Editing Reflex syncope

{{short description|Brief loss of consciousness due to a neurologically induced drop in blood pressure}}
{{cs1 config|name-list-style=vanc}}
{{Distinguish|Vagovagal reflex}}
{{Use dmy dates|date=August 2016}}
{{Infobox medical condition (new)
| name            = Reflex syncope
| synonyms        = Neurally mediated syncope, neurocardiogenic syncope<ref name=Ay2010/><ref name=Ad2017/>
| image           = Gray793.png
| caption         = [[Vagus nerve]]
| field           = [[Neurology]], [[cardiology]], [[emergency medicine]]
| symptoms        = [[Loss of consciousness]] before which there may be sweating, decreased ability to see, [[tinnitus|ringing in the ears]]<ref name=Ay2010/><ref name=Ad2017/>
| complications   = Injury<ref name=Ay2010/>
| onset           =
| duration        = Brief<ref name=Ay2010/>
| types           = Vasovagal, situational, carotid sinus syncope<ref name=Ay2010/>
| causes          =
| risks           =
| diagnosis       = Based on symptoms after ruling out other possible causes<ref name=Bri2011/>
| differential    = [[Heart arrhythmia|Arrhythmia]], [[orthostatic hypotension]], [[seizure]], [[hypoglycemia]]<ref name=Ay2010/>
| prevention      =
| treatment       = Avoiding triggers, drinking sufficient fluids, exercise, [[cardiac pacemaker]]<ref name=Ad2017/>
| medication      = [[Midodrine]], [[fludrocortisone]]<ref name=Shen2017/>
| prognosis       =
| frequency       = > 1 per 1,000 people per year<ref name=Ay2010/>
| deaths          =
}}
<!-- Definition and symptoms -->

'''Reflex syncope''' is a brief [[loss of consciousness]] due to a [[nervous system|neurologically]] induced drop in [[blood pressure]] and/or a  decrease  in  heart  rate.<ref>Morillo   CA,   Eckberg   DL,   Ellenbogen   KA,   Beightol   LA,   Hoag   JB,   Tahvanainen KU, Kuusela TA, Diedrich AM. Vagal and sympathetic mecha-nisms in patients with orthostatic vasovagal syncope. Circulation. 1997;96: 2509–2513. doi: 10.1161/01.cir.96.8.2509</ref><ref>Abboud    FM.    Neurocardiogenic    syncope.    N    Engl    J    Med.    1993: 1117–1120. doi: 10.1056/NEJM199304153281510</ref><ref>Chen-Scarabelli   C,   Scarabelli   TM.   Neurocardiogenic   syncope.   BMJ.2004;329:336–341. doi: 10.1136/bmj.329.7461.336Abboud FM. Neuro-cardiogenic syncope. N Engl J Med. 1993;328:1117–1120. doi: 10.1056/NEJM199304153281510</ref><ref>Grubb  BP.  Clinical  practice.  Neurocardiogenic  syncope.  N  Engl  J  Med.2005;352:1004–1010. doi: 10.1056/NEJMcp042601</ref><ref>Barón-Esquivias   G,   Cayuela   A,   Gómez   S,   Aguilera   A,   Campos   A,   Fernández M, Cabezón S, Morán JE, Valle JI, Martínez A, et al. [Quality of life in patients with vasovagal syncope. Clinical parameters influence]. Med Clin (Barc). 2003;121:245–249. doi: 10.1016/s0025-7753(03)75188-4</ref><ref>Zheng L, Sun W, Liu S, et al. The Diagnostic Value of Cardiac Deceleration Capacity in Vasovagal Syncope.   ''Circ. Arrhythm. electrophysiol..'' 2020;13(12):e008659. doi:10.1161/CIRCEP.120.008659, 10.1161/CIRCEP.120.008659</ref><ref name=Ad2017>{{cite journal|last1=Adkisson|first1=WO|last2=Benditt|first2=DG|title=Pathophysiology of reflex syncope: A review.|journal=Journal of Cardiovascular Electrophysiology|date=September 2017|volume=28|issue=9|pages=1088–1097|doi=10.1111/jce.13266|pmid=28776824|s2cid=39638908}}</ref> Before an affected person passes out, there may be sweating, a decreased ability to see, or [[tinnitus|ringing in the ears]].<ref name=Ay2010>{{cite journal|last1=Aydin|first1=MA|last2=Salukhe|first2=TV|last3=Wilke|first3=I|last4=Willems|first4=S|title=Management and therapy of vasovagal syncope: A review.|journal=World Journal of Cardiology|date=26 October 2010|volume=2|issue=10|pages=308–15|doi=10.4330/wjc.v2.i10.308|pmid=21160608|pmc=2998831 |doi-access=free }}</ref> Occasionally, the person may twitch while unconscious.<ref name=Ay2010/> Complications of reflex syncope include injury due to a fall.<ref name=Ay2010/>

<!-- Cause and diagnosis -->
Reflex syncope is divided into three types: vasovagal, situational, and carotid sinus.<ref name=Ad2017/> Vasovagal syncope is typically triggered by seeing [[blood]], pain, emotional stress, or prolonged standing.<ref name=NIH2017>{{cite web|title=Syncope Information Page|url=https://www.ninds.nih.gov/Disorders/All-Disorders/Syncope-Information-Page|website=National Institute of Neurological Disorders and Stroke|access-date=9 November 2017}}</ref> Situational syncope is often triggered by [[urination]], swallowing, or coughing.<ref name=Ad2017/> Carotid sinus syncope is due to pressure on the [[carotid sinus]] in the neck.<ref name=Ad2017/> The underlying mechanism involves the [[nervous system]] slowing the heart rate and dilating blood vessels, resulting in low blood pressure and thus not enough blood flow to the brain.<ref name=Ad2017/> Diagnosis is based on the symptoms after ruling out other possible causes.<ref name=Bri2011>{{cite book|last1=Brignole|first1=Michele|last2=Benditt|first2=David G.|title=Syncope: An Evidence-Based Approach|date=2011|publisher=Springer Science & Business Media|isbn=9780857292018|page=158|url=https://books.google.com/books?id=i-p7twz4qyIC&pg=PA158}}</ref>

<!-- Treatment and epidemiology -->
Recovery from a reflex syncope episode happens without specific treatment.<ref name=Ad2017/> Prevention of episodes involves avoiding a person's triggers.<ref name=Ad2017/> Drinking sufficient fluids, salt, and exercise may also be useful.<ref name=Ad2017/><ref name=Shen2017>{{cite journal|last1=Shen|first1=WK|last2=Sheldon|first2=RS|last3=Benditt|first3=DG|last4=Cohen|first4=MI|last5=Forman|first5=DE|last6=Goldberger|first6=ZD|last7=Grubb|first7=BP|last8=Hamdan|first8=MH|last9=Krahn|first9=AD|last10=Link|first10=MS|last11=Olshansky|first11=B|last12=Raj|first12=SR|last13=Sandhu|first13=RK|last14=Sorajja|first14=D|last15=Sun|first15=BC|last16=Yancy|first16=CW|title=2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society.|journal=Circulation|date=1 August 2017|volume=136|issue=5|pages=e25–e59|doi=10.1161/CIR.0000000000000498|pmid=28280232|doi-access=free}}</ref> If this is insufficient for treating vasovagal syncope, medications such as [[midodrine]] or [[fludrocortisone]] may be tried.<ref name=Shen2017/> Occasionally, an [[artificial cardiac pacemaker]] may be used as treatment.<ref name=Ad2017/> Reflex syncope affects at least 1 in 1,000 people per year.<ref name=Ay2010/> It is the most common type of [[Syncope (medicine)|syncope]], making up more than 50% of all cases.<ref name=Ad2017/>

==Signs and symptoms==
Episodes of vasovagal syncope are typically recurrent and usually occur when the predisposed person is exposed to a specific trigger. Before losing consciousness, the individual frequently experiences early signs or symptoms such as [[lightheadedness]], nausea, the feeling of being extremely hot or cold (accompanied by sweating), [[tinnitus|ringing in the ears]], an uncomfortable feeling in the heart, fuzzy thoughts, confusion, a slight inability to speak or form words (sometimes combined with mild stuttering), weakness and visual disturbances such as lights seeming too bright, fuzzy or tunnel vision, black cloud-like spots in vision, and a feeling of nervousness can occur as well. The symptoms may become more intense over several seconds to several minutes before the loss of consciousness (if it is lost). Onset usually occurs when a person is sitting up or standing.{{citation needed|date=April 2021}}

When people lose consciousness, they fall down (unless prevented from doing so) and, when in this position, effective blood flow to the brain is immediately restored, allowing the person to regain consciousness. If the person does not fall into a fully flat, supine position, and the head remains elevated above the trunk, a state similar to a [[Epileptic seizure|seizure]] may result from the blood's inability to return quickly to the brain, and the neurons in the body will fire off and generally cause muscles to twitch very slightly but mostly remain very tense.{{citation needed|date=April 2021}}

The [[autonomic nervous system]]'s physiological state (see below) leading to loss of consciousness may persist for several minutes, so
* If patients try to sit or stand when they wake up, they may pass out again
* The person may be nauseated, pale, and sweaty for several minutes or hours

==Causes==
Reflex syncope occurs in response to a trigger due to dysfunction of the heart rate and blood pressure regulating mechanism. When heart rate slows or blood pressure drops, the resulting lack of blood to the brain causes fainting.<ref>{{cite web |url=http://www.mayoclinic.org/diseases-conditions/vasovagal-syncope/symptoms-causes/dxc-20184778 |title=Vasovagal syncope: Causes |publisher=MayoClinic.com |date=7 August 2010  |access-date=10 August 2016}}</ref>

===Vasovagal===
Typical triggers include:
* Prolonged standing<ref name=NIH2017/>
* Emotional stress<ref name=NIH2017/>
* Pain<ref name=NIH2017/>
* [[Blood phobia|The sight of blood]]<ref name=NIH2017/>
* [[Fear of needles]]<ref name="accurso">{{cite journal |last=Accurso |first=V. |display-authors=etal |date=August 2001 |title=Predisposition to Vasovagal Syncope in Subjects With Blood/Injury Phobia |journal=Circulation |volume=104 |issue=8 |pages=903–907 |doi=10.1161/hc3301.094910 |pmid=11514377 |s2cid=11022384 |doi-access=}} [http://circ.ahajournals.org/cgi/content/full/104/8/903]</ref><ref name="hamilton">{{cite journal | author= James G. Hamilton| title= Needle Phobia - A Neglected Diagnosis | journal= Journal of Family Practice|date=August 1995| volume= 41| issue = 2 | pages = 169–175 REVIEW |pmid = 7636457}}</ref>
* Time varying magnetic field<ref name=Rossi>{{cite journal |vauthors=Rossi S, Hallett M, Rossini PM, Pascual-Leone A |title=Safety, ethical considerations, and application guidelines for the use of transcranial magnetic stimulation in clinical practice and research |journal=Clinical Neurophysiology |volume=120 |issue=12 |pages=2008–2039 |year=2009 |pmid=19833552 |pmc=3260536 |doi=10.1016/j.clinph.2009.08.016|hdl=11572/145680 }}</ref> (i.e. [[transcranial magnetic stimulation]])

===Situational===
* After or during urination ([[micturition syncope]])<ref name=Ad2017/>
* Straining, such as to have a bowel movement<ref name=Ad2017/>
* Coughing<ref name=Ad2017/>
* Swallowing<ref name=Ad2017/>
* Lifting a heavy weight<ref name=Ad2017/>

===Carotid sinus===
Pressing upon a certain spot in the neck.<ref name=NIH2017/> This may happen when wearing a tight collar, shaving, or turning the head.<ref name=NIH2017/>

==Pathophysiology==
Regardless of the trigger, the mechanism of syncope is similar in the various vasovagal syncope syndromes. The [[nucleus tractus solitarii]] of the [[brainstem]] is activated directly or indirectly by the triggering stimulus, resulting in simultaneous enhancement of [[parasympathetic nervous system]] ([[vagal]]) tone and withdrawal of [[sympathetic nervous system]] tone.{{citation needed|date=April 2021}}

This results in a spectrum of hemodynamic responses:{{cn|date=May 2024}}
# On one end of the spectrum is the cardioinhibitory response, characterized by a drop in heart rate (negative [[chronotropic]] effect) and in contractility (negative [[inotropic]] effect) leading to a decrease in cardiac output that is significant enough to result in a loss of consciousness. It is thought that this response results primarily from enhancement in [[parasympathetic tone]].
# On the other end of the spectrum is the vasodepressor response, caused by a drop in blood pressure (to as low as 80/20) without much change in heart rate. This phenomenon occurs due to [[vasodilation|dilation of the blood vessels]], probably as a result of withdrawal of [[sympathetic nervous system]] tone.
# The majority of people with vasovagal syncope have a mixed response somewhere between these two ends of the spectrum.

One account for these physiological responses is the [[Bezold-Jarisch reflex]].

Vasovagal syncope may be part of an evolved response, specifically, the [[fight-or-flight response]].<ref>{{cite journal |title=Vasovagal syncope in humans and protective reactions in animals|date=2015|vauthors=Blanc JJ, Alboni P, Benditt DG|pmid=25662986|doi=10.1093/europace/euu367|volume=17|issue=3|journal=Europace|pages=345–9|doi-access=free}}</ref><ref>{{cite journal |title=Vasovagal Syncope As A Manifestation Of An Evolutionary Selected Trait|journal=Journal of Atrial Fibrillation|date=2014|vauthors=Alboni P, Alboni M|pmc=5135249|pmid=27957092|doi=10.4022/jafib.1035|volume=7|issue=2|page=1035|doi-broken-date=1 November 2024}}</ref>

==Diagnosis==
In addition to the mechanism described above, a number of other medical conditions may cause [[Syncope (medicine)|syncope]]. Making the correct diagnosis for loss of consciousness is difficult. The core of the diagnosis of vasovagal syncope rests upon a clear description of a typical pattern of triggers, symptoms, and time course.{{citation needed|date=April 2021}}

It is pertinent to differentiate [[lightheadedness]], seizures, [[Vertigo (medical)|vertigo]], and [[hypoglycemia|low blood sugar]] as other causes.{{cn|date=May 2024}}

In people with recurrent vasovagal syncope, diagnostic accuracy can often be improved with one of the following diagnostic tests:
* A [[tilt table test]] (results should be interpreted in the context of patients' clinical presentations and with an understanding of the sensitivity and specificity of the test)<ref name="Fenton, A. M. 2000">{{cite journal |vauthors=Fenton AM, Hammill SC, Rea RF, Low PA, Shen WK |title=Vasovagal syncope |journal=Ann. Intern. Med. |volume=133 |issue=9 |pages=714–25 |year=2000 |doi=10.7326/0003-4819-133-9-200011070-00014 |pmid=11074905 |s2cid=45453509 }}</ref>
* Implantation of an [[Implantable loop recorder|insertable loop recorder]]
* A [[Holter monitor]] or event monitor
* An [[echocardiogram]]
* An [[electrophysiology study]]

==Treatment==
Treatment for reflex syncope focuses on avoidance of triggers, restoring blood flow to the brain during an impending episode, and measures that interrupt or prevent the [[#Pathophysiology and mechanism|pathophysiologic mechanism]] described above.{{citation needed|date=April 2021}}

===Lifestyle changes===
* The cornerstone of treatment is avoidance of triggers known to cause syncope in that person. However, research has shown that people show great reductions in vasovagal syncope through exposure-based exercises with therapists if the trigger is mental or emotional, e.g., sight of blood.<ref name="Durand, VM 2006. pp. 150">{{Cite book |author1=Durand, VM |author2=DH Barlow |year=2006 |title=Essentials of Abnormal Psychology 4th Edition |page=150 |publisher=Cengage Learning |url=https://books.google.com/books?id=OCaeCAAAQBAJ&q=Durand,+VM,+and+DH+Barlow.+2006.+Essentials+of+Abnormal+Psychology+4th+Edition&pg=PT6 |access-date=12 August 2016|isbn=978-1111836986 }}</ref> However, if the trigger is a specific drug, then avoidance is the only treatment.
* A technique known as "applied tension" may be additionally useful in those who have syncope with exposure to blood.<ref>{{cite book |last1=Hersen |first1=Michel |title=Encyclopedia of Behavior Modification and Cognitive Behavior Therapy |date=2005 |publisher=SAGE |isbn=9780761927471 |page=30 |url=https://books.google.com/books?id=LF05DQAAQBAJ&pg=PT50 }}</ref> The technique is done by tightening the skeletal muscles for about 15 seconds when the exposure occurs and then slowly releasing them.<ref name=Fel2006/> This is then repeated every 30 seconds for a few minutes.<ref name=Fel2006>{{cite book |last1=Felgoise |first1=Stephanie |last2=Nezu |first2=Arthur M. |last3=Nezu |first3=Christine M. |last4=Reinecke |first4=Mark A. |title=Encyclopedia of Cognitive Behavior Therapy |date=2006 |publisher=Springer Science & Business Media |isbn=9780306485817 |page=291 |url=https://books.google.com/books?id=bQ1KAAAAQBAJ&pg=PA291 }}</ref>
* Because vasovagal syncope causes a decrease in blood pressure, relaxing the entire body as a mode of avoidance is not favorable.<ref name="Durand, VM 2006. pp. 150"/> A person can move or cross their legs and tighten leg muscles to keep blood pressure from dropping so significantly before an injection.<ref name="pmid16398666">{{cite journal |vauthors=France CR, France JL, Patterson SM |title=Blood pressure and cerebral oxygenation responses to skeletal muscle tension: a comparison of two physical maneuvers to prevent vasovagal reactions |journal=Clinical Physiology and Functional Imaging |volume=26 |issue=1 |pages=21–5 |date=January 2006 |pmid=16398666 |doi = 10.1111/j.1475-097X.2005.00642.x |s2cid=2763372 }}</ref>
* Before known triggering events, the affected person may increase consumption of salt and fluids to increase blood volume. Sports drinks or drinks with electrolytes may be helpful.
* People should be educated on how to respond to further episodes of syncope, especially if they experience [[prodrome|prodromal]] warning signs: they should lie down and raise their legs, or at least lower their head to increase blood flow to the brain. At the very least, upon the onset of initial symptoms the patient should try to relocate to a 'safe', perhaps cushioned, location in case of losing consciousness. Positioning themselves in a way where the impact from falling or collapsing would be minimized is ideal. The 'safe' area should be within close proximity, since, time is of the essence and these symptoms usually climax to loss of consciousness within a matter of minutes. If the individual has lost consciousness, he or she should be laid down in the [[recovery position]]. Tight clothing should be loosened. If the inciting factor is known, it should be removed if possible (for instance, the cause of pain).
* Wearing graded compression stockings may be helpful. Moreover, assuming a sedentary position and raising the legs above the height of head.

===Medications===
* Certain [[medications]] may  also be helpful:
** [[Beta blocker]]s (β-adrenergic antagonists) were once the most common medication given; however, they have been shown to be ineffective in a variety of studies and are thus no longer prescribed. In addition, they may cause the syncope by lowering the blood pressure and heart rate.<ref name="pmid16505178">{{cite journal |vauthors=Sheldon R, Connolly S, Rose S, Klingenheben T, Krahn A, Morillo C, Talajic M, Ku T, Fouad-Tarazi F, Ritchie D, Koshman ML | title = Prevention of Syncope (POST): a randomized, placebo-controlled study of metoprolol in the prevention of vasovagal syncope | journal = Circulation | volume = 113 | issue = 9 | pages = 1164–70 | date = March 2006 | pmid = 16505178 | doi = 10.1161/CIRCULATIONAHA.105.535161 | doi-access =  | s2cid = 12778841 }}</ref><ref name="pmid11216978">{{cite journal |vauthors=Madrid AH, Ortega J, Rebollo JG, Manzano JG, Segovia JG, Sánchez A, Peña G, Moro C | title = Lack of efficacy of atenolol for the prevention of neurally mediated syncope in a highly symptomatic population: a prospective, double-blind, randomized and placebo-controlled study | journal = J. Am. Coll. Cardiol. | volume = 37 | issue = 2 | pages = 554–9 | date = February 2001 | pmid = 11216978 | doi = 10.1016/S0735-1097(00)01155-4 | doi-access = free }}</ref>
** Medications which may be effective include: CNS stimulants<ref>{{cite journal|title= The use of methylphenidate in the treatment of refractory neurocardiogenic syncope|date=2012-05-24 |pmid=8734752 | volume=19|issue=5 |journal=Pacing Clin Electrophysiol|pages=836–40|vauthors=Grubb BP, Kosinski D, Mouhaffel A, Pothoulakis A |doi=10.1111/j.1540-8159.1996.tb03367.x |s2cid=34197462 }}</ref> [[fludrocortisone]], [[midodrine]], [[SSRI]]s<ref>{{cite journal|last1=Ali Aydin|first1=Muhammet|last2=Salukhe|first2=Tushar|last3=Wilkie|first3=Iris|last4=Willems|first4=Stephan|title=Management and therapy of vasovagal syncope: A review|journal=World J Cardiol|pmc=2998831|pmid=21160608|doi=10.4330/wjc.v2.i10.308|volume=2|issue=10|year=2010|pages=308–15 |doi-access=free }}</ref> such as [[paroxetine]] or [[sertraline]], [[disopyramide]], and, in health-care settings where a syncope is anticipated, [[atropine]] or epinephrine (adrenaline).<ref>{{Cite journal |url=http://web.squ.edu.om/med-Lib/MED_CD/E_CDs/Nursing%20Drug%20Guide/mg/epinephrine.htm |title=epinephrine (adrenaline) |author=Amy M. Karch |journal=2006 Lippincott's Nursing Drug Guide |access-date=12 August 2016 |archive-date=29 June 2017 |archive-url=https://web.archive.org/web/20170629215823/http://web.squ.edu.om/med-Lib/MED_CD/E_CDs/Nursing%20Drug%20Guide/mg/epinephrine.htm |url-status=dead }}</ref>
* For people with the cardioinhibitory form of vasovagal syncope, implantation of a [[artificial pacemaker|permanent pacemaker]] may be beneficial or even curative.<ref>{{cite web |title=Vasovagal Syncope: What is it? |url=http://www.vasovagal-syncope.com/ |url-status=dead |archive-url=https://web.archive.org/web/20140103161954/http://vasovagal-syncope.com/ |archive-date=3 January 2014 |access-date=11 August 2016}}</ref>
Types of long-term therapy for vasovagal syncope include<ref name="Fenton, A. M. 2000"/>
* Preload agents
* Vasoconstrictors
* Anticholinergic agents
* Negative cardiac inotropes
* Central agents
* Mechanical device
* Discontinuation of medications known to lower blood pressure may be helpful, but stopping [[antihypertensive drugs]] can also be dangerous in some people. Taking antihypertensive drugs may worsen the syncope, as the hypertension may have been the body's way to compensate for the low blood pressure.

==Prognosis==

Brief periods of unconsciousness usually cause no lasting harm to health. Reflex syncope can occur in otherwise healthy individuals, and has many possible causes, often trivial ones such as prolonged standing with the legs locked.{{Citation needed|date=April 2017}}

The main danger of vasovagal syncope (or dizzy spells from vertigo) is the risk of injury by falling while unconscious. Medication therapy could possibly prevent future vasovagal responses; however, for some individuals medication is ineffective and they will continue to have fainting episodes.<ref>{{cite web |url=http://www.mdguidelines.com/vasovagal-syncope/prognosis |title=Vasovagal Syncope Prognosis |publisher=MDGuidelines |access-date=11 August 2016 |archive-date=3 July 2017 |archive-url=https://web.archive.org/web/20170703031536/http://www.mdguidelines.com/vasovagal-syncope/prognosis |url-status=dead }}</ref>

==See also==
* [[Cardioneuroablation]]
* [[Orthostatic hypotension]]
* [[Orthostatic intolerance]]
* [[Postural orthostatic tachycardia syndrome]]
* [[Roemheld Syndrome]]
* [[Stendhal syndrome]], alleged physiological phenomenon in response to seeing objects of great beauty, that includes fainting

==References==
{{reflist}}

{{Medical resources
|  DiseasesDB     = 13777
|  ICD10          = {{ICD10|R|55||r|50}}
|  ICD9           = {{ICD9|78Ø.2}}
|  ICDO           =
|  OMIM           =609289
|  MedlinePlus    =
|  eMedicineSubj =
|  eMedicineTopic =
|  MeshID         = D019462
}}
{{Disorders of consciousness}}
{{Autonomic diseases}}

{{DEFAULTSORT:Reflex syncope}}
[[Category:Cardiology]]
[[Category:Symptoms and signs of mental disorders]]
[[Category:Vagus nerve]]
[[Category:Wikipedia medicine articles ready to translate]]