A national general pediatric clerkship curriculum: the process of development and implementation.

OBJECTIVE: To describe a new national general pediatrics clerkship curriculum, the development process that built national support for its use, and current progress in implementing the curriculum in pediatric clerkships at US allopathic medical schools. CURRICULUM DEVELOPMENT: A curriculum project team of pediatric clerkship directors and an advisory committee representing professional organizations invested in pediatric student education developed the format and content in collaboration with pediatric educators from the Council on Medical Student Education in Pediatrics (COMSEP) and the Ambulatory Pediatric Association (APA). An iterative process or review by clerkship directors, pediatric departmental chairs, and students finalized the content and built support for the final product. The national dissemination process resulted in consensus among pediatric educators that this curriculum should be used as the national curricular guideline for clerkships. MONITORING IMPLEMENTATION: Surveys were mailed to all pediatric clerkship directors before dissemination (November 1994), and in the first and third academic years after national dissemination (March 1996 and September 1997). The 3 surveys assessed schools' implementation of specific components of the curriculum. The final survey also assessed ways the curriculum was used and barriers to implementation. OUTCOMES: The final curriculum provided objectives and competencies for attitudes, skills, and 18 knowledge areas of general pediatrics. A total of 216 short clinical cases were also provided as an alternative learning method. An accompanying resource manual provided suggested strategies for implementation, teaching, and evaluation. A total of 103 schools responded to survey 1; 84 schools to survey 2; and 85 schools responded to survey 3 from the 125 medical schools surveyed. Before dissemination, 16% of schools were already using the clinical cases. In the 1995-1996 academic year, 70% of schools were using some or all of the curricular objectives/competencies, and 45% were using the clinical cases. Two years later, 90% of schools surveyed were using the curricular objectives, 88% were using the competencies, 66% were using the clinical cases. The extent of curriculum use also increased. Schools using 11 or more of the 18 curriculum's knowledge areas increased from 50% (1995-1996) to 73% (1996-1997). CONCLUSION: This new national general pediatric clerkship curriculum developed broad support during its development and has been implemented very rapidly nationwide. During this period the COMSEP and the APA have strongly supported its implementation with a variety of activities. This development and implementation process can be a model for other national curricula.

Pentobarbital therapy for intracranial hypertension in metabolic coma. Reye's syndrome.

In severe Reye's syndrome, with nonspecific intensive supportive therapy, the mortality rate approaches 75%. In many instances, death is due to uncontrolled cerebral edema and elevated intracranial pressure. (ICP). Pentobarbital therapy, sufficient to maintain a blood barbiturate level between 2.5 mg% and 4.0 mg%, was used to control ICP in seven patients with metabolic coma complicated by intracranial hypertension (intracranial pressure greater than 30 mm Hg for 30 min). The nadir of their neurological function was characterized by no response to deep pain, absent or abnormal oculocephalic responses, bilaterally dilated, unreactive pupils, and markedly irregular or absent respirations. Before barbiturate administration hyperventilation, steroids, mannitol, and other supportive therapies commonly used in Reye's syndrome were begun. After institution of pentobarbital therapy, the daily mannitol dose required to maintain the intracranial pressure below 20 mm Hg was significantly reduced (p less than 0.001), from 3.7 +/- 0.3 to 0.5 +/- 0.2 g/kg/day. All the patients survived, and six have no obvious neurological sequelae. Pentobarbital is a useful adjunct for intracranial pressure control in advanced metabolic coma.