瑞芬太尼联合异丙酚静脉全麻用于支撑喉镜手术的临床观察

目的对比观察瑞芬太尼复合异丙酚与枸橼酸芬太尼异氟烷静吸复合麻醉对支撑喉镜手术的麻醉效果和麻醉恢复期的影响。方法ASAⅠ～Ⅱ级择期支撑喉镜手术患者60例，随即分为瑞芬太尼组（R组）和芬太尼组（F组），每组30例。两组均以异丙酚单次静注1．5-2mg／kg，R组以瑞芬太尼单次静注1μg／kg，F组以枸橼酸芬太尼（宜昌人福药业）2．5μg／kg（插管前3min静注），意识消失后以琥珀酰胆碱1～1．5mg／kg静注，随后行气管插管，机控通气。麻醉维持F组以1μg／（kg·min），异丙酚7—8mg／（kg·h）连续输注维持麻醉，R组以静脉注射芬太尼0．03μg／（kg·min），吸入2％异氟醚维持麻醉。记录两组各时段生命指征（血压、心率、氧饱和度），麻醉恢复情况（自主呼吸恢复时间、睁眼时间、拔管时间、定向力恢复时间和离开恢复室时间），术中不良事件的发生和药物使用情况，观察患者拔管后即刻、离开恢复室（PACU）、拔管后30min、1h和3h的意识状态（OAAS）。结果（1）两组在麻醉诱导、麻醉维持期间和麻醉恢复各时间段血流动力学稳定，MAP、HR分别和其基础值相比差异无统计学意义（P〉0．05）；（2）自主呼吸恢复时间、睁眼时间、拔管时间、定向力恢复时间和离开PACU时间瑞芬太尼组早于对照组（P〈0．05）。（3）瑞芬太尼组在拔管后即刻、离开PACU、拔管后30min、1h OAAS评分高于对照组（P〈0．05）。结论与常规静吸复合麻醉下行支撑喉镜手术相比，瑞芬太尼异丙酚静脉具有麻醉平稳、苏醒快、可控性好的特点，是支撑喉镜手术麻醉的良好选择。     

不同剂量瑞芬太尼对气管插管血流动力学的影响

【目的】观察不同剂量瑞芬太尼对气管插管血流动力学的影响。【方法】随机将30例ASAⅠ～Ⅱ级择期手术病人分为3组，每组10例，在静注咪唑安定0．04mg／kg，异丙酚1mg／kg，维库溴铵0．1mg／kg后，3组分别予芬太尼3μg／kg（F组）、瑞芬太尼1μg／kg（A1组）、2μg／kg（A2组）后插管，观察围插管期血流动力学变化。【结果】三组患者诱导后BP下降、HR减慢，与诱导前比较有统计学差异（P〈0．05）。F组插管后3min内各项参数明显升高，与诱导前及A1、A2组比较，差异均有显著性（P〈0．05），A1组患者插管后各项参数变化与诱导前比较无显著差异，与A2组比较差异有显著性（P〈0．05），插管后血压降低与诱导前无显著差异。【结论】瑞芬太尼1．0μg／比2．0μg／kg的效果好，更能维持全麻诱导期血流动力学稳定。     

瑞芬太尼与芬太尼对腹部手术患者麻醉气管插管血流动力学的影响

目的观察瑞芬太尼与芬太尼对腹部手术患者麻醉气管插管血流动力学的影响。方法择期行腹部手术病人42例，ASAⅠ～Ⅱ级、年龄18～72岁，随机分为瑞芬太尼组（R组，21例）、芬太尼组（F组，21例）；诱导方法：丙泊酚2mg／kg、罗库溴胺0．6mg／kg，其中R组用瑞芬太尼2μg／kg，F组采用芬太尼3μg／kg快速诱导；记录以下各时点的SBP、DBP、HR，麻醉诱导前1min（T0），诱导后1min插管前即刻（T1）及插管后1min（T2）、3min（T3），5min（T4）。结果R组SBP、DBP、HR在T1、T2、T3与基础值及与F组比较降低，差异分别为P〈0．01、P〈0．05，插管后5min回升至插管前水平。F组SBP、DBP在T1降低，T3恢复至插管前水平，HR差异无统计学意义。结论芬太尼、瑞芬太尼均能维持患者麻醉诱导插管时血流动力学稳定，瑞芬太尼抑制气管插管的应激反应优于芬太尼，但心率减慢、血压下降亦比芬太尼明显。     

瑞芬太尼复合咪达唑仑注射液用于纤维支气管镜引导下清醒气管插管的最佳剂量研究

目的研究瑞芬太尼复合咪达唑仑注射液用于纤维支气管镜引导下清醒气管插管的可行性及最佳剂量。方法将60例预计为困难气道拟行全身麻醉手术的患者随机分为3组：A组、B组和C组,每组20例。3组患者均静脉注射咪达唑仑注射液0．03mg／kg。3min后,A、B、C3组分别静脉注射瑞芬太尼0．5、1．0、1．5μg／kg。记录3组患者平均动脉压（MAP）、心率（HR）麻醉诱导中最低值和气管插管过程中最高值,记录气管插管一次性成功率及呼吸抑制、呛咳和躁动发生率情况。结果B、C2组MAP气管插管时最高值均明显较A组下降（均P〈0．05）．C组HR较A组下降（P〈0．05）;B、C2组气管插管一次性成功率均明显高于A组（均P〈0．05）。C组呼吸抑制发生率高于A、B2组（P〈0．05）。A组呛咳和躁动发生率高于B、C2组（P〈0．05）。结论充分表面麻醉的基础上,静脉注射咪达唑仑注射液0．03mg／kg、瑞芬太尼1．0μg／kg用于纤维支气管镜引导下清醒气管插管安全、可行,且为最佳剂量。     

瑞芬太尼在老年人腹部手术麻醉中的应用

【目的】观察瑞芬太尼复合静脉麻醉的效果,为老年手术病人临床应用提供依据。【方法】气管插管全身麻醉下老年患者腹部手术120例,随机分为瑞芬太尼组（RF）、芬太尼组（F）。诱导用咪唑安定0．08mg／kg,丙泊酚1mg／kg,瑞芬太尼1～2μg／kg（RF组）或芬太尼3～4μg／kg（F组）,阿曲库铵0．8mg／kg气管插管后接麻醉机行间隙正压通气,术中持续泵注瑞芬太尼0．2～0．3pg／（kg·min）（RF）组或芬太尼0．03～0．04pg／（kg·min）（F组）加丙泊酚0．06～0．08mg／（kg·min）,手术结束前10min停药,阿曲库铵15mg／30min,手术结束前30min停药。观察平均动脉压（MAP）、心率（HR）、自主呼吸恢复时间、呼之睁眼时间及拔管时间。【结果】插管后即刻和插管后5min两组间MAP、HR差异有显著性（P〈0．01）,RF组明显低于F组,术后恢复情况RF组病人呼吸恢复时间、呼之睁眼时间及拔管时间明显短于F组。【结论】瑞芬太尼复合静脉麻醉,用于老年病人腹部手术效果优良,苏醒快,恢复好。     

瑞芬太尼与氯胺酮用于剖宫产全麻时对血压、心率及胎儿评分影响的比较

目的：对照研究在全麻剖宫产术中应用瑞芬太尼和氯胺酮诱导对母婴的影响。方法：选择100例禁忌椎管内麻醉而须行全麻剖宫产手术的患者,分为两组,氯胺酮组静注异丙酚1.5 mg/kg＋氯胺酮1 mg/kg＋琥珀胆碱1.5 mg/kg;瑞芬太尼组静注异丙酚1.5 mg/kg＋瑞芬太尼1μg/kg＋琥珀胆碱1.5 mg/kg诱导插管,胎儿娩出后均静注芬太尼2 g/kg、泵注异丙酚3 mg/（kg.h）和吸入异氟醚0.5MAC维持麻醉,阿曲库铵维持肌松。结果：瑞芬太尼组插管（切皮）后血压、心率升高幅度显著小于氯胺酮组,两组新生儿1 min、5 min Apgar评分无明显差异。结论：瑞芬太尼用于产科全麻优于氯胺酮,安全可行。     

瑞芬太尼复合异丙酚静脉麻醉用于输尿管镜下气压弹道碎石术

目的探讨瑞芬太尼联合异丙酚静脉麻醉在输尿管镜下气压弹道碎石术的麻醉效果。方法选择ASAⅠ～Ⅱ级在输尿管镜下行气压弹道碎石术的患者60例，瑞芬太尼0．5μg／kg异丙酚2mg／kg诱导后，改为瑞芬太尼0．05μg／（kg·min）、异丙酚3mg／（kg·h）维持。手术全程监测血压（SBP／DBP）、心率（HR）、氧饱和度（SpO2）、呼吸抑制情况、停药至意识恢复时间。结果全手术过程中无记忆、无痛；在麻醉过程中SBP、DBP、HR、SpO2有不同程度下降（P〈0．01），但均在正常范围内，且术后恢复至术前水平（P〉0．05），有心率减慢及呼吸抑制发生。结论瑞芬太尼复合异丙酚用于输尿管镜下气压弹道碎石术具有麻醉效果好、术后苏醒快的优点，但术中要加强监测，及时处理。     

异丙酚复合芬太尼用于经鼻盲探气管插管的临床观察

目的评价经鼻盲探气管插管患者异丙酚复合芬太尼的麻醉效果。方法全麻患者60例,ASAⅠ或Ⅱ级,男52例,女8例,年龄18—52岁,体重52～75kg,随机分为两组：常规镇静组（Ⅰ组）30例和异丙酚复合芬太尼组（Ⅱ组）30例。静注芬太尼2彬kg、异丙酚2mg／kg麻醉诱导,然后以6mg,／（kg·h）速率持续榆注异丙酚,3～5min后经鼻行盲探气管插管,连续监测收缩压（SBP）、舒张压（DBP）、平均动脉压（MAP）、心率（HR）、呼吸频率（RR）、心电图、动脉血氧饱和度,分别于麻醉诱导前（T0）、气管插管时（TI）、气管插管后5min（T2）,记录SBP、DBP、MAP、HR、RR,计算气管插管一次性成功率,观察诱导过程中呼吸抑制发生情况。结果与T0比较,T1时Ⅱ组患者SBP、DBP、MAP、HR、RR均降低,但差异无统计学意义（P〉0．05）,1组患者均明显升高（P〈0．05）,并且两组间比较差异有统计学意义（P〈0．05）;T2时Ⅰ组上述指标略降低,与T0比较仍差异有统计学意义（P〈0．05）。与Ⅰ组比较,Ⅱ组患者经鼻盲探气管插管一次性成功率高,气管插管完成时闻较快（P〈0．05）,但呼吸暂停时间和呼吸抑制发生率两组间比较差异无统计学意义（P〉0．05）。结论异丙酚2mg／kg复合芬太尼2ug／kg麻醉诱导,然后输注异丙酚6mg／（kg·h）用于经鼻盲探气管插管,麻醉效果良好,血流动力学稳定,气管插管一次性成功率高,但存在一定程度的呼吸抑制发生率,术中应加强监测。     

瑞芬太尼复合丙泊酚及阿曲库胺全凭静脉麻醉在神经外科麻醉中的应用

目的：探讨瑞芬太尼复合丙泊芬及阿曲库胺全凭静脉麻醉在神经外科手术中应用的效果。方法：选择80例神经外科择期手术患者，随机均分为瑞芬太尼复合丙泊酚及阿曲库胺全凭静脉组（Ⅰ组）和静吸复合麻醉组（Ⅱ组）。瑞芬太尼和丙泊酚的诱导量分别为1μg／kg和1mg／kg，阿曲库胺为0．5mg／kg。瑞芬太尼以0．2μg／（kg·h）速率输注。麻醉中通过增减瑞芬太尼输注速率调整麻醉深度；丙泊酚按5：4：3方案输注，即5mg／（kg·h）输注10min，4mg／（kg·h）输注20min后，3mg／（kg·h）恒速输注。阿曲库胺以1mg／（kg·h）恒速输注。观察两组气管插管反应、麻醉效果、苏醒质量。结果：血流动力学指标：Ⅰ组与术前相比无显著差异；Ⅱ组插管后及术中各观测值均较术前显著升高（P〈0．05）；术后清醒时间Ⅰ组较Ⅱ组显著缩短（P〈0．01），但麻醉诱导期不良反应发生率Ⅰ组较Ⅱ组显著增高（P〈0．01）。结论：瑞芬太尼复合丙泊酚及阿曲库胺实施全凭静脉麻醉，采用负荷量加两种以上速率输注简便易行，术中情况平稳，管理方便，苏醒迅速，但诱导期不良反应发生率较高，应引起注意。     

不同剂量瑞芬太尼复合七氟醚诱导用于小儿无肌松药气管插管的研究

目的探求瑞芬太尼复合七氟醚诱导用于小儿无肌松药气管插管的剂量-效应关系。方法45例行择期手术的全麻患儿，按不同剂量瑞芬太尼随机均分4组：R1组2．0ug／kg，R2组2．5ug／kg，R3组3．0ug／kg。诱导使用8％七氟醚半紧闭吸入，待患儿入睡后开放静脉，维持2．5％七氟醚吸入15min后分别静脉注射3个不同剂量的瑞芬太尼辅助气管插管。分别于麻醉诱导前（T0）、气管插管前即刻（T1）、插管后1min（T2）、3min（T3）记录平均动脉压（MAP）、心率（HR），并对插管条件进行评估。结果R1组气管插管条件满意率低于R2、R3组（X^2=6．71，P〈0．05），但R2、R3组差异无统计学意义（X^2=0．24，P〉0．05）；与T0时比较，各组患儿在T1时HR、MAP均明显下降伊分别=7．56、6．35，P均〈0．05），R1组在T2、T3时HR、MAP较T1明显升高限分别=13．34、11．75，P均〈0．05），且与R2、R3组比较，差异均有统计学意义伊分别=8．59、7．81，P均〈0．05），但R2、R3组在R、B时HR、MAP与．r1比较，差异均无统计学意义（F分别=3．65、4．12，P均〉0.05）。结论瑞芬太尼2．5～3．0ug／kg复合2．5％七氟醚用于小儿无肌松药气管插管时，可提供满意的气管插管条件和稳定的血流动力学。     

Determination of creatine kinase isoenzyme MB activity in serum using immunological inhibition of creatine kinase M subunit activity. Activity kinetics and diagnostic significance in myocardial infarction.

This is a new method for the determination of creatine kinase isoenzyme MB activity in serum. The method uses direct activity measurement of creatine kinase B subunit activity after blocking of CK-M subunit activity by inhibiting antibodies. The test takes no longer than 15 min. The method yields an intra-serial C.V. of 2.0-12.9%, and a C.V. from day to day of 5.5%. The detection limit is 3.4 U/l creatine kinase MB. In the 95 cases with proven myocardial infarction several types of creatine kinase MB activity kinetics could be determined. The percentage of creatine kinase MB of peak CK-total is 6-25%, with a mean of 11.1%. The amount of creatine kinase MB with respect to total CK activity after reinfarction is higher than the amount after initial infarction.     

俯卧位通气对高海拔地区肺复张治疗无效急性呼吸窘迫综合征患者氧合的影响

目的 探讨俯卧位通气对高海拔地区肺复张术(RM)治疗无效急性呼吸窘迫综合征(ARDS)患者的治疗作用.方法 从海拔2260m的地区医院筛选RM治疗无效的41例ARDS患者[平均氧合指数( PaO2/FiO2)较RM前升高＜20％视为RM无效],依不同病因分为肺内源性ARDS组(ARDSp组)和肺外源性ARDS组(ARDSexp组),每组再按信封法随机分为俯卧位组和仰卧位组,即ARDSp俯卧位组(11例)、ARDSp仰卧位组(9例)、ARDSexp俯卧位组(10例)、ARDSexp仰卧位组(11例).在通气前及通气1、2、3、4h监测动脉血氧分压( PaO2)、PaO2/FiO2、静态顺应性(Cst)、气道阻力(Raw)的变化.结果 通气lh时,ARDSexp俯卧位组PaO2/FiO2( mm Hg,l mm Hg=0.133 kPa)即较通气前显著升高(157.4±40.6比129.3±48.7,P＜0.05),并随通气时间延长呈持续增高趋势,4h达峰值(219.1 ±41.1);且ARDSexp俯卧位组通气3h内PaO2/FiO2较其他3组显著增高,另3组间则差异无统计学意义.ARDSp俯卧位组、ARDSexp俯卧位组通气4h时PaO2/FiO2均较相应仰卧位组显著增高(208.8±39.7比127.4±47.1,219.1±41.1比124.9±50.8,均P＜0.05).4组通气前后Cst无显著改变,各组间差异也无统计学意义.ARDSp俯卧位组通气4h时Raw(cmH2O·L-1·s-1)较通气前显著降低(6.8±1.7比10.7±1.8,P＜0.05),且明显低于其他3组;其他3组各时间点Raw组内及组间比较差异均无统计学意义.结论 俯卧位通气作为ARDS机械通气重要策略之一,可以改善RM无效高原ARDS患者的氧合,为抢救患者赢得宝贵的时间.     

Digital imaging among medical facilities

The Department of Veterans Affairs (VA) in the USA operates a network of 172 medical centres which all utilize a hospital information system (HIS) which has been developed and is currently maintained by the VA. During the past several years, an image management and communication module has been developed, installed and clinically utilized at the Washington DC and Maryland VA Medical Centres. This image management and communication system, referred to as the decentralized hospital computer program (DHCP) imaging system, is fully integrated with a commercial picture archiving and communication system (PACS). The system is utilized to capture, archive, and display all images generated within the hospital including radiology, nuclear medicine, pathology, endoscopy, bronchoscopy, and dermatology, intraoperative photographs, ECG data, and a limited number of paper documents. The ultimate goal of the project is to have all patient text and image data available at any clinical workstation to any authorized user anywhere within the network of medical centres. Clinical requirements for an imaging workstation include ease of use, rapid and reliable access to the complete set of patient information, and images which are of acceptable quality to meet the requirements of the user and the subspecialty. Patient confidentiality and data security must be safeguarded at all times. Integration of the images with the remainder of the patient's database was found to be critical to the success of the project. The experience at the Washington and Maryland facilities suggests that an imaging system that is successfully integrated with a hospital information system can provide substantial clinical and economic benefits both within and among medical centres. Clinical acceptance and utilization of the system has been excellent, particularly in diagnostic radiology where DHCP Imaging has been interfaced to a commercial PAC system. Based upon this initial experience, the VA has begun to deploy the system throughout its large network of medical centres.     

Myocardial elastography at both high temporal and spatial resolution for the detection of infarcts

Myocardial elastography is a novel method for noninvasively assessing regional myocardial function, with the advantages of high spatial and temporal resolution and high signal-to-noise ratio (SNR). In this paper, in-vivo experiments were performed in anesthetized normal and infarcted mice (one day after left anterior descending coronary artery [LAD] ligation) using a high-resolution (30 MHz) ultrasound system (Vevo 770, VisualSonics Inc., Toronto, ON, Canada). Radiofrequency (RF) signals of the left ventricle (LV) in longitudinal (long-axis) view and the associated electrocardiogram (ECG) were simultaneously acquired. Using a retrospective ECG gating technique, 2-D full field-of-view RF frames were acquired at an extremely high frame rate (8 kHz) that resulted in high-quality incremental displacement and strain estimation of the myocardium. The incremental results were further accumulated to obtain the cumulative displacements and strains. Two-dimensional and M-mode displacement images and strain images (elastograms), as well as displacement and strain profiles as a function of time, were compared between normal and infarcted mice. Incremental results clearly depicted cardiac events including LV contraction, LV relaxation and isovolumetric phases in both normal and infarcted mice, and also evidently indicated reduced motion and deformation in the infarcted myocardium. The elastograms indicated that the infarcted regions underwent thinning during systole rather than thickening, as in the normal case. The cumulative elastograms were found to have higher elastographic SNR (SNR(e)) than the incremental elastograms (e.g., 10.6 vs. 4.7 in a normal myocardium, and 6.0 vs. 2.4 in an infarcted myocardium). Finally, preliminary statistical results from nine normal (m = 9) and seven infarcted (n = 7) mice indicated the capability of the cumulative strain in differentiating infracted from normal myocardia. In conclusion, myocardial elastography could provide regional strain information at simultaneously high temporal (>/=0.125 ms) and spatial ( approximately 55 microm) resolution as well as high precision ( approximately 0.05 microm displacement). This technique was thus capable of accurately characterizing normal myocardial function throughout an entire cardiac cycle, at the same high resolution, and detecting and localizing myocardial infarction in vivo.     

手转胎头术失败的原因与分娩结局临床分析

目的 探讨手转胎头术失败的原因与分娩结局.方法 选择2008年1月至2010年12月于我院住院分娩的持续性枕横位、枕后位产妇198例,根据行手转胎头术后结果分为成功组126例、失败组72例.比较两组分娩结局,对比分析失败原因.结果 失败组胎儿体质量≥3500 g的发生率[76.4％(55/72)]明显高于成功组[31.7％(40/126)],差异有统计学意义(x2=30.177,P=0.001)、失败组宫缩乏力发生率[58.3％(42/72)]高于成功组[38.1％ (48/126)],差异有统计学意义(x2=7.569,P=0.006)、失败组骨盆临界或轻度狭窄发生率[38.9％ (28/72)]高于成功组[23.8％(30/126)],差异有统计学意义(x2 =5.030,P=0.002)、失败组手转胎头时机不当(宫口开大＜6 cm、胎头位于坐骨棘上及宫口开大8～10 cm、胎头位于坐骨棘下≥2 cm)发生率[61.1％(44/72)]高于成功组[38.9％(49/126)],差异有统计学意义(x2=9.084,P=0.003).失败组母儿并发症(产后出血、产褥病率、胎儿窘迫、新生儿窒息)发生率高于成功组(x2 =9.586,P=0.002、x2=9.334,P=0.002、x2=5.910,P=0.015、x2=5.240,P=0.022)、失败组剖宫产发生率[72.2％(52/72)]明显高于成功组[34.1 ％(43/126),x2=26.641,P=0.001)].结论 手转胎头术能使难产变顺产,降低剖宫产率,减少母儿并发症,但须积极预防、处理导致手转胎头术失败的原因,对矫正失败后继续矫正及试产应慎重.     

Clinical Pharmacokinetics of Morphine

Morphine, the most widely used mu-opioid analgesic for acute and chronic pain, is the standard against which new analgesics are measured. A thorough understanding of the pharmacokinetics of morphine is required in order to safely and effectively use this analgesic in a wide variety of patients with different levels of organ function. A MEDLINE search was conducted to identify literature published between 1966 and January 2002 relevant to the pharmacokinetics of morphine. These publications were reviewed and the literature summarized regarding unique and clinically important elements of morphine disposition relative to its parenteral administration (including intravenous, intramuscular, subcutaneous, epidural and intrathecal administration), absorption profile (immediate release, controlled release, and sublingual/buccal, and rectal administration), distribution, and its metabolism/ excretion. Special populations, including infants, elderly, and those with renal/liver failure, have a unique morphine pharmacokinetic profile that must be taken into account in order to maximize analgesic efficacy and reduce the risk of adverse events.     

Evidence-Based Pain Management and Palliative Care in Issue Four for 2009 of The Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly. Issue 4 for 2009 contains 4027 complete reviews, 1906 protocols for reviews in production, and 11447 one-page summaries of systematic reviews published in the general medical literature. In addition, there are citations of 600,000 randomized controlled trials, and 12,200 cited papers in the Cochrane methodology register. The health technology assessment database contains over 7500 citations. This edition of the Library contains 90 new reviews, of which 19 have potential relevance for practitioners in pain and palliative medicine.     

Wie zuverlässig sind Angaben zu nichtentzündlichen ausgedehnten Schmerzen?

ZusammenfassungFragestellung Es wurde geprüft, wie sich der Differenziertheitsgrad zweier Schmerzmessmethoden auf Angaben zur Ausgedehntheit klinischer Schmerzen auswirkt. Zugleich wurde der Referenzzeitraum variiert, über den die Patienten berichten sollten.Methode Erfasst wurde der Einfluss zu Lasten der Befragungsdifferenziertheit durch den Vergleich zweier Körperschema-Bildvorlagen. Drei Referenzzeiträume (Schmerz aktuell, letzte Woche, letztes halbes Jahr) wurden vorgegeben.Ergebnisse Patienten mit ausgedehnten Schmerzen gaben bei differenzierter Befragung um so mehr Schmerzen an, je weiter die Schmerzen zurück lagen und je größer der Berichtszeitraum war. Patienten mit gelenknahen Schmerzen gaben bei hoch differenzierter Befragung weniger ausgedehnte Schmerzen in der Vergangenheit an als bei globaler Einschätzung. Patienten mit Rückenschmerzen berichteten bei differenzierter Befragung zum aktuellen Schmerz über weniger ausgedehnte Schmerzen als bei globaler Befragung.Schlussfolgerung Die Angaben zur Schmerzausdehnung variieren vor allem bei Patienten mit ausgedehnten Schmerzen in Abhängigkeit von der Differenziertheit der Befragung. In diesen Fällen ist die Wahrscheinlichkeit erhöht, dass sich die Beschwerdesymptomatik zumindest teilweise erst in der Reaktion auf die situativen Befragungsbedingungen konstituiert und daher nicht auf andere Befragungsbedingungen generalisiert werden kann.