Publications by authors named "Elena Lobo"

27 Publications

  • Page 1 of 1

A cross-national study of depression in preclinical dementia: A COSMIC collaboration study.

Alzheimers Dement 2020 11 3;16(11):1544-1552. Epub 2020 Sep 3.

Neuropsychiatry: Epidemiological and Clinical Research, INSERM, Montpellier University, Montpellier, France.

Introduction: Depression commonly accompanies Alzheimer's disease, but the nature of this association remains uncertain.

Methods: Longitudinal data from the COSMIC consortium were harmonized for eight population-based cohorts from four continents. Incident dementia was diagnosed in 646 participants, with a median follow-up time of 5.6 years to diagnosis. The association between years to dementia diagnosis and successive depressive states was assessed using a mixed effect logistic regression model. A generic inverse variance method was used to group study results, construct forest plots, and generate heterogeneity statistics.

Results: A common trajectory was observed showing an increase in the incidence of depression as the time to dementia diagnosis decreased despite cross-national variability in depression rates.

Discussion: The results support the hypothesis that depression occurring in the preclinical phases of dementia is more likely to be attributable to dementia-related brain changes than environment or reverse causality.
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http://dx.doi.org/10.1002/alz.12149DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7666102PMC
November 2020

Risk factors for symptomatic retears after arthroscopic repair of full-thickness rotator cuff tears.

J Shoulder Elbow Surg 2021 Jan 9;30(1):27-33. Epub 2020 Jun 9.

Department of Orthopaedics & Traumatology Surgery, Hospital ASEPEYO Sant Cugat, Sant Cugat del Vallès, Barcelona, Spain.

Background: Factors affecting a rotator cuff symptomatic retear after arthroscopic repair have yet to be clearly identified, since they usually influence the surgical decisions.

Methods: Consecutive patients with full-thickness tear of the supraspinatus who underwent arthroscopic repair were retrospectively analyzed. Cases of symptomatic retear, defined as Sugaya type IV and V on magnetic resonance imaging, associated with intensive pain and/or functional impairment were identified at follow-up. The patients with no symptomatic retear were selected as the control group. Information from potential risk factors of symptomatic retear, including depression and subacromial corticosteroid injections, was extracted from the medical records. The statistical analysis included multivariant logistic regression.

Results: The symptomatic retear rate was 9.5% in 158 patients. Patients in the symptomatic retear group were more likely to be smoking, to have massive tears, a short acromiohumeral distance, and moderate to severe fatty infiltration. They also had had more frequently subacromial corticosteroid injections and depression. However, following the multiple logistic regression analysis, only massive tears and moderate to severe fatty infiltration remained significantly associated. Similarly, in relation to the study hypothesis, both corticosteroid injections (odds ratio [OR] 6.66, 95% confidence interval [CI] 1.49, 29.81; P = .013) and depression (OR 8.26, IC 1.04, 65.62; P = .046) were significantly associated with symptomatic retear risk.

Conclusions: This study found support for the hypothesis that both depression and corticosteroid infiltration before surgery are independent risk factors for symptomatic retear after arthroscopic repair of rotator cuff.
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http://dx.doi.org/10.1016/j.jse.2020.05.010DOI Listing
January 2021

Does parity matter in women's risk of dementia? A COSMIC collaboration cohort study.

BMC Med 2020 08 5;18(1):210. Epub 2020 Aug 5.

Department of Neuropsychiatry, Seoul National University Bundang Hospital, Seongnam, South Korea.

Background: Dementia shows sex difference in its epidemiology. Childbirth, a distinctive experience of women, is associated with the risk for various diseases. However, its association with the risk of dementia in women has rarely been studied.

Methods: We harmonized and pooled baseline data from 11 population-based cohorts from 11 countries over 3 continents, including 14,792 women aged 60 years or older. We investigated the association between parity and the risk of dementia using logistic regression models that adjusted for age, educational level, hypertension, diabetes mellitus, and cohort, with additional analyses by region and dementia subtype.

Results: Across all cohorts, grand multiparous (5 or more childbirths) women had a 47% greater risk of dementia than primiparous (1 childbirth) women (odds ratio [OR] = 1.47, 95% confidence interval [CI] = 1.10-1.94), while nulliparous (no childbirth) women and women with 2 to 4 childbirths showed a comparable dementia risk to primiparous women. However, there were differences associated with region and dementia subtype. Compared to women with 1 to 4 childbirths, grand multiparous women showed a higher risk of dementia in Europe (OR = 2.99, 95% CI = 1.38-6.47) and Latin America (OR = 1.49, 95% CI = 1.04-2.12), while nulliparous women showed a higher dementia risk in Asia (OR = 2.15, 95% CI = 1.33-3.47). Grand multiparity was associated with 6.9-fold higher risk of vascular dementia in Europe (OR = 6.86, 95% CI = 1.81-26.08), whereas nulliparity was associated with a higher risk of Alzheimer disease (OR = 1.91, 95% CI 1.07-3.39) and non-Alzheimer non-vascular dementia (OR = 3.47, 95% CI = 1.44-8.35) in Asia.

Conclusion: Parity is associated with women's risk of dementia, though this is not uniform across regions and dementia subtypes.
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http://dx.doi.org/10.1186/s12916-020-01671-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7406389PMC
August 2020

The effect of occupation on the incidence of vascular dementia: A 12-year follow-up cohort study.

Rev Psiquiatr Salud Ment 2020 Jul 1. Epub 2020 Jul 1.

Instituto Universitario de Investigación Sanitaria en Aragón (IIS), Zaragoza, España; Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Ministerio de Ciencia, Innovación y Universidades, Madrid, España; Departamento de Microbiología, Medicina Preventiva y Salud Pública, Universidad de Zaragoza, Zaragoza, España.

Introduction: Vascular dementia (DV) is the second cause of dementia with 15.8-20% of cases. Previous studies of the effect of occupation in DV do not show conclusive results, therefore, the objective was to analyze if the type of occupation can vary the risk of developing DV in those older than 55 years.

Material And Methods: In the ZARADEMP project, a community sample of 4,803 individuals were followed longitudinally in 4 waves. The occupation was classified following the National Classification of Occupations of 2011 and the International Standard Classification of Occupations of 2008. Different standardized instruments were used: the medical and psychiatric histories (History and Aetiology Schedule) and other risk factors (Mini-Mental Status Examination, Geriatric Mental State-AGECAT). For this study, we calculated incidence rates, incidence rate ratios and hazard ratios in multivariate Cox regression models, stratified by gender. For this study, we included 3,883 participants.

Results: In women, the risk of DV was doubled in blue-collar workers, with a moderate effect (Cohen's d=0.54), and multiplying by 2.7 in homeworks respect to white-collar with a moderate effect (Cohen's d=0.77), although they did not reach statistical significance. We did not observe the effect of occupation on the risk of DV in men.

Conclusions: We have found a moderate but non-significant effect between occupation and DV risk in women. We found no effect of occupation on the risk of VD in males while other clinical factors (age, diabetes or body mass index) presented a clearer effect than the occupation.
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http://dx.doi.org/10.1016/j.rpsm.2020.05.002DOI Listing
July 2020

Cognition and daily activities in a general population sample aged +55.

Neuropsychol Dev Cogn B Aging Neuropsychol Cogn 2021 03 4;28(2):270-283. Epub 2020 Apr 4.

Department of Medicine and Psychiatry, Universidad de Zaragoza , Zaragoza, Spain.

We tested the association of individual cognitive domains measured with the Mini-Mental State Examination (MMSE) and disability. Cross-sectional study in a population-based cohort aged ≥55 years (n = 4,803). Sample was divided into two groups: individuals with cognition within the normal range (CNR) (n = 4,057) and those with cognitive impairment (CI) (n = 746). Main outcome measures: The MMSE, the Katz Index (Basic Activities of Daily Living, bADL), the Lawton and Brody Scale (Instrumental Activities of Daily Living, iADL), and the Geriatric Mental State (GMS-AGECAT). MMSE-orientation was associated with disability in bADL, iADL and a decrease in social participation, regardless of cognitive status. MMSE-attention was associated with disability in iADL, but only in CNR. MMSE-language was associated with disability in bADL, iADL and with reduced social participation, but only in CI. Conclusions: The associations observed between disability and orientation may have clinical and public health implications.
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http://dx.doi.org/10.1080/13825585.2020.1745140DOI Listing
March 2021

The effect of occupation type on risk of Alzheimer's disease in men and women.

Maturitas 2019 Aug 20;126:61-68. Epub 2019 May 20.

Instituto de Investigación Sanitaria de Aragón (IIS Aragón), Zaragoza, Spain; Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Ministry of Science and Innovation, Madrid, Spain; Servicio de Psiquiatría, Hospital Clínico Universitario, Avda. San Juan Bosco 15, 50009 Zaragoza, Spain; Departamento de Psiquiatría, Universidad de Zaragoza, C/Domingo Miral s/n, 50009 Zaragoza, Spain.

Objectives: To examine the association between the principal lifetime occupation and the incidence of Alzheimer's disease (AD) in men and women in a southern European population aged 55 years or more.

Study Design: A community-dwelling sample of 3883 dementia-free individuals aged 55 years or over was classified according the Spanish National Classification of Occupations (CNO-11) and the International Standard Classification of Occupations (ISCO-08) in a four-wave epidemiological study. Medical and psychiatric histories were collected using standardized instruments, including the Mini-Mental Status Examination (MMSE), the History and Aetiology Schedule (HAS), the Geriatric Mental State-AGECAT, and a risk factor Questionnaire. Cases of AD were diagnosed according to DSM-IV criteria. Cox regression models were performed, stratified by sex.

Main Outcome Measures: Cases of AD according to the main occupation and sex.

Results: In men, compared with the "white collar" category, the risk of AD in "farmers" was 66% times lower, after controlling for potential confounding factors (HR: 0.34; 95% CI: 0.08-1.33). It did not reach statistical significance but the magnitude was large (Cohen's d = 0.84). In women, "farmers" had almost 50% less risk of AD after controlling for all potential confounding factors (HR: 0.55; 95% CI: 0.17-1.78), compared with homemakers, but with a medium effect size (Cohen's d = 0.46).

Conclusions: Men and women farmers had a lower risk of AD, reinforcing the importance of lifetime occupation in the risk of AD at older ages. These results could suggest some environmental hypotheses.
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http://dx.doi.org/10.1016/j.maturitas.2019.05.008DOI Listing
August 2019

Dementia care in high-income countries.

Curr Opin Psychiatry 2019 09;32(5):465-470

Departamento de Psiquiatría, Universidad de Zaragoza.

Purpose Of Review: To identify recent advances in the field of dementia care in high-income countries.

Recent Findings: New national and international initiatives identified support the notion of an increased commitment to face the challenge of dementia care. Recent research has documented barriers and facilitators to provide good care, and provided data on the specific needs of caregivers; the needs for better training of general practitioners; the negative influence of behavioural and psychological symptoms of dementia (BPSD); the palliative care needs; and the increased risk of dementia associated with anxiety (the population-attributable fraction of Alzheimer's risk was 6.1%). Significant advances in new technologies applicable in the care of dementia have also been reported.

Summary: The increased awareness of the needs in dementia care is promising, although the Organisation for Economic Co-operation and Development has alerted about the limited implementation of the programmes. Barriers and facilitators identified have implications for both clinical practice and research. Particular implications for psychiatric action have the findings on BPSDs and on the preventive potential of the treatment of anxiety detected in the community. The data on palliative care needs and particularly on the advances of new technologies also have clinical implications.
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http://dx.doi.org/10.1097/YCO.0000000000000524DOI Listing
September 2019

Anxiety and risk of dementia: Systematic review and meta-analysis of prospective cohort studies.

Maturitas 2019 Jan 30;119:14-20. Epub 2018 Oct 30.

Instituto de Investigación Sanitaria de Aragón (IIS Aragón), Zaragoza, Spain; Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Ministry of Science and Innovation, Madrid, Spain; Departamento de Psicología y Sociología, Universidad de Zaragoza, C/Doctor Cerrada 1-5, 50009 Zaragoza, Spain. Electronic address:

Objectives: Anxiety is postulated to be modifiable risk factor for dementia. Our primary aim was to conduct a meta-analysis of community-based cohort studies that investigated the association between anxiety and dementia.

Design: We identified relevant, high-quality papers published up to January 2018 by searching PubMed and Web of Science. Prospective cohort studies reporting relative risks (RRs) for the association between anxiety and dementia, adjusted at least for age, were considered eligible. Study-specific RRs were combined using a random-effects model.

Results: Six prospective cohorts (reported in 5 studies), with a total of 10,394 participants, were included in the meta-analysis. The pooled RR of 1.29 (95% CI: 1.01-1.66) indicated a significant association between anxiety and dementia.

Conclusion: Anxiety significantly increases the risk of dementia. However, further research is needed to determine the extent to which anxiety is a cause of dementia rather than a prodrome or marker.
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http://dx.doi.org/10.1016/j.maturitas.2018.10.014DOI Listing
January 2019

Social brain, social dysfunction and social withdrawal.

Neurosci Biobehav Rev 2019 02 20;97:10-33. Epub 2018 Sep 20.

Department of Biomedical and NeuroMotor Sciences, University of Bologna, Italy.

The human social brain is complex. Current knowledge fails to define the neurobiological processes underlying social behaviour involving the (patho-) physiological mechanisms that link system-level phenomena to the multiple hierarchies of brain function. Unfortunately, such a high complexity may also be associated with a high susceptibility to several pathogenic interventions. Consistently, social deficits sometimes represent the first signs of a number of neuropsychiatric disorders including schizophrenia (SCZ), Alzheimer's disease (AD) and major depressive disorder (MDD) which leads to a progressive social dysfunction. In the present review we summarize present knowledge linking neurobiological substrates sustaining social functioning, social dysfunction and social withdrawal in major psychiatric disorders. Interestingly, AD, SCZ, and MDD affect the social brain in similar ways. Thus, social dysfunction and its most evident clinical expression (i.e., social withdrawal) may represent an innovative transdiagnostic domain, with the potential of being an independent entity in terms of biological roots, with the perspective of targeted interventions.
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http://dx.doi.org/10.1016/j.neubiorev.2018.09.012DOI Listing
February 2019

[The City of Girls and Boys of Huesca (Spain), an opportunity for designing healthy environment and public policies].

Gac Sanit 2019 May - Jun;33(3):296-298. Epub 2018 Jul 18.

Grupo Promotor del Proyecto La Ciudad de las Niñas y los Niños, Facultad de Ciencias Humanas y de la Educación, Huesca, España.

The City of Girls and Boys of Huesca (Spain) is an international project that seeks to foster children's autonomy and full participation in the construction of the city. Following its formal approval at the City Council of Huesca, the Girls and Boys Board and the City Laboratory were created, both of which include children from all the schools of Huesca. To highlightthe work on health, activities such as "Healthy School Paths", in which the asset mapping technique is used, were incorporated. Besides the interdisciplinary work among different areas of the city council, professionals from education (schools and university), health and social services, effects on the urban physical environment, with one street, park and square remodelled; and on the children's lifestyles, with more children walking to school alone, have been observed.
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http://dx.doi.org/10.1016/j.gaceta.2018.04.011DOI Listing
December 2019

Gender differences in the association of cognitive impairment with the risk of hip fracture in the older population.

Maturitas 2018 Mar 7;109:39-44. Epub 2017 Dec 7.

Servicio de Cirugía Ortopédica y Traumatológica, Hospital San Jorge, Avda. Martínez de Velasco 36, 22004 Huesca, Spain.

Objectives: To test the hypothesis that differences by gender will be observed in the association of hip fracture risk with stages of cognitive impairment; and to explore the association between Petersen's "mild cognitive impairment" (MCI) and DSM-5 "mild neurocognitive disorder" (MND).

Study Design: A community sample of 4803 individuals aged 55+ years was assessed in a two-phase case-finding enquiry in Zaragoza, Spain, and was followed up for 16 years. Medical and psychiatric history was collected with standardized instruments, including the Mini-Mental Status Examination (MMSE), Geriatric Mental State (GMS), History and Aetiology Schedule, and a Risk Factors Questionnaire. The statistical analysis included calculations of Hazard Ratios (HR) in multivariate Cox proportional hazards regression models.

Main Outcome Measures: Identified cases of hip fracture, validated by blind researchers.

Results: In men, hip fracture risk was increased at the "mild" (HR=4.99 (1.39-17.91)) and at the "severe" (HR=9.31 (1.35-64.06)) stages of cognitive impairment, indicated by MMSE performance. In contrast, in women no association could be documented at the "mild stage" (power=89%), and the association disappeared altogether at the "severe stage" in the final multivariate statistical model (power 100%). No association observed between hip fracture and mild cognitive impairment in both men (power=28% for P-MCI) and women (power=44% and 19% for Petersen's MCI and DSM-5 MND, respectively).

Conclusions: Increased hip fracture risk was associated with "mild" stages of cognitive impairment in men, but not in women. To explore the potential association with the construct MCI or MND, studies with greater statistical power would be required.
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http://dx.doi.org/10.1016/j.maturitas.2017.12.007DOI Listing
March 2018

[Influence of occupation on cognitive impairment with no dementia in a sample population over 55 years from Zaragoza].

Rev Esp Geriatr Gerontol 2018 May - Jun;53(3):134-140. Epub 2017 Dec 6.

Instituto Universitario de Investigación Sanitaria de Aragón (IIS); Departamento de Medicina, Psiquiatría y Dermatología, Universidad de Zaragoza, Zaragoza, España; Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Ministerio de Ciencia e Innovación, Madrid, España.

Introduction: The prevalence of cognitive impairment with no dementia (CIND) varies between 5.1% and 35.9%, increasing between 65 and 85 years. The CIND increases the risk of dementia. Factors such as education, occupation, and social activities are associated with the risk of cognitive impairment. The main objective of this study was to analyse the association between the main occupation developed throughout life and CIND in a general population sample of over 55 years.

Methods: In wave I of the ZARADEMP Project, a sample (n=4803) of people over 55 years was interviewed. CIND measurement was obtained through the Mini Mental State Examination. Occupational activity data were recoded into white collar, blue collar, homemakers, and farmers. The association between the occupation variables and CIND was estimated using the odds ratio, and 95% confidence intervals using logistic regression equations.

Results: The prevalence of CIND in the sample was 28.2%. As regards white collar workers, the CIND diagnosis odds was 53% higher for blue collar workers, 77% higher for women who were homemakers and almost twice for farmers, after controlling for socio-demographic, behavioural and clinical variables. All results were statistically significant.

Conclusions: CIND frequency is influenced by the previous occupation of the subjects. An occupation with higher intellectual requirements can help keep cognitive functions intact for longer.
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http://dx.doi.org/10.1016/j.regg.2017.07.001DOI Listing
January 2019

Gender differences in the incidence of and risk factors for hip fracture: A 16-year longitudinal study in a southern European population.

Maturitas 2017 Mar 28;97:38-43. Epub 2016 Dec 28.

Servicio de Cirugía Ortopédica y Traumatológica, Hospital San Jorge, Avda. Martínez de Velasco 36, 22004 Huesca, Spain.

Objectives: To analyze independently in men and women the incidence rate of and risk factors for hip fracture in a southern European population. Illiteracy, dementia, clinically significant depression and disability were factors to receive special emphasis.

Study Design: A community sample of 4803 individuals aged over 55 years was assessed in a two-phase case-finding study in Zaragoza, Spain, and was followed up for 16 years. Medical history and psychiatric history were collected with standardized instruments, including the History and Aetiology Schedule, the Geriatric Mental State (GMS) scale, and a Risk Factors Questionnaire. Operational criteria were used to define covariates, including diagnostic criteria for both dementia and depression. The statistical analysis included calculations of incidence rate, IR; women/men incidence rate ratio (IRR); and Hazard Ratios (HR) in multivariate Cox proportional hazards regression models.

Main Outcome Measures: Cases of hip fracture (International Classification of Diseases, WHO) identified in the treating hospitals, validated by blinded researchers.

Results: Hip fractures were more frequent among women than men (IRR=3.1). Illiteracy (HR=1.55) and depression (HR=1.44) increased the risk in women, and smoking (HR=2.13) and disability in basic activities of daily living (HR=3.14) increased the risk in men. Dementia was associated with an increased risk in an univariate analysis, but the association disappeared (power=85% in men, 95% in women) when disability was included in the multivariate models.

Conclusions: The IR of hip fractures was three times higher among women. Illiteracy and clinically significant depression among women and active smoking and disability (HR=3.14) among men independently increased the risk, but dementia did not.
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http://dx.doi.org/10.1016/j.maturitas.2016.12.009DOI Listing
March 2017

Mortality in Mild Cognitive Impairment Diagnosed with DSM-5 Criteria and with Petersen's Criteria: A 17-Year Follow-Up in a Community Study.

Am J Geriatr Psychiatry 2016 11 4;24(11):977-986. Epub 2016 Aug 4.

Department of Medicine and Psychiatry, Universidad de Zaragoza, Zaragoza, Spain; Instituto de Investigación Sanitaria de Aragón (IIS Aragón), Zaragoza, Spain; Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Ministry of Science and Innovation, Madrid, Spain. Electronic address:

Objective: To explore the possibility that the mortality risk of mild cognitive impairment (MCI) as diagnosed using Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria (DSM-5-MCI) will be higher than using Petersen's criteria (P-MCI) and to report the population-attributable fraction (PAF) of mortality due to MCI.

Methods: A representative community sample of 4,803 individuals aged 55 or more years was interviewed and then followed for 17 years. Standardized instruments were used in the assessment, including the Geriatric Mental State-AGECAT, and research psychiatrists diagnosed P-MCI and DSM-5-MCI cases following operationalized criteria. Mortality information was obtained from the official population registry. Kaplan-Meier age-adjusted survival curves were built for the MCI diagnostic groups, and Cox proportional hazards regression models were used to calculate the hazard ratio of death in participants with MCI relative to those without. We also estimated the PAF of mortality due to specific MCI diagnostic groups.

Results: Compared with noncases, the mortality rate ratio was approximately double in DSM-5-MCI individuals (2.3) than in P-MCI individuals (1.2). In the multivariate statistical analysis, a significant association between each diagnostic category and mortality was observed but was only maintained in the final model in DSM-5-MCI cases (hazard ratio: 1.24). The PAF of mortality due to MCI was approximately 1% in both MCI categories.

Conclusion: The mortality risk in comparison with noncases was higher in DSM-5-MCI than in P-MCI. The PAF of mortality in DSM-5-MCI individuals was ~ 1% over a 17-year period.
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http://dx.doi.org/10.1016/j.jagp.2016.07.005DOI Listing
November 2016

Assessing psychosocial vulnerability and care needs of pretransplant patients by means of the INTERMED.

Z Psychosom Med Psychother 2014 ;60(2):190-203

Objective: We investigated whether the INTERMED, a generic instrument for assessing biopsychosocial case complexity and direct care, identifies organ transplant patients at risk of unfavourable post-transplant development by comparing it to the Transplant Evaluation Rating Scale (TERS), the established measure for pretransplant psychosocial evaluation.

Method: One hundred nineteen kidney, liver, and heart transplant candidates were evaluated using the INTERMED, TERS, SF-36, EuroQol, Montgomery-Åsberg Depression Rating Scale (MADRS), and Hospital Anxiety & Depression Scale (HADS).

Results: We found significant relationships between the INTERMED and the TERS scores. The INTERMED highly correlated with the HADS,MADRS, and mental and physical health scores of the SF-36 Health Survey.

Conclusions: The results demonstrate the validity and usefulness of the INTERMED instrument for pretransplant evaluation. Furthermore, our findings demonstrate the different qualities of INTERMED and TERS in clinical practice. The advantages of the psychiatric focus of the TERS and the biopsychosocial perspective of the INTERMED are discussed in the context of current literature on integrated care.
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http://dx.doi.org/10.13109/zptm.2014.60.2.190DOI Listing
September 2014

Spatial scale and sampling resolution affect measures of gap disturbance in a lowland tropical forest: implications for understanding forest regeneration and carbon storage.

Proc Biol Sci 2014 Mar 22;281(1778):20133218. Epub 2014 Jan 22.

DMCii, , Guildford GU2 7AG, UK, Department of Plant Biology, University of Illinois at Urbana-Champaign, , 265 Morrill Hall, 505 S Goodwin, Urbana, IL 61801, USA, Smithsonian Tropical Research Institute, , Apartado 0843-03092, Balboa, Ancon, Republic of Panama.

Treefall gaps play an important role in tropical forest dynamics and in determining above-ground biomass (AGB). However, our understanding of gap disturbance regimes is largely based either on surveys of forest plots that are small relative to spatial variation in gap disturbance, or on satellite imagery, which cannot accurately detect small gaps. We used high-resolution light detection and ranging data from a 1500 ha forest in Panama to: (i) determine how gap disturbance parameters are influenced by study area size, and the criteria used to define gaps; and (ii) to evaluate how accurately previous ground-based canopy height sampling can determine the size and location of gaps. We found that plot-scale disturbance parameters frequently differed significantly from those measured at the landscape-level, and that canopy height thresholds used to define gaps strongly influenced the gap-size distribution, an important metric influencing AGB. Furthermore, simulated ground surveys of canopy height frequently misrepresented the true location of gaps, which may affect conclusions about how relatively small canopy gaps affect successional processes and contribute to the maintenance of diversity. Across site comparisons need to consider how gap definition, scale and spatial resolution affect characterizations of gap disturbance, and its inferred importance for carbon storage and community composition.
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http://dx.doi.org/10.1098/rspb.2013.3218DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3906953PMC
March 2014

Usefulness of 2 questions about age and year of birth in the case-finding of dementia.

J Am Med Dir Assoc 2013 Aug 15;14(8):627.e7-12. Epub 2013 Jun 15.

Psychiatry Service, Hospital Universitario Miguel Servet, Zaragoza, Spain.

Objective: To test the hypothesis that the efficacy of 2 simple questions commonly used in clinical practice, asking the age and year of birth of individuals, will be satisfactory to rule out cases of dementia.

Design: Population-based, longitudinal, prospective study focused on the incidence of dementia. In the baseline, a 2-phase procedure for identifying cases and noncases of dementia was implemented.

Setting: Zaragoza, Spain.

Participants: Individuals 65 years or older without previous diagnoses of dementia (n = 3613) drawn from the population-based random sample of the ZARADEMP project.

Measurements: Standardized instruments were used, including the Geriatric Mental State (GMS) and the History and Aetiological Schedule (HAS); cases were diagnosed according to DSM-IV criteria ("reference standard"). The simple cognitive test used in this study consists of the following 2 compulsory questions: "How old are you?" and "What year were you born?"

Results: The test was well accepted by the participants and took less than 30 seconds to complete. Compared with the "reference standard," validity coefficients for incorrect answers in both questions were as follows: sensitivity 61.2%, specificity 97.8%, positive predictive value 44.4%, negative predictive value 98.9%.

Conclusions: This ultra-short test has very good specificity and negative predictive power. Its use to rule out cases of dementia might be generalized, as it has the best efficiency reported to date.
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http://dx.doi.org/10.1016/j.jamda.2013.05.006DOI Listing
August 2013

Care complexity, mood, and quality of life in liver pre-transplant patients.

Clin Transplant 2013 May-Jun;27(3):417-25. Epub 2013 Mar 12.

Zaragoza University, Zaragoza, Spain; Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Zaragoza, Spain.

Rationale: This study was intended to document the frequency of care complexity in liver transplant candidates, and its association with mood disturbance and poor health-related quality of life (HRQoL).

Methods: Consecutive patients fulfilling inclusion criteria, recruited in three European hospitals, were assessed with INTERMED, a reliable and valid method for the early assessment of bio-psychosocial health risks and needs. Blind to the results, they were also assessed with the Hospital Anxiety and Depression Scale (HADS). HRQoL was documented with the EuroQol and the SF36. Statistical analysis included multivariate and multilevel techniques.

Results: Among patients fulfilling inclusion criteria, 60 patients (75.9%) completed the protocol and 38.3% of them were identified as "complex" by INTERMED, but significant between-center differences were found. In support of the working hypothesis, INTERMED scores were significantly associated with all measures of both the SF36 and the EuroQol, and also with the HADS. A one point increase in the INTERMED score results in a reduction in 0.93 points in EuroQol and a 20% increase in HADS score.

Conclusions: INTERMED-measured case complexity is frequent in liver transplant candidates but varies widely between centers. The use of this method captures in one instrument multiple domains of patient status, including mood disturbances and reduced HRQoL.
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http://dx.doi.org/10.1111/ctr.12104DOI Listing
January 2014

The teaching of liaison psychiatry.

J Psychosom Res 2012 Jun 17;72(6):457-9. Epub 2012 Feb 17.

Department of Psychiatry, University of Zaragoza, Zaragoza, Spain.

Objective: To document performance and satisfaction of medical students in a short course on liaison psychiatry.

Methods: The emphasis in this optional course is placed on the discussion of clinical cases, bed-side clinical teaching, and a research-oriented part. The "Innovative Teaching Plan" (ITP) is intended to train student-leaders to guide small groups (SG) of students. Trainee performance was assessed by the marks in the final examination, and a reliable and valid tool, the Medical Teaching Quality Questionnaire (MTQQ) was used to document trainee satisfaction. The results of four academic courses are presented in this report.

Results: External experts consulted assured that the content of the course was adequate. It has been completed by more than 200 medical students, and high marks have been obtained by most. Above average scores (AA, "high" or "very high") were given by substantial proportions of students in most items, related to the "relevance" of the subject, the "usefulness of the clinical cases" or the "enhancement of student-teacher interaction". Compared to the first academic course, students' satisfaction has improved. "Enhancement of a researcher's mind" was rated AA by 61.1% of students in the last academic course, and "global satisfaction" by 88.8%.

Conclusions: Good performance and high satisfaction of medical students was documented in a course on liaison psychiatry. Lessons may be drawn to inform about efficient and effective ways of teaching and learning this subject.
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http://dx.doi.org/10.1016/j.jpsychores.2012.01.012DOI Listing
June 2012

Relationship between physician and industry in Aragon (Spain).

Gac Sanit 2012 Jul-Aug;26(4):336-42. Epub 2012 Jan 12.

Departamento de Medicina Preventiva y Salud Pública, Universidad de Zaragoza, Zaragoza, Spain.

Objective: To describe the relationship between industry and physicians and to analyze the physician characteristics associated with the probability of receiving benefits from industry in Aragon (Spain).

Methods: We carried out an observational, cross-sectional study in which Aragonese physicians (north-east region in Spain) from public and private settings completed an anonymous questionnaire on a web page between June and November 2008. Visits/month with industry, samples, gifts, reimbursements and payments were used as dependant variables in the regression analyses. Year of medical license, specialty, work setting, time spent on direct care, articles read/month and being a resident's tutor were used as independent variables.

Results: A total of 659 questionnaires were considered valid for the analysis. Overall, 87% (n=573) of the respondents reported they had received some benefit in the previous year and 90.1% (n=593) reported having held meetings with industry representatives monthly. Non-clinical specialists received fewer gifts (odds ratio [OR]=0.38; 95% confidence interval [95%CI]: 0.18-0.77), reimbursements (OR=0.14; 95%CI: 0.06-0.35) and payments (OR=0.30; 95%CI: 0.13-0.74) than their clinical colleagues. The probability of receiving reimbursements (OR=0.37; 95%CI: 0.15-0.89) and payments (OR=0.39; 95%CI: 0.20-0.77) was lower in primary care physicians.

Conclusions: This study, performed in a sample of physicians from a southern European region, demonstrates differences in the intensity of the physician-industry relationship depending on physician specialty and work setting. These results provide important information for improving transparency and for future research on the appropriateness and efficiency of prescription in Spain and other countries with similar health systems.
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http://dx.doi.org/10.1016/j.gaceta.2011.11.003DOI Listing
November 2012

Reliability of INTERMED Spanish version and applicability in liver transplant patients: a cross-sectional study.

BMC Health Serv Res 2011 Jul 5;11:160. Epub 2011 Jul 5.

Departamento de Medicina Preventiva y Salud Pública, Universidad de Zaragoza, Domingo Miral s/n, 50009 Zaragoza, Spain.

Background: Integrated delivery methods in healthcare systems have been proposed to confront the increasing complexity in general health care. INTERMED is an empirically derived, observer-rated instrument to measure case complexity. It was intended as a visualized, action-oriented decision-support tool for the early assessment of bio-psychosocial health risks and health needs. This study aims to document the reliability and applicability of the Spanish version of INTERMED in liver transplant patients.

Methods: Cross-sectional study of patients who had been included in the liver transplant waiting list. Two nurses interviewed the patients with INTERMED, and scored the instrument blind to each other. Kappa and w-kappa, Spearman, Kendall and intraclass correlation coefficients, and Cronbach's alfa were calculated.

Results: No patient refused the interview. Satisfactory coefficients were documented in most INTERMED items. Kappa was = 0.858 for the categorization of patients as "complex", and 21 of them (48.8%) were classified in this category, and were considered to need integrated treatment.

Conclusions: The Spanish version of INTERMED is reliable. Its applicability in liver transplant patients adds to its generalizability.
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http://dx.doi.org/10.1186/1472-6963-11-160DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3142204PMC
July 2011

[Towards integrated care. Nursing assessment of a "complex" patient using intermed].

Enferm Clin 2010 Sep-Oct;20(5):309-12

Departamento de Microbiología, Medicina Preventiva y Salud Pública, Universidad de Zaragoza, Zaragoza, España.

Nurses are confronted with an increasing number of patients with complex health care needs. INTERMED (INTERdisciplinary MEDicine) is described here as an action oriented method to document the potential «complexity» of patients, summarising information on biological, psychological, social and health care domains, plotted on a time-axis (history, current state and prognoses). A 73 year old patient assessed with this tool on admission to an internal medicine ward is described. INTERMED identified that besides age, mental health problems were interfering with somatic state and identified the patient as a complex case. From an integral health care perspective, coordinated care was needed to focus on the psychological vulnerability of the patient that made the somatic state more complex, including all the health care providers involved. Complex patients are an important and interesting issue for today's nurses, challenging their ability for management, organisation and coordination of care beyond standard care and the INTERMED tool can be crucial in this development.
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http://dx.doi.org/10.1016/j.enfcli.2010.05.012DOI Listing
February 2011

Is there an association between low-to-moderate alcohol consumption and risk of cognitive decline?

Am J Epidemiol 2010 Sep 10;172(6):708-16. Epub 2010 Aug 10.

Departamento de Medicina Preventiva y Salud Pública, Universidad de Zaragoza, Zaragoza, Spain.

The authors evaluated the association of low-to-moderate alcohol consumption with risk of cognitive decline in a census-based cohort study of men and women aged ≥55 years conducted in Zaragoza, Spain (1994-1999). Participants free of dementia at baseline (N = 3,888) were examined after 2.5 and 4.5 years of follow-up. Information on alcohol intake was collected with the EURODEM Risk Factors Questionnaire and the History and Aetiology Schedule. The study endpoint was severe cognitive decline, defined as loss of ≥1 point/year on the Mini-Mental State Examination or a diagnosis of incident dementia (Diagnostic and Statistical Manual of Mental Disorders: DSM-IV, Text Revision criteria). Compared with those for abstainers, the multivariate-adjusted odds ratios for severe cognitive decline for male drinkers of <12 g alcohol/day, drinkers of 12-24 g alcohol/day, and former drinkers were 0.61 (95% confidence interval (CI): 0.31, 1.20), 1.19 (95% CI: 0.61, 2.32), and 1.03 (95% CI: 0.59, 1.82), respectively. The corresponding odds ratios for women were 0.88 (95% CI: 0.45, 1.72), 2.38 (95% CI: 0.98, 5.77), and 1.03 (95% CI: 0.48, 2.23). This study did not support the hypothesis that low-to-moderate alcohol consumption prevents cognitive decline. The inverse association between low-to-moderate alcohol intake and cognitive decline observed in other studies may have been due to inclusion of former drinkers in the abstainers reference category.
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http://dx.doi.org/10.1093/aje/kwq187DOI Listing
September 2010

[Early prediction of psychosocial intervention needs in pneumology patients after nurses' evaluation].

Med Clin (Barc) 2008 Nov;131(19):731-6

Departamento de Microbiología, Medicina Preventiva y Salud Pública, Universidad de Zaragoza, and Servicio de Neumología, Hospital Clínico Universitario, Zaragoza, Spain.

Background And Objective: This study was aimed to verify whether it is possible to detect at hospital admission, by means of INTERMED, pneumonology patients at risk of "complexity" and of specialized psychosocial intervention.

Patients And Method: With the Spanish version of INTERMED (for detection of risk for complexity of care) 144 patients were interviewed at admission by a standardized nurse. At discharge, patients were reassessed blindly with standardized Spanish versions of instruments including the Hospital Anxiety and Depression Scale (HADS). Somatic illness variables were independently documented, and severity was assessed by means of the Cumulative Illness Rating Scale. All variables were operationalized including complex (IM+; INTERMED>20) and non-complex patients (IM-), and probable need of psychosocial treatment/intervention. Statistical analysis included multivariate logistic regression.

Results: A complex course was documented in 9.6% of patients, and 28.8% had complex discharge. Significantly higher proportions of severe anxiety and/or depression were documented in IM+ cases (12.1%) when compared to IM- cases (0.9%), and the need of psychosocial treatment/intervention was also significantly more frequent among the former (24.2% versus 6.3% respectively). Furthermore, in the multivariate analysis and controlling for medical and sociodemographic confounders INTERMED was significantly associated with the variable need of psychosocial intervention.

Conclusions: In support of the clinical utility of the INTERMED method (Spanish version), this is the first report in the international literature documenting that standardized nurses are able to detect at admission those medical patients who will eventually need specialized psychosocial intervention.
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http://dx.doi.org/10.1016/s0025-7753(08)75487-3DOI Listing
November 2008

Complexity Prediction Instrument to detect 'complex cases' in respiratory wards: instrument development.

J Adv Nurs 2008 Oct;64(1):96-103

Department of Microbiology, Preventive Medicine and Public Health, Instituto Aragonés de Ciencias de la Salud and University of Zaragoza, Zaragoza, Spain.

Aim: This paper is a report of a study to test the hypothesis that the Spanish version of the Complexity Prediction Instrument is a reliable and valid measure of complexity of patients with respiratory disease and to identify the frequency of positive indicators of potential complexity.

Background: Respiratory patients are often disabled and severely ill, with co-morbid physical conditions and associated psychosocial problems and need complex nursing care.

Method: Trained nurses assessed 299 consecutive adult patients admitted to a respiratory service in Spain from May 2003 until June 2004 with the new, Spanish version of the instrument. Criterion-related validity was tested by studying its ability to predict complexity of care in terms of: severity of illness, scored using the Cumulative Illness Rating Scale; length of hospital stay; 'multiple consultations' during admission; and 'multiple specialists' after discharge.

Findings: The hypothesis was supported: patients rating above the standard cut-off point on the Complexity Prediction Instrument scored statistically significantly higher on most of the measures of care complexity studied. Linear regression models showed that the tool was associated with 'length of hospital stay', and predicted both 'multiple consultations' and 'multiple specialists', after controlling for potential confounders. The proportion of 'probable complex cases' was 59.5%. Five positive indicators of potential complexity had a frequency higher than 50%.

Conclusion: The Complexity Prediction Instrument is reliable and valid in a new clinical area, respiratory disease. It may be used by nurses for the early prediction of complexity of care. International comparisons may be facilitated with this new Spanish version.
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http://dx.doi.org/10.1111/j.1365-2648.2008.04756.xDOI Listing
October 2008

[Psychiatric morbidity in obese patients].

Med Clin (Barc) 2008 Jan;130(2):54-6

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http://dx.doi.org/10.1157/13115034DOI Listing
January 2008

Early detection of pneumology inpatients at risk of extended hospital stay and need for psychosocial treatment.

Psychosom Med 2007 Jan;69(1):99-105

Department of Microbiology, Preventive Medicine and Public Health, University of Zaragoza, Spain.

Background: In a context of increasing concern for complex care needs in medical patients, this study is intended to document the utility in pneumology patients of INTERMED, a reliable and valid instrument to assess case complexity at the time of hospital admission.

Methods: Three hundred and fifteen consecutive patients were assessed at hospital admission with INTERMED by a trained nurse. At discharge, independent research workers, blind to the previous results, reviewed the medical database and a subsample (n = 144) was assessed for psychopathological outcome. Severity of the pulmonary disease was assessed with the Cumulative Illness Rating Scale (CIRS), and psychopathology with the Hospital Anxiety and Depression Scale, Mini-Mental Status Examination (MMSE) (cognitive disturbances), and CAGE Scale (alcohol abuse). Operational definitions were used for measures of care complexity.

Results: Most patients were in geriatric age, and 78 patients (24.7%) were classified as "complex" by means of INTERMED (IM+). In support of the working hypotheses, IM+ patients scored significantly higher in measures of care complexity (Cumulative Illness Rating Scale, "number of consultations during admission" and "diagnostic count") and on both anxiety and depression. INTERMED was also associated with length of hospital stay (LOS) and with both anxiety and depression after controlling for significant predictors and socio-demographic data.

Conclusions: This is the first report about the ability of INTERMED to predict complexity of care in pneumology patients, and the first to predict a negative psychopathological outcome in any type of medical patients.
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http://dx.doi.org/10.1097/PSY.0b013e31802e46daDOI Listing
January 2007