Cancer has overtaken cardiovascular disease as the commonest cause of death in Scottish type 2 diabetes patients: A population-based study (The Ayrshire Diabetes Follow-up Cohort study).

AIMS/INTRODUCTION: The increased mortality risk associated with diabetes is well established. The aim of the present study was to determine the causes of death of people with type 2 diabetes in Ayrshire and Arran, Scotland, between 2009 and 2014, and compare them with the national mortality rates. MATERIALS AND METHODS: The primary causes of death were collated. The causes of death were clustered into nine categories: heart disease, stroke, infection, renal failure, respiratory disorders, cancer, mental health, decompensated diabetes and other. The total rates were compared with national rates using the standardized mortality ratio (SMR), and then individually with heart disease, cerebrovascular disease and cancer. RESULTS: There were 2116 deaths with the SMR, and 145 of those were caused by type 2 diabetes (n = 16,643; 95% confidence interval 139-152; P < 0.01). The SMR was >100 in all age bands, particularly in the younger age bands (P < 0.01). The SMR was consistently higher for women (P < 0.01). The SMR for heart disease was significantly >100 for both sexes in all age bands <65 years (P < 0.05). There was no difference in mortality causes related to the duration of diabetes. The most common cause of death was cancer (27.8%), followed by heart disease (24.1%). The SMR for cancer deaths was significantly elevated in women (120, 95% CI 104-137; P < 0.05). CONCLUSIONS: This study confirmed increased mortality risk in type 2 diabetes patients, and suggests that where cardiovascular risk factors are being treated aggressively, cancer takes on a greater importance in the cause of death. Should greater consideration now be given for cancer as a complication of diabetes?

Non-functional duodenal neuroendocrine carcinoma: a rare cause of diabetes mellitus.

A 40-year-old Caucasian female presented with hyperglycaemia, polyuria, polydipsia and weight loss of 6 kg over a 1-month period. There was no personal or family history of malignancy or diabetes mellitus. On examination, she was jaundiced with pale mucous membranes and capillary glucose was 23.1 mmol/L. Initial investigations showed iron deficiency anaemia and obstructive pattern of liver function tests. HbA1c was diagnostic of diabetes mellitus at 79 mmol/mol. Malignancy was suspected and CT chest, abdomen and pelvis showed significant dilatation of intra- and extra-hepatic biliary tree including pancreatic duct, with periampullary 30 mm mass lesion projecting into lumen of duodenum. Enlarged nodes were seen around the superior mesenteric artery. This was confirmed on MRI liver. Fasting gut hormones were normal except for a mildly elevated somatostatin level. Chromogranin A was elevated at 78 pmol/L with normal chromogranin B. Duodenoscopy and biopsy showed possible tubovillous adenoma with low-grade dysplasia, but subsequent endoscopic ultrasound and biopsy revealed a grade 1, well differentiated neuroendocrine tumour. The patient was started on insulin, transfused to Hb >8 g/dL and Whipple's pancreatico-duodenectomy was undertaken. This showed a well-differentiated neuroendocrine carcinoma arising in duodenum (Grade G1 with Ki67: 0.5%), with areas of chronic pancreatitis and preservation of pancreatic islet cells. There was complete resolution of diabetes post Whipple's procedure and patient was able to come of insulin treatment. Her last HBA1C was 31 mmol/mol, 4 months post tumour resection. LEARNING POINTS: Diabetes mellitus and malignancy can be related.A high index of suspicion is needed when diabetes mellitus presents atypically.Non-functional neuroendocrine tumours can present with diabetes mellitus.

Epidemiology of antibiotic-resistant wound infections from six countries in Africa.

INTRODUCTION: Little is known about the antimicrobial susceptibility of common bacteria responsible for wound infections from many countries in sub-Saharan Africa. METHODS: We performed a retrospective review of microbial isolates collected based on clinical suspicion of wound infection between 2004 and 2016 from Mercy Ships, a non-governmental organisation operating a single mobile surgical unit in Benin, Congo, Liberia, Madagascar, Sierra Leone and Togo. Antimicrobial resistant organisms of interest were defined as methicillin-resistant Staphylococcus aureus (MRSA) or Enterobacteriaceae resistant to third-generation cephalosporins. Generalised mixed-effects models accounting for repeated isolates in a patient, potential clustering by case mix for each field service, age, gender and country were used to test the hypothesis that rates of antimicrobial resistance differed between countries. RESULTS: 3145 isolates from repeated field services in six countries were reviewed. In univariate analyses, the highest proportion of MRSA was found in Benin (34.6%) and Congo (31.9%), while the lowest proportion was found in Togo (14.3%) and Madagascar (14.5%); country remained a significant predictor in multivariate analyses (P=0.002). In univariate analyses, the highest proportion of third-generation cephalosporin-resistant Enterobacteriaceae was found in Benin (35.8%) and lowest in Togo (14.3%) and Madagascar (16.3%). Country remained a significant predictor for antimicrobial-resistant isolates in multivariate analyses (P=0.009). CONCLUSION: A significant proportion of isolates from wound cultures were resistant to first-line antimicrobials in each country. Though antimicrobial resistance isolates were not verified in a reference laboratory and these data may not be representative of all regions of the countries studied, differences in the proportion of antimicrobial-resistant isolates and resistance profiles between countries suggest site-specific surveillance should be a priority and local antimicrobial resistance profiles should be used to guide empiric antibiotic selection.