Construction-process : fragmentation of integration ?

Recent projects of contractors and project-developers are increasingly realized in an international scope. Also the Dutch construction industry becomes more active in Europe and other parts of the world, while companies from abroad become more active in the Dutch construction market. Although several Dutch companies had already activities and experiences in other parts of the world, several of these companies encountered specific problems when working in Germany. After falling of the Berlin Wall in 1989 it became clear there would be an enormous construction marktet, and also the other East-European countries became interesting. But it seems that the entering of the German market by Dutch contractors was and is still quite difficult. The research, described in this article, is part of a Ph.D project, which searches for possible backgrounds for differences between the Netherlands and Germany in the construction-management process. To get a more practical view on the research-area, there has been created a possibility for a partly-continuous investigation inside some contractors and project-developers in Germany, which are from Dutch origin. One specific case-study according the realization of two hotel-projects in Germany is being described shortly in this article. The comparison is being made by investigating theory and practical experience, mainly according problems in construction-management and working with peopl

Construction-process : fragmentation of integration ?

Recent projects of contractors and project-developers are increasingly realized in an international scope. Also the Dutch construction industry becomes more active in Europe and other parts of the world, while companies from abroad become more active in the Dutch construction market. Although several Dutch companies had already activities and experiences in other parts of the world, several of these companies encountered specific problems when working in Germany. After falling of the Berlin Wall in 1989 it became clear there would be an enormous construction marktet, and also the other East-European countries became interesting. But it seems that the entering of the German market by Dutch contractors was and is still quite difficult. The research, described in this article, is part of a Ph.D project, which searches for possible backgrounds for differences between the Netherlands and Germany in the construction-management process. To get a more practical view on the research-area, there has been created a possibility for a partly-continuous investigation inside some contractors and project-developers in Germany, which are from Dutch origin. One specific case-study according the realization of two hotel-projects in Germany is being described shortly in this article. The comparison is being made by investigating theory and practical experience, mainly according problems in construction-management and working with peopl

[Treatment of rheumatoid arthritis by inhibition of tumor necrosis factor with infliximab or etanercept]

The current pharmacotherapy of rheumatoid arthritis (RA) consists of non-steroidal anti inflammatory drugs (NSAIDs) and disease-modifying antirheumatic drugs (DMARDs) such as sulphasalazine, leflunomide and methotrexate. DMARDs can be given as monotherapy or in combination. However, not all patients show an adequate response due to toxicity or lack of efficacy. From animal studies and clinical studies in patients with RA, we know that tumour necrosis factor (TNF) is directly involved in the pathogenesis of RA. Two forms of TNF inhibition therapy have been extensively investigated in RA: anti-TNF monoclonal antibodies (infliximab) and TNF receptor-Fc fusion protein (etanercept). Both types of TNF inhibition induce a rapid improvement in multiple clinical measures of disease activity and patient functional status. Furthermore, a beneficial effect was demonstrated on radiographic progression of joint damage. Etanercept and the combination infliximab-methotrexate are generally well tolerated

Somatic comorbidity and comorbid depression are associated with mortality among patients with established rheumatoid arthritis: an eleven years follow-up cohort study

Background Rheumatoid Arthritis (RA) is associated with premature mortality (1). Somatic comorbidity has been found to be one of the most important predictors for premature mortality (2). Comorbid conditions that are associated with premature mortality are: cardiovascular diseases, respiratory diseases, gastrointestinal system disorders, genitourinary diseases, hematologic diseases, infectious diseases, and malignancies. A few studies have found comorbid depression to be associated with an increased risk for mortality (3). The combination of both somatic comorbidity and comorbid depression as a risk factor for mortality has not yet been investigated. Whether this combination is an additional risk factor for premature mortality is important information for clinicians to be able to adapt their screening process and when necessary their treatment.Objectives To investigate which comorbid conditions are associated with premature mortality and if the combination of a somatic comorbid condition and comorbid depression is more associated with premature mortality than one of these conditions alone.Methods Longitudinal data over a period of eleven years were collected from 882 patients with RA at study inclusion. Data by means of self-reported questionnaires were collected in 1997, 1998, 1999, 2002 and 2008. Of all of the participants included at baseline, the mortality status was obtained from the register of the Statistics Netherlands. Somatic comorbidity was measured by a questionnaire including 20 chronic diseases. Comorbid depression was measured with the Center for Epidemiologic Depression Scale. To study the relationship between comorbidity and survival among RA patients, we performed a Cox regression analysis.Results 78% of the patients at baseline were women. The mean age was 59.3 (SD 14.8) years and the median disease duration was 5.0 (IQR 2.0-14.0) years. Comorbid conditions that were associated with premature mortality were respiratory conditions, gastrointestinal conditions, cancer and comorbid depression. The combination of a somatic comorbid condition and comorbid depression did not lead to an additional risk for premature mortality.Conclusions Both somatic comorbidity and comorbid depression are a risk factor for premature mortality among patients with RA. These results emphasize the importance of paying attention to both somatic comorbidity and comorbid depression in clinical practice, and highlight the importance of ascertaining the presence of such comorbidities and to adjust treatment when necessary

Somatic comorbidity and comorbid depression are associated with mortality among patients with established rheumatoid arthritis: an eleven years follow-up cohort study

Background Rheumatoid Arthritis (RA) is associated with premature mortality (1). Somatic comorbidity has been found to be one of the most important predictors for premature mortality (2). Comorbid conditions that are associated with premature mortality are: cardiovascular diseases, respiratory diseases, gastrointestinal system disorders, genitourinary diseases, hematologic diseases, infectious diseases, and malignancies. A few studies have found comorbid depression to be associated with an increased risk for mortality (3). The combination of both somatic comorbidity and comorbid depression as a risk factor for mortality has not yet been investigated. Whether this combination is an additional risk factor for premature mortality is important information for clinicians to be able to adapt their screening process and when necessary their treatment.Objectives To investigate which comorbid conditions are associated with premature mortality and if the combination of a somatic comorbid condition and comorbid depression is more associated with premature mortality than one of these conditions alone.Methods Longitudinal data over a period of eleven years were collected from 882 patients with RA at study inclusion. Data by means of self-reported questionnaires were collected in 1997, 1998, 1999, 2002 and 2008. Of all of the participants included at baseline, the mortality status was obtained from the register of the Statistics Netherlands. Somatic comorbidity was measured by a questionnaire including 20 chronic diseases. Comorbid depression was measured with the Center for Epidemiologic Depression Scale. To study the relationship between comorbidity and survival among RA patients, we performed a Cox regression analysis.Results 78% of the patients at baseline were women. The mean age was 59.3 (SD 14.8) years and the median disease duration was 5.0 (IQR 2.0-14.0) years. Comorbid conditions that were associated with premature mortality were respiratory conditions, gastrointestinal conditions, cancer and comorbid depression. The combination of a somatic comorbid condition and comorbid depression did not lead to an additional risk for premature mortality.Conclusions Both somatic comorbidity and comorbid depression are a risk factor for premature mortality among patients with RA. These results emphasize the importance of paying attention to both somatic comorbidity and comorbid depression in clinical practice, and highlight the importance of ascertaining the presence of such comorbidities and to adjust treatment when necessary

Mortality in patients with rheumatoid arthritis : a 15-year prospective cohort study

The aim of this study was to investigate (a) the mortality in a clinical cohort of patients with established rheumatoid arthritis in comparison with the general Dutch population over 15 years, (b) the trend in the mortality ratio during the study period, and (c) causes of death and compare these with the general population. In 1997, a sample of 1222 patients was randomly selected from the register of a large rheumatology outpatient clinic. Their mortality and primary causes of death between 1997 and 2012 were obtained from Statistics Netherlands. The standardized mortality ratio (SMR) for all-cause mortality and the number of life-years lost in the study period, adjusted for age, sex, and calendar year, were calculated. A linear poisson regression analysis was performed to evaluate change in all-cause SMR over time. Finally, the SMRs for cause-specific mortality were calculated. The mean age of the population at baseline was 60.4 (SD 15.4) years, and 72.6% of the patients were women. The estimated SMR (95% CI) for all-cause mortality was 1.54 (1.41, 1.67) with about one life-year lost over the study period. There was a trend to decreasing SMR (2% annually, p = .07). Mortality was higher compared with the general population for circulatory system diseases, respiratory system diseases, musculoskeletal system diseases, and digestive system diseases (p <.05). The observed mortality among patients with RA was 54% higher than in the general population after adjustment for age, sex and calendar year. More than one life-year was lost over 15 years, and the mortality tended to decrease over time. The mortality was higher for cardiovascular, respiratory, musculoskeletal and digestive diseases

Long-Term Physical Functioning and Its Association With Somatic Comorbidity and Comorbid Depression in Patients With Established Rheumatoid Arthritis: A Longitudinal Study

ObjectiveTo describe long-term physical functioning and its association with somatic comorbidity and comorbid depression in patients with established rheumatoid arthritis (RA). MethodsLongitudinal data over a period of 11 years were collected from 882 patients with RA at study inclusion. Patient-reported outcomes were collected in 1997, 1998, 1999, 2002, and 2008. Physical functioning was measured with the Health Assessment Questionnaire and the physical component summary score of the Short Form 36 health survey. Somatic comorbidity was measured by a questionnaire including 12 chronic diseases. Comorbid depression was measured with the Center for Epidemiologic Studies Depression Scale. We distinguished 4 groups of patients based on comorbidity at baseline. ResultsSeventy-two percent of the patients at baseline were women. The mean +/- SD age was 59.3 +/- 14.8 years and the median disease duration was 5.0 years (interquartile range 2.0-14.0 years). For the total group of patients with RA, physical functioning improved over time. Patients with somatic comorbidity, comorbid depression, or both demonstrated worse physical functioning than patients without comorbidity at all data collection points. Both groups with comorbid depression had the lowest scores. Only patients with both somatic comorbidity and comorbid depression showed significantly less improvement in physical functioning over time. ConclusionBoth somatic comorbidity and comorbid depression were negatively associated with physical functioning during an 11-year followup period. Furthermore, their combination seems to be especially detrimental to physical functioning over time. These results emphasize the need to take somatic comorbidity and comorbid depression into account in the screening and treatment of patients with RA

Long-Term Physical Functioning and Its Association With Somatic Comorbidity and Comorbid Depression in Patients With Established Rheumatoid Arthritis: A Longitudinal Study

ObjectiveTo describe long-term physical functioning and its association with somatic comorbidity and comorbid depression in patients with established rheumatoid arthritis (RA). MethodsLongitudinal data over a period of 11 years were collected from 882 patients with RA at study inclusion. Patient-reported outcomes were collected in 1997, 1998, 1999, 2002, and 2008. Physical functioning was measured with the Health Assessment Questionnaire and the physical component summary score of the Short Form 36 health survey. Somatic comorbidity was measured by a questionnaire including 12 chronic diseases. Comorbid depression was measured with the Center for Epidemiologic Studies Depression Scale. We distinguished 4 groups of patients based on comorbidity at baseline. ResultsSeventy-two percent of the patients at baseline were women. The mean +/- SD age was 59.3 +/- 14.8 years and the median disease duration was 5.0 years (interquartile range 2.0-14.0 years). For the total group of patients with RA, physical functioning improved over time. Patients with somatic comorbidity, comorbid depression, or both demonstrated worse physical functioning than patients without comorbidity at all data collection points. Both groups with comorbid depression had the lowest scores. Only patients with both somatic comorbidity and comorbid depression showed significantly less improvement in physical functioning over time. ConclusionBoth somatic comorbidity and comorbid depression were negatively associated with physical functioning during an 11-year followup period. Furthermore, their combination seems to be especially detrimental to physical functioning over time. These results emphasize the need to take somatic comorbidity and comorbid depression into account in the screening and treatment of patients with RA

Arthritis development in patients with arthralgia is strongly associated with anti-citrullinated protein antibody status: a prospective cohort study

BACKGROUND: Anti-citrullinated protein antibodies (ACPA) are associated with increased risk for rheumatoid arthritis. OBJECTIVE: To investigate the effect of the presence and levels of ACPA on arthritis development in patients with arthralgia. METHODS: Patients with arthralgia positive for ACPA or IgM rheumatoid factor (IgM-RF) were tested for the shared epitope (SE) and were prospectively followed up for at least 12 months. Absence of clinical arthritis at inclusion and arthritis development during follow-up were independently confirmed by two investigators. Cox regression hazard analyses were used to calculate hazard ratios (HRs) for arthritis development. RESULTS: 147 patients with arthralgia were included (50 ACPA positive, 52 IgM-RF positive and 45 positive for both antibodies). After a median follow-up of 28 months (interquartile range (IQR) 19-39), 29 patients developed arthritis in a median of 4 (IQR 3-6) joints and 26 (90%) of these were ACPA positive. The presence of ACPA (HR = 6.0; 95% confidence interval (95% CI) 1.8 to 19.8; p = 0.004), but not of IgM-RF (HR = 1.4, 95% CI 0.6 to 3.1) nor the SE (HR = 1.5, 95% CI 0.7 to 3.0), was associated with arthritis development. Within the group of ACPA-positive patients, the risk for arthritis was enhanced by the presence of IgM-RF (HR = 3.0; 95% CI 1.4 to 6.9; p = 0.01) and high ACPA levels (HR = 1.7; 95% CI 1.1 to 2.5; p = 0.008), but not the SE (HR = 1.0; 95% CI 0.5 to 2.1; p = 1.0). CONCLUSION: In patients with arthralgia the presence of ACPA (but not of IgM-RF or SE) predicts arthritis development. The risk in ACPA-positive patients may be further increased by the concomitant presence of IgM-RF or high levels of ACP