Methotrexate as a treatment in ocular cicatricial moderate pemphigoid

CLINICAL CASE

A 73 year-old woman presented with a history of non-specific symptoms and photophobia in both eyes of 1 year progression. The examination revealed a bilateral symblepharon and fornix shortening. Immunohistochemical analysis confirmed the presence of linear deposits of IgG, IgM and C3 along the conjunctival basement membrane. With the diagnosis of Ocular Cicatricial Pemphigoid, systemic treatment with subcutaneous methotrexate was prescribed.

DISCUSSION

We consider such treatment a very effective initial immunosuppressive alternative in patients with moderate conjunctival inflammation and in cases of rapid progression.

Influence of the selection of the suture material on the mechanical behavior of a biomaterial to be employed in the construction of implants. Part 1: Calf pericardium

A hydraulic stress simulator was employed to study the mechanical behavior of the calf pericardium used in the construction of cardiac valve leaflets. One hundred eighty pairs of tissue samples were subjected to tensile testing to rupture. One of the two samples from each of 144 pairs (four series of 36 pairs each) was sutured with commercially available threads made of nylon, silk, Prolene or Gore-Tex, while the other sample in each of these pairs was left unsewn. The remaining 36 pairs were employed as controls in which neither of the two samples was subjected to suturing. The sutured tissue samples showed a significant decrease in tensile strength at rupture (range: 11.81 to 26.04 MPa) when compared with unsutured samples (range: 39.38 to 87.96 MPa; p < 0.01). The application of morphological and mechanical selection criteria to maximize the homogeneity of the samples provided excellent fit with respect to the stress/strain curves. This method made it possible to carry out a predictive study of the mechanical behavior of a sutured sample, based on that observed in the corresponding unsutured fragment. The interaction of the different suture materials with the pericardial tissue was also assessed by comparing the mechanical behavior of the sutured samples with that of the control samples. At stresses of less than 0.8 MPa, samples sewn with Gore-Tex were found to show the least difference with respect to the controls, indicating that this material presented the lowest degree of interaction with the pericardium. In conclusion, the degree of the loss of resistance to tearing of the sutured samples is of no value in the selection of the optimal suture material. The selection process applied makes it possible to predict the mechanical behavior in response to suturing of a given unsewn tissue specimen by determining that of its sutured mate. The similarity between the findings in samples sewn with Gore-Tex and in the unsutured controls indicates a lesser degree of interaction between the suture material and the pericardium employed in the construction of cardiac valve leaflets.

Influence of the selection of the suture material on the mechanical behavior of a biomaterial to be employed in the construction of implants. Part 2: Porcine pericardium

Using a hydraulic stress simulator, the mechanical behavior of the porcine pericardium used in the construction of cardiac valve leaflets was characterized following the same procedure employed with calf pericardium in Part 1 of this study. One hundred fifty pairs of tissue samples were subjected to tensile testing to rupture. One of the two samples from each of 120 pairs (four series of 30 pairs each) was saturated with commercially available threads made of nylon, silk, Prolene or Gore-Tex, while the other sample in each of these pairs was left unsewn. The remaining 30 pairs were employed as controls in which neither of the two samples was subjected to suturing. The sutured tissue samples showed a significant decrease in tensile strength at rupture (range: 11.61 to 21.22 MPa) when compared with unsutured samples (range: 50.80 to 89.45 MPa; p < 0.01). When these results were compared with their equivalent in calf pericardium, no significant differences were observed (the mean values at rupture in calf pericardium ranged between 211.61 MPa and 26.04 MPa). Again, the application of morphological and mechanical selection criteria to ensure the homogeneity of the samples provided excellent fit with respect to the stress/strain curves. The interaction of the different suture materials with the pericardial tissue was also assessed by comparing the mechanical behavior of the sutured samples with that of the control samples. At the working stress of a cardiac valve leaflet, 0.250 MPa, samples sewn with Gore-Tex were found to show the least difference in behavior with respect to the controls, indicating that this material presented the lowest degree of interaction with the pericardium. In conclusion, the suture clearly has deleterious effects on the resistance of both calf and porcine pericardium, which showed no statistically significant differences in terms of resistance to rupture when their respective sutured or unsutured samples were compared, except in the case of porcine pericardium sewn with silk, which presented lower resistance to rupture in all the zones studied. These findings suggest that the hypothesis that porcine pericardium is less resistant is erroneous. The Gore-Tex suture also presented a lower degree of interaction with the porcine pericardium, with values similar to the working stress of a cardiac valve leaflet. This methodology and the results should be evaluated in dynamic studies, such as fatigue testing, that not only confirm the resistance of the material but establish the durability of the samples being assayed.

The influence of chemical treatment and suture on the elastic behavior of calf pericardium utilized in the construction of cardiac bioprostheses

Poor mechanical properties of biological tissue are known to cause wear, leading to the failure of cardiac bioprostheses made of calf pericardium. Different chemical agents such as sodium dodecyl sulfate (SDS) are presently being tested as possible inhibitors of the calcification process. The objective of this report was to determine the mechanical behavior of calf pericardium treated with SDS for 24 h and the influence of the suture on the mechanical properties of the tissue. Forty-eight samples were tested: 24 subjected to a standard treatment with glutaraldehyde (12 sewn with 4/0 silk suture thread) and 24 incubated with SDS for 24 h (12 sewn with the same suture thread). Each sutured and non-sutured sample was cut into two strips to yield paired samples. All were subjected to tensile stress to breaking point. The mean stress at breaking point in the non-sutured series treated with glutaraldehyde alone was 16.42 and 13.85 MPa depending on the region of the pericardium, while in the sutured samples subjected to glutaraldehyde the mean stress was 7.50 and 7.63 MPa, respectively, differences which were statistically significant (p = 0.03 and p = 0.003, respectively) when the means for non-sutured samples from equivalent regions treated with glutaraldehyde were compared. The stress at breaking point was lower in the SDS-treated series, ranging between 2.60 and 3.56 MPa. The mathematical functions that govern the stress/strain or deformation were obtained. In the series of pericardium treated with SDS, deformations of 10% were produced with stresses of under 0.4 MPa, an outcome that is intolerable from the constructive point of view. We established a regression model that enabled us to determine the mechanical behavior of a sutured sample by testing a contiguous piece of tissue, with a high correlation coefficient (r \gt 0.99). We consider this finding to be of interest in the selection of pericardium for use in the construction of leaflets for cardiac bioprostheses.

The influence of chemical treatment and suture on the elastic behavior of calf pericardium utilized in the construction of cardiac bioprostheses

Poor mechanical properties of biological tissue are known to cause wear, leading to the failure of cardiac bioprostheses made of calf pericardium. Different chemical agents such as sodium dodecyl sulfate (SDS) are presently being tested as possible inhibitors of the calcification process. The objective of this report was to determine the mechanical behavior of calf pericardium treated with SDS for 24 h and the influence of the suture on the mechanical properties of the tissue. Forty-eight samples were tested: 24 subjected to a standard treatment with glutaraldehyde (12 sewn with 4/0 silk suture thread) and 24 incubated with SDS for 24 h (12 sewn with the same suture thread). Each sutured and nonsutured sample was cut into two strips to yield paired samples. All were subjected to tensile stress to breaking point. The mean stress at breaking point in the nonsutured series treated with glutaraldehyde alone was 16.42 and 13.85 MPa, depending on the region of the pericardium, while in the sutured samples subjected to glutaraldehyde the mean stress was 7.50 and 7.63 MPa, respectively, differences which were statistically significant (p=0.03 and p=0.003, respectively) when the means for nonsutured samples from equivalent regions treated with glutaraldehyde were compared. The stress at breaking point was lower in the SDS-treated series, ranging between 2.60 and 3.56 MPa. The mathematical functions that govern the stress/strain or deformation were obtained. In the series of pericardium treated with SDS, deformations of 10% were produced with stresses of under 0.4 MPa, an outcome that is intolerable from the constructive point of view. We established a regression model that enabled us to determine the mechanical behavior of a sutured sample by testing a contiguous piece of tissue, with a high correlation coefficient (r\gt 0.99). We consider this finding to be of interest in the selection of pericardium for use in the construction of leaflets for cardiac bioprostheses.

Analysis of shearing stress in the limited durability of bovine pericardium used as a biomaterial

The objective of the study was to determine the shearing stress exerted by the suture thread under conditions of normal working stress. Thirty-six samples of calf pericardium, similar to that employed in the manufacture of bioprosthetic cardiac valve leaflets, were subjected to tensile testing. Prior to the trial, a continuous suture was sewn in the central zone of each sample, at a 45 degrees angle to the longest axis of the sample, using commercially-available threads (silk, Gore-Tex, Surgilene and nylon). Application of the Mohr circle for combined wear revealed that the shearing stress ranged between 2.68-fold greater (for samples sewn with silk) and 5.48-fold greater (for samples sewn with nylon) than the working tensile stress in the region of the suture. It is concluded that the shearing stress is responsible for the limited durability of sutured samples of calf pericardium prepared to simulate bioprosthetic cardiac valve leaflets.