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Byline: Robert O Wright (*), William J Lewander (*), Alan D Woolf (a ) Abstract: Methemoglobin (MHb) may arise from a variety of etiologies including genetic, dietary, idiopathic, and toxicologic sources. Symptoms vary from mild headache to coma/death and may not correlate with measured MHb concentrations. Toxin-induced MHb may be complicated by the drug's effect on other organ systems such as the liver or lungs. The existence of underlying heart, lung, or blood disease may exacerbate the toxicity of MHb. The diagnosis may be complicated by the effect of MHb on arterial blood gas and pulse oximeter oxygen saturation results. In addition, other dyshemoglobins may be confused with MHb. Treatment with methylene blue can be complicated by the presence of underlying enzyme deficiencies, including glucose-6-phosphate dehydrogenase deficiency. Experimental antidotes for MHb may provide alternative treatments in the future, but require further study. [Wright RO, Lewander WJ, Woolf AD: Methemoglobinemia: Etiology, pharmacology, and clinical management. Ann Emerg Med November 1999;34:646-656.] Author Affiliation: (*) Department of Pediatrics, Division of Emergency Medicine, Hasbro Children's Hospital, Brown Medical School, Rhode Island Poison Control Center, Providence, RI (a ) Department of Medicine, Program in Clinical Toxicology, Boston Children's Hospital; Harvard Medical School, Massachusetts Poison Control System, Boston, MA. Article History: Received 24 July 1998; Revised 8 February 1999; Revised 28 June 1999; Accepted 23 August 1999 Article Note: (footnote) [star] 0196-0644/99/$8.00 + 0 , [star][star] 47/1/102246

Competition is fierce today. Businesses are under extreme pressure to innovate and to do so quickly. If they are too slow bringing a new product to market, or they make a mistake along the way, they could be overtaken by faster moving competitors. But what factors improve new product development success? In a previous study, the authors interviewed 15 senior technical professionals involved in new product development. They used a benchcasing approach by sending each manager three in-depth cases and then asking each to identify the critical success factors. They identified 10 factors. The purpose of this study is to test their model in a large sample of managers from a wider cross section of technology-based companies. By studying the practices of 95 successful and unsuccessful new product projects, we validated only some of the past findings, not all of them. We found several factors, not only speed development, can improve new product success rates? These factors include having a long-term view of product development, having a stable project vision, and following a rigorous new product development (NPD) process. (Reprinted by permission of the publisher.)

Byline: Robert O Wright, Barbarajean Magnani, Michael W Shannon, Alan D Woolf Abstract: Study objective: To determine whether N-acetylcysteine (NAC)reduces methemoglobin. Methods: We carried out an in vitro laboratory experiment in which five healthy adult volunteers donated blood. Each sample was divided equally among three test tubes. Tube 1 served as a negative control. Sodium nitrite .18 mol/L with dextrose .28 mol/L was added to tube 2 and to tube 3. Next, phosphate-buffered saline solution (PBS) was added to tube 2 and NAC (200 mg/mL) to tube 3. Serial methemoglobin levels were measured over 5.5 hours. Results: Maximum methemoglobin levels were observed at 1.5 hours for both the NAC-nitrite and the PBS-nitrite sample (62.7%[+ or -]8.1% and 65.1%[+ or -]7.0%, respectively; data expressed as mean[+ or -]SD). The mean difference in methemoglobin between NAC-nitrite and PBS-nitrite was significant at 4.5 hours (29.3%[+ or -]23.0%, P=.046). The mean rate of methemoglobin decline in NAC-nitrite samples was also different from that of PBS-nitrite samples (10.7%[+ or -]1.0% versus 2.9%[+ or -]2.3%, P=.002). The rate of decline was linear (zero order) in the NAC-nitrite samples and represented by the equation: % change methemoglobin =.18 x time in minutes. Area under the concentration-time curve was also different among groups (P [Wright RO, Magnani B, Shannon MW, Woolf AD: N-acetylcysteine reduces methemoglobin in vitro. Ann Emerg Med November 1996;28:499-503.] Article History: Received 29 December 1995; Revised 9 May 1996; Accepted 23 May 1996 Article Note: (footnote) [star] From the Divisions of General Pediatrics* and Emergency Medicinea , the Program in Clinical Pharmacology/ToxicologyAs., the Departments of Medicinea[yen] and Laboratory Medicine and PathologyA[paragraph], Childrens Hospital; the Center for Experimental Therapeutics and Reperfusion Injury, Department of Anesthesia, Brigham and Women's Hospital #; and the Massachusetts Posion Control System **, Harvard University Medical School, Boston, Massachusetts., [star][star] Supported in part by the BWH Anesthesia Foundation, Incorporated., a Address for reprints: Robert O Wright, MD, Massachusetts Poison Control System, Children's Hospital, 300 Longwood Ave, Boston, Massachusetts 02115, 617-355-6609, Fax 617-738-0032, E-mail wright_r@a1.tch.harvard.edu, aa Reprint no. 47/1/76857

PURPOSE: To quantitate the impact of the recommendations contained in the Council on Graduate Medical Education (COGME) Fourth Report[1] on the position distribution in internal medicine residency and fellowship programs and to recommend alternative position allocations for discussion. DATA SOURCES: The COGME Fourth Report, the National Study of Internal Medicine Manpower,[3] and the American Medical Association Annual Survey of Graduate Medical Education.[4] RESULTS: Our analysis of the COGME Fourth Report indicates that internal medicine PGY-1 positions would decrease from the 8,936 on duty in the 1992 academic year to 6,533 (-26.9%) for the class of the year 2000. Four thousand will enter generalist careers in internal medicine (approximately a 70% increase over current generalist output). The COGME Fourth Report recommendations would allocate first-year fellowship positions for 1,400 graduates of internal medicine residencies (-63.1%). Career-bound internal medicine positions will decrease from approximately 6,000 to 5,400 (-10.0%). The loss in PGY-1 positions is predominantly due to a decrease in the number of preliminary medicine positions and to individuals who switch from career-bound internal medicine positions to other disciplines after the PGY-1 or PGY-2 years. Pediatric positions would increase moderately from 2,426 available in 1993 to 2,520 (+3.9%). Pediatric subspecialty positions would decrease by 25% to 420, with 2,100 residents entering careers in general pediatrics. Family medicine PGY-1 positions would increase from the 2,657 available in 1993 to 3,400 (+28%). CONCLUSIONS: The recommendations contained in the COGME Fourth Report would substantially reduce the number, and significantly alter the current distribution, of residency positions. The output goals of 50% generalist careers are met by an increase in career-bound generalist positions in all three generalist specialties. The limitation of total positions to the goal of 110% of 1993 U.S. graduates comes predominantly through reduction of specialty/subspecialty career-bound positions. Internal medicine residency and subspecialty fellowship positions and programs would be significantly altered by these recommendations. The reductions in internal medicine occur predominantly in loss of positions not currently destined for careers in internal medicine and in subspecialty fellowship positions. These reductions are partially offset by an increase in the complement of residents who are destined for careers in general internal medicine.