Добавил:

Sekretar kiopkiopkiop18@yandex.ru t.me/Prokururor I Вовсе не секретарь, но почту проверяю Опубликованный материал нарушает ваши авторские права? Сообщите нам.

Вуз:

Ростовский Государственный Медицинский Университет

Предмет:

Медицина общая

Файл:

Книга_138_библиотеки_им_акад_М_И_Перельмана

.pdf

Скачиваний:

Добавлен:

29.08.2026

Размер:

87 Мб

Скачать

☆

<<< < Предыдущая 1 2 34 / 504 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 > Следующая >>>

4.49 Model for a Clinically Reasoned Approach to EBP

https://t.me/med1917

111

—NOTES—

Identify the highest level of evidence

Generate a meaningful

question

Generate a meaningful hypothesis

Measure and

evaluate the

Apply the evidence

Test the

response

through inductive, deductive, and Bayesian reasoning

hypothesis

Modify hypothesis during the physical exam

Critically appraise the evidence

Contextual

Elements

Patient Values

Best Available

Evidence

Clinical

Experience

Context of the

Conversation

•  e scientiﬁ c method, EBP, and clinical reasoning are not mutually exclusive

constructs.  ey are all processes that are used to answer clinically meaningful questions. What makes these processes similar are:

°  ey start by formulating a clinical question and/or hypotheses °  ey go on to establish a disciplined process that sets the rules to the game

before playing the game

°  ey play the game based on the established rules and attain a result °  ey interpret the result based on the previously established rules °  ey do not attempt to change the rules of the game if they do not like the

result

°  ese processes require metacognition related to what is and is not going well

(reﬂ ection in action) during the game and what did and did not go well (reﬂ ec-

tion on action) after the game is played

5.1 Using the Literature in a Reasoned Approach to Evidence-based Practice

• Section 5

5.2 What is the problem related to?

• Is it related to:

Cause

Diagnosis

Prognosis

Intervention

5.3 Which questions should be answered ﬁ rst?

• Most important to the patient?

• Most important to the patient’s well-being?

• Most likely to make them feel better?

• Most likely to make them more functional?

5.4 Creating a Speciﬁ c, Answerable, Clinical Question

• What information do you need to answer the question?

112

—NOTES—

https://t.me/med1917

• Where can I ﬁnd the information?

• What is the best way to create a search strategy to ﬁnd the information?

• How can I quickly remove articles that are not relevant to the question?

Clinical Questions Should be Formulated Using PICO

5.5

• P-e Patient or Problem

• I-e “Intervention” or task (cause, diagnostic test, prognosis, treatment)

• C-Comparison intervention/task

• O-Outcome(s)

5.6

What sources potentially help identify the highest level of evidence?

• Expert opinion

• Textbooks

• Peer-reviewed literature

• Summary/Preprocessed sources

• Original papers

5.7

Tracking Down the Evidence

• Usefulness index-Is the internal validity of the research multiplied by the external

validity of the research divided by the amount of time and eﬀort it took to ﬁnd

113

the literature?

• To improve the usefulness of research for practicing clinicians, it is essential to

increase the quality of the literature and make it easier to ﬁnd

5.8 Where can you ﬁnd high-quality resources?

• Evidence-Based Practice Resources-

https://www.apta.org/patient-care/evidence-based-practice-resources

° Is a collection of evidence-based research tools that are available to members of

the American Physical erapy Association (APTA)

° Clinical Practice Guidelines (CPGs)-

https://www.apta.org/patient-care/evidence-based-practice-resources/cpgs

■

 

Clinical practice guidelines (CPGs) are systematically developed statements

to guide clinicians in using the best available evidence in patient care. PTNow has links to a collection of CPGs for the physical therapy profession

° Tests & Measures- https://www.apta.org/patient-care/evidence-based-

practice-resources/test-measures

■



APTA has secured permission for members to download copies of the tests/



tools/instruments for patient examination in the practice setting. e licensing agreements do not permit APTA to grant permission for other purposes or third-party use

° Clinical Summaries- https://www.apta.org/patient-care/evidence-

based-practice-resources/clinical-summaries

■

 

APTA Clinical Summaries synthesize evidence on managing speciﬁc condi-

tions in diﬀerent populations. You also can download condensed Portable Summaries

° Rehabilitation Reference Center- https://www.apta.org/patient-

care/evidence-based-practice-resources/rehabilitation-reference-center

■

 

e APTA Rehabilitation Reference Center (RRC) provides current infor-

mation and point-of-care resources in the ﬁelds of physical therapy, sports medicine, occupational, and speech therapy. It is designed to help clinicians provide the best plan of care for their patients. Content is updated daily and focuses on systematic identiﬁcation, evaluation, and consolidation of practice-changing information

• PEDro- http://www.pedro.fhs.usyd.edu.au/index.html

Academy of Orthopaedic Physical erapy, APTA.

For personal use only. No other uses without permission.

° PEDro is a free Physiotherapy Evidence Database of randomized trials, system-

https://t.me/med1917

atic reviews, and clinical practice guidelines in physiotherapy. PEDro provides the citation details, the abstract, and a link to the full text, where possible. All clinical trials on PEDro are assessed for quality by individuals trained on the use of the PEDro scale

° e PEDro scale has 11 criteria. e ﬁrst criteria is related to the presence of

inclusion and exclusion criteria in the study to determine the study’s external validity. Criteria 2 through 11 are used to determine the internal validity of the study. According to the PEDro website a PEDro score of 6 or greater for criteria 2-11 is required to determine if the study has a respectable level of internal validity.

• DiTA- https://dita.org.au/ ° DiTA is the Diagnostic Test Accuracy database that indexes systematic reviews

and primary diagnostic accuracy studies of clinical tests used to make a pathoanatomic diagnosis. DiTA allows the clinician to search for this literature using a number of diﬀerent parameters and provides citation details, abstracts, and links to full-text to the diagnostic accuracy literature

5.9

Finding Physical erapy Literature

• APTA Article Search- https://www.apta.org/patient-care/evidence-based-

practice-resources/article-search

° ArticleSearch provides APTA members with easy access to journals and other

resources relevant to clinical practice, including full-text access to research and articles from more than 4500 clinical and academic publications

• PubMed/MEDLINE- https://www.ncbi.nlm.nih.gov/pubmed/

° PubMed is the National Library of Medicine’s (NLM) free electronic database

of 20 million biomedical citations and abstracts. It covers the ﬁelds of medicine, nursing, and health and rehabilitation sciences, including physical therapy. Journal articles are indexed, and their citations are searchable. A tutorial on how to use the PubMed search features can be found at https://www.nlm.nih. gov/bsd/disted/pubmedtutorial/cover.html

• PubMed Central- https://www.ncbi.nlm.nih.gov/pmc/

° PubMed Central (PMC) is the US National Institutes of Health (NIH) free

digital archive of biomedical and life sciences journal literature. All the articles and journals posted in PMC are free. PMC also has the free author manuscripts of articles published by NIH-funded researchers

• MedlinePlus- https://medlineplus.gov/

° e National Library of Medicine’s MedlinePlus service includes links to addi-

tional sources of health-related information such as news articles, directories, organizations, databases, and medical dictionaries

• CINAHL- https://www.ebscohost.com/nursing/products/cinahl-databases

° CINAHL is the electronic version of the Cumulative Index of Nursing and

Allied Health Literature. APTA members have access to CINAHL through ArticleSearch. CINAHL covers 1961 to the present and includes citations from 3000+ journals and related magazines, including Physical erapy (PTJ) and

PT in Motion

• OVID- https://www.ovid.com/

° OVID is a search engine that is used to ﬁnd relevant medical research for pa-

tient care. Although there is an expense to using this database, some clinicians may have access to it through their employer or local library. A tutorial on how to use the OVID search features can be found at https://www.ovid.com/ support-training/product-training/online-training.html

• Cochrane Library https://www.cochranelibrary.com/

—NOTES—

https://t.me/med1917

° e Cochrane Library helps providers, practitioners, and patients make in-

formed decisions about health care

5.10

Research Designs and Statistics for Diﬀerent Clinical Questions

• If you have a speciﬁc clinical question that you would like to answer, beyond the

creation of a PICO question and ﬁnding the literature, it is essential to identify the highest level of evidence and best design to answer the question, before critically appraising the study for its quality and risk of bias

• A breakdown in the ability to identify and critically appraise the best available lit-

erature prevents the clinician from being able to accurately complete the process of EBP and breaks the deductive link between EBP and its application through the clinical reasoning process

• e following slides do not contain information that needs to be memorized.

is information should be used as a tool to help you answer your clinical questions by identifying the best available literature to answer the question

Prognosis: What is the natural history of LBP?

5.11

114

• Optimal Research Design: Inception cohort

• Examples of Common Statistical Representations: Survival curves

• Limitations: Diﬃcult to account for the eﬀect of variations in “standard of care”

during the condition

5.12 Prognosis: What factors inﬂuence my patient’s outcomes?

114

• Optimal Research Design: Inception cohort

• Examples of Common Statistical Representations: Odds ratios/Likelihood ratios

• Limitations: Diﬃcult to account for all the factors that inﬂuence outcome (as-

sembly bias)

5.13 Diagnosis: What screening tools are best to detect the presence or absence of a

condition?

114

• Optimal Research Design: Cross-sectional with comparison to “gold standard”

• Examples of Common Statistical Representations:

° Reliability of the test (kappa) ° Positive and negative speciﬁc agreement ° Sensitivity ° Speciﬁcity ° Likelihood ratios

• Limitations: Relies upon the validity of the gold standard; interpretation is great-

ly aﬀected by the prevalence of the condition

5.14 What treatment is best for my patient?

114

• Optimal Research Design:

° Low quality: case-series or group comparisons without random assignment ° High quality: randomized clinical trials ° High quality: systematic reviews and meta-analyses

• Examples of Common Statistical Representations:

° Low quality: Pre- to post-change scores or group comparisons (p-value, eﬀect

size diﬀerence)

° High quality: randomized clinical trials

■

 

Pre- to post-change scores or group comparisons (p-value, eﬀect size diﬀer-

ence, the number needed to treat)

° High quality: systematic reviews and meta-analyses

Academy of Orthopaedic Physical erapy, APTA.

For personal use only. No other uses without permission.

 ■ Appraisal and summary of the best available literature

https://t.me/med1917

• Limitations: ° Low quality: Lack of random assignment to a comparison (control) group

prevents conclusions regarding the actual eﬀect of the treatment

° High quality: randomized clinical trials

■

 

May be prone to statistical error due to small sample

° High quality: systematic reviews and meta-analyses

■

 

Between-study heterogeneity in sample and methods must be addressed

—NOTES—

5.15 What outcome measure is most useful for a given patient?

114

• Optimal Research Design: Longitudinal, case-series

• Examples of Common Statistical Representations: ° Reliability (intraclass correlation, Cronbach alpha, standard error of measure-

ment)

° Minimal detectable change (MDC) ° Minimal clinically important diﬀerence (MCID) ° Change score

• Limitations: Determining the minimal important change relies upon some out-

side reference, such as the global rating of change, that may be inﬂuenced by recall bias

Is the study valid?

5.16

• To determine if your patient is like the sample that was created for a study it is

crucial to accurately perform and report the patient’s history, systems review, and the speciﬁc tests and measures performed during the examination and evaluation process

• Internal validity-is an assessment of the quality of the study design to prevent

115

systematic errors or bias

• External validity-are the results of the study generalizable to your patient?

116

° Did the authors create a non-randomized relationship during the sampling

process by only screening the individuals that they thought would meet the

studies criteria instead of consecutively screening all patients that presented

with the diagnosis of interest?

° Does the sample of patients created from the population of interest look like

your patient (age, sex, ethnicity, etc)?

° Would your patient ﬁt the inclusion and exclusion criteria for the study?

• Risk of bias-outside biases related to a study design can also occur through re-

115

searcher conduct, data analysis, and reporting of the study

° Is there any evidence of conscious or non-conscious post-randomization bias?

117

 ■ For example, did the researcher(s) modify the ‘primary’ and ‘secondary’

outcomes labels between protocol, trial registry, and publication, and fail to report measures of variation for non-signiﬁcant outcomes?

117

5.17 If so, does it apply to the patient or patients that you treat?

• Is the study’s research question like the clinical question that you are trying to

answer?

• Is the sample that was created (inclusion and exclusion criteria) like the patient

or patients that you treat?

• Did you perform and document the physical examination in suﬃcient detail to

allow you to match your variables of interest with the study’s variables of interest?

• Is the study reported in suﬃcient detail to match your variables of interest with

the study’s variables of interest?

—NOTES—

https://t.me/med1917

5.18 Reporting Guidelines for Studies

• Reporting guidelines are used to ensure that a study is reported in suﬃcient detail

to allow for critical appraisal and to ensure that the trial is reproducible in the future

• ere are diﬀerent reporting guidelines for diﬀerent types of studies

• e Equator Network (https://www.equator-network.org/) is a website dedicat-

ed to reporting guidelines for the diﬀerent major types of studies

• A research study that reports having used a reporting guideline is more likely to

be published with suﬃcient detail to help you answer your clinical question

5.19 Diagnostic Literature

• Determining the quality of diagnostic literature is based on the pathoanatomic

model and compares a clinical test to a pathoanatomic reference (gold) standard such as radiographs, MRI, or arthroscopy

• Compares a reference standard to clinical test in a speciﬁc population

• Routine referral for diagnostic imaging in patients with knee and LBP provides

little to no beneﬁt for the patient

118

• Additionally, LBP imaging has been shown to be related to higher medical costs,

increased health care utilization, and increased absence from work hinder recovery

120

119

and may

• e commonly used reporting guideline is the STARD (https://www.equa-

tor-network.org/reporting-guidelines/stard/

)

5.20 Levels of Evidence for Diagnostic Studies

121

• Level 1 = Testing of previously developed diagnostic criteria in a series of consec-

utive patients with a universally applied reference gold standard

° A systematic review of level 1 studies

• Level 2 = Development of diagnostic criteria based on consecutive patients with

a universally applied reference gold standard

° A systematic review of level 2 studies

• Level 3 = Study on non-consecutive patients without a consistently applied ref-

erence gold standard

° A systematic review of level 3 studies ° Case-control study with a poor reference standard ° Expert opinion based on the best available evidence and/or expert panel con-

sensus

Sensitivity

5.21

122

• SnNout illustrates the clinical utility of sensitivity. SnNout means that a test with

high sensitivity (Sn) that is negative (N), helps to rule out something (out)

• It is essential to understand that a test that is high in sensitivity that is not speciﬁc

does not answer a speciﬁc, meaningful question during a physical exam when it is positive

• Sensitivity is an essential characteristic of a screening test

° Rule out serious pathology ° Rule conditions out by region

• Helps the clinician decide early during an exam if they should

° Evaluate and treat, ° Evaluate and refer, or ° Refer

• An example of a screening test with high sensitivity is the Ottawa Ankle Rules

5.22 Speciﬁcity

122

• SpPin illustrates the clinical utility of speciﬁcity. SpPin tells us that a test with a

high speciﬁcity (Sp) that is positive (P) helps to rule something (in)

Academy of Orthopaedic Physical erapy, APTA.

For personal use only. No other uses without permission.

• A speciﬁc test is most helpful when performed near the end of a clinical examina-

https://t.me/med1917

tion to verify the clinician’s primary hypothesis after completing active, passive, and resistive range of motion

• is may help to prevent cognitive errors related to veriﬁcation bias, premature

anchoring, and premature closure

• A speciﬁc test that is not sensitive that is found to be negative when performed

at the end of a physical exam suggests that the clinician has missed something

—NOTES—

5.23

Positive and Negative Likelihood Ratios

123

• A likelihood ratio is a test’s ability to modify the pretest probability of a diagnosis

being present or absent to the post-test probability of a diagnosis being present or absent

• e pretest probability is the probability that an individual has a diagnosis before

the test is carried out. It is based on variables such as the patient’s age, symptoms, epidemiological data, and clinical experience of the practitioner

• e post-test probability is the probability that an individual with a speciﬁc test

result has the diagnosis of interest following the test

• Positive likelihood ratio (LR+)

° Reﬂects the probability that a person who tests positive DOES have the disor-

der

° e threshold for a moderate or greater shift in the post-test probability that

the participant has the diagnosis occurs through a LR+ ≥ 5

• Negative likelihood ratio (LR-)

° Reﬂects the probability that a person who tests negative really DOES NOT

have the disorder

° e threshold for a moderate or greater shift in the post-test probability that

the participant does not have the diagnosis occurs through a LR- ≤ 0.20

5.24 Challenges of Diagnostic Accuracy Studies

124

• Pathoanatomic ﬁndings are a common ﬁnding in the asymptomatic population

and pathoanatomic changes naturally increase with age

• Measures of diagnostic accuracy are viewed through a pathoanatomic perspective

• e primary premise is that pathoanatomy is the “cause” of the participant’s

primary symptomatic complaint

• One of the signiﬁcant challenges for the pathoanatomic model as the “cause” of

a patient’s symptoms is we know that patients can be symptom-free in the presence of pathoanatomic ﬁndings and that they may have symptoms without any pathoanatomic changes

• e diagnostic accuracy of the clinical test is determined by comparing it to a

pathoanatomic gold standard, such as an MRI or arthroscopy

• Although a thorough discussion of the determination of diagnostic accuracy

from a pathoanatomic perspective is outside the scope of the monograph, I will discuss these terms as they relate to the clinical reasoning process

5.25 Common Problems with Diagnostic Studies

• ere may not be a “gold” or “reference standard” for the diagnosis

• Starts with the conrmation bias of assuming that pathoanatomy is the “cause” of

the patient’s symptoms

• Pathoanatomic ﬁndings are sensitive where a negative test is useful in ruling out

a pathoanatomic cause of the patient’s primary symptomatic complaint

• Positive pathoanatomic results do not mean that pathoanatomy is the “cause” of

the patient’s primary symptomatic complaint

124

—NOTES—

https://t.me/med1917

5.26 Common Biases in Diagnostic Studies

124

• Sampling bias- only screened participants that were thought to meet inclusion/

exclusion criteria instead of screening all potential participants with the condition

• Veriﬁcation bias- when not all participants are assessed by the reference standard

in the same fashion

° Can lead to overestimation of accuracy

• Incorporation bias- reference standard is included in the diagnostic test being

studied

° May occur when the examiner is not blinded to the diagnostic test result and

clinical condition of the participants

• Spectrum bias- participants are not representative of the population in which the

test is likely to be used

■

 

Should also have a spectrum of the disorder (mild to severe)

5.27 Other Potential Pitfalls of Diagnostic Tests

124

• e intended purpose of the test is not clearly deﬁned

• Lack of clarity in the description of the test performed

• Lack of clarity in the description of the test interpretation

• Judged by an examiner who is not blinded to the results of the reference study

5.28 What are the questions that need to be answered when reading a diagnostic

121

study?

• Are the results valid?

° Did the clinician face diagnostic uncertainty? ° Was there an independent blind comparison with a reference standard? ° Did the results inﬂuence the decision to perform the reference standard? ° Were the methods for conducting the test described in enough detail to allow

for replication in future studies?

• What are the results?

° Are the test likelihood ratios or the data required to calculate them present?

• How can I apply the results to patient care?

° Will reproducibility and interpretation of the test results be satisfactory in my

setting?

° Are the results applicable to my patient? ° Will the result change my management of the patient? ° Will the patient be better oﬀ as a result of the test?

What are some tools that can be used to assess the quality of a diagnostic study?

5.29

• QUADAS-2 is used to evaluate the risk of bias of diagnostic accuracy studies

(http://www.bristol.ac.uk/media-library/sites/quadas/migrated/documents/quadas2.pdf)

• CASP is used to evaluate diagnostic test studies (http://media.wix.com/ugd/

dded87_3815f02af1b34c21b8c3b2b5020024c3.pdf)

• Centre for Evidence-Based Medicine (CEBM) Diagnosis Critical Appraisal

Worksheet https://www.cebm.ox.ac.uk/resources/ebm-tools/critical-appraisaltools

5.30 Prognostic Studies

• Prognosis: is the predicted level of function that the patient will attain within a

speciﬁc timeframe

• Helps guide the intensity, duration, and frequency of the intervention, and aids

in justifying the intervention

Academy of Orthopaedic Physical erapy, APTA.

For personal use only. No other uses without permission.

• e commonly used reporting guideline is the STROBE (https://www.equa-

https://t.me/med1917

tor-network.org/reporting-guidelines/strobe)

—NOTES—

5.31

Levels of Evidence for Prognostic Studies

121

• Level 1 - High quality prospective study where all patients were enrolled at the

same point in their disease with ≥ 80% follow-up of the enrolled patients

° A systematic review of level 1 studies

• Level 2 -

° Retrospective study ° Untreated controls from a randomized controlled trial ° Lesser quality prospective study where patients were enrolled at diﬀerent times

during the recovery process or <80% follow-up

° A systematic review of level 2 studies

• Level 3 - Case-control study

• Level 4 - Case series

General Guidelines for Assessing Prognostic Studies

5.32

125,126

5.33 Are the results valid?

• Primary guidelines

° Was there a representative sample of participants?

■

 

Were the participants homogeneous with respect to their prognostic risk?

• Were participants at a similar point in the course of the disease?

° If subgroups with diﬀerent prognoses are identiﬁed

■

  

Did researchers provide estimates for all clinically relevant subgroups?

■

Was there an adjustment for important prognostic factors?



• Secondary guidelines

° Was follow-up suﬃciently long and complete? ° Were objective and unbiased outcome criteria used? ° What are the results?

■

   

How likely are the outcomes to occur over time?

■

How precise are the estimates of likelihood?

° Will the results help me in caring for my patient?

■

   

Were the study participants and their management like your own patient?

■

Are these results useful in assisting you with managing your patient?

Study Design and Statistics for Prognostic Studies

5.34

• Aspects to consider with prognosis

° Qualitative: Which outcomes could happen? ° Quantitative: How likely are they to happen? ° Temporal: Over what time period?

• Study designs examining prognosis

° Case-Control ° Cohort ° Randomized controlled trial-Each arm is a cohort representing a prognostic

factor of treatment and control/placebo intervention

• Type of statistics used to establish prognosis

° Descriptives, rates, proportions, risks for outcomes ° Odds ratios, likelihood ratios when dealing with clinical practice rules

5.35 Assessing the Validity of Prognostic Studies

• Validity related to homogeneity

° Participants should be at a similar point in their disease ° If at the beginning, it is an inception cohort

—NOTES—

https://t.me/med1917

° If not, point in time must be consistent

• Participants should be similar in risk ° How to decide? Known factors, clinical experience, and biology of the condi-

tion

° Risk adjustment may be necessary

• Validity related to follow-up ° “5 and 20 rule”

 

<5% loss probably = little bias

■



>20% loss seriously threatens the validity

■



° Ask “what if?” there are diﬀerential adverse outcome rates

• Validity related to outcome ° Target outcomes clearly speciﬁed a priori ° Specify the intensity and frequency of monitoring



■



Status of outcome assessors - blinded vs non-blinded

5.36 Assessing the Results of Prognostic Studies

• Result related to outcome over time ° Percentage of survival

     

■

Ex. 6-month, 1-year survival

■

Median survival

■

Survival curves

• Results related to precision ° Variability of data - 95% conﬁdence intervals ° e variability that is inconsistent over time - short term versus long term

follow-up

• Application ° Are the ﬁndings of this study generalizable to the patient that is sitting in front

of me?

5.37

User Guide for Prognostic Studies (Appendix 3)

121

• Are the results valid?

• Was the participant sample a smaller representation of the population of interest?

• Were the participants homogeneous with respect to their prognostic risk?

• Was the follow-up suﬃciently completed?

• Were outcome criteria objective and unbiased?

• What are the results?

5.38 User Guide for Prognostic Studies (Cont.) (Appendix 3)

121

• How likely are the outcomes over time?

• How precise are the estimates of likelihood?

• How do the results apply to my patient?

• Were the study participants and their management like the patients I see in prac-

tice?

• Was the follow-up long enough?

• Can I use the results to manage patients in my practice?

5.39 Critical Appraisal of Prognostic Studies

124

• Centre for Evidence-Based Medicine (CEBM) Prognosis Critical Appraisal Sheet

(https://www.cebm.net/wp-content/uploads/2018/11/Prognosis.pdf)

5.40 erapeutic Studies Investigating the Results of an Intervention

121

Academy of Orthopaedic Physical erapy, APTA.

For personal use only. No other uses without permission.

<<< < Предыдущая 1 2 34 / 504 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 > Следующая >>>

Соседние файлы в папке Библиотека им академика М.И. Перельмана

#
05.09.202618 Мб0Книга_1157_Библиотеки_им_академика_М_И_Перельмана.pdf
#
05.09.202618 Мб0Книга_1158_Библиотеки_им_академика_М_И_Перельмана.pdf
#
05.09.202618 Мб0Книга_1160_Библиотеки_им_академика_М_И_Перельмана.pdf
#
29.08.2026101 Мб0Книга_136_библиотеки_им_акад_М_И_Перельмана.pdf
#
29.08.202691 Мб0Книга_137_библиотеки_им_акад_М_И_Перельмана.pdf
#
29.08.202687 Мб0Книга_138_библиотеки_им_акад_М_И_Перельмана.pdf
#
30.08.202674 Мб0Книга_139_библиотеки_им_акад_М_И_Перельмана.pdf
#
30.08.202672 Мб0Книга_140_библиотеки_им_акад_М_И_Перельмана.pdf
#
30.08.202671 Мб0Книга_141_библиотеки_им_акад_М_И_Перельмана.pdf
#
30.08.202665 Мб0Книга_142_библиотеки_им_акад_М_И_Перельмана.pdf
#
30.08.202656 Мб0Книга_143_библиотеки_им_акад_М_И_Перельмана.pdf