PRINCIPLES OF CRYOSURGERY
Cryosurgery (cryotherapy) is the application of extreme cold to destroy abnormal or diseased tissue.
The term comes from the Greek words cryo ("icy cold") and surgery meaning "hand work" or "handiwork".
Cryosurgery has been historically used to treat several diseases and disorders, especially variety of benign and malignant skin conditions.
Mechanism of cryosurgery
o The destructive effect of freezing tissue has been categorized into two major mechanisms-
Immediate cell destruction.
Delayed cell destruction.
Application techniques
Probe freezing: It is done by direct application of a probe tip to the lesion. The cryogen circulates through the probe tip and super cools it, when allowed to contact the target tissue. Probe freezing can be accomplished by one of the two mechanisms: contact freezing and penetration freezing.
In contact freezing, firm contact is made between the cryoprobe and the target tissue.
While in penetration freezing probe penetrates the target tissue, providing a large area of direct contact.
Spray freezing: It is done by direct application of the liquid nitrogen to the tissue and is the most destructive method. Liquid nitrogen is delivered to the target tissue at such a volume and velocity that it evaporates at the edge of the lesion. The spray orifice allows deeper and faster tissue penetration than the probe tip but the probe method is safer and more precise.
Benefits of Cryosurgery in Veterinary Medicine
Painless.
No Preparation.
No post op care.
No open wounds – No Bleeding.
No suturing.
No general anaesthesia – safe for older animals.
Rapid treatment time – only seconds.
Cost Effective.
Pressure to treat lesion.
Pinpoint Accuracy.
CryoProbe’s different micro applicators tips allow pinpoint accuracy to treat skin lesions from 1mm to 8mm in size.
Blue dot applicator Applications 1-3 mm.
White dot applicator Applications 2-4 mm.
Green dot applicator Applications 3-6 mm.
Yellow dot applicator Applications 4-10 mm.
Lesions
With the CryoProbe you will be able to treat (but not limited) to the following lesions successfully:
Perianal Adenomas.
Epuli.
Papilloma.
Lick Granulomas.
Warts.
Small Sarcoids.
Eye Lid Tumors.
You will be able to quickly and easily treat skin lesions that you could not treat before without undesired side effects.
Disadvantages of Cryosurgery
As with the advantages of cryosurgery, the disadvantages can also be categorized into those for the clinician and those for the patient.
Disadvantages for the clinician include the following:
Liquid nitrogen needs to be delivered and stored. A liquid nitrogen generator may be purchased. If that is not done, nitrous oxide tanks or other supplies will need to be replenished as needed.
its my presentation about scoliosis ,anatamically and therapiutically i explained everything about this here.one of the biggest problem now adays in world.
Burn is coagulative necrosis of the skin’s tissues, usually caused by excessive heat
Excess heat causes rapid protein denaturation and cell damage
Wet heat (scald) travels more rapidly into tissue than dry heat (flame)
A surface temperature of over 60˚C produces immediate cell death as well as vessel thrombosis
The dead skin tissue is known as Eschar
its my presentation about scoliosis ,anatamically and therapiutically i explained everything about this here.one of the biggest problem now adays in world.
Burn is coagulative necrosis of the skin’s tissues, usually caused by excessive heat
Excess heat causes rapid protein denaturation and cell damage
Wet heat (scald) travels more rapidly into tissue than dry heat (flame)
A surface temperature of over 60˚C produces immediate cell death as well as vessel thrombosis
The dead skin tissue is known as Eschar
spirochete, (order Spirochaetales), also spelled spirochaete, any of a group of spiral-shaped bacteria, some of which are serious pathogens for humans, causing diseases such as syphilis, yaws, Lyme disease, and relapsing fever. Examples of genera of spirochetes include Spirochaeta, Treponema, Borrelia, and Leptospira.
Spirochetes are gram-negative, motile, spiral bacteria, from 3 to 500 m (1 m = 0.001 mm) long. Spirochetes are unique in that they have endocellular flagella (axial fibrils, or axial filaments), which number between 2 and more than 100 per organism, depending upon the species. Each axial fibril attaches at an opposite end and winds around the cell body, which is enclosed by an envelope. Spirochetes are characteristically found in a liquid environment (e.g., mud and water, blood and lymph).
yaws
yaws
Treponema includes the agents of syphilis (T. pallidum pallidum) and yaws (T. pallidum pertenue). Borrelia includes several species transmitted by lice and ticks and causing relapsing fever (B. recurrentis and others) and Lyme disease (B. burgdorferi) in humans. Spirochaeta are free-living nonpathogenic inhabitants of mud and water, typically thriving in anaerobic (oxygen-deprived) environments. Leptospirosis, caused by Leptospira, is principally a disease of domestic and wild mammals and is a secondary infection of humans.
Surgical diathermy involves the intra cellular conversion of high frequency alternating current to thermal energy in order to generate a variety of tissue effect during surgery
spirochete, (order Spirochaetales), also spelled spirochaete, any of a group of spiral-shaped bacteria, some of which are serious pathogens for humans, causing diseases such as syphilis, yaws, Lyme disease, and relapsing fever. Examples of genera of spirochetes include Spirochaeta, Treponema, Borrelia, and Leptospira.
Spirochetes are gram-negative, motile, spiral bacteria, from 3 to 500 m (1 m = 0.001 mm) long. Spirochetes are unique in that they have endocellular flagella (axial fibrils, or axial filaments), which number between 2 and more than 100 per organism, depending upon the species. Each axial fibril attaches at an opposite end and winds around the cell body, which is enclosed by an envelope. Spirochetes are characteristically found in a liquid environment (e.g., mud and water, blood and lymph).
yaws
yaws
Treponema includes the agents of syphilis (T. pallidum pallidum) and yaws (T. pallidum pertenue). Borrelia includes several species transmitted by lice and ticks and causing relapsing fever (B. recurrentis and others) and Lyme disease (B. burgdorferi) in humans. Spirochaeta are free-living nonpathogenic inhabitants of mud and water, typically thriving in anaerobic (oxygen-deprived) environments. Leptospirosis, caused by Leptospira, is principally a disease of domestic and wild mammals and is a secondary infection of humans.
Surgical diathermy involves the intra cellular conversion of high frequency alternating current to thermal energy in order to generate a variety of tissue effect during surgery
New modern technique nowadays used for treatment....specially for medical students....Gain knowledge as much as you can and form wherever you can..i hope you will like it
Cryotherapy is a controlled and targeted destruction of diseased tissue by the application of cold temperature substance.
Used for treatment of diverse benign lesions and well corcumscribed pre malignant and malignant tumours
cryogenics is the production and behaviour of materials at very low temperatures. It is an effort to save lives by using temperatures so cold that a person beyond help by today's medicine can be preserved for decades or centuries until a future medical technology can restore that person to full health. Cryonics sounds like science fiction, but is based on modern science.
Cryotherapy, sometimes known as cold therapy, is the local or general use of low temperatures in medical therapy. Cryotherapy may be used to treat a variety of tissue lesions. The most prominent use of the term refers to the surgical treatment, specifically known as cryosurgery or cryoablation.
Cryotechniques and their methods.
1.cryotomy and What is cryopreservation.
2.cryopreservation of cells, tissue, and organisms.
3.freeze fracture
4.freeze drying.
5.freezable tissues.
6.mechanism of cryopreservation.
7.cryopreservation of embryos.
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Cryonics In Nanotechnology Raising From Deathmanyamkusuma
The most important application of nanotechnology is cryonics.
Cryonics – derived from the Greek language, kryos meaning icy cold. Cryonics is the low-temperature preservation of living things who/which can no longer be sustained by contemporary medicine, with the hope that healing and resuscitation may be possible in the future. Preserving to the point where molecular physical decay completely stops this state is known as cryonics suspension. The idea of cryonics was proposed by Robert Ettinger a Physics teacher after he read a book The Jameson Satellite by Neil R Jones in the year 1931. Later he published the books so called, The penultimate Triumph and The Prospects of Immortality in the years 1948 and 1962 respectively, which is a modern era of cryonics.
Robert Ettinger - ‘ originator and pioneer of cryonics’.
The word cryonics was proposed by Kerl Werner in 1965.
Later it was developed by CSM, CSC(not in use know),
CI, Alcor. In medicine, cryonics was once considered on the outer edge but is now moving closer to reality which means someone who died and was frozen last week may have a future again. Cryonics and nanotechnology form a useful pair.
Cryonics can transport a terminally ill patient to future medical technology.
The French Revolution, which began in 1789, was a period of radical social and political upheaval in France. It marked the decline of absolute monarchies, the rise of secular and democratic republics, and the eventual rise of Napoleon Bonaparte. This revolutionary period is crucial in understanding the transition from feudalism to modernity in Europe.
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A Strategic Approach: GenAI in EducationPeter Windle
Artificial Intelligence (AI) technologies such as Generative AI, Image Generators and Large Language Models have had a dramatic impact on teaching, learning and assessment over the past 18 months. The most immediate threat AI posed was to Academic Integrity with Higher Education Institutes (HEIs) focusing their efforts on combating the use of GenAI in assessment. Guidelines were developed for staff and students, policies put in place too. Innovative educators have forged paths in the use of Generative AI for teaching, learning and assessments leading to pockets of transformation springing up across HEIs, often with little or no top-down guidance, support or direction.
This Gasta posits a strategic approach to integrating AI into HEIs to prepare staff, students and the curriculum for an evolving world and workplace. We will highlight the advantages of working with these technologies beyond the realm of teaching, learning and assessment by considering prompt engineering skills, industry impact, curriculum changes, and the need for staff upskilling. In contrast, not engaging strategically with Generative AI poses risks, including falling behind peers, missed opportunities and failing to ensure our graduates remain employable. The rapid evolution of AI technologies necessitates a proactive and strategic approach if we are to remain relevant.
The Roman Empire A Historical Colossus.pdfkaushalkr1407
The Roman Empire, a vast and enduring power, stands as one of history's most remarkable civilizations, leaving an indelible imprint on the world. It emerged from the Roman Republic, transitioning into an imperial powerhouse under the leadership of Augustus Caesar in 27 BCE. This transformation marked the beginning of an era defined by unprecedented territorial expansion, architectural marvels, and profound cultural influence.
The empire's roots lie in the city of Rome, founded, according to legend, by Romulus in 753 BCE. Over centuries, Rome evolved from a small settlement to a formidable republic, characterized by a complex political system with elected officials and checks on power. However, internal strife, class conflicts, and military ambitions paved the way for the end of the Republic. Julius Caesar’s dictatorship and subsequent assassination in 44 BCE created a power vacuum, leading to a civil war. Octavian, later Augustus, emerged victorious, heralding the Roman Empire’s birth.
Under Augustus, the empire experienced the Pax Romana, a 200-year period of relative peace and stability. Augustus reformed the military, established efficient administrative systems, and initiated grand construction projects. The empire's borders expanded, encompassing territories from Britain to Egypt and from Spain to the Euphrates. Roman legions, renowned for their discipline and engineering prowess, secured and maintained these vast territories, building roads, fortifications, and cities that facilitated control and integration.
The Roman Empire’s society was hierarchical, with a rigid class system. At the top were the patricians, wealthy elites who held significant political power. Below them were the plebeians, free citizens with limited political influence, and the vast numbers of slaves who formed the backbone of the economy. The family unit was central, governed by the paterfamilias, the male head who held absolute authority.
Culturally, the Romans were eclectic, absorbing and adapting elements from the civilizations they encountered, particularly the Greeks. Roman art, literature, and philosophy reflected this synthesis, creating a rich cultural tapestry. Latin, the Roman language, became the lingua franca of the Western world, influencing numerous modern languages.
Roman architecture and engineering achievements were monumental. They perfected the arch, vault, and dome, constructing enduring structures like the Colosseum, Pantheon, and aqueducts. These engineering marvels not only showcased Roman ingenuity but also served practical purposes, from public entertainment to water supply.
Biological screening of herbal drugs: Introduction and Need for
Phyto-Pharmacological Screening, New Strategies for evaluating
Natural Products, In vitro evaluation techniques for Antioxidants, Antimicrobial and Anticancer drugs. In vivo evaluation techniques
for Anti-inflammatory, Antiulcer, Anticancer, Wound healing, Antidiabetic, Hepatoprotective, Cardio protective, Diuretics and
Antifertility, Toxicity studies as per OECD guidelines
Synthetic Fiber Construction in lab .pptxPavel ( NSTU)
Synthetic fiber production is a fascinating and complex field that blends chemistry, engineering, and environmental science. By understanding these aspects, students can gain a comprehensive view of synthetic fiber production, its impact on society and the environment, and the potential for future innovations. Synthetic fibers play a crucial role in modern society, impacting various aspects of daily life, industry, and the environment. ynthetic fibers are integral to modern life, offering a range of benefits from cost-effectiveness and versatility to innovative applications and performance characteristics. While they pose environmental challenges, ongoing research and development aim to create more sustainable and eco-friendly alternatives. Understanding the importance of synthetic fibers helps in appreciating their role in the economy, industry, and daily life, while also emphasizing the need for sustainable practices and innovation.
Acetabularia Information For Class 9 .docxvaibhavrinwa19
Acetabularia acetabulum is a single-celled green alga that in its vegetative state is morphologically differentiated into a basal rhizoid and an axially elongated stalk, which bears whorls of branching hairs. The single diploid nucleus resides in the rhizoid.
How to Make a Field invisible in Odoo 17Celine George
It is possible to hide or invisible some fields in odoo. Commonly using “invisible” attribute in the field definition to invisible the fields. This slide will show how to make a field invisible in odoo 17.
2. Cryosurgery
Application of extreme cold to destroy
abnormal or diseased tissue.
The term comes from the Greek words cryo
("icy cold") and surgery meaning "hand work"
or "handiwork".
Cryosurgery has been historically used to
treat a number of diseases and disorders,
especially variety of benign and malignant
skin conditions.
3. HISTORY OF CRYOSURGERY
James Arnott, in 19th century, stated that a
very low temperature will arrest every
inflammation which is near enough to the
surface.
The first cryogens were liquid air and
compressed carbon dioxide snow.
In 1961, Cooper and Lee developed the first
cryotherapy probe system, involving the
circulation of liquid nitrogen through a
closed metal tube placed in direct contact
with the target tissue.
5. Liquid nitrogen
Cryogun used to spray liquid nitrogen
A common method of freezing lesions is using
liquid nitrogen as the cooling solution. The
super-cooled liquid may be sprayed on the
diseased tissue, circulated through a tube
called a cryoprobe, or simply dabbed on with
a cotton or foam swab.
Carbon dioxide
Less frequently, doctors use carbon
dioxide"snow" formed into a cylinder or mixed
with acetone to form a slush that is applied
directly to the treated tissue.
6. Argon
Recent advances in technology have allowed for the
use of argon gas to drive ice formation using a
principle known as the Joule-Thomson effect. This
gives physicians excellent control of the ice, and
minimizing complications using ultra-thin 17 gauge
cryoneedles.
Dimethyl ether – propane
A mixture of dimethyl ether and propane is used in
some preparations such as Dr. Scholl's Freeze Away.
The mixture is stored in an aerosol spray type
container at room temperature and drops to −41 °C
when dispensed. The mixture is often dispensed into
a straw with a cotton- tipped swab.
7. Mechanism of cryosurgery
The destructive effect of freezing tissue has
been categorized into two major mechanisms
Immediate cell destruction
Delayed cell destruction
8.
9. Application techniques
Probe freezing: It is done by direct application of
a probe tip to the lesion. The cryogen circulates
through the probe tip and super cools it, when
allowed to contact the target tissue. Probe
freezing can be accomplished by one of the two
mechanisms: contact freezing and penetration
freezing.
In contact freezing, firm contact is made
between the cryoprobe and the target tissue.
10. Application techniques
While in penetration freezing probe penetrates
the target tissue, providing a large area of direct
contact.
Spray freezing: It is done by direct application of
the liquid nitrogen to the tissue and is the most
destructive method. Liquid nitrogen is delivered
to the target tissue at such a volume and velocity
that it evaporates at the edge of the lesion. The
spray orifice allows deeper and faster tissue
penetration than the probe tip but the probe
method is safer and more precise.
12. COOLING RATE
In cryosurgery, rapid cooling rate i.e. more than
50ºC/min produces intracellular ice- crystals which
is more destructive.
Such higher rates of cooling can only be achieved
close to the cryoprobe
TEMPERATURE
Mazur stated that the lethal temperature range is
between - 5ºC to -50ºC.
The treatment of tumor requires a tissue
temperature at which all the abnormal cells are
certainly dead.
13. From the review of all experimental studies the end
point temperature below -40 0C has been
considered prime factor for tissue destruction
14. Thawing rate
Thawing rate should be slow and continued for
longer time period; rapid thaw rates allow cell
survival.
Repetitive freeze- thaw cycle
Rapid freezing and slow thawing do not guarantee
effective cell destruction.
Use of repeated freeze-thaw cycle is also beneficial
in treatment of cancerous tumor
15.
16. Bio-heat Equation
Several heat transfer mechanisms occur during
cryosurgery, including conduction, convection,
metabolism and phase change.
Heat transfer by conduction has been assumed to be
the primary heat transfer process during cryosurgery
since the cryoprobe operates at an extremely low
temperature.
Bio-heat transfer is the study of heat transfer in
biological system.
The fundamental heat transfer equation in biological
tissue was firstly suggested by Pennes.
17. Pennes suggested that the rate of heat transfer
between blood and tissue is proportional to the product
of the volumetric perfusion rate and the difference
between the arterial blood temperature and the local
tissue temperature.
He expressed that relationship as follows
Where,
hb is the rate of heat transfer per unit volume of tissue,
V is the perfusion rate per unit volume of tissue,
ρb is the density of blood,
cb is the specific heat of blood,
K is a factor that accounts for incomplete thermal
equilibrium between blood and tissue (0<K<1, for some
cases K = 0)
Ta is the temperature of arterial blood, and
T is the local tissue temperature
18. Procedure
Warts, moles, skin tags, solar keratoses, and small
skin cancers are candidates for cryosurgical
treatment.
Several internal disorders are also treated with
cryosurgery, including liver cancer, prostate cancer,
cervical disorders and, more commonly in the past,
hemorrhoids.
Cryosurgery works by taking advantage of the
destructive force of freezing temperatures on cells. At
low temperatures, ice crystals form inside the cells,
which can tear them apart. More damage occurs when
blood vessels supplying the diseased tissue freeze
19. The application of liquefied N₂0 sprayed directly
on the skin will bring temperature fully under
control (nitrous oxide always evaporates at -127⁰)
Sophisticated micro-applicator technology
enables an unprecedented level of accuracy of
treatment from 1mm. The prevention of trauma to
surrounding tissue will assure patient’s comfort
The pressure of the spray at 721 psi will give
maximum control over depth of freezing and will
guarantee the results of the treatment.
20. Why Pressure
The penetration of the ice crystal into the
lesion as a result of cryosurgery with the
CryoProbe will go faster and deeper with
minimal surface trauma.
The freezing rate of CryoProbe is 1mm per 5
seconds .
Depth of treatment: the CryoProbe freezes up
to a maximum 5 mm cell structure
21. In this approach, several hollow probes
(needles) are placed in direct contact with
target tissue.
The doctor guides them into the gland(tumor)
using Trans-Rectal Ultra-Sound (TRUS).
This type of procedure requires spinal or
epidural anesthesia (where the lower half of
your body is numbed) or general anesthesia.
22. Very cold gases are then passed through the
needles, creating ice balls that destroy the
gland(tumor).
23. After the procedure, there will be some
bruising and soreness in the area where the
probes were inserted. Patients might need to
stay in the hospital overnight, but many
patients leave the same day.
The most common method of freezing lesions
is using liquid nitrogen as the cooling
solution. The super-cooled liquid may be
sprayed on the diseased tissue, circulated
through a tube called a cryoprobe.
24.
25.
26.
27.
28. Benefits of Cryosurgery in Veterinary
Painless
No Preparation
No post operative care
No open wounds – No Bleeding
No suturing
No general anaesthesia – safe for older animals
Rapid treatment time – only seconds
Cost Effective
Pressure to treat lesion
Pinpoint Accuracy
30. Cryogun used to spray liquid
nitrogen
Manufacturers have devised
various metal attachments to
serve as heat-conducting probes
for cryotherapy. Copper, because
of its high conductivity, is
typically used
31. CryoProbe’s different micro applicators tips allow
pinpoint accuracy to treat skin lesions from 1mm to
8mm in size!
Blue dot applicator Applications 1-3 mm
White dot applicator Applications 2-4 mm
Green dot applicator Applications 3-6 mm
Yellow dot applicator Applications 4-10 mm
32. Lesions
With the CryoProbe you will be able to treat (but not
limited) to the following lesions successfully:
Perianal Adenomas
Epuli
Pappilomas
Lick Granulomas
Warts
Small Sarcoids
Eye Lid Tumors
You will be able to quickly and easily treat skin
lesions that you could not treat before without
undesired side effects!
47. Cryotherapy was chosen as the treatment
because it causes little discomfort
requires no preparation and no follow up care.
Since the CryoProbe has a penetration rate of
freezing into the tissue @ 1mm per 5 seconds,
a 20-30 second treatment is was performed on
the lesion that is estimated to be 3 to 4mm
deep.
An ulcerous skin lesion on the top of the head
53. Disadvantages of Cryosurgery
As with the advantages of cryosurgery, the
disadvantages can also be categorized into those for
the clinician and those for the patient.
Disadvantages for the clinician include the following:
Liquid nitrogen needs to be delivered and stored. A
liquid nitrogen generator may be purchased. If that
is not done, nitrous oxide tanks or other supplies will
need to be replenished as needed.
The clinician must be certain of the diagnosis
because no tissue will be sent for pathology.
Cryosurgery is not as accurate as a scalpel or laser
in cosmetic work.
54. Disadvantages of Cryosurgery
Disadvantages for the patient include:
Erythema and swelling are the normal. Blistering is
common.
Pain, especially throbbing pain around the nail folds.
Pain with walking if plantar warts are treated.
May require multiple visits.
Hypopigmentation.
Damage to adjacent structures such as joints and
bones may lead to lameness and fracture.
Risk of uncontrolled freezing - resulting in
destruction of normal tissue.
55. RECENT ADVANCES
While cryosurgery is not a new modality, the tools used to deliver
the required temperature change are evolving, making the target
areas very precise. This enhanced precision reduces collateral
tissue damage, leading to faster healing and less scarring. The
capacity to achieve this precision is also what makes the biggest
difference in treating smaller lesions. The specific unit I use in my
practice is the CryoProbe X+, which runs at about -127°F. This
specific model includes five separate tip sizes that can be used to
match the lesion being treated, and can be operated with available
8g and 16g cartridges. (While treatment is often done without
sedation or general anesthesia, the locations of some lesions will
still require chemical immobilization to achieve desired results).
Thanks to the precision of the micro-applicator tips, there is no
collateral damage to healthy tissue, resulting in no discomfort to
the patient. As such, treatments are very controlled and can be
longer in duration if necessary. There is no required post-operative
care; there is no bleeding, and sutures and cones are unnecessary,
a wonderful benefit for both patients and caregivers. The following
discussion identifies common lesions the author has treated with
cryotherapy, but the modality’s use is certainly not limited to these.
Zielinska et al., 2017
56. Sebaceous adenomas
Cutaneous histiocytomas
Mast cell tumors:
Acral lick granulomas
Epidermal and follicular inclusion cysts:
Meibomian gland adenomas:
Eosinophilic granuloma complex, ulcerative paradental stomatitis and
oral neoplasia:
Prior to cryosurgery implementation, it is imperative that current
standards of care be followed, with appropriate cytological and
histopathological diagnostic steps performed as indicated. If a mass is
deemed malignant with metastatic potential, addressing the mass with
aggressive surgical intervention, radiation and chemotherapy would be
indicated based on oncologist recommendations should the patient’s
owner elect to pursue that line of treatment. Once a mass has been
diagnosed, the use of cryosurgery can be employed for nearly any
lesion on the skin, as well as some mucus membrane tissues.
cryosurgical unit to my treatment toolbox, I have been able to offer
another option for commonly-seen dermatological lesions that is quick,
effective, less invasive, and requires little to no anesthesia.
Cryosurgery has been readily accepted by my clientele and well
tolerated by my patients, making it a great fit for my practice.
57. References
Korpan, N.N. (2001). Cryosurgery in the 21st Century. In:
Korpan, N.N. (eds) Basics of Cryosurgery. Springer,
Vienna. https://doi.org/10.1007/978-3-7091-6225-
5_1
Baxter, J.S. and Meek, R., 1988. Cryosurgery in the
treatment of skin disorders in reptiles. Herpetological
journal, 1(6), pp.227-229.
De Queiroz, G.F., Matera, J.M. and Zaidan Dagli, M.L.,
2008. Clinical study of cryosurgery efficacy in the
treatment of skin and subcutaneous tumors in dogs and
cats. Veterinary Surgery, 37(5), pp.438-443.