Ozone application in different industries: A review of recent developments.

Ozone - a powerful antimicrobial agent, has been extensively applied for decontamination purposes in several industries (including food, water treatment, pharmaceuticals, textiles, healthcare, and the medical sectors). The advent of the COVID-19 pandemic has led to recent developments in the deployment of different ozone-based technologies for the decontamination of surfaces, materials and indoor environments. The pandemic has also highlighted the therapeutic potential of ozone for the treatment of COVID-19 patients, with astonishing results observed. The key objective of this review is to summarize recent advances in the utilisation of ozone for decontamination applications in the above-listed industries while emphasising the impact of key parameters affecting microbial reduction efficiency and ozone stability for prolonged action. We realise that aqueous ozonation has received higher research attention, compared to the gaseous application of ozone. This can be attributed to the fact that water treatment represents one of its earliest applications. Furthermore, the application of gaseous ozone for personal protective equipment (PPE) and medical device disinfection has not received a significant number of contributions compared to other applications. This presents a challenge for which the correct application of ozonation can mitigate. In this review, a critical discussion of these challenges is presented, as well as key knowledge gaps and open research problems/opportunities.

Differences in sensorimotor and functional recovery between the dominant and non-dominant upper extremity following cervical spinal cord injury.

STUDY DESIGN: Post hoc analysis of prospective multi-national, multi-centre cohort study. OBJECTIVE: Determine whether cerebral dominance influences upper extremity recovery following cervical spinal cord injury (SCI). SETTING: A multi-national subset of the longitudinal GRASSP dataset (n = 127). METHODS: Secondary analysis of prospective, longitudinal multicenter study of individuals with cervical SCI (n = 73). Study participants were followed for up to 12 months after a cervical SCI, and the following outcome measures were serially assessed - the Graded Redefined Assessment of Strength, Sensibility, and Prehension (GRASSP) and the International Standards for the Neurological Classification of SCI (ISNCSCI), including upper extremity motor and sensory scores. Observed recovery and relative (percent) recovery were then determined for both the GRASSP and ISNCSCI, based on change from initial to last available assessment. RESULTS: With the exception of prehension performance (quantitative grasping) following complete cervical SCI, there were no significant differences (p < 0.05) for observed and relative (percent) recovery, between the dominant and non-dominant upper extremities, as measured using GRASSP subtests, ISNCSCI motor scores and ISNCSCI sensory scores. CONCLUSION: Despite well documented differences between the cerebral hemispheres, cerebral dominance appears to play a limited role in upper extremity recovery following acute cervical SCI.

Development of the spinal cord injury pressure sore onset risk screening (SCI-PreSORS) instrument: a pressure injury risk decision tree for spinal cord injury rehabilitation.

STUDY DESIGN: Psychometric study based on retrospectively collected data. OBJECTIVE: Development of a pressure injury (PI) risk screening instrument for use during spinal cord injury (SCI) rehabilitation. SETTING: Tertiary rehabilitation center. METHODS: Medical charts of 807 inpatients participating in SCI rehabilitation were reviewed. Two models (recursive partitioning and logistic regression) were developed with demographic and Functional Independence Measure (FIM) variables and compared with the SCI Pressure Ulcer Scale (SCIPUS, n = 603) and Braden scale (n = 100) using modeling (n = 615) and validation (n = 192) datasets. Sensitivity and specificity analyses were completed for each model. Models yielding high sensitivity and area under the curve (AUC), while minimizing false negatives (FN < 0.5%) were preferred. RESULTS: In the modeling dataset, a single dichotomized FIM variable, Bed/Chair Transfers <4, was predictive of PI incidence (sensitivity = 97%, AUC = 74%, FN = 0.49%) and had similar metrics as the logistic regression model (sensitivity = 97%, AUC = 76%, FN = 0.49%). The recursive partitioning model had fewer FN (sensitivity = 98%, AUC = 75%, FN = 0.33%). When applied to the validation dataset, both models performed similarly. The SCIPUS performed poorly (AUC < 70%). When analyses were limited to cases with available Braden data and no admission PI, recursive partitioning outperformed the other methods for PI risk screening. CONCLUSION: A recursive partitioning model, named the SCI-PreSORS (SCI Pressure Sore Onset Risk Screening), demonstrated promise for PI risk screening during inpatient SCI rehabilitation. Prospective validation of the new model is warranted.

Development of a novel neurogenic bowel patient reported outcome measure: the Spinal Cord Injury Patient Reported Outcome Measure of Bowel Function & Evacuation (SCI-PROBE).

STUDY DESIGN: Outcome measure item generation and reduction. OBJECTIVES: To develop a patient reported outcome measure (PROM) addressing the impact of neurogenic bowel dysfunction (NBD) on individuals living with traumatic or nontraumatic spinal cord injury (SCI). SETTING: Tertiary rehabilitation center in Toronto, Canada. METHODS: A PROM based on the International Classification of Functioning, Disability and Health (ICF) framework was developed using the following steps: (a) item generation, (b) item refinement through iterative review, (c) completion of items by individuals living with SCI and NBD followed by cognitive interviewing, and (d) further item refinement, item reduction, and construction of the preliminary PROM. RESULTS: Following initial item generation and iterative review, the investigative team agreed on 55 initial items. Cognitive interviewing, additional revisions, and item reduction yielded an instrument comprised of 35 items; while ensuring at least two items were retained for each of the 16 previously identified challenges of living with NBD following the onset of a SCI. Scoring for the preliminary PROM ranges from 0 to 140. CONCLUSIONS: A preliminary PROM informed by the ICF for assessing the impact of NBD post-SCI has been devised, which can be used to inform clinicians and decision-makers on optimal ways to treat this serious secondary health complication. Future work will assess the validity and clinimetric properties of the PROM.

Determining Pressure Injury Risk on Admission to Inpatient Spinal Cord Injury Rehabilitation: A Comparison of the FIM, Spinal Cord Injury Pressure Ulcer Scale, and Braden Scale.

OBJECTIVE: Assess the utility of the admission Spinal Cord Injury Pressure Ulcer Scale (SCIPUS), Braden Scale, and the FIM for identifying individuals at risk for developing pressure injury during inpatient spinal cord injury (SCI) rehabilitation. DESIGN: Retrospective cohort. SETTING: Two tertiary rehabilitation centers. PARTICIPANTS: Individuals (N=754) participating in inpatient SCI rehabilitation. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Logistic regression analysis was performed to determine the utility of the SCIPUS, Braden Scale, and FIM for identifying individuals at risk for developing pressure injury (PI) during inpatient SCI rehabilitation. Sensitivity, specificity, positive predictive value, negative predictive value, false negative rate, odds ratio, likelihood ratio, and area under the curve (AUC) are reported. RESULTS: The SCIPUS total score and its individual items did not demonstrate acceptable accuracy (AUC≥0.7) whereas the Braden Scale (0.73) and the FIM score (0.74) did. Once items were dichotomized into high and low risk categories, 1 Braden item (friction and shear), 5 FIM items (bathing, toileting, bed/chair transfer, tub/shower transfer, toilet transfer), the FIM transfers subscale, FIM Motor subscale, and the FIM instrument as a whole, maintained AUCs ≥0.7 and negative predictive values ≥0.95. The FIM bed/chair transfer score demonstrated the highest likelihood ratio (2.62) and overall was the most promising measure for determining PI risk. CONCLUSION: Study findings suggest that a simple measure of mobility, admission FIM bed/chair transfer score of 1 (total assist), can identify at-risk individuals with greater accuracy than both an SCI specific instrument (SCIPUS) and a PI specific instrument (Braden). The FIM bed/chair transfer score can be readily determined at rehabilitation admission with minimal administrative and clinical burden.

Implementation of Pressure Injury Prevention Best Practices Across 6 Canadian Rehabilitation Sites: Results From the Spinal Cord Injury Knowledge Mobilization Network.

OBJECTIVE: To use the theoretical frameworks of implementation science to implement pressure injury (PI) prevention best practices in spinal cord injury (SCI) rehabilitation. DESIGN: Quality improvement. SETTING: Six Canadian SCI rehabilitation centers. PARTICIPANTS: Inpatients (N=2371) admitted from 2011 to 2015. INTERVENTIONS: The SCI Knowledge Mobilization Network (SCI KMN) selected and implemented 2 PI prevention best practices at 6 Canadian SCI rehabilitation centers: (1) completing a comprehensive PI risk assessment comprised of a structured risk assessment instrument followed by an individualized, interprofessional risk factor determination and prevention plan; and (2) providing structured and individualized PI prevention patient education. Active Implementation Frameworks provided a systematic approach to best practice implementation. MAIN OUTCOME MEASURES: Implementation indicators (completion rates) and patient outcomes (PI incidence, patient education survey). RESULTS: After implementation, risk assessment completion rates improved from 46% to 94% (P<.05). Between initial (2012-2013) and full (2014-2015) implementation stages, completion rates improved for both interprofessional risk factor determination (67% to 96%) and prevention plans (67% to 94%). Documentation of patient education also increased to 86% (vs. 71% preimplementation). At rehabilitation admission 22% of patients had PIs, with 14% of individuals developing new PIs during rehabilitation. The overall PI prevalence was 30%. Considering only PIs of stage 2 or greater, prevalence was 21% and incidence 7%. There were no statistically significant differences in PI incidence between pre- and postimplementation. Patient education surveys indicated that PI education improved patients' knowledge of prevention strategies. CONCLUSIONS: Active Implementation Frameworks supported successful implementation of PI prevention best practices across the 6 participating SCI KMN sites. Achieving a reduction in PI incidence will require additional measures, and there is an ongoing need to strengthen the evidence base underpinning PI prevention guidelines.

The Spinal Cord Injury Pressure Ulcer Scale (SCIPUS): an assessment of validity using Rasch analysis.

STUDY DESIGN: Secondary analysis of retrospective data. OBJECTIVE: The aim of this study was to further validate the Spinal Cord Injury Pressure Ulcer Scale (SCIPUS) using Rasch analysis. SETTING: Two rehabilitation centers in Canada. METHOD: Data were collected as part of the Spinal Cord Injury Knowledge Mobilization Network (SCI KMN) initiative. The SCIPUS was completed within 72 h of inpatient admission. Persons admitted for initial rehabilitation in two inpatient spinal cord rehabilitation programs were included in the project. RESULTS: Data from 886 participants were analyzed, approximately 60% of whom were males. Rasch analyses demonstrated that the SCIPUS, in its current format did not meet criteria required for true measurement. A transformed version of the SCIPUS obtained by deletion of misfitting items and modification of the response scales improved fit to the model and showed preliminary evidence of unidimensionality. The person separation index, however indicated that the scale requires further adjustments of its scoring options. CONCLUSIONS: In its original form, the SCIPUS does not meet the requirements of the Rasch model and its total score should be used cautiously. However, following some adjustments to the items such as addressing DIF between sites to insure a standardized assessment across sites and adding response options to some of the items, interval-scale measurement should be possible.

Optimizing the Management of Spasticity in People With Spinal Cord Damage: A Clinical Care Pathway for Assessment and Treatment Decision Making From the Ability Network, an International Initiative.

The recognition, evaluation, and management of disabling spasticity in persons with spinal cord damage (SCD) is a challenge for health care professionals, institutions, health systems, and patients. To guide the assessment and management of disabling spasticity in individuals with SCD, the Ability Network, an international panel of clinical experts, developed a clinical care pathway. The aim of this pathway is to facilitate treatment decisions that take into account the effect of disabling spasticity on health status, individual preferences and treatment goals, tolerance for adverse events, and burden on caregivers. The pathway emphasizes a patient-centered, individualized approach and the need for interdisciplinary coordination of care, patient involvement in goal setting, and the use of assessment and outcome measures that lend themselves to practical application in the clinic. The clinical care pathway is intended for use by health care professionals who provide care for persons with SCD and disabling spasticity in various settings. Barriers to optimal spasticity management in these people are also discussed. There is an urgent need for the clinical community to clarify and overcome barriers (knowledge-based, organizational, health system) to optimizing the management of spasticity in people with SCD.

Clinical Assessment of Spasticity in People With Spinal Cord Damage: Recommendations From the Ability Network, an International Initiative.

A thorough assessment of the extent and severity of spasticity, and its effect on functioning, is central to the effective management of spasticity in persons with spinal cord damage (SCD). These individuals however do not always receive adequate assessment of their spasticity. Inadequate assessment compromises management when the effect of spasticity and/or need for intervention are not fully recognized. Assessment is also central to determining treatment efficacy. A barrier to spasticity assessment has been the lack of consensus on clinical and functional measures suitable for routine clinical practice. To extend on existing work, a working group of the Ability Network identified and consolidated information on possible measures, and then synthesized and formulated findings into practical recommendations for assessing spasticity and its effect on function in persons with SCD. Sixteen clinical and functional measures that have been used for this purpose were identified using a targeted literature review. These were mapped to the relevant domains of the International Classification of Functioning, Disability and Health to assess the breadth of their coverage; coverage of many domains was found to be lacking, suggesting a focus for future work. The advantages, disadvantages, and usefulness of the measures were assessed using a range of criteria, with a focus on usefulness and feasibility in routine clinical practice. Based on this evaluation, a selection of measures suitable for initial and follow-up assessments are recommended. The recommendations are intended to have broad applicability to a variety of health care settings where people with SCD are managed.

Optimizing the Management of Disabling Spasticity Following Spinal Cord Damage: The Ability Network-An International Initiative.

Optimizing the treatment of disabling spasticity in persons with spinal cord damage is hampered by a lack of consensus regarding the use of acceptable definitions of spasticity and disabling spasticity, and the relative absence of decision tools such as clinical guidelines and concise algorithms to support decision-making within the broader clinical community. Many people with spinal cord damage are managed outside specialist centers, and variations in practice result in unequal access to best practice despite equal need. In order to address these issues, the Ability Network-an international panel of clinical experts-was initiated to develop management algorithms to guide and standardize the assessment, treatment, and evaluation of outcomes of persons with spinal cord damage and disabling spasticity. To achieve this, consensus was sought on common definitions through facilitated, in-person meetings. To guide patient selection, an in-depth review of the available tools was performed and expert consensus sought to develop an appropriate instrument. Literature reviews are guiding the selection and development of tools to evaluate treatment outcomes (body functions, activity, participation, quality of life) as perceived by people with spinal cord damage and disabling spasticity, and their caregivers and clinicians. Using this approach, the Ability Network aims to facilitate treatment decisions that take into account the following: the impact of disabling spasticity on health status, patient preferences, treatment goals, tolerance for adverse events, and in cases of totally dependent persons, caregiver burden.

Psychometric Properties of the Spinal Cord Injury Pressure Ulcer Scale (SCIPUS) for Pressure Ulcer Risk Assessment During Inpatient Rehabilitation.

OBJECTIVE: To assess the psychometric properties of the Spinal Cord Injury Pressure Ulcer Scale (SCIPUS) for pressure ulcer (PU) risk assessment during inpatient rehabilitation. DESIGN: Prospective cohort. SETTING: Tertiary rehabilitation centers. PARTICIPANTS: Individuals (N=759) participating in inpatient spinal cord injury rehabilitation between January 3, 2012, and April 23, 2014. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Admission SCIPUS scores and the corresponding risk stratification, PU incidence, intraclass correlation coefficient (ICC) for interrater reliability, sensitivity, specificity, and likelihood ratios (LRs). Receiver operating characteristic analysis was performed to calculate the area under the curve (AUC). RESULTS: Mean SCIPUS scores were higher for individuals who developed PUs than for those who did not (mean SCIPUS score, 9.8±2.5 vs 8.5±2.6). Interrater reliability was excellent for SCIPUS composite scores (ICC=.91) and very good for risk stratification (ICC=.86). Using the existing cutoff value of ≥6 for "high risk" category, sensitivity and specificity were estimated to be .97 and .12, respectively, with an LR of 1.1. A cutoff value of ≥8 yielded a better balance between sensitivity and specificity (.85 and .38, respectively). The AUC equaled .64 with an LR of 1.4. Results were similar when the analysis was confined to PUs of stage II or greater. CONCLUSIONS: The psychometric properties of the SCIPUS do not currently support its routine use as a measure of PU risk in individuals with spinal cord injury undergoing inpatient rehabilitation. LRs of <2 indicate that stratification as high risk or very high risk does not substantially increase the likelihood of identifying individuals who develop PUs beyond chance alone. AUCs were also below the desired cutoff value of 0.7.

Phenomenological study of neurogenic bowel from the perspective of individuals living with spinal cord injury.

OBJECTIVE: To gain greater insight into the lived experience of individuals with spinal cord injury (SCI) and neurogenic bowel dysfunction (NBD). DESIGN: Qualitative (phenomenologic) interviews and analysis. SETTING: Community. PARTICIPANTS: Individuals with SCI and NBD (N=19) residing in the community. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Concerns related to living with NBD after SCI. RESULTS: Challenges related to living with SCI and NBD included costs and requirements, emotional impact, diet, education and employment, intimacy and interpersonal relations, social participation, spontaneity and daily schedule, travel, lack of appropriate and consistent assistance, loss of autonomy (independence, privacy), lack of predictability and fear of incontinence, medical complications, pain or discomfort, physical effort of the bowel routine, physical experience, and time requirements. CONCLUSIONS: Living with NBD presents many challenges. When categorized according to the International Classification of Functioning, Disability and Health, identified domains include body functions and structures, activity, participation, environmental factors, and personal factors. Identified issues have implications for improving clinical management and should be assessed when determining the impact and efficacy of interventions.

Maladaptive dependency schemas, posttraumatic stress hyperarousal symptoms, and intimate partner aggression perpetration.

This study examined the associations between maladaptive dependency-related schemas, posttraumatic stress disorder (PTSD) hyperarousal symptoms, and intimate-partner psychological and physical aggression in a sample of court-referred men (N = 174) participating in a domestic-abuser-intervention program. The men were largely African American; average age was 33.5 years. The extent to which hyperarousal symptoms moderated the association between dependency schemas and aggression was also examined. Maladaptive dependency-related schemas were positively associated with severe psychological, and mild and severe physical aggression perpetration. Hyperarousal symptoms were positively associated with mild and severe psychological aggression, and mild physical aggression perpetration. Multiple regression analyses showed a significant interaction for mild physical aggression: For those with high levels of hyperarousal symptoms, greater endorsement of maladaptive dependency schemas was associated with the perpetration of aggression (B = 0.98, p = .001). For those with low levels of hyperarousal symptoms, there was no association between dependency schemas and aggression (B = 0.04, ns). These findings suggest that focusing on problematic dependency and PTSD-hyperarousal symptoms in domestic-abuser-intervention programs may be helpful, and that examining related variables as possible moderators between dependency schemas and intimate aggression would be a fruitful area for future research.

The synergistic antibacterial activity of ozone and surfactant mists.

The microbiological safety of medical equipment and general surfaces is paramount to both the well-being of patients and the public. The application of ozone (a potent oxidant) has been recognised and implemented for this purpose, globally. However, it has primarily been utilised in the gaseous and aqueous forms. In this study, we investigate the potency of fine ozone mists and evaluate the synergistic effect when combined with cationic, anionic and non-ionic surfactants (dodecyl trimethyl ammonium bromide - DTAB, sodium dodecyl sulfate - SDS, alkyl polyglycoside - APG) as well as polyethylene glycol (PEG). Ozone mist is generated via a nebuliser (equipped with a compressed gas stream) and the piezoelectric method; whereas fabric substrates contaminated with Escherichia coli and Staphylococcus aureus are utilised in this study. Contamination levels on the fabric swatches are evaluated using agar dipslides. Compared to gaseous ozonation and aqueous ozonation (via nanobubble generation), the produced ozone mists showed significantly inferior antimicrobial properties for the tested conditions (6 ppm, 5-15 min). However, the hybrid mist-based application of 'ozone + surfactants' and 'ozone + PEG' showed considerable improvements compared to their independent applications (ozone mist only and surfactant mist only). The 'ozone + DTAB' mist had the highest activity, with better results observed with the micron-mist nebuliser than the piezoelectric transducer. We propose a likely mechanism for this synergistic performance (micellar encapsulation) and demonstrate the necessity for continued developments of novel decontamination technologies.

A Scoping Review of Epidural Spinal Cord Stimulation for Improving Motor and Voiding Function Following Spinal Cord Injury.

Objectives: To identify and synthesize the existing evidence on the effectiveness and safety of epidural spinal cord stimulation (SCS) for improving motor and voiding function and reducing spasticity following spinal cord injury (SCI). Methods: This scoping review was performed according to the framework of Arksey and O'Malley. Comprehensive serial searches in multiple databases (MEDLINE, Embase, Cochrane Central, Cochrane Database of Systematic Reviews, LILACS, PubMed, Web of Science, and Scopus) were performed to identify relevant publications that focused on epidural SCS for improving motor function, including spasticity, and voiding deficits in individuals with SCI. Results: Data from 13 case series including 88 individuals with complete or incomplete SCI (American Spinal Injury Association Impairment Scale [AIS] grade A to D) were included. In 12 studies of individuals with SCI, the majority (83 out of 88) demonstrated a variable degree of improvement in volitional motor function with epidural SCS. Two studies, incorporating 27 participants, demonstrated a significant reduction in spasticity with SCS. Two small studies consisting of five and two participants, respectively, demonstrated improved supraspinal control of volitional micturition with SCS. Conclusion: Epidural SCS can enhance central pattern generator activity and lower motor neuron excitability in individuals with SCI. The observed effects of epidural SCS following SCI suggest that the preservation of supraspinal transmission is sufficient for the recovery of volitional motor and voiding function, even in patients with complete SCI. Further research is warranted to evaluate and optimize the parameters for epidural SCS and their impact on individuals with differing degrees of severity of SCI.

Ozone Decontamination of Medical and Nonmedical Devices: An Assessment of Design and Implementation Considerations.

The control of infectious diseases can be improved via carefully designed decontamination equipment and systems. Research interest in ozone (a powerful antimicrobial agent) has significantly increased over the past decade. The COVID-19 pandemic has also instigated the development of new ozone-based technologies for the decontamination of personal protective equipment, surfaces, materials, and indoor environments. As this interest continues to grow, it is necessary to consider key factors affecting the applicability of lab-based findings to large-scale systems utilizing ozone. In this review, we present recent developments on the critical factors affecting the successful deployments of industrial ozone technologies. Some of these include the medium of application (air or water), material compatibility, efficient circulation and extraction, measurement and control, automation, scalability, and process economics. We also provide a comparative assessment of ozone relative to other decontamination methods/sterilization technologies and further substantiate the necessity for increased developments in gaseous and aqueous ozonation. Modeling methodologies, which can be applied for the design and implementation of ozone contacting systems, are also presented in this review. Key knowledge gaps and open research problems/opportunities are extensively covered including our recommendations for the development of novel solutions with industrial importance.

Challenges and Opportunities in Academic Physiatry: An Environmental Scan.

ABSTRACT: Environmental scans determine trends in an organization's or field's internal and external environment. The results can help shape goals, inform strategic decision making, and direct future actions. The Association of Academic Physiatrists convened a strategic planning group in 2020, composed of physiatrists representing a diversity of professional roles, career stages, race and ethnicity, gender, disability status, and geographic areas of practice. This strategic planning group performed an environmental scan to assess the forces, trends, challenges, and opportunities affecting both the Association of Academic Physiatrists and the entire field of academic physiatry (also known as physical medicine and rehabilitation, physical and rehabilitation medicine, and rehabilitation medicine). This article presents aspects of the environmental scan thought to be most pertinent to the field of academic physiatry organized within the following five themes: (1) Macro/Societal Trends, (2) Technological Advancements, (3) Diversity and Global Outreach, (4) Economy, and (5) Education/Learning Environment. The challenges and opportunities presented here can provide a roadmap for the field to thrive within the complex and evolving healthcare systems in the United States and globally.

The challenge of spinal cord injury care in the developing world.

Great strides have been made in reducing morbidity and mortality following spinal cord injury (SCI), and improving long-term health and community participation; however, this progress has not been uniform across the globe. This review highlights differences in global epidemiology of SCI and the ongoing challenges in meeting the needs of individuals with SCI in the developing world, including post-disaster. Significant disparities persist, with life expectancies of 2 years or less not uncommon for persons living with paraplegia in many developing countries. The international community has an important role in improving access to appropriate care following SCI worldwide.

Secondary Complications in SCI Across the Continuum: Using Operations Research to Predict the Impact and Optimize Management Strategies.

Secondary complications following traumatic spinal cord injury (tSCI) have a tremendous impact on quality of life and health care costs. Although some complications result from the injury itself, many originate from the care provided; complications arising early in the tSCI journey can predispose an individual to recurrence later. To measure the total impact of secondary complications on patient outcomes and health care costs, all the stages of care, from first response to life in the community, must be spanned. Interventions to ameliorate secondary complications need to consider the effects on the whole system and not just individual phases of care; however, such an approach is not common in the literature. To measure the impact of complications as well as the effect of proposed interventions, a partnership between clinical researchers and operations research professionals was formed to develop a discrete-event simulation model of the entire continuum of tSCI care. In this article, we focus on the part of the model concerning common secondary complications (eg, pressure ulcers, pneumonia). We first describe early results from the model, discuss how the effects from the complications impact care throughout the tSCI continuum, and review assumptions of the model. The article concludes with a discussion as to the possible uses of the model, their strengths/limitations, and future directions.

Microbial Inactivation: Gaseous or Aqueous Ozonation?

For decades, ozone has been known to have antimicrobial properties when dissolved or generated in water and when utilized in its gaseous form on different substrates. This property (the ability to be used in air and water) makes it versatile and applicable to different industries. Although the medium of ozonation depends on the specific process requirements, some industries have the inherent flexibility of medium selection. Thus, it is important to evaluate the antimicrobial efficacy in both media at similar concentrations, an endeavor hardly reported in the literature. This study provides insights into ozone's efficacy in air and water using two Gram-negative bacteria (Escherichia coli NTCC1290 and Pseudomonas aeruginosa NCTC10332), two Gram-positive bacteria (Staphylococcus aureus ATCC25923 and Streptococcus mutans), and two fungi (Candida albicans and Aspergillus fumigatus). For gaseous ozonation, we utilized a custom-made ozone chamber (equipped with ultraviolet lamps), whereas an electrolysis oxygen radical generator was applied for ozone generation in water. During gaseous ozonation, the contaminated substrates (fabric swatches inoculated with bacterial and fungal suspensions) were suspended in the chamber, whereas the swatches were immersed in ozonated water for aqueous ozone treatment. The stability of ozone nanobubbles and their resulting impact on the aqueous disinfection efficiency were studied via dynamic light scattering measurements. It was observed that ozone is more effective in air than in water on all tested organisms except Staphylococcus aureus. The presented findings allow for the adjustment of the treatment conditions (exposure time and concentration) for optimal decontamination, particularly when a certain medium is preferred for ozonation.