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EMR Helps Reduce Unnecessary CT Scans in ER Patients with Abdominal Pain

By MedImaging International staff writers
Posted on 30 May 2012

A new electronic medical record (EMR) application that records patients’ earlier radiation exposure from computed tomography (CT) scans helps reduce potentially unwarranted use of the imaging modalities among emergency room (ER) patients with abdominal pain.

Researchers from the Perelman School of Medicine at the University of Pennsylvania (Philadelphia, USA) presented their findings in May 2012 at the annual meeting of the Society for Academic Emergency Medicine, held in Chicago (IL, USA). More...

The new study demonstrated that when the application is utilized, patients are 10% less apt to undergo a CT scan, without increasing the number of patients who are admitted to the hospital.

Abdominal pain is the most typical complaint why people seek care in emergency rooms in the United States, accounting for 10 million visits each year. But the symptoms may be caused by myriad problems, from those that can be fixed with a single dose of an over-the-counter drug to those that could prove life-threatening within hours: from an attack of gastrointestinal (GI) distress to an ectopic pregnancy; from constipation to an appendix about to burst; from a hernia to signs of a chronic disorder such as Crohn’s disease.

This complex diagnostic face-off plays a huge role in why emergency physicians tend to lean heavily on tests like CT scans, even though they expose patients to radiation and there are few clear guidelines on which patients should get them. Since the mid-1990s, the use of CT scans to diagnose ER patients has surged, increasing ten-fold. Currently, 14% of all emergency room patients are scanned--as statistic experts frequently refer to as a contributor to expanding health care costs.

“Most patients with abdominal pain aren’t in major danger, but some of the conditions that are on the list of things we consider as causes can be fatal within a short amount of time,” said Angela M. Mills, MD, an assistant professor of emergency medicine and medical director of the emergency department at the Hospital of the University of Pennsylvania. “We need to be sure about our diagnosis in order to keep patients safe, but we need to balance the risks of giving a test like a CT scan with the chance that the test will truly provide us with information we could not get in some other way with less risk to the patient.”

The Penn researchers investigated a new tool embedded within patients’ EMRs that walked physicians through a series of questions that served as checks and balances for their decision to order a CT scan to investigate a patient’s abdominal pain. They were questioned, for instance, on what diagnosis they were striving for (from appendicitis to colitis to an ovarian cyst or tumor), and how likely they thought it was that the patient really had that problem. Moreover, if a medical resident ordered the test, it had to be approved by an attending physician before the patient could receive the scan. Those steps, the researchers said, appeared to play a role in prompting the care team to rethink their choice of tests.

The authors examined 11,176 patients seen in two Penn Medicine emergency rooms between July 2011 and March 2012. Before implementing the new accountability tool, 32.3% of patients seen received CT scans. After its use was adopted, the number dropped to 28%. After adjusting for various confounding factors, the researchers determined that patients were 10% less likely to undergo a CT scan after the tool was built into the electronic medical record. The patients were no more likely to be admitted to the hospital--a typical event when a diagnosis remains uncertain--after implementation of the approach.

An enhanced version of the program, launched since the new study was completed, also provides data on how many different abdominal imaging tests the patient has previously had at Penn, and tallies their total radiation exposure from previous CT scans. Dr. Mills hopes that additional data will help cut down on unnecessary tests even more. “For many patients, like those who are older or have cancer, this tool might not make a difference,” Dr. Mills said, “but there are many abdominal patients who are younger, healthier, and who have things that are usually not life-threatening like kidney stones, for whom we are hoping this will reduce their exposure to unnecessary radiation.”

In the future, as EMRs become more effective and accessible between different hospitals, she hopes a similar tool can be used to obtain data about the past CT scans of a larger number of patients.

Related Links:
University of Pennsylvania’s Perelman School of Medicine

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57 (61.03515625): 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=294740882 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

58 (405.07316589355): 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=294740882 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

59 (!!!!! 1320.1236724854): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294740882 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294740882 AND published='1' LIMIT 1

60 (65.088272094727): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294740882 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294740882 AND published='1' LIMIT 1

61 (!!!!! 4562.8547668457): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294740882 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294740882 AND published='1' LIMIT 1

62 (122.0703125): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294740882 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294740882 AND published='1' LIMIT 1

63 (96.08268737793): 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

64 (607.01370239258): SELECT fid FROM jos_deeppockets WHERE id=294740882 AND published='1' union SELECT fid FROM jos_deeppockets_archive WHERE id=294740882 AND published='1' LIMIT 1

65 (46.968460083008): 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`

66 (40.054321289062): select jos_twitters.link from jos_twitters where cat=10

67 (29.087066650391): select jos_facebook.link from jos_facebook where cat=10

68 (!!!!! 3283.0238342285): select jos_google_plus.link from jos_google_plus where cat=10

69 (84.161758422852): select jos_linkedin.link from jos_linkedin where cat=10

70 (51.975250244141): SELECT fid FROM jos_deeppockets WHERE id=294740882 AND published='1' union SELECT fid FROM jos_deeppockets_archive WHERE id=294740882 AND published='1' LIMIT 1

71 (41.007995605469): 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`

72 (488.9965057373): SELECT fid FROM jos_deeppockets WHERE cat=10 AND id=294740882 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

73 (379.80079650879): SELECT fid FROM jos_deeppockets_archive WHERE cat=10 AND id=294740882 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

74 (64.849853515625): 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`

75 (56.982040405273): SELECT show_live FROM jos_com_show_setting LIMIT 1

76 (30.040740966797): SELECT show_live FROM jos_com_show_setting LIMIT 1

77 (28.133392333984): SELECT show_live FROM jos_com_show_setting LIMIT 1

78 (28.133392333984): SELECT show_live FROM jos_com_show_setting LIMIT 1

79 (27.894973754883): SELECT show_live FROM jos_com_show_setting LIMIT 1

80 (27.894973754883): SELECT show_live FROM jos_com_show_setting LIMIT 1

81 (26.941299438477): SELECT show_live FROM jos_com_show_setting LIMIT 1

82 (29.087066650391): SELECT show_live FROM jos_com_show_setting LIMIT 1

83 (41.007995605469): SELECT show_live FROM jos_com_show_setting LIMIT 1

84 (40.054321289062): SELECT show_live FROM jos_com_show_setting LIMIT 1

85 (37.193298339844): SELECT show_live FROM jos_com_show_setting LIMIT 1

86 (29.802322387695): SELECT show_live FROM jos_com_show_setting LIMIT 1

87 (28.848648071289): SELECT show_live FROM jos_com_show_setting LIMIT 1

88 (28.133392333984): SELECT show_live FROM jos_com_show_setting LIMIT 1

89 (58.174133300781): SELECT fid FROM jos_deeppockets WHERE cat=10 AND id=294740882 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

90 (30.040740966797): SELECT fid FROM jos_deeppockets_archive WHERE cat=10 AND id=294740882 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

91 (35.04753112793): 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`

92 (47.922134399414): SELECT show_live FROM jos_com_show_setting LIMIT 1

93 (30.994415283203): SELECT show_live FROM jos_com_show_setting LIMIT 1

94 (27.894973754883): SELECT show_live FROM jos_com_show_setting LIMIT 1

95 (27.894973754883): SELECT show_live FROM jos_com_show_setting LIMIT 1

96 (!!!!! 3719.0914154053): SELECT show_live FROM jos_com_show_setting LIMIT 1

97 (124.93133544922): SELECT show_live FROM jos_com_show_setting LIMIT 1

98 (54.121017456055): SELECT show_live FROM jos_com_show_setting LIMIT 1

99 (43.153762817383): SELECT show_live FROM jos_com_show_setting LIMIT 1

100 (44.107437133789): SELECT show_live FROM jos_com_show_setting LIMIT 1

101 (40.054321289062): SELECT show_live FROM jos_com_show_setting LIMIT 1

102 (39.100646972656): SELECT show_live FROM jos_com_show_setting LIMIT 1

103 (28.848648071289): SELECT show_live FROM jos_com_show_setting LIMIT 1

104 (46.014785766602): SELECT show_live FROM jos_com_show_setting LIMIT 1

105 (27.894973754883): SELECT show_live FROM jos_com_show_setting LIMIT 1

106 (83.92333984375): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294740882 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294740882 AND published='1' LIMIT 1

107 (44.822692871094): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294740882 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294740882 AND published='1' LIMIT 1

108 (74.863433837891): 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=294740882 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

109 (528.09715270996): 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=294740882 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

110 (77.009201049805): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294740882 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294740882 AND published='1' LIMIT 1

111 (46.968460083008): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294740882 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294740882 AND published='1' LIMIT 1

112 (58.174133300781): 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=294740882 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

113 (567.91305541992): 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=294740882 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

114 (648.02169799805): 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

115 (411.03363037109): 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

116 (139.95170593262): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294740882 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294740882 AND published='1' LIMIT 1

117 (57.93571472168): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294740882 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294740882 AND published='1' LIMIT 1

118 (61.988830566406): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294740882 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294740882 AND published='1' LIMIT 1

119 (41.961669921875): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294740882 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294740882 AND published='1' LIMIT 1

120 (56.028366088867): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294740882 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294740882 AND published='1' LIMIT 1

121 (41.007995605469): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294740882 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294740882 AND published='1' LIMIT 1

122 (58.174133300781): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294740882 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294740882 AND published='1' LIMIT 1

123 (51.021575927734): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294740882 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294740882 AND published='1' LIMIT 1

124 (238.89541625977): SELECT * FROM trending_articles WHERE `journal_id` = 10 AND `timestamp` <= NOW() + INTERVAL 7 DAY ORDER BY `order`

125 (!!!!! 45482.158660889): 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

126 (596.04644775391): SELECT fid FROM jos_deeppockets WHERE cat=10 AND id=294740882 AND type='deeppockets_item' AND published='1' union SELECT fid FROM jos_deeppockets_archive WHERE cat=10 AND id=294740882 AND type='deeppockets_item' AND published='1' LIMIT 1

127 (!!!!! 22675.99105835): ( 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

128 (303.98368835449): ( 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

129 (123.97766113281): 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

130 (!!!!! 1564.9795532227): 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

131 (78.916549682617): 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

132 (44.822692871094): 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

133 (324.96452331543): 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

134 (182.15179443359): 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

135 (54.836273193359): 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

136 (42.915344238281): 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

137 (698.80485534668): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294740882 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

138 (406.98051452637): SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294740882 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

139 (236.98806762695): SELECT name FROM jos_deeppockets WHERE id=216

140 (32.901763916016): SELECT name FROM jos_deeppockets WHERE id=216

141 (521.18301391602): 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

142 (423.90823364258): 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

143 (559.09156799316): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294740882 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294740882 AND published='1' LIMIT 1

144 (59.843063354492): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294740882 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294740882 AND published='1' LIMIT 1

145 (!!!!! 18643.856048584): TRUNCATE TABLE jos_trademed_module

146 (82.969665527344): 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=294740882 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

147 (56.028366088867): 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=294740882 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

148 (452.99530029297): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294740882 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

149 (619.88830566406): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294740882 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

150 (74.863433837891): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294740882 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294740882 AND published='1' LIMIT 1

151 (45.061111450195): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294740882 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294740882 AND published='1' LIMIT 1

152 (!!!!! 2384.9010467529): 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

153 (!!!!! 3829.0023803711): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294740882 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294740882 AND published='1' LIMIT 1

154 (130.89179992676): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294740882 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294740882 AND published='1' LIMIT 1

155 (39.100646972656): SELECT fid FROM jos_deeppockets WHERE cat=10 AND id=294740882 AND type='deeppockets_item' AND published='1' union SELECT fid FROM jos_deeppockets_archive WHERE cat=10 AND id=294740882 AND type='deeppockets_item' AND published='1' LIMIT 1

156 (29.087066650391): 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)

157 (31.948089599609): 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)

158 (39.100646972656): SELECT livesite FROM jos_dp_categories WHERE id=10 AND published='1' LIMIT 1

159 (128.98445129395): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294740882 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294740882 AND published='1' LIMIT 1

160 (42.915344238281): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294740882 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294740882 AND published='1' LIMIT 1

161 (39.100646972656): select jos_twitters.link from jos_twitters where cat=10

162 (25.98762512207): select jos_facebook.link from jos_facebook where cat=10

163 (27.894973754883): select jos_google_plus.link from jos_google_plus where cat=10

164 (25.98762512207): select jos_linkedin.link from jos_linkedin where cat=10

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