Original article
The Volume-Viscosity Swallowing Test – Portuguese Version: Validation and prevalence of safety and efficacy clinical signs in acute stroke patients
La prueba de deglución volumen-viscosidad - versión portuguesa: validación y prevalencia de seguridad y signos clínicos de eficacia en pacientes con accidente cerebrovascular agudo
a Faculty of Medicine of the University of Coimbra, Coimbra, Portugal
b Center for Research in Health Technologies and Services (CINTESIS @RISE), Porto, Portugal
c School of Health Sciences, University of Aveiro (ESSUA), Aveiro, Portugal
d Centre for Research and Development in Mathematics and Applications (CIDMA), Department of Mathematics, University of Aveiro (DMAT), Portugal
e Faculty of Medicine of the University of Coimbra, Coimbra, Portugal
f Center for the Study and Development of Continuing and Palliative Care, Faculty of Medicine of the University of Coimbra, Coimbra, Portugal
g Centre for Health Studies and Research of the University of Coimbra – Faculty of Economics of University of Coimbra, Portugal
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"apellidos" => "Joshi" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0214460322000341?idApp=UINPBA00004N" "url" => "/02144603/0000004200000004/v1_202210230632/S0214460322000341/v1_202210230632/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original article</span>" "titulo" => "The Volume-Viscosity Swallowing Test – Portuguese Version: Validation and prevalence of safety and efficacy clinical signs in acute stroke patients" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "227" "paginaFinal" => "237" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Catarina Camões, Assunção Matos, Pedro Sa-Couto, Marília Dourado" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Catarina" "apellidos" => "Camões" "email" => array:1 [ 0 => "camoes.catarina@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Assunção" "apellidos" => "Matos" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0025" ] ] ] 2 => array:3 [ "nombre" => "Pedro" "apellidos" => "Sa-Couto" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "Marília" "apellidos" => "Dourado" "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "aff5" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">f</span>" "identificador" => "aff0020" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">g</span>" "identificador" => "aff0035" ] ] ] ] "afiliaciones" => array:7 [ 0 => array:3 [ "entidad" => "Faculty of Medicine of the University of Coimbra, Coimbra, Portugal" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Center for Research in Health Technologies and Services (CINTESIS @RISE), Porto, Portugal" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "School of Health Sciences, University of Aveiro (ESSUA), Aveiro, Portugal" "etiqueta" => "c" "identificador" => "aff0025" ] 3 => array:3 [ "entidad" => "Centre for Research and Development in Mathematics and Applications (CIDMA), Department of Mathematics, University of Aveiro (DMAT), Portugal" "etiqueta" => "d" "identificador" => "aff0015" ] 4 => array:3 [ "entidad" => "Faculty of Medicine of the University of Coimbra, Coimbra, Portugal" "etiqueta" => "e" "identificador" => "aff5" ] 5 => array:3 [ "entidad" => "Center for the Study and Development of Continuing and Palliative Care, Faculty of Medicine of the University of Coimbra, Coimbra, Portugal" "etiqueta" => "f" "identificador" => "aff0020" ] 6 => array:3 [ "entidad" => "Centre for Health Studies and Research of the University of Coimbra – Faculty of Economics of University of Coimbra, Portugal" "etiqueta" => "g" "identificador" => "aff0035" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "La prueba de deglución volumen-viscosidad - versión portuguesa: validación y prevalencia de seguridad y signos clínicos de eficacia en pacientes con accidente cerebrovascular agudo" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1204 "Ancho" => 3175 "Tamanyo" => 165943 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Prevalence of clinical signs of safety and efficacy of oral and pharyngeal phases of swallowing for each bolus volume and viscosity during the V-VST EP application. The ordinate axis is the percentage value of the prevalence of the safety and efficacy signs and the volume administrated in ml is on the abscissa axis.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">According to the Direção Geral de Saúde (a Directorate of the Portuguese Health Ministry) (<a class="elsevierStyleCrossRef" href="#bib0090">Health, 2018</a>), cerebrovascular and heart diseases were the cause of 29.7% of deaths in Portugal in 2018. Strokes account for 10.8% of deaths (<a class="elsevierStyleCrossRef" href="#bib0095">INE, 2015</a>). Despite all the scientific advances that have allowed an increase in the number of stroke survivors, worldwide these patients present various sequelae and dependencies that affect their daily lives. Therefore, a stroke is an important cause of morbidity as well as disability in global terms (<a class="elsevierStyleCrossRefs" href="#bib0100">Johnson et al., 2016; Sá, 2009</a>).</p><p id="par0010" class="elsevierStylePara elsevierViewall">Currently, acute cerebrovascular disease, namely ischemic stroke, has emerged as a serious complication of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), an infection associated with the Coronavirus Pandemic of 2019 (COVID-19) (<a class="elsevierStyleCrossRefs" href="#bib0190">Trejo-Gabriel-Galán, 2020; Vogrig et al., 2021</a>). The virus can affect the brain parenchyma, the endothelium, the heart and alter the coagulation, culminating in a stroke. In addition to the fact that the pandemic could increase the incidence of strokes, social isolation decreased the control of risk factors and the access to health services (<a class="elsevierStyleCrossRefs" href="#bib0070">Ghosal et al., 2020; Valtorta et al., 2018</a>).</p><p id="par0015" class="elsevierStylePara elsevierViewall">Underlying the neurological sequelae of a stroke, a significant number of individuals present oropharyngeal dysphagia (OD), with an incidence varying between 2 and 25% after six months of the acute episode (<a class="elsevierStyleCrossRef" href="#bib0075">Guillén-Solà et al., 2013</a>) and a prevalence ranging from 2.4% to 80.0% depending on the underlying aetiology, age, environment and way of investigation (<a class="elsevierStyleCrossRef" href="#bib0020">Audag et al., in press</a>). In the presence of OD, if no timely intervention is made, there is an increased susceptibility to develop aspiration pneumonia, as well as experience dehydration and malnutrition, among other consequences. This will result in more days of hospitalization, with the consequent increase in health costs, and the need to spend more time and resources on rehabilitation (<a class="elsevierStyleCrossRefs" href="#bib0030">Belafsky et al., 2008; Nogueira et al., 2015</a>). Dysphagia also has a significant impact on the social and psychological context of patients and their families, namely due to episodes of isolation during meals and decreased social interaction (<a class="elsevierStyleCrossRef" href="#bib0130">Moloney and Walshe, 2017</a>). In order to avoid these complications, an early detection, evaluation and intervention is required (<a class="elsevierStyleCrossRefs" href="#bib0030">Belafsky et al., 2008; Nogueira et al., 2015; Rofes et al., 2012</a>). Thus, the use of appropriate and valid screening instruments, with good sensitivity and specificity, is essential (<a class="elsevierStyleCrossRefs" href="#bib0040">Clavé et al., 2008; Speyer, 2013</a>). These instruments should also be of easy administration, low time-consuming, non-invasive (avoiding distress to patients), and not requiring a complex training for its application and interpretation. Screening is considered an essential first step in the management of patients at risk for aspiration or unsafe swallowing and can be performed by any trained health practitioner. If patients fail the screen, further assessment (clinical assessment) is required by a specialist in swallowing disorders (<a class="elsevierStyleCrossRef" href="#bib0175">Speyer, 2013</a>), commonly a speech and language therapist (SLT). Clinical assessment allows the identification of possible causes of OD, and the evaluation of swallowing safety or risk of aspiration. This evaluation will decide between oral or other alternative feeding routes for the patient, to clarify the need for further assessment (instrumental assessment), and to establish pre-treatment clinical data (allowing for follow-up assessments after intervention or during progressive diseases) (<a class="elsevierStyleCrossRef" href="#bib0175">Speyer, 2013</a>).</p><p id="par0020" class="elsevierStylePara elsevierViewall">A few bedside screenings have been described in the literature (<a class="elsevierStyleCrossRefs" href="#bib0010">Antonios et al., 2010; Belafsky et al., 2008; DePippo et al., 1992; Martino et al., 2016; Nogueira et al., 2015; Rofes et al., 2014; Trapl et al., 2007</a>). The Volume-Viscosity Swallow Test (V-VST), originally created by <a class="elsevierStyleCrossRef" href="#bib0040">Clavé et al. (2008)</a>, is one of these instruments. The aim of the V-VST is to identify clinical signs of impaired safety (particularly through clinical signs of aspiration such as the presence or absence of coughing, changes in the quality of the voice, including wet voice, and/or fall in oxygen saturation ≥3%) and to identify clinical signs of impaired efficacy (such as impaired lip closure, piecemeal deglutition, and oral or pharyngeal residues) (<a class="elsevierStyleCrossRef" href="#bib0040">Clavé et al., 2008</a>). The V-VST evaluates the patient's ability to swallow for different consistencies (liquid, nectar and pudding) and quantities (5<span class="elsevierStyleHsp" style=""></span>ml, 10<span class="elsevierStyleHsp" style=""></span>ml and 20<span class="elsevierStyleHsp" style=""></span>ml). The application algorithm proposed by <a class="elsevierStyleCrossRef" href="#bib0040">Clavé et al. (2008)</a> suggests that the evaluation should start with nectar viscosity and increase volumes from 5<span class="elsevierStyleHsp" style=""></span>ml to 10<span class="elsevierStyleHsp" style=""></span>ml and 20<span class="elsevierStyleHsp" style=""></span>ml boluses in a progression of increasing difficulty. If there are no major symptoms of aspiration, a less safe liquid viscosity series should be assessed also with boluses of increasing difficulty. Finally, a safer pudding viscosity series is assessed in the same way. When any clinical sign is found that compromises patient safety, no higher volume or lower viscosity is delivered. It is concluded that the patient is not at risk of having dysphagia when there are no signs of alteration in safety or efficacy at any time of the test. On each screen, it is recorded whether signs of alteration in safety and/or efficacy are present. This evaluation may also result in a preventive recommendation regarding the patient's diet, until the patient is clinically evaluated by an SLT (<a class="elsevierStyleCrossRef" href="#bib0040">Clavé et al., 2008</a>). The V-VST has good validity indices, with sensitivity values of 83.7% and specificity values of 64.7% for bolus penetration into the larynx and 100% sensitivity and 28.8% specificity for aspiration (<a class="elsevierStyleCrossRef" href="#bib0040">Clavé et al., 2008</a>).</p><p id="par0025" class="elsevierStylePara elsevierViewall">The scarcity of validated instruments for screening and diagnosis of dysphagia for the European Portuguese (EP) population is a reality (<a class="elsevierStyleCrossRef" href="#bib0140">Nogueira et al., 2015</a>). The only existing screening test translated and validated to EP by the time of this study is the Eating Assessment Tool 10 (P-EAT 10) (<a class="elsevierStyleCrossRef" href="#bib0140">Nogueira et al., 2015</a>). The EAT-10 is a 10-item self-administered questionnaire that assesses dysphagia symptoms in persons with different etiologies and in different clinical settings. The Cronbach's alpha of the P-EAT 10 was 0.952, and item-total and the intraclass correlation coefficient were classified as very good. However, the P-EAT 10 is a self-administration questionnaire and not all the people with stroke manage to respond to the items, due to the presence of possible cognitive and language impairments (<a class="elsevierStyleCrossRef" href="#bib0170">Schumacher et al., 2019</a>). <a class="elsevierStyleCrossRef" href="#bib0120">Matos et al. (2015)</a> made the translation and content validation of the V-VST: EP version. However, by the end of their work they have concluded that some items still presented content validation index values below recommended (<0.78). Moreover, the validation of its instructions manual and algorithm, as well as the analysis of its psychometric characteristics, were not performed. The aim of this study is to contribute to the overall validation of the V-VST: EP version (Matos, 2015). It is also intended to analyze the prevalence of the clinical signs of safety and efficacy in the oral and pharyngeal phases of swallowing in patients who have had an acute stroke.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Material and method</span><p id="par0030" class="elsevierStylePara elsevierViewall">This study was carried out in two phases: Phase 1, which consisted in the content validation of the V-VST: EP, instructions manual and the algorithm of the instrument by a panel of experts (PE); Phase 2, which consisted in a study of the reliability of the V-VST: EP and prevalence of clinical signs of safety and efficacy. The study was conducted at the acute stroke unit of Coimbra Hospital and University Centre (CHUC), between April and September 2017.</p><p id="par0035" class="elsevierStylePara elsevierViewall">All participants in the study signed an informed written consent and the study was approved by the Ethics Committee of FMUC and CHUC</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Measurement of viscosity</span><p id="par0040" class="elsevierStylePara elsevierViewall">Thickened liquids are used to overcome the swallowing difficulties resulting from a stroke and to aid swallowing and minimize the occurrence of penetration and aspiration (<a class="elsevierStyleCrossRefs" href="#bib0065">Garcia, 2005; Rofes et al., 2011</a>). Liquids may be thickened using a modified cornflour or xanthan gum thickener (<a class="elsevierStyleCrossRef" href="#bib0065">Garcia, 2005</a>). In the original validation study of the V-VST (<a class="elsevierStyleCrossRef" href="#bib0040">Clavé et al., 2008</a>), the thickener used was a modified cornflour (Resource Thicken Up® from Nestlé). This is formed by a carbohydrate polymer, consisting of amylose and amylopectin that in contact with water, increases its viscosity. However, this type of thickener has limitations, such as its flavour and grainy texture and increased viscosity over time due to continuous absorption and hydrolysis resulting from contact with saliva (<a class="elsevierStyleCrossRef" href="#bib0200">Vilardell et al., 2015</a>). To overcome these limitations, the thickener Nutilis Clear® from Nutricia was used in the present study. This thickener has xanthan gum in its basic constitution, which thickens faster and is more stable. This thickener has a nicer flavour than the previous one and a stable viscosity that is not affected over time (<a class="elsevierStyleCrossRef" href="#bib0200">Vilardell et al., 2015</a>). Both thickeners are scientifically proven to have benefits for the swallowing safety in patients with post-stroke OD symptomatology (<a class="elsevierStyleCrossRefs" href="#bib0065">Garcia, 2005; Vilardell et al., 2015; McCullough et al., 2003</a>). For the viscosity values of the original study to be achieved, a study with the use of a Visco Star Plus R rotational viscosimeter, was carried out. This was performed at room temperature (22<span class="elsevierStyleHsp" style=""></span>°C on average), just as in the original study (<a class="elsevierStyleCrossRef" href="#bib0040">Clavé et al., 2008</a>). To ensure the appropriate viscosity, for the nectar and pudding consistencies, respecting not only the values of the standard study but also the values defined by the National Dysphagia Diet Task Force (<a class="elsevierStyleCrossRef" href="#bib0035">Cichero, 2006</a>), the following intervals were tested: liquid viscosity (1–50<span class="elsevierStyleHsp" style=""></span>mPa<span class="elsevierStyleHsp" style=""></span>s*); nectar viscosity (51–350<span class="elsevierStyleHsp" style=""></span>mPa<span class="elsevierStyleHsp" style=""></span>s*); and pudding viscosity (>1750<span class="elsevierStyleHsp" style=""></span>mPa<span class="elsevierStyleHsp" style=""></span>s*), where s* represents millipascal per second.</p><p id="par0045" class="elsevierStylePara elsevierViewall">We concluded that it is necessary to add 2 and 6 grams of Nutilis Clear® to 100<span class="elsevierStyleHsp" style=""></span>ml of water in order to obtain the same nectar and pudding viscosity values, respectively. <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> presents the comparison of the different viscosity values of the consistencies considering the two different thickeners.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Instructions manual and algorithm</span><p id="par0050" class="elsevierStylePara elsevierViewall">The instructions manual was developed for the V-VST: EP version according to other authors (<a class="elsevierStyleCrossRefs" href="#bib0040">Clavé et al., 2008; Rofes et al., 2012</a>). Matos (2015) considered the algorithm proposed by <a class="elsevierStyleCrossRef" href="#bib0040">Clavé et al. (2008)</a> as insufficient for other health professionals (nurses and doctors) to use the V-VST as a screening test, once many of these professionals, in Portugal, had little information about OD. In order to facilitate its use, they included in the instruction's manual some indications about how to prepare the different consistencies used, in grams and volumes, a description of the interpretation of the test algorithm and how to register the presence or absence of its efficacy and safety signs. They also highlighted the need of the evaluator to refer the patient to a SLT when the V-VST is altered and the fact that the diet indicated is just a preventive diet to use until a formal clinical assessment is performed (<a class="elsevierStyleCrossRefs" href="#bib0040">Clavé et al., 2008; Matos, 2015; Rofes et al., 2012</a>).</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Phase 1: instruction's manual and V-VST: EP content validation by a panel of experts</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Participants – panel of experts</span><p id="par0055" class="elsevierStylePara elsevierViewall">Eight SLTs were invited to participate in the study to constitute the panel of experts. The selection of these experts was based on their clinical experience in dysphagia and English language domain. Detailed information is presented in results section.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Protocol</span><p id="par0060" class="elsevierStylePara elsevierViewall">Following the principles of the Delphi method (<a class="elsevierStyleCrossRef" href="#bib0080">Hasson et al., 2000</a>) eight SLTs were identified and invited to participate in the study. This invitation was sent by email, with a copy of the V-VST: EP version and a specific spread sheet to record the overall assessments, namely the clarity and relevance of each of its items: viscosity (liquid, nectar, and pudding), volume (5<span class="elsevierStyleHsp" style=""></span>ml, 10<span class="elsevierStyleHsp" style=""></span>ml, 20<span class="elsevierStyleHsp" style=""></span>ml), presence of cough, changes in voice, oxygen saturation, impaired lip closure, piecemeal deglutition, oral and pharyngeal residues. Also, in attachment, it was sent the instructions manual and the application algorithm. The same content validation procedure was used as for the V-VST: EP test. The clarity and relevance evaluation were evaluated using a 5 points Likert scale as follows: 1 – I totally disagree, 2 – disagree, 3 – neither agree nor disagree, 4 – I agree, 5 – I totally agree (<a class="elsevierStyleCrossRef" href="#bib0105">Likert et al., 2010</a>). Suggestions for improvement were also recorded. According to the experts’ suggestions, some words/sentences of the instruction's manual were reformulated and improved, to make them more easily understandable. Subsequently, all these documents were resent to the expert panel, asking for a new evaluation, to reach a version with a final consensus.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Statistical analysis</span><p id="par0065" class="elsevierStylePara elsevierViewall">Data obtained from the panel of experts were analyzed according to the calculation of the Content Validation Index (CVI), calculated as the number of items classified as 4 or 5 divided by the total number of responses. <a class="elsevierStyleCrossRef" href="#bib0145">Polit and Beck (2006)</a> state that items with a CVI less than 78% should be the subject of a reformulation.</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Phase 2: V-VST: EP reliability and prevalence of clinical signs of safety and efficacy.</span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Participants</span><p id="par0070" class="elsevierStylePara elsevierViewall">A convenience sample of patients recovering from an acute stroke was selected according to the following inclusion criteria: being over 18; in the subacute phase of a stroke; no previous swallowing alterations and being able to understand and follow simple orders. Exclusion criteria included alteration of awareness, and clinical evidence of severe dysphagia (total impairment of oral intake) as demanded by the ethics commission that approved the study.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Protocol</span><p id="par0075" class="elsevierStylePara elsevierViewall">Concerning the reliability of the V-VST: EP, inter-evaluator assessment was conducted by using two independent evaluators (evaluator 1 – SLT and evaluator 2 – rehabilitation nurse) at the same day. In order to establish a uniform test procedure and interpretation of the V-VST among both testers, a workshop about the theme was performed few days before. Evaluator 1 was seated in front of the patient and the bolus was administered with a syringe, as suggested by Clavé (<a class="elsevierStyleCrossRef" href="#bib0155">Rofes et al., 2014</a>). The V-VST: EP results were recorded on a paper format. Immediately after and under the same conditions, Evaluator 2 carried out a new evaluation. Intra-evaluator reliability was conducted by Evaluator 1 (test–retest reliability) after a maximum period of 48<span class="elsevierStyleHsp" style=""></span>h.</p><p id="par0080" class="elsevierStylePara elsevierViewall">The concurrent validity of the V-VST: EP version was assessed by using the 3 OZ water swallow test (3 OZ wst) (<a class="elsevierStyleCrossRef" href="#bib0045">DePippo et al., 1992</a>). Given 3OZ wst simplicity, it was not necessary to perform any process of cultural translation and/or adaptation. The 3OZ wst is a dysphagia screening instrument that assesses the swallowing of three ounce of water (total 90<span class="elsevierStyleHsp" style=""></span>ml in volume), without interruption. If the patient stops, coughs, chokes, or shows a wet voice during the test or in the next minute, the patient is considered a risk patient (<a class="elsevierStyleCrossRef" href="#bib0045">DePippo et al., 1992</a>). Sensitivity of 3OZ wst for predicting aspiration status during instrumental assessment using Fibreoptic Endoscopic Evaluation of Swallowing (FEES) is 96.5%, specificity is 48.7%, with a false positive rate of 51.3%. Sensitivity for identifying individuals who were deemed safe for oral intake based on FEES results is 96.4%, specificity is 46.4%, and false positive rate is 53.6% (<a class="elsevierStyleCrossRef" href="#bib0180">Suiter and Ledr, 2008</a>). The 3OZ wst screening test was applied by the Evaluator 1 after the first V-VST: EP assessment by Evaluator 2.</p><p id="par0085" class="elsevierStylePara elsevierViewall">The prevalence of clinical signs of impaired safety and efficacy presented during both V-VST: EP evaluations were analyzed. The prevalence values obtained by the two independent evaluators follow a similar pattern, regardless of the viscosity evaluated.</p><p id="par0090" class="elsevierStylePara elsevierViewall">Safety of swallowing was expressed as the percentage of patients that could swallow without clinical signs of coughing, changes in voice, or a fall in oxygen saturation ≥3. Efficacy of swallowing was expressed as the percentage of patients that could swallow without any signs of impaired lip closure, piecemeal deglutition, and oral and pharyngeal residues.</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Statistical analysis</span><p id="par0095" class="elsevierStylePara elsevierViewall">The statistical test used was Cohen's kappa (binary categorical classification) for both inter and intra-evaluator reliability. Cohen's kappa statistic adjusts the observed agreement with the expected agreement Kappa values greater than 0.60 were considered good and any higher than 0.80 were considered very good, which highlights the ‘paradox’ of the kappa statistic, particularly for binary categorical classifications when high values for concordance results correspond to low values of kappa (<a class="elsevierStyleCrossRefs" href="#bib0005">Altman, 1991; Feinstein and Cicchetti, 1990</a>). To resolve this aspect, the percentage of agreement is also presented here.</p><p id="par0100" class="elsevierStylePara elsevierViewall">The concurrent validity was performed comparing the results obtained with the V-VST: EP and the 3 OZ wst results. The sensitivity and specificity parameters, as well the percentage of agreement and the Cohen's kappa for concordance were calculated.</p><p id="par0105" class="elsevierStylePara elsevierViewall">The prevalence of the clinical signs of impaired safety and efficacy of the V-VST: EP was obtained. The effect of increased bolus volume and viscosity on the safety and efficacy parameters was evaluated by the non-parametric Cochran Q test, which compares multiple related proportions (p). Post hoc analysis was used when this test provided significant results and the Bonferroni correction was applied for the multiple comparisons. For each combination of bolus volume and viscosity increments, the evaluators classified as positive (if the participant successfully completed the task) or negative (if they did not complete the task). Statistical significance was accepted if p-values were<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05.</p></span></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Results</span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Phase 1: Instruction manual and V-VST: EP content validation by a panel of experts</span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Participants – panel experts</span><p id="par0110" class="elsevierStylePara elsevierViewall">Although eight SLTs were invited to participate, only six agreed to join the panel of experts. Most SLTs in the panel were female (83.3%), with an average age of 34.0<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>7.82. All participants have a degree in SLT and either have a Master's or Postgraduation in the field of dysphagia. Professionally, most of them work in public hospitals (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>4), one in a private clinic and one in a medical and rehabilitation centre. They have an average of 9.5<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>7.9 years of professional experience in the field of dysphagia.</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Content validation</span><p id="par0115" class="elsevierStylePara elsevierViewall">Concerning the V-VST: EP content validation, a CVI value of 100% was observed for most of its items (“liquid”, “nectar”, “pudding”, “5<span class="elsevierStyleHsp" style=""></span>ml”, “10<span class="elsevierStyleHsp" style=""></span>ml”, “cough”, “voice change”, “impaired lip closure”, “oral residue”, “piecemeal deglutition” and “pharyngeal residue”). However, two expert panel elements considered the inclusion of an intermediate consistency pertinent (in this case, it was the honey consistency). The “oxygen desaturation” item showed a CVI value of 83%, while the item “20<span class="elsevierStyleHsp" style=""></span>ml volume” presented a CVI value of 67%. Concerning this last item, some of the specialists argued that this volume could place the safety of the participants at risk. However, this item was not adapted to other volume because it would modify the original test.</p><p id="par0120" class="elsevierStylePara elsevierViewall">The algorithm proposed presented a CVI value of 83%, while the V-VST: EP instructions manual was evaluated globally with a CVI value of 67%. Because of this and following the experts’ suggestions, the following points were re-written: “explanation of the algorithm in practice” and “the procedure for dietary recommendation”. After submitting the reformulated instructions manual to the panel of experts, an overall CVI value of 83% was obtained, and therefore a final and consensual version was drawn up.</p></span></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Phase 2: V-VST: EP reliability and prevalence of clinical signs of safety and efficacy</span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Participants</span><p id="par0125" class="elsevierStylePara elsevierViewall">A convenience sample consisting of 33 patients who had a stroke was obtained. General characteristics of the sample, regarding gender and age, and the aetiology of stroke are described in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>. The sample consisted mainly of female patients (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">=</span><span class="elsevierStyleHsp" style=""></span>21), with an average age of 75 years, who had suffered an ischemic stroke (49%).</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Reliability study</span><p id="par0130" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRefs" href="#tbl0015">Tables 3–5</a> summarize the data from the inter- and intra-evaluator reliability analysis based on Cohen's kappa and the percentage of concordance between assessors.</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0135" class="elsevierStylePara elsevierViewall">The majority (75.0%) of the inter-evaluator results presents Cohen's kappa values that are considered good (higher than 0.60) or very good (higher than 0.80) independently of the viscosity or the volume administrated. In the cases of kappa values lower than 0.60 (25.0% of cases), the percentage of agreement ranged from 83.3% to 100%, showing a higher degree of concordance between both evaluators.</p><p id="par0140" class="elsevierStylePara elsevierViewall">For the intra-evaluator results, a similar pattern of results can be found as for the inter-evaluator reliability results. The Cohen's kappa values that are considered good (higher than 0.60) or very good (higher than 0.80) are around 70.0% of the cases analyzed. For the kappa values lower than 0.60 (30.0% of cases), the percentage of agreement ranged from 75.0% to 100% showing, just as for the case of the inter-reliability analysis, higher values of concordance/agreement between test and retest situation.</p><p id="par0145" class="elsevierStylePara elsevierViewall">For the concurrent validity, the results of sensitivity and specificity were 100% and 57.1%, respectively, with a percentage of agreement of 76.0% and a significant Cohen's kappa of 0.54 (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.003). These results show a negligible false negative rate while the false positive rate is somewhat high (42.9%).</p></span></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Prevalence of clinical signs of impaired safety and efficacy in the oral and pharyngeal phases of swallowing</span><p id="par0150" class="elsevierStylePara elsevierViewall">The prevalence of clinical signs of impaired safety and efficacy in oral and pharyngeal phases of swallowing for each bolus volume and viscosity during assessment of the V-VST: EP version is presented in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>. As mentioned before, the prevalence values obtained by the two independent evaluators follow a similar pattern, regardless of the viscosity evaluated, and therefore, the results presented are only for evaluator 1.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0155" class="elsevierStylePara elsevierViewall">For the nectar viscosity, the increase in the administered volume (5<span class="elsevierStyleHsp" style=""></span>ml, 10<span class="elsevierStyleHsp" style=""></span>ml, and 20<span class="elsevierStyleHsp" style=""></span>ml) implies an increase in the prevalence of the following signs of a lack of efficacy: impaired lip closure (3%, 31% and 36%, respectively; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.008; Post hoc analysis: 5<span class="elsevierStyleHsp" style=""></span>ml; 10<span class="elsevierStyleHsp" style=""></span>ml<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>20<span class="elsevierStyleHsp" style=""></span>ml) and piecemeal deglutition (6%, 19%, and 50%, respectively; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001; Post hoc analysis: 5<span class="elsevierStyleHsp" style=""></span>ml<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span>ml; 20<span class="elsevierStyleHsp" style=""></span>ml). For example, for the efficacy of impaired lip closure, there are significant differences in the prevalence among the administered volumes, with two groups of different effects: the first constituted only by the volume of 5<span class="elsevierStyleHsp" style=""></span>ml and the second constituted by the volumes of 10 and 20<span class="elsevierStyleHsp" style=""></span>ml. For oral residues, no statistical results were found for prevalence (6%, 0%, and 10%, respectively, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.135). Finally, for pharyngeal residues no statistical differences was found for prevalence (3%, 13%, and 24%, respectively, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.05). For signs of impaired safety when swallowing, the prevalence of safety decreases according to the increase in the volume administered (97%, 0.88%, and 0.89%, respectively, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.05).</p><p id="par0160" class="elsevierStylePara elsevierViewall">For the liquid viscosity, the increase in the volume administered (5<span class="elsevierStyleHsp" style=""></span>ml, 10<span class="elsevierStyleHsp" style=""></span>ml, and 20<span class="elsevierStyleHsp" style=""></span>ml) increases the prevalence of the sign of impaired lip closure (0%, 19%, and 39%, respectively, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.010; Post hoc analysis: 5<span class="elsevierStyleHsp" style=""></span>ml<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span>ml; and 10<span class="elsevierStyleHsp" style=""></span>ml<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>20<span class="elsevierStyleHsp" style=""></span>ml). For the efficacy sign of piecemeal deglutition, it presents two distinct groups of prevalence among the administered volumes: the first constituted by the volumes of 5<span class="elsevierStyleHsp" style=""></span>ml and 10<span class="elsevierStyleHsp" style=""></span>ml and the second group with the volume of 20<span class="elsevierStyleHsp" style=""></span>ml (16%, 14%, and 50%, respectively; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.006; Post hoc analysis: 5<span class="elsevierStyleHsp" style=""></span>ml<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span>ml; 20<span class="elsevierStyleHsp" style=""></span>ml). For the oral residues, for all the volumes administered, the prevalence was equal to 0%. Finally, for pharyngeal residues no statistical differences was found for prevalence (8%, 5%, and 17%, respectively, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.61). For the sign of safe swallow, the prevalence value decreases significantly with the volume administered (84%, 86%, and 33%, respectively; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001; Post hoc analysis: 5<span class="elsevierStyleHsp" style=""></span>ml<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span>ml; 20<span class="elsevierStyleHsp" style=""></span>ml).</p><p id="par0165" class="elsevierStylePara elsevierViewall">For the pudding viscosity, no statistical differences was found in the prevalence for the impaired lip closure (6%, 0%, 18%, respectively, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.05). For the sign of efficacy of piecemeal deglutition there are two distinct groups of prevalence among the volumes administered (6%, 19%, and 50%, respectively; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.008; Post hoc analysis: 5<span class="elsevierStyleHsp" style=""></span>ml<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span>ml and 10<span class="elsevierStyleHsp" style=""></span>ml<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>20<span class="elsevierStyleHsp" style=""></span>ml), a group consisting of the volumes 5<span class="elsevierStyleHsp" style=""></span>ml and 10<span class="elsevierStyleHsp" style=""></span>ml and a second one formed by the volumes 10<span class="elsevierStyleHsp" style=""></span>ml and 20<span class="elsevierStyleHsp" style=""></span>ml. For the oral residues, as it happens for the other consistencies, no statistically significant results was found (0%, 0%, and 9%, respectively, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>0.05). Finally, for pharyngeal residues no statistical differences was found for prevalence (3%, 9%, and 9%, respectively, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.51). For the sign of safe swallow, the prevalence value decreases with the volume administered (100%, 100%, and 94%, respectively; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.135). The lowest prevalence values were obtained with the highest administered volume, as it was expected.</p><p id="par0170" class="elsevierStylePara elsevierViewall">It is noteworthy that the lowest safe swallow item (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) has a prevalence of 33.0%, for the liquid viscosity with a volume of 20<span class="elsevierStyleHsp" style=""></span>ml. It was therefore considered that most of the participants had swallowing difficulties for the liquid viscosity. An increase in viscosity promotes a safer swallowing.</p></span></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Discussion</span><p id="par0175" class="elsevierStylePara elsevierViewall">The aim of this study was to contribute to the overall validation of the V-VST: EP (Matos, 2015). It was also intended to analyze the prevalence of clinical signs of impaired safety and efficacy in the oral and pharyngeal phases of swallowing, in patients who have had an acute stroke.</p><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Phase 1</span><p id="par0180" class="elsevierStylePara elsevierViewall">According to the results of this study, the experts consulted considered the translation and cultural adaptation of the V-VST: EP clear and relevant as almost all the items presented a CVI of 100%. The content validation performed by <a class="elsevierStyleCrossRef" href="#bib0120">Matos et al. (2015)</a> obtained similar results after a second revision. However, by the end of the process, some items still presented values considered bellow recommended (<0.78). In our study, the panel of experts considered the item of the volume of 20<span class="elsevierStyleHsp" style=""></span>ml to be excessive, assigning it with a CVI of 67.0%. This value is somewhat below from what would be expected, since the value of CVI should be greater than 0.78 to be considered as valid (<a class="elsevierStyleCrossRef" href="#bib0145">Polit and Beck, 2006</a>). It was decided that this item should not be subjected to reformulation or discussion. According to <a class="elsevierStyleCrossRef" href="#bib0040">Clavé et al. (2008)</a>, the volume of 20<span class="elsevierStyleHsp" style=""></span>ml is the one for which there are more frequent changes in the signs of efficacy (approximately 30% of piecemeal deglutition and 50% of pharyngeal residues), which indicates the impairment before, during and after swallowing. Based on these facts it was decided to maintain this volume in the V-VST: EP version. Two experts also suggested the inclusion of a honey consistency as an intermediate viscosity to assess. In the study by <a class="elsevierStyleCrossRef" href="#bib0160">Rofes et al. (2012)</a> the authors present a long version of the V-VST application algorithm in which, at the end of the evaluation of nectar, liquid and pudding consistency, a honey consistency is also evaluated with the objective of optimizing the amount of thickener to use. However, and as reinforced by <a class="elsevierStyleCrossRef" href="#bib0160">Rofes et al. (2012)</a> and <a class="elsevierStyleCrossRef" href="#bib0040">Clavé et al. (2008)</a>, the three consistencies included in the V-VST allow dysphagia screening, as they are organized by progression of swallowing difficulty in order to reduce the risk of aspiration. As the present study used the original version created for the application of V-VST, where a honey consistency is not included in the application algorithm, it was decided not to include this consistency for the purpose of this study. Concerning the instruction manual, some changes were made based on the experts’ suggestions, for example, the explanation of the algorithm and the practical and procedural aspects of the recommended diet were reformulated. We obtained a CVI of 83% for these reformulated instructions, indicating a final agreement among the experts. As a result, the final version of the instruction manual is now more descriptive, allowing a clearer identification of situations of possible dysphagia. In addition, the recommendations regarding the most appropriate volume and consistency for each patient have become more accurate.</p></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Phase 2</span><p id="par0185" class="elsevierStylePara elsevierViewall">Both the inter- and intra-evaluator results showed that most of the kappa values were considered good or very good (higher than 75% for the inter-evaluator and 70% for the intra-evaluator) in the reliability study. For the situations of lower kappa values, the percentage agreement between evaluators presented higher values, starting from 83.3% for inter-evaluator and from 75% for intra-evaluator. The low kappa values resulted from the well-described paradox related to Cohens’ kappa statistic, especially for binary categorical classifications, when the expected agreement is sensitive to the distribution of the marginal totals (<a class="elsevierStyleCrossRef" href="#bib0055">Feinstein and Cicchetti, 1990</a>). From the analysis of the contingency table, it was clear that this was the case: high values of percentage agreement result in low kappa values. Due to the nature of the binary class (positive or negative), in some cases (presented in the tables as n.a.) the evaluator classified all participants as positive or negative. In this situation, it was not possible to present inferential statistical results because the sample values were all equal to a constant.</p><p id="par0190" class="elsevierStylePara elsevierViewall">In the concurrent validity, the V-VST: EP version shows a sensitivity value of 100% and specificity value of 57.1%. Despite that the V-VST: EP may incorrectly show positive results for patients without disease, and that can be a problem for financial expenses and SLT time consuming, it has a very good capacity to detect negative results for people who have the condition, avoiding the common consequences of OD. The study by <a class="elsevierStyleCrossRef" href="#bib0040">Clavé et al. (2008)</a>, using Videofluoroscopy (VFS) as the gold standard test, indicates that diagnostic sensitivity and specificity of the V-VST for clinical signs of impaired safety of swallow (aspiration or penetration) were 88.2% and 64.7%, respectively. The same study showed that the sensitivity of the V-VST was 100% in recognizing patients with aspiration confirmed by VFS and also following a negative V-VST result, the probability of no aspiration was 100%. These results, as well as the results obtained in our study, indicate that the V-VST is a valid test to use in clinical practice and gives very good indications about the safety of the assessed patients.</p><p id="par0195" class="elsevierStylePara elsevierViewall">Concerning the prevalence of clinical signs of impaired safety and efficacy obtained during this study, it was possible to observe that all the acute stroke patients involved showed some of these signs, indicating the possible presence of OD. The piecemeal deglutition efficacy values for the nectar consistency (25%, considering the average values for 5<span class="elsevierStyleHsp" style=""></span>ml, 10<span class="elsevierStyleHsp" style=""></span>ml, and 20<span class="elsevierStyleHsp" style=""></span>ml), liquid consistency (26.8%) and pudding consistency (26.3%) were a bit different from the values obtained in the original study, that were 25.9%, 15.3% and 30.6% respectively (<a class="elsevierStyleCrossRef" href="#bib0040">Clavé et al., 2008</a>). As for the item of oral residues, lower values were obtained in our study (consistency: nectar<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>4.3%; liquid<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0%; pudding<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>3%) than the corresponding values in the original study (consistency: nectar<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>10.6%; liquid<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>3.5%; pudding<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>12.9%) (<a class="elsevierStyleCrossRef" href="#bib0040">Clavé et al., 2008</a>). This variation, in the values obtained with both signs of impaired efficacy, may be justified by the differences in the sample used. In the original study the sample was composed by patients with OD of several aetiologies, such as elderly patients with cerebro-vascular disease, geriatric diseases or head and neck diseases and middle-aged patients with neurodegenerative diseases (<a class="elsevierStyleCrossRef" href="#bib0040">Clavé et al., 2008</a>), while the sample in the present study was composed only by acute stroke patients.</p><p id="par0200" class="elsevierStylePara elsevierViewall">For the item of pharyngeal residues, the prevalence values obtained were also different from those of the original study (consistency: nectar<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>15.9%; liquid<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>15.3%; pudding<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>56.6%). In the present study the values found were: nectar<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>13.5%; liquid<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>9.8%; and pudding<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>7.1%. This difference may be justified by the fact that pharyngeal residues are difficult to assess just through the subjective sensation of their presence affirmed by the patients, especially in post stroke patients who often have pharyngeal and/or laryngeal sensitivity impairments. The evaluation of pharyngeal residues could have been confirmed through the use of complementary diagnostic exams such as a VFS or a Fibreoptic Endoscopic Evaluation of Swallowing (FEES) (<a class="elsevierStyleCrossRef" href="#bib0135">Newman et al., 2016</a>), however due to financial restrictions this was not possible.</p><p id="par0205" class="elsevierStylePara elsevierViewall">As <a class="elsevierStyleCrossRef" href="#bib0040">Clavé et al. (2008)</a>, who identified changes in clinical safety according to the consistency (50%–75.3% of patients with liquid, 23.4%–39.2% of patients with nectar and 14.5%–27.6% of patients with pudding), we also observed that increasing the thickness of the swallow significantly improves swallowing safety. That is, the pudding consistency has the highest safety values (0%–6%) compared to liquid (14%–67%) and nectar (3%–12%).</p><p id="par0210" class="elsevierStylePara elsevierViewall">It is noteworthy that, despite the difference of the values obtained among the studies, the present study concluded that the liquid consistency was the least safe consistency with the presence of coughing and wet voice, during swallowing. As suggested by <a class="elsevierStyleCrossRef" href="#bib0150">Rofes et al. (2011)</a> we may also conclude that a reduction in the volume and an increase in the bolus viscosity promote a safer swallowing.</p><p id="par0215" class="elsevierStylePara elsevierViewall">A potential limitation of this study is the lack of use of a validated gold standard as already described. The concurrent validity presented in this study is limited to the use of a second screening test (the 3OZ wst). This poses a problem in the interpretation of some of the results obtained in terms of sensitivity and specificity for laryngeal aspiration and penetration. Another limitation was the imposition made by the ethics committee that we could not involve patients with severe dysphagia. This fact influenced the prevalence results obtained because it eliminated the population that most likely would demonstrate alterations in the evaluated signs. Also the study sample size (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>33) caused some difficulties related to the statistical analysis, especially for the Cohen's kappa statistics inference, due to its small size. Finally, the use of a 48-hour window between the two assessments may have interfered with the results. Our population is in an acute phase in which the clinical prognosis may change very quickly.</p></span></span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">Conclusion</span><p id="par0220" class="elsevierStylePara elsevierViewall">In conclusion, our study demonstrates that the V-VST: EP has good content and concurrent validity, inter evaluator reliability and test–retest reproducibility. It has proven to be a reliable and valid instrument for the screening of OD in patients who have suffered an acute stroke. Further studies are needed to assess its use in the screening of other dysphagic populations.</p></span><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0175">Statement of ethics</span><p id="par0225" class="elsevierStylePara elsevierViewall">The study was approved by the combined Ethics Committee of the Faculty of Medicine of the University of Coimbra, and the Ethics Committee – Innovation and Development Unit of CHUC, Portugal.</p><p id="par0230" class="elsevierStylePara elsevierViewall">An informed written consent from the patient or his/her legal representative was obtained after confidentiality of the collected data was guaranteed.</p><p id="par0235" class="elsevierStylePara elsevierViewall">The company responsible for V-VST in Portugal, Nutricia, was contacted and a declaration of consent to use the Portuguese version of V-VST and its application instructions was obtained.</p></span><span id="sec0130" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0180">Funding sources</span><p id="par0240" class="elsevierStylePara elsevierViewall">This article was supported by National Funds through <span class="elsevierStyleGrantSponsor" id="gs1">FCT – <span class="elsevierStyleItalic">Fundação para a Ciência e a Tecnologia</span></span> within CIDMA (reference UID/MAT/04106/2019).</p></span><span id="sec0135" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0185">Conflict of interest</span><p id="par0245" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:14 [ 0 => array:3 [ "identificador" => "xres1788395" "titulo" => "Abstract" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Purpose" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Method" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1567522" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1788394" "titulo" => "Resumen" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "abst0020" "titulo" => "Propósito" ] 1 => array:2 [ "identificador" => "abst0025" "titulo" => "Método" ] 2 => array:2 [ "identificador" => "abst0030" "titulo" => "Resultados" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1567523" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Material and method" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Measurement of viscosity" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Instructions manual and algorithm" ] 2 => array:3 [ "identificador" => "sec0025" "titulo" => "Phase 1: instruction's manual and V-VST: EP content validation by a panel of experts" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Participants – panel of experts" ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "Protocol" ] 2 => array:2 [ "identificador" => "sec0040" "titulo" => "Statistical analysis" ] ] ] 3 => array:3 [ "identificador" => "sec0045" "titulo" => "Phase 2: V-VST: EP reliability and prevalence of clinical signs of safety and efficacy." "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0050" "titulo" => "Participants" ] 1 => array:2 [ "identificador" => "sec0055" "titulo" => "Protocol" ] 2 => array:2 [ "identificador" => "sec0060" "titulo" => "Statistical analysis" ] ] ] ] ] 6 => array:3 [ "identificador" => "sec0065" "titulo" => "Results" "secciones" => array:3 [ 0 => array:3 [ "identificador" => "sec0070" "titulo" => "Phase 1: Instruction manual and V-VST: EP content validation by a panel of experts" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0075" "titulo" => "Participants – panel experts" ] 1 => array:2 [ "identificador" => "sec0080" "titulo" => "Content validation" ] ] ] 1 => array:3 [ "identificador" => "sec0085" "titulo" => "Phase 2: V-VST: EP reliability and prevalence of clinical signs of safety and efficacy" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0090" "titulo" => "Participants" ] 1 => array:2 [ "identificador" => "sec0095" "titulo" => "Reliability study" ] ] ] 2 => array:2 [ "identificador" => "sec0100" "titulo" => "Prevalence of clinical signs of impaired safety and efficacy in the oral and pharyngeal phases of swallowing" ] ] ] 7 => array:3 [ "identificador" => "sec0105" "titulo" => "Discussion" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0110" "titulo" => "Phase 1" ] 1 => array:2 [ "identificador" => "sec0115" "titulo" => "Phase 2" ] ] ] 8 => array:2 [ "identificador" => "sec0120" "titulo" => "Conclusion" ] 9 => array:2 [ "identificador" => "sec0125" "titulo" => "Statement of ethics" ] 10 => array:2 [ "identificador" => "sec0130" "titulo" => "Funding sources" ] 11 => array:2 [ "identificador" => "sec0135" "titulo" => "Conflict of interest" ] 12 => array:2 [ "identificador" => "xack631610" "titulo" => "Acknowledgement" ] 13 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2021-07-28" "fechaAceptado" => "2022-03-21" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1567522" "palabras" => array:4 [ 0 => "Acute stroke" 1 => "V-VST" 2 => "Dysphagia screening" 3 => "Swallowing disorders" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1567523" "palabras" => array:4 [ 0 => "Accidente cerebrovascular agudo" 1 => "V-VST" 2 => "Detección de disfagia" 3 => "Trastornos de la deglución" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Purpose</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The early identification of oropharyngeal dysphagia (OD) in patients after an acute stroke using non-invasive and easily administered instruments can minimize its consequences and reduce comorbidity and mortality. The Volume-Viscosity Swallow Test (V-VST) is a screening test that makes it possible. The goal of this study is to contribute to the validation of the V-VST European Portuguese (V-VST: EP) version and study the prevalence of safety and efficacy signs in acute stroke patients.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Method</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">The V-VST: EP, its instructions manual and algorithm, was presented to a panel of experts, to assess its content validity. It was applied to 33 acute stroke patients, with signs of OD, to analyze its psychometric properties. Finally, the prevalence of impaired signs of safety and efficacy was analyzed.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">The V-VST: EP and its instruction manual (content) demonstrate very good agreement values. Most of the results for inter and intra-evaluator reliability presented Cohen's kappa values higher than 0.60 or 0.80 (75.0%). The concurrent validity (against the 3 OZ wst) presented a sensitivity of 100% and a specificity of 57.1%. For evaluator 1, the results presented are for the nectar, liquid and pudding consistencies, the prevalence values for the 5 ml, 10 ml and 20 ml volume capacity was: impaired lip closure (36%, 39%, 18%), piecemeal deglutition (50%, 50%, 50%), oral residue (7%, 0%, 9%), pharyngeal residue (25%, 17%, 9%) and safe swallowing (89%, 33%, 94%), respectively.</p></span>" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Purpose" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Method" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Propósito</span><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">La identificación temprana de la disfagia orofaríngea (DO) en pacientes después de un accidente cerebrovascular, utilizando instrumentos no invasivos y de fácil administración, puede minimizar sus consecuencias y reducir la comorbilidad y la mortalidad. El examen <span class="elsevierStyleItalic">Volume-Viscosity Swallow Test</span> (V-VST) es una prueba de detección que lo hace posible. El objetivo de este estudio es contribuir para la validación del V-VST Versión en portugués europeo (V-VST: EP) y estudio de prevalencia de signos de seguridad y eficacia en pacientes con ictus agudo.</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Método</span><p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Se presentó el V-VST: EP, su manual de instrucciones y algoritmo, a un panel de expertos, para evaluar su validez de contenido. Se aplicó a 33 pacientes con ictus agudo, con signos de DO, para analizar sus propiedades psicométricas. Finalmentese analizó la prevalencia de señales de deterioro de seguridad y eficacia.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Resultados</span><p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">El V-VST: EP y su manual de instrucciones (contenido) demuestran valores demuy buenaconcordancia. La mayoría de los resultados de confiabilidad inter e intra evaluador presentaron valoreskappa de Cohen superiores a 0,60 o 0,80 (75,0%). La validez concurrente (contra el peso de 3 OZ) presentada una sensibilidad del 100% y una especificidad del 57,1%. Para el evaluador 1, los resultados presentados son para las consistencias de néctar, líquido y budín, los valores de prevalencia para los 5 ml, 10 ml y 20 ml capacidad de volumen fue: deterioro del cierre de los labios (36%, 39%, 18%), deglución fragmentaria (50%, 50%, 50%), residuo oral (7%, 0%, 9%), residuo faríngeo (25%, 17%, 9%) y deglución segura (89%, 33%, 94%), respectivamente.</p></span>" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "abst0020" "titulo" => "Propósito" ] 1 => array:2 [ "identificador" => "abst0025" "titulo" => "Método" ] 2 => array:2 [ "identificador" => "abst0030" "titulo" => "Resultados" ] ] ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1204 "Ancho" => 3175 "Tamanyo" => 165943 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Prevalence of clinical signs of safety and efficacy of oral and pharyngeal phases of swallowing for each bolus volume and viscosity during the V-VST EP application. The ordinate axis is the percentage value of the prevalence of the safety and efficacy signs and the volume administrated in ml is on the abscissa axis.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="\n \t\t\t\t\ttable-head\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">Consistency \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">National Dysphagia Diet Task Force \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Resource ThickenUp® (V-VST)</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Nutilis Clear® (V-VST)</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Amount (g/100<span class="elsevierStyleHsp" style=""></span>ml) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Viscosity (mPa<span class="elsevierStyleHsp" style=""></span>s) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Amount (g/100<span class="elsevierStyleHsp" style=""></span>ml) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Viscosity (mPa<span class="elsevierStyleHsp" style=""></span>s) \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Liquid \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1–50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Nectar \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">51–350 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">295 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">295 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pudding \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">>1750 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3682 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2175 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Comparison of the different viscosity values of the consistencies of the two thickeners.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Age (years; <span class="elsevierStyleItalic">M</span><span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>SD): 75.15<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>2.07.</p>" "tablatextoimagen" => array:1 [ 0 => array:1 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">N</span> (%) \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Gender</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 (36.0) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Female \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">21 (64.0) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Stroke aetiology</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Right Ischemic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16 (49.0) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Ischemic (undefined) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 (24.0) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Left Ischemic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 (18.0) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hemorrhagic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (9.0) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Characterization of the sample included in the pilot study of the application of the V-VST EP to a Portuguese population with dysphagia resulting from stroke aetiology.</p>" ] ] 3 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Agree: percentage of agreement; SE: standard error; n.a.: not applicable because the sample values were all equal to a constant.</p>" "tablatextoimagen" => array:1 [ 0 => array:1 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="\n \t\t\t\t\ttable-head\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">Variables \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Inter-evaluator reliability</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Intra-evaluator reliability</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Cohen's Kappa (<span class="elsevierStyleItalic">k</span><span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>SE) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Agree (%) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Cohen Kappa (k<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>SE) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Agree (%) \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="5" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Oral phase</span></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="5" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Impaired lip closure</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>ml \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.00<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.00 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n.a. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span>ml \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.57<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">83.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.48<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">81.3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>20<span class="elsevierStyleHsp" style=""></span>ml \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.66<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">88.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.51<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">78.6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="5" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Piecemeal deglutition</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>ml \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.00<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.00 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.00<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.00 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span>ml \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.82<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">93.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.52<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">84.4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>20<span class="elsevierStyleHsp" style=""></span>ml \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.76<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">88.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.50<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">75.0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="5" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Oral residues</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>ml \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.65<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.32 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">97.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.65<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.32 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">97.0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span>ml \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n.a. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n.a. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>20<span class="elsevierStyleHsp" style=""></span>ml \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.65<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.32 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">96.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.65<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.32 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">96.4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="5" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="5" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Pharyngeal phase</span></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="5" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Safe swallow</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>ml \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.48<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">94.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.65<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.32 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">97.0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span>ml \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.53<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.23 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">90.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.84<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">97.0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>20<span class="elsevierStyleHsp" style=""></span>ml \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.83<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">96.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.00<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.00 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="5" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Pharyngeal residue</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>ml \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.00<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.02 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">94.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n.a. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span>ml \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.48<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.31 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">93.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.64<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.23 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">93.8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>20<span class="elsevierStyleHsp" style=""></span>ml \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.78<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">92.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.58<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">85.7 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Inter and intra-evaluator reliability values for nectar viscosity (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>33).</p>" ] ] 4 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at4" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Agree: percentage of agreement; SE: Standard error; n.a.: not applicable because the sample values were all equal to a constant</p>" "tablatextoimagen" => array:1 [ 0 => array:1 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="\n \t\t\t\t\ttable-head\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">Variables \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Inter-evaluator reliability</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Intra-evaluator reliability</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Cohen's Kappa (<span class="elsevierStyleItalic">k</span><span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>SE) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Agree (%) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Cohen's Kappa (<span class="elsevierStyleItalic">k</span><span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>SE) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Agree (%) \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="5" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Oral phase</span></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="5" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Impaired lip closure</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>ml \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n.a. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n.a. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span>ml \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.00<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.00 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.00<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.00 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>20<span class="elsevierStyleHsp" style=""></span>ml \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.86<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">93.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.70<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">85.7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="5" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Piecemeal deglutition</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>ml \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.83<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">95.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.63<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">92.0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span>ml \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.77<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.22 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">93.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.77<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.22 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">94.1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>20<span class="elsevierStyleHsp" style=""></span>ml \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.87<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">93.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.71<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">85.7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="5" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Oral residues</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>ml \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n.a. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n.a. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span>ml \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n.a. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n.a. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>20<span class="elsevierStyleHsp" style=""></span>ml \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n.a. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n.a. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="5" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="5" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Pharyngeal phase</span></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="5" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Safe swallow</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>ml \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.48<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">85.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.58<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">84.0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span>ml \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.00<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.00 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.00<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.00 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>20<span class="elsevierStyleHsp" style=""></span>ml \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.00<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.00 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.00<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.00 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="5" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Pharyngeal residue</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>ml \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.00<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.00 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n.a. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span>ml \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.00<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.05 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">87.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n.a. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>20<span class="elsevierStyleHsp" style=""></span>ml \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.29<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.31 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">80.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.53<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">78.6 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Inter and intra-evaluator reliability values for liquid viscosity (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>33).</p>" ] ] 5 => array:8 [ "identificador" => "tbl0025" "etiqueta" => "Table 5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at5" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Agree: percentage of agreement; SE: Standard error; n.a.: not applicable because the sample values were all equal to a constant.</p>" "tablatextoimagen" => array:1 [ 0 => array:1 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="\n \t\t\t\t\ttable-head\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">Variables \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Inter-evaluator reliability</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Intra-evaluator reliability</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Cohen's Kappa (<span class="elsevierStyleItalic">k</span><span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>SE) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Agree (%) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Cohen Kappa (<span class="elsevierStyleItalic">k</span><span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>SE) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Agree (%) \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="5" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Oral phase</span></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="5" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Impaired lip closure</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>5 ml \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n.a. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.78<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">97.0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>10 ml \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n.a. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n.a. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>20 ml \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n.a. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.67<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">91.0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="5" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Piecemeal deglutition</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>5 ml \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.64<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.23 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.64<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.23 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">94.0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>10 ml \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.71<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">90.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.64<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">87.9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>20 ml \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.81<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">90.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.69<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">66.7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="5" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Oral residues</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>5 ml \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n.a. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n.a. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>10 ml \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n.a. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n.a. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>20 ml \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.63<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">94.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.35<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.29 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">91.0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="5" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="5" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Pharyngeal phase</span></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="5" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Safe swallow</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; 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Cicchetti" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/0895-4356(90)90158-l" "Revista" => array:6 [ "tituloSerie" => "Journal of Clinical Epidemiology" "fecha" => "1990" "volumen" => "43" "paginaInicial" => "543" "paginaFinal" => "548" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2348207" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0065" "etiqueta" => "Garcia, 2005" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Viscosity measurements of nectar – and honey – thick liquids: Product, liquid, and time comparisons" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "J.M. 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