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Point-of-Care Ultrasound for Suspected Appendicitis in Children Deemed Effective Front-Line Tool

By MedImaging International staff writers
Posted on 17 Feb 2014

Image: A recent study showed portable ultrasound used as a first-line imaging tool in children with suspected appendicitis helps cut emergency room length of stay and reduces the need for computed tomography (CT) scanning (Photo courtesy of James W. Tsung, M.D / Icahn School of Medicine at Mount Sinai).

Portable ultrasound used as a first-line imaging tool in children with suspected appendicitis helps cut emergency room length of stay and reduces the need for computed tomography (CT) scanning. Bedside ultrasound, also known to as point-of-care (POC) ultrasonography, has a specificity of about 94%, according to recent research.

The study’s findings were published online February 2014 in the journal Academic Emergency Medicine. “From an institutional perspective, this is the most common surgical problem that we encounter with children in the emergency department,” said the study’s senior author, James W. Tsung, MD, MPH, associate professor of emergency medicine and pediatrics at the Icahn School of Medicine at Mount Sinai (New York, NY, USA). “CT scans have been the best imaging test for diagnosing appendicitis, but they expose children to radiation, which cumulatively can prove harmful, as increasing numbers of studies have shown.”

Several studies have reported lifetime risks of cancer from abdominal and pelvis CT scanning in children results in one cancer death for every 500 to 3,000 CT scans ordered, depending on age and sex. Efforts to try to reduce the four million radiation-emitting CT scans obtained in children annually are underway, led by front-line radiologists, physicians, and radiologic professional societies. “CT scanning rate was reduced by over 35%, from a 44% CT scan rate prior to the study to a 27% rate during the study,” commented Ee Tay, MD, assistant professor of emergency medicine and pediatrics, Icahn School of Medicine at Mount Sinai, and the study’s second author.

Investigators, in their research, used a prospective observational sample of 150 children seen consecutively between May 1, 2011 and October 1, 2012 in an urban pediatric emergency department. All children were under evaluation for suspected appendicitis. Outcomes were determined by surgical or pathology report in those found to have appendicitis and three weeks later in patients who were considered not to have appendicitis. Operator accuracy reading the ultrasound scans was reviewed in a blinded fashion by trained pediatric emergency medicine sonologists. The time to perform the POC ultrasound and CT scan use was measured.

The study’s findings revealed that emergency department length of stay decreased by two hours and 14 minutes (46% decrease) for those requiring radiology department ultrasound and almost six hours (68% decrease) for those requiring CT scanning when POC ultrasound was inconclusive as a first-line imaging study. Significantly, no instances of appendicitis were overlooked with the POC ultrasound protocol and no needless surgeries were performed for a normal appendix. Pediatric emergency clinicians, with the use of focused ultrasound training, were able to assess ultrasound exams with the similar accuracy as radiologists (approximately 94% accuracy). Dr. Tsung noted, “Surgeons are becoming more comfortable using ultrasound for decision-making and that is a big change from reliance on CT scans.”

The Mt. Sinai division of emergency ultrasound is involved with an effort to educate providers to use safer ultrasound as a faster first-line study in children.

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Icahn School of Medicine at Mount Sinai

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57 (!!!!! 2367.0196533203): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294750757 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294750757 AND published='1' LIMIT 1

58 (!!!!! 4020.9293365479): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294750757 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294750757 AND published='1' LIMIT 1

59 (!!!!! 1513.0043029785): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294750757 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294750757 AND published='1' LIMIT 1

60 (283.95652770996): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294750757 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294750757 AND published='1' LIMIT 1

61 (!!!!! 10915.994644165): 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 (888.10920715332): SELECT fid FROM jos_deeppockets WHERE id=294750757 AND published='1' union SELECT fid FROM jos_deeppockets_archive WHERE id=294750757 AND published='1' LIMIT 1

63 (986.81449890137): 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 (!!!!! 3782.0339202881): select jos_twitters.link from jos_twitters where cat=10

65 (64.13459777832): select jos_facebook.link from jos_facebook where cat=10

66 (50.783157348633): select jos_google_plus.link from jos_google_plus where cat=10

67 (43.869018554688): select jos_linkedin.link from jos_linkedin where cat=10

68 (341.89224243164): SELECT fid FROM jos_deeppockets WHERE id=294750757 AND published='1' union SELECT fid FROM jos_deeppockets_archive WHERE id=294750757 AND published='1' LIMIT 1

69 (37.908554077148): 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 (526.18980407715): SELECT fid FROM jos_deeppockets WHERE cat=10 AND id=294750757 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

71 (!!!!! 2031.0878753662): SELECT fid FROM jos_deeppockets_archive WHERE cat=10 AND id=294750757 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

72 (313.04359436035): 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 (650.16746520996): SELECT show_live FROM jos_com_show_setting LIMIT 1

74 (251.05476379395): SELECT show_live FROM jos_com_show_setting LIMIT 1

75 (246.04797363281): SELECT show_live FROM jos_com_show_setting LIMIT 1

76 (43.153762817383): SELECT show_live FROM jos_com_show_setting LIMIT 1

77 (83.92333984375): SELECT show_live FROM jos_com_show_setting LIMIT 1

78 (115.87142944336): SELECT show_live FROM jos_com_show_setting LIMIT 1

79 (78.201293945312): SELECT show_live FROM jos_com_show_setting LIMIT 1

80 (454.90264892578): SELECT show_live FROM jos_com_show_setting LIMIT 1

81 (50.067901611328): SELECT show_live FROM jos_com_show_setting LIMIT 1

82 (45.061111450195): SELECT show_live FROM jos_com_show_setting LIMIT 1

83 (46.014785766602): SELECT show_live FROM jos_com_show_setting LIMIT 1

84 (38.862228393555): SELECT show_live FROM jos_com_show_setting LIMIT 1

85 (36.954879760742): SELECT show_live FROM jos_com_show_setting LIMIT 1

86 (133.99124145508): SELECT show_live FROM jos_com_show_setting LIMIT 1

87 (!!!!! 4401.9222259521): SELECT fid FROM jos_deeppockets WHERE cat=10 AND id=294750757 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

88 (119.20928955078): SELECT fid FROM jos_deeppockets_archive WHERE cat=10 AND id=294750757 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

89 (!!!!! 3920.0782775879): 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 (69.856643676758): SELECT show_live FROM jos_com_show_setting LIMIT 1

91 (34.093856811523): SELECT show_live FROM jos_com_show_setting LIMIT 1

92 (30.994415283203): SELECT show_live FROM jos_com_show_setting LIMIT 1

93 (39.100646972656): SELECT show_live FROM jos_com_show_setting LIMIT 1

94 (39.100646972656): SELECT show_live FROM jos_com_show_setting LIMIT 1

95 (30.040740966797): SELECT show_live FROM jos_com_show_setting LIMIT 1

96 (!!!!! 2573.9669799805): SELECT show_live FROM jos_com_show_setting LIMIT 1

97 (77.009201049805): SELECT show_live FROM jos_com_show_setting LIMIT 1

98 (31.948089599609): SELECT show_live FROM jos_com_show_setting LIMIT 1

99 (29.802322387695): SELECT show_live FROM jos_com_show_setting LIMIT 1

100 (29.087066650391): SELECT show_live FROM jos_com_show_setting LIMIT 1

101 (29.087066650391): SELECT show_live FROM jos_com_show_setting LIMIT 1

102 (29.087066650391): SELECT show_live FROM jos_com_show_setting LIMIT 1

103 (28.848648071289): SELECT show_live FROM jos_com_show_setting LIMIT 1

104 (!!!!! 3314.9719238281): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294750757 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294750757 AND published='1' LIMIT 1

105 (118.01719665527): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294750757 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294750757 AND published='1' LIMIT 1

106 (59.127807617188): 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=294750757 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

107 (!!!!! 3482.8186035156): 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=294750757 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

108 (112.05673217773): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294750757 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294750757 AND published='1' LIMIT 1

109 (57.93571472168): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294750757 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294750757 AND published='1' LIMIT 1

110 (147.10426330566): 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=294750757 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

111 (647.78327941895): 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=294750757 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

112 (988.00659179688): 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 (!!!!! 2033.9488983154): 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 (118.01719665527): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294750757 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294750757 AND published='1' LIMIT 1

115 (72.002410888672): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294750757 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294750757 AND published='1' LIMIT 1

116 (56.982040405273): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294750757 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294750757 AND published='1' LIMIT 1

117 (44.107437133789): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294750757 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294750757 AND published='1' LIMIT 1

118 (57.93571472168): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294750757 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294750757 AND published='1' LIMIT 1

119 (58.889389038086): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294750757 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294750757 AND published='1' LIMIT 1

120 (57.93571472168): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294750757 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294750757 AND published='1' LIMIT 1

121 (43.153762817383): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294750757 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294750757 AND published='1' LIMIT 1

122 (408.17260742188): SELECT * FROM trending_articles WHERE `journal_id` = 10 AND `timestamp` <= NOW() + INTERVAL 7 DAY ORDER BY `order`

123 (!!!!! 51995.992660522): 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 (!!!!! 5186.0809326172): SELECT fid FROM jos_deeppockets WHERE cat=10 AND id=294750757 AND type='deeppockets_item' AND published='1' union SELECT fid FROM jos_deeppockets_archive WHERE cat=10 AND id=294750757 AND type='deeppockets_item' AND published='1' LIMIT 1

125 (!!!!! 34758.0909729): ( 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 (61.988830566406): ( 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 (656.1279296875): 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 (238.89541625977): 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 (514.98413085938): 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 (229.83551025391): 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 (!!!!! 1125.0972747803): 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 (39.815902709961): 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 (504.97055053711): 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 (44.822692871094): 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 (!!!!! 2993.106842041): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294750757 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

136 (721.93145751953): SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294750757 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

137 (427.0076751709): SELECT name FROM jos_deeppockets WHERE id=214

138 (41.961669921875): SELECT name FROM jos_deeppockets WHERE id=214

139 (607.96737670898): 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 (467.06199645996): 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 (604.86793518066): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294750757 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294750757 AND published='1' LIMIT 1

142 (74.148178100586): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294750757 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294750757 AND published='1' LIMIT 1

143 (!!!!! 17509.937286377): TRUNCATE TABLE jos_trademed_module

144 (!!!!! 11183.977127075): 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=294750757 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

145 (!!!!! 4577.8751373291): 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=294750757 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

146 (!!!!! 8270.0252532959): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294750757 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

147 (!!!!! 7291.0785675049): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294750757 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

148 (!!!!! 3926.0387420654): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294750757 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294750757 AND published='1' LIMIT 1

149 (!!!!! 1189.2318725586): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294750757 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294750757 AND published='1' LIMIT 1

150 (!!!!! 1648.1876373291): 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 (!!!!! 4994.1539764404): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294750757 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294750757 AND published='1' LIMIT 1

152 (430.10711669922): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294750757 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294750757 AND published='1' LIMIT 1

153 (!!!!! 5244.0166473389): SELECT fid FROM jos_deeppockets WHERE cat=10 AND id=294750757 AND type='deeppockets_item' AND published='1' union SELECT fid FROM jos_deeppockets_archive WHERE cat=10 AND id=294750757 AND type='deeppockets_item' AND published='1' LIMIT 1

154 (414.84832763672): 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 (!!!!! 1089.0960693359): 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 (40.054321289062): SELECT livesite FROM jos_dp_categories WHERE id=10 AND published='1' LIMIT 1

157 (!!!!! 3074.1691589355): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294750757 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294750757 AND published='1' LIMIT 1

158 (789.88075256348): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294750757 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294750757 AND published='1' LIMIT 1

159 (904.08325195312): select jos_twitters.link from jos_twitters where cat=10

160 (641.1075592041): select jos_facebook.link from jos_facebook where cat=10

161 (205.99365234375): select jos_google_plus.link from jos_google_plus where cat=10

162 (!!!!! 4339.9333953857): select jos_linkedin.link from jos_linkedin where cat=10

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