Mortality in perinatally HIV-infected young people in England following transition to adult care: an HIV Young Persons Network (HYPNet) audit.

OBJECTIVES: Mortality in young people with perinatally acquired HIV infection (PHIV) following transfer to adult care has not been characterized in the UK. We conducted a multicentre audit to establish the number of deaths and associated factors. METHODS: Fourteen adult clinics caring for infected young people reported deaths to 30 September 2011 on a proforma. Deaths were matched to the Collaborative HIV Paediatric Study, a clinical database of HIV-infected children in the UK/Ireland, to describe clinical characteristics in paediatric care of those who died post-transition. RESULTS: Eleven deaths were reported from 14 clinics which cared for 248 adults with PHIV. For the 11 deaths, the median age at transfer to adult care was 17 years (range 15-21 years), and at death was 21 years (range 17-24 years). Causes of death were suicide (two patients), advanced HIV disease (seven patients) and bronchiectasis (one patient), with one cause missing. At death, the median CD4 count was 27 cells/µL (range 0-630 cells/µL); five patients were on antiretroviral therapy (ART) but only two had a viral load < 50 HIV-1 RNA copies/mL. Nine had poor adherence when in paediatric care, continuing into adult care despite multidisciplinary support. Eight had ART resistance, although all had potentially suppressive regimens available. Nine had mental health diagnoses. CONCLUSIONS: Our findings highlight the complex medical and psychosocial issues faced by some adults with PHIV, with nine of the 11 deaths in our study being associated with poor adherence and advanced HIV disease. Novel adherence interventions and mental health support are required for this vulnerable cohort.

Vertically acquired HIV diagnosed in adolescence and early adulthood in the United Kingdom and Ireland: findings from national surveillance.

OBJECTIVE: The aim of the study was to describe the characteristics of young people with vertically acquired HIV diagnosed aged > or =13 years. METHODS: A retrospective review of HIV diagnoses reported to well-established national paediatric and adult HIV surveillance systems in the United Kingdom/Ireland was conducted. RESULTS: Forty-two young people with vertically acquired HIV diagnosed aged > or =13 years were identified; 23 (55%) were female, 40 (95%) were black African and 36 (86%) were born in sub-Saharan Africa. The median age at HIV diagnosis was 14 years (range, 13-20 years). Half of the patients presented with symptoms; the remainder were screened for HIV following diagnosis of a relative. The median CD4 count at diagnosis was 210 cells/microL (range, 0-689 cells/microL), 12 patients (29%) were diagnosed with AIDS at HIV diagnosis or subsequently, and 34 (81%) started combination antiretroviral therapy (ART), most (31 of 34) within a year of diagnosis. CONCLUSION: A small number of young people with vertically acquired HIV survive childhood without ART and are diagnosed at age > or =13 years in the United Kingdom/Ireland. Half of the patients were asymptomatic, highlighting the importance of considering HIV testing for all offspring of HIV-infected women, regardless of age or symptoms. Increased awareness among clinicians and parents is required to reduce delayed presentation with advanced disease and to avoid onward transmission as these young people become sexually active.

Is vaginal microscopy an essential tool for the management of women presenting with vaginal discharge?

SUMMARY: Point-of-care microscopy is the gold standard for the diagnosis of vaginal discharge in genitourinary (GU) medicine clinics but not used in primary care settings and reproductive health clinics to which many patients present. In our GU medicine clinic setting, we conducted an audit to assess the utility of microscopy of vaginal secretions versus clinical diagnosis alone for the differential diagnosis of uncomplicated lower vaginal infections. Clinical diagnosis (including pH) of bacterial vaginosis had a sensitivity between 85% and 88% at two clinic sites. Our results suggest that it may be safe and more cost-effective to restrict vaginal microscopy to a subgroup of women presenting with vaginal discharge.

Would offering rapid point-of-care testing or non-invasive methods improve uptake of HIV testing among high-risk genitourinary medicine clinic attendees? A patient perspective.

While most genitourinary (GU) medicine clinics achieve a high uptake for testing HIV in new patients, they may still miss testing those at highest risk. Point-of-care testing (POCT) and salivary samples are acceptable and feasible but have not yet been shown to increase uptake among high-risk patients (HRP). This study aimed to describe reasons why HRP decline HIV testing and whether offering POCT along with standard testing would increase the uptake of testing HIV in two London GU medicine clinics. Anonymous self-administered questionnaires were offered to all new and rebooked patients. Eight hundred and ninety-nine questionnaires were analysed of which 598 were HRP. Uptake of HIV testing was 77.1% among HRP and 65.8% among the rest. A total of 51.1% of HRP who declined HIV testing said they would be more likely to accept a POCT and 32.8% a salivary test. Introduction of rapid POCT for HIV would increase patient's choice and may increase the likelihood of HRP accepting an HIV test.

Management of HIV infection in adolescents attending inner London HIV services.

Increasing numbers of HIV-infected children are now reaching adulthood and young people account for 10% of new HIV diagnosis in the UK each year. This audit of young people attending specialist and generic HIV services in Inner London in 2006 (n=39) highlights the complex medical and psychosocial needs of this patient group: 63% were diagnosed with HIV because of poor health, 39% had received more than three antiretroviral regimens, 21% had resistance to two antiretroviral classes and 32% had significant mental health problems. In addition, 45% reported to be sexually active with poor uptake of contraception other than condoms and frequent non-disclosure of their HIV status to a sexual partner.

Prevalence of Chlamydia trachomatis in sexual contacts of gonorrhoea.

The British national and local clinic guidelines recommend epidemiological treatment for Chlamydia trachomatis (CT) in patients with gonococcal infection but not their contacts. We aimed to determine the prevalence of CT amongst all gonorrhoea contacts attending over a 30 months period through a retrospective notes review. Of 223 contacts, gonorrhoea was diagnosed in 110 (49.3%) while CT was diagnosed in 54 (24.2%). CT was significantly more prevalent in younger people [(37.8% of contacts <25 years versus 9.6% of contacts >/=25 years (P = 0.000)]. All patients with CT identified as heterosexual except one. Amongst heterosexuals, there was no significant difference in the prevalence between males and females, being 31.6% and 27.8% respectively (P = 0.5995). CT was prevalent in 29.1% of N. gonorrhoeae positive contacts and 19.5% of N. gonorrhoeae negative contacts (p = 0.0935). The high prevalence suggests that epidemiological treatment for CT in gonorrhoea contacts is indicated.

Chronic angiotensin-converting enzyme inhibition may improve sodium excretion in cardiac transplant hypertension.

Cyclosporine-associated hypertension (CAH) may be mediated in part by sodium and volume retention. To investigate this issue, we studied the effects of a calcium antagonist, nitrendipine (NIT, 10-20 mg b.i.d.), and a converting enzyme inhibitor, lisinopril (LIS, 10-20 mg o.d.), on blood pressure (office BP, 24 hr ambulatory BP), excretion of an acute sodium load (200 mmol/2 hr i.v.), glomerular filtration rate (insulin clearance), cumulative dopamine excretion, plasma atrial natriuretic peptide (ANP), and endothelin excretion in 8 patients with CAH after cardiac transplantation in a double-blind, randomized, crossover trial for 6 weeks. Five patients received a diuretic during the trial at a constant dose. Office diastolic BP (DBP) decreased significantly with LIS from 97 +/- 6 to 87 +/- 9 mmHg and with NIT from 96 +/- 7 to 92 +/- 12 mmHg. Ambulatory 24 hr DBP decreased significantly from 96 +/- 7 mmHg to 86 +/- 10 mmHg (LIS) and to 84 +/- 11 mmHg (NIT). Ambulatory DBP during the day was lowered significantly from 98 +/- 11 mmHg to 87 +/- 10 mmHg (LIS) and to 88 +/- 9 mmHg (NIT) and during the night from 95 +/- 9 mmHg to 86 +/- 8 mmHg (LIS) and to 79 +/- 7 mmHg (NIT). Cumulative sodium excretion 6 hr after an acute sodium load increased to 52 +/- 39 mmol (placebo), 96 +/- 44 mmol (LIS, P < 0.05 vs. placebo), and 71 +/- 34 mmol (NIT). Glomerular filtration rate, cumulative dopamine excretion, ANP, and endothelin excretion did not differ between either treatment group. We conclude, that: (1) both drugs were similar in lowering office BP and during the day, but NIT tended to be more effective during the night; and (2) cumulative sodium excretion during LIS was significantly increased compared with placebo. There was a similar trend during NIT also. Therefore, it is possible that chronic angiotensin-converting enzyme inhibition and possibly calcium antagonists might improve the sodium-retaining state in CAH independent of differences in blood pressure, ANP, dopamine, or renal function.

Increased plasma levels of endothelin in diabetic patients with hypertension.

In order to gain insight into the potential role of endothelin, a 21 amino acid peptide produced by endothelial cells, in the development of complications of diabetes mellitus, basal plasma endothelin levels were measured in 152 patients with diabetes mellitus (83 patients with type 1 diabetes mellitus, 69 patients with type 2 diabetes mellitus) and compared to those in 50 healthy controls. Blood was drawn at 8:00 AM under resting conditions and endothelin was measured after prior extraction by a sensitive radioimmunoassay specific for both endothelin 1 and 2. Endothelin levels were increased in patients with diabetes mellitus in comparison to controls. In type 1 diabetes mellitus a positive correlation between endothelin levels and age was found. We found that 60% of patients with type 1 diabetes mellitus and elevated endothelin levels higher than 2.5 pg/mL (highest value in a control person) had had diabetes for more than 20 years (P less than .05 v patients with normal endothelin levels). In type 2 diabetes mellitus the relation between elevated endothelin levels and diabetes duration was reversed. Glycosylated hemoglobin (HbA1) concentrations above 10% of total hemoglobin were measured in 62% of the patients. Arterial hypertension was present in 60% of the patients with type 1 diabetes mellitus and increased endothelin levels greater than 2.5 pg/mL (both P less than .05 v patients with normal endothelin levels).(ABSTRACT TRUNCATED AT 250 WORDS)

Modification of the responses of endothelin-1 to exhaustive physical exercise under simulated high-altitude conditions with acute hypoxia.

To assess whether acute alveolar hypoxia leads to the release of endothelin-1 (ET) in vivo, ET, cortisol (CORT), and lactate (LA) levels were determined in 15 healthy subjects at rest and during exhaustive incremental cycle ergometry on two separate test days. The subjects were to breathe a gas mixture with reduced O2 content ([H] fraction of inspired O2, 0.14) on one day and normal air on the other (N). Modified responses of LA and CORT to exhaustive incremental cycle ergometry on the H day indicated elevated anaerobic tissue metabolism and increased physical stress. With acute alveolar hypoxia, the response of ET to exhaustive physical labor was found to be augmented.

Elevated endothelin-1 levels after cigarette smoking.

The effect of short-term nicotine consumption on endothelin-1 (ET-1) levels was studied in 10 male healthy smokers. Volunteers smoked in random order on 3 separate days a low-tar cigarette or a high-tar cigarette, or were studied without having smoked (no-cigarette experiment). ET-1, corticotropin, and cortisol levels, heart rate, and blood pressure were determined before and 1, 3, 5, 10, 20, and 30 minutes after smoking. In contrast to results obtained after smoking a low-tar cigarette or not smoking, smoking a high-tar cigarette resulted in a significant increase in ET-1 levels within 10 minutes, followed by an increase in corticotropin levels within 20 minutes after smoking. Thirty minutes after smoking, cortisol levels were higher after a high-tar cigarette compared with a low-tar cigarette or no smoking. Increases in heart rate and systolic blood pressure were likewise higher after smoking a high-tar cigarette than after smoking a low-tar cigarette. In conclusion, it is tempting to speculate that ET-1 may indeed act as the long-searched-for link between vasopressin and corticotropin-releasing hormone (CRH) and thus play an essential role in the stimulation of the hypothalamic-pituitary-adrenal axis. In addition, these results suggest that the increase in the level of ET-1, a powerful vasoconstrictor and mitogen, may play an important part in the disease mechanisms of atherosclerosis arising from smoking.

Clinical evidence for a neuromodulator action of endothelin in the hypothalamic-pituitary-adrenal axis in man.

In order to investigate whether the ubiquitous signalling peptide endothelin might also act as a neuromodulator in the stimulation of the hypothalamic-pituitary-adrenal axis, 15 patients (4 female, 11 male, aged 35-67 years) with hypopituitarism were investigated and the results were compared to those of 8 healthy male volunteers (aged 24-31 years). Patients and controls received double-blind in random order either 0.1 IE per kg body weight regular insulin (insulin induced hypoglycemia) or 1 ml 0.9% sodium chloride (placebo) on 2 separate days. Control subjects only received on an additional day 0.1 IE per kg body weight regular insulin plus glucose 10% (euglycemic hyperinsulinemic glucose clamp). In control subjects hypoglycemia resulted in a significant increase in adrenocorticotropin (ACTH) and cortisol which was preceded by an increase in circulating endothelin levels (p < 0.01 vs placebo and euglycemic clamp) while endothelin, ACTH and cortisol remained unchanged both after placebo and in the euglycemic hyperinsulinemic clamp. In contrast, patients with hypopituitarism showed neither changes in circulating endothelin levels nor a stimulation of the hypothalamic-pituitary-adrenal axis during insulin-induced hypoglycemia. These data demonstrate that 1) endothelin levels are enhanced by metabolic stress 2) the responsiveness of endothelin levels to metabolic stress is linked to the presence of an intact pituitary gland and 3) endothelin might be involved in the stimulation of the hypothalamic-pituitary-adrenal axis.

Increase of serum insulin and stable c-peptide concentrations with exhaustive incremental graded exercise during acute hypoxia in sedentary subjects.

Hypoxia was shown to reduce insulin concentrations at rest and during exercise. However, some studies have also demonstrated increases in the hormone associated with arterial desaturation. This study was conducted in order to decide [1] whether acute alveolar hypoxia increased or decreased the circulating insulin levels, and [2] to elucidate whether interactions of insulin with other hormones were of relevance in this respect. Glucose (GLU), insulin (INS), c-peptide (CP), adrenaline and noradrenaline (CATs), atrial natriuretic peptide (ANP) and cortisol (CORT) as well as the capillary blood gases were determined in 15 healthy fasting male volunteers (age: 26.2 +/- 2.8 years, body mass index: 22.4 +/- 2.7 kg.m-2). On two separate test days the subjects breathed, in random order, either normal air (N) or a gas mixture with reduced oxygen content (H; FIO2: 0.14). Measurements were made at rest as well as during an incremental cycle exercise in a supine position (increments of 6 min and 50 W) at 100 W and 150 W, at volitional exhaustion (N: 227 +/- 36 W; H: 200 +/- 32 W) as well as in the 5th min of recovery. Arterial desaturation was seen throughout on H-day. At rest all hormones and GLU were normal and showed no influence of H. During exercise INS remained constant on N-day, increased on H-day and was significantly higher with H than with N, most pronounced at 150 W and at volitional exhaustion with 20%, respectively. For CP and GLU no significant exercise-induced changes were seen on either test day and no influence of H was detected.(ABSTRACT TRUNCATED AT 250 WORDS)

Chemoprophylaxis of diabetic nephropathy in the elderly.

Renal disease in elderly diabetic patients is costly in terms of morbidity, mortality and medical payments. Therefore, prevention of diabetic nephropathy has become a prominent goal in the treatment of diabetic patients. Preventive treatment should begin not later than at the stage of persistent microalbuminuria, and regular screening for microalbuminuria is recommended for both elderly and younger diabetic patients. Improved metabolic control, through diet and hypoglycaemic therapy, has been demonstrated to lower urinary albumin excretion. The target level of glycated haemoglobin is < 8%, or < 2% higher than the upper limit of normal in nondiabetic people. Insulin therapy has no adverse effects on renal indices, unless it increases bodyweight and consequently raises blood pressure. To preserve renal function in elderly diabetic patients, blood pressure should be kept well below 140/90 mm Hg. Treatment with ACE inhibitors may be the 'gold standard' intervention, and should be initiated at the lowest possible dosage and then titrated until the maximum tolerated dosage has been reached. Nonchronotropic calcium antagonists have been shown to be as effective as ACE inhibitors with regard to their effects on blood pressure, renal haemodynamics and urinary albumin excretion. Most dihydropyridines have been found to increase or to have no effect on urinary albumin excretion despite significant blood pressure reduction. A renoprotective action of diuretics is generally unlikely, with the possible exception of indapamide. Although beta-blockers are effective antihypertensive agents, they may not adequately preserve kidney function in diabetic patients. Because beta-blocker treatment may mask the symptoms of hypoglycaemia, they should be reserved for patients with coronary artery disease or arrhythmias.

Hormonal modifications in patients admitted to an internal intensive care unit for acute hypoxaemic respiratory failure.

To clarify which endocrine modifications can be observed in acute hypoxaemic respiratory failure, 15 severely ill male patients [PAT; median age: 61 (range: 48 years); median height: 173 (range: 12) cm; median mass: 73 (range 31) kg] were investigated immediately upon admission to an intensive care unit (ICU) for this clinical disorder. Before starting treatment, the blood gases were measured and a number of selected hormones with special relevance for an ICU setting were determined. These are known to be modified by acute hypoxaemia in healthy subjects and to possess glucoregulatory properties, or an influence upon cardiocirculation or the vascular volume regulation: insulin, cortisol, adrenaline, noradrenaline, atrial natriuretic peptide, renin, aldosterone, angiotensin converting enzyme, and endothelin-I (ET). To elucidate whether potential endocrine changes resulted from acute hypoxaemia alone, the underlying disease, or unspecific influences connected with the ICU setting, all measurements were compared to those of a completely healthy reference group (REF) with comparable acute experimental hypoxaemia. The latter state was achieved by having the REF breathe a gas mixture with the oxygen content reduced to 14% (H). In the REF, neither the medians nor the distribution of endocrinologic measurements were modified significantly by acute hypoxaemia. In the PAT, the medians were increased considerably, yet with a slight diminution of ET. The distribution of individual values was considerably broader than in the REF with H. In conclusion, considerable increases in the means of the above hormones, with the exception of ET, can be registered in severely ill patients admitted to ICUs with acute hypoxaemic failure. However, such modifications cannot be considered attributable exclusively to acute arterial hypoxaemia. The underlying clinical disorders, such as septicaemia or an unspecific endocrine epiphenomenon, including severe and not only hypoxaemic stress, seem to be predominant.

Somatic pain threshold and reactive hyperemia in autonomic diabetic neuropathy and silent myocardial ischemia.

In 31 patients with coronary artery disease (autonomic neuropathy, n = 11; diabetes without neuropathy, n = 10; silent myocardial ischemia without diabetes, n = 10) difference in somatic pain threshold and plethysmographically determined reactive hyperemia induced by forearm skeletal muscle ischemia was investigated. There was no difference in reactive hyperemia after passive maximum forearm ischemia in the three groups indicating identical vascular reactivity. After symptom-limited ischemic work however, reactive hyperemia was significantly higher in patients with silent myocardial ischemia as compared to diabetic patients. Exercise time was longer in patients with silent myocardial ischemia (153 +/- 51 s) as in patients with diabetic neuropathy (139 +/- 45 s) and diabetics without neuropathy (120 +/- 45 s). Pain as a cause of termination of symptom-limited ischemic forearm exercise occurred less frequently in patients with diabetic neuropathy (2/11) and patients with silent myocardial ischemia (3/10) as compared to patients with diabetes without neuropathy (9/10). In conclusion, patients with silent myocardial ischemia have a higher ischemic tolerance in the working forearm as compared to diabetic patients with and without neuropathy. There is a quantitative difference in ischemic tolerance between patients with silent myocardial ischemia and patients with diabetic neuropathy.

Gonorrhoea in young heterosexuals attending urban STD clinics in Britain: a cross-sectional survey.

Young people in the UK bear the brunt of sexually transmitted infections, in particular of gonorrhoea. We aimed to assess whether young people with gonorrhoea (under 21 years) attending sexual health clinics differed from older individuals with gonorrhoea in their behavioural and clinical characteristics and management outcomes. The results of this cross-sectional study suggest that young people were more likely to be female (66.2% vs 34.1%), have concurrent infection with Chlamydia trachomatis (55.4% vs 30.2%) and a history of recent gonococcal infection (81.3% vs 35.5%) if they ever had gonorrhoea. Young women were more likely to experience treatment delay and not to attend for follow-up than older women. Resistance to ciprofloxacin was high in both age groups but the prevalence of penicillinase-producing Neisseria gonorrhoeae was higher in older patients (11.5% vs 1.3%). Different management protocols for young and older patients with gonorrhoea may need to be considered.

How useful are high vaginal swabs in general practice? Results of a multicentre study.

Vulvovaginal symptoms are a common reason for consultation with a general practitioner (GP). High vaginal swabs (HVS) are used to investigate symptoms, but their usefulness is poorly evaluated and microbiological tests performed vary between laboratories. In this multicentre study of 797 women with genital symptoms attending GPs, diagnostic yield of HVS was poor except for Candida spp. (22%). There is an urgent need to establish the most cost-effective approach for the management of these women.

Pituitary adenomas: serum hormone levels and immunohistochemical staining for ACTH, GH and prolactin.

In 37 pituitary adenomas obtained by surgery the immunohistochemical staining for ACTH, GH and prolactin and the tumor size were related to the basal serum hormone levels. 5 adenomas were associated with Cushing syndrome, 9 with acromegaly, 17 with hyperprolactinemia and 6 were preoperatively diagnosed as inactive. A rather close correlation between immunoreactivity of tumor tissue and basal serum hormone levels was found for GH and prolactin whereas these two parameters were not significantly correlated in the corticotrophic adenomas examined. Furthermore there was no obvious correlation between serum hormone levels and tumor size. Several non immunoreactive adenomas showed slight hyperprolactinemia; all of them were macroadenomas with extended sellar lesions. This fact may be explained by disturbances in the hypothalamic-hypophyseal regulation of serum prolactin.

[The status of the gonadotropin releasing hormone test in differential diagnosis of delayed puberty in adolescents over 14 years of age]. / Stellenwert des Gonadotropin-Releasing-Hormon-(GnRH-) Tests in der Differentialdiagnose der Pubertas tarda bei Heranwachsenden über 14 Jahren.

BACKGROUND: In patients with delayed puberty with a bone age less than 11 years in girls or 12 years in boys, the clinical and endocrinological examination allows the differentiation of patients with the various forms of hypergonadotropic hypogonadism, but not of patients with hypogonadotropic hypogonadism from more prevalent constitutional delay in puberty. Therefore, watchful waiting is generally recommended for differential diagnosis in patients with delayed puberty. On the other hand, the late onset of sexual hormone replacement in patients with hypogonadism will worsen their outcome. PATIENTS AND METHOD: Therefore, we decided to carry out a retrospective study in 105 adolescents who were examined because of short stature or delayed puberty, who were aged 14 to 22 years at first visit and in whom the differential diagnosis of delayed puberty was documented after an at least one-year follow-up in order to find out which endocrinological parameters could have effectively predicted the final diagnosis already at the first visit. RESULTS: Patients with hypogonadotropic hypogonadism differed from patients with constitutional delay in puberty by lower responses of luteinizing hormone (LH) and follicle-stimulating hormone (FSH) levels to gonadotropin-releasing hormone stimulation (GnRH, 100 micrograms iv) (p < 0.01) as well as by smaller testicular volume (p < 0.05) and by lower testosterone levels (p < 0.01). Stimulated LH < 10 mU/ml differentiated patients with hypogonadotropic hypogonadism from constitutional delay in puberty with a sensitivity of 82% and a specificity of 98%. CONCLUSION: In patients with delayed puberty aged 14 years and older bone age usually exceeds 11 years in girls or 12 years in boys. It thus is in the range, in which normal adult responses of LH to GnRH can be expected. In contrast to patients aged less than 14 years, therefore, measuring GnRH-stimulated LH levels in these patients allows the rapid and effective differential diagnosis of delayed puberty.

[Compliance problems in therapy with levothyroxine]. / Compliance-Probleme bei der Therapie mit Levothyroxin.

In order to evaluate problems with long-term levothyroxine therapy, the course of treatment in 185 patients of an endocrinological outpatient ward (88 with euthyroid goiter, 41 with overt or latent hypothyroidism, ten with Hashimoto's thyroiditis, 46 after resection of goiter) was analyzed retrospectively. Duration of therapy ranged from one to 28 years. Suppressive therapy of euthyroid goiter was stopped by the treating physician in eleven patients (11%), in five permanently. To the contrary, 30 patients (34%) stopped medication by themselves 31 times, 29 times, however, levothyroxine was restarted again. Observations in the group with latent hypothyroidism were similar. After operation levothyroxine therapy was stopped by the physician eight times, six times only for a limited time period. Eight patients (17%) decided to stop therapy without knowledge of the treating physician, but in all it was restarted later. The presented results show that the success of levothyroxine therapy of euthyroid goiter as well as of prophylaxis of goiter relapse after operation is threatened by dyscompliance of the patients. In goiter suppression therapy compliance is further challenged by a lack of consequence in therapy planning and guidance.