{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,13]],"date-time":"2026-06-13T15:10:12Z","timestamp":1781363412658,"version":"3.54.1"},"reference-count":57,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,3,11]],"date-time":"2026-03-11T00:00:00Z","timestamp":1773187200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Med."],"abstract":"<jats:sec>\n                    <jats:title>Objective<\/jats:title>\n                    <jats:p>To construct the symptom network of elderly patients with type 2 diabetes mellitus (T2DM) and perform association rule analysis for each symptom cluster, identify core symptoms, and explore the sentinel symptoms, to provide references for accurate and efficient symptom management.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>Convenience sampling was employed. Eligible elderly patients with T2DM were enrolled from the department of endocrinology, affiliated hospital of North Sichuan Medical College, Nanchong City, from March 2024 to July 2024, with data collected using the Chinese Version of Diabetes Symptom Checklist-Revised (DSC-R). The correlation was analyzed using the Apriori algorithm model to identify the sentinel symptoms of each symptom cluster, and the core symptom was identified based on the network analysis method.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      The most prevalent symptoms were thirst and dry mouth (71.69%), general fatigue (70.78%), and frothy urine (69.58%). Regarding symptom burden severity, general fatigue (2.48 \u00b1 1.89), asthenia (2.42 \u00b1 1.94), and insomnia (2.39 \u00b1 1.98) had the highest scores. Sentinel symptoms, including excessive sleepiness, limb numbness, limb swelling, and polydipsia, are characteristic manifestations of distinct symptom clusters: psychological cognition symptom cluster, peripheral nerve symptom cluster, nephropathy symptom cluster, and hyperglycemia symptom cluster. At the global level, general fatigue (r\n                      <jats:sub>s<\/jats:sub>\n                      = 1.207) emerged as the core symptom.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>This study identifies general fatigue as the core symptom, with excessive sleepiness, limb numbness, limb swelling, and polydipsia emerging as sentinel symptoms, within their respective symptom clusters. From the perspective of symptom network analysis and sentinel symptoms, clinical staff can develop accurate and efficient intervention measures to improve the efficiency of symptom management and reduce the burden of symptoms in elderly patients with T2DM.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.3389\/fmed.2026.1728665","type":"journal-article","created":{"date-parts":[[2026,3,11]],"date-time":"2026-03-11T06:52:28Z","timestamp":1773211948000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":1,"title":["Exploring core and sentinel symptoms in elderly patients with type 2 diabetes through network analysis and the Apriori algorithm"],"prefix":"10.3389","volume":"13","author":[{"given":"Tingting","family":"Tan","sequence":"first","affiliation":[{"name":"Department of nursing, Affiliated Hospital of North Sichuan Medical College","place":["Nanchong, China"]},{"name":"North Sichuan Medical College","place":["Nanchong, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Chongyao","family":"Yang","sequence":"additional","affiliation":[{"name":"Department of nursing, Affiliated Hospital of North Sichuan Medical College","place":["Nanchong, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Qingqing","family":"Wang","sequence":"additional","affiliation":[{"name":"Department of nursing, Affiliated Hospital of North Sichuan Medical College","place":["Nanchong, China"]},{"name":"North Sichuan Medical College","place":["Nanchong, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Cong","family":"Xu","sequence":"additional","affiliation":[{"name":"Department of nursing, Affiliated Hospital of North Sichuan Medical College","place":["Nanchong, China"]},{"name":"North Sichuan Medical College","place":["Nanchong, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sijing","family":"Wang","sequence":"additional","affiliation":[{"name":"West China School of Public Health and West China Fourth Hospital, Sichuan University","place":["Chengdu, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bingbing","family":"Xiao","sequence":"additional","affiliation":[{"name":"Department of nursing, Affiliated Hospital of North Sichuan Medical College","place":["Nanchong, China"]},{"name":"North Sichuan Medical College","place":["Nanchong, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jing","family":"Zhao","sequence":"additional","affiliation":[{"name":"Department of nursing, Affiliated Hospital of North Sichuan Medical College","place":["Nanchong, China"]},{"name":"North Sichuan Medical College","place":["Nanchong, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Huan","family":"He","sequence":"additional","affiliation":[{"name":"Department of Stomatology, Affiliated Hospital of North Sichuan Medical College","place":["Nanchong, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Miaoqin","family":"Wang","sequence":"additional","affiliation":[{"name":"Outpatient Department, Affiliated Hospital of North Sichuan Medical College","place":["Nanchong, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2026,3,11]]},"reference":[{"key":"B1","first-page":"16","article-title":"Guidelines for the prevention and treatment of type 2 diabetes in China (2024 Edition)","volume":"17","year":"2025","journal-title":"Chin J Diabetes"},{"key":"B2","doi-asserted-by":"publisher","first-page":"7","DOI":"10.1093\/ndt\/gfaf177","article-title":"IDF diabetes atlas 11th edition 2025: global prevalence and projections for 2050","volume":"41","author":"Duncan","year":"2025","journal-title":"Nephrol Dial Transplant"},{"key":"B3","doi-asserted-by":"publisher","first-page":"271","DOI":"10.1016\/j.diabres.2018.02.023","article-title":"Diabetes atlas: global estimates of diabetes prevalence for 2017 and projections for 2045","volume":"138","author":"Cho","year":"2018","journal-title":"Diabetes Res Clin Pract."},{"key":"B4","doi-asserted-by":"publisher","first-page":"S27","DOI":"10.2337\/dc25-S002","volume":"48","year":"2025","journal-title":"Diabetes Care."},{"key":"B5","doi-asserted-by":"publisher","first-page":"71","DOI":"10.51866\/oa.416","article-title":"Prevalence and burden of diabetes mellitus-related symptoms in patients with type 2 diabetes mellitus: a cross-sectional study","volume":"18","author":"Tan","year":"2023","journal-title":"Malays Fam Physician."},{"key":"B6","doi-asserted-by":"publisher","first-page":"1674","DOI":"10.1007\/s11606-012-2132-3","article-title":"Symptom burden of adults with type 2 diabetes across the disease course: diabetes & aging study","volume":"27","author":"Sudore","year":"2012","journal-title":"J Gen Intern Med."},{"key":"B7","doi-asserted-by":"publisher","first-page":"270","DOI":"10.1097\/00002820-200507000-00005","article-title":"Symptom clusters: concept analysis and clinical implications for cancer nursing","volume":"28","author":"Kim","year":"2005","journal-title":"Cancer Nurs."},{"key":"B8","doi-asserted-by":"publisher","first-page":"102566","DOI":"10.1016\/j.ejon.2024.102566","article-title":"Sentinel and networked symptoms in patients with breast cancer undergoing chemotherapy","volume":"70","author":"Liang","year":"2024","journal-title":"Eur J Oncol Nurs."},{"key":"B9","doi-asserted-by":"publisher","first-page":"57","DOI":"10.1007\/s10865-019-00056-x","article-title":"Assessing the association of depression and anxiety with symptom reporting among individuals with type 2 diabetes","volume":"43","author":"Asman","year":"2020","journal-title":"J Behav Med."},{"key":"B10","doi-asserted-by":"publisher","first-page":"768","DOI":"10.1037\/a0031322","article-title":"Lagged relationships among sleep disturbance, fatigue, and depressed mood during chemotherapy","volume":"32","author":"Jim","year":"2013","journal-title":"Health Psychol."},{"key":"B11","doi-asserted-by":"publisher","first-page":"E425","DOI":"10.1188\/11.ONF.E425-E435","article-title":"A symptom cluster and sentinel symptom experienced by women with lung cancer","volume":"38","author":"Brown","year":"2011","journal-title":"Oncol Nurs Forum."},{"key":"B12","doi-asserted-by":"publisher","first-page":"1423","DOI":"10.1007\/s00520-016-3527-1","article-title":"Prospective exploration of symptom burden clusters in women with breast cancer during chemotherapy treatment","volume":"25","author":"Browall","year":"2017","journal-title":"Support Care Cancer."},{"key":"B13","doi-asserted-by":"publisher","first-page":"5","DOI":"10.1002\/wps.20375","article-title":"A network theory of mental disorders","volume":"16","author":"Borsboom","year":"2017","journal-title":"World Psychiatry."},{"key":"B14","doi-asserted-by":"publisher","first-page":"1081786","DOI":"10.3389\/fonc.2023.1081786","article-title":"Contemporaneous symptom networks and correlates during endocrine therapy among breast cancer patients: a network analysis","volume":"13","author":"Jing","year":"2023","journal-title":"Front Oncol."},{"key":"B15","doi-asserted-by":"publisher","first-page":"102282","DOI":"10.1016\/j.ejon.2023.102282","article-title":"Symptom cluster trajectories and sentinel symptoms during the first cycle of chemotherapy in patients with lung cancer","volume":"63","author":"Ju","year":"2023","journal-title":"Eur J Oncol Nurs."},{"key":"B16","doi-asserted-by":"publisher","first-page":"578","DOI":"10.1007\/s00520-023-08024-7","article-title":"Exploring core symptoms and interrelationships among symptoms in children with acute leukemia during chemotherapy: a network analysis","volume":"31","author":"Fang","year":"2023","journal-title":"Support Care Cancer."},{"key":"B17","doi-asserted-by":"publisher","first-page":"1270","DOI":"10.1111\/jocn.70077","article-title":"Exploring core and bridge symptoms among people with type 2 diabetes mellitus in china: a network analysis","volume":"35","author":"Liu","year":"2025","journal-title":"J Clin Nurs."},{"key":"B18","first-page":"1857","article-title":"Dynamic network analysis of postoperative core symptoms in hepatocellular carcinoma patients and nursing insights","volume":"60","author":"Sun","year":"2025","journal-title":"Chin J Nurs."},{"key":"B19","doi-asserted-by":"publisher","first-page":"100361","DOI":"10.1016\/j.apjon.2023.100361","article-title":"Symptoms experienced after transcatheter arterial chemoembolization in patients with primary liver cancer: a network analysis","volume":"11","author":"Xu","year":"2024","journal-title":"Asia Pac J Oncol Nurs."},{"key":"B20","doi-asserted-by":"publisher","first-page":"253","DOI":"10.1111\/j.1464-5491.1994.tb00268.x","article-title":"Development of a type 2 diabetes symptom checklist: a measure of symptom severity","volume":"11","author":"Grootenhuis","year":"1994","journal-title":"Diabet Med."},{"key":"B21","doi-asserted-by":"publisher","first-page":"27","DOI":"10.2147\/DMSO.S9465","article-title":"A psychometric evaluation of the diabetes symptom checklist-revised (DSC-R) cognitive distress, fatigue, hyperglycemia, and hypoglycemia subscales in patients with type 1 and type 2 diabetes","volume":"3","author":"Naegeli","year":"2010","journal-title":"Diabetes Metab Syndr Obes."},{"key":"B22","article-title":"Chinese revision and application of the symptom burden assessment scale for patients with type 2 diabetes mellitus [Thesis]","author":"Luo","year":"2023","journal-title":"Nanchang."},{"key":"B23","doi-asserted-by":"publisher","first-page":"30","DOI":"10.1007\/s00125-016-4154-6","article-title":"Depression: a common and burdensome complication of diabetes that warrants the continued attention of clinicians, researchers and healthcare policy makers","volume":"60","author":"Pouwer","year":"2017","journal-title":"Diabetologia."},{"key":"B24","doi-asserted-by":"publisher","first-page":"542444","DOI":"10.3389\/fpsyg.2020.542444","article-title":"Management and treatment of patients with major depressive disorder and chronic diseases: a multidisciplinary approach","volume":"11","author":"Almeida","year":"2020","journal-title":"Front Psychol."},{"key":"B25","doi-asserted-by":"publisher","first-page":"418","DOI":"10.1177\/1479164116653240","article-title":"Diabetic peripheral neuropathic pain is a stronger predictor of depression than other diabetic complications and comorbidities","volume":"13","author":"D'Amato","year":"2016","journal-title":"Diab Vasc Dis Res."},{"key":"B26","doi-asserted-by":"publisher","first-page":"105497","DOI":"10.1016\/j.aap.2020.105497","article-title":"Application of association rules mining algorithm for hazardous materials transportation crashes on expressway","volume":"142","author":"Hong","year":"2020","journal-title":"Accid Anal Prev."},{"key":"B27","doi-asserted-by":"publisher","first-page":"8854772","DOI":"10.1155\/2020\/8854772","article-title":"An Apriori algorithm-based association rule analysis to identify herb combinations for treating uremic pruritus using chinese herbal bath therapy","volume":"2020","author":"Lu","year":"2020","journal-title":"Evid Based Compl Alt."},{"key":"B28","doi-asserted-by":"publisher","first-page":"4579801","DOI":"10.1155\/2018\/4579801","article-title":"Association rule analysis for validating interrelationships of combined medication of compound kushen injection in treating colon carcinoma: a hospital information system-based real-world study","volume":"2018","author":"Yang","year":"2018","journal-title":"Evid-Based Complement Altern Med."},{"key":"B29","doi-asserted-by":"publisher","first-page":"488","DOI":"10.1097\/NCC.0000000000001058","article-title":"An investigation of symptom clusters and sentinel symptoms during the first 2 cycles of postoperative chemotherapy in patients with lung cancer","volume":"45","author":"Ma","year":"2022","journal-title":"Cancer Nurs."},{"key":"B30","doi-asserted-by":"publisher","first-page":"498","DOI":"10.7475\/kjan.2021.33.5.498","article-title":"Symptom clusters and quality of life in patients with type 2 diabetes mellitus","volume":"33","author":"Hong","year":"2021","journal-title":"Korean J Adult Nurs."},{"key":"B31","doi-asserted-by":"publisher","first-page":"385","DOI":"10.1007\/s00520-024-08600-5","article-title":"Identification of symptom clusters and sentinel symptoms during the first cycle of chemotherapy in patients with lung cancer","volume":"32","author":"Luo","year":"2024","journal-title":"Support Care Cancer."},{"key":"B32","doi-asserted-by":"publisher","DOI":"10.1097\/NCC.0000000000001488","article-title":"Sentinel and networked symptoms during remission induction chemotherapy in acute lymphoblastic leukemia children","author":"Shen","year":"2025","journal-title":"Cancer Nurs."},{"key":"B33","doi-asserted-by":"publisher","first-page":"2307","DOI":"10.2147\/CMAR.S536992","article-title":"Identification of symptom clusters and sentinel symptoms during radiotherapy in lung cancer patients: a longitudinal study","volume":"17","author":"Zhang","year":"2025","journal-title":"Cancer Manag Res."},{"key":"B34","doi-asserted-by":"publisher","first-page":"503","DOI":"10.1016\/j.ijid.2021.05.084","article-title":"Evolving symptom networks in relation to HIV-positive duration among people living with HIV: a network analysis","volume":"108","author":"Zhu","year":"2021","journal-title":"Int J Infect Dis."},{"key":"B35","doi-asserted-by":"publisher","DOI":"10.1159\/000535586","article-title":"Network analysis of borderline personality features in adolescence using a screening tool in a Chinese community sample","author":"Wang","year":"2024","journal-title":"Psychopathology."},{"key":"B36","doi-asserted-by":"publisher","first-page":"195","DOI":"10.3758\/s13428-017-0862-1","article-title":"Estimating psychological networks and their accuracy: a tutorial paper","volume":"50","author":"Epskamp","year":"2018","journal-title":"Behav Res Methods."},{"key":"B37","doi-asserted-by":"publisher","first-page":"244","DOI":"10.1016\/j.metabol.2014.09.011","article-title":"Excessive daytime sleepiness and metabolic syndrome: a cross-sectional study","volume":"64","author":"Hayley","year":"2015","journal-title":"Metabolism."},{"key":"B38","doi-asserted-by":"publisher","first-page":"93","DOI":"10.2174\/157016107780368280","article-title":"Inflammation, sleep, obesity and cardiovascular disease","volume":"5","author":"Miller","year":"2007","journal-title":"Curr Vasc Pharmacol."},{"key":"B39","doi-asserted-by":"publisher","first-page":"183","DOI":"10.1016\/j.diabet.2011.11.006","article-title":"Inflammation and type 2 diabetes","volume":"38","author":"Calle","year":"2012","journal-title":"Diabetes Metab."},{"key":"B40","doi-asserted-by":"publisher","first-page":"4157","DOI":"10.2337\/dc13-0863","article-title":"Association between excessive daytime sleepiness and severe hypoglycemia in people with type 2 diabetes: the Edinburgh type 2 diabetes study","volume":"36","author":"Inkster","year":"2013","journal-title":"Diabetes Care."},{"key":"B41","doi-asserted-by":"publisher","first-page":"455","DOI":"10.1177\/0145721709333857","article-title":"Daytime sleepiness and functional outcomes in older adults with diabetes","volume":"35","author":"Chasens","year":"2009","journal-title":"Diabetes Educ."},{"key":"B42","doi-asserted-by":"publisher","first-page":"74","DOI":"10.1177\/0145721712467683","article-title":"Effect of poor sleep quality and excessive daytime sleepiness on factors associated with diabetes self-management","volume":"39","author":"Chasens","year":"2013","journal-title":"Diabetes Educ."},{"key":"B43","doi-asserted-by":"publisher","first-page":"521","DOI":"10.1016\/S1474-4422(12)70065-0","article-title":"Diabetic neuropathy: clinical manifestations and current treatments","volume":"11","author":"Callaghan","year":"2012","journal-title":"Lancet Neurol."},{"key":"B44","doi-asserted-by":"publisher","first-page":"41","DOI":"10.1038\/s41572-019-0092-1","article-title":"Diabetic neuropathy","volume":"5","author":"Feldman","year":"2019","journal-title":"Nat Rev Dis Primers."},{"key":"B45","doi-asserted-by":"publisher","first-page":"1148","DOI":"10.1111\/jdi.13105","article-title":"Painful and non-painful diabetic polyneuropathy: clinical characteristics and diagnostic issues","volume":"10","author":"Gylfadottir","year":"2019","journal-title":"J Diabetes Investig."},{"key":"B46","doi-asserted-by":"publisher","first-page":"1187","DOI":"10.1038\/ki.1990.332","article-title":"Pathophysiological aspects of edema formation in diabetic nephropathy","volume":"38","author":"Hommel","year":"1990","journal-title":"Kidney Int."},{"key":"B47","doi-asserted-by":"publisher","first-page":"S30","DOI":"10.1681\/ASN.2004110970","article-title":"Pathogenetic mechanisms of diabetic nephropathy","volume":"16","author":"Schena","year":"2005","journal-title":"J Am Soc Nephrol."},{"key":"B48","doi-asserted-by":"publisher","first-page":"157","DOI":"10.1007\/s11325-021-02380-6","article-title":"Impact of inflammatory markers on the relationship between sleep quality and diabetic kidney disease","volume":"26","author":"Meng","year":"2022","journal-title":"Sleep Breath."},{"key":"B49","doi-asserted-by":"publisher","first-page":"135","DOI":"10.1055\/s-0043-1761205","article-title":"Guidelines on the management of type 2 diabetes","volume":"5","author":"Fisher","year":"2023","journal-title":"J Diabetes Endocr Pract."},{"key":"B50","doi-asserted-by":"publisher","first-page":"82","DOI":"10.2337\/diaclin.19.2.82","article-title":"Hyperglycemic crises in patients with diabetes mellitus","volume":"19","year":"2001","journal-title":"Clin Diabetes."},{"key":"B51","doi-asserted-by":"publisher","first-page":"S17","DOI":"10.2337\/dc22-S002","volume":"45","year":"2021","journal-title":"Diabetes Care."},{"key":"B52","doi-asserted-by":"publisher","first-page":"815","DOI":"10.2337\/diacare.15.7.815","article-title":"Onset of NIDDM occurs at least 4\u20137 yr before clinical diagnosis","volume":"15","author":"Harris","year":"1992","journal-title":"Diabetes Care."},{"key":"B53","doi-asserted-by":"publisher","first-page":"197","DOI":"10.1177\/1099800419898002","article-title":"Real-time associations between glucose levels and fatigue in type 2 diabetes: sex and time effects","volume":"22","author":"Fritschi","year":"2020","journal-title":"Biol Res Nurs."},{"key":"B54","doi-asserted-by":"publisher","first-page":"e0165652","DOI":"10.1371\/journal.pone.0165652","article-title":"Fatigue in type 2 diabetes: impact on quality of life and predictors","volume":"11","author":"Singh","year":"2016","journal-title":"PLoS ONE."},{"key":"B55","doi-asserted-by":"publisher","first-page":"e0273675","DOI":"10.1371\/journal.pone.0273675","article-title":"Resilience-based Islamic program as a promising intervention on diabetes fatigue and health-related quality of life","volume":"17","author":"Kusnanto","year":"2022","journal-title":"PLoS ONE."},{"key":"B56","doi-asserted-by":"publisher","first-page":"236","DOI":"10.2337\/dc10-1970","article-title":"Depression in diabetes: have we been missing something important?","volume":"34","author":"Gonzalez","year":"2011","journal-title":"Diabetes Care."},{"key":"B57","doi-asserted-by":"publisher","first-page":"e14938","DOI":"10.1111\/dme.14938","article-title":"Sense of vitality is associated with cardiovascular events in type 2 diabetes independently of traditional risk factors and arterial stiffness","volume":"40","author":"Vergara","year":"2023","journal-title":"Diabet Med."}],"container-title":["Frontiers in Medicine"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fmed.2026.1728665\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,3,16]],"date-time":"2026-03-16T13:49:39Z","timestamp":1773668979000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fmed.2026.1728665\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,3,11]]},"references-count":57,"alternative-id":["10.3389\/fmed.2026.1728665"],"URL":"https:\/\/doi.org\/10.3389\/fmed.2026.1728665","relation":{},"ISSN":["2296-858X"],"issn-type":[{"value":"2296-858X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,3,11]]},"article-number":"1728665"}}