Analysis of the characteristics of anticipatory postural adjustments in older adults using smartphones: Association between cognitive and balance functions.

OBJECTIVES: Using smartphones, we aimed to clarify the characteristics of anticipatory postural adjustments (APA) in older adults and examine the relationship between cognitive and balance functions. METHODS: The study participants were 10 young and 13 older adults. An accelerometer built into a smartphone was attached to the lower back (L5) of the participant, and acceleration in the mediolateral direction was measured using a one-leg stance (OLS). As APA features, we analyzed the time to the peak value in the stance direction (peak latency [PL]) and the amount of displacement to the peak value in the stance direction (peak magnitude [PM]). Additionally, the measured PL was divided by PM for each group to obtain the APA ratio (APAr). We investigated the relationship between the APAr and Mini-BESTest subitems. RESULTS: Older adults showed delayed PL and decreased PM levels (p < 0.01). While in the Mini-BESTest sub-items, deductions were most common in the order of dual-task and single-leg standing, and most participants with low APAr scores were degraded in APA of sub-items. The correlation was observed between APAr and both TUG and dual-task cost (DTC) (r= -0.56, r= -0.67). According to the receiver operating characteristic curve, the APAr value was 1.71 in the older age group. CONCLUSIONS: Older adults showed delayed PL and decreased PM, and APAr was associated with cognitive and locomotor functions. By evaluating the APAr at the initiation of movement, it may be possible to distinguish the APA of the older adluts from the possible to the impossible of OLS movement.

Reliability and validity of quantitative evaluation of anticipatory postural adjustments using smartphones.

[Purpose] This study aimed to investigate the reliability and validity of the quantitative evaluation of anticipatory postural adjustments using smartphones. [Participants and Methods] The study included 10 young control participants who underwent a one-legged stance with an accelerometer and a smartphone that were simultaneously attached to their lower back (L5). Acceleration was measured as the mediolateral component of the lumbar movement toward the stance side. The peak value of the time (peak latency) and the amount of displacement (peak magnitude) in the stance side direction of the lumbar acceleration were analyzed as anticipatory postural adjustment features. Intra-rater reliability was calculated for both accelerometer and smartphone measurements, while inter-rater reliability was calculated for smartphone measurements by two examiners. Validity was determined for both accelerometer and smartphone measurements. [Results] In this study, the intra-rater reliability of the peak latency and peak magnitude in accelerometer and smartphone measurements was confirmed, as was the inter-rater reliability in smartphone measurements. The intra-rater reliability was confirmed through re-testing, while the validity of the accelerometer and smartphone measurements was also confirmed. [Conclusion] The findings of this study suggest that the use of smartphones to measure anticipatory postural adjustments is highly reliable and valid, making it a useful clinical balance index. The method is simple and can be used for continuous patient monitoring.

New quantitative evaluation of anticipatory postural adjustments using a smartphone in patients with Parkinson's disease.

OBJECTIVE: To investigate a smartphone-enabled quantitative evaluation of anticipatory postural adjustments (APA) during one-leg stance (OLS) movements among individuals with Parkinson's disease (PD). METHODS: This cross-sectional study included 10 young controls, 10 older individuals, and 13 individuals with PD. A smartphone and accelerometer were attached to the participants' lower back (L5), and the movements of the lower back toward the stance side during OLS were measured. For acceleration, the time to the peak value in the stance direction (peak latency [PL]) and the amount of displacement to the peak value in the stance direction (peak magnitude [PM]) were analyzed as APA characteristics. Additionally, the measured PL was divided by the PM for each group to obtain the APA ratio (APAr) as a new index. RESULTS: Individuals with PD showed a delayed PL and decreased PM (vs. young controls: p = .002 for PL, p < .001 for PM) (vs. older individuals: p = .022 for PL, p = .001 for PM). The APAr clustered the young controls, older individuals, and individuals with PD. According to the receiver operating characteristic curve the APAr value was 0.95, and individuals in the PD group were identified (i.e. area under the curve: 0.98; sensitivity: 85.0%; specificity: 100%). Moreover the APAr was correlated with severity and balance ability in individuals with PD (p = .015 for NFOG-Q, p = .028 for UPDRS, p = .036 for TUG, p = .015 for Mini-BESTest, p = .018 for OLS time). CONCLUSIONS: This smartphone-based evaluation using the APAr index was reflective of disease severity and decreased balance ability among individuals with PD. The facilitation of this measurement can help clinicians and physiotherapists quantitatively evaluate the APA of individuals with PD at laboratories and hospitals as well as in home environments.

Separated center-of-pressure measurements reveal new characteristics of reduced anticipatory postural adjustments during gait initiation in patients with Parkinson's disease.

BACKGROUND AND OBJECTIVE: Accelerations, ground reaction force data, and other quantitative data obtained from kinematic analyses of gait initiation serve as measures of dyskinesia in patients with Parkinson's disease. The objective of this study was to determine whether a separate center of pressure information could reveal new characteristics of reduced anticipatory postural adjustments in patients with Parkinson's disease. METHODS: Ten healthy elderly subjects and 10 patients with Parkinson's disease participated in this study. Motions at gait initiation in response to a light signal to begin the task were analyzed. Anticipatory postural adjustments were characterized using trunk acceleration data and center of pressure displacement data. RESULTS: The separated center of pressure in patients with Parkinson's disease showed longer peak latency (p < .01) and larger peak magnitude (p < .01) in the stance leg than in the stepping leg. In patients with Parkinson's disease, the displacement peak latency of the stance leg center of pressure correlated negatively with the Timed Up and Go time (r = -0.46, p < .05), while displacement peak latency of the stepping leg center of pressure correlated negatively with Unified Parkinson's Disease Rating Scale (r=  -0.47, p < .05), and positively with Berg Balance Scale score (r = 0.50, p < .05). CONCLUSIONS: Patients with Parkinson's disease experience asymmetry between the stance leg and stepping leg at gait initiation. These findings may help clinicians understand the changes to motor function in patients with Parkinson's disease and suggest strategies for improved rehabilitation training.

Measurements of the centre of pressure of individual legs reveal new characteristics of reduced anticipatory postural adjustments during gait initiation in patients with post-stroke hemiplegia.

OBJECTIVES: To determine whether individual measurements of the centre of pressure for the stance and stepping legs can reveal new characteristics of reduced anticipatory postural adjustments during gait initiation in post-stroke hemiplegic patients. METHODS: Subjects included 30 stroke patients and 10 healthy age-matched controls. The acceleration of the trunk, and the centre of pressure of each leg, were measured during gait initiation, 3 times each with the paretic and non-paretic legs leading. Anticipatory postural adjustments were characterized using trunk acceleration and centre of pressure displacement data. RESULTS: Latency of the posterior displacement peak of the paretic leg centre of pressure with either the paretic or non-paretic leg leading was significantly longer in stroke patients compared with controls, and was also longer than that of the non-paretic leg. The magnitude of the posterior displacement peak of the paretic leg centre of pressure was smaller than that of the non-paretic leg. Peak latency of the paretic stepping leg centre of pressure correlated with the clinical measures of motor dysfunction, postural balance, and gait ability. CONCLUSION: Measurements of the latency and magnitude of centre of pressure displacement peak individually for the paretic and non-paretic legs can help elucidate the mechanism behind reduced anticipatory postural adjustments. This information will be useful in designing new treatment strategies for stroke patients.

Plasma mycophenolic acid concentration and the clinical outcome after lung transplantation.

BACKGROUND: The therapeutic drug monitoring of mycophenolic acid (MPA) has been investigated for renal and heart transplantations; however, its usefulness in lung transplantation is unclear. METHODS: The MPA area under the plasma concentration-time curve (AUC) was calculated in 59 adult lung transplant recipients. The MPA AUC0-12 s were compared among the three groups determined by the presence of adverse events (no events, infection, and chronic lung allograft dysfunction [CLAD]). Next, MPA AUC0-12 thresholds for the adverse events were identified by receiver operating characteristic analysis. Cumulative occurrence rate of the adverse events was compared between two groups (adequate and inadequate groups) according to the thresholds. RESULTS: The MPA AUC0-12 s in the no event, infection, and CLAD groups were 30.3 ± 6.5, 36.8 ± 10.7, and 20.6 ± 9.6 µg·h/mL, respectively (P = .0027), while the tacrolimus trough levels were similarly controlled in the groups. The thresholds of MPA AUC0-12 for the occurrence of infection and CLAD were 40.5 and 22.8 µg·h/mL, respectively. The cumulative occurrence rate of adverse events of adequate group (15.3%) was significantly lower than that of inadequate group (56.0%) (P = .0050). CONCLUSIONS: The MPA AUC0-12 may affect the occurrence of adverse events in lung transplant recipients.

Utility of Dynamic Balance Measurements in Discriminating Community Ambulation Levels Among Individuals with Stroke: A Cross-sectional Study.

OBJECTIVE: To examine the association between dynamic balance measurements and community ambulation levels among individuals with chronic stroke. METHODS: This cross-sectional study was performed in 2-day care facilities for older adults located in urban areas. Forty-seven community-dwelling poststroke adults who could walk independently were participated. Community ambulation performance was assessed using the Functional Ambulation Classification of the Hospital at Sagunto (FACHS). Dynamic balance and mobility were measured with the Mini-Balance Evaluation Systems Test (Mini-BESTest), the Timed Up and Go (TUG) test, and 10 m maximum walking speed. RESULTS: Participants were classified into 3 groups according to FACHS scores: household (n = 15), neighborhood (n = 19), and community walkers (n = 13). Neighborhood and community walkers scored significantly higher on the Mini-BESTest and had a shorter TUG test time than household walkers. Community walkers had a significantly faster walking speed than household walkers, whereas neighborhood walkers did not have a faster walking speed than household walkers. Ordinal logistic regression analyses revealed the Mini-BESTest score (odds ratio [OR] 1.24; 95% confidence interval [CI]: 1.07-1.44) and the TUG test time (OR .91; 95% CI: .85-.98) were significantly associated with ambulation levels after adjusting for confounders. CONCLUSIONS: Dynamic balance measurement tools may have better responsiveness in detecting community ambulation levels among individuals with chronic stroke than walking speed.

Clinicopathological features of intraoperative pleural lavage cytology for non-small cell lung cancer.

OBJECTIVE: The significance of clinicopathological features of pre- and post-resection pleural lavage cytology (PLC) for non-small cell lung carcinoma (NSCLC) currently remains unknown. METHODS: Between January 2010 and December 2012, pre- and post-resection PLC were performed for NSCLC in 565 patients at Tohoku University, Miyagi Cancer Center, or Sendai Medical Center. The relationship between the clinicopathological features and patient outcomes was analyzed. RESULTS: Twenty-two patients (3.9%) had positive findings from pre- or post-resection PLC. Both PLC were correlated with pT and pl factors, while only post-resection PLC was correlated with pN factor (p < 0.005). The 5-year disease-free survival (DFS) rate of the positive pre-resection PLC was significantly poorer than that of negative (26.7% vs. 76.9%, p < 0.0001). In addition, the 5-year DFS of the positive post-resection PLC was also poorer than that of negative (14.3% vs. 76.0%, p < 0.0001). Multivariate analyses revealed that both PLC were not independent prognostic factors in our study. CONCLUSIONS: A significant association of post-resection PLC with N factor is considered to be characteristics of post-resection PLC different from pre-resection PLC. A prognostic impact of post-resection PLC and its detailed difference from pre-resection PLC should be clarified by further investigations.

[Successful Multidisciplinary Treatment Accomplished by Collaboration of Multiple Clinical Departments for Synchronous Quadruple Cancer].

A 60-year-old man consulted a clinic complains of sore throat. Squamous cell carcinoma of the hypopharynx and adenocarcinoma of the stomach were pointed out and he was refered to our hospital. As a result of detailed systemic examination, squamous cell carcinoma of the esophagus and squamous cell carcinoma of the right lung were also pointed out, which led to a diagnosis of synchronous quadruple cancer. On the basis of discussions among multiple clinical departments, systemic chemotherapy with cisplatin(CDDP), fluorouracil (5-FU) and docetaxel(DTX) was preceded locolegional therapies. After that, complete thoracoscopic right lower lobectomy and then a laparoscopic distal gastrectomy was performed. Radiation therapy was applied for hypopharyngeal cancer. Finally, endoscopic submucosal dissection for esophageal cancer was performed. Twenty months have passed since the last treatment, the patient is alive with a relapse-free condition.

[Oral Rehydration Therapy in Thoracic Surgery].

The purpose of this study is to evaluate the safety and the efficacy of preoperative oral rehydration therapy comparison with infusion therapy in thoracic surgery. Eighty-four patients scheduled for thoracic surgery were assigned to an oral rehydration group or an infusion group. We checked the amount of their urine and performed blood and urine test. And we carried out questionnaire concerning preoperative therapies to these patients. No morbidity concerned with preoperative therapies was encountered. There was no significant difference in blood and urine test in 2 groups. The answer of questionnaire showed more difficulties in the preoperative period in the infusion therapy group. Present study showed that the preoperative oral rehydration therapy could be done as safely as the infusion therapy with less difficulties compared to the infusion therapy even in the field of thoracic surgery.

Quantification of trunk segmental coordination and head stability in laterally unstable sitting identifies aging and cerebellar ataxia.

BACKGROUND: We quantified trunk segmental coordination and head stability in unstable sitting and investigated whether it can discriminate postural control, age-related differences and presence of coordination disorder. METHODS: Subjects were a healthy younger group (n = 7), a healthy elderly group (n = 7), and a cerebellar ataxia group (n = 8). The motion sensors and surface electrodes were located on the trunk and/or head segments to measure angle displacements, acceleration and electromyograms in unstable sitting during a lateral tilt task. Trunk lateral angle cross-correlation and electromyogram cross-correlation for the trunk segmental coordination, head root mean square (RMS) for the head stability, clinical performance scales, and gait parameters (velocity, coefficient of variation, and RMS ratio) were analyzed. FINDINGS: Trunk lateral angle cross-correlation showed a significantly negative correlation in the healthy younger group compared with the two other groups (p < 0.01). Head RMS showed a significantly larger value in the cerebellar ataxia group compared with the two other groups (p < 0.01). Trunk lateral angle cross-correlation had moderate correlation with the clinical performance scale of ataxia and gait parameters; however, it was not correlated with head RMS. Classification using trunk lateral angle cross-correlation and head RMS was validated by discriminant analysis and hierarchical cluster analysis. INTERPRETATION: We found that trunk lateral angle cross-correlation reflected age-related differences and head RMS characterized the pathology of cerebellar ataxia. Trunk segmental coordination and head stability, as two aspects of sitting postural control, can be used to discriminate the degree of aging and cerebellar ataxia.

Chest wall/parietal pleural invasions worsen prognosis in T4 non-small cell lung cancer patients after resection.

OBJECTIVES: Appropriate selection for surgery is particularly important in T4 non-small cell lung cancer patients. In clinical settings, patients those who are positive for T4 criteria occasionally are also positive for T3 factors which are independently defined from original T4 or even have multiple T4 factors. Significance of these factors on prognosis is still unknown. METHODS: We retrospectively reviewed clinicopathorogical data of 113 patients with T4 non-small cell lung cancer those who underwent surgery between 1990 and 2015 in Tohoku University Hospital. Significance on prognosis of single or multiple T4 factors and with or without independent T3 factors were statistically analyzed. RESULTS: No significant difference was seen in the 5-year survival rate between patients with single (35.6%) and multiple (31.4%) T4 factors (P = 0.94), but the rate was significantly lower when patients also had independent T3 factors (19.6%) compared with when they did not (42.5%) (P = 0.011). The 5-year survival rate was particularly lower among patients with invasion of the chest wall or parietal pleura (8.1%) than in those without (40.6%) (P = 0.0052). CONCLUSIONS: Invasion of the chest wall or parietal pleura is poor prognostic factors in T4 non-small cell lung cancer patients.

Slower Reorientation of Trunk for Reactive Turning while Walking in Hemiparesis Stroke Patients.

We examined the behavioral characteristics of reactive turning in hemiplegic stroke patients when they were informed of the turning direction just before turning was required at an unpredictable time. Eleven stroke patients and 20 healthy elderly control people were asked to initiate a turn as soon as a visual cue to inform them of the turning direction was activated unpredictably using a foot switch. Both the segmental reorientation and stepping type when turning 90° while walking were measured. The results indicated preserved segmental reorientation of the head and pelvis in stroke patients. Stroke patients showed delays in pelvic turning but not in head turning. Their delayed pelvic movement might be due to motor dysfunction and the time taken to ensure stability when deciding when to turn.

Life-Space Mobility and Relevant Factors in Community-dwelling Individuals with Stroke in Japan: A Cross-sectional Study.

OBJECTIVE: Individuals with stroke frequently experience mobility deficits and limited community reintegration. This study aimed to investigate life-space mobility and relevant factors in community-living individuals with stroke. METHODS: This was a cross-sectional study of 46 community-dwelling individuals with chronic stroke in Japan (mean age 72.7 ± 7.4 years; mean time post-stroke 63.6 ± 43.3 months; 26 men/20 women). We measured life-space mobility using a Japanese translation of the Life-Space Assessment. The following factors that might affect life-space mobility were assessed: the ability to perform activities of daily living, physical performance, fear of falling, and cognitive function. RESULTS: A total of 41 participants (89.1%) had restricted life-space mobility (Life-Space Assessment score <60 points). A multiple linear regression analysis showed that limitations in activities of daily living, walking speed, and Falls Efficacy Scale-International scores were independently related to Life-Space Assessment scores. This model explained 51.3% of the variance in Life-Space Assessment scores. CONCLUSIONS: Most individuals with stroke had restricted life-space mobility. Life-space mobility was associated with the ability to perform activities of daily living, walking speed, and fear of falling. These findings could contribute to the development of rehabilitation interventions for regaining life-space mobility in individuals with stroke.

Muscle synergies underlying sit-to-stand tasks in elderly people and their relationship with kinetic characteristics.

BACKGROUND: Physiological evidence suggests that the nervous system controls motion by using a low-dimensional synergy organization for muscle activation. Because the muscle activation produces joint torques, kinetic changes accompanying aging can be related to changes in muscle synergies. OBJECTIVES: We explored the effects of aging on muscle synergies underlying sit-to-stand tasks, and examined their relationships with kinetic characteristics. METHODS: Four younger and three older adults performed the sit-to-stand task at two speeds. Subsequently, we extracted the muscle synergies used to perform these tasks. Hierarchical cluster analysis was used to classify these synergies. We also calculated kinetic variables to compare the groups. RESULTS: Three independent muscle synergies generally appeared in each subject. The spatial structure of these synergies was similar across age groups. The change in motion speed affected only the temporal structure of these synergies. However, subject-specific muscle synergies and kinetic variables existed. CONCLUSIONS: Our results suggest common muscle synergies underlying the sit-to-stand task in both young and elderly adults. People may actively change only the temporal structure of each muscle synergy. The precise subject-specific structuring of each muscle synergy may incorporate knowledge of the musculoskeletal kinetics.

[Vacuum-assisted Closure Therapy for Residual Space after Open Window Thoracotomy for Pleural Empyema due to Bronchopleural Fistula].

A 73-year-old man underwent right middle-lower bilobectomy for lung adenocarcinoma. He suffered from pneumonia followed by empyema due to bronchopleural fistula. On day 19 after the operation, an open window thoracostomy was created. Then the pleural space was treated conservatively with saline irrigation and petrolatum gauze packing. Progressive formation of healthy granulation tissue was observed around the bronchopleural fistula and the adjacent pulmonary artery, resulting in a complete closure of the bronchopleural fistula. And then we applied vacuum-assisted closure (VAC) therapy to the residual pleural cavity. At 4 weeks after the initiation of VAC therapy, the pleural cavity was completely filled with granulation tissue and re-expanded residual lung. In conclusion, VAC therapy is a safe and effective treatment for residual space after open window thoracostomy for empyema due to bronchopleural fistula, if it is applied after closure of bronchopleural fistula and adequate granulation tissue formation on the great vessels.

Frequency analysis of ultrasonic echo intensities of the skeletal muscle in elderly and young individuals.

BACKGROUND: The skeletal muscle echo intensity (EI) during ultrasound imaging has been investigated to evaluate the muscle quality. However, EI fluctuates according to the scanning conditions. METHODS: The motor functions and ultrasound images of 19 elderly (73 ± 3.2 years) and 19 young (22 ± 1.5 years) individuals were investigated and an EI frequency component was assessed for more reliable evaluations. Healthy elderly and young subjects participated in this study. The motor functions were assessed during walking and according to the knee extension muscle strength. The muscle thicknesses of rectus femoris (RF), vastus intermedius (VI), and quadriceps femoris (QF) were investigated. EIs were calculated and the mean frequencies of the regions of interest (MFROIs) for RF and VI were analyzed. RESULTS: EIs and MFROIs were greater in elderly subjects than in young subjects (P<0.01 for RF, and P<0.001 for VI, in EIs; and P<0.01 for RF, and P<0.05 for VI, in MFROIs). In young subjects, EI of RF was greater than that of VI; however, there was no difference between the RF and VI MFROIs in both elderly and young subjects. EIs of VI exhibited a significantly negative correlation with the QF thickness in both elderly and young subjects. RF MFROIs negatively correlated with the QF thickness and positively correlated with EI of VI in elderly subjects alone. CONCLUSION: These findings suggest that MFROIs of elderly individuals would have a larger value than those of young individuals; moreover, MFROIs did not fluctuate greatly with the tissue depth and scanning conditions. MFROIs might be thus useful for further investigations of muscle quality and applications for the early prevention of age-related motor functional decline.

The prognostic significance of eukaryotic elongation factor 1 alpha-2 in non-small cell lung cancer.

BACKGROUND: Eukaryotic elongation factor 1 alpha-2 (eEF1A2) has been recently shown to be a putative oncogene of lung cancer. MATERIALS AND METHODS: We analyzed the expression and prognostic significance of eEF1A2 in 69 primary non-small cell lung cancer (NSCLC) cases. We also suppressed eEF1A2 expression using RNA interference and then analyzed cell proliferation, migration and invasion of five adenocarcinoma cell lines. RESULTS: eEF1A2 protein expression was positive in 84.1%. Negative immunostaining for eEF1A2 was shown to be an independent prognostic factor and significantly correlated with lymph node metastasis. There was no significant correlation between eEF1A2 protein and mRNA expression levels. Among the five examined cell lines, transfection of eEF1A2 siRNA inhibited cell migration in only one cell line while it did not change cell proliferation and invasion. CONCLUSION: Negative immunostaining of eEF1A2 predicted for poor prognosis of NSCLC. The mechanism of this result could not be elucidated by cell proliferation, migration and invasion assays.

[The fluorodeoxyglucose-positron emission tomography (FDG-PET) findings and surgical strategy for pulmonary sclerosing hemangioma].

The pulmonary sclerosing hemangioma is a comparatively rare lung tumor. We operated on 7 patients of the pulmonary sclerosing hemangioma during January, 2009 from December, 2001. We collected the information such as preoperative image findings, surgical methods, and the postoperative course. FDG-PET was performed in 4 patients preoperatively, and there was FDG uptake in 2 patients, and no FDG uptake in 2 patients. In 2 cases with FDG uptake, there was a tendency to increase the tumor diameter during preoperative follow-up. Among 7 patients, 1 patient underwent tumor enucleation, 2 patients underwent partial resection, and 2 patients underwent thoracoscopic lobectomy. Lung biopsy was performed in remaining 2 cases. Because a tumor was located in pulmonary hilum in 1 case, we underwent lung needle biopsy under thoracoscopy. Because another case was a multiple case, and the resection of all lesions was impossibile, we performed lung biopsy (partial resection). In all cases, the recurrence or exacerbation of the tumor was not detected postoperatively. We thought that the findings of FDG-PET reflected proliferation potency of the pulmonary sclerosing hemangioma. The clinical features of the pulmonary sclerosing hemangioma are various. Therefore, the surgical treatment should be determined in each case carefully while considering the FDG-PET findings.

[Experience of a vascular stent placement under bronchoscopy for a severe airway stenosis like a pinhole].

The patient was a 32-year-old woman. She suffered repeated hemoptysis due to a congenital right pulmonary artery deficiency and underwent right pneumonectomy at 19 years of age. Immediately after the operation, postpneumonectomy syndrome appeared. The left main bronchus was compressed and almost obstructed, and so metallic stent was urgently installed. However, she subsequently suffered from repeated stenosis due to granulation and repeated obstructive pneumonia. She underwent 7 stent installations, laser therapy, low dose radiotherapy, and ballooning to treat her airway stenosis. However, her left main bronchus gradually became a severe stenosis like a pinhole. When she admitted to our hospital due to obstructive pneumonia last time, it was impossible to install usual airway stents because of extreme kinking of airway and severe stenosis. Therefore, a vascular stent for iliac artery was chosen to treat her airway stenosis and the stent was placed to regain good patency. As a result of the treatment, she had immediate relief of symptoms and survived obstructive pneumonia.