Meaningful Recognition for Nurse Managers.

Nurse managers have played an instrumental and essential role in the successful delivery of patient care for decades. Often described as the "hardest job in healthcare," the importance of the nurse manager role is never more apparent during a crisis such as a national nursing shortage or a global pandemic. However, the nurse manager role and its contributions have gone unrecognized. The DAISY Nurse Leader Award is one way healthcare leaders can elevate and recognize nurse manager's contributions.

"You know, we can change the services to suit the circumstances of what is happening in the world": a rapid case study of the COVID-19 response across city centre homelessness and health services in Edinburgh, Scotland.

BACKGROUND: The COVID-19 pandemic has necessitated unprecedented changes in the way that health, social, and housing services are delivered to individuals experiencing homelessness and problem substance use. Protecting those at high risk of infection/transmission, whilst addressing the multiple health and social needs of this group, is of utmost importance. This study aimed to document the impact of the COVID-19 pandemic on individuals who were experiencing homelessness in one city centre in Scotland, and how services adapted in response. METHODS: Semi-structured interviews were conducted with individuals with lived/living experience of homelessness (n = 10), staff within onethird sector service (n = 5), and external professionals (n = 5), during April-August 2020, using a rapid case study design. These were audio-recorded, fully transcribed, and analysed using Framework. Analysis was informed by inclusion health and equity-orientated approaches to meeting the needs of people with multiple and complex needs, and emerging literature on providing harm reduction in the context of COVID-19. RESULTS: Those with lived/living experience of homelessness and problem substance use faced a range of additional challenges during the pandemic. Mental health and use of substances were affected, influenced by social isolation and access to services. A range of supports were provided which flexed over the lockdown period, including housing, health and social care, substance use treatment, and harm reduction. As well as documenting the additional risks encountered, findings describe COVID-19 as a 'path-breaking' event that created opportunities to get evidence into action, increase partnership working and communication, to proactively address risks. CONCLUSIONS: This rapid case study has described the significant impact of the COVID-19 pandemic on a group of people experiencing homelessness and problem substance use within one city centre in Scotland and provides a unique lens on service/professional responses. It concludes with lessons that can inform the international and ongoing response to this pandemic. It is vital to recognise the vision and leadership that has adapted organisational responses in order to reduce harms. We must learn from such successes that were motivated both by compassion and care for those vulnerable to harms and the desire to provide high-quality, evidence-based, harm reduction services.

'They already operated like it was a crisis, because it always has been a crisis': a qualitative exploration of the response of one homeless service in Scotland to the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic has necessitated unprecedented changes in the way that services are delivered to individuals experiencing homelessness and problem substance use. Protecting those at high risk of infection/transmission, whilst addressing the multiple health and social needs of this group, is of utmost importance. The aim of this novel qualitative study was to document how one service in Scotland, the Wellbeing Centre run by The Salvation Army, adapted in response. METHODS: Care was taken to identify methods that did not create additional stress at this pressured time. Semi-structured interviews were conducted with Centre clients (n = 10, in-person and telephone) and staff (n = 5, telephone), and external professionals (n = 5, telephone), during April-August 2020. These were audio-recorded, fully transcribed, and analysed using Framework. Service documents were used to enhance contextual understanding. Analysis was informed by theories of psychologically informed environments and enabling environments. RESULTS: The start of the pandemic was a time of confusion, disruption, and isolation. Centre staff rapidly adapted methods of engagement to provide a range of comprehensive physical and emotional supports, to both existing and new clients, through telephone and online communication and, eventually, socially distanced in-person support. This involved balancing the risks of COVID-19 infection/transmission with the benefits of continuity of support to those highly vulnerable to a range of harms. Whilst the pandemic created many challenges, it also facilitated removal of barriers, particularly concerning provision of harm reduction services which had previously been severely constrained. Clients described the Centre as a 'lifeline', providing stability and safety during a period of profound disruption when other services closed their doors. Strong leadership, intensive team working, support/training for staff, a focus on relationships, and active use of client feedback, enabled responsive adaptation to fast-changing demands and the creation of a 'culture of care'. CONCLUSION: This study provides a unique insight into the pandemic by analysing the response of one homeless service during the height of the pandemic. We present a range of implications that have international relevance for those designing policies, and adapting front-line services, to proactively respond to COVID-19 and the continued public health crises of homelessness and drug-related deaths.

Nurse-Led Model of Care That Helps a Community Heal: Curbside Immunizations With Assistance in Social Determinants.

The COVID-19 pandemic has overwhelmed communities. Physical, emotional, and financial struggles have heightened, especially with our vulnerable populations. People have been afraid to return to their provider's office. For children, there has been an interruption of well-visits and immunizations. As the nation saw a decline in immunization uptake, a pilot nurse-led program was designed to increase vaccinations and address the social determinant needs during a global pandemic. The purpose of this article is to describe the planning and implementation of a curbside immunization event. The Logic model was used as a framework to ensure an efficient and replicable process. Initial observations showed an overall increase in immunization uptake and 97% of participants current with recommended vaccinations. Most parents (93%) would attend again and recommend it to others. They also felt that infection control precautions helped make the care delivered safe and efficient. Social determinants of health were assessed and addressed. This method of vaccine delivery is a viable model going into the future. Others may replicate this model, and it may also serve as a platform regarding flu or COVID-19 vaccine distribution.

The Impact of Nurse-Led Innovations and Tactics During a Pandemic.

The COVID-19 pandemic hit southeast Michigan hard and a rapid influx of patients forced Beaumont Health to shift rapidly into an emergency management model with a laser focus on transforming clinical care and administrative processes to meet complex patient care needs. Navigating this landscape required agility, surge planning, strong interprofessional teams, transformational leadership, nurse-led innovations, support, and transparency to manage the ever-changing environment. This article explains nursing's response and nurse-led innovations that were implemented to meet the needs of the community, patients, and staff, as well as lessons learned to ensure preparedness for any potential future surge.

Developing Statewide Violence Prevention Programs in Health Care: An Exemplar From Massachusetts.

Workplace violence is on the rise in health care. This problem contributes to medical errors, ineffective delivery of care, conflict and stress among health professionals, and demoralizing and unsafe work conditions. There is no specific federal statute that requires workplace violence protections, but several states have enacted legislation or regulations to protect health care workers. To address this problem in their state, the Massachusetts Health & Hospital Association developed an action plan to increase communication, policy development, and strategic protocols to decrease workplace violence. The purpose of this article is to report on the quality and safety improvement work that has been done statewide by the Massachusetts Health & Hospital Association and to provide a roadmap for other organizations and systems at the local, regional, or state level to replicate the improvement process.

Creating Healthful Work Environments to Deliver on the Quadruple Aim: A Call to Action.

Nurses face workplace stressors that contribute to job dissatisfaction, burnout, and turnover, impacting not only patient safety but the nurses' physical and emotional well-being. At the 2018 American Academy of Nursing conference, a policy dialogue "Creating Healthy Work Environments to Address the Quadruple Aim" was convened focusing on creating healthy work environments by addressing stressors such as violence and bullying. That discussion is encapsulated in this article, providing proven and practical strategies for reducing risk.

Plasma elemental responses to red meat ingestion in healthy young males and the effect of cooking method.

PURPOSE: Elemental deficiencies are highly prevalent and have a significant impact on health. However, clinical monitoring of plasma elemental responses to foods remains largely unexplored. Data from in vitro studies show that red meat (beef) is a highly bioavailable source of several key elements, but cooking method may influence this bioavailability. We therefore studied the postprandial responses to beef steak, and the effects of two different cooking methods, in healthy young males. METHODS: In a randomized cross-over controlled trial, healthy males (n = 12, 18-25 years) were fed a breakfast of beef steak (270 ± 20 g) in which the meat was either pan-fried (PF) or sous-vide (SV) cooked. Baseline and postprandial blood samples were collected and the plasma concentrations of 15 elements measured by inductively coupled plasma-mass spectrometry (ICP-MS). RESULTS: Concentrations of Fe and Zn changed after meal ingestion, with plasma Fe increasing (p < 0.001) and plasma Zn decreasing (p < 0.05) in response to both cooking methods. The only potential treatment effect was seen for Zn, where the postprandial area under the curve was lower in response to the SV meal (2965 ± 357) compared to the PF meal (3190 ± 310; p < 0.05). CONCLUSIONS: This multi-element approach demonstrated postprandial responsiveness to a steak meal, and an effect of the cooking method used. This suggests the method would provide insight in future elemental metabolic studies to evaluate responses to meat-based meals, including longer-term interventions in more specifically defined cohorts to clearly establish the role of red meat as an important source of elements.

Strategies and Barriers to Engaging Dual-Eligible Patients in a Hospital Patient and Family Advisory Program.

As national efforts intensify to improve health outcomes and reduce health care costs, hospitals search for effective ways to partner with patients and families to achieve these goals. Many are implementing patient and family advisory programs (PFAPs) where patients, families, administrators, and clinicians work together to improve the patient experience. However, hospitals struggle with engaging the underserved-specifically, dual-eligible patients enrolled in both Medicare and Medicaid-in PFAPs. This quality improvement project used telephone interviews with 12 dual-eligible beneficiaries and 4 of their providers to identify successful approaches to engage these patients in the hospital PFAP. While none of the participants had direct experience with a PFAP, many of the strategies and barriers identified from their individual care experiences will be used to inform the hospital's plan to engage this patient population in future patient and family engagement efforts.

Nursing and the Public Health Legacies of the Russian Revolution.

The centenary of the October Revolution in 1917 provides a timely opportunity to assess the legacies of that event. I examine the role of the revolution in public health with a focus on nursing, assessing the Imperial Russian health care system, the development of Soviet nursing, and current plans for nursing and public health care in Putin's Russia. Analyzing nursing shows that there was a great deal of continuity in terms of medical personnel and ideas on how public health care service in Russia should operate. Nursing illuminates some of the complexities of Soviet health care and ideology, particularly the state's desire to create a socialist form of nursing in theory, despite the strong links with the prerevolutionary past in the form of personnel. This situation changed after the collapse of the Soviet Union, when the new Russian state attempted to sever connections with the past, this time with the Soviet past. But as I show, making a clean break with the past is a difficult and often fraught process.

Patient and Family Engagement Summit: Needed Changes in Clinical Practice.

Patient and family engagement is a strategy to enhance healthcare outcomes through strong clinician-patient partnerships. A new care delivery process, in which the patient is the driver of the healthcare team, is required to achieve optimal health. A summit partially funded by a seed grant from the Robert Wood Johnson Executive Nurse Fellow Alumni Foundation was held with interprofessional colleagues and patient representatives to identify needed clinical competencies and future practice changes. Recommended shifts in the care delivery process included a focus on patient strengths, including the patient as a valued team member, doing care "with me" and not "to me," and considering all entities or providers including the patient, as equal partners.

Nurses across borders: displaced Russian and Soviet nurses after World War I and World War II.

Russian and Soviet nurse refugees faced myriad challenges attempting to become registered nurses in North America and elsewhere after the World War II. By drawing primarily on International Council of Nurses refugee files, a picture can be pieced together of the fate that befell many of those women who left Russia and later the Soviet Union because of revolution and war in the years after 1917. The history of first (after World War I) and second (after World War II) wave émigré nurses, integrated into the broader historical narrative, reveals that professional identity was just as important to these women as national identity. This became especially so after World War II, when Russian and Soviet refugee nurses resettled in the West. Individual accounts become interwoven on an international canvas that brings together a wide range of personal experiences from women based in Russia, the Soviet Union, China, Yugoslavia, Canada, the United States, and elsewhere. The commonality of experience among Russian nurses as they attempted to establish their professional identities highlights, through the prism of Russia, the importance of the history of the displaced nurse experience in the wider context of international migration history.

Impact of the design of adult mental health inpatient facilities on healthcare staff: a mixed methods systematic review.

OBJECTIVES: Mental health inpatient facilities are increasingly focusing on creating therapeutic, person-centred care environments. However, research shows that this focus may have unintended consequences for healthcare staff. Designs that do not pay attention to staff needs may risk contributing to stress, burnout, job dissatisfaction and mental exhaustion in the work environment. This systematic review aims to identify and synthesise current research on the design factors of adult mental health inpatient facilities that impact healthcare staff. DESIGN: A mixed method systematic review was conducted to search for empirical, peer-reviewed studies using the databases CINAHL, Embase, PsycINFO, PubMed and Web of Science from their inception up to 5 September 2023. The Joanna Briggs Institute's critical appraisal checklists were used to assess the methodological quality of the eligible studies. Data were extracted and grouped based on the facility design factors. RESULTS: In our review, we included 29 peer-reviewed empirical studies that identified crucial design factors impacting healthcare staff in adult mental health inpatient facilities. Key factors included layouts providing optimal visibility, designated work and respite areas, and centrally located nursing stations. Notably, mixed perceptions regarding the benefits and challenges of open and glass-enclosed nursing stations suggest areas requiring further research. Facilities in geographically remote locations also emerged as a factor influencing staff dynamics. Additionally, although only supported by a limited number of studies, the significance of artwork, sensory rooms for respite, appropriate furniture and equipment, and access to alarms was acknowledged as contributory factors. CONCLUSION: Through the synthesis of existing research, this review identified that the design of mental health facilities significantly impacts staff well-being, satisfaction, performance and perception of safety. Concluding that, in order to create a well-designed therapeutic environment, it is essential to account for both service users and staff user needs. PROSPERO REGISTRATION NUMBER: CRD42022368155.

The Role of the Built Environment as a Therapeutic Intervention in Mental Health Facilities: A Systematic Literature Review.

OBJECTIVES: This systematic literature review synthesizes and assesses empirical research concerning the use of the built environment as a therapeutic intervention in adult mental health inpatient facilities. The review explores the impact of facility design on patient outcomes. BACKGROUND: There is a growing recognition that the built environment in mental health facilities must strike a balance between ensuring safety and providing a therapeutic atmosphere. A review addressing how facility design contributes to this therapeutic environment is warranted. METHODS: Database searches were conducted in CINAHL, Embase, PsychInfo, PubMed, and Web of Science from inception up to March 10, 2022. The Scottish Intercollegiate Guidelines Network (SIGN50) critical appraisal checklists were used to assess the quality of included studies. RESULTS: Of the 44 peer-reviewed studies identified from nine countries, several factors emerged as vital for the therapeutic environment in mental health inpatient facilities. These included personal spaces prioritizing privacy and control of the environment, daylight-optimized spaces, versatile communal areas promoting activities and interaction, designated areas for visits and spiritual/contemplative reflection, homelike environments, the inclusion of artwork in units, open nursing stations, and dedicated female-only areas. Yet, there is a need for research yielding stronger evidence-based designs harmonizing with therapeutic needs. CONCLUSION: This review offers initial guidance on designing mental health facilities that foster a therapeutic environment, while highlighting that the influence of facility design on mental health inpatients is considerably under-researched.

ABIN1 protein cooperates with TAX1BP1 and A20 proteins to inhibit antiviral signaling.

Upon virus infection, the innate immune response provides the first line of protection and rapidly induces type I interferons (IFNα/ß), which mediate potent antiviral effects. To maintain homeostasis and prevent autoimmunity, IFN production is tightly regulated; however, the mechanisms of negative regulation are poorly understood. Herein, we demonstrate that the A20 binding inhibitor of NF-κB 1 (ABIN1) is a novel negative regulator of antiviral signaling. Overexpression of ABIN1 inhibited IFN-ß promoter activation in response to virus infection or poly(I:C) transfection, whereas siRNA-mediated knockdown of ABIN1 enhanced IFN-ß production upon virus infection. ABIN1 interacted with the A20 regulatory molecule TAX1BP1 and was essential for the recruitment of TAX1BP1 and A20 to the noncanonical IκB kinases TBK1 and IKKi in response to poly(I:C) transfection. ABIN1 and TAX1BP1 together disrupted the interactions between the E3 ubiquitin ligase TRAF3 and TBK1/IKKi to attenuate lysine 63-linked polyubiquitination of TBK1/IKKi. Finally, an intact ubiquitin binding domain of ABIN1 was essential for ABIN1 to interact with TBK1/IKKi and inhibit IFN-ß production upon poly(I:C) transfection or virus infection. Together, these results suggest that ABIN1 requires its ubiquitin binding domain and cooperates with TAX1BP1 and A20 to restrict antiviral signaling.

Creating an innovative tool to measure Magnet® readiness.

Magnet designation has become a highly sought-after credential for hospitals across the United States and internationally who want to distinguish themselves for clinical excellence and employee engagement. This article chronicles how Emory Healthcare, the largest, comprehensive academic healthcare system in Georgia, developed the Magnet Readiness Index™ to assess the status of nursing compared with the standards prior to submission of an application.

Antidiabetic activity of avocado seeds (Persea americana Mill.) in diabetic rats via activation of PI3K/AKT signaling pathway.

The treatment of diabetes involves the use of herbal plants, attracting interest in their cost-effectiveness and efficacy. An aqueous extract of Persea americana seeds (AEPAS) was explored in this study as a possible therapeutic agent in rats with diabetes mellitus. The induction of diabetes in the rats was achieved by injecting 65 mg/kg body weight (BWt) of alloxan along with 5% glucose. This study was conducted using thirty-six (36) male Wistar rats. The animals were divided into 6 equal groups, (n = 6) and treated for 14 days. In vitro assays for total flavonoid, phenols, FRAP, DPPH, NO, α-amylase, and α-glucosidase, were performed. Biochemical indices fasting blood sugar (FBS), BWt, serum insulin, liver hexokinase, G6P, FBP, liver glycogen, IL-6, TNF-α, and NF-ĸB in the serum, were investigated as well as the mRNA expressions of PCNA, Bcl2, PI3K/Akt in the liver and pancreas. The in vitro analyses showed the potency of AEPAS against free radicals and its enzyme inhibitory potential as compared with the positive controls. AEPAS showed a marked decrease in alloxan-induced increases in FBG, TG, LDL-c, G6P, F-1, 6-BP, MDA, IL-6, TNF-α, and NF-ĸB and increased alloxan-induced decreases in liver glycogen, hexokinase, and HDL-c. The diabetic control group exhibited pancreatic dysfunction as evidenced by a reduction in serum insulin, HOMA-ß, expressions of PI3K/AKT, Bcl-2, and PCNA combined with an elevation in HOMA-IR. The HPLC revealed luteolin and myricetin to be the phytochemicals that were present in the highest concentration in AEPAS. The outcome of this research showed that the administration of AEPAS can promote the activation of the PI3K/AkT pathway and the inhibition of ß-cell death, which may be the primary mechanism by which AEPAS promotes insulin sensitivity and regulates glycolipid metabolism.

Annona muricata L. peel extract inhibits carbohydrate metabolizing enzymes and reduces pancreatic ß-cells, inflammation, and apoptosis via upregulation of PI3K/AKT genes.

BACKGROUND AND OBJECTIVE: Annona muricata L. peel has been recognized for many ethnobotanical uses, including diabetes management. However, limited detailed scientific information about its mechanism of antidiabetic activity exists. The objective of this study was to evaluate the anti-diabetic properties of an aqueous extract of A. muricata peel (AEAMP) and its mechanism of action on alloxan-induced diabetic rats. METHODS: In vitro antidiabetic assays, such as α-amylase and α-glucosidase were analyzed on AEAMP. Alloxan monohydrate (150 mg/kg b.w) was used to induce diabetes in the rats. 150 mg/kg b.w positive control group doses of 6.67, 13.53, and 27.06 mg/kg were administered to 3 groups for twenty-one days. The positive control group was administered 30 mg/kg of metformin. The negative and normal control groups were administered distilled water. The fasting blood glucose, serum insulin, lipid profile, inflammatory cytokines, antioxidant markers, carbohydrate metabolizing enzymes, and liver glycogen were analyzed as well as PI3K/AKT and apoptotic markers PCNA and Bcl2 by RT-PCR. RESULTS: AEAMP inhibited α-amylase and α-glucosidase enzymes more effectively than acarbose. AEAMP reduced FBG levels, HOMA-IR, G6P, F-1,6-BP, MDA, TG, TC, AI, CRI, IL-6, TNF-α, and NF-κB in diabetic rats. Furthermore, in diabetic rats, AEAMP improved serum insulin levels, HOMA-ß, hexokinase, CAT, GST, and HDL-c. Liver PI3K, liver PCNA and pancreas PCNA were not significantly different in untreated diabetic rats when compared to normal rats suggesting alloxan induction of diabetes did not downregulate the mRNA expression of these genes. AEAMP significantly up-regulated expression of AKT and Bcl2 in the liver and pancreatic tissue. It is interesting that luteolin and resorcinol were among the constituents of AEAMP. CONCLUSIONS: AEAMP can improve ß-cell dysfunction by upregulating liver AKT and pancreatic PI3K and AKT genes, inhibiting carbohydrate metabolizing enzymes and preventing apoptosis by upregulating liver and pancreatic Bcl2. However, the potential limitation of this study is the unavailability of equipment and techniques for collecting more data for the study.

Antidiabetic Activity of Elephant Grass (Cenchrus Purpureus (Schumach.) Morrone) via Activation of PI3K/AkT Signaling Pathway, Oxidative Stress Inhibition, and Apoptosis in Wistar Rats.

Ethnopharmacological Relevance: The management of diabetes over the years has involved the use of herbal plants, which are now attracting interest. We assessed the antidiabetic properties of aqueous extract of C. purpureus shoots (AECPS) and the mechanism of action on pancreatic ß-cell dysfunction. Methods: This study was conducted using Thirty-six 36) male Wistar rats. The animals were divided into six equal groups (n = 6) and treatment was performed over 14 days. To induce diabetes in the rats, a single dose of 65 mg/kg body weight of alloxan was administered intraperitoneal along with 5% glucose. HPLC analysis was carried out to identified potential compounds in the extract. In vitro tests α-amylase, and α-glucosidase were analyzed. Body weight and fasting blood glucose (FBG) were measured. Biochemical parameters, such as serum insulin, liver glycogen, hexokinase, glucose-6-phosphate (G6P), fructose-1,6-bisphosphatase (F-1,6-BP), interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-α), and nuclear factor kappa B (NF-ĸB), were analyzed. Additionally, mRNA expressions of phosphatidylinositol 3-kinase/protein kinase B (PI3K/AKT), B-cell lymphoma 2 (Bcl-2), and proliferating cell nuclear antigen (PCNA) were each evaluated. Results: This in vitro study showed inhibitory potency of Cenchrus purpureus extract (AECPS) as compared with the positive controls. AECPS showed a gradual decrease in alloxan-induced increases in FBG, total cholesterol (TC), triglycerides (TG), low density lipoprotein (LDL-c), G6P, F-1,6-BP, malondialdehyde (MDA), IL-6, TNF-α, and NF-ĸB and increased alloxan-induced decreases in liver glycogen, hexokinase, and high density lipoprotein (HDL-c). The diabetic control group exhibited pancreatic dysfunction as evidenced by the reduction in serum insulin, homeostasis model assessment of ß-cell function (HOMA-ß), expressions of PI3K/AKT, Bcl-2, and PCNA combined with an elevation in homeostatic model assessment of insulin resistance (HOMA-IR). High performance liquid chromatography (HPLC) revealed 3-O-rutinoside, ellagic acid, catechin, rutin, and kaempferol in AECPS. Conclusion: AECPS showed efficient ameliorative actions against alloxan-induced pancreatic dysfunction, oxidative stress suppression as well as, inflammation, and apoptosis via the activation of PI3K/AKT signaling pathways.

Effect of apolipoprotein E genotype on apolipoprotein B-100 metabolism in normolipidemic and hyperlipidemic subjects.

The effect of apolipoprotein (apo) E genotype on apoB-100 metabolism was examined in three normolipidemic apoE2/E2, five type III hyperlipidemic apoE2/E2, and five hyperlipidemic apoE3/E2 subjects using simultaneous administration of (131)I-VLDL and (125)I-LDL, and multi-compartmental modeling. Compared with normolipidemic apoE2/E2 subjects, type III hyperlipidemic E2/E2 subjects had increased plasma and VLDL cholesterol, plasma and VLDL triglycerides, and VLDL and intermediate density lipoprotein (IDL) apoB concentrations (P < 0.05). These abnormalities were chiefly a consequence of decreased VLDL and IDL apoB fractional catabolic rate (FCR). Compared with hyperlipidemic E3/E2 subjects, type III hyperlipidemic E2/E2 subjects had increased IDL apoB concentration and decreased conversion of IDL to LDL particles (P < 0.05). In a pooled analysis, VLDL cholesterol was positively associated with VLDL and IDL apoB concentrations and the proportion of VLDL apoB in the slowly turning over VLDL pool, and was negatively associated with VLDL apoB FCR after adjusting for subject group. VLDL triglyceride was positively associated with VLDL apoB concentration and VLDL and IDL apoB production rates after adjusting for subject group. A defective apoE contributes to altered lipoprotein metabolism but is not sufficient to cause overt hyperlipidemia. Additional genetic mutations and environmental factors, including insulin resistance and obesity, may contribute to the development of type III hyperlipidemia.