Cervicocerebral arterial dissections (CAD) are an important cause of strokes in younger patients accounting for nearly 20% of strokes in patients under the age of 45 years. Extracranial internal carotid artery dissections comprise 70%–80% and extracranial vertebral dissections account for about 15% of all CAD. Aetiopathogenesis of CAD is incompletely understood, though trauma, respiratory infections, and underlying arteriopathy are considered important. A typical picture of local pain, headache, and ipsilateral Horner’s syndrome followed after several hours by cerebral or retinal ischaemia is rare. Doppler ultrasound, MRI/MRA, and CT angiography are useful non-invasive diagnostic tests. The treatment of extracranial CAD is mainly medical using anticoagulants or antiplatelet agents although controlled studies to show their effectiveness are lacking. The prognosis of extracranial CAD is generally much better than that of the intracranial CAD. Recurrences are rare in CAD.

Background: Iron deficiency anaemia (IDA) is a recognised feature of coeliac disease in adults and can be its only presentation. Objective: To determine the yield of routine distal duodenal biopsies in diagnosing coeliac disease in adult and elderly patients with IDA whose endoscopy revealed no upper gastrointestinal cause of iron deficiency. Study design: Prospective study in a teaching hospital endoscopy unit. Method: Altogether 504 consecutive patients with IDA, aged 16-80 years, attending for endoscopy were included in this study. At least two distal duodenal biopsies were taken if endoscopy revealed no cause of iron deficiency. Result: In nine (1.8%) patients duodenal biopsies revealed typical histological features of coeliac disease. Of these, five patients were above 65 years old. Conclusion: In adult and elderly patients undergoing endoscopy for IDA, the endoscopist should take distal duodenal biopsies to exclude coeliac disease if no upper gastrointestinal cause of anaemia is found. Coeliac disease is not an uncommon cause of IDA in patients .65 years of age and a history of chronic diarrhoea increases diagnostic yield in this age group.

Parkinson’s disease is often recognised as a motor disease characterised by rest tremor, rigidity, bradykinesia, and postural disturbances. However, there are several non-motor aspects of the disease that are of at least equal importance in the management of patients with Parkinson’s disease. They include depression, cognitive impairment, anxiety, and psychosis among others. It is important to recognise them, as they are common and they contribute significantly to patients’ morbidity, quality of life, and institutionalisation to long term care homes. In addition to the disease duration and severity, other factors including drugs may contribute to their occurrence. Pathogenesis of these aspects is not fully understood, though there has been a significant increase in the knowledge in recent years. Management of these aspects involves a multidisciplinary approach.

Acute confusional states in the older patient often have a remediable cause. Every effort should be made to ascertain the cause so that appropriate treatment can be given and future episodes prevented. A patient is described who presented with recurrent episodes of acute psychosis after ingestion of Atropa belladonna (deadly nightshade).A 70 year old Asian woman with a previous history of "schizophreniform" disorder was admitted with a 24 hour history of confusion associated with inability to concentrate, visual hallucinations, delusions, inappropriate laughter, dizziness, and headache. There was no fever, ear discharge, skin rash, herpetic eruption, or any reported change in medication recently. The patient had been diagnosed with recurrent psychosis on account of three such episodes in the preceding three years; each episode had lasted several days. On examination she was disorientated in time, place, and person. She was afebrile, tachycardic, and her pupils were dilated. Both fundi were normal and signs of meningeal irritation were absent. Routine full blood count, renal and liver function tests, urine dipstick, urine and blood cultures, chest radiography, electrocardiography, and cerebrospinal fluid examination (on two separate occasions) were unremarkable. Computed tomography of the brain, viral and bacterial studies of blood, and cerebrospinal fluid were negative. The symptoms were confirmed to be due to ingestion of berries, which the patient's daughter brought in the next day. The berries grew on a wild shrub close to the patient's residence (fig 1). As on previous occasions the symptoms had followed ingestion of similar berries in the autumn months. The berries were identified as Atropa belladonna or "deadly nightshade". Chemical analysis of her blood and the berries identified high concentrations of L-atropine, DL-hyoscynamine, and hyoscine. Over the next 48 hours she gradually improved with supportive treatment and had returned to normal by the fourth day of her hospital admission. The public health department was duly informed about the presence of the shrubs.

Background: Unsedated oesophagogastroduodenoscopy (OGD) is considered by most endoscopists to be a quick, safe, and well tolerated procedure. Older patients are said to tolerate it better than younger patients. However, patients' perception of the discomfort for the unsedated OGD has not been well studied.Objective: This study was undertaken to compare (1) patients' perception of discomfort with the endoscopist's perception of patients' discomfort for the unsedated OGD, (2) tolerability between older (>75 years) and younger (,75 years) patients. Design and subjects: A total of 130 consecutive patients attending a day case endoscopy unit were recruited for the study. The patients and endoscopist recorded their assessment using a visual analogue scale (VAS). The results were analysed using non-parametric tests. Thirty patients were excluded from the study based on exclusion criteria. Sixty three (57%) patients were aged >75 years and 37 (43%) were ,75 years. Results: A significant difference was noted between patients' perception of the discomfort and the endoscopist's assessment of the patient's discomfort as suggested by the overall higher VAS scores for patients (median 4.9, SD 2.6) than those of the endoscopist (median 2.2, SD 1.2), giving a significant difference in median VAS score of 3.4 (p,0.001). Older and younger patients had similar scores, with median (SD) VAS scores of 4.8 (2.5) for >75 years and 4.9 (2.8) for ,75 years. The endoscopist's median scores for these two groups were 2.2 (1.2) and 2.1 (1.3), respectively. Conclusions: Patients' discomfort during OGD performed without sedation was greatly underestimated by the endoscopist. There was no significant difference in acceptability between old and the young patients.

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