原发性高血压患者左心室构型与冠状动脉内皮功能障碍间关系的超声研究

目的　了解原发性高血压患者左心室构型与冠状动脉内皮功能障碍之间的关系。方法　超声观察 34例原发性高血压患者和 15例正常人的心脏结构和功能,随后运用冷加压超声心动图试验结合含服硝酸甘油所致的血管内径变化分别评价冠状动脉内皮依赖性扩张(DICPT)和非内皮依赖性扩张(DING)。结果　①左室正常构型组、向心性重构组的DICPT[(8. 19±1. 74)%, (8. 60±2. 37)% ]较正常对照组[(14. 98±1. 54)% ]显著减小(P<0. 001),而前两组间差异无显著性意义。三组间的DING差异无显著性意义。②与左室正常构型组、向心性重构组相比,左室向心性肥厚组、离心性肥厚组的DICPT[(3. 32±1. 76)%, (2. 86±0. 48)% ]显著减小,且离心性肥厚组较向心性肥厚组更加显著(P<0. 001)。③与左室正常构型组、向心性重构组、向心性肥厚组相比,左室离心性肥厚组患者的左室射血分数和左室短轴缩短率显著减小(P<0. 001),但前 3组与正常对照组间左室射血分数、左室短轴缩短率差异无显著性意义。④不同左室构型组血压较正常对照组显著增高(P<0. 001),但年龄、血糖、血胆固醇及血甘油三脂与正常对照组间的差异无显著性意义。⑤DICPT与左室质量指数、左室相对室壁厚度、左室射血分数、左室短轴缩短率呈负相关(r=-0. 54,P<0. 0001; -0. 24     

高频超声评价甲亢性心肌病兔不同左室构型血管内皮功能的变化

目的 探讨高频超声评价甲状腺功能亢进(甲亢)性心肌病兔不同左室构型血管内皮功能变化的价值.方法 新西兰纯种白兔30只,随机分为实验组(20只)和对照组(10只).实验组腹腔注射左旋甲状腺素(45 μg/ (kg·d)×28 d)建立甲亢动物模型,实验组依据超声参数分为两型:向心性肥厚组(CH组)和离心性肥厚组(EH组),超声检测各组兔的血管内皮依赖性舒张功能( EDD)和血管内皮非依赖性舒张功能(NEDD).结果 CH组、EH组的EDD显著减小,且EH组进一步减小,差异具有显著性意义(P＜0.01).与对照组及CH组相比较,EH组NEDD显著减小,差异具有显著性意义(P＜0.01).结论 高频超声能准确评估甲亢性心肌病兔不同左室构型血管内皮功能的变化.     

高血压病人左室重构的超声表现

目的 :观察高血压病人左室不同构型的临床特点。方法 :对 2 2 8例高血压患者进行超声心动图检查 (高血压组 ) ,同时设 6 0例正常人为对照组。结果 :高血压组中左室正常构型占 2 1.9% ,向心性重构占 36 .4 % ,向心性肥厚占 32 .9% ,离心性肥厚占 8.8%。高血压组主动脉根部内径和左房内径高于对照组 (P <0 .0 5 ) ,以向心性肥厚和离心性肥厚患者更为明显 ;离心性肥厚患者的心指数 (CI)和心搏指数 (SVI)高于对照组和向心性重构患者 (P<0 .0 5 ) ;向心性重构患者射血分数 (EF)和左室短轴收缩率 (FS)值最高 (P <0 .0 5 ) ,离心性肥厚患者EF值最低 (P<0 .0 5 ) ;高血压组E/A比值均低于对照组 (P <0 .0 5 ) ,尤其是向心性肥厚和离心性肥厚患者。总外周血管阻力(TPR)在向心性重构患者最高 (P <0 .0 5 ) ,离心性肥厚患者最低 (P <0 .0 5 )。结论 :左室不同几何构型有其各自的特点 ,提示应采取不同的治疗措施。     

原发性高血压患者左室肥厚与内皮功能改变间关系的超声研究

目的　研究原发性高血压 (EH)患者左室肥厚 (L VH)与内皮功能改变间的关系。方法　超声心动图了解 55例无并发症的 EH患者和 2 0例正常人的心脏结构功能 ,利用高分辨超声技术观察受检者的肱动脉充血后反应性扩张 (DTRH)和含服硝酸甘油后血管内径的变化 (DTNG)。结果　 L VH (2 4/ 55)和非 L VH (3 1/ 55)患者的 DTRH均较正常组减小 ,且前者较后者的 DTRH进一步显著减小 [(4.18± 2 .12 ) % vs (8.2 4± 1.65) % ,P<0 .0 0 0 1]、左室质量指数 (L VMI)增大 [(154.81± 2 8.3 1) g/ m2 vs (98.2 9± 15.76) g/ m2 ,P<0 .0 0 0 1] ,而 DTNG及年龄、血压、血脂、血糖等无显著性差异。单因素相关分析显示 :EH患者的 L VMI与 DTRH呈负相关 (r=-0 .59,P<0 .0 0 0 1)、与舒张压 (DBP)及平均压 (MBP)呈正相关 (r=0 .2 8、 0 .3 0 ,P<0 .0 5) ,但多元回归分析表明L VMI仅与 DTRH有良好相关性。结论　 EH患者左室肥厚与血管内皮功能减退 (ED)改变密切相关 ,ED可能不依赖血压独立参与左室肥厚的发生发展过程     

原发性高血压患者血管紧张素转换酶基因多态性与左室肥厚的相关性研究

目的探讨原发性高血压(EH)患者血管紧张素转换酶(ACE)基因多态性与左室肥厚(LVH)的关系。方法轻、中度高血压病患者420例,测定血浆肾素活性(PRA)、血浆ACE浓度、血管紧张素Ⅱ(AngⅡ)浓度和醛固酮(ALD)浓度,同时用聚合酶链反应(PCR)法检测ACE基因的插入或缺失(I/D)多态性,用超声心动图测量舒张末期左心室内径(LVDd)、左心室后壁厚度(LVPWT)、舒张末期左心室间隔厚度(INSTd),比较不同左室构型患者ACE基因型的分布。结果420例患者中,左室构型异常者284例,其中向心性重构者占26.3%,向心性肥厚者占32.3%,离心性肥厚者占41.1%。正常左室构型、向心性重构、向心性肥厚、离心性肥厚患者血浆ALD浓度分别为(416.9±127.36)pmol/L、(379.2±117.9)pmol/L、(418.7±129.47)pmol/L和(457.1±134.29)pmol/L。不同左心室构型ACE基因型和等位基因分布差异无统计学意义。结论向心性肥厚和离心性肥厚者血浆ALD浓度显著高于其他构型者;向心性重构和向心性肥厚者收缩压高于其他构型患者;ACE基因I/D多态性与原发性高血压患者左室肥厚无相关性。     

不同左室构型高血压病患者血浆利钠肽浓度变化

目的评价不同左室构型高血压病(EH)患者血浆B型利钠肽(BNP)变化。方法选择78例EH患者及18例正常对照者行经胸超声心动图检查,测量室间隔厚度(IVST)、左室后壁厚度(LVPWT)、左室舒张末期内径(LVEDD)、左室射血分数(LVEF)及左心房内径(LAD)。计算左室质量指数(LVMI)、左心室室壁相对厚度(LVRWT)。同时采用酶联免疫吸附法(ELISA)测定其血浆中BNP浓度。结果按照经超声心动图测值计算的LVMI、LVRWT结果将78例EH患者分为4个亚组:左室构型正常组、左室向心性重构组、左室向心性肥厚组及左室离心性肥厚组。各组血浆BNP浓度与对照组(38±19)μg/L相比均明显增高,增高程度依次为:左室离心性肥厚组(782±407)μg/L、左室向心性肥厚组(446±368)μg/L、左室向心性重构组(194±63)μg/L及左室构型正常组(94±41)μg/L,各组间差异有统计学意义(F=41.17,P<0.01)。结论不同左室构型组EH患者血浆BNP浓度与正常对照组相比均明显升高,且各组间浓度变化差异有统计学意义。     

组织追踪法评价兔甲亢性心肌病不同左室构型左室收缩功能的变化

目的 探讨组织追踪法评价兔甲亢性心肌病不同左室构型左室收缩功能变化的价值.方法 新西兰纯种白兔30只,随机分为实验组(20只)和对照组(10只).实验组腹腔注射左旋甲状腺素(45 μg·kg-1·d-1×28d)建立甲亢动物模型,依据超声参数可将其分为向心性肥厚组(CH组)和离心性肥厚组(EH组),采用组织追踪法测量各组实验兔心脏二尖瓣环的收缩期位移峰值(Ds);M型超声心动图测量二尖瓣环收缩期下移距离(Dm);Teichholm公式法计算左室射血分数(LVEF)、左室短轴缩短率(FS),并对各组指标进行比较分析.结果 实验组中20只实验兔于第2、3周各死亡1只,最终纳入研究的有18只,其中CH组7只,EH组11只.EH组二尖瓣环Ds、Dm、LVEF、FS均较对照组和CH组明显减低(P＜0.01);CH组与对照组比较,二尖瓣环Ds、Dm为正常低值,LVEF、FS未见明显减低.结论 组织追踪法能准确评估兔甲亢性心肌病不同左室构型左室收缩功能的变化.     

Tei指数评价原发性高血压不同左室构型左室功能的研究

目的　探讨 Tei指数评价原发性高血压不同左室构型左室功能的临床价值。方法　原发性高血压患者 94例 ,按 Ganau分类法将原发性高血压分为 4型 :正常构型 ( 组 ,2 4例 )、向心性重构 ( 组 ,30例 )、向心性肥厚 ( 组 ,2 2例 )、离心性肥厚 ( 组 ,18例 ) ;正常对照组 30例。以常规超声心动图检查测量舒张末期室间隔、左室后壁厚度及左室内径 (IVS、L VPW、L VEDD) ,二尖瓣血流频谱图舒张早期与舒张晚期血流峰值比 (E/ A) ,二尖瓣前叶瓣环运动频谱图收缩期运动幅度 S峰及舒张早期与舒张晚期峰速比 (Ea/ Aa) ,左室射血分数 (EF)以及 Tei指数。结果　 、 、 组 E/ A均 <1(P<0 .0 5 ) ; 、 、 组与对照组比较 S值减低 (P<0 .0 5 ) ;Ea/ Aa均 <1(P<0 .0 5 ) ; 组 EF值低于正常对照组 (P<0 .0 5 ) ;高血压各组 Tei指数均较对照组增加 (0 .30± 0 .0 6 ,0 .4 3± 0 .1,0 .4 8± 0 .2 ,0 .5 1± 0 .12 ,0 .79± 0 .2 ;P<0 .0 5 ) ,呈递增趋势 , 组与 组 , 组与 、 、 组间差异有显著性意义 ;Tei指数和 S值 ,Ea/ Aa,EF均为轻度负相关 (r分别为- 0 .4 3、- 0 .33、- 0 .4 7,P值分别为 P<0 .0 0 1、P<0 .0 5、P<0 .0 0 1) ,Tei指数和 E/ A无相关性 (P>0 .0 5 )。结论　 Tei指数能简便、敏感、综合评价高血压病患者     

实时三维超声心动图与左房追踪技术评价不同左心室构型原发性高血压患者左心房的容积与功能

目的：应用实时三维超声心动图（Real-time three-dimensional echocardiography,RT-3DE）及左房追踪技术（Left atrial tracking,LAT）评价不同左心室构型原发性高血压（Essential hypertension,EH）患者左心房容积与功能的变化。方法：正常对照组32例和原发性高血压（EH组）患者133例,按Ganau法将EH组分为：正常左室构型组（Ⅰ组）、向心性重构组（Ⅱ组）、向心性肥厚组（Ⅲ组）、离心性肥厚组（Ⅳ组）。应用RT-3DE技术获得左心房最大容积（LAVmax）、左心房最小容积（LAVmin）、左心房每搏量（LASV）、左心房射血分数（LAEF）、左心房管道容积（LACV）。应用LAT技术获得左心房容积-时间曲线测量得到： LAVmax’、LAVmin’、左心房收缩前容积（LAVpre）;根据公式计算得到：LASV’、LAEF’、左心房被动排空容积（LAVp）。比较EH各组与对照组、EH组内的差异性。结果：①EH组LAVmax、LAVmin、LASV、LAEF、LAVmax’、LAVmin’、LASV’、LAEF’值高于对照组,LACV、LAVp值小于对照组。②EH组内：向心性肥厚组（Ⅲ组）和离心性肥厚组（Ⅳ组）各参数变化明显（P<0.01）,LAEF与LAEF’值在离心性肥厚组（Ⅳ组）较向心性肥厚组（Ⅲ组）减低（P<0.05）;向心性重构组（Ⅱ组）LACV与LAVp值较正常左室构型组（Ⅰ组）略有减少,但差异无统计学意义（P>0.05）。结论：高血压早期即正常左室构型时左心房储存功能及助力泵功能增加,管道功能减低;离心性肥厚阶段左心房助力泵功能减低。正常左室构型与向心性重构阶段左心房管道功能无变化。RT-3DE及LAT两种技术相结合可以很好的评价不同左室构型EH左心房的容积与功能。     

二维应变超声评价高血压左室重构患者收缩期多维形变

目的 应用二维应变超声心动图观察高血压不同左室构型患者收缩期心肌多种方向上的应变和心室扭转.方法 将221例LVEF正常的高血压患者分为正常构型(NG)、向心性重构(CR)、向心性肥厚(CH)和离心性肥厚(EH)4组,应用二维应变技术分析各组左室收缩期纵向、周向、径向峰值应变以及扭转角度.另取年龄、性别与之相匹配的正常血压者30例为对照组(NC).结果 NG和CR组只出现左室纵向应变降低(P＜0.05),CH和EH组的各向应变指标均低于NG和CR组(P＜0.05),而各构型组扭转角度无明显变化.结论 原发性高血压患者随着左室重构程度的加重出现空间上不同程度的收缩应变受损,早期以纵向应变降低为主,随后出现多种方向上心肌应变能力降低.     

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.