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Medical Toxicology Core Content Task Force for the Medical Toxicology Subboard & Julia N J. Med. Toxicol. (2012) 8:183–191 DOI 10.1007/s13181-012-0223-5 SPECIAL ARTICLE The 2012 Core Content of Medical Toxicology Lewis S. Nelson & Beth A. Baker & Kevin C. Osterhoudt & Curtis P. Snook & The Medical Toxicology Core Content Task Force for the Medical Toxicology Subboard & Julia N. Keehbauch & for the American Board of Emergency Medicine Published online: 30 May 2012 # This article is being published without copyright 2012 Keywords Core content . Medical toxicology. Curriculum Medical Toxicology. The Core Content encompasses the spe- cialty of medical toxicology and outlines the areas of knowl- edge considered essential for the practice of medical toxicology. Functionally, the Core Content provides the orga- Preamble nizational framework for the development of the medical toxicology certification and cognitive expertise examinations, In December 2011, the Medical Toxicology Subboard, com- and details the knowledge to be tested on those examinations, posed of representatives from emergency medicine, pediatrics, beginning with the 2014 examinations. In addition, the Core and preventive medicine, approved a revised Core Content of Content may serve as a template for the development of medical toxicology fellowship curricula. The previous version, 1 Medical Toxicology Subboard Members: Frederick Fung, M.D., initiated in 2000, approved in 2002, and published in 2004, Daniel A. Goldstein, M.D., Rama B. Rao, M.D., Anne-Michelle Ruha, will be retired and replaced by this new version. M.D., and Saralyn R. Williams, M.D. The first Medical Toxicology Core Content was devel- James H. Jones, M.D. (American Board of Emergency Medicine Board oped to assist in the construction of the first examination in Liaison), Julia N. Keehbauch (American Board of Emergency Medicine) 1994. This document consisted of 22 major content areas The Core Content of Medical Toxicology is used with the permission of and was organized, in part, by toxicant classification. Listed the American Board of Emergency Medicine, American Board of under most of these major content areas were exhaustive Pediatrics, and American Board of Preventive Medicine, copyright 2012. lists of drugs and toxicants of which a medical toxicologist L. S. Nelson was expected to have knowledge. New York University School of Medicine, In 2000, the Medical Toxicology Subboard embarked on New York, NY, USA a major revision of the original Core Content. This under- B. A. Baker taking was initiated to update the 1994 Core Content, as University of Minnesota School of Public Health, well as to improve the framework that conceptualizes the Minneapolis, MN, USA expanding breadth of medical toxicology. In addition, the Subboard wanted to devise a conceptual document that K. C. Osterhoudt The Children’s Hospital of Philadelphia, would accommodate future discoveries and changes. A task Philadelphia, PA, USA force of Medical Toxicology Subboard members was con- vened to develop and draft the revised Core Content, and C. P. Snook comments were solicited from stakeholders. Cincinnati Veterans Administration Medical Center, Cincinnati, Ohio, USA J. N. Keehbauch (*) American Board of Emergency Medicine, 1 Wax PM, Ford MD, Bond GR, Kilbourne EM, Walter FG; for 3000 Coolidge Road, Medical Toxicology Core Content Task Force; Avery AN, Clark RF, East Lansing, MI 48823, USA Liebelt EL; for Medical Toxicology Subboard Members. The core e-mail: [email protected] content of medical toxicology. Ann Emerg Med. 2004;43:209–214. 184 J. Med. Toxicol. (2012) 8:183–191 The latest Core Content Task Force was established in 2009 to propose updates to the 2004 Core Content. Devel- opment included both extensive discussion by the Medical Toxicology Subboard and the use of a survey of practi- tioners, which will be reported separately. During the pro- cess, input was solicited from the American College of Medical Toxicology, American Academy of Clinical Toxi- cology, and other interested stakeholders, such as diplo- mates, medical toxicology fellowship directors, and related organizations. The Core Content now contains six distinct subject areas: Medical Toxicology Major Core Content Categories (1) principles of toxicology, (2) toxins and toxicants, (3) 1.0 Principles of Toxicology clinical assessment, (4) therapeutics, (5) assessment and 2.0 Toxins and Toxicants population health, and (6) analytical and forensic toxicolo- 2.1 Drugs gy. The most significant change was the addition of an entire 2.2 Drugs of Abuse subject area, clinical assessment. Since many clinical 2.3 Industrial, Household, and Environmental Toxicants encounters begin with a symptom or clinical finding rather 2.4 Natural Products than with the knowledge of a specific toxin, the inclusion of 2.5 Warfare and Terrorism this section better aligns the Core Content with clinical 2.6 Radiological practice. 3.0 Clinical Assessment As with previous revisions of the Core Content, the 4.0 Therapeutics Medical Toxicology Core Content Task Force grappled 5.0 Assessment and Population Health with what level of detail to include in the document. In 6.0 Analytical and Forensic Toxicology this latest revision, the Core Content Task Force revised many of the sections of the previous version, both add- ing and reducing detail as appropriate. The rationale for Medical Toxicology Core Content adjusting the level of detail provided was the perception that some areas, such as the occupational toxicants, were Part 1: Principles of Toxicology too specific and needed to be broadened while others, 1.1 Pharmacology/Toxicology such as drugs of abuse, were not sufficiently inclusive. 1.1.1 Pharmacokinetics/Toxicokinetics Given the ongoing introduction of new pharmaceuticals 1.1.1.1 Bioavailability and Absorption and chemicals, yearly updating of the document to in- 1.1.1.2 Clearance clude a definitive list of all toxins and toxicants becomes 1.1.1.3 Distribution increasingly unwieldy. A few representative examples are 1.1.1.4 Elimination included in many of the drug and toxicant classes for 1.1.1.5 Metabolism clarity, but the scope of medical toxicology and the 1.1.1.6 Models (e.g., Compartmental, Physiologic) examination is not limited to these examples. The Sub- 1.1.2 Pharmacodynamics/Toxicodynamics board believes it is reasonable that test items can be 1.1.2.1 Dose/Concentration Relationship to Effect developed on any agent that could be classified either 1.1.2.2 Receptor Agonism/Antagonism under a broader category (e.g., drugs that affect the 1.1.2.3 Receptor Regulation cardiovascular system) or a narrower category (e.g., 1.1.2.4 Structure–Activity Relationship antihypertensives). 1.1.3 Adverse Effects The Core Content is intended to be a living document, 1.1.3.1 Idiosyncratic in keeping with the ever-evolving practice of medical 1.1.3.2 Mechanistic (Predictable) toxicology. The Medical Toxicology Subboard anticipates 1.1.4 Interactions regular updates to the Core Content. In order to allow the 1.1.4.1 Xenobiotic–Environment update process to accurately reflect this evolution, the 1.1.4.2 Xenobiotic–Food Subboard welcomes input from its stakeholders. Sug- 1.1.4.3 Xenobiotic–Xenobiotic (e.g., Drug–Drug) gested changes to the Core Content can be addressed to 1.1.5 Proteomics [email protected]. 1.1.6 Tolerance and Withdrawal J. Med. Toxicol. (2012) 8:183–191 185 1.1.6.1 Behavioral (Pharmacodynamic) Tolerance 1.6.1.2 Effects on Gametogenesis and Gametes 1.1.6.2 Biologic (Pharmacokinetic) Tolerance 1.6.1.3 Effects on Gonads 1.1.6.3 Dependence 1.6.1.4 Spontaneous Abortion and Perinatal Death 1.1.7 Immunologic Response (e.g., Antibodies, 1.6.2 Factors Determining Fetal or Infant Exposure to Cytokines) Agents 1.1.8 Pharmacogenetics/Toxicogenetics 1.6.2.1 Breast Milk Transfer 1.1.8.1 Assessment and Profiling of Polymorphisms 1.6.2.2 Placental Transfer 1.1.8.2 Role in Adverse Drug Events 1.6.2.3 Xenobiotic Disposition (e.g., Maternal Xeno- 1.2 Molecular Components/Mechanisms biotic Disposition, Fetal Pharmaco- kinetics) 1.2.1 Channels and Pumps 1.6.3 Offspring Effects 1.2.2 Enzymes and Transport Proteins (e.g., Methemo- 1.6.3.1 Cancer globin, G6PD) 1.6.3.2 Congenital Anomalies and Malformations 1.2.3 Glycolysis and Oxidative Phosphorylation 1.6.3.3 Development of Infant/Child 1.2.4 Membranes 1.6.3.4 Genetic Mutations 1.2.5 Neurotransmitters 1.6.4 Pharmacology of the Neonate 1.2.5.1 Receptor Isoforms and Subtypes 1.6.5 Pharmacology of Pregnancy 1.2.5.2 Regulation and Messengers Part 2: Toxins and Toxicants 1.2.5.3 Signal Transduction 2.1 Drugs 1.2.6 Other Metabolic Pathways (e.g., Amino Acids 2.1.1 Analgesics, Anti-Inflammatory Drugs and Urea Cycle) 2.1.1.1 Acetaminophen 1.3 Cytotoxic Mechanisms (e.g., Apoptosis, Microtubular 2.1.1.2 NSAIDs Dysfunction) 2.1.1.3 Opioids 1.4 Principles of Radiation (e.g., Decay, Units) 2.1.1.4 Salicylates 1.5 Mutagenesis and Carcinogenesis 2.1.1.5 Others (e.g., Antigout Drugs, Gold) 1.5.1 Mutagenesis 2.1.2 Antimicrobials 1.5.1.1 Chromosome Aberrations (Structural, 2.1.2.1 Numerical) Antibiotics 2.1.2.2 1.5.1.2 Gene Mutation (Oncogenes, Tumor Suppressor Antifungals 2.1.2.3 Genes) Antimycobacterials 2.1.2.4 Antiparasitics 1.5.2 Development of Neoplasia 2.1.2.5 Antiprotozoals 1.5.2.1 Initiation (e.g., Genotoxic Mechanisms) 2.1.2.6 Antiretrovirals 1.5.2.2 Procarcinogens and Conversion to Carcino- 2.1.2.7 Antiseptics gens (e.g., Biotransformation) 2.1.2.8 Antivirals 1.5.2.3 Progression (e.g., Growth, Invasiveness) 2.1.3 Chemotherapeutic Drugs 1.5.2.4 Promotion (e.g., Nongenotoxic Mechanisms) 2.1.3.1 1.5.3 Inhibition of Carcinogenesis Modulating Alkylators
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