Scope of research
1. Cardiac Arrest
- Out of hospital cardiac arrest – management and outcomes
- Linguistic analysis of dispatch
- Injuries – including falls
- Trauma i.e. traffic accidents
- Prehospital models of care
- Critical illness ‘journey’
- Prehospital clinical practice
- Patient outcomes St John WA
- Prehospital emergency systems modelling – GIS
Our research involves both clinical trials of interventions, and observational studies of patient outcomes. The focus of our research includes the prehospital management of cardiac arrest, trauma, stroke, myocardial infarction (‘heart attack’); heart failure, respiratory failure, asthma and acute pain.
UPDATE: CANCELLED DUE TO WA LEGISLATION
The EXACT study is a phase three multi-centre randomised controlled trial to determine whether reducing oxygen administration to target an oxygen saturation of 90-94 per cent, compared to 98-100 per cent, as soon as possible following successful resuscitation from out of hospital cardiac arrest improves outcome at hospital discharge. The administration of 100 per cent oxygen for the first hours after resuscitation is largely based on tradition and not on any supportive clinical data.
Previous research suggests that the delivery of oxygen at the standard high level (100 per cent) in the hours after a cardiac arrest may increase injury to the brain. This study will investigate if a safe but lower level of oxygen can be administered by paramedics to patients shortly after they have a cardiac arrest and during transportation to hospital. The EXACT study is being undertaken in Western Australia, Victoria and South Australia.
The WA Data Linkage System was established in 1995 to connect all available health and related information for the WA population. This information is used for ethically approved research, planning and evaluation projects which aim to improve the health of Western Australians.
The linkage of St John WA clinical data to other health data such as WA emergency department attendances, WA hospitalisation records and WA death records allows researchers (with suitable ethics approval) to use the de-identified data to determine the outcomes for patients who receive emergency care in the prehospital setting.
The Prehospital Care Record Linkage Project sub-study list includes:
- The epidemiology of out-of-hospital cardiac arrest (OHCA) in Western Australia
- The Epidemiology of out of hospital cardiac arrest in Western Australia: A population-based linked data study
- Relative survival after out-of-hospital cardiac arrest
- Accuracy of call-taker assessment of patient conscious state during emergency ambulance calls in WA
- Improving ambulance dispatch to time-critical emergencies
- Improving ambulance dispatch to time-critical emergencies – Stroke
- The epidemiology of trauma patients attended to by a paramedic staffed emergency service in Perth, Western Australia
- Development of an empirical model for the strategic placement of automated external defibrillators (AEDs) in public locations: improving survival from out-of-hospital cardiac arrest
- Epidemiology of sepsis patients attended by paramedic staffed ambulances in Perth, WA
- Epidemiology of patients with recreation-related incidents attended by St John emergency ambulances in Western Australia.
- Descriptive epidemiology of community based falls related incidents attended by St John WA
- Prehospital emergency medical services prioritisation of road crash victims
- The descriptive epidemiology of agitated patients & the use of sedative agents for patients attended by St John paramedics in Perth, WA
- The epidemiology of older adults attended by ambulance paramedics in WA
As demand for Emergency Department (ED) services continues to exceed any increase that can be explained by population growth, strategies to reduce demand and/or increase supply are being explored.
Since 2016, PRECRU has been investigating emergency call interactions – when a caller rings the ambulance for an Out of Hospital Cardiac Arrest (OHCA) patient. By including a linguist on our team, we can take a mixed methods approach to understanding the communication issues that occur during the phone calls, with a view to improving patient outcomes.
We apply a fine-grained analysis, known as Conversation Analysis, of the turn-taking dialogue between the lay caller and the St John Ambulance call taker. Through this research we can find ways to improve understanding between the two parties, and to reduce the time it takes to dispatch an ambulance and to commence resuscitation on an OHCA patient. Improving phone call communication has the potential to increase a patient’s chance of survival from cardiac arrest.
PRECRU has two linguists in its team:
Current projects include:
Language barriers in OHCA calls
More than a fifth of Australia’s population speak a language other than English at home, yet emergency medical services tend to be English-centric when it comes to communication with the public. Telephone interpreting services are available but are not seen as a viable option for a time-critical emergency like a cardiac arrest.
Our study sets out to:
- identify the differences between language barrier and non-language barrier calls in terms of time intervals to critical points in the call process (such as OHCA recognition); and benchmark these times against the American Heart Association’s time standards for telecommunicator CPR;
- understand the interactional patterns between call-takers and callers in language barrier calls, via linguistic analysis, with a view to recommending how call-takers can effectively handle communication issues.
Unintentional injuries account for a substantial proportion of ambulance attendances, emergency department presentations and hospitalisations in Western Australia. Complementing the strengths of PRECRU’s work on out of hospital cardiac arrest, in 2018 Dr Peter Buzzacott joined PRECRU as Senior Research Fellow to develop and lead an injury research team.
Previous research identified falls as the most common reason for dispatching ambulances in Perth, more common than assault, motor vehicle crashes and stroke combined. In 2018 alone it is estimated there were more than 28,000 falls incidents attended by a St John WA ambulance in WA.
In 2019 a summary of what was currently known about St John WA ambulance falls data was included in the inaugural WA Falls Report, published by Injury Matters and the WA Department of Health. Then, in 2020 Paige Watkins, BSc(Hons), enrolled in a PhD with PRECRU, researching falls attended by SJWA ambulances. This research aims to describe who in WA is attended by an ambulance after falling, what injuries they report, what treatments they receive and what their outcomes are (e.g. treated and not transported, or transported to an emergency department, or elsewhere). A better understanding of the big picture of falls in WA may assist prioritise health care resources, aimed at improving patient outcomes. Furthermore, SJWA falls data (compiled by PRECRU) are again to be included in the forthcoming 2020 WA Falls Report.
Next, a project examining injuries sustained while engaged in trails-type recreation has been identified as a Faculty of Health Sciences strategic priority, and applications for a PhD scholarship are now sought. Details are available here. It is thought the majority of recreational activity in WA is unregulated, non-team based, and that much of it involves trails (hiking, running, mountain biking, horse riding, trail bikes, wildlife photography, camping, etc). Currently, little is known about injuries or adverse health events that occur during the types of activities that often involve trails. The aim of this project is to enable people to use West Australian trails, that take into account, (and mitigate where possible), the types of injuries people experience during their chosen recreation.
PEC-ANZ (Prehospital and Emergency Care Australia and New Zealand) is a new NHMRC funded Centre of Research Excellence established in 2018. Our team comprises some of the most experienced and renowned Austral fields of prehospital emergency care and trauma.We aim to save lives by improving the experiences of Australians relying on ambulance services. We will do this by:
• Generating new knowledge that will enable efficient and effective prehospital emergency care policy and practice.
• Facilitate and coordinate collaborative research projects and build capacity in emergency medical services (EMS) research in Australia (and New Zealand).
• Strengthen the evidence-base on which ambulance services can formulate policies and practices, in order to maximise patient outcomes.
Over the coming years, our new Centre will engage in a series of trials and research projects exploring delivery of care to vulnerable people, the 000 call centre pathway, pain management, explore the impact of emergency-related communications campaigns and more
Severe respiratory distress with extreme breathlessness and distress (for example, from chronic obstructive pulmonary disease, acute pulmonary odema, pneumonia) is potentially life-threatening. Continuous positive airway pressure (CPAP) applied by face mask is an integral part of hospital treatment but better patient outcomes may be achieved when CPAP is applied earlier by paramedics in the prehospital setting. Link here.
Sudden cardiac arrest is a common event in the community. Therapeutic hypothermia decreases the brain injury caused by the cardiac arrest and is currently used in the hospital after successful resuscitation. However, there may be better outcomes if the brain is cooled by paramedics during resuscitation. We will compare survival rates for those patients cooled early by paramedics using an infusion of ice-saline during cardiac arrest with those patients who are later cooled by the hospital.
As demand for Emergency Department (ED) services continues to exceed any increase that can be explained by population growth, strategies to reduce demand and/or increase supply are being explored. The concept of ambulance paramedics providing an alternative model of care to the current ‘see and transport to ED’ has intuitive appeal and a small number of so-called ECPs have been introduced in NSW and SA. Our project will develop and test (through simulation) the feasibility and safety of empirically derived clinical protocols for an ECP role for the Perth metropolitan area. In addition, we will model the impact of the introduction of ECPs on ED demand and investigate the potential for ameliorating the problem of ED over-crowding in Perth.
Staff and Student Publications
Perera, N., Riou, M., Ball, S., Birnie, T., Morgan, A., Whiteside, A., Bray, J., Bailey, P., & Finn, J. (2022). The trajectory of repairs in the defibrillator sequence during emergency cardiac arrest calls – Balancing progressivity and intersubjectivity. Communication and Medicine, 17(2), 150–164.
Finn, J., Brink, D., McKenzie, N., Garcia, A., Tohira, H., Perkins, G., Arendts, G., Fatovich, D., Hendrie, D., McQuillan, B., Summers, Celenza, A., Mukherjee, A., Smedley, B., Pereira, G., Ball, S., Williams, T., & Bailey, P. (2022). Prehospital continuous positive airway pressure (CPAP) for acute respiratory distress: A randomised controlled trial. Emergency Medicine Journal, 39(1), 37-44.
Belcher J, Finn J, Whiteside A, Ball S. ‘Is the patient completely alert?’ – accuracy of emergency medical dispatcher determination of patient conscious state. Australasian Journal of Paramedicine. 2021;18.
Blaxill J, Buzzacott P, Finlay J. Prognostic indicators for naïve canine non-indolent T-cell lymphoma treated with combination lomustine, vincristine, procarbazine and prednisolone (LOPP) chemotherapy. Veterinary and Comparative Oncology. 31/08/2021. https://doi.org/10.1111/vco.12768
Buzzacott P, Anderson G, Tillmans F, Grier JW, Denoble PJ. Incidence of cardiac arrhythmias and left ventricular hypertrophy in recreational scuba divers. Diving Hyperb Med. 2021;51(2):190-8.
Buzzacott P, Hornsby A, Shreeves K. Mortality rate during professionally guided scuba diving experiences for uncertified divers, 1992-2019. Diving Hyperb Med. 2021;51(2):147-51.
Buzzacott P, Tohira H, Bailey P, Arendts G, Ball S, Brown E, Finn J. Fall from standing height, or greater, and mortality among ambulance-transported patients with major trauma from falls. Australasian Journal of Paramedicine. 2021;18.
Buzzacott, P & Skrzypek, G. 2021, Thermal anomaly and water origin in Weebubbie Cave, Nullarbor Karst Plain, Australia. Journal of Hydrology: Regional Studies. 2021:4;100793. Doi: 10.1016/j.ejrh.2021.100793
Doan T N, Wilson D, Rashford S, Ball S, Bosley. Spatiotemporal variation in the risk of out-of-hospital cardiac arrest in Queensland, Australia. Resuscitation Plus. 2021;8.
Howard A, Buzzacott P, Gawthrope C, Banham ND. Effect of antiplatelet and/or anticoagulation medication on the risk of tympanic barotrauma in hyperbaric oxygen therapy patients and development of a predictive model. Diving and Hyperbaric Medicine, 2020;50(4):338-42.
Lautridou J, Dugrenot E, Amérand A, Guernec A, Pichavant-Rafini K, Goanvec C, Inizan M, Albacete G, Belhomme M, Galinat H, Lafère P, Balestra C, Moisan C, Buzzacott P, and Guerrero F. Physiological characteristics associated with increased resistance to decompression sickness in male and female rats. Journal of Applied Physiology. 2020:129(3). doi: 10.1152/japplphysiol.00324.2020.
Majewski D, Ball S, Bailey P, Bray J, Finn J. Long-term survival among OHCA patients who survive to 30 days: Does initial arrest rhythm remain a prognostic determinant? Resuscitation. 2021;162:128-134.
Paiano R, Feletti F, Tarabini M, Buzzacott P. Use of a prospective survey method to capture a picture of overuse injuries in kitesurfing. Muscle Ligaments and Tendons Journal. 2020;10(2);163-8.
Riou M, Ball S, Morgan A, Grant S, Perera N, Whiteside A, Bray J, Bailey P, Finn J. ‘I think he’s dead’: A cohort study of the impact of caller declarations of death during the emergency call on bystander CPR. Resuscitation. 2021.
Watkins P M, Buzzacott P, Brink D, Masters S, Hill A. Pre-hospital management, injuries and disposition of ambulance attended adults who fall: A scoping review protocol. Australian Journal of Paramedicine. 2021;18.
Belcher J, Finn J, Whiteside A, Ball S. Accuracy of call-taker assessment of patient level of consciousness: a systematic review. Australasian Journal of Paramedicine. 2020;17.
Bray JE, Cartledge S, Finn J, Eastwood GM, McKenzie N, Stub D, Straney L, Bernard S. The current temperature: A survey of post-resuscitation care across Australian and New Zealand intensive care units. Resuscitation Plus. 2020;1-2:100002.
Bray J, Nehme Z, Nguyen A, Lockey A, Finn J, Education Implementation Teams Task Force of the International Liaison Committee on Resuscitation. A systematic review of the impact of emergency medical service practitioner experience and exposure to out of hospital cardiac arrest on patient outcomes. Resuscitation. 2020.
Brown E, Tohira H, Bailey P, Finn J. Is age associated with emergency medical service transport to a trauma centre in patients with major trauma? A systematic review. Australasian Journal of Paramedicine. 2020;17.
Brown E, Tohira H, Bailey P, Fatovich D, Pereira G, Finn J. A comparison of major trauma patient transport destination in metropolitan Perth, Western Australia. Australasian Emergency Care. 2020;23(2):90-6.
Cartledge S, Saxton D, Finn J, Bray JE. Australia’s awareness of cardiac arrest and rates of CPR training: results from the Heart Foundation’s HeartWatch survey. BMJ Open. 2020;10(1):e033722.
Ceklic E, Tohira H, Ball S, Brown E, Brink D, Bailey P, Whiteside A, Finn J. Motor vehicle crash characteristics that are predictive of high acuity patients: an analysis of linked ambulance and crash data. Prehosp Emerg Care. 2020:1-13.
Ceklic E, Tohira H, Ball S, Finn J. A systematic review of the relationship between ambulant status and the need for a lights and sirens ambulance response to crashes. Annals of Emergency Dispatch & Response 2020;7(3).
Fatovich D, Finn J, Webb S, Macdonald S. The challenges of obtaining consent in emergency care research. Tasman Medical Journal. 2020;2(1):11-4.
Finn J, Jacobs I, Williams TA, Gates S, Perkins GD. Adrenaline and vasopressin for cardiac arrest. Emergencias. 2020;32(2):133-4.
Greif R, Bhanji F, Bigham BL, Bray J, Breckwoldt J, Cheng A, Duff JP, Gilfoyle E, Hsieh MJ, Iwami T, Lauridsen KG, Lockey AS, Ma MH, Monsieurs KG, Okamoto D, Pellegrino JL, Yeung J, Finn JC, Baldi E, Beck S, Beckers SK, Blewer AL, Boulton A, Cheng-Heng L, Yang CW, Coppola A, Dainty KN, Damjanovic D, Djarv T, Donoghue A, Georgiou M, Gunson I, Krob JL, Kuzovlev A, Ko YC, Leary M, Lin Y, Mancini ME, Matsuyama T, Navarro K, Nehme Z, Orkin AM, Pellis T, Pflanzl-Knizacek L, Pisapia L, Saviani M, Sawyer T, Scapigliati A, Schnaubelt S, Scholefield B, Semeraro F, Shammet S, Smyth MA, Ward A, Zace D, Baldi E, Beck S, Beckers SK, Blewer AL, Boulton A, Cheng-Heng L, Yang CW, Coppola A, Dainty KN, Damjanovic D, Djarv T, Donoghue A, Georgiou M, Gunson I, Krob JL, Kuzovlev A, Ko YC, Leary M, Lin Y, Mancini ME, Matsuyama T, Navarro K, Nehme Z, Pellis T, Pflanzl-Knizacek L, Pisapia L, Saviani M, Sawyer T, Schnaubelt S, Scholefield B, Semeraro F, Shammet S, Smyth MA, Ward A, Zace D, Education I, Teams C. Education, Implementation, and Teams: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Resuscitation. 2020;156:A188-A239.
Kiguchi T, Okubo M, Nishiyama C, Maconochie I, Ong MEH, Kern KB, Wyckoff MH, McNally B, Christensen E, Tjelmeland I, Herlitz J, Perkins GD, Booth S, Finn J, Shahidah N, Shin SD, Bobrow BJ, Morrison LJ, Salo A, Baldi E, Burkart R, Lin CH, Jouven X, Soar J, Nolan JP, Iwami T. Out-of-hospital Cardiac Arrest across the World: First Report from the International Liaison Committee on Resuscitation (ILCOR). Resuscitation. 2020.
Majewski D, Ball S, Bailey P, Bray J, Finn J. Relative long-term survival in out-of-hospital cardiac arrest: Is it really improving? Resuscitation. 2020.
Mckenzie N, Finn J, Dobb G, Bailey P, Arendts G, Celenza A, Fatovich D, Jenkins I, Ball S, Bray J, Ho KM. Non-linear association between arterial oxygen tension and survival after out-of-hospital cardiac arrest: A multicentre observational study. Resuscitation. 2020
Morley PT, Atkins DL, Finn JC, Maconochie I, Nolan JP, Rabi Y, Singletary EM, Wang TL, Welsford M, Olasveengen TM, Aickin R, Billi JE, Greif R, Lang E, Mancini ME, Montgomery WH, Neumar RW, Perkins GD, Soar J, Wyckoff MH, Morrison LJ. Evidence Evaluation Process and Management of Potential Conflicts of Interest: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation. 2020;142(16_suppl_1):S28-S40.
Morley PT, Atkins DL, Finn JC, Maconochie I, Nolan JP, Rabi Y, Singletary EM, Wang TL, Welsford M, Olasveengen TM, Aickin R, Billi JE, Greif R, Lang E, Mancini ME, Montgomery WH, Neumar RW, Perkins GD, Soar J, Wyckoff MH, Morrison LJ. Evidence Evaluation Process and Management of Potential Conflicts of Interest: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Resuscitation. 2020;156:A23-A34.
Perera N, Ball S, Birnie T, Morgan A, Riou M, Whiteside A, Perkins GD, Bray J, Fatovich DM, Cameron P, Brink D, Bailey P, Finn J. “Sorry, what did you say?” Communicating defibrillator retrieval and use in OHCA emergency calls. Resuscitation. 2020;156:182-9.
Perkins GD, Kenna C, Ji C, Deakin CD, Nolan JP, Quinn T, Scomparin C, Fothergill R, Gunson I, Pocock H, Rees N, O’Shea L, Finn J, Gates S, Lall R. The influence of time to adrenaline administration in the Paramedic 2 randomised controlled trial. Intensive Care Medicine. 2020.
Riou M, Ball S, Whiteside A, Gallant S, Morgan A, Bailey P, Finn J. Caller resistance to perform cardio-pulmonary resuscitation in emergency calls for cardiac arrest. Social Science & Medicine. 2020;256:113045.
Schnaubelt S, Monsieurs KG, Semeraro F, Schlieber J, Cheng A, Bigham BL, Garg R, Finn JC, Greif R, International Liaison Committee on Resuscitation Education ITTF. Clinical outcomes from out-of-hospital cardiac arrest in low-resource settings – A scoping review. Resuscitation. 2020;156:137-45.
Talikowska M, Ball S, Rose D, Bailey P, Brink D, Stewart K, Doyle M, Davids L, Finn J. CPR quality among paramedics and ambulance officers: a cross-sectional simulation study. Australian Journal of Paramedicine. 2020.
Yeung J, Djarv T, Hsieh MJ, Sawyer T, Lockey A, Finn J, Greif R, Education I, Team Task F, Neonatal Life Support Task Force of the International Liaison Committee on R. Spaced learning versus massed learning in resuscitation – A systematic review. Resuscitation. 2020;156:61-71.
Belcher J FJ, Whiteside A, Ball S. Accuracy of call-taker assessment of patient level of consciousness, in the setting of telephone calls to an emergency service – a systematic review. Australasian Journal of Paramedicine. 2019;17.
Bray J, Cartledge S, Finn J, Eastwood G, McKenzie N, Stub D, Straney L, Bernard S. The Current Temperature: A Survey of Post-Resuscitation Management Across Australian and New Zealand Intensive Care Units. Australian Critical Care. 2019;32:S4.
Bray JE, Smith K, Hein C, Finn J, Stephenson M, Cameron P, Stub D, Perkins GD, Grantham H, Bailey P, Brink D, Dodge N, Bernard S, investigators E. The EXACT protocol: A multi-centre, single-blind, randomised, parallel-group, controlled trial to determine whether early oxygen titration improves survival to hospital discharge in adult OHCA patients. Resuscitation. 2019;139:208-13.
Brown E, Tohira H, Bailey P, Fatovich D, Finn J. Major trauma patients are not who you might think they are: a linked data study. Australasian Journal of Paramedicine. 2019;16.
Brown E, Tohira H, Bailey P, Fatovich D, Pereira G, Finn J. Longer Prehospital Time was not Associated with Mortality in Major Trauma: A Retrospective Cohort Study. Prehosp Emerg Care. 2019;23(4):527-37.
Brown E, Tohira H, Bailey P, Fatovich D, Pereira G, Finn J. Older age is associated with a reduced likelihood of ambulance transport to a trauma centre after major trauma in Perth. Emerg Med Australas. 2019;31(5):763-71.
Brown E, Tohira H, Bailey P, Fatovich D, Pereira G, Finn J. A comparison of major trauma patient transport destination in metropolitan Perth, Western Australia. Australas Emerg Care. 2019.
Buzzacott P, Schoffl I, Chimiak J, Schoffl V. Rock climbing injuries treated in US Emergency departments. Wilderness and Environmental Med, 2019;30(2):121-28.
Buzzacott P, Grier JW, Walker J, Bennett CM, Denoble PJ. Estimated workload intensity during volunteer aquarium dives. Occupational Medicine, 2019;69(3):177-81.
Cartledge S, Finn J, Smith K, Straney L, Stub D, Bray J. A cross-sectional survey examining cardiopulmonary resuscitation training in households with heart disease. Collegian. 2019;26(3):366-72.
Davis TME, Bruce DG, Finn J, Curtis BH, Barraclough H, Davis WA. Temporal changes in the incidence and predictors of severe hypoglycaemia in type 2 diabetes: The Fremantle Diabetes Study. Diabetes Obes Metab. 2019;21(3):648-57.
Dyson K, Brown SP, May S, Smith K, Koster RW, Beesems SG, Kuisma M, Salo A, Finn J, Sterz F, Nurnberger A, Morrison LJ, Olasveengen TM, Callaway CW, Shin SD, Grasner JT, Daya M, Ma MH, Herlitz J, Stromsoe A, Aufderheide TP, Masterson S, Wang H, Christenson J, Stiell I, Vilke GM, Idris A, Nishiyama C, Iwami T, Nichol G. International variation in survival after out-of-hospital cardiac arrest: A validation study of the Utstein template. Resuscitation. 2019;138:168-81.
Finn J, Jacobs I, Williams TA, Gates S, Perkins GD. Adrenaline and vasopressin for cardiac arrest. Cochrane Database of Systematic Reviews. 2019(1):Art. No.: CD003179.
Majewski D, Ball S, Finn J. Systematic review of the relationship between comorbidity and out-of-hospital cardiac arrest outcomes. BMJ Open. 2019;9(11):e031655.
Perkins GD, Kenna C, Ji C, Deakin CD, Nolan JP, Quinn T, Fothergill R, Gunson I, Pocock H, Rees N, Charlton K, Finn J, Gates S, Lall R. The effects of adrenaline in out of hospital cardiac arrest with shockable and non-shockable rhythms: Findings from the PACA and PARAMEDIC-2 randomised controlled trials. Resuscitation. 2019;140:55-63.
Perkins GD, Nolan JP, Finn J. Epinephrine in Out-of-Hospital Cardiac Arrest. N Engl J Med. 2019;380(4):397-8.
Wang Q, Guerrero F, Lambrechts K, Mazur A, Buzzacott P, Belhomme M, Theron M. Simulated air dives induce superoxide, nitric oxide, peroxynitrite and Ca2+ alterations in endothelial cells. Journal of Physiology and Biochemistry. 2019; 76(1):61-72.
Wang M, Zhang K, Kong W, Buzzacott P, Huang G, Yu X, Yi H, Xu W. Biphasic effects of autophagy on decompression bubble-induced endothelial injury. Journal of Cellular and Molecular Medicine. 2019; 23(12):8058-8066.