37 research outputs found

    Approche bioéconomique d'optimisation de la gestion de la reproduction dans les populations de bovins laitiers

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    Les décisions de gestion de la reproduction sont complexes et centrales dans les systèmes de production laitière. Évaluer les décisions optimales est difficile en raison des multiples critères à prendre en compte. En effet, la reproduction est directement liée à la prévalence des maladies, à la production laitière et à la longévité des vaches. C’est pourquoi un compromis entre les objectifs et la considération multicritère est proposé. Pour déterminer les coûts et avantages marginaux des stratégies de gestion de la reproduction et de la stratégie optimale maximisant les revenus des agriculteurs sous contrainte de main-d’œuvre, un modèle d’optimisation bioéconomique innovant (DairyHealthSim®) est utilisé. Le modèle de simulation de la partie biologique est basé sur la chaîne Markof sur une durée de 10 ans sur une base vache-semaine qui prend en compte toutes les maladies et les résultats de la production et leurs interactions. L’évaluation économique d’optimisation est basée sur le coût d’opportunité d’une gestion non optimale et le coût marginal de la charge de travail supplémentaire des agriculteurs grâce à une représentation holistique de la dynamique du troupeau et une représentation ouverte des producteurs de la chaîne de valeur. Les résultats montrent que lorsque l'éleveur est progressivement contraint sur sa charge de travail liée à la reproduction, des solutions optimales suggèrent un changement de stratégie pour le taux de détection. Lorsqu'une contrainte plus élevée sur la longévité est appliquée, les résultats optimaux suggèrent un changement dans la stratégie de période d'attente volontaire uniquement pour un niveau élevé de contraintes sur la main-d’œuvre. La marge brute annuelle moyenne de l'agriculteur est très sensible à DR et peu à VWP. Le gain marginal moyen par heure supplémentaire consacrée à la détection des chaleurs varie de 166 € à 450 €

    Impact of opioid rescue medication for breakthrough pain on the efficacy and tolerability of long-acting opioids in patients with chronic non-malignant pain

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    There is little evidence that short-acting opioids as rescue medication for breakthrough pain is an optimal long-term treatment strategy in chronic non-malignant pain. We compared clinical studies of long-acting opioids that allowed short-acting opioid rescue medication with those that did not, to determine the impact of opioid rescue medication use on the analgesic efficacy and tolerability of chronic opioid therapy in patients with chronic non-malignant pain. We searched MEDLINE (1950 to July 2006) and EMBASE (1974 to July 2006) using terms for chronic non-malignant pain and long-acting opioids. Independent review of the search results identified 48 studies that met the study selection criteria. The effect of opioid rescue medication on analgesic efficacy and the incidence of common opioid-related side-effects were analysed using meta-regression. After adjusting for potentially confounding variables (study design and type of opioid), the difference in analgesic efficacy between the 'rescue' and the 'no rescue' studies was not significant, with regression coefficients close to 0 and 95% confidence intervals that excluded an effect of more than 18 points on a 0-100 scale in each case. There was also no significant difference between the 'rescue' and the 'no rescue' studies for the incidence of nausea, constipation, or somnolence in both the unadjusted and the adjusted analyses. We found no evidence that rescue medication with short-acting opioids for breakthrough pain affects analgesic efficacy of long-acting opioids or the incidence of common opioid-related side-effects among chronic non-malignant pain patients

    Soins palliatifs en réanimation : évolutions, limites, enjeux et perspectives

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    Un tiers des patients qui décèdent à l’hôpital trépasse en service de réanimation. Ces services aigus sont donc en lien avec des situations palliatives, et ce parfois bien avant la question de la fin de vie. Pour autant, l’organisation des soins tout autant que la culture professionnelle des soignants oeuvrant dans ces services ne facilite pas les accompagnements. Nous faisons le point dans cet article autour des limites de la notion d’accompagnement palliatif en service de réanimation, leurs natures, et proposons une réflexion sur des évolutions à apporter en ce domaine

    Oral or transdermal opioids for osteoarthritis of the knee or hip.

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    BACKGROUND: Osteoarthritis is the most common form of joint disease and the leading cause of pain and physical disability in the elderly. Opioids may be a viable treatment option if patients suffer from severe pain or if other analgesics are contraindicated. However, the evidence about their effectiveness and safety is contradictory. OBJECTIVES: To determine the effects on pain and function and the safety of oral or transdermal opioids as compared with placebo or no intervention in patients with osteoarthritis of the hip or knee. SEARCH STRATEGY: We searched CENTRAL, MEDLINE, EMBASE, and CINAHL (up to 28 July 2008), checked conference proceedings, reference lists, and contacted authors. SELECTION CRITERIA: Studies were included if they were randomised or quasi-randomised controlled trials that compared oral or transdermal opioids with placebo or no treatment in patients with osteoarthritis of the knee or hip. Studies of tramadol were excluded. No language restrictions were applied. DATA COLLECTION AND ANALYSIS: We extracted data in duplicate. Standardised mean differences (SMDs) and 95% confidence intervals (CI) were calculated for pain and function, and risk ratios for safety outcomes. Trials were combined using inverse-variance random-effects meta-analysis. MAIN RESULTS: Ten trials with 2268 participants were included. Oral codeine was studied in three trials, transdermal fentanyl and oral morphine in one trial each, oral oxycodone in four, and oral oxymorphone in two trials. Overall, opioids were more effective than control interventions in terms of pain relief (SMD -0.36, 95% CI -0.47 to -0.26) and improvement of function (SMD -0.33, 95% CI -0.45 to -0.21). We did not find substantial differences in effects according to type of opioid, analgesic potency (strong or weak), daily dose, duration of treatment or follow up, methodological quality of trials, and type of funding. Adverse events were more frequent in patients receiving opioids compared to control. The pooled risk ratio was 1.55 (95% CI 1.41 to 1.70) for any adverse event (4 trials), 4.05 (95% CI 3.06 to 5.38) for dropouts due to adverse events (10 trials), and 3.35 (95% CI 0.83 to 13.56) for serious adverse events (2 trials). Withdrawal symptoms were more severe after fentanyl treatment compared to placebo (SMD 0.60, 95% CI 0.42 to 0.79; 1 trial). AUTHORS' CONCLUSIONS: The small to moderate beneficial effects of non-tramadol opioids are outweighed by large increases in the risk of adverse events. Non-tramadol opioids should therefore not be routinely used, even if osteoarthritic pain is severe
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