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In this review article, we highlight several potential biologic and chemical agents of "neuroterrorism" of which neurohospitalists should be aware: anthrax, botulism toxin, brucella, plague, smallpox, organophosphates and nerve agents, cyanide, and carfentanil. Such agents may have direct neurologic effects, resulting in encephalopathy, paralysis, and/or respiratory failure. Neurohospitalists should be on the lookout for abnormal neurologic syndrome clustering, especially among patients presenting to the emergency department. If use of such a "neuroterrorism" agent is suspected, the neurohospitalist should immediately consult with emergency department personnel, infection control, infectious disease physicians, and/or Poison Control to make sure the scene is safe and to stabilize and isolate patients if necessary. The neurohospitalist should also immediately contact their local and/or state health department (or alternatively the US Centers for Disease Control and Prevention Emergency Operations Center) to report their suspicions and to obtain guidance and assistance.

Background Implant brachytherapy (IBT) is a well-recognized treatment modality for early stage prostate cancer. Rectal ulcer and rectourethral fistula complicating IBT may cause an alteration of the normal anatomic landmarks. In this context, pseudomalignant radiation-induced changes within prostatic epithelium may be misinterpreted as a primary rectal malignancy. Such challenging and misleading findings have not been described, and may not be recognized as such. Materials and methods We present the clinical and pathologic aspects of two patients who underwent IBT for low stage prostate cancer that was complicated by deep rectal ulcer. Both patients underwent extensive palliative surgical resection for disease control. Results The histologic changes in both cases were noteworthy for extensive necrosis and inflammation of the prostate, associated with loss of recto-prostatic anatomical landmarks. Prostatic glands showed striking radiation-induced atypia and pseudomalignant epithelial changes extending to the rectal ulcer bed, with no residual viable tumor. The first patient had undergone a biopsy of the rectal ulcer bed that was misinterpreted as a rectal adenocarcinoma prior to surgery. The similarity between atypical glands of the biopsy and the benign prostatic tissue with radiation-induced atypia in resection specimen confirmed their benign nature. Conclusions Deep rectal ulcer complicating IBT may lead to distortion of the normal recto-prostatic anatomical landmarks, resulting in detection of pseudo-malignant prostatic glands at the ulcer base. Such findings may be mistaken for a primary rectal malignancy in limited biopsy material if not familiar to the pathologist.

OnabotulinumtoxinA (Botox A) has gone from investigational to a recognized standard for neurogenic detrusor overactivity (NDO) in patients intolerant or inadequately managed by anticholinergics. A large number of initial studies were done using the 300 unit dose, including the initial report on 200 vs. 300 U. There was a suggestion that 300 units may have some advantage but statistical sample size was small. Two pivotal phase 3 studies compare 200 units to 300 units of BotoxA for NDO. The result of these studies did not show an advantage to the higher dose. These studies did lead to the Food and Drug Administration (FDA) approval, in August 2011, of BotoxA 200 units for refractory or inadequately treated NDO patients. A subsequent pooled extension study was performed. Patients were then followed for five to eight treatment cycles of onabotulinumtoxinA. The data demonstrated no significant increased efficacy of the higher dose of onabotulinumtoxinA for patient management.

Women with urinary urgency and frequency may also have pelvic floor muscle spasm. Transvaginal biofeedback (TVBF) and electrical stimulation (EStim) is a treatment modality that has been used to treat vaginismus and chronic pelvic pain. In this study, TVBF/EStim was evaluated in women with pelvic floor muscle spasm associated with urinary symptoms. Fifty-two women underwent therapy with TVBF/EStim and reported a mean symptom improvement of 64.5%.