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Ultrasonic Detection of Liver Stiffness a Useful Screening and Prognostic Test

By MedImaging International staff writers
Posted on 23 Feb 2010

Researchers from France and Hong Kong determined that transient elastography (TE), a noninvasive, ultrasound imaging modality, can be accurately performed in the majority of patients with nonalcoholic fatty liver disease (NAFLD) to exclude advanced fibrosis.

The findings of this study, funded by the Chinese University of Hong Kong, appear in the February 2010 issue of the journal Hepatology. NAFLD is the most common cause of liver disease worldwide. Determining a prognosis for this condition is difficult, as there are no clear predictors of whether NAFLD will progress to nonalcoholic steatohepatitis (NASH), which can lead to cirrhosis and other complications.

Liver biopsy is the standard for diagnosing NASH and fibrosis, but this procedure can be risky and samples only a small percentage of liver tissue. According to the U.S. National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), part of the National Institutes of Health (NIH; Bethesda, MD, USA), biopsy carries a small risk of hemorrhage, puncture of other internal organs, infection, and spread of cancer cells. Transvenous liver biopsy carries an additional risk of adverse reaction to the contrast material.

To meet the urgent need for noninvasive alternatives to liver biopsy, a research team led by Victor de Lédinghen, M.D., Ph.D., from the Service d'Hépato-Gastroentérologie, Centre d' Investigation de la Fibrose hépatique, Hôpital Haut Lévesque (Bordeaux, Pessac, France), conducted an evaluation of the accuracy of TE and biochemical tests for the diagnosis of fibrosis and cirrhosis in NAFLD patients. "Transient elastography by Fibroscan is a noninvasive method for the diagnosis of liver fibrosis…Nevertheless, NAFLD patients are underrepresented in previous validation studies,” explained Dr. de Lédinghen. The team also examined liver stiffness in association with hepatic steatosis, inflammation, and obesity, and set out to identify factors associated with discordance between liver stiffness measurements (LSM) and histology.

The Fibroscan technology used in this study was developed by EchoSens (Paris, France). Using the device, a mechanical pulse is generated at the skin surface, which is propagated through the liver. The velocity of the wave is measured by ultrasound. The velocity is directly correlated to the stiffness of the liver, which in turn reflects the degree of fibrosis--the stiffer the liver is the greater the degree of fibrosis. The technique is used to quantify hepatic fibrosis in a totally noninvasive and painless manner, with no contra-indications for the patient.

The research team evaluated 246 patients from two ethnic groups from two hospitals in France and Hong Kong with valid LSM acquisitions and satisfactory liver biopsy specimens. Men who consumed more than 30 g of alcohol per week and women who consumed more than 20 g of alcohol per week were excluded. Patients with secondary causes of hepatic steatosis (e.g., chronic use of systemic corticosteroids), positive hepatitis B surface antigen or anti-hepatitis C virus antibody, or histologic evidence of other concomitant chronic liver diseases were also excluded. Since the aim of transient elastography was to diagnose significant fibrosis and early cirrhosis, patients with clinical and radiologic evidence of cirrhosis were excluded.

Researchers found that successful measurement could be obtained in over 97% of patients with BMI below 30 kg/m2 and 75% of obese patients. LSM was not affected by hepatic steatosis, necroinflammation, and obesity. Most discordance between TE and histology occurred in patients with short liver biopsy lengths and mild or no fibrosis. In addition, TE had superior performance to other noninvasive biochemical tests in diagnosing advanced fibrosis and cirrhosis.

"The adoption of transient elastography could potentially spare two-thirds of NAFLD patients from liver biopsies. Since the prevalence of NAFLD is high in many affluent countries, this approach would be cost-saving,” speculated Dr. de Lédinghen.

Dr. de Lédinghen also cautioned that while TE has a high negative predictive value, the positive predictive value of TE and other noninvasive tests to diagnose advanced fibrosis in NAFLD patients remains modest. He stated, "The main value of these tests is to exclude advanced fibrosis as screening tests. Based on our data, it is reasonable to consider liver biopsy in patients whose LSM is 7.9 kPa or above.”

Prof. Leon Adams, an associate professor at the University of Western Australia (Perth), and author of an editorial in the same issue of Hepatology, agreed, stating, "de Lédinghen et al have provided valuable data regarding the use of TE in NAFLD patients. Its strength appears to be excluding advanced fibrosis and cirrhosis; however, there are a number of issues that need to be clarified before it is routinely utilized in the clinical setting.” Prof. Adams pointed out issues in successfully conducting TE evaluations on obese patients, varying results due to diverse patient populations, and the fact that cost and availability may play a role in the decision to employ TE and other noninvasive tests in the future.

Related Links:
Chinese University of Hong Kong
Hôpital Haut Lévesque
EchoSens
University of Western Australia

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56 (457.0484161377): 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=294728129 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

57 (!!!!! 1419.0673828125): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294728129 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294728129 AND published='1' LIMIT 1

58 (!!!!! 3938.9133453369): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294728129 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294728129 AND published='1' LIMIT 1

59 (160.93254089355): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294728129 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294728129 AND published='1' LIMIT 1

60 (58.174133300781): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294728129 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294728129 AND published='1' LIMIT 1

61 (!!!!! 9544.849395752): select cover from jos_number where journalid in (5) and cover is not null order by left(issue,2)+right(issue,2)*12 desc limit 1

62 (692.12913513184): SELECT fid FROM jos_deeppockets WHERE id=294728129 AND published='1' union SELECT fid FROM jos_deeppockets_archive WHERE id=294728129 AND published='1' LIMIT 1

63 (384.09233093262): 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`

64 (!!!!! 3504.9915313721): select jos_twitters.link from jos_twitters where cat=10

65 (48.87580871582): select jos_facebook.link from jos_facebook where cat=10

66 (44.107437133789): select jos_google_plus.link from jos_google_plus where cat=10

67 (39.100646972656): select jos_linkedin.link from jos_linkedin where cat=10

68 (60.081481933594): SELECT fid FROM jos_deeppockets WHERE id=294728129 AND published='1' union SELECT fid FROM jos_deeppockets_archive WHERE id=294728129 AND published='1' LIMIT 1

69 (60.081481933594): 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`

70 (!!!!! 1392.126083374): SELECT fid FROM jos_deeppockets WHERE cat=10 AND id=294728129 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

71 (353.09791564941): SELECT fid FROM jos_deeppockets_archive WHERE cat=10 AND id=294728129 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

72 (!!!!! 1175.8804321289): SELECT id,name,title FROM jos_deeppockets WHERE cat=10 AND TYPE='file_folder' AND published=1 AND id != 294743300 AND id != 294743301 AND id != 294743302 AND id != 294743303 AND id != 294743304 AND id != 294743305 AND id != 294743306 AND id != 294743307 AND id != 294743308 AND id != 294743309 AND id != 294743310 AND metakey != 'aacc' ORDER BY `ordering`

73 (!!!!! 1763.1053924561): SELECT show_live FROM jos_com_show_setting LIMIT 1

74 (!!!!! 4761.9342803955): SELECT show_live FROM jos_com_show_setting LIMIT 1

75 (131.13021850586): SELECT show_live FROM jos_com_show_setting LIMIT 1

76 (48.160552978516): SELECT show_live FROM jos_com_show_setting LIMIT 1

77 (76.055526733398): SELECT show_live FROM jos_com_show_setting LIMIT 1

78 (48.160552978516): SELECT show_live FROM jos_com_show_setting LIMIT 1

79 (42.915344238281): SELECT show_live FROM jos_com_show_setting LIMIT 1

80 (40.054321289062): SELECT show_live FROM jos_com_show_setting LIMIT 1

81 (45.061111450195): SELECT show_live FROM jos_com_show_setting LIMIT 1

82 (43.153762817383): SELECT show_live FROM jos_com_show_setting LIMIT 1

83 (694.03648376465): SELECT show_live FROM jos_com_show_setting LIMIT 1

84 (416.04042053223): SELECT show_live FROM jos_com_show_setting LIMIT 1

85 (56.982040405273): SELECT show_live FROM jos_com_show_setting LIMIT 1

86 (37.908554077148): SELECT show_live FROM jos_com_show_setting LIMIT 1

87 (!!!!! 1929.9983978271): SELECT fid FROM jos_deeppockets WHERE cat=10 AND id=294728129 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

88 (72.002410888672): SELECT fid FROM jos_deeppockets_archive WHERE cat=10 AND id=294728129 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

89 (66.995620727539): SELECT id,name,title FROM jos_deeppockets WHERE cat=10 AND TYPE='file_folder' AND published=1 AND id != 294743300 AND id != 294743301 AND id != 294743302 AND id != 294743303 AND id != 294743304 AND id != 294743305 AND id != 294743306 AND id != 294743307 AND id != 294743308 AND id != 294743309 AND id != 294743310 AND metakey != 'aacc' ORDER BY `ordering`

90 (!!!!! 6549.8352050781): SELECT show_live FROM jos_com_show_setting LIMIT 1

91 (!!!!! 2039.909362793): SELECT show_live FROM jos_com_show_setting LIMIT 1

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 (36.954879760742): SELECT show_live FROM jos_com_show_setting LIMIT 1

95 (38.14697265625): SELECT show_live FROM jos_com_show_setting LIMIT 1

96 (41.007995605469): SELECT show_live FROM jos_com_show_setting LIMIT 1

97 (30.994415283203): SELECT show_live FROM jos_com_show_setting LIMIT 1

98 (29.087066650391): SELECT show_live FROM jos_com_show_setting LIMIT 1

99 (29.087066650391): SELECT show_live FROM jos_com_show_setting LIMIT 1

100 (29.087066650391): SELECT show_live FROM jos_com_show_setting LIMIT 1

101 (28.848648071289): SELECT show_live FROM jos_com_show_setting LIMIT 1

102 (37.908554077148): SELECT show_live FROM jos_com_show_setting LIMIT 1

103 (30.040740966797): SELECT show_live FROM jos_com_show_setting LIMIT 1

104 (796.07963562012): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294728129 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294728129 AND published='1' LIMIT 1

105 (90.122222900391): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294728129 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294728129 AND published='1' LIMIT 1

106 (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.cat=10 AND dp.id=294728129 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

107 (!!!!! 3432.9891204834): 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=294728129 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

108 (!!!!! 4459.8579406738): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294728129 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294728129 AND published='1' LIMIT 1

109 (!!!!! 2789.9742126465): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294728129 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294728129 AND published='1' LIMIT 1

110 (106.0962677002): 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=294728129 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

111 (561.95259094238): 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=294728129 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

112 (!!!!! 1022.1004486084): SELECT dp.name, dp.id, dp2.name as channel, ex.name as author_name, ex.specialization, ex.images FROM jos_deeppockets as dp LEFT JOIN jos_experts as ex ON ex.id = dp.author LEFT JOIN jos_deeppockets as dp2 ON dp2.id = dp.fid WHERE dp.author != 0 AND dp.cat = 10 AND dp.published = 1 AND ( (dp.fid = 294743300) OR (dp.fid = 294743301) OR (dp.fid = 294743302) OR (dp.fid = 294743303) OR (dp.fid = 294743304) OR (dp.fid = 294743305) OR (dp.fid = 294743306) OR (dp.fid = 294743307) OR (dp.fid = 294743308) OR (dp.fid = 294743309) OR (dp.fid = 294743310) ) ORDER BY RAND() LIMIT 1

113 (!!!!! 5903.0055999756): 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 (!!!!! 11543.989181519): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294728129 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294728129 AND published='1' LIMIT 1

115 (!!!!! 7966.0415649414): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294728129 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294728129 AND published='1' LIMIT 1

116 (!!!!! 7583.1413269043): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294728129 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294728129 AND published='1' LIMIT 1

117 (!!!!! 7944.1070556641): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294728129 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294728129 AND published='1' LIMIT 1

118 (!!!!! 7660.8657836914): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294728129 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294728129 AND published='1' LIMIT 1

119 (!!!!! 7931.9477081299): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294728129 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294728129 AND published='1' LIMIT 1

120 (!!!!! 7673.978805542): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294728129 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294728129 AND published='1' LIMIT 1

121 (!!!!! 7977.0088195801): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294728129 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294728129 AND published='1' LIMIT 1

122 (!!!!! 7036.9243621826): SELECT * FROM trending_articles WHERE `journal_id` = 10 AND `timestamp` <= NOW() + INTERVAL 7 DAY ORDER BY `order`

123 (!!!!! 135947.94273376): SELECT * FROM jos_deeppockets WHERE jos_deeppockets.cat = 10 AND jos_deeppockets.type = 'deeppockets_item' AND jos_deeppockets.published = 1 AND jos_deeppockets.created + INTERVAL 14 DAY >= NOW() ORDER BY jos_deeppockets.hits DESC LIMIT 7

124 (!!!!! 7695.9133148193): SELECT fid FROM jos_deeppockets WHERE cat=10 AND id=294728129 AND type='deeppockets_item' AND published='1' union SELECT fid FROM jos_deeppockets_archive WHERE cat=10 AND id=294728129 AND type='deeppockets_item' AND published='1' LIMIT 1

125 (!!!!! 51852.941513062): ( SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets AS dp WHERE dp.video != '' AND dp.video_source != '' AND dp.cat = 10 AND dp.published = 1 AND dp.type != 'deeppockets_item_link' ORDER BY created DESC LIMIT 3 ) UNION ( SELECT dpa.id, dpa.name, dpa.title, dpa.video, dpa.video_source, dpa.created FROM jos_deeppockets_archive AS dpa WHERE dpa.video != '' AND dpa.video_source != '' AND dpa.cat = 10 AND dpa.published = 1 AND dpa.type != 'deeppockets_item_link' ORDER BY created DESC LIMIT 3 ) ORDER BY created DESC LIMIT 3

126 (!!!!! 7973.9093780518): ( 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 (!!!!! 7823.9440917969): SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets AS dp WHERE dp.id = 294803337 LIMIT 1

128 (!!!!! 6264.9250030518): 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 (!!!!! 1508.9511871338): SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets AS dp WHERE dp.id = 294803276 LIMIT 1

130 (!!!!! 2531.0516357422): 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 (!!!!! 1461.9827270508): SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets_archive AS dp WHERE dp.id = 294803276 LIMIT 1

132 (!!!!! 3969.9077606201): 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 (282.04917907715): SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets AS dp WHERE dp.id = 294802958 LIMIT 1

134 (969.88677978516): 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 (!!!!! 9606.8382263184): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294728129 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

136 (732.8987121582): SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294728129 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

137 (442.0280456543): SELECT name FROM jos_deeppockets WHERE id=214

138 (62.942504882812): SELECT name FROM jos_deeppockets WHERE id=214

139 (907.89794921875): 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

140 (848.05488586426): 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 (!!!!! 8554.9354553223): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294728129 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294728129 AND published='1' LIMIT 1

142 (138.0443572998): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294728129 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294728129 AND published='1' LIMIT 1

143 (!!!!! 19081.115722656): TRUNCATE TABLE jos_trademed_module

144 (!!!!! 6089.2105102539): 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=294728129 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

145 (946.044921875): 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=294728129 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

146 (!!!!! 3381.9675445557): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294728129 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

147 (163.07830810547): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294728129 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

148 (144.00482177734): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294728129 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294728129 AND published='1' LIMIT 1

149 (116.10984802246): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294728129 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294728129 AND published='1' LIMIT 1

150 (!!!!! 4609.1079711914): SELECT jos_item.* FROM jos_item INNER JOIN jos_number ON jos_item.numberID=jos_number.id WHERE 1=1 AND (jos_item.imgMini<>'') AND jos_item.type='L' AND jos_item.numberID= ( SELECT jos_number.id FROM jos_number WHERE jos_number.journalID IN (10) and jos_number.id in (select distinct jos_number.id from jos_number join jos_item on jos_item.numberid=jos_number.id where jos_item.type='P') ORDER BY (CONVERT(SUBSTRING(issue,1,2),SIGNED) + (CONVERT(SUBSTRING(issue,3,2),SIGNED)*100)) DESC LIMIT 0,1 ) ORDER BY RAND() DESC LIMIT 6

151 (!!!!! 1045.9423065186): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294728129 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294728129 AND published='1' LIMIT 1

152 (787.97340393066): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294728129 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294728129 AND published='1' LIMIT 1

153 (!!!!! 2551.794052124): SELECT fid FROM jos_deeppockets WHERE cat=10 AND id=294728129 AND type='deeppockets_item' AND published='1' union SELECT fid FROM jos_deeppockets_archive WHERE cat=10 AND id=294728129 AND type='deeppockets_item' AND published='1' LIMIT 1

154 (359.05838012695): 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)

155 (!!!!! 3425.121307373): 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 (!!!!! 3732.9196929932): SELECT livesite FROM jos_dp_categories WHERE id=10 AND published='1' LIMIT 1

157 (252.96211242676): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294728129 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294728129 AND published='1' LIMIT 1

158 (141.14379882812): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294728129 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294728129 AND published='1' LIMIT 1

159 (94.890594482422): select jos_twitters.link from jos_twitters where cat=10

160 (40.054321289062): select jos_facebook.link from jos_facebook where cat=10

161 (38.14697265625): select jos_google_plus.link from jos_google_plus where cat=10

162 (35.04753112793): select jos_linkedin.link from jos_linkedin where cat=10

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