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					WORLD HEALTH ORGANIZATION            IPCS/INTOX/Clin Tox Curric/ Report - draft
INTERNATIONAL LABOUR ORGANIZATION
UNITED NATIONS ENVIRONMENT PROGRAMME

                         INTERNATIONAL PROGRAMME ON CHEMICAL SAFETY


          Workshop to Develop and Deliver a Core Curriculum on Clinical Toxicology
                      Held at the Royal Infirmary of Edinburgh, Edinburgh, UK.
                                           th     st
                                         19 to 21 July 2006

                                            Draft Report


1     Welcome and introductory remarks
    1.1 Mrs Alison Good from the Scottish Poisons Information Bureau welcomed the
         participants to the meeting.


2     Selection of officers and approval of agenda
    2.1 It was decided that there would be a rotating Chair. Professor Balali Mood chaired the
         meeting on the first day and Dr Fountain chaired for the remaining 1.5 days. Ms
         Tempowski took the meeting record. The agenda is given at Annex 1. The list of
         participants is given at Annex 2.


3     Background and purpose of the workshop
    3.1 Clinical toxicology was not a recognized specialty is most countries and,
         consequently, was little taught. One obstacle to better teaching was the lack of
         accessible, good quality teaching materials. This was particularly true in developing
         and in-transition countries, yet these were the countries that saw large numbers of
         poisoning cases with a high morbidity and mortality. If frontline health professionals
         were better educated in clinical toxicology this would improve the management of
         poisoning and contribute to reducing morbidity and mortality.

    3.2    WHO was committed to assisting Member States to improve the training of their
           health professionals, in particular by making innovative use of information and
           communication technology. These activities were coordinated through the technical
           unit for E-Health in the Department of Knowledge Management and Sharing.

    3.3    The Global Plan of Action agreed under the Strategic Approach to International
           Chemicals Management (SAICM) included the need to improve capacities in
           countries to manage poisonings, and to access and use scientific knowledge. The
           Quick Start Programme would provide funds to countries, and possibly to non-
           governmental organizations, for activities directed towards meeting these needs.

    3.4    Professor Andrew Dawson of the South Asian Clinical Toxicology Research
           Collaboration (SACTRC) approached IPCS with a proposal for developing and
           delivering teaching materials on clinical toxicology using the Internet. The purpose of
           the meeting was to explore Dr Dawson's proposal and to agree a plan for putting the
           proposal into practice.


4     Proposal for developing and disseminating a clinical toxicology curriculum
    4.1 Professor Dawson's proposal was to use a web-based open-source platform such as
         a wiki site for the compilation and delivery of teaching materials. Contributors would
         upload their teaching materials to the site and these could then be freely used by
            anyone wishing to teach themselves or others. Contributors would, for the most part,
            use pre-existing materials rather than be expected to create new materials.

    4.2    There was already a lot of material on the Internet, however, it was difficult for the
           user to judge its quality. This project would offer a collection of high quality material
           for teaching, as well as links to other vetted websites.


5     Experiences in developing clinical toxicology education and in e-learning
    5.1 Six presentations were given:

           Ms Tempowski spoke about the WHO Health Academy and the Global Public
            Health Platform. The Health Academy provided interactive teaching packages
            aimed at changing behaviours that contributed to bad health
            (http://www.who.int/healthacademy/courses/en/). WHO was collaborating with the
            Department of Public Health, University of Iowa to explore the use of advanced
            telecommunication tools for distance learning through the Global Public Health
            Platform http://www.who.int/kms/events/Events/en/index.html).

           Dr Besbelli presented the WHO/UNEP Multi-Level Resource Tool for the Safe
            Management of Pesticides. This included information on safe handling of pesticides
            and on management of poisoning, as well as links to authoritative websites. The
            teaching materials were stratified into basic, intermediate and advanced. The
            resource tool was available on CD-ROM.

           Dr Groszek presented the results of a survey of clinical toxicology teaching in
            Central and Eastern Europe. Only four countries: Poland, Bulgaria, Serbia and
            Russia had formal post-graduate specialization and training in clinical toxicology.

           Professor Faiz spoke about the profile of poisoning in Bangladesh, and the teaching
            of clinical toxicology. This was not a recognized specialty, but some teaching
            modules had been developed for both undergraduate and postgraduate teaching.
            Poisoning was usually managed by forensic medicine specialists.

           Professor Balali Mood described clinical toxicology training in Iran. There were three
            teaching centres: Shiraz, Mashhad and Tehran. Clinical toxicology had been
            incorporated into national medical boards for internal, forensic and industrial
            medicine. A curriculum for a formal fellowship and sub-specialty Board in Clinical
            Toxicology was submitted last year to the Ministry of Health and Medical Education.

           Dr Thompson described the Medical Toxicology diploma and masters course taught
            by distance learning from the University of Wales College of Medicine. This course
            was taken by a range of health professionals. He also demonstrated the web-based
            platform used to provide learning materials and to enable students to submit their
            work.

    5.2    These presentations highlighted the fact that different types of health professionals
           would require teaching materials, and that the priorities in terms of subject varied
           from country to country, according to the different patterns of poisoning.


6     Definition and prioritization of the key elements of the curriculum content
    6.1 Teaching materials were needed for the education of professionals from a range of
         specialties and backgrounds e.g. forensic medicine, emergency medicine, nursing,
         poisons information. Materials were needed for both undergraduate and postgraduate
         teaching. They were also needed at different levels of content (basic, intermediate
         and advanced). It was decided, however, that contributors should not be required to

                                                                                                       2
          adapt their existing materials for different levels of teaching. The aim was to provide a
          package of materials that was sufficiently comprehensive that it could be adapted by
          the user for these different target and levels. On the other hand, if a contributor had
          materials aimed at a specific target group, they could identify this group when they
          submitted their material.

    6.2   It was felt that priority should be given to dealing with the issues that caused the
          highest morbidity and mortality. While the needs, in terms of substance-specific
          materials varied in different countries, there was core material that would be needed
          by everyone e.g. diagnosis of poisoning, initial patient management. There were also
          some poisonings that were common to many developing and in-transition countries
          e.g. pesticides and snake bite.

    6.3   A priority list of topics was agreed, and this is given in Annex 3. The aim was to
          populate this 'skeleton' with teaching materials during the pilot phase of site
          development. The priority list was a cut-down version of the curriculum developed by
          the American Board of Emergency Medicine. It was not intended to be exclusive: if
          contributors had materials on topics not included in the cut-down list they could still
          submit these to the site. Professor Dawson would add the 'skeleton' to the site and
          would provide instructions for contributors.


7         Structure and content of the site
    7.1   For each topic there would be 3 sections: section 1 would provide additional
          information on the topic that could be added to, or edited by, contributors. Section 2
          would be the teaching package. The third section would be a discussion board.

    7.2   The teaching package would comprise: PowerPoint slides (as .ppt so that they could
          be adapted by the user) and supporting background text to the slides, either as a .pdf
          or as notes attached to the slides in the PowerPoint file. If appropriate the contributor
          could indicate the level or target group towards which their material was aimed. Test
          questions and answers could also be provided. There would be links to materials on
          other sites though it was preferable to have as much supporting material as possible
          provided in one place. This was particularly important if the site was going to be
          downloaded to a CD-ROM or other stand-alone medium for dissemination.

    7.3   The possibility was raised of adding an image library in the future.


8         Issues of quality, intellectual property rights
    8.1   The quality of the teaching content would be assured by inviting contributions from
          experienced and well-regarded clinical toxicologists and by peer review. The Home
          page of the site would list the people, and also possibly the institutions, that had
          contributed material to the site. In addition the names of steering group members
          would be listed. This would enable users to make a judgment about the quality and
          credibility of the teaching materials.

    8.2   Peer review would be carried out by fellow contributors. It was also suggested that a
          small number of external experts be identified who, though they might not be willing
          to submit materials themselves, would be willing to carry out peer review. Before
          approaching people for this task some information about the concept and the tasks of
          the external reviewers needed to be written. This should probably wait until the
          project group had gained some experience in the process themselves, but could
          nevertheless start within the pilot phase of the project.

    8.3   After the start-up phase the pool of contributors would widen, as users of the website
          would also be invited to submit their materials. How these materials should be peer-

                                                                                                   3
          reviewed was yet to be decided in detail. One proposal was to provide a list of peer
          reviewers of the website from which the contributor could select one individual to
          carry out the peer-review. It was agreed that when the project group had gained more
          experience in the process of submitting and reviewing materials this procedure would
          be further developed.

    8.4   It was recognized that there were many uncertainties in clinical toxicology and there
          could therefore be a range of views on best management. Moreover, in many parts of
          the world 'best management' was determined by the availability of resources. It was
          important to reflect these different positions in the teaching materials. Section 1 of
          each topic provided a medium through which controversies could be discussed.
          The process of moderating submitted materials would ensure that those containing
          information that was a long way from accepted norms would be excluded. The Home
          page would alert the user to the fact that they might find differing views expressed,
          and would explain why this was.

    8.5   There was an audit trail, in that the wiki site enabled contributors to see where
          changes had been made, and old versions of documents were retained .

    8.6   A draft procedure for submitting materials is given at Annex 4. A code of conduct for
          authors would also be written.

    8.7   The decision whether to put their name on their materials was left to the contributor.
          The site would in any case list the contributors. Contributors would be advised about
          the possible need to remove institutional logos or other identification.

    8.8   Authors should remove any material from their slides that was copyrighted to others
          unless they had permission to use the material for the purpose of putting it on the
          website. A copy of the permission document should be sent to the site moderator.
          This issue needed further clarification, however, and Professor Dawson would
          consult with a copyright lawyer about liability for the use of copyrighted material,
          since this could happen inadvertently.

    8.9   Photographs of patients should only be included if they added to the understanding of
          the subject being described. Such photographs should be anonymised as far as
          possible and the use of such pictures should comply with the standard requirements
          of medical journals, e.g. with respect to patient permission.

    8.10 Contributors to the site should understand that acceptance of their submissions was
         on the basis that the materials would have unrestricted use for educational purposes.

    8.11 There would need to be a disclaimer on the site. This would incorporate the usual text
         about not accepting liability for the way in which the site content was used and
         interpreted, and would also draw attention to the fact that users might find a number
         of different views expressed about the same subject.


9         Promotion of the site
    9.1   In order to be promotable, the site needed to have an attractive and appropriate
          name. The choice might be limited by the availability of domain names. The name
          would be decided at the next meeting but could be discussed on the wiki site.

    9.2   A number of means for promoting the site were suggested. It was important to repeat
          promotional activities at intervals. Possible means included:




                                                                                                   4
           Asking toxicological and medical societies and associations to include a link on their
            websites.

           Sending information via list serves e.g. INTOX-general, those belonging to
            medical/toxicological societies.

           Identifying a 'champion' in each country who could publicize the site nationally and
             encourage its use.

           Asking medical journals, both those with an international and those with a primarily
            national readership, to include information about the site.

           Informing medical schools and medical libraries.

           Giving presentations at congresses and writing papers about the initiative.

           Asking websites used for continuing professional development to include a link.

    9.3     In addition, users would be asked to acknowledge the source of their materials by
            means of a slide about the site that would be provided for them.


10    Functional requirements
 10.1 A wiki site would be used in the first instance, though it was possible that this might
      change as the site developed. Some functionality requirements identified so far were:

           Ability to track changes made to materials

           Ability to have threaded discussions about topics

           Back-up functionality

           Assignment of differential rights to users e.g. for uploading, editing, read-only

           Ability to download the entire content onto another website or into a different
            medium such as a CD-ROM or the eGranary Digital Library 1


11 Evaluation of the site
 11.1 A number of evaluation methods were agreed:

           Check that all the priority topics have materials

           Monitor of web hits – look at country/region and the topics downloaded

           Number of new contributions offered by users

           Check Comments/Discussion section

           Ask a trainee e.g. a Fellow or MSc student to develop a presentation using
            materials on the site and get their feedback


1
  The eGranary Digital Library provides millions of digital educational resources to institutions lacking adequate
Internet access. Web site content is downloaded (with permission) and delivered to intranet Web servers at
partner institutions in developing countries, enabling millions of multimedia documents to be instantly accessed by
users over their local area networks at no cost. http://www.widernet.org/digitallibrary/

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      Invite users to provide feedback

      Put a survey form on the website

      If the website becomes heavily used, consider requiring registration before
       materials can be downloaded – use this for evaluation surveys

      Organize a research project to evaluate the site from different perspectives e.g.
       penetrance, effectiveness

      Ask the external reviewers to provide comments on the overall site


12 Possibilities of translation into other languages
 12.1 There was a need for teaching materials in languages other than English. This could
      be achieved in a number of ways. The pool of contributors could be widened to
      include those in other countries who would be invited to submit materials in their own
      language. In addition users of the site who translated materials for their own use
      would be asked to submit these for use by others. Translated materials would need
      to be reviewed by a clinical toxicologist who was a native speaker of that language.


13 Costs and possible sources of funding
 13.1 The costs for the pilot phase of the project were low: around US$1000 p.a. to use the
      wiki site without advertisements. At the end of the pilot phase it would be useful to
      have a meeting of contributors in order to evaluate how the project had progressed
      and to decide on next steps. It was suggested that this meeting could be held back-
      to-back with the Toxicology Update course in Cardiff, UK in November. A meeting in
      the UK would cost approximately $20,000. Other cost items are listed in Annex 5.

 13.2 In terms of possible sources of funding for the longer term, it was possible that the E-
      Health unit of WHO could contribute up to $10,000, depending on the platform
      chosen. In addition it might be possible to apply to the SAICM Quick Start
      Programme (QSP). An application would have to be made through the SAICM focal
      point in a country. Since SACTRC was in Sri Lanka, Dr Fernando would explore the
      possibility of an application from there. This would be for the second wave of QSP
      funding.

 13.3 Other possible sources included donor agencies and other UN bodies, such as
      UNESCO. Dr Fountain said some funds might be available from TOXINZ in return for
      contributions to the database. An additional possible source was to present the
      website as a research project and to seek funding for its implementation and
      evaluation of its usage.

 13.4 It was felt that it would be better to approach potential funders once the pilot site had
      been established. Thus the issue of funding would be considered again at the next
      meeting.


14 Next steps and timeline

 14.1 It was agreed that there would be a three-month pilot phase when the site would only
      be open to contributors. This period would be used to test the process of populating
      the site and to identify problems e.g. with conflicting information, overpopulation of
      some topics and lacunae in others, quality issues etc. A meeting would take place
      after that time, preferably in association with an existing meeting, the outcome of the


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       pilot phase would be reviewed, and a decision be taken about next steps.

 14.2 The following actions and timelines were agreed:


                     Action                            When                By whom
Establish wiki site:                            By 31 July            Andrew Dawson
 set up website & write instructions for
   authors;
 identify group members;
 set up: contributor rights, administrative
   pages & group email

 Authors to upload material, at least one       By 31 Aug             All contributors
 package per person

 Review the uploading and downloading           Start when first      All
 process                                        material uploaded,
                                                finished by 30 Sept
 Prepare background information,                Late Sept / early     Andrew Dawson
 instructions & invite external contributors    Oct?

 Test the utility of the site and its content   Oct                   All
 rough external review e.g. ask Fellows,
 students etc to try and use site to prepare
 talks

 2nd meeting:                                   16-17 Nov, Cardiff,   All
  iron out problems;                           UK
  review: progress, evaluation, costs;
  agree next set of goals;
  draft funding proposals;
  identify other contributors & external
     reviewers;
  decide on name;
  prepare for going public including
     disclaimer;
  develop marketing plan



15 Further business
 15.1 During the discussions it became clear that there were a number of terms and roles
      that would need to be defined. This could be carried out during the next 3 months
      through the wiki site. The terms/roles identified at the meeting were:

          Contributors
          Core contributors
          Invited contributors
          Unsolicited contributions
          Steering group
          Site moderator
          Users
          Target group
          Package
          Topic area


                                                                                           7
16 Closure of meeting
 16.1 Ms Tempowski closed the meeting by thanking Mrs Good and colleagues at the
      Scottish Poisons Information Bureau for organizing and hosting the workshop. She
      also thanked the participants for their active contribution to the workshop.




                                                                                         8
Annex 1

WORLD HEALTH ORGANIZATION            IPCS/INTOX/Clin Tox Curric/ Agenda-final
INTERNATIONAL LABOUR ORGANIZATION
UNITED NATIONS ENVIRONMENT PROGRAMME

                       INTERNATIONAL PROGRAMME ON CHEMICAL SAFETY


       Workshop to Develop and Deliver a Core Curriculum on Clinical Toxicology
                   Held at the Royal Infirmary of Edinburgh, Edinburgh, UK.
                                          th     st
                                        19 to 21 July 2006

                                        Adopted agenda


   1    Welcome and introductory remarks

   2    Selection of officers and approval of agenda

   3    Background and purpose of the workshop

   4    Proposal for developing and disseminating a clinical toxicology curriculum

   5    Experiences in developing clinical toxicology education and in e-learning

   6    Definition and prioritization of the key elements of the curriculum content

   7    Structure and content of the site

   8    Issues of quality, intellectual property rights

   9    Promotion of the site

   10 Functional requirements

   11 Evaluation of the site

   12 Possibilities of translation into other languages

   13 Costs and possible sources of funding

   14 Next steps and timeline

   15 Further business

   16 Closure of meeting




                                                                                      9
Annex 2

          Workshop to Develop and Deliver a Core Curriculum on Clinical Toxicology
                                Edinburgh, United Kingdom
                                    19 to 21 July 2006

                                   List of invited participants


Professor Madhi BALALI-MOOD                                Tel: + 98 511 8819301
Medical Toxicology Center                                  Fax: +98 511 8813714
Imam Reza hospital                                         E-mail: mbalalimood@hotmail.com
Mashhad, 91735-348
Islamic Republic of Iran

Dr Nida BESBELLI                                           Tel: +41 22 791 4287
World Health Organization                                  Fax: +41 22 791
Avenue Appia 20                                            E-mail: besbellin@who.int
CH-1211 Geneva 27
Switzerland

Professor Peter BLAIN                                     Tel: +44 191 222 7195
Chemical Hazards and Poisons Division (Newcastle)          Fax: +44 191 222 6442
Health Protection Agency                                   E-mail: p.g.blain@ncl.ac.uk
Wolfson Unit
Claremont Place
Newcastle upon Tyne
NE2 4AA
United Kingdom

Dr Paul DARGAN                                             Tel: +44 20 7771 5315
Guy's & St Thomas' Poisons Unit                            Fax: +44 20 7771 5306
Guy's & St Thomas' Hospital Trust                          E-mail: paul.dargan@gstt.nhs.uk
Avonley Road
London SE14 5ER
United Kingdom

Professor Andrew DAWSON                                    Tel: +94 814479822
Faculty of Medicine                                        Fax: +94 814479822
University of Peradeniya                                   E-mail: adawson@hypertox.com
Peradeniya
Sri Lanka

Professor Abul FAIZ                                        Tel: +88 02 8616780
Dhaka Medical College                                      Fax: +88 031 610029
Dhaka-1000                                                 E-mail: mrg@spnetctg.com
Bangladesh                                                 mafaiz@dbn-bd.net

Dr Ravindra FERNANDO                                       Tel: +94 11 2694016/ 2693266
National Poisons Information Centre                        Fax: +94 11 2691581
Faculty of Medicine                                        E-mail:
Kynsey Road                                                ravindrafernando@hotmail.com
Colombo 8
Sri Lanka



    Invited but unable to attend

                                                                                          10
Dr John FOUNTAIN                                       Tel: +64 3 467 5168
New Zealand National Poisons Centre                    Fax: +64 3 477 0509
University of Otago                                    E-mail: john.fountain@otago.ac.nz
PO Box 913
Dunedin
New Zealand

Dr Barbara GROSZEK                                     Tel: +48 12 646 89 85
Department of Clinical Toxicology                      Fax: +48 12 646 89 85
Collegium Medium Jagiellonian University               E-mail: mfgrosze@cyf-kr.edu.pl
Rydygier's Hospital
Os. Zlotej Jesieni 1
31 826 Krakow
Poland

Dr Bob HOFFMAN                                         Tel: +1 212 447 8153
New York City Poison Control Center                    Fax: +1 212 447 8223
455 First Avenue                                       E-mail: bobhoff@pol.net
Room 123
New York
NY 10016
USA

Professor Ratnam KOTEA                                Tel: +230 454 1041
Faculty of Science                                     Fax: +230 454 9642
Department of Health Sciences                          E-mail: kotear@uom.ac.mu
Level 7, New Academic Complex Building
University of Mauritius
Réduit
Mauritius

Dr John THOMPSON                                       Tel: +44 29 2071 6944
Academic Centre                                        Fax: +44 2920 703454
Llandough Hospital                                     E-mail: thompsonjp@cardiff.ac.uk
Penlan Road
Vale of Glamorgan
CF64 2XX
United Kingdom

Local Organizers

Dr Nick BATEMAN                                        Tel: +44 131 242 1391 / 1383
NPIS Edinburgh (Scottish Poisons Information Bureau)   Fax: +44 131 242 1387
Royal Infirmary of Edinburgh                           E-mail:
Little France Crescent                                 nick.bateman@luht.scot.nhs.uk
Edinburgh
EH16 4SA
United Kingdom

Ms Alison GOOD                                         Tel: +44 131 242 1391 / 1383
NPIS Edinburgh (Scottish Poisons Information Bureau)   Fax: +44 131 242 1387
Royal Infirmary of Edinburgh                           E-mail: n Good, Alison
Little France Crescent                                 alison.good@luht.scot.nhs.uk

    Invited but unable to attend

                                                                                        11
Edinburgh
EH16 4SA
United Kingdom

Dr Michael EDDLESTON                                   Tel: +44 131 242 1383
NPIS Edinburgh (Scottish Poisons Information Bureau)   Fax: +44 131 242 1387
Royal Infirmary of Edinburgh                           E-mail: eddlestonm@eureka.lk
Little France Crescent                                 michael.eddleston@luht.scot.nhs.uk
Edinburgh
EH16 4SA
United Kingdom

Dr Ruben THANACOODY                                    Tel: +44 131 242 1391 / 1383
NPIS Edinburgh (Scottish Poisons Information Bureau)   Fax: +44 131 242 1387
Royal Infirmary of Edinburgh                           E-mail:
Little France Crescent                                 ruben.thanacoody@luht.scot.nhs.uk
Edinburgh
EH16 4SA
United Kingdom

Secretariat

Ms Joanna TEMPOWSKI                                    Tel: +41 22 791 3571
International Programme on Chemical Safety             Fax: +41 22 791 4848
World Health Organization                              E-mail: tempowskij@who.int
Avenue Appia 20
CH-1211 Geneva 27
Switzerland




                                                                                     12
Annex 3


          Initial Priority Subject Areas for Clinical Toxicology Curriculum

(Based upon the American Board of Emergency Medicine (ABEM) curriculum for medical
toxicology. NB numbering of sections does not correspond to that of ABEM curriculum)

Teaching materials can be introduced at any level in this listing

1 Pharmacology/Toxicology
1.1 Pharmacokinetics/Toxicokinetics
1.2 Pharmacodynamics/Toxicodynamics

2 Therapeutics
2.1 ABCs: Resuscitation

3 Initial Management
3.1 Differential Diagnosis
3.2 Toxidromes
3.3 Decontamination Strategies

4. Enhanced Elimination Techniques

5. Supportive and Other Care
5.1 Seizures
5.2 Arrhythmias
5.3 Control of Agitation
5.4 Control of Temperature
5.5 Correct Electrolyte and Acid-Base Disturbances
5.6 Fluid Resuscitation
5.7 Patient Monitoring
5.8 Pressor Agents and Control of Blood Pressure
5.9 Protect Airway/Ventilation/Manage Airway Injury
5.10 Psychiatric Issues
5.11 Social Issues
5.12 Transplantation

6 Drugs
6.1 Analgesics, Anti-inflammatory Drugs
6.1.2 Acetaminophen/paracetamol
6.1.3 Nonsteroidal Anti-inflammatory Drugs
6.1.4 Opioids
6.1.5 Salicylates
6.1.6 Others (e.g., antigout drugs, gold), colchicine

6.2 Drugs that Affect the Cardiovascular System
6.2.1 Antidysrhythmics
6.2.2 Calcium channel blockers
6.2.3 Cardiac glycosides
6.2.4 Antihypertensives
6.2.5 Adrenergic (and mixed) antagonists


6.3 Drugs that Affect the Nervous System
6.3.1 Anticonvulsants


                                                                                       13
6.4 Drugs that Affect Autonomic Homeostasis
6.4.1 Anticholinergics
6.4.2 Antihistamines
6.4.3 Sympathomimetics (e.g., amphetamines, cocaine)

6.5 Ethanol

6.6 Psychoactive Drugs and Hallucinogens (e.g., marijuana, lysergic acid diethylamide
[LSD])

6.7 Psychotropics
6.7.1 Anxiolytics and sedative-hypnotics
6.7.2 Antidepressants
6.7.3 Antipsychotics
6.7.4 Mood stabilizers

7 Pesticides
7.1 Fumigants and Sterilants
7.2 Fungicides
7.3 Herbicides

7.4 Insecticides and Repellents
7.4.1 Carbamates
7.4.2 Organochlorines
7.4.3 Organophosphates
7.4.5 Pyrethrins and pyrethroids

7.5 Rodenticides
7.5.1 Anticoagulant
7.5.2 Non-anticoagulant

8. Cleansers and Caustics
8.1 Acids
8.2 Alkali
8.3 Bleach

9. Hydrocarbons/Solvents/Fuels
9.1 Alcohols and Glycols
9.1.1 Diethylene glycol
9.1.2 Ethylene glycol
9.1.3 Glycol ethers
9.1.4 Isopropanol
9.1.5 Methanol

10 Natural Products
10.1 Plants
10.1.1 Cardiovascular Toxic Plants (e.g. Aconitum napellus, Nerium oleander)
10.1.2 Cutaneous/Mucus Membrane Toxic Plants (e.g. Toxicodendron sp, Dieffenbachia sp)
10.1.3 Gastrointestinal Toxic Plants (e.g. Phytolacca Americana, Solanum sp)
10.1.4 Hepatotoxic Plants (e.g. Bilghia sapida, Symphatum sp)
10.2.5 Multisystem Toxic Plants (e.g. Prunus sp, Ricinus communis)
10.2.6 Neurotoxic Plants (e.g. Datura sp, Nicotiana tabacum)

10.2 Fungi

10.3 Envenomations

                                                                                    14
10.3.1 Arthropods
10.3.2 Marine Creatures
10.3.3 Reptiles/Amphibians

11. Metals/Metalloids




                             15
Annex 4

                  Provisional procedures for submission and review


Start-up phase – approx. 3 months
(Site will be open to small group of contributors only - the purpose of this phase is to identify
problems and issues needing clarification)

   1. Each contributor will post their package of materials to the website. A topic skeleton
      will be provided into which the contributor can slot their materials.

   2. Others in the group will look at and comment on the materials. Each package will be
      looked at by another contributor or external reviewer at least once and preferably a
      second time after a few weeks to check any changes. This will be ensured by the site
      moderator.

   3. The author will make the changes judged to be necessary (NB only the author can
      change their own materials)

   4. The package will be accepted for subsequent public use.



Live phase - provisional procedure
(This will be revised in the light of experience during the pilot phase)

   1. Existing contributors will simply post their materials to the site without the need for
      review, provided that this has been shown to be acceptable in the start-up phase.

   2. New, external contributors will be asked to send their materials to a reviewer chosen
      from a list established by the project group. This list will be on the website with short
      information about each member’s areas of expertise.

   3. Once the reviewer has ‘passed’ the materials these will be posted to the site.




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Annex 5

                  Cost items for clinical toxicology curriculum site

Item                                          One-off costs            Recurring costs
                                                   $                    $ per annum
Pilot phase
Wiki space                                                                         1,000
Meeting                                                    20,000

Wiki space - greater functionality                                       To be confirmed
Domain name                                                                          100
Secretarial costs 1 FTE in Sri Lanka                                               1,800
Research assistant                                                                 3,600
Computer                                                      1,200
Back-up
Steering committee meeting costs @ 1                                              10,000
per year
TOTAL                                                      21,200                 16,500




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