Preventing Episodic Migraine With Caloric Vestibular Stimulation: A Randomized Controlled Trial.

OBJECTIVE: To evaluate the safety and efficacy of a novel solid-state, caloric vestibular stimulation (CVS) device to provide adjuvant therapy for the prevention of episodic migraine in adult migraineurs. BACKGROUND: Migraine causes significant disability in ∼12% of the world population. No current migraine preventive treatment provides full clinical relief, and many exhibit high rates of discontinuation due to adverse events. Thus, new therapeutic options are needed. CVS may be an effective and safe adjuvant-therapy for the prevention of episodic migraine. METHODS: In a multicenter, parallel-arm, block-randomized, placebo-controlled clinical trial (clinicaltrials.gov: NCT01899040), subjects completed a 3-month treatment with the TNM™ device for CVS (refer to Fig. 2 for patient enrollment and allocation). The primary endpoint was the change in monthly migraine days from baseline to the third treatment month. Secondary endpoints were 50% responder rates, change in prescription analgesic usage and difference in total subjective headache-related pain scores. Device safety assessments included evaluation of any impact on mood, cognition, or balance. RESULTS: Per-protocol, active-arm subjects showed immediate and continued steady declines in migraine frequency over the treatment period. After 3 months of treatment, active-arm subjects exhibited significantly fewer migraine days (-3.9 ± 0.6 from a baseline burden of 7.7 ± 0.5 migraine days). These improvements were significantly greater than those observed in control subjects (-1.1 ± 0.6 from a baseline burden = 6.9 ± 0.7 migraine days) and represented a therapeutic gain of -2.8 migraine days, CI = -0.9 to -4.7, P = .012. Active arm subjects also reported greater reductions in acute medication usage and monthly pain scores compared to controls. No adverse effects on mood, cognition, or balance were reported. Subjects completed the trial with an average rate of 90% treatment adherence. No serious or unexpected adverse events were recorded. The rate of expected adverse events was similar across the active and the placebo groups, and evaluation confirmed that subject blinding remained intact. CONCLUSION: The TNM™ device for CVS appears to provide a clinically efficacious and highly tolerable adjuvant therapy for the prevention of episodic migraine.

The relationship between HIV and AIDS and water scarcity in Nyamakate resettlements land, north-central Zimbabwe.

HIV and AIDS and water variability have been studied separately, yet, they impact on rural households simultaneously in an interactive manner. The study provide narratives on various realities from a study in the Nyamakate community that illustrates the dialectical relationship between HIV and AIDS and water scarcity. A qualitative research methodology was employed, and the following data collection tools were used: semi-structured interviews, focus group discussions (FGDs) and participant observations. The study showed that in the Nyamakate area, HIV- and AIDS-affected households utilise more water if there is a bedridden patient. Such households utilise an average of 145 litres per day and reported a water shortage of 103 litres per day. Although community rules and customs stipulate that water should be accessible to everyone, exclusion of HIV- and AIDS-affected households is underlined by cultural issues, scorn at poor levels of hygiene, infectious opportunistic infections and labour shortage, which limited access to water points by households directly affected by HIV and AIDS. In cases where women were overwhelmed with caregiving roles, men fetch water. We conclude that HIV and AIDS and water scarcity are dialectically related and hence should be considered in an interactive manner in order to understand the challenges faced by affected households.

Caught between the global economy and local bureaucracy: the barriers to good waste management practice in South Africa.

Empirical research shows that good waste management practice in South Africa is not always under the volitional control of those tasked with its implementation. While intention to act may exist, external factors, within the distal and proximal context, create barriers to waste behaviour. In addition, these barriers differ for respondents in municipalities, private industry and private waste companies. The main barriers to implementing good waste management practice experienced by respondents in municipalities included insufficient funding for waste management and resultant lack of resources; insufficient waste knowledge; political interference in decision-making; a slow decision-making process; lack of perceived authority to act by waste staff; and a low priority afforded to waste. Barriers experienced by respondents in private industry included insufficient funding for waste and the resultant lack of resources; insufficient waste knowledge; and government bureaucracy. Whereas, barriers experienced in private waste companies included increasing costs; government bureaucracy; global markets; and availability of waste for recycling. The results suggest that respondents in public and private waste organizations are subject to different structural forces that shape, enable and constrain waste behaviour.

Part II--the effect of data on waste behaviour: the South African waste information system.

Combining the process of learning and the theory of planned behaviour into a new theoretical framework provides an opportunity to explore the impact of data on waste behaviour, and consequently on waste management, in South Africa. Fitting the data to the theoretical framework shows that there are only three constructs which have a significant effect on behaviour, viz experience, knowledge, and perceived behavioural control (PBC). Knowledge has a significant influence on all three of the antecedents to behavioural intention (attitude, subjective norm and PBC). However, it is PBC, and not intention, that has the greatest influence on waste behaviour. While respondents may have an intention to act, this intention does not always manifest as actual waste behaviour, suggesting limited volitional control. The theoretical framework accounts for 53.7% of the variance in behaviour, suggesting significant external influences on behaviour not accounted for in the framework. While the theoretical model remains the same, respondents in public and private organisations represent two statistically significant sub-groups in the data set. The theoretical framework accounts for 47.8% of the variance in behaviour of respondents in public waste organisations and 57.6% of the variance in behaviour of respondents in private organisations. The results suggest that respondents in public and private waste organisations are subject to different structural forces that shape knowledge, intention, and resultant waste behaviour.

Part 1: The role of waste data in building knowledge: the South African waste information system.

An empirical study was undertaken with 31 organisations submitting data to the South African Waste Information System (SAWIS) in order to explore the relationship between data and resultant waste knowledge generated through a process of learning. The results show that of the three constructs of knowledge (experience, data/information, and theory), experience has the greatest influence on building waste knowledge, nearly twice that of data/information and three times that of theory. Together the three constructs account for 54.1% of the variance in knowledge. Respondents from municipalities and private waste organisations reflect two distinct sub-groups in the data set. While the theoretical model remains the same for the two sub-groups, the way in which knowledge is constructed, and the variance in knowledge explained by the model, differs for the two. A mixed methods research design, combining quantitative statistical analysis and rich qualitative data, contributes to a comprehensive interpretation of the role of waste data in building knowledge in South Africa. While waste data has a minor influence on building knowledge, respondents acknowledge that waste data does have a positive impact on the way their organisations manage waste. However, it is not the data, but rather the resultant waste knowledge and raised level of awareness that causes the operational response. Experience is obtained predominantly through learning from others. Respondents in municipalities, emphasised learning from consultants, landfill site contractors, and colleagues in city-twinning programmes, while respondents in private waste companies, emphasised learning from experienced, senior colleagues.

Improving waste management through a process of learning: the South African waste information system.

Piloting of the South African Waste Information System (SAWIS) provided an opportunity to research whether the collection of data for a national waste information system could, through a process of learning, change the way that waste is managed in the country, such that there is a noticeable improvement. The interviews with officials from municipalities and private waste companies, conducted as part of the piloting of the SAWIS, highlighted that certain organizations, typically private waste companies have been successful in collecting waste data. Through a process of learning, these organizations have utilized this waste data to inform and manage their operations. The drivers of such data collection efforts were seen to be financial (business) sustainability and environmental reporting obligations, particularly where the company had an international parent company. However, participants highlighted a number of constraints, particularly within public (municipal) waste facilities which hindered both the collection of waste data and the utilization of this data to effect change in the way waste is managed. These constraints included a lack of equipment and institutional capacity in the collection of data. The utilization of this data in effecting change was further hindered by governance challenges such as politics, bureaucracy and procurement, evident in a developing country context such as South Africa. The results show that while knowledge is a necessary condition for resultant action, a theoretical framework of learning does not account for all observed factors, particularly external influences.

Towards the creation of a health information system for cancer in KwaZulu-Natal, South Africa.

The paper aims to evaluate the potential of Geographical Information Systems (GIS) in the creation of a health information system (HIS) for cancer. A case study describes the spatial distribution of reported cancer in KwaZulu-Natal, South Africa and correlates this with levels of development. The study illustrates the problems of data shortage in a developing country. The mapping of reported cancer reveals a concentration of cancer in the developed metropolitan districts, where the hospitals are located. The study therefore provides a 'geography of accessibility to treatment centres' due to the under-reporting of the disease. Despite incomplete data and under-reporting of the disease, the study illustrates the potential of GIS to add value to a HIS for cancer.

Long-term use of narcotic/antidepressant medication in the management of phantom limb pain.

The successful management of 5 consecutive patients with intractable phantom limb pain is described. The main therapy is a combination of a narcotic and antidepressant. Medication remained effective during the average observation time of 22 months. There were no signs of habituation or addiction. We conclude that narcotics can be safely and successfully utilized for long-term management of phantom limb pain.

Intrathecal normal saline without preservative does not have a local anesthetic effect.

The effects of intrathecally administered normal saline (preservative-free) were studied in patients undergoing differential spinal block anesthesia for evaluation of chronic pain below the waist. The injection of 5 ml saline did not significantly change the sensitivity to pinprick measured in the lower back and both lower extremities. Temperature measurement in both the lower extremities and psychogalvanic skin reflex did not show evidence of sympathetic block; the psychogalvanic skin reflex was abandoned because of inconsistent results. These findings refute the earlier conclusion of Urban and McKain who found that normal saline acts as a weak local anesthetic when injected intrathecally. We recommend use of normal saline (preservative-free) in 5 ml doses as a placebo for differential spinal block anesthesia.