Aligning incentives in orthopaedics: opportunities and challenges -- the Case Medical Center experience.

For 30 years, the orthopaedic faculty at Case Western Reserve University worked as an independent private corporation within University Hospitals Case Medical Center (Hospital). However, by 2002, it became progressively obvious to our orthopaedic practice that we needed to modify our business model to better manage the healthcare regulatory changes and decreased reimbursement if we were to continue to attract and retain the best and brightest orthopaedic surgeons to our practice. In 2002, our surgeons created a new entity wholly owned by the parent corporation at the Hospital.

Mental health and social services: results from the School Health Policies and Programs Study 2006.

Background: Schools are in a unique position not only to identify mental health problems among children and adolescents but also to provide links to appropriate services. This article describes the characteristics of school mental health and social services in the United States, including state- and district-level policies and school practices.

Methods: The Centers for Disease Control and Prevention conducts the School Health Policies and Programs Study (SHPPS) every 6 years.

A man with palpable purpuric hand lesions.

A 75-year-old man with seronegative rheumatoid arthritis presented with a three-day history of low-grade fever, new arthralgias, mouth sores, and bilateral cutaneous hand lesions. He had not had hand trauma.

An obese man with anxiety, sweating, and headache.

A 47-year-old man reported becoming confused, disoriented, and anxious while driving his car. He recalled sweating and having blurred vision, palpitations, and a diffuse headache shortly before pulling to the side of the road and losing consciousness. Emergency service personnel arrived about 15 minutes later and administered a 50% solution of dextrose intravenously.

A man with a history of skin lesions and seizures.

A 38-year-old man presented with painful growths around his toenails. Since their first occurrence at age three, several had been surgically removed. He had had similar growths around his fingernails and multiple facial lesions since age seven.

Toward ending the marginalization and fragmentation of mental health in schools.

For efforts to address mental health and psychosocial concerns in schools to be effective, practices must not be marginalized and must be implemented cohesively at each school and among families of schools. Mechanisms and processes must be established to minimize marginalized and fragmented practice, weave together school and community resources, and develop comprehensive and multifaceted approaches. A school-based, resource-oriented team represents one key mechanism.

Promoting mental health in schools in the midst of school reform.

Efforts to promote mental health in schools have encountered a variety of systemic problems. Of particular concern is that planning and implementing programs and services often occurs in an unsystematic and ad hoc fashion resulting in fragmented and piecemeal activities and an inefficient use of limited resources. Even more fundamental is the degree to which schools marginalize all efforts to address barriers to student learning.

A woman with leg cramps and rash.

A 68-year-old woman presented with generalized weakness and a rash on her lower extremities. The weakness began one week earlier, shortly after treatment for leg cramps and two days before the rash appeared. She had also had blood-streaked sputum a few days before admission.

A skin lesion found by serendipity.

A 77-year-old retired postal worker presented with symptoms of recurrent aspiration pneumonia, for which he had last been seen one month earlier. Oropharyngeal dysfunction, presumably caused by previous strokes, was demonstrated by video-esophagoscopy, and a percutaneous gastrostomy tube was placed at that time.

A man with fever, rigors, and poor oral hygiene.

A 62-year-old man presented to the emergency department with a one-week history of subjective fever and rigors. He had had epigastric pain for three weeks, for which he was taking ranitidine, and in the past two to three months had experienced night sweats, a nonproductive cough, nausea, vomiting, and a 30-lb weight loss. He denied dsypnea, chest pain, hematochezia, melena, or any change in bowel habits.

An alcoholic man with an abnormal pulse.

A 47-year-old man who smelled of alcohol presented with a three-day history of sore throat. He had not had fever, nausea, vomiting, diarrhea, rhinorrhea, cough, chest pain, or palpitations. On evaluation in the emergency department, he was found to have tachycardia and an irregular pulse.