Laboratory Risk Indicator for Necrotizing Fasciitis score for early diagnosis of necrotizing fasciitis in Darwin.

BACKGROUND: Soft tissue infections are a major health burden in the Top End of the Northern Territory of Australia. Necrotizing fasciitis (NF) is associated with mortality rates from 8 to 40%. Early recognition and aggressive surgical debridement are the cornerstones of successful treatment. The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score, developed by Wong et al., uses six routine biochemical variables to aid early diagnosis. We aim to assess the diagnostic efficacy of the LRINEC score in our population. METHODS: A retrospective review of patients with NF between 2005 and 2013 was conducted. A time matched cohort of abscesses/cellulitis was selected. Admission bloods were used to calculate the LRINEC score. An intraoperative finding of NF was used as the gold standard definition for comparison. The diagnostic accuracy of the LRINEC score was assessed. RESULTS: Ninety-eight patients with NF and 205 control patients were identified. The area under the receiver operator curve for the LRINEC score in detecting NF was 0.925 (0.890-0.959, P < 0.001). The sensitivity of the LRINEC ≥5 for NF was 76.3%, with a specificity of 93.1%. The positive and negative predictive values were 95.5 and 88.1%, respectively. The positive and negative likelihood ratios were 11 and 0.25. CONCLUSION: The LRINEC score is a useful, robust, non-invasive and easily calculated scoring system that can be used as an adjunct to early diagnosis of NF. However, a high degree of clinical suspicion remains the most important factor in early diagnosis of NF.

Emergency neurosurgery in Darwin: still the generalist surgeons' responsibility.

BACKGROUND: Royal Darwin Hospital (RDH) is the only major hospital for the 'Top End' of Northern Territory and Western Australia. As retrieval distances exceed 2600 km, resident generalist surgeons undertake all emergency neurosurgery. METHODS: Retrospective clinical study from RDH records and review of prospectively collected datasets from RDH Intensive Care Unit and National Critical Care Trauma Response Centre for all emergency neurosurgery patients between 2008 and 2013. RESULTS: Data were obtained from 161 patients with 167 admissions (73% male, 39% indigenous) who underwent 195 procedures (33 per year), including burr hole, craniotomy, cerebral and posterior fossa craniectomy, elevation fracture and ventricular drain. Trauma accounted for 68%, with alcohol as a known factor in 57%. Subdural haematoma (SDH) accounted for 53%. Severity of head injury at presentation correlated with outcome (R(2) = 0.12, P < 0.001). Factors associated with death included injury at remote location (P = 0.022), time injury to operation >24 h (P = 0.023) and specific diagnoses of acute SDH (P = 0.006), acute-on-chronic SDH (P = 0.053) and infection (P = 0.052). Indigenous patients were younger (40 versus 55 years, P < 0.001) and more likely to have alcohol as a factor in trauma cases (71% versus 49%, P = 0.027). Time from injury to hospital was high for accidents at a remote location (12.9 versus 1.3 h, P < 0.001); however, Glasgow Outcome Scales (P = 0.13) were no different to accident at metropolitan Darwin. CONCLUSION: General surgeons at RDH perform a wide range of emergency neurosurgical procedures primarily for trauma. Factors contributing to poor outcomes included remote location of trauma and delay in reaching the hospital. Outcomes at 3 months appear acceptable.