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Many patients discontinue long-term opioid therapy (especially oral opioids) due to adverse events or insufficient pain relief; however, weak evidence suggests that patients who are able to continue opioids long-term experience clinically significant pain relief. Whether quality of life or functioning improves is inconclusive. Many minor adverse events (like nausea and headache) occurred, but serious adverse events, including iatrogenic opioid addiction, were rare.

We conducted a systematic literature review and analysis of programs for evaluating swallowing in order to prevent aspiration pneumonia. This article derives from an evidence report on diagnosis and treatment of swallowing disorders (dysphagia) in acute-car stroke patients prepared by us as an Evidence-based Practice Center (EPC) under contract to the U.S. Agency for Healthcare Research and Quality (AHRQ). Available evidence on the diagnosis and treatment of dysphagia for preventing pneumonia is limited. We found reported pneumonia rates in one historical controlled study of a program using bedside exams (BSE) for acute stroke patients; one uncontrolled case series study of acute stroke patient-reporting of swallowing difficulty; one controlled case series study of videofluoroscopic study of swallowing (VFSS) for acute stroke patients; and one historical controlled study of fiberoptic endoscopic examination of swallowing (FEES) for patients referred for swallowing evaluation in rehabilitation centers. Comparing these results with historical controls indicates that implementation of dysphagia programs is accompanied by substantial reductions in pneumonia rates. While all these methods appeared effective, the small sizes of available studies did not allow determination of the relative efficacy of BSE, VFSS, or FEES.

Conclusion:Less than 5% of patients with asymptomatic carotid stenosis will benefit from revascularization. Patients with asymptomatic carotid stenosis should receive intensive medical therapy and only be considered for revascularization if microemboli are demonstrated by transcranial Doppler (TCD) imaging.Summary: The principle cardiovascular event in patients with asymptomatic carotid stenosis is myocardial infarction rather than stroke (Stroke 1994;25:759-65). Randomized trials have demonstrated a reduction in late stroke with carotid endarterectomy for asymptomatic high-grade carotid stenosis, with a high number needed to treat to prevent one stroke. In addition, the benefit of surgery in these trials occurred in an era of less intense medical therapy than what is prevalent now. The authors previously reported that TCD detection of microemboli is useful in identifying patients with asymptomatic carotid stenosis who might be candidates for revascularization. The authors noted, however, that patients with asymptomatic carotid stenosis with detectable microemboli by TCD have become fewer in number in the last few years. They hypothesized that the incidence of microemboli has been reduced through a possible mechanism of stabilization of carotid plaques with more intensive medical therapy.This study was designed to compare the proportion of asymptomatic carotid stenosis patients with TCD-determined microemboli, cardiovascular events, and carotid plaque progression correlated with baseline medical therapy before and after 2003. The study involved 468 patients collected prospectively with asymptomatic carotid stenosis Ͼ60% as determined by duplex scanning.

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