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Using Portable Ultrasound to Identify Possible Heart Attacks and Strokes Before Symptoms Arise

By MedImaging International staff writers
Posted on 19 Jan 2015

A study of portable ultrasound performed in the United States, Canada, and India has revealed the potential of this technology for identifying plaques in peripheral arteries that can lead to heart attacks and stroke before symptoms occur, in both developed and developing country environments, allowing preventive treatment in those affected. More...

The study, published December 2014 in Global Heart, the journal of the World Heart Federation, was conducted by Dr. Ram Bedi, affiliate assistant professor, department of bioengineering, University of Washington (Seattle, WA, USA), and Prof. Jagat Narula, editor-in-chief of Global Heart and Icahn School of Medicine at Mount Sinai (New York, NY, USA), and colleagues.

Many research studies have shown that it is possible to evaluate subclinical atherosclerotic cardiovascular disease (ASCVD) using ultrasound imaging. Because more portable and lower cost ultrasound devices are now available, combined with increased automation and enhancements, it may be possible in the near future to typically examine people with ultrasound to establish any ASCVD present before symptoms arise, so that future disease can be prevented, for example using medication. In this study, ASCVD was determined using ultrasound of both the carotid arteries and the ileofemoral arteries. The findings were summarized in an easy to understand index called the Fuster-Narula (FUN) Score.

Data were gathered from four cohorts, two Indian and two North American. In India, a medical camp setting was used, and screening with automated ultrasound imaging was conducted over eight days in 941 comparatively young (mean age 44 years, 34% female) asymptomatic volunteers recruited from the semi-urban town of Sirsa (Haryana) and urban city of Jaipur (Rajasthan) in northern India. The cohort from Sirsa was specifically recruited because all participants had already undergone aggressive lifestyle changes (smoking cessation, no alcohol, vegetarian diet, physically active lifestyles, daily meditation), radiology resident physicians who had no earlier training in vascular ultrasound were trained right on the spot to perform the ultrasound examinations.

To compare the imaging findings with traditional risk factors, two cohorts (481 persons) were recruited from primary care clinics in North America (one in Richmond, TX, USA, the other in Toronto, Canada). As well as the same ultrasound examinations given in the Indian cohort, comprehensive ASCVD risk factor information collected from these participants, all of whom were self-referred asymptomatic individuals (mean age 60 years, 39% female). Data collected included cholesterol levels, blood pressure, glucose level, weight, height, smoking and family history. These people were attending clinics for routine health examinations in most cases. Effectiveness of established ASCVD prevention guidelines was then compared to findings from direct imaging; ultrasound was performed by trained experts at each center.

In India, ultrasound revealed plaques in at least one artery in almost a quarter (24%) of those examined; 107 (11%) had plaques in only the carotids, 70 (7%) in both the carotids and iliofemoral arteries, and 47 (5%) had plaques in only the iliofemoral arteries. If just the carotids had been examined, 177 (19%) of the asymptomatic individuals would have been identified with plaques; by adding the iliofemoral examination, 47 additional individuals (5% of the total) were identified with plaque. Older age and male sex were associated with the presence of plaque both in urban and semi-urban populations (the much higher levels of smoking in men could account for their higher risk).

Data from the American and Canadian clinics showed that 203 subjects (42%) had carotid plaque; 166 of these (82% of those with plaque) would not have qualified for lipid-lowering therapy such as statins under the most widely used guidelines known as ATP III (Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults [Adult Treatment Panel]) guidelines. Using the recently published, more rigid ATP IV guidelines, 67 people (one-third of those with plaque and 14% of the total US/Canadian cohort) individuals with carotid plaque would also have failed to qualify for treatment.

Furthermore, the study revealed 34 individuals in the United States and Canada who qualified for treatment under ATP III but did not have any plaques, and this number increased to 81 under ATP IV (if receiving treatment such as statins, these people could be said to be overtreated, since no plaques were seen).

The investigators reported, “Our study shows that automation in ultrasound imaging technology allows even non-expert users to rapidly evaluate the presence of subclinical atherosclerosis in a large population. Detection of subclinical atherosclerosis is further enhanced by inclusion of the iliofemoral artery examination. It seems that plaque information from ultrasound images may serve as a guide for initiating medical intervention regardless of the availability or knowledge of traditional risk factors. Our results further suggest that not only in low- and middle-income countries, but even in the developed nations, ultrasound images may help refine strategies for medical intervention. It might however still be too contentious to suggest that risk factors-positive and imaging-negative asymptomatic subjects may be spared from medical intervention. Conversely, arguments against initiating medical intervention on risk factors-negative and imaging-positive asymptomatic subjects become harder to justify.”

In a linked comment published with this article, Dr. Tasneem Z. Naqvi, professor of medicine at the Mayo College of Medicine and division of cardiology (Scottsdale, AZ, USA), added, “This study shows that the assessment of subclinical atherosclerosis by a portable, user-friendly bedside tool is feasible in large populations and the technique of carotid ultrasound imaging and IMT assessment could be adopted by novices after an eight-hour crash course. The study by Bedi et al puts into perspective the weakness of risk factor-based approach to identify individuals with subclinical atherosclerosis who are more likely to develop future cardiovascular events. The study shows that the vascular ultrasound imaging technology is ripe and that the previously existing barriers such as poor resolution, cumbersome protocols, need for off line processing and need for expert performer no longer exist. The question that this study does not address—and perhaps no study in future might—is whether this imaging based approach would save more lives than the risk-based approach. We need to ponder if treating nearly 50% of the adults with statins with a risk scoring algorithm [as happens in the United States] is more appropriate versus treating only those who have subclinical atherosclerosis based on comprehensive and readily available, cheap and simple screening method. This study makes a compelling argument in favor of imaging for screening.”

In an additional comment, Prof. Paul Leeson, a member of the Imaging Enhancement Expert Working Group for UK Biobank (with specific responsibility for the vascular imaging component), professor of cardiovascular medicine at the University of Oxford and Clinical director of the Oxford Cardiovascular Clinical Research Facility (UK), and not connected to the study or the journal, stated, “Ultrasound seems to be firmly establishing itself as the advanced imaging technology of choice for global health care issues. Current ultrasound scanners generate accurate cardiovascular measures safely, rapidly, and relatively inexpensively. This paper nicely demonstrates how people with little imaging experience can undergo a short training program and then use portable ultrasound systems in a wide variety of global healthcare settings. The fact this imaging technology can be applied to large populations has also made it an attractive option for many of the major biobank research projects, such as UK Biobank. These projects are planned to generate vascular images for hundreds of thousands of individuals in different countries that, over the next few years, can be used to determine the true value of vascular imaging for disease prediction.”

Related Links:
University of Washington
Icahn School of Medicine at Mount Sinai

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46 (88.930130004883): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294756739 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294756739 AND published='1' LIMIT 1

47 (726.93824768066): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294756739 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294756739 AND published='1' LIMIT 1

48 (77.009201049805): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294756739 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294756739 AND published='1' LIMIT 1

49 (787.97340393066): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294756739 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294756739 AND published='1' LIMIT 1

50 (77.962875366211): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294756739 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294756739 AND published='1' LIMIT 1

51 (!!!!! 5846.9772338867): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294756739 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294756739 AND published='1' LIMIT 1

52 (111.10305786133): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294756739 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294756739 AND published='1' LIMIT 1

53 (!!!!! 1188.0397796631): SELECT name FROM jos_deeppockets WHERE id=294756739 LIMIT 1

54 (890.01655578613): SELECT name FROM jos_deeppockets_archive WHERE id=294756739 LIMIT 1

55 (94.890594482422): SELECT a.* FROM jos_components AS a WHERE ( a.admin_menu_link = 'option=com_syndicate' OR a.admin_menu_link = 'option=com_syndicate&hidemainmenu=1' ) AND a.option = 'com_syndicate'

56 (173.09188842773): 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=294756739 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

57 (!!!!! 1063.1084442139): 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=294756739 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

58 (!!!!! 3021.0018157959): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294756739 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294756739 AND published='1' LIMIT 1

59 (93.221664428711): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294756739 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294756739 AND published='1' LIMIT 1

60 (988.96026611328): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294756739 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294756739 AND published='1' LIMIT 1

61 (100.85105895996): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294756739 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294756739 AND published='1' LIMIT 1

62 (118.01719665527): 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 (574.11193847656): SELECT fid FROM jos_deeppockets WHERE id=294756739 AND published='1' union SELECT fid FROM jos_deeppockets_archive WHERE id=294756739 AND published='1' LIMIT 1

64 (120.87821960449): 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 (!!!!! 1217.8421020508): select jos_twitters.link from jos_twitters where cat=10

66 (51.021575927734): select jos_facebook.link from jos_facebook where cat=10

67 (32.901763916016): select jos_google_plus.link from jos_google_plus where cat=10

68 (29.802322387695): select jos_linkedin.link from jos_linkedin where cat=10

69 (35.04753112793): SELECT fid FROM jos_deeppockets WHERE id=294756739 AND published='1' union SELECT fid FROM jos_deeppockets_archive WHERE id=294756739 AND published='1' LIMIT 1

70 (35.04753112793): 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 (!!!!! 2916.0976409912): SELECT fid FROM jos_deeppockets WHERE cat=10 AND id=294756739 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

72 (!!!!! 3439.9032592773): SELECT fid FROM jos_deeppockets_archive WHERE cat=10 AND id=294756739 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

73 (55.789947509766): 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 (56.028366088867): SELECT show_live FROM jos_com_show_setting LIMIT 1

75 (30.994415283203): SELECT show_live FROM jos_com_show_setting LIMIT 1

76 (29.087066650391): SELECT show_live FROM jos_com_show_setting LIMIT 1

77 (27.894973754883): SELECT show_live FROM jos_com_show_setting LIMIT 1

78 (28.133392333984): SELECT show_live FROM jos_com_show_setting LIMIT 1

79 (27.179718017578): SELECT show_live FROM jos_com_show_setting LIMIT 1

80 (27.894973754883): SELECT show_live FROM jos_com_show_setting LIMIT 1

81 (34.093856811523): SELECT show_live FROM jos_com_show_setting LIMIT 1

82 (28.848648071289): SELECT show_live FROM jos_com_show_setting LIMIT 1

83 (27.894973754883): SELECT show_live FROM jos_com_show_setting LIMIT 1

84 (34.093856811523): SELECT show_live FROM jos_com_show_setting LIMIT 1

85 (30.040740966797): SELECT show_live FROM jos_com_show_setting LIMIT 1

86 (30.040740966797): SELECT show_live FROM jos_com_show_setting LIMIT 1

87 (30.040740966797): SELECT show_live FROM jos_com_show_setting LIMIT 1

88 (56.982040405273): SELECT fid FROM jos_deeppockets WHERE cat=10 AND id=294756739 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

89 (30.994415283203): SELECT fid FROM jos_deeppockets_archive WHERE cat=10 AND id=294756739 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

90 (35.04753112793): 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 (51.021575927734): SELECT show_live FROM jos_com_show_setting LIMIT 1

92 (30.040740966797): SELECT show_live FROM jos_com_show_setting LIMIT 1

93 (28.133392333984): SELECT show_live FROM jos_com_show_setting LIMIT 1

94 (28.133392333984): SELECT show_live FROM jos_com_show_setting LIMIT 1

95 (27.894973754883): SELECT show_live FROM jos_com_show_setting LIMIT 1

96 (27.894973754883): SELECT show_live FROM jos_com_show_setting LIMIT 1

97 (28.133392333984): SELECT show_live FROM jos_com_show_setting LIMIT 1

98 (45.061111450195): SELECT show_live FROM jos_com_show_setting LIMIT 1

99 (53.882598876953): SELECT show_live FROM jos_com_show_setting LIMIT 1

100 (29.087066650391): SELECT show_live FROM jos_com_show_setting LIMIT 1

101 (40.054321289062): SELECT show_live FROM jos_com_show_setting LIMIT 1

102 (29.087066650391): SELECT show_live FROM jos_com_show_setting LIMIT 1

103 (27.894973754883): SELECT show_live FROM jos_com_show_setting LIMIT 1

104 (27.894973754883): SELECT show_live FROM jos_com_show_setting LIMIT 1

105 (77.962875366211): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294756739 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294756739 AND published='1' LIMIT 1

106 (46.014785766602): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294756739 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294756739 AND published='1' LIMIT 1

107 (69.856643676758): 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=294756739 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

108 (51.021575927734): 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=294756739 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

109 (72.002410888672): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294756739 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294756739 AND published='1' LIMIT 1

110 (45.061111450195): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294756739 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294756739 AND published='1' LIMIT 1

111 (82.015991210938): 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=294756739 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

112 (510.21575927734): 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=294756739 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

113 (530.95817565918): 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 (344.99168395996): 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 (141.14379882812): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294756739 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294756739 AND published='1' LIMIT 1

116 (73.909759521484): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294756739 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294756739 AND published='1' LIMIT 1

117 (60.081481933594): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294756739 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294756739 AND published='1' LIMIT 1

118 (41.007995605469): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294756739 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294756739 AND published='1' LIMIT 1

119 (44.107437133789): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294756739 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294756739 AND published='1' LIMIT 1

120 (39.100646972656): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294756739 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294756739 AND published='1' LIMIT 1

121 (46.014785766602): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294756739 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294756739 AND published='1' LIMIT 1

122 (37.908554077148): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294756739 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294756739 AND published='1' LIMIT 1

123 (331.87866210938): SELECT * FROM trending_articles WHERE `journal_id` = 10 AND `timestamp` <= NOW() + INTERVAL 7 DAY ORDER BY `order`

124 (!!!!! 24942.874908447): 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 (597.95379638672): SELECT fid FROM jos_deeppockets WHERE cat=10 AND id=294756739 AND type='deeppockets_item' AND published='1' union SELECT fid FROM jos_deeppockets_archive WHERE cat=10 AND id=294756739 AND type='deeppockets_item' AND published='1' LIMIT 1

126 (!!!!! 7708.0726623535): ( 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 (92.983245849609): ( 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 (39.815902709961): 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 (30.040740966797): 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 (43.153762817383): 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 (29.802322387695): 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 (373.12507629395): 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 (56.982040405273): 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 (500.20217895508): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294756739 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

137 (380.9928894043): SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294756739 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

138 (38.862228393555): SELECT name FROM jos_deeppockets WHERE id=214

139 (37.908554077148): SELECT name FROM jos_deeppockets WHERE id=214

140 (633.00132751465): 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 (534.0576171875): 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 (73.19450378418): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294756739 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294756739 AND published='1' LIMIT 1

143 (46.968460083008): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294756739 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294756739 AND published='1' LIMIT 1

144 (!!!!! 8263.8263702393): TRUNCATE TABLE jos_trademed_module

145 (102.99682617188): 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=294756739 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

146 (64.13459777832): 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=294756739 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

147 (866.88995361328): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294756739 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

148 (54.836273193359): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294756739 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

149 (61.988830566406): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294756739 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294756739 AND published='1' LIMIT 1

150 (51.021575927734): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294756739 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294756739 AND published='1' LIMIT 1

151 (!!!!! 1249.0749359131): 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 (77.009201049805): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294756739 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294756739 AND published='1' LIMIT 1

153 (47.922134399414): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294756739 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294756739 AND published='1' LIMIT 1

154 (46.968460083008): SELECT fid FROM jos_deeppockets WHERE cat=10 AND id=294756739 AND type='deeppockets_item' AND published='1' union SELECT fid FROM jos_deeppockets_archive WHERE cat=10 AND id=294756739 AND type='deeppockets_item' AND published='1' LIMIT 1

155 (36.954879760742): select distinct links.* from jos_textlinks links join jos_textlinks_placement placement on links.id=placement.link_id where journal_id=(10) and (channel_id=214 or channel_id is null)

156 (34.093856811523): 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 (46.014785766602): SELECT livesite FROM jos_dp_categories WHERE id=10 AND published='1' LIMIT 1

158 (400.06637573242): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294756739 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294756739 AND published='1' LIMIT 1

159 (61.03515625): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294756739 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294756739 AND published='1' LIMIT 1

160 (41.007995605469): select jos_twitters.link from jos_twitters where cat=10

161 (31.948089599609): select jos_facebook.link from jos_facebook where cat=10

162 (33.140182495117): select jos_google_plus.link from jos_google_plus where cat=10

163 (38.862228393555): select jos_linkedin.link from jos_linkedin where cat=10

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