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Tuition fees for medical school are continuously and riotously increasing. This upsurge is amassing debts on the backs of students. In the class of 2018, 75% finished medical school with an outstanding balance of $196,520, on average-a $5826 increase from 2017. Tuition fees differ in terms of the ownership of the medical school (public vs. private) and according to the medical student residence status (in-state or out-of-state). It is critical that students arrange a long-term budget that shows them where they stand: in surplus or in deficit. Students may classify expenditures into two groups: "fixed" and "variable," where they can manipulate the variable expenses to fit into their budget. To pay for their tuition, medical students have four possibilities: cash, scholarships and grants, service-obligation scholarships, and loans. Loans are the most common alternatives, and so there are Traditional Repayment Plans and Income-Driven Repayment Plans. This article serves to provide medical students with attainable alternatives for funding their education and for repaying their debts., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Acute compartment syndrome (ACS) is a condition typically associated with long bone fractures or severe trauma; however, non-traumatic etiologies also occur. We describe a case of an otherwise healthy female pediatric patient presenting with unilateral forearm pain without an inciting injury. Intracompartmental pressures of the forearm were measured and she was diagnosed with idiopathic compartment syndrome. Our goal is to encourage clinicians to consider acute compartment syndrome even in the absence of trauma.

Normal function of the adrenal gland can be disrupted not only by metastases of nonadrenal cancers but also by their treatment. In addition, tumors of the adrenal gland itself can cause disease by hypersecretion of a variety of hormones, adrenal gland destruction with inadequate production of cortisol, and by metastasis to other sites. Although rare, abnormal adrenal function should be considered in the appropriate clinical settings as failure to recognize and treat can result in significant morbidity and mortality. The adrenal "incidentaloma" is a frequent finding of abdominal radiologic studies. All patients with an unexpected adrenal mass should be referred for further evaluation.

Potassium disorders are the most common electrolyte abnormality identified in clinical practice. Presenting symptoms are similar for both hypo- and hyperkalemia, primarily affecting the cardiac, neuromuscular, and gastrointestinal systems. Generally, mild hypokalemia is the most common potassium disorder seen clinically;however, severe complications can occur. Hyperkalemia is less common but more serious, especially if levels are rising rapidly. The etiologies and treatments for both hypo- and hyperkalemia are discussed, with special emphasis on the role medications play in the etiologies of each.

OBJECTIVE: To assess perceptions of emergency medicine (EM) program directors (PDs) of the resident selection process. METHODS: PDs of 120 EM residencies were mailed a 22 question survey immediately following the 1999 match. (Applicants interviewing in more than one specialty and post-interview communications were areas of interest). Non-respondents received a second mailing. RESULTS: Ninety-eight (81. 7%) completed surveys were returned. Five PDs felt that interviewing in more than one specialty was ethically wrong, while most felt multi-specialty interviews were a system byproduct (42%) or that there was nothing wrong (41%). Eighty-one percent of PDs felt the applicant's rank order would be negatively affected if the applicant disclosed interviewing in >1 specialty. Forty-seven percent of PDs (always or frequently) told applicants to keep in touch if interested in the program. However, 88% of PDs were skeptical or did not believe an applicant's communicated intent to rank the program 'high,' nor did this communication influence an applicant's rank order (75%). Forty-two percent of PDs reported informal commitments by applicants. PDs frequently felt lied to by applicants (always (4%), frequently (42%), sometimes (42%)). Applicants often ask how the program intends to rank them. Highly ranked applicants receive positive responses from 61% of PDs vs. 33% of PDs who give negative responses to low ranked applicants. Ten percent of PDs offer residency positions outside of the match. CONCLUSIONS: Applicants who interview in >1 specialty are viewed negatively by PDs. Post-interview communications by applicants are viewed with skepticism. Gamesmanship is practiced commonly during the resident selection process.

The steady growth in EM residency programs reflects the desirability of EM as a specialty area for training. However, a profile of programs offered nationwide is not available. OBJECTIVE: To characterize emergency medicine (EM) programs nationwide according to program format, curriculum, and opportunities for subspecialty training. METHODS: In this descriptive study, U.S. emergency medicine residency curriculums were evaluated electronically using SAEM and FRIEDA residency information websites. Data collected included program format, hospital size and volume, rotation durations, curriculum and electives offered. RESULTS: The most common format (72%, n = 87) is PGY 1, 2, 3 and PGY 2, 3, 4 accounted for 18% (n = 22) and PGY 1, 2, 3, 4 for 10% (n = 12). The average length of training in the ED is 19 months (range 7-40). Average general pediatric training is 1.8 months (range 0-5). The average number of rotations outside the primary site is 4.9 (range 0-19) and elective rotation time and topics varied considerably. Opportunities for air medical training differed by program format (82% of PGY 1-3, 79% of PGY 1-4, 75% of PGY 2-4) (table 11-1). CONCLUSIONS: There is substantial variation in curriculum, in subspecialty exposure, and in opportunity for electives for residents depending on program format and location.

Resident procedure and resuscitation tracking is an onerous task required for residency accreditation and for future hospital privilege applications by the resident. To date, most tracking systems have been somewhat cumbersome and prone to data loss (forms not being filled out, recorded, etc.). Our residency program uses a palm computer database tracking system utilizing Palm III (3Com) hardware and a custom written data collection form utilizing an inexpensive, commercially available software package (Pendragon Forms (version 2), Pendragon Software Corporation, Libertyville, IL). Every resident receives a Palm III on entry into the residency. Residents enter basic demographic data and record procedures and resuscitations into the Palm III after each encounter. Generally, each patient logged requires approximately one minute for data entry. On a frequent basis, the resident's Palm is 'HotSync-ed' and the recorded data transferred to the program's central computer. Resident data are easily manipulated and reports are generated using a common, relational database program (Access97, Microsoft Corporation, Redmond, WA). We have found this system to be relatively inexpensive, to improve data capture, to reduce demands on secretarial time, and to allow improved tracking of resident procedure and resuscitation experiences.

The majority of skin trauma incidents cause minor injury that can be treated effectively in the outpatient setting. A new approach to the closure of skin lacerations using tissue adhesive is presented and the current management of abrasions, blisters, burns, skin tears, and subungual hematomas are reviewed. An overview of wound dressings is provided to assist in obtaining the optimal wound-healing environment.

Methemoglobinemia is a rare cause of cyanosis in pediatric patients. A 16-month-old male presented to the Emergency Department cyanotic and short of breath after ingestion of a hair-care-equipment cleaning solution. After calling the salon and consulting Poisindex, the substance was found to be Mar-V-cide, containing 20% Hyamine 3500, 50% cationic detergents, 20% isopropyl alcohol, and 1% sodium nitrite, which caused the methemoglobinemia in this case. Initial pulse oximetry on room air was 72% and improved minimally with supplemented oxygen. The patient's methemoglobin level was 63%. Methylene blue was administered (2 mg/kg intravenously), and the patient rapidly improved. Nitrates occur in high concentrations in some food and water. Infants are particularly susceptible to chronic nitrate-induced methemoglobinemia because of their low stomach acid production, large numbers of nitrite-reducing bacteria, and the relatively easy oxidation of fetal hemoglobin. Acute nitrite toxicity results from industrial exposure, accidental ingestion (e.g., abuse of organic nitrites as an aphrodisiac, especially in the male homosexual population), and suicidal ingestion. Methemoglobinemia may occur in a number of drug or chemical ingestions, but a comprehensive review of the literature failed to identify a similar reported case.

5'-Methylthioadenosine (MTA), a naturally occurring nucleoside, inhibited in vitro colony formation by murine erythroid (CFU-E) and granulocyte-macrophage (CFU-GM) progenitor cells in a dose-dependent fashion with maximal inhibition at concentrations of 2 X 10(-3) M and 1 X 10(-4) M, respectively. The inhibitory effect was reversible after up to 8 h of exposure to MTA but was irreversible after 24 h. MTA also inhibited hematopoietic progenitors in vivo. In mice given daily intraperitoneal injections of MTA for 28 days, CFU-GM were maximally reduced on day 14 to 51% of control. CFU-GM returned toward control levels by day 28 despite the continued administration of MTA. Hematocrit and leukocyte count were not reduced until day 28 and then only to 90% and 70% of control, respectively. MTA reached peak plasma levels of 2.8 X 10(-5) M 5 min after a single intraperitoneal injection of 75 mg/kg and was almost completely cleared by 60 min. These findings indicate that MTA produces reversible inhibition of murine hematopoietic progenitors both in vitro and in vivo. Despite the inhibitory effect on progenitors there is little effect on peripheral blood counts, which suggests that MTA inhibits hematopoietic proliferation without affecting hematopoietic differentiation.

The effect of 5'-deoxy-5'-methylthioadenosine (MTA) on the growth of culture murine lymphoid cells was examined. MTA inhibited the growth of murine lymphoid cell lines of both B- and T-cell origin in a reversible, nontoxic, and dose-dependent fashion. When measured 2 days after the addition of MTA to the cells, the concentration that inhibited proliferation by 50% for MTA was about 250 muM. Cells incubated in the presence of 0.5 mM MTA for 1, 2, or 3 days were able to recover from the inhibitory effect of the nucleoside and resumed growth. Six structural analogs of MTA were also found to inhibit cell growth. Five of these analogs served as alternative substrates for MTA phosphorylase, while one, the 7-deaza analog (5'-deoxy-5'-methylthiotubercidin), was not a substrate for the phosphorylase but was a potent inhibitor of enzyme activity. Inhibition of growth by 5'-deoxy-5'-methylthiotubercidin was dose dependent (the concentration that inhibited proliferation by 50% approximately or equal to 10 muM) and at 50 muM was reversible and nontoxic.