Accuracy of early shock recognition by paramedics: a multicenter prospective observational study in Japan
Objective: Early recognition of shock status by paramedics significantly affects patient prognosis; however, its accuracy remains unclear. This study assessed the diagnostic accuracy of paramedics in classifying shock and the characteristics of misdiagnoses.Materials and Methods: This multicenter pr...
Saved in:
| Published in | Journal of Rural Medicine Vol. 20; no. 2; pp. 125 - 131 |
|---|---|
| Main Authors | , , , |
| Format | Journal Article |
| Language | English |
| Published |
Japan
THE JAPANESE ASSOCIATION OF RURAL MEDICINE
2025
The Japanese Association of Rural Medicine |
| Subjects | |
| Online Access | Get full text |
| ISSN | 1880-487X 1880-4888 |
| DOI | 10.2185/jrm.2024-053 |
Cover
| Abstract | Objective: Early recognition of shock status by paramedics significantly affects patient prognosis; however, its accuracy remains unclear. This study assessed the diagnostic accuracy of paramedics in classifying shock and the characteristics of misdiagnoses.Materials and Methods: This multicenter prospective observational study compared the on-scene shock diagnoses of paramedics between July 2022 and June 2023 with those of physicians upon hospital arrival.Results: The overall diagnostic accuracy for shock revealed substantial agreement (k=0.64), whereas diagnosis by category ranged from slight to moderate agreement (k=0.11–0.51). Patients without systolic hypotension were more frequently missed during diagnosis.Conclusions: Enhanced clinical education is needed to improve the accuracy of shock diagnosis by paramedics. |
|---|---|
| AbstractList | [Abstract] [Objective] : Early recognition of shock status by paramedics significantly affects patient prognosis ; however, its accuracy remains unclear. This study assessed the diagnostic accuracy of paramedics in classifying shock and the characteristics of misdiagnoses. [Materials and Methods] : This multicenter prospective observational study compared the on-scene shock diagnoses of paramedics between July 2022 and June 2023 with those of physicians upon hospital arrival. [Results] : The overall diagnostic accuracy for shock revealed substantial agreement (k=0.64), whereas diagnosis by category ranged from slight to moderate agreement (k=0.11-0.51). Patients without systolic hypotension were more frequently missed during diagnosis. [Conclusions] : Enhanced clinical education is needed to improve the accuracy of shock diagnosis by paramedics. Early recognition of shock status by paramedics significantly affects patient prognosis; however, its accuracy remains unclear. This study assessed the diagnostic accuracy of paramedics in classifying shock and the characteristics of misdiagnoses.ObjectiveEarly recognition of shock status by paramedics significantly affects patient prognosis; however, its accuracy remains unclear. This study assessed the diagnostic accuracy of paramedics in classifying shock and the characteristics of misdiagnoses.This multicenter prospective observational study compared the on-scene shock diagnoses of paramedics between July 2022 and June 2023 with those of physicians upon hospital arrival.Materials and MethodsThis multicenter prospective observational study compared the on-scene shock diagnoses of paramedics between July 2022 and June 2023 with those of physicians upon hospital arrival.The overall diagnostic accuracy for shock revealed substantial agreement (k=0.64), whereas diagnosis by category ranged from slight to moderate agreement (k=0.11-0.51). Patients without systolic hypotension were more frequently missed during diagnosis.ResultsThe overall diagnostic accuracy for shock revealed substantial agreement (k=0.64), whereas diagnosis by category ranged from slight to moderate agreement (k=0.11-0.51). Patients without systolic hypotension were more frequently missed during diagnosis.Enhanced clinical education is needed to improve the accuracy of shock diagnosis by paramedics.ConclusionsEnhanced clinical education is needed to improve the accuracy of shock diagnosis by paramedics. Objective: Early recognition of shock status by paramedics significantly affects patient prognosis; however, its accuracy remains unclear. This study assessed the diagnostic accuracy of paramedics in classifying shock and the characteristics of misdiagnoses.Materials and Methods: This multicenter prospective observational study compared the on-scene shock diagnoses of paramedics between July 2022 and June 2023 with those of physicians upon hospital arrival.Results: The overall diagnostic accuracy for shock revealed substantial agreement (k=0.64), whereas diagnosis by category ranged from slight to moderate agreement (k=0.11–0.51). Patients without systolic hypotension were more frequently missed during diagnosis.Conclusions: Enhanced clinical education is needed to improve the accuracy of shock diagnosis by paramedics. Early recognition of shock status by paramedics significantly affects patient prognosis; however, its accuracy remains unclear. This study assessed the diagnostic accuracy of paramedics in classifying shock and the characteristics of misdiagnoses. This multicenter prospective observational study compared the on-scene shock diagnoses of paramedics between July 2022 and June 2023 with those of physicians upon hospital arrival. The overall diagnostic accuracy for shock revealed substantial agreement (k=0.64), whereas diagnosis by category ranged from slight to moderate agreement (k=0.11-0.51). Patients without systolic hypotension were more frequently missed during diagnosis. Enhanced clinical education is needed to improve the accuracy of shock diagnosis by paramedics. |
| ArticleNumber | 2024-053 |
| Author | Tanohata, Rina Saito, Katsutoshi Nagano, Takehiko Ochiai, Hidenobu |
| Author_xml | – sequence: 1 fullname: Tanohata, Rina organization: Department of Emergency, Critical Care, and Disaster Medicine, University of Miyazaki Hospital, Japan – sequence: 1 fullname: Nagano, Takehiko organization: Department of Emergency, Critical Care, and Disaster Medicine, University of Miyazaki Hospital, Japan – sequence: 1 fullname: Saito, Katsutoshi organization: Department of Emergency, Critical Care, and Disaster Medicine, University of Miyazaki Hospital, Japan – sequence: 1 fullname: Ochiai, Hidenobu organization: Department of Emergency, Critical Care, and Disaster Medicine, University of Miyazaki Hospital, Japan |
| BackLink | https://www.ncbi.nlm.nih.gov/pubmed/40182164$$D View this record in MEDLINE/PubMed |
| BookMark | eNpVUU2P0zAQjdAi9gNunJGPHOjisZ3E4YKWFbsLWokLSNysiTttXVI72Eml_HucbalAsjy25s17o_cuizMfPBXFa-DXAnT5fht314ILteClfFZcgNZ8obTWZ6d3_fO8uExpy3lZNUK_KM4VBy2gUheFu7F2jGgnFlaMMHYTS5tgf7FINqy9G1zwrJ1YjxF3tHQ2fWDIdmM3OEt-oMj6GFJPdnB7YqFNFPc4D2HH0jAuJ-Y8-4o9-pfF8xV2iV4d61Xx4-7z99uHxeO3-y-3N48Lq-paLmzLOWmCVSUsLEFKhQCqaoG3VAtONSEK4GVJFmzJV43SUpcSZE2aYy3kVfHxwNuPbd543jJiZ_rodhgnE9CZ_zvebcw67A1AUwloIDO8PTLE8HukNJidS5a6Dj2FMRkJupKlUlBm6Jt_xU4qfw3OgHcHgM02pUirEwS4mfMzOT8z52dyfhl-f4A_eY1d8J3zZLZhjNnRZOxeZDz5eaI0nIt8cmkMh_kPElRerGp0Zvp0YNqmAdd0ksWYk-voKGvE03WUPzXtBqMhL_8AoAC9Ag |
| Cites_doi | 10.1177/001316446002000104 10.1016/j.ajem.2014.05.038 10.1186/s13054-015-0884-y 10.1186/s12873-022-00678-6 10.1186/s13054-023-04495-6 10.1136/emermed-2018-207588 10.1016/j.resuscitation.2006.10.011 10.1016/j.emc.2009.09.010 10.1097/CNQ.0000000000000407 10.7861/clinmedicine.19-3-260 10.1056/NEJMra1208943 10.1186/s13049-021-00856-8 10.1007/s00068-022-02186-5 10.1371/journal.pone.0119331 10.1016/j.injury.2021.05.015 10.1038/bmt.2012.244 10.1186/s13049-020-00761-6 |
| ContentType | Journal Article |
| Copyright | 2025 by THE JAPANESE ASSOCIATION OF RURAL MEDICINE 2025 The Japanese Association of Rural Medicine. 2025 The Japanese Association of Rural Medicine 2025 |
| Copyright_xml | – notice: 2025 by THE JAPANESE ASSOCIATION OF RURAL MEDICINE – notice: 2025 The Japanese Association of Rural Medicine. – notice: 2025 The Japanese Association of Rural Medicine 2025 |
| CorporateAuthor | Critical Care and Disaster Medicine Department of Emergency University of Miyazaki Hospital |
| CorporateAuthor_xml | – name: University of Miyazaki Hospital – name: and Disaster Medicine – name: Department of Emergency – name: Critical Care |
| DBID | AAYXX CITATION NPM 7X8 5PM |
| DOI | 10.2185/jrm.2024-053 |
| DatabaseName | CrossRef PubMed MEDLINE - Academic PubMed Central (Full Participant titles) |
| DatabaseTitle | CrossRef PubMed MEDLINE - Academic |
| DatabaseTitleList | MEDLINE - Academic PubMed |
| Database_xml | – sequence: 1 dbid: NPM name: PubMed url: https://proxy.k.utb.cz/login?url=http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed sourceTypes: Index Database |
| DeliveryMethod | fulltext_linktorsrc |
| EISSN | 1880-4888 |
| EndPage | 131 |
| ExternalDocumentID | PMC11962191 40182164 10_2185_jrm_2024_053 cv2jrmen_2025_002002_009_0125_01314544698 article_jrm_20_2_20_2024_053_article_char_en |
| Genre | Journal Article |
| GroupedDBID | .55 2WC 5GY ADBBV ADRAZ ALMA_UNASSIGNED_HOLDINGS AOIJS BAWUL BKOMP CS3 DIK HYE JMI JSF JSH KQ8 M48 MOJWN OK1 PGMZT RJT RPM RZJ TKC X7M AAYXX CITATION NPM 7X8 5PM |
| ID | FETCH-LOGICAL-c4773-cb00e8e1f62c1d1334a1146b10be720e7eaa21055ec1c50f9483853137e80a723 |
| IEDL.DBID | M48 |
| ISSN | 1880-487X |
| IngestDate | Thu Aug 21 18:38:13 EDT 2025 Sat Apr 26 11:49:39 EDT 2025 Sun Apr 06 01:22:40 EDT 2025 Sun Jul 06 05:09:30 EDT 2025 Sun Jul 13 07:20:24 EDT 2025 Wed Sep 03 06:30:37 EDT 2025 |
| IsDoiOpenAccess | true |
| IsOpenAccess | true |
| IsPeerReviewed | false |
| IsScholarly | true |
| Issue | 2 |
| Keywords | emergency medical services shock diagnosis clinical education paramedics |
| Language | English |
| License | https://creativecommons.org/licenses/by-nc-nd/4.0/deed.ja 2025 The Japanese Association of Rural Medicine. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives (by-nc-nd) License. (CC-BY-NC-ND 4.0: https://creativecommons.org/licenses/by-nc-nd/4.0/) |
| LinkModel | DirectLink |
| MergedId | FETCHMERGED-LOGICAL-c4773-cb00e8e1f62c1d1334a1146b10be720e7eaa21055ec1c50f9483853137e80a723 |
| Notes | ObjectType-Article-1 SourceType-Scholarly Journals-1 ObjectType-Feature-2 content type line 23 |
| OpenAccessLink | http://journals.scholarsportal.info/openUrl.xqy?doi=10.2185/jrm.2024-053 |
| PMID | 40182164 |
| PQID | 3186354415 |
| PQPubID | 23479 |
| PageCount | 7 |
| ParticipantIDs | pubmedcentral_primary_oai_pubmedcentral_nih_gov_11962191 proquest_miscellaneous_3186354415 pubmed_primary_40182164 crossref_primary_10_2185_jrm_2024_053 medicalonline_journals_cv2jrmen_2025_002002_009_0125_01314544698 jstage_primary_article_jrm_20_2_20_2024_053_article_char_en |
| PublicationCentury | 2000 |
| PublicationDate | 2025 |
| PublicationDateYYYYMMDD | 2025-01-01 |
| PublicationDate_xml | – year: 2025 text: 2025 |
| PublicationDecade | 2020 |
| PublicationPlace | Japan |
| PublicationPlace_xml | – name: Japan |
| PublicationTitle | Journal of Rural Medicine |
| PublicationTitleAlternate | J Rural Med |
| PublicationYear | 2025 |
| Publisher | THE JAPANESE ASSOCIATION OF RURAL MEDICINE The Japanese Association of Rural Medicine |
| Publisher_xml | – name: THE JAPANESE ASSOCIATION OF RURAL MEDICINE – name: The Japanese Association of Rural Medicine |
| References | 15. Ramadan A, Abdallah T, Abdelsalam H, et al. Accuracy of echocardiography and ultrasound protocol to identify shock etiology in emergency department. BMC Emerg Med 2022; 22: 117. 6. Rainer TH, Cheung NK, Yeung JH, et al. Do trauma teams make a difference? A single centre registry study. Resuscitation 2007; 73: 374–381. 3. Wilson C, Harley C, Steels S. Systematic review and meta-analysis of pre-hospital diagnostic accuracy studies. Emerg Med J 2018; 35: 757–764. 8. Xiang H, Wheeler KK, Groner JI, et al. Undertriage of major trauma patients in the US emergency departments. Am J Emerg Med 2014; 32: 997–1004. 9. Benhamed A, Fraticelli L, Claustre C, et al. Risk factors and mortality associated with undertriage after major trauma in a physician-led prehospital system: a retrospective multicentre cohort study. Eur J Trauma Emerg Surg 2023; 49: 1707–1715. 5. Cohen J. A coefficient of agreement for nominal scales. Educ Psychol Meas 1960; 20: 37–46. 7. Sturms LM, Driessen MLS, van Klaveren D, et al. Dutch trauma system performance: are injured patients treated at the right place? Injury 2021; 52: 1688–1696. 10. Smith GB, Redfern OC, Pimentel MA, et al. The National Early Warning Score 2 (NEWS2). Clin Med (Lond) 2019; 19: 260. 2. Patel S, Holden K, Calvin B, et al. Shock. Crit Care Nurs Q 2022; 45: 225–232. 13. Koivulahti O, Tommila M, Haavisto E. The accuracy of preliminary diagnoses made by paramedics—a cross-sectional comparative study. Scand J Trauma Resusc Emerg Med 2020; 28: 70. 11. Vincent JL, De Backer D. Circulatory shock. N Engl J Med 2013; 369: 1726–1734. 17. Pietersen PI, Mikkelsen S, Lassen AT, et al. Quality of focused thoracic ultrasound performed by emergency medical technicians and paramedics in a prehospital setting: a feasibility study. Scand J Trauma Resusc Emerg Med 2021; 29: 40. 12. Kristensen AK, Holler JG, Mikkelsen S, et al. Systolic blood pressure and short-term mortality in the emergency department and prehospital setting: a hospital-based cohort study. Crit Care 2015; 19: 158. 16. Yoshida T, Yoshida T, Noma H, et al. Diagnostic accuracy of point-of-care ultrasound for shock: a systematic review and meta-analysis. Crit Care 2023; 27: 200. 14. Perera P, Mailhot T, Riley D, et al. The RUSH exam: Rapid Ultrasound in SHock in the evaluation of the critically lll. Emerg Med Clin North Am 2010; 28: 29–56, viivii. 4. Kanda Y. Investigation of the freely available easy-to-use software ‘EZR’ for medical statistics. Bone Marrow Transplant 2013; 48: 452–458. 1. Holler JG, Bech CN, Henriksen DP, et al. Nontraumatic hypotension and shock in the emergency department and the prehospital setting, prevalence, etiology, and mortality: a systematic review. PLoS One 2015; 10: e0119331. 11 12 13 14 15 16 17 1 2 3 4 5 6 7 8 9 10 |
| References_xml | – reference: 11. Vincent JL, De Backer D. Circulatory shock. N Engl J Med 2013; 369: 1726–1734. – reference: 7. Sturms LM, Driessen MLS, van Klaveren D, et al. Dutch trauma system performance: are injured patients treated at the right place? Injury 2021; 52: 1688–1696. – reference: 13. Koivulahti O, Tommila M, Haavisto E. The accuracy of preliminary diagnoses made by paramedics—a cross-sectional comparative study. Scand J Trauma Resusc Emerg Med 2020; 28: 70. – reference: 3. Wilson C, Harley C, Steels S. Systematic review and meta-analysis of pre-hospital diagnostic accuracy studies. Emerg Med J 2018; 35: 757–764. – reference: 5. Cohen J. A coefficient of agreement for nominal scales. Educ Psychol Meas 1960; 20: 37–46. – reference: 9. Benhamed A, Fraticelli L, Claustre C, et al. Risk factors and mortality associated with undertriage after major trauma in a physician-led prehospital system: a retrospective multicentre cohort study. Eur J Trauma Emerg Surg 2023; 49: 1707–1715. – reference: 17. Pietersen PI, Mikkelsen S, Lassen AT, et al. Quality of focused thoracic ultrasound performed by emergency medical technicians and paramedics in a prehospital setting: a feasibility study. Scand J Trauma Resusc Emerg Med 2021; 29: 40. – reference: 2. Patel S, Holden K, Calvin B, et al. Shock. Crit Care Nurs Q 2022; 45: 225–232. – reference: 8. Xiang H, Wheeler KK, Groner JI, et al. Undertriage of major trauma patients in the US emergency departments. Am J Emerg Med 2014; 32: 997–1004. – reference: 10. Smith GB, Redfern OC, Pimentel MA, et al. The National Early Warning Score 2 (NEWS2). Clin Med (Lond) 2019; 19: 260. – reference: 15. Ramadan A, Abdallah T, Abdelsalam H, et al. Accuracy of echocardiography and ultrasound protocol to identify shock etiology in emergency department. BMC Emerg Med 2022; 22: 117. – reference: 12. Kristensen AK, Holler JG, Mikkelsen S, et al. Systolic blood pressure and short-term mortality in the emergency department and prehospital setting: a hospital-based cohort study. Crit Care 2015; 19: 158. – reference: 16. Yoshida T, Yoshida T, Noma H, et al. Diagnostic accuracy of point-of-care ultrasound for shock: a systematic review and meta-analysis. Crit Care 2023; 27: 200. – reference: 6. Rainer TH, Cheung NK, Yeung JH, et al. Do trauma teams make a difference? A single centre registry study. Resuscitation 2007; 73: 374–381. – reference: 1. Holler JG, Bech CN, Henriksen DP, et al. Nontraumatic hypotension and shock in the emergency department and the prehospital setting, prevalence, etiology, and mortality: a systematic review. PLoS One 2015; 10: e0119331. – reference: 4. Kanda Y. Investigation of the freely available easy-to-use software ‘EZR’ for medical statistics. Bone Marrow Transplant 2013; 48: 452–458. – reference: 14. Perera P, Mailhot T, Riley D, et al. The RUSH exam: Rapid Ultrasound in SHock in the evaluation of the critically lll. Emerg Med Clin North Am 2010; 28: 29–56, viivii. – ident: 5 doi: 10.1177/001316446002000104 – ident: 8 doi: 10.1016/j.ajem.2014.05.038 – ident: 12 doi: 10.1186/s13054-015-0884-y – ident: 15 doi: 10.1186/s12873-022-00678-6 – ident: 16 doi: 10.1186/s13054-023-04495-6 – ident: 3 doi: 10.1136/emermed-2018-207588 – ident: 6 doi: 10.1016/j.resuscitation.2006.10.011 – ident: 14 doi: 10.1016/j.emc.2009.09.010 – ident: 2 doi: 10.1097/CNQ.0000000000000407 – ident: 10 doi: 10.7861/clinmedicine.19-3-260 – ident: 11 doi: 10.1056/NEJMra1208943 – ident: 17 doi: 10.1186/s13049-021-00856-8 – ident: 9 doi: 10.1007/s00068-022-02186-5 – ident: 1 doi: 10.1371/journal.pone.0119331 – ident: 7 doi: 10.1016/j.injury.2021.05.015 – ident: 4 doi: 10.1038/bmt.2012.244 – ident: 13 doi: 10.1186/s13049-020-00761-6 |
| SSID | ssj0056928 ssib006287783 ssib058493325 |
| Score | 2.2786655 |
| Snippet | Objective: Early recognition of shock status by paramedics significantly affects patient prognosis; however, its accuracy remains unclear. This study assessed... [Abstract] [Objective] : Early recognition of shock status by paramedics significantly affects patient prognosis ; however, its accuracy remains unclear. This... Early recognition of shock status by paramedics significantly affects patient prognosis; however, its accuracy remains unclear. This study assessed the... |
| SourceID | pubmedcentral proquest pubmed crossref medicalonline jstage |
| SourceType | Open Access Repository Aggregation Database Index Database Publisher |
| StartPage | 125 |
| SubjectTerms | clinical education emergency medical services Original paramedics shock diagnosis |
| Title | Accuracy of early shock recognition by paramedics: a multicenter prospective observational study in Japan |
| URI | https://www.jstage.jst.go.jp/article/jrm/20/2/20_2024-053/_article/-char/en http://mol.medicalonline.jp/en/journal/download?GoodsID=cv2jrmen/2025/002002/009&name=0125-0131e https://www.ncbi.nlm.nih.gov/pubmed/40182164 https://www.proquest.com/docview/3186354415 https://pubmed.ncbi.nlm.nih.gov/PMC11962191 |
| Volume | 20 |
| hasFullText | 1 |
| inHoldings | 1 |
| isFullTextHit | |
| isPrint | |
| ispartofPNX | Journal of Rural Medicine, 2025, Vol.20(2), pp.125-131 |
| link | http://utb.summon.serialssolutions.com/2.0.0/link/0/eLvHCXMwpV1Lb9QwEB6VwgGpQkW8wqMyEhwNseO8WiFaIaqqUjmx0t4sxztRtwKHZruI_ffM5CUWeuOSKIqd2B6Pvxl7HgBval0br72TRFwtDWGWLL0y0qBTxmeZUYq9kS--ZGczcz5P5zswZhsdBnB1q2rH-aRm7bd3v643H4nhP7AZM8HN-6uWXcq1kTSh7sBdwqSM1bALM50npFnZZVnl4GOSRPR5bwL_T-0tcLp3RfIZO97vfe_PTPrYFbeJon9bVP4BUaf78GCQLcVJPxkewg6GR7A88X7dOr8RTS2QwxmL1SUtgmIyHWqCqDaCY4B3LVgdCic6O0P-DbaC2jH6Y4qmmnZx6U9dbFqxDOKcIDc8htnp56-fzuSQX0F6k-eJ9MRyWKCqM-3VgpRV49hHuVJxhbmOMUfnNCfQRK98GtelKRJCd5XkWMQu18kT2A1NwGcgyprUvsQlyK6pKQGgR5fHhVtkelEVizSCt-PA2h99GA1L6gcTwBIBLBPAEgEiOOpHfSo1MNBQyuruMpSeXrKHGrF5BMdbpLLjdLL-p6YPYOCqqWUZOdZ0Ky3hMz2rRJnUcDLNCF6P1LXEaHx64gI265WlxY-EM1Y_I3jaU3tqJCmphSbFM4Jiax5MBTiI9_absLzsgnkrWgIJNdTz_-r5C7jPPev3hl7C7k27xlckLd1UBx0jHHTbWL8BypEWOQ |
| linkProvider | Scholars Portal |
| openUrl | ctx_ver=Z39.88-2004&ctx_enc=info%3Aofi%2Fenc%3AUTF-8&rfr_id=info%3Asid%2Fsummon.serialssolutions.com&rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Ajournal&rft.genre=article&rft.atitle=Accuracy+of+early+shock+recognition+by+paramedics%3A+a+multicenter+prospective+observational+study+in+Japan&rft.jtitle=Journal+of+Rural+Medicine&rft.au=Tanohata%2C+Rina&rft.au=Nagano%2C+Takehiko&rft.au=Saito%2C+Katsutoshi&rft.au=Ochiai%2C+Hidenobu&rft.date=2025&rft.pub=THE+JAPANESE+ASSOCIATION+OF+RURAL+MEDICINE&rft.issn=1880-487X&rft.eissn=1880-4888&rft.volume=20&rft.issue=2&rft.spage=125&rft.epage=131&rft_id=info:doi/10.2185%2Fjrm.2024-053&rft.externalDocID=article_jrm_20_2_20_2024_053_article_char_en |
| thumbnail_l | http://covers-cdn.summon.serialssolutions.com/index.aspx?isbn=/lc.gif&issn=1880-487X&client=summon |
| thumbnail_m | http://covers-cdn.summon.serialssolutions.com/index.aspx?isbn=/mc.gif&issn=1880-487X&client=summon |
| thumbnail_s | http://covers-cdn.summon.serialssolutions.com/index.aspx?isbn=/sc.gif&issn=1880-487X&client=summon |