{'fraction_non_alphanumeric': 0.026545002073828285, 'fraction_numerical': 0.011198672749896308, 'mean_word_length': 4.955555555555556, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Novel methods of self-poisoning: repeated cardenolide poisoning after accessing Cerbera odollam seeds via the internet

The internet can be the source of beneficial information and assistance, but it may also contribute to self-harm and help facilitate suicide [1], being a source of easily accessible information on methods of self-harm and of poisons themselves [2,3]. Accessibility is a clear factor in determining the choice of poisons in suicide attempts and interventions restricting access to poisons have been shown to be effective in suicide prevention [4]. We report a case of recurrent presentations with cardenolide poisoning following ingestion of the seeds of the Cerbera odollam tree (“pong pong” or “suicide” tree), a cause of cardenolide poisoning in South Asia where these plants are usually found. Cases have occurred outside this region because the seeds are readily available on the internet, at a modest cost (GBP 5), as ornaments or for horticulture (Table 1). A 49-year-old woman with a history of emotionally unstable personality disorder, depression and self-harm was undergoing voluntary treatment at a local psychiatric hospital. She formed a suicide pact with another inpatient and together they researched the toxic effects of various substances on the internet including C. odollam. She purchased the seeds online and had them delivered to her own residence. The other person involved in the suicide pact backed out of the plan. Despite this, the patient went ahead and cut up two seeds into fragments and ingested them. She then informed the hospital staff of her act. She was immediately transferred to our hospital for further management. Two hours after ingestion of the seeds, she developed nausea, marked retching and recurrent vomiting. She also reported central chest and upper abdominal pain. There was no xanthopsia. On admission, she had a heart rate of 66 beats per minute and a blood pressure of 155/91mmHg. Cardiac monitoring recorded a heart rate varying between 63 and 93 beats per minute with frequent missed beats, second degree heart block and sinus pauses, confirmed on a 12-lead electrocardiogram. Despite this, there was no evidence of haemodynamic instability. Her initial serum potassium was 5.4mmol/L, peaking at 7.1mmol/L within the first 24 hours of seed ingestion, which correlated with increased frequency and duration of sinus pauses and heart block;