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The presence of fever buy cheap endep symptoms zollinger ellison syndrome, chills order endep no prescription medications used for migraines, and low back pain can indicate involvement of the kidneys buy endep 50mg without prescription medicine hollywood undead. The presence of additional symptoms caused by other conditions can confuse the diagnosis even further purchase endep 10 mg with mastercard treatment junctional rhythm. That is especially true if you are also experiencing fever, abdominal or ﬂank pain, or nausea and vomiting. If a urine culture indicates the presence of bacteria, it is appropriate to follow up with another culture 7 to 14 days after treatment is started to ensure it has been resolved. Notify your physician if any change occurs in your condition (fever, more painful urination, low back pain, etc. For most bladder infections, especially those that are chronic or recurrent, the best treatment appears to be the natural approach. There is a growing concern that antibiotic therapy actually promotes recurrent bladder infection by disturbing the bacterial ﬂora of the vagina and by giving rise to antibiotic-resistant strains of E. One of the body’s most important defenses against bacterial colonization of the bladder is a protective shield of healthful bacteria that line and protect the external portion of the urethra. When antibiotics are used, this normal protective shield can be stripped away or replaced by less effective organisms. If a woman tends to suffer from recurrent bladder infections, or if antibiotics have been used, it is appropriate to reintroduce friendly bacteria into the vagina. The best way to do this is to use commercially available Lactobacillus acidophilus products. Use a product that is a capsule or tablet, and simply place one or two in the vagina before going to bed, every other night for two weeks. In addition, oral supplementation with a probiotic is recommended (5 billion to 10 billion live bacteria per day). Speciﬁcally, this refers to enhancing the ﬂow of urine by achieving and maintaining proper hydration, promoting a pH that inhibits the growth of infectious organisms, preventing bacterial adherence to the endothelial cells of the bladder, and enhancing the immune system. In addition, several botanical medicines with antimicrobial activity can be employed. Eliminating food allergens appears to be a valid goal, as food allergies have been shown to produce cystitis in some patients. Repeated ingestion of a food allergen could easily explain the chronic nature of interstitial cystitis. Speciﬁcally, gotu kola extracts have been shown to heal ulcerations of the bladder and to improve the integrity of the connective tissue that lines the bladder wall. Increasing Urine Flow Increasing urine ﬂow can be easily achieved by increasing the amount of liquids consumed. Ideally, the liquids should be in the form of water, herbal teas, and fresh fruit and vegetable juices diluted with at least an equal amount of water. Drink at least 64 ﬂ oz from this group, with at least half of this amount being water. Although many practitioners believe acidifying the urine is the best approach in addressing cystitis, several arguments can be made for alkalinizing the urine. Many popular methods of attempting to acidify the urine, such as vitamin C supplementation and cranberry juice, have little effect on pH at commonly prescribed doses. These salts are rapidly absorbed and metabolized without affecting gastric pH or producing a laxative effect. They are often used for temporary relief until the results of a urine culture are available. There was more variation in response to treatment in the group of women with proven bacterial infection, with those having symptoms of urethral pain (7 of 10) and dysuria (13 of 18) improving more than those with symptoms of frequency (9 of 17) and urgency (6 of 13). These results were similar to those of a previous study that demonstrated signiﬁcant symptomatic relief in 80% of the 159 women who did not have bacteria in their urine. Rather than its action as an antibiotic or acidifying the urine, the most likely explanation for cranberry’s beneﬁcial effects are that components known as proanthocyanidins interfere with the adherence of bacteria to the cells that line the urinary tract. In order to cause an infection in the urinary tract, bacteria must ﬁrst attach to these cells. And, in the case of an active infection, the proanthocyanidins can make it too “slippery” for the bacteria to maintain their hold. In the studies looking at cranberry and bacterial adherence, cranberry was found to decrease adherence in more than 60% of the strains of bacteria tested. The effectiveness of cranberry may be enhanced by using well-deﬁned preparations standardized for proanthocyanidin content rather than commercial cranberry juice. Most cranberry juices on the market contain one-third cranberry juice mixed with water and sugar. Since sugar has such a detrimental effect on the immune system (see the chapter “Immune System Support”), use of sweetened cranberry juice cannot be recommended. Fresh cranberry juice (sweetened with blueberry juice) or blueberry juice is preferred. One study did compare the efﬁcacy and cost of taking a cranberry extract (CranMax) in tablet form vs. Both cranberry juice and cranberry tablets signiﬁcantly decreased the number of patients experiencing at least one symptomatic infection per year (20% and 18%, respectively) compared with a placebo (32%). The average annual cost of cranberry tablets was $624, whereas the juice cost $1,400. The possible explanation again is that since cranberry proanthocyanidins do not prevent the adhesion of all types of bacteria to the urinary tract lining, cranberry may not be effective in all cases. The bottom line is that cranberry is very safe and can be quite effective, so it is worth using. One sure beneﬁt is that cranberry ingestion can signiﬁcantly reduce strong urinary odor—a common problem in elderly people, especially those in nursing homes or assisted living facilities. It has been used by women for centuries, with the ﬁrst recorded use in the thirteenth century. It exerts urinary antiseptic activity by means of its component arbutin, which typically makes up 6. It is the hydroquinone that prevents bacterial growth, and it is most effective in an alkaline urine. The preventive effect of a standardized uva ursi extract on recurrent cystitis was evaluated in a double-blind study of 57 women. These impressive results indicate that regular use of uva ursi, like cranberry, may prevent bladder infections. Uva ursi has also been shown to be helpful in increasing the susceptibility of antibiotic-resistant bacteria to antibiotics. Goldenseal Goldenseal (Hydrastis canadensis) is one of the most effective of the herbal antimicrobial agents. Its long history of use by herbalists and naturopathic physicians for the treatment of infections is well documented in the scientiﬁc literature. Immune Support See the chapter “Immune System Support,” for a complete discussion on how to optimize the functioning of your immune system. Owing to the possibility of a kidney infection, it is imperative to consult a physician if there is fever, low back pain, nausea, or vomiting. Although the occasional acute bladder infection is easily treated, dealing with chronic cystitis can be a challenge.
If the patient is intubated using succinylcholine as a paralytic cheap endep online visa shinee symptoms mp3, he will lose his pulse and demonstrate a wide-complex tachycardia (consistent with severe hyperkalemia) on the monitor discount endep online master card medicine used for uti. Predictors of respiratory failure include inability to cough order endep symptoms 0f pregnancy, stand buy 25 mg endep withdrawal symptoms, lift the elbows or head, and elevated liver enzymes. As with any demyelinating disorder, acetyl cholinesterase receptors are upregu- lated. This can cause severe, prolonged hyperkalemia when a depolarizing neu- romuscular blocker is used. The pain is intermittent, feels tight and squeezing and has been increasing in severity. She denies diarrhea, fever, dysuria, chest pain, vaginal bleeding, or shortness of breath. Abdomen: bilateral lower quadrant tenderness with guarding; bowel sounds normal, mild distension, no masses, no hernias, nontender at McBurney’s point, negative Murphy sign g. Patient: continues to have signifcant pain (until a total of 6 mg of morphine or equivalent is administered) 152 Case 32: Abdominal Pain and Vomiting H. The patient is at increased risk of obstruction because of her prior abdominal surgeries, which can lead to scar- ring and adhesions that may block proper fow of intestinal contents. If fuids are not administered, the patient may become tachycardic and hypotensive. Her pain will continue to increase until an opioid medication (such as morphine) is administered. If a nasogastric tube is not placed after diagnosis, the patient may continue vomiting and aspirate. The x-rays may reveal distended loops of small bowel and the upright abdominal flm may show a pattern of intestinal air-fuid arranged similarly to a stepladder proximal to the obstruction. Middle-aged and elderly patients with epigastric pain should be evaluated for coronary ischemia. Nonchest pain presentations are common in this age group, especially upper abdominal pain and/or shortness of breath. If an immediate operation is advocated or if the patient has signs of peritonitis or ischemia, the patient should be given broad-spectrum antibiotics. Surgical intervention is often needed to correct obstruction although a trial of medical management initially can be pursued for obstruction that has not been complicated by ischemia, peritonitis, or bowel perforation. The pain is in the left chest and is accompanied by left arm tingling but no radiation of pain to the back, arm, or jaw. General: alert and oriented, slightly agitated and uncomfortable due to chest pain b. Abdomen: minimally tender in umbilical region; no masses, bowel sounds normal, no distension g. The patient’s symp- toms of chest pain were likely due to cocaine-induced vasoconstriction of the coronary arteries. If benzodiazapines are not administered, the patient will become more tachycardic and hypertensive. Chest pain in the context of cocaine use may be caused by etiologies that are cardiac (such as myocardial ischemia/infarction, aortic dissection, or endocar- ditis with septic pulmonary emboli) or noncardiac (such as those from inha- lation-related barotraumas including pneumomediastinum, pneumothorax, pneumopericardium, pulmonary hemorrhage/infarction). Benzodiazapines (eg, lorazapam or diazepam) are useful to treat hypertension and tachycardia and thus reduce myocardial oxygen demand. Avoid haloperi- dol, droperidol, and chlorpromazine, as they may contribute to hyperthermia and may lower the seizure threshold. Treat potential ischemia or acute coronary syndromes according to standard protocol, including nitrates, morphine, oxygen, aspirin and possible hepa- rin and stress test and/or cardiac catheterization. Traditionally, b-adrenergic antagonists have been avoided because of concern that unopposed a-adrenergic stimulation may exacerbate symptoms. An hour ago, the patient was noted by his mother to feel warm and was given ibuprofen. Patient’s mother was rechecking his temperature when he had generalized, rhythmic shaking with eyes rolling back. The patient has had rhinor- rhea for the past 2 days, but no cough, vomiting, or diarrhea and no fever before today. Neuro: awake, alert, appropriate for age; gait normal for age; can reach, grab, and hold onto objects with each hand j. Discussion with patient’s parents about diagnosis, prevention, precautions, and follow-up c. Critical actions == Detailed history and physical examination to assess for meningitis or other obvious bacterial infection == Acetaminophen administered every 4 hours or ibuprofen every 6 hours to reduce fever == Counsel parents about simple febrile seizures and follow-up L. If acetamino- phen or ibuprofen has not been given, the fever will persist and the patient will Case 34: seizure Case 35: Chest Pain 161 seize. A simple febrile seizure can be presumed in children with a normal neurological examination after a generalized seizure lasting less then 15 minutes in the setting of fever. Laboratory evaluation (other than perhaps a glucose fLaboratory evaluation (other than perhaps a glucose fnger stick), lumbar punc-nger stick), lumbar punc- ture, and hospitalization are almost never needed for children with a simple febrile seizure. Treatment of simple febrile seizure is aimed at its etiology; acetaminophen or ibuprofen should be given to treat fevers. Hospitalization for children with a simple febrile seizure is not needed unless the seizure recurs within several hours to 1 day and/or if the fever has a com- plicated etiology not easily treated at home. The pain is located in the right chest under the breast, is stabbing, radiates to her back, and is worse with breathing. Extremities: pitting edema in left leg; normal capillary refll; no calf tenderness i. Heparin sodium bolus and drip or low molecular weight heparin (such as enoxaparin) ii. If a major contraindication to heparin is present (eg, recent large cerebral infarction or major trauma), consider emergent infe- rior vena cava flter placement. Breathing: some stridor, coughing noted; breath sounds otherwise clear and equal bilaterally, no accessory muscle use or retractions c. Pharynx: nonproductive cough, some stridor; diffuse bilateral wheezing; breath sounds equal bilaterally; no accessory muscle use or retractions e. Abdomen: nontender, no masses, bowel sounds normal, no distension, no peri- toneal signs. Give parents prescription for epinephrine autoinjector, diphenhydramine, ranitidine, and steroids d. If epinephrine and diphenhydramine are not given, respiratory distress should continue and worsen. If the patient is monitored for less than 4 hours, the patient will have a relapse of respiratory distress. Most fatalities from anaphylaxis happen within 30 minutes of antigen expo-Most fatalities from anaphylaxis happen within 30 minutes of antigen expo- sure. Fatalities occur from bronchospasm, laryngeoedema, and/or cardiovascu- lar collapse. Multiple boluses may be required, as patients often lose vascular tone with multisystem involvement.
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Supplementation with zinc has been shown to reestablish normal thyroid function in hypothyroid patients who were zinc deﬁcient buy generic endep on-line treatment 32 for bad breath, even though they had supposedly normal serum T levels cheap endep 25mg without prescription medicine allergies. Vitamin B2 (riboﬂavin) buy endep on line medications via endotracheal tube, B3 (niacin) generic endep 50mg overnight delivery treatment goals and objectives, B6 (pyridoxine), and C are also necessary for normal thyroid hormone manufacture. Exercise Exercise is particularly important in a treatment program for hypothyroidism. Exercise stimulates thyroid gland secretion and increases tissue sensitivity to thyroid hormone. Many of the health benefits of exercise may be a result of improved thyroid function. The health beneﬁts of exercise are especially important in overweight hypothyroid individuals who are dieting. A consistent effect of dieting is a decrease in the metabolic rate as the body strives to conserve fuel. Diet The recommendations given in the chapter “A Health-Promoting Diet” are suitable, with the following caveat: the diet should be low in raw goitrogens and high in foods rich in the trace minerals needed for thyroid hormone production and activation. Goitrogens to be limited include brassica-family foods (turnips, cabbage, rutabagas, mustard greens, radishes, horseradishes), cassava root, soybeans, peanuts, pine nuts, and millet. When these foods are eaten, they should be cooked to break down their goitrogenic constituents. We also recommend ruling out gluten sensitivity, as gluten may lead to the formation of thyroid-related autoantibodies in sensitive individuals. Infertility (Female) • Inability to conceive a child after 12 months of regular, unprotected intercourse at least twice weekly with the same male partner and in the absence of male causes. It is estimated that one in seven couples in the United States experiences infertility. The normal monthly success rate for couples trying to conceive naturally at age 25 is 25%. Fecundity is deﬁned as the couple’s chance of conception in a single menstrual cycle. A couple’s fecundity is generally highest in the ﬁrst three months of unprotected sex; successful conception rates decline gradually thereafter. By age 40, half of women will have completely lost their capacity for reproduction. By 45 years of age, the fertility rate is only 1 pregnancy per 100 inseminated women. The general recommendations in this chapter can be used along with conventional medical treatments. It is important to realize that there are three types of patients suffering from infertility: • Those who achieve pregnancy by maximizing their fertility • Those who require assistance in the form of in vitro fertilization and other assisted-reproduction technologies • Those who simply cannot get pregnant owing primarily to age, genetic disorders, or various health conditions that compromise fertility The ﬁrst step to successful conception is timing the attempt of conception during a woman’s window of fertility. A widely held misinterpretation is that frequent ejaculations decrease male fertility. A retrospective study analyzed 9,489 men with normal semen quality, sperm concentrations, and motility and found that proﬁles remained normal even with daily ejaculation. So, in other words, daily intercourse is probably more important than trying to time it just right. Hence, the fertility window is best deﬁned as the six-day interval ending on the day of ovulation. Body Fat Percentage For optimal fertility, women need to ensure that their body fat percentage is between 20 and 25%. A body fat percentage below 17% can result in irregular menstrual cycles, and some research suggests that even after ideal body fat levels have been achieved, it can take as long as two years before regular conception occurs. Obesity increases the risk for miscarriage, birth defects, and pregnancy complications. Environmental Factors Industrialization and the use of agricultural chemicals has contributed to increased exposure to thousands of chemicals now associated with negative impact on male and female infertility. Exposure to environmental toxins such as radiation, heavy metals, and chemicals can cause oxidative stress and damage, negatively affecting female fertility. These issues are more fully discussed in the chapter “Infertility (Male)” but also apply to female infertility. Smoking Cigarette smoking, whether active or passive, reduces both pregnancy rates and long-term ovarian function. Additionally, smokers are more likely to have premature menopause, thus making smoking one of the easiest preventable causes of infertility. Smoking appears to reduce fertility by having a direct effect on the uterus, eggs, and embryo. Considering that the average age for conception today is 30 and fertility tends to decline greatly after 38 years of age, it should be obvious that a woman trying to get pregnant needs to stop smoking. Even passive smoking is associated with reduced fertility and decreases the chance of a healthy live birth in both fertile and infertile populations. In addition, diuretic properties will increase the loss of nutrients that are beneficial to fertility. Alcohol The effect of alcohol intake on female fertility is variable from one woman to the next, but there is no question that it can negatively affect fertility in many women. One study estimated that as little as one drink per week could lead to a 50% reduction in conception. It is a well-known fact that alcohol intake during pregnancy can produce fetal abnormalities. Diet and Lifestyle There is abundant scientiﬁc research showing the importance of nutrition and lifestyle to a woman’s fertility. Speciﬁcally, research clearly indicates that eating a healthful diet improves the chances for ovulation, conception, and the birth of a healthy child. In particular, it is important to point out that iron deﬁciency is the most common nutritional deﬁciency in women and can be a cause of infertility. A high antioxidant intake, both dietary and supplemental, improves fertility in women as well as reduces the risk for miscarriage. Arginine Arginine is a precursor to the synthesis of nitric oxide, which is required for the formation of new blood vessels to nourish the developing fetus, as well as other aspects of fertility. Probiotics Alterations in the microﬂora of the vagina and subsequent genital and intrauterine infections have been linked to reproductive failure and adverse pregnancy outcomes such as preterm labor, miscarriage, and spontaneous preterm birth. Botanical Medicines Chasteberry The best-documented herb for improving fertility is chasteberry (Vitex agnus-castus). It seems to be especially useful when there is an elevation in the hormone prolactin, which can disrupt the menstrual cycle and contribute to infertility. Chasteberry can inhibit prolactin secretion and has been shown to correct menstrual irregularities caused by mild elevations of prolactin. General Recommendations • Identify and eliminate exposure to environmental hazards, including pesticides, solvents, heavy metals, and other toxins • Utilize effective stress-reduction techniques (employ psychological counseling if needed) • Avoid cigarette smoking, alcohol, and recreational drugs • Avoid douches, vaginal sprays, scented tampons, or other feminine products that change the pH of the vagina and disturb vaginal microecology. If you are using the liquid extract, the typical dosage is 2 to 4 ml (1/2 to 1 tsp) per day. Infertility (Male) • Inability to conceive a child after six months of unprotected sex at least twice weekly with the same partner in the absence of female causes • A total sperm count lower than 5 million/ml • The presence of greater than 50% abnormal sperm • Inability of sperm to impregnate egg, as determined by the postcoital or hamster-egg penetration tests Infertility affects about 7. It is estimated that one in seven couples in the United States experiences infertility.
A second glass microscope slide placed on top of the first allows the sample to spread between the two Sample Collection by Aspiration glass surfaces when the slides are pulled horizontally Fine-needle aspiration biopsy is a simple buy endep 25 mg visa jnc 8 medications, inexpen- apart trusted endep 10 mg medications while pregnant. Two specimens for cytologic examination are sive procedure for obtaining material for cytologic thus created buy discount endep 75mg online medications and pregnancy. Using an alcohol swab generic 25 mg endep amex 2c19 medications, the “squash preparation technique” because the sam- the skin overlying the biopsy site is cleansed and ple is compressed between the two slide surfaces. A hypodermic needle (eg, 22 ga, Abdominocentesis is an aspiration biopsy procedure one-inch needle) attached to a syringe (12 ml or used to collect cytologic samples from birds with larger) is inserted into the tissue to be sampled. The abdominal space vacuum is applied to the syringe using the syringe is small in normal birds and contains little fluid. Because the abdominal air sacs occupy a large por- tion of the abdomen, it is difficult to enter the perito- neal cavity of normal birds. However, as peritoneal fluids accumulate, the air sacs are compressed later- ally, increasing the size of the peritoneal cavity and making it easier to sample. Abdominocentesis begins with a surgical preparation of the site along the ventral midline just distal to the point of the keel. The needle (21 to 25 ga, one-inch) is attached to a syringe and is directed through the body wall at the midline, pointing toward the right side of the abdo- men to avoid the ventriculus, which lies to the left of the midline (Figure 10. The abdominal fluid is aspirated into the syringe and prepared for cytologic examination, either by making a direct smear as one would prepare a blood film or by using a concentra- tion method. The goal of abdominocentesis is to collect fluid from the abdominal cavity for diagnostic purposes. The material that is collected (eg, gut contents, unwillingness to fly and depression. The hen had been incubating egg yolk, cells from a mass) should be evaluated with eggs, and it was uncertain how long she had been clinically symp- respect to its potential source. The masses in areas where the skin avian species (macaws) will produce small quantities was thin appeared grossly as small, white-to-yellow nodules. Cy- of fluid in response to egg-related peritonitis, while tologic examination of a fine-needle aspirate from the mass re- others (cockatiels) will produce voluminous fluids. Articular gout is common in birds that become dehydrated or that have primary or secondary renal disease. The fluid is placed in a plastic test tube and centrifuged at 600 G (gravity) for ten minutes. Unlike urine sediments, cytologic sediments from poorly cellular fluids do not have a visible button or pellet at the bottom of a spun tube. Therefore, the concentrated cells are usually obtained by aspirating the fluid at the bottom of the tube into a pipette or syringe. The sample is then placed onto a microscope slide and a smear is made in the manner described for concentrating cells in a smear. Special cytocentri- fuge equipmenta is available for concentrating cells on microscope slides while absorbing the fluid onto filter paper. This equipment is expensive and not practical for the average veterinary laboratory. Because centrifugation distorts the appearance of the cells, a cell concentration method that utilizes gravity provides a concentrated sample with normal appearing cells. A simple, inexpensive sedimentation device can be made for use in the veterinary labora- tory. This device consists of a base to support the slide and a clamping mechanism to hold the fluid column onto the microscope slide (Figure 10. The column that holds the fluid is made from a one millimeter tuberculin syringe barrel with the tip removed. The base of the syringe barrel allows for the syringe to be held in place by a clamp (usually made of wood). A piece of filter paper (eg, Whatman #2) is cut to the dimensions of the microscope slide and a standard 2 mm paper hole punch is used to create a hole in the center of the filter paper. Fluid samples having low cellularity require a con- centration procedure for easier examination of the cells. A simple method is to marginate the cells on a smear made by the conven- tional wedge technique used for making blood films. A drop of the fluid sample is placed on a microscope slide and spread slowly using a spreader slide. Just prior to reaching the end of the smear, the spreader slide is quickly backed slightly into the advancing smear, just before lifting it from the surface of the slide containing the smear. This should produce a slide with the marginated cells concentrated at the end of the film. A simple device that uses gravity to concentrate cells provides cytologic samples of better quality than centrifugation (courtesy of Terry Campbell). The clamp is used to secure the aspirated into the tube using a syringe attached to column to the slide. In cases where allowed to stand undisturbed, the fluid is drawn by material cannot be aspirated for examination, a gravity and absorbed into the filter paper. The cells wash sample can be obtained by infusing a small in the fluid fall onto the surface of the slide where amount of sterile isotonic saline into the crop and they adhere. Once the fluid has drained from the aspirating the fluid back into the tube and syringe. After staining, the cells can be Aspiration of the infraorbital sinus of birds suffering found concentrated in the two millimeter circle cre- from sinusitis can provide diagnostic material for ated by the filter paper and column. One technique of sinus aspiration in psittacine birds samples the large Cytologic evaluation of the ingluvies (crop) can be sinus between the eye and the external nares (Figure performed from samples obtained by aspiration. With the head and body properly restrained, a is indicated in birds showing clinical signs of regur- needle (eg, 22 ga one-inch) is passed through the gitation, vomiting, delayed emptying of the crop or fleshy skin at the commissure of the mouth. A crop aspirate is obtained by needle is directed toward a point midway between inserting a sterile plastic, metal or rubber feeding the eye and external nares, keeping parallel with the tube through the mouth and esophagus into the side of the head. The tube should pass matic bone, which lies between the lower corner of freely and not be forced into the crop. Often the tube is facilitated by extending the head and neck to passage of the needle is improved by keeping the straighten the esophagus. This procedure requires some practice and complete restraint to prevent damage to the globe. A caudally misdirected needle could mouth, directing the needle under the zygomatic result in penetration of the ocular orbit; however, bone and ending in the sinus cavity below the eye more commonly, a misdirected needle results in pene- (Figure 10. It is impor- Collection of synovial fluid by arthrocentesis is an- tant to note that in some species (eg, some passerine other example of sample collection by aspiration. Therefore, a surgery, a needle (22 ga or smaller) attached to a bilateral sinusitis may require bilateral aspirations. The cytologic adequate sample, the anesthetized bird may be held sample is prepared by making direct smears using with the head parallel to the floor and the affected the “squash preparation technique. The sinus is flushed from underneath Wash samples are aspiration techniques in which a with the needle directed up; see Chapter 22). This sinus usually yields collect a cytologic sample from locations that may be a smaller sample volume than the previously de- difficult to sample or that provide a poorly cellular scribed sinus.