A randomized trial of hemithyroidectomy versus Dunhill for the surgical management of asymmetrical multinodular goiter.

OBJECTIVE: To assess the immediate and long-term clinical results of 2 different surgical procedures for the treatment of asymmetrical multinodular goiter (AMG). BACKGROUND: Half of the patients presenting with a single benign thyroid nodule have contralateral subclinical disease. There is a controversy whether these patients should be treated with hemithyroidectomy (HMT) or with a more extensive procedure. METHODS: Adult patients with a benign unilateral dominant nodule and contralateral nodule(s) with a diameter of less than 10 mm detected on neck ultrasonography were randomized to HMT or Dunhill (DUN). Rates of complications, remnant growth, incidental carcinoma, and reoperation were assessed. RESULTS: A total of 118 patients (F/M:110/8, mean age 43 years) were included and randomized: 65 to HMT and 53 to DUN. After randomization, 28 patients were excluded leaving 47 HMT and 43 DUN long-term (55 ± 35 months) evaluable patients. Mean nodule size was 38 and 6 mm for the dominant and contralateral nodules, respectively. No differences were found in operative time, accidental parathyroidectomy, parathyroid autotransplantation, or wound complications. Transient hypocalcemia was more common in DUN (30% vs 8%; P < 0.001). No permanent complications were observed. At the last follow-up visit, thyroid-stimulating hormone was similar in both groups. Remnant growth (20 vs 0%; P < 0.001), appearance of new nodules (55 vs 14%; P < 0.001), and overall reoperation rate (9.2 vs 1.8%, P = 0.2) were more common in HMT, mostly because of undiagnosed cancer requiring completion thyroidectomy. Thirty percent of HMTs developed hypothyroidism and required long-term T4 supplementation. CONCLUSIONS: DUN appears superior to HMT for the treatment of AMG in terms of early reoperation for missed carcinomas and disease progression. Both procedures have a similarly uneventful postoperative course.

Measurement of fasting ketonuria and capillary blood glucose after main meals in women with gestational diabetes mellitus: How well is the metabolic picture captured?

AIM: Metabolic monitoring of women with gestational diabetes mellitus (GDM) usually consists of measuring fasting ketonuria and postprandial capillary blood glucose (CBG) after main meals. We aimed to evaluate how this monitoring system captures the metabolic picture as compared to a scheme with a greater number of time points. METHODS: Thirty-five women with GDM were recommended to follow a fractionated diet and trained in CBG and ketonuria monitoring. They were asked to monitor ketonuria before a main meal, and to monitor CBG at fasting and 1 h postprandial after any two of the six daily meals. Participants were requested to monitor different meals each day. The goal for 1 h postprandial CBG was <135 mg/dL (7.5 mmol/L). Ketonuria was defined as significant before a certain meal when ≥30% of measurements at that point were positive. Similarly, postprandial CBG was defined as abnormal after a meal when ≥30% measurements exceeded the goal. RESULTS: Ketonuria was significant in 22.5% of the time points and 41.2% of women had significant ketonuria at one or more time points; 61% of the time points and 35.7% of the women with significant ketonuria would have been undetected with monitoring restricted to breakfast. Postprandial CBG was abnormal in 17.6% of meals and 57% of women had abnormal postprandial CBG at one or more meals; 37.8% of points and 15% of women with abnormal postprandial CBG would have been undetected with monitoring restricted to main meals. CONCLUSION: A substantial proportion of metabolic abnormalities in GDM women are not detected with a monitoring program that measures only fasting ketonuria and postprandial CBG after main meals.