True Learn #2 Flashcards
1
Q
What is the most important prognostic factor for soft tissue sarcomas?
[True Learn]
A
Mitotic index
[The amount of necrosis is also a very important prognostic factor.]
2
Q
Heparin-induced thrombocytopenia (HIT) is a paradoxical thrombotic state initiated by antibodies to what?
[True Learn]
A
The heparin-platelet factor IV complex
3
Q
What is the best course of management of a uniloculated splenic abcess?
[True Learn]
A
CT-guided drainage
[multilocular lesions require splenectomy.]
4
Q
What is the best diagnostic test for acute aortic dissection?
[True Learn]
A
Helical CT scanning
[It requires IV contrast medium that may limit its use in certain clinical situations but it generates images familiar to most practitioners and has a high sensitivity and specificity.]
5
Q
What percent of a persons blood volume is lost in a class I hemorrhage?
[True Learn]
A
10-15% (500cc-750cc)
[This causes minimal change in the patient’s clinical condition. Slight tachycardia with a drop in pulse pressure may be the only manifestation.]
6
Q
What are the two components of fibrin glue?
[True Learn]
A
- Fibrinogen
- Thrombin
7
Q
What is the appropriate treatment for VIPoma?
[True Learn]
A
Distal pancreatectomy
[Surgical excision is appropriate in nearly all patients with Verner-Morrison syndrome (VIPoma). Most tumors are located in the distal pancreas where they are amenable to resection via distal pancreatectomy.]
8
Q
Which type of choledochal cysts are characterized as saccular or fusiform dilation of a portion or entire common bile duct with normal intrahepatic duct and what is the treatment?
[True Learn]
A
- Type I choledochal cysts
- Treatment with cyst excision with Roux-en-Y jejunostomy
[Most common (80-90%) variety. This type of choledochal cyst is associated with recurrent cholangitis, progressive liver damage and high risk of cancer. The choledochal cyst wall is the primary location of carcinomas. Roux-en-Y jejunostomy is advocated because this operative approach eliminates the potentially premalignant epithelial cyst lining and also separates the pancreatic drainage from the biliary drainage.]
9
Q
Which type of choledochal cysts are characterized as isolated diverticulae protruding from the common bile duct and what is the treatment?
[True Learn]
A
- Type II choledochal cysts
- Treatment is simple cyst resection only
[Biliary reconstruction is typically not required.]
10
Q
Both intralobular and extralobular pulmonary sequestrations are found more frequently on which side of the body?
[True Learn]
A
Left side
[In 85% of cases, the intralobular sequestration is supplied by an anomalous systemic vessel arising from the infradiaphragmatic aorta and located within the inferior pulmonary ligament. The venous drainage is usually through the inferior pulmonary vein, but may also occur by way of systemic veins.]
11
Q
What presents with nonspecific clinical features such as steatorrhea, diabetes, hypochlorhydria, and cholelithiasis, and evidence of a mass in the pancreas?
[True Learn]
A
Somatostatinoma
[Fasting plasma somatostatin levels of greater than 100 pg/mL can be used to confirm the diagnosis.]
12
Q
What is the diagnostic modality of choice for assessing gallbladder polyps?
[True Learn]
A
Right upper quadrant ultrasound
[If there is any suspicion of malignancy when a gallbladder polyp is found, cross-sectional imaging with a contrast enhanced CT or MRI to determine the extent of invasion is crucial to definitive treatment and diagnosis of a malignant lesion.]
13
Q
What is produced by antigen presenting cells and is involved in activation of CD4 lymphocytes?
[True Learn]
A
IL-1
14
Q
Production of which hormone(s) can result from small cell lung cancer?
[True Learn]
A
- ACTH
- ADH
[Squamous cell cancer is associated with over production of PTH-related peptide leading to hypercalcemia.]
15
Q
What is the treatment for a proximal gastric adenocarcinoma?
[True Learn]
A
Total gastrectomy
[Total gastrectomy in these patients is associated with less morbidity and mortality when compared to a subtotal gastrectomy due to the anatomical position near the GE junction. The definitive treatment for gastric adenocarcinoma is surgical resection with at least 5 cm margins. Distal tumors can usually achieve an adequate margin and a subtotal gastrectomy with 5 cm margins can be performed.]
16
Q
Which structure(s) form the internal inguinal ring?
[True Learn]
A
The internal oblique muscle and the transversalis fascia
17
Q
In treating a pseudoaneurysm, the main complication of thrombin injection is what?
[True Learn]
A
Thrombosis of the femoral artery
[The loss of pulses is never normal after a pseudoaneurysm and is an indication for immediate operative intervention.]
18
Q
Acute aortic dissection is defined as one that presents within what time frame from the intial event?
[True Learn]
A
Within 2 weeks
19
Q
What is the best test for both acute and chronic adrenal insufficiency?
[True Learn]
A
Rapid ACTH stimulation test
[Synthetic ACTH (250ug) is administered by IV, and plasma cortisol levels are measured 30 and 60 minutes later. Normal peak cortisol response should exceed 20 ug/dL. Measurement of ACTH by immunoradiometric assay is then used to distinguish primary from secondary and tertiary adrenal insufficiency. High plasma concentration of ACTH (greater than 200 pg/dL) and low plasma cortisol (less than 10 mg/dL) are diagnostic of primary adrenal insufficiency. Low levels of plasma ACTH indicate secondary (pituitary) or tertiary (hypothalamic) adrenal insufficiency.]
20
Q
What are the 2 most important predictors of poor outcome in melanoma?
[True Learn]
A
- Distant metastasis
- Lymph node involvement
[Melanoma depth is the most powerful predictor of prognosis.]
21
Q
Which breast lesion is equivalent to carcinoma in situ and will almost universally transform into invasive ductal carcinoma within 1 year?
[True Learn]
A
Paget’s disease of the breast
[It has high malignant potential, and when it undergoes malignant transformation, will spread lymphatically. Simple mastectomy should be first line treatment.]
22
Q
What is the best conduit for repair of a lower extremity vascular injury?
[True Learn]
A
Contralateral greater saphenous vein
[The contralateral vein is preferred to ensure there are no venous injuries or contamination.]
23
Q
What is the major fuel source for the enterocyte?
[True Learn]
A
Glutamine
[In times of severe stress glutamine administration has shown to decrease hospital stay, improve nitrogen balance and decrease infection rates. It is believed that these effects are due to improved barrier function in the GI tract.
24
Q
What is the gold standard for the diagnosis of Hirschsprung’s disease?
[True Learn]
A
Rectal biopsy In the newborn period
[This is done at the bedside with minimal morbidity using a special suction rectal biopsy instrument. It is important to obtain the sample at lest 2 cm above the dentate line to avoid sampling the normal transition from ganglionated bowl to the paucity or absence of ganglia in the region of the internal sphincter.]
25
What is the most powerful predictor of prognosis in melanoma?
[True Learn]
Melanoma depth
[It divides melanoma into thickness categories that inversely correlate with survival. Lymph node involvement and distant metastasis are the most important predictors of poor outcome in melanoma. Positive lymph nodes = stage III disease regardless of tumor depth.]
26
What is the appropriate adjuvant treatment for post-menopausal females with ER-positive breast cancer who are node positive?
[True Learn]
Hormone therapy alone
[In general, all patients with positive nodes will require chemotherapy. The only exception is with post-menopausal, ER positive patients who may be treated with Anastrozole alone or Anastrozole + chemotherapy.]
27
How is the urine affected by metabolic alkalosis secondary to vomiting?
[True Learn]
Aciduria
[Recurrent vomiting is associated with chloride-responsive metabolic alkalosis usually as a result of loss of Cl- and H+ from the stomach. Chloride-responsive alkalosis is usually accompanied by volume depletion, which stimulates aldosterone secretion and results in reabsorption of Na+ and loss of K+. Metabolic alkalosis with hypokalemia can be associated with paradoxical aciduria due to activation of the H+/K+ exchanger to conserve potassium.]
28
A GI bleed in a patient with chronic pancreatitis is indicative of what?
[True Learn]
Splenic vein thrombosis
[Treatment is splenectomy.]
29
What is the most XRT-sensitive germ cell tumor?
[True Learn]
Seminomas
[Sarcomas (not a germ cell tumor) are known to be resistant to radiation.]
30
Which type of choledochal cysts are characterized as intraduodenal or intrapancreatic dilations of the distal common bile duct and what is the treatment?
[True Learn]
* Type III choledochal cysts (or choledochoceles)
* Treatment is traditionally transduodenal marsupialization of the cyst
[Increasingly choledochoceles are being treated by sphincterotomy or cyst marsupialization during an ERCP. These cysts are associated with cholangitis and pancreatitis due to the build up of protein.]
31
What must the predicted postoperative diffusion capacity of the lung for carbon monoxide (DLCO) be to proceed with lung resection?
[True Learn]
40% or greater
[A procedure is contraindicated if the predicted postoperative DLCO value is less than 40%.]
32
What is the formula for calculating the fractional excretion of sodium (FENa)?
[True Learn]
(Urine sodium x plasma creatinine)/(plasma sodium x urine creatinine) x 100
[FENa of less than 1% is pre-renal. FENa of greater than 1% is indicative of intrarenal pathology such as acute tubular necrosis or other kidney damage. FENa of greater than 4% is likely postrenal.]
33
Is pain alleviated by lifting the testicle (positive Prehn's sign) in epididymitis or in testicular torsion?
[True Learn]
Epididymitis
[Epididymitis usually presents with acute testicular pain, swelling, erythema, and tenderness to palpation. Fever may also be present. Cremasteric reflex is typically present. Testicular pain is alleviated by lifting the testicle (positive Prehn's sign).]
34
What is the treatment for vulvar cancers with greater than 1 mm depth?
[True Learn]
Radical vulvectomy and lymph node dissection
[Radical vulvectomy extends down to the endopelvic fascia, with a 2 cm margin, and bilateral inguinal node disection. Vulvar cancer with less than 1mm depth can be treated with wide local excision.]
35
At what time interval should appendectomy be performed on a patient who presents with perforated appendicitis?
[True Learn]
6-8 weeks after presentation
[Some evidence suggests that early appendectomy carries an increased risk of bowel obstruction, wound infection and reoperation.]
36
Where do small bowel adenocarcinomas most commonly occur?
[True Learn]
In the duodenum
37
What is the treatment for biliary atresia in an infant?
[True Learn]
Roux-en-Y hepatic portoenterostomy (Kasai procedure)
[The operation involves excision of the entire extrahepatic biliary tree with transection of the fibrous portal plate near the hilum of the liver. Bilioenteric continuity is then reestablished with a Roux-en-Y limb. The ultimate goal of the procedure is to allow drainage of bile from the liver into the roux limb via microscopic ductules in the portal plate.]
38
What is the appropriate managment of a thyroid nodule with a fine needle aspiration (FNA) that reveals follicular cells?
[True Learn]
Thyroid lobectomy
[Follicular cells seen on fine needle aspiration can not be used to make a definitive diagnosis of follicular cancer. Surgical resection is needed to rule out malignancy. The diagnosis of follicular cancer is made when capsular or vascular invasion is present. Lobectomy should be performed first since only 5-10% of nodules will contain cancer. If cancer is found, then a completion thyroidectomy should be performed at that time.]
39
Which type of choledochal cysts are characterized as multiple dilations in the extrahepatic and intrahepatic bile ducts and what is the treatment?
[True Learn]
* Type IVa choledochal cysts
* Treatment with cyst excision with Roux-en-Y jejunostomy
[Type IVb involve only the extrahepatic bile ducts. Type IV choledochal cysts are associated with recurrent cholangitis, progressive liver damage and high risk of cancer. The choledochal cyst wall is the primary location of carcinomas. Roux-en-Y jejunostomy is advocated because this operative approach eliminates the potentially premalignant epithelial cyst lining and also separates the pancreatic drainage from the biliary drainage.]
40
What is a common cause of splenic vein thrombosis?
[True Learn]
Chronic pancreatitis
[Splenic vein thrombosis causes isolated gastric varices due to retrograde flow through the short gastric and posterior gastric veins. These gastric varices only bleed about 10% of the time so prophylactic splenectomy is not indicated. An ultrasound should be performed to confirm the diagnosis.]
41
Which treatment modality is best for grade IV internal hemorrhoids?
[True Learn]
Hemorrhoidectomy
[The hemorrhoid is dissected off the underlying sphincter and is ligated at the apex. While this may be left open, most US surgeons reapproximate the mucosa which leads to faster wound healing.]
42
What percent of a persons blood volume is lost in a class IV hemorrhage?
[True Learn]
40% or greater (Greater than 2L)
[Represents a severe physiological insult. Systolic hypotension may be profound, and the diastolic blood pressure may be unobtainable. Mental status changes progress from restlessness and agitation to listlessness and obtundation, producing a moribund condition because cerebral blood flow is insufficient to maintain neurological function. Loss of more than 50% of circulating blood volume results in loss of consciousness, pulse, and blood pressure.]
43
Which type of thyroid cancer is derived from parafollicular cells which arise embryologically from the neural crest?
[True Learn]
Medullary thyroid carcinoma
[With the exception of medullary carcinoma, most thyroid carcinomas are derived from the thyroid follicular epithelium. Anaplastic cancer is an undifferentiated neoplasm. The ventral portion of the 4th pharyngeal pouch develops into the ultimobranchial bodies early in the development of the thyroid gland. These structures contain neural crest cells which will ultimately fuse with the thyroid and lead to the formation of the parafollicular cells. Calcitonin is the product of these "C cells". Medullary thyroid carcinoma is a neuroendocrine neoplasm derived from the parafollicular cells and calcitonin, therefore, can be used as a surveillance marker for recurrence following resection.] Through T22 Through 42
44
In what order do the stomach, small bowel, and colon recover bowel function after abdominal surgery?
[True Learn]
1. Small bowel
2. Stomach
3. Colon
[After laparotomy, small bowel motility returns within several hours, gastric motility within 24-48 hours, and colonic motility in 48-72 hours.]
45
What is the strongest risk factor for the development of an abdominal aortic aneurysm (AAA)?
[True Learn]
Smoking
[Degeneration of the walls of an AAA are from increases in matrix metalloproteinases and decreases in elastic and smooth muscle fibers. Family history, age, hypertension, and hypercholesterolemia are other risk factors for AAA.]
46
Cancer of which 3 organs are the top 3 causes of cancer death worldwide?
[True Learn]
1. Lung
2. Stomach
3. Liver
47
What is the most common type of sarcoma in the GI tract?
[True Learn]
Gastrointestinal stromal (GIST) tumors
48
What is the most common cause for liver transplant in the USA?
[True Learn]
Hepatitis C
49
Which structure(s) form the external inguinal ring?
[True Learn]
External oblique aponeurosis
[The medial fibers of the external oblique aponeurosis divide into medial and lateral crura to form the external inguinal ring.]
50
What are the conservative measures that can be taken to treat bile reflux gastritis?
[True Learn]
Lifestyle modification, cholestryramine, metoclopramide
[This condition is most common in those that have undergone a partial gastrectomy, especially a Billroth II reconstruction. If conservative measures fail, conversion to a Roux-en-Y reconstruction is indicated.]
51
Which kind of pancreatic tumor can not be identified by somatostatin receptor scintigraphy (SRS)?
[True Learn]
Insulinoma
[SRS or Octreoscan has become an important imaging modality for neuroendocrine tumors of the pancreas. For most neuroendocrine tumors and carcinoid tumors, it is excellent and correctly identifies 90%. However, insulinomas are the exception, and they usually do not image on SRS.]
52
What presents with a dry cough, bilateral hilar adenopathy, and a pre-tibial rash?
[True Learn]
Sarcoidosis
[It can also be associated with uveitis. This is a disease in which abnormal collections of chronic inflammatory cells (granulomas) form as nodules in multiple organs. The cause of sarcoidosis is unknown. granulomas (of the non-caseating type) most often appear in the lungs or the lymph nodes, but virtually any organ can be affected. The diagnosis can be confirmed with a biopsy via bronchoscopy or open lung biopsy. Pathology will describe noncaseating granulomas.]
53
What can be performed as a palliative procedure in patients with unresectable pancreatic cancer and intractable pain?
[True Learn]
Celiac plexus neurolysis
[This is and endoscopic procedure performed for palliation of intractable pain in pancreatic cancer patients. It involves injection of alcohol into the celiac plexus. In one study, 59% of patients that underwent this procedure had complete relief while the other 41% had partial relief of their symptoms. At 3 months 90% maintained some level of symptom relief.]
54
What is the first line treatment for immune thrombocytopenic purpura?
[True Learn]
High-dose corticosteroid therapy
[IV IgG immunoglobulin is second line therapy and takes between 3-5 days to show effects. Splenectomy is indicated in patients who fail to achieve a sustained remission with medical therapy. Rituximab and Romiplostim are usually used as third line agents after splenectomy failure.]
55
What are the Light's criteria?
[True Learn]
* Pleural fluid to serum protein ratio of greater than 0.5
* Pleural fluid to serum LDH ratio of greater than 0.6
[Exudative effusions will be high in protein and LDH. Other factors suggestive of an exudate are low glucose, elevated specific gravity, and a low pH.]
56
What is the earliest sign of hypocalcemia?
[True Learn]
Circumoral or fingertip numbness
57
What manifests as hypokalemia and hypertension refractory to multiple medications?
[True Learn]
Primary hyperaldosteronism
[Adrenal adenoma or bilateral adrenal hyperplasia are the 2 most common causes. The mean age at diagnosis is 50. Primary hyperaldosteronism is potentially curable when treated surgically. When there is a good response to spironolactone, the response to surgery is usually better.]
58
What is the order of arrival of fibroblasts, lymphocytes, macrophages, neutrophils, and platelets to populate a new wound?
[True Learn]
1. Platelets
2. Neutrophils
3. Macrophages
4. Lymphocytes
5. Fibroblasts
[Platelets arrive with the early inflammatory cascade and are essential for hemostasis and initiation of the inflammatory response. Platelets release adenosine diphosphate (ADP), which, in the presence of calcium, stimulates further platelet aggregation. Platelets also release multiple cytokines that work as chemotactic agents for fibroblasts, endothelial cells, and macrophages. Neutrophils are the first cells to arrive. They are attracted to the site within 24-48 hours after injury. Neutrophils cleanse the wound via phagocytosis of bacteria and foreign debris. Macrophages are the key regulatory cells for repair and are the predominant cell type present between 48-72 hours after injury. Macrophages attract fibroblasts into the wound. Fibroblasts function to deposit collagen into the wound and assist the myofibroblast in wound contraction.]
59
Spigelian hernias most commonly occur below which landmark?
[True Learn]
Below the arcuate line
[Spigelian hernias often present with abdominal pain, but are difficult to identify by physical exam because the defect is covered by external oblique aponeurosis. As a result, the diagnosis is often made by imaging. Spigelian hernias most often occur below the arcuate line between the semilunar line and the lateral edge of the rectus muscle. There is a high risk of incarceration with these hernias and all do require surgical repair. The surgical approach is through a transverse abdominal incision over the defect.]
60
Post-transplant lymphoproliferative disorder (PTLD) results from chronic immunosuppression and is most commonly associated with which virus?
[True Learn]
Epstein-Barr virus (EBV)
[EBV is most commonly associated with the development of lymphoma in the immunosuppressed state. The severity of PTLD has a wide range and some mild cases may not need treatment. However, many patients will need to be taken off immunosuppressive medications or begin treatment with chemotherapy in more severe cases.]
61
What percent of a persons blood volume is lost in a class II hemorrhage?
[True Learn]
15-30% (750cc-1500cc)
[The patient becomes anxious and mildly tachycardic with a clear drop in pulse pressure. Systolic blood pressure is still maintained by virtue of peripheral vasoconstriction, manifested as pallor and delayed capillary refil. Elevated levels of vasopressin and aldosterone coupled with adrenergic-mediated renal arteriolar constriction induce a mild oliguria.]
62
How accurate in terms of false positives and false negatives is serological testing in patients with hydatid disease of the liver?
[True Learn]
High rates of false positives and false negatives
[ELISA detection of specific antigens and immune complexes of the cyst has a much greater sensitivity, while ELISA and radioallergosorbent test (RAST) can also detect specific IgE antibodies.]
63
What is the best treatment for stage III or IV mucosa associated lymphoid tissue (MALT) lymphoma?
[True Learn]
Chemotherapy
[Cyclophosphamide + doxorubicin + vincristine + prednisolone (CHOP).]
64
What is the standard approach to an adrenal tumor that is nonfunctioning and benign in appearance?
[True Learn]
Repeat imaging at 6, 12, and 24 months
[Annual hormonal testing should also be performed for four years. Growth greater than 1 cm or development of autonomous hormonal secretion is an indication for adrenalectomy. All functioning adrenal tumors and those with suspicious radiographic appearance should be excised regardless of size.]
65
what is the most important predictive measure of a patient's ability to tolerate a lung resection?
[True Learn]
FEV1
[If the predicted postoperative FEV1 is greater than 0.8L, then the patient will likely tolerate the procedure.]
66
What is the appropriate management of a large, but asymptomatic lesion identified as focal nodular hyperplasia (FNH) of the liver?
[True Learn]
No surgery or serial imaging required
[Asymptomatic FNH should not be resected and does not require follow up imaging.]
67
What is the most common cause of bloody nipple discharge and what is the treatment?
[True Learn]
Intraductal papilloma Treatment is simple duct excision through a circumareolar incision
[There is no associated increased risk of breast cancer.]
68
What percent of a persons blood volume is lost in a class III hemorrhage?
[True Learn]
30-40% (1500cc-2000cc)
[Leads to the classic findings of hemorrhagic shock. Patients almost always present with marked tachycardia, tachypnea, significant alterations in mental status, and a measurable fall in blood pressure. In normal individuals, this is the least amount of blood loss that consistently causes a drop in systolic blood pressure.]
69
What is produced by CD4 lymphocytes and facilitates the maturation of CD8 lymphocytes?
[True Learn]
IL-2
70
What is the best course of management of a multiloculated splenic abcess?
[True Learn]
Splenectomy
[Unilocular lesions can be treated with CT-guided drainage.]
71
Where will most swallowed foreign objects get stuck?
[True Learn]
At the level of the cricopharyngeus
[63-84% of foreign bodies are retained at the level of the cricopharyngeus muscle. Coins remain the most common esophageal foreign body in children. Owing to their size, quarters most often lodge at the cricopharyngeus whereas smaller dimes and pennies may appear more distally. The other two most common locations are where the aorta crosses the esophagus (10-17%) and the lower esophageal sphincter (5-20%).]
72
IL-1 is produced by antigen presenting cells and is involved in the activation of which cells?
[True Learn]
CD4 lymphocytes
73
Calcifications seen within the pancreas on CT are a pathognomonic finding for what?
[True Learn]
Chronic pancreatitis
[An enlarged and edematous pancreas with peripancreatic fat stranding is characteristic of acute pancreatitis. Diffuse enlargement of the pancreas without peripancreatic inflammation can be seen in cases of autoimmune pancreatitis.]
74
What is the expected weight loss after 2 years following sleeve gastrectomy?
[True Learn]
60% of original excess weight
75
Which benign breast lesion fluctuates in size with menstrual cycles and is usually a small mass with discrete, smooth edges that is mobile?
[True Learn]
Fibroadenoma
[After menopause, fibroadenomas often present as a calcified density on mammogram.]
76
What is the recommended predicted postoperative FVC when contemplating lung resection?
[True Learn]
FVC greater than 1.5L
[FEV1 is the most important predictive measure of a patient's ability to tolerate a lung resection. If the predicted postoperative FEV1 is greater than 0.8L, then the patient will likely tolerate the procedure.]
77
What is the appropriate treatment of a 2cm biopsy-proven invasive ductal carcinoma of the breast with no palpable axillary lymph nodes?
[True Learn]
Lumpectomy with sentinel lymph node biopsy
[She may also need adjuvant radiation. Without contraindications such as multi-centric disease, a large mass, or contraindications to radiation, breast conserving therapy should be instituted.]
78
Budd-Chiari syndrome traditionally presents with which triad of symptoms?
[True Learn]
1. Right upper quadrant pain
2. Hepatomegaly
3. Ascites
[Budd-chiari syndrome is characterized by obliteration of the hepatic veins. It may be due to congenital webs of the hepatic veins or suprahepatic cava or may generate from a spontaneous thrombosis of the hepatic veins. Diagnosis is made by inferior vena cavagram or magnetic resonance venography.]
79
TGF-beta is known to inhibit activation of which cells?
[True Learn]
T-cells
80
Which two hormones have been shown to increase lower esophageal sphincter (LES) pressure?
[True Learn]
1. Gastrin
2. Motilin
[Cholecystokinin, estrogen, glucagon, progesterone, somatostatin, and secretin decrease LES pressure.]
81
What is the "Rule of 6" according to the Kidney Dialysis Outcome Quality Initiative (KDOQI)?
[True Learn]
1. Fistula diameter should be at least 6mm
2. Fistula depth should be at least 6mm below the skin
3. Flow should be at least 600ml/min
82
What is the most commonly found type of collagen in cartilage?
[True Learn]
Type II collagen
83
Which signal molecule is known to inhibit T-cell activation?
[True Learn]
TGF-beta
84
What is the next step in evaluating a patient for lung resection if preoperative testing (I.E. predicted values of FEV1, DLCO, or FVC are too low) suggests that the patient will not tolerate the procedure?
[True Learn]
Ventilation/perfusion (V/Q) scan
[This will show the distribution of ventilation and blood flow to each lobe of the lungs. If the desired lobe has a minimal contribution to the FEV1, then the patient can still likely tolerate a resection.]
85
IL-4 is released by CD4 lymphocytes and helps the maturation of which cells?
[True Learn]
B cells
86
The definitive treatment for gastric adenocarcinoma is surgical resection with what size margin?
[True Learn]
At least 5 cm
[Proximal tumors require a total gastrectomy. Distal tumors can usually achieve an adequate margin and a subtotal gastrectomy with 5 cm margins can be performed.]
87
Which treatment is indicated in addition to total thyroidectomy in both papillary and follicular cancer?
[True Learn]
Radioactive iodine therapy
[After undergoing a total thyroidectomy, patients should receive radioactive iodine treatment to ablate the remnant thyroid bed to decrease the likelihood of recurrent disease.]
88
What is the Parkland formula?
[True Learn]
4ml x Weight (Kg) x %TBSA = 24 hour fluid requirement
[Half of this amount is infused in the first 8 hours. The rest is giben hourly over the next 16 hours.]
89
Which enzyme is the final common denominator for both the intrinsic and extrinsic pathways of apoptosis?
[True Learn]
Caspase
[Caspases are the central enzyme in apoptosis. Once activated, caspases destroy cells via the physical breakdown of cytoskeleton and other structural proteins. They affect DNA synthesis and repair by inactivating the repair enzymes and inducing DNA fragmentation enzymes. They inhibit cell adhesion molecules thus isolating cells from other cells and their surroundings. The extrinsic pathway is initiated by the binding of proapoptotic ligands such as tumor necrosis factor (TNF) to death receptors on the cell surface. This triggers an intracellular cascade. The intrinsic pathway begins the cell death cascade by recognizing intracellular signals of cell demise such as gentoxic damage or growth factor and nutrient deprivation via the Bcl-2 protein family.]
90
Mucosa associated lymphoid tissue (MALT) lymphoma is associated with which infection?
[True Learn]
H. Pylori
[H. Pylori is the factor that contributes to ulcer pathogenesis in most patients, and is associated with MALT lymphoma.]
91
What is the appropriate management of an asymptomatic biopsy-confirmed fibroadenoma?
[True Learn]
Observation with clinical exam or ultrasound if the mass is not palpable
[If there is any concern for cancer on biopsy, the mass is enlarging, or it causes pain, it should be excised. It usually requires excision if it grows over time, is large (greater than 2-3 cm) at diagnosis, or it is painful. Overall, there is little to no proven increase in the risk of developing breast cancer with the finding of a true fibroadenoma.]
92
What is the treatment of an echinococcal hydatid cyst of the liver?
[True Learn]
Surgical resection
[In elderly, asymptomatic patients with small, densely calcified cysts, conservative management is recommended.]
93
What is the diagnostic test for Meckel's diverticulum in the pediatric population?
[True Learn]
Meckel's Scintigraphy (Technetium-99m)
[This is study is 85% sensitive in pediatric patients because of the concentrated heterotopic gastric mucosa within the diverticulum in children. In adults, however, it becomes much less sensitive due to atrophic gastric mucosa.]
94
What is the treatment for chronic (\>6 weeks) anal fissures?
[True Learn]
Medical treatment (nitroglycerine ointment, calcium channel antagonists, phosphodiesterase inhibitors, botulinum toxin injections, steroid injections, etc.) for about 6 weeks
[Acute anal fissures are treated with high fiber diet and pain control. Surgical division of the internal sphincter muscle is the most effective treatment but is usually reserved for refractory cases due to the risk of fecal incontinence.]
95
What is the best marker for long term nutritional status?
[True Learn]
Serum albumin
[Serum albumin has a half-life of ~21 days and thus serves as a biomarker of long term nutritional status. This becomes less reliable in the face of an acute inflammatory process as the liver shifts away from its production in favor of synthesis of the "positive" acute phase reactants (I.E C reactive protein). For patients with more acute inflammatory processes, nutrition should be assessed with a marker that has a shorter turnover time (IE transferrin with half life of 8 days or prealbumin with half life of 1-2 days).]
96
What are the 3 absolute contraindications to laparoscopic cholecystectomy?
[True Learn]
1. Inability to tolerate general anesthesia
2. Gallbladder cancer (suspected or confirmed)
3. "Frozen abdomen" due to previous surgery or peritonitis
97
What is the treatment for acute, symptomatic paraesophageal hernias?
[True Learn]
Laparoscopic surgical reduction, repair of diaphragmatic defect, and nissen fundoplication
98
Injury to which nerve causes winging of the scapula?
[True Learn]
Long thoracic nerve
[This nerve innervates the serratus anterior muscle, produces instability and unsightly prominence of the scapula.]
99
What is released by CD4 lymphocytes and helps the maturation process of B cells?
[True Learn]
IL-4
100
What is the appropriate management of an asymptomatic hepatic adenoma in a woman taking oral contraceptives?
[True Learn]
This can be managed conservatively and followed with serial CT scans with the woman off oral contraceptives
[Observation for regression after stopping OCPs is an option, although progression and rupture have been observed in this setting. Symptomatic masses should be resected. Overall, the surgeon must compare the risks of expectant management with serial imaging studies and alpha-fetoprotein (AFP) measurements against those of resection.]
101
Which 2 ventilator settings can be adjusted to the benefit of a patient with acute respiratory distress syndrome (ARDS)?
[True Learn]
1. Increase the Positive end expiratory pressure (PEEP)
2. Decrease the tidal volume
[A patient with ARDS will have stiff, non-compliant lungs that are difficult to oxygenate. Increasing the PEEP can be of benefit in treating patients with ARDS.]
102
IL-2 is produced by CD4 lymphocytes and facilitates the maturation of which cells?
[True Learn]
CD8 lymphocytes
103
What is the definition of stage IV Hodgkin's lymphoma?
[True Learn]
Stage IV disease is disseminated and involves non-lymphatic organs
[Hodgkin's lymphoma is staged based on extent of involved lymph tissue. If the patient has constitutional symptoms, such as night sweats, weight loss, or pruritis, they are designated with a "B" along with the stage number (I.E. stage IVB is with constitutional symptoms vs stage IVA which is without).]
104
What are the 4 most common donor sites for full-thickness grafts?
[True Learn]
1. Ears
2. Upper eyelids
3. Neck
4. Groin
[Full-thickness grafts are only suitable for small defects because the donor site must be closed primarily.]
105
What are the levels of invasion of the following TNM stages of gallbladder cancer?
* T1a
* T1b
* T2
* T3
* T4
[True Learn]
* T1a: Invasion of lamina propria
* T1b: Invasion of muscle layer
* T2: Invasion of perimuscular connective tissue but does not invade through serosa
* T3: Invasion through serosa and directly invades one adjacent organ or structure
* T4: Invasion greater than 2 cm into the liver or invasion of two or more adjacent organs
106
Which treatment modality is best for grade II and III internal hemorrhoids?
[True Learn]
Rubber band ligation
[Injection sclerotherapy is best for grade I and II hemorrhoids. Grade IV hemorrhoids usually require surgical excision.]
107
What are the 2 main risks of liver adenoma?
[True Learn]
1. Rupture
2. Malignant transformation
[The risk of rupture depends on size and can be as high as 30-50%. Hemorrhage from this can be life threatening. Although there are numerous reports of transformation of a liver adenoma into hepatocellular carcinoma, the true risk for transformation is probably low.]
108
Production of which hormone(s) can result from squamous cell lung cancer?
[True Learn]
PTH-related hormone
[Small cell cancer can be associated with elevated levels of ACTH and ADH.]
109
What are the indications for deep inguinal (ileo-obturator) lymph node dissection in a patient with melanoma on his/her lower extremity?
[True Learn]
1. More than four positive lymph nodes on superficial dissection
2. Palpable or extra-capsular invasion of the femoral lymph nodes
3. Positive cloquet node
4. Enlarged ileo-obturator lymph nodes on CT scan
[With metastasis ruled out, positive sentinel lymph node should be followed by locoregional control with inguinofemoral (superficial) lymph node dissection with or without ilio-obturator lymph node dissection. Radical right inguinal lymph node dissection is a combination of the superficial and deep lymph node dissection. For example, in the course of superficial dissection, if the cloquet node was positive on frozen section, deep dissection should be done.]
110
What is the goal of treatment of any branchial cleft remnant?
[True Learn]
Complete surgical resection
111
IFN-gamma is involved in the activation of which cells?
[True Learn]
Macrophage and natural killer cells
112
How should seroma formation after laparoscopic ventral hernia repair be initially managed?
[True Learn]
Nonoperative treatment with reassurance and follow up in 2 weeks
[Seroma formation after laparscopic hernia repair may occur into the dead space left from the hernia and dissection. Drains may be placed in this cavity at the time of initial operation, but seroma formation may still occur when the drain is removed. This condition is typically self limiting and resolves as the mesh incorporates into the defect. Aspiration should not be done unless the seroma is symptomatic or lasts for longer than 6-8 weeks due to the risk of mesh infection.]
113
What is the best marker for evaluating a patient's current visceral protein stores (recent nutritional status)?
[True Learn]
Prealbumin
[Prealbumin has a half-life of 24-48 hours making it the best biomarker for estimation of recent nutritional status. Serum albumin has a half-life of ~21 days and thus serves as a biomarker of long term nutritional status.]
114
What is the mechanism of action of aldosterone?
[True Learn]
It promotes sodium retention in the distal tubule via a Na-K and Na-H exchange
[Aldosterone acts by promoting sodium and chloride retention in the distal tubule. In exchange for sodium, hydrogen and potassium are excreted in the urine.]
115
Damage to which nerve will cause weakness with adduction and internal rotation of the arm?
[True Learn]
Thoracodorsal nerve
[The thoracodorsal (subscapular) nerve innervates the latissimus dorsi muscle in its course with the thoracodorsal (subscapular) vessels and is commonly sacrificed when lymphatics are discovered to be involved with metastases at axillary dissection. Sacrifice of this nerve results in minimal physical disability.]
116
What is the most common presentation of a soft tissue sarcoma?
[True Learn]
Asymptomatic mass
[Higher index of suspicion for malignancy is warranted for masses that are large (\>5cm), fixed, or deep.]
117
What is the primary modality for removal of a foreign object in the esophagus?
[True Learn]
Rigid esophagoscopy
[Rigid esophagoscopes are more versatile than flexible scopes because they allow for passage of various different grasping forceps.]
118
What is the half-life of Amiodarone?
[True Learn]
10 days
[The drug is not fully eliminated until a mean of 53 days after administration.]
119
What is the primary plasma carrier of cholesterol?
[True Learn]
LDL
[This is the lipoprotein with the highest concentration of cholesterol.]
120
Invasive gallbladder cancer will first metastasize to which nodes?
[True Learn]
Cystic duct lymph nodes
[Gallbladder cancer that has invaded past the mucosa will need a liver bed excision along with a cholecystectomy.]
121
What is the definition of hypotension in the pediatric population?
[True Learn]
Systolic blood pressure that is less than 70 + (2 x age)
122
Which type of IV fluids is best to replace losses from proximal small bowel fluid losses as in a patient with a proximal small bowel obstruction?
[True Learn]
Normal saline with sodium bicarbonate
[These patients will have a large amount of sodium and bicarbonate losses. They will have a normal anion gap acidosis. The best fluid replacement for these patients is with an isotonic solution and supplemental bicarbonate.]
123
When should pediatric inguinal hernias be operated on?
[True Learn]
Within 72 hours of reduction
[Sedation, elevation of the lower half of the body, and gentle pressure should be used to reduce the hernia as soon as it is detected to prevent bowel gangrene and ease the pain. The hernia should then be repaired within 72 hours of reduction to prevent reincarceration, which may occur early.]
124
Where is type IV collagen primarily found?
[True Learn]
Cornea
[It is found wide spread in the body but primarily in the cornea.]
125
What is the definition of stage I Hodgkin's lymphoma?
[True Learn]
Stage I disease is found in a single lymphatic site
[Hodgkin's lymphoma is staged based on extent of involved lymph tissue. If the patient has constitutional symptoms, such as night sweats, weight loss, or pruritis, they are designated with a "B" along with the stage number (I.E. stage IB is with constitutional symptoms vs stage IA which is without).]
126
Which signal molecule is involved in macrophage and natural killer cell activation?
[True Learn]
IFN-gamma
127
Which treatment modality is best for grade I and II internal hemorrhoids?
[True Learn]
Injection sclerotherapy
[Rubber band ligationy is best for grade II and III hemorrhoids. Grade IV hemorrhoids usually require surgical excision.]
128
What is the first step in managing massive hemoptysis?
[True Learn]
Rigid bronchoscopy and airway packing
[Once the source of bleeding has been identified and controlled, other measures can be taken to definitively control the bleeding. These include surgical resection, angiographic embolization, and laser ablation.]
129
What is the definition of stage II Hodgkin's lymphoma?
[True Learn]
Stage II disease can be found in two or more sites, but on the same side of the diaphragm
[Hodgkin's lymphoma is staged based on extent of involved lymph tissue. If the patient has constitutional symptoms, such as night sweats, weight loss, or pruritis, they are designated with a "B" along with the stage number (I.E. stage IIB is with constitutional symptoms vs stage IIA which is without).]
130
What is the earliest sign of shock in a pediatric trauma patient?
[True Learn]
Tachycardia
[Even this may not be evident until \>25% blood loss however.]
131
What is the treatment for acute anal fissures?
[True Learn]
High fiber diet, pain control, and sitz baths
[Chronic anal fissures (longer than 6 weeks in duration) are treated medically for about 6 weeks. Surgical division of the internal sphincter muscle is the most effective treatment but is usually reserved for refractory cases due to the risk of fecal incontinence.]
132
What is the definition of stage III Hodgkin's lymphoma?
[True Learn]
Stage III disease is found on both sides of the diaphragm, and the spleen is counted as involved lymph tissue
[Hodgkin's lymphoma is staged based on extent of involved lymph tissue. If the patient has constitutional symptoms, such as night sweats, weight loss, or pruritis, they are designated with a "B" along with the stage number (I.E. stage IIIB is with constitutional symptoms vs stage IIIA which is without).]
133
Which test should be ordered preoperatively when laboratory values are suggestive of primary hyperparathyroidism?
[True Learn]
Sestamibi scan
[The majority of hyperparathyroidism is caused by an adenoma, and less commonly by parathyroid hyperplasia. Preoperative sestamibi scans can localize a parathyroid adenoma to limit the dissection for a parathyroidectomy.]
134
What are the following characteristics of a good Lichtenstein inguinal hernia repair that have been shown to reduce recurrence and chronic pain?
* Mesh size
* Mesh shape
* Medial mesh border
* Lateral mesh border
* Superior mesh border
* Mesh size: **Large mesh (7 x 15 cm)**
* Mesh shape: **Tracing of a foot print of tear drop**
* Medial mesh border: **2 cm medial to pubic tubercle**
* Lateral mesh border: **5 to 6 cm lateral to internal ring**
* Superior mesh border: **At least 3 to 4 cm above Hesselbach's triangle**
135
What is the difference between CPN and TPN in terms of caloric distribution between carbohydrates, protein, and fat?
**_CPN_**
* Contains 1 kcal/ml
* 55% to 60% of calories come from carbohydrates (high concentration dextrose)
* 15% to 20% of calories come from protein
* Lipids should contribute no more than 30% of total calories in almost all circumstances
**_TPN_**
* Most calories are derived from fat (at least 50%)
* 30% of calories are derived from carbohydrates (in the form of 5% dextrose)
* 20% of calories are derived from protein
[TPN is usually undesirable because there is no evidence that it improves outcomes or significantly decreases nitrogen losses, and the high-fat content may impair reticuloendothelial cell function and therefore immune responsiveness.]
