Understanding hepatitis B; a tick update; reconstructive urology: Upstate Medical University's HealthLink on Air for Sunday, June, 4, 2023

Host Amber Smith: Coming up next on Upstate's "HealthLink on Air," a family medicine doctor goes over new recommendations for hepatitis B screening and prevention.

Sana Zekri, MD: ... Hepatitis B does increase the risk of cancer of the liver, and that's another thing that as a family medicine doctor, we screen for, and we watch out for in patients who have hepatitis B. ...

Host Amber Smith: A tick expert tells what Central New Yorkers can expect from ticks this summer.

Saravanan Thangamani, PhD: ... They are persistent animals. They will actually crawl over you, your clothing material or under the skin all the way until it finds its perfect spot to attach and feed for longest period of time. ...

Host Amber Smith: And a pair of reconstructive urologists tell about their expertise.

All that, three book recommendations from a pediatrician, and 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, a tick expert tells what we can expect from ticks this summer. Then, two reconstructive urologists explain their specialty work. But first, there are new recommendations for hepatitis B prevention: Do you need to be tested?

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

New recommendations from the CDC (Centers for Disease Control and Prevention) are meant to increase awareness of hepatitis B infection and reduce chronic disease and premature death. So what do patients need to know for answers? I'm talking with Dr. Sana Zekri. He's an assistant professor of family medicine at Upstate.

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

Sana Zekri, MD: Thank you. It's nice to be here.

Host Amber Smith: These recommendations say all adults should be tested for the hepatitis B virus infection at least once in their lifetime, and that some adults should get periodic testing. Why the emphasis on hepatitis B?

Sana Zekri, MD: I'd like to first start off by talking about what hepatitis B is. It's a hepatic virus. So, hepatitis -- "hepat" means liver, and then "itis" means inflammation. So, there's many ways that you can develop inflammation of the liver, medications that you take, alcohol use, but then there's also viruses that can cause that inflammation of the liver. There's hepatitis A, there's hepatitis B, and people have also heard of hepatitis C. There's actually other ones as well. And these hepatitis viruses, some of them have been with mankind for a really, really long time. And hepatitis B is one of the ones that has been with mankind for a long time and has unfortunately resulted in a lot of premature death due to liver disease.

The reason that there's so much emphasis on hepatitis B in particular is that this is something that is mostly found in humans. It's something that can be effectively prevented by knowledge of where it came from. But unfortunately, when it takes root, when it takes hold, it's really difficult to get rid of it. And so this increased emphasis on hepatitis B testing and prevention is really aimed at trying to reduce the overall burden of premature death from hepatitis B that takes hold, takes root, in people.

Host Amber Smith: So how would a person know they've been infected?

Sana Zekri, MD: Well, that's actually really difficult. The hepatitis viruses in general can be very quiet viruses. Sometimes they're very angry viruses. So, hepatitis B, it actually depends on when you get it in your life. In an adult who gets hepatitis B, they will often have the signs of hepatitis, which is yellowing of the skin. That's called jaundice. They'll have pain or tenderness in the right upper quadrant of the abdomen, like underneath the right side of your ribs. That's where your liver is. They may have nausea. They may have vomiting and fever and get kind of sick.

But actually children who get hepatitis B may have almost no symptoms at all. And it actually makes a difference how much of a symptomology you have. The more symptomatic you are, the more likely it is that your body will fight off the virus; and the less of an illness that you get, the less symptomatic you are, it seems like it makes it more likely that the virus will quietly take hold and take root, and you'll be chronically infected with hepatitis B.

Host Amber Smith: How does it transmit from person to person?

Sana Zekri, MD: So hepatitis B is one of the viruses that can be transmitted in multiple ways. The one that is most concerning, the most problematic, the one that we -- well, two ways that we have really significant concerns about. No. 1 is vertical transmission. So vertical transmission means mom has hepatitis B, and baby gets hepatitis B from mom. And you remember that I said that children who get hepatitis B -- that includes babies -- may have very low symptoms, but they actually 85 to 90% of babies who have hepatitis B at birth go on to develop the chronic infection, which we don't have good effective treatments for.

The other group of people that we're really worried about are people who get blood transfusions or who are regularly being exposed to blood products. Think people who maybe who live in nursing homes and who have to have their blood sugar checked multiple times a day, or people who are in the hospital and have to have labs done on a frequent basis, or patients who are undergoing dialysis. Those are two really high risk groups of people because hepatitis B is very easily transmitted through blood. Hepatitis B can also be transmitted through sexual contact. And when I say sexual contact, I don't mean kissing. And I don't mean breastfeeding. But I do mean sex. Vaginal secretions and semen, they can carry the hepatitis B -- and anal secretions as well -- they can all carry hepatitis B.

Host Amber Smith: So what is involved in testing for hepatitis B? Is it just a blood test?

Sana Zekri, MD: Yeah. Basically, it's blood testing. Yeah. There's several blood tests that are done, but it can all be done in one session. You get several tests that are done all at once. In some cases, hepatitis B has a window in which your body hasn't yet responded to the infection, and your tests may come back negative in the very first period when you get the infection. And in those cases, some people where there's high suspicion, they may need to be retested again, which is part of the reason why the CDC recommends that patients be retested if they're at high risk of getting hepatitis B. So redoing blood tests is not something that's unheard of.

Host Amber Smith: As a doctor of family medicine, what do you do for someone who tests positive?

Sana Zekri, MD: There's acute hepatitis B, which is when a person has the symptoms and they don't feel well, and with that it's mostly watching and waiting and seeing if they're going to clear or not. There are a few antivirals that maybe can help a little bit, but mostly it's watching and waiting and seeing what the body will decide to do.

With chronic hepatitis B, unfortunately, there's not a lot of treatment for it. So it comes down to watching for the problems that can come from hepatitis B. So the problems that can come from hepatitis B are slow damage to the liver that can cause something called cirrhosis, which many people have heard of. But cirrhosis is kind of where the liver is no longer functioning appropriately, and puts you at risk of problems like confusion, puts you at risk of problems like bleeding episodes and unfortunately can also kill you.

And there is also the risk of cancer of the liver. Hepatitis B does increase the risk of cancer of the liver, and that's another thing that as a family medicine doctor, we screen for and we watch out for in patients who have hepatitis B. So we're watching to make sure we know when they develop cirrhosis, and we take appropriate action when they develop cirrhosis. And we're watching to make sure that if they develop liver cancer, we identify it early so that we can treat them early.

The other thing is that when we have patients who are of childbearing age who have hepatitis B, we're very, very careful about making sure that we monitor their hepatitis B. And if they become pregnant, we make sure to take as many steps as possible to ensure that the hepatitis B is not transmitted to their child.

And then finally, we recommend for everyone who does have hepatitis B, we strongly recommend that their partners and the people in their families be vaccinated and immunized against hepatitis B to reduce the risk of transmission to other people.

Host Amber Smith: This is Upstate's "HealthLink on Air" with your host, Amber Smith. I'm talking with Dr. Sana Zekri. He's an assistant professor of family medicine at Upstate, and he sees a variety of patients from birth through the senior years as a doctor of family medicine. We're talking about new recommendations from the CDC about hepatitis B.

Newborn babies now receive a hepatitis B vaccine. Does that mean that when they grow up, they're not going to need to be tested? Does that protect him for life?

Sana Zekri, MD: The hepatitis B vaccine is very, very effective at preventing hepatitis B in childhood, which is the highest risk period. However, there is evidence that the hepatitis B vaccine wanes over time, and particularly after 15 to 20 years, it appears that the hepatitis B efficacy does wane. So people do need to be retested at a later phase as well, especially if they participate in what we consider high-risk activities. And so those patients do need to be retested again in the future.

And I think an important thing to point out here is -- and I do encounter this sometimes where people will say, "Well, I don't have hepatitis B. You've tested me for hepatitis B during my pregnancy. I don't think that my child needs to be vaccinated against hepatitis B. So you know, I don't have it, so why would I need to do it?" And I think that an important point there is that hepatitis B, unfortunately, is very transmissible and actually can stick around on surfaces for several days. There are some unfortunate incidents where children playing on playgrounds have gotten hepatitis B probably because someone who had hepatitis B got a cut while they were on the playground and another child got it on their hands, or they had a small cut on their hands. This is one of the most transmissible viruses. So I usually recommend that every single child, every single baby, be vaccinated against hepatitis B because that childhood age is the highest risk time for child developing chronic hepatitis B.

And even though members of the family may not have hepatitis B, there could be unknown exposures from outside that we can't control.

Host Amber Smith: What about adults? Can they get vaccinated against hepatitis B?

Sana Zekri, MD: They can, and we actually recommend that they do. We recommend that patients who are at high risk for contracting hepatitis B or patients who have had waning immunity be revaccinated against hepatitis B. And if they've never been vaccinated against hepatitis B, we do recommend that they get the hepatitis B vaccine.

Host Amber Smith: All adults across the board, regardless of their risk?

Sana Zekri, MD: It's recommended to receive at least the first series of vaccines. As to whether or not you have to be revaccinated, that kind of depends on risk, but it is recommended that everyone receive at least the first series of hepatitis B vaccines.

Host Amber Smith: Who are the people who are recommended to undergo periodic hepatitis B testing?

Sana Zekri, MD: People who should undergo periodic hepatitis B testing are people who are considered to be at risk. Now first of all, this is all pregnant women should undergo hepatitis B testing with each pregnancy, similar to HIV testing and hepatitis C testing. Other individuals who are recommended to undergo periodic hepatitis B testing are people who have had a history of sexually transmitted infections, or people who have multiple sex partners, or people who receive money for sex, people who have a history of other types of chronic hepatitis infections, such as hepatitis C, people who are currently or formerly incarcerated, people who were born to individuals who had hepatitis B, people who are born in regions where there's a lot of hepatitis B, and people who inject drugs, have a history of injection drug use, people who have H I V, men who have sex with men, individuals living with people who have hepatitis B, and people who are getting maintenance dialysis, such as patients who have kidney disease, really severe kidney disease and have to get dialysis. And then in general, anyone who has high liver enzymes should be tested for hepatitis B to make sure that's not what's causing their high liver enzymes.

Host Amber Smith: Well, before we wrap up, if someone has a hepatitis B infection that goes undetected because they never got tested, or they just never saw a doctor, what may happen healthwise to them?

Sana Zekri, MD: Unfortunately, we do have examples of people having hepatitis B for a prolonged period of time and not knowing that they have it and it being not detected.

One of the major issues is, of course, transmission to other people, unintentional and unknowing transmission to other people. But from a personal perspective, patients who have chronic hepatitis B are at higher risk of developing cirrhosis, which is the long-term damage to the liver that makes a person at a higher risk of bleeding and confusion, yellowing of the skin and can actually lead to a person's premature death, and they are also at significantly increased risk of developing liver cancer.

Fortunately for the liver cancer part of things, we do have treatments that can help to reduce the damage from liver cancer if caught early.

When it comes to cirrhosis, it's mostly about managing the other risk factors. We don't have great treatments for hepatitis B itself. We only have preventive treatments, but when a person does have chronic hepatitis B, it's important to be monitored to make sure that if there is long-term damage, we can avoid the worst sequelae (resulting conditions) of it.

Host Amber Smith: Dr. Zekri, I appreciate you making time for this interview. Thank you.

Sana Zekri, MD: Thank you.

Host Amber Smith: My guest has been Upstate doctor of family medicine Sana Zekri. I'm Amber Smith for Upstate's "HealthLink on Air."

What's the outlook for ticks this summer? Next, on Upstate's "HealthLink on Air."

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

Over the past four years, Dr. Saravanan Thangamani's lab has tested more than 26,000 ticks from Central and Upstate New York. A third of them carried at least one pathogen, most often the bacteria that causes Lyme disease. We'll hear more about tick research from Dr. Saravanan Thangamani. He's a professor of microbiology and immunology at Upstate, and the director of the SUNY Center for Vector-borne Diseases.

Welcome back to "HealthLink on Air," Dr. Thangamani.

Saravanan Thangamani, PhD: Thank you for having me again.

Host Amber Smith: Before we delve into your research, I'd like to get your prediction for what this year's tick season is liable to be like, since Central New York had a really kind of mild winter. Do ticks like mild winters?

Saravanan Thangamani, PhD: Yes, a mild winter is directly proportional to the number of ticks that humans will encounter in spring and summer and the fall. As we all know that when the winter is mild, we get early spring. That means that we get out early as well, you know, and also ticks, it's the right time for the ticks to be out as well, to seek a mammalian host. And humans, or dogs, or our pets kind of venture into the wooded areas. They get bitten by a tick and they bring it home, and in turn they crawl on us and bite us as well. So it's a confluence of events that is all triggered by warm winter.

Host Amber Smith: So can you remind us where ticks like to live?

Saravanan Thangamani, PhD: In general, ticks tend to be found in wooded areas, tall grass or brush, edges where woods and lawn meet, in the leaf litter, under the ground cover of the plants, and around stone walls and wood piles, where small mammals like mice and squirrels tend to live in.

Host Amber Smith: I know there's a lot of different species of ticks. Do they coexist with one another? Do they get along?

Saravanan Thangamani, PhD: Well, I wouldn't say they coexist, but actually they might be sharing the same habitat. In some of our field tick collection sites, we collect three or four different tick species, not necessarily from the same pile of wooded area, but in the whole neighborhood. We tend to see that. So they can tend to live in the same property, not necessarily coexist.

Host Amber Smith: Now, which ticks are the most prevalent in Central and Upstate New York?

Saravanan Thangamani, PhD: Deer ticks, of course. They are the most prevalent tick species, followed by dog tick and lone star tick. But I must warn that although we are more focused on the Lyme disease agent tick, which is the deer tick, two other tick species that I mentioned is also making its way to Central New York and to the Northern New York and Western New York. Ticks like lone star ticks, and Gulf Coast ticks are also on the emergence. Right now, they tend to cluster at the lower Hudson Valley or tri-state area. But what I'm seeing from our own data is that slowly we are starting to see these ticks in Central New York, which means that in the next few years we can see those ticks establishing population, probably encountering humans and causing human health illness as well.

Host Amber Smith: Your data showed that most of the ticks that were submitted through the Citizen Science Tick Testing program have been female. Why is that?

Saravanan Thangamani, PhD: I think it is the biology of the ticks. You know, for the ticks to perpetrate in nature, they need more females because female slice thousands of eggs. The only purpose of male is to mate with the female, and females are the one that is responsible for the reproduction and to have thousands of larval ticks. So it is probably an evolutionary processes over millions of years that females are necessary to maintain the species level in this ecology. Males only serve to mate with the females, and that's it.

Host Amber Smith: Well, you published a paper in Nature.Com's Scientific Reports Journal not long ago about where ticks attach to humans. Which areas do the deer ticks favor?

Saravanan Thangamani, PhD: So deer ticks, generally they are found throughout the body. However, I would say they tend to prefer head, mid-section and groin areas. So those are the places where we tend to see the majority of the ticks. But our data show that deer ticks can actually, attach to human all over the body.

Host Amber Smith: So, how fast do they move? If I'm thinking, if you're walking through leaves, and they climb onboard your ankle, how long until they make it to your groin or to your chest?

Saravanan Thangamani, PhD: They are persistent animals. They will actually crawl over you, your clothing material or under the skin all the way until it finds its perfect spot to attach and feed for longest period of time. And they are very clever. They have adapted this behavior over millions of years that they need to go and attach in a location that is safe for them, so humans don't actually easily locate and pull it off. You know, if that happens, it defeats the purpose of its life cycle, right? So they're very clever to adapt themselves for that kind of activity.

And also, people, they spray their body with the chemicals, right? Repellents or mosquito repellent that repels them. But we don't put all over our body, right? We only put our forearms or legs, whatever we expose our skin to, or around the neck. So that's why they like to kind of escape from those area because they are being repelled from that area. They're forced to move out of that area. And then they find areas where we don't actually put repellants.

Host Amber Smith: So that's why they like the groin or the chest or the midsection?

Saravanan Thangamani, PhD: That is one possibility, but also it is nice warm and humid environment there as well. You know, that favors attachment. And, again, is one of the least places we will try to apply tick repellants.

Host Amber Smith: So does that apply to dog ticks and lone star ticks, too? Do they like the same areas?

Saravanan Thangamani, PhD: Not necessarily. Dog ticks preferably, they like to go to the head, head and neck area. And, lone star ticks, they prefer thigh, groin and abdominal as well, similar to deer ticks. We are still trying to understand why dog ticks prefer the head, but that's something that we are hoping that -- you know, we have large sets of data now we are currently analyzing to see, are we still seeing the same pattern or not?

The data set that we published was from the year 2020, but now we have three years' worth of data instead of one year. So we are actually reanalyzing the whole thing, three years worth of data, and then trying to see that, OK, are we still seeing the same correlation? Are we still seeing the same pattern? And we are hoping to publish this in the next year or so.

Host Amber Smith: What did you find about infected versus non-infected ticks?

Saravanan Thangamani, PhD: So, interestingly in the deer ticks, because our dataset had enough infected ticks for us to analyze, we saw that there was a change in the bite-site location, if it was a Borrelia infected tick or Borrelia uninfected tick. Primarily, the infected ticks prefer to feed on the groin and midsection area of the body, over the rest of the body section. So that is something that we saw.

Again, this was from a dataset from a single year. Now we have three years worth of data. We are going to compare it. Our dataset is now more robust, and we are currently analyzing it. But the trend is there, and we are hoping to apply statistical analysis to make sure that whatever we find are indeed statistically significant.

Host Amber Smith: Have you looked at where ticks prefer to attach on dogs?

Saravanan Thangamani, PhD: That is a great question. I think that's something that one of our lab researchers is looking into that. We are currently teasing apart this data. We do have the data. We are now teasing apart the data.

Host Amber Smith: So if you take your dog for a walk in the woods, and you come back and the dog has ticks that you may or may not see are the ticks likely to get into the carpet back at your house or get wherever they can find a spot and then hang out, waiting for a human? Or once you comb it off the dog or they fall off the dog, they're just going to die?

Saravanan Thangamani, PhD: So what happens, ticks will try to first crawl on your body first before they go around the ear of the dog to kind of attach because that's where dogs can't groom easily. The rest of the body, they will groom nicely. Or under the tail. Those are the difficult parts for them to reach out, so that's where they go. Or right below, right behind the neck, actually, that's where I see ticks in our dog. That's consistently, that's where I see, because dogs can't reach there, right?

But ticks, they will first try to crawl to the legs and then slowly make its way, right, before it reaches this nice spot, if it comes back to the home and it started playing with your kid, and then somehow the kid rubs off the tick, it goes into the carpet, right? Accidentally. And then it waits for the next human to come to you, or they will start to crawl to the corner of the house and wait. Or if the dog shares the bed with you, for at least for a playful time, the ticks will drop off in the bed and then waiting for us to go and lie down and sleep the whole night. So that whole night is available for the tick to find us and eat. And that's why I tell the pets are the worst factor in this equation of diseases. Sorry, the dogs. Dogs and cats, I would say equally are the major factor in actually bringing ticks into the home and exposing humans because they have thick coat, they try to comb as much as possible. And, when we walk in the woods, dogs are the ones that they want to wander. We like to throw the stick and try to make them grab, or ball, to grab.

The moment they move away from the walking path, I think they are exposed to ticks, particularly in Central New York. I would, anytime the dogs go into the woods and come back, even if it is for like, let's say 10, 20 seconds, I would do a thorough check on the dog for the tick.

So dogs play a major role. That's why I'm telling that I kind of attribute that to human behavior as well because it's humans who actually encourage the pets to wander off and come back, and it's humans who allow the dog to sleep with us. So I attribute that anthropogenic behavior is actually a factor in putting us in risks of exposing to tick bites.

Host Amber Smith: This is Upstate's "HealthLink on Air" with your host, Amber Smith. I'm talking with professor Saravanan Thangamani about tick season this year.

I'd like to ask you about the impact of climate change on the geographic expansion of tick-borne diseases in Upstate New York. We've had a series of mild winters. What is that doing overall, like long-term, to the prevalence of ticks?

Saravanan Thangamani, PhD: I think three things will happen. One, the number of ticks will increase. The geographic expansion of ticks into new geographical areas where ticks have never been reported will also expand. Three, the number of infected ticks will also increase. I would attribute that to the change in climate, change in human behavior and change in wildlife behavior that are directly as a result of climate change.

Host Amber Smith: So are we seeing ticks here in Central New York that used to only be found in warmer areas?

Saravanan Thangamani, PhD: I wouldn't say warmer areas because we only collect data for the state of New York. But I can tell that ticks that are used to be presented in the Tri-State area -- which is really New York City and Long Island area -- we are now starting to see them in Central New York and Upstate. And that is a trend that when we started this program in 2019, we never saw those things.

And then in 2020 we started to see those ticks appearing. And then over the years, we are getting more and more ticks from Central New York, and let's say Oswego County, like closer to the Canadian border, and Western New York. And if you look into our nyticks.org tick map dashboard, we are seeing more ticks in Western New York compared to, I would say, 2019. So that is definitely an indication that ticks are actually emerging in new geographical areas. Ticks are increasing in greater numbers. And infected ticks are also increasing in greater numbers.

Host Amber Smith: And so, logically, would we likely see more people who become ill with a tick-borne disease, Lyme disease, and there's others, too, right?

Saravanan Thangamani, PhD: Unfortunately, humans will encounter the ticks. But if they actually follow proper precautions, proper procedures to remove the tick as soon as they come back from an outdoor activity, they don't need to have tick-borne illnesses. So basically, they will encounter -- we cannot stop that because we can't eliminate the tick population -- the humans will definitely encounter more ticks in the future. However, will they succumb to the disease or not? It depends on the human behavior. It depends on do they do the tick checking? Do they apply the natural chemicals or the tick repellent products, or do they treat their outerwears with permethrin that repels the tick and kills the tick? So it depends on a combination of human behavior as well.

Host Amber Smith: Where do things stand with your work on an anti-tick vaccine or a transmission-blocking vaccine?

Saravanan Thangamani, PhD: We kind of put that work on a pause for a while because my entire lab focused on the Citizen Science Tick Testing program. It kind of swallowed our lab, for a good reason. I think we did get a really good set of data. We help the public. We are helping the clinicians. We are helping the public policy makers as well.

But that kind of took all of our resources, I would say, into the Citizen Science program. But now we are taking a step back from the Citizen Science program and then trying to refocus on our basic science, our translational research to develop an anti-tick vaccine.

So, I'm hoping that -- you know, we have identified potential candidates. We are evaluating that in a preclinical model system, and if that is successful in a preclinical model system, we can then take it to the next level. So it is, we have switched gears on the project now.

Host Amber Smith: The way you envision it though, would a tick vaccine protect humans from infection but not harm the tick?

Saravanan Thangamani, PhD: No, actually. So it will prevent the ticks from feeding on us. So they will try to attach, but they will not feed on us, and they will drop off even before they have the ability to transmit a disease-causing agent. And eventually the tick will die because ticks try to feed on humans only once. So when they lose the chance, they will die.

Host Amber Smith: So they don't go looking for another human if things don't work out with the first one?

Saravanan Thangamani, PhD: I think the biology is that they try because they have already wasted the resources in attaching, because when they actually try to get into our skin, they secrete certain salivary proteins including cement proteins. They're mostly glues. And actually that damages some of their biological properties to reattach. So it's very rarely they will go on reattach. They might probe on you. But once they stay attached for a good amount of time, let's say, half a day, they, when they drop off, they will never go and find it.

So the good thing is that ticks will drop off. The second thing is that, the ticks will drop off before it has the ability to transmit, like, Borrelia burgdorferi, the Lyme disease-causing agent.

Host Amber Smith: Is there a benefit to ticks? Do they have a role in nature?

Saravanan Thangamani, PhD: I think they do have a role in nature. Every single organism plays a role in the ecology. And as far as the ticks are concerned, I think that they are used as food for birds. Chickens eat them. And ants also forage on ticks, as well. Fire ants, at least in Texas, I know that if you see more fire ants on your property, you will not see ticks.

In ecology, every single species plays a role in such a way that it helps other species to perpetuate. And definitely, ticks are a good nutritious meal for birds and ants and chicken and possums.

Host Amber Smith: Well, Dr. Thangamani, thank you for making time for this interview.

Saravanan Thangamani, PhD: Thank you very much. I really appreciate talking to you about this program.

Host Amber Smith: My guest has been Dr. Saravanan Thangamani. He's a professor of microbiology and immunology at Upstate. I'm Amber Smith for Upstate's "HealthLink on Air."

Next on Upstate's "HealthLink on Air," visiting professors from Japan and San Francisco talk about reconstructive urology.

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air." We'll be talking about reconstructive urology today with Dr. Akio Horiguchi from Japan, and Dr. Mang Chen from San Francisco. They are two of 10 visiting professors in Syracuse for an international reconstructive urology event organized by Dr. Dmitriy Nikolavsky, a professor of urology at Upstate who is director of reconstructive urology. Welcome to "HealthLink on Air," Dr. Horiguchi and Dr. Chen.

Akio Horiguchi, MD, PhD: Thank you.

Mang Chen, MD: Thank you so much, Amber. It's a pleasure to be here.

Host Amber Smith: Now, Dr. Horiguchi, you're involved in urinary reconstructive surgery and urinary tract revival, and I'd like to ask you about the surgery you offer for urethral stricture. For listeners who are unfamiliar with this, can you explain what causes a urethral stricture?

Akio Horiguchi, MD, PhD: Yes. Urethral stricture is characterized by the spongiofibrosis and narrowed urethral lumen caused by various etiologies including trauma and instrumentation to the urethra and inflammation. But most of the strictures is unknown origin.

Host Amber Smith: But it's an issue that needs to be corrected, typically. How do you approach this if catheterization and dilation are not effective? What is the goal of the surgery that you offer?

Akio Horiguchi, MD, PhD: Yes. Generally, transurethral surgery such as urethrotomy or dilation is performed, but it is not generally effective. So, we need offer urehthroplasty that is open reconstruction is recommended for most of our patients. The goal is cure of stricture. It is an important point of the stricture management.

Host Amber Smith: Now, Dr. Horiguchi, can you tell us about the work you're doing with stem cells? But first, would you explain what stem cells are and how they're being used medically?

Akio Horiguchi, MD, PhD: Yes. Stem cell therapy for regenerative therapy is a current issue of promising therapy. In my case, we use buccal mucosa cells harvested from the inner cheek and prepared in the medical laboratory and then introduced to the urethral stricture disease.

Host Amber Smith: So you're able to take from a patient cells from the inside of their mouth on the inside the cheek, and you ...

Akio Horiguchi, MD, PhD: Yes.

Host Amber Smith: ... transfer those into the area where you've got the stricture that you're working on?

Akio Horiguchi, MD, PhD: Yes, exactly. And it is important to note only small amount of the buccal mucosa is enough. But in contrast, in urethralplasty, open surgery, a large amount of buccal mucosa is required. But in my case treatment only small amount of buccal mucosa is enough, and expands the cell culture at thereafter.

Host Amber Smith: So you only have to take a small portion from inside the cheek. Does it grow, does the tissue sort of grow on its own once you place it in the stricture area?

Akio Horiguchi, MD, PhD: Yeah, exactly. And after expanding the cell culture, we inject the cells inside the urethra. So the invasiveness is much lower than the open urethroplasty.

Host Amber Smith: Interesting.

This is Upstate's "HealthLink on Air" with your host Amber Smith. I'm talking with two visiting professors who specialize in reconstructive urology who are in Syracuse for an international reconstructive urology event at Upstate. Dr. Akio Horiguchi of Japan has been describing urethroplasty and how he's using stem cells. And now we're going to shift to Dr. Mang Chen and the work he does in San Francisco.

Dr. Chen, your specialty is genitourinary surgeries for transmasculine individuals. So these are gender-affirming surgeries for people who were born female, and you and your team will do the penis/scrotal/perineal reconstruction, is that right?

Mang Chen, MD: That's correct, Amber. That's my prime focus in my current profession as a solo private-practice reconstructive urologist.

Host Amber Smith: So can you talk about the different approaches and how you help patients decide which approach is best?

Mang Chen, MD: It depends all on the patient's surgical goals. Many patients prioritize having male, or masculine, anatomy, being able to urinate through the penis and even having sexual, penetrative sexual, function with the penis.

And many patients also want a pouchlike, anatomically male scrotum. So that's where I can help them.

Host Amber Smith: So you're able to do that using tissue from the patients' other parts of their body?

Mang Chen, MD: That's correct. So let's say someone comes to me and they say, "Dr. Chen, I want male-appearing anatomy. I want to be able to stand to pee. I want a pouchlike scrotum, to know that I have basically a masculinized genital region, and I don't want the risk of taking tissue from another part of my body, like my arm or thigh, to make a bigger penis. I'm OK with something that's small."

In that situation, that patient would be best treated with metoidioplasty, which involves doing something called vaginectomy where the canal is removed, the mucosa inside the canal is removed and closed. And then you take the minora tissue to extend the urethra from where it is originally to the head of the native penis. Then you take the majora tissue to make a pouch-like scrotum. And then you close the area behind the scrotum, make it flat and masculinized.

For patients who want all those goals, to be able to stand to pee, have a pouchlike scrotum, but want the ability to penetrate with intercourse in the future and have a more physiologic or proportional-sized penis, they would need a phalloplasty, which is tissue taken from, most commonly, the arm or the thigh. That tissue is taken as a big rectangle of skin and fat with its associated nerve and blood vessels. That rectangle is divided into a smaller rectangle and a medium rectangle. The small rectangle gets rolled into a tube we call the urethra. And then the medium rectangle gets rolled around that to create the penis itself. It's the tube-in-tube design.

Host Amber Smith: So what you're describing, is this multiple surgeries or is this one big surgery, where you have a lot of things to do during that operation?

Mang Chen, MD: It can be either. Some centers are more equipped to stage the procedure, so they'll do the penis and the urethra first, and then they do the perineal masculinization part later. Or other centers will do the perineal masculinization first and then the phalloplasty part later.

The plastic surgeons I work with, we prefer to do it all at once because we're equipped to do so. We've been working together for a long time. Our argument for doing it all at once is that it meets the patient's goals the quickest and in our hands, the safest. Basically we operate together. The microsurgeons will most commonly operate on the arm while I'm operating down below. While I'm doing my part of the procedure -- which is the vaginectomy, extending the urethra, burying the native penis, dissecting out a nerve that goes to the native penis, and then making the majora into a scrotum -- the microsurgeons are harvesting the tissue from the arm.

When they're done, I'm done. We get together, they hand me the penis from the arm. I put a catheter that lines up the arm urethra with the minora urethra. I sew the urethra together. And then the microsurgeons connect the nerve I dissected from the native penis, and that nerve is connected to the sensory nerve of the arm penis so that the new penis has a chance of feeling like a penis, about a year or two later.

Host Amber Smith: I was going to ask about recovery. But, so a patient may not feel the full effects for a couple of years?

Mang Chen, MD: Yes. In general, it's about a year. But it could take as long as four years to start developing sensation in a new penis. But the average is about a year or less.

Host Amber Smith: Now, what happens to the female internal organs, the uterus, fallopian tubes, ovaries? Do you remove those, or do they stay? What happens?

Mang Chen, MD: Great question, Amber. Most patients get a hysterectomy with or without removal of the fallopian tubes and the ovaries prior to surgery, about three months prior. That's the most common scenario. Patients then come to us to get a vaginal removal and then conversion of female anatomy into male anatomy.

Host Amber Smith: Very interesting. Where did you learn your skill? This sounds like it requires not only technical skill, but it sounds like there's some artistry in your work.

Mang Chen, MD: It was kind of learning on the job. At the time, there were no formal training programs, no fellowships in these types of surgeries. My first job was actually was in academic urology at the University of Pittsburgh. And then after three years I was in invited to come out and see these procedures. And selfishly they were very interesting procedures. But then what got me hooked was basically meeting the patients and seeing how amazing they were, how much they go through to get the body they need and deserve.

And then from there it was learning on the job and then basically seeing the issues that arise from the surgery during its evolution, its early evolution. And now the surgery we do is very different from what we did back in 2015.

Host Amber Smith: Lots of progress. Well, I'm very appreciative of Dr. Nikolavsky inviting both of you to this conference. And, I appreciate you both making time for this interview, Dr. Akio and Dr. Chen.

Mang Chen, MD: Thank you so much, Amber. It was a pleasure to be here.

Akio Horiguchi, MD, PhD: Thank you.

Host Amber Smith: My guests have been Dr. Akio Horiguchi of Japan and Dr. Mang Chen of San Francisco, both visiting professors at an Upstate event focused on reconstructive urology.

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

Here's some expert advice from (pediatrician) Dr. Jaclyn Sisskind, from Upstate Medical University. What books are you recommending to your patients lately?

Jaclyn Sisskind, MD: There are so many different books that I've recommended to my patients. I never recommend a book to my patients that I haven't read first, and this time of year is really exciting for me, reading-wise and recommending-wise because the American Library Association Youth Media Awards came out just at the end of January. That includes the Newbery (for children's literature) and the Caldecott (for children's picture book), and then a lot of others that people are not as familiar with. And so for me, February and March is really just reading through that list and getting excited about all of the great books that came out last year.

I think the three books that I'm probably talking about the most with my patients right now: one is called "Different Kinds of Fruit," and that's by Kyle Lukoff, one is called "The Poet X" by Elizabeth Acevedo, and the other is "Starfish" by Lisa Fipps. These are three books that I've been recommending a lot recently because they deal with issues that my patients have been coming to me with recently.

"Starfish" is about body image and bullying. "Different Kinds of Fruit" is about a student who is struggling with their own sexual identity and learning about how they fit in with their group of friends, one of whom happens to come out as nonbinary. And "The Poet X" is a novel in verse that has won every possible award a children's book can win, and it is about a girl who's in a difficult relationship with her mom and is trying to find her way. And the way she finds herself is through poetry and spoken word.

I tend to recommend those a lot, and what really warms my heart is recently, as I've been talking about some of those books, my patients have said, "Oh, I heard about that one already," either through school or through a friend, and so it's really exciting to me that these titles are getting the traction that they deserve.

I hate to call out one particular book over another because there's so many I recommend, and I don't want anyone to be left out, but I think those are the three that I'm recommending the most recently. And it's worth noting that "Different Kinds of Fruit" and "The Poet X" are on the list of some of the most challenged titles in school districts right now, and not just in school districts, but also public libraries. And so, as much as it warms my heart that when I recommend them, people have heard about it, it really makes me sad to know that the access to these books is being limited across the country.

They're lovely, important books, and I think what is objectional about them is that they feature characters who have not traditionally been featured in the literature that came before. So there are characters that are not white, characters that are queer, characters that have traditionally been bullied.

You know, it's not often that an overweight child is the main protagonist in a book. Often they're the sidekick, or they're treated as someone who's not intelligent, or they're the butt of the joke. And so, to put those characters that have often been marginalized in the spotlight and say, "This is my story, this is what's happening to me," I think that's the problem that people have with a lot of these books.

And, and I think it's a problem that has two prongs. The first is that it denies kids the chance -- and I'm just talking about children's literature right now; certainly adults can find themselves in these books too, right? -- but it takes kids that might see themselves in that book, and it decreases their opportunity for them to see themselves on the page, to see their experience represented. And that could make them feel ashamed for who they are, especially if they're being told that book is not available because it is quote inappropriate right? That's telling the child, you are inappropriate.

It's also going to make the child feel erased. It may make them feel less apt to speak up about an experience that they've had because they think that it's not acceptable to others. So that's a big problem.

And I think that the second problem is that it denies any child the opportunity to see the experience of others through a book, right? So there are some people who perhaps are white, perhaps are cisgendered, perhaps consider themselves to be straight, but could certainly benefit from reading about the experience of someone else their age who is not those things. And In a very idealistic way, I think that could make us a more accepting, peaceful society if we all listened to each other's experiences more. And what better opportunity to do that than in childhood, in adolescence, when your brain is so open to learning and being accepting to other people's experiences.

Host Amber Smith: You've been listening to pediatrician Jaclyn Sisskind, from Upstate Medical University.

Host Amber Smith: 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: Two of our poets sent us very different views of a wake. Both views allow us to see how this ritual can be celebratory as well as devastating. First up comes from our Tennessee poet and professor, Daniel Gleason from Bryan College. Here is his "Toast at a Wake":

To your eyes, to their light and to their color.

To your ability to see every shade of color.

To pastels, neons, warms, cools, watercolors.

To dyed eggs and to the High Museum of Art.

To your kitchen, to the kitchen work

you did in countless kitchens in others' homes.

To keeping dirty dishes on one side of the sink.

To boiling eggs for precisely 13 minutes.

To mashed potatoes and gravy, to butter .

To your mother's squash casserole recipe.

To color schemes in culinary arts.

To the day you returned to the kitchen

after all the years, after all the treatments --

trazadone, doxepin, electroshock, witch hazel.

To knowing that you might not have returned, but did.

To seeing light and color return to your eyes.

To resurrection. To you I raise this toast.

See us.

Our second reading comes from Jennifer Campbell, an English professor from Buffalo, New York. Here's her poem "Deciding to Attend the Wake" -- for A.B.

It's not about whether I'd like

to be there, but do I have the right

to step into the tsunami of grief.

Signposts holding me back:

Young. Suicide. Jumped.

The prodigal son rent the earth

in two one sunny morning,

traffic halted by the divide.

Now a whole town in line

to tug you above the waves,

something I am not strong enough

to do having barely survived

the initial blast. I have one living son.

Even now, his light pries open my eyes

every day; his breathing calms mine

every night. How can I tell you

the cleaving is irreparable,

aftershocks expected?

Little comfort in knowing the feet

will still move forward, even when

there's no certainty of ground.

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," emergency care for older adults.

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.