Feasibility and Effectiveness of Electrochemical Dermal Conductance Measurement for the Screening of Diabetic Neuropathy in Primary Care.
Phase: NA
Conditions: Neuropathy, Diabetic, Diabetes Mellitus, Type 2
Sponsor: Fundacio d'Investigacio en Atencio Primaria Jordi Gol i Gurina

1
STUDY PROTOCOL
Study information
Title
Feasibility and effectiveness of
electrochemical dermal conductance
measurement for the screening of diabetic
neuropathy in Primary Care. DECODING
Study (Dermal Electrochemical
Conductance in Diabetic Neuropathy).
Rationale and design.
Ethical committee protocol number
P14/147
Protocol version identifier
1.0
Date of the last version of protocol
30/09/2014
ClinicalTrials.gov register number
Study not yet registered
Intervention
Dermal Electrochemical Conductance
Research question and objectives
To evaluate the feasibility, effectiveness and
performance of a new technique which
measures DEC (sudomotor reflex) in the
screening of diabetic neuropathy in Primary
Care.
Authors
Juan J Cabré,
Teresa Mur,
Bernardo Costa;
Francisco Barrio,
Charo López-Moya,
Ramon Sagarra,
Montserrat García-Barco,
Jesús Vizcaíno,
Immaculada Bonaventura,
Nicolau Ortiz,
Gemma Flores-Mateo
Ethical Committee
CEIC IDIAP Jordi Gol
Gran Via 587 àtic
08007 Barcelona

2
Correspondence to:
Dr Juan J Cabré, Jordi Gol Primary Care Research Institute, Reus-Tarragona Diabetes
Research Group, Catalan Health Institute, Primary Health Care Division, Camí de
Riudoms
53-55, 43202, Reus, Spain.
E-mail: juanjocabre@gmail.com
(*) JJC and TM ranks equal: both equally contributed to the conception, design and
writing of the manuscript.
(**) A complete list of members of the coordinating committee and participating centres
is given at the end of the article.
Authors: email adresses:
Juan J Cabré: juanjocabre@gmail.com
Teresa Mur: tmm637@gmail.com
Bernardo Costa: costaber@gmail.com
Francisco Barrio: ciscobarrio@gmail.com
Charo López-Moya:
rlopez21340@coib.net
Ramon Sagarra:
rsagarraalamo@gmail.com
Montserrat García-Barco:
mgarciab.tgn.ics@gencat.cat
Jesús Vizcaíno: jvizcainom@gmail.com
Immaculada Bonaventura:
17002ibi@gmail.com
Nicolau Ortiz: nortiz@grupsagessa.com
Gemma Flores-Mateo:
gemmaflores@gmail.com

3
INDEX
INTRODUCTION............................................................................................................ 6
HYPOTHESIS AND OBJECTIVES ............................................................................. 10
METHODS..................................................................................................................... 11
Design......................................................................................................................... 11
Sites ............................................................................................................................ 11
Study subjects............................................................................................................. 11
Sample size................................................................................................................. 12
Variables and dynamic data collection:...................................................................... 13
STATISTICAL ANALYSIS.......................................................................................... 16
LIMITATIONS OF THE STUDY ................................................................................. 17
QUALITY ASPECTS .................................................................................................... 19
FINANCIAL SUPPORT................................................................................................ 22

4
Abbreviations
CHOD-PAP: 
Cholesterol 
oxidase
phenol-aminophenazone
CI95%: Confidence interval 95%
CKD-EPI: Chronic Kidney Disease
Epidemiology Collaboration
DEC: 
Dermal 
Electrochemical
Conductance
DECODING: Dermal Electrochemical
Conductance in Diabetic Neuropathy
DM: Diabetes mellitus
DSPN: 
distal 
symmetric
polyneuropathy
EMG: electromiography
HLD: High density lipoprotein
HPLC: 
High 
Resolution 
Liquid
Chromatography
ICS: Institut Català de la Salut –
Catalan Institute of Health
IDIAP :
Institut 
d’Investigació 
en
Atenció Primària
–
Primary Care
Research Institute
IFG: Impaired fasting glucose
IGT: Impaired glucose tolerance
LDL: Low density lipoprotein
MDRD: Modification of Diet in Renal
Disease
MFT: Monofilament testing
MNI : Michigan Neuropathy Instrument
NDS: Neuropathy Disability Score
NSS : Neuropathy Symptoms Score
OGTT: Oral glucose tolerance test
PN: polyneuropathy
QOL-DN: 
Quality 
of 
Life
Questionnaire-Diabetic Neuropathy
ROC: 
Receptor 
Operative
Characteristics
UENS: Utah Early Neuropathy Scale
VO2 max: Maximum Oxygen Volume
WHO: World Health Organization

5
ABSTRACT:
Diabetes mellitus is the leading cause of polyneuropathy in the Western world. Diabetic
neuropathy is a frequent complication of diabetes and may have great clinical
transcendence due to pain and possible ulceration of the lower extremities. It is also a
relevant cause of morbidity and mortality in patients with diabetes. Although the cause
of polyneuropathy in patients with diabetes is only partially known, it has been
associated with chronic hyperglycaemia suggesting the possible aetiopathogenic
implication of advanced glycosylation end-products.
The strategy of choice in the
medical management of diabetic neuropathy is early detection since glycaemic control
and the use of certain drugs may prevent or slow the development of this disease.
Diabetic neuropathy most often presents with a dysfunction of unmyelinated C-fibers,
manifested as an alteration of the sweat reflex of the eccrine glands. This dysfunction
can now be demonstrated using a newly developed technology which measures dermal
electrochemical conductivity. This noninvasive test is easy and cost-effective. The aim
of the present study is to evaluate the feasibility and effectiveness of dermal
electrochemical conductance measurement (quantitative expression of the sudomotor
reflex) as a screening test for the diagnosis of diabetic neuropathy in patients in primary
care.

6
INTRODUCTION
The prevalence of diabetes mellitus (DM) is very high in Spain, being nearly 14%
according to oral glucose tolerance test (OGTT) results (1). The management of DM
requires a significant consumption of healthcare resources, mainly in relation to the care
of vascular complications. Among the late microvascular events which may develop in
patients with DM, polyneuropathy (PN) is the most common and disabling, and is the
leading cause of morbidity and mortality in these patients (2). Indeed, in Spain, the
leading cause of neuropathy is DM, with its prevalence increasing with the presence of
DM and other risk factors such as obesity (3).
PN is defined as the presence of symptoms and/or signs of peripheral nerve dysfunction
in people with DM after the exclusion of other possible causes (4). The Toronto Panel
Consensus on PN defined this disorder as "symmetrical, depending on large fibers,
sensory-motor attributable to metabolic and microvessel disorders, as a result of chronic
hyperglycemia and other risk factors" (2). In patients with PN, thin fibers (autonomic
system - sweating) and thermal and tactile sensitivity are first affected, followed by the
involvement of large fibers, presenting an altered vibrating sensation which eventually
alters electromyography (EMG) patterns. Therefore, dysfunction of sweat reflex in
small distal fibers is one of the earliest changes to be detected in these patients (5).
The most common clinical presentation of PN is distal symmetric polyneuropathy
(DSPN), being predominantly sensory in 80% of cases (3). Pain is the most important
symptom, being described as burning or flashing, lancinanting, deep, and with frequent
exacerbations during rest (4). Pain often affects the quality of life of these patients, and

7
it is a frequent cause of depression and/or anxiety (6). Moreover, some patients may
develop hypoesthesia, which may lead to severe foot lesions (7).
The prevalence of DSPN varies greatly according to the population, definition and
detection method. The Rochester study, including more than 64,000 patients, reported
the prevalence of PN to be between 66% and 59% for type1 DM and type 2 DM,
respectively (8). The 3rd report of the Technical Study Group of Diabetes of the World
Health Organization (WHO) described a prevalence of 40% (8), and 50% in patients
with more than 25 years of DM evolution. Pirart et al. (9) reported a prevalence ranging
from 25 to 48% (7,10-17), while in Spain, Cabezas-Cerrato et al. published a figure of
24.1% (11). DSPN-related factors are: age, DM duration, metabolic control, male
gender, acute myocardial infarction, hyperlipidaemia (especially hypertriglyceridaemia),
smoking, and general cardiovascular risk factors (2,15,16,18). Puig et al. (15) also
included urinary albumin excretion as a risk factor of presenting DSPN.
The diagnosis of DSPN is commonly made based on signs and symptoms and usually
includes the use of several questionnaires such as the Neuropathy Disability Score
(NDS), the Neuropathy Symptoms Score (NSS) and the Michigan Neuropathy
Instrument (MNI). These questionnaires are easy to perform and are reproducible,
sensitive and adequate for use in a screening program (16). Additionally, It was
included a short scale (UENS - Utah Early Neuropathy Scale) to screen early
neuropathy (17). This sensitive, fast and practical test, has 5 items and their score ranges
from 0 to 42 points.

8
There are many confirmatory tests, including measurements of nerve conduction
velocity (EMG) and biothesiometry or skin biopsy. However, those most commonly
used are the measurement of altered sensations using a vibrating tuning fork with 128
Hz and/or pressure with Semmes-Weinstein 5:07 monofilament (18). Monofilament
testing (MFT) is widely accepted and recommended by all scientific societies because
of its validity, predictive risk, efficiency and simplicity. Feng et al. (19) reported that
MFT has a sensitivity of 57-93%, a specificity of 75-100%, a positive predictive value
of 36-94% and a negative predictive value of 84-100% compared to the measurement of
nerve velocity by EMG. Although electrophysiological measures are more objective and
reproducible, they are limited in that they only detect dysfunction based on the presence
of thicker and faster (myelinated) fibers and show their involvement later. Consequently,
EMG is a specific, albeit very insensitive, test.
Recently developed non invasive techniques are more reproducible and reliable for the
detection of early dysfunction of small fibers. One of these new techniques involves the
measurement of dermal electrochemical conductance (DEC) or sudomotor
dysfunction index and has been evaluated by well-designed studies (Calvet, Dupin,
Winiecki, Black, 2013; Casellini 2013; Devigili 2008; Peltier 2009) which support its
use as a screening test (20).
Ramachandran et al (21) studied the use of DEC to detect diabetes and other disorders
of glucose metabolism. In a study on the use of DEC Casellini et al (5) applied a PN test
which showed a low sensitivity of 78% and a specificity of 92% in diabetic patients
without neuropathy compared to other subjects with neuropathy and a control group. In
this latter study, correlation with clinical parameters showed adequate reproducibility of

9
the results, particularly in regard to the measurements of the feet (5). Several other
studies (22) also obtained significantly lower DEC values on comparing diabetic
patients and controls. In a study of patients following a 12-month program of intense
physical activity, Raisanen et al (23) observed a greater improvement in DEC compared
to weight, waist circumference or maximum oxygen volume (VO2 max).
Therefore, taking into account the large number of  methods used and the learning curve
required to correctly implement these techniques as well as the absence of consensus as
to which method is the most adequate to diagnose DSPN, the aim of this study is to
validate the usefulness of DEC measurement in the early diagnosis of DSPN compared
with traditional techniques in the Primary Care setting.

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HYPOTHESIS AND OBJECTIVES
The hypothesis of our study is that the measurement of DEC is feasible, sensitive and
specific and more or equally effective to other techniques commonly used in the initial
screening of diabetic neuropathy in Primary Care.
Main objective
To evaluate the feasibility, effectiveness and performance of a new technique which
measures DEC (sudomotor reflex) in the screening of diabetic neuropathy in Primary
Care.
Specific objectives
1. Determine the performance of DEC (quantitative assessment of sudomotor reflex) as
a tool for the screening of diabetic neuropathy in Primary Care compared with the
Semmes-Weinstein 5:07 MFT when an EMG is used to confirm the presence of diabetic
peripheral neuropathy in patients with prediabetes and type 2 diabetes.
2. Determine the performance of DEC (quantitative assessment of sudomotor reflex) as
a tool for screening diabetic neuropathy in Primary Care compared with the Semmes-
Weinstein 5:07 MFT when the UENS (Utah Early Neuropathy Score) is used to confirm
the presence of diabetic peripheral neuropathy in patients with prediabetes and type 2
diabetes.
3. Estimate the cost and cost-effectiveness of the use of DEC in the screening of early
diabetic neuropathy in Primary Care.

11
METHODS
Design
We will perform a blind, prospective study comparing DEC (sudomotor reflex)
(Sudoscan®, Impeto Medical, France), EMG, the Semmes-Weinstein 5:07 MFT (10 g),
the sensitivity of a vibrating tuning fork 128 Hz, the NDS score and the UENS score in
a consecutive series of patients treated in Primary Care.
Sites
The Primary Care teams of Terrassa-Sud and other partners belonging to the Mutua
Terrassa reference hospital and those of the University Hospital Sant Joan de Reus
reference hospital.
Study subjects
We will consecutively include patients with type 2 DM over 40 years of age, with or
without symptoms of neuropathy, attended in Primary Care. We will also include the
following two groups of patients matched by age and gender: one including patients
with prediabetes (intermediate alterations of glucose metabolism defined as impaired
fasting glucose (IFG) and/or impaired glucose tolerance (IGT) determined by OGTT
after 2-hour 75 g oral glucose administration and another including patients without
glucose alterations (normal glucose tolerance) (control group).

12
Three main diagnostic categories (normal, pre-diabetes and diabetes) were defined
using the WHO criteria based on 2-h postload glucose [<7.8 (140 mg/dL), 7.8–11.0
mmol/L (140-200 mg/dL) and / or fasting plasma glucose (6.1–6.9 mmol/L; 110-126
mg/dL) and >11.1 mmol/L (>200 mg/dL), respectively.
The exclusion criteria are: Type 1 DM, upper or lower limb amputation (except
phalanges), diagnosis of neuropathy not related to diabetes, neuropathy by entrapment,
use of psychoactive substances, chronic alcoholism, malnutrition; treatment with beta-
blockers, presence of terminal disease or life expectancy less than 3 years.
Pregnancy will be ruled out in women (negative pregnancy test) and a possible history
of gestational diabetes will also be taken into account.
The study period is from January 1, 2017 to 30 November 2019.
Sample size
To estimate the validity and performance of a screening test that showed a sensitivity of
82%, a precision of 9% and a confidence interval of 95% (CI95%), considering a loss
percentage of 20%, this study will include a total of 160 participants. The proportion of
diabetes / prediabetes / normal glucose tolerance will be 2:1:1. The contribution by
centres will be: 66% from the Mutua de Terrassa (106 cases) and 34% from Reus (54
cases).

13
Variables and dynamic data collection:
After verifying the inclusion criteria and receiving written informed consent to
participate, during the first visit to the Primary Care centres the medical history of the
patient will be obtained and a physical examination will be performed using the MFT
and the NDS and UENS questionnaires will be given to screen for PN. The patient will
also undergo DEC quantification using the Sudoscan® device.
The following variables were collected:
- Age, sex and country of origin.
- Family history of type1 or type2 DM: (yes / no).
- In diabetic population, length of diabetes evolution (in years) since diagnosis.
- Toxic habits: smoking (active smoker / ex smoker / non-smoker); drinking (teetotal,
occasional drinker, habitual drinker).
- Other complications of diabetes and year of diagnosis (retinopathy, ischemic heart
disease, peripheral vascular disease, cerebral vascular disease and diabetic nephropathy)
will be collected from the patient medical records.
- Diabetes treatment.
- Other pharmacological treatments related to: hypotension, hypolipidemia, arterial
thrombosis, among others.
On physical examination the following variables will be collected:
- Anthropometric data: Height (cm), weight (kg) (using validated clinical scale with
stadiometer in light clothing), waist circumference (cm) (using a flexible measuring
tape), measuring the point between the navel and upper iliac crest.

14
- Systolic/diastolic blood pressure; presence of pulses in pedia/posterior tibial arteries.
Blood pressure (mmHg) measurements will be made three times while seated after 30
minutes of rest using a validated automatic device, with each measure being made at
least one minute apart. The data recorded will be the mean of the second and third
readings.
Other data to be collected include:
- Blood/urine tests: OGTT (Except in known DM); glycosylated hemoglobin A1c (High
Resolution Liquid Chromatography (HPLC)), glomerular filtration rate [Modification of
Diet in Renal Disease (MDRD) / Chronic Kidney Disease Epidemiology Collaboration
(CKD-EPI)]; lipid profile (total cholesterol, triglycerides and LDL and HDL fractions
using the cholesterol oxidase-phenol + aminophenazone (CHOD-PAP) method. These
latter parameters should have been determined no more than 6 months previously. If not
the determinations should be made in the reference laboratory.
- A score of 8 out of 8 with the Semmes-Weinstein 5:07 MFT(10 g) will be considered
as sensitive.
- A NDS score greater than or equal to 6 points will be considered as the presence of PN.
- A UENS score greater than or equal to 10 points will be considered as the presence of
PN.
- The determination of vibration sensitivity will be performed using a 128 Hz Rydel-
Seiffer tuning fork. The test will be considered positive for PN when vibration of the
tuning fork is not perceived when applied to the thumb or external maleolus.
In the second visit, done at the reference hospital, a neurologist blinded to previous test
results, will perform neurographyc test including sensory conduction study of the
median, ulnar and sural nerves, and motor conduction study of the deep peroneal nerve.

15
The studied variables will be amplitude of compound muscle action potential and distal
latency of the motor nerves, and amplitude and distal latency of sensory nerves. DEC
determination and the other neuropathy screening and electrophysiological tests will
take no longer than one month.
The third visit will be carried out in the Primary Care centre where the results of the
previous visit will be recorded and the patient will be informed of the results and the
diagnosis.
The cost effectiveness of the different diagnostic methods studied will be evaluated and
the incremental cost method to detect new cases compared to traditional methods will
be calculated. In addition, a computer simulated model will determine the long term as
well as the direct and indirect costs of the different methods.

16
STATISTICAL ANALYSIS
The Chi-square test will be used to analyse qualitative variables and the Student t-test
will be performed for quantitative variables. Logistic regression will be used to identify
predictors of diabetic neuropathy. Dependent variables (Response) will include the
presence of diabetic neuropathy diagnosed by EMG or the NDS / UENS questionnaires.
We will compare the performance of DEC with that of the MFT as screening tests of
PN.
To determine the validity and reliability of DEC we will calculate the sensitivity,
specificity, the positive and negative predictive values, and the positive and negative
likelihood ratios. A ROC curve will be used and the area under the curve will be
calculated. A p value <.05 will be considered as statistically significant. The analysis
will be performed with the statistical packages STATA/SE 12.0 and R for Windows.

17
LIMITATIONS OF THE STUDY
The main limitation of the present study is accurate diagnosis of diabetic neuropathy
since some studies have shown that some cases of diabetic neuropathy present no
alterations in the EMG. Indeed, several considerations should be taken into account.
Firstly, the EMG test is more specific, albeit not very sensitive, showing positive results
in advanced stages of PN. The fingerboard and the NDS questionnaire are commonly
used for the diagnosis of diabetic neuropathy, probably because the NDS is carried out
prior to EMG and is actually often used to avoid the need for EMG. Therefore, both
the EMG and the NDS score, which mainly assess the dysfunction of myelinated fibers
provide a good profile for diagnostic confirmation. On the other hand, both the DEC
and the MFT are able to diagnose and stage diabetic neuropathy earlier than the
previous two tests by the detection of unmyelinated fiber dysfunction. But, another
limitation is that MFT is a good test for prediction of a foot ulcer but is certainly
insensitive for the detection of early neuropathy.  For this reason, we think about the
UENS, because of its sensitivity to early sensory loss and ability to record modest
anatomic change in sensory function, considering patients with milder neuropathy.
Therefore for purposes of simplification and taking into account the possible limitations,
we will compare the effectiveness of the measurement of DEC and the use of MFT as
diagnostic tools in Primary Care according to whether the true diagnosis is achieved by
a) the EMG or b) the score of the NDS or UENS questionnaires.
Obviously there are another tests to detect early neuropathy, i.e. the Norfolk QOL-DN
scale; but this questionnaire is not practical in the clinical scenario. Certainly, this test is
a good tool to detect unaware neuropathy in patients with diabetes (24). This study used
the Norfolk QOL-DN scale on 25000 patients with diabetes and found 6600 patients
who were not aware of their neuropathy nor did their physicians know.

18
Another limitation of this study is the possibility of introducing a selection bias, and
thus, we will consecutively include patients with type 2 DM, excluding patients with
type 1 DM. We will also include a group of patients without DM or other glucose
homeostasis disorders matched by age and gender to a 2:1:1 ratio (80 with DM, 40 with
prediabetes and 40 with normal glucose tolerance).

19
QUALITY ASPECTS
This project will promote a strategy to determine whether the implementation of a new
technique simplifies the detection of a major complication of diabetes, such as
neuropathy.
Primary Care is clearly the most appropriate setting for the screening of this
complication. Indeed, the earlier the diagnosis the better the prognosis.
This strategic action on health is directly linked to:
(A) New medical technologies to promote personalized medicine based on the profiles
of the individuals and not the disease.
(B) Translational and clinical research, evidence-based scientific and technological
knowledge.
(C) Validation of a promising new technology for early detection of diabetic neuropathy
in Primary Care.
(D) Application of evidence in clinical practice. This is a validation study of diagnostic
technology implemented in real life conditions which would provide additional
knowledge for everyday clinical practice.
It is of note that this study will also determine the cost-effectiveness of this new tool
which is essential for the validation of new technologies aimed at different healthcare
areas such as Primary Care.
Additionally, this project will establish synergies at different levels such as Primary

20
Care and Neurology, and the results can be shared with a number of centers, primary
care areas and different scientific societies involved in the comprehensive care of
patients with diabetes.
The results of previous studies support the feasibility of DEC in Primary Care, although
further studies should be aimed at complementing and extending our hypothesis to
different types of candidates and determining the cost-effectiveness of the systematic
use of DEC.
Technical and collaborative aspects
The number of centres involved is limited, including Primary Care centres of the
Catalan Institute of Health (ICS) of Reus (Tarragona) and the Mútua Terrassa
(Barcelona).
In addition, IDIAP Jordi Gol and the Pere Virgili Health Research Institute - Hospital de
Sant Joan (Reus), and IDIAP Jordi Gol and Mútua Terrassa have signed a cooperation
agreement regarding research in the field of primary care.
Author’s contributions
All authors substantially contributed to designing the study protocol or to data analysis
and interpretation, and to drafting or revising the article. Specifically, JJC, TM and BC
formulated the research question, designed the study (by cooperating with FB, RS, JV
and GFO), and wrote the research proposal as well as the first draft of the manuscript.

21
JJC, TM and BC discussed the proposal and his approach to the reality of primary care.
BC, TM, FB, CLM, MGB, IB, NO and GFO critically revising the proposal for
scientifical content.
All authors contributed to the revision of the manuscript, read and approved the final
version.
Competing interests
The authors declare that they have no competing interests.
Ethics approval and consent to participate
The research ethics committee board at the Jordi Gol Research Institute (Barcelona)
(www.idiapjordigol.org) approved the protocol (January 2015, reference number
P14/147) and each participant signed a written informed consent.

22
FINANCIAL SUPPORT
The DECODING project was funded by: (1) First prize of the Research Grants of the
CAMFiC (Catalonian Society of Family and Community Medicine), grant agreement no.
XV/2014), (2) Grant from the Laboratorios del Dr. Esteve, S.A.U. and (3) Department
of Health, Generalitat de Catalunya and the PERIS (Pla Estratègic de Recerca i
Innovació en Salut) 2016-2020, grant agreement SLT002/16/00093. As DECODING is
part of diabetes prevention projects (Catalan Diabetes Prevention Research Group), its
team also participated in the grant agreements SLT002/16/00045, SLT002/16/00154
within this national call for research.
Members of the Catalan Diabetes Prevention Research Group
Bernardo Costa (Jordi Gol Primary Care Research Institute); Conxa Castell (Public
Health Division, Department of Health); Joan-Josep Cabré, Montserrat García-Barco,
Francesc Barrio, Ramon Sagarra, Santiago Mestre, Cristina Jardí, Gemma Flores, Josep
Basora, Susanna Dalmau (Reus – Tarragona); Xavier Cos, Marta Canela (Sant Martí –
Barcelona); Claustre Solé, Ana Martínez (El Carmel – Barcelona); Teresa Mur, Charo
López, Montserrat Roca, Núria Porta (Mútua Terrassa – Barcelona); Sofía Aguilar,
Antoni Boquet, Miguel-Ángel Carreiro (Hospitalet-Cornellà – Barcelona); Francesc
Pujol, Juan-Luis Bueno (Tàrrega-Cervera – Lleida); Mercè Bonfill, Montserrat Nadal
(Amposta-Ulldecona – Terres de l’Ebre); Albert Alum, Concepción García (Blanes-
Tordera – Girona); Alba Capdevila, Ana Gómez (La Seu d’Urgell – Pirineus Nord);
Marta Roura, Anna Llens (Figueres-Olot – Girona Nord).

23
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