Homo antecessor from TD6-2. In case of the MIR4 assemblage, the results are similar except in the treatment of skulls. Our results indicate that high frequencies of anthropogenic modifications are common after an intensive butchering process intended to prepare a hominin body for consumption in different contexts .Two archaeological assemblages from the Sierra de Atapuerca sites show evidence of anthropogenic cannibalism. These are the late Early Pleistocene level TD6-2 at Gran Dolina, and the Bronze Age level MIR4 in the Mirador Cave. Despite the chronological distance between these two assemblages, they share the common feature that the human remains exhibit a high frequency of anthropogenic modifications . This frequency could denote special treatment of bodies, or else be the normal result of the butchering process. In order to test these possibilities, we subjected a chimpanzee carcass to a butchering process. The processing was intensive and intended to simulate preparation for consumption. In doing this, we used several simple flakes made from quartzite and chert from quarries in the Sierra de Atapuerca. The skull, long bones, metapodials and phalanges were also fractured in order to remove the brain and bone marrow. As a result, about 40% of the remains showed some kind of human modification. The frequency, distribution and characteristics of these modifications are very similar to those documented on the remains of  Among the archaeological deposits in the Sierra de Atapuerca , two assemblages show evidence of cannibalism. These are the late Early Pleistocene level TD6–2 of Gran Dolina and the Bronze Age level MIR4 in Mirador Cave. Remains of hominins/humans (hereafter referred to as human remains) were recovered with obvious evidence of butchering and consumption –6. All oThe cut marks, along with the anthropogenic bone breakage, can provide a remarkable amount of paleo-economic information about prehistoric human groups. Since the 1980s, a great deal of research has focused on the macroscopic and microscopic morphology of cut marks –14 and tIn this line of research, several proposals have been put forth as to the different variables that may influence the frequency of cut marks. Binford  suggesteEgeland  used an Dewbury and Russell  concludeFinally, Domínguez-Rodrigo and Yravedra  proposedIn this context, our goal is to create an experimental framework that would allow us to describe the butchery activities performed on the cannibalized human corpses recovered from level TD6–2 of Gran Dolina and level MIR-4 of the Mirador Cave. We have developed this research starting from an uniformitarian assumption. The specific objective of this experimental work is to provide actualistic observations for the interpretation of the frequency of cut marks on human remains. It is difficult to perform these experiments with human bodies. For this reason when the opportunity arose we decided that the processing of the carcass of a chimp could be helpful to our goal. We have created this actualistic framework through carrying out the butchering process (bone breakage included) on the carcass of a chimpanzee. We must point out that although there are similarities between chimpanzees and humans, we are also aware that there are considerable differences. The most important of these differences is that humans are bipedal while chimpanzees are terrestrial quadrupeds that support their forelimbs on their knuckles and not on the palms of their hands or paws like other quadrupeds. However, they can stand up and walk on their legs  when circumstances require freeing up their hands for use. This characteristic makes the anatomy of these primates closer to hominins than that of any fully quadruped mammals, despite the clear differences in the proportions of the segments of the body.The Atapuerca complex  contains several archaeological and palaeontological sites dating from the Early Pleistocene to the Holocene –34 EvideH.antecessor remains were recovered [The oldest evidence of the practice of cannibalism among hominins was found in level TD6–2 at the Gran Dolina site . Several stratigraphic studies have established that level TD6 dates to the late Early Pleistocene –39. H.anecovered , along wecovered ,41.The hominin remains exhibit several anthropogenic modifications on their surfaces which indicate that they had been processed and consumed by other hominins ,5H. antecessor sample was found to contain 181 remains (155 bones and 26 teeth) from 11 individuals (MNI). Cut marks are present on all types of bones . All the remains had been deposited in a small (40 x 25 x 10 cm) oval pit [Mirador Cave is located on the southern slope of the Sierra de Atapuerca. In level MIR 4, a 6 moval pit . CharcoaThe skeletal remains of six individuals, consisting of a total of 165 specimens (148 bones and 17 isolated teeth) were recovered from MIR4A [H. sapiens and ovicaprini remains from MIR4A and MIR4. This emphasizes the high degree to which anthropogenic modifications are present, as they were found on over 60% of the hominin assemblage. Ovicaprini remains exhibit anthropogenic modifications on fewer than 30% of the assemblage.The body of the chimpanzee was made available to the IPHES team by the Fundació Mona primate recovery center . The Fundació Mona is a nonprofit organization  whose aim is to ensure the welfare of confiscated primates that have been detected in illegal or abuse situations. The foundation has a recovery center close to the city of Girona which is used as a home for rescued primates in order to rehabilitate and protect them. The foundation also has a research unit with an interdisciplinary team of psychologists, biologists, veterinarians and anthropologists. The chimpanzee died under veterinarian care at the Fundació Mona from natural causes at 57 years old. We will not offer images of the process described here out of respect to animal, its caregivers and the center’s generous sponsor.The chimpanzee had lost most of its dentition and had osteoarthritis in most of its bone articulations, related to its advanced age.Butchering process was recorded by photographing it and taking notes. In addition, following the advice of Nilssenthe entirFor skinning, defleshing and disarticulation, we used simple chert and quartzite flakes. From the Lower Pleistocene to the Holocene , chert aWe have make an ANOVA test to evaluate possible differences in the frequency or the locations of the cut marks produced by the two main butchers involved in processing the chimpanzee carcass. The analytical variables used were: NISP of remains with cut marks on: Clavicles; Os Coxae; Scapulae; Humeri; Radii; Ulnae; Femurs; Tibiae; Fibulae; NISP Total; Maximum number of cut marks on one specimen; Maximum number of cut marks on one element; Total number of cut-marks; NISP of shafts with cut marks; NISP of epiphyses with cut marks.In the laboratory, bones were boiled to make it easier to remove the meat scraps, tendons and fat. The bones were then dried in the shade. A total of 314 bone specimens were collected. There were also 140 unidentifiable fragments less than 2 cm long that were recorded but not included in the analysis.The entire surface of every bone was examined, both macroscopically and microscopically (OPTHEC 120HZ), and for each anthropogenic modification  the location, segment, portion and face were noted.We recognized three types of cut marks: slicing, scraping and chop marks ,47. SlicThe analysis of cut marks took into account the number of individual striae, location on the skeletal element, distribution over the surface  and orientation in relation to the longitudinal axis of the bone . Maximum length of the cut marks was measured in millimeters.Cervus/Dama) remains from level TD6–2 and those for the human and Ovis/Capra remainsfrom level MIR4.We also recorded the presence/absence and location of percussion pits, impact points, adhered flakes on the surface, conchoidal scars, hammerstone/anvil abrasions and peeling on each item studied –51. PeelThe butchering process of the chimpanzee carcass consisted of making the fullest possible use of the animal by skinning, dismembering, defleshing, disarticulating it and bone breakage to extract the marrow. In this paper, the intensive butchering process is understood to mean removing the maximum amount of soft tissue suitable for consumption. We did not remove the viscera of the chimpanzee because it had undergone a necropsy, so the thoracic cavity had been opened and visceral content had been clinically removed.The process began with longitudinal slices from the parietals to frontal and orbital area. It then continued with oblique movements from parietal to occipital and, after that, towards the temporal bone in order to remove the right ear. The next step was to extract the lower lip, working below the chin and neck toward the left side of the mandible, removing the upper lip and finishing by extracting the left ear. Removing the skin from the trunk and limbs was easier because it required fewer slices with the tools. Longitudinal cuts were made along the inner side of the limbs, from the chest to the wrist for the arms, and from the abdomen to the ankle for the legs. The process was completed by removing the skin from the back and pelvis . During The dismembering process consisted of several stages . First, The carcass was defleshed, whenever possible, along the lines of the muscular membranes, separating each of the muscles individually. However, they were sometimes too large or were difficult to differentiate, and in these cases they were cut into portions. The muscles were completely removed from the limbs, trunk and skull, and efforts were made to leave no flesh attached to the bones.The defleshing of the head began by removing flesh of the face, then of the temporal and occipital bones, and the jaw. The lower extremities were defleshed. Longitudinal cuts on the femurs made it possible to open up the muscle and reach the bone. Transverse and oblique movements were required to remove the muscle. The same process was used on the tibiae and fibulae. Defleshing of the arms began by removing meat from the scapulae with cuts on both the ventral and dorsal faces. On the humeri, longitudinal cuts were made to reach the bone shaft and continued with oblique and transverse cuts. This technique was used on the radii and ulnae, as well. The trunk was defleshed by first removing the flesh from the back and then removing the intercostal meat.Defleshing involves contact between the tool and the bones, especially in areas where there is less muscle mass, such as the skull. On the long bones, contact usually took place near the epiphysis and midshaft portions of the long bones.Disarticulation was performed after the main segments had been defleshed, except for the hands and feet. These were processed by first separating the fingers or toes and subsequently defleshing the hand or foot . Once thOnce the process of soft tissue removal was completed, we proceeded to break the skull, mandible, ribs, long bones, phalanges and metapodials. The technique used for the cranial and appendicular bones was percussion using quartzite hammers and three limestone anvils. One anvil had a flat surface and the other two had angular surfaces; when the flat anvil was used, the bones were placed on the edges. The bones were passive objects in this process, except for the skull for which the passive and active roles were combined; the active movement of the skull proved a more effective breaking technique. The metapodials and phalanges were hit on the shaft to break them and to access the marrow. The ribs were broken by simply bending them, as discussed above (section 3.2). A total of 314 specimens from the chimpanzee skeleton were analyzed . BetweenOf the cut marks, slicing marks were the most abundant . These wOn the skull , the marks are related to skinning, defleshing and disarticulation. Most of the slicing marks associated with the skinning process were longitudinal (the longest of these measured 20 mm in length) and were located on the parietal, orbital, temporal and frontal parts of the skull. The sternocleidomastoid muscle was cut in order to remove the ears during skinning. There were some oblique, transversal and longitudinal cuts on the bone which were located on the parietal, frontal and zygomatic bones. These cuts are associated with the removal of the epicranius, temporalis, masseter and orbicularis oculi muscles and caused by the disarticulation and defleshing of the cranium .1 zone) and are related to cutting the masseter and depressor anguli oris muscles , exhibited transverse or oblique cut marks. The cuts were located on the vestibular side of the mandibular notch and on the mandibular body , cut marks were documented on cervical and thoracic vertebrae. The atlas exhibited transversal slicing marks on the lamina of the arch and on the transverse process and right pedicle, which were caused by cutting the levator scapulae tensor. These cut marks and the broken left pedicle are due to the disarticulation in which the chimpanzee’s head was separated from the trunk . The 5thOn the clavicles  the cut marks were clustered, and transversal and oblique . They weCut marks on the ribs  were mostly clustered and transversal and oblique . Scrape Cuts marks on the coxae  were clustered, transversal and oblique. They were located on the lateral and medial sides and on the ischium portion. These marks appeared at the insertions of the quadratus femori and gluteus maximum muscles, indicating that the slicing marks were generated during defleshing.On the scapulae , cut marks were mostly clustered , and ranCut marks on the humeri  were clustered, transversal and oblique . The sliThe radii  exhibited clustered, isolated and located cut marks on the ainterosseous cresta, radial tuberosity and posterior side. Cuts were generated during the removal of the flexor digitorum superficialis and biceps brachii muscles and supinator and pronator tendons, and the slicing marks were caused during defleshing .Cut marks on the ulnae  were clustered and oblique and located on the shaft and all sides of the bones. Most of the cuts were slicing marks, although there were scrape marks on the medial side of the right and left ulnae. Cuts located were made during the removal of flexor digitorum profundus, extensor pollicis longus and flexor carpi ulnaris muscles .The femurs  bore clustered, transversal and oblique cut marks located along the length of the bones and on all sides of the bones . On proxCut marks on the tibiae  were clustered, transversal and oblique. On the proximal epiphysis and shaft, the cut marks are located where the popliteus tendon, extensor tibial anterior, soleus and plantaris muscles attach. Slicing marks were visible on the distal epiphyses (the fibular notch) and distal shaft; these were caused by cutting the extensor hallucis longus muscle and the Achilles tendon, and are associated with defleshing and disarticulation .The fibulae  shows cut marks that were clustered, transversal and oblique . On the All of the long bones were broken , resultiCut marks were located on six metapodials, two metacarpals and four metatarsals .On the metacarpals , clustered and isolated, transversal and oblique cut marks were found on the 2nd and 5th metacarpals . On the On the metatarsals  the cuts were clustered and oblique . They weOn the carpals , only the right pisiform bone exhibited transversal slicing marks along the length of the bone and on the anterior and posterior sides . These cAmong the tarsals , only the chimpanzee’s left calcaneus shows cut marks. The cuts were clustered and transversal. Slicing marks were located on the calcaneal tuberosity and related to cutting the Achilles tendon.There were nine cut marks on the phalanges  , five ofTwo phalanges and a 4th metatarsal had percussion pits and hammerstone/anvil abrasions, two of which were impact flakes . These mThe butchering process is a set of exclusively anthropogenic activities for the purpose of obtaining nutrients and other products derived from animal carcasses. The butchering process begins with accessing the carcass of an animal, and ends with discarding the unused or exhausted remains . The priHowever, many of these assemblages share a common feature in that a high frequency of human remains displays anthropogenic modifications. Between 40 and 60% of the human remains found at El Mirador, Fontbrégoua (France), Gough’s Cave (Great Britain), Moula Guercy (France) and TD6–2 show anthropogenic modifications. Even for the ungulate remains in these assemblages, anthropogenic modifications have been documented on 20% of the specimens ,9,55,56.These two assemblages do, however, share the high frequency of anthropogenic modifications to the remains recovered, especially cut marks, but also bone breakage. Of the human remains from TD6–2, 44.5% exhibit some anthropogenic modification, whereas 29.7% of the medium size Cervidae remains show signs of a butchering process. In Mirador Cave, 60.1% of the human remains show signals of butchering [In our experiment, the chimpanzee was skinned, defleshed and dismembered, and finally its bones were fractured to simulate a model of making intensive use of all the tissues. The viscera had already been removed, so this part of the process could not be taken into account. The result was that 42.7% of the recovered remains exhibited some kind of human modification. This is close to that observed on the remains found at archaeological sites where cannibalism occurred, and especially close to for the remains from level TD6–2.In the experimental sample we considered fragments that in an archaeological assemblage could hardly be identified anatomically beyond the more general classifications (long and flat bones) and could not have been assigned to a specific taxonomic group with reasonable certainty. For this reason, we separated out those remains which, in our experience, could not have been identified in an archeological assemblage because of the lack of landmarks . Removing these pieces from the sample changes the percentage of anthropogenically modified bones only slightly (to 44.2%). Therefore, our experimental results do not seem to be affected by the degree to which the remains can be identified.H. antecessor have been documented. In addition, the conservation of some human elements such as vertebrae and ribs, which are likely to disappear in assemblages affected by carnivores, is higher than in the case of other animals, mainly the ungulates [Any comparison must also take into consideration the fact that the taphonomic history of archaeological remains is more complex, and all of the possible effects of post-depositional modifications cannot be controlled. These include increased fracturing of the remains by diagenesis during the fossilization process. Neither the archaeological assemblage of TD6–2 or the more modern case of Mirador Cave appear to have been significantly affected by taphonomic processes after human activity. In TD6–2, dry fractures affected only 2% of the specimens. The most common post-depositional modification is manganese oxide staining, but this does not affect the bone structure, and so does not affect the degree of anatomical and taxonomic identification or the morphology of the anthropogenic signatures (cut marks or fractures). No signs of carnivore consumption on the remains of ngulates ,62. ThisThe post-cannibalistic taphonomic history of the human remains from Mirador Cave has been affected by the activity of the individuals who deposited the bones in the pit, but did not participate in the consumption . HoweverMuch research in the past ten years has aimed to establish the origin of the different frequencies of cut marks found in archaeological assemblages –25,27,28In the case of archaeological sites, however, it is difficult to assess the number of butchers or their ability. This difficulty is partly due to the fact that the analysis of archaeological assemblages often reveals palimpsests that point to different events occurring during the same or different occupations and involving the same or different individuals, thereby rendering it impossible to objectively evaluate the number of butchers or their experience.An analysis of the distribution of the modifications to the chimpanzee’s bones revealed that the most of cut marks were located on the muscle attachments and, primarily, on the skeletal segments and elements with the largest muscles or sets of muscles.H. antecessor from TD6–2 and H. sapiens from MIR4 showed cut marks in similar locations [The elements with the highest number of marks were the scapulae, humeri, vertebrae and ribs; on the latter there were cut marks associated with removing the flesh from the animal’s back. Regarding the high number of cut marks on the ribs, we must take into account that no marks were caused by evisceration—a process including evisceration would yield an even higher number of marks on the ribs. The remains of ocations ,4,5 whicocations , althougSkinning has been documented in all three cases on the bones of the skull. However, in this respect there are considerable differences in the calvariae recovered MIR4. The six documented skulls show a pattern of very definite modifications . These mH. antecessor and H. sapiens may be that the bodies were treated differently from how animals were treated. However, the remains of the animals identified in both assemblages were processed in the same way in TD6–2 and MIR-4, except that, at Mirador Cave the human remains were cooked and burned. These similarities extend to our results from processing the chimpanzee. The only notable differences between the human and ungulate samples are related to the skinning of the carcasses. On the ungulates remains, these signs are more common on phalanges or metapodials than on skulls, suggesting that we cannot assume differential treatment. Furthermore, both sets of ungulates underwent the full butchering process, including the removal of the viscera, so these animals’ tissues were also intensively used in both assemblages.One explanation for the high frequency of cut marks on H. antecessor and the cervids from TD6–2, and H. sapiens and the ovicaprini from MIR 4. The most discriminating variable is found on Axis 1 , which separates the human and chimpanzee specimens (to the left of the axis) from the ungulates, which are at the right margin of the graph. This separation seems to be related to the higher number of modified axial specimens in the hominin remains. Of the two types of hominin remains studied, a stronger relationship was found between the cut marks on the chimpanzee remains and those on the H. antecessor remains. The H. sapiens results are clearly influenced by the number of cranial remains with anthropogenic modifications . Clustering in the cases of the cervids and ovicaprini is marked by the presence of cut marks on limb bones and their reduced presence on the vertebrae and ribs.The question is, therefore, what causes the differences in the frequencies of cut marks? To try to resolve this issue, a correspondence analysis  was perfH. antecessor remains is the presence of ribs, vertebrae and phalanges, defined by Marean and Clerghorn (2003) as low survival elements as they are not typically well preserved in archaeological sites.This result seems to be related to the frequency of cut marks and the anatomical distribution in the four taxa. Obviously, we had all of the chimpanzee skeletal elements. One of the features that characterize the set of The human remains from Mirador Cave mainly consist of calvariae and intensely processed skull fragments. These may have been used for purposes other than providing food, or for purposes in addition to providing food. Processed long bones are present are present in both assemblages. Ungulates from both assemblages are well represented by fragments of shafts of long bones; ribs and vertebrae are also present, but in low numbers, and skull fragments are poorly represented.These anatomical profiles are also visible in other assemblages in which the frequency of cut marks on the hominin remains is higher than for ungulates. In the sample from Moula Guercy (France), over 50% of the Neanderthal remains exhibit cut marks, while cut marks are found on only 22% of the deer specimens ,9. In thAnother similar case is the Magdalenian assemblage from Brillenhöhle (southwestern Germany) in which 64% of the human remains exhibit cut marks. Orschiedt  interpreThe case of Mirador Cave is slightly different because of the secondary burial of the human bones, although the modifications are clearly related to processing for consumption, regardless of whether or not there was a ritual treatment. However, the selection of these remains for burial is what made the intensively processed skulls stand out. The frequency of cut marks documented on the chimpanzee bones may be affected by the fact that we have the entire skeleton, including low survival bones, which typically show many cut marks.The remains from TD6–2 and MIR4 show evidence of specific taphonomic histories that provide insight into the episodes of cannibalism that occurred at the sites, and explain the differences between the skeletal profiles recovered in the two assemblages. At Mirador Cave, most of the human remains were found in a pit in which the remains of other animals were completely absent ,5. The rH. antecessor and ungulate samples lies in the fact that while the latter were clearly modified by carnivores, no hominin remains affected by scavenging carnivores have been documented (or the evidence of this is so slight as to be invisible) [H. antecessor were not affected by secondary consumption by carnivores led to the conservation of low survival elements, mainly ribs and vertebrae, the latter of which exhibit numerous cut marks and abundant bone breakage. These data are consistent with the observations made by Domínguez-Rodrigo and Yravedra [In TD6–2, the main difference between the visible) . This havisible) . The facYravedra , who staThis study compares the products of three different processes from different contexts  and three different skeletal samples . However, in all three cases the frequency of anthropogenic modifications is high.This diversity indicates that it is not only the skeletal profile that determines the frequency of anthropogenic damage, although it definitely plays an important role. The fact that these assemblages have not been ravaged by carnivores is also an important consideration. Furthermore, our results may be affected by the differences between chimpanzee and hominin anatomy. It is clear that the higher or lower frequency of anthropogenic modifications must be judged in each particular context, as suggested by Lyman. There m


Anna Lena Lopez and colleagues give an overview of the cholera situation in Vietnam and discuss how an oral cholera vaccine was developed and used as a component of a public health strategy against the disease.Please see later in the article for the Editors' Summary Vietnam is the first and only country in the world to regularly use oral cholera vaccines (OCVs) in their cholera control program.From 1998 to 2012, more than 10.9 million doses of the locally produced OCV were deployed in the country through its public health system.We present an overview of cholera epidemiology in Vietnam and the development and deployment of the OCV.Since 1997, the number of cholera cases in Vietnam has declined, in association with increased OCV use as well as improvements in socioeconomic and water and sanitation conditions. It is not possible to establish the relative contributions of each of these to the reduction in cholera rates.Hue, the only province to use OCVs consistently every year, has not reported any cholera case since 2003.As WHO organizes a stockpile of OCV for use in emergencies and recommends the use of OCVs together with traditional means of control, the experience in Vietnam will be helpful to other at-risk countries as they look towards adopting the vaccine in their cholera control programs.Vibrio cholerae. As cholera continues to be a global public health problem, in 2011, the World Health Assembly called for an integrated and comprehensive approach to cholera control, including oral cholera vaccines (OCVs) The emergence of cholera in Haiti highlighted the difficulties in containing cholera outbreaks with only safe water, sanitation, hygiene, and appropriate case management. In less developed settings where cholera occurs, these basic needs are often not met or are rapidly overwhelmed during man-made or natural disasters. Prior to the Haitian outbreak, countries in Africa and Asia had borne most of the cholera burden, with an estimated 1.4 billion people at risk, 2.8 million cases, and 100,000 to 200,000 deaths occurring annually OCVs have been available for more than 20 years, but public health use has been limited. Vietnam is the first and currently the only country in the world to use killed OCVs routinely in its public health program. This article describes the cholera problem in Vietnam and how an oral cholera vaccine was developed and used as a component of a public health strategy against the disease.V. cholerae O1 El Tor was first identified in the country. Vietnam uses the term “severe watery diarrhoea” for culture-confirmed cases of cholera or clinically diagnosed cholera during an outbreak. Reports of cholera are forwarded to and collated by the Epidemiology Unit of the National Institute of Hygiene and Epidemiology (NIHE) under the Ministry of Health . In a review of cholera epidemiology in Vietnam from 1991 to 2001 by Kelly-Hope et al., the average annual incidence for the whole country was 2.7 cases per 100,000 people From 1992 to 1995, 2,500 to 6,000 cases were reported annually In October 2007, an increase in the number of cases was seen in Hanoi, subsequently affecting nearby provinces in the North. 1,907 and 886 cases were reported in 2007 and 2008, respectively. This outbreak in Hanoi was unusual because of the large number of cases that lasted through the winter season. Between 1998 and 2012, case numbers varied between 0 and 1,907 per annum, with an estimated annual incidence of 0 to 2.24 cases per 100,000 people (median 0.03 and mean 0.28) . The majThe history of the development of oral cholera vaccine in Vietnam is shown in On 19 August 1997, the Vietnamese government issued a directive including OCVs in the National Expanded Programme on Immunization (EPI) schedule in areas at risk for cholera. In the EPI schedule, two doses of OCV are to be provided two weeks apart to children two to five years of age; however, local health policy makers may decide on the age groups included for vaccination depending on the local epidemiology, the number of vaccine doses available, and the capability of local government to support the vaccination.From 1998 to 2012, more than 10.9 million doses of OCV were deployed in 16 provinces and major cities through Vietnam's EPI. Of these doses, 78% were procured from 1998 to 2006  and wereIn most provinces, vaccination targeted children aged two to five years. However, in Hue, all non-pregnant residents of communes aged two years and older were vaccinated every three to five years After Hue, Ca Mau province deployed the second highest number of vaccine doses, mostly in 2000–2001 and 2003–2006. In most years, Ca Mau provided vaccines to children aged two to five years. However, in 2001, 234 children at a primary school (aged five to 12 years old) in Ca Mau City received OCVs when the local health authorities determined that these children were at risk for cholera Quang Tri province, located just north of Hue near the Laotian border, immunized children aged two to five years from 2000 to 2007 (except in 2003) in communes perceived to be at risk. Cholera was reported in 1999 and 2000, then again in 2003. Because of its proximity to the border, OCVs were deployed when cases were reported in nearby Laos. Outbreaks of cholera were reported in Laos in 1994 to 1996 and then again in 1998 to 2002 From 1998–2005, OCVs were deployed in select communes in An Giang province in the South for five years, where cholera was reported in five of the seven years. Cholera reappeared in An Giang in 2010, after five years of absence from 2005–2009, and OCVs were again deployed in 2011.Cholera vaccines were used in areas with the highest number of cholera cases . Apart fIn the EPI, the decision to vaccinate a specific district is made at the provincial Centre for Preventive Medicine (CPM). Once cholera cases are detected in a district, the provincial CPM deliberates whether or not to vaccinate against cholera and to identify the age groups to be vaccinated. This decision has to be approved by the local provincial government, who finances the deployment of cholera vaccines at the local level.Although provinces may request their preferred number of doses of OCV, procurement of vaccines is limited by the amount allocated for EPI vaccines in the national budget. If the number of OCV doses allocated to the province is less than the amount the province requested, then provinces may request additional doses for deployment the following year.While the National EPI pays for the purchase and shipping of OCVs, the provincial CPM is responsible for planning and implementing the vaccine deployment. Since 1998, OCVs are provided just prior to the expected cholera season, and in Hue the cholera season is during the months of May to November. Vaccines are delivered to the provincial CPM, then transported and stored at the district Health Centre. On the day of the campaign, vaccines are brought in cold boxes to commune health stations where vaccinations are conducted.Vaccinations are arranged similarly to other mass campaigns. The vaccine is administered in commune health centres (CHC), where routine EPI vaccines are also given. Community mobilization consists of commune health workers going to households and informing them of the dates of vaccination and the need for two doses to ensure protection. During vaccination days, CHCs are open from 8A.M. to 5P.M., and campaigns usually last for two days, with one day being on a Saturday or a Sunday in order to allow for participation of those who work during the weekdays. Vaccination cards are provided to individuals who are vaccinated and logbooks containing the names of vaccine recipients are maintained. Those who were vaccinated are advised to return for the second round, scheduled two weeks later. Commune health workers provide reminders prior to the second round to ensure compliance with the schedule. If families are unable to go to the CHCs, commune health workers visit the residence to provide vaccines.V. cholerae O1 Inaba were identified, children attending two primary schools located near waterways were vaccinated Reactive campaigns with OCVs are conducted once a cholera outbreak has already begun. Reactive vaccinations were conducted in Ca Mau city in 2001, in Hai Phong and Kien Giang in 2003, and in Hanoi in 2008. In Ca Mau, after three cases of More recently, during the Hanoi outbreak in 2007–2008, the Ministry of Health directly purchased OCVs and, together with NIHE, implemented a mass vaccination campaign in two affected districts located near waterways where residents were assessed to have poor access to clean water, hygiene, and sanitation. The campaign included only individuals older than ten years (who were not pregnant) because the majority of the cases in Hanoi were in people aged ten years and older First and second dose recipients, vaccine coverage and wastage are reported to the National EPI. Although an incident of mass psychogenic illness among primary school children occurred in Ca Mau City in 2001 In 1998, costs for the first cholera vaccination in Hue City were calculated at US$0.89 per fully vaccinated person, and 79% of this amount was spent on vaccines V. cholerae since 2005 . A factor influencing this decision to use OCVs in Hue was the burgeoning tourism sector; the local government of Hue understood that cholera outbreaks would hinder tourists from visiting their province and felt that continued use of OCVs, along with improvements in water and sanitation, was important to their cholera control effort.Vietnam has now delivered over 10 million doses of vaccine, and OCV use has been associated with a substantial decline in cholera in this country. Hue, a province that has used OCVs annually since 1998, has not reported any cholera cases since the last outbreak in 2003. Furthermore, quarterly environmental sampling of the water from the Perfume River running through Hue City has consistently been negative for While the absence of cholera may have been affected by economic progress and improvements in water and sanitation facilities in Hue, access to clean water and sanitation in the province has not been uniform. In 2009, a survey revealed that only 37% of the surveyed individuals in Hue had access to a centralized water system, lower than the reported 52%. Furthermore, this supply was intermittent through the day, especially during times of drought The impact of OCVs is harder to assess in other provinces because of the variability in implementation. There was a precipitous decline in the number of cholera cases in 1997, even prior to extensive usage of OCVs. The initial decline may have been due to the cyclical nature of the disease. However, this decline was sustained, and apart from the outbreaks in Hanoi and the northern provinces in 2007, there were never more than 1,000 reported cases nationwide, annually. Furthermore, if the province followed the recommended age for oral cholera vaccination, which is two to five years old, the number of doses deployed would be lower. Recent studies have shown that OCVs confer herd protection provided that high enough coverage is achieved. In Kolkata, coverage of at least 28% resulted in indirect protection. If only two- to five-year-olds were vaccinated, indirect protection would have been less likely. In contrast, in Hue, where OCVs are given to all non-pregnant individuals older than one year, indirect protection of the unvaccinated segment of the population may explain the continued absence of cholera despite the phased vaccination that the province implements.This assessment shows a temporal association between the sustained decline in cholera incidence and increased use of OCVs. It does not aim, nor is it able to show an overall causal relationship between OCV use and the general decline in cholera cases. Cholera control in the country may have been enhanced by factors other than vaccination, including implementation of public health control measures and improvement of water and sanitation infrastructure, as well as general economic development. Instead, the experience in Vietnam shows how OCVs have been used as an immediate measure against cholera while appropriate infrastructure is built, and how they have been included as part of an integrated strategy to control cholera.Vietnam uses a “bottom-up” approach in determining use of OCV. The provincial CPM determines how many doses are to be requested and how to deploy them. Depending on the national budget and the availability of vaccine, vaccine is provided to the provinces. The vaccine is then provided without cost to the province, but the province must pay for the cost of its distribution and administration. This method facilitates local decision making and places additional responsibility on the local authorities to evaluate their needs and to cover the programmatic costs for vaccination. This approach assumes that local authorities have information on how best to determine if they need vaccine and how to allocate it within the province.A factor that may have affected the non-deployment of OCVs, especially during the 2007–2008 outbreaks, may be the expenditures that provinces have to bear in mounting vaccination campaigns. In Hue, the incremental costs for mounting the campaign may not be substantial; however, in places that do not routinely conduct mass cholera vaccination, the costs may be higher. Since cholera cases will more likely affect these less developed areas, allocations to support program costs for OCV campaigns may be needed to prevent cholera in these high-risk areas since improvements in water and sanitation will take time.OCV continues to be used in Vietnam; however, budgetary constraints have resulted in fewer doses being procured by the government, due to the perception of a lower threat from cholera as well as other competing priorities. As vaccines for other diseases are being recommended, governments will prioritize which vaccines to implement. With the need to prioritize, cholera surveillance becomes increasingly important to understand when and where to implement future OCV campaigns.V. cholerae O1 isolates obtained during the cholera outbreaks in Thailand in January to October 2007 and in Laos in December 2007 Though endemic cholera has declined in Vietnam, cholera may also spread from other countries. The last large cholera outbreak in Hanoi and other northern provinces lasted for 20 months, affecting more than 1,500 individuals in 22 cities and provinces of northern Vietnam. Patient isolates from this outbreak were similar to As the cholera incidence in Vietnam decreases, the most affected age groups will change. Adults and older children will increasingly bear the brunt of the disease. Indeed, in the 2007–2009 outbreak in northern Vietnam, among 8,064 cases only 4.6% of cholera cases were reported among children aged more than five years. Intensified disease surveillance should be conducted to monitor these epidemiologic changes to guide the government in future policies as regards OCV use. Furthermore, as the economy of Vietnam improves, initiatives toward cholera elimination may be considered.Since Vietnam is the only country that has used OCVs extensively as part of an overall national strategy to control cholera, the experience with this vaccine in Vietnam may be useful for other areas now considering its use. The revised recommendations of the WHO encouraging the use of OCV in endemic areas and the decision by Global Alliance for Vaccines and Immunization (GAVI) to help support the use of OCVs should lead to increased use of the vaccine. In July 2013, a global cholera vaccine stockpile was developed as an additional tool for cholera control. The vaccine currently included in the stockpile is Shanchol, an OCV very similar to mORC-Vax. Shanchol was shown to be effective This experience of Vietnam in deploying a two-dose oral cholera vaccine for more than 15 years indicates that the vaccine can be feasibly used in public health settings. Some of the lessons from Vietnam may prove to be useful in other countries where cholera remains a problem. The availability of a vaccine that may be used, even during an outbreak as part of an integrated strategy provides hope in countries that continue to battle the scourge of this disease.Table S1Immunization schedule in Vietnam's expanded programme on immunization.(DOCX)Click here for additional data file.Table S2Changes in formulation of the Vietnamese oral cholera vaccine.(DOCX)Click here for additional data file.Text S1Background information and data sources.(DOCX)Click here for additional data file.


There is an urgent need to address the massive treatment gap for mental health problems, especially in low income settings. Packages of care integrated in routine primary health care are posited as a strategy to scale-up mental health care, yet more needs to be known about the most feasible and effective way to go about this.The study follows a combined methods design that includes engaging an expert panel in a priority setting exercise, running workshops to develop a Theory of Change and conducting in-depth qualitative interviews and focus group discussions with key stakeholders. The results of each research step were taken forward to inform the subsequent one.There was strong endorsement for a system of care that encompasses both the perspectives of health facility and the community. Issues related to increasing access and demand, guaranteeing a sustainable supply of psychotropic medicine, adequate human resourcing, and ensuring positive family involvement came up as priority areas of attention.The study underlines many of the known barriers in developing mental health services. At the same time it provides a distinct pathway and concrete recommendations for overcoming these challenges in Nepal. Mental health needs of people in low and middle income countries are largely unmet, with only a small fraction of those affected receiving adequate treatment ,2. The aMultiple studies have demonstrated that interventions provided by trained non-specialists (i.e. task shifting) in low income settings can be effective in achieving significant treatment gain -7. HowevThe goal of developing population-wide mental health services in LMIC is not new. Previous programs have shown that practice-oriented mental health trainings for general health workers led to substantially increased uptake of mental health care services in Afghanistan ; while tThe PRogramme for Improvement of Mental health carE (PRIME), a research consortium working in India, Uganda, Ethiopia, South Africa and Nepal, aims to evaluate the feasibility, acceptability and impact of a multi-faceted mental health care approach that targets the health facility, community and health service organization . Each siWhile the development of a scalable model of mental health care is challenging in any LMIC, in fragile states or complex humanitarian emergencies this is particularly the case due to the increased risk of mental health problems ,19, and The research was conducted in Chitwan, a district in southern Nepal. Nepal is a low income country, one of the poorest countries in Asia and is categorized by the World Bank as a fragile state . The couThe study consisted of three stages, each with a separate methodology. First, a priority setting exercise was conducted among an expert panel of mental health experts in Nepal to determine the most urgent mental health problems to target in the future mental health care plan. An initial list of senior mental health professionals (n = 21) was drafted. Inclusion was based on known track record  and held positions . All approached participants were asked to name other experts to be added (n = 9). The final group of experts was invited to participate in the study of whom 26 participated (86.6% response rate), including psychiatrists (58%), psychologists (31%), psychosocial counselors (8%) and a psychiatric nurse (3%), with a mean of 19.1 years (SD = 9.9) of professional experience. Among the non-responders one refused, one was not available and two did not reply after two reminders. For the expert panel we used a questionnaire that asked each participant to prioritize among all mental disorders that are included in the mhGAP. Scoring was done following three criteria , commonness of the disorder in their practice, relevance of the disorder within the cultural context of Nepal, and perceived feasibility to provide treatment within non-specialist settings.Second, Theory of Change (TOC) workshops were organized with primary health care staff and policy makers to ascertain the different intermediate outcomes that constitute the expected pathway to change. Change here refers to the implementation of an integrated mental health plan leading to improved functioning among people with mental health problems. The TOC workshops followed a procedure as proposed by Anderson , which eThird, an explorative qualitative study using Focus Group Discussions (FGD) and semi-structured Key Informant Interviews (KII) was conducted to assess implementation issues for each of the TOC building blocks. The research question was; what are the opinions and perceptions of community member, health workers and policy maker on provision of mental health care at the community level and making it more widely available? The core interview templates were developed by the PRIME consortium, subsequently adapted for Nepal. The adaptation consisted of adding questions related to feasibility of the components of the TOC. Translation of the instruments was conducted following a systematic procedure developed for use in transcultural research that involves translation, back-translation and focus groups . In totaAll formative research was conducted between April 2011 and November 2012. Ethical clearance for the study was gained from the Nepal Health Research Council and the Human Research Ethics Committee at the University of Cape Town. All interviews and workshops were conducted by a team of four local research assistants, who received a three-week training in basic research principles and skills. Informed consent was obtained from all participants to the study, for the qualitative study consent was in written form, which included assurance of confidentiality. See Table The results of the expert panel were analyzed by computing intermediate criterion-based scores by adding up all the informed  answers . The sum was divided by the number of received informed answers. Blanks were left out of the calculation in both numerator and denominator . An overThe content and pathways as proposed by participants of the workshops were immediately displayed visually, thereby building up the TOC. Proposed changes were discussed and altered in the displayed TOC. All discussions and outputs were documented by a note taker, following a pre-established format.Qualitative data from the explorative study was analyzed following a Framework Analyses approach . First, Table a priori as ‘improved social economic and health of people with mental disorders treated by the program’. The first workshop developed a broad outline of preconditions related to service delivery, problem identification and detection, mental health literacy and stigma reduction, capacity building, quality assurance mechanisms, budget availability and political buy-in. The TOC formulated at this stage included a pathway for outcomes and associated interventions within the health facilities that focus mainly on the capacity of health care workers to identify, treat and follow-up with patients. This pathway was combined with questions about the additional burden the proposed activities would pose on health staff. Another pathway was aimed at the community, which involved training community volunteers in identification, sensitization and providing support to people with mental health problems. Related to this, respondents emphasized the need to systematically include families, peer and schools in the process. The availability of community-level service delivery agents was seen as the most important hurdle. A third pathway within the overall TOC concerned outcomes related to the functioning of the health organization. These included the establishment of a supervision system and the policy for procurement of psychotropic medications. Respondents were particularly concerned about the feasibility of a regular and reliable drug supply chain. Fine-tuning of the TOC in subsequent workshops resulted in recommendations towards the inclusion of preliminary outcomes or interventions related to livelihoods, rehabilitation, referral mechanisms and technical oversight, as well as defining assumptions around the participation of service users and adopting an approach combining pharmacological treatment with community-based psychosocial support mechanisms.After four consecutive workshops conducted alternatively with  health care providers and policy makers, a final Theory of Change map was drawn up  in combination with people who are respected public figures  would expectedly sort the largest impact. The situation presented was even more nuanced, as education and awareness alone were found to be insufficient to actually change attitudes, as that required actual involvement of key stakeholders with mental health issues.A recurrent theme was that for a mental health care plan to be introduced there is an urgent need to improve access to services. Having treatment available in itself would not guarantee access and uptake of such services. Community members stated that it was a necessity that health workers were sensitive and maintained confidential when dealing with people with mental health problems. They also pointed towards a need to change the commonly held notion that services at the health posts are for the poor and that the more affluent should go to the district hospital. But also more practical concerns would need to be addressed in order to improve access. For instance, health workers reported that the detection of people with mental health problems is fraught with difficulties, in part due to the low mental health literacy and persistent negative attitudes, also and especially in the people closest to people with mental health problems. Still, many respondents believed that lay people, especially after receiving training, would be able to identify that something was wrong, even if not able to identify the type of mental health problems. However, in the absence of specialized resources in the community, respondents stressed that health workers are ultimately responsible for the detecting mental illness. Access can further be increased by more pragmatic measures that were proposed during several of the interviews by community members and health workers, such as arranging support for the recurrent transport to and from the health facilities. Efforts to improve identification and access need to be sensitive to unhelpful sentiments among both help seekers and health providers. Currently, the former feared accusations and discrimination and therefor hid their problems, while the latter feared anger and aggressivity from patients.In many of the processes involved in the establishment of a mental health care plan the families of people with mental health problems play a crucial, albeit dual, role. Families appeared to be somewhat of a double edged sword. On the one end, families were seen as the key agents to help in improving the detection, access and maintenance of mental health treatment and care. On the other hand, family members, due to fear for loss of status or being discriminated against, take part in the ill-treatment or neglect that patients experience. For example the family members were reported to restrict access to care by protecting the client from stigmatization and hostility by hiding the illness; others were reported to threaten to reject him or her from the family all together.Numerous issues were raised by the respondents with regards to making task-shifting feasible and acceptable. Beyond the obvious need for training, all respondents emphasized the risk of over-burdening health workers and the need for compensations for all those involved in task-shifting. The formal recognition of training and mandate of the work was for many health workers as important as financial reimbursement. According to the majority of respondents people in the community should also be trained in mental health care, rather than health workers alone. It was suggested to have focal points in each village, or for every 15–20 households, who can play a role in the care and support of people with mental health problems.The literature on the integration of mental health into primary health care in LMIC is characterized by description of lessons learned from actual practice. To date, there is little formative research done in this area. The present study describes a systematic approach integrating formative research that provides data to inform the development of a comprehensive mental health care plan, incorporating the different perspectives of key stakeholders. We believe that a comprehensive methodology to identify and address barriers to acceptability and feasibility is important especially when applying mental health interventions cross-culturally . The preA strategy for decentralized mental health care has also been advocated in other post conflict settings such as Burundi ,Uganda  and LebaAs the systematic introduction of community mental health care cannot, from the onset, feasibly target all disorders, prioritization is required. Should governments choose to target the disorders that are most prevalent, those that cause most burden or those that can be addressed most feasibly? As such decision has potentially large implications for the country’s mental health strategy, it is important to have such prioritization done by key stakeholders in Nepal. The PRIME consortium has opted for depression disorder, alcohol use disorder and psychoses as priority disorders exactly because these impose the largest burden of disease and culturally acceptable interventions supported with robust evidence for effectiveness exists . The resThe present study has a number of implications for the development of the mental health care plan in Nepal. The preliminary (i.e. before pilot-testing) care plan consists of different components. Within the community these included stigma reduction, sensitization, case detection, user group mobilization and focused psychosocial support. Within the health facility these included awareness raising, screening and assessment, pharmacological and psychosocial treatment, all of which are largely based on the mhGAP guidelines . TraininThese components and interventions are informed by the present study in multiple ways. First, in the selection of priority disorders, in that epilepsy has been included based on the high priority score it received. Second, it has resulted in specific adaptations or strategies for implementation. Given the crucial and complex role of family members in the support for, and perpetuation of, mental health problems, interventions targeting families have been emphasized in the plan. Issues raised in relation to poor demand and access are addressed by a novel method for proactive case-finding by well-placed community-informants. Related, strategies aimed to reduce pervasive negative attitudes about mental health are now being developed encompassing the suggestions made in this study (including the sphere of intervention and most adequate delivery agent). Also, the concern about overburdening health staff and volunteers has led to a clear division of tasks and training of different cadres of health workers (i.e. making a distinction between prescribing and non-prescribing staff). Moreover, it has resulted in the decision to not rely on the cadre of community health volunteers . Even if appropriate, they are currently unpaid and are overburdened by multiple task-shifting roles. Finally, following recommendations by health workers in the study, to aid identification and detection at health facilities easy-to-use protocols and visual charts will be developed for frontline staff. Third, it has provided clear suggestions for additional foci in the plan. The need of a district-level focal point for mental health has since been advocated. Similarly, the need to formalize the training certificates now features on the agenda in discussions with the Ministry of Health. Together with the emphasis given on securing a reliable supply of pharmacological medicine, respondents warn for issues related to sustainability. The need to deal with the issue of sustainability right from the start has been one of the main lessons learned from other community mental health programs in LMIC . The nexThe process of the subsequent research steps feeding into each other has been important in formulating recommendations for practice. The priority setting defined the focus of the TOC, in turn the TOC defined the scope of the qualitative study. Furthermore, besides the concrete implications, by eliciting stakeholders’ opinions and their active involvement we hope that these methods will ensure ownership and buy-in on the development of a mental health care plan by stakeholders.A few limitations should be noted. The research is conducted in the district where the further development and pilot-testing of the care package is going to take place. With the vast socio-economic, cultural and geographical differences, the findings may not necessarily generalize to all of Nepal. Second the priority setting exercise was largely based on purposive sampling. While we are confident that most senior mental health professionals were involved, the results are largely based on experts based in urban clinical settings. In addition, the low priority scores given to the developmental disorders are surprising, especially given other reports about their importance . The scaOur research has laid out a comprehensive framework for setting priorities for mental health care in Nepal. It has outlined major challenges as well as recommending concrete strategies about how to overcome them. There was a strong endorsement of a hybrid system that encompasses community-, and facility-based care. Guaranteeing a sustainable supply of psychotropic medicine and making sure to not over-burden health workers or volunteers were identified as key challenges. The dual capacity of families, both the natural sphere of support for people with mental health problems and the ones maintaining or reinforcing negative attitudes towards sufferers, was also seen as needing attention. This study provides the foundation for further development and evaluation of integrated mental health care in Nepal.The authors declare that they have no competing interests.MJ developed study design, was responsible for analyses, responsible for drafting and revising the manuscript; NL was responsible for implementation of the study, was involved in the development of the study design, contributed to drafting manuscript; MT was involved in the development of the study design, contributed to drafting manuscript; IK was involved in the development of the study design, contributed to drafting manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-244X/13/332/prepubHighlight results from qualitative interviews. This table provides an overview of the main findings from the qualitative study, presenting the results in terms of barriers and recommended solutions.Click here for file


Premature infants not only feel and understand the pain, but also respond more intensively compared with term infants. Non-pharmacological methods of pain control are suitable to relieve pain in painful procedures. The facilitated tucking position is considered as a non-pharmacological method of pain control in infants; however, its impact on frequent and repeated procedural pain such as endotracheal suctioning remains to be studied.This paper is the report of a study that examined the impact of facilitated tucking position on behavioral pain during suctioning in premature neonates. Design: This was a clinical trial study with a crossover design. Settings: The study was conducted in a level II Neonatal Intensive Care Unit, located in a teaching hospital, affiliated to Tehran University of Medical Sciences, Tehran, Iran. Participants: Thirty four infants were enrolled in this study based on the following inclusion criteria: age between 29 to 37 weeks of gestational age, birth weight 1200 grams or more, having an endotracheal tube, no congenital anomalies, no seizures diagnosis, no chest tubes, no intracranial hemorrhage higher than degree II, not receiving opiates and sedatives four hours before intervention and not receiving any painful procedure at least half an hour before the intervention. Methods: The samples were randomly received a sequence of suctioning with/without or suctioning without/with facilitated tucking. Preterm Infant Pain Profile (PIPP) was used to collect the data. SPSS version 16.0 for Windows  was used for statistical analysis.While 38.2% of infants experienced severe pain during suctioning without intervention, only 8.8% of them experienced severe pain during suctioning with intervention. The results of the paired t-test show that there is a statistically significant difference in the mean scores of pain between non-intervention and intervention cases (p<0.001), and the mean pain score substantially reduced in cases with intervention.Given the multiplicity of endotracheal suctioning frequency and the impossibility of frequent use of pharmacological methods of pain relief, the facilitated tucking position can be used as a safe non-pharmacological method for procedural pain management. Annually, about 13 million premature infants are born worldwide which represents 9% of total births . This raDuring hospitalization in Neonatal Intensive Care Unit, premature neonates require more frequent routine care and procedures than term neonates, therefore, the hypersensitivity elongates and the pain threshold reduces. As a result, non-noxious stimuli such as changing the position and performing routine care may become painful for them and causes stress responses . InadequNurses and other health care team members need to know how to control pain with pharmacological and non-pharmacological approaches . The American Academy of Pediatrics recommends (2000) to use painful procedures in a neonatal intensive care unit only when necessary.Pain in neonates is controlled by pharmacological and non-pharmacological methods. To control severe pain, some medications such as opiates may be used; however, the use of drugs is not without risk and may cause symptoms such as respiratory depression, nausea, seizures and physiological dependence . These sReducing light and noise and changing positions as a part of the developmental care program, aimed at increasing the infant’s energy to cope with painful procedures, are recommended as one of the pain management strategies . ProvidiThe aim of this study was to evaluate the impact of facilitated tucking position on behavioral pain during suctioning in premature neonates admitted to the neonatal intensive care unit. In this study, the following hypothesis was tested:“The score of pain during suctioning in facilitated tucking position is less than the pain score during suctioning alone.”This was a clinical trial study with a crossover design, in which subjects randomly received a sequence of either suctioning with intervention- suctioning without intervention or suctioning without intervention- suctioning with intervention.The study was conducted in a level II Neonatal Intensive Care Unit, affiliated with Tehran University of Medical Sciences, Tehran, Iran. Sampling was done purposefully by the main researcher from January 2013 to May 2013, based on the following inclusion criteria: age between 29 to 37 weeks of gestational age, birth weight 1200 grams or more, having an endotracheal tube, no congenital anomalies, no seizures diagnosis, no chest tubes, no intracranial hemorrhage higher than degree II, not receiving opiates and sedatives four hours before intervention and not receiving any painful procedure at least half an hour before the intervention. Thirty four neonates who met the inclusion criteria were enrolled in this study. After that, random sequencing was done to determine the intervention- non intervention receiving order for each neonate by the main researcher.Demographic characteristics form and Preterm Infant Pain Profile (PIPP) were used to collect the data. The information on gestational age, weight, underlying diseases and the Apgar Score at fifth minute and the method of delivery were collected using the demographic characteristics form. Given that the dependent variable in this study was pain during suctioning, the PIPP tool was used to measure this variable. The PIPP is a relatively easier tool which does not require extensive training . The PIPThe university ethics committee approved the study. The researcher provided a full explanation about the study and its purposes for the head nurse and personnel as the researcher assistants. Considering that implementing the intervention and variables measurement needed another individual presence with the principal researcher, the researcher assistants help the main researcher at all stages of performing intervention and the measurements.After selecting the subjects, written informed consent was taken from the parents of the neonates, and demographic data were collected and recorded from their medical records. Half of the neonates under study initially received suctioning without intervention and then, suctioning associated with intervention, and the other half initially received suctioning with intervention and then, suctioning with no intervention. Given that suctioning was done based on the infant’s need, just in such cases, the researcher measured data, performed suctioning and intervened.The neonates were kept in a quiet environment during the intervention, and it was tried to minimize the environmental stimuli such as light and sound at all stages of the study and keep them alike. In cases the neonates recruited for the study need suctioning, the researcher first was setting the video camera to cover the infant’s whole body in its filming filed while the face was toward the camera. Then, the recently calibrated pulse oximetry probe was attached to the infant’s right foot followed by recording the heart rate and oxygen saturation from the monitors, 15 seconds before the start of suctioning . Scores given to the infant’s facial expression immediately after suctioning, together with heart rate and oxygen saturation levels were used to calculate the PIPP score. After filming, the recording of each neonate was watched and coded by the first researcher. Cases with and without intervention were separated and scored by the second researcher in two consecutive days. The steps of the study are shown in In cases when the neonates were prescribed to receive suctioning without intervention, the researcher assistant performed the suction and the researcher only recorded the study variables. In cases where the neonates were receiving suctioning with intervention, the suctioning was carried out by the researcher assistant and the researcher implemented the intervention (placing the neonate in facilitated tucking position). To implement facilitated tucking, the neonate was placed on his/her side, his/her back was gently bent, the legs were getting up and flexion at an angle greater than 90 degrees, the shoulders were also constricted up to 90 degrees and the researcher hands were placed over the head close to the mouth or on the neonate’s face. The interval between suctioning without intervention and suctioning with the intervention was at least two hours.SPSS version 16.0 for Windows  was used as a platform for statistical analysis. Descriptive statistics were used to present a general picture of participants’ demographics. Means (with/without intervention) were compared using a paired t - test.Demographic characteristics of neonates are shown in The results of the paired t-test show that there is a statistically significant difference between the mean scores of pain in non-intervention and intervention cases (p< 0.001), and the mean pain score substantially reduced in cases with intervention .One of the limitations of this study was to include only the infants with gestational age 29 weeks and older, and we do not know whether the facilitated tucking position is effective for younger or more severely ill babies or not. Although data collection was done by one researcher and scoring was done by another researcher and the second researcher was not aware of the scores in cases with and without intervention, but the researcher responsible for the pain scoring was aware of the study objectives.Intensive care for neonates includes performing of many diagnostic and therapeutic procedures, which are associated with pain. Thus, prevention and treatment of neonatal pain are of great importance in the neonatal intensive care unit . The preIn this study, the pain during endotracheal suctioning was taken into account, for this painful procedure is commonly carried out in the neonatal intensive care unit, but it has been neglected in previous studies . ResultsBased on the results of the study regarding pain levels, it was found that in cases of using facilitated tucking position, the frequency of neonates with severe pain has dropped, and the neonates have experienced mostly mild to moderate pain with this position, while in cases of doing endotracheal suctioning without intervention, they had experienced mostly moderate to severe pain.Given the multiplicity of endotracheal suctioning frequency and the impossibility of frequent use of pharmacological methods of pain relief, the facilitated tucking position can be used to reduce pain during the suctioning procedure in premature neonates. The presence of pain assessment tools such as the PIPP, which can be easily used by nurses, will help them to document the impact of their pain management action on neonatal pain.The best method of pain management in infants includes the prevention of pain with clinical judgment about the need to do any painful procedure, clustering the procedures and performing each procedure slowly. In addition, every painful procedure should be combined and associated with an effective and safe pain relieving approach. Findings from this study show that the facilitated tucking position can be used as a non-pharmacological and safe method of procedural pain management.


Intestinal pneumatosis (IP) defined as the presence of gas within the bowel wall and the presence of gas in the portomesenteric vein complex, a rare clinical condition that are typically associated with intestinal ischemia (II) and a fatal outcome.We present a case of IP, diagnosed at ED, through the use of US scanning used by EP.A patient with abdominal pain, with a final diagnosis of a II assessing US, performed by EP.82 year old woman, active and independent, who came to the ER with abdominal pain from 12 hours, which started about 2 hours after dinner. The patient presented malaise, affected by pain, hypotensive and tachycardic. Given the general malaise the patient underwent an abdominal ultrasound scan at the bedside of the patient showed many small echogenic mobile pictures that moved through the portal vein and its branches, and in the left hepatic lobe level we saw also multiple linear echogenic pictures in the portal branches with posterior acoustic shadows. Suspecting IP and gas in the abdominal venous complex portomesenteric urgent contrast CT was made, which confirmed the diagnosis.CT and US are the most commonly used imaging modalities in patients with acute abdomen and even if CT represents the gold standard in the evaluation of patients with II. However, there are some disadvantages associated with this technique, such as radiation exposure, potential nephrotoxicity and the risk of an allergic reaction to the contrast agents. Thus, not all patients with suspected bowel ischaemia can be subjected to these examinations. Despite its limitations, bedside ultrasound performed by EP could constitutes a good imaging method as first examination in acute settings of suspected mesenteric ischemia.Ultrasonography by EP, can be a useful tool in cases with serious diseases. Incorporate ultrasound in the ER lowers overall service times, since the EP is more effective, efficient and dynamic management "time-dependent" emergency, providing greater clinical patient safety.The study was conducted in accordance with the ethical standards dictated by applicable law. Informed consent was obtained from each owner to enrolment in the study and to the inclusion in this article of information that could potentially lead to their identification.