Taking pills as prescribed; an innovative cancer treatment; med students as teachers: Upstate Medical University's HealthLink on Air for Sunday, Jan. 21, 2024

Host Amber Smith: Coming up next on Upstate's "HealthLink on Air," diabetes researchers discuss the dangers of skipping medications.

Ruth Weinstock, MD, PhD: ... If we define low adherence to taking medications as taking less than 80% of the amount of the pill that was prescribed, 80% were low adherent. ...

Host Amber Smith: A surgeon tells about a new treatment option for people with colorectal or bile duct cancer that has spread to the liver.

Mashaal Dhir, MD: ... The principle of this therapy is to deliver the high dose of chemotherapy directly into the artery, which supplies these tumors. ...

Host Amber Smith: A medical student talks about teaching about health advocacy.

Amelia Gabor: ... We try to teach them, in addition to personal health skills, this idea that they can be an advocate for their health. ...

Host Amber Smith: All that, followed by a visit from The Healing Muse, right after 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, we'll learn about hepatic artery pump infusion therapy. Then we'll hear about Upstate medical students who teach health advocacy at Syracuse University. But first, a pair of diabetes researchers look into medication adherence.

From Upstate Medical University in Syracuse, New York. I'm Amber Smith. This is "HealthLink on Air."

Young adults with Type 2 diabetes don't take their hypertension and cholesterol medicine as they should. This may explain earlier research showing early onset of serious health problems for this patient population and worsening medical conditions as these people age.

With me to talk about their medication adherence study are Dr. Ruth Weinstock, who is medical director of the Clinical Research Unit and the Joslin Diabetes Center at Upstate, and Dr. Paula Trief, a professor of psychiatry and medicine at Upstate. Both are SUNY distinguished service professors.

Welcome back to "HealthLink on Air," both of you.

Ruth Weinstock, MD, PhD: Thank you so much.

Paula Trief, PhD: Thank you for your interest.

Host Amber Smith: Your study that was published recently in the Journal of the American Medical Association Network is called "Anti-Hypertensive and Lipid-Lowering Medication Adherence in Young Adults With Youth-Onset Type 2 Diabetes." Can you tell us how many people are included in this study, what the age range is, and were they all from Central New York?

Paula Trief, PhD: So you have to understand the context of this. This was a study that was kind of an offshoot of the TODAY study (Treatment Options for Type 2 Diabetes in Adolescents & Youth).

In the TODAY study, about 700 youths, kids and adolescents, were enrolled. And that was at 15 centers across the United States, so no, it wasn't just Central New York. And they all had Type 2 diabetes. They had developed it as children, as teenagers. And the purpose of TODAY was to test three interventions to see which work best to control their blood sugar. After TODAY, a group of them were followed annually, so there was no more intervention, but they were assessed regularly to see how things progressed. And that was called TODAY2.

And our study, we called it the iCount study, assessed them towards the end of TODAY2, so at that point, they were young adults. I think the mean age was 26 years old. In this particular paper, we looked at 196 of them who had hypertension (high blood pressure) or nephropathy, which is kidney disease, and then 146 who had dyslipidemia, which is high cholesterol.

Host Amber Smith: And what did you find in those with either hypertension or high cholesterol?

Ruth Weinstock, MD, PhD: Well, the findings were sad. What we found is that if we define low adherence to taking medications as taking less than 80% of the amount of the pill that was prescribed, 80% were low adherent who had hypertension or high blood pressure, and two-thirds weren't taking any medication at all for those conditions.

In terms of the high cholesterol, 94%, so most of them, were low adherent and 84% were not taking any cholesterol-lowering medication at all, even though statin therapy is what has been recommended, and had been recommended, earlier during the TODAY trial.

Host Amber Smith: How does that compare with previous studies that you've looked at for adherence for oral diabetes medicines?

Paula Trief, PhD: That was also poor. It was a little bit better, but not much. The results were really similar. We found that 65.4% were low adherent to their oral medications, again, taking less than 80% of their prescribed pills, and 36.3% were low adherent to insulin.

Now the insulin was just by self-report, so that's probably an underestimation, we would say.

Host Amber Smith: Now why is not taking blood pressure medicine or cholesterol medicine risky, particularly for people with Type 2 diabetes? Dr. Weinstock?

Ruth Weinstock, MD, PhD: For people with Type 2 diabetes, the largest cause of morbidity and mortality -- actually, of death -- is heart disease and stroke.

And we know that to prevent heart disease and stroke that it's important to keep the blood sugars as best under control as one can, but also extremely important is to treat high blood pressure and to treat high cholesterol levels with drugs called statins. That is well known, and so by them not taking the simple medication -- pills -- to lower blood pressure and a statin drug, which is a pill, to lower their cholesterol level, they're greatly increasing their risk of heart disease and stroke.

Diabetes is a large risk factor for heart disease and stroke, but we know that people with diabetes with hypertension and high cholesterol levels are at even higher risk.

In addition, there are other complications of diabetes, for example, kidney disease, and we know that this population is developing early kidney disease, and having untreated high blood pressure in addition to diabetes also increases the progression and increases the risk of having kidney disease.

Host Amber Smith: I think of kidney failure and cardiovascular disease and stroke as diseases of older people. How young are you seeing these diseases in people?

Ruth Weinstock, MD, PhD: So we found in the TODAY study, which of course is also very sad, that in their teens, many of them were developing high blood pressure, as well as early evidence that their kidneys were being affected by the diabetes.

This is alarming, really. We have some individuals, actually, from this study who are now on dialysis in their 20s, so they are developing it early, and by not treating the high blood pressure and the high cholesterol levels, they're increasing the risk of a more rapid progression of kidney failure, eye problems related to diabetes, as well as heart disease and stroke.

Host Amber Smith: And it sounds like this goes back to if they took the medication to manage these conditions, the high blood pressure or the high cholesterol, they wouldn't be in that situation.

Ruth Weinstock, MD, PhD: That's what we believe. So many of them didn't take the medication. There were very few who were taking it.

So in this particular population, we weren't able to make that comparison. But certainly based on all the studies in adults, that is the case, that people who take the statin drugs and control their blood pressure have much better outcomes.

Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking to Dr. Ruth Weinstock and Dr. Paula Trief about their research, which was paid for by the National Institutes of Health and was published recently in the Journal of the American Medical Association Network.

Now, do you know the reasons that young adults are not adherent?

Paula Trief, PhD: Well, that was kind of the focus of this study. What we wanted to look at was, what are some of the psychological and some of the social factors that might affect medication adherence?

I have to say that it's not just young adults who are not really that adherent. I mean, the (medical) literature suggests that, of people who get prescriptions for medications, 50% of them actually fill the prescriptions, and of those, 50% actually take them as prescribed.

So the medication adherence is a huge concern that's kind of, we think, understudied. But in this particular case, we were looking at what factors affected it in these young adults with youth-onset Type 2 diabetes.

And the one thing that came across loud and clear was that the beliefs that they have about medicines are important. We found that if they had concerns about medicines, concerns like becoming dependent, thinking of a medicine that you have to take over a prolonged period of time as meaning you're dependent on it, or being concerned about side effects. That predicted low adherence over time, meaning if you had these kinds of beliefs at one point, a year later, you were still likely to be low adherent to oral medications.

And also, unmet social and material needs; so that's things like housing insecurity and medication, health care coverage, not having health care coverage. Those are considered unmet material needs that also predicted low adherence to oral medications. Similarly, believing that medicines are harmful. This is a general belief, that medicines in general are harmful, or medicines in general are overused, that predicted low adherence to insulin.

Those kinds of thoughts and cognitions, we would call it, are predictive of poor adherence. And it was also interesting what we did not find. So we did not find that being depressed predicted low adherence or anxiety or having low self-efficacy or confidence in your ability to do what you need to do. They did not predict low adherence in this population. And there's an assumption always that if someone's depressed, if you then treat their depression, they'll do better with their adherence. And that may be true, but so far there's really no strong evidence for that.

Host Amber Smith: And these medications that we're talking about, are they generally covered by health insurance plans, or was there sort of a fear of not being able to afford it?

Ruth Weinstock, MD, PhD: These are extremely inexpensive medications. Very inexpensive. They're generic, and you can get them at certain pharmacies for $10 or $12 for a three-month supply, so the cost is not a barrier for these medications. And the insurances do cover it, but even without insurance, they're inexpensive.

Host Amber Smith: Did you get a sense of whether the people in your study have a lack of understanding about what might happen if they don't take the medicines? Is there, like, an education gap?

Paula Trief, PhD: We really can't answer that, but I would have to say that in this group, in particular, they had had a lot of education about the importance of taking them regularly when they were involved in the TODAY study, which was the intervention trial. And then also, they would be coming back on a regular basis for these assessments and meeting with the staff people, who provided a lot of support. And I'm sure we'll be talking to them about medication. So if there is a knowledge gap, this particular group would be the least likely to have had that.

The problem with the understanding about how bad things can be if you don't take your medicines is that if you emphasize potential bad things that can happen, you raise anxiety and fear. And fear, honestly, is just not generally a good motivator. It often leads people to just avoid dealing with the issue at all. If I look at my pills, and it makes me anxious, I don't remember if I've taken them or what they're going to do to me if I don't take them. People just kind of push them aside.

So that's something that just, in general, I don't think our field has figured out really well, to be honest.

Host Amber Smith: Have you tossed around ideas for ways to help this group of patients?

Paula Trief, PhD: Yeah, of course. So the focus here was, again, to figure out what might be underlying some of it. Most interventions that have been done on medication adherence work on ways to remind people, because people say, "Oh, I forgot."

So we figure, OK, well then, we'll remind you. And so there are those things like setting schedules. There's a lot of new apps that people can use that can remind them when they're supposed to take their medications. But right now there's really no evidence that just reminding people works or even that forgetting is the main issue, despite the fact that that's what patients often say.

So, based on our data, we think one thing is that it's important for providers first to focus on medication adherence when they meet with a patient. Because sometimes, if a patient's not doing well, if their numbers don't look good, then providers just will increase their medications or switch the medications and maybe not have the time to explore with them: Are they actually even taking them, or are they taking them properly?

So one is just to focus on medication adherence, and then the other is to try to address this issue about beliefs about medicines. Again, all this takes time, and providers are so stressed for time, it's difficult, but it means saying something to them like: So, here, I'm going to give you the script (prescription) for medicines. What are your thoughts about this? What are your thoughts about the medicines that you've been taking? How have you been doing? Let's spend a little time talking about it.

And so if you can find out that your patient has fears that drugs are overused, or that they're going to be harmful to them, or that they're going to be dependent, at least they can start to address those through this kind of conversation.

Host Amber Smith: Are there suggestions for how friends or family members can intervene to help these young adults?

Paula Trief, PhD: I think it's the same thing. I think it's to pay attention to medication adherence and to ask about how it's going, not in a shaming way, and not in a way that, again, as I said, just makes people anxious and fearful. And family members are often also anxious and fearful. But accept that most patients, not just these young adults, don't take their meds as prescribed. And it's not just for them, as I said.

So, spending some time talking to them about it and then asking how they can help. Say: OK, is there anything I can do to help you stay on track with this? Because I love you and because I'm worried about you, and I want to be an aide and a collaborator with you in this process.

Host Amber Smith: We've talked before about the obesity epidemic fueling the increase in the number of people developing Type 2 diabetes as children. Do either of you see that changing in the near future?

Ruth Weinstock, MD, PhD: Well, unfortunately there's no evidence that it's changed yet, although we can always be hopeful for the future. There are new anti-obesity medications that are being used in adults, and now some of them are approved for children. But we have not seen yet that that trend has changed.

But we're hopeful. We're always hopeful that there'll be new treatments and new, other, prevention efforts that can change this trajectory. But there may also be other environmental influences, as well as genetic influences, that are responsible for some of this. And one needs to keep in mind that not just Type 2 diabetes, but Type 1 diabetes also, which is not associated with obesity, is also increasing in incidence and prevalence, in the U.S. and other parts of the world. So there's a lot to research; it's a lot that we still don't understand. But unfortunately, at the moment, the incidence and prevalence of diabetes just continues to increase worldwide.

And the other thing to keep in mind is that both Type 1 and Type 2 diabetes, but we'll talk specifically about Type 2, is very heterogeneous. We talk about Type two diabetes as if it's one disease, but it's really not. The more we learn about it, the more we're going to find that within Type 2 diabetes, we're going to have new names and maybe a dozen or more types of diabetes as we learn more about the genetics, as we learn more about the differences.

Some people with Type 2 diabetes are not obese. There are probably many different types of Type 2 diabetes, which in the future will probably have different names. as we learn more about them. And as we learn more about them, hopefully, better ways to prevent and treat all the different people with diabetes.

Host Amber Smith: Dr. Trief?

Paula Trief, PhD: I think everybody is very optimistic, or let's say positive, about these new anti-obesity drugs. I'm always a little wary about anything new, so I guess we'll see. That may help a segment of the population, but even with that, you have to give yourself a shot. There's going to be adherence questions there as well, I'm sure.

Ruth Weinstock, MD, PhD: Yeah. I think the other concern is that this study that we're talking about -- this was Type 2 diabetes that developed in childhood, not in adults. And so they're still growing, the teenagers. And so, the new obesity drugs, whereas they are very helpful to certain people to lose weight, you have to continue to take them. There's weight regain when you stop taking them. So what are the possible long-term side effects when you're talking about starting drugs like this in a child, in someone who's still growing or someone who has not had her children yet? So I think there are a lot of unanswered questions as well.

Host Amber Smith: Well, I appreciate both of you for making time for this interview. Thank you.

Ruth Weinstock, MD, PhD: Thank you so much.

Paula Trief, PhD: Thank you for your interest.

Host Amber Smith: My guests have been Dr. Ruth Weinstock, the medical director of the Clinical Research Unit and the Joslin Diabetes Center at Upstate, and Dr. Paula Trief, a professor of psychiatry and medicine at Upstate.

I'm Amber Smith for Upstate's "HealthLink on Air."

Next on Upstate's "HealthLink on Air," a new treatment option for some liver cancers.

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."

For people with colorectal or bile duct cancer that has spread to the liver, a new treatment option may improve survival and life expectancy. Dr. Mashaal Dhir is here to tell us about hepatic artery infusion therapy. He's an associate professor of surgery at Upstate and the section chief of hepatobiliary and pancreatic surgery.

Welcome to "HealthLink on Air," Dr. Dhir.

Mashaal Dhir, MD: Thank you for having me.

Host Amber Smith: First of all, do colorectal and bile duct cancers typically spread to the liver?

Mashaal Dhir, MD: Yes, the colorectal cancers, they typically arise in the colon and rectum part, which is connected to the liver, through a big vein called portal vein. So liver becomes the next step for many of these cancers. And in general, 50 percent of the patients with colorectal cancer will have spread of the disease to the liver during their lifetime.

The bile duct cancers which are particularly relevant to this type of therapy are the ones which start within the liver. The medical term we use for these are intrahepatic. That means the ones which are arising within the liver. Those are the ones which are treated by this type of treatment.

Host Amber Smith: And how's this traditionally been treated when you have a colorectal or bile duct cancer that has spread to the liver? In the past, how's it been treated?

Mashaal Dhir, MD: For colorectal cancer, surgery has been the forefront of treatment in addition to chemotherapy. There are other treatment options for some of the patients as well. For example, radiation or injection of radioactive particles into the liver. And hepatic artery chemotherapy has been around for some time, but just not at our institution.

Similarly, for the bile duct cancers arising within the liver, it's a combination of surgery with chemotherapy. And for patients who are not candidates for surgery, it's typically chemotherapy alone, in conjunction with radiation for some patients.

Host Amber Smith: So tell us about what is hepatic artery infusion therapy? How does it work?

Mashaal Dhir, MD: One of the unique things for these colorectal liver metastases, as well as the bile duct cancers arising in the liver, is that they derive their blood supply from the hepatic artery, which is the liver artery. And liver in itself has two blood supplies, the artery and the vein. So the principle of this therapy is to deliver the high dose of chemotherapy directly into the artery, which supplies these tumors and in a way could be 400 times more effective than infusing the same chemotherapy in the IV form.

Host Amber Smith: So that it goes just to the liver, as opposed to the whole body?

Mashaal Dhir, MD: Yes. Yes. And 95% of this chemotherapy is cleared by the liver within 10 minutes, and a very small amount of the chemo goes into the circulation. So a lot of it is effective locally with very small amount of side effects which patients experience, so that's the main strength of this treatment.

Host Amber Smith: That's good to know. Now, what are the risks of this procedure, because to get this to be done you have to insert a pump, right?

Mashaal Dhir, MD: That's true. That's true. That traditionally has been one of the drawbacks of this therapy that you have to undergo procedure to implant a pump which sits underneath the skin and put the catheter in the liver artery. But more and more data suggests that it really prolongs life, and patients do bounce back quickly from the procedure itself.

And over the last few years we are also doing this procedure robotic. We haven't started doing it robotic here at Upstate, but that's something I trained in and I have written about it in the past. However, we started our program as offering it open to our patients and making it readily available to them.

Host Amber Smith: How long does the infusion therapy last once the pump is implanted?

Mashaal Dhir, MD: It really depends on what the intent of the treatment is. In a way, if we are doing the treatment for -- it can be done in two ways, I should clarify that -- one for patients where we cannot remove their disease, where the disease is unresectable. That's the term we would use. For those patients, either it can be for as long as they can tolerate, or if the tumors become resectable, we can take them to surgery down the road and stop treatment at that time, or if some side effects of the treatment start showing up.

So it can vary from patient to patient, how they tolerate, at what point do they develop any side effects, and if their disease becomes amenable to surgery down the road.

Host Amber Smith: So if all goes well, does the pump get removed at the end of the chemotherapy?

Mashaal Dhir, MD: That's an excellent question. It is possible to remove the pump. The procedure to remove the pump is actually much simpler, where you just make an incision and remove the pump. We leave the catheter in the artery as such, and it doesn't pose any threats or side effects. But there are other medications which can be put into this pump which keep it open, and those medications can be replaced every three months or so to make the life of the patients easier.

Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with surgeon, Dr. Mashaal Dhir, who's the section chief of hepatobiliary and pancreatic surgery at Upstate. And we're talking about a new hepatic artery infusion pump that can help some patients with certain cancers that have spread to the liver.

Now, who would be a candidate for hepatic artery infusion, and is there anything that would disqualify someone?

Mashaal Dhir, MD: The two particular diseases for which we use this therapy are the colorectal liver metastases. So in general, it is recommended for those patients who have unresectable disease. That means disease which cannot be removed, which typically involves both sides of the liver. And such patients also should not have disease outside the liver as well, for example, to their lungs or bones, because we are delivering this therapy to one organ only.

And same for unresectable bile duct cancers, the intrahepatic cholangiol, like we discussed before. These are the bile duct cancers arising within the small bile ducts within the liver. So, unresectable disease is one clear-cut indication, but in some patients where we resect the disease, but they have lots of lesions in the liver, pump can still be implanted to prevent recurrence down the road or to treat the recurrence if they were to develop one down the road.

Host Amber Smith: How soon do you know whether the therapy is working?

Mashaal Dhir, MD: This is similar to as we do for most patients who undergo chemotherapy. Usually we check a scan after two to three months of treatment. If patient has elevated blood tumor markers, which are elevated in some patients with bile duct cancers and colon cancers, we can also check those in their blood levels. But usually we check a scan in about two to three months after the treatment.

Host Amber Smith: So far, how does the effectiveness with the hepatic artery infusion compare with traditional chemotherapy?

Mashaal Dhir, MD: Over the last few years, there have been several studies. More recent data suggests that, actually, if we use both, rather than one versus other, it can enhance the effectiveness.

And in patients who have unresectable disease, if we add this therapy to their chemotherapy regimen, it can actually double their survival. So, it depends on the intent. And for unresectable patients, if it is added to chemotherapy, over 30 to 40 percent of those patients can become resectable down the road. So the data is very, very encouraging, especially when we combine this with modern chemotherapy regimens.

Host Amber Smith: It does sound encouraging. There are other types of cancer that travel to the liver. Would an infusion pump work for those cancers too?

Mashaal Dhir, MD: In general, this therapy is not recommended for those types of cancers, just because the mode of spread is different, and they progress at different times, and it's a more systemic disease when we think of those types of cancers. I would say intrahepatic cholangio as well as the colorectal liver metastases are the two major indications for hepatic artery infusion chemotherapy.

Host Amber Smith: Well, I understand you recently published a paper about the global trends in primary liver cancer. Can you share the highlights?

Mashaal Dhir, MD: Thank you for bringing that up.

So I think it was interesting that traditionally there has been increase in the incidence of the primary liver cancers, but what we saw when we studied the Global Can (Global Cancer Observatory) database was that the numbers are starting to plateau.

And I think some of it may have to do with some vaccinations in endemic areas, for example, hepatitis B and so forth. But I think these things may change in future as well as we see obesity and other diseases which can impact liver health increase. They may impact the numbers going forward, but so far compared to 2012 and 2020, based on the database, the numbers seem to be plateauing, which is good news in general.

Host Amber Smith: Which regions are historically endemic for liver cancer?

Mashaal Dhir, MD: The eastern region, including China, would be one. But then there are certain parts of Africa and the different regions. WHO (World Health Organization) divides world into six major regions. So I would say there are several endemic regions, but Eastern Asia has been one of the major endemic.

Host Amber Smith: Well, it's encouraging. If the incidence is going down, that's going in the right direction, I suppose.

Mashaal Dhir, MD: Yes.

Host Amber Smith: Well, Dr. Dhir, thank you so much for making time for this interview. I appreciate it.

Mashaal Dhir, MD: Well, thank you for having me.

Host Amber Smith: My guest has been Dr. Mashaal Dhir, an associate professor of surgery at Upstate and the section chief of hepatobiliary and pancreatic surgery.

I'm Amber Smith for Upstate's "HealthLink on Air."

Medical students are the teachers: next, on Upstate's "HealthLink on Air."

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."

from Upstate Medical University Norton College of Medicine team up to teach a seminar course at Syracuse University. Here to tell us about it is one of the organizers, Amelia Gabor, who happens to be a Cazenovia native and is now almost halfway through medical school.

Welcome to "HealthLink on Air," Ms. Gabor.

Amelia Gabor: Thank you, Amber.

Host Amber Smith: I've always thought medical students hardly had time to sleep, let alone do anything else. But you and two of your classmates have made time to teach this seminar class once a week on health advocacy. What can you tell us about it?

Amelia Gabor: Yeah, so definitely finding time to sleep is a challenge, but you also find time to do the things you love and to advocate for the things you're passionate about. So, my colleagues and I are really passionate about working with folks with intellectual disabilities. And so we've teamed up with InclusiveU at Syracuse, which is a fully inclusive education program for students with intellectual disabilities. And we teach a seminar course called Health Advocacy. It meets once a week for an hour, and we teach our students everything about health, whether it's personal health or how to navigate the health care system.

Host Amber Smith: So this is one of the seminars. I know SU has a variety of different topics of these seminar classes. What is the kind of overall goal of the seminar on health advocacy?

Amelia Gabor: So, the reason we started writing this course was because we know that in the population of people with intellectual disabilities, there tends to be a lot of health disparities. So this population faces a lot of challenges to not only obtaining adequate health care, but just making sure that they themselves are living their most healthful life.

So, in health advocacy, we try to give our students the knowledge and tools to live as independently as they can, and to really live a life filled with comprehensive wellness.

Host Amber Smith: It sounds like you're helping the students become their own health advocates.

Amelia Gabor: Right, exactly. And we try to teach them, in addition to personal health skills, this idea that they can be an advocate for their health and that somebody like a doctor can be an ally for them, when they're thinking about "How can I live really independently and safely and healthfully?"

Host Amber Smith: So this was a semester-long seminar. What were the specific topics each week? And how did you and your classmates come up with these topics?

Amelia Gabor: We really tried to teach a wide variety of health topics. So, we talked about nutrition. We talked about fitness, mental health, emotional health, sleep, dealing with stress, so really thinking really broadly about health and trying to teach our students that health is more than not being sick, right? But really this idea of comprehensive wellness.

We worked with administration at InclusiveU to ask them, what do their students really need to learn about health. And a common theme that we saw emerge was this idea that these are InclusiveU students. A lot of our seminar students are freshmen. So this is their first time living alone on a college campus, right? So when I was a freshman in college, it was hard for me to find the balance between school and sleeping and eating well, right? All of that stuff. And those same challenges exist for students with intellectual disabilities at InclusiveU.

So what the InclusiveU administration really emphasized was trying to establish kind of cause-and-effect connections. So a lot of times the students may come into class completely exhausted, almost falling asleep. And when we ask, "OK, why?" it's really hard for them to ascertain or pinpoint something that has caused them to be tired. Digging a little deeper, we can figure out that they went to sleep at 3 o'clock last night, right? But that kind of cause and effect, that's something we really try to work with the students to develop those ideas.

Host Amber Smith: What were the topics that were most popular with the students? Was there one week that you remember that they really were engaged and really interested?

Amelia Gabor: I think the highlight week this semester was when we talked about going to the doctor. So, again, this course is about advocating for yourself through the lens of health, so we thought it was important to talk about going to the doctor, and we asked the students about the importance of going to the doctor, and of course they were able to draw from their personal experience to tell us about doctors help you when you're sick, and they help you prevent illness, right?

But what we also did was we wanted to tell the students why doctors do what they do. So we pulled out a stethoscope, and of course all of our students know what a stethoscope is, but we went into a little bit of the physiology. What exactly is a doctor listening for, when they listen to your heart? Because that was really exciting for the students. And they were really curious about that stuff.

The other thing we did was, we used our own stethoscopes on them, and we listened to their hearts, and we used our reflex hammers. And then we gave them the opportunity to try it on us. Going to the doctor for this population can sometimes be really anxiety inducing. So we figured if we give our students the opportunity to touch and to hold some of the tools, that could be helpful. So they were listening to my heart. They were looking at my pupillary reflexes, shining a light in my eye. And that was really fun for them to not only just experience, but also kind of understand why do doctors do what they do. And then hopefully the next time they go to the doctor, anxiety might be eased a little bit.

Host Amber Smith: This is Upstate's "HealthLink on Air" with your host, Amber Smith.

I'm talking with Amelia Gabor. She's a medical student at Upstate Medical University Norton College of Medicine, and we're talking about a Syracuse University InclusiveU program she's really passionate about and the health advocacy seminar she's involved in teaching.

So tell us, why did you want to teach this class? Why were you anxious to volunteer?

Amelia Gabor: I'm really passionate about working with this population, specifically through the lens of health. It's kind of a two-fold explanation. So, first of all, what we know from research about medical education is that medical students do not get a lot of exposure to working with patients with intellectual disabilities. And then what happens is when they become doctors, they really aren't comfortable taking care of these patients. That creates all sorts of health disparities that we see with this population.

And the other reason I was interested in teaching this class was to try to get at some of those health disparities. So, trying to teach our students the hands-on skills that they can use to enhance their health. We talk a lot about lifestyle changes, so not anything that they necessarily need a doctor for, but the things they can do themselves. They can eat healthy, they can go to bed, they can manage their stress, right?

Those things are what we try to teach our students. So, while we're doing that, we also bring in medical students, some of my peers from SUNY Upstate, for them to try to experience working with this population so that while we're teaching this population about their health, my peers, who may not have a lot of experience working with this population, are gaining comfort. So that when they see a patient with Down syndrome, for example, on rotation (as they learn about various medical specialties), they'll feel comfortable and know how to interact with them, know how to talk to them.

Host Amber Smith: You seem like you feel very comfortable already working with intellectually disabled. Is that the case?

Amelia Gabor: Yeah. I have a lot of experience working with this population, and it really goes back to my dear friend from kindergarten. His name's Harry Dydo. And we met when we were 5 years old, and we're 26 now, so he is my longest-standing friend.

We met in kindergarten before I really could conceptualize what Down syndrome was. So to me, Harry maybe spoke a little bit differently and maybe looked a little bit differently, but that really didn't phase either of us. And so what ensued was the formation of a really organic, authentic friendship. Maybe in third grade, I began to realize what a disability was, what Down syndrome was, but that didn't change anything.

We went all throughout high school together completely locked at the hip. And to this day, he is really one of my best friends. He's one of my favorite people in the world.

Host Amber Smith: So tell us how V United Scholars came about at Villanova. That's where you did your undergrad, right?

Amelia Gabor: Correct. So, V United was completely inspired by Harry. Like I mentioned, Harry and I went all throughout high school together. And then we both graduated. And I went to Villanova, and Harry enrolled at InclusiveU at Syracuse. And in those first weeks of freshman year for both of us, we were on the phone with each other, realizing that we were having really similar experiences. And I thought that was just the coolest thing in the world, that my childhood friend with Down syndrome was having the exact same freshman year experience as me.

And so I started thinking, what if I could do something like that at Villanova. And so I talked to the administration at InclusiveU, who were really supportive and really generous and got some ideas from them and then tried to replicate it at Villanova.

We started really small at first -- once-a-week life skills course that met for two hours -- and then slowly throughout my four years at Villanova, we continued to grow V United. Toward the end of my time, we aligned with some really like minded, really generous individuals who shared our passion, and they were able to give us a really generous donation that allowed us to do what I had always wanted, which was to become a residential program.

So now, V United Scholars is really similar to InclusiveU in that our students are on campus 24/7. They live in the dorms. They're getting a robust, fulfilling college experience.

What is really special about Inclusive U is the way they tailor each student's educations to their passions.

So, for example, my friend Harry really loves sports, and he came into InclusiveU with that passion. So the support at InclusiveU, what they tried to do for him, was figure out how can we have you live your life independently and pursue this passion of sports? So throughout Harry's time, he took classes on fitness and exercise science. And now he works full time at the fitness center at Syracuse. So, really, what InclusiveU does, I think, is work with each student to figure out what are your passions, what are your goals, and how can we help you achieve that?

Host Amber Smith: Well, I know you were the instructor, but did you learn anything from the InclusiveU students at SU, or from this teaching experience?

Amelia Gabor: Oh, certainly, certainly. What I'd often ask them was, I would say, "Tell me what I can do better if I was to be your doctor." And something they often said was, "When I go to the doctor, the doctor is very nice, and I like going to the doctor, but the doctor usually talks to my mom, or the doctor talks to my dad, and the doctor doesn't really talk to me."

And that's a really important lesson for me, and for my peers who are going to be doctors. When we think about how are we going to care for these patients with disabilities. On the one hand, there are certainly things that you need to do differently because people with disabilities, part of their disability, there might be some pathophysiologies or pathologies that present differently in people with disabilities than in the general population. So there are some things that a doctor might need to do differently. But, for the most part, there's not a lot you have to do differently.

Talking directly to the patient, listening to the patient, using empathy, trying to build a relationship. That's what's really important, right? And you can apply that to all patients, not just patients with disabilities.

Host Amber Smith: Based on your experience, do you have any advice for nonmedical people who have contact with someone who has a disability?

Amelia Gabor: Well, I guess for anyone, health care professional or not, interacting with somebody with a disability, I think it's really important to remember that these people are so much more than just their disability. Right? These are complex people just like you or me, and they have hopes and dreams and ambitions. And it's really important to see the person first before seeing the disability.

Host Amber Smith: Well, Ms. Gabor, I really appreciate you making time for this interview. Thank you.

Amelia Gabor: Thank you, Amber.

Host Amber Smith: My guest has been medical student Amelia Gabor from Upstate Medical University Norton College of Medicine. I'm Amber Smith for Upstate's "HealthLink on Air."

Here's some expert advice from Dr. Elizabeth Asiago-Reddy, the chief of infectious disease at Upstate Medical University. What do adults need to know about the RSV (respiratory syncytial virus) vaccine?

Elizabeth Asiago-Reddy, MD: This is something new that has just come out. There were actually two vaccines that were evaluated in June by the FDA (Food and Drug Administration), one that's made by GSK and one that's made by Pfizer. Those are called Arexvy and Abrysvo, respectively. And they're both highly effective in preventing severe lower respiratory tract infection from respiratory syncytial virus, or RSV.

The GSK Arexvy appears to be slightly more effective when we look at the available data. And it had a unanimous vote of approval, versus a couple of dissenters on the Pfizer vaccine. But both were approved, and both, again, are effective in preventing severe disease and specifically lower respiratory tract disease -- so that means pneumonia -- in adults, age 60 and up.

So these are currently being recommended as a single dose for adults age 60 and up. What we don't know right now, to my awareness, is whether there'll be additional recommendations for others who might have risk for respiratory syncytial virus based on immune compromise. At this point, I'm only aware of the older adult recommendation at this point.

There is a monoclonal antibody available for children, which is new as well. So with these combinations of prevention options, we're hoping that we'll have a less severe RSV season than last year. So last year was a very severe RSV season that was somewhat unprecedented.

For right now, there's no contraindication to (reason to avoid) getting all three vaccines together at the same time -- so that would be flu, RSV and COVID. I would definitely recommend anyone who's eligible asking their primary care provider about all of these vaccines and how best to give them in combination.

It looks like, because the RSV vaccine is adjuvanted -- what that means is that there's a medication put into the vaccine that boosts the immune response. There's a possibility that people might have some more symptoms associated with getting multiple vaccines delivered at once.

That having been said, when reviewing expert advice and realities on the ground, what happens when you split up vaccines is that people oftentimes just don't get them. And so it would be better to get all three, especially for those individuals who are at highest risks, so those include the people in the age groups recommended, and especially those with comorbidities.

Host Amber Smith: You've been listening to Upstate infectious disease chief Dr. Elizabeth Asiago-Reddy.

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

Deirdre Neilen, PhD: COVID continues to be a focal point for many writers. We received excellent poems from physicians describing some of their experiences with it. The first poem I'd like to read is by fourth-year medical student Ellen Zhang. She is a student at Harvard, and her poem "To Open Doors," won our Sean Hodge Prize for Poetry in Medicine.

"To Open Doors"

Your arrival reminds me of what it means to care

in the moment. It was not the way you weighed

merely two pounds, the way you necessitated

emergency surgery, or the way you gripped

onto life even though it caught you off guard.

It was the way your mother broke rumbling

of the monitors, wrapped in mask and goggles,

wearing gloves to cradle you. Asking for you to be

loved for the first time by grandparents, uncles,

aunts, cousins. To be loved for a long, long time.

In hospitals, so many bodies share the

same air. In times of pandemic, supplies are

lacking, regulations proliferative. Your ribs

barely rise to fall. Reminders that oxygen is

a scarce resource. But, love, love is plentiful.

Dr. Sarath Reddy is a gastroenterologist practicing in Brookline, Massachusetts. His poem "Unfinished Conversation" recalls the impact some patients can have on us.

The virus left his lungs moth eaten,

parched leaves crumbling to touch

unable to bear the work of breathing,

until machine, not man, was driving life.

Desk shrouded in silence, a friend taken

for granted like scenery, I sketch him

back in, give him back his Greek accent,

staccato on the computer.

As he bounces between topics, musings

on chili pepper and menu of India Delight

spicy samosas and vindaloo,

brought him back

long enough to say I'm sorry --

that I could give him only prayers

and not potions, had reluctantly lent

his obituary a pen,

that we never spoke about God or Plato

never got beyond headlines, whimsical weather,

and pleasantries

just like trees regret never asking autumn

leaves the questions that really matter.

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," efforts to improve outcomes for patients with traumatic brain injury.

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 Bill Broeckel.

This is your host, Amber Smith, thanking you for listening.