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Chapter 4: The Inflammatory Response Study Mode

1.

How many cases of severe sepsis occur in the United States each year?

A.

250,000

B.

500,000

C.

750,000

D.

1 million

2.

Cytokines are:

A.

Lipid mediators secreted by lymphocytes

B.

Proteins that form the contractile elements of muscle cells

C.

Toxins secreted by bacteria

D.

Small hormone-like proteins secreted by individual cells

3.

Which of the following mediators is a Th2 cytokine?

A.

TNF

B.

IL-1β

C.

IL-10

D.

IL-12

4.

Which of the following receptors is essential for activation of macrophages by bacterial

lipopolysaccharide (LPS)?

A.

TLR4

B.

IL-1RI

C.

IRAK

D.

LBP

5.

Treatment with a monoclonal anti-TNF antibody has been shown to be effective for the

treatment of selected cases of which of these diseases?

A.

Asthma

B.

Septic shock

C.

Myocardial infarction

D.

Crohn's disease

6.

Which of the following agents has been approved by the FDA for the adjuvant

treatment of severe sepsis?

A. Recombinant human IL-6

B. Recombinant human activated protein C

C. Recombinant human growth hormone

D. Recombinant human IL-1RA

7.

In critically ill victims of trauma, high circulating levels of IL-6 are:

A.

Associated with an increased risk of death

B.

Associated with a high likelihood of survival

C.

Rarely detectable

D.

A measurement artifact

8.

Which of the following is the main cell type that is activated by IL-8?

A.

Enterocytes

B.

Macrophages

C.

Monocytes

D.

Neutrophils

9.

HMGB1 is:

A.

A late-acting proinflammatory cytokine

B.

A nuclear protein that supports DNA transcription

C.

A protein with high electrophoretic mobility

D.

All of the above

10. Nitric oxide:

A. Is a widely used anesthetic gas

B. Is a potent endogenous vasoconstrictor

C. Is generated by cells from the amino acid L-arginine

D. Stimulates the aggregation of platelets

Chapter 06: Metabolism in Surgical Patients

1. A 5-year-old boy with an unresolved congenital umbilical hernia is admitted for hernioplasty. After a moderate fasting period prior to surgery, the child is profoundly asleep and unable to be roused. Marked hypoglycemia and ketonuria, accompanied by low levels of alanine and insulin, are noted during workup. Administration of alanine produces a rapid rise in his blood glucose level. The metabolic alteration most likely causing the symptoms of this patient is expected in which of the following pathways?

A.

Protein breakdown in muscle tissue

B.

Mitochondrial β-oxidation of fatty acids by the liver

C.

Lipolysis by desnutrin in adipose tissue

D.

Glucagon secretion by alpha cells of the pancreas

2.

A 52-year-old man is admitted with an episode of severe upper gastrointestinal bleeding.

The patient has a 25-year history of excessive alcohol consumption and was diagnosed with cirrhosis 5 years ago. Because of recurrent and refractory bleeding from esophageal varices, he consents to an emergency portocaval shunt. After surgery, the bleeding is controlled and the patient seems to be improving until he subsequently falls into a deep coma. The best next step in the diagnostic assessment of this patient is to order which of the following tests?

A.

Blood glucose level

B.

Serum bilirubin level

C.

Serum albumin level

D.

Blood culture

E.

Serum ammonia level

3.

Indicate which of the following is not a contraindication to enteral nutrition.

A.

Gastrointestinal ischemia

B.

Severe short bowel syndrome

C.

Distal high-output intestinal fistulas

D.

Severe acute pancreatitis

4.

In the management of enteral feeding associated diarrhea, which of the following is the

most appropriate initial action?

A. Change of antibiotics in use.

B. Change to an elemental-type formula (e.g., EleCare).

C. Change to an enteral formulation with fiber.

D. Start a small dose of loperamide.

5.

In performing perioperative assessments, the most reliable biochemical predictors of

operative morbidity and mortality across surgical specialties include which of the

following?

A.

Serum albumin level

B.

Defects in cellular immunity and phagocytic function

C.

Serum urea nitrogen level

D.

Prothrombin time

6.

A patient receives 2500 mL of Vivonex Pediatric/day, consisting of a total of 60 g of fat,

60 g of protein, and 325 g of carbohydrates. The daily caloric intake of this patient is best

represented by which of the following values?

A.

1600 kcal/day

B.

1700 kcal/day

C.

1900 kcal/day

D.

2200 kcal/day

7.

A previously healthy, 18-year-old man is admitted to the ICU after sustaining multiple

injuries in a motorcycle accident. Multiple facial fractures, as well as ribs, pelvis, and right femur fractures, were found in the initial scan. In addition, multiple deep dermal abrasions affecting 40% of his body surface area were apparent. Nutritional support should be initiated by which of the following?

A.

Preferentially via the IV route

B.

Only via enteral feeding tube to decrease the patient's high risk of aspiration

C.

Immediately after resuscitation is complete (i.e., within the first 48 to 72 hours)

D.

After definitive treatment of the injuries has been completed

8.

This question concerns the same patient as in question 7.) Two months postinjury and

after operative procedures that included tracheostomy, open reductions with internal fixation, exploratory laparotomy, and persistent ventilator support, a 20% loss of body weight is noted as compared with admission. By simply considering weight loss, which of the following can be accurately expected?

A. 50% increased risk of mortality

B. Reduced risk for pressure sores and pneumonia

C. 10% increased risk of mortality

D. Increased difficulty healing and weaning of ventilator support

9. A 9-year-old girl suffered an 86% TBSA, third-degree burn injury during a house fire. She was found unconscious. The patient arrives to the burn unit with a heart rate (HR) of 130 beats/min, BP of 100/70 mm Hg, respiratory rate (RR) of 18 breaths/min, and temperature (T) of 37.6° C. She receives standard care with adequate IV resuscitation, thermoregulation of the room's thermostat to 33° C, and excision and grafting of her wounds on postinjury day. What is the most reliable method to estimate caloric requirements in this patient? (Questions 9 through 12 apply to this patient.)

A.

Harris-Benedict equation

B.

Curreri formula

C.

Indirect calorimetry

D.

Fick's equation

10.

7 days postinjury, HR = 165 beats/min, BP = 105/80 mm Hg, RR = 22 breaths/min, T =

38.5° C, plasma glucose level = 250 mg/dL, [Na] = 145 mEq/dL, [Cl] = 100 mEq/dL, and [K] = 4.5 mEq/dL. You administer IV fluids, insulin, and potassium chloride. What should be done to prevent mortality through the management of hyperglycemia in this critically ill surgical patient?

A. Titrate patients to a glucose level goal between 80 and 110 mg/dL.

B. Consider starting the patient on an oral hypoglycemic.

C. Use insulin only if the plasma glucose level is >200 mg/dL

D. Minimize significant fluctuations of glucose and potassium carefully.

E. Request an endocrinology consultation.

11. Fifteen days following severe burns, excision, and autograft surgery, an increase of

>25% of insulin requirements is noted over the previous 24-hour period. What is the best next step in the management of this patient?

A.

Schedule further surgery to decrease hypermetabolic response.

B.

Further increase the insulin drip until a glucose level of 140 to 180 mg/dL is reached.

C.

Order cultures and band neutrophil of peripheral blood.

D.

Repeat blood glucose level testing and order a new metabolic panel.

12.

Four weeks postinjury, during the daily abdominal examination, you palpate the lower

edge of the liver 4 cm below the edge of the ribs. No tenderness to palpation is reported and

there is no evidence of jaundice. Which of the following best explains the findings seen in pathology?

A. Increased dietary intake of fats

B. Increased synthesis of fats from sugar-enriched diet

C. Excessive peripheral lipolysis.

Chapter 07: Wound Healing

1.

Fetal wound healing is different from adult wound healing in that:

A.

Fetal wounds heal without scarring and without dermal appendages.

B.

Fetal wounds have increased amounts of TGF-β and FGF-2.

C.

Fetal fibroblasts have decreased prolyl hydroxylase activity.

D.

Fetal wounds have increased responses to inflammation and growth factor stimulation.

E.

The ECM of the fetal wound has low levels of hyaluronic acid.

2.

Elastin is:

A.

Organized in mammalian skin in a basket weave pattern to resist multidimensional tensile stress

B.

Produced late in life; has a high turnover rate

C.

An extremely hydrophilic molecule, which accounts for its functional properties

D.

An important component of the extracellular matrix of blood vessels; mutations causing elastin protein deficiency result in intimal hyperplasia, leading to arterial narrowing.

E.

Affected in Ehlers-Danlos syndrome, which is characterized by fragile skin

3.

The cells or cell components central to wound healing are:

A.

B cells

B.

T cells

C.

Leukocytes

D.

Macrophages

E.

Platelets

4.

Thromboxane causes:

A.

Fibroblast chemotaxis

B.

Vasoconstriction

C.

Collagen cross linking

D.

Endothelial proliferation

E.

Bacterial lysis

5.

Iron deficiency has an impact on wound healing by decreasing:

A.

Early tensile strength

B.

DNA synthesis

C.

Conversion of hydroxyproline to proline

D.

Tissue oxygenation

E.

Fibroblast proliferation

6.

Hypertrophic scar is:

A.

Another term for keloids

B.

More likely to occur on the face

C.

Genetic in origin

D.

Preventable

E.

Worsened with glucocorticoids

7.

The effects of diabetes on wound healing include:

A.

Slowed epithelialization

B.

Reduced phagocytosis

C.

Glycosylated collagen

D.

Thickened basement membrane

E.

All of the above

8.

Ionizing radiation causes hypoxia by:

A.

Direct cellular injury to endothelium

B.

Basal membrane injury

C.

Release of histamine and serotonin

D.

Preventing the hypoxic stimulus of angiogenesis

E.

Increased dermal fibrosis and thickening

9.

Nicotine ingestion affects wound healing by:

A.

Increasing fibroblast proliferation

B.

Increasing platelet adhesion

C.

Competitively competing with oxygen

D.

Inhibiting oxidative metabolism

E.

Inhibiting oxygen transport

10. Which of the following events occurs in the proliferative phase of wound healing?

A. Histamine release

B. Collagen cross linking

C. Thromboxane release

D. Phagocytosis

E. Collagen synthesis

11.Chronic wounds characteristically have:

A. Tissue inflammation

B. Decreased tissue inhibitor of metalloproteinases levels

C. Increased gelatinase levels

D. Increased collagenase levels

E. All of the above

12.

The wound healing impairment caused by corticosteroid administration can be

reversed by:

A. Vitamin A

B. Vitamin C

C. Zinc

D. Vitamin K

E. Vitamin B 12

13. Which of the following glycosaminoglycans is not a component of skin?

A. Hyaluronic acid

B. Chondroitin sulfate

C. Dermatan sulfate

D. Heparin sulfate

E. Heparin

14. Most human collagen is:

A. Type I

B. Type III

C. Type IV

D. Type V

E. Type VII

15. Endothelial cells are induced to form tubules by:

A. Vascular endothelial growth factor (VEGF)

B. Hypoxia

C. Tumor necrosis factor-α (TNF-α)

D. Transforming growth factor-β (TGF-β)

Chapter 08: Regenerative Medicine

1. Which of the following is not a primary cellular source currently being investigated for

use in tissue repair?

A.

Embryonic stem cells

B.

Somatic cell nuclear transfer

C.

Circulating fetal stem cells

D.

Stromal fraction of adult bone marrow and fat

E.

Cancer stem cells

2.

Adult mesenchymal stem cells can be characterized by:

A.

Their ability to undergo clonal expansion, with the ability to differentiate

into fat, cartilage, and bone under appropriate conditions

B. Their low frequency in fat, but significantly higher frequency and ease of harvest in bone

marrow, with minimal morbidity

C. The disparate growth kinetics and gene transduction capacity between fat and bone marrow

sources

D. The inability for bone marrow–derived cells to undergo myogenic differentiation

E. A higher risk for whole blood contamination from fat-derived cells relative to bone marrow

sources

3. Which of the following is not true of fetal stem cells?

A. Fetal stem cells do not proliferate as fast as adult stem cells.

B. Fetal stem cells have been found to possess capacity for adipogenic, osteogenic, and

chondrogenic differentiation.

C. Xenogeneic transplantation has shown fetal stem cells to engraft and undergo site-specific

tissue differentiation.

D. The use of fetal stem cells is limited by ethical debate and attendant risks associated with

intrauterine procedures.

4. Which of the following is not one of the transcription factors used in cellular

reprogramming to create iPS cells?

A. Oct-4

B. Sox-9

C. Klf-4

D. Nanog

5.

Which of the following is not true of ASCs?

A.

ASCs can be differentiated into bone, fat, and cartilage.

B.

The major advantage of ASCs is their relative abundance and ease of isolation from subcutaneous adipose tissue through standard lipoaspirate techniques.

C.

ASCs represent a homogeneous cell line derived from lipoaspirate cells.

D.

None of the above

6.

Which of the following cell types is not pluripotent?

A.

ESCs

B.

iPS cells

C.

ASCs

D.

Cells derived by somatic cell nuclear transfer (SCNTs)

7.

Induced pluripotent stem cells are characterized by:

A.

Requirement for viral integration of defined transcription factors to dedifferentiate into

pluripotent state

B.

Cells that are identical to embryonic stem cells

C.

Cells that give rise to teratoma comprising all three germ layers when injected into immunodeficient mouse

D.

Inability to differentiate into neurons

8.

In the skin, epidermal stem cells reside in:

A.

Sweat glands

B.

Bulge region along hair follicles

C.

Superficial epidermis

D.

Subcutaneous fat

Chapter 09: Evidence-Based Surgery: Critically

1.

The difference between efficacy and effectiveness is:

A.

The manner in which the outcome of interest is measured.

B.

Efficacy is based on best case patient care and outcomes from research settings, whereas effectiveness more closely approximates real-world results.

C.

Effectiveness is based on best case patient care and outcomes from research settings, whereas efficacy more closely approximates real-world results.

D.

No difference.

2.

In performing a health economic analysis, the author(s) must be certain to describe

which of the following?

A.

The perspective being adopted

B.

Discounting (to account for the future value of the dollar, usually 3% to 5%) and inflation adjustment

C.

The assessment of costs rather than charges

D.

All of the above

3.

Using observational data, causality can be inferred if:

A.

Exposure precedes the outcome.

B.

The exposure can plausibly and/or biologically lead to the outcome.

C.

The magnitude of the association between exposure and outcome is large, with potentially varying magnitudes of association between exposure dose and outcome.

D.

All of the above.

4.

In any study, both the hypothesis and plan of analysis should be stated a priori to

decrease the risk of:

A. A negative study.

B. A type I error.

C. A type II error.

D. Low statistical power.

5.

A group of investigators perform a randomized trial comparing a control intervention

(A) to an experimental intervention (B). Their hypothesis is that intervention B is superior to A with regard to the outcome of interest. The trial is adequately powered to identify a difference if one truly exists. However, the results demonstrate no statistically significant difference between these two interventions. The investigators conclude that the two interventions are likely equivalent with regard to this outcome. What can safely be stated about the result and the authors' conclusions?

A.

The authors are correct; intervention B is equivalent to A in terms of the outcome of interest.

B.

Intervention B would likely demonstrate a statistically significant improvement over A if the sample size were larger.

C.

The authors are incorrect because equivalence can only be ascertained using a noninferiority trial design.

D.

The conclusions depend on the manner in which the authors chose to control for confounding factors.

6.

Which of the following is true regarding the commonly used P value significance level of

.05?

A.

This has been mathematically shown to be the cutoff for statistical significance.

B.

It is commonly used and should therefore always be chosen as the cutoff for statistical significance.

C.

If a statistical test attains this level of significance, it definitively proves a difference exists.

D.

It is arbitrary and a different level for statistical significance can be selected.

7.

In analyzing data from a randomized trial, which of the following analytic approaches is

most appropriate?

A.

Per-protocol

B.

Case-complete

C.

Intent to treat

D.

Meta-analysis

8.

Which of the following is true when comparing the odds with the probability of an

outcome?

A. The odds can overestimate the probability if the outcome of interest is common in the underlying population.

B. The odds can underestimate the probability if the outcome of interest is common in the underlying population.

C. The odds can overestimate or underestimate the probability if the outcome of interest is common in the underlying population.

D. The two values are the same.

Chapter 13: Surgical Complications

1. Which of the following are mechanisms for heat loss that contribute to the development

of hypothermia?

A .Cool environment

B.

Direct body contact to cooler materials

C.

Heat loss with evaporated water vapor

D.

Exhalation of warmed air

E.

All the above

2.

Which of the following is required to make a definitive diagnosis of malignant

hyperthermia?

A.

Administration of an epidural anesthetic

B.

Tachycardia

C.

Cyanosis

D.

Muscle biopsy

E.

Muscle rigidity

3.

Which of the following is not usually required for the clinical diagnosis of pneumonia?

A.

Decreased breath sounds

B.

Temperature that is usually greater than 38.5°C

C.

Pleuritic chest pain with coughing

D.

Elevated peripheral white blood cell count

E.

Chest radiographic infiltrate

4.

Which of the following criteria is indicative of the presence of acute lung injury (ALI)

rather than adult respiratory distress syndrome (ARDS)?

A.

Pulmonary capillary wedge pressure < 20 mm Hg

B.

PaO 2 /FIO 2 ratio < 300

C.

PaO 2 /FIO 2 ratio < 200

D.

Bilateral infiltrates on chest radiography

E.

An acute change in lung function

5.

What is the expected reinfarction rate for patients undergoing noncardiac surgery after

a recent acute myocardial infarction (AMI)?

A. No difference compared with other myocardial infarction patients

B. 8% at less than 3 months, 3.5% at 3 to 6 months, then similar to other myocardial infarction patients

C. 20% in the first 6 months and then similar to other myocardial infarction patients

D. 15% at less than 3 months, 10% at 3 to 6 months, 5% at more than 6 months

E. 50% at less than 3 months, 25% at 3 to 6 months, 15% at more than 6 months

6.

Components of the syndrome of inappropriate secretion of antidiuretic hormone

(SIADH) include:

A.

Hyponatremia

B.

Hypernatremia

C.

Peripheral edema

D.

Serum hyperosmolality

E.

Hypertension

7.

Which of the following is not a common cause of a small bowel obstruction in an adult?

A.

Hernia

B.

Tumor

C.

Volvulus

D.

Adhesions

E.

Ileocolic intussusception

8.

An abdominal compartment syndrome produces all the following except:

A.

Acute renal failure

B.

Hypoxia

C.

Intestinal obstruction

D.

Elevated urinary bladder pressure

E.

Hypercarbia

9.

Intital treatment of acute gastrointestinal bleeding includes:

A.

H 2 receptor antagonists

B.

Aggressive volume resuscitation

C.

Gastrointestinal endoscopy

D.

Sucralfate

E.

Antibiotics

10. Surgical antibiotic prophylaxis is indicated:

A. In all emergency operations

B. For wounds classified as clean-contaminated

C. For wounds classified as contaminated

D. For wounds classified as dirty-infected

E. For all wounds

11. Postrenal causes of acute renal failure include all the following except:

A. Ureteral obstruction caused by stones

B. Bladder dysfunction caused by nerve injury

C. Urethral obstruction caused by prostatic enlargement

D. A blocked Foley catheter

E. Myoglobinuria

Chapter 14: Surgery in the Geriatric Patient

1. Which of the following statements is true?

A. Life expectancy of a patient 90 years old, who has no comorbid conditions, is 6 months.

B. The proportion of individuals 65 years old and older will remain constant over the next 50

years.

C. Age is frequently a risk factor in predicting postoperative morbidity and mortality.

D. There is a decline in physiologic function in all organ systems with aging.

E. It is estimated that approximately 25% of patients in most general surgical practices are older

than 65 years.

2. Which of the following statements is false?

A. Systolic cardiac function decreases with age at a constant rate.

B. Predictable decreases in renal function occur with age and relate specifically to the glomerular

filtration rate.

C. Insulin secretion from the beta cell decreases as a function of age.

D. Forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV 1 ) decrease

steadily with aging.

E. The synthetic capacity of the liver, as measured by standard liver function tests, remains

unchanged with age.

3. Which of the following is not a necessary part of the preoperative assessment in an older

adult?

A.

Baseline cognitive evaluation

B.

Exercise capacity testing

C.

Determination of nutritional status

D.

Advance directives and discussion of end-of-life wishes

E.

Evaluation of ADLs and IADLs

4.

In emergency surgery for perforated ulcer disease, a patient with preoperative shock,

more than 48 hours of perforation, and significant comorbid disease has a mortality rate close to:

A. 0%

B. 25%

C. 50%

D. 75%

E. 100%

5.

Which of the following is true regarding appendicitis in older adults ?

A. Most patients present with classic signs and symptoms of right lower quadrant pain, increased

white blood cell count, and fever.

B. Although there are typically delays in presentation to the hospital, the diagnosis is usually

made in a timely fashion.

C.

Of these patients, 18% present with no abdominal pain.

D.

Reported rates of perforated appendicitis in octogenarians are less than 50%.

E.

The overall mortality in patients older than age 65 with appendicitis is approximately 18%.

6.

In an older patient with suspected biliary disease, which of the following statements is

false?

A. The rate of gallstones is 30% to 40% of individuals older than 80 years.

B. There is an increased incidence of common bile duct stones in patients undergoing

cholecystectomy.

C. Gallbladder motility is typically normal.

D. The conversion rate from laparoscopic cholecystectomy to open procedures is higher than in

younger patients.

E.

Biliary tract disease is a frequent cause of acute abdominal complaints in older adults.

7.

Which of the following statements is not true?

A.

Breast cancer in older women is more frequently associated with the presence of favorable

tumor markers.

B. Stage per stage, survival for older women with breast cancer is better than that seen in

younger women.

C. Breast cancer trials in the United States have a disproportionately low enrollment of older

women.

D. Advanced age is not a contraindication to breast-conserving surgery.

E. older women have an increased incidence of significant side effects from axillary lymph node

dissection (ALND).

8. Which of the following is not currently recommended for an older surgical patient?

A. Carotid endarterectomy

B. Carotid angioplasty and stenting

C. Open abdominal aortic aneurysm repair

D. Endovascular aneurysm repair

E. Peripheral arterial bypass

Chapter 15: Morbid Obesity

1.

Hormones or peptides involved in satiety include:

A.

Gastrin

B.

Somatostatin

C.

Glucagon

D.

Ghrelin

E.

Estrogen

2.

Currently accepted guidelines from the National Institutes of Health for preoperative

selection of patients for weight reduction surgery include all the following except:

A.

Patients with Prader-Willi syndrome

B.

BMI > 35 kg/m 2 with associated medical comorbidity worsened by obesity

C.

Failed medical therapy

D.

Psychiatrically stable

E.

Motivated patient

3.

Absolute contraindications for bariatric surgery include:

A.

Cardiomyopathy

B.

Pickwickian syndrome

C.

Type 1 diabetes mellitus

D.

Nonalcoholic steatotic hepatitis

E.

None of the above

4.

Laparoscopic sleeve gastrectomy has:

A.

A higher leak rate than laparoscopic RYGB

B.

A lower mortality rate for super obese BMI > 60 kg/m 2 undergoing duodenal switch

C.

A theoretical advantage over RYGB for iron absorption

D.

All of the above

E.

None of the above

5.

One specific problem that may arise with persistent vomiting after any of the bariatric

operations is Wernicke's encephalopathy, which can be treated with parenteral:

A. Vitamin B 12

B. Omeprazole

C. Thiamine (vitamin B 1 )

D. Ascorbic acid (vitamin C)

E. Scopolamine

6.

Morbid obesity is defined as:

A.

1.5 times ideal body weight

B.

BMI > 40 kg/mg 2

C.

20% above ideal body weight for adolescents

D.

A function of physical activity, comorbid conditions, and weight

E.

Weight > 40 kg

7.

Bariatric operative procedures that produce weight loss by a combination of restriction

of oral intake and malabsorption include all the following except:

A.

Vertical banded gastroplasty

B.

Duodenal switch

C.

Biliopancreatic diversion

D.

Roux-en-Y gastric bypass

E.

None of the above

8.

Long-term metabolic complications of Roux-en-Y gastric bypass include:

A.

Hyperlipidemia

B.

Vitamin C deficiency

C.

Vitamin K deficiency

D.

Lactic acidosis

E.

Iron deficiency

9.

Medical therapy that has proven to have significant long-term success in morbidly obese

patients includes:

A. Low-calorie diets

B. Sibutramine

C. Ghrelin

D. Orlistat

E. None of the above

10. Produced in the proximal stomach, levels of the hormone ghrelin:

A. When decreased, seem to produce increased food intake

B. Are suppressed in postoperative patients who have undergone gastric bypass

C. Are decreased in individuals on a low-calorie diet

D. Regulate release of insulin

E. Are decreased in patients after adjustable gastric banding.

Chapter 16: Anesthesiology Principles, Pain

1.

halothane?

Which

of

the

following

statements

is

true

regarding

isoflurane

compared

with

A.

Isoflurane is associated with smoother inhalational induction.

B.

Isoflurane produces greater sensitization to the arrhythmogenic effects of catecholamines.

C.

Isoflurane has greater potency, as reflected in a lower minimal alveolar concentration (MAC).

D.

Isoflurane is associated with more rapid emergence.

E.

Isoflurane increases bronchoconstriction, whereas halothane decreases bronchoconstriction.

2.

Which of the following drugs is useful as a premedicant because of its potent amnesic

effects?

A.

Glycopyrrolate

B.

Etomidate

C.

Midazolam

D.

Ketamine

E.

Thiopental

3.

Which of the following statements most accurately describes the differences between

subarachnoid block and epidural block?

A. Subarachnoid block is associated with more rapid onset of hypotension.

B. Subarachnoid block is associated with greater risk of systemic local anesthetic toxicity.

C. Subarachnoid block is associated with less risk of post–lumbar puncture headache.

D. Subarachnoid block should not be performed with a mixture of local anesthetic and opioids.

E. Subarachnoid block is associated with a small risk of cardiac arrest for which resuscitation is

uncomplicated.

4. Essential monitors for all anesthetics include which of the following?

A. Direct arterial pressure

B. Exhaled volatile anesthetic concentration

C. Bioimpedance cardiac output

D. Electrocardiography

E. Anesthetic depth (bispectral index)

5.

Which of the following muscle relaxants is largely metabolized by Hofman degradation

in plasma and is relatively independent of renal elimination?

A. Pancuronium

B. Vecuronium

C. Cisatracurium

D. Rocuronium

E. Atracurium

6. Which of the following statements is accurate regarding preoperative cardiac evaluation? A. Older patients undergoing cataract surgery require preoperative stress testing.

B. Patients who require major vascular surgery should undergo cardiac catheterization before

scheduling the vascular procedure.

C. Patients can be stratified for the need for cardiac evaluation based on symptoms and

magnitude of the anticipated surgery.

D. Patients with previous myocardial revascularization are at high risk for perioperative

myocardial infarction.

E. Ambulatory electrocardiography is sensitive and specific for the identification of patients at

high perioperative risk.

7. Which of the following guidelines is recommended for preoperative fasting?

A. Aspiration of gastric contents is not a problem; all patients can take food and liquids freely

until immediately before surgery.

B.

A fasting period of 2 hours or more is recommended after ingestion of clear liquids.

C.

All patients should not receive food or liquids after midnight before surgery the next day.

D.

A fasting period of 6 hours or more is recommended after ingestion of solids.

E.

Both B and D

8.

Which of the following statements is accurate regarding local anesthetic toxicity?

A.

The earliest symptoms are referable to the central nervous system.

B.

At the first sign of local anesthetic toxicity, succinylcholine should be given.

C.

When local anesthetics are used for regional block, adding epinephrine decreases the toxic

dose.

D. Bupivacaine is the least toxic of currently used local anesthetics.

E. Ester-type local anesthetic agents are more toxic than amide agents because of slow

metabolism.

9. Which of the following problems is commonly recognized in the postanesthesia care unit (PACU)?

A. Delirium

B. Emesis

C. Hypoxemia

D. Hypertension

E. All of the above

10. Characteristics of moderate sedation include which of the following?

A. Absence of movement in response to a skin incision

B. Preserved airway reflexes

C. Motor response only to painful stimuli

D. Moderate respiratory depression

E. Moderate hypotension

11. Which four steps accurately describe the process of nociception?

A. Transduction, transmission, modulation, and perception

B. Recognition, registration, amplification, and interpretation

C. Perception, integration, orientation, and implementation

D. Description, analysis, formulation, and recognition

E. Deformation, translation, registration, and formulation

12. Which of the following opioids is partially converted to a metabolite that can accumulate and cause seizures in patients with renal impairment?

A. Fentanyl

B. Hydromorphone

C. Codeine

D. Morphine

E. Meperidine

13 .What is the correct term for the physiologic process in which a previously effective dose of an opioid fails to provide adequate analgesia?

A. Addiction

B. Psychological dependence

C. Physical dependence

D. Tolerance

E. Malingering

14. Compared with patients who receive conventional, intermittent, nurse-administered opioid delivery, patients who receive intravenous patient-controlled analgesia experience which of the following advantages?

A. Prompt analgesia

B. Smaller doses of opioids

C. Better maintenance of blood concentration of drugs in the analgesic range

D. Lower incidence of drug-related side effects

E. All of the above

Chapter 19: The Difficult Abdominal Wall

1. Abbreviated laparotomy is the initial phase of damage control surgery. The indications

are as follows:

A.

Temperature less than 35° C

B.

Medical bleeding

C.

Arterial pH less than 7.20

D.

Urine output less than 30 mL/kg/hr

E.

A, B, and C are correct

2.

The most common indications for the use of the open abdomen technique in general

surgery are as follows:

A.

Abdominal compartment syndrome

B.

Ruptured abdominal aortic aneurysm

C.

Trauma-damage control

D.

Acute pancreatitis

E.

All of the above

3.

If not recognized and treated, intra-abdominal hypertension can progress to abdominal

compartment syndrome. Which of the following clinical signs are hallmarks of abdominal

compartment syndrome?

A.

Oliguria

B.

Metabolic alkalosis

C.

Increased peak inspiratory pressures

D.

Intestinal ileus

E.

A and C are correct

4.

There are several techniques for creating a temporary abdominal closure for the open

abdomen. The key to all techniques must include the following:

A. Quick application

B. Seal in moisture and temperature

C. Quickly removable

D. High tensile strength

E. A, B, and C are correct

5.

During the staged abdominal repair phase of damage control surgery, the surgeon has

several challenging questions to answer on return to the operating room. Which of the following approaches can be used to address small and large bowel injuries?

A.

Resection of devitalized tissue

B.

Primary repair

C.

Externalization with creation of a stoma

D.

Primary bowel anastomosis

E.

All of the above

6.

The open abdomen technique has a high rate of nonclosure because of the following

complications:

A.

Intra-abdominal abscess and intra-abdominal sepsis

B.

Acute lung injury

C.

Atmospheric intestinal fistula

D.

Urinary tract infection

E.

A and C are correct

7.

Which of the following mesh products should not be used in the open abdomen setting

because they have very high rates of intestinal fistula formation and mesh infection?

A.

Human dermal acellular dermis

B.

PTFE

C.

Porcine dermal matrix

D.

Polypropylene

E.

B and D are correct

8.

The decision to close an open abdomen with visceral edema can be complicated. Which

of the following physiologic criteria can be used to guide abdominal closure in the operating room?

A. Decrease in urine output by 10 mL/hr

B. Change in peak inspiratory airway pressure less than 10 cm H 2 O while attempting to bring the

fascia together

C. Increase in intracranial pressure by 5 cm H 2 O

D. Sustained increase in intra-abdominal pressure less than 20 mm Hg

E. B and C are correct

Chapter 20: Emergency Care of Musculoskeletal

1.

Which of the following will increase the stiffness of an external fixation construct?

A.

Using stainless steel instead of titanium pins

B.

Using more pins

C.

Placing the bars closer to the bone

D.

Placing the bars in multiple planes

E.

All of the above

2.

A patient is found to have an isolated fracture of the medial malleolus on an ankle series

x-ray. What other imaging should be performed?

A. AP, lateral, and oblique views of the foot to look for a fifth metatarsal fracture.

B. CT scanning of the ankle to look for a tibial plafond fracture

C. AP and lateral views of the tibia and fibula to look for a proximal fibular fracture

D. AP and cross-table lateral views of the hip to look for a femoral neck fracture

E. PA and lateral views of the lumbar spine to look for a lumbar burst fracture

3. An absolute indication to perform a four-compartment fasciotomy of the leg for compartment syndrome is:

A.

Firm compartments on physical examination

B.

P < 30 mm Hg

C.

Subjective complaints of paresthesias in the foot

D.

Severe leg pain

E.

Unconscious patient with a tibial shaft fracture

4.

A 36-year-old man presents to the trauma bay after a motorcycle crash. His systolic

pressures remain in the 70s despite resuscitation with packed red blood cells and crystalloid. His chest x-ray is normal. His pelvic x-ray is shown in Figure 20-30. What is the

next most appropriate treatment?

A. Application of a pelvic binder

B. Placement of a chest tube

C. CT of chest, abdomen, and pelvis

D. Emergent exploratory laparotomy

E. Arteriography

5.

A 26-year-old man presents to the emergency department with the fracture seen in

Figure 20-4A. A Hare traction splint was placed in the field. Traction on the injured limb

should be maintained. Which of the following is the most appropriate method of traction for this patient?

A.Skin traction with a Buck boot

B. Distal femoral traction pin placed from medial to lateral

C.Proximal tibial traction pin placed from medial to lateral D.Proximal tibial traction pin placed from lateral to medial

E.

Hare traction splint left in place

6.

A 47-year-old woman sustains the fracture shown in Figure 20-40. Which examination

tests the nerve most commonly injured with this fracture pattern?

A. Shoulder abduction

B. Elbow flexion

C. Wrist extension

D. Wrist flexion

E. Finger flexion

Chapter 21: Burns

1.

The zone of stasis in a burn wound is associated with which of the following?

A.

Direct thermal damage

B.

Vasodilation

C.

Neutrophil adherence

D.

Platelet degranulation

E.

Non-nutrient shunting

2.

Deep second-degree wounds reepithelialize from retained keratinocytes in:

A.Rete ridges

B.

Hair follicles

C.

Moll glands

D.

Reticular dermis

E.

Meissner corpuscles

3.

A patient with burns to the entire back, scalp (50% of the head and neck), and posterior

thighs has what percentage of his or her total body surface area (TBSA) burned?

A.40%

B.28%

C.20%

D.32%

E.36%

4. Severe burns are associated with which of the following immunodeficiencies in the acute

phase?

A.

Neutropenia

B.

Granulocyte colony-stimulating factor deficiency

C.

Decreased cytotoxic T cell activity

D.

Increased neutrophil apoptosis

E.

Antibody overproduction

5.

After major burn injury, the metabolic changes are characterized by an ebb and flow

phase. Changes consistent with the ebb phase include:

A. Increased oxygen delivery

B. Low cardiac output

C. Hypermetabolism

D. Hyperthermia

E. Hyperglycemia

6.

Which of these therapeutic approaches to attenuate the hypermetabolic response can

lead to hyperglycemia?

A. Insulin

B. Growth hormone

C. Metformin

D. PPAR-γ agonists

E. Oxandralone

7. A 40-year-old, 100-kg man is involved in a house fire with burns to 45% of his TBSA. He comes to the emergency department with two peripheral IV lines that are not being used. It is 2 hours since his injury, and he has not received any resuscitation. His initial IV fluid rate should be:

A.

250 mL/hr

B.

500 mL/hr

C.

1000 mL/hr

D.

1500 mL/hr

E.

2000 mL/hr

8.

The relative surface area of regions of the body used in calculating burn surface area

differs in children from adults. Which of the following statements describes these differences?

A. Children have relatively less surface area in the arms and legs and more in the trunk.

B. Adults have relatively more surface area in the trunk and less in the upper extremities.

C. Children have relatively more surface area in the head and neck and less in the lower

extremities.

D.

Adults have more surface area in the head and neck and less in the lower extremities.

E.

Children have relatively less area in the head and neck and more in the trunk

9.

Which of the following synthetic and biologic dressings are currently used for burn

wound closure?

A. Allograft

B. Xenograft

C. Stem cells

D. Biobrane

E. Integra

10. Injury from smoke inhalation during a house fire occurs from which of the following?

A. Thermal injury

B. Excessive coughing

C. Splinting leading to atelectasis

D. Plugging of airways from concentration of soot

E. Toxic chemicals in smoke particles

11.

What are the three zones of injury after burn?

A. Coagulation, stasis, necrosis

B. Fibrinolysis, stasis, injury

C. Coagulation, injury (stasis), hyperemia

D. Edema, injury, necrosis

12. What proinflammatory mediators are responsible for the postburn hypermetabolic response?

A.TNF-α, IL-1, IL-6, catecholamines, glucagon, cortisol, endotoxin, nitric oxide

B.

Cortisol, IL-5, IL-2, epinephrine, insulin

C.

IL-10, CD4, insulin, TNF-α, glucosamine

D.

Glucose, cortisol, norepinephrine, nitric oxide

13.

One cause of multisystem organ failure after severe burn injury is:

A.

Decreased intestinal permeability to macromolecules

B.

Diminished blood volume and cardiac output

C.

Decreased peripheral vascular resistance

D.

Decreased presence of endotoxin

14.

Severely burned patients with no other complications can lose 25% of total body mass

after acute burn injury. This loss is associated with:

A.

Pneumonia and pressure ulcers

B.

Pneumonia and decreased wound healing

C.

Immune dysfunction and death

D.

Decreased wound healing and immune dysfunction

15.

Improvements in morbidity from severe burn injury stem from:

A.

Decreased ambient temperature, late excision and grafting after resuscitation, and early

aggressive parenteral nutrition

B. Increased ambient temperature, early excision and grafting, and early enteral nutrition

C. Controlling sepsis and late excision and grafting

D. Selective beta blockers and high-fat and high-protein diets

Chapter 22: Bites and Stings

1. Which of the following statements regarding snakebite management in North America is

true?

A. Antivenom should be administered to any patient who presents to the hospital with a bite

from a definitively identified rattlesnake.

B. Skin testing for possible allergy should be performed before the administration of CroFab.

C. CroFab is effective for reversing venom poisoning by all North American pit vipers and coral

snakes.

D. Fasciotomy should be performed only in the setting of objectively measured elevation of

pressures in involved muscle compartments.

2. Which of the following injuries is considered low risk for becoming infected and can be

repaired by primary closure?

A.

Dog bite to the face

B.

Cat bite to the upper arm

C.

Human bite over the dorsum of the metacarpophalangeal joint

D.

Primate bite to the foot

3.

Which of the following statements is false regarding cat bites?

A.

Pasteurella multocida is the primary organism involved in infections.

B.

Puncture wounds are common.

C.

Wound infection occurs in 10% to 20% of cat bites.

D.

Most cat bites are considered high risk for infection and inappropriate for primary closure.

4.

Which of the following statements is false regarding rabies?

A.

Most patients acquiring rabies from a bat do not recall being in contact with the bat.

B.

Rabies is caused by rhabdovirus found in the saliva of mammals.

C.

Patients with preexposure rabies immunization need active immunization only.

D.

If diagnosed early, rabies is usually treatable.

5.

Prophylactic antibiotics should be administered for all of the following injuries except:

A.

Cat bite to the foot

B.

Human bite to the ear

C.

Dog bite to the arm of a diabetic patient

D.

Dog bite to the scalp of a child

6.

Management of spider bites should include:

A.

Prompt administration of antivenom for any victim of a black widow spider bite

B.

Application of local cooling measures and conservative wound care

C.

Empirical administration of dapsone for wounds believed to be consistent with brown recluse spider bites

D.

Early (1 hour) excision of the bite site to limit venom spread

7.

Which of the following statements regarding Lyme disease is true?

A.

Patients with early Lyme disease often present with a rash consistent with erythema

multiforme.

B.

Neurologic involvement, neuroborreliosis, occurs in approximately 80% of untreated patients.

C.

First-line treatment for early Lyme disease without neurologic involvement includes doxycycline for 14 to 21 days.

D.

Attempts to develop a safe effective vaccine for Lyme disease have so far proven unsuccessful.

8.

Treatment of Hymenoptera-induced anaphylactic shock should include:

A.

Epinephrine

B.

Antihistamines (H 1 and H 2 blockers)

C.

Steroids

D.

Referral to an allergist for possible desensitization therapy

E.

All of the above

9.

Treatment for a moray eel bite includes:

A.

Antirabies immunization

B.

Débridement and primary closure

C.

Débridement and delayed primary closure

D.

Administration of antivenin

10. Treatment for a sea urchin puncture includes:

A. Percussion and fragmentation of the spine

B. Rapid extraction of the spine, followed by wide excision

C. Exploration of any discolored skin marking

D. Ice water immersion

E. None of the above

Chapter 23: Surgical Critical Care

1. A patient is defined as having brain death if the patient has complete absence of cortical

brain function and which of the following?

A.

Loss of pupillary reflex to light

B.

Loss of the vestibulo-ocular reflex

C.

Loss of oropharyngeal reflex (gag reflex)

D.

Apnea on consecutive tests despite adequate stimulation (PaCO 2 >60 mm Hg)

E.

There is no one accepted definition of brain death nationally

2.

The Confusion Assessment Method (CAM-ICU) is useful in determining the presence or

degree of which of the following in patients in the intensive care unit?

A.

Chronic dementia

B.

Adequacy of sedation regimens in mechanically ventilated patients

C.

Adequacy of analgesia in postoperative surgical patients

D.

Identifying, evaluating, and managing acute delirium

E.

Managing alcohol withdrawal

3.

In a mechanically ventilated patient with a traumatic brain injury or in a patient in a

coma (GCS <8) in whom there is suspected elevation of intracranial pressure (ICP), what is

an appropriate PaCO 2 goal to maintain?

A. 25 to 30 mm Hg

B. 30 to 35 mm Hg

C. 35 to 40 mm Hg

D. 40 to 45 mm Hg

E. 45 to 50 mm Hg

4. Which of the following statements is true regarding measurement of central venous pressure (CVP) in postoperative surgical patients as a guide for management of fluid resuscitation?

A. Right-sided heart function is a reliable predictor of left-sided heart function.

B. It is inaccurate in assessing volume status in a diverse group of surgical patients.

C. Values can be interpreted regardless of the patient's degree of mechanical ventilation requirements of positive end-expiratory pressure (PEEP).

D. It is a good guide for instituting and managing vasopressor agents in hypotensive patients.

5.

A postoperative patient with new-onset unstable atrial fibrillation with systolic blood

pressure of 70 mm Hg should be treated with which of the following modalities?

A.

Direct current cardioversion

B.

Intravenous beta blocker

C.

Intravenous calcium channel blocker

D.

Digoxin

6.

Which of the following modalities has been shown to reduce mortality in adult patients

with the acute respiratory distress syndrome (ARDS) in prospective randomized trials?

A. Corticosteroid early in the course of ARDS (<7 days)

B. Surfactant replacement therapy

C. Nitric oxide

D. Maintenance of lower filling pressure with pulmonary capillary wedge pressure (PCWP) less than 8 mm Hg

E. Lung protective ventilation with low tidal volumes of 6 mL/kg of ideal body weight

7. Abdominal compartment syndrome (ACS) is best described by which of the following?

A.

Intra-abdominal pressure greater than 15 mm Hg

B.

Intra-abdominal pressure greater than 25 mm Hg and evidence of decreased end organ perfusion (i.e., oliguria, renal dysfunction, hypotension)

C.

Intra-abdominal pressure greater than 35 mm Hg with hypoxemia

D.

Peak airway pressure greater than 40 cm H 2 O

8.

Which of the following have been shown to be clinical advantages of enteral feeding

versus total parenteral nutrition (TPN) in critically ill surgical patients?

A.

Preservation of gut mucosal integrity and barrier function

B.

Secretory IgA production of the gut

C.

Decreased rates of catheter-related bloodstream infections

D.

Lower cost

E.

All of the above

9.

Which of the following are strict indications to guide the institution of renal replacement

therapy in the form of intermittent hemodialysis or continuous venovenous filtration or

hemodialysis in critically ill surgical patients?

A. Increasing oxygen requirement and chest x-ray findings of interstitial edema and engorged pulmonary vasculature

B. Blood pH less than 7.25

C. Potassium level greater than 6.0 mEq/L

D. There are no specific or strict indications to start renal replacement therapy

E. CO 2 level less than 16 mEq/L on chemistry profile

10. Which of the following is most appropriate regarding glycemic control in critically ill surgical patients?

A. Goal glucose should be 80 to 110 mg/dL to improve outcomes in patients with traumatic brain

injury.

B. Stress-related hyperglycemia should be managed with longer acting forms of insulin such as

insulin glargine.

C. Maintaining glucose levels less than 180 mg/dL compared with maintaining a range of 81 to

110 mg/dL results in fewer episodes of hypoglycemia and lower mortality.

Chapter 27: Liver Transplantation

1.The most common indication for liver transplantation in the United States is:

A. EtOH

B. Sclerosing cholangitis

C. Hepatitis B virus

D. Hepatitis C virus

E. Hepatocellular carcinoma

2.An infant with extrahepatic biliary atresia, chronic liver insufficiency, and failure to thrive may be

served by:

A. Whole pediatric liver transplantation

B. Split orthotopic liver transplantation

C. Live donor liver transplantation

D. All of the above

E. None of the above

3.The current risk of death to the donor for live donor liver transplantation is:

A. About the same as the risk to a potential kidney donor

B. 1/100

C. 1/1,000

D. 1/10,000

E. 1/100,000

4.The current system of liver distribution is primarily based on:

A. Insurance

B. Medical necessity

C. Region

D. Recipient age

E. None of the above

5.The liver can be divided into segments based on

A. Portal vein inflow

B. Hepatic artery inflow

C. Biliary outflow

D. Hepatic vein outflow

E. All of the above

6.Which are appropriate treatment(s) for hepatocellular carcinoma and cirrhosis?

A.Whole liver transplantation

B. Liver resection

C. Live donor liver transplantation

D. Resection with salvage transplantation

E. All of the above

7.Which statement about immunosuppression medication is false?

A. Cellcept (mycophenolate) is an antiproliferation agent.

B. Calcineurin inhibitors have nephrotoxic and neurotoxic side effects.

C.Calcineurin inhibitors prevent expansion of the host response by inhibiting IL-10 production.

D. Immunosuppressive agents are optionally used in combination to maximize their effect and minimize

toxicity.

Chapter 28: Kidney and Pancreas Transplantation

1.A 50-year-old man arrives in the recovery room following an uneventful living donor kidney

transplantation. It was documented that there was good urine output in the operating room. When the

patient arrives, there is no urine output. The next best step would be to:

A. Order an ultrasound.

B. Perform an emergent biopsy to rule out hyperacute rejection.

C. Examine the patient.

D. Flush the Foley catheter.

2.A 50-year-old man arrives in the recovery room following an uneventful living donor kidney

transplantation. It was documented that there was good urine output in the operating room. When the

patient arrives, there is no urine output. The physical exam reveals BP, 134/70 mm Hg, HR, 76

beats/min, RR, 14 breaths/min, O 2 saturation, 100%, Foley is intact. An inspection of the abdomen

reveals a distended right lower quadrant. The incision is dry. The next best step is to:

A. Order an ultrasound.

B. Open the wound at the bedside.

C. Flush the Foley catheter.

D. Return to the operating room.

3.A 50-year-old man arrives in the recovery room following an uneventful living donor kidney

transplantation. It was documented that there was good urine output in the operating room. When the

patient arrives, there is no urine output. The most likely diagnosis in this case is:

A. Lymphocele

B. Urine leak

C. Hyperacute rejection

D. Wound dehiscence

E. Arterial thrombosis

4.A 35-year-old woman with type 1 diabetes wishes to be evaluated for a kidney pancreas

transplantation. She has a history of hypertension and has recently started dialysis. There is no family

history of cardiac disease.

Her initial workup should include:

A. C-peptide level

B. Cardiac stress test

C. Pap smear

D. All of the above

5.A 35-year-old woman with type 1 diabetes wishes to be evaluated for a kidney pancreas

transplantation. She has a history of hypertension and has recently started dialysis. There is no family

history of cardiac disease. The patient presents at 3 weeks post-transplantation with an elevated amylase

level and her creatinine level is also somewhat elevated at 1.4 mg/dL, from a baseline of 1.0 mg/dL. Her

glucose level is normal and her urine output has been normal. Diagnostic tests should include:

A. Abdominal and pelvic CT scan

B. Urinalysis

C. CMV polymerase chain reaction assay

D. Ultrasound and kidney biopsy

E. C-peptide level

Chapter 29: Small Bowel Transplantation

1. Which of the following patients would be considered an appropriate candidate for intestinal

transplantation?

A. A 2-year-old boy with long-segment Hirschsprung disease extending into the jejunum with an end

jejunostomy. He receives a combination of continuous tube feeds via a gastrostomy tube and supplemental intravenous fluids via a tunneled central venous catheter. He has had the central venous line replaced once because of a break in the line but has not had a known central venous line infection.

B. A 23-year-old woman with a history of Crohn disease who has had multiple bowel resections because of

strictures. She is currently dependent on TPN, although she can tolerate small amounts of oral intake. Her liver

function is normal. She has had one central venous line infection owing to Staphylococcus epidermidis, which was successfully treated with antibiotics.

C. A 1-year-old girl who was born prematurely and lost most of her small intestine secondary to necrotizing

enterocolitis. She is currently dependent on TPN and has been hospitalized five times for central venous line infections, two of which were due to Candida albicans.

D. A 10-year-old boy with pseudo-obstruction who has recurrent episodes of abdominal pain and distention.

He has recently had to begin TPN because of failure to maintain adequate growth.

2. A 2-year-old boy with intestinal failure secondary to gastroschisis and parenteral nutrition–associated

liver disease (PNALD) is on the waiting list for a combined liver-intestine transplant. His blood type is

A, and he weighs 13 kg. Which of the following potential donors would be most appropriate?

A. A 1-year-old donor who sustained head traumas as a result of child abuse; the donor is blood type A and

weighs 8 kg

B. An 8-year-old donor who sustained head trauma as a result of a bicycle versus motor vehicle accident; the

donor is blood type A and weighs 25 kg

C. A 20-year-old donor who sustained head trauma as a result of a motorcycle accident; the donor is blood

type A and weighs 60 kg

D. A 2{1/2}-year-old donor who sustained head trauma as a result of a motor vehicle accident; the donor is

blood type A and weighs 14 kg

3.For patients who require a liver transplant in addition to an intestinal transplant owing to intestinal

failure and parenteral nutrition–associated liver disease (PNALD), what is the advantage of including

the pancreas en bloc with the other organs?

A. Most patients with intestinal failure and PNALD also have diabetes.

B. Including the pancreas avoids having to perform any hilar dissection in the donor organs and avoids having

to perform separate vascular anastomoses for the liver and the intestine during implantation in the recipient.

C. The native pancreas is removed from the recipient with the recipient's liver and remnant small intestine and

needs to be replaced.

D. Including the pancreas has been shown to decrease the incidence of rejection.

4. Which of the following is the most effective induction agent for intestinal transplantation?

A. Alemtuzumab (Campath)

B. Basiliximab (Simulect)

C. Daclizumab (Zenapax)

D. Rabbit antithymocyte globulin (Thymoglobulin)

E. No agent has been proven superior to the others

5.The most effective method of monitoring an intestinal allograft for rejection is:

A. Serum liver function tests

B. Endoscopically obtained mucosal biopsy specimens reviewed by a pathologist

C. Measuring stoma or stool output

D. Clinical signs such as abdominal pain and distention

6.Infection with which of the following pathogens may mimic rejection in intestinal transplant

recipients?

A. Epstein-Barr virus

B. Escherichia coli

C. Cytomegalovirus

D. Enterobacter species

E. Klebsiella species

7.Recipients of which transplanted organ are at the highest risk of developing post-transplant

lymphoproliferative disorder (PTLD)?

A. Kidney

B. Intestine

C. Heart

D. Liver

8.The most common cause of death after intestinal transplantation is:

A. Infection

B. Post-transplant lymphoproliferative disorder (PTLD)

C. Graft-versus-host disease (GVHD)

D. Chronic rejection

Chapter 30: Tumor Biology and Tumor Markers

1.Which of the following genetic changes may be involved in tumorigenesis?

A. Activation of a proto-oncogene

B. Loss of a tumor suppressor gene

C. Activation of a growth factor receptor–encoding gene

D. All of the above

2.Which of the following statements is incorrect?

A. Cancer is the second most common cause of death in the United States.

B. Cancer disproportionally affects people 65 years and older.

C. It is estimated that 15% to 50% of all cancer deaths in the United States can be attributed to overweight and

obesity.

D. Cancer incidence is the number of cancer patients in the population.

3.Which type of adjuvant therapy may provide the best strategy for the postoperative eradication of

residual microscopic disease?

A. Chemotherapy

B. Radiation therapy

C. Immunotherapy

D. Combination therapy

4.Germline mutations have been postulated to be associated with several tumors. Which of the following

is an example?

A. p53

B. APC

C. KRAS

D. All of the above

5.Tumor growth is dependent on:

A. Paracrine factors

B. Autocrine and paracrine factors

C. Immune cell infiltrate

D. Autocrine factors

6.Which early events in the primary tumor are characteristic for the formation of metastases?

A. Angiogenesis

B. Intravasation and extravasation

C. Evasion of cell death

7. What is most essential for the development of a tumor?

A. Successive genetic alterations

B. The ability to produce growth factors

C. Deletion of p53

D. Immunosuppressed or immunodeficient host

8.An ideal tumor marker is

A. Detectable early with a high degree of false-negative findings

B. Detectable only when tumors metastasize

C. Characterized by a high specificity and low sensitivity

D. exclusively by the particular tumor

9.CA 19-9 levels may be elevated in which of the following conditions?

A. Pancreatic adenocarcinoma

B. Benign biliary stricture

C. Malignant biliary stricture

D. Colon cancer

E. All of the above

10.A false-positive CEA test can occur in which of the following benign conditions?

A. Ulcerative colitis

B. Cirrhosis

C. COPD

D. Gallstone pancreatitis

E. All of the above

11.Which of the following is not correct regarding the use of alpha-fetoprotein (AFP) as a tumor marker

for hepatocellular carcinoma (HCC)?

A. AFP levels may be elevated in other gastrointestinal malignancies.

B. The combination of ultrasound with AFP improves the sensitivity of screening for HCC.

C. Following complete resection, AFP levels should fall below 10 ng/mL.

D. The rate at which the AFP level rises is not associated with a worse prognosis.

E. None of the above.

12.Which of the following is correct regarding prostate-specific antigen (PSA)?

A.

PSA levels do not rise after digital rectal examination.

B.

PSA level > 4 ng/mL is diagnostic of prostate cancer.

C.

After complete resection, the PSA level should normalize after 2 to 3 weeks.

D.

An elevated but stable PSA level after radiotherapy does not portend clinical relapse.

13

A

highly specific test for a tumor marker may still yield a large number of false-positive test results:

A.

When the test has low sensitivity

B.

When the prevalence of the disease tested for is low in the tested population

C.

When the test is done with urine samples instead of serum samples

D.

When the assay is a radioimmunoassay

E.

When the test has to be done on fresh tumor samples instead of preserved samples

14

Breast

cancer specimens are now routinely tested for which of the following tumor markers?

A. Estrogen receptor

B. Progesterone receptor

C. Her2/neu expression

D. A and B

E. A, B, and C

15.Her2/neu expression status of a breast tumor is important for:

A. Monitoring the efficacy of therapy

B. Determining treatment for recurrent cancer

C. Diagnosis

D. Timing of second-look procedures

E. All of the above

16.Patients with metastatic colorectal cancer who lack a KRAS mutation in codon 12 or 1:

A. Are more likely to respond to anti-EGFR antibody therapy

B. Are less likely to respond to anti-EGFR antibody therapy

C. Have improved disease-free survival when treated with anti-EGFR antibody therapy

D. Have no change in overall survival when treated with anti-EGFR antibody therapy

E. A and C

F. A and D

17.Which of the following statements is incorrect regarding the use of the 21-gene assay, Oncotype DX,

in breast cancer?

A. Predicts likelihood of local tumor recurrence

B. Was designed for patients with node-negative, tamoxifen-treated breast cancer

C. Cannot be used in ER-negative tumors

D. Alters treatment choice in approximately 25% of cases

E. Assays 16 tumor-associated gene

Chapter 32: Melanoma and Cutaneous Malignancies

1.What percentage of patients with BCC or SCC develop a second skin cancer within 5 years of the first

skin cancer?

A. 10%

B. 25%

C. 50%

D. 80%

E. 100%

2.After 10 years of immunosuppression, what percentage of transplantation patients develop

malignancies?

A. 1%

B. 10%

C. 25%

D. 50%

E. 80%

3.Which form of skin cancer is associated with the highest risk of simultaneous internal malignancies?

A. BCC

B. SCC

C. Melanoma

D. Extramammary Paget's disease

E. Bowen's disease

4.Which of the following skin malignancies causes the highest number of deaths each year?

A. Squamous cell carcinoma

B. Basal cell carcinoma

C. Merkel cell carcinoma

D. Melanoma

Chapter 34: Bone Tumors

1.Factors that limit local recurrence in low-grade extremity soft tissue sarcoma include all of the

following except:

A.Complete local resection

B. Histologically negative margins

C. Adjuvant external beam radiation therapy

D. Adjuvant brachytherapy

E. Primary presentation

2.Risk factors for local recurrence in extremity soft tissue sarcoma include all of the following except:

A. Positive microscopic margin

B. Fibrosarcoma histopathology

C. Deep location

D. High histologic grade

E. Previous recurrence

3.Risk factors for distant metastasis in extremity soft tissue sarcoma include all of the following except:

A. Recurrent presentation

B. Size = 10 cm

C. Deep location

D. Fibrosarcoma histopathology

E. High histologic grade

4.True statements about soft tissue sarcomas include the following:

A. Approximately 50% occur in the extremities.

B. Prior radiation therapy is a causative agent.

C. Lymphedema is a predisposing factor.

D. Liposarcoma is the most common histopathology

E. All of the above

5.Which one of the following is an important factor indicating poor prognosis in extremity soft tissue

sarcoma?

A. High histologic grade

B. Liposarcoma histopathology

C. Size < 8 cm

D. Distal limb site

E. Prior incisional biopsy

6.Biopsy of a primary bone tumor should be done:

A. As soon as the lesion is discovered

B. After thorough staging studies are completed

C. In the operating room

D. At the same time that a venous access port is placed

7.Which of the following bone tumors are radiographic diagnoses and do not require biopsy?

A. Chondrosarcoma

B. Metastasis

C. Giant cell tumor

D. Osteochondroma

8.Impending fractures should be treated by:

A. Radiation therapy

B. Chemotherapy

C. Internal fixation

D. Bisphosphonates

9.Preoperative chemotherapy for osteogenic sarcoma is:

A. Needed to perform limb-preserving surgery

B. Predictive of disease-free survival

C. Useful to tailor postoperative chemotherapy

D. Determined by the translocation type causing the tumor

10.Joint replacement to reconstruct defects after a tumor resection is:

A. As successful as after removal of an arthritic joint

B. Not possible in children younger than 10 years old

C. Best for benign tumor cases

D. Can be combined with allograft bone transplantation

Chapter 35: Head and Neck

1.Which of the following statements regarding aerodigestive tract cancer associated with human

papillomavirus (HPV) is false?

A. The incidence of HPV-associated aerodigestive tract cancer specific to the tonsil and tongue base subsites is

increasing in North America.

B. HPV-related aerodigestive tract cancer tends to occur in older patients compared with non—HPV-related

aerodigestive tract cancers.

C. The incidence of HPV-related aerodigestive tract cancers is increasing at a higher rate in nonsmokers

compared with smokers.

D. Theincidence of HPV-related aerodigestive tract cancers is increasing at a higher rate in non—alcohol

abusers compared with alcohol abusers.

2.A neck dissection that resects nodal levels I through V but preserves the sternocleidomastoid muscle,

the spinal accessory nerve, and the internal jugular vein is referred to as a:

A. Selective neck dissection

B. Modified neck dissection

C. Radical neck dissection

D. Functional neck dissection

3.To reduce the chance of a vocal fold paralysis postoperatively, the preferred approach to the cervical

spine should be:

A. Left-sided because it reduces the tension on the recurrent laryngeal nerve during the exposure

B. Left-sided because of the incidence of nonrecurrent recurrent laryngeal nerve on the right side

C. Right-sided because it reduces the tension on the recurrent laryngeal nerve during the exposure

D. Right-sided because of the incidence of nonrecurrent recurrent laryngeal nerve on the left side

4.Why should percutaneous tracheotomy performed in the ICU be avoided in patients with prolonged

transoral intubation secondary to ventilator dependence?

A. Percutaneous tracheotomy has a higher incidence of postdecannulation stenosis in patients undergoing

tracheotomy owing to failure to wean from mechanical ventilation.

B. Percutaneous tracheotomy has a higher incidence of complications from accidental decannulation because

an inferiorly based trachea-to-skin flap specific to this procedure is not created.

C. Percutaneous tracheotomy has a higher incidence of "false lumen" creation than traditional open

tracheotomy performed in the operating room.

D. Percutaneous tracheotomy does not have a higher incidence of intraoperative or postoperative

complications and is as safe to perform in ventilator-dependent patients as traditional open tracheotomy

5.An adult patient presents with an asymptomatic, solitary 4-cm neck mass that has been present for 1

month. Physical examination and history are otherwise unremarkable. The initial step in the workup for

this mass would be:

A. CT scan with intravenous contrast agent

B. Open incisional biopsy

C. Fine-needle aspiration

D. Open excisional biopsy with conversion to neck dissection depending on intraoperative frozen section

diagnosis

6.A patient presents with a glottic squamous cell carcinoma involving both anterior true vocal cords but

not either of the arytenoid cartilages, and is not a candidate for endoscopic surgical treatment because

of the inability to expose the larynx for laser excision. A viable conservation surgical therapy would be:

A. Supraglottic laryngectomy

B. Supracricoid laryngectomy with cricohyoidoepiglottopexy

C. Vertical partial laryngectomy

D. Total laryngectomy with tracheoesophageal puncture

7. A 30-year-old woman presents with a slowly growing, asymptomatic, 3-cm parotid mass. Office fine-

needle aspiration is inconclusive. Assuming that the intraoperative frozen section shows this mass to be a

benign salivary neoplasm, the most appropriate surgical plan would be to perform:

A. Incisional biopsy without the need for further surgery

B. Total parotidectomy with facial nerve dissection and preservation

C. Excisional biopsy without the need for further surgery

D. Superficial parotidectomy with facial nerve dissection and preservation

8.A patient has a recurrent laryngeal nerve resection as part of removal of an aggressive thyroid

malignancy. Postoperatively, her voice is breathy and weak and is insufficient for performing at her

profession. The goal of subsequent voice restoration surgery is to:

A. Create volitional abduction and adduction of the affected vocal cord to preserve both voice and airway

patency

B. Create volitional abduction and adduction of the affected vocal cord to preserve both voice and airway

protection from aspiration during swallowing

C. Medialize the affected vocal cord to create static contact with the opposite, mobile cord

D. Place a Silastic implant that is capable of directly contacting the opposite, mobile cord

9.An adult patient presents with a right-sided, 3-cm asymptomatic neck mass deep to the

sternocleidomastoid muscle at the level of the hyoid bone that has been growing over the past 3 months.

The most likely etiology in this patient is:

A. Branchial cleft cyst