Hospital da Restauração

The history of games is obscured by our inability to recognise indicators of play in the archaeological record. Lines incised on a piece of rounded limestone found at the Roman site of Coriovallum in Heerlen, The Netherlands, evoke a board game yet do not reflect the grid of any game known today. Here, the results of use-wear analysis are used to inform artificial intelligence-driven simulations based on permutations of rules from historic Northern European games. Disproportionate wear along specific lines favours the rules of blocking games, potentially extending the time depth and regional use of this game type.

Hereditary elliptocytoses (HE) are a group of autosomal dominant disorders characterized by peripheral blood smears showing at least 70% of erythrocytes with an elliptical shape. This abnormal morphology occurs because mutations in the spectrin protein of the cytoplasmic membrane cause erythrocytes to lose elasticity. Defects in spectrin dimer–dimer associations and in the spectrin–actin–protein 4.1 complex of the red cell membrane junction lead to weaker horizontal connections in the cytoskeleton. HE affects populations worldwide, with an estimated incidence of approximately 1 in every 2.000 to 4.000 individuals. It is more prevalent in malaria-endemic areas, as elliptocytes may offer some resistance to the protozoan, providing a selective advantage to those affected with HE. For example, in West Africa, the prevalence of HE is approximately 1 in every 100 individuals [1]. Here, we report unusual findings in an 88-year-old woman with the symptomatic form of HE and no family history of erythrocyte membrane disorders. The patient did not report any medication use, nor were there signs of hepatic, renal, or endocrine dysfunction. Her blood tests showed a normal leukocyte count (7.9 × 109/L; reference: 4–11 × 109/L) and a platelet count (166 × 109/L; reference: 150–450 × 109/L). However, her hematimetric indices revealed anemia, with a low erythrocyte count (2.4 × 1012/L; reference: 4.0–5.4 × 1012/L), hemoglobin level (7.4 g/dL; reference: 12.0–16.0 g/dL), and hematocrit (21.9%; reference: 36%–46%). The red blood cell indices were as follows: mean corpuscular volume (MCV) 91.2 fL (reference: 80–101 fL), mean corpuscular hemoglobin (MCH) 30.8 pg (reference: 27–33 pg), mean corpuscular hemoglobin concentration (MCHC) 33.7 g/dL (reference: 31.5–36 g/dL), and red cell distribution width (RDW) 16.3% (reference: 11.5%–15.5%), indicating anisocytosis. Her peripheral blood smear showed over 75% elliptocytes and the peculiar presence of erythrocytes that agglutinated and were arranged perpendicularly to each other, forming a cross or an “X” shape (Figure 1A–C). To rule out other hematological disorders that could explain this unusual erythrocyte arrangement, additional tests were performed. A myelogram presented normal results (apart from the presence of elliptocytes), and immunophenotyping of peripheral blood also showed no abnormalities. Together, these findings confirmed the diagnosis of HE. To date, erythrocyte agglutination has only been described in the form of rouleaux—where red cells stack on top of one another—or in cases triggered by cold or warm antibodies, which result in irregular aggregates of erythrocytes [2]. However, “crossed” erythrocytes have not been described in either of these conditions. To investigate the cause of these crossed erythrocytes, a sample of whole blood was washed five times with 0.9% saline solution. New blood smears were then prepared. The cytological assay showed that the crossed erythrocytes disappeared (Figure 1D), suggesting that their formation was due to alterations in surface electric charges between erythrocytes, which were reversed by the saline washes [3]. Three months later, a follow-up blood smear confirmed the recurrence of “crossed” erythrocytes, and again, saline washing abolished their formation. Interestingly, the presence of “crossed” erythrocytes has also been occasionally observed by our group in the peripheral blood of other HE patients. M.A.W.M., C.M.S., and M.M.R. wrote the manuscript and contributed to the diagnosis of the case. G.S.A. critically revised the article. All authors read and approved the final version of the manuscript. The Article Processing Charge for the publication of this research was funded by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brasil (CAPES) (ROR identifier: 00x0ma614). The article processing charge for the publication of this research was funded by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior -Brasil (CAPES). The authors have nothing to report. The authors have nothing to report. The authors declare no conflicts of interest. The data that support the findings of this study are available from the corresponding author upon reasonable request.

Abstract The middle meningeal artery (MMA) supplies over two-thirds of the cranial dura mater, making its anatomical knowledge crucial for surgery. Rarely, the MMA may originate from the basilar artery. Typically, it arises between the superior cerebellar artery and anterior inferior cerebellar artery, following a course near the trigeminal nerve to reach the petrous branch of the MMA. An embryological origin involves anastomosis between persistent stapedial and trigeminal arteries. The image illustrates an unusual case of a patient with right MMA originating from the posterior circulation via the basilar artery.

Objetivo: Identificar a taxa de infecção relacionada ao uso de cateter vesical de demora em pacientes internados em unidades de terapia intensiva. Método: Estudo transversal e retrospectivo em um hospital público de referência na região metropolitana de Pernambuco. Os dados foram analisados no software SPSS, versão 26, e foram geradas análises descritivas com valores médios, mínimo, máximo e desvio-padrão. Os dados coletados foram dados demográficos, idade e sexo, informações clínicas, inserção do CVD, duração, diagnóstico de ITU, uso de antimicrobianos, microrganismos e desfecho, que incluía alta, transferência ou óbito. Resultados: Foram avaliadas 192 fichas de notificação, entre essas, 71,88% utilizaram cateter vesical de demora por mais de 10 dias, com duração máxima de 106 dias. Durante a internação, 120 pacientes tiveram suspeita de infecção do trato urinário e realizaram exame de urocultura. O total de 61 pacientes (31,77%) foram diagnosticados com infecções relacionadas a cateteres vesicais de demora. O agente etiológico mais encontrado em análises laboratoriais foi Candida spp., seguido de Pseudomonas aeruginosa. Conclusão: Os resultados indicam uma alta frequência de infecções relacionadas a cateteres vesicais de demora em pacientes internados em UTI, tornando importante a implementação de medidas preventivas.

The recent study by Almani et al. [1] provides an important contribution to understanding risk in transcatheter aortic valve replacement (TAVR). Among nearly 300,000 patients, only 0.2% had hypertrophic obstructive cardiomyopathy (HOCM), yet this subgroup showed markedly worse in-hospital outcomes, including a threefold increase in mortality and higher rates of atrioventricular block, cardiogenic shock, and acute kidney injury. These findings remind interventional cardiologists that procedural success in TAVR depends not only on anatomical precision but also on ventricular physiology [2]. The authors appropriately highlight the hemodynamic complexity of patients with combined fixed and dynamic obstruction. These results, however, invite reflection on the importance of diagnostic precision before intervention. In daily practice, patients with left ventricular hypertrophy and aortic stenosis often fall into a diagnostic gray zone. The key question is whether the hypertrophy represents a secondary adaptation to valvular overload or an underlying cardiomyopathy. This distinction has major therapeutic implications. When hypertrophic cardiomyopathy (HCM) coexists or predominates, other strategies such as surgical septal myectomy, often combined with valve replacement, or alcohol septal ablation may offer more physiologically appropriate solutions than isolated TAVR. Accurate identification of HCM before TAVR is therefore not merely an academic concern but one that can alter the treatment pathway entirely. Multimodality imaging, particularly cardiac magnetic resonance, is essential to detect asymmetric hypertrophy, systolic anterior motion, or midventricular obstruction. Even so, imaging findings can overlap in older patients with long-standing hypertension or calcific aortic stenosis, making differentiation difficult. In such cases, complementary tools such as targeted genetic testing may refine diagnosis and guide referral toward the most appropriate therapy [3]. This approach represents a practical expression of precision medicine, where clinical and molecular information combine to ensure that the chosen intervention aligns with the underlying disease. Recent imaging studies support the biological basis of this differentiation. Chung et al. [4] demonstrated that carriers of sarcomere mutations exhibit significantly greater myocardial fibrosis than genotype-negative counterparts, with 90% showing late gadolinium enhancement compared with 60% among noncarriers (p < 0.001). Even in myocardial regions without visible enhancement, extracellular volume was higher (32.4% vs. 30.7%, p = 0.025), confirming diffuse interstitial fibrosis. This fibrotic substrate increases stiffness and reduces compliance, limiting the heart′s ability to tolerate abrupt unloading. Such pathophysiology helps explain why ventricles with hypertrophic cardiomyopathy are prone to post-TAVR collapse and instability despite technically successful implantation. Although genetic testing is not part of routine pre-TAVR evaluation, it could be selectively applied to patients with disproportionate septal thickening or dynamic gradients. Identifying a sarcomeric substrate before intervention could inform the choice between TAVR and surgical strategies or justify septal reduction before transcatheter valve replacement. Ultimately, the study by Almani et al. highlights that outcomes after TAVR depend not only on device technology but on accurate disease characterization. In patients with unexplained or asymmetric hypertrophy, comprehensive evaluation that includes consideration of hypertrophic cardiomyopathy and potential septal reduction should precede transcatheter intervention. The convergence of imaging, myocardial biology, and clinical judgment defines the future of precision-guided structural cardiology, ensuring that valve replacement treats the disease mechanism rather than its manifestation. The authors declare no conflicts of interest.

Idiopathic spinal cord herniation (ISCH) is a rare condition caused by a defect in the dura mater, resulting in ventral displacement of the spinal cord. Its etiology is not fully understood, but it mainly affects middle-aged women and manifests as progressive myelopathy. Surgical treatment is the best option to avoid neurological worsening. This report presents a case of spinal cord herniation in a 45-year-old man, complaining of numbness for 4 months, with paraparesis that progressed to gait disorder. This condition was diagnosed by magnetic resonance imaging and computed tomography. The patient underwent T2 to T3 laminectomy, hernia reduction, and duroplasty, with successful resolution of the condition.

Nodular fasciitis is a pseudosarcomatous, self-limited lesion composed of fibroblasts and myofibroblasts. Craniofacial lesions are more common in pediatric patients. This report presents a rare case of nodular fasciitis involving the face of an adult patient. A 32-year-old woman presented with a painless subcutaneous mass at the right zygomatic region, with one year of duration. The diagnostic hypotheses were epidermoid cyst and neurofibroma. An excisional biopsy was performed, and the microscopic examination exhibited an admixture of spindle-shaped cells and acellular areas associated with prominent collagen bands. No cellular atypia was observed. Immunohistochemical findings demonstrated positivity for alpha-SMA, HHF35, and beta-catenin. Tumor cells were negative for STAT6. The final diagnosis was nodular fasciitis. The patient has not presented any recurrences so far. Clinicians and pathologists must be capable to distinct nodular fasciitis and malignant tumors to avoid misdiagnosis and overtreatment.