The Advisory Committee on Immunization Practices (ACIP), which advises the Centers for Disease Control and Prevention (CDC) on vaccine issues, voted on the new recommendation during its February 24, 2010 meeting in Atlanta. The vote took place against a backdrop of incremental increases in the numbers and groups of people recommended for influenza vaccination in years past, and lessons learned from the world’s still ongoing first flu pandemic in 40 years.

Prior to today’s vote, ACIP recommendations for seasonal influenza vaccination – which focused on vaccination of higher risk persons, children 6 months through 18 years of age and close contacts of higher risk persons – already applied to about 85 percent of the U.S. population.

Discussion at the ACIP meeting focused on the value of protecting all people 19 to 49 years of age, who have been hard hit by the 2009 H1N1 pandemic virus, which is likely to continue circulating into next season and beyond. Another reason cited in favor of a universal recommendation for vaccination is that many people in currently recommended “higher risk” groups are unaware of their risk factor or that they are recommended for vaccination. The ACIP discussion also recognized the practicality and value of issuing a simple and clear message regarding the importance of influenza vaccination in the hopes that this would remove impediments to vaccination and expand coverage. Finally, new data collected over the course of the 2009 H1N1 pandemic indicates that some people who do not currently have a specific recommendation for vaccination may also be at higher risk of serious flu-related complications, including those people who are obese, post-partum women and people in certain racial/ethnic groups.

More influenza vaccine doses will be required to vaccinate all adults. However, based on current projections, more licensed types and brands of seasonal influenza vaccines will be available in the 2010-11 influenza season than has ever been available before. Historically, uptake of seasonal influenza vaccine has been less than half of the number of persons with a specific recommendation for vaccination.

Annual influenza vaccination is a safe and preventive health action that benefits all age groups. However, certain people have a higher risk for influenza complications, including people aged 65 years and older, children younger than 6 months of age, pregnant women, and people of any age with certain chronic medical conditions.

These people, their household and close contacts, and all health care personnel should continue to be a primary focus for vaccination efforts as providers and programs transition to routinely vaccinating all people 6 months of age and older.

Results of the study, published in the Annals of Allergy, Asthma and Immunology, show there are missed opportunities to intervene early and thus relieve a child’s symptoms, possibly reduce the extent of the attack and prevent visits to the emergency room.

The study stems from comments received by two lay asthma coaches employed by Washington University School of Medicine. The coaches are trained to help educate families dealing with asthma by offering information and social support. They also have asthma themselves or a family member who has it.

While talking to parents of children with asthma, the coaches noticed that parents were often unsure of exactly how to use albuterol, a bronchodilator that relaxes muscles in the airways and increases airflow to the lungs, when they noticed signs that their child’s asthma symptoms were worsening. The study followed up on those observations to determine if they are true among a larger group.

Asthma is one of the most common childhood diseases in the United States. Every year, two of every three children with asthma have at least one attack, or exacerbation. These exacerbations often result in missed school days, visits to the emergency room and hospitalizations. But researchers at the School of Medicine say some of these exacerbations could be prevented with early home treatment with albuterol.

For the study, the coaches telephoned 101 parents of children ages 2-12 who had recent visits to the emergency department at St. Louis Children’s Hospital with an asthma exacerbation or who had called the hospital’s After Hours Call Center. More than 60 percent of the families had Medicaid insurance. The coaches surveyed the parents about how they detected that their child was about to have an asthma attack and what they did to prevent or treat it.

Parents reported noticing signs such as coughing, wheezing, shortness of breath, chest tightness or pain, cold or allergy symptoms, or even behavioral signs such as becoming quiet or more temperamental.

“Every time the child had an exacerbation, many parents noticed the same medley of signs preceding it,” says Jane Garbutt, M.B., Ch.B., associate professor of medicine and of pediatrics. “But even though they noticed the signs consistently, they often didn’t do anything about it. If parents had known to give albuterol earlier, they may have been able to manage things at home and avoid a trip to the emergency room,” says Garbutt, also director of the Washington University Pediatric and Adolescent Ambulatory Research Consortium.

Garbutt says one of the reasons parents may not begin treatment is that they believe they are following doctor’s instructions.

“The asthma plan from the doctor often says to start using albuterol when parents notice the child is wheezing or coughing or short of breath, but the doctor may have a different definition for those symptoms than the parent,” Garbutt says.

Another problem the researchers found was that parents may not notice some of the early signs that predict an exacerbation. One in four parents who was interviewed reported seeing late signs of an exacerbation in the child, including gasping for breath or sucking in the rib muscles when breathing.

“Those kids have to go to the emergency department because they are too far along in their exacerbation to do anything at home,” Garbutt says. “If we can talk to parents and find out that’s the issue, we can teach them to take action sooner.”

In some instances, parents knew they needed to give their child albuterol, but weren’t sure how much or how often.

“Parents varied in terms of how often they used it, if they used it with a nebulizer, how often they repeated it and how they determined if it was working,” Garbutt says. “A careful assessment of exactly which medicines are used and how they are administered and dosed could identify problems. We think that is something that can be addressed with education.”

Prednisone is a corticosteroid that prevents the release of inflammatory-causing substances in the body. Many parents said they kept the drug on hand at home in case of an asthma attack, but few parents in this study used it, instead calling the doctor’s office or going to the emergency room.

Garbutt and fellow researchers are conducting a follow-up study in which the asthma coaches are working with physicians to promote earlier use of albuterol as well as other effective self-management behaviors. In addition, the coaches are working with parents to help them identify the early signs of an asthma exacerbation by giving parents a symptom diary to help parents see symptom patterns.

Source: Annals of Allergy; Asthma and Immunology, Washington University in St. Louis (2/10/2010)

“For hundreds of years, the cause of stuttering has remained a mystery for researchers and health care professionals alike, not to mention people who stutter and their families,” said James F. Battey, Jr., M.D., Ph.D., director of the NIDCD. “This is the first study to pinpoint specific gene mutations as the potential cause of stuttering, a disorder that affects 3 million Americans, and by doing so, might lead to a dramatic expansion in our options for treatment.”

Stuttering is a speech disorder in which a person repeats or prolongs sounds, syllables, or words, disrupting the normal flow of speech. It can severely hinder communication and a person’s quality of life. Most children who stutter will outgrow stuttering, although many do not; roughly 1 percent of adults stutter worldwide. Current therapies for adults who stutter have focused on such strategies as reducing anxiety, regulating breathing and rate of speech, and using electronic devices to help improve fluency.

Stuttering tends to run in families, and researchers have long suspected a genetic component. Previous studies of stuttering in a group of families from Pakistan had been done by Dennis Drayna, Ph.D., a geneticist with the NIDCD, which indicated a place on chromosome 12 that was likely to harbor a gene variant that caused this disorder.

In the latest research, Dr. Drayna and his team refined the location of this place on chromosome 12 and focused their efforts on the new site. They sequenced the genes surrounding a new marker and identified mutations in a gene known as GNPTAB in the affected family members. The GNPTAB gene is carried by all higher animals, and helps encode an enzyme that assists in breaking down and recycling cellular components, a process that takes place inside a cell structure called the lysosome.

They then analyzed the genes of 123 Pakistani individuals who stutter — 46 from the original families and 77 who are unrelated — as well as 96 unrelated Pakistanis who don’t stutter, and who served as controls. Individuals from the United States and England also took part in the study, 270 who stutter and 276 who don’t. The researchers found some individuals who stutter possessed the same mutation as that found in the large Pakistani family. They also identified three other mutations in the GNPTAB gene which showed up in several unrelated individuals who stutter but not in the controls.

GNPTAB encodes its enzyme with the help of another gene called GNPTG. In addition, a second enzyme, called NAGPA, acts at the next step in this process. Together, these enzymes make up the signaling mechanism that cells use to steer a variety of enzymes to the lysosome to do their work. Because of the close relationship among the three genes in this process, the GNPTG and NAGPA genes were the next logical place for the researchers to look for possible mutations in people who stutter. Indeed, when they examined these two genes, they found mutations in individuals who stutter, but not in control groups.

The GNPTAB and GNPTG genes have already been tied to two serious metabolic diseases known as mucolipidosis (ML) II and III. MLII and MLIII are part of a group of diseases called lysosomal storage disorders because improperly recycled cell components accumulate in the lysosome. Large deposits of these substances ultimately cause joint, skeletal system, heart, liver, and other health problems as well as developmental problems in the brain. They are also known to cause problems with speech.

“You might ask, why don’t people with the stuttering mutations have more serious complications? Why don’t they have an ML disease?” posed Dr. Drayna, senior author of the paper. “ML disorders are recessive. You need to have two copies of a defective gene in order to get the disease. Nearly all of the unrelated individuals in our study who stuttered had only one copy of the mutation. Also, with stuttering, the protein is still made, but it’s not made exactly right. With ML diseases, the proteins typically aren’t made at all. Still, there are a few complexities remaining to be understood, and we’d like to learn more about them.”

The findings open new research avenues into possible treatments for stuttering. For example, current treatment methods for some lysosomal storage disorders involve injecting manufactured enzyme into a person’s bloodstream to replace the missing enzyme. The researchers wonder if enzyme replacement therapy might be a possible method for treating some types of stuttering in the future.

The researchers estimate that roughly 9 percent of people who stutter possess mutations in one of the three genes. Among the next steps, they are conducting a worldwide epidemiological study to better determine the percentage of people who carry one or more of these mutations. They are also conducting biochemical studies to determine specifically how the mutations affect the enzymes. A long-term goal is to use these findings to determine how this metabolic defect affects structures within the brain that are essential for fluent speech.

Source: National Institutes of Health (NIH), February 10, 2010.

The U.S. Food and Drug Administration approved Kalbitor (ecallantide) on Dec. 1 to treat sudden and potentially life-threatening fluid buildup that can occur in people with a rare genetic condition known as hereditary angioedema (HAE).

HAE is caused by a defect in the blood protein C1 esterase-inhibitor, which plays a role in regulating how certain immune system and blood clotting pathways function. Decreased function of this protein can lead to rapid and serious swelling of the face or other parts of the body, which may result in permanent disfigurement, disability or death. Swelling of the digestive tract may cause excruciating abdominal pain, nausea, and vomiting, while airway swelling puts patients at risk of suffocation. About 10,000 people in the United States have HAE.

“Kalbitor offers another potentially life-saving option for those people with HAE,” said John Jenkins, M.D., director, Office of New Drugs, in the FDA’s Center for Drug Evaluation and Research. “FDA is committed to facilitating the development and approval of safe and effective therapies for patients with rare conditions.”

This is the second drug marketed in the United States to treat HAE attacks. In October 2009 the FDA approved Berinert, a C1-inhibitor derived from blood plasma to treat facial and abdominal attacks of HAE.

Kalbitor is a liquid that is intended to be injected under the skin for patients age 16 and older who experience HAE attacks.

The medication’s most serious side effect is anaphylaxis, a severe allergic reaction that can close a person’s airways and stop them from breathing. Other side effects include headache, nausea, diarrhea, swelling in the nose and throat, fever, and skin irritations.

Kalbitor should only be administered by a healthcare professional with appropriate medical support to manage anaphylaxis.

The drug is marketed by Dyax Corp., Cambridge, Mass. The second HAE drug, Berinert, is marketed by CSL Behring Inc., Marburg, Germany.

Agriflu, manufactured by Novartis Vaccines and Diagnostics in Siena, Italy, was approved using the FDA’s accelerated approval pathway, which helps safe and effective medical products for serious or life-threatening diseases become available sooner. In this case, Novartis demonstrated that the vaccine induced levels of antibodies in the blood likely to be effective in preventing seasonal influenza.

Agriflu is administered as a single injection in the upper arm and is available in single dose, pre-filled syringes that do not contain preservatives.

“The approval of the new seasonal influenza vaccine, Agriflu, is an important step in adding to the production capacity to enhance the supply of vaccine for the United States for future influenza seasons,” said Karen Midthun, M.D., acting director of the FDA’s Center for Biologics Evaluation and Research.

Common side effects in clinical studies included pain, swelling and redness at the injection site, headache, muscle aches and malaise. People with severe or life-threatening allergies to chicken eggs, or to any other substance in the vaccine, should not be vaccinated.

Novartis is required to conduct further studies to verify that the vaccine will decrease seasonal influenza disease after vaccination.

The company also manufactures another licensed seasonal influenza vaccine, Fluvirin, for use in the United States. Fluvirinis approved for people ages 4 years and older.

Ayurvedic Medicine: The Basics

• The aim of Ayurvedic medicine is to integrate and balance the body, mind, and spirit. This is believed to help prevent illness and promote wellness.
• Ayurvedic medicine uses a variety of products and techniques to cleanse the body and restore balance. Some of these products may be harmful if used improperly or without the direction of a trained practitioner. For example, some herbs can cause side effects or interact with conventional medicines.
• Before using Ayurvedic treatment, ask about the practitioner’s training and experience.
• Tell your health care providers about any complementary and alternative practices you use. Give them a full picture of what you do to manage your health. This will help ensure coordinated and safe care.

History of Ayurvedic Medicine

Ayurvedic medicine, also called Ayurveda, originated in India several thousand years ago. The term “Ayurveda” combines the Sanskrit words ayur (life) and veda (science or knowledge). Thus, Ayurveda means “the science of life.”

In the United States, Ayurvedic medicine is considered a type of CAM and a whole medical system. As with other such systems, it is based on theories of health and illness and on ways to prevent, manage, or treat health problems.

Ayurvedic medicine aims to integrate and balance the body, mind, and spirit; thus, some view it as “holistic.” This balance is believed to lead to happiness and health, and to help prevent illness. Ayurvedic medicine also treats specific physical and mental health problems. A chief aim of Ayurvedic practices is to cleanse the body of substances that can cause disease, thus helping to reestablish harmony and balance.

Ayurvedic Medicine in India

Ayurvedic medicine, as practiced in India, is one of the oldest systems of medicine in the world. Many Ayurvedic practices predate written records and were handed down by word of mouth. Two ancient books, written in Sanskrit more than 2,000 years ago, are considered the main texts on Ayurvedic medicine—Caraka Samhita and Sushruta Samhita. The texts describe eight branches of Ayurvedic medicine:

• Internal medicine
• Surgery
• Treatment of head and neck disease
• Gynecology, obstetrics, and pediatrics
• Toxicology
• Psychiatry
• Care of the elderly and rejuvenation
• Sexual vitality.

Ayurvedic medicine continues to be practiced in India, where nearly 80 percent of the population uses it exclusively or combined with conventional (Western) medicine. It is also practiced in Bangladesh, Sri Lanka, Nepal, and Pakistan.

Most major cities in India have an Ayurvedic college and hospital. The Indian government began systematic research on Ayurvedic practices in 1969, and that work continues.

Use of Ayurvedic Medicine in the United States

According to the 2007 National Health Interview Survey, which included a comprehensive survey of CAM use by Americans, more than 200,000 U.S. adults had used Ayurvedic medicine in the previous year.

Underlying Concepts of Ayurvedic Medicine

Ayurvedic medicine has several key foundations that pertain to health and disease. These concepts have to do with universal interconnectedness, the body’s constitution (prakriti), and life forces (doshas).

Interconnectedness. Ideas about the relationships among people, their health, and the universe form the basis for how Ayurvedic practitioners think about problems that affect health. Ayurvedic medicine holds that:

• All things in the universe (both living and nonliving) are joined together.
• Every human being contains elements that can be found in the universe.
• Health will be good if one’s mind and body are in harmony, and one’s interaction with the universe is natural and wholesome.
• Disease arises when a person is out of harmony with the universe. Disruptions can be physical, emotional, spiritual, or a combination of these.

Constitution (prakriti). Ayurvedic medicine also has specific beliefs about the body’s constitution. Constitution refers to a person’s general health, the likelihood of becoming out of balance, and the ability to resist and recover from disease or other health problems.

The constitution is called the prakriti. The prakriti is a person’s unique combination of physical and psychological characteristics and the way the body functions to maintain health. It is influenced by such factors as digestion and how the body deals with waste products. The prakriti is believed to be unchanged over a person’s lifetime.

Life forces (doshas). Important characteristics of the prakriti are the three life forces or energies called doshas, which control the activities of the body. A person’s chances of developing certain types of diseases are thought to be related to the way doshas are balanced, the state of the physical body, and mental or lifestyle factors.

Ayurvedic medicine holds the following beliefs about the three doshas:

• Each dosha is made up of two of five basic elements: ether (the upper regions of space), air, fire, water, and earth.
• Each dosha has a particular relationship to bodily functions and can be upset for different reasons.
• Each person has a unique combination of the three doshas, although one dosha is usually prominent. Doshas are constantly being formed and reformed by food, activity, and bodily processes.
• Each dosha has its own physical and psychological characteristics.
• An imbalance of a dosha will produce symptoms that are unique to that dosha. Imbalances may be caused by a person’s age, unhealthy lifestyle, or diet; too much or too little mental and physical exertion; the seasons; or inadequate protection from the weather, chemicals, or germs.

The doshas are known by their original Sanskrit names: vata, pitta, and kapha.

The vata dosha combines the elements ether and air. It is considered the most powerful dosha because it controls very basic body processes such as cell division, the heart, breathing, discharge of waste, and the mind. Vata can be aggravated by, for example, fear, grief, staying up late at night, eating dry fruit, or eating before the previous meal is digested. People with vata as their main dosha are thought to be especially susceptible to skin and neurological conditions, rheumatoid arthritis, heart disease, anxiety, and insomnia.

The pitta dosha represents the elements fire and water. Pitta controls hormones and the digestive system. A person with a pitta imbalance may experience negative emotions such as anger and may have physical symptoms such as heartburn within 2 or 3 hours of eating. Pitta is upset by, for example, eating spicy or sour food, fatigue, or spending too much time in the sun. People with a predominantly pitta constitution are thought to be susceptible to hypertension, heart disease, infectious diseases, and digestive conditions such as Crohn’s disease.

The kapha dosha combines the elements water and earth. Kapha helps to maintain strength and immunity and to control growth. An imbalance of the kapha dosha may cause nausea immediately after eating. Kapha is aggravated by, for example, greed, sleeping during the daytime, eating too many sweet foods, eating after one is full, and eating and drinking foods and beverages with too much salt and water (especially in the springtime). Those with a predominant kapha dosha are thought to be vulnerable to diabetes, cancer, obesity, and respiratory illnesses such as asthma.

Ayurvedic Treatment

Ayurvedic treatment is tailored to each person’s constitution. Practitioners expect patients to be active participants because many Ayurvedic treatments require changes in diet, lifestyle, and habits.

The patient’s dosha balance. Ayurvedic practitioners first determine the patient’s primary dosha and the balance among the three doshas by:

• Asking about diet, behavior, lifestyle practices, recent illnesses (including reasons and symptoms), and resilience (ability to recover quickly from illness or setbacks)
• Observing such physical characteristics as teeth and tongue, skin, eyes, weight, and overall appearance
• Checking the patient’s urine, stool, speech and voice, and pulse (each dosha is thought to make a particular kind of pulse).

Treatment practices. Ayurvedic treatment goals include eliminating impurities, reducing symptoms, increasing resistance to disease, and reducing worry and increasing harmony in the patient’s life. The practitioner uses a variety of methods to achieve these goals:

• Eliminating impurities. A process called panchakarma is intended to cleanse the body by eliminating ama. Ama is described as an undigested food that sticks to tissues, interferes with normal functioning of the body, and leads to disease. Panchakarma focuses on eliminating ama through the digestive tract and the respiratory system. Enemas, massage, medical oils administered in a nasal spray, and other methods may be used.
• Reducing symptoms. The practitioner may suggest various options, including physical exercises, stretching, breathing exercises, meditation, massage, lying in the sun, and changing the diet. The patient may take certain herbs—often with honey, to make them easier to digest. Sometimes diets are restricted to certain foods. Very small amounts of metal and mineral preparations, such as gold or iron, also may be given.
• Increasing resistance to disease. The practitioner may combine several herbs, proteins, minerals, and vitamins in tonics to improve digestion and increase appetite and immunity. These tonics are based on formulas from ancient texts.
• Reducing worry and increasing harmony. Ayurvedic medicine emphasizes mental nurturing and spiritual healing. Practitioners may recommend avoiding situations that cause worry and using techniques that promote release of negative emotions.

Use of plants. Ayurvedic treatments rely heavily on herbs and other plants—including oils and common spices. Currently, more than 600 herbal formulas and 250 single plant drugs are included in the “pharmacy” of Ayurvedic treatments. Historically, Ayurvedic medicine has grouped plant compounds into categories according to their effects (for example, healing, promoting vitality, or relieving pain). The compounds are described in texts issued by national medical agencies in India. Sometimes, botanicals are mixed with metals or other naturally occurring substances to make formulas prepared according to specific Ayurvedic text procedures; such preparations involve several herbs and herbal extracts and precise heat treatment.

Practitioner Training and Certification

Many practitioners study in India, where there are more than 150 undergraduate and 30 postgraduate colleges for Ayurvedic medicine. Training can take 5 years or longer. Students who receive their Ayurvedic training in India can earn either a bachelor’s degree (Bachelor of Ayurvedic Medicine and Surgery, BAMS) or doctoral degree (Doctor of Ayurvedic Medicine and Surgery, DAMS) there. After graduation, some Ayurvedic practitioners choose to provide services in the United States or other countries.

The United States has no national standard for training or certifying Ayurvedic practitioners, although a few states have approved Ayurvedic schools as educational institutions.

Concerns About Ayurvedic Medications

Ayurvedic practice involves the use of medications that typically contain herbs, metals, minerals, or other materials. Health officials in India and other countries have taken steps to address some concerns about these medications. Concerns relate to toxicity, formulations, interactions, and scientific evidence.

Toxicity. Ayurvedic medications have the potential to be toxic. Many materials used in them have not been thoroughly studied in either Western or Indian research. In the United States, Ayurvedic medications are regulated as dietary supplements. As such, they are not required to meet the safety and efficacy standards for conventional medicines. An NCCAM-funded study published in 2004 found that of 70 Ayurvedic remedies purchased over-the-counter (all manufactured in South Asia), 14 contained lead, mercury, and/or arsenic at levels that could be harmful. Also in 2004, the Centers for Disease Control and Prevention reported that 12 cases of lead poisoning occurring over a recent 3-year period were linked to the use of Ayurvedic medications.

Formulations. Most Ayurvedic medications consist of combinations of herbs and other medicines. It can be challenging to know which components are having an effect and why.

Interactions. Whenever two or more medications are used, there is the potential for them to interact with each other. As a result, the effectiveness of at least one may increase or decrease in the body.

Scientific evidence. Most clinical trials (i.e., studies in people) of Ayurvedic approaches have been small, had problems with research designs, lacked appropriate control groups, or had other issues that affected how meaningful the results were. Therefore, scientific evidence for the effectiveness of Ayurvedic practices varies, and more rigorous research is needed to determine which practices are safe and effective.

Other Points To Consider About Using Ayurvedic Medicine

• Tell your health care providers about any complementary and alternative practices you use, including Ayurvedic medicine. Give them a full picture of what you do to manage your health. This will help to ensure coordinated and safe care.
• Women who are pregnant or nursing, or people who are thinking of using Ayurvedic therapy to treat a child, should be especially sure to consult their health care provider.
• It is important to make sure that any diagnosis of a disease or condition has been made by a provider who has substantial conventional medical training and experience with managing that disease or condition.
• Proven conventional treatments should not be replaced with an unproven CAM treatment.
• It is better to use Ayurvedic remedies under the supervision of an Ayurvedic medicine practitioner than to try to treat yourself.
• Before using Ayurvedic treatment, ask about the practitioner’s training and experience.
• Find out whether any rigorous scientific studies have been done on the therapies in which you are interested.

Essential oils (also known as volatile oils) are the basic materials of aromatherapy. They are made from fragrant essences found in many plants. These essences are made in special plant cells, often under the surface of leaves, bark, or peel, using energy from the sun and elements from the air, soil, and water. If the plant material is crushed, the essence and its unique fragrance are released.

When essences are extracted from plants in natural ways, they become essential oils. They may be distilled with steam and/or water, or mechanically pressed. Oils that are made with chemical processes are not considered true essential oils.

There are many essential oils used in aromatherapy, including Roman chamomile, geranium, lavender, tea tree, lemon, cedarwood, and bergamot. Each type of essential oil has a different chemical structure that affects how it smells, how it is absorbed, and how it is used by the body. Even varieties of plants within the same species may have chemical structures different from each other because they are grown or harvested in different ways or locations.

Essential oils are very concentrated. For example, it takes about 220 lbs of lavender flowers to make about 1 pound of essential oil. Essential oils are very volatile, evaporating quickly when they come in contact with air.

How is Aroma Therapy Administered

Aromatherapy is most often used in one of two ways:

• Inhalation (taking into the body by breathing). This can be done by using a diffuser or placing drops of essential oils near the patient.
• Topical treatment (applied to the surface of the body), usually in a diluted form. This can be done by massaging with essential oils diluted in a carrier oil, or by using essential oils in bathwater, lotions, or dressings.

Aromatherapy is rarely taken by mouth.

There are some essential oils commonly chosen to treat specific conditions. However, the types of oils used and the ways they are combined may vary, depending on the experience and training of the aromatherapist. This lack of standard methods has led to conflicting research on the effects of aromatherapy.

Laboratory and Animal Studies of Aroma Therapy

Many studies of essential oils have found that they have antibacterial effects when applied to the skin. In addition, studies in rats have shown that different essential oils can be calming or energizing. When rats were exposed to certain fragrances under stressful conditions, their behavior and immune responses were improved.

One study showed that after essential oils were inhaled, markers of the fragrance compounds were found in the bloodstream, suggesting that aromatherapy affects the body directly like a drug, rather than indirectly through the central nervous system.

Clinical Trials with Aroma Therapy

Clinical trials of aromatherapy have mainly studied its use in the treatment of stress, anxiety, and other health-related conditions in seriously ill patients. Several clinical trials of aromatherapy in patients with cancer have been published with mixed results.

A few early studies have shown that aromatherapy may improve quality of life in patients with cancer. Some patients receiving aromatherapy have reported improvement in symptoms such as nausea or pain, and have lower blood pressure, pulse, and respiratory rates.

Studies of massage with or without aromatherapy in cancer patients found that they had less anxiety and more restful sleep, although there is mixed evidence about whether aromatherapy itself adds to the benefits of massage therapy.

A small study of tea tree oil as a topical treatment to clear antibiotic-resistant MRSA bacteria from the skin of hospital patients found that it was as effective as the standard treatment.

Aroma Therapy Risks and Side Effects

Safety testing on essential oils shows very few bad side effects or risks when they are used as directed. Some essential oils have been approved as ingredients in food and are classified as GRAS (generally recognized as safe) by the U.S. Food and Drug Administration, within specific limits. Eating large amounts of essential oils is not recommended.

Allergic reactions and skin irritation may occur in aromatherapists or in patients, especially when essential oils are in contact with the skin for long periods of time. Sun sensitivity may develop when citrus or other oils are applied to the skin before sun exposure.

Lavender and tea tree oils have been found to have some hormone-like effects. They have effects similar to estrogen (female sex hormone) and also block or decrease the effect of androgens (male sex hormones). Applying lavender and tea tree oils to the skin over a long period of time has been linked to breast enlargement in boys who have not yet reached puberty. It is not known if the use of lavender and tea tree oils is safe for women who have a high risk for breast cancer that is estrogen-receptive.

Source: NCCAM, National Institutes of Health

Common Names—aloe vera, aloe, burn plant, lily of the desert,
elephant’s gall

Latin Names—Aloe vera, Aloe barbadensis

What Aloe Vera Is Used For

• Traditionally, aloe was used topically to heal wounds and for various skin conditions, and orally as a laxative.
• Today, in addition to traditional uses, people take aloe orally to treat a variety of conditions, including diabetes, asthma, epilepsy, and osteoarthritis. People use aloe topically for osteoarthritis, burns, and sunburns.
• Aloe vera gel can be found in hundreds of skin products, including lotions and sunblocks.
• The Food and Drug Administration (FDA) has approved aloe vera as a natural food flavoring.

How Aloe Vera Is Used

• Aloe leaves contain a clear gel that is often used as a topical ointment.
• The green part of the leaf that surrounds the gel can be used to produce a juice or a dried substance (called latex) that is taken by mouth.

What the Science Says About Aloe Vera

• Aloe latex contains strong laxative compounds. Products made with various components of aloe (aloin, aloe-emodin, and barbaloin) were at one time regulated by the FDA as oral over-the-counter (OTC) laxatives. In 2002, the FDA required that all OTC aloe laxative products be removed from the U.S. market or reformulated because the companies that manufactured them did not provide the necessary safety data.
• Early studies show that topical aloe gel may help heal burns and abrasions. One study, however, showed that aloe gel inhibits healing of deep surgical wounds. Aloe gel does not prevent burns from radiation therapy.
• There is not enough scientific evidence to support aloe vera for any of its other uses.

Aloe Vera Side Effects and Cautions

• Use of topical aloe vera is not associated with significant side effects.
• Abdominal cramps and diarrhea have been reported with oral use of aloe vera.
• Diarrhea, caused by the laxative effect of oral aloe vera, can decrease the absorption of many drugs.
• People with diabetes who use glucose-lowering medication should be cautious if also taking aloe by mouth because preliminary studies suggest aloe may lower blood glucose levels.
• Tell your health care providers about any complementary and alternative practices you use. Give them a full picture of what you do to manage your health. This will help ensure coordinated and safe care.

Source: NCCAM, National Institutes of Health

In the United States, where practitioners incorporate healing traditions from China, Japan, Korea, and other countries, acupuncture is considered part of complementary and alternative medicine, a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine. Complementary medicine is used together with conventional medicine, and alternative medicine is used in place of conventional medicine (CAM).

Acupuncture: Key Points

• Acupuncture has been practiced in China and other Asian countries for thousands of years.
• Scientists are studying the efficacy of acupuncture for a wide range of conditions.
• Relatively few complications have been reported from the use of acupuncture. However, acupuncture can cause potentially serious side effects if not delivered properly by a qualified practitioner.
• Tell your health care providers about any complementary and alternative practices you use. Give them a full picture of what you do to manage your health. This will help ensure coordinated and safe care.

About Acupuncture

The term “acupuncture” describes a family of procedures involving the stimulation of anatomical points on the body using a variety of techniques. The acupuncture technique that has been most often studied scientifically involves penetrating the skin with thin, solid, metallic needles that are manipulated by the hands or by electrical stimulation.

Practiced in China and other Asian countries for thousands of years, acupuncture is one of the key components of traditional Chinese medicine. In TCM, the body is seen as a delicate balance of two opposing and inseparable forces: yin and yang. The concept of yin and yang is two opposing yet complementary forces described in traditional Chinese medicine. Yin represents cold, slow, or passive aspects of the person, while yang represents hot, excited, or active aspects. A major theory is that health is achieved through balancing yin and yang and disease is caused by an imbalance leading to a blockage in the flow of qi.

Yin represents the cold, slow, or passive principle, while yang represents the hot, excited, or active principle. According to TCM, health is achieved by maintaining the body in a “balanced state”; disease is due to an internal imbalance of yin and yang. This imbalance leads to blockage in the flow of qi. In traditional Chinese medicine, qi is the vital energy or life force proposed to regulate a person’s spiritual, emotional, mental, and physical health and to be influenced by the opposing forces of yin and yang. Qi can be unblocked, according to TCM, by using acupuncture at certain points on the body that connect with these meridians. Sources vary on the number of meridians, with numbers ranging from 14 to 20.
One commonly cited source describes meridians as 14 main channels “connecting the body in a weblike interconnecting matrix” of at least 2,000 acupuncture points.

Acupuncture became better known in the United States in 1971, when New York Times reporter James Reston wrote about how doctors in China used needles to ease his pain after surgery. American practices of acupuncture incorporate medical traditions from China, Japan, Korea, and other countries.

Acupuncture Use in the United States

The report from a Consensus Development Conference on Acupuncture held at the National Institutes of Health (NIH) in 1997 stated that acupuncture is being “widely” practiced—by thousands of physicians, dentists, acupuncturists, and other practitioners—for relief or prevention of pain and for various other health conditions. According to the 2007 National Health Interview Survey, which included a comprehensive survey of CAM use by Americans, an estimated 3.1 million U.S. adults and 150,000 children had used acupuncture in the previous year. Between the 2002 and 2007 NHIS, acupuncture use among adults increased by three-tenths of 1 percent (approximately 1 million people).

Acupuncture Side Effects and Risks

The U.S. Food and Drug Administration (FDA) regulates acupuncture needles for use by licensed practitioners, requiring that needles be manufactured and labeled according to certain standards. For example, the FDA requires that needles be sterile, nontoxic, and labeled for single use by qualified practitioners only.

Relatively few complications from the use of acupuncture have been reported to the FDA, in light of the millions of people treated each year and the number of acupuncture needles used. Still, complications have resulted from inadequate sterilization of needles and from improper delivery of treatments. Practitioners should use a new set of disposable needles taken from a sealed package for each patient and should swab treatment sites with alcohol or another disinfectant before inserting needles. When not delivered properly, acupuncture can cause serious adverse effects, including infections and punctured organs.

Status of Acupuncture Research

There have been many studies on acupuncture’s potential health benefits for a wide range of conditions. Summarizing earlier research, the 1997 NIH Consensus Statement on Acupuncture found that, overall, results were hard to interpret because of problems with the size and design of the studies.

In the years since the Consensus Statement was issued, the National Center for Complementary and Alternative Medicine (NCCAM) has funded extensive research to advance scientific understanding of acupuncture. Some recent NCCAM-supported studies have looked at:

• Whether acupuncture works for specific health conditions such as chronic low-back pain, headache, and osteoarthritis of the knee
• How acupuncture might work, such as what happens in the brain during acupuncture treatment
• Ways to better identify and understand the potential neurological properties of meridians and acupuncture points
• Methods and instruments for improving the quality of acupuncture research

Finding a Qualified Acupuncture Practitioner

Health care providers can be a resource for referral to acupuncturists, and some conventional medical practitioners—including physicians and dentists—practice acupuncture. In addition, national acupuncture organizations (which can be found through libraries or Web search engines) may provide referrals to acupuncturists.

• Check a practitioner’s credentials. Most states require a license to practice acupuncture; however, education and training standards and requirements for obtaining a license to practice vary from state to state. Although a license does not ensure quality of care, it does indicate that the practitioner meets certain standards regarding the knowledge and use of acupuncture.
• Do not rely on a diagnosis of disease by an acupuncture practitioner who does not have substantial conventional medical training. If you have received a diagnosis from a doctor, you may wish to ask your doctor whether acupuncture might help.

What To Expect from Acupuncture Visits

During your first office visit, the practitioner may ask you at length about your health condition, lifestyle, and behavior. The practitioner will want to obtain a complete picture of your treatment needs and behaviors that may contribute to your condition. Inform the acupuncturist about all treatments or medications you are taking and all medical conditions you have.

Acupuncture needles are metallic, solid, and hair-thin. People experience acupuncture differently, but most feel no or minimal pain as the needles are inserted. Some people feel energized by treatment, while others feel relaxed. Improper needle placement, movement of the patient, or a defect in the needle can cause soreness and pain during treatment. This is why it is important to seek treatment from a qualified acupuncture practitioner.

Treatment may take place over a period of several weeks or more.

Treatment Costs

Ask the practitioner about the estimated number of treatments needed and how much each treatment will cost. Some insurance companies may cover the costs of acupuncture, while others may not. It is important to check with your insurer before you start treatment to see whether acupuncture is covered for your condition and, if so, to what extent.

Source: NCCAM, National Institutes of Health

“We’ve gotten a lot of encouraging comments from families,” says Pitts, a music therapy major from Memphis, Tenn. “Sometimes families who hear us say, ‘Can you come and play a song or two?’ Even one session with a music therapist can reduce pain and anxiety in this setting.”

Pitts’ experiences in hospice care inspired her to research how students doing clinical practice in hospices react to the experience. She won the E. Thayer Gaston Award for outstanding student paper, and she continues her survey research with her mentor, Dr. Andrea Cevasco, assistant professor of music at UA. The resulting article is titled “A Survey of Music Therapy Students’ Practical Experiences in Hospice and Palliative Care.” Part of Pitts’ motivation for pursuing this research was the lack of resources she could draw on when working with hospice patients.

“In this particular area, there’s not a lot of research to go to as a student,” Pitts says. “The emotional component and goals are a little bit different from other clinical settings. You’re improving the quality of life or helping with the changing needs of the patient, and you’re also helping to provide closure and support for families. For students, it’s a very difficult thing to handle.”

Music therapy, taught in a four-year program with a six-month internship following coursework, combines work in music, psychology and other disciplines. It has many applications in a wide variety of environments and a broad range of clients, from premature babies to people needing physical or psychological therapy. The key is to get a patient moving or involved with the music, perhaps singing along or playing an instrument as the therapist plays on the guitar.

It might be that we have kids playing drums,” Cevasco says. “They reach and extend their arms out, which might help a child who has cerebral palsy whose muscles may be tense. Reaching out and playing the drum is fun and enjoyable, but the therapy also is important, because the child is using specific muscles that might normally be painful to use during physical therapy and daily exercises.”

The music therapy program has had a relationship with Hospice of West Alabama since 2007. Cevasco says one of her students came to her asking if she could work in hospice for her clinical experience, so Cevasco set it up. She notes that it takes a student with a particular interest in working with patients at the end of life to follow this path.

“I don’t force the students, but if they’re interested in it, we move in that direction,” Cevasco says. “As an undergrad myself, I never pictured myself doing any kind of hospice work. Personally, I wasn’t ready to deal with death and dying as an 18 to 22-year-old.”

Pitts chose to work with hospice patients because of a personal experience that brought her face to face with mortality.

“I’ve also faced death in someone my own age,” she says. “Last year, my brother dealt with a potentially fatal health condition. I understand you need someone to support you at that time. As a therapist, I can be there for people when they face very difficult times in their lives.”

Her work with the hospice patients varied; two clients became well enough that they could leave hospice. In one case, Pitts, at the request of a family who had heard her play did perform music while a patient died.

“The family requested a few songs, and I played straight through,” Pitts says. “I added a couple of songs of my own that I felt were appropriate. I felt like what she (the patient) needed was slowing-down music as her breathing slowed. I got to be there as she was dying, and we all got a chance to be a part of that.”

Patients in hospice care, depending on their illnesses, may or may not be able to participate in the playing of music for therapy, Pitts says. But music still matters. In her clinical experience, Pitts says she found a wide range of music to be helpful in working with hospice patients and families. Hymns, including “Amazing Grace,” are often requested, but patients frequently want to hear other styles of music as well.

“Typically, when we go in, I have a list of songs I know,” she says. “I prepare songs from different genres – hymns, show tunes, or sometimes songs from the ’30s, ’40s and ’50s, which may be from the patients’ young adult years. If the patient isn’t responsive and awake, I find out what the family wants me to play. If I’m in a situation where the patient is actively dying, I just play a few songs, and I’ll be a very passive member of the room. The family is just there saying goodbye, and I’m providing an atmosphere for that.”

The working with hospice patients – that element of saying goodbye – troubles young music therapists, Cevasco says.

“For all the students, they’re wondering how they’re going to deal with this relationship and this attachment that has developed with this patient and having the patient pass away — how they’re going to cope with this aspect of the job,” Cevasco says.

In the survey Pitts and Cevasco collaborated on, they note that students feared how they would cope when working with dying patients, particularly in how they handled “emotional attachments or relationships with clients, talking about the death and dying process and how previous experiences would affect current clinical work.”

The survey also asked students some open-ended questions about their own beliefs about the end of life. Finding out what those fears and beliefs are, Pitts says, may help instructors better train the students who plan to work with hospice patients.

“The students said it was a very difficult and emotional thing to do,” Pitts says. “Some people had done palliative care with children, but others didn’t realize that was what it was – that the patients died. They didn’t realize what the unit did.”

For Pitts, this kind of therapy represents a way she can use her deep background in music to help people. She ended up choosing to pursue music therapy in college, particularly once she became involved in the clinical part of the degree program.

“I grew up in a very musical family,” she says. “I had piano lessons, and I started singing in middle school and high school choir. . . . I found music therapy to be a nice mix of psychology and music.”

Cevasco says she admires the work Pitts has done, both with the research article and the therapy she provided the hospice clients.

“I was really surprised when she chose hospice,” Cevasco says. “I realized, and she realized, how great she was working with patients with mental-health needs in the previous semesters of her clinical work. I was very surprised, and I was so pleased with her and her work that she did with those hospice patients. It was beautiful the way she was able to work with the hospice families. And the beauty of her being able to play the guitar and sing and provide these families with what they needed and the patients what they needed at this critical moment of their life.”