Patient and Family Perpetrated Cyber-Incivility and Cyber-Aggression Within Healthcare: A Cross-Sectional Descriptive Study.

Introduction: Verbal violence may manifest in written form as cyber incivility within patient portal communications. As a form of digital technology, patient portal messages create a physical and emotional distance leading the sender to be disinhibited and disassociated from the recipient nurse. Written patient portal messages may contain uncivil language deemed verbally violent when the content escalates beyond professional standards. When these messages are encountered as part of patient care, they may lead to nurses' psychological distress. Although cyber-incivility has been studied within social media and business, little is known about cyber-incivility within healthcare. Objectives: The purpose of the study was to define cyber-incivility as it manifests within healthcare compared to business, determine sender demographics, and quantify the impact on nurses. Methods: A cross-sectional descriptive study was conducted to analyze portal communications. Nurses forwarded aggressive messages to leadership and quantified their level of distress after receiving the message. Sender demographics were tracked, and content was analyzed using Braun and Clarke's Thematic Analysis. Results: Of the 31 included messages, senders were of varying ages, genders, and marital statuses. Messages rarely related to medications and rarely contained expletives. The most distressing messages were ad hominem, demanding, accusatory, or contained threats. These messages illustrated how healthcare cyber-incivility manifested and deviated from appropriate professional standards to become a form of verbal workplace violence. Message content also identified antecedents; related to unmet expectations, patient accountability, or difficulty navigating healthcare. Conclusions: Written incivil/uncivil/aggressive patient portal messages contained personal attacks and professionally degrading content, which were distressing to nurses. A healthcare-specific framework was created and provided context to understand the difficult and aggressive messages nurses received while providing digital patient care. Awareness of cyber-incivility within healthcare allows for better support of nurses who are exposed to this form of workplace violence and is foundational to future intervention development.

Degradation and remodeling of small intestinal submucosa in canine Achilles tendon repair.

BACKGROUND: Extracellular matrix derived from porcine small intestinal submucosa is used for the repair of musculotendinous tissues. Preclinical evaluation and clinical use have suggested that small intestinal submucosa extracellular matrix degrades rapidly after implantation and can be replaced by host tissue that is functionally and histologically similar to the normal tissue. METHODS: The present study analyzed the temporal degradation of a ten-layer multilaminate device of small intestinal submucosa extracellular matrix used for the repair of canine Achilles tendon and examined the corresponding histological appearance of the remodeled tissue during the course of scaffold degradation. Devices were fabricated from small intestinal submucosa extracellular matrix labeled with 14C. The amount of 14C remaining in the remodeled graft was measured by liquid scintillation counting at three, seven, fourteen, twenty-eight, sixty, and ninety days after surgery. Blood, urine, feces, and other parenchymal tissues were also harvested to determine the fate of scaffold degradation products. Tissue specimens were prepared for routine histological analysis to examine the morphology of the remodeled graft at each time-point. RESULTS: The small intestinal submucosa extracellular matrix graft degraded rapidly, with approximately 60% of the mass lost by one month after surgery, and the graft was completely resorbed by three months after surgery. The graft supported rapid cellular infiltration and host tissue ingrowth. By ninety days after surgery, the remodeled small intestinal submucosa extracellular matrix consisted of a dense collagenous tissue with organization, cellularity, and vascularity similar to that of normal tendon. CONCLUSIONS: Small intestinal submucosa extracellular matrix is rapidly degraded after implantation for the repair of a musculotendinous tissue in this canine Achilles tendon repair model and is replaced by the deposition and organization of host tissue that is histologically similar to that of normal tissue.

Esophageal reconstruction with ECM and muscle tissue in a dog model.

An in vivo study was conducted to determine if an extracellular matrix (ECM) scaffold co-localized with autologous muscle tissue could achieve constructive remodeling of esophageal tissue without stricture. ECM derived from the porcine urinary bladder was processed, decellularized, configured into a tube shape, and terminally sterilized for use as a bioscaffold for esophageal reconstruction in a dog model. Twenty-two dogs were divided into four groups, three groups of five and one group of seven. Groups 1 and 2 were repaired with either ECM alone or muscle tissue alone, respectively. Groups 3 and 4 were repaired with ECM plus either a partial (30%) covering with muscle tissue or a complete (100%) covering with muscle tissue, respectively. Animals in groups 1 and 2 were sacrificed within approximately 3 weeks because of the formation of intractable esophageal stricture. Four of five dogs in group 3 and six of seven dogs in group 4 were survived for 26 days to 230 days and showed constructive remodeling of esophageal tissue with the formation of well organized esophageal tissue layers, minimal stricture, esophageal motility, and a normal clinical outcome. Mechanical testing of a subset of the remodeled esophageal tissue from animals in groups 3 and 4 showed progressive remodeling from a relatively stiff, non-compliant ECM tube structure toward a tissue with near normal biomechanical properties. We conclude that ECM bioscaffolds plus autologous muscle tissue, but not ECM scaffolds or muscle tissue alone, can facilitate the in situ reconstitution of structurally and functionally acceptable esophageal tissue.

Use of a particulate extracellular matrix bioscaffold for treatment of acquired urinary incontinence in dogs.

OBJECTIVE: To evaluate use of a particulate bioscaffold consisting of the extracellular matrix (ECM) of the urinary bladder from pigs for treatment of acquired urinary incontinence in dogs resistant to medical treatment. DESIGN: Case series. ANIMALS: 9 female dogs with acquired urinary incontinence. PROCEDURE: In 6 dogs, 30 mg of particulate ECM in 1.0 mL of a carrier consisting of glycerin and saline 10.9% NaCI) solution was injected into each of 3 equally spaced sites around the circumference of the internal urethral sphincter via an endoscopic technique. In the remaining 3 dogs (control dogs), 1.0 mL of the carrier alone was injected in 3 equally spaced sites around the circumference of the internal urethral sphincter in a similar manner. RESULTS: For dogs treated with the ECM, median duration of urinary continence following treatment was 168 days (range, 84 to 616 days), whereas for the control dogs, median duration of urinary continence following the procedure was 14 days (range, 7 to 31 days). Two of the 3 control dogs were treated with the ECM at the end of the study and were continent for 119 and 252 days. No adverse effects were observed in any dog. CONCLUSIONS AND CLINICAL RELEVANCE: Results suggest that endoscopically guided injection of particulate ECM into the internal urethral sphincter may be useful for the treatment of acquired urinary incontinence in female dogs.

Production and characterization of ECM powder: implications for tissue engineering applications.

Two methods to produce a particulate form of extracellular matrix (ECM) from porcine urinary bladder were investigated. One method to produce the powder involved snap freezing a lyophilized form of the material and then pulverizing it in a grinding mill. The second method was similar except that the ECM was saturated in a solution of NaCl prior to snap freezing to precipitate salt crystals within the matrix before grinding. Several methods were utilized to analyze the particle size distribution and ultrastructure including sonic sifting, laser diffraction, and scanning electron microscopy (SEM). The salt precipitation method yielded a more uniform distribution of particles with a smaller mean diameter (158 vs. 191 microm). SEM showed that the particles produced by grinding without salt precipitation were irregularly shaped, sheet-like particles. ECM particles produced by the salt precipitation method were round and porous in appearance with many particles in the range of 1 microm which tended to agglomerate with the larger particles and with each other. We conclude that the production of a comminuted form of ECM is possible and that the uniformity of particle size and shape are dependent upon the manufacturing methodology.

Extracellular matrix as a scaffold for laryngeal reconstruction.

Porcine-derived xenogeneic extracellular matrix (ECM) has been successfully used as a scaffold for tissue repair and reconstruction in numerous preclinical animal studies and human applications. These scaffolds are completely and rapidly degraded and replaced by host-derived tissues that frequently mimic the original tissue composition and architecture. The purpose of the present study was to examine the morphology of ECM scaffolds after their use for laryngeal reconstruction. Thirty adult female dogs were subjected to a partial hemilaryngectomy. The right thyroid cartilage and vocal fold were replaced with ECM scaffold, and the dogs were painlessly sacrificed from 1 week to 12 months after surgery. Histologic examination of the reconstructed tissue showed the presence of a simple squamous epithelial lining, organized glandular structures within the submucosa, reconstructed thyroid cartilage, and bundles of skeletal muscle by 3 months after surgery. We conclude that ECM scaffolds are promising templates for constructive remodeling of laryngeal tissue.

Morphologic study of small intestinal submucosa as a body wall repair device.

BACKGROUND: The extracellular matrix (ECM) derived from porcine small intestinal submucosa (SIS) has been used as a constructive scaffold for tissue repair in both preclinical animal studies and human clinical trials. Quantitative characterization of the host tissue response to this xenogeneic scaffold material has been lacking. MATERIALS AND METHODS: The morphologic response to a multilaminate form of the SIS-ECM was evaluated in a chronic, 2-year study of body wall repair in two separate species: the dog and the rat. Morphologic response to the SIS-ECM was compared to that for three other commonly used bioscaffold materials including Marlex mesh, Dexon, and Perigard. Quantitative measurements were made of tissue consistency, polymorphonuclear cell response, mononuclear cell response, tissue organization, and vascularity at five time points after surgical implantation: 1 week, 1, 3, and 6 months, and 2 years. RESULTS: All bioscaffold materials functioned well as a repair device for large ventral abdominal wall defects created in these two animal models. The SIS-ECM bioscaffold showed a greater number of polymorphonuclear leukocytes at the 1-week time point and a greater degree of graft site tissue organization after 3 months compared to the other three scaffold materials. There was no evidence for local infection or other detrimental local pathology to any of the graft materials at any time point. CONCLUSIONS: Like Marlex, Dexon, and Perigard, the SIS-ECM is an effective bioscaffold for long-term repair of body wall defects. Unlike the other scaffold materials, the resorbable SIS-ECM scaffold was replaced by well-organized host tissues including differentiated skeletal muscle.