Itami City Hospital

Delirium is a common and distressing complication in terminally ill patients with advanced cancer, often impairing communication and decision-making, and diminishing the quality of the remaining life. Effective symptom management is essential; however, current clinical guidelines offer limited recommendations, and supporting evidence remains insufficient. This scoping review systematically mapped the existing literature on pharmacological and nonpharmacological interventions for delirium symptom management in terminally ill patients with cancer and identified gaps in the evidence base. Following the framework proposed by Arksey and O'Malley and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews guidelines, we conducted a comprehensive literature search of PubMed, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Ichushi-Web of the Japan Medical Abstract Society for studies published up to August 31, 2023. Subsequently, two updated searches were conducted using the same procedure with the first covering studies published between September 1, 2023, and September 30, 2024, and the second covering studies published between October 1, 2024, and September 30, 2025. Eligible studies evaluated interventions for delirium in adults with terminal cancer with a life expectancy of one month or less. Two reviewers independently screened the studies for inclusion. Of the 1640 articles identified, seven met the inclusion criteria including four randomized controlled trials on pharmacologic interventions, one randomized controlled trial on hydration, and two observational studies on opioid switching. All studies targeted terminally ill patients with advanced cancer and assessed the outcomes related to delirium symptom relief. This review revealed that the literature addressing delirium symptom management in terminally ill patients with cancer is limited and heterogeneous. Further research is warranted to strengthen the evidence base and to inform clinical practice guidelines for the care of this vulnerable population.

Background: Recent advances in artificial intelligence (AI) have produced ChatGPT-4o, a multimodal large language model (LLM) capable of processing both text and image inputs. Although ChatGPT has demonstrated usefulness in medical examinations, few studies have evaluated its image analysis performance. Methods: This study compared GPT-4o and GPT-4 using public questions from the 116th–118th Japanese National Medical Licensing Examinations (JNMLE), each consisting of 400 questions. Both models answered in Japanese using simple prompts, including screenshots for image-based questions. Accuracy was analyzed across essential, general, and clinical questions, with statistical comparisons by chi-square tests. Results: GPT-4o consistently outperformed GPT-4, achieving passing scores in all three examinations. In the 118th JNMLE, GPT-4o scored 457 points versus 425 for GPT-4. GPT-4o demonstrated higher accuracy for image-based questions in the 117th and 116th exams, though the difference in the 118th was not significant. For text-based questions, GPT-4o showed superior medical knowledge, clinical reasoning, and ethical response behavior, notably avoiding prohibited options. Conclusion: Overall, GPT-4o exceeded GPT-4 in both text and image domains, suggesting strong potential as a diagnostic aid and educational resource. Its balanced performance across modalities highlights its promise for integration into future medical education and clinical decision support.

Abstract Background Serum leucine-rich alpha-2 glycoprotein (LRG) is a biomarker reflecting endoscopic activity in patients with ulcerative colitis (UC) and, may serve as treatment target for advanced therapy (AT), like C-reactive protein (CRP). However, unlike CRP, serum LRG is produced also by intestinal epithelium in response to stimulation not only by Interluekin-6 (IL-6) but also tumor necrosis factor (TNF) and IL-22. Therefore, a certain number of cases exist where serum LRG is elevated even when CRP is negative. This study aimed to investigate the optimal selection of AT based on serum LRG levels in patients with UC with serum CRP-negative. Methods This was a multicentre prospective cohort study including 259 patients with UC who received AT from January 2019 to March 2024 at 16 hospitals. Among them, 134 patients with UC with CRP-negative who received one of four classes of AT—anti-TNF, vedolizumab (VDZ), ustekinumab (UST), or Janus kinase inhibitor (JAKi)—were included in the present analysis [anti-TNF, n = 27; VDZ, n = 41; UST, n = 42; JAKi, n = 24]. The effectiveness and safety of AT was assessed by comparing the proportion of clinical remission (CR) at week 52 and the incidence rate of adverse events (AE) requiring discontinuation of AT using the person-year (PY) method. We defined CR as a partial Mayo score ≤2, with each subscore ≤1 and no-bleeding, CRP-negative as < 0.20 mg/dL and the low-LRG group as < 14.0 μg/mL, the high-LRG group as ≥ 14.0 μg/mL. Results Among 134 patients with UC who had negative CRP (female, 43%; pancolitis, 73%; AT exposure, 38%), 59 patients (44%) were classified as the high-LRG group. At week 0, median serum LRG and CRP levels were 13.1 μg/mL [Interquartile range (IQR) 10.7-17.9] and 0.04 mg/dL [IQR 0.00-0.09]. Concomitant corticosteroids and immunomodulators were used in 65 (49%) and 47 (35%) patients. In high-LRG group, the proportion of patients achieved CR at week 52 tended to differ among the four AT classes and that in patients received VDZ was only <50% (P = 0.091; anti-TNF, 88%; VDZ, 42%; UST, 60%; JAKi, 75%), and there was no difference in the incidence rate of AEs (anti-TNF, 0; VDZ 0.9; UST, 3.0; JAKi, 0 per 100PY). In low-LRG group, the proportion of CR at week 52 was significantly different among the four AT classes and that in patients received VDZ or UST was >70% (P = 0.013; anti-TNF, 39%; VDZ, 75%; UST, 73%; JAKi, 33%), and there was no difference in the incidence rate of AEs (anti-TNF, 0; VDZ 0.9; UST, 3.0; JAKi, 0 per 100PY) Conclusion For AT selection in CRP-negative UC patients, ATs other than VDZ can be prioritized in the high-LRG group, whereas VDZ and UST are appropriate in the low-LRG group. Conflict of interest: Dr. Amano, Takahiro: No conflict of interest Yoshihara, Takeo: No conflict of interest Sakakibara, Yuko: No conflict of interest Yamada, Takuya: No conflict of interest Hiyama, Satoshi: No conflict of interest Murayama, Yoko: No conflict of interest Ogiyama, Hideharu: No conflict of interest Uema, Ryotaro: No conflict of interest Tsujii, Yoshiki: No conflict of interest Inoue, Takahiro: No conflict of interest Shinzaki, Shinichiro: Shinichiro Shinzaki has received grant support from AbbVie, EA Pharma, Nippon Kayaku, advisor fees from AbbVie, EA Pharma, Gilead Sciences, Janssen Pharmaceutical, Sekisui Medical and Takeda Pharmaceutical and honoraria from AbbVie, EA Pharma, Gilead Sciences, Janssen Pharmaceutical, Mitsubishi Tanabe Pharma, Nippon Kayaku, Pfizer, Sekisui Medical, and Takeda Pharmaceutical. Iijima, Hideki: No conflict of interest Hayashi, Yoshito: No conflict of interest

Adjuvant anti-PD-1 (adj PD-1) antibodies are extensively used to improve survival in patients with resected melanoma. Clinical trials on adj PD-1 antibodies have revealed significant improvements in recurrence-free survival (RFS); however, few of these trials have included patients with acral melanoma (AM). Clinical data were retrospectively collected from Japanese patients who underwent resection of stage III sole AM between 2014 and 2021. Survival outcomes, including RFS, distant metastasis-free survival (DMFS), and overall survival (OS), were compared between patients without adjuvant therapy (OBS group) and those receiving adj PD-1 group. This study included 139 patients (OBS: 79; adj PD-1: 60), with a median follow-up of 2.6 years. The baseline characteristics were comparable, except for age and nodal metastasis. No significant differences in survival were observed between the OBS and adj PD-1 groups (3-year RFS: 36.7% v 27.5%, P = .13; 3-year DMFS: 51.0% v 45.3%, P = .51; 3-year OS: 65.3% v 67.4%, P = .45). Multivariate analysis showed no survival benefit of adj PD-1 (RFS: hazard ratio [HR], 1.25, P = .29; DMFS: HR, 1.03, P = .89; and OS: HR, 0.69, P = .23). Each survival outcome after propensity score matching confirmed no significant difference between the matched OBS group (n = 52) and adj PD-1 group (n = 52; 3-year RFS: 34.3% v 25.9%, P = .22; 3-year DMFS: 45.6% v 46.5%, P = .85; 3-year OS: 60.7% v 68.9%, P = .29). Adj PD-1 did not improve the prognosis in sole AM. However, further studies are essential to evaluate the efficacy of the adj anti-PD-1 antibody in AM.

要旨：ペランパネル（PER）は、AMPA受容体を選択的、非競合的に阻害する新規の抗てんかん発作薬である。PERを一次単剤療法として30カ月の長期間使用した際の有効性および安全性、QOLへの影響等を検討した12カ月時中間結果を報告する。焦点起始発作を伴う新規発症または再発のてんかんと診断され、PER単剤で治療開始した4歳以上の患者61例を対象とした。本結果から、治療開始後12カ月時の実臨床におけるPERは低用量であり、特に神経系副作用を低減するためには低用量での開始と維持が有効な可能性が示唆された。また治験時や他国での実臨床報告と差異のない有効性、継続率および安全性が示された。さらに患者や保護者のQOLも悪化は見られなかった。小児、高齢者を含めた新規または再発てんかん患者の治療においてPERが有効かつ安全な選択肢の一つとなることが示唆された。

ABSTRACTINTRODUCTIONAutoimmune neutropenia (AIN) is a rare disease that causes neutropenia due to autoantibodies directed against neutrophils. Neutropenia is associated with an increased risk of infection, such as surgical site infection or febrile neutropenia. To our knowledge, however, there are few reports of surgical or neoadjuvant chemotherapeutic treatments for colorectal cancer with AIN. Herein, we present a case with AIN undergoing multidisciplinary treatment of cecal cancer and metachronous liver metastases.CASE PRESENTATIONA 74-year-old woman with AIN presented to our hospital with epigastric pain lasting for 3 weeks. Abdominal CT showed obstructive cecal cancer and swollen regional lymph nodes. She had been under observation for primary AIN in the hematology department in our institution. The blood test revealed white blood cell count of 2300/μL, neutrophil count of 19.4%, and thus absolute neutrophil count of 446/μL. Granulocyte-colony stimulating factor (G-CSF; filgrastim 75 μg) was administered to lower the risk of infectious complications before surgery. After the absolute neutrophil count levels increased sufficiently, laparoscopic ileocecal resection was performed. Pathological findings showed T3N1aM0, pStage IIIB (UICC 8th edition), HER2 score 0, and a RAS codon 12S mutation. Six months after curative surgery, multiple liver metastases appeared. A total of 8 cycles of mFOLFOX6 with bevacizumab, combined with G-CSF (filgrastim 75 μg) were administered. After preoperative chemotherapy, the patient underwent right anterior sectionectomy and partial resection of segment 6. She was uneventful in the postoperative course. Throughout the perioperative period and chemotherapy, no infectious complications were observed.CONCLUSIONSThe administration of G-CSF to prevent neutropenia allowed the patient with AIN to safely undergo multidisciplinary treatment.