[A Giant Pseudoaneurysm Associated with a True Left Ventricular Aneurysm].

A 66-year-old man developed exertional dyspnea. The patient had undergone total arch replacement for a dissecting aortic arch aneurysm at the age of 53 and conservative treatment for myocardial infarction at the age of 60. Several imaging studies revealed a giant pseudoaneurysm that likely originated from a true ventricular aneurysm. The pseudoaneurysm severely compressed the right ventricle. Surgery was promptly performed. The patient had a history of cardiac surgery and had exclusively dense pericardium adhesion. Therefore, we incised the pseudoaneurysm and sutured the rupture orifice directly from inside the pseudoaneurysm under rapid pacing. This approach may represent an effective surgical alternative in patients with small rupture orifice and dense adhesions.

[Staged Fenestrated Endovascular Repair of Thoracoabdominal Aneurysm].

Fenestrated endovascular repair (FEVAR) can be a treatment option for thoraco-abdominal aneurysm( TAAA), especially in the cases with high surgical risks. Spinal cord ischemic injury( SCI) continues to be the most devastating complication, that has multifactorial etiologies including embolic events and coverage of Adamkiewicz's artery (AKA). Recently, we experienced a case of Crawford III TAAA. The 77 year-old male had multiple comorbidities including recent myocardial infarction, chronic heart failure with reduced ejection fraction, and an end-stage renal disease. A colostomy was located on the left side of the abdomen after the surgical resection of rectal cancer. The AKA was originated from the intercostal artery at the level of the tenth thoracic vertebra( THV), which was intended to be covered by a stent-graft. To reduce the risk of SCI, FEVAR was scheduled in a staged fashion, with the proximal coverage up to the tenth THV and a branch-typed endovascular reconstruction of the celiac artery performed as the first stage treatment. The completion repair was achieved in 4 weeks, with the remaining superior mesenteric and renal arteries successfully stented. Neither SCI nor endoleak was detected periprocedurally.

Concomitant Mitral Regurgitation in Severe Aortic Stenosis　- A Report From the CURRENT AS Registry.

BACKGROUND: The clinical significance of concomitant mitral regurgitation (MR) has not been well addressed in patients with severe aortic stenosis (AS).Methods and Results:We analyzed 3,815 patients from a retrospective multicenter registry of severe AS in Japan (CURRENT AS registry). We compared the clinical outcomes between patients with moderate/severe MR and with none/mild MR according to the initial treatment strategy (initial aortic valve replacement [AVR] or conservative strategy). The primary outcome measure was a composite of aortic valve-related death or heart failure hospitalization. At baseline, moderate/severe MR was present in 227/1,197 (19%) patients with initial AVR strategy and in 536/2,618 (20%) patients with a conservative strategy. The crude cumulative 5-year incidence of the primary outcome measure was significantly higher in patients with moderate/severe MR than in those with none/mild MR, regardless of the initial treatment strategy (25.2% vs. 14.4%, P<0.001 in the initial AVR strategy, and 63.3% vs. 40.7%, P<0.001 in the conservative strategy). After adjusting confounders, moderate/severe MR was not independently associated with higher risk for the primary outcome measure in the initial AVR strategy (hazard ratio [HR] 1.11, 95% confidence interval [CI] 0.67-1.83, P=0.69), and in the conservative strategy (HR 1.13, 95% CI 0.93-1.37, P=0.22). CONCLUSIONS: Concomitant moderate/severe MR was not independently associated with higher risk for the primary outcome measure regardless of the initial treatment strategy.

Mortality and predictors of survival in patients with recent ventricular septal rupture.

Ventricular septal rupture (VSR) is a rare but fatal complication after acute myocardial infarction (AMI). However, the mortality in patients with recent VSR and appropriate timing of surgical repair have not been clarified. To examine the background characteristics and mortality of VSR patients as well as the usefulness and appropriate timing of surgery in this patient cohort. Among 3,947 consecutive patients with AMI at our hospital, 39 patients diagnosed with VSR from 2002 to 2020 were included in the analysis. All patients underwent transthoracic echocardiography to confirm VSR on admission. Coronary angiography (CAG) and measurement of pulmonary-systemic flow ratio were performed before emergent surgery. The use of mechanical support devices before or after procedures was considered for all patients who underwent CAG. Basically, we performed emergent or urgent operations to patients who were in a shock state or who needed mechanical support. The final decision of the timing of the operation was made by the cardiac team. Patients' mean age was 76.3 years, and 33.3% of them were males. Most culprit lesions were located in the left anterior ascending artery (81.3%). The mean pulmonary-systemic flow ratio after VSR onset was 3.07 ± 1.98. On admission, 48.7% of patients were in a shock state. Surgical repair was possible in 28 patients at a median of 1 day after admission, with a mortality rate of 25%. Among all patients, the mortality rate was 43.6%. Survivors were significantly younger (71.3 ± 11.3 vs. 82.7 ± 6.2 years, p < 0.01), had higher mean arterial blood pressure (75.6 ± 14.4 vs. 62.8 ± 16.2 mmHg, p = 0.0496) and lower ejection fraction (44.3 ± 11.7% vs. 54.8 ± 7.9%, p = 0.04), and underwent surgical repair more frequently (95.5% vs. 41.2%, p < 0.01) than the non-survivors. In multivariate analysis, younger age (odds ratio [OR] 1.18 95% confidence interval [CI] 1.01-1.38, p = 0.04) and surgical repair (OR 0.04, 95% CI 0.00-0.73, p = 0.03) were significant predictors of survival. In surgical repair cases, time from admission to operation did not differ significantly between survivors and non-survivors. Surgical repair and younger age are predictors of survival in patients with recent VSR, but the timing of surgery was not.

[Cardiac Surgery for Mitral Regurgitation Associated with Essential Thrombocythemia].

An 80-year-old woman with essential thrombocythemia was diagnosed with severe mitral regurgitation and moderate tricuspid regurgitation. Preoperatively, she had been treated with hydroxycarbamide and low-dose aspirin since her platelet count was high( 96.2×104/µl). After the platelet count was reduced to 46.2×104/µl, she underwent mitral valve repair and tricuspid valve annuloplasty. Atypical heparin resistance was noted intraoperatively. After initial heparin infusion, the activated clotting time(ACT) increased as expected. However, it decreased after initiation of cardiopulmonary bypass, despite additional heparin infusion and heparin concentration maintenance. A correlation between platelet factor 4 and heparin resistance was suggested. On discharge, she had no complications. We should consider the possibility of heparin resistance in essential thrombocythemia even when platelet count is adequately controlled.

[Aortic Valve-preserving Root Remodeling in a Patient with Bicuspid Aortic Valve and Severe Annulo-aortic Ectasia].

A 48-year-old man underwent aortic root remodeling for a giant aneurysm of sinus of Valsalva, 98 mm in diameter, as well as a bicuspid aortic valve. The aortic valve was defined as type 0(L-R) according to Sievers classification and the aortic annulus was highly dilated up to 35 mm. Geometric height of the left and right cusps were 22 mm and 32 mm in diameter, respectively. Dacron straight graft of 24 mm was chosen and each tongue was then created in a 180°fashion. After completion of root reconstruction, external circular suture annuloplasty using CV-0 expanded polytetrafluoroethylene (ePTFE) was made to adjust the annulus down to 22 mm in diameter. The free margin of both cusps were centrally plicated to raise the effective height to 9 mm. Postoperative echocardiography at 2 year showed trivial aortic regurgitation but no root re-dilatation. Remodeling with external circular suture annuloplasty is a reproducible and reliable method to stabilize the root, even for the patient with a giant aneurysm of sinus of Valsalva.

Early Surgery vs. Surgery After Watchful Waiting for Asymptomatic Severe Aortic Stenosis.

BACKGROUND: There is no large-scale study comparing postoperative mortality after aortic valve replacement (AVR) for asymptomatic severe aortic stenosis (AS) between initial treatment with AVR vs. eventual AVR after conservative management. Methods and Results: We analyzed data from a multicenter registry enrolling 3,815 consecutive patients with severe AS. Of 1,808 asymptomatic patients, 286 patients initially underwent AVR (initial AVR group), and 377 patients were initially managed conservatively and eventually underwent AVR (AVR after watchful waiting group). Mortality after AVR was compared between the 2 groups. Subgroup analysis according to peak aortic jet velocity (Vmax) at diagnosis was also conducted. There was no significant difference between the 2 groups in 5-year overall survival (OS; 86.0% vs. 84.1%, P=0.34) or cardiovascular death-free survival (DFS; 91.3% vs. 91.1%, P=0.61), but on subgroup analysis of patients with Vmax ≥4.5 m/s at diagnosis, the initial AVR group was superior to the AVR after watchful waiting group in both 5-year OS (88.4% vs. 70.6%, P=0.003) and cardiovascular DFS (91.9% vs. 81.7%, P=0.023). CONCLUSIONS: Asymptomatic severe AS patients who underwent AVR after watchful waiting had a postoperative survival rate similar to those who initially underwent AVR. In a subgroup of patients with Vmax ≥4.5 m/s at diagnosis, however, the AVR after watchful waiting group had worse postoperative survival rate than the initial AVR group.

Five-Year Clinical Outcome of Asymptomatic vs. Symptomatic Severe Aortic Stenosis After Aortic Valve Replacement.

BACKGROUND: There is discordance regarding the effect of symptom status before aortic valve replacement (AVR) on long-term outcome after AVR in severe aortic stenosis (AS).Methods and Results:The CURRENT AS registry is a multicenter retrospective registry enrolling 3,815 consecutive patients with severe AS. Among 1,196 patients managed with the initial AVR strategy, long-term clinical outcomes were compared between the symptomatic patients (n=905), and asymptomatic patients (n=291). Median follow-up interval was 1337 days with a 91% follow-up rate at 2 years. AVR was performed in 886 patients (98%) in the symptomatic group and in 287 patients (99%) in the asymptomatic group. Symptomatic patients were older and more often had comorbidities than asymptomatic patients with similar echocardiographic AS severity. The cumulative 5-year incidences of all-cause death and heart failure (HF) hospitalization were significantly higher in symptomatic patients than in asymptomatic patients (25.6% vs. 15.4%, P=0.001, and 14.2% vs. 3.8%, P<0.001, respectively). On landmark analysis at 30 days after AVR, the differences in mortality and HF hospitalization between the 2 groups were mainly observed beyond 30 days. CONCLUSIONS: When managed with the initial AVR strategy, the long-term outcomes of symptomatic severe AS were worse than those of asymptomatic severe AS. Early AVR strategy might be recommended in some selected asymptomatic severe AS patients with reasonable operative risk.

Favorable Clinical Outcomes of Transcatheter Aortic Valve Implantation in Japanese Patients　- First Report From the Post-Approval K-TAVI Registry.

BACKGROUND: Very limited data exist on the outcomes of transcatheter aortic valve implantation (TAVI) since Japanese marketing approval of the first TAVI device.Methods and Results:The Kyoto University-related hospital Transcatheter Aortic Valve Implantation (K-TAVI) registry includes prospectively collected data from 6 participating hospitals in Japan. We included 302 patients with severe aortic stenosis who underwent TAVI using the SAPIEN XT balloon-expandable valve via transfemoral (TF; n=203, 67%) or transapical (TA; n=99, 33%) approach between October 2013 and September 2015. Device success rate, based on the Valve Academic Research Consortium-2 criteria, was very high in the TF (97.0%) and TA (99.0%) groups. The 30-day mortality rates were 1.5% and 1.0% in the TF and TA groups, respectively. Major complications included stroke (transient or persistent: 2.3%), annulus rupture (1.0%), coronary intervention (1.0%), major vascular complications (1.7%), and permanent pacemaker implantation (5.4%). The procedure times of the post-proctoring period (n=210) were decreased compared with those of the proctoring period (n=89) without affecting the clinical outcomes. The survival rates at 6 and 12 months were 96.9% and 92.5% in the TF group, and 93.9% and 91.8% in the TA group, respectively. CONCLUSIONS: The K-TAVI registry data revealed that the early outcomes of TAVI using the SAPIEN XT were favorable in real-world Japanese patients.

Retrograde Stent Placement for Symptomatic Spontaneous Isolated Dissection of the Superior Mesenteric Artery.

Various treatment options are currently available for spontaneous isolated dissection of the superior mesenteric artery (SIDSMA) including conservative management, anticoagulation therapy, endovascular stenting, and surgical repair. We report an experience with retrograde open mesenteric stenting for SIDSMA. A 45-year-old man presented to the emergency department with acute onset of severe abdominal and back pain. Computed tomography angiography revealed a long occlusion of the SMA trunk. Initially, an endovascular solution was attempted, but this was unsuccessful as the guidewire failed to cross the lesion. Four hours after the onset of symptoms, because of aggravation of abdominal pain, the patient underwent an exploratory laparotomy under general anesthesia. The small intestine looked pale, and the arterial pulsation was not recognized in the mesentery. A 5-cm mesenteric portion of the SMA trunk was exposed. The SIDSMA diagnosis was confirmed after arteriotomy because a freshly formed thrombus and a severely stenosed true lumen (TL) were detected beneath the adventitia. From the proximal stump of the TL, a 6-French sheath introducer was inserted in a retrograde fashion. The occlusion was traversed with a 0.035-in guidewire. After predilatation, self-expandable stents were placed inside the occluded SMA. The patient was discharged from the hospital 3 weeks after the operation. Stent patency has been confirmed for 6 months. Retrograde stenting performed under laparotomy could be a rescue procedure after the failure of percutaneous stenting for SIDSMA.

Endovascular Aneurysm Repair of Acute Occlusion of Abdominal Aortic Aneurysm with Intra-Aneurysmal Dissection.

BACKGROUND: To report a rare case of acute abdominal aortic aneurysm (AAA) occlusion successfully treated by endovascular aneurysm repair (EVAR). CASE REPORT: An 89-year-old man complained of severe back pain and weakness in the bilateral lower extremities. Although there were neither acute ischemic signs on the brain computed tomography (CT) nor critical leg ischemia, the patient presented progressing weakness in the bilateral lower extremities and decreased sensation in the perianal and saddle area. Contrast-enhanced CT demonstrated an infrarenal AAA, the formation of an ulcer-like lesion in the aneurysmal wall, and the complete occlusion of distal AAA because of the caudal extension of intramural hematoma. Both common iliac arteries were patent because of the development of collateral vessels. The neurologic symptoms were considered to be caused by the occlusion of lumbar radicular arteries. EVAR seemed anatomically feasible, if the occlusion could be crossed by guidewires from both side of the common femoral artery. Wires easily traversed the occlusion, and the stent graft could be smoothly unwrapped and opened. The patient could recover decent iliac arterial flow. The neurovascular deficits recovered within 4 days after the procedure. CONCLUSIONS: Although our experience may not be reproduced in all case of AAA occlusion, EVAR warrants consideration to reduce the high mortality rate associated with the classical treatments.

Impact of statin therapy on patients with coronary heart disease and aortic aneurysm or dissection.

OBJECTIVE: The impact of statin therapy on cardiovascular outcome in coronary artery disease (CAD) patients with aortic aneurysm or dissection (AD) is still unclear. The aim of this study was to elucidate the effect of statins at discharge to improve outcomes in CAD patients with AD. METHODS: Among 14,834 consecutive patients who underwent first coronary revascularization in the CREDO-Kyoto PCI/CABG registry, we identified 699 patients (4.7%) with AD. The primary outcome measure was defined as a composite of all-cause death, myocardial infarction, and stroke. The effect of statin therapy was assessed by a Cox proportional hazards model incorporating clinically relevant factors. RESULTS: The risk for the primary outcome measure was significantly higher in patients with AD (adjusted hazard ratio [HR], 1.43; 95% confidence interval [CI], 1.23-1.66; P < .0001). In patients with AD, 215 patients (31%) had already undergone aneurysm repair, and only 274 patients (39%) were treated with statins at discharge. Patients treated with statins were younger, had higher body mass index, and were more often treated with percutaneous coronary intervention. Heart failure, anemia, and hemodialysis were more prevalent in patients treated without statins. In patients without AD, 7014 patients (50%) were treated with statins. Patients treated with statins were younger and had higher body mass index, and more patients were treated for CAD due to myocardial infarction. Heart failure, prior stroke, hemodialysis, anemia, and malignant disease were more prevalent in patients treated without statins. The use of statins was associated with lower risk for the primary outcome measure in patients with AD (adjusted HR, 0.71; 95% CI, 0.51-0.99; P = .045) as well as in patients without AD (adjusted HR, 0.79; 95% CI, 0.73-0.85; P < .0001). The effect size of statin use was similar between the patients with AD and those without AD (P interaction = .69). CONCLUSIONS: CAD patients with AD had significantly higher long-term risk for cardiovascular events. Statin therapy was associated with lower risk for cardiovascular events in patients with CAD with AD as well as in patients without AD.

[Successful endovascular treatment under cardiopulmonary resuscitation for spontaneous rupture of the thoracic aorta].

The patient was a 67-year-old man. He was admitted to a local hospital with severe back pain, and left hydrothorax was noted by a chest X-ray. Then, he went into shock and was transferred to our hospital. Enhanced computed tomography (CT) showed massive liquid retention of the left thorax, but no aortic dissection or aneurysms. He was diagnosed with spontaneous aortic rupture, and endovascular treatment was chosen because of his unstable hemodynamics. He fell into cardiac arrest 10 minutes after the operation started, and we implanted 2 stent-grafts while giving cardiac massage. After 23 minutes cardiac massage, he was resuscitated. He was discharged without any complication. Even if no signs of aortic aneurysms or aortic dissection were detected, the possibility of spontaneous aortic rupture should be suspected. Endovascular treatment is a reliable option in the case of unstable hemodynamics.

Effectiveness of exercise-heat acclimation for preventing heat illness in the workplace.

The incidence of heat-related illness in the workplace is linked to whether or not workers have acclimated to a hot environment. Heat acclimation improves endurance work performance in the heat and thermal comfort at a given work rate. These improvements are achieved by increased sweating and skin blood flow responses, better fluid balance and cardiovascular stability. As a practical means of acclimatizing the body to heat stress, daily aerobic exercise training is recommended since thermoregulatory capacity and blood volume increase with physical fitness. In workers wearing personal protective suits in hot environments, however, little psychophysiological benefit is received from short-term exercise training and/or heat acclimation because of the ineffectiveness of sweating for heat dissipation and the aggravation of thermal discomfort with the accumulation of sweat within the suit. For a manual laborer who works under uncompensable heat stress, better management of the work rate, the work environment and health is required.

[Influence of an 8-week exercise intervention on body composition, physical fitness, and mental health in female nursing students].

To determine the effectiveness of habitual exercise on the health promotion of college students, we measured the body composition and physical fitness of female nursing students before (Pre) and after (Post) an 8-week low-intensity exercise intervention. We also conducted a questionnaire survey of their mental health condition before and at every 4 weeks during the intervention. The quantity of physical exercise increased (P < 0.0001) from 0.9 ± 0.2 METsï½¥hr/week in the pre-intervention period to 6.6 ± 0.7 METsï½¥hr /week during the intervention period. The exercise intervention did not alter the body weight, but decreased the body fat (Pre, 26.8 ± 0.5%; Post, 24.9 ± 0.5%, P < 0.01) and increased the whole-body muscle mass (Pre, 69.1 ± 0.5%; Post, 70.8 ± 0.4%, P < 0.01). The results of physical fitness tests showed that the intervention promoted muscular strength, muscular endurance, flexibility, agility, and muscular power. The scores for mental health were significantly raised by the intervention. These results suggest that habitual exercise for 8 weeks was effective for the promotion of physical and mental health in female nursing students.

[A study of "sudden death" in end-stage cancer patients receiving home care].

We retrospectively examined the actual status and management of sudden changes in end-stage cancer patients receiving home care. We defined "sudden death" as an incident in which patients who had been ambulatory suddenly experienced a change in condition and died within a day. As per this definition, 32 of 130 end-stage cancer patients (24.6%) who died at home during a period of 2 years experienced "sudden death". The reasons for sudden changes included liver rupture, liver failure, hematemesis/melena, and renal failure. It was presumed that 87.5% of patients who experienced "sudden death" had a life expectancy of days or weeks. Those who experienced sudden change in the presence of their family and died immediately thereafter or were found in a state of respiratory arrest accounted for 43.8% of cases. At the time of sudden change, sedation was performed in 34.3% of cases. Patient families were generally able to take action in a calm manner. Healthcare professionals and patient families should always be aware of the possibility of sudden changes in end-stage cancer patients. In addition, it is important for healthcare professionals to confirm how patients and their families perceive the disease condition, provide pain relief, and support families who are upset and anxious at the time of sudden changes.

A two-week exercise intervention improves cold symptoms and sleep condition in cold-sensitive women.

BACKGROUND: We examined whether an aerobic exercise intervention in young women with cold sensitivity symptoms improves sleep quality and decreases cold complaints. Furthermore, we examined the association with increased foot skin temperature (Tsk) before falling asleep and decrease in sensitivity to cold in the brain. METHODS: We recruited 16 female adult volunteers who had cold sensitivity and were not engaged in daily exercise training, and they were divided into an exercise group (EXE) and a control group (CON). EXE was given a 2-week exercise intervention that consisted mainly of walking and jogging. Before and after the intervention, temperature sensation and body temperature parameters were measured just before bedtime; electroencephalogram measurements were taken during sleep; and subjective sleep surveys, including Oguri-Shirakawa-Azumi (OSA) sleep inventory (middle-aged and aged version) and visual analogue scale (VAS), were conducted immediately after waking up. All experiments were performed in the winter season. RESULTS: In EXE, overall and foot warmth and comfort increased (p < 0.05) after the 2-week exercise intervention. The exercise intervention also decreased (p < 0.05) the scores for cold feeling in the fingertips, feet, and toes. In the OSA sleep inventory, factor IV (refreshing) and factor V (sleep length) were increased (p < 0.05) by the exercise intervention. Subjective sleep quality evaluated by VAS increased (p < 0.05) with exercise intervention. The exercise intervention in EXE shortened middle awake time after sleep onset (p < 0.05) and prolonged deep sleep length (p < 0.05). The exercise intervention increased (p < 0.05) alpha-wave power before sleep. In CON, all variables remained unchanged throughout the 2-week control period. CONCLUSION: Short-term aerobic exercise alleviated peripheral extremity cold sensitivity symptoms and improved subjective sleep quality. Our findings suggest that these improvements were not due to increased Tsk at rest before bedtime but to decreased sensitivity to cold in the brain that was expressed as increased alpha activity.

Life Expectancy of Patients With Severe Aortic Stenosis in Relation to Age and Surgical Risk Score.

BACKGROUND: There is a paucity of data regarding shorter life expectancy after aortic valve replacement (AVR) in patients with severe aortic stenosis (AS). METHODS: Among 3815 patients with severe AS enrolled in the CURRENT AS (Contemporary outcomes after sURgery and medical tREatmeNT in patients with severe Aortic Stenosis) registry, there were 1469 patients (initial AVR: n = 647; conservative strategy: n = 822) with low surgical risk, 1642 patients (initial AVR: n = 433; conservative strategy: n = 1209) with intermediate surgical risk, and 704 patients (initial AVR: n = 117; conservative strategy: n = 587) with high surgical risk. Among 1163 patients who actually underwent surgical AVR as the initial strategy, patients were divided into 4 groups according to age <65 years (n = 185), 65 to 74 (n = 394), 75 to 80 (n = 345), and >80 (n = 239). The expected survival of the general Japanese population was obtained from the Statistics Bureau of Japan. The surgical risk was estimated using The Society of Thoracic Surgery (STS) score. RESULTS: The median follow-up was 3.7 years. The cumulative incidences of all-cause death were significantly lower in the initial AVR strategy than in the initial conservative strategy across the 3 STS groups. Shorter life expectancy after surgical AVR was seen especially in younger patients. The observed mortality in low-risk patients was comparable to the expected mortality across all the age-groups, while intermediate-risk patients aged <75 years, and high-risk patients across all age-groups had higher mortality compared with the expected mortality. CONCLUSIONS: The risk stratification according to age and STS score might be useful to estimate shorter life expectancy after AVR, and these findings have implications for decision making in the choice of surgical or transcatheter AVR.

Case of an octogenarian with an asymptomatic double aortic arch undergoing CABG.

Double aortic arch is a rare congenital anomaly of the aortic arch system where a complete vascular ring is formed around the trachea and esophagus. Case reports of elderly patients are extremely rare. We report a case of coronary bypass grafting in an elderly patient with right-dominant DAA.

[Physical characteristics of female nursing students in the first year at university].

We measured the physique and physical fitness of 528 first year female nursing students in order to develop a plan for the health education and health promotion of nursing students. We also conducted a questionnaire survey of their health condition and athletic activities. The results showed that, compared to the national average for the same age group, the female nursing students had lower body weight, greater agility, and less muscle strength. In addition, they had little experience of athletic activities in junior and senior high school, and a high percentage of them were concerned about their physical fitness.