多裂肌退变与腰椎滑脱患者腰背痛的相关性分析

目的研究多裂肌退变与腰椎滑脱患者腰背痛的相关性,为腰背痛的诊断与治疗提供理论依据。方法纳入2016-06-2017-06诊治的82例腰椎滑脱患者,均进行腰椎MRI检查,测量两侧多裂肌横截面积平均值以及L5椎体的横截面积,两者比值为多裂肌萎缩值。根据MRI横截面L5水平T2加权图像进行多裂肌脂肪浸润分级,将0～1级设为对照组,2～3级设为观察组;比较两组患者ODI指数、VAS评分,采用Pearson相关分析法进行多裂肌萎缩值、脂肪浸润分级与ODI指数、VAS评分的相关性分析。结果观察组多裂肌萎缩值、脂肪浸润分级均显著高于对照组(P0.05);观察组VAS评分、ODI指数均显著高于对照组(P0.05)。多裂肌萎缩值与VAS评分、ODI指数均呈负相关(P0.05),多裂肌脂肪浸润分级与VAS评分、ODI指数均呈正相关(P0.05)。结论多裂肌退变严重程度与腰椎滑脱患者腰背痛疼痛程度具有明显相关性,多裂肌退变越严重,腰背疼痛以及腰椎功能障碍越重。     

退变性腰椎滑脱患者腰部多裂肌退变与腰背痛的相关性研究

目的分析退变性腰椎滑脱患者腰椎多裂肌退变程度与其视觉模拟疼痛评分(visual analogue score,VAS)以及Oswestry功能障碍指数(Oswestry disability index,ODI)的相关性。方法回顾性分析64例患者,男性24例,女性40例;年龄45~84岁,平均(63.02±10.59)岁。通过腰椎MRI测量患者两侧多裂肌平均横截面积与第5腰椎椎体横截面积比值,通过多裂肌内脂肪浸润面积比例将患者分为0、1、2、3共四级,将0、1级患者分为A组,2、3级为B组,并对两组间VAS及ODI评分进行比较,对多裂肌萎缩程度、脂肪浸润分级与VAS、ODI评分进行相关性分析。结果 64例患者多裂肌萎缩值平均为(0.78±0.05)。多裂肌脂肪浸润分级为:0级6例,1级11例,2级20例,3级27例。所有患者VAS评分平均(5.3±1.4)分,ODI评分平均(47.1±13.5)%。A组VAS评分平均(4.7±1.9)分,ODI评分平均(33.7±8.6)%。B组VAS评分平均(5.8±1.4)分,ODI评分平均(53.2±9.3)%。A组VAS评分低于B组(P=0.016),A组ODI评分也低于B组(P=0.009)。多裂肌萎缩值与VAS及ODI评分具有负相关性(r=-0.43,P=0.024;r=-0.49,P=0.004),而脂肪浸润分级与VAS及ODI评分具有正相关性(r=0.53,P=0.019;r=0.44,P=0.015)。结论退变性腰椎滑脱患者多裂肌退变程度与腰背痛程度存在相关性。严重的多裂肌退变程度预示着更严重的腰背痛及功能障碍。     

磁共振成像下退变性腰椎滑脱不同节段多裂肌改变的研究

[目的]以MRI为评估方法比较退变性腰椎滑脱患者不同节段多裂肌改变,并分析其与腰椎滑脱之间关系。[方法]选取退变性腰椎滑脱患者88例,其中L_3滑脱6例(Ⅰ度滑脱6例),L_4滑脱62例(Ⅰ度滑脱53例,Ⅱ度滑脱9例),L_5滑脱20例(Ⅰ度滑脱16例,Ⅱ度滑脱4例);年龄45~65岁,男性24例,女性64例;同时选取20例无症状志愿者作为对照组:年龄45~65岁,男性5例,女性15例。测得所有纳入对象性别、年龄、体重指数(BMI)无差异,并对纳入患者进行ODI下腰痛量表评分(Oswestry disability index)。通过腰椎MRI,测量并计算所有纳入对象L_(3、4),L_(4、5),L_5S_1椎间隙水平层面多裂肌净横截面面积占多裂肌区域横截面面积的比值,LCSA/GCSA(the ratio of the lean mutifidus muscle cross sectional area to gross mutifidus muscle cross sectional area)。对所有滑脱患者与正常对照组测得定量数据应用两独立样本t检验进行统计分析,对L_4滑脱不同滑脱程度之间数据应用两独立样本t检验进行统计分析;分类资料用x~2检验进行统计分析。应用方差分析比较同一滑脱节段三个层面比值间是否存在差异,不同滑脱节段相同层面间是否存在差异;应用Pearson线性分析,就滑脱节段与非滑脱节段进行相关性分析。[结果]所有滑脱患者三个不同层面数据与正常对照组之间差异具有统计学意义(P0.05),L_4滑脱患者不同程度滑脱组三个不同层面之间差异具有统计学意义(P0.05),L_4滑脱与L_5滑脱三个不同层面之间差异具有统计学意义(P0.05),滑脱层面与非滑脱层面存在差异,三组滑脱患者在L_(3、4)层面差异无统计学意义(P0.05),其余层面差异具有统计学意义(P0.05)。L_4及L_5滑脱患者非滑脱节段与滑脱节段之间存在相关性(P0.05)。[结论]腰椎滑脱患者,其多裂肌整体会发生退变,多裂肌存在脂肪浸润,肌肉出现萎缩。同时随着滑脱的进展,多裂肌退变将加重。在年龄、BMI、症状及病因相似的情况下,滑脱节段多裂肌退变最为严重,可能是引起相应节段发生滑脱的原因之一。同时非滑脱节段多裂肌也会因此发生退变。     

腰椎管狭窄症患者椎旁肌形态与其Oswestry功能障碍指数的相关性分析

目的探讨退变性腰椎管狭窄症(degenerative lumbar spinal stenosis,DLSS)患者椎旁肌形态与临床症状和功能状态之间的关系。方法选择2016年1月-2018年12月在本院就诊的DLSS患者作为研究对象,采用MRI 32位Osirix多平面重建后,应用Image J软件从轴向T2加权图像中对多裂肌、直立肌和腰肌的定量测量,观察不同Oswestry功能障碍指数(oswestry dysfunction index,ODI)与患者椎旁肌定量测量的关系。结果以ODI≤24分和ODI24分将患者分为轻中度功能丧失组46例和重度功能丧失组41例。轻中度功能丧失组L_5椎板上端和下端多裂肌功能横截面积/总横截面积、L_5椎板下端直立肌总横截面积对称性和腰肌相对截面积水平均高于重度功能丧失组(P0.05); L_5上端和下端多裂肌功能横截面积/总横截面积、L_5下端腰肌相对截面积均与腰椎ODI指数均呈明显的负相关关系(P0.05)。结论多裂肌脂肪浸润和腰肌相对截面积与DLSS患者的腰椎功能障碍之间存在明显的相关性。     

长节段与短节段固定治疗退行性腰椎侧凸并椎管狭窄的短期临床疗效分析

目的分析长节段与短节段固定治疗退行性腰椎侧凸(DLS)并椎管狭窄的短期临床疗效,探索手术适应证。方法回顾性分析第二军医大学附属长征医院脊柱外科2014年1月—2015年7月收治的81例DLS并椎管狭窄患者临床资料,其中长节段组(A组)33例,手术节段为T_(10)~S_1 10例、T_(10)~L_5 4例、T_(11)~S_1 12例、T_(11)~L_5 7例;短节段组(B组)48例,手术节段为L_(2~4) 2例、L_(3,4) 4例、L_(3~5) 10例、L_(4,5) 12例、L_4~S_1 12例,L_5~S_1 8例。记录并比较术前及末次随访时腰椎侧凸Cobb角、腰椎活动度(ROM)、腰痛视觉模拟量表(VAS)评分、下肢痛VAS评分、Oswestry功能障碍指数(ODI)及并发症发生情况。结果 A组末次随访时腰椎侧凸Cobb角、腰椎ROM显著小于B组,差异有统计学意义(P0.05)。A组末次随访腰痛VAS评分及ODI显著低于B组,差异有统计学意义(P0.05);下肢痛VAS评分2组比较差异无统计学意义(P0.05)。A组围手术期出现脑脊液漏2例、切口感染2例、肺部感染1例、一过性神经根损伤1例,B组出现脑脊液漏1例、一过性神经根损伤1例。结论 2种固定方式均能有效改善DLS并椎管狭窄患者下肢疼痛及间歇性跛行症状。与短节段固定相比,长节段固定对腰痛改善效果较好,但腰椎ROM变小且围手术期并发症较多。     

椎旁肌退变对退变性腰椎侧凸短节段减压融合病人术后临床疗效的影响

目的分析椎旁肌退变程度对退变性腰椎侧凸短节段减压融合病人术后临床疗效的影响。方法退变性腰椎侧凸行短节段(≤3个节段)椎管减压椎体间融合治疗的病人53例,根据术前核磁共振是否存在椎旁肌退变分为观察组28例,对照组25例。比较两组术前术后腰椎Cob角、椎旁肌(竖脊肌、多裂肌、腰大肌)横截面积、椎旁肌脂肪化率、视觉模拟量表评分、Oswestry功能障碍指数。结果两组病人术前Cob角、VAS、ODI评分比较,差异无统计学意义(P0.05)。术后6个月两组病人Cob角与术前比较,差异有统计学意义(P0.05)。术后12个月观察组Cob角大于对照组,对照组VAS、ODI评分优于观察组,差异有统计学意义(P0.05)。观察组多裂肌和竖脊肌的凹侧横截面积与对照组比较,差异具有统计学意义(P0.05),观察组中凹侧和凸侧比较,多裂肌及竖脊肌横截面积比较差异有统计学意义(P0.05)。多裂肌脂肪化率与术后ODI评分存在显著相关性(r=0.462)。结论退变性腰椎侧凸病人术前应重视椎旁肌退变程度的评价,特别是多裂肌的脂肪化率,延长固定节段或注意加强腰背肌的锻炼,有助于缓解病人术后腰背痛。     

腰椎滑脱症术后脊柱骨盆矢状面参数变化与临床疗效的相关性分析

目的观察退行性腰椎滑脱症患者术后脊柱骨盆矢状面参数变化,并评估术后疗效,探讨脊柱骨盆矢状面参数变化与临床疗效的相关性。方法纳入自2015-06—2017-01行后路腰椎椎体间融合术(PLIF)的30例L4、5退行性腰椎滑脱症。测量手术前后脊柱骨盆矢状面参数:骨盆入射角(PI)、骨盆倾斜角(PT)、骶骨倾斜角(SS)、腰椎前凸角(LL)、滑脱程度(SD)、椎间隙高度(DH)。采用Pearson相关分析脊柱骨盆矢状面参数与ODI指数、VAS评分的相关性。结果本组30例均获得3~19(12.73±7.06)个月随访。末次随访时VAS评分、ODI指数、PT、SS、LL、SD、DH较术前明显改善,差异有统计学意义(P0.05);而PI与术前比较差异无统计学意义(P0.05)。Pearson相关分析显示,术前PT、SD与术前ODI指数、VAS评分呈正相关,SS、LL、DH与ODI指数、VAS评分呈负相关,而PI与ODI指数、VAS评分无明显相关性。手术前后PT、SS、LL、SD、DH的变化值与ODI指数及VAS评分改善率呈正相关。结论退行性腰椎滑脱症患者术后脊柱骨盆矢状面参数改变与临床疗效存在相关性,术中应尽可能恢复脊柱骨盆矢状面平衡以获得良好疗效。     

多裂肌萎缩与腰椎退行性疾病的相关性研究进展

腰椎退行性疾病是脊柱外科常见病和多发病,是引起下腰痛的主要原因^［1］,下腰痛是以腰骶、臀部伴/不伴下肢疼痛为主要症状的综合征^［2］。有研究^［3-4］发现,下腰痛的发生、发展与脊柱稳定性的失衡密切相关。椎旁肌是脊柱邻近肌群的总称,分为前群（髂腰肌、腰方肌、腰大肌）和后群（多裂肌、竖脊肌等）。椎旁肌良好的功能状态对脊柱稳定性起着重要作用。多裂肌作为腰椎稳定性的重要来源,其萎缩与腰椎椎间盘突出症、腰椎椎管狭窄症、腰椎滑脱症等腰椎退行性疾病关系密切^［5-6］。本文通过查阅多裂肌萎缩与腰椎退行性疾病的相关文献,对多裂肌萎缩的影像学变化、多裂肌萎缩与腰椎退行性疾病的关系及多裂肌的保护与治疗等方面进行分析梳理,综述如下。     

微创和传统开放后路腰椎椎间融合术治疗腰椎退行性疾病的远期预后

目的探讨微创后路腰椎椎间融合术(MIS-PLIF)和传统开放PLIF对腰椎退行性疾病(LDD)远期疗效及安全性的影响。方法 2011年1月-2014年12月收治LDD患者182例,其中96例采用传统开放PLIF治疗(PLIF组),86例采用MIS-PLIF治疗(MIS-PLIF组)。比较2组腰椎矢状位参数、多裂肌横截面积及萎缩率、融合率、疼痛视觉模拟量表(VAS)评分、日本骨科学会(JOA)评分、Oswestry功能障碍指数(ODI)及术后并发症发生情况,分析多裂肌萎缩率与顽固性腰背痛的相关性。结果 2组术后各随访时间点椎间隙高度恢复值和节段性前凸角恢复值差异均无统计学意义(P > 0.05)。2组术后1年腰椎前凸角恢复值差异无统计学意义(P > 0.05);但术后5年和末次随访时,MIS-PLIF组腰椎前凸角恢复值显著高于PLIF组,差异均有统计学意义(P < 0.05)。MIS-PLIF组术后各随访时间点多裂肌横截面积大于PLIF组,多裂肌萎缩率低于PLIF组,差异均有统计学意义(P < 0.05)。2组术后随访6个月融合率差异无统计学意义(P > 0.05)。2组术后各随访时间点下肢痛VAS评分差异无统计学意义(P > 0.05);MIS-PLIF组术后各随访时间点腰痛VAS评分、JOA评分及ODI均优于PLIF组,差异有统计学意义(P < 0.05)。MIS-PLIF组顽固性腰背痛发生率显著低于PLIF组,差异有统计学意义(P < 0.05)。合并顽固性腰背痛患者多裂肌萎缩率高于未合并顽固性腰背痛的患者,差异有统计学意义(P < 0.05)。结论术后多裂肌萎缩可能是导致顽固性腰背痛的重要原因,相较于传统开放PLIF,MIS-PLIF治疗LDD能够更有效地保持腰椎生理曲度,改善肢体活动功能,降低多裂肌萎缩程度,有助于避免顽固性腰背痛的发生。     

关节突关节倾斜度与退行性腰椎滑脱的相关性研究

目的通过研究邻近节段腰椎小关节方向探讨关节突关节倾斜度与退行性腰椎滑脱(lumbar degenerative spondylolisthesis,LDS)之间的因果关系。方法将2013年至2015年南方医院住院的120例L4~5退行性腰椎滑脱患者纳入LDS组,再选取120例L4~5峡部裂性腰椎滑脱患者纳入峡部裂腰椎滑脱(lumbar isthemic spondylolisthesisat,LIS)组,对照组(lumbar spondylolisthesis-free,LS-free组)由在南方医院进行体检的120例无脊柱疾病的人组成。基于CT图像分析腰椎关节突关节的方向。在L_(2~3)、L_(3~4)、L_(4~5)和L_5S_1的节段,测量水平面腰椎关节突关节角度,并记录年龄、身高、性别、体重等基本信息。结果峡部裂性腰椎滑脱(LIS组)各节段关节突关节角与对照组(LS-free组)差异无统计学意义(P0.05),退行性腰椎滑脱(LDS组)各节段关节突关节角与对照组(LS-free组)差异有统计学意义(P0.01)。不同程度退行性腰椎滑脱的非滑脱节段关节突关节角度之间差异无统计学意义(P0.05)。L_(3~4)与L_(4~5)关节突关节角度线性相关(R=0.575)。结论滑脱对邻近节段关节突关节角度无影响,邻近节段关节突关节角度呈线性相关。退行性腰椎滑脱关节突关节角度均小于正常人,且该小于正常人群的关节突关节角度在滑脱前已经存在,为滑脱危险因素。滑脱节段关节突关节存在滑脱后形变。     

Reduction of Plasma Fibrinogen, Immunoglobulin G, and Immunoglobulin M Concentrations by Immunoadsorption Therapy with Tryptophan and Phenylalanine Adsorbents

Abstract Immunoadsorption (1A) therapy with tryptophan (TR-350) or phenylalanine (PH-350) adsorbents has been used to reduce the concentration of serum antibodies in human lymphocyte antigen (HLA)-immunized patients. Other forms of plasma purification have been reported to reduce the level of fibrinogen, which affects the blood properties. In this study we investigated the effects of IA therapy using both adsorbents on plasma fibrinogen and immunoglobulins G and M in 13 patients (8 patients were treated with TR-350, and 5 patients were treated with PH-350). During each session 1 plasma volume (2.8 ± 0.4 L of plasma) was processed through the immunocolumn and then returned to the patient together with the blood cells. Compared with the pretreatment values, the plasma fibrinogen, IgG, and IgM concentrations were significantly reduced after IA therapy (p < 0.01 for TR-350; p < 0.04 for PH-350). There was a positive correlation between the degree of reduction of plasma proteins and the number of IA treatments given. A nonpara-metric test (Wilcoxon's signed-rank test or the Mann-Whitney test) was used for statistical analysis. We conclude from our study that IA therapy effectively lowers the plasma levels of fibrinogen, IgG, and IgM and thus can be considered a valuable alternative to other blood purification methods.     

Vasopressor hormone response following mesenteric traction during major abdominal surgery

Background : We investigated the vasopressor hormone response following mesenteric traction (MT) with hypotension due to prostacyclin (PGI₂) release in patients undergoing abdominal surgery with a combined general and epidural anesthesia. Methods : In a prospective, randomized, placebo-controlled study we administered 400 mg ibuprofen (i.v.) in 42 patients scheduled for abdominal surgery. General anesthesia was combined with epidural anesthesia (T4-L1). Before as well as 5, 15, 30, 45, and 90 min after MT we recorded plasma osmolality, hemodynamics and measured 6-keto-PGFlα (stabile metabolite of PGI₂), TXB₂ (stabile metabolite of thromboxane A₂) active renin, and arginine vasopressin (AVP) plasma concentrations by radioimmunoassay. Catecholamine levels were assessed by high-pressure liquid chromatography (HPLC) with electrochemical detection. Results : Following MT, arterial hypotension occurred along with a substantial PGI₂ release. This was completely abolished by ibuprofen administration. Although plasma levels of 6-keto-PGF_1α (1133 (708) vs. 60 (3) ng/L, median (median absolute deviation), P=0.0001, placebo vs. ibuprofen) remained significantly elevated, blood pressure was restored within 30 min after MT in the placebo group. At the same point in time plasma concentrations of TXB² (164 (87) vs. 58 (1) ng/L, P=0.0001), epinephrine (46 (33) vs. 14 (6) ng/L, P=0.001), AVP (41 ± (18) vs. 12 (7) ng/L, P=0.0004), and active renin (27 (12) vs. 12 (4) ng/L, P = 0.001) were significantly higher in placebo-treated patients. Conclusion : Under combined general and epidural anesthesia arterial hypotension following MT due to endogenous PGI₂ release is associated with enhanced release of AVP, active renin, epinephrine and thromboxane A₂, presumably contributing to hemodynamic stability within 30 min after MT.     

The multiply injured child

Blunt trauma is the principal cause of childhood death in many developed countries. This review outlines the differences between adults and children with respect to resuscitation and treatment of orthopaedic injuries in a child with polytrauma. Recent advances in techniques of fracture stabilization are reported.     

Microspheres Based Detoxification System: A New Method in Convective Blood Purification

Abstract: A variety of protein-bound or hydrophobic substances, accumulating as a result of pathologic conditions such as exogenous or endogenous intoxications, are removed poorly by conventional detoxification methods because of low accessibility (hemodialysis), insufficient adsorption capabilities (hemosorption), low efficiency (peritoneal dialysis), or economic limitations (high-volume plasmapheresis). Combining advantages of existing methods with microspheric technology, a module-based system was designed. Major operating parameters of the latter can be modified to allow for adjustment to individual clinical situations. An extracorporeal blood circuit including a plasmafilter is combined with a secondary high-velocity plasma circuit driven by a centrifugal pump. Different microspheric adsorbers can be combined in one circuit or applied in sequence. Thus, a prolonged treatment can be tailored using specially designed selective adsorber materials. Comparing this system with existing methods (high-flux hemodialysis, molecular adsorbent recycling system), results from our in vitro studies and animal experiments demonstrate the superior efficiency of substance removal.     

Development of Selective Low-Density Lipoprotein (LDL) Apheresis System: Immobilized Polyanion as LDL-Specific Adsorption for LDL Apheresis System

Abstract: Low-density lipoprotein (LDL) is widely recognized as one of the major risk factors for developing coronary heart diseases. Despite intensive development of LDL-lowering drugs, there still exist those patients with refractory hyperlipidemia whose plasma LDL levels are not sufficiently lowered by drugs. LDL apheresis, direct removal of plasma LDL from circulating blood, is thought to be the most promising treatment for such refractory patients. Various techniques, such as the use of an im-munoadsorbent utilizing an anti-LDL antibody, have been used in an attempt to achieve the selective removal of LDL. However, none were widely used because of complications, poor selectivity, and so forth. To establish a safe and effective LDL apheresis system, we chose a synthetic affinity adsorbent as the LDL-removing device. Synthetic polyanion compounds were used as the affinity ligands for LDL adsorbent to simulate the anion-rich sequence of LDL binding sites in the human LDL receptor. Among various polyanion compounds, those polyanions with sulfate or sulfonate groups and hydrophilic backbone were found to have strong affinity for LDL. In contrast, polyanions with carboxyl groups showed poor affinity. Dextran sulfate (DS) was selected as the affinity ligand of LDL adsorbent for its high affinity and low toxicity. The influence of its charge density and molecular weight on its affinity for LDL was suitable. The affinity rapidly increased as the charge density increased, then, reached a constant value. Little affinity was found for either the DS monomer (glucose sulfate) or DS with a molecular weight higher than 10⁴ daltons whereas DS with molecular weights in the midrange showed strong affinity. DS with a midrange molecular weight was immobilized on cellulose hard gel to give LDL adsorbent clinical application. The adsorbent demonstrated an excellent selectivity for LDL and very low density lipoprotein (VLDL) in vitro. Adsorption of high-density lipoprotein and major plasma proteins was almost negligible. Additional study of the LDL-binding mechanism revealed that DS directly interacts with positively charged sites on LDL, which demonstrates that the nature of the interaction is the same as that of LDL receptor. An LDL adsorption column (Liposorber) packed with an LDL adsorbent and polysulfone hollow-fiber plasma separator (Sulflux) was developed as an efficient LDL apheresis system. Clinical investigation proved that this system is capable of intensively lowering the plasma LDL level without affecting major plasma components.     

Artificial organs 2010: a year in review

In this Editor's Review, articles published in 2010 are organized by category and briefly summarized. As the official journal of The International Federation for Artificial Organs, The International Faculty for Artificial Organs, and the International Society for Rotary Blood Pumps, Artificial Organs continues in the original mission of its founders "to foster communications in the field of artificial organs on an international level."Artificial Organs continues to publish developments and clinical applications of artificial organ technologies in this broad and expanding field of organ Replacement, Recovery, and Regeneration from all over the world. We take this time also to express our gratitude to our authors for offering their work to this journal. We offer our very special thanks to our reviewers who give so generously of time and expertise to review, critique, and especially provide such meaningful suggestions to the author's work whether eventually accepted or rejected and especially to those whose native tongue is not English. Without these excellent and dedicated reviewers the quality expected from such a journal could not be possible. We also express our special thanks to our Publisher, Wiley-Blackwell, for their expert attention and support in the production and marketing of Artificial Organs. In this Editor's Review, that historically has been widely received by our readership, we aim to provide a brief reflection of the currently available worldwide knowledge that is intended to advance and better human life while providing insight for continued application of technologies and methods of organ Replacement, Recovery, and Regeneration. We look forward to recording further advances in the coming years.     

Avaliação do clube de revista de anestesiologia por meio de mudanças semânticas

Background and objectives

The interactive approach of a journal club has been described in the medical education literature. The aim of this investigation is to present an assessment of journal club as a tool to address the question whether residents read more and critically.

Methods

This study reports the performance of medical residents in anesthesiology from the Clinics Hospital – University of São Paulo Medical School. All medical residents were invited to answer five questions derived from discussed papers. The answer sheet consisted of an affirmative statement with a Likert type scale (totally disagree–disagree–not sure–agree–totally agree), each related to one of the chosen articles. The results were evaluated by means of item analysis – difficulty index and discrimination power.

Results

Residents filled one hundred and seventy three evaluations in the months of December 2011 (n = 51), July 2012 (n = 66) and December 2012 (n = 56). The first exam presented all items with straight statement, second and third exams presented mixed items. Separating “totally agree” from “agree” increased the difficulty indices, but did not improve the discrimination power.

Conclusions

The use of a journal club assessment with straight and inverted statements and by means of five points scale for agreement has been shown to increase its item difficulty and discrimination power. This may reflect involvement either with the reading or the discussion during the journal meeting.