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Intrapleural t-PA-DNase therapy improved fluid drainage in patients with pleural infection and reduced the frequency of surgical referral and the duration of the hospital stay. Treatment with DNase alone or t-PA alone was ineffective. (Funded by an unrestricted educational grant to the University of Oxford from Roche UK and by others; Current Controlled Trials number, ISRCTN57454527.).

Abstractondary to pulmonary tuberculosis up to 1932 when Kjaergard described primary sponBackground -Primary spontaneous pneumothorax (PSP) is a common clinical taneous pneumothorax (PSP) as a separate entity occurring in previously healthy adults.3 problem and its incidence is thought to be increasing. The risk of recurrence is high Devilliers was the first to suggest the rupture of subpleural blebs as a cause for spontaneous and various studies quote rates of 20-60%. Factors which may or may not predispose pneumothorax and Hewson described thoracocentesis for its relief. PSP is a common clinical problem occurring in apparently healthy subjects with a reported Methods -In a study period of four years 291 cases with a diagnosis of pneumo-incidence of 7.4-28/100 000 per year for men and 1.2/100 000 per year for women. 4 The thorax were reviewed; 153 patients with PSP were included in the study. Their risk incidence of PSP is believed to be increasing, and the recurrence rate has been variably reof recurrence was analysed with particular reference to the following variables: age, ported as 20-60%5 with few studies of predisposing risk factors. sex, height and body mass index (BMI) of the patient, the initial size of pneumoThis retrospective study, which preceded publication of the BTS guidelines, 8 was conthorax, the smoking status of the patient, and the primary form of treatment em-ducted to evaluate the recurrence rate of PSP with particular reference to the following variployed. Univariate analysis was carried out by 2 testing and multivariate analysis ables: age, sex, height and BMI of the patient, initial size of the pneumothorax, smoking status was calculated by a logistic regression model. of the patient, and the primary form of treatment employed. Results -A retrospective study of 275 episodes of PSP in 153 patients over a four year period confirmed a high incidence of recurrence (54.2%). PSP was twice as Methods common in men as in women, though The study was carried out at a cardiothoracic women were significantly more likely to surgical centre (Castle Hill Hospital) for the develop a recurrence ( 2 =7.58, df=1, region of East Yorkshire. A total of 429 patients p<0.01 ). Male height was the second most with a diagnosis of pneumothorax were idenimportant factor, and smoking cessation tified from a computer-generated diagnostic the only other variable which significantly index for the period from February 1990 to influenced the risk of recurrence.March 1994. A proportion of patients (n= Conclusions -Analysis of several potential 104, 24%) were tertiary referrals for surgery risk factors revealed that recurrence was from neighbouring hospitals and were excluded not related to the BMI of the patient, the from the analysis to avoid selection bias. Miss- spontaneous pneumothorax, recurrences, study period. The following data were col-

In 1983 a postal survey of the bronchoscopic practice of chest physicians in the United Kingdom produced a 90% response rate. Two hundred and thirty one physicians were carrying out bronchoscopy; they had performed about 40 000 bronchoscopies in the preceding year, 87% of these being fibreoptic procedures with topical anaesthesia. The mortality rate of fibreoptic bronchoscopy was 0.04%, with a 0.12% incidence of major complications. Transbronchial biopsy carried both an appreciably higher mortality rate of 0.12% and a major complication rate of 2.7%. There is wide variation in the use and choice of sedative drugs for fibreoptic bronchoscopy. Many of the drug combinations could be criticised on pharmacological grounds. The mean dose of lignocaine was 342 mg, most operators exceeding the usual maximum recommended dose; but adverse reactions were rare. Routine supplemental oxygen was given by only 18% of bronchoscopists. Basic resuscitation equipment was often inadequate. Radiological screening was used for transbronchial lung biopsy by 53% of respondents and significantly reduced the incidence of pneumothorax from 2.9% to 1.8%. Both the number of bronchoscopies performed and the complication rate were higher than previous estimates. Bronchoscopists should re-examine their policy on drugs and safety precautions to minimise the risks of the procedure.

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