Category Archives: Cholesterol

WHO warns over measles immunisation rates as cases rise 400% across Europe

2017 saw more than 21,000 cases and 35 deaths, with large outbreaks in one in four countries, says World Health Organisation

Confidence in the measles, mumps and rubella (MMR) vaccine was damaged following discredited claims linking it to autism.


Confidence in the measles, mumps and rubella (MMR) vaccine was damaged following discredited claims linking it to autism. Photograph: Alamy Stock Photo

Measles cases have soared across Europe over the last year, with large outbreaks affecting one in four countries, according to the World Health Organisation (WHO) which is concerned by low rates of immunisation against the disease.

WHO Europe says there has been a 400% increase during 2017, with more than 21,000 cases and 35 deaths. That will be a major disappointment following the record low in 2016, when there were just 5,273 cases in Europe.

“Every new person affected by measles in Europe reminds us that unvaccinated children and adults, regardless of where they live, remain at risk of catching the disease and spreading it to others who may not be able to get vaccinated,” said Dr Zsuzsanna Jakab, WHO regional director for Europe. “Over 20,000 cases of measles, and 35 lives lost in 2017 alone, are a tragedy we simply cannot accept.”

Measles can kill or cause long-term damage. One in every thousand children affected develops encephalitis, which is swelling of the brain and can lead to deafness or learning difficulties.

Measles is targeted for elimination around the world, because of the efficacy of the vaccine, but it has been bedevilled by regular outbreaks. WHO said there were large outbreaks last year in 15 of the 53 countries in the European region. Romania was worst affected with 5,562 cases, followed by Italy with 5,006 and Ukraine with 4,767.

Immunisation in those countries has hit a number of problems in recent years. There have been declines in overall routine immunisation coverage, consistently low coverage among some marginalised groups, interruptions in vaccine supply or underperforming disease surveillance systems.

Greece (967), Germany (927), Serbia (702), Tajikistan (649), France (520), the Russian Federation (408), Belgium (369), the United Kingdom (282), Bulgaria (167), Spain (152), Czechia (146) and Switzerland (105) also experienced large outbreaks, many of which were in decline by the close of 2017.

Confidence in the MMR – measles, mumps and rubella – vaccine and in immunisation generally has been an issue in Europe and in the United States following the discredited claims of the researcher Andrew Wakefield, who linked the MMR to the development of autism.

UK hits visa cap on skilled workers for third month in row

NHS and other key employers face staffing crisis as Home Office refuses visa applications

Home Office UK visas & immigration building in Croydon


The cap on skilled worker numbers operates on an annual quota of 20,700 with a fixed number of spaces available each month. Photograph: Alamy Stock Photo

Britain has hit its cap on visas for skilled non-European workers for an unprecedented third month in a row, deepening the staffing crisis facing the NHS and other key employers.

When the monthly quota was reached in December and January for the first time in seven years immigration lawyers had expected it would prove to be a blip, but they now fear it is turning into a long-term problem.

More than a third of the tier-2 work visas issued by the Home Office go to medical and other staff recruited to work in the NHS. Migration experts expect that among the first group to be turned away will be doctors and other healthcare staff, software developers and scientists.

The next set of quarterly immigration figures will be published on Thursday. They are expected to show increasing evidence of a “Brexodus” over the past year, with an accelerating decline in the numbers of EU nationals coming to work in Britain while increasing numbers return home.

The Home Office sent out hundreds of emails to UK employers and businesses last week telling them that their applications for the certificates of sponsorship required to recruit mostly highly skilled workers from outside the EU had been refused because they did not meet the minimum points score set for the February quota.

The cap on skilled worker numbers operates on an annual quota of 20,700 with a fixed number of spaces available each month. Until last December the monthly quota had only been exceeded in one month since the cap was introduced by Theresa May as home secretary in 2011.

The Home Office confirmed that the minimum salary for a job to qualify for a skilled work visa was normally £30,000, or £20,800 for a graduate recruit. However, in December it was set at £55,000 and in January tier-2 visa applications for jobs paying less than £46,000 a year were refused unless they were PhD-level roles or were for jobs on the official shortage occupation lists.

The points-based immigration system prioritises applicants according to their advertised salary, with the minimum annual pay changing according to the number of applicants above the quota and their points rating. This hits the NHS particularly hard.

Q&A

Does the UK have enough doctors and nurses?

The UK has fewer doctors and nurses than many other comparable countries both in Europe and worldwide. According to the Organisation for Economic Co-operation and Development (OECD), Britain comes 24th in a league table of 34 member countries in terms of the number of doctors per capita. Greece, Austria and Norway have the most; the three countries with the fewest are Turkey, Chile and Mexico. Jeremy Hunt, the health secretary, regularly points out that the NHS in England has more doctors and nurses than when the Conservatives came to power in 2010. That is true, although there are now fewer district nurses, mental health nurses and other types of health professionals.

NHS unions and health thinktanks point out that rises in NHS staff’s workloads have outstripped the increases in overall staff numbers. Hospital bosses say understaffing is now their number one problem, even ahead of lack of money and pressure to meet exacting NHS-wide performance targets. Hunt has recently acknowledged that, and Health Education England, the NHS’s staffing and training agency, last month published a workforce strategy intended to tackle the problem.

Read a full Q&A on the NHS winter crisis

Nichola Carter, an immigration specialist at Carter Thomas solicitors, said: “From the information I’m receiving it is starting to look like the threshold for rejection in February could be around the £50k mark. Initially it was thought that December and January were just blips. Now it’s starting to feel like this could be a long-term issue.”

She said employers were increasingly seeking to sponsor skilled workers because they needed certainty in their recruitment plans.

“The government has to step in now and either change the points or the criteria or create exemptions. Calls for NHS workers to be removed have already been made.”

Carter added that she had seen two applications refused for clients last week: a software developer and a designer for a bespoke luxury goods manufacturer.

All jobs offered to skilled workers from outside the EU that are not on the official shortage occupation lists have to be advertised in Britain first for a set period unless the salary will be at least £159,600.

“I know of employers who are now willing to pay £65,000 for a job they were previously offering a salary of £35,000 for just to make sure they get a visa in the next round of allocations,” Carter added.

The immigration law firm Fragomen confirmed that the cap had been reached for the third time. “Since the quota has been exceeded three times consecutively it is highly likely to be exceeded again next month due to the volume of reapplications. Applicants can reapply next month provided the job advertisement is still valid. There is no right of appeal following refusal.”

Danny Mortimer, the chief executive of NHS Employers, has pressed the Home Office to exempt medical staff from the quota, saying NHS organisations were “increasingly concerned at their inability to obtain permits for essential medical colleagues”.

A doctor on an NHS ward


More than a third of tier-2 work visas issued by the Home Office go to medical and other staff recruited by the NHS. Photograph: Peter Byrne/PA

A Home Office spokesperson said: “It is important that our immigration system works in the national interest, ensuring that employers look first to the UK resident labour market before recruiting from overseas.

“The tier 2 visa route is intended to fill gaps in the labour market. When demand exceeds the month’s allocation of tier 2 (general) visas, priority is given to applicants filling a shortage or PhD-level occupations.

“The published shortage lists include a range of medical professionals, including consultants specialising in clinical radiology and emergency medicine, and we estimate that around a third of all tier 2 places go to the NHS.”

DIY faecal transplants carry risks including HIV and hepatitis, warn experts

Faecal transplants have been used in medical settings to tackle superbugs, but following YouTube videos at home is too risky, say researchers

Links between microbes in the gut and a host of health problems have led to growing interest in the idea of faecal transplants.


Links between microbes in the gut and a host of health problems have led to growing interest in the idea of faecal transplants. Photograph: Getty Images

Concerns have been raised about the growing trend for DIY faecal transplants, with experts fearing such attempts could put individuals at an increased risk of HIV and hepatitis as well as conditions ranging from Parkinson’s and multiple sclerosis to obesity and sleep disorders.

The transfer of faeces from one human to another has gained attention as a growing number of studies have suggested links between microbes in the gut and a host of health problems, from autoimmune diseases to anxiety.

Currently, implanting a “healthy” gut microbiome into a recipient is one of the treatments used in medical settings to tackle the superbug Clostridium difficile. But with some claiming the procedure could help a wide range of conditions, a plethora of YouTube videos have sprung up revealing in how to carry out faecal transplants at home.

Experts have raised concerns, stressing that screening is vital to prevent problematic microbes, including those linked to MS and Parkinson’s, from being transferred to recipients – a particular concern for those attempting a DIY procedure.

“Given that we know that these are things that in mice, at least, can be transmitted by the microbiome, it is not cause for panic yet, but it is certainly cause for concern that the same might be true in humans,” said Rob Knight, professor of paediatrics, computer science and engineering at the University of California San Diego, who is presenting his latest work on the microbiome at the meeting of the American Association for the Advancement of Science in Austin this week.

While research has long suggested that obesity could be linked to the microbiome, recent studies have suggested a host of other issues, including sleep disorders, could also be associated with changes in the gut flora. Furthermore, Knight noted that studies have revealed that there are differences in the microbiomes of those with and without conditions such as multiple sclerosis and Parkinson’s disease. “[Very recently] we were able to show that you can transmit aspects of the disease from humans into mice by transmitting the microbiome,” said Knight, although he noted that a particular genetic change was needed in the mice in the case of Parkinson’s.

Currently faecal transplant is used as a treatment for Clostridium difficile infections – the goal being to reseed the gut with “good” microbes. Donors are screened for conditions including infectious diseases and parasites, while those with autoimmune diseases, a history of cancer or gastrointestinal problems are excluded as donors. However Knight stressed that with research throwing up an ever-increasing number of conditions linked to the microbiome, screening is set to become increasingly important. “Tests that look at the whole microbiome profile are still at the research stage,” he said.

The risk of inadvertently transferring either diseases or problematic microbes, he added, are even greater for individuals taking matters into their own hands – a trend Knight said is growing. “It is regrettably something that is increasing in frequency,” he said, noting that in particular those with incurable diseases are often willing to try anything, even if evidence for a procedure is scanty.

The fear that faecal transplants could give recipients more than they bargained for is underscored by a case study from 2015 in which a woman undergoing a faecal transplant for a C. difficile infection ended up becoming obese after receiving a stool sample from her healthy but overweight daughter.

Knight added that his team is currently part of a project that will “Basically capture stool from donors and recipients of faecal transplants on a national scale in the United states so we can get a sense of long term outcomes not just short term outcomes.”

The team is also joining forces with IBM’s Watson to develop a system that can help researchers, patients, reporters and doctors sift and understand the growing body of research on the microbiome. “Human intelligence just can’t keep up with all the literature that is coming out on the microbiome, and so if we can use artificial intelligence to advance our capabilities that will make it really helpful,” Knight said.

Prescription of opioid drugs continues to rise in England

Doctors give patients drugs such as tramadol despite risks of addiction and ineffectiveness when treating chronic pain

Tramadol packet


Tramadol was the most commonly prescribed opioid in England from August 2010 to February 2014. Photograph: Jeremy Durkin/Rex Features

The prescription of opioid drugs by GPs in England is steadily rising, especially in more deprived communities, even though they are potentially dangerous and do not work for chronic pain, a new study reveals.

The study shines an alarming new light on the legal use of opioids in England; potentially inappropriate yet sanctioned by doctors. It also reveals a north-south divide. Nine out of 10 of the highest-prescribing regions were in the north. Prescriptions of painkillers were higher in areas of socio-economic deprivation.

Opioids have hit the headlines mainly because of their abuse in the United States. The authors of the study in the British Journal of General Practice, which uses official government data, say opioids are rightly given to people to cope with cancer pain and short-lived acute pain. But as the authors also point out, the widespread prescribing of opioids for people with long-term pain is controversial because “opioids are ineffective in much chronic pain beyond modest effects in the short term”.

Q&A

Why is there an opioid crisis in America?

Almost 100 people are dying every day across America from opioid overdoses – more than car crashes and shootings combined. The majority of these fatalities reveal widespread addiction to powerful prescription painkillers. The crisis unfolded in the mid-90s when the US pharmaceutical industry began marketing legal narcotics, particularly OxyContin, to treat everyday pain. This slow-release opioid was vigorously promoted to doctors and, amid lax regulation and slick sales tactics, people were assured it was safe. But the drug was akin to luxury morphine, doled out like super aspirin, and highly addictive. What resulted was a commercial triumph and a public health tragedy. Belated efforts to rein in distribution fueled a resurgence of heroin and the emergence of a deadly, black market version of the synthetic opioid fentanyl. The crisis is so deep because it affects all races, regions and incomes

They are also potentially dangerous. Luke Mordecai, a pain research fellow at University College London Hospital and the lead author of the study, is calling for a register of all those who are taking the equivalent of more than 120mg of morphine a day. “There should be a national database to keep track of these people,” he said. “There is very high morbidity and mortality [among them], a lot of it avoidable.”

The gold standard, he said, was treatment by a multi-disciplinary team of pain experts, including a specialist consultant, nurse, psychologist and physiotherapist. Yet that is rare: only 40% of pain consultants provide it. Many people could come off opioids altogether with the best care.

Chronic pain is very common. As many as one in seven people have complained of moderate to severely disabling pain and the numbers rise with age. Opioids do not work, but, says the study, many GPs prescribe them because they think it is unethical to refuse their patients painkillers.

The study looks at the total amount prescribed in grams of each of eight common opioid drugs and finds a rise in six of them. Mordecai talked of “a steady increase” but declined to quantify it in percentage terms because of the relatively short time period.

The most prescribed opioid drug in England over the 43 months of the study, from August 2010 to February 2014, was tramadol. It is stronger than over-the-counter codeine but does not have the stigma of the powerful morphine.

“It is not seen as a strong opiate although actually I think it really is,” said Mordecai. “It is the first port of call for troublesome pain but it can become quite addictive.”

Tramadol is implicated in a rising number of deaths due to drug misuse – in Northern Ireland up from 9% to 40% in 2011. In England it was found responsible for 132 deaths in 2010 but 240 in 2014. In that year, it was reclassified as schedule 3 and prescription was limited to one month’s supply at a time. But, the study’s authors note, that failed to work with codeine in Australia. Prescriptions of buprenorphine, oxycodone, codeine and morphine also rose, the study finds. There was a small rise in fentanyl prescription, while prescribing of methadone and dihydrocodeine dropped.

Mordecai said more studies would be needed to find out why prescriptions were highest in more deprived areas and in the north. “We know that chronic pain affects more people of low socio-economic status,” he said. The paper notes that an association has also been found between unemployment and poor outcomes in chronic pain.

“It is something that needs a great deal more work. People of higher socio-economic status might have access to better facilities and ask more questions or want the best treatment possible,” he said.

“This study exposes increasing rates of prescription of a class of drugs whose use for chronic pain is controversial, with potential for abuse, and an association with serious adverse effects and premature death,” concludes the paper. “The authors call on policymakers to identify the reasons for this variation to enable avoidable harm to be addressed.”

Prescription of opioid drugs continues to rise in England

Doctors give patients drugs such as tramadol despite risks of addiction and ineffectiveness when treating chronic pain

Tramadol packet


Tramadol was the most commonly prescribed opioid in England from August 2010 to February 2014. Photograph: Jeremy Durkin/Rex Features

The prescription of opioid drugs by GPs in England is steadily rising, especially in more deprived communities, even though they are potentially dangerous and do not work for chronic pain, a new study reveals.

The study shines an alarming new light on the legal use of opioids in England; potentially inappropriate yet sanctioned by doctors. It also reveals a north-south divide. Nine out of 10 of the highest-prescribing regions were in the north. Prescriptions of painkillers were higher in areas of socio-economic deprivation.

Opioids have hit the headlines mainly because of their abuse in the United States. The authors of the study in the British Journal of General Practice, which uses official government data, say opioids are rightly given to people to cope with cancer pain and short-lived acute pain. But as the authors also point out, the widespread prescribing of opioids for people with long-term pain is controversial because “opioids are ineffective in much chronic pain beyond modest effects in the short term”.

Q&A

Why is there an opioid crisis in America?

Almost 100 people are dying every day across America from opioid overdoses – more than car crashes and shootings combined. The majority of these fatalities reveal widespread addiction to powerful prescription painkillers. The crisis unfolded in the mid-90s when the US pharmaceutical industry began marketing legal narcotics, particularly OxyContin, to treat everyday pain. This slow-release opioid was vigorously promoted to doctors and, amid lax regulation and slick sales tactics, people were assured it was safe. But the drug was akin to luxury morphine, doled out like super aspirin, and highly addictive. What resulted was a commercial triumph and a public health tragedy. Belated efforts to rein in distribution fueled a resurgence of heroin and the emergence of a deadly, black market version of the synthetic opioid fentanyl. The crisis is so deep because it affects all races, regions and incomes

They are also potentially dangerous. Luke Mordecai, a pain research fellow at University College London Hospital and the lead author of the study, is calling for a register of all those who are taking the equivalent of more than 120mg of morphine a day. “There should be a national database to keep track of these people,” he said. “There is very high morbidity and mortality [among them], a lot of it avoidable.”

The gold standard, he said, was treatment by a multi-disciplinary team of pain experts, including a specialist consultant, nurse, psychologist and physiotherapist. Yet that is rare: only 40% of pain consultants provide it. Many people could come off opioids altogether with the best care.

Chronic pain is very common. As many as one in seven people have complained of moderate to severely disabling pain and the numbers rise with age. Opioids do not work, but, says the study, many GPs prescribe them because they think it is unethical to refuse their patients painkillers.

The study looks at the total amount prescribed in grams of each of eight common opioid drugs and finds a rise in six of them. Mordecai talked of “a steady increase” but declined to quantify it in percentage terms because of the relatively short time period.

The most prescribed opioid drug in England over the 43 months of the study, from August 2010 to February 2014, was tramadol. It is stronger than over-the-counter codeine but does not have the stigma of the powerful morphine.

“It is not seen as a strong opiate although actually I think it really is,” said Mordecai. “It is the first port of call for troublesome pain but it can become quite addictive.”

Tramadol is implicated in a rising number of deaths due to drug misuse – in Northern Ireland up from 9% to 40% in 2011. In England it was found responsible for 132 deaths in 2010 but 240 in 2014. In that year, it was reclassified as schedule 3 and prescription was limited to one month’s supply at a time. But, the study’s authors note, that failed to work with codeine in Australia. Prescriptions of buprenorphine, oxycodone, codeine and morphine also rose, the study finds. There was a small rise in fentanyl prescription, while prescribing of methadone and dihydrocodeine dropped.

Mordecai said more studies would be needed to find out why prescriptions were highest in more deprived areas and in the north. “We know that chronic pain affects more people of low socio-economic status,” he said. The paper notes that an association has also been found between unemployment and poor outcomes in chronic pain.

“It is something that needs a great deal more work. People of higher socio-economic status might have access to better facilities and ask more questions or want the best treatment possible,” he said.

“This study exposes increasing rates of prescription of a class of drugs whose use for chronic pain is controversial, with potential for abuse, and an association with serious adverse effects and premature death,” concludes the paper. “The authors call on policymakers to identify the reasons for this variation to enable avoidable harm to be addressed.”

Prescription of opioid drugs continues to rise in England

Doctors give patients drugs such as tramadol despite risks of addiction and ineffectiveness when treating chronic pain

Tramadol packet


Tramadol was the most commonly prescribed opioid in England from August 2010 to February 2014. Photograph: Jeremy Durkin/Rex Features

The prescription of opioid drugs by GPs in England is steadily rising, especially in more deprived communities, even though they are potentially dangerous and do not work for chronic pain, a new study reveals.

The study shines an alarming new light on the legal use of opioids in England; potentially inappropriate yet sanctioned by doctors. It also reveals a north-south divide. Nine out of 10 of the highest-prescribing regions were in the north. Prescriptions of painkillers were higher in areas of socio-economic deprivation.

Opioids have hit the headlines mainly because of their abuse in the United States. The authors of the study in the British Journal of General Practice, which uses official government data, say opioids are rightly given to people to cope with cancer pain and short-lived acute pain. But as the authors also point out, the widespread prescribing of opioids for people with long-term pain is controversial because “opioids are ineffective in much chronic pain beyond modest effects in the short term”.

Q&A

Why is there an opioid crisis in America?

Almost 100 people are dying every day across America from opioid overdoses – more than car crashes and shootings combined. The majority of these fatalities reveal widespread addiction to powerful prescription painkillers. The crisis unfolded in the mid-90s when the US pharmaceutical industry began marketing legal narcotics, particularly OxyContin, to treat everyday pain. This slow-release opioid was vigorously promoted to doctors and, amid lax regulation and slick sales tactics, people were assured it was safe. But the drug was akin to luxury morphine, doled out like super aspirin, and highly addictive. What resulted was a commercial triumph and a public health tragedy. Belated efforts to rein in distribution fueled a resurgence of heroin and the emergence of a deadly, black market version of the synthetic opioid fentanyl. The crisis is so deep because it affects all races, regions and incomes

They are also potentially dangerous. Luke Mordecai, a pain research fellow at University College London Hospital and the lead author of the study, is calling for a register of all those who are taking the equivalent of more than 120mg of morphine a day. “There should be a national database to keep track of these people,” he said. “There is very high morbidity and mortality [among them], a lot of it avoidable.”

The gold standard, he said, was treatment by a multi-disciplinary team of pain experts, including a specialist consultant, nurse, psychologist and physiotherapist. Yet that is rare: only 40% of pain consultants provide it. Many people could come off opioids altogether with the best care.

Chronic pain is very common. As many as one in seven people have complained of moderate to severely disabling pain and the numbers rise with age. Opioids do not work, but, says the study, many GPs prescribe them because they think it is unethical to refuse their patients painkillers.

The study looks at the total amount prescribed in grams of each of eight common opioid drugs and finds a rise in six of them. Mordecai talked of “a steady increase” but declined to quantify it in percentage terms because of the relatively short time period.

The most prescribed opioid drug in England over the 43 months of the study, from August 2010 to February 2014, was tramadol. It is stronger than over-the-counter codeine but does not have the stigma of the powerful morphine.

“It is not seen as a strong opiate although actually I think it really is,” said Mordecai. “It is the first port of call for troublesome pain but it can become quite addictive.”

Tramadol is implicated in a rising number of deaths due to drug misuse – in Northern Ireland up from 9% to 40% in 2011. In England it was found responsible for 132 deaths in 2010 but 240 in 2014. In that year, it was reclassified as schedule 3 and prescription was limited to one month’s supply at a time. But, the study’s authors note, that failed to work with codeine in Australia. Prescriptions of buprenorphine, oxycodone, codeine and morphine also rose, the study finds. There was a small rise in fentanyl prescription, while prescribing of methadone and dihydrocodeine dropped.

Mordecai said more studies would be needed to find out why prescriptions were highest in more deprived areas and in the north. “We know that chronic pain affects more people of low socio-economic status,” he said. The paper notes that an association has also been found between unemployment and poor outcomes in chronic pain.

“It is something that needs a great deal more work. People of higher socio-economic status might have access to better facilities and ask more questions or want the best treatment possible,” he said.

“This study exposes increasing rates of prescription of a class of drugs whose use for chronic pain is controversial, with potential for abuse, and an association with serious adverse effects and premature death,” concludes the paper. “The authors call on policymakers to identify the reasons for this variation to enable avoidable harm to be addressed.”

It’s very rare to wake up during a general anaesthetic | Letters

Anaesthetists respond to a recent Guardian article

An anaesthetist administering general anaesthetic in France


An anaesthetist administering general anaesthetic in France. Photograph: BSIP/UIG via Getty Images

Accidental awareness (when a patient becomes conscious during a general anaesthetic) is an incredibly important issue to both patients and anaesthetists (The long read, 9 February). Patients undergoing surgery can be assured that it is highly uncommon to wake up during a general anaesthetic.

The largest ever research study (NAP5) performed on this topic was carried out in 2014 by the Royal College of Anaesthetists and the Association of Anaesthetists of Great Britain and Ireland. It showed that approximately one person in 20,000 reported awareness, and it most commonly occurred before surgery started or after it finished.

Anaesthetists work extremely hard to ensure that the approximately 3m general anaesthetics performed each year deliver safe, comfortable and stress-free surgery – we always put patient safety first. Anaesthesia is a highly complex medical speciality and all anaesthetists undergo rigorous education and training programmes and continuous performance appraisals.

The risk of accidental awareness differs according to certain patient characteristics and the type of surgery and anaesthetic the patient requires. Our 2014 NAP5 report makes clear recommendations on what steps anaesthetists can take to minimise the risk of awareness and address any psychological harm from these rare events.

Important and accurate information about anaesthesia can be found online at http://bit.ly/rcoa_patientinfo
Dr Liam Brennan President, Royal College of Anaesthetists
Dr Paul Clyburn President, Association of Anaesthetists of Great Britain and Ireland

General anaesthetics do not act by “reacting with the slick membranes of the nerve cells in the brain”. It was shown in 1979 by Franks and Lieb that general anaesthetics had no effect on membranes at physiological concentrations. In 1984 they showed that the anaesthetic molecule, halothane, inhibited the action of the protein luciferase at anaesthetic concentrations similar to those that anaesthetised animals. The most common general anaesthetic, propofol, was shown in 2013 by a team at Imperial College London to interact specifically with one site on a complex five-chain protein present in brain cells called Gamma-Amino Butyric Acid Receptor type A (GABAR-A). Another anaesthetic, etomidate, interacts with the same protein but at a different site. These interactions cause the receptor to remain in the “open” state for a longer period of time, thereby allowing the entry of chloride ions into the cell and “hyperpolarising” the cell, causing it to fire less often. The details of the circuitry that is then involved in shutting down areas of the brain responsible for consciousness are still being elucidated, but it probably involves the thalamus, one of the major structures deep in the brain.

Other “hypnotic” drugs in use by anaesthetists such as nitrous oxide, ketamine, and the noble gas xenon, have been known since the late 1990s to act on different proteins in the brain, called NMDA receptors.

While the first public demonstration of anaesthesia in western society might have been in 1846, it is worth noting that the Chinese surgeon Hua Tuo (c 140–208) used a concoction of drugs called mafeisan to allow the opening of patients’ abdomens with little pain. The Japanese surgeon Seishu Hanaoka (1760-1835) used a similar combination of drugs to mafeisan which were given orally to perform major surgery. In 1805 he carried out a number of radical operations for breast cancer.
Dr Chris Edge
Consultant anaesthetist, Royal Berkshire NHS Foundation Trust; honorary senior lecturer, Department of Biophysics, Imperial College, London

Join the debate – email guardian.letters@theguardian.com

Read more Guardian letters – click here to visit gu.com/letters

It’s very rare to wake up during a general anaesthetic | Letters

Anaesthetists respond to a recent Guardian article

An anaesthetist administering general anaesthetic in France


An anaesthetist administering general anaesthetic in France. Photograph: BSIP/UIG via Getty Images

Accidental awareness (when a patient becomes conscious during a general anaesthetic) is an incredibly important issue to both patients and anaesthetists (The long read, 9 February). Patients undergoing surgery can be assured that it is highly uncommon to wake up during a general anaesthetic.

The largest ever research study (NAP5) performed on this topic was carried out in 2014 by the Royal College of Anaesthetists and the Association of Anaesthetists of Great Britain and Ireland. It showed that approximately one person in 20,000 reported awareness, and it most commonly occurred before surgery started or after it finished.

Anaesthetists work extremely hard to ensure that the approximately 3m general anaesthetics performed each year deliver safe, comfortable and stress-free surgery – we always put patient safety first. Anaesthesia is a highly complex medical speciality and all anaesthetists undergo rigorous education and training programmes and continuous performance appraisals.

The risk of accidental awareness differs according to certain patient characteristics and the type of surgery and anaesthetic the patient requires. Our 2014 NAP5 report makes clear recommendations on what steps anaesthetists can take to minimise the risk of awareness and address any psychological harm from these rare events.

Important and accurate information about anaesthesia can be found online at http://bit.ly/rcoa_patientinfo
Dr Liam Brennan President, Royal College of Anaesthetists
Dr Paul Clyburn President, Association of Anaesthetists of Great Britain and Ireland

General anaesthetics do not act by “reacting with the slick membranes of the nerve cells in the brain”. It was shown in 1979 by Franks and Lieb that general anaesthetics had no effect on membranes at physiological concentrations. In 1984 they showed that the anaesthetic molecule, halothane, inhibited the action of the protein luciferase at anaesthetic concentrations similar to those that anaesthetised animals. The most common general anaesthetic, propofol, was shown in 2013 by a team at Imperial College London to interact specifically with one site on a complex five-chain protein present in brain cells called Gamma-Amino Butyric Acid Receptor type A (GABAR-A). Another anaesthetic, etomidate, interacts with the same protein but at a different site. These interactions cause the receptor to remain in the “open” state for a longer period of time, thereby allowing the entry of chloride ions into the cell and “hyperpolarising” the cell, causing it to fire less often. The details of the circuitry that is then involved in shutting down areas of the brain responsible for consciousness are still being elucidated, but it probably involves the thalamus, one of the major structures deep in the brain.

Other “hypnotic” drugs in use by anaesthetists such as nitrous oxide, ketamine, and the noble gas xenon, have been known since the late 1990s to act on different proteins in the brain, called NMDA receptors.

While the first public demonstration of anaesthesia in western society might have been in 1846, it is worth noting that the Chinese surgeon Hua Tuo (c 140–208) used a concoction of drugs called mafeisan to allow the opening of patients’ abdomens with little pain. The Japanese surgeon Seishu Hanaoka (1760-1835) used a similar combination of drugs to mafeisan which were given orally to perform major surgery. In 1805 he carried out a number of radical operations for breast cancer.
Dr Chris Edge
Consultant anaesthetist, Royal Berkshire NHS Foundation Trust; honorary senior lecturer, Department of Biophysics, Imperial College, London

Join the debate – email guardian.letters@theguardian.com

Read more Guardian letters – click here to visit gu.com/letters

Parental alcohol abuse linked to child deaths and injuries

One in three child deaths or serious injuries from neglect or abuse linked to alcohol misuse

Person drinking bottle of beer


The study, commissioned by a cross-bench group of MPs and peers, found that more than half of councils did not have a strategy to help children of alcoholics. Photograph: David Jones/PA

More than one in three deaths or serious injuries suffered by a child through neglect or abuse is linked to parental drinking, a study has found.

A report commissioned by a cross-bench group of MPs and peers found that alcohol abuse by parents was behind horrific problems for children and warned that budgets of alcohol and drug treatment programmes were being cut.

“Parental alcohol misuse scars kids for life and can lead many into a life of drinking too much themselves,” said Liam Byrne, the Labour MP and chairman of the All-Party Group for Children of Alcoholics.

“Millions of parents drink too much and their misuse of alcohol causes horrific problems for their children.”

Alcohol misuse was implicated in 37% of cases of a child’s death or serious injury after abuse or neglect between 2011 and 2014, the study found.

More than half of councils did not have a strategy to help children of alcoholics. Referrals to alcohol treatment services were falling in more than 50% of local authorities, according to information released under freedom of information laws.

The study also found that 92% of the 53 councils that responded were cutting budgets for alcohol and drug treatment services. Cuts differed in severity, from £9.6m – or 58.1% – in Lancashire, to £87,000 – or 1.1% – in Wolverhampton. The average cut to local authority funding was around £198,000.

The group also found that 15% of children had their bedtime routine disrupted due to their parents’ drinking and 18% were embarrassed at seeing their parent drunk.

The report called for better funding to help youngsters affected by parents who drink. Byrne, who lost his father to alcoholism in 2015, said the group’s campaign had won a “new commitment from government for a national strategy to stop parental alcohol misuse”.

He added that the report showed “just why the government must act fast to put an effective plan in place”.

The study, published by the Parliamentary Office of Science and Technology following a request by the all-party parliamentary group for children of alcoholics, found that 61% of care applications in England involved misuse of alcohol and/or drugs.

Children living with alcohol-dependent parents reported feeling socially isolated and reluctant to seek help, due to feelings of stigma, shame and guilt about not wanting to betray parents, the study found.

A Department of Health and Social Care spokeswoman said: “We are acutely aware of the impact some parents drinking can have on their children – that’s why work is well underway on a new children of alcoholics strategy, which will look at what further support we can provide to families to tackle alcohol harms.

“This comes in addition to our new higher duties to target cheap, high strength cider and the UK chief medical officers’ guidelines, which help adults make informed decisions about their drinking.”

The shadow health secretary, Labour’s Jonathan Ashworth, said: “This report lays bare the real and damaging impact parental drinking can have on children. The findings of this report make me more determined than ever to prioritise tackling addiction while supporting the children and families affected.

“Having recently spoken about my own father’s drinking problems, I welcomed the government’s commitment to support children of alcoholics. However, this report emphasises there is still a long way to go. Almost all local authorities have cut treatment services and many still do not have strategies for children of alcoholics in place.

“It’s time we as a society took these issues more seriously so that children no longer need suffer in silence.”

‘Suddenly my world would flip’: the woman who is permanently lost

Sharon’s world is regularly reversed by a rare brain malfunction. Now neurologists, and Wonder Woman, have come to the rescue

An image and a flipped image of Sharon, who has a rare brain condition


‘Your world hasn’t flipped but your perception of it has,’ says Sharon. Photograph: Benjamin Rasmussen for the Guardian

In 1952, when she was a child, Sharon was playing in the front garden. She was blindfolded while her friends ran around her, laughing, trying not to be caught in a game of blind man’s buff. Sharon grabbed hold of someone’s sleeve and whipped off the scarf that covered her eyes. “You’re it!” she shouted.

Then she blinked and looked around her. She panicked. The house and the street looked different. She had no idea where she was. Sharon ran into the back garden and discovered her mother sitting in a lawn chair.

“What are you doing here?” Sharon asked. “Whose back yard is this? Where am I?”

Her mother looked at her, puzzled. “What’s wrong with you?” she asked her daughter. “This is our house!”


Her mum pointed a finger at Sharon, aged five: ‘Don’t tell anyone about this. They’ll say you’re a witch and burn you’

Sharon told her mother that everything around her looked different. Her mother looked irritated. Sharon didn’t understand: why wasn’t her mother helping her?

“I don’t know where this place is, it all looks wrong,” she said. “I’m so confused.”

Her mum looked her in the eye, and pointed a finger at her face.

“Don’t ever tell anybody about this,” she said. “Because they’ll say you’re a witch and burn you.”

***

“I can remember that moment as if it were yesterday,” Sharon says, more than 60 years later. “I was five years old.”

Sharon woke up the next morning knowing that something weird had happened again. It was as though her walls had moved in her sleep. She was in her bedroom but things didn’t look as if they were in the right place. Her door was on the wrong side. “I knew it had to be my bedroom,” she says, “and bits of the room were familiar, but it was all wrong at the same time. Nothing was where I thought it should be.”

Sharon’s disorientation began to occur more frequently, until it became constant. It made finding her way around her neighbourhood and her school impossible. She never mentioned her problem to anyone. Instead, she used her sense of humour and intelligence to complete her education, make friends and get married, without anyone ever knowing she was almost permanently lost.

“I hid it for 25 years,” she says.

***

I meet Sharon at her home in Denver, Colorado. Even here, she can get lost walking between her bathroom and her kitchen.

Sharon has flaming-copper hair, swept into a stylish crop set off by a bright pink blouse. The colours complement her deep-red lipstick. Outside her front door sits a giant metal lobster with a faded ‘Welcome’ sign written across his rusty belly. Inside, her house is open plan and as neat as a pin. Stuck on to her fridge door are pictures of friends, phone numbers, notes from grandchildren, a picture of Wonder Woman and a large photo of a handsome young Italian. It is held up with a magnet that says: “A true friend knows everything about you… and likes you anyway.” A smaller photo, of Sharon and the same man together, arms round each other’s shoulders and smiling at the camera, is pinned above it.

Sharon's fridge with pictures of Dr Giuseppe Iaria and Wonder Woman


Dr Giuseppe Iaria who diagnosed Sharon, and Wonder Woman who inspired her solution, both feature on her fridge. Photograph: Benjamin Rasmussen for the Guardian

“That’s Giuseppe,” says Sharon. “Isn’t he cute? He’s such a gentle and compassionate man. He changed my life.”

As a young post-doc, Giuseppe Iaria was fascinated by navigation. While working at the University of British Columbia, he investigated why some healthy people have a better sense of direction than others. One day, a middle-aged woman, Claire, showed up at his lab complaining of a peculiar problem: she was constantly lost.

Iaria suspected that Claire’s disorientation was the result of another condition. He began ruling out possible options one by one. He knew that inner-ear infections can damage a delicate structure called the labyrinth, causing the sensation that your world is moving around you. Brain tumours, lesions and dementia can damage the hippocampus, which is involved in many types of memory. Or maybe it was epilepsy, sudden bursts of uncontrolled electrical activity in the brain, that was stopping her from being able to memorise directions. It took Iaria and a colleague two years to eliminate all the potential problems. But, as far as their tests showed, Claire was in perfect health.

Claire told Iaria that she hadn’t lost the ability to orientate herself; she’d just never learned it in the first place. She recalled that, from the age of six, she would panic at the supermarket each time her mother disappeared from view. She never left home by herself, because she got lost each time she tried.


Spinning fixes the problem. ‘I go into a cubicle, close my eyes and spin around. It’s my Wonder Woman impression’

As an adult, Claire had figured out how to get to work by taking a particular bus, memorising the stop and a prominent landmark near her office. But her employer was moving to an unfamiliar area, and she had decided it was time to get some professional help.

Iaria routinely encountered disorientation as a symptom of other conditions, but never as a developmental disorder – one that occurs as you grow up. He took Claire for a short walk around the local area. He then handed her detailed directions so she could repeat the route by herself. Claire followed the directions without any mistakes. However, when Iaria asked her to draw a map of the route she had just walked, or of the town in which she lived, she found it impossible. She said she did not have “in my mind a map to report”.

Iaria called her Patient One and named the condition “developmental topographical disorientation”: the inability to generate, and therefore use, a mental map of your surroundings, despite an absence of any brain damage.

Over time, Iaria found others with the same condition. One person told him: “No matter how long I live in the same building, I can never picture in my mind where the bathroom is.”

At 60, Sharon was Iaria’s case number four.

***

Sharon tells me that she was not permanently lost from the age of five. “Some of the time, my world looked perfectly normal and I could navigate perfectly well. But then all of a sudden my world would flip, and I’d become completely disoriented.”

And she never told anyone? “No. Instead I was the class clown. I thought if I could stand up and make the class laugh, they wouldn’t know my secret.” No one ever noticed that most of the time she was lost. “I would follow my friends when we walked to school, and if it happened during class, I’d spend the rest of the lesson trying to memorise the way the room looked so I’d know where everything was the next time it happened.”

One day, when Sharon was still a young girl, she discovered a solution. She was at a friend’s party, and next to play pin the tail on the donkey. “After I spun around, I knew something was horribly wrong. I felt like I was walking in completely the wrong direction.” When she took off the blindfold, she thought, “I know I’m at my friend’s house, but this doesn’t look like my friend’s house.”’


They said I needed to see a psychiatrist – they thought I was crazy. I wanted to die

But when it was her turn to be blindfolded and spun around for a second time, Sharon’s world flipped back to normal. “That’s when I learned that spinning could cause the disorientation. But that it also fixed it.”

“These days I usually try to find the nearest bathroom,” Sharon says. “I go into a cubicle, close my eyes and spin around. When I open my eyes, my world is recognisable again.”

She chuckles and points towards the picture pinned to her fridge. “I call it my Wonder Woman impression.”

Why does she do it in the bathroom?

“Well, what would you think if you saw an old woman standing by her car spinning around in circles with her eyes closed? I always did it in secret because I was humiliated by it.”

***

For most of us, navigating feels easy. But many of Iaria’s patients feel as if they live in a constant “first day”. No matter how much time they spend somewhere, their surroundings never become familiar. Like Claire, many have learned to navigate the most important routes in their life by remembering a specific sequence of turns. But to remember all your journeys this way would place a huge strain on your memory. Instead, we use a dynamic tool, a cognitive map, a kind of internal representation of our surroundings that becomes familiar.

Our cognitive map is created by a number of different cells. There are those that fire only when we pass through a specific location. A nearby cell fires at a different location. Then there are cells that fire only when our head is facing a particular direction, and others that are responsible for where we are in relation to walls and boundaries. One might fire, say, when there’s a wall to the south or when we’re near the edge of a cliff.

We also fill our mental maps with permanent landmarks that are meaningful to us, like the post box at the end of our road, or the bus stop outside our office. There is a part of the brain dedicated to this task – the retrosplenial cortex. The current theory is that the combination of all these cells’ activity creates a map of our world, which is constantly updated to help us find our way around. But when one or more of these regions isn’t working correctly, things can get very confusing.

Sharon drives us to a nearby restaurant for lunch, insisting she knows the way. From her condo we drive around a couple of roundabouts, pass through a set of traffic lights and indicate left then right without a hitch. We turn on to a small highway that runs through the town, the Rocky Mountains dominating the landscape to the west. Sharon tells me that sometimes she’ll be driving into town when she suddenly realises that the mountains are to the north and she’ll know that her world has flipped. Then we fly past the entrance.

Later, when we get there, we sit down and Sharon explains what she sees when her world flips. She tells me to think about a busy street. “Imagine you’ve had a day shopping,” she says. “You come out of the last shop and head left towards the station. All of a sudden, you realise the station is actually on your right, because you were in a shop on the opposite side of the street to where you thought you were. In that split second, you feel momentarily disoriented because the station that you thought should be east is now west. Your world hasn’t flipped but your perception of it has.”

Most people’s brains are surprisingly forgiving. As soon as it gets confused, the brain spins everything around and reorients itself within milliseconds. But that split second in which your mental map doesn’t match with where things actually are is how Sharon feels when her world is flipped.


The doctor looked at me like I was telling a made-up story. She asked how I correct it and I told her I spin around

“I just can’t flip my world back around like you can,” says Sharon. “Unless I do my Wonder Woman impression.”

I ask why we missed the entrance to the restaurant. Sharon explains that it was on a curved road, and that they make her world flip. It has made finding work difficult. Every time she had an interview, she would have to work out in advance where the building was and whether it sat on a curved road. If there were a lot of winding passages in the building itself, she would have to turn down the job.

Was it not possible for her to recognise enough of her environment to work out which way to turn? “Think about standing in front of a bathroom cabinet with a mirrored door,” she says. “Open that door and look at the rest of the room through it and you’ll know it’s your bathroom, but everything’s kind of in the wrong place. Plus you’re stressed because everything looks different. It makes it hard.”

When Sharon has to get up in the night to go to the toilet, or if she’s in a rush in the morning and doesn’t have time to do her Wonder Woman impression, she says she feels like she is in a different condo. When she had young children, she would have to follow their cries to find their room in the night.

Sharon was almost 30 before her secret came out. Her brother had phoned her, asking to be taken to the hospital. He had Crohn’s disease and was feeling unwell. Sharon rushed out of the house in a panic, got into the car and set off on the short journey to his house. But on the way, her world flipped and she got completely lost. She pulled into a petrol station to call him. “I can’t find your house,” she said, and described the petrol station. Her brother was confused. He said, “You’re two blocks away from me – how do you not know where you are?” After the two of them had returned from the hospital, her brother asked her what was going on.

“It was so emotional for me, I could hardly say the words.” It was the first time Sharon had talked about her condition since she was five. Sharon’s brother told his doctor, and the doctor set up a meeting with a neurologist. He told her it sounded like a benign tumour or epilepsy. He organised a barrage of tests, but Sharon’s brain looked healthy.

“They said I needed to see a psychiatrist – they thought I was crazy.” She suffered a bout of severe depression. “I wanted to die. I’d just had my hopes raised, thinking that the doctors would find something that could be fixed.”

Sharon saw a psychologist for more than a year, and although he helped her work through her depression, he was unable to fix her disorientation. He told her to keep checking in with a neurologist every few years, to see if the research community had discovered anything new.

Sharon with her eyes closed


‘I’ve always been silly and funny because it misdirected people away from the things I was hiding,’ says Sharon. Photograph: Benjamin Rasmussen for the Guardian

When Sharon turned 40 she decided to see another doctor. But as soon as she sat down, she felt uncomfortable. “She looked at me like I was telling her a made-up story. She asked me how I correct it and I told her I spin around and it fixes it. She said, ‘Let me see you do it.’” Sharon had never spun in front of anyone before. She winces at the memory. “I swallowed my pride, stood up and closed my eyes. I spun around in circles until I knew the world had flipped.”

The doctor asked Sharon what she saw. “I said, ‘Well, I’m in a different room now. I know logically I’m not, but this doesn’t look like the same room.’”

Sharon spun around again and sat back down. The doctor put down her pen and pad and said: “Has anyone ever suggested the possibility that you have a multiple personality disorder?” Sharon was mortified. “I felt like I was being told I was crazy again. I just couldn’t go through that again. I left.”

It was another decade before Sharon made a further attempt to understand what was wrong with her brain. A friend had read some books by the neurologist Oliver Sacks and recommended that Sharon write to him. Sacks replied, apologising that he had not heard of such a condition. But he said the problem might be similar to another condition called prosopagnosia, in which people are unable to recognise familiar faces.

Sharon Googled “prosopagnosia” and found a website that tested how good you are at recognising faces. After the test, there was a questionnaire. One of the questions hit a nerve: “Have you ever been in an environment that you know you should recognise but doesn’t look familiar?”

“I was like, ‘Holy shit!’” says Sharon, who wrote everything about her condition in the notes section. “Within a week, I received a call from Brad Duchaine, a researcher at University College London.” Duchaine had created the online test. “He was so sweet,” says Sharon. “He believed everything I said, and assured me that at some point there would be someone doing research on my problem.”

Two years later, in 2008, Duchaine emailed her, saying he had good news. There was an Italian researcher moving to Vancouver to start researching the condition she had described. That man was Giuseppe Iaria.

“The first time Giuseppe called, I told him everything. He was such a gentle man. He nearly cried when I told him about the witch thing.”

Iaria told Sharon that he thought there might be a problem with the way in which the different navigational cells in her brain communicate with each other. Over the next five years, he began to test this theory.


Sharon’s brain looks anatomically normal, but several of the areas involved in navigation don’t communicate properly

He started by scanning the brains of healthy people, looking at how different brain regions known to be important for orientation and navigation communicate with each other. His team concluded that the best navigators were those with higher levels of communication.

This concept is called network theory and it’s an idea that underlies many human behaviours – that the connections between different regions of the brain may be more important than how well the regions function by themselves. It’s like having a quartet of the world’s best brass players who individually make wonderful sounds. But if they’re not playing in time with one another, that music turns into mayhem.

Iaria’s team then scanned the brains of a group of people with Sharon’s disorder. They noted a difference in the activity of their right hippocampus, an area involved in memory, and parts of their frontal cortex, an area that allows us to draw all the information about navigation together. It’s also an area involved in reasoning and general intelligence.

As Iaria’s patients had no problem with their memory, or reasoning, he concluded that the condition must be a result of ineffective communication between the two regions. “It’s not enough for the individual parts of the brain to be able to speak,” he tells me. “They have to have good conversational abilities, too.”

Since then, Iaria’s team has discovered that, just like Claire’s, Sharon’s brain looks anatomically normal; but several of the areas involved in navigation don’t communicate properly. Still, how could Sharon sometimes navigate perfectly well and then suddenly flip?

“Some people don’t actually lack the skill of forming a mental map,” Iaria explains, “but somewhere in the process of collecting all the pieces of the puzzle, errors accumulate, information gets lost, and suddenly the map shifts.”

To Iaria’s knowledge, Sharon’s spinning technique is unique. “I have to admit I have no idea why it works,” he says. “There’s nothing wrong with her vestibular system – she doesn’t get nauseous or have problems with her balance – but somehow shaking this system resets her mental map.” He sighs. “I can scan her brain, but I can’t enter her mind.”

A lobster ornament outside Sharon’s home


Louie the lobster, the ornament that tells Sharon she’s home. Photograph: Benjamin Rasmussen for the Guardian

Recently, Iaria has been testing his theory that developmental topographical disorientation has a genetic link. Of all the people he has identified with the condition – almost 200 of them – about 30% have at least one other family member affected. His team identified a handful of potential genes that might be causing the problem. While it’s unlikely that they will be able to replace the broken genes any time soon, it might be possible to intervene – using brain-training exercises that help children with these genes use other parts of their brain to navigate.

I ask Sharon whether her daughter, son or grandchildren have any signs of the condition. “No, thank goodness – they are all really good at navigating,” she says. Did Sharon’s condition appear spontaneously, I wonder, or might it have been inherited?

“My mum?” Sharon guesses. “Yes, I think she must have had it. Looking back, it all makes sense. She never told my dad about my condition, probably because she’d never told him about hers. She never walked us to school or picked us up from anywhere, unless there were other people with us. She never went anywhere by herself.”

Knowing there are people out there trying to understand her condition has helped. “I’ve always been silly and funny because it misdirected people away from the things I was hiding. Everyone said, ‘You’re always in such a good mood.’ They didn’t know that I would go home at night and cry. Before meeting Giuseppe, I was still a scared little girl. I don’t think I grew up and became a woman until the last 10 years, really. I’m happy now. I realised that in order to be fulfilled I needed to learn to like myself and accept who I am.”

As I leave, I catch another glimpse of her lobster lawn ornament. “I know he’s awful,” says Sharon, as she walks me to my car, “but I call him Louie.” She looks back at the house. “If I’m lost and I see Louie, I know I’m home.”

  • Some names have been changed. Sharon asked that we did not use her surname.
    This is an edited extract from Unthinkable: An Extraordinary Journey Through the World’s Strangest Brains, by Helen Thomson, published on 22 February by John Murray at £20. To order a copy for £17, go to bookshop.theguardian.com or call 0330 333 6846.
    Commenting on this piece? If you would like your comment to be considered for inclusion on Weekend magazine’s letters page in print, please email weekend@theguardian.com