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ObjectiveTo determine the feasibility of a definitive trial in primary care of electronic clinical decision support (eCDS) for possible oesophago-gastric (O-G) cancer.Design and settingFeasibility study in 42 general practices in two regions of England, cluster randomised controlled trial design without blinding, nested qualitative and health economic evaluation.ParticipantsPatients aged 55 years or older, presenting to their general practitioner (GP) with symptoms associated with O-G cancer. 530 patients (mean age 68 years, 58% female) participated.InterventionPractices randomised 1:1 to usual care (control) or to receive a previously piloted eCDS tool for suspected cancer (intervention), for use at the discretion of the GPs, supported by a theory-based implementation package and ongoing support. We conducted semistructured interviews with GPs in intervention practices. Recruitment lasted 22 months.OutcomesPatient participation rate, use of eCDS, referrals and route to diagnosis, O-G cancer diagnoses; acceptability to GPs; cost-effectiveness. Participants followed up 6 months after index encounter.ResultsFrom control and intervention practices, we screened 3841 and 1303 patients, respectively; 1189 and 434 were eligible, 392 and 138 consented to participate. Ten patients (1.9%) had O-G cancer. eCDS was used eight times in total by five unique users. GPs experienced interoperability problems between the eCDS tool and their clinical system and also found it did not fit with their workflow. Unexpected restrictions on software installation caused major problems with implementation.ConclusionsThe conduct of this study was hampered by technical limitations not evident during an earlier pilot of the eCDS tool, and by regulatory controls on software installation introduced by primary care trusts early in the study. This eCDS tool needed to integrate better with clinical workflow; even then, its use for suspected cancer may be infrequent. Any definitive trial of eCDS for cancer diagnosis should only proceed after addressing these constraints.Trial registration numberISRCTN125595588.

Update to this article In October 2022, three years after the initial publication of this guideline, the first trial of the effect of colonoscopy screening was published. The implications of this new evidence for the current recommendations were evaluated by the guideline panel in January 2023. The guideline panel judged that this new evidence did not alter the current recommendations, and therefore that an update of the following guideline was not needed (see table 2 for details). Clinical question Recent 15-year updates of sigmoidoscopy screening trials provide new evidence on the effectiveness of colorectal cancer screening. Prompted by the new evidence, we asked: “Does colorectal cancer screening make an important difference to health outcomes in individuals initiating screening at age 50 to 79? And which screening option is best?” Current practice Numerous guidelines recommend screening, but vary on recommended test, age and screening frequency. This guideline looks at the evidence and makes recommendations on screening for four screening options: faecal immunochemical test (FIT) every year, FIT every two years, a single sigmoidoscopy, or a single colonoscopy. Recommendations These recommendations apply to adults aged 50-79 years with no prior screening, no symptoms of colorectal cancer, and a life expectancy of at least 15 years. For individuals with an estimated 15-year colorectal cancer risk below 3%, we suggest no screening (weak recommendation). For individuals with an estimated 15-year risk above 3%, we suggest screening with one of the four screening options: FIT every year, FIT every two years, a single sigmoidoscopy, or a single colonoscopy (weak recommendation). With our guidance we publish the linked research, a graphic of the absolute harms and benefits, a clear description of how we reached our value judgments, and linked decision aids. How this guideline was created A guideline panel including patients, clinicians, content experts and methodologists produced these recommendations using GRADE and in adherence with standards for trustworthy guidelines. A linked systematic review of colorectal cancer screening trials and microsimulation modelling were performed to inform the panel of 15-year screening benefits and harms. The panel also reviewed each screening option’s practical issues and burdens. Based on their own experience, the panel estimated the magnitude of benefit typical members of the population would value to opt for screening and used the benefit thresholds to inform their recommendations. The evidence Overall there was substantial uncertainty (low certainty evidence) regarding the 15-year benefits, burdens, and harms of screening. Best estimates suggested that all four screening options resulted in similar colorectal cancer mortality reductions. FIT every two years may have little or no effect on cancer incidence over 15 years, while FIT every year, sigmoidoscopy, and colonoscopy may reduce cancer incidence, although for FIT the incidence reduction is small compared with sigmoidoscopy and colonoscopy. Screening related serious gastrointestinal and cardiovascular adverse events are rare. The magnitude of the benefits is dependent on the individual risk, while harms and burdens are less strongly associated with cancer risk. Understanding the recommendation Based on benefits, harms, and burdens of screening, the panel inferred that most informed individuals with a 15-year risk of colorectal cancer of 3% or higher are likely to choose screening, and most individuals with a risk of below 3% are likely to decline screening. Given varying values and preferences, optimal care will require shared decision making.

Aims Distinguishing the rare child presenting with new onset type 1 diabetes (T1D) from the large number with similar symptoms and minor undifferentiated illness is challenging for both primary care physicians and families. This study analyses free text responses from a questionnaire completed by parents of children recently diagnosed with T1D to explore the parents’ perspectives of the pathway to diagnosis of T1D in children. Methods A questionnaire about the pathway from first symptom (s) to diagnosis was completed by the parent (s)/guardian (s) of children aged 1 month to 16 years diagnosed with T1D within the previous three months in the East of England. The free text questions asked what they felt symptoms were due to, what factors contributed to their decision to seek medical advice and whether they felt there was anything that delayed reaching the diagnosis. Responses were grouped into similar categories and coded. Results 88/164 (54%) of invited families returned the questionnaire. The time from symptom onset to diagnosis ranged from 2 to 315 days (median 25 days). Most of this was the appraisal interval from symptom onset until perceiving the need to seek medical advice (median 25 days (interquartile range 14–50)). Most parents found alternative explanations for their child’s symptoms (Table 1). For example, polydipsia was attributed most commonly to hot weather (19/58, 33%) or infection (13/58, 22%), polyuria and nocturia were frequently explained by drinking more (29/47, 62% and 26/40, 65%) and tiredness was thought to be school related (12/44, 27%) or secondary to infection (5/44, 12%) or nocturia (4/44, 10%). Worsening or persistent symptoms was the most common reason parents mentioned for seeking medical help (n = 20) and their main concern at presentation was most commonly polydipsia (n = 40), followed by polyuria (n = 24). Finding alternative explanations for symptoms (n = 24) was the most common reason cited by parents for prolonging the time before diagnosis. Conclusions The appraisal interval for T1D is complex for parents. Most parents find reasonable alternative explanations for their child’s symptoms, which contributes to the time to diagnosis. Future interventions should recognise these difficulties and will need to include more than just a list of symptoms.

Aims Children are referred to paediatric secondary care by general practitioners (GPs) for numerous reasons. Cardiac complaints such as heart murmurs are common, and children with murmurs are referred for assessment which may include echocardiography. Given the increasing pressure to reduce referrals across all specialties, this study reviewed outcomes of GP referrals to a paediatrician with expertise in cardiology (PEC) to evaluate the use of echocardiography and provide guidance for GPs. Methods We retrospectively reviewed electronic hospital records of children under 16 years old newly referred by NHS GPs to a local PEC clinic during 2011. We excluded children previously seen by any cardiology service. Results Two hundred and seventy one children were referred, 165 (60%) were referred for investigation of a murmur: 137 for an asymptomatic murmur alone and 28 for a murmur plus either symptoms or family history of cardiac disease. All underwent echocardiography. 31 (19%) were diagnosed with congenital heart disease (CHD) of which 7 have required catheter or surgical intervention (4% of the new GP referrals for assessment of a murmur). Younger children with murmurs were more likely to have CHD: 9/24 (37.5%) children under 3 months, 9/39 (23%) children between 3 months and one year, 10/58 (17%) children between 1–5 years, 1/14 (7%) between 5–10 years and none over 10 years. Forty nine children (18%) were referred for a family history of cardiac problems (e.g. CHD, cardiomyopathy) with 1 child having CHD that has not needed intervention. Other complaints included chest pain (8), palpitations (19), cyanosis (4) and syncope/dizziness (9). None of these other presenting complaints had any underlying pathology. Conclusion The finding that a large proportion of children referred by GPs with asymptomatic heart murmurs have CHD supports current GP referral practise and the use of echocardiography for assessing murmurs. Children with a murmur under 3 months of age have the highest risk of CHD. In this review other presenting complaints do not seem to have any associated life-threatening heart disease – these children might initially be safely managed in the community without echocardiography.

Objective To explore the pathway to diagnosis of type 1 diabetes (T1D) in children from the perspective of the child, family and general practitioner (GP). Design Qualitative interview study. Participants Parents of children aged 1 month to 16 years diagnosed with new onset T1D within the previous 3 months, children over 6 years diagnosed with new onset T1D within the previous 3 months and GPs who saw those children prior to diagnosis. Setting Children and parents were identified and recruited from two hospitals within the East of England. Results The parents of 16 children (2–16 years) were interviewed. The total interval from onset of symptoms to diagnosis ranged from 6 to 127 days. The appraisal interval was the longest for almost all children and the diagnostic interval the shortest. Even with some knowledge of T1D, it took many parents several weeks of a complex cyclical and iterative decision-making process and often a physical trigger, such as weight loss, to decide to consult a healthcare professional. By that stage, many had already made or suspected the diagnosis of T1D themselves. Five GPs were interviewed. They felt that the main challenges to diagnosing T1D in children were the rarity of the condition coupled with how well most of the children appeared, and the difficulty in obtaining urine or blood samples from children. Conclusions This study highlights the difficulties for parents and GPs in recognising the early symptoms of T1D. It suggests that future interventions should be targeted at parents in the appraisal interval and include the importance of timely presentation to a healthcare professional and the differences between types 1 and 2 diabetes. Primary care physicians should also take parental concerns seriously and do urine dipstick tests during the consultation for children with symptoms of T1D.

OBJECTIVE: To identify the factors associated with diabetic ketoacidosis at diagnosis of type 1 diabetes in children and young adults. DESIGN: Systematic review. DATA SOURCES: PubMed, EMBASE, Web of Science, Scopus, and Cinahl and article reference lists. STUDY SELECTION: Cohort studies including unselected groups of children and young adults presenting with new onset type 1 diabetes that distinguished between those who presented in diabetic ketoacidosis and those who did not and included a measurement of either pH or bicarbonate in the definition of diabetic ketoacidosis. There were no restrictions on language of publication. RESULTS: 46 studies involving more than 24,000 children in 31 countries were included. Together they compared 23 different factors. Factors associated with increased risk were younger age (for