Bowdoin Science Journal

Martina Tognato Guaqueta

From Pack to Patient: Improvising Stability in the Backcountry

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In remote and wilderness environments, injuries that are manageable in hospitals can quickly become life-threatening due to delayed access to medical care. Femur fractures are particularly dangerous because they cause severe pain and often substantial internal blood loss. Without rapid stabilization, patients may experience shock before reaching definitive treatment (Broken Femur). Considering that evacuation from remote areas may take hours or even days, effective field stabilization is critical.

In modern emergency medicine, traction splints are commonly used to stabilize femoral fractures during transport. These devices apply longitudinal traction to the injured leg, helping align bone fragments. By maintaining proper alignment, traction splints can reduce pain and limit additional bleeding, making them part of the pre-hospital care toolkit.

In wilderness settings, however, rescuers and outdoor travelers often lack access to specialized medical equipment. As a result, wilderness medicine training frequently teaches practitioners how to construct improvised traction splints using available materials, such as sticks or clothing. 

wilderness traction splint showing the lower leg
Stick to It: Mastering the Art of Improvised Splint Techniques. Retrieved May 3, 2026, from https://www.sixptsurvival.com/post/stick-to-it-mastering-the-art-of-improvised-splint-techniques

Despite their widespread use in training, surprisingly little empirical research has evaluated the effectiveness of traction splints in prehospital care. Even fewer studies have examined whether improvised traction splints can generate adequate traction or provide stability comparable to commercially manufactured devices (Weichenthal et al., 2012). This lack of evidence raises an important question for wilderness medicine practitioners: can improvised traction splints function as reliable alternatives when commercial equipment is unavailable?

To address this question, Weichenthal and colleagues conducted a pilot study comparing an improvised traction splint with three commercially available devices. The researchers designed a prospective randomized crossover study involving 10 healthy volunteers. Each participant tested all four splints, allowing the researchers to directly compare device performance.

Participants were placed in four traction splints in randomized order: the Hare traction splint, the Sager splint, the Faretech CT-EMS splint, and an improvised traction splint constructed using standard wilderness first aid techniques. Each device remained in place for 30 minutes before measurements were taken.

Three types of femur traction splints
Three types of traction splints were used as comparisons for the improvised traction splint. Illustration by Martina Toganto Guaqueta

The primary outcome measured in the study was the amount of traction force generated after 30 minutes. Traction force was measured in pounds to determine whether each splint produced clinically appropriate levels of traction. Researchers also assessed outcomes related to patient experience. After each trial, participants rated the comfort and stability of the splint on a scale from 1 to 10 and reported any side effects, such as pain or numbness.

The results showed that all four devices generated similar traction forces, ranging from 10.4 to 13.3 pounds. These values fall within the commonly recommended guideline of approximately 10 percent of a patient’s body weight, indicating that each device produced clinically adequate traction (Davis et al., 2026). Importantly, the improvised traction splint performed comparably to the three commercial splints in this primary measure.

Participants’ subjective ratings also showed minimal differences among the devices. Comfort and stability scores were similar across all four splints, suggesting that the improvised splint did not compromise the user experience. Side effects, including mild discomfort and occasional numbness, were reported with every splint tested. However, these effects were not unique to the improvised device; in fact, the improvised splint produced fewer reported side effects than some commercial splints.

Although these findings suggest that improvised traction splints may be effective, several limitations must be considered. First, the study included only 10 participants, limiting the statistical power and generalizability of the results. Larger studies would be needed to confirm these findings. Additionally, the participants were healthy volunteers rather than patients with actual femur fractures. In real injuries, pain, swelling, and muscle spasms could influence both splint performance and patient comfort. The study was also conducted in a controlled environment, not during an actual wilderness scenario. In practice, splints may remain in place for extended periods while patients are transported across uneven terrain or exposed to harsh environmental conditions. These factors could affect how effective the improvised devices are.

Despite these limitations, the study provides preliminary evidence that improvised traction splints can generate traction comparable to commercial devices while maintaining similar levels of comfort and stability. In the back country, where access to specialized equipment may be limited, the ability to improvise effective stabilization methods is an essential skill. Further research involving patients with actual femur fractures, larger participant groups, and real evacuation scenarios would help clarify the clinical effectiveness of improvised traction splints. Nevertheless, this pilot study suggests that when commercial devices are unavailable, improvised traction splints may serve as a practical and potentially effective tool for stabilizing femur fractures in wilderness settings.

 

This article is based on Lori Weichenthal’s Improvised Traction Splints: A Wilderness Medicine Tool or Hindrance?. 

 

References:

Broken Femur: Causes, Symptoms, and Treatment. (n.d.). Cleveland Clinic. Retrieved May 3, 2026, from https://my.clevelandclinic.org/health/diseases/22299-broken-femur

Davis, D. D., Ginglen, J. G., Kwon, Y. H., & Kahwaji, C. I. (2026). EMS Traction Splint. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK507842/

Stick to It: Mastering the Art of Improvised Splint Techniques. (n.d.). Retrieved May 3, 2026, from https://www.sixptsurvival.com/post/stick-to-it-mastering-the-art-of-improvised-splint-techniques

Weichenthal, L., Spano, S., Horan, B., & Miss, J. (2012). Improvised Traction Splints: A Wilderness Medicine Tool or Hindrance? Wilderness & Environmental Medicine, 23(1), 61–64. https://doi.org/10.1016/j.wem.2011.12.005

 

An Eight-Week Shot at Equality: Advancing Male Hormonal Contraceptives

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For decades, contraceptive responsibility has largely fallen on women. While multiple hormonal birth control methods exist for females, options for men remain limited to condoms or vasectomy. With vasectomy being considered a more permanent choice, the tubes are charged with moving the sperm from the testes to the head of the penis.  This imbalance has prompted researchers to explore hormonal contraceptives for men that temporarily suppress sperm production without permanently affecting fertility. One promising approach involves injectable hormone combinations that can reduce sperm counts while maintaining normal hormone levels in the body.

Male hormonal contraceptives work by disrupting the hormonal signals that regulate sperm production. Under normal conditions, the hypothalamus and pituitary release luteinizing hormone (LH)(What Is Luteinizing Hormone?) and follicle-stimulating hormone (FSH) (Follicle-Stimulating Hormone (FSH): What It Is & Function), which stimulate the testes to produce testosterone and sperm. Introducing external hormones interferes with this process through negative feedback. The higher levels of hormones inhibit further production.  Gu et al. , used testosterone undecanoate (TU), a long-acting form of testosterone, together with depot medroxyprogesterone acetate (DMPA), a progestin that further suppresses gonadotropin production. The DMPA is the same hormone found in the commonly used female contraceptive known as the depot shot (Depot Medroxyprogesterone Acetate and Bone Effects). This dual-hormone strategy reduces sperm production while maintaining circulating testosterone levels necessary for normal male physiology. 

Gu et al. investigated whether combining TU and DMPA could provide an effective injectable contraceptive. Their Phase I open-label clinical trial included 30 healthy Chinese men, divided into three treatment groups: TU alone, TU with a low dose of DMPA, and TU with a higher dose of DMPA. The study took place over an eight-week baseline period, followed by 24 weeks of hormone treatment, and finally a 24-week recovery phase after treatment ended. During this time, researchers monitored sperm counts and hormone levels to assess both effectiveness and safety. 

To evaluate whether the treatment could function as a contraceptive, researchers monitored sperm concentration for slightly over a year. Azoospermia refers to the complete absence of sperm in semen, while severe oligozoospermia describes extremely low sperm counts. Both conditions significantly reduce the likelihood of fertilization and are commonly used as indicators of contraceptive effectiveness. 

The results showed that the combination of TU and DMPA suppressed sperm production more effectively than testosterone alone. Nearly all participants receiving the dual-hormone regimen reached azoospermia or severe oligozoospermia, while two individuals in the TU-only group experienced a rebound in sperm concentration. Importantly, sperm production returned to normal levels during the recovery phase, suggesting that the contraceptive effect was reversible. 

These findings support the growing interest in dual-hormone male contraceptive strategies, mirroring the already existing female contraceptives. By combining an androgen with a progestin, researchers were able to suppress sperm production more consistently than with testosterone alone. The eight-week injection interval may also make this approach practical, as longer dosing intervals are generally easier for patients to maintain.

However, several limitations remain. The small sample size restricts the ability to generalize the results, and the relatively short duration prevents researchers from fully evaluating long-term safety. The study also did not track pregnancy outcomes directly, and instead relied on sperm counts as a proxy for contraceptive effectiveness. Additionally, because the participants were drawn from a single demographic group, hormonal responses may differ in more diverse populations. 

Despite these limitations, the study represents an important step toward expanding male contraceptive options. A reliable injectable contraceptive lasting several weeks could help shift contraceptive responsibility toward a more equitable model of family planning. Consequent research will likely focus on larger clinical trials, optimizing hormone dosages, and testing alternative progestins to further improve effectiveness and acceptability.

Ultimately, advances in male hormonal contraception could transform how couples approach birth control. By providing men with a safe and reversible contraceptive option, these approaches may move reproductive decision-making toward a more shared responsibility.

 

This article is based on Yi-qun Gu’s Male Hormonal Contraception: Effects of Injections of Testosterone Undecanoate and Depot Medroxyprogesterone Acetate at Eight-Week Intervals in Chinese Men. 

 

References:

BuzzRx. (2022, November 28). How Would Male Birth Control Work? [Post]. buzzrx.com. (How Would Male Birth Control Work?). BuzzRx. https://www.buzzrx.com/blog/how-would-male-birth-control-work

Depot Medroxyprogesterone Acetate and Bone Effects. (n.d.). Retrieved May 3, 2026, from https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2014/06/depot-medroxyprogesterone-acetate-and-bone-effects

Follicle-Stimulating Hormone (FSH): What It Is & Function. (n.d.). Retrieved May 3, 2026, from https://my.clevelandclinic.org/health/articles/24638-follicle-stimulating-hormone-fsh

Gu, Y., Tong, J., Ma, D., Wang, X., Yuan, D., Tang, W., & Bremner, W. J. (2004). Male Hormonal Contraception: Effects of Injections of Testosterone Undecanoate and Depot Medroxyprogesterone Acetate at Eight-Week Intervals in Chinese Men. The Journal of Clinical Endocrinology & Metabolism, 89(5), 2254–2262. https://doi.org/10.1210/jc.2003-031307

What Is Luteinizing Hormone? (n.d.). Cleveland Clinic. Retrieved May 3, 2026, from https://my.clevelandclinic.org/health/body/22255-luteinizing-hormone

Rethinking Fluids in Pediatric Septic Shock: Early Adrenaline Instead of More Fluid

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Septic shock is a severe complication of infection in which the body’s immune response becomes dysregulated. Those in septic shock experience impaired circulation, poor tissue perfusion, and ultimately organ dysfunction (What Is Septic Shock?). In pediatric patients, septic shock remains a major cause of critical illness, with mortality rates estimated between 17–32%. Pediatric cases often present differently from adult cases, most notably, children decompensate very fast and have a “cold shock” presentation. This means that rather than the vasodilation characteristic of “warm shock,” they experience low cardiac output and high vascular resistance. Essentially, children will appear stable, then quickly nosedive (Condition Topics). 

To improve oxygen delivery to tissues and restore circulating blood volume, current treatment guidelines advocate rapid fluid resuscitation with 40–60 mL/kg of intravenous fluids in the first hour of sepsis and treatment. Interestingly, there is little evidence to support this guideline, and growing observational data indicate that excessive fluid administration may worsen outcomes, including increased mortality and the need for respiratory assistance. The guideline itself is based on an adult model; however, it does not translate to a pediatric situation. Alternative resuscitation techniques are becoming more popular as a result of these worries, especially if starting vasoactive drugs earlier could lessen the requirement for large fluid quantities while preserving hemodynamic stability. Hemodynamic stability refers to stable blood pressure, flow, and adequate oxygen delivery. 

To investigate whether earlier initiation of vasoactive support could reduce fluid exposure in pediatric septic shock, Harley et al. conducted the Resuscitation in Pediatric Sepsis Randomized Controlled Pilot Platform Study in the Emergency Department  (RESPOND ED). This was an open-label, randomized controlled study in four pediatric emergency departments throughout Australia. The trial was made up of  40 children with septic shock, ranging from 28 days to 18 years. 

Children in the early-adrenaline group received an initial 20 mL/kg fluid bolus followed by early initiation of adrenaline. On the other hand, the standard-care group received 40–60 mL/kg of fluid resuscitation before administering medications that force the heart to contract (inotropes), consistent with current guidelines. A fluid bolus is the rapid administration of intravenous fluids. The primary aim of the study was to evaluate the feasibility of future related studies, while an exploratory outcome measured 28-day survival free of organ dysfunction.

This study demonstrated that the protocol was feasible. Adrenaline was given significantly earlier in the intervention group (~16 minutes) compared with the standard-care group (~49 minutes), which resulted in reduced fluid exposure. The early-adrenaline group received no additional fluid beyond the initial amount administered, while the standard-care group received around 20 mL/kg more fluid within the first 24 hours. 

Clinical outcomes were similar between groups, with no mortality observed, comparable organ dysfunction–free days, and similar pediatric intensive care unit (PICU) admission rates and length of stay. Importantly, the intervention appeared safe, with no serious adverse events, such as extravasation injuries or limb ischemia associated. These circulation-based conditions are common side effects of peripheral adrenaline administration.

The RESPOND ED pilot trial demonstrates that an early-adrenaline, fluid-sparing resuscitation strategy is feasible and safe in pediatric emergency departments. While the study was not made to detect differences in mortality or major clinical outcomes, it showed that clinicians can successfully initiate vasoactive support earlier and reduce overall fluid exposure without increasing adverse events. These findings challenge the long-standing fluid-first treatment approach and suggest that earlier hemodynamic support may be a viable alternative approach. Future research will need to build on these results through larger trials, optimized dosing strategies, and broader patient populations to better determine whether early vasoactive therapy can improve outcomes and better define treatment guidelines for pediatric septic shock.

 

This article was based on Amanda Harley’s Early Resuscitation in Paediatric Sepsis Using Inotropes – A Randomised Controlled Pilot Study in the Emergency Department (RESPOND ED): Study Protocol and Analysis Plan. 

 

References 

Condition Topics. (n.d.). Yale Medicine. Retrieved May 3, 2026, from https://www.yalemedicine.org/conditions

Harley, A., George, S., King, M., Phillips, N., Keijzers, G., Long, D., Gibbons, K., Bellomo, R., & Schlapbach, L. J. (2021). Early Resuscitation in Paediatric Sepsis Using Inotropes – A Randomised Controlled Pilot Study in the Emergency Department (RESPOND ED): Study Protocol and Analysis Plan. Frontiers in Pediatrics, 9, 663028. https://doi.org/10.3389/fped.2021.663028

What Is Septic Shock? (n.d.). Cleveland Clinic. Retrieved May 3, 2026, from https://my.clevelandclinic.org/health/diseases/23255-septic-shock

When Distraction Helps: Music as a Tool for Focus in ADHD Cases

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Attention Deficit Hyperactivity Disorder (ADHD) is a developmental disorder that is characterized by inattention, hyperactivity, and impulsivity. This is one of the most common learning disorders diagnosed in children. ADHD not only takes a toll on an individual’s academic sphere but also their social sphere(Martin-Moratinos et al., 2023). From struggling to focus in class to having their impulsiveness affect their interpersonal relationships, symptoms permeate children’s worlds. The diagnosis process includes a variety of tests, interviews, questionnaires, and, in children, observation(ADHD Screening). For example, the Wechsler Intelligence Scale for Children-Revised (WISC-R), developed in 1974, is a test that attempts to measure intelligence through testing 10 abilities. This test, among others, such as the Wide Range Achievement Test-Revised (WRAT), was used in the diagnostic process for the participants in Abikoff et al. (1996). 

 

In 1983, Andries Frans Sanders proposed the underaroused theory in the Cognitive-Energetic Model. The theory stated that those with ADHD have abnormally low levels of physiological arousal and, in turn, seek out input via hyperactivity(Sanders, 1983). Abikoff et al. sought to use music as a high salience extra task stimulation to investigate this theory. This study assessed the impact of music on the arithmetic performance of a group of 40 second graders with ADHD. The theorized goal was to reach an optimal level of arousal(1996). They assessed this by giving the group of 40 boys an arithmetic test to match their ability and having them complete it in different conditions. Rather than just silence or music, researchers added a speech condition. Students were subjected to three arithmetic tasks of the same difficulty. The first test was done with 10 minutes of their 3 favorite songs on loop, the second was 10 minutes of background speech, and the third and final test was 10 minutes of silence. 

 

Through these results, researchers concluded that music was the ideal condition for kids with ADHD. This iteration of testing resulted in an accuracy of 82%, compared to 77% for speech and 79% for silence. Furthermore, when looking at the testing results of the control group, which was made up of non-disabled students at the same grade level, it was revealed that changes in condition did not affect their performance. A nuance that came to the surface through the analysis was that the effects of the conditions were order-dependent. Children who had music as their first condition had more than twice as many correct answers as those who had music as their second or third test condition. 

 

These results lend support to the under-arousal theory. Distractibility is often a characteristic thought to be heightened in those with ADHD, and is often attributed to extra stimuli that are not related to the work they are assigned. However, Abikoff et al. offer a counter to this. Using this study as a tool, focused facilitation strategies can be developed to better support students with ADHD. 

 

Despite the strengths of this study, it is also important to address some key limitations. It is worth glancing at the limitations of the study itself. Since this study took place in 1996, it is important to consider more recent developments in ADHD research. This could result in theories being disproved. However, even recent studies seem to support the idea that music can help with focus in ADHD patients (Martin-Moratinos et al., 2023). For example, Madjar et al showed improved reading scores in students with ADHD when exposed to music while reading(2020). Additionally, the presence of the following studies aids in the fact that the study had a relatively small sample size (40 participants), and they were all boys. Because Abikoff et al. (1996) only studied boys, it’s hard to know whether the same pattern would hold for girls with ADHD, especially since girls tend to show fewer outward hyperactive symptoms and more subtle, internalized ones. However, later work that did include girls—like Madjar et al. (2020), who tested mixed-gender preadolescents—also found that music boosted performance for students with ADHD. This suggests that the helpful effect of music isn’t limited to boys, even if the way it supports attention might look a little different across genders.

 

Ultimately, the management of ADHD in and out of the classroom requires an individualized, holistic approach. The demonstration of music as a coping mechanism can usher it into becoming a tool in treatment plans. In the same spirit, further development of this finding could lead to additional understandings of the impact of other types of stimuli (visual, tactile, or olfactory) on ADHD management. Overall, the study’s results open the door to using music not just as background noise, but as a strategic tool for cultivating focus in children with ADHD. As researchers expand this work—with larger, mixed-gender samples and broader types of sensory stimulation—we move closer to individualized interventions that address the whole child, both inside and outside the classroom. 

 

 

References:

Abikoff, H., Courtney, M. E., Szeibel, P. J., & Koplewicz, H. S. (1996). The effects of auditory stimulation on the arithmetic performance of children with ADHD and nondisabled children. Journal of Learning Disabilities, 29(3), 238–246. https://doi.org/10.1177/002221949602900302 

ADHD Screening: What To Expect. (n.d.). Cleveland Clinic. Retrieved December 24, 2025, from https://my.clevelandclinic.org/health/diagnostics/24758-adhd-screening 

Everything You Need to Know About ADHD. (n.d.). Retrieved December 24, 2025, from https://www.adhdevidence.org/blog/everything-you-need-to-know-about-adhd 

Madjar, N., Gazoli, R., Manor, I., & Shoval, G. (2020). Contrasting effects of music on reading comprehension in preadolescents with and without ADHD. Psychiatry Research, 291, 113207. https://doi.org/10.1016/j.psychres.2020.113207 

Martin-Moratinos, M., Bella-Fernández, M., & Blasco-Fontecilla, H. (2023). Effects of Music on Attention-Deficit/Hyperactivity Disorder (ADHD) and Potential Application in Serious Video Games: Systematic Review. Journal of Medical Internet Research, 25, e37742. https://doi.org/10.2196/37742 

Sanders, A. F. (1983). Towards a model of stress and human performance. Acta Psychologica, 53(1), 61–97. https://doi.org/10.1016/0001-6918(83)90016-1

Timing Matters: How the menstrual cycle influences ACL injury in Female athletes

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The knee, one of the major joints of the body, powers athletes in their endeavors; it is made up of three bones (the femur, tibia, and fibula), which are scaffolded by a milieu of muscles and ligaments. Injuries most often occur on this scaffolding. A particularly devastating injury is the tear or partial tear of the anterior cruciate ligament (ACL). This ligament is tasked with holding the femur and the tibia together and preventing excessive rotation and forward slipping. ACL tears happen when an individual pivots or puts too much sideways pressure on the knee(Knee Joint).

Unfortunately, female athletes are disproportionately affected by this injury in comparison to their male counterparts. In part, it is due to anatomical differences in the alignment of the leg bones. For example, female pelvises tend to be wider, which increases the Q-angle (the angle between the quadriceps and the patellar tendon). This predisposes the knee to collapse inward and give way to ACL tears. However, this is not the only factor on a small scale; hormones are also to blame. In turn, it seems as though the menstrual cycle has an impact on the ACL’s propensity for injury in women(Why Do Young Female Athletes Face Higher Risk for ACL Injuries?).

 

The menstrual cycle is a 28-day hormonal cycle that governs female reproduction. It is made up of 3-4 phases: menstrual, follicular, ovulation, and luteal. The follicular phase and the menstrual cycle are often grouped. Throughout the cycle, different hormones ebb and flow. The main ones are FSH (follicle-stimulating hormone), LH (luteinizing hormone), estrogen, elastin, and progesterone. These are all hormones that are responsible for moving the menstrual cycle along, ranging from the release of the egg from the ovary to the thickening of the endometrium. For example, estrogen is responsible for triggering the thickening of the uterine lining and the release of the egg from the ovary (Wojtys et al., 1998). 

(Menstrual Cycle | Description, Phases, Hormonal Control, Ovulation, & Menstruation | Britannica)

Wojtys et al. investigated whether the menstrual cycle phase actually had anything to do with ACL tear risk, especially since most earlier studies focused only on structural differences between male and female knees. The athletes they studied were mostly in their mid-20s and played sports like soccer, basketball, volleyball, track, gymnastics, and skiing—all activities where non-contact ACL tears are common. Each woman filled out a questionnaire that asked about her menstrual cycle (things like typical cycle length, when her last period started, whether she used birth control, and whether her cycles were regular) as well as the exact situation in which the injury happened. Only women with consistent, regular cycles were kept in the sample, which left them with 29 usable responses (1998).   

 

What they found from all this was a clear correlation between menstrual cycle timing and ACL injury, with women most likely to tear their ACL during the ovulation phase, which is when relaxin and estrogen peak. As the name suggests, relaxin is responsible for the relaxation of ligaments and tendons. Outside of the uterus, estrogen is also responsible for the reduction of ACL tensile strength and an increase in laxity. Similarly, relaxin causes a restructuring of collagen, which is theorized to play a role in the susceptibility to ACL injury. (Relaxin.; Wojtys et al., 1998)

 

An interesting note is that women on oral contraceptives seemed to have lower injury rates. Birth control’s mechanism is stopping ovulation (the phase in which most injuries were observed). Hormonal birth control keeps estrogen levels much more stable by preventing the mid-cycle estrogen surge, so instead of a sharp spike during ovulation, estrogen stays at a steadier and lower baseline. Since that spike is linked to increased ligament laxity, this hormonal stabilization may help reduce the ACL’s vulnerability to injury(Wojtys et al., 1998).

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This study provides support for the theory that part of the increased likelihood of females for ACL injury, in addition to the mechanical theory, brings forth a hormonal argument. It is worth noting the limitations of the study, however. These are also discussed in the literature itself. The main issue is the accuracy of the self-report. The women were asked at what point they were in their menstrual cycle, as there was no official tracking, there may be inconsistencies here. Moreover, the range in age and level of activity is quite large, especially in such a small sample size (29 individuals). 

 

This type of study can be part of the picture in injury prevention for athletes. ACL tears in particular, are quite devastating injuries. These season enders take 9-12 months to fully heal, in turn barring return to a competitive sport for an extended period of time (Writers, 2021). The consideration of hormonal fluctuations affecting ACL tears can influence training strategies and open the door to understanding oral contraceptives as a preventative measure. 

 

Further directions expanding upon this study could be looking at the menstrual cycle in a more controlled manner, in addition to looking at other connective tissue injuries. Ultimately, the mechanism of soft tissue can be better understood with a deeper view into alternative factors such as hormonal shifts.

 

References

BCOS. (2023, May 23). What is an ACL Injury? | Symptoms, Causes, & Treatments | BCOS. Burlington County Orthopaedic Specialists P.A. https://burlingtoncountyortho.com/blog/what-is-an-acl-injury/ 

Knee Joint: Function & Anatomy. (n.d.). Cleveland Clinic. Retrieved December 24, 2025, from https://my.clevelandclinic.org/health/body/24777-knee-joint 

Menstrual cycle | Description, Phases, Hormonal Control, Ovulation, & Menstruation | Britannica. (n.d.). Retrieved December 24, 2025, from https://www.britannica.com/science/menstrual-cycle 

Relaxin: Hormone, Production In Pregnancy & Function. (n.d.). Cleveland Clinic. Retrieved December 24, 2025, from https://my.clevelandclinic.org/health/body/24305-relaxin 

Why Do Young Female Athletes Face Higher Risk for ACL Injuries? (n.d.). Retrieved December 24, 2025, from https://www.cedars-sinai.org/newsroom/why-do-young-female-athletes-face-higher-risk-for-acl-injuries/ 

Wojtys, E. M., Huston, L. J., Lindenfeld, T. N., Hewett, T. E., & Greenfield, M. L. (1998). Association between the menstrual cycle and anterior cruciate ligament injuries in female athletes. The American Journal of Sports Medicine, 26(5), 614–619. https://doi.org/10.1177/03635465980260050301 

Writers, Uch. (2021, October 14). How long is recovery time from an ACL tear? UCHealth Today. https://www.uchealth.org/today/acl-tears-how-long-does-it-take-to-recover-and-return-to-sports/

POTS vs Atomoxetine: The Unseen Interaction

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Postural Orthostatic Tachycardia Syndrome (POTS) is a malfunction in the body’s autonomic nervous system. Rather than the blood vessels below their heart compensating by constricting, when a person with POTS goes from a lying to a standing position, a large amount of blood pools in the legs and abdomen. Normally, the blood vessels in the lower extremities constrict to maintain appropriate blood pressure throughout the whole body and help return the blood to the heart and head. The autonomic system (the part of the nervous system that is in charge of the involuntary aspects of the body) responds to low blood pressure by releasing norepinephrine and adrenaline, which cause vasoconstriction and a rise in heart rate. In POTS patients, vessels do not respond to the hormones and remain vasodilated. This combination of high heart rate and insufficient blood flow to the brain causes characteristic dizziness, fainting, and fatigue. POTS can be aggravated by a variety of things, including strenuous exercise, caffeine, hot environments, and certain medications (POTS, n.d.). 

One such class of medications is norepinephrine reuptake inhibitors (NOIs). Used to treat ADHD, major depressive disorder, and narcolepsy, NOIs block the uptake of norepinephrine in the synapses (De Crescenzo et al., 2018). This type of medication allows norepinephrine to stay in the blood longer, elevating mood and energy levels and enhancing focus. A common side effect is an elevated heart rate, which aggravates POTS. 

Green et al. conducted the first study examining the acute effects of atomoxetine on POTS patients. The study was composed of 27 patients and a variety of tests. A baseline was created to manage the patients’ diets. This entailed removing methylxanthines from their diet, which includes caffeine among other compounds, and moderating sodium and potassium intake. Additionally, all long-term medications were suspended for at least 5 half-life periods to ensure no hormonal effects would be present. All of these measures were taken to minimize the exacerbation of POTS symptoms (Green et al., 2013). 

All patients received the atomoxetine and the placebo (on different days). During this time, a posture study was done. Measurements of heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), and plasma catecholamines were taken during a lying position and a standing position. This targets the effects of POTS, highlighting the possible impact of the atomoxetine. 

The posture study was paired with the medication study. During the medication study, patients were asked to fill out a symptom feedback form before the experiment, and every hour up to 4 hours after drug administration. This is because peak atomoxetine concentration occurs 1-2 hrs after ingestion. The Vanderbilt Orthostatic Symptom Score (VOSS) was used on the symptom feedback form, where patients are asked to rank the following on a scale from 1-10: mental clouding, brain fog, shortness of breath, palpitations, tremors, headache, tightness in the chest, blurred vision, and nausea. The lowest (1) is no symptom burden, and 10 is the worst. 

Researchers found that when patients took atomoxetine, their symptom burden increased. This presented a statistically significant increase in heart rate and a general upward trend in blood pressure throughout the 4 hours. In the case of the placebo, there was a decrease in symptom burden as the 4-hour period progressed. 

Atomoxetine is a non-stimulant medication used to treat ADHD; unfortunately, the stimulant alternatives are found to have similar effects on POTS patients. Due to a susceptibility to heart rate changes, ADHD medication negatively interacts with the condition and must be administered with exceeding caution. This interaction is important for prescribing professionals to be aware of. As this is a relatively under-researched intersection, consideration of mechanisms and close patient-doctor communication is necessary when considering medication. 

Figure 1: Results of VOSS with and without atomoxetine (Green et al., 2013)

Graph describing the effects of the medication on POTS symptoms

References

De Crescenzo, F., Ziganshina, L. E., Yudina, E. V., Kaplan, Y. C., Ciabattini, M., Wei, Y., & Hoyle, C. H. (2018). Noradrenaline reuptake inhibitors (NRIs) for attention deficit hyperactivity disorder (ADHD) in adults. The Cochrane Database of Systematic Reviews, 2018(6), CD013044. https://doi.org/10.1002/14651858.CD013044

Green, E. A., Raj, V., Shibao, C. A., Biaggioni, I., Black, B. K., Dupont, W. D., Robertson, D., & Raj, S. R. (2013). Effects of norepinephrine reuptake inhibition on postural tachycardia syndrome. Journal of the American Heart Association, 2(5), e000395. https://doi.org/10.1161/JAHA.113.000395

POTS: Causes, Symptoms, Diagnosis & Treatment. (n.d.). Cleveland Clinic. Retrieved April 8, 2025, from https://my.clevelandclinic.org/health/diseases/16560-postural-orthostatic-tachycardia-syndrome-pots

 

TMJ Arthroscopy: How well does it work in Ehlers Danlos patients?

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The temporomandibular joint (TMJ) is responsible for the mandible’s chewing, talking, and all movement. As a condylar joint, this joint allows motion in two planes: side to side and up and down. A disc cushions the bone to facilitate this motion and serves as a lubricant. 

 

Figure 1: TMJ diagram (TMJ Disorders – Symptoms and Causes, n.d.).

 Temporomandibular disorders (TMD) often arise from damage or irritation relating to the disc. To determine the condition of the joint, physicians use the Wilkes scale, which allows for the assessment of internal derangement/damage of the TMJ. TMD is often a symptom of a larger condition, it can arise from connective tissue disorders, injury, teeth grinding, etc.

 

Figure 2: Wilkes Scale descriptive table (Table 1 . Wilkes Classification of TMJ Internal Derangement, n.d.)

 

 

A patient’s placement on this scale indicates the type of treatment they could be a candidate for.  This could range from over-the-counter medications to physical therapy, to Botox injections, and a variety of surgeries. A surgery often seen is a TMJ arthroscopy.  The arthroscopic element refers to the minimally invasive approach assisted by a camera called an arthroscope. Done under general anesthesia, a surgeon will enter the joint space through a small incision. The image of the joint is delivered to a screen through an arthroscope. During the procedure, the surgeon may reposition the disc, flush the joint, and remove scar tissue to alleviate pain (Arthroscopy for Temporomandibular Disorders (TMDs) | Kaiser Permanente, n.d.). This, however, is not the only option, and can only be decided upon looking at the full picture of a patient’s history—for example, a connective tissue disorder. 

Ehlers-Danlos (EDS) is a group of connective tissue disorders that can affect many systems, including the joints and, in turn, the TMJ.  Within the group, each particular variation has a different set of symptoms. For example, vascular EDS causes the blood vessels to rupture, whereas hypermobile EDS (hEDS) causes frequent joint dislocations. Some types of EDS have a clear genetic link, however, the origins of hEDS have yet to be understood. Due to the overly flexible nature of their joints, hEDS patients often encounter issues with their TMJ.  (Ehlers-Danlos Syndrome – Symptoms and Causes, n.d.).

Jerjes et al. conducted a retrospective case study that looked at the outcomes of 18 hEDS patients who underwent arthroscopic surgery to treat their TMDs. All patients were female and between the ages of 23-60 years old. Due to the EDS, TMJ dislocation was a common history within the sample. In turn, the dislocations were linked to the damage and pain, which were visualized during the arthroscopies. This demonstrated a link between the state on the TMJ and hEDS status. Moreover, 12 out of the 18 experienced TMD bilaterally, meaning there was pain on both sides (Jerjes et al., 2010). 

Furthermore, it seemed as though the intervention was most commonly done at/by the Wilkes Stage III (9 patients at Stage III and 5 at Stage II ). As seen in Figure 2, Stage III is characterized by moderate disc deformity and frequent pain/dislocations.  As the Wilkes Scale goes on, the condition becomes more painful and harder to treat. However, although minimally invasive, arthroscopy is considered a more extreme treatment for TMJ. Over the years, the procedure has developed and improved, reaching an 80-90% success rate (Insel et al., 2020). Despite this, the National Institute of Dental and Craniofacial Research brochure still has a negative outlook on the surgical route as a treatment for TMDs (Jerjes et al., 2010). 

Notwithstanding the controversy, Jerjes et al. demonstrate positive post-operative results. The pain subsided quickly (within 1 week post-operative) for 15 out of 18 patients and 5-6 weeks for the remaining 3. Delayed healing occurred in 4 out of 18 patients. Slow healing is a characteristic of hEDS and could be a potential reason in this case for the post-surgical complication. Most importantly, the mouth opening measured 6 months postoperatively increased from an average of approximately 23-28 mm,  with all final postoperative results being positive. 

Overall, the study aims to illustrate the success of TMJ arthroscopy in hEDS patients and suggests it as the first consideration for invasive procedures. Due to hEDS patients often having a difficult time with wound healing, a minimally invasive procedure is favored. Additionally, these patients have previously sought out other forms of treatment before surgery. This study does not suggest that surgery should be an initial consideration, but it should not be forgotten as an option. 

 

Figure 3: Outside view of an TMJ arthroscopy 

Figure 4: Internal photo is TMJ arthroscopy

 

The hEDS population is small; therefore, studies that center on them and how treatments interact with their condition are few and far between. Moreover, providers for TMJ-related surgeries are scarce. In turn, this middle ground (as noted by Jerjes et al. ) is a neglected area of research. Further development would focus on EDS patients more and seek to understand the interconnectedness of EDS and joint pain and how it can impact the choice of treatments. 

 

References

Arthroscopy for Temporomandibular Disorders (TMDs) | Kaiser Permanente. (n.d.). Retrieved April 8, 2025, from https://healthy.kaiserpermanente.org/health-wellness/health-encyclopedia/he.arthroscopy-for-temporomandibular-disorders-tmds.hw209368

Ehlers-Danlos syndrome—Symptoms and causes. (n.d.). Mayo Clinic. Retrieved April 8, 2025, from https://www.mayoclinic.org/diseases-conditions/ehlers-danlos-syndrome/symptoms-causes/syc-20362125

Insel, O., Glickman, A., Reeve, G., Kahan, B., Tran, T., & Israel, H. (2020). New criteria demonstrate successful outcomes following temporomandibular joint (TMJ) arthroscopy. Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology, 130(1), e20–e21. https://doi.org/10.1016/j.oooo.2019.12.022

Jerjes, W., Upile, T., Shah, P., Abbas, S., Vincent, A., & Hopper, C. (2010). TMJ arthroscopy in patients with Ehlers Danlos syndrome: Case series. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology, 110(2), e12–e20. https://doi.org/10.1016/j.tripleo.2010.03.024

Table 1. Wilkes classification of TMJ internal derangement. (n.d.). ResearchGate. Retrieved April 8, 2025, from https://www.researchgate.net/figure/Wilkes-classification-of-TMJ-internal-derangement_tbl1_7691660

TMJ disorders—Symptoms and causes. (n.d.). Mayo Clinic. Retrieved April 8, 2025, from https://www.mayoclinic.org/diseases-conditions/tmj/symptoms-causes/syc-20350941

Top Five Fun Facts About The TMJ. (2022, July 14). Ladner Village Physiotherapy | Delta BC. https://ladnervillagephysio.com/blog/top-five-fun-facts-about-the-tmj

 

Asthma and ADHD: How do Pediatricians Approach This Intersection?

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According to the CDC, 11.4% of children aged 3-17 in the USA are diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) (Data and Statistics on ADHD | Attention-Deficit / Hyperactivity Disorder (ADHD), 2024). ADHD is a developmental disorder characterized by symptoms of hyperactivity, impulsivity, and inattention, as the name suggests. Treating this disorder often requires a variety of approaches including medication, psychotherapy, and workplace or school-based accommodations (Attention-Deficit/Hyperactivity Disorder – National Institute of Mental Health (NIMH), n.d.).  Comorbidities are very common in people with ADHD, this makes it so that it is rarely the only concern during a primary care visit (Silver, 2024). Sleath et al. discuss the communication primary physicians held with families with children that have both ADHD and asthma. There has been found to be a correlation between the severity of ADHD and asthma symptoms (Blackman & Gurka, 2007). In turn, balancing treatment for both primary care visits was a driver for the paper. Asthma is a chronic lung condition that results in the narrowing of the lung pathways. Medication to alleviate symptoms of both ADHD and asthma is often prescribed at primary care visits hence the study of their intersection. 

Figure 1. Happy little girl and pediatrician doing high five after medical checkup. AAP Schedule of Well-Child Care Visits. (2023). Healthy Children.org. https://www.healthychildren.org/English/family-life/health-management/Pages/Well-Child-Care-A-Check-Up-for-Success.aspx

Sleath et al. approach this balance by studying the communication between patients with ADHD and asthma and pediatricians. The study focuses on the communication breakdown when the patient has ADHD during an asthma visit. All of these were pediatric visits. To measure the effectiveness of communication, the American Association of Pediatrics (AAP) guidelines for discussing ADHD were used. The percentage of adherence was measured through the visits using recordings. 

Before data collection eligibility tests were conducted. This made sure that all participants in the study were 8-16 years of age, could speak English, was capable of filling out an assent form, had had at least one prior visit to the clinic, had persistent asthma, and had a guardian present who is over the age of 18 and is competent in English. After the visits concluded, guardians were provided with questionnaires, and children were interviewed. These were used to supplement the recordings. 

The audio taping and coding are the backbone of the data. The audio tapes were transcribed by a coding tool that was flagged for AAP guidelines. To ensure accuracy two research assistants met twice a month to review and refine criteria. The other important aspect of the collection was a thorough socio-demographic data set: gender, age, race, insurance, and tears of asthma. All demographic data but asthma status was also recorded from guardians. 

The results yielded from this were extreme. Throughout the visits 23% of the 296 children had ADHD noted in their medical chart. It was found that boys were more likely to have ADHD diagnoses. It is important to note that it is not because ADHD affects males more, but women are less likely to get diagnosed or are diagnosed later in life due to inattentive presentations (Attoe & Climie, 2023). When understanding the extent of utilization of AAP guidelines, categories were formed; functioning, outcomes, treatment plan, ADHD asthma relationship, chronic and follow-up visits. In all of these categories, the percentage of providers that used AAP guidelines never rose above 40%. In the adherence to medication, only one provider out of the 35 discusses the topic (41 providers participated, but recording forms only 35 were usable). Overall, it was shown that AAP guidelines were more likely to be followed if the visit was unrelated to asthma, highlighting providers’ tendency to neglect proper ADHD management in patients with comorbidities. 

The aim was to highlight the need for better communication practices in the pediatric setting. Particularly in cases where comorbid conditions are present. Future development in this field would be understanding the reason behind the present communication pattern. Approaching the issue from the physician and patient perspective. On the other hand, research on how to remedy the disparity in guideline adherence. 

 

Article based on ‘Communication about ADHD and its treatment during pediatric asthma visits’

Sleath, B., Sulzer, S. H., Carpenter, D. M., Slota, C., Gillette, C., Sayner, R., Davis, S., & Sandler, A. (2014, Feb). Communication about ADHD and its treatment during pediatric asthma visits. Community Ment Health J ., 50(2), 185-192. 10.1007/s10597-013-9678-3

References

AAP Schedule of Well-Child Care Visits. (2023). Healthy Children.org. https://www.healthychildren.org/English/family-life/health-management/Pages/Well-Child-Care-A-Check-Up-for-Success.aspx

Attention-Deficit/Hyperactivity Disorder – National Institute of Mental Health (NIMH). (n.d.). National Institute of Mental Health. Retrieved November 1, 2024, from https://www.nimh.nih.gov/health/topics/attention-deficit-hyperactivity-disorder-adhd

Attoe, D. E., & Climie, E. A. (2023, March 30). Miss. Diagnosis: A Systematic Review of ADHD in Adult Women. J Atten Disord, 27(7), 645–657. 10.1177/10870547231161533

Blackman, J. A., & Gurka, M. J. (2007). Developmental and Behavioral Comorbidities of Asthma in Children. Journal of Developmental & Behavioral Pediatrics, 28(2), 92-99. 10.1097/01.DBP.0000267557.80834.e

Data and Statistics on ADHD | Attention-Deficit / Hyperactivity Disorder (ADHD). (2024, May 22). CDC. Retrieved November 1, 2024, from https://www.cdc.gov/adhd/data/index.html

Silver, L. (2024, April 3). ADHD Symptoms Or ADHD Comorbidity? Diagnosing Related Conditions. ADDitude. Retrieved November 1, 2024, from https://www.additudemag.com/when-its-not-just-adhd/

Sleath, B., Sulzer, S. H., Carpenter, D. M., Slota, C., Gillette, C., Sayner, R., Davis, S., & Sandler, A. (2014, Feb). Communication about ADHD and its treatment during pediatric asthma visits. Community Ment Health J ., 50(2), 185-192. 10.1007/s10597-013-9678-3