非ST段抬高急性冠脉综合征患者3O天内发生急性心血管事件的危险因素探讨

目的 分析预测非ST段抬高急性冠状动脉综合征(ACS)患者30天内发生心血管事件的独立危险因素。方法 根据283例非ST段抬高ACS患者就诊即刻的临床情况、心电图变化和心肌生化标志物水平，判断预测30天内急性心血管事件的独立危险因素；急性心血管事件的定义为死亡、恶性室性心律失常、再发心肌梗死和心绞痛、急性左心功能衰竭、需重复经皮冠状动脉成形术(PTCA)或冠状动脉旁路移植术(CABG)或再次住院。结果 共33例患者(11．7％)发生急性心血管事件；多因素分析发现30天内心血管事件的独立预测因素包括高龄(OR=1.39，95％CI 1.13～1．82，P=0．006)、糖尿病史(OR=2．21，95％CI 1．29～3．79，P=0．013)、就诊时心电图ST段压低(OR=2．49，95％CI 1．26～3．98，P=0．004)、就诊12小时内心肌生化标志物阳性(OR=2．84，95％CI 1．42～5．38，P=0．003)。结论 年龄增加、糖尿病、就诊即刻心电图ST段压低和就诊12小时以内心肌特异性酶学改变(CK-MB或TNT)4项因素是非ST段抬高ACS患者在30天内发生急性心血管事件的独立预测因素。     

血浆脑钠素水平测定对无ST段抬高的急性冠状动脉综合征患者预后的预测价值

目的探讨血浆脑钠素(BNP)对无ST段抬高的急性冠状动脉综合征(ACS)患者预后的预测价值。方法对192例无ST段抬高的ACS患者(ACS组),20例性别、年龄相匹配的健康体检者(正常对照组)进行血浆BNP测定,并观察6个月内心血管事件(包括不稳定型心绞痛、急性心肌梗死、心力衰竭、全因死亡)发生情况。结果ACS组血浆BNP(36.45±14.96)ng/L,明显高于正常对照组(11.45±3.95)ng/L(P<0.01);在ACS组内,心肌梗死(AM I)亚组中血浆BNP(43.19±15.26)ng/L,明显高于不稳定型心绞痛(UA)亚组(31.73±12.85)ng/L(P<0.01);正常对照组无1例发生心血管事件;ACS组中,BNP>30 ng/L亚组心血管事件发生率为29.5%,显著高于BNP正常亚组的16.3%(P=0.029),比数比(OR)2.146(95%可信区间为1.07~4.29),血浆BNP>30 ng/L判断心血管事件的阳性预测值为29.5%,阴性预测值为83.6%。结论血浆BNP检测对无ST段抬高的ACS患者预后有较好的判断价值。     

血浆生长分化因子-15与急性冠状动脉综合征患者预后的关系

目的探讨血浆生长分化因子-15(growth differentiation factor-15,GDF-15)与急性冠状动脉综合征(acute coronary syndrome,ACS)患者预后的关系。方法回顾性分析371例ACS患者的临床资料,记录入院时血浆GDF-15水平,观察1a后心血管终点事件发生情况,应用多因素logistic回归分析心血管终点事件发生的危险因素。结果随访1a,出现心血管终点事件者55例为观察组,未出现心血管终点事件者316例为对照组;观察组入院时血浆GDF-15水平[(1 314.4±542.3)ng/L]高于对照组[(832.6±367.2)ng/L](P0.01);多因素logistic回归分析显示,高血浆水平GDF-15(OR=2.086,95%CI:1.583~2.623,P=0.000),糖尿病(OR=2.504,95%CI:1.337~4.890,P=0.014),吸烟(OR=1.802,95%CI:1.913~4.623,P=0.012)是ACS患者1a心血管终点事件发生的危险因素。结论高血浆水平GDF-15为ACS患者心血管终点事件发生的危险因素。     

尿酸及二氧化碳结合力与急性心肌梗死患者急诊PCI术后对比剂性急性肾损害的相关性研究

目的探讨尿酸、二氧化碳结合力与急性心肌梗死患者急诊经皮冠状动脉介入治疗(PCI)后对比剂性急性肾损害(CI-AKI)的相关性。方法连续入选2012年1月至2014年6月入院的急性心肌梗死(包括急性ST段抬高型心肌梗死和急性非ST段抬高型心肌梗死)并行急诊PCI的208例患者的临床资料。将患者分为4组:Ⅰ组术前尿酸(UA)、二氧化碳结合力(CO2-CP)均正常;Ⅱ组高UA,CO2-CP正常;Ⅲ组UA正常,CO2-CP异常(22.0 mmol/L);Ⅳ组高UA,CO2-CP22.0 mmol/L。前瞻性的观察4组患者的CI-AKI的发生率及院内临床事件。结果 208患者中12例发生CI-AKI(5.8%),其中Ⅳ组7例(3.4%),Ⅱ组3例(1.4%),Ⅲ组2例(1.0%),Ⅰ组为0例。多因素Logistic回归分析结果显示:年龄70岁(OR=1.045,95%CI:1.007~1.092,P=0.019)、术后低血压(OR=1.892,95%CI:1.229~2.751,P=0.001)、慢性心功能不全(OR=1.681,95%CI:1.227~2.298,P=0.001)、e GFR60 ml·min-1·1.73 m-2(OR=1.708,95%CI:1.168-2.495,P=0.005)、高尿酸(OR=1.896,95%CI:1.269~2.830,P=0.002)、二氧化碳结合力22.0 mmol/L(OR=1.695,95%CI:1.231-2.333,P=0.001)是CI-AKI的独立危险因素。结论高尿酸血症和二氧化碳结合力22.0 mmol/L是急性心肌梗死患者急诊PCI术后对比剂性急性肾损害的独立危险因素。     

胸痛中心持续改进对急性ST段抬高型心肌梗死患者再灌注及预后的影响

目的探讨胸痛中心认证后,各部门急救流程的持续改进对急性ST段抬高型心肌梗死患者再灌注及预后的影响。方法回顾性分析2018年3月至2019年7月于安徽医科大学第三附属医院合肥市第一人民医院胸痛中心确诊为急性ST段抬高型心肌梗死并行经皮冠状动脉介入治疗的患者206例临床资料,将认证前收治的98例患者设为对照组,认证后收治的108例患者设为研究组。对比研究组及实验组患者的开始发病至初次医疗接触时间、进门至植入球囊扩张时间、初次医疗接触至植入球囊扩张时间、总缺血时间及经皮冠状动脉介入治疗术后30 d主要心血管不良事件发生率,并对术后30 d主要心血管不良事件发生的影响因素进行Logistic回归分析。结果研究组患者初次医疗接触至植入球囊扩张时间[84.5(73.0,96.0)min]、总缺血时间[205.0(159.8,307.0)min]、进门到植入球囊扩张时间[72.5(58.3,83.8)min]较对照组[112.0(93.0,132.5)min、241.0(199.0,329.0)min、78.0(68.0,96.5)min]明显缩短,差异均有统计学意义(P均<0.05);研究组患者开始发病至初次医疗接触时间稍短于对照组[124.5(77.3,201.0)min与130.0(76.3,216.0)min],差异无统计学意义(P>0.05);与对照组比较,研究组患者术后30 d主要心血管不良事件发生率更低[16.7%(18/108)与28.6%(28/98)],差异有统计学意义(P=0.040)。根据多因素Logistic回归分析结果,KillipⅢ、Ⅳ级(OR 2.618,95%CI 1.244~5.509,P=0.011)、开始发病到初次医疗接触时间>90 min(OR 4.562,95%CI 2.167~9.603,P<0.001)、进门到植入球囊扩张时间>60 min(OR 2.227,95%CI 1.087~4.563,P=0.029)是术后30 d主要心血管不良事件发生的独立危险因素。结论胸痛中心流程的持续改进可以促使本地区内医疗资源的合理利用,更有效地缩短心肌梗死患者的救治时间,减少术后30 d内主要心血管不良事件的出现。     

十二导联心电图对左主干病变导致急性冠状动脉综合征的诊断价值

目的探讨十二导联心电图对左主干病变导致急性冠状动脉综合征（ACS）的诊断价值。方法37例ACS患者根据冠状动脉造影结果分为A组（左主干病变导致ACS组）17例和B组（左前降支近段病变导致ACS组）20例,2组患者胸痛发作时均行十二导联心电图检查,分析冠状动脉病变血管与相应心电图变化的关系。结果A组在Ⅱ、Ⅲ、aVF、V2、V3、V4、V5、V6导联上相应ST段压低的发生率高于B组（P〈0．05或P〈0．01）。A组ST段在aVR、V1导联抬高并aVF、V2、V4导联压低发生率高于B组（P〈0．05）。结论十二导联心电图上aVR、V1导联ST段抬高并aVF、V2、V4导联压低对ACS患者左主干病变有较好的阳性预测价值。     

非ST段抬高的急性冠状动脉综合征的介入治疗进展

急性冠状动脉综合征(ACS)是以冠状动脉粥样硬化斑块破裂或侵蚀,继而发生完全或不完全闭塞性血栓形成为病理基础的一组临床综合征,包括从不稳定性心绞痛(UA)至急性心肌梗死(AMI)的一系列临床病征。现代诊疗策略以初始心电图有无持续性ST段抬高分为ST段抬高的急性冠状动脉综合症和非ST段抬高的急性冠状动脉综合征。对于ST段抬高的ACS,     

白细胞介素-33与急性心肌梗死患者经皮冠状动脉介入术后心肌无复流发生的相关性研究

目的探讨白细胞介素-33(IL-33)与急性ST段抬高性心肌梗死(STEMI)经皮冠状动脉介入术(PCI)后心肌无复流发生风险的关系。方法共计纳入STEMI行急诊PCI的患者59例,其中男39例,女20例。于PCI术前采集血样本,以酶联免疫吸附法(ELISA)测定血清可溶性IL-33和高敏C反应蛋白(hs-CRP)水平。心肌无复流(MNR)定义为TIMI血流分级≤2或TIMI(TIMI)3且心肌呈色分级(MBG)≤2。结果共计21例(35.6%)STEMI患者发生MNR,与复流组相比,无复流组IL-33水平显著降低(P=0.019),hs-CRP水平显著升高(P=0.031)。多因素Logistic回归分析表明糖尿病(OR=0.123,95%CI:0.018~0.811,P=0.026)、发病至再灌注时间(OR=0.392,95%CI:0.314~1.106,P=0.025)、血栓负荷评分(OR=0.078,95%CI:0.007~0.913,P=0.040)、hs-CRP(OR=1.441,95%CI:1.162~1.793,P<0.001)、IL-33水平(OR=0.624,95%CI:0.436~0.877,P=0.014)是MNR的独立预测因子。结论 IL-33在MNR的发生中具有重要作用,其水平降低可能是MNR发生的危险因素之一。     

心型脂肪酸结合蛋白对急性冠脉综合征患者的近期危险预测

目的:对比研究心型脂肪酸结合蛋白(H-FABP)和传统预测指标对急性冠脉综合征(ACS)患者近期心血管事件的危险预测价值。方法:ACS患者于发作12h内入院者152例入选研究组,其中急性心肌梗死75例、不稳定型心绞痛77例。采用双抗体两步夹心ELISA法定量测量待测血清H-FABP;采用Cox比例风险模型(the Coxproportional hazard model,Cox模型)对H-FABP和传统预测指标(年龄;性别;收缩压高于140mmHg;有无糖尿病史;既往有无心肌梗死病史;Killip分级>Ⅱ与否;ST段抬高与否;吸烟)进行多因素危险分析,并计算各危险因素对ACS患者近期(30d)发生心血管事件(心源性猝死、再发ACS、充血性心衰)的相对危险度。结果:H-FABP阳性者心血管事件的相对危险度为6.186(95%CI1.246～30.717),P值为0.026,远高于其他传统预测指标。结论:H-FABP阳性是ACS短期内心血管危险的一个独立危险因素,比传统指标更具预测价值,对高危ACS患者接受适当的治疗有明确的指导意义。     

急性冠状动脉综合征非ST段抬高患者心血管危险因素及其影像学特征

目的：分析比较非ST段抬高的急性冠状动脉综合征与ST段抬高的急性心肌梗死患者的心血管危险因素和影像学特征。 方法：选择2003-01／2004-04在南方医科大学南方医院心内科住院并 接受冠脉造影的冠心病患者，按照2002年美国心脏病学学院／美国心脏协会不稳定型心绞痛和非ST段抬高心肌梗死治疗指南及2000年中华医学会心血管病学分会的不稳定性心绞痛诊断和治疗建议进行诊断分类。非ST段抬高的急性冠状动脉综合征患者33例(非ST段抬高组)，男30例，女3例。ST段抬高的急性心肌梗死患者33例(ST段抬高组)，男27例，女6例。对两组患者的心血管危险因素和影像学特征进行对比统计分析。 结果：进入结果分析非ST段抬高急性冠状动脉综合征患者33例，ST段抬高急性心肌梗死患者33例。非ST段抬高组与ST段抬高组具有相同程度的冠心病危险因素年龄、血脂紊乱、高血压、肥胖、合并糖尿病、有吸烟史、有早发冠心病家族史(P>0．05)。非ST段抬高组患者具有2个以上心血管危险因素，其病变血管数与ST段抬高维相似；冠状动脉狭窄程度重于ST段抬高组[狭窄程度<50％：8，3例；50％～74％：9，9例；75％～99％：53，43例；100％：1，20例，Z=3．45，P=0．001]，但>75％以上严重的狭窄病变占总病变的76％。严重狭窄病变形态差于ST段抬高组(Z=3．23，P=0．001)。 结论：非ST段抬高的急性冠状动脉综合征与ST段抬高的心肌梗死患者具有相似的危险因素；ST段抬高的急性心肌梗死患者冠状动脉狭窄更严重，而且较严重的病变形态多于非ST段抬高的急性冠脉综合征患者。     

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.     

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.     

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.     

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.