Jeremy Hunt attacks 'complacent' hospitals

Jeremy Hunt attacks 'complacent' hospitals

By Nick Triggle

Health correspondent,

Mr Hunt said his words were aimed at the bulk of hospitals that were not excellent and not poor

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Too many hospitals are coasting along, settling for meeting minimum standards, according to the health secretary.

In a speech on Friday, Jeremy Hunt will attack a culture of "complacency" and "low aspirations", which he believes is holding the NHS in England back.

He is expected to say while there is a concerted effort to tackle failing hospitals, there should also be a focus on "mediocrity".

Labour's Andy Burnham blamed ministers for the failings in front line care.

Mr Hunt's comments come a month after the problems at Stafford Hospital were laid bare.

The final report of the public inquiry into the scandal, published at the start of February, attacked the way the system protected corporate self-interest rather than putting patients first.

The warnings have already led to investigations into 14 hospital trusts with high death rates.

But Mr Hunt, in a speech to the Nuffield Trust think-tank in Dorking, Surrey, will say part of the challenge is tackling "mediocrity and low expectations before they turn into failure and tragedy".

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So how many hospitals are mediocre?

The health secretary will make it clear in his speech that he is not saying the vast majority are mediocre, but according to sources his words are aimed at a significant bulk of those plodding along in the middle.

It is commonly said about a 10th of hospital trusts are failing, although double that are actually not meeting all the essential standards set out by the Care Quality Commission.

That leaves about 80% of trusts that are doing what they should. Some of these will be excellent - perhaps about 10-15% - and some will be striving to become excellent - perhaps a similar number. That leaves close to half that could be said to be stuck in the middle, coasting along.

'Complacency'

"Coasting can kill. Not straight away, but over time as complacency sets in, organisations look inwards, standards drop and then suddenly something gives," he will say.

"I would never describe the majority of hospitals or wards in the NHS as mediocre - but I do believe our system fails to challenge low aspirations in too many parts of the system.

"Imagine for a moment that the main objective for our Olympic athletes was not to win but to 'not come last'. How many gold medals would we have won then?

"It sounds ridiculous doesn't it? But today I want to suggest that too much of the NHS is focused on doing just that.

"Not on achieving world class levels of excellence - the gold medals of healthcare - but meeting minimum standards, the equivalent of 'not coming last'."

Sources said Mr Hunt's words were aimed not at those that are failing minimum standards or waiting time targets, but the bulk in the middle that were not excellent and not poor.

Family test

He is expected to single out Walsall Manor, a hospital in the West Midlands, which has turned itself around after faring badly in the national patients' survey two years ago. The hospital decided to carry out one-to-one interviews with 100 patients to find out what they thought of their care and the staff that looked after them.

On the Today programme, Richard Kirby, chief executive of Walsall NHS Healthcare Trust, said this led to investment in specific areas flagged up by patients and a better understanding of what patients want. The Trust has also introduced a friends and family test.

"Every patient who is admitted to our hospital is asked when leaving if they would recommend us to friends and family and scores are shared with all of our teams week in, week out.

Jo Webber from the NHS Confederation: ''People come to do the best they possibly can for patients''

"We get critical and positive responses. It gives us a simple, clear way of understanding how we are doing."

Katherine Murphy, of the Patients Association, said the health secretary was right to draw attention to the issue.

"There is a malaise in the NHS which has allowed mediocrity to become commonplace," she said.

"We hear from patients every day who are not happy with their care. I am not talking about the really bad, just those that are not putting patients first."

Investment

But shadow health secretary Mr Burnham said it was "no good for ministers to blame hospitals and staff when it is they who have thrown the whole system into chaos with a huge re-organisation, which has siphoned £3bn out of front line care.

Shadow Health Secretary Andy Burnham: "Coasting is the last thing hospitals are doing - they are working flat out."

"Hospitals across England are on a knife-edge and they need a government that provides support rather than points the finger," he said.

Royal College of Nursing director general Peter Carter said: "From one perspective I absolutely agree with him, of course we don't want mediocrity.

"But to make sure that does not happen we need to invest in staff. When we won one gold medal in the 1996 Olympics we started investing in our athletes, rowers and cyclists.

"To achieve gold medal standards in the NHS we need to do the same. It requires proper leadership, time to train and appropriate pay."

Mike Farrar, chief executive of the NHS Confederation, said there was room for improvement, adding hospitals needed to be more open and transparent.

"I believe that there is a crucial opportunity to make this culture change happen. We cannot miss this chance to deliver better care."

Why has Romania got such a bad public image?

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In today's Magazine

• The babies who nap in sub-zero temperatures
• Quiz of the week's news
• Getting teary over Les Miserables
• The Monitor

The Romanian Prime Minister Victor Ponta has defended his country after a wave of negative reporting about it in the UK and elsewhere in Europe. Why does it have a bad public image?

Of course, it had to be Romania.

You could almost sense the relief for some when, in the midst of the horsemeat scandal, the finger of blame was pointed at abattoirs in an eastern European state.

Now it made sense. Cue stock footage of gypsy horse and carts and knowing references to organised crime.

Except, of course, there is no evidence that any horsemeat left Romania labelled as anything other than horsemeat.

But slurs about horsemeat are just the latest in a long line of public relations problems to have hit Romania.

Students and young professionals from Romania talk about living and working in the UK - and whether they plan to return home

The country's prime minister, Victor Ponta, has this week been forced to launch an all-out charm offensive over fears about a flood of immigrants when the EU opens its labour market to his country, and neighbouring Bulgaria, on 1 January 2014.

Headlines such as "The Mafia bosses who can't wait to flood Britain with beggars", "We want to get into your country before someone locks the door" and "An immigration calamity looms" have incensed Romanians living in the UK.

On Friday, the country's ambassador to London, Ion Jinga, claimed such "alarmist" and "inflammatory" coverage could lead to Romanians being assaulted in the street.

He argues that all the Romanians who want to work in the UK are already there, on work permits or self-employed.

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Romania - facts and figures

• Area of 148,000 sq miles (238,400 sq km) and population of 21.4m people
• Under Communist rule from end of WWII to 1989 when ruler Nicolae Ceausescu was deposed and shot
• Joined Nato in 2004; became EU member in 2007 - current president Traian Basescu

• Romania profile

In an article in the Times, the Romanian prime minister strikes a more emollient tone, inviting Britons to come and enjoy a "strong pint" in Bucharest's Old Town or a "quiet holiday" in the sleepy Transylvanian villages beloved by Prince Charles.

Improved job rates in Romania mean that "Britain can rest assured", he writes.

This argument cuts little ice with Migration Watch chairman, former diplomat Sir Andrew Green, who says the presence of a settled Romanian population in the UK is a "pull factor" that will encourage more to make the journey.

The press has seized on a report by Migration Watch claiming 50,000 Romanians a year will travel to the UK when working restrictions are lifted.

Migration Watch's chairman cites events from 2004, when the government grossly under-estimated the number of migrants that would travel from new EU states such as Poland. The government said there would be net immigration of between 5,000 and 13,000 a year. In fact, 2011 Census data showed the Polish population alone had risen in England and Wales from 58,000 in 2001 to 579,000 10 years later.

Romania has been trying to reshape its image for some time. The government has launched a number of advertising and PR campaigns in recent years aimed at improving the country's perception abroad.

In 2011, it launched a global "Why I Love Romania" poster campaign, trumpeting the achievements of famous Romanians such as tennis player Ilie Nastase, gymnast Nadia Comanenci and scientist Nicolae Paulescu, who discovered insulin.

Last year, it launched a campaign to attract more tourists to the Carpathian Mountains, which was much mocked in the Romanian press.

Did stories about horsemeat play up to prejudices about Romania?

And a Romanian ad agency, GMP, has produced tongue-in-cheek ads hitting back at, so far unfounded, claims that the UK is considering a campaign to deter Romanians from coming to the UK.

The proposed Why Don't You Come Over? campaign in Romania features slogans such as "We speak better English than anywhere you've been in France" and "Charles bought a house here in 2005. And Harry has never been photographed naked once."

The campaign slogan is: "We may not like Britain, but you will love Romania."

Ronnie Smith, a British business consultant based in Romania, says the UK "ought to be ashamed" of its coverage of Romania but he does not believe the country's government has the resources, or the will, to respond effectively.

"There is not a rebranding campaign. There should be but there won't be, not to the extent that's needed," he says.

Romania's image problem may even be traceable to the late 19th Century, when travellers returned from Transylvania with tales of a strange, forbidding land, says Dr James Koranyi, a history lecturer at Durham University.

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What about Bulgaria?

About 53,000 Bulgarians already live in the UK, with work permits or self-employed.

Bulgaria's ambassador in London, Konstantin Dimitrov, says: "We have identified elements of a negative campaign against Bulgarians and Bulgarian people - both those living in Bulgaria and those residing in the UK.

"We don't see any sociological basis for such exaggerated stories. They are either done for financial reasons or are a deliberate effort to misinform the British people."

"Just as Dracula sucked the blood of the young English women Mina and Lucy, so, too, are Romanians accused of taking British jobs and sucking the welfare state dry," writes Koranyi in an article for Open Democracy.

But most observers believe Romania's recent past, as a Communist dictatorship, looms far larger in the public mind.

For many people in the West, images of children abandoned in Soviet-era orphanages are the first thing they associate with Romania, says Liam Lever, a British journalist who writes for English-language Romanian news site Romania Insider.

Like other members of the growing expatriate British community in Romania, he believes outdated stereotypes are holding the country back.

"When you say you are going to Romania, people look at you with shock and horror, as if you are going to some place where there is no law and order and bandits roaming in the hills.

"The reality is something quite different."

Like its smaller neighbour Bulgaria, Romania remains one of the most corrupt countries in Europe, according to Transparency International, despite EU-inspired efforts to clean up its political system.

It has also been singled out for criticism by Amnesty International for its prejudicial treatment of the Roma community, who make up 10% of the country's population.

There is poverty in Romania but the economy is growing...

Little wonder, say critics, that the Roma have relocated in their thousands to other EU countries, including the UK.

There have been newspaper stories in the UK pointing to Romanian involvement in certain type of crime, with allegations that 92% of cash machine scams are carried out by nationals. Ten Romanian police officers were sent to London last year to help tackle begging and anti-social behaviour

But Romania's image as a violent "mafia state" among some commentators is far wide of the mark, its defenders point out.

Violent crime in Bucharest is among the lowest of any capital city in Europe, according to figures compiled by The UN Office on Drugs and Crime.

The country's economy is also growing faster than the UK and there are plenty of opportunities for entrepreneurs, according to the British business people based there.

Ambassador Jinga has said the 68,000 Romanians already living in the UK are the best advert for his country.

The vast majority are aged under 35 and are in highly skilled or shortage professions. Six thousand are studying at British universities.

... and wages have risen

Brought up on idealised images of the West, they are bemused, and in some cases, angry at the British media's portrayal of their country.

Unlike Poland, which forged close ties with the UK during World War II, Romania had few links with the UK before the fall of Communism.

"We do have very different cultures," says Carmen Campeanu, a project manager at the Romanian Cultural Centre, in Central London. "We are a Latin country. Statistics show Romanians would prefer to go to Italy or Spain or Portugal or even France."

Stefan Rusud, a 24-year-old management student, says the media storm over immigration has not changed his view of the UK, a country he has always regarded as "a temple of democracy".

Adrian Cherciu, who runs a business importing Romanian food, says he has had to put up with a lot of horsemeat jokes from his British friends in recent weeks.

But he is not worried by "anti-Romanian" press coverage, as it does not fit with his own experience as a British resident and, since 2004, the owner of Romani Online, a website for Romanians in the UK.

"There is no prejudice based on your colour, your religion or nationality," he says

Romanian orphans 1989, the outside world first saw images of tens of thousands of abandoned children living in cramped, filthy institutions across the country.

Editor's note: Following the Christmas Day execution of Romania’s long-time communist dictator Nicolae Ceausescu in 1989, the outside world first saw images of tens of thousands of abandoned children living in cramped, filthy institutions across the country.

Ceausescu’s policies — including outlawing abortion and birth control and dictating that every woman bear a minimum of five children — had created a generation of children that were cared for by the state.
Many didn’t survive. But nearly a quarter of a century later, those who did are now young adults.
This is the second of a two-part series that takes a look at two young men who lead very different lives as they navigate society on the outside today.
BUCHAREST, Romania — Eight years ago, Gabriel Ciobotaru didn’t know how he would avoid living on the streets, let alone find an apartment, land a job and otherwise build a life.
Living in one of Romania’s notorious orphanages, he was given virtually no guidance about how to survive when it came time to leave.
“They don’t prepare you for life,” says Ciobotaru, who was 26 when he was first sent out on his own. Now 34, his thinning, graying hair and slight frame make him appear much older than his years.
“That’s the problem for 2,000 young people who leave every year,” he adds. “They aren’t able to maintain a job, they don’t know how to cook… so they can’t create a family.”
More than two decades after the fall of communism exposed shocking conditions for the country’s abandoned children living in state institutions, life for many has improved. But the state still provides no formalized life-training program or ongoing support for the estimated 70,000 children who fall under the care of the Department of Child Protection, let alone the tens of thousands more believed to live on the streets.
More from GlobalPost: Romanian orphans, Part 1
Laurentiu Ierusalim grew up in an orphanage after he was abandoned in a hospital at birth. Now 26, he says he was told he’d be discharged only the day before he had to leave.
“I spent the entire first day standing in front of the orphanage,” he says. “I didn’t know what to do, so I slept in a playground across the street.”
Ierusalim stayed homeless. Bundled in a warm sweatshirt, his dark eyes cast downward, he describes spending three years moving from city to city, knocking on doors to ask for work, food and shelter.
A priest at an Orthodox church helped find families to take him in — three months here, a month there. He finally secured a job as a grocery store clerk two months ago.
The authorities say they’re addressing the problem he faced. Christina Cuculas of the Labor, Family and Social Protection Ministry says social workers, educators and other specialists spend years teaching orphans fundamental skills.
“They help them with what we call ‘gathering independent life skills’ from the moment [orphans] enter the special protection system,” she says.
But many say “life training” and other help for integrating into society greatly varies if it’s available at all.
Most discharged orphans are thrust into society provided with less than $140 as soon as they legally become adults at age 18. There are no national job or housing assistance programs.
Although Cuculas says companies contact her ministry to request workers whose skills fit their needs, many orphans who turn down a first offer say they get no further help from the state.
Many, like Ierusalim, face the terrible hazards of living alone on the streets. “I was traveling with a group that was into drugs, but I left them,” he says. “I slept in random places on the street… I prayed to God for help. I never gave up.”
A lucky few who are able to attend college are allowed to continue living in institutions until age 26.
But only a small handful earn the top marks on their entrance exams that enable Romanians to attend university free.
Among them, Ciobotaru was orphaned at age 10 when his mother died during childbirth. His father, a pilot, had died in a plane crash when Ciobotaru was an infant.
Without his parents, he relied on his own initiative and a bond with an American family he’d never met.
During his teens, Carolyn and Bruce Coughlin of Massachusetts began sponsoring him through the Boston-based charity Romanian Children’s Relief.
Ciobotaru says Carolyn’s encouragement and interest made a great difference. “I knew someone was thinking about me,” he says. “She was like an angel, very glad for every achievement I had. She used to tell me I was an amazing child.”
The Coughlins became close to Ciobotaru through monthly letters. They first met after 15 years of correspondence when he organized a choir trip to the United States for a children’s singing group in 2010.
“They’re my family,” he says. “Every child in this world can have a family no matter the distance.”
He says he was lucky to have been orphaned in Bucharest because more private aid is available in the capital than in the countryside, together with occasional temporary jobs and short-term housing.
But Ciobotaru was never your average orphan. He says he found ways to cope from the start, including minimizing frequent bullying by helping others.
“Ironing clothes for the younger kids, for example, and helping in the kitchen,” he says. “The adults in charge began trusting me. That protected me.”
Ciobotaru managed to pick up some household skills and win the attention of the orphanage director and other key figures.
As a teenager, he came up with plans to raise money for children to hold monthly birthday celebrations, attend camps and go on fieldtrips.
Later, he expanded his mission to help others by applying for a social work degree at a Bucharest university after earning the highest possible score on an entrance exam.
After he won a contest to speak at a conference in Norway, he funded his flight there through UNICEF. He was later recruited to speak at a similar program in India.
More from GlobalPost: Russia: Tens of thousands protest US adoption ban
He now works with at-risk youth for the Department of Child Protection.
In 2011, Ciobotaru founded Sansa Ta, “Your Chance,” a foundation that raises money for the homeless and collects donations for needy children.
It also plans to build an apartment building for orphans entering society.
Twelve have already been selected to help with construction on land promised by the government in Bufeta, just outside Bucharest. Their labor will serve as security deposits and initial rent payments on studio apartments.
“I was different than other kids because I liked to get involved,” he says of his childhood. “But like other orphans, I knew I’d have to go out into a new world where life isn’t easy.”

Sacked saline inquiry nurse Rebecca Leighton lodges appeal

Sacked saline inquiry nurse Rebecca Leighton lodges appeal

Rebecca Leighton was in prison for six weeks before charges were dropped

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• Saline case nurse hires publicist
• Police defend saline nurse arrest

Sacked Stepping Hill Hospital nurse Rebecca Leighton has lodged an appeal against her dismissal.

Ms Leighton was arrested during an inquiry into contaminated saline solution, linked to three patient deaths at the Stockport hospital.

Criminal charges against her were dropped, but she was sacked by the Stockport NHS Foundation Trust after admitting stealing opiate drugs.

The trust confirmed Ms Leighton's appeal will be heard in February.

A trust spokeswoman said she was unable to comment further until the appeal is concluded.

Poisonings investigated

The nurse, from Heaviley, Stockport, lost her job in early December after a Nursing and Midwifery Council (NMC) heard her admit the drugs theft, which she said she carried out to treat her throat infection.

The NMC lifted a ban order preventing Ms Leighton from nursing, which it had imposed while she was being investigated by police.

She spent six weeks in custody until her release in September.

Police are continuing to investigate the deaths of Stepping Hill Hospital patients, Tracey Arden, 44, Arnold Lancaster, 71, and 83-year-old Derek Weaver, who police said were all administered insulin unlawfully.

Greater Manchester Police confirmed it is also examining the poisoning of 19 other patients, after they were first called in to the hospital on 12 July after an experienced nurse reported a higher than normal number of patients on a ward with "unexplained" low blood sugar levels.

More on This Story

Related Stories

• Saline case nursing ban is lifted 14 SEPTEMBER 2011, MANCHESTER
• Saline case nurse hires publicist 07 SEPTEMBER 2011, MANCHESTER
• Police defend saline nurse arrest 05 SEPTEMBER 2011, MANCHESTER

Related Internet links

• Stockport NHS Trust

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Vertical gaze palsy

Vertical gaze palsy

Contributors

Jason J S Barton MD PhD, author. Dr. Barton of the University of British Columbia in Vancouver has no relevant financial relationships to disclose.

James Goodwin MD, editor. Dr. Goodwin of the University of Illinois at Chicago has no relevant financial relationships to disclose.

Publication dates

Originally released July 19, 2001; last updated February 27, 2012; expires February 27, 2015

Key points

  • Vertical gaze palsies are due to damage to pre-motor structures in the midbrain, namely the rostral interstitial nucleus of the medial longitudinal fasciculus and the interstitial nuclear of Cajal.

  • Vertical gaze palsies can involve upgaze, downgaze, or both.

  • Parkinsonian conditions with vertical gaze palsies are due most often to tauopathies, such as progressive supranuclear palsy and corticobasal degeneration.

  • Several genetic defects can cause cerebellar ataxia with vertical gaze palsies, chief of which is Niemann Pick type C disease.

Historical note and nomenclature

  The term “gaze palsy” is best restricted to deficits in conjugate eye movements that affect both eyes. Thus, strictly unilateral problems such as palsies of cranial nerves III, IV, or VI are not gaze palsies, even though they do affect gaze. Likewise, impairments in vergence control, such as convergence or divergence insufficiency, are not gaze palsies, as they do not involve conjugate eye movements.

  A fundamental distinction is between vertical and horizontal gaze palsies. Most gaze palsies affect 1 direction in 1 plane of eye movement only, reflecting the separation of the prenuclear control systems for vertical and horizontal eye movement. Reduction of eye movements in all planes is best termed “generalized ophthalmoparesis.” These reductions are most commonly myopathic, occurring with mitochondrial disorders (chronic progressive external ophthalmoplegia, Kearns-Sayre syndrome, MELAS) or muscular dystrophies (myotonic dystrophy, oculopharyngeal dystrophy, congenital fibrosis), among others.

  The term “gaze palsy” requires further elaboration. There are many different types of conjugate eye movements, including saccades, pursuit, optokinetic, and vestibulo-ocular responses. The anatomic systems that control these diverge and converge at various levels, and it is possible for some lesions to impair some eye movement systems and spare others. Hence, a left saccadic palsy is a selective gaze palsy affecting only leftward saccades but not leftward pursuit or vestibulo-ocular response. A palsy affecting all types of eye movements should be designated as a nonselective gaze palsy. Most vertical gaze palsies are selective in nature.

  In contrast, the terms “partial” or “complete” when applied to gaze palsy indicate whether some motion across midline in the paretic direction is present.

Clinical manifestations

  Vertical palsies usually appear selective, affecting primarily saccades. However, though clinical testing often shows sparing of pursuit and vestibulo-ocular range, quantitative testing of eye movements shows that this selectivity is relative and not absolute (Sharpe and Kim 2002). Pursuit gain and vestibulo-ocular reflexes are impaired in many patients, though dissociable. Upgaze palsy is most frequent, combined upgaze and downgaze palsy is next in frequency, and pure downgaze palsy the most unusual (Bogousslavsky et al 1988). Because these are due to lesions of rostral midbrain nuclei, associated signs include pupillary or ocular motor signs of partial nuclear or fascicular third palsies (Castaigne et al 1981; Beversdorff et al 1995), including rarely a wall-eyed bilateral internuclear ophthalmoplegia (Sierra-Hidalgo et al 2010), impaired convergence, and skew deviation (Ranalli and Sharpe 1988; Steinke et al 1992). Somnolence or even a transient fluctuating coma at onset reflects damage to the reticular activating system (Castaigne et al 1981; Bogousslavsky et al 1988; Beversdorff et al 1995). Behavioral disturbances from thalamic damage include hemineglect, amnestic syndromes (Bogousslavsky et al 1988; Beversdorff et al 1995), akinetic mutism, or subcortical demented states with apathy and slowness of thought (Guberman and Stuss 1983).

  Upgaze palsy.  This is frequent with unilateral lesions at either the thalamomesencephalic junction (Bogousslavsky et al 1986; 1988), or the posterior commissure, or its nucleus(Buttner-Ennever et al 1982). There are often other signs of the pretectal syndrome. A lesion of the periaqueductal grey matter rarely causes this, perhaps by destroying descending outputs from the riMLF (Thames et al 1984). Rarely, it occurs as a transient effect of right frontoparietal lesions, with bilateral ptosis (Averbuch-Heller et al 1996).

  Downgaze palsy. This occurs with bilateral dorsomedial lesions of the rostral intrastitial nucleus of the medial longitudinal fasciculus (Buttner-Ennever et al 1982; Bogousslavsky et al 1988). It is hypothesized that bilateral lesions extending laterally impair upgaze also; therefore, selective downgaze palsy must require a small and specific lesion, accounting for its rarity (Pierrot-Deseilligny et al 1982). Convergence, accommodative responses, and the pupillary near response may all be impaired too (Cogan 1974). The pupillary light response can be affected (Cogan 1974) or preserved (Pierrot-Deseilligny et al 1982). Skew deviation and internuclear ophthalmoplegia can occur (Cogan 1974).

  Downgaze is also affected by akinetic movement disorders, most typically progressive supranuclear palsy (Cogan 1974).

  Combined up and down gaze palsy. The lesions involve the riMLF or the interstitial nucleus of Cajan, most frequently bilaterally. In the less common unilateral cases the lesion of the ipsilateral riMLF likely also interrupts decussating fibers from the contralateral riMLF. Vertical vestibulo-ocular response frequently appears normal (Buttner-Ennever et al 1982; Page et al 1982; Pierrot-Deseilligny et al 1982; Yamamoto 1989; Bogousslavsky et al 1990), but is sometimes absent (Beversdorff et al 1995) or impaired in 1 direction alone (Guberman and Stuss 1983). Torsional and vertical nystagmus may occur if the interstitial nucleus of Cajal is involved (Ranalli and Sharpe 1988). Bell phenomenon can be absent (Page et al 1982) or inverted (Ranalli and Sharpe 1988).

  Pretectal syndrome. This syndrome combines vertical supranuclear palsy, affecting either upgaze alone or both upgaze and downgaze, sparing vestibulo-ocular response range, with a variable number of other signs (Keane 1990). These include light-near pupillary dissociation, with loss of the pupillary light reactions from damage to the pretectum, Collier lid retraction sign, and skew deviation. Horizontal conjugate eye movements are spared but there may be esotropia, exotropia, or convergence insufficiency. An unusual convergence-retraction nystagmus is pathognomonic. Fragmentary pretectal syndrome, with only some of the above features, is common.

  Vertical one-and-a-half and other syndromes. Rarely a patient may have a vertical impairment that spares only a single direction in 1 eye. Supranuclear bilateral downgaze paresis affecting all movements combined with monocular elevator palsy occurs with bilateral midbrain infarction (Deleu et al 1989). The opposite, supranuclear bilateral upgaze paresis with monocular depressor palsy, has also been described with unilateral midbrain infarctions (Bogousslavsky and Regli 1984; Miyashita et al 1987; Gulyas et al 2006). A unique case of ipsilateral monocular elevator paresis and contralateral monocular depressor paresis, combined with mild bilateral ptosis, has been reported (Wiest et al 1996). Finally, a patient with supranuclear vertical palsy combined with complete ophthalmoplegia of 1 eye has been described, with the ophthalmoplegia attributed to a combination of oculomotor nerve palsy and pseudoabducens palsy (Thurtell et al 2009).

  Vertical congenital ocular motor apraxia is rare (Ro et al 1989; Brown and Willshaw 2003) and has been related to perinatal hypoxia (Hughes et al 1985) or bilateral mesencephalic-diencephalic lesions (Ebner et al 1990).

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Aqueductal Stenosis

General Information

• Aqueductal stenosis is one of the known causes of hydrocephalus and the most common cause of congenital (present at birth) hydrocephalus. It can also be acquired during childhood or adulthood. In some cases, this is due to a brain tumor compression (such as a pineal tumor) surrounding the aqueduct of Sylvius.

Symptoms

• Symptoms are related to hydrocephalus. Hydrocephalic patients with aqueductal stenosis are more likely to have difficulty looking up (“upward gaze palsy”).

Diagnosis

• The diagnosis of aqueductal stenosis is best made by magnetic resonance imaging (MRI), particularly using a special constructive interference in steady state (CISS), or fast imaging employing steady-state acquisition (FIESTA) sequence. CISS imaging is not available at all imaging Centers.

Treatment

• Endoscopic third ventriculostomy.
  • This technique is generally favored.
  • More than 200 endoscopic third ventriculostomies have been performed in adults at UCLA.
• Shunt placement.
• Endoscopic aqueductoplasty and stent placement.

The Neuro-ICU cares for patients with all types of neurosurgical and neurological injuries, including stroke, brain hemorrhage, trauma and tumors. We work in close cooperation with your surgeon or medical doctor with whom you have had initial contact. Together with the surgeon or medical doctor, the NeuroICU attending physician and team members direct your family member's care while in the ICU. The NeuroICU team consists of the bedside nurses, nurse practioners, physicians in specialty training (Fellows) and attending physicians. UCLA Neuro ICU Family Guide