Oregon's bold experiment: whatever happened to rationing?

In 1994 Oregon began rationing health care for its Medicaid population, offering health policy makers and analysts around the country a view of one alternative future for health care delivery. The question now, four years after the experiment began, is what does that future look like? The short answer is that it does not look all that different from the present, but it looks different enough to offer important lessons to other states and the federal government. The Oregon experiment, including the prioritization of services and the aggressive use of managed care, has facilitated the expansion of health care coverage to over 100,000 additional Oregonians, helped decrease the percentage of the uninsured as well as reduce uncompensated care in hospitals, reduced the use of hospital emergency rooms, and reduced cost shifting. By most measures, the Oregon experiment appears to be a success.

Hepatocellular injury in Streptococcus pneumoniae-associated hemolytic uremic syndrome in children.

Streptococcus pneumoniae is an uncommon etiological organism in hemolytic uremic syndrome (HUS). Production of neuraminidase by S. pneumoniae results in exposure of red blood cell T-antigen, resulting in hemolysis, thrombocytopenia, and acute renal failure. Hepatic involvement in this form of HUS has not been described in the literature. We report in three children with S. pneumoniae-associated HUS the presence of severely elevated transaminases and conjugated hyperbilirubinemia. Increases in asparagine transaminase ranged from 11 to 46 times normal values and an increase in alanine transaminase ranged from 1.6 to 8 times normal. In all patients the rise in total bilirubin was 7-15 times normal. Biliary tree obstruction and viral causes for liver dysfunction were absent. Hepatocellular injury in S. pneumoniae-associated HUS likely results from mechanisms involved in sepsis and pneumonia-induced jaundice, combined with severely increased bilirubin production following massive hemolysis. The hepatic injury in all three patients resolved within 9, 5, and 10 days. Our experience suggests that an extensive evaluation including liver biopsy is not indicated.

Pseudotumor cerebri with vision impairment in two children with renal transplantation.

The syndrome of pseudotumor cerebri consists of headaches, difficulty with vision and papilledema associated with raised intracranial pressure (ICP) without localizing neurological mass lesions. Recently, an association of pseudotumor cerebri and renal insufficiency, chronic dialysis or renal transplantation has been noted. Loss of vision remains a serious threat in children with pseudotumor cerebri. We report two children who developed pseudotumor cerebri with impairment of vision 5 years after renal transplantation. An awareness of this association should prompt the nephrologist to investigate and treat the symptoms of raised ICP to prevent visual loss.

Health care reform in Vermont: the next chapter.

It seemed inconceivable that Vermont would not enact comprehensive health care reform in 1994. Two years earlier the Vermont legislature had created the Vermont Health Care Authority to prepare the groundwork for major reform. Yet the 1994 Vermont General Assembly could not reach agreement on legislation. What went wrong? Some on the political left and right say that the legislature stopped "bad" legislation. The Vermont story reveals the failure of reformers to convince interest groups and ordinary citizens about the capacity of government to reform the health system.

Increased incidence of HLA-B40 group antigens in children with hemolytic-uremic syndrome.

Hemolytic uremic syndrome (HUS) develops in 25-30% of children infected with Escherichia coli strains that produce Shiga-like toxins, also known as verocytotoxins. Mild HUS also occurs in 1 in 4 of the other family members, suggesting a familial predisposition to HUS. To understand the possible genetic predisposition, the frequency of HLA antigens was evaluated in 30 children (12 boys, 18 girls; mean age 3.8 years) with HUS following a prodrome of bloody diarrhea. When compared to a blood donor population from the same geographic area and ethnic background, no significant differences were noted in the frequency of HLA-A, HLA-C, HLA-DR, and HLA-DQ antigens. However, the frequency of HLA-B40 and its splits (B60, 61, 41, 47) was significantly higher in the study population (corrected p < 0.005). The relative risk of developing HUS was 6.04 when HLA-B40 and HLA-B40 split products were present, and the risk increased to 8.5 when the analysis was extended to include the cross-reactive antigens B44 and B13. These HLA-B antigens share common amino acid sequences at positions 41-45 and 67-74 on the alpha-1 domain of the HLA class I molecule. Our data suggest that the inheritance of HLA-B40, its splits, and cross-reactive antigens increases the risk of developing HUS.

Outcome of renal transplantation in children aged 1-5 and 6-18 years.

Results of renal transplantation in younger children have not been very encouraging in the past. We therefore studied the effect of newer immunosuppressive regimens on the outcome of renal transplantation of 5 children aged 2.9 +/- 1.3 years (range 1.6-5.0), and compared it to 10 children of an older pediatric patient group aged 11.4 +/- 4.4 years (range 6.0-18.5). All patients with the exception of 1 underwent dialysis. The percentage of cadaveric and live-related transplants was similar in both groups. Recipients of a cadaveric transplant had at least 3 blood transfusions; recipients of live-related transplants had donor-specific transfusions with azathioprine. Posttransplantation immunosuppression consisted of prednisone and azathioprine; recipients of cadaveric transplants received also ciclosporin. Rejection episodes and side effects (hypertension, hirsutism) were comparable in both groups. In the younger patient group, 1 patient died of a congenital lung abnormality but had a functioning graft. In the older patient group, 1 patient lost his graft 16 months posttransplantation due to reduction of his immunosuppressives, necessitated by a severe CMV infection. Growth and development improved in the younger patient group, but was stable in older patients. Renal transplantation is a suitable option in younger pediatric patients. Graft survival rates are comparable to those of older patients.

Focal segmental glomerulosclerosis in desquamative interstitial pneumonia.

Renal involvement in desquamative interstitial pneumonitis (DIP) manifesting as chronic renal failure has been reported only once. An uncommon disorder in children, DIP has been associated with a variety of systemic disorders and has an immune-mediated pathogenesis. A 16-year-old Black male was diagnosed to have DIP on lung biopsy at the age of 10 months. He was first noted to have proteinuria at age 5 which progressed to nephrotic syndrome by age 13 when the laboratory tests showed elevated IgG, normal serum complement, increased circulating immune complexes and absent anti-GBM antibodies. A percutaneous renal biopsy specimen performed at age 13 revealed focal segmental glomerulosclerosis. Despite prednisone treatment of 2 mg/kg/day for 12 weeks, renal failure progressed requiring hemodialysis. Pulmonary functions, although reduced, remained stable.

Early diagnosis of Bardet-Biedl syndrome.

A 3-year-old boy presented with decreased renal function, hypertension, obesity and developmental delay. Evaluation of his kidneys revealed blunting of the calyces and multiple renal cortical cysts. Ophthalmologic evaluation showed no abnormalities on examination but electroretinography showed reduced retinal function suggesting a diffuse retinal disorder. Based on the clinical presentation with the associated abnormalities, the diagnosis of Bardet-Biedl syndrome, a form of the Laurence-Moon-Biedl syndrome was made. This syndrome should be considered and specific diagnostic efforts should be made in pediatric patients who present with renal failure and obesity.