Overnight placements for Send pupils under threat
One mother says she fears her son will struggle as the school he attends may have to stop its residential service.
Fosse Way School, in Midsomer Norton, offers a 24-hour, residential option for some children with special educational needs and disabilities (Send).
However, Bath and North East Somerset Council has withdrawn its funding for the service, saying there are no children in its care who qualify for a residential placement. It said current pupils will be able to complete their one-year placements.
"We, as parents, will have to pick up the pieces. I'll have to work twice as hard," said Sharon Wilson, whose son Ruben, 15, goes to Fosse Way.
Ruben, who is autistic and non-verbal, has been living at Fosse Way for a year.
"Last year, Ruben's world was small," Ms Wilson said. "Since being at Fosse Way, his bubble has gotten bigger and he's talking to more people."
She said she fears he will lose all the skills he has learned and his world will "get smaller again".
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Jessica Clark has an autistic son who went to Fosse Way House in his teens.
He is now 20 and lives in supported housing.
"You always worry about what happens when we as parents pass away," Ms Clark said. "What is his care going to look like?"
Jason Towells, residential education manager at Fosse Way, said it had been graded as outstanding by the education watchdog Ofsted for the past three years.
"We do a lot of work on preparing for adulthood," Mr Towells said. "We want them to access the community and build friendships."
Mr Towells said the school believes there are many students who require a 24-hour curriculum.
However, Mr May said: "For the academic year starting September 2025, no children have been identified whose needs would be met by the residential provision at Fosse Way."
He added: "When a child is placed in Fosse Way, it is with the clear understanding that it is for one academic year and the children currently placed there will be able to complete this year-long placement.
"Fosse Way House is not a council-run facility and decisions about its future are matters for The Partnership Trust whose work we value."
A spokesperson for The Partnership Trust added: "Currently seven young people have been placed at Fosse Way House by the council. Such a placement was deemed as being necessary and appropriate when each child's Education Health Care Plans were reviewed last year.
"The professionals who work with the young people understand their complex needs well, and all evidence suggests that they are thriving at Fosse Way School and Fosse Way House.
"Currently, only children who go to Fosse Way School can access Fosse Way House. As all children are funded through local authorities, over 90% of which come through BANES Council, our options are very, very limited if the council determines not to place children there."
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Medscape
4 days ago
- Medscape
Anemia in a Heavy Smoker
Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians, but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please email us at ccsuggestions@ with the subject line "Case Challenge Suggestion." We look forward to hearing from you. Background and Initial Presentation A 40-year-old man presents to the emergency department with complaints of repeated vomiting and dizziness for the past 2 days. He has no fever or diarrhea. He has been experiencing dyspepsia and abdominal fullness after meals for a month. These symptoms have increased during this time, causing him to decrease his food intake week by week. He has tried over-the-counter drugs, such as antacids and pantoprazole, with no effect. This condition has been associated with epigastric pain; his general practitioner tested him for Helicobacter pylori , which was negative. The patient has been a heavy smoker for the past 15 years, smoking one pack per day. Since his symptoms began, he has tried to quit smoking using nicotine patches. He attributed his dyspepsia to the use of the nicotine patch, considering his negative H pylori test. He therefore decreased the duration of his nicotine patch use, but his symptoms only minimally improved. He has also experienced easy fatigability over the past 4 months. He noted that at times during the previous month, his eyes have become yellow. His family history shows that his father died of colon cancer in his 50s. The patient's presentation is suspicious for hemolytic anemia, so it will be important to confirm this with a Coombs test and a peripheral blood smear for schistocytes.[1] ESR and CRP and GGT levels will not help diagnose the cause of hemolytic anemia. Physical Examination and Workup Examination: Blood pressure: 100/60 mm Hg Pulse: 95 beats/min Temperature: 37.5 °C (99.5 °F) General examination: Pallor of the inner lips; hand creases apparent, not faded Abdominal examination: Splenomegaly Laboratory investigations: Sodium: 130 mEq/L (range, 135-145) Potassium: 3 mEq/L (range, 3.5-5.2) Creatinine: 1.5 mg/dl (range, 0.7-1.3) Blood urea nitrogen: 50 mg/dL (range, 6-24) Coombs test: 3+ (range, 0-4) Hemoglobin: 9 g/dL (range for men, 13.2-16.6) Calcium level: 9 mg/dL (range, 8.5-10.2) Complete blood film shows schistocytes count of 6% (range, normal is < 0.5%, although usual values are < 0.2%) Mean corpuscular volume: 90 fl (range, 80-100) Platelet: 150,000/µL (range, 150,000-450,000) White blood cells: 6000/µL (range, 4,500-11,000) ESR: 120 mm/hr (range for men, < 50 years old: < 15) CRP: 70 mg/dL (range, < 0.3) A CT of the abdomen with contrast was taken, showing the lesions in Figure 1. Figure 1. Abdominal CT with contrast showing lesions. MAHA as a paraneoplastic syndrome in infiltrative gastric cancer is the most likely diagnosis. MAHA as a paraneoplastic syndrome is a rare presentation of metastatic gastric cancer, with only about 50 cases documented in the literature. MAHA is caused by tumor-associated thrombotic microangiopathy and is considered an oncologic emergency.[2] It is associated with poor prognosis.[3] In one single-center analysis, most of the patients with MAHA showed infiltrative diffuse gastric cancer with partial or complete signet ring cellular morphology. All patients had metastatic disease at the time of presentation of MAHA, either at first diagnosis or recurrence.[2] Gastric cancer (GC) is a major cause of cancer-related deaths, mostly due to diagnosis at advanced stages of the disease;[4] it is often asymptomatic in the early stages.[5] Asymptomatic cancers can present with nonspecific paraneoplastic symptoms such as anemia or endocrine disturbances. Rapid development of pernicious anemia due to adenocarcinoma of the stomach has been reported in the literature.[6] Advanced GC symptoms may include iron deficiency anemia.[5] Anemia due to bleeding in cancers presents as microcytic anemia with low iron and ferritin levels (although ferritin can be elevated as part of the immune response to cancer).[7] Anemia due to malabsorption is usually due to deficiencies of B12 or folate causing macrocytic anemia or to iron malabsorption causing microcytic anemia.[7,8] In this patient, the Coombs test result was positive for hemolytic anemia, and the blood smear indicated elevated schistocytes. His anemia is normocytic hemolytic anemia due to destruction of the red blood cells with elevated lactate dehydrogenase and schistocytes. The presence of clear invasive GC provides a cause of his anemia. In the CT of the abdomen with contrast (Figure 1), circumferential wall thickening up to 15 mm was seen throughout the stomach. Multiple enlarged pathologic lymph nodes were noted perigastric, peripancreatic, within the porta-hepatis, and para-aortic. The largest was seen at porta hepatis measuring 30 x 14 mm. Mild ascites was present. The liver echo pattern was inhomogeneous with multiple bilobar hypodense non-enhancing hepatic focal lesions: one in segment VI/VII measuring 8 x 7 mm and the other in segment III subcapsular exophytic lesion measuring 14 x 12 mm. An upper GI endoscopy was performed and biopsies were taken. Endoscopy showed thickened mucosa of the stomach with decreased gastric rugae and volume (Figure 2). Figure 2. Upper GI endoscopy showing thickened stomach mucosa with decreased gastric rugae and volume. The pathology report of the gastric antral biopsies showed diffuse signet ring cellular morphology stage III. Of note, in all newly diagnosed patients with GC, testing for microsatellite instability (MSI) status by PCR/next-generation sequencing or mismatch repair status by immunohistochemistry is recommended.[4] Testing for MSI status also should be done in patients with locally advanced and unresectable or metastatic GC to tailor treatment.[5] Signet ring cell cancer grade 3 usually shows recurrence within 2 years after standard treatment of radical surgery and chemotherapy. Signet ring cell cancer is often chemoresistant; even the use of adjuvant chemotherapy is controversial.[9] Adequate surgical resection is considered the main therapeutic option for signet ring cell GC;[10] surgery is recommended for appropriate metastatic GC candidates.[4] Advanced GC signet ring cell type is treated with 5-fluorouracil (5-FU);[11] for stage III, the treatment regimen is chemotherapy with a 5-FU-based combination.[2] For patients who are candidates for treatment with PD-1 inhibitors, PD-L1 testing may be considered. A specimen with a combined positive score ≥ 1 is viewed as exhibiting PD-L1 expression.[4] The patient was referred to surgery for a radical gastrectomy. After 1 month, he started chemotherapy with a 5-FU-based combination. After completing his 13-month course of chemotherapy, the patient began to experience cough and dyspnea. He presented to the emergency department with cyanosis and severe dyspnea. On examination, his temperature was normal but his oxygen saturation was 70%, and there was decreased air entry on both sides of the chest. A chest radiograph demonstrated bilateral pleural effusion. Chest CT with contrast was performed to exclude metastasis (Figure 3). The chest CT showed bilateral encysted pleural effusion with mild pericardial effusion. The lungs exhibited areas of atelectasis in relation to the effusion. Lung biopsies confirmed metastasis. Figure 3. Chest CT with contrast showing bilateral encysted pleural effusion. The findings indicated recurrence with metastatic presentation. Because of the late stage of disease and the type of tumor, the oncologist recommended personalized palliative immunotherapy to prolong survival and improve the patient's general condition. Immunotherapy options for GC include immunomodulators, checkpoint inhibitors,[4,5,12] and vaccines targeting the tumor.[12] The patient has recurrent disease following treatment with a 5-FU-containing regimen, and he had received a radical gastrectomy when he presented at stage III. His dyspnea is considered a rare presentation of GC, although it can occur in cases of pulmonary metastasis, pulmonary lymphangitic carcinomatosis, or pulmonary tumor thrombotic microangiopathy.[13] Immunotherapy for signet ring cell GC includes immune checkpoint inhibitors targeting PD-1 and PD-L1. In selected cases of signet ring cell cancer, where MSI is high with deficient mismatch repair proteins, immunotherapy with PD-1 could be effective.[10] PD-1 and PD-L1 checkpoint inhibitors decrease T-cell tolerance to the tumor cells, enhancing the body's adaptive immune response against cancer cells.[12] This patient had high MSI and started PD-1 inhibitor immunotherapy. His pulmonary symptoms improved, with decreased dyspnea and fatigue and increased oxygen saturation. Later chest CT showed absence of pleural effusion and pericardial effusion, and the metastatic nodules regressed. Signet ring cell GC comprises about 17% of primary gastric tumors.[14,15] Patients with signet ring cell gastric carcinoma usually exhibit higher TNM staging at presentation as compared with patients with non-signet ring cell tumors.[15] More patients with signet cell GC receive chemotherapy than those with non-signet cell cancer. Bone metastasis was higher in patients with signet ring cell cancer as compared with those with non-signet ring cell cancer GC in a large cohort (> 36,000) of GC patients.[15] First-line treatment for stage IV signet ring cell cancer includes palliative chemotherapy with docetaxel-5-FU-oxaliplatin. If the patient has stage IV disease at diagnosis, radical gastrectomy with chemotherapy (13 months) provides longer survival than chemotherapy alone (7 months).[14] However, in the REGATTA trial, palliative gastrectomy in stage IV disease did not provide any survival benefit over chemotherapy alone.[16] PD-1 inhibitor immunotherapy may be effective in patients with signet ring cell cancer with high MSI and deficient tumor mismatch repair.[10] As noted previously, PD-1 and PD-L1 checkpoint inhibitors decrease T-cell tolerance to the tumor cells, enhancing the body's adaptive immune response against cancer cells.[12] Although the patient's chest CT showed bilateral pleural effusion, that is not a prognostic marker for PD-1 inhibitor response. As noted earlier, signet ring cell cancer is often chemoresistant, and grade 3 usually shows recurrence within 2 years after the standard treatment of radical surgery and chemotherapy,[17] neither of which are prognostic markers for PD-1 inhibitor response.


Medscape
5 days ago
- Medscape
Medical Misogyny or Following the Differential Dx?
I recently presented a clinical scenario of a young woman who presented with fatigue and had a long history of nightmares. I was concerned that she might have posttraumatic stress disorder (PTSD), and I asked readers whether they agreed with my management of this patient. Thank you for the comments on this case. The majority of the comments focused on a workup for the patient's symptoms beyond mental illness, which is completely appropriate for this patient. First, a targeted history should be completed to include the following elements: Menstrual history to evaluate the possibility of anemia due to irregular menses and pregnancy Cold intolerance or skin and hair changes, as a potential sign of hypothyroidism Any alterations in appetite and diet, which could indicate disordered eating and/or a possible vitamin deficiency Medication use, including supplements Substance use I would also recommend the following basic laboratory evaluation: Other labs may be ordered, as needed, based on the patient's targeted history. But adding all those elements to this case would yield quite a lengthy document to read online! And of course, there are always more questions to ask of patients and more studies to be ordered, but the pressure of time in primary care dictates that we be judicious with our fact-gathering. Although my decision to ask the patient about past events that might relate to her fatigue and bad dreams was the most popular answer selected in the reader poll, some commenters disagreed with my approach. I was surprised by multiple comments that suggested my consideration of a potential psychological disorder would be considered patronizing or offensive to this patient, and one commenter recommended 'physiology before psychiatry.' I respectfully disagree. First, a mental health or sleep disorder is at the top of the differential diagnosis of an otherwise healthy young woman with fatigue. When a physician fails to address a potential mental health disorder for fear of offending said patient, they risk delayed diagnosis, worsening symptoms, diminished treatment options, and a breakdown of trust in her care, all of which could have devastating consequences. As mentioned in my original article, PTSD negatively affects multiple domains of function and is associated with an increased risk for suicide. I completely understand that patients can feel marginalized by the idea of a mental health diagnosis. And it's entirely understandable that a woman presenting with persistent fatigue might fear that a psychological explanation simply repeats historical patterns of medical sexism; after all, attributing women's health complaints to 'hysteria' is a real historical wrong. Yet when that same fatigue is coupled with a decade-long history of recurring nightmares — symptoms strongly suggestive of an underlying mood or stress ‐ related disorder — a thoughtful clinician must expand the differential diagnosis to include those possibilities. By transparently describing how each symptom fits into a broader clinical picture, the doctor honors the patient's concerns and makes a diagnosis based on comprehensive evidence, not gender bias. In responsible practice, a physician uses validated screening questions, explains the medical rationale clearly, and invites open dialogue with the patient (at their own pace). That way, mental health issues are assessed objectively, based on clinical need and symptom presentation. We, as a society, need to move away from stigmatizing mental health diagnoses, and that starts with the patient encounters we have every day. There is no reason that mental health diagnoses should be placed at some level below other diagnoses. Mental health diagnoses incur significant amounts of morbidity and are risk factors for other diseases, such as coronary heart disease. Patients who are diagnosed with mental health disorders should not feel any different from patients with a diagnosis of type 2 diabetes or rheumatoid arthritis. It is up to us, as clinicians, to lead insightful, evidence-based, empathic evaluations of our patients to accurately diagnose their conditions and treat them appropriately. I hope that this case reminds you of that calling.


Health Line
5 days ago
- Health Line
Does Medicare Cover a Kidney Transplant?
Key takeaways Medicare covers most services related to organ transplantation performed in approved hospitals, including heart, intestine, kidney, liver, and cornea transplants. Medicare Part A covers inpatient services during hospitalization. Part B covers doctor's services related to the transplant, and Part D helps cover prescription drugs needed for transplantation, including immunosuppressant drugs. Medicare generally covers almost all costs related to Medicare-approved organ transplants, including pre-transplant services, surgery, follow-up care, immunosuppressant drugs, and medical care for the organ donor. In this article, we'll discuss when Medicare covers organ transplants, what you need to know about Medicare coverage, and what out-of-pocket costs you can expect for organ transplantation. Which Medicare part covers a kidney transplant? Medicare Part A is hospital insurance. It covers any necessary services related to the following transplants: heart lung kidney pancreas intestine liver In addition, Medicare also covers other transplants that aren't organ transplants. This includes the following transplants: cornea stem cell bone marrow Under Part A, covered services include most inpatient services during hospitalization, such as laboratory testing, physical exams, room and board, and pre-and post-op care for you and your organ donor. On the other hand, Medicare Part B is medical insurance, which means it covers any doctor's services related to your transplant. Services covered under Part B include those related to your diagnosis and recovery, such as doctor's or specialist's visits, laboratory testing, or certain prescription drugs. Part B will also cover these services for your organ donor when necessary. Part C Medicare Part C (Medicare Advantage) covers all the services listed above in Part A and Part B. Some Part C plans also cover prescription drugs and possibly additional health perks, like fitness memberships and meal services. Medicare Advantage Special Needs Plans (SNPs) are plans that offer coordinated services for people with chronic or disabling conditions. These plans can be especially beneficial to people who have certain conditions that may require an organ transplant, such as end stage renal disease and chronic heart failure. Part D Medicare Part D helps cover prescription drugs needed for organ transplantation. While Part D coverage varies by plan, all Medicare prescription drug plans must cover immunosuppressant drugs. These medications, which weaken your immune system to make it less likely that your body will reject a new organ, are required for transplantation. Most prescription drug plans also cover other medications that may be necessary for organ transplant recovery, such as pain relievers, antidepressants, and others. When does Medicare cover organ transplants? Once a doctor has determined that a Medicare beneficiary requires a covered organ transplant, the program should cover the procedure. Medicare doesn't set any criteria for covered organ transplants, but exceptions to this are people undergoing intestine or pancreas transplants must have their transplants at a hospital with a Medicare-approved liver and kidney transplant program, respectively. In addition, organ transplant programs generally have eligibility requirements. What these requirements are depends on the type of transplant and may involve limitations on age or people living with certain health conditions. How much does an organ transplant cost with and without Medicare? According to a 2020 research report on transplant costs in the United States, the average costs for organ transplants include: Heart transplant: $1,664,800 Lung transplant: $1,295,900 (double lung) or $929,600 (single lung) Intestine transplant: $1,240,700 Liver transplant: $878,400 Kidney transplant: $442,500 Pancreas transplant: $408,800 Medicare pays for most services and costs associated with Medicare-approved organ transplants. Services include: pretransplant services, such as testing, lab work, and exams surgery follow-up services immunosuppressant and other necessary prescription drugs, in some cases Medicare also pays for all costs related to finding a donated organ and all medical care for the organ donor, such as doctor's visits, surgery, and other necessary medical services. While Medicare covers almost all organ transplantation costs, you'll still owe out-of-pocket costs. Out-of-pocket costs for organ transplant in 2025 Type of cost Medicare Part A Medicare Part B Medicare Part C Medicare Part D Monthly premium $0 to $518, depending on your work history $185, depending on your income depends on the plan you choose depends on the plan you choose Deductible $1,676 per benefit period $257 per year depends on the plan you choose $0 to $590, depending on the plan you choose Copay and coinsurance coinsurance of 0% to 100% per day, depending on how many days you stay 20% of the Medicare-approved amount for covered services depends on the plan you choose coinsurance or copays depend on the plan you choose You may have other costs associated with your organ transplant surgery that Medicare doesn't cover. These out-of-pocket costs may include: transportation and lodging for the surgery child care or other expenses at home potential loss of income What if you can't afford a kidney transplant? Your Medicare coverage should significantly lower your out-of-pocket cost for your transplant. In addition, you may be able to lower your remaining out-of-pocket costs by enrolling in a Medicare supplement plan or Medigap. Medigap helps cover Original Medicare deductibles, copayments, and coinsurance. Some Medigap plans also cover Part B excess charges and foreign travel costs. That said, you cannot use Medigap with Part C. Your transplant provider may also offer a payment plan so that you can spread the cost over a longer period of time. In addition, if your income falls below a certain threshold, you may also qualify for Medicaid. In addition, the American Transplant Foundation lists several organizations that offer resources on fundraising for a transplant. Are liver transplant patients eligible for Medicare? If you are not eligible for Medicare but anticipate that you require an organ transplant, your eligibility for Medicare depends on either your age or the type of transplant that you need. Anyone ages 65 and over is automatically eligible for Medicare, and by law, no insurance plan can deny you based on a preexisting condition. That said, if you are younger than 65 and you need a transplant, you can only qualify for Medicare if you are living with end stage renal disease (ESRD) and are undergoing dialysis. Other types of needed organ transplants do not count for this exception. Takeaway An organ transplant can be an expensive surgery, but Medicare generally covers beneficiaries for almost all services under their plan. Part A covers most hospital-related services, while Part B covers most medical-related services. Part D can help cover prescription drug costs for immunosuppressants you may need to take before or after the transplant, while Medigap can help tackle some of the out-of-pocket costs associated with each Medicare plan. Contact your doctor or healthcare team for more information on what Medicare will cover for your organ transplant surgery and what to expect. The information on this website may assist you in making personal decisions about insurance, but it is not intended to provide advice regarding the purchase or use of any insurance or insurance products. Healthline Media does not transact the business of insurance in any manner and is not licensed as an insurance company or producer in any U.S. jurisdiction. Healthline Media does not recommend or endorse any third parties that may transact the business of insurance.