Secundino López-Pousa

IDIBGI Girona Biomedical Research Institute, Girona, Catalonia, Spain

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Publications (128)218.77 Total impact

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    Josep Lluís Conde-Sala, Secundino López-Pousa
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    ABSTRACT: Los cuestionarios al informador, en sentido estricto, están pensados para ser administrados a un informador, habitualmente el cuidador principal, y tienen como finalidad más inmediata la evaluación cognitiva de los pacientes con deterioro cognitivo y/o demencia. Suelen ser breves e incluyen preguntas sobre las capacidades cognitivas y funcionales del estado actual, en relación a su situación previa. Pueden ser utilizados como instrumento de cribado o complementarios a la evaluación clínica. Como ejemplo de ellos estarían el Blessed Dementia Scale (BDRS)1, el Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE)2 y el Ascertain Disease-8 (AD8)3. Un segundo grupo de instrumentos son aquellos que, aplicados directamente al paciente, permiten un análisis del estado global del paciente, aunque incluyen una parte específica dirigida al informador. El Clinical Dementia Rating (CDR)4 y el General Practitioner Assessment of Cognition (GPCOC)5 serían ejemplos de este tipo de cuestionarios. Existe un tercer grupo de instrumentos, también para ser administrados al informador, que tienen como objetivo proporcionar información acerca de algún aspecto específico de la situación del paciente: capacidades funcionales, síntomas psicológicos y conductuales, dependencia, etc. En este grupo se encontrarán cuestionarios como el Functional Activities Questionnaire (FAQ)6 o el Neuropsychiatric Inventory (NPI)7. Los motivos para la elaboración de los cuestionarios específicos al informador son varios, el más importante se refiere a la dificultad que puede presentar la evaluación del paciente en algunos casos: incapacidad, enfermedad, negativa a la evaluación, anosognosia, etc. Así mismo ayudan a obtener información sistemática con pruebas más simples y de fácil aplicación para la detección del deterioro cognitivo, siendo especialmente útiles en la atención Primaria. La mayoría de los instrumentos de este tipo obtienen unos valores de sensibilidad y especificidad superiores a los logrados con el Mini Mental State Examination (MMSE) en la detección del deterioro cognitivo. Jorm (1996)8 plantea varias ventajas de los cuestionarios: el conocimiento diario del informador, el no requerir la presencia del paciente, la aplicación en pacientes no testables, la facilidad para responder por teléfono o por e-mail y la perspectiva longitudinal que puede aportar el informador. Por el contrario el inconveniente principal de los cuestionarios al informador es el de poder acceder a un informador fiable, o bien que en algunos informadores pueden producirse valoraciones sesgadas.
    Los cuestionarios al informador, Valencia (Spain). LXVI Reunión Anual de la Sociedad Española de Neurología. 2014; 11/2014
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    Josep Lluís Conde-Sala, Secundino López-Pousa
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    ABSTRACT: The objective of this cross-sectional and multicenter study was to evaluate the psychometric properties of the Spanish version of the Dependence Scale (DS) and to assess the relationship between dependence and clinical measures according to disease severity. Medical comorbidities, cognitive status and functional status, behavior, dependence, caregiver burden, and medical and social resources were assessed using standardized instruments. The sample consisted of 343 patients (32.1% mild, 36.7% moderate, and 31.2% severe), the mean age was 78.9 years (standard deviation = 7.4), and 67.0% were women. Criterion and construct validity index of DS were appropriate. The DS standard error of measurement was ±1.23. The explained variance in DS ranged between 0.598 and 0.731, and the relative contribution of clinical measures depended on disease severity. Current findings confirm that the Spanish version of the DS has appropriate psychometric indices and suggest that clinical indicators have different contribution to dependence according to disease severity.
    Journal of Geriatric Psychiatry and Neurology 10/2014; · 3.53 Impact Factor
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    ABSTRACT: Background: There is a lack of information regarding geographical differences in the incidence and prevalence of dementia diagnosis according to the degree of aging of the population. The objectives of this study were to analyze the rate of dementia diagnoses, and to compare the dementia subtypes and the clinical characteristics of the patients depending on the degree of aging of their municipalities. Methods: We used data from the Registry of Dementias of Girona (ReDeGi), containing the cases of dementia diagnosed in the memory clinics of the Health Region of Girona, in Catalonia (Spain), during 2007-2012. The municipalities were classified by a cluster analysis as aged or young municipalities according to their proportion of older people using population ageing indicators. The incidence rates of dementia diagnosis in each type of municipality were compared. Results: The ReDeGi registered 4,314 cases in the municipalities under surveillance. The clinical incidence of dementia was lower in aged municipalities (4.5 vs. 6.1 cases per 1,000 person-years aged 65 and over). Patients from young municipalities had an increased frequency of behavioral and psychological symptoms of dementia. Conclusions: The environment may influence the clinical manifestations of dementia that predispose people to visit health specialists and obtain a diagnosis.
    International Psychogeriatrics 10/2014; · 2.19 Impact Factor
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    ABSTRACT: Although numerous studies have examined caregiver burden in the context of Alzheimer’s disease, discrepancies remain regarding the influence of certain factors. This study aimed to identify trajectories of caregiver burden in the context of Alzheimer’s disease, as well as the factors associated with them. A cohort of patients and caregivers (n = 330) was followed up over three years. Growth mixture models were fitted to identify trajectories of caregiver burden according to scores on the Zarit Burden Interview (ZBI). A multilevel multinomial regression analysis was then conducted with the resulting groups and the patient and caregiver factors. In the sample as a whole, burden increased during follow-up (F = 4.4, p = 0.004). Three groups were identified: G1 (initially high but decreasing burden), G2 (moderate but increasing burden), and G3 (low burden that increased slightly). Patients in G1 and G2 presented more neuropsychiatric symptoms and poorer functional status than did those in G3. Caregivers in G1 and G2 had poorer mental health. Spouses and, especially, adult children who lived with their parent (the patient) were more likely to belong to G2 (odds ratio [OR] 6.24; 95% CI 2.89–13.47), as were sole caregivers (OR 3.51; 95% CI 1.98–6.21). The patient factors associated with increased burden are neuropsychiatric symptoms and functional status, while among caregivers, being the sole carer, poor mental health, and living with the patient are of relevance.
    Journal of Alzheimer's disease: JAD 06/2014; 42(2):623-633. · 4.17 Impact Factor
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    ABSTRACT: Background and objective: The presence of anosognosia is a disorder that affects the clinical presentation of Alzheimer's disease (AD), increasing in frequency with the evolution of AD. The objective was to determine the prevalence of anosognosia and analyze the associated factors and predictors. Patient and Method: Multicenter transversal and observational study of 345 AD patients. Anosognosia was assessed by Anosognosia Questionnaire in Dementia (AQ-D) and the evolutionary stage with the Global Deterioration Scale (GDS). Tests were used MMSE, DAD and NPI to assess cognition, functional status and neuropsychiatric symptoms, respectively. We adjusted linear regression models to determine the associated variables and binary logistic regression (RLog) to identify predictors of anosognosia. Results: The overall prevalence of anosognosia was 46.7% (confidence interval 95% [95% CI] 41.3 to 52.1). The prevalence in stages was 28.4% (GDS 4), 64.6% (GDS 5) and 91.4% (GDS 6). The RLog identified as predictors older age (odds ratio [OR] 1.04; IC 95% 1.01-1.09), lower functional capacity (OR 0.96; IC 95% 0.93-0.98), lower cognitive level (OR 0.9; IC 95% 0.88-0.99), and greater apathy (OR 1.1; IC 95% 1.03-1.18), disinhibition (OR 1.2; IC 95% 1.09-1.50), irritability (OR 1.1; IC 95% 1.09-1.50) and motor disorders (OR 1.2; IC 95% 1.09-1.50). Conclusions: Anosognosia increases with further deterioration. In patients undergoing mild predictor variables were apathy, disinhibition and motor disorders.
    Medicina Clínica 06/2014; 143(1):13-19. · 1.40 Impact Factor
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    ABSTRACT: The objective of this cross-sectional study was to validate an abridged version of the Anosognosia Questionnaire—dementia (AQ-D) for screening anosognosia in daily practice. The authors reduce the AQ-D from 30 items to 9, with a large simple (n = 352) of patients with Alzheimer disease (AD). The Cronbach a was .793 and an area under the receiver–operating characteristic curve was 0.946. The k index between new abridged AQ-D (AAQ) and original AQ-D was .800. The AAQ presents good validity and reliability indicators and kept concordance with the original scale. It is quick and easy to administer and it can simplify the clinical screening of anosognosia in patients with AD.
    Journal of Geriatric Psychiatry and Neurology 04/2014; 27(3):220-226. · 3.53 Impact Factor
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    ABSTRACT: Psychotropic drugs are usually prescribed to deal with behavioral and psychological symptoms of dementia, especially when nonpharmacologic approaches are not available or have limited efficacy. Poor outcomes and serious adverse events of the drugs used must be addressed, and risk-benefit ratios need to be considered. The aim of this longitudinal study was to describe the evolution of dispensation of psychotropic drugs in patients with Alzheimer's disease (AD) and to identify the associated demographic and clinical variables. Longitudinal study using 698 cases with AD included in the Registry of Dementias of Girona in 2007 and 2008 and followed up during 3 years. Drugs were categorized according to the Anatomical Therapeutic Chemical classification. Binary logistic regression analyses were used to detect the variables associated with the use of antipsychotics, selective serotonin reuptake inhibitors (SSRIs), anxiolytics, and hypnotics. Of the patients, 51.2% consumed antipsychotics at least once during the three years of the study, whereas 73.3% and 58.2% consumed SSRIs and anxiolytics, respectively; 32.8% used hypnotics. Antipsychotic use was associated with a diagnosis of AD with delusions) [odds ratio (OR) = 5.7] and with increased behavior disorders (OR = 1.2). Patients with AD with depressed mood were more likely to be treated with SSRIs (OR = 3.1), while being a woman was associated with increased dispensation of anxiolytics (OR = 1.9) and SSRIs (OR = 2.2). Consumption of psychotropic drugs by the patients with AD registered in the Registry of Dementias of Girona is very high. Despite all the described adverse effects and recommendations of caution in their use, antipsychotics still are extensively used.
    Journal of the American Medical Directors Association 03/2014; · 5.30 Impact Factor
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    ABSTRACT: Cross-sectional studies report notable discrepancies between patient and caregiver ratings of the quality of life of patients (QoL-p) with Alzheimer’s disease (AD). This study aimed to identify the factors associated with any changes in QoL-p ratings and any discrepancies between patient and caregiver ratings of QoL-p. Three-year follow-up of a cohort of non-institutionalized patients (n = 119). QoL-p was assessed by the Quality of Life in AD (QoL-AD) scale. We analyzed the influence of functional and cognitive status and behavioral problems in patients, and burden and mental health in caregivers. Repeated measures analysis was applied to the scores of patients and caregivers on the QoL-AD, and to the discrepancies between them. Generally, patients’ own ratings remained stable over time (F 3,116 = 0.9, p = 0.439), whereas caregiver ratings showed a decline (F 3,116 = 9.4, p < 0.001). In the analysis of discrepancies, patients with anosognosia gave higher ratings (F 1,117 = 11.9, p = 0.001), whereas caregiver ratings were lower when the patient showed greater agitation (F 1,117 = 13.0, p < 0.001), apathy (F 1,117 = 15.4, p < 0.001), and disabilities (F 1,117 = 17.1, p < 0.001), and when the caregiver experienced greater burden (F 1,117 = 9.0, p = 0.003) and worse mental health (F 1,117 = 10.1, p = 0.003). Patient ratings of QoL-p remain generally stable over time, whereas those of caregivers show a decline, there being significant discrepancies in relation to specific patient and caregiver factors.
    Journal of Alzheimer's disease: JAD 02/2014; 39(3):511-525. · 4.17 Impact Factor
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    ABSTRACT: INTRODUCTION. The rates of cognitive decline in patients with Alzheimer's disease show variations due to various factors. AIM. To determine the influence of age, education, gender, activities of daily living (ADL) and acetylcholinesterase inhibitors (IAChE) and memantine in the rhythm and rate of cognitive decline. PATIENTS AND METHODS. Retrospective study of a sample of 383 patients with Alzheimer's disease, with neuropsychological assessments over three years. Cognitive measure was used as the Cambridge Cognitive Examination (CAMCOG). Patients were grouped according to their rate of annual decline (RAD) and performed a bivariate and multivariate regression analysis using as dependent variable the difference in scores on the CAMCOG (baseline-final). RESULTS. The younger age (beta = -0.23; p < 0.001), more educated (beta = 0.26; p < 0.001) and the greater deterioration of ADL (beta = 0.24; p < 0.001) were associated with a greater decline in all patients. The drugs had a beneficial effect (beta = -0.18; p = 0.011) in the group with lower and slower decline (RAD < 5%). CONCLUSIONS. The lower age, higher education and the deterioration of ADL are associated with a greater cognitive decline. The IAChE and memantine had a beneficial effect, slowing the decline in the group of patients with lower RAD.
    Revista de neurologia 06/2013; 56(12):593-600. · 1.18 Impact Factor
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    ABSTRACT: OBJECTIVES: Anosognosia is the lack of deficit awareness, and it is a common symptom in patients with Alzheimer's disease (AD). The objective of this study was to assess the relationship between anosognosia and caregiver burden. METHODS: This was a cross-sectional, analytical study of patients who were diagnosed with AD and their caregivers. Anosognosia was evaluated using the Experimenter Rating Scale, and caregiver burden was evaluated using the Burden Interview (BI). Using the BI's comprehensive scoring and each of its five factors as dependent variables, we adjusted six linear regression models to determine the effect of anosognosia on caregiver burden. RESULTS: The sample consisted of 124 patients and 124 caregivers. The mean patient age was 78.9 years (SD = 6.9); the mean caregiver age was 59.7 years (SD = 13.6), and 66.6% of the caregivers were women. The prevalence of anosognosia was 24.2% (95% confidence interval = 16.7-33.3). The degree of caregiver burden was associated with the degree of anosognosia (r(2) = 0.426; standardised beta [βs] = 0.346; p < 0.001), which explained 14.7% of the variance. For the BI factors, the Experimenter Rating Scale was associated with physical and social burden (r(2) = 0.452; βs = 0.378; p < 0.001), relationship of dependence (r(2) = 0.301; βs = 0.203; p = 0.010) and emotional stress (r(2) = 0.212; βs = 0.227; p = 0.014). CONCLUSIONS: The presence of anosognosia in patients with AD is an independent factor that increases caregiver burden by increasing physical wear, social isolation, dependence and tension related to patient care. Copyright © 2012 John Wiley & Sons, Ltd.
    International Journal of Geriatric Psychiatry 05/2013; 28:291-297. · 3.09 Impact Factor
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    ABSTRACT: Objective Fibromyalgia (FM) is characterized by a heterogeneous group of clinical symptoms that are evaluated using a wide variety of instruments. This study sought to develop and validate a new scale, the Comprehensive Rating Scale for Fibromyalgia Symptomatology (CRSFS), to facilitate the joint evaluation of the most frequent symptoms in patients with FM. Methods CRSFS items were based on a literature review and a focus group composed of patients and healthcare professionals. Four samples of patients (FM, non-FM rheumatic pain, depression, and healthy volunteers) were used to study the reliability and validity of the CRSFS. The factor structure of the CRSFS was determined through exploratory and confirmatory factor analyses. The test–retest and inter-examiner reliabilities were evaluated in a subsample of participants with FM. The criterion and convergent construct validity were compared using valid and reliable instruments to assess the impact of FM on quality of life, pain, fatigue, mood, and quality of sleep. The capacity to differentiate groups of patients was examined by comparing the CRSFS scores of the four samples to each other and using receiver operating characteristics curves. Results The sample was composed of 240 participants, the mean age was 49.1years (SD=10.4), and 97.5% of them were women. The factor analyses, as well as the tests of reliability and validity, were positive. The final version of the CRSFS consisted of 20 symptoms evaluated using 60 items. Conclusion The CRSFS is a valid and reliable 4-factor scale that evaluates the most frequent clinical symptoms of patients with FM.
    Journal of Psychosomatic Research 02/2013; · 3.27 Impact Factor
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    ABSTRACT: The Stroop Color and Word Test (SCWT) is a short test that is widely used in neuropsychological assessment to evaluate the executive aspects of attention control, information processing speed, selective attention, cognitive flexibility, and executive function in terms of the ability to inhibit a usual response in favor of an unusual response. The aim of this study was to create normative data from the SCWT adjusted for age, sex, and educational level for its clinical use in a population of 55 years of age and above. The SCWT was administered to a population-based sample of 2,151 participants aged 55 or older, and the effect of sex, age, and educational level was determined in the SCWT by means of linear regression models. Normative tables were created following the traditional method based on the stratification by relevant variables and on regression models.
    Archives of Clinical Neuropsychology 02/2013; · 2.00 Impact Factor
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    ABSTRACT: The objective of this paper was to assess the prevalence, incidence, persistence, and risk and mortality factors for Apathy Syndrome in Alzheimer's disease (ASAD) in a clinical sample. This was a cohort study of 491 patients with probable Alzheimer's disease (AD). The Cambridge Examination for Mental Disorders of the Elderly (CAMDEX), the Neuropsychiatric Inventory (NPI), the Rapid Disability Rating Scale (RDRS-2), and the Zarit Burden Interview (ZBI) were administered, and all patients were reevaluated after 12 months. Baseline ASAD diagnosis was made using specific diagnostic criteria. ASAD prevalence and incidence/year were 21.0% and 10.6%, respectively. After one year, ASAD persisted in 61.2% of patients. At baseline, patients with ASAD scored lower on the CAMCOG and higher on the Blessed, RDRS-2, and ZBI. Antipsychotic use was the only risk factor for ASAD (RR = 3.159; 95% CI: 1.247-8.003). ASAD was related to an increased functional disability, but no relationship with cognitive impairment or increased caregiver burden was detected. Finally, ASAD was associated with an increased risk of mortality (HR = 1.987; 95% CI: 1.145-3.450; p = 0.014). ASAD suggests a more severe AD clinical profile, with poorer functional progression and increased mortality risk. Antipsychotic use seems to be the only risk factor for ASAD.
    Journal of Alzheimer's disease: JAD 01/2013; 33(2):535. · 4.17 Impact Factor
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    ABSTRACT: Abstract Background: Pain prevalence is high among elderly people, and equally prevalent in those with dementia. The aim of this study was to describe the use analgesics, as well as the cost of these treatments in old people with dementia. Methods: We used a cross-sectional design using 1,186 cases registered by the Registry of Dementias of Girona from 2007 to 2008. All drugs were categorized following the Anatomic Therapeutic Chemical (ATC) classification and grouped according to the World Health Organization (WHO) analgesic ladder steps. Descriptive statistical methods were used. Results: Analgesics were prescribed to 78.6% (95% CI: 76.2-81.0) of the registered cases. Of them, 80.6% (95% CI: 78.0-83.2) were treated following step 1 of the WHO analgesic ladder, 16.8% (95% CI: 14.4-19.3) following step 2, and 2.6% (95% CI: 1.5-3.6) following step 3. Pain treatment in old people with dementia had a cost of 42.1 € per patient and year, with no significant differences depending on the subtype of dementia. Conclusions: The use of analgesics in our sample was not associated to age or to dementia severity, which are themselves risk factors for increased pain. Moreover, no differences were detected depending on the subtype of dementia.
    The International journal of neuroscience 12/2012; · 0.86 Impact Factor
  • Revista de neurologia 12/2012; 55(11):702-3. · 1.18 Impact Factor
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    ABSTRACT: PURPOSE: To describe the pattern of drug consumption among patients with dementia in a geographically defined general population in Catalonia (Spain), and to determine its association with age, gender, type of dementia and severity indicators. METHODS: Cross-sectional study that included 1,894 cases of dementia registered by the Registry of Dementias of Girona from 2007 to 2009. Prescribed drugs were categorized according to the Anatomical Therapeutic Chemical (ATC) classification. A descriptive analysis of drug consumption was stratified according to age, gender, dementia subtypes and dementia severity. Binary logistic regression models were adjusted to detect the association of these variables with drug consumption according to the ATC groups. RESULTS: The most commonly prescribed drugs were for the central nervous system (CNS) (96.4 %), cardiovascular system (79.4 %) and digestive and metabolic system categories (77.7 %). No significant differences were found between the use of nervous system drugs and age, gender, dementia subtypes or dementia severity. The use of alimentary tract and metabolism related drugs, as well as cardiovascular and blood system drugs, were positively correlated with age and secondary dementia. The prevalence of use of cardiovascular and musculoskeletal drugs was higher in women than in men (OR: 1.34; OR: 1.26 respectively). A negative association was found between the severity of dementia and the use of musculoskeletal drugs (OR: 0.71), while its use was significantly higher in the youngest patients (OR: 1.71). CONCLUSIONS: Almost all patients with dementia received a CNS drug, being at risk of inappropriate treatment. Treatment for comorbidities in patients with dementia should not be withheld on the basis of age or dementia severity, but rather on the benefit/risk ratio of its prescription. Further studies are needed to evaluate potentially inappropriate drug use and possible untreated conditions in this population.
    European Journal of Clinical Pharmacology 11/2012; · 2.74 Impact Factor
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    ABSTRACT: OBJECTIVES:: To establish the prevalence, incidence, persistence, risk factors, and mortality risk increase of psychosis of Alzheimer disease (PoAD) in a clinical sample. DESIGN, PARTICIPANTS, AND MEASUREMENTS:: Cross-sectional, observational study of 491 patients with probable AD who, at baseline visit, were evaluated with the Cambridge Examination for Mental Disorders of the Elderly, the Neuropsychiatric Inventory-10, the Rapid Disability Rating Scale-2, and the Zarit Burden Interview. All participants were reevaluated at 6, 12, 18, and 24 months. PoAD diagnoses were made using specific criteria. RESULTS:: PoAD prevalence was 7.3%, and the cumulative incidence at 6, 12, 18, and 24 months was 5.8%, 10.6%, 13.5%, and 15.1%, respectively. After 1 year, psychotic symptoms persisted in 68.7% of the patients with initial PoAD. At baseline, patients with PoAD scored lower in the Cambridge Cognitive Examination and Mini-Mental State Examination and higher in the Rapid Disability Rating Scale-2 and Zarit Burden Interview tests. Both low scores in the Cambridge Cognitive Examination subscale of learning memory (hazard ratio [HR] = 0.874; 95% CI: 0.788-0.969; Wald χ = 6.515; df = 1) and perception (HR = 0.743; 95% CI: 0.610-0.904; Wald χ = 8.778; df = 1), and high scores in expressive language (HR = 1.179; 95% CI: 1.024-1.358; Wald χ = 5.261; df = 1) and calculation skills (HR = 1.763; 95% CI: 1.067-2.913; Wald χ = 4.905; df = 1) were found to be associated with PoAD. PoAD leads to a faster functional impairment, and it increases mortality risk (HR = 2.191; 95% CI: 1.136-4.228; Wald χ = 5.471; df = 1) after controlling for age, gender, cognitive and functional disability, general health status, and antipsychotic treatment. CONCLUSIONS:: PoAD seems to define a phenotype of AD of greater severity, with worsened functional progression and increased mortality risk.
    The American journal of geriatric psychiatry: official journal of the American Association for Geriatric Psychiatry 09/2012; · 3.35 Impact Factor
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    ABSTRACT: The most frequent behavioral manifestations in Parkinson's disease (PD) are attributed to the dopaminergic dysregulation syndrome (DDS), which is considered to be secondary to the iatrogenic effects of the drugs that replace dopamine. Over the past few years some cases of patients improving their creative abilities after starting treatment with dopaminergic pharmaceuticals have been reported. These effects have not been clearly associated to DDS, but a relationship has been pointed out. Case study of a patient with PD. The evolution of her paintings along medication changes and disease advance has been analyzed. The patient showed a compulsive increase of pictorial production after the diagnosis of PD was made. She made her best paintings when treated with cabergolide, and while painting, she reported a feeling of well-being, with loss of awareness of the disease and reduction of physical limitations. Dopaminergic antagonists (DA) trigger a dopaminergic dysfunction that alters artistic creativity in patients having a predisposition for it. The development of these skills might be due to the dopaminergic overstimulation due to the therapy with DA, which causes a neurophysiological alteration that globally determines DDS.
    Case Reports in Neurology 09/2012; 4(3):159-66.

Publication Stats

723 Citations
218.77 Total Impact Points

Institutions

  • 2014
    • IDIBGI Girona Biomedical Research Institute
      Girona, Catalonia, Spain
  • 2009–2014
    • University of Barcelona
      Barcino, Catalonia, Spain
  • 1998–2014
    • Institut d'Assistència Sanitaria
      Girona, Catalonia, Spain
  • 2009–2013
    • Universitat de Girona
      • Departament de Psicologia
      Girona, Catalonia, Spain
  • 2012
    • Hospital Universitari de Girona Dr. Josep Trueta
      Girona, Catalonia, Spain