Well-being has been measured based on different perspectives in positive psychology. However, it is necessary to measure affects and emotions correctly and to explore the independence of positive and negative affect. This cross-sectional study adapts and validates the Scale of Positive and Negative Experience (SPANE) with a non-probabilistic sample of 821 Spanish adults. A confirmatory factor analysis confirmed two related factors with two correlated errors. The average variance extracted was 0.502 for negative affect (SPANE-N) and 0.588 for positive affect (SPANE-P). The composite reliability was 0.791 for SPANE-N and 0.858 for SPANE-P. Measurement invariance analysis showed evidence of scalar invariance. Item-total corrected polyserial correlations showed values between 0.47 and 0.76. The path analysis used to test temporal stability, and the structural equation models used to test convergent and concurrent validity with other well-being measures, showed good fit. All path coefficients were statistically significant and over 0.480. For the validity models, the magnitude of the correlations was large and in the expected direction. The Spanish version of the SPANE show good psychometric properties. Future studies of emotional well-being in Spain can benefit from the use of this scale, and new studies must test cross-cultural invariance. Historically, the pursuit of happiness and human well-being have been central themes in literature, philosophy, and theology. Positive psychology has studied the psychological processes that underlie the search for happiness and that promote greater well-being ,2,3. DifThe eudemonic perspective, represented by psychological well-being (PWB), associates the well-being of the individual with the development of human potential. According to this perspective, well-being is intrinsically linked to the performance of activities congruent with the deep values of the individual that promote their personal development and growth  , conceives the well-being of a person as the evaluation that people make about the satisfaction they experience in their lives and the balance between positive and negative affects ,4. To asHowever, Aristotle already held that happiness should involve feeling emotions that people consider appropriate given their needs and motives. The Aristotelian model proposes that such people would be happier the more they feel the emotion they desire, even though that emotion is unpleasant. The traditional SWB model holds that people would be happier the less they feel that unpleasant emotion because pleasant emotions are considered as good and unpleasant emotions as bad.The hedonic, eudemonic, and Aristotelian models of happiness probably overlap and complement each other to some extent. When individuals desire pleasant emotions, people are happier if they experience as much of a pleasant emotion as they desire. In this case, all the models match. However, when people desire unpleasant emotions, the models differ. Which emotions people consider desirable are different across situations, individuals, and cultures, as some authors have found . Their rIn order to put these models to the test and study which one of them best explains people’s well-being and happiness, it is necessary to correctly measure affects and emotions. However, ever since the beginning of the study of affect, there has been a continuous debate about the independence of positive and negative affect. Initially, researchers supported the idea that the positive and negative affect were independent . HoweverThe Scale of Positive and Negative Experience (SPANE) was created to offer a solution to the affect independence debate . The SPAWhen the psychometric properties of the SPANE were studied, the authors conducted two principal axis factoring, one for the SPANE-N and one for the SPANE-P, among USA university students. Both factors showed a unidimensional structure with an explained variance of 53% and 61%, respectively. The positive and negative subscales showed a correlation of −0.60 with each other. The authors suggested a balanced score (SPANE-B) in which positive and negative items are subtracted and the score ranges from −24 to 24. In addition, the authors calculated normative scores, item-total correlations, and convergent and criterion validity with scales, including the Satisfaction With Life Scale (SWLS) , and PosThe SPANE has been validated in many countries, including Portugal , China , Japan , Canada The SPANE has shown promising psychometric properties  in different populations and has been used widely in different well-being studies across the globe. The SPANE has the potential to allow researchers to test the different models of people’s well-being and happiness. Therefore, this paper aims to adapt the SPANE to the Spanish population and study its psychometric properties with a large Spanish sample. Furthermore, we study the SPANE’s measurement invariance for gender and use structural equation modeling (SEM) to study its factor structure, the test–retest reliability, and correlations with other well-being measures. We use the SEM methodology to study validity because it allows us to estimate the error contained in the observed scores, as is done when estimating the confirmatory factor analysis (CFA). If the correlation between the total scores of the different measures used to study validity is calculated, correlations between observed scores will be obtained. However, since these observed scores contain errors, these correlations will underestimate the validity. If the correlation between the latent variables is calculated using an SEM, the error (which is estimated separately) will be extracted from these correlations, as occurs when estimating a CFA. For this reason, performing an SEM is a more reliable way to estimate the relationship between measures. On the other hand, conducting the exploratory factor analysis is not necessary for the present paper, for at least two reasons. First, there is a strong theoretical expectation for the two-factor structure of the SPANE. Second, the two-factor structure has been supported in all previous studies.www.limesurvey.org). Participants had to read and accept an online informed consent before entering the study. They then responded to the socio-demographic variables and to all the questionnaires. A retest was conducted one month later to study test–retest reliability, by sending again the link to the survey to all the participants in the test stage. The study was conducted in compliance with Spanish legislation  and the code of ethics for research involving human subjects, as outlined by the Universitat de València Human Research Ethics Committee (ACGUV194/2006).The Spanish adaptation process of the SPANE was conducted using the International Test Commission (ITC) criteria ,37,38. TParticipants were included if they identified themselves as Spaniards in the survey and if they were at least 18 years of age. The final sample comprised 821 participants. The average age was 30 years  ranging from 18 to 71 years of age. Of the sample, 32.5% were men, 49.1% had completed at least college/university education, 46.5% had completed high-school level education, and 4.4% had finished compulsory secondary studies or had only primary studies. Regarding marital status, 57.7% were single, 38.7% were married or cohabiting, and 3.6% were divorced or widowed. Regarding the working status, 37.3% were students only, 22.3% were students and had sporadic or part-time jobs, 33% were employed or self-employed, 4.8% were unemployed, 1.2% were inactive, and 1.5% were retired. The retest sample was composed of 52 participants. Of them, 32.7% were men. The average age was 35.06 years (SD = 12) ranging from 21 to 66 years of age. No more socio-demographic data were collected for the retest sample.Scale of Positive and Negative Experience (SPANE). This is a twelve-item instrument describing a wide range of human experiences . The scaFlourishing Scale (FS). This is an eight-item instrument describing important aspects of human functioning including positive relationships, feelings of competence, and having meaning and purpose in life . The insPositive And Negative Affect Schedule (PANAS). This scale measures two domains, positive and negative affect . This 20Satisfaction With Life Scale (SWLS). This is a five-item instrument designed to measure global cognitive judgment of satisfaction with one’s life . ParticiLife Orientation Test-Revised (LOT-R). This questionnaire has been used to measure optimism and pessimism . The sca2 goodness of fit test, we used different indices to determine model fit: The comparative fit index (CFI), the root mean square error of approximation (RMSEA), and the standardized root mean squared residual (SRMR). CFI values of 0.90 and RMSEA values above 0.06 and below 0.08 are indicative of acceptable model fit. CFI values of 0.95 or above and RMSEA values below 0.05 are indicative of good empirical fit, and SRMR values close to 0.08 are indicative of good model fit , and SRMR = 0.072. However, three modification indices showed high values, between item 7 (scared) and 20 (afraid) of the PANAS (MI = 224.098), between item 9 (afraid) of the SPANE and 7 (scared) of the PANAS (MI = 209.200), and between item 9 (afraid) of the SPANE and 20 (afraid) of the PANAS (MI = 135.244). For these pairs of items, the meaning is practically the same, and probably that is the reason for such big modification indices. Therefore, we fitted the model again to the data estimating the correlation of residuals between these pairs of items. This model showed a better fit: χ2(725) = 2526.180 (p < 0.001), χ2/gl = 3.48, CFI (0.850), RMSEA (0.055), RMSEA 90% CI , and SRMR (0.070). p < 0.001), and ranged between 0.65 and 0.70 for the Positive and Negative Affects Schedule (negative), between 0.42 and 0.75 for the Positive and Negative Affects Schedule (positive), between 0.48 and 0.74 for the Scale of Positive and Negative Affects (negative), between 0.68 and 0.78 for the Scale of Positive and Negative Affects (positive) and between 0.51 and 0.75 for the Flourishing Scale.Regarding the validity models, the two-factor model for the SPANE with correlated errors for items 1 and 2, and for items 3 and 4, was fitted to the data, as this was the model that showed the best fit when studying the factor structure. The convergent validity model with the FS and the PANAS subscales showed acceptable fit to data: χ2(218) = 558.541 (p < 0.001), CFI = 0.951, RMSEA = 0.044, RMSEA 90% CI , and SRMR = 0.042. p < 0.001). p < 0.001) and ranged between 0.57 and 0.82 for the Pessimism Subscale, between 0.68 and 0.73 for the Optimism Subscale, between 0.45 and 0.77 for the Scale of Positive and Negative Affects (negative), between 0.60 and 0.79 for the Scale of Positive and Negative Affects (positive), and between 0.64 and 0.89 for the Satisfaction with Life Scale.The concurrent validity model with the optimism and pessimism subscales of the LOT-R, and with the SWLS, showed very good fit to data: χWell-being has been measured based on different perspectives in positive psychology. However, it is necessary to correctly measure affects and emotions and to explore the independence of positive and negative affect. One of the most popular instruments used to measure affects is the Scale of Positive and Negative Experience (SPANE) . In thisFindings from this study show that the version of the SPANE among Spaniards has good construct, convergent, and concurrent validity, as well as good temporal stability, reliability (Composite Reliability Index and Average Variance Extracted Index) and scalar invariance for gender. Specifically, we found that the best model for the SPANE for Spaniards is the one that proposes a structure of two related factors, with positive and negative affects highly correlated, but different from each other. This high correlation between the two types of affect has also been found in the original version  and in tIn our study, we found that the model with two correlated factors with correlated errors had the best fit, which is in line with the Chinese validation of the SPANE . PositivThe authors confirm with this study the SPANE’s scalar invariance for gender in a Spanish population. Validation studies from Greece , China , and RomBoth affects measure three general and three specific emotions encompassing a wide range of human experiences. Usually, existing surveys ask about specific feelings and weight them all identically, omitting important general feelings. Based on these scales, a person could feel generally positive or negative affect, but not feel many of the specific emotions listed on the scale. This person could score at an intermediate level on the scale despite feeling generally positive affect continuously. The SPANE, conversely, allows individuals to evaluate the degree to which these emotions are more desirable or pleasant for them. For instance, many of the items in the PANAS  are not The SPANE reflects all levels of arousal for both positive and negative feelings, and the emotions used in this scale allow for capturing the major emotions included in most affect theories . MoreoveOther interesting approaches have emerged to decrease cognitive bias when measuring affects, such as the Ecological Momentary Assessment (EMA) and the Day Reconstruction Method (DRM) . The EMAThere are more valuable implications for this study regarding the use of this scale. Spain and other Spanish-speaking countries can benefit from the Spanish validation of the SPANE to assess the efficacy of interventions aiming to improve well-being and use it to measure the positive affects. The SPANE can be used in randomized trials to evaluate the efficacy of interventions on health. For instance, some trials have shown that a six-week yoga intervention  can imprLimitations of this study include not measuring discriminant validity, which leaves the question of which constructs are unrelated to the SPANE unanswered. Since the sample is not representative of the population, this can lead to problems with generalization of the results. To our knowledge, no version of the SPANE has been validated using probability samples. Future validations should address this issue by using a probabilistic sample. It would be desirable, too, to develop norms for different groups in large and probability samples. On the other hand, responsiveness to change was not assessed in this study, and future studies should assess whether the SPANE is associated with health outcomes. Similarly to chronic stress, the frequency of positive and negative stress could be associated with a psycho-neuro-immunological system that is related to disease . For thiThe present study provides a version of a widely used measure of perceived well-being, the SPANE, for Spaniards. The study details the back translation process and study measurement invariance by gender, as well as factor structure and psychometric properties using structural equation modeling methodology. Our results indicate that the Spanish adaptation of the SPANE has adequate psychometric properties, similar to those in previous studies. The Spanish population and researchers can benefit from this short and easy-to-understand scale that can be implemented in a variety of studies including randomized trials, population surveys, or the design and validation of related instruments. This scale can be an efficient and valuable tool for clinicians and researchers in Spain.


Fried physical frailty, with mobility frailty and non-motor frailty phenotypes, is a heterogeneous syndrome. The coexistence of the two phenotypes and cognitive impairment is referred to as cognitive frailty (CF). It remains unknown whether frailty phenotype has a different association with hearing loss (HL) and tinnitus.Of the 5,328 community-dwelling older adults, 429 participants aged ≥58 years were enrolled in the study. The participants were divided into robust, mobility, and non-mobility frailty, mobility and non-mobility CF , and cognitive decline [subdivided into mild cognitive impairment (MCI) and pre-MCI] groups. The severity and presentations of HL and/or tinnitus were used as dependent variables in the multivariate logistic or nominal regression analyses with forward elimination adjusted for frailty phenotype stratifications and other covariates.Patients with physical frailty (mobility frailty) or who are robust were found to have lower probability of developing severe HL and tinnitus, and presented HL and/or tinnitus than those with only cognitive decline, or CF. Patients with RCF and non-mobility RCF had higher probability with less HL and tinnitus, and the presentation of HL and/or tinnitus than those with PRCF and mobility RCF. Other confounders, age, cognitive and social function, cardiovascular disease, depression, and body mass index, independently mediated the severity of HL and tinnitus, and presented HL and/or tinnitus.Frailty phenotypes have divergent association with HL and tinnitus. Further research is required to understand the differential mechanisms and the personalized intervention of HL and tinnitus.ClinicalTrials.gov identifier, NCT2017K020. Frailty is a heterogeneous clinical syndrome with a decline in the functioning of multiple physiological systems, including physical, cognitive, social, or psychosocial frailty phenotypes. It could result in adverse outcomes, such as dependency, falls, disability, and death . The coeHearing loss, or presbycusis, which is the most common sensory dysfunction, is an important component of frailty index, and both presbycusis and the degree of frailty index are associated with a higher risk of developing cognitive impairment and dementia . The coeSubjective tinnitus is another common comorbid disorder of the auditory system in older adults. Apart from an aberrant auditory sensory perception, chronic tinnitus is closely associated with cognitive deficits and emotional, psychological, and mental health disorders, such as depression, anxiety, and sleep disturbance or insomnia . ChronicHence, the present study aimed to investigate the association between the severity of age-related HL or chronic tinnitus and frailty phenotypes, including CF subtypes, as well as the association between the presentation of HL and/or tinnitus with frailty phenotype stratifications.The participants of the Shanghai study of health promotion for elderly individuals with frailty, which is a population-based cross-sectional study, were enrolled in the present study . We analAfter excluding individuals with severe disability, complete loss of hearing and vision, and dementia based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition , 429 quaThe study was approved by the Ethics Committee of Huadong Hospital , and written informed consent was obtained from each volunteer or authorized representative.Hearing was objectively measured using a pure-tone audiometry in a sound-attenuating booth according to the American National Standards Institute standards. The air conduction thresholds in each ear [in decibel (dB) hearing level] were measured from 500 to 8,000 Hz. The pure-tone average (PTA) in the better hearing ear was calculated using the 0.5-, 1-, 2-, and 4-kHz thresholds . The parThe Tinnitus Handicap Inventory (THI) is validated in Chinese people with a 25-item self-rating instrument and can yield a score  from 0 to 100. THI includes items concerning general tinnitus severity, quality of life, and psychological aspects of tinnitus . TinnituThe objective assessment of cognitive performance had been reported in the literature , 2020. IThe mobility and non-mobility frailty phenotypes were evaluated using the five-item Fried scale with Chinese reference values . MobilitDemographic information , self-reported smoking, alcohol intake, and chronic comorbidity, which were validated by conducting a medical chart review were obtained by trained medical staff in 2018–2019. Chronic comorbidity was evaluated according to our previous study . A totalvia one-way analysis of variance. If the test of homogeneity of variances was inappropriate, the Mann–Whitney U-test was employed to analyze the univariate correlation. Some categorical data were expressed as a proportion and compared using the χ2 test. All significant categorical and continuous variables associated with HL and/or tinnitus were further analyzed using multivariate logistic regression or nominal regression with forward elimination. The p-value for multiple comparisons was corrected, and a p-value < 0.05 was considered significant. All analyses were conducted using the SPSS 18.0 software.The distribution of continuous variables of frailty phenotype stratifications was tested for normality using the Kolmogorov–Smirnov Test. The difference between the groups was analyzed using a bivariate correlation . The difference in categorical variables among groups was tested p < 0.001) and the presentation of HL and/or tinnitus (p = 0.003) were significantly different among frailty phenotype stratifications. Tinnitus severity based on THI score (p = 0.177) and TFI score (p = 0.385) was not significantly different among frailty phenotype stratifications (ications .p = 0.076), non-mobility RCF , and pre-MCI  phenotypes were associated with higher odds of normal hearing, and the non-mobility RCF group with higher odds of mild HL  than of the moderate and severe HL  in model 3 and TMT B in model 4 were also independent risk factors of the severity of HL.After the adjustment for confounders, the robust and mobility frailty phenotypes were associated with significantly higher odds of normal hearing  than that of moderate and severe HL when compared with the cognitive decline phenotype model 3, . When comodel 5,  when commodel 5, . TMT B ap = 0.066, 0.086, 0.075, and 0.07 in models 1–4) or mobility RCF phenotype  was associated with marginally lower odds of mild and moderate tinnitus than that of severe and disastrous tinnitus. BMI was an independent factor associated with the tinnitus severity in all three groups in model 1 of p = 0.054; model 6) were independently associated with the severity of tinnitus.Compared with the cognitive decline or MCI group, other frailty stratifications were not associated with odds of without tinnitus or with severe and disastrous tinnitus  and pre-MCI  stratifications were associated with marginally higher odds of without HL and tinnitus than those of HL and tinnitus when compared with the MCI stratification  and mobility frailty  phenotypes were associated with higher odds of without HL and tinnitus than those of HL and tinnitus (model 6, p = 0.054 in model 2; p = 0.065 in model 3; p = 0.078 in model 6; and p < 0.05 in other models; Among the six frailty stratifications in model 3 of model 5, . After emodel 6, . Age wasFrom the cross-sectional study, we found that frailty phenotypes and CF subtypes had a different association with the severity of HL and tinnitus and presented HL and/or tinnitus. Patients with physical frailty, such as mobility frailty or who are robust had lower probability with severe HL, tinnitus, and presented HL and/or tinnitus than those with cognitive decline, CF, and mobility RCF and PRCF. Patients with RCF and non-mobility RCF had higher probability with less HL, tinnitus, and presented HL and/or tinnitus than those with PRCF and mobility RCF. Our findings provided additional evidence supporting the results of a previous longitudinal study, which indicated that the frailty phenotypes are heterogeneous with different longitudinal trajectories of mortality and disability .Although many epidemiological studies indicated that physical frailty increases the risk of future cognitive decline , the addApart from frailty phenotypes, age was the most significant independent risk factor for HL severity and HL with tinnitus. Previous epidemiological studies revealed that the prevalence of sensory and motor dysfunction and cognition deficit, frailty, and tinnitus increases with age . AlthougCognitive function is associated with HL and tinnitus. Individuals with HL had memory  and execThe total amount of social dysfunction might be detected with the Social Dysfunction Rating Scale optimal cut-off value ≥ 26 . The cutMultidisciplinary studies showed that peripheral and central HL, and motor dysfunction are observed in the preclinical AD stage. The major AD pathological changes, including amyloid plaques and neurofibrillary tangles, were observed in the central auditory neural pathway, primary motor cortex, and supplementary motor areas in AD patients. Interventions targeting the amelioration of sensory-motor deficits in AD may enhance patient function as AD progresses . The comz-scores of six neuropsychological tests and process z-scores of HVLT-R (A major strength of this study is the objective cognitive measures. Cognitive status was measured on the basis of the normative f HVLT-R , which df HVLT-R , includif HVLT-R , and lonFrailty phenotypes had different associations with the severity of HL and tinnitus, and the presentation of HL with tinnitus. Patients with cognitive decline or CF had higher risk for severe HL and tinnitus, and presented HL with tinnitus than robust and those with physical frailty. Patients with RCF or non-mobility RCF had lower risk for severe HL and tinnitus, and presented HL with tinnitus than those with PRCF or mobility RCF.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.The study was approved by the Ethics Committee of Huadong hospital and written informed consent was obtained from each volunteer or authorized representative. The patients/participants provided their written informed consent to participate in this study.QR and ZY designed the study and drafted the initial version of the manuscript. QR, JC, WZ, JR, and ZY collected the data, performed clinical and neuropsychological test measures, and data analysis. MZ, RZ, and CH performed hearing and tinnitus assessment. All authors contributed to the final version of the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Bubalus bubalis) in Germany and their potential relations to herds in other parts of Europe or worldwide. To this end, animals from different herds in Germany, Bulgaria, Romania, and Hungary were genotyped and compared to genotypes from other populations with worldwide distribution and open to the public. The pilot study analyzed population structure, phylogenetic tree, and inbreeding events in our samples. In buffalos from Germany, a mixed genetic make-up with contributions from Bulgaria (Murrah breed), Romania, and Italy was found. All in all, a high degree of genetic diversity was identified in European buffalos, and a novel genotype was described in Hungarian buffalos by this study. We demonstrate that European buffalos stand out from other buffalo populations worldwide, supporting the idea that buffalos have not completely disappeared from the European continent during the late Pleistocene. The high genetic diversity in European buffalos seems to be an excellent prerequisite for the establishment of local breeds characterized by unique traits and features. This study may also be considered as an initial step on the way to genome characterization for the sustainable development of the buffalo economy in Germany and other parts of Europe in the future.This is the first study to explore the genetic diversity and population structure of domestic water buffalo ( Bubalus bubalis) is a multipurpose animal, producing meat, milk, leather products, and dung. In developing countries, buffalos are used as draught animals, providing more than 40% of farm labor  and river buffalo . While their taxonomical status is still being debated, B. bubalis is supposed to be descended from Indian wild buffalo  domesticated ≈5,000 years ago  have been lacking until now (Bos primigenius), wisent (Bos bonasus), and buffalo . This linguistic approach supports the hitherto controversial bone finds from the same area at about the same time. It is unclear whether water buffalos repopulated Europe after the ice age or whether they survived in refugial areas. Because rock reliefs, dated back to ≈16,000 BC in France, clearly display buffalos , when buffalos were also present in Central Europe . Althougontinent . The preontinent  but geneontinent . Based oontinent . Howeverntil now . Accordibuffalos . This, iDomesticated water buffalos in Europe are referenced during the centuries VI–XII C.E.  and had While local Bulgarian buffalos were a significant European Mediterranean population raised for draft power, meat, and milk purposes, they started to be crossed with Murrah breed since 1972, mainly to improve their performance for milk production. A selection program was initiated to develop a typical Bulgarian Murrah breed for milk with high butterfat content .® Buffalo Genotyping Array 90K from Affymetrix, now enables genome analysis of this comparably novel farm animal species and could be useful for the initiation of genetic selection in German buffalo. A subsequent release of the first assembly of the water buffalo genome  genotyping assay specific for river buffalo , Axiom® o genome  further All sampling occurred as part of commercial buffalo breeding programs and strictly adhered to national and international laws.® Buffalo Genotyping Array 90K from Affymetrix1 were performed by ATLAS Biolabs GmbH . Allele calling was carried out using Axiom Analysis Suite software V4.0.1 (Applied Biosystems by Thermo Fisher Scientific) following the pipeline for Affymetrix Axiom genotyping workflow  through the commands –update-map, –update-chr, –update-alleles of PLINK V1.7 software   analysis was performed to explore the genetic relationship between four different buffalo populations. To this end, a symmetric matrix of the identity-by-state (IBS) distances, for all pairs of individuals, was generated in PLINK V1.7 software  based onST)  matrix oST) .ROH) using R package “DetectRUN”  was exclusively conducted on Central and East Europe buffalo populations genotyped in this study  and basetectRUN”  and applLROH is the sum of the length of ROH for each individual, and Lgenome is the length of the genome analyzed, which was around 2.65 Gb in buffalo.ΣThe frequency of occurrence of SNPs into an ROH was analyzed, identifying the genomic regions most commonly associated with ROH. Regions were selected containing the top 1% of most common ROH-associated SNPs (ROH hotspots or ROH islands) . GraphicN = 14). The MDS plot  with 0.41–0.35 for observed values (Ho) and 0.40–0.35/0.32 for expected values (He), respectively. Similar heterozygosity values were found in the Hungarian and Romanian samples, lowest in relation to the other population groups (from 0.35 to 0.38 Ho and from 0.32 to 0.36 He), while German buffalos had the highest values of diversity, after the Bulgarian buffalo population, between groups, and within its group . To suppx matrix  was consx matrix . Two priROH = 0.047). Romanian samples from Mera village had 185.31 Mb of the genome in ROH with an FROH of 0.074, lower than the second farm (Rom_Serc) with 252.31 Mb and FROH 0.102. The buffalo population in Mera (Rom_Mera) is distributed in smaller herds from multiple private farms. The second Romanian population (Rom_Serc) studied here is located in Sercaia and is managed by the Institute of Research and Development for Buffalo Breeding. Buffalos from Sercaia were characterized by ancient inbreeding, showing the highest proportion of ROH in the category 5–15 Mb. These values are in agreement with the results presented in ROH (0.144 and 0.173), Földes (Hun_HT) with lower FROH (0.121). The different values of FROH obtained within the German group were an indication of the high variability between farms  enrichment was found. All the hotspot SNPs in each population were in the short ROH length, likely suggestive of ancient inbreeding or selection events  showed the highest proportion of long size ROH that confirms the small population size but is also indicative of recent inbreeding events. It may be due to the application of selection programs and the sign of environmental adaptation of the Mediterranean Carpathian buffalo in Rom_Serc population, while in Mera the animals are less subjected to predefined or joint selection programs. According to ROH values between Central and East European populations. Indeed, the Bulgarian is the biggest population analyzed in this study, and the samples were collected from two different locations, which also could be related to comparably low levels of inbreeding. In the German populations, genomic relationships with Bulgarian Murrah, Italian Mediterranean breeds, and Romanian genetics were identified. Buffalos in Germany had the highest observed and expected heterozygosity values within all Central Eastern European populations studied here. The observed genetic diversity is a significant factor for their potential adaptation to the local environment and provides a valuable substrate for an upcoming selection program. Drift rather than mutation has likely created this variability due to the short period in generations and the relatively small effective population sizes  were separated from the other farm located in a former Hungarian village (Mera), now part of Romania. The origin of Romanian buffalo is still unclear. According to Borghese, it is a Mediterranean type adapted to the cold climate and local environment and is classified as a Mediterranean Carpathian breed . Becauseon sizes . Buffaloon sizes . The higIl18bp, Rhog) and autophagy (Atg16l2) were only found in Saxony. It is reported that the gene Atg16l2 (autophagy related 16 like 2) influences the adaptation of the immune system to the recovery from mastitis in Danish Holstein cattle (The control of inbreeding in a population is necessary to avoid depression of phenotype traits . Considen cattle . From thThis work aimed to contribute to an improved understanding of Central and Southeast European buffalo populations from a genomic perspective. We defined the genetic characteristics of European buffalo populations in Romania, Bulgaria, and Hungary. Together with the Italian Mediterranean breed, these populations contribute to the high degree of genetic diversity of European buffalos. Incidentally, we may have genetic evidence for a novel or original Hungarian breed, characterized by outmost uniformity in three different farms with no clear relations to any other genotype described so far. Since all farms are in the close neighborhood, follow-on studies may help to unravel the origin of the Hungarian population. This novel genetic identity found in Hungarian buffalos thus adds one additional specific breed to the existing genetic diversity in Europe, which so far consisted only of the Italian Mediterranean, Bulgarian Murrah, and Romanian genetics.This is the first genetic characterization of buffalos in Germany, where farming started only about 40 years ago and therefore is in its infancy. We have identified familiar relations to all genotypes identified in European buffalos so far with the exception of Hungary. Importantly and based only on a comparably small number of herds, a diverse genetic make-up is available in European and German buffalos, which can be seen as an excellent prerequisite for the development of Buffalo-based bioeconomy in Europe based on local breeds characterized by unique features.https://datadryad.org/stash/share/eT_rs3441UHCMlN4qpbRi8u6sFPHdX-ZtDPuVS5TpSI and https://datadryad.org/resource/doi:10.5061/dryad.h0cc7.Our data set has been uploaded in the Dryad Repository, Ethical review and approval was not required for the animal study because sampling occurred as part of livestock breeding programs which are granted by international law and therefore are not reviewed by ethical committees. Written informed consent was obtained from the owners for the participation of their animals in this study.AN, KW, and AH conceived the project and designed the experiments. AN performed the laboratory part. AN, SQ, RG-P, and ML-S performed the data analysis. AN, SQ, RG-B, JB, RK, and AH contributed to the interpretation of results and wrote the manuscript. MiT, M-AF, HP, AB, LV, CH, LH, PP, YI, TP, WL, MaT, and AH collected or provided samples and contributed to data production. All authors read, made corrections, and approved the final version of the manuscript.M-AF, MiT, HP, and RK are employed by the companies Gut Darss GmbH & Co., Hof am Meer GmBH, Wiesenburger Land eG, and Energiequelle GmbH, respectively. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Forgiveness is linked with well-being, and social and health research has focused on the role and aspects of forgiveness that has been recently suggested as a phenomenon of public health importance. The Heartland Forgiveness Scale (HFS) was developed gathering three subscales to assess the forgiveness of others, forgiveness of self, and forgiveness of situation. The present study aimed to adapt the HFS into European Portuguese, and investigate its reliability and validity.Translation and cross-cultural adaptation were conducted using a multistep forward-back translation process. Internal consistency was assessed by Cronbach’s alpha. Confirmatory factor analysis was conducted to verify that the factor structure is the same as in the original HFS. The short version of the Ruminative Response Scale (RRS) and the Satisfaction with Life Scale (SWLS) were used to examine convergent validity.A sample of 222 university students, selected through convenience sampling, was used to access the validity of the European Portuguese version of the HFS (EPHFS). Cronbach’s alpha for the European Portuguese HFS subscales were 0.777, 0.814 and 0.816 for Self, Others and Situation, respectively, indicating acceptable reliability. The 3-factor model of the original HFS was replicated in confirmatory factor analysis. As expected by evidence in the literature, positive and statistically significant correlations were found between SWLS and HFS and subscales. RRS showed negative and statistically significant correlations with HFS and subscales.The European Portuguese version of the HFS presented acceptable internal consistency, construct validity and confirmed the three-factor structure of the original HFS. Forgiveness has gained an increasing focus in social and health research. Recently, Dr. Tyler J. VanderWeele, professor at Harvard, wrote an editorial called “Is Forgiveness a Public Health Issue?” , statingAmong different researchers’ definitions, forgiveness can be defined as the framing of a perceived transgression such that the responses to the transgression (and its sequelae) and the transgressor are transformed from negative to positive or neutral. The object of forgiveness (source of a transgression) may be oneself, another person, or a situation viewed as beyond anyone’s control .Forgiving has the potential to reduce stress, breaking cycles of negative affect and rumination  . ForgivThe Heartland Forgiveness Scale (HFS) was developed to assess the forgiveness of others, forgiveness of self, and forgiveness of situation using three subscales with six items each , on a seThe translation and adaptation of HFS has been performed to different languages, including Japanese , TaiwaneTranslation: two translations were performed independently from English (source language) to European Portuguese (T1 and T2), by an informed (aware of the concepts being examined in the questionnaire) and an uninformed translator, both bilingual and Portuguese native speakers. Both were professional translators; one being a biologist, and the second one with bachelor in languages and a master degree in translation.Synthesis of the translations: the two translators and one recording observer sat down to synthesize the results of the translations T1 and T2, producing one consensual translation T-12.Back translation: the two back translations (BT1 and BT2) were created, based on the T-12 version, by two professional bilingual (English and Portuguese) translators blinded for the original version, with English as their mother tongue, with master degrees in translation and multilingual information management. They worked independently on their translation process.Expert committee review: translations were reviewed and consolidated , together with written reports, reaching consensus on discrepancies, and producing a prefinal version for field testing.Test of the prefinal version: prefinal version was tested in a small group  for comprehensiveness and to check the interpretation and cultural relevance of the translation.Submission of documentation to the developer of the original questionnaire for appraisal of the adaptation process: submission of reports and forms to the developer of the original questionnaire to verify that the recommended stages were followed, and a reasonable translation was achieved.For the creation of the EPHFS, a methodological study of cultural adaptation and validation was performed. After authorisation from the author of the original scale, the HFS was translated according to a standard criteria for instrument cross-cultural adaptation, following the steps proposed by Beaton et al.: translation, synthesis of translations, back translation, expert committee review and test of the pre-final version .TranslaIn order to confirm that the Portuguese HFS represents the related construct, related measures to forgiveness were additionally taken into consideration and applied to the same participants: the Ruminative Response Scale (RRS) and the Satisfaction with Life Scale (SWLS). A short version of the RRS was formed by Treynor, Gonzalez, and Nolen-Hoeksema  to removThe SWLS was developed by Diener et al.  to measuRegarding sample size requirements for factor analysis, rules-of-thumb vary from four to 10 subjects per variable, including a minimum of 100 subjects in order to ensure stability of the variance-covariance matrix . MoreoveTo validate the HFS in the European Portuguese population, reliability, construct validity and convergent validity were assessed via confirmatory factor analysis and correlation analysis.Factor analysis should be applied to determine whether the items form only one factor or dimension  or more than one. In cases where there is a clear hypothesis regarding the factor structure, as is the case of HFS for which the factor structure has been already determined  and confχ2/df, which is said to be less sensitive to sample size than the respective p-value. However, there is little statistical or logical rational for it and thus it is not recommended for model fit assessment ; SRMR = 0.077.CFA was pursued with first and second-order factors models, following validations published reporting other translations and the original HFS paper , 21. Theχ2(1) = 10.86; p = 0.001] were performed. The four modification indices introduced were correlations between items (belonging to the same factor) with the same wording, raising the possibility for the exploration of a deeper model, including methods factors relative to the positive and negative wording of the items, as proposed in ; SRMR = 0.0703; AIC = 329.17 and BIC = 475.49. The significant p-value associated with the chi-square test for both versions, means that the exact-fit hypothesis is rejected. However, the relative fit statistics are above the recommended thresholds for acceptance, with the exception of TLI which is close to but less than 0.9 and thus we can accept this model as reasonable, but should also explore another model.Results for the obtained model revealed reasonable model fit indices for the three-factor model of HFS: r = 0.289; HFS Self and HFS Situation, r = 0.804; HFS Others and HFS Situation, r = 0.389). These correlation coefficients mean that the three scores change in the same direction, supporting the three-factor model of the HFS in terms of construct validity.Factor loadings were all statistically significant and their standardized estimates ranged between 0.413 and 0.762. Moreover, results for the estimated correlation coefficients of each factor pair indicated positive correlations with each other  = 206.84, p < 0.001; TLI = 0.925; CFI = 0.939; RMSEA = 0.054 with 90% CI ; SRMR = 0.064; AIC = 298.84 and BIC = 455.37.This model resulted in better fit indices, all above the thresholds for adequate model fit: r = 0.326; HFS Self and HFS Situation, r = 0.740; HFS Others and HFS Situation, r = 0.326).For this second model, factor loadings of items were all statistically significant and their standardized estimates ranged between 0.414 and 0.830. Also, results for the estimated correlation coefficients of each factor pair indicated positive correlations with each other but two slightly smaller than in the first model , indicative of a better fit.For EPHFS dimensions of self forgiveness, others forgiveness and situation forgiveness, adequate inter-item correlations were obtained, 0.360, 0.425 and 0.429, respectively, indicating that items must be assessing the same content. Regarding corrected item-total correlations, for each dimension, all items showed adequate item-total correlations (ranging between 0.328 and 0.670), indicating that all items are well correlated with the corresponding factor. Cronbach’s alpha coefficient for EPHFS subscales were 0.777 for HFS Self, 0.814 for HFS Others and 0.816 for HFS Situation, indicating acceptable reliability. Descriptive statistics and internal consistency estimates for the HFS subscales, HFS Total, SWLS and RRS are displayed in Table Floor and ceiling effects were 0% for the three dimensions with the exception of HFS-Situation which had a 0.9% of participants reaching the higher possible value of the subscale. Together with presenting no missing data, these results provide evidence of the content validity of our EPHFS.Statistically significant and positive correlations were found between the SWLS and the European Portuguese Heartland Forgiveness Scale and subscales, with the HFS Situation subscale achieving the highest correlation, and the HFS Others achieving the lowest (see Table p < 0.001) of satisfaction with life, even accounting for the contributions of forgiveness of self and others , confirming the hypothesis raised.Another validation was performed regarding the hypothesis raised in the original scale, that dispositional forgiveness (assessed by HFS Situation) would be a significant predictor of measures of physiological wellbeing, even after adjusting for forgiveness of self and others in the regression model . In the r = 0.159; p = 0.018) but not for self or others forgiveness.In agreement with Macaskill  we also We reported the cross-cultural adaptation and validation of the EPHFS. The proposed version was developed according to a standard guideline for instrument cross-cultural adaptation . The PorResults of this study provide evidence that the EPHFS is a valid and reliable instrument for evaluating forgiveness in the Portuguese population, as defined in the three factor structure proposed by the original HFS version . The EPHr = 0.74) while self and others were the least (r = 0.33), supporting also the findings in the original HFS [To our knowledge only three published studies have assessed the factor structure of the HFS, based on different target populations , 21, 42.In contrast, the Turkish study, also based on a students’ sample, described a first-order model  and the Regarding the convergent validity of HFS, correlations among the EPHFS, the RRS and SWLS, revealed negative correlation between HFS and RRS (high score on the HFS more likely to have lower RRS scores), and positive correlation between HFS and SWLS (high HFS score more likely to get higher scores on the SWLS), both highly significant. Hence, forgiveness was associated with lower rumination and greater life satisfaction, in line with the hypothesis raised from theoretical studies and other translations validation , 21.Besides providing a translated and cross-cultural validated EPHFS, our study contributes to the characterization of the HFS factor structure and also for the measurement of its reliability and validity among Portuguese faculty students. However, some limitations should be acknowledged. A convenience sample of healthcare students from a public Portuguese university was used, thus the sample may not be representative of the entire population of university students in Portugal.Another limitation refers to the size of the sample, as large samples are recommended for reducing measurement errors and generalizable results to the real population structure . NeverthThe consistency of the EPHFS across time, or test-retest reliability, was not explored in this study, presenting a final limitation. This psychometric property is particularly interesting in clinical practice, for the follow-up of patients, and hence future work should address the temporal consistency of this instrument.The EPHFS presented acceptable internal consistency, confirmatory factor analysis of the three-factor structure, and construct validity. Hence, this version can be used in clinical practice and research. The availability of this EPHFS version will enable its use in the Portuguese population promoting forgiveness studies. By the other hand, its equivalence with the original HFS and other language translations may, in the long run, potentiate multi-cultural studies with the gathering of data obtained from equivalent measures of the Heartland Forgiveness Scale. The results here described concerning a new language translation and cultural validation add on previous HFS’s translations and students adaptations pursued, further suggesting that the conceptual structure of HFS is stable in many different countries .Additional file 1. HFS European Portuguese.


The aim of this study was to compare the symptomatology, palliative care outcomes, therapeutic procedures, diagnostic tests, and pharmacological treatments for people with dementia (PWD) and without dementia (PW/OD) admitted to Spanish nursing homes. Design: This was a cross-sectional study which is part of a long-term prospective follow-up of elderly people performed in nursing homes to measure end-of-life care processes. Participants: 107 nursing home patients with advanced or terminal chronic diseases were selected according to the criteria of the Palliative Care Spanish Society. Setting: Two trained nurses from each nursing home were responsible for participant selection and data collection. They must have treated the residents and had a minimum seniority of 6 months in the nursing home. Measurements: Sociodemographic data; Edmonton Symptom Assessment Scale; Palliative Care Outcome Scale; and prevalence of diagnostic tests, pharmacological treatments, and therapeutic procedures were evaluated. Results: Pain, fatigue, and nausea were found to be significantly higher in the nondementia group and insomnia, poor appetite, and drowsiness were significantly higher in the dementia group. Patient anxiety, support, feeling that life was worth living, self-worth, and practical matters management were higher in the nondementia group. Regarding drugs, use of corticoids was higher in the nondementia group, while use of anxiolytics was higher in the dementia group. Diagnostic procedures such as urine analysis and X-ray were higher in the dementia group. Conclusions: Differences in symptom perception, diagnostic tests, and pharmacological procedures were found between patients with and without dementia. Specific diagnostic tools need to be developed for patients with dementia. Dementia is one of the main causes of disability and death in the elderly, affecting 35.6 million people worldwide and steadily increasing . DementiThe probability of institutionalization increases significantly with occurrence of dementia (odds ratio (OR) = 154.1) . AccordiBecause of that, there is a high prevalence of dementia in nursing homes among European countries. A German study published in 2014 showed that the prevalence of dementia was 51.8% in nursing home residents versus 2.7% in community-dwelling elderly [In Spain, the functions attributed to hospices are assumed by other long-stay centers. In the case of elderly patients, these functions are carried out mostly by nursing homes. Of all Spanish nursing homes, 71.53% were private in 2019, for a total of 3844 private nursing homes. Private centers generally offer a number of places arranged with the Public System . DependiIn a three-year prospective study in northern Spain on a cohort of patients with palliative needs, it was observed that almost a quarter of people with palliative needs live in nursing homes . This poNevertheless, research has demonstrated that in nursing homes, there is a high prevalence of poorly controlled symptoms, such as urinary and fecal incontinence, psychological and behavioral symptoms, pain, nausea, infections, restlessness, dyspnea, edema, and delirium ,10,11,12A palliative care approach is needed for older people with dementia (PWD) institutionalized in nursing homes. High-quality palliative care in nursing homes requires structured evaluation and treatment of physical, psychosocial, emotional, and spiritual symptoms, as well as recognition of and satisfaction with the information needs of patients with dementia and their relatives.One of the pillars of the palliative approach is to reduce burdensome interventions that might not have value at end of life and to focus on optimizing quality of life. Despite this, aggressive therapies, prescription of futile drugs, and burdensome interventions are still commonplace in older nursing home residents with advanced dementia ,14. HealNevertheless, differences in palliative care outcomes, symptoms, and interventions between residents with or without dementia who potentially require palliative care have not yet been examined. Furthermore, no studies have been found that quantitatively evaluate these outcomes in residents with or without dementia in the Spanish context.We hypothesized that patients without dementia (PW/OD) would have different symptoms and palliative outcomes, consume different drugs, and undergo different diagnostic and therapeutic procedures than patients with dementia.Related to symptoms, our hypothesis was that patients without dementia would experience more frequently and more intensely symptoms requiring self-identification as pain, fatigue, anorexia, nausea, depression, or anxiety than patients with dementia, while other symptoms would be experienced equally by both groups of patients.Concerning palliative outcomes, the starting hypothesis was that patients with dementia would present worse outcomes in those aspects related to communication and self-esteem, as well as family anxiety, than those patients without dementia. Patients with dementia would consume more psychopharmaceuticals  and fewer analgesics, antiemetics, and antidepressants than patients without dementia due to the limited assessment of pain and other patient-referred symptoms in patients with cognitive impairment. On the other hand, we hypothesized that the use of antibiotics would be higher in patients with dementia. The use of diagnostic procedures would be higher in patients with dementia due to the difficulty in diagnosing concurrent pathologies. On the contrary, the use of therapeutic procedures would be lower in patients with dementia than in the rest of the patients.The aims of this study were (i) to describe symptoms perceived by professionals, palliative care outcomes, pharmacological treatments, diagnostic tests, and therapeutic procedure interventions and of older adults identified as palliative care patients in Spanish nursing homes and (ii) to compare existing differences between palliative care patients with dementia and those without dementia.A cross-sectional study was carried out in 6 nursing homes in the Metropolitan Health District of Granada.Nursing homes were selected based on their institutional characteristics. All had more than 60 beds and were privately funded. The selection of the nursing homes was performed as a convenience selection based on the presence of a multidisciplinary team, professionals interested in the possible involvement in the study, and the offer of both public and private beds. The research team explained the aims of the study to nursing homes managers. In each center, one or two nurses with close knowledge of the residents and who had been working at the nursing home for at least 6 months were responsible for data collection. All the nurses who participated gave their informed consent. In order to control bias and to produce reliable data for the research, these professionals received a training course designed to explain the study in order to ensure uniformity of data collection. The research team was in contact with them by phone if new questions or scenarios were presented and they visited the centers regularly, at least once a month.-Advanced, progressive, and incurable disease-Lack of reasonable possibilities of response to a specific treatment-Presence of numerous problems or intense, multiple, multifactorial, and changing symptoms-Great emotional impact on patient, family, and staff-Life expectancy limited to 6 months.Each nursing home professional selected patients with chronic diseases that met the following criteria according to the Spanish Society of Palliative Care :Twenty patients meeting the above inclusion criteria were selected from each center for randomized follow-up. They were observed and the data of interest were recorded without interfering with the natural course of events. Data were collected between June 2016 and January 2017. All participants, patients, and caregivers were fully informed and signed the informed consent agreement. Informed consent was given by the patient if he or she did not have dementia and by the patient’s representative in the case of patients with dementia. Thirteen patients dropped out of the study: 3 of them moved on to another nursing home and 10 did not provide informed consent by either the patient or the representative. Among these 10, 6 had dementia and 4 did not.A structured questionnaire was used to collect sociodemographic  and clinical  data from patient records.For the systematic symptom assessment, we used the Edmonton Symptom Assessment System (ESAS) , the SpaPalliative care outcomes were measured with the Palliative Outcome Scale (POS). The POS is a 10-item multidimensional scale that covers physical, psychological, emotional, and spiritual domains of life. It is a suitable instrument for evaluating palliative care needs coverage and symptoms of people with or without dementia . The SpaAn ad hoc questionnaire was used to identify whether certain interventions had been performed (at least once) in the past month. We evaluated interventions such as common drug prescriptions at end of life , diagnostic tests , and therapeutic procedures  which were used in the past month.A descriptive analysis was carried out to describe the main characteristics of the study population. Numerical variables were described by medians and interquartile ranges (P25–P75) and categorical variables by absolute frequencies and percentages.p < 0.01). Because of this, nonparametric inferential tests were used.Quantitative variables were assessed for normality using the Kolmogorov–Smirnov test and all were found to deviate significantly from the normal distribution ; p-values of less than 0.05 were considered significant. OR and 95% confidence interval were calculated for each variable in which statistically significant differences were found between the two groups.A chi-squared test was used to assess independence between categories and the Mann–Whitney All participants (PW/OD) or representatives (PWD) gave their informed consent. The study received the approval of the Granada Research Ethics Committee (PI-0619-2011). In compliance with Spanish law , patients’ data were anonymized.p = 0.05). Other sociodemographic and clinical data of the sample are shown in Overall, 120 patients were selected, but 13 of them were lost for various reasons, such as transfers to other centers. A total 107 nursing home residents were assessed. Residents’ mean age was 84 (81–89) years, and 63.6% of the residents were women. The median length of the nursing home stay was 2.0 years. Chronic Obstructive Pulmonary Disease (COPD) had a significantly higher prevalence among PW/OD than in the PWD group (p = 0.002), fatigue (p = 0.025), nausea (p = 0.035), poor appetite (p = 0.004), and insomnia (p = 0.042), with higher scores in the group without dementia. Drowsiness (p = 0.002) was rated higher in the dementia group. No differences in total scale score were observed when comparing groups  range = ,5,6,7,8) range = ,5,6,7,8)g groups .p = 0.05) and depression (p = 0.05) were observed in the nondementia group compared with the dementia group. As shown in p = 0.49). However, the group without dementia showed higher scores for sharing their feelings with their family (p = 0.001) and more practical matters (p = 0.002) than patients with dementia. As for the Eastern Cooperative Oncology Group (ECOG), patients in the dementia group were more dependent than those in the nondementia group (p = 0.001). The total score was lower in the group of patients with dementia.Regarding palliative care outcomes, the mean score of the global POS of the group with dementia ranked between one and two, while those of the group without dementia ranked between two and three. More intense anxiety (p = 0.035) and anxiolytics (p = 0.005). The percentage of patients with corticosteroids was higher in the nondementia group, while the percentage of patients with anxiolytics was higher in the dementia group.The most commonly used drugs for patients with dementia were hypnotics and barbiturates (62.7%), followed by analgesics (60%) and antidepressants (33%). For the group without dementia, 60.7% received nonopioid analgesics, followed by anxiolytics and bronchodilators (32.1%). Statistically significant differences were observed for corticoids (Patients with dementia showed a higher probability of taking anxiolytics than those without dementia (OR = 3.521). Patients with dementia showed a lower probability of taking corticoids than those without dementia (OR = 0.306), as shown in p = 0.009) and X-rays (p = 0.009) was observed in patients with dementia compared with patients without dementia  had a urine test and 38.3% had a blood test. On the other hand, in the group without dementia, 32.7% had a blood analysis and 19.6% had a urine analysis. It is notable that in the case of X-rays, in the group with dementia, 17.5% were performed, while in the group without dementia, no case was reported. Greater use of urine analysis  and 25.393  times the probability of having a urinalysis and X-ray performed than those without dementia, respectively.For the group with dementia, 25.5% had an IV peripheral catheter and 23.7% carried a urinary catheter. Only 19.6% and 15.7% had oxygen therapy and aerosol sprays, respectively. For the group without dementia, the most frequent interventions were oxygen therapy (39.3%) and aerosol sprays (32.1%). The use of oxygen therapy was significantly less frequent among patients with dementia (OR = 0.378) .Intensity of perceived symptoms, diagnostic and therapeutic procedures, and quality of palliative care were found to differ between residents with or without dementia in Spanish nursing homes. Our results showed that pain, fatigue, and nausea were significantly higher in the nondementia group. On the other hand, insomnia, poor appetite, and drowsiness were significantly higher in the dementia group. Concerning drugs, use of corticoids was higher in the nondementia group, while use of anxiolytics was higher in the dementia group. Diagnostic procedures such as urine analysis and X-ray were higher in the dementia group. Patient anxiety, lack of perceived support, lack of self-worth, and lack of practical matters management were higher in the nondementia group. Below, the implications for practice and research are discussed.Although no differences were observed between groups in terms of total ESAS scale score, significant differences were observed between different symptoms. Pain is one of the most studied symptoms in residents with dementia institutionalized in nursing homes ,21,22,23According to our hypothesis and previous studies ,24,25, oRegarding palliative care outcomes, contrary to our initial hypothesis, the mean score of the POS was higher in nondementia patients, who also showed more anxiety, a lack of family support, and felt worst about themselves than dementia patients. Again, this could be linked to the absence of specific validated tools in the Spanish context to report anxiety and depression in dementia patients. As with the ESAS, POS data of dementia patients were reported by professionals. Nevertheless, professionals of nursing homes are not well trained in recognizing and treating emotional problems in dementia patients ,27.Although family anxiety was found to be higher in dementia patients, this difference was not statistically significant. It could be expected that families of dementia patients in nursing homes report higher levels of anxiety ,28. HoweAccording to our results, having dementia does not seem to be an impediment to receiving information, compared to those without dementia. It is necessary to highlight that the POS includes all the information that has been given both to the patient or the family. Communication is a challenge for dementia patients’ relatives, but it is not only for them. In fact, Hermans et al.  showed iOn the other hand, professionals and families spend more time on appointments related to healthcare. This may be due to greater difficulty in diagnosing pain or other symptoms and their possible causes .In terms of the drugs used, contrary to the initial hypothesis, although more pain was reported in patients without dementia than in patients with dementia, no differences were observed in analgesic consumption. This absence of differences may indicate that pain is underevaluated and undertreated in nursing homes ,33,34. HPhysicians have shown a preference to start with a weak analgesic, such as a Nonsteroidal Anti-Inflammatory Drug (NSAID), and gradually move upwards, rather than begin with powerful analgesics such as opioids . In our Regarding antibiotic consumption, a study carried out by van den Noortgate et al.  in BelgiIn our results, contrary to the initial hypothesis, no statistically significant difference was found in antibiotic consumption between groups, as opposed to what was observed by Hendriks et al.  in theirAccording to our hypothesis, no differences were found in reported anxiety between dementia and nondementia patients, and a greater administration of anxiolytics and hypnotics/barbiturates was observed in the group with dementia. Agitation and restlessness can have several causes, such as pain or emotional distress . DiagnosDue to the difficulties in diagnosing concurrent diseases or complications in dementia patients, according to our hypothesis, higher percentages of diagnostic procedures were observed in these patients for many of the evaluated tests, although statistically significant differences were only found in urine analysis and X-ray tests. The difficulty of diagnosing urinary tract infections has been previously reported in patients with advanced dementia in nursing homes . SimilarRegarding therapeutic procedures, contrary to the initial hypothesis, there were no differences between groups. This is consistent with the literature, where patients with dementia are not usually subjected to onerous interventions . NeverthSome limitation should be pointed out. For this study, palliative patients were identified according to current Spanish Society of Palliative Care  criteria, but since the data collection procedure finished, specific tools such as the NECPAL-CCOMS-ICO © tool  have beeFinally, sample size may be a limitation for analysis in order to find other statistically significant differences between the two populations. Regardless, our study showed numerous differences with a high level of significance in spite of the sample size. However, the results of this study should be interpreted with caution, as they refer to a specific geographical context. Comparisons between different countries should be made in the future so that the differences found can be generalized.Pain, fatigue, and nausea were found to be significantly higher in patients without dementia. In contrast, insomnia, poor appetite, and drowsiness were significantly higher in the dementia patients. Regarding drugs, use of corticoids was higher in the nondementia group, while use of anxiolytics was higher in the dementia group. Diagnostic procedures such as urine analysis and X-ray were higher in the dementia group. Patient anxiety, lack of perceived support, and lack of practical matters management were higher in nondementia patients, while more time was wasted on healthcare appointments in the dementia group. Specific tools are needed in order to evaluate symptoms and palliative care outcomes in dementia patients.This is one of the first studies to evaluate and compare symptoms, pharmacological treatments, diagnostic and treatment procedures, and palliative outcomes between dementia and nondementia patients in nursing homes. This study provides valuable data about which symptoms are more prevalent and intense in dementia and nondementia patients, which are the most performed procedures, and which are the unmet palliative care needs.


Quality of life is an important indicator of health and has multiple dimensions. It is adversely affected in patients with trauma history, and psychiatric disorders play an important role therein. Studies in trauma-affected populations focus mainly on the development of psychiatric disorders. Our study explored various aspects of quality of life in trauma patients in a clinical setting, mainly focusing on the association of psychiatric disorders on various domains of quality of life.One hundred patients seeking help at the psychiatry outpatient of a tertiary hospital in Kathmandu, Nepal, and with history of trauma were interviewed using the World Health Organization Composite International Diagnostic Interview version 2.1 for trauma categorization. Post-traumatic stress disorder symptoms were assessed using the Post-Traumatic Stress Disorder Checklist-Civilian Version; while the level of anxiety and depression symptoms was assessed using the 25-item Hopkins Symptom Checklist-25. Quality of life was assessed using the World Health Organization Quality Of Life-Brief Version measure. Information on sociodemographic and trauma-related variables was collected using a semi-structured interview schedule. The associations between psychiatric disorders and quality of life domains were explored using bivariate analyses followed by multiple regressions.The mean scores (standard deviations) for overall quality of life and health status perception were 2.79 (.87) and 2.35 (1.11), respectively. The mean scores for the physical, psychological, social and environmental domains were 12.31 (2.96), 11.46 (2.84), 12.79 (2.89), and 13.36 (1.79), respectively. Natural disaster was the only trauma variable significantly associated with overall quality of life, but not with other domains. Anxiety, depression and post-traumatic stress disorder were all significantly associated with various quality of life domains, where anxiety had the greatest number of associations.Quality of life, overall and across domains, was affected in various ways based on the presence of psychiatric disorders such as anxiety, depression and post-traumatic stress disorder in patients with trauma. Our findings therefore emphasize the need to address these disorders in a systematic way to improve the patients’ quality of life.The online version contains supplementary material available at 10.1186/s12888-021-03104-6. Trauma has been defined in the tenth revision of the International Classification of Diseases ICD-10) as any stressful event with a probability of causing severe distress in almost anyone, for example, natural disasters such as earthquake, flood, hurricane or manmade trauma, such as torture, war, terrorism, violent accident, rape, or physical or sexual assault 0 as any –5. A numQOL does not have a single consensus definition , 16. It Psychiatric diagnoses in trauma patients include anxiety disorders, depression, post-traumatic stress disorder (PTSD) and substance-use disorders, either singly or in some combination –19. ManyStudies have suggested associations of QOL domains with different trauma types such as earthquake , war/comFemale gender –35 and eQOL as a construct has a complex relationship with multiple factors such as sociodemographic, trauma-related, and clinical diagnoses after trauma exposure. Nepal, a country in South Asia, is quite vulnerable to traumas of all kinds because of its unstable geopolitical structure . A handfThis study is a part of a large-scale study, i.e. ‘Study of health outcomes after trauma’ (SHOT) , 44, wheThe inclusion criteria were age between 18 and 60 years and history of at least one trauma at least 1 month prior to the study period as defined by the ICD-10 PTSD section. Patients were excluded if they had serious medical or neurological illness, organic mental disorder, psychotic disorders, history of severe head trauma, cerebral infection and dyslexia, which was determined via inquiring with the patients and checking their past medical history.Sample size:The sample size was calculated using the following formula:wheren = desired sample size,1− α /2)2 = 1.96 for 95% confidence interval, = 96.04 ~ 96.Considering a possible 10% dropout from the study, the total required sample size was 106. A total of 102 patients were recruited, but because two did not meet the criterion for age, they were excluded, and we had a total number of 100 patients instead. For one patient, data on many variables were missing so we included 99 patients for our analyses purpose. The data were collected over a period of 16 months from 1 April, 2017 to 14 August, 2018.Patients who agreed to participate were provided detailed information regarding the project and the aims of the study. Written informed consent was obtained from each participant prior to conducting the interviews. For illiterate participants, the accompanying informant provided the consent on their behalf after detailing about the consent process. Information on the study and the possibility of withdrawing voluntarily was given both in written form and verbally.2/ 075/076), Nepal, and the Research Ethical Committee (REK), Norway (reference number 2015/2081). The methodology has been detailed previously [Ethical clearance was obtained from the Nepal Health Research Council  and the Institute of Medicine Institutional Review Committee 6eviously .A semi-structured questionnaire was designed specifically for the participants to obtain sociodemographic variables such as age, gender, place of residence, marital status, education status, socioeconomic status, employment level and trauma-related variables such as trauma type and number of traumas experienced. Place of residence was categorized into two groups: rural and urban, depending on where the participant resided at the time of trauma. Marital status was categorized into two broad groups: married or single . Education status was categorized into three groups: illiterate, up to high school, and above high school. Religion was broadly categorized into two groups: Hindu, and others, as the majority of the Nepali population are Hindu by religion. The socioeconomic status (SES) of the participants was assessed using the Kuppuswami SES scale . SES wasThe WHO WMH-CIDI is a fully structured interview for diagnosing current and lifetime psychiatric disorders as per the criteria set by ICD-10 and the fourth edition of the Diagnostic Statistical Manual of Mental Disorders (DSM-IV) and was first developed in 1980 by the WHO. It is available in computer and paper and pencil form, where the paper and pencil form is mostly used in epidemiological studies. The psychometric properties of the CIDI, including its reliability and validity, are acceptable to good . CIDI veWe used the PCL-C to measure current PTSD symptoms and diagnosis. This is a 17-item self-rated scale that parallels the diagnostic criteria B, C, and D for PTSD as described in the DSM-IV . Items aThis is a Likert type scale with a total of 25 items derived from the 90-item symptom checklist (SCL) . Part I The WHOQOL-BREF was derived from the complete WHOQOL 100-item version. The complete version was developed in around 15 cultural settings and tested in 37 field trials over several years. It is now available in 29 languages. It provides scores across multiple domains and therefore is a comprehensive measure of QOL. The shorter WHOQOL-BREF, with 26 items and good psychometric properties, was later developed and used very frequently in research across nations and settings because of its brevity and simplicity . The firMeans and standard deviations (SDs) for continuous variables, and frequencies for categorical variables were used as descriptive statistics. The normal distribution of the continuous variables was checked by using skewness and kurtosis ±3.29 , and as p-value of .05 was taken as significant in all statistical tests. Data were analysed using Statistical Package for the Social Sciences (SPSS) 26 .Bivariate analyses were first performed between the different dependent and predictor variables to examine their associations using Spearman’s rank correlation and Pearson’s correlation where applicable. The first two items of QOL were treated as ordinal items, while gender was coded as a binary item, with female = 1 and male = 0. In the final models, ordinal linear regression was used via a generalized linear model for the first two items of QOL domains, where these two QOL indicators were retained as dependent variables, while the mean PTSD and mean anxiety and depression scores measured from PCL-C and HSCL-25, respectively, along with age and gender, were retained as predictor variables. In another final model, multivariate regressions were performed to predict the four QOL domains, i.e. physical, psychological, social and environmental; again, the mean PTSD scores (PCL-C) and mean anxiety and depression scores (HSCL-25) along with age and gender were retained as predictor variables. Preliminary analyses were conducted to ensure no major violation of normality, linearity, multicollinearity and homoscedasticity. A The mean participant age was 33.31 (10.44) years. An almost equal number of males (48%) and females (52%) were represented in the study. Seventy-nine percent of the participants were married, while the remaining 21% were single, separated, divorced or widowed. The vast majority (82%) practiced Hinduism, while the rest belonged to other religious backgrounds such as Christianity, Islam or Buddhism. More than half (56%) had completed high school, while 27% had completed more than high school, and 17% were illiterate. Forty-six percent of the participants had upper middle SES, 34% had lower middle SES, 12% had upper SES and 8% had lower SES. An almost equal number of participants came from rural (49%) and urban (51%) backgrounds. The majority (78%) of the participants suffered less or equal to at least two major traumas, while the rest (22%) had experienced > 2 traumas. Based on trauma type, slightly more than half (57%) had experienced natural disaster, while 43% experienced other traumas.The mean scores on overall perception of QOL and overall perception of health are presented in Table Bivariate analyses suggested significant association of overall perception of QOL; overall perception of health; and the physical, psychological, social and environmental QOL domains with psychiatric diagnoses such as anxiety and depression as assessed by the HSCL-25 and PTSD as assessed by the PCL-C. Age and gender had no significant associations with the QOL scales Tables  and 2.Although they were not statistically significant in the bivariate analysis, age and gender were also retained in the final regression models because various studies identified them as important demographic predictors , 39, 55.2 = .05, F = 1.16, p = .04 and β = −.39).Regressions were done for different trauma types, where trauma was dichotomized as natural disaster and others, and also on the numbers of traumas experienced by the participants, i.e. < 2 and > 2, and adjusting for age and gender. The models were not significant for predicting any domain or overall perception of QOL and health, although the natural disaster trauma type was an independent predictor for overall perception of QOL  was recorded for the environmental domain and lowest mean score was for the psychological domain 11.46 (2.84). Similar findings have been reported in a study from Norway, where the environmental domain had the highest score, but contrary to our findings, the physical domain had the lowest score . PsycholOur findings reveal that psychiatric diagnoses are associated with different aspects of QOL. Other studies have reported similar finding in those exposed to trauma , 56, 58.In our study, depression was significantly associated with overall perception of QOL, and the physical and social domains. However, this was not consistent with other studies. Araujo et al. found that depression affected all QOL domains . AnotherIn our study, PTSD scores predicted overall perception of QOL and psychological wellbeing in the final regression models. Similar findings were reported in a study from Norway, where both depression and PTSD were associated with reduced overall QOL even 6 years after the trauma . A studyAnother study found that PTSD negatively affected the physical and psychological domains . PTSD syIn the present study, there were two trauma variables, namely trauma type  and trauma number. We grouped all other traumas besides natural disaster as others, as they were much fewer in number. In our sample, trauma was not significantly associated with QOL domains except for natural trauma, which was associated with overall QOL. Natural disasters such as earthquakes, floods and tsunamis are uncertain and are of such large scale that they disrupt families, societies and living places, and at the same time make people feel that life is unpredictable, leading to disruption, and overall impairment of QOL, which could explain the results we obtained. Another possible reason is the nature of social support people receive during times of natural traumas, as the majority of the population gets involved.This finding is quite different from that of other studies, where trauma was associated with QOL in studies involving refugee status , sexual Our findings could be explained with a number of reasons. First, trauma is a broad term encompassing various types. In our study, trauma type was categorized as either natural or others. Ten different types of trauma were included in the others category as listed in section K of the CIDI version 2.1. Second, several participants reported more than one type of trauma exposure, but we recorded only the trauma considered most distressing by the participant and included that in the analyses of QOL. This is also in accordance with the classification by the CIDI, where major trauma considered the most distressing by the participant is classified as the primary trauma. Besides, trauma severity and extent rather than number, personality of a person, past psychiatric history and social support all play more vital roles .In the present study, sociodemographic variables were not significantly associated with QOL. Most studies have suggested otherwise. One study reported positive correlations between higher education and higher income, while, age correlated negatively with QOL .Female gender , 68, oldOur study is the first of its kind in Nepal and in South Asia to explore the aspects of QOL in the clinical population with trauma history at a tertiary hospital. We used objective rating scales to assess the level of anxiety, depression and PTSD symptoms, while sociodemographic and trauma-related information was collected using a semi-structured proforma designed for this study. All interviews were carried out by a qualified psychiatrist and there was limited missing information during data analysis. However, the sample size was small, and it was a clinical population from a single centre, so the generalizability of the results to non-clinical population is limited. We also used convenience sampling. Although we calculated the sample size using a standard formula, some of the findings might be due to inadequate power. The major limitation was that age and gender, as demographic variables, were included in the final regression models for obtaining results although they were not statistically significant in the bivariate analysis. Further, the majority of the participants reported experiencing > 1 trauma, and some reported having been exposed to both natural and others trauma; however, this was not taken into consideration during the analyses, so correlating trauma types with QOL was difficult. Although trauma was an important variable, we did not control for trauma in our final regressions. Another major limitation is that this was a cross- sectional study, so the directionality of the clinical diagnoses and QOL domains is questionable. We also do not have information on the predictability of the clinical diagnoses on the QOL domains. There was no comparison group, meaning we had no patients with trauma and without diagnoses of any psychiatric disorders under study and the study of QOL in this particular group of patients could have yielded a better conclusion regarding the association of psychiatric disorders with QOL.QOL across multiple domains is affected in patients with trauma history, and these aspects are variably affected by anxiety, depression and PTSD, not considering their sociodemographic and trauma-related variables. More than PTSD, anxiety and depression seem to exert greater effects on various aspects of QOL. Assessing QOL is therefore important when examining patients with clinical diagnoses of anxiety, depression and PTSD in patients with trauma and addressing these disorders post-trauma has a huge impact on improving their QOL. We recommend further studies on the QOL of this population, with more critical research design over larger samples, across settings, and with longitudinal design.Additional file 1.