73 research outputs found
Post covid syndrome and rheumatic diseases: focus on rheumatoid arthritis (own data)
Introduction. In modern reality postcovid syndrome (PCS) is characterized by clinical heterogeneity and multi-organ involvement, often presenting a differential diagnostic and therapeutic problem. However, in most studies of PCS, stratification of patients taking into account individual comorbid conditions was not performed. Thus, only an extremely small number of studies have been devoted to assessing the course of PCS in rheumatic diseasesPurpose. To characterize the features of the course of COVID-19 in patients with rheumatoid arthritis, as well as to conduct a comparative assessment of clinical and demographic parameters in groups of patients with rheumatoid arthritis, differentiated by the presence of PCS.Materials and methods. The material of the questionnaire which contained questions regarding socio-demographic data of respondents, information on rheumatological history, comorbid diseases, data on past COVID-19, including cases of re-infection, and PCS.Results.The study included 32 adult patients (29 women, 90%) with a reliable diagnosis of rheumatoid arthritis. Of the 32 patients who underwent COVID-19, in 23 cases it was possible to form a judgment about the presence or absence of PCS. To study PCS, 23 patients were stratified into two groups: 11 (47.8%) patients developed PCS (Group 1) and 12 patients had COVID-19 without consequences (Group 2). Both groups were represented predominantly by women (90.9% and 91.7%, respectively). In the general group 37.5% of patients with COVID-19 required inpatient treatment. The number of symptoms associated with COVID-19 did not correlate with RA activity, however, patients with higher RA activity were more likely to report increased arthralgia as a symptom of COVID-19. 47.8% of COVID-19 survivors experienced PCS. The average age, the number of comorbid diseases and the severity of RA symptoms at the time of COVID-19 were relatively higher in the group of patients with RA and PKS. Patients with PKS also noted a higher frequency of hospitalizations and a more severe course of COVID-19.Conclusions. A quantitative assessment of the risk of developing PKS is needed, which will serve as a basis for developing a strategy aimed at prevention, timely diagnosis and treatment of this syndrome in patients with RS. To this end, further studies on larger cohorts of patients are required
Structure and hardness of B2 ordered refractory AlNbTiVZr0.5 high entropy alloy after high-pressure torsion
High-pressure torsion (HPT) at room temperature was applied to an AlNbTiVZr0.5 refractory high entropy alloy. In the initial as-cast condition the alloy was composed of a coarse-grained B2 matrix phase and a continuous network of C14 Laves phase particles with the volume fraction of 19%. HPT resulted in the formation of a nanocrystalline structure in the B2 matrix with an average size of grains/subgrains of 25 nm after 5 revolution
ΠΠΊΡΡΠ°Π»ΡΠ½ΡΠ΅ Π²ΠΎΠΏΡΠΎΡΡ Π²Π΅Π΄Π΅Π½ΠΈΡ ΠΏΠ°ΡΠΈΠ΅Π½ΡΠΎΠ² Ρ ΠΠΠ§-ΠΈΠ½ΡΠ΅ΠΊΡΠΈΠ΅ΠΉ ΠΈ ΡΠ΅Π²ΠΌΠ°ΡΠΈΡΠ΅ΡΠΊΠΈΠΌΠΈ Π·Π°Π±ΠΎΠ»Π΅Π²Π°Π½ΠΈΡΠΌΠΈ
According to experts, the human immunodeficiency virus (HIV) epidemic has a steady downward trend, but the attention of the medical community to this problem is not waning. Before the introduction of highly active antiretroviral therapy, the prevalence of rheumatic manifestations in HIV-infected patients ranged from 3 to 71% and was associated with late stages of infection and severe immunosuppression. HIV-associated arthritis, reactive arthritis, psoriatic arthritis, arthralgias and diffuse infiltrative lymphocytosis syndrome are the most common rheumatic pathologies in HIV. Most people with HIV and musculoskeletal inflammatory disease respond well to NSAIDs, opioids, and basic anti-inflammatory drugs. In cases that are torpid to the abovementioned treatment, the use of biologic disease-modifying antirheumatic drugs may be required.The lecture summarizes modern data on the features of the course and treatment of immunoinflammatory rheumatic diseases in HIV infection.ΠΠΎ ΠΎΡΠ΅Π½ΠΊΠ°ΠΌ ΡΠΊΡΠΏΠ΅ΡΡΠΎΠ², ΡΠΏΠΈΠ΄Π΅ΠΌΠΈΡ Π²ΠΈΡΡΡΠ° ΠΈΠΌΠΌΡΠ½ΠΎΠ΄Π΅ΡΠΈΡΠΈΡΠ° ΡΠ΅Π»ΠΎΠ²Π΅ΠΊΠ° (ΠΠΠ§) ΠΈΠΌΠ΅Π΅Ρ ΡΡΡΠΎΠΉΡΠΈΠ²ΡΡ ΡΠ΅Π½Π΄Π΅Π½ΡΠΈΡ ΠΊ ΡΠΏΠ°Π΄Ρ, ΠΎΠ΄Π½Π°ΠΊΠΎ Π²Π½ΠΈΠΌΠ°Π½ΠΈΠ΅ ΠΌΠ΅Π΄ΠΈΡΠΈΠ½ΡΠΊΠΎΠ³ΠΎ ΡΠΎΠΎΠ±ΡΠ΅ΡΡΠ²Π° ΠΊ Π΄Π°Π½Π½ΠΎΠΉ ΠΏΡΠΎΠ±Π»Π΅ΠΌΠ΅ Π½Π΅ ΠΎΡΠ»Π°Π±Π΅Π²Π°Π΅Ρ. ΠΠΎ Π²Π½Π΅Π΄ΡΠ΅Π½ΠΈΡ Π²ΡΡΠΎΠΊΠΎΠ°ΠΊΡΠΈΠ²Π½ΠΎΠΉ Π°Π½ΡΠΈΡΠ΅ΡΡΠΎΠ²ΠΈΡΡΡΠ½ΠΎΠΉ ΡΠ΅ΡΠ°ΠΏΠΈΠΈ ΡΠ°ΡΠΏΡΠΎΡΡΡΠ°Π½Π΅Π½Π½ΠΎΡΡΡ ΡΠ΅Π²ΠΌΠ°ΡΠΈΡΠ΅ΡΠΊΠΈΡ
ΠΏΡΠΎΡΠ²Π»Π΅Π½ΠΈΠΉ Ρ ΠΠΠ§-ΠΈΠ½ΡΠΈΡΠΈΡΠΎΠ²Π°Π½Π½ΡΡ
Π±ΠΎΠ»ΡΠ½ΡΡ
ΡΠΎΡΡΠ°Π²Π»ΡΠ»Π° ΠΎΡ 3 Π΄ΠΎ 71% ΠΈ Π±ΡΠ»Π° ΡΠ²ΡΠ·Π°Π½Π° Ρ ΠΏΠΎΠ·Π΄Π½ΠΈΠΌΠΈ ΡΡΠ°Π΄ΠΈΡΠΌΠΈ ΠΈΠ½ΡΠ΅ΠΊΡΠΈΠΈ ΠΈ Π²ΡΡΠ°ΠΆΠ΅Π½Π½ΠΎΠΉ ΠΈΠΌΠΌΡΠ½ΠΎΡΡΠΏΡΠ΅ΡΡΠΈΠ΅ΠΉ. ΠΠΠ§-Π°ΡΡΠΎΡΠΈΠΈΡΠΎΠ²Π°Π½Π½ΡΠΉ Π°ΡΡΡΠΈΡ, ΡΠ΅Π°ΠΊΡΠΈΠ²Π½ΡΠΉ Π°ΡΡΡΠΈΡ, ΠΏΡΠΎΡΠΈΠ°ΡΠΈΡΠ΅ΡΠΊΠΈΠΉ Π°ΡΡΡΠΈΡ, Π°ΡΡΡΠ°Π»Π³ΠΈΠΈ ΠΈ ΡΠΈΠ½Π΄ΡΠΎΠΌ Π΄ΠΈΡΡΡΠ·Π½ΠΎΠ³ΠΎ ΠΈΠ½ΡΠΈΠ»ΡΡΡΠ°ΡΠΈΠ²Π½ΠΎΠ³ΠΎ Π»ΠΈΠΌΡΠΎΡΠΈΡΠΎΠ·Π° β Π½Π°ΠΈΠ±ΠΎΠ»Π΅Π΅ ΡΠ°ΡΡΠ°Ρ ΡΠ΅Π²ΠΌΠ°ΡΠΈΡΠ΅ΡΠΊΠ°Ρ ΠΏΠ°ΡΠΎΠ»ΠΎΠ³ΠΈΡ ΠΏΡΠΈ ΠΠΠ§. ΠΠΎΠ»ΡΡΠΈΠ½ΡΡΠ²ΠΎ Π»ΠΈΡ, ΡΡΡΠ°Π΄Π°ΡΡΠΈΡ
ΠΠΠ§ ΠΈ Π²ΠΎΡΠΏΠ°Π»ΠΈΡΠ΅Π»ΡΠ½ΡΠΌ ΠΏΠΎΡΠ°ΠΆΠ΅Π½ΠΈΠ΅ΠΌ ΠΎΠΏΠΎΡΠ½ΠΎ-Π΄Π²ΠΈΠ³Π°ΡΠ΅Π»ΡΠ½ΠΎΠ³ΠΎ Π°ΠΏΠΏΠ°ΡΠ°ΡΠ°, Ρ
ΠΎΡΠΎΡΠΎ ΠΎΡΠ²Π΅ΡΠ°ΡΡ Π½Π° Π½Π΅ΡΡΠ΅ΡΠΎΠΈΠ΄Π½ΡΠ΅ ΠΏΡΠΎΡΠΈΠ²ΠΎΠ²ΠΎΡΠΏΠ°Π»ΠΈΡΠ΅Π»ΡΠ½ΡΠ΅ ΠΏΡΠ΅ΠΏΠ°ΡΠ°ΡΡ, ΠΎΠΏΠΈΠΎΠΈΠ΄Ρ ΠΈ Π±Π°Π·ΠΈΡΠ½ΡΠ΅ ΠΏΡΠΎΡΠΈΠ²ΠΎΠ²ΠΎΡΠΏΠ°Π»ΠΈΡΠ΅Π»ΡΠ½ΡΠ΅ ΠΏΡΠ΅ΠΏΠ°ΡΠ°ΡΡ. Π ΡΠ»ΡΡΠ°ΡΡ
, ΡΠΎΡΠΏΠΈΠ΄Π½ΡΡ
ΠΊ ΡΠΊΠ°Π·Π°Π½Π½ΠΎΠΌΡ Π»Π΅ΡΠ΅Π½ΠΈΡ, ΠΌΠΎΠΆΠ΅Ρ ΠΏΠΎΡΡΠ΅Π±ΠΎΠ²Π°ΡΡΡΡ ΠΏΡΠΈΠΌΠ΅Π½Π΅Π½ΠΈΠ΅ Π³Π΅Π½Π½ΠΎ-ΠΈΠ½ΠΆΠ΅Π½Π΅ΡΠ½ΡΡ
Π±ΠΈΠΎΠ»ΠΎΠ³ΠΈΡΠ΅ΡΠΊΠΈΡ
ΠΏΡΠ΅ΠΏΠ°ΡΠ°ΡΠΎΠ². Π Π»Π΅ΠΊΡΠΈΠΈ ΠΎΠ±ΠΎΠ±ΡΠ΅Π½Ρ ΡΠΎΠ²ΡΠ΅ΠΌΠ΅Π½Π½ΡΠ΅ Π΄Π°Π½Π½ΡΠ΅, ΠΊΠ°ΡΠ°ΡΡΠΈΠ΅ΡΡ ΠΎΡΠΎΠ±Π΅Π½Π½ΠΎΡΡΠ΅ΠΉ ΡΠ΅ΡΠ΅Π½ΠΈΡ ΠΈ Π»Π΅ΡΠ΅Π½ΠΈΡ ΠΈΠΌΠΌΡΠ½ΠΎΠ²ΠΎΡΠΏΠ°Π»ΠΈΡΠ΅Π»ΡΠ½ΡΡ
ΡΠ΅Π²ΠΌΠ°ΡΠΈΡΠ΅ΡΠΊΠΈΡ
Π·Π°Π±ΠΎΠ»Π΅Π²Π°Π½ΠΈΠΉ ΠΏΡΠΈ ΠΠΠ§-ΠΈΠ½ΡΠ΅ΠΊΡΠΈΠΈ.
Π£Π΄Π΅ΡΠΆΠ°Π½ΠΈΠ΅ Π½Π° ΡΠ΅ΡΠ°ΠΏΠΈΠΈ ΡΠΎΡΠ°ΡΠΈΡΠΈΠ½ΠΈΠ±ΠΎΠΌ ΠΏΠ°ΡΠΈΠ΅Π½ΡΠΎΠ² Ρ ΡΠ΅Π²ΠΌΠ°ΡΠΎΠΈΠ΄Π½ΡΠΌ Π°ΡΡΡΠΈΡΠΎΠΌ (Π΄Π°Π½Π½ΡΠ΅ ΡΠ΅Π°Π»ΡΠ½ΠΎΠΉ ΠΊΠ»ΠΈΠ½ΠΈΡΠ΅ΡΠΊΠΎΠΉ ΠΏΡΠ°ΠΊΡΠΈΠΊΠΈ)
Evaluation of the reasons for discontinuation of therapy with Janus kinase inhibitors (JAKi) may provide a clue to their more effective use.Objective : to analyze the survival of tofacitinib (TOFA) therapy and the reasons for its discontinuation in rheumatoid arthritis (RA) in real clinical practice.Patients and methods. The study included 30 adult patients with RA hospitalized to the V.A. Nasonova Research Institute of Rheumatology from 2018 to 2020 for the biologic disease modifying antirheumatic drugs (bDMARDs) or JAKi treatment. Patients were followed up for 3 years or until treatment with TOFA was discontinued, whichever occurred first.Results and discussion. TOFA was prescribed as the first line therapy in 3 patients. In all these patients, the drug was discontinued for the following reasons: insufficient efficacy (IE) after 2 full years of treatment; adverse reaction (AR); administrative reasons (AdR), i.e. the inability to continue therapy due to the lack of drug supply at the place of residence. 11 patients received TOFA as the second line therapy, in 8 of them the treatment was interrupted: in 4 due to IE, in 3 due to AR (skin allergy) and in 1 due to AdR one year after its initiation. TOFA was prescribed as a third line therapy in 9 patients, in 2 of them the drug was discontinued due to IE and in 3 due to AR (allergic dermatitis in 2, dyspepsia in 1). Another 1 patient refused treatment due to a planned pregnancy. 6 patients received TOFA as the fourth line therapy, 5 of them (83.3%) continued to receive it for more than 3 years. In 1 patient, TOFA was discontinued after 1 month due to the dry cough and shortness of breath onset. In another 1 patient who was prescribed TOFA as the fifth line therapy, treatment was discontinued due to AR (recurrent Herpes zoster).Conclusion. As the results of the study show, no relationship was found between the incidence of AR or IE and clinical and demographic indicators, as well as the frequency of TOFA withdrawal and the line of therapy. At the same time, the shortest duration of retention on TOFA therapy was noted when it was prescribed as a first-line drug.ΠΡΠ΅Π½ΠΊΠ° ΠΏΡΠΈΡΠΈΠ½ ΠΎΡΠΌΠ΅Π½Ρ ΡΠ΅ΡΠ°ΠΏΠΈΠΈ ΠΈΠ½Π³ΠΈΠ±ΠΈΡΠΎΡΠ°ΠΌΠΈ Π―Π½ΡΡ-ΠΊΠΈΠ½Π°Π· (uJAK) ΠΌΠΎΠΆΠ΅Ρ Π΄Π°ΡΡ ΠΊΠ»ΡΡ ΠΊ Π±ΠΎΠ»Π΅Π΅ ΡΡΡΠ΅ΠΊΡΠΈΠ²Π½ΠΎΠΌΡ ΠΈΡ
ΠΏΡΠΈΠΌΠ΅Π½Π΅Π½ΠΈΡ.Π¦Π΅Π»Ρ ΠΈΡΡΠ»Π΅Π΄ΠΎΠ²Π°Π½ΠΈΡ β Π°Π½Π°Π»ΠΈΠ· Π²ΡΠΆΠΈΠ²Π°Π΅ΠΌΠΎΡΡΠΈ ΡΠ΅ΡΠ°ΠΏΠΈΠΈ ΡΠΎΡΠ°ΡΠΈΡΠΈΠ½ΠΈΠ±ΠΎΠΌ (Π’ΠΠ€Π) ΠΈ ΠΏΡΠΈΡΠΈΠ½ Π΅Π³ΠΎ ΠΎΡΠΌΠ΅Π½Ρ ΠΏΡΠΈ ΡΠ΅Π²ΠΌΠ°ΡΠΎΠΈΠ΄Π½ΠΎΠΌ Π°ΡΡΡΠΈΡΠ΅ (Π Π) Π² ΡΠ΅Π°Π»ΡΠ½ΠΎΠΉ ΠΊΠ»ΠΈΠ½ΠΈΡΠ΅ΡΠΊΠΎΠΉ ΠΏΡΠ°ΠΊΡΠΈΠΊΠ΅.ΠΠ°ΡΠΈΠ΅Π½ΡΡ ΠΈ ΠΌΠ΅ΡΠΎΠ΄Ρ. Π ΠΈΡΡΠ»Π΅Π΄ΠΎΠ²Π°Π½ΠΈΠ΅ Π²ΠΊΠ»ΡΡΠ΅Π½ΠΎ 30 Π²Π·ΡΠΎΡΠ»ΡΡ
ΠΏΠ°ΡΠΈΠ΅Π½ΡΠΎΠ² Ρ Π Π, Π³ΠΎΡΠΏΠΈΡΠ°Π»ΠΈΠ·ΠΈΡΠΎΠ²Π°Π½Π½ΡΡ
Π² Π€ΠΠΠΠ£ Β«ΠΠ°ΡΡΠ½ΠΎ-ΠΈΡΡΠ»Π΅Π΄ΠΎΠ²Π°ΡΠ΅Π»ΡΡΠΊΠΈΠΉ ΠΈΠ½ΡΡΠΈΡΡΡ ΡΠ΅Π²ΠΌΠ°ΡΠΎΠ»ΠΎΠ³ΠΈΠΈ ΠΈΠΌ. Π.Π. ΠΠ°ΡΠΎΠ½ΠΎΠ²ΠΎΠΉΒ» Ρ 2018 ΠΏΠΎ 2020 Π³. Π΄Π»Ρ Π½Π°Π·Π½Π°ΡΠ΅Π½ΠΈΡ Π³Π΅Π½Π½ΠΎ-ΠΈΠ½ΠΆΠ΅Π½Π΅ΡΠ½ΡΡ
Π±ΠΈΠΎΠ»ΠΎΠ³ΠΈΡΠ΅ΡΠΊΠΈΡ
ΠΏΡΠ΅ΠΏΠ°ΡΠ°ΡΠΎΠ² (ΠΠΠΠ), Π° ΡΠ°ΠΊΠΆΠ΅ ΠΈ./AK. ΠΠ°ΡΠΈΠ΅Π½ΡΡ ΠΎΡΡΠ°Π²Π°Π»ΠΈΡΡ ΠΏΠΎΠ΄ Π½Π°Π±Π»ΡΠ΄Π΅Π½ΠΈΠ΅ΠΌ Π² ΡΠ΅ΡΠ΅Π½ΠΈΠ΅ 3 Π»Π΅Ρ ΠΈΠ»ΠΈ Π΄ΠΎ ΠΌΠΎΠΌΠ΅Π½ΡΠ° ΠΏΡΠ΅ΠΊΡΠ°ΡΠ΅Π½ΠΈΡ Π»Π΅ΡΠ΅Π½ΠΈΡ Π’ΠΠ€Π, Π² Π·Π°Π²ΠΈΡΠΈΠΌΠΎΡΡΠΈ ΠΎΡ ΡΠΎΠ³ΠΎ, ΠΊΠ°ΠΊΠΎΠ΅ ΡΠΎΠ±ΡΡΠΈΠ΅ Π½Π°ΡΡΡΠΏΠ°Π»ΠΎ ΡΠ°Π½ΡΡΠ΅.Π Π΅Π·ΡΠ»ΡΡΠ°ΡΡ ΠΈ ΠΎΠ±ΡΡΠΆΠ΄Π΅Π½ΠΈΠ΅. Π ΠΊΠ°ΡΠ΅ΡΡΠ²Π΅ ΠΏΠ΅ΡΠ²ΠΎΠΉ Π»ΠΈΠ½ΠΈΠΈ ΡΠ΅ΡΠ°ΠΏΠΈΠΈ Π’ΠΠ€Π Π±ΡΠ» Π½Π°Π·Π½Π°ΡΠ΅Π½ 3 ΠΏΠ°ΡΠΈΠ΅Π½ΡΠ°ΠΌ. Π£ Π²ΡΠ΅Ρ
ΡΡΠΈΡ
ΠΏΠ°ΡΠΈΠ΅Π½ΡΠΎΠ² ΠΏΡΠ΅ΠΏΠ°ΡΠ°Ρ Π±ΡΠ» ΠΎΡΠΌΠ΅Π½Π΅Π½ ΠΏΠΎ ΡΠ»Π΅Π΄ΡΡΡΠΈΠΌ ΠΏΡΠΈΡΠΈΠ½Π°ΠΌ: Π½Π΅Π΄ΠΎΡΡΠ°ΡΠΎΡΠ½Π°Ρ ΡΡΡΠ΅ΠΊΡΠΈΠ²Π½ΠΎΡΡΡ (ΠΠ) ΠΏΠΎΡΠ»Π΅ 2 ΠΏΠΎΠ»Π½ΡΡ
Π»Π΅Ρ Π»Π΅ΡΠ΅Π½ΠΈΡ; Π½Π΅ΠΆΠ΅Π»Π°ΡΠ΅Π»ΡΠ½Π°Ρ ΡΠ΅Π°ΠΊΡΠΈΡ (ΠΠ ); Π°Π΄ΠΌΠΈΠ½ΠΈΡΡΡΠ°ΡΠΈΠ²Π½ΡΠ΅ ΠΏΡΠΈΡΠΈΠ½Ρ (ΠΠ), Ρ. Π΅. Π½Π΅Π²ΠΎΠ·ΠΌΠΎΠΆΠ½ΠΎΡΡΡ ΠΏΡΠΎΠ΄ΠΎΠ»ΠΆΠ°ΡΡ ΡΠ΅ΡΠ°ΠΏΠΈΡ Π² ΡΠ²ΡΠ·ΠΈ Ρ ΠΎΡΡΡΡΡΡΠ²ΠΈΠ΅ΠΌ ΠΎΠ±Π΅ΡΠΏΠ΅ΡΠ΅Π½ΠΈΡ ΠΏΡΠ΅ΠΏΠ°ΡΠ°ΡΠΎΠΌ ΠΏΠΎ ΠΌΠ΅ΡΡΡ ΠΆΠΈΡΠ΅Π»ΡΡΡΠ²Π°. Π ΠΊΠ°ΡΠ΅ΡΡΠ²Π΅ Π²ΡΠΎΡΠΎΠΉ Π»ΠΈΠ½ΠΈΠΈ ΡΠ΅ΡΠ°ΠΏΠΈΠΈ Π’ΠΠ€Π ΠΏΠΎΠ»ΡΡΠ°Π»ΠΈ 11 Π±ΠΎΠ»ΡΠ½ΡΡ
, Ρ 8 ΠΈΠ· Π½ΠΈΡ
Π»Π΅ΡΠ΅Π½ΠΈΠ΅ Π±ΡΠ»ΠΎ ΠΏΡΠ΅ΡΠ²Π°Π½ΠΎ: Ρ 4 β ΠΈΠ·-Π·Π° ΠΠ, Ρ 3 β ΠΈΠ·-Π·Π° ΠΠ (ΠΊΠΎΠΆΠ½Π°Ρ Π°Π»Π»Π΅ΡΠ³ΠΈΡ) ΠΈ Ρ 1 β ΠΏΠΎ ΠΠ ΡΠ΅ΡΠ΅Π· Π³ΠΎΠ΄ ΠΏΠΎΡΠ»Π΅ Π΅Π³ΠΎ Π½Π°ΡΠ°Π»Π°. Π ΠΊΠ°ΡΠ΅ΡΡΠ²Π΅ ΡΡΠ΅ΡΡΠ΅ΠΉ Π»ΠΈΠ½ΠΈΠΈ ΡΠ΅ΡΠ°ΠΏΠΈΠΈ Π’ΠΠ€Π Π±ΡΠ» Π½Π°Π·Π½Π°ΡΠ΅Π½ 9 Π±ΠΎΠ»ΡΠ½ΡΠΌ, Ρ 2 ΠΈΠ· Π½ΠΈΡ
ΠΏΡΠ΅ΠΏΠ°ΡΠ°Ρ Π±ΡΠ» ΠΎΡΠΌΠ΅Π½Π΅Π½ Π² ΡΠ²ΡΠ·ΠΈ Ρ ΠΠ ΠΈ Ρ 3 β Π² ΡΠ²ΡΠ·ΠΈ Ρ ΠΠ (Π°Π»Π»Π΅ΡΠ³ΠΈΡΠ΅ΡΠΊΠΈΠΉ Π΄Π΅ΡΠΌΠ°ΡΠΈΡ β Ρ 2, Π΄ΠΈΡΠΏΠ΅ΠΏΡΠΈΡ β Ρ 1). ΠΡΠ΅ 1 ΠΏΠ°ΡΠΈΠ΅Π½ΡΠΊΠ° ΠΎΡΠΊΠ°Π·Π°Π»Π°ΡΡ ΠΎΡ Π»Π΅ΡΠ΅Π½ΠΈΡ ΠΈΠ·-Π·Π° Π·Π°ΠΏΠ»Π°Π½ΠΈΡΠΎΠ²Π°Π½Π½ΠΎΠΉ Π±Π΅ΡΠ΅ΠΌΠ΅Π½Π½ΠΎΡΡΠΈ. Π ΠΊΠ°ΡΠ΅ΡΡΠ²Π΅ ΡΠ΅ΡΠ²Π΅ΡΡΠΎΠΉ Π»ΠΈΠ½ΠΈΠΈ ΡΠ΅ΡΠ°ΠΏΠΈΠΈ Π’ΠΠ€Π ΠΏΠΎΠ»ΡΡΠ°Π»ΠΈ 6 Π±ΠΎΠ»ΡΠ½ΡΡ
, 5 ΠΈΠ· Π½ΠΈΡ
(83,3%) ΠΏΡΠΎΠ΄ΠΎΠ»ΠΆΠ°Π»ΠΈ Π΅Π³ΠΎ ΠΏΡΠΈΠ΅ΠΌ Π±ΠΎΠ»Π΅Π΅ 3 Π»Π΅Ρ. Π£ 1 ΠΏΠ°ΡΠΈΠ΅Π½ΡΠΊΠΈ Π’ΠΠ€Π Π±ΡΠ» ΠΎΡΠΌΠ΅Π½Π΅Π½ ΡΠ΅ΡΠ΅Π· 1 ΠΌΠ΅Ρ Π² ΡΠ²ΡΠ·ΠΈ Ρ Π²ΠΏΠ΅ΡΠ²ΡΠ΅ ΠΏΠΎΡΠ²ΠΈΠ²ΡΠΈΠΌΠΈΡΡ ΡΡΡ
ΠΈΠΌ ΠΊΠ°ΡΠ»Π΅ΠΌ ΠΈ ΠΎΠ΄ΡΡΠΊΠΎΠΉ. ΠΡΠ΅ Ρ 1 Π±ΠΎΠ»ΡΠ½ΠΎΠ³ΠΎ, ΠΊΠΎΡΠΎΡΠΎΠΌΡ Π’ΠΠ€Π Π±ΡΠ» Π½Π°Π·Π½Π°ΡΠ΅Π½ Π² ΠΏΡΡΠΎΠΉ Π»ΠΈΠ½ΠΈΠΈ ΡΠ΅ΡΠ°ΠΏΠΈΠΈ, Π»Π΅ΡΠ΅Π½ΠΈΠ΅ Π±ΡΠ»ΠΎ ΠΏΡΠ΅ΠΊΡΠ°ΡΠ΅Π½ΠΎ ΠΈΠ·-Π·Π° ΠΠ (ΡΠ΅ΡΠΈΠ΄ΠΈΠ²ΠΈΡΡΡΡΠΈΠΉ Herpes zoster).ΠΠ°ΠΊΠ»ΡΡΠ΅Π½ΠΈΠ΅. ΠΠ°ΠΊ ΠΏΠΎΠΊΠ°Π·Π°Π»ΠΈ ΡΠ΅Π·ΡΠ»ΡΡΠ°ΡΡ ΠΈΡΡΠ»Π΅Π΄ΠΎΠ²Π°Π½ΠΈΡ, ΡΠ²ΡΠ·ΠΈ ΠΌΠ΅ΠΆΠ΄Ρ ΡΠ°ΡΡΠΎΡΠΎΠΉ Π²ΠΎΠ·Π½ΠΈΠΊΠ½ΠΎΠ²Π΅Π½ΠΈΡ ΠΠ ΠΈΠ»ΠΈ ΠΠ ΠΈ ΠΊΠ»ΠΈΠ½ΠΈΠΊΠΎ-Π΄Π΅ΠΌΠΎΠ³ΡΠ°ΡΠΈΡΠ΅ΡΠΊΠΈΠΌΠΈ ΠΏΠΎΠΊΠ°Π·Π°ΡΠ΅Π»ΡΠΌΠΈ, Π° ΡΠ°ΠΊΠΆΠ΅ ΡΠ°ΡΡΠΎΡΠΎΠΉ ΠΎΡΠΌΠ΅Π½Ρ Π’ΠΠ€Π ΠΈ Π»ΠΈΠ½ΠΈΠ΅ΠΉ ΡΠ΅ΡΠ°ΠΏΠΈΠΈ Π½Π΅ Π²ΡΡΠ²Π»Π΅Π½ΠΎ. Π ΡΠΎ ΠΆΠ΅ Π²ΡΠ΅ΠΌΡ Π½Π°ΠΈΠΌΠ΅Π½ΡΡΠ°Ρ Π΄Π»ΠΈΡΠ΅Π»ΡΠ½ΠΎΡΡΡ ΡΠ΄Π΅ΡΠΆΠ°Π½ΠΈΡ Π½Π° ΡΠ΅ΡΠ°ΠΏΠΈΠΈ Π’ΠΠ€Π ΠΎΡΠΌΠ΅ΡΠ΅Π½Π° Π² ΡΠ»ΡΡΠ°Π΅ Π΅Π³ΠΎ Π½Π°Π·Π½Π°ΡΠ΅Π½ΠΈΡ Π² ΠΊΠ°ΡΠ΅ΡΡΠ²Π΅ ΠΏΡΠ΅ΠΏΠ°ΡΠ°ΡΠ° ΠΏΠ΅ΡΠ²ΠΎΠΉ Π»ΠΈΠ½ΠΈΠΈ
Π₯ΡΠΎΠ½ΠΈΡΠ΅ΡΠΊΠΈΠΉ Π³Π΅ΠΏΠ°ΡΠΈΡ Π Ρ ΠΏΠ°ΡΠΈΠ΅Π½ΡΠΎΠ² ΡΠ΅Π²ΠΌΠ°ΡΠΎΠ»ΠΎΠ³ΠΈΡΠ΅ΡΠΊΠΎΠ³ΠΎ ΡΡΠ°ΡΠΈΠΎΠ½Π°ΡΠ°: ΠΏΡΠΎΠ±Π»Π΅ΠΌΡ ΡΠΊΡΠΈΠ½ΠΈΠ½Π³Π° ΠΈ ΡΠ΅Π°ΠΊΡΠΈΠ²Π°ΡΠΈΠΈ ΠΈΠ½ΡΠ΅ΠΊΡΠΈΠΈ
Β Β Objective:Β to evaluate the completeness of screening for hepatitis B virus (HBV) infection in HBsAg-positive patients admitted to a rheumatology hospital and to follow the history of HBV reactivation/seroversion during antirheumatic therapy.Β Β Material and methods.Β The results of initial and repeated (if applicable) hospitalizations were analyzed in 80 patients with rheumatic diseases (RD), including 55 (69%) women and 25 (31 %) men, with Australian surface antigen (HBsAg), admitted to the V.A. Nasonova Institute of Rheumatology from January 1, 2020 to July 20, 2022 (30 months).Β Β Results and discussion.Β The total number of hospitalizations to the clinic during the observation period, including repeat admissions, was 13,681. The number of hospitalizations in 80 patients with HBV infection during the observation period, including repeat admissions, was 144, of which for systemic vasculitis β 6 (8 %), other systemic connective tissue diseases β 16 (20 %), osteoarthritis and post-traumatic changes of joints β 14 (15 %), inflammatory joint diseases β 42 (54 %). Cases of HBV reactivation/seroverion, both in anamnesis and during observation, were detected in 9 (11 %) patients, and most frequently (n = 5) they were registered during methotrexate therapy.Β Β Conclusion.Β HBV infection in patients with RD leads to significant difficulties in the selection of drug therapy, due to the risk of reactivation of the infection. The results obtained indicate incomplete screening of patients with RD for HBV infection during the preclinical phase. Further investigation is needed to develop clear recommendations for the management of patients with RD infected with HBV.Β Β Π¦Π΅Π»Ρ ΠΈΡΡΠ»Π΅Π΄ΠΎΠ²Π°Π½ΠΈΡ β ΠΎΡΠ΅Π½ΠΈΡΡ ΠΏΠΎΠ»Π½ΠΎΡΡ Π²ΡΠΏΠΎΠ»Π½Π΅Π½ΠΈΡ ΡΠΊΡΠΈΠ½ΠΈΠ½Π³Π° Π½Π° Π½Π°Π»ΠΈΡΠΈΠ΅ ΠΈΠ½ΡΠ΅ΠΊΡΠΈΠΈ, Π²ΡΠ·Π²Π°Π½Π½ΠΎΠΉ Π²ΠΈΡΡΡΠΎΠΌ Π³Π΅ΠΏΠ°ΡΠΈΡΠ° Π (HBV), Ρ Π±ΠΎΠ»ΡΠ½ΡΡ
, ΠΏΠΎΠ·ΠΈΡΠΈΠ²Π½ΡΡ
ΠΏΠΎ HBsAg, ΠΏΠΎΡΡΡΠΏΠ°ΡΡΠΈΡ
Π² ΡΡΠ°ΡΠΈΠΎΠ½Π°Ρ ΡΠ΅Π²ΠΌΠ°ΡΠΎΠ»ΠΎΠ³ΠΈΡΠ΅ΡΠΊΠΎΠ³ΠΎ ΠΏΡΠΎΡΠΈΠ»Ρ, ΠΈ ΠΏΡΠΎΡΠ»Π΅Π΄ΠΈΡΡ ΠΈΡΡΠΎΡΠΈΡ ΡΠ΅Π°ΠΊΡΠΈΠ²Π°ΡΠΈΠΈ/ΡΠ΅ΡΠΎΡΠ΅Π²Π΅ΡΡΠΈΠΈ HBV Π½Π° ΡΠΎΠ½Π΅ Π°Π½ΡΠΈΡΠ΅Π²ΠΌΠ°ΡΠΈΡΠ΅ΡΠΊΠΎΠΉ ΡΠ΅ΡΠ°ΠΏΠΈΠΈ.Β Β ΠΠ°ΡΠ΅ΡΠΈΠ°Π» ΠΈ ΠΌΠ΅ΡΠΎΠ΄Ρ. ΠΡΠΎΠ°Π½Π°Π»ΠΈΠ·ΠΈΡΠΎΠ²Π°Π½Ρ ΡΠ΅Π·ΡΠ»ΡΡΠ°ΡΡ ΠΏΠ΅ΡΠ²ΠΈΡΠ½ΠΎΠΉ ΠΈ ΠΏΠΎΠ²ΡΠΎΡΠ½ΠΎΠΉ (ΠΏΡΠΈ Π½Π°Π»ΠΈΡΠΈΠΈ) Π³ΠΎΡΠΏΠΈΡΠ°Π»ΠΈΠ·Π°ΡΠΈΠΈ Ρ 80 Π±ΠΎΠ»ΡΠ½ΡΡ
Ρ ΡΠ΅Π²ΠΌΠ°ΡΠΈΡΠ΅ΡΠΊΠΈΠΌΠΈ Π·Π°Π±ΠΎΠ»Π΅Π²Π°Π½ΠΈΡΠΌΠΈ (Π Π), ΡΡΠ΅Π΄ΠΈ ΠΊΠΎΡΠΎΡΡΡ
Π±ΡΠ»ΠΎ 55 (69 %) ΠΆΠ΅Π½ΡΠΈΠ½ ΠΈ 25 (31 %) ΠΌΡΠΆΡΠΈΠ½, ΠΈΠΌΠ΅ΡΡΠΈΡ
ΠΏΠΎΠ²Π΅ΡΡ
Π½ΠΎΡΡΠ½ΡΠΉ Β«Π°Π²ΡΡΡΠ°Π»ΠΈΠΉΡΠΊΠΈΠΉΒ» Π°Π½ΡΠΈΠ³Π΅Π½ (HBsAg), Π³ΠΎΡΠΏΠΈΡΠ°Π»ΠΈΠ·ΠΈΡΠΎΠ²Π°Π½Π½ΡΡ
Π² Π€ΠΠΠΠ£ Β«ΠΠ°ΡΡΠ½ΠΎ-ΠΈΡΡΠ»Π΅Π΄ΠΎΠ²Π°ΡΠ΅Π»ΡΡΠΊΠΈΠΉ ΠΈΠ½ΡΡΠΈΡΡΡ ΡΠ΅Π²ΠΌΠ°ΡΠΎΠ»ΠΎΠ³ΠΈΠΈ ΠΈΠΌ. Π. Π. ΠΠ°ΡΠΎΠ½ΠΎΠ²ΠΎΠΉΒ» Ρ 1. 01. 2020 ΠΏΠΎ 20. 07. 2022 Π³. (30 ΠΌΠ΅Ρ).Β Β Π Π΅Π·ΡΠ»ΡΡΠ°ΡΡ ΠΈ ΠΎΠ±ΡΡΠΆΠ΄Π΅Π½ΠΈΠ΅. ΠΠ±ΡΠ΅Π΅ ΡΠΈΡΠ»ΠΎ Π³ΠΎΡΠΏΠΈΡΠ°Π»ΠΈΠ·Π°ΡΠΈΠΉ Π² ΠΊΠ»ΠΈΠ½ΠΈΠΊΡ Π·Π° Π²ΡΠ΅ΠΌΡ Π½Π°Π±Π»ΡΠ΄Π΅Π½ΠΈΡ, Π²ΠΊΠ»ΡΡΠ°Ρ ΠΏΠΎΠ²ΡΠΎΡΠ½ΡΠ΅, ΡΠΎΡΡΠ°Π²ΠΈΠ»ΠΎ 13 681. Π§ΠΈΡΠ»ΠΎ Π³ΠΎΡΠΏΠΈΡΠ°Π»ΠΈΠ·Π°ΡΠΈΠΉ Ρ 80 Π±ΠΎΠ»ΡΠ½ΡΡ
Ρ HBV-ΠΈΠ½ΡΠ΅ΠΊΡΠΈΠ΅ΠΉ Π·Π° ΠΏΠ΅ΡΠΈΠΎΠ΄ Π½Π°Π±Π»ΡΠ΄Π΅Π½ΠΈΡ, Π²ΠΊΠ»ΡΡΠ°Ρ ΠΏΠΎΠ²ΡΠΎΡΠ½ΡΠ΅, ΡΠΎΡΡΠ°Π²ΠΈΠ»ΠΎ 144, ΠΈΠ· Π½ΠΈΡ
ΠΏΠΎ ΠΏΠΎΠ²ΠΎΠ΄Ρ ΡΠΈΡΡΠ΅ΠΌΠ½ΡΡ
Π²Π°ΡΠΊΡΠ»ΠΈΡΠΎΠ² β 6 (8 %), Π΄ΡΡΠ³ΠΈΡ
ΡΠΈΡΡΠ΅ΠΌΠ½ΡΡ
Π·Π°Π±ΠΎΠ»Π΅Π²Π°Π½ΠΈΠΉ ΡΠΎΠ΅Π΄ΠΈΠ½ΠΈΡΠ΅Π»ΡΠ½ΠΎΠΉ ΡΠΊΠ°Π½ΠΈ β 16 (20 %), ΠΎΡΡΠ΅ΠΎΠ°ΡΡΡΠΈΡΠ° ΠΈ ΠΏΠΎΡΡΡΡΠ°Π²ΠΌΠ°ΡΠΈΡΠ΅ΡΠΊΠΈΡ
ΠΈΠ·ΠΌΠ΅Π½Π΅Π½ΠΈΠΉ ΡΡΡΡΠ°Π²ΠΎΠ² β 14 (15 %), Π²ΠΎΡΠΏΠ°Π»ΠΈΡΠ΅Π»ΡΠ½ΡΡ
Π·Π°Π±ΠΎΠ»Π΅Π²Π°Π½ΠΈΠΉ ΡΡΡΡΠ°Π²ΠΎΠ² β 42 (54 %). Π‘Π»ΡΡΠ°ΠΈ ΡΠ΅Π°ΠΊΡΠΈΠ²Π°ΡΠΈΠΈ/ΡΠ΅ΡΠΎΡΠ΅Π²Π΅ΡΡΠΈΠΈ HBV ΠΊΠ°ΠΊ Π² Π°Π½Π°ΠΌΠ½Π΅Π·Π΅, ΡΠ°ΠΊ ΠΈ Π² ΠΏΡΠΎΡΠ΅ΡΡΠ΅ Π½Π°Π±Π»ΡΠ΄Π΅Π½ΠΈΡ Π²ΡΡΠ²Π»Π΅Π½Ρ Ρ 9 (11 %) Π±ΠΎΠ»ΡΠ½ΡΡ
, ΠΏΡΠΈΡΠ΅ΠΌ Π½Π°ΠΈΠ±ΠΎΠ»Π΅Π΅ ΡΠ°ΡΡΠΎ (n = 5) ΠΎΠ½ΠΈ ΡΠ΅Π³ΠΈΡΡΡΠΈΡΠΎΠ²Π°Π»ΠΈΡΡ Π½Π° ΡΠΎΠ½Π΅ ΡΠ΅ΡΠ°ΠΏΠΈΠΈ ΠΌΠ΅ΡΠΎΡΡΠ΅ΠΊΡΠ°ΡΠΎΠΌ.Β Β ΠΠ°ΠΊΠ»ΡΡΠ΅Π½ΠΈΠ΅. ΠΠ½ΡΠΈΡΠΈΡΠΎΠ²Π°Π½Π½ΠΎΡΡΡ HBV Π±ΠΎΠ»ΡΠ½ΡΡ
Ρ Π Π ΡΠΎΠ·Π΄Π°Π΅Ρ Π·Π½Π°ΡΠΈΡΠ΅Π»ΡΠ½ΡΠ΅ ΡΡΡΠ΄Π½ΠΎΡΡΠΈ ΠΏΡΠΈ ΠΏΠΎΠ΄Π±ΠΎΡΠ΅ Π»Π΅ΠΊΠ°ΡΡΡΠ²Π΅Π½Π½ΠΎΠΉ ΡΠ΅ΡΠ°ΠΏΠΈΠΈ, ΠΏΠΎΡΠΊΠΎΠ»ΡΠΊΡ ΡΡΡΠ΅ΡΡΠ²ΡΠ΅Ρ ΠΎΠΏΠ°ΡΠ½ΠΎΡΡΡ ΡΠ΅Π°ΠΊΡΠΈΠ²Π°ΡΠΈΠΈ ΠΈΠ½ΡΠ΅ΠΊΡΠΈΠΈ. ΠΠΎΠ»ΡΡΠ΅Π½Π½ΡΠ΅ ΡΠ΅Π·ΡΠ»ΡΡΠ°ΡΡ ΡΠ²ΠΈΠ΄Π΅ΡΠ΅Π»ΡΡΡΠ²ΡΡΡ ΠΎ Π½Π΅ΠΏΠΎΠ»Π½ΠΎΠΌ ΠΎΠ±ΡΠ»Π΅Π΄ΠΎΠ²Π°Π½ΠΈΠΈ ΠΏΠ°ΡΠΈΠ΅Π½ΡΠΎΠ² Ρ Π Π Π½Π° HBV-ΠΈΠ½ΡΠ΅ΠΊΡΠΈΡ Π½Π° Π΄ΠΎΠ³ΠΎΡΠΏΠΈΡΠ°Π»ΡΠ½ΠΎΠΌ ΡΡΠ°ΠΏΠ΅. ΠΠ΅ΠΎΠ±Ρ
ΠΎΠ΄ΠΈΠΌΡ Π΄Π°Π»ΡΠ½Π΅ΠΉΡΠΈΠ΅ ΠΈΡΡΠ»Π΅Π΄ΠΎΠ²Π°Π½ΠΈΡ Π΄Π»Ρ Π²ΡΡΠ°Π±ΠΎΡΠΊΠΈ ΡΠ΅ΡΠΊΠΈΡ
ΡΠ΅ΠΊΠΎΠΌΠ΅Π½Π΄Π°ΡΠΈΠΉ ΠΏΠΎ Π²Π΅Π΄Π΅Π½ΠΈΡ Π±ΠΎΠ»ΡΠ½ΡΡ
Ρ Π Π, ΠΈΠ½ΡΠΈΡΠΈΡΠΎΠ²Π°Π½Π½ΡΡ
HBV
ΠΠΈΡΡΡΠ½Π°Ρ ΠΌΠΈΠΊΡΡ-ΠΈΠ½ΡΠ΅ΠΊΡΠΈΡ, ΠΎΡΠ»ΠΎΠΆΠ½Π΅Π½Π½Π°Ρ ΠΎΡΡΡΡΠΌ Π³Π΅ΠΏΠ°ΡΠΈΡΠΎΠΌ ΠΈ ΡΠΎΠΊΡΠΈΠΊΠΎ-Π°Π»Π»Π΅ΡΠ³ΠΈΡΠ΅ΡΠΊΠΈΠΌ Π΄Π΅ΡΠΌΠ°ΡΠΈΡΠΎΠΌ (ΠΊΠ»ΠΈΠ½ΠΈΡΠ΅ΡΠΊΠΈΠΉ ΡΠ»ΡΡΠ°ΠΉ)
Epstein-Barr virus (EBV) belongs to the family of herpesviruses (herpes type 4) and is one of the most common and highly contagious. During the pandemic of a new coronavirus disease, it was found that in patients previously infected with EBV, COVID-19 can cause its reactivation, which is often manifested by the clinic of acute hepatitis. The article presents a clinical case of the development of acute hepatitis in a patient with mixed infection with EBV and SARS-CoV-2 in combination with allergic toxic reaction while taking sulfasalazine prescribed for spondyloarthritis. A feature of this case was the development of severe hepatitis of mixed genesis with a favorable outcome. The importance of adherence to drug monitoring rules for newly prescribed drugs for COVID-19 was emphasized. In severe cases of the disease, the possibility of mixed infection should be taken into account.ΠΠΈΡΡΡ ΠΠΏΡΡΠ΅ΠΉΠ½Π°βΠΠ°ΡΡ (ΠΠΠ) ΠΎΡΠ½ΠΎΡΠΈΡΡΡ ΠΊ ΡΠ΅ΠΌΠ΅ΠΉΡΡΠ²Ρ Π³Π΅ΡΠΏΠ΅ΡΠ²ΠΈΡΡΡΠΎΠ² (Π³Π΅ΡΠΏΠ΅Ρ 4-Π³ΠΎ ΡΠΈΠΏΠ°) ΠΈ ΡΠ²Π»ΡΠ΅ΡΡΡ ΠΎΠ΄Π½ΠΈΠΌ ΠΈΠ· ΡΠ°ΠΌΡΡ
ΡΠ°ΡΠΏΡΠΎΡΡΡΠ°Π½Π΅Π½Π½ΡΡ
ΠΈ Π²ΡΡΠΎΠΊΠΎΠ½ΡΠ°Π³ΠΈΠΎΠ·Π½ΡΡ
. Π ΠΏΠ΅ΡΠΈΠΎΠ΄ ΠΏΠ°Π½Π΄Π΅ΠΌΠΈΠΈ Π½ΠΎΠ²ΠΎΠΉ ΠΊΠΎΡΠΎΠ½Π°Π²ΠΈΡΡΡΠ½ΠΎΠΉ Π±ΠΎΠ»Π΅Π·Π½ΠΈ Π±ΡΠ»ΠΎ ΠΎΠ±Π½Π°ΡΡΠΆΠ΅Π½ΠΎ, ΡΡΠΎ Ρ ΠΏΠ°ΡΠΈΠ΅Π½ΡΠΎΠ², ΡΠ°Π½Π΅Π΅ ΠΈΠ½ΡΠΈΡΠΈΡΠΎΠ²Π°Π½Π½ΡΡ
ΠΠΠ, COVID-19 ΠΌΠΎΠΆΠ΅Ρ Π²ΡΠ·Π²Π°ΡΡ Π΅Π³ΠΎ ΡΠ΅Π°ΠΊΡΠΈΠ²Π°ΡΠΈΡ, ΡΡΠΎ Π½Π΅ΡΠ΅Π΄ΠΊΠΎ ΠΏΡΠΎΡΠ²Π»ΡΠ΅ΡΡΡ ΠΊΠ»ΠΈΠ½ΠΈΠΊΠΎΠΉ ΠΎΡΡΡΠΎΠ³ΠΎ Π³Π΅ΠΏΠ°ΡΠΈΡΠ°. Π ΡΡΠ°ΡΡΠ΅ ΠΏΡΠ΅Π΄ΡΡΠ°Π²Π»Π΅Π½ΠΎ ΠΎΠΏΠΈΡΠ°Π½ΠΈΠ΅ ΡΠ°Π·Π²ΠΈΡΠΈΡ ΠΎΡΡΡΠΎΠ³ΠΎ Π³Π΅ΠΏΠ°ΡΠΈΡΠ° Ρ ΠΏΠ°ΡΠΈΠ΅Π½ΡΠ° Ρ ΠΌΠΈΠΊΡΡ-ΠΈΠ½ΡΠ΅ΠΊΡΠΈΠ΅ΠΉ ΠΠΠ ΠΈ SARS-CoV-2 Π² ΡΠΎΡΠ΅ΡΠ°Π½ΠΈΠΈ Ρ ΡΠΎΠΊΡΠΈΠΊΠΎ-Π°Π»Π»Π΅ΡΠ³ΠΈΡΠ΅ΡΠΊΠΎΠΉ ΡΠ΅Π°ΠΊΡΠΈΠ΅ΠΉ Π½Π° ΡΠΎΠ½Π΅ ΠΏΡΠΈΠ΅ΠΌΠ° ΡΡΠ»ΡΡΠ°ΡΠ°Π»Π°Π·ΠΈΠ½Π°, Π½Π°Π·Π½Π°ΡΠ΅Π½Π½ΠΎΠ³ΠΎ ΠΏΠΎ ΠΏΠΎΠ²ΠΎΠ΄Ρ ΡΠΏΠΎΠ½Π΄ΠΈΠ»ΠΎΠ°ΡΡΡΠΈΡΠ°. ΠΡΠΎΠ±Π΅Π½Π½ΠΎΡΡΡΡ Π΄Π°Π½Π½ΠΎΠ³ΠΎ ΡΠ»ΡΡΠ°Ρ ΡΠ²Π»ΡΠ»ΠΎΡΡ ΡΠ°Π·Π²ΠΈΡΠΈΠ΅ ΡΡΠΆΠ΅Π»ΠΎΠ³ΠΎ Π³Π΅ΠΏΠ°ΡΠΈΡΠ° ΡΠΌΠ΅ΡΠ°Π½Π½ΠΎΠ³ΠΎ Π³Π΅Π½Π΅Π·Π° Ρ Π±Π»Π°Π³ΠΎΠΏΡΠΈΡΡΠ½ΡΠΌ ΠΈΡΡ
ΠΎΠ΄ΠΎΠΌ. ΠΠΎΠ΄ΡΠ΅ΡΠΊΠ½ΡΡΠ° Π²Π°ΠΆΠ½ΠΎΡΡΡ ΡΠΎΠ±Π»ΡΠ΄Π΅Π½ΠΈΡ ΠΏΡΠ°Π²ΠΈΠ» Π»Π΅ΠΊΠ°ΡΡΡΠ²Π΅Π½Π½ΠΎΠ³ΠΎ ΠΌΠΎΠ½ΠΈΡΠΎΡΠΈΠ½Π³Π° Π΄Π»Ρ Π²ΠΏΠ΅ΡΠ²ΡΠ΅ Π½Π°Π·Π½Π°ΡΠ°Π΅ΠΌΡΡ
ΠΏΡΠ΅ΠΏΠ°ΡΠ°ΡΠΎΠ² ΠΏΡΠΈ COVID-19. ΠΡΠΈ ΡΡΠΆΠ΅Π»ΠΎΠΌ ΡΠ΅ΡΠ΅Π½ΠΈΠΈ Π·Π°Π±ΠΎΠ»Π΅Π²Π°Π½ΠΈΡ Π½Π΅ΠΎΠ±Ρ
ΠΎΠ΄ΠΈΠΌΠΎ ΠΏΡΠΈΠ½ΠΈΠΌΠ°ΡΡ Π²ΠΎ Π²Π½ΠΈΠΌΠ°Π½ΠΈΠ΅ Π²ΠΎΠ·ΠΌΠΎΠΆΠ½ΠΎΡΡΡ ΠΌΠΈΠΊΡΡ-ΠΈΠ½ΡΠ΅ΠΊΡΠΈΠΈ
Π Π²ΠΎΠΏΡΠΎΡΡ ΠΎ Π±Π΅Π·ΠΎΠΏΠ°ΡΠ½ΠΎΡΡΠΈ ΠΏΡΠΈΠΌΠ΅Π½Π΅Π½ΠΈΡ Π³Π»ΡΠΊΠΎΠΊΠΎΡΡΠΈΠΊΠΎΠΈΠ΄ΠΎΠ² Π² ΡΠ΅ΡΠ°ΠΏΠΈΠΈ ΡΠ΅Π²ΠΌΠ°ΡΠΎΠΈΠ΄Π½ΠΎΠ³ΠΎ Π°ΡΡΡΠΈΡΠ°
Glucocorticoids (GCs) are one of the most commonly used drugs for the treatment of rheumatoid arthritis (RA), the effectiveness of which is beyond doubt. The review considers current literature data on the safety of GCs use, as well as the most common adverse events associated with such therapy. Most authors point to an increased risk of complications with an increase in the daily dose and/or duration of GCs treatment. At the same time, a safe dose of GCs has not been determined. Probably, the optimal tactic is the selection of an individual dose of GCs in each individual case, taking into account the activity of RA and the spectrum of comorbid conditions. In this case, the minimum effective doses and short courses of GCs should be used, regular monitoring of clinical and laboratory parameters should be carried out in order to detect adverse events early.ΠΠ»ΡΠΊΠΎΠΊΠΎΡΡΠΈΠΊΠΎΠΈΠ΄Ρ (ΠΠ) β ΠΎΠ΄Π½ΠΎ ΠΈΠ· Π½Π°ΠΈΠ±ΠΎΠ»Π΅Π΅ ΡΠ°ΡΡΠΎ ΠΏΡΠΈΠΌΠ΅Π½ΡΠ΅ΠΌΡΡ
ΡΡΠ΅Π΄ΡΡΠ² Π΄Π»Ρ Π»Π΅ΡΠ΅Π½ΠΈΡ ΡΠ΅Π²ΠΌΠ°ΡΠΎΠΈΠ΄Π½ΠΎΠ³ΠΎ Π°ΡΡΡΠΈΡΠ° (Π Π), ΡΡΡΠ΅ΠΊΡΠΈΠ²Π½ΠΎΡΡΡ ΠΊΠΎΡΠΎΡΠΎΠ³ΠΎ Π½Π΅ ΠΏΠΎΠ΄Π»Π΅ΠΆΠΈΡ ΡΠΎΠΌΠ½Π΅Π½ΠΈΡ. Π ΠΎΠ±Π·ΠΎΡΠ΅ ΡΠ°ΡΡΠΌΠΎΡΡΠ΅Π½Ρ ΡΠΎΠ²ΡΠ΅ΠΌΠ΅Π½Π½ΡΠ΅ Π΄Π°Π½Π½ΡΠ΅ Π»ΠΈΡΠ΅ΡΠ°ΡΡΡΡ ΠΎ Π±Π΅Π·ΠΎΠΏΠ°ΡΠ½ΠΎΡΡΠΈ ΠΏΡΠΈΠΌΠ΅Π½Π΅Π½ΠΈΡ ΠΠ, Π° ΡΠ°ΠΊΠΆΠ΅ Π½Π°ΠΈΠ±ΠΎΠ»Π΅Π΅ ΡΠ°ΡΡΡΠ΅ Π½Π΅Π±Π»Π°Π³ΠΎΠΏΡΠΈΡΡΠ½ΡΠ΅ ΡΠ²Π»Π΅Π½ΠΈΡ, ΡΠ²ΡΠ·Π°Π½Π½ΡΠ΅ Ρ ΡΠ°ΠΊΠΎΠΉ ΡΠ΅ΡΠ°ΠΏΠΈΠ΅ΠΉ. ΠΠΎΠ»ΡΡΠΈΠ½ΡΡΠ²ΠΎ Π°Π²ΡΠΎΡΠΎΠ² ΡΠΊΠ°Π·ΡΠ²Π°ΡΡ Π½Π° ΠΏΠΎΠ²ΡΡΠ΅Π½ΠΈΠ΅ ΡΠΈΡΠΊΠ° ΡΠ°Π·Π²ΠΈΡΠΈΡ ΠΎΡΠ»ΠΎΠΆΠ½Π΅Π½ΠΈΠΉ ΠΏΡΠΈ ΡΠ²Π΅Π»ΠΈΡΠ΅Π½ΠΈΠΈ ΡΡΡΠΎΡΠ½ΠΎΠΉ Π΄ΠΎΠ·Ρ ΠΈ/ΠΈΠ»ΠΈ ΠΏΡΠΎΠ΄ΠΎΠ»ΠΆΠΈΡΠ΅Π»ΡΠ½ΠΎΡΡΠΈ Π»Π΅ΡΠ΅Π½ΠΈΡ ΠΠ. Π ΡΠΎ ΠΆΠ΅ Π²ΡΠ΅ΠΌΡ Π±Π΅Π·ΠΎΠΏΠ°ΡΠ½Π°Ρ Π΄ΠΎΠ·Π° ΠΠ Π½Π΅ ΠΎΠΏΡΠ΅Π΄Π΅Π»Π΅Π½Π°. ΠΠ΅ΡΠΎΡΡΠ½ΠΎ, ΠΎΠΏΡΠΈΠΌΠ°Π»ΡΠ½ΠΎΠΉ ΡΠ°ΠΊΡΠΈΠΊΠΎΠΉ ΡΠ²Π»ΡΠ΅ΡΡΡ ΠΏΠΎΠ΄Π±ΠΎΡ ΠΈΠ½Π΄ΠΈΠ²ΠΈΠ΄ΡΠ°Π»ΡΠ½ΠΎΠΉ Π΄ΠΎΠ·Ρ ΠΠ Π² ΠΊΠ°ΠΆΠ΄ΠΎΠΌ ΠΎΡΠ΄Π΅Π»ΡΠ½ΠΎΠΌ ΡΠ»ΡΡΠ°Π΅ Ρ ΡΡΠ΅ΡΠΎΠΌ Π°ΠΊΡΠΈΠ²Π½ΠΎΡΡΠΈ Π Π ΠΈ ΡΠΏΠ΅ΠΊΡΡΠ° ΠΊΠΎΠΌΠΎΡΠ±ΠΈΠ΄Π½ΡΡ
ΡΠΎΡΡΠΎΡΠ½ΠΈΠΉ. ΠΡΠΈ ΡΡΠΎΠΌ ΡΠ»Π΅Π΄ΡΠ΅Ρ ΠΈΡΠΏΠΎΠ»ΡΠ·ΠΎΠ²Π°ΡΡ ΠΌΠΈΠ½ΠΈΠΌΠ°Π»ΡΠ½ΡΠ΅ ΡΡΡΠ΅ΠΊΡΠΈΠ²Π½ΡΠ΅ Π΄ΠΎΠ·Ρ ΠΈ ΠΊΠΎΡΠΎΡΠΊΠΈΠ΅ ΠΊΡΡΡΡ ΠΠ, ΠΏΡΠΎΠ²ΠΎΠ΄ΠΈΡΡ ΡΠ΅Π³ΡΠ»ΡΡΠ½ΡΠΉ ΠΌΠΎΠ½ΠΈΡΠΎΡΠΈΠ½Π³ ΠΊΠ»ΠΈΠ½ΠΈΡΠ΅ΡΠΊΠΈΡ
ΠΈ Π»Π°Π±ΠΎΡΠ°ΡΠΎΡΠ½ΡΡ
ΠΏΠΎΠΊΠ°Π·Π°ΡΠ΅Π»Π΅ΠΉ Ρ ΡΠ΅Π»ΡΡ ΡΠ°Π½Π½Π΅Π³ΠΎ Π²ΡΡΠ²Π»Π΅Π½ΠΈΡ Π½Π΅Π±Π»Π°Π³ΠΎΠΏΡΠΈΡΡΠ½ΡΡ
ΡΠ²Π»Π΅Π½ΠΈΠΉ
ΠΠ΅Π±ΡΡ Π²ΠΎΡΠΏΠ°Π»ΠΈΡΠ΅Π»ΡΠ½ΠΎΠΉ ΡΠΊΠ΅Π»Π΅ΡΠ½ΠΎ-ΠΌΡΡΠ΅ΡΠ½ΠΎΠΉ ΠΏΠ°ΡΠΎΠ»ΠΎΠ³ΠΈΠΈ Ρ ΠΏΠ°ΡΠΈΠ΅Π½ΡΠΎΠ², ΠΏΠΎΠ»ΡΡΠ°ΡΡΠΈΡ ΠΏΡΠΎΡΠΈΠ²ΠΎΠΎΠΏΡΡ ΠΎΠ»Π΅Π²ΠΎΠ΅ Π»Π΅ΡΠ΅Π½ΠΈΠ΅ ΠΈΠ½Π³ΠΈΠ±ΠΈΡΠΎΡΠ°ΠΌΠΈ PD-1/PD-L1-ΠΏΡΡΠΈ
Objective: to describe musculoskeletal immune-mediated adverse events (iAEs) associated with the therapy of solid tumors with immune checkpoint inhibitors (ICIs, inhibitors of the PD-1/PD-L1 pathway).Patients and methods. 13 patients receiving ICIs therapy with musculoskeletal iAEs were examined. The average age of patients was 59Β±10 years. All cases had a histologically verified diagnosis of a malignant solid neoplasm: melanoma (n=5), kidney cancer (n=3), bladder cancer (n=2), non-small cell lung cancer (n=1), breast cancer (n=1), cervical cancer (n=1). All patients were prescribed inhibitors of the PD-1/PD-L1 signaling pathway: nivolumab (n=6), pembrolizumab (n=3), atezolizumab (n=3), prolgolimab (n=1). In 7 (54%) patients, in addition to musculoskeletal disorders, other AEs were also detected: thyroiditis (n=3), neuropathy (n=2), rash (n=1), dry syndrome (n=1), hepatitis (n=1). The median time from the start of antitumor immunotherapy (IT) to the onset of musculoskeletal pathology was 20 [9; 48] weeks.Results and discussion. Clinical manifestations of musculoskeletal pathology included: synovitis in 9 (69%) patients, tenosynovitis in 11 (85%), enthesitis in 4 (31%), morning stiffness in the joints for more than 30 minutes in 4 (31%). In 11 cases, musculoskeletal pathology was persistent (in 9 patients with arthritis and 2 with periarthritis) and in 2 β transient. The knee (77%), shoulder (69%) and hand (54%) joints were most frequently affected, with bilateral involvement in 9 (69%) patients. Inflammatory changes in the joints were represented by mono- (n=1), oligo- (n=3) and polyarthritis (n=5), including those involving the small joints of the hands and/or feet (n=5) and predominantly affecting the joints of the lower limbs (n=3). In 3 patients with arthritis, periarticular changes dominated in clinical picture (in 2 patients with symmetrical polyarthritis and severe tenosynovitis, in another 1 patient β with RS3PE syndrome). The severity of musculoskeletal pathology was assessed using the CTCAE v5.0 toxicity criteria: grade 1 was documented in 2 (15.5%), grade 2 in 9 (69%), and grade 3 in 2 (15, 5%) patients. Laboratory workup revealed elevation of ESR β₯30 mm/h (median β 34 [14; 42] mm/h) in 7 out of 12 (58%) patients, elevation of CRP level >5 mg/l (median β 7.2 [4.6; 12.9] mg/l) β in 7 out of 10 (70%). In 7 out of 10 patients, antinuclear antibodies (Hep2) were detected in titers: 1:160 (n=2), 1:320 (n=3), 1:640 (n=2). Rheumatoid factor and antibodies to cyclic citrullinated peptide were not detected in any case. Therapy for musculoskeletal AEs included non-steroidal anti-inflammatory drugs (n=10), oral systemic glucocorticoids β GC (n=5), methotrexate β MT (n=1) and hydroxychloroquine (n=5), intra-articular administration of GC (n=1). Five patients with arthritis required long-term therapy (median duration β 12 [3; 12] months), in 1 patient with polyarthritis and severe tenosynovitis, antitumor IT was interrupted for the duration of the course of MTX treatment.Conclusion. It has been shown that musculoskeletal iAEs have heterogeneous manifestations and may require long-term treatment and in rare cases, anticancer therapy interruption. Additional studies and close cooperation between rheumatologists and oncologists are needed to obtain a more complete understanding of the nature and spectrum of musculoskeletal AEs, to identify their clinical, laboratory and instrumental features, and to develop an management of patients algorithm.Π¦Π΅Π»Ρ ΠΈΡΡΠ»Π΅Π΄ΠΎΠ²Π°Π½ΠΈΡ β ΠΎΠΏΠΈΡΠ°ΡΡ ΡΠΊΠ΅Π»Π΅ΡΠ½ΠΎ-ΠΌΡΡΠ΅ΡΠ½ΡΠ΅ ΠΈΠΌΠΌΡΠ½ΠΎΠΎΠΏΠΎΡΡΠ΅Π΄ΠΎΠ²Π°Π½Π½ΡΠ΅ Π½Π΅ΠΆΠ΅Π»Π°ΡΠ΅Π»ΡΠ½ΡΠ΅ ΡΠ²Π»Π΅Π½ΠΈΡ (ΠΈΠΠ―), Π°ΡΡΠΎΡΠΈΠΈΡΠΎΠ²Π°Π½Π½ΡΠ΅ Ρ ΡΠ΅ΡΠ°ΠΏΠΈΠ΅ΠΉ ΡΠΎΠ»ΠΈΠ΄Π½ΡΡ
ΠΎΠΏΡΡ
ΠΎΠ»Π΅ΠΉ ΠΈΠ½Π³ΠΈΠ±ΠΈΡΠΎΡΠ°ΠΌΠΈ ΠΊΠΎΠ½ΡΡΠΎΠ»ΡΠ½ΡΡ
ΡΠΎΡΠ΅ΠΊ (ΠΠΠ’, ΠΈΠ½Π³ΠΈΠ±ΠΈΡΠΎΡΡ PD-1/PD-L1-ΠΏΡΡΠΈ).ΠΠ°ΡΠΈΠ΅Π½ΡΡ ΠΈ ΠΌΠ΅ΡΠΎΠ΄Ρ. ΠΠ±ΡΠ»Π΅Π΄ΠΎΠ²Π°Π½ΠΎ 13 ΠΏΠ°ΡΠΈΠ΅Π½ΡΠΎΠ² ΡΠΎ ΡΠΊΠ΅Π»Π΅ΡΠ½ΠΎ-ΠΌΡΡΠ΅ΡΠ½ΡΠΌΠΈ ΠΈΠΠ―, ΠΏΠΎΠ»ΡΡΠ°ΡΡΠΈΡ
ΡΠ΅ΡΠ°ΠΏΠΈΡ ΠΠΠ’. Π‘ΡΠ΅Π΄Π½ΠΈΠΉ Π²ΠΎΠ·ΡΠ°ΡΡ Π±ΠΎΠ»ΡΠ½ΡΡ
β 59Β±10 Π»Π΅Ρ. ΠΡΠ΅Ρ
ΡΠ»ΡΡΠ°ΡΡ
ΠΈΠΌΠ΅Π»ΡΡ Π³ΠΈΡΡΠΎΠ»ΠΎΠ³ΠΈΡΠ΅ΡΠΊΠΈ Π²Π΅ΡΠΈΡΠΈΡΠΈΡΠΎΠ²Π°Π½Π½ΡΠΉ Π΄ΠΈΠ°Π³Π½ΠΎΠ· Π·Π»ΠΎΠΊΠ°ΡΠ΅ΡΡΠ²Π΅Π½Π½ΠΎΠ³ΠΎ ΡΠΎΠ»ΠΈΠ΄Π½ΠΎΠ³ΠΎ Π½ΠΎΠ²ΠΎΠΎΠ±ΡΠ°Π·ΠΎΠ²Π°Π½ΠΈΡ: ΠΌΠ΅Π»Π°Π½ΠΎΠΌΠ° (n=5), ΡΠ°ΠΊ ΠΏΠΎΡΠΊΠΈ (n=3), ΡΠ°ΠΊ ΠΌΠΎΡΠ΅Π²ΠΎΠ³ΠΎ ΠΏΡΠ·ΡΡΡ (n=2), Π½Π΅ΠΌΠ΅Π»ΠΊΠΎΠΊΠ»Π΅ΡΠΎΡΠ½ΡΠΉ ΡΠ°ΠΊ Π»Π΅Π³ΠΊΠΎΠ³ΠΎ (n=1), ΡΠ°ΠΊ ΠΌΠΎΠ»ΠΎΡΠ½ΠΎΠΉ ΠΆΠ΅Π»Π΅Π·Ρ (n=1), ΡΠ°ΠΊ ΡΠ΅ΠΉΠΊΠΈ ΠΌΠ°ΡΠΊΠΈ (n=1). ΠΡΠ΅ΠΌ ΠΏΠ°ΡΠΈΠ΅Π½ΡΠ°ΠΌ Π±ΡΠ»ΠΈ Π½Π°Π·Π½Π°ΡΠ΅Π½Ρ ΠΈΠ½Π³ΠΈΠ±ΠΈΡΠΎΡΡ ΡΠΈΠ³Π½Π°Π»ΡΠ½ΠΎΠ³ΠΎ ΠΏΡΡΠΈ PD-1/PD-L1: Π½ΠΈΠ²ΠΎΠ»ΡΠΌΠ°Π± (n=6), ΠΏΠ΅ΠΌΠ±ΡΠΎΠ»ΠΈΠ·ΡΠΌΠ°Π± (n=3), Π°ΡΠ΅Π·ΠΎΠ»ΠΈΠ·ΡΠΌΠ°Π± (n=3), ΠΏΡΠΎΠ»Π³ΠΎΠ»ΠΈΠΌΠ°Π± (n=1). Π£ 7 (54%) ΠΏΠ°ΡΠΈΠ΅Π½ΡΠΎΠ², ΠΊΡΠΎΠΌΠ΅ ΡΠΊΠ΅Π»Π΅ΡΠ½ΠΎ-ΠΌΡΡΠ΅ΡΠ½ΡΡ
Π½Π°ΡΡΡΠ΅Π½ΠΈΠΉ, ΡΠ°ΠΊΠΆΠ΅ Π²ΡΡΠ²Π»ΡΠ»ΠΈΡΡ Π΄ΡΡΠ³ΠΈΠ΅ ΠΈΠΠ―: ΡΠΈΡΠ΅ΠΎΠΈΠ΄ΠΈΡ (n=3), Π½Π΅Π²ΡΠΎΠΏΠ°ΡΠΈΡ (n=2), ΡΡΠΏΡ (n=1), ΡΡΡ
ΠΎΠΉ ΡΠΈΠ½Π΄ΡΠΎΠΌ (n=1), Π³Π΅ΠΏΠ°ΡΠΈΡ (n=1). ΠΠ΅Π΄ΠΈΠ°Π½Π° Π²ΡΠ΅ΠΌΠ΅Π½ΠΈ ΠΎΡ Π½Π°ΡΠ°Π»Π° ΠΏΡΠΎΡΠΈΠ²ΠΎΠΎΠΏΡΡ
ΠΎΠ»Π΅Π²ΠΎΠΉ ΠΈΠΌΠΌΡΠ½ΠΎΡΠ΅ΡΠ°ΠΏΠΈΠΈ (ΠΠ’) Π΄ΠΎ Π΄Π΅Π±ΡΡΠ° ΡΠΊΠ΅Π»Π΅ΡΠ½ΠΎ-ΠΌΡΡΠ΅ΡΠ½ΠΎΠΉ ΠΏΠ°ΡΠΎΠ»ΠΎΠ³ΠΈΠΈ ΡΠΎΡΡΠ°Π²ΠΈΠ»Π° 20 [9; 48] Π½Π΅Π΄.Π Π΅Π·ΡΠ»ΡΡΠ°ΡΡ ΠΈ ΠΎΠ±ΡΡΠΆΠ΄Π΅Π½ΠΈΠ΅. ΠΠ»ΠΈΠ½ΠΈΡΠ΅ΡΠΊΠΈΠ΅ ΠΏΡΠΎΡΠ²Π»Π΅Π½ΠΈΡ ΡΠΊΠ΅Π»Π΅ΡΠ½ΠΎ-ΠΌΡΡΠ΅ΡΠ½ΠΎΠΉ ΠΏΠ°ΡΠΎΠ»ΠΎΠ³ΠΈΠΈ Π²ΠΊΠ»ΡΡΠ°Π»ΠΈ: ΡΠΈΠ½ΠΎΠ²ΠΈΡ Ρ 9 (69%) Π±ΠΎΠ»ΡΠ½ΡΡ
, ΡΠ΅Π½ΠΎΡΠΈΠ½ΠΎΠ²ΠΈΡ Ρ 11 (85%), ΡΠ½ΡΠ΅Π·ΠΈΡ Ρ 4 (31%), ΡΡΡΠ΅Π½Π½ΡΡ ΡΠΊΠΎΠ²Π°Π½Π½ΠΎΡΡΡ Π² ΡΡΡΡΠ°Π²Π°Ρ
Π±ΠΎΠ»Π΅Π΅ 30 ΠΌΠΈΠ½ Ρ 4 (31%). Π 11 ΡΠ»ΡΡΠ°ΡΡ
ΡΠΊΠ΅Π»Π΅ΡΠ½ΠΎΠΌΡΡΠ΅ΡΠ½Π°Ρ ΠΏΠ°ΡΠΎΠ»ΠΎΠ³ΠΈΡ Π½ΠΎΡΠΈΠ»Π° ΠΏΠ΅ΡΡΠΈΡΡΠΈΡΡΡΡΠΈΠΉ Ρ
Π°ΡΠ°ΠΊΡΠ΅Ρ (Ρ 9 ΠΏΠ°ΡΠΈΠ΅Π½ΡΠΎΠ² Ρ Π°ΡΡΡΠΈΡΠΎΠΌ ΠΈ 2 Ρ ΠΏΠ΅ΡΠΈΠ°ΡΡΡΠΈΡΠΎΠΌ) ΠΈ Π² 2 β ΡΡΠ°Π½Π·ΠΈΡΠΎΡΠ½ΡΠΉ. ΠΠ°ΠΈΠ±ΠΎΠ»Π΅Π΅ ΡΠ°ΡΡΠΎ ΠΏΠΎΡΠ°ΠΆΠ°Π»ΠΈΡΡ ΠΊΠΎΠ»Π΅Π½Π½ΡΠ΅ (77%), ΠΏΠ»Π΅ΡΠ΅Π²ΡΠ΅ (69%) ΡΡΡΡΠ°Π²Ρ ΠΈ ΡΡΡΡΠ°Π²Ρ ΠΊΠΈΡΡΠ΅ΠΉ (54%) Ρ Π΄Π²ΡΡΡΠΎΡΠΎΠ½Π½ΠΈΠΌ Π²ΠΎΠ²Π»Π΅ΡΠ΅Π½ΠΈΠ΅ΠΌ Ρ 9 (69%) ΠΏΠ°ΡΠΈΠ΅Π½ΡΠΎΠ². ΠΠΎΡΠΏΠ°Π»ΠΈΡΠ΅Π»ΡΠ½ΡΠ΅ ΠΈΠ·ΠΌΠ΅Π½Π΅Π½ΠΈΡ ΡΡΡΡΠ°Π²ΠΎΠ² Π±ΡΠ»ΠΈ ΠΏΡΠ΅Π΄ΡΡΠ°Π²Π»Π΅Π½Ρ ΠΌΠΎΠ½ΠΎ- (n=1), ΠΎΠ»ΠΈΠ³ΠΎ- (n=3) ΠΈ ΠΏΠΎΠ»ΠΈΠ°ΡΡΡΠΈΡΠΎΠΌ (n=5), Π² ΡΠΎΠΌ ΡΠΈΡΠ»Π΅ Ρ Π²ΠΎΠ²Π»Π΅ΡΠ΅Π½ΠΈΠ΅ΠΌ ΠΌΠ΅Π»ΠΊΠΈΡ
ΡΡΡΡΠ°Π²ΠΎΠ² ΠΊΠΈΡΡΠ΅ΠΉ ΠΈ/ΠΈΠ»ΠΈ ΡΡΠΎΠΏ (n=5) ΠΈ ΠΏΡΠ΅ΠΈΠΌΡΡΠ΅ΡΡΠ²Π΅Π½Π½ΡΠΌ ΠΏΠΎΡΠ°ΠΆΠ΅Π½ΠΈΠ΅ΠΌ ΡΡΡΡΠ°Π²ΠΎΠ² Π½ΠΈΠΆΠ½ΠΈΡ
ΠΊΠΎΠ½Π΅ΡΠ½ΠΎΡΡΠ΅ΠΉ (n=3). Π£ 3 Π±ΠΎΠ»ΡΠ½ΡΡ
Ρ Π°ΡΡΡΠΈΡΠΎΠΌ Π² ΠΊΠ»ΠΈΠ½ΠΈΡΠ΅ΡΠΊΠΎΠΉ ΠΊΠ°ΡΡΠΈΠ½Π΅ ΠΏΡΠ΅ΠΎΠ±Π»Π°Π΄Π°Π»ΠΈ ΠΏΠ΅ΡΠΈΠ°ΡΡΠΈΠΊΡΠ»ΡΡΠ½ΡΠ΅ ΠΈΠ·ΠΌΠ΅Π½Π΅Π½ΠΈΡ (Ρ 2 ΠΏΠ°ΡΠΈΠ΅Π½ΡΠΎΠ² Ρ ΡΠΈΠΌΠΌΠ΅ΡΡΠΈΡΠ½ΡΠΌ ΠΏΠΎΠ»ΠΈΠ°ΡΡΡΠΈΡΠΎΠΌ ΠΈ ΡΡΠΆΠ΅Π»ΡΠΌ ΡΠ΅Π½ΠΎΡΠΈΠ½ΠΎΠ²ΠΈΡΠΎΠΌ, Π΅ΡΠ΅ Ρ 1 β Ρ RS3PE-ΡΠΈΠ½Π΄ΡΠΎΠΌΠΎΠΌ). Π’ΡΠΆΠ΅ΡΡΡ ΡΠΊΠ΅Π»Π΅ΡΠ½ΠΎ-ΠΌΡΡΠ΅ΡΠ½ΠΎΠΉ ΠΏΠ°ΡΠΎΠ»ΠΎΠ³ΠΈΠΈ Π±ΡΠ»Π° ΠΎΡΠ΅Π½Π΅Π½Π° Ρ ΠΏΠΎΠΌΠΎΡΡΡ ΠΊΡΠΈΡΠ΅ΡΠΈΠ΅Π² ΡΠΎΠΊΡΠΈΡΠ½ΠΎΡΡΠΈ CTCAE v5.0: 1-Ρ ΡΡΠ΅ΠΏΠ΅Π½Ρ ΡΡΡΠ°Π½ΠΎΠ²Π»Π΅Π½Π° Ρ 2 (15,5%), 2-Ρ β Ρ 9 (69%) ΠΈ 3-Ρ β Ρ 2 (15,5%) ΠΏΠ°ΡΠΈΠ΅Π½ΡΠΎΠ². ΠΡΠΈ Π»Π°Π±ΠΎΡΠ°ΡΠΎΡΠ½ΠΎΠΌ ΠΎΠ±ΡΠ»Π΅Π΄ΠΎΠ²Π°Π½ΠΈΠΈ ΡΠ²Π΅Π»ΠΈΡΠ΅Π½ΠΈΠ΅ Π‘ΠΠ β₯30 ΠΌΠΌ/Ρ (ΠΌΠ΅Π΄ΠΈΠ°Π½Π° β 34 [14; 42] ΠΌΠΌ/Ρ) Π²ΡΡΠ²Π»Π΅Π½ΠΎ Ρ 7 ΠΈΠ· 12 (58%) Π±ΠΎΠ»ΡΠ½ΡΡ
, ΠΏΠΎΠ²ΡΡΠ΅Π½ΠΈΠ΅ ΡΡΠΎΠ²Π½Ρ Π‘Π Π >5 ΠΌΠ³/Π» (ΠΌΠ΅Π΄ΠΈΠ°Π½Π° β 7,2 [4,6; 12,9] ΠΌΠ³/Π») β Ρ 7 ΠΈΠ· 10 (70%). Π£ 7 ΠΈΠ· 10 Π±ΠΎΠ»ΡΠ½ΡΡ
ΠΎΠ±Π½Π°ΡΡΠΆΠ΅Π½ Π°Π½ΡΠΈΠ½ΡΠΊΠ»Π΅Π°ΡΠ½ΡΠΉ ΡΠ°ΠΊΡΠΎΡ (Hep2) Π² ΡΠΈΡΡΠ°Ρ
: 1:160 (n=2), 1:320 (n=3), 1:640 (n=2). Π Π΅Π²ΠΌΠ°ΡΠΎΠΈΠ΄Π½ΡΠΉ ΡΠ°ΠΊΡΠΎΡ ΠΈ Π°Π½ΡΠΈΡΠ΅Π»Π° ΠΊ ΡΠΈΠΊΠ»ΠΈΡΠ΅ΡΠΊΠΎΠΌΡ ΡΠΈΡΡΡΠ»Π»ΠΈΠ½ΠΈΡΠΎΠ²Π°Π½Π½ΠΎΠΌΡ ΠΏΠ΅ΠΏΡΠΈΠ΄Ρ Π½Π΅ Π²ΡΡΠ²Π»Π΅Π½Ρ Π½ΠΈ Π² ΠΎΠ΄Π½ΠΎΠΌ ΡΠ»ΡΡΠ°Π΅. Π’Π΅ΡΠ°ΠΏΠΈΡ ΡΠΊΠ΅Π»Π΅ΡΠ½ΠΎ-ΠΌΡΡΠ΅ΡΠ½ΡΡ
ΠΈΠΠ― Π²ΠΊΠ»ΡΡΠ°Π»Π° ΠΏΡΠΈΠΌΠ΅Π½Π΅Π½ΠΈΠ΅ Π½Π΅ΡΡΠ΅ΡΠΎΠΈΠ΄Π½ΡΡ
ΠΏΡΠΎΡΠΈΠ²ΠΎΠ²ΠΎΡΠΏΠ°Π»ΠΈΡΠ΅Π»ΡΠ½ΡΡ
ΠΏΡΠ΅ΠΏΠ°ΡΠ°ΡΠΎΠ² (n=10), ΠΎΡΠ°Π»ΡΠ½ΡΡ
ΡΠΈΡΡΠ΅ΠΌΠ½ΡΡ
Π³Π»ΡΠΊΠΎΠΊΠΎΡΡΠΈΠΊΠΎΠΈΠ΄ΠΎΠ² β ΠΠ (n=5), ΠΌΠ΅ΡΠΎΡΡΠ΅ΠΊΡΠ°ΡΠ° β ΠΠ’ (n=1) ΠΈ Π³ΠΈΠ΄ΡΠΎΠΊΡΠΈΡ
Π»ΠΎΡΠΎΡ
ΠΈΠ½Π° (n=5), Π²Π½ΡΡΡΠΈΡΡΡΡΠ°Π²Π½ΠΎΠ΅ Π²Π²Π΅Π΄Π΅Π½ΠΈΠ΅ ΠΠ (n=1). ΠΡΡΡ ΠΏΠ°ΡΠΈΠ΅Π½ΡΠΎΠ² Ρ Π°ΡΡΡΠΈΡΠΎΠΌ Π½ΡΠΆΠ΄Π°Π»ΠΈΡΡ Π² ΠΏΡΠΎΠ΄ΠΎΠ»ΠΆΠΈΡΠ΅Π»ΡΠ½ΠΎΠΉ ΡΠ΅ΡΠ°ΠΏΠΈΠΈ (ΠΌΠ΅Π΄ΠΈΠ°Π½Π° Π΄Π»ΠΈΡΠ΅Π»ΡΠ½ΠΎΡΡΠΈ β 12 [3; 12] ΠΌΠ΅Ρ), Ρ 1 ΠΏΠ°ΡΠΈΠ΅Π½ΡΠ° Ρ ΠΏΠΎΠ»ΠΈΠ°ΡΡΡΠΈΡΠΎΠΌ ΠΈ ΡΡΠΆΠ΅Π»ΡΠΌ ΡΠ΅Π½ΠΎΡΠΈΠ½ΠΎΠ²ΠΈΡΠΎΠΌ ΠΏΡΠΎΡΠΈΠ²ΠΎΠΎΠΏΡΡ
ΠΎΠ»Π΅Π²Π°Ρ ΠΠ’ Π±ΡΠ»Π° ΠΏΡΠ΅ΡΠ²Π°Π½Π° Π½Π° Π²ΡΠ΅ΠΌΡ ΠΏΡΠΎΠ²Π΅Π΄Π΅Π½ΠΈΡ ΠΊΡΡΡΠ° Π»Π΅ΡΠ΅Π½ΠΈΡ ΠΠ’.ΠΠ°ΠΊΠ»ΡΡΠ΅Π½ΠΈΠ΅. ΠΠΎΠΊΠ°Π·Π°Π½ΠΎ, ΡΡΠΎ ΡΠΊΠ΅Π»Π΅ΡΠ½ΠΎ-ΠΌΡΡΠ΅ΡΠ½ΡΠ΅ ΠΈΠΠ― ΠΈΠΌΠ΅ΡΡ Π³Π΅ΡΠ΅ΡΠΎΠ³Π΅Π½Π½ΡΠ΅ ΠΏΡΠΎΡΠ²Π»Π΅Π½ΠΈΡ ΠΈ ΠΌΠΎΠ³ΡΡ ΠΏΠΎΡΡΠ΅Π±ΠΎΠ²Π°ΡΡ Π΄Π»ΠΈΡΠ΅Π»ΡΠ½ΠΎΠ³ΠΎ Π»Π΅ΡΠ΅Π½ΠΈΡ, Π° Π² ΡΠ΅Π΄ΠΊΠΈΡ
ΡΠ»ΡΡΠ°ΡΡ
β ΠΈ ΠΏΡΠΈΠΎΡΡΠ°Π½ΠΎΠ²ΠΊΠΈ ΠΏΡΠΎΡΠΈΠ²ΠΎΠΎΠΏΡΡ
ΠΎΠ»Π΅Π²ΠΎΠΉ ΡΠ΅ΡΠ°ΠΏΠΈΠΈ. ΠΠ»Ρ ΠΏΠΎΠ»ΡΡΠ΅Π½ΠΈΡ Π±ΠΎΠ»Π΅Π΅ ΠΏΠΎΠ»Π½ΠΎΠ³ΠΎ ΠΏΡΠ΅Π΄ΡΡΠ°Π²Π»Π΅Π½ΠΈΡ ΠΎ ΠΏΡΠΈΡΠΎΠ΄Π΅ ΠΈ ΡΠΏΠ΅ΠΊΡΡΠ΅ ΡΠΊΠ΅Π»Π΅ΡΠ½ΠΎ-ΠΌΡΡΠ΅ΡΠ½ΡΡ
ΠΈΠΠ―, Π²ΡΠ΄Π΅Π»Π΅Π½ΠΈΡ ΠΈΡ
ΠΊΠ»ΠΈΠ½ΠΈΠΊΠΎ-Π»Π°Π±ΠΎΡΠ°ΡΠΎΡΠ½ΡΡ
ΠΈ ΠΈΠ½ΡΡΡΡΠΌΠ΅Π½ΡΠ°Π»ΡΠ½ΡΡ
ΠΎΡΠΎΠ±Π΅Π½Π½ΠΎΡΡΠ΅ΠΉ, ΡΠ°Π·ΡΠ°Π±ΠΎΡΠΊΠΈ Π°Π»Π³ΠΎΡΠΈΡΠΌΠ° ΠΊΡΡΠ°ΡΠΈΠΈ Π½Π΅ΠΎΠ±Ρ
ΠΎΠ΄ΠΈΠΌΡ Π΄ΠΎΠΏΠΎΠ»Π½ΠΈΡΠ΅Π»ΡΠ½ΡΠ΅ ΠΈΡΡΠ»Π΅Π΄ΠΎΠ²Π°Π½ΠΈΡ ΠΈ ΡΠ΅ΡΠ½ΠΎΠ΅ ΡΠΎΡΡΡΠ΄Π½ΠΈΡΠ΅ΡΡΠ²ΠΎ ΡΠ΅Π²ΠΌΠ°ΡΠΎΠ»ΠΎΠ³ΠΎΠ² ΠΈ ΠΎΠ½ΠΊΠΎΠ»ΠΎΠ³ΠΎΠ²
ΠΠΊΡΡΠ°Π»ΡΠ½ΡΠ΅ ΠΏΡΠΎΠ±Π»Π΅ΠΌΡ ΠΏΡΠΈΡ ΠΎΠ»ΠΎΠ³ΠΈΡΠ΅ΡΠΊΠΎΠ³ΠΎ ΡΠΎΠΏΡΠΎΠ²ΠΎΠΆΠ΄Π΅Π½ΠΈΡ ΠΎΠ±ΡΠ°Π·ΠΎΠ²Π°Π½ΠΈΡ
Introduction. Assistance to learners and other educational actors in gaining access to mental health support is important at its various levels, from the pre-university stage to doctoral, professional development and retraining programs. Timely (preventive or possibly earlier) and appropriate (targeted) intervention, designed as maintenance / facilitation, distributed in the space and time of the clientΒ»s life, or emergency, clearly directed and technologically verified intervention (Β«impactΒ») are usually associated with better results of the service, individual and organizational health of participants in the educational process.Purpose setting. The aim of the study is to analyze the current problems of psychological support of the educational process at different stages of higher education in the context of systemic, targeted and timely provision of psychological support to a person in solving the tasks facing him of coping with the crises of personal, interpersonal, and educational and professional development.Methodology and methods of the study. The research method is a theoretical analysis of topical problems of psychological support of the educational process in higher education. The methodological basis of the study is an integrative approach to the analysis of the problems of psychological support of the educational process in higher education.Results. The peculiarities of the activities of university academic psychological support services are associated with the helping young and adults, students and educators, as well as other employees of universities / institutes and their families. The main form of activity around which and about which a system of main and additional goals and trends in the activities of these services is built is educational, tutorial and training. However, at the university, it is not just educational, but both educational and professional activity: the central task of education is to (re) train a specialist, including in the field of developing his psychological culture, with which he will enter the real labor process, to future employees, subordinates and managers, clients and customers, etc., with which he will live, building family and friendships, neighborhood relationships and hobbies. The leading problems of academic services remain: a) spiritual-ideological and theoretical-methodological aspects of the psychological support of the educational process and the development of students and teachers as individuals, partners and members of society, as students and professionals; b) strategies for building and developing helping relationships with difficult clients, with clients in extremely difficult personal microsocial and macrosocial situations; c) (re) training and advanced training, along with expanding the methodological tools and powers of academic psychologists and other support service specialists, coordinating and improving the work of interdisciplinary support teams; d) psychological expertise and support of educational innovations, the use of the educational situation to solve the problems of personal, interpersonal, educational and professional development and improvement of the main participants in education and its stakeholders.Conclusion. Psychological support of the educational process in higher education acts as an area of professional, interprofessional and quasi-professional activity, represented in numerous forms and directions of providing help from person to person. The wealth of tasks facing a person, difficulties and crises of personal, interpersonal and educational-professional formation and development that an individual faces in an educational environment can be covered and can be solved by the systemically organized work of the academic service for psychological support of education. This service includes assistance to different groups of clients who are in difficult, conflict and crisis situations of varying intensity and volume: assistance in finding resources to cope with the problems of personal, interpersonal, and educational and professional development.ΠΠ²Π΅Π΄Π΅Π½ΠΈΠ΅. ΠΠΎΠΌΠΎΡΡ ΠΎΠ±ΡΡΠ°ΡΡΠΈΠΌΡΡ ΠΈ ΠΈΠ½ΡΠΌ ΡΡΠ±ΡΠ΅ΠΊΡΠ°ΠΌ ΠΎΠ±ΡΠ°Π·ΠΎΠ²Π°Π½ΠΈΡ Π² ΠΏΠΎΠ»ΡΡΠ΅Π½ΠΈΠΈ Π΄ΠΎΡΡΡΠΏΠ° ΠΊ ΠΏΠΎΠ΄Π΄Π΅ΡΠΆΠΊΠ΅ Π² ΠΎΠ±Π»Π°ΡΡΠΈ ΠΏΡΠΈΡ
ΠΈΡΠ΅ΡΠΊΠΎΠ³ΠΎ Π·Π΄ΠΎΡΠΎΠ²ΡΡ Π²Π°ΠΆΠ½Π° Π½Π° ΡΠ°Π·Π½ΡΡ
Π΅Π³ΠΎ ΡΡΡΠΏΠ΅Π½ΡΡ
, Π½Π°ΡΠΈΠ½Π°Ρ Ρ ΡΡΠ°ΠΏΠ° ΠΏΠΎΠ΄Π³ΠΎΡΠΎΠ²ΠΊΠΈ ΠΊ ΠΏΠΎΡΡΡΠΏΠ»Π΅Π½ΠΈΡ Π² Π²ΡΠ· ΠΈ Π·Π°ΠΊΠ°Π½ΡΠΈΠ²Π°Ρ ΠΏΡΠΎΠ³ΡΠ°ΠΌΠΌΠ°ΠΌΠΈ Π΄ΠΎΠΊΡΠΎΡΠ°Π½ΡΡΡΡ, ΠΏΠΎΠ²ΡΡΠ΅Π½ΠΈΡ ΠΊΠ²Π°Π»ΠΈΡΠΈΠΊΠ°ΡΠΈΠΈ ΠΈ ΠΏΠ΅ΡΠ΅ΠΏΠΎΠ΄Π³ΠΎΡΠΎΠ²ΠΊΠΈ. Π‘Π²ΠΎΠ΅Π²ΡΠ΅ΠΌΠ΅Π½Π½ΠΎΠ΅ (ΠΏΡΠ΅Π²Π΅Π½ΡΠΈΠ²Π½ΠΎΠ΅ ΠΈΠ»ΠΈ, Π²ΠΎΠ·ΠΌΠΎΠΆΠ½ΠΎ, Π±ΠΎΠ»Π΅Π΅ ΡΠ°Π½Π΅Π΅) ΠΈ ΡΠΌΠ΅ΡΡΠ½ΠΎΠ΅ (Π°Π΄ΡΠ΅ΡΠ½ΠΎΠ΅) Π²ΠΌΠ΅ΡΠ°ΡΠ΅Π»ΡΡΡΠ²ΠΎ, ΠΎΡΠΎΡΠΌΠ»Π΅Π½Π½ΠΎΠ΅ ΠΊΠ°ΠΊ ΡΠ°ΡΠΏΡΠ΅Π΄Π΅Π»Π΅Π½Π½ΠΎΠ΅ Π² ΠΏΡΠΎΡΡΡΠ°Π½ΡΡΠ²Π΅ ΠΈ Π²ΡΠ΅ΠΌΠ΅Π½ΠΈ ΠΆΠΈΠ·Π½ΠΈ ΠΊΠ»ΠΈΠ΅Π½ΡΠ° ΡΠΎΠΏΡΠΎΠ²ΠΎΠΆΠ΄Π΅Π½ΠΈΠ΅/ΡΠ°ΡΠΈΠ»ΠΈΡΠ°ΡΠΈΡ ΠΈΠ»ΠΈ ΡΠΊΡΡΡΠ΅Π½Π½ΠΎΠ΅, ΡΠ΅ΡΠΊΠΎ Π½Π°ΠΏΡΠ°Π²Π»Π΅Π½Π½ΠΎΠ΅ ΠΈ ΡΠ΅Ρ
Π½ΠΎΠ»ΠΎΠ³ΠΈΡΠ΅ΡΠΊΠΈ Π²ΡΠ²Π΅ΡΠ΅Π½Π½ΠΎΠ΅ Π²ΠΌΠ΅ΡΠ°ΡΠ΅Π»ΡΡΡΠ²ΠΎ (Β«Π²ΠΎΠ·Π΄Π΅ΠΉΡΡΠ²ΠΈΠ΅Β») ΡΠ²ΡΠ·Π°Π½Ρ ΠΎΠ±ΡΡΠ½ΠΎ Ρ Π»ΡΡΡΠΈΠΌΠΈ ΡΠ΅Π·ΡΠ»ΡΡΠ°ΡΠ°ΠΌΠΈ Π΄Π΅ΡΡΠ΅Π»ΡΠ½ΠΎΡΡΠΈ ΡΠ»ΡΠΆΠ±Ρ, ΠΏΠΎΠ²ΡΡΠ΅Π½ΠΈΠ΅ΠΌ ΠΈΠ½Π΄ΠΈΠ²ΠΈΠ΄ΡΠ°Π»ΡΠ½ΠΎΠ³ΠΎ ΠΈ ΠΎΡΠ³Π°Π½ΠΈΠ·Π°ΡΠΈΠΎΠ½Π½ΠΎΠ³ΠΎ Π·Π΄ΠΎΡΠΎΠ²ΡΡ ΡΡΠ°ΡΡΠ½ΠΈΠΊΠΎΠ² ΠΎΠ±ΡΠ°Π·ΠΎΠ²Π°ΡΠ΅Π»ΡΠ½ΠΎΠ³ΠΎ ΠΏΡΠΎΡΠ΅ΡΡΠ°.ΠΠΎΡΡΠ°Π½ΠΎΠ²ΠΊΠ° Π·Π°Π΄Π°ΡΠΈ. Π¦Π΅Π»Ρ ΠΈΡΡΠ»Π΅Π΄ΠΎΠ²Π°Π½ΠΈΡ β Π°Π½Π°Π»ΠΈΠ· Π°ΠΊΡΡΠ°Π»ΡΠ½ΡΡ
ΠΏΡΠΎΠ±Π»Π΅ΠΌ ΠΏΡΠΈΡ
ΠΎΠ»ΠΎΠ³ΠΈΡΠ΅ΡΠΊΠΎΠ³ΠΎ ΡΠΎΠΏΡΠΎΠ²ΠΎΠΆΠ΄Π΅Π½ΠΈΡ ΠΎΠ±ΡΠ°Π·ΠΎΠ²Π°ΡΠ΅Π»ΡΠ½ΠΎΠ³ΠΎ ΠΏΡΠΎΡΠ΅ΡΡΠ° Π½Π° ΡΠ°Π·Π½ΡΡ
ΡΡΡΠΏΠ΅Π½ΡΡ
Π²ΡΡΡΠ΅Π³ΠΎ ΠΎΠ±ΡΠ°Π·ΠΎΠ²Π°Π½ΠΈΡ Π² ΠΊΠΎΠ½ΡΠ΅ΠΊΡΡΠ΅ ΡΠΈΡΡΠ΅ΠΌΠ½ΠΎΠ³ΠΎ, ΡΠ΅Π»Π΅Π½Π°ΠΏΡΠ°Π²Π»Π΅Π½Π½ΠΎΠ³ΠΎ ΠΈ ΡΠ²ΠΎΠ΅Π²ΡΠ΅ΠΌΠ΅Π½Π½ΠΎΠ³ΠΎ ΠΎΠΊΠ°Π·Π°Π½ΠΈΡ ΡΠ΅Π»ΠΎΠ²Π΅ΠΊΡ ΠΏΡΠΈΡ
ΠΎΠ»ΠΎΠ³ΠΈΡΠ΅ΡΠΊΠΎΠΉ ΠΏΠΎΠ΄Π΄Π΅ΡΠΆΠΊΠΈ Π² ΡΠ΅ΡΠ΅Π½ΠΈΠΈ ΡΡΠΎΡΡΠΈΡ
ΠΏΠ΅ΡΠ΅Π΄ Π½ΠΈΠΌ Π·Π°Π΄Π°Ρ ΡΠΎΠ²Π»Π°Π΄Π°Π½ΠΈΡ Ρ ΠΊΡΠΈΠ·ΠΈΡΠ°ΠΌΠΈ Π»ΠΈΡΠ½ΠΎΡΡΠ½ΠΎΠ³ΠΎ, ΠΌΠ΅ΠΆΠ»ΠΈΡΠ½ΠΎΡΡΠ½ΠΎΠ³ΠΎ ΠΈ ΡΡΠ΅Π±Π½ΠΎ-ΠΏΡΠΎΡΠ΅ΡΡΠΈΠΎΠ½Π°Π»ΡΠ½ΠΎΠ³ΠΎ ΡΠ°Π·Π²ΠΈΡΠΈΡ.ΠΠ΅ΡΠΎΠ΄ΠΈΠΊΠ° ΠΈ ΠΌΠ΅ΡΠΎΠ΄ΠΎΠ»ΠΎΠ³ΠΈΡ ΠΈΡΡΠ»Π΅Π΄ΠΎΠ²Π°Π½ΠΈΡ. ΠΠ΅ΡΠΎΠ΄ ΠΈΡΡΠ»Π΅Π΄ΠΎΠ²Π°Π½ΠΈΡ β ΡΠ΅ΠΎΡΠ΅ΡΠΈΡΠ΅ΡΠΊΠΈΠΉ Π°Π½Π°Π»ΠΈΠ· Π°ΠΊΡΡΠ°Π»ΡΠ½ΡΡ
ΠΏΡΠΎΠ±Π»Π΅ΠΌ ΠΏΡΠΈΡ
ΠΎΠ»ΠΎΠ³ΠΈΡΠ΅ΡΠΊΠΎΠ³ΠΎ ΡΠΎΠΏΡΠΎΠ²ΠΎΠΆΠ΄Π΅Π½ΠΈΡ ΠΎΠ±ΡΠ°Π·ΠΎΠ²Π°ΡΠ΅Π»ΡΠ½ΠΎΠ³ΠΎ ΠΏΡΠΎΡΠ΅ΡΡΠ° Π² Π²ΡΠ·ΠΎΠ²ΡΠΊΠΎΠΌ ΠΎΠ±ΡΠ°Π·ΠΎΠ²Π°Π½ΠΈΠΈ. ΠΠ΅ΡΠΎΠ΄ΠΎΠ»ΠΎΠ³ΠΈΡΠ΅ΡΠΊΠΎΠΉ ΠΎΡΠ½ΠΎΠ²ΠΎΠΉ ΠΈΡΡΠ»Π΅Π΄ΠΎΠ²Π°Π½ΠΈΡ ΡΠ²Π»ΡΠ΅ΡΡΡ ΠΈΠ½ΡΠ΅Π³ΡΠ°ΡΠΈΠ²Π½ΡΠΉ ΠΏΠΎΠ΄Ρ
ΠΎΠ΄ ΠΊ Π°Π½Π°Π»ΠΈΠ·Ρ ΠΏΡΠΎΠ±Π»Π΅ΠΌ ΠΏΡΠΈΡ
ΠΎΠ»ΠΎΠ³ΠΈΡΠ΅ΡΠΊΠΎΠ³ΠΎ ΡΠΎΠΏΡΠΎΠ²ΠΎΠΆΠ΄Π΅Π½ΠΈΡ ΠΎΠ±ΡΠ°Π·ΠΎΠ²Π°ΡΠ΅Π»ΡΠ½ΠΎΠ³ΠΎ ΠΏΡΠΎΡΠ΅ΡΡΠ° Π² Π²ΡΠ·ΠΎΠ²ΡΠΊΠΎΠΌ ΠΎΠ±ΡΠ°Π·ΠΎΠ²Π°Π½ΠΈΠΈ.Π Π΅Π·ΡΠ»ΡΡΠ°ΡΡ. ΠΡΠΎΠ±Π΅Π½Π½ΠΎΡΡΠΈ Π΄Π΅ΡΡΠ΅Π»ΡΠ½ΠΎΡΡΠΈ Π²ΡΠ·ΠΎΠ²ΡΠΊΠΈΡ
Π°ΠΊΠ°Π΄Π΅ΠΌΠΈΡΠ΅ΡΠΊΠΈΡ
ΡΠ»ΡΠΆΠ± ΠΏΡΠΈΡ
ΠΎΠ»ΠΎΠ³ΠΈΡΠ΅ΡΠΊΠΎΠ³ΠΎ ΡΠΎΠΏΡΠΎΠ²ΠΎΠΆΠ΄Π΅Π½ΠΈΡ ΡΠ²ΡΠ·Π°Π½Ρ Ρ ΠΏΠΎΠΌΠΎΡΡΡ ΠΌΠΎΠ»ΠΎΠ΄ΡΠΌ ΠΈ Π²Π·ΡΠΎΡΠ»ΡΠΌ Π»ΡΠ΄ΡΠΌ, ΠΎΠ±ΡΡΠ°ΡΡΠΈΠΌΡΡ ΠΈ ΠΎΠ±ΡΡΠ°ΡΡΠΈΠΌ, Π° ΡΠ°ΠΊΠΆΠ΅ ΠΈΠ½ΡΠΌ ΡΠΎΡΡΡΠ΄Π½ΠΈΠΊΠ°ΠΌ ΡΠ½ΠΈΠ²Π΅ΡΡΠΈΡΠ΅ΡΠΎΠ²/ΠΈΠ½ΡΡΠΈΡΡΡΠΎΠ² ΠΈ ΡΠ»Π΅Π½Π°ΠΌ ΠΈΡ
ΡΠ΅ΠΌΠ΅ΠΉ. ΠΡΠ½ΠΎΠ²Π½Π°Ρ ΡΠΎΡΠΌΠ° Π°ΠΊΡΠΈΠ²Π½ΠΎΡΡΠΈ, Π²ΠΎΠΊΡΡΠ³ ΠΊΠΎΡΠΎΡΠΎΠΉ ΠΈ ΠΏΠΎ ΠΏΠΎΠ²ΠΎΠ΄Ρ ΠΊΠΎΡΠΎΡΠΎΠΉ Π²ΡΡΡΡΠ°ΠΈΠ²Π°Π΅ΡΡΡ ΡΠΈΡΡΠ΅ΠΌΠ° ΠΎΡΠ½ΠΎΠ²Π½ΡΡ
ΠΈ Π΄ΠΎΠΏΠΎΠ»Π½ΠΈΡΠ΅Π»ΡΠ½ΡΡ
ΡΠ΅Π»Π΅ΠΉ ΠΈ ΡΡΠ΅Π½Π΄ΠΎΠ² Π΄Π΅ΡΡΠ΅Π»ΡΠ½ΠΎΡΡΠΈ Π΄Π°Π½Π½ΡΡ
ΡΠ»ΡΠΆΠ± β ΠΎΠ±ΡΠ°Π·ΠΎΠ²Π°ΡΠ΅Π»ΡΠ½Π°Ρ, ΡΡΠ΅Π±Π½Π°Ρ ΠΈ ΠΎΠ±ΡΡΠ°ΡΡΠ°Ρ. ΠΠ΄Π½Π°ΠΊΠΎ Π² Π²ΡΠ·Π΅ ΡΡΠΎ ΡΠΆΠ΅ Π½Π΅ ΠΏΡΠΎΡΡΠΎ ΠΎΠ±ΡΠ°Π·ΠΎΠ²Π°ΡΠ΅Π»ΡΠ½Π°Ρ, Π° ΠΎΠ±ΡΠ°Π·ΠΎΠ²Π°ΡΠ΅Π»ΡΠ½ΠΎ-ΠΏΡΠΎΡΠ΅ΡΡΠΈΠΎΠ½Π°Π»ΡΠ½Π°Ρ Π΄Π΅ΡΡΠ΅Π»ΡΠ½ΠΎΡΡΡ: ΡΠ΅Π½ΡΡΠ°Π»ΡΠ½ΠΎΠΉ Π·Π°Π΄Π°ΡΠ΅ΠΉ ΠΎΠ±ΡΠ°Π·ΠΎΠ²Π°Π½ΠΈΡ ΡΠ²Π»ΡΠ΅ΡΡΡ (ΠΏΠ΅ΡΠ΅) ΠΏΠΎΠ΄Π³ΠΎΡΠΎΠ²ΠΊΠ° ΡΠΏΠ΅ΡΠΈΠ°Π»ΠΈΡΡΠ°, Π² ΡΠΎΠΌ ΡΠΈΡΠ»Π΅ Π² ΠΎΠ±Π»Π°ΡΡΠΈ ΡΠ°Π·Π²ΠΈΡΠΈΡ Π΅Π³ΠΎ ΠΏΡΠΈΡ
ΠΎΠ»ΠΎΠ³ΠΈΡΠ΅ΡΠΊΠΎΠΉ ΠΊΡΠ»ΡΡΡΡΡ, Ρ ΠΊΠΎΡΠΎΡΠΎΠΉ ΠΎΠ½ Π²ΡΠΉΠ΄Π΅Ρ Π² ΡΠ΅Π°Π»ΡΠ½ΡΠΉ ΡΡΡΠ΄ΠΎΠ²ΠΎΠΉ ΠΏΡΠΎΡΠ΅ΡΡ, ΠΊ Π±ΡΠ΄ΡΡΠΈΠΌ ΡΠΎΡΡΡΠ΄Π½ΠΈΠΊΠ°ΠΌ, ΠΏΠΎΠ΄ΡΠΈΠ½Π΅Π½Π½ΡΠΌ ΠΈ ΡΡΠΊΠΎΠ²ΠΎΠ΄ΠΈΡΠ΅Π»ΡΠΌ, ΠΊΠ»ΠΈΠ΅Π½ΡΠ°ΠΌ ΠΈ Π·Π°ΠΊΠ°Π·ΡΠΈΠΊΠ°ΠΌ ΠΈ Ρ. Π΄., Ρ ΠΊΠΎΡΠΎΡΠΎΠΉ ΠΎΠ½ Π±ΡΠ΄Π΅Ρ ΠΆΠΈΡΡ, ΡΡΡΠΎΡ ΡΠ΅ΠΌΠ΅ΠΉΠ½ΡΠ΅ ΠΈ Π΄ΡΡΠΆΠ΅ΡΠΊΠΈΠ΅ ΠΎΡΠ½ΠΎΡΠ΅Π½ΠΈΡ, ΠΎΡΠ½ΠΎΡΠ΅Π½ΠΈΡ ΡΠΎΡΠ΅Π΄ΡΡΠ²Π° ΠΈ Ρ
ΠΎΠ±Π±ΠΈ. ΠΠ΅Π΄ΡΡΠΈΠΌΠΈ ΠΏΡΠΎΠ±Π»Π΅ΠΌΠ°ΠΌΠΈ Π°ΠΊΠ°Π΄Π΅ΠΌΠΈΡΠ΅ΡΠΊΠΈΡ
ΡΠ»ΡΠΆΠ± ΠΎΡΡΠ°ΡΡΡΡ: Π°) Π΄ΡΡ
ΠΎΠ²Π½ΠΎ-ΠΈΠ΄Π΅ΠΎΠ»ΠΎΠ³ΠΈΡΠ΅ΡΠΊΠΈΠ΅ ΠΈ ΡΠ΅ΠΎΡΠ΅ΡΠΈΠΊΠΎ-ΠΌΠ΅ΡΠΎΠ΄ΠΎΠ»ΠΎΠ³ΠΈΡΠ΅ΡΠΊΠΈΠ΅ Π°ΡΠΏΠ΅ΠΊΡΡ ΠΏΡΠΈΡ
ΠΎΠ»ΠΎΠ³ΠΈΡΠ΅ΡΠΊΠΎΠ³ΠΎ ΡΠΎΠΏΡΠΎΠ²ΠΎΠΆΠ΄Π΅Π½ΠΈΡ ΡΡΠ΅Π±Π½ΠΎΠ³ΠΎ ΠΏΡΠΎΡΠ΅ΡΡΠ° ΠΈ ΡΠ°Π·Π²ΠΈΡΠΈΡ ΡΡΡΠ΄Π΅Π½ΡΠΎΠ² ΠΈ ΠΏΡΠ΅ΠΏΠΎΠ΄Π°Π²Π°ΡΠ΅Π»Π΅ΠΉ ΠΊΠ°ΠΊ Π»ΠΈΡΠ½ΠΎΡΡΠ΅ΠΉ, ΠΏΠ°ΡΡΠ½Π΅ΡΠΎΠ² ΠΈ ΡΠ»Π΅Π½ΠΎΠ² ΡΠΎΡΠΈΡΠΌΠ°, ΠΊΠ°ΠΊ ΡΡΠ΅Π½ΠΈΠΊΠΎΠ² ΠΈ ΠΏΡΠΎΡΠ΅ΡΡΠΈΠΎΠ½Π°Π»ΠΎΠ²; Π±) ΡΡΡΠ°ΡΠ΅Π³ΠΈΠΈ ΠΏΠΎΡΡΡΠΎΠ΅Π½ΠΈΡ ΠΈ ΡΠ°Π·Π²ΠΈΡΠΈΡ ΠΏΠΎΠΌΠΎΠ³Π°ΡΡΠΈΡ
ΠΎΡΠ½ΠΎΡΠ΅Π½ΠΈΠΉ ΡΠΎ ΡΠ»ΠΎΠΆΠ½ΡΠΌΠΈ ΠΊΠ»ΠΈΠ΅Π½ΡΠ°ΠΌΠΈ, Ρ ΠΊΠ»ΠΈΠ΅Π½ΡΠ°ΠΌΠΈ, Π½Π°Ρ
ΠΎΠ΄ΡΡΠΈΠΌΠΈΡΡ Π² ΠΊΡΠ°ΠΉΠ½Π΅ ΡΠ»ΠΎΠΆΠ½ΡΡ
Π»ΠΈΡΠ½ΠΎΡΡΠ½ΡΡ
ΠΌΠΈΠΊΡΠΎΡΠΎΡΠΈΠ°Π»ΡΠ½ΡΡ
ΠΈ ΠΌΠ°ΠΊΡΠΎΡΠΎΡΠΈΠ°Π»ΡΠ½ΡΡ
ΡΠΈΡΡΠ°ΡΠΈΡΡ
; Π²) (ΠΏΠ΅ΡΠ΅) ΠΏΠΎΠ΄Π³ΠΎΡΠΎΠ²ΠΊΠ° ΠΈ ΠΏΠΎΠ²ΡΡΠ΅Π½ΠΈΠ΅ ΠΊΠ²Π°Π»ΠΈΡΠΈΠΊΠ°ΡΠΈΠΈ Π½Π°ΡΡΠ΄Ρ Ρ ΡΠ°ΡΡΠΈΡΠ΅Π½ΠΈΠ΅ΠΌ ΠΌΠ΅ΡΠΎΠ΄ΠΈΡΠ΅ΡΠΊΠΎΠ³ΠΎ Π°ΡΡΠ΅Π½Π°Π»Π° ΠΈ ΠΏΠΎΠ»Π½ΠΎΠΌΠΎΡΠΈΠΉ Π°ΠΊΠ°Π΄Π΅ΠΌΠΈΡΠ΅ΡΠΊΠΈΡ
ΠΏΡΠΈΡ
ΠΎΠ»ΠΎΠ³ΠΎΠ² ΠΈ ΠΈΠ½ΡΡ
ΡΠΏΠ΅ΡΠΈΠ°Π»ΠΈΡΡΠΎΠ² ΡΠ»ΡΠΆΠ±Ρ ΡΠΎΠΏΡΠΎΠ²ΠΎΠΆΠ΄Π΅Π½ΠΈΡ, ΠΊΠΎΠΎΡΠ΄ΠΈΠ½Π°ΡΠΈΡ ΠΈ ΡΠΎΠ²Π΅ΡΡΠ΅Π½ΡΡΠ²ΠΎΠ²Π°Π½ΠΈΠ΅ ΡΠ°Π±ΠΎΡΡ ΠΌΠ΅ΠΆΠ΄ΠΈΡΡΠΈΠΏΠ»ΠΈΠ½Π°ΡΠ½ΡΡ
ΠΊΠΎΠΌΠ°Π½Π΄ ΡΠΎΠΏΡΠΎΠ²ΠΎΠΆΠ΄Π΅Π½ΠΈΡ; Π³) ΠΏΡΠΈΡ
ΠΎΠ»ΠΎΠ³ΠΈΡΠ΅ΡΠΊΠ°Ρ ΡΠΊΡΠΏΠ΅ΡΡΠΈΠ·Π° ΠΈ ΡΠΎΠΏΡΠΎΠ²ΠΎΠΆΠ΄Π΅Π½ΠΈΠ΅ ΠΎΠ±ΡΠ°Π·ΠΎΠ²Π°ΡΠ΅Π»ΡΠ½ΡΡ
ΠΈΠ½Π½ΠΎΠ²Π°ΡΠΈΠΉ, ΠΈΡΠΏΠΎΠ»ΡΠ·ΠΎΠ²Π°Π½ΠΈΠ΅ ΠΎΠ±ΡΠ°Π·ΠΎΠ²Π°ΡΠ΅Π»ΡΠ½ΠΎΠΉ ΡΠΈΡΡΠ°ΡΠΈΠΈ Π΄Π»Ρ ΡΠ°Π·ΡΠ΅ΡΠ΅Π½ΠΈΡ Π·Π°Π΄Π°Ρ Π»ΠΈΡΠ½ΠΎΡΡΠ½ΠΎΠ³ΠΎ, ΠΌΠ΅ΠΆΠ»ΠΈΡΠ½ΠΎΡΡΠ½ΠΎΠ³ΠΎ, ΡΡΠ΅Π±Π½ΠΎΠ³ΠΎ ΠΈ ΠΏΡΠΎΡΠ΅ΡΡΠΈΠΎΠ½Π°Π»ΡΠ½ΠΎΠ³ΠΎ ΡΡΠ°Π½ΠΎΠ²Π»Π΅Π½ΠΈΡ ΠΈ ΡΠΎΠ²Π΅ΡΡΠ΅Π½ΡΡΠ²ΠΎΠ²Π°Π½ΠΈΡ ΠΎΡΠ½ΠΎΠ²Π½ΡΡ
ΡΡΠ°ΡΡΠ½ΠΈΠΊΠΎΠ² ΠΎΠ±ΡΠ°Π·ΠΎΠ²Π°Π½ΠΈΡ ΠΈ Π΅Π³ΠΎ ΡΡΠ΅ΠΉΠΊΡ
ΠΎΠ»Π΄Π΅ΡΠΎΠ².ΠΡΠ²ΠΎΠ΄Ρ. ΠΡΠΈΡ
ΠΎΠ»ΠΎΠ³ΠΈΡΠ΅ΡΠΊΠΎΠ΅ ΡΠΎΠΏΡΠΎΠ²ΠΎΠΆΠ΄Π΅Π½ΠΈΠ΅ ΠΎΠ±ΡΠ°Π·ΠΎΠ²Π°ΡΠ΅Π»ΡΠ½ΠΎΠ³ΠΎ ΠΏΡΠΎΡΠ΅ΡΡΠ° Π² Π²ΡΡΡΠ΅ΠΌ ΠΎΠ±ΡΠ°Π·ΠΎΠ²Π°Π½ΠΈΠΈ Π²ΡΡΡΡΠΏΠ°Π΅Ρ ΠΊΠ°ΠΊ ΠΎΠ±Π»Π°ΡΡΡ ΠΏΡΠΎΡΠ΅ΡΡΠΈΠΎΠ½Π°Π»ΡΠ½ΠΎΠΉ, ΠΌΠ΅ΠΆΠΏΡΠΎΡΠ΅ΡΡΠΈΠΎΠ½Π°Π»ΡΠ½ΠΎΠΉ ΠΈ ΠΊΠ²Π°Π·ΠΈΠΏΡΠΎΡΠ΅ΡΡΠΈΠΎΠ½Π°Π»ΡΠ½ΠΎΠΉ Π°ΠΊΡΠΈΠ²Π½ΠΎΡΡΠΈ, ΠΏΡΠ΅Π΄ΡΡΠ°Π²Π»Π΅Π½Π½Π°Ρ Π² ΠΌΠ½ΠΎΠ³ΠΎΡΠΈΡΠ»Π΅Π½Π½ΡΡ
ΡΠΎΡΠΌΠ°Ρ
ΠΈ Π½Π°ΠΏΡΠ°Π²Π»Π΅Π½ΠΈΡΡ
ΠΎΡΡΡΠ΅ΡΡΠ²Π»Π΅Π½ΠΈΡ ΠΏΠΎΠΌΠΎΡΠΈ ΡΠ΅Π»ΠΎΠ²Π΅ΠΊΠ° ΡΠ΅Π»ΠΎΠ²Π΅ΠΊΡ. ΠΠΎΠ³Π°ΡΡΡΠ²ΠΎ ΡΡΠΎΡΡΠΈΡ
ΠΏΠ΅ΡΠ΅Π΄ ΡΠ΅Π»ΠΎΠ²Π΅ΠΊΠΎΠΌ Π·Π°Π΄Π°Ρ, ΡΡΡΠ΄Π½ΠΎΡΡΠ΅ΠΉ ΠΈ ΠΊΡΠΈΠ·ΠΈΡΠΎΠ² Π»ΠΈΡΠ½ΠΎΡΡΠ½ΠΎΠ³ΠΎ, ΠΌΠ΅ΠΆΠ»ΠΈΡΠ½ΠΎΡΡΠ½ΠΎΠ³ΠΎ ΠΈ ΡΡΠ΅Π±Π½ΠΎ-ΠΏΡΠΎΡΠ΅ΡΡΠΈΠΎΠ½Π°Π»ΡΠ½ΠΎΠ³ΠΎ ΡΡΠ°Π½ΠΎΠ²Π»Π΅Π½ΠΈΡ ΠΈ ΡΠ°Π·Π²ΠΈΡΠΈΡ, Ρ ΠΊΠΎΡΠΎΡΡΠΌΠΈ ΡΡΠ°Π»ΠΊΠΈΠ²Π°Π΅ΡΡΡ ΠΈΠ½Π΄ΠΈΠ²ΠΈΠ΄ Π² ΠΎΠ±ΡΠ°Π·ΠΎΠ²Π°ΡΠ΅Π»ΡΠ½ΠΎΠΉ ΡΡΠ΅Π΄Π΅, ΠΌΠΎΠΆΠ΅Ρ ΠΎΡ
Π²Π°ΡΠΈΡΡ ΠΈ Π² ΡΠΎΡΡΠΎΡΠ½ΠΈΠΈ ΠΏΠΎΠΌΠΎΡΡ ΡΠ°Π·ΡΠ΅ΡΠΈΡΡ ΡΠΈΡΡΠ΅ΠΌΠ½ΠΎ ΠΎΡΠ³Π°Π½ΠΈΠ·ΠΎΠ²Π°Π½Π½Π°Ρ ΡΠ°Π±ΠΎΡΠ° Π°ΠΊΠ°Π΄Π΅ΠΌΠΈΡΠ΅ΡΠΊΠΎΠΉ ΡΠ»ΡΠΆΠ±Ρ ΠΏΡΠΈΡ
ΠΎΠ»ΠΎΠ³ΠΈΡΠ΅ΡΠΊΠΎΠ³ΠΎ ΡΠΎΠΏΡΠΎΠ²ΠΎΠΆΠ΄Π΅Π½ΠΈΡ ΠΎΠ±ΡΠ°Π·ΠΎΠ²Π°Π½ΠΈΡ. Π’Π°ΠΊΠ°Ρ ΡΠ»ΡΠΆΠ±Π° Π²ΠΊΠ»ΡΡΠ°Π΅Ρ ΠΏΠΎΠΌΠΎΡΡ ΡΠ°Π·Π½ΡΠΌ Π³ΡΡΠΏΠΏΠ°ΠΌ ΠΊΠ»ΠΈΠ΅Π½ΡΠΎΠ², Π½Π°Ρ
ΠΎΠ΄ΡΡΠΈΡ
ΡΡ Π² ΡΡΡΠ΄Π½ΡΡ
, ΠΊΠΎΠ½ΡΠ»ΠΈΠΊΡΠ½ΡΡ
ΠΈ ΠΊΡΠΈΠ·ΠΈΡΠ½ΡΡ
ΡΠΈΡΡΠ°ΡΠΈΡΡ
ΡΠ°Π·Π½ΠΎΠΉ ΠΈΠ½ΡΠ΅Π½ΡΠΈΠ²Π½ΠΎΡΡΠΈ ΠΈ ΠΎΠ±ΡΠ΅ΠΌΠ°: ΠΏΠΎΠΌΠΎΡΡ Π² ΠΏΠΎΠΈΡΠΊΠ΅ ΡΠ΅ΡΡΡΡΠΎΠ² ΡΠΎΠ²Π»Π°Π΄Π°Π½ΠΈΡ Ρ ΠΏΡΠΎΠ±Π»Π΅ΠΌΠ°ΠΌΠΈ Π»ΠΈΡΠ½ΠΎΡΡΠ½ΠΎΠ³ΠΎ, ΠΌΠ΅ΠΆΠ»ΠΈΡΠ½ΠΎΡΡΠ½ΠΎΠ³ΠΎ ΠΈ ΡΡΠ΅Π±Π½ΠΎ-ΠΏΡΠΎΡΠ΅ΡΡΠΈΠΎΠ½Π°Π»ΡΠ½ΠΎΠ³ΠΎ ΡΠ°Π·Π²ΠΈΡΠΈΡ
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