14. 下列何者不適合用於 intrathecal route 治療 neuropathic pain 的第一線用藥？
(A) morphine
(B) ziconotide
(C) hydromorphine
(D) baclofen

40. 認知行為療法(Cognitive-behavioral therapy CBT)為全方位疼痛治療的必要模式之一，下列何項是 CBT 的重要組成要素? (A) 教育病患有關疼痛及其相關症候群的內容 (B) 協助病患專注於增加自身活動及功能提升而非止痛 (C) 教育訓練病患有關 biofeedback, relaxation 及 stress management 的技巧 (D) 協助病患進行未來目標的設定 (goal setting for the future) (E) 以上皆是

41. Which one of the following statement is correct? (A) Functional imaging techniques applied for the study of pain are positron emission tomography (PET), functional magnetic resonance imaging (fMRI), near-infrared spectroscopy (NIRS), multi-channel electroencephalography (EEG) and magnetoencephalography (MEG), and intracranial recordings. (B) NIRS is an optical approach that also analyses changes in hemoglobin oxygenation levels by using light in the near infrared range (650 to 950 nm). (C) EEG and MEG are noninvasive neurophysiologic techniques that measure the respective electrical potentials and magnetic fields generated by neuronal activity of the brain and propagated to the surface of the skull where they are picked up with EEG electrodes or, in the case of its magnetic counterpart, received by supra conducting quantum interference device (SQUID) sensors located outside the skull. (D) (D.) Invasive recordings, which are assessed during neurosurgical interventions in patients ongoing epileptic surgery, or deep brain stimulation (DBS) procedures (most common in Parkinson disease), are extremely helpful to directly measure supraspinal pain signals. (E) All of the above are correct.

42. Which one of the following statement is wrong? (A) The person who has a chronic pain condition resides in a complex and costly world that is populated not only by themselves but also by their significant others, including health care providers, employers, and third-party payers. (B) People with chronic pain may feel that their health care providers, employers, and even family members are blaming them when their condition fails to respond to treatment as expected. (C) In the absence of cure or even substantial relief, individuals experiencing chronic pain may withdraw from contacts； lose their sources of income； alienate family, friends, and coworkers； and become more and more isolated, despondent, depressed, and, in general, demoralized. (D) Psychosocial and behavioral factors play an insignificant role in the experience, maintenance, and exacerbation of pain and potentially even the cause. (E) Because some level of pain persists in the majority of people with chronic pain regardless of treatment, self-management is an important complement to biomedical approaches.

43. 下列對於肌筋膜疼痛及纖維肌痛的比較，何者錯誤：

44. During peripheral sensitization of nociceptors, which of the coupling is wrong? (A) prostaglandin E2 (PGE2) --- EP receptor (B) bradykinin --- B2 receptor (C) heat --- TRPV1 receptor (D) ATP --- P2Y receptor (E) all of the above are right

45. Arrange the pain intensity of the following conditions from the strongest to the least according to long form McGill Pain Questionnaire. 1 Labor pain, 2 Amputation of digit, 3 Male low abdominal surgery, 4 Fracture: (A) 1＞2＞3＞4 (B) 2＞1＞4＞3 (C) 2＞1＞3＞4 (D) 1＞2＞4＞3 (E) None of above is right

46. Regarding the actions of spinal and supraspinal analgesia for opioids, which of the following statement is most likely: (A) Opioid receptors are mostly located at a predominantly 70% postsynaptic location on the central terminals of only small diameter nociceptive primary afferents. (B) The contribution of kappa, delta and mu receptors to the total opiate binding throughout the spinal cord is estimated to be delta ＞ mu ＞kappa. (C) Opioids inhibit OFF cells via GABA neurons and activate ON cells in the rostromedial medulla (RVM) leading to changes in spinal descending controls. (D) Nitric oxide (NO) is required for the 5-HT-mediated inhibition of PAG output and reversal of antinociception. (E) Fibers descending from the PAG to the dorsal horn of the spinal cord are mostly enkephalinergic, glycinergic and GABAergic.

47. 周邊神經切除會形成 neuroma 引起疼痛，下列敘述何者不正確： (A) 是因為 axon 不正常的 regenerative sprouting (B) 疼痛發生大多與 C-fiber 出現不正常的 ectopic firing 有關 (C) 糖尿病或神經炎，也會出現 microneuroma，引起疼痛 (D) 在新生兒周邊神經損傷，反而少出現神經瘤 (E) Tineal sign 可以作為診斷 ectopic firing 的依據

48. 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

49. 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

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