A summary of the latest evidence-based nutrition guidelines for the prevention and management of diabetes is presented. These guidelines are based on existing recommendations last published in 2011, and were formulated by an expert panel of specialist dietitians after a literature review of recent evidence. Recommendations have been made in terms of foods rather than nutrients wherever possible. Guidelines for education and care delivery, prevention of Type 2 diabetes, glycaemic control for Type 1 and Type 2 diabetes, cardiovascular disease risk management, management of diabetes-related complications, other considerations including comorbidities, nutrition support, pregnancy and lactation, eating disorders, micronutrients, food supplements, functional foods, commercial diabetic foods and nutritive and non-nutritive sweeteners are included. The sections on pregnancy and prevention of Type 2 diabetes have been enlarged and the weight management section modified to include considerations of remission of Type 2 diabetes. A section evaluating detailed considerations in ethnic minorities has been included as a new topic. The guidelines were graded using adapted 'GRADE' methodology and, where strong evidence was lacking, grading was not allocated. These 2018 guidelines emphasize a flexible, individualized approach to diabetes management and weight loss and highlight the emerging evidence for remission of Type 2 diabetes. The full guideline document is available at www.diabetes.org.uk/nutrition-guidelines.

Background: People with cystic fibrosis (CF) report a variety of gastrointestinal (GI) symptoms, independent of pancreatic enzyme insufficiency (PEI), reminiscent of other chronic GI disorders. There are currently no accepted or validated assessment tools and neither the range, frequency nor severity of GI symptoms has been systematically described in CF. We present results of a cross-sectional study using established tools and compare them to current measures of quality of life (QOL). Methods: Consecutive patients attending specialist CF appointments were asked to complete questionnaires including the GI Symptom Rating Scale (GSRS); Irritable Bowel Syndrome Symptom Severity Score (IBS-SSS) and Cystic Fibrosis Questionnaire (CFQ-R). Questionnaire terminology was altered to replace references to 'IBS' with 'GI symptoms'. Results: In total, 107 patients were recruited (mean age, 27.8 AE 9.6 years; 60 female), and 94 (88%) had PEI. Body mass index was 22.1 AE 3.6 kg/m 2 , forced expiratory volume in one second was 59 þ 27.7% predicted. Fifty-three (49.5%) were p.Phe508del homozygous. Overall 69/107 (65%) reported significant GI symptoms independent of PEI or adherence to pancreatic enzyme replacement therapy (PERT), with the four most frequent being attributable to the lower GI tract: bloating/distension, flatulence, abdominal pain and borborygmi (gurgling). There was no numerical correlation between any CFQ-R domain (particularly Digestion domain) and GSRS or SSS. Conclusion: This is the first systematic study measuring GI symptoms in CF using validated GI tools. Symptoms are not related to PERT or genotype and appear to be captured well by the GSRS. Further research will study longitudinal changes with treatment, and therapeutic trials in CF may use these tools to demonstrate a positive impact on 'non-respiratory' symptoms and QOL.

these mechanisms may enable novel approaches to reduce intestinal toxicity. Methods Proximal SI derived enteroids from C57BL/6 wildtype mice were treated with 0-100 mM irinotecan and imaged daily for 96 hrs. Enteroid circularity (4p(area)/ perimeter 2 ) was measured as a marker of enteroid health and active caspase-3 IHC was used to assess apoptosis. Enteroids were microinjected with 1 mg/ml Texas Red and treated 30 mins post injection with 100mM irinotecan or 5 mM EGTA. Fluorescent images were taken hourly for 4 hrs. Mean pixel intensity was measured after injection. The minimum threshold was set by mean intensities of untreated, none injected enteroids. Subsequent time point mean pixel intensity was expressed as a percentage of immediate post injection intensity. Images were manually quantified to validate the method. Results Healthy enteroids maintained circularity values of 0.38±0.06. Irinotecan caused dose and time dependant increases in enteroid circularity with maximal rounding at 100 mM by 48 hrs (0.75±0.05). Dose and time-dependent increases in active caspase-3 were observed. Microinjection assays were optimised to assess very early effects of irinotecan on SI permeability. Control enteroids stabilised to 71.33 ±8.5% starting intensity at 1 hr, EGTA (positive control) dropped to 31.31±1.97% and 100 mM irinotecan reduced mean intensity to 46.04±3.71% after 30 mins. Area under the curve (AUC) for 0-4 hrs post-treatment showed statistically significant increased SI permeability for irinotecan (p<0.005) and EGTA (p<0.001). Automated and manual scoring was congruent. Conclusion Irinotecan caused a rapid onset of SI barrier dysfunction in enteroids suggesting that this precedes irinotecaninduced apoptosis and may be in part due to the disruption of TJs. Further investigation is now needed to determine whether pre-treatment with TJ stabilising drugs may ameliorate irinotecan-induced permeability and diarrhoea.

IntroductionIn April 2010, the government introduced a new Statement of Fitness to Work or ’Fit Note' for patients requiring time off of work or adaptations to their work due to illness. Responsibility to issue these documents has shifted from primary to secondary care. Hospital clinicians are required to issue for inpatients and for outpatients where clinical responsibility has not been taken over by the general practitioner (GP). However, awareness of this change is lacking. Misdirecting patients to their GP for the sole purpose of receiving a ’Fit Note' is an unnecessary use of appointment time and negatively impacts on patients. King’s College Hospital NHS Trust receives a number of quality alerts from primary care regarding this issue.MethodsA trust-wide educational initiative was designed and implemented to increase staff awareness of Fit Notes and their correct usage in order to reduce the number of patients being misdirected to their GP to obtain one. Interventions included direct staff engagement, a trust-wide promotional campaign and creation of an electronic version of the document.ResultsUptake of the electronic version of the Fit Note has steadily increased and there has been a fall in the number of quality alerts received by the trust. However, staff awareness on the whole remains low.ConclusionsPatients being misdirected to their general practice for Fit Notes is an important issue and one on which the baseline level of awareness among hospital clinicians is low. Challenges during this intervention have been in penetrating a trust of this size and getting the message across to staff. However, digitising the Fit Note can help to increase its use.

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