HorAa Mor},T pa3BrrTbcrr
B TeqeHlre 12 r"rec y naqueHToB ua @oue xponuvecxoft
norreqHorl HeAocraroqHocru. I4HorIa roQycu lroryr
IIofl BplTbcrr npu oTcyrcTBlrlr [peAruecTB]'roru]Ix ocTpbx
npr{cr}rrroB, oco6eHHo y naur4eHToB c OA, uoryrarc-
ulr{x Tepaluro Tr,ra3uAHbrMr{ Ar,lypeTI{KaMu.
AnnAPATA
B Aononnenue K nopaxeHlrro onopHo-ABI{ra-
TeJrbHoro aflrapara, xpoHuqecKas ruflepypuKeMl{f,
Moxer ocJroxHrrrbcr o6pasonaHraeu raunell B rlorl-
Kax, B TsxeJrbrx cry{a.f,x,
- HapyueHlteu @yHxqufi
rroqeK c pa3B}rTr4eM r{HTepcTr,ruuaJrbHoro neQpura
B pe3ynbrare ocax.4eHr,r.s yparoB B IIoqKax. oro oco-
6euuo pacnpocrpaHeHo y [aqI{eHToB c xponuvecrofi
ro@ycuoft rroAarpoft, Koropble rloJlyr{alor repanuK)
AIIYPCTI,IKAMI{.
I l4ccnegoBaHne
luaruo: noAarpbl Moxer 6rrrr noArsepxreH BbI-
,IBJIEHI'IEM KP}ICTZL'INOB YPATOB B ACNUPATE U3 CYCTABA,
cycranuoft cyMKI4 umr ro@yca (crvr. puc. 3,6, A). flpu
ocrpofi rloAarpe cr,IHoBuaJ'IbHarI xI,IAKocrb Moxer
BcJreAcrBr{e rroBblrrreHHoro coAepxaHl{,
neftrpoQu-rron. flpu xpoHl,rqecKoIZ noAarpe nneururti
suA 6oree lr3MeHqI{B, Ho HHorAa xriArocrl Kaxercfl
6erofi B cBs3r.r c npuc),rcrBl,IeM KpI,IcrzuInoB yparoB.
flpu acnuparrulr xr,rAKocru lls I nrrccue@araHroBoro
cycTaBa r{Jrr4 KoJreHHoro cycTaBa B MexnpllcTyn-
nrrft nepuoA Bce eure uoryn o6HapyxuBarbcrl KpH-
CTILIIJIbI.
B cs.trgu c Bo3MoxHocrbro HaJII{quq Nlera6oruqe-
cKoro cr,rHApoMa cneAyer flpoBecrl,I 6raoxprMu.Iecrull
cKpr{Hr{Hr, BKrIorIafl oqexxy @yrruutZ no.rex, ypoBHfl
Nlo.resorl KIlcJ'IorbI, rJIIoKo3bI Ir nuflpl.uHoro
flpu no4arpe o6blqHo na6rronaercfl runeplpuKeMl{s,
Ho ypoBeHb rr,roqesori Kr{cJrorbl Bo BpeMf, npl{cryna
Moxer 6urr nopnra,rbHbrM, rrocKonbKy co.{epxaHl,Ie
ypaToB B cbrBopoTKe Bo BpeMrI BoclliueHvs.cHldxaeTc ,.
Ocrpax no.[arpa xapaKrepu3yercrl noBblrueHHoll COO
r{ ypoBHeM CPE, uetirpo$ur.uefi., Koropble Bo3Bpatua-
rorcrr K HopMe uo Mepe perpeccr{u nprrcryrla. To$ycuaa
noAarpa MoxeT conpoBoxlaTbcrl yMepeHHbIM, Ho xpo-
HI'IqECKT{M IIOBbIIXEHIIEU COO U YPONUX CPE.
flpu ocrpou noAarpr.{rrecKoM aprp}Ire peHrreHorpa-
Su-a o6rruuo He BburBJrrrer ra3nreHeHnfi, Ho y [aq]IeHToB
c xpoHr{irecKoit utu ro@ycuorl no4arporl Mor}"r Ha-
6.rrcAarrcs .rerKo pa3rpaHl,IqeHHble 3po3llr{ (p wc. 3.27 ).
To$ycu uoryr rarcre 6lrm u{3yaJIr{3I{poBaHbI Ha peHT-
reHoJrorr4qecKoM cHtIMKe B Bprle xapaKTepHoro oreKa
MqrKl.rx rKaHefi. Ha no:Aur{x cra,[urrx 3a6oreBaHr.rfl Mo-
ryr Bo3HI,IKarb AecrpyKTr{BHhIe I,I3MeHeHU,I, CXOAHbIe
c raKoBbrMra [pr.r Apyrux @opuax nporpeccupyoqero
BocniurlrTeJrbHoro apTpr.rra.
I Ileqexrae
Jle.reHue .[or:rmo 6urr cocpeAoroqeHo Ha k]Trr{po-
BaHyfi4 ocrporo npr{cr}r[a, an AalruerirueM Ha npo-
-
 'erroHlrd(uomru rftr ]r )B) 'r(uulrnlrdu ex
.ixoxel ou aon fucudu xqfuco exrarxeruQodu el^rutrox
-goau nuueder urlfrBlrtlr4Hr{ rHer ror4r BH 'r,(c/rlr 971 on'
romgH['I,Irasd ee Noregro ruIqHrea)etreeH c soJHonn?ll
f rtamgeusretr e 'r"(c/rlt 98 rerflrsurcoc Brotr resordurc
ruHhrqgo 'lrrauudel arenun s rsrrfucudu ersfuco reegrce
-Iqg oHhrlgo os 'rroHradr(uornre r,{eh'HesrarxeQQe eerog
u6 'rcre-(gadr en rseotr ruloreddox rlrcoHhorurcotraH
udll u'uHehelt a ,fiirreurogeraw rcree.rdeg
EoHheholr
-trou r?rcoox,{ga6r'nr,xeQQe arirHhogou rousrqrrirs
Irtrr,r He€e)ouogurodu ronr,rdr{uorre etrtox'xren (trc
xer s e)orur e 'ronud^(uorue eH r roresro llrlsHJusxaft
-eH c sorHeu[eu ,{ rcrerlreltudll Ho oHhrrgg 'r(eun'
-llc)oHlrJHucx r,er(du gz.tHI,I oxxEI rurcocxfg e6
'OHHOH8I/IXOX qI€X
-rotrodu onutroxgoeH 'soredrt rnsodr( er{HexotHc €H
or,(nnerseduun'orrauudel sorHeufi€u esrcHumsrog
'Iqrorcux r^4osehor r rHsod,{ nudorunolt rjtlirHtroJexe^
rcrefYnelroxed esuuaucdeu EonnodcoJrotr eorog g
'erudtde o.rod.lco xrunersrodu xrssdeu lrdu elreradu
rfi r roHo[osr,rHtrodx u
f,glIH 'NoHufrprxro) qc]rrJBrr
-80 qrBsoYHeNoxed oxxor{ r rerH3uIr€u rqeureHdersre
esroehu) g 'sofircew xr,nq[oxcoH xrssdeu er,rHeher s
JSUH uru (rxilc s eeed Z Jn S'0) BHuluxro) rrr4H
-eneltudu oronsrudodeu oJo)coh[r,xeruQodu ltar"(u
qJLI8LTHC OHXOI I eU,fuCUdU TpIHeAOH)lrHooS )Cr,rd
'uud,tcudu yutuaced eer,^ftrc s oxetr orulEder sre)KroE
-odu cu4codlorr 14 eJHer,rluu srutredu.(tredu re,(trerc
wor€ gO 'rsfu€trorr rsrrfrcudu ersdrco rcror€trorrg€H
orceh 'soredr( rHsod,( er.tHexuHc BH goHHerseduen
'nlluuder ETBhBH er.rcolI '(rIc/ur 996) tseo['4owe,(V
- nertoxad [oH<rrEhruc)Eht rI,IHexHr )oY L4ltu aorxeQ
-Qe xsnnogou yuHesoHxnHeos'rqrotrcl,tx HoseholI
rnsodd o.rofl eren BuHe)rc{ltor otr (or<rrcoHhoJurcoEaH
HoHhehou J Hatrorrr H xrqmD(ou I rlt gg) ueH i erqu
-xB) Jr^r 001 eH cresr.thurasd ro,{rarc eroHr.rd xorflr€
z(eo[''urconhorercotroH goHhehou r.rdu u sorHeurreu
xnnlrxor ,{ .utr gg uuu t"frcf tw 00I rertrsurcoc eeoE
reuqtraher yuna,&lneltoxe4',fu,orcrx oilsehor^r s €Hr,rr
-Hec) r4 eHl{rH€c)orm rltnelnedgedu or,IHamsHeru(
x rutrogudu olt' ',{eeYr.rcxoHr{JHuc) r,e,{duguJrn u6
'edogne ltorudeuadu yclerrs.B ronud,{uoriry
'(tl/rN g) r/srowxr,t ggE
euHehuHo ilJBsot<Ilfoucu rcrartrneruoxed unrruueaerog
-e0 uwnrcehlruensed c egsdog ou lrJlrrr rlro)c4euodaE
asrc[oso)^d s )e) uVJor '(tX/JN 9) r/sron;llr 99€ Jerrr
-surcoc o[HohEHe eosotodou sorororungad esrcemgo
oroxcnewrdg unrvlrutrHararoxad c uualcresrooc g
' rudl;es erud,(
uredfiaJoHon rsrflmcudx rcroileedgo
Itodorox ndu 'rngod.( o)Kr,rH IqrolrolD{ Xosehollt uult
-efuira[nox rHHe)Kr,rHc reho B€ ao[rfucudu uunatluds
ll.8 r II4dldV l4t4yC3hl4uwlCl4dy
eeerclc t4un t4lco>t lgvtH
eeurruodSep.l . -etixadeou eercsuareeexofit .
crcoHhoJ-elcoUoHreHhahollo rudrdB4nrcenudreUou
rsc{$o1 . frcdrco r4llinorldrenUnhes .
!
-lotradu s rcroehorrDrur rraHeher s[etr reHhodcorrofi'
'(py'g 'rgrL.) sJusrs[€rr>tro eH oHirrer€uox ot{Hoholr
(r]rueode uru aocr(Qor or4Horsrou) guueuxorco
vprrovtrur udu uurtrfu )e!\r ZI uranerrrrodu en erudrde
oroxcenr.rdreEou xuufucr4du xrsdrco eerog u x,(atr udu
oH 'sorBdr{ nrsodr{ euHexr,rnc en orr{nneraedueH 'oluu
-eder slenuHcaH oHirrereorgooH'rsd.rufiou ur{lcudu
r,uqHHosJcHI,IEa oooHr r€HB s I^Ir.rfflorewu
'lteluou[€11
evuDeuuQodlJ
'aoruoxurdgxo)orrrJ
unmrnoq,Hr.r r,rwrqHs€Jc^cradr/firs c rcsJ,uaodunlrgltox
roxow uumeQHr,r rrr{Hehorrflor,r u eroHJEr.{tr xoHheHr
-oHtro udu u 'gogerc^(, xrsHu,(dx uuxexedou udu on
-Hogooo 'vrog srlrruerrgo Jexon rlrco)trtrx goHsercl(c
ruleduucy'eufu cudu rruresodu[^,U o[ qJaKrotrodil
r,r sonorrwuc xrssdeu ul{Hersrou udu o.re srumuHlldu
irJBHr{hBH'unouoEun[edu uura €HuIIuxIIo)'f,gI_IH
ceuE€ qJ,eflI,I r,fuolt raltetroeuue ralruhorr(dusutrr4trad c
IsrHounelI 'Notrsu oc rqre)uu oHJceN qrBso€quouclr
oHxor r o)K)BJ sor rorunr.ro rr{HehJergo rr[, 'o)fod
rcre€heHeeH I,IrcoNI,IoJc Ijoxocrla en4edx Be-ell oH
'ueazueQQ€ (Se't 'rgr.l 'nr) gunuftrrxene) €JI-[I4
dorugutul4 '(gg'E 'rger) f,gilH u eHutlrxro) urcoH
-hlrJ)or xcud 4nnnomrlsou xufflolelIu'elcedeog
oJorfl.rxou solHourleu .{ r.,tenner.eff nrsHsl.{reHdersrB
Bcrorrrsr u nnuurxsQQe sueno AatrY t-Z ouHeheJ s
(w / a $c / tw 0Z I
-0 8 ) Horoor4Hvedurmror r uru (sdr-,(tra
ilc/rn OZ-gl) noroerantredu 'UgX lrrfl4 ruHesorogee
ersHdrrf)ceaodgeden'enrcratr(cor-osr.a[dec eut[or
-r(slcr^uoc rcJorowu'gofuetrou 4ofuco xumor€trBdrc
'sorHoHII€u xI,IJoHIlt I r(xsroxcou 'exed rc.lorr(esrou
-crr oH 'nuaurxeQQe ex)er f,SUH enusredodell
'vadenY ra u.r,osd '€.LoHmor rcrorrrsr ulrelxeQQe
I,INIirHhogou unrrqnnenedrcoduced eerogrleH'xurr
-uQodrgeu a xenogfdrodxult uxdogc ruHorsetsou
rrar,tr re,(srcgof HO 'arudrde ltoxcar'ufuevou nrod.r,co
udu edogrsu rtoruduuedu ycleyrrsr'r.DrJ-(c eeeed E-7
Jllr S'0 e€otr s sdrrft{a ulirneghuH€eH 'Hllltuxtro)
edteilou sedno
'aoxdJcr,rdu xurngeHsretr uranelnedsrotredu u
Iqrorcnl gosenonr nHsodr( rrl,IHexlrHo lltoxcerrurxerzQ
372 o PEBMATOflOTUC U 3AEOrIEBAHl4fl OflOPHO-ABHTATEJIbHOTO AnnApATA
Ypuxoaypu.recKr{e npeflaparhr, TaKr{e KaK npo6e-
Heurll, cyrr$unuupa3oH Ir 6eu:6ponrapoH, cHr4xaroT
ypoBeHbypaToB, Ho pe.{Ko r,tclonb3yroTcx a pyrunnorz
KjrlrHlrqecKofi npaxrure. ouu npoTr.rBo[oKa3aHbr
laqrreHraM c u36brrorrHorl lpo4yrqlreri yparor u
rIaIIIaeHTaM c no.Ie.rHoll HeAocrarorlHocrblo I,IJILI Mo-
qeKaMeHHoft 6onesHrro. Kpoue roro, npu prx nprrMe-
ueuuu rpe6yercx norpe6leHne 6oatruoro KoJrr{qecrBa
xLIIKocrI4 no Lrs6exaHl{e Kp}IcrrIJIJIyBa\uv }ro.Ieaoll
KI'ICJIOTbI B NOgEqHbIX KAHIUIbUAX.
fleuoruraga,'
- gro 6uo:roru.recxnft npenapar,
xoropurf KoHtrorupyer $epueur yprlKa3y (orurclaer
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qoao-6egpennoro or4ena u o6pasoeaxue ocreoer,tra (O)
eHTaM CneAyeT peKoMelUOBaTb cHIrDKeHlIe MaCCbI TeJIa B
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ureQco@ oJoHsoHco soure.Lcl4dx aI4Hexorro
erHesouogeS eoux/tuyltor^v I
{rcHcue)ou
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-ulr\e :rvfiql.ax uruQcoQ oJoHsoHco sorrelcudx euH
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'etqHsrerettudJ,o
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urudrdu oJo)cohllruoc oJo)cehuHodx'ueod;en oron
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orc€h I{ rutrdectredu orosedu sore.Iedru osroehuuo)
aolll<rtrog gemuxde['o c' I4rco)trI4x 4oHq IfeJHIrPUcos
osuede rl,{ rsnies,go el'Iruilrog roter,,(rou vrv\rcdvl.rfce
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qrog
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re,(duccefu odu eunuaerogeg' r-roxe,(fueu 4oudelteadn
g
uura 4owtedr rcrer(dultosodu €tsJoHI4 'xusutc'(c
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sorrercudx el,IHexorro eondnmgo v'rodorox ndu
'lrodtrnuc Uulxtrad ore - ('pad'natrnd11 -'vumtodtde
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376 o PEBMATOTIOfU9 U 3A6OI|EBAHl4fl OflOPHO-ABhTATEIIbHOTO AnnApATA

Ta6nuqa 3.47. Cnexrp Knl4HlrqecKt4x cltunroMoe HbrM cI,rMfIToMoM. r{acro Hacryrlaer vnBur;zp.n3a\ufl .
i npm Qu6poniruanrrra Xorq rauueHTbr, KaK flpaBlr]ro, He yrpaq]rBalor cnoco6-
Xapaxrepxure cuMnroMbt HOCTb K CaMOO6CnyXXBaH[rO, OHr4 MOryT 6Hrr ne s
cocTosHr,rr,r BbIIIolIHflTb TaKI4e 3aAarII{, KaK COBepIIIeHT{e
. PacnpocrpaHeHHae 6onb
. rroKynoK vnvpa6oTa rro AoMy, r.rcrrhrTbrBaTb 6onlurue
YroMrgeN/ocrb
. 3aTpyAHeHr,rfl ua pa6ore nn norb,{o yBonbHeHr.rfl B cBs3r.r
ly'HBanilAHocrb
. HapylueHilq cHa c oonbro xpoHr,rqecKorl ycrarocrbro.
r.r
. HtrcKni4 aQQeKr, pa3gpaKilrenbHocrb, nroxae KoHqeHTpaqilt Pesylrrarlr ocMorpa He BblrlBJrflror flaroJlorlrr4, 3a
ucKIroqeHI.IeM HaJrurrfug, tytfiep:urre3l,Iu IIpu wepeHHoM
Pasnuqxure ABurarenbHbte cuMnroMbt
HAAABJIIIBAHI,IU NAITqAUU (AOCTATOqHO A ABIIEH],1IL, I]lql/l-
I CKoBaHHocrb B paHHue yrpeHHre qacbt BOAqlIefo K no.sBreHr.rlo 6eloro oKparxlrBaHr.ra Homx)
. OrqylleHhe oreKa pyK [opilxeHHbrMr{ }^{acrKaMn (puc. 3.31).
Ha.q
. T'loKarbrBaHile B AilcralbHbtx orAenax naJtbqeB

flononxureluxbte HeAB[rarenbHbte cuMnroMbl 06cne,qosaHne il neqeHile

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, Konwxu B xr4Bore, B3gyrile xr4Bora, eapua6eluHocrb pilrMa
nurl orcyrcrBylor, Ho B€DKHo rrcKJrroqr{TbApyrue cocro-
,qegexaquu (cuHgpov pa3gpaKeHHoro xruevHrxa)
. HanorneuHocrb MoqeBoro ny3btpF, qacroe MoqeilcnycKaHile B
qHr,Ifl ,
Koropbre Moryr o6r.f, cHurr tce r,rJrr,r HeKoropble
HoLrHbre sacbr (pasgpaxeuurri Laoeeeoi nysurps) (ra6n. 3.4t3). Ilpoae.{eHr,re
I,I3 cLIMnroMoB rrarlpreHra
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auu (annopnnun)
cunHrurpa@lrg rocreft Moxer lrcKtrroqurb cocrosHr,rq,
. Llacrure no6oqHure eSQercrur reKapcrBeHHbrx npenaparoB
(noeuruennaa vyecrerrelutocru)
Koropbre cnoco6crnyror pa3Blrrlrro paclpocrpaHeH-
nofi 6olr,r.

,KoxHaq cKnarqKa Mexocrucrsre

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orlrccedur{corilllIlru' LegevY 4nndexec' (y4 noeedgo
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rlr[txeQnu 'ger.(u xrqHqrreJexrqtr xranxdes urm r,rxo)
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or^)cohuJoroxuc[ r4 ]rr{Heaorogu€ o orr{nundoQnu
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rr.0 14
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I oJoHqlrerurt?rcog euHersrodu en or€
- vrog reue,(@
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1416 euunudu orn 'qreH€udu re,{trer3 'undxeuo uru
,rqnec soHerh' urddu,{c euner,,(go srutrosodu owutrox
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rcxulfiorrHudxoc aunem adted' uuuuorcoc o €rHaufr
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ur4Hesouogee 01
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378 . PEBMATOIOTUfl h 3AEOrlEBAHnq OnOPHO-AB[rArEnbHOrO AnflAPATA
i Tafinuqa 3.49. Oco6exnocru rar$exquoHro_-Bocna'
I rurerrbHoro nopaxeHlr9 cycraBoB lil KocTell
i e noxunoir Bo3pacre
r BaHrre; Kynbrypbr rloJloxl{renbHbl [pprMepH o s 90% , i
lrlH0exqm no3BoHoqHt4Ka Bcrperiaercfl varqe. ,luaruoe cra-
B'4TCF nO3AHo, nOCKOnbKy CilMnrol,4b] CBq3blBapr c KoMnpec-
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o6srqto ocroxHqlorcg ocreoMrtert4Tot,4
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roTcfl qau.le BcneACTBr4e yBenn9eHilc qacToTbl npoTe3ilpoBa-
HU' CyCTaBOB y nOxmutx lo4efi
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- 6olee qacrble naroreHbl,
rev y vorogurx nngeil
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pr,rcKoM pasBrrur ruQexquu, eutgaanHoti Clostidium difficile
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oflyxlrr4fi, ropgqurlHa olqlrrlb r{ KpacHbIIl, xapaKTep-
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lopaxarorcq cycraBbl Hr{xHr{x KoHeqHocre k, raxue
KaK KoJreHHuIT u raso6eApeHuuft. flauuenrrr, yxe
crpa"4arourre aprprrroM, Moryr rrMeTb MHOXeCTBeHHbIe
nopaxeHl,Ifl cycTaBoB.
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raUueHroB c PA n caxapHblM .4ua6erou. Y tr,lo:roArrx,
ceKcyzulbHo aKTuBHbIx B3pocnblx npuvunoft Moxer
6rrrr roHoroKKoBa.[ uH$exuuq. PaclpocrpaHeHHarl
roHoKoKKoBar uusexutu Bcrpellaercs y 3Vo \a\ueH-
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IueHHaq KpoBbIo, Ho Moxer Ka3arbcfl Hopualuroti.
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cl,IHoBrliurbHofi xraArocu,I AoJIxeH BKrloqarl
Balg.vrg.
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oKparrrr4BaHr,re
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rr{B, B cnyqae roHoKoKKoBoti uuSerrllru Kynbrypi
crrHoB l{iurbHoft xn.[rocru rloJloxr{TenbHa roJIbKo 1
30% ctrytaeB, qro AeJIaer BaxHbIM oAHoBpeMeHHol
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na6,rrc.uaercq rellxouuro3 c IloBblurennoti COO t
ypoBHeM CPB, uo grl4 rIpH3HaKr4 MOI')'T orcytcrBoBar.
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6rennnu uuMyHlITeToM LI Ha paHHI,Ix cra,[nqx sa6ore
flocneAosareJlbHble u3MepeHl{fl yponHq CPE t
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I Ileuexue
flpuHuulrt JleqeHlrfl *phao lr3JtoxeHbl n 'ra6.l
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o6rerqeslrg 6onr4 r4 napeHrepa,'IbHoro BBeAeHI4s aHTI,I
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Merr{ur4rr,rr}rHy Staphylococcus aureus (nanpuuep, np.
paHee Bbr.f,BneHHoM HocllTeJrbcrBe), n oxra4anuu pe
3ynbTaTOB IIOCQBa CneAyeT Ha3HaqI'ITb BaHKOMIIIII/IF
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v{er,IHemoHrooc c erHeHuilroxgrtc r'loxc4l'ItrHl4 SH H
euodag s o/O'l-8'O oHqlrorl4€lIrgndu 'rerraurcoc Vd
qlcounenedlcoduce4 'xuuur(fu xntcehl{Hr€ xecg os u
edrani r,tecs os rcl^rorfiolened'rca'er,ud.lde oJoHquoJI'Ir
-Bucos gol^ldoQ gounenedlcoduced rcrarlrsr Vd
rmdrdu flqHtrilorutNsad
' eY v Yrfiret,prtfirgerx rexcenurd'(drrx
rlrccedultox
€)uHhoHoscou IaI'IHoxEdou udu e 'euHeretr't eoxcer'
-
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'I4He)l
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exrcur,.{ oronnexedou rucxol'Ig eNl'ItroxgoeH €eoHJuI{V
runennorr{ rrY'o)tred eH4edx urcoxtrrx l-{oHqlruusoH
-uc s rcrolrlrsnsg I'Iudelx€go)Ian u 'rtunuQrlfierrceH
olh'l'[or c utrsc g
rllHoHerltel,I enlcehl,IJouonetttred
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'(xrx.reu s oJecs
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NTqHHoJOTUNoJ IID{HOS0OU S roEtr€uoll rratueQutl ren
-ear.fidegf1 'Iierso) xnrer'g,(dr xnunurV u xnxrodox
xeratrro xnudeeuQeutr s exed I4 xrrso) xrsleng'fu a
'4ercox xnreng,{dr xIsHHI'Iffi x€refto xnndeeuQuue
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Pnc. 3.32. llaroSnsuororilff peBMarouAHoro aprpr4ra. t4so6paxenbr HeKoropbre q[roKr4Hbr r
KneroeHbre asaruogeficrenr,
Koropbre cqurarcrcs MroqeBbtMt4 $arropar,4ra npl4 peBMaro[AHoM aprpfire. (ADAMTSs arrpeKaHa3a; Vjll raHrepneixnH;
M-KCO rr,raxpoQaranunutfi xonoHuecruMynupyrorr.lafi Qaxrop; MMn - -
- MarpilKcHae Merannonporeranasa; RANKL
peqenropa aKr[Baropa qAepHoro Sarcropa xanna B; OHO - nuraH.q
-
$axrop HeKpo3a onyxolra)
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ADAMTS-5, pa3pyrxaror MsrKue rKaHu r..r xparq. flpo- (aHruorenes), n pesylrrare rlero BocIIzuIeHHafl cu*o-
crarJraH,ur{Hbr r4 oKcr,rA a3ora, o6pa:youluec_s B Bocna- BtturbHas. o6oloqra coAepxr,rr 6olrruoe Korr.rqecrBo
leuuor7 cr{HoB}rar'IbHor7 o6oro.rxe, Bbr3blBalor pacull4- cocyAoB. Bnyrpu srux KpoBeHocHbrx cocyAoB npoBoc-
peH[e cocyAoB, qro rrpr.rBoAr{T K oreKy u 6o:reeouy cun- IiuIr{TeJIbHbre rII{ToKr,rHbI aKTr{BI,IpyroT SHAOTeJII{anb-
IpoMy. Cucreunoe sucso6ox4e laue VJI-6 3arycKaer HhIe KJIerKr,r, Koropbre o6ecrequsalor Ml{rpallurc erqe
nupa6orry nerreHbro 6e.nron ocrpori @asu. C xpaeoorl 6omruero xolr,r.{ectsa reIZKour{ToB An-a no r,rlepxaHr,rq
noBepxHocTl{ cycTaBa BocniuleHHarl cI,rHoBI,Iar'IbHarl BocniurlrTeJrbHoro flpouecca.
o6o,ro.rxa (nannyc) HenocpeAcrBeHHo rrpoHr,rKaer B flo rrlepe lporpeccupo Balalafl sa6oJreaaHr.{s Moxer
KOCTHyIO TKaHb !I Xpfrq, BhI3brBarI 3po3l4ro cycranuoft Bo3Hr4KHyrb $u6posnurl unu KocrHbrfi anxulog.
noBepxHocrr4. KJrro.renHu $axropou rraroreHesa Mruuqrr, nprlnerarourlre K BocliueHHbrM cycraBaM,
sposurl rocreri u tepnaprvrKynqpHoro ocre onopo3a arpo$upyrorcrr r{ Moryr 6rrrr nnQulrrpupoBaHhr
flBJIfleTcfl aKTilBa\nfl ocTeoKJIacToB, CTr4MyJIUpyeMarI ruruSoquranau. Oro npuBoAr.rr K nporpeccupfoilIeMy
npo4yrquefr uaxpo$ara,rbHoro KoJroHr.{ecrr.rMynr.rpy- HapylreHlrro 6uolrexanuqecxorl @yxrqura rl Moxer
rcurero $axropa KJrerKaMlr cuHoBlrzurbHori o6o:ro.rKr.r AOrroJrHr,rTeJrbHo ycunr,rBarb pa3pyrxeHr{e cycTaBoB.
u RANKL - aKrLrBr{poBaHHbrMr{ T-lutr,r@oqurauu y PO- ra ACPA-no3r,rrlrBHhrx [aqueHroB Bcrpe-
(ptlc. 3.32). O6pasl,rorcx HoBbre KpoBeHocHbre cocynbr qaloTcrl peBMaToI4IHbre y3eJrKI{, KoTOpbIe B OCHOBHOM
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funr ou @fHuBU uuhendoSeU 'sosprc^c xrqsoJHeue$
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no)€ro r vId hmrqn xr)uem 4euQodre c sehcueu shheueeU
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xrlsoJHureQeHoorrflr )orsrrsroll' Herreregr,t'rc lrutrrDr(ox
-,{c xemururBrs os sox[ae,,( runeaoeedgo eusJctrercs
seniuruu airHuxretfl oHxowrog 'x.{d aenqreu Uelrel;eg
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s u,rtroxcuodu ore alrruh 'r[o)e.r.o u rrrorndldur,rrou
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384 o PEBMATOIOTIC il 3AEOrlEBAHt4g OnOPHO-ABurATEIbHOFO AnnApATA

pa3Br{Tr{eM Ao[oJrHr,rreJrbHhrx c],]!roK ]r Mo3oneri. B saA-

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4e$opuaqras nqroqHofi Kocrlr B pe3ynbrare noBpex- Cncreuxute
AeHr.rfl roJreHocrorrHoro tr rroArapaHHoro cycranon. Oro . IuxopaAxa o lloesruieHHaq yroMrfleMocrb
rIacTo cBrr3aHo c r{cqe3HoBeHI4eM npOAOnbHOrO CBOAa . noreps Maccbr rera r l-lpegpacnoroxeHHocrb
crorrbr (nuocxocronue) rcle4crnue pa3pbrBa cyxoxu- r uH$exqra*r,r
ruq saAHerZ 6oluue6epuonoft ulrurqu. Y laqueHron Co cropoxur onopHo-ABurarenbHoro annapara
c cr,rHoBuToM KoJIeHHOTO CyCTaBa MOryT BO3HtlKaTb . Arpo$ltq r\autuJq '. EYPcnr
Kr.rcTbr rloAKoJreHHoir suru (xucru Eertxepa), npn . TeHocilHoarr Ocreonopoe
KOTOpbIX CTTHOBUaJ'IbHUUI XI4,[KOCTb, [pOHUKarI B Kr{CTy, Feuaronoruqecxne
He MOXeT flepeTellb B cycTaB BcJreIcTBrre KJTaIIaHHOTO r Aueuun . 3osilrioOtaruq
MexaHI,I3Ma; AanHUfi Cr{MnTOM He CIIeUU-
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SuvHuu a.nq PA. Cru1auue KoJreHa'IBJIflerCf,
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pa3pbrB Kr{crbr, qro rtpuBoAur x 6olu a uxponoxnoft . CrHApov <Denrr (or,t. ra6n. ' . CrureHol,4erarhq
3.54)
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zuruHlrqecKyro KaprprHy rpou6osa r.ny6oxux aen. Brr- Ysenxu

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BacKynr,(raMu, $opuupoBaHlreM rpaHyneM u y3eJrKoB
(ra6.r. 3.53).

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y PO- ra ACPA-no3r,rrr,rBHbrx
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386 . PEBMATOTOTH, h 3A6O,IEBAHT49 ONOPHO.ABUTATE,IbHOTO ANNAPATA

rrrurbHoMoxer 6urr npunlrcaHo aKTr,rBHocrr{ ocHoB-
noro sa6oreBaHufl.. Oqeuxa peSlexcon ?r Mrrure.rHori
cunbr y [aqVeHToB c BbIpaxeHHbrM fropaxeH]reM
cycraBoB Moxer 6urr HeuuQopMarr{BHa, B cBrr3r4
c 3TlrM xau6oree BaxHbIMu flBr.f,rorc.f, ceHcopHbre
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c npl43HaKaMrr cAaBireHnq cIIuHHoro Mo3Ia Hyx-
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JrlrMQoMbr, Koropafl rrarqe Bcrpeqaerc.s y [auueHToB c
AJrLrreJrbHbrM aHaMnegoM PA.
Iffi
,{uarurocrr,rxa PA ocnosaHa Ha xaao6ax ilKrryrrtkr-
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tIo3BOHOqHUKa. 3.55). y 6onrruuncrsa narllreHroB orMeqaercs noBbr-
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rrreHr,re
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ro ct4H.(poMa. YpsIa nauueHron na6:rroAaercfl Mr,rKpo- Bcrperrarorcs y 6oauunncrBa narlrreHToB errle Ao KJII4-
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H II BC-accoulrr{poBaHHoro xenyAorrHo-Kr,r[reqHoro Bcrperraercrr np[rMepHo B 70Vo cttylplez, 6olrruuucrno
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noro PA, flprl KoropoM Bo3Hr{Kaer crureHoMerur4fl B
coqeraHlrlr c nelirpone:aueir. u rpovr6ouuroneHueft
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i npu peBMaroxAHoM aprphre
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Bnepeute guaruocr14PoBaHHbl14
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6lrororra.Iecrofi rePanurl.
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B reqeHue 12 Hqenb 'l* |

Cnuxeuue gostt I HeMeAnrauexrosHoe neqexue

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-qr,(c'trnlroufr@er rorehorDls BrdHohelr rq,r,Heudus
anns[reHderqrv'(4ulores,nu xrsHxo)[ou eYI,Is s u14HPs0u0u33r,l
rc.r,ernelrudx oHhrrgo Ho 4oretr xpDrqHerer^r f) erec ' ulteuodrdeorflrtrHo[c gonnexedrss oxeed
-xedr,o.lelr er,rHesoeqlroror4 Bcr;eyrrsy rtutuederosdruru eorog r reurugeud c sresodnccefuodu rexon menaneds
udu lrordutrsBJ3'rs[HBnox Uroxdeurr[rlfrculDKow oc rufude 4nHHesod[r4trocJ€-r]r€eJH6'yu3 raxuwdoQ
rur,cer,1( refgedr orr, 'eurelrlruu rssodotre oJoxcehr,rx
rcuwIalfloleslrnlnrufuooytec rcrolrrsr'oHrtrodeg'Er
-uxuvt oJo)cohr{ruQ orefngo exxdetrtro[ rr rr{Hohelr -ufude oronnesoduufiocce-rueeure rEur-.{rc oUJoHIAI
gusJc[ercou xrsHJ,ruduoJ€rgeH uufrp€unllHuri[ s ' lrolrodtrnr.rc NrsHderutt oreQolt er c eHe€,Bs.c
VI4 OI
'l,toccefiodu NlirHillreu,rruucos es orodurox lrodrc ewdoQ u.l6 'erqHqueJufiHdro ounrrgo ereruureor,{e ex
-Iqg I,r illoHH?d s Ecreeho{rDr€e troxtrox rlosehorrr;
IruHesotrorccu rslelsrfced 'gdf, nrrodr{ u 6gJ waHH
-onuregf '4euwoue cur{Herehoc s )er,orogo xrsneodec
nel{Helf?u3os u ueulrBJelltoHalrllcorelleJ'IrttoJ}ldJd€'il]t
'gI urx ludlde -BrrHelrqcrqs' 4roxYedoxrar rcre.(eudelxedex (urrur3
{u)cahrrrrrec en r,runed€otrorr r,rdu rargnneso[eucc]r qHeeffog )E) HrrHrcesou eeued) y1464 yrrqHr rarcr.{J
NrqHxBs yxleylrsrr (rnuoxcodlde en e) urcoxtrux 'rcr,orrretraduo oH errerr{rnuor,(u
goHqlrcusoHuc su'rrcduucy'rcslexdetr€os raftrerc xrar,(df .{ xex rneds or s'urunsqralloro[o[-Vd]V r{]fli
uuuoxcodrdu ro oJ 'rc.r,sl(qed.l eHilvttLtokrg er,rHetres /u -Aarcrorrrsn ritrneufieu ersdoroxeH :neserodera:
-odu urcg 'soserc^{c xrarfdtr fiuHehersos r,rdu lran VI4OI 4nndrr.{xltdeurog'r{wrlrHiruor}rxorou-vFlv
'Bgelcl(c oJoHrroJcoHerroJ ra rqlroJc r,rr,rHexedou r,tdu Bclo{ylf'Iy IqJHeI,Inuu elrJoHI^I lr 'nrolrteg.( c qergf,
emrrs sorBrsrr(ead xrsHsffer?rlr4d.r,oorrxor sueaod6 ncJe€suxe[cod11'uorerc,(c xnHuddx r,teunexedou
'€JusoHucoH eL vlfyt erusoHl,Ic o,letuorr(gJ,cJr(uoc YI,IH rrirsHr.udrel^tnll,lce rcrer(euder,xudex I,I EIIoII oJo)cHex
-elfxdesJ[ou rrtr udogns neuHeso[erccu roleyvtry sorHeutteu .( rcreenedrcs efleh ng 'aeen{rx olgg
yg6'xuuede enerdo rrnnexedou xcud 4rsnnemrsa oro)o rcluVoxlrdl orrotr oJe BH 'VI4OI rr'olnrdoQ Hon
-orr BH .r,oresrseex,( uYl4ol ndu seeMrc obgl-ob a -nenedrcoducud eeroguuH rcrorrsr J.udrdeolar6
rcrorer,afucs VHV rsdJul orqHqrer[xouolI'u€erex 'urcorede gosororr runerudl,ceg of,,
norufiuQe[ x eH E' yvHaserogeo oJoxceh]rHodx uulr sosurcr(c xrsHHatrxedgou gull)H/{o oruHorsoHeJcCos
-eHe r reurussed c Heergc 'oJecg eoHrrodeg 'eHI,Igoru rer(arcgocouc HeprHesorogBs trBH srodJ,Hox &rrirHsH.r
-oneJ <IHeso&( grxezg 'ueox4er (oxYed eu4edx) utntt -xeQQe gerotr xr,rxsHoren 'ureJ nrccuru f>raugudu n
B)I,IHhOmI,DI BI,IHBSoIrO9B0 OJOHIITAIUTBIICOS oUhUITEH rcod en u xer '4otcoHheHo) ^ erarugeed BH x€x roffirs
eH sregrseu)d rexoru eO) ru)ocrqs trHehg 'gr,rHeheH€ onsre.rufiladl.o 4aretr ^{ rudrdy'eccetrodu oJoHs[orur
xrsHqrBrrdoH xeffotradu s rcqJr,rvoxus r,frox oilrcen -uxJos srrooHsr,rue BH 'oJecg eltxedu 'roBgrqeexf ouo
-Be lt III{HaHol,ttc}I xlqHqlrerulrBucos oI<IJcoHHexBdIqs ercedeos no)cJetr s 'uge.lcfc geunendoQetr ra weuHetr
BcJ-orcusutqe au eueurxeor.(y xrqLrcodee r( r xe>i 'ex erxel vcll
{rcHcuat ilxouou-vdcv
' 4rcHcrrol-r4xorJou-od
80c14eoJ_He
g noruexedou 3
errdrdeorruo enrdoQ (eoeerc,ic rruu
lrcHcuol4xouou-VHV geHHeHedrcoduced eHxorNeoe :t-t,4dtdenuoll eeren eu) rudrderuog
(eoeerc{c xedrqrer
lilc Hc rIo.Lr4xorJou -vHV rtaee^ 'eoeerclc xrsruAdr rndrdy 09 eeuog eu) rudrdeo:nug
tsl4LIEJey\OHeUUCOIeUOI
' uhiued-rde'eursc'e>iUedoxry g r4tcHr,lorcr4c
vl/ol
nveserdu euxcaxurouoxlwnq cuxouecodu auycohr4Hurry o7o'ercouxexedrcoduce6 uurEog
erudrdB oJo)rcshlrreuolrtsn oJoHqu]4Hoao ut4HousBodu onycanuxut y '/g'g ehfiugel
!
680 . ll4dldv ul4ycehHJ.vuot4un l4lqHqu1/|H:Igo
390 . PEBMATONOTNg H SAEOflEBAHUq ONOPHO-ABHTATE,IbHOTO ANNAPATA
IOIIA rrp]r yBer,rrix. C.ruraerc.f,, vro uuxo$eHoJrar
lr raKponlrMyc r{rparor oco6yo ponb roJrbKo B Jreqe-
r,vru .vnevr a. Kou 6uHupoBaHHa-f, reparr4s npra IO I4A
u3yqeHa fIJIoxo. Er,ro-rrorlt.IecKl,Ie MeroAbI JIeqeHI,Iq,
BKJrroqzu ucrroJrb3oBaHlre aHTlrreJr x OHO, s$@er-
rr4BHbr npu IOI4A B Hacrosrqee BpeMrr .sBr.f,rorc.s
r,r
cralrlaprHbrM MeroAoM JreqeHr{-fl rrp}r Hzuruqr{[ pe@-
paKTepHoro 3a6oreBaHr,rfl , a raror(e HerrepeHoclrMocrlr
MerorpeKcara r{ Apyrux He6uororn.{ecKl,tx I,IMMyHo -
TepaleBT[qecKlrx npenaparoB. Toqruusyttla6 rarore
s$Sertlrnex npu IOI,IA n 6ul oAo6pes NICE a-nq
rrcrroJrb3oBanr,rs s Bealrro6pnranuu.
$Nt$,ffimflfimil in||ffi
floeAHs.s Ar{arHocruKa [r orcyrcrBue cBoeBpe-
MeHHOTO MeI(I}ICUUTUIIrHapHOIO [O.4XOAa, Hea.4eK-
sarnrrll KoHTponb HaA sa6orenaHueM, cI,IMTIToMBI
yBelITa, uanu$ecraqr,H B Br{Ie crrcreMHoro IOI,IA y
Myxqr,rH lr rrloxoe ssauMoAeftcrBr{e c BpaqoM
- 9To
re $arropu, Koropbre Bo MHoroM Brr,r.flror na ne6naro-
rpuaruuft [porHo3 3a6oreBaHufl. flcraxonornqecrafl
noAqep)rra 6onrnrrx 2.eretrt u ux ceueft npuBoAlrr K
n) rrur{M pe3yJrbraraM. Oluroapruryn-apnuft IOI4A
rracTo pa3pemaeTcs B [epr4oA noiroBoro co3peBaHr,tfl.
fI oluaprnxyr flplr^as. 6oresHr u ctrcreMHbrft IO
ocTarcTcs aKTuBHbrMr{ B 3penoM Bo3pacTe npr,rMepHo B
50% c[Waes. O6uue upo6leurr, cBfl3aHHbre c flepe-
xoAoM noApocTKoB Bo Bspocnyro ){([r3Hb, noKa3aHbr B
ra6n. 3.58.
Ta6nnqa 3.58. l0aexuncnufi ngronaruqecrui
fi,iff apTplrr B nogpocTKoBoM BoSpacre
. olocpeAoBaHHoro lr3MeHeHilrMr,r B cr,rcreMe UJI-12,
Yseur Moxer He npogBJlgTbcs rnr4HilgecKil 14 coxpaHgTbcq
spenoM Bo3pacre. Bce naqreHrur (re roluxo AHA-noroxr-
reruuure) HlDK4aorcr e oQraruuororilqecKoM o6clegoaanuu
.
B qeJrgx BbrsBjreHil9 nopaxeHilq opraHoB 3peHil,
Coxpaxexue B 3peroM Bo3pacre ecrpevaercR e 50%
cnyqaeB, oco6euHo nph o4creMHoM ga6oreeaHuu. ,[olxno
6urs eanrannpoBaHo cneqr4arbHoe nopAepxilBatolqee
JreqeHile npil nepexoAe or noapocrKoBoro BGpacra K ffipoc-
rori xugsn
o Yuexuurexue nuxoeoi rocrxoi Maccbt qacro Bcrpeqaercq
npfi nonilaprpr4re il cilcreMHoM tOtzlA, uo AaHHbtx o pr4cKe
neperoMoB Maro, a AoKaoarenbHas 6asa gta reqeH!4fl
.
cKyAHae
Ieqerue: MerorpeKcar gBltqercs craHAaprHbtM JteqeHreM,
ilcnolrffiyeMbrM nocne roro, KaK npilMeHeHile ogHmx HIlBC
craHoBr4rce HeAocraroqHbtM. AHrrrela x OHO e$Qerrneuur
np!4 Bcex SopMax lOlzlA, no EonrocpoqHae 6esonacHocru
ocraercq negcsori
CnoHflrnoaprponarrn
Cnorqmoaprponarr.{u (CnA) upeacrasnqrcr co6ofi
TPYNNY POACTBEHHbIX BOCIUUIUTEJIbHbIX SA6OIENAHI,Ifi
onopHo-ABI,rraTeJIbHoIo anlapaTa co cxoAHbrMvr K)rvt-
Hr,rqecKr{Mrr npogBJIeHI,Ifl MI{ I{ pIMMyHOreHeTr,rqecKoIz
cBrr3bro c aHTr{reHoM rrrcrocoBMecrr.rMocrr,r HLA-B27
(ra6.rr. 3.59).
Onu nuroqaror cneAyrorque Krrr,rHprqecxue Sopuu:
. AxcCrA;
. AC;
. peaKruBHbritaprpur;
. fIcA;
. aprpr.{T c Boc[rurlrreJrbHbrM sa6oresaHueM K]rureq-
uura (eHteponarr.rqecKr4rl CnA).
IIpu AxcCuA u AC npeuuyxlecrBeHHo flopoKaer-
cs ocenorl cKeJrer. B orrtr.r.rI,te or PA, npu CnA uacro
Bcrpeqarorcrr 3aMerHbre necuuof,iaa-nbHbre nopiDKeHr,rs
onopHo-ABr,rrareJrbHofo a[flapaTa
- B ocHoBHoM Boc-
riurr{TeJrbHbre no cnoerf [pr{poAe nopzrxeHr,rs cBs3oK,
cyxoxuaratl, HaAKocrHlrurr. Orara.rureJrbHhrM npr{-
3HaKoM scex CnA flBlrflercfl.9Hre3r{r, roropufi npeg-
craBrrler co6oft BocnuureHr4e B Mecre [p]IKperureHr{fl
cBg3KI{ I{nu c}xoxl4rrrlrr K Kocrrr. Taxxe Moxer Bo3-
HI,IKH)"Tb BOCIIaIIeHI,Ie nZUrbrIeB pyK I,I HOr
I4A I.AKTVT_ILIIIT
(cu. pnc. 3.43).
-
Eruo uo.uc.ruraHo, qro oKoJro 1% nspocloro na-
ceJIeHlIrI CIIIA uoxer crpalarr CnA (oxoro 2,7 wwr).
flpu eron orueqaercrl cBrl3b c aHTI4reHoM rr{crocoBMe-
crlrMocrr4 HLA-827, oco6enno npra AC (6otee 95%) -
Kpoue roro, cql,ITaerc.f,, .Iro CnAsosHI{KaIor B pe3ynb-
rare a6eppaHTHoro orBera opraHr,rsMa na un@erquro
u aHoMzulbHoro I,rMMyHr,rrera cJll,I3r{croft o6onovrra,
B
UJI-23 uThl7. B ueroroprx curya\ilsx r.loxer 6rrm
.
il H:xffi i;3?;3f#li
c,MnroMbr
Acuuverprqruril eocnarhreruHurri oluroaprpur (Huxlnr
KoHeqHocrb nopaxeHa 6oluue, LreM BepxHqg xoHevlocru)
. AHalaHes BocnarL4TerbHoro 6oreaoro cilHppoMa B cnr4He
. Caxpoulerr il ocre/T no3BoHoqHilKa
. Suregrr (Hanprvep, npilKpenaeHL4e cpegHeu rro4urvuofr
i/bmr-lbr, Mecro n poilcxoxAeHL4e nogou aer rori Sacqu r)
. TeHAeHq[q x ceverinori arperaqr!4
. Ceqsu c NIA-827
. llcopuas (xoxu u/unn tonei)
. Vaet4t
. CreprluHurti yperpilr n/unu npoclratnt
. BocnaluteluHute sa6oresaFrilF Kt4lueqHilKa
. FopaxeHilR KopHF aoprbr (uepocrarornocrb aopralbHoro
KnanaHa, HapyLlJeHL4t npOeOgnt',lOCrn)
 eveSoueh nlcov\l4J.comsoc xoSaHe)I e!'{eJ"cl4c t41rl4 ' rqHoJr4J.He arqHdeJ-[hovrou euv0oheEoueh
5.ouag IlcHsr4r.vPod-C gdC :el.]4dJdBouhuHouc o{r4Hoh^eil ou o8J-cetngo aoHuodeH^Uxafu
- \nH - - SVSV'nrHehonlrdLt
odrov"rco tldt t\ut
a€a*rwBHe I ntqHHot/8utqs 'yloyeHer4du y\t4Huo olno c elilour/odrPc y,,tEvEH8t4du vlldcehurouoHoJrHod ou HPEodrIcoHlEl4u q-Llca loxov'i cv
'Er4ollilodvec ilt,18-tc1^c.l.o ildu l/\ovPHerd u vll4rcohl4H rl LIy v"lil HUo Y"loh
ae{Jog c so1t1ailheu xlqHquolr4xouou -LZA-V1H{ seueBrcou c-Lrcg -Lexov\ axxer eou-rcrf ruueeoUeucgo uur edroulco trlovcanurun udu
I
'aeaHyreHe t4tcHHaLr€BlqE 'yerendu nuUo + 14y1 €H l4orn4odvBc :eenderndv xr,rlnotlUer-rc urueUotugoc ildu screr(dilrcoruerU yuSc>ty
gdc 4rcHHomrcEolJ
{rqHquoJ-r4xouou - LZa-v1H 6ilHeEOueuCCfl
eeudocg
r4vrorfv r4oHuIdJ oilHodilmced oHomqHen^
'!/,uul>4ell
'xgrcovcouu 'rr408A
'1r4rorHe dronco
xoHcrlBuods h r4oHcueuruec I Bvt4HhoHoseou
ouoEro }\oHhr4Hcsou E tIhHexilEU ouHahilHEdJO
'rudrdy. 1414vc0h14H14lry
evilHh0ml,4v Bl.4He8ouogee oloHcuo.Lt/ueucoE eoHv\IEHV
'vuc goHv\eHe 4rcHt4or\oc
'0Ht/luc I
uuog rureeoduuriv eUrae E SBllH nendu eu reel.o 4rmodoX
'reLr ercedeoe E Br4HeEouogee rogelt g
g, oxouo!\
'etf09 6€HhoH t
'olIeheH ooHHol]or-cou e
'oorou I tst4HehioLrgoerercr.(cr6 '7
aovou 't4r.rnenxedul oucou BcloemcHev\A L
e ccreemqHer,\/{ eH oH '{t4HoHxEduI eLrcou 'eoverendu xrlnotl{Ueuc ilrBU eil odtcloh tqudervedex
BCr,OehJOrrgO 'Cor,'\l g oeuog ahl4Hc6ou €quog r4odoro>r BUE 'cov\ e oolrog ,lt4Hexsrodu PH oil4Hcuou e clIog SeHNBHV
dolvedex
4rcHuexedrse l-ucoH ur4HoHot',r ev wca'oilr{edl
-oHer$od pH r4oLIilodveg filHHodorcoHuo
'rcHcrIouheHgoH sr4HoHov',lsl4 t/t co oxBu
'oyrli\edroHe.l1Hod eu rueuuodvec f uHHodo]c^sL/ ldl/\ EH orsuor rneuuodre3 urheerue[eng
CV vucc)lv 4uderndy
(uudauadx euxcrdog-oteg etsuxeeoduhuSnUon) eruuuUHouc
oletnoldueouuxe n (gygy) erudrdpounuxou3 oJoHquBlrcre saudarndx xurcahurcoHJeuU a[HaxapdC'09'e ehfiugel !
Ir€holII>Ia' go Hu)oJ,lrfi xlqH<IlrorpllrBucos xrlHhl.rr€ed oJoxcehuoedroseftned eulnoilgafu ' (69' g'rger) 3y
o)JogBdrls ) Il{trosl4du oJe 'I{xholrogo 4orcr{€I4lfc LDrr{rcoHJBrr[ uuderudx' oHHesJcJosroo]' rI,IH€ser
ererr{H.(r rHr.r s ilrod ol/{sehollr) roledJr{ eHdorox -0930 xBrrtr€rc xl{HtrCou BH rCrOIeSI,ISSed ?eOIfl.I)HB u
'41q1 xorerx NoLIroEh-( c ,(rougod)rrn o{.(Hhelrltrx ulteluQorrcetrHr,rc c rlH€xr ?toHrcox 4osoH 6r,IH€so0Bd
BH er{sr{HBJdO rlter{Il)€ed 4oHiIIreNoHB IiIHOITSOICI9O -9o etrfls s ruHeHeru€u alqHd,{r;t,(drc i14121 olqrflon
f,v lr vrrf,3xv orh 'oJoJ arcqrer€€Bxo[ emqrog o3s -orr c rirHesodueurefeug s.r.ng rfuox H YlJcxV rfi'
BCrerrsrolf '09ril u sosercf,AI,IHuBeIrogss I leuHedrJ rsHdeJ)EdBx Brero)c oJoseco oJecs urlHexrJ,odu es
-o9o c oHesoduurlocss orh' aw>r s. sauaSotaD Dilalsqalx BI,IHOHAI^IEI'I EIqHIIITEIUIJSI]COg'VIISCXV I4 JV 4TD{CEh}IC
osJcirrou{coH rcreBher rro JV xusHHelrxdeartrou c -cerx re?horrxs H{JSuOdtdsOIMtrHOIrC TSHqITBHCXV
soJHouIrB[ A'rI]I[ XIiIHHOXO[O[CedtrOdu I4XCehI'Ir
-eHeJ ^{ €r r€rrH€Jdo Utol^Ier3l{c UroHH^{Nh{I,I c rstredc
4elnorexfdxo aodorxeQ xIqHHeJorBIr Bl,Isrc4otron ' ur,r.r,uuofu deorMtrHouc
-uu€s ereJqrfeod s rcrorssl,Is€Ed f,v u YIrf,cxY euu,(fu s ruHeselrog€o eril(dtren lr rcqrrHedlcoduced
rexow o)IoIBr oH '€rHollrlgu Er,IHSserogB€ oJoHJod)Ho)
iu.rououeusoreg I rIff EHdeJ)Bdex oxsror eH rl4Il€oudoJcelrx r€HIJoI [eJ
'JV Bcreesuaeud ytr3cxy 3 sorHoI,IrIEl 'rurrHcreH rcreuJco deruudr IJLIHmeHs geuhrftIc esrc
xacg ,{ eH 'ruHeserogeE ul,IHolrsrod[ xlD{cehvt}lvllf>t -Hr,rmqnog g os'eludled,{ oron4Iatrru\rcrcx Yttrv. uudel
xlqHqlreh€H rl,rHSrsrolI ercoll rau oJoHI I Brc.(IIc Ifcrol -Hesr,rtr 4onsreudelxeg ellcox erud.tdu wonsurxeed
- rH al^t Hdu ot,(rcur,ee' €lraeruodxuc ruHetrxdesrtrox radu xsx'HeJorerr gnnderrudr xeaodultuQkrlrreYu
-ii . HHlVrJodrdvouuuHouc
392 o PEBMATOIOTI4f, 14 3AEOI|EBAH]49 OnOPHO-ABUrArEflbHOrO AnnApATA

l'exeru,{ecxas
. HLA-827
. ERAP-I
o STAT3, pltlll23
Tprrrep
oKpy)€lor4ei
cpeAbr
smmAf
Ur*pooroJl
a
ruuteqxura I o
npogy*ru,
xil3HeAee-
I
ff^,"fli1
Maxpo$ar Hefirpo$ua

r1
1 m.-.* iln-*.----+
@----)r4n{
Tyvxan uerxa
1
, (DHO-cr

Kuueqxuril Atcruaaqun uuuynnux TxaHeesre IMMyHHbte

onurenvfi ruerox a nogcnusucroil KnETKil
ocHoBe

Puc.3.38. liaro$usnorortaf, aKcuElnbHof cnoHAunoaprponaruu. llpegnonaraercr, rlro y TeHertaeecKu npeApacnonoxeHHbrx nrcAefi

6axrepralunute KoMnoHeHTbt npoHuKaor 9epe3 6apbep cnuaucrofi o6ono.lKr4 Kt4ueqHnKa, aKrilBtapyn uarpoQaru il AeHApr4THbte
KnerKu B ero noAcn[3ilcroM crloe. eru xrerxr npoAyqr4pyror noBbruJeHHoe KoluvecrBo uHrepneftxuHa 23(An-23), Koropbtfr, Bo3-
AeftcrBye xa T-nuuQoqrarur, HeilrpoQranbr ta ryqHble KnerKu, cr4Myn[pyer eurceo6oxgen vle nn-fi; V1I1-17 , e cBo]o ovepeAb, urpaer
KflloqeByrc ponb B aKrhBaqrta BocnaneH[f,, npuBognJ.lero K pa3Br4Ttato caKpor4reura I oHTe3ura. llpegcraaleHue aHTureHa AeH-
Apt4THbtMt4 KnerKaMr raKxe urpaer naroTeHerur{ecKyro ponb B aKTt,tBaqilh T-lnuQoqnroa, a Saxrop HeKpo3a onyxolra (<DHO),
npolqyqupyeMblfi trrarpo$arauh il aKrhBt4poBaHHbrM14 T-ruuSoqrrar'ara, cnoco6creyer pa3Bul4o BocnaJleHnr. [lpegnonaraercR, rro
autpa6orxa lAIl-22T-nuu$oqtaraMil Bbr3brBaer o6pa3oBaHue Hoeofi rocrn, rr4n[eHoe Mq aKch€ulbHofi cnoH4uloaprponaruh

VIJI-L2,l4II-23, VlJl-|7 u tDHOo, Hrparcuux xrr3- Bbr3brBa.s floBuruennuft crpecc gHrolna3Marr.rqecKoro

HeHHO BIDKHyTO ponb B rraToreHe3e sHTe3uTa r,r ,4pyrux
BocliurureJrbHbrx lopaxeNurZ (pnc. 3.38).
Cyrqecrsyer recHarr cBrr3b Mex,qy arcual*roft
crroHAr4Jroaprponarueft r.r HoclrreJrbcrBoM MoneKyJrbr
I uacca DraBHoro KoMlJreKca rilcrocoBMecrr{Mocrr{
HLA-827. Oro or.rerrlrBo npocnexr4Baercf, cpeAlr
naur{eHroB c AC, 6olee 95% us Koropbrx uMeror rro-
Jloxr,rreJrbHbrfi pesylrrar recra Ha HLA-827 . BaxHyro
ponb B naroreHe3e AC rarpaer rcs ERAP- I (6elor eu-
AorrJla3MarlrilecKoro peruKynyt![a, o6ner.raroufiri npo-
ueccl{Hf BHyrpuKleToqHoro aHTLIIeHa I,I CB.tr3bIBaHLIe C
flpe.qcraBnrrouer; ero MoJreryloft rnaanoro KoMrureKca
rr4crocoBMecrr,rMocrlr HLA-827 ), peuenrop I4II-23 u
HpIXeCTOfl IIIUe CIrrHilJIbHbIe MoneKyJrbr, y{acTBylouple
B ynpaBJIeHlI n Thl 7 - xlerorrHblMr,r orBeraM u, TaKlIe
PETI,IKYJIWA C NOCJIEAYIOIII}IM BbIIEJIEH}IEM BOCNIUIII-
TeJrbHbrx rllrroKr,rHoB uaxpoSaraurr r,r Aerupr,rrHbrM[
KJIeTKaMII, BbI3bIBa.fl TeM CaMbIM BOCnaJII{TeJIbHOe
3a6oreBaHr,re.
I Axcnanuxuft cnoxfl nnoaprpur
Knnnuqecxas KapruHa
Ocnosnrrr,r[ [pr,r3HaKaMr{ ArcCuA ssn-srcrcq 6orl
BOCN{UII'ITEJIbHOTO XAPAKTCPA B CNI'IHE H YTPEHHS'I CKO-
BaHHOCTb, IIpII nopilKeHl{pr KpecTIIoBo-noAB3.UOIIIHbIX
co.ureHeHr,rft 6onr s uogcHur\e vpparuupyer B qroAuubr
rr 3a,uHroro noBepxHocrl 6e.upa. Culrnrourr ycyry6na-
IOTC_S B yCJIOBI{,X rUrO- I{ ankIIlAMI",.VL U }'}{eHbIXarOTCS

xar STAT3 (cu. pnc. 4.3). Moneryna HLA-B27 sHo- Bo BpeMrr n'suxeHuit. BosMoxHa 3rrlr3o,r[uqecKr4 Bo3-
clrr cgol7 BKJIa,II 3a cqer ee aHTlrreHnpeseHrupylouerl HI,IKaIouIaq cKeJIerHo-MbIIIreqHzur 6olr n o6nacru no-
@ysxuuu nrn cnoco6nocrlr K o6pasonanurc roMoAx- pilxeHHoro cycraBa vt, ecJrvr 6olr Hocr,m nocrosHHr,rli
MepoB, Koropbre aKTr.rBr.rpyror neriKorlr.{Thr. Mo.rlexylu I{ paclpocrpauenHrrrZ xapaKTep, ee r,rHorAa orru6o.rHo
HLA-827 raroKe Moryr HenpaBlrJrbHo cBopaqr{Barbcrr, npr,rHr,rMaror sa (DM. t{acro Ha6nrc.uaercrr rroBbrrrreH-
'l:€ orfoxo reBrsgJcoc H[rrlHex r{ Hr,rhx^r{ er,rHem
-oHrooJ'BxHHhoHoseou sorHer^rer€ rlrHorrr?dc o[
srBsodHJJefuod[ ffJon oJorr,r NoHheHo) s arrdoJo)
' gx H H hoH o I so u e nu{u d.I o n a.r.ln e d e H g u H eH e I^t e u
xnsdifuxddrc xu.rr(dV u etuaruod)eJ vnr,ilyen udu
rcra,{durcosJeuV (CV) VrrJ Hr,rmorfdraeorr.lxrry
udrdeourEHouc [rtntxrtdrcourxHv
'f,V o[' r]tresoduccedrodu orou
-xow€os n esoH.rodu oronrruduoJurrgeH ulwdexdzr[
rorolrrsr'oHtrodos'rlrnemr(dug enusrenoutrxnfQ
arsHHaxudrqs r4 gdJ sHesod,{ Hurnor,(durcucdau
Ir.{)ocrqs 'LZg-y'IH c rufrcurloccv 'Jerr xr,rJoHrr or{H
-aher s lrxcehl,rtroclrrr€ rc<rJrugtrodll ulrufu etudoQ
IoHsurxeeH s sruxerodu roxoru 1trrrf,oxv sorHeulr€r
ESICHUIIIqIrO9 r( Orn 'OHtrUSOhO 'ISHeh.(eU eH EnHO) OY
VrrJcxV trtoroHJeutr c soureuleu I eeomodu rsdexder
'otts?treH oHorelfiqs olrlqg er.rHB8elrogBo,$rsroxcoll
eoHrodlJ
'ruHeselrogeE
euHoher eoHHesrcorce BH lrr.rueder 4onlleY vvrHrurrs o
coduos NrqHcnaH rcreerco on 'yu3cxy lrdu rusoxed
-ou oJo)cohudeQudeu u )pr' orosqr.l-vx>te uHHemoH
-ro s )ux uuaurxeQQe OHO ) r,rn€rorr{rHu rrauedel
' (E g' g' rgurwc) ugerr(urx.{yec y L-Ul edorugunu
nIrH OHO aodoruguruu welrHusorirroucu c uuuedat
Uo)cohrrJouor,rg ) Etroxedeu srcoHxor r€os s.lad.lonrc
-ced rs.(trero 'JSI_IH suacoHedeu rr(.rolr eH vrypr
epIHohaII EH eresJo oJoHJutr)etru
rolowu en erqdorox
(ouaUeego) BJeour oJoH
-rco) )eJ.o ucreeUorugeu (ta>tuedrc) ultHexedou oJoHeueode
elaercUeuce 4ercoxeodeu ltmprHayralre c {[HeHeuhoc xtcH
-moUeeUou-osohrcedy xnogo .rld>rog'errdrdeouuUxouc r/{oH
-quet,tcyp udu rreuuodyec 4uuuodorcleU seho{^dhdrcroneU
'uuhvaodu 4ousreruodQ os (U[S) 11 ri'rnxrodox c (or4H
-eusoHerocos-sr4cdasHu, crcoHquelBsoUaucou-16y1'eruau
-hodyec ndu uu$edlovlor ueHcHeHoead-ouruuleyl .6e.0 .cxd
*.'
iE€ . rttrvuodtdvouxuHouc
'sorHeufiuu 'Bcceltodu aunusoduccedlodu en u
e)uHhoHoseolI
^ rl{H?selrog?o rrwoJ,I]I^Ir.rc uH J,olrulIs
en rqrudeuedu ur6 ')Ihl tt >ter,'er.vrturecuQsrr(c
)E>r or,rHeHer^rudu oueudgoooeren yu3 xrunerurodu
xlqHherrrrirn- oHroroxc xlDlcenudeQlrdeu xMHHroJcotr
*tuufu xtt:.raxrr ud11' Bvr,esevogeo erorgetr s ruHeher
ulreuulnradr u^rirHsurJ rcro{rrsr ruuudaloueuQ u
I (lnronc tredeu xalilratrxogoscHs ltrqHHelrtrenB0 c rqw
-doQ annnesrcdexeu uuu roru.(c a eed 1 ousrelruruo)
f,BUH ouHeso€qrouclr'sorseuluu aunenl(96
auHahoff
'eXUnrrerlru sI,IHBsOIrOg€€ OJOH
-slreruruucos orefi ordsrcr,(uoc exrarcoHJuutr s worcer
NIqsoJHuHHdxc yurqneerott rcrorrsr nurxerodusrgx
{trrHqnu)eo' LZs.-Y-lH rlrrqHqreruxorou r4 But^reHe
r
'(grauenene xrrnsrer rdoH x€retradlr s rclgaselco rfuow
lrroruoe)ou orsHHe[) 943 ruaod,( u OOf, euHemrqsol
roreshor rro sorHer4freu Etrrdr1 '(0t'E 'cnd) 146 vrl4t^
rott(esroucu esercr(c oronnexedou ex{rcoHJel,ttr g
uuHesouauccyl
'(ff -SVSV) yu3 oruuer.(eu
ou BsrcaI[go o.rostrodes.,(fxehtr rssodov€ rr,rHrorcoc
qneJ€€u)ou 'I,IJcoHJceh a '14r3cxy LIJIdLcoIJJevY rtltr
anunlrQulelc oouog' lr)Hefro rsrHer^{,(dlcHl,I ensoH
rrororpsrrJegedeed rfl eda eetrtroJcuH g' (aUC-SVOW)
3y radu yur.eaauogee urcoHsur)B qrorp€B)or u
(tgSVg) 3y lrdu 4unam,(deu xrqHlrrreHor,rlrxxfrp
cxetrHu 4ru)crug '(tVOSVg) 3y radu rr,rH€serogec
urcoHsuuu c)etrHu glaxcJ?g )gx xl{xer'goxllllcoduo
xu) cehr{H r,rrr) xrqHH etrxde gJ,,{ trrd sresoeirroucu
oHxor r 3y r,rdu rr{Hrorcoc oJoHqrr?Hor{tou,{@ u ruu
-Egerog?€ r,rrJoHsuDrB u)Heno rr[''eneuu Nuxraffl
-IsI^rtrBHx 4urrxoxfc rr,rnaruedxudu olcel.t ]I urco)
4ounedtreg flrerdes,{ltomvrog ) rsfirnrqw r^{oHhutroJr
4eHvedc rl,rHernredxudu orceru'exr,rHHoroxtreH )o€rsc
rqcr,rEerH€' uutrcuQ 4onHesmotro[ rr.rHolfxoxro orcen
:
' rurtor<oxr(c u trolrwxe lrfiHerruedxradu orconi rIc]I€erH€
outfiorl(Eorc rc.lorexedou oHhrsgo'ururerH€ r,D{engudu
erqnnexudrss u ol,IHeHerhoc eoHmotrostrox-osofrrcad)
uH LllaHorsetr udu srog 'xruHers?duuH xecs os ax,tH
-hoHoseou ouetrro NoHhI{Hcro[ s guHaxustr pr {eltgo
eranenuuefu o or.rHur^ruHs r.ge) Eru.lorutnedgo edrolrco
udg'(aufnoilsrcemtredu urz eutu,{xer) exnnr,emlrx
rryrrrv,sayoge€ oJoHqreruruucos rqnorrlruc u (euleEod
r,rHaueJc 4oadeu B)HHHesJctsod .( uru Er,rluorl{srcem
-tredu 'guln(xal,) eeudocu eH o€eHrruHz s erlHeee),{
rcJo{rrsr ultudorxeQ uwnro{<ug'qJconerrfl^ror"( run
394 . PEBMATOIOTU9 U 3A5OrlEBAH14, OnOPHO-ABl4rATErlbHOrO AflflAPATA
B Enpone 6or ee 90Vo raqpreHroB qBJrflrorcfl }jLA-B.27 -
IroJloxlrreJrbHbrMr,r (pacnpocrpaHeHHocrb }{LA-B27
cpe.u,r flpe.EcraBr{renerl eBponeou.4Horl pacbr cocraB-
r^r.er 9%). O6rqas pacnpocrpaHeHHocrb AC Huxe
0,5% s 6omtunHcrne rpyn[ HacereHr,r.s. Borce 75%
laqr{eHToB coxpaHJrror pa6orocnoco6nocrb r,r xopouee
KaqecrBo xI{3HrI. Passurue r.rrxeJroro aHKIlJro3a He
npl4BoAr{r K BbrpaxeHHuu @yuxquoHzurbHbrM orpa-
HeIi-
HUqeHLI-,IM npI.'I yCJIOBI,IU CpaXIeHI,Lg IO3BOHKOB B
TpzIJIbHOM nonoxeH}rlr IO3BOHOTIHI4Ka, IIOA KOTOpbIM
rroHuMaeTcrl HopMillbHafl ocaHKa B IIoJIoxeHI,Ivt cTofl,.
Knunuqecxan KapruHa
Kfl.rxlr.Iecrag Kapr]IHa Bo MHoroM cxoxa c raxoeoft
nplr ArcCnA. AC, rar upaBlrJro, pa3BtrBaercrr MeAJreH-
Ho, c pa3Jll{qnoIl crenenuo BhrpaxeHHocrr.r Bocluu}I-
TeJIbHoro [poqecca B IIo3BoHoqHI{Ke, y 6omuruHcrna
rraul4eHToB aHKI4IIO3 pa3B[BaeTCq B TeqeHI{e MHOTIIX
ler.HepeAxo Bo3HlrKaer nropravnrul ocreonopo3 Ten
no3BoHKOB, qTO [pUBO.{nT K yBenuqeHr,rrc pUCKa }IX
nepenoMoB.
flpu AC cpauleHlre [o3BoHKoB pa3rr,rqaercs rto
caoeft mrpaxeHHocrlr tI, KaK IrpaBr,rro, He Bbr3brBaer
rslpaxennorl crlr6arelrnofi ue$opuaqvry\ Ho B ps.ue
cnyraeB pa3B[Baerc.f, Bbrpaxennrrri ru@os rpy4uoro u
uretinoro orreJroB rIo3BoHoqHlIKa, qro B 3Haqr,ITel*rofi
creneHr4 yxyArrJaer Kaqecrso xusHu 6omnrrx. 9ro uo-
xer flprlBecrr.r K yrpare rpyAocnoco6nocrr.l, oco6enHo
ecnu co[poBoxraercq $uxcuponaunsruu cru6arem-
HbrMu KoHTpaKTypauu rago6eApeHHbrx co.ileneHr4ri
I{f,II{ KOJIeHHbIX CyCTaBOB.
lo 40% flarl]reHroB raraKe r{Meror nepu@epuvecxr.re
cKeJreTHo-MbIIIIeqHbIe IIOpaXeHr.rfl (acUUlterpuunue
flopaxeHlrf, KpynHbrx cycraBoB, raK[x KaK Ta3o6e-
ApeHHbre, KoJreHHbre, roJleHocTolHrre u meuenrre).
Iloaruuenna.fl yroNfi-seMocrb sBJr.sercrr ocnosHofi
xaro6oft, o6ruefi .u.n-fl scex rr{rroB CuA, uo flpuqr,rHa ee
NO,SBIEHI,I'I HEI{3BECTHA.
Ocrpuri nepeAuuri yBer{r nau6o-rree pacnpo-
-
cTpaHeHHoe BHecycTaBHoe nposBJ,IeHue, I{HorAa [pe.{-
rrrecrByer 3a6oneBaHr,rrc cycraBoB. BosMoxHrr r,rHrre
BHeCyCTaBHbIe [porlBneHr,rfl, HO OHI{ BCTpeTIaIOTC_f,
pe.rrKo (ra6r.3.61).
llccnegoaanun
Y uauueuron c AC npn penrrenorpa$ulr Kpecrrlo-
BO-nOAB3AOIIIHOTO COlUreHeHI{rI BbITIBJTSTOTCfl HepOB-
HOCTb I{ noTepq KOpTUK[UIbHbIX KpaeB, paCU[peHLIe
cycrasnoli uervr, aB AaJrbnerhueu
- cKJrepo3, cyxeHr,re
cycrannori ueJrlr rr cpatrleHr4e. Peurreuorpa@ux opra-
nporBreHm aKcn-
Ta6nraqa 3.61. BxecycraBHbre
il albHoro cnoHAxnoaprpl{Ta u aHKnnosxpyroqero
II
cnoHArn]/|Ta
. lloautLueHHaq yroMlqel,4ocrb, aHeMilt
. IepeAxuri yaew (25o/o)
. Fpocrarrr (80% vyxvur) u crepmururri yperpilr
r BocnalureruHoe ea6oreeaHile KruJeqHr,rKa (no 50%)
. Ocreonopos
. CepAeqxo-cocyAllcrbre sa6oreeanilq (sa6oreeaHlre aoprarrb-
Hor-o KlanaHa 20o/ol
. -
AvilroilAos (peAxo)
. ArrnrqHurrT Qr6poa eepxneri Aonil nerKoro (o,ieuu pegxo)
HOB rpyAHOrO U IOqCHUTIHOIO OTAeJIOB IIO3BOHOqHI,TKa
n 6oxosoft [poeKur{r,r .Moxer BbrrrBr,rrb r{3MeHeH}re
reoMeTpr{lr rro3BoHKoB B BI,IAe vx KBanpaTI.l3aUxLt c
yrparorl BorHyrocrrr BcneAcrBr.{e epo:urZ }r cKJrepo3a
rlepenHplx ylnoB, a TaIoKe nepxocTr4Ta Ten [o3BoHKoB.
K lpyrrau BaxHbrM rrplr3HaKaM, BbrsBrfleMbrM rrplr
peHTreHorpa$ur, ornocrr cuH,upr\ao$r{Thr
- Beprr{ -
KzL'IbHble ocreo$rarrr, coeAuHfl rourue relra IIo3BoHKoB
u npeAcraBJrflroul[e co6ofi 3oHhr Kzurbuu0uxa\uu
BoKpyr @u6posnoro Korrbua (puc. 3.40). flpu pacnpo-
crpaHeHHoM ga6onesaHr4u uoryr ua6lrc4arbcq oKo-
creHeHlre nepe.qnefi npo4o,nruotl cBg3Klr t4 crrvsHne
@acerounoro cycraBa. Co.{eraHue grr,rx nprl3HaKoB Mo-
xer rrpr4Becru x @opuupoBaHr,ro rrar[.rHori Kaprr,rHbr
<,6aNr6yrosoro> no3BoHorrHnKa (puc. 3.41). B no6ro-
novr cuu@use, ceAaJrr4ruHux 6yrpax u nepuSeplrvecrcrx
cycTaBax 3aqacTyro Bbr,IBIfl IoTcg 3po3l{BHbre r{3MeHe-
Hraa. Hepegro Bo3HrlKaer ocreorropo3, upusoAflrur.rfi x
pa3Bl{Tr{ro crroHTaHHbrx [epeJroMoB lognonxon. B ra-
rIecTBe IIO3AHeTO npI{3HaKa MOXeT IIOSBUTbC.f, BbIBI,IX
arJraHToaKcrlzurbHoro cycraBa. Mero.uuxa MPT 6olee
IIYBCTBI4TENbHA EIfl. BbISBIEHI,{fl PAHHEIO CAKPOVJIEI4TA
no cpaBHeHr4ro c peHrreHorpa@uefi (cru. puc. 3.39), a
raroKe rro3BoJrrrer o6napyxurr BoclalrrrerbHbre r{3-
MeHeHaf, B rroscHr.rqHoM orAere no3BoHovNraxa. .(9PA
I{Meer BzDKHoe 3HaqeH}Ie rpu o6creAonaHr{}r no [oBo.{y
MUrJrOTpaBMaTr{qHOrO nepenoMa.
Kar u rpu AxcCnA, COO u yponens CPE o6H.rHo
rroBbllIralorcrl npu aKTUBHoM TeqeHl4tt sa6olenaulu,
Ho Moryr uopua,rbHbrMlr, qacro np[cyrcrByer
6urr
aueuvrfl. Alroaurure ra,
raKyre xax P@, ACPA u AHA,
o6rr.rHo orpuuarenbHbr.
Ileqenue
I{erra levenus raK[e xe, rar rrpu AxcCnA: o6ner-
.Iurs 6om r.r cKoBaHHocrb, nogepxarb uarcuualrHrrft
o6reM Asr,rxeruuil u lro6exarr pasnurur 4eQopuauuli.
Baxnrr uo6uru:upyrculre ynpaxHeHr,rs, Koropbre
rrpoAeMoHcrpr,rpoBaHbr n o6nosrsrorcrr Ha MHortrx
aliou qrgxuHtos rexon 'yu3 c glilHH€ersc eg 'lradr I'{OCS }{r'tUrnOr.(SrCreSrOOC'UvUeXUH0l,IdU Ultr4XCerrnn
-de IuqHsuuued orr, 'oHqroreher{ud11 'vtuuucdeu u -ulrx c sodeuudr xrsHsrur.rderseg Yyd eH ru[xeed
FILa?JHm' IqmreHor{qrec'delxegoruuwex'ltutrlur€tx or€ - (rudlduoru[nouc) rfldrde glqHsl,Irxeed
rJrorrrsr rurudarl.ldr unrrHrces€I4'Vxf, rr€uur
ur4Houoalco seHHeeoetaredeHol u Beerc^c o.JoH
-moUesUou-osohrcedv eeUodrde'(ta>tuadrc) tsruSorrceUuuc 'B)}rHhoHos€ou {erIr€I/{doQen' 4oxcenru,oQtol
eneaedy arqur,udrevrvur3'eruuuUnouc oretnoildueouvrvHB 4onneaodraeornrH€ rlorexm c aorHeurleu .( raner.olr
uutterc 4axEeou eH )[HhoHogeou <nqsov,{9neg, 'tt'e'cxd osrcehex qrramMrrr( oHnesrcerMc Jexor^r rreou/udoego
oronsrerude rnsemr,fil( u rarcorr(,rz(c uulrxeddox rrtr
Bx,rHhor{oseou wrworoerco'ol4HesodueeroduotrHe
rcsreaogedJou rexon vO wlqHhlrdol,g c soaercfc
oJosehor[ rr oJoHHerrox'otollttodtregoc€J eludrde
lrrorerrrr radll's)LrHhoHos0o[uuHoxedou udu rsHaur
-xeQQeau uHo oH 'eu,Iesd ltofuco udu rc<ruaogedrou
r,(rolr rstruoxuldoxoxollrJ arsHslredode 11' erudrde
moxcer,udeQndeu u xrlrJ€rro0eJHe xu.tddtr' aJ[I,IIIceQ
,lroHHeamotroll r'remol(durcucdo[ udu lxaQQe sretr
r,tron aoVuoxurdoxo)ollrJ ul,I[rxeq.HllelilHrcel I
'rr,rHBsa[o9€0 er{Hehor eoHHesrc3rce eH vfi
rolrurs Ir eorlr)IH€ IrHo r{r rorcrn?dsrovedu 'ogcreg
og'[xur€ltoilIn]Io Ilto)cohI,IHI,IIDI rugemn firr( xffieII
s uxrqHsr,rrxeQQe rcrorusrirce)o ordlcehes rI{HohoII
rirYoJerI ou)cehr,rJoffoug'eHsurxaQQe oHhorercotr
-en rraueder resrdetrne.r,c xrsdorox ,( 'sorHeurleu I
rcqruaufuer{cced errxrotr 'yl3cxy c eendrc s u xE)
'VLI-IIII ) nl^rurerurll^e vut[ OHO ) r,rw€roilrrHB
ruuedel'r'roHc tredo[ rlrsrc4re[ oJonxeaod[.IHoIrodu
f, g 11 H arananelrndu rcle,(trnelroxod u.lconHeso)c
4ouuedlf rr,rHehJorgo xrrorr g '(CV ol]rHehelr orl
r,ruuerudgoxurog esmelfl go oJoHqrBHor,rtrBH eJ43c
I en'dewudueu) xecddced-resdelsu xrsnsreulnQo
(aruadrc) eruuuUnouc o.rovcohhreudocu suU
orqHhuur4r- 'rsruQowcaUuuc erqgoedy eH 'ercHl,udray\nuce 'eng[d: g '(exr-redrc) errurUuouc o:elnorldneouuvae yid orqHhnuur
'rsruQonceUunc erqeoedy erqur,udrewyrnc eta)ueyr
-
y 'arrdrdeourflHouc udu suHeHensu eurcer'u$edJoHaJrHod 'gr'e 'c]rd
-
960 . hHI.VIJOdIdVOUTVHOUC
396 . PEBMATOTOTNf, 14 3AEO,IEBAHI4f, ONOPHO.ABUTATEflbHOTO ANNAPATA
uu@lrquponaHl,Ifl MHoruMr,r BI,IpycaMI{, Mr,IKorura3Ma-
un, 6oppe:rurlMl,I, crpeIIToKoKKaMlr ra uuro6axrepra-
f,Mr,I, BKJIIoqax M. leprae, Koroparl BbI3bIBaer npoKa3y
(6ore:ur XaHceHa), oAHaKo peaKur,rq B srl{x cfly{aqx
o6rr.rHo 3aKrroqaercrl B Mr,roaprpanrl{I4, He cB-f,3aHa c
HLA-827 r{, KaK npaBr.rJro, He flBJrqercx xponuvecxofi.
Aprpur, csqsanuruZ c peBMarr{rrecxori rurxopa.[Kor1,
TaKXe ,IBIrfleTC,{ rrpr,IMepoM peaKTr{BHoro apTp}ITa,
xoroprrrl He cBr3aH cHIA-B27.
PeaxrusHlui aprprrr npu un$erc1usx, nepeAaBae-
Mbrx rroJroBbrM rr,,reM (SARA), 9ro rrper,rMyrrlecrBeH-
-
no ga6oresaHlre MonoAbrx .rlrcAefi c npeo6la4auueu
cpeAr4 MyiKrrrrH ( 1 5: I ) . 9ror Saxr orpiDKaer rpyAHocrr{
B AUaTHOCTI,IKe COCTOflHIITI y MOIOAbTX XeHIULIH, y KO-
ropbrx xJraMr.rfluiruar uu$eKur.ur qacro rrporexaer 6ec-
cr{MrrroMHo r4 ee rpyAHo o6Hapyxlru xlunuqecxra. Or
I lo 2% rrarlrreHroB c uecuequ@r{qecKxM yperpr{roM,
Ha6rrcAaroquxcrl rro noBoAy :a6olenarurft Mo.Ieuoro-
noft cucrerrarr, r,rMeror SARA. Cunqpou x.naurafluft noro
ypeTpllTa, KoHT,IoHKTr,IBrtT a U peaKTr,IBHOro apTpuTa
pauee 6rur tr3BecreH rar 6o:resHl Peftrepa.
Kor4a rpurrepoM Bbrcryrraer Kr,r[errHax rax$exqux
(sureponaru.recKr,rfi peaxrr,rnHrui aprpur), HLA-B.27
MOXeT npeAcKa3aTb pa3BlrTue u T_rlxecTb peaKTlIBHoro
apTpuTa, xoTrl TaKoe cocTo.flHue MoxeT pasBkrTbcs, v y
HLA-827 - orpr.{uarenbHrrx lrcAeft . I{acrora cnequ -
Suvecxux uuSerqnft , Bbr3brBaroulnx pearrunHrrft
apTpr,rT Bo BceM Mrrpe, 3aBucr{T oT 9rrlrAeMl{oJlofr{}r
uu@exquu u pacrpocrpaHeHHocrrr HLA-B27 cpegu
MECTHOIO HACEJIEHI{fl.
I Knunrqecxan xapruxa
Ha.raro o6H.{Ho ocrpoe, c Boclrarr{TeJrbHblM
3HTe3lrroM, onl{roaprpl,I r ou u f ultu BocrIaJIe H}Ie M
lo3BoHorrHura. 9aue Bcero nopaxalorcrl cycraBbr
u oHTe3rIcbI Hr,rxHI,Ix KoHeirHocreft. IIptI Bcex rr,Iflax
peaKTr,rBHoro aprpr,rra uoryr sa6lrc Aarbcfl. BbrpaxeH-
Hbre cucreMHble rrpof,BJreHilfl,c nuxop4xotf u noreperi
Maccbr reJla. Tarore Moxer BbrqBlrflTbcg. gHTe3ur Mecra
npr.rKperrneHrs. axvruroBa cyxoxunlr r. f r eugunur
axI4rIJIoBaclxoxr4trlrfl LrJrur rroAorrrBennrrft Sacqunr.
llepnuft npucryrr aprpvrra, KaK npaBruro, rpoxoAlrr
caMocToflTeJlbHo, HO MOXeT pa3Br4TbCS peUr4Ir4Br{py-
roruuri LrnH xpoHlrqecxlrft aprpur,uy l0% [aqLreHToB
crrycrrr 20 rcr [ocJre uepnr,rvnorT araKvr Moryr Ha-
6rroAarucs [prr3HaKr{ aKrr{BHoro ga6oresaHns. Eolt
B IIOflCHT{rIe LI CKOBaHHOCTb BCJTeACTBI{e 3HTe3r,rTa II
ocrer,rra aBrtflrorcfl o6uqulrlr gBJIeHr{eM, uy 15-20%
naulreHToB pa3BllBaerc, caKpotuelrr. rlacro npu pe-
aKTr,rBHoM aprpr,rre na6lroAaercrr flopaxeHue Kox]r,
oco6euno npra SARA:
. KoJrbrleBlrInurl 6a.uanr,rr, xoropuft HaquHaercrr B
Br,rIe ny3brpbKoB Ha seHe.rHor7 6opos.(e xpaftueri
ruIOTI,I II IOJIOBKI,I NOJIOBOIO TUIEHA C IIOCNEAYIOIIII,IM
pa3pbrBoM ra o6pasoraHr4eM rroBepxHocrHbrx gpo-
suir c MVuuMuLrrbHo BbrpiDKeHHori spurerr.lorl oxpy-
xarcueft Koxlr, 9po3r,ru Moryr cnr{Barrcx, o6pasyx
Konbuo;
. 6leunopparuqecKas KeparoAepMlrrr, nposBnrrrc-
llaflcrr 4ucxperuorl, rocroo6pasuori, xelro-xo-
puvuenofi Be3r.rKyJrorrycryle:urt cbrrrbro c ueny-
uaIqI{MI,ICS KpaflMU, I,IHOTAa CJII4BaIOIU}IMLICfl
C
o6pasonauueM KplmHbrx rBepAbrx 6lxruer, lopa-
xarotqux Koxy naAoHeri u no.qorus;
. nycryne3Hbrft ncopnas;
. 4ucrpo@r,rx Horrer? c [o.uHorreBbrM rr{nepKeparo-
30M;
. .s3Bbr B IIOnOCTI,I pTa;
. KOHbIOHKTUBI,IT;
. yBerar, roropurl peAKo flpra nepBoM
rrplrcryrre, Ho Bo3Hr,rKaer ""rftrurr""
y 30% [auueHroB c pequ-
Ar,rBr4pyroulrM vrrru xpoHruecxuM apTpr,rToM.
Apyrue ocJroxHe H r.r fl. lpkr peaKrr,rBHoM aprpr,rre
ua6rrcAarcrcs peAKo r{ BKJrroqaror HeAocrarotrHocrb
aopTiulbHoro KJrarIaHa, HapyrxeHurl IpoBoAr{MocTI4,
IureBponep[Kap.ur.rT, nepra@epuuecq/ro HeBponar]rro,
cyAoporlr r,r MeHr,rHrogHrleQalur.
I lrlccneAoeaxffi
,{r,rarno3, *uarruu-
KJI Moxer norpe6oaaruca
I,IHnqecKr,rx AaHHbrx, Ho
acrfilpa\ufl, cycraaHofi xr,rAKocrlr ArrI ucKrroqeHr,I-g
Kpr,rcrzuuuqecKoro aprpr{Ta r uHSexquoHHbrx no-
paxenuft cycraBa. COO u ypoBeHb CPB nontrlrensr,
yperpr4T Moxer 6rrrr no4rnepxleH lrccJre4oBaHr,reM
Moqu npl,r BhurBJreHHu cJll43racmxHratefi n nepnori nop-
ulrlr Moqr{ H r,rx orcyrcrBur{ Bo nropori. Kyllrypa-urnoe
r,rccJreAoBaHlII,I Ma3Ka c 3a,UHeIO CBOAa BJIaIaJ'II4tUa
rro3Borf,er Ar{arHocrr{poBarb xJraMtrAlros. 3a r{cKrrlo-
qeHueM IlocTciurbMoHeJlrle3Horo apTpI,ITa, KynbTyphl
Kzlna K MoMeHTy pasBvrrufl. aprplfia o6n.rHo 6rrnarcr
oTplrrlaTenbHblMr,r, Ho cepoJloruqecKl,Ie r4ccneAoBaHr4rr
Moryr noATBepIr,rTb paHee [epeHeceHH],ro Ar.r3eHTepr{rc.
P(D, ACPA u AHA orpuqarenbHbr.
flplr xponuvecKoM purv pelql,zp.nstrpyouleu sa6o-
Ha peHTreHOIpaMMaX BbIgBLqIOTCf, OKOJIO -
JI9BAI{I,,I.d
cycranuorl ocreonopo3, npolu@eparuBHbre opo3trr,r
n o6racru cycraBHbrx coqneHeHurl, nepuocrrar (oco-
6euuo rurrocHeBbrx rocreri, $a.naHr r.r xocrefi rasa),
6onuulre [rIToqHhIe rxlopbl. B ornz.Il4e or AC, nrr-
ssrqeN,rHr? nppr peHTreHorpa@rau caKpolr,[eur qacro
flBJIgeTC . ACytMMeTp[lIHbrM, a ]IHOrAa OAHOCTOpOHHT4M,
 ' (7y' g' cwd) ItoHE)r oruneYxedsou u ycl-.1 urahex ra$racceuv UVd SVC'ol4Hehavr rdu
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r
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or€ ecg 'YLl-lII4 HI,I)oJLIII
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s/ ,Od 1l\01 t4tsusuerehrdrg .
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r,rHtrusurxu u exsodulHedetpQun'-l' .le,(arcgocouc ee-LcYod t4Houalc
stradeho orosc s orh'r,rr,rrexrerx ltnrrsHludYueY EZ-VVI r( eeBrdocu ooHl/"lBH[ o
4odore nun r4oedeu eolrluo€rcUod
ornnx^(trodu or,(nnorrsgeu reealqelqs r,{lntu.rc 4utn (euueg 7) eerdocu t4rlnbtel o
uraruaeud a (eouu oueee>I oH t/uco 'uueg t) eel4derudv xntnotAUauc eu
-orexc.(uee oln 'trcreel€roxtredll 'ycg
ucl4v,i!4fnoreerqilelDrc 'r4v\Euueq e c v\oh geHon oH (screerHe ruu
qrod or,tser'urx r,eufuu U-YVl/tZ-[14 sr,{u oJh'oJor
v14HhoHoEgou'eerc,{c) eoeerclc oilHeEouogpe ooHcr0-Ll4ljeuco8
srcqrorBea)otr emqrog ecs rtJerlrslroll 'g-V-IH I,I
J-V'IH lrwurHelades UVoLI ,fifxew III{[€uIIocou 4o)c !
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398 . PEBMATOIOTUT U 3AEOTIEBAH149 OflOPHO-ABMTATEflbHOTO AflflAPATA

. HLA.C, HLA-B
. Apyrue reHbt
T4MMyHHOTO OTBeTa
MarpoQar

Hapyuenue
perynrqilil uMMyHHoro
orBera B crueucrofi
o6onoqre hru Koxe OHO-cr
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npil ncopharuqecKoM aprpure. (ADAMTS-S
BaKHbrMr4
cl4Mynilpylor{uft $arcrop; MMn
- arrpeKaHa3a; V1fi
MarpvrKcHafl MeralnonporeuHasa; OHO
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- - Qarrop -
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.{ecrpyrrurHsul ap, pur u uHBanr,uHocrb Bcrperrarorcf,

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-sBtrs olsHhehor roIBhoIIDIs I^ erJoH rI,lHoHeI I€tr4
'xotrsc xlqao€Er
4raxelruedxudu ercel r ra,tedged x trmnlnt xsudegedxaw
'r(goulrodxe ) Isfimlql^t 4oHtrflsorsro[ 'uJ3o) 4os0h
-enu,{xnelflrsr'ttrBH ) 4wnnroxlc'rtreldag r{lnlomurog
) rirlmrqN 4oHhr4troJr 4eHvodc'edYeg,(xrelnrsl^I
.&nronsrEda,rur x odtreg xutflrtrosro 'fimlqn 'exI{HHer
-o)trEH rDr€rsc'uultcuQ 4oHHesmovou' rltrrxoxr(c
esorflrraxe tgnneruedxudu e.lcenr rsHexedou' omgedu
)€)' nwrlHHuso€ure)or uIrI4 I,IrtIqHH enedrcoducud
srrsg rfuolt rilnoruwl,I3 '(rueerrre) llrco) ) )oorsc u
4urrxox^{c runaruedxr,rdu xercow s oI<IrcoHHBao)c
lr orqrog rcrenrsrodil rl{Heserogue ertdoQ ur6
tuearHe A utnoilduH n Nofrl
'<(I IOreHdOr C UXr{dr> }{IrI4 <(BIIqITBII OJO)CahI4UO)3
-arrer>> lrreunesoduv{doQ c rufieltdo@en' renderxtdex
rJrausHssed'ncroregIEIredox.( HtIsIreU'sosercfc
ItlJoH<Irl,IgurceH goHHexedrsg x rutrogudu I4HB)I
r-roHrJox n emrdx altremr(deed aonnaxedrsg 'VoI_I
gr€r.il: %S s BJreesHgeed 'ron u x,td tstlsruu tltll[flolBx
-edou' urdrde naueode r4utnu.(dulnudoQar o16
4 rs
Mdtde qulnulduuutllly V
66€ . ltlu.YuodldYolfi{uHouc
 400 o PEBMATOTOTIfi u 3AEorIEBAHnq onopHo-ABxrATEIbHoro AnnApATA
oceBoro cKeJIeTa qacTo BbrflBffroT npr{3HaKI{, CXOAHbTe
c TaKoBhrMr{ npu xpoH[qecKoM peaKTLTBHOM aprpHTe:
rpy6ue, acxMMerplrrrHbre, HeKpaeBhre cr{HlecMo$urrr
H acr{MMerpr{unuri caxpoutrerar. MPT u y3I4 c euepre-
rn.Iecxori Aonrureporpa$ueft sce qarqe rrcrroJrb3yrorcq
AJrg BbuIBJIeHr,IrI BoclliureH Efl cllHoBuurlnofi o6oloqrol
}I 3HTC3OB.
I Ileqenne
flpule*ofiOoOrffi
cllMlroMoB Moxer 6rrrr AocrarorlHo npI{MeHeHr.rrI
H fI B C Ir aHaJ'rbrerv xor. BuyrpucycraBHbre r,rHbeK-
ulru DrroKoKoprlrKor.rAoB naoryr 6urr e$@exrunnrr_
MU tIpI{ I{3OJII{pOBaHHOM CUHOB}IT9 VUWI 3HTe3UTe.
B cssgu co cKlroHHocruo x @n6po3HoMy lr KocrHoMy
aHKlrJro3y cneAyer ras6erarr uclonb3oBaHlrfl IIIITH
r4 AnprrenbHoft u urr.r o6u nvrca\uvr. fI auue Hrarr.r c o
cnoHllunr.rroM noKa3aHa rrporpaMMa pe a6u:lura\uu c
KoMlJreKcoM yupaxuenurl 4rts yKperueHlrq ocaHKlr,
rrro u rlpla AxcCnA/AC. flpu crortxoM crrHoBr,rre, He
IIOA{aIOUIeMCTI KOHCepBaTr,rBHOMy JIeqeHI,IIO, CneAyeT
paccMorperb Ha3HaqeHue EMAPfI. Merorpexcar
flBJrflercq [peflaparoM nu6opa r{ raKxe e@$exrunen
[pr{ KoxHbrx flporrBneHr{flx. Tarcre Moryr oKa3arb no-
noxr.rreJrbHbrrl e@$err u 4pyrr,re BMAPfI, n rou vtrcle
cyrr@aca.na3rrH, ur.rKJrocnopr,rH u le0lyuorrrr,rA. Oco-
6oe sH[N,raHr4e cne.(yer yreJrrrrb KoHTpoJrro sa SyHr-
qlretT ue.reHr.r y naqueHToB, [oJryr{arournx BMApfI,
raK KaK npu fIcA vacro ua6lrcAaercfl ee yxyArrreHr{e.
IugporcuxlopoxraH o6rr.rHo craparorcfl He [pr{Me-
Hqrb, TaK KaK oH Moxer Bbl3brBarb ercSoluarunnrre
KoxHbre peaKur{r{; TeM He MeHee s He6omuroft uoA_
rpyrrne AHA-no-noxr,rreJrbHbrx [au]reHToB c yMepeH-
HbrM[ np[3HaKaMr.r fIcA npu oTcyTcTBLrU nCOpXa3a
Bo3MoxHa noIIbITKa ero Ha3Haqeuug..y [aur{eHToB c
AKTI{BHbIM CI{HOBI,TTOM, KOTOPbIE HCAAEKBATHO OTBE-
qaror Ha craHraprHbre EMAPII, cneAyer paccMorperb
repanuro aHrurelalur x OHO, xoroprre e$@exrranHrr
KaK flnpl,r fIcA, rax il ilpu [copraa3e. ycrerunyua6
(veroneuecxrae MoHoKJIoHiuIbHhIe aHTI,ITeJIa, cBrl3brBa-
rcrulre u ner7rpalusyouue cy6re4unurqy p40 IdII-L2
u l4ll-23) ynyquaer K;u4Hr4secKyo xapruHy sa6o-
neBaHj.{g. B Cn) {ae [opaDKeHHrI CyCTaBOB, AAKTHJTVITA
Lr 3Hre3r,rra npr fIcA. Cexyxuuyl,ra6 (velonevecroe
MoHoICTIoH:urbHoe aHTprreJlo, HaueJIeHHoe xa I4JI _ I 7A)
o6naAaer cxoAnorl e$$errr,rBHocrbro c uHrlr6uropaun
OHO. Alpeuunacr sBnrfl,er cfl nepopurJrbHbrM Hr{3Ko
MoJreKyJrrrpHrura uHru6r,rropoM Soc$oauscrepa3br
4-ro ruta, roroprrri esserrrneH npu fIcA B cn) rae
orcyrcrBus orBera Ha repanr{rc EMApfI, xor.rr, no_
BLrAr,rMoMy, oH MeHee s@@errraaen rro cpaBHeHrlro c
6uororlr.recKr,rMr,r npenaparaura. flo6oqHrre sS@exrrr
BKJIIOqaIOT [OTepIO MaCCbr TeJIa, .{enpecc}Irc u cwt\u_
AZLTIbHbIE MbICJII{.
SHreponarltqecKilfr aprpt4r
(cnougrnoaprprr)
O6ruag pacnpocrpaHeHHocrb Boc[aJr]rreJrbHbrx
ga6o.nenanrarl onopuo -ABlrrareJrbHoro annapara
npx BocnanlrreJlbHblx ga6onesaHr,r_f, x Kl,tuteqHuKa
(6ole:Hz Kpoua lr s3BeHHoM ronure) Ao KoHrIa He
I43) {eHa, TaK KaK B }ICCJTe,UOBaHI,IflX He npoBoAunll
AAEKBATHYIO OIIEHKY 3HTE3}ITA V OCTEVITA, HO NPO-
g.Brre}{ils. co cTopoHbl orropHo-ABr{IaTeJIbHOrO an_
ilapara coorBercrByror @eHoruny CnA. flopaxeHr,re
uepn$epuvecKrrx cycraBos Ha6rroAaercrr npr{MepHo
y 20% nauueHToB c Bocrr€urr{TeJutru ga6oneBaHr{eM
KlrrrrerrHr{Ka. flpu onaroaprr,rrgnrrpHoM xapaKTepe 3a-
6orenanuq [peuMyruecrBeHHo nopuDKarorcr KpynHbre
cycraBbr HHxHlrx KoHeqHocreft (xolenurre, raso6e_
ApeHHbre r.r roJreHocronHue). PenrrenonoruqecKr,re
nprr3HaKu caKpolrJrer,rra npucyrcTByroT flpr,rMepHo y
20-25% narlueHroB c BocliurrreJrbHhrM ga6oresa-
Kr,rlrelrHrrKa. flpu 6olesnu Kpona qailIe, qeM
Hr.reM
flplr rr3BeHHoM KoJrlrre, aprpr,rr MaHr,r$ecrupyer oano_
BPEMEHHO C K}IITCqHbIMI{ CI,IMITOMAMU VI YJTyr{IJJ.AETCr
upu e$@exu{BHoM neqeHr.rlr ocHoBHoro ga6olenanuq.
Cyruecmyer flpe.4lronoxeH]Ie, gro rrlxecrb u Harruuo
BOCNZUII{TEJIbHbIX CKEJICTHO - MbIIIIEqHbIX CI,IMIITOMOB
Moryr 3aB[cerb or r{3MeHeHraft uelocrnocrrr r{rreo-
rleKanbHoro KlIaIIa}Ia, gTo rIoBbrrIIaeT BepogTHOCTb
uslaeneHuli s xuute.rHorl r4uxpo$lope, aucrynarorqefi
B KarrecTBe Bo3MOXHOIO Tpllrrepa B pa3BI,ITI{I,I aCCO_
qlrlrpoBaHHoro CnA.
Cre.uyer us6eraru [pr,rMeHeHr,ra HfIBC, TaK KaK
oHr,r Moryr ycyry6rars reqeHlre Bocnuur.rreJlbHoro 3a-
6oresaHu.f, KurueqHuKa. Buecro slrx uoxer 6rrrr
paccMorpeHo o6ocnosaHHoe ucnoJrb3oBaHr4e rnrc-
KoKoprr{KotrAon, cylr$acatra3vtHa ra MTK. Brr6op
Tepanlrl{ AoJrxeH ocyrqecTBJIrITbCrI COBMeCTHO racTpo_
gHTeponoroM u peBMaroJroroM. Anrrarela r (DHO
e$$errnnnbr rrpu 3HTepolartrqecKoM aprpr.rre, Ho
lpuMeHeHus graHeprlenra nf{rrre z36erarr, TaK KaK
oH uesS@eru,rBeH nplr Boclzurr{TeJrrnrrx sa6oresa-
Hl,r-f, x Kr.rureqnuxa. B cnyqae yxyArIreHI,IrI cKeJIerHo -
ruHure.IHori cI{MrIToMarI{Kr{, HecMorpq Ha repanxlo
- aHTr{TeJraMr,r x (DHO, uelecoo6pa3Ho r,rcKtrrostrrb B
KaqecrBe BepoxrHort nprvl,IHbr cI,IHIpolr lrs6rrro.rHoro
6axreplralrnoro pocra ua @oHe cra3a roHKoft ruurxu
(clrrgpou clenoft rrarueqHorl neuu).
'X'JJ /(eqroll s og}Ir rordsJrqreJetrr,rsc rDreHor,rd[ ur€
lcrarSu HauHers.reeeed u Neunadumced xu 'godrrnruru
-gx <nel,IHe[3ulqg> c ulruolr uxn,tctEd o.touqrultdon
ordarou qwrrelrro oHxol^r (,{xox eH oJoHHeceH€H
'ErcEW u) uuoxcolrsrerQo olsrnonorr c Bxolr oJoser
-JoH rrr,ruo)codnnruruuv ud11 'rou 4oxcx$t I{ oHEed
unodtrHl,Ic eoeHlIBHB oJoHgenoc suslcJr{clo 'tat 97
oerog rr,IHosou)r,rH€os rHor lon eH lcedeos rrcoHJo
'on4o4 nodtrnHc BH r rurflor€erqt8),{ 'rrrudaJJ/ldxSl'qz9
oV Urororceh c uufirlrfuou rjeIrlgo u rc4etnolunedlca
'onEe4 r.rHoerog ro qrusodurruadetpQutr onutroxgoaH
' uuexl 4ous[e[IH[treoc ulltBr4HBgelrogee ranrsHHr$^u{u
-orfe ulrur.(dtru g;3 c grrHHeorso'on4e4 ltodYun3
'norudrde uw 4eutrcdl:de c ftrrdes oH4ed vroltodtr
-nuc sresodurceQuHew Jexon B)J 'sov.rorrnllc
xurfdV ruHeusrou otr rstsoJ uIIu IsIITJoI{ €e qrB)LIH
-€os Joxow u rcreenedros orceh oHged nodVnu3
oHued fiodilHuc
' oHhurrlrreH 4ercorxdeaou
xrsHseJ.c,(c euHegodueode oH' 4urrxox[c ruHelorede
-ou elrsrctseuca (fxxey ruluuodrdu) rcsreaodult
-doQe[ rfuon rsserc^(3 'oxtred rcreer,edrcs goserc,{c
orqrcorxr(uudu c rr.raoHuc 4Isnnexedlqs DlcohlrHr,Irx
ox?Htro 'eJ,}lgoHncoHar anrugeud oHxol leos e)Norel
'xeserc,,(c g olqrcoHHeso)c tleunedr,( rcrep['xosoduoc
orceh r,r'gotgeufteu o696 [, ucwutrtorer'edrcg'IrrtoI{oJU
- hrH J I^r rq H Hanudrcoduced rcreyrsy rulrudrdy
udtdv
'eccefiodu oroH
-flrarH[?uJog olqr,oHsr.tl)IB J Htrsc Ioxrah <IIaxrH aH
H HXFTHHToJ:nu srrsg r.l(.rox (xeuercfc u urog enHsxc
-HaLHHeH U qrJorrrarnlrorr( runnemnuou) aurfdr xex
B[Jor'rlHeserog"e 4unedrcogo rltedg os <rrexrHeos
rfton 'ruleuouetruQnur rumqrogeH r,r euer rlccen
ouHexuHc 'extredoxur >tE) ell)er 'nxolul,tu3
eHxrdev tsPvcehnHrrfy I
'soHerdo orrlnellxedsou u
erlflr,{xces olr,fiprseud x unrumBtrosudu'gy3 goualrJ,xe
udu genexr runallxedgor lln?IltcplHexellt I,INIqHxEg
rcro{rrsu €c)errullro) oronndlrltu euneuodlrtdoQ u
reruilruorr(€ rufi)^trodu oJh 'bcreururrc 'uHl,tt udu
-osdeu uurqg uH rqg sso)B) ')orerfi eunetrxedaorr
Jor€srr€rqs u ccodrc rIrsHalrrEtr[c)o rorasurl{c,(' (uurr
-xaQxlr' euueMreu eoaoreuouQefusrr() g;13 ruuafuc
-ogo er,rhorcsn€rrs'rstredc gehorex,(dxo rsdor>rcQ oln
'neJ rJreetrxdesrVou oJO'rerprrHeor^(e uuttxdtrodu
r 0r o l,t HVXr 140Hq u3r4 H ]4ffgOo rU HVSS UOgVe iIIqHHAWII|HOI^V
u sorflfioQv{vllt - L vr - g xrqHqrBHorxrrlrolr uurIesI,II)?
) aot[rtrosl4du 'xolerx sJ,coHxdegou eH soHoJI,rrHB
xrqHhorerrxudlr(rrs eusrc4e[oos eo)ceh]IJolroueuQau
roeslqelqs orh'rorotr>I xrDloahl{rouloue ecgeduvx uttu
Booruore aorxaQaY ellsrctrorcs rcsresuseed rexo]t
g)l orh 'wor o rq€erorruJ orunesodumdoQ x oreaudu
olg 'edtrr ltru e)retrx g eurloldgrcrrtctldu 'lqsoJlttHe
€H rqHeroIleH XI,IH 0lr elrJoHN ou '4euemlrlt e.ildx or
-oxodum rrr,rHamoHro s otqJcoHhl{Qufieuc roIEY€IIgo
enerrureo.r;(B 1116'roJltneo.u(e rulrxdrodu YJLerr
-sr g)f, orirrooHHegoco 4onderxedex ruHede lDlhor
r1o)cehr,rJououdwlttt J')ororrx xrsHH-,fitrtu I4I,ITDHIQ
uuflrrfuad s rot,(slcehr( xrsdorox eu osrcHumqlrog
'gy3 x rorereroucudtradu ersdorox 'soHeJ Btrrd oJolren
rrneuQdowuro[ Bcel,Irfiuur.edrca orceh I,Irrusrlqg
rl[rtrEr,rfiorcs xrlrHr^roHeJ rruHEsotrorccl4' I xEuI ) H tr
rseealr),(Hoe)€ urM qIIIU,tc{ E1 udorueled'V) u ZJ
'b 1
3 eurewerutluo) soJHeHoulto) xthler s uNruIIeJ.&{
umrsl^Ie,{trelfceH c eH€€rsc g)f, xrenr(rc xndorox
-eH g '\flH ac,{xor s uxurHer,rdua uwnnQdonr{ro[
3 €He€rso oHrer irH€elrog u 'slcoltlHBtrdo)Hox rE)oJ
-Iss eaffog r3routrorlrgBH sofleHtl{Irg xrIHroJI,{€oHoI^t
'ltedorxeQ NrucehrrroHeJ rlrxertrEHudu srod relrr{<es
^
oH 'EHor r^reosoc eH g):) yutus.ted enunlrdll
tsl,tJouo1/|en$oreg I
'
IruHesoroguo xrsmuff coc-onnetrdoc
yur;vsted olennud excud oJoHHomrlso[ eusJctrorrs
IltoHaoHco s 'eroIl lt urcedsog oJoHhuJoIfBH? ulltett
-udfu uxrsxsrodrHox c orr,rneHgudc ou nrconrdeltc
lreHneMresr{ fl rsHJed)uJrx r,r rdrcone8aeuogee ltor,cod
r u<rH<rreJuhBHo rcJeeYxosoduoc g)C 'Jeri 0t otr 0Z ro
rarusercoc'euueaarogue refdulorgetr ltodorox udu
'rcBd0oe 4}IHtradc e 'rqsulruex - soJHeI,IIIpr] 0106
orro)O'sosodrco xrucande; rI,IHeIreoeH oJoHtrI,Iofu
-as f obZ'1 otr rqced 4onYuoauodse geueJusu.lc[edu
d %effO Jo rcrargarov o,rodo.r,ox srcoHHeHudrcodu
-ced 'euHesarog€o eo)tred o.r,e (exHunrou) 913
-
' (reruureor"(e) exeunurdo nrH?)r
NrrHHosrcgoc )
reJr4rHe 4oxr,ogedrsa c eJesro oJoH
-pfirnu nu[Kr,fied soccefiodu wrsemr(dzH eusJctrercs
rcxuIfl ol?staaeed'EuneaelrogBe IltBr,IHersrodu I^{[xceh
-r.rHur.o{ wuosc ouxsHeedgooneeduuuz(fu o.le unex.l
goHqreu,rHr.rVaoc ruH€sarogee ennudnltuo.r;(y
-
1/r HEIlr [ 0 H
q u01r4 H r4u003
814 HU8 0U09ES 0 rq H H^r/! m U otu{V
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4-/
IJ;
Pnc. 3,44. Ocrputfi eropuvnurft cr4HApoM Peino c c3BaMu Ha
nanbqax
ru6o rqxerori Soprr,ru 6oresHu PeriHo. IIpu rxxelou
Ter{eHr.ru cuHllpoua Per7uo no3MoxHo o6pasoBaHr{e -rr3B
Ha rriL'rlqax (puc. "3.44).
Koxa
flopaxeuue Koxlr rr,rnuqHo trnfl CKB, npu erovr
[oqBreHue xoxnofi cbrnu [poBoul{pyer eosAeiicrsue
yrrrpa@raoneroBoro ceera. OcHoBHbrMlr Br.r.qaMr4 rro
pa)(eHufl. Koxu rrBJ'IqrcTcs cneA),roull4e.
. Kraccz.recKafl cbrrrb Ha Jruue (rc 20% nauueHros).
Oro epureuaro3Hbre, [puflotrHrrrbre u 6o:re:neu-
nrre :ru6o 3yAflrur,re Bbrcr,rrraHl{q Ha rqeKax, He 3a-
0,{
w
L,
P
Puc, 3.45. Burcurnaunn e Qoprrle 6a6o,{xu npn cncreuHofi
rpacHoil BorqaHKe, He 3arparuBanu.lue Hocory6xbte cKnaAK[.
Curnu noxoxa Ha po3aqea, Koropafi caMa no ce6e uoxer
orMeqarbcs npu BocnErnurerbHbtx aa6oneeaHurx cycraBoB
(Hanpnuep, ncopuar[qecKou aprprre)
TparlrBaroulue uocory6nbre cKrra4Kr,r (pnc. 3.45).
Ora crrur [oxoxa Ha po3arlea.
. Ancronunar cbrrrb, xapaKTepl,I3yloua.sc , rlrnepKe-
paro3oM rr 3aKylopKorl @orurraryroB, npu Bo3HlrK-
HoBeHlr[ Ha BoJloctlcroft qacrrr Kox]I roJIoBbI
py6qororl aaonerluerl.
- c
. Au@@ysHa"s, o6uuHo Hepy6qonar zuoneqr,m, Koro-
pas raroKe Moxer Bo3HlrKarb npu o6ocrpeuula ga-
6onesaHu-s.
. KpanrEnnuqa.
. Cerqaroe JrrrBeAo (puc. 3.46), Koropoe raror(e flB-
rflerc . rrpoflBneHr,reu auru$oc@oJrr,rnr,rAHoro cuH-
ApoMa, a B TDKeJIbIX Cnyrlasx MOXeT tIpOgBJIqTbCrI
BacKyJrr,rToM.
lloqxn
flopaxenue noqeK flBJurercs oAHI,rM u3 KJIIoqeBbx
lporHocruqecrurx QarropoB rrporln3 a za6otenatut,
nosroMy Heo6xo4rau peryaxpuuft xoHrpoJrb 3a aHuuru-
3aMr,r Moqr{ r4 ypoBHeM A,4. TunuqHhrM rroprl)KeHr,reM
noqeK frBrrflercfl. npolrQeparnnnrul uouepylone@-
pr,rr, xaparoepusylorquft cq rsxerorl reuarypueft , upo-
- reunypueft u HzlJrr{qrreM UI,IJI}{HIpoB, BbtflBJrfleMblx np}r
MIIKpOCKOIILII{ MOqU.
Ce p4e,a u o - cocy4ucr a f, cu cre M a
Hapr6onee qacrbrM rtpo.f, BneHr4eu ga6onenanr,rs
Taxxe Bo3MoxHbr Mr{oKap-
aBrrs.ercs. nepr,rKap.ulrr.
I,ur kt gHAoKapAr,rr Jlra6uaua- Carc a. OnAoKap.ur,rr
PA3BUBACTC,tr BCJIEACTBI,IE HAKOIUIEHI,Iq HA CEPAEqHbIX
KJralaHax crepuJrbHbrx Sn6puHco4epxaru[x Berera-
qurl, uro cqr4Taerc.fl [posBreHrleM r]rnepKoaryJrrUr{r,r,
cs.s:aHH ofi c auru $ o c SoJr r{rrr{AH brM t4 arrT vrr e rav^rz,.
Pncr arepocKlepo3a 3Haqr,rrenbHo Bo3pacraer, paBHo
Pnc. 3.46. Cerqaroe nt,tBeAo (cncreunar KpacHae BorqaHKa il
aHrn$oc$onrnugHuril cuxgpou)
 'xeeuueHe xtququeUeed x[eU g. el^rdoQ s 4LIHeuIqcIqs ')eholr rl4HaxBdolr €Jorc€h BE)l
soxeH€ildu L ! eU xlcgolti tttttt(ve{ v\oHHonodsoHEo
-oclqs oelrog rcre€honiro u}IgJctrercolls oHhr'IJoITPHV
ruu vrvtHorr€Bou yIoHcUoIBEOEOUCOU t4du 8)C loot'lt4 rlCUCOdeB
' 'xsrcodss r( Neh 'orll€h rcrolEhodJcs BuHorsrodll eIqH
-xo) u )ehou euHexedox g)f, IioHqruHesol [dII
t4 t4h Hohcodo^uSou{Y'l Y'u't
nrquueU ou 'VHV drur tltsrremtseo;-1 VHV
i uuHeesuogee auHahot utcoHHogoco
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Hsrb coJrHrle3aurrrrHbre cpeAcrBa (conHrlesaunrrmrrl
@arrop 25-50).
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I axrt,teHocrt,t sa6oneeaHt,ts
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COIIETAHI4LI C IIMMYHOAEIIPECCAHTAMII, TAKI4MU KAK
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groM pe3ynbrarrr 6rrru corocraBr{Mbr c raKoBbrMrr
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Pr,rc.3.48. Tnnil,{Huri eHeuJxt4fi eug lrqa c reneaHrugKTa3ueMt4
npta nuMurr4poaaxHoi Qopue cucreunoil cxlepogepuuu
lxpnoft ceur. 9acro nopaxarorc.f, Jrr{qo ra ruefl, rrpvr
groM npoucxoAr{T }rcroHrreHr.re
ry6 u Soprr,rrapoBaHr{e
pa.El4anbHbrx 6oposg BoKpyr pra. Y HeKoropbrx naurl-
eHTOB yTonrueHr,re KoxI{ Ha 3ToM 3Tane npeKparqaeTcs.
Tarurr o6pasou, nopaxeHr,re Koxrl, orpaHr,rqeHHoe
yqacrKaMu Ar,rcrzurbHee Jroxrerl u KoJreH (rpoue .rruqa),
rnaccuOuuupyercfl KaK nrlMurrapoBaHHax @opua CCI
(pnc. 3.48). Bosre.reHr,re B rrpoqecc Koxr,r rylroBr{rqa,
a TarcKe ee ) {acTKoB, HaXOA.flIII}IXC,I npoKcI4M€UIbHee
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Oro yuunepciurbHoe npoqBreHue 3a6otenarut,
KOTOPOE MOXET BO3HI{KATb 3A MHOrO JIET AO TOflBJICH}If,
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acs rneds aellroJc€H a) aorurrficea xrsHHesodlllIlr -IIDICTHeJI,IJ OJOHHBSTTIS'€eOdouoa.lco exurxeruQodu -BI
-oJJB-VfIHV xnrddtr ro rclJerflolehuruo't-letltoroleu orr r4I,IrI€trHeWO)ed 'ce-t\r lz-zl el,IHeher s nleHvadc s
HOHqratrIo f CIO€JI,IhC I4IoII{I'{JHEI{rOu c eOreweU,{Hedr rqtrr.loxr,rrdoxo)o{rJ Iq]^Il,ItroxgoeH sorHeun€Il [sJcHI'Im
4 nnsrmQo uueoe' gg 4 vIru l€eYvc>rodeuore uw x erer -srog 'sre[oH o)quo)JeH eeden roremuHudutredu rteotr
-xrnu HHax,(dungo susg rfuolt seehrfiIc %09 sYLo){ rI,IHoxI4Hc r$IJrsuou ot.&rdor,gou e' u]f!.;goduccad.red
'rur.uQouueo€ rcreEtro{IrgsH o)olEr € 'g43 *reuodr( t't
uno 4odorox ex '4ol oV qrl,{nurea,{ re,(trelr3 r(eotr sol I IlI
€oJ rcJolsmlqsou rI,IHEseIfogEo I IeI'IHeher NrIHsuJ)€ -orrrwl{c Ill,IHelrsoHgoeoa ud11 'fircon s JI I I €H qmx -t[
f, sorHeHnull 6 'rxr-texosdgso['1(coc nor,rar,(xceg meuH -lIHc ro^{Vorc r(eo[' 'rI,IHeheIr €IrBh€H BJHoI^[oN c traH 8 -o
-axedou J arlHHuersc'Iqflourw[c erIHlIITEHI'Iv{otrge eeder, ondeltudIr JI I SI-0I Iqootr rI,IHe)oIJcotr xrrrall xuI
rorahrH sorHeuflBll %Og oY'erueodac eusrctrercs €r s '6OJ rItoHI{hI,Iros I4 buHuserrogee I{I lul^loruwl{c qctr
-ouHa oJonsrefitrdexl/tdeu urM oJoHllrcdselru e)orur -,(srr[osorr(d'ql€xlttlc oHHeuorcoll ror(trerc sotrfio)
e 'goredrcruQnu xnurroJer euHelrsrolr oHxol [60B -r,rrdoxovorrr ,l(eo[ xrer,,trc x]Iogo g 'Irugeuc €troxtrou
'rnr.uQonuto€ ulndgeHoHoII 4rlHHesrcexoHlI
oJo)sr e€eg:reHqIeleo€rotr ruox '(ilc/rlnt 0Z-SO uuJ
4nnnnfu al urtuce' (rxreef urrul edlfu d,(u) rtlnenelten -rrur{r urrrolr go)cehlareI{sed lrdu ruen '(r.,(c/rn 03-09)
aHHxo) :goxeHeldu atrelrdr 4efflol.(Velrc s BoreBh €Horoer,rHtradu rseotr elrxoclqs eelroq Joilesroucn y;11
-orl:rec ruHeselrogue er,rnerarodu eodr,co eoHhI4IrI{I radu onr'ng6 'soJHourlurr xecs,( ]Dlcehllnudu I,II{ued
'orrodrnox rcJe?[?ou oxolru orcer, rudorox '4oltlce
-eJ €rruheH elrcolr h (,L-8n eI,IHeheJ s lol(duccedJed
4amoddurotgetr oHtr€ox oHqrosotr u,{con s souurorr orqJcoHrrou TINoJITI^II{o pI 'trBxoclqg qHeho Ir}IHeheIr
naxnesoeedgo'ltotuuud ltuxcenurdenre rc4ulnot srcoxaurxeQQe '(Zq'e 'rgur) runado uderor lttoxcud
-"ftxdarxedex'troltdou 4rsnsruwodtrod[ rcJeutrolIrg eI,IHeheIr qr€heH oHqrer
, uera, s laroHorogrtHtredu
-3H ral* \rrloHhi ar4HoheJ s sorHsI'ITIBU ewd -rrrEeNB€oH re^{[erc 3H lrunedeo[ou ud11
'antd11 Y)IJ
orcl,Ih
'%Ol raumrqsedu aoruQonueo€^'('?ad
- oxHohou
EErox 'xnl'HQonneoe Xom<Ilrog o r,rdoso.I onnlsgo) I
9tt o I9II4UA)OVE
416 . PEBMATOTOTUg }I 3AEO,IEBAHH9 ONOPHO-ABUTATE,IbHOTO ANNAPATA
qeHlrfl. flarluenrau c 6olee rqxerbrM 3a6orenaxneu,
oco6enno [pH Haluquu ue@pura, Moryr rorpe6o-
BaTbCs InIOKOKOpTI,IKOLIAbI I,I I4MMyHOCynpeCCr4BHa.f,
Tepaflu.s.
Kpuorno6yn il HeM ilqecKilt,r BacKyn ur
Oro nacryrur MeJrKlrx cocyroB, xoropur? Bo3Hr,r-
Kaer npr,r ocaxreHur,r Ig Ha xoroAe. Kpuomo6ynuuu
noApa3Aenrrrorcf, Ha rpu runa (cu. ra6n. 4.21). Trnu
II u III csssaHbr c pa3BnrlreM BacKyJrr4ra. TunuqHrrruu
flposBleH[sl,ru sa6oresaHr,rs .flBr-f,rorcq xoxHrrft sa-
CKyJIlm Ha HI,DIGIITD( KOHOqHOCT9X, apTpZUIrlIlI, CUr[{pOM
Peftuo r,r HeBponaruu. B prae cJrynraeB sa6oresaHue
6rrraer nroplrqHo no orHorrreHlrro K BlrpycHoMy refla-
rury C urr,r KrpymM ayror.rMMyunrru ga6oreBaHlrsM.
flaquenrau nyxcno npoBor[Tb cKpr,rHr{Hr Ha Br,rpycHbre
relarlrrbr B n C, a npn noJroxlrreJrbHbxpe3yJrbrarzx
Ha3Haqarb coorBercrByroruee reqeHue. Orcyrcrayer
- 3HAKVL, Cr{MnTOMbr [OpaXeHr,IS qepelHbrx HepBoB,
eAI'IHOe MHeHI'Ie OTHOCI{TeJIbHO TOIO, KaK nyrlllle
Bcero Jreqr{Tr rpuouo6yruHeMuqecruft nacrylnr
npr.{ orcyrcrBr,ru ero .flBHoro rpr,rrrepa. flpuuenenue
urroKoKoprlrKolrAoB Lr raMMyHocynpeccuaHoft rcpanuu
qacro Hocrlr gMnupuqecrorft xaparrep, rrogToMy I{x
s@$exrunHocrb HescHa. B rprenrrx cryqux Mo){cro
paccMorperb [poBeAeHr,re masuaQepesa.
3ro nacryrur Heu3BecrHori grl,roJrorlru, xoroprrft
lopaxaer MeJrKr,re aprepl,z.lz r,r BeHyJrbr. Ou peAxo
Bcrpeqaerc-f, n 3araAnoft Enpoue u qarue BbIsBrs-
ercs B crpaHax, qepes Koropbre npoxo.[u:r Be.nurrafi
Puc. 3,54. flgeur norocru pra npn 6oresxn Eexvera
ruerxosru? [yrb, B CpeA]rger\,rHoMopbe u -Ilnouun, rge
lpocnexr,rBaercrr recHzur cB.f,3b c HIA-BS1.
.flssrr s uorocru pra na6lroAalorcfl y Bcex [aurleH-
ror (puc. 3.54). B orJruqr{e or a@rosnux-fl3B, oH}I, KaK
npaBItIIo, rny6orure u Hocsr MHoxecrBeHuuft xapax-
Tep, coxpaHs.f,cb B TeqeHue 10-30 auefi. fenlrra-nrrrue
.ssBbr raraKe fl BJrrrrorcrr pacnpocrpaHeHuorl npo6reuofi ,
Bc'rperrarcrueftcs n 60-80% ctryuaen. Tunu.IHrrr4u no-
paxeHprqMu Kox[ cquTaroTcf y3JroBaTaq 3puTeMa H
ylpeBas cbrlrb, Ho raroKe Bo3MoxHo pa3BI,ITI,Ie MI4rpI,I-
pyrouero rpou6o$re6 vra il BacKy trura. flopaxeHue
ura3 Bcrpeqaercs qacro !r Moxer BK;rroqarb nepeAnuft
u sa.4:ruh WeilT wvt BacKyJrur cerqarKr,r. flopaxeuue
nepnnori cr{cTeMbr BcTperraeTcfl Y'5Vo ila\ueHToB H B
ocHoBHoM 3aTparllBaeT cTBoJI MO3ra, XOTq B rIpOqeCC
TaIoKe Moryr BoBJIeKarbcrI Mo3ronrre o6oroqKl,I, floJry-
ruapuq u c[]rHHoft Mo3r, qro Bbr3brBaer rrr,IpaMI,rIHbIe
crBoJra Mo3ra r,rJrr4 reMr,rrapeau. Taxxe f,bsN,roxHo
Bo3Hr,iKHoBeHr,re peqr,rAr,rBlrpyour{x rpou6oson. flo-
piDKeHrae noqeK Bcrperraercfl rpariue peAKo.
,[uaruos craBvlTcfl.) KaK npaBrrJlo, Ha ocHoBaHl,r]r
K;rr,rHr,rqecKr4x flpoqBneHurl (ra6n. 3.68), uo o.uuofi
xaparrepnofi oco6eHHocrbro, Koropar{ Moxer r,rMerb
.[HarHocTl{qecKoe 3HarIeH}Ie, flBJrf,eTcg nonox}rTenb-
Hrrft recr rlareprlrrr
- [ycryJre3Hble BbrcbrlraHrfl Ha
Koxe, Bo3HI,IKaIoilIue B TeqeHue 48 q ua Mecre yKona
nrrtori B rrerbrpex roqKax npe.q[leqbfl.
.f,ssrr norocrr,r pra MoxHo requrb c noMorrrbro
MecrHblx rnloKoKoprl,IKouroB (norocxanue rloJlocrll
pTa pacTBopoM [peAHI{3OJIOHa, cTepOI,IAHbIe rvraSu).
Korxprqus Moxer AaBarb s$$exr npn yslonaroft
3plrreMe il aprpantrflx. Ta;ru,qouugr' (100-300 ur/
cyr B reqeHr,re 28.uneft) oqeHb e$$errraren npr pe-
3T,ICTeHTHbIX B TIOJIOCTII pTa I{ paCnOnOXeHHbX
Ha [oJroBbrx 'I3BaX
opraHurx, no o6laAaer reparoreHHbrM r,r
ueft poroxclrqecKr,rM Aer?crsueM. flrcroroprnKo}rlbr
lI ITMMyHO.{elpeccaHTbr rroKa3aHbr npu yBer4Tzx r,r HeB-
pOIOruqeCKUX CLIMIITOMZX.
Kpurepx}r
t ;::::,T lSr$uaruocru{ecKme
Peqngreupyror4ile esBbr norocl,r pra: MaJrbre a$roeuurc,
6oruu:re a$roeriure mu repnernQopMHbre RsBbr, o6ocrpeHun
He MeHee 3 pas sa 1 2 uec nrpc ABa npilsHaKa u3 cneAyrculilx
r PeqilAilBr4pyrorlre qaBbl noroBbrx opraHoB
. llopaxeHnq mae: nepeEHuri yBeur, saAHilri yBeur, KnerKu B
creMoBr4AHoM Tene npil ocMorpe c noMolLlbro qeleeori
IaMnbr, BacKyJtt4T ceT9aTKu
. fl opaxeHne Koxr4: y3noBarae opilreMa, nceeAoQo.nrrryrur,
nanynonycryne3Haq cbrnb, yrpeBr4AHbre y3enKfi
. lloroxureruxurri recr nareprilil
 llctuqle
(92-6t 'd '28'p1'9;02'euog // snlels clr'louoceolcos.pue apl?A rap uP^
"{qdel0oe6'xes
''U ''l/\'3 slun3 eU)
l; i U uoot l
.a6e r4rm uorle,e^ :Z,0Z-886t ruop6ury pa,un,oql ri;;.1;ii;,tOorofr"prO::l, 3 u U 'edVeg nxlem
.o+ra'$raerooc unnx[yrr i-nratnnex I y{orcedeoe i ffi;;;ffi *"]t t' b.,o-Uxev tqrorcen orHeHov{Evl - .99'8.c14d
_J.t{$oyroseheuu_E.Pyt4HhoHoseou_s.,,,.,,u"'_y:ura$edlorrelrua6.eeodouoelcoauo$extsnouedel
rcedeog
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edUeg ex4e61
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u

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'(gg'g 'cnd) ro€rcedcos lnto'rcedeos c gov'Ioredeu xuJ'e
I{ )ex,solHeooedUalOn.{.yttrtU U SOtrI'IO>IUIdO)O)OIIIJ
qrcousesedrcoducu4 'udtreg ex4am Ir qmo) resehelflr
' (aoxuoaeou nlnloredeu)
- 'erJol I NOHhrIulIr
xI'IHhoHos€oII' (' pad' nawndg
s uh'fir rloredeu) (ecurnroll l^tor
-edau) eqhelruVodu rcrolrrsr ,evYreLy.lje)olr 4orcEh

-il rir€otr ol.DIoclsa rclot,(gedr lrllHexEdolr Nonsruuxnodg

-oexufu hrolrexrr udu xex rwedg oJ s 'JSLIH trsoVr4
-oxrar,do>toxo{rJ Iseotr errxgt{H r<nelrrxe@Q€
oHhrlgo
rl4H€souoge€ I'tuHehor l\lo)Jelr ud11' <twes,go-)orolr>>
qrenou rfuovu woeodou
oelrogtluH oH 'Iarco) erlgo{r g 'trI4H€xIsV oJeHmeHs
I,IIIJoU go)HeIIo 3 elfcl'Ih NoJ
-oeJ3o c IsJHoI'II€U '(VaeD €eoHJ€utr I,I)soH€rcoII I
rsItlrtroxgoen ersdorox 'rltruorouxel rnsod^ orox
,rnrriE crutrosod[ re,{'[orro'qrcoHqlre'Ler rorlratr
rffi -eduo nioJoHI I og orh 'ltoxsdl ra unu'r'dor rl,IHexedo[
-€HH 8€-€I{ 'xeuo4ed xuxcqlfec s oHHagoco 'erHoHLIr
r4Jcexrr nanereVeduo nrf 'gd3 sHesod'( u 6C)3
-uo>gr{C WO)CIIII/II'HI,I €H r{ rruev a YcJ-vft:,o]( l4v3LeYUsE
BoJoI€[IiIsou rl4H€saroge€ uJcoHsurxe nd11'afiuu
-ns oHhorercoEen eodouoerco' Yvr*auecer vuttedetc -mrdxtreH a redrsruQuu IjlilHilrerurelcos rerrsrlqs
'J )
ee-eu ,(drart .{vtecs ou eeed g-7 a t-{'nedsos 0s0z
elnrdx rucuoug 'efiVdec aoHBUBIDI I'II4IDu'(Q erauem'(d
'eeodouoalco exoQ €H xl4flItremoeuodu'sonroredou -eu u ex^{rc orderou 'Iladerxc 'nllltcoHedell e]4HetrBuee
'r{HoIDK rHeNoI I
auHehelr en rcrefuee 'lteeogtodu oII
rol€hollfis rnnersrodu eu.rddff 'exo[Iss eH soul4dx
or-I^{o)ux s ultunloredeu ro{Etredro emderc I4 reff 0S xurflrJcl4sc o{[HeIftIEo[ ra .(dotrudrc'olrm€)'ucottoJ
,rrndron rlrnr,(w srceh reJnr u Hl{ffiHexxecs t fi ov urcorundxo x uatrosudu elnrdx oronqrerxuodgoexedr
"
-oxg 'lrtoeodouoerco pIIM Iitol4HelroerSo c gorHel4rleu
'{ aunexedoll'ltH€xr IltoH<Ireu'lHutreoo rllHeselroge€ rllrlr
oroeI I reeNlr xI4H 0I,I osrcHI'Im<IUog I'1 'xeaorer' urrut 6'3 rl,IHeserog€e ercHH-{vu{uor,{e eralnorfsrcL{uoc
rolehlu
os
aerog roten{.rorr IqNOIIOdOT oHtroJexe edlllt Hess sorHel4fieu o/Ot ouo)I} 'qrcBh oilgemrdxeH oIo{Hx[H
orh'BcregJuh]'gercox weuH€selrogee nlsHHeHedtc IloHtro
eetnotexudorr eH 'Hl'Isoxed xHHm'( x]rego I4IruI
- oduced oxodram aellogrreH Yc
Lerlrsv eodouoercg
orsrcorx,{ufldu u otsrog 4odrco roreEtrxo{oduoc on
e0d0u0orc0 -hlqgo eodorox'etnrdx eI'IHBserogE€ eoHqrerulrEucos
eoxn'ed or€ - uadtrnoxr'ilrou 4ulnoIddt'tsum{ned
rt,tdUHoxl4 uou IufnuAd me nUt,the6
/L? o hIICOY CI4HVS:IUO9VE
418 . PEBMATOflOfU9 r 3A6OIEBAH]49 OflOPHO-ABITATEJIbHOTO AnflAPATA
flocrolrry Bcero oKoJro l/3 rruuuetroB c nepenoMa-
Mr,r rro3BoHKon o6paruarcTc.s K Bpaqy (cnnrnrolrurre
nepenoMbl no3BoHKoB), I{cTI{HHoe q}IcJro [arI]reHToB c
AauHotZ naronorlrefi HaMHoro 6olrtue, qeM IroKa3aHo
Ha prrc. 3.55. Ileperouu ruer7xra 6eApa auarcrefl.tl,av-
6o.nee cepresHbrMr,r, nplr groM KparKocporrHa.g Jlerartb-
Hocrb npu Hr4x cocraBrqer o xotto 12%, a tto cpaBHeHr4ro
c KoHTpoJrbHorl rpynuorl roro xe Bo3pacra cMeprHocrb
B rlenoM y rraurreHToB c naHHofi naro,roruefi aurue upr.r-
MepHo sa20%. Ha,re.{eHfle [auueHToB c flepenoMaMu
ruertxu 6e4pa npuxo[urcs 6omuraq qacrb pacxoAoB,
cB.g3aHHbIX C JIeqeHUeM OCTeOilOpO3a.
I llaro$u3lrororrt
OupeAer.f, roruuM npr,r3HaKoM ocreo[opo3a rrBnr-
eTcf, cHl{xeHue [rIoTHocTrI KocTI,I, KoTopoe BbI3brBaeT
HapyrueH r{e Mr{Kpoapxrrre KTypbr rocruor7 rKar.tr u
rrpr{BoAr4T K froBbrrrreHHoMy pr{cKy nepenoMa B oTBeT
Ha He3Haqr.{TenbHyro rpaBMy. Pucx neperoMa 3aMerHo
Bo3pacraer c Bo3pacroM y rrpeAcraBr.renerl o6oux uo-
ron (puc. 3.55). B ocHoBHoM oro cB.[3aHo c rroBbrueH-
HbrM pr4cKoM Ila"qeHnq no Mepe cTapeHuq qeJroBeKa,
HO TaKXe I4 C BO3paCTHbrM CHrrXeHr{eM TTJTOTHOCT}I
rocrnorl rKaHr4, oco6eHno y xeHrqr4H (puc. 3.56).
C rrolrenra poxreHu.g KocrHarl Macca nocreneHHo
yBenuqltBaercfl, rocrvtafl. nr,rKa B Bo3pacre or 20 Ao
45 ,r.er, Ho 3areM cHr4)Gerc.f, y rrpeAcraBr4renerl o6orax
noJroB c ycKopeHHori $asorl norepr,i rocrHori Maccbr
rrocJre MeHorray3br y xeHur{H BcJreAcrBr,re AeOuuura
3crporeHoB. florepa xocrnoft Maccbr trpv crapervrlt
Bbr3BaHa Auc6a-rancoM B ur4Krre peMoAenr{poBay,rz.fl.
Kocrrr, nplr KoropoM Korr,rqecrno nonotT KocrHori
TKaHI{, o6pasonannotl ocreo6ra craMt4, He noKpbrBa-
eT ee KoJIlIgecTBo, pa3pyuarcueecrl ocTeoKr'racTaMu
(cnr. puc. 3.2). Cuuraerc.s, rITo cHIDKenue o6pasoBanvrfl.
s
F BBoAr{r n :a6ryx.uenrre, rrocKoJrbry y 6o-nrmr{HcrBa
o
o
Y (ecrlr He y ncex) laur{eHroB Aauuor? rpynrrbr r{Meercrr
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a Hoprrra
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F
s
Y Ocreonopos
+
02040
Boepacr (rogur)
Pr,rc, 3.56. lzlgrrreneHur xocrHofi Maccbt t4 M14KpOCrpyKrypbr
Kocrr4 c Bo3pacroM. l4s[4eHeHun y MyxquH (crHnn nranrar) ra
xeHqilH (xpacnar rnnur)
xocrHofi TKaHlr nporlcxoArlT qacrplqHo BcJreAcrBI,Ie
au$@epexuuauulr crBoJroBbrx KJreroK KocrHoro Mo3ra
B aAr4nour4T6r, a He B ocreo6.nacrrr. Ocreonopos rlHofAa
Bo3HI,IKaer 1I3-3a Heclroco6nocru Aocrraqb a.ueKBarHhlx
yponuefi nzxosorl xocrnorl Maccbr, Ho qarue BcneA-
-
crBue Bo3pacrnori rroreplr rocrHoft Macchl.
Ocreouopos npeAcraBn.ser co6oft cJroxHoe 3a6o-
JIeBaHLIe, KOTOpOe MOXer BO3HI{KHytb B CB.g3U C UrU-
poKrlM cneKTpoM @arropon pflcKa, flpe.{craBneHHblx
n ra6,r. 3.69. fexeruqecKrae $arropu r{Meror B3ar{Mo-
cB-f,3b c 80% napuaurafi uornocrlr rocrnorl TKalnvr, u.
fronHoreHoMHble I4ccJIeA oBa}J.Lrfl 3TI{x B3ar{Mocnsgefi
IroKa3aJ'II4, IITO [peApaCIIOJIOXe HHOCTb rracTr,rqHo
onpeAen.flercs 6om[ur,r KoJrr{qecrBoM pacnpocrpa-
HeHHbrx Bapr.{aHToB, r{3 KoTopbrx HeKoTopbre r{acTBy-
Ior B cr4rHzurbHbrx ryrsx RANK u Wnt (cu. puc. 3.3).
PeAro ocreonopo3 Moxer 6rrrr srrssaH Myrarlu.f,Ml{
B OT.[eJrbH],rX feHax. <Daxropu oKp]rKaroqeft cpeAu,
raKrre xax @usuvecKue Harpy3Klr u uorfb6renue
Kiulbuurl B AeTcKoM r,r noApocrKoBoM Bo3pacre, Ba){G{bI
AJr-rr AocrI,DKeHIu MaKcr,rMyr!{a nuronotT rocrHotl uaccrr
roKa3arenerl rocruenouaysamnorl
r{ peryJrr4poBaHu.f,
rrorepu rocruoft Maccbr. Kypeuue oKa3brBaer He-
rarr,IBHoe Bo3AeftcrB[e Ha MfIK u conpoBoxraercfl
noBbIIIreHHbrM pI4CKOM rIepenOMOB OTqaCTU TIOTOMy,
qTo y Kypsur{x xeHrur{H MeHonay3a Hacrynaer paHb-
ure, qeM y HeKyp.f,rur{x. Yrorpe6reHrae zlrrKororfl B
6o.uuur,rx KoJrr{qecrBax sBJrsercs o6rqerpusnauHot7
npuvuuoft ocreolopo3a r,r nepeJroMoB, Ho yr!{epeHHoe
ynorpe6leurre uurKoroJrf, cyqecrBeHHo He Bruqer Ha
pr{cK nepeJroMoB.
ll guo n ar uuecKu rt ocre o n opo3
Teprrluu <<I{.{[oIIarl4q ecxuit ocreonopo3)> qacro
ucnonb3yeTcq B cnyqae pa3BvrTlllfl. y [aur4eHToB ocTeo-
noposa 6es nuauuoh npuqr{Hbr. 9ror repuuH HeMHoro
rospacrHoft ocreolopo3 r4Jrr4 ocreoflopos, cntsaHuull
c HacJIeAoBaHLreM reHeTIrqecKI,Ix BaplIaHToB, KoTopble
Ocreouopos Moxer Bo3Hr{Karb B cBrr3r4 c pa3Jr}rq-
HbIMr{ sa6orenaHusMr.r, Ha Sone npuueHeH}Lg neKap-
crBeHHbIx cpe.tlcTB pt Bo MHorI,Ix cJI) {aflx fBrs.ercs,
cneAcrBlreM HaIrvl,qvIfl 6oree o.rlHoro sa6oresaHr,r.f,
ulu $arropoB pr,rcKa. Har6oree lracrbre npuqr.rHbr
BTopr{rrHoro ocreonopo3a npraBeAeHH s ra6,'r. 3.69.
BropuvHrrfi ocreonopo3 Hara6o.nee qacro BbrrrBrrrerc.q
rqrdou r(lueudseHe ordlnorusrlerrccud '614 ee rsrrHudu -eln (c u ur{etrfioxlr.r,doxoxorrl nl{u€der urcoHlllrerlD(
oHhogumo qusgr-,{row u{xnerc or,ftrmordg urrrl rx.lerx -ro[odu l,t rseo[ Jo rlrcusee Boodoloerco )clrd 'xl,txJerr '
HoHtrffu crcen orofirtredeu eH rcqJrHedrcoduced rfuolt I{I^trUHESeIfOg€e I{}tIlDICOhr/IgOdX U I{NIqHqTOTLIITBUCOS I
r4HO 'aHrruc s u[o9 eIiIHqIMJ arsdrco BoroletrolrgeH rlhirqHr{ercr{c c sorHel,I[eu .( {tolntergodu 4ouuen
soJHer4rr€r xrqdoroxen 6 'rloneed su<Ig rexow so) -edl.coducud r,JLeBlrsB codouoeJco 4Isnfiaode,r3
-Ho{eou gov{o[edeu enrardex re)cehprH]rlr1'enodorc
eodouootco AqHiluodatC
4onnaxudou €H qJcoHheHo>r ux,{desx or,(r,(Hdesou
u or^{nnenodox.( reelru v eyet- r(ccew orr{nnearcgoc 'lrnudoJ,xeQ eeodouoa.Lco oilail,rseed x IIWUI[otBJBIrou
srexdeV,{ uulayo;oox a eu (lteuuehollrxcu lr.tl,ured e€)
-cedtredu' ul.,rtlqr'tuh€H0 eorogusH rcrolrlrsr rIIoJox?
rHor,rrrer ed[eg nr4em emoredeu ud11 '4ercox rI{tIEW
euHergedrour( eoHr,ousgeu u (exuu 'ltc) sotruox
-doQe[ u qrcoHHeHterog ruHqlru)or'srog rcrolrrsr
-r,rrdoxoxorr.r neudu' w€IrtrEHoJouI,IJ' e€odoloerco
urronedeu HhrruHersrodu lutlrxcenr{Hl4lr1 '(gzt 'c u
seuh.,trc Etrcuh oJerngo ol\s Ler]fseJjcoc u sunxflt I
1g'E 'crd) rl,IHolroerco rcreuhowro uarcnumrrog ,(
oH 'Llrcox qJcoHrom or.&rqreltdon rolenu ersdorox ']4I.ICUHAOLCOC r4v{r4J-e C OJOHHeCESC 'eeod
_eH ire.(sror.,(CrO eOdOuOerro WOnOredeU rr,rrsHnr,rr -ouoolco uutuaeed e quod reedJu exver rdenUpHoJoutu.,
'ErIoJovue oJoHHeusPgeeden .I g1 t/l
-ensedrolrelt c gotrom BsroHumqffog ,( oln 'qrrrHl,rtou -
oHxug 'eeodouoerco rrtr Hehrlul4r HO 'gemqHew UIM fundereroduoerco ofio_l sHeoLIo! o
r euarurreor.(y o BrzhxeQrr-rylg .
Brcod oJoHHesJcgoo rqrocrira c yuHeYeu arursr.{eed a
ennedlv ooHrcoue . r.tqueu'lcrfouc
rratroxclrodu 4rrdorox 'unroredeu rvHexvuo ylfl rrclra ercrcreHoncceQodg .
zwl>t Bl
-r(es[oucu <<ltoredeu ulqHhuremsedrolrBlll> uultdel oeHot/\ ELIor- teccen creuuy o *,utlcledole ueuedeg .
'NeuHotrBU wrsrcodu oJecs olleh '4oltaedr IqH€s€Ha uuheerungonny r Brdluuercriono_1 r
BtrJecs LrJhou so)Hoseou rsltorrade1 'ltoredeu Jeeslqg eoruhorcen rlrcHr"rorcr4C o vtl,,tou0t1l/\ r
eeodouoerco lnrerurersrodu NlD{cehr{Hurix lttsadeg 14r4JorroreU eur{df
eHnrdev UevcehuH[tfy 8l\ . [I9OX .
I xuvJau EUH?8otro988
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ilHehou
4etuorr(arce[tradu c gorHelrrreu r{ urconneltadeg ohHEEALrOgee eOroehurody o ,tahgdocaesre|/\ .
rweds os u,rtroxcuodu our,ngo redo.r,ox 'ttccunr tlou
-rcox udoro[ wer{Hehr{res.,( c uHeergc quqg rexon oH ervedr o:outamuv-onxofluex uuHeeouogeg
'BHroesolreH rr4H€serogee euunudg'r.tcouneltedeg urdeue1 r XEeoU xtqr
adlcewud,r III lrru II s so)Hoscou r{I IBI Ioredeu r,tltl .rlcft! g eeuog -deneedh e nounc>iodrr-1
-rirHHeflrcexoHrlr u eHuuc s uwrrrog rcreuYxoaoduoc uriororrlE arueugedrou4 . urlLedor BEHguollzrlconeg r
rcredeuedu BHor"tdo.t
oHhrqgo rudorox 'u€odouoerco ertdo@ rextred or,6
erqHxodoU^cosrrodl . -.rlruerurd-unuodroUeuo.r
rsrorUunEruoeerl . lgro4HoJ! r
utcoHHowodeg udu eodouootco
rqeerBnode rsdorrgu.ruy r rgUtto>irrdoroxottl_.1 r
'rar^rerceu)oeroo r{rco) oru[tgdoeed ercEedc xrqxsogrcdeveu euueuenud g
re.(dur,{wurc grsdorox'eoedurudeudeuur 4nHr,ud Vd . erilHhOmn) 6uH
-ors u lrr ruxhou rvfisrE) oualedxcxe ordnnemlqgou yu3 r4uInoldreoull)H! o -eeouogee orsHsrJOJl4rJEUcog r
'e)uHhelllux 0r{ r}rfiqrBx uuHesrlcecs euHelrsetrou unHPsauogEe otcHquort4t BuSoE
Joruhorrr)s rsr^mlrHexefl eutnoilarcgocouc auffdft''aor
errnm{y AodUHilC o ooedmdeuur_1 .
-uIloeJco I{ soJcplIgoerco torlloue reslqElqs pI I,IHEXJ
eoadrredeudeun-1 . nerUeuo-tourl .
rJoHJco) rnueaoeudgo rr,rnesodugr{JH}r ousJctrerJs
H14HesAuOg?e etsxxttdxOUug
'orusudu xux'eodouoerro ror€srirtga rstrltoxltrdoxox
-otr1 'uuueder goHrreJcrlrc I,IuHeso€qrolcu udu lter. Buelodrce
'elottt o-totl teH Ir{ore udu ueodouoerco xcrad on 'uH€xr xc-L(u xr,r.roFrri eodoruehed nrhedyl -
oe rqrueudee orclceh - 96g1 ruher,fu1 *
4oHroox HJcoHJorru o{ranemqnerrtd x srfltrospldu ilJolr[ oilHesoEouceH ooHHertauoll o tsilHemAdeH orqHHoroHof! .
rcruoxr.tdoxo)orrru erqHHoufirruruq' (ufuoxurdoxoy
-otr: o:orddtr [EoV or,(nureresurxe uru) cax[ € eeriog ouxcahuraHaJ
arrHaher s uHorocuHtredu rw g'7 eelrog utrr-yrurtudrt eeodouoerco
oHsaHrexa alcdorox 'sorHeulruu ^( reercedeog oHHesrc urruaeed evcnd ndorxe6 '69'e ehuugel !
:.; e EIIJ-COY 6HHVS3UO9VC
420 . PEBMATOIOTU, U SAEOIIEBAHhq OnOPHO-ABnrATErlbHOrO AnnAPATA

500 16
Hopuaruxan MflK OcreoneHuq Ocreonopos I Hopnlanunaq MnK
450 14o fl ocreonexran
400 o
= E ocreonopos
o 125
o
B 3s0 o)
18Yo
E
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&
o
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2o
t', "a 9^ o' 9aZot',u'
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0

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"7r
T-noragareru nrlorHocrl4 Kocrt4

Pnc.3,57. BsauMoceqsu Mexny MrHepanbHof nnorHocrbro Kocr4 (Ml-lK) u nepefloMaMu. OrHocnrerunutfi pucx nepenoMoB Bo3-
pacraersKcnoHeHquanbHo npu cH[xeHuu Ml-1K(cr,tHrr nuaue)u craHoBl4rcn a 14 pae Bbtueynrogefi cT-rpurQueu <3,5 no
cpaBHeHulo c nro4bMt4 c Hopraaaurofi Ml-1K. O4Haxo s a6cororHola BbrpaKeHuu 6onuu:e nepenoMoB npoucxoAl4T y logefi c
xopuarunoil Ml-lK ocreonennel (xpacnar nuHur). E npoqexr nepefloMoB, Bo3HuKaoul4x y nroAefi c xopualuxofi MllK,
raara
-
ocreonexuefi u ocreonopo3oM

Boepacr >50 aer Boepacr >50 rer I

reHororuqecKoM I,IccneAoBaHHI{, BbITIOIIHfl e MOM rIO
O.{exu Nroulxute I ApyrlrM [puqr,IHaM.
Qarropur pracxa I

I l,lccneAoaaxuq
AEPA
no3BoHoqHuKa
Hau6olee BaxHbIM uccneAoBaHlaeM flBJrfl,er cg
u 6eApa A9PA [ogcHlrr{Horo orAeJra rIo3BoHoqHI{Ka v tneiIKzl
6e4pa (cru. pnc. 3.9). Ee nposeAeHlae uelecoo6pa3Ho
y flaur{eHroB craprlre 50 ner c ManorpaBMarL{qHbIMI{
Ocreonexilq I flepenoMaMu B aHaMHe3e u c $arropaMll pllcKa nepe-
-ocreonopog
JroMoB (ra6n. 3. 70), coBoKyrrHocrb Koropbrx Aaer Bblco -
xrari noxa:arem. Yporeur prlcKa, npI,I KoropoM cneAyer
Koppexqun flor,lcx I BbrnorHsrb AOPA, ocraerc-s [peAMeroM Aucryccuft ,
vogu$uqupyeusrx BTOphr{Hbrx I
Qaxropoe prcxa npilquH I HO B KatrecTBe [oporoBoro 3HarreHurl 6ru npe.{.noxert
l0-nernufi pucx 6oree l0%, nocronbKy [p]I raKoM
Koppexqun I
pucKe r,lMeroTcrr,[oKa3aTenbcTBa npeuMylqecTB IIpoBo-
uoAu$ur{upye-l AHMOTO JreqeHU.A. Tarcre .{oPA noragaHa nauueHTaM B
rr,lurx $arropoa I
pucxa + rexap-l eospacre 4o 50.ner, xotoprre r,IMeIor Morlluue @arroprt
crBeHHae I pucKa (naupurrrep, [pexreBpeMeHHas MeHor ay 3a vurut
repanrt I
lpr,rMeHeHr4e BbIcoKI4x Ao3 DlloKoKopruroragor). Ha
Pnc,3.58. Arropuru o6cneAoBaH[f, naqueHroB c noAmpe- puc. 3.58 rpeAcraBneH nosuoxnrrfi €uropl{rM o6cne-
HueM Ha ocreonopo3. Pucx neperoua oqeHuBaercq c ucnorb- AOBaHrrs [aur{eHToB c noAo3peHr{eM Ha ocTeonopo3.
3oBaHreM uHcrpyMeHroB FRAX mu QFracture (cu. pasgen
flra nrranne Hr,rs rrc6rrx lpeApacloJrararc[Il4x
",[ononnurenunan un$opuaqna", c. 442)
@axropon, TaKrlx KaK paHHfl.g. MeHorlay3a, vpe3Mep-
r,rJrr4 rraroJrorrrrc opraHoB 6prourHorl rroJlocrl,I. Tapre Hoe ynorpe6lenne turKorors, KypeHI,Ie LI rerleHrte
oHr{ Moryr rrposBrsrbc.f, ropMoxeHl{eM pocra I,I Kfl@o- rnroKoKoprr{Kor4IaM}r, cne4yer co6parr auaune:. flpra
soIvr xars 6eg6oresot4 BappIaHTe, TaKII c xpoHn.Iecxoft ocMoTpe cneAyer rIcKaTb nplI3HaKlI 3HAOKpIIHHbIX
6oarrc B cnlrHe. Idlaor1a ocreolopo3 flpo.sBrqercrl sa6orenaHuri, nosoo6pasonanufi r{ BoclzurHTeJIbHbIx
ocreoneHpreri unu neQopuauueft rro3BoHKa rrpu peHr- :a6olenanurl. CreAyer co6parr aHaMHe3 r:.aI.erruir n
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lqccem
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3 'vohou cHeouog
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c en e c eodouoarco flq^I4HcBqgooH
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I IoH {ll)cHox tqsrauodroUelol u tsue"rodrce
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IsH Bilreuenl\El ueHcuEHou'roHol/\ .
}IHo rl4Hevestr ercoll 'ulen elssoxog elqHh[r€ed 'erloue,n eoxr-reg eedoQodotaug
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goadeu
cceIDI 016 'eeodouoelco BllHohou Ytll ttlllaut:ll
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tlledeuedu IItogoc Jolrrs€Jotredu nleuoQcoQcug tlouUueolalnedeu uouldo-1
HEHoQcoQcug eoedraredeudeuru 4rslr'lredeg
.EXI4H €H ut4hEUPl,\oorco
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ruxgodtrou eelrog 'ZL't'rryel s tsHetresudrr ullHeo€x r4tcnnuedeg e reQcoS u tluhcLrey
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g uneuuel 4oEoHEYu euorl'llHv
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udu u)troxou olqrcosuhyior,c'(en v vltrr]./lJevz[
-dorsou c HrHeIltI€LI'Hrunanxedu'( l tuxcenueu@ eaodouoarco udu ruHeeoueucct4'lI'8 ehuugel
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'1 eeodouoerco
ee tcctu o te m e Ns a,q Heo tHo w ex nil oNoH
tllehueeed c l4uHeuoorco sulHBeoduccedlodu eluehg
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422 . PEBMATOflOTUS YI 3ASONEBAH]4C ONOPHO-ABUTATE'IbHOTO ANNAPATA

Ta6nraua 3.72. flexapcrBeHHbte cpegcroa Ann fleqeHnn ocreonopo3a

Ilerapcraerxutil npenapar Pexuu flocruexonaysartxut[ Crepougxuft Ocreonopos

ocTeonopos ocreonopo3 y Myx'lxH

Kilcrora
ArengpoHoean 70 ur/reg auyrpu

Puee4poHaro 35 vr/ueg arYrPu

y'l6angpoHaro 150 rr,tr/vec axyrpu. ,/
3Mrl pase3vece/e
3onegpoHoear KilcJtora 5 n,lr e rog e/e

,QeHocyua6 60 N4r 1 pa3 e 6 vec n/x'/

Kanurlral,r l atfiawlt D Karuqr.rtr
- 50G-1000 nar/cyr' /
BnrauuH D 40G-800 MVcYr
-
TITA 20 uxrlcYt n/x

A6aronaparug' 80 vxr/cyt n/x

3avecrrrelurat ropN/oHarbHat Pagruqxure npenaparbt

repanilfl

Panoxcr,rser 60 vr/cYr euYrPs

Tu6onon 1,25 rvr/cyr exy'rpu ,/

Euc$ocQoxar Atrv6upoeanne npreM 6uc@oc@oHaroa (6onee 4%), r,e.ueuue cnenyer

cKoppeKrr.rpoBarb. qaule ncero ocFuecTBnqeTcrl nepe-
npuMeHrDr BHyrpb ocreoKnacroB
r4Jlr4 BHyrpr4BeHHO yBeIhquBaeT nIoTHocTb
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KI4CJrOTbr, HO y naIIXeHTOB C TTIXeJIbIM OCTeOIOpO3OM

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(TIITA). llpu o / a BBeAeH?tI{

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c asrcoxofi aeug- .7 B ocTeo-
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424 . PEBMATOTOThC YI 3AEO'IEBAH]49 ONOPHO.AB]4TATE'IbHOTO ANNAPATA
paul{oHe nauueHTa AocTaToqHo KUL'IbIIIrI, TO B KaqeCTBe
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Hanrrrnft (1-34) fITf .rerosera. Oro s$QexrunHoe
cpeAcrBo JIeqeHLITI oCTeOnOpO3a, KOTOpOe CTI{MyJII4-
pyer o6pasoBaHl{e HosoIZ Kocru. Xorx repunaparl,z.A
raKxe crr{Mynl{pyer pesop6uurc KocrI,I, yBenl'IrreHue
o6pasonaxuq Kocrl4 [po[cxoAl{T 6olee nlrpaxeHuo,
qro npHBoAuT K )tsenuqeHlllo IUIOTHOCTI'I KOCTI4, OCO-
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B
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rnhnSeU r rilxed 'uilhuuerrooro0
'orlrrrogr re oilsodIax
u el;q.lmdletexruren rxr,errt €E-€I,I uJ0ow oJoHHr,ruc
euHers€Yc ror€horlrxa d.{trefiodil xrrego rsrxeQQe
arqHhogolI'oIrreh rcJorunad.lcs lslxaQQe ersrHhogox
oH'qrcoHsr.{rxe@@e go)r,rJc€rruodgerdea c orrt{userc
-ouoc reenu UHO'r^rolerrr{dxereltruleru rcrorHrfo[€0
lte.r,ee
4rsdorox' uorrug rcraes,{treud kr euJlr rcJ,l{tross
€)Hoa0ou orer eonnexudou s eehdrc wor€ s oH'xBgrc
-ir[orrorcgo xrqHhuJorEHE s rcruVosodu uxurceruoQ
-r1 '(exudewy 4ondeae3 s oHHegoco) rcre.(eurouclr
oxodram olfie eos eHo 'ed.{[ofrodu-msreQ neh'trr,rHes
'cud
-rzffogsogo oremr,rfir reetr eH exlrrceruodgerdea orn
'Hlree€)ou BuHesotselrcclt elslHHusoduelltotrned rroy
'urleerceHB I^{oHrcoru }r arcredc xrsHsr4J€troc Ir}rHeHow
-udu exoQ EH E)Hosro[ orrer eoHHexedou s ererfl4dx
-erowtrllreht oIufDIeq,HI,I reereroutredu eHO'so)Hosoox
goworedeu xrsHHoracceduno, xrqHHoH0etrog I{I4HaheIr
N)
(n
ndu rcre.,(elrroucr4 EEJoHu exnrceruodgerdeg
'eeodxen olosdrr,(xcese excud oJoxocgs
F .,(Yt4 ss eserc,{c oronnedtre gole L rrlaresodueeroduoYne
o r roHirlreJor I{ru e)I4Jceffuodrdurararer s rcrorulfxr{H
C
\= onr,rsgo edEeg v)Hem r^[onoredell nrsHsr,(cuexudilHs
c rsJHeufiell'sonorredeu xrxcenurodouooJco raulue
-utrvgelJ r,r ur4frr.rooued rrtr rcrol/{gefu oJ,cun AaLfirEx
-xu@ 4eunedl{Hs c nprlrudauo erxcenutreuordg
onHohau oovcahnJdldnx
 426 . PEBMATO,IOTU' n 3AEo,IEBAH]4q onoPHo-ABurATE,IbHoro AnnAPATA

Ta6nlrqa 3.75. flpu.rlrrur ocreoMansq]tt u paxlra

Ilpegpacnonaranqrft Qaxrop Mexauugu

ffeQu4ur auraunua D
Kraccrqecxaq Hegocrarox corHeqHoro cBera nroxoe
14 CHnxeHre cL4HTe3a xolexaluqusepola e
NATAHVE xoxe / auawfi ypoBeHb BilraMilHa D e paquoHe
3a6oreeaHrae xenygoqHo-Klru.teeHoro Hapyuerre BcacbtBaHilt HapyLreuue BcacblBaHuq silrai/ilHa D il
TpaKra
KanbL[4r, coAepxau]ilxcg B n/u.le
Hapyuexue cuHreaa l,2S(OH)2D|
Xpouuvecxan noqeqHae HeAocraroqHocrb [rnepSocQareN/r1r 11 noBpexIeHr4e noqeK KoHBepcr4r,l 25(OH)D, e
lqqytqlry
1,25(OH),D3
BrraurH- D-pearcrenruurit paxw I runa Myraqrr c norepei QyHxqr,lra Sepr,lerra llqytqy. KoHBepo4,l 25(OH)D, a
(ayrocorrtro-peqeccuanurri) 25(OH)D 0-r,4gpoKc,tna3bt noqeK
1 1,25(OH),D3

fleQen pe4enropa euraunxa D

Brrar',tnH-D-pesucrenruurri paxrar ll rrna Myraqur c noreperi SyHxqura B peqen- HapyLreHre orBera Ha 1,25(OH)rD3
(ap ocovno-peqeccrarurri) rope errauuua D
Hapywexun uera6onusua $oc$arca n nupoeocearoa
f r no$ocQarela utecxuit paxut Myraqrr a re+e PHEX Veerr4qeHL4e npou3BoAcrBa OpO23{uexarrsr,r
(X-cqenneHr-rurri 4ounuauuurfi
) uenceH)
Ayrocovno-4or,,lrnarrHurri nanoSocsare- Myrar4au e reae Ap@23
Myrarr OPO23 ycrorZvraa K pa3pyueH/p
vuvecxrri paxnr
Ay'rocorairo-peqecoraHurri rrano$ocsare- Mfraqrara a reae DMpl Yserul,leHhe npor,reeopcrea OpO23
Mntecxut' paxut
Mec+rurr7 geQnqnr DMP1 roprr,tosrar
r!,t4HepanL43a[.[4lO

lzle6urroqHaq npogyxqran OpO23

llogaeneure [,4ilHepan il3aUL4t4 Kocre14 BcneA-

crBu4e HaKonneHnr nlrpo$ocSara B Kocl,4

llprr',lenerre 6r'rc0ocQoHaroe BbrcoK/e Eo3br evgporara/nauilApoHara MeA,4KaMeHro3Hoe HapyL]reHile

MnHeparv3aLMV
Anouuaui't lzlcnorusoeaH/e anovuHrricogepxaul/x lzhgyqrzpoeanHoe arloMr,rHileM yxyA1jreH14e
Qoc$arcersureaoulilx npenaparol WV MtlHepan/3aLlut4
arlcMt/|Hvle B Ailanil3Llpyrou.leN,t pacTBope
OfOpf 4Ut o^.o
Bstcoroe conpnyaHr/o
Burcoroe rhrnnunno e
coAepxaHile eropragoe o eope t^,,-,A,,^^^^,,,.^
[taru6upoeauue MuHepanil3aqr4r4 sropu4avra

o6oratueHhr BlrraMr4HoM D. IIpu [ocryrrJreHr{r{ B KZL'rbUrag B cbrBopoTKe, BhIf,BJIqIOUeecq iIyBcTBUTenb_

KpoBoroK Br,rraMlrH D rugpoxcu,rilpyercfl B fleqeHu c HbIMI{ K KZL'IbUIIrc PEqENTOPAMI,I, PACIIOJIOXEHHbIMI,I
o6pasoraHr.reu 25(OH) suraMuHa D, a 3areMAorroJrHlr_ Ha noBepxHocTr,I KJIeTOK napauIlrToBtIAHbIX XeJIe3.
ruI'poKcwl4pyerc.s B rroqKax c o6pa3oBaHueM
TeJrbHo pesylrrare yBerur{uBaerc.rr ceKperl}rs
1,25(OH)2D, 6lro.noruvecKr.r aKrr{BHoro ltera6ollrra.
B [ITI, roropuri
BOCCTaHaBJrr,rBaeT ypoBeHb Kanbuu.f, .rlo HopMiL'rbHoro.
1,25(OH)rD nogAeficrsyer, rJraBHbrM o6pa3oM, Ha Kr{- I,lrrenHo no3ToMy Ae$r,rur,rr
IIIeqHUK, yBeIuqLIBa.s BCacbrBaHLIe Kallb]-JJ,1l'., a TaICKe Ha
BlirTaMv|tsla D o6H.rHo
xapaKrepr.r3yerc_rr Hu3KuM ypoBHeM 25(OH)D u no_
cKeJrer, crr{Mynr.rpyr peMoAenr{poBaHr{e Kocr}r. Cunres BbrrrreHHbrM ypoBHeM fITf.
ZHoraa Hrr3KLre ypoBHrl
1, 2 5 (OH) D perynupyercq nerreri orpraqarenlnofi
2 25(OH)D Moryr na6lrcAarrcs rpu Hoprualrnori
o6parHori cBfl3vr, ylpaBnseMori uapauluroBr4,(HhrMlr KoHueHrpaullu fITI. Krltru.recroe 3HarreHr4e groro
xeJre3aMlr. Kor.ua ypoBeHb BlrraMrrHa D naAaer r
@enolreHa ue ycraHoBJIeHo, Ho oH uoxer 6rrrr cBs3aH
pe3yJlbTaTe 6olee nugxoro nosnerlcrBu.f, coIHerIHOrO c pa3ruqu.f,Mr4 B ypoBH.f,x Burarultr_D_cB.s3hrBaloruero
cBeTa vlnu flpu HeAOCTaTOTIHOM nocTylrJleHr{vt c ilu_ 6e:rra. Crrnoporovnbre KoHueHTpauw nzraltrua D
rqerl, nupa6orxa 1,25(OH)rD cHzxaercq, BbrsbrBaf, KoHTponr4pyroTcq reHaMn r.r cB_s3aHhr c Bapr{aHTaMr,r
yMeHbIneHI,Ie BCaCbIBaHLITI K[Urb[r,rf, r.r3 KUIII€ rrHr,IKa.
tetl, a G C, KoAr{pFourero B}rraMr{H - D - css gtrsarcuufi
Oro srrsrraaer KparKoBpeMeHHoe cHlDKeHr{e ypoBH.f, nporer{H; reHoM DHC RZ, Koar.rpyouru 7_,uerlrApo_
 '4evolu xutnotarog i( -
'Ht^{doH xu[otredu s rcrrtrox€H oHhrqgo C eHI'lNBrHs
ruIruQetr rJlsunexudns flIroA
rI4HBII{U OJOXOTflT I/l €regc oJoHheHlfoc LI,tSJC4etr€G
arlIIIHQetr NoHHeH)KoIIcooH ud[ e)rodosHc s Br€QcoQ eedoxc T
oron Br4HexI{HC erersur{eed s ro{e)}lHeos 'oJecs
H BHnqIrB)'OIII lIHsodA'€Eoodl{r€dtudeura'r qlilHHesrctreffc-oHHlIhI4du roreltu nr
' u derxedex
-r.Hdors ellhlllreH BH reeslsee)"{ '{)qllo)cou 'euHen€HE
c tr6da rrertrconuees ure'Bl'IH€serog€o elqH<Ilrerur?u
aem<Iuog JeeNI{ or€ or 'JILI Nensod'{ I IrsHHemrlsou
'uHne'lodu -cos ourcohulrodx pr eoderxc 4rsxurecced 'rogeulr
,rron.Jno, q(gg)97 uuuod,( auxeun rarcg osrcHum
c He€rsc 4lsudexec' tllueaauogee xflxcehl4Jolro)Ho
oJemolssrqtrsc-Cl-Hl4] leJfla xel{god'('{I'DI€I'rH
<ruqg rexow I4 eI'IHehEHe oo)cehl{Hl',Ilr) ogulr-eo)E) -"uog tnnorrrxa'I1tlu€aarogue nodlxeuc rtlrxodum
c rcror^(dlrultoc c€ C[ € HlIWurIla oremot,{ du r'{xdun
,."^, 4unem,(den xur,(d[ lrrasrcJ'(clo I'rdu q(g6)97 {I{x
u ereQcoQ uuII€dJHenHo) oDI0I'IH'rl4H€sotrorocl'I oJo'ceh[I
4rrElIH orh'oH.Lrodesolrel I'Om qledr eoHJe}Itr H
,axrodoslqc
"r."odi -oI,I9 Sor€rstrr(eed u[lregoHco BH rcu{s€rc 'l
s ru[srr8) 'JIU rIeHSOdr( fifireno ru[u'DeV
'golrtourl{Iac re€sntrqg eH C €HIII{€rus
-oncced re^[erc e)ol€r AGO)SZ ltensod'( NloI€I4H
c soJHel{tleu6 'exlodoanc s C(HO)S7 YltuexdeYoc eHutdex EevcohuHuuy
rqnedeltez ltarrtr nersercoll qrlilg rexol't eou:eu['
'C'(HO) gZ'tZ rl{Irogeron gIqHsI'IrxBeH s((HO)SZ
6uHesovauccu - n7,- g'
elr*rernuOgeOu ee ol'ft+rasJcrosro
"(eurnacxodtrn:
u 'I'IHehou
'rqHcreH rqsodo[e rllHrorcoc oJemgo lr lltorcox rI{Hr -HI,IW€II,{g numol,(dl{tro) 'tYrzd,[,) NoHoJ
q e*:zt\te Lvlta Llr;co Hhorurc otr s C eHI4I lerras uuHesodnrrrlcxodtrra'r s oilmort(srJ
- orco 3 oJoHqreludon nffi
'O)KIIH -, *',{rrrrcxodtrur - Hl'Inerue ]i[[mol(dl4[ov
I 7 - C[ -
-eu lr euarluQetr oJo)cehl4l II4XOI',Ig Br{SICtre[coII olracdesuox ol&c
rc.reelrxr(cgo oth 'Jtlx€ d u Yu\rctrul Ioerco qrfn:rprn 'If,Zdl)NoHer :O(ttO)SZ s Cgq-4
IB.l,r'Ia -"orir*rn, ee ot-&lres.Lc't osro
-eos rfuow o,L 'onsrerurtr rcrernedxoc C[ €HI'II "(eeJ)'(trednudercerox
'nrco>t oturhgdoeed u avuxnemnv e suhquex
erc)or E eHeueercuedu unhendoQHt't uengoduog -P.,'Jog,rev\
'o1Ho)gz' I oloH'l4ne nauHeeoeedgo c xe)hou l'l
euHesrcc,cs g^dyru^l,ur-c irr.roerno-r re^d,,fuJ
'-n"-*,
ucree.rdaeuou '""0"'6i'
o Hr4r/lerus urareg
'uuderce,ox a 3;1q-t unueeoeedqoadu nailu gqr6
r4Hohau e orhHeeoduur,lcyodurru ,{yrosuereou '(god g ere,ousedrsu{
ra,(erc4auoenrodu
,/ucH. ,roHar cc-Le^drauoy.urqoo-rov 'Eeerv,(rednr.d.rr.roroour-,au-e-rir'elnoeo
wauercr4aueoe uou (y1ff-lteHnde-Lce,oxodur-,eu-z
rr.xo, g scre^duearHuc o Ht4vr'l,rl4g'o eHhvlernE uleuuogelay\'19'e'cnd
a
I a,t...'"'Y
I
I /l rchcueHev olqHhohoU
! J BuhqueY
I auHEElCcec8 {forrneuoreex).,
I ogso\sz'vz
t
I
t
I #^, LV'ZdAC
rUXhemr)l \
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13r . FIItO)l t*lllVElU(XIVC
428 . PEBMATOTIOTU9 il 3A6Or|EBAH]4R OflOPHO-IBUrATEIbHOrO AI.IIIAPATA
Ileqenne
Krnnuqecxas rroJrb3a rerreHu-f, ra6oparopuo au-
flBJreHHoro Ae0uuura suraMvHa D Heo.IesI.IAna. Euo-
JIoruqecKLI aKTr,rnnrre Ao6anrar c BlrraMr{Honr D cle.uyer
peKoMeHroBarb rauueHraM c Hlr3KrrM lponHeu 25(OH)
D u nosrrureHHbrM ypoBHeu fITI. Y 6o.nuuuucrBa na-
ur{eHroB nplreMa KoJreKrurbu}rSepona B Aose 800 ME/
cyr 6unaer .uocraroqHo Anfl KoppeKur{u Ae$I{uI{ra
BllraMlrHa D. flonrsa or reqeHu.f, ce3oHHoro Ae0rr-
\uraBlaTaMuHa D unlr HeAocraroqHocru sural{uHa D
HeorIeBH.uHa. Ecrr HeKoropbre cBr{AereJrbcrBa roMy,
r{To y nauueHToB c Aeouunrou BlrraMr,rHa D orner Ha
reqeHue ocreonopo3a 6rac$oc$oHaroM cHr{xeH, r,r
3TO _rrBr_rreTcs eue o.uHuM noKa3aHlreM K rrprrMeHeHl{rc
6zororrt.{ecKr,r aKTr,rBHbrx Ao6anor. Y naqlteuton,
Koropble non) {alor n/n 6uc$ocSoHarbl u.[eHocyua6
Ms. re!{eH}Ifl. ocTeolopo3a, cne.uyeT KoppeKrr4poBaTb
aeOnuur BlrraMuHa D c nouorubro 6uonoruqecKr.I
aKTr4BHbrx Ao6asox AJrrr cHuxeHnr pvrcKa pa3Bvrrurfl
il,rrroKzulbul4euulr. B groM cny{ae [pI,IHrITo Ha3Haqarb
6oree sHcoKxe Ao3br BrrraMuna D (20 000-25 000 ME)
I pas n neAerro s re.reHr.re 4 neA r,r,ru 6onee Hr{3Krae.uo3br
B TeqeHlre 6onee A.nureJrbHoro nepuoAa.
I Ocreomaneqne n paxrr
TffKerHri r{ AJrr{TeJrbHo coxpaHrrrour,uicx 4e$uqur
Br,rraMrrHa D uoxer npuBecrl{ K Bo3H}IKHoBeHI{ro
ocreoMiurflur,rur y B3pocnbrx u paxlrra y AererU. B pas-
BI,ITbIX CTpaHaX yJryrIlIeHI{e ilVITA}lVTfl. npI{BeJIO K TOMy,
qTo B HacTo.guee BpeMrI STu cocTorIHI4rI Bbl.f,BrflIoTcfl
.uoBonbHo peAKo, Ho oHrr no-npexHeMy pacflpocTpa-
HeHhI y noxl4nbrx lrcneri, nocro.f,HHo HaxoAqulzxcq
AOMa, HeKOTOpbTX MyCyJIbMaHCKI,IX XeHIIIUH, KOTOpbIe
Hocfl r uapangxy/xuaxa6, rroKpbrBarouue 6olruryro
qacrb orKpblTofi roxu, r4 narIZeHToB, crpaAaloruux
naanm6cop6uraerl.
llatorexes
OcreoMar.flultfl v paxur Bo3HlrKaror B pe3ynbra-
Te xpoHflrlecKoro BTopurIHoro ruIIepnapaTl{peo3a,
xoropurl Her{3MeHHo conpoBoxAaer rsxerrrrl u
A;IurenbHo coxpaHqrouurlcs ae$uuur sr4ral,rrlHa D.
Ycroft.rusoe noBbrrrreHlre ypoBHrr fITf noalepxprBaer
nopuanrHrrfi ypoBeHb Kuurbur.r-f, B cbrBoporKe KpoBlr 3a
ctrer yBerurleuux pesop6uul,I Kocrl4, qro B KoHeqHoM
lrTore BbrshrBaer nporpecc[prouyrc .rleMfiHepanr,r3a-
ulrro cKeJrera. OocSaru, BbrAeJrflroruuecf, B lpoqecce
pesop6quu Kocrr,r, Teprrrorcrr rr3 - 3a noBbrruennori
sKcKpeUI4I{ noqKaMI,I, rITo [pI,IBo.[ur x runoQoc$a-
reMr{r{. flonrrruennbre ypoBHI,I fITf cruuyrllpylor
aKTlrBHocrb ocreo6racroB r,r Bbr3brBaror o6pa3oBaHue
HoBoft Kocrr{, Ho Marp}rua 6unaerAolxnstu o6pasox
He Mr{Hepanr43oBaHa BcJreacTBue .4eor4ul,ITa KuulbuH-s
u Soc$aron. HeAocraroqHo MuHepanLl3oBaHHaq
rocrr 6rrsaer u.arxorZ, neycroft.urnotl x uexanuqe-
r{ noABepxennor? ueperouau
cKr,rM Bo3.{eftcrnusl.{
(oco6eHno crpeccoBbrM). HopnaarruutZ yponenr
KZUTbUUqB CbTBOpOTKe MOxeT nOAAepXlrBaTbC.s Ao
oqeHb uosAHeft craI:zvr sa6oresaHr,rfl, KorAa Bo3HLI-
KAET TI,1NOKAJIbIIIIIEMI,Ifl..
Knuunqecxan KapruHa
Ae@uuur Br4raMlrHa D y aerefi Bbr3brBaer 3aMell-
JIeHHOe pa3BI4TIrte, il,IIIOTOHHIO MbIIUU, fparf UOra6eC
(xe6omurue ueocu,r$uqupoBaHHbre y{acrKu B Me-
crax gH4ecMiurbHoro oKocreHeHl{g rocreft qepefla,
Koropbre noArarorcfl AaBJIeHr,ro niurqa Coruyrueuueu
pacrpecKrlBaxlrr), rrrnxvunanue no6Hblx I{ TeMeHHbD(
rocrerl u orcpoqeHHoe 3arpurue 6olruoro poAHr,rqKa,
yBenurleHue enu@rason Ha Hr,rxHeM KoHrIe nyrenofi
Kocrr{ r{ yroJruleHr.re pe6epHux xpxrqeft B Mecre Irx
coeALIHeHlIrr c rocrHofi .racrrrc pe6ep (<(paxurl,rqecKfie
uerxu,>). OcreoNra:rquu.s y B3pocrbrx Moxer [porrB-
Jlsrbcf, nepeJroMaMlr u Hngxoft Mr,rHepiurbHofi nror-
HOCTbIO KOCTI'I, VIMI,ITI.dpyS. IIpOSBJIeHI,IS OCTeOlOpO3a.
Apyrue clrMnroMhr BKrrroqaror 6om n Kocrrrx u o6ulee
HeAoMoraHrIe. Bupaxeua c-na6ocrr [poKcl{MrulbHbrx
MbIIIru, Koropafl rrposBr.serct yruuoit uoxoAxoft u
TpyAHOCTflMvr trpvt nonbrrKe [oAH_sTbc.s no recTHr4ue
ttrryr Bcrarb co cryJla. Bosl\.{oxHo norIBreHI,Ie 6ores-
HEHHOCTI'I B KOCTSX II MbIIIIqAX NPII HA.{ABJII,IBAHVTV, A
oqaroBas 6om s Kocr.flx Moxer 6brrb Bbr3BaHa rperqu-
uauu pe6ep vrra3a.
Abcnegoaauun
fluaruos o6H.rno craB]rrc.f, npr,r Il3MepeHu]r
yponueft 25(OH)D, fITf, raarqur, $oc$ara r IIf@
B cbrBoporKe KpoBr,r. Kax nparu.no, ypoBeHb IIIO s
cblBoporKe noBbruraerc.f,, ypoBeHb 25(OH)D He olpe-
p.ell;ercs, a yponenr IITI sar{erHo nonrrruaerc.s. Ecrra
sa6oresaHue He nporpeccr{pyer, ro yporeHr $oc$aror
B cbrBoporKe o6rr.rHo uu3ruir, a ypoBeHb KuL.rbrlnfl,
KaK rrpaBr,rlro, B HopMe. llpu peurreuorpa@lru vacro
BbITIBITIOT OCTeOneHI,IIO Un[ nepeJroMbr ITO3BOHKOB,
a rrpu nporpeccrtpyorleM xapaKrepe sa6oresaHr,r-s s
pe6pax, Kocrflx raga v.uJII,IHHbIx Kocrqx uoryr 6urr
Brr.uHbr $oxaaruue 3oHbr npocBerreHlr.f, (ncen4one-
peJroMbr, r4rrr,r 3oHbr Jloosepa) (pnc. 3.62, A). Y nereft
rlrxBd rIrsHrHaJcu€ed-C-HIrtI^lErI4g'eHoI,fI€d s BI'IfIsre)
ururluQotr uusrcr(3Jo udu Ulllsl{utroxgoeH rcrolrr
-sB oH 'r^{r4rlqrP) eurnexdo[oc 'ltxsegotr eIqHsI,IDe
tDrcohr{Joffor4g' (sdr^Hs oHseHtraxe JxIt 09' I -sz'O)
c r roHr{r^r€Jlrsuc)odtrHJr,rv-9z'| UIM (Sdr^.HS OHSeHtr
-axe J)I^{ z-l) anoHuy[gr}tsfic)odtrI,IJ-Dl - (I eHr{I{
-eJ,ils. vytelvrogErel I I,INTIHSLTJ)U eI,IHeheIr eH reuhesro
omodox eilur I rrxBd 4rIHJHercueed-C-HLIN€rug
ouHehou
'rqHomlqsou tC'(HO)SZ't lI JIU unsod,( B 'eltdon
s C(HO)9Z sHesodl( euI,IJ II e.luxed mon.rnercraeed
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puon. VAuuareJIbHo, Ho rnyxora peAKo Bo3HI{Kaer B
pe3ynbTare cI.aBlreHufl cJllxoBoro HepBa, Ho gBrqercrl
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rroxrrJrbrx nauueHToB c orpaHI4qeHHbIM CepAeqHbIM
pe3epBoM. Ocreocapro Ma flBlrs.ercs. Herr{nuqHblM, Ho
cepbe3HblM ocJroxHeHI,IeM, KOTOpOe COnpOBOXIaeTC.S
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paxeHHoro y{acTKa.
I l[qcn.Aora*
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HopMzrJrbHbIM npl{ [opilKeHI,II{ ToJIbKo oAHofi Kocrl{.
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xocru o6rr.Iuo ne rpe6yercs, Ho Moxer floMoqb ]rc-
KIIOqI'ITb OCTEOCKIIEPOT}IqECKI,IE METACTA3bI B CNYqAE
HerlcHofo AI,IarHo3a.
I fleqexue
OcxosHrrr,I noKa3aHI{eM K reqeHulo I,IHru6uropauu
rocruofi pe:op6t\uunsnr,ercs 6orl s xocrflx, Koropa.fl,
KaK [oJlaranr, cBq3aHa c noBbIIIreHHoti N{era6orrue-

*)

Prac. 3,63. EoaeeHu llegxera. A cqraHrurpaQun c ss'Tc y naqueHra c 6oresxuto f1e4xera, unnncrpt4pyroqar uHreHcuatutfi
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npo6neanqurrru Kopr4KanbHbtfi crofi rocrefi (crperxn)
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434 . PEBMATONOT]4f, ]/T 3AEO'IEBAH]4g ONOPHO.ABUTATE'IbHOTO ANNAPATA
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lr MbrruerKrr 6eapa. B pxge cnyqaeB 3ro cocro-sHrle
Bo3Hr,IKaer B pe3ynbrare HerlocpeAcrBeHnoIZ rpaBMbI'
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6e4penuofi Kocrl{ y naIIIreHToB c noABeprelIbHbIMrI
nepenoMaMll urelku 6eApa, a rarcKe y nauueHroB c
rporrl6o@un uefi u reuouo6unonarl'IrlMr{ (uanpu -
Mep, c cepnoBl{AHouero'Iuofi aueruueft). K gpyrult
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u ge$optr,tauuu nopzlxeH -
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y Koropblx lrMeercrl locroflHHarl 6ols n coqeraHul{
co 3HarIr{TeJIbHbIM CTpyKTypHbIM rroBpexIeHl{eM IIO-
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Lancet. 2010. Vol. 376. P. 1094-1108. thefreelibrary.com r.ru$opMar1lrs o reKapcrBeHHo-I{Hry-
7. Taurog J.D., Avneesh C., Colbert R.A. Ankylosing spon-
7.
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dylitis and axial spondyloarthdtis // N. Engl. J. Med. 2016. 8. vasculitis.oqg pecypc Enponeftcroro o6rqecrBa I,Is) reHLIfl
Yor. 374. P. 2563-2567. BacKyJrr,rroB,
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sis // PLoS One. 2016. Vol. 11. P. e0158765.
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cKopocrb Bo BHyrpuloqeqHbrx aprepuxx), xoroputl Moli no.rex rroKa3aHa rpex$asuax KT c orcpoveHuoft
Moxer yBerlrquBarlca (6olee 0,7) npu pa3rr{rrHblx
ga6oresaHu-f,x,
$a:ori Anrr oueHKrr ueJrocrHocrr{ MoqeBbIBoA.sIqeIl
B ToM r{I{cJre npr4 oc'rpoM KaHzuIbIreBoM cr,rcreMbr. He.qocrarxauu KT c KoHTpacrlIpoBaHI4eM
HeKpo3e I{ oTTOpXeHlru loqeqHoro TpaHclnaHTaTa. ,rBJrf, lorcrr neo6xoAuuocrb BBeAeHIITI orHocurerbHo
OAuaro Y3I,1 noqer 3aBr{cr{T or xnalu@rKarl}r[ one- 6omurrax Ao3 KoHTpacrHoro BeluecrBa, qro Moxer
paropa, u y [aur{eHroB c o){orpeHueM pesynbTaTbl qacTo Bbr3Barb 4rac$yHxqulo rorleK, u 3HatrurerbHas Ao3a
MeHee f,cHbr. o6ryreuun (ra6,1. 4.4).

3gopoaa.n novxa 5 llpocrar Kilcra noqKil B l-ilApoxe$pos F KauenuBnoqKe I Onyxonsno.{KhTlb

:r ti_,i-,/
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Puc.4,4, Ynurpasayroeoe uccaeAoBaHr4e noqeK: A egopoaar no,{xa. B HopMe oxoreHHocrb KopKoBoro BeulecrBa ur,txe (6onee
TeMHoe raso6paxeHrae) npunexaqeri neqeHu. [1K noleqHa, ropa; l1C
-
noqequurfi cuHyc (vaurevxa, noqei{Ha, noxaHKa, Kpo-
BeHocHbre cocy4br, xr4poBae rxaxs oanyca); 5
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runnvHar npocra, Kucra noqKu: Kpyrnoe, oxoHeraruBHoe o6pasoaaHue, 6ea
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neperopogoK, xapaKTepHo 3agHee aKycrr4qecKoe ycuneHile. I ,rauJe,{ra; fl - [croH.reHHac napeHxuua; l1fl - noqeqHac
noxaHKa; M Nao.{ero..trux; B
-
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- - 14

yKa3brBaer Ha xpoHur{ecKuil xapaxrep o6crpyrqnu; I-

- runnqnurfi no.re,rHutfi KaMeHb c 3aAHuM 3areMHeHileM. AT - sagxrn
aKycruqecKaflrenu;,[-onyxonbno,rxuTlb.fl-noqxa;[le.{-neqeHb;O-onyxonu(A-A-no6eeHonpegocraBneHo
Dr. Tobias Klatte, Addenbrooke's Hospital, Cambridge)
rororrtrsr ondorox'sotedeuedultduQoutred ruHetress
eumo{dgefu 'nr4Hesotrercclr erqHqrruHor,rrD{H,(0 016
urHesoueuccr orqHurarxfnonEe4
'seeh.,trc esrcHr4mqffog a uuIrx,(drogo ['oxgo s rHerc
srusoHerc.(rerrosrou exoreru (g' y'crd) uuuoxcorcull
lrdu exunnorenov{ esrcrt s edererex orosoxlHhorehon
prr,rnetress udu rcrorHrlouna ruQefuoreuu ex renYefu
-ofue4 'orutrxfdrcgo or-(9orr eeder, nxcenurxedu rsr
-Hero elqso)I,IHhorehor r urcegodu rerrrossou olr(Jcer'ee
e)oler oH 'uhow Bxollo runemddeg ercalt emrsa 4er,tr
xulfirtroslssor,ow er,rnegodr,ilred[ srrrsrceln {co oxsffor
oH renroscou rudorox'ulutorcodQeH goHHollrrxH[Ir
4orrxoxcedn r,rdu rcre,(esroucu uuQufu orerau rentrefu
-erHB'ur4fu,(drc9o rsHunudu unfietvrcefrtut elntod;
'Errur{ rBxHor rcu4tross lteffofuirox w]ncehr4lro)coHeJ
-ured uru flrsso),(seudJsr^ trou lnhorr ,{lterclrc or.{n
-hoHexo[-oHnemun u ulr@efuoreuu 4ontrefueure ud11
'nuIrx,(drc9o xu rsHur,udu rlrHerslrns nrtr rcrer{osrou
-cu orceh .{ruor,eou'4eilu xumrtroslssehow rirretrro
elurxdes u rfi.rercuc or^,firsreludugoc sruuoducurefeus
rerroa€ou er4HBsotrerccu ole orecg emhdl' (ou[efuodr
-ed) ,{euuc uru (onYefuerue) ,&deuc xeholr,{ltercuc
or,(nqreredugoo s oHHesrctredcouen rcrlrtrosg osrc
-elflefl eonrcedrHoxonerrrred uuQedroreuu udg
EuQedroualru
'e?rcoNoJ wrrl^I€c wer
resuheuoego' ugltodr orr.truaodulntdoQ roila.lcgocouc
u etr{coc udr.{ns rcroresuhr(dxc r4HO '4erudrauc xrsu
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rfu cuQ xrqHeoHasoudardu u sov,(coc xI,ttflehoroBod)
Hueolrxxo rlrtr BorarHaltudu B)Htroreht gr€ 'oJol
altody 'r,rudarde [oHhehou er.rrregodurHerl uwn wnF.
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lrudarde {oHhehou ooHoro rcrorBrsr oil.rHesoVerccfl )
Irnur,rHu€?)ou r{NrirHsoHco'esrcetneg oJoHJcefuHo)
eeH s rl,rHotress oJoHHesrctredcouen ercou ,(eedc
uudarde UoHhohorr euHesotreffcor,r eo)csoHe,r.lnod
gogoc rerrserctredu ru@edrouderde runnenoll
'rJSSres xlDrrlen xu IsI€oHeJ,c
qresoduerlre,(enfl rerrrosrorr €trJecs eH EHo '4udatde
xlqHheholl xlsHur{dx u)Herlo I^totroJ,oN NIqHxetr€H
r,xl.;erusrr ruQefu oulnu rrBHcH€Hooed-oHU,THJBN oJh
or en rfuolrceH'(V't'ugur) 4erarrxu,tQ xu rJoHHem
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ruruseed xcud qremrssolr Jexow I,IHeuerc godor,oxeu
s ruHI roVEJ esoHco en goJ,eduuedu xrqnrcedl,Ho)oH
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I 4ouurenders ye yclrelrlrrslr ruQudrourue nenurenoeed l
- oHrlrHJer^r 4ude rde xlqHhohou uurleculre^€ua ud g
'eHerrh oJoaorou u rdrser{u oJosehollt 'rseerex 4otl
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I,I EI IOqgO Uranenr'Orr( UdU er{xenuH€ eolllqrog reeNr{
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.urcedrxox altHeYess ex eodgu$ {HHwercltc 4nuuelod$eg
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nun t4eal ovquovcoH eedeh gcreeeileeed 'ouueedu ley .
(urauogneodere) tsuuogne reeoxudarcauol
I trufieetlueAena
rqUoren orcFreilrerderque qradronrccBd 'L,rvocrqs urcnd tauc3 .
tqeur,edoeilrodu
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s erltnrdoQren tsr4HoheHeeH ro ccqrexdeUeoe silHetrxedeou
oJoHhohou orodrco v,tr'tuaeed ildU CBLIH clrlHenro oHHen
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h^rr\ 092
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or^ncrcdodeu or{Hqlrel:adeeEedu otlur,ore-rcoU slt euceg6 r
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regerU r4rsudexe3 .
ilHenede evl(xerrrodu
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)ohou f[hvH^O eusemldBu rceetnoreu'ry .
ercud trdorxe6
eBtcafnoE
orourcedruovouer-ired BtaHoUoEE e/€ or/cou h 8t oeHEeou
eH tscoofroreHrheu '4r,rhxn{S xrqHhehou eruemUAxl eodrc6 .
esrcelnes oroxrcedruov s.lcout'tacxorod$eg
xB}lHeaotsauccx xr,rrcohr,rjouoH
-elned tadu uuxoxxouco arqHhehou'g'p ehnugel !
456 r HEOPOflOfU9 UYPOI|OTUA
Puc. 4.5. PerporpagHar nuenorpaQur. fluenorpa$ur ryvue
Bcero no3Bolger Bu3yelnu3upoearu co6upareJlbHyto cr4creMy
(na pucynre
- nopua). Karerep 6uu aae4en B neByp noqeq-
Hyn noxaHKy npil Ll4crocKonun. BugHur HopM€IlbHbte Kopan-
noBu4Hbre yaueqK[ c i{erK[Mr4 KoHrypaMh. flo6eeHo npe4o-
craBfleHo Dr. Bayliss A.P. ra Dr. Thorpe P., Aberdeen Royal
lnfirmary)
-rl
IIEBA9 = 610/o nPABAt = 39%
B]/E C3Mr/
Puc, 4.6. PaguoHyxnragHoe uccneAoBaH[e c se.Tc-gt4MepKan-
rocyKr.luHaroM (eug csagu). Ha uso6paxeHu[ npegcraBneHa
Heu3MeHeHHa9 reBae noyKa h yMeHbuJeHHae B pa3Mepax
npaBae noqKa c npn3HaKaMh py6qoaofi geQopuaqrara a
o6nacru BepxHero u Hl4xHero nofloca, QyxxquoHaluHan
aKr[BHocrb roropofi cocraBrrer ecero 39% o6qefi $yxxqra-
onaluHofi cnoco6Hocrn o6eux noqex
I,ICTOqHIIKOM Y-L{3[yrIeHUfl , 3ZXBaTbIBaIOTC' I,I BbIBOA.f,T-
[oqKaMu, r,r sror npouecc Mo)rcro 3aSuxcuporarr c
c.s
noMorrlbro sHerrHeft y-KaMepbr.
.[uuauuuecKr,re paAr,roHyKJrr,r.uHbre rlccJre4oBaHr.rf,
npoBo.qqT c MepKanToarleTrrJrTp[fn[rur{HoM, MeqeH-
HbrM rexHeuraeu (ee'Tc-MAI- 3), xoroprrft npo@ra-rrr-
rpoBbrBaerca n uy6ourax lr BbrBo.{t4Tcs. c Moqoft.
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qeuuyto unQopMaur{rc o nep$ysnn xaxgoft nouxll, Ho
HE IBTIETCr HA.4CXHbIM METO.4OM BbISBJIEHI,Ifl CTEHO3A
no.re.rHoft aprepuyr. Y nauueuroB co 3Haq[rreJrbHbrM
HapyrrreHr.{eM orToKa Morrlr BcneAcrnue o6crpyKur,ru
MorreBhrBoArllrx nyrefi emTc-VIAI'-3 3aAepxr,rBaerc.s
B ttoqerlHofi JIoxaHKe, v g.ax,le BBeAeH]Ie flerJleBoro
Al,IyperlrKa He Moxer ycKopr,rrb ero BbrBeAeHrae. flpo-
BeAeHr,re eroft npo6u Moxer 6rrrr seo6xoAr,rMo Anfl
orrpeAeneHprx SyurquoHalrnori 3HaqlrMocru BbrqB-
nenHoft n co6nparerurofi c[creMe floqxu ofcrnVrUrau
6es nuelorpa$uu.
PaAlronyrrruaHhre r,rccJreA oBauvrs.) Haflpr,rMep, tlo
KJrr,rpeHcy Ar,rsrr4neHTpr,raMr,rH[eHTayKcycHorf rorclorrr
(ee-Tc-ATfIA), xnnarorcs <<3oJrorbrM craH,(aproM)> r,r3-
MepeHrs CKO.
CrarrEqecxue paAr.roHyK.lrlr.qHbre r{ccne.uoBaHufl
npoBoAflTcq c AuMepKanroxnrapnofi Kr4ctroroft, Me-
qeHHorU rexHerllreM (ee'Tc-AuuepKanrocyKrlr,rHar),
KOTOpaq CeKpeTr,rpyeTcfl KJreTKaMr.r lpoKcr.rMiurbHbrx
KaH€rnbueB. I,Iso6paxeuufl floqeqHoll Kopbr, Koropble
noJryr{arorcfl nocJre a/s sseAeHuq npelapara, Aaror
npeAcraBneHne o @opue u pa3Mepix rroqeK, a raraKe
fl o3Bor.f, ror flpoBecr]r ceJreKTlrBrryro oqeHKy OyHKuuri
rroqeK (puc. 4.6). I4soronHas peuorpaSua c eemTc-
ArrMepKanTocyKrI[HaToM flHilseTcf, qyBcTBr,rTenbHbrM
MeroAoM 4rr o6HapyxeHufl Koprr,rKzurbHbrx py6qon,
Bbr.flBreHr4fl pe@nrcrc-ue@ponaruu u orleHKlr Oynr-
uuu raxAoti noqKlr rro orlenbHocrlr.
Y naqueuroB c pacnpocrpaHeHHbrrrlu @opnaa-
Mlr paKa npeAcrareJmnofi xeresbl Anr BbrflBreHus
Meracrar[qecKoro nopaxeHuq rocreft u o6reua
lopDKeHlrrr [poBoAuTcs pa,q]roHyKJrr,uHoe cKaH]rpo-
BaHr,re (cqunrurpaSur) c uerzleu4n@oc@oHarou
(ry'Tc-M.{@).
Br,roncu.s floqKrl npoBo.uurc.f, 4la repu@rEKarlu]r
ALIarHO3a I,I OlpeAeneHnf, CTeIIeHII TS)KeCTU IIOpilKe-
Hr{.f, [oqeK, Heo6xo.ul4Mblx IJIfl oueHKI,I [porHo3a u
npvrHsrvrfl, peilreHrs o raKrrKe JreqeHt,I"f, (ra6l. 4.5).
flpoqelypa BbrloJrHsercq qpecKoxHo no4 uecrnoft
anecregueri. O6ecneqeHr,re rorrHocrr,r rryHrclulr rroruoca
ogr,ru Udrr€fu oJosehor^r r{)4em eeHlrrErcutr rcqrss I{rce 'e€h/(Irc wor s nuHxodu rcsJeserco JexoN I,IhoI I
-rilso€pllrE)olr H UoHIrou quqg eHxrotr eno een,(rc taraqgo r.rr,rHe)Kr,ruc ud11 'xufisrgHe) xrirHhehorr s
O)J
lryor€ s u'uudf,uu u uudf,lulto oturugeed ) urces 4ounuaodugdocgeed 'uroo)trflx pr 'xuxnog.&or r roEem
-udu rexow {er,(u xutnrtrosrqsehor r rulrxfdrJgo -auaod,r,uruQodr'I{rco)trIfx exoqgo No]rHarrroHJooc
'(9'y' rgur) urudQenor,{dalrorr oreln rcrenretreduo r{hol^I rjor rerlrerrss osrcohr,ruo)
-or^(duccedroduodrcrsg weurusred u rryur^reHrrtroneJ 't[c/uw 001 eeHer[ 4audiue e']rhor^r m{ 00, eeHehr
-
Irxrr{c es euHorolilss rorBr rr{Hou rleud,fuuro tro11
4onvrudrxafi nnrrunemr(deH Hr^rrsra)Krt'4ar,(u xlrln
-rtrosnsehon Heumrdfu cgo frxew srlrtrosodu rafverc
,{xurconruutr ordHsrer.rfiuedaQQun' uud,Ktla uvluta€ed aud(uvpwdfumug
ud1'ueed,{utr euHexHHJ aoHqrerulrafuc rcsretrorrg€H
Jexow xruMrc xrsdoroxeH I oH ')ehou rnnexedou
ederxedex ro rHcI,IsB€ oln 'xeretredu xlqHqlreJprheHg a ror/{u xHrnB[08rcr80h0r/\r 14 y0h0u
sresodusdes roxon r,rhor^r Hor^rerreVrqs y{eq,go I_IUO r u HE80u09e0 3H r,rrdBy HEycahil H 14 ux
udg '4oudz(eo)orrrJ 4onnexedrss c e€otrunuore) noxc
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en nunemr{dBH elqHglruHededu exou 'dou xel otr edew -e[ocu qu<rg rexon 'raucuougodQeu udu 4rsuner,-,{rou
4enurcdx ou 'ros.Lesurhvresd exBtrr,rnr rcqrrrHewor4 eH 'u)hor ltrexr fiseudgo 'r {or4HBsodurcudurox agehou
Jexon I,lhor{ Konrarretrrss xreqgo sofisruHe) uutrxu,(Q I'I4H€SOtrOTCCU OJO)CEhI,IJOIIOHOJIHEd VIWI KT1,i,YIEJNrEH
-cl{tr goIflor,(grcJr{uoc uru EsJceIles oroHr{adosrced 4oaoxdueefusr,{ wosrctrodcou roreesuherrcego r/D{hox
I4llnedrHefrHo) r,roxo3rqg udu rlnteda ex or g 'Istros
'ouHeepvouoshrodu eoueuerucoHr6
Lr vtrol orutrgdocaeed roresrturesd ore €H rosro s
eeeJcoel/lloJ nunuxdefiTou rlntuHexel,{ eIsseIIqrBHE) r4vcohr4Hr1r, bev\r,rheHe orUed'eufu cuQ uereoreeouderdy r
e'B)Leexutto O)f, u[.rox '(11110 noHqreHededu 4euhedeuo
r/rlr4 noelccuol.emene c rr$edrorune eeIrtolgedr
udu'delruduun) unolr rrauuaoeudgo rrlremquelrrf 14 00H8r,1ccBv\ eu-:oru 'uyr,ou i^dyoe ,4Heyr e erlenetoeody r
r reusrctrem srrsg rfuow rrudfiue u yudttutt1 ')ehox
{vuuoy or{ur,enou u ouh>rldrcao
ruHBselrogut HroaxBr lrtodorexratrnu I^IIsHXaYEH rcre 'evrcfuc eruesoeedgo c.tegerce r-oxov\ oH 'ooHcuor-lrh
-rrstr eH Hhor I rJoh{errelfrqs Wo<rgo 'ltoeudgo rltl)Er -eHeeH 'ouileedu yev 'ur.(u erlncfoerceenon e erleneroeody .
HeqeLrC OHhlcgO 'sttOg r
irufigdocgued reaorsreHu) BcJeex]rHc onsrrel,.redeu
BI4HgH)l(OUCO
(urcuorgudu4uMuluouxreeorrog{rri rrdQerou[denou.t
oTogg;) rru{xcee 4rsuxeeodur,rhocce 4nlno{duc (eorelreuucuedr enodr) *e>Lou ueuuoercurf3 r
-yfigy qnuaxur 'yf{g y euo.rxlHv -cedloduodrcrsg silHoheHe oroy,lefdreoruodu %Og eoHoy,,r r4yhou denee6 r
1y reneldnuodrHo)rol{ r
(reusueuedoreuer' uemurexedouUdor) cr4r{oheroeodv
vcrd ropm
une{Qdauouu.r uemueuorluMQ ueuaxul -rqeou rcueiedieurue eruIdU u
eodxeu4rceehsueuex4ndrco[rcuaxul (eeuuodorcfeU) Qunduucy) Blouu4y 6esour4h
-uuecuurohv urreuoruhognodr uur uuhcufueoy auruemldeg r
4rdede xqHhohou xenou uuelQdeu
lror4Hohotrsoe c Frdoe ouHooucced eruamr(deg ruxeeexouoeurodg
(orEed) eehsueue>r eerc14odrcced oJoHl,\oic14c14rJou
rnF>Idrcao'sud^uuercildy 6eHBilccey\ eoyeHeildu r4rn4 yohou 4uhxn,{Q ghHemAdeH uilercMcro ildu
(runer ererUueouuedoy'ouileedu nrdlnrerodu 4ouHexedrce ogerJc foHHesodnuoeu uuttr uud
rex) eemuuod@er 14ruuodorclefl -fueu're: 4or.rueeoduuoen ildu gcrhUoeodu xceh,(uc xta>tUed g r
ghHexedou oioeeh^u erBrHeuucHBdr oJoHhahou ruhlrl{$crf r
'e>ied'eeodqrS oroHqreeuorudeuodred vrodUsuc 4uxcenrrud$e;1 .
auuaeed Be-eil sorilHhol-ohoN ot4HohorJ tscfillno€tffiou eH uur ilyeHehdu
qrconrEoxodrer uur-tuodorcrisfl orqHhuul,rJ-E 4utnoenr 'r1ercU I
nodUHilc 4rucer,rrod$e;1 .
sdrqe/iu xrqucodee
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oueur uy6oxuu (Auxauue Kyccrnlayl.a), paswrnarorca
MhlllreqHbre II oAeprI,IBaH]Ifl , Cy.UOpOrI{, COHJII',IBOCTb
,I KOMA.
I'la6oparopHbte u ilHcrpyMeHTafl bHble
Pexoueugyeuue aa6oparopHo- I'IHcrpweI{rrIJIbHhIe
uccneAoBaHnfl y fla\uertos c XEII nepequcneHbl B
ra6n. 4.29. I,Ix ocHonnrre qenl{ cJIeAyIoq}Ie.
. l4cr;troqurr OfIlI, Koropoe rpe6yer 6esorrara-
TeJrbHoro Aoo6caeAonanvs. v nu6opa coorBercrBy-
rcuefi re.Ie6Hoft TaKruKI,I. flpu nnepnrre BbIf,BJIeH-
HOM rrOBbIIleHlII4 ypOBHfl MOqeBIIHbI
(ynerur.renuu rro cpaBHeH]Irc c [peAbIAyIIIvlMt 3Ha-
qeIJUHMll Utrv rIptt oTcyTcTBlII{ flpeAllrecTBylouux
pe3yJrbraroB), qro6H He nporrycrllrr Oflfl, B reqe-
sne 2 neA neo6xoAnuo noBropHo oqenlrsarr OyHx-
uuI/I noqeK.
. flo so3rloxHocTl{
onpeAenl,ITb ocHoBHyIo ilpl4tlu-
Hy, TaK KaK 3TO MOXeT IOBILI.STb Ha TaKTI'IKy ne-
qeHI{q.
. Brrsnurb o6pamurre $arropu, Koropble Moryr
yxyArrII,ITb @ynroruu rroqeK (nanprauep, Af rura o6-
crpyKulrrc MoqeBblBo4.trurnx nyreft).
. Ycranorurb ocJloxHeHus XEII (nanpnuep, raxue
KaK aHeMrIs rr noqeqHas ocreorucrpoO]ts).
. Bussurr cepAerlHo-cocyrllcrble Saxropu pllcKa.
Hanpanaenne x neQpo.nory uenecoo6pasHo Ars
rrarllreHToB c noreHlll,tztnrrro rypa6eJIbHbIM ocHoB-
nrrM ga6oaeBaHr{eM I,I Tex, y Koro sa6orenaHl'Ie
Moxer nporpeccupoBarb Ao TIIH. flpegaaraeurre
Kprrrepulr HalpaBIIeHI,Ia x xe$ponory [epequcreHbl
s ra6r. 4.30.
lI KpearI4HI{Ha Tarruxa BeIleytvIs [au[IeHToB c XEfI.
. Konrpom ga OyHIaIusMI,I noqeK.
. flpe4OrsparrleHlle IrJII{ 3aMeAJreH}re AZInbHeftrUerO
noBpexAeHI,Is.
floqeqHoro ]
. Ilpo$tutarrrra ocaoxneHuft noqe'IHoft
HeAOCTaTOqHOCTU.
. Kopperclu-n $arropon pucKa cepAeqHo-cocyArrcrblx
sa6oresaxltfi.
. flpr neo6xoAtuocrl,I noAroronxa x 3IIT.

Ta6nlrqa rt,29. PexouengyeMble na6oparopxure l4 xHcTpyMeHrarlbHbre nccreAoBaHnq npu xpoHxqecxoi 6one:nu

E noqeK
14ccnegoaarnn 14xrepnperaqur

Moqee,aHa ,,1 Kpear[Ht4H fun oqerrra ua1vntsaqwtlnporpeccilpoBaHilc - cpaBHl4rb c npeAbEyLLlt/Mn pe3ynbraraMl4

O6r4urZ anarue uovn u l-evarypr,rn il npqreuHypt4t Mgrfr yKa3btBaTb Ha rnqMepyngnarwt vt neO6xOgtlvOCru 6vOnAnt.
KOJIU9eCTBeHHag OqeHKa f]poreraHypur yKa3btBaer Ha pucK nporpeccilpoBanras X6[], vro rpe6yer npoQularcrurecroro
npoTe14Hyp1414 Ha3HaveHr't, u*v,6ntoPaAflO ulu EPA ll

Snexrporrrur ,[pR aurneleHrR n nepKutvieMrh u auilAo3a

Karuquil, QocQar, l-1Tl- n 25(OH)D OqeHxa ueQporer-ruofr ocreogrcrpoQrn

Alu6yvttH Hrexrafi ypoeeru als6yt',lraHa paccMorperb BepoerHocrb HeAocraroqHocrnnvralta,

-
BocnareHrn, ueQporrvecroro c/HApoMa

(t Fe,
O6u.lrai auarras xpoara [1pur aHeuru !4cKnroqilTb eacrbre oKcrpapeHaJ]bHbte npt4el4Hbl, a 3areM req[Tb KaK xeoporelHyto
$eppnrux, Qorar, B,r) aHeMun

pnugur, T1troKo3a * HbA," Burcoxri pr4cK cepneqHo-cocyAr4crbrx sa6oneeaH!4f npra X5[1: aKTuBHo KoppeKrilpoBaru Qarroput
pilcKa

V3[ul noqex Tonuxo npra Harillr4r4 cilMnroMoB o6crpyxqrara MoqeBblBog ull4x nyrefi, croirofi reMarypiln,
ceraerisoro aHaMHesa flKfl ranu nporpeccupytolLlefi XEI-I, Yraeuuu:euue pa3MepoB noqeK
yKa3brBaer na xpouruecxnil npoqecc. Acnlauerpurnuti pasMep noqeK Bo3MoxeH npu
peHoBacKyaqpHoil 6oreeHu unt4 nopoKe pa3BilTtlt

Cepoloruvecxre ilccflegoBaHL4q Ha Eclr nnanrapyerc+ Anarng l,,rn,r rpaHcnnaHTaqrr. CepoHerarL4BHblN/ naql4eHTaM peKoMeHgyercn
renarur u Blzl! BaKqilHallilt or renarrra B

,[py1ae rcclegoearlrn Paccraorperu qerecoo6pasnocrb coorBercrBytou.ltlx l4ccneAoaar,nh ng ru6n. 4.25, oco6eHHo

ecflil npilqilHa XEI-I He/oeecrna

flpuuevaxnr. 6PA ll 6rorarop peqenropoB ll; 25(OH)D 25-rugpoxcheurar'/tux D.

- -
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nrsHHe gJ,ceIlllt^ruedu
c sorH e u\ett uulJle da r orqffarr 4oH Btto 'oror alrodx 'runrrltreed aorHatlneu xrqneud ,(
-soHco Ecrerusv uudiHualodu ugeuerc eunemqnelrr{ HurrxH,{Q UroHhehou rr,rHoxunc sJ,codoxc 11gX ]rd1
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r}rHEaoduccefuodu riruwer roexr/rHc [! ruauaod^{ ue
srodrHox 4urofuc o)EHtro '11gy ruruaeud rsHr.rn[du
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euHehen 'ouxon€os uucg'(E7'p'rud) 11g s irrooH uneredeuedu ilr,,{rqHeileHerdour4.lt4rlre
- g adrou u ruH€s effo ge€, ]rvHers]r,odu euxc er, y|P^t4u>t uy{qdrcroF, ur,rueder eloQ el sey,le,(dtauodx]o! oxouu ,_lg o
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11 o.rotdexec uuuedet 4oueeleUe elo$ en vuue:egeni
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(Uo: e ,n eL'l/HtA
'1gg yleaoduu oauog uuu rlorBrquleed nrln{UrqUedu c oirlHoH
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-uru oHHorltedseosc rorrrosror orn ,11111 eurlrssud -eBdc ou o1og7 eevog) llahxn{S foHhohou ot4Hoxr4Hc eodrcrsg .
srusodueoH.IodU eXCXer U'eJHOpItIer ruHesotrercgootr zw e|l/HtArt7uvr 0e ooHol l O)Cd .
rleaogafuou rexoru oodorox'ggy eunusoduccefuodu AJouodQoH)l rahou oNHeauog lorcar,nxodx I eor f]
eoHua€eHs slulsrlqa'O)J ruHa>Kulac rr,trede ?rxhor J -Hamheu oruHaueeduex x tsr{Heeexou .6g.p ehnugel f]
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r{Hcynbr r{ 3a6oneBaHux nepu@eprqecKux apt epuit.
flpu srou Her KaKoro-lu6o onpereneHHoro no-
poroBoro 3HaqeHu.f,, Hr{xe Koroporo 6n 3TI{ pI{cKI,I
yMeHbrxaJrrlcl, u ,tto6oe cHI{xeHLIe A.{ npuuoclrr
rronbsy. flpe.u,rara,rucb pa3nrrqHbre rreJreBbre 3HaqeHu-f,
A[, nanpuuep MeHee 140/90 MM pr.cr. y raul4eHroB c
XEf[ ra 6esanr6yuurrypuu (An/KpueHee 3 rvr/uuolr).
Y nauuenroB c yNlepeHHofi a,rr6yuuwypueit (fut/Kp
3-30 nr/rranaonl) cle4yer paccMorperb 6o:ree Ht,tsroe
ueJreBoe 3HaqeHue A,{
- 130/80 MM pr.cr., Koropoe
raKxe peKoMeHAyercq r,rrfl rlorerl c Al/Kp 6oree
30 ur/uuonr. fllx naquexroe c XEII u sHaqr4rer],Horl
nporelrHyplrefi (OE/Kp 6onee 100 ur/uuom utruAtr/
Kp 6oree 70 nar/uuolr) uoxer 6urr ue:recoo6pasuo
paccMorperb Aaxe 6olee Hn3Kue ueJIeBbIe 3HaqeHI,IrI
A,[, Haupul,rep, 125/75 MM pr.cr. [n eaponeftcKux pe-
KoMeHIarlu.f,x no AlrarHocrrrKe lr JreqeHlrro Af (2018)
He peKoMeHAyercq cHr{xarb A[ y naquenron c XBII
Huxe 130/80 MM pr.cr. - Ilpuueu. ped.l. [ocruxeuue
TaKI,rx ueneBux gna.reHuri A[.racro rpe6yer Ha3Harre-
nlrs xoN{6uH a\yru aHTrrrurlepreH3l{BHblx [peflaparoB,
a repaneBrr{.recKuri e$Sexr Moxer 6rrrl orpaHuueu
pa3BrrrlreM HexeJrareJrbHhrx sBreHurl u uloxori upu-
BepxeHHocrblo nauueHTa JIeqeHr4Io.
Yuenrurenue flporer{Hypnu. flauueHrbr c npore-
vtnypuefi, r{Me ror rroBbrrrreHHbrri pucr pa3B}rrr,r.rr rro -
.{eqFlofi HeAocraroqHocrvt, v Ha ceroAHrlilrul,ttl .{egr
cyruecrByror y6e.qurenlnbre AaHHbre o 3aM eAJreHr,rr{
flporpeccr{p oBaHlzs. XE fI npu yMeHbrrreHr{r,r crerreHr{
nporer.rHypr,ru. Vsru6uropu AIIO lr BPA ropMo3rrr
pa3Blrrrre XBlI nocpe,ucrBoM yMeHbrrreHul Bhrpa-
xeHHocrr{ nporer{Hypur.r. 9acru.rHo sror e@Qexr
,4ocrr{raercrr 3a cqer cHl4xeHrur A.(, Ho, KpoMe roro,
r{MeIoT MecTo AoKa3aTeJIbcTBa peanv3a\vvt SToro fro-
Jroxr4reJrbHoro n:reriorpouuoro eS@eKTa y nauueHToB
c nporer4Hypueft (OE/Kp 6onee 50 vrr/uuolr u:ru Al/
Kp 6onee 30 ur/uuo.rrr) :a cver yMeHbrrreHra nep$y-
3r{oHHoro AaBreHu.g n r,ry6ovrax. B Ao6aueHr4e K BbI-
rrrecKa3aHHoMy, Ha3Harrenrae unrra6uropon AfI(D npu
XEII npo4euoHcrpr.{poBiL,ro cH}DKeHr,re pucKa cepAerr-
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qun. Taxralr o6pa3oM, unru6uroprr AII@ u/uma BPA
cneAyer Ha3Haqarb BceM naulleHTaM c.[ua6err.r.{ecror7
He$ponaruefi pr nauuenrau c XEII u nporezrrypueft
He3aBlIcI{Mo or HaJrr,rqufl conyrcrB},rouerl AI.
B ro nperu rar raHru6uroptr AII@ u EPA flBJrsrorcs.
npeBocxoAHbrMu npenapaTaMu Anrr [aur4eHroB, crpa-
Aaroulfix caxapsuu Aua6eron luu XBfI upu HaJru\rw
npoTeuHyplru, B onpeAeJreHHblx cI,ITyaupIrIx oHI,I troJDK-
HbI Ha3Har{arbcq c ocropoxHocrblo. Haqa;ro flpneMa
lruru6uropon AfI<D u EPA Moxer conpoBox.[arbcrl
rotrru oAHoBpeMeHHbIM cHl,IxeHueu CK@, nogroMy
B TerreHlle 7-10 aueft or MoMeHTa lrx Ha3HaqeHlrrl
flIu )tsenuqeHr,rq Ao3hr y [au]reHToB cneAyer KoHTpo-
Jrr{poBarb Synxrlr,rro noqeK. flpoAorxarb repanurc
rauru6uropauu AfI(D nnra EPA MoxHo Ao rex [op,
noKa cHr{xenue CK(D He npeBbrruaer 25% rlcxoaHblx
sHa.reHrrrl r{ He nporpecclrpyer. Peuarcuee 3HarreHue
B ayroperynsuuu CKO npl4 cHl,IxeHnoft no.Ie.IHoft
nepQy:rara rrrpaer aHrr,roreH3uH II (cu. ptac. 4. l, l-),
nosroMy Ha3HarreHue unru6uropos AfI@ ulu EPA
Moxer ycyry6um reireHue rrpepeHaJlbHotl uo.{e.{Hoft
HeAocraroqHocru (cu. puc. 4.19). B cnx:u c Bblrrre-
cKa3aHHbIM IIaurIeHTbr, npuuttuarctque r,rnru6r.rroprr
A[[O/EPA, AoJrxHbr 6srrr npe4ynpex,{eHbr o He-
o6xoAuuocu4 npr4ocraHoBr,rrb r{x np}reM B cnyqae
)xyArxeHl{fl cocToqHl{q, Hanpl{Mep npu IlorlBneHl{rr
Jrr,lxopa,{Kr{, pBorbr vuwr. Anapev, ra noso6Hog[Tb reqe-
craHerJryqme. Tarcre ero orHocfrc.g u r
Hr4e , KOfAa r,rM
Apyrr4M rrrprpoKo paclpocTpaHeHHbrM neKapcTBeHHbrM
flpenapaTaM, KoTopbre npuMeHrrroTcrr y [au]reHToB c
XEfI, raxnu KaK Ar{yperr,rrra, uerQopMr{H rr HIIBC,
r{ AaHHyro peKoMeH.uarlurc MoxHo rro.uKpenlrTb rrpeAo-
craBJreHr,reM nucruennort uu@opruaqupr, Harrpr{Mep
naM.f,rKu An-fl flaur{eHra (ra6l. 4.31). B css:u c reN{.rro
unrra6nroprr AfI<D u EPA uonruuaror ypoBeHb KaJrufl.
B CbTBOpOTKe KpOBr,r, UX He CneAyeT Ha3HaqaTb IIaULIeH-
raM c r{cxoAHbrM }poBHeM Kiuru.s 6olee 5,5 rrruomf.
flpu nrrxnneHr,ru ypoBH.s Kurkrs. B cbrBoporKe 6oree
6 uuonr/.rr y [aur4eHToB, Koropbre yxe npLrHprMaror
ranru6uroprr AII(D u.nu EPA, cleayer rur6o cHr{3rrrb
Ao3y grrrx flpelaparoB, ru6o nolnocrbro flpeKparr{Tb
rrx rrpueM, Ho ronbKo flocJle roro, xax 6ygyr npe.u-
npuHqTbr Bce ocTzL,rbHbre Mepbr no cHr{xeHr4ro ypoBHs
KaJrvr.s. (cu. Hlrxe). CleAyer lrs6erarr Ha3HaqeHuq
xou6uuuponanHoft repar,lrrz uHru6nroparr.rr,r AfI@ c
i
Ecrn eur eyBcrByere ce6q nroxo il Bac 6ecnoxocr pBora,
A|,i'apen t4ltvt nilxopanKa, oTMeHhTe npileM cneAylorlr4x
IeKapcTBeHHbrx cpeAcTB
o lzluru6uropur A[1O: lerapcraeHHbre cpeAcrBa, oKaHqilBapu.[4-
eaq Ha -npufi, HanpilMep, Jrr43r4HonpilJr, paMilnpiln
. EPA: neKapcrBeHHbre cpeAcrBa, oKaHqilBaou.{ilecs Ha
-cpraH, HanpuMep, up6ecaprau, nffiapraH, KaHAecapraH
o Hl-lBC: HanpilMep, u6ynpoQeu (SpySeHr), Aux-no$enax
(Boruraperf)
. Ailyperr4Kr,r: HanpilMep, SypoceuuA, 6engpo$ryuervasv1p,
cnilpoHolaKroH
14HAanaMil,q,
. MerQopuuu: npenapar Ane neqeHile caxapHoro gua6eru
Boso6noenre npileM npenaparoB, KorAa Bbr nonpaBilrecs (vepes
2448,4 nocle roro, KaK Bbr cMoxere HopManbHo ecru u nrrs)
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nrr4mo{r(trercolI c ]r]rwerosoIIuJ runelnudsrotredu
vtra 'I6udtes uroc eulrExdetsoc 'ltxgegotr elsHsunB
etDIcehI,IJoIIOI'rg rBhorrD{s' Iq[og pI YudJLeP. runergedr
-ou H,rHehurread rer(gedr orn 'lt)hou 4elnorrdersroc
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eraner,I4res^ oneedgooca(etl sJrsg Jexolt uufDH,(Q IloH
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a srcongefuorr reex{Hoos 'orusedu xex 'ulrfiufruc 4ox
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ee elreunerdo s rlrco)tstrx exxdetrue HoHqreJllheHt
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rcHesodurx.{drcsuodu quitg rqrrxroE m,Inorosdeur{J
ulrexeneudu uwrsHdesorcotr o IsrHeHrIeLI 'JV euHosoH
-xlHeoa qresoduttosoduc rexow u so)ero rl,IHersuou
etrlrs s elrer,rneldo s exxdetrBe xr,r ) rfltrosudu onnrsgo
orn 'rqYog u vudleu lrxuirgsu elteunerdo tu su,Itros
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runugoduccefuodu n{Herrtrer ru€ r4uHemoHro s rstqlror
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KOCTf,X I{ IOJIOBHOM MO3re.
a.
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B 50% cnyqaeB olryxorb [orrKI'I nporeraer 6eccl4M-
nroMHo u cryraftuo BblrlBJtflercfl Bo BpeMq o6cleAo-
Ba:avrs., flpoBoArlMoro rro ApyroMy [oBoAy. Ilpuuepuo
t 60% ctrytaeB BbulBrrIercq reMarypu x, 40% 6onrrrsrx
o6paulatorcs K Bpaqy B cBrI3I,I c noqBreHuell 6orra s
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c.fl o6reMHoe o6pasonaHue B Mecre rlpoeKlluu [oqKrl.
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BKrroqalouritfl 6o:m, reuarlpraro r'I o6lertroe o6pasona-
Hr{e, qro cBr{AereJlbcrByer o A€uleKo salreAruefi crag.vkl
B KJII'IHI'IqecKoIl raprune
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teuuit , cpeAI,I Koropblx
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nporelrHeMrlfl rI orKJroHeHue or HopMbr -na6oparopHux
nora:areleft @ynxuuu [eqeHI'I. I4uorAa :a6olenaHIae
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lrJrI,I pexe HeBpoflaruefi. Pgl, cr{creMHblx flporlBne-
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oflyxonl{ uaHu@ecrlrpyor 6es6oresHeHHoll MaKpo-
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