丝裂原活化蛋白激酶p38与低浓度一氧化碳对脂多糖诱导肺损伤大鼠肺炎症反应的作用

目的:观察低浓度一氧化碳(CO)吸入对脂多糖(LPS)诱导急性肺损伤(ALI)大鼠肺炎症反应的影响及影响过程中丝裂原活化蛋白激酶p38(p38 MAPK)的变化.方法:4组SD大鼠静脉注入5 mg/kg质量LPS或等容量生理盐水,1 h后.对照及LPS组吸入室内空气,C0吸人及LPS+CO吸入组吸入250 ppm CO.观察3 h后放血处死,取肺组织,酶联免疫吸附法测定肿瘤坏死因子-α(TNF-α)、白细胞介素-6(IL-6)及白细胞介素-10(IL-10)含量.蛋白印迹法测定磷酸化p38 MAPK表达.结果:LPS组TNF-α、IL-6、磷酸化p38 MAPK表达明显升高、IL-10显著降低,与对照组及CO吸人组比较,差异有统计学意义(P均<0.01).LPS+CO吸入组TNF-α、IL-6显著低于、IL-10和磷酸化p38 MAPK表达明显高于LPS组(P均<0.05).结论:p38 MAPK信号转导通路可能参与了低浓度CO吸入对LPS诱导ALI大鼠肺炎症反应的抑制.     

白细胞介素-10对内毒素诱导急性肺损伤大鼠炎症因子的影响

目的研究白细胞介素-10(IL-10)对内毒素诱导急性肺损伤(ALI)大鼠肺组织炎症因子mRNA表达的影响,探讨IL-10对急性肺损伤的保护作用。方法24只SD大鼠随机分为3组:对照组,实验组,治疗组。实验组于尾静脉注射内毒素,治疗组注射内毒素和IL10,对照组注射生理盐水。测定各组肺组织肿瘤坏死因子-α(TNF-α)、白介素-1β(IL-1β)和白介素-6(IL-6)mRNA表达和血浆TNF-α、IL-1β和IL-6水平,观察各组大鼠肺组织的病理改变。结果TNF-α、IL-1β和IL6mRNA的表达:实验组、治疗组高于对照组,P<0.01;实验组高于治疗组,P<0.05。血浆TNF-α、IL1-β、IL-6:实验组高于治疗组对照组,P<0.05。肺组织病理改变:治疗组明显轻于实验组。结论IL10能抑制内毒素诱导ALI大鼠肺组织中TNF-α、IL-1β和IL6mRNA的表达,降低血浆炎症因子水平,减轻肺组织的病理损害,能起到治疗ALI的作用。     

大鼠低温爆震伤对肺组织中IL-1β和TNF-α表达的影响

目的:建立大鼠低温爆震伤致肺损伤模型,研究爆震伤后大鼠血清和肺组织中IL-1β和TNF-α表达的变化。方法:将40只大鼠随机分成空白对照组(10只)、低温对照组(10只)及低温实验组(20只),进行爆震伤造模,实验后对大鼠进行状态观察,行苏木精-伊红染色观察肺脏病理变化,采用ELISA方法检测大鼠血清中IL-1β和TNF-α含量,采用荧光定量PCR和Western blot方法测定IL-1β和TNF-α基因和蛋白相对表达量变化,并对其结果进行分析。结果:苏木精-伊红染色结果显示,低温对照组大鼠肺脏有少量炎性细胞,低温实验组大鼠肺组织肺泡壁增厚,有大量的血细胞及炎性细胞产生。血清ELISA结果显示,低温对照组和低温实验组大鼠血清中IL-1β和TNF-α含量高于空白对照组(P0.05)。荧光定量PCR和Western blot结果显示,低温对照组和低温实验组大鼠肺组织中IL-1β和TNF-α基因相对表达量高于空白对照组,且低温实验组大鼠肺组织中IL-1β和TNF-α基因相对表达量高于低温对照组(P0.05);低温对照组和低温实验组肺组织中IL-1β和TNF-α蛋白相对表达量高于空白对照组,且差异有统计学意义(P0.05);与低温对照组比较,低温实验组肺组织中IL-1β和TNF-α蛋白相对表达量较高,且差异有统计学意义(P0.05)。结论:大鼠低温肺爆震伤导致血清中IL-1β和TNF-α含量升高,肺组织中IL-1β和TNF-α基因和蛋白的相对表达量升高,其损伤机制可能是IL-1β和TNF-α表达量升高导致炎症反应的产生。     

大鼠创伤失血性休克复合内毒素打击模型中p38丝裂原活化蛋白激酶磷酸化水平的改变

目的　探讨创伤失血性休克复合内毒素打击模型中大鼠腹腔巨噬细胞 (M)内p38丝裂原活化蛋白激酶(p38MAPK)磷酸化水平的改变。方法　制作大鼠创伤失血性休克复合内毒素打击动物模型 ,检测伤后 90min、4h血清中TNF-α、IL - 1β含量的改变及大鼠腹腔M内p38MAPK磷酸化水平的变化 ,并观察致伤组大鼠肺及小肠组织的病理改变。 结果　大鼠在创伤失血性休克复合内毒素打击后血清TNF -α、IL - 1β的含量较对照组明显升高 (P <0 .0 1) ,腹腔M内p38MAPK磷酸化水平较对照组明显升高 (P <0 .0 1) ,致伤组大鼠肺及小肠组织炎症病理改变显著。结论　p38MAPK的激活状态可能在大鼠创伤失血性休克复合内毒素打击模型的炎症反应中占有重要地位。     

血必净注射液对复苏后大鼠细胞因子和p38丝裂素活化蛋白激酶通路的影响

目的 探讨窒息致心搏骤停(CA)心肺复苏(CPR)后大鼠心、脑组织中肿瘤坏死因子-α(TNF-α)、白细胞介素-1β(IL-1β)和p38丝裂素活化蛋白激酶(p38MAPK)的变化及血必净注射液的影响.方法 采用呼气末夹闭气管窒息法建立大鼠CA模型后进行CPR.将50只健康Wistar大鼠随机分为对照组、模型组及小、中、大剂量血必净治疗组(血必净注射液浓度分别为5.0、7.5、15.0 ml/kg)5组.复苏24 h后处死大鼠,取心、脑组织标本,电镜下观察心、脑组织的病理改变;采用酶联免疫吸附法(ELISA)检测心、脑组织中TNF-α、IL-1β和p38MAPK含量.结果 组织病理观察显示,心、脑细胞超微结构出现损伤性改变,以模型组最重,大剂量血必净组最轻.模型组心、脑组织中TNF-α、IL-1β和p38MAPK含量较对照组明显升高(均P<0.01);血必净治疗组心、脑TNF-α、IL-1β、p38MAPK含量较模型组明显下降,其中大剂量组较小剂量组下降更明显(均P<0.05).结论 CA复苏后大鼠心、脑组织内TNF-α、IL-1β和p38MAPK含量增多;血必净注射液可明显调节心、脑组织中的TNF-α、IL-1β和p38MAPK含量,而且存在明显量-效关系,从而缓解CA大鼠复苏中缺氧及再灌注后炎症因子所带来的损伤.     

大黄对急性肺损伤大鼠血浆和支气管肺泡灌洗液中炎症细胞因子表达的影响

目的:探讨大黄对实验性急性肺损伤(ALI)大鼠炎症细胞因子在血浆和肺泡灌洗液中表达的影响.方法:用舌下静脉注射内毒素(LPS)的方法复制ALI模型,将145只雄性Wistar大鼠随机分成LPS组、对照组、大黄治疗组和地塞米松治疗组;分别测定大鼠血浆和支气管肺泡灌洗液中肿瘤坏死因子-α(TNF-α)、白细胞介素-1β(IL-1β)和IL-8含量.结果:与对照组相比,LPS组血浆和支气管肺泡灌洗液中TNF-α、IL-1β和IL-8均明显升高(P均<0.05),而地塞米松治疗组和大黄治疗组则均明显下降(P<0.05或P<0.01).结论:LPS诱导的大鼠ALI表现为肺和全身炎症反应;大黄和地塞米松能减轻肺和全身炎症反应,其机制可能是通过抑制TNF-α、IL-1β和IL-8活性来实现的.     

乌司他丁对体外循环过程中肺保护作用的影响

目的体外循环导致急性肺损伤，本研究在体外循环过程中应用乌司他丁后观察肺组织损伤程度的变化，及探讨肺损伤与丝裂原激活蛋白激酶（MAPK）的变化规律的关系。方法100例风湿性心脏病行二尖瓣人工机械瓣置换的病人分为Ⅰ、Ⅱ组。Ⅰ组50例，行常规体外循环，心脏阻断40—55分钟，术中持续肺灌注低温氧合机器血；Ⅱ组50例，体外循环方法同Ⅰ组，在Ⅱ组术中用乌司他丁加低温氧合机器血行肺灌注；分别在不同时段取二组病人血液标本，测量P38MAPK活性，炎症细胞因子IL-6、ID8，及术后气道峰值压力、氧指数等。结果Ⅰ组P38MAPK活性明显增高，Ⅰ组肺损伤与Ⅱ组相比加重（出现统计学差异）。结论体外循环过程中，抑制P38MAPK活性表达可减轻肺损伤，术中应用乌司他丁肺灌注有抑制肺损伤的作用，为体外循环术中肺保护提供一种切实可行的方法。     

内毒素致伤大鼠肺组织促炎与抗炎细胞因子mRNA表达的时相性研究

目的 研究不同剂量内毒素致伤大鼠肺组织促炎和抗炎细胞因子mRNA表达的时相性,并探讨这些细胞因子在全身炎症反应失控和急性肺损伤中的可能作用。方法 采用逆转录-聚合酶链反应(RT-PCR)检测不同剂量脂多糖(LPS)致伤大鼠肺组织肿瘤坏死因子-α(TNF-α)、白细胞介素(IL)-1β、IL-6、IL-4、IL-10和IL-13的mRNA表达。结果 随着LPS剂量增加,TNF-α、IL-1β、IL-6、IL-4、IL-10和IL-13的mRNA表达均增强(与生理盐水对照组比较,P均<0.01);LPS≥6 mg/kg组上述细胞因子表达显著高于此剂量以下组(P均<0.01)。表达峰值时间:TNF-α为1 h,IL-6为4 h,其他均在2 h。结论 内毒素致急性肺损伤中,TNF-α是早期表达的促炎细胞因子,而IL-6在炎症进一步发展中发挥作用;抗炎细胞因子IL-4、IL-10、IL-13高表达亦可能促进炎症的放大而不是起保护作用。     

丹参酮ⅡA对脓毒症大鼠肺损伤及p38MAPK/ERK信号通路的影响

目的探讨丹参酮ⅡA对脓毒症大鼠肺损伤及p38MAPK/ERK信号通路的影响。方法将30只SD大鼠随机分为对照组、模型组和丹参酮ⅡA组各10只,模型组和丹参酮ⅡA组采用盲肠结扎穿孔手术法制作大鼠脓毒症模型。丹参酮ⅡA组于术后即刻腹腔注射20 mg/kg的丹参酮ⅡA注射液,连续治疗48 h。治疗后,HE染色观察肺组织的病理变化,测定肺组织湿/干质量(W/D)和内毒素(LPS)水平,采用ELISA法测定肺组织中肿瘤坏死因子α(TNF-α)、白介素(IL)-6、丙二醛(MDA)、超氧化物歧化酶(SOD)和谷胱甘肽(GSH)水平,Western blot检测p38MAPK/ERK信号通路的磷酸化水平。结果与对照组相比,模型组和丹参酮ⅡA组肺组织W/D显著升高(P 0. 05),SOD酶活性和GSH水平显著下降(P 0. 01),LPS、MDA、IL-6和TNF-α水平显著升高(P 0. 01),p-p38和p-ERK1/2蛋白的表达显著上调(P 0. 01);与模型组相比,丹参酮ⅡA组肺组织W/D显著下降(P 0. 05),SOD酶活性和GSH水平显著升高(P 0. 01),LPS、MDA、IL-6和TNF-α水平显著下降(P 0. 01),p-p38和p-ERK1/2蛋白的表达显著下调(P 0. 01); HE染色显示肺组织的病理变化明显减轻。结论丹参酮ⅡA可能通过抑制p38MAPK/ERK信号通路,降低脓毒症大鼠炎症因子和氧化应激水平,保护大鼠肺损伤。     

百草枯中毒致大鼠肺组织损伤时氨溴索对肺组织Bcl-2/Bax的表达及细胞凋亡的影响

目的 探讨在百草枯(PQ)中毒所致大鼠急性肺损伤时氨溴索(AM)对肺组织Bcl-2/Bax的表达及细胞凋亡的影响.方法 44只大鼠随机分为4组:正常对照组(C组)6只、AM对照组(AM组)6只、急性肺损伤组(PQ组)16只和急性肺损伤+AM治疗组(PQ+AM组)16只.取肺组织苏木精-伊红(HE)染色来评价肺组织损伤情况;检测血清中肿瘤坏死因子α(TNF-α)水平;蛋白质印迹方法检测肺组织p38丝裂酶原激活蛋白激酶(MAPK)表达;肺组织Bcl-2、Bax免疫组化分析;TUNEL检测肺组织细胞凋亡.结果 C组和AM组大鼠的肺组织结构基本完整,PQ组肺组织损伤程度加重,PQ+AM组肺组织损伤程度较PQ组减轻.PQ组血清TNF-α水平、p38 MAPK和Bax蛋白表达、肺组织细胞凋亡均较C组和AM组显著增加(P＜0.05),PQ+AM组较PQ组均有降低(P＜0.05),而抗凋亡基因Bcl-2在AM干预后较PQ组升高(P＜0.05).结论 百草枯中毒导致了大鼠急性肺损伤,经氨溴索治疗后,通过调节p38 MAPK、Bcl-2和Bax蛋白的表达从而使肺组织细胞凋亡减少,从而有效地减轻了百草枯中毒所致的大鼠急性肺损伤.     

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.