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Brock Macdonald1, Evi Vakiani2, Rhonda K Yantiss3, Jun Lee4, Robert S Brown Jr5, Samuel H Sigal61Division of Gastroenterology, Department of Medicine, University of California-San Francisco, San Francisco, CA, 2Department of Pathology, Memorial Sloan–Kettering Cancer Center, New York, NY, 3Department of Pathology and Laboratory Medicine, New York Weill Cornell Medical College, New York, NY, 4Division of Nephrology, Department of Medicine, Weill Cornell Medical College, New York, NY, 5Division of Gastroenterology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, 6Division of Gastroenterology and Hepatology, Department of Medicine, New York University, New York, NY, USAAbstract: The use of sirolimus as an alternative to calcineurin inhibitors for posttransplant immunosuppression is associated with a variety of inflammatory conditions. In this report, we describe the case of a 34-year-old man who developed abnormal liver tests 6 years after live-donor kidney transplantation and 5 years after initiation of sirolimus-based immunosuppression. Elevated aminotransferase levels persisted after withdrawal of potentially hepatotoxic medications, and serologic evaluation for viral hepatitis, autoimmune disease, and genetic disorders was unrevealing. Liver biopsy revealed prominent hepatocellular injury associated with a mixed inflammatory infiltrate and liver tests normalized within 2 weeks of discontinuation of sirolimus. In this report, we review previous reports of sirolimus hepatotoxicity and propose a unifying hypothesis for the various inflammatory conditions that have been attributed to sirolimus.Keywords: sirolimus, immunosuppression, transplant, inflammatory conditions, hepatotoxicity

Abstract Background Violence against nurses is common. Previous research has recommended further development of the measurement of violence against nurses and integration of the individual and ward-related factors that contribute to violence against hospital nurses. This study was designed to address these issues by investigating the associations between violence, the listening climate of hospital wards, professional burnout, and perceived quality of care. For this purpose, we used a new operationalization of the violence concept. Methods We sought nurses to participate in the study through social media which yielded 765 nurses working in various healthcare systems across Israel who volunteered to complete a self-administered online questionnaire. 80% of the sample were hospital nurses, and 84.7% were female. The questionnaire included validated measures of burnout, listening climate, and quality of care. Instead of using the traditional binary measure of exposure to violence to capture the occurrence and comprehensive impact of violence, this study measured the incremental load of violence to which nurses are subjected. Results There were significant correlations between violence load and perceived quality of care and between constructive and destructive listening climates and quality of care. Violence load contributed 14% to the variance of burnout and 13% to the variance of perceived quality of care. The ward listening climate moderated the relationship between burnout and quality of care. Conclusions The results of this study highlight the impact of violence load among nurses and the ward listening climate on the development of burnout and on providing quality care. The findings call upon policymakers to monitor violence load and allocate resources to foster supportive work environments to enhance nurse well-being and improve patient care outcomes.

Abstract Objectives To examine the association between listening and disruptive behaviors and the association between disruptive behavior and the wellbeing of the nurse. To test whether constructive and destructive listening has an incremental validity. Methods A structured questionnaire survey that measured the (constructive & destructive) listening climate at work, exposure to disruptive behaviors, well-being and feeling as a victim. We presented this survey using the Qualtrics software. Results Of the final sample of 567 respondents who reported that they were nurses, MAge = 38.41, 67% indicated that they were exposed to some form of disruptive behavior. Experiencing listening in the ward was associated with low levels of exposure to disruptive behaviors; exposure to disruptive behaviors, in turn, predicted reduction in the nurses’ wellbeing; the reduction in wellbeing was especially pronounced among nurses who felt like a victim. Each of the facets of the listening measure—constructive listening and destructive listening—had incremental validity in predicting exposure to disruptive behaviors. Finally, the effect of exposure to disruptive behavior on wellbeing was curvilinear. Conclusions Disruptive behavior is a major challenge to the workplace well-being for nurses. The victim mentality has an adverse impact on nurses. Preventive efforts aimed at reducing disruptive behaviors among nurses and decreasing their sense of victimization are crucial for the well-being of nurses.

Abstract Background Violence against medical personnel is unexpected in hospitals which are devoted to healing, and yet, it is frequent and of concern in the health system. Little is known about the factors that lead to hospital violence, and even less is known about the interactions among these factors. The aim of the study was to identify and describe the perceptions of staff and patients regarding the factors that lead to violence on the part of patients and those accompanying them. Methods A mixed-methods study in a large, general, university tertiary hospital. A self-administered survey yielding 678 completed questionnaires, comprising 34% nurses and 66% physicians (93% response rate). Eighteen in-depth interviews were conducted separately with both victims and perpetrators of violent episodes, and four focus-groups (N = 20) were undertaken separately with physicians, staff nurses, head-nurses, and security personnel. Results Violence erupts as a result of interacting factors encompassing staff behavior, patient behavior, hospital setting, professional roles, and waiting times. Patients and staff reported similar perceptions and emotions regarding the episodes of violence in which they were involved. Of 4,047 statements elicited in the staff survey regarding the eruption of violence, 39% referred to staff behavior; 26 % to patient/visitor behavior; 17% to organizational conditions, and 10% to waiting times. In addition, 35% of the staff respondents reported that their own behavior contributed to the creation of the most severe violent episode in which they were involved, and 48% stated that staff behavior contributed to violent episodes. Half of the reasons stated by physicians and nurses for violence eruption were related to patient dissatisfaction with the quality of service, the degree of staff professionalism, or an unacceptable comment of a staff member. In addition, data from the focus groups pointed to lack of understanding of the hospital system on the part of patients, together with poor communication between patients and providers and expectations gaps. Conclusions Our various and triangulated data sources show that staff and patients share conditions of overload, pressure, fatigue, and frustration. Staff also expressed lack of coping tools to prevent violence. Self-conscious awareness regarding potential interacting factors can be used to develop interventions aimed at prevention of and better coping with hospital violence for both health systems' users and providers.