The HIV et AIDS and STI National Strategic Plan 2007-2011: a Paediatric Perspective

Objective. To analyse paediatric-specific goals and objectives in the HIV et AIDS and STI National Strategic Plan (NSP) for South Africa 2007 - 2011. Methods. This paper reviews key interventions described in the NSP regarding HIV prevention; management and treatment in children under 14 years of age. A general overview of the plan and its implications for the health system was previously published. Results. The NSP contains 4 priority areas; which were disaggregated into 19 goals. Each goal specifies several clearly worded objectives together with 5-year targets; and identifies lead agencies responsible for the achievement of these targets. Nine of the 19 goals (47) address interventions which mention or affect children directly. Paediatric-specific objectives encompass HIV prevention and treatment; legislation; social security; education; mental health; and developmental monitoring. If implemented comprehensively; it will appreciably improve the country's chances of achieving Millennium Development Goal 4; i.e. the reduction by two-thirds of the mortality rate among children under 5 years of age by 2015. However; substantial resources are required to achieve the goals and objectives of the NSP; including legal and policy amendments. Conclusion. The NSP is an important framework document; which should provide the necessary direction for addressing the paediatric HIV epidemic in South Africa

A model study of changes in excitability of ventricular muscle cells: inhibition, facilitation, and hysteresis.

A model study was carried out to investigate the mechanism of changes in excitability at long cycle lengths (i.e., > 1,000 ms), which are responsible for various phenomena, including electrotonic inhibition, active facilitation, and hysteresis of excitability in ventricular muscle at slow frequencies of stimulation. Experimental studies suggested that with repetitive activity the inward rectifier potassium current (IK1) is not a passive component of membrane response and that the dynamics of IK1 are responsible for the changes in excitability at long cycle lengths. In the present study, we have used new experimental data as the basis to modify the equations for IK1 in the ionic model for ventricular muscle of the Luo and Rudy (LR) model. The modified equations for IK1 incorporate an additional slow gate (s-gate), which governs the transition from a high steady-state conductance at rest to a lower conductance with repetitive stimulation. In simulation studies, electronic inhibition was seen in the original and the modified LR model and was shown to depend on changes in the delayed rectifier current (IK). However, addition of the s-gate to IK1 of the LR model extended the frequency dependence of excitability to longer cycle lengths and allowed for the demonstration of active facilitation and hysteresis. These results support the hypothesis that the inward rectifier is involved in the dynamic control of membrane excitability. The overall results provide mechanistic explanations for heart rate-dependent excitation abnormalities that may be involved in the genesis of cardiac arrhythmias.

Electrotonic inhibition and active facilitation of excitability in ventricular muscle.

INTRODUCTION: The effects of subthreshold electrical pulses on the response to subsequent stimulation have been described previously in experimental animal studies as well as in the human heart. In addition, previous studies in cardiac Purkinje fibers have shown that diastolic excitability may decrease after activity (active inhibition) and, to a lesser extent, following subthreshold responses (electrotonic inhibition). However, such dynamic changes in excitability have not been explored in isolated ventricular muscle, and it is uncertain whether similar phenomena may play any role in the activation patterns associated with propagation abnormalities in the myocardium. METHODS AND RESULTS: Experiments were performed in isolated sheep Purkinje fibers and papillary muscles, and in enzymatically dissociated guinea pig ventricular myocytes. In all types of preparations introduction of a conditioning subthreshold pulse between two suprathreshold pulses was followed by a transient decay in excitability (electrotonic inhibition). The degree of inhibition was directly related to the amplitude and duration of the conditioning pulse and inversely related to the postconditioning interval. Yet, inhibition could be demonstrated long after (> 1 sec) the end of the conditioning pulse. Electronic inhibition was found at all diastolic intervals and did not depend on the presence of a previous action potential. In Purkinje fibers, conditioning action potentials led to active inhibition of subsequent responses. In contrast, in muscle cells, such action potentials had a facilitating effect (active facilitation). Electrotonic inhibition and active facilitation were observed in both sheep ventricular muscle and guinea pig ventricular myocytes. Accordingly, during repetitive stimulation with pulses of barely threshold intensity, we observed: (1) bistability (i.e., with the same stimulating parameters, stimulus:response patterns were either 1:1 or 1:0, depending on previous history), and (2) abrupt transitions between 1:1 and 1:0 (absence of intermediate Wenckebach-like patterns). Simulations utilizing an ionic model of cardiac myocytes support the hypothesis that electrotonic inhibition in well-polarized ventricular muscle is the result of partial activation of IK following subthreshold pulses. On the other hand, active facilitation may be the result of an activity-induced decrease in the conductance of IK1. CONCLUSION: Diastolic excitability of well-polarized ventricular myocardium may be transiently depressed following local responses and transiently enhanced following action potentials. On the other hand, diastolic excitability decreases during quiescence. Active facilitation and electrotonic inhibition may have an important role in determining the dynamics of excitation of the myocardium in the presence of propagation abnormalities.

Phase resetting and entrainment of pacemaker activity in single sinus nodal cells.

The phase-resetting and entrainment properties of single pacemaker cells were studied using computer simulations in a model of the rabbit sinus nodal cell, as well as using the whole-cell patch-clamp (current-clamp) technique in isolated rabbit sinus nodal cells. Spontaneous electrical activity in the cell model was reconstructed using Hodgkin-Huxley-type equations describing time- and voltage-dependent membrane currents. In both simulations and experiments, single subthreshold current pulses (depolarizing or hyperpolarizing) were used to scan the spontaneous cycle of the cells. Such pulses perturbed the subsequent discharge, producing temporary phasic changes in pacemaker period, and enabled the construction of phase response curves. On the basis of these results, we studied entrainment characteristics of the cells. For example, application of repetitive pulses allowed for phasic changes in the spontaneous cycle and resulted in stable 1:1 entrainment at a range of basic cycle length around the spontaneous cycle, or a 2:1 pattern at basic cycle length values about half the spontaneous cycle length. Between the two entrainment zones, complex Wenckebach-like patterns (e.g., 5:4, 4:3, and 3:2) were observed. The experimental data from the isolated cell were further analyzed from a theoretical perspective, and the results showed that the topological characteristics of the phase-resetting behavior accounts for the experimentally observed patterns during repetitive stimulation of the cell. This first demonstration of phase resetting in single cells provides the basis for phenomena such as mutual entrainment between electrically coupled pacemaker cells, apparent intranodal conduction, and reflex vagal control of heart rate.

Nonlinear dynamics of rate-dependent activation in models of single cardiac cells.

Recent studies in isolated cardiac tissue preparations have demonstrated the applicability of a one-dimensional difference equation model describing the global behavior of a driven nonpacemaker cell to the understanding of rate-dependent cardiac excitation. As a first approximation to providing an ionic basis to complex excitation patterns in cardiac cells, we have compared the predictions of the one-dimensional model with those of numerical simulations using a modified high-dimensional ionic model of the space-clamped myocyte. Stimulus-response ratios were recorded at various stimulus magnitudes, durations, and frequencies. Iteration of the difference equation model reproduced all important features of the ionic model results, including a wide spectrum of stimulus-response locking patterns, period doubling, and irregular (chaotic) dynamics. In addition, in the parameter plane, both models predict that the bifurcation structure of the cardiac cell must change as a function of stimulus duration, because stimulus duration modifies the type of supernormal excitability present at short diastolic interval. We conclude that, to a large extent, the bifurcation structure of the ionic model under repetitive stimulation can be understood by two functions: excitability and action potential duration. The characteristics of these functions depend on the stimulus duration.

Sustained vortex-like waves in normal isolated ventricular muscle.

Sustained reentrant excitation may be initiated in small (20 x 20 x less than 0.6 mm) preparations of normal ventricular muscle. A single appropriately timed premature electrical stimulus applied perpendicularly to the wake of a propagating quasiplanar wavefront gives rise to circulation of self-sustaining excitation waves, which pivot at high frequency (5-7 Hz) around a relatively small "phaseless" region. Such a region develops only very low amplitude depolarizations. Once initiated, most episodes of reentrant activity last indefinitely but can be interrupted by the application of an appropriately timed electrical stimulus. The entire course of the electrical activity is visualized with high temporal and spatial resolution, as well as high signal-to-noise ratio, using voltage-sensitive dyes and optical mapping. Two- and three-dimensional graphics of the fluorescence changes recorded by a 10 x 10 photodiode array from a surface of 12 x 12 mm provide sequential images (every msec) of voltage distribution during a reentrant vortex. The results suggest that two-dimensional vortex-like reentry in cardiac muscle is analogous to spiral waves in other biological and chemical excitable media.

Supernormal excitability as a mechanism of chaotic dynamics of activation in cardiac Purkinje fibers.

Supernormality, which can be defined as greater than normal excitability during or immediately after action potential repolarization, has been observed in a variety of cardiac preparations. However, as yet, no description of the dynamics of tissue response to repetitive stimulation in the presence of supernormal or relatively supernormal excitability has appeared. Isolated sheep cardiac Purkinje fibers (2-5 mm in length) were superfused with Tyrode's solution and stimulated with depolarizing current pulses through a suction pipette. Recovery of excitability, restitution of the action potential duration, and response patterns were measured in each fiber for a wide range of current amplitudes and stimulation frequencies. When the potassium chloride concentration of the Tyrode's solution was decreased from 7 to 4 mM, the excitability recovery function consistently changed from monophasic ("normal") to triphasic ("supernormal'). During repetitive stimulation at increasing rates, normal preparations responded only with gradual changes in the activation ratio, expressed as periodic phase-locked responses (i.e., Wenckebach-like patterns, etc.). Supernormal preparations showed a nonmonotonic change in the activation ratio, as well as complex aperiodic response patterns. Numerical results from an analytical model gave a quantitative basis for the relation between nonmonotonicity in the excitability function and the development of complex rhythms in cardiac Purkinje fibers. Both our experimental and theoretical results indicate that the presence of supernormality and the slope of the action potential duration restitution curve at short diastolic intervals are responsible for the development of chaotic dynamics. Moreover, our results give an accurate description of the supernormality phenomenon, predict the behavior expected under such conditions, and provide insight about the role of membrane recovery in determining regular and irregular frequency-dependent rhythm and conduction disturbances.

Chaotic activity in a mathematical model of the vagally driven sinoatrial node.

Phase-locking behavior and irregular dynamics were studied in a mathematical model of the sinus node driven with repetitive vagal input. The central region of the sinus node was simulated as a 15 x 15 array of resistively coupled pacemakers with each cell randomly assigned one of 10 intrinsic cycle lengths (range 290-390 msec). Coupling of the pacemakers resulted in their mutual entrainment to a common frequency and the emergence of a dominant pacemaker region. Repetitive acetylcholine (ACh; vagal) pulses were applied to a randomly selected 60% of the cells. Over a wide range of stimulus intensities and basic cycle lengths, such perturbations resulted in a large variety of stimulus/response patterns, including phase locking (1:1, 3:2, 2:1, etc.) and irregular (i.e., chaotic) dynamics. At a low ACh concentration (1 microM), the patterns followed the typical Farey sequence of phase-locked behavior. At a higher concentration (5 microM), period doubling and aperiodic patterns were found. When a single pacemaker cell was perturbed with repetitive ACh pulses, qualitatively similar results were obtained. In both types of simulation, chaotic behavior was investigated using phase-plane (orbital) plots, Poincaré mapping, and return mapping. Period-doubling bifurcations (2:2, 4:4, and 8:8) were found temporally and spatially within the array. Under certain conditions of stimulation, the attractor in the return map during chaotic activity of the single cell resembled the Lorenz tent map. However, when electrical coupling between cells was allowed, the interactions with neighboring cells exhibiting chaotic dynamics resulted in characteristic alterations of the attractor geometry. Our results suggest that irregular dynamics obeying the rules derived from other chaotic systems are present during vagal stimulation of the sinus node. In addition, application of the same analytical tools to the analysis of simulation of reflex vagal control of sinus rate suggests that chaotic dynamics can be obtained in the physiologically relevant case of the baroreceptor reflex loop. These results may provide insight into the mechanisms of dynamic vagal control of heart rate and may help to provide insights into clinically relevant disturbances of cardiac rate and rhythm.

Slow recovery of excitability and the Wenckebach phenomenon in the single guinea pig ventricular myocyte.

The cellular mechanisms of Wenckebach periodicity were investigated in single, enzymatically dissociated guinea pig ventricular myocytes, as well as in computer reconstructions of transmembrane potential of the ventricular cell. When depolarizing current pulses of the appropriate magnitude were delivered repetitively to a well-polarized myocyte, rate-dependent activation failure was observed. Such behavior accurately mimicked the Wenckebach phenomenon in cardiac activation and was the consequence of variations in cell excitability during the diastolic phase of the cardiac cycle. The recovery of cell excitability during diastole was studied through the application of single test pulses of fixed amplitude and duration at variable delays with respect to a basic train of normal action potentials. The results show that recovery of excitability is a slow process that can greatly outlast action potential duration (i.e., postrepolarization refractoriness). Two distinct types of subthreshold responses were recorded when activation failure occurred: one was tetrodotoxin- and cobalt-insensitive (type 1) and the other was sensitive to sodium-channel blockade (type 2). Type 1 responses, which were commonly associated with the typical structure of the Wenckebach phenomenon (Mobitz type 1 block), were found to be the result of the nonlinear conductance properties of the inward rectifier current, IK1. Type 2 sodium-channel-mediated responses were associated with the so-called "millisecond Wenckebach." These responses may be implicated in the mechanism of Mobitz type 2 rate-dependent block. Single-cell voltage-clamp experiments suggest that variations in excitability during diastole are a consequence of the slow deactivation kinetics of the delayed rectifier, IK. Computer simulations of the ventricular cell response to depolarizing current pulses reproduced very closely all the response patterns obtained in the experimental preparation. It is concluded that postrepolarization refractoriness and Wenckebach periodicity are properties of normal cardiac excitable cells and can be explained in terms of the voltage dependence and slow kinetics of potassium outward currents. The conditions for the occurrence of intermittent activation failure during diastole will depend on the frequency and magnitude of the driving stimulus.

Ionic basis and analytical solution of the wenckebach phenomenon in guinea pig ventricular myocytes.

The ionic mechanisms of slow recovery of cardiac excitability and rate-dependent activation failure were studied in single, enzymatically dissociated guinea pig ventricular myocytes and in computer simulations using a modified version of the Beeler and Reuter model for the ventricular cell. On the basis of our results, we developed a simplified analytical model for recovery of cell excitability during diastole. This model was based on the equations for current distribution in a resistive-capacitive circuit. A critical assumption in the model is that, in the voltage domain of the subthreshold responses, the sodium and calcium inward currents do not play a significant role, and only the two potassium outward currents, the delayed rectifier (IK) and the inward rectifier, are operative. The appropriate parameters needed to numerically solve the analytical model were measured in the guinea pig ventricular myocyte, as well as in the Beeler and Reuter cell. The curves of recovery of excitability and the rate-dependent activation patterns generated by numerical iteration of the analytical model equations closely reproduced the experimental results. Our analysis demonstrates that slow deactivation of the delayed rectifier current determines the observed variations in excitability during diastole, whereas the inward rectifier current determines the amplitude and shape of the subthreshold response. Both currents combined are responsible for the development of Wenckebach periodicities in the ventricular cell. The overall study provides new insight into the ionic mechanisms of rate-dependent conduction block processes and may have important clinical implications as well.

Electrical uncoupling and impulse propagation in isolated sheep Purkinje fibers.

Alterations in electrical coupling may have a major role in the development of cardiac rhythm and conduction disturbances. We have used microelectrodes and linear Purkinje fibers to analyze the relative importance of cell-to-cell coupling on action potential propagation and to study the changes in the relationship between conduction velocity (theta) and upstroke velocity (Vmax) induced by three agents (heptanol, hypertonic solution, and ouabain) known to alter gap junction resistance. Heptanol superfusion (1.5-3.0 mM) reversibly led to a major decrease in theta and ultimately to block at a time when Vmax had been reduced by approximately 38%. Conduction delay was closely correlated with an increase in intracellular resistance (Ri), calculated as the sum of myoplasmic and junctional resistances, assuming a one-dimensional cable model. Qualitatively similar results were obtained by superfusion with 0.1-0.5 mM ouabain or hypertonic Tyrode solution (up to 600 mM sucrose added) instead of heptanol. In contrast, when the Vmax vs. theta relationship was studied by changing the KCl from 4 to 20 mM, decreases in Vmax correlated well with changes in theta. No significant effects on Ri were observed during KCl superfusion. Finally, we developed a computer model of action potential propagation along a one-dimensional strand of 90 electrically coupled heart cells. By changing systematically the degree of electrical coupling or the maximum sodium conductance in the model and by studying the effects of these changes on propagation and Vmax, we obtained strong evidence supporting the validity of our experimental results. The overall data provide testable predictions regarding the role of electrical uncoupling on abnormal impulse propagation.

Mechanisms of sinoatrial pacemaker synchronization: a new hypothesis.

A model of electrically coupled sinus node cells was used to investigate pacemaker coordination and conduction. Individual cells were simulated using differential equations describing transmembrane ionic currents. Intrinsic cycle lengths (periods) were adjusted by applying constant depolarizing or hyperpolarizing bias current, and cells were coupled through ohmic resistances to form two-dimensional arrays. Activation maps of 81-225 coupled cells showed an apparent wavefront conducting from a leading pacemaker region to the rest of the matrix even though the pattern actually resulted from mutual entrainment of all spontaneously beating cells. Apparent conduction time increased with increasing intercellular resistance. Appropriate selection of pacemaker cycle lengths and intercellular resistances permitted the accurate simulation of the activation sequence seen experimentally for the rabbit sinus node. Furthermore, a simulated acetylcholine pulse applied to a randomly selected 20% of the cells in this model produced a pacemaker shift that lasted several beats. These results support the hypothesis that sinus node synchronization occurs through a "democratic" process resulting from the phase-dependent interactions of thousands of pacemakers.

Effects of increasing intercellular resistance on transverse and longitudinal propagation in sheep epicardial muscle.

Propagation in cardiac muscle is faster in the longitudinal than in the transverse axis of the cells. Yet, as a result of the larger upstroke velocity of action potentials propagating transversely, it has been suggested that longitudinal propagation is more vulnerable to block. To study the relation between conduction velocity and maximal upstroke velocity (Vmax), as well as the time course of conduction delay and block in the transverse vs. longitudinal direction, thin square pieces of sheep epicardial muscle were superfused with the cellular uncoupler heptanol (1.5 mM). Action potentials were recorded with microelectrodes at opposite corners of the preparation while stimulating alternately in the longitudinal or transverse direction with bipolar electrodes located at contralateral corners. In all cases, block occurred more promptly for transverse than for longitudinal propagation. The decrease in conduction velocity was greater than expected for Vmax decay and, in some cases, Vmax increased while conduction velocity decreased. In the presence of high grade conduction impairment, foot potentials appeared and the upstrokes became "notched." We conclude that when intercellular coupling is impaired, transverse propagation is more vulnerable to block, and need not be dependent on changes in Vmax.

Modulated parasystole originating in the sinoatrial node.

A computer model of "modulated sinus parasystole" was devised in which two sinus pacemakers interacted electrotonically, entraining each other's periodicity according to their beat-to-beat phasic relationships. Depending on the preestablished rules, the model gave rise to various rhythm patterns that were similar to those recorded in patients with sinoatrial arrhythmias. The validity of the model in predicting clinically observed rhythm disturbances was tested in a case of sinoatrial extrasystolic activity. The sinoatrial origin of parasystolic discharges giving rise to various patterns of group beating in this case was diagnosed according to the following electrocardiographic criteria: premature P waves having contour identical to P waves of basic beats, variable coupling intervals, and absence of compensatory pauses (i.e., returning cycles having duration similar to that of the basic P-P interval). For the analysis, it was assumed that two distinct but closely apposed sinoatrial pacemaker centers were competing for activation of the heart. The model accurately simulated the arrhythmias in the electrocardiographic trace. The best fit was found when the two pacemakers interacted on the basis of "resetting" in one direction and electronic modulation in the other. In fact, under appropriate conditions, the model matched precisely all frequency-dependent patterns of extrasystolic activity observed in the trace. We conclude that the modulated parasystole hypothesis can readily explain the mechanism of sinus extrasystolic discharges whose returning cycle equals the basic P-P interval. Moreover, the model predicts that, when the rules for mutual entrainment between "dominant" and parasystolic sinus pacemaker are appropriate, the returning cycle can be shorter than the basic cycle.

Dynamic interactions and mutual synchronization of sinoatrial node pacemaker cells. A mathematical model.

Dynamic interactions and mutual entrainment of coupled sinoatrial pacemaker cells with different intrinsic frequencies were investigated using a computerized mathematical model. Transmembrane potentials were simulated using equations of individual membrane currents based on voltage clamp data for the sinoatrial node. The intrinsic frequency of a given cell was altered by applying bias hyperpolarizing current, or by changing the amount of slow inward current. Cells were coupled through simple ohmic resistances to form linear arrays of two or more cells. Simulations closely reproduced previous experimental work showing that the mutual interactions between pacemakers are mediated electrotonically and show phase dependence. Results from the present simulations provide an explanation for the ionic basis of these phase-dependent interactions. In addition, it is demonstrated that the mutual entrainment of coupled pacemakers can lead to their coordinated behavior (synchronization). Two pacemaker cells can synchronize at simple harmonic (i.e., 1:1, 2:1, etc.) or more complex ratios (3:2, 5:3, etc.), depending on the differences in intrinsic frequencies and the degree of electrical coupling between cells. Simulations using larger numbers of linearly connected cells yielded various patterns of pacemaker activity including 2:1 sinoatrial block and complex dysrhythmic activity. The overall results may be used to predict higher order interactions of thousands of cells comprising the sinus node. Under such a scheme, synchronization occurs not by the conducted influence of a dominant pacemaker cell, but by the mutual "democratic" interaction of individual pacemaker cells.

Effects of changes in excitability and intercellular coupling on synchronization in the rabbit sino-atrial node.

The mechanisms of synchronization between sino-atrial pace-maker cells were studied in biological preparations from rabbit hearts, and in computer simulations of the Hodgkin & Huxley type. For biological experiments, thin strips of sino-atrial node were placed in a three-compartment bath. The electrical properties of the tissue in the middle segment (the 'gap') were manipulated pharmacologically to alter electrical coupling and/or excitability of cells in that segment, and to study the patterns of interaction between two pace-maker centres in the external segments. Superfusion of the gap segment with either verapamil (2 microM) or acetylcholine (10 microM) produced a loss of 1:1 synchrony (entrainment) of spontaneous discharges generated by the external pace-makers but subharmonic (i.e. 3:2; 5:4; 9:8; etc.) entrainment was always maintained. When the gap segment was superfused with heptanol (3.5 mM), which is known to increase intercellular resistance, the pace-maker centres in the external chambers beat independently of one another. Progressive loss of synchrony paralleled reductions in amplitude of electrotonic responses to current pulses applied across the gap. Gap superfusion with hypertonic Tyrode solution (600 mosM) produced a major reduction in the degree of synchronization between the external pace-makers, even though the cells in the central compartment maintained their excitability. Under these conditions, as many as three independent pace-maker centres, one in each chamber, coexisted in a given preparation. Using computerized simulations based on equations of time- and voltage-dependent membrane currents, three 'cells', each capable of maintaining spontaneous activity, were connected in a linear array through ohmic resistances. When selective parameters (e.g. membrane conductances, coupling resistance) were modified appropriately, the mathematical simulations reproduced very closely the interaction patterns observed in the experimental preparations. Our results show that synchronization in the sinus node results from mutual interactions and entrainment between all the cells in this region. These interactions are of the kind expected for a population of coupled, self-sustained oscillators, and are mediated through electrotonic propagation of current across low-resistance junctions.

A mathematical model of the effects of acetylcholine pulses on sinoatrial pacemaker activity.

A mathematical model of dynamic vagus-sinus interactions was devised based on Hodgkin and Huxley-type equations of time- and voltage-dependent membrane currents. Brief vagal pulses were modeled with a concentration-dependent, acetylcholine-activated, potassium current. Single acetylcholine ("vagal") pulses scanning the sinus cycle induced changes in pacemaker rhythm that depended on pulse magnitude, duration, and time of occurrence during the cycle. Phase-response curves summarizing these effects are strikingly similar to experimental results. Notably, appropriately timed acetylcholine pulses could produce an acceleratory response. With repetitive acetylcholine input, the model produced various patterns of synchronization of the sinus pacemaker. There was stable entrainment at harmonic (i.e., 1:1, 2:1, etc.) relations, as well as more complex arrhythmic patterns that depended on the relationship between the acetylcholine cycle length and the sinus pacemaker period. In some cases, shortening of the acetylcholine input cycle length led to "paradoxical" acceleration of the sinus pacemaker. Simulations suggest that many clinically observed sinus rhythm disturbances can be explained by dynamic vagus-sinus interactions.