What is FCE, Anyway?

To understand FCE (fibrocartilaginous embolism), one has to understand some anatomy of the vertebral column. The vertebral column consists of numerous small bones called vertebrae that are linked together by joints called intervertebral disks. The disks are similar to the joints that connect arm or leg bones together in many ways. They allow flexibility between vertebrae so that you can arch or twist your back voluntarily, just as you can flex and extend a knee or elbow.

The disks are unique as well. A joint of the appendicular skeleton, say a knee or elbow, has a capsule that secretes a lubricating fluid. The bones are capped with smooth cartilage to facilitate frictionless gliding as the surfaces move during flexion and extension. The disk is nothing like this. It is more like a cushion between the end plates of the vertebrae. It is round (hence the name disk) and fibrous on the outside with a soft gelatinous inside to absorb the forces to which the bones are exposed. This jelly-like inside material inside is called the nucleus pulposus, and it is this material that makes up the fibrocartilaginous embolus.

The vertebral column provides a bony protective case around the vulnerable spinal cord.

The spinal cord is the cable of nerves and nerve connections that transmits messages to and from the brain and controls the reflexes of the body. The spinal cord is fed by a network of spinal arteries.   

In FCE, somehow the material from the nucleus pulposus, all the way in the center of the disk, gets into a spinal artery. The artery carries the nucleus pulposus material to the spinal cord until the artery becomes too narrow for the nucleus pulposus to go any further. The artery is plugged and the area of spinal cord it is supposed to feed dies. (The nucleus pulposis is “fibrocartilaginous” in nature, and the artery obstruction is an “embolism.”) This process is not painful except possibly briefly at first, but recovery is far from guaranteed.  The good news is that after the first 24 hours, the condition is not going to get worse. 

There are many theories of how disk material might gain access to the arterial blood supply, but no one really knows how this happens.

The Typical Patient

Any dog can be a victim of FCE,  although about half of the victims are large-breed dogs. Some feel the Miniature Schnauzer has a higher risk for FCE as this breed tends to circulate excess blood fats and cholesterol, which may predispose to embolism. 

Breeds that are called chondrodystrophic (meaning they have as part of their normal breed conformation dwarf-like characteristics) tend to calcify their disk material, making it too hard to participate in an FCE, and they are thus at lower risk. Such lower-risk breeds include Basset hounds and Dachshunds. Instead, these breeds tend to get Type I disk herniation, a different spinal problem but one at least amenable to surgery. 

Most FCE dogs are young adults between the ages of 3 and 6 years. In one study, 61% were evaluated after some kind exercise injury or trauma. There may be a yelp at the time of the trauma but the injury is generally not painful. There is about a 50:50 chance that the lumbar area of the spinal cord will be affected, which means only the rear legs will be involved. Because the embolism is not generally a symmetrical event, both left and right may not be equally affected.

Will My Dog Be Okay?

This depends on how much loss of function there is. The good news, as mentioned, is that the loss of function will not progress; after the first 24 hours, the maximum function loss has occurred. Your dog may or may not be able to improve (about 74% of dogs in one study showed some improvement ultimately; other studies show at least 50% of dogs can recover fully) but be prepared for no improvement and ask yourself what kind of care will be needed and can your dog get around. Maximum improvement has generally occurred by 3 weeks after the time of the injury, with some dogs showing some additional slow improvement over months.

Many dogs are completely paralyzed. See more information on caring for a paralyzed dog.

Many dogs are simply weak in the affected limbs. They may or may not need assistance in getting around. It all depends on how severe the embolism was and where in the spinal cord it occurred.

How Can We Be Sure This Was FCE?

Acute neurologic weakness after trauma could also be caused by Type I disk herniation or by spinal cord trauma. In Type I disk herniation, a mineralized intervertebral disk “slips” upward and presses on the spinal cord. The pressure may be relieved with medication (if it is not severe) or surgery may be needed. In either case, the spot where the disk is pressing is painful, and the pain is an important distinguishing feature. Beyond this, with disk disease, abnormalities may be seen when the patient’s back is radiographed, whereas in FCE, the radiographs will appear normal.

In some cases, the collapsed disk spaces are not obvious, and more advanced spinal cord imaging is needed. A myelogram involves general anesthesia and injecting dye in the space around the spinal cord. If there is an area of compression, it will be visible, and the patient can then proceed to surgery. In FCE, there is no such compression.

As for acute spinal cord trauma, it may not be apparent whether this or FCE has occurred. If the lesion is acute, it is not unreasonable to treat it as an acute spinal injury and see if improvement results.

Magnetic resonance imaging (MRI) is not yet readily available to most veterinary practices but is likely to become the imaging modality of choice for the diagnosis of FCE. MRI is able to distinguish embolized areas of the spinal cord from those with swelling or compression as long as at least 72 hours have elapsed from the initial event. Still, absolute confirmation of the FCE diagnosis requires a piece of spinal cord tissue for analysis, and this is not something that would be done in a living patient. For the time being, diagnosis of FCE is made based on the clinical picture of a patient in the appropriate age group with an acute spinal deficit, no other abnormalities on imaging, and no painful areas.

FCE is unlikely to be a recurrent condition, so that if a dog has one episode, they are not likely to experience another.

Physical Therapy

The physical state of inadequate red blood cells is called anemia, and when it is severe enough, it is a life-threatening condition.

Pets will not itch from their fleas unless they are allergic to flea bites. No scratching does not mean no fleas.

It is easy to underestimate a pet’s infestation. Only animals allergic to flea bites will itch from their fleas. This means that the animal who is not allergic to flea bites will not be scratching or losing hair. Thus the owner may not realize that the pet has a heavy infestation. If your pet is effective at licking and self-grooming, it may be hard to see the fleas, especially if the owner does not have a flea comb. Do not rely on your own ability to see the fleas; use reliable flea control regardless of what you see or do not see.

Check for Flea Dirt

The black, pepper-like specks found in an infested pet’s coat are actually bits of blood that have been sucked up by the flea and excreted in neat little packages to feed the larval fleas that hatch in the environment. Even if live fleas are not seen, flea dirt means that live fleas are there.

Who Are the Victims?

• Elderly cats who go outdoors. The elderly cat is often debilitated from other metabolic problems. Grooming is less efficient, besides which an older cat is just not strong enough to withstand much blood loss.
• Outdoor puppies. Their situation is similar to that of the kittens’: too small to effectively groom and trying to grow in the face of ongoing blood loss.

Eventually, the weakness catches up with these animals, and they will die unless they receive a blood transfusion.

Evaluation and Treatment

The good news is that these patients can still be treated even fairly late in the course of the disease. Often they will need blood transfusions or transfusions with blood substitutes. They will also need to have their fleas removed and will ultimately need to be returned to an environment where they will be protected from further flea infestation.

The first step is recognizing the problem. This is not difficult for a trained veterinary healthcare worker, but it may not be easy for an uninformed pet owner. The affected animal will have pale gums (normal gums are shell-pink; anemic gums can be completely white). In advanced diseases, the patient will be listless and even cold. A flea comb can be used to check for flea dirt. Pets sometimes eat small pebbles, dirt, or cat litter when they are anemic in an effort to obtain more iron.

• Be familiar with the normal color of your pet’s gums so that you can recognize a problem.
• Regular flea combing can help nip a big problem in the bud.
• Use flea control products all year round so you don’t get caught with a surprise heavy flea burden in the spring.

A test called a hematocrit (HCT) or packed cell volume (PCV) is easily done in your veterinarian’s office to assess the degree of anemia. The hematocrit or PCV reflects the percentage of red blood cells that should be in a sample of blood. In dogs, the normal range is 38 to 57; for cats, 24 to 45. Blood transfusions are considered when values reach 20 or less.

Ridding the critically ill patient of fleas can be problematic. Often the patient is too sick to tolerate the stress of a bath and is too young or too small for flea control products. In this situation, veterinarians have to use their judgment on what is the safest route to removing the fleas. It is worth mentioning nitenpyram (brand names Capstar®, PetArmor FastCaps®, and Capguard®) at this point as this simple product has greatly enhanced our ability to clear fleas from a patient quickly and safely. Nitenpyram is available as a fast-acting flea-killing tablet with no known side effects for mammals. It is labeled for use in animals weighing 2 lbs or more and begins killing fleas within 20 minutes of oral administration. While it does not have long-acting flea protection, its ability to rapidly remove a lethal flea burden has made it especially popular for use on patients with dangerous flea infestations.

Returning Home

Of course, after all the blood transfusions, heat support, and flea removal, the pet will ultimately go home, potentially to the same environment where the infestation occurred in the first place. Usually, topical flea control products will provide adequate future protection, and the use of a vitamin and iron supplement will help the patient rebuild red blood cell reserves. 

If the infestation is severe, consider treating the home environment separately before the patient returns to it. Your veterinarian can help you select safe and effective home treatments. The most important prevention is the owner’s education.

There Is No Reason for a Pet to Carry a Flea Burden in This Day and Age

There are still common misconceptions among pet owners:

• People commonly believe they have a flea bite sensitivity, and if they themselves do not perceive fleas biting, then there cannot be a significant flea burden. Fleas actually only bite people when they are newly emerged from their cocoons and are hunting for their permanent host. Waiting for a person to perceive a flea bite requires the flea population to have successfully established in the environment (i.e., the house) and progressed all the way to the production of new adult fleas. In reality, when the fleas are biting people, a significant population has been present for weeks or longer.
  
• Many people believe that a pet with fleas will scratch or be itchy. In reality, only the pets allergic to fleas will be itchy.
  
• It is also commonly believed that fleas are simply part of pet ownership and that there is no way to avoid them. This may have been true at one time, but, in reality, fleas have been optional for decades, with flea control methods achieving higher levels of convenience and safety each year. The days of sprays, powders, and foggers are largely gone, supplanted by chewable tablets and spot-on preparations. No pet needs to have fleas in the 21^st century, and new products are being released every year.

The general pet-owning population has certainly heard of fleas and is aware of most of the modern flea control products. Yet, still, pets die from this easily preventable problem because people do not realize how serious it can be and cannot recognize when it has gotten to a serious point. Be proactive and keep up your flea control all year round; if you wait for what you think of as warm weather, your pet may well already be infested. Do not assume a pet with fleas will scratch. Do not assume that if the humans are not being bitten, then the flea burden must be light. Do not be one of those people whose beloved pet is lost to an easily preventable disease.

Compare flea-preventive products to help you decide which product is best for your situation. If you need help selecting flea control products, remember that your veterinarian and staff are professionally educated in this subject and will be happy to assist you.

The resulting inflammation may target the GI tract or other organ systems, but in dogs and cats, the skin is frequently included in this immunologic activity.

Cats itch around the face or neck, which produces scabs and hair loss. In dogs, signs include facial itching, foot or limb chewing, itchy anal area, and recurrent ear infections.

Many people erroneously assume itching due to food allergy requires a recent diet change of some sort. In fact, the opposite is true.

Food allergies require time to develop; most animals have been eating the offending food for years with no trouble.

What Kind of Allergy?

Diagnosing and treating allergic skin disease and its secondary infections make up a large proportion of cases seen in small animal practice.  Pets can be allergic to insect bites (fleas are not inherently itchy unless the pet is allergic to flea bites), airborne proteins (such as molds, pollens, and dust mite parts), or foods. Pets can and often do have multiple allergies, adding together to make them itchy. The skin infections that come from scratching perpetuate the itching. To solve the problem, the infection must be cleared up and the offending allergen(s) removed from the pet’s world.

There is controversy about how common food allergy is in dogs and cats. Some experts feel it is relatively rare, while others feel is much more common than we realize. It is hard to tell because there is no simple test for food allergy, and the skin lesion distribution is difficult to distinguish from that of airborne allergy, which is frequently concurrent in the same patient.

So what are our clues that a pet has a food allergy? There are several hints:

• The itching is not seasonal (this is hard to tell in areas that do not freeze during winter).
• Itching started when the pet was less than six months of age or greater than five to six years of age.
• No response to treatment for sarcoptic mange (a condition with a similar itchy skin pattern).
• Corticosteroids have not helped manage the itching. Corticosteroids may or may not work on food allergy itching but they almost always work for other allergies.
• There are accompanying intestinal signs like vomiting or diarrhea. These are seen in 30 percent of food allergic pets.
• The lesion distribution is compatible with food allergy, especially if an itchy anal area and/or recurrent ear infections are involved.

Any of the above findings or observations warrant the pursuit of food allergy.

Please note that several of the above criteria relate to what you observe at home. Trouble results when the veterinarian must speak to different family members about the pet and there is disagreement in their observations. It is best to have one person, preferably the one who has the most contact with the pet, be the spokesperson and make the relevant judgments.

The Flea Factor

The short answer is not to waste money on these tests. Blood tests for allergy can detect antibodies against certain food proteins, but this does not necessarily mean the pet has an allergy. It may mean nothing more than the pet has eaten that type of protein before. Furthermore, the pet’s body may alter a food protein during digestion, and it is the altered protein that generates the allergy. There is no predicting how a protein could be altered and thus no test can be devised for altered proteins. Laboratory tests are simply not valid for determining if a pet has an allergy to a certain type of food.

Hypoallergenic Diet Trial

To determine whether or not a food allergy or intolerance is causing the skin problem, a hypoallergenic diet is fed for a set period. If the pet recovers, the original diet is fed for up to two weeks to see if itching resumes. (Actually, exposure to an allergen generally leads to itching within 12 hours, but it takes two weeks to be completely sure.)

If we see recovery with the test diet and itch with the original diet, then food allergy is diagnosed, and the pet is returned to either the test diet or another appropriate commercial food indefinitely.

There is no other way to determine if a pet has a food allergy. Blood tests are not useful.

Before reviewing diet strategies for this process, here are some additional concerns:

• The diet must be strict (meaning the pet should not have any other protein sources besides the test protein). This includes rawhides and chew toys, flavored chewable medications (these will need to be changed for unflavored tablets) and vitamins, and treats.
• All family members must be on board with the trial. No one should be giving the pet other foods or treats when no one else is looking.
• It is probably best for all animals in the house to be fed the test protein so as not to have food-sharing issues.
• Itching must be managed during the trial in a way that the results of the trial are not foiled.
• Diet trials often span a season change period. If a dog has a pollen allergy and winter comes during the period of the diet trial, it may appear that the diet worked when, in fact, the seasons simply changed. This is why a diet challenge is important at the end, even if the pet is doing well.
• The diet trial will take eight weeks. Most animals will respond in three to four weeks, but to be sure, you will need to feed the test diet for two months.

What Is a Good Hypoallergenic Diet?

There are two approaches to test diets: novel protein and hydrolyzed protein. Traditionally, a novel protein is used. This is a diet with a single protein source that the patient has never eaten before. It typically takes years to become allergic to a food protein so the patient should not be allergic to something new.

Fortunately, many pet food companies have discerned the need for diets using unusual protein and carbohydrate sources with a minimum of additives. Foods can be obtained based on venison and potato, fish and potato, egg and rice, duck and pea, and even kangaroo. Diets used for allergy trials must contain one protein and one carbohydrate source, and neither can be something the pet has had before. Recently, several diets that include duck, venison, and so on have been released to the general market. Be aware of foods that contain these ingredients because these ingredients will not be useable for future diet trials if they are ever used in the pet’s regular food.

It is important that no unnecessary medications are given during the diet trial. No edible chew toys (such as rawhides or bones) should be given. Treats must be based on the same food sources as the test diet. (Beware of rice cakes, though, as wheat is commonly used as a filler.) Chewable heartworm preventives should be replaced with tablets or topicals.

Over-the-Counter Food? Therapeutic Diet? Home Cooked?

Recently several pet food companies have released single protein diets for over-the-counter sales. These tend to cost less than the therapeutic diets available from your veterinarian’s office directly. While these diets are attractive, they are probably not a good choice for an actual diet trial. Immunological tests on these foods found that many of them contain additional proteins (probable contaminants from prior batches in the pet food factory). These impurities could defeat a diet trial which is hard enough to perform without such issues. The therapeutic diets did not have these contaminants.

Home cooking is a fine alternative to commercially prepared foods for the diet trial. The problem is that the test diets will most likely not be balanced but for the 2 months or so of testing, this should not be a problem. Home cooking is a bit of an inconvenience, but for the right person, it is a good choice. Ideally, a nutritionist should be involved in designing the diet. Recipes for appropriate diets can be purchased through BalanceIt, Petdiets.com or by any nutritionist listed at the American College of Veterinary Nutrition website.

The Hydrolyzed Protein Method

Several therapeutic diets are made from hydrolyzed proteins. This means that a conventional protein source is used but the protein is broken down into molecules too small to excite the immune system. There are various hydrolyzed diets on the market; discuss with your veterinarian which is best for your pet.

Trial Diet Timeframe

Studies have shown that 80 percent of dogs will have shown a response by 4 to 6 weeks on the diet, but by extending the diet to 8 weeks, 90 percent will respond. The Labrador retriever and cocker spaniel appear to require longer trials. Most veterinary dermatologists recommend 8 to 12 weeks, which is a long time to be strict on the diet, but that is the only way to detect food allergic dogs.

What To Do if the Diet Is Successful?

To confirm food allergy, return to the original food; itching generally resumes within 14 days if food allergy was truly the reason for the itchy skin. Many people do not want to take a chance of returning to itching if the patient is doing well; it is not unreasonable to simply stay with the test diet if the pet remains free of symptoms. Often it is difficult to remember 10 to 12 weeks later how itchy the dog used to be before the diet trial. The diet challenge helps make it more obvious whether the diet trial has worked or not.

It is possible to more specifically determine the identity of the offending foods after the pet is well. To do this, a pure protein source (such as cooked chicken, tofu, wheat flour, or any other single food) is added to the test diet with each feeding. If the pet begins to itch within two weeks, then that protein source represents one of the pet’s allergens. Return to the test diet until the itching stops, and try another pure protein source. If no itching results after two weeks of feeding a test protein, the pet is not allergic to this protein.

What To Do if the Diet Is Unsuccessful?

Assuming secondary skin infections have been controlled, an unsuccessful food trial is strongly suggestive that an inhalant allergy is a primary problem, but some other considerations should at least be mentioned:

1. Are you certain that the dog received no other food or substances orally during the trial?
2. Was sarcoptic mange ruled out?
3. Your pet may require a longer diet trial. Are you certain regarding the factor that pointed toward the food allergy?

If your pet has not been biopsied, now may be a good time. If an inhalant allergy has risen to the top of the list, symptomatic relief either via medication, baths with specific shampoos, or allergy shots will likely be necessary. Chronic itchiness can be extremely uncomfortable and prompt relief is our goal as well as yours.

What are follicular cysts in dogs?

Your veterinarian may start by taking a small sample from the skin mass using a needle, which is called a fine needle aspirate. Especially if the follicular cyst is growing or painful, your veterinarian may remove the entire mass in a surgery (biopsy).

How are follicular cysts treated?

Follicular cysts do not spread beyond the skin but can become infected. If this happens, your veterinarian may take a sample for skin culture (bacterial culture and sensitivity) to choose an appropriate antibiotic (a drug that fights bacteria). If a follicular cyst grows in size and becomes itchy or painful, your veterinarian may recommend surgery. A follicular cyst will not regrow after it is removed.

The femoral head osteotomy (referred to as FHNO) is the hip surgery where the head and neck of the femur (thigh bone) are cut off and permanently removed. There are many reasons why a pet might benefit from removal of the femoral head and neck.

Some typical reasons include:

• A dislocated hip
• A broken femoral head and/or femoral neck
• Hip arthritis
• Legg-Perthes disease (a developmental hip degeneration).

The Normal Hip Joint

The hip joint is a ball and socket type joint that attaches the rear leg to the trunk of the body. The ball part is the head of the thigh bone (the uppermost long bone of the rear leg), called the femur, and the socket is the part of the pelvis known as the acetabulum. The femoral head is held in place by a thick ligament called the capital ligament, or simply the round ligament of the femoral head. Also keeping the bones in their proper location are the muscles of the hip; the upper rim of the acetabulum, which acts as a protective ledge, and the fact that the whole joint is enclosed in a fibrous capsule.

The Optimal Patient

The FHNO surgery is best done on a smaller patient, about 45 pounds or less. This is because a false joint simply is not strong enough to readily support the weight of a large dog, and mobility would be compromised. On the other hand, lots of activity strengthens the muscles and builds a stronger false joint, so a very active, larger patient may end up with better mobility than a less active, smaller patient.

Surgery

As mentioned, surgery involves removing the femoral head under general anesthesia. Your pet will be in the hospital overnight on pain management medication and will go home when he has a good appetite and is mobile on three legs. It will take time before the pet is willing to bear weight on the leg, so he/she will be walking on three legs at first. There may or may not be visible stitches. Recovery can be expected to take approximately six weeks.

The First Two Weeks after Surgery

During this period, the tissues are healing from having been cut and manipulated during surgery. The focus is on pain management and rest. After the second day, apply warm (not lukewarm but very warm) compresses for 10 to 20 minutes are helpful to improve circulation to the area. This should be done two to six times daily.

If the patient tolerates it, moving the hip forward and back (passive range of motion, or PROM) will help keep the muscles from becoming stiff or scarred. The entire leg should receive flexion/extension.

Do not perform PROM if your dog is too painful. Try to keep the movements to a range that does not evoke pain. If you think your dog is in too much pain for any of this, notify your veterinarian so that the pain management regimen can be revised.

The pet should be confined indoors to one room during this period with no running or jumping onto furniture. Dogs should be walked on a leash outside to go to the bathroom and right back in with no further walks outside.

At the end of the first week, the foot should be touching down.

After the First Two Weeks

At this stage, the post-operative pain has largely resolved, and the goal is to strengthen muscle and prevent atrophy from disuse. The above exercises should be easily performed more definitively, plus other activities may be restarted: walking through water (better than swimming), walking (especially upstairs or uphill), and “dancing” (holding the pet up by his front legs and walking him on his hind legs). If the false joint forms too tightly, the pet will not regain normal range of motion, so exercise is important during this time.

Healing is generally complete after six weeks. The recovery time may be prolonged if activity is limited by arthritis in any of the other legs, by the size/weight of the patient, or if there is scarring or atrophy of muscles from the initial condition that necessitated the femoral head osteotomy in the first place. More formal rehabilitation programs (by a qualified animal physical therapist) can be designed for patients with these situations or who are behind schedule on their recovery for unknown reasons. If you have questions or concerns about your pet’s recovery, let your veterinarian know at once so that your pet can get back on track for normal mobility.

Epulides/epuli (plural of epulis) are common benign growths found in dogs’ mouths.

There are three types:

Acanthomatous ameloblastoma (previously called acanthomatous epulis) is classified as benign but it tends to invade adjacent bone and it is locally aggressive. It can be pre-cancerous. However, it does not spread to other regions of the body. This tumor often has a rough cauliflower-like, ulcerated surface. It occurs most commonly in the incisor and canine tooth area of the lower and upper jaw. It occurs less commonly near the fourth upper premolar in the upper jaw and the lower jaw’s first molar.

Statistics

Epulis is the fourth most common tumor found in the canine mouth. It is very rare in cats.

This tumor is more common in brachycephalic breeds. Brachycephalic breeds are those that have a very short nose and muzzle. Boxers and English Bulldogs are brachycephalic dog breeds, for example.

Middle-aged and older dogs get epulides more often than young dogs do. The average age of an affected dog is seven years old.

The overgrowths are generally a reaction to trauma, such as a tooth rubbing on the gum in brachycephalic mouths, for example.

Clinical Signs

Signs include a lump on the gums, drooling, halitosis, facial deformity, and other signs of mouth injury. The visible lump is the most common sign.

Diagnosis

Diagnosis begins with a visual examination of the mouth.

Radiographs of the head can determine how invasive the tumor is.

Biopsy and histopathological (microscopic) examination of the lump will determine which type of epulis is present.

Treatment

Fibromatous epulis: Treatment involves removing the mass, extracting the involved tooth, and thoroughly scraping the tooth socket clean.

Peripheral odontogenic fibroma: Treatment involves removing the mass, extracting the involved tooth, and thoroughly scraping the tooth socket clean. This surgery can be more difficult than that for fibromatous epulis.

Acanthomatous ameloblastoma: Treatment is surgical removal, including removing the affected areas of the upper or lower jaw (maxillectomy or mandibulectomy).

In some inoperable epulis cases, radiation therapy may help.

Aftercare

After surgery, your pet may need a softer diet. Your veterinarian will advise you about this.

Prognosis

The less tissue involved, the better. If a large section of the jaw has to be removed, it can affect the dog’s quality of life.

The oral tumors don’t usually recur if the entire tumor has been removed. However, some can. Checking your dog’s mouth frequently will help you spot any tumor recurrence or new tumors.

The E tube can be in place as a temporary support measure or can be used long-term as an indefinite support measure. As you get used to using the tube, feeding will come to be a simple process and part of your regular pet routine.

To Feed your Pet

Have everything ready before beginning. You will need:

• A syringe full of the liquid food in the appropriate amount. The diet should be warmed but not hot. Do not microwave the diet, or you may get hot spots that are too hot. To warm the food, microwave a tall glass of water and insert the syringe of food in the warm water and let it sit until the food is at least room temperature, and ideally close to body temperature.
  
• A small glass or cup of tepid (lukewarm) water.
• Any medication you should be giving at this time.

Clear the tube by squirting 6 ccs of tepid water through it to be sure it is not clogged. Next, hook up the food syringe and slowly deliver the food to the patient. It is tempting to just blast it all in there but for patient comfort, try to take several minutes or so and take your time. Follow the food with a chaser of 6 ccs of tepid water to clear the tube. Liquid medicine can be given through the tube as long as the tube is cleared with 6ccs of tepid water before and after each time. Do not put pills in the tube as it could clog. Pills can be crushed and given through the tube only if they are well dissolved in liquid. Any caking of pill powder has the potential to clog the tube, so be sure to flush the tube with tepid water after use.

You will need to clean the stoma (the opening of the skin where the tube enters) daily with a baby wipe or moist tissue, otherwise discharge and/or crusting will accumulate there. Periodically the wraps will need changing. A special type of collar may be helpful in keeping the tube neat and comfortable.

Be sure to allow time for digestion between feedings. How much time depends on your pet’s feeding plan.
Be sure you understand the amount for each feeding and the feeding schedule provided by your veterinarian.

• If these two solutions do not work, the tube may have slipped too low inside the esophagus. If the tube is dipping into the stomach, the patient may vomit. The doctor can take an x-ray to see if this is the case and then easily reposition the tube. If none of these things seem to be happening, the patient’s primary disease may be progressing. Your veterinarian will need to evaluate your pet more comprehensively.

Tube clogged?

A clogged tube can be a challenge. First, try to force 6 ccs or so of tepid water through the tube by pushing. If the clog does not give way, try hooking up a syringe of 6 ccs or so of water and alternately push and pull back, creating a “toilet plunger” effect. Continue fairly rapid push-pull action until the tube is cleared.

Note: some people feel that incubating 6 ccs of cola soda in the tube overnight is helpful in dissolving a clog. Whether or not this works is somewhat controversial, but it may be worth a try, as the tube will be useless if it cannot be unclogged.

Crusting or pus at the tube exit site?

The patient’s body does not like having a foreign body sticking out of it and frequently there is some inflammation at the exit hole. True infection is unusual, and most of the time simply cleaning the area with gauze or a moist tissue is sufficient to solve the problem.

Esophagostomy tubes can stay in place for months without needing to be replaced. Hopefully your pet’s condition will have resolved before that time. When the time comes, the tube’s anchoring sutures can be snipped and the tube pulled out. The hole left behind will simply heal on its own. If you have any questions about the tube or its care, your veterinarian will be happy to assist you.

What is Enrichment and Why is it Important for Senior Dogs?

Enrichment is important for all species of animals, including people! Sometimes we enrich our lives and our animal’s life without even noticing, such as going for walks outside or eating a yummy treat. Sometimes enrichment takes planning, such as a vacation or assembling food puzzles for your dog. Understand that what is considered enrichment should be from your dog’s perspective and each dog needs to be able to choose if they want to participate or interact with the enrichment item or not. We can entice dogs to participate by offering their favorite treats or petting in their favorite spots but ultimately it will still be their choice to interact or not.

Dogs can have several age-related diseases that can result in behavior changes and welfare concerns, such as arthritis, dental disease, cancer, diabetes, and other endocrine diseases. Additionally, dogs can develop canine cognitive dysfunction, a syndrome that is similar to Alzheimer’s disease in humans.  Pain is more likely to occur in senior dogs with age-related diseases, leading to decreased activity, increased anxiety, restlessness, and occasionally aggression. Due to these age-related challenges, we should find ways to enrich their lives and help manage these conditions. While senior dogs may not be able to participate in much physical enrichment, such as long walks, other forms can be mentally stimulating and tiring.

If you have noticed behavioral changes in your senior dog, work with your veterinarian to determine if there is an underlying medical condition that may be causing the behavior. You should also discuss your dog’s weight and nutrition with your veterinarian to keep them at a healthy weight and as comfortable as possible.

By working with your veterinarian to manage age-related health conditions and providing individual and age-appropriate enrichment, you can enhance your pet’s quality of life and improve your bond with your aging dog.

This 13-year old dog is eating her breakfast from a small box filled with kibble.
Photo by VIN.

Enrichment Ideas for Senior Dogs

1. Puzzle Feeders – There are many different puzzle feeders available for dogs. You can shop online, in pet stores, or make them yourself! You can use some or all of your pet’s regular diet in the puzzle feeders, and you can also use special treats. For a simple DIY puzzle feeder, put some kibble in a plastic bottle without the lid, or save toilet paper or paper towel tubes and put kibble inside with the ends folded. Just make sure your dog doesn’t try to eat the bottle or cardboard! Another simple idea is to feed your dog from a muffin tin; you can even put tennis balls on top of the muffin tin to make it more challenging. Sometimes, you can freeze food in puzzle feeders to make them last longer.
   
2. Snuffle Mats – Snuffle mats look like extra shaggy rugs. You can purchase them or you can make them yourself. They can be used as a food puzzle or you can use them with scents. If you are adding scent, make sure that it is safe for dogs. Certain essential oils such as cinnamon, tea tree, peppermint, and wintergreen are not safe. Scents such as coconut, vanilla, ginger, and valerian are safe. Additionally, some dogs respond to catnip, and it can help them relax. Snuffle mats encourage sniffing and encourage normal foraging behaviors.
   
3. Scavenger Hunts – Hide treats, food items, and toys around the house or yard. Some dogs enjoy playing hide and seek with their favorite toys. Hide items in safe places. Hide items near places the dog frequents, such as by their bed or water bowl, and then expand from there.  
   
4. Positive Reinforcement Training – An old dog absolutely can learn new tricks! Positive reinforcement training will improve your bond with your pet at any life stage, and senior dogs are no exception. Positive reinforcement is rewarding your dog, usually with a food treat, for doing what you ask. Clicker training is a great way to use positive reinforcement to train your dog. You can teach useful behaviors such as sit, lay down, crate, and stay, or you can teach fun behaviors to your dog such as shake, target, speak, fetch. Positive reinforcement training is a great tool for senior dogs because it is mentally stimulating but does not require physical exertion.
   
5. Socialize with other Senior Dogs or Calm dogs – If your dog enjoys the company of other dogs, arrange for play dates with other calm or senior dogs. Make sure that your dog enjoys this experience by monitoring their body language. Your dog should choose to engage with the other dogs, have loose body language, and be relaxed.

What the Pancreas Normally Does

The pancreas is a small light pink glandular organ nestled under the stomach and alongside the upper small intestine. There are two types of pancreatic tissues to know about. The first tissue is the “endocrine” pancreas which is the part of the pancreas that secretes hormones involved in blood sugar regulation, such as insulin, (which you have probably heard about if you know anyone with diabetes mellitus). The “exocrine” pancreas produces enzymes we use to digest our food. These two parts of the pancreas are not in separate areas but instead these two different types of pancreatic tissues are all mixed together throughout the entire pancreas.

Digestive enzymes break down fats, starches and proteins into smaller units so that we can absorb them into our bodies. These enzymes are stored as inactive forms inside special granules in the exocrine pancreatic tissue (the “acinar cells”). The enzymes sit there harmlessly until a chemical signal tells the pancreas to secrete them down the pancreatic duct and into the intestine where the food is waiting.

Once nutrients are broken down into smaller molecules (i.e. they are digested), they can be absorbed down the entire length of the GI tract. Without an adequate amount of enzymes, we cannot break down/digest our food. If we cannot digest the food, we cannot absorb the food. We get skinny, have especially nasty, rather greasy diarrhea, or both. Often, pets will develop a dry, dandruffy coat from their inability to absorb dietary fats and can be anemic from a vitamin B12 deficiency. Difficulty in clotting blood (vitamin K-related coagulopathy) can result as well.

Exocrine Pancreatic Insufficiency (also called Maldigestion)

About 70% of dogs with exocrine pancreatic insufficiency are German Shepherd dogs and 20% are Rough Collies.

Recently a juvenile onset form of exocrine pancreatic insufficiency has been described in the Greyhound, however, because this breed is primarily used in racing, sickly puppies are commonly euthanized thus keeping the condition from being recognized in the pet population.

In cats, chronic pancreatitis is the usual cause of exocrine pancreatic insufficiency. There does not appear to be a genetic concern; though, rarely, cats that eat grasshoppers may get infected with a pancreatic fluke carried by grasshoppers (Eurytrema procyonis). This fluke, similar to a very small worm, can cause enough inflammation to cause pancreatitis or enough general pancreatic damage to cause exocrine insufficiency. Fluke infection is rare, as mentioned, but feline pancreatitis is actually very common especially in older cats. There is frequently a link to chronic intestinal disease. 

Diagnosis Requires Specific Tests

A dog or cat with EPI will have almost no serum trypsin-like immunoreactivity in the bloodstream. The patient must be fasted for the test to be accurate, but only a single blood sample is needed to make the diagnosis. The feline version of this test often requires that the sample be sent to a university laboratory and generally a week or so is needed to get results but the canine test can be run in just a few days.

Other Tests

Another popular diagnostic is the fecal protease test, where a stool sample is tested for protein digesting enzymes. Fasting is not necessary and any fecal sample will do; however, three consecutive samples are needed to get a consistent result as there is tremendous variability in fecal enzyme activity over the day. Sometimes soybeans are given to dogs to help stimulate release of pancreatic protein digestion enzymes and get a more accurate test.

The fecal elastase test (elastase is another digestive enzyme) is the newest test and it is only available for dogs. A single fecal sample is needed but the problem is that sometimes normal dogs will test negative for elastase. This means that EPI can be ruled out when the elastase test is positive but not confirmed when the elastase test is negative.

Treatment

Dietary supplementation with digestive enzymes is an effective therapy for EPI even though most of the supplement given is digested in the stomach along with other dietary proteins. The little bit that survives the acid bath of the stomach and the patient’s own protein-digesting chemicals turns out to be enough to stop the diarrhea and enable the patient to actually gain some weight. Powdered enzymes (Viokase-V, Pancrezyme, PanaKare, and other brands) seem to work the best; tablets are available but do not seem to break down consistently. If the pet finds the taste of the enzymes objectionable, a compounding pharmacy can fill gel capsules with the powder. Again, enteric-coated tablets simply do not seem to work well.

In the past, it was suggested that incubating the enzymes in the patient’s food would help initiate the digestion process in the food bowl but this has not been found to be true; the enzymes can be fed immediately mixed with the patient’s regular pet food. Some patients respond best when an H2 blocker-type antacid (such as famotidine) is given concurrently with the enzymes.

It is important to thoroughly mix the enzyme powder into the food, because if it is sprinkled on top, it can be abrasive and lead to ulceration in the pet’s mouth. If ulceration has already occurred in this situation, incubating the food with the enzymes can help resolve the problem. A six-hour incubation at room temperature should suffice. If the food is to be refrigerated, a 24-incubation has been recommended. 

Raw beef or lamb pancreas can also be used as a possibly inexpensive form of enzyme replacement but the problems with raw foods include parasite and bacterial contamination. Cooking the pancreas relieves these concerns but inactivates the desired digestive enzymes. Raw pancreas can be stored frozen without losing digestive enzyme activity.

Generally a high-digestibility diet is the best choice for an EPI patient. These foods are low in fiber and may be especially helpful for patients with trouble gaining weight. Many animals simply use enzymes mixed with their regular food if prescription diets prove too expensive.

EPI patients commonly have an overgrowth of bacteria in their intestines, which means that the unabsorbed nutrients in the tract have fed the bacteria living there, instead of the patient, and an over-population of bacteria has occurred. This results in a vitamin B-12 (also called cobalamin) deficiency as the bacteria consume the vitamin instead of the patient getting his share. Periodic injections of vitamin B-12 and blood test monitoring have been recommended for patients with EPI. The B-12/cobalamin deficiency is a particularly big problem for cats with EPI, who typically require injections every couple of weeks for life. Folate deficiency is also common in cats and supplements are required for the first month of therapy. Regular cobalamin and folate blood levels important for cats with EPI. Supplementation with the fat soluble vitamins (especially vitamin K and vitamin E) are not usually needed.

Treatment is for life and without enzyme supplementation, all the unpleasant symptoms will recur. The good news is that a response to therapy is generally seen within a week of beginning it. Response can be excellent but approximately one dog in five will simply not respond well. Many do not ever regain a normal amount of weight. 

What if Results Are not as Rapid as Expected? 

Most pets respond in a matter of days to enzyme supplementation but if a week or so goes by and results are underwhelming, here are some tips to consider:

1. Use more enzyme powder with each meal. 
2. Check the powder’s expiration date. Consider a different brand of powder.
3. Be sure to supplement vitamin B12 by injection. Many pets will not get better until this deficiency is corrected
4. Treat the bacterial imbalance. Some patients will not get better without a course of antibiotics.
5. Consider incubating the enzymes in the food. This is not supposed to matter but some pet owners feel that it does.
6. Consider a prescription diet if one is not already in use.

If all of these factors are already controlled and diarrhea still has not cleared up, it may be time to consider that a second disease is afoot. Discuss this possibility with your veterinarian.

Want more support online? Join an Exocrine Pancreatic Insufficiency Forum for dog owners.

The declaw surgery is an instant permanent solution to these problems; however, it is popularly held that a number of adverse conditions result from declawing, possibly including chronic pain for the cat. Pet owners need an understanding all of the alternative options involved as well as what the actual facts are regarding this procedure. 

The American Veterinary Medical Association policy regarding declawing is: The AVMA discourages the declawing (onychectomy) of cats as an elective procedure and supports non-surgical alternatives to the procedure. The AVMA respects the veterinarian’s right to use professional judgment when deciding how to best protect their individual patients’ health and welfare. Therefore, it is incumbent upon the veterinarian to counsel the owner about the natural scratching behavior of cats, the alternatives to surgery, as well as the details of the procedure itself and subsequent potential complications. Onychectomy is a surgical amputation and if performed, multi-modal perioperative pain management must be utilized.

Alternatives to Declaw Surgery to Try First

Scratching is a natural behavior of cats, which makes it difficult to modify. The usual goal is to transfer the cat’s scratching instinct to a scratching post or other scratching toy; it is virtually impossible to control the desire to scratch completely. Some cats take quickly to alternative scratching surfaces while other cats require time-consuming training. 

Training tips include:

• The cat can be punished for furniture scratching attempts but it is important that the cat cannot connect the punishment with the person administering it (otherwise the cat will simply learn not to scratch while that person is watching). Yelling, spanking, or shaking a can with pennies in it is too directly associated with the person rather than the act of scratching. A water squirt bottle is better but only if the cat does not see where the squirt comes from. Booby traps can be set up using balloons. If mouse traps are used, it is vital that they be turned upside-down so that the cat cannot possibly catch a foot in the trap. Stacked traps can be set up so that they pop upward when tripped, making a surprising noise. In this way, punishment can still be carried out when the owner is not at home. The idea is to convince the cat that the furniture piece is not a good area for scratching and that the appropriate scratch toy can be used with no adverse experience.

Many owners are not excited about putting mousetraps up against their living room furniture, upholstering in aluminum foil, or decorating sofas and chairs with balloons. It is easy to see why a surgical solution would be attractive. Fortunately, there are more options.

Nail Trimming

For some cats, simply keeping the nails short is adequate control but many people do not know how to trim their cat’s nails. In fact, the non-pigmented nail of a cat makes it easy to see where not to cut. This video on YouTube shows exactly what to do. 

Blunt Acrylic Nail Caps

• Some cats are not in the least discouraged from scratching by these caps and are able to simply scratch larger holes in the upholstery.

Surgical Declaw (Onychiectomy)

Despite our best efforts to deflect scratching or decrease claw sharpness, sometimes nothing works and an immediate, permanent solution is needed. It is important to consider that the declaw surgery alters the cat permanently and should not be done if alternative methods are effective. The cat will need some special care during the post-operative healing period: special litter, pain medication, and some activity restriction as he/she will have tender feet for a week or two after surgery. The declawed cat should be forever indoors or outdoors only with supervision as they will no longer have the ability to defend themselves against dogs or other cats.

There is a great deal of controversy regarding this procedure and it has been legally restricted in many areas. Few veterinary surgeries encounter as much bias as the declaw, and a political has movement emerged. Some concerns are valid and some less so. Before making a declaw decision, it is important to review the arguments and find your own perspective. Here are some of the issues.

• The declaw is viewed by many as performing an unethical surgical alteration of a companion animal for the sake of convenience. This is frequently countered by the idea that convenience is not the issue but that the relationship between the pet and its owner is at stake. If that relationship fails, a much bigger life quality issue is at stake including relinquishing the cat to the shelter where euthanasia is a real possibility.
  
• Chronic pain may result from alterations in the foot anatomy and that long-term arthritis is promoted. While there may be truth to this, it is important to realize that 90% of cats over age 10 have arthritis in at least one joint. While it is certainly better to prevent arthritis in a cat’s senior years if we can, we still need the cat to get to its senior years. Arthritis can be treated; euthanasia cannot.
  
• Some people believe that a cat’s indoor only lifestyle is not humane because it is not natural, or an indoor only lifestyle may be impractical because of other people or other animals coming and going in the home. It is true that a declawed cat should become an indoor only pet for its own protection.
  
• There is belief that the procedure is performed too casually and that alternatives are not properly given consideration. Regardless of one’s feelings are on whether to declaw a cat, the fact remains that we are talking about a permanent alteration with a potential for negative ramifications later on. This procedure is not to be done lightly and it is important to at least attempt some of the alternatives discussed above.

Research has been conducted to sort out truth from political propaganda. The AVMA has an excellent source where this research has been collated and the concerns are addressed. Here are some conclusions but feel free to examine the AVMA’s information on your own. 

Myth #1:  After declawing, a cat is likely to become fearful or experience behavior changes, impairing an affectionate relationship with his owner.

Numerous scientific studies have been unable to document any behavior changes post-declaw. In fact, in one survey 70 percent of owners of declawed cats reported an improved relationship with their cat after the procedure.  

Myth #2:  A declawed cat cannot climb trees.

Declawed cats are not as effective at climbing trees as cats with claws, but declawing does not prevent tree climbing. That said, declawed cats should be kept indoors where they do not need claws to assist in self-defense. 

Myth #3:  A declawed cat cannot catch prey.

Declawed cats are not as effective at catching prey as cats with claws but declawing does not prevent effective hunting. 

Myth #4:  A declawed cat has lost its ability to defend itself and should not be allowed outside.

This one is true. Without claws, a cat has indeed lost an important part of his defense system. Declawed cats should be housed indoors only. 

Myth #5:  Declawed cats are more likely to bite since they can no longer claw.

Declawed cats do not seem to realize they have no claws. They will continue to scratch ineffectively as if they did not know the difference. As for biting, there have been some studies that show an increased tendency to bite in declawed cats while other studies have not shown that. The trouble in interpreting this information is that one of the reasons cats are declawed is to control aggression. Cats that are aggressive, even in play, are more likely to be declawed to at least remove the claw portion of the human hazard. The same cat is still perfectly able to bite and will continue to bite. Studies on cats that bite after declaw have not explored whether the same cats were biting before the declaw so conclusions are difficult to draw.

Myth #6:  The post-operative period involves tremendous pain.

Pain management techniques have improved greatly in recent years and include regional nerve blocks eliminating pain completely from the feet during the first few days of healing, fentanyl pain relief patches, as well as injectable and oral medications. This means that a declawed cat should be comfortable in the recovery period. 

That said, if proper pain relief is not practiced, the declawed cat will have sore feet after surgery. The larger the cat, the more discomfort there is and reluctance to bear weight.  

The recovery period should not last longer than a week or so. Healing should be complete by two weeks. Pain after this recovery period is not normal or expected in any way and if a declawed cat seems to be uncomfortable or lame, a recheck appointment is definitely needed. 

If you plan to declaw your cat, you may want to ask your veterinarian about the pain relief plan they expect to utilize so you know what to expect. 

Myth #7:  A declawed cat will not use a litter box again.

It is important that litter not get impacted in the declaw incisions during the recovery period. Shredded paper is the usual recommendation during recovery and some cats simply will not use shredded paper. The recycled newspaper litters are an excellent alternative. The only litter problem one might expect would be lack of acceptance of a new litter during the recovery period. Declawed cats do not lose their litter box instinct.

Declaw Methods

Three techniques are commonly used for permanent declaw surgery: the Resco or clipper blade method; the disarticulation method; and the Laser declaw.

Resco/Clipper Blade Method

This is probably the most common method used by veterinarians to declaw cats as it is associated with the fastest surgery time. It involves the use of a sterile nail trimmer to cut through the bone of the third digit of the toe. The cat loses the part of the bone from which the claw grows. The incision is either sewn closed with suture material or closed in surgical glue.

What to Expect / Possible Complications

• Patients commonly spend at least one night in the hospital for bandaging, monitoring for bleeding and pain assessment.
  
• Some spotting of blood is normal from the toes during the first few days at home (beware if you have white carpeting).
  
• Shredded paper or pelleted recycled newspaper litter is recommended during the healing period. Conventional clay or sand litters can impact inside the tiny incisions and cause infections.
  
• Pain medication is essential, especially for larger or older cats who have more weight to carry on their tender healing toes. The amount of weight carried on the feet (the size of the cat) is the biggest factor in post-operative pain. There are numerous regimens employed for declaw pain control.
  
• Occasionally not enough of the third bone is removed and the claw regrows. When this occurs, infection is generally inevitable and the remaining bone must be removed. This is not a potential complication when the disarticulation method is employed.
  
• A study by Martell-Moran et al published in the Journal of Feline Medicine and Surgery in 2017 found that cats declawed with this method had more back pain later in life than disarticulated cats or undeclared cats.

Disarticulation Method

1. Because the entire third bone is removed, there is a zero possibility of the claw growing back; however, the cut ligaments allow for a subtle drop in the way the foot is held. Most owners do not notice this change in posture.
   
2. Two nights in the hospital are required for this procedure (one night with bandages and one without).
   
3. Some spotting of blood from the toes is normal during the first few days at home (be aware of this with white carpeting).
   
4. Shredded paper or pelleted recycled newspaper litter  is recommended for 10 days after surgery. Conventional clay or sand litters can impact the tiny incisions and cause infections.
   
5. Pain medication is a good idea, especially for larger or older cats. The amount of weight carried on the feet (the size of the cat) is the biggest factor in post-operative pain. I recommend the use of the fentanyl patch for post-op pain control as well as pre-operative local blocks to the feet for pain control.
   
6. Occasionally not enough of the third bone is removed and the claw regrows. When this occurs, infection is generally inevitable and the remaining bone must be removed.
   
7. If the ungual crest of the nail is not removed (the area from which the claw grows), the claw may be able to partly grow back and a second surgery will be needed.

The Laser Declaw: Another Way to Disarticulate

Recently, the laser declaw has received a great deal of attention. In this surgery, a laser rather than a scalpel blade is used to disarticulate the third toe bone. Advantages of laser surgery include virtually no bleeding during surgery or afterwards, possibly less post-operative pain, and in many cases, no bandages.

The downside is the expense of the equipment. The cost of the laser equipment itself is $20,000 to $40,000. To justify such an expense, the laser must be able to generate substantial revenue for the hospital. This means that the cost of the laser declaw to the pet owner is likely to exceed the price of the conventional declaw by an additional $50 to $150 dollars.

Tendonectomy: A Surgical Alternative to Declawing

This surgical procedure has emerged as an alternative to the bone removing declaws. Here, a tendon is cut on the underside of each toe to prevent grasping motions. The claws remain but the cat cannot extend them.

What to Expect / Possible Complications

• Because the incisions needed for this procedure are so small, the recovery is minimal. No bandages, no special litter, no blood spotting. There are usually no stitches to remove and the tiny incisions are closed in surgical glue.
  
• Because the cat can no longer make grasping motions, the claws will naturally grow in a circular manner into the foot pads causing pain and infection unless the owner is able to trim the nails on a regular basis. The tendonectomy patient will require life-long regular nail-clipping. This may not be practical in an aggressive cat and may not be the right choice for an owner seeking a low-maintenance pet.
  
• The August 1, 1998 issue of the Journal of the American Veterinary Medical Association reports a study to compare the long- and short-term complications of tendonectomy vs. those of traditional declaw. Owner satisfaction with both procedures was also measured. While cats who received the tendonectomy showed significantly lower pain scores immediately post operatively, both procedures showed an equal frequency of other complications (bleeding, lameness, and infection). The number of days it took for a cat to walk normally again was not different between the declawed cats and the tendonectomy cats. There was no significant difference between the percentage of owners satisfied with declaw versus the percentage of owners satisfied with tendonectomy. In a 2001 survey, more people were satisfied with the declaw over tendonectomy.