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Stevan Cordas DO Incapacitants

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1 Stevan Cordas DO Incapacitants
Stevan Cordas DO MPH Stevan Cordas DO Incapacitants

2 Stevan Cordas DO Incapacitants
Definition Under the Department of Defense definition, an incapacitant is an agent that produces temporary physiological or mental effects, or both, which will render individuals incapable of concerted effort in the performance of their assigned duties. Stevan Cordas DO Incapacitants

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History 600 BC – Solon used hellebore to cause diarrhea in enemy. 184 BC – Hannibal used belladonna to create disorientation. 1500 AD – Hashish used by Muslims. 1672 AD - Bishop of Muenster proposed belladonna grenades. 1881 – Natives in Africa and Vietnam used indigenous plant to cause disorientation in occupying troops. Stevan Cordas DO Incapacitants

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History Following WWII the CIA and the DoD began to explore various substances to act as incapacitants. quinuclidinyl benzilate termed BZ (NATO) was the only one weaponized. Department of Defense joint non-lethal weapons program (JNLWP). Stevan Cordas DO Incapacitants

5 Types of Psychoactive Incapacitants
Central nervous system stimulants – amphetamines, cocaine etc. Central nervous depressants – antipsychotics, barbiturates, opioids, benzodiazepines. Psychedelics –LSD –25, PCP, MDMA etc. Delerients – scopolamine, BZ, atropine etc. Stevan Cordas DO Incapacitants

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Epidemiology Psychoactive drugs and plants readily available worldwide. BZ is commercially available as QNB. Hard to make in a home lab. Sudden delirium in a previously healthy person or group of persons should raise suspicion. Stevan Cordas DO Incapacitants

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Epidemiology Anticholinergics are readily found in plants such as belladonna (Atropa belladonna), mandrake root, Black henbane (Hyoscyamus niger), the thornapple or Jimson weed (Datura stramonium) and woody nightshade (Solanum dulcamara) and Jerusalem cherry (Solanum pseudocapsicum), all members of the Solanaceae botanical family (along with tobacco coincidentally). 1998 British report that Iraq had stockpiled Agent 15, a glycolic acid ester, an agent similar to BZ. The existence of Agent-15 in Iraq's arsenals was revealed by the British Secretary of State George Robertson in a statement to the House of Commons on 9 February According to the statement, Iraq may have possessed large quantities of the agent since the 1980s. A document found by the UN Special Commission on Iraq (UNSCOM) in August 1995 contained a brief reference to Agent-15 and subsequent assessment of relevant scientific and other background material indicated the size of the stockpile. Stevan Cordas DO Incapacitants

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Pathophysiology BZ is an anticholinergic. This is a class of drugs that blocks, as a competitive inhibitor of acetylcholine, the post synaptic and postjunctional muscarinic receptor sites on the peripheral and/or the central nervous system. The nicotinic receptors in the skeletal muscle are not affected. Stevan Cordas DO Incapacitants

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Pathophysiology Anticholinergics, such as BZ and Agent 15, work the direct opposite of nerve gas agents and cause an understimulation of muscarinic exocrine gland, central and peripheral nervous system and smooth muscle receptors. Stevan Cordas DO Incapacitants

10 Differential Diagnosis
Lead, mercury. Solvents. Alcohol. Anxiety states. Recreational drug abuse. Medical disease –hepatic failure, renal failure, hypothyroidism. Stevan Cordas DO Incapacitants

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Toxicology of BZ A stable crystalline solid. Not soluble in water but in DMSO and solvents. Can be aerosolized. Formula C21H23NO3. MW is ; melting 167° C; Boiling point 320° C. Safety margin 30. ID50 is 6.2g/kg. Less than 1 mg will cause delirium in a 70 kg man. Stevan Cordas DO Incapacitants

12 Clinical Manifestations of BZ
Ocular –Mydriasis, loss of near vision, dry eyes. Oral – Xerostomia. Cardiac - unpredictable – usually tachycardia lasting one to two days. Skin – Dry, flushed, hyperthermic. GU – Bladder distended, decreased force. Stevan Cordas DO Incapacitants

13 Clinical Manifestations of BZ
Dose dependent central effects. Level of consciousness –drowsy, sedated, stupor to coma. Perceptual – mad as a hatter, hallucinations, illusions. Attention and memory impairment. Disturbances in insight and judgment – Vulgarity, confabulation. Stevan Cordas DO Incapacitants

14 Clinical Manifestations of BZ
Deficits in expression and comprehension. – Slurred speech, flat voice, preserveration, semiautomatic speech, handwriting deteriorates, cannot converse. Disorientation – time and place, picking behaviors, mumbling, vulgarity. Sharing of illusions and hallucinations. Paranoia – especially as other symptoms resolve. Stevan Cordas DO Incapacitants

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Laboratory Testing There are no laboratory tests for BZ and no field detection equipment. Stevan Cordas DO Incapacitants

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Treatment Evacuate. Restrain if necessary. Treat hyperthermia if it is severe. Watch for cardiac arrhythmias, destructive behavior and general status. Give specific antidote IM or IV – Physostigmine. Not effective in the first four hours however. Stevan Cordas DO Incapacitants

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Physostigmine IM 2 to 4 mg every one to 4 hours for 4 or 5 doses. IV, if restrained, 30 g/kg slowly. A fast bolus IV may cause a fatal cardiac arrhythmia or convulsions. Available as Antilirium or Eserine. Other similar agents do not cross the blood brain barrier. Stevan Cordas DO Incapacitants

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Prophylaxis If pre-warned, military protective gear will prevent the effects of anticholinergics. No preventive therapy available for civilians. Evacuate area as BZ persists especially in water, soil and moist surfaces. Stevan Cordas DO Incapacitants

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Reporting There are currently no formal reporting requirement for incapacitants. All unusual circumstances that are suspected of being related to terrorist actions must be reported to law enforcement officials. It is also advisable to report such actions voluntarily to local health departments. Stevan Cordas DO Incapacitants

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Ricin Toxin Stevan Cordas DO MPH Stevan Cordas DO Incapacitants

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Ricin Ricin is a glycoprotein toxin derived from castor plant beans. It can be produced relatively easily and inexpensively in large quantities in a fairly low technology setting. Ricin can be prepared in liquid, crystalline or powder form. Stevan Cordas DO Incapacitants

22 Ricinus Communis (Castor Plant)
Stevan Cordas DO Incapacitants

23 Ricin - A 66 Kilodalton Heterodimer With an A and B Chains
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History of Ricin Since antiquity, it is known that the oil is helpful but the plant is poisonous. Ricin, mainly in the seeds, first named 1888. Ehrlich discovered the basic principle of antibody production using ricin – the beginning of immunology – 1896. Named compound W after WWI – developed by both U.S. And Great Britain into weapons. Stevan Cordas DO Incapacitants

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History of Ricin Allies developed a W bomb in WWII but did not use it. Increased production and weaponization by both allies and others starting in 1950. United states ceased biological warfare production in 1969 and destroyed supplies. Iraq and others produced ricin weaponry as part of their inventory. Stevan Cordas DO Incapacitants

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History of Ricin First shown to inhibit tumors in 1951. Modern use as research tool developed in 1972 by Sharon and Lis. Chimeric toxins use is currently being studied – native ricin is conjugated to tumor specific monoclonal antibody. Used by Bulgarian secret police to assassinate a defector in 1978. Stevan Cordas DO Incapacitants

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Epidemiology World wide distribution of plant. Readily separated and concentrated. Widespread availability. Implicated with several domestic terrorist incidents. A cluster of cases in the same locality with severe pulmonary distress must include in differential diagnosis. Stevan Cordas DO Incapacitants

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Pathophysiology B chain has lectin properties - permit binding to galactosides on cell wall and permitting endocytic uptake of the protein. Once in cell, the A chain acts as an enzyme after a latent period of 8-24 hours in vivo, cell death occurs by cleaving the 28A subunit of RNA. Protein synthesis ceases. Multiple areas of multifocal ulcerations and hemorrhage. Nephritis, liver necrosis. Stevan Cordas DO Incapacitants

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Toxicology Ricin composes about 5% of the Castor plant. Especially in beans and seeds. Both chains are glycoproteins 32 kd each. It has been purified and crystallized. 100 fold variation in toxicity for various animals. Toxicity varies by route of administration and is 100 times more lethal by injection than orally. Stevan Cordas DO Incapacitants

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Toxicology Low oral toxicity is due to poor absorption of toxin. Target cell receptors are widespread over the body but macrophages and monocytes are the only white cells to contain galactose in cell membrane. LD50 is 20 mg/kg(100 hours) orally. 4g/kg by inhalation and intravenously. (Mice). Stevan Cordas DO Incapacitants

32 Clinical Manifestations - Oral
Oral – Rauber et el – 751 cases. 14 fatalities. Death rate in general said to be 6%. Often just nausea, vomiting, diarrhea sometimes bloody and abdominal cramps with prostration. Also burning eyes noted. More severe cases also had dilated pupils, shock, anuria, sore throat, fever, vascular collapse, shock and possibly death. Stevan Cordas DO Incapacitants

33 Clinical Manifestations - Injection
Low doses 18-20g/kg in cancer patients could be tolerated with fatigue and flu like symptoms. Vascular leak syndrome seen. Lasted 1-2 days after a latent period of 4 to 6 hours. Stevan Cordas DO Incapacitants

34 Clinical Manifestations - Injection
Markov was assassinated in London by the Bulgarian KGB with 500g. Immediate local pain hours later high fever, nausea, vomiting. 36 hours later localized lymphadenopathy,then suddenly hypotensive, cardiac rate 160 then complete AV block, GI bleeding, anuria, shock and death. Death 3-5 days. Stevan Cordas DO Incapacitants

35 Clinical Manifestations - Inhalation
Allergic reaction to castor beans in workers rhinitis, asthma and conjunctivitis seen. Inhalation of ricin would produce same picture as by subcutaneous except that experimentally a diffuse necrotizing pneumonitis occurs with alveolar flooding. An 8 hour latent period is noted. Dose dependent. Tracheitis and mediastinal purulent lymphadenitis also seen. Stevan Cordas DO Incapacitants

36 Differential Diagnosis of Ricin Aerosol
Staphylococcus B enterotoxin Organofluorine polymers Phosgene Oxides of nitrogen Paraquat  - Naphthylthiourea (ANTU) Stevan Cordas DO Incapacitants

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Laboratory Diagnosis ELISA analysis of swab of nasal mucosa if obtained within 24 hours of exposure. Survivors after about 2 weeks develop antibodies. Identification in body fluids is difficult as it is bound rapidly and metabolized. Immunohistochemical means on autopsy or tissue. Stevan Cordas DO Incapacitants

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Field Testing Field screening testing is now possible using tests such as the RAMP Ricin field test. This is a 15 minutes immunochromatographic test. See for more details Stevan Cordas DO Incapacitants

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Treatment No vaccine or immunization is available for humans. Toxoid has been submitted to the FDA for an IND. Experimentally inhalation of protective antibody (passive protection) is highly effective after exposure. For oral – super activated charcoal and IV fluids. Stevan Cordas DO Incapacitants

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Treatment For aerosol – supportive measures -positive end expiratory ventilatory pressure, iv fluids, anti-inflammatory drugs and analgesics. Research drugs to block enzymatic action of A protein. Detoxify (decontaminate) using water or dilute bleach. Wear N95 mask if inhalation source. Stevan Cordas DO Incapacitants

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Prophylaxis No prophylaxis is currently possible though it is possible with animal experiments using a vaccination. Stevan Cordas DO Incapacitants

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Reporting Ricin is a putative bioterrorism weapon. Report to your local or state health department immediately. Stevan Cordas DO Incapacitants

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Castor Beans Stevan Cordas DO Incapacitants

44 Stevan Cordas DO MPH Consultant Texas Department of Health
T2 and Other Mycotoxins Stevan Cordas DO MPH Consultant Texas Department of Health Stevan Cordas DO Incapacitants

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Fungi Over 100,000 species of fungi found in four phyla. Consists of mushrooms, lichens, corals, molds and others. Just as mushrooms can be used beneficially but some can be fatal, molds also can be viewed in this manner. Molds produce a number of extracellular products as products of metabolism, protective toxins to permit survival, and byproducts of cell wall structures. Examples include mold derived volatile organic hydrocarbons, toxins, b-D-glycans, and enzymes. In addition they are the second most common aeroallergen in the United States. Mold toxins are called Mycotoxins and include aflatoxins, fumonisins, rubratoxins, and trichothecenes and ochratoxins. These are natural plant toxins and can produce disease if heavily infested plants are consumed. Reports of illness occurring due to the ingestion of mycotoxins, presumably T2, are well recorded and have been termed alimentary toxic aleukia. Fusarium is a fungus that has been incriminated in those cases. This fungus is also a suspected cause of the anencephaly cases along the Rio Grande, since the toxins of Fusarium interfere with folic acid metabolism. Fusariosis in a natural state usually affects immunocompromised individuals and can be fatal in HIV patients. Fuminosins care a cause of esophageal carcinoma in parts of China and Africa. Ochratoxin A is a probable carcinogen and may cause bladder and renal damage in people from Eastern and Central Europe. Rubratoxins are a cause of illness in Japan. Stevan Cordas DO Incapacitants

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Molds 75% of fungi belong to the family Ascomycota which produce the sexual spores internally in a structure called the ascus. These fungi are molds that can produce products that are fatal to plants, animals and humans. One product is called T2. More recently physicians have had to contend with an increasing amount of cases of sick building syndrome from suspected mycotoxins and allergens. The mycotoxins most incriminated in these cases are trichothecenes from certain species of Aspergilla, Penicillium and Stachybotrus Atra (chartarum). The trichothecenes are a closely related family of about 150 compounds known chemically as sesquiterpenoids. They are of low molecular weight 250 to 350 mw that are lipophilic so are relatively insoluble in water but not solvents. They are heat resistant and require 900  F. for 10 minutes in inactivate this chemical. They can also be inactivated by 5% hypochlorite. Trichothecenes are immunosuppressive as well as irritating. Stevan Cordas DO Incapacitants

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(3",4$,8")-12,13,-Epoxytrichothec-9-ene-3,4,8,15-tetrol 4,15-diacetate 8-(3-methylbutanoate); 3" -hydroxy -4$, 15-diacetyloxy-8"-(3-methylbutyryloxy)-12,13-epoxy -)9 -tricothecene While the first mycotoxin isolated in 1955 is also the most carcinogenic, Aflatoxin, Another mycotoxin is considered to be more of a threat from terrorists because of evidence that links this toxin, T2, to previous incidents. T2 is a trichothecene mycotoxin produced by Fusarium tricinctum. Its molecular weight is In animal models, application of small amounts result in severe skin irritation and vesiculation followed by skin necrosis and sloughing. Systemic effects effects also occurred which resulted in death. Stevan Cordas DO Incapacitants

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T2 is a mycotoxin. It was the only such toxin to be weaponized until Sadam Hussein weaponized aflatoxin. It is the only biologic agent that can kill by transdermal absorption. Oral ingestion probably caused ATA (alimentary toxic aleukia). References: 1. R. Bamburg et al, Tetrahedron 24, 3329 (1968). Physicochemical data 2. A. E. Pohland et al, Pure Appl. Chem. 54, 2119 (1982). Synthesis M.C. Wani et al., J. Org. Chem. 52, 3468 (1987). Biosynthetic study F. Van Middlesworth et al., J. Org. Chem. 55, 1237 (1990). Toxicology studies W. F. 0. Marasas et al., Toxicol. Appl. Pharmacol. 15, 471 (1969) H. B. Schiefer, D. S. Hancock, ibid. 76, 464 (1984) D. A. Creasia et al, Fund. Appl. Toxicol 14, 54 (1990). Implicated as a chemical warfare agent in Southeast Asia with nivalenol, q.v. N. Wade, Science 214, 34 (1981) R. T. Rosen, J. D. Rosen, Biomed Mass Spectrum. 9, 443 (1982). Review: Developments in Food Science vol. 4, Y. Ueno, Ed., entitled "Trichothecenes: Chemical, Biological and Toxicological Aspects" (Kodansha Ltd. and Elsevier, New York, 1983) 310 pp. Review of pharmacokinetics and metabolism: B. Yagen, M. Bialer, Drug Metab. Rev. 25, (1993). Stevan Cordas DO Incapacitants

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History of T2 Evidence of T2 use as “yellow rain” in Laos, Cambodia and Afghanistan by Soviets and their surrogates. May have been used in the Iran- Iraq war. No conclusive human case from a biological attack of T2 has been documented. Testimony from the late 1970’s indicated that Laos and Kampuchea were attacked by planes and helicopters delivering aerosols of several colors. After being exposed, people and animals became disoriented and ill, and a small percentage of those stricken died. Some of these clouds were thought to be comprised of trichothecene toxins (in particular, T2 mycotoxin). These attacks are grouped under the label “yellow rain”. There has been a great deal of controversy about whether these clouds were truly biological warfare agents. Some have argued that the clouds were nothing more than feces produced by swarms of bees. The evidence as reviewed in the Textbook of Military Medicine is strongly suggested that T2 was used since bee feces is nontoxic. It has been estimated that there were more than 6,300 deaths in Laos, 1,000 in Kampuchea, and 3,042 in Afghanistan. The alleged victims were usually unarmed civilians or guerrilla forces. The relevance of the use of T2 increases when one realizes that in 1972 a treaty was signed by the Soviets, the United States and many other nations to ban the production, stockpiling and weaponization of biological agents. T2 use in Southeastern Asia is one of the three violations of that treaty. Ricin utilization by the Bulgarian Secret police and the release of anthrax at Sverdlovsk are the other two. Aflatoxin can be fatal acutely to various animals and is believed to be an important cause of human hepatocellular carcinoma especially when combined with Hepatitis B or C. Experimentally flavones and antioxidants are chemoprotective against aflatoxin induced hepatocellular carcinoma. Reference: 1. Textbook of Military Medicine. Medical Aspects of Chemical and Biologic Warfare. Eds. Zajtchuk R, Bellamy R Office of the Surgeon General, Department of the Army. Borden Institute. Walter Reed Medical Center. Washington 2. Siess MH, Le Bon AM, Canivenc-Lavier MC, Suschetet M. Mechanisms involved in the chemoprevention of flavonoids. Biofactors 2000;12(1-4):193-9 3. Pitt JI. Toxigenic fungi and mycotoxins. Br Med Bull 2000;56(1):184-92 4. Peraica M, Radic B, Lucic A, Pavlovic M. Toxic effects of mycotoxins in humans. Bull World Health Organ 1999;77(9):754-66 Stevan Cordas DO Incapacitants

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Iraq United nations inspectors reported in 1995 that Iraq weaponized a number of biologic agents including anthrax, clostridia botulinum and a mycotoxin, aflatoxin. Aflatoxin is one of the most potent mutagens and carcinogens known. Iraqi Biologic Stockpiles In 1995, further information on Iraq’s offensive program was made available to United Nations inspectors. Iraq conducted research and development work on anthrax, botulinum toxins, Clostridium perfringens, aflatoxins, wheat cover smut, and ricin. Field trials were conducted with Bacillus subtilis (a simulant for anthrax), botulinum toxin, and aflatoxin. Biological agents were tested in various delivery systems, including rockets, aerial bombs, and spray tanks. In December 1990, the Iraqis filled 100 R400 bombs with botulinum toxin, 50 with anthrax, and 16 with aflatoxin. In addition, 13 Al Hussein (SCUD) warheads were filled with botulinum toxin, 10 with anthrax, and 2 with aflatoxin. These weapons were deployed in January 1991 to four locations. In all, Iraq produced 19,000 liters of concentrated botulinum toxin (nearly 10,000 liters filled into munitions), 8,500 liters of concentrated anthrax (6,500 liters filled into munitions) and 2,200 liters of aflatoxin (1,580 liters filled into munitions). Aflatoxins are produced by Aspergillus flavus and Aspergillus parasiticus. In massive amounts, airborne release would be expected to produce acute hepatitis. Chronic effects would be fibrosis and primary liver cancer. Reference: USAMRIID Medical Management of Biological Casualties Handbook (2001) Fourth Edition: U.S. Army Research Institute of Infectious Disease. Fort Detrick, Fredericksburg Md. Stevan Cordas DO Incapacitants

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Toxicology of T2 Maintained as crystalline powders or liquids. Non volatile. Can extract from fungal cultures with organic acids. Cytotoxic to most eukaryotic cells by inhibiting protein synthesis. LD 50 varies with species. In monkey it is 0.8 mg/kg. These toxins are stable in air, light or heat variations. They are not inactivated by autoclaving. They will be inactivated by 5% bleach. DNA is inhibited to a significant extent and RNA less so. They also increase lipid peroxidation of cellular membranes and inhibit electron transport activity. They don’t require metabolic activation. Stevan Cordas DO Incapacitants

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Toxicology Inhibits protein and DNA metabolism. Rapidly crosses pulmonary and intestinal mucosa. Slowly absorbs across skin unless a penetrant is added. Liver is main organ for metabolism of T2. Metabolites can be detected up to 28 days. Stevan Cordas DO Incapacitants

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Clinical Effects Acute – gastric and intestinal lesions. Hematopoetic and immunological effects are radiomimetic. CNS –lassitude, anorexia, nausea. T2 toxicity depends on route of exposure, environmental factors, nutritional status, liver damage, stress and other factors. Stevan Cordas DO Incapacitants

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Clinical Effects Vascular effects with shock and possibly death. Reproduction organ function suppressed. Weakness, cough, chest pain, diarrhea often bloody. Dermal effects – if that route was used – inflammation and necrosis, vesicles. Bloody ooze from nose and mouth. Note that multiple route of exposure were felt to be present in the attacks in Afghanistan and Southeast Asia. Polysystemic effects are seen. The skin effects are almost immediate unlike HD. Stevan Cordas DO Incapacitants

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Chronic Effects of T2 ATA – immediate phase of GI effects, weakness, and dizziness followed by leucopoenia primarily granulocytes. If exposure continues a dark red rash with ulcers and gangrenous areas – larynx gets involved with death by strangulation. If they survive it takes months to recover. Its noted that all blood elements drop in those who survive. Pancytopenia persists and is part of the chronic state. Since ALA occurred in Siberia during and shortly after WWII when heavily toxic grain which was unknowingly baked in bread and was consumed by the soldiers and villagers the Soviets investigating this outbreak discovered the cause to be Fusarium. They then investigated this fungus and found about 40 mycotoxins from Fusarium. Secondary sepsis related to the Pancytopenia was often fatal. The Soviets then began to implement this toxin as a biowarfare agent. Stevan Cordas DO Incapacitants

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Chronic Effects Since it is a potent inhibitor of replication and is most toxic to rapidly proliferating cells. A phase I and II Cancer trial was done with a similar mycotoxin (anguidine or DAS) given IV 3 mg/m3 daily for 5 days. Life threatening toxicity and severe hypotension occurred. Effects included confusion, ataxia, chills, vomiting diarrhea and burning erythema. The United States military also has had interviews with laboratory workers who noted burning erythema when accidentally contacting T2 even though they washed their hands immediately. Agricultural workers noted rhinitis, pharyngitis with aphonia and pulmonary manifestations including dyspnea, cough and chest pain. Stevan Cordas DO Incapacitants

58 Differential Diagnosis
A sudden attack on a otherwise healthy cohort with irritant polysystemic symptoms including skin burning in the absence of miosis after being exposed to a vapor with yellow or reddish color. Staph B does not affect the skin. Other vesicants have an odor this does not. Stevan Cordas DO Incapacitants

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Laboratory Diagnosis Requires a high index of suspicion. No detector to warn one ahead of time. Obtain samples for presumptive testing by liquid - gas chromatography then mass spectroscopy for confirmatory testing. Screening testing is becoming available. White count takes about 48 hours to drop. Stevan Cordas DO Incapacitants

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Treatment In the military a protective suit and M40 or later mask is used. Or N95 mask. Remove from area. Decontaminate after removing clothing with soap and water. No specific therapy is known. Superactive charcoal may trap some of the T2. Use 5 % bleach to wash equipment or material. Let stand 6 hours. Use standard ER techniques. Irrigate eyes vigorously. Use calomine lotion or aloe vera cream on burning skin. Acute pulmonary edema may occur. May need specialized pulmonary medicine support. Stevan Cordas DO Incapacitants

61 General Therapeutic Protocol in Animals
Supercharcoal Magnesium sulfate Metoclorpramide Dexamethasone Sodium bicarbonate Normal saline Vitamin E, Flavones, Vitamin C, selenium and emetine have experimentally helped reduced acute effects. Stevan Cordas DO Incapacitants

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Prophylaxis No vaccine is available though several are in research with some efficacy in animals. If protective garment and mask is available use it. Stevan Cordas DO Incapacitants

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Reporting T2 is a putative bioterrorist agent and must be reported to the local or state health department and law enforcement immediately on suspicion. Stevan Cordas DO Incapacitants

64 Always Contact Local Public Health Department
Tarrant County Public Health 1101 S. Main Street Fort Worth, Texas 76104 Dallas County Department of Health & Human Services 2377 N. Stemmons Freeway Dallas, Texas Stevan Cordas DO Incapacitants


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