Opportunistic Use of CT Imaging for Osteoporosis Screening and Bone Density Assessment: A Qualitative Systematic Review
The purpose of this study was to determine the clinical opportunities for the use of computed tomography (CT) imaging for inferring bone quality and to critically analyze the correlation between dual x-ray absorptiometry (DXA) and diagnostic CT as reported in the literature. A systematic review of t...
Uložené v:
| Vydané v: | Journal of bone and joint surgery. American volume Ročník 99; číslo 18; s. 1580 |
|---|---|
| Hlavní autori: | , , , , |
| Médium: | Journal Article |
| Jazyk: | English |
| Vydavateľské údaje: |
United States
20.09.2017
|
| Predmet: | |
| ISSN: | 1535-1386, 1535-1386 |
| On-line prístup: | Zistit podrobnosti o prístupe |
| Tagy: |
Pridať tag
Žiadne tagy, Buďte prvý, kto otaguje tento záznam!
|
| Abstract | The purpose of this study was to determine the clinical opportunities for the use of computed tomography (CT) imaging for inferring bone quality and to critically analyze the correlation between dual x-ray absorptiometry (DXA) and diagnostic CT as reported in the literature.
A systematic review of the MEDLINE database was performed in February 2016 using the PubMed interface. The inclusion criteria were English language, studies performed using living human subjects, studies pertaining to orthopaedics, use of conventional diagnostic CT scans, studies that measured cancellous bone, and studies that reported Hounsfield unit (HU) measurements directly rather than a computed bone mineral density.
Thirty-seven studies that reported on a total of 9,109 patients were included. Of these, 10 studies correlated HU measurements of trabecular bone with DXA-based bone assessment. Reported correlation coefficients ranged between 0.399 and 0.891, and 5 of the studies reported appropriate threshold HU levels for diagnosing osteoporosis or osteopenia.
Direct HU measurement from diagnostic CT scans has the potential to be used opportunistically for osteoporosis screening, but in its current state it is not ready for clinical implementation. There is a lack of exchangeability among different machines that limits its broad applicability. Future research efforts should focus on identifying thresholds at specific anatomic regions in high-risk patients in order to have the greatest impact on patients. However, using diagnostic CT to infer region-specific osteoporosis could be extraordinarily valuable to orthopaedic surgeons and primary care physicians, and merits further research. |
|---|---|
| AbstractList | The purpose of this study was to determine the clinical opportunities for the use of computed tomography (CT) imaging for inferring bone quality and to critically analyze the correlation between dual x-ray absorptiometry (DXA) and diagnostic CT as reported in the literature.
A systematic review of the MEDLINE database was performed in February 2016 using the PubMed interface. The inclusion criteria were English language, studies performed using living human subjects, studies pertaining to orthopaedics, use of conventional diagnostic CT scans, studies that measured cancellous bone, and studies that reported Hounsfield unit (HU) measurements directly rather than a computed bone mineral density.
Thirty-seven studies that reported on a total of 9,109 patients were included. Of these, 10 studies correlated HU measurements of trabecular bone with DXA-based bone assessment. Reported correlation coefficients ranged between 0.399 and 0.891, and 5 of the studies reported appropriate threshold HU levels for diagnosing osteoporosis or osteopenia.
Direct HU measurement from diagnostic CT scans has the potential to be used opportunistically for osteoporosis screening, but in its current state it is not ready for clinical implementation. There is a lack of exchangeability among different machines that limits its broad applicability. Future research efforts should focus on identifying thresholds at specific anatomic regions in high-risk patients in order to have the greatest impact on patients. However, using diagnostic CT to infer region-specific osteoporosis could be extraordinarily valuable to orthopaedic surgeons and primary care physicians, and merits further research. The purpose of this study was to determine the clinical opportunities for the use of computed tomography (CT) imaging for inferring bone quality and to critically analyze the correlation between dual x-ray absorptiometry (DXA) and diagnostic CT as reported in the literature.BACKGROUNDThe purpose of this study was to determine the clinical opportunities for the use of computed tomography (CT) imaging for inferring bone quality and to critically analyze the correlation between dual x-ray absorptiometry (DXA) and diagnostic CT as reported in the literature.A systematic review of the MEDLINE database was performed in February 2016 using the PubMed interface. The inclusion criteria were English language, studies performed using living human subjects, studies pertaining to orthopaedics, use of conventional diagnostic CT scans, studies that measured cancellous bone, and studies that reported Hounsfield unit (HU) measurements directly rather than a computed bone mineral density.METHODSA systematic review of the MEDLINE database was performed in February 2016 using the PubMed interface. The inclusion criteria were English language, studies performed using living human subjects, studies pertaining to orthopaedics, use of conventional diagnostic CT scans, studies that measured cancellous bone, and studies that reported Hounsfield unit (HU) measurements directly rather than a computed bone mineral density.Thirty-seven studies that reported on a total of 9,109 patients were included. Of these, 10 studies correlated HU measurements of trabecular bone with DXA-based bone assessment. Reported correlation coefficients ranged between 0.399 and 0.891, and 5 of the studies reported appropriate threshold HU levels for diagnosing osteoporosis or osteopenia.RESULTSThirty-seven studies that reported on a total of 9,109 patients were included. Of these, 10 studies correlated HU measurements of trabecular bone with DXA-based bone assessment. Reported correlation coefficients ranged between 0.399 and 0.891, and 5 of the studies reported appropriate threshold HU levels for diagnosing osteoporosis or osteopenia.Direct HU measurement from diagnostic CT scans has the potential to be used opportunistically for osteoporosis screening, but in its current state it is not ready for clinical implementation. There is a lack of exchangeability among different machines that limits its broad applicability. Future research efforts should focus on identifying thresholds at specific anatomic regions in high-risk patients in order to have the greatest impact on patients. However, using diagnostic CT to infer region-specific osteoporosis could be extraordinarily valuable to orthopaedic surgeons and primary care physicians, and merits further research.CONCLUSIONSDirect HU measurement from diagnostic CT scans has the potential to be used opportunistically for osteoporosis screening, but in its current state it is not ready for clinical implementation. There is a lack of exchangeability among different machines that limits its broad applicability. Future research efforts should focus on identifying thresholds at specific anatomic regions in high-risk patients in order to have the greatest impact on patients. However, using diagnostic CT to infer region-specific osteoporosis could be extraordinarily valuable to orthopaedic surgeons and primary care physicians, and merits further research. |
| Author | Nwachukwu, Benedict U Schreiber, Joseph J Lane, Joseph M Gausden, Elizabeth B Lorich, Dean G |
| Author_xml | – sequence: 1 givenname: Elizabeth B surname: Gausden fullname: Gausden, Elizabeth B organization: 1Hospital for Special Surgery, New York, NY 2Raleigh Orthopaedic Clinic, Raleigh, North Carolina 3New York Presbyterian Hospital, New York, NY – sequence: 2 givenname: Benedict U surname: Nwachukwu fullname: Nwachukwu, Benedict U – sequence: 3 givenname: Joseph J surname: Schreiber fullname: Schreiber, Joseph J – sequence: 4 givenname: Dean G surname: Lorich fullname: Lorich, Dean G – sequence: 5 givenname: Joseph M surname: Lane fullname: Lane, Joseph M |
| BackLink | https://www.ncbi.nlm.nih.gov/pubmed/28926388$$D View this record in MEDLINE/PubMed |
| BookMark | eNpNkM1PwjAYxhujkQ89ejU9ehm2a9lab4BfEBKiwHnptrekZmvnukH47x0RE0_v1y_P8-YZoEvrLCB0R8kopCR6XEwX6xGNRoTEXF6gPh2zcUCZiC7_9T008P6LEMI5ia9RLxQyjJgQfXRYVZWrm9Ya35gMbz1gp_Fsg-el2hm7w9rVeOUbcB3mvPF4ndUA9nRSNsfT7hv8DNab5ogn3oP3JdjmCU_wR6sK06jG7AGvj51EqU4Wn7A3cLhBV1oVHm7PdYi2ry-b2XuwXL3NZ5NlkDEmaMBAylykGaRa61iGXFAeR4xozeI0z4Xgmo91Krq9inkecpmHROUZi2Q3ShIO0cOvblW77xZ8k5TGZ1AUyoJrfUIlp0SyLpkOvT-jbVpCnlS1KVV9TP7CCn8AndVuMA |
| CitedBy_id | crossref_primary_10_1016_j_crad_2022_04_002 crossref_primary_10_1038_s41574_021_00482_5 crossref_primary_10_1053_j_semnuclmed_2023_10_008 crossref_primary_10_1177_1071100718799102 crossref_primary_10_1111_odi_12950 crossref_primary_10_1016_j_ejro_2023_100492 crossref_primary_10_1186_s13020_024_00961_7 crossref_primary_10_1016_j_spinee_2023_12_007 crossref_primary_10_1097_RCT_0000000000001437 crossref_primary_10_3390_jcm13206063 crossref_primary_10_5582_bst_2023_01327 crossref_primary_10_1097_BRS_0000000000005231 crossref_primary_10_3390_medicina61091517 crossref_primary_10_1080_07853890_2025_2554930 crossref_primary_10_1136_ijgc_2021_003169 crossref_primary_10_1055_s_0044_1788816 crossref_primary_10_1007_s00408_023_00650_6 crossref_primary_10_1007_s00198_022_06491_y crossref_primary_10_1016_j_jacr_2024_10_003 crossref_primary_10_1016_j_wneu_2022_05_030 crossref_primary_10_1007_s00402_018_2938_5 crossref_primary_10_1016_j_xnsj_2025_100591 crossref_primary_10_1016_j_bone_2020_115561 crossref_primary_10_1007_s00198_019_05212_2 crossref_primary_10_1007_s00586_024_08331_5 crossref_primary_10_1016_j_fas_2025_01_007 crossref_primary_10_3390_ani12141793 crossref_primary_10_1097_OI9_0000000000000033 crossref_primary_10_1002_jor_25409 crossref_primary_10_1177_02841851211021035 crossref_primary_10_1016_j_jos_2023_03_008 crossref_primary_10_1177_21514593221098620 crossref_primary_10_1053_j_jfas_2020_10_002 crossref_primary_10_1016_j_injury_2020_03_063 crossref_primary_10_1016_j_wneu_2022_06_104 crossref_primary_10_1097_BRS_0000000000004418 crossref_primary_10_1148_radiol_211561 crossref_primary_10_1007_s00261_018_1770_2 crossref_primary_10_1016_j_spinee_2023_08_003 crossref_primary_10_1080_02688697_2021_1933383 crossref_primary_10_1055_s_0043_1776430 crossref_primary_10_1002_jbm4_10807 crossref_primary_10_1007_s11657_022_01061_5 crossref_primary_10_1259_bjr_20220992 crossref_primary_10_1148_ryai_220042 crossref_primary_10_1007_s11657_025_01588_3 crossref_primary_10_3390_bioengineering10121364 crossref_primary_10_1007_s00113_019_0658_0 crossref_primary_10_1016_j_spinee_2022_10_018 crossref_primary_10_1002_jbmr_3672 crossref_primary_10_1177_2151459320956958 crossref_primary_10_1053_j_jfas_2021_06_016 crossref_primary_10_1007_s43390_023_00646_5 crossref_primary_10_3390_hematolrep16040061 crossref_primary_10_1038_s41598_024_69743_3 crossref_primary_10_1186_s13256_021_02880_9 crossref_primary_10_1007_s11999_0000000000000241 crossref_primary_10_1007_s00330_022_09157_9 crossref_primary_10_1016_j_clinimag_2024_110372 crossref_primary_10_1038_s41598_022_23142_8 crossref_primary_10_1007_s00586_018_5776_9 crossref_primary_10_1007_s00117_023_01190_z crossref_primary_10_1016_j_acra_2024_06_041 crossref_primary_10_1007_s00586_024_08565_3 crossref_primary_10_2106_JBJS_17_01376 crossref_primary_10_1016_j_injury_2025_112147 crossref_primary_10_1053_j_jfas_2021_10_007 crossref_primary_10_1186_s12891_022_05409_3 crossref_primary_10_1177_000313481908500940 crossref_primary_10_1016_j_ejrad_2022_110197 crossref_primary_10_1245_s10434_023_13969_4 crossref_primary_10_1016_j_clnu_2018_12_004 crossref_primary_10_1016_j_xnsj_2023_100204 crossref_primary_10_3390_cancers14030495 crossref_primary_10_1148_radiol_231808 crossref_primary_10_3348_jksr_2019_0193 crossref_primary_10_1002_jsp2_1195 crossref_primary_10_1038_s41584_019_0274_y crossref_primary_10_1007_s11914_022_00764_5 crossref_primary_10_1016_j_dental_2022_03_010 crossref_primary_10_3171_2020_7_SPINE20920 crossref_primary_10_1186_s12891_022_05263_3 crossref_primary_10_1155_2019_3085258 crossref_primary_10_1007_s11914_018_0450_z crossref_primary_10_1016_j_neurad_2022_08_001 crossref_primary_10_1016_j_spinee_2024_05_017 crossref_primary_10_1186_s13020_020_00368_0 crossref_primary_10_1016_j_jos_2023_08_020 crossref_primary_10_1007_s12350_019_01803_y crossref_primary_10_1148_radiol_2019181648 crossref_primary_10_1007_s00198_019_04931_w crossref_primary_10_1007_s00198_019_04977_w crossref_primary_10_1016_j_crad_2023_07_006 crossref_primary_10_1007_s00414_024_03315_y crossref_primary_10_1016_j_jbo_2024_100641 crossref_primary_10_1016_j_wneu_2023_07_006 crossref_primary_10_1080_10428194_2021_1975193 crossref_primary_10_1007_s00068_021_01714_z crossref_primary_10_1177_1071100721997070 crossref_primary_10_1007_s00784_019_03158_7 crossref_primary_10_1371_journal_pone_0197336 crossref_primary_10_1097_BRS_0000000000004211 crossref_primary_10_1186_s12859_022_04596_z crossref_primary_10_1016_j_bone_2024_117176 crossref_primary_10_1111_1754_9485_13537 crossref_primary_10_1055_a_2258_3612 crossref_primary_10_1186_s12891_025_09036_6 crossref_primary_10_1016_j_clinimag_2021_08_005 crossref_primary_10_1016_j_clinimag_2021_08_009 crossref_primary_10_1097_RLI_0000000000000781 crossref_primary_10_1177_02841851231190795 crossref_primary_10_1007_s00330_020_07312_8 crossref_primary_10_1097_BRS_0000000000003917 crossref_primary_10_1007_s00595_019_01954_y crossref_primary_10_1007_s00198_019_05245_7 crossref_primary_10_1007_s00198_020_05477_y crossref_primary_10_1111_os_14299 crossref_primary_10_25305_unj_320680 crossref_primary_10_1007_s00256_020_03573_y crossref_primary_10_1016_j_maturitas_2020_05_006 crossref_primary_10_1067_j_cpradiol_2019_10_004 crossref_primary_10_3390_medicina58081085 crossref_primary_10_1007_s00330_024_11046_2 crossref_primary_10_1183_16000617_0031_2021 crossref_primary_10_2147_IDR_S363208 crossref_primary_10_1007_s00256_024_04703_6 crossref_primary_10_1038_s41598_024_79985_w crossref_primary_10_1089_end_2017_0940 crossref_primary_10_3171_2020_5_FOCUS20192 crossref_primary_10_1007_s11657_018_0431_y crossref_primary_10_1177_1071100720976096 crossref_primary_10_1177_23094990211028048 crossref_primary_10_1186_s12891_022_06049_3 crossref_primary_10_1007_s00414_020_02349_2 crossref_primary_10_1177_1945892418768159 crossref_primary_10_1016_j_acra_2025_02_041 crossref_primary_10_1002_jor_25630 crossref_primary_10_1007_s11926_018_0784_7 crossref_primary_10_1007_s00256_021_03918_1 crossref_primary_10_1002_mp_15953 crossref_primary_10_1007_s00423_025_03649_0 crossref_primary_10_2106_JBJS_20_01071 crossref_primary_10_1097_CORR_0000000000000480 crossref_primary_10_1016_j_jacr_2022_09_007 crossref_primary_10_1016_j_ejca_2024_113604 crossref_primary_10_1177_03635465211001758 crossref_primary_10_1007_s11657_020_00745_0 crossref_primary_10_1097_BPB_0000000000001131 |
| ContentType | Journal Article |
| DBID | CGR CUY CVF ECM EIF NPM 7X8 |
| DOI | 10.2106/JBJS.16.00749 |
| DatabaseName | Medline MEDLINE MEDLINE (Ovid) MEDLINE MEDLINE PubMed MEDLINE - Academic |
| DatabaseTitle | MEDLINE Medline Complete MEDLINE with Full Text PubMed MEDLINE (Ovid) MEDLINE - Academic |
| DatabaseTitleList | MEDLINE MEDLINE - Academic |
| Database_xml | – sequence: 1 dbid: NPM name: PubMed url: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed sourceTypes: Index Database – sequence: 2 dbid: 7X8 name: MEDLINE - Academic url: https://search.proquest.com/medline sourceTypes: Aggregation Database |
| DeliveryMethod | no_fulltext_linktorsrc |
| EISSN | 1535-1386 |
| ExternalDocumentID | 28926388 |
| Genre | Systematic Review Journal Article |
| GroupedDBID | .XZ 08P 0R~ 123 29K 34G 36B 39C 4.4 53G 5RE 5RS 6NX 8F7 AAAAV AAAXR AAFTM AAGIX AAHPQ AAIQE AAMOA AAQKA AASCR AAWTL AAXQO ABASU ABDIG ABJNI ABPMR ABPXF ABVCZ ABXVJ ABZZY ACCJW ACEWG ACGFS ACGOD ACILI ACIWK ACLDA ACNWC ACPRK ACXJB ACZKN ADGGA ADGHP ADHPY AEETU AFBFQ AFCHL AFDTB AFMFG AFRAH AFUWQ AHMBA AHOMT AHQNM AHVBC AIJEX AINUH AJCLO AJIOK AJNWD AJZMW AKCTQ AKULP ALKUP ALMA_UNASSIGNED_HOLDINGS ALMTX AMJPA AMKUR AMNEI AOHHW AOQMC BOWHD BQLVK BYPQX C45 CGR CS3 CUY CVF D-I DIWNM E3Z EBS ECM EEVPB EIF EJD ERAAH F5P FCALG GNXGY GQDEL HLJTE IKREB IKYAY JG8 K-O L7B M5~ NPM O9- OCB OGEVE OHH OPUJH OVD OVDNE OVIDH OVLEI OXXIT PZZ RLZ SJN TEORI TSPGW VVN W1K WH7 YOC ZY1 ~H1 ~ZZ 7X8 ACBKD ADKSD ADSXY |
| ID | FETCH-LOGICAL-c3381-3e99d8bcebfff79248147630ff37bdd884f45fb8481a74d249d20adc36974d902 |
| IEDL.DBID | 7X8 |
| ISICitedReferencesCount | 179 |
| ISICitedReferencesURI | http://www.webofscience.com/api/gateway?GWVersion=2&SrcApp=Summon&SrcAuth=ProQuest&DestLinkType=CitingArticles&DestApp=WOS_CPL&KeyUT=00004623-201709200-00011&url=https%3A%2F%2Fcvtisr.summon.serialssolutions.com%2F%23%21%2Fsearch%3Fho%3Df%26include.ft.matches%3Dt%26l%3Dnull%26q%3D |
| ISSN | 1535-1386 |
| IngestDate | Sun Nov 09 12:10:07 EST 2025 Tue Jun 24 01:31:44 EDT 2025 |
| IsPeerReviewed | true |
| IsScholarly | true |
| Issue | 18 |
| Language | English |
| LinkModel | DirectLink |
| MergedId | FETCHMERGED-LOGICAL-c3381-3e99d8bcebfff79248147630ff37bdd884f45fb8481a74d249d20adc36974d902 |
| Notes | ObjectType-Article-1 SourceType-Scholarly Journals-1 ObjectType-Feature-2 ObjectType-Review-3 content type line 23 ObjectType-Undefined-4 |
| PMID | 28926388 |
| PQID | 1941093004 |
| PQPubID | 23479 |
| ParticipantIDs | proquest_miscellaneous_1941093004 pubmed_primary_28926388 |
| PublicationCentury | 2000 |
| PublicationDate | 20170920 |
| PublicationDateYYYYMMDD | 2017-09-20 |
| PublicationDate_xml | – month: 9 year: 2017 text: 20170920 day: 20 |
| PublicationDecade | 2010 |
| PublicationPlace | United States |
| PublicationPlace_xml | – name: United States |
| PublicationTitle | Journal of bone and joint surgery. American volume |
| PublicationTitleAlternate | J Bone Joint Surg Am |
| PublicationYear | 2017 |
| SSID | ssj0004407 |
| Score | 2.6037912 |
| SecondaryResourceType | review_article |
| Snippet | The purpose of this study was to determine the clinical opportunities for the use of computed tomography (CT) imaging for inferring bone quality and to... |
| SourceID | proquest pubmed |
| SourceType | Aggregation Database Index Database |
| StartPage | 1580 |
| SubjectTerms | Bone Density Humans Osteoporosis - diagnostic imaging Osteoporosis - pathology Osteoporotic Fractures - prevention & control Predictive Value of Tests Tomography, X-Ray Computed - methods |
| Title | Opportunistic Use of CT Imaging for Osteoporosis Screening and Bone Density Assessment: A Qualitative Systematic Review |
| URI | https://www.ncbi.nlm.nih.gov/pubmed/28926388 https://www.proquest.com/docview/1941093004 |
| Volume | 99 |
| WOSCitedRecordID | wos00004623-201709200-00011&url=https%3A%2F%2Fcvtisr.summon.serialssolutions.com%2F%23%21%2Fsearch%3Fho%3Df%26include.ft.matches%3Dt%26l%3Dnull%26q%3D |
| hasFullText | |
| inHoldings | 1 |
| isFullTextHit | |
| isPrint | |
| link | http://cvtisr.summon.serialssolutions.com/2.0.0/link/0/eLvHCXMwpV07T8MwELaAMrDwEK_ykpFYQ9PEsRMW1BYqqERbqa3ULYpfUgeSQgqIf89dkhYmhMSSIbElyz5f7vN3_o6QKx4KZiMbOIpzBQAF_KAMEuOgEIqKXF95MimKTYh-P5xOo2F14JZXaZVLn1g4ap0pPCNvANhG5SNY09v5i4NVo5BdrUporJOaD6EMpnSJ6Q-1cFZcl4ZNHaDWHi81NgHk8Eav3RtdN5GIEOyX6LL4y3R3_ju-XbJdxZe0VRrEHlkz6T75GMwxzEbmGl7TSW5oZmlnTB-fiyJFFCJXOoD1zqBZls9yOlKYj4OfklTTdpYaeoep7otP2lpped7QFi01OAr1cDpaqULTknI4IJPu_bjz4FQVFxwFULXp-CaKdCiVkdZaAdAsbDJwQK61vpBahyGzLLASJfgTwTRAN-25iVY-B1iiI9c7JBspDOmYUC54IA20sJ5iIZdSqEgo6KCTwAoT1cnlch5jsGikKZLUZG95_D2TdXJULkY8L6U3YoCHHniM8OQPvU_Jloe2hxSSe0ZqFvazOSeb6n0xy18vClOBZ3_49AXDBsoY |
| linkProvider | ProQuest |
| 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=Opportunistic+Use+of+CT+Imaging+for+Osteoporosis+Screening+and+Bone+Density+Assessment%3A+A+Qualitative+Systematic+Review&rft.jtitle=Journal+of+bone+and+joint+surgery.+American+volume&rft.au=Gausden%2C+Elizabeth+B&rft.au=Nwachukwu%2C+Benedict+U&rft.au=Schreiber%2C+Joseph+J&rft.au=Lorich%2C+Dean+G&rft.date=2017-09-20&rft.eissn=1535-1386&rft.volume=99&rft.issue=18&rft.spage=1580&rft_id=info:doi/10.2106%2FJBJS.16.00749&rft_id=info%3Apmid%2F28926388&rft_id=info%3Apmid%2F28926388&rft.externalDocID=28926388 |
| thumbnail_l | http://covers-cdn.summon.serialssolutions.com/index.aspx?isbn=/lc.gif&issn=1535-1386&client=summon |
| thumbnail_m | http://covers-cdn.summon.serialssolutions.com/index.aspx?isbn=/mc.gif&issn=1535-1386&client=summon |
| thumbnail_s | http://covers-cdn.summon.serialssolutions.com/index.aspx?isbn=/sc.gif&issn=1535-1386&client=summon |