进展性脑梗死患者超敏C反应蛋白和脂蛋白a测定的临床研究

目的 探讨进展性脑梗死患者血清超敏C反应蛋白（hs-CRP）和脂蛋白a[Lp（a）]测定的临床价值.方法 检测31例进展性脑梗死患者（进展组）和35例非进展性脑梗死患者（非进展组）血请hs-CRP和Lp（a）水平,并与40名健康体检者（对照组）作对照.结果 进展组hs-CRP水平（11.33±2.76 mg/L）显著高于非进展组（6.35±2.15 mg/L）和健康对照组（1.28±0.92 mg/L）（P＜0.01）;进展组Lp（a）水平（485.63±186.80 mg/L）显著高于非进展组（311.75±28.51 mg/L）和健康对照组（106.87±63.41 mg/L）（P＜0.01）.结论 血清hs-CRP和Lp（a）联合检测对进展性脑梗死的诊断、病情严重程度、预后具有重要参考价值.     

血清C反应蛋白水平与脑卒中的病情及预后关系探讨

目的：探讨急性脑卒中患者发病早期血液中C反应蛋白（CRP）含量高低与病情严重程度及预后的影响。方法：对155例患者血清CRP含量进行测定，其中脑梗死41例（脑梗死组），脑出血40例（脑出血组），腔隙性梗死33例（脑隙性梗死组）及非脑卒中41例（对照组）。结果：（1）脑卒中患者CRP阳性率明显较对照组升高（P〈0．01）；其中脑出血组较脑梗死组CRP水平高（P〈0．05），脑梗死组较腔隙性梗死组水平高（P〈0．05），而腔隙性梗死组与对照组比较无明显升高（P〉0．05）。结论：急性脑卒中患者早期血清CRP升高提示病情严重且预后不良     

β-淀粉样蛋白和C-反应蛋白与脑血管疾病的关系

目的研究人急性脑梗死（acute cerebral infarction，ACI）、脑出血（intracerebral hemorrhage，ICH）后血清β－淀粉样蛋白（β－amyloid protein，Aβ）和C-反应蛋白（C-reactive protein，CRP）的含量变化。探讨二者与脑血管疾病发病的可能机制。方法采集急性脑梗死、脑出血患者血清标本，应用放射免疫分析法检测Aβ，免疫比浊法测定CRP，同时与正常对照组比较。结果ACI组患者Aβ（1.39±0.27）mg／ml，CRP（7.67±2.21）mg／L；ICH组Aβ（1.32±0.19）mg／ml，CRP（8.35±2.25）mg／L；正常对照组Aβ（1.05±0.17）mg／ml，CRP（2.35±1.67）mg／L。脑血管疾病组均高于正常对照组，差异有统计学意义（P〈0.05）；且Aβ和CRP之间呈正相关关系（r=0.740，P〈0.01）。结论Aβ与CRP可能是脑血管疾病发病的共同危险因素，推测两因素参与脑血管损伤导致脑血管疾病。     

脑梗死患者不同时期血浆蛋白S水平与梗死范围的关系

目的：通过观察脑梗死患者外周血不同时期血浆蛋白S水平的变化，探讨蛋白S水平与脑梗死范围的关系。方法：选择2002—07／2003-01上海第二医科大学附属仁济医院神经内科住院或急诊留院观察急性脑梗死患者38例（脑梗死组）。对照组为来本院体检的健康者38例，性别、年龄均与脑梗死组相匹配（P〉0，05）。脑梗死组在入院时（发病5d以内）、发病后20d采静脉血2mL（对照组与脑梗死组同时间点采血）。总蛋白S和游离蛋白S含量均采用双抗体夹心酶联免疫吸附法测定。结果：参加实验脑梗死组39例，对照组38例，均采样至实验结束。①不同病程阶段蛋白S水平的变化：脑梗死组急性期（5d内）、亚急性期（20d）总蛋白S水平均较对照组明显下降[（13．80&;#177;2，83），（14．69&;#177;2，66），（16，91&;#177;4，04）mg／L，（t=-3．888，-2．828，P〈0．01）]。脑梗死组急性期、亚急性期游离蛋白S水平均较对照组明显下降[（6．36&;#177;2．02），（6．88&;#177;1．60），（8，80&;#177;2．41）mg／L，（t=-4．782，-4．095，P〈0．01）]。②不同梗死范围蛋白S水平的变化：根据入院1周时MRI的检查结果分为腔隙性脑梗死组11例和非腔隙性脑梗死组27例。急性期、亚急性期非腔隙性脑梗死组患者总蛋白S水平低于腔隙性梗死组患者1急性期：（13．22&;#177;2．79），（15．22&;#177;2．50）mg／L；亚急性期：（13．88&;#177;2．16），（16．68&;#177;2．83）mg／L，（t=-2．062，-3.313，P〈0．05）]；明显低于对照组[（16．91&;#177;4．04）mg／L（t=-4．098，-3，906，P〈0．01）1。急性期、亚急性期非腔隙性脑梗死组患者游离蛋白S水平低于腔隙性梗死组患者[（5．78&;#177;1．69），（7．79&;#177;2．14）mg／％；（6．41&;#177;1，40），（8．03&;#177;1．52）mg／L，（t=-3．077，-3．151，P〈0．05）]；明显低于对照组[（8，80&;#177;2．41）mg／L，（t=-5．944，-5．031，P〈0．01）]。结论：脑梗死患者蛋白S水平在急性期、亚急性期均明显下降，其下降的水平与病灶大小有一定关系。     

C-反应蛋白对急性心肌梗死患者的诊断价值

目的了解急性心肌梗死（AMI）患者血清中C-反应蛋白（CRP）的变化。方法在东芝TBA-30RF全自动生化分析仪上用散射比浊两点法检测血清中CRP水平。结果AMI患者血清中CRP为（34.25±18.66）mg/L,冠心病患者CRP为（21.5±14.32）mg/L;健康对照组CRP水平为（4.01±0.68）mg/L;前两者与健康对照组比较P〈0.05。结论AMI患者血清CRP水平是较心肌肌钙蛋白I（cTnI）及心肌酶谱更具敏感性的参考指标,与cTnI、CK-MB同时检测,对AMI的快速诊断及病情预测具有重要临床价值。     

恶性肿瘤患者治疗前后血浆纤维蛋白原含量分析

目的 观察恶性肿瘤患者治疗前后血浆纤维蛋白原（FIB）含量与抗肿瘤治疗疗效的关系。方法 采用全自动血凝分析仪测定188例恶性肿瘤患者治疗前后血浆FIB含量,115例健康体检者为对照。结果恶性肿瘤组FIB含量（5.05±1.12）g/L较健康体检组（2.91±0.87g/L）显著升高（P〈0.01）。临床Ⅲ、Ⅳ期患者FIB含量（5.13±1.48g/L）显著高于Ⅰ、Ⅱ期（4.62±1.26g/L）的患者（P〈0.05）。治疗后有效的患者FIB含量（2.92±1.33g/L）较治疗前（4.85±1.36g/L）显著下降（P〈0.01）。无效者治疗前FIB含量（5.41±1.05g/L）与治疗后（4.85±1.26g/L,）比较无显著变化（P〉0.05）。结论 血浆FIB含量在恶性肿瘤的辅助诊断、疗效判断及预后评估方面有一定临床意义。     

血清同型半胱氨酸与青壮年脑梗死关系的研究

目的探讨血清同型半胱氨酸与青壮年脑梗死的关系。方法检测79例青壮年脑梗死患者及40例健康对照者血清同型半胱氨酸（Hcy）、叶酸（FA）、维生素B12（VitB12）水平，及传统意义危险因素的血脂、血糖和血压水平。结果①脑梗死组血清Hcy水平（16．83±4．92μmol／L）显著高于对照组（10．46±1．03μmol／L），差异有统计学显著性意义（P〈0．01）；脑梗死组血清FA水平（7．48±2．87ng／L）显著低于对照组（10．10±3．91ng／L），差异有统计学显著性意义（P〈0．01）；脑梗死组血清VitB12水平（246．8±118．6pg／L）显著低于对照组（410．6±190．6pg／L），差异有统计学显著性意义（P〈0．01）；血清Hcy与FA、VitB12呈负相关。②血清三酰甘油（TG）水平脑梗死高Hcy组（3．32±2．15mmol／L）及脑梗死正常Hcy组（3．11±2．13mmol／L）均高于对照组（1．61±0．63mmol／L），差异有统计学显著性意义（均P〈0．05）；脑梗死高Hcy组与脑梗死正常Hcy组血清TG水平比较，差异无统计学意义（P〉0．05）；三组间血清胆固醇、血糖及血压水平比较，差异均无统计学意义（均P〉0．05）。结论高同型半胱氨酸血症可能为青壮年脑梗死的独立危险因素，血清Hcy水平与FA、VitB12呈负相关。传统危险因素中血清TG升高为突出因素。     

血管性认知功能障碍患者血脂代谢及C反应蛋白水平的研究

目的 研究血管性认知功能障碍（vascular cognitive impairment，VCI）患者血脂代谢及C-反应蛋白水平的变化，促进对血管性认知功能障碍病因及临床特点的认识，提高诊断及防治水平。方法 测定220例VCI组和280例对照组的血清总胆固醇（TC）、甘油三酯（TG）、高密度脂蛋白（HDL）、低密度脂蛋白（LDL）、C-反应蛋白（CRP）水平。结果 VCI组血清中，TC、TG、HDL、LDL、CRP的水平分别为（5．41±1．16）mmol／L、（1．37±0．44）mmol／L、（1．03±0．31）mmol／L、（3．44±0．81）mmol／L、（7．58±1．35）mg／L，而对照组相应指标分别为（4．89±1．12）mmol／L、（1．31±0．45）mmol／L、（1．24±0．33）mmol／L、（2．89±0．78）mmol／L、（6．47±1．32）mg／L。其中VCI组TC、LDL、CRP均明显高于对照组，差异有显著性（P〈0．001）；TG稍高于对照组，而差异无显著性（P〉0．05）；HDL明显低于对照组，差异有显著性（P〈0．001）。结论VCI组患者存在明显的脂质代谢紊乱，TC、HDL、LDL、CRP可能对VCI的发病及预测有一定的关系。     

脑梗死患者血清可溶性血管细胞黏附分子1的变化

背景：在不同炎性和自身免疫性疾病患者中，血清内可溶性血管细胞黏附分子1水平增高．其变化可成为重要的免疫学功能检测指标，但其在急性脑梗死时的变化规律尚不清楚。 目的：观察脑梗死血清可溶性血管细胞黏附分子1的变化及其临床意义，并与脑出血患者和正常人比较。 设计：病例一对照分析。 单位：解放军第三军医大学大坪医院野战外科研究所脑二科。 对象：选择2002—05／2004-04解放军第三军医大学大坪医院野战外科研究所脑二科住院患者132例。其中脑梗死89例，根据梗死灶分为为大梗死组（n=25，〉10cm^3），中梗死组（n=31，4～10cm^3），小梗死组（n=33，〈4cm^3）；脑出血组43例。以30例健康人为正常对照组。 方法：脑梗死患者分别在发病后分别在发病后24h、3,7和14d取血，脑出血患者分别在发病后24h和14d取血。3组均取静脉血4mL。采用双抗体夹心法测定所有受试者血清可溶性血管细胞黏附分子1水平。 主要观察指标：①脑梗死不同病程中血清可溶性血管细胞黏附分子1水平的动态变化，并与其他两组比较。②不同大小梗死灶的脑梗死患者血清可溶性血管细胞黏附分子1水平比较。③脑梗死并发感染时血清可溶性血管细胞黏附分子1的变化。 结果：162例进入结果分析。①脑梗死患者在发病24h血清可溶性血管细胞黏附分子1水平明显高于脑出血组和正常对照组[（1184．5&;#177;68．3），（693．9&;#177;41．7），（576．1&;#177;39．8）μg，P〈0．01]。梗死发生后24h至第7天呈上升趋势，7-14d呈下降趋势，但第14天脑梗死患者血清可溶性血管细胞黏附分子1仍明显高于脑出血组和正常对照组（P〈0．01）。②大梗死灶组血清可溶性血管细胞黏附分子1水平明显高于中梗死灶组和小梗死灶组[（1217．4&;#177;59．3），（1132．6&;#177;51．9），（983．7&;#177;54．2）μg／L，P〈0．01]。③脑梗死后并发感染者在发病后3，7，14d血清可溶性血管细胞黏附分子1水平明显高于无感染（P〈0．01）。 结论：可溶性血管细胞黏附分子1参与了脑梗死的病理变化过程，可作为脑梗死时病情变化的监测指标。阻断其生成和表达为改善脑梗死的预后提供了新的思路。     

强直性脊柱炎患者的血小板活化功能研究

目的 探讨强直性脊柱炎患者的血小板活化功能.方法 选取2005年11月至2006年10月的35例强直性脊柱炎患者与15例正常人对照,空腹采血2 ml至2%乙二胺四乙酸抗凝试管,行单克隆抗体直接标记,30 min内进行流式细胞仪检测外周血血小板CD62P和CD63的表达,同时免疫比浊法测定C-反应蛋白（CRP）与魏氏法测定血沉（ESR）,血细胞计数仪检测血小板数量.结果 强直性脊柱炎组患者的外周血CD62P表达（13.60±7.64）%明显高于正常对照组（2.78±1.04）%（P＜0.01）;强直性脊柱炎组患者的外周血CD63表达（6.92±4.16）%明显高于正常对照组（4.13±1.85）%（P＜0.05）;CRP（20.18±23.17）mg/L与ESR（36.86.±31.23）mm/h明显高于正常对照组的（3.21±2.18）mg/L与（12.25±5.05）mm/h（均P＜0.01）;强直性脊柱炎患者组血小板计数（259.54±102.59× 109/L）高于正常对照组（197.00±55.70×109/L）（P＜0.05）.结论 强直性脊柱炎患者的血小板活化功能明显高于正常人.     

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.