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Figure 10
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Summary of indications for pacing in patients with reflex syncope. CI-CSS = cardioinhibitory carotid sinus syndrome.

Figure 10
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Summary of indications for pacing in patients with reflex syncope. CI-CSS = cardioinhibitory carotid sinus syndrome.

In two observational studies, cardiac pacing reduced syncope burden in patients with documented asystolic syncope by 92 184 and 83%, 200 but did not prevent all syncopal events. In the randomized double-blind Third International Study on Syncope of Uncertain Etiology (ISSUE)-3 trial, 185 77 patients who had documentation, by means of ILR, of syncope with ≥3-s asystole or ≥6-s asystole without syncope were randomly assigned to receive either dual-chamber pacing with rate drop response or sensing only. During follow-up, the 2-year estimated rate of syncope recurrence was 57% with pacemaker off and 25% with pacemaker on (log-rank P= 0.039). The risk of recurrence was reduced by 57%. In the ILR subgroup of the multicentre Syncope Unit Project (SUP) 2 study, 292 the estimated rates of syncope recurrence with pacing were 11% at 1 year, 24% at 2 years, and 24% at 3 years, and were significantly lower than the corresponding rates observed in untreated control patients. The above evidence supports a class IIa recommendation

There is sufficient evidence that dual-chamber cardiac pacing should be considered to reduce recurrence of syncope when the correlation between symptoms and ECG is established in patients ≥40 years of age with the clinical features of those in the ISSUE studies.

The evidence supporting the benefit of cardiac pacing in patients affected by cardioinhibitory CSS is limited to a few small controlled trials and retrospective observational studies. In a review 293 including 12 studies for a total of 601 paced and 305 unpaced patients, the syncopal recurrence rate during follow-up ranged from 0–20% with pacing, whereas the recurrence of syncope was always higher in untreated patients, who showed a rate between 20–60%. In a meta-analysis of the three studies 293 with a control group of untreated patients, syncope recurred in 9% of 85 paced patients and in 38% of 91 controls (relative risk 0.24, 95% CI 0.12–0.48). In a single-centre registry of 169 consecutive patients treated with pacemakers, the actuarial estimate of syncopal recurrence was 7% at 1 year, 16% at 3 years, and 20% at 5 years. 90 In the CSS subgroup of the multicentre SUP 2 study, 292 the estimated syncope recurrence rates with pacing were 9% at 1 year, 18% at 2 years, and 20% at 3 years, and were significantly lower than the corresponding rates observed in untreated controls, which were 21%, 33%, and 43%, respectively. Given the similar outcome of patients with reflex spontaneous asystolic pauses and those with CSS, this Task Force voted to downgrade the recommendation for pacing in patients with CSS from class I (as in the 2013 ESC Pacing Guidelines 294 ) to class IIa.

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Biology Dictionary
By Editors

Epithelial Tissue Definition

Epithelial tissues are thin tissues that cover all the exposed surfaces of the body. They form the external skin, the inner lining of the mouth, digestive tract, secretory glands, the lining of hollow parts of every organ such as the heart, lungs, eyes, ears, the urogenital tract, as well as the ventricular system of the brain and central canals of the spinal cord.

The cells making up epithelia are often closely bound to one another through specialized structures called tight junctions . They are also free from blood vessels and nerves and are supported by a connective tissue called the basement membrane. They have polarity with a distinct basal domain facing the basement membrane and the other apical surface facing the lumen of an organ or the external environment.

Epithelial tissue has a number of functions, which include protection against abrasion, radiation damage, chemical stress and invasion by pathogens. A single organ can have different types of epithelial tissue based on the substances to which different surfaces are exposed. Protective tissue tends to be thicker, made of multiple layers of cells and often has inclusions such as keratin to provide mechanical strength and resistance. The skin of most mammals contains layers of thick keratinized dead epithelial cells protecting them against water loss and other stresses. Similarly, the esophagus is also exposed to a wide range of different textures, pH levels and chemical compositions from food and drink. Therefore, it also contains protective epithelium. Due to its involvement in the digestive process, however, it remains non-keratinized, and secretes mucus to smoothen the passage of food.

Alternatively, epithelial tissue can be involved in absorption, secretion and movement of substances. These epithelia are usually thin, containing cilia or microvilli and are often made of one layer of cells. With the exception of the mouth and esophagus, the rest of digestive tract consisting of the stomach, small and large intestine is covered by these kinds of thin epithelia. These cells secrete enzymes and play an important role in selectively absorbing digested food. The small intestine is particularly noted for the presence of microvilli on the epithelium that increase the surface area for absorption. Epithelia in bronchioles of the lungs contain cilia that move mucus and improve immune function. Similar ciliated epithelia in the fallopian tubes move the egg from the ovaries towards the uterus.

Some tissues, such as transitional epithelia, have a specialized structure that allows them to stretch and expand the capacity of the organ. Transitional epithelia are found lining the urinary bladder as well as the ureters and urethra. Small numbers of these cells are found in the urine, as part of the normal sloughing of dead cells. However the presence of a large number of cells from the transitional epithelium or from epithelial cells in the kidney indicate urinary tract infection, high cholesterol, diabetes or kidney disease.

Methods . The medical records of Schneider Children's Medical Center of Israel (Tel Aviv) were reviewed for all patients who were suspected of having infections with nontuberculous mycobacteria or tuberculosis and who attended the day care unit in 1995–2000, and the registry of the hospital's microbiology laboratory was reviewed for all diagnoses of culture-proven nontuberculous mycobacterial infection and tuberculosis within the same period. All culture samples were obtained by needle aspiration and isolated as described elsewhere [ 3 ]. M. tuberculosis PPD (5 TU; Pasteur Mérieux Connaught) was used for skin testing. For all patients, the size of the maximum indurative reaction was measured using the ball-pen method by the same infectious disease specialist (J.A.) 48–72 h after placement. The following data were also recorded: site of infection, mycobacterial species isolated, relevant physical findings, findings on a chest radiograph, history of exposure to tuberculosis, tuberculin test results for family members, BCG vaccination status, and demographic characteristics. The statistical tests used were Pearson's correlation and analysis of variance.


Results . Sixty-five generally healthy patients aged 1–21 years (median age, 3 years) were evaluated for suspected nontuberculous mycobacterial lymphadenitis. Culture-proven nontuberculous mycobacterial infections were identified in 29 patients (15 male and 14 female patients; age range, 8 months to 18 years; median age, 2.5 years). Eight patients had presumed tuberculosis (3 male and 5 female patients; age range, 1.5–21 years; median age, 14 years); tuberculosis was culture-proven in 3 patients (1 male and 2 female patients; age range, 8.5–21 years; median age, 19 years). None of the patients had been vaccinated with BCG.


The cervical lymph nodes were the site of infection for all patients with nontuberculous mycobacteria. Four species were isolated: Mycobacterium avium-intracellulare complex (from 14 patients [48%]), Mycobacterium haemophilum (from 12 [41%]), Mycobacterium simiae (from 2 [7%]), and Mycobacterium scrofulaceum (from 1 [3%]). The median size of reaction to M. tuberculosis PPD for all species was 16 mm (range, no reaction to 33 mm); the median reactions by species were 15.5 mm (range, 7–33 mm), 14.5 mm (range, no reaction to 30 mm), 20 mm (both patients) and 23 mm, respectively ( figure 1 ). Four patients (14%) had no indurations; 7 (24%) had indurations of <10 mm, 12 (41%) had indurations of <15 mm, and 17 (59%) had indurations of ⩽15 mm. All patients had normal findings on chest radiographs. No significant statistical correlations were found between induration size and either nontuberculous mycobacterial species or patient age. Two of the patients with pulmonary tuberculosis had a reaction to M. tuberculosis PPD of 30 mm, and 1 had a reaction of 20 mm.

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