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In dogs, peripheral nerve sheath tumors usually present as circumscribed, lobulated cutaneous masses of variable consistency. They are generally 2 to 3 cm in diameter, but occasionally may measure up to 5 cm. They most often develop in the subcutaneous tissue and may expand into the dermis. Myxoid peripheral nerve sheath tumors (myxoid schwannomas) have been observed on the digits of dogs only. In cats, cutaneous peripheral nerve sheath tumors are usually smaller intradermal nodules located on the head and neck. One source found a 3: 1 female predominance for feline benign neural tumors, but the total number of cases was small (Goldschmidt & Shofer, 1992). The latter are mainly subcutaneous and occasionally have delicate projections of tumor tissue extending into adjacent fat and along fascial planes. In dogs, benign peripheral nerve sheath tumors are composed of predominantly small spindle cells embedded in a delicate collagenous stroma. Cells have ovoid, fusiform or serpentine nuclei, which are small and euchromatic, and pale, poorly defined cytoplasm. Electron microscopy shows that the basal lamina around the tumor cells is often thickened and folded. The neoplastic cells are arranged in wavy bundles, streams, and concentric whorls. The latter most likely represent an attempt to reduplicate tactile receptor structures. Palisading and herringbone patterns appear less common than in schwannomas of humans (Koester & Higgins, 2002), but if present, they are very characteristic. Moreover, formation of Verocay bodies, as described in human tumors, characterized by a double row of palisading tumor cells, is rare. Some areas of the neoplasms may contain polygonal cells with small dark nuclei, loosely distributed in a fibrillar and mucinous matrix. Hemangiopericytoma and benign peripheral nerve sheath tumors may be very similar architecturally and difficult to differentiate. Concentric whorling around central branching capillaries is a feature of hemangiopericytoma. However, concentric circling around central small vessels may also occasionally be seen with benign peripheral nerve sheath tumors. In comparison to peripheral nerve sheath tumors, hemangiopericytomas are often more cellular. A predominance of fusiform and serpentine nuclei with smaller nucleoli is more consistent with the diagnosis of a peripheral nerve sheath tumor, while hemangiopericytomas have round to oval nuclei. Additional differential diagnoses for benign peripheral nerve sheath tumors include fibroma, fibrosarcoma, spindle cell lipoma, and dermatofibroma. Fibrosarcomas also lack palisading and marked whorling of cells, and stromal collagen is usually coarser. Both peripheral nerve sheath tumors and spindle cell lipomas contain myxoid stroma, but most spindle cell lipomas have a fair amount of admixed adipose tissue. The spindle cells of spindle cell lipoma are not arranged in whorls and they do not palisade. Dermatofibromas and benign superficial peripheral nerve sheath tumors have similar cellularity and architecture. Dermatofibromas can usually be distinguished by their ragged margins and entrapment of pre-existing dermal collagen bundles by the proliferating fibrocytes; dermatofibromas may also be partially mineralized. In cats, benign peripheral nerve sheath tumors have morphologic features similar to their canine counterparts. However, they tend to be less cellular and are characterized by more abundant collagenous and mucoid matrix. Palisading is more common than in canine peripheral nerve sheath tumors (Koester & Higgins, 2002).

After childbirth, women are encouraged to eat hot foods to regain their strength [27]. Nutrients at risk of deficiency Iron There is an increased risk of iron deficiency in young Vietnamese children [70]. Calcium Children are at risk of calcium deficiency, especially if minimal milk and associated products are eaten [27]. The rice traditionally grown in Vietnam is a good source of calcium, but is unavailable in Britain. Traditional Vietnamese fruit and vegetables also contain more calcium than British varieties [27]. In addition, many Vietnamese women believe that breast feeding will cause their breasts to sag. Hence the incidence of breast feeding is low and there is a need for culturally sensitive health education programmes to support breast feeding in this group. Infants are typically given a rice based porridge at Dietary patterns Somalis are of Arab-African ethnicity and their faith is Islam. As a result many Southern Somalis eat Italian food and spaghetti is a national dish. Lunch is the main meal and usually consists of spaghetti or rice with a meat sauce (beef or goat) and mixed vegetables. Food is often flavoured with aromatic spices (cumin powder, cinnamon, cloves, cardamon, garlic, cilantro, parsley). The evening meal consists of injera or bread with butter and jam, or a traditional meal of rice, beans, butter and sugar. During pregnancy Somali women tend to decrease their meals to ensure an easier delivery. They believe that too much food will make the baby grow too big and it will be hard to deliver normally. The diet usually improves during the third trimester although most women do not take prenatal vitamins. Hebbelinck M, Clarys P, De Malsche A Growth, development, and physical fitness of Flemish vegetarian children, adolescents, and young adolescents. Weiss R, Fogelman Y, Bennett M Severe vitamin B12 deficiency in an infant associated with a maternal deficiency and strict vegetarian diet. Nutritional infantile vitamin B12 deficiency: pathobiochemical considerations in seven patients. Committee on Medical Aspects of Food Policy Present day practice in infant feeding. Colostrum is thought to have a poor nutritional value or to be unhealthy, and it often expressed and discarded. Vitamin D deficiency has been reported in 82% of Somalis living in Liverpool [72]. Increased risk of vitamin B12 and iron deficiency in infants on macrobiotic diets. Effects of macrobiotic diets on linear growth in infants and children until 10 years of age. Health Education Authority Nutrition in Minority Ethnic Groups: Asians and Afro-Caribbeans in the United Kingdom. Are there intergenerational differences in the diets of young children born to first- and second-generation Pakistani Muslims in Bradford, West Yorkshire Rona R, Chinn S National study of health and growth: social and biological factors associated with height of children from ethnic groups living in England.

Before a diagnostic elimination diet is embarked upon it is essential to consider whether the child and/or parent are sufficiently motivated and able to adhere to the diet as non-compliance renders the diet trial a waste of time. Elimination diets for diagnosis Throughout the period of the dietary manipulations and for at least a week before any diet starts it is extremely useful for the parent (or patient) to keep a symptom score diary. It is then possible to be reasonably objective about change in severity of symptoms. Physical symptoms can be listed at the end of each day and a numerical score can be given for each one. Phase 1: initial diagnostic diet A full diet history is mandatory before embarking on a diet and may indicate possible provoking foods. It is not uncommon for parents to be mistaken as to which foods affect their child and intolerance to staple foods eaten several times a day, such as milk and wheat, often go unnoticed. Keeping a food diary for some weeks before starting a diet may provide a baseline but seldom adds any useful information about suspect foods that has not been revealed by diet history. A diagnostic elimination diet should avoid disliked foods and foods that are craved or eaten in large amounts. Degree of activity Observation date Restless or overactive Excitable, impulsive Disturbs other children Short attention span Constantly fidgeting Inattentive, easily distracted Demands must be met immediately Cries often and easily Mood changes quickly and drastically Temper outbursts, explosive and unpredictable behaviour Not at all Just a little Pretty much Very much 264 Clinical Paediatric Dietetics the initial diet may exclude one or a large number of foods. The choice of diet is a matter of clinical judgement taking into account age, severity of symptoms and whether diets have already been tried. There are broadly three levels of dietary restriction: an empirical diet, a few foods diet or an elemental diet. Empirical diet An empirical diet is used where food hypersensitivity is suspected and causative agents are not known. Studies with children who have delayed reactions to food indicate anecdotally that the most common provoking foods are similar to those listed for immediate reactions to foods except that reactions to some food additives and chocolate appears more common and reactions to fish and nuts less common. A diet avoiding egg and milk, together with any known problem foods, is sometimes used for eczema. It is not unusual for paediatric gastroenterologists to use a diet free of milk, egg, wheat, (rye) and soya for children with gastrointestinal symptoms (p. Several adult centres use a diet free of all grains (some include rice), egg, milk, chocolate and additives. A very similar diet was described by Rowe and Rowe [23] for the diagnosis and treatment of food induced asthma. Foods containing the above additives usually also contain flavours which do not have E numbers and these cannot be assumed to be inert. Because most manufactured foods containing additives usually include several additives, it is difficult to get a picture of which ones give the most problems. An empirical additive free diet could be considered to avoid artificial colours, benzoate, sulphur dioxide, nitrite preservatives and food flavours where possible. There is some evidence that urticaria may sometimes be provoked by aspirin and this has been used as an argument for removing fruits and vegetables containing natural salicylates from the diet. A self-help group also suggests hyperactive children may be affected by these fruits and vegetables. The only available analysis of salicylate content of fruits and vegetables has been carried out by Swain et al. Many children with food hypersensitivity are affected adversely by some fruits but can tolerate others that contain salicylates. Problems occur with empirical diets when excluded foods are inadvertently replaced by others that are equally capable of causing adverse reactions; for example, a child on a milk free diet may drink soya milk or orange juice instead and it is possible to be equally reactive to these foods. Failure to respond to an empirical diet does not rule out the possibility of food hypersensitivity. Few foods diet There are considerable difficulties in teaching people how to avoid a large number of foods. For very restricted diets it is easier to decide on which foods the child can eat and teach the diet in terms of which foods are allowed rather that concentrating on those that are forbidden. Three to four weeks is the longest time one should consider using a very restricted diet, although improvement may occur in a shorter time. The simplest few foods diet to have been described consists of lamb, pears and spring water only. Diets using one meat, one carbohydrate source, one fruit and one vegetable have been used [26].

If systemic fungal infection is suspected, culture should not be performed until the systemic mycoses blastomycosis, histoplasmosis, and coccidioidomycosis are ruled out by impression smear and histopathology, since attempted culture may be dangerous (see p. Biopsy site selection An entire nodule should be removed using wedge resection technique. If the lesion is solitary, as in early cases, this may afford the added benefit of a potential surgical cure. If dermatophytic pseudomycetoma is suspected clinically, a deep portion of the lesion should be submitted for dermatophyte culture, after the overlying epidermis has been removed using sterile technique. Care must be taken not to seed the surgical site with organisms during the biopsy process. Granules composed of discrete colonies of dermatophytes are surrounded and interspersed by granulomatous inflammation. The overlying epidermis and superficial dermis may be unremarkable, except for mild to moderate acanthosis, or minimal perivascular or periadnexal mixed inflammation. Often there is some colonization of hair shafts by dermatophytic spores and hyphae. Large amorphous aggregates are composed of tight clusters of somewhat refractile, pleomorphic fungal hyphae. These are tangled and delicate, and contain numerous large, clear, bulbous, thick-walled dilatations, resembling spores. Granules are cuffed by and intermingled with large macrophages, giant cells, and variable, sometimes numerous neutrophils. Proliferating fibroblastic tissue may surround the outer aspect of the lesions but also courses amongst the granules, often creating lobules composed of multiple granules and their attendant inflammation. Lymphocytes and plasma cells may be present in small numbers at the margins of the lobules or at the outer edges of the mycetoma. Note the thin rim of neutrophils surrounding the granule and large epithelioid macrophages in the outer zone of inflammation. This is suggested by the presence of intact portions of hyphae in many macrophages that lie beyond the boundaries of tissue granules. Immunohistochemistry using rabbit anti-Microsporum canis antiserum identified this etiologic agent in two canine cases by specifically staining the fungal organisms in tissue (Abramo et al. The reported case of granulomas caused by Trichophyton mentagrophytes in a dog differed histopathologically from dermatophytic pseudomycetomas. Organisms, which also heavily colonized the keratin of hair follicles and the epidermis, were diffusely organized within granulomatous inflammation of the dermis, panniculus, and subcutis. Tissue grains containing aggre- gates of organisms were not identified (Bergman et al. The histopathologic appearance of dermatophytic pseudomycetoma is distinctive, but may need to be differentiated from other fungal infections. Most of the systemic and opportunistic fungi affecting cats and dogs are smaller and more uniform in appearance in tissue section, and do not accumulate in tissue grains or granules. In contrast, the diffuse distribution of Trichophyton mentagrophytes in dermatophytic granulomas is similar to opportunistic fungal infection (Bergman et al. Concurrent identification of Trichophyton mentagrophytes in the keratin of hair follicles and epidermis (typical of this organism) will allow diagnosis. Canine blastomycosis is the most common systemic mycosis seen in small animal practice; skin lesions are seen in up to 40% of affected dogs (Legendre, 1998). Cutaneous involvement is uncommon in histoplasmosis and coccidioidomycosis (Greene, 1998; Wolf, 1998). Cryptococcosis, another systemic mycosis caused by an encapsulated yeast-like fungus, is discussed separately as the organism is viewed as an opportunist with infection predominantly seen in conjunction with debilitating underlying disease or immunosuppression (see p. The organisms that cause these systemic mycoses, Blastomyces dermatitidis, Histoplasma capsulatum, and Coccidioides immitis, are able to invade the normal immunocompetent host, usually via inhalation of conidia, and are thus differentiated from the opportunistic systemic mycosis, cryptococcosis, plus other opportunistic fungal infections. In most cases, cutaneous infection with these three systemic fungi should be considered a manifestation of underlying disseminated visceral disease.