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Operator Expertise is Important when Performing Ultrasound Exams to Detect Ovarian Cancer

By MedImaging staff writers
Posted on 31 Mar 2008

Using expert ultrasonographers over regular operators for diagnosing ovarian cancer results in significant reduction in the overall number of diagnostic procedures required as well as in the length of inpatient hospital stays, according to a recent report.

The advantage of expert operators, according to study investigator Dr. More...

Joseph Yazbek and colleagues, from King's College, Guy's and St. Thomas' Hospitals (London, UK), is their greater skill in differentiating benign from malignant ovarian pathology. "This ability decreases the number of patients who are treated as potentially having ovarian cancer and aids the use of more conservative management options.”

The established way to distinguish benign from malignant tumors in the region of the ovary, uterus, or fallopian tubes (known as adnexal tumors) is assessment of structural features (such as wall structure, blood vessels, and presence of fluid) using ultrasound images. Ultrasonography, however, is subject to substantial interobserver variability, with experienced operators being significantly more accurate in their diagnosis than the less experienced. Failure to distinguish between benign and malignant masses has the unfortunate consequence of patients being referred for major abdominal surgery to rule out the possibility of cancer, as opposed to the possibility of minimally invasive surgery (laparoscopy) to remove the benign mass or a wait and see approach.

In the study, Dr. Yazbek and colleagues set out to assess whether the level of operator skill had a measurable impact on patient management. Overall, 150 patients with suspected ovarian cancer, referred to the regional gynecologic cancer center at Guy's and St Thomas' National Health System (NHS) Foundation between May 3, 2004 and February 15, 2007, were randomized to level III (expert) ultrasonography (n = 77) or level II (routine) ultrasonography (n = 73). Level III ultrasonography was undertaken by gynecologists with a special interest in gynecologic ultrasound who had more than 10 years' experience in the procedure; while level II ultrasonography was undertaken by ultrasonographers trained in gynecologic ultrasonography. For all patients both transvaginal and transabdominal scans were undertaken to ensure complete assessment of the entire abdominal cavity.

Results showed the number of major surgical staging procedures for presumed ovarian cancer undertaken in women screened by a level III (expert) ultrasonographer was 17 of 77 (22%); compared with 27 of 73 (37%) for those screened by level II ultrasonography (p = 0.049). There was also a reduction in follow-up procedures after expert sonography with the median number of follow up scans being two (range 0-5) in the level II group, compared with one (0-4) in the level III group (p = 0.0004).

"This finding is likely to be the consequence of the greatly increased proportion of patients in whom a conclusive diagnosis of the nature of the adnexal tumor was possible from level III ultrasonography compared with level II ultrasonography,” wrote the researchers, who published their study in the February 2008 issue of the journal Lancet Oncology.

Furthermore, the findings showed that a histologic diagnosis was provided to clinicians for 76 of 77 (99%) of patients in the level III group compared with only 38 out of 73 (52%) of patients in the level II group (p < 0.0001). The total number of surgical procedures was similar between the two groups--35 of 73 (48%) in the level II group versus 33 of 77 (43%) in the level III group (p = 0.53). However, the number of minimally invasive procedures was higher for the level III group than the level II group.

This, according to the investigators, is likely to have contributed to the significant decrease in the length of hospital stays for patients in the expert level III group. The median duration of hospital stay for level II group patients was six days (range 3-13 days), compared to five days (range 1-9 days) for the level III group (p = 0.01).

The researchers added that the effect of expert scanning might have been even greater if it had been used in the primary assessment of ovarian pathology. "Increased confidence in the diagnosis of benign ovarian lesions is likely to decrease the need for additional diagnostic tests, such as magnetic resonance imaging [MRI] or serum CA- [cancer antigen]-125 concentration, and also decreases the number of referrals to regional cancer centers,” they wrote in their article.

In an accompanying commentary, Dr. Usha Menon, from University College (London, UK), reported, "In the current climate, where there is an increasing effort to rationalize procedures done by medical staff, this study is extremely important.” There is urgent need, she added, for detailed cost-benefit and quality of life analyses to be undertaken for the widespread introduction of expert sonography.

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56 (87.02278137207): 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=276690000 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

57 (672.1019744873): 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=276690000 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

58 (!!!!! 1794.0998077393): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=276690000 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=276690000 AND published='1' LIMIT 1

59 (100.13580322266): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=276690000 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=276690000 AND published='1' LIMIT 1

60 (176.90658569336): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=276690000 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=276690000 AND published='1' LIMIT 1

61 (87.02278137207): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=276690000 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=276690000 AND published='1' LIMIT 1

62 (152.8263092041): 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 (766.03889465332): SELECT fid FROM jos_deeppockets WHERE id=276690000 AND published='1' union SELECT fid FROM jos_deeppockets_archive WHERE id=276690000 AND published='1' LIMIT 1

64 (78.916549682617): 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=214 ORDER BY `ordering`

65 (61.03515625): select jos_twitters.link from jos_twitters where cat=10

66 (85.830688476562): select jos_facebook.link from jos_facebook where cat=10

67 (66.041946411133): select jos_google_plus.link from jos_google_plus where cat=10

68 (41.007995605469): select jos_linkedin.link from jos_linkedin where cat=10

69 (68.902969360352): SELECT fid FROM jos_deeppockets WHERE id=276690000 AND published='1' union SELECT fid FROM jos_deeppockets_archive WHERE id=276690000 AND published='1' LIMIT 1

70 (59.843063354492): 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=214 ORDER BY `ordering`

71 (483.98971557617): SELECT fid FROM jos_deeppockets WHERE cat=10 AND id=276690000 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

72 (408.88786315918): SELECT fid FROM jos_deeppockets_archive WHERE cat=10 AND id=276690000 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

73 (100.85105895996): 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 (82.015991210938): SELECT show_live FROM jos_com_show_setting LIMIT 1

75 (51.021575927734): SELECT show_live FROM jos_com_show_setting LIMIT 1

76 (41.007995605469): SELECT show_live FROM jos_com_show_setting LIMIT 1

77 (52.928924560547): SELECT show_live FROM jos_com_show_setting LIMIT 1

78 (55.074691772461): SELECT show_live FROM jos_com_show_setting LIMIT 1

79 (42.915344238281): SELECT show_live FROM jos_com_show_setting LIMIT 1

80 (46.014785766602): SELECT show_live FROM jos_com_show_setting LIMIT 1

81 (38.14697265625): SELECT show_live FROM jos_com_show_setting LIMIT 1

82 (38.862228393555): SELECT show_live FROM jos_com_show_setting LIMIT 1

83 (43.153762817383): SELECT show_live FROM jos_com_show_setting LIMIT 1

84 (58.889389038086): SELECT show_live FROM jos_com_show_setting LIMIT 1

85 (41.007995605469): SELECT show_live FROM jos_com_show_setting LIMIT 1

86 (51.021575927734): SELECT show_live FROM jos_com_show_setting LIMIT 1

87 (66.995620727539): SELECT show_live FROM jos_com_show_setting LIMIT 1

88 (91.075897216797): SELECT fid FROM jos_deeppockets WHERE cat=10 AND id=276690000 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

89 (53.882598876953): SELECT fid FROM jos_deeppockets_archive WHERE cat=10 AND id=276690000 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

90 (54.121017456055): 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 (90.122222900391): SELECT show_live FROM jos_com_show_setting LIMIT 1

92 (56.982040405273): SELECT show_live FROM jos_com_show_setting LIMIT 1

93 (39.100646972656): SELECT show_live FROM jos_com_show_setting LIMIT 1

94 (31.948089599609): SELECT show_live FROM jos_com_show_setting LIMIT 1

95 (30.040740966797): SELECT show_live FROM jos_com_show_setting LIMIT 1

96 (30.994415283203): SELECT show_live FROM jos_com_show_setting LIMIT 1

97 (30.040740966797): SELECT show_live FROM jos_com_show_setting LIMIT 1

98 (29.802322387695): SELECT show_live FROM jos_com_show_setting LIMIT 1

99 (29.087066650391): SELECT show_live FROM jos_com_show_setting LIMIT 1

100 (61.03515625): SELECT show_live FROM jos_com_show_setting LIMIT 1

101 (46.014785766602): SELECT show_live FROM jos_com_show_setting LIMIT 1

102 (43.869018554688): SELECT show_live FROM jos_com_show_setting LIMIT 1

103 (54.121017456055): SELECT show_live FROM jos_com_show_setting LIMIT 1

104 (42.915344238281): SELECT show_live FROM jos_com_show_setting LIMIT 1

105 (154.97207641602): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=276690000 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=276690000 AND published='1' LIMIT 1

106 (83.92333984375): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=276690000 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=276690000 AND published='1' LIMIT 1

107 (92.983245849609): 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=276690000 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

108 (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_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=276690000 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

109 (112.05673217773): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=276690000 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=276690000 AND published='1' LIMIT 1

110 (66.995620727539): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=276690000 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=276690000 AND published='1' LIMIT 1

111 (66.995620727539): 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=276690000 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

112 (742.19703674316): 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=276690000 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

113 (688.07601928711): 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 (472.06878662109): 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 (102.04315185547): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=276690000 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=276690000 AND published='1' LIMIT 1

116 (122.0703125): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=276690000 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=276690000 AND published='1' LIMIT 1

117 (52.213668823242): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=276690000 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=276690000 AND published='1' LIMIT 1

118 (41.007995605469): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=276690000 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=276690000 AND published='1' LIMIT 1

119 (84.877014160156): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=276690000 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=276690000 AND published='1' LIMIT 1

120 (51.021575927734): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=276690000 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=276690000 AND published='1' LIMIT 1

121 (47.922134399414): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=276690000 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=276690000 AND published='1' LIMIT 1

122 (39.100646972656): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=276690000 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=276690000 AND published='1' LIMIT 1

123 (387.90702819824): SELECT * FROM trending_articles WHERE `journal_id` = 10 AND `timestamp` <= NOW() + INTERVAL 7 DAY ORDER BY `order`

124 (!!!!! 24530.172348022): 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 (663.04206848145): SELECT fid FROM jos_deeppockets WHERE cat=10 AND id=276690000 AND type='deeppockets_item' AND published='1' union SELECT fid FROM jos_deeppockets_archive WHERE cat=10 AND id=276690000 AND type='deeppockets_item' AND published='1' LIMIT 1

126 (!!!!! 8885.1451873779): ( 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 (107.0499420166): ( 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 (55.789947509766): 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 (30.994415283203): 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 (97.990036010742): 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 (45.061111450195): 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 (338.07754516602): 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 (45.061111450195): 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 (33.855438232422): 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 (29.087066650391): 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 (560.99891662598): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=276690000 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

137 (404.83474731445): SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=276690000 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

138 (46.968460083008): SELECT name FROM jos_deeppockets WHERE id=214

139 (30.994415283203): SELECT name FROM jos_deeppockets WHERE id=214

140 (809.90791320801): 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 '((;)|(^))214((;)|($))' AND catid IN (0,110) ORDER BY publish_up ASC LIMIT 3

141 (726.93824768066): 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 '((;)|(^))214((;)|($))' AND catid IN (0,110) ORDER BY publish_up ASC LIMIT 3

142 (111.10305786133): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=276690000 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=276690000 AND published='1' LIMIT 1

143 (75.817108154297): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=276690000 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=276690000 AND published='1' LIMIT 1

144 (!!!!! 15892.028808594): TRUNCATE TABLE jos_trademed_module

145 (180.00602722168): 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=276690000 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

146 (86.069107055664): 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=276690000 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

147 (615.11993408203): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=276690000 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

148 (56.982040405273): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=276690000 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

149 (97.036361694336): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=276690000 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=276690000 AND published='1' LIMIT 1

150 (58.889389038086): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=276690000 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=276690000 AND published='1' LIMIT 1

151 (!!!!! 1294.1360473633): 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 (75.101852416992): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=276690000 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=276690000 AND published='1' LIMIT 1

153 (85.115432739258): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=276690000 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=276690000 AND published='1' LIMIT 1

154 (77.009201049805): SELECT fid FROM jos_deeppockets WHERE cat=10 AND id=276690000 AND type='deeppockets_item' AND published='1' union SELECT fid FROM jos_deeppockets_archive WHERE cat=10 AND id=276690000 AND type='deeppockets_item' AND published='1' LIMIT 1

155 (52.928924560547): 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=214 or channel_id is null)

156 (47.206878662109): 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=214 or channel_id is null)

157 (72.956085205078): SELECT livesite FROM jos_dp_categories WHERE id=10 AND published='1' LIMIT 1

158 (299.93057250977): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=276690000 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=276690000 AND published='1' LIMIT 1

159 (80.82389831543): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=276690000 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=276690000 AND published='1' LIMIT 1

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

161 (30.994415283203): select jos_facebook.link from jos_facebook where cat=10

162 (36.001205444336): select jos_google_plus.link from jos_google_plus where cat=10

163 (29.087066650391): select jos_linkedin.link from jos_linkedin where cat=10

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