Objective: Investigate whether residential prenatal exposure to heavy metal hazardous air pollutants (HMHAPs) is associated with an increased risk of hypospadias. Methods: Data on non-syndromic hypospadias cases (n = 8981) and control patients delivered in Texas were obtained from the Texas Birth Defects Registry and matched 1:10 by birth year. Average exposure concentrations of HMHAPs were obtained from the 2005 U.S. Environmental Protection Agency National-Scale Air Toxics Assessment and categorized into quintiles. Odds ratios and 95% confidence intervals were estimated. STROBE reporting guidelines were followed. Results: We observed associations between hypospadias and prenatal HMHAP exposure. Manganese demonstrated significant increased risk of hypospadias at the medium, medium-high and high exposure quintiles; lead in the medium-high and high exposure quintiles. Cadmium, mercury and nickel demonstrated a significant inverted “U-shaped” association for exposures with significant associations in the medium and medium-high quintiles but not in the medium-low and high quintiles. Arsenic and chromium demonstrated a significant bivalent association for risk of hypospadias in a lower quintile as well as a higher quintile with non-significant intermediate quintiles. Conclusions: Using data from one of the world’s largest active surveillance birth defects registries, we identified significant associations between hypospadias and HMHAP exposures. These results should be used in counseling for maternal demographic risk factors as well as avoidance of heavy metals and their sources.

Introduction: We sought to perform a quantitative and qualitative analysis of online Twitter discussion of enuresis using the hashtag #Enuresis. Methods: Symplur, a fee-based Twitter analytics service, was employed to aggregate and analyze Twitter activity, users, and content for #Enuresis, the official Twitter hashtag for enuresis, between June 2016 and November 2018. Twitter activity was analyzed using average tweets and new users per month. Users were classified based on geographic location, occupation, and organizational affiliation. Content analysis was performed by retrieving information about Twitter engagement metrics, including retweets, links, media, mentions, replies, and frequently used words and hashtags. Results: A total of 3133 tweets and 1555 users utilizing #Enuresis were identified between June 28, 2016 and November 28, 2018. The average ± standard deviation [SD] number of tweets using #Enuresis per month were not significantly different from 2016 through 2018 (p=0.292). The number of users increased from six to 1555 during the study period, but there was no statistically significant increase in number of new users per month (p=0.346). Physicians comprised 14% of the top 100 influencers followed by medical device organizations (13%). Popular hashtags in #Enuresis tweets were #Bedwetting, #PisEnLaCama, #schoolnurses, #helpingkids, #ninos, and #salud. Hyperlinks used in #Enuresis tweets included advocacy, academic, commercial, and other social media websites. Conclusions: Our analysis of #Enuresis demonstrates that the online Twitter discussion regarding enuresis is growing. These results indicate that enuresis has a global appeal and has especially gained traction in European countries, as well as in the U.S.