“Everything Is Relative,” Maybe even Absolute Contraindications
Notice bibliographique
Résumé
Dear Editor, “Infectious arthritis is the most serious contraindication to corticosteroid injection” [1]. This is what we were taught during medical school and physical medicine & rehabilitation residency, and this is what is stated in almost all the articles and textbook chapters on the use of intraarticular (IA) corticosteroid injections (CSIs). However, although injecting corticosteroids in a septic joint is contraindicated, it might also not be as catastrophic as expected. In this brief article, we will discuss how a clinical case triggered a reflection on dogma in medicine and the potential role of CSI in septic arthritis (SA). An 82-year-old woman with stage 4 metastatic breast cancer was admitted to our university hospital for atraumatic left shoulder pain for about one week. She had skin erythema and antalgic loss of shoulder range of motion. Neurovascular examination of the upper extremities was unremarkable. She was afebrile and normotensive. She had a life expectancy of less than three months, was known for multiple metastases including to the spine and pelvis, and was on a waiting list for a private palliative care facility. Upon admission at the emergency department, she refused any life-prolonging treatments but wanted relief for her left shoulder pain. A shoulder x-ray did not show any metastatic bone lesion. There were small calcifications in the rotator cuff area. The differential diagnosis included microcrystalline arthropathy, subacromial calcific bursitis, and shoulder SA. She was therefore admitted to the hospital palliative care unit. Physical medicine and rehabilitation was consulted to optimize the patient’s comfort. A bedside ultrasound (US) scan of the left shoulder with a portable Philipps Lumify device equipped with a linear 12–4-MHz probe was performed. It showed left bicipital groove as well as bursal and glenohumeral joint effusion. Moderate Doppler hypervascularity within the bursal walls was also present, in addition to a complete supraspinatus tear. These sonographic findings were most compatible with septic arthritis and bursitis with complete supraspinatus tear. The patient agreed to a US-guided joint aspiration followed by lidocaine + CSI, as she wanted rapid relief. Using an aseptic technique, 8 mL of thick and opaque blood-stained fluid was aspirated with a 21-G 1.5-inch needle from the subacromial space via the zone of complete supraspinatus tear, quickly followed by an injection of 40 mg of methylprednisolone with 4 mL of 2% lidocaine. The procedure was well tolerated, and the patient noticed a reduction in pain >50% at rest but remained symptomatic with movement in the hours after the procedure.
Récupéré en direct depuis OpenAlex et désinversé. Les résumés ne sont pas conservés dans cette base de données : les index inversés représentent 8,6 Go des 9,3 Go de texte de la base, et le serveur dispose de 13 Go libres.
Comment cette classification a été obtenuedéplier
Prédiction machine sur la base complète
Imitation des enseignantsNi prévalence calibrée, ni vérité terrain. Validation humaine à venir. Le volet Gemma est une étiquette directe du modèle pour chaque travail de la base, lue sur la notice réduite au titre. Le volet Codex est un classifieur appris des 10 348 étiquettes directes de Codex et calibré sur les taux pondérés de l'échantillon; les champs sans appui suffisant ne portent aucun appel Codex. Le mode candidate est l'union des deux volets; le consensus est leur intersection. Ces sorties portent le statut machine_predicted_unvalidated et ne sont pas des étiquettes humaines.
Scores du classifieur distillé par catégorie (deux têtes)
| Catégorie | Codex | Gemma |
|---|---|---|
| Métarecherche | 0,002 | 0,026 |
| Méta-épidémiologie (sens strict) | 0,001 | 0,001 |
| Méta-épidémiologie (sens large) | 0,002 | 0,001 |
| Bibliométrie | 0,001 | 0,001 |
| Études des sciences et des technologies | 0,001 | 0,003 |
| Communication savante | 0,003 | 0,006 |
| Science ouverte | 0,002 | 0,001 |
| Intégrité de la recherche | 0,008 | 0,015 |
| Charge utile insuffisante (le modèle a refusé de juger) | 0,007 | 0,006 |
Scores machine (provisoires)
Les deux têtes enseignantes du modèle étudiant, lues sur ce travail. Un score ordonne la base pour la relecture; il n'affirme jamais une catégorie, et le statut de validation accompagne chaque rangée tel quel.
Scores de référence d'un modèle non mature (critères de maturité non atteints, 7 itérations). Un score ordonne; il n'affirme jamais une catégorie.
score_only:v0-immature-baseline · tel quel depuis la passe de notation : score_only signifie que le nombre peut ordonner les travaux, et qu'aucune étiquette de catégorie n'en découleClassification
machine, non validéePrédiction automatique; un appel candidat d’une seule source (Gemma direct ou Codex distillé), pas un consensus.
Le détail, modèle par modèle et score par score, se trouve en fin de page sous « Comment cette classification a été obtenue ».