ࣈෂ˟ԠԈ֥ᢿ˟৫᥵ᨼᇹᲮ‫ׅ‬ԠԈ֥ᢿ˟ၐ̊౨᚛˟
ᇹᲰ‫ׅ‬Ꮝƕǜᄂᆮ˟․•‣ ࠰‣․உ‣ ଐ≋⁥⁓⁦≌

৯‫ؙ‬ઃ

ᇹᲮ‫ׅ‬ԠԈ֥ᢿ˟ၐ̊౨᚛˟


ᲴᲴ
Ჴ೉࿚ভళลஓ৖ভभऒोऽद‫؞‬ऒोऊै 

ഌ੘೉࿚ভ୰੹‫ؙ‬ళลஓ৔ఐ৖শ
೔িඤ౓ౠশ‫୴૸؞‬ਧ੕়୰੹‫ؙ‬ళลஓ৔ఐ ৖শగ௿༟಻ 

1ॽ঎ঝঐঈ਺ଖ৏पৈ&.ഷඪ়॑ಡख੎ඪ൙૮ৡඪ॑৅ඪखञ୻
ਮ೎৘য়୰੹‫ؙ‬ᇯᯂ৔ఐশદਆಜ঳‫ؚ‬ኧ೗‫ؚ‬পিඤ৻‫ૣؚ‬ળਫ೗

2૏ડཡ୅‫؞‬ອ࿒জথঃතᇯপपेॊਞ੊൷ኋ‫؞‬ంᑖ๢়॑ಡख੘௜৭උपౙൟखञཡᏣቅभ঳୻
প࿩ಧો୰੹‫ؙ‬৔ఐ௼ਣ࿓௶‫ؚ‬஌মઌ૓৕‫ؚ‬੎িຶ੦‫ؚ‬౱িᅔয‫ؚ‬৛ম፮‫ؚ‬ি੨ౘপ

3ཡቅपेॊਞଵীว৖୰૗पৌखथVLGHE\VLGHPHWKRGद૏ડ਌ਞଵ੍५ॸথॺ॑ዠোखञ ୻ഌ੘೉࿚ভ୰੹‫ؙ‬ళลஓ৔ఐ  ‫ؚ‬৊੕়৔ఐ ௖ഓၔ  ‫ؚ‬೔িඤ౓  ‫ؚ‬೔৔ઌဣ  ‫≥ؚ‬ઢ๬಻  ‫ؚ‬೔মඤ೗  ‫ؚ‬ির෥౴  ‫ؚ‬਴িഺ৥  ‫ؚ‬ฝਉข  ‫ؚ‬೔িዹ঳ 

4ৈఢణᅼಕ₊৕पेॊ൏⍔୒ध৲৾௜১पथ೰୵खइञཡ୅৖ཡ⑻਴঱ຜቅभ঳୻
੡ଽો೉࿚ভ੕়୰੹ళลஓ৔ఐ  ‫ؚ‬৊ళลஓਗఐ  ‫ؚ‬৊೰૶੕়൧௜ఐ ഌவઋ੦  ‫ؚ‬૭ు୲๕  ‫ؚ‬প਴ೢ๕ 

5

2VLPHU WLQLEऋས஍खञቅਙᇈჍ༇भ ୻ഌ੘೉࿚ভ୰੹‫ؙ‬ళลஓ৔ఐ  ‫ؚ‬৊੕়৔ఐ ೔৔ઌဣ  ‫ؚ‬೔িඤ౓  ‫≥ؚ‬ઢ๬಻  ‫ؚ‬೔মඤ೗  ‫ؚ‬ির෥౴  ‫ؚ‬਴িഺ৥  ‫ؚ‬ฝਉข  ‫ؚ‬೔িዹ঳ ౠশ‫؞‬ழஏ೉࿚ভ੕়୰੹‫ؙ‬৔ఐ ৖শᅷেბฆ 

6ॡজ॰ॳॽঈ‫ؚ॔‬ঞॡॳॽঈ਺ଖ৏प3'धऩॉ७জॳॽঈऋས஍खञ$/. ੆়఩஫৕഻ਙశ৵಍ཝཡቅभ୻
প࿩ಧો୰੹‫ؙ‬৔ఐি੨ౘপ‫ؚ‬஌মઌ૓৕‫ؚ‬੎িຶ੦‫ؚ‬౱িᅔয‫ؚ‬৛ম፮‫ؚ‬௼ਣ࿓௶

7॔ঞঝॠ‫ش‬ਙਞଵ੍ཡ॔५ঌঝॠঝ५ඪभ  ୻ഌ੘೉࿚ভ୰੹‫ؙ‬ళลஓ৔ఐ  ‫ؚ‬৊੕়৔ఐ ൽఖෞ৕  ‫ؚ‬೔িඤ౓  ‫ؚ‬೔৔ઌဣ  ‫≥ؚ‬ઢ๬಻  ‫ؚ‬೔মඤ೗  ‫ؚ‬ির෥౴  ‫ؚ‬਴িഺ৥  ‫ؚ‬ฝਉข  ‫ؚ‬೔িዹ঳ 

8๊ᔄधঐॖ॥উছ६ঐभ੎ള૎ഉपेॉཡ༇‫ິؚ‬ႇચ౮ଞ॑ऌञखञ঳୻
૸୴ਧ੕়୰੹‫ؙ‬৔ఐ ‫ؚك‬৊ళลஓ৔ఐ ৵ྒల਴ ‫ؚك‬૝ম೦঳ ‫ؚك‬గ௿༟಻ ‫ك‬

9ঐॖ॥উছ६ঐཡ༇‫ؙ‬൧૵঱भਖ਻ਡ
ਮ೎৘য়୰੹‫ؙ‬ళลஓ৔ఐ ‫ؚك‬৊ᇯᯂ৔ఐ ஬ੇಋේ  ‫ؚ‬ൈেბ৕  ‫ؚ‬૝মႿಂ  ‫ؚ‬৵ਣਮื  ‫ؚ‬ળඤ৕  ‫ৣૈؚ‬อ಻  ‫ؚ‬শદਆಜ঳  ‫ૣؚ‬ળਫ೗ ᇹᲰ‫ׅ‬Ꮝƕǜᄂᆮ˟Ჴ Ჴ

ᏍƕǜЎ‫܇‬೅ႎ඙ၲȕǩȸȩȠౠশഌ੘೉࿚ভ୰੹‫ؙ‬ళลஓ৔ఐ ৖শ೔িඤ౓੔ে

੦৹൥౰ శ৵಍ཝཡቅभગেਫ਼पणःथ‫ॢॱع‬জॵ९അੳ৏भਠ૾‫ع‬౰঻੺ྡপ৾ୢ৾৖‫ؙ‬৔ఐ৾ᇯᯂ৔ఐ৖୅൥పির‫ؙ‬ႎ੔েౠশਮ೎৘য়୰੹‫ؙ‬੕শૣળਫ೗੔ে

્શ൥౰ َ(*)5ٕ7. ,भິਙਃ๰धजभ੘௜ਅറُ
౰঻੺ྡপ৾ୢ৾৖ਗఐ৾ઇ஼ళลஓਗఐ৖୅ઇ౸୾༴ජ࿙੔ে





1ॽ঎ঝঐঈ਺ଖ৏पৈ&.ഷඪ়॑ಡख
੎ඪ൙૮ৡඪ॑৅ඪखञ  ୻ਮ೎৘য়୰੹‫ؙ‬ᇯᯂ৔ఐশદਆಜ঳‫ؚ‬ኧ೗‫ؚ‬পিඤ৻‫ૣؚ‬ળਫ೗

ඪ‫୻ؙ‬
ၐ̊↞

ബ‫⅚ࣱڡ‬᩼տ໺ᎍ⅚‷ ‹ ‸ ⁄ ᢡˡ‫ီ٭܇‬ᨗ ࣱ ‚ ‾‪‧‪⁄ ‛ Ꮝᐄၶ ⅛‥ ഏ඙ ၲ↗ↆ↕⇱∂∑∄⇼⇁

᧏‫⇟∞⇙․⅛↎ↆڼ‬৲ɨࢸ⁖⁓⁫․ ↚μ៲͎࣭ज़ ⅚߼ა წɦ‫⅚׶‬ᫀᢿၘ⅚ሂщ˯ɦ⇁ᛐ↰λᨈ↗↙→↎⅛λᨈ଺౨௹↖↞‵ ⁂‽‒᭗͌‚ ‧※⁇‡⁞ ‛↖ⅱ→↎⅛

β၃⇖∓⇼∐∙‫ٻ‬᣽ၲඥ⇁଀ᘍ↱⅚‶⁓⁫‥•↚⇕∐∞⇢↚ᐱ→↎↎↰⅚‴ ※⁂″⁂↚↷↺ԠԈሥྸ↗⅚ҥኝᘉ๶ʩ੭ၲඥ⇁ᘍ→↎⅛ࢸଐ৴ ″ ⁕⁚⁄ ৴˳ࣱᨗ↗Й ଢↆ↎↎↰⅚ࡽⅼዓⅼβ၃Ԉბၲඥ⇁ᘍ→↎⅛ࢹ⅝↚ၐཞ↞᠉ࣛↆ⅚⇟⇬∓⇊⇯඙ၲ⇁ᡙьↆ⁖⁓⁫ ‧↚‴※⁂″⁂ⅺ↸ᩉᏮↆ↎⅛‒⇱∂∑∄⇼↞ஊஓ↙ᕤд↖ⅱ↹⅚ʻࢸ↌↝ ᢘ ࣖ↞ ˂ ၶ ᆔ ↧ ਘ ‫↺↻ↄٻ‬ⅻ ⅚৲ɨ↚࢘↎→↕↞ ᧙ ̞Ӳᅹ↝ዬ݅↙ᡲઃ↚↷↺и˺ဇ‫ݣ‬ሊⅻ࣏᪰↖ⅱ↹⅚и˺ဇ⇁ᙸᓳ↗ↈↂ↗ⅻ↙ⅳ↷ⅵ⅚॰᣻↙ᚮၲ७ࡇⅻ൭↰↸↻↺⅛↭↎ஜၐ̊↝↷ⅵ↙ᆇ↙и˺ဇ↚᧙ↆ↕↞↌↝ऴ‫⇁إ‬σஊↆ↕ⅳⅾ࣏ᙲⅻⅱ↺↗ᎋⅷ
↸↻↺⅛

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2

૏ડཡ୅‫؞‬ອ࿒জথঃතᇯপपेॊਞ੊൷ኋ‫؞‬ం ᑖ๢়॑ಡख੘௜৭උपౙൟखञཡᏣቅभ঳୻
প࿩ಧો୰੹‫ؙ‬৔ఐ௼ਣ࿓௶‫ؚ‬஌মઌ૓৕‫ؚ‬੎িຶ੦‫ؚ‬౱িᅔয‫ؚ‬৛ম፮‫ؚ‬ি੨ౘপ

ඪ‫୻ؙ‬

‪ബ⅚ဏࣱ

਌‫ؙ‬୪

ႆ༏⅚Զ

ਠ୰ഄ
⁊‟‣․ଐ↷↹ᱠ൬⅚Թ᪽ၘ⇁ᐯᙾ ⅛⁊‟‧ଐ↷↹Զ⅚ၝ⇁ᛐ↰ ⁊ உ ⁊ ଐ࢘ᨈӖᚮↆλᨈ↗↙→↎⅛៲ ˳ ৑ᙸɥ߼Ꮯᢿ↚⁕⁡⁓⁤⁥⁗‒⁕⁤⁓⁕⁝⁞⁗⁥⅚μ៲ႝᐎ↝᱅ᑥ‫⇁҄٭‬ᛐ↰↎⅛Ꮯᢿ‵ ⁆ ↚↕ൢᏽཞ‫⅚҄٭‬ɲͨᏍᧉ∝ጏᨠ∐∙⇷ራᏽ‫߼⅚ٻ‬ɦᓶේ๾ࢨ⅚߼Ꮯ൦⇁ᛐ↰↎⅛߼᧍‫ࣱص‬Ꮝ໒ ⅚‵⁁⁂‶↗ᚮૺↆ″‴⁂‵‡⁅‴⁆ ৲ɨ⇁᧏‫⅛↎ↆڼ‬ᇹ … ၏ଐ↷↹ԠԈ‫׉‬ᩊ∝մ ᯚ‫ف‬फↆ⅚ ⁂⁅‾‒…• ⁙⁷․ ৲ɨ⅚ₒХນᕤԈλ⇁᧏‫⅛↎ↆڼ‬ᇹ ‧၏ଐᏟ൦ᆲХ⇁ᘍⅳ⅚߼ ᐝ Ꮯ↗ᚮૺↆ↎⅛ԠԈཞ७↞ોծ↊↉⅚ᇹ ၏ଐ
⅙߼ɼൢሥૅ⅚ӫɶ᧓ൢሥૅ࠴⊡ɦᓶൢሥૅ↚⇟⇬∙⇮⇁သፗↆ↎⅛ᇹ‣•၏ଐൢሥૅᦟ౨௹⇁ᘍⅳ⅚ൢሥϋ↝ᨙឪࣱ၏‫↹↷٭‬ဃ౨⇁଀ᘍↆ↎⅛˯Ў҄‫׹‬ᐄၶ⅚‷‹‸⁄ ‫ီ٭‬ᨏࣱ⅚″ ‾ ‽ ᠃ࡈᨏࣱ↖ⅱ→↎⅛ᇹ․ ၏ଐ ᪽ᢿᡯࢨ ‿⁄※⇁଀ᘍↆ᠃ᆆ⇁ᛐ↰↙ⅺ→↎⅛ᇹ․‪၏ଐ ⁂‷ ⁆‟‵ ⁆଀ᘍ⅛Ꮝˌ‫᠃↝ٳ‬ᆆ↞↙ⅾ⅚⁕⁆⁪⁀‥‿•‒⁅⁦⁓⁙⁗‒⃿‴↗ᚮ ૺↆ↎ ⅛
ᇹ… ၏ଐ↷↹‵‴‶‵″”⁂⁆⁊”⁄⁆⁪↚↕඙ၲ⇁᧏‫⅛↎ↆڼ‬અ‫ؙ‬௄ൢᢊ᧍‫ص‬ၐཞⅱ↹Ҿ၌ध↝඙ၲ⇁౨᚛ↆ↎↱↝↝⅚᧍ ‫ࣱص‬Ꮝ໒∝߼ᐝᏟ⇁ӳ́ↆज़௨↝⇙∙⇮∓∞∑⇁Οέ↊ↅ↺ࢽ↙ⅳཞඞ↖ⅱ→↎⅛࢘И↞˯௿᫱ཞ ७↖ⅱ↹⇟⇬∙⇮သፗ ⅚્ ‫ݧ‬ዴ඙ၲ↝↮↝‴⁅‵
૾ᤆ↱౨᚛ↆ↎⅛⇟⇬∙⇮သፗ↳ൢሥૅਘࢌдԈλ⅚ൢሥૅᦟɦ↝ၝԈࡽ⅚৴ᓏᕤ৲ɨ↚↕ज़௨↝⇙∙⇮∓∞∑ⅻ˄ⅾ↚↓↻″‶‾↱Ӽɥↆ⅚ᐝᏟ↝඙ၷ⇁ࢳ→↕೅แႎ඙ၲ⇁ᘍⅵↂ↗ⅻ↖ⅼ↎⅛ᐝ Ꮯ↚‫ݣ‬ↈ↺඙ၲ⇁ᘍⅵໝ↚↞ᏽ ၨ↚‫↺ↈݣ‬඙ၲ↱࣏ᙲ↖ⅱ↹⅚඙ ၲ૾ᤆ↝ᢠ৸↚ᒊॾↆ↎ၐ̊↖ⅱ→↎⅛
ᡶᘍᏍၶ↚ᐝᏟ↙↘⇙∙⇮∓∞∑‫׉‬ᩊ↙ज़௨ ၐ⇁ӳ́ↆ↎‫ ئ‬ӳ⅚৴ ၶ д඙ ၲ↝ᢘ ࣖ‫↹↙↗ٳ‬ᆢ ಊ ႎ඙ၲⅺ↸ગᡚ↊ↅ↺ࢽ↙ⅳ⇗∞⇟ⅻ‫ٶ‬ⅳ⅛ᐝ Ꮯ⇁ӳ́ↆ↎Ꮝၶ↝‫ئ‬ӳ⅚‫ٳ‬ᅹႎ඙ၲ⇁ᢠ৸ↆ↎‫إ‬ԓ↞‫ٶ‬ⅳⅻ⅚̬‫܍‬ႎ඙ၲ↝ࢸ⅚৴ၶд৲ɨ↧ᆆᘍ↖ⅼ↎ᡶᘍၶ↝‫إ‬ԓ↞‫↙ݲ‬ⅳ⅛Ӳᆔ඙ၲ↝Мໜ⅚എໜ⇁౨᚛ↆ॰᣻↚඙ၲ⇁ᢠ৸ↈ↺࣏ᙲⅻⅱ↺↗ᎋⅷ↸↻↎ ⅛

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ཡቅपेॊਞଵীว৖୰૗पৌखथ
VLGHE\VLGHPHWKRGद૏ડ਌ਞଵ੍५ॸথॺ॑ዠোखञ୻
ഌ੘೉࿚ভ୰੹‫ؙ‬ళลஓ৔ఐ  ‫ؚ‬৊੕়৔ఐ ௖ഓ‫ؙ‬ၔ  ‫ؚ‬೔িඤ౓  ‫ؚ‬೔৔ઌဣ  ‫≥ؚ‬ઢ๬಻  ‫ؚ‬೔মඤ೗ ির෥౴  ‫ؚ‬਴িഺ৥  ‫ؚ‬ฝਉข  ‫ؚ‬೔িዹ঳ ඪ‫୻ؙ‬ၐ̊↞ ․ബဏࣱ↖⅚‣∜உЭⅺ↸↝ԠԈ‫׉‬ᩊ↖ ⁊ ࠰‣உ ‪ଐ↚࢘ᨈ્‫ݧ‬ዴᅹ↚Ꮯᢿҥኝ‵⁆↖ኰʼ⅚ီࠝ⇁ᛐ↰↕፻ଐ⅚࢘ᅹ↧ኰʼↄ↻↎⅛Ꮯᢿҥኝ‵⁆↖ӫɥᓶ ⁅‣⁓ ↚ᏽၭ⇁ᛐ↰⅚Ꮝᧉ∝ጏᨠ∐∙⇷ራᏽ‫↹↷↚ٻ‬ൢሥЎ‫ޟ‬ᢿ↝‫⇁࢟٭‬ˤ→↕ⅳ↎↎↰⅚Иᚮ଺↚Ꮯᐃᢿᡯࢨ‵ ⁆⇁଀ᘍ⅚ӫɼൢሥૅ↝‫ܦ‬μ᧍‫↗ص‬ӫɦᓶ↝ᢿЎ໯ൢᏍ⇁ԑↈ↺↗σ↚⅚ൢሥɦᢿ⊡߼ɼൢሥૅλӝᢿ↚ⅺↀ↕᭗ࡇ཰ᆵ⇁ᛐ↰↎⅛ኵጢ‫↝׹‬ൿ‫ܭ‬ⅻ᣻ᙲ↗Йૺↆ⅚ӷଐ⅚แዬ࣯ႎ↚ൢሥૅᦟɦဃ౨⇁଀ᘍ⅚ɶЎ҄‫׹‬৒࠯ɥႝၶ↗ᄩ‫⅛↎ↆܭ‬Иᚮⅺ↸ ‣ᡵ᧓↖⇟⇬∞⇞∙⇖⇁ᘍⅳ⅚
⁕⁆․⁓⁀․‿‣⁓‒⁥⁦⁓⁙⁗※⁈↗ᚮૺↆ↎ⅻ⅚↌↝᧓↚࣯ນ↙ԠԈཞ७↝फ҄⇁ᛐ↰⅚҄‫ܖ‬ၲඥ∝્‫ݧ‬ዴၲඥ↚↷↺ ⁥⁓⁞⁨⁓⁙⁗↞‫׉‬ᩊ↗Йૺↆ⅚‫ھ‬ऒႎ↚ӫɼൢሥૅ⇟⇬∙⇮≋ ⁇⁞⁦⁤⁓⁘⁤⁗⁪„‒⁕⁡⁨⁗⁤⁗⁖„‒…⁕ „‒₥‣…
ሥ⇟⇬∙⇮≋⁇⁞⁦⁤⁓⁘⁞⁗⁪„‒⁔⁓⁤⁗„‒…⁕ „‒₥‣

≌ӏ↢ൢ≌⇁သፗↆ↎⅛သፗↆ↎ ․ଐࢸⅺ↸‵‴‶‵″‒‚″⁇‵‒‧ ‛‒”‒⁂″‵‚․•• ⁙‡․‛‒⁣․‣⁖⁓⁫⁥⇁᧏‫↎ↆڼ‬ⅻ⅚⁖⁓⁫‒‧↖ൢሥૅᦟ↝ϐ౨⇁ᘍ→↎↗ↂ↼⅚ᏽၨ↝୼↙↺ᡶ‫⇁ޒ‬ᛐ↰⅚ɲͨɼൢሥ
≋ ⁇⁞⁦⁤⁓⁘⁤⁗⁪„‒⁕⁡⁨⁗⁤⁗⁖„‒
ૅλӝᢿ↞᭗ࡇ཰ᆵ⇁ԑↆ↎↎↰⅚⁥⁛⁖⁗‟⁔⁫‟⁥⁛⁖⁗‒ ⁗⁦⁚⁡⁖↚↷↹ɲͨɼൢሥૅ⇟⇬∙⇮⁕ „‒₥‣…

≌⇁သፗↆ↎⅛ↂ↻↚↷↹⅚ԠԈཞ७↞тႎ↚ોծↆ⅚‫ٳ‬ஹ҄‫ܖ‬ၲඥ↧↗ᆆᘍ ⅚․ ⇛⇊⇕∑Ⴘ↝‵ ⁆ ᚸ̖↞ ⁂⁄ ↖⅚↌↝ࢸ⅚… ⇛⇊⇕∑↭↖඙ၲ⇁ᘍ→↎⅛ᡙь඙ၲ⇁ᘍ↾↉↚ኺᢅᚇ‫ݑ‬ɶ⅚඙ၲ᧏‫ڼ‬ⅺ↸ ∜உ↖࣎ᐥᆳ໱ര≋ࣱ࣯࣎ሂయ‫˂↕↚≌ ص‬မↆ↎⅛⅙ᡵҥˮ↖↝࣯ᡮ↙ᡶᘍ⇁ԑↈ↺᩼‫ݱ‬ኬᏘᏍၶ↚↷↺ൢᢊ཰ᆵ↚‫ھ⅚↕ↆݣ‬ऒႎ↙⇟⇬∙⇮သፗ⇁ᘍⅵʙ↖⅚҄‫ܖ‬ၲඥⅻ‫ڌ‬јↈ↺↭↖↝଺᧓⇁ᆙⅿↂ↗ⅻЈஹ↕⅚धᎍ↝ ⁃⁁‾ ોծӏ↢ʖࢸࡨᧈ↚݃ɨↆ↎⅛

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4

ৈఢణᅼಕ₊৕पेॊ൏⍔୒ध৲৾௜১पथ
೰୵खइञཡ୅৖ཡ⑻਴঱ຜቅभ঳୻
੡ଽો೉࿚ভ੕়୰੹
ళลஓ৔ఐ  ‫ؚ‬৊ళลஓਗఐ  ‫ؚ‬৊೰૶੕়൧௜ఐ ഌவઋ੦  ‫ؚ‬૭ు୲๕  ‫ؚ‬প਴ೢ๕ ඪ‫୻ؙ‬
ၐ̊↞ ․ബဏࣱ ⅛‵⁁⁂‶↗ ॸࣱ࣎ɧμ↚↕ ᡫᨈɶ↖ⅱ→↎ⅻ ⅚ԠԈ‫ ׉‬ᩊ↗ᘉ ၝ⇁ɼᚫ↚‫ ܭ‬஖ ‫ٳ‬Ӗᚮↆ↎⅛Ꮯᢿ ‵ ⁆↚↕߼Ꮝᧉᢿ↚ᏽၭࢨ⇁ᛐ ↰⅚ҾႆࣱᏍၶ↗ᎋⅷ↸↻⅚߼ɼൢሥૅ↧↝ේ๾↱ွ↾↻↎⅛৴ᘉ‫ݱ‬ெᕤ⇁ ․ дϋ஌ↆ↕ⅳ↎↎↰⅚ࢳೞႎ↙ൢሥૅϋᙻ ᦟ ౨௹⇁ʖ‫↕ↆܭ‬ⅳ↎ⅻ⅚
߼໯ൢᏍ↗᧍‫ࣱص‬Ꮝ໒⇁ဃↇ⅚ԠԈཞ७ⅻफ҄ↆ↎↎↰⅚ᇹ‫‫‬၏ଐ↚ൢሥϋ਴ሥɦ↖↝ʴ߻ԠԈ֥ሥྸ↗↙→↎⅛ᇹ‣• ၏ଐ↚ൢሥૅϋᙻᦟ⇁଀ᘍↆ⅚߼ɼൢሥૅ⇁ҩਗↈ↺ᏽၭ⇁ᛐ↰ ⅚ဃ౨↚↕
৒࠯ɥႝၶ↗ᚮૺↄ↻↎⅛᭗ԗඬϹ‫׍‬᤯‫↕↚܇‬ᏽၨ⇁໲ໍↆ↙ⅻ↸ᨊӊↆ⅚ᇹ‣…၏ଐ↚↱ᡙь඙ၲ⇁ᘍⅵↂ↗↖⅚߼ɦᓶૅ↝᧏‫↺ࢽ⇁܍‬ↂ↗ⅻ↖ⅼ⅚ᇹ‣ ၏ଐ↚ʴ߻ԠԈ֥ሥྸⅺ↸ᩉ Ꮾↆ↎⅛↌↝ࢸ҄‫ܖ‬ၲඥ⇁଀ᘍↆ⅚ᏽၨ↝጑‫↗ݱ‬μ៲ཞ७↝ોծⅻࢽ↸↻⅚ᇹ…• ၏ଐ↚᠉ࣛᡚᨈ↗↙→↎ ⅛ʴ ߻ԠԈ֥ሥྸɦ↖↝᭗ԗඬϹ‫׍‬᤯‫↺↷↚܇‬ᏽၨ໲ໍᘐ↚↕૔ԡↆⅷ↎ၐ̊⇁ኺ᬴ↆ↎↝↖‫إ‬ԓↈ↺⅛

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5

2VLPHUWLQLE ऋས஍खञቅਙᇈჍ༇भ  ୻ഌ੘೉࿚ভ୰੹‫ؙ‬ళลஓ৔ఐ  ‫ؚ‬৊੕়৔ఐ ೔৔ઌဣ  ‫ؚ‬೔িඤ౓  ‫≥ؚ‬ઢ๬಻  ‫ؚ‬೔মඤ೗ ির෥౴  ‫ؚ‬਴িഺ৥  ‫ؚ‬ฝਉ‫ ؙ‬ข  ‫ؚ‬೔িዹ঳ ూ‫ؙ‬ବ‷‹‸⁄‟⁆‽※ ৲ɨഭⅻⅱ↹⁆ ‫ ‿•‫‬ࣱᨗ↝ၐ̊↚↓ⅳ↕↞⁡⁥⁛ ⁗⁤⁦⁛⁠⁛⁔↝ஊјࣱⅻ‫إ‬ԓↄ↻↕ⅳ↺⅛

ඪ‫୻ؙ‬․ബ‫ݦ⅚ࣱڡ‬ಅɼۡ ⅛ᚆ஀ഄ•ബ↖ᅠ໺ ⅚↌↻↭↖․•ஜ‡ଐ⅛ใ༼ഄ᭗ᘉ‫ן‬ၐ⅚Ꮲឋီࠝၐ⅛ਠ୰ഄ‫৽؞‬ૌᡈҔ↚↕ᡫᨈь ၲɶ ⅚⁊‟․‒࠰‣•‒உⅺ↸↝Զ֏↖ ‵⁊⁄⇁જ ࢨ ⅚Ꮝ ၶ↝ွⅳ↖ኰʼ⅛Ꮯᢿ ‵ ⁆ ↖߼ɥᓶ↝ᏽၭ⅚ጏᨠ∐∙⇷ራᏽ‫⅚ٻ‬Ꮯᭌ᠃ᆆ⇁↮↗↰⅚ൢሥૅᦟ↖ᐄၶ‒‚ ‷‹‸⁄‒ ‬‒‾‪‧‪⁄ ‒‛↗ᄩ‫⅚ↆܭ‬μ៲౨ኧ↝ኽ ௐ⅚⁕⁆․⁓⁀‥‿‣⁔‒‚ ⁁⁅⁅ ‛‒⁥⁦⁓⁙⁗‒※⁈↗ᚮૺↆ↎⅛ɟഏ඙ၲ↗ↆ↕ ‵‴‶‵″≎⁂‷ ‿ ⇁ ᧏ ‫⅚ↆڼ‬ʚഏ඙ ၲ↗ↆ↕⁙⁗⁘⁛ ⁦⁛ ⁠ ⁛ ⁔ ⇁‫ݰ‬λↆ↎ⅻଔ஖↚⁂‶↗↙↹⅚
⁊‟‣࠰ ‫‫‬உⅺ↸⁗⁤⁞⁡⁦ ⁛⁠⁛⁔‒‚ ‷ ‛‒ ≎‒⁔⁗⁨⁓⁕⁛⁬⁧ ⁓⁔‒‚ ‴‛‒́ဇၲඥ⇁᧏‫↗↎ↆڼ‬ↂ↼⅚‫ ڌ‬јↆ↎ⅻ ႝ ၉ⅻࢍⅾↃஜʴ↝ॖӼ↖ ⇛⇊⇕∑↚↕ɶഥ↗↙→↎⅛⁊ ࠰ ‥உⅺ↸⁠⁛⁨⁡⁞⁧ ⁓⁔⇁᧏‫↗↎ↆڼ‬ↂ↼⅚‥⇛⇊⇕∑ᡦɶ↷↹⅚᫢ഒɧਰ ⅚᪽ၘ⅚ࣱ఍↝‫⅚҄٭‬ତࣱࣦ↙↘ⅻЈྵↆଐࠝဃ෇↚ૅᨦ⇁ஹↆ↎⅛
ᐮ࠿ኺᢅ↗᪽ᢿᡯࢨ‿ ⁄ ※ ဒ ΂৑ᙸ ⅺ↸ၶࣱ᭒ ᐏ ໒≋
‒ ‾⁗⁢⁦⁡ ⁗⁠⁛⁠⁙⁗⁓⁞‒‿⁗⁦⁓⁥⁦⁓⁥⁛⁥≝‾‿ ≌⇁ ࢍⅾွⅳ⅚
᏿ౢᆲХ⇁଀ᘍↆ↎↗ↂ↼ ⅚᭒ ෩ ኬ Ꮨ ᚮ ↖ ᐄ ၶ⇁౨Јↆ↎⅛⁂⁗⁤⁘⁡⁤ ⁓⁠⁕⁗‒⁅⁦⁓⁦⁧⁥ⅻ … ↚˯ɦↆ↕
λᨈ ⅚‷‴ ၲඥ↝ϐ᧏≋ִɦೞᏡ↝˯ɦⅻᓸↆⅾ⅚ቇତভບඥ↚↷↹ኺᱠᏎሥ⇁ဇⅳ↕ ‷⇁৲ɨ≌↚↷↹⅚
ᒉ࠮ોծↆ↎ⅻ ⅚↌↝ࢸ ⅚᭒෩↝‷‹‸⁄ ᢡˡ‫ီ٭܇‬ⅻ ⁆ ‫‾‒”‒‿•‫‬‪‧‪⁄↗Йଢↆ↎↎↰⅚⁊࠰‧உ․‧ଐⅺ↸ ኺᱠᏎሥ⇁ဇⅳ↕⁡⁥⁛ ⁗⁤⁦⁛⁠⁛⁔↝৲ɨ⇁᧏‫↗↎ↆڼ‬ↂ↼⅚т ႎ↚ཞ ७ ↞ો ծ⅚ኺӝઅ ӕ↱ӧ Ꮱ↗
↙↹⅚ྸ‫ܖ‬ၲඥ↚↷↹ഩᘍ᚞ጀ↙↘↱ӧᏡ↗↙↹⅚ྵ‫∜‧† ⅚ נ‬உ↝໯‫ف‬फဃ‫⇁܍‬ʭӖↆ↕ⅳ↺⅛

અ‫ؙ‬௄‷‹‸⁄ ᢡˡ‫ီ٭܇‬ࣱᨗᏍၶ↖↞‾‿⇁ԃ↰↎ɶ௔ᅕኺኒ↖↝᠃ᆆϐႆⅻ‫ٶ‬ⅳ↗ↄ↻↺⅛‷‹‸ ⁄‟⁆ ‽※↝᎑ࣱೞࡀ↝ኖҞૠ⇁ҩ↰↺⁆ ‫↺ↈݣ↚‿•‫‬ᑣ‫↙ڤ‬৴ᏽၨ෇ࣱ⇁ஊↈ↺ᇹ ‥ɭˊ ‷‹‸⁄ ‟⁆‽※↝⁡⁥⁛ ⁗⁤⁦⁛⁠⁛⁔↞᭒෩ᆆᘍࣱⅻಊ↰↕ᑣ‫↖ڤ‬ⅱ↹⅚ↂ↻↭↖ஊј↙඙ၲඥⅻႏ໯↖ⅱ→↎‾‿↚‫↺ↈݣ‬ಊ↰↕ஊஓ↙඙ၲඥ↗ᎋⅷ↸↻↺⅛‷‹‸⁄‒⁆ ‫⇁‿•‫‬౨Јↆ↎ᨥ↚⅚⁡⁥⁛ ⁗⁤⁦⁛⁠⁛⁔↗⇽∏⇧⇰́ဇၲඥ↝ⅳ↉↻⇁ဇⅳ↺ⅺ↚↓ⅳ↕↝ᇹ ※※※Ⴛᚾ ᬴≋ ″⁇⁄″‥ ≌↝ኽௐⅺ↸↞⁡⁥⁛ ⁗⁤⁦⁛⁠⁛⁔ⅻஊဇ↗ᎋⅷ↸↻↕ⅳ↺ⅻ⅚ஜ̊↖↞ ‾ ‿↖
↝ϐႆ↖ⅱ↺ʙ↱⁡⁥⁛ ⁗⁤⁦⁛⁠⁛⁔↝ᑣⅳᢘࣖ↖ⅱ→↎↗ᎋⅷ↸↻↺⅛↙ⅹ⅚ஜ̊↖⁡⁥⁛ ⁗⁤⁦⁛⁠⁛⁔↞ ‾ ‿ ↚‫↕ↆݣ‬‫ڌ‬јↆ↎ⅻ⅚Ҿႆߺ↞⁅‶↝↭↭↖ⅱ↹⅚ᏽၨ↝⁚⁗⁦⁗⁤⁡⁙⁗⁠⁗⁛⁦⁫↚↷↺↱↝↗ᎋⅷ↸↻↎⅛

6ॡজ॰ॳॽঈ‫ؚ॔‬ঞॡॳॽঈ਺ଖ৏प3'धऩॉ७জॳॽঈऋས஍खञ
$/.੆়఩஫৕഻ਙశ৵಍ཝཡቅभ୻
প࿩ಧો୰੹‫ؙ‬৔ఐি੨ౘপ‫ؚ‬஌মઌ૓৕‫ؚ‬੎িຶ੦‫ؚ‬౱িᅔয‫ؚ‬৛ম፮‫ؚ‬௼ਣ࿓௶ඪ‫୻ؙ‬‪ബ⅚‫ࣱ ڡ‬ਠ୰ഄᎰ‫ͤئ‬ᚮ↖Ꮝ᣼↝ီࠝᨏࢨ⇁ਦઇ⅛⁂‷ ⁆౨௹↖Ꮝ᣼μ˳⅚ɲᏍᧉ⅚ጏᨠ⅚ɲᦋᭌɥᆾ∐∙⇷ራ⅚ᫀౢ⅚
Ꮯౢ↚‸‶‹ᨼᆢⅱ↹⅛᪽ᢿ‿⁄※↖‫ݱ‬Ꮿ᠃ᆆⅱ↹⅛߼ᦋᭌɥᆾ∐∙⇷ራဃ౨↖ᐄၶ℉″‾‽ᗡӳᢡˡ‫܇‬ࣱᨗ↝↎↰⇕∐⇤⇧⇱⇼৲ɨ ℉ ‫ڌ‬јↆ↎ⅻ ኖ‣•∜உࢸ↚ӫɶᓶ↚ϐႆ⅚Ꮿ ᠃ᆆ⇁ਦઇ ℉ μᏯༀ‫଀ݧ‬ᘍↆ⇈−⇕⇧⇱⇼↚‫ڌ℉୼٭‬јↆ↎ⅻኖ‣‣∜உኺᢅࢸ↚Ꮯᢿ‵⁆↖ӫɦᓶ↚ϐႆ⅚Ꮿ᠃ᆆ↝ϐႆ⇁ਦઇↄ↻↎⅛৽‫ؙ‬ૌӫɦᓶ↝ේ๾ࢨ↚↓ⅳ↕↞ൢሥૅᦟɦ↚ဃ౨⇁ᘍⅳᐄၶ℉⇡∐⇧⇱⇼↚‫⅛୼٭‬᪽ᢿ‿⁄※↖↞‧‫↝ٻ‬ᏽၨ⇁‥̾ᛐ↰↎ⅻ⅚⇈−⇕⇧⇱⇼ⅻᏯ᠃ᆆ↚‫↱↕ↆݣ‬ᓸјↆ↎↎↰⅚ʻ‫ݧ્↞ׅ‬ዴ඙ၲ⇁ᘍ↾↉↚⇡∐⇧⇱⇼↝јௐ⇁ࢳ↓૾ᤆ↗ↆ↎⅛⇡∐⇧⇱⇼৲ɨ᧏‫‥ ࢸڼ‬ᡵ᧓↖Ꮝ᣼↝ᨏࢨ⅚Ꮿ᠃ᆆߺ↗↱↚጑‫⇁ݱ‬
ᛐ ↰↎⅛

અ‫ؙ‬௄
⇡∐⇧⇱⇼↞இ↱ૼↆⅳ ″ ‾ ‽ ᗡ ӳ ᢡˡ‫܇‬ᨗ ࣱ̊↚‫↺ↈݣ‬඙ၲᕤ↖ⅱ↺⅛⇕∐⇤⇧⇱⇼⅚⇈−⇕⇧⇱⇼
ଏ඙ၲ̊↖‫ڌ‬јⅻࢽ↸↻↎↗ⅳⅵᚇໜⅺ↸ᐻԛขⅳ̊↗ᎋⅷ↸↻↺↎↰⅚ဒ΂৑ᙸ↝ਖ਼ᆆ⇁ԃ↰‫إ‬ԓ
ↈ↺⅛

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7

॔ঞঝॠ‫ش‬ਙਞଵ੍ཡ॔५ঌঝॠঝ५ඪभ  ୻ഌ੘೉࿚ভ୰੹ళลஓ৔ఐ  ‫ؚ‬৊੕়৔ఐ ൽఖෞ৕  ‫ؚ‬೔িඤ౓  ‫ؚ‬೔৔ઌဣ  ‫≥ؚ‬ઢ๬಻  ‫ؚ‬೔মඤ೗  ‫ؚ‬ির෥౴  ‫ؚ‬਴িഺ৥  ‫ؚ‬ฝਉ‫ؙ‬ข  ‫ؚ‬೔িዹ঳ ඪ‫୻ؙ‬

…‪ബ⅚
‒‫ࣱڡ‬

਌‫ؙ‬୪

ʑࣱԶ֏⅚ԠԈ‫׉‬ᩊใ༼ഄܴ࣎ɶᨠഎ੷ၐఌ඙ᘐ≋‥‫‫‬ബ ≌⅚ൢሥૅմऒ≋‥‫‫‬ബ≌ᚆ‫஀ؙ‬‥‫‫‬ബ↖ᅠ໺≋↌↻↭↖ ․•ஜ‡ଐ≌
⅚᫩ᣒ↙ↆ

েણഄ

໯Ꮀ⅚ብ‫୵ػ‬ᩧഭ↙ↆ⅚∀⇩⇮᫫Ꮛ↙ↆ⅚፶ൗࠋ‫ׇ̅‬ဇഭ↙ↆਠ୰ഄൢሥૅմऒ↖ᡈҔ≋၏ᨈ≌↚↕ьၲɶ≋ ‸⁂‡⁅‿‟‶⁂※‒‧••‒”‒‾⁆⁄″≌⅚⁊࠰…உ᪭ⅺ↸ʑࣱԶ֏⅚і˺଺ԠԈ‫׉‬ᩊ≋ ‿⁄‵‒⁙⁤⁓⁖⁗‒․‟‥≌⇁ᐯᙾ⅚඙ၲↄ↻↺↱ોծ↊↉⅚ӷ࠰ உ‪ଐ↚ᡈҔ≋⇕∐⇱⇩⇕≌⇁Ӗᚮ⅚‵ ⁊ ⁄↖߼ᐾғ໯ൢᏍ⇁ਦઇↄ↻⅚ உ‫‫‬ଐ↚࢘ᅹ↧ኰʼↄ↻↎⅛Ꮯᢿ‵⁆⇁જࢨↆ↎↗ↂ↼⅚߼ᐾғ໯ൢ Ꮝ⅚ጏᨠ∐∙⇷ራᏽ‫↚ٻ‬ьⅷ↕⅚໯ൢᏍϋᢿ↚ቬ෩ఀ⇁ᅆՐↈ↺⁚⁛⁙⁚‒⁖⁗⁠⁥⁛⁦⁫↙၏‫⇁٭‬ᛐ↰↎⅛৽‫ؙ‬ૌ⁊࠰ உ‣…ଐ↚ൢሥૅᦟ⇁଀ᘍ⅚߼ᐾғ↚᰾ᑥլၝ↝ߓ᪶⇁ᛐ↰⅚Ԉࡽↆ↕ᨊӊↆ↎↗ↂ↼⅚ၐཞ↞
ોծ⅚ᐮ࠿ႎ↚⇈−∑⇔∞ ࣱൢሥૅᏍ⇈⇟∀∑⇔∑⇟ၐ≋ ″‴⁂″ ≌↗ᚮૺↆ⅚ӷଐ↷↹⇽−⇯⇱⇤∓∙≋⁂⁅‾ ≌‥•∽↝ϋ஌⇁᧏‫⅛↎ↆڼ‬↌↝ࢸ⅚ኵጢᚮ↖Ⅴᓸଢ↙‫ڤ‬ᣠྶේ๾⇁ˤⅵൢ ሥૅቬᐏɥႝ Ⅵ↗ᚮૺⅻ↓ⅼ⅚ உ‣‫‫‬ଐ↷↹⇊⇮∏⇙⇰⇤∞∑≋ ※ ⁆ ‵ ⁌ ≌․•• ∽‡ଐ⇁ ́ ဇↆ⅚⁂⁅‾⇁․ ᡵ᧓൑↚๴ ถ ⅚⁊࠰ ‫‫‬உ‥•ଐ↝Ꮯᢿ‵⁆↖↞߼ᐾғ↝໯ൢᏍ↞ᚐᨊↄ↻⅚
ൢሥૅਘࢌ⇁ˤⅵၬၕ΂⇁ԑↆ⅚ӫɶɦᓶ↚૝‫↕ↆנ‬ⅳ↎ቩ ཞ ࢨ↱ෞ‫↕ↆڂ‬ⅹ↹⅚
※ ⁆‵ ⁌ ⇁ኳʕ⅚⁂⁅‾ ↞․ᡵ᧓൑↚‣ ∽↉↓๴ถↆ↕⅚
‣․உⅺ↸․ ∽↖ዜ ਤↆ↎⅛↌↝ࢸ⅚໯ၐཞ↖ኺᢅↆ↕ⅳ↎ⅻ⅚⁊”‣ ࠰‪உ‣‫‫‬ଐ↝Ꮯᢿ ‵ ⁆↖ӫɶᓶૅ↚⁚⁛⁙⁚‒⁖⁗⁠⁥⁛⁦⁫⇁ԑↈ↺ቬ෩ఀ↝ߓ᪶⅚ɶᓶ໯ൢᏍ⇁ᛐ ↰⅚⁂⁅‾‒‥• ⁙↚‫ف‬᣽ↆ↕※ ⁆‵⁌⇁ϐ᧏⅚‫‫‬உ․ଐ↝‵ ⁊⁄↖↞ᨏࢨ↱ોծↆ↕
ⅹ↹⁂⁅‾‒․• ⁙↧๴ถ ⅚․ᡵ᧓൑↚ †‧∽↭↖๴ถࢸ⅚…ᡵ᧓↖‧∽↗ↆ⅚ˌࢸ↞ዜਤↆ↕ⅳ↺⅛અ‫ؙ‬௄
″ ‴ ⁂″ ↞ ᩊ ඙ ࣱ ↝ൢ ሥૅ մ ऒ↖⅚໯ ൢ Ꮝ ⅚ɶ ௔ࣱൢሥ ૅਘ ࢌ ⇁ˤⅵ‫ئ‬ӳ↚ᦷ К ᚮ ૺ↚ਫⅻ↹⅚⁄ ⁡ ⁥ ⁗ ⁠ ⁔ ⁗ ⁤ ⁙ ↝ ᚮ ૺ ؕ แ ⇁ Ӌ ᎋ ↚ↆ↕ ᐮ ࠿ ᚮ ૺ ⇁ ᘍ ⅵ⅛ ൢ ሥ ૅ ਘ ࢌ ↚ ቬ ෩ ఀ ⇁ ˤⅵ ‫ ئ‬ӳ≋ ⁘⁛⁠⁙⁗⁤‟⁛⁠‟⁙⁞⁡⁨⁗‒⁥⁛⁙⁠ ≌⅚ቬ෩ఀ↚ ⁚⁛⁙⁚‒⁖⁗⁠⁥⁛⁦⁫⇁ˤⅵ‫ئ‬ӳ≋․•‟․‧‗↖ ․ ഏࣱ⇑∑⇝⇌∆ආბ⇁ˤⅵ≌↚↞ཎ↚″‴⁂″⇁ွⅳ⅚ɶ௔ͨ↝᧍ ‫ص‬ೞ᠃↝౨ኧ↖ൢሥૅᦟ⇁ᘍⅳ⅚ᒧᑥ↝ቬ෩ఀ‫⇁܇‬ᛐ↰⅚၏ྸ‫ܖ‬ႎ↚‫ڤ‬ᣠྶේ๾⇁ᛐ↰↺ᨥ↚″‴⁂″⇁↷↹ࢍⅾွⅳ⅚↌↝˂↝ऴ‫⇁إ‬ዮӳႎ↚ѥకↆ↕ᚮૺↈ↺⅛඙ၲ↞⇟⇬∓⇊⇯↝μ៲৲ɨ↚↷↹ൢ ᢊી጑⅚ൢሥૅቬᐏᨦܹ⇁Сࣂↈ↺ʙⅻ᣻ᙲ↖ⅱ↺ⅻ⅚৴Ⴧᓏᕤ↝́ဇ↞⇟⇬∓⇊⇯↝๴ถ⇁ܾତ↚ↈ↺ⅻ⅚࣏᪰↖↞↙ⅳ↗ↄ↻↺⅛

8๊ᔄधঐॖ॥উছ६ঐभ੎ള૎ഉपेॉཡ༇‫ؚ‬ິႇચ౮ଞ॑ऌञखञ঳୻
૸୴ਧ੕়୰੹৔ఐ ‫ؚك‬৊ళลஓ৔ఐ ‫ك‬৵ྒల਴ ‫ؚك‬૝ম೦঳ ‫ؚك‬గ௿༟಻ ‫ك‬ూ‫ؙ‬ବ᧙ᙱ‫ ׎‬ᨥ ᆰ ล⅚঺ဋ‫׎‬ᨥᆰลԗᡀ↖᰺ ၉↝්ᘍⅻᛐ↰↸↻ᅈ˟ႎբ᫆↗↙→↎⅛ҘᓶჄ௅ৎࠊ↖
↱धᎍⅻ‫ٶ‬ႆↆ⇈⇌⇮⇼−⇊⇕ⅻᄩᛐↄ↻↎⅛

ඪ‫୻ؙ‬․•ബ‫঺⅚ࣱڡ‬ဋᆰล Ꮀ Ճ⅚∕⇕⇧∙੗ᆔ ഭⅱ↹਌‫ؙ‬୪Զ⅚ၝ⅚ႆ༏

ਠ୰ഄ․•‣⁊࠰‪உ․•ଐ᪭↷↹ႆ ༏⅚Զ⅚ၝⅻⅱ↹″ ၏ᨈ⇁‪உ․‧ଐ↚Ӗᚮↆ↎ ⅛
Ꮯᢿ ⁊ዴ↖Ꮝ໒↗ᚮૺↄ↻⁅‴⁆‡″‴⁂‵↖඙ၲⅻ᧏ ‫⅛↎↻ↄڼ‬ၐ ཞોծ↙ⅾ⁆″⁌ ‡ ⁂※ ⁂‵↚‫ࢸ↎ↆ୼٭‬↚μ៲↝ᐔ ᨙ ၉ⅻЈྵↆɶഥ ⅛‿ ‷ ⁂‿ ” ‿ ※ ⁀⁁↝඙ၲ ↚‫↗↎ↆ୼٭‬ↂ↼μ៲↚ႆ ၉ⅻ Ј ྵ ⅚ᕤ ၉
ⅻွ↾↻↎⅛඙ၲ‫ ׉‬ᩊ↗ↄ↻‫‫‬உ․ଐ↚࢘ᨈ ↧᠃ ᨈ↗↙→↎ ⅛ಏ෫৽ૌμ៲↚ႆ၉ⅻᛐ↰↸↻ᕤ၉↷↹↱᰺၉ⅻွ↾↻↎⅛↭↎ᐮ࠿ኺᢅ↞∄⇊⇙⇽∏⇠∄ज़௨ၐⅻွ↾↻⅚Ꮯᢿ‵ ⁆ ৑ᙸ↞߼ɦᓶ↝ේ๾ࢨ↚૝‫↝ࣱנ‬૮ཞࢨ⇁ᛐ↰↎⅛
ၐཞ↗ᨏࢨ↞ોծͼӼ↚ⅱ→↎ⅻ᭗ᘉኄⅻᛐ↰↸↻⇊∙⇟∐∙඙ၲ⇁‫ݰ‬λↆ↎⅛ࢸଐ↚Йଢↆ↎∄⇊⇙⇽∏⇠∄↞৴˳ࣱᨗⅺ↓ఋᣠࣱᨗ⅚᰺၉↱※ ⁙‿ ৴˳ࣱᨗ⅚ఋ ᣠ ࣱᨗ↖᣻ᙐज़௨↗ᎋⅷ↸↻↎⅛᭗ᘉኄཞ७↞ࢹ⅝↚ોծↆज़௨ࢸ↝ᐘ޽໒ⅻွ↾↻↎⅛અ‫ؙ‬੧᰺၉↞‫׎‬ϋ↖‫්ݱ‬ᘍ⇁ጮ↹ᡉↆ⅚ʻ‫↞ׅ‬ෙ‫ٳ‬ⅺ↸↝᠞λज़௨↱ွ↾↻↎⅛঺ʴ᰺၉↖∕⇕⇧∙੗ᆔ̊↞ၐཞⅻ᩼‫׹ܭ‬ႎ↖ⅱ↹⅚ज़௨‫ݣ‬ሊɥ↖දॖ⇁ᙲↈ↺⅛ஜၐ↞∄⇊⇙⇽∏⇠∄↗↝᣻ᙐज़௨⅚ज़௨ࢸ↝᎑ኄᏡီࠝ↗ᙐᩃ↙ኺᢅ⇁↗↹ᐻԛขⅳၐ̊↖ⅱ→↎⅛

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9

ঐॖ॥উছ६ঐཡ༇‫ؙ‬൧૵঱भਖ਻ਡ
ਮ೎৘য়୰੹ళลஓ৔ఐ  ‫ؚ‬৊ᇯᯂ৔ఐ ஬ੇಋේ  ‫ؚ‬ൈেბ৕  ‫ؚ‬૝মႿಂ  ‫ؚ‬৵ਣਮื  ‫ؚ‬ળ‫ؙ‬ඤ৕  ‫ৣૈؚ‬อ಻  ‫ؚ‬শદਆಜ঳  ‫ૣؚ‬ળਫ೗ ඪ‫୻ؙ‬‿⁫⁕⁡⁢⁞⁓⁥ ⁓‒⁢⁠⁗⁧ ⁡⁠⁛⁓⁗‒↞ᒉ࠰ᎍ⇁ɶ࣎↚ɥൢᢊ ⊡ɦൢ ᢊ ज़ ௨↝᣻ ᙲ↙ឪ‫׆‬ᓏ↖ⅱ↺⅛ɟ ᑍ ႎ↚∄⇊⇙⇽∏⇠∄Ꮝ໒↝ဒ΂৑ᙸ↞ൢሥૅѣᏦԗ‫᧓׊‬ឋ᪸؏↝၏‫٭‬ӏ↢‫ݱ‬ᓶɶࣱ࣎↝ᨏࢨⅻ᭗᫁ࡇ↗
ↄ↻↺ⅻ‫ٻ‬ᓶࣱᏍ໒↝⇷⇥∞∙⇁ᅆↈↂ↗ⅻⅱ↹ဒ΂↝↮↖ኬᓏࣱᏍ໒↗↝ᦷК↞ɧӧᏡ↖ⅱ↺⅛
ؔ ᫱↚↷↹ᓏ⇁Ⴚ ੗ ᚰ ଢ ↖ⅼ↻↟ᄩ‫ܭ‬ᚮૺ↗↙↺ⅻؔ᫱↞ཎഷ↙ؔ‫⇁ע‬ᙲↆɟᑍ↚↞‫׉‬ᩊ↖ⅱ↺⅛
ࢼஹ↞∄⇊⇙⇽∏⇠∄↚‫↺ↈݣ‬ᘉฌ৴˳̖⇁ย‫⇈∀⅚ ↆܭ‬ᘉฌ⇁ဇⅳ↕ᚮૺↆ↕ⅼ↎ ⅛ↆⅺↆࣱ࣯஖ᚮૺ↚↞ஊဇ↖↞↙ⅾ↭↎ଏज़௨↝‫ئ‬ӳࣱᨗⅻਤዓↈ↺↙↘ܱဇɥբ᫆ⅻⅱ→↎⅛ᡈ࠰‾ ″‿ ⁂ඥ⇁ဇⅳ↎∄⇊⇙⇽∏⇠∄↝ఋᣠӷ‫ܭ‬౨௹ⅻ̬ͤᢘࣖ↗↙→↎⅛‾″‿⁂ ඥ↖↞ↂ↻↭↖ᄩ‫ܭ‬ᚮૺ↚‣ ᡵ ᧓ ᆉࡇᙲↆ↕ⅳ↎↝ⅻ ․ ଐˌϋ↚ჺ ጑ↄ↻↺↪ⅺज़ࡇ ཎီ ࡇ↗↱Ο↻↕ⅳ↺⅛↌↝↎↰̅ဇ᫁ࡇ↝᭗ⅳₒ∏⇕⇥∆ᕤ↚໯ј↙∄⇊⇙⇽∏⇠∄↚‫↺ↈݣ‬৴ᓏᕤ↝ᢠ৸↚ஊဇ↗ᎋⅷ↸↻↎⅛

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ࣈ ෂ˟ԠԈ֥ᢿ˟ƷƜǕǇưȷƜǕƔǒ‫ܢ‬඙ࣈෂ˟၏ᨈ
ԠԈ֥ϋᅹ ᢿᧈųᇦဋᨙʂ


䛂ᚨὪ఍࿧྾ჾ㒊఍䛾䛣䜜䜎䛷䞉䛣䜜䛛䜙䛃➨6ᅇ⫵䛜䜣◊✲఍➨4ᅇ࿧྾ჾ㒊఍⑕౛᳨ウ఍㻌ᖹᡂ28ᖺ12᭶17᪥㛤ദᏱ἞ᚨὪ఍⑓㝔㻌 ࿧྾ჾෆ⛉㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 ➉⏣㻌 㝯அ䞉䛂⤌⧊䛃䛸䛿(Wikipedia)䛂ᚨὪ఍࿧྾ჾ㒊఍䛾䛣䜜䜎䛷䞉䛣䜜䛛䜙䛃䡚⫵䛜䜣デ⒪䛾㐍Ṍ䜢ྵ䜑䛶䡚ᚨὪ఍䜾䝹䞊䝥་⒪⤒Ⴀᡓ␎䝉䝭䝘䞊㻌
ᖹᡂ28ᖺ11᭶26᪥㛤ദᏱ἞ᚨὪ఍⑓㝔㻌 ࿧྾ჾෆ⛉㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 ➉⏣㻌 㝯அ䞉䛂⤌⧊䛃䛸䛿(Wikipedia)ᮏ᪥䛾ෆᐜ

ᮏ᪥䛾ෆᐜ

䞉䛂᩿䜙䛺䛔་⒪䛃䛸⑌⑓ᵓ㐀䛾ኚ໬㻌 䞉䛂᩿䜙䛺䛔་⒪䛃䛸⑌⑓ᵓ㐀䛾ኚ໬㻌 䞉 ྛ✀䛜䜣䞉⫵䛜䜣䛾␿Ꮫ 䛂⤌⧊䛃䛸䛧䛶䛾䛂࿧྾ჾ㒊఍䛃ĺ䛂ඹ㏻䛾┠ᶆ䛃䞉䛂ศᴗ䛸ㄪᩚ䛃䞉࿧྾ჾ⑌ᝈデ⒪䛾⌧≧(⫵⒴䛾⤒Ⴀ䜈䛾ᙳ㡪䠖ᙜ㝔䝕䞊䝍)䞉 ྛ✀䛜䜣䞉⫵䛜䜣䛾␿Ꮫ䞉࿧྾ჾ⑌ᝈデ⒪䛾⌧≧(⫵⒴䛾⤒Ⴀ䜈䛾ᙳ㡪䠖ᙜ㝔䝕䞊䝍)䞉࿧྾ჾᑓ㛛་䛾೫ᅾ(ᮏ㑥䞉ᚨὪ఍䜾䝹䞊䝥)䞉࿧྾ჾᑓ㛛་䛾೫ᅾ(ᮏ㑥䞉ᚨὪ఍䜾䝹䞊䝥)䞉ᚨὪ఍࿧྾ჾ㒊఍タ❧(࿧྾ჾ⑌ᝈデ⒪䛻ᮃ䜎䜜䜛యไ)䞉ᚨὪ఍࿧྾ჾ㒊఍タ❧(࿧྾ჾ⑌ᝈデ⒪䛻ᮃ䜎䜜䜛యไ)䞉⫵䛜䜣◊✲఍/࿧྾ჾ㒊఍⑕౛᳨ウ఍(IP䝭䝙䝺䜽䝏䝱䞊)䞉⫵䛜䜣◊✲఍/࿧྾ჾ㒊఍⑕౛᳨ウ఍(IP䝭䝙䝺䜽䝏䝱䞊)䞉⫵䛜䜣デ⒪䛾㐍Ṍ䞉⫵䛜䜣デ⒪䛾㐍Ṍ䞉ᚨὪ఍࿧྾ჾ㒊఍䛾ᒎᮃ䞉ᚨὪ఍࿧྾ჾ㒊఍䛾ᒎᮃࣈ ෂ˟ԠԈ֥ᢿ˟ƷƜǕǇưȷƜǕƔǒ‫ܢ‬඙ࣈෂ˟၏ᨈ
ԠԈ֥ϋᅹ ᢿᧈųᇦဋᨙʂ


䞉䛂᩿䜙䛺䛔་⒪䛃䞉୺せṚᅉูṚஸ⋡䛾㛗ᮇ᥎⛣㻌 ㈨ᩱ䠖ཌ⏕ປാ┬㻌㻌 㻌 䛂ேཱྀືែ⤫ィ䛃

1973ᖺ:ᚨ⏣⑓㝔㛤タ
1975ᖺ:་⒪ἲேᚨὪ఍タ❧ᖹᡂ28ᖺ3᭶28᪥㻌 ᚨὪ᪂⪺䞉୺せṚᅉูṚஸ⋡(2014ᖺ) 㻌 ㈨ᩱ䠖ཌ⏕ປാ┬㻌㻌 㻌 䛂ேཱྀືែ⤫ィ䛃䞉་⒪䜒䛂⮬↛㑅ᢥ(Ὲử)䛃䛾᫬௦䛻⮬↛䛾ኚ໬䛻㐺ᛂ䛧䛯䜒䛾䛜⏕䛝ṧ䜛Charles Darwin䞉ᚨὪ఍䜸䞁䝁䝻䝆䞊䝥䝻䝆䜵䜽䝖(2004ᖺ)Alfred Wallace䞉ᚨὪ఍䜸䞁䝁䝻䝆䞊䝥䝻䝆䜵䜽䝖(2004ᖺ)⠛ᓮఙ᫂ᑓົ⌮஦᪂ὠὒྖ㑻ᩍᤵ

䞉⫵䛜䜣⮫ᗋヨ㦂 (CBDCA+S-1㝸᪥ᢞ୚)䞉䛂᩿䜙䛺䛔་⒪䛃䛛䜙䛂㑅䜀䜜䜛་⒪䛃䜈(㧗㱋⪅ 㠀ᑠ⣽⬊⫵⒴)ᚨὪ఍䜸䞁䝁䝻䝆䞊䝥䝻䝆䜵䜽䝖䠖2013ᖺ૥ୡලറ੡㻌

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UMIN000010989

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2nd lineਰఋ75ୃਰ঱
PS0-2

೉Ὢভ崘嵓嵤崿

32

PFSৈೡ঻ਤষశ৵಍ཝཡቅ峕ৌ峃峵
S-1࿒঩਺ଖ㻛崓嵓嵄崿嵑崩嵛ಡ৷௜১峘ਸ਼IIৼ૥ୡ㻌
UMIN000012098

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PS0-2

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45

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ᖹᡂ28ᖺ8᭶1᪥㻌 ᚨὪ᪂⪺ᮏ᪥䛾ෆᐜ

䞉ྛ✀䛜䜣䛾㒊఩ู⨯ᝈᩘ(2012ᖺ) ㈨ᩱ䠖ᅜ❧䛜䜣◊✲䝉䞁䝍䞊䛜䜣ᑐ⟇᝟ሗ䝉䞁䝍䞊䞉䛂᩿䜙䛺䛔་⒪䛃䛸⑌⑓ᵓ㐀䛾ኚ໬㻌 ᪥ᮏ䛻䛚䛡䜛Ṛᅉ䛾➨1఩䛿䚸䛂䛜䜣䛃䛷䛩䚹㻌䜎䛯䚸㒊఩ู䛜䜣⨯ᝈ⋡䛾➨3఩䛿䚸䛂⫵䛜䜣䛃䛷䛩䡝㻌䞉 ྛ✀䛜䜣䞉⫵䛜䜣䛾␿Ꮫ䞉࿧྾ჾ⑌ᝈデ⒪䛾⌧≧(⫵⒴䛾⤒Ⴀ䜈䛾ᙳ㡪䠖ᙜ㝔䝕䞊䝍)

䖃2012ᖺ䛾⨯ᝈᩘ (඲ᅜ᥎ィ್) 䛜ከ䛔㒊఩䛿㡰䛻
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⫶

⫵

⏨ዪィ ኱⭠⫶⫵ஙᡣ ๓❧⭢ ኱⭠䜢⤖⭠䛸┤⭠䛻ศ䛡䛯ሙྜ䚸⤖⭠3఩䚸┤⭠6఩䞉࿧྾ჾᑓ㛛་䛾೫ᅾ(ᮏ㑥䞉ᚨὪ఍䜾䝹䞊䝥)䞉ᚨὪ఍࿧྾ჾ㒊఍タ❧(࿧྾ჾ⑌ᝈデ⒪䛻ᮃ䜎䜜䜛యไ)䞉⫵䛜䜣◊✲఍/࿧྾ჾ㒊఍⑕౛᳨ウ఍(IP䝭䝙䝺䜽䝏䝱䞊)4఩

5఩

๓❧⭢ ⫢⮚ ኱⭠䜢⤖⭠䛸┤⭠䛻ศ䛡䛯ሙྜ䚸⤖⭠4఩䚸┤⭠5఩Ꮚᐑ ኱⭠䜢⤖⭠䛸┤⭠䛻ศ䛡䛯ሙྜ䚸⤖⭠3఩䚸┤⭠7఩䞉⫵䛜䜣デ⒪䛾㐍Ṍ䞉ᚨὪ఍࿧྾ჾ㒊఍䛾ᒎᮃ䞉ྛ✀䛜䜣䛾㒊఩Ṛஸᩘ䛾ኚ㑄(-2014ᖺ) 䞉ྛ✀䛜䜣䛾㒊఩ูṚஸ⋡㈨ᩱ䠖ேཱྀືែ⤫ィ㻌(ཌ⏕ປാ኱⮧ᐁᡣ⤫ィᒁ᝟ሗ㒊)㈨ᩱ䠖ཌ⏕ປാ┬㻌 ᖹᡂ㻝㻣ᖺேཱྀືែ⤫ィ㻌᪥ᮏ䛻䛚䛡䜛Ṛᅉ䛾➨1఩䛿䚸䛂䛜䜣䛃䛷䛩䚹㻌䜎䛯䚸㒊఩ู䛜䜣Ṛஸ⋡䛾➨1఩䛿䚸䛂⫵䛜䜣䛃䛷䛩䡝㻌

;୓ேͿ
ᵐᵓ

;୓ேͿ
ᵐᵓ

ဏᴾ ࣱᴾ

‫ڡ‬ᴾ ࣱᴾ

ႉᘉ၏ᴾ

ႉᘉ၏ᴾ‫ٶ‬ႆࣱᭌ᭒ᏽᴾ

‫ٶ‬ႆࣱᭌ᭒ᏽᴾ

䕔㻌୺䛺㒊఩ู䛜䜣Ṛஸ⋡㻌(2005ᖺ)䕔㻌୺䛺ṚᅉูṚஸᩘ䛾๭ྜ (2005ᖺ)

ᵔᵎᴾ

ᵓᵎᴾ

ʴӝᵏᵎɢ‫ݣ‬ᴾ

1975ᖺ:་⒪ἲேᚨὪ఍タ❧फࣱἼὅἣᏽᴾ

1975ᖺ:་⒪ἲேᚨὪ఍タ❧फࣱἼὅἣᏽᴾᵐᵎဍཞᐄᴾᏴὉ‫ބ‬ែίᐆᏝᨊẪὸᴾ ᵐᵎᏴὉ‫ބ‬ែίᐆᏝᨊẪὸᴾ
ᐆᏝᴾ

ᐆᏝᴾ

ᵒᵗᵌᵐᴾ

ҳߺᴾ
Эᇌᐄᴾ

ᵐᵕᵌᵐᴾ

‫ܷ܇‬ᴾ
ʐ৐ᴾ
ႝᐎᴾ

ᵏᵖᵌᵐᴾ

ᵐᵎᴾ

ᵏᵎ

Ꮝᴾ

ᵏᵎ

ᵏᵓᵌᵎᴾ

ᐘᐥᴾ

Ꮑᐥᴾ

ᏐֳὉᏐሥᴾ

‫ٻ‬ᐂᴾ

Ꮑᐥᴾ
Ⴚᐂᴾ

ᵓ

‫ٻ‬ᐂᴾ
Ⴚᐂᴾ
ኽᐂᴾ

Ꮞᴾ

Ꮞᴾ
᫢ᢊᴾ

ӝᏸὉԹ᪽ᴾ

ᵐᵎᵏᵒ

ᵐᵎᵏᵑ

ᵐᵎᵏᵐ

ᵐᵎᵏᵏ

ᵐᵎᵏᵎ

ᵐᵎᵎᵓ

ᵐᵎᵎᵎ

ᵏᵗᵗᵓ

ᵏᵗᵗᵎ

ᵏᵗᵖᵓ

ᵐᵎᵏᵒ

ᵐᵎᵏᵑ

ᵐᵎᵏᵐ

ᵐᵎᵏᵏ

ᵐᵎᵏᵎ

ᵐᵎᵎᵓ

ᵐᵎᵎᵎ

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᫢ᢊᴾ

ᵎ
ᵏᵗᵖᵎ

ӝᏸὉԹ᪽ᴾ

ᵎ

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ᐘᴾ

ኽᐂᴾ

Эᇌᐄᴾ

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ᵏᵗᵕᵎ

Ꮝᴾ

ᵓ

ᵏᵗᵕᵓ

ᵎᴾ

ᵏᵗᵔᵓ

Ꮿᘉሥ၌धᴾίᏯҡɶὸᴾᵏᵐᵌᵑήᴾ࣎၌धᴾί࣎ᐥ၏ὸᴾᵏᵔᵌᵎήᴾ‫ܷ܇‬ᫀᢿᴾᏐֳὉᏐሥᴾ

ᵏᵎᴾ

Ꮝ໒ᴾ
ᵗᵌᵗήᴾ

‫˳ܷ܇‬ᢿᴾ

ᐘᐥᴾ

ᵏᵗᵔᵎ

ɧॾỉᴾ
ʙ૏ᴾ
ᵑᵌᵕήᴾ

ര
ʧ ᵑᵎᴾ
ྙ

Ꮝᴾ

ᵏᵗᵕᵎ

ᐯൈᴾ
ᵐᵌᵖήᴾ

ᵑᵐᵌᵒᴾ

ᵏᵓ

ᵏᵗᵔᵓ

ᵑᵎᵌᵏήᴾ

ႝᐎᴾ

ᵏᵓ

ᴾ

ᎊᘛᴾ
ᵐᵌᵒήᴾ

फࣱૼဃཋᴾ
ίầỮὸᴾ

ᵑᵗᵌᵗᴾ

ᵒᵎᴾ

ᵏᵗᵔᵎ

Ẹỉ˂ᴾ
ᵐᵐᵌᵗήᴾࣈ ෂ˟ԠԈ֥ᢿ˟ƷƜǕǇưȷƜǕƔǒ‫ܢ‬඙ࣈෂ˟၏ᨈ
ԠԈ֥ϋᅹ ᢿᧈųᇦဋᨙʂ


ᮏ᪥䛾ෆᐜ

䞉࿧྾ჾෆ⛉䛷ᢅ䛖⑌ᝈ(⫵⭘⒗䞉⤖⠇䛾㚷ู)䞉㻌 ⫵⒴௨እ䛾Ꮩ❧ᛶ⤖⠇䞉䛂᩿䜙䛺䛔་⒪䛃䛸⑌⑓ᵓ㐀䛾ኚ໬㻌 䞉 ྛ✀䛜䜣䞉⫵䛜䜣䛾␿Ꮫ䞉㻌 ⫵䛾₽䜜(ᯈ≧↓Ẽ⫵)䞉࿧྾ჾ⑌ᝈデ⒪䛾⌧≧(⫵⒴䛾⤒Ⴀ䜈䛾ᙳ㡪䠖ᙜ㝔䝕䞊䝍)䞉㻌 ⫵ෆ䝸䞁䝟⠇(⫵ෆ䝸䞁䝟⿦⨨) 䞉⅖⑕ᛶ⤖⠇䞉࿧྾ჾᑓ㛛་䛾೫ᅾ(ᮏ㑥䞉ᚨὪ఍䜾䝹䞊䝥)䞉㻌 㝈ᒁᛶჾ㉁໬⫵⅖䞉ᚨὪ఍࿧྾ჾ㒊఍タ❧(࿧྾ჾ⑌ᝈデ⒪䛻ᮃ䜎䜜䜛యไ)䞉㻌 ⫗ⱆ⭘(⫵⤖᰾⑕䚸㠀⤖᰾ᛶᢠ㓟⳦⑕)

䞉⫵䛜䜣◊✲఍/࿧྾ჾ㒊఍⑕౛᳨ウ఍(IP䝭䝙䝺䜽䝏䝱䞊)䞉㻌 ⅖⑕ᛶഇ⭘⒆

䞉⫵䛜䜣デ⒪䛾㐍Ṍ䞉㻌 Ⰻᛶ⭘⒆(⫵㐣ㄗ⭘䞉⫵◳໬ᛶ⾑⟶⭘)䞉ᚨὪ఍࿧྾ჾ㒊఍䛾ᒎᮃ䞉㻌 ⫵ື㟼⬦⒦(ື㟼⬦ወᙧ)

䞉࿧྾ჾෆ⛉䛷ᢅ䛖⑌ᝈ(㛫㉁ᛶ⫵⅖䛾㚷ู)䞉࿧྾ჾෆ⛉䛷ᢅ䛖⑌ᝈ(ឤᰁ⑕䛾ືྥ)᪥ᮏ࿧྾ჾᏛ఍ 䛂≉Ⓨᛶ㛫㉁ᛶ⫵⅖デ᩿䛸἞⒪䛾ᡭᘬ䛝䛃ᨵゞ➨2∧ (2011)䞉䜾䝻䞊䝞䝹䛻䜏䛯Ṛᅉ䛾ୖ఩10఩䞉⫵䛜䜣デ⒪䛻䜘䜛⑓㝔⤒Ⴀ䜈䛾ᙳ㡪䞉 ⫵䛜䜣デ⒪䛻䜘䜛⑓㝔⤒Ⴀ䛾Ᏻᐃ໬ (cf. COPD)⹫⾑ᛶᚰ⑌ᝈ⬻⾑⟶㞀ᐖ䞉 COPD (ᖺ㢠䠖᳨ᰝ㈝⏝䛾䜏)䠖 ྜィ 36900෇ / ᖺ៏ᛶ㛢ሰᛶ⫵⑌ᝈୗẼ㐨ឤᰁ⑕㻌 䞉 ⬚㒊༢⣧X⥺෗┿ (3200෇ / 1䞄᭶㽢2ᅇ = 6400෇)Ẽ⟶䞉Ẽ⟶ᨭ䞉⫵⒴㻌 䞉 ⬚㒊༢⣧CT (17500෇ / 12䞄᭶㽢1ᅇ = 17500෇)࿧྾ჾ⑌ᝈ㻌 䞉 ࿧྾ᶵ⬟᳨ᰝ (6500෇ / 6䞄᭶㽢2ᅇ = 13000෇)

WHO Fact sheet(2014 May)

䞉⫵䛜䜣デ⒪䛻䜘䜛⑓㝔⤒Ⴀ䜈䛾ᙳ㡪䞉࿧྾ჾ⑌ᝈデ⒪䛾⌧≧(domestic / global)䞉㻌 ࿧྾ჾ⑌ᝈ䛿㟂せ䛜ከ䛔䞉 ⫵䛜䜣デ⒪䛻䜘䜛⑓㝔⤒Ⴀ䛾Ᏻᐃ໬ (cf. COPD)䞉㻌 ࿧྾ჾ⑌ᝈ䛿ከᒱ䛻Ώ䜛㻌䞉 ⫵⒴ (ᖺ㢠䠖᳨ᰝ㈝⏝䛾䜏)䠖 ྜィ 389420෇ / ᖺ䞉㻌 ࿧྾ჾ⑌ᝈ䛿1⑌ᝈᙜ䜚䛾㚷ูデ᩿䜒ከᒱ䛻Ώ䜛㻌 䞉 ⭘⒆䝬䞊䜹䞊 (4000෇ / 1䞄᭶㽢12ᅇ = 48000෇)Ⱥ࿧྾ჾ⑌ᝈ䛿ㄗデ䛾䝸䝇䜽䛜㧗䛔㻌 䞉 ⬚㒊༢⣧X⥺෗┿ (3200෇ / 1䞄᭶㽢12ᅇ = 38400෇)㻌 䞉 ⬚⭡㒊㐀ᙳCT (29290෇ / 3䞄᭶㽢4ᅇ = 117160෇)㻌 䞉 㢌㒊㐀ᙳMRI (31720෇ / 4䞄᭶㽢3ᅇ = 95160෇)䞉㻌 ᝏᛶ⭘⒆䞉㛫㉁ᛶ⫵⅖䛺䛹ணᚋ୙Ⰻ䛷་⒪㈨※䛜኱Ⱥ࿧྾ჾᑓ㛛་䛿඲ᅜⓗ䛻䜒㟂せ䛜ከ䛔㻌 䞉 㦵䝅䞁䝏䜾䝷䝣䜱䞊 (45350෇)㻌 / 6䞄᭶㽢2ᅇ = 90700෇)㻌ᮏ᪥䛾ෆᐜ

䞉ෆ⛉⣔୺せᑓ㛛ศ㔝䛾་ᖌ೫ᅾ(ᮏ㑥)䞉䛂᩿䜙䛺䛔་⒪䛃䛸⑌⑓ᵓ㐀䛾ኚ໬㻌 䞉 ྛ✀䛜䜣䞉⫵䛜䜣䛾␿Ꮫ(఍ဨᩘ䠖ᾘ໬ჾ⑓Ꮫ఍䠷2015.12.31䠹䞉ᚠ⎔ჾᏛ఍䠷2016.6.1䠹䞉࿧྾ჾᏛ఍䠷2016.1.31䠹)(ᑓ㛛་ᩘ䠖ᾘ໬ჾ⑓Ꮫ఍䠷2016.10.22䠹䞉ᚠ⎔ჾᏛ఍䠷2016.4.1䠹䞉࿧྾ჾᏛ఍䠷2016.7.27䠹)(ே)

䞉࿧྾ჾ⑌ᝈデ⒪䛾⌧≧(⫵⒴䛾⤒Ⴀ䜈䛾ᙳ㡪䠖ᙜ㝔䝕䞊䝍)ᾘ໬ჾ : ᚠ⎔ჾ : ࿧྾ჾ = 3 : 2 : 1(33933)䞉࿧྾ჾᑓ㛛་䛾೫ᅾ(ᮏ㑥䞉ᚨὪ఍䜾䝹䞊䝥)䞉ᚨὪ఍࿧྾ჾ㒊఍タ❧(࿧྾ჾ⑌ᝈデ⒪䛻ᮃ䜎䜜䜛యไ)(26014)(19530)䞉⫵䛜䜣◊✲఍/࿧྾ჾ㒊఍⑕౛᳨ウ఍(IP䝭䝙䝺䜽䝏䝱䞊)(13690)(11931)䞉⫵䛜䜣デ⒪䛾㐍Ṍ䞉ᚨὪ఍࿧྾ჾ㒊఍䛾ᒎᮃ䞉ෆ⛉⣔୺せᑓ㛛ศ㔝䛾་ᖌ೫ᅾ(ᚨὪ఍)(ᚨὪ఍ᮾிᮏ㒊䠷2016.10.19䠹)ᾘ໬ჾ : ᚠ⎔ჾ : ࿧྾ჾ = 3 : 4 : 1

(ே)

(657)

(657)

䞉᪥ᮏ࿧྾ჾᏛ఍ㄆᐃ᪋タ(ᚨὪ఍䜾䝹䞊䝥)䞉㻌 ༓ⴥᚨὪ఍⑓㝔(༓ⴥ┴)
䞉㻌 •༡㙊಴⥲ྜ⑓㝔(⚄ዉᕝ┴)䞉㻌 •༡⸨ἑᚨὪ఍⑓㝔(⚄ዉᕝ┴) 䞉㻌 ඵᑿᚨὪ఍⥲ྜ⑓㝔(኱㜰ᗓ)᪥ᮏ࿧྾ჾᏛ఍㻌ㄆᐃ6᪋タ䞉㻌 ࿴Ἠᕷ❧⑓㝔(኱㜰ᗓ)
䞉㻌 Ᏹ἞ᚨὪ఍⑓㝔(ி㒔ᗓ)䞉㻌 ᮐᖠᮾᚨὪ఍⑓㝔(໭ᾏ㐨䠖㛵㐃᪋タ)

(89)
(57)
(21)

䞉㻌 㙊䞄㇂⥲ྜ⑓㝔(༓ⴥ┴䠖㛵㐃᪋タ)

᪥ᮏ࿧྾ჾᏛ఍㻌㛵㐃2᪋タࣈ ෂ˟ԠԈ֥ᢿ˟ƷƜǕǇưȷƜǕƔǒ‫ܢ‬඙ࣈෂ˟၏ᨈ
ԠԈ֥ϋᅹ ᢿᧈųᇦဋᨙʂ


䞉࿧྾ჾ⑌ᝈデ⒪䛾⌧≧(ᚨὪ఍䜾䝹䞊䝥)䞉࿧྾ჾ⑌ᝈ䛾デ⒪䛻ᮃ䜎䜜䜛యไ(࿧྾ჾデ⒪䛾⏕䛝ṧ䜚䜢㉃䛡䛯)䞉㻌 ࿧྾ჾ⑌ᝈ䛾㟂せ䛻ぢྜ䛖ᑓ㛛་☜ಖ䛜㏵ୖ䞉࿧྾ჾᑓ㛛་䛾⫱ᡂ㻌 䞉㻌 ࿧྾ჾᑓ㛛་䛾೫ᅾ䛜ᮏ㑥௨ୖ䛻㝿❧䛴⌧≧䞉 ࿧྾ჾᑓ㛛་䛾୰䛷䛾⣽ศ໬ ĺ ᑓ㛛ศ㔝䛾update!!

䞉㻌 ᪥ᮏ࿧྾ჾᏛ఍ㄆᐃ᪋タ䞉㛵㐃᪋タ䜒㝈ᐃⓗȺ࿧྾ჾᑓ㛛་䛾☜ಖ䞉⫱ᡂ䛜ᛴົ䞉ᝏᛶ⭘⒆䞉㛫㉁ᛶ⫵⅖䞉COPD䞉Ẽ⟶ᨭႍᜥ䞉࿧྾ჾឤᰁ⑕䞉࿧྾⟶⌮䞉⫵ᚠ⎔䞉╧╀᫬↓࿧྾䞉⥲ྜෆ⛉䞉⥲ྜデ⒪⛉䛷䛾ึᮇデ⒪䞉༠ຊ䞉㻌 ⌧≧䛷䛿䚸⥲ྜෆ⛉䞉⥲ྜデ⒪⛉䛷䛾࿧྾ჾデ⒪䞉⥲ྜデ⒪ᑓ㛛་䛻ᑐ䛩䜛࿧྾ჾ⑌ᝈ䛾ၨⵚάືȺᚨὪ఍䜾䝹䞊䝥ෆ䛷࿧྾ჾ⑌ᝈ䛾᝟ሗඹ᭷䞉௚⛉(እ⛉䞉ᩆᛴ䞉ᨺᑕ⥺⛉䞉⑓⌮デ᩿⛉) 䛸䛾㐃ᦠȺྛ⛉ᶓ᩿ⓗ䛺஫ᜨ㛵ಀ䛾㔜せᛶᮏ᪥䛾ෆᐜ

䞉ᚨὪ఍࿧྾ჾ㒊఍䛾タ❧(2015.Jul.11)䞉䛂᩿䜙䛺䛔་⒪䛃䛸⑌⑓ᵓ㐀䛾ኚ໬㻌 䞉 ྛ✀䛜䜣䞉⫵䛜䜣䛾␿Ꮫ 䛂⤌⧊䛃䛸䛧䛶䛾䛂࿧྾ჾ㒊఍䛃ĺ䛂ඹ㏻䛾┠ᶆ䛃䞉䛂ศᴗ䛸ㄪᩚ䛃䞉࿧྾ჾ⑌ᝈデ⒪䛾⌧≧(⫵⒴䛾⤒Ⴀ䜈䛾ᙳ㡪䠖ᙜ㝔䝕䞊䝍)䞉࿧྾ჾᑓ㛛་䛾೫ᅾ(ᮏ㑥䞉ᚨὪ఍䜾䝹䞊䝥)䞉ᚨὪ఍࿧྾ჾ㒊఍タ❧(࿧྾ჾ⑌ᝈデ⒪䛻ᮃ䜎䜜䜛యไ)䞉⫵䛜䜣◊✲఍/࿧྾ჾ㒊఍⑕౛᳨ウ఍(IP䝭䝙䝺䜽䝏䝱䞊)䞉⫵䛜䜣デ⒪䛾㐍Ṍ䞉ᚨὪ఍࿧྾ჾ㒊఍䛾ᒎᮃ
ᖹᡂ27ᖺ7᭶27᪥㻌 ᚨὪ᪂⪺䞉࿧྾ჾ⑌ᝈ䛾デ⒪䛻ᮃ䜎䜜䜛యไ䞉࿧྾ჾ⑌ᝈ䛾デ⒪䛻ᮃ䜎䜜䜛యไ䞉࿧྾ჾᑓ㛛་䛾⫱ᡂ㻌 ĺ ᩍ⫱◊ಟጤဨ఍

䞉࿧྾ჾᑓ㛛་䛾⫱ᡂ㻌 ĺ ᩍ⫱◊ಟጤဨ఍䞉 ࿧྾ჾᑓ㛛་䛾୰䛷䛾⣽ศ໬ ĺ ᑓ㛛ศ㔝䛾update!!

䞉 ࿧྾ჾᑓ㛛་䛾୰䛷䛾⣽ศ໬ ĺ ᑓ㛛ศ㔝䛾update!!
ĺ Ꮫ⾡௻⏬ጤဨ఍䞉⥲ྜෆ⛉䞉⥲ྜデ⒪⛉䛷䛾ึᮇデ⒪䞉༠ຊ䞉⥲ྜෆ⛉䞉⥲ྜデ⒪⛉䛷䛾ึᮇデ⒪䞉༠ຊ䞉⥲ྜデ⒪ᑓ㛛་䛻ᑐ䛩䜛࿧྾ჾ⑌ᝈ䛾ၨⵚάື䞉⥲ྜデ⒪ᑓ㛛་䛻ᑐ䛩䜛࿧྾ჾ⑌ᝈ䛾ၨⵚάືጤဨ㛗䠖⎩⏕ᜤ❶ඛ⏕ጤဨ㛗䠖ᒾ℩ᙲᙪඛ⏕ඵᑿᚨὪ఍⥲ྜ⑓㝔ෆ⛉㒊㛗༓ⴥす⥲ྜ⑓㝔࿧྾ჾෆ⛉㒊㛗䞉௚⛉(እ⛉䞉ᩆᛴ䞉ᨺᑕ⥺⛉䞉⑓⌮デ᩿⛉) 䛸䛾㐃ᦠ䞉௚⛉(እ⛉䞉ᩆᛴ䞉ᨺᑕ⥺⛉䞉⑓⌮デ᩿⛉) 䛸䛾㐃ᦠ

䞉࿧྾ჾ⑌ᝈ䛾デ⒪䛻ᮃ䜎䜜䜛యไ䞉࿧྾ჾ⑌ᝈ䛾デ⒪䛻ᮃ䜎䜜䜛యไ䞉࿧྾ჾᑓ㛛་䛾⫱ᡂ㻌 ĺ ᩍ⫱◊ಟጤဨ఍

䞉࿧྾ჾᑓ㛛་䛾⫱ᡂ㻌 ĺ ᩍ⫱◊ಟጤဨ఍䞉 ࿧྾ჾᑓ㛛་䛾୰䛷䛾⣽ศ໬ ĺ ᑓ㛛ศ㔝䛾update!!
ĺ Ꮫ⾡௻⏬ጤဨ఍䞉 ࿧྾ჾᑓ㛛་䛾୰䛷䛾⣽ศ໬ ĺ ᑓ㛛ศ㔝䛾update!!
ĺ Ꮫ⾡௻⏬ጤဨ఍䞉⥲ྜෆ⛉䞉⥲ྜデ⒪⛉䛷䛾ึᮇデ⒪䞉༠ຊ䞉⥲ྜෆ⛉䞉⥲ྜデ⒪⛉䛷䛾ึᮇデ⒪䞉༠ຊ䞉⥲ྜデ⒪ᑓ㛛་䛻ᑐ䛩䜛࿧྾ჾ⑌ᝈ䛾ၨⵚάືጤဨ㛗䠖⏣ᮧᖾ኱ඛ⏕ĺ ᗈሗጤဨ఍
኱㝮㮵ᒇ⑓㝔๪㝔㛗䞉ෆ⛉㒊㛗䞉⥲ྜデ⒪ᑓ㛛་䛻ᑐ䛩䜛࿧྾ჾ⑌ᝈ䛾ၨⵚάືጤဨ㛗䠖ụཎᗣ୍ඛ⏕ĺ ᗈሗጤဨ఍
▼ᇉᓥᚨὪ఍⑓㝔㝔㛗(እ⛉)

䞉௚⛉(እ⛉䞉ᩆᛴ䞉ᨺᑕ⥺⛉䞉⑓⌮デ᩿⛉) 䛸䛾㐃ᦠ䞉௚⛉(እ⛉䞉ᩆᛴ䞉ᨺᑕ⥺⛉䞉⑓⌮デ᩿⛉) 䛸䛾㐃ᦠĺ Ꮫ㝿㐃ᦠጤဨ఍

ᮏ᪥䛾ෆᐜ
䞉䛂᩿䜙䛺䛔་⒪䛃䛸⑌⑓ᵓ㐀䛾ኚ໬㻌 䞉➨1ᅇ⫵䛜䜣◊✲఍(2014.Feb.15)
ᚨὪ఍䜸䞁䝁䝻䝆䞊䝥䝻䝆䜵䜽䝖䞉 ྛ✀䛜䜣䞉⫵䛜䜣䛾␿Ꮫ䞉࿧྾ჾ⑌ᝈデ⒪䛾⌧≧(⫵⒴䛾⤒Ⴀ䜈䛾ᙳ㡪䠖ᙜ㝔䝕䞊䝍)䞉࿧྾ჾᑓ㛛་䛾೫ᅾ(ᮏ㑥䞉ᚨὪ఍䜾䝹䞊䝥)䞉ᚨὪ఍࿧྾ჾ㒊఍タ❧(࿧྾ჾ⑌ᝈデ⒪䛻ᮃ䜎䜜䜛యไ)䞉⫵䛜䜣◊✲఍/࿧྾ჾ㒊఍⑕౛᳨ウ఍(IP䝭䝙䝺䜽䝏䝱䞊)䞉⫵䛜䜣デ⒪䛾㐍Ṍ⚟ᒸṇ༤࿴Ἠᕷ❧⑓㝔⥲㛗䞉ᚨὪ఍࿧྾ჾ㒊఍䛾ᒎᮃཧຍ⪅䠖45ྡ䞉➨2ᅇ⫵䛜䜣◊✲఍(2015.Apr.4)ᚨὪ఍䜸䞁䝁䝻䝆䞊䝥䝻䝆䜵䜽䝖䞉➨3ᅇ⫵䛜䜣◊✲఍(2015.Jul.11)ᚨὪ఍䜸䞁䝁䝻䝆䞊䝥䝻䝆䜵䜽䝖᪂ὠὒྖ㑻ᩍᤵཧຍ⪅䠖38ྡཧຍ⪅䠖53ྡࣈ ෂ˟ԠԈ֥ᢿ˟ƷƜǕǇưȷƜǕƔǒ‫ܢ‬඙ࣈෂ˟၏ᨈ
ԠԈ֥ϋᅹ ᢿᧈųᇦဋᨙʂ


䞉➨4ᅇ⫵䛜䜣◊✲఍(2016.Jan.9)䞉➨5ᅇ⫵䛜䜣◊✲఍(2016.Jul.23)ᚨὪ఍䜸䞁䝁䝻䝆䞊䝥䝻䝆䜵䜽䝖ᚨὪ఍䜸䞁䝁䝻䝆䞊䝥䝻䝆䜵䜽䝖ཧຍ⪅䠖65ྡ

䞉≉Ⓨᛶ㛫㉁ᛶ⫵⅖

ཧຍ⪅䠖69ྡ䞉≉Ⓨᛶ⫵⥺⥔⑕䛾⮬↛ྐ(ᛴᛶቑᝏ/៏ᛶ࿧྾୙඲)䞉 ୺せ≉Ⓨᛶ㛫㉁ᛶ⫵⅖ ( major idiopathic interstitial pneumonias )䞉 ៏ᛶ⥺⥔໬ᛶ㛫㉁ᛶ⫵⅖ ( chronic fibrosing interstitial pneumonia )䞉 ≉Ⓨᛶ⫵⥺⥔⑕ ( IPF ) 䞉 㠀≉␗ᛶ㛫㉁ᛶ⫵⅖ ( NSIP )䞉 ᛴᛶ/ளᛴᛶ㛫㉁ᛶ⫵⅖ ( acute / subacute interstitial pneumonia )䞉 ≉Ⓨᛶჾ㉁໬⫵⅖ ( COP ) 䞉 ᛴᛶ㛫㉁ᛶ⫵⅖ ( AIP )䞉 ႚ↮㛵㐃㛫㉁ᛶ⫵⅖ ( smoking-related interstitial pneumonia )䞉 ๤㞳ᛶ㛫㉁ᛶ⫵⅖ ( DIP ) 䞉 ࿧྾⣽Ẽ⟶ᨭ⅖㛵㐃㛫㉁ᛶ⫵⑌ᝈ ( RB-ILD )䞉 ⛥ᑡ≉Ⓨᛶ㛫㉁ᛶ⫵⅖ ( rare IIPs )䞉 ≉Ⓨᛶ䝸䞁䝟⌫ᛶ⫵⅖ ( LIP ) 䞉 PPFE (pleuroparenchymal fibroelastosis)䞉 ศ㢮୙⬟ᆺ㛫㉁ᛶ⫵⅖ ( unclassifiable IIPs )䞉≉Ⓨᛶ⫵⥺⥔⑕䛾⮬↛ྐ

Intern Med. 34: 388-92, 1995

䞉≉Ⓨᛶ⫵⥺⥔⑕䛾Ṛᅉĺ ᛴᛶቑᝏ䞉៏ᛶ࿧྾୙඲䞉⫵⒴䞉䛭䛾௚䞉୙᫂㻌
5%acute exacerbation20%ĺ ⏕Ꮡᮇ㛫୰ኸ್䛿stage IV EGFR㑇ఏᏊኚ␗㝧ᛶ⫵⒴䛸ྠᵝchronic respiratory failure
40%
11%

others24%

Am J Respir Crit Care Med. 190: 773-9, 2004

lung cancer

unknown
Am J Respir Crit Care Med. 190: 773-9, 2014

䞉⥺⥔໬䛾䝯䜹䝙䝈䝮䞉ᢠ⥺⥔໬⸆

䞉⥺⥔໬䜢᮶䛩ྛ✀ᡂ㛗ᅉᏊ(growth factors) 䛾⏘⏕⣽⬊䞉 Pirfenidone
䞉PDGF, TGF-ȕ IL-12䛾ᢚไ䞉⭷䛾Ᏻᐃ໬䚸ᢠ⅖⑕స⏝

Pirfenidone

Pirfenidone

Azuma A, et al. Core Evidence 2015; 10: 89-98

䞉ᢠ⥺⥔໬⸆

Azuma A, et al. Core Evidence 2015; 10: 89-98

䞉≉Ⓨᛶ⫵⥺⥔⑕䛾ᣦᶆ(6M change in %FVC)

䞉 Nintedanib䞉PDGF, FGF, VEGF䛾3⤒㊰䜢ไᚚĺ6䞄᭶䛾᫬Ⅼ䛷FVC䛜5-10%䛾marginal䛺పୗ䛜䛒䜛㻌 ሙྜ䜒ணᚋ䛿୙Ⰻ䛷䛒䜚䚸ὀព䜢せ䛩䜛

Am J Respir Crit Care Med. 184: 1382-89, 2011

Azuma A, et al. Core Evidence 2015; 10: 89-98

䞉ᢠ⥺⥔໬⸆

䞉ᢠ⥺⥔໬⸆

䞉 Nintedanib : Phase III trials

䞉 Nintedanib : Phase III trials

䞉INPULSIS-1 (Change in FVC at week 52) 䞉INPULSIS-2 (Change in FVC at week 52) 

N Engl J Med. 2014; 370: 2308-92

N Engl J Med. 2014; 370: 2308-92ࣈ ෂ˟ԠԈ֥ᢿ˟ƷƜǕǇưȷƜǕƔǒ‫ܢ‬඙ࣈෂ˟၏ᨈ
ԠԈ֥ϋᅹ ᢿᧈųᇦဋᨙʂ


䞉ᢠ⥺⥔໬⸆

䞉≉Ⓨᛶ⫵⥺⥔⑕䛾㚷ู⑌ᝈ䞉 Nintedanib : Phase III trials
䞉INPULSIS-1, -2 (Acute Exacerbation) ȺINPULSIS-2䛷AEᢚไຠᯝ䜢♧၀᪥ᮏ࿧྾ჾᏛ఍ 䛂≉Ⓨᛶ㛫㉁ᛶ⫵⅖デ᩿䛸἞⒪䛾ᡭᘬ䛝䛃ᨵゞ➨2∧ (2011)

N Engl J Med. 2014; 370: 2308-92䞉⫵⑓ኚ䜢క䛔䜔䛩䛔⭺ཎ⑓䞉⭺ཎ⑓䛻䛚䛡䜛⫵⑓ኚ䛾ฟ⌧㒊఩䞉 㛵⠇䝸䜴䝬䝏 ( rheumatoid arthritis : RA )㛫㉁ᛶ⫵⅖ Ẽ㐨⑓ኚ ⬚⭷⑓ኚ ⫵ື⬦⑓ኚ ⫵⬊ฟ⾑

䞉 ከⓎᛶ➽⅖/⓶⭵➽⅖ ( polymyositis/dermatomyositis : PM/DM )

RA

++

++

++

+

-

䞉 ඲㌟ᛶᙉ⓶⑕/◳໬⑕ ( systemic sclerosis : SSc )

PM/DM

+++

-

-

+

-

䞉 䝅䜵䞊䜾䝺䞁⑕ೃ⩌ ( Sjögren’s syndrome : SS )

SSc

+++

-

-

+++

-

䞉 ඲㌟ᛶ䜶䝸䝔䝬䝖䞊䝕䝇 ( systemic lupus erythematosus : SLE )

SS

++

++

+

+

-

䞉 ΰྜᛶ⤖ྜ⤌⧊⑓ ( mixed connective tissue disease : MCTD )䞉 ANCA㛵㐃⾑⟶⅖ ( ANCA-associated vasculitis : AAV )ĺ⫵⑓ኚඛ⾜ᆺ⭺ཎ⑓⫵䜒ᛕ㢌䛻⨨䛟ᚲせ䞉⭺ཎ⑓⫵䛻䛚䛡䜛⤌⧊ᆺ䛾㢖ᗘ
UIP

NSIP

OP

LIP

DAD

+++

++

++

+

+

PM/DM

+

+++

+++

-

++

SSc

+

+++

+

-

+

SS

+

++

-

++

+

SLE

+

++

+

+

++

+

++

+

-

+

+

+++

+

++

++

+

+

++

-

RA : rheumatoid arthritis, PM : polymyositis, DM : dermatomyositis,
SSc : systemic sclerosis, SS : Sjögren’s syndrome, SLE : systemic lupus erythematosus,
MCTD : mixed connective tissue disease
Fischer A, du Bois R. Lancet 2012; 380: 689-98

䞉㛫㉁ᛶ⫵⅖䛾デ⒪䛷ᚲせ䛺஦

RA

MCTD

SLE
MCTD

-

UIP : usual interstitial pneumonia, NSIP : nonspecific interstitial pneumonia,
OP : organizing pneumonia, LIP : lymphocytic interstitial pneumonia,
DAD : diffuse alveolar damage䞉 ≉Ⓨᛶ⫵⥺⥔⑕䛾☜ᐇ䛺デ᩿䛜㔜せ䞉ྛ✀⭺ཎ⑓䛾⌮ゎ䛸⭺ཎ⑓⫵䛾㚷ู䛜㔜せ䞉≉䛻䚸⫵⑓ኚඛ⾜ᆺ⭺ཎ⑓䛾௒ᚋ䛾ᒎ㛤䜒ὀど䛜ᚲせȺLD-CTD (lung dominant-connective tissue disease), UCTD
(undifferentiated connective tissue disease), AFI-ILD (autoimmune
featured-interstitial lung disease) 䛺䛹䛾ືྥ䛻䜒ὀព䜢ᡶ䛔䚸⭺ཎ⑓ᑓ㛛་䛸䛾䜽䝻䝇䝖䞊䜽䜢⾜䛖஦䛜᪩ᮇデ᩿䞉἞⒪௓ධ䛻㔜せFischer A, du Bois R. Lancet 2012; 380: 689-98



䞉➨5ᅇ⫵䛜䜣◊✲఍(2016.Jul.23)䞉➨5ᅇ⫵䛜䜣◊✲఍(2016.Jul.23)ᚨὪ఍䜸䞁䝁䝻䝆䞊䝥䝻䝆䜵䜽䝖⥲ホ䠖⚟ᒸ ṇ༤ ඛ⏕ (࿴Ἠᕷ❧⑓㝔 ⥲㛗)㻌䞉➨6ᅇ⫵䛜䜣◊✲఍(2016.Dec.17)ᇽᓥ䝩䝔䝹 (኱㜰ᕷ)≉ูㅮ₇䠖ග෠ ᚭဢ ඛ⏕ (㏆␥኱Ꮫ࿧྾ჾእ⛉୺௵ᩍᤵ)䞉➨7ᅇ⫵䛜䜣◊✲఍(2017.Jul.8)୰㒊ᚨὪ఍⑓㝔ᩍ⫱ㅮ₇䠖ᚨὪ఍䜾䝹䞊䝥⑓㝔䛛䜙ᣍ⪸ணᐃ䞉➨8ᅇ⫵䛜䜣◊✲఍(2017.Nov.18)
䕿䕿䝩䝔䝹 (ி㒔ᕷ)≉ูㅮ₇䠖㔛ෆ ⨾ᘺᏊ ඛ⏕ (රᗜ┴❧䛜䜣䝉䞁䝍䞊 㒊㛗)䞉⫵䛜䜣⸆≀⒪ἲ䛾㐍ṌᚨὪ఍䜸䞁䝁䝻䝆䞊䝥䝻䝆䜵䜽䝖᠓ぶ఍ ஝ᮼ䛾䛤Ⓨኌ䠖ཎ⏣ ༤㞞 ඛ⏕ (ඵᑿᚨὪ఍⥲ྜ⑓㝔 㝔㛗)㻌ᮏ᪥䛾ෆᐜ
䞉䛂᩿䜙䛺䛔་⒪䛃䛸⑌⑓ᵓ㐀䛾ኚ໬㻌 䞉 ྛ✀䛜䜣䞉⫵䛜䜣䛾␿Ꮫ䞉࿧྾ჾ⑌ᝈデ⒪䛾⌧≧(⫵⒴䛾⤒Ⴀ䜈䛾ᙳ㡪䠖ᙜ㝔䝕䞊䝍)䞉࿧྾ჾᑓ㛛་䛾೫ᅾ(ᮏ㑥䞉ᚨὪ఍䜾䝹䞊䝥)䞉ᚨὪ఍࿧྾ჾ㒊఍タ❧(࿧྾ჾ⑌ᝈデ⒪䛻ᮃ䜎䜜䜛యไ)䞉⫵䛜䜣◊✲఍/࿧྾ჾ㒊఍⑕౛᳨ウ఍(IP䝭䝙䝺䜽䝏䝱䞊)䞉⫵䛜䜣デ⒪䛾㐍Ṍ䞉ᚨὪ఍࿧྾ჾ㒊఍䛾ᒎᮃ䞉㐲㝸㌿⛣ཪ䛿⬚Ỉ䜢క䛖㠀ᑠ⣽⬊⫵⒴㻌 䞉㠀ᑠ⣽⬊⫵⒴䛷ึ䜑䛶໬Ꮫ⒪ἲ䛜BSC䛻඲⏕Ꮡ䛷຾䛳䛯䞉 ⣽⬊㞀ᐖᛶᢠ䛜䜣๣䞉 ศᏊᶆⓗ⸆ : 䝗䝷䜲䝞䞊㑇ఏᏊኚ␗ (oncogenic driver)䞉 ศᏊᶆⓗ⸆ : ⾑⟶᪂⏕㜼ᐖ (anti-VEGF therapy)䞉 ච␿⒪ἲ : immune checkpoint inhibitor

BMJ 311: 899-909, 1995

ࣈ ෂ˟ԠԈ֥ᢿ˟ƷƜǕǇưȷƜǕƔǒ‫ܢ‬඙ࣈෂ˟၏ᨈ
ԠԈ֥ϋᅹ ᢿᧈųᇦဋᨙʂ


䞉⣽⬊㞀ᐖᛶᢠ䛜䜣๣䛾Ṕྐ(㠀ᑠ⣽⬊⫵⒴)1980䡚㻌 㻌 㻌 1986䡚㻌 㻌 1990䡚 㻌 㻌 1995䡚㻌 㻌 2000䡚
㻌 1985㻌 㻌 㻌 1990㻌 㻌 㻌 1995㻌 㻌
2000
Platinum

CDDP
VDS
VP-16
MMC

Other

Molecular
Targeting
Agents

CBDCA
Paclitaxel
Docetaxel
Gemcitabine
Vinorelbine
CPT-11➨୕ୡ௦䝺䝆䝯䞁

➨஧ୡ௦䝺䝆䝯䞁

Oxaliplatin
Pemetrexed
S-1
Amurubicin䞉⣽⬊㞀ᐖᛶᢠ䛜䜣๣䛾㐍Ṍ㻌 䞉㠀ᡥᖹୖ⓶⒴䛾ಶู໬἞⒪
䞉Pemetrexed (PEM) 䠖㻌 㠀ᡥᖹୖ⓶⒴䛷䝧䝛䝣䜱䝑䝖䞉Bevacizumab (BEV) 䠖㻌 ዌຠ⋡䚸PFSᘏ㛗ຠᯝ䛜ㄆ䜑㻌㻌 㻌㻌䜙䜜䜛䜒䚸ᡥᖹୖ⓶⒴䛷䝸䝇䜽㻌⌧⾜䝺䝆䝯䞁
Bevacizumab
Gefitinib
Erlotinib
Crizotinib䞉⣽⬊㞀ᐖᛶᢠ䛜䜣๣䛾㐍Ṍ
1725 Pts. With NSCLC (Ad. 847, Sq. 473, Large 153 , NOS 252), PS 0-1

䞉⫵䛜䜣⸆≀⒪ἲ䛾㐍Ṍ䞉 ⣽⬊㞀ᐖᛶᢠ䛜䜣๣

CDDP (75mg/m2) on day1 and GEM (1250mg/m2) on days 1, 8 q21days x 6cycles
CDDP (75mg/m2) and PEM (500mg/m2) on days 1 q21days x 6cycles

䞉 ศᏊᶆⓗ⸆ : 䝗䝷䜲䝞䞊㑇ఏᏊኚ␗ (oncogenic driver)䞉 ศᏊᶆⓗ⸆ : ⾑⟶᪂⏕㜼ᐖ (anti-VEGF therapy)䞉 ච␿⒪ἲ : immune checkpoint inhibitor

p=0.0011

䞉䛜䜣䛾ᡂ䜚❧䛱䞉㠀ᑠ⣽⬊⫵⒴䛻䛚䛡䜛㑇ఏᏊ⫼ᬒ
Non-synonymus mutations per tumor (somatic)㻌

Science 2013; 339: 1546-1558

䞉ேయ䜢ᵓᡂ䛩䜛඙ಶ䛾⣽⬊䞉䛭䛾䛖䛱䚸᪥䛻⣙൨ಶ䛜⣽⬊ศ⿣䞉䛖䛱䚸୓ᅇ䛻ᅇ䛾๭ྜ䛷㑇ఏᏊ䛾」〇䜶䝷䞊Ⱥྠ⩏ኚ␗(䝘䞁䝉䞁䝇ኚ␗) vs. 㠀ྠ⩏ኚ␗(synonymus mutation)(non-synonymus mutation)

䞉䛜䜣㑇ఏᏊ䛾άᛶ໬䚸䛜䜣ᢚไ㑇ఏᏊ䛾ḞኻȺ䛜䜣⣽⬊䛾ㄌ⏕ ( ᪥䛻䡚⣽⬊)

䞉㠀ᑠ⣽⬊⫵⒴䛻䛚䛡䜛㑇ఏᏊ⫼ᬒ䞉Oncogenic Driver䜢ᶆⓗ䛸䛧䛯ಶู໬኱⭠䛜䜣ከẁ㝵Ⓨ⒴䝰䝕䝹䠖 Multistep basis of tumorgenesis

Oncogene addiction䞉䞉䞉
ᝏᛶᙧ㉁䛜≉ᐃ䛾䝗䝷䜲䝞䞊㑇ఏᏊ䛻ᙉ䛟౫Ꮡ䛧䛶䛔䜛䚹
Driver mutation䛜䜣⣽⬊䛾ቑṪ䜔㌿⛣䛺䛹䛾ᝏᛶᙧ㉁䛻┤᥋㛵୚䛩䜛䚹

Fearon ER and Vogelstein B㻌
Cell 1990; 61: 759-767

Passenger mutation䛜䜣⣽⬊䛾䝀䝜䝮୙Ᏻᐃᛶ䛻౽஌䛧䛶ច㉳䛥䜜䛯ኚ␗䚹䛜䜣䛾ᝏᛶᙧ㉁䛻ᐤ୚䛧䛶䛔䜛䚹

Science 2013; 339: 1546-1558䞉㠀ᑠ⣽⬊⫵⒴䛻䛚䛡䜛Oncogenic Driver⭢⒴
MAP2K1AKT1
PIK3CA
BRAF
HER2
ALK
fusions䞉Oncogenic Driver䜢ᶆⓗ䛸䛧䛯ಶู໬

ᡥᖹୖ⓶⒴

NRAS
ROS1 fusions
KIF5B-RET

Unknown
EGFR

KRAS

Pao W, et al. Nat Med. 2012;18:349-351.

Gene

Event TypeFrequency, %FGFR1

Amplification

20-25

FGFR2

Mutation

5

PIK3CA

Mutation9

PTEN

Mutation deletion

18

CCND1

Amplification

8

CDKN2A

Deletion/mutation

45

PDGFRA

Amplification
mutation

9

EGFR

Amplification

10

MCL1

Amplification

10

BRAF

Mutation

3

DDR2

Mutation

4

ERBB2

Amplification2

cytotoxic agents

gefitinib /erlotinib / afatinib

crizotinib /alectinib

All comer

EGFR mutation(+)
Ad 30-50%

ALK fusion (+)
Ad 3-5%RR

20-30%

70-80%

61%

DCR

50-60%

90%

88%

Pt

PFS

6M

10-13 M

10.2 M / >20.3 M

OS

12 M

28-30 M

>24 M

Hammerman P, et al. WCLC 2011. Abstr. PRS.1

䞉⫵䛜䜣⸆≀⒪ἲ䛾㐍Ṍ䞉 ⣽⬊㞀ᐖᛶᢠ䛜䜣๣䞉 ศᏊᶆⓗ⸆ : 䝗䝷䜲䝞䞊㑇ఏᏊኚ␗ (oncogenic driver)䞉㠀ᡥᖹୖ⓶⒴䛾ಶู໬἞⒪
䞉Bevacizumab (BEV) 䠖㻌 ዌຠ⋡䚸PFSᘏ㛗ຠᯝ䛜ㄆ䜑㻌㻌 㻌㻌䜙䜜䜛䜒䚸ᡥᖹୖ⓶⒴䛷䝸䝇䜽㻌䞉 ศᏊᶆⓗ⸆ : ⾑⟶᪂⏕㜼ᐖ (anti-VEGF therapy)䞉 ච␿⒪ἲ : immune checkpoint inhibitorࣈ ෂ˟ԠԈ֥ᢿ˟ƷƜǕǇưȷƜǕƔǒ‫ܢ‬඙ࣈෂ˟၏ᨈ
ԠԈ֥ϋᅹ ᢿᧈųᇦဋᨙʂ


99 Pts. With NSCLC (Ad. 60, Sq. 20, Large 10 , Other 9), PS 0-2
CBDCA (AUC=6) + PTX (200mg/m2) on days 1 q21days x 6cycles
CBDCA (AUC=6) + PTX (200mg/m2) + BEV (7.5 or 15mg/Kg) on days 1 q21days x 6cycles

䞉Bevacizumab㐺ᛂᇶ‽䛾ኚ㑄䞉⫵䛜䜣⸆≀⒪ἲ䛾㐍Ṍ䞉 ⣽⬊㞀ᐖᛶᢠ䛜䜣๣䞉 ศᏊᶆⓗ⸆ : 䝗䝷䜲䝞䞊㑇ఏᏊኚ␗ (oncogenic driver)䞉 ศᏊᶆⓗ⸆ : ⾑⟶᪂⏕㜼ᐖ (anti-VEGF therapy)䞉 ච␿⒪ἲ : immune checkpoint inhibitor䞉ච␿⒪ἲ䛾ኚ㑄䞉⭘⒆ච␿䛻䜘䜛䛜䜣⣽⬊䛾᤼㝖ᶵᵓफࣱ᱅ᑥᏽỉᴾ ЭᇌᐄầỮỂИỉᴾ ЏᨊɧᏡễफࣱᴾ
᱅ᑥᏽỆ‫ݣ‬ẴỦᴾᏽၨཎီႎᴾ ᫱‫܇‬β၃ᴾᙀяၲඥểᴾβ၃ၲඥỉ১ᛐᴾ
ၲඥᴾ
৴˳ᴾẲềỉIFN-Į (sipuleucel-Tᾉ቟‫)׎‬ᴾ ἝἮἽἰἨỉ১ᛐᴾ(ଐஜẆ቟‫)׎‬ᴾᴾЏᨊɧᏡễफࣱᴾ
᱅ᑥᏽỆ‫ݣ‬ẴỦᴾ
ỶἦἼἲἰἨᴾỉ১ᛐᴾ(ଐஜ)ᴾᴾầỮኬᏘᴾ

ᵐᴾ ᏽၨ৴ҾửTኬᏘỆ੩ᅆᴾ
৴Ҿ੩ᅆኬᏘᴾ
ίᵟᵮᵡὸᴾᵏᴾᏽၨ৴Ҿỉᢂᩉᴾ

1970࠰ˊᴾ 1980࠰ˊᴾ 1990࠰ˊᴾ

2000࠰ˊᴾ

2011࠰ᴾ2014࠰ᴾ2015࠰ᴾ䐟~䐡: priming phase

෇ࣱ҄ᴾ
ᵲኬᏘᴾ

(ච␿⣽⬊䛜⭘⒆䛾᝟ሗ䜢ྲྀᚓ)TኬᏘầᏽၨ৴Ҿửᛐᜤᴾ ᵒᴾफࣱ᱅ᑥᏽỉᴾ
ᐯ໱ᡚ጑ửᴾ̟Ẵᴾβ၃ἅὅἯὊᴾ
἟ὅἚᴾИỉᏽၨ᧙ᡲᴾ৴ҾỉᴾἁἿὊὅ҄ᴾ(MAGE-1)ᏴኬᏘầỮểᴾफࣱ᱅ᑥᏽỆᴾ‫ݣ‬ẴỦᵧᵪᵋᵐỉᴾ
১ᛐᴾ(቟‫)׎‬ᴾᡶᘍफࣱ᱅ᑥᏽᴾ
Ệ‫ݣ‬ẴỦᴾ
ỶἦἼἲἰἨᴾ
ỉ১ᛐ (഑቟)ᴾЏᨊɧᏡễᡶᘍὉᴾ
ϐႆỉ᩼‫ݱ‬ኬᏘᏍၶᴾ
Ệ‫ݣ‬ẴỦᴾἝἮἽἰἨỉ১ᛐᴾ(ଐஜ)

Kirkwood J.M. et al. : J Clin Oncol. 2008; 26 : 3445
Kantoff P.W. et al. : N Engl J Med. 2010; 363 : 411
Hodi F.S. et al. : N Engl J Med. 2010; 363 : 711

TኬᏘỉᴾᵑᴾ ෇ࣱ҄Ὁ‫ف‬഻ᴾ
ɧ෇ࣱᴾ
ᵲኬᏘᴾ

෇ࣱ҄ᴾ
ᵲኬᏘᴾ

ầỮኬᏘᴾ

䐢~䐣: effector phase(ච␿⣽⬊䛜⭘⒆䜢ᨷᧁ)TኬᏘầᏽၨኬᏘửૌએᴾ ᵓᴾầỮኬᏘᴾ

1. Andersen MH, et al. J Invest Dermatol. 2006; 126: 32–41
2. Pardoll DM. Nat Rev Cancer. 2012; 11: 252–264
3. Mellman I, et al. Nature. 2011; 480: 480–489
4. Heemskerk B, et al. EMBO J. 2013; 32: 194–203
5. Boudreau JE, et al. Mol Ther. 2011; 19: 841–853
6. Janeway CA, et al. Immunobiology: The Immune System in Health and Disease. 6th ed. New York, NY: Garland Science; 2004

䞉Immune checkpoint䜢ᶆⓗ䛸䛧䛯ච␿⒪ἲ

䞉Immune checkpoint䜢ᶆⓗ䛸䛧䛯ච␿⒪ἲ

(Immune checkpoint inhibitor: ICI)㻌

(Immune checkpoint inhibitor: ICI)㻌

䞉 ⭘⒆ච␿ (ᢠཎᥦ♧䜢ཷ䛡䛯T⣽⬊) 䜢୙ά໬䛩䜛⤒㊰䞉 CheckMate017䠖2nd line docetaxel vs. nivolumab (SqCC): Anti-CTLA4

ĺPD-1/PD-L1⤒㊰䞉CTLA4⤒㊰

Ipilimumab
Tremelimumab

86

Nivolumab

CTLA4

Docetaxel: Anti-PD-1

Anti-PD-L1

Nivolumab
Pembrolizumab

Atezolizumab
Duvalumab

42%(1ᖺ⏕Ꮡ⋡:)

24%(1ᖺ⏕Ꮡ⋡:)

Xia B, Herbst RS. Immunotherapy 2016; 8:279-98.

Brahmer J, Reckamp KL, et al. N Engl J Med. 2015; 373:123-35.

䞉Immune checkpoint䜢ᶆⓗ䛸䛧䛯ච␿⒪ἲ

䞉Immune checkpoint䜢ᶆⓗ䛸䛧䛯ච␿⒪ἲ

(Immune checkpoint inhibitor: ICI)㻌
䞉 CheckMate057䠖2nd line docetaxel vs. nivolumab (Non-Sq)

Nivolumab
Docetaxel

51%(Immune checkpoint inhibitor: ICI)㻌
Mutation burden determines sensitivity to anti-PD-1 therapy(Pembrolizumab) in non-small-cell lung cancer㻌

39%(1ᖺ⏕Ꮡ⋡:) (18䞄᭶⏕Ꮡ⋡:)

39%

23%

(1ᖺ⏕Ꮡ⋡:) (18䞄᭶⏕Ꮡ⋡:)㠀ྠ⩏ኚ␗䛻䜘䜛mutation burden䛜㧗䛔䜋䛹ᢠPD-1ᢠయ䛾ຠᯝ䛿ᙉ䛔㻌Borghaei H, Paz-Ares L, et al. N Engl J Med. 2015; 373:1627-39.

䞉Immune checkpoint inhibitor䛾᭷ᐖ஦㇟

Rizvi NA, Hellmann MD, et al. Science 2015; 348: 124-8.

䞉ᑠᣓ䐟䛂⫵䛜䜣䛃䛿౫↛䛸䛧䛶䛂㞴἞䛜䜣䛃䛷䛒䜛䞉䛧䛛䛧䚸⤌⧊ᆺ䚸㑇ఏᏊኚ␗䚸⑓ᮇ䛻ᛂ䛨䛶䚸ᡭ⾡䞉ᨺᑕ⥺⒪ἲ䞉໬Ꮫ⒪ἲ䜢㐺ษ䛻౑䛔ศ䛡䜛஦䛻䜘䜚䚸䛂᰿἞䛃䜒┠ᣦ䛫䚸䛂᰿἞䛃䛜୙ྍ⬟䛺ᝈ⪅䛥䜣䛻䜒䛂ᜠᜨ䛃䛜䜒䛯䜙䛥䜜䜛᫬௦䛻䛺䛳䛶䛔䜛䚹䐠䛂⫵䛜䜣䛃䛾἞⒪䛷䛿䚸䛂⤌⧊ᆺ䛃䛾Ỵᐃ䛜➨୍ẁ㝵䞉䛂㌿⛣䛜䛒䜛䛛䜙἞⒪䛿୙ྍ⬟䚸⦆࿴䜿䜰䛃䛸ゝ䜟䜜䛶䜒䚸⤌⧊ᆺ䜔㑇ఏᏊኚ␗䛻ᛂ䛨䛶໬Ꮫ⒪ἲ䛻䜘䜛ᜠᜨ䛜༑ศ䛻ᮇᚅ䛷䛝䜛䚹䞉䛂࿧྾ჾෆ⛉ᑓ㛛་䛃䛻䜘䜛デᐹ䛜ᚲ㡲䛷䛒䜛䚹ࣈ ෂ˟ԠԈ֥ᢿ˟ƷƜǕǇưȷƜǕƔǒ‫ܢ‬඙ࣈෂ˟၏ᨈ
ԠԈ֥ϋᅹ ᢿᧈųᇦဋᨙʂ


ᮏ᪥䛾ෆᐜ

䞉ᚨὪ఍࿧྾ჾ㒊఍䛾ᒎᮃ䞉䛂᩿䜙䛺䛔་⒪䛃䛸⑌⑓ᵓ㐀䛾ኚ໬㻌 䞉 ྛ✀䛜䜣䞉⫵䛜䜣䛾␿Ꮫ䞉 ࿧྾ჾᑓ㛛་䛾⫱ᡂ䞉࿧྾ჾ⑌ᝈデ⒪䛾⌧≧(⫵⒴䛾⤒Ⴀ䜈䛾ᙳ㡪䠖ᙜ㝔䝕䞊䝍)䞉 ⫵䛜䜣◊✲఍ / ࿧྾ჾ㒊఍⑕౛᳨ウ఍䛾⥅⥆䞉ᕤኵ䞉࿧྾ჾᑓ㛛་䛾೫ᅾ(ᮏ㑥䞉ᚨὪ఍䜾䝹䞊䝥)䞉ᚨὪ఍࿧྾ჾ㒊఍タ❧(࿧྾ჾ⑌ᝈデ⒪䛻ᮃ䜎䜜䜛యไ)䞉 ⥲ྜෆ⛉䜢ྵ䜑䛯௚⛉䛸䛾᭷ᶵⓗ㐃ᦠ䛾ಁ㐍䞉⫵䛜䜣◊✲఍/࿧྾ჾ㒊఍⑕౛᳨ウ఍(IP䝭䝙䝺䜽䝏䝱䞊)ȺᚨὪ఍䜾䝹䞊䝥ෆ䛷䛾᝟ሗඹ᭷䜢᭦䛻ᙉ໬䞉⫵䛜䜣デ⒪䛾㐍ṌȺᚨὪ఍䜾䝹䞊䝥እ䜈䛾᝟ሗⓎಙ䞉ᚨὪ఍࿧྾ჾ㒊఍䛾ᒎᮃ䞉ᚨὪ఍࿧྾ჾ㒊఍䛾ᒎᮃ䞉ᚨὪ఍࿧྾ჾ㒊఍䝩䞊䝮䝨䞊䝆ᚨὪ఍䜲䞁䝣䜷䝯䞊䝅䝵䞁䝅䝇䝔䝮ᰴᘧ఍♫䞉 ࿧྾ჾᑓ㛛་䛾⫱ᡂ䞉 ⫵䛜䜣◊✲఍ / ࿧྾ჾ㒊఍⑕౛᳨ウ఍䛾⥅⥆䞉ᕤኵ䞉 ⥲ྜෆ⛉䜢ྵ䜑䛯௚⛉䛸䛾᭷ᶵⓗ㐃ᦠ䛾ಁ㐍ȺᚨὪ఍䜾䝹䞊䝥ෆ䛷䛾᝟ሗඹ᭷䜢᭦䛻ᙉ໬ȺᚨὪ఍䜾䝹䞊䝥እ䜈䛾᝟ሗⓎಙ䛾᭦䛺䜛ᙉ໬䞉ᚨὪ఍࿧྾ჾ㒊఍䝩䞊䝮䝨䞊䝆ᚨὪ఍䜲䞁䝣䜷䝯䞊䝅䝵䞁䝅䝇䝔䝮ᰴᘧ఍♫䞉ᚨὪ఍࿧྾ჾ㒊఍HP (䝇䝬䝩∧)ᚨὪ఍䜲䞁䝣䜷䝯䞊䝅䝵䞁䝅䝇䝔䝮ᰴᘧ఍♫

䞉䜾䝻䞊䝞䝹䛻䜏䛯᝟ໃȺෆྥ䛝䞉ಖㆤ୺⩏䞉䜰䝯䝸䜹ྜ⾗ᅜ➨45௦኱⤫㡿䠖Donald J Trump

CNN
Nov. 9, 2016䞉ᮏ㑥䛻䛚䛡䜛་⒪᝟ໃȺෆྥ䛝䛾ྍ⬟ᛶ䞉᪂ᑓ㛛་ไᗘ

䞉䜾䝻䞊䝞䝹䛻䜏䛯᝟ໃȺෆྥ䛝䞉ಖㆤ୺⩏䞉䜲䜼䝸䝇䛜EU䜢㞳⬺ (Brexit)

BBC
Jun. 24, 2016䞉ᚨὪ఍࿧྾ჾ㒊఍䛾ᒎᮃ(ෆྥ䛝䛾᝟ໃ䛷)➨44ᅇ♫఍ಖ㞀ᑂ㆟఍
Feb. 18, 2016

䞉 ࿧྾ჾᑓ㛛་䛾⫱ᡂ䞉 ⫵䛜䜣◊✲఍ / ࿧྾ჾ㒊఍⑕౛᳨ウ఍䛾⥅⥆䞉ᕤኵ䞉 ⥲ྜෆ⛉䜢ྵ䜑䛯௚⛉䛸䛾᭷ᶵⓗ㐃ᦠ䛾ಁ㐍ȺᚨὪ఍䜾䝹䞊䝥ෆ䛷䛾᝟ሗඹ᭷䜢᭦䛻ᙉ໬ȺᚨὪ఍䜾䝹䞊䝥እ䜈䛾᝟ሗⓎಙ䛾᭦䛺䜛ᙉ໬Ⱥྠ䛨ᚿ䛾௰㛫䜢ቑ䜔䛧䚸䛂㑅䜀䜜䜛་⒪䛃䜢㏣ồ䞉ᚨὪ఍࿧྾ჾ㒊఍䛾ᒎᮃ(᭦䛺䜛ᒎᮃ)䞉 ྛ䜾䝹䞊䝥⑓㝔䜢⧅䛔䛰࿧྾ჾ䇾tumor board䇿䛾タ⨨䞉 㐌1ᅇ䛾Web఍㆟㛤ദ䛷䚸ၥ㢟⑕౛ / ඲౛䛸䛩䜛䛛䞉 ࿧྾ჾ⑌ᝈ䛷䛿⏬ീ⢭ᗘ䛜㔜せ䛷DICOM⏬ീ䛿㔜䛔

ȺWeb఍㆟Live ON䛿䝉䜻䝳䝸䝔䜱䞊䛸⏬㉁䛻ㄢ㢟Ⱥ㧗㏿㏻ಙᅇ⥺䛿䝁䝇䝖䛻ㄢ㢟ȺᚨὪ఍䜲䞁䝣䜷䝯䞊䝅䝵䞁䝅䝇䝔䝮ᰴᘧ఍♫䛸ᛂ┦ㄯ䛤Ύ⫈䛒䜚䛜䛸䛖䛤䛦䛔䜎䛧䛯

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