NextLens-The Next Generation of Surgical Navigation: Proof of Concept of an Augmented Reality System for Surgical Navigation.

Objective The aim of this work was the development of an augmented reality system including the functionality of conventional surgical navigation systems. Methods An application software for the Augmented Reality System HoloLens 2 from Microsoft was developed. It detects the position of the patient as well as position of surgical instruments in real time and displays it within the two-dimensional (2D) magnetic resonance imaging or computed tomography (CT) images. The surgical pointer instrument, including a pattern that is recognized by the HoloLens 2 sensors, was created with three-dimensional (3D) printing. The technical concept was demonstrated at a cadaver skull to identify anatomical landmarks. Results With the help of the HoloLens 2 and its sensors, the real-time position of the surgical pointer instrument could be shown. The position of the 3D-printed pointer with colored pattern could be recognized within 2D-CT images when stationary and in motion at a cadaver skull. Feasibility could be demonstrated for the clinical application of transsphenoidal pituitary surgery. Conclusion The HoloLens 2 has a high potential for use as a surgical navigation system. With subsequent studies, a further accuracy evaluation will be performed receiving valid data for comparison with conventional surgical navigation systems. In addition to transsphenoidal pituitary surgery, it could be also applied for other surgical disciplines.

IMAGINER: improving accuracy with a mixed reality navigation system during placement of external ventricular drains. A feasibility study.

OBJECTIVE: The placement of a ventricular catheter, that is, an external ventricular drain (EVD), is a common and essential neurosurgical procedure. In addition, it is one of the first procedures performed by inexperienced neurosurgeons. With or without surgical experience, the placement of an EVD according to anatomical landmarks only can be difficult, with the potential risk for inaccurate catheter placement. Repeated corrections can lead to avoidable complications. The use of mixed reality could be a helpful guide and improve the accuracy of drain placement, especially in patients with acute pathology leading to the displacement of anatomical structures. Using a human cadaveric model in this feasibility study, the authors aimed to evaluate the accuracy of EVD placement by comparing two techniques: mixed reality and freehand placement. METHODS: Twenty medical students performed the EVD placement procedure with a Cushing's ventricular cannula on the right and left sides of the ventricular system. The cannula was placed according to landmarks on one side and with the assistance of mixed reality (Microsoft HoloLens 2) on the other side. With mixed reality, a planned trajectory was displayed in the field of view that guides the placement of the cannula. Subsequently, the actual position of the cannula was assessed with the help of a CT scan with a 1-mm slice thickness. The bony structure as well as the left and right cannula positions were registered to the CT scan with the planned target point before the placement procedure. CloudCompare software was applied for registration and evaluation of accuracy. RESULTS: EVD placement using mixed reality was easily performed by all medical students. The predefined target point (inside the lateral ventricle) was reached with both techniques. However, the scattering radius of the target point reached through the use of mixed reality (12 mm) was reduced by more than 54% compared with the puncture without mixed reality (26 mm), which represents a doubling of the puncture accuracy. CONCLUSIONS: This feasibility study specifically showed that the integration and use of mixed reality helps to achieve more than double the accuracy in the placement of ventricular catheters. Because of the easy availability of these new tools and their intuitive handling, we see great potential for mixed reality to improve accuracy.

Mixed reality for spine surgery: a step into the future with a human cadaveric accuracy study.

OBJECTIVE: Current application of mixed reality as a navigation aid in the field of spinal navigation points to the potential of this technology in spine surgery. Crucial factors for acceptance include intuitive workflow, system stability, reliability, and accuracy of the method. The authors therefore aimed to investigate the accuracy of the system in visualization of anatomical structures using mixed reality in the example of pedicles of the thoracic spine in a human cadaveric study. Potential difficulties and limitations are discussed. METHODS: CT scans of a human cadaveric spinal column specimen were performed. After segmentation and import into the advanced HoloLens 2 software, the vertebrae were exposed. The vertebral arches were preserved on one side for a landmark-based surface registration, whereas pedicles were exposed on the other side in order to measure and evaluate deviation of the overlay holographs with regard to the exact anatomical structure. Accuracy was measured and statistically evaluated. RESULTS: In this work it was demonstrated that the overlay of the virtual 3D model pedicles with the real anatomical structures with anatomical landmark registration was within an acceptable surgical accuracy with the mean value of 2.1 mm (maximum 3.8 mm, minimum 1.2 mm). The highest accuracy was registered at the medial and lateral pedicle wall, and the measurement results were best in the region of the middle thoracic spine. CONCLUSIONS: The accuracy analysis for mixed reality (i.e., between the virtual and real anatomical situation of the thoracic spine) showed a very good agreement when focus was on the pedicles. This work is thus a rare proof of the precision of segmentation to the potential surgical area. The results encourage researchers to open up mixed reality technology in its development and application for spinal navigation.

A new concept for expansion screws on the cervical spine using shape memory alloy - a feasibility study.

BACKGROUND: In general, sufficient anchoring of screws in the bone material ensures the intended primary stability. METHODS: Shape memory materials offers the option of using temperature-associated deformation energy in a targeted manner in order to do justice to the special situation of osteoporotic bones or the potential lack of anchoring. An expansion screw was developed that takes this possibility and these requirements into account. Using finite element analysis, the variability of screw configuration and actuator was assessed from shape memory. In particular, the dimensioning of the screw slot, the actuator length and the actuator diameter as well as the angle of attack in relation to the intended force development were considered. RESULTS: As a result of the finite element analysis, a special configuration of expansion screw and shape memory element could be found. Accordingly, with an optimal screw diameter of 4 mm, an actuator diameter of 0.8 mm, a screw slot of 7.8 mm in length and an angle of attack of 25 degrees, the best compromise between individual components and high efficiency in favor of maximum strength can be predicted. CONCLUSION: Shape memory material offers the possibility of using completely new forms of power development. By skillfully modifying the mechanical and shape memory elements, their interaction results in a calculated development of force in favor of a high primary stability of the screw material used. Activation by means of body temperature is a very elegant way of initializing the intended locking and screw strength.

Development of a 3D-printed, patient-specific stereotactic system for bihemispheric deep brain stimulation.

The aim of the project was to develop a patient-specific stereotactic system that allows simultaneous and thus time-saving treatment of both cerebral hemispheres and that contains all spatial axes and can be used as a disposable product. Furthermore, the goal was to reduce the size and weight of the stereotactic system compared to conventional systems to keep the strain on the patient, who is awake during the operation, to a minimum. In addition, the currently mandatory computed tomography should be avoided in order not to expose the patient to harmful X-ray radiation as well as to eliminate errors in the fusion of CT and MRI data.3D printing best meets the requirements in terms of size and weight: on the one hand, the use of plastic has considerable potential for weight reduction. On the other hand, the free choice of the individual components offers the possibility to optimize the size and shape of the stereotactic system and to adapt it to the individual circumstances while maintaining the same precision. The all-in-one stereotactic system was produced by means of the Multi Jet Fusion process. As a result, the components are highly precise, stable in use, lightweight and sterilizable. The number of individual components and interfaces, which in their interaction are potential sources of error, was significantly reduced. In addition, on-site manufacturing leads to faster availability of the system.Within the project, a patient-specific stereotaxy system was developed, printed, and assembled, which enables the execution of deep brain stimulation via only three bone anchors located on the skull. Pre-developed MRI markers, which can be screwed directly onto the bone anchors via the sleeves, eliminate the need for a CT scan completely. The fusion of the data, which is no longer required, suggests an improvement in target accuracy.

Development of an individual helmet orthosis for infants based on a 3D scan.

An early childhood skull deformity can have long-term health and aesthetic consequences for the growing toddler. Individual helmet therapy aims at a healthy growth of the skull shape, although not every helmet shape guarantees an optimal result. To ensure an optimal fit, a scanning procedure based on a hand-held surface scanner was evaluated.The new helmet orthosis has an inner layer adapted to the shape of the head, which can be exchanged depending on the growth stage without changing the outer layer.In collaboration with surgeons and engineers, a new helmet orthosis concept was developed that is intended to offer improvements in wearing comfort, overall weight, fit and user-friendliness compared to conventional systems. In the course of the development process and in constant exchange with parents, a multi-layer helmet system with generous perforations was created using additive manufacturing processes. The new helmet shape promises easier handling, especially through the closure system.The helmet shape developed in this study is of high quality, especially in terms of fitting accuracy. Unpleasant perspiration is significantly reduced. The integration of the closure as a direct component of the helmet represents a secure closure option.

Development of 3D printed patient-specific skull implants based on 3d surface scans.

Sometimes cranioplasty is necessary to reconstruct skull bone defects after a neurosurgical operation. If an autologous bone is unavailable, alloplastic materials are used. The standard technical approach for the fabrication of cranial implants is based on 3D imaging by computed tomography using the defect and the contralateral site. A new approach uses 3D surface scans, which accurately replicate the curvature of the removed bone flap. For this purpose, the removed bone flap is scanned intraoperatively and digitized accordingly. When using a design procedure developed for this purpose creating a patient-specific implant for each bone flap shape in short time is possible. The designed skull implants have complex free-form surfaces analogous to the curvature of the skull, which is why additive manufacturing is the ideal manufacturing technology here. In this study, we will describe the intraoperative procedure for the acquisition of scanned data and its further processing up to the creation of the implant.

Mechanistic assessment and ablation of left ventricular assist device related ventricular tachycardia in patients with severe heart failure.

Aims: Left-ventricular-assist-devices (lvad) are an established treatment for patients with severe heart failure with reduced ejection fraction (HF) and reduce mortality. However, HF patients have significant substrate for ventricular tachycardia (VT) and the lvad itself might be pro-arrhythmogenic. We investigated the mechanism of VT in lvad-patients in relation to the underlying etiology and provide in silico and ex-vivo data for ablation in these HF patients. Methods and Results: We retrospectively analyzed invasive electrophysiological (EP) studies of 17 patients with VT and lvad. The mechanism of VT was determined using electroanatomical, entrainment and activation time mapping. Ischemic cardiomyopathy was present in 70% of patients. VT originated from the lvad region in >30%. 1/6 patients with VT originating from the lvad region had episodes before lvad implantation, while 7/11 patients with VT originating from other regions had episodes before implantation. Number and time of radiofrequency (RF)-ablation lesions were not different between VTs originating from the lvad or other regions. Long-term freedom from VT was 50% upon ablation in patients with VT originating from the lvad region and 64% if ablation was conducted in other regions. To potentially preemptively mitigate lvad related VT in patients undergoing lvad implantation, we obtained in silico derived data and performed ex-vivo experiments targeting ventricular myocardium. Of the tested settings, application of 25 W for 30 s was safe and associated with optimal lesion characteristics. Conclusion: A significant percentage of patients with lvad undergoing VT ablation exhibit arrhythmia originating in close vicinity to the device and recurrence rates are high. Based on in silico and ex-vivo data, we propose individualized RF-ablation in selected patients at risk for/with lvad related VT.

Oscillatory Correlates of Intentional Forgetting: The Role of Theta and Alpha Power in Item-Method Directed Forgetting.

Results from item-method directed forgetting suggest that individuals are able to intentionally forget processed information. Most research suggests that either selective rehearsal of to-be-remembered or inhibitory control of to-be-forgotten information is accountable for the effects of intentional forgetting. Some research, however, hypothesized that the time to process information mediates the underlying mechanism. To test this hypothesis, the current study investigated associations between oscillatory power in theta (3-7.5 Hz) and alpha frequencies (8-13 Hz) and intentional forgetting in human participants and explored whether or not these mechanisms depended on processing time. Previously, theta power was shown to be associated with the creation of episodic memory traces and alpha power with inhibition. We therefore expected to find associations between these neural signatures and behavioral effects. Consistent with our hypotheses, we revealed increased theta power for to-be-remembered and increased alpha power for to-be-forgotten information and that the effects of activity in both frequency bands were influenced by the time individuals were given for processing the memory cue. These results suggest that not one but two mechanisms, rehearsal and inhibitory control, are accountable for item-method directed forgetting, both with different temporal profiles.

Revisiting the Karyotypes of Alligators and Caimans (Crocodylia, Alligatoridae) after a Half-Century Delay: Bridging the Gap in the Chromosomal Evolution of Reptiles.

Although crocodilians have attracted enormous attention in other research fields, from the cytogenetic point of view, this group remains understudied. Here, we analyzed the karyotypes of eight species formally described from the Alligatoridae family using differential staining, fluorescence in situ hybridization with rDNA and repetitive motifs as a probe, whole chromosome painting (WCP), and comparative genome hybridization. All Caimaninae species have a diploid chromosome number (2n) 42 and karyotypes dominated by acrocentric chromosomes, in contrast to both species of Alligatorinae, which have 2n = 32 and karyotypes that are predominantly metacentric, suggesting fusion/fission rearrangements. Our WCP results supported this scenario by revealing the homeology of the largest metacentric pair present in both Alligator spp. with two smaller pairs of acrocentrics in Caimaninae species. The clusters of 18S rDNA were found on one chromosome pair in all species, except for Paleosuchus spp., which possessed three chromosome pairs bearing these sites. Similarly, comparative genomic hybridization demonstrated an advanced stage of sequence divergence among the caiman genomes, with Paleosuchus standing out as the most divergent. Thus, although Alligatoridae exhibited rather low species diversity and some level of karyotype stasis, their genomic content indicates that they are not as conserved as previously thought. These new data deepen the discussion of cytotaxonomy in this family.

Evaluation of bismuth-based dispersion energy donors - synthesis, structure and theoretical study of 2-biphenylbismuth(iii) derivatives.

A series of 2-biphenyl bismuth(iii) compounds of the type (2-PhC6H4)3-nBiXn [n = 0 (1); n = 1, X = Cl (2), Br (3), I (4), Me (5); n = 2, X = Cl (6), Br (7), I (8)] has been synthesized and analyzed with focus on intramolecular London dispersion interactions. The library of the compounds was set up in order to investigate the Biπ arene interaction by systematic variation of X. The structural analysis in the solid state revealed that the triarylbismuth(iii) compound 1 shows an encapsulation of the metal atom but the distances between the bismuth atom and the phenyl centroids amount to values close to or larger than 4.0 Å, which is considered to be a rather week dispersion interaction. In the case of monomeric diorganobismuth(iii) compounds 2-5 the moderate crowding effectively hinders the formation of intermolecular donor-acceptor interactions, but allows for intramolecular dispersion-type interactions with the 2-biphenyl ligand. In contrast, the structures of the monoorganobismuth compounds 6-8 show the formation of Bi-XBi donor-acceptor bonds leading to the formation of 1D ribbons in the solid state. These coordination bonds are accompanied by intermolecular dispersion interactions with BiPhcentroid distances < 4.0 Å. In solution the diorganobismuth(iii) halides 2-4 show a broadening of their NMR signals (H-8, H-8' and H-9, H-9' protons of the 2-biphenyl ligand), which is a result of dynamic processes including ligand rotation. For further elucidation of these processes compounds 2, 4 and 7 were studied by temperature-dependent NMR spectroscopy. Electronic structure calculations at the density functional theory and DLPNO-coupled cluster level of theory were applied to investigate and quantify the intramolecular London dispersion interactions, in an attempt to distinguish between basic intramolecular interactions and packing effects and to shed light on the dynamic behavior in solution.

Protocol for rapid clearing and staining of fixed Arabidopsis ovules for improved imaging by confocal laser scanning microscopy.

BACKGROUND: A salient topic in developmental biology relates to the molecular and genetic mechanisms that underlie tissue morphogenesis. Modern quantitative approaches to this central question frequently involve digital cellular models of the organ or tissue under study. The ovules of the model species Arabidopsis thaliana have long been established as a model system for the study of organogenesis in plants. While ovule development in Arabidopsis can be followed by a variety of different imaging techniques, no experimental strategy presently exists that enables an easy and straightforward investigation of the morphology of internal tissues of the ovule with cellular resolution. RESULTS: We developed a protocol for rapid and robust confocal microscopy of fixed Arabidopsis ovules of all stages. The method combines clearing of fixed ovules in ClearSee solution with marking the cell outline using the cell wall stain SCRI Renaissance 2200 and the nuclei with the stain TO-PRO-3 iodide. We further improved the microscopy by employing a homogenous immersion system aimed at minimizing refractive index differences. The method allows complete inspection of the cellular architecture even deep within the ovule. Using the new protocol we were able to generate digital three-dimensional models of ovules of various stages. CONCLUSIONS: The protocol enables the quick and reproducible imaging of fixed Arabidopsis ovules of all developmental stages. From the imaging data three-dimensional digital ovule models with cellular resolution can be rapidly generated using image analysis software, for example MorphographX. Such digital models will provide the foundation for a future quantitative analysis of ovule morphogenesis in a model species.

Correction: The AGC protein kinase UNICORN controls planar growth by attenuating PDK1 in Arabidopsis thaliana.

[This corrects the article DOI: 10.1371/journal.pgen.1007927.].

A concept for a 3D-printed patient-specific stereotaxy platform for brain biopsy -a canine cadaver study.

The treatment of intracranial lesions requires a precise diagnosis with subsequent identification of an adequate therapeutic approach. Stereotactic tumor biopsy may be considered the safest neurosurgical procedure in terms of anticipated results and potential surgical complications. The aim of the present paper was to demonstrate a new method of stereotactic biopsy, based on a patient-specific 3D printed platform in dogs. The system was tested on two canine cadavers, a small (Shih Tzu) and a large (Labrador) breed. Imaginary biopsy targets were defined in a superficial (caudate nucleus) and a deep (piriform lobe) position. Based on 3 Tesla MRI, individualized stereotactic platforms were designed using a semi-automatic approach, and manufactured additively using ABS M30. A pre- and intra-operative CT was performed to compare the planned vs. the realized needle position for precision analyses of the procedure. The target points varied with a precision between 0.09 mm and 0.48 mm. Manufacturing time required 480 to 700 min per platform. The presented patient-specific stereotactic system seems a suitable instrument for application in small animal neurosurgery. In particular, the implementation of relevant stereotactic data may help performing the procedure in rapid sequence and with higher precision than currently-used systems. Required adjustments and adaptions to the respective anatomical conditions are omitted and make the procedure reliable and safe.

The AGC protein kinase UNICORN controls planar growth by attenuating PDK1 in Arabidopsis thaliana.

Tissue morphogenesis critically depends on the coordination of cellular growth patterns. In plants, many organs consist of clonally distinct cell layers, such as the epidermis, whose cells undergo divisions that are oriented along the plane of the layer. The developmental control of such planar growth is poorly understood. We have previously identified the Arabidopsis AGCVIII-class protein kinase UNICORN (UCN) as a central regulator of this process. Plants lacking UCN activity show spontaneous formation of ectopic multicellular protrusions in integuments and malformed petals indicating that UCN suppresses uncontrolled growth in those tissues. In the current model UCN regulates planar growth of integuments in part by directly repressing the putative transcription factor ABERRANT TESTA SHAPE (ATS). Here we report on the identification of 3-PHOSPHOINOSITIDE-DEPENDENT PROTEIN KINASE 1 (PDK1) as a novel factor involved in UCN-mediated growth control. PDK1 constitutes a basic component of signaling mediated by AGC protein kinases throughout eukaryotes. Arabidopsis PDK1 is implied in stress responses and growth promotion. Here we show that loss-of-function mutations in PDK1 suppress aberrant growth in integuments and petals of ucn mutants. Additional genetic, in vitro, and cell biological data support the view that UCN functions by repressing PDK1. Furthermore, our data indicate that PDK1 is indirectly required for deregulated growth caused by ATS overexpression. Our findings support a model proposing that UCN suppresses ectopic growth in integuments through two independent processes: the attenuation of the protein kinase PDK1 in the cytoplasm and the repression of the transcription factor ATS in the nucleus.

The role of KDEL-tailed cysteine endopeptidases of Arabidopsis (AtCEP2 and AtCEP1) in root development.

Plants encode a unique group of papain-type cysteine endopeptidases (CysEP) characterized by a C-terminal KDEL endoplasmic reticulum retention signal (KDEL-CysEP) and an unusually broad substrate specificity. The three Arabidopsis KDEL-CysEPs (AtCEP1, AtCEP2, and AtCEP3) are differentially expressed in vegetative and generative tissues undergoing programmed cell death (PCD). While KDEL-CysEPs have been shown to be implicated in the collapse of tissues during PCD, roles of these peptidases in processes other than PCD are unknown. Using mCherry-AtCEP2 and EGFP-AtCEP1 reporter proteins in wild type versus atcep2 or atcep1 mutant plants, we explored the participation of AtCEP in young root development. Loss of AtCEP2, but not AtCEP1 resulted in shorter primary roots due to a decrease in cell length in the lateral root (LR) cap, and impairs extension of primary root epidermis cells such as trichoblasts in the elongation zone. AtCEP2 was localized to root cap corpses adherent to epidermal cells in the rapid elongation zone. AtCEP1 and AtCEP2 are expressed in root epidermis cells that are separated for LR emergence. Loss of AtCEP1 or AtCEP2 caused delayed emergence of LR primordia. KDEL-CysEPs might be involved in developmental tissue remodeling by supporting cell wall elongation and cell separation.

Spirocyclic tin salicyl alcoholates - a combined experimental and theoretical study on their structures, 119Sn NMR chemical shifts and reactivity in thermally induced twin polymerization.

The spirocyclic tin salicyl alcoholate, 4H,4'H-2,2'-spirobi[benzo[d][1,3,2]dioxastannine] (1), and its 6,6'-dimethoxy (2) and 8,8'-di-tert-butyl-6,6'-dimethyl derivative (3) were synthesized and thermally induced twin polymerization of precursor 2 was performed to give a SnO2-containing hybrid material. Studies on the molecular structures of 1-3 were carried out using 119Sn{1H} CP MAS NMR spectroscopy and DFT calculations. Crystallization of compound 3 from dimethyl sulfoxide solution provided the Lewis acid-base adduct 3(dmso)2 exhibiting a hexacoordinated tin atom in the solid state, in agreement with the results of the spectroscopic and DFT calculation data. 119Sn NMR spectroscopy of the compounds 1-3 and 3(dmso)2 revealed equilibria among the diverse oligomers in solution phase pointing at hexacoordinated tin atoms.

Surface lignin removal on coir fibers by plasma treatment for improved adhesion in thermoplastic starch composites.

The high lignin to cellulose ratio of coir fibers results in low compatibility between these fibers and natural polymers like starch, leading to poor mechanical properties in the composites. Plasma treatment using either air or oxygen proved to be an effective in removing the lignin rich amorphous layer on coir fibers, as it was clearly observed by SEM. The ratio of the FTIR signal related to lignin (1508cm-1) and cellulose (1317cm-1) decreases 10 times for air plasma treated fibers and 20 times for oxygen plasma treated samples. Composites of plasma treated short coir fibers and thermoplastic starch presented considerable increase in mechanical properties in comparison to composites made with untreated fibers. Tensile strength increased by up to 300% and elastic modulus improved by a factor of nearly 20 times, which was associated with enhanced fiber-matrix adhesion after plasma treatment with oxygen for 7.2min at 80W power.

Differential effects of ongoing EEG beta and theta power on memory formation.

Recently, elevated ongoing pre-stimulus beta power (13-17 Hz) at encoding has been associated with subsequent memory formation for visual stimulus material. It is unclear whether this activity is merely specific to visual processing or whether it reflects a state facilitating general memory formation, independent of stimulus modality. To answer that question, the present study investigated the relationship between neural pre-stimulus oscillations and verbal memory formation in different sensory modalities. For that purpose, a within-subject design was employed to explore differences between successful and failed memory formation in the visual and auditory modality. Furthermore, associative memory was addressed by presenting the stimuli in combination with background images. Results revealed that similar EEG activity in the low beta frequency range (13-17 Hz) is associated with subsequent memory success, independent of stimulus modality. Elevated power prior to stimulus onset differentiated successful from failed memory formation. In contrast, differential effects between modalities were found in the theta band (3-7 Hz), with an increased oscillatory activity before the onset of later remembered visually presented words. In addition, pre-stimulus theta power dissociated between successful and failed encoding of associated context, independent of the stimulus modality of the item itself. We therefore suggest that increased ongoing low beta activity reflects a memory promoting state, which is likely to be moderated by modality-independent attentional or inhibitory processes, whereas high ongoing theta power is suggested as an indicator of the enhanced binding of incoming interlinked information.

Health status, renal function, and quality of life after multiorgan failure and acute kidney injury requiring renal replacement therapy.

BACKGROUND: Critically ill patients with acute kidney injury (AKI) in need of renal replacement therapy (RRT) may have a protracted and often incomplete rehabilitation. Their long-term outcome has rarely been investigated. STUDY DESIGN: Survivors of the HANnover Dialysis OUTcome (HANDOUT) study were evaluated after 5 years for survival, health status, renal function, and quality of life (QoL). The HANDOUT study had examinded mortality and renal recovery of patients with AKI receiving either standard extendend or intensified dialysis after multi organ failure. RESULTS: One hundred fifty-six former HANDOUT participants were analyzed. In-hospital mortality was 56.4%. Five-year survival after AKI/RRT was 40.1% (86.5% if discharged from hospital). Main causes of death were cardiovascular complications and sepsis. A total of 19 survivors presented to the outpatient department of our clinic and had good renal recovery (mean estimated glomerular filtration rate 72.5±30 mL/min/1.73 m(2); mean proteinuria 89±84 mg/d). One person required maintenance dialysis. Seventy-nine percent of the patients had a pathological kidney sonomorphology. The Charlson comorbidity score was 2.2±1.4 and adjusted for age 3.3±2.1 years. Numbers of comorbid conditions averaged 2.38±1.72 per patient (heart failure [52%] > chronic kidney disease/myocardial infarction [each 29%]). Median 36-item short form health survey (SF-36™) index was 0.657 (0.69 physical health/0.66 mental health). Quality-adjusted life-years after 5 years were 3.365. CONCLUSION: Mortality after severe AKI is higher than short-term prospective studies show, and morbidity is significant. Kidney recovery as well as general health remains incomplete. Reduction of QoL is minor, and social rehabilitation is very good. Affectivity is heterogeneous, but most patients experience emotional well-being. In summary, AKI in critically ill patients leads to incomplete rehabilitation but acceptable QoL after 5 years.