Trauma Literature Research Articles

Sequential low molecular weight heparin and rivaroxaban for venous thromboprophylaxis in pelvic and acetabular trauma.

Patients with pelvic trauma are at high risk of thromboembolic complications, but effective methods of prophylaxis are still to be accepted widely. The incidence of venous thromboembolism (VTE) has been reported to be as high as 61%, which represents the commonest cause of morbidity and mortality in this cohort. New oral anticoagulants are now available and may be used instead of LMWH injections for extended prophylaxis. Rivaroxaban has not been comprehensively considered in the previous pelvic and acetabular trauma literature, but its known benefits include increased patient compliance, especially in the minority of patients who are unable to self-administer injections, and that it does not require monitoring. All patients referred to our pelvic trauma service between 2015 and 2020 were considered for this study, exclusion criteria involved those patients who had contraindications to rivaroxaban, those who were referred to our service but were never managed at our centre and those managed by other teams (e.g. neurosurgery). Operative patients were initially managed with LMWH until 24h post-operatively when they started rivaroxaban. Conservatively managed patients started Rivaroxaban straight away. Data were collected on demographics, injury mechanism, fracture classification and clinically relevant VTE and bleeding events up until 3months post discharge. The overall incidence of VTE was 2%. These represented 3 DVTs and 3 PEs, and occurred in patients who were managed operatively. No major bleeding events were observed. There were two minor bleeding events, both occurring in patients who were managed conservatively with rivaroxaban alone, and they did not require further intervention. 90% of patients surveyed expressed preference for oral prophylaxis. Reported compliance with rivaroxaban was 100%. Our data show that this VTE regimen protocol is safe and effective in this group of injured patients and is at least non-inferior to the standard prophylaxis of LMWH alone.

The Financial and Radiation Burden of Early Reimaging in Neurosurgical Patients: An Original Study and Review of the Literature.

The computed tomographic (CT) scanner has become ubiquitous in healthcare. When trauma patients are imaged at facilities not equipped to care for them, imaging is often repeated at the receiving institution. CTs have clinical, financial, and resource costs, and eliminating unnecessary imaging will benefit patients, providers, and institutions. This paper reviews patterns of repetition of CT scans for transferred trauma patients and motivations underlying such behaviors via analysis of our Trauma Registry database and literature published in this area.Neurosurgeons are fundamentally impactful in this decision-making process. The most commonly repeated scan is a CT head (CTH). More than ¼ of our patients receiving a clinically indicated repeat CTH also had a repeat scan of their cervical spine with no reason given for the cervical scan. Herein, we discuss our findings that both non-trauma center practitioners and non-neurosurgical staff at trauma centers cite a lower level of comfort with neuroradiology and fear of litigation as motivators in overzealous neuroimaging. As a result, inappropriate neurosurgical imaging is routinely ordered prior to transfer and again upon arrival at trauma centers. Education of non-neurosurgical staff is essential to prevent inappropriate neuroaxis imaging.

Emulating an RCT in observational research in chest trauma: The target trial approach.

While the concept of a "target trial"-optimizing the quality of observational studies by attempting to emulate the ideal world conditions of a randomized controlled trial-was first expounded over a decade ago, the take up of this concept in the design and analysis of trials in trauma is lacking. The target trial approach avoids common errors in observational research to increase its scientific validity as well as potentially enable causal questions to be answered without the expense and intricacies of a randomized controlled trial. This review article briefly introduces the reader to the concepts and utility of a "target trial" approach before providing demonstrations of its application in the subject area of chest trauma. Four articles published in the last 5 years-two case control and two cohort studies-are chosen and considered in terms of their causal question; study population; inclusion and exclusion criteria; designation of time 0; clarity of the follow-up period; study outcomes; methods to minimize confounding; results; overall issues regarding study time; and the presence of avoidable errors such as introduction of immortal time bias or information bias. Two of the studies had an unclear causal question; none of the studies designated a time 0; the follow-up period was unclear for all but one of the studies; and one study had a serious issue with information bias resulting from differential misclassification. Failure to emulate a "target trial" framework may lead to serious methodologic issues in observational research. Expansion of the awareness of this approach in trauma literature will improve the quality of our observational research and potentially translate into significant benefits for our patients.

“Screaming, ‘No! No!’ It was Literally Like Being Raped”: Connecting Sexual Assault Trauma and Coerced Obstetric Procedures

Abstract How does the victimization of women’s bodies in medical interactions contribute to their experience of gendered violence? We answer this question by joining sexual assault and birth trauma literatures with the medical sociology conversation on the power of hospitals as organizations and the hierarchy of the doctor-patient relationship to analyze the interviews of 101 women who identify as having experienced a coerced, pressured, or forced labor or birth procedure. We find some respondents analogize their experiences to that of someone who has been sexually assaulted, and they and other respondents describe the aftermath effects in ways similar to those who have been victims of sexual assault. Our research demonstrates that clinicians and hospitals are harming patients, often through the normal application of established hospital protocols and behaviors, when women do not feel involved in decisions about their care.

Cold Compresses on Patient with Fracture: Systematic Review

The purpose of this study was to see whether the cold compress method was effective in overcoming the clinical conditions felt by patients with fractures. This study uses a systematic review approach by collecting several articles from a selected database consisting of ScienceDirect and ProQuest and Pubmed with articles published in 2014-2021. Article searches were conducted by entering the keywords Compress OR Ice bag AND Pain OR Swelling AND Fracture. Article search was limited to inclusion criteria and exclusion criteria. The inclusion criteria in this study were diabetic patients with fracture. The study design was a randomized controlled trial and a quasi-experimental study, while the exclusion patient trauma non fracture, cross sectional and literature study. The conclusion in this study Cold compresses can be used to treat swelling, edema and pain in patients with fractures but there are other therapies that are more effective and comprehensive

Does the insurance status influence in-hospital outcome? A retrospective assessment in 30,175 surgical trauma patients in Switzerland

IntroductionThere has been growing evidence in trauma literature that differences in insurance status lead to inequality in treatment and outcome. Most studies comparing uninsured to insured patients were done in the USA. We sought to gain further insights into differences in the outcomes of trauma patients in a healthcare system with mandatory public health coverage by comparing publicly versus privately insured patients.MethodsWe used a prospective national quality assessment database from the Arbeitsgemeinschaft für Qualitätssicherung in der Chirurgie (AQC). More than 80 surgical departments in Switzerland are part of this quality program. We included all patients in the AQC database with any S- or T-code diagnosis according to the International Classification of Diseases ICD-10 (any injuries) who were treated during the 11-year period of 2004–2014. Missing insurance status information was an exclusion criterion. In total, 30,175 patients were included for analysis. The primary outcome was in-hospital mortality. Secondary outcomes included overall and intra- and postoperative complications. Bi- and multivariate analyses were performed, adjusted for insurance status, age, sex, American Society of Anesthesiologists (ASA) physical status category, type of injury, and surgeon’s level of experience.ResultsIn total, 76.8% (n = 23,196) of the patients were publicly insured. Patients with public insurance were significantly younger (p < 0.001), more often male (p < 0.001), and in better general health according to the ASA physical status category (p < 0.001). Length of pre- and postoperative stay and the number of operations per case were similar in the two groups. Patients with public insurance had a lower mortality rate (1.3% vs. 1.9%, p < 0.001), but after adjusting for confounders, insurance status was not a predictor of mortality. Overall complication rates were significantly higher for publicly insured patients (8.4% vs. 6.2%, p < 0.001), and after adjusting for confounders, insurance status was identified as an independent risk factor for overall complications (p < 0.001).ConclusionDifferences exist with respect to patient and procedural characteristics: publicly insured patients were younger, more often male, and scored better on ASA physical status. Insurance status seems not to be a predictor for fatal outcome after trauma, although it is associated with complications.

Opportunities to improve sleep of children exposed to interpersonal violence: A social-ecological perspective

Over 25% of U.S. children are witness to traumatic intrafamilial or community violence each year, and sleep medicine and developmental research jointly suggest that trauma-exposed youth experience more sleep disturbance than their non-exposed counterparts. Sleep medicine literature emphasizes physical and social environmental factors affecting sleep, and trauma literature underscores children’s seeking out physically and emotionally safe and predictable environments during trauma recovery. This study employed a hermeneutic phenomenological framing to explore the lived experiences of 65 violence-exposed children and families, and to examine how youths’ social and physical sleep environments facilitated or impeded sleep in the aftermath of trauma. Children’s sleep experiences following violence exposure shared two primary essences of experience: a) navigating external threats that agitated sleep after trauma; and b) exercising agency over sleep and related environments to restabilize emotional security. Clinicians and social services coordinators working with children and families are uniquely positioned to indicate sleep assessments as part of treatment following trauma, and to also facilitate identification of tangible, sleep-supportive and changeable factors in sleep environments.

Evaluation of spin in the abstracts of orthopedic trauma literature: A cross-sectional review

ObjectivesA cross-sectional analysis of orthopedic trauma randomized controlled trial (RCT) abstracts to assess the frequency and manifestations of spin, the misrepresentation or distortion of research findings, in orthopedic trauma clinical trials. MethodsThe top 5 orthopedic trauma journals were searched from January 1, 2012, to December 31, 2017. RCTs with nonsignificant endpoints (p > .05) were analyzed for spin in the abstract. The primary endpoint of our investigation was the frequency and type of spin. The secondary endpoint was to assess whether funding source was associated with the presence of spin. Due to the low reporting of funding sources no statistics were able to be computed for this outcome. ResultsOur PubMed search yielded 517 articles. Primary screening excluded 303 articles, and full text evaluation excluded an additional 161. Overall, 53 articles were included. Spin was identified in 35 of the 53 (66.0%) abstracts analyzed. Evidence of spin was found in 21 (39.6%) abstract results sections and 22 (41.5%) abstract conclusion sections. Of the 21 RCTs reporting a clinical trial registry, 3 (14.3%) had evidence of selective reporting bias. ConclusionsOrthopedic trauma RCTs from highly ranked journals with nonsignificant endpoints published from 2012 to 2017 frequently have spin in their abstracts. Abstracts with evidence of spin may influence a reader's perception of new drugs or procedures. In orthopedic trauma, the implications of spin may affect the treatment of patients with orthopedic trauma, so efforts to mitigate spin in RCT abstracts must be prioritized.

Understanding cost-utility analysis studies in the trauma and orthopaedic surgery literature.

Cost-utility analysis (CUA) studies are becoming increasingly important due to the need to reduce healthcare spending, especially in the field of trauma and orthopaedics.There is an increasing need for trauma and orthopaedic surgeons to understand these economic evaluations to ensure informed cost-effective decisions can be made to benefit the patient and funding body.This review discusses the fundamental principles required to understand CUA studies in the literature, including a discussion of the different methods employed to assess the health outcomes associated with different management options and the various approaches used to calculate the costs involved.Different types of model design may be used to conduct a CUA which can be broadly categorized into real-life clinical studies and computer-simulated modelling. We discuss the main types of study designs used within each category. We also cover the different types of sensitivity analysis used to quantify uncertainty in these studies and the commonly employed instruments used to assess the quality of CUAs. Finally, we discuss some of the important limitations of CUAs that need to be considered.This review outlines the main concepts required to understand the CUA literature and provides a basic framework for their future conduct.Cite this article: EFORT Open Rev 2021;6:305-315. DOI: 10.1302/2058-5241.6.200115

A Literary Inquiry into Disability, Trauma and Narrative Strategies in Lisa Genova’s Novels

The reaisltic illustration of central characters suffering from rare and severe neurological sicknesses in Lisa Genova’s novels provide an ideal prospect to study trauma in pathography novels, a subset of science fiction. However, despite its scope, these genres of novels have received little consideration in American literary trauma studies. This paper will present a new analysis of trauma in relationship to the ‘neuro’genre, followed by an analysis of narrative and literary devices employed by the author to illustrate traumatic episodes in her novels. Through this case study and critical reflection of how the author has engaged trauma in the novels supports strengthening literary trauma theory within trauma literature and the genre also. The writing of traumatic experiences of the victims, transformed identity, stigmas, fears and phobias and providing face to the sufferer doomed fate, offers an opportunity for a neuroscientist turned novelist like Lisa Genova to advocate about the neurological sicknesses and its suffering with enriched empathetic experience to the non-scientific societies. It also provides a balanced realistic narrative platform for the reader to reflect on their own uncertainties, brought on by the representation of such fictional characterization. This literary research analysis will provide scope to science fiction authors, particularly those aiming to engage with medicine and literature, for a more accurate depiction of trauma in their work. It will further broaden the scope of research in phenomenology, narrative and genre theories and criticism in literary studies.

Characterizing Epidemiology and Associated-Factors of Adolescent Sports-Related Traumas Using Trauma Quality Improvement Program.

Sports-related injuries contribute to a considerable proportion of pediatric and adolescent craniofacial trauma, which can have severe and longstanding consequences on physical and mental health. The growing popularity of sports within this at-risk group warrants further characterization of such injuries in order to enhance management and prevention strategies. In this study, the authors summarized key trends in 1452 sports-related injuries among individuals aged 16 to 19 using the American College of Surgeon's Trauma Quality Improvement Program database from 2014 to 2016. The authors observed a preponderance of injuries associated with skateboarding, snowboarding, and skiing, with significantly higher percentages of traumatic brain injuries among skateboarding-related traumas. Notably, we observed that traumatic brain injurie rates were slightly higher among subjects who wore helmets. Intensive care unit durations and hospital stays appeared to vary by sport and craniofacial fracture. Altogether, this study contributes to the adolescent sports-related injuries and craniofacial trauma literature.

Conflict of interest disclosure in orthopaedic and general surgical trauma literature

SignificanceFinancial relationships between industry and physicians are a key aspect for the advancement of surgical practice and training, but these relationships also result in a conflict of interest with respect to research. Financial payments to physicians are public within the United States in the Open Payments Database, but the rate of accurate financial disclosure of payments has not previously been studied in trauma surgery publications. ObjectiveTo determine the rate of accurate financial disclosure in major surgical trauma journals compared with the Open Payments Database. Materials and MethodsThe names of all authors publishing in The Journal of Orthopaedic Trauma, Injury, and The Journal of Trauma and Acute Care Surgery between 2015 and 2018 were obtained from MEDLINE. Non-physicians, physicians outside of the United States, physicians without payments in the Open Payments Database, and physicians with payments types of only “Food and Drink” were excluded. Financial disclosure statements were obtained from the journal websites and manually compared against Open Payments Database entries the year prior to submission and during the year of submission up until 3 months prior to publication for each individual physician. Main outcomes were accuracy of disclosure published with each article, total amount of payments received (disclosure or undisclosed), surgical subspecialty of the reporting physician. Statistical comparisons were made using Chi-square testing with significance defined as p<0.05. ResultsBetween 2015 and 2018, 5070 articles were published involving 28,948 authors. 2945 authors met inclusion criteria. 490 authors accurately disclosed their financial relationships with industry (16.6%). The median value of undisclosed payments was $22,140 [IQR $6465, $77,221] which was significantly less than the medial value of disclosed payment of $66,433 [IQR $24,624, $161,886], p<0.001 Orthopaedic surgeons disclosed at a higher rate (26.3%, 479/1818) than general surgeons (4.8%, 47/971), p<0.001. ConclusionsPhysician-industry relationships are key for advancing surgical practice and providing training to physicians. These relationships are not inherently unethical, but there is consistently high inaccuracy of financial disclosure across multiple trauma surgery journals which may indicate the need for further education on financial disclosures during surgical training or active obtainment of publicly available financial disclosures by journals.

Educational Strategies for Deployment of Resuscitative Endovascular Balloon Occlusion of the Aorta in a Tertiary Canadian Emergency Department

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is not a novel intervention in the trauma literature. However, the incorporation of this intervention into the Canadian emergency department setting is recent in onset. This healthcare setting is dynamic and the nurses who practice in the emergency setting must be efficient care providers for an infinitely diverse set of potential patient presentations. The introduction of this complex procedure was accompanied by a variety of educational strategies to enhance the uptake of this new knowledge. The usage of small groups, didactic teaching, hands-on practice, establishing unit champions, coordinating in-situ simulations, and creating workflow documents were strategies used by the education team at this academic center for this particular knowledge dissemination exercise.

Long term changes to auditory sensitivity following blast trauma in mice

Blast trauma is a common acoustic/physical insult occurring in modern warfare. Twenty percent of active duty military come into close proximity to explosions and experience mild to severe sensory deficits. The prevalence of such injuries is high but correlating auditory sensitivity changes with the initial insult is difficult because injury and evaluations are often separated by long time periods. Here, auditory sensitivity was measured before and after a traumatic blast in adult CBA/CaJ mice using auditory brainstem responses, distortion production otoacoustic emissions, and behavioral detection of pure tones. These measurements included baseline auditory sensitivity prior to injury in all mice, and again at 3, 30, and 90 days after the blast in the two physiological groups, and daily for up to 90 days in the behavioral group. Mice in all groups experienced an initial deterioration in auditory sensitivity, though physiological measurements showed evidence of recovery that behavioral measurements did not. Amplitudes and latencies of ABR waves may reflect additional changes beyond the peripheral damage shown by the threshold changes and should be explored further. The present work addresses a major gap in the current acoustic trauma literature both in terms of comparing physiological and behavioral methods, as well as measuring the time course of recovery.

Historical Observations on Clamshell Thoracotomy.

Bilateral transverse thoracosternotomy, known colloquially as "clamshell thoracotomy," provides quick and extensive exposure to the thoracic organs. The origins of the radical incision are unclear, and its influence on historical developments in surgery has not been elaborated. Transsternal extension to bilateral thoracotomy likely occurred during World War I and was designated as Tuffier's method by 1922. Théodore Tuffier had already solidified his reputation as a trailblazing thoracic surgeon in Paris when the French army summoned him to design triage systems for trauma patients during the Great War. Following World War II, cardiac surgery grew tremendously during the 1950s, and many pioneering open-heart procedures utilized the bilateral incision for safe exposures with satisfactory results. Median sternotomy became the incision of choice for open-heart surgery by the early 1960s; however, thoracotomy remained important to the trauma surgeon's repertoire. Transsternal conversion was only briefly mentioned in trauma literature through the 1980s, although up to one-half of reported emergency thoracotomies at busy trauma centers were clamshells. The moniker clamshell thoracotomy came in 1994 when thoracic surgical oncology and lung transplantation flourished with complex operations requiring larger incisions. The twenty-first century has brought two iterations of evidence-based guidelines for emergency thoracotomy, but incision choice has not been formally discussed. Renewed conversation in recent years has advocated for the clamshell as arguably the best approach for patients in extremis. Given these trends, the tortuous history of this controversial incision deserves attention.

A graphic guide to the percutaneous tripod acetabular reconstruction for metastatic cancer.

Symptomatic peri-acetabular metastatic lesions are often treated with open surgery such as modified Harrington procedures. In an effort to avoid surgical complications inherently associated with open surgical approaches, we developed and recently reported a novel Tripod percutaneous screw technique. The tripod technique is minimally invasive and was found to yield excellent outcomes regarding both pain control and functionality. The procedure is performed in a standard operative theater using fluoroscopic guided percutaneous screws. Despite the simplicity of intraoperative set-up and instrumentation, it is technically demanding. Obtaining the correct fluoroscopic views and troubleshooting intraoperative hurdles can be challenging for even an experienced orthopedic surgeon. The technique and bony conduits were previously described in the trauma literature, however, there are key points of difference in the setting of metastatic disease. Here we provide a compilation of a stepwise graphic guide for the tripod model in the setting of metastatic peri-acetabular lesions, as well as the tips and tricks based on our own experience. These encompass preoperative preparation, operating room settings, intraoperative fluoroscopic guidance, postoperative care, and subsequent conversion to a cemented total hip arthroplasty, if needed.

1136 The FAST exam in obstetrics: a feasibility study

The Focused Assessment with Sonography for Trauma (FAST) exam, is a point of care ultrasound evaluation used routinely in surgical and trauma evaluation of critically ill patients to assess intrabdominal free fluid. It is a cost effective, noninvasive approach with no radiation exposure, which allows for rapid decision making in surgical intervention. Although extensively evaluated in the trauma and critical care literature, this study has never been evaluated in an obstetric population. Our objective was to create an ultrasound training protocol and evaluate the feasibility of this study during pregnancy. This is a prospective, observational study completed in large academic center. Health care providers (sonographers and physicians) underwent an ultrasound training protocol involving a live webinar and on-site supervision to obtain the four standard FAST exam views (the right upper quadrant, left upper quadrant, subcostal cardiac, and pelvis). Patients were enrolled after their routine obstetric ultrasound evaluation and additional images for the FAST exam were completed. The images were then reviewed for quality by a blinded physician subspecialist in clinician performed ultrasound and critical care echocardiography. 64 ultrasound studies were completed each evaluating standard FAST exam views. 62/64 (96.8%) of exams had adequate visualization of all windows. Fisher exact test was completed and no significant differences in visualization across gestational age between early pregnancy (24 weeks) , or BMI were noted (P<0.05). The FAST exam is a feasible study among pregnant women, it is not affected by gestational age or BMI. Training of obstetric providers with a web-based ultrasound protocol and quality review of images demonstrates the ability of clinicians familiar with obstetric ultrasound the ability to complete the FAST exam successfully. This is a novel study, suggesting the FAST exam may serve as a useful clinical adjunct during assessment of critically ill obstetric patients.

The Role of God’s Mighty Acts in Joel : The Book of Joel as an Example of Trauma Literature

The Book of Joel abounds in the descriptions of God’s mighty acts, including his interventions in the workings of nature and the unfolding historical events in the life of Israel and the so-called heathen nations. It has long been recognized that these acts are important in structuring the book as a whole. They can be labelled as negative or positive for the life of Israel, depending on which part of the book we interpret. In the final form of the work there is a centreline between its two major parts (1:1–2:17; 2:19–4:21), separating the descriptions of divine punishment and lament from the accounts of restoration and joy when it comes to the relationship of the covenant community with God: “Then the Lord became jealous for his land, and had pity on his people” (Joel 2:18). This verse also serves as an introduction to 2:19–4:21. What has not yet been examined in detail, however, is that the descriptions of God’s working in the nations’ history and in nature can help read the book from the viewpoint of trauma/crisis and tenacity. In the midst of crises Israel’s only hope is to repent and turn to the Lord to have mercy. In repentance, the prophet’s resilience and compassion is also significant; his words are handed down to us in a form that resembles the terminology, mood and theological teaching of certain lament psalms of the Hebrew Bible, yet representing the tradition of the day of the Lord especially important in prophetic literature. This paper aims at investigating the Book of Joel from the perspec­tive of trauma and tenacity with a view to the scriptural allusions the author employs.&#x0D;

Publication Characteristics of Foot and Ankle Trauma Publications: A Review of Articles From 1997 to 2017.

BackgroundThe purpose of this study is to evaluate and compare publishing characteristics in foot and ankle trauma articles published in two subspecialty journals and two general orthopedic journals.MethodsAll trauma articles related to foot and ankle surgery published from five different time intervals over a 20-year period were collected and the following was analyzed: authorship, level of evidence, type of study, citations, and geographic region.ResultsFoot and Ankle International (FAI) had the highest percentage of last and corresponding authors that were fellowship-trained in foot and ankle. The Journal of Bone and Joint Surgery American and British volumes (JBJS(A) and JBJS(B), respectively) and the Journal of Orthopaedic Trauma (JOT) articles had a higher percentage of last and corresponding authors that were fellowship-trained in trauma.ConclusionFoot and ankle-trained authors are currently under-represented in foot and ankle trauma literature. As the field of foot and ankle continues to grow, it is important that the experts in the field are well represented in the literature.

The Quality of the Evidence in Craniomaxillofacial Trauma: Are We Making Progress?

The purpose of this study is to evaluate the level of evidence in the craniomaxillofacial trauma literature. The secondary purpose is to determine if improvement in the quality of evidence has been made over the past 2 decades. This retrospective cohort study analyzed clinical articles published in select craniomaxillofacial surgery journals. Patient-focused articles were selected. The year of publication (1999, 2009, 2019) was the primary predictor variable. Secondary predictor variables included study funding status, anatomical facial region (eg maxilla, mandible, and so on), specific journal, and journal impact factor. The level of evidence was determined using the Center of Evidence-Based Medicine criteria, which served as the outcome variable. The statistical analysis included descriptive, bivariate, and regression analysis. The sample consisted of 469 craniomaxillofacial trauma articles, with 13.2% being published in 1999, 44.1% in 2009, and 42.6% in 2019. The majority of the studies (77.5%) were published in 4 journals. The impact factor varied among the journals with a significant improvement in the mean impact factor from (0.89 ± 0.29) in 1999 to (1.4 ± 0.47) in 2009 and a slight decline in 2019 (1.26 ± 0.71). Mandibular fractures (31.6%) and orbital trauma (26%) were the most investigated topics. Level 4 studies accounted for 67.4% of the sample, with level 3 evidence of 4.7%, level 2 of 22.6%, and level 1 of 5.3% of the included studies. Significant progress in the level of evidence has been made from 1999 but not since that time (P=.002). It is unclear why this may be but sheds light on the need for further development of high quality studies. Finally, a higher quality of evidence is associated with journal impact factor (odds ratio=1.9; P<.01) and funded research (odds ratio=4.69; P=.02). While there has been some improvement in the level of evidence in the craniomaxillofacial trauma literature over the past 2 decades, the current quality remains low, and further progress is needed to support the practice of evidence-based medicine.