Variability in endoscopic assessment of Nissen fundoplication wrap integrity and hiatus herniation

2021 ◽  
Author(s):  
Erin J Song ◽  
Rena Yadlapati ◽  
Joan W Chen ◽  
Alice Parish ◽  
Matthew J Whitson ◽  
...  
Keyword(s):  
Nissen Fundoplication ◽  
Survey Study ◽  
Upper Endoscopy ◽  
Rater Agreement ◽  
Endoscopic Evaluation ◽  
Provider Type ◽  
Diagnostic Confidence ◽  
The Mean ◽  
Endoscopic Assessment ◽  
Final Cohort

Summary Background Upper endoscopy (EGD) is frequently performed in patients with esophageal complaints following anti-reflux surgery such as fundoplication. Endoscopic evaluation of fundoplication wrap integrity can be challenging. Our primary aim in this pilot study was to evaluate the accuracy and confidence of assessing Nissen fundoplication integrity and hiatus herniation among gastroenterology (GI) fellows, subspecialists, and foregut surgeons. Methods Five variations of post-Nissen fundoplication anatomy were included in a survey of 20 sets of EGD images that was completed by GI fellows, general GI attendings, esophagologists, and foregut surgeons. Accuracy, diagnostic confidence, and inter-rater agreement across providers were evaluated. Results There were 31 respondents in the final cohort. Confidence in pre-survey diagnostics significantly differed by provider type (mean confidence out of 5 was 1.8 for GI fellows, 2.7 for general GI attendings, 3.6 for esophagologists, and 3.6 for foregut surgeons, P = 0.01). The mean overall accuracy was 45.9%, which significantly differed by provider type with the lowest rate among GI fellows (37%) and highest among esophagologists (53%; P = 0.01). The accuracy was highest among esophagologists across all wrap integrity variations. Inter-rater agreement was low across wrap integrity variations (Krippendorf’s alpha <0.30), indicating low to no agreement between providers. Conclusion In this multi-center survey study, GI fellows had the lowest accuracy and confidence in assessing EGD images after Nissen fundoplication, whereas esophagologists had the highest. Diagnostic confidence varied considerably and inter-rater agreement was poor. These findings suggest experience may improve confidence, but highlight the need to improve the evaluation of fundoplication wraps.

scholarly journals POS0733 REAL-LIFE PHYSICAL ACTIVITY IN SLE PATIENTS: ASSOCIATIONS WITH FATIGUE AND QUALITY OF SLEEP

2021 ◽  
Vol 80 (Suppl 1) ◽  
pp. 617.1-617
Author(s):  
H. Wohland ◽  
N. Leuchten ◽  
M. Aringer
Keyword(s):  
Physical Activity ◽  
Sleep Quality ◽  
Disease Activity ◽  
Lupus Erythematosus ◽  
Real Life ◽  
Survey Study ◽  
Cross Sectional Survey ◽  
Cross Sectional ◽  
Fatigue Score ◽  
The Mean

Background:Fatigue is among the top complaints of patients with systemic lupus erythematosus (SLE), but only in part associated with SLE disease activity. Physical activity can help to reduce fatigue and should therefore be recommended to SLE patients. Vice versa, fatigue may arguably lead to reduced physical activity.Objectives:To investigate the extent of physical activity and the perception of fatigue and sleep quality in patients with SLE.Methods:Starting in February 2019, SLE patients were invited to participate in a cross-sectional survey study of fatigue and physical exercise during their routine outpatient clinic visits. Participants filled out a ten-page paper questionnaire focused on physical activity. To evaluate fatigue, we primarily used a 10 cm visual analogue scale (0-100 mm, with 100 meaning most fatigued), but also the FACIT fatigue score (range 0-52). Sleep quality was estimated using grades from 1 (excellent) to 6 (extremely poor).Results:93 SLE patients took part in the study. All patients fulfilled the European League Against Rheumatism/ American College of Rheumatology (EULAR/ACR) 2019 classification criteria for SLE. 91% of the patients were female. Their mean (SD) age was 45.5 (14.3) years and their mean disease duration 12.1 (9.4) years. The mean BMI was 25.2 (5.6). Of all patients, 7.5% had a diagnosis of (secondary) fibromyalgia. The mean fatigue VAS was 32 (27) mm and the mean FACIT fatigue score 35.7 (10.3). As expected, fatigue by VAS and FACIT was correlated (Spearman r=-0.61, p<0.0001). The mean SLEDAI was 1 (1) with a range of 0 to 6. Median glucocorticoid doses were 2 mg prednisolone equivalent, with a range from 0 to 10 mg.Out of 66 patients in payed jobs, 64 (97%) reported details on their working space. One person (2%) worked in a predominanty standing position, 37 (58%) worked in essentially sedentary jobs and 26 (40%) were in positions where they were mildly physically active in part. The mean fatigue VAS was 31 (24) mm for patients with partly active jobs and 27 (30) mm for those in sedentary jobs. Sleep was graded 2.9 (0.9) by those with active and 3.1 (1.3) by those with sedentary jobs.Half of the patients (51%) reported more than one physical recreational activity. 44 (47%) were walking and for five persons (5%) this was the only form of activity. Cycling was reported by 19 patients (20%), 18 of whom also practiced other activities. For transport, 52 (56%) in part chose active modes, such as walking and cycling. Patients who reported any of the above activities showed a mean fatigue VAS of 28 (25) mm, compared to 36 (28) mm in the patient group without a reported activity. Sleep quality was very similar: 3.1 (1.2) and 3.2 (1.1) for more active and more passive patients, respectively.65 (70%) patients regularly practiced sports. Of these, 39 (60%) practiced one kind of sport, 15 (23%) two, 7 (11%) three, and 2 (3%) each four and five kinds of sports. Fatigue VAS of patients practicing sports was 27 (25) mm versus 43 (28) in those who did not (p=0.0075). Sleep quality was 2.9 (1.1) in the sports cohort and 3.5 (1.1) in the no-sports cohort (p=0.0244).Conclusion:A majority of SLE patients in remission or low to moderate disease activity regularly practiced sports, and those doing so reported lesser fatigue and better sleep quality. The absolute values on the fatigue VAS were in a moderate range that made fatigue as the main cause of not performing sports rather unlikely for most patients.Disclosure of Interests:Helena Wohland: None declared, Nicolai Leuchten Speakers bureau: AbbVie, Janssen, Novartis, Roche, UCB, Consultant of: AbbVie, Janssen, Novartis, Roche, Martin Aringer Speakers bureau: AbbVie, Astra Zeneca, BMS, Boehringer Ingelheim, Chugai, Gilead, GSK, HEXAL, Lilly, MSD, Novartis, Pfizer, Roche, Sanofi, UCB, Consultant of: AbbVie, Astra Zeneca, BMS, Boehringer Ingelheim, GSK, Lilly, MSD, Roche, Sanofi, UCB

scholarly journals Vocabulary Learning Strategies Employed by Gamers In The “Simulation Video Game”

2018 ◽  
Vol 2 (1) ◽  
pp. 22
Author(s):  
Moh. Hasbullah Isnaini ◽  
Resda Cintami Laksana
Keyword(s):  
Learning Strategies ◽  
Language Learners ◽  
Video Game ◽  
Vocabulary Learning ◽  
Cognitive Strategy ◽  
Survey Study ◽  
Vocabulary Strategies ◽  
Vocabulary Learning Strategies ◽  
The Social ◽  
The Mean

<p class="abstract"><span lang="EN-AU">This study aims at investigating the phenomena of vocabulary strategies used by gamers of the Harvest Moon game. A survey study was conducted to see the most and the least frequent strategies used by the gamers while playing the game. To gain the data, the researcher distributed a questionnare which is adapted from the Schmitt’s taxonomy of VLS namely determination, social (discovery), social (consolidation), cognitive, memory, and metacognitive strategies. The result of the present study shows that the most frequent strategy used is cognitive strategy, the mean is 2.28 which indicates that most of the gamers use this strategy to improve their vocabulary learning. Meanwhile, the least strategy used is the social startegy since the mean score is 1.07 which suggests that the gamers do not really seek help from friends when they have problems with vocabulary. Taking the result of the study into the learning of vocabulary, it is suggested that teachers provide language learners with the cognitive strategy to accomodate their vocabulary learning, so that they can enhance their vocabulary.</span></p>

Abstract TP52: Comparison of Two Methods of the Alberta Stroke Program Early CT Score

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Alex J Linn ◽  
Steve O’Donnell ◽  
Adam de Havenon
Keyword(s):  
Ct Perfusion ◽  
High Reliability ◽  
Scoring Systems ◽  
Weighted Kappa ◽  
Medical Decision ◽  
Rater Agreement ◽  
Clinical Tool ◽  
Ct Angiogram ◽  
The Mean

Introduction: Alberta Stroke Program Early CT Score (ASPECTS) is a validated clinical tool to predict early ischemic changes in acute ischemic stroke (AIS). In addition to scoring of non-contrast brain CT images (CT), head CT angiogram source images (CTA) have also been demonstrated as useful for scoring. We hypothesized that CTA ASPECTS would show superior inter-rater reliability as compared to CT ASPECTS, and that both would perform better in the setting of the favorable target mismatch (TM) profile on CT perfusion imaging (CTP). Methods: We reviewed AIS patients from 2010-2014 with an acute M1 middle cerebral artery occlusion that underwent CT, CTA, and CTP imaging at hospital admission. CT and CTA were independently scored by two experienced physician raters using the standard ASPECTS methodology. Inter-rater agreement was calculated with a weighted kappa. The cohort was then further stratified into either favorable or non-favorable TM profiles using volumetric measurements from the Olea Sphere software and the DEFUSE-3 definition of TM. Results: We included 68 patients. The mean±SD age was 62±18 years. 60% were men. The mean NIH stroke scale was 14.5±7.9. The median (IQR) follow-up modified Rankin Scale (mRS) was 3 (1,6). 37 of 68 (54%) patients had the TM profile and were significantly more likely to have lower follow-up mRS scores (z=3.5, p<0.001). Inter-rater agreement of CTA ASPECTS (kappa=0.82) was superior to CT ASPECTS (kappa=0.76). Patients with the TM profile demonstrated more reliable agreement on both CTA and CT ASPECTS scoring systems (kappa=0.79, 0.78), compared to those without the TM profile (kappa=0.71, 0.75). Discussion: We found that inter-rater agreement was higher for CTA ASPECTS as compared to CT ASPECTS and that both performed better in patents with the TM profile. Clinically this is important because it reaffirms the utility of CTA ASPECTS in this population of patients in which high reliability is paramount, as ASPECTS is often used in medical decision making when determining eligibility for medical and/or endovascular thrombolytic therapies.

SPORT WORKOUT AND PARTICIPATION ASSOCIATED MENSTRUAL PROBLEMS AMONG ADOLESCENT ATHLETES OF ALIGARH

2019 ◽  
Vol 2 ◽  
pp. 12-22
Author(s):  
Dr. Abdul Roof Rather ◽  
Nazia Khan ◽  
Abdul Kaisar
Keyword(s):  
Medical Practitioner ◽  
Sports Participation ◽  
Study Data ◽  
Survey Study ◽  
Adolescent Athletes ◽  
Menstrual Cycles ◽  
The Social ◽  
The Mean ◽  
Age Of Menarche ◽  
Structured Questionnaire

Background: Menstruation and related problems are issues of great importance for adolescent athletes. The concern becomes more crucial when it comes to the sports participation of athletes. The social and cultural setup in India leaves very less space for adolescent athletes to talk freely about menstruation. This raises a great concern regarding menstruation from health perspective. Objectives: To study sport workout and participation associated menstrual problems among adolescent athletes. Materials and Methods: A questionnaire based survey study was carried out during open sports meet 2017 in Aligarh, India. A sample of 158 girl athletes participated in this study. Data was collected using a 23-item semi structured questionnaire. Data collection lasted for two weeks and analysis was done using descriptive statistics, percentages and proportions. Results: Showed that the mean age of menarche was 13.5 years. 37.19% had irregular menstrual cycle. 73.23% (20.11% severe and 53.12% mild) athletes had abdominal pain and cramping during menstruation. While, mere, 7.98% athletes seek any medical practitioner or OB-GYN about their menstruation problems. 56.97% athletes think that sports training and participation effect their menstrual periods. 49.78% reported that diet provided to them was not well balanced and 59.09% reported that imbalanced diet had caused many problems like that of irregular menstrual periods, dizziness, sleeping difficulties, mood swings, constipation and feelings of depression to them. Conclusion: The knowledge of the participants of this study about the menstruation and related problems was very weak and did not know the safe maintenance procedures. They also have the ill faith that sports participation hampers the menstrual periods. Besides this the significant weight loss could be due to training load and dietary imbalances. This seems to have had played major role in the irregularity of the menstrual cycles.

scholarly journals Do You See What I See? An Assessment of Endoscopic Lesions Recognition and Description by Gastroenterology Trainees and Staff Physicians

2019 ◽  
Vol 3 (5) ◽  
pp. 216-221
Author(s):  
Lara Hart ◽  
Mallory Chavannes ◽  
Peter L Lakatos ◽  
Waqqas Afif ◽  
Alain Bitton ◽  
...  
Keyword(s):  
Severe Disease ◽  
Observer Agreement ◽  
Rater Agreement ◽  
Severity Rating ◽  
Management Plans ◽  
Endoscopic Score ◽  
Inflammatory Bowel ◽  
The Mean ◽  
Better Than ◽  
Inflammatory Burden

Abstract Background Gastroenterologists should accurately describe endoscopic findings and integrate them into management plans. We aimed to determine if trainees and staff are describing inflammatory bowel disease (IBD) lesions in a similar manner. Methods Using 20 ileocolonoscopy images, participants described IBD inflammatory burden based on physician severity rating, and Mayo endoscopic score (MES) (ulcerative colitis [UC]) or simple endoscopic score (SES-CD) (Crohn’s disease [CD]). Images were selected based on agreement by three IBD experts. Findings of varying severity were presented; 10 images included a question about management. We examined inter-observer agreement among trainees and staff, compared trainees to staff, and determined accuracy of response comparing both groups to IBD experts. Results One hundred and twenty-nine staff and 47 trainees participated from across Canada. There was moderate inter-rater agreement using physician severity rating (κ = 0.53 UC and 0.52 CD for staff, κ = 0.51 UC and 0.43 CD for trainees). There was moderate inter-rater agreement for MES for staff and trainees (κ = 0.49 and 0.48, respectively), but fair agreement for SES-CD (κ = 0.37 and 0.32, respectively). For accuracy of response, the mean score was 68.7% for staff and 63.7% for trainees (P = 0.028). Both groups identified healed bowel or severe disease better than mild/moderate (P &lt; 0.05). There was high accuracy for management, but staff scored higher than trainees for UC (P &lt; 0.01). Conclusion Inter-rater agreement on description of IBD lesions was moderate at best. Staff and trainees more accurately describe healed and severe disease, and better describe lesions in UC than CD.

scholarly journals Endoscopic esophagogastric anastomosis with luminal apposition Axios stent (LAS) approach: a new concept for hybrid “Lewis Santy”

2017 ◽  
Vol 05 (06) ◽  
pp. E455-E462
Author(s):  
Adrian Culetto ◽  
Jean-Michel Gonzalez ◽  
Geoffroy Vanbiervliet ◽  
Pablo Miranda Garcia ◽  
Juan Tellechea ◽  
...  
Keyword(s):  
Operative Time ◽  
Hybrid Approach ◽  
Esophagogastric Anastomosis ◽  
Pathological Examination ◽  
Gastrojejunal Anastomosis ◽  
Endoscopic Suture ◽  
The Mean ◽  
The Right ◽  
Good Patency ◽  
Endoscopic Assessment

Abstract Background and study aims Esophagogastric anastomosis (EGA) has a high risk of leakage. Based upon our experience in endoscopic gastrojejunal anastomosis using LAS, the aim of this study was to verify the technical feasibility and the safety of performing an EGA using a hybrid approach (endoscopic and surgical). Materials and methods A pilot prospective study was performed on 8 survival pigs. The procedure was carried out in 2 stages: (i) surgical step consisting of an esogastrectomy by laparotomy with separated suture of the esophagus and stomach; (ii) endoscopic esophagogastric anastomosis using the LAS. The first 2 pigs allowed for the setting of the 2 steps procedure, and 6 were included in the study for assessing the efficacy and safety of the procedure with a 3-week survival course. The primary endpoint was morbidity and mortality. Results All procedures were successfull. The mean operative time was 98 minutes, with a mean endoscopic time of 46 minutes. Three early deaths occurred within the first weeks, unrelated to the LAS anastomosis. At 3 weeks, endoscopic assessment followed by necropsy demonstrated the right position and the endoscopic removability of the stent with good patency of the esophagogastric anastomosis, without leakage of the endoscopic suture. Pathological examination confirmed the patency of the anastomosis with fusion of mucosal and muscle layers. Conclusion Endoscopic esophagogastric anastomosis with LAS is feasible and reproducible, without anastomotic leakage. It could be a new alternative to perform safe anastomoses, as part of a hybrid approach (surgical and endoscopic).

FORMULATIONS OF THE MAIN GOAL IN LIFE: A QUALITATIVE CONTENT ANALYSIS

2018 ◽  
Vol 7 ◽  
pp. 104-114
Author(s):  
Aleksandrs Koļesovs ◽  
Irina Salima ◽  
Andris Maskovs
Keyword(s):  
Content Analysis ◽  
Thematic Analysis ◽  
Qualitative Content Analysis ◽  
Purpose In Life ◽  
Rater Agreement ◽  
Additional Step ◽  
The Mean ◽  
Work Family ◽  
Open Question ◽  
Humanistic Tradition

Humanistic tradition emphasizes the main goal in life as something towards which people determine themselves. The main goal (or a group of goals with the highest priority) provides the basis for the sense of purpose in life and for development of its meaning. This study aimed at revealing categories in formulations of the main goal in life. Participants were 226 adults aged from 18 to 69 (M = 25.34, SD = 8.51, 65% females). They answered an open question: “Kā Jūs raksturotu galveno dzīves mērķi? Lūdzu, padalieties ar savām pārdomām. [How could You describe the main goal in life? Please, share your opinion.]” The qualitative content analysis resulted in 29 categories. Inter-rater agreement among three raters was acceptable and varied from .72 to 1.00 (the mean Krippendorff’s alpha was .88). Work, Family, and Satisfaction were the most frequently selected categories for a formulation of the main goal, while Love, Leisure, and Transcendent Issues were the less selected ones. An additional step of thematic analysis demonstrated that categories can be joined in four overarching themes: Vague Formulations, Self, Others, and Desired States.

scholarly journals Content validity of the Geriatric Health Assessment Instrument

2016 ◽  
Vol 14 (2) ◽  
pp. 158-177 ◽  
Author(s):  
Rhaine Borges Santos Pedreira ◽  
Saulo Vasconcelos Rocha ◽  
Clarice Alves dos Santos ◽  
Lélia Renata Carneiro Vasconcelos ◽  
Martha Cerqueira Reis
Keyword(s):  
Content Validity ◽  
Assessment Tool ◽  
Health Assessment ◽  
The Elderly ◽  
Assessment Instrument ◽  
Rater Agreement ◽  
Validity Index ◽  
Content Validity Index ◽  
Percent Agreement ◽  
The Mean

ABSTRACT Objective Assess the content validity of the Elderly Health Assessment Tool with low education. Methods The data collection instrument/questionnaire was prepared and submitted to an expert panel comprising four healthcare professionals experienced in research on epidemiology of aging. The experts were allowed to suggest item inclusion/exclusion and were asked to rate the ability of individual items in questionnaire blocks to encompass target dimensions as “not valid”, “somewhat valid” or “valid”, using an interval scale. Percent agreement and the Content Validity Index were used as measurements of inter-rater agreement; the minimum acceptable inter-rater agreement was set at 80%. Results The mean instrument percent agreement rate was 86%, ranging from 63 to 99%, and from 50 to 100% between and within blocks respectively. The Mean Content Validity Index score was 93.47%, ranging from 50 to 100% between individual items. Conclusion The instrument showed acceptable psychometric properties for application in geriatric populations with low levels of education. It enabled identifying diseases and assisted in choice of strategies related to health of the elderly.

Practice of Intubation of the Critically Ill at Mayo Clinic

2017 ◽  
Vol 34 (3) ◽  
pp. 204-211 ◽  
Author(s):  
Nathan J. Smischney ◽  
Mohamed O. Seisa ◽  
Katherine J. Heise ◽  
Kyle D. Busack ◽  
Theodore O. Loftsgard ◽  
...  
Keyword(s):  
Critically Ill ◽  
Difficult Intubation ◽  
Airway Device ◽  
Surgical Intensive Care Unit ◽  
Complication Rates ◽  
Common Complication ◽  
Surgical Intensive Care ◽  
First Pass ◽  
The Mean ◽  
Final Cohort

Objective: To describe the practice of intubation of the critically ill at a single academic institution, Mayo Clinic’s campus in Rochester, Minnesota, and to report the incidence of immediate postintubation complications. Patients and Methods: Critically ill adult (≥18 years) patients admitted to a medical–surgical intensive care unit from January 1, 2013, to December 31, 2014, who required endotracheal intubation included. Results: The final cohort included 420 patients. The mean age at intubation was 62.9 ± 16.3 years, with 58% (244) of the cohort as male. The most common reason for intubation was respiratory failure (282 [67%]). The most common airway device used was video laryngoscopy (204 [49%]). Paralysis was used in 264 (63%) patients, with ketamine as the most common sedative (194 [46%]). The most common complication was hypotension (170 [41%]; 95% confidence interval [CI]: 35.7-45.3) followed by hypoxemia (74 [17.6%]; 95% CI: 14.1-21.6), with difficult intubation occurring in 20 (5%; 95% CI: 2.9-7.3). Conclusion: We found a high success rate of first-pass intubation in critically ill patients (89.8%), despite the procedure being done primarily by trainees 92.6% of the time; video was the preferred method of laryngoscopy (48.6%). Although our difficult intubation (4.8%) and complication rates typically associated with the act of intubation such as aspiration (1.2%; 95% CI: 0.4-2.8) and esophageal intubation (0.2%; 95% CI: 0.01-1.3) are very low compared to other published rates (8.09%), postintubation hypotension (40.5%) and hypoxemia (17.6%) higher.

FEESST: A New Bedside Endoscopic Test of the Motor and Sensory Components of Swallowing

1998 ◽  
Vol 107 (5) ◽  
pp. 378-387 ◽  
Author(s):  
Ted Kim ◽  
Kathy Goodhart ◽  
Jonathan E. Aviv ◽  
Ralph L. Sacco ◽  
Beverly Diamond ◽  
...  
Keyword(s):  
Superior Laryngeal Nerve ◽  
Oral Feeding ◽  
Sensory Testing ◽  
Endoscopic Evaluation ◽  
Sensory Deficits ◽  
Laryngeal Penetration ◽  
Sensory Capacity ◽  
Bedside Method ◽  
Normal Sensitivity ◽  
Endoscopic Assessment

We here introduce an office or bedside method of evaluating both the motor and sensory components of swallowing, called fiberoptic endoscopic evaluation of swallowing with sensory testing (FEESST). FEESST combines the established endoscopic evaluation of swallowing with a technique that determines laryngopharyngeal (LP) sensory discrimination thresholds by endoscopically delivering air pulse stimuli to the mucosa innervated by the superior laryngeal nerve. Endoscopic assessment of LP sensory capacity followed by endoscopic visualization of deglutition was prospectively performed 148 times on 133 patients with dysphagia over an 8-month period. The patients had a variety of underlying diagnoses, with stroke and chronic neurologic disease predominating (n = 94). Subsequent to LP sensory testing, a complete dysphagia evaluation was conducted. Various food and liquid consistencies were dyed green, and attention was paid to their management throughout the pharyngeal stage of swallowing. Evidence of latent swallow initiation, pharyngeal pooling and/or residue, laryngeal penetration, laryngeal aspiration, and/or reflux was noted. Recommendations for therapeutic intervention were based on information obtained during the FEESST and often involved the employment of compensatory swallowing strategies, modification of the diet or its presentation, placement on non-oral feeding status, and/or referral to other related specialists. All patients successfully completed the examination. In 111 of the evaluations (75%), severe (>6.0 mm Hg air pulse pressure [APP]) unilateral or bilateral LP sensory deficits were found. With puree consistencies, 31% of evaluations with severe deficits, compared to 5% of evaluations with either normal sensitivity or moderate (4.0 to 6.0 mm Hg APP) LP sensory deficits, displayed aspiration (p <.001, χ2 test). With puree consistencies, 69% of evaluations with severe deficits, compared to 24% with normal or moderate deficits, displayed laryngeal penetration (p <.001, χ2 test). FEESST allows the clinician to obtain a comprehensive bedside assessment of swallowing that is performed as the initial swallowing evaluation for the patient with dysphagia.

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