Guy Leschziner

From the second row, where the neurology registrars sat, it felt a little like being in one of the amphitheatres of Rome — and we were about to be fed to the lions. The craftiest registrars among us would find a patient that urgently needed assessment on the wards so that they could creep into the rear of the auditorium late, along with the hordes of junior doctors, medical students and visiting neurologists from abroad. The most devious would arrange for a colleague to page them early in the proceedings so they could make a show of leaving to deal with ‘an emergency’ before sneaking in at the back of the lecture theatre later on.

The best neurologists I have worked with are the ones who have the patience and the ruthless determination to extract the full history, like a forensic FBI interrogator.

As a schoolboy, I vividly remember picking up a copy of Oliver Sacks’s book, The Man Who Mistook His Wife for a Hat. As I read these stories of a mariner unable to form new memories, of a man who could not recognise his own leg, of the woman who heard music as a result of epileptic seizures, I was gripped. But it was the context in which he put these symptoms, the impact on the lives of the human beings in front of him, that led to a deeper understanding of the nature of these conditions and how they affect us. And it was reading these stories that inspired my interest in neuroscience, and no doubt many of my colleagues too.

And, as neurologist Oliver Sacks so aptly put it: ‘In examining disease, we gain wisdom about anatomy and physiology and biology. In examining the person with disease, we gain wisdom about life.’

Our 24-hour rhythm influences our brain, our gut, our kidneys, our liver and our hormones — every cell in our bodies. In fact, remove a cell, place it in a Petri dish, and it will demonstrate a 24-hour rhythm in some form or other.

Within the neurones of the suprachiasmatic nucleus, a complex dance occurs on a daily basis, with several genes with names like CLOCK and Period interacting with each other, feeding back to each other, conducting the ticking of our clock.

Sleep apnoea may run in families, and is often related to the shape of the airway. A large tongue base or a recessed lower jaw will cause a narrowing, as sometimes do very large tonsils. Sleep apnoea appears to be more common in people of Southeast Asian ancestry, perhaps related to the shape of the head and resultant shape of the airway.

Increased weight may precipitate or worsen sleep apnoea in several ways. Local deposition of fat in the neck makes the airway narrower and more likely to collapse, but fat on the chest increases the effort of breathing, reduces lung volume due to weight on the chest, and increases the metabolic demands on the body. And weight loss often improves sleep apnoea.

has now been recognised that sleep apnoea is strongly associated with high blood pressure and the serious problems that it can cause, such as heart disease and strokes. Recurrent jolts of sleep disruption in themselves cause spikes in blood pressure, entirely independent of drops in oxygen, but it seems that intermittent low oxygen levels have an additive effect

The intermittent hypoxia that is a feature of sleep apnoea has been shown to fundamentally influence the effects of insulin, the hormone that controls the breakdown and storage of glucose that is crucial to the prevention of diabetes. Sleep apnoea lessens the body’s response to insulin, causing what is termed insulin resistance, the first step in the development of diabetes, and results in higher blood glucose levels.