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ment may be found on the contrast-enhanced MRI, as described by Sherman and Stern and by Christoforidis et al The intensity of enhancement may be reduced after the administration of corticosteroids for several days There is indeed a wide variety of changes that has been described on MRI Positron emission tomography may be helpful by demonstrating increased activity that corresponds to a brain or cord lesion and also by revealing increased activity at the site of involved pulmonary lymph nodes Radionuclide scanning with gallium67 shows uptake in the chest, spleen, salivary or lacrimal glands in almost half of patients and can be a useful ancillary test Test material for the formerly popular Kveim-Siltzback skin reaction (a homogenate of spleen or lymph node from patients with known sarcoid) is no longer generally available It has also been found that sarcoid can give rise to a noncaseating epithelioid granuloma at the site of a Mantoux test (for tuberculosis) placed on the skin of the forearm (a skin biopsy is necessary to demonstrate it), but we do not know the validity of this test The latency in development of the granuloma (up to 6 weeks), during which time corticosteroids cannot be given, and a limited rate of positivity (less than two-thirds of patients) also reduce this test s usefulness (see Mankodi et al) Delayed hypersensitivity skin reactions to other antigens are frequently depressed Mild anemia, lymphocytopenia (occasional eosinophilia), slightly elevated sedimentation rate, hypercalcemia, and hyperglobulinemia are common ndings in active disease Serum levels of angiotensin-converting enzyme (ACE) are increased in two-thirds of the patients but seem to us to be less helpful in the diagnosis of CNS involvement It is not clear if the concentration of ACE in the spinal uid is expected to be increased in CNS sarcoid Obviously, evidence of primary sarcoidosis in the mediastinum and lungs should be sought in these cases by chest x-ray and CT scan The differential diagnosis of what has been termed neurosarcoidosis is quite broad and includes multiple sclerosis as well as a number of other entities such as Sjogren syndrome, systemic lupus, lymphoma, isolated angiitis of the CNS, intravascular lymphoma, leprosy, cryptococcosis and other fungal infections that cause abscesses and meningitis, toxoplasmosis, brucellosis, syphilis, Wegener granulomatosis, and, of course, tuberculosis Treatment Administration of corticosteroids is the main therapy, but it has not been subjected to scrutiny in an adequate trial Cyclosporine can be used when the patient cannot tolerate steroids or as an adjunctive treatment to reduce the dose of steroid Other immunosuppressive drugs have not proved to be as effective; methotrexate, cyclophosphamide, chloroquine, and radiation of focal lesions have found favor in various clinics, but again, the results are dif cult to judge The major problem is in knowing when to treat the patient, because the disease may remit spontaneously in about half the cases The recent onset of neurologic symptoms, indicating an active phase of the disease, or a disabling syndrome such as myelopathy are the most certain indications for steroid therapy One approach is to use prednisone in divided daily doses of 40 mg, given for 2 weeks, followed by 2-week periods in which the dose is reduced by 5 mg, until a maintenance dose of 20 to 10 mg on alternate days is reached Therapy should be continued for at least 6 months and in many cases is required for several years.

Short-term covering long exposure Another feasible strategy for covering long maturity exposure is to consider buying puts or selling calls or short market spreads on shorter maturities with the logic that the yield curve will atten and the shorter maturity will have a more dramatic effect by increasing interest rates before longer maturities In recent years, long-term rates have responded in step or shortly following increases in the Fed discount rate and T-bill discounts This strategy may be effective if the logic regarding the yield curve holds, but it is also likely that long-term rates will respond quickly and cause any hedge effect to be useless or minimal at best ETF options Last but not least is to utilize option positions in Treasury index-based exchange-traded funds The same hedge philosophy applies with selling calls, buying puts, or utilizing one of our spread strategies for short market positioning Determine or you may be able to look up the DV01 for Treasury index funds and compare the DV01 to your portfolio If you can nd a comparable sensitivity to rates or nd a ratio of income index funds to match your portfolio, the index provides a diversi ed method of carrying interest-rate risk without direct involvement in Treasury futures This may be considered a more conservative approach with less risk and potentially less margin risk The disadvantage is the contract size in that the US Treasury bond contract represents $100,000 per contract, while the index fund will likely not have as signi cant a perbasis-point value to the portfolio Conversely, if your exposure is based signi cantly in xed income ETFs or mutual funds and you have an exposure greater than the

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