BACKGROUND & AIMS:Hypofibrinolysis is prevalent in obesity and type 2 diabetes mellitus (T2D) and may be involved in their pathophysiology. Metabolic bariatric surgery (MBS) markedly improves both obesity and T2D, but whether these improvements are related to fibrinolysis is not known. In this study, biomarkers of fibrinolysis were assessed before and after MBS in patients with and without T2D. METHODS:A single center prospective cohort study with 2-year follow-up. The participants were adults with obesity with (n = 28) or without T2D (n = 33) undergoing MBS preceded by 2 weeks of a low-calorie diet (LCD). The plasma concentrations of plasminogen activator inhibitor 1 activity (PAI-1act), tissue plasminogen activator activity (tPAact) and antigen (tPAag), plasmin-antiplasmin complexes (PAP) and fibrinogen were determined at baseline, after LCD and at 6 weeks, 1 and 2 years after MBS. RESULTS:After LCD and prior to MBS, PAI-1act decreased and PAP increased significantly. Two years after MBS, PAI-1act decreased from baseline 29.8 (63) to 3.8 (121) while tPAact increased (0.08 (390) to 0.23 (150) IU), and PAP increased (544 (54) to 814 (60) ng/mL). tPAag and fibrinogen decreased (16.4 (29) to 9.7 (51) ng/mL and 4.15 (23) to 3.82 (20) g/L, respectively); p < 0.001 for all; (geometric means, except tPAact which is arithmetic mean, coefficient of variation (%CV)). There were no differences in fibrinolysis between groups at baseline or after surgery. Multivariate analysis showed that reduction in body weight and fat mass had the most important influence on fibrinolysis. CONCLUSION:Fibrinolysis is significantly improved two years after MBS, as also indicated earlier after the two-week LCD. The lack of differences between patients with vs. without T2D suggests that fat mass reduction rather than improvement of glucose control is most important for improved fibrinolysis after MBS. In summary, our results support hypofibrinolysis as a mechanism in the pathophysiology in obesity.

AIMS:How individual components of cardiac rehabilitation (CR) programmes predict attainment of risk factor targets after myocardial infarction (MI), and their predictive strength relative to patient characteristics, remain unclear. We aimed to identify organizational and patient-level predictors of risk factor target attainment at 1-year post-MI. METHODS AND RESULTS:Organizational structure and processes followed at all 78 CR centres in Sweden were surveyed and merged with patient-level registry data (n = 6755). Predictors of attaining low-density lipoprotein-cholesterol (LDL-C) and blood pressure (BP) targets and smoking abstinence were identified using orthogonal partial least squares discriminant analysis, generating variables of importance for the projection (VIP) values. Variables with VIP > 0.8 were considered meaningful. The strongest predictors for attaining LDL-C and BP targets included availability of psychosocial management, medication adjustment protocols for nurses, continuity in nurse-patient contact, extended opening hours and adequate facilities, and having a medical director at the CR centre. The strongest patient-level predictors of attaining LDL-C and/or BP targets included low baseline LDL-C and having no history of hypertension, respectively, and the patient having participated in exercise-based CR. For smoking abstinence, the strongest organizational predictors were availability of psychosocial management, having a medical director, prescribing nicotine replacement therapy and varenicline, and self-reported team spirit. Patient-level predictors included having participated in exercise-based CR and group education. CONCLUSION:We identified multiple CR organizational predictors of attaining key risk factor targets after MI. These results may influence the future design of comprehensive CR programmes.

Background The use of Assisted Reproductive Technology (ART) is increasing worldwide. These treatments involve ovarian stimulation to enable multiple follicle recruitment, hence inducing supraphysiological estrogen levels. While most long-term follow-up of women undergoing ART has concerned cancer incidence, the long-term safety regarding cardiovascular and metabolic diseases remains under-explored. This study was performed to assess the risk of acute myocardial infarction, cerebral ischemic conditions, intracranial hemorrhage, type 2 diabetes mellitus, heart failure, aortic aneurysm or dissection, and chronic kidney disease in women that conceived with ART, and to investigate the role of the underlying infertility and its risk factors. Methods and findings Swedish national registers allowed us to follow a nationwide cohort of 380,756 women from their first birth between 1992 and 2002 until the end of 2023. The safety of ART was evaluated by comparing women with infertility who conceived with and without ART, while adjusting for baseline differences in age, body mass index, country of origin, socioeconomic factors, pre-existing comorbidity, smoking and year. The role of infertility was additionally explored by comparing all women with and without infertility adjusting for age, as well as the aforementioned baseline characteristics. Cumulative risks were plotted using inverse-probability weighted Kaplan-Meier curves. To facilitate the comparison of groups, we also estimated risk differences and ratios at 10-, 20-, and 30 years of follow-up. Use of ART was not associated with cardiovascular disease except for an excess risk of cerebral ischemic conditions, with a 30-year risk ratio of 1.44 (95% Confidence Interval (CI) [1.09,1.90]). With the exception of cerebral ischemic conditions, intracranial hemorrhage, aortic dissection, and chronic kidney disease, women with a history of infertility exhibited consistently higher risk of all outcomes, and adjustment for differences in baseline characteristics explained some but not all of these elevated risks. Even though the study period was restricted with respect to the earliest years of ART implementation, the number of exposed was still low and risks calculated with limited precision, particularly at the beginning and at the end of the follow-up due to very few events and decreasing numbers at risk, respectively. Conclusions With the exception of ischemic cerebral conditions, the findings provide reassurance regarding the long-term cardiometabolic safety of ART use, while adding to the growing literature suggesting that infertility can act as a marker of women’s cardiovascular and metabolic disease.

Aims Improved dietary habits are important for successful secondary prevention after myocardial infarction (MI), with counselling and support on healthy dietary habits constituting a cornerstone of cardiac rehabilitation (CR). However, there is limited knowledge on how to optimize CR organization to motivate patients to adopt healthy dietary habits. We aimed to explore associations between CR programme structure, processes, and self-reported dietary habits 1 year post-MI. Methods and results Organizational data from 73 Swedish CR centres and patient-level data from 5248 CR patients were analysed using orthogonal partial least squares discriminant analysis to identify predictors for healthy dietary habits. Variables of importance for the projection (VIP) values exceeding 0.80 were considered meaningful. Key predictors included the CR centre having a medical director [VIP (95% confidence interval)] [1.86 (1.1-2.62)], high self-reported team spirit [1.63 (1.29-1.97)], nurses have formal training in counselling methods [1.20 (0.75-1.65)], providing discharge information on risk factors [2.23 (1.82-2.64)] and lifestyle [1.81 (1.31-2.31)], time dedicated to patient interaction during follow-up [1.60 (0.80-2.40)], and centres aiming for patients to have the same nurse throughout follow-up [1.54 (1.17-1.91)]. The more positive predictors a CR centre reported to follow, the further improvement in patient-level dietary habits, were analysed by multivariable regression analysis [odds ratio for each additional positive predictor reported 1.03 (1.02-1.05), P < 0.001]. Conclusion Several variables related to CR structure and processes were identified as predictors for patients reporting healthier dietary habits. These findings offer guidance for CR centres in resource allocation and optimizing patient benefits of CR attendance.

CONTEXT:Bariatric surgery is associated with reduced risk of cardiometabolic disease in obesity and type 2 diabetes (T2D). The mechanisms are not fully understood, but improvement in endothelial dysfunction has been implicated. OBJECTIVE:This work aimed to assess endothelial biomarkers before and after surgery. METHODS:A prospective cohort study with 2-year follow-up was conducted at a single center in Stockholm, Sweden. Participants included adults undergoing bariatric surgery, 28 with and 33 without T2D. Intervention included Roux-en-Y gastric bypass preceded by a 2-week low-calorie diet (LCD). Main outcome measures included plasma concentrations of glycocalyx biomarkers (hyaluronan [HA] and syndecan-1), E-Selectin, von Willebrand factor (VWF), and thrombomodulin (TM). RESULTS:At baseline, patients with diabetes had higher concentrations of E-Selectin (P = .041) whereas other biomarkers did not differ between groups. After LCD, E-Selectin, syndecan-1, and VWF were reduced. Two years after surgery, TM was unchanged whereas E-Selectin decreased, geometric mean (CV%) 41 (40) to 24 (61) ng/mL, syndecan-1 from 50 (73) to 38 (81) ng/mL, and VWF from 120 (52) to 103 (45)%, while HA increased from 25 (96) to 40 (78) ng/mL (P < .001 for all). E-Selectin initially declined faster in patients with diabetes (P < .003); otherwise the biomarker changes did not differ between groups. Variables with the highest predictive value for improvement in biomarkers were decrease in body weight and fat mass and increase in insulin sensitivity (HOMA-IR). CONCLUSION:Bariatric surgery is associated with sustained, beneficial alterations in biomarkers of glycocalyx and endothelial function in patients with obesity, both with and without T2D. It is suggested that reduced body weight/fat mass and improved insulin sensitivity are of particular importance for these alterations.

AIMS:This study investigates changes in the quality of information in sickness certificates over time, before and after the 2011 national introduction of a revised sickness certificate, and identified factors associated with certificate quality. METHODS:Four experts independently assessed the quality of a total of 783 sickness certificates issued in primary care in 2004, 2009, and 2012. A Global Quality Score (GQS) was constructed by the research group, rating quality on a 10-point scale. The cut-off for high quality was set to GQS >5. The inter-rater reliability of the GQS was tested using Intra-Class Correlation and internal consistency by Pearson correlation coefficients (r). Sickness certificates issued in 2004 and 2009 were merged into one group and compared to sickness certificates in 2012. Logistic binomial regression analyses examined associations between patient-, sick leave-, and physician-related variables and GQS. RESULTS:The GQS demonstrated moderate to good inter-rater reliability (ICC= 0.79, 95% CI: 0.6-0.9) and good internal consistency. Certificate quality improved significantly (p < 0.001) from 3.6 (SD 1.5) in 2004/2009 to 4.7 (SD 1.2) in 2012. In 2004/2009, mental disorder or an extended length of sick leave was negatively associated with high quality. In 2012, only female sex of the patient was negatively associated with high certificate quality. CONCLUSION:While sickness certificate quality was overall low, it improved significantly after the 2011 revision of the sickness certificate. Also, diagnosis, sick leave duration, and patient's sex were factors associated with the quality and varied over time, highlighting the need for further research regarding potential remaining differences in quality of sickness certificates.

Introduction:Multiple students are placed on clinical wards simultaneously due to increasing student numbers. This has the potential to create stress for the supervisor and reduce quality of student learning. Peer learning as a pedagogical framework to supervise multiple students has been widely shown to have advantages for the students by developing teaching skills, team collaboration, and independence. However, whether peer learning impacts the characteristics of supervision and the experience of the supervisor is less understood. It is unknown whether wards that use peer learning as a pedagogical framework (peer learning wards) are any different compared to wards that do not (non-peer learning wards), from the supervisor's perspective.Methods:We aimed to develop and pilot test a questionnaire to compare peer-learning wards and non-peer learning wards from the supervisor's perspective. We used the AMEE 7-step guide to develop questions investigating supervision, the learning environment and satisfaction. We piloted the questionnaire with 46 nurse supervisors working on inpatient hospital wards in Stockholm, Sweden. We compared answers from peer learning with non-peer learning wards. We used Orthogonal Projections to Latent Structures (OPLS) discriminant analysis to show what differed between the wards.Results:Peer learning wards compared to non-peer learning wards had more student-centred activities, the physical space had more adaptations for students, more support available to the supervisor, and supervisors perceived greater overall satisfaction with the quality of education and with the ward as a whole. The variables that had most influence on the discrimination between the two ward types related to peer learning activities and perceptions (p=0.0034).Conclusion:This pilot study shows that peer learning wards differ compared to non-peer learning wards regarding peer learning activities and perceptions among supervisors. Our questionnaire needs to be distributed on a larger scale to validate our findings and explore further the way in which the pedagogical framework and peer learning can affect supervision and satisfaction.

Objectives Self-monitoring of physical activity (PA) has the potential to contribute to successful behaviour change in PA interventions in different populations, including people with inflammatory joint diseases (IJDs). The objectives of this study were to describe the use and knowledge of self-report-based and device-based PA measures in people with IJDs in four European countries, and to explore if the use of such devices, sociodemographic or disease-related variables were associated with adherence to the recommendations of at least 150 min of moderate to vigorous PA per week. Setting Cross-sectional survey, performed in 2015–2016. Participants People with IJDs in Belgium, Denmark, Ireland and Sweden. Primary and secondary outcome measures Use of self-report and device-based PA measures, receipt of instructions how to use PA measures, confidence in using them, adherence to PA recommendations and associated factors for adherence to PA recommendations. Results Of the 1305 respondents answering questions on PA measures, 600 (46%) reported use of any kind of self-report or device-based measures to self-monitor PA. Between country differences of 34%–58% was observed. Six per cent and four per cent received instructions from health professionals on how to use simple and complex devices, respectively. Independent associated factors of fulfilment of recommendations of PA were living in Ireland (OR=84.89, p<0.001) and Sweden (OR=1.68, p=0.017) compared with living in Denmark, not perceiving activity limitations in moderate activities (OR=1.92, p<0.001) and using a device to measure PA (OR=1.56, p<0.001). Those living in Belgium (OR=0.21, p<0.001) were less likely to fulfil recommendations of PA. Conclusions Almost half of the participants with IJDs used self-report-based or deviced-based PA measures, although few used wearable devices regularly. The results indicate that participants meeting public PA health guidelines were engaged in self-monitoring of PA.

Background: Benefits of cardiac rehabilitation (CR) programme components on attaining risk factor targets post-myocardial infarction (MI) and their predictive strength relative to patient characteristics remain unclear. We aimed to identify organizational and patient-level predictors of risk factor target attainment at one-year post-MI. Methods: In this observational study data on CR organization at 78 Swedish CR centres was collected and merged with patient-level registry data (n = 7549). Orthogonal partial least squares discriminant analysis identified predictors (Variables of Importance for the Projection (VIP) values >0.8) of attaining low-density lipoprotein-cholesterol (LDL-C) <1.8 mmol/L, blood pressure (BP) <140/90 mmHg and smoking abstinence. Results: The strongest predictors (VIP [95% CI]) for attaining LDL-C and BP targets were offering psychosocial management (2.14 [1.78-2.50]; 2.45 [1.91-2.99]), having a psychologist in the CR team (1.62 [1.36-1.87]; 2.05 [1.67-2.44]), extended opening hours (2.13 [2.00-2.27]; 1.50 [0.91-2.10]), adequate facilities (1.54 [0.91-2.18]; 1.89 [1.38-2.40]), and having a medical director (1.70 [0.91-2.48]; 1.46 [1.04-1.88]). The strongest patient-level predictors of attaining LDL-C and/or BP targets were low baseline LDL-C (3.95 [3.39-4.51]) and having no history of hypertension (2.93 [2.60-3.26]), respectively, followed by exercise-based CR participation (1.38 [0.66-2.10]; 1.46 [1.14-1.78]). For smoking abstinence, the strongest organizational predictor was varenicline being prescribed by CR physicians (1.88 [0.95-2.80]) and patient-level predictors were participation in exercise-based CR (2.47 [2.07-2.88]) and group education (1.92 [1.43-2-42]), and no cardiovascular disease history (2.13 [1.78-2.48]). Conclusions: We identified multiple CR organizational and patient-level predictors of attaining risk factor targets post-MI. These results may influence the future design of comprehensive CR programmes.

INTRODUCTION:A common focus in many studies, in the short-term perspective, is to evaluate students' workplace learning and its outcome. However, the outcome can be perceived differently depending on when it was evaluated. The aim of this study was to explore student nurses' learning activities in an acute internal medicine unit and the nurses perceived learning outcome in a long-term perspective. MATERIAL AND METHODS:Repetitive ethnographic observations were performed in an internal medicine care unit at a teaching hospital in Sweden between 2011 and 2013. Four student nurses and supervisors were repetitively observed. Two years later retrospective interviews were performed with four nurses who had performed workplace learning, as students, in this unit during the observation period. An inductive comparative analysis involving all interviews and observational data was applied. RESULTS:Three themes were identified: To handle shifting situations - illustrating how student nurses learnt to adapt to shifting situations, to manage stress, to create structure and space for learning and to deal with hierarchies; To build relationships - illustrating how student nurses learnt to collaborate and to interact with patients; To act independently - illustrating how student nurses trained to act independently in the unit, took responsibility, and prioritized in this complex context. CONCLUSION:Learning activities in a complex acute medical unit setting were characterized by a high workload and frequent stressful situations, and a demand on students to interact, to take responsibility, and to prioritize. To learn in such a stressful context, have in a long-term perspective, a potential to develop students' embodied understanding of and in practice, making them more prepared to work and independently apply their nursing expertise in similar contexts as graduated nurses.

BACKGROUND:The assisted reproductive technique in vitro fertilization (IVF) is associated with an increased risk of venous thromboembolism (VTE) and pulmonary embolism (PE) during the first trimester. OBJECTIVES:To compare the incidence of VTE and PE during the first trimester of IVF pregnancies using fresh or frozen-thawed embryo transfer to that during natural pregnancies. PATIENT/METHODS:Nationwide Swedish registry-based cohort study of women who gave birth (n = 902 891) at the age of 15-50 years to their first child from the 1st of January 1992 until the 31st of December 2012. Exposure groups were IVF with fresh respectively frozen-thawed embryo transfer. Incidences of VTE and PE were calculated, and time-varying hazard ratios estimated for all trimesters after fresh respectively frozen-thawed embryo transfer IVF and compared to natural conception. RESULTS AND CONCLUSION:Women giving birth after fresh embryo transfer IVF had a more than eightfold increased incidence of venous thromboembolism (hazard ratio [HR] 8.96, 95% CI 6.33 to 12.67) and pulmonary embolism during the first trimester, (HR 8.69, 95% CI 3.83 to 19.71) compared to women giving birth after natural conception. The incidence of VTE in women giving birth after frozen-thawed embryo transfer was not increased during the first trimester. To conclude, fresh embryo transfer IVF was associated with a significantly increased incidence of VTE and PE during the first trimester. These results suggest that frozen-thawed embryo transfer could be a preferred method of IVF with a minimised maternal risk.

Platelet microvesicles (PMV) have previously been found elevated in acute ischemic stroke (IS) and could be biomarkers for risk of recurrence. PMV surface antigens such as P-selectin and phosphatidylserine (PS) reflect platelet activation and procoagulance. Tissue factor-positive microvesicles (TF + MV) are considered procoagulant, in particular if co-expressing PS. We enumerated MV subpopulations with these surface antigens in a cohort of 211 patients with primarily non-cardioembolic IS or transient ischemic attack (TIA) and investigated their association with long-term outcome. MV concentrations were determined by flow cytometry in the acute and convalescent phase. Primary outcome was a composite of fatal and non-fatal recurrent IS or myocardial infarction. Secondary outcomes were recurrent IS and all-cause mortality. Outcome events were obtained from Swedish registers during a follow-up of 1100 patient years. Concentrations of PS-positive and PS-negative MV populations were elevated in patients compared with healthy controls in both the acute and convalescent phase. PS + TF + PMV displayed pronounced elevations, median fold change 77 in the acute phase ( p < 0.0001) but were not associated with outcome, neither were PS + P-selectin + PMV. The only subpopulation positively associated with primary outcome was PS − TF + PMV, with adjusted hazard ratio of 1.86 (1.04–3.31, p = 0.036) by Cox regression. Unexpectedly, several MV subpopulations tended to be associated with reduced risk of poor long-term outcome. Our results suggest that PS + TF + PMV may be a promising marker for cerebral ischemia, and that the in vivo generation of PS − MV after IS/TIA warrants further study. Future MV studies should ideally enumerate PS + and PS − MV subpopulations separately.

We are now in the beginning of the fifth decade of in vitro fertilization (IVF) with more than ten million children born and an annual growth rate of half a million. It was recently found that there is a sevenfold increase in the incidence of pulmonary embolism (PE) during the first trimester of an IVF pregnancy as compared to spontaneous pregnancy. PE is a major cause of maternal mortality, and it is thus of outmost importance to understand the pathophysiological mechanism. The oestrogen surge during the ovarian stimulation has been hypothesized to be the initiating pathophysiological event. A support of this is a current report showing that embryo transfer performed directly after ovarian stimulation increased the risk of PE more than eightfold, whereas no such increase was noted after delayed embryo transfer. This increased risk coincides with a persisting increased oestrogen level. Further reported cardiovascular problems are arterial thromboses, pre-eclampsia and gestational hypertension. Global haemostasis tests change in the direction of increased coagulability, but mostly within normal limits. Cell-bound haemostasis and in particular platelet activation are less studied. However, a major increase in the number of microvesicles (MVs) and markers indicating platelet activation was reported during ovarian stimulation. We now need longitudinal data concerning haemostatic variables that extends into the first trimester. A major research focus should be to identify biomarkers that could be used already before instigation of IVF. Another way to avoid risk could be to delay embryo transfer by adapting a freeze-all strategy.

Background While patient performance after participating in cardiac rehabilitation programmes after acute myocardial infarction is regularly reported through registry and survey data, information on cardiac rehabilitation programme characteristics is less well described. Aim The aim of this study was to evaluate Swedish cardiac rehabilitation programme characteristics and adherence to European Guidelines on Cardiovascular Disease Prevention. Method Cardiac rehabilitation programme characteristics at all 78 cardiac rehabilitation centres in Sweden in 2016 were surveyed using a web-based questionnaire (100% response rate). The questions were based on core components of cardiac rehabilitation as recommended by European Guidelines. Results There was a wide variation in programme duration (2–14 months). All programmes reported offering an individual post-discharge visit with a nurse, and 90% (n = 70) did so within three weeks from discharge. Most programmes offered centre-based exercise training (n = 76, 97%) and group educational sessions (n = 61, 78%). All programmes reported to the national audit, SWEDEHEART, and 60% (n = 47) reported that performance was regularly assessed using audit data, to improve quality of care. Ninety-six per cent (n = 75) had a core team consisting of a cardiologist, a physiotherapist and a nurse and 76% (n = 59) reported having a medical director. Having other allied healthcare professionals included in the cardiac rehabilitation team varied. Forty per cent (n = 31) reported having regular team meetings where nurses, physiotherapists and cardiologist could discuss patient cases. Conclusion The overall quality of cardiac rehabilitation programmes provided in Sweden is high. Still, there are several areas of potential improvement. Monitoring programme characteristics as well as patient outcomes might improve programme quality and patient outcomes both at a local and a national level.

Ann Hägg-Martinell Håkan Hult Peter Henriksson 2 Anna Kiessling 2 1Department of Health Sciences, The Swedish Red Cross University College, Huddinge, Sweden; 2Department of Clinical Sciences Danderyd Hospital, Karolinska Institutet, Stockholm, 3Department of Clinical Sciences, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden Introduction: A common focus in many studies, in the short-term perspective, is to evaluate students’ workplace learning and its outcome. However, the outcome can be perceived differently depending on when it was evaluated. The aim of this study was to explore student nurses’ learning activities in an acute internal medicine unit and the nurses perceived learning outcome in a long-term perspective. Material and Methods: Repetitive ethnographic observations were performed in an internal medicine care unit at a teaching hospital in Sweden between 2011 and 2013. Four student nurses and supervisors were repetitively observed. Two years later retrospective interviews were performed with four nurses who had performed workplace learning, as students, in this unit during the observation period. An inductive comparative analysis involving all interviews and observational data was applied. Results: Three themes were identified: To handle shifting situations – illustrating how student nurses learnt to adapt to shifting situations, to manage stress, to create structure and space for learning and to deal with hierarchies; To build relationships – illustrating how student nurses learnt to collaborate and to interact with patients; To act independently – illustrating how student nurses trained to act independently in the unit, took responsibility, and prioritized in this complex context. Conclusion: Learning activities in a complex acute medical unit setting were characterized by a high workload and frequent stressful situations, and a demand on students to interact, to take responsibility, and to prioritize. To learn in such a stressful context, have in a long-term perspective, a potential to develop students’ embodied understanding of and in practice, making them more prepared to work and independently apply their nursing expertise in similar contexts as graduated nurses.

The incidence of pulmonary and venous thromboembolism is increased during the first trimester of pregnancies after assisted reproductive technology (ART) compared to spontaneous conception. We previously found that haemostatic plasma variables changed but within normal limits during controlled ovarian hyperstimulation (COH) concomitant with a major increase in plasma microvesicles (MVs) and markers indicating cell activation. We now explored the proteome of these MVs. Thirty-one women undergoing ART were blood sampled at down-regulation (DR) of oestrogen and at high level stimulation (HLS) with its 10–100-fold increased oestrogen level. Samples were analysed by liquid chromatography and tandem mass spectrometry to identify and quantify the proteome. We identified 306 proteins in the MVs and 72 had changed significantly at HLS compared to DR and more than 20% of them were associated with haemostasis. Thus, proteins related to both haemostasis and complement activation altered in plasma MVs in parallel with MV activation during COH. This needs to be further explored in the clinical context.

BACKGROUND:The out-of-hospital mortality in patients with acute myocardial infarction remains unchanged in contrast to a decrease in inhospital mortality. Interventions aiming to shorten patient delay have been largely unsuccessful. A deeper understanding is apparently needed on patients' appraisal prior to care-seeking.AIM:To investigate whether appraisal processes influence patient delay, and if the questionnaire 'Patients' appraisal, emotions and action tendencies preceding care seeking in acute myocardial infarction' (PA-AMI) could discriminate between patients with prolonged care-seeking and those with a short delay.METHODS:A cross-sectional study including 326 acute myocardial infarction patients filling out the validated questionnaire PA-AMI. The impact of subscales on delay was analysed by projection to latent structures regression. Discrimination opportunities between patients with short and long delays were analysed by projection to latent structures discriminant analysis.RESULTS:The subscales 'perceived inability to act' and 'symptom appraisal' had a major impact on patient delay (P<0.0001). 'Perceived inability to act' had its main influence in patients with a delay exceeding 12 hours, and 'symptom appraisal' had its main influence in patients with a delay shorter than one hour.CONCLUSION:Appraisal processes influence patient delay. Acute myocardial infarction patients with a prolonged delay were, besides a low perceived symptom severity and urgency to seek medical care, characterised by a perceived loss of control and ability to act. Therefore, future interventions aimed at decreasing delay should pay attention to appraisal processes, and perceived inability to act may be a sign of a health threat and therefore a signal to seek medical care.

OBJECTIVES:Almost all healthcare today is team-based in collaboration over professional borders, and numerous students have work-based learning in such contexts. However, interprofessional learning (IPL) in clinical settings has mostly been systematically explored in specially designed contexts dedicated to interprofessional education (IPE). This study aimed to explore the possibilities for IPL activities, and if or how they occur, in an acute ward context not dedicated to IPE.DESIGN AND SETTING:Between 2011 and 2013 ethnographic observations were performed of medical and nursing students' interactions and IPL during early clerkship at an acute internal medicine ward in Sweden. Field notes were taken and analysed based on the framework of IPE: learning with, from and about.PARTICIPANTS:21 medical, 4 nursing students and 30 supervisors participated.RESULTS:Learning with-there were no organised IPE activities. Instead, medical and nursing students learnt in parallel. However, students interacted with staff members from other professions. Learning from-interprofessional supervision was frequent. Interprofessional supervision of nursing students by doctors focused on theoretical questions and answers, while interprofessional supervision of medical students by nurses focused on the performance of technical skills. Learning about-students were observed to actively observe interactions between staff and learnt how staff conducted different tasks.CONCLUSION:This study shows that there were plenty of possibilities for IPL activities, but the potential was not fully utilised or facilitated. Serendipitous IPL activities differed between observed medical and nursing students. Although interprofessional supervision was fairly frequent, students were not learning with, from or about each other over professional borders.