Proof of infectivity of hepatitis E virus particles from the ejaculate of chronically infected patients.

Recently, hepatitis E virus (HEV, Paslahepevirus balayani) particles were detected for the first time in the ejaculate of two chronically infected patients. Since then, we have been able to detect HEV in ejaculate in five further patients, and thus in a total of seven out of nine (78%) chronically infected men (age 36-67 years, median 56 years). In five patients, the HEV RNA concentration was more than 100-fold higher compared to the serum, while in two patients, the viral load was more than 10-fold lower. However, it has remained unclear whether viral particles shed in the ejaculate were infectious, as a previous cell culture model had failed to demonstrate the infectivity. In the current study, we employed an optimized HEV cell culture system based on overconfluent PLC/PRF/5 cells to investigate the infectivity of HEV particles from ejaculate and other body fluids. With this approach, we were able to show for the first time that HEV particles in the ejaculate from several patients were infectious. HEV replicated to high viral loads of 1e9 HEV RNA copies per ml. This indicates that HEV-positive ejaculate could bear a risk of infection for sexual partners.

[Supporting rehabilitation facilities in implementing diversity-sensitive care: Development of the DiversityKAT manual]. / Unterstützung von Rehabilitationseinrichtungen bei der Umsetzung einer diversitätssensiblen Versorgung: Entwicklung der DiversityKAT-Handreichung.

BACKGROUND: Expectations regarding health care including rehabilitation differ depending on age, gender, and also the migration history of the patient population. To meet the diverse expectations, health care needs to be diversity-sensitive, which can have a positive effect on the utilization and outcomes of care. Diversity-sensitive care, however, should take into consideration not only the expectations of diverse patient groups but also the opportunities and challenges offered by diversity of staff. Managers of health care facilities and health care staff in Germany are well aware of the need for diversity-sensitive care, but corresponding measures, so far, have been applied rarely and only unsystematically. The aim of the study was to develop a manual consisting of a catalogue of instruments and a guideline that can support rehabilitation facilities in implementing diversity-sensitive care. METHODS: A mixed methods approach was used for the study. Based on a scoping review, suitable instruments (n=34) were identified that can be used for the implementation of diversity-sensitive health care. Consensus on a draft of the manual was then reached in seven focus group discussions with health care staff (n=44) and a discussion circle consisting of n=5 representatives of the rehabilitation providers. RESULTS: The DiversityKAT manual, which was developed in a participatory manner, presents diversity-sensitive tools, including instructions, questionnaires, checklists and concepts that can be used to take into account the diversity of needs and expectations in everyday health care. In line with the feedback from health care staff, the manual includes information that can be used as a step-by-step guide to select and implement appropriate tools. At the request of the staff and the rehabilitation providers, exemplary case descriptions were added to present the use of selected instruments in specific situations. A matrix was developed for purposes of quick orientation and pre-selection of suitable instruments. DISCUSSION: Through practice-oriented advice and low-threshold guidance, the DiversityKAT-manual can increase user orientation in rehabilitation but needs to be further examined in future evaluation studies.

High prevalence of periodontal disease in patients with NASH- possible association of poor dental health with NASH severity.

INTRODUCTION AND OBJECTIVES: Recent translational research indicated a bidirectional relationship between NASH (non-alcoholic steatohepatitis) and periodontitis; however, few clinical cohorts have studied this in detail. Thus we investigated this assumed association in a well-defined cohort. MATERIALS AND METHODS: Data were generated prospectively for 132 patients (32 patients with NASH and 100 unselected, consecutively collected, anonymized controls from a local dental practice): detailed periodontal parameters, i.e., pocket-probing-depths (PPD), bleeding-on-probing (BOP), plaque-index, and utilization of dental care were assessed and correlated with relevant hepatic parameters (liver stiffness via fibroscan, AST, ALT, bilirubin, and MELD-score). Gingiva samples were tested for Porphyromonas gingvalis (P.g.) and Actinobacillus actinomyctemcomitans (A.a.) by PCR. RESULTS: 87.5% of NASH patients and 47% of controls suffered from moderate to severe periodontitis (p=0.01). Liver stiffness was significantly correlated with elevated PPD (p=0.02) and BOP (p=0.03). 34 % of the NASH patients did not make use of regular dental health care. In these patients, AST (p=0.04), MELD score (p<0.01), and liver stiffness (p=0.01) were significantly elevated compared to those who see a dentist regularly. The severity of NASH was not associated with the intraoral detection of P.g. and A.a. CONCLUSIONS: The present study suggests that NASH might be associated with periodontitis, irrespective of the intraoral presence of P.g. and A.a. Moreover, regular dental care utilization might mitigate the course of NASH, and patients should be reminded by their hepatologists of the importance of regular dental visits. Future studies should investigate the role of regular dental care and additional anti-inflammatory treatments of the oral cavity.

[Implementation Strategies of Diversity-Sensitive Health Care and Administration - A Nationwide Postal Survey of Inpatient Rehabilitation Facilities]. / Umsetzungsstrategien einer diversitätssensiblen Gesundheitsversorgung und Unternehmensführung ­ Eine bundesweite postalische Befragung von Rehabilitationseinrichtungen.

BACKGROUND: Diversity characteristics such as disability, gender, age or migration background are associated with different expectations towards health care. If these are not sufficiently considered in rehabilitative care, this may have a negative impact on the satisfaction with and outcomes of health care. Sensitivity towards the diversity of patients can promote patient-centered health care by helping to address different needs and expectations. The aim of the present study was to examine what measures inpatient rehabilitation facilities in Germany use to provide diversity-sensitive health care and which barriers prevent their proper implementation. METHODS: Between May and August 2019, administrative managers of rehabilitation facilities were invited to participate in a nationwide postal questionnaire survey (n=1,233). The questionnaire included questions on addressing the diversity of employees and rehabilitation patients. Responses were received from a total of 223 inpatient rehabilitation facilities (response rate: 18.9%). Results were analyzed descriptively. RESULTS: The survey shows that diversity-sensitive health care is a relevant topic for many rehabilitation facilities. It is regarded particularly important for the satisfaction of rehabilitation patients, treatment outcomes and employee satisfaction. Obstacles to the implementation of diversity-sensitive care comprise a lack of incentives on the part of health care organization, a lack of financial resources and organizational difficulties. DISCUSSION: The majority of the administrative managers surveyed acknowledge the relevance of diversity-sensitive care. Instruments enabling it, however, are used only sparingly and unsystematically. To promote diversity-sensitive care, health care facilities need support in competence building and in selecting and implementing appropriate measures. A handbook with instructions on how diversity-sensitive care can be implemented can contribute to that goal.

Diversity-sensitive measures in German hospitals - attitudes, implementation, and barriers according to administration managers.

BACKGROUND: Populations have varying needs and expectations concerning health care that result from diversity characteristics such as a migrant background, gender identity, disability, and age. These needs and expectations must be considered to ensure adequate utilization and quality of health services. Approaches to address diversity do exist, however, little is known about the extent to which they are implemented by health care facilities. The present study aims to examine, which measures and structures hospitals in Germany employ to address diversity, as well as which barriers they encounter in doing so. METHODS: A mixed-mode survey among administration managers of all registered German hospitals (excluding rehabilitation hospitals; n = 1125) was conducted between May and October 2019 using pen-and-paper and online questionnaires. Results were analyzed descriptively. RESULTS: Data from n = 112 hospitals were available. While 57.1% of hospitals addressed diversity in their mission statement and 59.9% included diversity considerations in quality management, dedicated working groups and diversity commissioners were less prevalent (15.2% each). The majority of hospitals offered multi-lingual admission and exit interviews (59.8%), treatments or therapies (57.1%), but only few had multi-lingual meal plans (12.5%) and seminars or presentations (11.6%). While 41.1% of the hospitals offered treatment and/or nursing exclusively by staff of the same sex, only 17.0% offered group therapies for both sexes separately. According to the managers, the main barriers were a lack of financial resources (54.5%), a lack of incentives from the funding providers (49.1%), and organizational difficulties (45.5%). Other reported barriers were a lack of conviction of the necessity among decision makers (28.6%) and a lack of motivation among staff members (19.6%). CONCLUSIONS: Administration managers from only a small proportion of hospitals participated in our survey on diversity sensitivity. Even hospitals of those who did are currently not adequately addressing the diversity of staff members and patients. Most hospitals address diversity on an ideational level, practical measures are not widely implemented. Existing measures suggest that most hospitals have no overarching concept to address diversity in a broader sense. The main reported barriers relate to economic aspects, a lack of support in organizing and implementing corresponding measures and a lack of awareness or motivation.

Lack of evidence of acute HEV infections as a sexually transmitted disease: Data from a German cohort of PrEP users.

BACKGROUND: While the sexual transmissibility of HAV in MSM has been extensively described, the potential for sexual transmission of HEV has not been definitively established. Although HEV has been detected in the ejaculate of chronically infected men, studies among MSM PrEP users in France did not observe an elevated anti-HEV seroprevalence as an indicator of increased exposure risk by sexual intercourse. PATIENTS AND METHODS: A total of 111 unselected PrEP users and 111 age- and sex-matched blood donors were tested for anti-HEV IgG, IgM and HEV (PCR). Of the participants 79/111 (71 %) responded to a questionnaire covering topics as sexual preferences, previous sexually transmitted diseases, profession, food consumption, and pet ownership. RESULTS: The anti-HEV IgG seroprevalence in PrEP users (22 %) did not differ significantly from the rate in controls (17 %). While one PrEP user and three controls tested positive for anti-HEV IgM, all PrEP users and controls tested PCR negative. CONCLUSION: In immunocompetent individuals with frequent changes of sexual partners, the epidemiology of Hepatitis E Virus does not significantly involve the sexual transmission route.

[Officer in charge, that unknown being - an explorative, qualitative study of unconscious fears, wishes, and defense mechanisms]. / Das Unbekannte Wesen Einsatzleiter - Eine Explorative Qualitative Studies zur Erfassung Unbewusster Ängste, Wünsche und Abwehrmechanismen.

OBJECTIVES: The stress and coping strategies found among emergency relief personnel have been studied in detail but without considering their function in the team. However, specifically officers in charge have to be addressed and investigated separately. This study focuses on the unconscious desires, fears, and defense mechanisms present in order to improve our understanding of the stress experienced during operations. METHODS: Four officers in charge were interviewed concerning their stressful experiences during operations. These interviews were then coded and analysed using the JAKOB Narrative Analysis ("Klinische Erzählanalyse JAKOB", Boothe et al. 2002). RESULTS: The recorded unconscious desires included solidarity, phallic integrity, generativity, unconscious fears destruction, loss of power/influence, and social hostility, and as defense strategies rationalism, repression/denial, and idealization. CONCLUSIONS: The analysis of the interviews shows a high reliability between the raters (0.74-0.79). The greatest burden for officers in charge is a loss of safety. Especially being confronted with strains in their own team leads to stress, which shows that the methods used for stress management following critical incidents is not sufficient.

High incidence of periodontitis in patients with ascitic decompensated cirrhosis.

BACKGROUND: Periodontitis has been associated with various liver diseases. However, the relevance of periodontitis in the progression of decompensated cirrhosis remains inconclusive. In particular, it is unclear whether the common periodontitis pathogens, Porphyromonas gingivalis (P. gingivalis) and Actinobacillus actinomycetemcomitans (A. actinomycetemcomitans), can be detected not only in the oral mucosa but also in ascites and stool. AIM: To investigate the significance of periodontitis, P. gingivalis, and A. actinomycetemcomitans in cirrhosis patients with ascitic decompensation. METHODS: This prospective study was conducted at the University Hospital Hamburg-Eppendorf, a tertiary center in Northern Germany. A cohort of 27 patients with ascitic decompensated liver cirrhosis underwent dental examinations to assess the association between periodontitis and various clinical parameters of cirrhosis, as well as patient outcomes. PCR was used to test gingival samples, ascites, and stool for the presence of P. gingivalis and A. actinomycetemcomitans. Gingival samples were collected by probing the deepest gum pocket of a sextant and wiping them on a cotton swab. RESULTS: Periodontitis was diagnosed in 22 out of 27 (82%) ascite patients, which is significantly more common than in a control cohort of 100 unselected patients (59%, P = 0.04). P. gingivalis was detected in the gingiva of six patients, and one of them also had P. gingivalis in their stool. However, P. gingivalis was not found in the ascites of any patient. Five out of six patients with P. gingivalis had periodontitis (83%). A. actinomycetemcomitans was not detected in any sample. Patients without periodontitis had a significantly higher mortality rate compared to those with periodontitis, and survival (Kaplan-Meier analysis) was longer in patients with periodontitis (P = 0.02). Transplant-free survival was also more common in patients with periodontitis compared to those without (63% vs 0%, P = 0.02). CONCLUSION: Decompensated cirrhotic patients frequently suffer from periodontitis. However, there was no evidence of the translocation of P. gingivalis or A. actinomycetemcomitans into ascites. The survival of cirrhotic patients with periodontitis was not reduced.

Evidence for broad cross-reactivity of the SARS-CoV-2 NSP12-directed CD4+ T-cell response with pre-primed responses directed against common cold coronaviruses.

Introduction: The nonstructural protein 12 (NSP12) of the severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) has a high sequence identity with common cold coronaviruses (CCC). Methods: Here, we comprehensively assessed the breadth and specificity of the NSP12-specific T-cell response after in vitro T-cell expansion with 185 overlapping 15-mer peptides covering the entire SARS-CoV-2 NSP12 at single-peptide resolution in a cohort of 27 coronavirus disease 2019 (COVID-19) patients. Samples of nine uninfected seronegative individuals, as well as five pre-pandemic controls, were also examined to assess potential cross-reactivity with CCCs. Results: Surprisingly, there was a comparable breadth of individual NSP12 peptide-specific CD4+ T-cell responses between COVID-19 patients (mean: 12.82 responses; range: 0-25) and seronegative controls including pre-pandemic samples (mean: 12.71 responses; range: 0-21). However, the NSP12-specific T-cell responses detected in acute COVID-19 patients were on average of a higher magnitude. The most frequently detected CD4+ T-cell peptide specificities in COVID-19 patients were aa236-250 (37%) and aa246-260 (44%), whereas the peptide specificities aa686-700 (50%) and aa741-755 (36%), were the most frequently detected in seronegative controls. In CCC-specific peptide-expanded T-cell cultures of seronegative individuals, the corresponding SARS-CoV-2 NSP12 peptide specificities also elicited responses in vitro. However, the NSP12 peptide-specific CD4+ T-cell response repertoire only partially overlapped in patients analyzed longitudinally before and after a SARS-CoV-2 infection. Discussion: The results of the current study indicate the presence of pre-primed, cross-reactive CCC-specific T-cell responses targeting conserved regions of SARS-CoV-2, but they also underline the complexity of the analysis and the limited understanding of the role of the SARS-CoV-2 specific T-cell response and cross-reactivity with the CCCs.

Pictorial Assessment of Health-Related Quality of Life. Development and Pre-Test of the PictoQOL Questionnaire.

The aim of the present study was to develop a pictorial questionnaire for the assessment of health-related quality of life (PictoQOL) and to examine its content validity and usability across three exemplary population groups of different origin residing in Germany (non-migrants, Turkish migrants and Arabic-speaking migrants). A mixed-methods design combining qualitative and quantitative methods was used, comprising 6 focus group discussions with a total of 17 participants, 37 cognitive interviews and a quantitative pretest with 15 individuals. The PictoQOL consists of a pictorial representation of a total of 15 different situations. Using a visual Likert scale, respondents indicate how much each situation applies to them. Some representations proved to be culturally sensitive and were adapted. Respondents found the use of an additional graphic layer in the form of symbols in addition to pictures helpful for interpretation. The PictoQOL is considered to allow a more accessible assessment and better comparability of HRQOL across different population groups regardless of their literacy level. It is therefore considered to be superior to existing instruments for routine use in health research and practice. Future studies need to examine its convergent and factorial validity.

Lack of Evidence for an Association between Previous HEV Genotype-3 Exposure and Glomerulonephritis in General.

Among numerous other immune-mediated diseases, glomerulonephritis has also been suspected to be an extrahepatic manifestation of HEV infection. In this prospective study, we tested 108 patients with glomerulonephritis and 108 age- and sex-matched healthy controls at the University Hospital Hamburg Eppendorf, Hamburg, Germany, for anti-HEV IgG (Wantai test) as a marker for previous HEV exposure. A total of 24 patients (22%) tested positive for anti-HEV IgG. Males tended to be more frequently anti-HEV IgG positive (29%) in comparison to females (16%). However, this does not reach statistical significance (p = 0.07). Anti-HEV IgG positive patients were older in comparison to negative patients (mean 53 vs. 45 years, p = 0.05). The kidney function seems to be slightly decreased in anti-HEV IgG positive patients in comparison to and anti-HEV IgG negative patients basing on creatinine (p = 0.04) and glomerular filtration rate (GFR) (p = 0.05). Slightly higher values of bilirubin could be found in IgG positive patients (p = 0.04). Anti-HEV-IgG seropositivity rate (22%) in glomerulonephritis patients, did not differ significantly in comparison to an age- and sex-matched control cohort of healthy blood donors (31/108 positive, 29%). A total of 2/2 patients with membranoproliferative glomerulonephritis (MPGN) tested anti-HEV IgG positive (p = 0.002 in comparison to glomerulonephritis patients with other subtypes). In conclusion, our findings indicate that previous HEV exposure in a region where GT3 is endemic is not associated with glomerulonephritis in general. However, the subgroup of MPGN patients should be investigated in future studies. Furthermore, future studies are needed to investigate whether the observed association between anti-HEV IgG positivity and reduced GFR in glomerulonephritis patients is HEV associated or is an age-related effect.

Right and left mesial temporal lobe seizures in one patient: bona fide semiological, interictal, ictal, and MRI evidence.

We present the case of a 36-year-old patient with bilateral independent manual automatisms associated with seizures coming independently from the left and right temporal lobes, as documented by surface EEG ictal recordings. An MRI showed evidence of bilateral mesial temporal sclerosis, more prominent on the right side. We speculate whether clinical semiology (along with the ictal EEG and imaging findings) discourages the pursuit of invasive monitoring, leading to more aggressive medical management in this particular case.

Lack of evidence of acute HEV infections as a sexually transmitted disease: Data from a German cohort of PrEP users

Abstract Background While the sexual transmissibility of HAV in MSM has been extensively described, the potential for sexual transmission of HEV has not been definitively established. Although HEV has been detected in the ejaculate of chronically infected men, studies among MSM PrEP users in France did not observe an elevated anti-HEV seroprevalence as an indicator of increased exposure risk by sexual intercourse. Patients and methods A total of 111 unselected PrEP users and 111 age- and sex-matched blood donors were tested for anti-HEV IgG, IgM and HEV (PCR). Of the participants 79/111 (71 %) responded to a questionnaire covering topics as sexual preferences, previous sexually transmitted diseases, profession, food consumption, and pet ownership. Results The anti-HEV IgG seroprevalence in PrEP users (22 %) did not differ significantly from the rate in controls (17 %). While one PrEP user and three controls tested positive for anti-HEV IgM, all PrEP users and controls tested PCR negative. Conclusion In immunocompetent individuals with frequent changes of sexual partners, the epidemiology of Hepatitis E Virus does not significantly involve the sexual transmission route.

Cognitive function assessment in idiopathic Parkinson's disease.

Idiopathic Parkinson's disease (PD) is characterized by reduced nigrostriatal and cortical dopaminergic influence, with changes in movement and, subsequently, behavioral and cognitive disturbances. We studied cognitive impairment in Parkinson's disease by assessing a group of 30 idiopathic Parkinson's disease patients with an average age of 64.23 years (PG group) and compared our findings with those for a control group of 30 patients (CG group). All the patients were submitted to the following assessments: motor function, using the UPDRS; staging, using the Hoehn-Yahr scales (PG group only); depression, using the Montgomery-Asberg scale; attention impairment; verbal fluency (FAR and animals); cognitive function, using the Mini Mental State Examination; visuospatial and executive functions; and clock drawing. In addition to altered motor function in PD patients, we found statistically significant differences between PD patients and controls in terms of cognitive function, verbal, executive and visuospatial functions, and attention deficits. Depression was more prevalent in the PG group.

Event-related potentials (P300) and neuropsychological assessment in boys exhibiting Duchenne muscular dystrophy.

OBJECTIVE: To examine auditory cognitive evoked potentials (P300 potentials) and neuropsychological dysfunction in patients with Duchenne muscular dystrophy (DMD). METHOD: P300 potentials and neuropsychological test results were obtained from 16 healthy control boys and 20 DMD patients. Full Intelligence Quotients (IQ) were estimated for patients and control group. Mean age was 9.5 years in the DMD patient group, and 10 years in the control group (p>0.05). RESULTS: The mean IQ values were 64.35 in the DMD patients and 82.68 in the control group (p=0.01). Mean P300 values were 347.6 in the DMD group and 337.4 in the control group (p=0.14). There was no significant correlation between parameters in each group. CONCLUSION: DMD patients showed a poor performance as evaluated by P300 potential compared to the control group, although the difference was not statistically significant. Systematic alterations in neuropsychological test results were found, the differences paralleling those detected in IQ.

The Wada Test: contributions to standardization of the stimulus for language and memory assessment.

The Wada Test (WT) is part of the presurgical evaluation for refractory epilepsy. The WT is not standardized and the protocols differ in important ways, including stimulus type of material presented for memory testing, timing of presentations and methods of assessment. The aim of this study was to contribute to establish parameters for a WT to Brazilian population investigating the performance of 100 normal subjects, without medication. Two parallel models were used based on Montreal Procedure adapted from Gail Risse's (MEG-MN,EUA) protocol. The proportions of correct responses of normal subjects submitted to two parallel WT models were investigated and the two models were compared. The results showed that the two models are similar but significant differences among the stimulus type were observed. The results suggest that the stimulus type may influence the results of the WT and should be considered when constructing models and comparing different protocols.

Bizarre behavior during intracarotid sodium amytal testing (Wada test): are they predictable?

The intracarotid sodium amytal test (ISAT or Wada Test) is a commonly performed procedure in the evaluation of patients with clinically refractory epilepsy candidates to epilepsy surgery. Its goal is to promote selective and temporary interruption of hemispheric functioning, seeking to define language lateralization and risk for memory compromise following surgery. Behavioral modification is expected during the procedure. Even though it may last several minutes, in most cases it is subtle and easily manageable. We report a series of patients in whom those reactions were unusually bizarre, including agitation and aggression. Apart of the obvious technical difficulties (patients required physical restraining) those behaviors potentially promote testing delay or abortion and more importantly, inaccurate data. We reviewed those cases, seeking for features that might have predicted their occurrence. Overall, reactions are rare, seen in less than 5% of the ISAT procedures. The barbiturate effect, patients' psychiatric profiles, hemisphere dominance or selectiveness of the injection were not validated as predictors. Thorough explanation, repetition and simulation may be of help in lessening the risk of those reactions.

Cerebellar hemorrhage as a complication of temporal lobectomy for refractory medial temporal epilepsy: report of three cases.

Cerebellar hemorrhage is listed among the potential complications following neurosurgical procedures. In this scenario it is usually reported as a rare condition. However, it seems that epilepsy surgery patients are somewhat more prone to this kind of complication, compared to other surgical groups. Head positioning, excessive cerebral spinal fluid draining and the excision of non-expanding encephalic tissue (or combinations among the three) are likely to be cause underlying remote cerebellar hemorrhage. Out of the 118 ATL/AH performed at our institution, between 1996 and 2002, we identified 3 (2.5%) patients presenting with cerebellar hemorrhage. We report on such cases and review the literature on the topic.

Limited predictive power of hospitalization variables for long-term cognitive prognosis in adult patients with severe traumatic brain injury.

OBJECTIVES: Traumatic brain injury (TBI) is a main cause of mortality and morbidity. Association studies between hospitalization variables and cognitive impairment after TBI are frequently retrospective, including non-consecutive patients showing variable degrees of TBI severity, and poor management of missing (drop out) cases. METHODS: We assessed prospectively the demographic and hospitalization variables of 234 consecutive patients with severe TBI (admission Glasgow Coma Scale [GCS] ≤8) and determined their independent association with cognitive performance in a representative sample (n = 46) of surviving patients (n = 172) evaluated 3 (±1.8) years after hospitalization. RESULTS: In all, 85% of patients were male and the mean age was 34 (SD ±13) years. The education level was 9 (±4.7) years. As expected, education and age showed a moderately to strong linear relationship with the cognitive performance in 14 of 15 neuropsychological tests (R coefficient = 0.6-0.8). The cognitive test scores were not independently associated with gender, admission GCS, associated trauma, and Marshal CT classification. Admission-elevated blood glucose levels and the presence of sub-arachnoid haemorrhage were independently associated with lower scores on Rey Auditory Verbal Learning retention and Logical Memory-I tests, respectively. CONCLUSIONS: After correction for education and age distribution, the variables that are commonly associated with mortality or Glasgow Outcome Scale including admission pupils' examination, Marshal CT Classification, GCS, and serum glucose showed a limited predictive power for long-term cognitive prognosis. Identification of clinical, radiological, and laboratory variables as well as new biomarkers independently associated with cognitive outcome remains an important challenge for further work involving severe TBI patients.