The impact of heavy rainfall events on waterborne diarrheal diseases is uncertain. We conducted weekly, active surveillance for diarrhea in 19 villages in Ecuador from February 2004 to April 2007 in order to evaluate whether biophysical and social factors modify vulnerability to heavy rainfall events. A heavy rainfall event was defined as 24-hour rainfall exceeding the 90th percentile value (56 mm) in a given 7-day period within the study period. Mixed-effects Poisson regression was used to test the hypothesis that rainfall in the prior 8 weeks, water and sanitation conditions, and social cohesion modified the relationship between heavy rainfall events and diarrhea incidence. Heavy rainfall events were associated with increased diarrhea incidence following dry periods (incidence rate ratio = 1.39, 95% confidence interval: 1.03, 1.87) and decreased diarrhea incidence following wet periods (incidence rate ratio = 0.74, 95% confidence interval: 0.59, 0.92). Drinking water treatment reduced the deleterious impacts of heavy rainfall events following dry periods. Sanitation, hygiene, and social cohesion did not modify the relationship between heavy rainfall events and diarrhea. Heavy rainfall events appear to affect diarrhea incidence through contamination of drinking water, and they present the greatest health risks following periods of low rainfall. Interventions designed to increase drinking water treatment may reduce climate vulnerability.

Key Points Question What are the characteristics of US counties with high rates of opioid overdose mortality and low capacity to deliver medications for opioid use disorder? Findings In this cross-sectional study of data from 3142 US counties, counties in the South Atlantic, Mountain, and East North Central divisions had more than twice the odds of being at high risk for opioid overdose mortality and lacking in capacity to deliver medications for opioid use disorder. Higher density of primary care clinicians, a younger population, micropolitan status, and lower rates of unemployment were associated with lower risk of opioid overdose and lower risk of lacking in capacity to deliver medications for opioid use disorder. Meaning Strategies to address mortality from opioid overdose by increasing treatment for addiction should target urban counties in Appalachia, the Midwest, and the Mountain division and include efforts to increase primary care clinicians and employment opportunities.

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IMPORTANCE Violence is a leading cause of morbidity and mortality among youth, with more than 700 000 emergency department (ED) visits annually for assault-related injuries. The risk for violent reinjury among high-risk, assault-injured youth is poorly understood. OBJECTIVE To compare recidivism for violent injury and mortality outcomes among drug-using, assault-injured youth (AI group) and drug-using, non–assault-injured control participants (non-AI group) presenting to an urban ED for care. DESIGN, SETTING, AND PARTICIPANTS Participants were enrolled in a prospective cohort study from December 2, 2009, through September 30, 2011, at an urban level I ED and followed up for 24 months. We administered validated measures of violence and substance use and mental health diagnostic interviews and reviewed medical records at baseline and at each point of follow-up (6, 12, 18, and 24 months). EXPOSURE Follow-up over 24 months. MAIN OUTCOMES AND MEASURES Use of ED services for assault or mortality measured from medical record abstraction supplemented with self-report. RESULTS We followed 349 AI and 250 non-AI youth for 24 months. Youth in the AI group had almost twice the risk for a violent injury requiring ED care within 2 years compared with the non-AI group (36.7% vs 22.4%; relative risk [RR], 1.65 [95% CI, 1.25-2.14]; P < .001). Two-year mortality was 0.8%. Poisson regression modeling identified female sex (RR, 1.30 [95% CI, 1.02-1.65]), assault-related injury (RR, 1.57 [95% CI, 1.19-2.04), diagnosis of a drug use disorder (RR, 1.29 [95% CI, 1.01-1.65]), and posttraumatic stress disorder (RR, 1.47 [95% CI, 1.09-1.97]) at the index visit as predictive of ED recidivism or death within 24 months. Parametric survival models demonstrated that assault-related injury (P < .001), diagnosis of posttraumatic stress disorder (P = .008), and diagnosis of a drug use disorder (P = .03) significantly shortened the expected waiting time until the first ED return visit for violence or death. CONCLUSIONS AND RELEVANCE Violent injury is a reoccurring disease, with one-third of our AI group experiencing another violent injury requiring ED care within 2 years of the index visit, almost twice the rate of a non-AI comparison group. Secondary violence prevention measures addressing substance use and mental health needs are needed to decrease subsequent morbidity and mortality due to violence in the first 6 months after an assault injury.

The risk for firearm violence among high-risk youth after treatment for an assault is unknown.

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Background and Purpose— Effective stroke prevention depends on accurate stroke risk prediction. We determined the discriminative ability of NfL (neurofilament light chain) levels for distinguishing between adults with diabetes mellitus who develop incident stroke and those who remain stroke free during a 7-year follow-up period. Methods— We performed a case-control study of participants selected from the previously completed ACCORD trial (Action to Control Cardiovascular Risk in Diabetes). Cases were all ACCORD subjects who were stroke free at enrollment and developed incident stroke during follow-up (n=113). Control subjects (n=250) were randomly selected ACCORD subjects who had no stroke events either before or after randomization. NfL was measured in baseline samples using Single Molecule Array technology (Quanterix). Results— Baseline NfL levels were higher in stroke subjects, compared to controls, after adjusting for age, race, blood pressure, weight, and the Framingham Stroke Risk Score. Relative to the subjects in the lowest quintile of NfL levels, the hazard ratios of incident stroke for subjects in the second to fifth quintiles were 3.91 (1.45–10.53), 4.05 (1.52–10.79), 5.63 (2.16–14.66), and 9.75 (3.84–27.71), respectively, after adjusting for race and Framingham Stroke Risk Score. Incorporating NfL levels into a predictive score that already included race and Framingham Stroke Risk Score increased the score’s C statistic from 0.71 (95% CI, 0.66–0.77) to 0.78 (95% CI, 0.73–0.83), P <0.001. Older age, nonwhite race, higher systolic blood pressure, glomerular filtration rate <60, and higher hemoglobin A1C were independent predictors of serum NfL in this cohort but diastolic blood pressure, durations of hypertension or diabetes mellitus, and lipid levels were not. In total, cardiovascular disease risk factors explained 19.2% of the variability in baseline NfL levels. Conclusions— Serum NfL levels predict incident stroke and add considerably to the discriminatory power of the Framingham Stroke Risk Score in a cohort of middle-aged and older adults with diabetes mellitus.

Context: Sporting organizations limit full-contact football practices to reduce concussion risk and based on speculation that repeated head impacts may result in long-term neurodegeneration.Objective: To directly compare head-impact exposure in high school football players before and after a statewide restriction on full-contact practices.Design: Cross-sectional study. Setting: High school football field.Patients or Other Participants: Participants were varsity football athletes from a single high school. Before the rule change, 26 athletes (age ¼ 16.2 6 0.8 years, height ¼ 179.6 6 6.4 cm, weight ¼ 81.9 6 13.1 kg) participated. After the rule change, 24 athletes (age ¼ 15.9 6 0.8 years, height ¼ 178.3 6 6.5 cm, weight ¼ 76.2 6 11.6 kg) participated. Nine athletes participated in both years of the investigation.Main Outcome Measure(s): Head-impact exposure was monitored using the Head Impact Telemetry System while the athletes participated in football games and practices in the seasons before and after the rule change. Head-impact frequency, location, and magnitude (ie, linear acceleration, rotational acceleration, and Head Impact Telemetry severity profile [HITsp], respectively) were measured.Results: A total of 15 398 impacts (592 impacts per player per season) were captured before the rule change and 8269 impacts (345 impacts per player per season) after the change. An average 42% decline in impact exposure occurred across all players, with practice-exposure declines occurring among linemen (46% decline); receivers, cornerbacks, and safeties (41% decline); and tight ends, running backs (including fullbacks), and linebackers (39% decline). Impact magnitudes remained largely unchanged between the years.Conclusions: A rule change limiting full-contact high school football practices appears to have been effective in reducing head-impact exposure across all players, with the largest reduction occurring among linemen. This finding is likely associated with the rule modification, particularly because the coaching staff and offensive scheme remained consistent, yet how this reduction influences concussion risk and long-term cognitive health remains unknown.Key Words: concussions, traumatic brain injuries, protective equipment Key PointsWhen full-contact high school practices were restricted to no more than 2 days per week, head impacts declined by 42%. The decline varied by player position; linemen experienced the largest reduction. The coaching staff and offensive scheme remained unchanged, so the rule change is likely responsible for the decline in head impacts. R epetitive concussive and nonconcussive head impacts are speculated to result in long-term neurodegenerative disease. 1 The proposed model suggests that each impact results in the deposition of phosphorylated s protein in the depths of the cerebral sulci that accumulates over time, causing impaired cognitive functioning. Many conclusions have been drawn from observational data, and American football has attracted the most attention, leading sporting organiz...