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The hypothesis of the existence of one or more schizophrenia susceptibility loci on chromosome 22q is supported by reports of genetic linkage and association, meta-analyses of linkage, and the observation of elevated risk for psychosis in people with velocardiofacial syndrome, caused by 22q11 microdeletions. We tested this hypothesis by evaluating 10 microsatellite markers spanning 22q in a multicenter sample of 779 pedigrees. We also incorporated age at onset and sex into the analysis as covariates. No significant evidence for linkage to schizophrenia or for linkage associated with earlier age at onset, gender, or heterogeneity across sites was observed. We interpret these findings to mean that the population-wide effects of putative 22q schizophrenia susceptibility loci are too weak to detect with linkage analysis even in large samples.

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Bipolar affective disorder is a severe mood disorder that afflicts approximately 1% of the population worldwide. Twin and adoption studies have indicated that genetic factors contribute to the disorder and while many chromosomal regions have been implicated, no susceptibility genes have been identified. We undertook a combined analysis of 10 cM genome screen data from a single large bipolar affective disorder pedigree, for which we have previously reported linkage to chromosome 13q14 (Badenhop et al, 2001) and 12 pedigrees independently screened using the same 400 microsatellite markers. This 13 pedigree cohort consisted of 231 individuals, including 69 affected members. Two-point LOD score analysis was carried out under heterogeneity for three diagnostic and four genetic models. Non-parametric multipoint analysis was carried out on regions of interest. Two-point heterogeneity LOD scores (HLODs) greater than 1.5 were obtained for 11 markers across the genome, with HLODs greater than 2.0 obtained for four of these markers. The strongest evidence for linkage was at 3q25-26 with a genome-wide maximum score of 2.49 at D3S1279. Six markers across a 50 cM region at 3q25-26 gave HLODs greater than 1.5, with three of these markers producing scores greater than 2.0. Multipoint analysis indicated a 20 cM peak between markers D3S1569 and D3S1614 with a maximum NPL of 2.8 (P = 0.004). Three other chromosomal regions yielded evidence for linkage: 9q31-q33, 13q14 and 19q12-q13. The regions on chromosomes 3q and 13q have previously been implicated in other bipolar and schizophrenia studies. In addition, several individual pedigrees gave LOD scores greater than 1.5 for previously reported bipolar susceptibility loci on chromosomes 18p11, 18q12, 22q11 and 8p22-23.

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Bipolar affective disorder is a severe mood disorder that afflicts approximately 1% of the population worldwide. Twin and adoption studies have indicated that genetic factors contribute to the disorder and while many chromosomal regions have been implicated, no susceptibility genes have been identified. We undertook a combined analysis of 10 cM genome screen data from a single large bipolar affective disorder pedigree, for which we have previously reported linkage to chromosome 13q14 (Badenhop et al, 2001) and 12 pedigrees independently screened using the same 400 microsatellite markers. This 13-pedigree cohort consisted of 231 individuals, including 69 affected members. Two-point LOD score analysis was carried out under heterogeneity for three diagnostic and four genetic models. Non-parametric multipoint analysis was carried out on regions of interest. Two-point heterogeneity LOD scores (HLODs) greater than 1.5 were obtained for 11 markers across the genome, with HLODs greater than 2.0 obtained for four of these markers. The strongest evidence for linkage was at 3q25-26 with a genome-wide maximum score of 2.49 at D3S1279. Six markers across a 50 cM region at 3q25-26 gave HLODs greater than 1.5, with three of these markers producing scores greater than 2.0. Multipoint analysis indicated a 20 cM peak between markers D3S1569 and D3S1614 with a maximum NPL of 2.8 (P= 0.004). Three other chromosomal regions yielded evidence for linkage: 9q31-q33, 13q14 and 19q12-q13. The regions on chromosomes 3q and 13q have previously been implicated in other bipolar and schizophrenia studies. In addition, several individual pedigrees gave LOD scores greater than 1.5 for previously reported bipolar susceptibility loci on chromosomes 18p11, 18q12, 22q11 and 8p22-23.

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The hospital marketing function has been widely adopted as a way to learn about markets, attract sufficient resources, develop appropriate services, and communicate the availability of such goods to those who may be able to purchase such services. The structure, tasks, and effectiveness of the marketing function have been the subject of increased inquiry by researchers and practitioners alike. A specific understanding of hospital marketing in a growing managed care environment and the relationship between marketing and managed care processes in hospitals is a growing concern. Using Kotler and Clarke's framework for assessing marketing orientation, we examined the marketing orientation of hospitals in a single state at two points in time--1993 and 1999. Study findings show that the overall marketing orientation score decreased from 1993 to 1999 for the respondent hospitals. The five elements of the Kotler and Clarke definition of marketing orientation remained relatively stable, with slightly lower scores related to customer philosophy. In addition, we evaluated the degree to which selected managed care activities are carried out as part of its marketing function. A significant (p < .05) decrease in managed care processes coordinated with the formal marketing function was evident from 1993 to 1999. With increasing numbers of managed care plan enrollees, hospitals are likely focusing on organizational buyers as important customers. In order to appeal to organizational buyers, hospital executives may be focusing more on clinical quality and cost efficiency in the production of services, which will improve a hospital's position with organizational buyers.

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In this article the adoption of case management processes in US hospitals is discussed. While such process change is prevalent, there is a paucity of systematic empirical evidence that hospital case management improves efficiency or effectiveness. Using an institutional theoretical framework, motivations other than improved efficiency and effectiveness are proposed that may drive hospitals to adopt change to their technical core processes, in the form of case management. Further research using these propositions as an adjunct to cost-benefit analyses would be important to validate the rationale behind the widespread adoption of hospital case management processes.

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PURPOSE: To determine end-of-life (EOL) care core competencies and educational needs from practicing oncology nurses and to describe the characteristics of the respondents that are associated with selection of the leading core competencies. DESIGN AND METHODS: A researcher-developed mailed descriptive survey to members of the Oncology Nursing Society in Georgia, Virginia, Washington, and Wisconsin in late 1999. FINDINGS: Nearly all respondents indicated that EOL care was a part of their practice and that continuing education was important, but one-third of the respondents had less than 2 hours of continuing education in 2 years. How to talk to patients and families about dying was the top-rated core competency, consistent across age, educational level, practice role, and practice setting. Pain control and comfort care were also frequently selected as important EOL care issues about which more education is needed. CONCLUSIONS: Results show guidelines for improving educational curricula and considering characteristics of nurses when planning EOL educational programs.

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OBJECTIVE: To estimate the cost and cost-effectiveness of universal newborn hearing screening. STUDY DESIGN AND SETTING: Decision analysis model utilizing the hospital perspective. This model evaluated 4 distinct protocols for screening a fixed and defined hypothetical cohort of newborn infants. OUTCOME MEASURES: Cost of screening and the number of infants with hearing loss identified through universal screening. RESULTS: Otoacoustic emissions testing at birth followed by repeat testing at follow up demonstrated the lowest cost ($13 per infant) and had the lowest cost-effectiveness ratio ($5100 per infant with hearing loss identified). Screening auditory brainstem evoked response testing at birth with no screening test at follow-up was the only protocol with greater effectiveness, but it also demonstrated the highest cost ($25 per infant) and highest cost-effectiveness ratio ($9500 per infant with hearing loss identified). These findings were robust to sensitivity analysis, including best-case and worst-case estimation. The prevalence of hearing loss and the fraction of infants returned for follow-up testing had a large impact on the absolute level, but not relative level of protocol cost and cost-effectiveness. CONCLUSION: The otoacoustic emissions testing protocol should be selected by screening programs concerned with cost and cost-effectiveness, although there are certain caveats to consider. SIGNIFICANCE: The most significant barriers to implementation of universal newborn hearing screening programs have been financial, and this study compares the most common protocols currently in use. This study can assist program directors not only in the decision to initiate universal screening but also in their choice of screening protocol.

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Drawing upon the twelve-year history of Virginia Commonwealth University's (VCU) online distance learning Executive Program, this article identifies factors important to the success of online distance learning and major changes in distance learning over time. It discusses curriculum, instructional design, technology infrastructure and support, educational strategy and pedagogy, faculty, and student program dimensions. As one of the oldest online health administration or business programs, the Executive Program at VCU and this examination thereof are particularly suited to identify significant lessons learned from experience with online education. The article concludes with a summary of challenges facing this and other distance learning programs in health administration.

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Accelerated, nontraditional, advanced practice nursing programs are an alternative way to increase the supply of nurse practitioners. This study profiles demographic and job characteristics of second degree, non-nurse college graduates who pursued graduate degrees in nursing. Graduates' sex, age, income, previous education, nursing experience, factors describing the scope of the advanced practice role, and quality of the educational experience were studied. Data were collected from 29 graduates (57%) from Virginia Commonwealth University's accelerated second-degree nursing program from 1995 through 1999. The findings have implications for nursing educators, health care administrators, employers, and other persons who plan and recruit for this type of nursing education program.

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For centuries, the Catholic Church has been a major social actor in the provision of health services, particularly health care delivered in hospitals. Through a confluence of powerful environmental forces at the beginning of the twenty-first century, the future of Catholic health care is threatened. Although Catholic hospitals are a separate case of private, nonprofit hospitals, they have experienced environmental pressures to become isomorphic with other hospital ownership types and, on some dimensions, they are equal. To keep pace with the changing demands of religion and the social role of the hospital, Catholic hospitals continue to redefine themselves. To justify a distinct and legitimate social role, more research should be conducted to develop and measure indicators of Catholic identity.

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Chaos is order without predictability (1 ). Any unfortunate patient who has recently made a trek to an Emergency Department (ED) or even better, has watched the immensely popular TV show, ER, knows that the visit can be a frustrating and a time consuming experience. The waits are so protracted that one can observe all cycles of birth, death, love, and romance in the waiting room. The process is tedious for the patient who must tell one's tale to a triage nurse, a registration clerk, the primary nurse, the nursing care partner, and finally the emergency physician. Then, the patient must face more delays while being pushed, ineffectively, in a horizontal fashion, through vertical functional silos of care, such as laboratory and radiology. The mind-set or dominant logic of this system of ED patient flow assumes that waits are acceptable and unavoidable, and that the function of the ED is to care for only the truly emergent patient. This dominant logic, coupled with the market constraints of population-based versus case-based payment mechanisms, has led to a declining trend in ED visits for the first time in 20 years (2). In order to improve the quality of ED care as well as to increase acceptability for patient and payer, the dominant logic must be challenged. An understanding of chaos theory and perception of the Emergency Department as a complex adaptive system foster methods for challenging the dominant logic.

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In an environment of change, innovators or entrepreneurs emerge to develop new methods and processes of delivering health care in a way that lowers the overall costs of care while improving outcomes. This qualitative study looks at the factors that motivate nurse entrepreneurs as well as the characteristics of nurse entrepreneurs and their business ventures. The rationale for health care managers to capitalize on nurse entrepreneurship is discussed as an effective method of strategic adaptation.

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To adapt to a workplace characterized by chaos and complexity, individual nurses and the profession as a whole must position themselves in a more entrepreneurial stance. We describe the forces in the health care environment that present opportunities for nursing entrepreneurship. Skills and personality traits that promote entrepreneurship are discussed with suggestions for positioning the nursing profession and individual nurses as proactive innovators to satisfy the needs of the new health care marketplace.

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Catholic hospitals maintain a significant presence in delivering hospital services in the United States, but little is known about the ways they differ from other ownership forms in similar market environments. This paper analyzes characteristics of Catholic, other private nonprofit, and investor-owned hospitals in metropolitan areas of the United States to identify the extent to which Catholic hospitals differ from other ownership types on three dimensions of mission-driven identity--access, stigmatized, and compassionate care services. Based on 1993 data, Catholic hospitals offered more compassionate care services than other private nonprofit hospitals, and more compassionate care and stigmatized services than investor-owned hospitals, controlling for four market and six organizational characteristics. The results may help Catholic hospitals differentiate their services and help justify their tax-exempt status.

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This article describes factors that can affect the refer rate for otoacoustic emission (OAE) based newborn hearing screening, including the population of infants being screened, the adequacy of probe fit, software options used, external ear conditions, screener training, and baby handling. The effect of the infant's age on screening outcomes is also discussed using results of screening for 1328 regular nursery newborns, ranging in age from 6 to 60 hours, who were screened with transient evoked otoaoustic emissions (TEOAE) prior to hospital discharge. The youngest infants (6-9 hours old) were as likely to pass (90% pass rate) as the infants who were 24-27 hours old (94% pass rate). The results of this study are consistent with reports from many TEOAE-based screening programs that have demonstrated that acceptably low refer rates (mean = 6.9%) can be obtained when appropriate screening procedures are followed.

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Although more and more hospitals are implementing universal newborn hearing screening programs, there is still very little information available about the costs of newborn hearing screening programs. The few articles which have been published evaluate technologies or protocols which are no longer used, are incomplete, or are based on hypothetical estimates of the costs and time necessary to do screening. After briefly reviewing the extant literature, this article describes a cost analysis of a TEOAE-based universal newborn hearing screening program. Reasons why the cost per baby ($7.42) is lower than in previous reports are explained, and the benefits of having accurate cost analysis data are summarized.

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This study investigates the efficiency of community-based youth services in the Commonwealth of Virginia using data envelopment analysis (DEA). Efficiency was calculated based on resources available, the demand of services, and the service units produced. Results demonstrated the extent of inefficiency in community-based youth programs and how much efficiency can be improved relative to comparison with peer groups. The differences between large and small communities, urban and rural communities, and rich and poor communities were analyzed. There was no significant difference between each type for all three categories.

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