We examined the association of individual HLA genes with rheumatoid arthritis (RA), using oligonucleotide probes that identified both DRCassociated and non-DR4-associated genes. Two distinct HLA-DRP alleles (Dw4 and Dw14) were found in DR4+ RA patients compared with controls (Dw4 50% versus 17%; Dw14 35 % versus 5 % ; total DR4 73 % versus 30 % ) , indicating that these 2 alleles are independent susceptibility genes. Remarkably, the majority of the DR4-RA patients also demonstrated a linear DNA sequence, apparently "shuffled" between different susceptibility alleles, identified with an oligonucleotide probe to a key portion of the Dw14 gene.The etiology of rheumatoid arthritis (RA) is multifactorial, involving both genetic and nongenetic

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The incidence of obstructive sleep apnea has been underestimated in morbidly obese patients who present for evaluation for weight loss surgery. This retrospective study shows that the incidence of obstructive sleep apnea in this patient population is greater than 70 per cent and increases in incidence as the body mass index increases. Obstructive sleep apnea (OSA) is a common comorbidity in obese patients who present for evaluation for gastric bypass surgery. The incidence of sleep apnea in obese patients has been reported to be as high as 40 per cent. A retrospective review of our prospectively collected database was performed. All patients being evaluated for weight loss surgery for obesity were screened preoperatively for OSA using a sleep study. The overall incidence of sleep apnea in our patients was 78 per cent (227 of 290). All 227 were diagnosed by formal sleep study. There were 63 (22%) males and 227 (78%) females. The mean age was 43 years (range, 17–75 years). The mean body mass index (BMI) was 52 kg/m2 (range, 31–94 kg/m2). The prevalence of OSA in the severely obese group (BMI 35–39.9 kg/m2) was 71 per cent. For the morbidly obese group (BMI 40–40.9 kg/m2), the prevalence was 74 per cent and for the superobese group (BMI 50–59.9 kg/m2) 77 per cent. Those with a BMI 60 kg/m2 or greater, the prevalence of OSA rose to 95 per cent. The incidence of sleep apnea in patients presenting for weight loss surgery was greater than 70 per cent in our study. Patients presenting for weight loss surgery should undergo a formal sleep study to diagnose OSA before bariatric surgery.

Peritoneal dialysis (PD) is an underutilized form of renal replacement therapy. Recent data have emphasized that only 12% of end-stage renal disease (ESRD) patients are initiated on this form of therapy in the United States. Patients requiring PD have most often been referred to general surgeons for catheter placement. This has incurred additional delays in starting treatment and loss of decision-making control by the referring nephrologist. To address this issue, we developed and incorporated our own PD access placement program into the preexisting chronic kidney disease (CKD) education program. To date, 46 patients have undergone 71 procedures. These included 51 (72%) PD catheter insertions, 14 (20%) removals, and 6 (8%) repositioning procedures for poor drainage. PD catheter insertion was performed peritoneoscopically under local anesthesia and a Fogarty catheter was used to reposition a migrated catheter. All of the procedures were performed by nephrologists in a dedicated interventional nephrology (IN) laboratory. All six repositioning procedures failed to restore optimal drainage. Five of these patients had the catheter removed and a new catheter placed during the same procedure. Of these five patients, one had recurrence of poor drainage and opted for hemodialysis (HD). The sixth patient declined reinsertion and chose HD. Of the remaining seven removal procedures, three were due to fungal peritonitis, one due to bowel perforation, one due to severe depression, one due to transplant, and one catheter was removed at the request of the primary physician in a terminally ill patient. Eight of the 51 catheter insertions were during the initial admission of a catastrophic dialysis start. Two of these patients started acute PD and avoided catheter placement for HD. Thirty-seven of 46 patients have a functional PD catheter with a follow-up of 8.6 +/- 0.8 (mean +/- SE) months. During an 18-month period our PD population has increased from 43 to 80 patients. We conclude that a dedicated PD access placement program coupled with a CKD education program can have a dramatic impact on patient choice and PD growth.