Katarina Eeg-Olofsson

Aims/hypothesis: Reports from several countries suggested increased incidence of type 1 diabetes during the COVID-19 pandemic, but causality has remained unclear. We investigated incident type 1 diabetes related to SARS-CoV-2 infection and vaccination in Swedish children and adults and assessed whether vaccination modified infection-related risk. Methods: We assembled a register-based cohort of all residents aged <80 years on 1 January 2020 and births during follow-up (1 January 2020–31 December 2023). Risk windows after infection (and after each vaccine dose) were 0–30 days, 31–180 days, 181–365 days, and 1–2 years. Incident type 1 diabetes was defined by the earliest ICD-10 diagnosis E10 in the National Diabetes Register or in the National Patient Register. Cox regression with calendar time as the timescale was used with time-varying exposures; analyses were stratified by age (children 0.5). When vaccination was investigated as the exposure, children showed lower HRs (0.77; 0.67, 0.88) within 2 years, but this association was not observed in ages 12–17 (1.00; 0.80, 1.26); adults showed a small excess risk within 0–30 days after dose 1 (1.32; 1.07, 1.62), but not in later windows or doses. Conclusions/interpretation: Short-term elevations in incident type 1 diabetes diagnoses were observed in the first 30 days after infection and after first vaccination, and did not persist, supporting detection/diagnostic acceleration rather than a sustained causal effect of SARS-CoV-2 infection or vaccination on type 1 diabetes.

Background: Trigger finger surgery typically has a successful outcome, also in patients with diabetes mellitus (DM). However, the impact of glycemic control on long-term outcomes after open trigger finger release (OTFR) remains unclear. This study examines whether high hemoglobin A 1c ( HbA 1c) levels affect patient-reported outcome (PRO) following OTFR in individuals with type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM). Methods: Data from 2010 to 2020 were sourced from the Swedish national quality register for hand surgery (HAKIR) and cross-linked with the Swedish National Diabetes Register. Adults ≥18 years undergoing OTFR were included. Patient-reported outcomes were assessed using the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) and HAKIR Questionnaire-8 (HQ-8) questionnaires (evaluating stiffness, pain, and satisfaction) preoperatively and at 3 and 12 months postsurgery. Participants were stratified into tertiles based on mean HbA 1c : “optimal control” (≤48 mmol/mol), “acceptable control” (48.1-64 mmol/mol), and “poor control” (>64 mmol/mol). Linear mixed model regression, adjusted for sex, age, DM duration, smoking, mean arterial pressure, body mass index, and physical activity, analyzed outcomes over time, using “acceptable control” group as reference. To adjust for multiple comparisons, a Bonferroni correction was used. Results: In total, 496 individuals with T1DM and 869 individuals with T2DM underwent OTFR and were registered in HAKIR. Of these, 53% (n = 710) answered at least 1 questionnaire. There was no difference in QuickDASH nor the studied HQ-8 between the different HbA 1c groups at 12 months, neither in individuals with T1DM nor T2DM. Conclusion: Poor glycemic control was not associated with worse PRO 12 months after OTFR. Thus, for long-term outcome, preoperative HbA 1c testing does not seem to be necessary.

Aims/hypothesis: Type 1 diabetes develops gradually, and previous exposures may influence incidence. We aimed to assess the geographical variation in type 1 diabetes incidence in Sweden by considering all residential locations from birth to diagnosis in individuals aged 0–30 years, diagnosed between 2005 and 2022. Significant high- and low-risk clusters were identified for different life stage exposure windows. Methods: In 21,774 individuals with type 1 diabetes, all residential geographical locations from birth to diagnosis were geocoded. Geostatistical analysis of the incidence of type 1 diabetes was conducted at the municipality level using the most common residential location during four life stage-specific exposure windows (at diagnosis, the first 5 years after birth, 5 years prior to diagnosis, and from birth to diagnosis). Spatial scan statistics were used to identify statistically significant high- and low-risk clusters for each window. Land use and land cover within these clusters were also characterised. Results: Significant geographical variation in the incidence of type 1 diabetes was observed. The incidence was consistently higher in rural, low-population-density areas, particularly in central Sweden, and lower in major urban areas. The largest number of spatial clusters of both high risk (RR 1.29–16.0) and low risk (RR 0.32–0.73) was identified when using the most common residential location during the first 5 years after birth. High-risk clusters for this exposure window were characterised by forested and agricultural land, while low-risk clusters were characterised by urban land and open land other than agricultural land. Conclusions/interpretation: Our findings suggest that the development of type 1 diabetes in Sweden varies geographically and is associated with specific features of the local surroundings in early childhood. This is important knowledge as a basis for identifying possible environmental risk factors and the relationship with risk of type 1 diabetes in future studies. Graphical

Aims/hypothesis: It has been proposed that severe hypoglycaemia events (SHE) may increase the risk of adverse CVD complications in adults with type 1 diabetes. The aim of this study was to evaluate the risk of CVD complications following SHE in a large cohort of adults with type 1 diabetes, and to compare the risk of post-SHE CVD complications for users of intermittently scanned continuous glucose monitoring (isCGM) vs users of blood glucose monitoring (BGM). Methods: This comparative retrospective cohort study used data from the Swedish National Diabetes Register and the Swedish National Patient Register. We identified people with type 1 diabetes who had a hospitalisation for CVD complications. Rates of hospitalisation were compared between those with an index SHE and those without, and within isCGM or BGM subgroups. The study baseline was date of the first SHE prior to the isCGM index date. Results: We identified 14,829 adults with type 1 diabetes with up to 2 years of follow-up, of which 1313 had an index SHE. In the full cohort, the relative rate of hospitalisations for CVD complications was 2.06-fold (95% CI 1.48, 2.85) in those with prior SHE. Of these 1313 participants with prior SHE, 970 were using isCGM and 343 were using BGM. Hospitalisations for post-SHE CVD complications were significantly lower for isCGM users (5.40 per 100 person-years of follow-up; 95% CI 4.59, 6.31) compared with BGM control participants (14.23 per 100 person-years of follow-up; 95% CI 11.95, 16.82), which represents a 78% relative reduction in rates of post-SHE CVD complications for isCGM users (relative rate 0.22; 95% CI 0.11, 0.43; p<0.001), after adjustment for confounders. Conclusions/interpretation: In adults with type 1 diabetes, SHE is associated with an increased risk of hospitalisation for adverse CVD complications. This risk is significantly reduced in isCGM users compared with BGM control participants. Graphical

Introduction To assess the prevalence of diabetic retinopathy (DR) in persons with newly diagnosed type 2 diabetes (T2D) to understand the potential need for intensified screening for early detection of T2D. Research design and methods Individuals from the Swedish National Diabetes Registry with a retinal photo Results In total, 77 681 individuals with newly diagnosed T2D, mean age 62.6 years, 41.1% females were included. Of these, 13 329 (17.2%) had DR. DR was more common in older persons (adjusted OR 1.03 per 10-year increase, 95% CI 1.01 to 1.05) and men compared with women, OR 1.10 (1.05 to 1.14). Other variables associated with DR were OR (95% CI): lower education 1.08 (1.02 to 1.14); previous stroke 1.18 (1.07 to 1.30); chronic kidney disease 1.29 (1.07 to 1.56); treatment with acetylsalicylic acid 1.14 (1.07 to 1.21); ACE inhibitors 1.12 (1.05 to 1.19); and alpha blockers 1.41 (1.15 to 1.73). DR was more common in individuals born in Asia (OR 1.16, 95% CI 1.08 to 1.25) and European countries other than those born in Sweden (OR 1.11, 95% CI 1.05 to 1.18). Conclusions Intensified focus on screening of T2D may be needed in Sweden in clinical practice since nearly one-fifth of persons have retinopathy at diagnosis of T2D. The prevalence of DR was higher in men, birthplace outside of Sweden, and those with a history of stroke, kidney disease, and hypertension.

Aim: To investigate the impact of the COVID-19-pandemic on antidiabetic drug initiation Methods: Using Swedish national health registers, an interrupted time series study for all first-time dispensed antidiabetic drugs was performed. A minimum 14-month washout period was used. We calculated monthly cumulative incidence of antidiabetic drug initiations per 1000 population and estimated trends before and after the onset of the pandemic using segmented regression analysis. Results: Among 167,889 participants between 1Mar2019 and 30Nov2021, male sex (53%), age 18-64 (55.3%), unmarried status (52.5%), upper secondary education level (46.2%), and being employed (53.5%) were the most frequent characteristics. Mar2020, there was an immediate level drop in antidiabetic drug initiation (β ₂₌ -0.087%, P=0.01); however, the trend exhibited a rapid increase thereafter. Significant immediate level drops were identified for DPP4i (−0.087%, P=0.01), GLP1a (−0.008%, P=0.01) and SGLT2i (−0.033%, P=0.003). Older people (≥65) showed the largest immediate drop for antidiabetic drug initiation (−0.272%, P=0.003). SGLT2i demonstrated an increasing pattern both before and after the pandemic while metformin did reveal an increasing pattern among patients ≥65 years old after the pandemic. Conclusion: The results identified an immediate level drop at the onset of the pandemic for any antidiabetic drug initiation, but the trend increased rapidly thereafter.

Background: The Diabetes Questionnaire is a digital patient-reported outcome and experience measure for adults living with diabetes. The Diabetes Questionnaire is intended for use in routine clinical visits in diabetes care and to enable patient perspectives to be integrated into the Swedish National Diabetes Register. The Diabetes Questionnaire was developed on the basis of patients’ perspectives, and evidence for its measurement qualities has been demonstrated. Patients receive an invitation to complete the questionnaire before clinical visits, and the patient and health care professional (HCP) can discuss the findings, which are instantly displayed during the visit. Implementation processes for new tools in routine care need to be studied to understand the influence of contextual factors, the support needed, and how patients and HCPs experience clinical use. Objective: The aim of this study was to describe patients’ and HCPs’ experiences of initiating the use of the digital Diabetes Questionnaire as a clinical tool in routine diabetes care, supported by a structured implementation strategy involving initial education, local facilitators, and regular follow-ups. Methods: In this qualitative study, semistructured focus group discussions were conducted 12 months after the use of the Diabetes Questionnaire was initiated. Participants were diabetes specialist nurses and physicians (20 participants in 4 groups) at hospital-based outpatient clinics or primary health care clinics and adults with type 1 or type 2 diabetes (15 participants in 4 groups). The audiotaped transcripts were analyzed using inductive qualitative content analysis. Results: The results revealed 2 main categories that integrated patients’ and HCPs’ experiences, which together formed an overarching theme: While implementation demands new approaches, the Diabetes Questionnaire provides a broader perspective. The first main category (The Diabetes Questionnaire supports person-centered clinical visits) comprised comments expressing that the digital Diabetes Questionnaire can initiate and encourage reflection in preparation for clinical visits, bring important topics to light during clinical visits, and broaden the scope of discussion by providing additional information. The second main category (The process of initiating the implementation of the Diabetes Questionnaire) comprised comments that described differences in engagement among HCPs and their managers, challenges of establishing new routines, experiences of support during implementation, thoughts about the Diabetes Questionnaire, need to change local administrative routines, and opportunities and concerns for continued use. Conclusions: The Diabetes Questionnaire can broaden the scope of health data in routine diabetes care. While implementation demands new approaches, patients and HCPs saw potential positive impacts of using the questionnaire at both the individual and group levels. Our results can inform further development of implementation strategies to support the clinical use of the questionnaire.

Introduction ‘The diabetic hand’ has traditionally referred to hand complications due to diabetes mellitus (DM), including trigger finger (TF) and Dupuytren’s disease (DD). Recent publications have also proposed DM as a risk factor for carpal tunnel syndrome (CTS), ulnar nerve entrapment (UNE), and possibly osteoarthritis (OA) of the first carpometacarpal (CMC-1) joint. This study aimed to explore prevalence and incidence of diabetic hand complications among the population in southern Sweden. Research design and methods Approximately 1.1 million inhabitants in the region of Skåne aged ≥18 years, whereof 50 000 with DM, were included. Data on incident CTS, UNE, TF, DD, and OA of the CMC-1 joint between 2004 and 2019 were collected from the Skåne Healthcare Register and cross-linked with the National Diabetes Register. Prevalences on December 31, 2019 and 10-year incidence ratios were calculated for type 1 diabetes (T1D), type 2 diabetes (T2D), and the population without DM, stratified for sex. Prevalence ratios and incidence rate ratios with 95% CIs were used for group comparisons. Results The prevalences of all five studied diagnoses were higher in both men and women with T1D and T2D (pConclusions CTS, UNE, and possibly also OA of the CMC-1 joint should be included together with TF and DD when referring to ‘the diabetic hand’. The incidence of hand disorders was up to eight times higher among T1D, and both T1D and T2D had more concomitant prevalent diagnoses compared with the population without DM. Future studies should elucidate the pathophysiology behind diabetic hand complications to enable development of effective preventive measures in patients with diabetes.

Aims: This study assessed hemoglobin A1c (HbA1c) across the lifespan in people with type 1 diabetes (T1D) in Germany/Austria, Sweden, and the United States between 2011 and 2017 to ascertain temporal and age-related trends. Methods: Data from the Diabetes-Patienten-Verlaufsdokumentation (DPV) ( n = 25,651 in 2011, n = 29,442 in 2017); Swedish Pediatric Diabetes Quality Registry (SWEDIABKIDS)/National Diabetes Register (NDR), ( n = 44,474 in 2011, n = 53,690 in 2017); and T1D Exchange ( n = 16,198 in 2011, n = 17,087 in 2017) registries were analyzed by linear regression to compare mean HbA1c overall and by age group. Results: Controlling for age, sex, and T1D duration, HbA1c increased in the United States between 2011 and 2017, decreased in Sweden, and did not change in Germany/Austria. Controlling for sex and T1D duration, mean HbA1c decreased between 2011 and 2017 in all age cohorts in Sweden ( P < 0.001). In the United States, HbA1c stayed the same for participants P < 0.05). In Germany/Austria, HbA1c stayed the same for participants P < 0.01); and increased for participants ≥25 years ( P < 0.05). Conclusions: The comparison of international trends in HbA1c makes it possible to identify differences, explore underlying causes, and share quality improvement processes. National quality improvement initiatives are well accepted in Europe but have yet to be implemented systematically in the United States. However, disparities created by the lack of universal access to health care coverage, unequal access to diabetes technologies (e.g., continuous glucose monitoring) regardless of insurance status, and high out-of-pocket cost for the underinsured ultimately limit the potential of quality improvement initiatives.

BACKGROUND The Diabetes Questionnaire is a digital patient-reported outcome and experience measure for adults living with diabetes. The Diabetes Questionnaire is intended for use in routine clinical visits in diabetes care and to enable patient perspectives to be integrated into the Swedish National Diabetes Register. The Diabetes Questionnaire was developed on the basis of patients’ perspectives, and evidence for its measurement qualities has been demonstrated. Patients receive an invitation to complete the questionnaire before clinical visits, and the patient and health care professional (HCP) can discuss the findings, which are instantly displayed during the visit. Implementation processes for new tools in routine care need to be studied to understand the influence of contextual factors, the support needed, and how patients and HCPs experience clinical use. OBJECTIVE The aim of this study was to describe patients’ and HCPs’ experiences of initiating the use of the digital Diabetes Questionnaire as a clinical tool in routine diabetes care, supported by a structured implementation strategy involving initial education, local facilitators, and regular follow-ups. METHODS In this qualitative study, semistructured focus group discussions were conducted 12 months after the use of the Diabetes Questionnaire was initiated. Participants were diabetes specialist nurses and physicians (20 participants in 4 groups) at hospital-based outpatient clinics or primary health care clinics and adults with type 1 or type 2 diabetes (15 participants in 4 groups). The audiotaped transcripts were analyzed using inductive qualitative content analysis. RESULTS The results revealed 2 main categories that integrated patients’ and HCPs’ experiences, which together formed an overarching theme: While implementation demands new approaches, the Diabetes Questionnaire provides a broader perspective. The first main category (The Diabetes Questionnaire supports person-centered clinical visits) comprised comments expressing that the digital Diabetes Questionnaire can initiate and encourage reflection in preparation for clinical visits, bring important topics to light during clinical visits, and broaden the scope of discussion by providing additional information. The second main category (The process of initiating the implementation of the Diabetes Questionnaire) comprised comments that described differences in engagement among HCPs and their managers, challenges of establishing new routines, experiences of support during implementation, thoughts about the Diabetes Questionnaire, need to change local administrative routines, and opportunities and concerns for continued use. CONCLUSIONS The Diabetes Questionnaire can broaden the scope of health data in routine diabetes care. While implementation demands new approaches, patients and HCPs saw potential positive impacts of using the questionnaire at both the individual and group levels. Our results can inform further development of implementation strategies to support the clinical use of the questionnaire.