Prediction of land use changes based on Land Change Modeler and attribution of changes in the water balance of Ganga basin to land use change using the SWAT model.

Conflicts between increasing irrigated agricultural area, commercial crops, shifting cultivation and ever increasing domestic and industrial demand has already been a cause of tension in the society over water in the Ganga River Basin, India. For the development of sustainable water resource strategies, it is essential to establish interaction between landuse changes and local hydrology through proper assessment. Precisely, seeing how change in each LULC affects hydrologic regimes, or conversely evaluating which LULC shall be appropriate for the local hydrological regime can help decision makers to incorporate in the policy instruments. In this study, hydrologic regimes of the Ganga River basin have been assessed with landuse change. Catchment hydrologic responses were simulated using Soil and Water Assessment Tool (SWAT). Meteorological data from IMD of 0.25°â€¯× 0.25° spatial resolution were taken as the climate inputs. Simulated stream flow was compared at different gauge stations distributed across the Gang River and its tributaries. Urbanization has been the topmost contributor to the increase in surface runoff and water yield. While increased irrigation demands were the dominant contributor to the water consumption and also added to the increased evapotranspiration. This study can be important tool in quantifying the changes in hydrological components in response to changes made in landuse in especially basins undergoing rapid commercialization. This shall provide substantive information to the decision makers required to develop ameliorative strategies.

Guidelines for the management of postoperative obstructive symptoms in children with Hirschsprung disease.

Although most children with Hirschsprung disease ultimately do well, many experience a variety of ongoing problems after pull-through surgery. The most common include obstructive symptoms, soiling, enterocolitis and failure to thrive. The purpose of this guideline is to present a rational approach to the management of postoperative obstructive symptoms in children with Hirschsprung disease. The American Pediatric Surgical Association Board of Governors established a Hirschsprung Disease Interest Group. Group discussions, literature review and expert consensus were then used to summarize the current state of knowledge regarding causes, methods of diagnosis, and treatment approaches to children with obstructive symptoms following pull-through for Hirschsprung disease. Causes of obstructive symptoms post-pull-through include mechanical obstruction; persistent or acquired aganglionosis, hypoganglionosis, or transition zone pull-through; internal sphincter achalasia; disordered motility in the proximal intestine that contains ganglion cells; or functional megacolon caused by stool-holding behavior. An algorithm for the diagnosis and management of obstructive symptoms after a pull-through for Hirschsprung disease is presented. A stepwise, logical approach to the diagnosis and management of patients experiencing obstructive symptoms following pull-through for Hirschsprung disease can facilitate treatment. Level of evidence V.

Appearance of cholinergic myenteric neurons during enteric nervous system development: comparison of different ChAT fluorescent mouse reporter lines.

BACKGROUND: Cholinergic neurons have been identified with the acetylcholine synthetic enzyme choline acetyltransferase (ChAT). However, ChAT is difficult to localize in newly differentiated peripheral neurons making the study of cholinergic neuronal development problematic. Consequently, researchers have used mouse reporter lines to indicate the presence of ChAT. METHODS: Our objective was to determine which ChAT reporter line was the most sensitive indicator of ChAT expression. We utilized two different fluorescent ChAT reporter lines (ChAT-GFP and ChAT-Cre;R26R:floxSTOP:tdTomato) together with immunolocalization of ChAT protein (ChAT-IR) to characterize the spatial and temporal expression of ChAT in myenteric neurons throughout enteric nervous system (ENS) development. KEY RESULTS: ChAT-IR cells were first seen in the intestine at E10.5, even within the migration wavefront of neural precursors. Myenteric neurons within the distal small intestine (dSI) and proximal colon were first labeled by ChAT-IR, then ChAT-GFP, and finally ChAT-Cre tdTomato. The percentage of ChAT-IR neurons is equivalent to adult levels in the dSI by E13.5 and proximal colon by P0. After these stages, the percentages remained relatively constant throughout development despite dramatic changes in neuronal density. CONCLUSIONS & INFERENCES: These observations indicate that neurotransmitter expression occurs early and there is only a brief gap between neurogenesis and neurotransmitter expression. Our finding that the proportion of ChAT myenteric neurons reached adult levels during embryonic development suggests that the fate of cholinergic neurons is tightly regulated and that their differentiation might influence further neuronal development. ChAT-GFP is a more accurate indicator of early ENS cholinergic neuronal differentiation than the ChAT-Cre;R26R:floxSTOP:tdTomato reporter mouse.

Snowmelt contributions to discharge of the Ganges.

Himalayan headwaters supply large quantities of runoff derived from snowmelt and monsoon rainfall to the Ganges River. Actual snowmelt contribution to discharge in the Ganges remains conjectural under both present and future climatic conditions. As snowmelt is likely to be perturbed through climatic warming, four hydrological models, VIC, JULES, LPJmL and SWAT, appropriate for coupling with regional climate models, were used to provide a baseline estimate of snowmelt contribution to flow at seasonal and annual timescales. The models constrain estimates of snowmelt contributions to between 1% and 5% of overall basin runoff. Snowmelt is, however, significant in spring months, a period in which other sources of runoff are scarce.

Modeling hydrology, groundwater recharge and non-point nitrate loadings in the Himalayan Upper Yamuna basin.

The mountainous Himalayan watersheds are important hydrologic systems responsible for much of the water supply in the Indian sub-continent. These watersheds are increasingly facing anthropogenic and climate-related pressures that impact spatial and temporal distribution of water availability. This study evaluates temporal and spatial distribution of water availability including groundwater recharge and quality (non-point nitrate loadings) for a Himalayan watershed, namely, the Upper Yamuna watershed (part of the Ganga River basin). The watershed has an area of 11,600 km(2) with elevation ranging from 6300 to 600 m above mean sea level. Soil and Water Assessment Tool (SWAT), a physically-based, time-continuous model, has been used to simulate the land phase of the hydrological cycle, to obtain streamflows, groundwater recharge, and nitrate (NO3) load distributions in various components of runoff. The hydrological SWAT model is integrated with the MODular finite difference groundwater FLOW model (MODFLOW), and Modular 3-Dimensional Multi-Species Transport model (MT3DMS), to obtain groundwater flow and NO3 transport. Validation of various modules of this integrated model has been done for sub-basins of the Upper Yamuna watershed. Results on surface runoff and groundwater levels obtained as outputs from simulation show a good comparison with the observed streamflows and groundwater levels (Nash-Sutcliffe and R(2) correlations greater than +0.7). Nitrate loading obtained after nitrification, denitrification, and NO3 removal from unsaturated and shallow aquifer zones is combined with groundwater recharge. Results for nitrate modeling in groundwater aquifers are compared with observed NO3 concentration and are found to be in good agreement. The study further evaluates the sensitivity of water availability to climate change. Simulations have been made with the weather inputs of climate change scenarios of A2, B2, and A1B for end of the century. Water yield estimates under climate change scenarios have been made and implications on groundwater and groundwater quality have been assessed. The delicate groundwater resource balance that connects livelihoods of millions of people seems to be under tremendously increasing pressure due to the dynamic conditions of the natural environment of the region and the future climate changes.

Altered neuronal density and neurotransmitter expression in the ganglionated region of Ednrb null mice: implications for Hirschsprung's disease.

BACKGROUND: Hirschsprung's disease (HSCR) is a congenital condition in which enteric ganglia, formed from neural crest cells (NCC), are absent from the terminal bowel. Dysmotility and constipation are common features of HSCR that persist following surgical intervention. This persistence suggests that the portion of the colon that remains postoperatively is not able to support normal bowel function. To elucidate the defects that underlie this condition, we utilized a murine model of HSCR. METHODS: Mice with NCC-specific deletion of Ednrb were used to measure the neuronal density and neurotransmitter expression in ganglia. KEY RESULTS: At the site located proximal to the aganglionic region of P21 Ednrb null mice, the neuronal density is significantly decreased and the expression of neurotransmitters is altered compared with het animals. The ganglia in this colonic region are smaller and more isolated while the size of neuronal cell bodies is increased. The percentage of neurons expressing neuronal nNOS and VIP is significantly increased in Ednrb nulls. Conversely, the percentage of choline acetyltransferase (ChAT) expressing neurons is decreased, while Substance P is unchanged between the two genotypes. These changes are limited to the colon and are not detected in the ileum. CONCLUSIONS & INFERENCES: We demonstrate changes in neuronal density and alterations in the balance of expression of neurotransmitters in the colon proximal to the aganglionic region in Ednrb null mice. The reduced neuronal density and complementary changes in nNOS and ChAT expression may account for the dysmotility seen in HSCR.

Giant congenital nevi: a 20-year experience and an algorithm for their management.

A variety of treatment options exists for the management of giant congenital nevi. Confusion over appropriate management is compounded because not all giant congenital nevi are pigmented, and malignant potential varies between different types. The present study sought to define factors in the presentation of giant congenital nevi that could provide an algorithm for their management, with respect to both the extent of resection and subsequent reconstructive options.A retrospective review of all patients who presented with a congenital nevus of 20 cm2 or greater since 1980 was performed, distinguishing among nevi involving the head and neck, the torso, and the extremities. Sixty-one patients with giant congenital nevi were evaluated (newborn to age 16 years), of which 60 nevi in 55 patients have been operated on. Giant congenital nevi having malignant potential were pigmented nevi (53 patients) and nevus sebaceus (four patients). Those not having malignant potential were verrucous epidermal nevi (three patients) and a woolly hair nevus (one patient). Of the 60 giant congenital nevi operated on, expanded flaps were used in 25, expanded full-thickness skin grafts were used in 10, split-thickness or nonexpanded full-thickness skin grafts were used in 13, and serial excision was used in 30. After 1989, operations tended to use multimodality treatment plans, with an increased use of expanded full-thickness grafts and immediate serial tissue expansion. The use of serial excision, particularly in the extremities, also increased after 1989. Serial excision was the treatment of choice when it could be completed in two procedures or less, which occurred in more than 80 percent of cases using serial excision alone. Expanded flaps were the most common mode of reconstruction in the head and neck region and were used in 49 percent of these procedures. Serial excision was the most common form of treatment in the extremities, used in 50 percent of procedures. Tissue expansion in the extremities was infrequently used to provide an expanded flap (8 percent of procedures), whereas it was frequently used to provide expanded full-thickness skin grafts harvested from the torso (used in 31 percent of procedures). On the basis of these data, algorithms for the extent of resection and subsequent reconstructive options for giant congenital nevi were developed. Their management should be formulated relative to pigmentation, malignant potential, and anatomic location of the respective lesions.

Localization of the cortical response to smiling using new imaging paradigms with functional magnetic resonance imaging.

Functional magnetic resonance imaging (fMRI) can serve to localize activity in the cerebral cortex. The present study was performed to develop a quantitative means of describing the cortical location activated during voluntary smiling in multiple subjects and to determine whether this location is specific to smiling when compared with other motor tasks. Five human subjects were instructed to smile or to tap the fingers of both hands. Both tasks were performed in a blocked-trial paradigm that consisted of alternating 15-second blocks of a repetitive motor task and 15 seconds of rest. Smiling was also performed as an event-related paradigm in which the subject smiled briefly once every 15 seconds for 20 repetitions that were combined to produce an average response to a single smile. A series of 300 images was acquired using an echo-planar imaging sequence (24-cm field of view; 5-mm slice thickness; repetition time/echo time, 1000/27.2 msec). Each subject's three-dimensional brain images were transformed to Talairach coordinates by stretching or compressing the brain images to fit the standard brain as defined in the Talairach atlas. This allowed data from five subjects to be combined for a numeric description. Functional activation maps acquired by use of the event-related paradigm contained significantly fewer motion artifacts than maps acquired with the blocked-trial paradigm, allowing better visualization of functionally active areas. Three-dimensional Talairach coordinates to describe the locations of peak cortical activity after smiling and finger tapping were established. These coordinates were consistent among subjects. During smiling, statistically significant activation was seen in the motor cortex, primarily along the precentral sulcus; this was inferior and anterior to the region that was associated with finger tapping. This study demonstrates that motion artifacts associated with traditional blocked-trial fMRI protocols can be overcome by employing an event-related paradigm to obtain an average response from a single smile. With the implementation of new imaging paradigms with fMRI, an area of the cerebral cortex has been identified that is specifically activated during voluntary smiling, and remains consistent among subjects. Quantification of fMRI data represents a powerful tool by which to study the cortical response to motor activity and to monitor possible alteration in this activity after injury or surgery. When combined with biofeedback therapy, this technique may help to improve the outcome of facial reanimation procedures in the future.

The role of transforming growth factor-beta in the modulation of mouse cranial suture fusion.

Transforming growth factor-beta (TGF-beta) is actively expressed during mouse calvarial suture fusion. However, the role TGF-beta plays in this process remains unclear. The present study was performed to investigate whether modulation of suture fusion can be achieved by blocking the bioavailability of TGF-beta. Both in vitro and in vivo models were studied. For the in vitro model, the posterior frontal sutures from 24-day-old mice were harvested and cultured for 2, 3, or 4 weeks in the presence of 20 microg/ml of pan-specific TGF-beta polyclonal antibody or rabbit IgG as a control. Culture media were changed every 48 hours and fresh antibody or rabbit IgG was added during each media change. Suture fusion was evaluated by histometric analysis. For the in vivo model, TGF-beta antisense plasmid DNA complexed with lipofectamine was injected into the subgaleal layer along the frontal suture of 22-day-old mice under anesthesia. For control groups, empty vector plasmid DNA+ complexed with lipofectamine was used. The posterior frontal sutures were harvested at various time points and examined by histometric analysis and reverse transcription and polymerase chain reaction for the detection of messenger RNA. The in vitro studies demonstrated that the presence of TGF-beta antibody in culture media delayed posterior frontal suture fusion. By 3 weeks in culture, new bone area was only 20 percent of that in control groups as determined by histometric analysis. By the end of the fourth week, suture fusion was only 25 percent completed compared with controls. The in vivo studies demonstrated that, compared with the control, posterior frontal suture fusion was significantly delayed in the animals injected with antisense plasmid DNA. Suture fusion was complete in control animals by postnatal day 45. There was a 70 percent inhibition of suture fusion (new bone area) in antisense groups measured with histometric analysis. Four days after antisense plasmid DNA injection (age of 26 days), messenger RNA expression for TGF-beta 1 was 77 percent lower than in the control group. We have demonstrated that modulation of TGF-beta affects calvarial suture formation in vitro and in vivo with TGF-beta antibody and TGF-beta1 antisense plasmid DNA treatment, respectively. These data indicate that TGF-beta may play a causative role in mouse posterior frontal suture fusion. Modulation TGF-beta 1 gene expression in vivo can alter the natural history of cranial suture fusion.

Quantitative assessment of cranial defect healing and correlation with the expression of TGF-beta.

Circular parietal defects from 3 to 12 mm in diameter were made in 45 6-month old skeletally mature guinea pigs, and animals were sacrificed after survival periods of 3 days to 12 weeks. The original defect was harvested in continuity with a rim of surrounding bone and the adjacent dura and pericranium. After 12 weeks, all 3 and 5 mm defects were completely covered by a bridge of bone, while residual defects were noted within the 8 and 12 mm wounds. Percentage of new bone formation was significantly higher within 3 mm defects, than in all larger defects at each time interval from 1 week on (P < .05), reaching a mean of 93% in 3 mm defects and remaining below a mean of 31% in the remaining defect sizes. Immunolocalization demonstrated an osteogenic front in which the osteoblasts stained strongly for all isoforms of TGF-beta, with the intensity decreasing after the majority of the defects had reossified; this front was located at the advancing bone edge of the defect as well as the endocranial side adjacent to the dura. In conclusion, isoforms of TGF-beta are upregulated during a limited "window" of time corresponding to the period of calvarial reossification, and are localized to osteoblasts within an osteogenic front at the periphery and dural surfaces of the defects.

Early surgical intervention in a patient with Kasabach-Merritt phenomenon.

A 3-day-old male infant with a 3-cm firm subcutaneous mass was found to have decreased platelets, decreased fibrin, and increased fibrin split products diagnostic of Kasabach-Merritt phenomenon. The vascular lesion was resected without complications. We suggest that early surgical intervention is an excellent therapeutic option for Kasabach-Merritt phenomenon.

Distraction osteogenesis of the craniofacial skeleton.

In summary, distraction osteogenesis is a safe and effective means of achieving bone lengthening. These techniques were originally applied to the long bones of the extremities; over the past 10 years they have been effectively applied to the bones of the craniofacial skeleton. The new bone regenerate that is observed after distraction osteogenesis is stable, and relapse rates after skeletal advancement are believed to be lower than with conventional osteotomy and bone graft techniques. There is considerable variability in distraction protocols employed in clinical practice, including differences in the types of devices used and in the rate, rhythm, latency, and period of consolidation for distraction osteogenesis. The greatest application for distraction osteogenesis in the craniofacial skeleton has been with mandible lengthening, for which there is presently a 10-year clinical experience. Midfacial advancement is a newer application of distraction osteogenesis, for which clinical experience has been accrued over the past 5 years. This latter experience indicates that distraction osteogenesis is a viable treatment option for lengthening of the hypoplastic mandible and midface. These techniques have advantages over conventional means of bone graft and rigid fixation because of the quality of the bone regenerate, the decrease in the long-term relapse rate of the advanced bone segments in both the mandible and the midface, and the simultaneous soft-tissue elongation that accompanies the distraction process. Distraction osteogenesis is particularly applicable to the correction of severe deformities of the mandible and midface in children with developmental hypoplasia and syndromic craniosynostosis. However, growth is an added variable in this patient population. The amount of overcorrection in lengthening of the hypoplastic bone required to compensate for continued growth discrepancy of the adjacent facial bones is difficult to predict. Therefore, the families of these patients should be informed that many children will require repeated operations at a later age as they reach skeletal maturity.

Furlow palatoplasty to restore velopharyngeal competence following tonsillectomy avulsion of a pharyngeal flap.

OBJECTIVE: We report the successful use of a Furlow palatoplasty to salvage velopharyngeal competence following iatrogenic avulsion of a pharyngeal flap that had been previously established to treat velopharyngeal insufficiency associated with a submucous cleft palate. INTERVENTION: A tonsillectomy, conducted by a surgeon unaffiliated with a cleft palate team, was used to remove enlarged tonsils that had developed after pharyngeal flap surgery and extended into the lateral ports causing nasal obstruction and hypernasality because of mechanical interference with port closure. A posttonsillectomy evaluation revealed avulsion of the pharyngeal flap, which was successfully treated using a Furlow palatoplasty. CONCLUSIONS: To our knowledge, this is the first report of iatrogenic avulsion of a pharyngeal flap caused by tonsillectomy. Based on a review of the literature and this case experience, we would conclude that tonsillectomy should not be regarded as a routine procedure in patients previously treated with a pharyngeal flap. If required, it should be performed by a skilled otolaryngologist, preferably one affiliated with a multidisciplinary cleft palate team who is familiar with pharyngoplasty surgery. Finally, our experience would suggest that the Furlow palatoplasty is sufficiently robust to be used as a secondary salvage procedure to restore velopharyngeal sufficiency following iatrogenic avulsion of a pharyngeal flap.

Congenital pressure necrosis of the forearm in a newborn infant.

The authors report a case of congenital pressure necrosis of the forearm presenting in a newborn infant. The patient presented with an edematous and purpuric upper extremity with no underlying vascular compromise. After demarcation of the nonviable tissue during the first month of life, the extremity was debrided, and a thin split-thickness skin graft was applied. Graft contracture over the subsequent year was released and reconstructed with a full-thickness skin graft. Patient follow-up at age 22 months demonstrated progressive return of strength and function of the extremity with restoration of soft-tissue bulk and contour. When presented with this unusual circumstance, the plastic surgeon should be familiar with its differential diagnosis and management. Conservative debridement and age-appropriate resurfacing of the remaining wound were the essential treatment principles followed in this patient.

Efficacy of preoperative decontamination of the oral cavity.

This two-part study consisted of: (1) a survey to assess current practice patterns, and (2) an experiment designed to assess the results of varying intraoral preparations. A 48 percent response rate was obtained from the survey of the 318 active members of the American Society of Maxillofacial Surgeons. This survey demonstrated that significant controversy continues regarding the efficacy of preoperative decontamination of the oral cavity. This prospective, randomized experimental study of 30 patients (saline, 10; povidone-iodine, 10; no preparation, 10) demonstrates a significant and sustained reduction of both anaerobic and aerobic bacteria after intraoral preparation with povidone-iodine solution but not saline. The patient's age, use of preoperative intravenous cephalosporin, and type and length of procedure did not influence the postoperative bacterial counts. Although none of the patients in this study developed an infection, recommendations are provided for standardized preoperative treatment of the oral cavity.

Osteogenesis in cranial defects: reassessment of the concept of critical size and the expression of TGF-beta isoforms.

Transforming growth factor-betas (TGF-beta) have been demontstrated to be upregulated during osteoblast function in vitro and during cranial suture fusion in vivo. The authors hypothesized that spontaneous reossification of calvarial defects was also associated with upregulation of TGF-beta. The present study was designed to (1) evaluate the concept of a critical-size defect within the calvaria in an adult guinea pig model and (2) investigate the association between the ossification of calvarial defects and TGF-beta upregulation. Paired circular parietal defects with diameters of 3 and 5 mm and single parietal defects with diameters of 8 or 12 mm were made in 45 six-month-old skeletally mature guinea pigs. Three animals per defect size were killed after survival periods of 3 days, 1 week, 4 weeks, 8 weeks, or 12 weeks. New bone ingrowth was evaluated by assessing for linear closure by a traditional linear method and by a modified cross-sectional area method using an image analysis system in which the thickness of new bone was taken into account. Immunohistochemistry was performed using rabbit polyclonal antibodies to localize TGF-beta1, -beta2, and -beta3. All specimens were photographed, and the intensity of immunostaining was graded based on subjective photographic assessment by three independent reviewers. No defect demonstrated any measurable bone replacement after a survival period of 3 days. All 3- and 5-mm defects were completely reossified after 12 weeks based on the linear analysis of new bone, indicating these defects to be less than critical size. However, new bone formation in the 5-mm defects never exceeded a mean of 40 percent by cross-sectional area of new bone. Percent of new bone formation by cross-sectional area was significantly higher within 3-mm defects than in all larger defects 4 weeks after the craniotomy, reaching a mean of 89 percent new bone by 12 weeks. Persistent gaps were noted on linear analysis of the 8- and 12-mm wounds by 12 weeks, and mean percent new bone by cross-sectional area remained below 30 percent. Immunolocalization demonstrated osteogenic fronts at the advancing bone edge and the endocranial side, in which the osteoblasts stained strongly for all isoforms of TGF-beta. The intensity of osteoblast expression waned considerably after the majority of the defect had reossified. These data indicate that histometric analysis based on cross-sectional area more accurately reflects the osteogenic potential of a cranial defect than does linear inspection of defect closure. Although the interpretation of immunolocalization studies is highly subjective, independent assessment by three reviewers indicates that isoforms of TGF-beta were upregulated during a limited "window" of time corresponding to the period of active calvarial reossification, and expression of TGF-beta corresponded to osteoblast activity within osteogenic fronts.

Ulnar nerve compression by an anomalous muscle following carpal tunnel release: a case report.

We describe the acute development of ulnar nerve compression following carpal tunnel release in a patient with an accessory palmaris longus muscle. Although anomalous muscles in the wrist are relatively common and may produce ulnar nerve compression, this particular occurrence following carpal tunnel release has not been previously described in the literature. We theorize that the compression of the ulnar nerve proximal to Guyon's canal was caused by increased tension along the long axis of the anomalous accessory palmaris longus muscle as a consequence of transverse carpal ligament division.

Role of three-dimensional computed tomography in the assessment of nasoorbitoethmoidal fractures.

Successful management of nasoorbitoethmoidal (NOE) fractures requires early diagnosis and accurate determination of the extent of injury. Although the anatomic complexity of the NOE region merits a clear interpretation of the spatial relationships associated with each injury, the role of three-dimensional (3D) computed tomography (CT) in the assessment of these fractures remains unclear. To clarify the diagnostic value of 3D CT, this retrospective analysis compares statistically the accuracy of two-dimensional (2D) CT against 3D CT in the detection of NOE fracture line tracts in 21 consecutive patients with surgically confirmed NOE fractures. Accuracy of radiographic findings of both modalities were compared with intraoperative findings serving as the "gold standard" for detecting fracture lines in NOE fractures. This statistical analysis indicates that combining 3D CT and 2D CT produces a higher diagnostic yield in the evaluation of NOE fractures than using either modality alone. Although 2D CT was significantly superior (p < 0.05) for inspection of the medial orbital wall, 3D CT offered significantly greater diagnostic accuracy (p < 0.05) along the medial maxillary buttress, particularly at the piriform aperture. 3D CT clarified spatially several unusual NOE injuries that were indiscernible with 2D CT alone. We recommend the combination of 3D CT with 2D CT for serious NOE injuries, particularly those involving displacement of the NOE complex or associated with other major midfacial fractures.