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acteristic clinical features Probably this means that each disease has a distinctive mechanism and that the locus of the metabolic effect is somewhat different from one disease to another The sudden and excessive neuronal discharge that characterizes an epileptic seizure is a common coma-producing mechanism Usually focal seizure activity has little effect on consciousness until it spreads from one side of the brain (and the body if there is a convulsion) to the other Coma then ensues, presumably because the spread of the seizure discharge to deep central neuronal structures paralyzes their function In other types of seizure, in which consciousness is interrupted from the very beginning, a diencephalic origin has been postulated (centrencephalic seizures of Pen eld) Concussion exempli es another special pathophysiologic mechanism of coma In blunt , or closed head injury, it has been shown that at the moment of the concussive injury there is an enormous increase in intracranial pressure, on the order of 200 to 700 lb/in2, lasting a few thousandths of a second The vibration set up in the skull and transmitted to the brain was for many years thought to be the basis of the abrupt paralysis of nervous function that characterizes concussive head injury Instead, it is more likely that the sudden swirling motion of the brain induced by the blow to the head, producing a rotation (torque) of the cerebral hemispheres around the axis of the upper brainstem, is the proximate cause of loss of consciousness These same physical forces, when extreme, cause multiple shearing lesions or hemorrhages in the diencephalon and upper brainstem The subject of concussion is discussed fully in Chap 35 Yet another unique form of coma is that produced by inhalation anesthetics The effects of general anesthesia had for many years been attributed to changes in the physical chemistry of neuronal membranes More recently, it has been recognized that there are interactions with ligand-gated ion channels and alterations in neurotransmitter function that are of direct consequence in causing anesthesia-induced unconsciousness Inhalation anesthetics are unusual among coma-producing drugs in respect to the sequence of inhibitory and excitatory effects that they produce at different concentrations During anesthesia, suf cient inhibition of brainstem activity can be attained to eliminate the pupillary responses and the corneal re ex Both return to normal by the time the patient is able to speak Sustained clonus, exaggerated tendon re exes, and Babinski signs are common during the process of arousal These ndings have been studied systematically by Rosenberg et al Pre-existing focal cerebral de cits from strokes often worsen transiently with the administration of anesthetics, as is true to a lesser extent with other sedatives, metabolic encephalopathies, and hyperthermia Recurring Stupor and Coma Aside from repeated drug overdose, recurring episodes of stupor are usually due to the decompensation of an encephalopathy from an underlying biochemical derangement, hepatic failure being the most common A similar condition of periodic hyperammonemic coma in children and adults can come about from urea cycle enzyme defects, such as ornithine transcarbamylase de ciency These are discussed in Chap 37, in the section on inherited hyperammonemias Under the title of idiopathic recurring stupor, a rare condition has been described in adult men who displayed a prolonged state of deep sleepiness lasting from hours to days intermittently over a period of many years Despite the impression of a sleep disorder related to narcolepsy, the EEG showed widespread fast (beta) ac-.

volatility then as the trend reverses traders pull capital from the market causing decreasing volatility This pattern of long-side volatility isn t likely to improve until investors in general develop a better understanding of short market positions Short-side volatility is often a contest between larger market players with knowledge and expertise in trading short positions and those participants trying to exit existing market positions This contest often takes place between hedge funds and index funds Individual investors are typically averse to the risk of short market trading and are mostly contributors to downward market volatility, primarily from a liquidating standpoint rather than any short market position

The pie chart is one of my favorites because it can get the message across to the customer quickly and make the information very clear and concise Sure, it doesn t offer any additional bells and whistles, such as what-if statements, but with a couple of variables, we can definitely work this one into any dashboard to improve its display For the pie chart type, let s go with the 2D look and feel, as shown in the next illustration

tivity, and both the stupor and EEG changes were promptly reversed by umazenil, a benzodiazepine receptor antagonist During the bouts, a hundredfold increase of circulating endozepine-4, a naturally occurring diazepine agonist, was found in the serum and spinal uid Subsequently, the authors of the original reports (Lugaresi et al) found, by the use of more advanced techniques, that intoxication with lorazepam may have accounted for at least some of the cases Although cases such as this in which diazepine antagonists reverse episodes of recurrent coma (Huberfeld et al) continue to be reported, the status of this entity is ambiguous The vigilance-producing drug, moda nil, has also been effective in one report (Scott and Ahmed) It is unclear to us whether migraine can cause a similar syndrome, as suggested in the study of familial hemiplegic migraine by Fitzsimmons and Wolfenden Basilar migraine may exceptionally cause transient stupor and coma Catatonic stupor and KleineLevin syndrome of periodic hypersomnolence and behavioral changes (page 344) also need to be considered

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