The Change of Symptom Clusters in Gastrointestinal Cancer Patients During the Perioperative Period: A Longitudinal Study

The Change of Symptom Clusters in Gastrointestinal Cancer Patients During the Perioperative Period: A Longitudinal Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Change of Symptom Clusters in Gastrointestinal Cancer Patients During the Perioperative Period: A Longitudinal Study Jianjian Wei, Hongxia Yan, Wen Yin, Fang He This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3897026/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Aim and objectives: The aim of this study was to describe the numbers, types, and trajectory of symptom clusters during the perioperative period in gastrointestinal cancer patients at four different time points. The study also aimed to identify the changes and consistency of these symptom clusters over time. Design: This was a longitudinal study. Methods This study conducted at a tertiary cancer hospital involving 205 gastrointestinal cancer patients. The M.D. Anderson Symptom Inventory Gastrointestinal Cancer Module was used to assess the incidence and severity of symptom clusters. Exploratory factor analysis was employed to extract the symptom clusters. Results The study identified four symptom clusters in gastrointestinal cancer patients during the perioperative period: gastrointestinal symptom cluster, physical symptom cluster, psychological symptom cluster, and sleep disturbance symptom cluster. These clusters were observed across two to four time points. Conclusion The findings of this study provide scientific evidence for medical staff and researchers to gain a better understanding of the symptom experiences of gastrointestinal cancer patients during the perioperative period. This knowledge can be valuable in developing individualized symptom management interventions. Relevance to clinical practice : Gastrointestinal cancer patients suffered from various symptom clusters and lasted from day before surgery to one month after surgery, which should be paid attention by clinical staff. gastrointestinal cancer symptoms symptom cluster 1. Background According to global cancer statistics in 2020, there were 1 million new cases and 0.7 million deaths from gastrointestinal cancer worldwide, posing a significant threat to human health. Surgery is the preferred treatment for gastrointestinal cancer[ 1 ]. During the perioperative period, gastrointestinal cancer patients often experience multiple coexisting symptoms, such as fatigue, nausea, and vomiting[ 2 ]. These coexisting symptoms were first referred to as symptom clusters by Dodd [ 3 ] in 2001, defined as three or more related symptoms occurring simultaneously, although the symptoms within the cluster may not share a common etiology mechanism. Symptoms within a cluster can have synergistic and reinforcing effects [ 4 ], where the worsening of one symptom leads to an increase in the severity of other symptoms. If left uncontrolled, these symptom clusters can significantly impact patients' quality of life, functional status, and treatment outcomes, including mortality rates[ 5 ]. However, this clustering also presents an opportunity for targeted interventions to have a synergistic effect on managing symptoms. Managing symptoms based on symptom clusters can improve management efficiency, reduce hospital stays, and alleviate the burden on healthcare providers [ 6 ]. To effectively manage symptoms, it is essential to understand the types, severity, and changes of symptoms at different time points before and after surgery, as well as how these symptoms affect patients.In our clinical practice and routine follow-up, we have found that patients usually had various symptoms during their hospitalization and long time after discharge. Some patients experiencing were deeply disturbed by the symptoms suffered from low quality of life. There are some original studies and reviews exploring the symptom clusters in gastrointestinal cancer patients, however, most of them concentrated on patients during chemotherapy. Some studies explored the symptoms in gastrointestinal cancer after surgery only at one time point or the concept of symptom cluster was not proposed[ 7 – 10 ]. Under the circumstances, less attention has been paid to the trajectory of symptoms in gastrointestinal cancer patients during their perioperative period, which was equally important for their recovery, quality of life and follow-up treatment. Thus, it is important to figure out the symptoms patients for clinical staff to provide guidance to these patients. 2. Aims To describe the trajectory, numbers, and types of symptom clusters at various time points surrounding surgery in order to provide scientific evidence for the development of individualized symptom management strategies by medical staff and researchers. 3. Methods 3.1 Study design This study was conducted in a descriptive and longitudinal design. 3.2 Participants and settings Participants who were first diagnosed gastrointestinal cancer and to receive surgery in a cancer hospital in Beijing, China were recruited. The inclusion criteria were as follows: a) age ≥ 18 years, b) initial diagnosis of gastrointestinal cancer, c) requirement for radical surgery, and d) capacity for communication and provision of informed consent. The exclusion criteria were: a) performance of palliative surgery, b) discharge without undergoing the operation for any reason, c) self-reported history of comorbidities associated with other malignant tumors, consciousness disorders, or mental illness, d) combined organ resection, e) occurrence of severe postoperative complications that hindered cooperation with researchers. Participants who refused to continue, were dead or lost connection were eliminated in this study. 3.3 Data collection The data was collected from November 2022 to October 2023. Eligible participants were approached at their admission in the hospital and provided written informed consent. Participants filled in the questionnaires through QR code. Data collection was conducted in four time points: 1 (the day before surgery), T2 (1–3 days after surgery), T3 (from 7 days postoperatively until discharge), and T4 (1 month postoperatively). 3.4 Instruments 3.4.1 General Questionnaire This questionnaire was developed by the research team, primarily including the characteristics of the participants, including age, gender, marriage, economic status, occupation, stage of cancer, morbidities and type of operation. 3.4.2 M.D. Anderson Symptom Inventory Gastrointestinal Cancer Module (MDASI-GI) The M.D. Anderson Symptom Inventory (MDASI) is a reliable and validated tool for assessing symptoms related to cancer, regardless of the specific cancer diagnosis [ 11 ]. The MDASI includes 13 items that evaluate the severity of symptoms at their worst in the past 24 hours, as well as 6 items that assess the interference caused by these symptoms during the same time period. Each item is rated on a numeric scale ranging from 0 to 10. The MDASI also includes a gastrointestinal (GI) module specifically designed to measure symptom prevalence and burden in GI cancer patients. The Chinese version of the MDASI-GI has been translated and validated for use in GI patients, demonstrating good internal consistency with Cronbach's α of 0.852 [ 12 , 13 ]. 3.5 Data analysis The statistical analysis was performed using IBM SPSS Statistics 26.0. Descriptive statistics such as frequency, percentage, and rate were calculated for categorical data, while mean ± standard deviation was used for continuous data. To identify symptom clusters, exploratory factor analysis(EFA)was conductedbased on the occurrence rate and severity of symptoms using MPlus V.8.6.. A factor loading of ≥ 40% was used as the criterion for including symptoms in the clusters, with each cluster consisting of at least two symptoms[ 14 ].For the occurrence rate, tetrachoric correlations were used to create the matrix of associations, and for the severity ratings polychoric correlations were used to create the matrix of associations.EFA for severity was conducted using severity ratings that included a zero (i.e,0,1,2,3,4,5,6,7,8,9,10). If the patient reported that they did not have the symptom, a severity score of zero were assigned. Symptoms with an incidence of less than 10% were excluded from the exploratory factor analysis to enhance the clinical relevance of the identified symptom clusters[ 15 ]. Factor solutions were expected for two through six factors. The factor solutions with the greatest interpretability and clinical meaningfulness were selected as it met the criteria set for evaluating simple structure. Symptom clusters were named based on the highest factor loadings and the majority of the symptoms in the cluster[ 16 ]. The Stability and Consistency of Symptom Clusters In our study, we use the term stability and consistency to describe the characteristics of symptom clusters. The stability was used to describe whether the same clusters are identified over time points, across symptom dimension or study samples. The consistency was used to describe whether the specific symptoms remain the same over time points, across symptom dimensions or study samples (percent agreement among the symptom dimensions within the clusters). 4. Results 4.1 Characteristics of participants A total of 205 participants were recruited for the study, with a mean age of 57.73 ± 10.48 years. Among the participants, 141 (68.78%) were male and 64 (31.20%) were female, shown in Table 1 . Table 1 Demographic and Clinical Characteristics of Participants (N = 205) Item Number Frequency (%) Gender male 141 68.78 female 64 31.22 Marital status Married 176 85.85 Not married 19 9.27 Divorced or widowed 10 4.88 Education Illiteracy 20 9.76 Elementary school 55 26.83 Middle or high school 105 51.22 University or above 25 12.19 Payment method Medical insurance 114 55.61 NCMS 82 40.00 Business insurance 5 2.44 Other 4 1.95 New adjuvant chemotherapy Yes 37 18.05 Not 168 81.95 Operation methods Laparoscopic- assisted 161 78.54 Laparotomy 32 15.60 Total laparoscopic 6 2.93 LOC 6 2.93 Resection site and extent Distal gastrectomy 144 70.24 Proximal gastrectomy 21 10.24 Total gastrectomy 40 19.52 Digestive tract reconstruction Billroth I 7 3.41 Billroth II 158 77.07 Roux-en-Y 6 2.93 Others 34 16.59 Blood transfusion during operation Yes 19 9.27 No 186 90.73 Transmission to ICU atT1 Yes 32 15.61 No 173 84.39 Enteral nutrition Yes 168 81.95 No 37 18.05 Type of enteral nutrition OP 99 58.93 Glutamine combined with OP 21 12.50 TPF-T 5 2.97 TPF-D 21 12.50 TP 22 13.09 NRS < 3 138 67.32 ≧ 3 67 32.68 BMI(kg/m 2 ) < 18.5 14 6.83 18.5–23.9 86 41.94 ≧ 24 104 50.73 TNM Tis 18 8.78 I 74 36.10 II 37 18.05 III 73 35.61 IV 3 1.46 Abbreviation: NCMS, new rural cooperative medical system;OP, Oral hydrolyzed protein༛LOC, Laparoscopic conversion to open surgery 4.2 Symptom prevalence and severity across four time points Regarding the prevalence and severity of symptoms across the four time points, a total of 18 symptoms were explored in postoperative gastrointestinal cancer patients. At T1, symptoms such as shortness of breath, problems with remembering things, drowsiness, numbness or tingling, changes in taste, and difficulty in swallowing were not reported. The incidence of pain, fatigue, distress, dry mouth, vomiting, constipation, and diarrhea was present but was less than 20%. The three symptoms with the highest incidence were disturbed sleep (50.73%), feeling sad (40.49%), and experiencing nausea (18.05%). At T2, several symptoms were reported by more than 80% of the participants, including pain (96.10%), fatigue (92.20%), disturbed sleep (85.37%), lack of appetite (81.95%), feeling sad (80.49%), constipation (80.98%), and bloating (85.37%). At T3, the symptoms with high incidence included pain (67.80%), fatigue (58.54%), distress (70.73%), drowsiness (66.83%), and bloating (70.24%). At T4, the two symptoms with the highest incidence were distressed (70.73%) and fatigue (58.05%). All other symptoms occurred in less than half of the participants, as shown in Table 2 . Table 2 Occurrence and severity of symptoms in gastric cancer patients over different time points (N = 205) Symptoms Occurrence rates n(%) Severity rating with zeros Mean (SD) Severity rating without zeros Mean (SD) T1 T2 T3 T4 T1 T2 T3 T4 T1 T2 T3 T4 Pain 29(14.25) 197(96.10) 139(67.80) 27(13.17) 0.23(0.61) 4.38(1.37) 2.83(2.14) 0.30(0.79) 1.66(0.48) 4.56(1.06) 4.12(1.15) 2.21(0.57) Fatigue 24(11.71) 189(92.20) 120(58.54) 119(58.05) 0.34(1.02) 5.14(1.70) 2.54(2.16) 2.49(2.19) 2.92(1.18) 5.57(0.83) 4.29(0.57) 4.29(0.70) Nausea 37(18.05) 125(60.98) 91(44.39) 33(16.10) 0.48(1.07) 2.55(0.98) 1.76(2.01) 0.48(1.17) 2.68(0.63) 2.55(0.98) 3.92(0.71) 3.00(0.94) Disturbed sleep 104(50.73) 175(85.37) 90(43.90) 40(19.51) 0.14(0.52) 2.71(1.30) 2.03(2.35) 0.69(1.42) 1.87(0.64) 3.18(0.70) 4.65(0.65) 3.53(0.55) Distressed 22(10.73) 131(63.90) 145(70.73) 133(64.88) 2.13(2.20) 2.09(0.64) 2.27(1.79) 2.57(2.08) 4.20(0.91) 2.09(0.64) 3.49(0.79) 3.85(1.23) Shortness of breath 0(0.00) 17(8.29) 4(1.95) 4(1.95) 0.00(0.00) 0.17(0.62) 0.13(0.93) 0.04(0.33) - 2.33(0.49) 6.75(0.96) 2.25(0.96) Problems with remembering things 0(0.00) 11(5.37) 6(2.93) 3(1.46) 0.03(0.22) 0.14(0.61) 0.08(0.50) 0.03(0.29) - 2.64(0.51) 2.83(0.98) 2.33(0.58) Lack of appetite 50(24.39) 168(81.95) 101(49.27) 82(40.00) 0.61(1.11) 4.30(0.68) 2.04(2.11) 1.63(2.09) 2.52(0.51) 4.30(0.68) 4.10(0.68) 4.07(0.91) Drowsy 0(0.00) 157(76.59) 137(66.83) 28(13.66) 0.00(0.00) 1.80(1.69) 1.20(0.97) 0.31(0.79) - 2.75(1.33) 1.79(0.58) 2.25(0.44) Dry mouth 2(0.98) 134(65.37) 97(47.32) 38(18.50) 0.02(0.20) 3.06(1.83) 1.98(2.15) 0.48(1.05) 2.00(0.00) 4.00(0.79) 4.18(0.72) 2.58(0.68) Sad 83(40.49) 165(80.49) 111(54.15) 97(47.30) 1.93(2.42) 1.54(0.84) 1.69(1.68) 1.19(1.43) 4.76(0.98) 1.92(0.40) 3.13(0.82) 2.52(1.00) Vomiting 30(14.63) 67(32.68) 39(19.02) 19(9.27) 0.32(0.78) 0.87(1.35) 0.43(0.97) 0.25(0.86) 2.17(0.38) 2.66(0.90) 2.20(0.95) 2.68(1.25) Numbness or tingling 0(0.00) 17(8.29) 5(2.44) 4(2) 0.00(0.00) 0.11(0.38) 0.03(0.23) 0.05(0.40) - 1.29(0.47) 1.40(0.55) 2.75(0.96) Constipation 17(8.29) 166(80.98) 123(60.00) 78(38) 0.24(0.83) 3.57(1.89) 3.06(2.55) 1.33(1.84) 2.94(0.56) 4.40(0.83) 5.08(0.67) 3.49(1.15) Change in taste 0(0.00) 12(5.85) 23(11.22) 12(5.8) 0.00(0.00) 0.20(0.82) 0.33(0.83) 0.16(0.65) - 3.42(0.67) 2.12(0.78) 2.67(0.65) Bloated 61(29.76) 175(85.37) 144(70.24) 56(27.3) 0.93(1.51) 3.31(1.76) 0.06(0.33) 1.01(1.74) 3.11(0.88) 3.42(0.67) 4.09(1.39) 3.70(1.06) Diarrhea 23(11.22) 8(3.90) 27(13.17) 24(11.70) 0.18(0.52) 0.11(0.56) 2.85(2.21) 0.29(0.49) 1.57(0.51) 2.87(0.35) 4.39(0.99) 2.61(0.50) Difficulty in swallowing 0(0.00) 6(2.93) 6(2.93) 4(2.00) 0.00(0.00) 0.09(0.51) 0.58(1.54) 0.07(0.49) - 3.00(0.00) 2.00(0.00) 3.50(0.58) 4.3 Symptom clusters over time Based on the occurrence and symptom ratings, factor analysis was conducted at each time point to extract symptom clusters (Table 3 ). At T1, a three-factor solution was obtained. The factors were identified as thegastrointestinal symptom cluster, psychological symptom cluster, and physical symptom cluster. At T2, a four-factor solution was obtained. The factors were identified as the gastrointestinal symptom cluster, physical symptom cluster, sleep disturbance symptom cluster, psychological symptom cluster.At T3, a four-factor solution was obtained. The factors were identified as the physical symptom cluster gastrointestinal symptom cluster, psychological symptom cluster, and sleep disturbance symptom cluster.At T4, a four-factor solution was obtained. The factors were identified as thepsychological symptom cluster, sleep disturbance symptom cluster, physical symptom cluster and gastrointestinal symptom cluster Table 3 Numbers and types of symptoms within each symptom cluster across four time points based on occurrence and severity (N = 205) Symptom clusters Symptoms within the cluster Occurrence Severity T1 T2 T3 T4 T1 T2 T3 T4 Gastrointestinal Nausea 0.835 - 0.730 0.785 0.857 0.792 0.775 0.808 Bloated 0.856 0.725 0.408 0.701 0.838 0.487 0.552 0.747 Lack of appetite 0.618 - 0.509 0.564 0.693 0.547 0.428 0.629 Vomiting 0.768 0.737 0.440 0.790 0.635 0.457 - Diarrhea 0.768 - 0.707 0.826 0.713 - 0.673 0.863 Constipation 0.688 0.669 0.647 0.493 0.697 0.640 0.666 0.579 Dry mouth - 0.913 0.541 - - 0.826 0.532 - Change in taste - - 0.749 - - - 0.801 - Number of symptoms in the cluster 6/8 4/8 8/8 5/8 6/8 6/8 8/8 5/8 Psychological Distressed - - 0.591 0.770 0.937 0.756 0.719 0.791 Sad - 0.877 0.704 0.709 0.899 0.767 0.724 0.811 Number of symptoms in the cluster - 1/2 2/2 2/2 2/2 2/2 2/2 2/2 Physical Pain - 0.867 0.833 -0.413 0.858 0.828 0.928 -0.411 Fatigue - 0.817 0.824 0.816 0.829 0.547 0.935 0.851 Number of symptoms in the cluster - 2/2 2/2 2/2 2/2 2/2 2/2 2/2 Sleep disturbance Disturbed sleep - 0.636 0.651 0.776 - 0.739 0.620 0.810 Drowsy - 0.676 - 0.669 - 0.736 0.669 0.686 Number of symptoms in the cluster - 2/2 1/2 2/2 - 2/2 2/2 2/2 4.4 Stability and Consistency in symptom clusters The stability and consistency of each of these clusters is reported next, as shown in Table 4 and Table 5 . Table 4 Consistency of symptoms within each symptom cluster across symptom dimensions and time points(N = 205) Symptom cluster Time point Occurrence Severity Symptom agreement across dimension * Gastrointestinal T1 Nausea Nausea 3 of 3 Bloated Bloated Vomiting Vomiting T2 Bloated Nausea 1 of 3 Vomiting Constipation Dry mouth Dry mouth T3 Nausea Nausea 3 of 3 Diarrhea Diarrhea Change in taste Change in taste T4 Nausea Nausea 3 of 3 Bloated Bloated Diarrhea Diarrhea Symptom agreement over time # 0 of 3 1 of 3 Psychological T1 NI Distressed NA NI Sad - - T2 NI Distressed NA Sad Sad - - T3 Distressed Distressed 2 of 2 Sad Sad - - T4 Distressed Distressed 2 of 2 Sad Sad - - Symptom agreement over time NA 2 of 2 Physical T1 NI Pain NA NI Fatigue - - T2 Pain Pain 2 of 2 Fatigue Fatigue - - T3 Pain Pain 2 of 2 Fatigue Fatigue - - T4 Pain Pain 2 of 2 Fatigue Fatigue - - Symptom agreement over time NA 2 of 2 Sleep disturbance T1 NI NI NA NI NI - - T2 Disturbed sleep Disturbed sleep 2 of 2 Drowsy Drowsy - - T3 Disturbed sleep Disturbed sleep 1 of 2 NI Drowsy - - T4 Disturbed sleep Disturbed sleep 2 of 2 Drowsy Drowsy - - Symptom agreement over time NA NA Time points: T1 = the day before surgery, T2 = 1–3 days after surgery, T3 = from 7 days postoperatively until discharge, and T4 = 1 month postoperatively -= Only two symptoms were identified at a dimension and/or time point. *Calculated as the number of symptoms out of two or three that were identified across the four time points # Calculated as the number of symptoms out of two or three that were identified across the two symptom dimensions (occurrence, severity) NI = not identified, NA = not assessed. Table 5 Comparison of stability of symptom clusters across the total sample using ratings of occurrence and severity 4.4.1 Gastrointestinal symptom clusters This cluster comprised 4 (T2 for occurrence) to 8 symptoms (T3 for occurrence and severity), was stable across time points and dimensions. Except for T2 for occurrence, nausea had the highest factor loading across the times and dimensions. Regarding the consistency of symptoms over time, only nausea met the criteria of consistency for severity ratings. For the consistency of symptoms across dimensions, tall of the three symptoms remained consistent at T1, T3 and T4. 4.4.2 Psychological symptom cluster This cluster was composed of two symptoms (T1 for occurrence, T2 and T3 for occurrence and severity ratings) and stable across all time points for severity and T3, T4 for occurrence. At T3 and T4, the two symptoms remained consistent. 4.4.3 Physical symptom cluster This cluster was composed of two symptoms (T1 for occurrence, T2 to T4 for occurrence and severity ratings) Symptoms within the physical clusters remained stable and consistent across all time points and dimensions expect T1 for occurrence. 4.4.4 Sleep disturbance symptom cluster This cluster was composed of two symptoms (T2 to T4 across dimensions) and stable at T4 for occurrence and T2, T3, T4 for severity ratings. The two symptoms remained consistent at T2 and T4. 5. Discussion This study is the first to provide detailed characteristics of symptoms that adult gastrointestinal cancer patients suffered across the period from the day before surgery to one month after surgery, and described the stability and consistency of symptom clusters across the time and dimensions. This study identified four symptom clusters across four time points. The two most common symptom clusters were the physical, and psychological symptom clusters, which were found consistently in gastrointestinal cancer patients across time points and dimensions. Physical symptom cluster was stable and consistent over time and symptom dimensions. Similar results were found in previous studies [ 17 , 18 ]. Because pain and fatigue were two of the most common symptoms associated with physical symptoms, it’s imperative to routinely assess for these symptoms and develop interventions in clinical practice. The finding of psychological symptom clusters was consistent with previous studies in patients with breast [ 19 ], gynecological[ 20 ] and lung cancer[ 14 ].In these studies, distressed and sad were the consistent symptoms for the EFAs. This finding highlights the importance of considering these symptoms in the clinical management of gastrointestinal cancer patients. However, there were also two other symptom clusters that appeared less frequently but should still be taken into consideration. The gastrointestinal symptom cluster included five to eight symptoms: vomiting, diarrhea, constipation, nausea, change in taste, dry mouth, lack of appetite and bloating. Diarrhea was reported as one of the most common complications in postoperative gastrointestinal cancer patients and has been associated with early enteral feeding through a tube or orally, as mentioned in previous studies [ 21 ]. Constipation was also common during the perioperative period, particularly 1–3 days after surgery, with a high incidence (T2, 80.89%). This can be mainly attributed to perioperative fasting and water restrictions. Even at T3 (7 days post-operation to discharge), constipation persisted in 61% of participants. The reasons for constipation at this stage are multifaceted. Firstly, the radical excision and reconstruction of the digestive tract can disrupt its normal function. Secondly, the surgical stimulation of the gastrointestinal tract leads to a protective inhibition state, resulting in delayed and impaired recovery of gastrointestinal function. Lastly, the use of opioid painkillers after surgery can slow down bowel movements, contributing to constipation. Similar findings have been reported in previous studies [ 22 , 23 ]. Without timely and adequate management, constipation can negatively impact patients' postoperative recovery and quality of life. Therefore, healthcare providers should closely monitor and address constipation in their care. As results from previous studies on symptom clusters in gastrointestinal cancer patients, the gastrointestinal symptom cluster was one of the most common symptom clusters. However, depending on the surgery, anesthesia and post-surgery recovery, the stability and consistence of symptom were highly variable[ 24 ]. For example, vomiting was identified only in T1 and T2, dry mouth was most common in T2 which might be caused by the surgery and fasting. Nausea were consistently present across four time points This can be attributed to the side effects of anesthesia and the surgical stimulation of the gastrointestinal tract[ 25 ]. It is worth noting that females may be more vulnerable to nausea[ 26 ], which aligns with the findings of our study. The onset and increasing dose of tube or oral feeding can trigger stomach and intestinal movement, leading to nausea. At T3, 44.39% of patients reported nausea during feeding. Lack of appetite is a common symptom after major surgery[ 27 ] and has been observed in previous studies[ 28 , 29 ]. Pain and fatigue were part of the physical symptom cluster. Pain and fatigue were the most common and long-lasting symptoms, present from T1 to T4in gastrointestinal cancer patients. Around 14.2% of patients reported mild upper stomach pain after eating, with a severity rating of 1.66 ± 0.484. From the first day after surgery to discharge, pain was reported by 96.10% (T2) and 67.80% (T3) of patients, respectively, with moderate pain severity (4.56 ± 1.061 and 4.14 ± 1.152) due to the use of opioid painkillers. As the incision and stomas healed and patients gradually adapted to their reconstructed digestive tracts, pain complaints decreased to 13.17%. Postoperative pain is a complex phenomenon influenced by physiological and psychological factors and is almost present in every patient[ 30 ]. Fatigue is reported as one of the most common symptoms in various types of cancer patients, particularly in gastrointestinal cancer patients[ 31 , 32 ]. In our study, patients experienced mild to moderate fatigue before and after surgery, with incidence ranging from 11.71–92.20%. Similar results have been reported in other studies [ 17 , 33 , 34 ]. Timely, adequate, and individualized management of pain and fatigue is necessary and important. Distress and sadness were observed in the psychological symptom cluster, with distress and sadness present across allT1 to T3, ranging from 10.73–70.73% and 40.49–80.49%, respectively. Similar findings have been reported in previous studies[ 35 ]. Psychological distress has been recognized as the sixth vital sign by the International Psycho-Oncology Society[ 35 ]. Distress and sadness in perioperative gastrointestinal cancer patients are often related to fears regarding surgery, treatment, relapse, quality of life, and even death[ 35 ]. Prolonged distress and sadness can have a detrimental effect on patients' mental health and lower their quality of life[ 36 ]. However, compared to other physical symptoms, psychological symptoms are often neglected. This highlights the importance of focusing on patients' psychological well-being and providing necessary treatment. Sleep disturbances were also observed in the sleep disturbance symptom cluster, including disturbed sleep with occurrence ranging from 19.51–85.37% and feeling drowsy with highest occurrence of 76.59%. Similar findings have been reported in other studies[ 31 ]. These sleep disturbances are often attributed to pain or the effects of surgery. Lack of sleep at night can result in daytime drowsiness and decreased engagement in rehabilitative exercises, thereby slowing down the postoperative recovery process. Healthcare providers should be aware of the impact of sleep disturbances and provide individualized interventions to resolve this issue. 6. Limitations This study has several limitations that should be considered. Firstly, the study was conducted in a single hospital department, which may limit the generalizability of the findings to other medical institutions. Secondly, the assessment of symptoms relied solely on quantitative measures, and a combination of quantitative and qualitative methods may have provided a more comprehensive understanding of patients' symptom experiences during the perioperative period. Future research should consider incorporating qualitative approaches to gain a deeper insight into patients' experiences. 7. Conclusions This study identified four symptom clusters in gastrointestinal cancer patients during the perioperative period. These clusters included gastrointestinal, physical, psychological, and sleep disturbance symptom clusters. Many of the symptoms within these clusters persisted across time points and symptom dimensions, highlighting the need for comprehensive symptom management strategies. Additionally, it is important to acknowledge that there may be individual symptoms that are not included in these clusters but are still significant and can impact patients' outcomes and quality of life. Therefore, a more comprehensive assessment should be conducted to provide further information and evidence for future researchers and healthcare professionals. Declarations Declarations The study has been approved by the ethics committee of National Cancer Center/ Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College (23/228–3970) and was made in accordance with the ethical standards laid down in the Declaration of Helsinki. Conflicts of interest The authors declare no competing interests. Funding None Author Contribution First author: JIANJIAN WEI,Contribution: Conceptualization, Methodology, Data analysis , Data collection, Writing-original manuscript Second author:Hongxia Yan,Contribution: Data collection, SupervisionThird author:Wen Yin, Contribution: Data collectionCorresponding author:Fang He, Contribution: Methodology, Supervision, Manuscript Review and Editing. References Sung, H., et al., Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries . CA Cancer J Clin, 2021. 71(3): p. 209–249. Lin, Y., et al., Common and Co-Occurring Symptoms Experienced by Patients With Gastric Cancer . Oncol Nurs Forum, 2020. 47(2): p. 187–202. Dodd, M.J., C. Miaskowski, and S.M. Paul, Symptom clusters and their effect on the functional status of patients with cancer . Oncol Nurs Forum, 2001. 28(3): p. 465–70. Wang, X.S., et al., Chinese version of the M. D. Anderson Symptom Inventory: validation and application of symptom measurement in cancer patients . Cancer, 2004. 101(8): p. 1890–901. Choi, S. and E. Ryu, Effects of symptom clusters and depression on the quality of life in patients with advanced lung cancer . Eur J Cancer Care (Engl), 2018. 27(1). Kim, H.J., et al., Symptom clusters: concept analysis and clinical implications for cancer nursing . Cancer Nurs, 2005. 28(4): p. 270 – 82; quiz 283-4. Kim, G.M., et al., Prevalence and prognostic implications of psychological distress in patients with gastric cancer . BMC Cancer, 2017. 17(1): p. 283. Climent, M., et al., Weight loss and quality of life in patients surviving 2 years after gastric cancer resection . Eur J Surg Oncol, 2017. 43(7): p. 1337–1343. Oh, H.J., et al., Acid Secretion and Its Relationship to Esophageal Reflux Symptom in Patients with Subtotal Gastrectomy . Dig Dis Sci, 2018. 63(3): p. 703–712. Shim, E.J., et al., Trajectory of severity of postoperative delirium symptoms and its prospective association with cognitive function in patients with gastric cancer: results from a prospective observational study . Support Care Cancer, 2019. 27(8): p. 2999–3006. Cleeland, C.S., et al., Assessing symptom distress in cancer patients: the M.D. Anderson Symptom Inventory . Cancer, 2000. 89(7): p. 1634–46. Li, J.J., et al., Change in symptom clusters perioperatively in patients with lung cancer . Eur J Oncol Nurs, 2021. 55: p. 102046. Chen, R.W., et al., Validation and Application of the Chinese Version of the M. D. Anderson Symptom Inventory Gastrointestinal Cancer Module (MDASI-GI-C) . J Pain Symptom Manage, 2019. 57(4): p. 820–827. Russell, J., et al., Stability of Symptom Clusters in Patients With Lung Cancer Receiving Chemotherapy . J Pain Symptom Manage, 2019. 57(5): p. 909–922. Kim, H.J., et al., Treatment-related symptom clusters in breast cancer: a secondary analysis . J Pain Symptom Manage, 2008. 36(5): p. 468–79. Harris, C.S., et al., Symptom clusters in oncology outpatients: stability and consistency across a cycle of chemotherapy . BMJ Support Palliat Care, 2022. Fu, L., et al., Symptom Clusters and Quality of Life in Gastric Cancer Patients Receiving Chemotherapy . J Pain Symptom Manage, 2022. 63(2): p. 230–243. Hammer, M.J., et al., Identification of Distinct Symptom Profiles in Cancer Patients Using a Pre-Specified Symptom Cluster . J Pain Symptom Manage, 2022. 64(1): p. 17–27. Sullivan, C.W., et al., Stability of Symptom Clusters in Patients With Breast Cancer Receiving Chemotherapy . J Pain Symptom Manage, 2018. 55(1): p. 39–55. Pozzar, R.A., et al., Stability of Symptom Clusters in Patients With Gynecologic Cancer Receiving Chemotherapy . Cancer Nurs, 2022. 45(4): p. E706-e718. Wanden-Berghe, C., et al., Complications Associated with Enteral Nutrition: CAFANE Study . Nutrients, 2019. 11(9). Mesía, R., et al., Opioid-Induced Constipation in Oncological Patients: New Strategies of Management . Curr Treat Options Oncol, 2019. 20(12): p. 91. Smith, J.T. and M.S. Smith, Does a preoperative bowel preparation reduce bowel morbidity and length of stay after scoliosis surgery? A randomized prospective study . J Pediatr Orthop, 2013. 33(8): p. e69-71. Han, C.J., et al., Symptom Clusters in Patients With Gastrointestinal Cancers Using Different Dimensions of the Symptom Experience . J Pain Symptom Manage, 2019. 58(2): p. 224–234. Apfel, C.C., et al., A simplified risk score for predicting postoperative nausea and vomiting: conclusions from cross-validations between two centers . Anesthesiology, 1999. 91(3): p. 693–700. Gan, T.J., et al., Fourth Consensus Guidelines for the Management of Postoperative Nausea and Vomiting . Anesth Analg, 2020. 131(2): p. 411–448. Hackett, A.F., C.K. Yeung, and G.L. Hill, Eating patterns in patients recovering from major surgery–a study of voluntary food intake and energy balance . Br J Surg, 1979. 66(6): p. 415–8. Wong, M.L., et al., Differences in Symptom Clusters Identified Using Ratings of Symptom Occurrence vs. Severity in Lung Cancer Patients Receiving Chemotherapy . J Pain Symptom Manage, 2017. 54(2): p. 194–203. Wang, S.Y., et al., Symptom clusters and relationships to symptom interference with daily life in Taiwanese lung cancer patients . J Pain Symptom Manage, 2008. 35(3): p. 258–66. Zhang, M., et al., Application and efficacy evaluation of an NBASS-APS pain management model in postoperative analgesia for gastric cancer patients . J buon, 2018. 23(5): p. 1426–1431. Lin, S., et al., Pain, fatigue, disturbed sleep and distress comprised a symptom cluster that related to quality of life and functional status of lung cancer surgery patients . J Clin Nurs, 2013. 22(9–10): p. 1281–90. Wu, J.M., et al., Association between Interleukin-6 Levels and Perioperative Fatigue in Gastric Adenocarcinoma Patients . J Clin Med, 2019. 8(4). Yang, H.Y., et al., Relationship Between Symptom Distress and Fatigue Characteristics in Patients with Gastric Cancer During 1 Month after Gastrectomy . Clin Nurs Res, 2022. 31(3): p. 463–472. Oliveira, M., et al., Surgical Oncology: Evolution of Postoperative Fatigue and Factors Related to Its Severity . Clin J Oncol Nurs, 2016. 20(1): p. E3-8. Guo, M., et al., Symptom clusters and related factors in oesophageal cancer patients 3 months after surgery . J Clin Nurs, 2019. 28(19–20): p. 3441–3450. Fitzgerald, P., et al., The relationship between depression and physical symptom burden in advanced cancer . BMJ Support Palliat Care, 2015. 5(4): p. 381–8. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 07 Apr, 2024 Reviewers agreed at journal 05 Apr, 2024 Reviews received at journal 16 Mar, 2024 Reviewers agreed at journal 29 Feb, 2024 Reviewers invited by journal 29 Feb, 2024 Editor assigned by journal 28 Feb, 2024 Submission checks completed at journal 29 Jan, 2024 First submitted to journal 25 Jan, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3897026","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":269956548,"identity":"7706c797-0bd2-4fe7-934f-d6f0402c342b","order_by":0,"name":"Jianjian Wei","email":"","orcid":"","institution":"Cancer Hospital of Chinese Academy of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Jianjian","middleName":"","lastName":"Wei","suffix":""},{"id":269956549,"identity":"7d0ed11b-f315-4182-b422-b5ce04936964","order_by":1,"name":"Hongxia Yan","email":"","orcid":"","institution":"Cancer Hospital of Chinese Academy of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Hongxia","middleName":"","lastName":"Yan","suffix":""},{"id":269956550,"identity":"13315df8-9059-4eaf-bd90-c9758d3108f6","order_by":2,"name":"Wen Yin","email":"","orcid":"","institution":"Cancer Hospital of Chinese Academy of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Wen","middleName":"","lastName":"Yin","suffix":""},{"id":269956551,"identity":"3cc71e16-30c5-4f12-bc0c-e92cd6ea1b83","order_by":3,"name":"Fang He","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3UlEQVRIie3Rrw6CQBzA8d/JBoZjNHebgVc4Z1A3HuYsJILJKhubFuwyfQjewGO3QUEzm0GY1UAkGIRkk4tu3jf/PvvdHwCV6gejAIgDOJtzFnBeN3IEWuIiP0+XSRTKE4H8wpuKoS5BZsauFObW1VCY1wIw2NaIfyeLkLOWOLpm7GOxmsMkOrKegxWMd1uwji+xOGBg9NZH7pXfEkEw8UqBdRlSaNARSogHkiR3ITldXUZxSttHJhJ3ybKqfK4dRo3gUdeNY1vjHtI1MD/fQfrHu1DzkhtUqVSqP+0NrU9O8YivncgAAAAASUVORK5CYII=","orcid":"","institution":"Cancer Hospital of Chinese Academy of Medical Sciences","correspondingAuthor":true,"prefix":"","firstName":"Fang","middleName":"","lastName":"He","suffix":""}],"badges":[],"createdAt":"2024-01-25 11:44:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3897026/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3897026/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":50421785,"identity":"2e4e9624-344a-4250-b42c-a54132ff2e41","added_by":"auto","created_at":"2024-01-31 09:38:49","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":530594,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3897026/v1/9557e3b7-1e72-42e1-99da-ab7ea08e1b81.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Change of Symptom Clusters in Gastrointestinal Cancer Patients During the Perioperative Period: A Longitudinal Study","fulltext":[{"header":"1. Background","content":"\u003cp\u003eAccording to global cancer statistics in 2020, there were 1\u0026nbsp;million new cases and 0.7\u0026nbsp;million deaths from gastrointestinal cancer worldwide, posing a significant threat to human health. Surgery is the preferred treatment for gastrointestinal cancer[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. During the perioperative period, gastrointestinal cancer patients often experience multiple coexisting symptoms, such as fatigue, nausea, and vomiting[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. These coexisting symptoms were first referred to as symptom clusters by Dodd [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] in 2001, defined as three or more related symptoms occurring simultaneously, although the symptoms within the cluster may not share a common etiology mechanism. Symptoms within a cluster can have synergistic and reinforcing effects [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], where the worsening of one symptom leads to an increase in the severity of other symptoms. If left uncontrolled, these symptom clusters can significantly impact patients' quality of life, functional status, and treatment outcomes, including mortality rates[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. However, this clustering also presents an opportunity for targeted interventions to have a synergistic effect on managing symptoms. Managing symptoms based on symptom clusters can improve management efficiency, reduce hospital stays, and alleviate the burden on healthcare providers [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. To effectively manage symptoms, it is essential to understand the types, severity, and changes of symptoms at different time points before and after surgery, as well as how these symptoms affect patients.In our clinical practice and routine follow-up, we have found that patients usually had various symptoms during their hospitalization and long time after discharge. Some patients experiencing were deeply disturbed by the symptoms suffered from low quality of life. There are some original studies and reviews exploring the symptom clusters in gastrointestinal cancer patients, however, most of them concentrated on patients during chemotherapy. Some studies explored the symptoms in gastrointestinal cancer after surgery only at one time point or the concept of symptom cluster was not proposed[\u003cspan additionalcitationids=\"CR8 CR9\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Under the circumstances, less attention has been paid to the trajectory of symptoms in gastrointestinal cancer patients during their perioperative period, which was equally important for their recovery, quality of life and follow-up treatment. Thus, it is important to figure out the symptoms patients for clinical staff to provide guidance to these patients.\u003c/p\u003e"},{"header":"2. Aims","content":"\u003cp\u003eTo describe the trajectory, numbers, and types of symptom clusters at various time points surrounding surgery in order to provide scientific evidence for the development of individualized symptom management strategies by medical staff and researchers.\u003c/p\u003e"},{"header":"3. Methods","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Study design\u003c/h2\u003e \u003cp\u003eThis study was conducted in a descriptive and longitudinal design.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Participants and settings\u003c/h2\u003e \u003cp\u003e Participants who were first diagnosed gastrointestinal cancer and to receive surgery in a cancer hospital in Beijing, China were recruited. The inclusion criteria were as follows: a) age\u0026thinsp;\u0026ge;\u0026thinsp;18 years, b) initial diagnosis of gastrointestinal cancer, c) requirement for radical surgery, and d) capacity for communication and provision of informed consent. The exclusion criteria were: a) performance of palliative surgery, b) discharge without undergoing the operation for any reason, c) self-reported history of comorbidities associated with other malignant tumors, consciousness disorders, or mental illness, d) combined organ resection, e) occurrence of severe postoperative complications that hindered cooperation with researchers. Participants who refused to continue, were dead or lost connection were eliminated in this study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Data collection\u003c/h2\u003e \u003cp\u003eThe data was collected from November 2022 to October 2023. Eligible participants were approached at their admission in the hospital and provided written informed consent. Participants filled in the questionnaires through QR code. Data collection was conducted in four time points: 1 (the day before surgery), T2 (1\u0026ndash;3 days after surgery), T3 (from 7 days postoperatively until discharge), and T4 (1 month postoperatively).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e3.4 Instruments\u003c/h2\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003e3.4.1 General Questionnaire\u003c/h2\u003e \u003cp\u003eThis questionnaire was developed by the research team, primarily including the characteristics of the participants, including age, gender, marriage, economic status, occupation, stage of cancer, morbidities and type of operation.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003e3.4.2 M.D. Anderson Symptom Inventory Gastrointestinal Cancer Module (MDASI-GI)\u003c/h2\u003e \u003cp\u003eThe M.D. Anderson Symptom Inventory (MDASI) is a reliable and validated tool for assessing symptoms related to cancer, regardless of the specific cancer diagnosis [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The MDASI includes 13 items that evaluate the severity of symptoms at their worst in the past 24 hours, as well as 6 items that assess the interference caused by these symptoms during the same time period. Each item is rated on a numeric scale ranging from 0 to 10. The MDASI also includes a gastrointestinal (GI) module specifically designed to measure symptom prevalence and burden in GI cancer patients. The Chinese version of the MDASI-GI has been translated and validated for use in GI patients, demonstrating good internal consistency with Cronbach's α of 0.852 [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e3.5 Data analysis\u003c/h2\u003e \u003cp\u003eThe statistical analysis was performed using IBM SPSS Statistics 26.0. Descriptive statistics such as frequency, percentage, and rate were calculated for categorical data, while mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation was used for continuous data.\u003c/p\u003e \u003cp\u003eTo identify symptom clusters, exploratory factor analysis(EFA)was conductedbased on the occurrence rate and severity of symptoms using MPlus V.8.6.. A factor loading of \u0026ge;\u0026thinsp;40% was used as the criterion for including symptoms in the clusters, with each cluster consisting of at least two symptoms[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].For the occurrence rate, tetrachoric correlations were used to create the matrix of associations, and for the severity ratings polychoric correlations were used to create the matrix of associations.EFA for severity was conducted using severity ratings that included a zero (i.e,0,1,2,3,4,5,6,7,8,9,10). If the patient reported that they did not have the symptom, a severity score of zero were assigned. Symptoms with an incidence of less than 10% were excluded from the exploratory factor analysis to enhance the clinical relevance of the identified symptom clusters[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFactor solutions were expected for two through six factors. The factor solutions with the greatest interpretability and clinical meaningfulness were selected as it met the criteria set for evaluating simple structure. Symptom clusters were named based on the highest factor loadings and the majority of the symptoms in the cluster[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe Stability and Consistency of Symptom Clusters\u003c/p\u003e \u003cp\u003eIn our study, we use the term stability and consistency to describe the characteristics of symptom clusters. The stability was used to describe whether the same clusters are identified over time points, across symptom dimension or study samples. The consistency was used to describe whether the specific symptoms remain the same over time points, across symptom dimensions or study samples (percent agreement among the symptom dimensions within the clusters).\u003c/p\u003e \u003c/div\u003e"},{"header":"4. Results","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e4.1 Characteristics of participants\u003c/h2\u003e \u003cp\u003eA total of 205 participants were recruited for the study, with a mean age of 57.73\u0026thinsp;\u0026plusmn;\u0026thinsp;10.48 years. Among the participants, 141 (68.78%) were male and 64 (31.20%) were female, shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic and Clinical Characteristics of Participants (N\u0026thinsp;=\u0026thinsp;205)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItem\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrequency (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e141\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e68.78\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003efemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31.22\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarital status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e176\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e85.85\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot married\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.27\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDivorced or widowed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.88\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIlliteracy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.76\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eElementary school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26.83\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMiddle or high school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e105\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51.22\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUniversity or above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.19\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePayment method\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedical insurance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e114\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55.61\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNCMS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBusiness insurance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.44\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.95\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNew adjuvant chemotherapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e168\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e81.95\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperation methods\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLaparoscopic- assisted\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e161\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e78.54\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLaparotomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.60\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal laparoscopic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.93\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLOC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.93\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResection site and extent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDistal gastrectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e144\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e70.24\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProximal gastrectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.24\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal gastrectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19.52\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDigestive tract reconstruction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBillroth I\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.41\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBillroth II\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e158\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e77.07\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRoux-en-Y\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.93\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.59\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlood transfusion during operation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.27\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e186\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e90.73\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTransmission to ICU atT1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.61\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e173\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e84.39\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEnteral nutrition\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e168\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e81.95\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType of enteral nutrition\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58.93\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGlutamine combined with OP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.50\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTPF-T\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.97\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTPF-D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.50\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.09\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNRS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e138\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e67.32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e≧\u0026thinsp;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32.68\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI(kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;18.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.83\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18.5\u0026ndash;23.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41.94\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e≧\u0026thinsp;24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e104\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50.73\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTNM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.78\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36.10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35.61\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.46\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eAbbreviation: NCMS, new rural cooperative medical system;OP, Oral hydrolyzed protein༛LOC, Laparoscopic conversion to open surgery\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e4.2 Symptom prevalence and severity across four time points\u003c/h2\u003e \u003cp\u003eRegarding the prevalence and severity of symptoms across the four time points, a total of 18 symptoms were explored in postoperative gastrointestinal cancer patients. At T1, symptoms such as shortness of breath, problems with remembering things, drowsiness, numbness or tingling, changes in taste, and difficulty in swallowing were not reported. The incidence of pain, fatigue, distress, dry mouth, vomiting, constipation, and diarrhea was present but was less than 20%. The three symptoms with the highest incidence were disturbed sleep (50.73%), feeling sad (40.49%), and experiencing nausea (18.05%). At T2, several symptoms were reported by more than 80% of the participants, including pain (96.10%), fatigue (92.20%), disturbed sleep (85.37%), lack of appetite (81.95%), feeling sad (80.49%), constipation (80.98%), and bloating (85.37%). At T3, the symptoms with high incidence included pain (67.80%), fatigue (58.54%), distress (70.73%), drowsiness (66.83%), and bloating (70.24%). At T4, the two symptoms with the highest incidence were distressed (70.73%) and fatigue (58.05%). All other symptoms occurred in less than half of the participants, as shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOccurrence and severity of symptoms in gastric cancer patients over different time points (N\u0026thinsp;=\u0026thinsp;205)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"13\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c13\" colnum=\"13\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSymptoms\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003eOccurrence rates\u003c/p\u003e \u003cp\u003en(%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c9\" namest=\"c6\"\u003e \u003cp\u003eSeverity rating with zeros\u003c/p\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c13\" namest=\"c10\"\u003e \u003cp\u003eSeverity rating without zeros\u003c/p\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eT1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eT2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eT3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eT4\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eT1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eT2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eT3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eT4\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eT1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003eT2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c12\"\u003e \u003cp\u003eT3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c13\"\u003e \u003cp\u003eT4\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e29(14.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e197(96.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e139(67.80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e27(13.17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.23(0.61)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e4.38(1.37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e2.83(2.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.30(0.79)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e1.66(0.48)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e4.56(1.06)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e4.12(1.15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e2.21(0.57)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFatigue\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e24(11.71)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e189(92.20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e120(58.54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e119(58.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.34(1.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e5.14(1.70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e2.54(2.16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e2.49(2.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e2.92(1.18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e5.57(0.83)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e4.29(0.57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e4.29(0.70)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNausea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e37(18.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e125(60.98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e91(44.39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e33(16.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.48(1.07)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e2.55(0.98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1.76(2.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.48(1.17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e2.68(0.63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e2.55(0.98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e3.92(0.71)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e3.00(0.94)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisturbed sleep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e104(50.73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e175(85.37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e90(43.90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e40(19.51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.14(0.52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e2.71(1.30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e2.03(2.35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.69(1.42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e1.87(0.64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e3.18(0.70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e4.65(0.65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e3.53(0.55)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDistressed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22(10.73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e131(63.90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e145(70.73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e133(64.88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2.13(2.20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e2.09(0.64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e2.27(1.79)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e2.57(2.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e4.20(0.91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e2.09(0.64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e3.49(0.79)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e3.85(1.23)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShortness of breath\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0(0.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17(8.29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4(1.95)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4(1.95)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.00(0.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.17(0.62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.13(0.93)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.04(0.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e2.33(0.49)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e6.75(0.96)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e2.25(0.96)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProblems with remembering things\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0(0.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11(5.37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6(2.93)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3(1.46)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.03(0.22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.14(0.61)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.08(0.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.03(0.29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e2.64(0.51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e2.83(0.98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e2.33(0.58)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLack of appetite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e50(24.39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e168(81.95)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e101(49.27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e82(40.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.61(1.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e4.30(0.68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e2.04(2.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e1.63(2.09)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e2.52(0.51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e4.30(0.68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e4.10(0.68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e4.07(0.91)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDrowsy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0(0.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e157(76.59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e137(66.83)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e28(13.66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.00(0.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.80(1.69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1.20(0.97)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.31(0.79)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e2.75(1.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e1.79(0.58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e2.25(0.44)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDry mouth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2(0.98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e134(65.37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e97(47.32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e38(18.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.02(0.20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e3.06(1.83)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1.98(2.15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.48(1.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e2.00(0.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e4.00(0.79)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e4.18(0.72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e2.58(0.68)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSad\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e83(40.49)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e165(80.49)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e111(54.15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e97(47.30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.93(2.42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.54(0.84)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1.69(1.68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e1.19(1.43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e4.76(0.98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e1.92(0.40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e3.13(0.82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e2.52(1.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVomiting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e30(14.63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e67(32.68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e39(19.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19(9.27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.32(0.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.87(1.35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.43(0.97)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.25(0.86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e2.17(0.38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e2.66(0.90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e2.20(0.95)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e2.68(1.25)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumbness or tingling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0(0.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17(8.29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5(2.44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4(2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.00(0.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.11(0.38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.03(0.23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.05(0.40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e1.29(0.47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e1.40(0.55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e2.75(0.96)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConstipation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17(8.29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e166(80.98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e123(60.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e78(38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.24(0.83)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e3.57(1.89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e3.06(2.55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e1.33(1.84)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e2.94(0.56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e4.40(0.83)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e5.08(0.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e3.49(1.15)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChange in taste\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0(0.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12(5.85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e23(11.22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12(5.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.00(0.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.20(0.82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.33(0.83)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.16(0.65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e3.42(0.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e2.12(0.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e2.67(0.65)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBloated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e61(29.76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e175(85.37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e144(70.24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e56(27.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.93(1.51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e3.31(1.76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.06(0.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e1.01(1.74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e3.11(0.88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e3.42(0.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e4.09(1.39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e3.70(1.06)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiarrhea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e23(11.22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8(3.90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e27(13.17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e24(11.70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.18(0.52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.11(0.56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e2.85(2.21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.29(0.49)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e1.57(0.51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e2.87(0.35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e4.39(0.99)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e2.61(0.50)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDifficulty in swallowing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0(0.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6(2.93)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6(2.93)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4(2.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.00(0.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.09(0.51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.58(1.54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.07(0.49)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e3.00(0.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e2.00(0.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e3.50(0.58)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e4.3 Symptom clusters over time\u003c/h2\u003e \u003cp\u003eBased on the occurrence and symptom ratings, factor analysis was conducted at each time point to extract symptom clusters (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). At T1, a three-factor solution was obtained. The factors were identified as thegastrointestinal symptom cluster, psychological symptom cluster, and physical symptom cluster. At T2, a four-factor solution was obtained. The factors were identified as the gastrointestinal symptom cluster, physical symptom cluster, sleep disturbance symptom cluster, psychological symptom cluster.At T3, a four-factor solution was obtained. The factors were identified as the physical symptom cluster gastrointestinal symptom cluster, psychological symptom cluster, and sleep disturbance symptom cluster.At T4, a four-factor solution was obtained. The factors were identified as thepsychological symptom cluster, sleep disturbance symptom cluster, physical symptom cluster and gastrointestinal symptom cluster\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eNumbers and types of symptoms within each symptom cluster across four time points based on occurrence and severity (N\u0026thinsp;=\u0026thinsp;205)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSymptom clusters\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSymptoms within the cluster\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c6\" namest=\"c3\"\u003e \u003cp\u003eOccurrence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c10\" namest=\"c7\"\u003e \u003cp\u003eSeverity\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eT1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eT2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eT3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eT4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eT1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eT2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eT3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eT4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"8\" rowspan=\"9\"\u003e \u003cp\u003e\u003cb\u003eGastrointestinal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNausea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.835\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.730\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.785\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.857\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e0.792\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e0.775\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e0.808\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBloated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.856\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.725\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.408\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.701\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.838\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.487\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.552\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e0.747\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLack of appetite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.618\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.509\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.564\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.693\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.547\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.428\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.629\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVomiting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.768\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.737\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.440\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.790\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.635\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.457\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDiarrhea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.768\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.707\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.826\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.713\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e0.673\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e0.863\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConstipation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.688\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.669\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.647\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.493\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.697\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e0.640\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.666\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.579\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDry mouth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.913\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.541\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e0.826\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.532\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eChange in taste\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.749\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e0.801\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of symptoms in the cluster\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6/8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4/8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8/8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5/8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6/8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e6/8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e8/8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e5/8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003ePsychological\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDistressed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.591\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.770\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.937\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e0.756\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e0.719\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e0.791\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSad\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.877\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.704\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.709\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.899\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e0.767\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e0.724\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e0.811\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of symptoms in the cluster\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1/2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2/2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2/2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2/2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2/2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e2/2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e2/2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003ePhysical\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.867\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.833\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-0.413\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.858\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e0.828\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e0.928\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-0.411\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFatigue\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.817\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.824\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.816\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.829\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e0.547\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e0.935\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e0.851\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of symptoms in the cluster\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2/2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2/2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2/2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2/2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2/2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e2/2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e2/2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eSleep disturbance\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDisturbed sleep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.636\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.651\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.776\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e0.739\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e0.620\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e0.810\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDrowsy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.676\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.669\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e0.736\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e0.669\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e0.686\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of symptoms in the cluster\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2/2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1/2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2/2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2/2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e2/2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e2/2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e4.4 Stability and Consistency in symptom clusters\u003c/h2\u003e \u003cp\u003eThe stability and consistency of each of these clusters is reported next, as shown in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e and Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eConsistency of symptoms within each symptom cluster across symptom dimensions and time points(N\u0026thinsp;=\u0026thinsp;205)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSymptom cluster\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTime point\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOccurrence\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSeverity\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSymptom agreement across dimension\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"11\" rowspan=\"12\"\u003e \u003cp\u003eGastrointestinal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eT1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNausea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNausea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e3 of 3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBloated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBloated\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVomiting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eVomiting\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eT2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBloated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNausea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e1 of 3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVomiting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eConstipation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDry mouth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDry mouth\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eT3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNausea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNausea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e3 of 3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDiarrhea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDiarrhea\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eChange in taste\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eChange in taste\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eT4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNausea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNausea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e3 of 3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBloated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBloated\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDiarrhea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDiarrhea\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eSymptom agreement over time\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 of 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 of 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"11\" rowspan=\"12\"\u003e \u003cp\u003ePsychological\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eT1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDistressed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSad\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eT2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDistressed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSad\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSad\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eT3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDistressed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDistressed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e2 of 2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSad\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSad\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eT4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDistressed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDistressed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e2 of 2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSad\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSad\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eSymptom agreement over time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 of 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"11\" rowspan=\"12\"\u003e \u003cp\u003ePhysical\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eT1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFatigue\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eT2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e2 of 2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFatigue\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFatigue\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eT3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e2 of 2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFatigue\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFatigue\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eT4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e2 of 2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFatigue\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFatigue\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eSymptom agreement over time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 of 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"11\" rowspan=\"12\"\u003e \u003cp\u003eSleep disturbance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eT1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNI\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eT2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDisturbed sleep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDisturbed sleep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e2 of 2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDrowsy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDrowsy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eT3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDisturbed sleep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDisturbed sleep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e1 of 2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDrowsy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eT4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDisturbed sleep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDisturbed sleep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e2 of 2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDrowsy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDrowsy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eSymptom agreement over time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eTime points: T1\u0026thinsp;=\u0026thinsp;the day before surgery, T2\u0026thinsp;=\u0026thinsp;1\u0026ndash;3 days after surgery, T3\u0026thinsp;=\u0026thinsp;from 7 days postoperatively until discharge, and T4\u0026thinsp;=\u0026thinsp;1 month postoperatively\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e-= Only two symptoms were identified at a dimension and/or time point.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e*Calculated as the number of symptoms out of two or three that were identified across the four time points\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e# Calculated as the number of symptoms out of two or three that were identified across the two symptom dimensions (occurrence, severity)\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eNI\u0026thinsp;=\u0026thinsp;not identified,\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eNA\u0026thinsp;=\u0026thinsp;not assessed.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5 \u0026nbsp; Comparison of stability of symptom clusters across the total sample using ratings of occurrence and severity\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cimg 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\" width=\"751\" height=\"182\"\u003e\u003c/strong\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e4.4.1 Gastrointestinal symptom clusters \u0026nbsp; This cluster comprised 4 (T2 for occurrence) to 8 symptoms (T3 for occurrence and severity), was stable across time points and dimensions. Except for T2 for occurrence, nausea had the highest factor loading across the times and dimensions. Regarding the consistency of symptoms over time, only nausea met the criteria of consistency for severity ratings. For the consistency of symptoms across dimensions, tall of the three symptoms remained consistent at T1, T3 and T4.\u003c/p\u003e\n\u003cp\u003e4.4.2 Psychological symptom cluster \u0026nbsp; This cluster was composed of two symptoms (T1 for occurrence, T2 and T3 for occurrence and severity ratings) and stable across all time points for severity and T3, T4 for occurrence. At T3 and T4, the two symptoms remained consistent.\u003c/p\u003e\n\u003cp\u003e4.4.3 Physical symptom cluster \u0026nbsp; This cluster was composed of two symptoms (T1 for occurrence, T2 to T4 for occurrence and severity ratings) Symptoms within the physical clusters remained stable and consistent across all time points and dimensions expect T1 for occurrence.\u003c/p\u003e\n\u003cp\u003e4.4.4 Sleep disturbance symptom cluster \u0026nbsp; This cluster was composed of two symptoms (T2 to T4 across dimensions) and stable at T4 for occurrence and T2, T3, T4 for severity ratings. The two symptoms remained consistent at T2 and T4.\u003c/p\u003e"},{"header":"5. Discussion","content":"\u003cp\u003eThis study is the first to provide detailed characteristics of symptoms that adult gastrointestinal cancer patients suffered across the period from the day before surgery to one month after surgery, and described the stability and consistency of symptom clusters across the time and dimensions. This study identified four symptom clusters across four time points. The two most common symptom clusters were the physical, and psychological symptom clusters, which were found consistently in gastrointestinal cancer patients across time points and dimensions.\u003c/p\u003e \u003cp\u003ePhysical symptom cluster was stable and consistent over time and symptom dimensions. Similar results were found in previous studies [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Because pain and fatigue were two of the most common symptoms associated with physical symptoms, it\u0026rsquo;s imperative to routinely assess for these symptoms and develop interventions in clinical practice.\u003c/p\u003e \u003cp\u003eThe finding of psychological symptom clusters was consistent with previous studies in patients with breast [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], gynecological[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] and lung cancer[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].In these studies, distressed and sad were the consistent symptoms for the EFAs. This finding highlights the importance of considering these symptoms in the clinical management of gastrointestinal cancer patients.\u003c/p\u003e \u003cp\u003eHowever, there were also two other symptom clusters that appeared less frequently but should still be taken into consideration.\u003c/p\u003e \u003cp\u003eThe gastrointestinal symptom cluster included five to eight symptoms: vomiting, diarrhea, constipation, nausea, change in taste, dry mouth, lack of appetite and bloating. Diarrhea was reported as one of the most common complications in postoperative gastrointestinal cancer patients and has been associated with early enteral feeding through a tube or orally, as mentioned in previous studies [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Constipation was also common during the perioperative period, particularly 1\u0026ndash;3 days after surgery, with a high incidence (T2, 80.89%). This can be mainly attributed to perioperative fasting and water restrictions. Even at T3 (7 days post-operation to discharge), constipation persisted in 61% of participants. The reasons for constipation at this stage are multifaceted. Firstly, the radical excision and reconstruction of the digestive tract can disrupt its normal function. Secondly, the surgical stimulation of the gastrointestinal tract leads to a protective inhibition state, resulting in delayed and impaired recovery of gastrointestinal function. Lastly, the use of opioid painkillers after surgery can slow down bowel movements, contributing to constipation. Similar findings have been reported in previous studies [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Without timely and adequate management, constipation can negatively impact patients' postoperative recovery and quality of life. Therefore, healthcare providers should closely monitor and address constipation in their care. As results from previous studies on symptom clusters in gastrointestinal cancer patients, the gastrointestinal symptom cluster was one of the most common symptom clusters. However, depending on the surgery, anesthesia and post-surgery recovery, the stability and consistence of symptom were highly variable[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. For example, vomiting was identified only in T1 and T2, dry mouth was most common in T2 which might be caused by the surgery and fasting.\u003c/p\u003e \u003cp\u003eNausea were consistently present across four time points This can be attributed to the side effects of anesthesia and the surgical stimulation of the gastrointestinal tract[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. It is worth noting that females may be more vulnerable to nausea[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], which aligns with the findings of our study. The onset and increasing dose of tube or oral feeding can trigger stomach and intestinal movement, leading to nausea. At T3, 44.39% of patients reported nausea during feeding. Lack of appetite is a common symptom after major surgery[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] and has been observed in previous studies[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePain and fatigue were part of the physical symptom cluster. Pain and fatigue were the most common and long-lasting symptoms, present from T1 to T4in gastrointestinal cancer patients. Around 14.2% of patients reported mild upper stomach pain after eating, with a severity rating of 1.66\u0026thinsp;\u0026plusmn;\u0026thinsp;0.484. From the first day after surgery to discharge, pain was reported by 96.10% (T2) and 67.80% (T3) of patients, respectively, with moderate pain severity (4.56\u0026thinsp;\u0026plusmn;\u0026thinsp;1.061 and 4.14\u0026thinsp;\u0026plusmn;\u0026thinsp;1.152) due to the use of opioid painkillers. As the incision and stomas healed and patients gradually adapted to their reconstructed digestive tracts, pain complaints decreased to 13.17%. Postoperative pain is a complex phenomenon influenced by physiological and psychological factors and is almost present in every patient[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Fatigue is reported as one of the most common symptoms in various types of cancer patients, particularly in gastrointestinal cancer patients[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. In our study, patients experienced mild to moderate fatigue before and after surgery, with incidence ranging from 11.71\u0026ndash;92.20%. Similar results have been reported in other studies [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Timely, adequate, and individualized management of pain and fatigue is necessary and important.\u003c/p\u003e \u003cp\u003eDistress and sadness were observed in the psychological symptom cluster, with distress and sadness present across allT1 to T3, ranging from 10.73\u0026ndash;70.73% and 40.49\u0026ndash;80.49%, respectively. Similar findings have been reported in previous studies[\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Psychological distress has been recognized as the sixth vital sign by the International Psycho-Oncology Society[\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Distress and sadness in perioperative gastrointestinal cancer patients are often related to fears regarding surgery, treatment, relapse, quality of life, and even death[\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Prolonged distress and sadness can have a detrimental effect on patients' mental health and lower their quality of life[\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. However, compared to other physical symptoms, psychological symptoms are often neglected. This highlights the importance of focusing on patients' psychological well-being and providing necessary treatment.\u003c/p\u003e \u003cp\u003eSleep disturbances were also observed in the sleep disturbance symptom cluster, including disturbed sleep with occurrence ranging from 19.51\u0026ndash;85.37% and feeling drowsy with highest occurrence of 76.59%. Similar findings have been reported in other studies[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. These sleep disturbances are often attributed to pain or the effects of surgery. Lack of sleep at night can result in daytime drowsiness and decreased engagement in rehabilitative exercises, thereby slowing down the postoperative recovery process. Healthcare providers should be aware of the impact of sleep disturbances and provide individualized interventions to resolve this issue.\u003c/p\u003e"},{"header":"6. Limitations","content":"\u003cp\u003eThis study has several limitations that should be considered. Firstly, the study was conducted in a single hospital department, which may limit the generalizability of the findings to other medical institutions. Secondly, the assessment of symptoms relied solely on quantitative measures, and a combination of quantitative and qualitative methods may have provided a more comprehensive understanding of patients' symptom experiences during the perioperative period. Future research should consider incorporating qualitative approaches to gain a deeper insight into patients' experiences.\u003c/p\u003e"},{"header":"7. Conclusions","content":"\u003cp\u003eThis study identified four symptom clusters in gastrointestinal cancer patients during the perioperative period. These clusters included gastrointestinal, physical, psychological, and sleep disturbance symptom clusters. Many of the symptoms within these clusters persisted across time points and symptom dimensions, highlighting the need for comprehensive symptom management strategies. Additionally, it is important to acknowledge that there may be individual symptoms that are not included in these clusters but are still significant and can impact patients' outcomes and quality of life. Therefore, a more comprehensive assessment should be conducted to provide further information and evidence for future researchers and healthcare professionals.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eDeclarations\u003c/h2\u003e \u003cp\u003e The study has been approved by the ethics committee of National Cancer Center/ Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College (23/228\u0026ndash;3970) and was made in accordance with the ethical standards laid down in the Declaration of Helsinki.\u003c/p\u003e\u003ch2\u003eConflicts of interest\u003c/h2\u003e \u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eNone\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eFirst author: JIANJIAN WEI,Contribution: Conceptualization, Methodology, Data analysis , Data collection, Writing-original manuscript Second author:Hongxia Yan,Contribution: Data collection, SupervisionThird author:Wen Yin, Contribution: Data collectionCorresponding author:Fang He, Contribution: Methodology, Supervision, Manuscript Review and Editing.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSung, H., et al., \u003cem\u003eGlobal Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries\u003c/em\u003e. CA Cancer J Clin, 2021. 71(3): p. 209\u0026ndash;249.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLin, Y., et al., \u003cem\u003eCommon and Co-Occurring Symptoms Experienced by Patients With Gastric Cancer\u003c/em\u003e. Oncol Nurs Forum, 2020. 47(2): p. 187\u0026ndash;202.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDodd, M.J., C. Miaskowski, and S.M. Paul, \u003cem\u003eSymptom clusters and their effect on the functional status of patients with cancer\u003c/em\u003e. Oncol Nurs Forum, 2001. 28(3): p. 465\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang, X.S., et al., \u003cem\u003eChinese version of the M. D. Anderson Symptom Inventory: validation and application of symptom measurement in cancer patients\u003c/em\u003e. Cancer, 2004. 101(8): p. 1890\u0026ndash;901.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChoi, S. and E. Ryu, \u003cem\u003eEffects of symptom clusters and depression on the quality of life in patients with advanced lung cancer\u003c/em\u003e. Eur J Cancer Care (Engl), 2018. 27(1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim, H.J., et al., \u003cem\u003eSymptom clusters: concept analysis and clinical implications for cancer nursing\u003c/em\u003e. Cancer Nurs, 2005. 28(4): p. 270\u0026thinsp;\u0026ndash;\u0026thinsp;82; quiz 283-4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim, G.M., et al., \u003cem\u003ePrevalence and prognostic implications of psychological distress in patients with gastric cancer\u003c/em\u003e. BMC Cancer, 2017. 17(1): p. 283.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCliment, M., et al., \u003cem\u003eWeight loss and quality of life in patients surviving 2 years after gastric cancer resection\u003c/em\u003e. Eur J Surg Oncol, 2017. 43(7): p. 1337\u0026ndash;1343.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOh, H.J., et al., \u003cem\u003eAcid Secretion and Its Relationship to Esophageal Reflux Symptom in Patients with Subtotal Gastrectomy\u003c/em\u003e. Dig Dis Sci, 2018. 63(3): p. 703\u0026ndash;712.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShim, E.J., et al., \u003cem\u003eTrajectory of severity of postoperative delirium symptoms and its prospective association with cognitive function in patients with gastric cancer: results from a prospective observational study\u003c/em\u003e. Support Care Cancer, 2019. 27(8): p. 2999\u0026ndash;3006.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCleeland, C.S., et al., \u003cem\u003eAssessing symptom distress in cancer patients: the M.D. Anderson Symptom Inventory\u003c/em\u003e. Cancer, 2000. 89(7): p. 1634\u0026ndash;46.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi, J.J., et al., \u003cem\u003eChange in symptom clusters perioperatively in patients with lung cancer\u003c/em\u003e. Eur J Oncol Nurs, 2021. 55: p. 102046.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen, R.W., et al., \u003cem\u003eValidation and Application of the Chinese Version of the M. D. Anderson Symptom Inventory Gastrointestinal Cancer Module (MDASI-GI-C)\u003c/em\u003e. J Pain Symptom Manage, 2019. 57(4): p. 820\u0026ndash;827.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRussell, J., et al., \u003cem\u003eStability of Symptom Clusters in Patients With Lung Cancer Receiving Chemotherapy\u003c/em\u003e. J Pain Symptom Manage, 2019. 57(5): p. 909\u0026ndash;922.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim, H.J., et al., \u003cem\u003eTreatment-related symptom clusters in breast cancer: a secondary analysis\u003c/em\u003e. J Pain Symptom Manage, 2008. 36(5): p. 468\u0026ndash;79.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHarris, C.S., et al., \u003cem\u003eSymptom clusters in oncology outpatients: stability and consistency across a cycle of chemotherapy\u003c/em\u003e. BMJ Support Palliat Care, 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFu, L., et al., \u003cem\u003eSymptom Clusters and Quality of Life in Gastric Cancer Patients Receiving Chemotherapy\u003c/em\u003e. J Pain Symptom Manage, 2022. 63(2): p. 230\u0026ndash;243.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHammer, M.J., et al., \u003cem\u003eIdentification of Distinct Symptom Profiles in Cancer Patients Using a Pre-Specified Symptom Cluster\u003c/em\u003e. J Pain Symptom Manage, 2022. 64(1): p. 17\u0026ndash;27.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSullivan, C.W., et al., \u003cem\u003eStability of Symptom Clusters in Patients With Breast Cancer Receiving Chemotherapy\u003c/em\u003e. J Pain Symptom Manage, 2018. 55(1): p. 39\u0026ndash;55.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePozzar, R.A., et al., \u003cem\u003eStability of Symptom Clusters in Patients With Gynecologic Cancer Receiving Chemotherapy\u003c/em\u003e. Cancer Nurs, 2022. 45(4): p. E706-e718.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWanden-Berghe, C., et al., \u003cem\u003eComplications Associated with Enteral Nutrition: CAFANE Study\u003c/em\u003e. Nutrients, 2019. 11(9).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMes\u0026iacute;a, R., et al., \u003cem\u003eOpioid-Induced Constipation in Oncological Patients: New Strategies of Management\u003c/em\u003e. Curr Treat Options Oncol, 2019. 20(12): p. 91.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSmith, J.T. and M.S. Smith, \u003cem\u003eDoes a preoperative bowel preparation reduce bowel morbidity and length of stay after scoliosis surgery? A randomized prospective study\u003c/em\u003e. J Pediatr Orthop, 2013. 33(8): p. e69-71.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHan, C.J., et al., \u003cem\u003eSymptom Clusters in Patients With Gastrointestinal Cancers Using Different Dimensions of the Symptom Experience\u003c/em\u003e. J Pain Symptom Manage, 2019. 58(2): p. 224\u0026ndash;234.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eApfel, C.C., et al., \u003cem\u003eA simplified risk score for predicting postoperative nausea and vomiting: conclusions from cross-validations between two centers\u003c/em\u003e. Anesthesiology, 1999. 91(3): p. 693\u0026ndash;700.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGan, T.J., et al., \u003cem\u003eFourth Consensus Guidelines for the Management of Postoperative Nausea and Vomiting\u003c/em\u003e. Anesth Analg, 2020. 131(2): p. 411\u0026ndash;448.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHackett, A.F., C.K. Yeung, and G.L. Hill, \u003cem\u003eEating patterns in patients recovering from major surgery\u0026ndash;a study of voluntary food intake and energy balance\u003c/em\u003e. Br J Surg, 1979. 66(6): p. 415\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWong, M.L., et al., \u003cem\u003eDifferences in Symptom Clusters Identified Using Ratings of Symptom Occurrence vs. Severity in Lung Cancer Patients Receiving Chemotherapy\u003c/em\u003e. J Pain Symptom Manage, 2017. 54(2): p. 194\u0026ndash;203.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang, S.Y., et al., \u003cem\u003eSymptom clusters and relationships to symptom interference with daily life in Taiwanese lung cancer patients\u003c/em\u003e. J Pain Symptom Manage, 2008. 35(3): p. 258\u0026ndash;66.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang, M., et al., \u003cem\u003eApplication and efficacy evaluation of an NBASS-APS pain management model in postoperative analgesia for gastric cancer patients\u003c/em\u003e. J buon, 2018. 23(5): p. 1426\u0026ndash;1431.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLin, S., et al., \u003cem\u003ePain, fatigue, disturbed sleep and distress comprised a symptom cluster that related to quality of life and functional status of lung cancer surgery patients\u003c/em\u003e. J Clin Nurs, 2013. 22(9\u0026ndash;10): p. 1281\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWu, J.M., et al., \u003cem\u003eAssociation between Interleukin-6 Levels and Perioperative Fatigue in Gastric Adenocarcinoma Patients\u003c/em\u003e. J Clin Med, 2019. 8(4).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYang, H.Y., et al., \u003cem\u003eRelationship Between Symptom Distress and Fatigue Characteristics in Patients with Gastric Cancer During 1 Month after Gastrectomy\u003c/em\u003e. Clin Nurs Res, 2022. 31(3): p. 463\u0026ndash;472.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOliveira, M., et al., \u003cem\u003eSurgical Oncology: Evolution of Postoperative Fatigue and Factors Related to Its Severity\u003c/em\u003e. Clin J Oncol Nurs, 2016. 20(1): p. E3-8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGuo, M., et al., \u003cem\u003eSymptom clusters and related factors in oesophageal cancer patients 3 months after surgery\u003c/em\u003e. J Clin Nurs, 2019. 28(19\u0026ndash;20): p. 3441\u0026ndash;3450.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFitzgerald, P., et al., \u003cem\u003eThe relationship between depression and physical symptom burden in advanced cancer\u003c/em\u003e. BMJ Support Palliat Care, 2015. 5(4): p. 381\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"supportive-care-in-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jscc","sideBox":"Learn more about [Supportive Care in Cancer](https://www.springer.com/journal/520)","snPcode":"520","submissionUrl":"https://submission.nature.com/new-submission/520/3","title":"Supportive Care in Cancer","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"gastrointestinal cancer, symptoms, symptom cluster","lastPublishedDoi":"10.21203/rs.3.rs-3897026/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3897026/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eAim and objectives:\u003c/h2\u003e \u003cp\u003eThe aim of this study was to describe the numbers, types, and trajectory of symptom clusters during the perioperative period in gastrointestinal cancer patients at four different time points. The study also aimed to identify the changes and consistency of these symptom clusters over time.\u003c/p\u003e\u003ch2\u003eDesign:\u003c/h2\u003e \u003cp\u003eThis was a longitudinal study.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis study conducted at a tertiary cancer hospital involving 205 gastrointestinal cancer patients. The M.D. Anderson Symptom Inventory Gastrointestinal Cancer Module was used to assess the incidence and severity of symptom clusters. Exploratory factor analysis was employed to extract the symptom clusters.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe study identified four symptom clusters in gastrointestinal cancer patients during the perioperative period: gastrointestinal symptom cluster, physical symptom cluster, psychological symptom cluster, and sleep disturbance symptom cluster. These clusters were observed across two to four time points.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe findings of this study provide scientific evidence for medical staff and researchers to gain a better understanding of the symptom experiences of gastrointestinal cancer patients during the perioperative period. This knowledge can be valuable in developing individualized symptom management interventions.\u003c/p\u003e\u003ch2\u003eRelevance to clinical practice\u003c/h2\u003e \u003cp\u003e: Gastrointestinal cancer patients suffered from various symptom clusters and lasted from day before surgery to one month after surgery, which should be paid attention by clinical staff.\u003c/p\u003e","manuscriptTitle":"The Change of Symptom Clusters in Gastrointestinal Cancer Patients During the Perioperative Period: A Longitudinal Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-31 09:30:42","doi":"10.21203/rs.3.rs-3897026/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-04-07T20:34:28+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"7696e135-c730-4505-b22b-452f195e802b","date":"2024-04-05T11:10:01+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-03-17T02:54:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"74118fc7-2645-406d-81f0-1f1e9f82569a","date":"2024-02-29T21:36:32+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-02-29T13:28:08+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-02-28T19:50:14+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-01-30T03:29:02+00:00","index":"","fulltext":""},{"type":"submitted","content":"Supportive Care in Cancer","date":"2024-01-25T11:42:26+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"supportive-care-in-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jscc","sideBox":"Learn more about [Supportive Care in Cancer](https://www.springer.com/journal/520)","snPcode":"520","submissionUrl":"https://submission.nature.com/new-submission/520/3","title":"Supportive Care in Cancer","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"0d9c551b-e991-4816-9ad4-60c4421a51a5","owner":[],"postedDate":"January 31st, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2024-05-17T02:15:54+00:00","versionOfRecord":[],"versionCreatedAt":"2024-01-31 09:30:42","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3897026","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3897026","identity":"rs-3897026","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}