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order, particularly the observation that it occurs most often in patients with deep hemispheral lesions of the cerebral hemispheres Another striking aberration of ventilation is a loss of automatic respiration during sleep, with preserved voluntary breathing ( Ondine s curse ) The term stems from the German myth in which Ondine, a sea nymph, condemns her unfaithful lover to a loss of all movements and functions that do not require conscious will Patients with this condition are compelled to remain awake lest they stop breathing, and they must have nighttime mechanical ventilation to survive Presumably the underlying pathology is one that selectively interrupts the ventrolateral descending medullocervical pathways that subserve automatic breathing The syndrome has been documented in cases of unilateral and bilateral brainstem infarctions, hemorrhage, encephalitis (neoplastic or infectious for example, due to Listeria), in Leigh syndrome, and recovery from traumatic Duret hemorrhages The issue of a loss of automatic ventilation as a result of a unilateral brainstem lesion has been addressed above The converse of this state, in which there is complete loss of voluntary control of ventilation but preserved automatic monorhythmic breathing, has also been described (Munschauer et al) Incomplete variants of this latter phenomenon are regularly observed in cases of brainstem infarction or severe demyelinating disease and may be a component of the locked-in state The congenital central hypoventilation syndrome is thought to be an idiopathic version of the loss of automatic ventilation (see Shannon et al) This rare condition begins in infancy with apneas and sleep disturbances of varying severity or later in childhood with signs of chronic hypoxia leading to pulmonary hypertension As mentioned on page 345, several subtle changes in the arcuate nucleus of the medulla and a depletion of neurons in regions of the respiratory centers have been found in this condition, but further study is necessary Neurologic lesions that cause hyperventilation are diverse and widely located throughout the brain, not just in the brainstem In clinical practice, episodes of hyperventilation are most often seen in anxiety and panic states The traditional view of central neurogenic hyperventilation as a manifestation of a pontine lesion has been brought into question by the observation that it may occur as a sign of cerebral lymphoma, in which postmortem examination has failed to show involvement of the brainstem regions controlling respiration (Plum) Hiccup (singultus) is a poorly understood phenomenon It does not seem to serve any useful physiologic purpose, existing only as a nuisance, and is typically not associated with any particular disease It may occur as a component of the lateral medullary syndrome (page 678), with masses in the posterior fossa or medulla, and occasionally with generalized elevation of intracranial pressure, brainstem encephalitis, or with metabolic encephalopathies such as uremia Rarely, singultation may be provoked by medication, one possible offender in our experience being dexamethasone Since the triggers of hiccup often seem to arise in epigastric organs adjacent to the diaphragm, it is considered to be a gastrointestinal re ex, more than a respiratory one A physiologic study by Newsom Davis has demonstrated that hiccup is the result of powerful contraction of the diaphragm and intercostal muscles, followed immediately by laryngeal closure This results in little or no net movement of air He concluded that the projections from the brainstem responsible for hiccup are independent of the pathways that mediate rhythmic breathing Within a single burst or run of hiccups, the frequency remains relatively constant, but at any one.

This dashboard is titled Sales Analysis by Product Group and for this example we will accept that the default information around the required KPIs for this dashboard is accurate As you can see we have six KPIs with two key figures per view and a total of six views If I do the mathematics correctly we are looking at 12 KPIs for the business analyst to assimilate at one time This is a reasonable amount of information for the business user to assimilate In this example we presented the high-level information and summary by year for all of the metrics We could have added something in terms of a period analysis rather than a yearly analysis or we could also have set up something for a Year to Date analysis for 2009 These are excellent additions that could have been made and we could have added these additional metrics to this dashboard but as we mentioned before, we don t want to cram tons of metrics onto one dashboard If there are more we either a) use a tab page to add additional layers to the dashboard and assign an appropriate title such as Periodic Sales Analysis YTD 2009 by Product Group and this would have all of the same indicators as the current view of this dashboard but at the period level rather than the yearly level, or b) use some sort of drill-through to get to the additional detailed analysis Let s look at this based on the discussion we had earlier in this chapter In the case of clear titles and descriptions I think we can see that everything is well spelled out and consistent in nature There are no assumptions that the user has to make in understanding

time it may range anywhere from 15 to 45 per minute The contractions are most liable to occur during inspiration and they are inhibited by therapeutic elevation of arterial carbon dioxide (CO2) tension We cannot vouch for the innumerable home-brewed methods that are said to suppress hiccups (breath-holding, induced fright, anesthetization or stimulation of the external ear canal or concha, etc); but where the neurologist is asked to help in an intractable case of unknown origin (usually male), baclofen is sometimes effective

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