FOAM Eye-Catchers 8: New ACS rule out rule, Tamiflu Scandal, ACEP Seizure Policy & more

The exciting new Manchester Acute Coronary Syndrome Rule (MACS) is explained by Richard Body the lead author here on the St Emlyn’s blog and the study is available free in the BMJ’s Heart journal.

Essentially a computer calculator calculates a probability of ACS based on a combination of 6 clinical features and 2 biochemical markers that are assessed at the time of arrival in ED. The clinical features are:

  • ECG signs of ischaemia

  • Worsening angina

  • Radiation to right arm

  • Vomiting

  • Observed sweating

  • Hypotension

The biochemical markers are high sensitivity troponin and a new biomarker – heart type fatty acid binding protein (H-FABP).

Based on this calculation, patients are placed into one of 4 risk categories – very low, low, moderate and high. In the validation cohort, very low risk patients who represented 28% of the cohort could be safely discharged home with a risk of AMI of 0.0% and MACE (Major Adverse Cardiac Event) of 1.6% within 30 days. By contrast, just under 10% of patients were classified as high risk patients who had AMI and MACE rates of over 90% each and are therefore recommended to proceed straight to high dependancy area (e.g. coronary care unit) This rule therefore is able to both rule in and rule out patients.

This represents a significant advance in early ACS work up so watch this space for external international validation of this rule in the future.


Finally the truth is out about tamiflu – Emlitofnote discusses the findings of the recently updated Cochrane review of neuramindase inhibitors. For years the relevant drug companies withheld relevant data from clinical trials which, due to consistent pressure from this particular Cochrane group, has since been made available.

The effect of this deliberate withholding of scientific data has been for governments to spend billions of dollars stockpiling an influenza medication that has no proven ability to reduce complications of the flu. Such is the magnitude of this discovery, it has made the mainstream media. Check out this guardian article: what the tamiflu saga tells us about drug trials and big pharma, that I came across courtesy of gruntdoc.

The guardian article makes the obvious but seemingly incomprehensible point to regulators that we must demand access to all relevant scientific data before a drug is registered for widespread clinical use. Only a combination of consistent pressure from academics and legislation will achieve this. Well done to the Cochrane team for this historic achievement after years of pressure.

The wider issue of hidden trial data is gaining steam now through a major collaboration between major journals and medical institutions, including the BMJ and Cochrane, known as the All Trials campaign, with their purpose explained in this 3 minute video. There’s a petition and campaign for individuals and organisations to sign and get involved in. Locally of note for ED folks, ACEM (the Australasian College of Emergency Medicine) has signed the All Trials petition. If you believe doctors and regulators should have access to the results of all patient trials, not just the positive ones that drug companies want to release, then take a look and get involved.


ACEP have released a new clinical policy: “Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department with Seizures” which is described on this post and is currently available free in the April issue of Annals of Emergency Medicine. Key recommendations include (but are not limited to):

  • not needing to initiate anti-epileptic meds in the ED for patients with first unprovoked seizure without evidence of brain disease or injury, OR in first provoked seizure patients.

  • not needing to admit patients with first unprovoked seizure who have returned to their clinical baseline in the ED.

  • endorsing the use of both phenytoin and levetiracetam intravenously for patients with status epileptics who have failed to respond to benzodiazepines.

Note that most of the recommendations are level C.


The Swami dispels a few myths about DKA management. The evidence suggests:

  • VBG’s are as useful as ABG’s
  • Don’t rush to start insulin if you are hypokalaemic
  • There’s no established role for bicarb in DKA
  • Insulin boluses should be avoided.


A basic concept, exceedingly well explained with excellent illustrative images in this 4 minute video by Dr Andrew Dixon from