Hypothesis: Efficacious and cost-effective treatment of pediatric empyema can be accomplished following a protocol based on its radiographic appearance. Therapeutic modalities include thoracostomy tube drainage (TTD) with or without fibrinolytic therapy (FT) and videoassisted thoracoscopic debridement (VATD).Design: Retrospective case series.Setting: Tertiary referral center.Results: From 1995 through 1999, 31 children were treated ranging in age from 11 months to 18 years (mean age, 5.1 years). Twenty-seven (87.1%) underwent TTD; of these, 22 (81.5%) received FT with urokinase. The TTD failed in 4 children (14.8%) who required salvage VATD. Primary VATD was performed in another 4 children (12.9%). The mean length of stay was 14.6 days (TTD, 14.1 days; salvage VATD, 20.0 days; primary VATD, 11.5 days), ranging from 8.0 to 30.0 days. Complications included readmission for fever (2 patients [6.5%]) and gas-trointestinal bleeding (1 patient [3.2%]). There were no anaphylactic reactions or bleeding episodes due to urokinase. Two patients (7.4%) treated with TTD and FT developed an air leak that resolved spontaneously. The mean hospital charges were $78832

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low. It is difficult to know what the second figure "1 in 450 000 to 1 in 1 800 000" is intended to denote. It is presumably meant to imply that the average size of population expected to include nine such patients is 450 000-1 800 000. This figure is probably too high but in any case the total population from which the nine patients were ascertained is undefined and presumably unknown. The probability that the size of this population falls within 95% confidence limits of the above estimate is likely to be quite high. Moreover, three specialised rheumatological centres were involved so that the likelihood of biased ascertainment is considerable. Among 104 successive men with ankylosing spondylitis ascertained here, one has seropositive peripheral erosive polyarthritis with a rheumatoid olecranon nodule, his HLA typing including B27. The prevalence of this grade of rheumatoid arthritis is 1 00' in males.4 We therefore interpret the evidence as providing no support for a non-random association of the two diseases and indeed it would be surprising and even more interesting if such cases were not encountered. All the present clinical, immunological, and genetic evidence points to the likelihood that there is no aetiological connection between rheumatoid arthritis and ankylosing spondylitis.

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