Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3981_Библиотеки_им_академика_М_И_Перельмана.pdf
Cardiac Surgery: Questions
39
survival involves considerable subjective
clinical judgment by the transplant committee
because no reliable
objective prognostic criteria are available currently. Which of the
following is the strongest independent predictor of survival?
A. reduced VO
2,max
(<14 mL/kg per minute)
B. high pulmonary capillary wedge pressure (>25
mm Hg)
C. elevated plasma norepinephrine concentration (>600 pg/mL)
D. reduced serum sodium concentration (<130 mEq/dL)
E. N-terminal probrain natriuretic peptide (>5000 pg/mL)
2.50 The success of cardiac transplantation depends on effective donor-recipient
matching. Which of the following statement regarding donor-recipient matching is
correct?
A. Donor weight should be within 50% of recipient weight.
B. In cases of elevated pulmonary
vascular resistance in the recipient (5 to 6 Wood units),
a
smaller donor is preferred.
C. A prospective negative T-cell cross-match between the
recipient and donor sera is
mandatory prior to transplantation if the percent of panel reactive antibody is greater than
10%.
D. Routine prospective HLA matching is mandatory.
E. ABO barriers can be crossed in heart transplantation if HLA matching is achieved.
2.51 Denervation of the transplanted heart leads to loss of autonomic nervous
system
modulation of the heart’s electrophysiologic properties. The transplanted heart
A. preserves rapid heart rate modulation.
B. has accentuated chronotropic effects of
digoxin and atropine.
C. develops irreversible bradyarrhythmias in 75% cases.
D. is resistant to supraventricular arrhythmias.
E. has decreased maximum heart rate with exercise.
2.52 Immunosuppression following transplantation consists of an early induction
phase followed by a long-term maintenance phase. This basic strategy
essentially is
universal, although the choice of immunosuppressive agents,
dosages, and combination
protocols vary between transplantation centers.
Which of the following
immunosuppressive agent is a calcineurin inhibitor?
A. azathioprine
B. cyclosporine
C. antithymocyte globulin
D. OKT3
E. Prednisolone
2.53 Cyclosporine
A. is a 15-amino-acid cyclic peptide
produced by the fungus Tolypocladium inflatum.
B. attenuates suppressor T-lymphocyte population.
C. causes widespread immunosuppression.
D. has low therapeutic index.
Shahzad G. Raja
40
E. has improved cardiac transplant by reducing the incidence of immunosuppression-
induced nephropathy.
2.54 Tacrolimus
A. is an imidazole derivative from 6-mercaptopurine.
B. shows similar efficacy as cyclosporine in preventing rejection
and death within the
first year after transplant.
C. causes
more cases of hypertension and hyperlipidemia than cyclosporine.
D. is the least effective immunosuppressive agent in reversing recalcitrant rejection.
E. has been shown to
prevent cardiac allograft vasculopathy.
2.55 Azathioprine
A. is a macrolide antibiotic from Streptomyces tsukubaensis.
B. decreases the formation
of interleukin-2.
C. causes a
dose-related bone marrow suppression.
D. has been shown to
prevent cardiac allograft vasculopathy
E. causes impaired glucose metabolism.
2.56 Mycophenolate mofetil
A. inhibits a
key step in the de novo biosynthesis of purines.
B. is inferior to azathioprine in reducing mortality after transplantation.
C. causes profound leukopenia compared to azathioprine.
D. is currently used in 25% of heart transplant recipients.
E. receiving cardiac transplant patients have higher levels of C- reactive protein.
2.57 OKT3
A. is an equine monoclonal antibody directed against the chain of CD3
molecule.
B. facilitates the function of naive T cells.
C. has cytolytic effects on all circulating cells.
D. inhibits cytokine release syndrome.
E. is associated with the increased incidence
of posttransplant lymphoproliferative
disorders.
2.58 Cardiac allograft rejection is the normal host response to cells recognized
as
nonself. Which of the following statements regarding acute cardiac rejection is correct?
A. The vast majority of cases are mediated by antibodies.
B. The highest
risk factors are allografts from younger and female donors (irrespective
of
recipient sex).
C. In the cyclosporine era, the classical clinical manifestations of
acute rejection are more
frequently seen.
D. Cytotoxic T-lymphocyte count is the ―gold standard‖ for diagnosis of acute rejection.
E. Azathioprine is the cornerstone of antirejection therapy.
2.59 Cardiac allograft vasculopathy (CAV) is a unique, rapidly progressive form of
atherosclerosis
in transplant recipients. CAV
A. is characterized in its early
stages by luminal
stenosis of epicardial branches.
Cardiac Surgery: Questions
41
B. angiographically is detected in approximately
90% of patients by 5 years after
transplantation.
C. compared to atherosclerosis has concentric plaques.
D. is recognized by diffuse calcification of epicardial vessels.
E. is best treated by coronary artery bypass grafting.
2.60 Cardiac retransplantation
A. accounts for 10% of the cardiac
transplants currently performed.
B. actuarial survival at 3 years is 70%.
C. survival is better if the intertransplant interval is less than 6 months.
D. is associated with poor survival in older patients.
E. is primarily indicated for immunosuppression intolerance.
2.61 Implantable left ventricular assist devices have benefited patients with end-
stage heart failure as a bridge to cardiac transplantation. The Randomized Evaluation
of Mechanical Assistance for the Treatment of Congestive Heart Failure (REMATCH)
trial
A. randomized patients to receive a left ventricular assist device as destination therapy or
cardiac transplantation
B. recruited patients with NYHA class III heart failure.
C. showed a reduction of 48 percent in the risk of death from any cause in the group that
received left ventricular assist devices.
D. reported improved quality of life in patients on optimal medical therapy compared to
those with left ventricular assist devices.
E. reported similar frequency of serious adverse events in the device group as that in the
medical-therapy group.
2.62 The overall goal of the SYNTAX trial is to assess the most appropriate
revascularization strategy by randomizing patients to either (percutaneous intervention)
PCI with TAXUS Express stents or coronary artery bypass grafting (CABG). At 3 years
A. major adverse cardiac and cerebrovascular events were elevated in the CABG arm.
B. rate of repeat revascularization was elevated in the CABG arm.
C. rates of the composite safety endpoint (death/stroke/myocardial infarction) were
elevated in the PCI arm.
D. major adverse cardiac and cerebrovascular event rates were not significantly different
between arms in the left main stem subgroup.
E. major adverse cardiac and cerebrovascular event rates were not significantly different
between arms in the 3 vessel disease subgroup.
2.63 Randomized On/Off Bypass (ROOBY) trial was funded by the Department of
Veterans Affairs (VA) Cooperative Studies Program to further assess the relative
efficacy of on-pump and off-pump coronary artery bypass grafting (CABG).The
ROOBY trial
A. was a controlled, double-blind, randomized trial.
B. enrolled all-comers with no exclusion criteria.
Shahzad G. Raja
42
C. showed that there was no significant difference between off-pump and on-pump
CABG in the rate of the 30-day composite outcome.
D. showed that the proportion of patients with fewer grafts completed than originally
planned was similar with off-pump and on-pump CABG.
E. showed that the rate of the 1-year composite outcome was higher for on-pump than for
off-pump CABG.
2.64 Aortic dissection is the most frequently diagnosed lethal condition
of the aorta.
Which one of the following statements regarding aortic dissection is correct?
A. Type B dissections occur
with an overall greater frequency.
B. The intimal tear involves the full circumference of the aorta in majority of cases.
C. The primary
tear in type A dissection is usually located on the left anterior
aspect of
the ascending aorta.
D. Retrograde type A dissection involves the coronary ostia in 50% of cases.
E. Myocardial ischemia and rupture into
the pericardium are the cause of death in as
many as 80% of
deaths from acute dissection.
2.65 The recently published 30 day outcomes of multicentre CORONARY trial that
randomized 4752 patients to undergo on-pump or off-pump coronary artery bypass
grafting (CABG) suggest that
A. on-pump CABG is associated with significantly reduced rates of reoperation for
bleeding compared to off-pump CABG.
B. on-pump CABG is associated with reduced mortality compared to off-pump CABG.
C. on-pump CABG resulted in more respiratory complications compared to off-pump
CABG.
D. on-pump CABG resulted in more strokes compared to off-pump CABG.
E. on-pump CABG caused more new renal failure requiring dialysis compared to off-
pump CABG.
Chapter III
Thoracic Surgery
3.1 Which of the following statements regarding underlying concepts associated
with cancer screening is correct?
A. Incidence is the number of cancers that exist in a defined population at a given point in
time.
B. Incidence is expressed as cases per year per 100,000 individuals in the population.
C. Incidence is commonly expressed as cancers per 100,000 individuals in the
population.
D. Prevalence is expressed as cases per year per 100,000 individuals in the population.
E. Prevalence refers to the number of cancer cases that develop during a defined period
of time.
3.2 Which of the following statements regarding chest x-ray screening trials for lung
cancer is correct?
A. The Czechoslovakia randomized screening trial for lung cancer showed a significant
increase in the number of cancers detected in the intervention group.
B. The design of all the National Cancer Institute (NCI) sponsored randomized clinical
trials was similar.
C. The John Hopkins and Memorial Sloan-Kettering screening studies showed
differences in the number of cancers detected.
D. The Memorial Sloan-Kettering screening study showed a mortality benefit.
E. The Prostate, Lung, Colorectal, and Ovarian (PLCO) trial detected only 10% stage I
lung cancers.
3.3 A 63-year-old male patient with an incidentally discovered solitary pulmonary
nodule in the upper lobe of right lung on a routine chest radiograph was recommended
to undergo
18
F-FDG PET scan for further assessment of this nodule. Which of the
following statements about the inherent limitations of
18
F-FDG PET scan is true?
A. Bronchoalveolar carcinoma has a strong avidity for
18
F-FDG.
B. False-negative
findings are most commonly associated with uptake of
18
F-FDG
in
infectious or inflammatory tissue.
Shahzad G. Raja
44
C.
18
F-FDG PET for cancer imaging has a limited
reconstructed spatial resolution of 4–10
mm in available
commercial systems.
D.
18
F-FDG PET
is considered the investigation of first choice for assessment
of possible
cerebral metastases from known primary neoplasms.
E. Infection imaging with
18
F-FDG PET relies on the fact that granulocytes
and
mononuclear cells use glucose as an energy source at all times.
3.4 Which of the following statements regarding the role of
18
F-FDG PET scan for
diagnosis of lung cancer is true?
A. Availability of
18
F-FDG PET obviates the need for conventional work-up for the
diagnosis and staging
of lung cancer.
B.
18
F-FDG PET scan has no proven benefit in patients at low-risk for lung cancer.
C.
18
F-FDG PET will be most useful in patients
at a high risk of lung cancer.
D. For detection of mediastinal lymph node metastases, CT has a superior sensitivity and
specificity compared to
18
F-FDG PET.
E. In low-risk patients, the negative predictive value of
18
F-FDG PET is extremely high.
3.5 Chest CT scan of a 47-year-old male revealed the presence of a solitary
pulmonary nodule in the left lower lobe. Which of the following morphologic
characteristics is highly suggestive of malignancy?
A. Central nodular calcification
B. Diffuse calcification
C. Laminated calcification
D. Popcorn like calcification
E. Stippled calcification
3.6 A 52-year-old smoker requires a left upper lobectomy for a peripheral T1N0
squamous cell lung cancer. Which of the following pulmonary function study results
would indicate that the patient would be at very high risk for postoperative pulmonary
complications?
A. a DLCO of 70% of predicted with an FEV
1
of 1.4 liters
B. an FEV
1
of 1.5 liters and an arterial blood gas demonstrating a pO
2
of 72mmHg, a
pCO
2
of 38 mmHg and a pH of 7.40
C. an FEV
1
of 1.4 liters, an MVV of 55% of predicted and a VO
2
max of 20 cc per
kilogram per minute.
D. a quantitative ventilation-perfusion scan demonstrating 70% perfusion to the right
lung with an FEV
1
of 1.4 liters and a VO
2
max of 8 cc per kilogram per minute.
E. a quantitative ventilation-perfusion scan demonstrating 80% perfusion to the right lung
with an FEV
1
of 1.3 liters and a VO
2
max of 15 cc per kilogram per minute
3.7 A 64-year-old man developed severe respiratory failure and adult respiratory
distress syndrome following lung resection for lung cancer requiring mechanical
ventilatory support. A CT scan demonstrates pneumatoceles. This complication of
mechanical ventilation may have been prevented by
A. decreasing positive end expiratory pressure.
B. increasing tidal volume.
Thoracic Surgery: Questions
45
C. instituting pressure control ventilation.
D. pharmacologic muscle paralysis.
E. reducing the fractional inspired oxygen concentration.
3.8 Cervical mediastinoscopy is a common procedure used for the diagnosis
of
mediastinal disease and the staging of lung cancer. Although complications of cervical
mediastinoscopy are uncommon, the most common major complication is
A. airway disruption.
B. esophageal perforation.
C. hemorrhage.
D. recurrent nerve palsy.
E. stroke.
3.9 Traumatic diaphragmatic injuries are uncommon events but are associated with
a high mortality. Which of the following statements regarding injury to the diaphragm
is true?
A. Blunt injury to the diaphragm is more likely to involve the right side.
B. Delayed recognition of diaphragmatic injury is more common after penetrating trauma
than blunt injury.
C. Repair of acute diaphragm injuries is better handled using a transthoracic approach.
D. Repair of chronic diaphragm injuries (greater than three months) is best accomplished
abdominally.
E. The most common finding on the standard x-ray after penetrating injury is elevation of
the affected diaphragm.
3.10 Massive hemoptysis is one of the most dreaded of all respiratory
emergencies
and can have a variety of underlying causes. In
90% of cases, the source of massive
hemoptysis is the bronchial
circulation. Which of the following statements about
bronchial artery anatomy is correct?
A. Aberrant bronchial arteries enter the pulmonary parenchyma through the adherent
pleura
or via the pulmonary ligament.
B. Nonbronchial systemic collateral
vessels cannot be angiographically differentiated
from aberrant bronchial arteries.
C. The bronchial arteries originate directly from
the ascending thoracic aorta, most
commonly between the levels
of the T2 and T3 vertebrae.
D. The bronchial arteries only supply the intrapulmonary
airways and bronchovascular
bundles.
E. The majority of aberrant bronchial
arteries originate from the aortic arch.
3.11 Hemoptysis may be a life-threatening condition with an inclination to recur if
definitive treatment is not instituted. Massive hemoptysis
A. is defined as expectoration of blood of more than 200 mL per day.
B. is most commonly caused by non small cell lung cancer in the Third World.
C. is best managed medically with low rate of recurrence.
Shahzad G. Raja
46
D. managed with bronchial artery embolization may not be successful in 10% to 25% of
patients.
E. must be managed surgically in all patients.
3.12 A 52-year-old patient with localized bronchiectasis of right lower lobe presents
with a third documented episode of hemoptysis. Within six hours the bleeding stops.
One month ago the FEV
1
was 1.5 liters. The best management for this patient is
A. bronchoscopy followed by angiography with arterial embolization.
B. continued observation in the intensive care unit for another 48 hours and if no further
bleeding occurs discharge to home on antibiotics.
C. resection of the involved area.
D. treatment with anti-fungal chemotherapy for six weeks.
E. treatment with rotating bactericidal antibiotics.
3.13 A 62-year-old man with a 50 pack-year smoking history has had repeated
episodes of “bronchitis” characterized by a cough productive of purulent sputum. He
presents now with hemoptysis which began six hours ago. He produces 100 ml of blood
with the first cough you witness and he then continues to bring up blood every time he
coughs. His chest x-ray shows a cavitating lesion in the right upper lobe. He had one
previous episode of hemoptysis within the past year which was managed by his family
doctor. Pulmonary function studies performed three months ago demonstrated an FEV
1
of 2.2 liters (60% predicted). What should be the initial management of this patient?
A. angiography for bronchial arterial embolization.
B. bronchoscopy followed by thoracotomy and lobectomy.
C. flexible bronchoscopy with mainstem bronchial intubation with an endotracheal tube.
D. intensive care unit observation, sedation, anti-tussive medication and bedrest with the
bleeding side down.
E. rigid bronchoscopy with insertion of a balloon occlusion catheter.
3.14 Which of the following represents the most common cause of esophageal
perforation/rupture?
A. blunt trauma (deceleration and steering wheel).
B. esophageal instrumentation (iatrogenic).
C. foreign body aspiration/impaction.
D. penetrating civilian trauma.
E. spontaneous post-emetic rupture (Boerhaave‘s Syndrome).
3.15 The best management for a patient with a distal esophageal perforation which
occurs 48 hours prior to presentation is
A. antibiotics and proper drainage.
B. diversion and exclusion.
C. extensive debridement with T-tube controlled fistula.
D. primary repair with buttressing.
E. resection with cervical stoma, gastrostomy, and jejunostomy.
Thoracic Surgery: Questions
47
3.16 Fistula formation between the innominate artery and the trachea is a rare but
potentially catastrophic complication after tracheostomy. Which of the following
statements regarding tracheoinnominate artery fistula (TIF) is correct?
A. TIF associated bleeding can be temporarily stopped in 100% of cases with
overinflating the tracheostomy tube cuff.
B. TIF associated bleeding is best confirmed by flexible bronchoscopy.
C. TIF formation is seen with low-lying tracheostomy sites typically below the third
tracheal ring.
D. TIF in most cases presents as sentinel bleed.
E. TIF in most cases usually occurs within a week of placement of tracheostomy tube.
3.17 A 14-year-old ventilator-dependent girl with a history of anoxic brain injury
and a tracheostomy in-situ for 6 months suddenly develops massive bleeding from her
tracheostomy site. Which of the following is the best initial management in this case?
A. Chest radiograph to exclude pneumonia as a cause of massive hemoptysis.
B. Flexible bronchoscopy to visualize the site of bleeding.
C. Insertion of Fogarty balloon catheter via the brachial artery into the innominate artery
under radiograph guidance to achieve tamponade after balloon dilation.
D. Resection of the innominate artery with preservation of the right carotid-right
subclavian junction.
E. The tracheostomy tube cuff should be hyperinflated.
3.18 Which of the following is the second most common tracheal tumor?
A. adenoid cystic carcinoma.
B. carcinoid.
C. granular cell tumor.
D. mucoepidermoid tumor.
E. mucus gland adenocarcinoma.
3.19 Which of the following statements regarding adenoid cystic carcinoma (ACC)
of the trachea is correct?
A. Primary tracheal ACC is an aggressive tumor.
B. Primary tracheal ACC is commonly seen in the third decade.
C. Primary tracheal ACC is predominantly found in men.
D. Primary tracheal ACC of distal trachea has a worse prognosis.
E. Primary tracheal ACC spreads most commonly by lymphatic metastases.
3.20 A 46- year-old patient was found to have a one centimeter squamous cell cancer
of the mid trachea. The patient was treated with 6000 cGy. Two years later the patient is
found to have an eight millimeter local recurrence. The best management of this patient
is
A. brachytherapy.
B. cis-platinum based chemotherapy.
C. laser ablation.
D. tracheal resection and omental wrap.
Shahzad G. Raja
48
E. tracheal stent.
3.21 Which of the following arteries is the principle blood supply to the upper two
thirds of the trachea?
A. external carotid.
B. inferior thyroid.
C. internal thoracic.
D. superior thyroid.
E. transverse cervical.
3.22 Ten days after an extensive tracheal resection, a patient developed sudden
massive subcutaneous emphysema and respiratory distress. The patient was intubated
with great difficulty. At exploration complete dehiscence of the trachea is found. The
best management of this patient is
A. antibiotic therapy alone.
B. hilar and laryngeal release, and reanastomosis-with muscle flap buttress.
C. oral intubation and suction drainage through the neck.
D. tracheal stent and muscle flap buttress.
E. T-tube.
3.23 Which of the following is a recognized risk factor for anastomotic
complications
after tracheal resection?
A. diabetes
B. idiopathic laryngotracheal stenosis
C. postintubation tracheal stenosis
D. tracheoesophageal
fistula
E. tumor
3.24 An elderly patient has been intubated and ventilated for two weeks for severe
bilateral pneumonia. A nasogastric tube is in place for feedings. The patient is found to
have a tracheoesophageal fistula involving the upper third of the trachea. Endoscopy
reveals a circumferential area of tracheal damage from a cuff injury and a one
centimeter tracheoesophageal fistula. Which of the following is part of the initial
management of this problem?
A. esophageal diversion
B. gastrostomy tube
C. local division of the fistula with strap muscle interposition
D. T-tube placement and removal of the nasogastric tube
E. tracheal resection and fistula repair with strap muscle interposition
3.25 Mucoepidermoid carcinoma of the bronchus is similar to its counterpart
arising from the salivary glands but does have some distinct characteristics of its own.
Which of the following statements regarding bronchial mucoepidermoid carcinoma is
correct?
A. It accounts for approximately 15% of primary lung tumors.
B. It has a predilection for females.