Vitamin A and vision; dietary iron; prescription drug affordability: Upstate Medical University's HealthLink on Air for Sunday, Oct. 16, 2022

Host Amber Smith: Coming up next on Upstate's "HealthLink on Air," an ophthalmologist explains why he's seeing more vision problems in people who are vitamin A deficient.

Mark Breazzano, MD: ... Bariatric surgery has become quite popular, and with bariatric surgery, oftentimes there is a removal of tissue in the gastrointestinal tract that's important for absorbing fat-soluble vitamins, like vitamin A. ...

Host Amber Smith: A pediatric gastroenterologist discusses why iron is so important, especially in the diets of babies and children.

Aamer Imdad, MBBS: ... The babies who are born full term actually have a fair amount of iron stored in their body tissues, and they require minimal amount of iron. ...

Host Amber Smith: And pharmacists tell about a new program that provides prescriptions to people who lack health insurance.

Meaghan Murphy: It includes generic medications as well as branded medications. ...

Host Amber Smith: All that, plus a visit from The Healing Muse. But first, the news.

This is Upstate Medical University's "HealthLink on Air," your chance to explore health, science and medicine with the experts from Central New York's only academic medical center. I'm your host, Amber Smith. On this week's show, a pediatric gastroenterologist discusses iron and its role in the diets of babies and children. Then we'll learn about "Medications for Hope." But first, an ophthalmologist explains the connection between vitamin A and vision, and why more people with vision problems are finding they have a vitamin A deficiency.

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air." Vitamin A deficiency is a leading cause of blindness in underdeveloped countries, but this is also an increasing concern in developed countries, including the United States. Here with me to explain why and what can be done is Dr. Mark Breazzano. He's an assistant professor of ophthalmology and visual science at Upstate. Welcome back to "HealthLink on Air," Dr. Breazzano.

Mark Breazzano, MD: Thanks so much, Amber, for having me again.

Host Amber Smith: Now, you authored a paper about vitamin A deficiency that appears in the journal of the Royal College of Ophthalmologists, so much of what we're talking about today is covered in that paper. I'd like to start by asking how long we've known that vitamin A is linked to vision function.

Mark Breazzano, MD: Yes, it's a great question. In terms of specifically vitamin A, a lot of that came out of work around the time of the end of World War I, so about a century now, we've specifically linked that molecule to visual function, but knowledge of something along those lines, actually being critical for vision, has been long known, as far back as the ancient Egyptians.

It was known that with a certain type of vision loss, just eating animal liver could actually restore vision in people. So we knew that there was something happening and how critical and important it was, but just wasn't isolated that, "Hey, this is the actual molecule," or the rationale and basis for that.

Host Amber Smith: So retinol is the same thing as vitamin A?

Mark Breazzano, MD: Vitamin A has a few different molecular forms, and I'm sure one of our basic science colleagues can help elaborate on this more effectively than I can, but basically there's retinol, and then there's retinol esters, basically different formations of the same compound that are essentially vitamin A, as we know it.

And then there's also carotenoids, or these other molecules that can be converted into vitamin A, for use in our bodies by our own tissues. And those are generally present in plants like carrots, spinach, those types of foods that we eat every day.

Host Amber Smith: I was going to ask -- so we can get vitamin A from our food: meats, fish, eggs, dairy, plants. Is it the same as vitamin A supplements, or is one better than the other, dietary vitamin A versus supplements?

Mark Breazzano, MD: Our meats, our dairy products, those tend to carry the more classic vitamin A component, or preformed vitamin A, as it's often called, that can be directly used for vitamin A that our body needs.

The plant-based type of vitamin A materials, or the carotenoids, like beta-carotene is most commonly known, are found in the plants. And so that needs to be converted by our bodies, depending on its bioavailability. So supplements also are prone to the bioavailability, meaning how much of it can be absorbed and then turned into the useful version of the vitamin A.

So in reality, having more of the actual component available for use is obviously critical. But at the same time, there's a certain amount that is required, and once you meet that requirement, generally speaking, superseding that amount. As I often tell patients, for many of these components in your body, you can have too much of something, just like you can have too little.

And so hypervitaminosis, also known as too much of a vitamin, can be just as bad as hypovitaminosis, or having a deficiency.

Host Amber Smith: I understand how people in developing nations might not be able to eat a good nutritious diet with adequate amounts of vitamin A. Is that what's happening in the U.S.? Are people just not eating proper diets with adequate vitamin A?

Mark Breazzano, MD: It is interesting because certain food products that you might not necessarily expect to have vitamin A actually can have a little bit of vitamin A. So it's not necessarily avoiding certain products that people may be becoming deficient in. for example, the National Institutes of Health, or NIH. Has published a nice list of different food products that actually have vitamin. A in them and among them is actually, of all things, French vanilla ice cream, (which) actually has a little bit in there because of its dairy component. It's obviously not much, but it does have some in there.

Now the issue in the developed world is, obviously, we've seen a rising trend in obesity, and along with this, there has been a need to help correct the obesity with all the other morbidities and comorbidities (one or more diseases or conditions) and other health issues that go along with it.

And so bariatric surgery has become quite popular, and with bariatric surgery, oftentimes there is a removal of tissue in the gastrointestinal tract that's important for absorbing fat-soluble vitamins, like vitamin A. And so people that have had this are at risk for having deficiencies in vitamin A, along with other fat-soluble vitamins.

And so there may be this increasing risk in increasing prevalence of people who are deficient in vitamin A as a consequence of that. Others that are at risk are those with autoimmune or inflammatory diseases, like Crohn's disease, or anything else that can affect the gastrointestinal tract. So they're particularly at risk.

So it's not necessarily what we once thought, as a rare phenomenon in our part of the world, but in fact it is actually increasing.

Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with ophthalmologist Dr. Mark Breazzano about vitamin A deficiency and its impact on vision.

So how would a person know or suspect that they're deficient? Are there signs or symptoms to be on the lookout for?

Mark Breazzano, MD: Absolutely. One of the classic things we find on our exam is dryness of the eye, and there are certain aspects that can actually be appreciated potentially before this. So patients who have noticed a decline in their night vision, we coined this term nyctalopia, but basically a problem with seeing things in the dark and our environment effectively.

If there's been a decline, usually over weeks or months, sometimes it could be years, may be a sign of vitamin A deficiency in the right clinical context. There can be other reasons, of course, and so getting an eye exam, and particularly a dilated eye exam, will be important to help assess for that.

But usually the decrease in night vision is one of the first signs.

Host Amber Smith: But if someone came for their annual eye exam, this is something that might be picked up?

Mark Breazzano, MD: The subtle aspects of it can make it very challenging to actually diagnose. And one of the aspects of our paper that I think is particularly important and interesting is that we can use a device that's actually clinically available in many ophthalmology offices and certainly all retina offices, where basically there's an image that's used to assess the sensor part of the retina and assess for the anatomical structure there and alterations in there. And it may be one of the first signs anatomically that we can pick up, because a normal dilated eye exam may not be able to appreciate this, unless it's in its advanced stages, where you find these sort of deposits and these yellowish deposits out in the periphery, and as well as in the central macula and retina of the eye, that we may not be able to see in its earlier stages.

Host Amber Smith: What about a blood test? Would a blood test tell you that a person is deficient with vitamin A?

Mark Breazzano, MD: Much of the time it can help detect that, where the decreased level of retinol or retinol binding protein, the actual protein that helps bind the vitamin A to get it to the places it needs to in your body, with those levels are low from a blood test, that can be very helpful for establishing a diagnosis.

The problem is, because it is a fat-soluble vitamin, it's not one that's soluble in the bloodstream or in water per se, and it's stored in the liver, that you can actually have a relatively normal blood level but still be deficient because the entire liver stores in many cases need to be depleted or near depleted before the blood level actually reaches a low enough threshold that would be picked up on that blood test.

So there are many challenges with the diagnosis. In its more advanced forms, it's much easier to diagnose. You know, we were talking about the drying of the surface of the eye that can be picked up at the slit lamp. So once it gets to an advanced form, we can see it, but at its earlier or even moderate stages, it can be a little bit more challenging for all of these reasons.

Host Amber Smith: Now, you mentioned, in terms of signs and symptoms, the dryness to the eye. And I'm curious what happens to the eyes of someone without adequate levels of vitamin A and how rapidly problems might develop.

Mark Breazzano, MD: Fortunately, here we don't experience the severe effects from the dryness like we do in the developing world or underdeveloped world, in that usually if it gets to that point here, we do see the xerosis, as it's often called, basically the dryness of the conjunctiva. That's basically the translucent layer overlying the white part of the eye, or the sclera, and you can sort of see these waves and dry areas at the slit lamp. So, on real close biomicroscopic evaluation in clinic, we can see that. And if it goes untreated, usually it's not something that happens within necessarily a matter of days.

This is usually long-standing, and then it can progress to dryness of the cornea or the central, clear part of the eye, and then, in more severe cases, you can lose other aspects and end up getting what's called keratinization, or the cells actually change what they are and they start building up with material that's not normally there something that's called metaplasia where the cell type actually changes. And eventually you can get thinning and what's often described as melting of the cornea and conjunctival structures, but this is severe, sort of end-stage, changes from vitamin A deficiency, which fortunately we do not see frequently at all in our area, but unfortunately happens with some frequency from malnutrition in other parts of the world.

Host Amber Smith: So it sounds like vision can be impacted if it's not treated.

Mark Breazzano, MD: Absolutely. And it's a different mechanism in terms of the dryness and surface changes that has to do with maintenance of the cells on the surface of the eye versus the vitamin A being used as part of the visual cycle for the photoreceptors. Basically, if anyone's heard of the rods and cones of the eye, the rods, which are responsible for that dark vision, the nighttime vision, they're constantly turning over rhodopsin, which depends on vitamin A, in the back part of the retina. So two different mechanisms, but both extremely critical for the eye and for vision.

Host Amber Smith: Now in your paper, you shared some case studies of some patients, all of whom developed night blindness for several months or even a few years before this was diagnosed. Is that a typical presentation?

Mark Breazzano, MD: That is usually how this happens. And that's why whenever I hear that there is a challenge with nighttime functioning, you know, going to the bathroom at nighttime or any of these sort of night issues that weren't problematic before, and barring any other issues, like let's say increasingly dense cataracts or anything like that, that could also be causing these symptoms, I start digging a little bit more in terms of their medical history and just trying to determine what is the sort of timeline on this? It's not something that happens overnight or happens over the course of a few days. This usually happens over months and sometimes years. And one of the more tricky aspects of this as well is that oftentimes people are on vitamin supplementation or general vitamin supplementation after their surgery, bariatric surgery or gastrointestinal issues.

But the problem, again, becomes malabsorption, where they can't really absorb all of it through the supplements. And because there's been that damage, or changes to the gastrointestinal tract. And what we found is that even with normal oral supplementation, it may not be enough in many patients, and so many of us will elect to try to do the intramuscular dosage (a shot) of the vitamin A to get that quick, high-level vitamin A supplementation to restore the levels that are stored in the liver and whatnot, and to get them to the physiologic levels that we do need.

Some of it can be a challenge though. Getting the vitamin A supplementation or getting the access to specialists who can help with assessing and administering that can also be a challenge, though, in our health care system.

Host Amber Smith: So that would be a shot, an injection, or a shot, into the arm?

Mark Breazzano, MD: It could be into the arm, but it's usually in the lower body as well, I believe, more like in the thigh or the leg, as well.

Host Amber Smith: So vitamin A can be used to treat this. Does it reverse any damage, or is the damage permanent?

Mark Breazzano, MD: Fortunately, a lot of this can be reversible, and often right after administration, within days or weeks, night vision does actually recover quite expeditiously.

So it is one of the more rewarding aspects of our field in terms of being able to treat these patients and get their vision back.

One of the interesting parts of what we found, though, was the double carrot sign corresponds, instead of the rods and night vision aspect -- the cones are part of the central vision that help with color vision -- and we found the double carrot sign actually does improve or in our couple of cases, does potentially resolve, but there is some delay in the functional recovery of the center of the vision.

And so that part, we do need to learn a little bit more and explore more, but the peripheral and night vision component does appear to improve or resolve quite rapidly.

Host Amber Smith: Does the normal person who has not had bariatric surgery, do they get enough vitamin A through diet if they're eating sort of a general diet, or do regular people need to be concerned about this?

Mark Breazzano, MD: I think it's fairly challenging to have a vitamin A deficiency with even our current Western diet. There are certainly many criticisms from other perspectives of the Western diet, for sure. But in terms of vitamin A deficiency, I think it is very hard for a generally healthy individual in our society today to have that. However, barring other circumstances or issues, there are other underlying problems, such as autoimmune diseases, potentially trauma or surgeries or other medical issues that are affecting the gastrointestinal tract; then, I think it's something to consider in the back of someone's mind.

But it should be quite unusual for just a regular individual who otherwise is healthy to have this happen.

Host Amber Smith: Well, this has been very informative, and I want to thank you for making time for this interview, Dr. Breazzano.

Mark Breazzano, MD: Absolutely. Thanks so much again for having me, Amber, and it's been a pleasure.

Host Amber Smith: My guest has been ophthalmologist Dr. Mark Breazzano. He's an assistant professor of ophthalmology and visual science at Upstate. I'm Amber Smith for Upstate's "HealthLink on Air."

Next on Upstate's "HealthLink on Air": why iron is an important part of the human diet.

From Upstate Medical University in Syracuse, New York. I'm Amber Smith. This is "HealthLink on Air." What happens when a baby does not get adequate amounts of iron?

For help answering this question, I turn to Dr. Aamer Imdad. He's an assistant professor of pediatrics specializing in gastroenterology.

Dr. Imdad, thank you for being here.

Aamer Imdad, MBBS: Thank you for having me.

Let's start by first talking about what iron is and why we need it in our diets. I understand it's a mineral, but what does it do?

Well, iron, indeed, is a mineral that the body needs for growth and development. So, it is important for hemoglobin, which is a protein in the red blood cell that carries oxygen from the lungs to all parts of the body. It also plays a very important role in another protein called myoglobin, which is a protein that provides oxygen to the muscles. Iron is also involved in a bunch of hormones as well. So it's very critical to have adequate amount of iron in the body for proper functioning.

Host Amber Smith: Now, there are foods that are rich in iron, is that right?

Aamer Imdad, MBBS: That is correct.

Host Amber Smith: Are the dietary sources as good as supplements?

Aamer Imdad, MBBS: Well, let me go back and explain a little bit more about that. So the iron could be available in the heme form, which is the most bioavailable. And then there is a non-heme form. So the heme form comes typically from the animal products, like, for example, lean meat or seafood, poultry. And then the non-heme source comes from the plant base, like beans, lentils, spinach, kidney beans, peas and some of the nuts as well. Now the fortification that happens actually has more of the heme component to it. And heme is more bioavailable than the non-heme part of it. So putting this together, the bio availability of iron is better from the animal source. However, if the animal source and the plant-based source of iron is taken together, the bio availability increases even further.

Host Amber Smith: How much iron do we need? And does that change for if, as a baby going into toddlerhood, teen years, adult, seniors ... does it change over the lifespan?

Aamer Imdad, MBBS: That is correct. So the recommended daily average amount that is needed is different based on the age and gender as well. For very young babies, so the babies that are born full term and are less than six months, they actually have adequate amount of iron that they had stored from the mother. So an average requirement for a baby less than six months is only 0.27 milligrams per day. However, for babies older than that, for example, seven to 12 months, it goes up to 11 because they're rapidly growing. And then children say, 1 to 3 years, it's about 7 milligrams per day. And then older kids, like in teenagers, for example, the teen boys have about 11 milligrams, and the teen girls on the other hand about 15 milligrams per day. The requirement kind of decreases in older age group. For example, for adults more than 50 years of age, the requirement is only about 8 milligrams per day. Pregnant females and breastfeeding mothers have additional requirements for iron because of the requirements of pregnancy and lactation.

Host Amber Smith: Why do young women need more iron than young men?

Aamer Imdad, MBBS: It is mainly related, so for adolescent females, for example, they are developing, in terms of their secondary sexual characteristics, and also the blood loss during menstruation plays an important role. So, the young woman of reproductive age requires more iron, say, compared to their age-matched males.

Host Amber Smith: Now what happens if a person doesn't get enough iron?

Aamer Imdad, MBBS: It depends on the extent of the deficiency. So you can have marginal deficiency, which actually won't lead to a whole lot of symptoms, other than, say, just being fatigued or tired or, in very young kids, they may be more irritable, but if you develop severe deficiency, then you can develop iron-deficiency anemia, which is the decrease in the red blood cell mass in the body. And depending on age, it can lead to symptoms like lethargy and inability to play in very young kids to grownups, where they may not be able to perform their daily activities.

Host Amber Smith: Do you ever see people who have too much iron, and is that a problem?

Aamer Imdad, MBBS: Sometimes it is. It is not very often that there is an excessive iron intake. However, some of the supplementation, if taken over longer period of time, can lead to iron toxicity. Interestingly, in very young kids, sometimes they can overdose on the tablets that their parents had. For example, if the mom is pregnant for another baby, and the younger baby consumes the tablets that mom is supposed to take, that can lead to toxicity. And, it used to be one of the common causes of toxic overdose in young kids. And it has decreased over time because the way the tablets are packaged now. Previously, they were actually sugar coated. And nowadays they are not. And that has helped decrease the incidents where the over-ingestion can lead to severe complications in very young children.

Host Amber Smith: Well, now I'd like to focus on some research that you and your colleagues in Syracuse and elsewhere were involved in. You were assessing the iron content in a food product that is used to treat malnutrition, is that right?

Aamer Imdad, MBBS: That is correct.

Host Amber Smith: What were you looking for?

Aamer Imdad, MBBS: So we responded to a call from a World Health Organization -- and I'm going to call it WHO from here onwards -- so the WHO is interested to issue its guidelines on how to treat severe acute manlnutrition in children, especially in low and middle income countries. Now, when the children, especially very young children, develop severe acute malnutrition, which is defined based on their weight for their height, if it is less than the standard weight for height for their age, say, there is a term called Z score, which is a standard score that you're supposed to have for that age. If the weight for height is below three standard deviations from that standard, then you are thought to have severe acute malnutrition.

Now the kids who have severe acute malnutrition, more than half of them have severe iron deficiency-related anemia, which is the low blood counts. That is a risk factor for not only having an increased risk of infection, but also the risk of death is higher in children who have severe anemia. So, historically, these children who have severe acute malnutrition were treated inpatient. But more recently the WHO and other organizations like UNICEF (the United Nations Children's Fund) are trying to treat these children in the community setting because there are too many in numbers, and the resources are not available.

So in order to be treated in the community setting, they are fed something called ready-to-use therapeutic foods called RUTF. Now, RUTF are these dried peanut-based food product that has all the macronutrients. The macronutrients are the proteins, the carbohydrates and the fat. And it also has the micronutrients, including the iron, zinc and other important minerals that are needed for growth. Now, historically there was about 10 to 12 milligrams of iron per 100 grams of RUTF, but the studies have shown that this much of iron may not be enough to treat the amount of anemia or iron deficiency that is there in the children with severe acute malnutrition.

So we were asked to evaluate and look at the studies that have used higher doses of iron, like, say, up to 50 milligrams per 100 grams of RUTF, and if that has a better effect on treatment and prevention of anemia in these children. And what we concluded was that the higher dose indeed iseffective in treating the anemia in these children. And that is a potential avenue for future research, because the number of studies were small, but the data that is available, indeed, shows that the risk of anemia could be lower with increased dose of iron, in this study to use therapeutic foods.

Host Amber Smith: This is Upstate's "HealthLink on Air" with your host Amber Smith. I'm talking with Dr. Aamer Imdad. He's an assistant professor of pediatrics who specializes in gastroenterology at Upstate, and he's been involved in research that looks at the iron content in food products.

Now, you were describing a product that the World Health Organization recommends, ready-to-use therapeutic foods for infants. Is that a product that's available in the United States?

Aamer Imdad, MBBS: We typically don't use that in high-income countries, including United States. The risk factors for malnutrition are kind of different in low- and middle-income countries compared to high-income countries. Having said that, the resources available in developed countries are much more easily available, and the food insecurity and the community prevalence of infectious disease is lower in higher-income countries, so the number of children who have severe acute malnutrition is actually much smaller in high-income countries like United States. So we end up treating them with the traditional foods that we have depending on the age. For example, for very young kids, we have infant formulas that we can feed by mouth, or if we need to use a feeding tube, like a nasogastric tube or a gastrostomy tube. So we can help them go through nutritional rehabilitation with the resources.

In low- and middle-income countries, there is really not that many resources that are available. So these products which are readily available, that require minimal preparation or storage needs are advocated so that these kids could go through rehabilitation and could be prevented from complications, including this for infectious disease and possible death.

Host Amber Smith: Well, let me ask you about breastfeeding. Do babies get adequate iron if they're exclusively breastfed for the first two years of life?

Aamer Imdad, MBBS: It depends on the age. As I mentioned earlier, the babies who are born full term actually have a fair amount of iron stored in their body tissues, and they require minimal amount of iron. So for the first four months or so, if a full-term baby is exclusively breastfed, they don't need additional iron. However, after that, the American Academy of Pediatrics recommends to supplement the exclusively breastfed babies to have about 1 milligram per kilogram per day of iron. It is specifically further recommended for kids who may not be able to consume the complementary feedings, which is the feeding that is started somewhere around 4 to 6 months of age that does not have enough of the iron source in it. So those babies are at a higher risk of developing iron-deficiency anemia, and the academy recommends the supplementation and advocates for diverse type of foods that have iron in it to prevent the iron-deficiency anemia.

The older kids are at a relatively lower risk because as the kids grow, they eat more diverse types of diets. It is less likely to have iron deficiency later in life, like after 1 year of age. However, if the diet is not diverse, then there are at high risk of developing iron-deficiency anemia.

Host Amber Smith: I know your specialty is gastroenterology. What impact does iron have on digestion?

Aamer Imdad, MBBS: Iron, again, has a significant role. It obviously is a major part of the red blood cells, and it increases their oxygen carrying capacity. It also increases the storage capacityfor muscles in terms of the way they use the oxygen. The absorption of iron in gastrointestinal tract involves a number of different sites, including the stomach and the very last part of the small bowel terminal ileum. So if there is any defect or diseased part of the gastrointestinal tract where the absorption of, say, iron, happens, then that can lead to iron deficiency anemia. Similarly, if there is an overdose of iron, say, for any given age, if the iron was given more than 20 milligrams per kilogram, that can cause significant gastrointestinal problems, including the acute bleeding and risk of death. The iron supplements that are typically taken, say, during pregnancy or for treatment of iron-deficiency anemia can cause nausea and abdominal pain. Sometimes it can cause constipation or blood in the stool. Iron is very tightly controlled as it goes through the gastrointestinal tract. And, more than a typical dose can cause mild to moderate, to severe symptoms, depending on how much is the iron in terms of when it was taken.

Host Amber Smith: Well, thank you so much for taking the time to talk with me about this, Dr. Imdad.

Aamer Imdad, MBBS: My pleasure. Thank you for having me.

Host Amber Smith: My guest has been assistant professor of pediatrics Dr. Aamer Imdad. He specializes in gastroenterology at Upstate Medical University. I'm Amber Smith for Upstate's "HealthLink on Air."

New help for people who lack health insurance and need prescription medication -- next, on Upstate's "HealthLink on Air."

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air." Americans who don't have health insurance sometimes go without life saving prescription medications because they cannot afford them. Now Upstate offers "Medications for Hope," for Central New Yorkers who are uninsured and who meet income eligibility. Here to explain the program and how it works is Eric Balotin, upstate's director of retail specialty pharmacy services, and Meaghan Murphy, Upstate's ambulatory care pharmacy coordinator. Welcome back to "HealthLink on Air," both of you.

Eric Balotin: Thank you. Happy to be here.

Meaghan Murphy: Thank you.

Host Amber Smith: Ms. Murphy, let me start by asking you how big of an uninsured population we have in Central New York.

Meaghan Murphy: We have a huge uninsured population in Central New York. My team serves our clinic population, who have primary care providers here at our Upstate primary care clinics. So we don't have a huge uninsured population. However, when our patients have gaps in insurance coverage, it's really important that we have programs in place to help our patients have access to life saving medications, particularly insulins and anticoagulants or antithrombotics, as our pharmacy team really helps co-manage those chronic disease states. And if patients don't have access to those medications, it can really lead to rehospitalizations and the inability for patients to get better.

Eric Balotin: And with the uninsured population, things that people don't think about is the gaps in coverage, like Meaghan mentioned. Because you could be a fully employed person who has insurance, loses that job for a period of time and become uninsured, before you get your new job. So those are the type of patients that we're really trying to capture, patients that lose their insurance, don't have insurance, have gaps in coverage, and as well as we have a significant high poverty rate in this area that we want to capture those patients in need.

Host Amber Smith: So it sounds like this is something you would encounter every week, every day? I mean, it seems like it happens a lot, right?

Meaghan Murphy: It does. It happens regularly. And when it does, a lot of these medications are very expensive, upwards of hundreds of dollars per month. And as Eric said, with our high poverty rates andpatients with gaps in insurance due to job changes or financialrestrictions, it can be very difficult to find established programs that are in place here to support our specific patient population to give them access to the medications. And then not only that, but help the providers make the best choices for medication therapy decisions. It really helps providers choose the best therapy for that specific patient rather than, being cornered into less optimal therapies just based on financial affordability.

Host Amber Smith: I'm curious how Medications for Hope got its start. Mr. Balotin?

Eric Balotin: So this program's been around actually nationally since around 2007, and an organization out of Tennessee called Dispensary of Hope really was on the forefront of building this program to roll it out nationally. And what they did through some providers out there and through some national laws that were created back in the early 2000's allowed this organization to accept samples that were going to be discarded by manufacturers and then redistribute those samples out to indigent patients throughout the country. So the program's been around for quite a while. There's probably only about 100 of these dispensary locations throughout the country, so we've been fortunate to be able to get this organization kind of working with us in Central New York.

Host Amber Smith: Is this the only pharmacy that's supplied by the Dispensary of Hope outside of New York City?

Eric Balotin: Correct. For New York state, there's five of these locations within the city itself, but none outside of the city. And then the closest other state entity would be Northern Pennsylvania. Or really, this organization's a Southern organization. So if you looked at their map, most of these pharmacy dispensing locations are in the South, with a few out west and actually they just opened up the one location nationally in Africa. So it is starting to go global.

Host Amber Smith: Ms. Murphy, which medications are included in the Medications for Hope?

Meaghan Murphy: There is quite a bit. We have a lot of treatment options for patients. it It It includes generic It includes generic medications as well as branded medications for a variety of chronic illnesses, as well as acute illnesses. So, again, having the variety of medications from antibiotics and antivirals to blood pressure medications, insulins and anticoagulants can really help provide patients with access to medications who wouldn't otherwise have the ability to afford them and treat either an acute illness or continue their chronic disease treatment plan to keep these patients healthy and out of the hospital.

Host Amber Smith: How dangerous is it if someone who has diabetes -- that requires insulin, and they have a prescription for insulin, but they can't afford it, so they don't take it -- how dangerous is that for that person?

Meaghan Murphy: It's quite dangerous, actually, and can not only lead to hospitalization, but more troublesome side effects like diabetic ketoacidosis and even death. And so patients who require insulin and are unable to afford it and don't have access to fill those at the pharmacy can really be harmed if they are unable to obtain their medications. And so to have this program available for our patients is a really big perk. And it's great for not only the patients, but it feels great to have this program as a provider, honestly.

Host Amber Smith: This is Upstate's "HealthLink on Air" with your host, Amber Smith. I'm talking with two pharmacists about the new Medications for Hope program at Upstate. Eric Balotin is Upstate's director of retail specialty pharmacy services. And Megan Murphy is Upstate's ambulatory care pharmacy coordinator.

Now, Mr. Balotin, can you walk us through how a patient would access Medications for Hope?

Eric Balotin: It's a pretty simple process. And even the registration process, as I talked about, you'll find that is fairly simple as well. Soeven if you don't think you qualify, if you think you qualify or don't think you qualify, I would ask your providers to send your prescriptions to the SUNY Upstate Outpatient Pharmacy, which is located at 5000 W. Seneca Turnpike in Syracuse. Once the prescription arrives at the pharmacy, we have systems in place that looks for to see if a patient has insurance. So without even the patient calling us, once we receive the prescription, we evaluate that prescription. If you don't have insurance, we immediately have a team of medication assistance coordinators, which will directly reach out to patients and try to qualify them for this program, because we recognize that you're self-pay. There's no insurance on our screens that we can find for you. And then we try to qualify you based upon your financial ability to pay.

And what's nice about the qualifying criteria: A family of one, the income level's $40,770. A family of four, an income level of $83,250. When some people think of "indigent," they think of no money. We're talking about patients who still can have an income. Don't be afraid to reach out to us. And then really it's the not having that insurance piece is really the qualifying criteria to move forward. So once we have that prescription, we reach out to you. There's a very simple attestation form that you sign, that a patient would sign, that says, "Yes, I meet the income threshold. And yes, I don't have insurance." We don't ask for any kind of verification on the income. It's really a trusted type of form. You just have to sign it and say that I agree that I don't meet those levels.

Host Amber Smith: Now do patients have to have an Upstate provider in order to use the Upstate Outpatient Pharmacy, for this program?

Eric Balotin: They do not. What's nice about our pharmacies is we accept patients from Upstate providers or non-Upstate providers. So we encourage it. We know this program is going to be large and vast. It's going to actually cover in all the 19 counties that Upstate services. So, you know, some of those patients in different counties may not be a direct Upstate patient, but we want to help them. Part of being a state institution, part of being who we are at Upstate is really trying to make that extra effort to get out there and help our community. At the end of the day, if we don't do something, they're going to end up back in our emergency room, or they're going to end up back in the hospital. So this is our chance to try to do something, to prevent them from having any adverse effects from not taking their medications.

Host Amber Smith: So are there any residency requirements for Medications for Hope?

Eric Balotin: When the program first rolled out, we did kind of try to limit this to Onondaga County to see how this program would be received within our community. And then, we have been very fortunate now that we have rolled this program out to all 19 counties that are serviced by the Upstate University Hospital system.

Host Amber Smith: Now tell me again, where is the pharmacy located and what are its hours?

Eric Balotin: So the pharmacy that services this program -- Upstate's got two outpatient pharmacies -- but the one for this program is the SUNY Upstate Outpatient Pharmacy at Community campus. It's at 5000 W. Seneca Turnpike, Syracuse, New York. It is open Monday through Friday, 8 a.m. to 6 p.m. Now that may seem weird to somebody in Lewis County or Cayuga County, that we're in Syracuse, Onondaga County, but we have the ability to ship to the patients directly. So they will receive the meds within 24 hours by UPS. It's next-day shipping. A Friday would arrive on a Monday. But normally, Monday through Thursday, it's next-day shipping.

Host Amber Smith: That's good to know.

Ms. Murphy, can you tell us about other ways Upstate works to make prescriptions more affordable for people who maybe have insurance, but don't have enough money to pay for the prescriptions?

Meaghan Murphy: That's a great question, because we encounter that situation quite often, as well. Luckily we have Eric Balotin and his team to collaborate with. We serve a very diverse population here at Upstate in our primary care clinics, including our Center for International Health Services. We have a large refugee population, and so due to the diversity, we really have to have systems in place to help all types of patients.

Eric has set up a team of pharmacy technicians which comprise our medication assistance team, who serve all of our inpatient and outpatient clinics, really. And they have a plethora of programs under their belt and available because they do this every day, so they can help patients sign up for New York State EPIC, (Elderly Pharmaceutical Insurance Coverage.) We have some of our own homegrown financial assistance programs here. Patients provide financial information, and showing the need for that, as well as coupons and manufacturer assistance that they could help patients sign up for and facilitate those forms and applications. We consider ourselves, as pharmacists here in the clinic working directly with patients and chronic disease management, so lucky to have these resources under Eric's umbrella, so we can collaboratively as a team to care for the patients. There are a lot of resources here at Upstate that are very patient-centered and really help the patient have access to everything they need. And then to piggyback on what Eric said before, his pharmacy provides mail services for free, courier services. And so our patients with transportation barriers and some other barriers that prevent them from access to medications, we can help set up those courier and delivery services, so patients can get their medications, sometimes the same day, when we're talking about insulins and anticoagulants. So, it's fantastic.

Eric Balotin: What we also have done is we built some different thresholds built within our pharmacy system that automatically trigger our medication assistance coordinators to go to action. So if a patient's copay is going to be $20, whether they ask for it or not, our systems are designed that flags our medication assistance coordinators to look for manufacturer coupon cards and talk to the patients about their ability to pay, because our goal is to get patients to take their medications. And also as a state agency, and we're very fortunate to have the Upstate Foundation. They've been very good to our pharmacy with advocacy funds and some grants and foundations to Upstate that allow us to tap into those organizations, to meet patients' out-of-pocket costs and deductible costs when they are not able to meet those large deductibles.

Host Amber Smith: Well, before we wrap up, let's remind listeners how to reach the Upstate Outpatient Pharmacy. Can you let us know the phone number?

Eric Balotin: The phone number at the Upstate Outpatient Pharmacy, near the Community campus, we have two numbers that they can write down, if they want. 315-492-5311, which is the direct line. And then we have a very unique number within pharmacy. It's the 4 6 4 number, which is the same first three digits for every Upstate extension, and then we're "drug," DRUG, drug. So that's 315-464-3784, and the Community (hospital) campus is option 3.

Host Amber Smith: Well, thank you both for informing us about this program.

Eric Balotin: Thank you for having us.

Meaghan Murphy: Yes. Thank you so much.

Host Amber Smith: My guests have been Eric Balotin, Upstate's director of retail, specialty pharmacy services, and Meaghan Murphy, Upstate's ambulatory care pharmacy coordinator. I'm Amber Smith for Upstate's "HealthLink on Air."

Here's some expert advice from Dr. Debanik Chaudhuri from Upstate Medical University. Does bedtime affect heart disease risk?

Debanik Chaudhuri, MD: There is a clear signal from clinical trials that heart attacks tend to happen early in the morning. Sudden cardiac death also tends to happen early in the morning. There are studies on platelet reactivity, even when patients are on certain anti-platelet agents, which show that platelets are stickier between 5:00 AM and 10:00 AM than at other times, especially on certain medications. So there is a circadian diurnal variation of people's predisposition, predilection, vulnerability to heart attacks, if you will. And one of the things on that same study, what the author suggested was that if you're sleeping late, you're also waking up late, and the early morning sun is supposed to be one that resets the circadian clock, and you're missing that. So that clock is perennially disturbed, and that may have some impact on the way physiology reacts to that.

Host Amber Smith: You've been listening to Dr. Debanik Chaudhuri from the department of cardiology at Upstate Medical University.

And now, Deirdre Neilen, editor of Upstate's literary and visual arts journal, The Healing Muse, with this week's selection.

Deirdre Neilen, PhD: Ann Howells is a poet and editor whose poem "When the Breathing You Hear Is Your Own" is about a mother's love for a lost child. She begins with an epigram from Linda Gregerson: "We had not loved you half so well, had we not loved ineptly."

My uterus had superpowers,

a chrysalis, to contain him as he developed

lovely wings. I went to bed

imagining his laughter. He spun my world

when he dropped, heavy in my belly,

like a star plunging from the sky.

If joy were a leaf, he would have been

sunlight. If joy were an agate

he would have been coral hibiscus.

If joy were a snail he would have been

a meadowlark, fat and filled with song.

He existed beyond joy.

His name hovers in the air

like butterflies above marigolds.

Baby in the tiny casket of my heart --

ghost I visit in light, ineffectual sleep

littered with failings.

What if are unendurable words,

and I am a fragile being.

Pain has turned my scars, my years,

white and hard. I listen as earth moves,

watch stars spin. Sometimes,

I speak of death, the act of dying.

Each child I carried lives in my heart,

even the one I lost.

Host Amber Smith: This has been Upstate's "HealthLink on Air," brought to you each week by Upstate Medical University in Syracuse, New York. Next week on "HealthLink on Air": prepping for a colonoscopy. If you missed any of today's show, or for more information on a variety of health, science and medical topics, visit our website at healthlinkonair.org. Upstate's "HealthLink on Air" is produced by Jim Howe with sound engineering by Stephen Shaw. This is your host, Amber Smith, thanking you for listening.