Effect of a supportive-educational program, based on COPE model, on quality of life and caregiver burden of family caregivers of heart failure patients: a randomized clinical trial study.

BACKGROUND: Heart failure (HF) is one of the most common and spreading diseases worldwide. As HF symptoms progress, it is affected the quality of life and the caregiver burden of the family. The present study aimed to determine the effectiveness of the supportive-educational program, based on the COPE (creativity, optimism, planning and expert advice) care model, on the quality of life and caregiver burden of family caregivers of HF patients. METHOD: This clinical trial was conducted on 90 caregivers of HF patients admitted to Isfahan in 2021. The samples were divided into experimental (n = 45 people) and control (n = 45 people) groups based on random allocation (card method). The experimental group received problem-solving skills based on the four components of the COPE model in six sessions during one month. to collect data, the 36-Item Short Form Survey (SF-36) and the Zarit Burden Interview (ZBI) were used in two groups before, after and three months after the intervention. RESULTS: There was a significant difference between the experimental and control groups regarding gender, but This confounding factor had no significant effect on the two components of quality of life and caregiver burden. There was a significant difference between the two groups in terms of the mean score of quality of life immediately(75.99),and three months after the intervention (78.78) (P < 0.05) and the mean score of care burden, immediately (16.60) and three months after the intervention (12.73) (P < 0.05). CONCLUSIONS: One of the important duties of nurses is to implement educational-supportive programs for patients after the discharge of patients, These programs are family-oriented remotely for their caregivers. TRIAL REGISTRATION: This study was registered by the Iranian Registry of Clinical Trials with decree code: IRCT20211128053202N1on 2022-02-20.

The significance of essential oils and their antifungal properties in the food industry: A systematic review.

Essential oils (EOs) are natural products called volatile oils or aromatic and ethereal oils derived from various parts of plants. They possess antioxidant and antimicrobial properties, which offer natural protection against a variety of pathogens and spoilage microorganisms. Studies conducted in the last decade have demonstrated the unique applications of these compounds in the fields of the food industry, agriculture, and skin health. This systematic article provides a summary of recent data pertaining to the effectiveness of EOs and their constituents in combating fungal pathogens through diverse mechanisms. Antifungal investigations involving EOs were conducted on multiple academic platforms, including Google Scholar, Science Direct, Elsevier, Springer, Scopus, and PubMed, spanning from April 2000 to October 2023. Various combinations of keywords, such as "essential oil," "volatile oils," "antifungal," and "Aspergillus species," were used in the search. Numerous essential oils have demonstrated both in vitro and in vivo antifungal activity against different species of Aspergillus, including A. niger, A. flavus, A. parasiticus, A. fumigatus, and A. ochraceus. They have also exhibited efficacy against other fungal species, such as Penicillium species, Cladosporium, and Alternaria. The findings of this study offer novel insights into inhibitory pathways and suggest the potential of essential oils as promising agents with antifungal and anti-mycotoxigenic properties. These properties could make them viable alternatives to conventional preservatives, thereby enhancing the shelf life of various food products.

The concentration of potentially toxic elements (PTEs) in Iranian rice: a dietary health risk assessment study.

In the present study, six potentially toxic elements (PTEs), including chromium (Cr), arsenic (As), cadmium (Cd), lead (Pb), copper (Cu), and nickel (Ni), were determined in 41 domestic rice samples collected from Tehran using ICP-OES (inductively coupled plasma-optical emission spectrometry). The mean concentration of Cd, As, Cu, Pb, Cr, and Ni was found as 0.014 ± 0.01, 0.018 ± 0.005, 2.15 ± 1.84, 0.42 ± 0.31, 0.1 ± 0.16, and 0.48 ± 0.36 mg kg-1, respectively. Possible risks due to ingestion of PTEs via rice consumption for children and adults were assessed by Monte Carlo simulation. The 50th percentile of estimated Cr intake for children through domestic rice consumption exceeded the maximum tolerable daily intake. There was only a potential non-carcinogenic risk for single Cr exposure for children. The 95th percentile of the estimated hazard index (HI) for children and adults was 4.34 and 1.05, indicating a potential non-carcinogenic risk related to multiple PTE exposure. The lifetime cancer risk (ILCR) values derived from Cr, Ni, As, and Cd exposure exceeded the threshold value, indicating a carcinogenic risk due to PTEs' exposure. The deterministic assessment demonstrates that the Tehran population may be at risk through domestic rice consumption. This study indicates that risk related to the exposure to multiple PTEs through the consumption of rice in adults and children in Tehran is recognized as an important issue, thus supporting the importance of cumulative analysis of the risk of exposure to PTEs through food. Finally, national strategic environmental assessment and technological solutions for monitoring and protecting freshwater, soil, waste management, and chemicals as a global concern policy are needed for public health.

Preparation, characterization, and antioxidant activity of ß-cyclodextrin nanoparticles loaded Rosa damascena essential oil for application in beverage.

Rosa damascena essential oil (REO) is volatile and unstable. The host-guest complex of beta-cyclodextrin nanoparticles (ß-CD) with REO was produced to improve REO characteristics. The REO/ß-CD complex was characterized by entrapment efficiency, morphology, crystallinity, particle size, thermal stability, and antioxidant activity. Additionally, the structure of REO/ß-CD was evaluated using Fourier transform infrared spectroscopy (FT-IR) and nuclear magnetic resonance (NMR). Results confirmed the formation of REO/ß-CD in which the REO, as a guest molecule, was entrapped within the ß-CD as a host molecule. The encapsulated particles showed a spherical shape with an average diameter of 110 nm and no strong agglomerate. The entrapment of REO within ß-CD led to changes in some physicochemical characteristics and enhancement of the antioxidant activity of REO. Furthermore, beverages with the addition of ß-CD nanoparticle-loaded REO were produced. The beverage containing ß-CD nanoparticle-loaded REO form showed significantly higher overall acceptability than samples containing free REO.

Survey of the salt (NaCl) Contents of Traditional Breads in Tehran, 2016‒2018: Implication for Public Health.

Background: Considering the importance of non-communicable diseases (NCDs) in Iran, the aim of this study is to identify the trend in the salt (NaCl) levels of various types of traditional bread (sangak, barbari, taftoon, and lavash breads) in Tehran in 2016 and 2018 and its implication for public health. Methods: A total of 777 samples of various traditional breads were randomly collected from various districts located in Tehran in 2018. The salt content (expressed as g/100 g dry weight) in these breads were determined according to Volhard method. Results from this study were compared with those reported in 2016. Results: The present study indicated that the mean salt content in traditional breads in 2018 was significantly higher than that reported in 2016. Salt content in traditional breads collected in 2018 ranged from 0.03 to 6.52/100 g dry weight, with mean value of 1.43 g/100 g dry weight. When comparing with the permitted limit set by Institute of Standards and Industrial Research of Iran (ISIRI), there was an increase in the percentage of samples complying with the permitted limit; 50.8% (2016) vs 54.1% (2018). Conclusions: The daily salt intake increased from 1.56 g per person in 2016 to 2.31 g per person in 2018. Considering the high bread per capita consumption in Iran, it seems that half of the daily recommended salt intake could be reached exclusively through breads. Hence, the main strategies for salt intake reduction from bread could be achieved through evaluation of salt reduction programs and development of technological factors in bread baking.

A systematic review of the concentration of potentially toxic elements in fish from the Persian Gulf: A health risk assessment study.

Fish as a critical food source is responsible for supplying nearly 20% of the average per capita animal protein for 3.2 billion people worldwide. However, oral exposure to potentially toxic elements (PTE) such as mercury (Hg), cadmium (Cd), lead (Pb), and arsenic (As) through marine fish consumption can cause health risks in consumers. This study aimed to collect information among databases (2000-2020), including ScienceDirect, PubMed, SCOPUS, EMBASE, and Google Scholar, regarding the concentration of PTEs in different types of fish from the Persian Gulf. In this regard, thirty articles containing 266 samples were included in the current systematic review. In addition, the non-carcinogenic risk caused by ingestion of PTEs via consumption of fish was calculated. The average PTE concentrations in fish muscles were presented in the following order: As (0.37 mg/kg ww) > Pb (0.20 mg/kg ww) > Cd (0.17 mg/kg ww) > Hg (0.13 mg/kg ww). However, the mean concentration of PTEs was below the defined level by the World Health Organization, and the findings revealed that the calculated average daily dose (ADD) for Cd and Pb in Iranian children and adult consumers was lower than the reference dose (RfD), whereas the ADD of Hg was higher than the RfD for children consumers. The total target hazard quotient for Iranian and children consumers was >1. The excess lifetime cancer risk values for Pb were safe, unlike those for Cd, which were in an unsafe range (>10-4) for consumers.

Exposure to multiple mycotoxins in domestic and imported rice commercially traded in Tehran and possible risk to public health.

Mycotoxins are secondary fungi metabolites that induce acute and chronic toxic effects in humans and animals. In the present study, nine mycotoxins including aflatoxins (AFB1, AFB2, AFG1 and AFG2), fumonisins (FB1 and FB2), Ochratoxin A (OTA), deoxynivalenol (DON), and zearalenone (ZEN) were determined in one hundred rice samples collected from Tehran using high performance liquid chromatography (HPLC) with fluorescence or photodiode array detector. In addition, possible risk to public health was investigated by assessing dietary exposure through rice consumption, the margin of exposure (MOE), respective risk of cancer and hazard index (HI) of the monitored mycotoxins in children and adults. The higher mean levels were determined for DON (102.22 µg.Kg-1), followed by FB1 (85.00 µg.Kg-1). For the rests of mycotoxins the levels did not exceed 20 µg.Kg-1. The estimated AFB1 intake for the adults and children through rice consumption exceeds the safe levels established for both carriers and non-carriers of hepatitis B virus. The mean and median determined exposure levels of OTA, DON ZEN and FB1, were found lower than the Provisional Maximum Tolerable Daily Intake (PMTDI) value for both adults and children of Tehran that consuming domestic and imported rice. The mean HI for adults and median HI for adults and children were below one, and mean HI for children was close to one. All the mean, median and maximum MoE values were <10,000 in adults and children, indicating a risk due to AFB1 exposure through rice consumption in Tehran. In addition, the calculated mean cancer risk in adult and child populations of Tehran were 0.27 and 0.64 cases per year per 105 individuals, respectively, that shows population in Tehran could be at risk of cancer due to AFB1 exposure through rice consumption as calculated. So further studies are necessary for the monitoring mycotoxins in rice and different food products as well as estimating average dietary exposure and cumulative exposure assessment of mycotoxins for main foods in IR Iran.

Alginate/Fish Gelatin-Encapsulated Lactobacillus acidophilus: A Study on Viability and Technological Quality of Bread during Baking and Storage.

In the present study, Lactobacillus acidophilus LA-5 was microencapsulated in sodium alginate, followed by fish gelatin coating (0.5, 1.5, and 3%). The survival of L. acidophilus in bread before and after encapsulation in alginate/fish gelatin during the baking and 7-day storage was investigated. Moreover, the effect of alginate/fish gelatin-encapsulated L. acidophilus on the technological properties of bread (hardness, staling rate, water content, oven spring, specific volume, and internal texture structure) was evaluated. Compared with control (free bacteria), encapsulated L. acidophilus in alginate/fish gelatin showed an increase in the viability of bread until 2.49 and 3.07 log CFU/g during baking and storage, respectively. Good viability of (106 CFU/g) for probiotic in encapsulated L. acidophilus in alginate/fish gelatin (1.5 and 3%, respectively) after 4-day storage was achieved. Fish gelatin as a second-layer carrier of the bacteria had a positive effect on improving the technical quality of bread. Furthermore, the staling rate of bread containing encapsulated L. acidophilus alginate/fish gelatin 0.5, 1.5, and 3% decreased by 19.5, 25.8, and 31.7%, respectively. Overall, the findings suggested encapsulation of L. acidophilus in alginate/fish gelatin capsule had great potential to improve probiotic bacteria's survival during baking and storage and to serve as an effective bread enhancer.

A review of recent advances in the decontamination of mycotoxin and inactivation of fungi by ultrasound.

Innovative technologies for the pasteurization of food products have increased due to the global demand for higher-quality food products. In this regard, the current article aimed to provide an overview regarding the latest research on US application in the decontamination of fungi in food products and highlight the parameters influencing the effectiveness of this method. Therefore, the related article with inactivation of fungi and mycotoxins by ultrasound among last four years (2018-2021) by using terms such as 'mycotoxin,' 'inactivation,' 'ultrasound,' 'decontamination' among some international databases such as PubMed, Web of Science, Embase and Google Scholar" was retrieved. Ultrasound (US) is considered a non-thermal decontamination method for food products. In US, the release of energy due to the acoustic phenomenon destroys microorganisms. This technology is advantageous as it is inexpensive, eco-friendly, and does not negatively affect food products' food structure and organoleptic properties. The influence of the US on food structure and organoleptic properties dramatically depends on the intensity and energy density applied In addition, it can preserve higher levels of ascorbic acid, lycopene, and chlorophyll in sonicated food products. The treatment conditions, including frequency, intensity, duration, temperature, and processing pressure, influence the effectiveness of decontamination. However, US displays synergistic or antagonistic effects on bacteria, yeasts, molds, and mycotoxins when combined with other types of decontamination methods such as chemical and thermal approaches. Thus, further research is needed to clarify these effects. Overall, the application of US methods in the food industry for decreasing the microbial content of food products during processing has been applied. However, the use of US with other techniques needs to be studied further.

Incorporation of Low Molecular Weight Chitosan in a Low-Fat Beef Burger: Assessment of Technological Quality and Oxidative Stability.

In the present work, incorporating low molecular weight chitosan (LMWCH) (0, 0.5, 1, and 2%) as a fat replacer into low-fat beef burgers and technological, textural, and oxidative stability were investigated. The weight loss and shrinkage of samples decreased with the increase of LMWCH concentration. In contrast, the water-holding capacity and color of burgers were enhanced by the addition of LMWCH. The instrumental TPA results indicated an increase in the LMWCH levels, significantly increasing the hardness, springiness, and gumminess but decreasing the cohesiveness of low-fat beef burgers. The TBARS and peroxide values and free fatty acid content in the burgers supplemented with LMWCH increase slower than the control sample during refrigerated storage.

Effect of Omega-3 on Recurrent Aphthous Stomatitis and Improvement Quality of Life.

OBJECTIVE: Recurrent aphthous stomatitis is one of the most common chronic inflammatory diseases in oral mucosa. Beneficial effects of omega-3 supplements on some inflammatory diseases have been proved. The aim of present study was to evaluate the effect of omega-3 supplements in recurrent aphthous stomatitis management and improve oral health-related quality of life. METHODS: In this double-blind clinical trial, 40 patients with minor recurrent aphthous stomatitis were randomly divided into case and control groups. The case group received 1000 mg capsules of omega-3, while the control group received placebo capsules for 6 months. The questionnaires of the ulcer severity score and the chronic oral mucosal disease questionnaire were filled by the patients in three steps, at the baseline session, after 3 months, and after 6 months. The data were analyzed by SPSS 22 software through ANOVA, Mann-Whitney, and chi-square tests. P < 0.05 was considered as significant. RESULTS: In the omega-3 group, the ulcer severity score showed significant reduction by three-month and six-month follow-ups (P < 0.0001, P < 0.0001, respectively). The mean score of the chronic oral mucosal disease questionnaire significantly improved by three-month and six-month follow-ups in the omega-3-receiving group. CONCLUSION: Use of omega-3 oral supplements decreased the severity of aphthous ulcer and improved oral health-related quality of life.

Pesticide Residues Analysis in Iranian Fruits and Vegetables by Gas Chromatography-Mass Spectrometry.

Pesticide residues in fruits and vegetables are one of the highest concerns of consumers who need food safety. In this study, forty-eight pesticide residues from different chemical structures including organochlorine, organophosphorus, organonitrogen, dicarboximides, strobilurin, triazine, pyrethroids, and other chemical groups. In 85 fruits and vegetables were determined and confirmed by GC-MS. The pesticide was extracted with ethyl-acetate, then, the extracts cleaned using high performance gel permeation column chromatography (GPC) and solid phase column (SPE). The mean recoveries of the pesticides were between 81 and 136%. The reproducibility of the relative standard deviation values was 2.1% and 14.8%. Pesticide residues were more frequently found in vegetables (65.5%) than in fruits (26.7%). The limits of detection and quantification of pesticide residues for the method were ranged from 0.003 to 0.06 µg/g and between 0.01 to 0.1 µg/g respectively. The analyzed samples did not contain residues from the monitored pesticides that were higher than the accepted maximum residue limits (MRLs) as adapted by the FAO/WHO Codex Alimentarius Commission.

Preparation and Characterization of Nanoparticle ß-Cyclodextrin:Geraniol Inclusion Complexes.

The aim of the present study was to formulate ß-cyclodextrin (ß-CD) nanoparticles loaded with geraniol (GR) essential oil (EO) with appropriate physicochemical properties. Complexation of GR with ß-CD was optimized by evaluation of four formulations, using the co-precipitation method, and the encapsulation efficiency (EE), loading, size, particle size distribution (PDI) and zeta potential were investigated. Further characterization was performed with nuclear magnetic resonance spectroscopy (1H NMR), differential scanning calorimetry (DSC), scanning electron microscopy (SEM) and infra-red (IR) spectroscopy analysis. Results showed that the physicochemical properties of the nanoparticles were affected by GR content in formulations that yielded nanoscale-size particles ranging from 111 to 258 nm. The highest encapsulation efficiency (79.4 ± 5.4%) was obtained when the molar ratio of EO to ß-CD was 0.44: 0.13 with negative zeta potential (-21.1 ± 0.5 mV). The 1H-NMR spectrum confirmed the formation structure of the EO and ß-CD nanoparticle complex. Complexation with geraniol resulted in changes of IR profile, NMR chemical shifts, DSC properties, and SEM of ß-cyclodextrin. Inclusion complex of essential oil with ß-cyclodextrin was considered as promising bioactive materials for designing functional food.

Neonatal Intensive Care Nursing Curriculum Challenges based on Context, Input, Process, and Product Evaluation Model: A Qualitative Study.

BACKGROUND: Weakness of curriculum development in nursing education results in lack of professional skills in graduates. This study was done on master's students in nursing to evaluate challenges of neonatal intensive care nursing curriculum based on context, input, process, and product (CIPP) evaluation model. MATERIALS AND METHODS: This study was conducted with qualitative approach, which was completed according to the CIPP evaluation model. The study was conducted from May 2014 to April 2015. The research community included neonatal intensive care nursing master's students, the graduates, faculty members, neonatologists, nurses working in neonatal intensive care unit (NICU), and mothers of infants who were hospitalized in such wards. Purposeful sampling was applied. RESULTS: The data analysis showed that there were two main categories: "inappropriate infrastructure" and "unknown duties," which influenced the context formation of NICU master's curriculum. The input was formed by five categories, including "biomedical approach," "incomprehensive curriculum," "lack of professional NICU nursing mentors," "inappropriate admission process of NICU students," and "lack of NICU skill labs." Three categories were extracted in the process, including "more emphasize on theoretical education," "the overlap of credits with each other and the inconsistency among the mentors," and "ineffective assessment." Finally, five categories were extracted in the product, including "preferring routine work instead of professional job," "tendency to leave the job," "clinical incompetency of graduates," "the conflict between graduates and nursing staff expectations," and "dissatisfaction of graduates." CONCLUSIONS: Some changes are needed in NICU master's curriculum by considering the nursing experts' comments and evaluating the consequences of such program by them.

Physicochemical properties and antioxidant activity of α-tocopherol loaded nanoliposome's containing DHA and EPA.

The aim of this study was to prepare α-tocopherol loaded nanoliposomes as carriers of DHA and EPA and to investigate their physicochemical properties, such as peroxide value (PV), volatile compounds (VOCs), particle size, size distribution, zeta potential and morphology of the liposomes. The particle size of liposomes was in the range of 82.4-107.2nm. The highest extent of lipid oxidation was observed at 40°C for 90days, with the lowest PV and propanal levels for a nanoliposome formulation in comparison with the control sample. The zeta potential of the nanoliposomes was decreased during storage. No significant change in the PV and zeta potential of the liposome formulations with α-tocopherol was observed at 4°C after 90days (0.14meq/kg and -43.5mV, respectively). This study demonstrated that incorporation of α-tocopherol into liposomes contributes a significant antioxidant effect on DHA and EPA.

Nanocomposites in food packaging applications and their risk assessment for health.

Nanotechnology has shown many advantages in different fields. As the uses of nanotechnology have progressed, it has been found to be a promising technology for the food packaging industry in the global market. It has proven capabilities that are valuable in packaging foods, including improved barriers; mechanical, thermal, and biodegradable properties; and applications in active and intelligent food packaging. Examples of the latter are anti-microbial agents and nanosensors, respectively. However, the use of nanocomposites in food packaging might be challenging due to the reduced particle size of nanomaterials and the fact that the chemical and physical characteristics of such tiny materials may be quite different from those of their macro-scale counterparts. In order to discuss the potential risks of nanoparticles for consumers, in addition to the quantification of data, a thorough investigation of their characteristics is required. Migration studies must be conducted to determine the amounts of nanomaterials released into the food matrices. In this article, different applications of nanocomposites in food packaging, migration issues, analyzing techniques, and the main concerns about their usage are discussed briefly.

A Review of Nanoliposomal Delivery System for Stabilization of Bioactive Omega-3 Fatty Acids.

Currently, bioactive compounds are required in the design and production of functional foods, with the aim of improving the health status of consumers all around the world. Various epidemiological and clinical studies have demonstrated the salutary role of eicosapentaenoic acid (EPA, 22:6 n-3) and docosahexaenoic acid (DHA, 22:5 n-3) in preventing diseases and reducing mortality from cardiovascular diseases. The unsaturated nature of bioactive lipids leads to susceptibility to oxidation under environmental conditions. Oxidative deterioration of omega-3 fatty acids can cause the reduction in their nutritional quality and sensory properties. Encapsulation of these fatty acids could create a barrier against reaction with harmful environmental factors. Currently, fortification of foods containing bioactive omega-3 fatty acids has found great application in the food industries of different countries. Previous studies have suggested that nano-encapsulation has significant effects on the stability of physical and chemical properties of bioactive compounds. Considering the functional role of omega-3 fatty acids, this study has provided a literature review on applications of nanoliposomal delivery systems for encapsulation of these bioactive compounds.

Formulation, characterization and optimization of liposomes containing eicosapentaenoic and docosahexaenoic acids; a methodology approach.

Omega-3 fatty acids (FAs) have been shown to prevent cardiovascular disease. The most commonly used omega-3 fatty acids like eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) are highly vulnerable to oxidation and therefore, have short shelf life. Recent advances in nanoliposomes provided a biocompatible system for stabilizing omega-3 FAs. Several methods could be implemented to prepare nanoliposomes. To the best of our knowledge, the performances of these methods in preparation omega-3 FAs have not been examined. Nanoliposomes were prepared by thin film hydration followed by one of the following methods: 1- extrusion, ultrasonic irradiation; 2- bath sonication; 3- probe sonication; or 4- combined probe and bath sonication. The size of liposomes obtained from methods 1 to 4 were 99.7 ± 3.5, 381.2 ± 7.8, 90.1 ± 2.3, and 87.1 ± 4.10 nm with zeta potential being -42.4 ± 1.7, -36.3 ± 1.6, -43.8 ± 2.4, and 31.6 ± 1.9 mV, respectively. The encapsulation efficiency (EE) for DHA was 13.2 ± 1.1%, 26.7 ± 1.9%, 56.9 ± 5.2% and 51.8 ± 3.8% for methods 1 to 4, respectively. The corresponding levels for EPA were 6.5 ± 1.3%, 18.1 ± 2.3%, 38.6 ± 1.8%, and 38 ± 3.7%, respectively. The EE for DHA and EPA of liposomes for both methods 3 and 4 increased significantly (p<0.05). Propanal, as the major volatile product formed during liposomal preparations, amounts from 81.2 ± 4.1 to 118.8 ± 2.3 µg/Kg. The differential scanning calorimetry (DSC) study showed that DHA and EPA influence the phase transition temperature of small unilamellar vesicles (SUVs) of dipalmitoyl phosphatidyl choline (DPPC). Transmission electron microscopy (TEM) images of liposomes stained with uranyl acetate showed that the liposomes were spherical in shape and maintain high structural integrity. In conclusion, probe ultrasound of pre-formed liposomes facilitates significant loading of DHA and EPA into the nanoliposomal membrane.

The effect of endotracheal tube suctioning education of nurses on decreasing pain in premature neonates.

OBJECTIVE: Endotracheal tube suctioning (ETS) is a painful and invasive procedure. Studies have shown that the performance of nurses in this procedure is weak, so we conducted a study to evaluate the effect of ETS education for nurses on neonates' pain in neonatal intensive care units (NICUs). METHODS: In a quasi-experimental study, performance of 25 nurses working in NICU was assessed before and after ETS education by a checklist. In addition pain score of 50 neonates was measured using pain assessment tool (PIPP) one minute before, during and 5 minutes after ETS. The neonates had a gestational age of less than 37 weeks and were intubated (at least for 8 hours and up to 24 hours). A P. value of less than 0.05 was considered as statistically significant. FINDINGS: Mean scores of nurses' performance were significantly different before and after education (P≤0.001) by Wilcoxon test. Friedman test revealed that PIPPs before, during and after ETS were significantly different before and after education (P≤0.05). Mann-Whitney test showed no significant differences between PIPPs before ETS, before and after education (P=0.2), but PIPPs during and after ETS were significantly different (P≤0.01). CONCLUSION: ETS causes moderate to severe pain in neonates. Education improved performance of nurses and decreased pain in neonates during and after ETS. Despite education, neonates will experience mild pain during ETS, so other interventions need to be considerate.