Management of Acute Pulmonary Embolism in a Patient with Sickle Cell Anemia Using Catheter-Directed Thrombolysis.

The efficacy of thrombolytic therapy in submassive pulmonary embolism (PE) management is lacking, particularly in specific patient subgroups. The current case report demonstrates the use of catheter-directed thrombolysis (CDT) therapy in conjunction with standard systemic anticoagulation in a patient with sickle cell disease presenting with a submassive PE and chronic thrombus burden. CDT may potentially play a role in the management of submassive PE in sickle cell patients.

Bilateral, chronic, bacterial conjunctivitis in giant fornix syndrome.

Giant fornix syndrome (GFS) results in chronic, relapsing conjunctivitis in elderly patients with enophthalmos and enlarged fornices, in which infectious material collects and perpetuates inflammation. A 98-year-old woman presented with persistent, bilateral, purulent conjunctivitis; corneal epithelial defects and progressive blepharospasm that did not respond to artificial tears, topical antibiotics and steroids and amniotic membrane grafts. Additional findings of deep-set orbits with enlarged upper fornices were diagnostic of GFS. Over the next 2 months, she responded to a combination of topical and systemic antibiotics, autologous serum eye drops, povidone-iodine forniceal rinses, and hypochlorous acid treatment of the eyelashes. GFS is an important diagnostic consideration in elderly patients with chronic conjunctivitis and deep-set orbits.

Magnetic Resonance Imaging-Measured Cross-Sectional Area of the Median Nerve.

Purpose: The size of the median nerve may serve as a useful parameter to predict carpal tunnel syndrome (CTS) in a subset of patients. The purpose of this study was to evaluate magnetic resonance imaging-based measurements of median nerve cross-sectional area (CSA) to examine trends between patient subgroups and CSA that may assist in predicting the individuals who are most likely to develop CTS symptoms. Methods: A retrospective chart review of 1,273 wrist magnetic resonance images was performed, and the images were analyzed to evaluate the median nerve CSA at the level of the pisiform and the hook of hamate. The age, sex, height, weight, and body mass index (BMI) of the patients were collected from their medical records. Results: The median nerve size correlated with patient BMI. Additionally, patients with CTS had larger median nerves at the hook of hamate and pisiform than those without CTS. When subdividing patients on the basis of BMI, obese patients with CTS had larger median nerve CSA at the pisiform than those without CTS. Conclusions: This study demonstrated that increased BMI is associated with increased median nerve CSA at the hook of hamate and pisiform in patients with or without CTS. Additionally, patients with CTS had larger median nerve CSA than those without CTS. Measurements at these locations may help predict individuals who are likely to experience median nerve impingement. Type of study/level of evidence: Prognostic III.

Accuracy Assessment of Outpatient Telemedicine Encounters at an Academic Ophthalmology Department.

Purpose We assess the clinical accuracy of direct-to-patient real-time outpatient video visit encounters at our eye center. Design This was a retrospective longitudinal study. Subjects and Methods Patients who completed a video visit over a 3-week period between March and April 2020 were included. Accuracy assessment was determined by comparing diagnosis and management from the video visit with subsequent in-person follow-up over the next year. Results A total of 210 patients (mean age 55±18 years) were included, of whom 172 (82%) were recommended a scheduled in-person follow-up encounter after their video visit. Among the 141 total patients who completed in-person follow-up, 137 (97%) had a diagnostic agreement between telemedicine and in-person evaluation. Management plan agreed for 116 (82%), with the remainder of visits either escalating or deescalating treatment upon in-person follow-up with little substantive change. Compared with established patients, new patients had higher diagnostic disagreement following video visits (12 vs. 1%, p =0.014). Acute visits trended toward more diagnostic disagreement compared with routine visits (6 vs. 1%, p =0.28) but had a similar rate of management change on follow-up (21 vs. 16%, p =0.48). New patients were more likely to have early unplanned follow-up than established patients (17 vs. 5%, p =0.029), and acute video visits were associated with unplanned early in-person assessments compared with routine video visits (13 vs. 3%, p =0.027). There were no serious adverse events associated with the use of our telemedicine program in the outpatient setting. Conclusions Video visits had high diagnostic and management agreement with subsequent in-person follow-up encounters.

Olfactory and neurological outcomes of SARS-CoV-2 from acute infection to recovery.

Educational objective: To investigate the impact of SARS-CoV-2 on sinonasal quality of life, olfaction, and cognition at different stages of viral infection and evaluate the association between olfaction and cognition in this population cohort. Objectives: While olfactory dysfunction (OD) is a frequently reported symptom of COVID-19 (98% prevalence), neurocognitive symptoms are becoming more apparent as patients recover from infection. This study aims to address how different stages of infection [active infection (positive PCR test, symptomatic) vs. recovered (7 days post-symptoms)] compared to healthy control patients influence sinonasal quality of life, olfactory function, and cognition. Study design: Prospective, longitudinal, case-control. Methods: Participants completed the SNOT-22, University of Pennsylvania Smell Identification Test (UPSIT) and validated cognitive examinations to assess degree of smell loss and neurocognitive function at baseline and at 1 and 3 months for the active group and 3 months for the recovered group. Self-reported olfactory function and overall health metrics were also collected. Results: The recovered group had the lowest average UPSIT score of 27.6 compared to 32.7 (active) and 32.6 (healthy control). 80% (n = 24) of the recovered patients and 56.3% (n = 9) of the active patients suffered from smell loss. In follow-up, the active group showed improvement in UPSIT scores while the recovered group scores worsened. In terms of neurocognitive performance, recovered patients had lower processing speed despite an improving UPSIT score. Conclusion: SARS-CoV-2 infection was found to impact olfactory function in a delayed fashion with significant impact despite recovery from active infection. Although olfactory function improved, decrements in cognitive processing speed were detected in our cohort.

Fractional Exhaled Nitric Oxide as a Marker of Mucosal Inflammation in Chronic Rhinosinusitis.

BACKGROUND: Fractional exhaled nitric oxide (FeNO) is a cost-effective, noninvasive point-of-care test that has proven valuable in identifying patients with lower airway inflammation and predicting the likelihood of responsiveness to inhaled corticosteroid therapy in asthma. The utility of FeNO in upper airway disease, specifically in CRS, remains to be determined. OBJECTIVE: The goal of this study was to test whether FeNO could serve as a noninvasive marker of sinonasal mucosal inflammation in CRS patients. METHODS: FeNO was obtained using a nitric oxide analyzer (NIOX VERO) as well as nasal mucus, the 22-item Sinonasal Outcome Test (SNOT-22), University of Pennsylvania Smell Identification Test (UPSIT), and Lund-Kennedy endoscopic scores concurrently in 112 CRS patients. Nasal mucus was analyzed for cytokine expression using solid-phase sandwich ELISA. Linear regression with Spearman correlation coefficient was used to determine strength of relationship between variables. RESULTS: CRS patients showed elevated FeNO levels with asthma (47.12 ± 5.21 ppb) or without asthma (43.24 ± 9.810 ppb). Elevated FeNO levels correlated with sinonasal mucosal inflammation, as determined by increased levels of CCL26 and TNFα in nasal mucus obtained from CRS patients. Furthermore, elevated FeNO levels selectively correlated with worsened SNOT-22 nasal symptoms (P = 0.03) and Lund-Kennedy endoscopic scores (P = 0.007), but did not correlate with UPSIT scores. CONCLUSIONS: FeNO levels correlated with increased sinonasal mucosal inflammation and symptom severity in CRS regardless of asthma status. FeNO measurements may serve as a quick and noninvasive marker in evaluating CRS patients.

Applicant Perspectives on Virtual Otolaryngology Residency Interviews.

OBJECTIVE: Residency interviews serve as an opportunity for prospective applicants to evaluate programs and to determine their potential fit within them. The 2019 SARS-CoV2 pandemic mandated programs conduct interviews virtually for the first time. The purpose of this study was to assess applicant perspectives on the virtual interview. METHODS: A Qualtrics survey assessing applicant characteristics and attitudes toward the virtual interview was designed and disseminated to otorhinolaryngology applicants from 3 large academic institutions in the 2020 to 2021 application cycle. RESULTS: A total of 33% of survey applicants responded. Most applicants were satisfied with the virtual interview process. Applicants reported relatively poor quality of interactions with residents and an inability to assess the "feel" of a geographic area. Most applicants received at least 11 interviews with over a third of applicants receiving >16 interviews. Only 5% of applicants completed >20 interviews. Most applicants believed interviews should be capped between 15 and 20 interviews. Most applicants reported saving >$5000, with over a quarter of applicants saving >$8000, and roughly one-third of applicants saving at least 2 weeks of time with virtual versus in-person interviews. CONCLUSIONS: While virtual interviews have limitations, applicants are generally satisfied with the experience. Advantages include cost and time savings for both applicants and programs, as well as easy use of technology. Continuation of the virtual interview format could be considered in future application cycles; geographical limitations may be overcome with in-person second looks, and increased emphasis should be placed on resident interactions during and prior to interview day.

Management of Mucoceles, Sialoceles, and Ranulas.

Mucoceles are common salivary gland disorders. Mucoceles are benign, mucus-filled extravasation pseudocysts that commonly arise on the lower lip of children and young adults. Although surgical excision is commonly performed to remove these lesions, other treatments include marsupialization, micromarsupialization laser ablation, cryotherapy, intralesional steroid injection, and sclerosing agents. Traumatic sialoceles commonly arise from injury to the parotid duct. Treatment of sialoceles from acute parotid duct injury and for delayed presentations after injury are discussed. Ranulas are a subtype of mucocele from the sublingual gland classified as superficial or plunging. Treatment of ranulas must address the sublingual gland.

Disseminated Herpes Simplex Infection Presenting as Acute Supraglottitis in an Adult.

Supraglottitis is a life-threatening, predominantly bacterial disease that is rarely caused by viral etiologies. Herpes Simplex Virus (HSV) supraglottitis has been infrequently reported, but its presentation can mimic that of bacterial supraglottitis or pharyngitis which may lead to delayed diagnosis and increased morbidity. We present a case of supraglottitis in an immunocompetent man initially thought to have bacterial epiglottitis. After receiving a tracheostomy due to impending airway compromise and failing to improve on antibiotic therapy, biopsy of the upper airway tissue revealed infection with HSV type 2. The patient improved after multiple weeks of systemic antivirals. HSV supraglottitis remains an unusual but important diagnostic consideration in patients with dysphonia, dysphagia, ulcerative supraglottal lesions, and acute supraglottic inflammation unresponsive to antibiotics.

A Required Ophthalmology Rotation: Providing Medical Students with a Foundation in Eye-Related Diagnoses and Management.

Introduction: Current ophthalmologic training in medical school is inadequate in preparing medical students to handle basic eye complaints as nonophthalmology residents. Most medical students are uncomfortable performing eye examinations, but increased ophthalmology training improves confidence in this area. The University of Pittsburgh School of Medicine (UPSOM) teaches students the basics of ophthalmology with a required 1-week rotation during the 1-month specialty care clerkship (SCC), providing students with skills to perform rudimentary eye examinations as nonophthalmology providers. Methods: Within a 1-week ophthalmology rotation, we developed a series of interactive case-based teaching sessions, handouts, and homework that accompanied clinical instruction to familiarize third- and fourth-year medical students with ophthalmic equipment, terminology, diagnosis, and management. Of learners, 67 (roughly 11 per cohort) rotated on six consecutive SCCs beginning in May 2019. All learners completed an in-house exam and received resident clinical evaluations at the end of their rotation. Results: Of the 64 participants who responded to the survey, 100% rated the quality of teaching sessions outstanding or good, and 83% of students strongly agreed or agreed with the statement, "I believe the overall teaching in the ophthalmology clinical settings was good quality." The average clinical and exam score for ophthalmology over 6 months was 4.5 out of 5, and 83% respectively. Discussion: Generally positive student feedback as well as high clinical and exam scores suggested that the required UPSOM ophthalmology clerkship was both engaging and effective. This course can be easily adapted to teach students at other medical institutions.

Comparison of Clinical Features and Treatment Outcomes of Pseudomonas aeruginosa Keratitis in Contact Lens and Non-Contact Lens Wearers.

PURPOSE: To compare the outcomes of Pseudomonas aeruginosa keratitis (PAK) in contact lens wearers (CLWs) and non-contact lens wearers (non-CLWs) and identify risk factors for poor visual acuity (VA) outcomes in each group. DESIGN: Retrospective cohort study METHODS: Two hundred fourteen consecutive cases of PAK were included between January 2006 and December 2019. Clinical features, microbiologic results, and treatment course were compared between CLW and non-CLW groups. Analyses of clinical features predicting poor final VA were performed. RESULTS: This study identified 214 infected eyes in 207 patients with PAK, including 163 eyes (76.2%) in CLWs and 51 eyes (23.8%) in non-CLWs. The average age was 39.2 years in CLWs and 71.9 years in non-CLWs (P < .0001). The average logMAR visual acuity (VA) at presentation was 1.39 in CLWs and 2.17 in non-CLWs (P < .0001); average final VA was 0.76 in CLWs and 1.82 in non-CLWs (P < .0001). Stromal necrosis required a procedural or surgical intervention in 13.5% of CLWs and 49.0% of non-CLWs (P < .0001). A machine learning-based analysis yielded a list of clinical features that most strongly predict a poor VA outcome (worse than 20/40), including worse initial VA, older age, larger size of infiltrate or epithelial defect at presentation, and greater maximal depth of stromal necrosis. CONCLUSIONS: Non-CLWs have significantly worse VA outcomes and required a higher rate of surgical intervention, compared with CLWs. Our study elucidates risk factors for poor visual outcomes in non-CLWs with PAK.

Initial Results and Patient Survey of Virtual Inpatient Ophthalmology Consultations During the COVID-19 Pandemic.

Purpose: To examine the uptake, results, and patient assessment of virtual inpatient ophthalmology consultations at our academic medical center during the COVID-19 pandemic.Design: Retrospective review, pre and post COVID analysis, and teleophthalmology patient survey in the inpatient and emergency setting.Participants: Adult patients at our medical center for whom ophthalmology consultation was requested from February 24 through April 19, 2020.Methods: Patient encounters were retrieved and coded for all inpatient and emergency room ophthalmology consultations over a 4-week period before and a 4-week period after our department first offered virtual ophthalmology consultations. Theseconsultations took place over real-time video, audio, or photography between the on-call ophthalmologist and the patient and/or patient's primary physician. A four-item questionnaire was offered to patients who completed a virtual consultation.Main Outcome Measures: Virtual consultation diagnoses and management outcomes; patient assessment of virtual inpatient and emergent ophthalmic care.Results: Of all 423 included encounters, 258 (61%) occurred during the 4 weeks before offering virtual consultations and 165 (39%) encounters occurred during the subsequent 4-week period, indicating a 36% decrease in ophthalmology consultations over this pandemic period. A total of 120 (28%) encounters were conducted remotely during the 8-week period. In-person emergency department (ED) encounters (as percent of total encounters) decreased from 60% to 36% (p < .01) between the first and eighth weeks of the study period. In the 4 weeks since their implementation, virtual inpatient ophthalmology consultations were utilized in 34 of 165 (21%) consultations. Of those, 20 (59%) were high acuity and 1 (3%) was escalated to the ED for in-person evaluation. Most common management decisions made included medication prescription in 46 (55%) patients and scheduling follow-up for 44 (30%) patients. In a survey administered to all 120 patients who were managed over phone or video, 56 (47%) responded. Respondents were in general agreement (Cronbach's alpha = 0.92) and expressed satisfaction with phone and virtual encounters. Specifically, 42 (49%) of 86 patients who had phone encounters noted a mean weighted satisfaction score of 4.6 out of 5 and 14 (41%) responders of 34 virtual consultation encounters noted a mean weighted satisfaction score of 4.9 out of 5. The difference between the average weighted satisfaction scores favored virtual consultation over telephone encounters (p < .01).Conclusions: Virtual inpatient ophthalmology consultations are feasible and have reported high patient satisfaction. Implementing video-based technologies to deliver high-acuity ophthalmic triage and management may help to promote patient and provider safety. In our experience, patients favored virtual consultation over telephone encounters.

PET/CT Poorly Predicts AJCC 8th Edition Pathologic Staging in HPV-Related Oropharyngeal Cancer.

OBJECTIVE: The American Joint Committee on Cancer (AJCC) 8th edition introduced distinct clinical and pathological staging paradigms for human papilloma virus positive (HPV+) oropharyngeal squamous cell carcinoma (OPSCC). Treatment planning for OPSCC often utilizes positron emission tomography/computed tomography (PET/CT) to assess clinical stage. We hypothesize that PET/CT will accurately predict final pathologic AJCC 8th edition staging in patients with HPV+ OPSCC. METHODS: All patients with primary HPV+ OPSCC with preoperative PET/CT who underwent transoral robotic surgery and neck dissection between 2011 and 2017 were identified. Data were collected via chart review. Two neuroradiologists performed blinded re-evaluation of all scans. Primary tumor size and cervical nodal disease characteristics were recorded and TNM staging was extrapolated. Cohen's kappa statistic was used to assess interrater reliability. Test for symmetry was performed to analyze discordance between radiologic and pathologic staging. RESULTS: Forty-nine patients met inclusion criteria. Interrater reliability was substantial between radiologists for nodal (N) and overall staging (OS) (κ = 0.715 and 0.715). Radiologist A review resulted in identical OS for 67% of patients, overstaging for 31%, and understaging for 2%. Radiologist B review resulted in 61% identical OS, 39% overstaging, and 0% understaging. In misclassified cases, the test of symmetry shows strong bias toward overstaging N stage and OS (P < .001). Radiologic interpretation of extracapsular extension showed poor interrater reliability (κ = 0.403) and poor accuracy. CONCLUSION: PET/CT predicts a higher nodal and overall stage than pathologic staging. PET/CT should not be relied upon for initial tumor staging, as increased FDG uptake is not specific for nodal metastases. PET/CT is shown to be a poor predictor of ECE. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:1535-1541, 2021.

Treatment of tongue telangiectasia in a patient with hereditary haemorrhagic telangiectasia.

A 61-year-old Caucasian woman presented to an outpatient otolaryngology clinic with increased bleeding from a dorsal tongue telangiectasia for 3 weeks. Her history was significant for hereditary haemorrhagic telangiectasia (HHT), a rare condition that causes vascular dysplasia, and recent symptomatic anaemia requiring blood transfusions. After failing medical management with topical haemostatic agents, she was offered and underwent surgical intervention to remove the tongue telangiectasia with duel therapy potassium titanyl phosphate (KTP) laser coblation and bevacizumab injections. A team of otolaryngologists removed the lesion without complications, and the patient denied bleeding, had minimal pain, and endorsed increased quality of life postoperatively. Tongue telangiectasias can cause life-threatening bleeding in some patients with HHT, and no surgical management guidelines exist to treat them. This case demonstrates the efficacy of KTP laser followed by bevacizumab injections in treating tongue telangiectasias in a patient with HHT.

Incorporating Video Visits into Ophthalmology Practice: A Retrospective Analysis and Patient Survey to Assess Initial Experiences and Patient Acceptability at an Academic Eye Center.

INTRODUCTION: The coronavirus disease 2019 (COVID-19) pandemic has led to rapid adoption of teleophthalmology to deliver eyecare remotely. The purpose of our study was to assess the implementation and patient acceptability of video consultation for outpatient ophthalmic care at our institution. METHODS: We conducted a retrospective, cross-sectional analysis and patient survey of adult patients who completed a virtual video visit at our institution from 18 March 18 through to 27 April 2020. All video visit encounters were assessed for patient characteristics, diagnoses, management, and follow-up outcomes. Patients were surveyed for their feedback on acceptability and utility of their virtual video consultation. RESULTS: A total of 219 patients (mean age 55 years; range 21-89 years) completed 231 video visit encounters at our department over a 6-week period, of whom 118 were women (54%). About half of these encounters were acute visits (102 visits, 47%). The most common diagnosis of these visits was postoperative state (20 visits, 9% of the total), followed by conjunctivitis (16 visits, 7%), and keratitis (14 visits, 6%). The most common management decisions were medication prescription (102 visits, 46%) or reassurance (86 visits, 39%), while 17 video visit patients (8%) were escalated to an urgent, in-person evaluation. Ninety-two patients completed a follow-up survey (42% response rate), of whom 45 (49%) indicated that they might have delayed seeking care during this pandemic in the absence of a virtual video option. Seventy-two (78%) reported that they would consider participating in a video visit as an alternative to an office-based encounter in the future, and the overall video visit experience was rated highly, with a weighted mean Likert scale rating of 4.3 out of 5 (Cronbach's α = 0.88). CONCLUSION: Virtual video visits may be used to manage a range of ophthalmic complaints. Patients participating in this survey found such video visits acceptable and timesaving, and the majority would consider using video consultations for future eyecare encounters.

Ophthalmology Practice During the Coronavirus Disease 2019 Pandemic: The University of Pittsburgh Experience in Promoting Clinic Safety and Embracing Video Visits.

The coronavirus disease 2019 pandemic has led to widespread change as public health strategies for containment have emphasized social distancing and remaining at home. These policies have led to downscaled clinic volumes, cancellation of elective procedures, enhanced personal protective strategies in the clinic, and adoption of telemedicine encounters. We describe the evidence-based practical approach taken in our ophthalmology department to continue delivering eye care during the pandemic by rescheduling visits, enhancing clinic safety, and adopting virtual video encounters.

Inhibitory effects of progesterone differ in dendritic cells from female and male rodents.

BACKGROUND: Steroid hormones, such as progesterone, are known to have immunomodulatory effects. Our research group previously reported direct effects of progesterone on dendritic cells (DCs) from female rodents. Primarily affecting mature DC function, progesterone effects included inhibition of proinflammatory cytokine secretion, downregulation of cell surface marker (major histocompatibility complex class II, CD80) expression, and decreased T-cell proliferative capacity, and were likely mediated through progesterone receptor (PR) because the PR antagonist RU486 reversed these effects. OBJECTIVE: The goal of this study was to assess differences in response to progesterone by DCs from female and male rodents. METHODS: Using real-time reverse-transcriptase polymerase chain reaction, transcriptional expression of steroid hormone receptors was measured in immature bone marrow-derived DCs (BMDCs) from male and female rats. Expression of steroid hormone receptor protein was also assessed in these cells using flow cytometry and fluorescence microscopy. To evaluate functional differences between BMDCs from female and male rats in response to the steroid hormone progesterone, levels of secreted cytokines were measured using enzyme-linked immunosorbent assay. RESULTS: Higher numbers of immature BMDCs from males expressed glucocorticoid receptor (GR) and androgen receptor (AR) proteins compared with females (males vs females, mean [SD]: GR = 68.75 [7.27] vs 43.61 [13.97], P = NS; AR = 75.99 [15.38] vs 8.25 [1.88], P = 0.002), whereas higher numbers of immature BMDCs from females expressed PR protein compared with males (females vs males: PR = 74.19 [12.11] vs 14.14 [4.55], P = 0.043). These differences were not found at the level of transcription (females vs males: GR = 0.088 vs 0.073, P = NS; AR = 0.076 vs 0.069, P = NS; PR = 0.075 vs 0.065, P = NS). Compared with those from females, mature BMDCs from males produced higher quantities of cytokines (tumor necrosis factor-alpha [TNF-alpha], interleukin [IL]-1beta, IL-10) (females vs males: TNF-alpha = 920.0 [79.25] vs 1100.61 [107.97], P = NS; IL-1beta = 146.60 [38.04] vs 191.10 [10.47], P = NS; IL-10 = 167.25 [4.50] vs 206.15 [23.48], P = NS). Conversely, BMDCs from females were more sensitive to progesterone, as indicated by a more dramatic reduction in proinflammatory cytokine secretion (females vs males, highest concentration of progesterone: TNF-alpha = 268.94 [28.59] vs 589.91 [100.98], P = 0.04; IL-1beta = 119.50 [10.32] vs 154.35 [6.22], P = NS). CONCLUSIONS: These findings suggest that progesterone effects on DCs in rodents may be more pronounced in females than in males, and this is likely due to differences in PR protein expression. Our observations may help elucidate disparities in the incidence and severity of autoimmune disorders between females and males, and the role specific steroid hormones play in regulating immune responses.

Progesterone inhibits mature rat dendritic cells in a receptor-mediated fashion.

A variety of extraimmune system factors, including hormones, play a critical role in regulating immunity. Progesterone has been shown to affect immunity in rodents and humans, mainly at concentrations commensurate with pregnancy. These effects are primarily mediated via the progesterone receptor (PR), which acts as a transcription factor, although non-genomic effects of PR activation have been reported. In this study, we evaluated the effects of progesterone on rat dendritic cells (DCs) at ranges encompassing physiologic and pharmacologic concentrations to determine whether progesterone plays a role in modulating DC-mediated immune responses. DCs were derived by culturing rat bone marrow cells in granulocyte macrophage colony-stimulating factor and IL-4. Cells were analyzed for expression of PR using FACS analysis, real-time reverse transcriptase-PCR and fluorescent microscopy. Progesterone treatment of LPS-activated, mature bone marrow-derived dendritic cells (BMDCs) suppressed production of the pro-inflammatory response-promoting cytokines tumor necrosis factor-alpha and IL-1beta in a dose-dependent manner but did not affect production of the pro-inflammatory response-inhibiting cytokine IL-10. Treatment of cells with progesterone also resulted in down-regulation of co-stimulatory molecule CD80 and MHC class II molecule RT1B expression. In addition, progesterone inhibited DC-stimulated proliferation of T cells. Suppression of pro-inflammatory response-promoting cytokine production by progesterone was prevented using the PR antagonist RU486. There was no dose-dependent effect of progesterone treatment on immature DC capacity to take up antigenic peptide. These data indicate that progesterone directly inhibits mature rat BMDC capacity to drive pro-inflammatory responses. This mechanism could contribute to or account for some of the differential expression of autoimmune/inflammatory disease in females.