***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
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    Input: Summary This r and omized , multicenter clinical trial enrolled 103 children hospitalized with septated parapneumonic empyema ( PPE ) who were r and omized to receive thoracoscopy ( n=53 ) or urokinase ( n=50 ) . The main outcome variable was the length of hospital stay after treatment . The secondary outcomes were total length of hospital stay , number of days with the chest drain , number of days with fever , and treatment failures . No statistically significant differences were found between thoracoscopy and urokinase in the median postoperative stay ( 10 vs 9 days ) , median hospital stay ( 14 vs 13 days ) , or days febrile after treatment ( 4 vs 6 days ) . A second intervention was required in 15 % of children in the thoracoscopy group versus 10 % in the urokinase group ( P = 0.47 ) . The authors concluded that drainage plus urokinase instillation is as effective as video-assisted thoracoscopic surgery as first-line treatment of septated PPE in children BACKGROUND The role of intrapleural fibrinolytic agents in the treatment of childhood empyema has not been established . A r and omised double blind placebo controlled trial of intrapleural urokinase was performed in children with parapneumonic empyema . METHODS Sixty children ( median age 3.3 years ) were recruited from 10 centres and r and omised to receive either intrapleural urokinase 40 000 units in 40 ml or saline 12 hourly for 3 days . The primary outcome measure was length of hospital stay after entry to the trial . RESULTS Treatment with urokinase result ed in a significantly shorter hospital stay ( 7.4 v 9.5 days ; ratio of geometric means 1.28 , CI 1.16 to 1.41 p=0.027 ) . A post hoc analysis showed that the use of small percutaneous drains was also associated with shorter hospital stay . Children treated with a combination of urokinase and a small drain had the shortest stay ( 6.0 days , CI 4.6 to 7.8 ) . CONCLUSION Intrapleural urokinase is effective in treating empyema in children and significantly shortens hospital stay Objective : To confirm that either Fibrinolytic therapy or open decortication which of the two is an effective First line treatment of pleural empyema . Methods : This prospect i ve comparative study was conducted in the department of surgery Sheikh Zayed Medical College and Hospital , Rahim Yaar Khan . Seventy eight ( 78 ) patients were included in this study . There were two groups of patients ; Group I ( n=35 ) patients treated with fibrinolytic therapy , Group II ( n=43 ) patients treated with open decortication . Data was entered and analyzed in SPSS v16 . Student ’s t-test was used for comparison of quantitative variables . Chi-square and Fisher ’s Exact test were used for comparison of qualitative variables . P-value ≤ 0.05 was taken as significant difference . Results : There was no significant difference in base baseline characteristics of patients of Group I and II . Incidence of comorbidities was also same between the groups . Most of the patients in Group I and II were in empyema stage III . Fluid cultures was positive in 33 ( 94.3 % ) patients in group I and 39 ( 90.7 % ) patients in group II . 30 ( 85.7 % ) was successfully treated using fibrinolytic therapy but this therapy failed in five ( 14.3 % ) patients , two of these patients expired within the hospital . There was only one ( 2.3 % ) treatment failure in open decortication Group that patient expired within the hospital ( p-value 0.04 ) . Overall duration of hospitalization was significantly high in fibrinolytic group , this was 17.6± 1.95 days versus 12.09± 2.18 days in open decortication group ( p-value<0.0001 ) . There was no significant difference regarding operative mortality within the two groups . Conclusion : Open Drainage is associated with better outcomes as compared to fibrinolytic therapy when used as a First line treatment of empyema Today , in spite of the developments in imaging methods and antibiotherapy , childhood pleural empyema is a prominent cause of morbidity and mortality . In recent years , it has been shown that there has been an increase in the frequency of pleural empyema in children , and antibiotic resistance in microorganisms causing pleural empyema has made treatment difficult . Despite the many studies investigating thoracoscopic debridement and fibrinolytic treatment separately in the management of this disease , there is are not enough studies comparing these two treatments . The aim of this study was to prospect ively compare the efficacy of two different treatment methods in stage II and III empyema cases and to present a perspective for treatment options . We excluded from the study cases with : i ) thoracoscopic intervention and fibrinolytic agent were contraindicated ; ii ) immunosuppression or additional infection focus ; iii ) concomitant diseases , those with bronchopleural fistula diagnosed radiologically , and Stage I cases . This gave a total of 54 cases : 23 ( 42.6 % ) in stage II , and 31 ( 57.4 % ) cases in stage III . These patients were r and omized into two groups of 27 cases each for debridement or fibrinolytic agent application by video-assisted thoracoscopic decortication ( VATS ) . The continuity of symptoms after the operation , duration of thoracic tube in situ , and the length of hospital stay in the VATS group were of significantly shorter duration than in the streptokinase applications ( P=0.0001 ) . In 19 of 27 cases ( 70.37 % ) in which fibrinolytic treatment was applied and in 21 cases of 27 ( 77.77 % ) in which VATS was applied , the lung was fully exp and ed and the procedure was considered successful . There was no significant difference with respect to success rates between the two groups ( P=0.533 ) . The complication rate in our cases was 12.96 % and no mortality was observed . Similar success rates in thoracoscopic drainage and enzymatic debridement , and the low cost of enzymatic drainage both served to highlight intrapleural streptokinase treatment as a reliable method in reducing the need for surgery in complicated empyema OBJECTIVE . Controversy surrounds the optimal treatment of  parapneumonic effusions .  This trial of pediatric patients with community-acquired pneumonia and associated parapneumonic processes compared primary video-assisted thoracoscopic surgery with conventional thoracostomy drainage . DESIGN . A prospect i ve , r and omized trial was conducted at DeVos Children 's Hospital ( Gr and Rapids , MI ) between November 2003 and May 2005 . All of the patients under 18 years of age with large parapneumonic effusions were approached for enrollment in the study . After enrollment , each patient was r and omly assigned to receive either video-assisted thoracoscopic surgery or thoracostomy tube drainage of the effusion . Subsequent therapies ( fibrinolysis , imaging , and further drainage procedures ) were similar for each group per protocol . RESULTS . Eighteen patients were enrolled in the study : 10 in video-assisted thoracoscopic surgery and 8 in conventional thoracostomy .  The groups were demographically similar . No mortalities were encountered in either group , and everyone was discharged from the hospital with acceptable outcomes . Yet , there were multiple variables that demonstrated statistical difference . Hospital length of stay , number of chest tube days , narcotic use , number of radiographic procedures , and interventional procedures were all less in the patients who underwent primary video-assisted thoracoscopic surgery . In addition , no patient in the video-assisted thoracoscopic surgery group required  fibrinolytic therapy  , which was also statistically different from the thoracostomy drainage group . CONCLUSIONS . The outcomes of this study strongly suggest that primary video-assisted thoracoscopic surgery for evacuation of parapneumonic effusions is superior to conventional thoracostomy drainage BACKGROUND AND OBJECTIVE : Parapneumonic empyema ( PPE ) is a frequent complication of acute bacterial pneumonia in children . There is limited evidence regarding the optimal treatment of this condition . The aim of this study was to compare the efficacy of drainage plus urokinase versus video-assisted thoracoscopic surgery in the treatment of PPE in childhood . METHODS : This prospect i ve , r and omized , multicenter clinical trial enrolled patients aged < 15 years and hospitalized with septated PPE . Study patients were r and omized to receive urokinase or thoracoscopy .  The main outcome variable was the length of hospital stay after treatment . The secondary outcomes were total length of hospital stay , number of days with the chest drain , number of days with fever , and treatment failures . The trial was approved by the ethics committees of all the participating hospitals . RESULTS : A total of 103 patients were r and omized to treatment and analyzed ; 53 were treated with thoracoscopy and 50 with urokinase . There were no differences in demographic characteristics or in the main baseline characteristics between the 2 groups . No statistically significant differences were found between thoracoscopy and urokinase in the median postoperative stay ( 10 vs 9 days ) , median hospital stay ( 14 vs 13 days ) , or days febrile after treatment ( 4 vs 6 days ) . A second intervention was required in 15 % of children in the thoracoscopy group versus 10 % in the urokinase group ( P = .47 ) . CONCLUSIONS : Drainage plus urokinase instillation is as effective as video-assisted thoracoscopic surgery as first-line treatment of septated PPE in children OBJECTIVE To compare the efficacy of adjunctive intrapleural streptokinase ( SK ) with simple closed chest tube drainage ( Drain ) in the treatment of empyemas and complicated parapneumonic effusions . METHOD This was a controlled study of 52 patients ( mean age , 57 years ; 41 men ) with pleura space sepsis . Forty patients ( 77 % ) had empyema and 12 had complicated parapneumonic effusions . Twenty-nine patients were treated with Drain only while 23 received , in addition , repeated daily SK , 250,000 U in saline solution ( mean , 5.3 days ) . RESULTS The two groups of patients had comparable degrees of peripheral blood leukocytosis , frequency of loculated effusions , pleural fluid pH , and lactate dehydrogenase levels . Infective organisms were isolated in 54 % of which 32 % were anaerobic and 21 % were polymicrobial infections . The incidence of surgical decortication was 17 % and mortality was 15 % . A significantly larger volume of pleural fluid was drained from patients in the SK treatment group ( 2.0 [ 1.5 ] L ) than those in the Drain treatment group ( 1.0 [ 1.01 ] L ) . There were no significant differences , however , between the two treatment groups in terms of duration before defervescence , duration of hospital stay , the need for surgical intervention , or mortality rates . CONCLUSION We conclude that thrombolytic therapy increased the volume of fluid drained from pleural empyemas but did not markedly reduce morbidity and mortality We conducted a single-center , r and omized , placebo-controlled trial to determine whether streptokinase instillations adjunctive to chest tube drainage reduce the need for surgery and improve outcome in patients with pleural empyema . Fifty-three patients ( frank pus aspirated , 81 % ; microbiological agent cultured , 62 % ; mean effusion pH , 6.6 + /- 0.4 ) received antibiotic treatment , chest tube drainage , and once-daily pleural rinses with either normal saline or normal saline with streptokinase ( 250,000 IU ) . Nine patients were excluded for various reasons before pleural rinses were started .  Streptokinase ( n = 22 ) was instilled over 4.5 + /- 2 days and saline ( n = 22 ) was instilled over 3 + /- 1.3 days . One patient in each group died during treatment . Clinical treatment success and need for referral to surgery were the main outcome measures . No difference was observed after 3 days . After 7 days , streptokinase-treated patients had a higher clinical success rate ( 82 vs. 48 % , p = 0.01 ) and fewer referrals for surgery ( 45 vs. 9 % , p = 0.02 ) . No significant radiologic or functional differences were observed between groups during follow-up over 6 months . We conclude that intrapleural streptokinase adjunctive to chest tube drainage reduces the need for surgery and improves the clinical treatment success in patients with pleural empyema During 1996 - 2003 a total of 359 patients were treated for empyema . Forty eight of them ( with parapneumonic empyema ) were prospect ively r and omized into 2 groups of 24 patients who underwent early decortication either by thoracotomy or VATS . Comparing to thoracotomy group , VATS group had a significantly shorter chest tube duration ( 5.8+/-1.1 vs 9+/-1.3 days ; p=0.03 ) and postoperative in-hospital stay with parapneumonic empyema ( 8.7+/-0.9 vs 12.8+/-1.1 days ; p=0.009 ) . VATS has been found to be particularly useful 
    Output:
    
There was no statistically significant difference in mortality or procedural complications between groups .
This was true for both adults and children with or without fibrinolysis .
The subgroup analysis showed the same result in adults , but there was insufficient evidence to estimate an effect for children .
Our findings suggest there is no statistically significant difference in mortality between primary surgical and non-surgical management of pleural empyema for all age groups .
Video-assisted thoracoscopic surgery may reduce length of hospital stay compared to thoracostomy drainage alone .
There was insufficient evidence to assess the impact of fibrinolytic therapy .