初期研修

Application過去出題問題

2021年度初期臨床研修医採用試験(2020年8月15日)

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1.結核性腹膜炎に関する以下の文章を和訳しなさい。
Tuberculous peritonitis is an uncommon site of extrapulmonary infection caused by M. tuberculosis. Patients with HIV infection, cirrhosis, diabetes mellitus, and underlying malignancy are at increased risk. Noncirrhotic patients with tuberculous peritonitis usually have ascites with a high protein content, low glucose concentration, and a low serum-to-ascites albumin gradient (<1.1 g/dL). Patients almost always have an elevated ascitic fluid WBC count with a lymphocytic predominance. The algorithm in evaluation of patients with ascitic fluid that has a high lymphocyte count includes cytologic evaluation of the fluid and consideration of laparoscopy. Patients with lymphocytic ascites and fever usually have TB, whereas afebrile patients usually have malignancy-related ascites. Cancer is the cause of lymphocytic ascites about 10 times more frequently than TB. If peritoneal metastases are present, the cytologic findings are positive more than 90% of the time, and the laparoscopy can be avoided. If the cytology is negative, however, laparoscopy is performed and is nearly 100% sensitive in detecting tuberculous peritonitis. However, a number of noninvasive diagnostic tests are available to diagnose extrapulmonary disease. Adenosine deaminase levels are typically elevated in the ascitic fluid in tuberculous ascites, and this finding can help differentiate tuberculous peritonitis from peritoneal carcinomatosis. An enzyme-linked immunospot assay (ELISPOT) and PCR assay (Xpert MTB/RIF) are novel, rapid, noninvasive tests for M. tuberculosis. Tuberculous peritonitis may also appear as a pelvic mass on CT, with high serum levels of CA125, making the diagnosis difficult to distinguish from metastatic ovarian cancer.
2.I期とII期の非小細胞肺癌(NSCLC)の放射線療法に関する以下の文章を和訳しなさい。
There is currently no role for postoperative radiation therapy in patients following resection of stage I or II NSCLC with negative margins. However, patients with stage I and II disease who either refuse or are not suitable candidates for surgery should be considered for radiation therapy with curative intent. Stereotactic body radiation therapy (SBRT) is a technique used to treat patients with isolated pulmonary nodules (≤5 cm) who are not candidates for or refuse surgical resection. Treatment is typically administered in three to five fractions delivered over 1-2 weeks. In uncontrolled studies, disease control rates are >90%, and 5-year survival rates of up to 60% have been reported with SBRT. By comparison, survival rates typically range from 13 to 39% in patients with stage I or II NSCLC treated with standard external-beam radiotherapy. Cryoablation is another technique occasionally used to treat small, isolated tumors (i.e., ≤3 cm). However, very little data exist on long-term outcomes with this technique.

2021年度初期臨床研修医採用試験 (2020年8月22日)

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Ⅰ.家族性地中海熱に関する以下の文章を和訳しなさい。
Familial Mediterranean fever (FMF), an autosomal recessive disease, is characterized by recurrent self-limited attacks of fever, joint pain, and abdominal pain, most commonly in people of Mediterranean origin. The gene responsible for FMF, MEFV on chromosome 16, encodes the protein pyrin. MEFV gene analysis assists in diagnosis. Patients develop what appears to be an acute abdomen due to peritonitis. Their severe abdominal pain is reduced by lying motionless with hips flexed. The abdomen is rigid with rebound tenderness, reduced bowel sounds, and abdominal distension. There may be multiple air-fluid levels, a leukocytosis with a left shift, an increased ESR, and elevated acute-phase reactants. The attack begins to subside after 24 hours. Peritonitis results in protein- rich sterile exudates with fibrin and neutrophils that, when organized, may lead to adhesions and small bowel obstruction, sometimes with strangulation and necrosis. Patients are asymptomatic between episodes, although acute-phase reactants may be elevated, indicating subclinical inflammation. Serum amyloid concentration increases dramatically during febrile attacks. AA amyloidosis may develop independent of the frequency, duration, and intensity of flare-ups. Kidney impairment is the most clinically significant result, but amyloid can deposit in the GI tract and cause symptoms after many years. FMF is associated with other diseases such as IBD, some vasculitides, and irritable bowel syndrome. GI mucosal involvement may suggest IBD but mucosal healing can be achieved with colchicine alone.
Ⅱ.心不全と間質線維化に関する以下の文章を和訳しなさい。
Heart failure is accompanied by the progressive accumulation of interstitial collagen fibers, which decrease the myocardial contractility and compliance, and therefore cause ventricular systolic and/or diastolic dysfunction. The exact mechanism of these fibrotic changes is still unclear, but there are two main theories. First, it is thought that a reactive collagen fiber accumulation occurs in the interstitium and perivascular regions and leads to fibrotic changes. On the other hand, an adaptive, reparative fibrosis due to myocyte loss is suspected. Not only the amount of the cardiac collagen changes in heart failure, but also the quality with a shift from insoluble to soluble collagen, leading to reduced myocardial cross-linking and therefore an impaired ventricular contraction. The formed fibrotic tissue is a dynamic structure, metabolically active, contractile, and is able to adapt to changing circumstances. Due to interstitial fibrosis, the capillary density also reduces, which results in an impaired oxygen supply of the tissues and therefore hypoxia-induced structural changes and apoptosis/necrosis of the cells.

2021年度初期臨床研修医採用試験(2020年8月29日)

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Ⅰ.血管浮腫に関する以下の文章を和訳しなさい。
Recurrent angioedema of the skin is a commonly diagnosed clinical symptom that can be seen in various clinical entities. Some types of angioedema of the skin are associated with episodes of upper-airway obstruction that might be life-threatening. Asphyxiation by laryngeal oedema is well known in hereditary angioedema (HAE) due to C1-inhibitor (deficiency) and in recurrent angioedema induced by angiotensin-converting-enzyme (ACE) inhibitors. Therefore, the exact type of angioedema must be identified in each patient. In many patients, angioedema is associated with urticaria. If relapsing urticaria occurs simultaneously or otherwise with angioedema, the two disorders are assumed to be symptoms of the same disease. Recurrent angioedema without urticaria can result from inherited or acquired C1-inhibitor deficiency, or be induced by ACE inhibitors. HAE due to C1-inhibitor deficiency is not associated with urticaria, whereas ACE inhibitors may cause recurrent angioedema alone, or in association with urticaria. In recurrent angioedema C1-inhibitor deficiency, antihistamines and corticosteroids are not effective. Other types of angioedema without urticaria are rare and include local angioedema secondary to physical stress, such as vibratory angioedema. Some patients with recurrent angioedema have clinical symptoms that cannot be ascribed to one of these disorders. This type of angioedema is referred to as idiopathic angioedema.
Ⅱ.Covid-19入院患者におけるデキサメタゾン使用に関する以下の文章を和訳しなさい。
In this controlled, open-label trial comparing a range of possible treatments in patients who were hospitalized with Covid-19, we randomly assigned patients to receive oral or intravenous dexamethasone (at a dose of 6 mg once daily) for up to 10 days or to receive usual care alone. The primary outcome was 28-day mortality. Here, we report the preliminary results of this comparison. A total of 2104 patients were assigned to receive dexamethasone and 4321 to receive usual care. Overall, 483 patients (22.9%) in the dexamethasone group and 1110 patients (25.7%) in the usual care group died within 28 days after randomization (age-adjusted rate ratio, 0.83; 95% confidence interval [CI], 0.75 to 0.93; P<0.01). The proportional and absolute between-group differences in mortality varied considerably according to the level of respiratory support that the patients were receiving at the time of randomization. In the dexamethasone group, the incidence of death was lower than that in the usual care group among patients receiving invasive mechanical ventilation (29.3% vs. 41.4%; rate ratio, 0.64; 95% CI, 0.51 to 0.81) and among those receiving oxygen without invasive mechanical ventilation (23.3% vs. 26.2%; rate ratio, 0.82; 95% CI, 0.72 to 0.94) but not among those who were receiving no respiratory support at randomization (17.8% vs. 14.0%; rate ratio 1.19; 95% CI, 0.91 to 1.55). In patients hospitalized with Covid-19, the use of dexamethasone resulted in lower 28-day mortality among those who were receiving either invasive mechanical ventilation or oxygen alone at randomization but not among those receiving no respiratory support.

2021年度初期臨床研修医採用試験(2020年9月5日)

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1.結核性腹膜炎に関する以下の文章を和訳しなさい。
Tuberculous peritonitis is an uncommon site of extrapulmonary infection caused by M. tuberculosis. Patients with HIV infection, cirrhosis, diabetes mellitus, and underlying malignancy are at increased risk. Noncirrhotic patients with tuberculous peritonitis usually have ascites with a high protein content, low glucose concentration, and a low serum-to-ascites albumin gradient (<1.1 g/dL). Patients almost always have an elevated ascitic fluid WBC count with a lymphocytic predominance. The algorithm in evaluation of patients with ascitic fluid that has a high lymphocyte count includes cytologic evaluation of the fluid and consideration of laparoscopy. Patients with lymphocytic ascites and fever usually have TB, whereas afebrile patients usually have malignancy-related ascites. Cancer is the cause of lymphocytic ascites about 10 times more frequently than TB. If peritoneal metastases are present, the cytologic findings are positive more than 90% of the time, and the laparoscopy can be avoided. If the cytology is negative, however, laparoscopy is performed and is nearly 100% sensitive in detecting tuberculous peritonitis. However, a number of noninvasive diagnostic tests are available to diagnose extrapulmonary disease. Adenosine deaminase levels are typically elevated in the ascitic fluid in tuberculous ascites, and this finding can help differentiate tuberculous peritonitis from peritoneal carcinomatosis. An enzyme-linked immunospot assay (ELISPOT) and PCR assay (Xpert MTB/RIF) are novel, rapid, noninvasive tests for M. tuberculosis. Tuberculous peritonitis may also appear as a pelvic mass on CT, with high serum levels of CA125, making the diagnosis difficult to distinguish from metastatic ovarian cancer.
2.I期とII期の非小細胞肺癌(NSCLC)の放射線療法に関する以下の文章を和訳しな さい。
There is currently no role for postoperative radiation therapy in patients following resection of stage I or II NSCLC with negative margins. However, patients with stage I and II disease who either refuse or are not suitable candidates for surgery should be considered for radiation therapy with curative intent. Stereotactic body radiation therapy (SBRT) is a technique used to treat patients with isolated pulmonary nodules (≤5 cm) who are not candidates for or refuse surgical resection. Treatment is typically administered in three to five fractions delivered over 1-2 weeks. In uncontrolled studies, disease control rates are >90%, and 5-year survival rates of up to 60% have been reported with SBRT. By comparison, survival rates typically range from 13 to 39% in patients with stage I or II NSCLC treated with standard external-beam radiotherapy. Cryoablation is another technique occasionally used to treat small, isolated tumors (i.e., ≤3 cm). However, very little data exist on long-term outcomes with this technique.

2020年度初期臨床研修医採用試験(2019年8月17日)

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Ⅰ.Measlesに関する以下の文章を和訳しなさい。(下線部の訳は下記を参照すること)
Measles is an acute viral illness that starts with a prodromal phase, lasting 2 to 4 days, of fever and at least one of the “three Cs” (cough, coryza, and conjunctivitis), similar to any upper respiratory tract infection. The characteristic measles rash — an erythematous maculopapular exanthema — appears 2 to 4 days after the onset of fever, first on the face and head and then on the trunk and extremities; it may be confluent on the face and upper body. During the ensuing 3 to 5 days, the rash in different parts of the body fades in the order in which it appeared, and full recovery occurs within 7 days after rash onset in uncomplicated cases. Koplik spots, small bluish white plaques on the buccal mucosa, are present in up to 70% of cases and are considered pathognomonic of measles; they may appear 1 to 2 days before the onset of rash and may be present for an additional 1 to 2 days after rash onset. Complications associated with measles infection in industrialized countries include otitis media (7 to 9% of patients), pneumonia (1 to 6%), diarrhea (8%), postinfectious encephalitis (approximately 1 per 1000), subacute sclerosing panencephalitis (a progressive degenerative disease with onset usually 5 to 10 years after acute measles; approximately 1 per 10,000), and death (approximately 1 per 1000). an erythematous maculopapular exanthema:紅斑性丘疹 pathognomonic :(疾患に)特徴的な
Ⅱ.僧帽弁逸脱に関する以下の文章を和訳しなさい。
Mitral Valve Prolapse (MVP) is a common disorder afflicting 2-3% of the general population. It is characterized by typical fibromyxomatous changes in the mitral leaflet tissue with superior displacement of one or both leaflets into the left atrium. MVP can be associated with significant mitral regurgitation (MR), bacterial endocarditis, congestive heart failure, and even sudden death. MVP is a clinical entity that is not fully understood, despite being known for more than a century. A ‘mid-systolic click’ was first described in 1887 by Cuffer and Barbillon. In 1963 Barlow demonstrated the presence of MR by angiography in patients with the ‘click-murmur’ syndrome. Criley subsequently coined the term mitral valve prolapse. MVP may be familial or sporadic. Despite being the most common cause of isolated MR requiring surgical repair, little is known about the genetic mechanisms underlying the pathogenesis and progression of MVP. Studies on the heritable features of MVP have been limited by the analysis of relatively small pedigrees and by self-referral and selection biases, including a preponderance of data from hospital-based cohorts. Nonetheless, a majority of data favors an autosomal dominant pattern of inheritance in a large proportion of individuals with MVP. Despite the variability in the clinical features, familial MVP might be considered a prevalent Mendelian cardiac abnormality in humans. While filamin A has been identified as causing an X-linked form of MVP, the causative genes for the more common form of autosomal dominant MVP have yet to be defined.

2020年度初期臨床研修医採用試験 (2019年8月24日)

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Ⅰ.急性大動脈解離に関する以下の文章を和訳しなさい。
Acute aortic dissection is a rare but life-threatening condition with a lethality rate of 1 to 2% per hour after onset of symptoms in untreated patients. Therefore, its prompt and proper diagnosis is vital to increase a patient’s chance of survival and to prevent grievous complications. Typical symptoms of acute aortic dissection include severe chest pain, hypotension or syncope and, hence, mimic acute myocardial infarction or pulmonary embolism. Advanced age, male gender, long-term history of arterial hypertension and the presence of aortic aneurysm confer the greatest population attributable risk. However, patients with genetic connective tissue disorders such as Marfan, Loeys Dietz or Ehlers Danlos syndrome, and patients with bicuspid aortic valves are at the increased risk of aortic dissection at a much younger age. Imaging provides a robust foundation for diagnosing acute aortic dissection, as well as for monitoring of patients at increased risk of aortic disease. As yet, easily accessible blood tests play only a small role but have the potential to make diagnosis and monitoring of patients simpler and more cost-effective.
Ⅱ.レジオネラ肺炎に関する以下の文章を和訳しなさい。
Legionnaires’ disease is often included in the differential diagnosis of “atypical pneumonia,” along with pneumonia due to C. pneumoniae, Chlamydia psittaci, Mycoplasma pneumoniae, Coxiella burnetii, and some viruses. The clinical similarities among “atypical” pneumonias include a nonproductive cough with a low frequency of grossly purulent sputum. The clinical manifestations of Legionnaires’ disease are usually more severe than those of most “atypical” pneumonias. The course and prognosis of Legionella pneumonia more closely resemble those of bacteremic pneumococcal pneumonia than those of pneumonia due to other “atypical” pathogens. Patients with community-acquired Legionnaires’ disease are significantly more likely than patients with pneumonia of other etiologies to be admitted to an intensive care unit (ICU) on presentation. The mild cough of Legionnaires’ disease is only slightly productive. Sometimes the sputum is streaked with blood. Chest pain – either pleuritic or nonpleuritic – can be a prominent feature and, when coupled with hemoptysis, can lead to an incorrect diagnosis of pulmonary embolism. Shortness of breath is reported by one-third to one-half of patients. Gastrointestinal difficulties are often pronounced; abdominal pain, nausea, and vomiting affect 10-20% of patients. Diarrhea (watery rather than bloody) is reported in 25-50% of cases. The most common neurologic abnormalities are confusion or changes in mental status.

2020年度初期臨床研修医採用試験(2019年8月31日)

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Ⅰ.腹部身体所見に関する以下の文章を和訳しなさい。
Physical examination should include an assessment for signs of systemic disease. The presence of lymphadenopathy, especially supraclavicular lymphadenopathy (Virchow’s node), suggests metastatic abdominal malignancy. The abdominal examination should begin with inspection for the presence of uneven distention or an obvious mass. Auscultation should follow. The absence of bowel sounds or the presence of high-pitched localized bowel sounds points toward an ileus or intestinal obstruction. An umbilical venous hum may suggest the presence of portal hypertension, and a harsh bruit over the liver is heard rarely in patients with hepatocellular carcinoma or alcoholic hepatitis. Abdominal swelling caused by intestinal gas can be differentiated from swelling caused by fluid or a solid mass by percussion; an abdomen filled with gas is tympanic, whereas an abdomen containing a mass or fluid is dull to percussion. The absence of abdominal dullness, however, does not exclude ascites, because a minimum of 1500 mL of ascitic fluid is required for detection on physical examination. Finally, the abdomen should be palpated to assess for tenderness, a mass, enlargement of the spleen or liver, or presence of a nodular liver suggesting cirrhosis or tumor. Light palpation of the liver may detect pulsations suggesting retrograde vascular flow from the heart in patients with right-sided heart failure, particularly tricuspid regurgitation.
Ⅱ.結核(TB)の薬物療法に関する以下の文章を和訳しなさい。
The two aims of TB treatment are (1) to prevent morbidity and death by curing TB while preventing the emergence of drug resistance and (2) to interrupt transmission by rendering patients noninfectious. Chemotherapy for TB became possible with the discovery of streptomycin in 1943. Randomized clinical trials clearly indicated that the administration of streptomycin to patients with chronic TB reduced mortality rates and led to cure in the majority of cases. However, monotherapy with streptomycin eventually was associated with the development of resistance to this drug and the resulting failure of treatment. With the introduction into clinical practice of paraaminosalicylic acid (PAS) and isoniazid, it became axiomatic in the early 1950s that cure of TB required the concomitant administration of at least two agents to which the organism was susceptible. Furthermore, early clinical trials demonstrated that a long period of treatment―i.e., 12-24 months―was required to prevent recurrence. The introduction of rifampin (rifampicin) in the early 1970s heralded the era of effective short-course chemotherapy, with a treatment duration of <12 months. The discovery that pyrazinamide, which was first used in the 1950s, augmented the potency of isoniazid/rifampin regimens led to the use of a 6-month course of this triple-drug regimen as standard therapy.

2019年度初期臨床研修医採用試験(平成30年8月18日)

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Ⅰ.管腔臓器の閉塞に関する以下の文章を和訳しなさい。
Intraluminal obstruction classically elicits intermittent or colicky abdominal pain that is not as well localized as the pain of parietal peritoneal irritation. However, the absence of cramping discomfort should not be misleading because distention of a hollow viscus may also produce steady pain with only rare paroxysms. Small-bowel obstruction often presents as poorly localized, intermittent periumbilical or supraumbilical pain. As the intestine progressively dilates and loses muscular tone, the colicky nature of the pain may diminish. With superimposed strangulating obstruction, pain may spread to the lower lumbar region if there is traction on the root of the mesentery. The colicky pain of colonic obstruction is of lesser intensity, is commonly located in the infraumbilical area, and may often radiate to the lumbar region. Sudden distention of the biliary tree produces a steady rather than colicky type of pain; hence, the term biliary colic is misleading. Acute distention of the gallbladder usually causes pain in the right upper quadrant with radiation to the right posterior region of the thorax or to the tip of the right scapula, but it is also not uncommonly found near the midline. Distention of the common bile duct often causes epigastric pain that may radiate to the upper lumbar region. Considerable variation is common, however, so that differentiation between these may be impossible. The typical subscapular pain or lumbar radiation is frequently absent.
Ⅱ.慢性空洞性肺アスペルギルス症に関する以下の文章を和訳しなさい。
The hallmark of chronic cavitary pulmonary aspergillosis is one or more pulmonary cavities expanding over a period of months or years in association with pulmonary symptoms and systemic manifestations such as fatigue and weight loss. (Pulmonary aspergillosis developing over <3 months is better classified as subacute invasive aspergillosis.) Often mistaken initially for tuberculosis, almost all cases occur in patients with prior pulmonary disease (e.g., tuberculosis, atypical mycobacterial infection, sarcoidosis, rheumatoid lung disease, pneumothorax, bullae) or lung surgery. The onset is insidious, and systemic features may be more prominent than pulmonary symptoms. Cavities may have a fluid level or a well-formed fungal ball, but pericavitary infiltrates and multiple cavities―with or without pleural thickening―are typical. An irregular internal cavity surface and thickened cavity walls are indicative of disease activity. IgG antibodies to Aspergillus are almost always detectable in blood, and levels fall slowly with successful therapy. Some patients have concurrent infections―even without a fungal ball―with atypical mycobacteria and/or other bacterial pathogens. One or more Aspergillus nodules that resemble early lung carcinoma and may cavitate have been recognized. If untreated, chronic pulmonary aspergillosis typically progresses (sometimes relatively rapidly) to unilateral or upper lobe fibrosis.

2019年度初期臨床研修医採用試験 (平成30年8月25日)

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Ⅰ.Fever of unknown origin (FUO)に関する以下の文章を和訳しなさい。
The differential diagnosis of fever of unknown origin (FUO) can be subdivided in four categories: infections, malignancies, noninfectious inflammatory diseases (NIID), and miscellaneous causes. In Western countries, infections account for one-fifth of FUO cases, with next in frequency NIID and malignancies. In non-Western countries, infections (mostly tuberculosis) are a much more common cause of FUO (43% vs 17%) with similar cases due to NIID and malignancies. In most cases of FUO, there is an uncommon presentation of a common disease. Important for diagnosing FUO is a search for potentially diagnostic clues (PDCs) in a complete and repeated history-taking, physical examination, and the essential investigations. PDCs are defined as all localizing signs, symptoms, and abnormalities potentially indicating a certain diagnosis. Based on these PDCs, a limited list of probable diagnosis can be made. Further diagnostic procedures should be limited to specific investigations to confirm or exclude these possible diseases, because most investigations are helpful only when performed in patients with PDCs for the diagnosis searched for. When PDCs are absent, FDG-PET/CT should be performed to guide additional diagnostic tests. In case of negative FDG-PET/CT and persisting FUO, it is probably more rewarding to wait for new PDCs to appear than immediately perform more screening investigations.
Ⅱ.壁側腹膜の炎症に関する以下の文章を和訳しなさい。
The pain of parietal peritoneal inflammation is steady and aching in character and is located directly over the inflamed area, its exact reference being possible because it is transmitted by somatic nerves supplying the parietal peritoneum. The intensity of the pain is dependent on the type and amount of material to which the peritoneal surfaces are exposed in a given time period. For example, the sudden release into the peritoneal cavity of a small quantity of sterile1) acid gastric juice causes much more pain than the same amount of grossly contaminated neutral feces. Enzymatically active pancreatic juice incites more pain and inflammation than does the same amount of sterile bile containing no potent enzymes. Blood is normally only a mild irritant and the response to urine can be bland2), so exposure of blood and urine to the peritoneal cavity may go unnoticed unless it is sudden and massive. Bacterial contamination, such as may occur with pelvic inflammatory disease or perforated distal intestine, causes low-intensity pain until multiplication causes a significant amount of inflammatory mediators to be released. Patients with perforated upper gastrointestinal ulcers may present entirely differently depending on how quickly gastric juices enter the peritoneal cavity. Thus, the rate at which any inflammatory material irritates the peritoneum is important. 1)無菌の 2)刺激の少ない

2019年度初期臨床研修医採用試験(平成30年9月1日)

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Ⅰ.心臓突然死に関する以下の文章を和訳しなさい。
It is indisputable that sudden cardiac death (SCD) has been and remains a major population burden, even though there have been some notable advances over the years. Examples of the latter include a rapid 50% reduction in mortality from acute myocardial infarction after the development of coronary care units with antiarrhythmic therapy and bedside defibrillators, improvements in resuscitation sciences, and the development and use of implantable cardioverter-defibrillators in a subgroup of appropriately identified high-risk patients. Despite these advances, the opportunities offered by better capabilities for prediction and prevention of cardiac arrest remain an important challenge because ≈90% of victims of sudden cardiac arrest (SCA) occurring out of hospital do not survive, premature SCD and disabilities after SCA survival are a large burden on society because of loss of productive years of life, and healthcare costs attributed to SCA are large and growing. We, as scientific, clinical, and epidemiological communities, have not been successful in addressing many aspects of this challenge. Even elements that intuitively seem simple, such as generating reliable numbers for both events and causes, have been difficult, although they are a key first step for moving from population dynamics to improved individual risk prediction.
Ⅱ.Cough-variant asthmaに関する以下の文章を和訳しなさい。
The typical symptoms of asthma are intermittent episodes of wheezing, chest tightness, breathlessness, and cough. However, a subset of asthmatics will have cough-variant asthma, which manifests as a chronic cough as the only symptom with an otherwise normal physical examination. In studies of patients with chronic cough and a normal chest radiograph, asthma accounted for approximately one-third of all causes. Cough-variant asthma is more common in studies done in China, where it is the most common cause of chronic cough. In patients suspected of having cough-variant asthma, pulmonary function test (PFT) is the initial test and should include forced expiratory volume in 1 second (FEV 1), forced vital capacity (FVC), and FEV 1 -to-FVC ratio. The presence of an airway obstruction that improves after the administration of a bronchodilator agent is highly suggestive of asthma. The authors also recommend simultaneously assessing lung volume and diffuse capacity, in case the airway obstruction is irreversible, which would point toward a diagnosis of COPD. Failure to demonstrate a reversible airway obstruction does not exclude the diagnosis of asthma, and bronchoprovocation testing1), such as the methacholine2) inhalation challenge, can be considered to confirm the diagnosis. The negative predictive value of a methacholine challenge test is reported to be close to 100, so a negative result essentially rules out asthma. According to the American College of Chest Physicians (ACCP), if methacholine challenge is not available or cannot be performed, empiric antiasthma treatment is indicated. 1)気管支吸入誘発試験 2)メタコリン

平成30年度初期臨床研修医採用試験(平成29年8月12日)

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Ⅰ.糖尿病性足潰瘍に関する以下の文章を和訳しなさい。
The natural history of a diabetes-related foot ulcer is sobering. The risk of death at 5 years for a patient with a diabetic foot ulcer is 2.5 times as high as the risk for a patient with diabetes who does not have a foot ulcer. More than half of diabetic ulcers become infected. Approximately 20% of moderate or severe diabetic foot infections lead to some level of amputation. Peripheral artery disease independently increases the risk of nonhealing ulcers, infection, and amputation. Mortality after diabetes-related amputation exceeds 70% at 5 years for all patients with diabetes and 74% at 2 years for those receiving renal-replacement therapy. Whether such a high mortality is due to a combination of coexisting conditions (including the risk from an amputation procedure), lack of activity, and deconditioning or to other factors is not clear. The risk of death at 10 years for a patient with diabetes who has had a foot ulcer is twice as high as the risk for a patient who has not had a foot ulcer. A recent assessment of 785 million outpatient visits by people with diabetes in the United States between 2007 and 2013 suggested that diabetic foot ulcers and associated infections constitute a powerful risk factor for emergency department visits and hospital admission. The rate exceeds the rates for congestive heart failure, renal disease, depression, and most forms of cancer.
Ⅱ.縦隔腫瘍に関する以下の文章を和訳しなさい。
The first step in evaluating a mediastinal mass is to place it in one of the three mediastinal compartments, since each has different characteristic lesions. The most common lesions in the anterior mediastinum are thymomas, lymphomas, teratomatous neoplasms, and thyroid masses. The most common masses in the middle mediastinum are vascular masses, lymph node enlargement form metastases or granulomatous disease, and pleuropericardial and bronchogenic cysts. In the posterior mediastinum, neurogenic tumors, meningoceles, meningomyeloceles, gastroenteric cysts, and esophageal diverticula are commonly found. Computed tomography (CT) scanning is the most valuable imaging technique for evaluating mediastinal masses and is the only imaging technique that should be done in most instances. A definite diagnosis can be obtained with mediastinoscopy or anterior mediastinotomy in many patients with masses in the anterior or middle mediastinal compartments. A diagnosis can be established without thoracotomy via percutaneous fine-needle aspiration biopsy or endoscopic transesophageal or endobronchial ultrasound-guided biopsy of mediastinal masses in most cases. An alternative way to establish the diagnosis is video-assisted thoracoscopy. In many cases, the diagnosis can be established and the mediastinal mass removed with video-assisted thoracoscopy.   (mediastinotomy:縦隔切開術)

平成30年度初期臨床研修医採用試験 (平成29年8月26日)

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Ⅰ.Ⅲ期非小細胞肺癌(NSCLC)の治療に関する以下の文章を和訳しなさい。
Treatments for stage III NSCLC should not be withheld on the basis of age alone, although decisions should take comorbidity and performance status into consideration. Combined-modality therapy can be beneficial in selected older adult patients, although it is associated with an increase in toxicity. This was illustrated by a Japanese trial, in which 200 patients older than 70 years with unresectable stage III NSCLC were randomly assigned to chemoradiotherapy with radiation therapy (RT) plus concurrent carboplatin or RT alone. RT consisted of 60 Gy in 30 fractions over six weeks for both groups. At a median follow-up of 19 months, the combined-modality approach significantly prolonged overall survival. Secondary analyses of older adult patients enrolled in larger trials also support the use of concurrent chemoradiotherapy in carefully selected, fit patients. These analyses of multicenter trials have focused on older adult patients with particularly good performance status. However, the findings may not be applicable to patients with an impaired performance status. Furthermore, older adult patients treated with chemotherapy and/or RT may be at increased risk of cardiac disorders, even if they were free of such problems prior to the diagnosis of NSCLC.
Ⅱ.非閉塞性(血管攣縮性)腸管膜虚血に関する以下の文章を和訳しなさい。
Superior vena cava syndrome (SVCS) is the clinical manifestation of superior vena cava (SVC) obstruction, with severe reduction in venous return from the head, neck, and upper extremities. Malignant tumors, such as lung cancer, lymphoma, and metastatic tumors, are responsible for the majority of SVCS cases. With the expanding use of intravascular devices (e.g., permanent central venous access catheters, pacemaker/defibrillator leads), the prevalence of benign causes of SVCS is increasing now, accounting for at least 40% of cases. Lung cancer, particularly of small cell and squamous cell histologies, accounts for approximately 85% of all cases of malignant origin. In young adults, malignant lymphoma is a leading cause of SVCS. Hodgkin’s lymphoma involves the mediastinum more commonly than other lymphomas but rarely causes SVCS. When SVCS is noted in a young man with a mediastinal mass, the differential diagnosis is lymphoma vs primary mediastinal germ cell tumor. Metastatic cancers to the mediastinum, such as testicular and breast carcinomas, account for a small proportion of cases.

平成30年度初期臨床研修医採用試験(平成29年9月2日)

次の各問いに対する答えを解答用紙に記入しなさい。

Ⅰ.転移性乳癌の治療法に関する以下の文章を和訳しなさい。
In contrast with early breast cancer, metastatic breast cancer is considered incurable with currently available therapies. Based on data from 1996, long-term survivors do exist but are very rare - ie, less than 5%. Whether and how this percentage will change with current therapies that have shown an overall survival advantage is still unknown. Nowadays, patients with metastatic breast cancer differ substantially from patients 10-20 years ago and are much more difficult to treat because they have usually received very potent adjuvant therapies. Consequently, results from therapy trials started several years ago might not be completely transferable to current patients. Nevertheless, trials published since 2012, particularly in HER2-positive disease, have shown not just prolongation of progression-free survival, but also overall survival. These results indicate that the concept of metastatic breast cancer as a chronic disease controlled by sequential therapies over a long period is realistic, at least for certain subgroups. Next to prolongation of survival, therapeutic goals in metastatic breast cancer are maintenance of quality of life and palliation of symptoms. Therapy concepts are usually more individualised in metastatic breast cancer than in early breast cancer, since patients differ regarding preferences, pretreatments, and residual side-effects from previous therapies. Tumour biology is important together with duration of response to previous therapies and tumour burden with associated symptoms. Therapy concepts used to be decided by a multidisciplinary team right from the beginning. (注)adjuvant therapies: アジュバント療法 (注)HER2-positive: HER2(human epidermal growth factor receptor 2)陽性
Ⅱ.心不全と脳機能障害に関する以下の文章を和訳しなさい。
Acute heart failure (HF) may present as significant cerebral dysfunction. However, other explanations for these findings must be ruled out first. Considering the high prevalence of comorbidities and frequent use of antithrombotic therapy in the HF population, both acute cerebral ischemic and hemorrhagic events should always be included in the differential diagnosis. Similarly, metabolic and electrolyte imbalances should be considered, and the susceptibility of these patients to infection and sepsis cannot be ignored. Alcohol toxicity deserves special consideration because it may produce both cardiac and brain injury. Stabilization of acute HF with attempted normalization of blood pressure while avoiding possible damage to cerebral perfusion and function is therefore recommended. A recent study has shown that post-discharge 30-day mortality and readmission rates were strongly influenced by the presence of cognitive impairment (CI). Accordingly, overlooking the presence of this correctable condition might impact patients’ adherence to therapy, which could have a deleterious effect on outcomes.
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