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Acute myocardial infarction is relatively uncommon in patients under the age of 40 years. Unlike the older patients where rupture of coronary artery atherosclerotic plaque is the main underlying pathology, the pathogenesis in younger patients can be varied and may require different diagnostic and therapeutic approaches. Hypercoagulable state associated with nephrotic syndrome and antiphospholipid syndrome can lead to the development of occlusive coronary artery thrombus in absence of atherosclerotic coronary artery disease. Acute myocardial infarction in such a setting can sometimes be the first manifestation of an underlying disease. We describe a case of myocardial infarction in a young man with both nephrotic and antiphospho-lipid syndromes and present a brief literature review.

BackgroundThe use of musculoskeletal ultrasound (MSK US) in routine care is expanding. The number of rheumatologists using or seeking to learn the technique is also increasing, though it is unclear how US is being incorporated into routine work practices (RWP).ObjectivesThis survey sought to gain an insight into the use of MSK US in a region of Southern England.MethodsA questionnaire was designed by the authors to collect information on training, access & service delivery, indications and attitudes towards use of MSK US in RWP. All rheumatology consultants (RC), trainees (RT) and specialist nurses (SN) working in 19 Hospitals (Hs) (4 Medical School Universities, 15 District General) in London South, Kent, Surrey and Sussex regions of England were invited to complete the survey. Data were analysed using simple descriptive and summary statistics.ResultsA total of 70 questionnaires (51%) were returned (RC 61%, RT 27%, SN 12%) with at least one response from all 19 Hs.Training: Of the 70 responders (Rs), 42% report having had formal training in the use of US, however only 12% had support for this and 10% have a formal MSK US certificate.Access & service delivery: MSK US scans are most usually performed by radiologists (64%). In 11 Hs there are also US machines in the rheumatology department, of which 8/11 are currently used for routine care. The routine waiting time for a MSK US is up to 6 weeks.10 of the 29 Rs who have had training (34%) perform US scans themselves. They report greatest confidence scanning the hands (90%), followed by feet (70%) and 20% are confident to scan all joints. US guided injections are given by 50% and US guided synovial biopsies performed by 20%.The maximum number of joints scanned in one session varies from 5 – 40 joints, taking an average time of 20 minutes per scan.Indications: MSK US are requested for diagnostic purposes by 92%, guided injection by 80%, assessment of treatment response by 52%, research purposes by 8% and 75% request a scan at least 1 – 5 times a week. The proportion of Rs requesting MSK US per disease groups is: Inflammatory Arthritis (IA) >85% and soft tissue 63%.Attitudes: More than 60% of the Rs report that MSK US results often lead to a change in their management plans and that it enhances patients' satisfaction. 82% think it appropriate that RC should perform MSK US scans as part of their RWP. 50% of the RC and 72% of the RT think that proficiency in use of US should be a mandatory part of the rheumatology training curriculum. 51% of the Rs indicated a willingness to learn the technique.Free text responses revealed concerns about available time and proper training but others commented that MSK US is beneficial in an early IA setting.ConclusionsThis cross-sectional, observational, multicentre survey demonstrates widespread use of MSK US by rheumatologists in routine care in the South East Coast region of England. 82% of Rs think it appropriate that RC should perform MSK US in RWP and 57% believe training in this should be a mandatory part of the curriculum. In contr...

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