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OpenAccess Core Curriculum by Mind Map: OpenAccess Core Curriculum
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OpenAccess Core Curriculum


Proposal for developing and disseminating a clinical toxicology curriculum

In most countries clinical toxicology is not a recognized specialty. One consequence of this is that curriculum development in the specialty is either ignored or supplied by a number of providers. These providers may provide content from a number of sources of various levels of authority and relevance. As a consequence the standard of clinical toxicology may vary considerably. The provision of a curriculum outline that is supported by standard or approved resources could equip trainers to deliver local content that is consistent with best practice. These materials would need to be delivered with maximum freedom of access.

400,000 deaths per year

There are an estimated 400,000 deaths per year from deliberate poisoning in Asia alone. Most of the global deaths from poisoning occur in the developing world. In the developed world deliberate poisoning may account for up to 5% of hospital admissions. While mortality is low there is significant direct and opportunity costs involved in the treatment Despite the clinical need training in Clinical Toxicology at various levels is relatively scant. This is particularly true of many undergraduate courses. Such training is generally not provided by people with any training in clinical toxicology. This coupled with a relatively poor evidence base means that the standard of what is delivered is variable and often has to compete with other teaching priorities. The same could be inferred about delivery in other environments. The actual needs for delivery of different types of content could vary due to the type of institution, geographic position which ultimately produces different audiences An issue for the Discipline of Clinical Toxicology is that it is relatively small and at this time does not have a clear presence in all these environments. We are largely dependent upon others to deliver clinical toxicology training. this in part is one of the factors that contribute to the various clinical responses for certain poisoning. At present we do not have a vehicle to deliver content in an easily accessible manner. Essentially something that meets an acceptable standard, is free and has open access, with a low learning curve for delivery. Arguably much of the gains in reduction in mortality related to poisoning would accrue from getting the basic information right for example the first 10% of information may result in 50% of the gain. Hopefully at this level of information there is a higher level of agreement than there is for more esoteric areas





Geographic Variation


An outline of a core curriculum for clinical toxicology

High standard, Evidence based, Experienced base


Flexible to reflect change

The identification of which elements of this curriculum would be suitable for specific audiences

The support of this curriculum with “open source” teaching materials

A mechanism for gathering, assessing and distributing such material

This proposal is not specifically looking at accreditation of clinical toxicology training

Delivery Structures


Non website, Books, CD rom

Web based, Fixed, Website, Blackboard, Wiki, Plus, Flexible, cheap and fast, Multiple contributors in real time, Could be the final tool for construction & delivery, Could be the tool for construction & export to website, Minus, Multiple contributors in real time, Proposal, Staged introduction, Limited Authorship initially, Accrediation of new authors, Structure, Website, FTP Site


Course material with no accreditation, Plus, Variable output, Multiple Providers, Allows extraction of content for local audience, Minus, No WHO status

Course material with Accreditation, Plus, Status, Minus, labour intensive, Centralised, Difficult to taylor to specific audiences, Loss of ownership, Reduction of input



more notes


Target Audience

Primarily a health related audience.


Poisons Information Specialists






Filtered thru a local provider, Hospitals, Nurses, Doctors, Universities, Undergraduate, Postgraduate, Poisons Information Service, Poisons Information Specialists



See also Conflict resolution. The more contributors there are the faster the project will move towards completion However the less controlled with the input is the more likely that quality may diminish. Opensource models take this risk and balance this with the expectation that contributors act in good faith and will audit and edit each other. One way forward is to only allow contributors with a certain level of credentials to contribute for example board certified toxicologists. Initially it might be reasonable to identify groups who are likely to have large amounts of content to populate the curriculum and then extend the invitation to other groups. This would allow a period to troubleshoot the mechanism of contribution

Sources of material

Existing teaching material on peoples hard disks etc would be the fastest way forward. This may require some subsequent editing but much of this could be done at the time of cutting and pasting. An FTP site would need to be setup for resource materials such as powerpoint presentation Some formating may need to be done at a secreterial level

Acknowledging contributions

In a Wiki model there is a database that looks at contribution however most opensource arrangements would just list contributors to the overall project rather than just specific sections

Conflict Resolution

Sources of Conflict, Inevitable Intellectual debate, Resource determined

How much can we tolerate?

Is conflict important to resolve?

Should we be paralysed by consensus?

Editorial mechanisms


No Copyright

Copyright in Commons, Welcome | Creative Commons, Microsoft Addin, Download details: Office Add-in: Creative Commons Add-in for Microsoft Office, Also and Openoffice addin, Welcome | Science Commons, Documents

Content Description

Should we stratify curriculum outline?

Audience and Geography

Teaching Opportunity

Should we stratify content?

This becomes more complicated and could be a bit restrictive. Essentially this would mean identifying certain parts of monographs or talks as being directed at certain groups e.g. nurses or medical undergraduates. Alternatively having multiple parallel streams of information. The alternative is just to allow users to select the bits that are relevant

Curriculum topic

Monograph, Linked resources



A very low cost solution, also these meetings would be an appropriate venue for promotion of the project and recruitment of material (e.g. Keynotes Lectures etc) and authors




Specific Meeting

These are expensive to organise and can be inconvenient to the individuals

Perhaps based on Contribution

Web Based

Some of the Web based solutions such as Blogs would allow a dialog that would not require a realtime presence




Example from American Board Emergency Medicine

The list is long..perhaps we should prioritise e.g. High mortality/morbidity Developing country needs Early learners fundamentals

1.0 Principles of Toxicology

1.1 Pharmacology/Toxicology, 1.1.1 Pharmacokinetics/Toxicokinetics, Bioavailability and Absorption, Distribution, Metabolism, Elimination, Clearance, Models (eg, compartmental, physiologic), 1.1.2 Pharmacodynamics/Toxicodynamics, Dose/Concentration Relationship to Effect, Structure-Activity Relationship, Receptor Agonism/Antagonism, Receptor Regulation, 1.1.3 Adverse Effects, Mechanistic (predictable), Idiosyncratic, 1.1.4 Interactions, Xenobiotic-Environment, Xenobiotic-Food, Xenobiotic-Xenobiotic (eg, drug-drug), 1.1.5 Proteomics, 1.1.6 Tolerance and Withdrawal, Behavioral Tolerance, Biologic Tolerance, 1.1.7 Immunologic Response (eg, antibodies, cytokines), 1.1.8 Pharmacogenomics/Toxicogenomics (eg, xenobiotic response, gene expression profiling)

1.2 Molecular Components/Mechanisms, 1.2.1 Glycolysis and Oxidative Phosphorylation, 1.2.2 Other Metabolic Pathways (eg, amino acids and urea cycle), 1.2.3 Membranes, 1.2.4 Enzymes and Transport Proteins (eg, methemoglobin, G6PD), 1.2.5 Channels and Pumps, 1.2.6 Signal Transduction, Receptor Isoforms and Subtypes, Regulation and Messengers, Neurotransmitters

1.3 Cytotoxic Mechanisms (eg, apoptosis, microtubular dysfunction)

1.4 Mutagenesis and Carcinogenesis, 1.4.1 Mutagenesis, Chromosome Aberrations (structural, numeric), Gene Mutation (oncogenes, tumor suppressor genes), 1.4.2 Development of Neoplasia, Initiation (eg, genotoxic mechanisms), Procarcinogens and Conversion to Carcinogens (eg,, Progression (eg, growth, invasiveness), Promotion (eg, nongenotoxic mechanisms biotransformation)), 1.4.3 Inhibition of Carcinogenesis-Modulating Factors, Endogenous Factors (eg, age, sex, immune status, hormones), Exogenous Factors (eg, diet, radiation), 1.4.4 Interactive Carcinogenesis, Xenobiotic: Gene Interactions, Xenobiotic: Physical Interactions, Xenobiotic: Radiation Interactions, Xenobiotic: Viral Interactions

1.5 Adverse Reproductive and Developmental Outcomes, 1.5.1 Conception Impairment, Mutagenesis, and Teratogenesis, Chromosomal and Gene Abnormalities, Effects on Gametogenesis and Gametes, Effects on Gonads, Spontaneous Abortion and Perinatal Death, 1.5.2 Factors Determining Fetal or Infant Exposure to Agents, Breast Milk Transfer, Placental Transfer, Xenobiotic Disposition (eg, maternal xenobiotic disposition, feta pharmacokinetics)l, 1.5.3 Offspring Effects, Cancer, Congenital Anomalies and Malformations, Development of Infant/Child, Genetic Mutations

2.0 Toxins and Toxicants

2.1 Drugs, 2.1.1 Analgesics, Anti-inflammatory Drugs, Acetaminophen, Nonsteroidal Anti-inflammatory Drugs, Opioids, Salicylates, Others (eg, antigout drugs, gold), 2.1.2 Antimicrobials, Antibiotics, Antifungals, Antimycobacterials, Antiparasitics, Antiprotozoals, Antiretrovirals, Antiseptics, Antivirals, 2.1.3 Chemotherapeutic Drugs, Alkylators, Antimetabolites, Hormones, Natural Drugs, (eg, vinca alkaloids, antibiotics), Miscellaneous (eg, platinum, hydroxyurea), 2.1.4 Diagnostic Drugs (eg, radionuclides), 2.1.5 Drugs That Affect Cholesterol and Lipids, 2.1.6 Drugs That Affect the Cardiovascular System, Antidysrhythmics, Calcium channel blockers, Cardiac glycosides, Potassium channel blockers, Sodium channel blockers, Antihypertensives, Angiotensin system modulators, -Adrenergic (and mixed , ) antagonists, Centrally acting receptor agonists, Diuretics, Vasodilators (eg, nitrates, nitrites), Inotropes, 2.1.7 Drugs That Affect the Endocrine System, Antidiabetic Drugs, Insulin, Oral hypoglycemics, Others (eg, metformin, glitazones), Bone Active Drugs (eg, calcitonin, bisphosphonates), Electrolytes and Minerals, Glucocorticoids, Sex Hormones, Growth Hormones, and Anabolic Steroids, Thyroid Drugs, Vasopressin and Somatostatin Analogues, 2.1.8 Drugs That Affect the Gastrointestinal System, Antidiarrheals, Antiemetics, Drugs Used for Biliary and Pancreatic Diseases (eg, bile salts,, pancreatic enzymes), Drugs Used for Inflammatory Bowel Disease, Drugs Used to Treat Acid-Peptic Diseases, Laxatives, Promotilics, 2.1.9 Drugs That Affect the Hematologic System, Anticoagulants, Antifibrinolytics, Antiplatelet Drugs, Blood-Stimulating Drugs (eg, erythropoietin), Drugs Used to Treat Bleeding (eg, clotting factors, antiplasmin, drugs), Iron, Thrombolytics, 2.1.10 Drugs That Affect the Immune System (eg, interferon, cyclophos-, phamide), 2.1.10 Drugs That Affect the Immune System (eg, interferon, cyclophos-, phamide), 2.1.11 Drugs That Affect the Nervous System, Anesthetics, Inhalational and sedative anesthetics (eg, nitrous oxide,, propofol), Local anesthetics, Anticonvulsants, Antiparkinsonism Drugs, Drugs That Affect Autonomic Homeostasis, Anticholinergics, Antihistamines, Antiserotonergics, Cholinergics (eg, nicotine), Ergot and derivatives, Methylxanthines, Serotonin agonists and other proserotonergics (eg, dextro-, methorphan), Sympathomimetics (eg, amphetamines, cocaine), Ethanol, Muscle Relaxants, Neuromuscular Blockers, Psychoactive Drugs and Hallucinogens (eg, marijuana, lysergic, acid diethylamide [LSD]), Psychotropics, Anxiolytics and sedative-hypnotics, Antidepressants, Antipsychotics, Mood stabilizers, 2.1.12 Pharmaceutical Additives (eg, excipients), 2.1.13 Veterinary Products, 2.1.14 Vitamins

2.2 Industrial, Household, and Environmental Toxicants, 2.2.1 Airborne Solids, Asbestos, Coal Dust, Organic Dust, Silica, Other Minerals (eg, man-made mineral fibers), 2.2.2 Cleansers and Caustics, Acids, Alkali, Bleach, Detergents and Soaps, Disinfectants and Topical Anti-infectives, Swimming Pool Products, 2.2.3 Food Additives (eg, monosodium glutamate, sulfites), 2.2.4 Household Products, Aquarium Products, Art Products, Batteries, Cosmetics, Dental Products, Hair Products, Personal Hygiene Products, 2.2.5 Hydrocarbons/Solvents/Fuels, Aldehydes, Alcohols and Glycols, Diethylene glycol, Ethylene glycol, Glycol ethers, Isopropanol, Methanol, Aliphatic Hydrocarbons, Hexane and congeners, Mixtures (eg, gasoline, kerosene), Aromatic Hydrocarbons, Benzene, Polycyclic aromatic hydrocarbons, Toluene, Halogenated Hydrocarbons, Carbon tetrachloride, Chloroform, Methylene chloride, Perchloroethylene, Trichloroethylene, Vinyl chloride, Hydrazines, Ketones, Peroxides, Terpenes, 2.2.6 Metals/Metalloids, Arsenic (including arsine), Barium, Beryllium, Cadmium, Chromium, Cobalt, Copper, Lead, Manganese, Mercury, Nickel, Thallium, 2.2.7 Pesticides, Fumigants and Sterilants, Fungicides, Herbicides, Insecticides and Repellents, Carbamates, DEET, Moth balls, Organochlorines, Organophosphates, Pyrethrins and pyrethroids, Rodenticides, Anticoagulant, Nonanticoagulant, Other (eg, molluscides), 2.2.8 Pollutants, Air Pollutants (eg, respirable particulates), Persistent Organic Pollutants (eg, polychlorinated biphenyls, dibenzodioxins), Water Pollutants (eg, trihalomethanes), 2.2.9 Toxic Gases, Cellular Asphyxiant Gases, Carbon monoxide, Cyanide, Hydrogen sulfide, Irritant Gases, Chlorine, Nitrogen oxides, Ozone, Phosgene, Sulfur oxides, Radon, Simple Asphyxiants (eg, methane, nitrogen), Smoke Inhalation, 2.2.10 Miscellaneous Toxicants, Acrolein, Acrylamides, Acrylates, Amines, Aniline Compounds, Azides, Bromide Compounds, Butadienes, Carbon Disulfide, Chlorates, Coal Tar Products, Diamines, Dibromochloropropane (DBCP), Dimethylacetamide (DMAC), Dimethylformamide (DMF), Dinitrobenzene, Dinitrotoluene (DNT), Epichlorohydrin, Ethylene Dibromide (EDB), Ethylenediamine (EDA), Fluoride Compounds, Fuels, Hexachloro-1,3-Butadiene (HCBD), Isocyanates (eg, toluene diisocyante), Maleic Anhydride, Mercaptans, Methylene Diamine (MDA), Nitriles, O-Phenylenediamine (OPD), Phosphorus/phosphides, Phthalates, Polymers, Resins, Styrene, Trimellitic Anhydride, Triorthocresylphosphate (TOCP), Xylidine, 2.2.11 Syndromes Attributed to the Environment, Not Specified Elsewhere, Event-Specific Syndromes (eg, Gulf War syndrome, World Trade Center cough), Mold, Multiple Chemical Sensitivity Syndrome, Tight Building Syndrome

2.3 Natural Products

2.3.1 Food Poisoning, Bacterial, Marine

2.3.2 Fungi, Mushrooms, Other Fungal Toxins (eg, aflatoxins, trichothecene mycotoxins)

2.3.3 Herbal and Dietary Supplements

2.3.4 Plants, Cardiovascular Toxic Plants (eg, Aconitum napellus,Nerium oleander), Cutaneous/Mucus Membrane Toxic Plants (eg, Toxicodendron, sp,Dieffenbachiasp), Gastrointestinal Toxic Plants (eg, Phytolacca Americana,, Solanumsp), Hepatotoxic Plants (eg, Bilghia sapida,Symphatumsp), Multisystem Toxic Plants (eg, Prunussp,Ricinus communis), Neurotoxic Plants (eg, Daturasp,Nicotiana tabacum)

2.3.5 Toxic Envenomations, Arthropods, Marine Creatures, Reptiles/Amphibians

2.4 Warfare, Terrorism, and Riot Control Agents

2.4.1 Biological, Bacteria (eg, anthrax, plague), Toxins (eg, botulinum, staphylococcus B), Viruses (eg, smallpox)

2.4.2 Chemical, Acetylcholinesterase Inhibitors (eg, sarin, soman, VX), Blister Agents (eg, mustard), Incapacitating Agents (eg, calmatives, BZ [3-quinuclidinyl benzilate]), Tear Gases (eg, pepper spray)

2.4.3 Nuclear/Radiological

3.0 Therapeutics

3.1 ABCs: Resuscitation

3.2 Initial Management, 3.2.1 Assessment Skills, Differential Diagnosis, Signs and Symptoms, Toxidromes, 3.2.2 Decontamination Strategies, Dermal, Gastrointestinal, Ocular, 3.2.3 Enhance Elimination Techniques, Extracorporeal Removal, Gastrointestinal Dialysis, Urinary Approaches

3.3 Pharmacological Basis of Antidote Use, 3.3.1 Antagonize Effects of Poison, Enzyme Inhibitors (eg, physostigmine), Enzyme Reactivators (eg, pralidoxime), Physiological Antagonists (eg, calcium, glucagon), Receptor Antagonists (eg, atropine, flumazenil, naloxone), Reducing Agent (eg, methylene blue, N-acetylcysteine), 3.3.2 Dispositional Agents, Alcohol Dehydrogenase Antagonists, Antivenoms/Antibodies, Chelators, Cyanide Antidotes, Enzyme/Cofactor Replacement (eg, folinic acid, pyridoxine), Oxygen/Hyperbaric Oxygen, 3.3.3 Other Antidotes

3.4 Supportive and Other Care, 3.4.1 Adjunctive Therapy (eg, granulocyte colony-stimulating factor), 3.4.2 Anticonvulsants, 3.4.3 Antidysrhythmics, 3.4.4 Control of Agitation, 3.4.5 Control of Temperature, 3.4.6 Correct Electrolyte and Acid-Base Disturbances, 3.4.7 Critical Care Procedures (eg, arterial catheter and central line placement-, 3.4.8 Fluid Resuscitation, 3.4.9 Patient Monitoring, 3.4.10 Pressor Agents and Control of Blood Pressure, 3.4.11 Protect Airway/Ventilation/Manage Airway Injury, 3.4.12 Psychiatric Issues, 3.4.13 Social Issues, 3.4.14 Transplantation

3.5 Withdrawal Syndrome Management, 3.5.1 Alcohol, 3.5.2 Opioid, 3.5.3 Sedative-Hypnotic, 3.5.4 Stimulant and Nicotine, 3.5.5 Mixed Pattern

4.0 Assessment and Population Health

4.1 Criteria for Causal Inference, 4.1.1 Biological Plausibility, 4.1.2 Consistency, 4.1.3 Dose-Response Relationship (biological gradient), 4.1.4 Specificity (of exposure or outcome), 4.1.5 Strength of Association, 4.1.6 Temporal Relationship

4.2 Information, 4.2.1 Consultation Resources (eg, databases, National Library of Medicine), 4.2.2 Surveys/Surveillance (eg, poison center data, National Report on Human Exposures

4.3 Monitoring, 4.3.1 Biological Monitoring and Biomarkers (eg, population norms, indicators of excessive exposure), 4.3.2 Environmental Sampling/Exposure Monitoring

4.4 Occupational Assessment/Prevention, 4.4.1 Medical Surveillance, 4.4.2 Personal Protective Equipment, 4.4.3 Preemployment Screening

4.4.4 Workplace Safety Engineering

4.5 Principles of Epidemiology and Statistics, 4.5.1 Statistical Concepts (eg, interpretation of Pvalue, power calculation), 4.5.2 Study Design, Basic Types (eg, case series, randomized controlled trial), Basics of Validity/Generalizability (eg, bias, confounding, randomisation, Measurements (eg, sensitivity, predictive value, limits of detection), Measures of Association (eg, odds ratios)

4.6 Regional Poison Centers, 4.6.1 Administration/Organization, 4.6.2 Consultation at a Distance, 4.6.3 Education, 4.6.4 Prevention, 4.6.5 Surveillance/Interaction With Other Professional Health Organizations, 4.6.6 Triage

4.7 Response to Hazardous Materials (Hazmat) Incidents, Including Terrorism, 4.7.1 Chemical Weapons Convention and Other Treaties, 4.7.2 Decontamination (eg, patients and responders), 4.7.3 Incident Command System, Site Safety, and Control Zones, 4.7.4 Incident Response Planning and Emergency Preparedness, 4.7.5 National Pharmaceutical Stockpile: Deployment, 4.7.6 National Response Team: Federal Agency Coordination, 4.7.7 Regulatory and Legal Background (eg, Hazardous Waste Operations

4.8 Risk, 4.8.1 Risk Assessment, Carcinogenicity Testing, Extrapolation From High to Low Dose, Extrapolation of Animal Studies to Humans, Human Epidemiological Studies in Risk Assessment, Interpretation of Key Terms (eg, recommended exposure limit [REL]), No Observed and Lowest Observed Adverse Effect Levels (NOAEL, LOAEL), Role of Risk Assessment in Formulating Regulations, Target Risks (eg, 10 or 10 ), “Uncertainty Factors” (reasons for them, approximate values), 4.8.2 Risk Perception and Risk Communication

4.9 Role of Federal and International Agencies in Toxicology, 4.9.1 Agency for Toxic Substances and Disease Registry (ATSDR), 4.9.2 Centers for Disease Control and Prevention (CDC), 4.9.3 Consumer Product Safety Commission (CPSC), 4.9.4 Environmental Protection Agency (EPA), 4.9.5 Food and Drug Administration (FDA), 4.9.6 Health Resources and Services Administration (HRSA), 4.9.7 National Institute of Occupational Safety and Health (NIOSH), 4.9.8 Occupational Safety and Health Administration (OSHA), 4.9.9 World Health Organization (WHO)

4.10 Toxic Outbreaks of Historical Significance (eg, yusho, toxic oil)

5.0 Analytical and Forensic Toxicology

5.1 Assay Methods and Interpretation, 5.1.1 Clinical Drug Testing, Confirmatory Tests, Atomic Absorption, Gas Chromatography/Mass Spectrometry (GC/MS), High-Pressure Liquid Chromatography (HPLC), Screening Tests, Gas Chromatography (GC), Immunoassays (eg, enzyme-multiplied immunoassay technique EMIT, Colorimetric Tests (eg, color tests, thin layer chromatography), Serum/Blood Drug Levels and Interpretation, Urine Drug Testing, Interpretive Challenges (eg, benzodiazepines, opioids), Adulteration Techniques, Analytical Limitations and Interferences, 5.1.2 Hair Analysis, 5.1.3 Laboratory Issues, Point of Care Testing, Quality Assurance/Quality Control, 5.1.4 Special Toxicology Testing, Heavy Metal Screens, Cholinesterase Determinations, 5.1.5 Therapeutic Drug Monitoring

5.2 Laboratory and Other Diagnostic Assessments, 5.2.1 Anion Gap, 5.2.2 Blood Gases and Co-oximetry, 5.2.3 Electrolytes, 5.2.4 Hematologic and Coagulation Abnormalities, 5.2.5 Liver Function Tests, 5.2.6 Osmolality, 5.2.7 Renal Manifestations (eg, urine color, crystals), 5.2.8 Other Supportive Testing, Electroencephalography, Diagnostic Imaging, Electrocardiography, Electromyography/Nerve Conduction Studies

5.3 Forensics, 5.3.1 Chain of Custody, 5.3.2 Clandestine Laboratories, 5.3.3 Definition and Scheduling of Controlled Substances, 5.3.4 Interpretation of Postmortem Drug Levels, 5.3.5 Necrokinetics, 5.3.6 Selection of Postmortem Specimens, 5.3.7 Special Issues, Meconium, Vitreous Humor

5.4 Legal Ethanol, 5.4.1 Alcohol and the Law, 5.4.2 Alcohol-Induced Psychomotor Impairment, 5.4.3 Blood and Urine Alcohol Analysis, 5.4.4 Breath Alcohol Analysis, 5.4.5 Collection and Storage of Alcohol Specimens, 5.4.6 Disposition of Alcohol, 5.4.7 Saliva and Other Media

5.5 Medical Legal Issues (eg, role of expert witness)

5.6 Workplace Drug Test Interpretation, 5.6.1 Cutoffs, 5.6.2 Guidelines for Federal Workplace Drug Testing Programs, 5.6.3 Role of Medical Review Officer (MRO)