Search Results (479)

Polymer coatings are integral to nearly every modern cardiovascular and endovascular device, including drug-eluting stents (DESs) and drug-coated balloons (DCBs), bioabsorbable vascular scaffolds (BVSs), occluders, grafts, and catheter and guidewire hydrophilic surfaces. Persistent complications, including late stent thrombosis, delayed endothelialization, hypersensitivity, and restenosis, show that coatings actively shape biological responses rather than acting as inert drug carriers. Their surface chemistry, drug release kinetics, and degradation behavior are upstream determinants of blood– and tissue–material responses that govern healing and failure. This review frames coating selection as a structure–property–biological response problem. It surveys the major classes of synthetic polymer coatings and the defining surface and bulk properties. This review also examines how composition and architecture control drug release, and traces the interfacial cascade of protein adsorption, coagulation and complement activation, platelet and leukocyte responses, and neutrophil extracellular trap (NET) formation. These mechanisms are linked to contemporary design strategies that improve hemocompatibility, limit thrombosis, promote endothelial recovery, and tune degradation, and to the standardization and translation gaps that remain. The central message is that polymer coatings are not biologically equivalent. Their surface chemistries and degradation profiles determine the thrombo-inflammatory outcomes. Therefore, coating design should be guided by intended biological response, not drug release alone. Full article

Background/objectives: Catheter-related bloodstream infection (CRBSI) is a frequent and morbid complication in catheter-dependent maintenance hemodialysis, and rapid risk stratification is needed while awaiting cultures. This study aimed to evaluate admission complete blood count-derived indices—neutrophil-to-lymphocyte ratio (NLR), lymphocyte-to-monocyte ratio (LMR), platelet-to-lymphocyte ratio (PLR), systemic immune-inflammation index (SII), and pan-immune-inflammation value (PIV)—for identifying CRBSI. Methods: This single-center retrospective study (1 January 2011–31 October 2024) included adult catheter-dependent hemodialysis patients classified as CRBSI or controls. CRBSI required compatible clinical findings and concordant growth of the same microorganism(s) in paired simultaneous catheter and peripheral blood cultures. Controls were hospitalized for non-infectious reasons without infection during the index admission. Indices were calculated from admission blood counts. Discrimination was assessed using ROC analysis, and adjusted associations were evaluated using multivariable logistic regression. Results: Among 286 patients (147 CRBSI, 139 controls), CRBSI cases had higher NLR, SII, and PIV and lower LMR; PLR did not differ. NLR showed the numerically highest discriminatory performance among the evaluated indices (AUC 0.737; cut-off 5.96; sensitivity 68.7%, specificity 68.3%; p < 0.001). SII (cut-off 1189.21; AUC 0.693) and PIV (cut-off 821.62; AUC 0.686) had moderate discrimination, and LMR was modest (cut-off 1.65; AUC 0.642); PLR was not discriminatory (AUC 0.559; p = 0.086). In models adjusted for age, sex, hypertension, and cardiovascular disease, NLR remained associated with CRBSI (OR 1.159; p < 0.001), together with hypertension (OR 2.441; p = 0.017) and cardiovascular disease (OR 2.626; p < 0.001). Conclusions: Admission hematologic inflammation indices, particularly NLR, showed moderate ability to discriminate CRBSI from non-infectious admissions in catheter-dependent hemodialysis patients and may provide rapid adjunctive information while awaiting microbiological confirmation. Full article

Pediatric candidemia is a major cause of invasive fungal infections in hospitalized children, but long-term data on epidemiology, management, and mortality predictors remain limited. We conducted an 18-year retrospective cohort study of 465 pediatric candidemia episodes at a tertiary referral center in western Turkey between 2008 and 2025. The primary outcome was crude 30-day mortality; associated factors were assessed using univariable analyses, Kaplan–Meier estimates, and multivariable logistic regression. Non-albicans Candida species predominated, with Candida parapsilosis as the most frequent isolate (46%). Central venous catheters were present in 88.4% of episodes. Crude 30-day mortality was 10.8%. Reduced survival was observed among patients without catheter removal and among those with thrombocytopenia, severe neutropenia, or immunosuppressive therapy. Among 341 episodes classified as central line-associated bloodstream infections, crude 30-day mortality differed significantly by catheter removal timing. Mortality was 4.8% with catheter removal within 72 h versus 13.1% without early removal (p = 0.022). Using a 48 h threshold, mortality was 3.1% with removal within 48 h versus 12.3% without removal within 48 h (p = 0.029). In multivariable analysis, failure to remove the catheter was the strongest independent factor associated with mortality (adjusted odds ratio, 6.63; 95% confidence interval, 2.85–15.42; p < 0.001). Antifungal resistance patterns were not consistently associated with mortality. In this large pediatric candidemia cohort, 30-day mortality was mainly associated with host vulnerability and modifiable management factors, underscoring the importance of timely source control. Full article

Background: Chest radiography remains central to post-procedural assessment of central venous catheter (CVC) placement in intensive care units. Multimodal large language models (MLLMs) can process medical images, but their reliability for practical radiography tasks remains uncertain. This study assessed the diagnostic performance of MLLMs and intensivists for CVC access classification, CVC tip assessment, and pneumothorax-related radiographic findings. Methods: In this retrospective diagnostic performance study, consecutive portable anteroposterior chest radiographs obtained after CVC placement in adult critically ill patients were independently evaluated by four intensivists and five MLLMs. A radiologist consensus served as the reference standard. Interobserver agreement and diagnostic performance were assessed using Fleiss’ kappa, Gwet AC1, Cohen’s kappa, accuracy, sensitivity, specificity, precision, F1 score, balanced accuracy, and Matthews correlation coefficient. Results: The final cohort included 183 unique radiographs. Intensivist reviewers showed high performance for CVC access classification but lower and more heterogeneous performance for CVC tip-position assessment. Among MLLMs, CVC access accuracy ranged from 0.339 to 0.874, whereas CVC tip assessment was dominated by almost universal classification of tips as appropriate, with near-zero specificity and chance-level balanced accuracy. For pneumothorax-related findings, all MLLMs classified every case as negative. Intensivist reviewers had higher balanced accuracy than MLLMs for CVC access classification (difference, 0.420; 95% CI, 0.349–0.490; p < 0.001) and CVC tip assessment (difference, 0.247; 95% CI, 0.205–0.290; p < 0.001). Pneumothorax analyses were exploratory because only five positive cases were present. Conclusions: The evaluated MLLMs showed unreliable diagnostic performance compared with experienced intensivists. Apparent performance was influenced by class imbalance and dominant-response behavior, supporting cautious task-specific validation and complete diagnostic performance reporting. Full article

Background/Objectives: The Leiden University Medical Center (LUMC) and the Medical University of Vienna (MUV) both implemented video recording and review in their neonatal intensive care unit (NICU). The two centers initiated collaborative, multicenter video review sessions to facilitate international knowledge exchange. Methods: In this exploratory, descriptive study, collaborative video review sessions were organized with the interprofessional NICU staff of the LUMC and the MUV. We aimed to describe our experience with organizing these sessions and to report procedural variations, and document lessons learned that led to new perspectives on care. Results: We conducted five sessions using recordings of different patients undergoing intubation, less invasive surfactant administration, umbilical, central-catheter insertion and physiologically based cord clamping after birth. The videos were selected to ensure technical and clinical comparability. Sessions were attended by a mean of eight providers per center. A total of 19 relevant differences were described, of which seven (37%) prompted changes in practice or new insights for one or both centers. Finally, we developed a roadmap for organizing multicenter video review sessions. Conclusions: This study shows that multicenter video review may represent a feasible and innovative educational approach for identifying practice variations and fostering cross-institutional clinical refinement. Full article

Background and Objectives: Central venous catheters (CVCs) are widely used in intensive care units (ICUs) but are associated with catheter-related bloodstream infections (CRBSIs), which increase morbidity, mortality, and healthcare costs. Antimicrobial-impregnated catheters, including chlorhexidine–silver sulfadiazine (CSS)-coated CVCs, have been proposed to reduce this risk. This study evaluated the effectiveness of CSS-coated CVCs in preventing CRBSIs in ICU patients. Materials and Methods: A retrospective multicenter study was conducted in two ICUs in Naples, Italy. Patients admitted between October and December 2020 who received standard uncoated CVCs (Group A) were compared with patients admitted between October and December 2021 who received CSS-coated CVCs (Group B). Inclusion criteria were age 18–89 years, ICU admission with CVC placement, and negative blood cultures at admission. The primary outcome was the incidence of CRBSI, defined according to microbiological criteria consistent with current guidelines. The secondary outcome was the number of catheter removals due to confirmed CRBSI. Results: A total of 320 patients were included (170 in Group A and 150 in Group B). Baseline demographic characteristics and ICU admission diagnoses were comparable between groups. Microbiologically confirmed CRBSI incidence was significantly lower in Group B than in Group A (6.4% vs. 31.7%, p < 0.0001), corresponding to infection rates of 1.48 vs. 6.95 per 1000 catheter-days, respectively (p < 0.0001). Patients in Group B also required fewer catheter removals due to CRBSI (mean 1.6 vs. 3.2 per patient, p < 0.0001). Logistic regression confirmed a significantly lower risk of CRBSI with CSS-coated CVCs (OR 0.15; 95% CI 0.06–0.32). Conclusions: CSS-coated CVCs were associated with a significant reduction in CRBSI incidence and catheter replacement rates in ICU patients. However, given the retrospective design, univariable analysis, and highly unequal pandemic-related systemic stressors between the two periods, these findings demonstrate a clinical association rather than direct causation, and should be interpreted with caution due to potential residual confounding. Full article

Background: Arteriovenous fistula (AVF) maturation is a critical determinant for successful hemodialysis in patients with end-stage renal disease (ESRD). Endothelial dysfunction and arterial stiffness, which are highly prevalent in advanced chronic kidney disease (CKD), frequently impair AVF maturation. Emerging evidence suggests that a very-low-protein diet (VLPD) supplemented with ketoacid analogues (KA) mitigates nitrogenous waste accumulation and positively influences vascular health by reducing inflammation and improving endothelial function. This prospective observational study evaluates the effect of VLPD+KA on AVF maturation, endothelial function, inflammatory markers, nutritional status, and the timing of dialysis initiation. We enrolled 20 patients with advanced CKD (stage V) scheduled for AVF creation. Participants adhered to a strict VLPD protocol (0.3–0.4 g/kg/day) with KA supplementation (1 tablet/5 kg/day). We assessed biochemical parameters, inflammatory markers (CRP, ESR), uremic toxins (indoxyl sulfate [IS], p-cresyl sulfate [PCS]), endothelial function via flow-mediated dilation (FMD), and vascular imaging metrics. AVF maturation, central venous catheter (CVC) requirement, dialysis initiation, and nutritional parameters were monitored over a three-month follow-up period. Statistical analyses included paired t-tests or Wilcoxon signed-rank tests for within-group comparisons, Fisher’s exact test for categorical variables, and Kaplan–Meier analysis for time-to-event endpoints, performed using SPSS version 27.0. Results: The intervention led to significant improvements in endothelial function (FMD +1.7%, p < 0.01), substantial reductions in the uremic toxins IS (−38%, p < 0.001) and PCS (−43%, p < 0.001), and a marked decrease in CRP levels (from 3.2 to 1.1 mg/L, p < 0.01). Nutritional status, assessed by BMI, BIA-derived phase angle, and handgrip strength, remained stable throughout the intervention period, confirming the metabolic safety of the VLPD+KA regimen. Notably, AVF maturation was achieved in 95% of patients, with zero CVC dependency among those who initiated dialysis. Conclusions: These findings strongly support the hypothesis that VLPD+KA therapy enhances vascular integrity, reduces uremic endotheliotoxicity, and facilitates successful AVF maturation. This nutritional intervention warrants further investigation in larger, randomized controlled trials as a standard pre-dialysis care strategy. Full article

Cancer-associated thrombosis (CAT) is a leading cause of morbidity and mortality in patients with malignancy, yet its imaging manifestations extend far beyond the conventional diagnosis of deep vein thrombosis and pulmonary embolism. This comprehensive review examines the full spectrum of CAT as encountered by radiologists, from routine venous thromboembolism to unusual-site thromboses, arterial thromboembolic events, catheter-related complications, and endovascular management strategies. Patients with cancer face a four- to seven-fold increased risk of venous thromboembolism compared with the general population, and arterial thromboembolism occurs at more than twice the expected rate, particularly within the first six months following cancer diagnosis. The radiologist’s role spans detection, characterization, and therapeutic guidance across multiple vascular territories. Key diagnostic challenges addressed include the distinction between bland and tumor thrombus—a determination with direct implications for TNM staging, surgical planning, and systemic therapy selection—and the recognition of incidental thromboembolism, which carries prognostic weight equivalent to symptomatic events and warrants similar clinical management. Emerging applications of diffusion-weighted MRI, contrast-enhanced ultrasound, and FDG-PET/CT provide a multiparametric toolkit for thrombus characterization, while artificial intelligence and machine learning show promise for improving patient selection and reducing unnecessary imaging. The expanding recognition of cancer-associated arterial disease, including cerebrovascular, coronary, and peripheral arterial events, requires that cardiovascular structures receive systematic attention on routine oncologic imaging. Interventional radiology contributes actively to CAT management through inferior vena cava filtration, catheter-directed thrombolysis, and thrombolytic-sparing mechanical thrombectomy, the latter being particularly relevant in oncology patients with elevated bleeding risk. Conclusions: Realizing the full potential of imaging in CAT requires not only technical proficiency with individual modalities but a synthesized, oncology-informed interpretive approach that incorporates the patient’s treatment history, biomarker status, and thrombotic risk profile at the time of image interpretation, positioning the radiologist as a central rather than peripheral figure in oncologic care. Full article

Background and Objectives: Infective endocarditis (IE) remains a major clinical challenge. It carries high morbidity and mortality, despite advances in diagnostic and therapeutic methods. This study aimed to evaluate the epidemiological profile, microbiological characteristics, complications, and predictors of adverse outcomes among patients with IE treated at a tertiary cardiovascular center in Romania over 5 years. Materials and Methods: We conducted a retrospective study including 156 patients diagnosed with IE between January 2020 and December 2024. We analyzed demographic data, comorbidities, microbiological findings, treatment strategies, complications, and in-hospital outcomes. Results: The cohort was predominantly male (76.3%), with a mean age of 58.5 years. Native valve endocarditis was the most frequent form (80.1%). Streptococci were the most commonly identified pathogens, followed by enterococci and staphylococci. Complications occurred in 74.4% of patients. Heart failure (70.5%), acute kidney injury (37.2%), and embolic events (32.7%) were most frequent. Healthcare-associated infective endocarditis (HAIE) was seen in 10.3% of patients. Additional healthcare-associated infections (HAIs) occurred in 26.9% of patients and were associated with longer hospital stays (21.7 vs. 13.5 days; p < 0.001). Use of a central venous catheter independently predicted HAI development (adjusted OR, 3.89; 95% CI, 1.08–14.06; p = 0.038). The in-hospital mortality rate was 16.7%. Acute kidney injury and sepsis were the strongest factors associated with in-hospital mortality. Conclusions: IE remains associated with a high burden of complications and in-hospital mortality. HAIs complicate the clinical course and are closely linked to invasive device use. Mortality is mainly driven by systemic disease severity, especially acute kidney injury and sepsis. These findings highlight the importance of infection prevention, prompt risk stratification, and coordinated multidisciplinary care to improve outcomes in patients with IE. Full article

Cancer-associated thrombosis (CAT) is a major cause of morbidity and mortality in patients with cancer. The management of special situations—including recurrent venous thromboembolism (VTE), thrombosis at unusual sites, and central venous catheter-associated thrombosis (CVC-AT)—remains particularly challenging because of the limited availability of high-quality evidence. This narrative review synthesizes recommendations from major international and Spanish clinical practice guidelines and expert consensus documents, including those from SEOM, ESMO, ASCO, NCCN, ITAC and SEMI, to provide a structured framework for the management of these complex scenarios. Our analysis identified substantial heterogeneity across guidelines, particularly regarding anticoagulant selection, dosing strategies, and treatment duration. Although some convergence exists in the management of CVC-AT, important discrepancies and evidence gaps persist in areas such as splanchnic vein thrombosis, hepatic impairment, central nervous system involvement, and recurrent VTE despite treatment. In many cases, recommendations are based primarily on expert opinion rather than robust trial data, and several clinical scenarios are addressed by only a limited number of guidelines. These findings underscore the need for more standardized management strategies and prospective clinical studies to better inform decision-making in daily practice. Overall, this review highlights the growing importance of individualized anticoagulant management aimed at balancing thrombotic and bleeding risks in high-risk oncology patients, thereby helping to bridge the gap between expert consensus and evidence-based precision anticoagulation. Full article

Background: Accurate identification and positioning of thoracic devices on chest radiographs is critical for patient safety in intensive care. Multimodal large language models (LLMs) offer potentially generalizable automated evaluation, but their performance in this domain is underexplored. Methods: Three multimodal LLMs (GPT-4o, gpt-4o-2024-08-06; Gemini 3.1 Flash Lite Preview; Claude Sonnet 4.6) were evaluated on 4813 chest radiographs from the RANZCR CLiP dataset for device presence and positioning of ETT, NGT, CVC, and Swan–Ganz catheters. Performance was quantified with 95% Wilson confidence intervals, balanced accuracy, MCC, Cochran’s Q, Bonferroni-corrected McNemar, and Cohen’s/Fleiss’ kappa. Six additional analyses were performed: a blinded paired reader study (n = 377; two board-certified radiologists, blinded to ground truth and to all LLM outputs), external validation on PadChest (n = 200, device-presence detection only—PadChest lacks granular position labels), three-variant prompt-sensitivity analysis (n = 103), repeat-inference stability across three runs (n = 50), systematic error taxonomy, and a failure-case analysis. Results: Device-presence performance varied widely across models; abnormal-position sensitivity was uniformly poor (MCC ≤ 0.028; balanced accuracy 0.41–0.53). Inter-model agreement was poor to slight (Fleiss’ κ: 0.005–0.383 for presence; −0.280 to −0.025 for classification). Radiologists numerically outperformed all three LLMs in 42/42 paired comparisons; the superiority was statistically significant after Bonferroni correction in 33/42 (32/42 at p < 0.001). PadChest replicated the negative finding for device-presence detection (malposition not externally validated). Prompts and inference stochasticity introduced 2–3× sensitivity swings and run-to-run κ from 0.20 to 0.85. Case failures concentrated systematically in multi-device cases (p < 0.0001) but not in abnormal-position cases (p = 0.14). Conclusions: Current general-purpose multimodal LLMs are not yet reliable for autonomous thoracic-device assessment; their failure patterns are structurally characterizable across models, prompts, and case types and support, at most a circumscribed role, as adjunct device-presence screening tools. The findings do not generalize to purpose-built, regulator-approved clinical AI systems. Full article

Background: Although guidelines emphasize proper insertion techniques and tip positioning, catheter-related thrombosis (CRT) remains a common and clinically significant complication of peripherally inserted central catheters (PICCs) and midline catheters (MCs). In this context, the use of pharmacological prophylaxis is still debated. This study aims to assess the incidence of CRT in patients receiving anticoagulant therapy (therapeutic or prophylactic) and antiplatelet therapy. Methods: This retrospective study was conducted at a tertiary care hospital and included adult patients from March 2021 to May 2023. Six potential confounders were analyzed: anticoagulation status (none, prophylaxis, therapeutic), antiplatelet therapy, tip position (PICCs vs. MCs), number of lumens, CRT risk factors, and drug infusion requiring central access. CRT was diagnosed in symptomatic patients using compression ultrasonography. Propensity score weighting and logistic regression were employed to estimate odds ratios (OR) and average treatment effects. Results: A total of 1431 patients were enrolled. PICCs and therapeutic anticoagulant therapy were highly protective against CRT (OR 0.068 [95% CI 0.013–0.2] and OR 0.007 [95% CI 0.001–0.046], respectively). Prophylactic anticoagulant therapy (OR 0.328 [95% CI 0.200–0.519]) and antiplatelet therapy (OR 0.342 [95% CI 0.182–0.595]) also showed protective effects. At the same time, neither the number of lumens, the presence of risk factors, nor the infusion of irritating drugs was independently associated with CRT. Conclusions: The use of anticoagulant drugs (both prophylactic and therapeutic), antiplatelet therapy, and PICC use significantly lowered the risk of CRT. The findings support personalized prevention strategies and underscore the need for a well-designed randomized controlled trial to validate these findings. Full article

Background: Cardiac tamponade (CT) is a rare but life-threatening medical emergency caused by fluid accumulation in the pericardial sac, impairing cardiac filling and reducing output. More than 20% of CT cases are iatrogenic. CT is a recognized complication of central venous catheter (CVC) placement, with mortality rates in pediatric patients reported to reach 50%. Clinical presentation is often nonspecific, and echocardiography remains the diagnostic gold standard. Case report: We present two pediatric cases of CT due to late CVC migration, managed in the pediatric intensive care unit (PICU). The first case involved a 25-day-old neonate with short bowel syndrome who received prolonged parenteral nutrition via CVC. Four days after catheter insertion, the patient developed sudden cardiocirculatory collapse. The second case featured a 2-year-old child with Leigh syndrome who required mechanical ventilation and multimodal pharmacological therapy. Six days after CVC placement, the patient developed acute hemodynamic deterioration. In both cases, echocardiography confirmed CT, while chest radiography suggested intracardiac positioning of the catheter tip. Management and outcome: Emergency pericardiocentesis and advanced cardiopulmonary resuscitation were performed. Despite transient hemodynamic stabilization, both patients developed multiorgan failure with fatal outcomes. Conclusions: CT is a critical complication in pediatric patients with CVCs. Accurate verification of catheter tip position is essential, and intracardiac placement should be avoided. Any sudden clinical deterioration in a patient with a CVC should raise suspicion of late catheter migration and requires immediate life-saving intervention. Full article

Background/Objectives: Central line-associated bloodstream infection (CLABSI) remains a major healthcare-associated infection in intensive care units (ICUs). This study evaluated changes in CLABSI incidence following the implementation of a multimodal infection control intervention in the ICU. Methods: We conducted a quasi-experimental study in the adult ICUs of a referral hospital from January 2023 to December 2025. The interventions included staff education, performance feedback, infection control-led rounds, optimization of catheter practices, and reinforcement of environmental hygiene. The primary outcome was CLABSI incidence per 1000 central line-days. An interrupted time-series analysis using segmented Poisson regression with robust standard errors was used to assess temporal trends. Results: A total of 17 CLABSI cases occurred during the pre-intervention period, and 25 during the post-intervention period. There was no significant difference in CLABSI incidence between the two periods (incidence rate ratio, 1.07; 95% confidence interval, 0.58–1.98). However, interrupted time-series analysis demonstrated a significant decreasing trend in CLABSI incidence following the intervention (rate ratio, 0.89 per month; 95% confidence interval, 0.81–0.97; p = 0.01). This trend was observed despite the higher patient severity and increased use of advanced supportive therapies in the post-intervention period. The device utilization ratio and monthly blood culture rate remained unchanged. Avoidance of femoral venous access increased, and adherence to catheter-handling protocols significantly improved. Conclusions: A staged, multimodal intervention was associated with a significant decreasing trend in CLABSI incidence over time, suggesting a potential benefit of comprehensive infection prevention strategies in ICU settings. Full article

Background: Chronic hemodialysis (HD) patients face symptoms that significantly impact their quality of life and health outcomes. Longitudinal research on the dynamics of symptom severity and the integration of individual patient characteristics into cluster analyses is limited, hindering understanding of cluster evolution over time. Objective: The objective of this study was to characterize and compare symptom clusters across body systems based on frequency and severity at three time points in chronic HD patients. Methods: This prospective longitudinal study collected self-reported data on 23 symptoms using validated measures from 69 chronic HD patients (age range: 24–87 years) at three time points over a year. Symptoms were rated on a 0–10 scale. Symptom progression and clustering were analyzed using heat maps and principal component analysis. Results: Among 69 HD patients, a substantial symptom burden was identified at baseline, with fatigue, overall perceived health, worry or distress, and sleep disturbance reported as the most severe (mean scores > 4.0 on a 0–10 scale). Hierarchical clustering yielded a five-cluster solution; however, longitudinal analysis revealed poor structural stability in patient symptom profiles over 12 months (ARI < 0.70), indicating significant symptomatic reorganization. Gastrointestinal cluster showed a statistically significant reduction in severity over time (β = −0.914, p = 0.003); fatigue and overall perceived health remained a high burden. Subgroup analyses demonstrated that patients using central venous catheters reported significantly higher severity in pain, fatigue, and nausea compared to patients with arteriovenous fistulas, while Diabetes mellitus was uniquely associated with increased dyspnea (p < 0.001). Conclusions: Chronic HD patients experience a dynamic and multidimensional symptom burden, with significant variations in severity, progression, and clustering of symptoms over time. The observed temporal instability of symptom clusters and the heterogeneity of individual trajectories emphasize the importance of routine, longitudinal symptom assessment and flexible, patient-centered management strategies by nephrology nurse specialists, which may support value-based healthcare approaches. Full article