Download Iliopsoas Muscle Strains in Dogs

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WINTER 2011
8500 Arlington Boulevard
Fairfax, Virginia 22031
Tel: 703.752.9100
Fax: 703.752.9200
IN THIS ISSUE:
Iliopsoas Muscle Strains in Dogs
Iliopsoas Muscle
Strains in Dogs. . . . . . 1
CAROL WASMUCKY, BSPT, PET REHAB
News and
Celebrations . . . . . . . . 2
Updates from the
Veterinary Cancer
Society Meeting
Fall 2010 . . . . . . . . . . 2
What’s New in
Diagnostic Imaging
at SouthPaws? . . . . . . 3
As “Eye” See It. . . . . . 4
Thoughts on
Epilepsy
Management . . . . . . . 5
Enhanced
Endoscopy Services
at SouthPaws . . . . . . . 6
Surgical Updates
from the 2010
ACVS Meeting
Seattle, WA . . . . . . . . 7
Over the past few years clinicians in the DC area have diagnosed an
increasing number of Iliopsoas strains in dogs, most notably after last
winter’s record snowfall and ice.
The iliopsoas muscle runs along the groin with two originations (from
the lumbar spine and from the ventral surface of the ilium) to attach to
the lesser trochanter of the femur. This muscle is most often strained
when the dog splays the hip. Injury occurs through repetitive trauma
and movements associated with agility or work-related drills, as well as
through activities where a dog repeatedly jumps over and through
obstacles like snow, or sometimes, just slipping on slick surfaces.
Symptoms of an iliopsoas strain are decreased stride length, limping
(especially after exercise), as well as noticeably reduced hip extension, abduction, and internal rotation when the muscle is fully
stretched.
Rehabilitative treatments of iliopsoas strains are usually successful in
returning dogs to full function. Treatment modalities include ultrasound, laser, ice, and electrical stimulation to decrease pain and
inflammation, and promote healing. Massage and stretching to
increase flexibility and decrease muscle spasm are also essential
treatments. Dogs are started on a progressive strengthening program
with exercises for the hip and core abdominal and trunk muscles.
Activity modification is stressed as a key component of the rehab
process. Gradual and closely monitored increases in a dog’s activities,
in concert with treatment and exercise, allow our patient to return more
quickly to full and pain-free function. 䡲
Hyperbaric Oxygen
Therapy . . . . . . . . . . . 8
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News and
Celebrations
at SouthPaws
Updates from the Veterinary Cancer Society
Meeting, Fall 2010
DR. STACY SANTORO, DACVIM (ONCOLOGY), SOUTHPAWS ONCOLOGY
Mark your calendars now for
the TENTH biannual CE
Extravaganza on March
20,2011 where we’ll be hearing about thyroidal disease
and I-131, surgical therapy for
endocrine diseases, Addison’s disease, diabetic home
care, imaging for endocrine
diseases, head tilts/turns/
spins!
On October 3, 2010,
SouthPaws welcomed nearly
200 veterinarians, veterinary
technicians and assistants to
our ninth biannual CE
Extravaganza. Thanks to our
speakers Drs. Norton, Brehm,
Dahlgaard, Gieg, Toal,
Santoro, and Bromberg for
another informative and exciting session. We really appreciate sponsors Antech Labs,
Hill’s, MWI, Novartis, Pfizer,
and Procter&Gamble for their
continued financial support
which allows us to provide six
hours of free CE twice a year
to lots of people!
In September, 2010,
SouthPaws was delighted to
welcome back Dr. Matt
Nelson, DACVR. Dr. Nelson
was a SouthPaws intern after
finishing his veterinary degree
at Michigan State University,
and then went on to complete
his radiology training at the
University of Georgia. With Dr.
Nelson joining Drs. Cynthia
Sloan, DACVR and Robert
Toal, DACVR, you can now
count on SouthPaws radiology
for outpatient ultrasounds
seven days a week. All of our
radiologists are also happy to
be participating in the
BrightHeart Radiology
Network, which enables us
(and you!) to request radiographic interpretation from
the radiologists that you know
best!
In July, 2010, we added a
new CT machine. This Toshiba
continued page 6
Transitional cell carcinoma (TCC) is the most commonly diagnosed urinary
bladder cancer in dogs. It is a difficult tumor to treat and effective therapies
are limited. The most commonly used chemotherapy agents include mitoxantrone and carboplatin along with piroxicam. A prospective trial using vinblastine was completed at Purdue University. Tumor response was evaluated
using urinary tract ultrasound with bladder mapping on a monthly basis.
Although none of the dogs experienced a complete remission, 36% had a
partial response and 50% maintained stable disease. The majority of dogs
tolerated the chemotherapy well. This abstract presents an alternative therapy for treating TCC in dogs, but the response is still less than ideal.
Metronomic chlorambucil chemotherapy was also evaluated for the treatment
of TCC. Metronomic chemotherapy refers to continuous, low dose administration of a chemotherapy drug with the intention of targeting tumor blood
supply, not the tumor directly. Dogs received daily chlorambucil chemotherapy. Many of them had failed previous therapy and were currently taking a
COX inhibitor. Only one dog had a partial response and about 65-70% had
stable disease. The average time until progression was approximately 4
months. Similar to the vinblastine therapy, this study offers another option for
dogs with TCC who have failed standard chemotherapy.
At SouthPaws we use CCNU or lomustine at a standard, pulse dose manner
to treat a variety of tumors including lymphoma, histocytic sarcoma, and
mast cell tumors. Low dose CCNU was evaluated for tolerability when used
in a metronomic daily dosing schedule to treat a variety of tumors. It was
shown that almost 10% of dogs developed azotemia and many of them
required discontinuation of therapy due to adverse side effects. Therefore,
while CCNU is an option for metronomic dosing, azotemia is a serious side
effect. One of the known side effects of CCNU used in standard dosing fashion is hepatotoxicity which can result in a life threatening problem in ≤5% of
dogs treated with the drug. We routinely evaluate liver enzymes in patients
receiving CCNU. Denamarin® is a supplement that includes SAMe and silybin used as a hepatoprotectant for many liver diseases. Its concurrent use in
CCNU treated dogs was shown to result in less significant increase in liver
enzymes. Administering Denamarin® with CCNU may be something to consider especially in patients with an increased risk!
An exciting new option is available to treat dogs with lymphoma – peripheral
blood stem cell transplantation (PBSCT)! This still-experimental treatment is
currently performed at North Carolina State University. The ideal candidates
are large dogs with B cell lymphoma that are free of coexisting disease. This
treatment is a very complex and expensive process beginning after the successful completion of standard CHOP induction therapy, and involves high
dose chemotherapy, bone marrow stimulation using Neupogen and harvesting of blood stem cells using an apheresis machine. The patient also has
total body irradiation then receives an infusion of their own stem cells. It is a
bit intimidating – all dogs have ZERO neutrophils and almost no platelets
after the radiation therapy. They require intense management after the procedure, and several fatalities have been reported. This process takes 2-6
weeks of hospitalization at NCSU once standard chemo (which could be performed here at SouthPaws) has been completed, but offers hope for longer
remissions or even a possible cure for dogs with lymphoma. We are happy to
evaluate dogs with lymphoma to determine if they are candidates for this
procedure and to discuss the details with interested clients. 䡲
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What’s New in Diagnostic Imaging at SouthPaws?
DR. MATT NELSON, DACVR, SOUTHPAWS DIAGNOSTIC IMAGING CENTER
One slice, two slice, three slice, more slice!
With the capability to acquire four slices with every
rotation of the tube head, our new Toshiba Asteion
Quad Slice CT is over four times faster than our
previous unit. Adding that to a sub-second tube
rotation time means that we can achieve high resolution, thin slices in a minimum amount of time.
This allows us to acquire highly detailed images of
small regions such as feline nasal passages without prolonging anesthesia time or to scan a medium to large-sized canine thorax without respiratory
motion to confound interpretation. The case study
below is an example of how having thin slices can
make subtle abnormalities more pronounced.
Figure 1. Axial computed tomography image of the
skull, processed using an edge-enhancing convolution filter and displayed in a bone window for high
detail of fine osseous structures.
A 12 year old, neutered male, domestic short hair
cat was presented for a chronic history of unilateral, right-sided nasal discharge. On physical examination, anisocoria was noted. List the computed
tomographic findings and make your imaging diagnosis (answer on following page).
The right orbital fissure is widened when compared
to the left and filled with a soft tissue attenuating
structure, which likely involves the structures transmitted through this opening (ophthalmic, oculomoter, trochlear, and abducent nerves). This mass minimally enhances following contrast administration.
Additionally, lysis of the maxilla and hard palate
were noted, and the mass tracked rostrally into the
orbit. Soft tissue attenuating material was also present throughout the right nasal passage. Because of
the pattern of lysis, soft tissue mass, and extension
into the calvarial vault, neoplasia was considered
most likely. Differential diagnoses include lymphoma, adenocarcinoma, and meningioma. Given
this information, the owner elected to euthanize the
patient while under anesthesia and did not permit
necropsy.
Figure 2. Same image with orbital fissure outlined
(black arrows).
was at first noted on only one slice and could have
been attributed to slice artifact; however, the raw
data was used to reconstruct 1 mm thick slices,
and the abnormality became apparent on several
slices. The thin, high resolution slices afforded by
the CT scanner can give us valuable information in
differentiating true from artifactual findings and, in
this case, provide valuable information regarding
prognosis. 䡲
Though the slices were initially acquired at 1 mm
thick intervals, the computer reconstructed the
images at 3 mm thickness for more rapid evaluation
and a high signal to noise ratio. The asymmetry
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As “Eye” See It
NANCY M. BROMBERG, VMD, MS, DACVO, SOUTHPAWS OPHTHALMOLOGY
“Your Patient Needs Bifocals”
Several “normal” aging changes occur in the eyes
of dogs and cats. Occasionally, these changes
need to be differentiated from possible pathologic
problems which may present in a similar manner.
IRIS ATROPHY
Thinning and atrophy of
the iris sphincter muscle
and/or the stroma of the
iris is another frequent
aging change. Atrophy of
the iris sphincter muscle
occurs significantly more
frequently than does atrophy of the iris stroma.
Thinning of the stroma is,
however, seen commonly
in Yorkshire Terriers and
Toy Poodles. This atrophy may give the iris a lacy
appearance, almost as if the dog has more than
one pupil. The absence of a normal pupillary light
response causes an inability for the eye to control
how much light is entering it, causing the animal to
squint in bright light. In some instances, avoiding
exposure to bright sunlight might be indicated,
walking the dog instead early in the morning and at
or after dusk.
LENTICULAR SCLEROSIS
The most common change noted in the aging animal is lenticular sclerosis, or hardening of the lens.
The hardening of the lens fibers doesn’t allow for
the change in shape of the lens needed for focusing. As aging occurs in dogs, cats, and us humans,
a point is reached where near vision becomes a bit
out of focus without the
help of “reading glasses”. In most people, this
occurs in our forties. In
dogs and cats it usually
manifests itself about
nine to ten years of age.
Dog owners may recognize hesitancy with
stairways, as the dog
may have difficulty
determining how far down that first step is.
Occasionally owners may see a decreased ability
to catch toys, or an occasional nip on the fingertip
when giving a treat. With dogs in their teens, owners may notice a “flinching” response when the animal is approached, due to the lack of depth perception. Lenticular sclerosis rarely causes any
major vision changes, just depth perception difficulties. Of course, dogs and cats with sclerosis would
benefit from bifocals, but we’re not quite there YET!
Atrophy of the muscles of the pupil sphincter causes a decreased pupillary light response, and dilation of the pupil. Since the atrophy may not be symmetric in both eyes, anisocoria is commonly diagnosed. The naturally occurring pupil sphincter atrophy needs to be differentiated from pathological
abnormalities such as glaucoma, Horner’s syndrome, uveitis, other cranial nerve abnormalities,
and other causes of anisocoria.
ENDOTHELIAL DEGENERATION
OF THE CORNEA
The cornea is made up of three major layers, the
outer epithelium, the inner-most endothelium, and
the middle, largest part, the stroma, made up of
layers of collagen. The collagen layers are
arranged in layers, allowing light to pass through. A
failure of either the epithelium or endothelium in
keeping fluid out of the collagen layers causes the
cornea to become edematous or cloudy with a
blue-grey appearance.
Lenticular sclerosis is sometimes referred to as
“senile cataracts”, although this term can be misleading. With true cataracts, opacities exist within
the lens, obscuring vision. Frequently the older dog
with sclerosis may also develop concomitant
cataracts. Thorough ophthalmoscopic examination
of the fundus is essential when cataracts begin to
appear to determine if the animal will be a candidate for cataract surgery if and when the cataracts
progress.
Continued on page 5
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As “Eye” See It...Continued from page 4
With the forward motion of the fluid, the fluid may
accumulate between the stroma and the epithelium, forming small bullae of “water blisters”. If these
rupture, small recurrent corneal ulcerations may
occur. This condition is known as Bullous
Keratopathy. While there is no “cure” for this condition, it may be controlled with hyperosmotic 5%
NaCl ointment. This may prevent the chronic reoccurrence of the ulcerations, and occasionally facilitates partial clearing of the cornea. The presence
of corneal edema does have an effect on the animal’s vision. Because the cornea is no longer clear,
it is somewhat like looking through frosted glass.
When endothelial cells die,
as a function
of age, trauma,
or inflammation, they are
not replaced.
The remaining
cells enlarge
and ‘move’ toward each other to fill up the space.
As the eye is always under a certain amount of
intraocular pressure, there is a forward movement
of the intraocular fluid into the cornea. Under normal circumstances, the endothelial cells biochemically “pump” the fluid back into the anterior chamber, keeping the collagen fibers dehydrated. As
more and more of the endothelial cells degenerate,
the efficiency in which the remaining cells function
decreases, and they allow fluid to enter the collagen. The collagen fibers swell and the cornea
becomes edematous.
It is common to see corneal edema due to
endothelial degeneration in the older animal. There
are inherited forms of this endothelial change, as
seen in the Boston Terrier, Dachshund, and
Airedale. Corneal edema associated with endothelial degeneration must be differentiated from
corneal edema due to glaucoma or uveitis. 䡲
Thoughts on Epilepsy Management
DR. MIKE KNOECKEL, DACVIM(NEUROLOGY), SOUTHPAWS NEUROLOGY/NEUROSURGERY
in dogs. Concurrent treatment with phenobarbital
increases metabolism of zonisamide, requiring a
higher dose to achieve adequate tissue levels if
both drugs are used in the same patient.
Zonisamide has the advantage of a longer half-life
in cats, requiring only once daily administration. I
typically dose this at 10 to 20 mg once daily per
cat. It is now available in generic form, making it
much more affordable, though prices can still vary
dramatically between pharmacies.
Phenobarbital and potassium bromide have been
the backbone of seizure management for many
years in veterinary medicine. Many patients are well
controlled on one or both of the drugs with few side
effects. Unfortunately, some patients continue to
seizure and some show unacceptable side effects
such as hepatotoxicity with phenobarbital (uncommon but potentially very serious), asthma with
potassium bromide in cats, and excessive sedation
from either of these drugs. The sedative effects
tend to be more pronounced when the two drugs
are given together. Over the past few years, our
choices have expanded with the introduction of
zonisamide and leviteracetam. These newer medications are effective in dogs or cats where phenobarbital or bromide have not sufficed.
Leviteracetam has also shown to be a very effective drug in dogs and cats with minimal side
effects. Unfortunately, it does require TID dosing in
most cases, which can be problematic for some
pet owners. It has the advantage of being available
in injectable form so it can be used in management
of status epilepticus or refractory cluster-seizure
Zonisamide is typically dosed at 5 to 10 mg/kg BID
Continued on page 6
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Enhanced Endoscopy Services at SouthPaws
SOUTHPAWS INTERNAL MEDICAL
Drs. Jennifer Gieg and Heather Hoch (both diplomates of ACVIM in Small Animal Internal Medicine)
are pleased to announce that the endoscopy offerings at SouthPaws have been greatly enhanced in
the last few months. Videoendoscopy along with
both larger/longer and smaller/narrower scopes will
enable endoscopic examination of a wider range of
sizes of dogs/cats as well examination of more
'places' within these patients. Gastroduodenal,
colonic/ileal, and esophagoscopy are now possible
in very small (4 pound) to very large (150 pound)
dogs, and most sizes of cats as well. With the addition of new basket and grasping retrieval devices,
we have good success with removal of most gastric
and esophageal foreign bodies and our internists
are available to help with your foreign body emergencies 24 hours a day.
With our flexible scopes urethroscopy and cystoscopy can also be performed in most medium
sized male dogs. Rhinoscopy (retrograde and
retroflex) as well as bronchoscopy (complete with
cytologic brushings, BALs, and biopsy capabilities)
in all sizes of dogs and cats is also possible here at
SouthPaws. If you have a patient who would benefit
from diagnoses obtained in these minimally invasive procedures, just give Drs. Gieg or Hoch a call
and they'll let you know if your patient will "fit"! 䡲
In addition to our flexible scopes, we have rigid
scopes to allow cytsoscopy and urethroscopy in
most female dogs (10 lbs and larger) to aid in the
diagnosis of urinary incontinence, cystitis / urethritis, and neoplasia. Theses scopes also allows
vaginoscopy and examination of the vestibule for
dogs with recurrent infections or vulvar discharge.
Thoughts of Epilepsy Management...Continued from page 5
15-25 mg/kg TID (has a low but significant risk of
hepatotoxicity and should not be given in combination with phenobarbital), topiramate at 10 mg/kg
TID and gabapentin at 10 mg/kg TID. Over the past
couple years, I have been very impressed with the
effectiveness of pregabalin (Lyrica) starting at a
dose of 4 mg/kg TID, though its price may be prohibitive in larger dogs.
patients. I typically dose leviteracetam at 20mg/kg
TID in dogs or cats, increasing the dose as needed
to effect unless excessive sedation occurs.
Either of these drugs can be added to pre-existing
phenobarbital or bromide therapies, though that
may increase the potential for sedation. Since I’m
usually reaching for these medications when phenobarbital or potassium bromide have not been
effective or have caused excessive side effects, I
prefer to taper and discontinue the older medications as the newer drugs (zonisamide or leviteracetam) reach adequate tissue levels, typically over a
two to three week period.
Unfortunately, not all epileptics can be controlled
with these medications and finding the best combination can be frustrating, analogous to ‘cooking
without a recipe’ where we try adding a touch of
this and removing some of that over time until we
find the best combination to achieve the best control with the fewest side effects. 䡲
Other drugs that can be tried include felbamate at
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Surgical Updates from the 2010 ACVS Meeting in Seattle, WA
DR. DAN BREHM, DACVS, SOUTHPAWS SURGERY
There is growing evidence that
dogs with laryngeal paralysis
may be clinically manifesting
only one component of a progressive systemic polyneuropathy. In particular, esophageal
dysfunction appears to be a
common, concurrent problem,
and may explain the comparatively high risk of aspiration
pneumonia in laryngeal paralysis patients. A recent study at
Michigan State University in
which esophagrams were performed on laryngeal paralysis
patients and compared to
matched healthy dogs demonstrated significantly worse
esophageal function in the
laryngeal paralysis dogs. Also,
the laryngeal paralysis dogs that
developed aspiration pneumonia had significantly worse
esophageal function than those
dogs that did not develop pneumonia. Finally, one third of
affected dogs had generalized
neurologic signs on enrollment
in the study, and all dogs had
signs of polyneuropathy at study
end (12 months). The
esophageal dysfunction may be
a result of concurrent degeneration of the pararecurrent laryngeal nerves, which branch off of
the recurrent laryngeal nerves
as they arise from the vagus
nerve, and innervate the cervical
and cranial esophagus.
Although we are in the process
of evaluating this information, it
may be necessary to include
assessment of esophageal function (via esophagram) as part of
the diagnostic work up for laryngeal paralysis. If nothing else,
findings of concurrent
esophageal dysfunction may be
important information for the
owner in deciding how to
approach treatment as well as
understanding the level of risk
associated with the treatment.
Ultimately, the severity of the
respiratory dysfunction is the
most important factor in determining the necessity of corrective laryngeal surgery.
Silver-containing dressings are
widely used in human medicine
to assist with management of
infected wounds and those at
risk for infection. They are now
being used more commonly in
veterinary medicine. One example of a silver-containing dressing is Acticoat Flex 3+7, from
Smith and Nephew. This is a
nanocrystalline silver impregnated dressing that is placed in the
wound and hydrated with sterile
water before being covered with
a water-impervious outer dressing. The dressing can be left in
place for up to seven days,
although changes at 3-4 day
intervals is preferred. When in
contact with the wound, the
dressing releases silver ions
and kills bacteria by disrupting
their cell walls. A wide range of
bacteria are sensitive to this
treatment, including
Pseudomonas, methicillin-resistant Staph aureus, and vancomycin-resistant Enterococcus.
This dressing also promotes
granulation tissue formation in
addition to its antibiotic effects.
The Flex 3+7 dressing is flexible
and malleable, and can be cut
to match the shape of the
patient’s wound. It is changed at
appropriate intervals until the
wound bed is healthy and can
be definitively treated.
Negative pressure treatment of
open wounds has also become
available for veterinary patients.
Also known as vacuum-assisted
wound closure (VAC), it entails
exposing the wound bed to
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local, sub-atmospheric negative
pressure through a closed system to help with wound healing.
The negative pressure removes
fluid from the extravascular
space, improving circulation and
enhancing granulation tissue
proliferation. The system entails
placement of a sterile open cell
polyurethane foam into the
wound bed. A fenestrated
egress tube is placed into a slot
cut into the foam and connected
to a vacuum system. The wound
bed with the foam and the
egress tube are then covered by
an adhesive plastic sheet
adhered to the surrounding skin
to create a sealed cavity.
Negative pressure is then
applied to the wound (usually at
around – 125 mm Hg). The
bandages are changed every
two to three days until definitive
wound care can be applied.
Studies in humans have demonstrated better wound closure
and improvement in granulation
tissue formation compared to
wet to dry bandages.
The use of honey in wound beds
has achieved a resurgence in
veterinary medicine. The high
osmotic potential of honey
debrides wounds and draws
exudate from the wound bed. It
also has anti-inflammatory properties and promotes granulation
tissue formation. Antibacterial
properties are through enzymatic production of hydrogen peroxide from glucose, and its
hypertonicity, low pH, and inhibin content. Not all honey products work. Medicinal honey or
Manuka honey are preferred
and are used in open wounds
during the inflammatory and
early repair phases of wound
healing. 䡲
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Asteion Quad Slice has a rotation speed of less than 1 second, which means that we can
image a large dog’s entire thoracic cavity in 20 to 30 seconds. Image quality is excellent, and three dimensional
reconstruction is quite simple,
quick and routine. CT is the
best modality for imaging to
provide diagnostic, prognostic
and therapeutic information in
many diseases of the head,
neck, pelvis, abdomen and
chest. Questions about when
CT is preferred to plain radiographs, MR, or ultrasound?
Just ask us! Our radiologists
are happy to discuss options
for optimal patient imaging.
See Dr. Nelson’s article in this
newsletter to get an idea on
what type of very very small
lesion can be seen with this
this machine!
DR. DAN BREHM, DACVS, SOUTHPAWS SURGERY
At SouthPaws patients with
challenging wounds can be
managed with traditional
means or the new methods
outlined on page 5. We also
have our hyperbaric oxygen
therapy system readily available, which is of great value
for many patients, particularly
those with poorly healing
wounds, and for skin flap and
skin graft patients.
“Cookie”, a dog burned in a house fire is looking out while getting HBOT.
HBOT SAVES THE LEG: One
patient that stands out was a
cat who traumatically lost its forefoot (including all digits and all pads) at the
level of the metacarpal bones. There was also a fairly sizable degloving injury
from proximal to the carpus distally. The owner wished to preserve the leg if
possible, so we used HBOT after debridement until a healthy bed of granulation tissue developed. A partial thickness skin graft was applied to the degloving injury, and a pad graft was placed at the distal end of the limb to create a
new weight bearing surface. HBOT was again applied, and both the skin graft
and pad graft took at near 100%. As of the last examination, the cat is using
its pad-grafted leg nearly normally, with minor compensation for the slightly
shorter limb. HBOT in this case gave the cat the best chance for graft take
and preservation of near-normal limb function. 䡲
I-395
We thank you for your
consultations and referrals
in 2010—and greatly
appreciate your confidence in our services.
Hyperbaric Oxygen Therapy
y
Beltwa
Our convenient new location:
Just outside the beltway on
Route 50 near Fairfax Hospital
SouthPaws Veterinary Specialists & Emergency Center
8500 Arlington Blvd.
Fairfax, Virginia 22031
Tel: 703.752.9100
Fax: 703.752.9200
DIRECTIONS TO FACILITY
From the north and south directions on the Beltway take exit
50A US 50 West. Go to the second light, Javier Rd., and make a
right. Make an immediate left
onto Arlington Blvd. Frontage Rd.,
in front of the BB&T bank. Look
for the paw print on the building.
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