***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Background and Purpose — Retrospective studies have found that patients receiving general anesthesia for endovascular treatment in acute ischemic stroke have worse neurological outcome compared with patients receiving conscious sedation . In this prospect i ve r and omized single-center study , we investigated the impact of anesthesia technique on neurological outcome in acute ischemic stroke patients . Methods — Ninety patients receiving endovascular treatment for acute ischemic stroke in 2013 to 2016 were included and r and omized to general anesthesia or conscious sedation .  Difference in neurological outcome at 3 months , measured as modified Rankin Scale score , was analyzed ( primary outcome ) and early neurological improvement of National Institutes of Health Stroke Scale and cerebral infa rct ion volume . Age , sex , comorbidities , admission National Institutes of Health Stroke Scale score , intraprocedural blood pressure , blood glucose , Paco2 and Pco2 modified Thrombolysis in Cerebral Ischemia score , and relevant time intervals were recorded . Results — In the general anesthesia group 19 of 45 patients ( 42.2 % ) and in the conscious sedation group 18 of 45 patients ( 40.0 % ) achieved a modified Rankin Scale score ⩽2 ( P=1.00 ) at 3 months , with no differences in intraoperative blood pressure decline from baseline ( P=0.57 ) ; blood glucose ( P=0.94 ) ; PaCO2 ( P=0.68 ) ; time intervals ( P=0.78 ) ; degree of successful recanalization , 91.1 % versus 88.9 % ( P=1.00 ) ; National Institutes of Health Stroke Scale score at 24 hours 8 ( 3–5 ) versus 9 ( 2–15 ; P=0.60 ) ; infa rct ion volume , 20 ( 10–100 ) versus 20(10–54 ) mL ( P=0.53 ) ; and hospital mortality ( 13.3 % in both groups ; P=1.00 ) . Conclusions — In endovascular treatment for acute ischemic stroke , no difference was found between general anesthesia and conscious sedation in neurological outcome 3 months after stroke . Clinical Trial Registration — URL : https://www . clinical trials.gov . Unique identifier : NCT01872884 Importance Optimal management of sedation and airway during thrombectomy for acute ischemic stroke is controversial due to lack of evidence from r and omized trials . Objective To assess whether conscious sedation is superior to general anesthesia for early neurological improvement among patients receiving stroke thrombectomy . Design , Setting , and Participants SIESTA ( Sedation vs Intubation for Endovascular Stroke Treatment ) , a single-center , r and omized , parallel-group , open-label treatment trial with blinded outcome evaluation conducted at Heidelberg University Hospital in Germany ( April 2014-February 2016 ) included 150 patients with acute ischemic stroke in the anterior circulation , higher National Institutes of Health Stroke Scale ( NIHSS ) score ( > 10 ) , and isolated/combined occlusion at any level of the internal carotid or middle cerebral artery . Intervention Patients were r and omly assigned to an intubated general anesthesia group ( n = 73 ) or a nonintubated conscious sedation group ( n = 77 ) during stroke thrombectomy . Main Outcomes and Measures Primary outcome was early neurological improvement on the NIHSS after 24 hours ( 0 - 42 [ none to most severe neurological deficits ; a 4-point difference considered clinical ly relevant ] ) . Secondary outcomes were functional outcome by modified Rankin Scale ( mRS ) after 3 months ( 0 - 6 [ symptom free to dead ] ) , mortality , and peri-interventional parameters of feasibility and safety . Results Among 150 patients ( 60 women [ 40 % ] ; mean age , 71.5 years ; median NIHSS score , 17 ) , primary outcome was not significantly different between the general anesthesia group ( mean NIHSS score , 16.8 at admission vs 13.6 after 24 hours ; difference , -3.2 points [ 95 % CI , -5.6 to -0.8 ] ) vs the conscious sedation group ( mean NIHSS score , 17.2 at admission vs 13.6 after 24 hour ; difference , -3.6 points [ 95 % CI , -5.5 to -1.7 ] ) ; mean difference between groups , -0.4 ( 95 % CI , -3.4 to 2.7 ; P = .82 ) . Of 47 prespecified secondary outcomes analyzed , 41 showed no significant differences . In the general anesthesia vs the conscious sedation group , substantial patient movement was less frequent ( 0 % vs 9.1 % ; difference , 9.1 % ; P = .008 ) , but postinterventional complications were more frequent for hypothermia ( 32.9 % vs 9.1 % ; P < .001 ) , delayed extubation ( 49.3 % vs 6.5 % ; P < .001 ) , and pneumonia ( 13.7 % vs 3.9 % ; P = .03 ) . More patients were functionally independent ( unadjusted mRS score , 0 to 2 after 3 months [ 37.0 % in the general anesthesia group vs 18.2 % in the conscious sedation group P = .01 ] ) . There were no differences in mortality at 3 months ( 24.7 % in both groups ) . Conclusions and Relevance Among patients with acute ischemic stroke in the anterior circulation undergoing thrombectomy , conscious sedation vs general anesthesia did not result in greater improvement in neurological status at 24 hours . The study findings do not support an advantage for the use of conscious sedation . Trial Registration clinical trials.gov Identifier : NCT02126085 Purpose — The aim of this guideline is to provide a focused up date of the current recommendations for the  endovascular  treatment of  acute ischemic stroke . When there is overlap , the recommendations made here supersede those of previous guidelines . Methods — This focused up date analyzes results from 8 r and omized , clinical trials of endovascular treatment and other relevant data published since 2013 . It is not intended to be a complete literature review from the date of the previous guideline publication but rather to include pivotal new evidence that justifies changes in current recommendations . Members of the writing committee were appointed by the American Heart Association/American Stroke Association Stroke Council ’s Scientific Statement Oversight Committee and the American Heart Association/American Stroke Association Manuscript Oversight Committee . Strict adherence to the American Heart Association conflict of interest policy was maintained throughout the consensus process . Recommendations follow the American Heart Association/American Stroke Association methods of classifying the level of certainty of the treatment effect and the class of evidence . Prerelease review of the draft guideline was performed by 6 expert peer review ers and by the members of the Stroke Council Scientific Statement Oversight Committee and Stroke Council Leadership Committee . Results — Evidence -based guidelines are presented for the selection of patients with acute ischemic stroke for endovascular treatment , for the endovascular procedure , and for systems of care to facilitate endovascular treatment . Conclusions — Certain endovascular procedures have been demonstrated to provide clinical benefit in selected patients with acute ischemic stroke . Systems of care should be organized to facilitate the delivery of this care BACKGROUND In patients with acute ischemic stroke caused by a proximal intracranial arterial occlusion , intraarterial treatment is highly effective for emergency revascularization . However , proof of a beneficial effect on functional outcome is lacking . METHODS We r and omly assigned eligible patients to either intraarterial treatment plus usual care or usual care alone .  Eligible patients had a proximal arterial occlusion in the anterior cerebral circulation that was confirmed on vessel imaging and that could be treated intraarterially within 6 hours after symptom onset . The primary outcome was the modified Rankin scale score at 90 days ; this categorical scale measures functional outcome , with scores ranging from 0 ( no symptoms ) to 6 ( death ) . The treatment effect was estimated with ordinal logistic regression as a common odds ratio , adjusted for prespecified prognostic factors . The adjusted common odds ratio measured the likelihood that intraarterial treatment would lead to lower modified Rankin scores , as compared with usual care alone ( shift analysis ) . RESULTS We enrolled 500 patients at 16 medical centers in The Netherl and s ( 233 assigned to intraarterial treatment and 267 to usual care alone ) . The mean age was 65 years ( range , 23 to 96 ) , and 445 patients ( 89.0 % ) were treated with intravenous alteplase before r and omization . Retrievable stents were used in 190 of the 233 patients ( 81.5 % ) assigned to intraarterial treatment . The adjusted common odds ratio was 1.67 ( 95 % confidence interval [ CI ] , 1.21 to 2.30 ) . There was an absolute difference of 13.5 percentage points ( 95 % CI , 5.9 to 21.2 ) in the rate of functional independence ( modified Rankin score , 0 to 2 ) in favor of the intervention ( 32.6 % vs. 19.1 % ) . There were no significant differences in mortality or the occurrence of symptomatic intracerebral hemorrhage . CONCLUSIONS In patients with acute ischemic stroke caused by a proximal intracranial occlusion of the anterior circulation , intraarterial treatment administered within 6 hours after stroke onset was effective and safe . ( Funded by the Dutch Heart Foundation and others ; MR CLEAN Netherl and s Trial Registry number , NTR1804 , and Current Controlled Trials number , IS RCT N10888758 . ) BACKGROUND EpiPen and EpiPen Jr autoinjectors are often recommended for prehospital treatment of anaphylaxis . When these units become out date d , there may be a delay in replacing them . OBJECTIVES Our purpose was to evaluate unused , out date d EpiPen and EpiPen Jr autoinjectors  , obtained from patients at risk for anaphylaxis , for epinephrine bioavailability and epinephrine content . METHODS We conducted a prospect i ve , r and omized , cross-over study of epinephrine bioavailability after injection from out date d autoinjectors in rabbits ; controls included EpiPen and EpiPen Jr autoinjectors that had not expired ( " in- date " autoinjectors ) and intramuscular injection of 0.9 % saline solution .  In addition , the epinephrine content of the out date d EpiPen and EpiPen Jr autoinjectors was measured by a spectrophotometric method and an HPLC-UV method . RESULTS Twenty-eight EpiPen and 6EpiPen Jr autoinjectors were studied 1 to 90 months after the stated expiration date . Most were not discolored and did not contain precipitates . Epinephrine bioavailability from the out date d EpiPen autoinjectors was significantly reduced ( P < .05 ) compared with  epinephrine bioavailability from the in- date autoinjectors . The inverse correlation between the decreased epinephrine content of the out date d autoinjectors , assessed with an HPLC-UV method , and the number of months past the expiration date was 0.63 . CONCLUSIONS For prehospital treatment of anaphylaxis , we recommend the use of EpiPen and EpiPen Jr autoinjectors that are not out date d. If , however , the only autoinjector available is an out date d one , it could be used as long as no discoloration or precipitates are apparent because the potential benefit of using it is greater than the potential risk of a suboptimal epinephrine dose or of no epinephrine treatment at all Injectable formulations of L-adrenaline are commonly used in emergency medicine . Despite numerous studies , the comparative contribution and kinetics of the L-adrenaline inactivation pathways during storage have not been conclusively evaluated . We examined the kinetics of L-adrenaline degradation in a prospect i ve study and determined the extent of drug inactivation by different pathways during and beyond the stipulated product shelf-life in 42 batches of adrenaline ampules stored under controlled conditions . The content of L-adrenaline and degradation products was determined with a chiral high-performance liquid chromatography ( HPLC ) assay , and the degradation products were identified by mass spectrometric detection as D-adrenaline and L- and D-adrenaline sulfonate . The kinetics of the content change with storage was analyzed simultaneously for L-adrenaline and the degradation products using kinetic modeling . The lower acceptable level of adrenaline content in the formulation stated by US Pharmacopoeia ( 90 % as a sum of L- and D-isomers ) was attained after 2.0 years of storage , at which time the content of the therapeutically active L-isomer amounted to as low as 85 % . The modeling revealed significant differences in the degradation kinetics in the formulations produced before and after 1997 , whose cause remained unidentified in this study Background : The aim of the current study was to assess the influence of anesthetic management on the effect of treatment in the Multicenter R and omized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherl and s ( MR CLEAN ) . Methods : MR CLEAN was a multicenter , r and omized , open-label trial of intra-arterial therapy ( IAT ) vs no IAT .  The intended anesthetic management at the 
    Output:
    
An EpiPen Jr kept 4 years after expiration would probably not deliver an adequate dose to a child on the upper end of the indicated weight range