Joseph R. Anticaglia, M.D. Robert Thayer Sataloff, M.D. Mary Hawkshaw, RN., B.S.N.

Care of the Professional Voice ASSOCIATE EDITOR: Robert 1. Sataloff, MD, DMA

What Singing Teachers Should Know About Complementary, Alternative,

and Integrated Medicine

INTRODUCTION

Millions of Americans spend bil-lions of dollars annually on comple-mentary and alternative medicine (CAM), which includes the use of herbal products. Some CAM herbal preparations are beneficial, and oth-ers have no proven efficacy. Some are safe, and others are potentially harm-ful. Additionally, the quality of the product may vary from one manufac-turing company to another, and often, the ingredients listed on the label do not correspond to the product in the bottle. Recommended dosages of herbal products are not uniformly agreed upon, and the manufacturers are not regulated sufficiently at this time. Some singers use CAM indis-criminately despite these uncertain-ties and risks, and it behooves them, their singing teachers, and their health

Journal of Singing, September/October 2005 Volume 62, No. 1, pp. 45-52 Copyright 2005 National Association of'reachers of Singing

rare providers to become familiar with the potential benefits and risks of tak-ing complementary and alternative remedies.

Complementary medicines are ther-apies used along with or in addition to conventional medicine. In other words, the two (or more) therapies are used in concert since together they produce a therapeutic effect different from those produced separately, e.g., the use of massage for low back pain "along with" muscle relaxants. Alter-native medicine uses therapies in place of conventional medicine, e.g., home-opathy to treat rheumatoid arthritis, or the use of laetril to treat cancer (proven unsuccessful). Integrative medicine incorporates proven effec-tive outcomes of CAM with conven-tional medicine.

CAM is not limited to herbal prod-ucts. Homeopathy is based on the principles of similars and dilutions. Similars work on the concept that if a specific substance causes symptoms

in a healthy person similar to those of an ill patient, that substance can be used to cure the sick individual ("like cures like"). Dilutions use the principle that small doses of toxic sub-stances stimulate a beneficial immune response or "vital force" in the body.

Traditional Chinese medicine in-corporates acupuncture and herbal remedies. Chiropractors and osteo-paths use manipulation techniques. Some CAM practitioners utilize mas-sage, hypnosis, biofeedback, medita-tion; others use prayer and spiritual-ity, energy or naturopathy, as well as a host of other modalities.

The field of alternative and com-plementary medicine is vast. As of February 2003, the on-line research resource Pub-Med of the National Library of Medicine has listed more than 220,000 published abstracts or full articles. The challenge is to dis-tinguish the therapies that are useful from the useless, and those that are safe from the dangerous.

SIPrENtBER/OcrolLR 2005 45

Joseph ft Anticaglia, Robert Thayer Sataloff, and Mary Hawkshaw

Herbal products come from plants that have been investigated for their biochemical composition and poten-tial use as medication. Many people use the terms "herbal medicine" and "natural" (plants occur in nature) medicine interchangeably. A matter of concern is that many individuals, including singers, erroneously equate "natural" with safe and effective. The distinction between herbal products and conventional medications is grad-ually being obliterated. All biochem-ical products are potential poisons. The side effects of medications, al-though usually minor, may at times be disabling, devastating, or even fatal, whether it is an herbal product or conventional drug. When one intro-duces a foreign substance into the body, there is always the potential for an adverse reaction.

QUALITY CONTROL/ PRODUCT REGULATION

Pharmaceutical manufacturers must go through several phases before their drugs are deemed safe for use in humans and before it is determined which pharmaceuticals require a pre-scription and which do not. This pro-cess is called regulation. The safety, effectiveness, and side effects of the product must meet premarket stan-dards, as regulated by the Federal Drug Administration (FDA).

In contrast, when Congress passed the 1994 Dietary Supplement Health and Education Act (DSHEA), CAM manufacturers were able to put their products on the market without qual-ity control standards including FDA regulation and approval. This "free ride" is now being challenged by the FDA that sets regulations regarding the purity, quality, and strength of the products (recommended daily doses).'

The FDA has documented cases of supplements that have been contam-inated with lead, instances in which the declared amount of an ingredient (isoflavone) has been lacking by fifty percent, other examples (probiotics) lacking by 99 percent, and an instance in which the strength of a product (niacin) had been increased by a fac-tor of ten times resulting in nausea, vomiting, heart attack, and liver dam-age before the manufacturer recalled the product.' Contamination of herbal products has occurred with microor-ganisms (bacteria—staphylococcus aureus); heavy metals (lead, mercury; arsenic); radioactive agents (1-131); pesticides (DDT); microbial toxins (bacterial endotoxins); other plants (digitalis, belladonna); fumigation agents (ethylene oxide and adulter-ated with analgesics, diuretics, non-steroidal anti-inflammatory medica-tion and steroids).:

Until accurate labeling and manu-facturing controls are put in place, one must be especially diligent about purchasing supplements and herbal products from reputable companies with standardized formulations. The FDA has proposed rules regarding the labeling and manufacturing of supplements and herbal products; but, to date, it has not addressed the ques-tion of safety and effectiveness of these preparations.

HERBAL PRODUCTS

There are hundreds of herbal prod-ucts marketed (alone or in combina-tion) in the United States. CAM man-ufacturers are not allowed legally to claim their product cures or prevents disease, but they can say and have said things such as it boosts the immune system, burns fat, enhances stamina and energy, stimulates men-tal function, fights fatigue, improves

memory, elevates mood, fights osteo-porosis, and many other assertions. Below are selective considerations of several herbal products.

Kava Kava, also known as Kava-Kava,

is derived from the plant piper meth-ysticum; it is a member of the piper family, a plant native to the South Pacific islands. People use Kava to treat restlessness, and to reduce stress and anxiety.

Studies support the effectiveness of Kava for short-term use (one to eight weeks) for anxiety disorders.' Kava's ingredients, known as Kava-lactones, have an anxiolytic (calm-ing) and sedative effect.

Of paramount concern, Kava can cause unpredictable, severe liver dam-age that has required liver transplants in several patients,' and it has been implicated in deaths due to liver tox-icity. Hepatitis, cirrhosis, and liver failure have been reported as well as adverse effects including jaundice (yellowing of the skin), gastrointesti-nal upset, and impaired motor reflexes.

Some countries have limited its dis-tribution or banned its use (Switzer-land, Germany, Canada). If one can-not ascertain a set dosage for Kava or the mechanism by which it is broken down in the body, the consumption of products containing Kava poses an unacceptable health risk, and, in the primary author's opinion, it should be avoided. Certainly the health risk is heightened in those patients with liver problems, those who use drugs, herbs, or products whose effects or side effects are similar to Kava. For example, antihistamines, sedatives, alcohol, sleeping pills, St. John's Wort, ginseng, and chamomile are among the substances that can heighten drowsiness, and place one more at risk for liver damage.

46 JOURNAL OF SINGING

Care of the Professional Voice

Ginkgo biloba The ginkgo tree, which thrives in

China, Korea, and Japan, has been around for more than two hundred million years, can live more than one thousand years, and is considered by some to be one of the wonders of the world, a "living fossil."' Extracts of the ginkgo leaves contain active ingre-dients such as flavonoids, terpenoids that have antioxidant (prevent oxi-dation; process by which the body metabolizes ingested products), and anticoagulant (blood thinning) prop-erties. The majority of studies indi-cate that ginkgo is likely to be effec-tive in helping concentration and memory, and can help circulation for "intermittent claudication" (pain in the lower legs after walking due to vascular insufficiency). However, there are potentially untoward effects and side effects from ginkgo that must be considered before it is taken.

The usual recommended dose of ginkgo can cause palpations, gastroin-testinal upsets, headache, and other side effects. Large doses can cause nausea, vomiting, and restlessness. One of the most worrisome potential side effects of ginkgo is excessive spon-taneous bleeding (its anticoagulant property). There have been reports of spontaneous brain hemorrhage and excessive postoperative bleeding asso-ciated with ginkgo use. 7 These are rare occurrences, but potentially dev-astating. It is conceivable that inap-propriate use of ginkgo in singers could be a contributing factor in vocal fold hemorrhage, particularly in com-bination with other anticlotting prod-ucts such as aspirin, nonsteroidal anti-inflammatory drugs (NSAID), coumadin, or other herbs such as gar-lic, ginger, or ginseng.

Ginkgo extract can alter blood glu-cose levels. Therefore, in diabetic patients using insulin, glucose mon-

itoring should be done more fre-quently.' Ginkgo may reduce the effec-tiveness of seizure medications, and ginkgo should be used cautiously or avoided totally in patients prone to seizures disorders.' Ginkgo might interfere with fertility and generally should not be used by couples who are trying to conceive." People tak-ing thiazide, a diuretic, should avoid using ginkgo leaves because it can increase blood pressure."

Echinacea Echinacea is a perennial herb that

is native to the United States. Echi-nacea purpura is the plant most fre-quently used for research and herbal treatment. People use this American purple cone flower to treat upper res-piratory infections, influenza, and the common cold, as well as myriad other conditions. 2 Echinacea seems to be most effective in reducing the duration and severity of certain symp-toms of the common cold or influenza if it is taken when symptoms first appear and continued for seven to ten days.

Echinacea, in the short term, can have a stimulating effect on the im-mune system. However, if it is used for more than eight weeks, it may sup-press the immune system and may cause liver damage.' 3 Since Echinacea might stimulate the autoimmune sys-tem, it should be avoided in individ-uals with autoimmune disorders such as multiple sclerosis, psoriasis, rheu-matoid arthritis, and perhaps patients with HIV/AIDS.' 4 If one has liver problems or is taking medications that potentially can cause liver toxicity (such as Methotrexate, a chemother-apeutic agent that is sometimes used for rheumatoid arthritis, and autoim-mune ear disease), one should avoid taking Echinacea. Certain allergic pa-tients should avoid taking Echinacea

particularly if they are allergic to rag-weed, marigolds, daisies, chrysanthe-mums, or chamomile.

St. Johns Wort St. John's Wort is an herb with yel-

low flowers derived from Hype ricun perforatum, which is cultivated in the United States, Africa, Asia, and Europe. Wort, not to be confused with "wart," comes from the old English "wyrt," meaning plant. One explanation for the plant's common name is that its flowers typically blossom aroundJune 24, the birthday of St. John the Baptist. However, there are other folklore explanations for its name.

In the middle ages, people used St. John's Wort to cast out evil spirits for afflictions such as mental illness. St. John's Wort has gained widespread popularity and usage in recent years since its effectiveness as an antide-pressant medication has fewer side effects for mild to moderate depres-sion" and for Seasonal Affective Disorder (SAD—depression peaking in the fall/winter and declining dur-ing the spring/summer when there is more sunlight).

Side effects of St. John's Wort, al-though uncommon, include insom-nia, dry mouth, upset stomach, fatigue, dizziness, photosensitivity (hypersen-sitivity to light), and headache. This herb should be used cautiously with other antidepressants such as nefa-zodone (Serzone) Bristol-Meyers-Squib, sertraline (Zoloft) Pfizer, or paroxetine (Paxil) Glaxo-Smith-Kline, since it might cause "Serotonin Syndrome," a serious complication resulting in an increase in serotonin levels that may result in hypertension, extreme anxiety, tachycardia (increase in heart rate), confusion, and coma. 16

The herb may reduce the therapeutic effect of digitalis, decrease the con-centration of oral contraceptives caus-

SEPTEMBER/OCTnBER 2005 47

Joseph R. Anticaglia, Robert Thayer Sataloff, and Mary Hawkshaw

Herbal Products

Common Name Scientific Name Use Adverse Reactions Comments

Ginkgo, Ginkgo, Ginkgo Memory, and con- Bleeding, GJ. upset, Avoid using it with blood thinning Maidenhair Tree biloba centration, inter- headache, palpations, (anticoagulant) medication (e.g.,

mittent claudica- restlessness, nausea, coumadin, aspirin), insulin, thiazide tion, Alzheimer's, vomiting diuretics, antidepressants, antipsy-altitude sickness chotics.

Echinacea, Echinacea pur- Common cold, Liver damage. Avoid using it with liver toxic drugs Purple cone pura, E.pallida, upper respiratory Initially, it stimulates (Methotrexate), calcium channel flower, Black E. anugustifolia infections (flu) the immune system; blockers (Verapamil), antianxiety Sampson after 8 weeks maybe drugs (Valium), steroids

immuno-suppressive (Prednisone), patients with autoim-mune disease (e.g., HIV/ AIDS), Cross-Allergenicity (e.g., daisies, ragweed, marigolds).

St. John's Wort, Hypericum per- Antidepressant, Insomnia, anxiety, Avoid using SJW with herbal or pre-SJW, Amber, foratum Seasonal Affective G.I. upset, vivid scription products until you are Goatweed, Disorder (SAD), dreams, fatigue, photo- aware of the adverse reactions and Klamath weed anxiety sensitivity intermen- interactions of these medications.

strual bleeding Refer to text.

Ephedra. Ephedra sinica Reduce weight, Heart attacks, strokes, Avoid its use. Ephedra may be fatal. Ma Huang enhance physical seizures, hyperten-

performance sion, death

Valerian, Valeriana offici- Sedative-hypnotic, Morning drowsiness 22 Can cause additive effects with Phu,Garden nalis anxiolytic2' alcohol, and other medications that Heliotrope have sedative properties.

Ginseng, Korean Panax ginseng Improves cognitive Agitation, insomnia Avoid using with caffeine, blood and American (Korean); Panax function 23 ; lowers nervousness; estro- thinning and antidiabetic ginseng. quinque-folium fasting blood glu- genic effects may medication.

(American) cose24 cause vaginal bleeding

Saw Palmetto, Serenoa repens, Benign prostatic Infrequently, G.I. Improves urinary symptoms of BPH Dwarf palm tree Hypertrophy, upset, an instance of with fewer side effects 25 compared to

(UPH) intraoperative hemor- the drug finasteride (Proscar). Use rhage cautiously if at all with blood thin-

ning medication (coumadin, aspirin).

Horse Chestnut Aesculus Chronic venous G.I. upset, kidney toxi- Useful for CVI, 27 avoid use with (seed) hippocasta-num insufficiency city26 blood thinning medication, monitor

(CVI), varicose glucose levels in diabetic patients. veins

Pycnogenol, Pinus maritime CVI , varicose None reported Reduces edema by decreasing capil-Pine Bark P. pinaster veins, diabetic and lary permeability. Extract other etinopathies

48 JOURNAL OF SINGING

Care of the Professional Voice

Common Name Scientific Name Use Adverse Reactions Comments

Milk thistle Silybum marianum Cirrhosis of the Occasional laxative A member of the daisy family, the liver, hepatitis, effects German E Commission (compara. jaundice, liver poi- ble to FDA in USA) has approved soning (e.g., mush- its use for liver disorders as noted room poisoning) here under "use."

Garlic Allium sativum Lowers LDH (low Halitosis, G.I. upset. Can increase the risk of bleeding; density lipopro- the therapeutic effect is modest tein) and choles- compared to other cholesterol low-terol2l ering drugs.

Kava, Kava Kava Piper methysticum Stress, anxiety dis- Liver toxicity, G.I. Avoid using it. Several European orders" upset, headache, governments have banned its use.

dizziness Especially harmful in combination with liver toxic drugs, sedatives, sleeping pills, alcohol, Levadopa (Parkinson's Disease).

ing break-through bleeding and possi-bly pregnancy, and it can decrease the concentration of protease inhibitors and medications used for HIV/AIDS patients. It should be avoided in indi-viduals who are taking tetracycline, sulfa, and quinolones (e.g., Cipro), since in combination with these drugs it can contribute to an increased sen-sitivity to sunlight with resultant der-matitis, sunburn, inflamed mucous membranes, and oral blistering. The interaction of St. John's Wort with certain amino acids, for example tyra-mine-containing foods (red wine, chocolate, cheese, eggs) and trypto-phan (cottage cheese, beef liver, fish, peanuts), might cause a hypertensive crisis. 17 People with hypertension should be especially alert to these inter-actions of St. Johns Wort.

Ephedra, Ma Huang Ephedra comes principally from

Ephedra sinica, a shrub-like plant that is native to China. It should be dis-tinguished from the alkaloid-free American ephedra or Mormon tea,

which does not have either the tox-icity or therapeutic effects of ephedra.

For thousands of years, the Chinese have used Ephedra in pill or tea form for asthma, cough, and the common cold. Today, Ephedra is used most commonly to lose weight and to improve physical performance. It is clinically related to amphetamines (speed), and is found in a variety of products. Aspiring singers may use it to lose weight. A milder form of Ephedra, pseudoephedrine, is found in many decongestants, cold and cough medicines.

Side effects from Ephedra are not infrequent and can be life threaten-ing. It has been linked to heart attacks, hypertension, stroke, and seizures; such incidents have occurred in young professional athletes. Ephedra can constrict blood vessels, increase heart rate, and cause thermogenesis (ele-vation of the body temperature) and heat stroke. It has been associated with personality changes and depend-ency after long term use)5

The interaction of Ephedra with

caffeinated drinks can increase the side effects of nervousness, insom-nia, and dizziness. It can make some steroids less effective, elevate blood glucose, and should be avoided in patients with conditions such as angina, anxiety, heart disease, hypo-thyroidism, hypertension, diabetes, and urinary retention (e.g., patients with enlarged prostates). The Federal Drug Administration has received hundreds of reports linking Ephedra or Ephedrine use to serious side effects including deaths. Until better guide-lines are formulated, it is best to avoid Ephedra products.

Surgery One should avoid herbal medica-

tions for at least fourteen days prior to surgery, according to the American Society of Anesthesiologists." Ginkgo, ginger, ginseng, and garlic can con-tribute to excessive bleeding. Valerian and Kava can potentiate (increase) the sedative effects of anesthetics. Ephedra can provoke hypertension, cardiac irregularities, and tempera-

SEPTEMBER/OCTOBER 2005 49

Joseph R. Anticaglia, Robert Thayer Sataloff, and Mary Hawkshaw

ture elevation. Ginseng can lower blood sugar .20 Kava and Echinacea can cause liver damage particularly in conjunction with certain anesthetic

liver. Preoperatively, patients should let their surgeon and anesthesiologist know about all the medications they are taking, including all herbal and other CAM products.

CONCLUSIONS

In general, herbal therapies and conventional drugs are safe. Legally, herbs are foods that do not treat or cure disease. However, in the med-ical world, they are drugs that can help or hurt one's well-being. Even if the FDA imposes premarket safety and efficacy standards, singers and other voice professionals should take herbal products for the right reasons, at the right time, and from reputable manufacturers who have standard-ized the formulations of their prod-ucts. They should let responsible peo-ple know what medications they are taking, and recognize that at certain times they will be at greater risks com-pared to others because of the use of these substances.

The side effects, interactions, lack of quality control, and proven effec-tiveness of some herbal preparations have serious ramifications for profes-sional voice users, and the risks may seriously outweigh the benefits. What is on the label may not work or be in the bottle. Until more randomized control trials (RCT) are done to sub-stantiate the safety and usefulness of herbal products, one should use cau-tion in buying supplements.

Singing and acting teachers, speech-language pathologists, and laryngol-ogists are in a unique position to influ-ence the behavior of their clients. The above examples highlight only a few of the great many herbal products

available, and they emphasize the need for all who interact with voice per-formers to be aware of the strengths and limitations of CAM and to edu-

fessionals under their care.

NOTES

I. "FDA Proposes Labeling and Manu-facturing Standards for All Dietary Supplements," FDA News (7 March 2003).

2. Ibid.

3. E. Ernst and M. H. Pittler, "Medical Clinics of North America," Herbal Medicine 86, no- 1(2002): 149-161.

4. M. H. Pittler and E. Ernst, "Efficacy of Kava Extract for Treating Anxi-ety: Systemic Review and Meta-analy-sis,"Journal of Clinical Psycho phary-inacoloqy 20, no. 1 (2000): 84-89. H. P. Volz and N. Kieser, "Kava-kava Extract WS 1400 vs. Placebo in Anx-iety Disorders: Randomized Placebo-controlled 26-week Out-patient Tri-als," Pha rmaco psychology 30, no. I (1997): 1-5.

5. N. Escher,J. Desmeules, E. Giostra, and M. Gilles, "Drug Points: Hepati-tis Associated with Kava, an Herbal Remedy for Anxiety," British Med- ical journal 322 (2001): 139. K. Shaver, "Liver Toxicity with Kava," Pharmacist's Letter/Prescribers Let-ter 18 (2001): 18015.

6. M. T. Murray, The Healing Power of Herbs (Rocklin, CA: Prima Publish-ing, 1995).

7. J . Gilbert, "Ginkgo Biloba," Neurol-ogy48 (1997):1137,j. Rowin and S. L Lewis, "Spontaneous Bilateral Sub-dural Hematomas with Chronic Ginkgo Biloba Ingestion," Neurology 46(1996): 1775-76.J. N. Fessenden, W. W. Wittenborn, and L. Clark, "Ginkgo Biloba: A Case Report of Herbal Medicine and Bleeding Post-operatively from a Laparoscopic Cholecystectomy," American Surgeon 67 (2001)::33-35.

8. G. B. Kudulo, "The Effect of 3-month Ingestion of Ginkgo Biloba Extract on Pancreatic Beta-cell Function in Response to Glucose Loading in Nor-mal Glucose Tolerant Individuals," Clinical Pharmacology 40, no. 6 (2000): 647-654.

9. B. J. Gregory, "A Seizure Associated with Ginkgo Bioba?" Annual of Inter-nal Medicine 134, no. 4 (2001): 324.

10. R. R. Ondrizek, P. J. Chan, and A. King, "Inhibition of Human Sperm Motility by Specific Herbs Used in Alternative Medicines," Journal of Assisted Reproduction and Genetics 16 (1999): 87-91.

11. M.J.Jellin, B. J. Gregory, S. Patz, K. Hitchens, et al., Natural Medicine Comprehensive Data Base, 4th Edi-tion (Stockton, CA: Therapeutic Research Factory, 2002), 589.

12. R. N. Brinkeborn, D. V. Shah, and F. H. Degenring, "Echinaforce and Other Echinacea Fresh Plant Prepa-rations in the Treatment of Common Colds. A Randomized, Placebo Con-trolled, Double Blind Clinical Trial," Phytomedicine6 ( 1999): 1-6.

13. K. Bruss, ed., The American Cancer Society Guide to Complementary and Alternative Cancer Methods ( The American Cancer Society, 2000), 273.

14.J . T. Giles, C. T. Palat III, S. H. Chien, et al., "Evaluation of Echinacea for the Treatment of the Common Cold," Pharmacotherapy 20, no- 6 (2000): 690-97.

15. H. L. Ken,J. Streltzer, and D. Goe-bert, "St. John's Wort for Depression: A Meta-analysis of Well-defined Clin-ical Trials,"Journal of Nervous Men-tal Disorders 187 (1999): 532-39

16. T. M. Brown, "Acute St. John's Wort Toxicity," A nwri can Journal of E,ncr-gency Medicine 18 (2000): 231-32.

17. I. G. Merr, "Herbal Medicinals. Selec-tive Clinical Considerations Focus-ing on Known or Potential Drug-Herb Interactions," Archives of Internal Medicine 158 (1998): 1200-2000.

agents that also may be toxic to the cate the singers and other voice pro-

50 JOURNAl. OF SINGING

Care of the Professional Voice

18. H. Doyle and N. Kargin, "Herbal Stimulant Containing Ephedrine Has Also Caused Psychosis," British Med-ical Journal 313 (1996): 756. C. A. Hailer and M. L. Benowitz, "Adverse Cardiovascular and Central Nervous System Events Associated with Dietary Supplements Containing Ephedra Alkaloids," New England Journal of Medicine 343, no. 25 (2000): 1833-38.

19. R. Sabar, A. D. Kaye, and E. A. Frost, "Perioperative Considerations for the Patient Taking Herbal Medicines," Heart Disorders 3, no.2 (March/April 2001): 87-96.

20. J . B. Surow, "Alternative Medical Therapy' Use Among Singers: Preva-lence and Implications for the Med-ical Care of the Singer," journal of Voice 14, no. 3 (2000): 398-409.

21. M. Blumenthal, W. Busse, A. Golberg, et al. (ed.), The Complete German Commission E Monographg: Thera -peutic Guide to Herbal Medicines (Austin: American Botanical Coun-cil, 1998).

22. J. Kuhlmann, W. R. Berger, H. Podau-weit, et al., "The Influence of Valer-ian Treatment on 'Reaction Time, Alertness and Concentration' in Vol-unteers," Pharmaco psychology 32, no. 6 (1999): 234-41.

23. H. Sorensen and J. Sonne, "A Dou-ble Masked Study of the Effects of Ginseng on Cognitive Function," Cur-rent Therapy Review 57, no. 12 (1996): 959.

24. E. A. Sotaniemi, E. Haupkoske, A. Rautio, et al., "Ginseng Therapy in Non-insulin Dependent Diabetic Patients," Diabetes Care 18, no. 10 (1995):230-38.

25. T. J. Wilt, A. Ishuni, G. Stark, et al., "Saw Palmetto Extracts for Treat-ment of Benign Prostatic Hype rpla-sia: A Systematic Review," journal of the A men can Medical Association 200 (1998): 1604-09.

26. Jellin, Gregory, Patz, Hitchens, et al., 695.

27. M. H. Pittler and E. Ernst, "Horse-Chestnut Seed Extract for Chronic Venous Insufficiency," Archive of Der-matology 134 (1998): 1356-60.

28. P. Arcangeli, "Pyenogenol in Chronic Venous Insufficiency," Filoterapi.a 71 (2000): 236-40.

29. W. H. Sunter, "Warfarin and Garlic," Pharmacology Journal 246 (1991): 722.

30. Pittler and Ernst, "Efficacy of Kava Extract," 84-89.

Robert T Sataloff MD, DMA is Professor of Otolanjngologg at Jefferson Medical Col-lege, ThomasJeffcrson University in Phila-delphia; Chairman of the Department of Otolarijngolog,y-Head and Neck Surgery at Graduate Hospital; Adjunct Professor Otorhinolaryngolo,qy-Head and Neck Surgery, The University ofPennsylvania; on the faculty of the Academy of Vocal Arts; Conductor of the Thomas Jefferson Uni-versity Choir and Orchestra; Director of

the Jefferson Arts-Medical Center; and Director of The Voice Foundation's Annual Symposium on Care of the Professional Voice. Dr. Sataloff is also a professional singer and singing teacher. He holds an undergraduate degree from Haverford Col-lege in Music Composition, grad uated from Jefferson Medical College, received a DMA in Voice Performance from Combs College of Music, and completed his Residency in Otolaryngologjj-Head and Neck Surgery at the University of Michigan. He also com-pleted a Fellowship in Otology, Neurotology, and Skull Base Surgery at the University ofMichigan. Dr. Sataloff is Chairman of the Board of Directors of The Voice Founda-tion and of the American Institute for Voice and Ear Research. He is Editor-in-Chief oftheJournal of Voice, Editor-in-Chief of

the Ear, Nose and Throat Journal, and an Associate Editor of the journal of Singing, on the Editorial Board of Med-ical Problems of Performing Artists, and numerous other major otolaryngoloçjy jour-nals in the United States. Dr. Sataloff has

written over 500 publications, including twenty-nine books. Dr. Sataloff's medical practice is limited to care of the professional voice and to otology/neurotology/skull base surgery.

MarjjJ. Hankshaw, RN, BSN, CORLN has worked with Di: Sataloff since 1987 She has served as secretary/treasurer of

American Institute of Voice and Ear Re-search (AIVER) since 1988, and was named executive director ofAIVER inJan-uary 2000. She has also served on the Board of Directors of The Voice Foundation since 1990. She is agraduate of Shadyside Hos-pital School of Nursing in Pittsburgh, and holds a Bachelor of Science degree in nurs-ing from ThomasJefferson College ofAllied Health Sciences in Philadelphia. Along with Dr. Sataloff, she has coauthored and published more than ninety articles and two textbooks. She has served on the Edi-torial Board of the Journal of Voice since its inception, the Journal of ORL-Head and Neck Nursing, and the Journal of Occupational Hearing Loss. She has been an active member in the Society of Oto-laryngologic Head and Neck Nurses (SOHN) since 1988. She is recognized nationally and internationally for her extensive involvement in the subs pecia lt.ij of care of the professional voice.

Dr.Joseph Anticaglia received his BA degree from New York University, and his med-ical degree from the University of Bologna, Italy.

He served as Chief Medical Officer in the United States Public Health Service, re-searching health problems related to indus-trial noise exposure. In this capacity, he supervised scientific projects and published articles concerning physiology of the ear, loss of hearing, and other topics related to industrial otology. He completed his resi-dency at Thomas Jefferson University, Philadelphia, in Otolaryngology-Head and Neck Surgery and Facial Plastic Sur-gery. He also completed a Fellowship in the Care of Professional Voice. u'orkintj with

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Anthony Dean Griffey tA l.lr\ I.j tenor P,.' pj.lfljct

5p,ns<iid by the Marilyn Hori,. ,,,nd.it,on

Auditions: Auditions to participate in the Festival will be held at the Baldwin-Wallace College Conservatory of Music on February 4 and in New York City at Steinway Hall on February 18. Tape auditions are acceptable. Application deadline is January 5, 2006. Applicants must be a singer/pianist team. Ten teams will be selected to participate in the master classes offered by the guest artists and will perform in recital on the final day of the Festival.

Nonparticipants: Students, teachers and listeners may audit the Festival events including master classes, recitals, recep-tions and special workshops. Experience all the Art Song Festival has to offer and learn new techniques and repertoire.

Information: To receive a team application or for more information contact:

Dr. Joanne Uniatowski, Executive Director - ASF E-mail; artsong@bw.edu or 440-826-SONG

(440-826-7664)

52 JOURNAL OF SINGING