31. epidural steroid injection 治療邏輯是針對椎間盤 nucleus pulposus 所釋放的發炎物質，下列 數種發炎物質 何者與椎間盤突出最沒有直接相關性？
(A) phospholipase A2
(B) caspase
(C) interleukins ( 1α, 1β, 6)
(D) tumor necrosis factor
(E) nitric oxide

32. 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.

33. 關於頭頸癌症病人的的敘述，下列何者不恰當？ (A) 頭頸癌病人的疼痛問題，可能是腫瘤本身、化學治療、放射治療、或是手術造成的 (B) 粘膜炎(mucositis)的疼痛機制可能是黏膜產生潰瘍，暴露出神經末梢，使得黏膜表面變 得對疼痛敏感。 (C) 可以用來處置粘膜炎(mucositis)產生的疼痛，包括 topical benzydamine、乳狀鎂(milk of magnesia)、口服 acetaminophen, NSAIDs，甚至是嗎啡類藥物。 (D) 住院的癌症病患如果有嚴重的粘膜炎(mucositis)，可以考慮使用 Intravenous Patient-controlled analgesia (IVPCA) with morphine。 (E) 粘膜炎(mucositis)在頭頸癌病人很常發生，常會造成疼痛問題，是無法預防的 p.

34. 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

35. About the intrathecal drug delivery system, which of the following statements is NOT correct? (A) It places medication directly into the cerebrospinal fluid that surrounds the spinal cord. (B) Morphine delivered directly to the intrathecal space is particularly effective because it does no have to circulate systemically to reach the CSF and the dorsal horn of the spinal cord. (C) As a result, much smaller doses are needed (e.g., approximately 1/30 of an oral morphine dose), and the frequency of side effects is reduced. (D) Advantages of intrathecal therapy in pain includes effective pain relief, reduced side effects for patients, reduced consumption of systemic medication, improved ability to perform ADLs, and enhanced quality of life.

36. 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

37. Which of the followings clinical indicators with its suspected pathology for spinal pain is suggested to receive X-ray for first line test? (A) fracture due to severe trauma (B) aortic aneurysm with cardiovascular risk factors (C) weight loss due to tumor (D) susecpted infection with fever, sweating (E) x-ray is not a first line test for the above causes of spinal pain

38. 關於｢The principles of pharmacotherapy endorsed by WHO｣，下列敘述何者不適當? (A)五大原則: by the mouth, by the clock, by the ladder, for the individual, and with attention to detail。 (B) Cancer pain 病患盡可能以口服止痛藥物為主，但如果病患有 dysphagia, uncontrolled vomiting, or GI obstruction 可以考慮改用其他途徑給予止痛藥物。 (C) By the clock 的用意在於止痛藥物是”around-the-clock”的方式給予，讓大多數癌症病患 不再使用快速作用(immediate or rapid-onset)的嗎啡類止痛藥物。 (D) 沒有標準的嗎啡藥物使用劑量，理想的正確劑量是可以緩解病人疼痛，又能有最少的 副作用。 (E)癌症疼痛病患的處方，是需要定期追蹤服藥順從性、藥物止痛效果、身體功能、副作用、 或是有無服藥後異常行為。

39. Which one of the following statement about the pathophysiology of herpes zoster is wrong? (A) Herpes zoster most commonly manifests in the distribution of a single dorsal sensory or cranial nerve ganglion. (B) Why the reactivation of virus occurs in one ganglion when latent virus is present throughout the patient’s sensory ganglia is clear. (C) Declining cellular immunity is a major risk factor for reactivation of the virus, which is thought to occur when cell-mediated immunity falls below a critical level. (D) This impression is supported by evidence that even individuals with adequate levels of serum antibodies to varicella-zoster virus (VZV) antigen can, over time, exhibit T cells with reduced ability to proliferate and defend against VZV infections. (E) Cell-mediated immunity appears to play a crucial role in preventing reactivation of latent VZV.

40. 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 pe 口 nanent neurodestructive lesion is formed when neural temperatures exceed 42 C (E) All of the above

41. Which of the following drug is categorized as Agonist-Antagonist and should "Not" be used in opioid tolerant patients. (A) Morphine (B) Tramadol (C) Nalbuphine (D) Hydromorphone (E) Methadone

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