What comes first: teeth or face? Recommendations for an interdisciplinary collaboration between facial esthetic surgery and dentistry.

OBJECTIVE: The aim of the present study was to provide recommendations in order to facilitate communication between dental professionals and surgeons who are collaborating in the field of dentofacial esthetics. CLINICAL CONSIDERATIONS: Smile esthetics are beyond the scope, both of the surgeons who are collaborating with facial esthetics and of the dentists, as a wide range of treatment options from both sides is available. It can be difficult for the surgeon or the dentist that first comes in contact with the patient to conduct an individualized global treatment plan, in order to find out how the various phases of the treatment can be sequenced, as a workflow for an efficient interaction between facial surgery and dentistry still does not exist in the scientific literature. CONCLUSIONS: Facial cosmetic procedures and dental treatment have to be planned as individual elements of the whole dentofacial esthetic rehabilitation. The treatment has to be initiated with the design of the smile and the intraoral mock-up, followed by the required surgical interventions, and to be finished with the delivery of the definitive dental restoration. CLINICAL SIGNIFICANCE: Dentofacial esthetics require comprehensive communication between surgeons and dentists. Following the proposed recommendations, an individualized interdisciplinary treatment plan can be conducted, defining the role of each specialty.

Comparison of local flaps versus skin grafts as reconstruction methods for defects in the medial canthal region.

BACKGROUND: The medial canthal region features a complex three-dimensional and internal anatomical structure. When reconstructing a defect in this area, it is crucial to consider both functional and aesthetic aspects, which presents significant challenges. Generally, local flaps are preferred for reconstruction; however, skin grafts can be used when local flaps are not feasible. Therefore, we conducted a comparative analysis of surgical outcomes skin grafts when local flaps were not feasible, to determine which surgical method is more effective for medial canthal region reconstruction. METHODS: Twenty-five patients who underwent medial canthal region reconstruction using skin grafts or local flaps from 2002 to 2021 were enrolled. Patient information was obtained from medical records. Five plastic surgeons evaluated the surgical outcomes based on general appearance, color, contour, and symmetry. RESULTS: Skin grafts were used in eight patients and local flaps were used in 13. Combined reconstructions were employed in four cases. Minor complications arose in four cases but improved with conservative treatment. No major complications were reported. Recurrence of the skin cancer was noted in two cases. All categories showed higher scores for the local flap compared to both skin graft and combined reconstruction; however, the differences were not statistically significant respectively. CONCLUSION: The choice of appropriate surgical methods for reconstructing defects in the medial canthal region depends on various factors, including the patient's overall health, the size and depth of the defect, and the degree of involvement of surrounding structures. When a local flap is not feasible, a skin graft may provide favorable surgical outcomes. Therefore, a skin graft can serve as a viable alternative for reconstructing the medial canthal region.

A Collaborative Approach for Metal Pollution Assessment in Production System of Plastic-Shed Vegetables Near Industrial Areas.

A collaborative assessment approach, including impact index of comprehensive quality (IICQ), food pollution index (FPI), and single factor pollution index (PI), was used to simultaneously select priority metal pollutants and assess metal contamination status in the plastic-shed soil (PSS)-vegetable system of the industrial towns situated in the Yangtze River Delta, China. Overall, significant Cr increment as well as Cd and Cu pollution in PSS existed, which was related to anthropogenic activities, especially industrial wastewater irrigation. The evaluation using PI and FPI demonstrated that priority metal pollutants were Cu and Cd in PSS while Cr and Cd in vegetables. Additionally, the estimation using IICQ method revealed that 23.3% and 13.3% of the sampling sites were sub-moderately and heavily contaminated by metals, respectively. These sites especially with heavy pollution need priority pollution management. These data will be beneficial to metal pollution control in PSS-vegetable system around industrial areas.

Research priorities on microplastics in marine and coastal environments: An Australian perspective to advance global action.

Plastic and microplastic contamination in the environment receive global attention, with calls for the synthesis of scientific evidence to inform actionable strategies and policy-relevant practices. We provide a systematic literature review on microplastic research across Australian coastal environments in water, sediment and biota, highlighting the main research foci and gaps in information. At the same time, we conducted surveys and workshops to gather expert opinions from multiple stakeholders (including researchers, industry, and government) to identify critical research directions to meet stakeholder needs across sectors. Through this consultation and engagement process, we created a platform for knowledge exchange and identified three major priorities to support evidence-based policy, regulation, and management. These include a need for (i) method harmonisation in microplastic assessments, (ii) information on the presence, sources, and pathways of plastic pollution, and (iii) advancing our understanding of the risk of harm to individuals and ecosystems.

Rethinking plastic entrapment: Misconceptions and implications for ecosystem services in coastal habitats.

This study addresses the pressing issue of plastic pollution in coastal and marine ecosystems, challenging the misconception that the entrapment of plastics can be considered as an ecosystem service. We differentiate between essential natural processes that sustain ecological balance and biodiversity and the detrimental accumulation of synthetic polymers. The pathways through which plastics enter these environments-from terrestrial to maritime sources-are examined, alongside their pervasive impacts on crucial ecosystem services such as habitat quality, the vitality of marine species, and nutrient cycling. Our findings highlight the paradox of resilience and vulnerability in these ecosystems: while capable of accumulating substantial amounts of plastic debris, they suffer long-lasting ecological, socio-economic, and health repercussions. We argue for a paradigm shift in management strategies aimed at reducing plastic production at the source, improving waste management practices, conducting targeted cleanup operations, and rehabilitating impacted ecosystems. Emphasizing a comprehensive understanding of plastic pollution is vital for framing effective solutions and necessitates a reevaluation of societal, industrial, and regulatory frameworks. This shift is imperative not only to address current pollution levels but also to safeguard and sustain the functionality of coastal ecosystems, ensuring their ability to continue providing essential services and supporting biodiversity.

Photocatalytic Upcycling of Different Types of Plastic Wastes: A Mini Review.

With the escalating demand and utilization of plastics, considerable attention has been given to controlling plastic pollution. Among these methodologies, photocatalytic upcycling of plastic has emerged as a promising method for plastic management due to its energy-saving and eco-friendly properties. In the past several years, great efforts have been devoted to the photocatalytic conversion of a variety of commercial plastic types. These encouraging endeavors foreshadow the continued progression and application in this field. In this review, recent advancements in the photocatalytic upcycling of plastics are reviewed. The fundamentals and principles of photocatalytic deconstruction of plastics are first introduced. Then, we summarize the works on the reforming of different types of plastic, including polyolefins, polyesters, and other types. Finally, some challenges and possible solutions are provided for the development of photocatalytic upcycling of plastics.

Refractory type 1 plastic bronchitis in a child; case report.

BACKGROUND: Plastic bronchitis (PB) is a rare pediatric pulmonary condition characterized by the production of branching bronchial casts that cause partial or total obstruction of the bronchial lumen. CASE PRESENTATION: We describe a 13-year-old boy with a history of bronchial asthma and left lower lobectomy, with persistent cough and left-sided chest pain when he went to the emergency room. Chest radiography showed complete left lung opacity denoting total left lung collapse, and flexible bronchoscopy revealed cohesive casts totally occluding the left bronchus, with frequent recurrence that finally ended with left pneumonectomy. CONCLUSION: Plastic bronchitis is a rare, fatal disease in children that requires a high index of suspicion for both diagnosis and treatment. Although bronchoscopic removal of the bronchial casts together with the medical treatment are the main lines of treatment, cases with recurrent formation of casts are at high risk for surgical intervention in the form of either lobectomy or pneumonectomy.

Foam density mapping via THz imaging.

Plastic foams, near-ubiquitous in everyday life and industry, show properties that depend primarily on density. Density measurement, although straightforward in principle, is not always easy. As such, while several methods are available, plastic foam industry is not yet supported with a standard technique that effectively enables to control density maps. To overcome this issue, this paper proposes Terahertz (THz) time-of-flight imaging using normal reflection measurements as a fast, relatively cheap, contactless, non-destructive and non-dangerous way to map plastic foam density, based on the expected relationship between density and refractive index. The approach is demonstrated in the case of polypropylene foams. First, the relationship between the estimated effective refractive index and the polypropylene foam density is derived by characterizing a set of carefully crafted samples having uniform density in the range 70-900 kg/m3. The obtained calibration curve subtends a linear relationship between the density and the refractive index in the range of interest. This relationship is validated against a set of test samples, whose estimated average densities are consistent with the nominal ones, with an absolute error lower than 10 kg/m3 and a percentage error on the estimate of 5%. Exploiting the calibration curve, it is possible to build quantitative images depicting the spatial distribution of the sample density. THz images are able to reveal the non-uniform density distribution of some samples, which cannot be appreciated from visual inspection. Finally, the complex spatial density pattern of a graded foam sample is characterized and quantitatively compared with the density map obtained via X-ray microscopy. The comparison confirms that the proposed THz approach successfully determines the density pattern with an accuracy and a spatial scale variability compliant with those commonly required for plastic foam density estimate.

Chatting Up the Next Big Thing: Generating Novel Ideas for Systematic Reviews in Breast Reconstruction Research Using Chat-GPT.

BACKGROUND: In reconstructive plastic surgery, the need for comprehensive research and systematic reviews is apparent due to the field's intricacies, influencing the evidence supporting specific procedures. Although Chat-GPT's knowledge is limited to September 2021, its integration into research proves valuable for efficiently identifying knowledge gaps. Therefore, this tool becomes a potent asset, directing researchers to focus on conducting systematic reviews where they are most necessary. METHODS: Chat-GPT 3.5 was prompted to generate 10 unpublished, innovative research topics on breast reconstruction surgery, followed by 10 additional subtopics. Results were filtered for systematic reviews in PubMed, and novel ideas were identified. To evaluate Chat-GPT's power in generating improved responses, two additional searches were conducted using search terms generated by Chat-GPT. RESULTS: Chat-GPT produced 83 novel ideas, leading to an accuracy rate of 83%. There was a wide range of novel ideas produced among topics such as transgender women, generating 10 ideas, whereas acellular dermal matrix (ADM) generated five ideas. Chat-GPT increased the total number of manuscripts generated by a factor of 2.3, 3.9, and 4.0 in the first, second, and third trials, respectively. While the search results were accurate to our manual searches (95.2% accuracy), the greater number of manuscripts potentially diluted the quality of articles, resulting in fewer novel systematic review ideas. CONCLUSION: Chat-GPT proves valuable in identifying gaps in the literature and offering insights into areas lacking research in breast reconstruction surgery. While it displays high sensitivity, refining its specificity is imperative. Prudent practice involves evaluating accomplished work and conducting a comprehensive review of all components involved.

Wastewater-based epidemiology methodology to investigate human exposure to bisphenol A, bisphenol F and bisphenol S.

Wastewater-based epidemiology (WBE) has become an invaluable tool for tracking the evolution of use or exposure of/to numerous substances. Bisphenols, commonly utilized in manufacturing plastic goods, have been categorized as endocrine disrupting chemicals, underscoring the critical need for real-time data on their local-level exposure to safeguard public health. In this study, we have developed a novel analytical method and WBE framework for the assessment of population-level exposure to bisphenol A (BPA) and its most prominent substitutes, bisphenols F and S (BPF and BPS), through the determination their Phase II metabolites in wastewater by WBE. Stability and exclusivity tests denoted that glucuronides are not stable in sewage, whereas sulfate metabolites are good biomarkers. Therefore, a solid-phase extraction followed by liquid chromatography-tandem mass spectrometry method was developed for the bisphenols' monosulfates and BPA bissulfate. The analytical method was validated with three different wastewater matrices, providing trueness (as recovery) in the 79-112 % range with relative standard deviations < 12 %, and method quantification limits below 2 ng L-1 for monosulfates, but higher (35 ng L-1) for BPA bissulfate. Subsequently, the method was applied to 24h-composite raw wastewater samples collected over a week in 4 different locations in Spain and Portugal. BPA bissulfate was not detected, but the three monosulfate metabolites of each bisphenol were positively detected in the samples, being the metabolite of BPA the most prevalent, followed by those of BPF and BPS. Community-wide BPA intake was then estimated to be higher than the European Food Safety Agency (EFSA) tolerable daily intake (TDI) of 2 × 10-4 µg kg-1day-1 in all locations. In the case of BPF and BPS, there is not enough metabolism data or even established limit, but they would also surpass safe levels in several locations if a similar metabolism and TDI would be assumed. This innovative method could be used to a larger set of wastewater-treatment plants as an early-warning approach on human exposure to bisphenols.

Exploring the risk of microplastics to pollinators: focusing on honey bees.

The rapid increase in global plastic production and usage has led to global environmental contamination, with microplastics (MPs) emerging as a significant concern. Pollinators provide a crucial ecological service, while bee populations have been declining in recent years, and MPs have been recognized as a new risk factor contributing to their losses. Despite the pervasive distribution and persistence of MPs, understanding their risks to honey bees remains a critical knowledge gap. This review summarizes recent studies that investigate the toxicity of MPs on honey bee health from different perspectives. The findings revealed diverse and material-/size-/dosage-dependent outcomes, emphasizing the need for comprehensive assessments in the follow-up studies. MPs have been detected in honey and in bees' organs (e.g., gut and brain), posing potential threats to bee fitness, including altered behavior, cognitive abilities, compromised immunity, and dysfunction of the gut microbiota. It should be noticed that despite several laboratory studies suggesting the aforementioned adverse effects of MPs, field/semi-field experiments are still warranted. The synergistic toxicity of MPs with other environmental contaminants (pesticides, antibiotics, fungicides, heavy metals, etc.) still requires further investigation. Our review highlights the critical need to understand the relationships between MPs, pollinators, and the ecosystem to mitigate potential risks and ensure the sustainability of vital services provided by honey bees.

Behavioral and physiological responses of Girardia tigrina exposed to polyethylene microplastics.

Microplastic particles appear in great abundance and variety in freshwater ecosystems across the globe, spanning lakes and rivers, with increasingly frequent exposure of aquatic organisms. Studies on the mechanisms of any effects of plastic particles are still scarce, particularly in relation to the regenerative capacity of biota, for which there is no established model organism; however, planaria have shown sensitivity for assessing these risks to the aquatic environment. Thus, the present study aimed to investigate the behavioral and regeneration responses of the freshwater planaria Girardia tigrina exposed to polyethylene (PE) microplastics (MPs) incorporated into their food source. The greatest effect was observed on planarian regeneration, which was manifested at 10 µg/mg liver. Planaria reproduction and fertility were affected at 50 µg/mg liver; however, planaria locomotion was not affected at the concentrations evaluated. Mid-infrared absorption spectroscopy (FT-IR) was used to identify the constituent polymers, and ingestion of the polyethylene microplastic by the planaria was confirmed by infrared spectroscopy. The results highlight the potential adverse effects of exposure to polyethylene microplastic and show that the reproductive behavior and regeneration of a freshwater organism can be indicators of toxicity resulting from environmental pollution.

Towards Sustainable Production of Polybutylene Adipate Terephthalate: Non-biological Catalytic Syntheses of Biomass-derived Constituents.

Renewable chemicals, which are made from renewable resources such as biomass, have attracted significant interest as substitutes for natural gas- or petroleum-derived chemicals to enhance the sustainability of the chemical and petrochemical industries. Polybutylene adipate terephthalate (PBAT), which is a copolyester of 1,4-butanediol (1,4-BDO), adipic acid (AA), and dimethyl terephthalate (DMT) or terephthalic acid (TPA), has garnered significant interest as a biodegradable polymer. This study assesses the non-biological production of PBAT monomers from biomass feedstocks via heterogeneous catalytic reactions. The biomass-based catalytic routes to each monomer are analyzed and compared to conventional routes. Although no fully commercialized catalytic processes for direct conversion of biomass into 1,4-BDO, AA, DMT, and TPA are available, emerging and promising catalytic routes have been proposed. The proposed biomass-based catalytic pathways toward 1,4-BDO, AA, DMT, and TPA are not yet fully competitive with conventional fossil fuel-based pathways mainly due to high feedstock prices and the existence of other alternatives. However, given continuous technological advances in the renewable production of PBAT monomers, bio-based PBAT should be economically viable in the near future.

Study on significance of pillar dimensions on stability of caverns in rocks with high overburden.

The present study aims to examine the influence of pillar widths on the stability of caverns. Case study considering two caverns viz. Powerhouse Cavern (PHC) and Transformerhall Cavern (TC), in a major hydro-electric project in the eastern Himalayas is considered. 2D and 3D numerical analysis was carried out for w/B ratios 1.5 and 3.0 respectively. Primary aspects like major principal stress and development of plastic zone were investigated for the two pillar widths. An optimum pillar width was observed that resulted in reduced stress acting along the cavern periphery, a better stress distribution, and no overlap of plastic zones between the caverns. Further, the optimum pillar width resulted in a better stress-redistribution with progress of excavation and the in-situ stress became constant at an earlier stage of excavation. Observations from comparative analysis revealed that a pillar width nearly equal to the largest dimension or twice the width of the larger of the caverns in the group resulted in a better stability and hence can be considered as the optimum width. Furthermore, the analysis suggests that along the pillar width, maximum stress was observed at mid-height, and it is more in the vicinity of the face of the caverns.

The Duration of Dry Events Promotes PVC Film Fragmentation in Intermittent Rivers.

The majority of microplastics (MPs) found in the environment originate from plastic fragmentation occurring in the environment and are influenced by environmental factors such as UV irradiation and biotic interactions. However, the effects of river drying on plastic fragmentation remain unknown, despite the global prevalence of watercourses experiencing flow intermittence. This study investigates, through laboratory experiments, the coupled effects of drying duration and UV irradiation on PVC film fragmentation induced by artificial mechanical abrasion. This study shows that PVC film fragmentation increases with drying duration through an increase in the abundance and size of formed MPs as well as mass loss from the initial plastic item, with significant differences for drying durations >50% of the experiment duration. The average abundance of formed MPs in treatments exposed to severe drying duration was almost two times higher than in treatments nonexposed to drying. Based on these results, we developed as a proof of concept an Intermittence-Based Plastic Fragmentation Index that may provide insights into plastic fragmentation occurring in river catchments experiencing large hydrological variability. The present study suggests that flow intermittence occurring in rivers and streams can lead to increasing plastic fragmentation, unraveling new insights into plastic pollution in freshwater systems.

Complete 2,4,6-trichlorophenol degradation by anaerobic sludge acclimated with 4-chlorophenol: Synergetic effect of nZVI@BMPC and sodium lactate as an external nutrient.

Ball-milled plastic char supported nano zero-valent iron (nZVI@BMPC) and their application combined with anaerobic sludge for microbial dechlorination of 2,4,6-trichlorophenol (2,4,6-TCP) were investigated. The XRD and FTIR analysis proved composition of zero valent states of iron, and the BET and SEM analysis showed that nZVI was uniformly distributed on the surface of BMPC. Successive addition of 1000 mg/L sodium lactate and nZVI@BMPC enhanced the acclamation of anaerobic sludge and resulted in the degradation of 4-CP within 80 days. The acclimated consortium with nZVI@BMPC completely degraded 2,4,6-TCP into CH4 and CO2, and the key dechlorination route was through 4-CP dechlorinaion and mineralization. The degradation rate of 2,4,6-TCP with nZVI@BMPC was 0.22/d, greater than that without nZVI@BMPC. The dechlorination efficiency was enhanced in the Fe2+/Fe3+ system controlled by nZVI@BMPC and iron-reducing bacteria. Metagenomic analysis result showed that the dominant de-chlorinators were Chloroflexi sp., Desulfovibrio, and Pseudomonas, which could directly degrade 2,4,6-TCP to 4-CP, especially, Chloroflexi bacterium could concurrently be used to mineralize 4-CP. The relative abundance of the functional genes cprA, acoA, acoB, and tfdB increased significantly in the presence of the nZVI@BMPC. This study provides a new strategy can be a good alternative for possible application in groundwater remediation.

Structural Elucidation of a Metagenomic Urethanase and Its Engineering Towards Enhanced Hydrolysis Profiles.

While plastics like polyethylene terephthalate can already be degraded efficiently by the activity of hydrolases, other synthetic polymers like polyurethanes (PUs) and polyamides (PAs) largely resist biodegradation. In this study, we solved the first crystal structure of the metagenomic urethanase UMG-SP-1, identified highly flexible loop regions to comprise active site residues, and targeted a total of 20 potential hot spots by site-saturation mutagenesis. Engineering campaigns yielded variants with single mutations, exhibiting almost 3- and 8-fold improved activity against highly stable N-aryl urethane and amide bonds, respectively. Furthermore, we demonstrated the release of the corresponding monomers from a thermoplastic polyester-PU and a PA (nylon 6) by the activity of a single, metagenome-derived urethanase after short incubation times. Thereby, we expanded the hydrolysis profile of UMG-SP-1 beyond the reported low-molecular weight carbamates. Together, these findings promise advanced strategies for the bio-based degradation and recycling of plastic materials and waste, aiding efforts to establish a circular economy for synthetic polymers.

Volumetric Additive Manufacturing of Dicyclopentadiene by Solid-State Photopolymerization.

Polymerization in the solid state is generally infeasible due to restrictions on mobility. However, in this work, the solid-state photopolymerization of crystalline dicyclopentadiene is demonstrated via photoinitiated ring-opening metathesis polymerization. The source of mobility in the solid state is attributed to the plastic crystal nature of dicyclopentadiene, which yields local short-range mobility due to orientational degrees of freedom. Polymerization in the solid state enables photopatterning, volumetric additive manufacturing of free-standing structures, and fabrication with embedded components. Solid-state photopolymerization of dicyclopentadiene offers a new paradigm for advanced and freeform fabrication of high-performance thermosets.

A review of plastic waste nanocomposites: assessment of features and applications.

Hundreds of millions of metric tons of plastic waste are generated globally every year. Processing waste into secondary raw material is preferred over energy production and landfilling. However, mechanical recycling generally deteriorates the properties of plastic waste limiting its range of potential applications. Nanocomposite fabrication is a solution to recycle plastic waste into value-added applications due to improved properties generated by nanomaterial reinforcement, however received little study. The aim of this review is to present the current status, identify research gaps and provide topics for further research of polymer nanocomposites prepared from plastic waste in respect to utilized materials, processing methods, enhanced properties, sustainability, economics, nanomaterial safety, and applications. It is found that morphological, mechanical, thermal, flame retardancy, physical, barrier, electrical and shielding properties of plastic waste can be enhanced with low loadings of different nanomaterials making them promising materials for various applications including electronic, shielding, thermal, packaging, filtration, and water treatment. Utilization of plastic waste instead of virgin polymers can be beneficial in respect to economics and sustainability, but the energy intensive and expensive production of the most nanomaterials, and the plastic waste pretreatment methods can negate these benefits. To enhance sustainability, further research should be conducted on utilization of energy friendly nanomaterials in plastic waste nanocomposites. Further research is needed also on polymer nanocomposite safety because of the unknow composition of the plastic waste and the potential for nanomaterial release during nanocomposite's life cycle. All in all, further research and national regulations and guidance are needed on virgin polymer and plastic waste nanocomposites.

Efficacy of different stent types in post-liver-transplant anastomotic biliary strictures: a systematic review and meta-analysis.

Background: Stent selection in the endoscopic management of post-liver-transplant anastomotic biliary strictures remains controversial. This systematic review and meta-analysis aimed to evaluate the potential differences between available stents. Methods: MEDLINE, Cochrane, and Scopus databases were searched until April 2023 for comparative studies evaluating stricture management using multiple plastic stents (MPS) and self-expandable metal stents (SEMS), including fully-covered (FC)- and intraductal (ID)-SEMS. The primary outcome was stricture resolution, while secondary outcomes included stricture recurrence, stent migration and adverse events. Meta-analyses were based on a random-effects model and the results were reported as odds ratios (OR) with 95% confidence intervals (CI). Subgroup analyses by type of metal stent and a cost-effectiveness analysis were also performed. Results: Nine studies (687 patients) were finally included. Considering stricture resolution, SEMS and MPS did not differ significantly (OR 0.99, 95%CI 0.48-2.01; I 2=35%). Stricture recurrence, migration rates and adverse events were also comparable (OR 1.71, 95%CI 0.87-3.38; I 2=55%, OR 0.73, 95%CI 0.32-1.68; I 2=56%, and OR 1.47, 95%CI 0.89-2.43; I 2=24%, respectively). In the subgroup analysis, stricture resolution and recurrence rates did not differ for ID-SEMS vs. MPS or FC-SEMS vs. MPS. Migration rates were lower for ID-SEMS compared to MPS (OR 0.28, 95%CI 0.11-0.70; I 2=0%), and complication rates were higher after FC-SEMS compared to MPS (OR 1.76, 95%CI 1.06-2.93; I 2=0%). Finally, ID-SEMS were the most cost-effective approach, with the lowest incremental cost-effectiveness ratio: 3447.6 £/QALY. Conclusion: Stent type did not affect stricture resolution and recurrence; however, ID-SEMS placement was the most cost-effective approach compared to the alternatives.