Purpose: This study aimed to evaluate the structural complexity of craniofacial trabecular bone in multiple myeloma by fractal analysis of panoramic and lateral skull radiography, and to compare the fractal dimension values of healthy patients (HPs), pre-treatment patients (PTPs), and patients during bisphosphonate treatment (DTPs). Materials and Methods: Pairs of digital panoramic and lateral skull radiographs of 84 PTPs and 72 DTPs were selected. After application of exclusion criteria, 43 panoramic and 84 lateral skull radiographs of PTPs, 56 panoramic and 72 lateral skull radiographs of DTPs, and 99 panoramic radiographs of age- and sex-matched HPs were selected. The fractal dimension values from panoramic radiographs were compared among HPs, PTPs, and DTPs and between anatomical locations within patient groups using analysis of variance with the Tukey test. Fractal dimension values from lateral skull radiographs were compared between PTPs and DTPs using the Student t-test. Pearson correlation coefficients were used to assess the relationship between the mandible from panoramic radiographs and the skull from lateral skull radiographs. Intra-examiner agreement was assessed using intraclass correlation coefficients (α=0.05). Results: The fractal dimension values were not significantly different among HPs, PTPs, and DTPs on panoramic radiographs or between PTPs and DTPs on lateral skull radiographs (P>0.05). The mandibular body presented the highest fractal dimension values (P≤0.05). The fractal dimension values of the mandible and skull in PTPs and DTPs were not correlated. Conclusion Fractal analysis was not sensitive for distinguishing craniofacial trabecular bone complexity in multiple myeloma patients using panoramic and lateral skull radiography.

Background: Complete heart block is considered a unique and rare complication of Takotsubo cardiomyopathy, an otherwise self-resolving disease. When this occurs, there is a double clinical dilemma: first to find out which triggered the other and second, to decide whether or not to implant a permanent pacemaker.Case presentation: We present a case of a 77 years-old female patient, with previous medical history of arterial hypertension, diabetes mellitus, dyslipidemia and bifascicular block known since 2013. She came to the emergency department after recurrent syncopal episodes. At admission a complete heart block was diagnosed, and it was implanted a single chamber temporary pacemaker. The patient remained in disproportional acute decompensated heart failure despite pacemaker implantation. She denied chest pain although referring an episode of self-limiting chest pain 2 days before, after an argument with the family. Blood analysis showed an important rise in NTproBNP and troponin levels. Transthoracic echocardiogram showed a dilated left ventricle with akinesia of apical and mid segments, hyperkinesia of basal segments and severely depressed left ventricle ejection fraction. Coronary angiography showed no significant lesions and the diagnosis of Takotsubo cardiomyopathy was suspected. During the following days, she recovered her own intrinsic rhythm. Electrocardiogram evolved with deep T-wave inversion and prolonged QT interval and transthoracic echocardiogram showed resolution of the previous alterations. Despite complete reversion of rhythm alteration, it was decided to implant a permanent pacemaker. Conclusions We describe a rare, life-threatening and often underdiagnosed complication of the stress cardiomyopathy. Furthermore, we performed a literature revision of this rare complication and discussed the therapeutic challenge encountered in such patients.