Hello, Anthony Chadwick from the webinar vets, welcoming you to another one of our webinars. Today we're very fortunate to have Stephen Barrabas, veterinary surgeon who's gonna be speaking about regenerative medicine. It's an area that I'm fascinated in, some of the, the advances over the last decade have been amazing, and, and Stephen has been involved in this field, you know, for much of the last decade.

It's a huge area in human medicine. And I think we're maybe as always a little bit behind the curve with, with the veterinary medicine, but new things happening all the time. Stephen, as you know, runs BBS Direct, is very well known for his expertise in laser, but this is certainly another area that he's really fascinated in.

I thought it'd be a great opportunity just for us to update ourselves on where we're up to in regenerative medicine. And just to help Stephen out before we kind of get into the grips of the presentation, I thought it'd be interesting to know if any of you are using regenerative medicine in in any of its forms, and then, you know, are you using that mainly in small animal or in equine or in other species, so. I know not everybody will, will put stuff down, but if you can either in the in the chat box or the question and answer box, just start putting in, you know, if you are using regenerative medicine, and, you know, if so, what species are you using it in?

So I know there are quite a few of you out there and we've had a few say not using it yet, but if you're not sure, it's just that the chat should be at the bottom, and you should just be able to click on that and then write a bit of text in. So it'd be great if you could do that just to give Stephen a bit of a clue before we start. So Jen said yes, using laser, stem cell, PRP in exotics.

Christopher's saying not usually, so far only used it once. Zhao is saying not easy access to it. Sarah's not yet.

Lauren, no, not using it yet. Corinne said saw it tried in an owl owl eye lesion. Paul used small animals, stem cells activated platelets and laser.

Rebecca's saying, no, I don't use anything. Hazel's saying yes, small animal, plus, obviously, laser as well. Using PRP in dogs, is Anna, Simon's listening in from Australia, so hello, good day, good morning in Australia, not personally, I know clinics that do.

Christopher's saying he got it recently got a K laser at the practise. Andrew's saying yes in small animals, a few saying laser as well, so, great to have, Somebody from the other side of the world on good morning, I bet you're having slightly nicer weather than we are, we've got the, the big winds going through England and Liverpool at the moment, so, hopefully, Stephen, that's helpful. I'll let you crack on and if I'm sure you'll take some questions at the end as well, won't you?

Yeah, yeah, that'd be great. Thank you, Anthony, and thanks. Welcome to everyone tonight and thank you for tuning in or tuning in this morning wherever you are in the world.

this is gonna be a brief overview. there are quite a lot of slides to get through, but it it it's, it was interesting that some of you have some experience. And also that some of you have used it in exotics.

It was only recently have I used it in exotics, with some good success, but I haven't actually covered much in this presentation about that. We could have maybe questions at the end. But obviously the two main areas is equine and small animal, as the picture shows.

And actually equine was quite well ahead of the curve in the veterinary field compared to small animal meds and, using regenerative products. So, . The equine, especially some, people like Professor Roger Smith at the Royal Vett College, really led the way in regards of research and, clinical applications.

And so I will combine both them small and equine and some of the human research in this presentation. just to make it clear, we are talking about biological products, so these are autologous mainly. From the individual animal given back to the animal.

And there are a range of different products out there which come under this umbrella of regenerative medicine, and we'll go through briefly an IRAP and BMAC, which is bone marrow aspirates and stem cells. What I'm more familiar is platelets, so we'll spend more time on the platelets in the second half, but I'll give an overview first, and then we'll talk a little bit about the catabolic or anti-catabolic or is it anabolic? And, and go through some of the other aspects about it and a little bit about regulation as well.

So hopefully we'll cover all those points as we get through it. And you can see here just some pictures of how easy it is to go and inject. Most of the time, regenerative medicine is used on areas of the body that actually we're having challenges with, so that they tend to be used where we know that they're gonna have poor healing, that might be cartilage problems, it could be tendon injuries, but you can also see they cover other areas here.

You can see that it's not just joints and tendons, you can also do wounds, and in the humans, there is huge growth areas in diabetic ulcer. and also in corneal ulcers. So there are areas outwith which potentially in the veterinary world we should really be using these in.

Similar to, previous lectures I've given on laser, I think it's a brilliant time to be working on osteoarthritis. I think, yes, we do not have a cure, but we're able to manage animals so much better now. And we've got such a great arsenal of different things as long as we have clinical proof behind them, to be able to use them and, and do truly multi-modal aspects, to improve the welfare, but also the pain management and the longevity of the animals that we work with.

And, and so you can see a whole range of different things that, you, you have the choices of using, and, and, and, like some other, veterinary surgeons, regenerative medicine I have right at the very top there, and we'll show you some information later on on this. There is an eternal debate about whether we're, we are injecting products which are palliative, as in acting almost like a steroid or a non-steroidal in just reducing pain and inflammation, or whether they really do have curative effects, and I, I hope by the end of this you can see that there that there are definite studies that are beginning to show what we need. To see that we're making a clinical impact in regards to the quality of the healing, and, and the speed of healing where maybe drugs can be used in combination or, or, or not at all in certain scenarios, to improve our clinical outcomes and and and reduce pain and also heal.

There are 4 big areas in regards to regenerative medicine in the human and in the veterinary. The first one is called ACS or ACP, and these are autologous conditioned serum or autologous conditioned plasma, and they're they're targeting something called an interleukin 1 receptor, and they produce antagonists for this. the second half will really be talking about PRP, and platelet rich plasma and the growth factors involved with that.

And then I'll talk a little bit about BMAC and the bone marrow aspirations, and also what really gets the headlines in regards to regenerative medicine is the stem cell aspect about it. and you can source this from directly from bone marrow, adipose tissue, or, or, or often as a parent, you might be asked whether or not you want your child's stem cells from their cord, and that will be frozen under nitrogen, nitrogen kept, in case there are diseases or things that you need to source in the future. A lot of this will be based around osteoarthritis and joints, but this inflammatory soup that you can see in the middle of here is similar regardless of which tissue we're talking about.

So whether it's an eye inflammation or a, a tenocyte problem or a, a muscle tear or skin wounds, it's trying to get this balance of inflammatory and . Pro-inflammatory and non-inflammatory cytokines, into a balance so you get good equilibrium or you actually get an anabolic aspects about it. And, and we hope through regenerative medicine that we can manipulate this and try and get back to a more even keel or, or even an anabolic scenario in certain scenarios.

This is a general overview, and this is just a sort of state what is a problem. It's a problem for everyone in veterinary medicine. It's a problem actually for anyone who's reading about it and wanting to have the product injected in themselves or in their pet.

But, this is not a drug. You're not gonna, you're not injecting 10 Migs per gig. There are differences between individuals, there's differences between products.

There's different between all manner of of being able to extract and utilise these products and therefore, in this article, it said, study comparison is very difficult due to the great variability in this. OK, so we're just looking at PRP products, preparation methods, cell content, concentration, storage, activation, and even in the application. So, you know, I will not answer all your questions tonight, but hopefully I'll make you more inquisitive and make you ask the right questions in regards to products that you may or may not already be using.

The, the, the simplest product and more akin to a non-steroidal would be the ACS or the ACP products, and they have this, anachronism called IRAP, and, and, and these are interleukin receptor antagonist proteins. And basically there are receptors in all tissues of your body, which when they bind to interleukin one, a whole cascade of inflammation occurs. But like a lot of things in the body, there is a bit of yin and yang, so your body also does produce naturally these interleukin receptor antagonist proteins, but we just don't produce enough to go and dampen it down.

And therefore often when you have an acute injury or post surgery, you get too much interleukin one, and, and, and then using this product, you can actually go and rebalance that. It, it, it's predominantly used in the equine, and it's used in acute injuries. You could use it after arthroscopic where you know you're inducing damage, but where it's not recommended is directly injecting into tendon sheaths or fractures or chronic meniscal damage or, or even osteoarthritis.

So, so those areas are not areas where you'd consider this, and, and therefore it limits it quite considerably. The problem also as the end user is what you're sold and what it sounds like may actually be very different. So these are two products that were analysed on the marketplace, looking at the percentage increase compared to standard blood.

And you can see the ACP versus the ACS, one is a plasma, one's a serum. I don't even understand quite the difference between that, but you can clearly see the difference in the concentrations. So you can surmise by injecting one product, you may have a very different reaction in a group of individuals compared to injecting the other.

And therefore you do need to be careful about what you're injecting and what you're trying to achieve. An example of this was a study that was, done by Estrada now. This was done in Davies's vet school.

They injected 8 horses, which had had induced superficial lesion, digital lesions in both forelegs and hind legs. One leg, they would inject saline. The contralateral, they would inject this ACP product, produced, from the horse's own blood.

And they would inject on day 15 and day day 7 and day 15. And they were in day 0, and then they would monitor them over 22 weeks. At the end of the study, there was no histological difference between the saline versus the ACP product.

Biochemically, ultrasound, and lameness wise, there was no difference between the two products. and this article just illustrated the fact that you have to be careful about what you are injecting. Another issue in regards to it is the fact that you have to go and inject it 7 days apart.

And, and, and that may work in the equine world, but it's challenging when you've got such good nonsteroidals in the canine, especially in the feline area, why you'd use it, because, it, it is virtually the same as a non-steroidal, or even a steroid in that respect, and, and therefore it it it it it is difficult to justify doing these injections into a sterile area, repeatedly. You also have to be very careful because when you get the initial blood sample, you have to then incubate it, and you incubate it for 24 hours in the equine, 8 hours in the dog. And if you shake it, then you actually produce more inflammatory IL1 and, and less of the I wrap products, which, is what you're really trying to go and use it for.

OK. I won't talk much about PRP at this. It will be the latter stage of the lecture, but you can see there's a wide range of areas that you can use it for.

And it is a case of taking blood and either you're spinning it down or putting it through a filtration system, and then reinjecting the high level of platelet growth factors back into the joint itself. Pure PRP products, we are looking at the growth factors, and we're looking at these things like, platelet derived growth factors, transforming growth factors, interstitial growth factors. These are all the thousands and thousands of them that are within the actual platelet itself.

And when it degranulates to cause coagulation, it also releases all of these growth factors that then They have angiogenic, they have acceleratory, they can cause reduction in apoptosis. They can increase anabolism within the tissues, they can attract stem cells, they can do all sorts of things within the body system where you inject them to go and accelerate healing and, and, and reduce inflammation. From a BMAC point of view, this is a sort of step up from, platelets, and you are taking a needle and putting it directly into a sauce and it's bone, where you will be able to take out a lot of the bone marrow aspirate.

So in the case of dogs and horses, it tends to be a sterno bra or a a tubercoccy. and then you can spin it down, separate out the products that you need, and then reinject it back into the animal that you've taken it from. This is an example of a study that was out there, showing a core lesion in a deep digital flexor of a horse, and you can see the differences in 3 months where that fills in that area of the lesion.

The main challenge with BMAC is where you can source it, because you definitely need to anaesthetize the animal or in the horse, a very heavy sedation. It's not for the faint hearted and the horse because you're taking a, a, a, a, a 5-inch needle and shoving it up into the sternna bra around the 5th, sterna brae, which is just where they point to the apex of the heart is. And in the dog, you are tending to take it from the tubercoccy, which is, you know, there are some major nerves and blood vessels, and it is quite a painful procedure, so the animal will need analgesia afterwards.

But, but there is definitely science to show that it will help and, and, you've got platelet growth factors, you've got white blood growth factors, you've got other plasma growth factors. So there's a lot of good things in there, which can help the body, when it's super concentrated to go and regenerate. Stem cells are probably what got all the the glory in the headlines.

And the guru in the right top corner is Professor Roger Smith, at his, Royal Vet College centre, and he has a stem cell lab there, working on the equine and they're expanding into the small animal side. It, it, it, the, the, he, he, you know, if we went back a decade, the idea was that you'd get these mesenchymal cells from the adipose tissue or or or the cord blood or bone marrow, and when you inject it into an area, it suddenly miraculously changes into nerve cells, liver cells, whatever tissue you're wanting it to, but that isn't really the case now. We, we know that you could freeze stem cells and you'll still get the same effects as with living cells.

And we also know that . It it's really the trophins, the growth factors in there that then cause this cascade of events to the surrounding tissues and also attract internal stem cells to go and help the differentiation. The process itself takes about 28 days from when you sample the, the, the, the, usually fat, and, and then you send it off for a specialist laboratory to go and grow millions and millions of cells from that and, and purify it.

And then that's resent back in about 28 days later, then you can re-inject into the animal. So, so it is definitely two surgeries or two heavy sedations depending on the animal you're working with. And, and, and, you need to make sure you're using a VMD qualified lab to do it properly.

Here's some of the work, the blue is, when you inject mesenchymal stem cells, compared to the red or the green, which were the non-injected. And, one study by Sue Dyson, from the Animal Health Trust looked at national hunt and flat race, and you're looking at re-injury rate percentages, and you can definitely see a significant improvement in the, horses and the, especially in the. Hunt the lack of re-injury, and that was exacerbated.

You can, you, you can accentuate it by the work done by a mirror, and again, you can see even bigger numbers there, showing, what you saw on the Dyson work. And so there's something that's happening in the quality of the healing that is allowing those horses not only to get back to racing, but also not breaking down, which is essential, for this group of animals you're working with. The other work which is of interest shows that it's a numbers game.

So what you're looking at on the left hand column is the number of cells that are re-injected back into the horse. The second column is the number of horses, so you can see although the, the, the, the downside of this is we don't have a lot of data when we inject, you know, 50 million cells back. You're looking at the re-injury rate and then also the percentage, and, and, and on the graph on the right, you can clearly see the greater the number of cells you inject, the, the less likely you are to go and re-injure that area and cause a further tear in the tendon.

So numbers seem to be important, in regards to what you re-inject. There is some confusing side of things as well. This was a study that was done in the European orthopaedic congress.

And what you're looking at here is a study on rat tibial fractures, and you're looking at the percentage of, bone defect healing, and, there was. In the control group, 12% that still had a major defect, compared to about 5% in the PRP, in the PRP and stem cell, it was actually surprisingly higher, it was 8%, but the gold standard seemed to be adding PRP with BMAC, and that came down to about 2% defect. Similarly, when you look at the bone formation, it showed a similar picture to that.

The worst was, the control, followed by the PRP and adipose tissue, and then PRP and then PRP and BMAC. This is one study I open to add because there are other studies that do show a synergis between PRP and stem cells. So you need to be careful not only on what stem cells, but also on what PRP you add together in order to go and get the results you're looking for.

Interesting areas of stem cells as well. This is technesium marked stem cells, reinjected not into the joint or the tendon where you were wanting them to relocate, but actually into the major artery or vein supplying or draining that limb where the damage was done. And, and this is a, a new work.

It, it shows that the stem cells do relocate in the area that you actually want them to. But the clinical work is still outstanding yet to see whether there is enough of a change to have a, a truly clinical benefit from injecting it, in other areas in the joint of the tendon. Contrary to what is felt, it's the number of cells that's important, because you, if you freeze them, you will get similar results, whether they're a viable cell or they're a frozen killed cell, and therefore we believe it's the amount of trophins and growth factors in these that's the most key important factor.

There is a debate about using allergenic. Presently in in Europe it's not legal to be able to use allergenic. We can only use autologous, stem cells from the animal itself and re-injected.

28 days later. But in the future we might be able to have allergenic, which would definitely reduce the costs. And you could then have a bank of frozen thoroughbred allergenic stem cells or Labrador or German Shepherd, and then you could re-inject those and they would have been screened for diseases obviously beforehand.

Beware though, make sure you use a VMD registered or a properly regulated laboratory wherever you are in the world. OK, so quite the bulk of this, I would like to talk about stem cells, PRP sorry, and this is platelet rich plasma. And, taking you back to your biochem days, you get these big megaarriocytes and they bud off these non DNA cells, which last about 90 days in our blood system.

And, and they're, as we were taught at vet school, we're involved in clotting. And when they degranulate, when they meet damaged ecollagen, they open up, provide all the clotting factors, which then prevents bleeding. But what we probably weren't told at that school is they are full and packed full of these growth factors that then have this knock on angiogenic anabolic effect in regards of helping regenerators close to the tissue damage prior to the injury.

There is a difference as well. Obviously it depends on the products you're using, but there's a cost to the owner in stem cells in regards to the fact that you, you're requiring two different time phases of when you take the stem cells and when you re-inject them. So that may be two sedations or, or two general anaesthetics.

And there is definitely a cost of making sure the laboratory is doing it properly to make sure that you do have a sterile sample that you're re-injecting back into the animals that you've taken it from. You know, proven PRP systems, either centrifuge or filtration, they require one visit, and it's about a 30 to 60 minute procedure, and it should cost an owner in the UK somewhere around this area. There are thousands of chemicals in platelets.

To date, we know about 5000 different chemicals present in them, and there are much more. So trying to identify what one does with another is gonna be way beyond my lifetime. But I think we can see the individual effects of each of them, and then surmise how they can interact together.

So, when we look at some of the papers out there. This is looking at the, isolation of individual components of the platelets, into chondrop protection, regeneration, and anti-inflammatory. And when you break that down, you can look at the individual, molecules present within these platelets, and their effect on actually increasing immune infiltration.

So often when you inject PRP into a joint, that joint will actually swell, and it will go and get it become slightly more tender. and this is a natural process because you are actually trying to attract white blood cells, stem cells to that joint, to that tendon, to speed up that whole healing process. You'll also, if you repeatedly go and inject into a tendon, see a lot more blood vessels, or if you do in the human diabetic wounds, you'll see a lot more blood vessels forming around that, which will encourage proper healing and proper tissue.

Ability to be able to go back to as close as it was prior to the injury. We also, we know about the adhesive and the hemostatic, but what's very interesting is these platelets themselves have the effect on increasing proliferation, similar to like the trophins in stem cells. They cause migration of stem cells to the actual area.

They also may be involved directly in the differentiation of some of these stem cells and the other tissues into the different components that you're wanting where the tissue is based. And they have the ability of actually the existing cells, maybe you've got a cruciate injury, of actually protecting the remaining cartilage from apoptosis. And therefore you can actually prevent and increase, the survival of the cells, but also activate certain changes within them as well.

There there's been some great research out there. This was a study done looking at our PRP system, where they injected through needles directly into a hole in the heart in a child, and that stimulated without surgery, a filling in of the hole in the heart defect, so the child didn't have to go under surgery and was able to be done at a very early age and have a very good lifestyle afterwards. From, our sporting world, looking at Oxlade Chamberlain there from, Arsenal as he was, but now Liverpool.

When you do your cruise ship damage, almost all our major rugby and football players will end up with PRP injections. And from the study looking in North American use from sports physicians, 93% of them use PRP. And on average, they're injecting hamstring 3.14, and they're injecting other injuries on, on average on 2.19.

I wanna reiterate that because I think often in veterinary medicine, we think that if you inject once it's gonna be fine. That is not the case. You know, you do need to repeat injection and therefore, in the discussions with clients, you should first of all use a product that you're able to do that, but also you have the ability of being able to make them aware that in order to go and get the full effect, you might need multiple injections, after the initial procedure.

This is some of the work in humans, and on the left hand side you can see there's a filtration system from Cook Medical, and they've invested millions and millions in this in order to go and improve their perfusion in diabetic legs, so they prevent the . Amputation of toes because of the fact they're improving the vascularization of that foot and allowing much better options for treatment for those individuals and also healing of the wound itself. They will also inject actually around the ulcer itself, but it's around the actual vessels that it's really key and you can see that highlighted there.

In, in both human and equine, they are looking at activating, thrombin, which then induces a very acute release of growth factors, and within a sort of fibrine plaque, you can then add that either into bandages, or you can put them into, grafts, into bone grafts, or in this case, cartilage at the bottom, and it will stimulate, healing, and I, I'll show you some data later on about that. Sorry, sorry, it's just here now. So so this is a study looking at that where you've got an added, in this case, rabbit PRP and you've mixed it with demineralized bone matrix, which has had all of just the actual scaffolding that you're re-injecting.

And on the bottom you can see the picture of the pre-PRP and . demineralized bone matrix and the one on the right hand side, how well that's filled in. When we look at the actual stats, you've got the Group A, which is the PRP group.

You've got the Group C, which is the control group, and you've got the DB, which is the PRP and the bone matrix. And this is one of many studies I've seen, but it shows dramatically what an additive effect you can have where you put the growth factors in there, but you've already created a scaffold for the bone to go and fill in. And, and create a new bone and a healthy structure very rapidly.

From a, a, a fibroblast, and in this case, an, an anterior cruciate ligament fibroblast. This is a study looking at the effect of using, PRP and, peripheral, blood mononuclear cells. So, white blood cells floating around the body.

On the right hand side, it shows that there the grey is where no fibroblasts and the white is where there was a significant growth in the amount of fibroblasts from the cruciate ligament. And what they found when you added the IL 6 the the the PRP in the, in the. peripheral blood mononuclear cells was that you saw a massive increase in IL one, and IL one is a very important interleukin for regeneration.

So on the bottom there, the PBS is the control group. And you can see the, you know, the standard anterior ligaments, then added with peripheral, blood that I'm just gonna say PBMC and you can see there's a slight increase, just adding in platelet, poor plasma, just a serum, you, you can see the increases there. When you added the plasma and the, and the peripheral bloods, again, there was an increase.

PRP had a marked increase compared to the, just the ligaments alone. And then when you combined platelets and the peripheral blood, the growth factors of both the platelets and the peripheral blood, you had a very significant increase in regards of the ability to regenerate and produce high levels of IL6, but also, the ability of these anterior cruciate ligaments to regenerate. Interesting areas, I went to a good lecture last night, with the Central Vet Society, and, they were talking about eyes and the use of, PRP and plasma and other things, for injecting into or, or, or onto the actual eye surface.

And this is a study from humans, in ophthalmology. And they were super concentrating platelet growth factors by 4 times normal blood. 26 eyes where they topically gave this plasma rich platelet rich plasma into the eyes.

There were about 2 years standing, these ulcers, and there was a range of different types of ulcers. But over that period of time, 13 eyes healed completely. 11 significantly improved, and only 2 showed no change.

So improvements in symptoms, in the clarity of vision, inflammation, and also in the plane vision just by adding this growth factors from the platelets onto the eye itself. And it's a relatively simple procedure in order to be able to give that to the client to use at home. This is an example from that paper.

You can see a melting ulcer there on the left hand side and you can see after using this PRP system for two months, the eye completely healed, but this photo itself was taken 15 days after the first treatment. So you can already see dramatic changes and improvement in the both the conjunctiva, but especially the cornea, and also some of the inflammation in the anterior ua. This is, I don't have enough time tonight to go through everything, so I, I did a summary, and I used this meth analysis which was looking at about 100 different PRP papers, looking specifically at osteoarthritis and cartilage.

And so there are many, many, many studies out there showing in different species, the, the chondrogenic, the cartilage regenerative effect of PRP in osteoarthritic joints, . The study by Sun looked at 48 rabbits, and they showed a significant improvement not just in the cartilage regeneration compared to placebo, but also in the amount of good glycomin glycan, so the compressive ability of the cartilage to last after it was repaired. .

Similarly, there was the some of the studies highlighted the fact that the earlier you use these PRP systems, not waiting for an end stage arthritis, but the earlier you use them, whether that's with or without surgery, the better the results will be. So please use these things proactively. Similarly, when they compared it against hyaluronic acid or other injectable gly glycommini glycan type products in the joint, there was a significant improvement using PRPs on pain, but also functionality up to one year into the study itself.

But again, it illustrated the fact that the younger the patients, the better results. Of the studies they looked at, resoundingly, it said that when you repeat injections, you get much better results. And therefore, the patient should be warned that every 2 to 4 weeks after the initial injection, you may need a second, you may even need a 3rd injection to really get to proper healing and clinical results, which both the client and yourself are happy with.

Not many studies on hip osteoarthritis. This one from Sanchez looked at 40 patients. In the human, they use ultrasound guided, but, in, in the courses we run, you, you shouldn't really need to use ultrasound.

and using vast, WOMA, CAAS scores, there was a very significant reduction in pain and functionality compared to the placebo group. There there there there there are good studies out there, and, and the conclusion of this, they say that you should be using it post surgery as well. In the veterinary field, depending on where you are, there are centrifuge systems and there are probably 4 or 5 different veterinary centrifuge systems brought in from the human side.

And, and there are also filtration systems, that are available. There are debates in, the veterinary, which are not debates in the human side, so they're, they're in the human side, most of the products try and concentrate both white blood cells and platelets to go and super concentrate the growth factors. For some reason, there's been a lot of misinformation in the in the veterinary side where they talk about the detrimental effect of white blood cells, which does seem a bit ridiculous seeing that they're within our body system and there to protect us and help us.

But a lot of this is based around, promoting one negative study on white blood cells and platelets, which is an in vitro study. But there, in the human and in the veterinary and in other animal models, there is a lot of positive studies looking at the combination of these peripheral, blood mononucleocytes, nuclear cells, and adding platelet growth factors and having a synergistic effect. But we do need more studies to go and understand exactly how they're working.

. This study goes and shows 4 commercial human centrifuge systems, compared to the ACP system, compared to control blood. And you can see a very significant improvement in the or or or concentration in the amount of platelets in the three centrifuge systems, and you can also see a significant increase in the amount of white blood cells, and this is standard in the human side, where they are actually trying to increase growth factors both from the platelets and from the white blood cells. And from research that we did on our product, at this point was called EPET, that is now called VET.

And on the top you can see versus other centrifuge systems and also just from baseline, and also view the ACP system, you can see the increase in the platelets, the yellow being our product, and also the increase in the white blood cells. What's interesting though is when you actually look at the amount of growth factors, the growth factors were significantly higher in the EET product compared to the Centrifugue systems, or even the manual effects. And the reason.

For that is that you'll see later on that there's a stickiness to the platelets and the filtration system. So therefore often when you back flush, you actually break open the platelets. So you may not monitor the amount of platelets, but you actually will release the growth factors that are necessary for the regeneration.

Regardless of what PRP system, you need to take blood, this is a picture from a, an Italian, clinic using it, but I would recommend really if you can to take it from the juguer because often you're taking 55 mLs and, definitely in the horse, that's much more viable. But, in, in anything, from a cat to a dog, I, I'd prefer taking it from a jugular if I could. And often you can take two lots of 55 mLs if necessary, and you might be able to bank that and store that at a later date.

You don't really need it as quite a space age as this, but you do need to have sterility, because you are injecting often into a joint capsule or into a, a tendon, and, and therefore you want to keep the high levels of sterility, in order to be able to do that. The product I'm most familiar with is actually a philtre system. But I have used also Centrifuge systems as well.

And the filtration system, comes from a company called Pow which actually, does philtres for all different manners of, the, products across the world, and most of them are just trying to keep things out, whether it's vaccines or drugs or drink or spacesuits, but actually in the blood things, they're trying to maximise some of the good things within our blood system, so you super concentrate them. I in, in the VPEP product, what happens is not only do these philtres capture the white blood cells because they're big and allow most of the red blood cells to pass through, but the stickiness of the philtre captures the the platelets, and so you super concentrate platelets, and it's a super concentration of platelets that then is releasing all of these growth factors. So most of those may not pass through into the actual end concentrate it will be the growth factors once they split open, that will be present there.

And this is some of the data. Originally it was called CPAT EPAT, but now it's called VAT, and it's a combined product for both species, or even I've used it on things like ring-tailed lemurs and cats and other species of rats and mice and things. And you can see that, you get a super concentration of both the platelets and the white blood cells compared to standard blood.

And, it is sterile, it's rapid, and you should get some synergistic effects. On this, you're looking at the maximisation of the platelets compared to the basil, and, and we can get it up to 100 times concentration of platelet growth, the derived growth factors compared to the basil. So it it really can super concentrate the amounts that you're able to go and do.

Looking at some of the earlier work on this product, on equine, this was work done from Barcelona in the Royal Vet College, and you can see those lesions over 12 weeks in the digital flexors, and you can see both longitudinal and cross sectional, how that filled in the defect, but also from an ultrasonographer, but also from a clinical point of view, these horses, at least 2/3 of them got back to full racing capacity and didn't break down. From a smaller domestic species, you have the ability of really going from a Japanese chin or a chihuahua up to a Great Dane type dog, and you can also use it on domestic cats and and exotic species as well, as I heard in the introduction of some people. The aim, and different products will have different systems, is to try and super concentrate at least 3 times the platelet concentration of blood.

From all the studies, that seems to be the kicking point of really showing clinical response. And depending on the amount of blood you take, depends on, in our case, the amount of, solution harvest that you flush back, into the actual philtre system to go and super concentrate the platelets and white blood cells. Again.

Different companies will have different things. In our case, we provide sheets to go and tell you how much you could inject back in, but a lot of the people, using our product will inject until they feel no tension more within the joint, so they may, may actually inject a little bit more than what's on these charts. Initial work on this product, in the, in the small animals done in the dog, and there was a publication that came out at VCOT in 2012, which then went for a, a much bigger publication at Jamma in 2013 from work in a higher state in western state universities.

They looked at 20 client-owned dogs that had unilateral osteoarthritis only in one joint. And, then they, you know, injected the other joint, the other group with saline. So it was a, a, a true double blind placebo controlled study.

The saline group were then allowed at the end of it when they were told that it was saline to be off for VP and in this case, they all of them took it up. The inclusion criteria, they had to have no surgery, they had to have no injectables, and they had to have radiographic signs of osteoarthritis, joint narrowing just in one joint. And it was a 12 week study.

But they also just to standardise, they came off pain medication, but when I use regenerative medicine, I tell the clients to stay exactly on what they're on. I don't get them to take away any of the products. I may not inject steroids at the same time as I inject a joint.

I would leave a week between that. But if they're already on medication, oral medication or injectable subcu, then I, I, I, I wouldn't mind using the two in combination. In this case, they used a Hudson visual analogue scale.

They used a canine brief scale, and they also looked at peak force er and ran them over the force plate analysis in order to be able to monitor them. They looked at the bloods to make sure that you're getting at least 3 times concentration, at least 2 times in the white blood cell component. And over 12 weeks versus the saline, there was a 55% improvement using the Hudson visual analogue score, looking at a whole load of different parameters in lameness.

And when they looked at both the Hudson and the canine, there was a very significant improvement in the ones that were injected with the PRP system, the VPEP compared to the saline solution. And when they looked at the peak force level, there was, again, a significant improvement compared to the, the saline group, akin to what you'd see in a non-steroidal, meloxicam or a Rimidil or onsor type drug, study. This was not published, but, I, I often tell people to flush the joint before injecting the regenerative medicine products.

And in this case here, you can see that those dogs that were given the saline, the owners were offered to have the V test at the end of it, and all of them decided to have it. And now 6 months into the study, you can see 3 months after saline, 3 months after they had been injected with the the PRP system. Now you can see a significant improvement in the .

force plate of that damaged joint. It's a philtre system, it's easy. It takes roughly about 30 minutes to do.

And, there were no side effects, but, we didn't see any radiographic changes, but we did see clinical improvement. They also did a much bigger long study over, 137 dogs. This is an un controlled study.

And, and this random group of, veterinary dogs that were injected, you could see similar changes in the Havas score or in this case, a a a a very significant improvement over 12 weeks. And when they injected cruise ship ligament dogs which did not have surgery. Again, there was a significant improvement in these dogs' lameness, akin to what we're seeing in OA cases.

When you look long term wise, the question is how long do these things last? And I, I already illustrated in the human they inject regularly, and they often inject every 4 weeks for maybe up to 3 sessions. In this case, it was only injections once, and you could see that about 90% of the dogs at 6 months were still significantly improved compared to where they were prior to it.

And we have some data up to 12 months as well. What is important to know is the group that you're trying to inject. So, looking at zeros where they were at standard, and looking at age and also the improvements in lameness scores, you can see they all improved overall.

But the younger and the more medium aged dogs did better than the really old multiple osteoarthritic dogs, and this may be due to age, may also be down to the lack of, growth factors in your platelets, a whole manner of different things going on. This just gives you an illustration of what can happen, so the the this dog here that jumps up, had er er the, the, the product injected into its elbow, and it was really very lame. You can still see it's a little bit lame on its right side there and it drops a bit, but it's a happy dog.

Clinically it's able to exercise, and it's able to enjoy its life. So, you know, that was one injection and potentially it would need more injections, but, definitely an improvement clinically in how it did. And I'll end really with a case study here.

This is a, this is akin to what many of you would feel would happen to you in practise. It's not always easy to go and convince an owner to go and use regenerative medicine right at the beginning, and this is a case which really is at the end of its stage. They're not not an ideal candidate, but it hadn't been offered earlier in life.

So 12 year old black Labrador, it had both cruise ships done with TPLOs when it was young. And how it was very lethargic now. It, it was on 12 different supplements.

It, was hardly able to move its elbows, and it was very stiff in its stifles and in its back. It was, it was covered in lipomas as well, but that was kind of incidental. I, I, I, I, I always preached multimodal, so I had to do it in practise.

So I, I, I got rid of, 9 of the supplements and just kept her on a very high omega 3 and joint supplement, as well as multi-vits, which she wanted to continue. We used the laser because she was more comfortable initially in going and using laser therapy than regenerative, and a lot of you may find this initially, it's difficult to get them to do it straight away. but by that period of time, we'd already reduced the the minute andlo kept them down to a lower.

Once she'd done her reading, she'd read the literature, she'd read around it, she felt more comfortable. So at that point in December, we went and injected. And the dog showed such a marked improvement that she went on to inject both elbows.

And the stifles, and this dog has lived another sort of 2 to 3 years, a very happy life, in regards of its quality of life and continued using medication at lower dosage, supplements and also the laser therapy, so it's a good outcome. From a clinical point of view, from a practise, this is a new service, so clients would look at it as cutting edge because it is. It's safe because it's autologous.

From our own research, you're getting at least 84% showing a clinical good response. And often you see a response within 2 weeks, and it can last up to a year. It's a relatively inexpensive way to be able to treat them when you compare it to long term nonsteroidals, maybe in a Labrador dog.

And it can be used in combination, but, hopefully there is quite a lot of increasing clinical resources there to go and give you confidence in using it. My take home message is, I, I think there's a lot of good science. I only did a few papers tonight, but there's really is across a broad range of areas, a lot of good research and science.

I think we really now are showing from good regenerative products and anabolic, and also some anti-caabolic effects. But there is variation, so, you know, you're not gonna get it right every time. You need to, I would choose young, I'd use post-surgery, I'd use early osteoarthritis cases to try and do this.

And if you use it later, you may need multiple injections, . You can combine it also. I think there is increasing levels of evidence to show that maybe there is an additive benefit of BMAC and PRP or stem cells and PRP, but obviously there are costs involved.

And I didn't manage to show it tonight, but there are also some studies showing the involvement of stem cells and laser, and there's definitely some good studies out there showing a synergism between the two in combination. So ideally, use it early in life, early to medium arthritis, elbow disease, and young labs. Do it, for acute injuries, tendons and soft tissue, wounds and things.

But also I would incorporate it to help on the biology for joints, post-surgery as well. So, a whole range of areas. That was a lot to take in, but I tried to do it as quickly as possible.

I hope that that helped. That was great, thank you so much, Stephen. I'm sure we will have some questions on that.

Anonymous attendee, any side effects, I'm not sure exactly what that referred to, but with anything, as you all these side effects. I mean, sterility obviously you want to keep high levels of ster cos often you're injecting into a joint or a tendon, and therefore you really, you know, want to maintain that as sterile as possible, whichever way you could possibly can. You know, there's some The case studies are marvellous, aren't they, at the end though, you know, one treated with one injection doesn't need non-steroidals, the other one, you know, had obviously had multiple problems, had had operations, you know, on its knees, and, you know, with an injection you were able to reduce the medicine so that.

It it's definitely something that we should consider in our armament, isn't it, really, in ourorium? Yeah, I mean that, that, I mean, you know, case selection is important and client selection is important because, you know, it's not inexpensive to be able to do those things and . But, but, you know, I, if you can incorporate it into doing it post-surgery on cruciates or elbow, you know, scopes and things like that, then, you know, the cost isn't so big for the client and it is covered under insurance, and then if you get more familiar with using it, then, you know, you know, I know, and some of the clinics I work with, you know, they use 400 units a year.

And so it, it, they, they now use it as first line rather than a last resort. So it's completely reversed its way of being used. And, and that's just a confidence thing, you know, it's like anything, until you start using it and seeing the results, then it's hard to go and, you know, wholeheartedly jump on board.

And we've certainly, you know, for those of you who are interested, we've certainly done, you know, other webinars on regenerative medicine, and I am. Very excited about, you know, treating animals in, you know, slightly less traditional ways, but some of the incredible successes we're having with that. I know John Innes, you know, who was at Liverpool University was very interested in this area as well, so it's definitely .

Receiving a lot of interest from, you know, serious people like yourself and John as well and obviously I, Hear a lot about some of the stuff that's going on in human medicine as you've explained as well today, there are some, Really, really incredible cures that are happening, you know, even people walking again due to things like stem cell therapy. Understood, I mean, Anthony, begrudgingly you now have Oxlade Chamberlain, and he's gone from Arsenal to Liverpool, and you can see how much he's benefited from it. Yes, exactly, and he, he, he did it again, of course, 18 months, 2 years ago and is now really back again.

So yeah, presumably, you know, very good surgeon, but obviously the PRP and and stuff is also getting absolutely, it's not one or the other, you know, I think sometimes surgeons feel that they can just cut and then they, everything's gonna be fine. Well, there's a hell of a lot of biology that's happening. And, and, and in the human side.

Most surgeons now will combine it with surgical technique or or not surgery. So, so that you know that, it, it is much, much more a you know, and I work a lot with elite sports, physios, and they, they actually, they're, they're licenced to be able to use PRP but also as the medical surgeons as well and their whole team. Well, you know, it's a bit like dermatologists, you know, we could just put a dog on steroids, but actually we know that.

You know, if we can treat its malaitia infection, you know, treat its ears with air cleaner, maybe have it on, you know, immunotherapy, suddenly we don't need to use those steroids, or maybe we need to use them, but it's at a much lower level, so the more that we can have a holistic approach in anaesthesia. You know, in osteoarthritis, you know, in dermatology, it's, it's more complicated. You have to spend more time explaining it to clients rather than give it some of these tablets, the dog will stop itching, but somewhere down the line, there'll be a problem with that approach.

And, you know, similarly with, like, we've done the surgery, that's it, you know, we're not going to talk to you about keeping the weight off the dog, we're not gonna talk to you about non-steroidals or, you know, PRP or whatever. You know, it it you have to pick your client because obviously it is more complex, but I think if you can get the right people. You know, as you've shown here, you can get some remarkable results.

Absolutely. The other the other the other thing that needs to be reiterated is these are not drugs, so the regulation around them is fairly loose. So, so you really need to make sure that what you're using, you're confident in, because, it, it, it, you know, there is no the VMD's closed down a number of false, stem cell labs that sprung up in the UK.

But, but, but there are a lot of companies coming in with a lot of products which look good on paper. But need to actually have the science behind them. Yeah, and you know, I understand that.

Christopher's saying, and I think we've answered it, but you know, just in case you want to add anything else, how about using it intraoperatively in orthopaedics or soft tissue surgery? Yeah, again, I, I, I, I mean that that meta-analysis I tried to go through quickly, that they really went back and back in in that saying that it really should be used proactively and actually some of the better. Results coming out in the future are looking at, you know, standard surgery and standard surgery with a regenerative medicine product added in and, and, and there definitely is an enhancement in the speed of recovery.

And also like that data on the horses, a lack of breakdown later on, which is what we all want, really. So very much you've had cases where you're using these products intra rather than postoperatively. Yeah.

I, I, I, I, you know, I, I'm not too prescriptive in surgeons when they want to inject it. I prefer they inject it as soon as surgery is being done because the biology's happening straight away, but some of them like to incorporate it at the 10 day checkup. Where they often X-ray just to make sure all the plates and everything are in the right place.

And, and you know, I'm not, I'm not, you know, if it's in 2 weeks, I can understand that, but I wouldn't wait a month to 6 weeks to see whether their surgery has gone well and then inject because then the damage has happened together, yeah, and I think Chris has kind of, you know, reiterated this point if you would inject the PRP directly after surgery. Do you continue non-steroidals? Yeah, I would.

I, I, I, there's nothing I would stop, because you still, you know, they they they I mean non are fantastic analgesics, and you want that animal using that leg as close to normal as possible, within the strengths of what they are able to do. But yeah, I, I, I, I would, I think from an ethical and also from a biological point of view that it, it, it won't damage any of the effects that the regenerative medicine products are doing. I just wonder, with a show of hands, which we can't do with this, so it'd have to be a quick comment in, in, in the chat box.

Obviously Stephen's covered a lot of information in an hour. Would there be a benefit, to doing something that perhaps, you know, was more of a series on this area, . Is that something that would interest people and if there was a small cost to that, would that still interest them, so maybe yes, you're interested.

Know if you had to pay for it or yes, yes, just so we get an idea of if this is something that we should speak about more and I suppose Stephen, you know, from your perspective, Is this something where, you know, is it worth you? Having the opportunity if people are interested to speak to them on an individual basis if they'd like to, you know, understand more about maybe the PRP stuff that you've got and so on. Yeah, absolutely, I mean I I'm more than happy to talk to people and look at different applications.

I mean I this year I went and treated . A ring-tailed lemur in Bristol er er and you know, I didn't, I didn't know whether it was gonna work or not, but you know, it, it had a chronic wound that it was chewing and chewing at and and and and and with that and other medication we did manage to heal that, so, brilliant. What might be worth doing, Stephen, if you shout out your email address to us I can type that in so people have got it in the .

You know, in the, in the, in the box. Let me, let me just, don't move it and let me stick that in and then people can take that if they want it and you know, could almost come direct to you and possibly, you know, if they do want some more, you know, webinar training on this, you know, we can then sit down and and. Sort something out, you know, I mean, we do know that, I mean, there, there seems to be a dichotomy.

I mean, equine vets come out and they seem to want to inject everything, and, and small animal vets come out and unless you're an orthopaedic surgeon, you don't like injecting joints. So it is changing. But, but we do run courses with the Improve International, where we train people on how to inject joints, and we, we have one coming up in March in Swindon quite soon.

So that might also be worth, you know, looking at if you're particularly interested in doing it. Of course, to inject a horse joint is rather bigger than a Chihuahua's or whatever, so they're a bit easier to hit, aren't they? It, yeah, I mean, I, I'd still use ultra because some of the lesions are really small in the, in the tendon, but in the equine actually I would use ultrasound often, and that, yeah, and what we do is we score the needle so that it shows up on ultrasound so you know exactly where your needle is.

And that's quite good, but, but in the small animal, you know, we tend not to use ultrasound, very much, but it, it, it's, you know, there's certain good anatomical points to go and work it out. And actually injecting elbows and, stifles in a dog is really easy. .

Are you aware, Stephen, obviously we, I know we've got a couple of Aussies, we may have more, we may have a few people coming from other places as well. Is there, you know, your product or a product very similar to it? You know, in Australia and other places.

Yeah, I mean it has a global licence, but I, I mean the Australians actually are very proactive in regenerative medicine, yeah, they they they a lot of good, works going out there and and probably in all the world, Australia will be the first one to have allergenic stem cells, so so they are definitely pushing things in this area compared to. And the allergenic stem cells are to to help with allergies. No allergenic as in it's all allergenic is in, in, you know, I could end up having your stem cells heaven, heaven help us.

That would be terrible. You'd probably grow a foot though, Steve, and so you know. Oh, well, that would be awful.

And just because you've, you've, you've led me beautifully on to that point, I'm gonna shamelessly just, promote something that we'll be doing early next month. Believe it or not, Stephen, and I think you're probably similarly, around for as long. I know we're of a similar vintage.

Webinar vet is 10 years old on the 5th of March. Congratulations. And we're going to be.

Doing a round table on dermatology because the first webinar I ever did on the 5th of March was about pruritus, itchy dogs, and what we're gonna do this time is, it's only gonna be available as a live webinar. So we're gonna encourage people to join. If they join, we're gonna donate 50 pence to each delegate, to the Australian bushfire appeal.

People can obviously, you know, donate more if they want to. And we'll be also giving away various prizes and things, so it's gonna be quite a nice big event. I know we're we're gonna be doing a, a, a dinner later on in the year, so there'll probably be a few tickets for that, virtual congress tickets and things, so it should be a bit of fun.

Do look out for those emails coming at you probably next week and obviously it's free to attend, but it will be live. We're gonna run it at 9 o'clock so we can make it slightly more appealing to the Aussies at making it a good hour, and then obviously also Americans and Canadians who might want to listen in as well. So it would be great to have as many as possible at that.

But anyway, that's the commercial breakover . Stephen, that, that's been really excellent. I don't know if anybody else has any more questions.

Let me just see. Corinne has lots of questions. Can you use PRP in Burns?

Which I think you can, can't you, you were showing the, the serum. Yeah, cloth that you used in some of these. And there, there is, I mean, in the future they'll have bandages which incorporate it, and so you can, you know, it will just leech out growth factors into the actual tissues.

but the work that's done by Cook Medical, with our sister products on the human side, they not only do they cause angiogenesis and they, they, they, they wanna create a lot of white blood cells because they have a lot more angiogenic molecules. In it, but they, they inject directly into the ulcer itself. Go and create healing of the tissue, so in burns victims, absolutely they, they, they will be using serum, but there'll also be growth factors on there.

Yeah. We've got a a sort of clarification point, anonymous attendee, you are happy to continue non current non-steroidal regime pre and post the pet therapy. Yeah, I would.

And then with regards to repeat injections, you tend to wait to the effect first, so if less than expected then go for a second dose. I, what the cutoff. If you don't repeat in the 2 to 4 week window, do you miss the window for cumulative benefit?

Sadly, like a lot of things, there hasn't been the archetypal study, it's more case reports in regards to that. On the humans, there, there are studies there, but not on the animal model, but on the humans they definitely seem to inject, maybe for monetary reasons, but also for the end result, you know, 2 or 3 times. And they tend to inject every 4 weeks because that just fits in well with the system.

Yes. But obviously in the humans they can do it under local anaesthetic and an ultrasound, so it's a bit more complicated than the animal because it does need another sedation in order to go and do it. I, I tend to go and, and again, just speaking about our own product, you can take 55 mLs of blood from any dog over 10 kg of their weight.

And a Labrador, you can actually take 255 mLs. So I often go and freeze one product and use one. And, and in doing that, then you can, I know thaw, you know, thaw that just at the time of the next injection.

So if it has elbow arthritis or stifle arthritis, I will warn them that I probably will need two injections, and then it's not costing them any more than a sedation for the second time. Because you've already got their product available for which has just been stored frozen. And that's what I tend to do.

So, so I tend to warn them that in 4 weeks' time I'm gonna re-inject. Hm. Final question, people have still stuck on, so, the good thing about webinars is you can always slink out if you've got somewhere else to go and nobody will say anything, but Kerry's saying I work for a large mixed species sanctuary.

And I would be interested in using this on our osteoarthritis cases, can you give us a cost range? So, I think Kerry, that's probably one for you and Steve and to carry on, on an email basis, but I'd be happy to. That's certainly something that you can.

Chat about, isn't it? Yeah, I mean, I, in, in general, whatever the product you're using, I, I say that you should have two systems. You should have one where you're using it at the time of surgery, which obviously is a reduced cost, and then there's one as a standalone where, you know, the, the product itself, you might mark up a bit more but but also, you know, charge according to your time and sedation and all the other aspects that you're.

Spending time doing, so that's how I'd fit it into a practise. Good. And just a final one from Coin talking about temperature of storage of these products, are they left in the fridge?

Yeah, I mean, it would if you know, I wouldn't leave it in the fridge, but I would, if you're talking about the drops, you can leave it in the fridge at about 4 degrees and it would last for up to 2 weeks, just as a. Droper to go and use on melting ulcers and things like that. But but if I was storing it in the freezer, I would do it around, you know, sort of -18, a standard freezer temperature and then, yeah, and what I put it in, in the humans they produce multiple aliquats in the, in the, you know, you can have those little screw tops to the syringe, so it only goes one direction, doesn't come out the top when it freezes.

And then I would label it accordingly because some of our clinics may have like 400 dogs, syringes in there, so you really need to work it out. And after probably a year, I would discard it. We know that a year you've lost about 5% of the growth factor, you could try and keep it longer, but we wouldn't support your staff, yeah, less effective.

Corinne has got a lot of questions again, . If, if some of those haven't been answered, Karina, I would suggest Stephen would be very happy to to answer some on on . You know, on the, email as well.

Yeah, sorry, sorry, just said it preferred defrosting. I, I, I, would just, if you have a, if you know that animal's coming back in, I would take it out of the freezer in the morning and then let it get to room temperature by about midday. You know, or, or even put it in a a a a a very warm, you know, light warm water bath, but I wouldn't try and contaminate it too much.

So, so I'd prefer it just gently to rise temperature to room temperature. So by the time you do the operation or the the second procedure, you're just injecting at that point. I've really enjoyed, it's always an area that I'm fascinated with, so I really thank you so much for, for doing the webinar for us.

We've got Simon saying great talk, thank you, looking forward to the next webinar. So we've really all enjoyed it, Stephen, thanks so much. There's a lot of effort going into that, a lot of thought, and, a lot of things for us to go away and have a think about as well.

So thank you so much. No, much appreciated, Anthony, and thank you everyone for joining me tonight. Thank you, Stephen, we'll see you all on the webinar very soon.

Take care, bye bye, bye.