Since TBI has been linked to increased blood brain barrier permeability, it is possible that mechanisms associated with increased BBB permeability can enhance HIV’s penetration and virulence in HIV+TBI+ individuals . Viral proteins and inflammatory mediators could disrupt BBB regulation, allowing increased leukocyte migration and inducing subsequent neuronal damage and death . Our analyses were based on a study limited to HIV infected people. Therefore, though our results are compatible with a model of additivity, without examining HIV-uninfected groups that have TBI we cannot be certain whether these are additive or interactive effects. Because this was an exploratory study, we did not rigorously control for multiple comparisons, and thus the data must be regarded as preliminary. Furthermore, since our study was retrospective, some details about the TBIs were unavailable. It is possible that the TBI group itself differed in some way that we did not account for. A potential future prospective study could integrate more clinical information about a participant’s head injury such as the location of initial insult, Glasgow Coma Scale rating, or more precision on duration of unconsciousness. Future studies could also utilize functional magnetic resonance imaging information as another means to evaluate neuropsychological performance simultaneously with metabolic imaging. Looking at the number of head injuries that a person experienced could also have been worthwhile , as neuropsychological tests of memory, attention, and motor function have shown worse performance with repeated head injury . For example, HIV– individuals with multiple TBIs,growing rack when compared to those with a single TBI, exhibit significantly poorer memory and executive functioning .

Given that these two neurocognitive domains are the same as those that showed significant deficits in our study, it would be interesting to determine whether there are cumulative effects of multiple TBI on HIV-associated neurocognitive decline. Despite some limitations, our study does indicate that TBI may increase vulnerability to brain dysfunction in HIV-infected individuals. If confirmed, the results indicate that those involved with HIV care need to take head injury into account in their neurological evaluation and clinical management of HIV patients.Self-mutilating injuries are encountered predominantly in male patients in the ED.This pattern of behavior is seen in patients with personality, acute and chronic psychotic, major affective, and gender disorders. Self-harm behavior is primarily encountered in patients with personality disorders, especially in those with borderline personalities.Favazza postulated that this behavioral pattern is an effort to rid oneself of depersonalization, guilt, rejection, hallucinations, sexual involvements and complex emotional states.Self-harm behavior represents a rescue attempt triggered under circumstances in which expression of aggression is inhibited. Our case is a typical example of this behavior, seen frequently among prisoners.3 Authors cite that sexual, physical or emotional abuse and biological causes are important underlying factors in the etiology of self-harm behavior, abuse being the most important.Self-cutting is the most common type of self-injurious behavior. Cutting injuries to the wrists and arms are the most frequently encountered locations due to accessibility, although a myriad of different injury locations have been recorded.A variety of major self-mutilation attempts have been cited in the literature. Erdur et al. reported a 27-year-old patient with schizophrenia who amputated his tongue and penis.Ahsaini et al. published a report of a 40-year-old man who presented in hemodynamic shock after eviscerating both testes with his fingernails.Michopoulos et al reported a 66-year-old man who had been mutilating his fingers for the last six years.

This behavior started as nail biting and continued on to severe finger mutilation, resulting in loss of the terminal phalanges of all fingers in both hands. Koh and Lyeo wrote of a 20-year-old patient with schizophrenia who enucleated his own eye.Our patient was challenging in that he was a prisoner and not very cooperative, which hampered a thorough psychiatric evaluation. A presumptive diagnosis of psychosis was based on the patient’s indifferent attitude, limited cooperation, low-toned speech with short questions and answers, mystic delusions, auditory and sensory delusions – hearing commands and inappropriate affect. Self-harm behavior is seen primarily in patients with borderline and antisocial personality, major affective, and gender disorders and substance abuse. The fact of being imprisoned, along with possible secondary gains such as getting away from prison for admission to hospital due to “illness,” and lighter sentencing penalties, may have led the patient to engage in such behavior. Therefore, further investigation in terms of simulation, personality disorders and substance abuse is necessary. Self-mutilation associated with self-cannibalism is a rare condition. It can be due to a severe mental disorder such as schizophrenia. It could also be the result of a personality disorder or a malingering secondary behavior to get a lesser criminal penalty. Tobacco industry has continuously used product modifications, such as manipulating smoke pH with various chemical additives, to make combustible cigarettes more appealing to novice users. For decades, Philip Morris and other tobacco companies have used ammonia as a relatively innocuous additive for a variety of purposes, including augmenting certain flavors, cutting costs by expanding or “puffing up” the volume of cured tobacco leaves, preparing reconstituted tobacco sheet , denicotinizing tobacco , and even lowering/removing tobacco smoke carcinogens.

In the early 1960s, while evaluating the impact of ammoniated recons used in Marlboro cigarettes, Philip Morris discovered that freebase or unbound nicotine, as opposed to nicotine bound to other molecules , is more volatile and vaporizable, thus being highly bio-available. This led to the development of low-yield cigarettes that still had the nicotine kick necessary to keep customers “satisfied”. The freebased low-yield version of Marlboro cigarettes became the world’s most popular cigarette; Marlboro has remained the top selling cigarette brand in the world since 1972. The commercial success of Marlboro persuaded the rest of the tobacco industry to utilize ammonia to convert nicotine to its freebase form, as part of a new process for manufacturing cigarettes. However, this was achieved only after competitors uncovered Philip Morris’ “secret” of freebasing nicotine in cigarettes by reverse engineering the chemistry of Marlboro cigarettes. More than half a century later, a relatively unknown vape company, Juul Labs Inc., recognized the utility of salt-based nicotine for a novel electronic cigarette device, called JUU. Started in 2017, Juul Inc. is a spin off company from Pax Labs, which was a manufacturer of vaporizing devices for cannabis and loose-leaf tobacco; Pax Labs was preceded by Ploom as the original company for e-cig development. Remarkably, JUUL’s use of salt-based nicotine, which is significantly less aversive than freebase nicotine, made it very quickly popular among naïve users, particularly adolescents and youth. The high content of nicotine in JUUL, which was claimed to be equivalent to nicotine content of a pack of 20 cigarettes, also made JUUL highly appealing to adult smokers, seeking a putatively less-harmful alternative to combustible cigarettes. Shortly after its launch, JUUL became the preeminent vaping product on the market and a dominant player in the vaping industry. In December 2018, Altria, one of the world’s largest cigarette manufacturers and the parent company of Philip Morris USA, acquired a 35% stake in JUUL. This made Altria a major force in both the tobacco and vaping markets. Nearly 1 year later, the US Surgeon General declared “youth vaping” an “epidemic” in the United States [8], and the US Food and Drug Administration called JUUL a particular cause for concern. Not long after, in August 2019, the Centers for Disease Control and Prevention , the FDA, state and local health departments,drain trays for plants and other clinical and public health partners reported a nation-wide outbreak of vaping related severe lung illnesses and deaths, also referred to as “ecig, or vaping, product use-associated lung injury ”. Most EVALI cases reported using e-cig products containing vitamin E acetate and tetrahydrocannabinol , the principal psychoactive component of cannabis. However, the CDC did not rule out the etiologic involvement of other substances present in non-THC containing e-cig products. The EVALI outbreak lasted for several months, but declined considerably by February 2020. Worldwide, there are around 1.1 billion current cigarette smokers aged 15 or older, of whom 942 million are males and 175 million are females. In 2019, there were an estimated 155 million smokers aged between 15 and 24 years – equivalent to 20.1% of young men and 5.0% of young women, globally.

Two-thirds of all current smokers began smoking by age 20, and 89% of smokers began by age 25, highlighting a critical age window during which individuals develop nicotine addiction and transition to become established smokers. Globally, 7.4 trillion cigarette-equivalents of tobacco were consumed in 2019, amounting to 20.3 billion each day. Countries with the highest consumption per person were mostly in Europe. One in three male and one in five female smokers consumed 20 or more cigarette-equivalents per day, worldwide. The 10 countries with the largest number of tobacco smokers, which together comprised nearly two-thirds of the global tobacco smoking population in 2019, were China, India, Indonesia, the United States, Russia, Bangladesh, Japan, Turkey, Vietnam, and the Philippines—one in three current tobacco smokers lived in China. In many countries, progress in reducing the prevalence of smoking did not keep a pace with population growth, resulting in significant rises in the number of young smokers. India, Egypt, and Indonesia had the largest absolute increases in number of young male smokers. Turkey, Jordan, and Zambia had the largest increases in number of young female smokers. Over half of countries, worldwide, showed no progress in reducing smoking among 15–24 years old. Youth vaping is an evolving public health problem in the United States and around the world . Results from the 2020 National Youth Tobacco Survey and Monitoring the Future survey showed that nearly 3.6 million American teens were current users of e-cigs, of whom 80% reported using flavored products, such as fruit, mint, menthol, and candy, desserts, or other sweet-flavored eliquids. Specifically, one in five U.S. high school students and one in ten middle school students reported current use of e-cigs in 2020. The CDC and FDA analysis of the 2021 NYTS, conducted during January 18 – May 21, 2021, showed an estimated 2.06 million U.S. middle and high school students reporting current use of e-cigs. The authors, however, cautioned that because the 2021 NYTS was fully conducted amid the COVID-19 pandemic through mostly online data collection, estimates from this year’s survey should not be compared to previous NYTS survey waves that were primarily conducted on school campuses. Following a same trend, the percentage of college-age youth who vape nicotine, has risen dramatically in recent years. Between 2017 and 2019, the 30-day prevalence of e-cig use increased from 6 to 22% among college students, and from 8 to 18% among 19 to 22 year-olds not in college. Together, these data indicate a continued and dynamic evolution of the global tobacco epidemic and youth vaping epidemic. Tobacco smoking-related diseases, including cardiovascular disease, pulmonary disease, stroke, and cancer in multiple organ sites, such as the lung, mouth , throat, nose and sinuses, esophagus, bladder, kidney, and ureter, pancreas, stomach, liver, cervix and ovary, the bowel , and white blood cells , are the leading causes of preventable death, worldwide. In 2019, smoking was associated with 1.7 million deaths from ischemic heart disease, 1.6 million deaths from chronic obstructive pulmonary disease, 1.3 million deaths from tracheal, bronchus, and lung cancer, and nearly 1 million deaths from stroke. Approximately 87% of deaths attributable to tobacco smoking occurred among current smokers. Only 6% of global deaths attributable to smoking occurred among individuals who had quit smoking for at least 15 years. This underscores the significant health benefits of smoking cessation, especially when achieved earlier in life and soon after the initiation of smoking. Chemical analyses of e-cig vapor have revealed the presence of some of the same toxicants and carcinogens as those found in cigarette smoke, including carbonyl compounds, volatile organic compounds, free radicals, and heavy metals, albeit mostly at substantially lower concentrations.The latter likely arise from the mixing and heating of humectants [e.g., propylene glycol and glycerol ; PG/VG] and flavorings present in e-liquid. Overall, the reduced levels of toxicants and carcinogens in e-cig vapor are consistent with the fact that e-cigs, unlike traditional cigarettes, do not “burn” tobacco to produce inhalable materials. This has led to the perception that e-cig use/vaping is safe or less harmful than tobacco smoking [28, 29]. Whilst the lower levels of toxicants and carcinogens in e-cig vapor may imply mitigated health risk, they cannot, however, equate to no risk . In fact, exposure to many of the same constituents of e-cig vapor, at various concentrations, has been associated with a wide range of cardiovascular-, immune-related , and respiratory diseases, and cancer.