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Dr. Rosenquist and his colleagues describe how their academically based health maintenance organization joined in training for level-of-care decision making with the external managed behavioral health organization that was providing utilization review and case management decisions. The academic department later took over its own utilization review and in so doing internalized the utilization review function. This development, which is beginning to occur in several states, is an important solution to the "assault" that many providers of care have experienced as a result of the utilization review process. Having taken this step to deal with the realities of 21st-century health care, the authors then seize the opportunity to use their own data to improve decision making within the clinic. This process is how we get to best practices.

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Caffey (1950) suggested the term 'congenital stippled epiphyses' for a syndrorm consisting of achondroplasia, radiologial evidence of discrete centres of calcification in cartilaginous epiphyses, together with cataracts and mental deficwiency. The condition was first described by Conradi (1914) under the title 'Chondrodystrophia Foetalis Hypoplastica', and was reviewed by Ford, Schneider and Brandon (1951). Below is a case record, presenting some unusual features, with necropsy findings.Case Report A girl, birth weight 6 lb. 8 oz, was bom at home, after a normal pregnancy and delivery. The infant was admitted to the Jessop Hospital for Women at the age of 24 hours on account of cyanotic attacks. She was then found to have achondroplasia ( Fig. 1), bilateral talipes equinovarus, a dry, wrinkled skin ( Fig. 2) and bilateral cataracts. There was a grade 3 systolic murmur heard all over the precordium. She had no further cyanotic attacks, and was discharged, to be followed up in theBaby Clinic. 4). The diagnosis of congenital stippled epiphyses was then made.There was a facial resemblance to cretinism, and the total serum lipoids were found to be 945 mg. %. Other senum chemistry gave serum calium level, II 2 mg. %, senum phosphorus level, 4 2 mg. %, serum alkaline phosphatas level, 16 0 units. She was given a six weeks' course of thyroid extract, without effect Other findings at the age of I month were defectve head control when tested in the prone position, in ventral suspension and when pulled to the sitting position, and subluxation at the transverse tarsal joints.During the next eight months she was followed up in the Baby Clinic, but she made very little physical or developmental progress. She was extremely difficult to feed, not apparing to be hungry, and at the age of 8 months her weight was only 7 lb. 3 oz. She did not appear to have increased in size at all. There had been hardly any progress in head controL for there was almost complete head lag, and she could only momentarily lift the chin off the couch in the prone position. She took no notice of sound. As she was blind, she could not be tested for eye-following. Vocalizations were very defective and slight. It was clear that she was 09 15