Low-molecular-weight heparins (LMWHs) have become a near-routine prescription for venous thromboembolism (VTE) prevention in hospitalized patients in several parts of the world. Their use may be reinforced by embedded order sets and 'opt-out' defaults. However, the absolute clinical benefit of universal pharmacologic thromboprophylaxis for many low-risk medical inpatients appears small. Symptomatic VTE rates are low, mortality benefits with LMWH use are not clearly demonstrated, and any reductions in thrombotic events may be offset by bleeding complications. Several analyses suggest that a substantial proportion of patients classified as 'low-risk' by validated risk-assessment models still receive LMWH prophylaxis in practice. LMWH also carries a largely overlooked environmental footprint because it is derived almost exclusively from porcine intestinal mucosa via resource-intensive and low-yield manufacturing processes. It is also compounded by single-use injection materials and downstream monitoring requirements. We propose that 'sustainable thromboprophylaxis' should be framed within appropriate, value-based healthcare. We should prioritize LMWH for patients who meaningfully benefit, reducing potentially avoidable use in low-risk settings and explicitly accounting for environmental impact as a co-consideration where clinical benefit is marginal. Achieving this requires better VTE risk stratification integrated into workflows and formal life cycle assessment to quantify the carbon costs and supply chain vulnerabilities of current high-volume anticoagulantion practice.

We report a diagnostically challenging case of a 79-year-old man who presented with mediastinal lymphadenopathy, hepatosplenomegaly, and renal enlargement, raising suspicion for clinical lymphoma. However, the histological evaluation of a submandibular gland excision revealed fibrosis, a dense IgG4-positive plasma cell infiltrate (>100/HPF), and an IgG4:IgG ratio > 40%, supportive of IgG4-related disease (IgG4-RD) in the appropriate clinicopathologic context. This case illustrates an important but well-recognised diagnostic pitfall in which IgG4-RD may clinically and radiologically mimic lymphoma. PET-CT demonstrated multiorgan involvement with diffuse FDG uptake, but definitive diagnosis required the integration of clinical, radiologic, serologic, and pathologic findings. The patient’s laboratory profile, including hypocomplementemia and elevated inflammatory markers, supported the proliferative phenotype of IgG4-RD—recently proposed in the literature as a clinically distinct subgroup with systemic involvement and steroid responsiveness. Rather than representing a novel presentation, this case reinforces the importance of integrated assessment in distinguishing IgG4-RD from haematolymphoid malignancy. PET-CT served as a useful adjunct for identifying multiorgan disease and guiding diagnostic evaluation, but tissue evaluation remained essential to avoid misdiagnosis and inappropriate treatment. Recognition of this entity is vital to avoid misdiagnosis and inappropriate treatment.

Acute basophilic leukemia (ABL) transformed from myelodysplastic syndrome is exceedingly rare. We report the case of a 73-year-old man with ABL which transformed from IPSS-M High risk MDS. The patient had a history of metastatic castration-sensitive prostate cancer. Further investigations demonstrated circulating blasts on peripheral blood smear. Upon bone marrow examination, a diagnosis of ABL arising from underlying MDS was established, characterized by cytogenetic analysis demonstrating trisomy 8 (+ 8), with the additional copy of chromosome 8 present in the form of a ring chromosome, and a WT1 frameshift mutation. The patient was treated with azacitidine and venetoclax, followed by best supportive care after disease progression. This case highlights the rare occurrence of ABL secondary to MDS and provides insight into the diagnostic challenges, clonal evolution, and therapeutic limitations associated with this aggressive entity.

Blood smear examination involves classifying cells by morphology under a microscope, a labour-intensive process prone to subjective variation. Recent deep learning models achieve strong performance in blood cell classification but remain as "black boxes", offering little clinical transparency. We propose a dual-model framework that pairs a deep YOLO (You Only Look Once) classifier with a shallow, interpretable explainer. YOLO performs classification and segmentation, while clinically informed features are extracted from segmented images to train the explainer on YOLO predictions. SHapley Additive exPlanations (SHAP) quantify feature importance, with discrepancies flagged as "other reasons" to enhance transparency. Evaluated on proprietary and public datasets (PBC, Raabin), YOLO achieved AUCs of 0.997, 0.994, and 1.000 respectively, with the explainer demonstrating strong alignment: Score-CAM activation maps agreed with SHAP-identified features. In a user study with 9 trained and qualified haematologists and laboratory medical technologists, predictions achieved 96.9% concurrence. This work shows that the coupling of deep learning with interpretable models improves the confidence of predictions while providing clinical meaningful insights.

Abstract:Extracorporeal membrane oxygenation (ECMO) has increasingly been used in patients with refractory severe cardiorespiratory failure in recent years. The use of ECMO necessitates anticoagulation as blood passes through an extracorporeal circuit that has a membrane lung and a centrifugal pump. Although heparin is the most common anticoagulant used during ECMO runs, other anticoagulants like direct thrombin inhibitors and Factor X inhibitors have also been implemented in special circumstances. Bleeding is a well-known and severe complication while receiving ECMO, and balancing this against circuit thrombosis is a clinical challenge. While standard laboratory tests, such as activated partial thromboplastin time and point-of-care tests such as activated clotting time, help monitor anticoagulation on ECMO, they have their drawbacks. The use of viscoelastic assays (VEAs) in aiding anticoagulation management on ECMO has shown some benefits in reducing bleeding and thrombotic complications, though these assays are not widely used at present. This article explores the challenges of monitoring anticoagulation on ECMO and reviews the available evidence regarding VEAs in adult and pediatric ECMO.

Microplastics and nanoplastics (MNPs) are generated through mechanical, chemical, and ultraviolet-mediated plastic degradation and may enter the human bloodstream through ingestion, inhalation, dermal exposure, and iatrogenic sources. Their detection in human blood, atheromas, and thrombi has raised concern that they may contribute to thrombogenesis. We conducted a structured narrative review of English-language studies indexed in PubMed, Embase, and Scopus over the preceding 15 years, up to 31 March 2026. The search identified 981 database records and 39 additional manually identified articles; after duplicate removal and screening, 72 articles were included. Evidence was synthesized according to Virchow’s triad, focusing on endothelial injury, altered blood flow, hypercoagulability, cellular uptake, polymer type, surface charge, weathering, and protein corona formation. MNPs may contribute to all three components of Virchow’s triad. Proposed mechanisms include oxidative endothelial injury, glycocalyx disruption, monocyte adhesion, foam-cell formation, plaque instability, immune-cell-mediated microvascular obstruction, platelet activation, NETosis, von Willebrand factor interactions, factor XII activation, thrombin generation, and fibrin-rich clot stabilization. These effects appear modified by particle size, polymer composition, surface charge, and environmental weathering. However, much mechanistic evidence derives from polystyrene nanoparticle models, whereas human thrombus and atheroma studies more commonly detect polyethylene and polyvinyl chloride. MNPs are biologically plausible contributors to thrombogenesis, but clinical relevance remains uncertain. Prospective human studies, standardized contamination-controlled detection methods, and dose-response experiments using clinically relevant particles and concentrations are required.

Emperipolesis, a cell-in-cell phenomenon, involves a viable cell being transiently internalized within another cell’s cytoplasm from which it can exit without damaging either cell. In this report, we discuss the rarity of the emperipolesis of erythrocytes and erythroblasts, instead of the more commonly observed neutrophils. We report the case of a 52-year-old Chinese male who presented with pancytopenia and 33% blasts. Multiple mutations were revealed, including DNMT3A K826R, RUNX1 F396fs159, BCOR Q1208fs8, BCORL1 S575*, and PHF6 H302R. The patient was diagnosed with acute myeloid leukemia, myelodysplasia-related changes (AML-MR), and was treated with azacitidine and venetoclax, followed by daunorubicin and cytarabine (DA 3+7). This case highlights the rare occurrence of emperipolesis involving erythroid cells in AML-MR. We conducted a literature review exploring emperipolesis using PubMed, with search terms consisting of “emperipolesis”, “megakaryocytes”, “erythrocyte”, “erythroblast”, “neutrophil” and “lymphocyte”. A total of 24 articles that observed erythroid emperipolesis were referenced in this review, including 7 relevant case reports/series.

Anticoagulants are essential to health care, yet their global supply is inherently fragile. Reliance on animal-derived heparin creates vulnerability to contamination, animal disease, and logistical disruption, whereas synthetic alternatives like warfarin and direct oral anticoagulants face mounting manufacturing and geopolitical risks. The COVID-19 pandemic exposed how these intersecting threats can converge during a crisis, causing critical shortages. To build resilience, a systemic shift is required: developing nonanimal-derived anticoagulants, diversifying production geographically, establishing protected supply corridors, reducing high-carbon footprint manufacturing processes, and creating equitable allocation frameworks. Anticoagulants must be recognized as essential medical assets, necessitating sustained investment and international coordination to ensure reliable access for all health systems, particularly before the next pandemic or global shock.

Venous thromboembolism (VTE) remains a leading cause of preventable hospital mortality. Despite clear guidelines on risk assessment and prophylaxis, adherence varies worldwide. This study evaluated the perceptions and practices of VTE risk assessment and thromboprophylaxis among surgeons managing nonorthopedic hospitalized surgical patients in Singapore. A cross-sectional, anonymous online survey was conducted among consultant-grade surgeons across three public hospitals. The survey assessed perceptions of VTE incidence, use of risk assessment tools, and prophylaxis practices. Responses were analyzed by seniority, subspecialty, and training background. Forty-five surgeons responded: 35.5% were senior consultants, 48.9% consultants, and 15.5% associate consultants. 51.1% of the respondents routinely performed VTE risk assessments, while 68.9% routinely prescribed thromboprophylaxis. Senior consultants were less likely to perform formal risk assessments (31.3%) compared with associate consultants (71.4%) but more likely to prescribe prophylaxis. A perceived low incidence of VTE in Singapore (59.0%) was a key reason for omitting assessment. Prophylaxis was driven by perceived high patient risk (29.0%) and guideline adherence (38.7%). Most respondents (84.4%) supported routine assessment and prophylaxis. Suggested interventions included national guidelines, EMR-based tools, and continuing medical education. Uptake of VTE risk assessment and prophylaxis is moderate, with variability linked to seniority and training. The belief that VTE risk is low in Asian populations remains a barrier, despite rising incidence. National guidelines, EMR integration, and education may improve adherence and reduce preventable VTE events.

Art reveals core human emotions during catastrophes like epidemics, allowing people to narrate their coping stories. This review examines smallpox's historical evolution and treatment in Japan, integrating visual art with medical history. It provides chronological insights from smallpox's arrival and traditional remedies to the era of vaccination and public health measures leading to eventual eradication. Art played a vital role in Japan's smallpox eradication, helping to galvanise societal engagement and public trust. Efforts included utilising political and administrative systems for vaccination initiatives and effective public health methods for outbreak surveillance and containment. Japan's smallpox eradication story, depicted in art, offers valuable lessons on the power of robust public health policy and societal cooperation, providing a framework for managing current and future infectious diseases and pandemics.