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Radiologist Recommendations for Chest CT Scanning Offer Important Findings

By MedImaging International staff writers
Posted on 13 Jan 2015

Image: Chest CT image showing the lungs (Photo courtesy of MGH – Massachusetts General Hospital) .

$Image: Examples of lesions seen on chest radiographic images that prompted a recommendation for chest CT examination and the corresponding abnormality on chest CT. (a, b) In the first example, a nodular opacity (arrow on a) is seen projecting over the right posterior ninth rib in the chest radiographic image of a 50-year-old woman who presented with cough; the recommended chest CT examination demonstrated this to be callus from a remote rib fracture (arrow on b). (c, d) In the second example, a nodular opacity (arrow in c) is seen projecting over the left anterior first rib on the chest radiographic image of a 53-year-old man who is a former smoker and presented with cough; the recommended chest CT examination demonstrated this to be a suspicious nodule in the apicoposterior segment of the left upper lobe (arrow in d). On resection, this was found to be well-differentiated adenocarcinoma of the lung (Photo courtesy of RSNA).$

Image: Examples of lesions seen on chest radiographic images that prompted a recommendation for chest CT examination and the corresponding abnormality on chest CT. (a, b) In the first example, a nodular opacity (arrow on a) is seen projecting over the right posterior ninth rib in the chest radiographic image of a 50-year-old woman who presented with cough; the recommended chest CT examination demonstrated this to be callus from a remote rib fracture (arrow on b). (c, d) In the second example, a nodular opacity (arrow in c) is seen projecting over the left anterior first rib on the chest radiographic image of a 53-year-old man who is a former smoker and presented with cough; the recommended chest CT examination demonstrated this to be a suspicious nodule in the apicoposterior segment of the left upper lobe (arrow in d). On resection, this was found to be well-differentiated adenocarcinoma of the lung (Photo courtesy of RSNA).

A significant proportion of patients who receive radiologist recommendations for undergoing chest computed tomography (CT) scanning to evaluate abnormal findings on outpatient chest X-rays have clinically relevant findings, including cancer, according to a new research. The investigators have reported that the findings demonstrate that radiologist recommendations for additional imaging (RAIs) after chest X-rays represent valuable contributions to patient care.

The study was published online December 22, 2014, in the journal Radiology. RAIs, which have grown 200% since 1995, have drawn debate recently as the healthcare field transforms from volume-driven to value-based payment models. The scrutiny makes it increasingly important for the radiology community to confirm the clinical impact of its studies, according to study author Tarik K. Alkasab, MD, PhD, from Massachusetts General Hospital (MGH) and Harvard Medical School (both based in Boston, MA, USA). “There has been a great deal of research on how radiologists recommend an imaging exam, but little on what comes out of the exams that they recommend,” Dr. Alkasab said. “Prior studies were very broad, so in our study we tried to focus on a specific clinical scenario.”

Dr. Alkasab and colleagues examined chest X-rays, one of the most extensively performed outpatient diagnostic imaging studies in the United States. As many as 50% of all RAIs identified in thoracic diagnostic exams are the result of performing chest X-rays. The researchers searched through more than 29,000 reports of outpatient chest X-rays performed at a large academic center over one year to identify studies that included a recommendation for a chest CT. They found that radiologists interpreting outpatient chest X-rays made recommendations for CT in 4.5% of cases—a result in line with existing research. Increasing patient age and positive smoking history were associated with an increased likelihood of a chest CT recommendation.

When the researchers examined the chest CT scans obtained within one year of the index chest X-ray, they discovered that 41.4% detected a corresponding abnormality requiring treatment or further diagnostic workup. One in every 13 generated a corresponding abnormality representing a newly-diagnosed, biopsy-validated malignancy.

“In this era of concern about radiation dose risk, these findings suggest that the extremely low predicted risk of radiation-induced cancer associated with a chest CT is orders of magnitude less than the potential clinical benefits,” said study coauthor H. Benjamin Harvey, MD, JD, from Massachusetts General Hospital and Harvard Medical School. “If ordering physicians see a recommendation for chest CT, they need to ensure that the patient gets the recommended imaging.”

More than one-third of patients in the study group who were recommended for a follow-up chest CT did not receive the exam within one year—an oversight that could result in missed or delayed diagnoses, the researchers said. “More research is needed to understand the possible reasons for the less-than-optimal adherence to RAIs after chest X-ray,” Dr. Harvey said. “One thing we’re looking at is how the recommendation language affects recommendation adherence.”

The researchers hope that their study helps enhance awareness of the importance of follow-up CT scanning. “These results show that radiologists should be confident their recommendations are adding value and protecting patients,” Dr. Alkasab concluded.

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58 (576.97296142578): 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=294756677 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

59 (!!!!! 1642.9424285889): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294756677 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294756677 AND published='1' LIMIT 1

60 (67.949295043945): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294756677 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294756677 AND published='1' LIMIT 1

61 (196.93374633789): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294756677 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294756677 AND published='1' LIMIT 1

62 (81.062316894531): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294756677 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294756677 AND published='1' LIMIT 1

63 (157.83309936523): 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 (742.91229248047): SELECT fid FROM jos_deeppockets WHERE id=294756677 AND published='1' union SELECT fid FROM jos_deeppockets_archive WHERE id=294756677 AND published='1' LIMIT 1

65 (558.85314941406): 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`

66 (99.897384643555): select jos_twitters.link from jos_twitters where cat=10

67 (48.160552978516): select jos_facebook.link from jos_facebook where cat=10

68 (43.153762817383): select jos_google_plus.link from jos_google_plus where cat=10

69 (38.14697265625): select jos_linkedin.link from jos_linkedin where cat=10

70 (45.061111450195): SELECT fid FROM jos_deeppockets WHERE id=294756677 AND published='1' union SELECT fid FROM jos_deeppockets_archive WHERE id=294756677 AND published='1' LIMIT 1

71 (42.915344238281): 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`

72 (566.00570678711): SELECT fid FROM jos_deeppockets WHERE cat=10 AND id=294756677 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

73 (375.03242492676): SELECT fid FROM jos_deeppockets_archive WHERE cat=10 AND id=294756677 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

74 (66.041946411133): 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 (74.863433837891): SELECT show_live FROM jos_com_show_setting LIMIT 1

76 (34.093856811523): SELECT show_live FROM jos_com_show_setting LIMIT 1

77 (30.040740966797): SELECT show_live FROM jos_com_show_setting LIMIT 1

78 (27.894973754883): SELECT show_live FROM jos_com_show_setting LIMIT 1

79 (25.98762512207): SELECT show_live FROM jos_com_show_setting LIMIT 1

80 (27.179718017578): SELECT show_live FROM jos_com_show_setting LIMIT 1

81 (60.081481933594): SELECT show_live FROM jos_com_show_setting LIMIT 1

82 (31.948089599609): SELECT show_live FROM jos_com_show_setting LIMIT 1

83 (30.040740966797): SELECT show_live FROM jos_com_show_setting LIMIT 1

84 (34.093856811523): SELECT show_live FROM jos_com_show_setting LIMIT 1

85 (41.007995605469): SELECT show_live FROM jos_com_show_setting LIMIT 1

86 (36.001205444336): SELECT show_live FROM jos_com_show_setting LIMIT 1

87 (38.14697265625): SELECT show_live FROM jos_com_show_setting LIMIT 1

88 (33.855438232422): SELECT show_live FROM jos_com_show_setting LIMIT 1

89 (78.916549682617): SELECT fid FROM jos_deeppockets WHERE cat=10 AND id=294756677 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

90 (39.815902709961): SELECT fid FROM jos_deeppockets_archive WHERE cat=10 AND id=294756677 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

91 (47.922134399414): 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 (88.930130004883): SELECT show_live FROM jos_com_show_setting LIMIT 1

93 (46.968460083008): SELECT show_live FROM jos_com_show_setting LIMIT 1

94 (64.13459777832): SELECT show_live FROM jos_com_show_setting LIMIT 1

95 (41.007995605469): SELECT show_live FROM jos_com_show_setting LIMIT 1

96 (58.889389038086): SELECT show_live FROM jos_com_show_setting LIMIT 1

97 (40.054321289062): SELECT show_live FROM jos_com_show_setting LIMIT 1

98 (47.922134399414): SELECT show_live FROM jos_com_show_setting LIMIT 1

99 (41.961669921875): SELECT show_live FROM jos_com_show_setting LIMIT 1

100 (43.153762817383): SELECT show_live FROM jos_com_show_setting LIMIT 1

101 (44.822692871094): SELECT show_live FROM jos_com_show_setting LIMIT 1

102 (43.153762817383): SELECT show_live FROM jos_com_show_setting LIMIT 1

103 (69.856643676758): SELECT show_live FROM jos_com_show_setting LIMIT 1

104 (44.107437133789): SELECT show_live FROM jos_com_show_setting LIMIT 1

105 (36.954879760742): SELECT show_live FROM jos_com_show_setting LIMIT 1

106 (113.96408081055): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294756677 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294756677 AND published='1' LIMIT 1

107 (87.02278137207): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294756677 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294756677 AND published='1' LIMIT 1

108 (96.08268737793): 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=294756677 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

109 (103.95050048828): 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=294756677 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

110 (121.8318939209): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294756677 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294756677 AND published='1' LIMIT 1

111 (72.956085205078): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294756677 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294756677 AND published='1' LIMIT 1

112 (79.870223999023): 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=294756677 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

113 (843.04809570312): 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=294756677 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

114 (853.06167602539): 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 (593.18542480469): 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 (288.96331787109): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294756677 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294756677 AND published='1' LIMIT 1

117 (130.17654418945): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294756677 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294756677 AND published='1' LIMIT 1

118 (98.943710327148): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294756677 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294756677 AND published='1' LIMIT 1

119 (67.949295043945): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294756677 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294756677 AND published='1' LIMIT 1

120 (76.055526733398): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294756677 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294756677 AND published='1' LIMIT 1

121 (324.96452331543): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294756677 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294756677 AND published='1' LIMIT 1

122 (93.936920166016): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294756677 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294756677 AND published='1' LIMIT 1

123 (73.909759521484): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294756677 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294756677 AND published='1' LIMIT 1

124 (534.0576171875): SELECT * FROM trending_articles WHERE `journal_id` = 10 AND `timestamp` <= NOW() + INTERVAL 7 DAY ORDER BY `order`

125 (!!!!! 30207.15713501): 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 (848.05488586426): SELECT fid FROM jos_deeppockets WHERE cat=10 AND id=294756677 AND type='deeppockets_item' AND published='1' union SELECT fid FROM jos_deeppockets_archive WHERE cat=10 AND id=294756677 AND type='deeppockets_item' AND published='1' LIMIT 1

127 (!!!!! 11178.970336914): ( 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 (131.84547424316): ( 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 (452.04162597656): 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 (86.069107055664): 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 (396.9669342041): 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 (56.028366088867): 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 (311.13624572754): 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 (51.021575927734): 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 (306.12945556641): 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 (165.93933105469): 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 (779.86717224121): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294756677 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

138 (574.11193847656): SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294756677 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

139 (336.1701965332): SELECT name FROM jos_deeppockets WHERE id=211

140 (55.074691772461): SELECT name FROM jos_deeppockets WHERE id=211

141 (779.86717224121): 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 (737.90550231934): 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

143 (110.86463928223): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294756677 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294756677 AND published='1' LIMIT 1

144 (77.009201049805): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294756677 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294756677 AND published='1' LIMIT 1

145 (!!!!! 12381.792068481): TRUNCATE TABLE jos_trademed_module

146 (193.11904907227): 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=294756677 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

147 (105.14259338379): 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=294756677 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

148 (603.91426086426): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294756677 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

149 (87.976455688477): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294756677 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

150 (107.0499420166): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294756677 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294756677 AND published='1' LIMIT 1

151 (76.055526733398): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294756677 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294756677 AND published='1' LIMIT 1

152 (!!!!! 2021.7895507812): 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 (113.01040649414): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294756677 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294756677 AND published='1' LIMIT 1

154 (75.101852416992): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294756677 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294756677 AND published='1' LIMIT 1

155 (61.03515625): SELECT fid FROM jos_deeppockets WHERE cat=10 AND id=294756677 AND type='deeppockets_item' AND published='1' union SELECT fid FROM jos_deeppockets_archive WHERE cat=10 AND id=294756677 AND type='deeppockets_item' AND published='1' LIMIT 1

156 (45.061111450195): 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 (40.054321289062): 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)

158 (56.028366088867): SELECT livesite FROM jos_dp_categories WHERE id=10 AND published='1' LIMIT 1

159 (201.94053649902): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294756677 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294756677 AND published='1' LIMIT 1

160 (447.98851013184): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294756677 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294756677 AND published='1' LIMIT 1

161 (158.07151794434): select jos_twitters.link from jos_twitters where cat=10

162 (55.074691772461): select jos_facebook.link from jos_facebook where cat=10

163 (48.87580871582): select jos_google_plus.link from jos_google_plus where cat=10

164 (91.791152954102): select jos_linkedin.link from jos_linkedin where cat=10

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