“Everything Is Relative,” Maybe even Absolute Contraindications
Bibliographic record
Abstract
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.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.002 | 0.026 |
| Meta-epidemiology (narrow) | 0.001 | 0.001 |
| Meta-epidemiology (broad) | 0.002 | 0.001 |
| Bibliometrics | 0.001 | 0.001 |
| Science and technology studies | 0.001 | 0.003 |
| Scholarly communication | 0.003 | 0.006 |
| Open science | 0.002 | 0.001 |
| Research integrity | 0.008 | 0.015 |
| Insufficient payload (model declined to judge) | 0.007 | 0.006 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".