Ungleichheit – eine politische Entscheidung?

Die vorliegende Arbeit befasst sich mit der zunehmenden Ungleichverteilung der Einkommen in entwickelten Volkswirtschaften, die sich aufgrund der begrenzten Wirkung von Wirtschaftswachstum zum Ausgleich dieser Ungleichheiten ausdrückt. Ausgangspunkt bildet die Vergleichende Wohlfahrtsstaatsforschung und die darunter fallende Theorie nach Esping-Andersen (1989). Seine verwendeten Kategorien zur Bildung der „Drei Welten des Wohlfahrtskapitalismus“ dienen der Autorin als Anhaltspunkt, um jeweils Hypothesen in Zusammenhang mit der ungleichheitsreduzierenden Wirkung von Wohlfahrtsstaaten bilden zu können. Eine Sammlung vorwiegend quantitativer Studien über die Effekte wohlfahrtsstaatlicher Handlungsfelder und der Ungleichheitsreduzierung dient als Grundlage zur Bestätigung oder Widerlegung der jeweiligen Hypothesen. Die Anwendung der durch die recherchierten Studien bestätigten Zusammenhänge wird auf den Ländervergleich übertragen, wodurch zum Ausdruck kommt, dass verschiedene Ausgabenniveaus und Ausprägungen der wohlfahrtsstaatlichen Handlungsfelder einen Erklärungsfaktor für die unterschiedlich hoch ausfallende Ungleichverteilung der Einkommen zwischen Dänemark und Großbritannien darstellen können. Die bestätigten Hypothesen können somit als Ausgangspunkt für Politikempfehlungen Anwendung finden.For this thesis the rising trend in income inequality in richer economies in connection with socio-economic conflicts and the limits of economic growth to balance out the negative consequences of inequalities served as the research interest. For the theoretical perspective of this thesis Comparative Welfare State Research with Esping-Andersen’s (1989) categories is applied. The use of Esping-Andersen’s categories by which he grouped the “Three Worlds of Welfare Capitalism” allows the formulation of several hypotheses concerning the correlation between income inequality reduction and welfare states’ political actions. A selection of mainly quantitative comparative studies is used to confirm or condemn the hypotheses. The confirmed hypotheses are then applied to Great Britain and Denmark in order to evaluate differences in the level of and characteristics of social expenses between the two countries. As all confirmed hypotheses can be applied to the country examples it can be argued that welfare states, with a strong focus on social expenses and specific characteristics, are able to have a positive effect on income distribution. This argument can be seen as a starting point for political recommendations against welfare state retrenchment

Vergleich der Ergebnisse nach offener und endovaskulärer Therapie des abdominalen Aortenaneurysmas an der Charité Berlin im Zeitraum Dezember 2003 bis Dezember 2012

Hintergrund: Mit einer Gesamtprävalenz von 4 – 8 % bei Männern über 64 Jahre ist das infrarenale Bauchaortenaneurysma eine häufige und potentiell lebensbedrohliche Erkrankung. Circa ein Sechstel der infrarenalen Bauchaortenaneurysmen rupturieren, was überwiegend fatal endet. Kleinere Aneurysmen werden konservativ mit Minimierung der Risikofaktoren kontrolliert. Steigt das Rupturrisiko mit zunehmendem Gefäßdurchmesser, sollte es operativ ausgeschaltet werden. Hier stehen zwei Ansätze zur Verfügung: der langjährig bewährte offene Gefäßersatz (OAR – open aneurysm repair) oder die neue endovaskuläre Methode mit Implantation eines Gefäßstents über die Leistenarterien (EVAR – Endovascular Aneurysm Repair). Welche der beiden Methoden bessere Resultate erzielt, wird in der Literatur kontrovers diskutiert und ist noch nicht abschließend geklärt. Methodik: In der vorliegenden Arbeit wird das Therapieergebnis im peri-, postoperativen und im Langzeitverlauf nach elektivem offenem und endovaskulärem Gefäßersatz bei infrarenalem Bauchaortenaneurysma an der Berliner Charité, Campus Mitte im Zeitraum Dezember 2003 bis Dezember 2012 untersucht. Hierzu wurden alle Patientenfälle aus diesem Zeitraum retrospektiv aufgearbeitet. Es wurden 234 Patienten eingeschlossen, 113 wurden offen und 121 endovaskulär versorgt. Die Auswertung der Daten erfolgte mittels Kreuztabellierung und einer multivariaten Analyse. Das Signifikanzniveau wurde für quantitative Variablen mittels Mann-Whitney-U-Test beziehungsweise T-Test und für kategorielle Variablen mittels exaktem Fisher-Test ermittelt. Ergebnisse: Es zeigte sich nach endovaskulärer Therapie im Vergleich zum offenen Gefäßersatz eine geringere postoperative Letalität (OAR: 6,2 %, EVAR: 0 %, p = 0,006). Die Komplikationsraten waren nach offenem Gefäßersatz deutlich erhöht (OAR: 85,8 %, EVAR: 59,5 %, p < 0,001) und es musste häufiger reinterveniert werden (OAR: 21,2 %, EVAR: 7,5 %, p = 0,007). Die häufigsten Komplikationen waren respiratorischen Beeinträchtigungen (OAR: 33,7 %, EVAR: 5,8 %, p < 0,001), das Auftreten eines systemischen inflammatorischen Response-Syndroms (SIRS; OAR: 31,0 %, EVAR: 10,0 %, p < 0,001) und renale Komplikationen (OAR: 28,4 %, EVAR: 5,8 %, p < 0,001). Im Langzeitverlauf kamen insgesamt mehr endovaskulär Therapierte zu mindestens einer Kontrolluntersuchung (OAR: 53 %, EVAR: 76 %). Am häufigsten wurde eine Computertomographie durchgeführt (84,5 %). Von den insgesamt einmal Untersuchten mussten 21,1 % der endovaskulär versorgten und 10 % der offen versorgten Patienten eine Reintervention erhalten. Schlussfolgerung: Der peri- und postoperative Verlauf ist nach EVAR für den Patienten deutlich schonender und mit geringeren Letalitäts-, Komplikations- und Reinterventionsraten als nach OAR verbunden. Allerdings zeigen sich im Langzeitverlauf vermehrte Komplikationen nach EVAR, welche wiederum eine erhöhte Reinterventionsrate im Vergleich zur OAR bedingen.Background: Infrarenal abdominal aortic aneurysm is a life-threatening disease with a prevalence of 4 – 8 % in men aged over 64. Approximately 15 % of the cases showing this clinical picture develop a rupture which is mostly fatal. Small aneurysms can be conservatively controlled while minimizing the risk factors. If the risk of rupture increases with enlarging diameter of the vessel, it should be excised. There are two therapeutic approaches available: The open aneurysm repair (OAR) method, which has been applied over many years, and the new endovascular aneurysm repair (EVAR) method, implanting a vascular stent through the iliac arteries. The efficiency of the two methods is controversially being discussed in scientific journals. Methods: In this study, perioperative, postoperative and long-term data of patients with abdominal aorta aneurysm were examined confronting open and endovascular aneurysm repair methods applied at the Charité hospital in Berlin from December 2003 until December 2012. All cases were recorded retrospectively. All in all, 234 patients were taken into consideration, 113 underwent open and 121 endovascular treatment. The data were analyzed by cross-tabulation and multivariate analysis. The significance level was calculated for quantitative variables using the Mann-Whitney U test or T-test and for categorical variables using the Fisher’s exact test. Results: After endovascular repair, postoperative mortality occurred significantly less compared to postoperative mortality after OAR (OAR: 6.2 %, EVAR: 0 %, p = 0.006). Complication rates were significantly higher after OAR than after EVAR (OAR: 85.8 %, EVAR: 59.5 %, p < 0.001). OAR patients had to be re-operated in many cases (OAR: 21.2 %, EVAR: 7.5 %, p = 0.007). Major complications were respiratory impairments (OAR: 33.7 %, EVAR: 5.8 %, p < 0.001), SIRS - Systemic Inflammatory Response Syndrome (OAR: 31.0 %, EVAR: 10.0 %, p < 0.001), and renal complications (OAR: 28.4 %, EVAR: 5.8 %, p < 0.001). In the long run, more patients treated by EVAR made use of at least one check-up (OAR: 53 %, EVAR: 76 %) - computed tomography in most of the cases (84.5%). All in all, reinterventions were necessary for 21.1 % of the patients after EVAR and for 10 % of the patients after OAR. Conclusions: EVAR is significantly less challenging for the patient and causes lower mortality rates, complications and reinterventions in the perioperative and postoperative period than OAR. On the other hand, in a long-term perspective, higher rates of complications could be observed after endovascular than after open repair

Association of simple renal cysts and chronic kidney disease with large abdominal aortic aneurysm

Background: Abdominal aortic aneurysms (AAA) primarily affect men over 65 years old who often have many other diseases, with similar risk factors and pathobiological mechanisms to AAA. The aim of this study was to assess the prevalence of simple renal cysts (SRC), chronic kidney disease (CKD), and other kidney diseases (e.g. nephrolithiasis) among patients presenting with AAA. Methods: Two groups of patients (97 AAA and 100 controls), with and without AAA, from the Surgical Clinic Charité, Berlin, Germany, were selected for the study. The control group consisted of patients who were evaluated for a kidney donation (n = 14) and patients who were evaluated for an early detection of a melanoma recurrence (n = 86). The AAA and control groups were matched for age and sex. Medical records were analyzed and computed tomography scans were reviewed for the presence of SRC and nephrolithiasis. Results: SRC (74% vs. 57%; p<0.016) and CKD (30% vs. 8%; p<0.001) were both more common among AAA than control group patients. On multivariate analysis, CKD, but not SRC, showed a strong association with AAA. Conclusions: Knowledge about pathobiological mechanisms and association between CKD and AAA could provide better diagnostic and therapeutic approaches for these patients

Temporal muscle thickness is an independent prognostic marker in melanoma patients with newly diagnosed brain metastases.

OBJECTIVES: The purpose of this study was to evaluate the prognostic relevance of temporal muscle thickness (TMT) in melanoma patients with newly diagnosed brain metastases. METHODS: TMT was retrospectively assessed in 146 melanoma patients with newly diagnosed brain metastases on cranial magnetic resonance images. Chart review was used to retrieve clinical parameters, including disease-specific graded prognostic assessment (DS-GPA) and survival times. RESULTS: Patients with a TMT > median showed a statistically significant increase in survival time (13 months) compared to patients with a TMT < median (5 months; p < 0.001; log rank test). A Cox regression model revealed that the risk of death was increased by 27.9% with every millimeter reduction in TMT. In the multivariate analysis, TMT (HR 0.724; 95% 0.642-0.816; < 0.001) and DS-GPA (HR 1.214; 95% CI 1.023-1.439; p = 0.026) showed a statistically significant correlation with overall survival. CONCLUSION: TMT is an independent predictor of survival in melanoma patients with brain metastases. This parameter may aid in patient selection for clinical trials or to the choice of different treatment options based on the determination of frail patient populations

High correlation of temporal muscle thickness with lumbar skeletal muscle cross-sectional area in patients with brain metastases.

OBJECTIVES: This study aimed to assess the correlation of temporal muscle thickness (TMT), measured on routine cranial magnetic resonance (MR) images, with lumbar skeletal muscles obtained on computed tomography (CT) images in brain metastasis patients to establish a new parameter estimating skeletal muscle mass on brain MR images. METHODS: We retrospectively analyzed the cross-sectional area (CSA) of skeletal muscles at the level of the third lumbar vertebra on computed tomography scans and correlated these values with TMT on MR images of the brain in two independent cohorts of 93 lung cancer and 61 melanoma patients (overall: 154 patients) with brain metastases. RESULTS: Pearson correlation revealed a strong association between mean TMT and CSA in lung cancer and melanoma patients with brain metastases (0.733; p<0.001). The two study cohorts did not differ significantly in patient characteristics, including age (p = 0.661), weight (p = 0.787), and height (p = 0.123). However, TMT and CSA measures differed significantly between male and female patients in both lung cancer and melanoma patients with brain metastases (p<0.001). CONCLUSION: Our data indicate that TMT, measured on routine cranial MR images, is a useful surrogate parameter for the estimation of skeletal muscle mass in patients with brain metastases. Thus, TMT may be useful for prognostic assessment, treatment considerations, and stratification or a selection factor for clinical trials in patients with brain metastases. Further studies are needed to assess the association between TMT and clinical frailty parameters, and the usefulness of TMT in patients with primary brain tumors

Sarcopenia in Neurological Patients: Standard Values for Temporal Muscle Thickness and Muscle Strength Evaluation.

Temporal muscle thickness (TMT) was investigated as a novel surrogate marker on MRI examinations of the brain, to detect patients who may be at risk for sarcopenia. TMT was analyzed in a retrospective, normal collective cohort (n = 624), to establish standard reference values. These reference values were correlated with grip strength measurements and body mass index (BMI) in 422 healthy volunteers and validated in a prospective cohort (n = 130) of patients with various neurological disorders. Pearson correlation revealed a strong association between TMT and grip strength (retrospective cohort, ρ = 0.746; p < 0.001; prospective cohort, ρ = 0.649; p < 0.001). A low or no association was found between TMT and age (retrospective cohort, R2 correlation coefficient 0.20; p < 0.001; prospective cohort, ρ = -0.199; p = 0.023), or BMI (retrospective cohort, ρ = 0.116; p = 0.042; prospective cohort, ρ = 0.227; p = 0.009), respectively. Male patients with temporal wasting and unintended weight loss, respectively, showed significantly lower TMT values (p = 0.04 and p = 0.015, unpaired t-test). TMT showed a high correlation with muscle strength in healthy individuals and in patients with various neurological disorders. Therefore, TMT should be integrated into the diagnostic workup of neurological patients, to prevent, delay, or treat sarcopenia

Survival prediction using temporal muscle thickness measurements on cranial magnetic resonance images in patients with newly diagnosed brain metastases.

OBJECTIVES: To evaluate the prognostic relevance of temporal muscle thickness (TMT) in brain metastasis patients. METHODS: We retrospectively analysed TMT on magnetic resonance (MR) images at diagnosis of brain metastasis in two independent cohorts of 188 breast cancer (BC) and 247 non-small cell lung cancer (NSCLC) patients (overall: 435 patients). RESULTS: Survival analysis using a Cox regression model showed a reduced risk of death by 19% with every additional millimetre of baseline TMT in the BC cohort and by 24% in the NSCLC cohort. Multivariate analysis included TMT and diagnosis-specific graded prognostic assessment (DS-GPA) as covariates in the BC cohort (TMT: HR 0.791/CI [0.703-0.889]/p < 0.001; DS-GPA: HR 1.433/CI [1.160-1.771]/p = 0.001), and TMT, gender and DS-GPA in the NSCLC cohort (TMT: HR 0.710/CI [0.646-0.780]/p < 0.001; gender: HR 0.516/CI [0.387-0.687]/p < 0.001; DS-GPA: HR 1.205/CI [1.018-1.426]/p = 0.030). CONCLUSION: TMT is easily and reproducibly assessable on routine MR images and is an independent predictor of survival in patients with newly diagnosed brain metastasis from BC and NSCLC. TMT may help to better define frail patient populations and thus facilitate patient selection for therapeutic measures or clinical trials. Further prospective studies are needed to correlate TMT with other clinical frailty parameters of patients. KEY POINTS: • TMT has an independent prognostic relevance in brain metastasis patients. • It is an easily and reproducibly parameter assessable on routine cranial MRI. • This parameter may aid in patient selection and stratification in clinical trials. • TMT may serve as surrogate marker for sarcopenia

Evaluation of the Temporal Muscle Thickness as an Independent Prognostic Biomarker in Patients with Primary Central Nervous System Lymphoma.

In this study, we assessed the prognostic relevance of temporal muscle thickness (TMT), likely reflecting patient's frailty, in patients with primary central nervous system lymphoma (PCNSL). In 128 newly diagnosed PCNSL patients TMT was analyzed on cranial magnetic resonance images. Predefined sex-specific TMT cutoff values were used to categorize the patient cohort. Survival analyses, using a log-rank test as well as Cox models adjusted for further prognostic parameters, were performed. The risk of death was significantly increased for PCNSL patients with reduced muscle thickness (hazard ratio of 3.189, 95% CI: 2-097-4.848, p < 0.001). Importantly, the results confirmed that TMT could be used as an independent prognostic marker upon multivariate Cox modeling (hazard ratio of 2.504, 95% CI: 1.608-3.911, p < 0.001) adjusting for sex, age at time of diagnosis, deep brain involvement of the PCNSL lesions, Eastern Cooperative Oncology Group (ECOG) performance status, and methotrexate-based chemotherapy. A TMT value below the sex-related cutoff value at the time of diagnosis is an independent adverse marker in patients with PCNSL. Thus, our results suggest the systematic inclusion of TMT in further translational and clinical studies designed to help validate its role as a prognostic biomarker

Distributed changes of the functional connectome in patients with glioblastoma

Glioblastoma might have widespread effects on the neural organization and cognitive function, and even focal lesions may be associated with distributed functional alterations. However, functional changes do not necessarily follow obvious anatomical patterns and the current understanding of this interrelation is limited. In this study, we used resting-state functional magnetic resonance imaging to evaluate changes in global functional connectivity patterns in 15 patients with glioblastoma. For six patients we followed longitudinal trajectories of their functional connectome and structural tumour evolution using bi-monthly follow-up scans throughout treatment and disease progression. In all patients, unilateral tumour lesions were associated with inter-hemispherically symmetric network alterations, and functional proximity of tumour location was stronger linked to distributed network deterioration than anatomical distance. In the longitudinal subcohort of six patients, we observed patterns of network alterations with initial transient deterioration followed by recovery at first follow-up, and local network deterioration to precede structural tumour recurrence by two months. In summary, the impact of focal glioblastoma lesions on the functional connectome is global and linked to functional proximity rather than anatomical distance to tumour regions. Our findings further suggest a relevance for functional network trajectories as a possible means supporting early detection of tumour recurrence

Rising rural body-mass index is the main driver of the global obesity epidemic in adults

Body-mass index (BMI) has increased steadily in most countries in parallel with a rise in the proportion of the population who live in cities(.)(1,2) This has led to a widely reported view that urbanization is one of the most important drivers of the global rise in obesity(3-6). Here we use 2,009 population-based studies, with measurements of height and weight in more than 112 million adults, to report national, regional and global trends in mean BMI segregated by place of residence (a rural or urban area) from 1985 to 2017. We show that, contrary to the dominant paradigm, more than 55% of the global rise in mean BMI from 1985 to 2017-and more than 80% in some low- and middle-income regions-was due to increases in BMI in rural areas. This large contribution stems from the fact that, with the exception of women in sub-Saharan Africa, BMI is increasing at the same rate or faster in rural areas than in cities in low- and middle-income regions. These trends have in turn resulted in a closing-and in some countries reversal-of the gap in BMI between urban and rural areas in low- and middle-income countries, especially for women. In high-income and industrialized countries, we noted a persistently higher rural BMI, especially for women. There is an urgent need for an integrated approach to rural nutrition that enhances financial and physical access to healthy foods, to avoid replacing the rural undernutrition disadvantage in poor countries with a more general malnutrition disadvantage that entails excessive consumption of low-quality calories.Peer reviewe