On two species of the alpheid shrimp genus Salmoneus Holthuis, 1955 from Kuwait, one of them new to science (Malacostraca: Decapoda: Caridea).

The alpheid genus Salmoneus Holthuis, 1955 is reported from Kuwait for the first time, with two species. One species, Salmoneus ikaros sp. nov., is described based on a single specimen from Failaka Island, extracted from the burrow of the callianassid ghost-shrimp Balsscallichirus masoomi (Tirmizi, 1970), together with the host. The new species is characterised by its peculiar eyes, which together with other characters separate it from all previously described species of Salmoneus. The second species, Salmoneus gracilipes Miya, 1972, is reported from Kuwait based on three specimens from two different localities and different habitats. Two specimens were found under coral rocks at a depth of about 7 m off Kubbar Island, whereas the third specimen was extracted from the burrow of the echiuran worm, Listriolobus cf. brevirostris Chen Yeh, 1958, at the type locality of S. ikaros sp. nov. at Failaka Island. Material identified as S. gracilipes from across its wide distribution range appears to be morphologically heterogeneous, possibly containing more than one species, and thus will need further studies.

Taxonomic notes on Alpheus inopinatus Holthuis amp; Gottlieb, 1958 and Alpheus cf. lobidens De Haan, 1849 from Kuwait (Malacostraca: Decapoda: Alpheidae).

The status of the common intertidal snapping shrimp, Alpheus inopinatus Holthuis Gottlieb, 1958, is discussed based on newly collected material from Kuwait. Alpheus inopinatus was previously confused with morphologically very similar species in the Alpheus lobidens De Haan, 1849 species complex, formerly identified as A. crassimanus Heller, 1862 and herein tentatively referred to as A. cf. lobidens. The material herein examined strongly supports the validity of A. inopinatus based on several morphological characters, as well as differences in the colour pattern, compared to other members of the A. lobidens complex.

An Overview of the World Current and Future Assessment of Novel COVID-19 Trajectory, Impact, and Potential Preventive Strategies at Healthcare Settings.

This study is an overview of the current and future trajectory, as well as the impact of the novel Coronavirus (COVID-19) in the world and selected countries including the state of Kuwait. The selected countries were divided into two groups: Group A (China, Switzerland, and Ireland) and Group B (USA, Brazil, and India) based on their outbreak containment of this virus. Then, the actual data for each country were fitted to a regression model utilizing the excel solver software to assess the current and future trajectory of novel COVID-19 and its impact. In addition, the data were fitted using the Susceptible-Infected-Recovered (SIR) Model. The Group A trajectory showed an "S" shape trend that suited a logistic function with r2 > 0.97, which is an indication of the outbreak control. The SIR models for the countries in this group showed that they passed the expected 99% end of pandemic dates. Group B, however, exhibited a continuous increase of the total COVID-19 new cases, that best suited an exponential growth model with r2 > 0.97, which meant that the outbreak is still uncontrolled. The SIR models for the countries in this group showed that they are still relatively far away from reaching the expected 97% end of pandemic dates. The maximum death percentage varied from 3.3% (India) to 7.2% with USA recording the highest death percentage, which is virtually equal to the maximum death percentage of the world (7.3%). The power of the exponential model determines the severity of the country's trajectory that ranged from 11 to 19 with the USA and Brazil having the highest values. The maximum impact of this COVID-19 pandemic occurred during the uncontrolled stage (2), which mainly depended on the deceptive stage (1). Further, some novel potential containment strategies are discussed. Results from both models showed that the Group A countries contained the outbreak, whereas the Group B countries still have not reached this stage yet. Early measures and containment strategies are imperative in suppressing the spread of COVID-19.

Climate and COVID-19 pandemic: effect of heat and humidity on the incidence and mortality in world's top ten hottest and top ten coldest countries.

OBJECTIVE: The COVID-19 pandemic has caused a global public health crisis with social, psychological and long-lasting economical damages. Weather-related dynamics have an impact on the pattern of human health and disease. The present study aimed to investigate the impact of heat and humidity on daily basis incidence and mortality due to COVID-19 pandemic in ten of the world's hottest countries compared to ten of the coldest ones. MATERIALS AND METHODS: Worldwide, we selected 20 countries; 10 hottest countries with the highest temperatures and 10 coldest countries with the lowest temperature. The selection of the countries was based on the daily basis mean temperature from the date of appearance of the initial cases of COVID-19, Dec 29, 2019 to May 12, 2020. In the world's 10 hottest countries, the mean temperature was (26.31±1.51) and humidity (44.67±4.97). However, in the world's 10 coldest countries the mean temperature was (6.19±1.61) and humidity (57.26±2.35). The data on the global outbreak of COVID-19, daily new cases and deaths were recorded from World Health Organization, and daily information on temperature and humidity was obtained from metrological web "Time and Date". RESULTS: In countries with high temperatures and low humidity, the mean daily cases incidence were (407.12±24.33); cumulative cases (9094.34±708.29); and cumulative deaths (452.84±43.30) were significantly low compared to countries with low temperatures and high humidity: daily cases (1876.72±207.37); cumulative cases (44232.38±5875.11); and cumulative deaths (2008.29±310.13). Moreover, COVID-19 cases and deaths per million population were significantly low in countries with high temperatures (cases 711.23, and deaths 16.27) compared to countries with low temperatures (cases 1685.99; and deaths 86.40). Furthermore, in hottest countries, a 1% increase in humidity reduced number of cases and deaths by (ß = -5.40, p<0.001) and (ß = -0.187, p=0.004) respectively. A similar trend was seen with a 1°C increase in temperature, reducing the number of deaths by (ß = -1.35. p<0.001). CONCLUSIONS: The results revealed a significant decrease in incidence of daily cases and deaths in countries with high temperatures and low humidity (warmest countries), compared to those countries with low temperatures and high humidity (coldest countries). The findings could be of interest to the policymakers and the health officials on the epidemiological trends of COVID-19 pandemic and weather changes.

Variation in training requirements within general surgery: comparison of 23 countries.

Background: Many differences exist in postgraduate surgical training programmes worldwide. The aim of this study was to provide an overview of the training requirements in general surgery across 23 different countries. Methods: A collaborator affiliated with each country collected data from the country's official training body website, where possible. The information collected included: management, teaching, academic and operative competencies, mandatory courses, years of postgraduate training (inclusive of intern years), working-hours regulations, selection process into training and formal examination. Results: Countries included were Australia, Belgium, Canada, Colombia, Denmark, Germany, Greece, Guatemala, India, Ireland, Italy, Kuwait, the Netherlands, New Zealand, Russia, Saudi Arabia, South Africa, South Korea, Sweden, Switzerland, UK, USA and Zambia. Frameworks for defining the outcomes of surgical training have been defined nationally in some countries, with some similarities to those in the UK and Ireland. However, some training programmes remain heterogeneous with regional variation, including those in many European countries. Some countries outline minimum operative case requirement (range 60-1600), mandatory courses, or operative, academic or management competencies. The length of postgraduate training ranges from 4 to 10 years. The maximum hours worked per week ranges from 38 to 88 h, but with no limit in some countries. Conclusion: Countries have specific and often differing requirements of their medical profession. Equivalence in training is granted on political agreements, not healthcare need or competencies acquired during training.

Antecedentes: Existen muchas diferencias entre los programas de formación quirúrgica de posgrado del mundo. El objetivo de este estudio fue proporcionar una visión general de los requisitos formativos en cirugía general en 23 países diferentes. Métodos: En cada uno de los países participantes, un colaborador recopiló datos de la página web del organismo oficial encargado de la formación, si era posible. La información incluyó: gestión, formación, competencias académicas y operatorias, cursos obligatorios, años de formación de postgrado (que incluía el período de internado), regulaciones sobre las horas de trabajo, proceso de selección para la formación y existencia de un examen final. Resultados: Se incluyeron los datos de Australia, Bélgica, Canadá, Colombia, Dinamarca, Alemania, Grecia, Guatemala, India, Irlanda, Italia, Kuwait, Países Bajos, Nueva Zelanda, Rusia, Arabia Saudita, Sudáfrica, Corea del Sur, Suecia, Suiza, Reino Unido, Estados Unidos de América y Zambia. En algunos países existen los marcos normativos para definir los resultados del programa de formación, con ciertas semejanzas a los del Reino Unido e Irlanda. Sin embargo, algunos programas de formación, incluso en muchos países europeos, son muy heterogéneos con variaciones regionales. Pocos países describen el número mínimo de procedimientos quirúrgicos (rango 60 a 1.600), los cursos obligatorios o competencias quirúrgicas, académicos o de gestión exigidos. La duración de la formación postgraduada osciló de los 4 a los 10 años. El número de horas trabajadas máximas por semana oscilaron entre 38 y 88, sin límite en algunos países. Conclusión: Cada país tiene unos requisitos específicos, a menudo diferentes, para la formación de sus médicos. La convalidación se otorga por acuerdos políticos, más que por las necesidades médicas o por las competencias adquiridas durante la formación.

Bedside clinical neurologic assessment utilisation in paediatric cardiac intensive care units.

IntroductionNeurodevelopmental disabilities in children with CHD can result from neurologic injury sustained in the cardiac ICU when children are at high risk of acute neurologic injury. Physicians typically order and specify frequency for serial bedside nursing clinical neurologic assessments to evaluate patients' neurologic status.Materials and methodsWe surveyed cardiac ICU physicians to understand how these assessments are performed, and the attitudes of physicians on the utility of these assessments. The survey contained questions regarding assessment elements, assessment frequency, communication of neurologic status changes, and optimisation of assessments. RESULTS: Surveys were received from 50 institutions, with a response rate of 86%. Routine clinical neurologic assessments were reported to be performed in 94% of institutions and standardised in 56%. Pupillary reflex was the most commonly reported assessment. In all, 77% of institutions used a coma scale, with Glasgow Coma Scale being most common. For patients with acute brain injury, 82% of institutions reported performing assessments hourly, whereas assessment frequency was more variable for low-risk and high-risk patients without overt brain injury. In all, 84% of respondents thought their current practice for assessing and monitoring neurologic status was suboptimal. Only 41% felt that the Glasgow Coma Scale was a valuable tool for assessing neurologic function in the cardiac ICU, and 91% felt that a standardised approach to assessing pre-illness neurologic function would be valuable. CONCLUSIONS: Routine nursing neurologic assessments are conducted in most surveyed paediatric cardiac ICUs, although assessment characteristics vary greatly between institutions. Most clinicians rated current neurologic assessment practices as suboptimal.

Distribution Profiles of Melamine and Its Derivatives in Indoor Dust from 12 Countries and the Implications for Human Exposure.

Melamine and its derivatives (i.e., ammeline, ammelide, and cyanuric acid) are extensively used in household products, such as furniture, dinnerware, and food utensils. Nevertheless, limited information is available on human exposures, other than dietary sources, to melamine and its derivatives. In this study, the occurrence of melamine and its derivatives was determined, for the first time, in 341 samples of indoor dust, collected from 12 countries. All of the dust samples contained target analytes, with global median concentrations of 1800, 1100, 48, and 45 ng/g for melamine, cyanuric acid, ammelide, and ammeline, respectively. The total concentrations of melamine and its derivatives varied among countries in the following decreasing order: United States (median: 17 000 ng/g) > Japan (8400) > China (8000) > South Korea (7300) > Saudi Arabia (4400) > Romania (4300) > Greece (3400) > Kuwait (2400) > Vietnam (2300) > Colombia (1300) > Pakistan (820) > India (430). Correlation analysis indicated the existence of multiple and varied sources for melamine and cyanuric acid. Estimated daily intakes of melamine via indoor dust ingestion were at least 2 orders of magnitude below the current tolerable daily intake.

Identifying a Potential Summary Measure for Overall Caries Level in Children Examined with the International Caries Detection and Assessment System.

OBJECTIVE: To identify a potential summative summary measure that reflects a patient's overall caries level in children examined with the International Caries Detection and Assessment System (ICDAS). SUBJECTS AND METHODS: Participants were 1- to 15-year-old children from Kuwait, Brazil, and Spain. Children's teeth were examined using the ICDAS. Multiple measures of central tendency and dentition-specific indices were considered as potential summative measures. The relationship between the summative measures and number of caries lesions was evaluated considering degrees of caries severity using Spearman's correlation analysis. The results were generated using the Kuwaiti sample and were cross-validated using the Brazilian and Spanish samples. RESULTS: A total of 2,808 children participated in the present study. Total ICDAS score and mean ICDAS score showed a strong correlation with the number of caries lesions at different caries severity levels in primary, mixed, and permanent dentitions. The total ICDAS score of 51 buccal (B), 61B, 54 occlusal (O), 55O, 64O, 65O, 74O, 75O, 84O, and 85O surfaces in primary dentition and the total ICDAS score of 14O, 16 lingual (L), 16O, 24O, 26L, 26O, 36B, 36O, 37O, 46O, 46B, and 47O surfaces in permanent dentition or mixed dentition (if present) showed strong correlations with the number of caries lesions at different caries severity levels. CONCLUSIONS: Total ICDAS and mean ICDAS scores were the best summary measures of overall caries level at different dental stages. Total ICDAS scores of selectively examined 10 surfaces in primary dentition and 12 surfaces in permanent dentition can give an excellent summary measure for a patient's overall caries level with high diagnostic accuracy.

Evaluation of associations between single nucleotide polymorphisms in the FRMD3 and CARS genes and diabetic nephropathy in a Kuwaiti population.

Diabetic nephropathy is the leading cause of end-stage kidney disease in the world. Many single nucleotide polymorphisms (SNPs) have been associated with diabetic nephropathy. SNPs at the 4.1 protein ezrin, radixin, moesin domain 3 (FRMD3) and cysteinyl t-RNA synthetase (CARS) genes have a well-established relationship with diabetic nephropathy. However, this association has not been evaluated in a Kuwaiti population. DNA was extracted from blood samples obtained from patients with diabetic nephropathy (N = 38); the genes of interest were amplified, and the SNPs were genotypes. Diabetics without nephropathy (N = 64) were used as controls. The risk (G and C) and non-risk (C and T) allele frequencies of the SNPs at the rs1888747 and rs739401 loci of FRMD3 and CARS, respectively, did not differ significantly between the diabetics with (case) and without (control) nephropathy (P > 0.05). These findings suggest that the molecular mechanisms involved in diabetic nephropathy may be different in a Kuwaiti population, compared to other populations (such as Japanese and Caucasian Europeans). The discrepancies observed in our study could also be attributed to the smaller sample size analyzed in this study. Therefore, further analyses with larger samples are required to identify the susceptibility genes in a Middle-Eastern population.

Multiyear, Multinational Survey of the Incidence and Global Distribution of Metallo-ß-Lactamase-Producing Enterobacteriaceae and Pseudomonas aeruginosa.

Metallo-ß-lactamases (MBLs) hydrolyze all classes of ß-lactams except monobactams and are not inhibited by classic serine ß-lactamase inhibitors. Gram-negative pathogens isolated from patient infections were collected from 202 medical centers in 40 countries as part of a global surveillance study from 2012 to 2014. Carbapenem-nonsusceptible Enterobacteriaceae and Pseudomonas aeruginosa were characterized for bla genes encoding VIM, IMP, NDM, SPM, and GIM variants using PCR and sequencing. A total of 471 MBL-positive isolates included the following species (numbers of isolates are in parentheses): P. aeruginosa (308), Klebsiella spp. (85), Enterobacter spp. (39), Proteeae (16), Citrobacter freundii (12), Escherichia coli (6), and Serratia marcescens (5) and were submitted by sites from 34 countries. Of these, 69.6% were collected in 9 countries (numbers of isolates are in parentheses): Russia (72), Greece (61), Philippines (54), Venezuela (29), and Kuwait, Nigeria, Romania, South Africa, and Thailand (20 to 25 isolates each). Thirty-two different MBL variants were detected (14 VIM, 14 IMP, and 4 NDM enzymes). Seven novel MBL variants were encountered in the study, each differing from a previously reported variant by one amino acid substitution: VIM-42 (VIM-1 [V223I]), VIM-43 (VIM-4 [A24V]), VIM-44 (VIM-2 [K257N]), VIM-45 (VIM-2 [T35I]), IMP-48 (IMP-14 [I69T]), IMP-49 (IMP-18 [V49F]), and NDM-16 (NDM-1 [R264H]). The in vitro activities of all tested antibiotics against MBL-positive Enterobacteriaceae were significantly reduced with the exception of that of aztreonam-avibactam (MIC90, 0.5 to 1 µg/ml), whereas colistin was the most effective agent against MBL-positive P. aeruginosa isolates (>97% susceptible). Although the global percentage of isolates encoding MBLs remains relatively low, their detection in 12 species, 34 countries, and all regions participating in this surveillance study is concerning.

Occurrence of perchlorate in indoor dust from the United States and eleven other countries: implications for human exposure.

Perchlorate is a widespread environmental contaminant and potent thyroid hormone disrupting compound. Despite this, very little is known with regard to the occurrence of this compound in indoor dust and the exposure of humans to perchlorate through dust ingestion. In this study, 366 indoor dust samples were collected from 12 countries, the USA, Colombia, Greece, Romania, Japan, Korea, Pakistan, Kuwait, Saudi Arabia, India, Vietnam, and China, during 2010-2014. Dust samples were extracted by 1% (v/v) methylamine in water. Analyte separation was achieved by an ion exchange (AS-21) column and analysis was performed by high performance liquid chromatography-tandem mass spectrometry (HPLC-MS/MS). The overall concentrations of perchlorate in dust were in the range of 0.02-104µg/g (geometric mean: 0.41µg/g). The indoor dust samples from China contained the highest concentrations (geometric mean: 5.38µg/g). No remarkable differences in perchlorate concentrations in dust were found among various microenvironments (i.e., car, home, office, and laboratory). The estimated median daily intake (EDI) of perchlorate for toddlers through dust ingestion in the USA, Colombia, Greece, Romania, Japan, Korea, Pakistan, Kuwait, Saudi Arabia, India, Vietnam, and China was 1.89, 0.37, 1.71, 0.74, 4.90, 7.20, 0.60, 0.80, 1.55, 0.70, 2.15, and 21.3ng/kgbodyweight (bw)/day, respectively. Although high concentrations of perchlorate were measured in some dust samples, the contribution of dust to total perchlorate intake was <5% of the total perchlorate intake in humans. This is the first multinational survey on the occurrence of perchlorate in indoor dust.

Distinguishing deficiencies in the steroidogenic acute regulatory protein and the cholesterol side chain cleavage enzyme causing neonatal adrenal failure.

OBJECTIVES: To determine the genetic basis of disordered steroidogenesis in Kuwaiti siblings. STUDY DESIGN: Two siblings (46,XX and 46,XY) had normal female external genitalia and severe glucocorticoid and mineralocorticoid deficiency presenting in the first month of life. Abdominal ultrasonography showed normal size adrenal glands, suggesting cholesterol side chain cleavage enzyme (P450scc) deficiency. The CYP11A1 gene encoding P450scc and the STAR gene encoding the steroidogenic acute regulatory protein (StAR) were directly sequenced from leukocyte DNA. RESULTS: All exons and intron/exon boundaries of the CYP11A1 gene were normal; the STAR gene was homozygous for a novel 14-base deletion/frameshift in exon 4 (g.4643_4656del), so that no functional protein could be produced. Both parents and an unaffected sibling were heterozygous; zygosity was confirmed with a BsmF1 restriction fragment length polymorphism. CONCLUSIONS: Unlike most patients with StAR deficiency, our patients did not have the massive adrenal hyperplasia typical of congenital lipoid adrenal hyperplasia. The distinction between StAR and P450scc deficiency may require gene sequencing.

Pegylated interferon alfa-2b plus ribavirin for the treatment of chronic hepatitis C genotype 4 in adolescents.

BACKGROUND: Hepatitis C is endemic in the Middle East where genotype 4 accounts for most cases. Data regarding the safety and efficacy of peginterferon plus ribavirin for the treatment of chronic hepatitis C in children and adolescents, particularly those infected with genotype 4 is limited. Aim. To evaluate the efficacy and tolerability of peginterferon alfa-2b in combination with ribavirin in adolescents chronically infected with HCV genotype 4. PATIENTS AND METHODS: In an open-labeled, uncontrolled pilot study, 12 adolescents (range14-17 years) were treated with subcutaneous peginterferon alfa-2b at a dose of 1.5 mg/kg body weight once per week plus oral ribavirin (15 mg/kg/day) for 48 weeks. Patients were followed for 24 weeks post-treatment. All patients had biopsy proven hepatitis without cirrhosis. RESULTS: One patient withdrew from the study due to developing insulin dependent diabetes mellitus 4 months into treatment. The remaining patients received at least 80% of the prescribed dose of pegylated interferon and ribavirin. Sustained viral response was observed in 9 patients (75%). The most frequent side effect was flu like illness which was reported in all patients. Sixty seven percent had leucopenia, but only one individual required adjuvant therapy with hematologic growth factor. Four patients had anemia requiring ribavirin dose reduction. One patient developed hypothyroidism. CONCLUSION: Combination treatment of peginterferon alfa-2b with ribavirin appears to be efficacious and relatively safe in adolescents with chronic hepatitis C genotype 4.B.

Frequencies of the -330 (T --> G) IL-2 and -590 (T --> C) IL-4 gene polymorphisms in a population from south-eastern Brazil.

Polymorphisms in the promoter regions of cytokine genes may affect their transcription. A T/G substitution at position -330 of the interleukin-2 (IL-2) gene and a T/C substitution at position -590 of the interleukin-4 (IL-4) gene have been described previously. The -590 (T --> C) IL-4 gene polymorphism was associated with asthma and atopy in US and Japanese populations. Population genetics is a useful tool for determination of the biological significance of genetic polymorphisms. The aim of this study was to investigate the frequencies of polymorphisms in the promoter regions of the IL-2 and IL-4 genes in a population from south-eastern Brazil and to compare them with those published for other populations. Allele frequencies were estimated in 114 unrelated individuals from São Paulo State. These subjects had an average age of 41.2 years (+/- 12.4 years) and the ethnic composition of the sample was: 78.07% Caucasian, 11.4% Black and 10.53% Mulatto. DNA from subjects was extracted from epithelial buccal cells, and the PCR-RFLP technique was employed to investigate the -330 (T --> G) IL-2 and -590 (T --> C) IL-4 gene polymorphisms. The allele frequency of the IL-2 gene polymorphism obtained in our study was similar to that found in UK Caucasoid groups. The T allele frequency of the IL-4 gene polymorphism observed in the Caucasian Brazilian group was similar to that found in UK and Australian populations, while the frequency observed for the Black Brazilian group was similar to that found in Japanese and Kuwaiti Arab populations. The results for the -330 (T --> G) IL-2 and -590 (T --> C) IL-4 polymorphisms are consistent with the high contribution of European lineages to the population in south-eastern Brazil.

Molecular characterization of strains of Human herpesvirus 8 from Japan, Argentina and Kuwait.

Current genotyping systems for Human herpesvirus 8 (HHV-8) are based on the highly variable gene encoding the K1 glycoprotein. Most strains collected worldwide cluster into two subtypes (I/A and II/C). Sequenced African strains have belonged to subtypes I/A and IV/B. Members of all three of these subtypes can have either the M or P allele at the right-hand side (RHS) of the genome. Strains obtained predominantly from aboriginal or relatively isolated populations have formed clades that branch at a distance from subtypes I/A and II/C, all being of the RHS P allele. The characterization is reported here of 16 Japanese, two Kuwaiti and five Argentine HHV-8 strains obtained from human immunodeficiency virus-infected and non-infected patients with Kaposi's sarcoma (KS), primary effusion lymphoma, multicentric Castleman's disease or renal transplants. K1 sequences of five Japanese, one Kuwaiti and two Argentine strains were identified as subtype I/A and eight Japanese, one Kuwaiti and three Argentine strains were subtype II/C. Three strains from elderly classic KS patients originally from Hokkaido, a northern Japanese island, were relatively closely related to strains of subtypes III/D and E. Consistent with previous observations, both the M and P alleles were identified at the RHS of subgroup I/A and II/C genomes; only the P allele was detected among the three Hokkaido strains. Distances among the Hokkaido strains were similar to the distance between subtypes I/A and II/C, suggesting that the Hokkaido strains may represent two distinct subtypes and that, as more strains are analysed, the currently recognized III/D subgroups will probably emerge as independent subtypes.

Studies on Cercariae from Kuwait Bay. XI. Description and surface topography of Cercaria kuwaitae XI sp.n. (Digenea: Echinostomatidae).

A new echinostome cercaria, Cercaria kuwaitae XI sp.n., from the prosobranch gastropod Cerithidea cingulata (Gmelin) from Kuwait Bay is described. The new cercaria is characterized by 23 collar spines and primary excretory tubules with distinct diverticula. The cercaria encysts in the snail host and is similar to those of Acanthoparyphium sp. The surface topography of the redia, cercaria and metacercarial cyst wall is studied by scanning electron microscopy. This is the first echinostome cercaria to be recorded in a gastropod from the Arabian Gulf region.

Introduction of Hib conjugate vaccines in the non-industrialized world: experience in four 'newly adopting' countries.

Hib conjugate vaccines are widely used in the industrialized world, but are just now beginning to be introduced into other countries. To identify factors facilitating rapid global introduction, we evaluated the decision-making process, mode of introduction, effectiveness, and impact on the immunization program of Hib conjugate vaccine introduction in four non- industrialized countries through site visits and use of a standardized questionnaire. The key promoters of Hib introduction were the pediatric community and ministries of health. Local surveillance and severity data were critical in the decision to adopt Hib vaccine. Assistance with surveillance, introduction guidelines, educational material, tenders, and funding is needed to accelerate wider adoption.