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Electronic Alerts on Abnormal Imaging Test Results Do Not Always Result in Timely Follow-Up

By MedImaging International staff writers
Posted on 20 Oct 2009

Abnormal results on outpatient imaging tests sometimes may not receive appropriate follow-up even when clinicians receive and read results in an advanced, integrated electronic medical record system, according to a recent report.

"Communication breakdown is consistently identified as a preventable factor in studies of adverse events and a significant contributor to outpatient diagnostic errors from a lack of follow-up of abnormal test results,” the investigators reported in their study, published in the September 28, 2009, issue of Archives of Internal Medicine, one of the JAMA/Archives journals. The high volume and number of transitions between clinicians in outpatient care makes timely communication especially difficult. For instance, a primary care physician may refer a patient with respiratory symptoms to undergo several laboratory and imaging tests and a pulmonary consultation. Any abnormal findings, such as a lung mass, would need to be communicated rapidly and effectively to all clinicians involved in treating the patient.

Some healthcare systems use electronic communication with alerts to notify clinicians who order imaging tests about critical abnormal results--an approach that may have advantages over a paper-based reporting system. "However, effective communication involves more than just information transfer-it requires a response from the recipient, such as taking follow-up action and acknowledging receipt of the information to the sender,” the investigators stated in their study.

Hardeep Singh, M.D., M.P.H., from Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, both based in Houston, TX, USA) examined critical imaging alert notifications in the outpatient setting of one Department of Veterans Affairs facility between November 2007 and June 2008. The researchers used tracking software to determine whether alerts about abnormal test results were read within two weeks, then reviewed medical records and contacted healthcare practitioners to determine whether timely follow-up actions (such as ordering a follow-up test or consultation) were taken within four weeks of the alert transmission.

Of 123,638 imaging tests (including X-rays, computed tomograpy [CT] scans, magnetic resonance imaging [MRI] and mammograms) performed during the study period, results from 1,196 (0.97%) generated alerts to the ordering clinician. Of these alerts, 217 (18.1%) were not acknowledged. Alerts were more likely to be unacknowledged if the ordering clinician was a trainee or if an alert was sent to more than one clinician (for example, when the ordering clinician was not the patient's primary care physician, and alerts were sent to both the specialist and the patient's regular physician).

Timely follow-up of abnormal results did not occur following 92 (7.7%) of all alerts, including 7.3% of alerts that were acknowledged and 9.7% of alerts that were unacknowledged. This follow-up was also less likely to occur when more than one clinician received the alert, but more apt to occur when a radiologist also reported concerns about the results verbally, either by phone or in person. "Nearly all abnormal test results lacking timely follow-up at four weeks were eventually found to have measurable clinical impact in terms of further diagnostic testing or treatment,” the authors stated.

"Our findings suggest that an electronic medical record that facilitates transmission and availability of critical imaging results to the healthcare provider through either automated notification or direct access of primary report does not eliminate the problem of missed test results even when one or more healthcare providers read the results,” the investigators concluded. "Therefore, even in the best of information systems that contain advanced notification features, patients with abnormal imaging results are vulnerable to ‘falling through the cracks.' This underscores the need for a multidisciplinary approach involving human-computer interaction and informatics to complement the benefits achieved by automated notification and the need for continuous monitoring procedures to ensure follow-up even when healthcare providers ‘acknowledge,' i.e., read abnormal results.”

Related Links:
Michael E. DeBakey Veterans Affairs Medical Center
Baylor College of Medicine

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58 (!!!!! 7941.0076141357): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294726055 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294726055 AND published='1' LIMIT 1

59 (!!!!! 3057.0030212402): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294726055 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294726055 AND published='1' LIMIT 1

60 (!!!!! 3427.9823303223): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294726055 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294726055 AND published='1' LIMIT 1

61 (!!!!! 2318.8591003418): select cover from jos_number where journalid in (5) and cover is not null order by left(issue,2)+right(issue,2)*12 desc limit 1

62 (!!!!! 4211.1873626709): SELECT fid FROM jos_deeppockets WHERE id=294726055 AND published='1' union SELECT fid FROM jos_deeppockets_archive WHERE id=294726055 AND published='1' LIMIT 1

63 (507.11631774902): SELECT id,name,sponsor_text FROM jos_deeppockets dp left outer join jos_channel_sponsor cs on dp.id=cs.fid WHERE cat=10 AND TYPE='file_folder' AND published=1 AND id=216 ORDER BY `ordering`

64 (191.92695617676): select jos_twitters.link from jos_twitters where cat=10

65 (118.97087097168): select jos_facebook.link from jos_facebook where cat=10

66 (331.16340637207): select jos_google_plus.link from jos_google_plus where cat=10

67 (283.00285339355): select jos_linkedin.link from jos_linkedin where cat=10

68 (55.074691772461): SELECT fid FROM jos_deeppockets WHERE id=294726055 AND published='1' union SELECT fid FROM jos_deeppockets_archive WHERE id=294726055 AND published='1' LIMIT 1

69 (43.869018554688): SELECT id,name,sponsor_text FROM jos_deeppockets dp left outer join jos_channel_sponsor cs on dp.id=cs.fid WHERE cat=10 AND TYPE='file_folder' AND published=1 AND id=216 ORDER BY `ordering`

70 (327.11029052734): SELECT fid FROM jos_deeppockets WHERE cat=10 AND id=294726055 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

71 (368.11828613281): SELECT fid FROM jos_deeppockets_archive WHERE cat=10 AND id=294726055 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

72 (67.949295043945): SELECT id,name,title FROM jos_deeppockets WHERE cat=10 AND TYPE='file_folder' AND published=1 AND id != 294743300 AND id != 294743301 AND id != 294743302 AND id != 294743303 AND id != 294743304 AND id != 294743305 AND id != 294743306 AND id != 294743307 AND id != 294743308 AND id != 294743309 AND id != 294743310 AND metakey != 'aacc' ORDER BY `ordering`

73 (74.148178100586): SELECT show_live FROM jos_com_show_setting LIMIT 1

74 (!!!!! 2477.8842926025): SELECT show_live FROM jos_com_show_setting LIMIT 1

75 (97.990036010742): SELECT show_live FROM jos_com_show_setting LIMIT 1

76 (44.107437133789): SELECT show_live FROM jos_com_show_setting LIMIT 1

77 (41.007995605469): SELECT show_live FROM jos_com_show_setting LIMIT 1

78 (34.093856811523): SELECT show_live FROM jos_com_show_setting LIMIT 1

79 (36.001205444336): SELECT show_live FROM jos_com_show_setting LIMIT 1

80 (36.001205444336): SELECT show_live FROM jos_com_show_setting LIMIT 1

81 (36.001205444336): SELECT show_live FROM jos_com_show_setting LIMIT 1

82 (34.093856811523): SELECT show_live FROM jos_com_show_setting LIMIT 1

83 (36.001205444336): SELECT show_live FROM jos_com_show_setting LIMIT 1

84 (33.855438232422): SELECT show_live FROM jos_com_show_setting LIMIT 1

85 (37.193298339844): SELECT show_live FROM jos_com_show_setting LIMIT 1

86 (34.809112548828): SELECT show_live FROM jos_com_show_setting LIMIT 1

87 (79.870223999023): SELECT fid FROM jos_deeppockets WHERE cat=10 AND id=294726055 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

88 (421.04721069336): SELECT fid FROM jos_deeppockets_archive WHERE cat=10 AND id=294726055 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

89 (59.127807617188): SELECT id,name,title FROM jos_deeppockets WHERE cat=10 AND TYPE='file_folder' AND published=1 AND id != 294743300 AND id != 294743301 AND id != 294743302 AND id != 294743303 AND id != 294743304 AND id != 294743305 AND id != 294743306 AND id != 294743307 AND id != 294743308 AND id != 294743309 AND id != 294743310 AND metakey != 'aacc' ORDER BY `ordering`

90 (!!!!! 2214.9085998535): SELECT show_live FROM jos_com_show_setting LIMIT 1

91 (97.036361694336): SELECT show_live FROM jos_com_show_setting LIMIT 1

92 (53.882598876953): SELECT show_live FROM jos_com_show_setting LIMIT 1

93 (41.961669921875): SELECT show_live FROM jos_com_show_setting LIMIT 1

94 (43.153762817383): SELECT show_live FROM jos_com_show_setting LIMIT 1

95 (37.908554077148): SELECT show_live FROM jos_com_show_setting LIMIT 1

96 (51.975250244141): SELECT show_live FROM jos_com_show_setting LIMIT 1

97 (40.054321289062): SELECT show_live FROM jos_com_show_setting LIMIT 1

98 (38.862228393555): SELECT show_live FROM jos_com_show_setting LIMIT 1

99 (35.04753112793): SELECT show_live FROM jos_com_show_setting LIMIT 1

100 (36.954879760742): SELECT show_live FROM jos_com_show_setting LIMIT 1

101 (36.954879760742): SELECT show_live FROM jos_com_show_setting LIMIT 1

102 (43.869018554688): SELECT show_live FROM jos_com_show_setting LIMIT 1

103 (36.001205444336): SELECT show_live FROM jos_com_show_setting LIMIT 1

104 (!!!!! 1450.0617980957): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294726055 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294726055 AND published='1' LIMIT 1

105 (118.01719665527): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294726055 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294726055 AND published='1' LIMIT 1

106 (!!!!! 4175.1861572266): SELECT dp.*, ch.title as channel, exp.name as author_name, exp.specialization as author_specialization, exp.images as author_photo FROM jos_deeppockets as dp LEFT JOIN jos_experts as exp ON exp.id = dp.author LEFT JOIN jos_deeppockets as ch ON dp.fid = ch.id WHERE 1=1 AND dp.cat=10 AND dp.id=294726055 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

107 (742.91229248047): SELECT dp.*, ch.title as channel, exp.name as author_name, exp.specialization as author_specialization, exp.images as author_photo FROM jos_deeppockets_archive as dp LEFT JOIN jos_experts as exp ON exp.id = dp.author LEFT JOIN jos_deeppockets as ch ON dp.fid = ch.id WHERE 1=1 AND dp.cat=10 AND dp.id=294726055 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

108 (122.0703125): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294726055 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294726055 AND published='1' LIMIT 1

109 (150.91896057129): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294726055 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294726055 AND published='1' LIMIT 1

110 (82.015991210938): SELECT dp.*, ch.title as channel, exp.name as author_name, exp.specialization as author_specialization, exp.images as author_photo FROM jos_deeppockets as dp LEFT JOIN jos_experts as exp ON exp.id = dp.author LEFT JOIN jos_deeppockets as ch ON dp.fid = ch.id WHERE 1=1 AND dp.id=294726055 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

111 (648.97537231445): SELECT dp.*, ch.title as channel, exp.name as author_name, exp.specialization as author_specialization, exp.images as author_photo FROM jos_deeppockets_archive as dp LEFT JOIN jos_experts as exp ON exp.id = dp.author LEFT JOIN jos_deeppockets as ch ON dp.fid = ch.id WHERE 1=1 AND dp.id=294726055 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

112 (742.91229248047): SELECT dp.name, dp.id, dp2.name as channel, ex.name as author_name, ex.specialization, ex.images FROM jos_deeppockets as dp LEFT JOIN jos_experts as ex ON ex.id = dp.author LEFT JOIN jos_deeppockets as dp2 ON dp2.id = dp.fid WHERE dp.author != 0 AND dp.cat = 10 AND dp.published = 1 AND ( (dp.fid = 294743300) OR (dp.fid = 294743301) OR (dp.fid = 294743302) OR (dp.fid = 294743303) OR (dp.fid = 294743304) OR (dp.fid = 294743305) OR (dp.fid = 294743306) OR (dp.fid = 294743307) OR (dp.fid = 294743308) OR (dp.fid = 294743309) OR (dp.fid = 294743310) ) ORDER BY RAND() LIMIT 1

113 (!!!!! 2177.0000457764): SELECT dp.name, dp.id, dp2.name as channel, ex.name as author_name, ex.specialization, ex.images FROM jos_deeppockets as dp LEFT JOIN jos_experts as ex ON ex.id = dp.author LEFT JOIN jos_deeppockets as dp2 ON dp2.id = dp.fid WHERE dp.author != 0 AND dp.cat = 10 AND dp.published = 1 AND ( (dp.fid = 294743300) OR (dp.fid = 294743301) OR (dp.fid = 294743302) OR (dp.fid = 294743303) OR (dp.fid = 294743304) OR (dp.fid = 294743305) OR (dp.fid = 294743306) OR (dp.fid = 294743307) OR (dp.fid = 294743308) OR (dp.fid = 294743309) OR (dp.fid = 294743310) ) ORDER BY RAND() LIMIT 1

114 (159.97886657715): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294726055 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294726055 AND published='1' LIMIT 1

115 (73.909759521484): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294726055 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294726055 AND published='1' LIMIT 1

116 (103.95050048828): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294726055 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294726055 AND published='1' LIMIT 1

117 (68.902969360352): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294726055 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294726055 AND published='1' LIMIT 1

118 (84.877014160156): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294726055 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294726055 AND published='1' LIMIT 1

119 (61.03515625): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294726055 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294726055 AND published='1' LIMIT 1

120 (86.069107055664): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294726055 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294726055 AND published='1' LIMIT 1

121 (61.988830566406): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294726055 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294726055 AND published='1' LIMIT 1

122 (365.01884460449): SELECT * FROM trending_articles WHERE `journal_id` = 10 AND `timestamp` <= NOW() + INTERVAL 7 DAY ORDER BY `order`

123 (!!!!! 66290.855407715): SELECT * FROM jos_deeppockets WHERE jos_deeppockets.cat = 10 AND jos_deeppockets.type = 'deeppockets_item' AND jos_deeppockets.published = 1 AND jos_deeppockets.created + INTERVAL 14 DAY >= NOW() ORDER BY jos_deeppockets.hits DESC LIMIT 7

124 (582.93342590332): SELECT fid FROM jos_deeppockets WHERE cat=10 AND id=294726055 AND type='deeppockets_item' AND published='1' union SELECT fid FROM jos_deeppockets_archive WHERE cat=10 AND id=294726055 AND type='deeppockets_item' AND published='1' LIMIT 1

125 (!!!!! 18697.023391724): ( SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets AS dp WHERE dp.video != '' AND dp.video_source != '' AND dp.cat = 10 AND dp.published = 1 AND dp.type != 'deeppockets_item_link' ORDER BY created DESC LIMIT 3 ) UNION ( SELECT dpa.id, dpa.name, dpa.title, dpa.video, dpa.video_source, dpa.created FROM jos_deeppockets_archive AS dpa WHERE dpa.video != '' AND dpa.video_source != '' AND dpa.cat = 10 AND dpa.published = 1 AND dpa.type != 'deeppockets_item_link' ORDER BY created DESC LIMIT 3 ) ORDER BY created DESC LIMIT 3

126 (!!!!! 1640.796661377): ( SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets AS dp WHERE dp.video != '' AND dp.video_source != '' AND dp.cat = 10 AND dp.published = 1 AND dp.type != 'deeppockets_item_link' ORDER BY created DESC LIMIT 3 ) UNION ( SELECT dpa.id, dpa.name, dpa.title, dpa.video, dpa.video_source, dpa.created FROM jos_deeppockets_archive AS dpa WHERE dpa.video != '' AND dpa.video_source != '' AND dpa.cat = 10 AND dpa.published = 1 AND dpa.type != 'deeppockets_item_link' ORDER BY created DESC LIMIT 3 ) ORDER BY created DESC LIMIT 3

127 (!!!!! 4278.8982391357): SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets AS dp WHERE dp.id = 294803337 LIMIT 1

128 (82.969665527344): SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets AS dp WHERE dp.id = 294803337 LIMIT 1

129 (293.97010803223): SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets AS dp WHERE dp.id = 294803276 LIMIT 1

130 (61.988830566406): SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets AS dp WHERE dp.id = 294803276 LIMIT 1

131 (205.03997802734): SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets_archive AS dp WHERE dp.id = 294803276 LIMIT 1

132 (51.975250244141): SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets_archive AS dp WHERE dp.id = 294803276 LIMIT 1

133 (190.01960754395): SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets AS dp WHERE dp.id = 294802958 LIMIT 1

134 (49.114227294922): SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets AS dp WHERE dp.id = 294802958 LIMIT 1

135 (!!!!! 3144.9794769287): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294726055 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

136 (646.11434936523): SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294726055 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

137 (!!!!! 3041.9826507568): SELECT name FROM jos_deeppockets WHERE id=216

138 (95.129013061523): SELECT name FROM jos_deeppockets WHERE id=216

139 (915.0505065918): SELECT *, DATE_FORMAT(publish_up,'%d %b %Y') AS date_publish_up, DATE_FORMAT(publish_down,'%d %b %Y') AS date_publish_down FROM jos_events WHERE state=1 AND publish_up > NOW() and extra_info REGEXP '((;)|(^))216((;)|($))' AND catid IN (0,110) ORDER BY publish_up ASC LIMIT 3

140 (777.00614929199): SELECT *, DATE_FORMAT(publish_up,'%d %b %Y') AS date_publish_up, DATE_FORMAT(publish_down,'%d %b %Y') AS date_publish_down FROM jos_events WHERE state=1 AND publish_up > NOW() and extra_info REGEXP '((;)|(^))216((;)|($))' AND catid IN (0,110) ORDER BY publish_up ASC LIMIT 3

141 (110.14938354492): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294726055 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294726055 AND published='1' LIMIT 1

142 (67.949295043945): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294726055 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294726055 AND published='1' LIMIT 1

143 (!!!!! 15646.934509277): TRUNCATE TABLE jos_trademed_module

144 (!!!!! 6249.9046325684): SELECT dp.*, ch.title as channel, exp.name as author_name, exp.specialization as author_specialization, exp.images as author_photo FROM jos_deeppockets as dp LEFT JOIN jos_experts as exp ON exp.id = dp.author LEFT JOIN jos_deeppockets as ch ON dp.fid = ch.id WHERE 1=1 AND dp.cat=10 AND dp.id=294726055 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

145 (!!!!! 2123.8327026367): SELECT dp.*, ch.title as channel, exp.name as author_name, exp.specialization as author_specialization, exp.images as author_photo FROM jos_deeppockets_archive as dp LEFT JOIN jos_experts as exp ON exp.id = dp.author LEFT JOIN jos_deeppockets as ch ON dp.fid = ch.id WHERE 1=1 AND dp.cat=10 AND dp.id=294726055 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

146 (572.91984558105): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294726055 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

147 (84.877014160156): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294726055 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

148 (93.936920166016): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294726055 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294726055 AND published='1' LIMIT 1

149 (72.002410888672): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294726055 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294726055 AND published='1' LIMIT 1

150 (!!!!! 5461.9312286377): SELECT jos_item.* FROM jos_item INNER JOIN jos_number ON jos_item.numberID=jos_number.id WHERE 1=1 AND (jos_item.imgMini<>'') AND jos_item.type='L' AND jos_item.numberID= ( SELECT jos_number.id FROM jos_number WHERE jos_number.journalID IN (10) and jos_number.id in (select distinct jos_number.id from jos_number join jos_item on jos_item.numberid=jos_number.id where jos_item.type='P') ORDER BY (CONVERT(SUBSTRING(issue,1,2),SIGNED) + (CONVERT(SUBSTRING(issue,3,2),SIGNED)*100)) DESC LIMIT 0,1 ) ORDER BY RAND() DESC LIMIT 6

151 (410.07995605469): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294726055 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294726055 AND published='1' LIMIT 1

152 (77.962875366211): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294726055 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294726055 AND published='1' LIMIT 1

153 (61.03515625): SELECT fid FROM jos_deeppockets WHERE cat=10 AND id=294726055 AND type='deeppockets_item' AND published='1' union SELECT fid FROM jos_deeppockets_archive WHERE cat=10 AND id=294726055 AND type='deeppockets_item' AND published='1' LIMIT 1

154 (!!!!! 4740.9534454346): select distinct links.* from jos_textlinks links join jos_textlinks_placement placement on links.id=placement.link_id where journal_id=(10) and (channel_id=216 or channel_id is null)

155 (!!!!! 5351.0665893555): select distinct links.* from jos_textlinks links join jos_textlinks_placement placement on links.id=placement.link_id where journal_id=(10) and (channel_id=216 or channel_id is null)

156 (!!!!! 6139.0399932861): SELECT livesite FROM jos_dp_categories WHERE id=10 AND published='1' LIMIT 1

157 (!!!!! 6583.9290618896): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294726055 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294726055 AND published='1' LIMIT 1

158 (!!!!! 3738.8801574707): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294726055 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294726055 AND published='1' LIMIT 1

159 (78.916549682617): select jos_twitters.link from jos_twitters where cat=10

160 (45.061111450195): select jos_facebook.link from jos_facebook where cat=10

161 (45.061111450195): select jos_google_plus.link from jos_google_plus where cat=10

162 (40.054321289062): select jos_linkedin.link from jos_linkedin where cat=10

163 (348.09112548828): update jos_bannersmanager_banner set impmade=impmade+1 where id in(14202,14203)

164 (!!!!! 1284.122467041): insert into jos_banners_delta values (14202,'2025-06-21 16:39:28','216.73.216.120','view'),(14203,'2025-06-21 16:39:28','216.73.216.120','view')

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