BackgroundSome studies have suggested that transdermal administration of glyceryl trinitrate (GTN; nitroglycerin) in the first few hours after symptom onset increases the chance of a favourable... Show moreBackgroundSome studies have suggested that transdermal administration of glyceryl trinitrate (GTN; nitroglycerin) in the first few hours after symptom onset increases the chance of a favourable outcome after ischaemic stroke or intracerebral haemorrhage, possibly through an increase in intracranial collateral blood flow and a reduction in blood pressure. The Multicentre Randomised trial of Acute Stroke treatment in the Ambulance with a nitroglycerin Patch (MR ASAP) aims to assess the effect of transdermal GTN, started within 3 h after stroke onset in the prehospital setting, on functional outcome at 90days in patients with acute ischaemic stroke or intracerebral haemorrhage.MethodsMR ASAP is a phase III, multicentre, randomised, open-label clinical trial with a blinded outcome assessment. A total of 1400 adult patients with suspected stroke and a systolic blood pressure140mmHg will be randomised to transdermal GTN (5mg/day), administered as a transdermal patch by paramedics in the prehospital setting within 3h of stroke onset and continued for 24h or to standard care. The primary outcome is the score on the modified Rankin Scale (mRS) at 90days, analysed with ordinal logistic regression. Secondary outcomes include blood pressure and collateral circulation at hospital admission, neurological deficit measured with the National Institutes of Health Stroke Scale at 24h, and mortality and poor outcome (mRS score 3 to 6) at 90days. This trial will be conducted in the Netherlands and will use a deferred consent procedure. The trial is part of the Collaboration for New Treatments of Acute Stroke (CONTRAST) programme.DiscussionMR ASAP will assess whether very early administration of GTN improves outcome after stroke in a setting where rates of intravenous thrombolysis and endovascular treatment for acute ischaemic stroke are high. The deferred consent procedure facilitates prompt GTN treatment and will prevent delay to revascularisation therapies. If early transdermal GTN treatment proves to be effective, this low-cost treatment can be readily implemented into daily clinical practice.Trial registrationISRCTN Registry, ISRCTN99503308. Registered on 2 January 2018. Show less
Polarization is an interesting additional social indicator for analyzing income distribution across countries, as it captures the phenomenon of ‘clustering around extreme poles’. Income... Show morePolarization is an interesting additional social indicator for analyzing income distribution across countries, as it captures the phenomenon of ‘clustering around extreme poles’. Income polarization can be closely linked to social exclusion, which is relevant for EU social policy, because combatting social exclusion is a central element of the Lisbon Agenda and the Europe 2020 Strategy. Rising income polarization has been observed outside Europe, but within the EU, polarization is relatively unexplored. This paper provides theoretical insights into this relatively new dimension of income distribution and analyzes trends in income polarization in 28 EU countries and 3 non-EU countries, using micro-data from EU-SILC over the period 2004–2012. Income polarization is rather stable over this period in European countries, and Europe-wide. It was rising among the old EU15 countries in the sub-period 2004–2008, but declining afterwards. The opposite development is witnessed for New Member States. Despite the Great Recession we find quite stable income polarization in Europe. Show less
