Epica™ Education Blog

Physics and Physical Properties to consider when utilizing therapeutic laser energy

c.laughlin@epicamed.com (Chrissy Laughlin) — Fri, 12 Aug 2016 18:42:26 GMT

Physics and physical properties to be considered when utilizing therapeutic laser energy for bio modulation of cellular and tissue function.

Written by Dr. Peter H. Eeg BSc, DVM, CVLF, FASLMS
Poolesville Veterinary Clinic, Poolesville, Maryland

The following are four keys to understanding therapeutic laser energy that I feel will provide you with the best opportunity to provide your patients with the best treatment outcome.

Key #1: Wavelength Penetration
Do not confuse the level of Power being applied and the penetration of energy into tissue as the same thing, because they are not.

It is important to remember that while certain wavelengths of Diode therapeutic laser energy penetrates much more deeply into tissues (Figure 1.) others have a much more limited penetration capability. The first thing to consider is which wavelength you are planning to use and if it will reach the tissue you are targeting.

Key #2: Power and Fluence
A critical factor to consider with the relationship of energy and its transfer to target tissues using Diode laser wavelengths is the effect of the Lambert-Beer Law.

About 60 to 80% of the energy is absorbed in the top 1-2cm of tissue during the transmission (Figure 2). High levels of Power applied at the skin surface from the therapy laser probe head does not necessarily correlate to deeper penetration into tissue.

The Lambert-Beer law shows that Power (W) is non-linearly absorbed by the variety of chromophores that absorb photonic energy in the first 2 cm of tissue. Thus it is far more important to select the appropriate wavelength to effectively transmit laser energy to deeper target tissues than increase total power at the surface.

A photo-thermal effect is seen more commonly with 980nm wavelengths due to their relatively shallow penetration depth (Figure 1) and its relative higher absorption by water, hemoglobin, oxy-hemoglobin and melanin. Photo-thermal effects may raise cellular temperatures above 45o C where cellular metabolism slows and enzymatic function decay. Continued increased power levels can cause rupture of protein bonds and fragmentation of cohesive molecular forces ultimately causing cellular damage or cellular death.

The use of Power in Watts (W) to express the energy going into tissue is an excellent descriptor in surgical lasers but a very poor descriptor of the actual energy to be imparted to tissues during exposure via a therapy laser. The optical therapeutic window that encompasses Diode laser energy is a critical factor in the transmission of energy to the deeper tissues (Figure 3).

Figure 3. Optical Therapeutic window of Diode laser wavelengths

Key #3: Time and emission modality
Appropriately describing therapy laser energy requires information about the previously discussed penetration of the wavelength, Joules and Fluence applied to the tissue. Equally critical is the total time duration of the energy application to the tissue, including the emission modality and then the total irradiance (Figure 4). Figure 4 gives a quick overview of the formulas needed to be confident about sharing information with other clinicians about cases that you are treating with therapy lasers. Clinicians should provide the total mille-Joules/Joules to be delivered, the total time of delivery and the total surface area to receive bio modulatory TLE. This produced the total irradiance (J/cm2/time) that can be rectified between any therapy protocol guideline given by varying companies and clinicians. To simply indicate the Watts applied will not allow other clinicians with different devices an opportunity to replicate your results.

Figure 4. Formulas Needed to Determine Energy Application From Therapy Laser Equipment

These formulas indicate that energy density = Fluence which is the parameter that best permits us to interpret the protocols of varying therapeutic laser therapies. By example if we treat a 1 cm2 surface for 10 seconds with 10J/sec energy we will have a Fluence of 100J/ cm2. If we expose a 10 cm2 surface to the same power for the same time, then the Fluence will be only 10J/cm2 . Current research is showing that by varying all these factors changes the therapeutic value to the target tissue.

Equally important are the emission modalities available to apply the energy. By varying both the Hertz (Hz) and the total duty cycle (time of active output) of the laser energy being emitted (Figure 5) total energy application duration can be manipulated to maximize positive therapeutic effect. This is affected by changing the emission of the laser energy from a continuous output, to a chopped output (Figure 5, 808nm wavelength portion), or pulsed output (Figure 5, 905nm wavelength portion), or Q-switched ultra-pulsing (1064 nm). Further enhancing the total emitted energy is the synchronization (Figure 5) of one or more of these emission parameters to additional wavelengths. Synchronization and Q-switching can maximize the uniformity of energy dispersion into the targeted tissue and the energy delivery to specific cells and tissues thus giving a homogeneous and enhanced therapeutic effect.

Figure 5. Synchronous emission of continuous 808nm wavelength with a pulsed 905nm wavelength

Key #4: Laser/Tissue Interaction and the Bi-phasic Curve Effect
The bio modulatory effects on tissue from therapy laser energy are a combination of photo-chemical, photo-mechanical and photo-thermal effects. Depending on the wavelength, Fluence, emission modality and time the percentage of each effect varies to the target tissue and thus manipulated the bio modulatory effect.

Photochemical effects are most responsible for anti-inflammatory, anti-edema, analgesic and bio-stimulation and regenerative effects.

Photomechanical effects are most responsible for enhancing lymphatic peristalsis and realignment of damaged collagen fibers and connective tissues. This also can provide a regenerative component to TLE.

Photo-thermal effects can produce additional improvement in bio modulation when producing small incremental increases to the tissue temperature. High increases may raise cellular temperatures above 42o C where cellular metabolism slows and enzymatic function alters. Excessive energy release into tissue can cause rupture of protein bonds and fragmentation of cohesive molecular forces may occur.

Current basic research being done is finding that the selection of ultra-pulsed Q-switched 1064 nm and/or 800-810nm and 900-910nm near infrared wavelengths are recommended to maximize energy delivery to deeper target cells and produce the photo-bio modulation discussed above.

Photochemical effects associated with Q-switched 1064 nm ultra-pulsing and the 808nm wavelength are most responsible for anti-inflammatory, anti-edema, analgesic and photo-bio modulation effects.

Photomechanical effects associated with the 905nm wavelength are most responsible for enhancing lymphatic peristalsis and realignment of damaged collagen fibers and connective tissues.

Equally important is the fact that current research has shown that bio modulatory therapy laser energy has a biphasic dose response in the target tissue (Figure 6). This is just like the effect many medications have at the target. It is often termed the Arndt-Schulz curve. Too little produces no effect, the right amount produces a therapeutic photo-biostimulation effect and too much produces again no effect or a negative photo-biostimulation effect.

Figure 6: Idealized biphasic dose response curve (often termed Arndt-Schulz curve)
typically reported in Therapeutic Laser tissue application

The preceding four keys to a basic understanding of therapy laser/pathology interaction are fundamental to a fuller understanding of how laser wavelengths impacts the tissues and pathologies they are being utilized for in veterinary and human medicine and surgery.

As with other forms of medications, therapeutic laser energy has its active quantifiers that when combined together give the total bio modulatory picture for tissue interaction, modification and regeneration. Medicine (irradiation parameters) and Dose (the irradiation time), when thought of in way medications and radiation are calculated to produce the optimal therapeutic effect can give the veterinary clinician and technician a much clearer understanding of what they are doing when applying laser energy..

Irradiation parameters include; wavelength, irradiance, pulse structure, pulse time, wavelength penetration, coherence and polarization.

Irradiation time include: Energy (Joules, J), energy density (J/cm2) irradiation time (seconds to minutes) and treatment intervals (hours, days or weeks).

This clearly indicates the fact that energy has two components, power and time when discussing therapy laser-tissue bio modulation. Key to this is the realization that the two are not necessarily providing reciprocity between them, but a cumulative bio modulatory effect to the target cell type or tissue type. If the power doubled and the time is halved then the same energy is delivered but a different biological response is often observed to the pathology being treated.

For this reason the four keys must be viewed from two separate but equally important parameter settings to maximize the therapeutic window of the laser energy.

The medicine= irradiation parameters

The dose= irradiation time parameters

Cellular Chromophores are critical to the photo-biologic effect desired when using therapeutic laser energy. The photons must be absorbed by an electronic absorption band belonging to some molecular photo-acceptors or chromophores. A simple example is seen in chlorophyll used for plant photosynthesis, hemoglobin, cytochrome c oxidase, myoglobin, Flavin’s, flavo-proteins and porphyrins are also illustrations of such chromophores utilized by therapy laser energy application.

To optimize the effect there must be optical properties of the wavelength and tissue that allow the energy to reach the chromophores. This is known as the optical window where the penetration of the laser wavelength is maximized. This optical window runs approximately from 650nm to 1200nm. The absorption and scattering of light in tissue are both much higher in the blue region of the spectrum than the red, because the principle tissue chromophores in tissue are hemoglobin and melanin and have a high absorption band at shorter wave-lengths, tissue scattering of light is higher at shorter wave-lengths and furthermore water strongly absorbs infrared light at wave-lengths greater than 1100nm. Therefore the therapy laser energy use in animals is almost exclusively in the long visible red and near-infrared light ranges (600-1100nm)

Thus phototherapy is characterized by the ability to induce photo-biological processes in cells. Differing wavelengths produce differing action spectra. This is where research can identify where action spectrum can show specific wavelengths with the most effective and specific chemical reaction producing optimized cellular responses.

Tangential to this is the variation that pulse rated, and total time domain of TLE into a target tissue have on optimal bi-phasic maximization of bio modulatory effect. Here Q-switching for ultra pulse release of peak energy over extremely short time periods and synchronization of multiple wavelengths to maximize homogeneity of energy into the target cells and tissue are generating profoundly positive results.

Specific cellular structures and mechanisms revolve around mitochondria. Mitochondria plays a central role in energy generation and metabolism of the cell. This is where TLE can produce optimal positive energy release for improving or stimulating cellular respiration, cell wall stabilization and cell reformation if damaged. ATP formation via the process of oxidative phosphorylation is a central factor. Several pieces of evidence suggest that mitochondria are responsible for the cellular response to long red and near infrared light sources. Positive aspects include; increased proton electrochemical potentiation, more ATP synthesis, increased RNA and up regulation of protein synthesis. This enhances increased oxygen consumption, membrane potential, and enhanced synthesis of NADH and ATP.

The same COX (cytochrome c oxidase) we manipulate for anti-inflammatory mitigation, is proposed to be the primary photo-acceptor for the red-NIR range in mammalian cells (Karu and Kolyakov 2005).

Although the underlying mechanisms of TLE are still not completely understood, in vitro, in vivo and clinical studies have all tended to indicate that the delivery of appropriate doses of red-NIF light over appropriate time domains produce optimal photochemical and photo-biological effects to pathologies of mammalian tissue and thus a total bio modulatory enhancement of cellular function and proliferation, migration and adhesion in a variety of cell types from fibroblasts (Lubart et al. 1992, Yu et al. 1994), keratinocytes (Grossman iet al. 1998), endothelial cells (Moore et al. 2005), and lymphocytes (agaiby et al. 2000; Stadler et al. 2000). The enhancement of photo stimulatory effects to the mitochondria enhanced growth factor release and led to cell proliferation and attachment. All these positive cellular factors are dose-dependent with respect to the irradiance parameters and irradiance time parameters.

The extended positive tissue responses found in a large number of both animal trials and clinical studies have demonstrated that the above description of how therapeutic laser energy up regulates cellular respiration and cellular proliferation has a beneficial impact on a wide range of bio modulation to positively modify disease, injuries (chronic and acute) and tissue pathologies. Overwhelming research has determined that TLE can promote neovascularization, promote angiogenesis, increase collagen synthesis, promote healing of both acute and chronic wounds, stimulate improved nerve conduction and nerve regeneration, improve tendon re-alignment, promote cartilage regeneration, and even stimulate organ regeneration. These pro-regenerative effects promote reduction in pain directly and indirectly and the photomechanical effects promote reduction in inflammation and swelling.

There is no question that we do not yet have a very full understanding of the nuances that go into the symphony of interactions between the many three dimensional moving parts that make therapeutic laser administration. What is clear is that basic Diode wavelength effect research and a growing number of well done human and animal studies designed to identify the optimal proportions of all of the afore mentioned components that make up a photo-biostimulation effect by these near infra-red band wavelengths is very encouraging.

Therapeutic laser energy used alone or in concert with other therapeutic modalities can further enhance positive therapeutic outcomes for a host of current disease and pain processes. The time to think about using therapeutic lasers has passed. The time to use therapeutic lasers is now.

About Dr. Eeg
Dr. Peter Eeg grew up in Wheaton, Maryland and graduated from University of Maryland as an undergrad and graduate in Animal Science, Parasitology, and Immunology. He then attended and graduated with honors earning his veterinary degree from the Virginia-Maryland Regional College of Veterinary Medicine. Upon graduating, he interned at Peachtree Veterinary Clinic under the guidance of his lifelong friend; Dr. Chet Anderson. Dr. Eeg took over the reins of Poolesville Veterinary Clinic over 25 years ago, never looking back and always to the future.

To expanded his knowledge in veterinary medicine Dr. Eeg has obtained specialized training in laser surgery and therapy. Additionally, he worked in the first inter-disciplinary group related to pain management in people and animals, studied and lectured on the human-animal bond, quality of life issues and end of life care and euthanasia. He is an internationally recognized speaker in these areas and has traveled extensively at the request of National and International Veterinary Education Congresses.

Watch How Epica™ is Changing What is Possible with Artemis™

Therapeutic Lasers for veterinary use

c.laughlin@epicamed.com (Chrissy Laughlin) — Fri, 12 Aug 2016 18:40:02 GMT

Written by Dr. Peter H. Eeg, BSc, DVM, CVLF, FASLMS
Poolsville Veterinary Clinic

Therapeutic Lasers for Veterinary Use

Laser devices may also be used for bilateral tissue effect as therapeutic or surgical applications. 980 nm and 1064 nm wavelengths predominate in this dual modality. Diode wavelengths predominate overall in therapy applications with this technology.

Laser Classes include:

■ Low-level laser therapy (LLLT) are Class IIIB lasers that produce less than 500mW of energy.

■ High-power laser therapy (HPLT), are generally class IV lasers, that produce greater than 500mW of energy.

Therapy lasers currently in use will emit one or more wavelengths in the infrared (635–1064 nm) range of light that is non-destructive to living tissues at the irradiances they are delivered at to the target tissue.

Generally, the spot size is focused from 10–25 mm up to 5 cm in diameter, with scanning devices allowing for larger total surface area inclusion.

Clinical research the use and cellular tissue effects of therapy lasers (Tunér and Hode, 1999) is providing increasingly compelling evidence that the effect of these wavelengths of laser energy on improving:

damaged cellular organelles and membranes,
increasing cellular respiration (ATP production),
enhancing damaged cell recovery rates,
altering pain initiation and transmission pathways,
modifying pain receptor responses, reducing pain,
increasing endorphin production,
enhancing intra and extracellular fluid movement to reduce edema and inflammation to the target tissues (Huang, Chen, Carroll, Hamblin, International Dose-Response Society, 2009).

Laser wavelength depth of penetration (different for each wavelength) along with time of application, mode of energy release (continuous, pulsed, synchronized, Q-switched) and total energy release at the targeted tissue appear to be the primary driving factor in the therapeutic tissue responses identified in current research. A bi-phasic curve response related to total energy release is a consistent finding in most recent clinical research presented at the 2011 ASLMS meeting in Dallas-Fort Worth, Texas.

The entire concept is still being explored but has gained a significant following.

Unlike surgical lasers (CO₂and 980 nm/1064nm Diode/contact mode devices) that have their full impact in the first 0.1mm to 5mm of tissue, therapy lasers can if appropriately modulated transmit their energy much deeper into tissue. It is this ability of varying diode wavelengths to transmit energy up to 6 cm’s into tissue (1064 nm diode Q-switched devices) that gives therapeutic lasers such great potential to transfer energy uniformly to a predetermined area (cm²) of cells to promote improved damaged cellular function, reduce pain and pain transmission and limit edema and reduced circulatory flow to tissue.

There are a number of routine recommendations and considerations to keep in mind when you are preparing to implement therapeutic laser energy for bio modulation of tissue function and action into veterinary practice. Common sense and a general understanding of Diode laser wavelength physics will put the general practitioner or rehabilitation specialist in good stead for appropriate utilization of bio modulation of patient tissues.

Want more info on Laser Physics? Click Here

Regenerative medicine is an exciting field. The ability to regrow damaged tissue in a healthy way would change medical care in a profound way. Technologies like stem cells and PRP (Platelet Rich Plasma) therapies have had great promise, but have not really lived up to the hype. Research shows mixed and meager results for all such therapies and the invasive and often very painful methods used for these therapies have hardly been worth it. Epica™ has developed a new therapy called NRT™ (Noninvasive Regenerative Therapy). As the name suggests, NRT™ is a way to regenerate and even remodel already scarred tissue back to a normal healthy state completely non invasively, without pain or side effects but with tremendous efficacy.

A brief History of Laser Therapy

c.laughlin@epicamed.com (Chrissy Laughlin) — Fri, 12 Aug 2016 18:32:55 GMT

Written by Dr. Peter H. Eeg, BSc, DVM, CVLF, FASLMS
Poolsville Veterinary Clinic

A Brief History of Laser Therapy

LOW LEVEL LASER THERAPY- LLLT
Low level (power) laser therapy (LLLT)(Class II to IIIB) is the application of mono-chromatic light in a range of 1mW to 500mW emitted in a wavelength range from 600-1000nm to a pathology to promote tissue realignment, increased cellular activity, reduction in inflammatory promotors, alteration in biochemical function, neurologic modulation identification and responses to painful episodes.

Power densities (irradiance) between 1mW-5W/cm² are typically noted. It is typical to apply the energy for up to 30 minutes depending on the time domain needed to effectively irradiate the specific tissues being targeted for treatment.

HIGH POWER LASER THERAPY (HPLT)

High power (level) laser therapy (HPLT) (Class IV) is the application of laser light in a range of 500mW to up to 20W emitted in a wavelength range from 600- 980nm to a pathology to promote the same tissue effects as the LLLT (tissue realignment, increased cellular activity, reduction in inflammatory promotors, alteration in biochemical function, neurologic modulation identification and responses to painful episodes). The primary difference between LLT and HPLT is in the overall shortening of the time domain, modulation of peak power and pulsing of energy into tissue and increase in irradiance in that shorter duration to maximize tissue absorption and response.

The majority of current basic and phase III multi-centered, randomized, double-blinded, placebo controlled, clinical trials being published are seeking to identify which type of laser therapy level and modulation produced the best effect within the biphasic curve response to cellular and tissue activation, repair and reformation.

Positive outcomes have been produced from both forms of therapy laser applications and published on pathologies as diverse as osteoarthritis (Bertoucci and Grey 1995: Ozdemir et al. 2001; Stelian et al. 1992), Tendon and Ligament damage (Bjordal et al. 2006; Stergioulas et al. 2008; Schubert et al. 2007), Neurologic pain, Cervical disk disease and peripheral nerve injuries (Basford et al. 1999; Chow et al 2006; gur et al 2004; Rockkind et al 2007), Wounds (Caetano et al. 2009); Gupta et al. 1998; Ozcelik et al. 2008; Schubert et al. 2007), Muscle cell fatigue and damage (Leal Junior et al. 2008), Vascular flow disruption (Lampl et al. 2007; Zivin et al. 2009)

It should be noted that as we see with the bi-phasic curve response common to laser therapy treatment not all responses have been positive. This failure in certain circumstances can be attributed to several factors including dosimetry (inadequate or too much energy delivered over the wrong time domain or wavelength, inadequate or too much irradiance, inappropriate pulse structure or duration, irradiation of insufficient area to the pathology or time domain overlying the pathology, inappropriate anatomical treatment location and concurrent patient medications (such as steroidal and non-steroidal anti-inflammatories which can further modulate healing)( Aimbire et al. 2006; goncalves et al. 2007).

Artemis™ Regenerative Therapy Device
Artemis™, one of the most powerful therapy devices available for veterinary use, and is the only device that allows for limitless modification on the energy wave form to allow incredible depths of penetration, photomechanical effects, and bio-stimulation, resulting in efficacy for NRT™ and RIM™ therapy. The continuous wave ability delivered by Artemis™, makes it a very effective tool for Minimally Invasive Surgical Ablation, (MISA™), of tumors and masses.

CT Case review: Nasal cavity - possible foreign object

c.laughlin@epicamed.com (Chrissy Laughlin) — Wed, 25 May 2016 15:31:12 GMT

Small Animal Case Review by Dr. Bob O'Brien, DVM, DACVR

Patient
10-year-old male, neutered Cavalier King Spaniel.

History
Choking, gasping, coughing, difficulty eating, bark change for several days.

Image Protocol
A survey and post- i.v. contrast CT study was performed of the nasal cavity and skull.

Findings
Increased soft tissue material was seen in both nasal cavities (Figure 1). Normal turbinates were noted within this affected region without evidence of lysis or mass effect. A small (6 mm long by 1 mm wide and tall) mildly boney lesion was seen in the mid-rostral right nasal cavity (Figures 2 & 3). No mass lesions was seen to be associated with this linear-shaped lesion. Mild undulation of the septum was noted as a normal= breed variant (Figure 4). The right tympanic bulla was filled with soft tissue material and there was no evidence of either lysis or proliferation in the bulla wall (Figure 5). The left tympanic bulla was normal. Mild multifocal mineralization was seen in the horizontal and vertical ear canals bilaterally.

Imaging Diagnosis
Nasal cavity: possible foreign material (or atypical dystrophic mineralization) Right tympanic bulla: otitis media (mild, acute).

Final Diagnosis
Blades of grass were removed from the right nasal cavity on rhinoscopic evaluation. The otitis resolved on empirical antibiotics. The patient is now clinically normal.

This case is an excellent example of nonaggressive changes seen very well on the Vimago™ system due the exceptionally high spatial resolution. The excellent contrast resolution allowed identification and characterization of the grass material.

Discussion
CT is very sensitive to changes within the nasal cavities. The assessment of aggressive (versus nonaggressive) changes in the nasal cavity is based on presence of turbinate destruction, boney septum deviation or lysis, mass effect, and lysis of surrounding nasal vault. Staging the mass often hinges on presence of brain involvement. Non aggressive lesions include immune mediated, infectious (especially fungal), dental and foreign body causes. This case is an excellent example of nonaggressive changes seen very well on the Vimago™ system due the exceptionally high spatial resolution. The excellent contrast resolution allowed identification and characterization of the grass material.

Special Thank you to Dr. Lyman and his team @ A nimal Emergency and Referral Clinic nimal Emergency and Referral Clinic in Ft. Pierce, FL. Learn more abour AERC here.

What sets Vimago™ apart from other CT devices? Watch our short video.

How is Artemis™ different from other lasers?

c.laughlin@epicamed.com (Chrissy Laughlin) — Tue, 24 May 2016 16:04:31 GMT

How is Artemis™ different from other laser therapy devices currently available for veterinary use?
There is only minimally superficial similarities between Artemis™ and previous therapeutic lasers. Previous lasers were diode lasers and Low Level Laser Therapy (LLLT). Artemis™ is by far the most advanced High Intensity Laser Therapy device in the world.

Artemis™ works at 1064 nanometers and is very poorly absorbed by melanin and hemoglobin which means little conversion into heat; resulting in vastly deeper penetration (likely greater than 10cm) with minimal burn risk. This wavelength of light has a harmonic effect on organic molecules which means it has a photo-mechanical effect.

Artemis™ has a peak power of up to 70,000 Watts. This means more penetration and greater efficacy. Artemis™ can be adjusted separately for peak power and power per pulse, meaning; the wave form can be manipulated to match the needs of the individual case. Heat can be added as needed or avoided altogether.

Artemis™ is the only laser in the world capable of RIM™ (Rapid Inflammatory Mitigation), NRT™ (Noninvasive Regenerative Therapy), and MISA™ (Minimally Invasive Surgical Ablation).

Artemis™ can cause tissue remodeling and regeneration to normal tissue without scarring. Artemis™ is 3-6 times better for pain management than diode lasers or ultrasound therapy. Artemis™ has no damaging side effects like shock wave.

How does Artemis™ work at the cellular level?
Photomechanically. Artemis™ shakes the Carbon-Carbon Bonds. In doing so we can stop inflammation, open the lymphatic system and promote immune system activity and blood flow.

For cells rendered inert from inflammation, we can mimic the effect of receiving outside signals through pathways that are blocked due to inflammatory effects, shaking the cytoskeleton and ‘tricking’ the cell into turning back on.

When would Artemis™ be preferred over other biological treatments like stem cell and PRP?
Always over stem cells. Artemis™ is synergistic with PRP. PRP can cause inflammation in joints that Artemis™ can mitigate and provide additional growth stimuls. Artemis™ is much better in chronic lesions than PRP.

How long does the analgesic property last after a treatment session?
Analgesia is thought of as a covering of pain. Artemis™ removes inflammation that causes pain (Histamines binding to nerves causing hyperalgesia). Therefore the pain removal lasts as long as the inflammation is kept at bay. This varies case by case depending on the cause of inflammation, dependent on removal of the cause, and activity of the patient.

When used for chronic inflammatory type problems, how long after treatment is it recommended that the animal be conservative in its work as to not do damage because of feeling no pain and possible over stressing a fragile tissue?
This is a case by case answer. It is essential to understand what is wrong with the patient. If pain was from bruising from kicking a wall, the patient will not re injure. If the pain is from a necrosing tendon attachment, the patient is at great risk of injury due to over-activity. In the latter case we must use NRT™ and when we know the patient has experienced healing it must go through a normal rehab protocol.

What are the dangers of class IV laser treatments?
The Class of lasers is a regulatory matter that means kill switches and certain goggles are required and somebody must be designated as a laser safety officer. It has nothing to do with the actual danger of treatments but more with the engineered power with regulations designed primarily around industrial uses. You must be careful not to deliver too much energy in too short of a time in too small of an area, especially in highly pigmented patients or you may see thermal damage to skin. You may also reference ou blog post on laser safety here.

CT Case Review: Meningioma

c.laughlin@epicamed.com (Chrissy Laughlin) — Tue, 10 May 2016 05:30:00 GMT

Small Animal Case Review by Dr. Bob O'Brien, DVM, DACVR

PATIENT

9-year-old female spayed Border Collie that presented to a surgical specialty practice with a 6 month history of left sided exophthalmos.

IMAGE PROTOCOL

A survey and posti.v. contrast CT was performed of the head. The contrast dose was 2ml ml/lb BW of Iohexol (300mg/ml iodine) contrast media; half given as a bolus prior to image initiation and the remainder as a slow 15 sec bolus during the initial part of the 30 sec acquisition time immediately prior to image initiation.

FINDINGS

A mass was seen ventral and caudal to the left eye (OS)(FIG 1). The mass measured 2.0 cm long 2.0 cm tall x 1.3cm wide. The mass intensely, but mildly heterogeneously enhanced indicating overall good perfusion, with small indistinctly marginated regions of ischemia or necrosis. The mass extended caudally to the rostral level of the lacrimal gland, which was not clearly seen, Dorsally the mass seemed independent of, although in contact with the globe, extraocular muscles and optic nerve. A large aberrant artery was noted entering the caudal aspect of the mass indicating neoplastic neovascularization (FIG 2). No evidence of metastasis or adenopathy was noted.

IMAGING DIAGNOSIS

Retrobulbar mass: a. lacrimal gland adenocarcinoma (or adenoma) b. soft tissue sarcoma c. granuloma. gic.

"The Vimago™ veterinary CT scanner has excellent spatial resolution and provides very good contrast enhancement with injected iodinated nonionic contrast medium."

DISCUSSION POINT

This case indicates the very good contrast resolution of the Vimago™ veterinary CT scanner, indicated by the ability to resolve the contrast enhancement of the mass and excellent spatial resolution of the aberrant feeding artery. The excellent spatial resolution provided guidance for surgical resection. Whilst no obvious involvement of the mass was noted with the optic nerve and the patient had normal vision and cranial nerve reflexes, the mass was presumed to originate for the meninges surrounding the optic nerve. Approximately 3% of meningiomas are associated with the optic nerve. The Vimago™ HD CT has excellent spatial resolution and provides very good contrast enhancement with injected iodinated nonionic contrast medium.

Confused about the difference between standard CT and HD CT? Watch our short video below.

CT Case Review: Elbow Dysplasia

c.laughlin@epicamed.com (Chrissy Laughlin) — Fri, 06 May 2016 15:14:35 GMT

Small Animal Case Review by Dr. Bob O'Brien, DVM, DACVR

PATIENT

9-month-old male neutered Labrador retriever dog that presented with acute onset 3 days previously, of right forelimb lameness. On physical examination, bot elbows were painful on flexion and extension.

IMAGE PROTOCOL

Survey CT was performed of both elbows.

FINDINGS

Both elbows had similar findings. The was a large separate fragment cranial to the cranial aspect of the medial coronoid process of the ulna (FIG 1). Additionally, many small fragments (0.2 – 0.8 mm wide) were seen at the base of the larger fragments (FIG 2). The subcondral bone of the semilunar notch of the ulna was sclerotic. Osteophytes were seen on the medial and lateral aspects of the distal humerus, proximal aspect of the anconeal process and cranial border of the radial head. Irregular shaped subcondral lysis was seen surrounded by sclerosis in the medial condyle articular surface (FIG 3).he entire right nasal cavity and frontal sinus was filled with uniform soft tissue opacity, mildly enhancing material. There is indistinct turbinate destruction and deviation of the boney septum to the left. There was lysis on the left side of the nasal vault; maxilla, nasal and adjacent caudal bones. Lysis of the cribriform plate was seen with the mass invading into the brain causing deviation of the contrast enhanced meninges and mild leftward deviation of the contrastenhanced falx cerebri.

IMAGING DIAGNOSIS

Bilateral elbow degenerative joint disease cause by elbow dysplasia: a. fragmented medial coronoid process b. osteochondrosis of the medial condyle.

"The Vimago™ H D CT is the perfect imaging system for charavterization of developmental and acquired bone and joint diseases."

DISCUSSION POINT

Elbow imaging is the most common musculoskeletal CT study in young lame canine patients. This is because of the inherent insensitivity of conventional radiography (or ultrasound) for imaging the medial coronoid process of the ulna due to superimposition of adjacent structures. CT provides high detail crosssectional imaging without the disadvantages of superimposed structures. The Vimago™ veterinary CT scanner has excellent spatial resolution, much better than conventional CT, allowing accurate measurement of fragments of 0.2 mm in this case. Elbow studies are very easy to perform with the Vimago™ HD CT system. The forelimbs are extended to approximately the same level and a single image collection set is made. No contrast is necessary for these types of studies. The subsequent data set can easily be manipulated by the reviewer into any image plane necessary to identify all the pertinent structures of the bones of the elbows. The Vimago™ HD CT is the perfect imaging system for characterization of developmental and acquired bone and joint diseases.

Confused about the difference between standard CT and HD CT? Watch our short video below.

CT Case Review: Bacterial Otitis Media

c.laughlin@epicamed.com (Chrissy Laughlin) — Fri, 06 May 2016 15:11:17 GMT

Small Animal Case Review by Dr. Bob O'Brien, DVM, DACVR

PATIENT

4 year old male neutered domestic short haired cat that presented with a history of chronic ear scratching. Recently the patient developed a head tilt. On physical examination the patient had soft tissue swelling to the left base of the skull, head tilt, and nystagmus. The left ear canal was occluded at the junction of the horizontal and vertical ear canal regions.

IMAGE PROTOCOL

A survey and post-i.v. contrast CT was performed of the head. The contrast dose was 2ml ml/lb BW of Iohexol (300mg/ml iodine) contrast media; given as a bolus prior to image initiation.

FINDINGS

The right ear canal and tympanic bulla was normal (FIG1). Leftsided soft tissue swelling was seen in the subcutaneous and deeper fascial layers of the head surrounding the left ear base. This region had mild contrast enhancement. The majority of the left horizontal ear canal and tympanic bulla were filled with mild to moderately enhancing soft tissue attenuating material. There was lysis of the lateral dorsal wall and thickening of the ventral wall the left tympanic bulla. There was lysis of the skull base contiguous with the left tympanic bulla and in this region was a irregular shaped and moderately contrast enhancing mass lesion. Irregular activeappearing, speculated to palisading periosteal new bone formation was seen on the adjacent occipital and zygomatic bones of the left skull base. No enlarged lymph nodes or pulmonary lesions were identified. The pituitary gland was of normal size (FIG 2).

IMAGING DIAGNOSIS

Leftsided aggressive tympanic bulla disease with brain involvement: a. Otitis media (or neoplastic infiltration: carcinoma, soft tissue sarcoma) b. Reactive skull periosteal proliferation c. Soft tissue edema (or hemorrhage) Normal right tympanic bullae and ear canal.

"The Vimago™ veterinary CT scanner has excellent spatial resolution of the bone and soft tissue structures of the ear base"

DISCUSSION POINT

Imaging of the middle ear can be very challenging with conventional radiographs. Superimposition of contralateral structures often precludes complete or accurate characterization of lesions of the tympanic bulla and adjacent structures. The Vimago™ HD CT Scanner provides excellent spatial resolution of the bone and soft tissue structures of the ear base. Contrast enhancement is excellent with injected contrast media. As noted in this case, the enhancement in the brain was vital for staging this disease, although not exclusive for the differentiation between benign and malignant differentials. Evaluation of the contralateral bulla, assessment of adenopathy and ability to detect concurrent nasal and pulmonary lesions is vital for the complete workup of middle ear disease in cats and dogs. This can all be accomplished within a few minutes of imaging with the Vimago™ v eterinary CT scanner, providing detailed highresolution image sets.

Confused about the difference between standard CT and HD CT? Watch our short video below.

CT Case Review: Nasal Carcinoma

c.laughlin@epicamed.com (Chrissy Laughlin) — Fri, 06 May 2016 15:07:14 GMT

Small Animal Case Review by Dr. Bob O'Brien, DVM, DACVR

PATIENT

10-year-old male neutered welsh terrier dog that presented with a 2-month duration history of right sided mucopurulent nasal discharge that recently became bloody.

IMAGE PROTOCOL

A survey and post-i.v. contrast CT was performed of the skull. The contrast dose was 1ml ml/lb BW of Iohexol (300mg/ml iodine) contrast media given as a bolus immediately prior to image initiation.

FINDINGS

The entire right nasal cavity and frontal sinus was filled with uniform soft tissue opacity, mildly enhancing material. There is indistinct turbinate destruction and deviation of the bony septum to the left. There was lysis on the left side of the nasal vault; maxilla, nasal and adjacent caudal bones. Lysis of the cribriform plate was seen with the mass invading into the brain causing deviation of the contrast enhanced meninges and mild leftward deviation of the contrast enhanced falx cerebri.

IMAGING DIAGNOSIS

Right sided aggressive mass lesion Brain involvement.

"The Vimago™ HD CT system capabilities and spatial resolution advantages over conventional CT are demostrated clearly during nasal imaging."

DISCUSSION POINT

Nasal imaging was one of the very first using of veterinary CT technology. No imaging system in the world provides the combination of superior spatial resolution (< 200 uM) and very good injected contrast agent enhancement. This case demonstrates the advantage of CT over conventional skull images by providing both nasal cavity and nasal vault information. Brain involvement is a very important negative prognostic indicator with nasal cancer. Unequivocal brain involvement is seen in this case with excellent meningeal and faux contrast enhancement. The Vimago™ HD CT system capabilities and spatial resolution advantages over conventional CT are demonstrated clearly during nasal imaging.

Confused about the difference between standard CT and HD CT? Watch our short video below.

CT Case Review: OSA with Pathalogical fracture and hemothorax

c.laughlin@epicamed.com (Chrissy Laughlin) — Fri, 06 May 2016 15:04:53 GMT

Small Animal Case Review by Dr. Bob O'Brien, DVM, DACVR

PATIENT

6-year-old male neutered large mixed breed dog that presented with a history of acute lethargy and labored breathing. Thoracocentesis revealed hemothorax. Image protocol: The patient was imaged in dorsal recumbency. A survey and post-i.v. contrast CT was performed of the chest. The contrast dose was 1 ml/lb BW of Iohexol (300mg/ml iodine) contrast media; given as a bolus prior to image initiation.

FINDINGS

A lesion was seen in the distal aspect of the left 4th rib. The lesion had moth eaten lysis, irregular, speculated periosteal proliferation and a pathological fracture with minimal displacement. An extrapleural sign was seen with the adjacent lung. Soft tissue attenuation material is seen bilaterally in the dependent (dorsal) region bilaterally (left worse than right) .

IMAGING DIAGNOSIS

Primary rib neoplasia (OSA, CSA, atypical myeloma, metastatic lesion or osteomyelitis) with pathological fracture and secondary hemothorax.

"The Vimago™ HD CT is and excellent choice for imaging all intrathoracic diseases."

DISCUSSION POINT

This patient demonstrated the ability of the Vimago™ Veterinary CT Scanner to image larger patients. The spatial resolution of the rib and pleural space lesions were excellent. The ability to scan the remaining lung for metastatic lesions was excellent. We prefer to image the chest of dogs with the patient in dorsal recumbency since the inevitable mild movements are less evident than with the patient in ventral (sternal) recumbency. Even though 3 separate image acquisitions were required to cover the entire chest length, there is no evidence of the splicing that occurs to put the 3 sets of images together into one file. The Vimago™ HD CT is an excellent choice for imaging all intrathoracic diseases.

Confused about the difference between standard CT and HD CT? Watch our short video below.

Epica™ Education Blog

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Therapeutic Lasers for veterinary use

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A Brief History of Laser Therapy

CT Case review: Nasal cavity - possible foreign object

Patient10-year-old male, neutered Cavalier King Spaniel.

HistoryChoking, gasping, coughing, difficulty eating, bark change for several days.

Image ProtocolA survey and post- i.v. contrast CT study was performed of the nasal cavity and skull.

How is Artemis™ different from other lasers?

CT Case Review: Meningioma

PATIENT

IMAGE PROTOCOL

FINDINGS

IMAGING DIAGNOSIS

DISCUSSION POINT

CT Case Review: Elbow Dysplasia

PATIENT

IMAGE PROTOCOL

FINDINGS

IMAGING DIAGNOSIS

DISCUSSION POINT

CT Case Review: Bacterial Otitis Media

PATIENT

IMAGE PROTOCOL

FINDINGS

IMAGING DIAGNOSIS

DISCUSSION POINT

CT Case Review: Nasal Carcinoma

PATIENT

IMAGE PROTOCOL

FINDINGS

IMAGING DIAGNOSIS

DISCUSSION POINT

CT Case Review: OSA with Pathalogical fracture and hemothorax

PATIENT

FINDINGS

IMAGING DIAGNOSIS

DISCUSSION POINT

Patient
10-year-old male, neutered Cavalier King Spaniel.

History
Choking, gasping, coughing, difficulty eating, bark change for several days.

Image Protocol
A survey and post- i.v. contrast CT study was performed of the nasal cavity and skull.