In India there is a thrust towards promoting institutional delivery, resulting in problems of overcrowding and compromise to quality of care. Review of near-miss obstetric events has been suggested to be useful to investigate health system functioning, complementing maternal death reviews. The aim of this project was to identify the key elements required for a near-miss review programme for India.A structured review was conducted to identify methods used in assessing near-miss cases. The findings of the structured review were used to develop a suggested framework for conducting near-miss reviews in India. A pool of experts in near-miss review methods in low and middle income countries (LMICs) was identified for vetting the framework developed. Opinions were sought about the feasibility of implementing near-miss reviews in India, the processes to be followed, factors that made implementation successful and the associated challenges. A draft of the framework was revised based on the experts’ opinions.Five broad methods of near-miss case review/audit were identified: Facility-based near-miss case review, confidential enquiries, criterion-based clinical audit, structured case review (South African Model) and home-based interviews. The opinion of the 11 stakeholders highlighted that the methods that a facility adopts should depend on the type and number of cases the facility handles, availability and maintenance of a good documentation system, and local leadership and commitment of staff. A proposed framework for conducting near-miss reviews was developed that included a combination of criterion-based clinical audit and near-miss review methods.The approach allowed for development of a framework for researchers and planners seeking to improve quality of maternal care not only at the facility level but also beyond, encompassing community health workers and referral. Further work is needed to evaluate the implementation of this framework to determine its efficacy in improving the quality of care and hence maternal and perinatal morbidity and mortality. One of the key indicators used to assess maternal health is the maternal mortality ratio and, further to this, review of maternal deaths has been widely recommended . Review Audit of maternal deaths is considered a comprehensive way of checking the functioning of the health facility and also to identify gaps in service provision through use of a set of process indicators . SimilarIn India, recently introduced health sector reforms have managed to increase the demand for institutional delivery, resulting in an unprecedented growth in the rate of institutional births. Janani Suraksha Yojna (JSY), a conditional cash transfer scheme, has been instrumental in encouraging women to deliver in health facilities. Institutional deliveries in India have expanded from 53% in 2005 to 73% in 2009–10 . This phThe aim of this project was to identify the key elements required for a near-miss review programme through a literature analysis, and to conduct a key stakeholder analysis to develop a comprehensive framework for India, integrating the different levels of care in order to understand and identify actions to address the system deficiencies.A structured review was conducted to identify the various methodologies used in assessing near-miss cases. Google scholar, PUBMED, MEDLINE, Popline and the World Health Organization Global Health Library were searched using the key letters ‘maternal morbidity, near-miss, maternal death’, ‘maternal audit’, ‘near miss review’. The review was restricted to techniques used in LMICs. In addition, the website of the Indian health ministry was also searched for policy documents on guidelines or methods currently being promoted or used in India to assess maternal death and morbidity. The methodologies used were assessed based on the setting in which they were undertaken (i.e. whether at facility or community levels); the stakeholders involved in conducting the review; the types of tools used and the strengths and weaknesses of the methods. The findings of the structured review were used to develop a suggested framework and options for conducting near-miss reviews in India.Based on the structured review, a pool of experts who have worked extensively in either testing any of the near-miss review methods or validation of frameworks in LMICs was identified for vetting the framework. Eleven experts were identified, five from India and six who have worked in other LMICs such as sub-saharan and west African countries, Caribbean and Latin American countries. Experts included senior public health researchers, programme managers and technical experts. A guide highlighting the key themes for consultation was developed based on the structured review findings and the draft framework Table . DiscussOpinions were sought from the experts about the feasibility of implementing near-miss reviews in India, the processes to be followed, factors that make implementation successful and the associated challenges. Their views were sought on the framework developed on the basis of the structured review and its relevance in the present context. The discussion covered all the themes of the consultation guide and interviews continued until no new suggestions emerged on how to develop a framework to assess near-miss. A snowball technique was used to identify experts until thematic saturation was reached. Notes from the interviews were analysed thematically based on the elements that needed to be considered while undertaking a near miss review in LMICs. The draft framework was revised based on the analysis of the interviews.This study adheres to the RATS qualitative research guidelines and has been granted exemption from ethical review by the institutional ethics committee of the Public Health Foundation of India (TRC-IEC-222/14).The structured review identified five broad methods to conduct review and audit of near-miss cases or severe maternal morbidity in LMICs Table .Table 2The perspective of the experts on the key elements needed for a facility to undertake a near-miss review can be classified under four broad headings: identifying the appropriate method; adopting a step by step approach; not limiting the review process to an audit and engaging personnel at different levels in the health system.The structured review identified methodological options for near-miss reviews, such as criteria-based clinical audit and case reviews. However, the experts recognized that near-miss reviews involve time and resources in the facility. Therefore they felt the method to be adopted by a facility should be identified after assessing some key implementation aspects. The experts highlighted three considerations based on which the review method could be decided.Firstly, the number and type of cases the facility handles, i.e. whether it is primary care only, a referral centre at the secondary level or a tertiary care centre. This will determine the volume of near-miss cases the facility receives. Accordingly an individual centre can decide on whether the near-miss reviews and audit would involve review of all near-miss cases or review of a subset, such as the audit of all cases of a particular condition.Secondly, availability and maintenance of good data and documentation system was noted to be a deciding factor as it will determine whether there is need for introduction of new data collection formats for capturing the details of near miss cases, depending on the particular method being considered.Finally, policy level commitment and particularly local leadership and commitment of the staff was thought to be critical for sustainability of any approach or method for near-miss review.The experts felt that initiating a review and sustaining it should be a key objective of the facility. Therefore the decision on the method to be followed for near-miss review should be made through a collective process, which could involve both clinical and managerial staff to maximize ownership. This was thought to also help familiarize them with the process, assess the gaps in their data and documentation processes and ultimately allow the findings of the review to be linked with their own quality improvement plans. The respondents further emphasized that the frequency of the review process also needed to be decided jointly amongst all staff, and should be realistic and doable.Maternal death and severe morbidity audit can be a good quality marker. Quality improvement programs can use information about causes of deaths and morbidity to understand substandard care and how it can be averted. Respondents felt that near-miss case assessment provided further direction on how to improve the care that is provided, particularly where explicit audit standards do not exist. The changes identified as part of near-miss case reviews may be implementable at individual, team, or service level and, with further monitoring, can improve healthcare delivery. The experts felt that near-miss assessment can an effective tool to highlight the deficiencies as well as the positive elements in the provision of obstetric services in any health system and thus can be a good standard for any quality improvement process.Most of the experts felt that near-miss assessment should not be restricted to secondary or tertiary care levels. To understand a composite picture of the whole system (in a district), particularly the factors leading to delay in seeking and accessing care responsible for the near-miss condition of the women, it was felt to be additionally helpful to understand the factors at the community and primary care levels. Facilities conducting a near-miss review could therefore link with other facilities comprising the referral chain in their region.Based on the structured review and expert perspectives, a comprehensive framework for assessing maternal near-miss was developed. The framework provides options for health facilities to adapt and use either one or multiple methods of near-miss assessment, in order to monitor and improve their quality of maternal health services Figure . Option In conducting case reviews, a sample of near-miss cases can be identified and discussed by clinical and administrative staff at facility. The review team from the facility can prepare a case history, present the findings and facilitate the discussion in the meeting. The case history should include a woman’s age, obstetric history, condition during arrival, initial diagnosis, main procedure and other treatment provided, level of staff providing care, and outcome of care. The review should highlight favourable management procedures that saved the life of the woman, as well as adverse factors that led to the near-miss situation.Option 2 Figure  is a morIn order to have ownership of the findings and to devise solutions, the team constituting the assessment of near-miss cases at both the levels of the health system should be from the facility, particularly staff who attended the women, administrators of the health system and quality assurance program managers. This will ensure there is a holistic approach in analyzing gaps and deficiencies in the facility and devising solutions.This review and stakeholder analysis highlighted different approaches and methods that a health facility can adopt to identify and assess near-miss cases. The methods that a facility adopts depend on the type and number of cases the facility handles, availability and maintenance of good data and documentation system, availability of resources and local leadership and commitment of the staff. The proposed framework provides a holistic view of near-miss assessment and review if implemented in a geographical area by facilities at different levels. The inclusion of facilities at different levels can provide information about the overall functioning of the health system, thus implementing quality of care interventions in a more comprehensive way.Over the last two decades lessons have been learned concerning various methods to conduct maternal death review; some of the approaches have also been tested to assess near–miss or other maternal morbidity ,10,11. TIn low resource settings, it is often seen that many women reach higher-level health facilities in very poor health condition. This is often attributed to the delay in recognition of danger signs by the women and family members themselves, or delay in accessing the first level of care and further referral to the higher-level facilities ,28. The The framework highlighted in the study moves beyond clinical factors to address the issue of care provided by community level workers in terms of birth preparedness, knowledge of women/family members to identify danger signs and availability of transport, which plays a key role in accessing health services. One of the significant tools for assessing near-miss cases is the narrative of the survivor, which is critical for identifying deficiency in care. The survivor’s account can identify sub-standard care and assess the barriers at both the primary and secondary care level ,24. SimiThis paper proposes a comprehensive framework for assessing maternal near-miss in the Indian context, where access to and quality of primary care are likely to play important roles in precipitating maternal complications. The framework has been developed as a potential guide for researchers and planners seeking to improve overall maternal quality of care, not only at the facility level but also beyond, encompassing community health workers and referral. This framework, in terms of approach and tools for a comprehensive near-miss assessment involving both secondary and primary care level, can be integrated with the audit criteria developed by the Ministry of Health in India to assess near-miss cases . Further work is needed to evaluate the implementation of this framework, in terms of barriers to implementation, costs and outcomes to determine its efficacy in improving the quality of care and hence maternal and perinatal morbidity and mortality.


On the basis of Evalvid tool integrated in NS2 (Network Simulator version 2), the paper gets new set of tools, myEvalvid, to establish the simulation and evaluation platform for multimedia transmission. Then the paper investigates the effects of various influence factors when multimedia information is transmitted in the network and the relationships among these factors. Based on the analysis, the paper gets different evaluation models, respectively. In this paper, we study the impact on performance of several basic source and network parameters of video streams, namely, GOP (Group of Pictures) pattern, compression quantitative parameters, packet length, and packet error rate. Simulation results show that different parameters lead to different distortion levels which are calculated according to the reconstruction images at the receiver and the original images. The experimental results show that the video transmission and quality evaluation model we designed can evaluate multimedia transmission performance over complex environment very well. Image quality evaluation is one of the most important steps in the field of image processing. In all aspects of image processing, such as image compression, image transmission, and image deblur, image quality evaluation plays a very important role. Image quality evaluation methods can be divided into subjective evaluation method and objective evaluation method according to the subject of evaluation. The researchers often use mean opinion score method and the peak signal-to-noise ratio method. Over the past years, a lot of researches have been conducted towards the construction of objective video quality metrics. Applying NS2 (Network Simulator version 2) and Evalvid, video streams could be transmitted through the simulation network and the corresponding peak signal-to-noise ratio (PNSR) could be calculated. And the image transmission quality in different network environments, the influence factors on the quality of the image transmission can be analized of image transmission quality in different network environments and the influence factors on the quality of the image transmission.Recently, more and more telecommunication systems support different types of real-time transmission, and video transmission is one of the most important applications. The growing needs lead to the support of the video quality evaluation. Although many papers have been committed to study the QoS  mechanism which is supported through different types networks, many researchers are limited to the ranges of using packet loss rate, packet delay, and packet jitter as video transmission quality metrics. As known to us all, the above metrics cannot be easily transformed into video transmission quality. In fact, this relation may be due to coding scheme, hide loss scheme, and delay or jitter processing which are not the same leading to differences. To make detailed descriptions to these related parameters, we use NS2 and myEvalvid tools as simulation platform to obtain the transmission results. Obtained correlations among these parameters are of great significance to the evaluation of video quality.The paper creates the platform to simulate and evaluate the transmission image in the multimedia network. Various factors that affect the quality of video transmission are probed and the correlations among these factors are achieved. As for the issue of the simulation of video stream, the authors apply the method of introducing the traffic trace file of video stream to the network simulation circumstance, aiming to simulate the actual transmission of video stream in the network. Thus, the author can get the record file sd (send data) of sender and the record file rd (receive data) of receiver and use them to make an effect assessment. Different effects caused by various factors during video transmission can be also evaluated. Evaluation model could be established on the basis of these experimental findings. The results reveal that various value settings of GOP (Group of Pictures) pattern, quantization value, packet size, and packet error rate lead to different distortions between the original video and the reconstructed video.The remainder of this paper is organized as follows. Reference  used ANOSince in the real network environment the parameters of the network cannot be set to realize controllability and repeatability of the network damage, the paper presents the design of the simulation platform to simulate the process when the users watch video. The network transmission module is used to set up different QoS parameters and control network damage. Video quality evaluation module is used to compare the source video files and target video files to get user experience quality.myEvalvid: the interface program's main job is to learn to read VS (Video Sender) procedures from the film log files. The log files of each picture are cut into smaller segments, and the user in Tcl (Tool Command Language) Script can set in good time to the section which is the bottom of the UDP layer sending out.my_UDP: basically my_UDP agent is the extension of UDP agent. The new agent has the packet transmission time, packet identification, and packet load size recorded in the files which are set up by Tcl Script. Simply say, generally My_UDP's work is as Tcp-dump or Win-dump's work.myEvalvid_Sink: it is responsible for receiving packets which are issued by my_UDP. This agent records the receive time, packet identification, and packet load size in the files which are specified in Tcl Script.In order to improve Evalvid and to enhance the function of simulation, we can make Evalvid through the myEvalvid, my_UDP, and myEvalvid_Sink, which are three interface programs (or we can say agent) communicated with NS2. The integration is myEvalvid [20]. Below we aim at giving a simple introduction to myEvalvid, my_UDP, and myEvalvid_Sink.Using myEvalvid to evaluate image transmission quality, This paper uses akiyo_cif as an example and calculates PSNR value of each frame. A plot curve of results is shown in We can apply YUV viewer software to observe video frame distortion situation.When using myEvalvid to verify the multimedia network structure, we can calculate the PSNR of reconstructed video, which can be used to observe the difference between the received movie and the original movie. Taking 151st frame as example, the received PSNR value is 27.24. Compared with the 51st frame, the received PSNR value is 45.48, as shown in As shown from In network simulation transmission process, there are packet losses in the network. Since packet loss probabilities of different pictures are distinct, some pictures are in unsolvable state and the others are in solvable state. Therefore, distortion level of individual frame of the video stream will vary. That is to say, packet loss rate has a great influence on the quality of image transmission.For different multimedia streams, the quality of the transmission is distinct because of compression parameters, network parameters, and network states. In the network transmission, possible multimedia factors generally include the following: GOP pattern, quantization value, packet size, and packet error rate.Through the above analysis, we can change the settings of the parameters and conduct simulation experiment to obtain data. From the data analysis, we can discuss the influences of various kinds of factors on the quality of image transmission.(1) The influences of quantization parameters on the quality of image transmission; quantization is a process that attempts to determine which information can be safely discarded without a significant loss in visual fidelity.When the quantization parameters are set to 31, 20, and 10, the PSNR values of simulation results are shown in From (2) The influences of packet length in the quality of image transmission: to explore the influences of packet length in the quality of image transmission, we can change the packet size and MTU (Maximum Transmission Unit) values and keep other parameters constant. After conducting simulation, we can get different packet sizes and their correspondent average PSNR values. The processes of the experiments are complied with compression quantitative parameters simulation in the quality of the same image transmission. The results are shown in From (3) The influences of GOP pattern in the quality of image transmission: to explore the influences of GOP pattern in the quality of image transmission, we can set parameters of the GOP and calculate PSNR value to get the connection between the GOP and the quality of image transmission. The simulation results are shown in We can find from The two examples cited above are akiyo_cif and foreman_qcif because the two videos have different characteristics, considering the node, video dynamic, action, and complexity. Thus we make observation and comparison on different behaviors of each video and get the final results. It can be divided into the following steps to complete the evaluation model.First of all, conduction video is streaming under the reservation condition, with Evalvid frame integrated into NS2 module. Each of the two selected videos is simulated fifty times. All of the schemes, namely, 1, 2, 3, and 4 nodes, include a total of 400 times transmission.In the second step, we perform the statistical analysis. The goal is to get a more reliable and consistent database and eliminate the problems which may occur. Therefore, those who are away from the standard deviation value will be eliminated. one of these records contains the following QoS parameters: delay, jitter, and packet loss. This loss is calculated into total loss of a video. The loss refers to each frame's MPEG codec .In the third step, the original and decoded video file sequence are used to obtain QoS and QoE index. Using myEvalvid can obtain QoS index , MOS, and PSNR but cannot obtain more stable index, such as structural similarity and VQM . However, we can combine packets which are transmitted through myEvalvid to get QoS index.The last step is to multiple nonlinear regression equation to establish evaluation model and to evaluate its performance in the training sets and testing sets.Finally, through fitting, we get the superiority of the evaluation model.It can be seen from the front of the research that delay has nothing to do with video's user quality of experience, while the jitter and packet loss have great effects on the video's user quality of experience. Thus the research of network effect of multiple factors on video transmission draws the conclusion that it is mainly the combined effect of jitter and packet loss on the video of the user quality of experience. On the other hand, in the actual network conditions jitter and packet loss exist at the same time and have constant changes. So it is of more practical significance to research the jitter and packet loss's comprehensive influence on video's user quality of experience. It can be concluded that the influence of packet loss and jitter on the video quality is nonlinear relationship, so this paper adopts multiple nonlinear regression equation to establish nonparametric model. The regression equations are as follows:(a)The influence of DP on MQ: regression model is shown in(b) The influence of DP on VQ: regression model is shown inConsidering DP and JT separately, we can calculate their influence of MQ and VQ respectively.(c) The influence of JT on MQ: regression model is shown in(d) The influence of JT on VQ: regression model is shown inFrom Tables From Tables Taking first ninety frames of akiyo streaming video as example, we can draw PSNR value and MOS value of line charts. In Figures As shown in Verify the influences of all kinds of factors when investigating the quality of image transmission, by changing values of the parameters.Establish effective evaluation model on the basis of influence analysis of different factors, using linear regression model.The paper studied the video transmission and quality evaluation issue over NS2 and Evalvid based simulation networks. Contributions of this paper are summarized in the following.In the simulation platform, we implement the transmission and quality evaluation of video streams. The results show that the video transmission and quality evaluation model we designed can evaluate the multimedia transmission performance over complex environment very well, and it could be a powerful tool in multimedia transmission research.As for future work, we plan to study the impacts of network QoS on QoE of video, based on the model proposed in this paper. We will establish evaluation model of QoS to QoE and apply it to the network monitoring system which uses QoE as evaluation standard.


Epidemiological surveys over the last 20 years show a steady increase in the amount of alcohol consumed by older age groups. Physiological changes and an increased likelihood of health problems and medication use make older people more likely than younger age groups to suffer negative consequences of alcohol consumption, often at lower levels. However, health services targeting excessive drinking tend to be aimed at younger age groups. The aim of this study was to gain an in-depth understanding of experiences of, and attitudes towards, support for alcohol related health issues in people aged 50 and over.Qualitative interviews  and focus groups  were carried out with a purposive sample of participants who consumed alcohol or had been dependent.Participants’ alcohol misuse was often covert, isolated and carefully regulated. Participants tended to look first to their General Practitioner for help with alcohol. Detoxification courses had been found effective for dependent participants but only in the short term; rehabilitation facilities were appreciated but seen as difficult to access. Activities, informal groups and drop-in centres were endorsed. It was seen as difficult to secure treatment for alcohol and mental health problems together. Barriers to seeking help included functioning at a high level, concern about losing positive aspects of drinking, perceived stigma, service orientation to younger people, and fatalistic attitudes to help-seeking. Facilitators included concern about risk of fatal illness or pressure from significant people.Primary care professionals need training on improving the detection and treatment of alcohol problems among older people. There is also a compelling need to ensure that aftercare is in place to prevent relapse. Strong preferences were expressed for support to be provided by those who had experienced alcohol problems themselves. Population ageing is taking place in nearly all the countries of the world and this is expected to continue over the coming years . AlcoholAlcohol consumption has been associated with impairments in the instrumental activities of daily living and can Recent research has suggested that age-specific practices required to meet the needs of older people, in relation to alcohol consumption, and draw them into treatment are poorly understood. HoweverMid to later life has been defined as individuals aged 50 and over to reflect the eligibility criteria of the UKs leading charity for older people. The study was baseThe study involved qualitative interviews and focus groups with a purposive sample of middle aged and older people. Ethical approval was issued by Newcastle University Research Ethics Committee (application no. 000224/2009). Participants provided written informed consent to participate in this study. In line with the terms of consent to which participants agreed, the data are not publicly available and are not available to be shared outside the project team.Twenty-four in-depth interviews  were conducted between 19/11/09 and 15/03/10. Purposive sampling  aimed toTo compare individual accounts with socially negotiated versions of drinking in mid to later life, three focus groups were facilitated between 15/03/10 and 19/10/10. Staff at the three branches of Age UK distributed research information leaflets to members with experience of drinking alcohol and invited them to consider participating in a focus group, answered any questions they had about the research and asked those who were interested to complete a consent form. The first group comprised 9 participants ; the second group comprised 12 participants  and the third comprised 6 participants . To encourage participation, focus group participants were not required to disclose personal details other than age and date of birth; these data were gathered on consent forms. At the groups, participants were invited by the facilitator (GW) to offer views in general rather than recounting personal experience in front of others.Interviews and focus groups were conducted by GW, an experienced post-doctoral researcher, and lasted between 40 and 150 minutes either at individual respondent’s homes or the offices of participating organisations. The research team prepared topic guides (available on request) to initiate or return discussion to the research topics. Interview and focus group data were audio recorded, transcribed verbatim, anonymised and loaded into NVivo qualitative software, version 10. Data weNine of 15 participants still drinking alcohol described themselves as currently drinking sensibly, having reduced their alcohol consumption from previously higher levels. However some individuals had not reduced their drinking. The heaviest drinker reported consuming nine pints and a bottle of wine most days. Most women who reported drinking little nevertheless felt they had increased their consumption as they entered mid to later life.Going out to drink was a feature of the accounts of younger interviewees (50–69 years), with special occasions associated with heavier drinking:I’ve had the nights out with the girls, where we’ve got all of our troubles over in the last half hour and then concentrated on having a few good drinks and all that. I’ve had that, done that, been there, thoroughly enjoyed it, liked the feeling that it gave me. Choice of where to drink was limited for interviewees aged 70+ by their mobility or other circumstances, for instance if in a care home. Two of the older interviewees described being influenced to drink more by people living close to them. One older woman found she started to drink more when she became less mobile and received frequent visits at home from a neighbour who drank heavily.Interviewees who reported dependence described their drinking in mid to later life as increasingly taking place alone and at home. For female dependent drinkers this was a consequence of being at home much of the time; male dependent drinkers associated starting to drink at home with a shift to using alcohol as a coping strategy, or finding that drinking with other people inhibited their drinking. However, some dependent drinkers of both sexes valued social drinking as being less boring than drinking in the house alone. Some problem drinkers described drinking as a continuous process through the day, saving something at the end of an evening for an ‘eye-opener’ the next morning:I’ll come down on a morning after I’ve taken a bath upstairs. I hardly ever touch the drink upstairs, I’ll bring it down. I take my tablets with the whisky…and then I might have some breakfast. Since drinking had become a solitary activity for some, getting out of the house could be seen as an important measure in reducing or avoiding consumption. One woman who no longer allowed drink in her house explained:I used to go out to begin with, that was when I started drinking, and then I started staying in. That was when I started on the vodka because I thought well I’m in the house, if I get drunk nobody can see me. I can get as drunk as I want. I can make as big a fool of myself as I want. I’ve only got to get upstairs to bed, I haven’t got to walk up any banks or owt [anything] like that, and it just went downhill. In contrast to the individual interviews which were personalized, focus group participants tended to present themselves as responsible drinkers but described ‘other’ middle aged or older people they knew or knew of whose drinking was excessive or dependent.M: I knew a bloke who used to go in the [name] club, and he was, when he used to go in he’d say “I stand here, seven nights a week”, thinking he’s clever. Do you know where he is now? He’s got a leg off [amputated], aye he’s in a home, and he doesn’t know anybody, and it’s all down to drink. (Focus group 2)‘waiting till the sun passes the yardarm’:Some participants in particular described quite strict drinking habits or routines, for instance meeting particular groups of friends in pubs or clubs on specific nights, to help minimize the chance of heavy drinking. Those still working or volunteering during the week described drinking only on weekend nights when they would not be working the next day, or spoke of F: If it was after six in the evening I'd probably offer a drink before I would offer a tea or a coffee. (Focus group 3)nightcap’. For some participants, special occasions were the only times they reported having a drink. There were also suggestions that when away from home or on holiday, participants might drink greater amounts or more frequently:Routines included a drink out with a meal at lunchtime in the afternoon or merely a ‘F1: It's relaxing, a glass of wine, it's what you do abroad isn't it?F2: It is.GW: Is it? Do things change once you're on holiday?F3: Oh yes. Totally different on holiday.F2: Oh I think everybody changes when they're on holiday.F4: I drink more on holiday, well I do, I drink a lot when I go on holiday. (Focus group 3)Interviewees described consumption in pints, bottles, or cans rather than units and while some were aware of the UK government’s recommended guidelines they tended to be skeptical regarding their helpfulness. It was frequently argued that guidelines would not be relevant to everyone because they did not take account of individual differences in tolerance:I mean nobody goes out for a drink and says ‘I wonder how many units is in this? I better not drink that’ you know–nobody’s going to say that. Interviewees described themselves as aware of health campaigns targeting drinking, indeed some complained of their ubiquity. For some, public health messages were perceived as class-based ‘preaching’:I think the random, the average adult doesn’t drink too much in this country, but I don’t know, because I’ve got no figures and I think figures are done, are; they are created, put together by middle class people who haven’t worked at the coal mine or had a fishing boat or in the shipyards and they don’t see the socialisation, the outcomes of it, they only see the bad side of it. It was acknowledged that pressure from family or friends could build the impetus to change drinking behaviour. Older interviewees living in sheltered accommodation described censure from family members if they were thought to have been drinking too much, even though these relatives gave them bottles of alcohol as presents. Interviewees younger than 60 described realising that reducing their drinking might alleviate conflict in their family; for instance having received ultimatums from partners and children:Then one night he took the kids away from me and I pulled myself together overnight. I just got up one morning and said ‘enough’s enough–I want my kids back’ because my kids were my life. Some younger interviewees had sought help when their partner pointed out the impact of their drinking on the family. One interviewee described his carer as ‘bossy’, but was going to attend counselling because she had persisted in suggesting he do so. Family pressure was not always in the direction of reducing alcohol consumption; if other family members drank dependently, they could be seen as likely to increase the interviewee’s own alcohol consumption. Some interviewees recalled that their family had left them to their drinking, or that it had not been discussed when they came to visit. Some interviewees described themselves as disinclined to drink to excess because of anxiety around alcohol dependency. They recounted that acquaintances or family members had become dependent on alcohol or died from it, and this had made them cautious about drinking.Concern about the impact of alcohol on older bodies was voiced as likely to make older people reduce their drinking. Amongst those aged under 70 years, hangovers and the time ‘lost’ to them were seen as getting worse with age, and the desire to avoid them strengthened. Other strong incentives to limit consumption for this age group included ambitions for foreign travel and a desire to live more healthily, particularly to ensure a longer relationship with grandchildren or great-grandchildren. For interviewees aged 70+, fear of falling and the desire to avoid gaining weight were influential concerns. These incentives to reduce drinking were raised by both male and female interviewees.not drinking, such as the loss of an enjoyable part of their lives, possibly the only one left to them:However, when interviewees talked about giving up alcohol, they also recalled varied concerns about the consequences of I’d like to cut it down altogether, but even the last time–I cannot be going away and just sitting on my own. I don’t smoke, I don’t have nowt else and that’s the only pleasure I’ve got–drinking. Dependent drinkers were concerned about severe withdrawals or that they might be unable to cope with a return or worsening of their mental health problems. One interviewee with chronic obstructive pulmonary disease was concerned that cutting down had led her to smoke more. Others thought it would be difficult to spend time with friends or family if they did not drink:I couldn’t understand how you can have fun just going out and having a cup of coffee. You think how boring. I felt as though I could open up a lot more, you know, when you’ve had a few drinks. Those who had been dependent but had reduced their drinking cited severe medical events, or a warning from a doctor that this was imminent, as powerful incentives to change; for instance, bringing up blood, a diagnosis of pancreatitis or identification of an enlarged liver. Some interviewees felt it was ‘too late’ for them to attempt to change their dependent drinking:If you’re an alcoholic or an addict and say you’re 25 you have basically maybe 45 years to go, you know, of life. A person who is say 55 and drinking a lot says to himself ‘ah well I'm 55 now what’s there to look forward to now? Doesn’t matter if I stop drinking’ A number of reasons emerged why middle aged and older dependent drinkers might have delayed seeking help with their problem. For example, some perceived it as something to be dealt with by themselves, they felt able to function while drinking and perceived a strong stigma attached to being a dependent drinker, and they had been unaware or uncertain of what help was available.Only a few participants from the focus groups correctly specified what the recommended guidelines for alcohol consumption were, and most agreed that calculating units was confusing:M: I’ve seen it on the TV, so many units; I watched a programme about it on the TV, but I can’t remember the units…but they reckon is more, in theory, what women drink, there’s more in the wine, than what it is for beer. (Focus group 2)At two of the focus groups, participants suggested that many middle aged and older people would regard advertising campaigns against excessive drinking as targeting those who got themselves drunk or lost self-control when drinking, and therefore not relevant to themselves. Participants were also critical of mixed messages from research reports in the media over whether red wine was beneficial or not.Some incentives were mentioned by participants for moderating drinking, including diets, driving, the desire to see one’s grandchildren grow up, and the desire not to appear foolish:M: I could go out and drink 7, 8 pints, but it would be making a fool of myself really, you know. (Focus group 2)One group suggested that many middle aged and older people were motivated to avoid alcohol or minimise their intake because of fears they might become alcoholic.Interviewees who recounted problems with alcohol indicated that General Practitioners (GPs) were the first source of help encountered. Participants may have sought help either for their drinking, or for mental health problems with which the drinking was associated:At the time I was suffering from depression as well and obviously if you want something, some medication, that’s [GP’s] where you’re going to go. However, asking a GP for help usually meant overcoming a reluctance to do so, or to admit to being ‘drunk all the time’ or having an alcohol problem, which could be uncomfortable or embarrassing. One woman had not managed to face asking her GP for help until a friend took her along. Such interviewees recalled trying to hide their drinking from their GP or play down its extent. Some saw GPs as not wanting to treat drinkers, or did not see drinking as a ‘legitimate’ illness to trouble a doctor with:But you can’t imagine somebody going in [to the doctor] and saying ‘oh, I’ve got a problem, I’m drinking far too much, what help can I get?’ can you? While some participants felt they had been successful in hiding their drinking others recalled that their GP had asked about drinking because of the smell of alcohol:He [GP] said ‘have you been drinking?’ and I just said ‘aye, 1 or 2’ he said ‘do you know what time it is?’ I said ‘I’m quite aware of the time’ he said ‘I think you’ve got a problem’. GPs were identified, by some, as a source of pressure for changing behaviour. When they had been encouraging about a reduction in consumption, this was seen as positive. However, GPs could also be viewed as having high expectations of abstinence or drastic reductions that participants might have felt unable to meet. They had usually directed participants seeking help to contact a support service or group, or made a referral for detoxification or a psychiatric nurse rather than offering advice on how to cut down themselves:But Dr [name] is the type of doctor where he’s so laid back, he didn’t specifically say to me ‘that can happen with your liver–that can happen with your brain–that can happen…’ I didn’t get that information. It was just ‘you’ve got a problem–here’s a card now go and deal with it’. One participant thought that many GPs did not understand problems that middle aged and older people faced with drink, but simply referred them on without necessarily knowing the most appropriate service. Some participants felt that their GPs had tried to prescribe them medication in relation to their alcohol problem or associated mental health problems without listening to them or considering alternatives to medication.No clear differences emerged in experiences of primary care between men and women. Among the oldest group of interviewees (aged 70+), all but one said their GP no longer asked about alcohol; one explained this was “because they know I don’t drink”. The one man who said his GP still asked him about alcohol attributed this to his having had a stroke.At all three focus groups, participants thought that it was important for doctors to be able to ask about all areas of health, but one group agreed that doctors were overly prone to look to alcohol consumption to explain the symptoms they visited about. Older women in sheltered accommodation on the other hand said that they were never asked, or felt that their doctors knew them well enough personally to know that they had no problems with alcohol. As one woman put it ‘they [doctors] have never had to pick me off the ground’.Most interviewees who reported a serious alcohol problem had been through a detoxification programme at least once, in many cases several times, usually inpatient programmes or emergency responses to a hospitalisation. One interviewee who did not view himself as having any alcohol problems had been outraged to find that he received detox medication when hospitalised for a stroke:I says ‘get the forms, I’ll sign myself out’. I says ‘all you are thinking about is me being an alcoholic’… They were injecting something into my stomach. Some interviewees had been unable to arrange for a home detox because they lived in temporary accommodation or did not have 24 hour support. Others found it had been difficult to secure a referral for detox because they were not drinking enough at the time, including one woman who said she had been told to reduce her drinking to one bottle of cider a day, but was then told she drank too little to qualify.Detox programmes had enabled problem drinkers to stop drinking and, for instance, start eating again, but this had almost always been a temporary change. For one interviewee, the abstinence achieved had always been succeeded by complacency and relapse some months down the line. More often participants complained that after detoxification, they had returned to the settings or problems that had fueled their drinking with little or no follow-up to help them avoid alcohol:Detox and then back to your normal life. I mean the nurses come out every day and they give you vitamin injections which last 6 month[s]. Then come the end of the week, that’s it: they’re gone and you’re back to just keeping away from the pub. You know what I’m saying? It’s hard. Some complained that no attempt was made to address mental health problems alongside a detox. Those referred for detox by counselling services did feel they had been supported through counselling before and after, and appreciated this. One man, for instance, felt that the programme he was about to undertake was more likely than his previous referral to make a difference because of the ten weeks of counselling to prepare him for it.Rehabilitation programmes were viewed as more expensive, and referrals to them as harder to secure. This required one to demonstrate likelihood to achieve and sustain abstinence. One interviewee did not think that the rehabilitation facilities available were necessarily appropriate for middle aged or older people, describing one establishment as ‘scary’ as it accommodated ‘real winos’. Few participants mentioned having been through rehabilitation, but those who had, described it as an important part of their recovery. Views differed on the usefulness of the group work and activities that formed part of the programme, but the experience of sustained support and individual advice away from everyday routines was seen as a positive factor. They felt again that the support they required during the period after they left the programme had not always been available:It’s when you come out and you’ve got nobody–that’s when you need them. I came out…I went in on the 30th November, and I was only away a week…I think it was the second week in January I got a letter to say ‘make an appointment to see me’. The lack of support to follow up rehabilitation made relapse likelier, and one woman estimated she had been through five programmes. Long waiting lists were also viewed as a problem, meaning that the impulse or readiness to make a change in behaviour might have passed by the time a place became available.Due to the smaller numbers of participants experiencing detoxification and rehabilitation there were no differences that could be meaningfully attributed to age or gender.Those who had given up drinking as a response to counselling were positive about the help they had received; those who were still drinking and had received counselling appreciated the chance to talk to someone in private but did not see it as having had a significant effect. Counselling was seen as helping to deal with underlying problems, preparing them for other interventions, or supporting abstinence and relapse prevention. One participant whose GP had referred her to a psychotherapist for her mental health problems described this help as ‘brilliant’, as it had helped her understand why she drank. However, the experience of turnover in counsellors, when one moved to a new job, was unsettling, making participants feel as if they had to start from scratch in developing a relationship with the new counsellor, and one participant was inclined not to try counselling again because of this.Some participants expressed a preference for services that were not specifically dealing with alcohol problems, partly because they felt alcohol services brought them into contact with alcoholics who were likely to encourage relapse; for instance one interviewee said of Alcoholics Anonymous:It’s just a load of sob stories. I think ‘well I’ve got enough of my own’ without listening to somebody else’s. It made me feel depressed and I wanted a drink when I came out. Groups tended to be appreciated more when they were not focused solely on drinking. Relaxation, alternative therapies and arts classes were popular, helping to fill the day and allowing interviewees to expand their social circle. Both activity groups and drop-in centres  were enthusiastically endorsed as forms of support that gave access to other people to talk with on an ad-hoc basis:They know where you’re coming from and they're volunteers and they sit and they talk to you and you just chat and it's a way of putting in your time without going to the boozer or getting a drink. It was frequently emphasised that support was best coming from people at the same stage of struggling with alcohol as themselves, or from an ex-alcoholic, in part because they were seen as less likely to be judgmental about drinking and relapses. A voluntary organisation staffed by recovering drinkers was praised because volunteers understood the problems involved but presented the example of health and stability to aspire to. They were seen as a ‘little family’ with which interviewees could connect in the face of isolation experienced elsewhere:My world is drink and people who drink. The people in the [shopping centre], they might as well–either I might as well not be there or they might as well not be there because I can’t equate with them. Doubts were often expressed about people who had not been through alcohol problems themselves offering help because they lacked first-hand knowledge. Some people were also critical of receiving help from people much younger than themselves who did not know what alcohol problems were like for middle aged or older people, though others thought the age of the person helping you made no difference.Due to the smaller numbers of participants experiencing counselling and therapy there were no differences that could be reliably attributed to age or gender.Middle aged and older people’s alcohol misuse may be covert, isolated and carefully regulated and is therefore unlikely to be as obvious as that of young people drinking in public or in external networks of friendship or work groups. Targeting of health messages is therefore important. However the people who we spoke to were skeptical about recommended guidelines for alcohol and rarely measured consumption in units. This is consistent with the literature that older people are one of the least well informed groups about alcohol units both in the UK and AustPrimary health care emerged as important in the identification of problems and provision of advice since this is where middle aged and older people had looked first for help with alcohol problems. This is also consistent with previous research which showed that GPs were the preferred first point of contact for adults with alcohol problems. ScreeniPeople in this sample who had experienced alcohol dependence felt that detoxification services had been effective at least in the short term. Other research from the US has reported that older people are at least as likely to benefit from treatment as younger people; and they tend to follow treatment regimens more diligently too, 48. HowThis age group may perceive distinct barriers and incentives to seeking help for alcohol. People described feeling ashamed of being seen as an alcoholic, feeling that services regarded them as ‘on the shelf’, and perceiving themselves as too late in life to change or benefit from treatment. They were concerned about how to cope with boredom, isolation and other health problems without alcohol. However most of those we spoke to had reduced their drinking with or without specialist help. The goals of prolonging life and rebuilding family relationships were reported as strong incentives to change. Evidence for treatment regimes for older people suggest that uptake and success of interventions could be enhanced by facilitating understanding that alcohol problems need not represent an inevitable decline, and helping older people to plan for sustaining an active and involved lifestyle, 48 SimiIt has been postulated that behaviour is influenced not only by individual-level attributes but also the conditions under which people live. ParticiDifferences by age and gender were attributed to codes where all participants could provide an opinion but not to codes where only a proportion of participants had experience. There were subtle differences in results by age but not gender. Going out to drink was a feature of the accounts of younger interviewees while choice of where to drink could be limited for interviewees aged 70 or more by their mobility or other circumstances, for instance if in a care home. While this change in drinking location seemed to be a direct result of the ageing process there is currently a national trend for less on-trade and more off trade alcohol consumption. ConcernThis research contributes to the limited body of in-depth qualitative data regarding the issues surrounding alcohol consumption in mid to later life, highlighting the needs of middle aged and older people in relation to service provision around alcohol and health. While the sample was relatively small and restricted to a single region of the UK it did provide a depth of data which could not have been achieved via a large quantitative sample. It must be acknowledged however that while one of the aims of purposive sampling was to recruit both genders, females were over represented in the focus groups. Nevertheless considerable diversity was achieved in individual interviews with males well represented. Yet it appears that there is growing international recognition of the needs of older people in relation to alcohol consumption. The mosIt has been suggested that tailored screening tools perform better with older people and that


Malnutrition is highly prevalent among hospitalized patients, ranging from 30% to 50% depending on the patient population and the criteria used for diagnosis. Identifying early those who are malnourished and at risk of malnutrition and intervening at an early stage will improve patients overall prognosis and will reduce the costs to the state. Even though cardiac patients are at risk of malnutrition, data on the prevalence of malnutrition among cardiology inpatients is limited. The aim of the study was to assess malnutrition status of the newly admitted patients in a specialist cardiology institution in Sri Lanka by internationally recommended nutrition screening and assessment tools. During study period, 322 (61.22%) males and 204 (38.78%) females were recruited. Malnutrition status assessed by each screening tool had a wide variation. According to Mini Nutritional Assessment tool 69.6% were having possible malnutrition. Malnutrition Screening Tool 47.9% to be at risk of malnutrition. Subjective Global Assessments categorized only 4.2% as malnourished on the other hand Malnutrition Universal Screening Tool categorized 20.4% and 19.6% subjects as at medium risk and high risk of malnutrition respectively. Nutritional Risk Screening detected 6.3%, 25.1% and 24.9% patients to be mildly, moderately and severely malnourished respectively. Short Nutrition Assessment Questionnaire categorized 5.0% and 17.7% patients to be moderately malnourished and severely malnourished correspondingly. In conclusion, Although malnutrition was prevalent among this population, a wide variation in the nutritional status when assessed by widely used internationally recognized tools was observed.The online version of this article (doi:10.1186/2193-1801-3-412) contains supplementary material, which is available to authorized users. Malnutrition is any imbalance in nutrition; from over-nutrition to under-nutrition. Over-nutrition which was more prevalent in developed countries is now becoming a major health problem in less developed countries as well  is a simple instrument to identify patients at high risk of malnutrition  is the leading cause of mortality in hospitals in Sri Lanka accounting for 22.7 deaths per 100000 population while it has led to 330 admissions per 100,000 of all hospital admissions  was measured using a electronic flat scale  and height (to the nearest 1 mm) was measured using a standard stadiometer  by a trained medical officer. Body mass index (BMI) was calculated by dividing weight (kilograms) by the square of height (meter).Nutritional status was assessed by MST, MUST, SNAQ, MNA-SF, NRS and SGA questionnaires. MST is a simple, three-question tool assessing recent unintentional weight and appetite loss. MUST assess body mass index, unplanned weight loss in past 3–6 months and the presence or absence of acute illness or lack of nutritional intake >5 days. NRS 2002 includes reduced BMI, recent weight loss, recent decreased dietary intake and severity of the illness. MNA-SF utilizes information on decreased food intake, recent weight loss, degree of mobility, recent psychological stress, acute illness, neuropsychological problems and BMI. SNAQ assessed recent weight loss, recent decreased appetite, and recent intake of supplemental drinks or tube feeding. SGA was used to assess nutrition using data on weight change, dietary intake change, gastrointestinal symptoms , and changes in functional capacity  in relation to malnutrition as well as assessment of fat and muscle stores and the presence of oedema and ascites by a trained medical officer. The diagnosis made by the clinicians was utilized to calculate diagnosis related stress level measured in SGA.t-test were used to compare male and female population. P value < 0.05 was considered as statistically significant. Patients were classified in to different nutritional groups according to each different tool.Data entry and statistical analysis was performed using the SPSS Version 16.0 statistical package. Categorical variables were expressed as number and percentage (%) and continuous variables were expressed as mean and standard deviation. Chi square test and The present study was conducted according to the guidelines laid down in the Declaration of Helsinki and was approved by the Review Committee, National Hospital of Sri Lanka, Sri Lanka.-2 (±4.15) while the females had a higher BMI than males .Five hundred twenty six patients were included, of whom 322 61.22%) were males and 204 (38.78%) were females. The majority were Sinhalese  while Sri Lankan Tamils , Indian Tamils , Muslims  and other ethnic groups  made the rest of the population. A large proportion  had studied up to grade 11 and only 55 (10.5%) had not had a formal education. The population consisted of a variety of patients with the majority presenting with an acute coronary syndrome . Arrhythmias was the second commonest disease category and included 67 (12.7%) patients., Fifty nine patients presented with heart failure and cardiomyopathies while another Fifty nine patients (11.2%) were categorized under miscellaneous  patients were identified as having normal nutritional status, 336 (63.9%) as at risk of malnutrition and 30 (5.7%) as malnourished. MST detected 276 (52.1%) subjects to be normal and 250 (47.9%) to be at risk of malnutrition. SGA categorized 503 (95.8%) subjects as well-nourished and 23 (4.2%) as malnourished. Although the cumulative value of SGA was low, the sub-components of SGA relived nearly every second patient had lost weight unintentionally  was 40% in our population according to MUST which is compatible with the prevalence of malnutrition ranging from 19-60% in hospital inpatients .(DOC 144 KB)Additional file 1::


Chemical exchange saturation transfer (CEST) is an emerging MRI contrast mechanism that is capable of noninvasively imaging dilute CEST agents and local properties such as pH and temperature, augmenting the routine MRI methods. However, the routine CEST MRI includes a long RF saturation pulse followed by fast image readout, which is associated with high specific absorption rate and limited spatial resolution. In addition, echo planar imaging (EPI)-based fast image readout is prone to image distortion, particularly severe at high field. To address these limitations, we evaluated magnetization transfer (MT) prepared gradient echo (GRE) MRI for CEST imaging. We proved the feasibility using numerical simulations and experiments in vitro and in vivo. Then we optimized the sequence by serially evaluating the effects of the number of saturation steps, MT saturation power (B1), GRE readout flip angle (FA), and repetition time (TR) upon the CEST MRI, and further demonstrated the endogenous amide proton CEST imaging in rats brains (n = 5) that underwent permanent middle cerebral artery occlusion. The CEST images can identify ischemic lesions in the first 3 hours after occlusion. In summary, our study demonstrated that the readily available MT-prepared GRE MRI, if optimized, is CEST-sensitive and remains promising for translational CEST imaging. Chemical exchange saturation transfer (CEST) imaging is a variant of magnetization transfer (MT) MRI contrast mechanism that probes the chemical exchange between dilute labile protons and bulk water For dilute CEST agents undergoing slow and intermediate chemical exchange, the magnitude of CEST effect is typically a few percent and therefore, it is important to improve its sensitivity by optimizing the acquisition and post-processing strategies Dixon et al. proposed interleaving short frequency-selective saturation and spatially selective excitation pulses for CEST imaging, and demonstrated that for short TR, CEST effect approaches its steady state over the saturation time We also translated the optimized sequence and preliminary demonstrated endogenous amide proton transfer (APT) MRI Tissue-like CEST phantoms were prepared for optimizing CEST MRI All experimental protocols were approved by the Ethics Committee of Shantou University Medical College and all experiments were performed in accordance with guidelines from the Chinese Animal Welfare Agency. Five adult male Sprague Dawley (SD) rats (weighted about 200 g) were underwent permanent middle cerebral artery occlusion (MCAO) by thread embolism. First, the rats were anesthetized with 3% pentobarbital, intraperitoneal injection, and immobilized in a standard rat table. Then, MCAO models were performed by inserting the 4-0 nylon suture into the lumen of internal carotid artery to block the origin of the middle cerebral artery. Animal core temperature, respiration and heart rates were monitored throughout the procedure. Another normal adult male SD rat was used for multi-slice CEST imaging. MCAO rats were euthanized with overdose of Phenobarbital by intravenous injection after Scanning. All efforts were made to minimize animal suffering and to reduce the number of animals used.The time-dependent CEST effect for the proposed MT-prepared GRE CEST MRI sequence was analyzed by numerical simulation in Matlab . Specifically, we used Bloch-McConnell equations to simulate the two-pool proton exchange model. 0 field was shimmed using 3D gradient shimming that adjust high-order gradient shimming currents based on the derived B0 field map. The RF field and center frequency were calibrated in pre-scan. MT-prepared GRE MRI sequence was used for CEST imaging. First, the CEST imaging and Z-spectra were demonstrated by tissue-like phantoms and normal SD rat brain. Routine GRE MRI parameters were set: TR/TE = 26/2.3 ms and FA = 20°, unless specified otherwise. In addition, we had slice thickness = 2 mm, field of view (FOV) = 34×34 mm2, imaging matrix = 64×64, number of average (NA) = 1, dummy scan = 4, and bandwidth = 50 kHz. Total scan time was about 1.6 s for one slice.All MRI experiments were conducted using a horizontal bore (bore size 160 mm) Agilent 7 T animal MRI scanner  with a 63 mm internal diameter standard 1 H volume coil (one-channel) for RF transmission and reception. Field gradients: 400 mT/m in maximum 200A. The BCEST MRI was optimized as functions of the number of saturation steps (Steps), saturation power (B1), GRE readout FA and TR. Specifically, the Steps was varied from 32, 64, 128, 192, 256, and 512 to 1024 while the saturation power and duration were set to 0.59 µT and 20 ms. In addition, the MT saturation power was varied from 0.16 µT to 1.12 µT. Specifically, the MT saturation pulse was chosen as a 20 ms width gauss pulse, with flip angle varied from 50° to 350° with intervals of 50°, so their corresponding powers are from 0.16 µT to 1.12 µT with intervals of 0.16 µT . Moreover, FA was varied from 5° to 60° with intervals of 5° or 10°  and TR was varied from 26 to 210 ms in five steps .In order to be better applied in vivo, the same key parameters  were also evaluated in five adult male MCAO SD rats in the first three hours after occlusion. The rat brain was immobilized in a standard rat cradle. Images were averaged 64 times to improve its signal to noise ratio caused by the use of volume coil. First, the number of saturation steps was varied from 64, 128, 256, 512, 1024 to 2048 while the saturation power and duration were set to 0.39 µT and 15 ms. In addition, the MT saturation power  was varied from 0.39 µT to 1.57 µT with intervals of 0.19 µT with Step = 4096, TR = 21 ms, and FA = 5°. Moreover, FA was varied from 5° to 20° with intervals of 5°  and TR was varied from 21, 30 to 40 ms . Regions of interest (ROI) were manually drawn on the ischemic lesions and contralateral normal regions by three expert radiologists.2 were acquired for reference.Optimized data were obtained in five MCAO SD rats brains based on the optimized parameters . Total scan time was about 1.4 minutes for one image. Other routine MRI sequences: T2-weighted imaging  and ADC maps  with b-value of 1000 s/mmlabel) and reference (Iref) images with RF saturation applied at the labile proton frequency  and reference frequency , in addition to a control scan without RF irradiation (I0). The MTRasym was calculated as ref−Ilabel)/I0. Assessment of the contrast between the ischemic lesion and the contralateral normal region were performed via paired t-test. Values were presented as mean±SD, and p<0.05 was considered as statistically significant.Images were processed using the VnmrJ 3.1A  and Matlab . Z-spectra were calculated from the normalized images for ROI outlined in each phantom compartment. The scatters were drawn with mean signals as ordinate and RF offset as abscissas, smoothed using a spline function Our study found that although each brief MT pulse generates a small increase of CEST effect, it cumulates effectively for short TR over the number of saturation steps, consistent with the conclusion of Dixon et al. Our study showed that CEST effects strongly depend on TR and FA both in vitro and in vivo. Short TR reduces T1- relaxation induced loss of CEST effect for more efficient cumulative effect toward the steady state CEST MRI It is important to note that throughout all the experiments we used a standard one channel volume coil, which allowed us to have better B0 homogeneity than that in smaller coil. The full width at half maximum were about 15 in phantoms and 30 in rat brains. Moreover, although the direct saturation effect makes CEST imaging very sensitive to B0 inhomogeneity, it can be neglected in the APT imaging due to the small saturation B1. However, for large saturation B1, it is necessary to have B0 correction. More importantly, the signal to noise ratio can be improved significantly if the coil is upgraded, and the CEST effects can be easier to be observed. In summary, our study demonstrated that optimized MT-prepared GRE MRI is suitable for in vivo CEST imaging.Our study optimized MT-prepared GRE MRI for CEST imaging by evaluating the effects of the number of saturation steps, MT saturation power, GRE readout FA and TR in tissue-like phantoms. We have also demonstrated the endogenous amide proton CEST MRI both in healthy and in MACO SD rat brains on a 7 T scanner. In conclusion, this method can provide an alternative, straightforward, and effective way to obtain CEST images on clinic MR scanners without hardware or software modifications.