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OBJECTIVE: To study factors associated with hospitalization in an unselected population of patients aged 65 years or older treated for syncope in Spanish hospital emergency departments (EDs). To determine the prevalence of adverse events at 30 days in patients discharged home and the factors associated with such events. METHODS: We included all patients aged 65 years or older who were diagnosed with syncope during a single week in 52 Spanish EDs, recording patient clinical and ED case management data. We compared the findings between hospitalized patients and those discharged home, following the latter for 30 days. In discharged patients, we explored predictors of a composite adverse-event outcome (occurrence of any of the following: ED revisits, hospitalization related to the index visit, or any-cause death). RESULTS: A total of 477 patients with syncope were identified; 67 (14%) were admitted, and 5 (7.5%) died. The median (interquartile range) length of hospital stay was 6 days (3-11 days). Comorbidity increased the probability of hospitalization (odds ratio, 2.172; 95% CI, 1.013-4.655). Among the 410 patients (86%) discharged home from the ED, 9.2% experienced an adverse event within 30 days (ED revisits, 8.,1%; hospitalization, 2.2%; death, 1.5%). No factors were associated with the 30-day composite outcome. CONCLUSIONS: The majority of patients aged 65 years or older are discharged home from EDs, and 30-day adverse events, while infrequent, are difficult to predict. Hospitalization was related to comorbidity and an absence of cognitive decline.

OBJETIVO: Investigar en una muestra no seleccionada de población mayor (65 o más años) atendida en servicios de urgencias hospitalarios (SUH) españoles por síncope los factores que se asociaron con la hospitalización, prevalencia de eventos adversos (EA) a 30 días y los factores asociados a estos entre los pacientes dados de alta desde urgencias. METODO: Se incluyeron todos pacientes con 65 o más años diagnosticados de síncope durante una semana en 52 SUH españoles. Se recogieron datos de la situación clínica y el manejo en urgencias, que se compararon entre los pacientes hospitalizados y los dados de alta directamente desde urgencias. Estos últimos fueron seguidos durante 30 días y se identificaron aquellos que presentaron un EA combinado (reconsulta en urgencias u hospitalización relacionada con el evento índice y muerte por cualquier causa), y se investigaron los factores que predecían dicho EA combinado. RESULTADOS: Se identificaron 477 pacientes con síncope. Hospitalizaron 67 (14%), de los que fallecieron 5 (7,5%) y la estancia mediana fue de 6 días (RIC 3-11). La comorbilidad incrementó la probabilidad de ingreso (OR: 2,172, IC 95%: 1,013-4,655). Entre los 410 pacientes dados de alta de urgencias (86%), el 9,2% tuvo un EA durante los 30 días siguientes (reconsulta a urgencias: 8,1%; hospitalización: 2,2%; muerte: 1,5%). Ningún factor se asoció con el riesgo de EA combinado a 30 días. CONCLUSIONES: La mayoría de los pacientes con 65 años o más atendidos en los SUH por síncope son dados de alta directamente desde urgencias, y los EA a los 30 días fueron poco frecuentes, pero difíciles de predecir. La hospitalización se relacionó con presencia de comorbilidad y ausencia de deterioro cognitivo.

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A 10-year-old spayed female shih tzu dog was brought to the hospital because of recurring syncope that occurred simultaneously with a cough. Physical examination did not reveal an abnormal heart rhythm or abnormal heart sounds. Electrocardiography revealed sinus arrest of 4.7 s with intermittent escape beats during coughing. Additional examinations, including thoracic radiography, clinical pathology, and echocardiography, revealed no abnormalities of concern. Forty-eight-hour Holter monitoring captured 1 syncopal episode following severe coughing, during which the longest sinus arrest lasted 16 s with intermittent escape beats. This observation confirmed our strong suspicion that coughing was the cause of varying degrees of sinus arrest in this dog. Theophylline, codeine, and short-term prednisolone were prescribed to treat the dog's cough. The daily episodes of syncope ceased and coughing decreased. Subsequent 48-hour Holter monitoring revealed no abnormal pauses, and the owner did not report syncope. Theophylline and codeine were continued for 5 mo, during which time no syncope occurred. To our knowledge, this case provides the first clear evidence of a correlation between cough-induced sinus arrest and syncope in a veterinary patient, as confirmed by Holter monitoring and electrocardiography. Key clinical message: Cough-induced severe bradycardia and syncope were identified in a shih tzu dog. After the antitussive medication was adjusted, the signs resolved.

Bradycardie sévère et syncope provoquées par la toux chez un chienUne chienne shih tzu stérilisée âgée de 10 ans a été amenée à l'hôpital en raison d'une syncope récurrente survenue simultanément avec une toux. L'examen physique n'a révélé aucun rythme cardiaque anormal ni bruits cardiaques anormaux. L'électrocardiographie a révélé un arrêt sinusal de 4,7 s avec des battements d'échappements intermittents lors de la toux. Des examens complémentaires, notamment une radiographie thoracique, des analyses en pathologie clinique et une échocardiographie, n'ont révélé aucune anomalie préoccupante. Une surveillance Holter de 48 heures a capturé 1 épisode syncopal à la suite d'une toux sévère, au cours duquel l'arrêt sinusal le plus long a duré 16 s avec des battements d'échappements intermittents. Cette observation a confirmé nos fortes suspicions selon lesquelles la toux était la cause de divers degrés d'arrêt sinusal chez ce chien. De la théophylline, de la codéine et de la prednisolone de courte durée ont été prescrites pour traiter la toux du chien. Les épisodes quotidiens de syncope ont cessé et la toux a diminué. Une surveillance Holter ultérieure de 48 heures n'a révélé aucune pause anormale et le propriétaire n'a pas signalé de syncope. La théophylline et la codéine ont été poursuivies pendant 5 mois, période pendant laquelle aucune syncope ne s'est produite. À notre connaissance, ce cas constitue la première preuve claire d'une corrélation entre l'arrêt sinusal induit par la toux et la syncope chez un patient vétérinaire, comme le confirme la surveillance Holter et l'électrocardiographie.Message clinique clé :Une bradycardie et une syncope sévères induites par la toux ont été identifiées chez un chien shih tzu. Après ajustement du traitement antitussif, les signes ont disparu.(Traduit par Dr Serge Messier).

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CASE PRESENTATION: A 74-year-old woman with a history of hypertension and peripheral artery disease and a reported diagnosis of sarcoidosis presents for an episode of syncope and shortness of breath. She had a history of sarcoidosis diagnosed on chest radiography that showed lymphadenopathy. There were no associated symptoms, and she was not previously treated for sarcoidosis. She previously smoked and had quit smoking 9 years earlier.

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Vasovagal syncope, or fainting, can be triggered by various stimuli, including medical procedures. Syncope after vaccination has been reported, most commonly among adolescents, and can result in injuries. Using the Vaccine Adverse Event Reporting System (VAERS), we reviewed and summarized reports of syncope after live attenuated influenza vaccine, intranasal (LAIV) administered as the sole vaccine (i.e., no concomitant injections). From June 17, 2003 (date of LAIV licensure in the US) through May 31, 2024, VAERS received 50 reports of syncope after LAIV. Nearly half (23; 46 %) pertained to individuals 10-19 years of age. While the vast majority of reports (35; 70 %) did not describe any injuries, 15 people (30 %) were injured, most commonly by falling and hitting their head or face. Twenty-two people (44 %) required evaluation in the emergency department or doctor's office, including an individual who lost consciousness while he was driving home from the vaccination appointment. He did not report any injuries, but the car was severely damaged. Nearly three-quarters of people (37; 74 %) developed syncope within 15 min after vaccination, but fewer than half of reports (24; 48 %) stated that the patient had waited in the observation area for at 15 min. Based on approximately 111.9 million doses of LAIV distributed in the US during the same time period, the reporting rate is approximately 0.4 per million doses, suggesting that syncope following LAIV is rare. The information summarized here may enable clinicians, patients, and caregivers to make a more informed decision regarding preventing injuries that may occur following LAIV-related syncope.

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RATIONALE: Syncope is a common condition in emergency departments, posing a diagnostic challenge due to its multifactorial nature. Among the potential causes, carotid sinus hypersensitivity leading to carotid sinus syndrome (CSS) is a significant consideration that can severely impact patient quality of life. Despite its importance, establishing effective treatment methods for CSS has been difficult. PATIENT CONCERNS: A 43-year-old male presented with recurrent episodes of syncope, which significantly affected his daily life and well-being. DIAGNOSES: After a thorough evaluation, the patient was diagnosed with CSS, a condition that can be difficult to pinpoint and requires specialized diagnostic procedures to confirm. INTERVENTIONS: The patient was treated with stellate ganglion block therapy, a targeted intervention aimed at addressing the underlying cause of CSS. This treatment was administered over a 12-day period. OUTCOMES: Following the treatment, the patient's symptoms showed gradual improvement, and he was discharged after meeting the clinical cure criteria. During a 7-month follow-up, he remained symptom-free. LESSONS: The case highlights the effectiveness of transcutaneous stellate ganglion block therapy in treating CSS. It suggests that further research and clinical trials are needed to validate this treatment's efficacy, potentially offering a new therapeutic option for patients suffering from CSS.

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BACKGROUND: For emergency department (ED) patients with syncope, cardiac troponin can identify acute coronary syndrome (ACS) and prognosticate for 30-day serious adverse events. However, it is unclear if serial testing improves diagnostic yield and prognostication. METHODS: This was a secondary analysis of data from two prospective studies conducted to develop the Canadian Syncope Risk Score. Adults (age ≥ 16 years) with syncope were enrolled, and patient characteristics, vital signs, physician diagnostic impression, electrocardiogram and troponin results, and adjudicated 30-day serious adverse event were collected. The primary outcome was the detection of a serious adverse event within 30 days of ED disposition. The secondary outcome was comparison of ED length of stay among patients with single versus serial troponin measurements. RESULTS: 4996 patients [mean age 64.5 (SD 18.8) years, 52.2% male] were included: 4397 (89.8%) with single troponin [232 (5.3%) with serious adverse event in the ED and 203 (4.6%) after ED disposition]; 499 (10.2%) patients with > 1 troponin measurement [39 (7.8%) with serious adverse event in ED and 60 (12.0%) after ED disposition]. Among those with serial measurements, 10 patients (2.0%) had a rise from below to above the 99th percentile threshold, of whom 4 patients (0.8%) suffered serious adverse event: two with arrhythmias diagnosed on electrocardiogram, one with ACS and one suffered respiratory failure. Nine patients (1.8%) had Canadian Syncope Risk Score risk reclassification based on serial measurement, and none suffered 30-day serious adverse event. Median ED length of stay was significantly longer for patients with serial testing (5.6 vs. 3.8 h, p < 0.001). CONCLUSIONS: The initial troponin measurement was sufficient for serious adverse event detection and in-ED risk stratification. Serial troponin testing does not improve the diagnostic yield or prognostication and should be reserved for patients with ongoing symptoms or electrocardiogram findings suggestive of cardiac ischemia.

ABSTRAIT: CONTEXTE: Pour les patients du service des urgences (DE) atteints de syncope, la troponine cardiaque peut identifier le syndrome coronarien aigu (SCA) et le pronostic pour les événements indésirables graves de 30 jours. Cependant, il n'est pas clair si les tests en série améliorent le rendement diagnostique et le pronostic. MéTHODES: Il s'agissait d'une analyse secondaire des données de deux études prospectives menées pour élaborer le Canadian Syncope Risk Score. Des adultes (âgés de 16 ans) atteints de syncope ont été recrutés, et les caractéristiques du patient, les signes vitaux, l'empreinte diagnostique du médecin, les résultats de l'électrocardiogramme et de la troponine, ainsi que les événements indésirables graves évalués à 30 jours ont été recueillis. Le critère de jugement principal était la détection d'un événement indésirable grave dans les 30 jours suivant la décision de l'urgence. Le critère de jugement secondaire était la comparaison de la durée de séjour à l'urgence chez les patients ayant une seule mesure de troponine par rapport à la mesure en série. RéSULTATS: 4 996 patients [âge moyen 64,5 (ET 18,8) ans, 52,2 % d'hommes] ont été inclus : 4 397 (89,8 %) avec une seule troponine [232 (5,3 %) avec un événement indésirable grave à l'urgence et 203 (4,6 %) après l'urgence]; 499 (10,2 %) patients avec > 1 mesure de la troponine [39 (7,8 %) avec événement indésirable grave à l'urgence et 60 (12,0 %) après la décision à l'urgence]. Parmi les patients ayant fait l'objet de mesures en série, 10 (2,0 %) présentaient une augmentation du seuil inférieur à supérieur au seuil du 99e percentile, dont 4 (0,8 %) ont subi un événement indésirable grave : deux avec arythmies diagnostiquées par électrocardiogramme, un avec SCA et un avec insuffisance respiratoire. Neuf patients (1,8 %) ont présenté une reclassification du risque selon le score canadien de risque de syncope en fonction de la mesure en série, et aucun n'a subi d'événement indésirable grave de 30 jours. La durée médiane de séjour aux urgences était significativement plus longue pour les patients ayant subi des tests en série (5,6 vs. 3,8 heures, p < 0,001). CONCLUSIONS: La mesure initiale de la troponine était suffisante pour la détection des effets indésirables graves et la stratification des risques aux urgences. Les tests de troponine en série n'améliorent pas le rendement diagnostique ou le pronostic et doivent être réservés aux patients présentant des symptômes continus ou des résultats d'électrocardiogramme suggérant une ischémie cardiaque.

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BACKGROUND: Following standard syncope care, after exclusion of cardiac syncope, further workup is generally only recommended in cases of severe syncope due to consequential risk such that syncope is associated with injury or negative impacts on quality of life. This study is aimed to identify incidence and risk factors of severe syncope due to consequential risk, in a cohort of ED patients with non-cardiac syncope. METHODS: In a sample of 356 cases, we we conducted a case-control study comparing personal data, drug regimen, comorbidities, characteristics of syncope and previous episodes in patients with vs. without a severe syncope. RESULTS: Patients with severe syncope (120, 31.7% of total) resulted more frequently treated with a polypharmacy and CNS agents and affected by comorbidities entailing risk of falling; they more frequently had syncope occurred in a risky context, unwitnessed (55.8%), not preceded by prodromes (56.6%) and with clinical characteristics different from reflex syncope (82.3%); in these patients, previous episodes more frequently were clustered in the last years and complicated by major injuries. Absence of witnesses and prodromes and ED diagnosis different from reflex syncope resulted to be independently associated with severe syncope due to consequential risk. CONCLUSIONS: Syncope has a negative impact on a patient's life, through injuries or other personal consequences, in roughly one third of cases; to identity these patients, needing further investigation, emergency physicians should focus on episodes not preceded by prodromes, unwitnessed and with characteristic other than reflex syncope. Nonetheless, specific tools are needed to evaluate the impact of syncope on quality of life, to avoid clogging the path after ED discharge.

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AIMS: The study evaluated the positivity rate, haemodynamic responses, and prognosis in terms of syncopal recurrence among patients with situational syncope (SS) stratified according to the underlying situational triggers. METHODS AND RESULTS: We retrospectively evaluated all consecutive patients with SS who underwent nitroglycerine (NTG)-potentiated head-up tilt test (HUTT) at Syncope Unit of the University of Campania 'Luigi Vanvitelli'-Monaldi Hospital from 1 March 2017 to 1 May 2023. All patients were followed for at least one year. The study population was divided according to the underlying triggers (micturition, swallow, defaecation, cough/sneeze, post-exercise). Two hundred thirty-six SS patients (mean age 50 ± 19.3 years; male 63.1%) were enrolled; among them, the situational trigger was micturition in 109 patients (46.2%); swallow in 32 (13.6%) patients; defaecation in 35 (14.8%) patients; post-exercise in 41 (17.4%) patients; and cough/sneeze in 17 (7.2%) patients. There were no significant differences in baseline clinical characteristics and HUTT responses between different situational triggers. The Kaplan-Meier analysis did not show a statistically different rate of syncope recurrence across patients stratified by baseline situational triggers (log-rank P = 0.21). CONCLUSION: Situational syncope appears to be a homogenous syndrome, and different triggers do not impact the HUTT response or syncope recurrence at 1 year.

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BACKGROUND: Young (<18 years of age) patients with Brugada syndrome (BrS) are often under-represented in BrS studies and their management, especially related to syncopal episodes, remains unclear. OBJECTIVES: This study sought to describe the arrhythmia prevalence among young patients with BrS undergoing continuous rhythm monitoring by implantable loop recorder (ILR) and to assess the etiology behind syncope of undetermined origin. METHODS: A total of 147 patients with BrS with ILR were enrolled in 12 international centers and divided into pediatric (age <12 years; n = 77, 52%) and adolescents (age 13-18 years; n = 70, 48%). RESULTS: Mean age was 11.3 years, 53 patients (36.1%) were female, and 31 (21.1%) had spontaneous type 1 electrocardiograms. Over a median follow-up of 3.6 years (Q1-Q3: 1.6-4.8 years), an arrhythmic event was recorded in 33 patients (22.4%), mainly of nonventricular origin: 15 atrial (10.2%) and 16 bradyarrhythmic events (10.9%). Ventricular arrhythmias occurred in 4 patients, all with spontaneous BrS, and were fever-related in one-half. Among all patients with recurrence of syncope during follow-up, true arrhythmic syncope was documented in 5 (17.8%), and it was due to bradyarrhythmias or atrial arrhythmias in 3 cases (60%). CONCLUSIONS: Continuous rhythm monitoring with ILRs in young patients with BrS detects a broad range of arrhythmias. Ventricular arrhythmias occur predominantly in patients with spontaneous type 1 electrocardiograms and during fever. Despite the young age, bradyarrhythmias and atrial arrhythmias are frequent and represent the cause of arrhythmic syncope in 60% of patients. Young patients with BrS with syncope of undetermined origin may benefit from ILR implant.

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Intravenous infusion of sodium-channel blockers (SCB) with either ajmaline, flecainide, procainamide, or pilsicainide to unmask the ECG of Brugada syndrome is the drug challenge most commonly used for diagnostic purposes when investigating cases possibly related to inherited arrhythmia syndromes. For a patient undergoing an SCB challenge, the impact of a positive result goes well beyond its diagnostic implications. It is, therefore, appropriate to question who should undergo a SCB test to diagnose or exclude Brugada syndrome and, perhaps more importantly, who should not. We present a critical review of the benefits and drawbacks of the SCB challenge when performed in cardiac arrest survivors, patients presenting with syncope, family members of probands with confirmed Brugada syndrome, and asymptomatic patients with suspicious ECG.

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During fainting, disconnected consciousness may emerge in the form of dream-like experiences. Characterized by extra-ordinary and mystical features, these subjective experiences have been associated to near-death-like experiences (NDEs-like). We here aim to assess brain activity during syncope-induced disconnected consciousness by means of high-density EEG monitoring. Transient loss of consciousness and unresponsiveness were induced in 27 healthy volunteers through hyperventilation, orthostasis, and Valsalva maneuvers. Upon awakening, subjects were asked to report memories, if any. The Greyson NDE scale was used to evaluate the potential phenomenological content experienced during the syncope-induced periods of unresponsiveness. EEG source reconstruction assessed cortical activations during fainting, which were regressed out with subjective reports collected upon recovery of normal consciousness. We also conducted functional connectivity, graph-theoretic and complexity analyses. High quality high-density EEG data were obtained in 22 volunteers during syncope and unresponsiveness (lasting 22±8 s). NDE-like features (Greyson NDE scale total score ≥7/32) were apparent for eight volunteers and characterized by higher activity in delta, theta and beta2 bands in temporal and frontal regions. The richness of the NDE-like content was associated with delta, theta and beta2 bands cortical current densities, in temporal, parietal and frontal lobes, including insula, right temporoparietal junction, and cingulate cortex. Our analyses also revealed a higher complexity and that networks related to delta, theta, and beta2 bands were characterized by a higher overall connectivity paralleled by a higher segregation (i.e., local efficiency) and a higher integration (i.e., global efficiency) for the NDE-like group compared to the non-NDE-like group. Fainting-induced NDE-like episodes seem to be sustained by surges of neural activity representing promising markers of disconnected consciousness.

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AIMS: Prior case series showed promising results for cardioneuroablation in patients with vagally induced atrioventricular blocks (VAVBs). We aimed to examine the acute procedural characteristics and intermediate-term outcomes of electroanatomical-guided cardioneuroablation (EACNA) in patients with VAVB. METHODS AND RESULTS: This international multicentre retrospective registry included data collected from 20 centres. Patients presenting with symptomatic paroxysmal or persistent VAVB were included in the study. All patients underwent EACNA. Procedural success was defined by the acute reversal of atrioventricular blocks (AVBs) and complete abolition of atropine response. The primary outcome was occurrence of syncope and daytime second- or advanced-degree AVB on serial prolonged electrocardiogram monitoring during follow-up. A total of 130 patients underwent EACNA. Acute procedural success was achieved in 96.2% of the cases. During a median follow-up of 300 days (150, 496), the primary outcome occurred in 17/125 (14%) cases with acute procedural success (recurrence of AVB in 9 and new syncope in 8 cases). Operator experience and use of extracardiac vagal stimulation were similar for patients with and without primary outcomes. A history of atrial fibrillation, hypertension, and coronary artery disease was associated with a higher primary outcome occurrence. Only four patients with primary outcome required pacemaker placement during follow-up. CONCLUSION: This is the largest multicentre study demonstrating the feasibility of EACNA with encouraging intermediate-term outcomes in selected patients with VAVB. Studies investigating the effect on burden of daytime symptoms caused by the AVB are required to confirm these findings.

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RATIONALE: Neuromyelitis optica spectrum disorder (NMOSD) involves autoimmune and inflammatory responses in the central nervous system, primarily affecting the optic nerves and spinal cord. Atypical presentations such as ataxia and syncope complicate the diagnosis, and lesions in the medulla are easily mistaken for cerebral infarction. This case report emphasizes the need to recognize such manifestations to avoid misdiagnosis and ensure timely treatment. PATIENT CONCERNS: This case report presents an NMOSD female patient who experienced ataxia, syncope, and neuropathic pain during her illness. DIAGNOSIS: NMOSD. INTERVENTIONS: The patient managed her blood sugar with insulin, controlled neuropathic pain with pregabalin, and underwent 5 plasma exchanges. OUTCOMES: Significant improvement was noted 1 week post-plasma exchange, with complete resolution of neuropathic pain and no symptom recurrence reported at 6-month follow-up. LESSONS: Atypical manifestations of NMOSD, such as ataxia, syncope, and trigeminal neuralgia, increase diagnostic difficulty. Recognizing these symptoms is crucial to avoid misdiagnosis and ensure timely and appropriate treatment for patients.

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Objective: To investigate the value of implantable cardiac monitor (ICM) in the diagnosis and treatment of patients over 60 years old with unexplained syncope. Methods: This was a multi-center, prospective cohort study. Between June 2018 and April 2021, patients over the age of 60 with unexplained syncope at Beijing Hospital, Fuwai Hospital, Beijing Anzhen Hospital and Puren Hospital were enrolled. Patients were divided into 2 groups based on their decision to receive ICM implantation (implantation group and conventional follow-up group). The endpoint was the recurrence of syncope and cardiogenic syncope as determined by positive cardiac arrhythmia events recorded at the ICM or diagnosed during routine follow-up. Kaplan-Meier survival analysis was used to compare the differences of cumulative diagnostic rate between the 2 groups. A multivariate Cox regression analysis was performed to determine independent predictors of diagnosis of cardiogenic syncope in patients with unexplained syncope. Results: A total of 198 patients with unexplained syncope, aged (72.9±8.25) years, were followed for 558.0 (296.0,877.0) d, including 98 males (49.5%). There were 100 (50.5%) patients in the implantation group and 98 (49.5%) in the conventional follow-up group. Compared with conventional follow-up group, patients in the implantation group were older, more likely to have comorbidities, had a higher proportion of first degree atrioventricular block indicated by baseline electrocardiogram, and had a lower body mass index (all P<0.05). During the follow-up period, positive cardiac arrhythmia events were recorded in 58 (58.0%) patients in the ICM group. The diagnosis rate (42.0% (42/100) vs. 4.1% (4/98), P<0.001) and the intervention rate (37.0% (37/100) vs. 2.0% (2/98), P<0.001) of cardiogenic syncope in the implantation group were higher than those in the conventional follow-up group (all P<0.001). Kaplan-Meier survival analysis showed that the cumulative diagnostic rate of cardiogenic syncope was significantly higher in the implantation group than in the traditional follow-up group (HR=11.66, 95%CI 6.49-20.98, log-rank P<0.001). Multivariate analysis indicated that ICM implantation, previous atrial fibrillation, diabetes mellitus or first degree atrioventricular block in baseline electrocardiogram were independent predictors for cardiogenic syncope (all P<0.05). Conclusions: ICM implantation improves the diagnosis and intervention rates in patients with unexplained syncope, and increases diagnostic efficiency in patients with unexplained syncope.

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Observed and recorded in various forms since ancient times, 'syncope' is often popularly called 'fainting', such that the two terms are used synonymously. Syncope/fainting can be caused by a variety of conditions, including but not limited to head injuries, vertigo, and oxygen deficiency. Here, we draw on a large body of literature on syncope, including the role of a recently discovered set of specialized mammalian neurons. Although the etiology of syncope still remains a mystery, we have attempted to provide a comprehensive account of what is known and what still needs to be performed. Much of our understanding of syncope is owing to studies in the laboratory mouse, whereas evidence from human patients remains scarce. Interestingly, the cardioinhibitory Bezold-Jarisch reflex, recognized in the early 1900s, has an intriguing similarity to-and forms the basis of-syncope. In this review, we have integrated this minimal model into the modern view of the brain-neuron-heart signaling loop of syncope, to which several signaling events contribute. Molecular signaling is our major focus here, presented in terms of a normal heart, and thus, syncope due to abnormal or weak heart activity is not discussed in detail. In addition, we have offered possible directions for clinical intervention based on this model. Overall, this article is expected to generate interest in chronic vertigo and syncope/fainting, an enigmatic condition that affects most humans at some point in life; it is also hoped that this may lead to a mechanism-based clinical intervention in the future.

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INTRODUCTION: Cough is common in interstitial lung disease (ILD) and is associated with disease progression, yet its mechanisms are understudied. We investigated cough hypersensitivity features and impact in ILD. METHODS: Participants with ILD and cough (n = 195) completed a multiple choice and free text questionnaire on cough sensations/triggers and impacts. RESULTS: The majority of participants were male (54%), aged > 65 (64%), with idiopathic pulmonary fibrosis (IPF, 75%). Common cough triggers were body position (74%), physical activity (72%), and talking (62%). Common laryngeal sensations were globus (43%), and itch/tickle (42%). Cough impacted everyday life in 55%, and all activities in 31%, causing exhaustion (59%), social embarrassment (70%), urinary incontinence (46% females), and syncope/pre-syncope (12%). The total number of cough-provoking sensations/triggers correlated with impacts; ρ = 0.73, p < 0.001. CONCLUSION: Cough hypersensitivity symptoms are prevalent in ILD and detrimentally affect quality of life. Further studies investigating mechanisms of cough hypersensitivity and targeted pharmacotherapy are warranted.

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