Medical Students' Perceptions Towards Online Teaching During the Covid-19 Pandemic: A Cross-Sectional Study from Saudi Arabia.

Background: The Covid-19 has made a huge impact on higher education. Online teaching and learning became essential to deliver educational activities in all areas including medical education. In this study, we aimed to investigate medical students' perceptions on the role of online teaching and learning in facilitating medical education. Material and Methods: A cross-sectional study using a self-administered online questionnaire was conducted. Students eligible were medical students across all years at Imam Abdulrahman Bin Faisal University, Saudi Arabia. Perceptions analysis was conducted using SPSS software. Results: A total of 563 students participated in the study (prominent category female 64%, n = 361). There was a significant increase in the number of hours devoted to online learning during the pandemic. Live lectures/tutorials platform via zoom showed the highest rate of interaction compared to pre-recorded lectures and learning materials uploaded on blackboard. 50% of the students disagreed that online teaching is as effective as face-to-face teaching. The greatest perceived enjoyable aspect included the online accessibility of materials. Whereas the most frequent perceived barrier to online learning included internet connection. 17% of students reflected a poor understanding of scientific materials through online PBL. More than 50% of students revealed that online theoretical lectures are as good as classroom or better. Whereas the majority (70%) were unable to learn clinical skills online. The results indicated high impact on students' physical activities (80%). Impacts were higher on pre-clinical students' health and social life than on clinical students. Conclusion: Our findings reported that during emergency situations due to the pandemic, online teaching enables the continuity of medical education and provides adequate efficiency. The use of live online platforms showed high level of interaction. However, some barriers need to be addressed especially at the clinical skills development level to maximize the benefit of online teaching and learning.

Patients' awareness of their rights: An insight from a teaching hospital in Saudi Arabia.

BACKGROUND AND AIM: Knowledge and awareness of patients' rights are essential to reach the highest quality of care. In 2006, the Saudi Arabian government formulated "The Patients' Bill of Rights" to ensure that healthcare delivery is at its highest standard. Despite their efforts, several studies revealed patients' lack of awareness. In this study, we aim to investigate the patients' awareness of their rights according to the policy of a teaching hospital in Saudi Arabia. METHODS: A cross-sectional study was conducted where the participants (n= 384) were in-patients and out-patients of a tertiary care teaching hospital in the Eastern Province of Saudi Arabia. Informed consent was obtained, and confidentiality was maintained. The questionnaire consisted of 23 questions. Data were analyzed using Statistical Package Social Software version 26. RESULTS: Most of the participants were males (70.1%), in-patients (63.3%), and Saudi nationals (84.5%) with a mean age of 32 years. The mean awareness score was satisfactory (>7/14). However, more than half of the participants were unaware of their right to know the risks and benefits of treatment (55.1%), to know the identity of their healthcare providers (61.9%), to deny participation in research (58%), and appoint a healthcare proxy (64.8%). CONCLUSIONS: The present study revealed the lack of awareness of certain aspects of patients' rights that require action in the means of hospital awareness campaigns and educational materials. Further research is required to generalize a consensus on the Saudi population's level of awareness and consequent steps to optimize the delivery of healthcare in the country.

Emergency Physicians' Awareness of Medico-Legal Case Management: A Cross-Sectional Study from Saudi Arabia.

Background: Emergency department physicians often encounter medico-legal cases when patients initially present to the hospital, and thus there is a strong need for them to have robust medico-legal management and reporting knowledge. Objective: To assess the awareness of emergency department physicians of two major hospitals in the Eastern Province of Saudi Arabia in managing medico-legal cases. Methods: This descriptive cross-sectional survey-based study included all adult and pediatric emergency physicians working at King Fahd Hospital of the University and King Fahd Specialist Hospital, two major government hospitals in the Eastern Province of Saudi Arabia. The questionnaire included questions about demographic information, the workload in the emergency department, previous medico-legal training, and information about physicians' perspectives regarding medico-legal situations. Results: A total of 85 physicians completed the questionnaire, with most being Saudis (78.8%) and consultants (44.7%). Most participants (84.7%) immediately notified the police authority through the official procedure on suspicion of a case being criminal. However, only 28.2% of the participants were aware of how to complete the medico-legal report, and the majority (82.4%) had not received any specific training or attended specific courses in writing medico-legal reports. Most participants (91.8%) expressed the need for additional medico-legal case training programs, with continuous education (29.4%) being the preferred mode. In addition, 60% of the consultants were dissatisfied with the current medico-legal reporting and management workflow in their hospital. About half of the participants did not obtain photographs in medico-legal cases and did not know if their workplace provided a protocol for collecting evidentiary material such as clothes, swabs, bullets, remnants of foreign bodies, etc. Conclusions: The results of the present study indicate the necessity to consider periodical continuing medical education programs and workshops for emergency department physicians in the Eastern Province of Saudi Arabia to help them in appropriately handling medico-legal cases.

BRCA1 and BRCA2 carriers with breast, ovarian and prostate cancer demonstrate a different pattern of metastatic disease compared with non-carriers: results from a rapid autopsy programme.

AIM: To catalogue and compare the pattern of metastatic disease in germline BRCA1/2 pathogenic mutation carriers and non-carriers with breast, ovarian and prostate cancer from a rapid autopsy programme. METHODS AND RESULTS: The number of metastases in the major body systems and the proportion of participants with metastases were documented in 50 participants (19 germline mutation carriers). Analysis was conducted on the participants' pattern of disease for the different cancers and mutation subgroups. The four commonly affected organ systems were the digestive (liver only) (82%), respiratory (76%), gastrointestinal (65%) and reticuloendothelial (42%). There were significant differences in the pattern of metastatic breast cancer in BRCA1/2 germline carriers compared with non-carriers. Breast cancer carriers had significantly fewer organ systems involved (median n = 3, range = 1-3) compared with non-carriers (median n = 9, range = 1-7) (P = 0.03). BRCA1/2 carriers with ovarian carcinomas had significantly more organ systems with metastatic carcinoma (median n = 10, range = 3-8) than non-carriers (median n = 5, range = 3-5) (P < 0.001). There were no significant differences in the number of involved systems in BRCA2 carriers compared with non-carriers with prostate cancer (P = 1.0). There was an absence of locoregional disease (6.5%) compared with distant disease (93.5%) among the three cancer subtypes (P < 0.001). The majority of metastatic deposits (97%) collected during the autopsy were identified by recent diagnostic imaging. CONCLUSION: Even though a major limitation of this study is that our numbers are small, especially in the breast cancer carrier group, the metastatic patterns of breast and ovarian cancers may be impacted by BRCA1/2 carrier status, suggesting that tumours derived from patients with these mutations use different mechanisms of dissemination. The findings may focus clinical diagnostic imaging for monitoring metastases where whole-body imaging resources are scant.

Stature estimation from the hand dimensions in the Eastern Saudi Arabian adult male population.

BACKGROUND AND AIM: Anthropometry is widely used in preliminary forensic investigations involving the identification of unknown dismembered body parts. Stature estimation is an important indicator of forensic identification considered during such initial investigations. Different populations have different body sizes and proportions that affect the forensic anthropometric estimation of stature. Hence, the need for population-specific databases and analyses. The present study was conducted with the objective of estimating stature from the hand dimensions in the Eastern Saudi Arabian adult male population. METHODS: The present study included 200 Eastern Saudi Arabian males aged from 20 to 56 years. Stature and hand dimensions of hand length, palm length, and hand breadth were measured as per standard anthropometric procedures. Linear and multiple regression equations were derived to estimate stature from the aforementioned hand dimensions. RESULTS: Correlation coefficients between stature and the aforementioned hand dimensions were found to be statistically significant. The hand length and palm length showed higher correlation coefficients than the hand breadth. Single variable linear regression and multi-variable linear regression equations were derived to estimate stature from the hand dimensions. Higher correlation coefficients were obtained for multi-variable linear regression than single variable linear regressions. CONCLUSIONS: In conclusion, hand dimensions can be used as a reliable predictor to estimate stature in the Eastern Saudi Arabian adult male population. (www.actabiomedica.it).

Research trends in forensic anthropology: A bibliometric analysis.

This paper aims to examine the worldwide research development and trends in forensic anthropology by using bibliometric analysis. Scopus database was used to identify published papers on forensic anthropology from 1948 to 2020. A total of 4,499 records were analyzed for yearly publication productivity, authorship and citation pattern, types of documents, most productive journals, organizations, authors, and countries, frequently cited papers, most used keywords, countries of collaboration, and three-field plot analysis in the domain of forensic anthropology. The results indicated that the highest grand total publications were between the years 2016 and 2019, while the highest multi-authored publications were in the year 2018. The most productive journal, author, organization, and country were the 'Journal of Forensic Sciences' with grand total publications of 934, 'Cattaneo, C.' with 97 publications, 'Centre National de la Recherche Scientifique' with 130 publications, and the United States with 1020 total cited papers, respectively. The document with the highest number of citations was 'Buckberry and Chamberlain, 2002, Am J Phys Anthropol' with a total of 387. Three-field plot analysis regarding the most outstanding keyword-source-country was "Forensic anthropology"- "Journal of Forensic Sciences" and "Forensic Science International"- "USA", "France", and "UK". The predomination of certain countries over others in the field of forensic anthropology limits its prosperity as ethnic variety is of important regard. Research collaborations were mainly observed between the United States and European countries, which highlights the need for strengthening collaborations between developed and developing nations.

Postmortem findings in COVID-19 fatalities: A systematic review of current evidence.

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is responsible for the ongoing pandemic of coronavirus disease 2019 (COVID-19). Almost 17 months after the first COVID-19 case was reported, the exact pathogenesis of the virus is still open to interpretation. Postmortem studies have been relatively scarce due to the high infectivity rate of the virus. We systematically reviewed the literature available for studies that reported gross, histological, microscopic, and immunohistochemical findings in COVID-19 fatalities with the aim of reporting any recurrent findings among different demographics. PubMed and Scopus were searched up till the second of May 2021 and 46 studies with a total of 793 patients were shortlisted after the application of inclusion and exclusion criteria. The selected studies reported gross, histological, microscopic, and immunohistochemical autopsy findings in the lungs, heart, liver, gallbladder, bowels, kidney, spleen, bone marrow, lymph nodes, CNS, pancreas, endocrine/exocrine glands, and a few other miscellaneous locations. The SARS-CoV-2 virus was detected in multiple organs and so was the presence of widespread microthrombi. This finding suggests that the pathogenesis of this highly infectious virus might be linked to some form of coagulopathy. Further studies should focus on analyzing postmortem findings in a larger number of patients from different demographics in order to obtain more generalizable results.

Workplace hazards in forensic mortuaries in Saudi Arabia: A survey of forensic mortuary personnel.

Forensic mortuaries have always presented a potential threat to workers who come into contact with dead bodies. This research aims to identify hazards faced by forensic mortuary personnel, including forensic pathologists and technicians working in forensic mortuaries in forensic medicine centres throughout Saudi Arabia, to recognise the prevalence of exposure to workplace hazards and to discover the degree of awareness and use of safety practices. A descriptive, cross-sectional study was conducted in a total of 20 forensic medicine centres, using an online questionnaire distributed among forensic mortuary personnel. A total of 113 participants responded to the questionnaire. Just over half (53%) of workplaces always provided personal protective equipment, and 75% of participants always used them. The most common hazards were needle-prick wounds and accidental slips or falls. Almost two thirds (64%) of participants witnessed or experienced a work-related accident in the forensic mortuary. The lack of previous studies concerning hazard exposure among forensic mortuary personnel in Saudi Arabia means that this study provides foundational evidence for future research concerning forensic autopsy-related work accidents in Saudi Arabia.

Characteristics of Medico-Legal Cases and Errors in Medico-Legal Reports at a Teaching Hospital in Saudi Arabia.

INTRODUCTION: A medico-legal case (MLC) involves any injury or medical condition in which law enforcement agencies investigate and fix the responsibility regarding of an injury or medical condition. Incorrect or incomplete medico-legal reports (MLRs) may trigger a pause or delay in legal proceedings and patients' rights could be violated. The aim of this study is to describe the characteristics of MLCs and to identify errors in the MLRs. MATERIALS AND METHODS: This retrospective, descriptive study was conducted in a teaching hospital in the Eastern Province of Saudi Arabia. In total, 418 MLRs furnished during a 6-month period and reviewed for characteristics of MLCs and identification of errors. RESULTS: A total of 418 MLRs were included in the present study. Fights or physical assault and battery formed the major proportion of MLCs amounting to 83% of MLCs. Blunt injury was the dominant type of injury in most of the cases (81.8%). In relation to errors in MLRs, no MLR in the present study were without errors. CONCLUSION: Fights or physical assault and battery formed the major proportion of MLCs. Multiple errors were identified in the MLRs furnished by the physicians. Writing MLRs must follow standardized guidelines as it has a bearing on legal proceedings and patients' rights. We recommend training for physicians in writing MLRs in the interest of proper administration of justice.

Medical Students' Knowledge of the Cause-of-Death Certification: A Descriptive, Cross-Sectional Study from Saudi Arabia.

BACKGROUND: The medical certificate of cause-of-death is an important document of medicolegal significance. Errors in the completion of the death certificate by doctors are not uncommon. Therefore, it is important for medical students, the future doctors, to be trained in completing the medical certificate of cause-of-death. This study aimed to investigate the understanding of final-year medical students of the cause-of-death certification and to assess their ability to complete the cause-of-death statement. MATERIAL AND METHODS: The final-year medical students of Imam Abdulrahman Bin Faisal University, of the academic year 2020-21 formed the cohort of medical students that participated in the current descriptive, cross-sectional study wherein a self-administered online questionnaire was used. RESULTS: A total of 174 students provided complete responses. The immediate cause of death in the given case scenario was answered correctly by 107 (61.5%) of the students. The underlying cause of death was answered correctly by only 20 (11.5%) students. It was apparent that the chain of events leading to death in the given case scenario was wrongly understood by the majority of the students. Nonetheless, the other significant condition contributing to death was answered correctly by 151 (86.8%) students. Other errors included the use of abbreviations, mention of the mechanism of death as a cause of death, mention of clinical features or irrelevant causes of death and mention of the incorrect time interval between the onset of a cause of death and death. CONCLUSION: The current study found that the overall performance of final-year medical students was reasonably good except for the fact that most misunderstood the underlying cause of death in the given case scenario. The majority of the students had attended a tutorial on medical certification of cause-of-death before participating in the current study, which suggests that continuous training might be required.

Desert Related Death.

INTRODUCTION: Desert death is defined as any death that occurs in the desert and could be attributed to a list of causes including environmental, animal related, undetermined, and other causes. Death in the desert seems to be obscure and little discussed in the field of forensic medicine, despite its importance, and there is only limited literature available on this broad topic. This narrative review aims to identify the most common causes of desert death and its medicolegal implications. Desert death causes: Environmental causes of death could be a result of temperature and lightening-related causes. Moreover, a variety of animals found in deserts are considered to be threatening and fatal, in addition to other and undetermined causes. Medicolegal implications of desert death: Likely to arise from the difficulties faced in finding the cause of death are the identification of the victim and the postmortem injuries that occur. CONCLUSION: Desert death is a broad topic with great medicolegal significance. More information and case reports need to be added in the literature. Guidelines for people about the danger of going to deserts in specific weather conditions should be implemented. Safety regulations must be taken into account at all times.

Burden of Transport-Related Injuries in the Eastern Mediterranean Region: A Systematic Analysis for the Global Burden of Disease Study 2017.

BACKGROUND: Transport-related injuries (TIs) are a substantial public health concern for all regions of the world. The present study quantified the burden of TIs and deaths in the Eastern Mediterranean region (EMR) in 2017 by sex and age. METHODS: TIs and deaths were estimated by age, sex, country, and year using Cause of Death Ensemble modelling (CODEm) and DisMod-MR 2.1. Disability-adjusted life years (DALYs), which quantify the total burden of years lost due to premature death or disability, were also estimated per 100000 population. All estimates were reported along with their corresponding 95% uncertainty intervals (UIs). RESULTS: In 2017, there were 5.5 million (UI 4.9-6.2) transport-related incident cases in the EMR - a substantial increase from 1990 (2.8 million; UI 2.5-3.1). The age-standardized incidence rate for the EMR in 2017 was 787 (UI 705.5-876.2) per 100000, which has not changed significantly since 1990 (-0.9%; UI -4.7 to 3). These rates differed remarkably between countries, such that Oman (1303.9; UI 1167.3-1441.5) and Palestine (486.5; UI 434.5-545.9) had the highest and lowest age-standardized incidence rates per 100000, respectively. In 2017, there were 185.3 thousand (UI 170.8-200.6) transport-related fatalities in the EMR - a substantial increase since 1990 (140.4 thousand; UI 118.7-156.9). The age-standardized death rate for the EMR in 2017 was 29.5 (UI 27.1-31.9) per 100000, which was 30.5% lower than that found in 1990 (42.5; UI 36.8-47.3). In 2017, Somalia (54; UI 30-77.4) and Lebanon (7.1; UI 4.8-8.6) had the highest and lowest age-standardized death rates per 100,000, respectively. The age-standardised DALY rate for the EMR in 2017 was 1,528.8 (UI 1412.5-1651.3) per 100000, which was 34.4% lower than that found in 1990 (2,331.3; UI 1,993.1-2,589.9). In 2017, the highest DALY rate was found in Pakistan (3454121; UI 2297890- 4342908) and the lowest was found in Bahrain (8616; UI 7670-9751). CONCLUSION: The present study shows that while road traffic has become relatively safer (measured by deaths and DALYs per 100000 population), the number of transport-related fatalities in the EMR is growing and needs to be addressed urgently.

Suicidal Ideation Among Medical Students in Dammam, Saudi Arabia.

Background: Medical students are at high risk of suicidal ideation. Aim: We aimed to obtain information on suicidal ideation among medical students in Dammam located in the Eastern Province of Saudi Arabia. Method: This cross-sectional study was conducted at the College of Medicine affiliated with Imam Abdulrahman Bin Faisal University in the Eastern Province of Saudi Arabia. Suicidal ideation in the past 12 months was assessed based on responses to four questions in the depression subscale of the General Health Questionnaire 28 (GHQ-28). In addition, data were collected to examine the association of suicidal ideation with various factors. Results: We found that 1 in 3 medical students in the study had suicidal ideation in the past 12 months, while around 40% had lifetime suicidal ideation. Suicidal ideation was associated with feelings of parental neglect, history of physical abuse, and dissatisfaction with academic performance. Limitations: The cross-sectional nature of this study limits its ability to determine causality regarding suicidal ideation. Conclusion: These rates are considerably high when compared with rates from studies in other countries around the world. This study provides a reference in the field of suicidology for this region of Saudi Arabia.

Histologic Reliability of Tissues from Embalmed Cadavers: Can They be Useful in Medical Education?

BACKGROUND: Current trends in medical curricula are shifting from teaching histology and pathology as stand-alone disciplines. Therefore, it would be useful to examine the potential value of integrating these into the anatomical dissection experience. OBJECTIVES: The aim of this study was to assess the histologic reliability of tissues taken from embalmed cadavers in an anatomy laboratory. MATERIALS AND METHODS: A total of 112 tissue samples were obtained using standard autopsy techniques from various organs (heart, lung, thyroid, skeletal muscle, bone and skin) of 11 cadavers available at the anatomy laboratory of Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia, in 2019. Samples were prepared using the standard paraffin procedure followed by cutting sections at 4-µm thickness and staining with standard hematoxylin and eosin stain. Using predefined criteria, the quality of the samples was evaluated by two board-certified histopathologists and each slide was categorized as good, satisfactory or poor. RESULTS: Overall, 34.2% and 60.3% of the slides were of good and satisfactory quality, respectively. A significant difference in tissue quality was found between various organs. Thick skin and bone tissues had the highest "good" rating (84.6% and 81.8%, respectively), while thyroid and lung tissues had the highest "poor" rating (20% and 13.6%, respectively). CONCLUSION: Most of the tissues acquired from the embalmed cadavers were of good or satisfactory quality, thereby indicating the beneficial use of histological tissue from cadavers for educational purposes. Future research into how these findings translate into meaningful medical education would be beneficial.

The Islamic perspective on physician-assisted suicide and euthanasia.

Physician-assisted suicide (PAS) and euthanasia can be debated from ethical and legal perspectives, and there are a variety of views regarding their acceptability and usefulness. Religion is considered an important factor in determining attitudes towards such practices. This narrative review aims to provide an overview of the Islamic perspective on PAS and euthanasia and explore the Islamic approach in addressing the related issues. The PubMed database was searched to retrieve relevant articles, then the references listed in the selected articles were checked for additional relevant publications. Additionally, religious books (Quran and hadith) and legal codes of selected countries were also consulted from appropriate websites. The Islamic code of law discusses many issues regarding life and death, as it considers any act of taking one's life to be forbidden. Islam sanctifies life and depicts it as a gift from God (Allah). It consistently emphasises the importance of preserving life and well-being. Therefore Muslims, the followers of Islam, have no right to end their life. All Islamic doctrines consider PAS and euthanasia to be forbidden. However, if the patient has an imminently fatal illness, withholding or withdrawing a futile medical treatment is considered permissible. From a legal perspective, Islamic countries have not legalised PAS and euthanasia. Such practices are therefore considered suicides when patients consent to the procedure, and homicides when physicians execute the procedure.

Common errors in writing the cause of death certificate in the Middle East.

A death certificate is an official document in which the medical practitioner primarily records the cause of death sequence, the time interval between the onset of the cause of death and death, and personal details of the deceased. Errors in death certificate documentation are not uncommon. We aim to review the common errors in writing the cause of death certificate in the Middle East. For this review, we searched the PubMed database using a comprehensive search strategy to identify studies from the Middle East that reported errors in the cause of death certification from inception to August 17, 2019. Of the 308 items initially identified, 5 were eligible for inclusion. These studies were reported from only a few countries (Saudi Arabia, Iran, Lebanon and Palestine) in the Middle East and did not represent all the countries geographically located in the Middle East. The Middle East is not immune to errors in the medical certification of the cause of death. The absence of the cause of death, inappropriate listing and sequencing of the causes of death, mentioning the mechanism or mode of death instead of the cause of death, absence of time interval between the onset of the cause of death and death, use of abbreviations and symbols instead of formal medical terminology, and absence of the certifying medical practitioner's signature were the commonly death certification errors observed in this regional literature review. Additional studies to assess death certification errors in all the Middle East countries are needed. Efforts should be made to compulsorily include the teaching and learning of the cause of death certification in the undergraduate medical curriculum. Interactive workshops on drafting the cause of death certificate should be periodically conducted for the benefit of the interns and residents.

Uterine Transplant: A Risk to Life or a Chance for Life?

Being inherently different from any other lifesaving organ transplant, uterine transplantation does not aim at saving lives but supporting the possibility to generate life. Unlike the kidneys or the liver, the uterus is not specifically a vital organ. Given the non-lifesaving nature of this procedure, questions have been raised about its feasibility. The ethical dilemma revolves around whether it is worth placing two lives at risk related to surgery and immunosuppression, amongst others, to enable a woman with absolute uterine factor infertility to experience the presence of an organ enabling childbirth. In the year 2000, the first uterine transplantation, albeit unsuccessful, was performed in Saudi Arabia from where it has spread to the rest of the world including Sweden, the United States and now recently India. The procedure is, however, still in the preclinical stages and several ethical, legal, social and religious concerns are yet to be addressed before it can be integrated into the clinical setting as standard of care for women with absolute uterine factor infertility.

Clinicians' Attitudes Towards Do-Not-Resuscitate Directives in a Teaching Hospital in Saudi Arabia.

The Do-Not-Resuscitate (DNR) directive has provided a major leap in end-of-life care. To demonstrate the factors influencing physicians' DNR decisions in King Fahd University Hospital in the Eastern Province of Saudi Arabia, 42 physicians from the medical and surgical departments of the same center were requested to participate in a cross-sectional survey. Thirty-six questionnaires were completed and returned from a total of 42 distributed among physicians, making a response rate of 85.7%. Certain diagnostic categories increase the likelihood of issuing a DNR order for a patient. Neurological (58.3%) and cardiovascular (41.7%) diseases were the highest response among other diseases in influencing physicians' decisions. In addition, other factors like lack of comorbidities (55.5%), age (52.7%), and previous intensive care unit (ICU) admissions and resuscitation (44.4%) showed an effect on the directive decisions of DNR among investigated physicians. However, weak palliative care in the hospital (11.1%), religious beliefs (5.5%), and gender (2.7%) were the least associated factors affecting physicians' DNR decisions. This study addresses the influencing factors of DNR orders issuance among King Fahd Hospital of the University physicians. Physicians noted that cultural standards and religious beliefs do play a role in their decision-making but had less of an effect as compared to other clinical data such as comorbidities, age, and previous ICU admissions.

Cerbera odollam toxicity: A review.

Cerbera odollam is a plant species of the Apocynaceae family. It is often dubbed the 'suicide tree' due to its strong cardiotoxic effects, which make it a suitable means to attempt suicide. The plant grows in wet areas in South India, Madagascar, and Southeast Asia; and its common names include Pong-Pong and Othalanga. The poison rich part of the plant is the kernel which is present at the core of its fruit. The bioactive toxin in the plant is cerberin, which is a cardiac glycoside of the cardenolide class. Cerberin has a mechanism of action similar to digoxin; hence, Cerbera odollam toxicity manifests similar to acute digoxin poisoning. Ingestion of its kernel causes nausea, vomiting, hyperkalemia, thrombocytopenia, and ECG abnormalities. Exposure to high doses of Cerbera odollam carries the highest risk of mortality. Initial management includes supportive therapy and administration of atropine followed by temporary pacemaker insertion. Administration of digoxin immune Fab may be considered in severe cases, although efficacy is variable and data limited to isolated case reports.