Evidence-Based Practice Across the Health Professions, 2e

454 Pages·2013·8.62 MB·English

by  Tammy Hoffmann BOccThy(Hons) PhD

Evidence-bparascetdi ce
acrotshseh ealptrho fessions
2nde dition
Evidence-bparsaecdt ice
acrotshseh ealptrho fessions
2nde dition
TammyH offmann
SalBleyn tnte
ChsrD ieMla r
CHURCHILL
LMNGSTONE
SydneEyd inbuLrognhd on YorPkh iladelLpohuiiTaso rSotn to
New
ChurchLiUviIn gsonte
isa ni mprionfEt l sevier
Elsevier Australia.A CN 0010 023 57
(ad ivisioofRecdn InternatiBoonoakAustrallsi a PtyLtd )
Tower1 ,4 75Vi ctorAivae nuCeh,a tswood.N SW 2067
Thiesdi tio©n 2013Elsevi er AustraliaP.r evioeusd iti2o0n1 0Re.p rint2e0d1 3.
Thipsub licaitisoc no pyrigh&tc.cp ta sex presslypr oviidnedt hCeo pyrighAtc t1 96a8n dt hCeo pyright
Amendm{eDnigti Agteanld Aac)2t 0 0n0o,p aroftth isp ublicatiomna yb ere produced. storiedn a nyr etrieval
systoermtr ansmibttyanyed means( includidncctrgo nicm,e chanimciaclr,oc opyinpgh,o tocopryeicnogr,odi rng
othewirs)ewi thopurti wroirt tepne rmissifroonmt hpeub lsihe.r
c:JSBN:9 78072957882 2
Everya ttemphta bse enm adteo tr aa: anda cknowledgec opyrigbhutit,n s omcasese thism ayn oth avbee en
possibThel ep.ub lisahpeorl ogfoirsa esn ya a:identianlfr ingemaenntdw ouldw dcomaen yi nformatiotnor edress
tehs ituation.
Thisp ublicatiohna bse ecna refurlleviyew eda ndc hecketdoe nsutrheat th ceo ntenitsa sac curate: andc urrenats
possileba tti meo fp ublicatiWoenw .o ulrde commehnodw.CY ett,h athte r eader verifyany procedutrreesa,tm ents,
drug dosagoesr l c:gal contedescrnitb ed inth isb ookN.ei thert haeuth or, thec ontributnoors,rth ep ublisher
assum eany liabilfoirit nyj uarnyd/ odarm age tope rsonorsp ropearrtiys friongm a nyer roirn o ro missifroonm
thipsub lication.
NationLiablr aryo fA ustralia Cataloguing-iDna-tPau blication
AuthorH:o ffmannT,a mmy.
TitlEev:i dence-bparseadc tiaccreo ssthe healpthr ofesisonIsT a mmyH offmannS,a lBlye nneCthtr,Di ds Mar.
Edition:2 nde d.
ISBN: 978072954(1p3b5lc0. )
SubjectCsl:i nicmacdli cin�Dccimsaikionng E.v idence-bmaesdeidci ne.
OtheAutrh ors/ContributBoernsn:eS tatl,Dly d. Mar,C hris.
Dewey Nwnber: 616
PublishMeerl:i nMcdaE voy
DevelopmenEditotral: A mandaS imons
ProjCeocotr dinaLizt oMrasl:c oalnmdN ayagAith manathan
Edited byT eresaM cintyre
Permissieodintisn bgy Sar ah Johnson
ProofrebayTd i m Learner
Cover desigbny G eorgette Hall
Interndaesli gbny L isPae troff'
Inda byRo bertS wanson
Typeset byT oppaBnes t-set Prc:mc:Lidmiiat ed
PrinitneC dh inbayC hinTar ansl&a tiPrionnti ngS erviLciesm ited
CONTENTS
Foreword vii
Contributors viii
Reviewers
xv
Preface xvi
1 Introducttoie ovni dence-bpraascetdi ce
TammHyo ffmanSnal.Bl eyn ttn anedC hrDielsM ar
2 Inofrmatinoene ds, aqsukeisntgi aonnds ,s ome boasfri ecss easrtcuhd ies 16
Chris MDaerTl,a mmHyo ffanmna ndP auGlla sziou
3 Fidnintgh ee vidence 38
NancWyi lczyannsAdkn in iMcbKbon
4 Evidenacbeo uetff ecotsf i nterventions 61
SalBleyn ttn anedT ammyH offmann
5 Questiaobonust t hee ffecotfsi ntervteinonesx:a mploefsa ppraifsraoldmsi fferent
healptrho fessions 97
TammHyo ffmanJno,hW n B ennettM.a Blo yJleefC,fo mobesM,a rRkE klinEsd,z ard ErnsMto rAgnagnel,a
LiNsia ssClenar,ie R ickSahrardo,Sn an derAsl,an Sp encera nCda orUnWer ight
6 Evidence daibagonuots is 136
JenynD oust
7 Questiaobonust d iagnoesxiasm:p loefsa ppraifsarlosmd ifferheenatlp trho fessions 153
Chris MDaerSl,a lBleyn etntM.a Blo yJleefC,fo ombesM,a rRkE klinAsn,g elMao rgLainsN,ai ssen,
QairRei ckaSrhdar,o Sna ndeMrisch,aS lch neidrK-eolsankdyJ emmaS keat
8 Evidenacbeo uptr ognosis 1n
MarkR E klins
9 Questiaobonust p rognoseixsa:m ploefsa ppraifsraoldmsi fferehneta lptrho fessions 195
TammHyo ffmanMnar.iy nlB aiJrodh.n B eWn etntM.a Blo yJleefC.fo ombesM,a rkE lRk iLnissNa.i ssen,
SheenaR eyi.Cl llaRickirared an dS haron Sanders
10E videnacbeo upta tieenxtpse'r ieanncdec so ncerns 221
AlaPne arasnodKn a rHiannn se
11Q uestiaobonust p atieenxtpse'r ieanncdec so ncerenxsa:m ploefsa ppraisals
fromd ifferehneta lptrho fessions 240
SalBleyn ttn,Je ohBnen ntte.M aBlo yJleeC,ffo obmesC,r aLiogckw ood, NLiisssMaena ,er P iirotta,
SharonS anderasn Jdem maS keat
12A ppraisainndug n derstansdyisntge marteivci eowfqs u anttaitiavned
quatlaitievvei dence 283
SalBleyn ttn,eD enisOe' ConKnaroirHn,a nesn anSuds aDno yle
13C ilnicparalc tigcuei delines 313
TammHyo ffmaannnH d eatherB uchan
14T alkiwnigt h patienetsv iadbeonucte 328
TammHyo ffmaannnLd e iTgoho th
v
Forewor
Paradicgmhsa nogev teri. mTh eed evpemelnootf n eapw a radidgm.o ensodt oa waywi th otlhoden e,
buadta pantdsc hanigets. lIasntt h trheesew ehye aarvsee iennc reiasnreittsnei gnfi tttihneegvi dence
tot hien divipdautaiOlef cn uotr.es vei dencper-abc,iast neadi ddc iettioio tnfos c uosnt heev idence,
alesmop hasitshenese etdore lattheee vi detnotc heue n ique caonvandld uioetftsi h oienn dividual
patiTheinset m.p hasisiemspt oaranstp etchctels l:nc iocanld iotfei acohpn a tianedtn hteval iure s.
two
Wittgenssattiehdiea nvet r iyd ieasap ictanudr meia,tyb ,ei wef hauds etdhp ei ctblueortweh, a t
evidencem-ebdaisewocduil ndne o hta veb eedne scranidcb reidt asi c'oicosbkeodom ke diciinin tes'
earlyeyar s.
Throughthoneue tew d itoitfoh bnio sot khn eee dt ot ake tahlreoletf h efsacteo asrwe sl,asl foau rth,
thper acctoinctieen xacttcou,o n t whend emcaikiseisimn opgnh sas isevde ranyd e cxlpelaarOilnnyee d.
oft hwaeys inw hitchhhi asbs e eanc hiiebsvy ee xdp andtihnneumg b eorfd iscipllwonreke-ds pecific
plTheesi .m oprtaonftc heli isie nms a kitnhpger actoifec vied e--n-essceenttioga elt ttihrneig g ht
exam
informattoti hdoeen c iskiionpngo- i-mndatearrellye vaanntad c hietvaboal lhele aplrtohfe ssionals,
whattehveeurin ri rqlouieeis np rovidhienagl thcare.
Thee ditordso nathe ea rvejr oiobfifc c l earaiwnatgyh meys tioqftu hese u bmjaetctttome ark teh e
concanedpp trso cesansdea sce cscslThierbaolrue g.hi ottu,hbt io so k keepso nwt hhaietit ts foh cauts
clinaincpdia antsi reenantlesle tydok notwom akdee cisThiiosb nosos.kh ocuolndt rtiomb auktien g
surwee ar ea lalb lteog etth bee saavti laebvlied teone cveer y patianedne tve rccylh ioniiccea l
decoins.i
ProefssSoiMurri rG ray,C BEM D
DirecBtoetr,t Vera lHueaelc tahre
FormerClyh iKefno wledge Officero ft hNeati onHaeall Stehrv i(NHcSe,} U K
Contributors
MariBlayinBr Ad.O CRP.h D
AssocPiraotfees asnodFr o nudtaioHne adD,e partemnotfM ediIcmaalng gai ndR adiaStciieocnne Ms,o nsah
UniverMseiltbyrou,n Vei,c toAursitar,a lia
Marilcyrne atthecedu rricufolrtu hmde e greoef B acheolfoR ra diogranadp hMye dical Imwahgiincgh,
commenciend1 9,9an d8 subsequseunptelrvyi tsheeid n troduocfta inao rnt icumlaastteeddre sgr eien
medicuallt rasouanndd g raduate-emnasttreyrp sr ograimnrs ad iatitohne raapnydn uclemare dicine.
Mariliysan l stoh Aes sociDaetane T eachianngd L earninHge.rr esearicnht eresptrsi maridlirye cted
are
towardsi mproving cliniancda lle atrenacIihnnJi gun.ng 2e 00sh8e re-appoibnytt heeMd i nister
was
ofH eal(tVhi ctoarsPi reas)i deonftt h eM edicRaadli atiPornac titiBoonaredro sfVi ctoria.
JohWn B ennetBMte dSMcB,B SB.A (HonPsh)D.F. R ACGFPA.C HI
DsiciipnolefG eneral SPcrahcotooilfMc eedi,ic n,ae nd UTnhei veorfsQ iuetenysa lnHde alStehrv iTchee,
UniverosfQi uteye nasnldB,rb iasneA,u stralia
Johinsa p ractipcrei ncaitpt ahUeln iversHietayl Stehrv icThee, U niversoifQt uye enslaannddr, e gularly
usese videncem-ebdasiecdii nnh ei csl inpircala ctHiech eas.t augehvti dencem-ebdasiecdii nnB er isbane
and Oxford( atth eC entrfore Evidence-BMaseeddi ciannde )h as co-authao nruemdb eorf a rticles
relevanttoe vidence-pbraacsteiHdce e i.so ns everRaolya lA ustraCloilanl eogefG enerParlac titioners'
QualiCtarye committanede ss tritveosu se evidenicnte h ep roductoifor ne sourfocre gse neral
practitioners.
SalBleynn ettBO ccThoyn(sH)P.h D
SeinoLre crteuarn dS einoRre seaFrecowl,hl D iivsioofOn c cpuatioTnheaarlp yS,c hooofHl e alatnhdR ehabilitation
SciceenTs,he U niveorfsQ iueteyna snldB,r is,bA aunsetralia
Salilsany occupattihoenraalwp itishbt o tchl inanidc arle seaerxcphe rieSnhcehe as.d esigann eudm ber
ofe vidence-pbrasaecdt ciucrer icanudl taa ughetv idence-pbrasacetdi tcoeo ccupatitohneparyla,
physhieortaanpdy speepcaht holsotguyd efonrt 1s 1yea rsS.h eh as undertarekesenar chi ne vidence­
basedp ractiinccel,u dhienrPg h D,a ndh as authormeudl tiple CroecvhireanSwseh. eh elpeesdt ablish
and currentmlanya gest heO Tseekdeart ae-b--an as internationalloyc-cruepcaotgintoihnseaerlda py
evidednactea bSashee.i sac tivienb otnha tioannadil n ternaptrioofensasli coonmamli ttase aensa dvisor
one vidence-pbrasaecdtan idc iesa lsaom embeorf t heC riticAaplplrya iPseadp eArdsv isoBroyar dfo r
thAe ustraliOacnpc autionThaerlpa yj ournal
MalcoBlomy AlDei puBsA,D ipHSc(OAfmfbM )I,C AC ert, BlnfMoCTleicnhEP.ph iD.
SeinoLre crte,uDr epartemnotfC ommnutiyE megrencHye alatnhdP aarmedPirca ctMiocnseah,U niveirtsy,
VictAoursitar,a lia
Malcolpmr'ism atreyac hiarnega arse t raumsays tempsr,e -hoscpliitnaimlcan aalg emenptr,e -hospital
traummaan agementan d evidence-pbaraamseedd ipcr actiHcies.p rimarrye seairncthe riensctlsu de
pre-hostpriatuatmlar iapgree,- hostpriatuammlaa nagemetnhtle,i nkoifnam gb ulandcaet asteoot tsh er
health-redlaattaseeandtd s s ubsequeannatl ysiwso,r kplvaicoel eanncdei t esff ecantds ,a ttribanudt es
attitoufdu nedse rgrapdauraamteed anidc allhieeadls tthu deMnatlsc.o hlasmb eeanp aramedicw orking
inr uraraelas fo ro ve2r4 y earswi,t ht hleas t2 0y earass aM obilIen tenCsiarveeA mbulance Paramedic
inVi ctoria.
viii
Revewiers
NancLWy i lczyMnSsck, iP hD
AssisPtraonftesa snoRdre seaMracnha ,gH eeralItnhf otrimoRane seaUrncti( hH IRDUelp tamrneto fC ilincal
EpimdioeloagnyB di ostatMicsMtaiscUtsne,ir v erHsaimtiyl,tO onnt,a Crianoa,d a
Nancyt eacihnet sh Hee alRtehs eaMrecthh odolPorgyo griamn t hFeac ulotfyS cienwcheisc,ph r ovides
trainaittn hgMe Scan d PhDl evelSsh.eo versetehser e searccohn ducitnet dh HeI RUw,h icihsfo cused
ont he fioefhl eda litnhfo rmation ansdc iisde endciec attote hdege neratoifon ne wk nowleadbgoeu t
thnea tuorfeh ealatnhdc liniicnafolrm ation problems, otfhn ee wi dnefoverlmoaptmreiesoonuntr ces
tos uppoervti denceh-ebaaslectdarh ean d theeval uatioofvan r ioiunsn ovatiionon vesr comihnega lthcare
informatpiroonb lems.
CaroliWnrei ghMtS cP,G CEB,S C( HonsO)C,R( T)
SeinroL ecrteuirnR a diaTthieaoprnyD ,e partmofe nMte diIcmagali nagn dR adiaStciioenn Mcoensah,Us niversity,
MelbrounVei,c toArusitar,a lia
Carolicnuer'rse ronlte i sc onventihneggr aduate-emnasttreyr s in RadiataitoM no nThaesrha py
Univers.Hi etryr esearicnht eriensctlsut dhease s essmaenndtr egulaotffii tonne tsops r actiinss teu dents
and professiocnlailnsias,cs aels smanedn ta dvancipnrga ctiintc hepe r ofessSihoeni .sa m embeorf t he
EditorRieavli eBwo arfodr thej ourofna Rlad iothaperyi nP ractiancd ea membeorf t heM edical
RadiatPiroacntsi tiBoonaredor f t hVei ctoErdiuac atCioomnm ittee.
Revierwse
HeleBelni jlMeHvSec(n Hso ns)
Lecturearm/mPeLr eoagdrFearcl,ut oyfH ealatnhdE nviornmentSacli enDceepsa,r tofm eOnctcp uatiSocniaeln ce
anTdh reapAyU,T U niverAsuikctalyn,dN ,e wZ ealand
MariCniac caBreAlplpSi(c O ccThMyS)c,P, h D
AssocPiraotfees Sscoohro,ol f O ccpuaitonTahlea pyr anSdo cWioarlkF ,a clutoyfH ealStchic eenCs,u rtin
UniverPseirtWtyeh,s, t eAruns tralia
StevAe Fnr oBsNt,M PH
LecrteuSrch,o oofl N usrinagnM di wdifeUrnyi,v eorfWs eisttye Srydnn eya nIdn tievnCesa rLei,v erHpoooslp ital
SydnAeuys,t ralia
Anne HowBaHrdS c( Nat)A,d vD ip( HerMbe d)A,d vD ip( NutritMieodn)a l
SeinroL ecrte,uNr atuproathDye,pt amrenoft O cicdeanlMt ediicn,Ee ndaveouCro lleogfNe a tuHraela lth,
MelbrounAeu,s tralia
DebbHiowes onAs sDipMe(dRTr,ad)M Sc
LecrteuDri,iv sioofHn e alStchi enSccheso,oof l H ealStcihe nTcheeU, n iverofs SiotuytA uhs traAldieal,a ide,
Australia
PhDC andtiedI,ane trtniaoCneanlt freoA rl lHieeadl Etvihd ceenT,h eU niverofs SiotuyAt uhs trAadllaeiiad,, e
Australia
xv
Preface
When thep ublisahsekerdus s t op reparea s ecoenddi titohne,asy k edu st or espotnodfe edbactkh at
int hefo rm ofp opuldaerm and:m ore examplefosr moreh ealptrho fessiopnlaelassWe,e. are
was
delighttooe bdl iThgei.s e ditiooft nh beo ocko ntanienwsm atertihaailts r elevtanoet xe rcise physiolo­
gisantds human movements peciaplhiarsmtasc,i psaramtesd,i csa,n dc omplemenatnadar lyt ernative
medicipnreac titioinnade drist,i toont he1 0di sciptlhianweter sei ncluidnet dh efi rsetd ition.
We havee xpandeodu rc ontribtuetaoanmrd aswe lla sad dindgi scipelxipneerw tehs a,ve b eejno ined
bya hosotf i nternatainodnn aatli oenxaple ritnns u merofiuesl dosfe vidence-bpasreacdt iWcee .
welcomeo urn ewc ontributtoot rhseb ookan d thankal lo ft hea uthoforrs theivarl uable
contributions.
The overwhelmipnogsliytr ievacet itootn h fier setd itianodn t,h dee velopmetnhtaestv olvfreodm i t,
delighutsThe.ed fielodfe vidence-bpasreacdt iicsse o metinmaievesl anyd incorrvieecwetdlas y ar ela­
tivesllyo w-changinYge tas, weu pdateeadc ohft hceh apteevernswe werseu rprbiseytd h ne umber
area.
ofd evelopmanedn tpsr ogressisn cwee preparetdh efi rsetd itifoounry earsago . Fore xamplien,t o
Chapt1er2w e h avaed deidn formataiboonuq tu aliteavitdieven scyen theWsei hsa.v ael soa ddeadn ew
chapt(eCrh apt1e7r- Eemddibnevgi deen-cbpasreacd tiicen to croiluntiicncaearew lh)i crhe fleocntt sh e
importaonfanc eo rganisaetnivoinraoln mwehnitcp hr omoteevisd ence-bpasreadc taincdde e scribes
specisfiucp porsttirvaet egies.
Finlaylw,e h opteh atth ibso okh elpbsr intgo gethheera ltteha mme mberfrso md ifferdeinstc iplines
fora c ommonp urpoisnet ,h esam ew ayt hawet havdeo nseo i np roductihnibgso o--k--sot haqtu,i te
aparfrto me njoyeiancgoh t hecro'msp anyw,e delisveeram leisnst,e graantdue pd- to-edviadteen ce­
can
basedc aret oo urp atients.
Tatn.tny Hoffinann., SallBye n.nettand Chris DelM ar
LEARNING OBJECTIVES
Afterre aidntgh icsha pteyro,us hodu blea ble to:
•E xpailnw haits m eanbty t he teevrdime nec-basepdr actice
•U ndesrtantdh oe riingosf ev ideen-bcasepdr actice
•Expailnw hyev idences-ebdpa ractiicsie m protant
•D esrcibteh sec opoefev ideen-bcasehde alctahr e
•L isatn db rfileeyx lpiane ahco ft hfei vsetp est hamta keu pt heev diencbea-sed
;:-
practpircoec ess p
EVIDECNEB-ASEPDR ACTAICCREO STSH EH EALTPHR OFESS2IEO NS
WHATI SE VIDENCE-BAPSREADC TICE?
There isa famousd efinitbiyoP nr ofessor SDaacvkeitandtd someo fh isc olleawghuiecsdh e clares
evidence-bmaeseddi citnobe e e xpliancdi cto nscienattitoeumstp otfi sn dt heb esatvai labrlees earch
evidentcoeas sishte alptrho fessitoonm aalkset heb esdte cisifoornt hse piart ie1nE tvesn. t hought his
definitioonr igingailvelnwiy t hr espteoce tvi dence-bmaseeddi ciintie so, ft ene xtenbdeeyodn dt he
was
medical pranodfe sussieoasdn t hed efinitoifoe nvi dence-bparsacetdias c ew el1hle. definitmiaoyn
sounrda thamebri guoussol, e uts p icikt esl emeanptarsst o t hayotu fullayp preciwahtaeit s m eant
can
byt het erevm idenbcaseep-dracti ce.
1he purpoosfee vidence-bpasreacdt iicste o as sisitnc linidceacli smiaokni nTgo.m ake informed
clinidceacli sionnse,e tdo i ntegrlaottoesfp iecoefsi nformat�io hne.a lptrho fessionaarles ,
we we
typicvearlylgo yo da ts eekiinngfo rmatfrioomno urp atieanndt tsh efiamri lianeds fr omt hes ettiinng s
whicwhe wo rk;b utt,r aditionhaalvlneyo ,tb eeasn aware oft hien formattihoant gaifrno m
we we can
researWhcehn. Sackeantdt h isc oelalgureesfe tro ' evidentchee'cy,l ariitbfy y s pecify'ienvigd ence
fromre searcSho',a. l thoughn eeidn formatfrioomnm any sourceevsi,d ence-pbrasacetdis cheo ws
we
howr esearcha lspol aayr olieni nformicnlgi ndieccails iLoentus ss. i detforraa cm ko mentto l ook
can
brieafltwy h aretse arch offeurs t oe nhanocuerc linidceacli smiaokni ng.
can
We familiwiart ht hei mportanocfre e seaforrct he sttihnego rainedfos r p rovidiunsgwi tht he
are
background infortmhaafottri mospn ar to fo urc linical knowledgaeb.o usKntuo bwjlesecudtcgsashe
anatomyp,a thol,po sgyycholanodg syo cisatlr ucttuhraietses s senttioao lu rwo rkh as beerenfi neodve r
many yearst hrourghe searOcuhr.sc ience-btasreadi ngiinvegus s m odelosnw hicthob asoeu rc linical
managemento fp atieOnftc so.u rshea,vi nang understaonfdt ihnemg e chanisimssi mportant-for
examplec,o ulnde verh avem ades ensoefh eartfai luorred iabewtietsh ouuntd erstantdhiebn asgi c
we
mechanisomfst hesiel lneYsestefo,sc .u sionngl oyn t hem echanisomfsi llnceans sbe m isleading.
Evidence-bpasreadc teincceo uraugests o c oncentirnastteeo antd e sttihneig n formatdiiorne cThtilsy.
isac tualdliyffi cufolrth ealptrho fessiotnaodl os,b ecauseh aveb eetnr ainteocd o nsipdreirm arily
we
theu nderlmyeicnhgan isTmasb.l 1e1. g ivesso mec lineixcaamlp tloei sl lushtorwat thee approaches
two
differ.
Returnitnoge xplortihneeg l emeonftt sh ed efinitoifeo vind ence-bpasreacdt itcheed, e finitveiroyn
delibersattaettlehysaa tt temtpotfi sn de vidence bseh' oeuxlpdlan idc 'icto'n scienThteiroeiu sas g 'o.o d
TABLE 1.1:
EXAMPLEOSFH OW FOCUSIONNGYL ON TEHM ECHANISOMFIS LL NESSC ANB EM ILSEADING
remnnendatlon (based Rationale based on a mechanlsn Themepi ricalr esearch
Previous that showed It
on a mechanaplproachsn ) approach wrong
was
Pubta ebsio ntthoe ifrr ownhtesn If thsehyo uld ivntoh meisirlt e ep. Observatidoatnaha avle s hownth at
theyg ot os leep theym igshwta ltlhovweo miintt o baebsiar em orlei ktelody i es udden
of
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of
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of
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Coversiknwigonu ndasfter removaolf Top revtenb actegraiian aicncgesan sd A randmoiscedo ntrtroilsalhledo wtehdat
skinc ancer therefocraeu siinnfgect ion leavitnhgse k wionu ndosp end oenso t
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