血脂异常患者血清载脂蛋白水平的相关性分析

目的探讨血清载脂蛋白（apo）水平对血脂异常患者中罹患各种疾病的诊断价值。方法检测206例高三酰甘油（TG〉1.7 mmol/L）血症患者血清apo A-Ⅰ、apo B、apo CⅡ和apo CⅢ水平的变化,并以101名健康者作为对照组,观察高TG血症患者罹患各种疾病的apo血清水平的相互关系。结果冠心病组、糖尿病组、脑梗死组、其他疾病组与正常对照组比较,除apo A-I降低外,apo B、apo CⅡ和apo CⅢ均升高（P〈0.01）。在高TG血症患者中,冠心病组、糖尿病和脑梗死组与其他疾病组比较,分别表现为apo CⅡ和apo CⅢ,apo B、apo CⅡ和apo CⅢ,apo B和apo CⅢ血清水平不同程度的升高（P〈0.05、P〈0.01）。结论有高TG血症的冠心病、糖尿病和脑梗死患者存在着apo的代谢紊乱,而不同组合的apo B、apo CⅡ和apo CⅢ血清水平的升高分别与这些疾病的发病危险因素有一定的相互关系。     

高甘油三酯患者血清载脂蛋白含量分析

[目的]探讨血清载脂蛋白（apo）含量对高甘油三酯血症（hypenriglyceridemia,HTG）患者中罹患各种疾病的诊断价值。[方法]检测92例高三酰甘油（TG〉2．2mmol／L）血症患者血清APOA1、apoB、和apoCⅢ含量的变化,并以40名健康者作为正常对照组,观察HTG血症患者罹患各种疾病的apo血清水平的相互关系。[结果]HTG并冠心病组（In coronary heart disease CHD）、HTG并糖尿病组（diabetesmellitus DM）、HTG并脑梗死组（cerebral infarction CI）与正常对照组比较,除APOA1降低外,apoB、和apoCⅢ均升高（P〈0．01）。[结论]有HTG血症的冠心病、糖尿病和脑梗死患者存在着apo的代谢紊乱,而不同组合的apoB、apoCⅢ血清含量的升高分别与这些疾病的发病危险因素有一定的相互关系。     

用比值结果探讨高脂血症与血清载脂蛋白含量的关系

目的用比值结果来探讨高脂血症患者血清载脂蛋白与各项血脂含量之间的关系。方法在全自动生化分析仪上用免疫比浊法测定671例高脂血症和262例健康人的血清ApoAⅠ、AⅡ、B、CⅡ、CⅢ、E含量,并用比值结果分析高脂血症患者Apo与TC、TG、HDL-C、LDL-C的关系。结果与对照组比较,高脂血症时,ApoAⅠ/APOAⅡ比值明显降低(P<0.01)。ApoCⅡ/ApoCⅢ、LDL-C/HDL-C、nHDL-C/HDL-C比值明显升高(P<0.01)。LDL-C/ApoB比值在高胆固醇血症组升高,高甘油三酯和混合型高脂血症组下降(P<0.01)。nHDL-C/ApoB比值高胆固醇血症组和混合型高脂血症组升高,高甘油三酯组降低。结论用比值结果分析血清载脂蛋白与血脂含量的变化,有助于阐明高脂血症的发病机理以及血脂代谢紊乱与冠心病和动脉粥样硬化等疾病的相关性。     

小而密低密度脂蛋白胆固醇在心脑血管系统相关疾病中的意义

目的探讨小而密低密度脂蛋白胆固醇(sd-LDL-C)检测在4种心脑血管系统相关疾病[冠心病、2型糖尿病(T2DM)、高血压和脑梗死]中的意义。方法选取单纯高血压患者50例、单纯T2DM患者90例、脑梗死患者110例及冠心病患者129例,以体检健康者104名作为正常对照组。检测所有对象血糖(Glu)、载脂蛋白A1(apo A1)、载脂蛋白B(apo B)、载脂蛋白E(apo E)、总胆固醇(TC)、三酰甘油(TG)、同型半胱氨酸(Hcy)、高密度脂蛋白胆固醇(HDL-C)、低密度脂蛋白胆固醇(LDL-C)、sd-LDL-C。采用Spearman相关分析评价sd-LDL-C与其他指标的相关性。结果与正常对照组比较,高血压组apo B、TC、Glu、sd-LDL-C水平明显升高(P0.05);脑梗死组TG、Hcy水平明显升高(P0.05),apo A1、apo B、apoE、LDL-C水平明显降低(P0.05);T2DM组TC、Glu、TG、Hcy、sd-LDL-C水平明显升高(P0.05),apoA1水平明显降低(P0.05);冠心病组TC、Glu、TG、Hcy水平明显升高(P0.05),apo A1水平明显降低(P0.05)。在冠心病组中,sd-LDL-C与apo A1、apo B、apo E、TC和LDL-C呈正相关(r值分别为0.372、0.316、0.248、0.718、0.316,P0.05),与HDL-C呈负相关(r=-0.218,P0.05)。在T2DM组中,sd-LDL-C与apo A1、apo B、apo E、TC、TG和LDL-C呈正相关(r值分别为0.243、0.779、0.416、0.616、0.614、0.678,P0.05)。在高血压组中,sd-LDL-C与TC、TG和LDL-C呈正相关(r值分别为0.623、0.756、0.699,P0.05),与HDL-C呈负相关(r=-0.355,P0.05)。在脑梗死组中,sd-LDL-C与apo A1、apoE、TG呈正相关(r值分别为0.398、0.117、0.271,P0.05)。结论 T2DM及高血压患者血清sd-LDL-C水平升高。sd-LDL-C在心脑血管系统相关疾病中有一定意义。     

他汀类药物代谢相关基因检测在心脑血管疾病个体化用药中的作用

目的探讨他汀类药物代谢相关基因检测在心脑血管疾病患者个体化用药及血脂管理中的作用。方法选取141例心脑血管疾病患者(冠心病72例、脑梗死69例)及70名体检健康者(正常对照组)。检测所有对象血清载脂蛋白A(apo A)、载脂蛋白B(apo B)、载脂蛋白E(apo E)、脂蛋白(a)[Lp(a)]、总胆固醇(TC)、三酰甘油(TG)、低密度脂蛋白胆固醇(LDL-C)、高密度脂蛋白胆固醇(HDL-C)、游离脂肪酸(FFA)水平,同时检测他汀类药物代谢相关基因ABCB1(2677GT)、ABCB1(3435CT)和SLCO1B1*5(TC)单核苷酸多态性(SNP)。在72例冠心病患者中选取41例进行他汀类药物治疗前后基因多态性与血脂水平的相关性分析。结果心脑血管疾病组血清TG、HDL-C、apo A、Lp(a)、FFA水平与正常对照组比较,差异均有统计学意义(P0.05);冠心病组血清TG、HDL-C、LDL-C、apo A、Lp(a)、FFA水平与正常对照组比较,差异均有统计学意义(P0.05);脑梗死组血清TG、HDL-C、Lp(a)水平与正常对照组比较,差异均有统计学意义(P0.05);其他血脂项目各组间比较差异均无统计学意义(P0.05)。心脑血管疾病组、脑梗死组、冠心病组的基因分型和基因频率分布一致,均为ABCB1(2677GT)G等位基因频率高于T等位基因频率、ABCB1(3435CT)C等位基因频率高于T等位基因频率、SLCO1B1*5(TC)T等位基因频率高于C等位基因频率。41例冠心病患者采用他汀类药物治疗后,血清TG、TC、LDL-C水平明显低于治疗前(P0.05),血清HDL-C水平明显高于治疗前(P0.05)。不同基因型患者对他汀类药物的疗效存在明显差异(P0.05)。结论心脑血管疾病患者血脂水平异常,同一疾病患者的基因多态性存在明显的个体差异。心脑血管疾病患者的药物基因组学检测对指导他汀类药物临床降脂治疗有重要作用。     

血糖调节异常者血脂代谢的初步研究

目的初步评价血糖调节受损患者血脂代谢异常情况。方法检测糖耐量正常(NGT)、单纯空腹血糖异常(IFG)、单纯糖耐量异常(IGT)、空腹血糖异常合并糖耐量异常(IFG IGT)和糖尿病(DM)患者空腹血糖和餐后2 h血糖及空腹血清总胆固醇(TC)、三酰甘油(TG)、高密度脂蛋白胆固醇(HDL-C)、低密度脂蛋白胆固醇(LDL-C)、载脂蛋白A-I(apo A-I)和载脂蛋白B(apo B)水平,计算非高密度脂蛋白胆固醇(non-HDL-C)和血浆致动脉硬化指数(AIP),比较各组间血清脂质成分的差异。结果IFG组血清TC、LDL-C、non-HDL-C和apo B水平较NGT组明显升高(P<0.01),而TG、HDL-C、AIP差异无统计学意义(P>0.05)。IGT组血清TC、TG、LDL-C、non-HDL-C、apo A-I、apo B和AIP水平较NGT组显著升高(P<0.01),前6项指标与IFG IGT组差异无统计学意义(P>0.05)。IFG IGT组与NGT组比较,各指标差异均有统计学意义(P<0.01);HDL-C、non-HDL-C和AIP水平与IFG组比较差异有统计学意义(P<0.01)。DM组表现出典型的DM性脂代谢紊乱伴AIP水平显著异常。non-HDL-C和apo B间存在良好的相关性(P<0.01)。结论血糖调节受损者不同程度的存在血脂代谢异常,主要表现为TC、TG、LDL-C、non-HDL-C和apo B水平的升高和HDL-C、apo A-I的降低,伴不同程度AIP水平的改变。     

血脂及血清载脂蛋白A1、B测定对冠心病诊断的意义

目的 :测定冠心病患者和健康人的血清甘油三酯 (TG)、总胆固醇 (TC)、高密度脂蛋白胆固醇 (HDL C)和载脂蛋白(apo)A1 、B及其比值 ,比较这些项目在两组间的差异。方法 :随机选冠心病患者 83人和健康人 60人 (年龄 2 565岁 ) ,用Olympus全自动生化分析仪分别测这两组的TG、TC、HDL C、apo A1 、apo B。结果 :用统计学方法处理所得结果 ,并做比较分析。发现冠心病组的TG、TC、apo B都明显高于健康人组 (P <0 0 5或P <0 0 1 ) ,而HDL C、apo A1 /apo B明显低于健康人组 ,且在各项目对冠心病的预测值有效率中 ,apo A1 /apo B的有效率最高 (88 8% )。结论 :apo A1 /apo B对于临床上预防和诊断冠心病有重要意义。     

用比值结果探讨高脂血症与血清载脂蛋白含量的关系

目的用比值结果来探讨高脂血症患者血清载脂蛋白与各项血脂含量之间的关系.方法在全自动生化分析仪上用免疫比浊法测定671例高脂血症和262例健康人的血清ApoA Ⅰ、AⅡ、B、CⅡ、CⅢ、E含量,并用比值结果分析高脂血症患者Apo与TC、TG、HDL-C、LDL-C的关系.结果与对照组比较,高脂血症时,ApoA Ⅰ/APOAⅡ比值明显降低(P＜0.01).ApoCⅡ/ApoCⅢ、LDL-C/HDL-C、nHDL-C/HDL-C比值明显升高(P＜0.01).LDL-C/ApoB比值在高胆固醇血症组升高,高甘油三酯和混合型高脂血症组下降(P＜0.01).nHDL-C/ApoB比值高胆固醇血症组和混合型高脂血症组升高,高甘油三酯组降低.结论用比值结果分析血清载脂蛋白与血脂含量的变化,有助于阐明高脂血症的发病机理以及血脂代谢紊乱与冠心病和动脉粥样硬化等疾病的相关性.     

慢性肾衰透析患者胆固醇酯转运蛋白及血脂变化

本文检测 77例慢性肾衰血透患者 (HD)的胆固醇酯转运蛋白 (CETP)和血脂 ,结果显示 HD患者较对照组的 CETP、TC、HDL - C、apo AI明显降低 ,TG明显升高。按 TG分组 ,高 TG组和正常 TG组 HD患者 CETP仍显著低于对照组 ,但高 TG组 HD较正常 TG组 HD患者 TC、apo B明显升高 ,apo AI、HDL - C下降。CETP和血脂异常与 HD患者高发心、脑血管疾病密切相关 ,其发病机理需进一步探讨。     

孕中期血清载脂蛋白CⅢ、Apelin、Chemerin水平及对妊娠期糖尿病诊断和不良妊娠结局的影响

目的观察孕中期血清载脂蛋白CⅢ(apo CⅢ)、Apelin、Chemerin水平,并探讨三者对妊娠期糖尿病(GDM)的诊断价值及与妊娠不良结局的关系。方法选取2017年8月—2019年8月经筛查确诊为GDM的87例孕妇作为观察组,另选取同期筛查正常的孕妇80例作为对照组。比较两组血清apo CⅢ、Apelin、Chemerin水平,三者之间的相关性采用Pearson相关分析;受试者工作特征(ROC)曲线分析三者对GDM的诊断价值;影响GDM不良妊娠结局的危险因素采用多因素Logistic回归分析。结果观察组血清apo CⅢ、Apelin、Chemerin水平均高于对照组(P<0.01)。血清apo CⅢ、Apelin、Chemerin之间均呈正相关性(P<0.01)。血清apo CⅢ、Apelin、Chemerin及三者联合诊断GDM的ROC曲线下面积分别为0.841、0.718、0.785及0.861,三者联合诊断的敏感度为63.2%,特异度为93.7%。不良妊娠结局GDM患者血清apo CⅢ、Apelin、Chemerin水平均高于正常妊娠结局GDM患者(P<0.05);孕中期血清apo CⅢ、Apelin、Chemerin水平升高均是影响GDM患者不良妊娠结局的独立危险因素(P<0.05,P<0.01)。结论孕中期GDM血清apo CⅢ、Apelin、Chemerin均呈高表达,三者联合对GDM具有较高的诊断价值,且是影响GDM患者不良妊娠结局的独立危险因素。     

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.