速度向量成像评价DDD起搏前后左心室收缩同步性的初步临床研究

目的 探讨速度向量成像(velocity vector imaging,VVI)技术评估DDD起搏前后左心室心肌收缩同步性的应用价值.方法 13例DDD起搏患者,于手术前后应用VVI在系列心尖长轴及胸骨旁短轴观上显示左室速度向量图.心尖长轴观测量各节段收缩期纵向速度达峰时间(Tvl)和纵向应变达峰时间(Tsl),胸骨旁短轴观测量收缩期径向速度达峰时间(Tvr)和环向应变达峰时间(Tsc),并计算节段达峰时间的标准差(Tvl-SD,Tsl-SD,Tvr-SD,Tsc-SD)及任意两节段间最大达峰时间差值(Tvl-d,Tsl-d,Tvrd,Tsc-d).结果 与术前相比,术后左室收缩不同步指标Tvr-SD,Tsc-SD,Tsl-d,Tvr-d,Tsc-d均显著增加,差异有统计学意义(P＜0.05).结论 DDD起搏后左室心肌在纵向、径向和环向上均存在显著的收缩不同步.VVI技术可准确评价DDD起搏前后左室心肌收缩的同步性.     

速度向量成像评价左束支传导阻滞患者左心室收缩同步性

目的探讨速度向量成像（VVI）技术评估左束支传导阻滞（LBBB）患者左室心肌收缩同步性的临床应用价值。方法LBBB患者15例和健康志愿者30例,常规测量左室舒张末期内径（LVDd）、收缩末期内径（LVDs）、舒张末期容积（LVEDV）、收缩末期容积（LVESV）和射血分数（LVEF）。在系列心尖长轴及胸骨旁短轴观上,VVI成像显示左室速度向量图。心尖长轴观测量各节段收缩期纵向速度达峰时间（Tvl）,胸骨旁短轴观测量收缩期径向速度达峰时间（Tvr）和环向应变达峰时间（Tsc）,计算上述各达峰时间的标准差（Tvl-SD,Tvr-SD,Tsc-SD）及任意两节段间最大达峰时间差值（Tvl-diff,Tvr-diff,Tsc-diff）。结果①与对照组相比,LBBB组LVESV显著增加（P〈0.05）,LVEF显著降低（P〈0.05）,而LVDd、LVDs、LVEDV测值两组间比较差异无统计学意义。②LBBB组各节段Tvl、Tvr、Tsc测值及Tvl-SD、Tvr-SD、Tsc-SD、Tvl-diff、Tvr-diff、Tsc-diff测值均显著高于对照组的相应测值（P〈0.05或0.01）。③LBBB组前间隔心尖段Tvr测值最小,左室侧壁心尖段Tvr测值最大,两者间比较差异有统计学意义（P〈0.01）。结论LBBB患者左室心肌在纵向、径向与环向上均存在显著的收缩不同步。VVI技术为评价LBBB患者左室心肌收缩同步性,观察左室心肌收缩序列异常提供了一种新的方法。     

速度向量成像技术评价正常QRS波群心力衰竭患者左心室收缩同步性的初步临床研究

目的 探讨速度向量成像（VVI）技术评估正常QRS波群慢性心力衰竭（CHF）患者左室心肌收缩同步性的应用价值。方法 QRS≤120ms CHF患者和健康志愿者各30例，常规测量左室舒张末期内径（LVDd）、舒张末期容积（LVEDV）、收缩末期容积（LVESV）和射血分数（LVEF）。在系列心尖长轴及胸骨旁短轴观上，VVI成像显示所有受试者的左室速度向量图。心尖长轴观测量各节段收缩期纵向速度达峰时间（Tvl）和纵向应变达峰时间（Tsl），胸骨旁短轴观测量收缩期径向速度达峰时间（Tvr）和环向应变达峰时间（Tsc），计算节段达峰时间的标准差（Tvl—SD，Tsl—SD，Tvr-SD，Tsc-SD）及任意两节段间最大达峰时间差值（Tvl—diff，Tsl-diff，Tvr-diff，Tsc—diff）。结果 与对照组相比，CHF组LVDd，LVESV，LVEDV均显著增加（P〈0．05或0．01），LVEF显著降低（P〈0．01）。左室心肌收缩不同步指标Tvl—SD，Tsl—SD，Tvr—SD，Tsc-SD及Tvl—diff，Tsl-diff，Tvr-diff，Tsc-diff均显著增加（P〈0．01）。结论 QRS波群正常的CHF患者左室心肌在纵向、径向与环向上均存在显著的收缩不同步。VVI技术可准确评价CHF患者左室心肌收缩的同步性。     

速度向量成像技术评价完全性右束支传导阻滞患者左心室收缩期不同步CSCD

目的应用速度向量成像(VVI)技术分析完全性右束支传导阻滞(CRBBB)患者左心室收缩期同步性,为临床评价CRBBB患者左心室心肌力学及功能提供可靠依据。方法选择2011年3月至11月四川省医学科学院·四川省人民医院收治的CRBBB患者31例,另选取同期性别、年龄匹配的健康志愿者26名作为健康对照组。应用VVI技术获得所有受试者左心室收缩期纵向应变达峰时间(Tsl)、径向应变达峰时间(Tsr)、环向应变达峰时间(Tsc)、旋转角度达峰时间(Tra)。计算左心室18节段心内膜下收缩期纵向、径向、环向应变及旋转角度达峰时间的标准差Tsl-SD、Tsr-SD、Tsc-SD、Tra-SD作为左心室心肌纵向、径向、环向及旋转运动不同步指数。采用独立样本t检验比较健康对照组与CRBBB组Tsl-SD、Tsr-SD、Tsc-SD、Tra-SD差异。结果 CRBBB组左心室壁收缩期不同步指数Tsl-SD、Tsr-SD、Tsc-SD、Tra-SD分别为(27.65±6.78)、(32.63±11.82)、(42.81±9.72)、(37.01±7.73)ms,均高于健康对照组的(26.55±6.99)、(26.63±6.70)、(30.53±8.71)、(27.67±7.11)ms,但仅Tsc-SD、Tra-SD差异有统计学意义(t=4.911、4.980,P=0.000),Tsl-SD、Tsr-SD差异均无统计学意义。结论 CRBBB患者左心室周向及旋转运动不同步;VVI技术可反映左心室收缩期不同方向机械运动同步性。     

斑点追踪成像技术对扩张型心肌病患者左心室长轴二维应变的初步研究

目的 应用超声斑点追踪成像技术探讨扩张型心肌病(DCM)患者左心室长轴各节段心肌二维应变的变化.方法 对16例经临床诊断证实的DCM患者,获取心尖左室长轴连续三个心动周期图像.应用GE EchoPAC软件分析图像,得到各切面的收缩期整体应变峰值及各节段时间-应变曲线,记录纵向、横向应变的收缩期峰值及其达峰时间.对照组为20例健康体检者,获取左室相同切面超声心动图图像及参数.结果 DCM组各切面的收缩期整体应变峰值、各节段纵向应变峰值、多数节段(16/18)横向应变峰值均较对照组明显降低,多数节段(14/18)纵向应变达峰时间提前(P＜0.05);除前壁心尖段和中间段外,DCM组横向应变达峰时间延后,但仅后壁基底段间差异有统计学意义(P＜0.05);DCM组左室18节段间最大达峰时间差增大(P＜0.05).结论 DCM患者左室长轴各节段收缩期纵向应变峰值及多数节段横向应变峰值均明显低于正常人,18节段间最大达峰时间差增大,提示其左室收缩功能明显受损并出现左室收缩不同步.     

超声斑点追踪技术与多普勒组织速度显像评价心肌梗死患者左心室内不同步性

目的 评价超声斑点追踪技术在定量心肌梗死患者左心室内不同步性的价值.方法 采集30例心肌梗死患者左心室短轴切面(二尖瓣,乳头肌,心尖部)和心尖位四腔切面、二腔切面和左心室长轴的二维灰阶与组织多普勒(TVI)动态图,应用二维应变软件分别测量左心室短轴与左心长轴的各节段的径向与纵向应变收缩期达峰时间;同时用组织多普勒技术测量左心长轴的各节段的组织速度的收缩期达峰时间.如左心长轴每一节段6个壁的收缩期最早与最晚达峰时间的差值>110 ms、左心室短轴每一节段前间隔与后壁的达峰时间差值>130 ms即为左心室内收缩不同步.结果 基底部左心室短轴径向应变达峰时间明显长于组织多普勒纵向收缩期速度达峰时间(P<0.01);心尖部左心室短轴径向应变达峰时间明显长于左心室纵向应变达峰时间(P<0.01).二维应变短轴检出率高于二维应变长轴,两者均高于组织多普勒长轴.结论 超声斑点追踪技术可以较好地评价左心室内不同步性,二维应变短轴可更准确地判断心肌梗死患者心尖段的不同步性.     

速度向量成像技术对冠心病患者颈总动脉弹性和运动同步性的评价

目的 应用速度向量成像技术(VVI)评价颈动脉形态学正常的冠心病患者颈总动脉弹性及运动同步性。 方法 选择颈动脉形态学正常的疑似冠心病患者90例,根据CAG结果分为正常组(30例)、CAG阳性组 。采集右侧颈总动脉短轴二维图像,运用VVI脱机软件分析,测得血管短轴6个壁最大运动速度(Vmax)、最大应变(Smax)、最大应变率(SRmax)及最大位移(Dmax),并测量血管各壁的径向速度(Tvr)、环向应变(Tsc)、环向应变率(Tsrc)、径向位移(Tdr)达峰时间的标准差(Tvr-SD、Tsc-SD、Tsrc-SD、Tdr-SD)及最大差值(Tvr-max、Tsc-max、Tsrc-max、Tdr-max)。 结果 ①多支病变亚组颈总动脉各壁Vmax、Smax、SRmax、Dmax均小于正常组及单支病变亚组(P<0.05);②单支及多支病变亚组Tvr-SD、Tsc-SD、Tsrc-SD、Tdr-SD、Tvr-max、Tsc-max、Tsrc-max及Tdr-max均大于正常组(P<0.05)。 结论 VVI技术是检测颈总动脉弹性和运动同步性的可靠方法,可评价冠心病患者颈总动脉硬化的早期改变。     

速度向量成像技术评价扩张型心肌病患者径向室壁运动

目的 应用速度向量成像技术(velocity vector imaging,VVI)评价扩张型心肌病(dilated cardiomyopathy,DCM)径向局部心肌收缩功能和同步性.方法 16例DCM患者和20例对照者进行超声心动图检查,脱机分析左室短轴观中6个基底节段和6个中间节段共12个节段的径向收缩期峰值速度(V)、应变(ε)、应变率(SR)、径向速度达峰时间(PTV)、应变达峰时间(PTε),计算12节段的最早与最晚速度达峰时间差值(T-max)及速度达峰时间标准差(T-SD).结果 ①DCM组各节段的V、ε、SR的平均值均显著低于对照组相应节段(P＜0.01);②DCM组的PTV除乳头肌水平前间隔及后间隔外,其余节段均大于对照组(P＜0.05),PTε除前间隔二尖瓣水平、乳头肌水平和后间隔二尖瓣水平、乳头肌水平外,其余节段均显著延长(P＜0.05);③DCM组的T-max及T-SD显著大于对照组(P＜0.05).结论 VVI能检出DCM患者的左室壁径向运动异常,为评价局部心肌运动提供更多信息.     

超声斑点跟踪成像对扩张型心肌病患者左室短轴二维应变的定量研究

目的 应用超声斑点跟踪成像技术(STI)对扩张型心肌病(DCM)患者左心室短轴各节段心肌的二维应变进行定量研究,探讨其变化情况.方法 对26例经临床证实的DCM患者,获取胸骨旁左室短轴二尖瓣环、乳头肌、心尖平面连续三个心动周期图像(三个平面显示左室18节段).应用GE EchoPAC软件分析各短轴平面的整体应变峰值和各节段的收缩期应变峰值.对照组为30例健康体检者,以相同方式获取图像.结果 对照组各平面间及同一平面内节段间收缩期应变峰值具有一定规律,DCM组失去这种规律.与对照组比较,DCM组左室整体应变峰值、所有节段径向应变峰值及左室18节段中16节段环向应变峰值明显降低,差异有统计学意义(P＜0.01).结论 扩张型心肌病患者左室短轴各节段收缩期径向应变峰值及多数节段环向应变峰值明显低于正常人,提示其左室短轴收缩功能明显受损.     

二维斑点追踪应变成像对冠心病患者左心室同步性的定量研究

目的 探讨二维斑点追踪应变成像技术评价冠心病患者左室同步性的临床价值.方法 42例急性心肌梗死患者、39例冠心病心肌缺血患者和32例对照者接受二维超声检查,用二维应变软件分析心尖长轴观、心尖两腔观和四腔观以及左室短轴观基底水平、乳头肌水平、心尖水平的图像,测量自心电图QRS波起点至左室在心尖长轴观上的收缩期纵向应变达峰时间(Tssl)及胸骨旁短轴观上的收缩期径向和环向应变达峰时间( Tssr,Tssc).计算左室各节段达峰时间标准差(Tssl-SD,Tssr-SD,Tssc-SD)及节段达峰时间最大差值(Tssl-Dif,Tssr-Dif,Tssc-Dif),以左室短轴观乳头肌水平前室间隔和后壁的径向应变的达峰时间之差(TAS-POST)≥130 ms作为左室收缩不同步标准,同时测量18个心肌节段纵向应变峰值与收缩末应变的差值之和作为纵向应变延迟指数(LSDI),LSDI≥25％作为左室不同步标准.结果 急性心肌梗死组同步性参数较对照组增加(P ＜0.001或P＜0.05);心肌缺血组同步性参数较对照组增高(P＜0.05); LSDI与TAS-POST呈正向线性相关(r=0.676,P＜0.05);急性心肌梗死组中,LSDI检测左室不同步敏感性高于TAs-POST(P＜0.05).结论 二维斑点追踪应变成像技术能准确评价左室不同步性,LSDI与TAS-POST可定量评价冠心病患者左室不同步性.     

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.