Abstract
Objectives: to review the formal consultations received by the thoracic surgery team for the purpose of pleural catheter insertion to drain different cases of pleural effusion from different departments.
Methods: formal consultations to drain pleural effusion by the thoracic surgery division of the royal medical services were reviewed retrospectively during the period: January 2008 - December 2009. Four hundred and ten patients were included in the study. Data collected were: Department of the consultation, amount of pleural effusion (mild, moderate or severe), estimated time to drain the effusion and appropriateness of the consultation.
Results: There were 173 females (42%) and 237 males (58%). Age ranged from (12-84 years). The most common consulting department was the nephrology (26.8%), followed by the oncology (18.7%). Two hundred thirty one (56.3%) of consultations showed mild pleural effusion, that could be treated medically or by simple pleural tapping and we consider them inappropriate referral. The estimated time to prepare the tools inside the ward (tube or catheter, analgesia, surgical set, etc) ranged from 15 min to 2 hours while the estimated time of the procedure was 10min - 20min.
Conclusion: Our study highlights the need to establish a protocol to organize consultations regarding pleural effusion between thoracic surgery team and other specialties that commonly involved in pleural effusion management 1. Please address recurring typographical error of writing tow instead of two.
2. "suspicion of medical abuse" does not sound right. inappropriate referral will be a better term.
3. Your data demonstrating more then 50% inappropriate referral should appear in results section rather then in discussion. In discussion you can discuss the reasons for these findings rather then presenting this result for the first time in the entire paper.
4. You mention BTS guidelines. It would have been a better study if you had introduced these guidelines in the referring physicians and reviewed the change in referral pattern. You may still be able to do that.In addition a table of indications for referral as per BTS guidelines would have educational value.
5. In my experience there is a delay in referral of patients with pleural effusion as a consequence alot of patients with empyema thoracic get referred at the organising phase rather then fibrinous phase with obvious surgical / therapeutic consequences. Similarly patients with malignant effusions get referred when they are at deaths door as a consequence of lung atelectasis and hypoxia. It is important to maintain a balance when giving advice to our colleagues so as not to scare them off.
6. Chest drain insertion is possibly the most innocuous of procedures performed by Thoracic surgeons with the most gratifying result.

Key words: Pleural effusion, parapneumonic effusion, malignant effusion.