Background and Purpose. Admission to a Doctor of Physical Therapy (DPT) program has traditionally required a determined cognitive level with less emphasis being placed on noncognitive attributes. It is now appreciated that many noncognitive factors such as coping self-efficacy, resilience, and emotional intelligence can factor into students' ability to successfully complete a graduate program that presents with increased workload and other demands that can invoke stress. To maximize success, students must be able to effectively cope with these stresses. The first purpose of this study was to determine if a cohort of students enter a DPT program with similar perceptions of their abilities to cope with stress. The second purpose was to determine if perceived coping abilities and specific coping strategies of this cohort changed over the first year of the program. Subjects. Physical therapy students enrolled in the first year of a 3-year DPT program at a Midwestern university were invited to participate. Of this cohort, 29 (60%) responded to the first survey, 23 (79%) of the initial participants completed the second survey, and 19 (65%) completed the third survey. Methods. An electronic survey was sent to these students at the beginning of their first, second, and third semesters. Students completed the survey anonymously. The Coping Self-Efficacy Scale (CSE) was used along with open-ended prompts about students' coping strategies and sources of stress. Repeated-measures analysis of variance (ANOVA) and post hoc paired t tests with Bonferroni correction were used to compare mean CSE scores between each semester. Qualitative content analysis of the responses from the open-ended questions was completed. Results. The mean CSE score from the initial survey was 6.35 (SD ± 0.32). Of the 26 questions in the CSE survey, 19 questions had a variance in score of eight points or more on a 10-point scale. There was a statistically significant difference between CSE scores over the three testing periods as determined by a repeated-measures ANOVA, F(2,50) = 79.19, P < .001). A Bonferroni post hoc test revealed that the differences between CSE scores occurred between all levels of testing (P < .001). Five themes describing active coping strategies and one theme of avoidance strategy emerged in the first round of data collection. In the second and third rounds of data collection, the avoidance strategy theme disappeared and only active strategies were mentioned. Discussion. The ability to cope with stress is an important factor affecting a student's success in an academic program. In this study, there was wide variability in students' perceived ability to cope with stress as determined from the CSE score when entering a DPT program. Statistically significant increases in CSE scores over each subsequent semester indicated improved confidence in coping ability after succeeding despite stressful situations typical of the first year of a DPT program. Qualitative themes from open-ended prompts about coping strategies also supported this conclusion. Findings suggest that planned intervention on the part of academic faculty to further facilitate this growth in coping ability should be considered to increase student success.

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Background Augmentation of soft-tissue repairs with an autologous fibrin clot has been used clinically for nearly four decades; however, fibrin clots tend to produce an abundance of scar tissue, which is known to inhibit soft-tissue regeneration. Mesenchymal stem cells (MSCs) embedded in fibrin clots before repair could reduce scar tissue deposition and facilitate soft-tissue regeneration. To our knowledge, no published studies have directly evaluated the viability or bioactivity of MSCs in fresh human fibrin clots over time. The purpose of this study was to evaluate the viability and bioactivity of human MSCs inside human fibrin clots over time in nutritive and non-nutritive culture media. Questions/purposes We hypothesized that human MSCs would (1) be captured inside fibrin clots and retain their proliferative capacity, (2) remain viable for at least 7 days in the fibrin clots, (3) maintain their proliferative capacity for at least 7 days in the fibrin clots without evidence of active apoptosis, and (4) display similar viability and proliferative capacity when cultured in a non-nutritive medium over the same time periods. Methods Twelve patients (mean age 33.7 years; range 4-72 years) who underwent elective knee surgery were approached between February 2016 and October 2017; all patients agreed to participate and were enrolled. MSCs isolated from human skeletal muscle and banked after prior studies were used for this analysis. On the day of surgery and after expansion of the MSC population, 3-mL aliquots of phosphate-buffered saline containing approximately 600,000 labeled with anti-green fluorescent protein (GFP) antibodies were transported to the operating room, mixed in 30 mL of venous blood from each enrolled patient, and stirred at 95 rpm for 10 minutes to create MSC-embedded fibrin clots. The fibrin clots were transported to the laboratory with their residual blood for analysis. Eleven samples were analyzed after exclusion of one sample because of a processing error. MSC capture was qualitatively demonstrated by enzymatically digesting half of each clot specimen, thus releasing GFP-positive MSCs into culture. The released MSCs were allowed to culture for 7 days. Manual counting of GFP-positive MSCs was performed at 2, 3, 4, and 7 days using an inverted microscope at 100 x magnification to document the change in the number of GFP-positive MSCs over time. The intact remaining half of each clot specimen was immediately placed in proliferation media and allowed to culture for 7 days. On Days 1, 2, 3, 4, and 7, a small portion of the clot was excised, flash-frozen, cryosectioned (8-μm thickness), and immunostained with antibodies specific to GFP, Ki67 (indicative of active proliferation), and cleaved caspase-3 ([CC3]; indicative of active apoptosis). Using an inverted microscope, we obtained MSC cell counts manually at time zero and after 1, 2, 3, 4, and 7 days of culture. Intact fresh clot specimens were immediately divided in half; one half was placed in nutritive (proliferation media) and the other was placed in non-nutritive (saline) media for 1, 2, 3, 4, and 7 days. At each timepoint, specimens were processed in an identical manner as described above, and a portion of each clot specimen was excised, immediately flash-frozen with liquid nitrogen, cryosectioned (8-μm thickness), and visualized at 200 x using an inverted microscope. The numbers of stain-positive MSCs per field of view, per culture condition, per timepoint, and per antibody stain type were counted manually for a quantitative analysis. Raw data were statistically compared using t-tests, and time-based correlations were assessed using Pearson’s correlation coefficients. Two-tailed p values of less than 0.05 (assuming unequal variance) were considered statistically significant. Results Green fluorescence, indicative of viable GFP-positive MSCs, was absent in all residual blood samples after 48 hours of culturing; GFP-positive MSCs were visualized after enzymatic digestion of clot matrices. The number of GFP-positive MSCs per field of view increased between the 2-day and 7-day timepoints (mean 5.4 ± 1.5; 95% confidence interval, 4.7-6.1 versus mean 17.0 ± 13.6; 95% CI, 10.4-23.5, respectively; p = 0.029). Viable GFP-positive MSCs were present in each clot cryosection at each timepoint up to 7 days of culturing (mean 6.2 ± 4.3; 95% CI, 5.8-6.6). There were no differences in MSC counts between any of the timepoints. There was no visible evidence of GFP +/CC3 + double-positive MSCs. Combining all timepoints, there were 0.34 ± 0.70 (95% CI, 0.25-0.43) GFP+/Ki67+ double-positive MSCs per field of view. The mitotic indices at time zero and Day 7 were 7.5% ± 13.4% (95% CI, 3.0%-12.0%) and 7.2% ± 14.3% (95% CI, 3.3%-12,1%), respectively (p = 0.923). There was no visible evidence of GFP +/CC3 + double-positive MSCs (active apoptosis) at any timepoint. For active proliferation in saline-cultured fibrin clots, we found averages of 0.1 ± 0.3 (95% CI, 0.0-0.2) and 0.4 ± 0.9 (95% CI, 0.0-0.8) GFP/Ki67 double-positive MSCs at time zero and Day 7, respectively (p = 0.499). The mitotic indices in saline culture at time zero and Day 7 were 2.9% ± 8.4% (95% CI, 0.0%-5.8%) and 9.1% ± 20.7% (95% CI, 1.2%-17.0%; p = 0.144). There was no visible evidence of GFP +/CC3 + double-positive MSCs (active apoptosis) at any timepoint in either culturing condition. Conclusion These preliminary in vitro results show that human MSCs mixed in unclotted fresh human venous blood were nearly completely captured in fibrin clots and that seeded MSCs were capable of maintaining their viability, proliferation capacity, and osteogenic differentiation capacity in the fibrin clot for up to 7 days, independent of external sources of nutrition. Clinical Relevance Fresh human fibrin clots have been used clinically for more than 30 years to improve soft-tissue healing, albeit with scar tissue. Our results demonstrate that allogenic human MSCs, which reduce soft-tissue scarring, can be captured and remain active inside human fibrin clots, even in the absence a nutritive culture medium.