Treatment of neuromyelitis optica: state-of-the-art and emerging therapies.

Neuromyelitis optica (NMO) is an autoimmune disease of the CNS that is characterized by inflammatory demyelinating lesions in the spinal cord and optic nerve, potentially leading to paralysis and blindness. NMO can usually be distinguished from multiple sclerosis (MS) on the basis of seropositivity for IgG antibodies against the astrocytic water channel aquaporin-4 (AQP4). Differentiation from MS is crucial, because some MS treatments can exacerbate NMO. NMO pathogenesis involves AQP4-IgG antibody binding to astrocytic AQP4, which causes complement-dependent cytotoxicity and secondary inflammation with granulocyte and macrophage infiltration, blood-brain barrier disruption and oligodendrocyte injury. Current NMO treatments include general immunosuppressive agents, B-cell depletion, and plasma exchange. Therapeutic strategies targeting complement proteins, the IL-6 receptor, neutrophils, eosinophils and CD19--all initially developed for other indications--are under clinical evaluation for repurposing for NMO. Therapies in the preclinical phase include AQP4-blocking antibodies and AQP4-IgG enzymatic inactivation. Additional, albeit currently theoretical, treatment options include reduction of AQP4 expression, disruption of AQP4 orthogonal arrays, enhancement of complement inhibitor expression, restoration of the blood-brain barrier, and induction of immune tolerance. Despite the many therapeutic options in NMO, no controlled clinical trials in patients with this condition have been conducted to date

A comparison of magnetic resonance arthrography and arthroscopic findings in the assessment of anterior shoulder dislocations.

OBJECTIVE The aim of this study is to establish the sensitivity and specificity of MRA in the investigation of patients with traumatic anterior shoulder dislocations. MATERIALS AND METHODS A retrospective analysis of consecutive patients undergoing both magnetic resonance arthrography and arthroscopic assessment after a traumatic anterior shoulder dislocation between January 2011 and 2014 was performed. Demographic data were collected from electronic records. Images were interpreted by 8 musculoskeletal radiologists and patients were treated by 8 consultant orthopaedic surgeons. Arthroscopic findings were obtained from surgical notes and these findings were used as a reference for MRA. The sensitivity, specificity, and positive predictive value were calculated for the different injuries. RESULTS Sixty-nine patients underwent both an MRA and shoulder arthroscopy during the study period; however, clinical notes were unavailable in 9 patients. Fifty-three patients (88 %) were male, the mean age was 28 years (range 18 to 50) and 16 subjects (27 %) had suffered a primary dislocation. The overall sensitivity and specificity of MRA to all associated injuries was 0.9 (CI 0.83-0.95) and 0.94 (CI 0.9-0.96) retrospectively. The lowest sensitivity was seen in osseous Bankart 0.8 (CI 0.44-0.96) and superior labral tear (SLAP) lesions 0.5 (CI 0.14-0.86). The overall positive predictive value was 0.88 (CI 0.76-0.91) with the lowest values found in rotator cuff 0.4 (CI 0.07-0.83) and glenohumeral ligament (GHL) lesions 0.29 (CI 0.05-0.7). CONCLUSION Magnetic resonance angiography has a high sensitivity when used to identify associated injuries in shoulder dislocation, although in 8 patients (13 %) arthroscopy identified an additional injury. The overall agreement between MRA and arthroscopic findings was good, but the identification of GHL and rotator cuff injuries was poor

Magnetic resonance imaging and magnetic resonance arthrography of the shoulder: dependence on the level of training of the performing radiologist for diagnostic accuracy

PURPOSE: Discrepancies were identified between magnetic resonance (MR) imaging and clinical findings in patients who had MR imaging examinations evaluated by community-based general radiologists. The purpose of this study was to evaluate the diagnostic performance of MR imaging examinations of the shoulder with regard to the training level of the performing radiologist. METHODS: A review of patient charts identified 238 patients (male/female, 175/63; mean age, 40.4 years) in whom 250 arthroscopies were performed and who underwent MR imaging or direct MR arthrography in either a community-based or hospital-based institution prior to surgery. All MR imaging and surgical reports were reviewed and the diagnostic performance for the detection of labral, rotator cuff, biceps, and Hill-Sachs lesions was determined. Kappa and Student's t test analyses were performed in a subset of cases in which initial community-based MR images were re-evaluated by hospital-based musculoskeletal radiologists, to determine the interobserver agreement and any differences in image interpretation. RESULTS: The diagnostic performance of community-based general radiologists was lower than that of hospital-based sub-specialized musculoskeletal radiologists. A sub-analysis of re-evaluated cases showed that musculoskeletal radiologists performed better. kappa values were 0.208, 0.396, 0.376, and 0.788 for labral, rotator cuff, biceps, and Hill-Sachs lesions (t test statistics: p = <0.001, 0.004, 0.019, and 0.235). CONCLUSIONS: Our results indicate that the diagnostic performance of MR imaging and MR arthrography of the shoulder depends on the training level of the performing radiologist, with sub-specialized musculoskeletal radiologists having a better diagnostic performance than general radiologists