直接核酸测序法进行血友病A携带者及产前诊断

目的：对一血友病AfHA)家系进行携带及产前诊断。方法：用活化部分凝血活酶时间(APTT)、凝血酶原时间(PT)、纤维蛋白原(Fg)和血浆因子Ⅷ促凝活性(FⅧ：C)测定进行表型诊断；用FⅧ内含子22倒位直接检测以及FⅧ基因内外4个位点的多态性进行遗传连锁分析：用核酸直接测序法对FⅧ各外显子及其侧翼序列进行检测。结果：表型检测证明先证为重型HA，其妹妹FⅧ：C正常；FⅧ内含子22倒位直接检测及FⅧ基因内外4个位点的多态性遗传连锁分析均未获得有诊断意义的信息；直接核酸测序证实先证及其妹妹FⅦ基因24号外显子第2209位氨基酸存在Arg→Gin(CGA→CAA)错义突变，酶切结果与此一致，其妹为携带，后胎儿羊水细胞DNA检测为正常男性。结论：FⅧ基因24号外显子错义突变Arg209Gln(CGA→CAA)是该HA先证发病的分子机制。此突变位点为国内首次报道，且该家系为国内首例运用直接核酸测序法进行HA携带及产前诊断的家系。     

两个同源重组血友病家系的基因诊断

目的探讨特殊血友病家系的基因诊断。方法通过FⅧ基因内含子22倒位及内含子1倒位的直接检测与遗传连锁分析的间接诊断相结合对1个血友病A（HA）家系进行基因诊断；采用核酸直接测序法对FⅨ各外显子及其侧翼序列进行检测，并联合FⅨ基因相关的6个微卫星（STR）位点对1个血友病B（HB）家系进行基因诊断。结果HA家系先证者为FⅧ内含子1倒位阳性，家系中要求做携带者诊断的女性成员为内含子1倒位携带者；而FⅧ基因内外8个多态性位点遗传连锁分析证实该女性成员发生同源染色体重组。HB家系先证者除7号外显子测序未成功外，其余部分均未找到突变，家系中要求做携带者与产前诊断的女性，其羊水细胞经直接核酸测序未找到突变，利用FⅨ相关的6个STR位点进行遗传连锁分析发现该女性有染色体同源重组现象存在，胎儿为正常男性。结论在应用间接诊断方法进行HA和HB的携带者及产前基因诊断时，要考虑到染色体同源重组现象的发生可能导致误诊与漏诊的情况。在中国人群中应该开发更多的FⅧ和FⅨ分子中信息量大的多态性位点，以提高HA和HB的携带者及产前诊断的准确率。     

无先证者血友病A家系的基因诊断

目的 :探讨无先证者血友病A(hemophilia A,HA)家系的基因诊断。方法 :对5个无先证者的HA家系,采用长距离PCR及序列特异PCR直接检测疑似携带者的凝血因子Ⅷ(coagulation factorⅧ,FⅧ)基因内含子22倒位及1倒位;对其中未检测出的家系通过联合FⅧ基因内外的7个STR位点(FⅧCivs13、Intron25、3_486、5_147、5_226、DXS8069、DXS1073)进行遗传连锁分析,对于有产前诊断要求的孕妇则结合其男性胎儿脐带血的FⅧ活性检测结果作出分析。结果 :5个HA家系中,有3例疑似携带者的FⅧ基因内含子22倒位检测结果为阳性,1例疑似携带者的FⅧ基因内含子1倒位检测结果为阳性。对于另1例22倒位、1倒位检测结果均为阴性但有产前诊断要求的孕妇,通过联合FⅧ基因内外的7个STR位点进行遗传连锁分析,发现胎儿是携带1条致病X染色体的男性,且胎儿脐带血的FⅧ活性为1%,故联合诊断胎儿为男性HA患者。结论:在无HA先证者情况下,通过FⅧ基因内含子22及1倒位筛检,联合FⅧ基因内、外多个位点的遗传连锁分析及胎儿脐带血FⅧ活性检测,可为家系女性携带者的诊断及产前诊断提供有用信息。     

血友病A／B的携带者和产前诊断研究

目的：建立一套简易、快速且准确率高的血友病携带者和产前诊断体系。方法：对血友病A（HA）家系采用长距离聚合酶链反应（LD-PCR）及序列特异PCR进行F8基因内含子22及内含子1倒位检测。对有家族史的HA家系可联合F8基因内外的8个多态性位点进行遗传连锁分析．产前诊断加测性别位点（Amelo）。而对散发家系，则通过直接核苷酸测序查找先证者的基因突变，继而对家系女性成员进行携带者与产前诊断。对血友病B（HB）家系，采用直接核苷酸测序法确定其基因突变．结果：100个HA家系中。22例先证者的F8基因内含子22倒位检测结果为阳性；2例患者母亲为F8基因内含子1倒位的携带者：对有家族史的家系，综合应用倒位检测和遗传连锁分析，携带者与产前诊断率均为100％。34个HA散发家系除2个家系外均可找到致病突变：发现可能携带者105例，产前诊断65例，总诊断率为95．9％：23个HB家系中19个家系通过直接测序可找到突变．而联合F9基因外6个STR位点对HB家系进行遗传连锁分析，发现31例可能携带者及需产前诊断者16例，总诊断率为95．7％。结论：F8基因内含子22及1倒位筛检联合F8基因内、外多个位点的遗传连锁分析．可作为HA的携带者检测及产前诊断的方法；直接核苷酸测序可确定F9基因突变．而联合基因外多个多态性位点检测并进行遗传连锁分析．是HB携带者检测及产前诊断的简便、快速方法。     

血友病携带者与产前基因诊断

目的建立1种简便、快速的血友病携带者检测与产前诊断体系。方法对38个血友病A家系,用长链PCR及序列特异PCR作F8基因内含子22及1倒位检测;有家族史家系可联合F8基因内外的8个多态性位点进行遗传连锁分析,DXS 52(ST14)位点多态性以PCR产物凝胶电泳法检测,7个STR位点(F8C ivs13、CA22、DXS15、DXS9901、G6PD、DXS1073、DXS1108)的多态性以多重荧光PCR法检测,产前诊断加用性别位点(Amelo);对于散发家系,通过直接核苷酸测序查找先证者的基因突变,继而对家系女性成员作携带者与产前诊断。对12个血友病B家系采用直接核苷酸测序法确定基因突变,多重荧光PCR法检测F9基因外6个STR位点(DXS1192、DXS1211、DXS8094、DXS8013、DXS1227、DXS102)的多态性。结果38个血友病A家系中,10名先证者的F8基因内含子22倒位检测为阳性,1例先证者为F8基因内含子1倒位阳性,对于有家族史的家系,综合应用倒位检测和遗传连锁分析,携带者与产前诊断率均为100%;4个散发家系均可找到致病突变;38个血友病A家系的携带者及产前诊断总诊断率为94.81%。12个血友病B家系中有10个家系通过直接测序可找到突变,联合F9基因外6个STR位点对血友病B家系的遗传连锁分析的可诊断率为96.88%。结论F8基因内含子22及1倒位筛检联合F8基因内、外多个位点的遗传连锁分析可以进行血友病A的携带者及产前诊断;直接核苷酸测序可确定F9基因突变,而联合基因外多个多态性位点检测并进行遗传连锁分析,是血友病B携带者检测与产前诊断的简便、快速的方法。     

FⅧ基因内含子22倒位及X染色体非随机灭活导致的女性血友病A

目的 对1例女性血友病A(HA)患者进行产前诊断,探讨其分子发病机制.方法 利用测定FⅧ活性(FⅧ:C)、出血时间(BT)、血管性血友病因子(VWF)等指标进行HA表型诊断;用长链PCR及序列特异PCR进行FⅧ基凶内含子22及1倒位检测,对FⅧ基因的所有外显子及其侧翼序列进行测序.联合FⅧ基因内外的8个多态性位点进行遗传连锁分析,DXS 52(ST14)位点多态性以PCR产物凝胶电泳法榆测,7个微卫星位点(F8Civs13、CA22、DXS15、DXS9901、G6PD、DXS1073、DXS1108)的多态性以多重荧光PCR法检测,产前诊断加用性别位点(Amelo).利用甲基化敏感的限制性内切酶HpaⅡ对基因组DNA进行酶切,荧光PCR法对HpaⅡ酶切前后的基因组DNA进行人类雄激素受体基丙(HUMARA)中CAG重复序列的扩增,荧光扫描法对扩增产物进行检测,根据酶切前后PCR产物的峰值变化来分析判断X染色体的随机灭活模式.结果 先证者的FⅧ:C为2.1%,其余表型检测结果均正常,其家系成员表型检测结果均正常.FⅧ基因内含子22倒位检测示先证者为22倒位阳性携带者,家系其他成员及胎儿均为22倒位阴性;先证者FⅧ基因内含子1倒位检测结果为阴性,其FⅧ基因测序未发现突变.遗传连锁分析发现先证者的X染色体分别遗传自其父亲、母亲;其胎儿为女性且遗传了先证者来源于其母亲的1条X染色体.先证者为X染色体非随机灭活,其来自母亲的x染色体被大部分灭活,而来自父亲的x染色体大部分被保留活性.结论 FⅧ基冈内含子22倒位及X染色体非随机灭活导致了该例女性血发病A的发生,其胎儿为正常女性.     

血友病的携带者与产前分子诊断

目的：建立一种简便、快速的血友病携带者检测与产前诊断体系。方法：用聚合酶链反应(PCR)方法分别检测FⅧ内含子22倒位及血友病A家系中FⅧ基因内的BclⅠ位点、内含子13和22中STR和FⅧ基因外的DXS 52(ST14)位点的多态性；对血友病B家系检测FⅨ基因外6个STR位点(DXS1192、DXS1211、DXS8094、DXSS013、DXS1227、DXS102)的多态性。结果：综合应用直接检测倒位和遗传连锁分析。21个血友病A家系的可诊断率为94．7％；联合FⅨ基因外6个STR位点对血友病B家系进行遗传连锁分析。使10个家系全部得到诊断。结论：FⅧ内含子22倒位检测阳性，可以直接诊断血友病A的携带者及患儿；检测FⅧ基因内、外及FⅨ基因外多个位点的多态性并进行遗传连锁分析，是血友病携带者检测与产前诊断的简便、快速的方法。     

倒位PCR法检测血友病A FⅧ基因内含子22/1倒位

目的建立血友病A（hemophilia A,HA）FⅧ基因第22内含子倒位PCR检测法,并初步应用于HA直接基因诊断。方法应用倒位PCR（inversion-PCR,I-PCR）方法对24个HA家系中所有先证者的FⅧ基因22内含子倒位进行检测,对检测阳性者的母亲进一步用上述方法行携带者诊断,并对其中1例进行羊水产前基因诊断。检测阴性者再行内含子1倒位筛查。结果 24个HA家系中,7例先证者的F基因内含子22倒位检测为阳性,阳性检出率、可诊断率分别为29.17%、100%,未发现内含子1倒位;7例内含子22倒位突变阳性患者的母亲有6例为倒位携带者,羊水诊断未发现内含子22/1倒位。结论 I-PCR法能准确地检测F基因22内含子倒位突变,可应用于HA患者及携带者FⅧ基因22内含子倒位基因诊断及产前诊断。     

FⅧ基因内含子1倒位及X染色体非随机灭活导致的女性血友病A1例

目的：对1例女性血友病A（HA）患者进行基因分析，探讨其分子发病机制，并对其表姐进行携带者诊断．方法：测定1例女性HA患者的活化部分凝血活酶时间（APTT）、凝血酶原时间（PT）、FⅧ活性（FⅧ：C）、FⅨ活性（FⅨ：C）及血管性血友病因子（vWF）等，并进行HA表型诊断；采用长距离PCR及序列特异PCR检测其FⅧ基因内含子22及内含子1倒位，并对FⅧ基因的所有外显子及其侧翼序列进行测序。对FⅧ基因内外的8个多态性位点进行遗传连锁分析．应用凝胶电泳法检测PCR产物分析DXS52（ST14）位点多态性，采用多重荧光PCR法检测7个STR位点（F8Civs13、CA22、DXS15、DXS9901、G6PD、DXS1073及DXS1108）的多态性。应用甲基化敏感的HpaⅡ内切酶，对基因组DNA进行酶切；荧光PCR法对HpaⅡ酶切前后的基因组DNA进行人雄激素受体基因（HUMARA）CAG重复序列扩增：荧光扫描法对扩增产物进行检测，并根据酶切前后PCR产物的峰值变化，分析判断X染色体的随机灭活模式。结果：表型检测先证者APTT延长（128．5s），FⅧ：C活性明显下降（〈1％），家系另2例患者FⅧ：C活性亦明显下降（〈1％）。该家系成员FⅧ内含子22倒位检测均为阴性；1例位检测则显示该女性HA患者为阳性携带者，该家系另2例男性患者均显示为该倒位阳性：该女性HA患者FⅧ基因测序未发现突变。遗传连锁分析发现，该女性患者携带致病基因的染色体遗传自其母亲：其X染色体为非随机灭活，遗传自父亲的X染色体被大部分灭活，而遗传自母亲的X染色体保留3大部分活性．结论：该女性HA患者存在FⅧ基因内含子1倒位的X染色体来自其母亲，且在X染色体非随机灭活中保留了活性。FⅧ基因内含子1倒位及X染色体非随机灭活导致了女性HA的发生。     

临床不同背景情况下血友病A的产前诊断方案

目的建立临床不同背景情况下HA患儿产前诊断方案.方法对前来要求作HA产前诊断的15例孕妇进行遗传咨询,根据孕周和临床资料不同采取不同诊断方法.孕妇孕周＜23周,有先证者且已明确基因突变类型,抽羊水进行直接基因诊断和间接遗传连锁分析;有先证者但未明确基因突变类型,抽脐血进行间接遗传连锁分析和FⅧ活性检测;孕妇孕周＞23周且无先证者,抽脐血做FⅧ活性检测和性别染色体检查,但不能诊断携带者.直接基因诊断采用长距离PCR技术,对F8基因内含子22和内含子1倒位进行检测,找不到倒位者,行核苷酸测序;连锁分析采用F8基因内外的7个位点(DXS1108,F8Civs13,INTRON22,DXS1073,DXS9901,DXS15,DXS8069)以及性别位点(Amelo).产前诊断标本均需做母血污染鉴定.结果 15例产前诊断标本均无母血污染.明确诊断血友病A胎儿5例,其中脐血FⅧ活性＜1%的3例,1例伴21三体;F8基因22内含子倒位1例;F8基因23外显子错义突变p.Arg2182Cys 1例.结论对临床不同背景情况下采取不同方案进行HA产前诊断,可提高HA患儿检出率和准确性,最大程度地预防出生缺陷儿的发生.     

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.     

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.