106年 - 106 台灣疼痛醫學會專科醫師考題#122412

1. Which opioid described below belong to “full agonist”? (A) buprenorphine (B) fentanyl (C) nalbuphine (D) butorphanol (E) naltrexone

2. About diagnostic nerve blocks, which one of following statements is wrong? (A) May help in locating the origin of pain. (B) Pain originating from malfunctioning CNS pain modulation may also be relieved by a peripheral nerve block. (C) Repeated diagnostic blocks are mandatory before any attempted chemical or physical denervation. (D) Are reliable as prognostic aids for neurolytic procedures. (E) Pain relief from a saline block does not indicate a psychogenic pain or malingered pain.

3. Choice a right description about treatment of cancer pain. (A) Because of the complexity of cancer pain, 3 analgesic ladder from WHO was not useful. (B) Surgery, Chemotherapy and radiotherapy are not the analgesic titration for cancer pain. (C) Only 10-20% of patients ultimately require regular strong opioids. (D) Constipation is common for opioid use, but laxative can be used only when symptom exists. (E) None of above is right

4. Which kind of animal model of neuropathic pain is thought to have the least characteristics of thermal hyperalgesia? (A) Partial sciatic nerve section. (B) Chronic constriction injury (C) Spinal nerve ligation (D) Spared nerve injury (E) Ischemic peripheral nerve injury

5. What kind of fiber is usually thought to be the cause of tactile allodynia? (A) C fibers (B) Aα fibers (C) Aβ fibers (D) Aδ fibers (E) Sympathetic fibers

6. 一位 56 歲婦女經歷車禍，撞傷左側顏面產生骨折，左顏面術後兩年仍持續抱怨以下部位疼痛：skin of the tip and lateral aspect of the nose, intranasal mucosa, the infraorbital skin, intraoral maxillary mucosa, upper lip, upper teeth, the ear pinna and caudal head. 請問該婦女的神經痛與何處神經較不相關？ (A) the ophthalmic (V1) division of the trigeminal nerve (B) the maxillary (V2) division of the trigeminal nerve (C) the mandibular (V3) division of the trigeminal nerve (D) upper cervical nerves (E) all

7. 此婦女抱怨吃東西就產生劇烈牙痛，但又說不出是哪幾顆牙齒痛，且疼痛可幅射到臉頰甚至頸部，請問這可能是? (A) a feature of the trigeminal complex (B) referral of pain (C) the phenomenon of convergence onto a single central neuron receiving input from different primary afferents (D) widespread distribution of nociceptive input of the trigeminal complex (E) all

8. 此婦女的咀嚼動作併發劇烈牙痛，且痛到臉&頸部，請問以下何種解釋或併發現象是錯誤？ (A)與 peripheral sensitization 相關 (B)這是 trigeminal brain stem interneurons 誘發 peripheral sensitization 所致 (C)與 central sensitization 相關 (D)這是因為 trigeminal brain stem sensory nuclei 整合接受 nociceptive input from oral and craniofacial primary afferents (E) noxious stimulation mediated by trigeminal–parabrachial circuits 可能導致食慾喪失

複選題
9. Which of the following statements concerning the difference between phenol and alcohol when used in neurolytic blocks is/are FALSE?. (A) Phenol takes 15 minutes for neurolysis whereas alcohol’s neurolytic effect is immediate. (B) Phenol usually does not produce pain on injection. (C) Intrathecal alcohol is hypobaric, whereas phenol is hyperbaric. (D) Phenol is approximately twice as efficacious as alcohol.

10. 關於纖維肌痛症 (fibromyalgia)的定義，下列哪一項為 1990 年 ACR 的舊定義，而不屬於2010 年的新定義： (A)廣泛性疼痛(widespread pain index, WPI)為計算疼痛分布在身體 19 個區塊的數量 (B)疼痛部位需分布在身體的上、下、左、右、及中軸等部位 (C)症狀嚴重度 (Symptom Severity Scale, SSS)包括疲憊程度、記憶力減弱、睡眠不足 (D)SSS 還包括身體症狀，如頭痛、下腹痛、憂鬱等症狀 (E)身體症狀是指過去半年內曾發生的病史

複選題
11. 當病人一再來門診或急診要求注射成癮性止痛藥時，下列哪些現象暗示病患可能有「成癮」現象？ (A)病人抱怨最近的處方的止痛時間不夠久，藥效變差 (B)病人抱怨最近疼痛加重厲害，發作頻繁，他把三天的藥一天吃完 (C)病人自述出現嗜睡、噁心、性欲降低、便秘，但是疼痛都沒有減輕 (D)病人自述沒吃止痛藥會睡不著，希望睡前加重劑量輔助睡眠 (E)病人最近反覆敘述藥物遺失，而且發生很多次

12. 根據2014年 "National Institute for Health and Clinical Excellence" 對癌症末期瀕死病人的最好的支持性治療 ("Best Practice in the Last Hours and Days of Life")，下列哪一項敘述不正確： (A) Decisions are made to discontinue inappropriate interventions. (B) Discontinue or reduce subcutaneous opioid analgesics to avoid conscious depression or disturbance. (C) "As-required" subcutaneous medication is prescribed according to an agreed protocol to manage pain, agitation, nausea and vomiting, and respiratory tract secretions (D) Family and carers are given appropriate written information. (E) A plan of care is explained and discussed with the patient, family, and carers.

13. 下列關於 WHO Analgesic Ladder 的三階梯(3 steps)用藥，哪一項較不正確： (A) Paracetamol (Acetaminophen)是 step I 用藥，也可以是 step II 用藥 (B) Tramadol 是 weak opioid,屬於 step II 用藥 (C) Hydromorphone, oxycodone 是 strong opioids, 屬於 step III 用藥 (D) Ketamine 作用於 opioid-resistant pain, 可歸類於 step III 用藥 (E) Buprenorphine 是 partial opioid agonist, 歸類於 step II 用藥

14. About chemical neurolytic nerve blocks, which one of following statements is wrong? (A) Phenol or ethanol is usually used for chemical denervation (B) The duration of these blocks is often disappointingly brief. (C) They may induce deafferentation-neuropathic type pain. (D) They are often indicated for patients with chronic pain and a normal life expectancy. (E) They can be used in patients with advanced cancer disease.

15. Based on clinical situations, which kind of opioids owns the highest oral bioavailability ? (A) Hydromorphone (B) Morphine (C) Pethidine (meperidine) (D) Oxycodone (E) Tramadol

16. A 52-year-old man complains of a sudden onset of severe, stabbing pain in the left jaw and cheek that subsides in less than a minute. He is pain-free during the intervals between attacks. Activities such as combing his hair and shaving can cause the onset of this facial pain. He is otherwise healthy. The most likely diagnosis is (A) trigeminal neuralgia (B) atypical facial pain (C) postherpetic neuralgia (D) vascular facial pain

17. Which following item is not a criterion for the diagnosis of migraine? (A) Aggravation by or causing avoidance of routine physical activity (B) Unilaterallocation (C) Moderate or severe pain intensity (D) Throbbing/stabbing quality (E) All are criteria for diagnosis of migraine

18. Peripheral nerve injuries are often associated with neuropathic pain. Which of the following statement is least likely: (A) Nerve injury causes sprouting (or phenotypic changes) of large-diameter primary afferents from the deep dorsal horn into lamina I & II. (B) The cholera toxin B subunit is the primary marker used for sprouting of injured primary nerves. (C) During inflammatory pain, the dorsal root ganglion in the involved nerve show similar changes as seen in neuropathic pain. (D) Peripheral nerve injury may cause ongoing activity and after-discharges. (E) The overall increased excitatory drive may be combined with a compromised inhibitory control in the dorsal horn.

19. Which of the following description about cancer pain mechanism is wrong, ( if ABCD are all right , choice E)? (A) Ischemia is involved in cancer pain mechanism. (B) Tumor-induced release of protons is one of the possible mechanisms of cancer pain. (C) Nerve growth factors (NGF) is involved in some cancer pain mechanism. (D) Cyclooxygenase (COX) is not involved in cancer pain mechanism. (E) All the above descriptions are right.

20. About the failed back surgery syndrome (FBSS), which one of the following procedure may be the last to be considered due to possible poor response? (A) caudal steroids injection (B) epidural adhesive lysis (C) spinal cord stimulation (D) radiofrequency denervation (E) lumbar sympathetic block

21. A patient suffered from chronic low back pain with radiating to buttock, poster lateral thigh and lateral aspect of lower leg. Muscle weakness was observed in the extensor hallucis longus and tibialis anterior. Which lumbosacral root compression is the most likely？ (A) L2 root compression (B) L3 root compression (C) L4 root compression (D) L5 root compression (E) S1 root compression

22. 以下敘述何者錯誤？ (A) Trigeminal pain 是 a bottom-up process. (B) Trigeminal pain 可能與“top-down” nociceptive mechanisms 相關 (C)大腦皮質是 a major source of top-down modulation of pain (D) pain perception 並非是 an active process (E) Noxious inputs can modulate spinal outflow via the brain stem structures in a bidirectional fashion.

23. Which of the following is not true about objective characteristics of muscle pain? (A) No flexor reflexes when the muscle is painfully stimulated (B) Autonomic symptoms such as a drop in blood pressure, sweating (C) Convergent input from muscle and other sources to central neurons (D) Supraspinal processing in centers different from those for cutaneous pain (E) All of the above are correct.

24. ORL1 是 opioid receptors 家族中，最後被發現的一種，下列關於它的特性的敘述何者不正確？ (A)別名為 Nociceptin/orphanin FQ (B)與其他成員，同樣屬於 G protein-coupled receptor (GPCR), 有 7 個跨膜結構域 (transmembrane domain) (C)同樣可調控 Ca+2 及 K+離子的通透性，減少神經元的興奮性 (D)對一般的 opioid receptor agonists 的親和力很弱 (E)此受器的興奮可能出現疼痛過度(hyperalgesia)，出現 “anti-opioid effect”

25. 關於下列作用於 opioid receptor 的藥劑，何者不正確？ (A) hydromorphone 是 pure mu agonist，口服劑量的強度是 morphine 的 3-5 倍 (B) Methadone 是 pure opioid agonist 也是 NMDA receptor antagonist 和 serotonin 的回收抑制劑 (reuptake inhibitor), 常用於戒癮的 maintenance therapy (C) buprenorphine 是 agonist-antagonist；口服會因 first pass effect 而效果大減 (D) oxycodone 是半合成的 pure mu opioid agonist, 口服劑量的強度是 morphine 的 1.5-2 倍 (E) Tapentadol 是 mu agonist, 也是 norepinephrine reuptake inhibitor，適合用於神經病變疼痛

26. 關於使用鴉片類藥物出現的耐受性(tolerance)，下列敘述何者正確： (A)都必須要長期使用才會產生 (B)止痛耐受性、腸胃耐受性、鎮靜耐受性、及呼吸耐受性都是經由同樣機轉產生 (C)膽囊收縮素 (Cholecystokinin)的 anti-opioid effect，是造成耐受性的原因之一 (D)不同鴉片類藥物的高交叉耐受性 (cross tolerance)，造成藥物轉換(opioid rotation)上的主要障礙 (E)耐受性是造成鴉片成癮的主因

27. Which of the following description about autonomic, endocrine and immune interactions in pain is correct? (A) Signaling from the immune system to the CNS via vagal afferents and possibly small-diameter afferents innervating somatic tissues to induce sickness behavior (B) Modulation of the immune system and the inflammatory response by CNS circuits that control the production and release of neuroendocrine hormonal mediators in the sympathoadrenal stress axis (C) Coupling of the sensory nociceptive and sympathetic efferent components of the peripheral nervous system in the setting of inflammation and nerve injury to produce sympathetically maintained pain (D) All of above

28. Which of the following is the acceptable statement about neurodestructive RF lesions? (A) These temperatures are resulted from friction heat. (B) The size of RF lesion with 22 gauge RF needle is around with a radius of 5 mm (C) The heat is generated on the tip of RF needle. The RF needle then heat up the tissues. (D) The RF permanent neurodestructive lesion is formed when neural temperatures exceed 42 C (E) All of the above

29. Pain is a frequent consequence of spinal cord injury (SCI). Which of the following statement is least likely: (A) Below-level neuropathic pain is most likely described as severe or excruciating months or years following initial injury. (B) Damage to the spinothalamic tracts is an important ingredient in the development of neuropathic pain following SCI. (C) Chronic musculoskeletal pain is common in tetraplegic patients after SCI. (D) Patients with cervical SCI are at risk of developing CRPS affecting upper limbs. (E) Below-level neuropathic pain is also referred to deafferentation pain.

30. The innervation of deep somatic tissue like muscle and joint is quite complex. Which of the following description is not appropriate? (A) The nociceptors are predominantly activated by non-physiological stimuli which may cause damage to the structures (e.g. overload, twisting, strong pressure, ischemic contraction). (B) During inflammation or after trauma, nociceptors of joint and muscle show pronounced sensitization, in particular for mechanical stimuli. (C) Descending inhibition is enhanced during chronic inflammation but seems to be normalized during acute inflammation. (D) Both primary afferent fibers as well as sympathetic reflexes may aggravate inflammatory lesions. (E) Reduced release of hormones from the hypothalamic-pituitary-adrenal (HPA) axis such as cortisol, adrenal androgens and testosterone may cause a relative loss of anti-inflammatory activity.

31. 關於疼痛臨床研究與止痛方式的統計，下列何者正確？ (A)一般而言，某種止痛方式的 number need to treat 介於 8-12 之間，表示該方式是有效的 (B)統計結果 Number need to treat 數值愈大，表示該止痛方式效果越好 (C)統計結果 Number need to harm 不適合用以表達副作用或併發症的的發生率 (D)比較不同止痛方式的效果時，病人自控式止痛的嗎啡用量是很好的指標，比 pain score 更為客觀 (E)以上皆不正確

32. 關於鴉片類藥物的敘述，下列何者最不正確？ (A) Hydromorphone 效力比 morphine 強 3-5 倍(口服)，且具有 NMDA 受體拮抗劑與血清素再吸收抑制(serotonin reuptake inhibitor)的特性 (B) Buprenorphine 具有μreceptor partial agonist 及κantagonist 之性質 (C) Meperidine(pethidine)具有高度親脂性，容易引發「尋藥行為」(drug-seeking behavior) (D) Tapentadol 具有μagonist 與 noradrenaline reuptake inhibitor 之性質 (E)以皮下作為給藥路徑可以提供緩慢穩定的吸收，唯給藥量不宜超過 5 mL/hr

33. 下列對於肌筋膜疼痛及纖維肌痛的比較，何者錯誤：

34. MODULATION OF TRIGEMINAL NOCICEPTION 與何者相關？ (A) Segmental modulation (B) Descending modulation from the brain stem. (C) Diffuse noxious inhibitory control. (D) V Top-down modulation (E) all

35. Which of the following common manifestations of fibromyalgia syndrome has the lowest prevalence? (A) Widespread pain (B) Peripheral pain generators (C) Fatigue (D) Irritable bladder syndrome (E) Sleep disorder

36. Which of the following is not a common manifestation of the myofascial pain syndrome? (A) Regional body pain and stiffness (B) Abnormal findings on neurological examinationl (C) Limited range of motion of the affected muscle (D) One or more trigger points (E) Referral (triggering) pain from a trigger point to a zone of reference.

37. Which of the following combination of lesion site with referral site describing pain referral is not common in cancer patients suffering from cancer pain? (A) (Diaphragmatic irritation) and (Shoulder) (B) (Urothelial tract) and (Inguinal region and genitalia) (C) (C7–T1 vertebrae) and (Interscapular) (D) (L1–2) and (Sacroiliac joint and hip) (E) all of the above are common found in patients with cancre pain

38. Which of the following suggestion is not advisable for the use of opioids in children with cancer pain? (A) Use the oral route first in most circumstances (B) Treat constipation pre-emptively. (C) If side effects are bothersome with one opioid, consider switching to another one. (D) Use sufficient doses to keep the patient comfortable should be avoided due to the possible occurrence of adverse effects (E) Use the oral route first in most circumstances.

39. Which of the following oral opioids is not recommended for padiatric patients with cancer pain? (A) morphine (B) hydromorphone (C) oxycodone (D) meperidine (pethidine) (E) all of the above can be prescribed for pediatric patients with cancre pain

40. Adjuvant analgesics are often prescribed for managing caner pain, but which of the following drug – indication is not considered? (A) NSAIDs for Soft tissue pain (B) Anticonvulsants for Neuropathic pain (C) Steroids for Soft tissue pain (D) Baclofen for Muscle spasm (E) Benzodiazepines for Muscle spasm

41. Which of the following cell type sense the initial “endanger signal” and participates in the initial phase of pathogenesis of the nerve injury induced neuropathic pain? (A) Microglia (B) Spinal lamina I and II neuron (C) Astrocyte (D) oligodendrocyte

42. Which of the following description about spinal cord plasticity and pain is incorrect? (A) Some spinal nociceptive neurons receive convergent input from high- and low- threshold sensory fibers thus called wide–dynamic range neurons (B) Glutamate is the major fast excitatory neurotransmitter in all nociceptive afferent nerve fibers. Glutamate can bind to three types of ionotropic glutamate receptors and to G protein–coupled metabotropic glutamate receptors to modify neuroexcitability. (C) Hyperalgesia and allodynia can even be induced in humans in the absence of any sensory stimulus, such as during prolonged application of opioids or on abrupt withdrawal of opioids. (D) Spinal nociception is under powerful control from descending inhibitory and facilitatory pathways. Under normal conditions, descending facilitation appears to prevail over inhibitory pathway.

43. 下列關於 opioid rotation 或 opioid switch，哪一種敘述較不正確： (A) opioid switch/rotation 意思是指改變鴉片藥物的給藥途徑，可以提高止痛效果 (B)動物實驗上可發現，鴉片受器剔除小鼠仍可以保留部分對 fentanyl 注射的止痛效果 (C)理論基礎是基於人體對 opioid receptor 的 binding profile 及 affinity 具有基因多樣性 (heterogenecity). (D) 臨床上已成為改善癌症病人的嗎啡類藥物效果的常用方式 (E) tramadol 換成 morphine 不能稱為 opioid switch

44. 下列關於癌症病人的 breakthrough pain，下列敘述何者較不正確： (A) 包括了 incident pain 及 spontaneous pain (B) 一般不把"end-of-dose failure of analgesic"歸類在 breakthrough pain (C) 疼痛的特性包括了 somatic pain, visceral pain, neuropathic pain 或 mixed type (D) fentanyl buccal film 可以用來控制中重度的 breakthrough pain (E) breakthrough pain 的發生機率並不大，一般只出現在癌症末期或瀕死病人

45. 利用手術或介入性阻斷技術減少癌症疼痛的方式，下列敘述何者效果最差： (A) 以 internal surgical fixation 減少脊椎病理性骨折的疼痛 (B) 以 epidural steroid 減輕腫瘤浸潤引起的 lumbosacral radiculopathy (C) 以 IV-PCA 減輕 radiation-induced brachial plexopathy (D)以 neurolytic celiac plexus blockade 控制胰臟癌引起的腹痛 (E) 以 intrathecal morphine pump 治療 peritoneal carcinomatosis-induced pain

46. About image-guided lumbar sympathetic block, which the following indication is not proper? (A) Sympathetically maintained pain (B) Reflex sympathetic dystrophy (C) Phantom low limb pain (D) Raynaud’s disease (E) Chronic pancreatitis

47. Which of the following statement concerning painful polyneuropathies with prevalent loss of small fibers is most likely: (A) Chronic renal failure neuropathy. (B) Diabetes mellitus neuropathy. (C) Alcoholic neuropathy. (D) Myeloma neuropathy. (E) soniazid neuropathy.

48. About epidural steroid injection, which one of following statements is wrong? (A) Spinal stenosis is an indication for epidural steroid. (B) Do not use for non-specific low back pain. (C) Do not repeat more than three times per year. (D) May cause pain from chronic arachnoiditis. (E) Efficacy is less with radicular pain that has lasted longer than 3 months.

49. Pain is a frequent consequence of spinal cord injury (SCI). Which of the following statement is least likely: (A) Below-level neuropathic pain is most likely described as severe or excruciating months or years following initial injury. (B) Damage to the spinothalamic tracts is an important ingredient in the development of neuropathic pain following SCI. (C) Chronic musculoskeletal pain is common in tetraplegic patients after SCI. (D) Patients with cervical SCI are at risk of developing CRPS affecting upper limbs. (E) Below-level neuropathic pain is also referred to deafferentation pain.

50. Effects on postoperative morbidity of regional anaesthetic or analgesic techniques compared with those of general anaesthesia and systemic postoperative analgesics may reduce the following complications, except: (A) pulmonary embloism (B) myocardial complications (C) pulmonary infectious complications (D) cerebral complications (E) other thromboembloic complications

106年 - 106 台灣疼痛醫學會專科醫師考題#122412

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