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CT Scanning Not Necessary for Minor Head Injuries in Children

By MedImaging International staff writers
Posted on 24 Jul 2014

A US study of more than 40,000 children evaluated in hospital emergency departments for head trauma revealed that if children had only loss of consciousness, and no other signs or symptoms related to the head trauma, they are very unlikely to have sustained serious brain injuries. More...

Children who have only isolated loss of consciousness after head trauma do not routinely require computed tomography (CT) scans of the head, according to the investigators of the research.

Although CT scans are the most typical way to determine if a child has life-threatening bleeding in the brain that may necessitate surgical intervention, the radiation involved carries a small but quantifiable long-term risk of cancer. As such, the data indicate that CT evaluation for children with head trauma should not be routinely used if they are at low risk for clinically significant traumatic brain injuries.

The findings were published July 9, 2014, in the journal JAMA Pediatrics. “Fear of missing a clinically significant head injury, and the wide availability of CT scanners, have been the main factors driving an increase in the use of CT imaging over the past two decades,” said Nathan Kuppermann, professor and chair of the University of California (UC) Davis (USA) department of emergency medicine, and lead investigator of the original study from which the data and current analysis of head injuries were derived. “Our findings can help doctors confidently make a decision to forego CT testing when their patients are unlikely to benefit from it, enabling physicians to first observe their patients for a period of time before deciding on CT use.”

Whether the presence of a single factor suggestive of brain injury is reason enough to justify obtaining a CT scan has been a question Prof. Kuppermann and colleagues with the Pediatric Emergency Care Applied Research Network (PECARN; Salt Lake City, UT, USA) have been actively searching through a series of studies over the past few years. The current study revealed that children who lost consciousness after head trauma, but then were awake and alert in the emergency department, and had none of the other five factors determined important by PECARN guidelines for identifying children at low risk for clinically important brain injuries after head trauma (called the PECARN traumatic brain injury prediction rules), had a very low rate of clinically significant brain injuries—only 0.5%, or 1 in 200 children.

If a child had isolated loss of consciousness without any other symptoms or signs of head trauma (i.e., including factors outside of the PECARN traumatic brain injury prediction rules), the incidence of an important brain injury decreased to only 0.2%, or 1 in 500 children. Furthermore, the duration of the loss of consciousness did not significantly affect risk.

“Children with clinically important brain injuries rarely have loss of consciousness alone, and almost always present other symptoms, such as vomiting or showing signs of neurological problems,” said Dr. Lois K. Lee, lead author of the current study and director of trauma research at Boston Children’s Hospital (MA, USA). “Being able to make treatment decisions backed by strong data helps doctors and parents feel better about deciding whether further testing is really needed.”

Moreover, Dr. Lee noted that in instances in which a parent or physician is worried about a child’s condition, it would be sensible to observe the child in the emergency department for a few hours to see if any other signs or symptoms arise before making the decision whether to have a CT.

Research shows that exposure to the ionizing radiation related to CT scanning increase the risk of cancer. Based on a child’s age, one head CT scan for a child is the same as approximately 140 chest X-rays, according to The Essential Physics of Medical Imaging. Radiation exposure in the brains of developing children is of special concern and must be considered carefully against the risk of traumatic brain injury that could cause permanent damage or death if not identified early. The investigators noted that if the guidelines are applied correctly, the use of unnecessary CT scans could be substantially reduced.

An earlier, groundbreaking study led by Prof. Kuppermann and published by the Lancet in 2009 developed and validated a traumatic brain injury prediction rule to identify children at low risk for clinically important head injuries who probably do not require CT evaluation. Factors in the rule included abnormal mental status, scalp hematoma (in children younger than two years old), evidence of vomiting, a skull fracture, history of loss of consciousness associated with the head trauma, and severity of the injury process (such as a major fall). If a child with head trauma has none of the six associated factors, researchers determined that a CT scan would be very unlikely to reveal a clinically significant problem, making it unnecessary for a child to undergo the CT scan.

Two related studies led by Prof. Kuppermann and his team were recently published in the Annals of Emergency Medicine. One, in the June 2014 issue, examined whether vomiting by itself necessitates a CT scan in children who have acute head trauma. The second, in the March 2014 issue, evaluated whether swelling of the scalp in children younger than two years old, as a result of a head trauma by itself, justifies a CT scan. Both studies determined that the presence of these individual factors alone, with no other signs and symptoms of head trauma, were not sufficient to warrants an immediate CT scan. Instead, the researchers reported that children in these instances should be observed for a period of time before any decisions regarding CT use are made.

“Head trauma in children results in nearly half-a-million visits to US emergency departments annually,” said Dr. Peter Dayan, lead author of both recent studies and an associate professor of pediatrics at Columbia University (New York, NY, USA). “Our research provides important support for frontline doctors to help them avoid unnecessarily exposing children to the radiation risks inherent in CT testing.”

The head trauma study was designed by Prof. Kuppermann and colleagues in PECARN to determine which children evaluated in the emergency department for head trauma are at low risk for clinically significant traumatic brain injuries and who do not require cranial CT assessment. The pediatric research network comprises 18 hospital emergency departments across the nation and serves more than 1.2 million children. The immense amount of data generated by this patient population enables investigators to confidently answer questions about best practices, according to the investigators.

Related Links:

University of California, Davis

Boston Children’s Hospital

Pediatric Emergency Care Applied Research Network

Columbia University

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52 (61.03515625): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294753656 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294753656 AND published='1' LIMIT 1

53 (392.19856262207): SELECT name FROM jos_deeppockets WHERE id=294753656 LIMIT 1

54 (314.95094299316): SELECT name FROM jos_deeppockets_archive WHERE id=294753656 LIMIT 1

55 (45.061111450195): SELECT a.* FROM jos_components AS a WHERE ( a.admin_menu_link = 'option=com_syndicate' OR a.admin_menu_link = 'option=com_syndicate&hidemainmenu=1' ) AND a.option = 'com_syndicate'

56 (90.837478637695): 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=294753656 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

57 (447.98851013184): 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=294753656 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

58 (!!!!! 1527.0709991455): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294753656 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294753656 AND published='1' LIMIT 1

59 (72.002410888672): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294753656 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294753656 AND published='1' LIMIT 1

60 (154.01840209961): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294753656 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294753656 AND published='1' LIMIT 1

61 (71.048736572266): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294753656 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294753656 AND published='1' LIMIT 1

62 (108.95729064941): 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

63 (643.96858215332): SELECT fid FROM jos_deeppockets WHERE id=294753656 AND published='1' union SELECT fid FROM jos_deeppockets_archive WHERE id=294753656 AND published='1' LIMIT 1

64 (50.067901611328): 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=211 ORDER BY `ordering`

65 (42.915344238281): select jos_twitters.link from jos_twitters where cat=10

66 (32.186508178711): select jos_facebook.link from jos_facebook where cat=10

67 (33.140182495117): select jos_google_plus.link from jos_google_plus where cat=10

68 (31.948089599609): select jos_linkedin.link from jos_linkedin where cat=10

69 (37.908554077148): SELECT fid FROM jos_deeppockets WHERE id=294753656 AND published='1' union SELECT fid FROM jos_deeppockets_archive WHERE id=294753656 AND published='1' LIMIT 1

70 (34.809112548828): 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=211 ORDER BY `ordering`

71 (406.98051452637): SELECT fid FROM jos_deeppockets WHERE cat=10 AND id=294753656 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

72 (352.14424133301): SELECT fid FROM jos_deeppockets_archive WHERE cat=10 AND id=294753656 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

73 (46.014785766602): 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`

74 (67.949295043945): SELECT show_live FROM jos_com_show_setting LIMIT 1

75 (34.093856811523): SELECT show_live FROM jos_com_show_setting LIMIT 1

76 (144.00482177734): SELECT show_live FROM jos_com_show_setting LIMIT 1

77 (58.889389038086): SELECT show_live FROM jos_com_show_setting LIMIT 1

78 (49.114227294922): SELECT show_live FROM jos_com_show_setting LIMIT 1

79 (51.975250244141): SELECT show_live FROM jos_com_show_setting LIMIT 1

80 (38.14697265625): SELECT show_live FROM jos_com_show_setting LIMIT 1

81 (56.028366088867): SELECT show_live FROM jos_com_show_setting LIMIT 1

82 (48.87580871582): SELECT show_live FROM jos_com_show_setting LIMIT 1

83 (40.054321289062): SELECT show_live FROM jos_com_show_setting LIMIT 1

84 (54.836273193359): SELECT show_live FROM jos_com_show_setting LIMIT 1

85 (39.100646972656): SELECT show_live FROM jos_com_show_setting LIMIT 1

86 (42.915344238281): SELECT show_live FROM jos_com_show_setting LIMIT 1

87 (39.100646972656): SELECT show_live FROM jos_com_show_setting LIMIT 1

88 (92.029571533203): SELECT fid FROM jos_deeppockets WHERE cat=10 AND id=294753656 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

89 (50.067901611328): SELECT fid FROM jos_deeppockets_archive WHERE cat=10 AND id=294753656 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

90 (53.167343139648): 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`

91 (72.002410888672): SELECT show_live FROM jos_com_show_setting LIMIT 1

92 (46.014785766602): SELECT show_live FROM jos_com_show_setting LIMIT 1

93 (33.855438232422): SELECT show_live FROM jos_com_show_setting LIMIT 1

94 (30.040740966797): SELECT show_live FROM jos_com_show_setting LIMIT 1

95 (30.040740966797): SELECT show_live FROM jos_com_show_setting LIMIT 1

96 (30.040740966797): SELECT show_live FROM jos_com_show_setting LIMIT 1

97 (30.040740966797): SELECT show_live FROM jos_com_show_setting LIMIT 1

98 (30.994415283203): SELECT show_live FROM jos_com_show_setting LIMIT 1

99 (36.001205444336): SELECT show_live FROM jos_com_show_setting LIMIT 1

100 (36.954879760742): SELECT show_live FROM jos_com_show_setting LIMIT 1

101 (41.961669921875): SELECT show_live FROM jos_com_show_setting LIMIT 1

102 (40.054321289062): SELECT show_live FROM jos_com_show_setting LIMIT 1

103 (41.961669921875): SELECT show_live FROM jos_com_show_setting LIMIT 1

104 (36.954879760742): SELECT show_live FROM jos_com_show_setting LIMIT 1

105 (183.8207244873): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294753656 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294753656 AND published='1' LIMIT 1

106 (63.896179199219): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294753656 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294753656 AND published='1' LIMIT 1

107 (104.18891906738): 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=294753656 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

108 (61.988830566406): 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=294753656 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

109 (92.983245849609): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294753656 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294753656 AND published='1' LIMIT 1

110 (50.067901611328): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294753656 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294753656 AND published='1' LIMIT 1

111 (57.93571472168): 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=294753656 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

112 (637.05444335938): 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=294753656 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

113 (568.86672973633): 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 (334.9781036377): 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 (83.92333984375): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294753656 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294753656 AND published='1' LIMIT 1

116 (49.114227294922): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294753656 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294753656 AND published='1' LIMIT 1

117 (50.067901611328): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294753656 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294753656 AND published='1' LIMIT 1

118 (41.961669921875): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294753656 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294753656 AND published='1' LIMIT 1

119 (62.942504882812): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294753656 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294753656 AND published='1' LIMIT 1

120 (41.961669921875): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294753656 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294753656 AND published='1' LIMIT 1

121 (47.922134399414): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294753656 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294753656 AND published='1' LIMIT 1

122 (41.961669921875): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294753656 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294753656 AND published='1' LIMIT 1

123 (339.98489379883): SELECT * FROM trending_articles WHERE `journal_id` = 10 AND `timestamp` <= NOW() + INTERVAL 7 DAY ORDER BY `order`

124 (!!!!! 31485.080718994): 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

125 (766.99256896973): SELECT fid FROM jos_deeppockets WHERE cat=10 AND id=294753656 AND type='deeppockets_item' AND published='1' union SELECT fid FROM jos_deeppockets_archive WHERE cat=10 AND id=294753656 AND type='deeppockets_item' AND published='1' LIMIT 1

126 (!!!!! 10444.164276123): ( 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 (100.13580322266): ( 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 (60.081481933594): 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 (41.961669921875): 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 (64.849853515625): 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 (40.054321289062): 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 (443.93539428711): 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 (105.85784912109): 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 (57.93571472168): 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 (41.961669921875): 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 (594.13909912109): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294753656 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

137 (482.08236694336): SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294753656 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

138 (53.167343139648): SELECT name FROM jos_deeppockets WHERE id=211

139 (55.074691772461): SELECT name FROM jos_deeppockets WHERE id=211

140 (674.96299743652): 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 '((;)|(^))211((;)|($))' AND catid IN (0,110) ORDER BY publish_up ASC LIMIT 3

141 (576.97296142578): 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 '((;)|(^))211((;)|($))' AND catid IN (0,110) ORDER BY publish_up ASC LIMIT 3

142 (77.009201049805): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294753656 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294753656 AND published='1' LIMIT 1

143 (48.160552978516): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294753656 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294753656 AND published='1' LIMIT 1

144 (!!!!! 20799.875259399): TRUNCATE TABLE jos_trademed_module

145 (!!!!! 1201.1528015137): 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=294753656 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

146 (108.00361633301): 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=294753656 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

147 (493.04962158203): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294753656 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

148 (107.0499420166): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294753656 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

149 (82.015991210938): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294753656 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294753656 AND published='1' LIMIT 1

150 (63.180923461914): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294753656 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294753656 AND published='1' LIMIT 1

151 (!!!!! 1677.9899597168): 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

152 (102.04315185547): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294753656 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294753656 AND published='1' LIMIT 1

153 (65.088272094727): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294753656 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294753656 AND published='1' LIMIT 1

154 (46.014785766602): SELECT fid FROM jos_deeppockets WHERE cat=10 AND id=294753656 AND type='deeppockets_item' AND published='1' union SELECT fid FROM jos_deeppockets_archive WHERE cat=10 AND id=294753656 AND type='deeppockets_item' AND published='1' LIMIT 1

155 (36.954879760742): 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=211 or channel_id is null)

156 (35.04753112793): 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=211 or channel_id is null)

157 (37.908554077148): SELECT livesite FROM jos_dp_categories WHERE id=10 AND published='1' LIMIT 1

158 (!!!!! 1960.0391387939): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294753656 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294753656 AND published='1' LIMIT 1

159 (72.956085205078): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294753656 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294753656 AND published='1' LIMIT 1

160 (921.01097106934): select jos_twitters.link from jos_twitters where cat=10

161 (67.949295043945): select jos_facebook.link from jos_facebook where cat=10

162 (41.007995605469): select jos_google_plus.link from jos_google_plus where cat=10

163 (36.001205444336): select jos_linkedin.link from jos_linkedin where cat=10

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CT Scanning Not Necessary for Minor Head Injuries in Children

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