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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
Catarina Camõesa,
Corresponding author
camoes.catarina@gmail.com

Corresponding author.
, Assunção Matosb,c, Pedro Sa-Coutod, Marília Douradoe,f,g
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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          "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&#46; 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&#46;</p>"
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    "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 Dire&#231;&#227;o Geral de Sa&#250;de &#40;a Directorate of the Portuguese Health Ministry&#41; &#40;<a class="elsevierStyleCrossRef" href="#bib0090">Health&#44; 2018</a>&#41;&#44; cerebrovascular and heart diseases were the cause of 29&#46;7&#37; of deaths in Portugal in 2018&#46; Strokes account for 10&#46;8&#37; of deaths &#40;<a class="elsevierStyleCrossRef" href="#bib0095">INE&#44; 2015</a>&#41;&#46; Despite all the scientific advances that have allowed an increase in the number of stroke survivors&#44; worldwide these patients present various sequelae and dependencies that affect their daily lives&#46; Therefore&#44; a stroke is an important cause of morbidity as well as disability in global terms &#40;<a class="elsevierStyleCrossRefs" href="#bib0100">Johnson et al&#46;&#44; 2016&#59; S&#225;&#44; 2009</a>&#41;&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Currently&#44; acute cerebrovascular disease&#44; namely ischemic stroke&#44; has emerged as a serious complication of severe acute respiratory syndrome coronavirus 2 &#40;SARS-CoV-2&#41;&#44; an infection associated with the Coronavirus Pandemic of 2019 &#40;COVID-19&#41; &#40;<a class="elsevierStyleCrossRefs" href="#bib0190">Trejo-Gabriel-Gal&#225;n&#44; 2020&#59; Vogrig et al&#46;&#44; 2021</a>&#41;&#46; The virus can affect the brain parenchyma&#44; the endothelium&#44; the heart and alter the coagulation&#44; culminating in a stroke&#46; In addition to the fact that the pandemic could increase the incidence of strokes&#44; social isolation decreased the control of risk factors and the access to health services &#40;<a class="elsevierStyleCrossRefs" href="#bib0070">Ghosal et al&#46;&#44; 2020&#59; Valtorta et al&#46;&#44; 2018</a>&#41;&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Underlying the neurological sequelae of a stroke&#44; a significant number of individuals present oropharyngeal dysphagia &#40;OD&#41;&#44; with an incidence varying between 2 and 25&#37; after six months of the acute episode &#40;<a class="elsevierStyleCrossRef" href="#bib0075">Guill&#233;n-Sol&#224; et al&#46;&#44; 2013</a>&#41; and a prevalence ranging from 2&#46;4&#37; to 80&#46;0&#37; depending on the underlying aetiology&#44; age&#44; environment and way of investigation &#40;<a class="elsevierStyleCrossRef" href="#bib0020">Audag et al&#46;&#44; in press</a>&#41;&#46; In the presence of OD&#44; if no timely intervention is made&#44; there is an increased susceptibility to develop aspiration pneumonia&#44; as well as experience dehydration and malnutrition&#44; among other consequences&#46; This will result in more days of hospitalization&#44; with the consequent increase in health costs&#44; and the need to spend more time and resources on rehabilitation &#40;<a class="elsevierStyleCrossRefs" href="#bib0030">Belafsky et al&#46;&#44; 2008&#59; Nogueira et al&#46;&#44; 2015</a>&#41;&#46; Dysphagia also has a significant impact on the social and psychological context of patients and their families&#44; namely due to episodes of isolation during meals and decreased social interaction &#40;<a class="elsevierStyleCrossRef" href="#bib0130">Moloney and Walshe&#44; 2017</a>&#41;&#46; In order to avoid these complications&#44; an early detection&#44; evaluation and intervention is required &#40;<a class="elsevierStyleCrossRefs" href="#bib0030">Belafsky et al&#46;&#44; 2008&#59; Nogueira et al&#46;&#44; 2015&#59; Rofes et al&#46;&#44; 2012</a>&#41;&#46; Thus&#44; the use of appropriate and valid screening instruments&#44; with good sensitivity and specificity&#44; is essential &#40;<a class="elsevierStyleCrossRefs" href="#bib0040">Clav&#233; et al&#46;&#44; 2008&#59; Speyer&#44; 2013</a>&#41;&#46; These instruments should also be of easy administration&#44; low time-consuming&#44; non-invasive &#40;avoiding distress to patients&#41;&#44; and not requiring a complex training for its application and interpretation&#46; 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&#46; If patients fail the screen&#44; further assessment &#40;clinical assessment&#41; is required by a specialist in swallowing disorders &#40;<a class="elsevierStyleCrossRef" href="#bib0175">Speyer&#44; 2013</a>&#41;&#44; commonly a speech and language therapist &#40;SLT&#41;&#46; Clinical assessment allows the identification of possible causes of OD&#44; and the evaluation of swallowing safety or risk of aspiration&#46; This evaluation will decide between oral or other alternative feeding routes for the patient&#44; to clarify the need for further assessment &#40;instrumental assessment&#41;&#44; and to establish pre-treatment clinical data &#40;allowing for follow-up assessments after intervention or during progressive diseases&#41; &#40;<a class="elsevierStyleCrossRef" href="#bib0175">Speyer&#44; 2013</a>&#41;&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">A few bedside screenings have been described in the literature &#40;<a class="elsevierStyleCrossRefs" href="#bib0010">Antonios et al&#46;&#44; 2010&#59; Belafsky et al&#46;&#44; 2008&#59; DePippo et al&#46;&#44; 1992&#59; Martino et al&#46;&#44; 2016&#59; Nogueira et al&#46;&#44; 2015&#59; Rofes et al&#46;&#44; 2014&#59; Trapl et al&#46;&#44; 2007</a>&#41;&#46; The Volume-Viscosity Swallow Test &#40;V-VST&#41;&#44; originally created by <a class="elsevierStyleCrossRef" href="#bib0040">Clav&#233; et al&#46; &#40;2008&#41;</a>&#44; is one of these instruments&#46; The aim of the V-VST is to identify clinical signs of impaired safety &#40;particularly through clinical signs of aspiration such as the presence or absence of coughing&#44; changes in the quality of the voice&#44; including wet voice&#44; and&#47;or fall in oxygen saturation &#8805;3&#37;&#41; and to identify clinical signs of impaired efficacy &#40;such as impaired lip closure&#44; piecemeal deglutition&#44; and oral or pharyngeal residues&#41; &#40;<a class="elsevierStyleCrossRef" href="#bib0040">Clav&#233; et al&#46;&#44; 2008</a>&#41;&#46; The V-VST evaluates the patient&#39;s ability to swallow for different consistencies &#40;liquid&#44; nectar and pudding&#41; and quantities &#40;5<span class="elsevierStyleHsp" style=""></span>ml&#44; 10<span class="elsevierStyleHsp" style=""></span>ml and 20<span class="elsevierStyleHsp" style=""></span>ml&#41;&#46; The application algorithm proposed by <a class="elsevierStyleCrossRef" href="#bib0040">Clav&#233; et al&#46; &#40;2008&#41;</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&#46; If there are no major symptoms of aspiration&#44; a less safe liquid viscosity series should be assessed also with boluses of increasing difficulty&#46; Finally&#44; a safer pudding viscosity series is assessed in the same way&#46; When any clinical sign is found that compromises patient safety&#44; no higher volume or lower viscosity is delivered&#46; 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&#46; On each screen&#44; it is recorded whether signs of alteration in safety and&#47;or efficacy are present&#46; This evaluation may also result in a preventive recommendation regarding the patient&#39;s diet&#44; until the patient is clinically evaluated by an SLT &#40;<a class="elsevierStyleCrossRef" href="#bib0040">Clav&#233; et al&#46;&#44; 2008</a>&#41;&#46; The V-VST has good validity indices&#44; with sensitivity values of 83&#46;7&#37; and specificity values of 64&#46;7&#37; for bolus penetration into the larynx and 100&#37; sensitivity and 28&#46;8&#37; specificity for aspiration &#40;<a class="elsevierStyleCrossRef" href="#bib0040">Clav&#233; et al&#46;&#44; 2008</a>&#41;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The scarcity of validated instruments for screening and diagnosis of dysphagia for the European Portuguese &#40;EP&#41; population is a reality &#40;<a class="elsevierStyleCrossRef" href="#bib0140">Nogueira et al&#46;&#44; 2015</a>&#41;&#46; The only existing screening test translated and validated to EP by the time of this study is the Eating Assessment Tool 10 &#40;P-EAT 10&#41; &#40;<a class="elsevierStyleCrossRef" href="#bib0140">Nogueira et al&#46;&#44; 2015</a>&#41;&#46; The EAT-10 is a 10-item self-administered questionnaire that assesses dysphagia symptoms in persons with different etiologies and in different clinical settings&#46; The Cronbach&#39;s alpha of the P-EAT 10 was 0&#46;952&#44; and item-total and the intraclass correlation coefficient were classified as very good&#46; However&#44; the P-EAT 10 is a self-administration questionnaire and not all the people with stroke manage to respond to the items&#44; due to the presence of possible cognitive and language impairments &#40;<a class="elsevierStyleCrossRef" href="#bib0170">Schumacher et al&#46;&#44; 2019</a>&#41;&#46; <a class="elsevierStyleCrossRef" href="#bib0120">Matos et al&#46; &#40;2015&#41;</a> made the translation and content validation of the V-VST&#58; EP version&#46; However&#44; by the end of their work they have concluded that some items still presented content validation index values below recommended &#40;&#60;0&#46;78&#41;&#46; Moreover&#44; the validation of its instructions manual and algorithm&#44; as well as the analysis of its psychometric characteristics&#44; were not performed&#46; The aim of this study is to contribute to the overall validation of the V-VST&#58; EP version &#40;Matos&#44; 2015&#41;&#46; 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&#46;</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&#58; Phase 1&#44; which consisted in the content validation of the V-VST&#58; EP&#44; instructions manual and the algorithm of the instrument by a panel of experts &#40;PE&#41;&#59; Phase 2&#44; which consisted in a study of the reliability of the V-VST&#58; EP and prevalence of clinical signs of safety and efficacy&#46; The study was conducted at the acute stroke unit of Coimbra Hospital and University Centre &#40;CHUC&#41;&#44; between April and September 2017&#46;</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 &#40;<a class="elsevierStyleCrossRefs" href="#bib0065">Garcia&#44; 2005&#59; Rofes et al&#46;&#44; 2011</a>&#41;&#46; Liquids may be thickened using a modified cornflour or xanthan gum thickener &#40;<a class="elsevierStyleCrossRef" href="#bib0065">Garcia&#44; 2005</a>&#41;&#46; In the original validation study of the V-VST &#40;<a class="elsevierStyleCrossRef" href="#bib0040">Clav&#233; et al&#46;&#44; 2008</a>&#41;&#44; the thickener used was a modified cornflour &#40;Resource Thicken Up&#174; from Nestl&#233;&#41;&#46; This is formed by a carbohydrate polymer&#44; consisting of amylose and amylopectin that in contact with water&#44; increases its viscosity&#46; However&#44; this type of thickener has limitations&#44; such as its flavour and grainy texture and increased viscosity over time due to continuous absorption and hydrolysis resulting from contact with saliva &#40;<a class="elsevierStyleCrossRef" href="#bib0200">Vilardell et al&#46;&#44; 2015</a>&#41;&#46; To overcome these limitations&#44; the thickener Nutilis Clear&#174; from Nutricia was used in the present study&#46; This thickener has xanthan gum in its basic constitution&#44; which thickens faster and is more stable&#46; This thickener has a nicer flavour than the previous one and a stable viscosity that is not affected over time &#40;<a class="elsevierStyleCrossRef" href="#bib0200">Vilardell et al&#46;&#44; 2015</a>&#41;&#46; Both thickeners are scientifically proven to have benefits for the swallowing safety in patients with post-stroke OD symptomatology &#40;<a class="elsevierStyleCrossRefs" href="#bib0065">Garcia&#44; 2005&#59; Vilardell et al&#46;&#44; 2015&#59; McCullough et al&#46;&#44; 2003</a>&#41;&#46; For the viscosity values of the original study to be achieved&#44; a study with the use of a Visco Star Plus R rotational viscosimeter&#44; was carried out&#46; This was performed at room temperature &#40;22<span class="elsevierStyleHsp" style=""></span>&#176;C on average&#41;&#44; just as in the original study &#40;<a class="elsevierStyleCrossRef" href="#bib0040">Clav&#233; et al&#46;&#44; 2008</a>&#41;&#46; To ensure the appropriate viscosity&#44; for the nectar and pudding consistencies&#44; respecting not only the values of the standard study but also the values defined by the National Dysphagia Diet Task Force &#40;<a class="elsevierStyleCrossRef" href="#bib0035">Cichero&#44; 2006</a>&#41;&#44; the following intervals were tested&#58; liquid viscosity &#40;1&#8211;50<span class="elsevierStyleHsp" style=""></span>mPa<span class="elsevierStyleHsp" style=""></span>s&#42;&#41;&#59; nectar viscosity &#40;51&#8211;350<span class="elsevierStyleHsp" style=""></span>mPa<span class="elsevierStyleHsp" style=""></span>s&#42;&#41;&#59; and pudding viscosity &#40;&#62;1750<span class="elsevierStyleHsp" style=""></span>mPa<span class="elsevierStyleHsp" style=""></span>s&#42;&#41;&#44; where s&#42; represents millipascal per second&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">We concluded that it is necessary to add 2 and 6 grams of Nutilis Clear&#174; to 100<span class="elsevierStyleHsp" style=""></span>ml of water in order to obtain the same nectar and pudding viscosity values&#44; respectively&#46; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> presents the comparison of the different viscosity values of the consistencies considering the two different thickeners&#46;</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&#58; EP version according to other authors &#40;<a class="elsevierStyleCrossRefs" href="#bib0040">Clav&#233; et al&#46;&#44; 2008&#59; Rofes et al&#46;&#44; 2012</a>&#41;&#46; Matos &#40;2015&#41; considered the algorithm proposed by <a class="elsevierStyleCrossRef" href="#bib0040">Clav&#233; et al&#46; &#40;2008&#41;</a> as insufficient for other health professionals &#40;nurses and doctors&#41; to use the V-VST as a screening test&#44; once many of these professionals&#44; in Portugal&#44; had little information about OD&#46; In order to facilitate its use&#44; they included in the instruction&#39;s manual some indications about how to prepare the different consistencies used&#44; in grams and volumes&#44; a description of the interpretation of the test algorithm and how to register the presence or absence of its efficacy and safety signs&#46; 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 &#40;<a class="elsevierStyleCrossRefs" href="#bib0040">Clav&#233; et al&#46;&#44; 2008&#59; Matos&#44; 2015&#59; Rofes et al&#46;&#44; 2012</a>&#41;&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Phase 1&#58; instruction&#39;s manual and V-VST&#58; EP content validation by a panel of experts</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Participants &#8211; 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&#46; The selection of these experts was based on their clinical experience in dysphagia and English language domain&#46; Detailed information is presented in results section&#46;</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 &#40;<a class="elsevierStyleCrossRef" href="#bib0080">Hasson et al&#46;&#44; 2000</a>&#41; eight SLTs were identified and invited to participate in the study&#46; This invitation was sent by email&#44; with a copy of the V-VST&#58; EP version and a specific spread sheet to record the overall assessments&#44; namely the clarity and relevance of each of its items&#58; viscosity &#40;liquid&#44; nectar&#44; and pudding&#41;&#44; volume &#40;5<span class="elsevierStyleHsp" style=""></span>ml&#44; 10<span class="elsevierStyleHsp" style=""></span>ml&#44; 20<span class="elsevierStyleHsp" style=""></span>ml&#41;&#44; presence of cough&#44; changes in voice&#44; oxygen saturation&#44; impaired lip closure&#44; piecemeal deglutition&#44; oral and pharyngeal residues&#46; Also&#44; in attachment&#44; it was sent the instructions manual and the application algorithm&#46; The same content validation procedure was used as for the V-VST&#58; EP test&#46; The clarity and relevance evaluation were evaluated using a 5 points Likert scale as follows&#58; 1 &#8211; I totally disagree&#44; 2 &#8211; disagree&#44; 3 &#8211; neither agree nor disagree&#44; 4 &#8211; I agree&#44; 5 &#8211; I totally agree &#40;<a class="elsevierStyleCrossRef" href="#bib0105">Likert et al&#46;&#44; 2010</a>&#41;&#46; Suggestions for improvement were also recorded&#46; According to the experts&#8217; suggestions&#44; some words&#47;sentences of the instruction&#39;s manual were reformulated and improved&#44; to make them more easily understandable&#46; Subsequently&#44; all these documents were resent to the expert panel&#44; asking for a new evaluation&#44; to reach a version with a final consensus&#46;</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 &#40;CVI&#41;&#44; calculated as the number of items classified as 4 or 5 divided by the total number of responses&#46; <a class="elsevierStyleCrossRef" href="#bib0145">Polit and Beck &#40;2006&#41;</a> state that items with a CVI less than 78&#37; should be the subject of a reformulation&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Phase 2&#58; V-VST&#58; EP reliability and prevalence of clinical signs of safety and efficacy&#46;</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&#58; being over 18&#59; in the subacute phase of a stroke&#59; no previous swallowing alterations and being able to understand and follow simple orders&#46; Exclusion criteria included alteration of awareness&#44; and clinical evidence of severe dysphagia &#40;total impairment of oral intake&#41; as demanded by the ethics commission that approved the study&#46;</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&#58; EP&#44; inter-evaluator assessment was conducted by using two independent evaluators &#40;evaluator 1 &#8211; SLT and evaluator 2 &#8211; rehabilitation nurse&#41; at the same day&#46; In order to establish a uniform test procedure and interpretation of the V-VST among both testers&#44; a workshop about the theme was performed few days before&#46; Evaluator 1 was seated in front of the patient and the bolus was administered with a syringe&#44; as suggested by Clav&#233; &#40;<a class="elsevierStyleCrossRef" href="#bib0155">Rofes et al&#46;&#44; 2014</a>&#41;&#46; The V-VST&#58; EP results were recorded on a paper format&#46; Immediately after and under the same conditions&#44; Evaluator 2 carried out a new evaluation&#46; Intra-evaluator reliability was conducted by Evaluator 1 &#40;test&#8211;retest reliability&#41; after a maximum period of 48<span class="elsevierStyleHsp" style=""></span>h&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The concurrent validity of the V-VST&#58; EP version was assessed by using the 3 OZ water swallow test &#40;3 OZ wst&#41; &#40;<a class="elsevierStyleCrossRef" href="#bib0045">DePippo et al&#46;&#44; 1992</a>&#41;&#46; Given 3OZ wst simplicity&#44; it was not necessary to perform any process of cultural translation and&#47;or adaptation&#46; The 3OZ wst is a dysphagia screening instrument that assesses the swallowing of three ounce of water &#40;total 90<span class="elsevierStyleHsp" style=""></span>ml in volume&#41;&#44; without interruption&#46; If the patient stops&#44; coughs&#44; chokes&#44; or shows a wet voice during the test or in the next minute&#44; the patient is considered a risk patient &#40;<a class="elsevierStyleCrossRef" href="#bib0045">DePippo et al&#46;&#44; 1992</a>&#41;&#46; Sensitivity of 3OZ wst for predicting aspiration status during instrumental assessment using Fibreoptic Endoscopic Evaluation of Swallowing &#40;FEES&#41; is 96&#46;5&#37;&#44; specificity is 48&#46;7&#37;&#44; with a false positive rate of 51&#46;3&#37;&#46; Sensitivity for identifying individuals who were deemed safe for oral intake based on FEES results is 96&#46;4&#37;&#44; specificity is 46&#46;4&#37;&#44; and false positive rate is 53&#46;6&#37; &#40;<a class="elsevierStyleCrossRef" href="#bib0180">Suiter and Ledr&#44; 2008</a>&#41;&#46; The 3OZ wst screening test was applied by the Evaluator 1 after the first V-VST&#58; EP assessment by Evaluator 2&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The prevalence of clinical signs of impaired safety and efficacy presented during both V-VST&#58; EP evaluations were analyzed&#46; The prevalence values obtained by the two independent evaluators follow a similar pattern&#44; regardless of the viscosity evaluated&#46;</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&#44; changes in voice&#44; or a fall in oxygen saturation &#8805;3&#46; Efficacy of swallowing was expressed as the percentage of patients that could swallow without any signs of impaired lip closure&#44; piecemeal deglutition&#44; and oral and pharyngeal residues&#46;</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&#39;s kappa &#40;binary categorical classification&#41; for both inter and intra-evaluator reliability&#46; Cohen&#39;s kappa statistic adjusts the observed agreement with the expected agreement Kappa values greater than 0&#46;60 were considered good and any higher than 0&#46;80 were considered very good&#44; which highlights the &#8216;paradox&#8217; of the kappa statistic&#44; particularly for binary categorical classifications when high values for concordance results correspond to low values of kappa &#40;<a class="elsevierStyleCrossRefs" href="#bib0005">Altman&#44; 1991&#59; Feinstein and Cicchetti&#44; 1990</a>&#41;&#46; To resolve this aspect&#44; the percentage of agreement is also presented here&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">The concurrent validity was performed comparing the results obtained with the V-VST&#58; EP and the 3 OZ wst results&#46; The sensitivity and specificity parameters&#44; as well the percentage of agreement and the Cohen&#39;s kappa for concordance were calculated&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">The prevalence of the clinical signs of impaired safety and efficacy of the V-VST&#58; EP was obtained&#46; The effect of increased bolus volume and viscosity on the safety and efficacy parameters was evaluated by the non-parametric Cochran Q test&#44; which compares multiple related proportions &#40;p&#41;&#46; Post hoc analysis was used when this test provided significant results and the Bonferroni correction was applied for the multiple comparisons&#46; For each combination of bolus volume and viscosity increments&#44; the evaluators classified as positive &#40;if the participant successfully completed the task&#41; or negative &#40;if they did not complete the task&#41;&#46; Statistical significance was accepted if p-values were<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#46;</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&#58; Instruction manual and V-VST&#58; EP content validation by a panel of experts</span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Participants &#8211; panel experts</span><p id="par0110" class="elsevierStylePara elsevierViewall">Although eight SLTs were invited to participate&#44; only six agreed to join the panel of experts&#46; Most SLTs in the panel were female &#40;83&#46;3&#37;&#41;&#44; with an average age of 34&#46;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&#46;82&#46; All participants have a degree in SLT and either have a Master&#39;s or Postgraduation in the field of dysphagia&#46; Professionally&#44; most of them work in public hospitals &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#41;&#44; one in a private clinic and one in a medical and rehabilitation centre&#46; They have an average of 9&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&#46;9 years of professional experience in the field of dysphagia&#46;</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&#58; EP content validation&#44; a CVI value of 100&#37; was observed for most of its items &#40;&#8220;liquid&#8221;&#44; &#8220;nectar&#8221;&#44; &#8220;pudding&#8221;&#44; &#8220;5<span class="elsevierStyleHsp" style=""></span>ml&#8221;&#44; &#8220;10<span class="elsevierStyleHsp" style=""></span>ml&#8221;&#44; &#8220;cough&#8221;&#44; &#8220;voice change&#8221;&#44; &#8220;impaired lip closure&#8221;&#44; &#8220;oral residue&#8221;&#44; &#8220;piecemeal deglutition&#8221; and &#8220;pharyngeal residue&#8221;&#41;&#46; However&#44; two expert panel elements considered the inclusion of an intermediate consistency pertinent &#40;in this case&#44; it was the honey consistency&#41;&#46; The &#8220;oxygen desaturation&#8221; item showed a CVI value of 83&#37;&#44; while the item &#8220;20<span class="elsevierStyleHsp" style=""></span>ml volume&#8221; presented a CVI value of 67&#37;&#46; Concerning this last item&#44; some of the specialists argued that this volume could place the safety of the participants at risk&#46; However&#44; this item was not adapted to other volume because it would modify the original test&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">The algorithm proposed presented a CVI value of 83&#37;&#44; while the V-VST&#58; EP instructions manual was evaluated globally with a CVI value of 67&#37;&#46; Because of this and following the experts&#8217; suggestions&#44; the following points were re-written&#58; &#8220;explanation of the algorithm in practice&#8221; and &#8220;the procedure for dietary recommendation&#8221;&#46; After submitting the reformulated instructions manual to the panel of experts&#44; an overall CVI value of 83&#37; was obtained&#44; and therefore a final and consensual version was drawn up&#46;</p></span></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Phase 2&#58; V-VST&#58; 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&#46; General characteristics of the sample&#44; regarding gender and age&#44; and the aetiology of stroke are described in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46; The sample consisted mainly of female patients &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#61;</span><span class="elsevierStyleHsp" style=""></span>21&#41;&#44; with an average age of 75 years&#44; who had suffered an ischemic stroke &#40;49&#37;&#41;&#46;</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&#8211;5</a> summarize the data from the inter- and intra-evaluator reliability analysis based on Cohen&#39;s kappa and the percentage of concordance between assessors&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0135" class="elsevierStylePara elsevierViewall">The majority &#40;75&#46;0&#37;&#41; of the inter-evaluator results presents Cohen&#39;s kappa values that are considered good &#40;higher than 0&#46;60&#41; or very good &#40;higher than 0&#46;80&#41; independently of the viscosity or the volume administrated&#46; In the cases of kappa values lower than 0&#46;60 &#40;25&#46;0&#37; of cases&#41;&#44; the percentage of agreement ranged from 83&#46;3&#37; to 100&#37;&#44; showing a higher degree of concordance between both evaluators&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">For the intra-evaluator results&#44; a similar pattern of results can be found as for the inter-evaluator reliability results&#46; The Cohen&#39;s kappa values that are considered good &#40;higher than 0&#46;60&#41; or very good &#40;higher than 0&#46;80&#41; are around 70&#46;0&#37; of the cases analyzed&#46; For the kappa values lower than 0&#46;60 &#40;30&#46;0&#37; of cases&#41;&#44; the percentage of agreement ranged from 75&#46;0&#37; to 100&#37; showing&#44; just as for the case of the inter-reliability analysis&#44; higher values of concordance&#47;agreement between test and retest situation&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">For the concurrent validity&#44; the results of sensitivity and specificity were 100&#37; and 57&#46;1&#37;&#44; respectively&#44; with a percentage of agreement of 76&#46;0&#37; and a significant Cohen&#39;s kappa of 0&#46;54 &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;003&#41;&#46; These results show a negligible false negative rate while the false positive rate is somewhat high &#40;42&#46;9&#37;&#41;&#46;</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&#58; EP version is presented in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#46; As mentioned before&#44; the prevalence values obtained by the two independent evaluators follow a similar pattern&#44; regardless of the viscosity evaluated&#44; and therefore&#44; the results presented are only for evaluator 1&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0155" class="elsevierStylePara elsevierViewall">For the nectar viscosity&#44; the increase in the administered volume &#40;5<span class="elsevierStyleHsp" style=""></span>ml&#44; 10<span class="elsevierStyleHsp" style=""></span>ml&#44; and 20<span class="elsevierStyleHsp" style=""></span>ml&#41; implies an increase in the prevalence of the following signs of a lack of efficacy&#58; impaired lip closure &#40;3&#37;&#44; 31&#37; and 36&#37;&#44; respectively&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;008&#59; Post hoc analysis&#58; 5<span class="elsevierStyleHsp" style=""></span>ml&#59; 10<span class="elsevierStyleHsp" style=""></span>ml<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>20<span class="elsevierStyleHsp" style=""></span>ml&#41; and piecemeal deglutition &#40;6&#37;&#44; 19&#37;&#44; and 50&#37;&#44; respectively&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#59; Post hoc analysis&#58; 5<span class="elsevierStyleHsp" style=""></span>ml<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span>ml&#59; 20<span class="elsevierStyleHsp" style=""></span>ml&#41;&#46; For example&#44; for the efficacy of impaired lip closure&#44; there are significant differences in the prevalence among the administered volumes&#44; with two groups of different effects&#58; 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&#46; For oral residues&#44; no statistical results were found for prevalence &#40;6&#37;&#44; 0&#37;&#44; and 10&#37;&#44; respectively&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;135&#41;&#46; Finally&#44; for pharyngeal residues no statistical differences was found for prevalence &#40;3&#37;&#44; 13&#37;&#44; and 24&#37;&#44; respectively&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; For signs of impaired safety when swallowing&#44; the prevalence of safety decreases according to the increase in the volume administered &#40;97&#37;&#44; 0&#46;88&#37;&#44; and 0&#46;89&#37;&#44; respectively&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">For the liquid viscosity&#44; the increase in the volume administered &#40;5<span class="elsevierStyleHsp" style=""></span>ml&#44; 10<span class="elsevierStyleHsp" style=""></span>ml&#44; and 20<span class="elsevierStyleHsp" style=""></span>ml&#41; increases the prevalence of the sign of impaired lip closure &#40;0&#37;&#44; 19&#37;&#44; and 39&#37;&#44; respectively&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;010&#59; Post hoc analysis&#58; 5<span class="elsevierStyleHsp" style=""></span>ml<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span>ml&#59; and 10<span class="elsevierStyleHsp" style=""></span>ml<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>20<span class="elsevierStyleHsp" style=""></span>ml&#41;&#46; For the efficacy sign of piecemeal deglutition&#44; it presents two distinct groups of prevalence among the administered volumes&#58; 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 &#40;16&#37;&#44; 14&#37;&#44; and 50&#37;&#44; respectively&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;006&#59; Post hoc analysis&#58; 5<span class="elsevierStyleHsp" style=""></span>ml<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span>ml&#59; 20<span class="elsevierStyleHsp" style=""></span>ml&#41;&#46; For the oral residues&#44; for all the volumes administered&#44; the prevalence was equal to 0&#37;&#46; Finally&#44; for pharyngeal residues no statistical differences was found for prevalence &#40;8&#37;&#44; 5&#37;&#44; and 17&#37;&#44; respectively&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;61&#41;&#46; For the sign of safe swallow&#44; the prevalence value decreases significantly with the volume administered &#40;84&#37;&#44; 86&#37;&#44; and 33&#37;&#44; respectively&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#59; Post hoc analysis&#58; 5<span class="elsevierStyleHsp" style=""></span>ml<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span>ml&#59; 20<span class="elsevierStyleHsp" style=""></span>ml&#41;&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">For the pudding viscosity&#44; no statistical differences was found in the prevalence for the impaired lip closure &#40;6&#37;&#44; 0&#37;&#44; 18&#37;&#44; respectively&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; For the sign of efficacy of piecemeal deglutition there are two distinct groups of prevalence among the volumes administered &#40;6&#37;&#44; 19&#37;&#44; and 50&#37;&#44; respectively&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;008&#59; Post hoc analysis&#58; 5<span class="elsevierStyleHsp" style=""></span>ml<span class="elsevierStyleHsp" style=""></span>&#61;<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>&#61;<span class="elsevierStyleHsp" style=""></span>20<span class="elsevierStyleHsp" style=""></span>ml&#41;&#44; 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&#46; For the oral residues&#44; as it happens for the other consistencies&#44; no statistically significant results was found &#40;0&#37;&#44; 0&#37;&#44; and 9&#37;&#44; respectively&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; Finally&#44; for pharyngeal residues no statistical differences was found for prevalence &#40;3&#37;&#44; 9&#37;&#44; and 9&#37;&#44; respectively&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;51&#41;&#46; For the sign of safe swallow&#44; the prevalence value decreases with the volume administered &#40;100&#37;&#44; 100&#37;&#44; and 94&#37;&#44; respectively&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;135&#41;&#46; The lowest prevalence values were obtained with the highest administered volume&#44; as it was expected&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">It is noteworthy that the lowest safe swallow item &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41; has a prevalence of 33&#46;0&#37;&#44; for the liquid viscosity with a volume of 20<span class="elsevierStyleHsp" style=""></span>ml&#46; It was therefore considered that most of the participants had swallowing difficulties for the liquid viscosity&#46; An increase in viscosity promotes a safer swallowing&#46;</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&#58; EP &#40;Matos&#44; 2015&#41;&#46; It was also intended to analyze the prevalence of clinical signs of impaired safety and efficacy in the oral and pharyngeal phases of swallowing&#44; in patients who have had an acute stroke&#46;</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&#44; the experts consulted considered the translation and cultural adaptation of the V-VST&#58; EP clear and relevant as almost all the items presented a CVI of 100&#37;&#46; The content validation performed by <a class="elsevierStyleCrossRef" href="#bib0120">Matos et al&#46; &#40;2015&#41;</a> obtained similar results after a second revision&#46; However&#44; by the end of the process&#44; some items still presented values considered bellow recommended &#40;&#60;0&#46;78&#41;&#46; In our study&#44; the panel of experts considered the item of the volume of 20<span class="elsevierStyleHsp" style=""></span>ml to be excessive&#44; assigning it with a CVI of 67&#46;0&#37;&#46; This value is somewhat below from what would be expected&#44; since the value of CVI should be greater than 0&#46;78 to be considered as valid &#40;<a class="elsevierStyleCrossRef" href="#bib0145">Polit and Beck&#44; 2006</a>&#41;&#46; It was decided that this item should not be subjected to reformulation or discussion&#46; According to <a class="elsevierStyleCrossRef" href="#bib0040">Clav&#233; et al&#46; &#40;2008&#41;</a>&#44; 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 &#40;approximately 30&#37; of piecemeal deglutition and 50&#37; of pharyngeal residues&#41;&#44; which indicates the impairment before&#44; during and after swallowing&#46; Based on these facts it was decided to maintain this volume in the V-VST&#58; EP version&#46; Two experts also suggested the inclusion of a honey consistency as an intermediate viscosity to assess&#46; In the study by <a class="elsevierStyleCrossRef" href="#bib0160">Rofes et al&#46; &#40;2012&#41;</a> the authors present a long version of the V-VST application algorithm in which&#44; at the end of the evaluation of nectar&#44; liquid and pudding consistency&#44; a honey consistency is also evaluated with the objective of optimizing the amount of thickener to use&#46; However&#44; and as reinforced by <a class="elsevierStyleCrossRef" href="#bib0160">Rofes et al&#46; &#40;2012&#41;</a> and <a class="elsevierStyleCrossRef" href="#bib0040">Clav&#233; et al&#46; &#40;2008&#41;</a>&#44; the three consistencies included in the V-VST allow dysphagia screening&#44; as they are organized by progression of swallowing difficulty in order to reduce the risk of aspiration&#46; As the present study used the original version created for the application of V-VST&#44; where a honey consistency is not included in the application algorithm&#44; it was decided not to include this consistency for the purpose of this study&#46; Concerning the instruction manual&#44; some changes were made based on the experts&#8217; suggestions&#44; for example&#44; the explanation of the algorithm and the practical and procedural aspects of the recommended diet were reformulated&#46; We obtained a CVI of 83&#37; for these reformulated instructions&#44; indicating a final agreement among the experts&#46; As a result&#44; the final version of the instruction manual is now more descriptive&#44; allowing a clearer identification of situations of possible dysphagia&#46; In addition&#44; the recommendations regarding the most appropriate volume and consistency for each patient have become more accurate&#46;</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 &#40;higher than 75&#37; for the inter-evaluator and 70&#37; for the intra-evaluator&#41; in the reliability study&#46; For the situations of lower kappa values&#44; the percentage agreement between evaluators presented higher values&#44; starting from 83&#46;3&#37; for inter-evaluator and from 75&#37; for intra-evaluator&#46; The low kappa values resulted from the well-described paradox related to Cohens&#8217; kappa statistic&#44; especially for binary categorical classifications&#44; when the expected agreement is sensitive to the distribution of the marginal totals &#40;<a class="elsevierStyleCrossRef" href="#bib0055">Feinstein and Cicchetti&#44; 1990</a>&#41;&#46; From the analysis of the contingency table&#44; it was clear that this was the case&#58; high values of percentage agreement result in low kappa values&#46; Due to the nature of the binary class &#40;positive or negative&#41;&#44; in some cases &#40;presented in the tables as n&#46;a&#46;&#41; the evaluator classified all participants as positive or negative&#46; In this situation&#44; it was not possible to present inferential statistical results because the sample values were all equal to a constant&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">In the concurrent validity&#44; the V-VST&#58; EP version shows a sensitivity value of 100&#37; and specificity value of 57&#46;1&#37;&#46; Despite that the V-VST&#58; EP may incorrectly show positive results for patients without disease&#44; and that can be a problem for financial expenses and SLT time consuming&#44; it has a very good capacity to detect negative results for people who have the condition&#44; avoiding the common consequences of OD&#46; The study by <a class="elsevierStyleCrossRef" href="#bib0040">Clav&#233; et al&#46; &#40;2008&#41;</a>&#44; using Videofluoroscopy &#40;VFS&#41; as the gold standard test&#44; indicates that diagnostic sensitivity and specificity of the V-VST for clinical signs of impaired safety of swallow &#40;aspiration or penetration&#41; were 88&#46;2&#37; and 64&#46;7&#37;&#44; respectively&#46; The same study showed that the sensitivity of the V-VST was 100&#37; in recognizing patients with aspiration confirmed by VFS and also following a negative V-VST result&#44; the probability of no aspiration was 100&#37;&#46; These results&#44; as well as the results obtained in our study&#44; 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&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Concerning the prevalence of clinical signs of impaired safety and efficacy obtained during this study&#44; it was possible to observe that all the acute stroke patients involved showed some of these signs&#44; indicating the possible presence of OD&#46; The piecemeal deglutition efficacy values for the nectar consistency &#40;25&#37;&#44; considering the average values for 5<span class="elsevierStyleHsp" style=""></span>ml&#44; 10<span class="elsevierStyleHsp" style=""></span>ml&#44; and 20<span class="elsevierStyleHsp" style=""></span>ml&#41;&#44; liquid consistency &#40;26&#46;8&#37;&#41; and pudding consistency &#40;26&#46;3&#37;&#41; were a bit different from the values obtained in the original study&#44; that were 25&#46;9&#37;&#44; 15&#46;3&#37; and 30&#46;6&#37; respectively &#40;<a class="elsevierStyleCrossRef" href="#bib0040">Clav&#233; et al&#46;&#44; 2008</a>&#41;&#46; As for the item of oral residues&#44; lower values were obtained in our study &#40;consistency&#58; nectar<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#46;3&#37;&#59; liquid<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#37;&#59; pudding<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3&#37;&#41; than the corresponding values in the original study &#40;consistency&#58; nectar<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>10&#46;6&#37;&#59; liquid<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3&#46;5&#37;&#59; pudding<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>12&#46;9&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#bib0040">Clav&#233; et al&#46;&#44; 2008</a>&#41;&#46; This variation&#44; in the values obtained with both signs of impaired efficacy&#44; may be justified by the differences in the sample used&#46; In the original study the sample was composed by patients with OD of several aetiologies&#44; such as elderly patients with cerebro-vascular disease&#44; geriatric diseases or head and neck diseases and middle-aged patients with neurodegenerative diseases &#40;<a class="elsevierStyleCrossRef" href="#bib0040">Clav&#233; et al&#46;&#44; 2008</a>&#41;&#44; while the sample in the present study was composed only by acute stroke patients&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">For the item of pharyngeal residues&#44; the prevalence values obtained were also different from those of the original study &#40;consistency&#58; nectar<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>15&#46;9&#37;&#59; liquid<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>15&#46;3&#37;&#59; pudding<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>56&#46;6&#37;&#41;&#46; In the present study the values found were&#58; nectar<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>13&#46;5&#37;&#59; liquid<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>9&#46;8&#37;&#59; and pudding<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>7&#46;1&#37;&#46; 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&#44; especially in post stroke patients who often have pharyngeal and&#47;or laryngeal sensitivity impairments&#46; 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 &#40;FEES&#41; &#40;<a class="elsevierStyleCrossRef" href="#bib0135">Newman et al&#46;&#44; 2016</a>&#41;&#44; however due to financial restrictions this was not possible&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">As <a class="elsevierStyleCrossRef" href="#bib0040">Clav&#233; et al&#46; &#40;2008&#41;</a>&#44; who identified changes in clinical safety according to the consistency &#40;50&#37;&#8211;75&#46;3&#37; of patients with liquid&#44; 23&#46;4&#37;&#8211;39&#46;2&#37; of patients with nectar and 14&#46;5&#37;&#8211;27&#46;6&#37; of patients with pudding&#41;&#44; we also observed that increasing the thickness of the swallow significantly improves swallowing safety&#46; That is&#44; the pudding consistency has the highest safety values &#40;0&#37;&#8211;6&#37;&#41; compared to liquid &#40;14&#37;&#8211;67&#37;&#41; and nectar &#40;3&#37;&#8211;12&#37;&#41;&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">It is noteworthy that&#44; despite the difference of the values obtained among the studies&#44; the present study concluded that the liquid consistency was the least safe consistency with the presence of coughing and wet voice&#44; during swallowing&#46; As suggested by <a class="elsevierStyleCrossRef" href="#bib0150">Rofes et al&#46; &#40;2011&#41;</a> we may also conclude that a reduction in the volume and an increase in the bolus viscosity promote a safer swallowing&#46;</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&#46; The concurrent validity presented in this study is limited to the use of a second screening test &#40;the 3OZ wst&#41;&#46; This poses a problem in the interpretation of some of the results obtained in terms of sensitivity and specificity for laryngeal aspiration and penetration&#46; Another limitation was the imposition made by the ethics committee that we could not involve patients with severe dysphagia&#46; This fact influenced the prevalence results obtained because it eliminated the population that most likely would demonstrate alterations in the evaluated signs&#46; Also the study sample size &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>33&#41; caused some difficulties related to the statistical analysis&#44; especially for the Cohen&#39;s kappa statistics inference&#44; due to its small size&#46; Finally&#44; the use of a 48-hour window between the two assessments may have interfered with the results&#46; Our population is in an acute phase in which the clinical prognosis may change very quickly&#46;</p></span></span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">Conclusion</span><p id="par0220" class="elsevierStylePara elsevierViewall">In conclusion&#44; our study demonstrates that the V-VST&#58; EP has good content and concurrent validity&#44; inter evaluator reliability and test&#8211;retest reproducibility&#46; It has proven to be a reliable and valid instrument for the screening of OD in patients who have suffered an acute stroke&#46; Further studies are needed to assess its use in the screening of other dysphagic populations&#46;</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&#44; and the Ethics Committee &#8211; Innovation and Development Unit of CHUC&#44; Portugal&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">An informed written consent from the patient or his&#47;her legal representative was obtained after confidentiality of the collected data was guaranteed&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">The company responsible for V-VST in Portugal&#44; Nutricia&#44; was contacted and a declaration of consent to use the Portuguese version of V-VST and its application instructions was obtained&#46;</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 &#8211; <span class="elsevierStyleItalic">Funda&#231;&#227;o para a Ci&#234;ncia e a Tecnologia</span></span> within CIDMA &#40;reference UID&#47;MAT&#47;04106&#47;2019&#41;&#46;</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&#46;</p></span></span>"
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          "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 => "Detecci&#243;n de disfagia"
            3 => "Trastornos de la degluci&#243;n"
          ]
        ]
      ]
    ]
    "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 &#40;OD&#41; in patients after an acute stroke using non-invasive and easily administered instruments can minimize its consequences and reduce comorbidity and mortality&#46; The Volume-Viscosity Swallow Test &#40;V-VST&#41; is a screening test that makes it possible&#46; The goal of this study is to contribute to the validation of the V-VST European Portuguese &#40;V-VST&#58; EP&#41; version and study the prevalence of safety and efficacy signs in acute stroke patients&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Method</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">The V-VST&#58; EP&#44; its instructions manual and algorithm&#44; was presented to a panel of experts&#44; to assess its content validity&#46; It was applied to 33 acute stroke patients&#44; with signs of OD&#44; to analyze its psychometric properties&#46; Finally&#44; the prevalence of impaired signs of safety and efficacy was analyzed&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">The V-VST&#58; EP and its instruction manual &#40;content&#41; demonstrate very good agreement values&#46; Most of the results for inter and intra-evaluator reliability presented Cohen&#39;s kappa values higher than 0&#46;60 or 0&#46;80 &#40;75&#46;0&#37;&#41;&#46; The concurrent validity &#40;against the 3 OZ wst&#41; presented a sensitivity of 100&#37; and a specificity of 57&#46;1&#37;&#46; For evaluator 1&#44; the results presented are for the nectar&#44; liquid and pudding consistencies&#44; the prevalence values for the 5 ml&#44; 10 ml and 20 ml volume capacity was&#58; impaired lip closure &#40;36&#37;&#44; 39&#37;&#44; 18&#37;&#41;&#44; piecemeal deglutition &#40;50&#37;&#44; 50&#37;&#44; 50&#37;&#41;&#44; oral residue &#40;7&#37;&#44; 0&#37;&#44; 9&#37;&#41;&#44; pharyngeal residue &#40;25&#37;&#44; 17&#37;&#44; 9&#37;&#41; and safe swallowing &#40;89&#37;&#44; 33&#37;&#44; 94&#37;&#41;&#44; respectively&#46;</p></span>"
        "secciones" => array:3 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Purpose"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Method"
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          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Prop&#243;sito</span><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">La identificaci&#243;n temprana de la disfagia orofar&#237;ngea &#40;DO&#41; en pacientes despu&#233;s de un accidente cerebrovascular&#44; utilizando instrumentos no invasivos y de f&#225;cil administraci&#243;n&#44; puede minimizar sus consecuencias y reducir la comorbilidad y la mortalidad&#46; El examen <span class="elsevierStyleItalic">Volume-Viscosity Swallow Test</span> &#40;V-VST&#41; es una prueba de detecci&#243;n que lo hace posible&#46; El objetivo de este estudio es contribuir para la validaci&#243;n del V-VST Versi&#243;n en portugu&#233;s europeo &#40;V-VST&#58; EP&#41; y estudio de prevalencia de signos de seguridad y eficacia en pacientes con ictus agudo&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">M&#233;todo</span><p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Se present&#243; el V-VST&#58; EP&#44; su manual de instrucciones y algoritmo&#44; a un panel de expertos&#44; para evaluar su validez de contenido&#46; Se aplic&#243; a 33 pacientes con ictus agudo&#44; con signos de DO&#44; para analizar sus propiedades psicom&#233;tricas&#46; Finalmentese analiz&#243; la prevalencia de se&#241;ales de deterioro de seguridad y eficacia&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Resultados</span><p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">El V-VST&#58; EP y su manual de instrucciones &#40;contenido&#41; demuestran valores demuy buenaconcordancia&#46; La mayor&#237;a de los resultados de confiabilidad inter e intra evaluador presentaron valoreskappa de Cohen superiores a 0&#44;60 o 0&#44;80 &#40;75&#44;0&#37;&#41;&#46; La validez concurrente &#40;contra el peso de 3 OZ&#41; presentada una sensibilidad del 100&#37; y una especificidad del 57&#44;1&#37;&#46; Para el evaluador 1&#44; los resultados presentados son para las consistencias de n&#233;ctar&#44; l&#237;quido y bud&#237;n&#44; los valores de prevalencia para los 5 ml&#44; 10 ml y 20 ml capacidad de volumen fue&#58; deterioro del cierre de los labios &#40;36&#37;&#44; 39&#37;&#44; 18&#37;&#41;&#44; degluci&#243;n fragmentaria &#40;50&#37;&#44; 50&#37;&#44; 50&#37;&#41;&#44; residuo oral &#40;7&#37;&#44; 0&#37;&#44; 9&#37;&#41;&#44; residuo far&#237;ngeo &#40;25&#37;&#44; 17&#37;&#44; 9&#37;&#41; y degluci&#243;n segura &#40;89&#37;&#44; 33&#37;&#44; 94&#37;&#41;&#44; respectivamente&#46;</p></span>"
        "secciones" => array:3 [
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            "identificador" => "abst0020"
            "titulo" => "Prop&#243;sito"
          ]
          1 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "M&#233;todo"
          ]
          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"
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        "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&#46; 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&#46;</p>"
        ]
      ]
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        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
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        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at1"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
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                  \t\t\t\t" scope="col">Consistency&nbsp;\t\t\t\t\t\t\n
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                  \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&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " colspan="2" align="center" valign="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Amount &#40;g&#47;100<span class="elsevierStyleHsp" style=""></span>ml&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Viscosity &#40;mPa<span class="elsevierStyleHsp" style=""></span>s&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Amount &#40;g&#47;100<span class="elsevierStyleHsp" style=""></span>ml&#41;&nbsp;\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
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Viscosity &#40;mPa<span class="elsevierStyleHsp" style=""></span>s&#41;&nbsp;\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
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Liquid&nbsp;\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
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                  \t\t\t\t">1&#8211;50&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">21&nbsp;\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
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                  \t\t\t\t">0&nbsp;\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
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                  \t\t\t\t">14&nbsp;\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&nbsp;\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
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                  \t\t\t\t">51&#8211;350&nbsp;\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
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                  \t\t\t\t">4&#46;5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">295&nbsp;\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
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                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#62;1750&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">9&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">3682&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2175&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " colspan="2" align="left" valign="\n
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                  \t\t\t\t">16 &#40;49&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>20<span class="elsevierStyleHsp" style=""></span>ml&nbsp;\t\t\t\t\t\t\n
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                  \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
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>ml&nbsp;\t\t\t\t\t\t\n
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                  \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
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span>ml&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>20<span class="elsevierStyleHsp" style=""></span>ml&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>ml&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">100&nbsp;\t\t\t\t\t\t\n
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                  \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
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span>ml&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>20<span class="elsevierStyleHsp" style=""></span>ml&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>ml&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">85&#46;7&nbsp;\t\t\t\t\t\t\n
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                  \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
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span>ml&nbsp;\t\t\t\t\t\t\n
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                  \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&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#46;00<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;00&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">100&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \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&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">n&#46;a&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">100&nbsp;\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&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
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            0 => array:3 [
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Practical statistics for medical research"
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                          "autores" => array:1 [
                            0 => "D&#46;G&#46; Altman"
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                      "titulo" => "Analysis of a physician tool for evaluating dysphagia on an inpatient stroke unit&#58; The modified Mann assessment of swallowing ability"
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                          "etal" => false
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                            3 => "L&#46; Miller"
                            4 => "H&#46; Hubbard"
                            5 => "K&#46; Hood"
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              "etiqueta" => "Audag et al&#46;&#44; in press"
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                            3 => "J&#46;C&#46; Pryor"
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                          "autores" => array:6 [
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        "titulo" => "Acknowledgement"
        "texto" => "<p id="par0255" class="elsevierStylePara elsevierViewall">We would like to thank the support of the Acute Stroke Unit of Centro Hospitalar e Universit&#225;rio de Coimbra &#40;CHUC&#41; and of the Laboratory of Galenic and Pharmaceutical Technology&#44; Faculty of Pharmacy&#44; University of Coimbra&#44; during this study&#46;</p><p id="par0260" class="elsevierStylePara elsevierViewall">Finally&#44; we thank all Speech and Language Therapists and patients who agreed to participate in this research&#46;</p>"
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Original language: English
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