The perspective of being a family caregiver of a patient treated for oesophageal cancer : problems and needs

There is a need to put family caregivers on the cancer survivorship research agenda. Research among family caregivers of patients treated for oesophageal cancer is sparse. However, it has been indicated that they are at an increased risk of emotional distress in terms of anxiety and depression. To better understand the family caregivers’ situation there were two main aims of this thesis; 1) to explore the family caregivers’ experiences at one and two years after the patients’ surgery (study I-II) and 2) to investigate which factors impact the family caregivers’ health-related quality of life (HRQL) (study III-IV). Study I: This qualitative study used material from a Swedish nationwide and prospective cohort including patients surgically treated for oesophageal cancer and their closest family caregivers. Family caregivers received a questionnaire-kit one year after the patients’ surgical treatment. For this study, the responses to one open-ended question “Is there anything else you would like to share?” were analysed by using thematic analysis. In total, 112 responses from family caregivers to the open-ended question were included. The analysis rendered three themes: Discontinued support from healthcare – family caregivers had a positive experience during treatment, however, after the patients’ discharge from hospital, the family caregivers felt fully responsible for the patients’ care. A changed life – this was experienced as an unprepared situation that changed life by the time of the patients’ diagnosis. Family caregivers felt that they lost their identity and that nothing will ever be the same again. Psychological distress – this was experienced as a feeling of being alone. Now, the patient was the one that mattered and the family caregivers expressed a feeling of being invisible. Study II: This qualitative study was conducted among family caregivers of patients surgically treated for oesophageal cancer in Sweden in 2018. Thirteen telephone interviews were held in 2020, two years after the patients’ surgery. An abductive approach was used for the analysis, starting with an inductive approach using thematic analysis, and thereafter, a deductive approach to interpret the findings in relation to the conceptual model “The Cancer Family Caregiving Experience”. The study found that the family caregivers suffered from many stress factors. The most prominent stress factors were distress regarding fear of tumour recurrence, worry about the future and the patients’ nutritional status. Family caregivers also experienced a transition from family member to caregiver. Many psychosocial aspects in this transition were highlighted during the disease trajectory. Study III and IV: Study III and IV used data on HRQL (RAND-36 and QLQ-C30) from a Swedish nationwide and prospective cohort of patients surgically treated for oesophageal cancer and their closest family caregivers. Factors being investigated in study III were family caregivers’ characteristics (age, gender, education level) and patients related factors (tumour stage, complications, weight loss and comorbidities). In study IV, patients overall HRQL was used to find out whether it affected family caregivers’ HRQL. Linear regression models were used for measuring mean score differences (MSD) in study III and the regression coefficients (β) in study IV. In study III, 257 family caregivers were included. Family caregivers ≥65 years reported a lower physical function (MSD=-8.4; p=0.001) but a higher level of energy (MSD=9.2; p=0.002). Those with a higher education level had less pain (MSD=11.2; p=0.01) and better physical function (MSD=9.1; p=0.006). Regarding patient-related factors, postoperative complications were negatively associated with family caregivers’ physical function (MSD=- 6.0; p=0.01) and pain (MSD=-7.9; p=0.01). No associations were found for patients’ tumour stage and comorbidities. In study IV, 275 patients and paired family caregivers were included. Patients reported a mean HRQL summary score of 81.4, which indicates reductions in functions and burdensome symptoms. Lowest HRQL scores were reported among family caregivers for pain (69.2±26.0) and energy/fatigue (65.1±20.4). A 10-point change in the patients’ summary score corresponded to a 7-point change for family caregivers’ emotional role function (β=7.0; 95% CI: 3.6-10.3). No clinically relevant associations were found for patients’ HRQL and the other subscales of RAND-36. In conclusion, these studies suggest that family caregivers of patients treated for oesophageal cancer may struggle with the psychosocial consequences of a changed situation in life which, in turn, has an impact on their psychological health and social context. Moreover, their HRQL is affected by the patient’s cancer diagnosis and its treatments. It is of great importance to further investigate aspects of HRQL among family caregivers in order to predict the risk of poor HRQL. In addition, improved supportive interventions are needed for family caregivers during the whole disease trajectory of the patient

Ultraviolet-Induced Dna Repair Synthesis In Lymphocytes From Patients With Actinic Keratosis

Actinic keratosis is an epidermal cancer in situ. Extensive exposure to sunlight is considered as a contributing factor to the etiology of this tumor. Ultraviolet (UV) light of solar radiation induces structural damage in DNA, which may give rise to mutations and transformed cells if the damage is not repaired. Repair of UV-induced DNA lesions is an essential property of human cells. The conditions so far reported to have defective DNA repair are all associated with an increased incidence of malignancy. Do patients with actinic keratosis also exhibit a reduced capacity to repair UV-induced DNA lesions?DNA repair synthesis in peripheral leukocytes was studied in 10 patients with actinic keratosis and 10 healthy subjects of corresponding age. After irradiation with various doses of UV light the leukocytes were incubated for 2 hr with [3H]thymidine in the presence of hydroxyurea. A dose-response relationship for the UV-induced DNA repair synthesis was established for each individual. The average repair capacity in the patients with actinic keratosis was about 30% below that of the controls. The difference is statistically significant (p < 0.02). Reduced DNA repair synthesis may therefore be an important factor in the etiology of actinic keratosis

Liquidity analysis of leveraged forest properties

Priset på skogsmark har under det senaste decenniet ökat kraftigt. Samtidigt har andra priser, som ligger till grund för kassaflöden på skogsfastigheter inte ökat i samma takt. Virkespriserna har varierat under de senaste tio åren med en pristopp under 2010-2011, priserna har sedan dess fallit tillbaka närmare 20 %. Bankernas femåriga låneränta har under samma period också varierat, från ca 7 % till dagens historiskt låga nivå runt 3,5 %. Förändringar i låneränta och virkespriser kan påverka likviditeten för skogsägare och därmed orsaka finansiella störningar för deras långivare. Syftet med studien är att undersöka om ett urval skogsägare med fastigheter av varierande storlek och belåning kan komma att få likviditetsproblem inom en tioårsperiod och därmed orsaka finansiella risker för en tänkt långivare. För att mäta likviditetströmmarna på olika skogsfastigheter har en modell konstruerats i Excel. Modellen simulerar likviditetsströmmar under en tioårsperiod på 20 fastigheter som är belånade i varierad grad. Inkomstsidan består av avverkningsintäkter från slutavverkning och gallring. Utgifterna i modellen härrör från plantering, röjning, samlade fasta utgifter samt avverkningskostnader, (vid simulerade slutavverkningar och gallringar). Resultatet i grundanalysen visar att vid ”dagens nivå” om 3,5 % låneränta, 480 kr/m3fub timmerpris och 320 kr/m3fub massavedspris får 11 av de 20 studerade fastigheterna likviditetsbrist under tioårsperioden, om inget annat yttre kapital tillförs. Känslighetsanalysen indikerar att likviditeten på flertalet fastigheter är mycket känslig för både räntehöjningar och virkesprissänkningar. Ägare till belånade skogsfastigheter är exponerade mot både finansiell risk och rörelserisk. I fall där båda dessa risktyper är höga kan betydande ekonomiska konsekvenser uppkomma för låntagarna/skogsägarna och i förlängningen också för långivarna. Slutsatsen utav resultatet är att markägare med hög belåningsgrad kan få svårt att finansiera sina utgifter med inkomster från skogen. Långivaren bör vara medveten och vaksam över eventuella likviditetsproblem som kan uppkomma i fall där skogsfastigheter är högt belånade. Att tyda informationen i skogsbruksplaner på ett korrekt sätt är av central betydelse för att göra en rimlig bedömning av fastigheters förmåga att genera positiva kassaflöden över tiden. Risken för en långivare kan vara betydande i de fall där skogsägaren inte har några andra väsentliga inkomster eller andra former av kapital vid sidan av skogsfastigheten. Skogstillståndet på skogsfastigheten i kombination med övriga inkomster är avgörande för att bedöma risken för långivaren.The price of forestland has over the past decade increased markedly, at the same time as other values, which form the basis of cash flows on forest estates, hasn’t increased by the same rate. Timber prices have fluctuated over the past 10 years, with a price top in 2010-2011. Timber prices have since that time fallen nearly 20 %. Banks' five-year lending rate during the same period also varied from about 7 % down to the present historically low level around 3.5 %. Changes in the lending rate and timber prices may affect the liquidity for forest owners and cause financial disruption to their lenders. The purpose of this study is to investigate whether a sample of forest estates with varying size and different loan rates may get liquidity problems during the next ten years and as a consequence cause financial risks for a notional lender. To measure liquidity flows in different forest properties, a model was designed in Excel. The model simulates the cash flows over a ten year period for twenty different estates which are leveraged to varying degrees. Revenue side consists of logging revenues from final felling and thinning. The costs of the model are derived from planting, cleaning, overall fixed costs as well as harvesting costs associated with simulated final felling and thinning. The results of the initial analysis, at "current level" for loan rate and timber prices shows that 11 of the 20 studied forest properties get liquidity shortage during the 10-year period, if no external capital is to be supplied. The sensitivity analysis indicates that the liquidity of most estates is very sensitive to both increases of interest rate and timber-price reductions. The owner of the mortgaged forest properties are exposed to both financial risk and operating risk. In cases where both types of risk are high, significant financial implications arise for borrowers/ owners and, in extension, for lenders. The conclusion from the results is that landowners with high leverage may find it difficult to cover costs by revenues from the forest. The lender should be aware and vigilant of any liquidity problems that may arise in cases where forest land is highly leveraged. Ability to decipher the correct information in forest management plans is crucial in order to make a reasonable estimate of the estates generation of cash flows over time. The risk for a lender may be significant in cases where the landowner has no other significant income alongside forest property. The condition of forest land is a critical quality to assess the risk for the lender

Register-based studies of epidemiology and health care costs in type 2 diabetes

Type 2 diabetes is a public health problem of great magnitude. Globally, prevalence of the disease is increasing, mainly as a result of population ageing and increased rates of obesity. The overall aim of this thesis was to study the epidemiology and health care costs of type 2 diabetes and its complications in Uppsala county, Sweden using register data from clinical practice. A total of 11 856 patients with type 2 diabetes were retrospectively identified in computerised records from 26 primary care centers kept between years 1993 and 2004. Within Paper I, we estimated the prevalence and incidence of type 2 diabetes and its complications during years 1996-2003. Crude population prevalence of type 2 diabetes was found to increase from 2.2% to 3.5% but diabetes incidence did not exhibit any increase. Instead, increasing prevalence was a product of the number of patients diagnosed with type 2 diabetes each year being higher than the number of deaths among type 2 diabetic patients, as well as of declining mortality. Within Paper II, we examined trends in control of glycemia, total cholesterol and blood pressure among type 2 diabetic study patients during years 1996-2005. Over the observation period, the proportion of patients with adequate control increased from 38% to 56% for glycemia, from 8% to 27% for total cholesterol, and from 8% to 11% for blood pressure. Despite this increase, a substantial proportion of patients did not achieve adequate control, in particular with regard to blood pressure. Within Paper III, we examined medical resource use of study patients and estimated annual costs of health care. The average type 2 diabetic patient made 2 GP visits and 2 outpatient hospital visits per year. The mean (SD) total health care costs incurred by study patients were estimated at €3 602 (€9 537) in year 2004. Though a minority (16%) of patients were hospitalised during the year, inpatient care was the major contributor to costs, accounting for 57% of total health care costs. Within Paper IV, we determined the immediate and long-term impact of acute myocardial infarction (AMI) and stroke on health care costs in patients with type 2 diabetes. Suffering an AMI was associated with a 4.1-fold increase in total health care costs during the year of a first AMI and a 6.5-fold increase in total health care costs during the year of a first stroke. For both AMI and stroke, the increase in costs was largely accounted for by inpatient care. This thesis has contributed to increased knowledge of the epidemiology of type 2 diabetes in Sweden and has provided estimates of health care costs which may be used to inform capacity planning and as input into economic evaluations. This thesis also illustrates how computerised medical records from real-life clinical practice can be used to retrospectively identify cohorts of patients with a specific disease, how record linkage to can be used to retrieve information from complementary health care registers, and how epidemiological and health economical research questions can be studied through analysis of the resulting datasets

Farmers' private savings for retirement : values behind the decision

Self-employees in Sweden, there among farmers are not provided with any occupational pension, which means that one part of their retirement income is lacking. Therefore, they have a larger responsibility concerning their private savings for retirement in order to obtain a retirement income corresponding to the one they had during their active work period. Decisions regarding farmers’ retirement represent a complex matter, since farmers view their business as their lifestyle. Researchers have found that farmers tend to reinvest in their business instead of prioritizing private savings outside the business, which has an impact on their private retirement savings for the future. Decisions concerning retirement are not a daily decision, which the farmer can get immediate gratification from and this make these kinds of decisions more difficult for them. There are only a small number of studies, which have investigated retirement savings among farmers. Although, it is known that retirement is one reason for why farmers have private savings, but it has not been studied why farmers have private savings for retirement. In order to understand how this decision is made, the underlying values or goals behind the decision need to be known. Through these values, people become motivated to accomplish things like their goals, needs satisfactions or desirable end states that people want to achieve. The aim of the study is to explore which values motivate farmers’ decision-making concerning their private savings for retirement. The chosen theories are Means-end chain theory and Personal value theory. A qualitative approach is used. The chosen method is “soft” laddering, since it is used when revealing the means-end chains among people. The method is performed through in-depth telephone interviews with 25 participating farmers. The conclusions in this study suggest that the personal values which motivate farmers’ decision-making concerning their private savings for retirement are: “Safety”, “Financial stability”, “Good relations to relatives”, “Tradition”, “Not affect next generation financially”, “Fulfill dreams/do things that matter”, “Happiness” and “Good life as a pensioner”. These are further interpreted into personal value groups according to perspective of personal value theory: Security, Benevolence, Tradition, Self-direction, Stimulation and Hedonism.Svenska egenföretagare där även lantbrukare inkluderas, erbjuds ingen tjänstepension. Det betyder att de saknar en del i deras sammantagna pension om de inte kompenserar för den på egen hand. Det innebär ett större ansvar för Sveriges lantbrukare, när det gäller att kunna få en pensionsinkomst som lantbrukaren själv kan vara nöjd med. Beslut rörande pension är svåra att fatta bl.a. eftersom det inte är ett dagligt beslut och för att lantbrukaren inte får ut något omgående av beslutet, utan först efter ett visst antal år. Lantbrukare tenderar även att prioritera att återinvestera i företaget istället för att investera i något slags pensionssparande utanför företaget, vilket självklart påverkar deras sparande till pensionen. Det är endast få studier som har undersökt frågan rörande lantbrukares sparande till pensionen. Men pensionen är en av anledningarna till varför lantbrukare sparar, dock har det inte studerats vad det är som motiverar lantbrukares beslutsfattande när det gäller privat sparande till pensionen. För att kunna förstå varför detta beslut tas krävs det att ta reda på de värden som ligger bakom beslutet. De bakomliggande värdena är de som motiverar personer till att uppnå sina mål. De motiveras till att uppfylla sina behov och nå tillfredställelse. Syftet med studien är att undersöka vilka värden som motiverar lantbrukares beslutsfattande när det gäller privat pensionssparande. De valda teorierna är Means-end chain theory och Personal value theory. Means-end chain theory används för att både beskriva och förstå beslut hos konsumenter. Teorin beskriver vad som ligger bakom en persons beslut där beslutet beskrivs genom attribut, konsekvens och värde. Attribut är hur en person uppfattar en produkt, konsekvens är det som personen får ut av att konsumera denna produkt, slutligen uppnås värdet. Det är en hierarkisk relation mellan attribut, konsekvens och värde. Kombinationen av dessa element uppfattas som ett nätverk som kallas means-end chain. Denna teori används som ett verktyg i denna studie för att finna lantbrukarnas means-end chain nätverk. Personliga värden i Personal value theory, definieras som förväntade mål som existerar på en högre nivå av abstraktion. Personer har olika värden och vi prioriterar våra värden individuellt, hur vi prioriterar dem påverkas av vår bakgrund och nuvarande situation. Denna teori används för att kunna uppnå syftet med studien. Studien har en kvalitativ ansats som utfördes genom djupgående telefonintervjuer med 25 svenska lantbrukare, följaktligen kan inte resultaten från denna studie generaliseras. En kvalitativ ansats är passande då ett fenomen på djupare individuell nivå ska undersökas. Metoden valdes utifrån teorierna och för att Means-end chain theory har en nära koppling till den valda metoden, ”soft laddering”. ”Soft laddering” är en intervjuteknik som utförs md en respondent i taget för att utveckla en förståelse för hur konsumenters attribut kan leda till meningsfulla värden enligt Means-end chain theory. Denna metod är bra att använda när syftet är att hitta personers värden associerade med en produkt. I denna studie är produkten privat sparande till pensionen. Slutsatsen för denna studie genom perspektivet av Personal value theory, är att de värden som motiverar lantbrukares beslutsfattande när det gäller deras privata pensionssparande är: ”Trygghet” och ”Ekonomisk stabilitet” som tillhör gruppen Säkerhet, ”Ha goda relationer till närstående” som tillhör gruppen Välvilja, ”Tradition” som tillhör gruppen Tradition, ”Barn ska ej betala pensionen” som tillhör gruppen Självstyrning, ”Uppfylla drömmar/göra det man vill” tillhör gruppen Stimulans, ”Lycka” och ”Leva ett bra liv som pensionär” tillhör gruppen Hedonism