Children''s Hospital of Michigan,Detroit Medical Center

Pulse oximetry (SpO₂) is central to oxygenation assessment in pediatric and cardiac intensive care. Increasing evidence demonstrates that SpO₂ may systematically overestimate arterial oxygen saturation (SaO₂), particularly in individuals with darker skin pigmentation, thereby increasing the risk of occult hypoxemia—arterial hypoxemia not detected by pulse oximetry. We sought to synthesize current evidence and define implications for pediatric and congenital heart disease populations. We performed a narrative review of experimental physiology studies; observational adult and pediatric cohorts; pediatric COVID-19, ICU, and cardiac ICU investigations; device-comparison analyses; systematic reviews; and regulatory evaluations reporting paired SpO₂–SaO₂ measurements or validated reference standards stratified by race, ethnicity, or objectively measured skin pigmentation. Data sources included PubMed, MEDLINE, and bibliographies of relevant studies. Experimental data demonstrate directional SpO₂ overestimation that increases during hypoxemia. Large adult cohorts confirm higher rates of occult hypoxemia in patients with darker skin pigmentation, findings subsequently replicated in hospitalized children. Emerging pediatric cardiac ICU data suggest that physiologic complexity may further amplify SpO₂–SaO₂ discordance. Device-comparison studies reveal variability across manufacturers, influenced by calibration datasets and signal-processing algorithms. Across populations, misclassification is most clinically relevant near commonly used escalation thresholds. SpO₂ frequently overestimates SaO₂ in darker skin pigmentation and during hypoxemia, increasing vulnerability to occult hypoxemia in hospitalized and critically ill children. In pediatric cardiac populations—where narrow saturation thresholds guide management—contextual, bias-aware interpretation of pulse oximetry is essential to support accurate decision-making and equitable care.

BACKGROUND:About 90% of cases with idiopathic nephrotic syndrome (NS) respond to corticosteroids. The remaining 10%, classified as steroid-resistant nephrotic syndrome (SRNS), typically undergo a kidney biopsy before receiving additional immunosuppression. This study examined the extent to which kidney biopsy findings influenced management in children and young adults with newly diagnosed idiopathic SRNS. METHODS:We conducted a retrospective chart review of patients aged 1-21 years and diagnosed with SRNS at the Detroit Medical Center from January 2000 to December 2024. Exclusion criteria were patients with syndromic diagnoses and presentation with gross hematuria, hypertension, or identifiable systemic disease. RESULTS:The study included 55 patients, 46 underwent kidney biopsy after the diagnosis of SRNS (mean age 10.9 ± 4.6 years), and 9 had elective biopsies based on age before being diagnosed with SRNS (mean age 16 ± 1.7 years). Biopsy diagnoses included focal segmental glomerulosclerosis (72%), minimal change disease (24%), and membranous nephropathy (4%). Sixty-five percent of cases had mild to moderate interstitial fibrosis/tubular atrophy. Most patients (84%) were admitted overnight, 71% had flank or back pain, and 15% had a hematoma. Post-biopsy, 96% of patients received calcineurin inhibitors (CNIs): cyclosporine (n = 38) or tacrolimus (n = 15). At one year, 96% remained on CNIs. CONCLUSIONS:Kidney biopsy did not significantly alter immunosuppressive management in newly diagnosed patients with SRNS at our center. Larger multicenter studies are needed to confirm these findings and evaluate whether more selective biopsy criteria could spare patients from a potentially avoidable invasive procedure, improve clinical management, and reduce healthcare costs.

OBJECTIVES:Linoleic acid (LA) is the most abundant polyunsaturated fatty acid in diet, and it is a precursor to inflammatory lipid mediators called oxylipins. The role of LA and its oxylipins in pediatric sepsis and organ injury is uncertain. Recently, pediatric sepsis phenotypes were described, with phenotype D characterized by the highest proportion of acute kidney injury (AKI), multiple organ failure, and risk of death. We aimed to test the hypothesis LA may play a role in sepsis-associated organ dysfunction. We therefore investigated whether increasing plasma LA and LA-derived lipoxygenase oxylipins are associated with sepsis phenotype D and with AKI in a cohort of critically ill children with sepsis. DESIGN:We studied a subset of 108 patients from the Phenotyping Sepsis-Induced Multiple Organ Failure Study (PHENOMS) cohort by means of untargeted metabolomics of heparinized plasma samples. Primary outcome was phenotype group. Key secondary outcomes included AKI (defined as both creatinine > 1 mg/dL and oliguria < 0.5 mL/kg/hr), other organ dysfunctions, and hospital mortality. Patients were followed up until discharge or 28 days. SETTING:ICU. PATIENTS:One hundred eight patients with sepsis. INTERVENTIONS:None. MEASUREMENTS AND MAIN RESULTS:Higher LA levels were associated with sepsis phenotype D as compared with phenotypes A-C (odds ratio [OR], 1.67; 95% CI, 1.05-2.65; p = 0.03). LA-derived oxylipins 9-hydroxyoctadecadienoic acid and 13-hydroxyoctadecadienoic acid (9-HODE/13-HODE) were also associated with sepsis phenotype D (jointly reported in one variable; OR, 1.26; 95% CI, 1.01-1.57; p = 0.04). Higher LA showed a trend and 9-HODE/13-HODE was associated with AKI (OR, 1.52; 95% CI, 0.97-2.38; p = 0.07 and OR, 1.27; 95% CI, 1.03-1.56; p = 0.02, respectively). Neither LA nor oxylipins were associated with hospital mortality. CONCLUSIONS:LA levels and LA-derived lipoxygenase oxylipins are associated with pediatric sepsis phenotype D and AKI. These results support future mechanistic studies to investigate lipid metabolism in the pathophysiology of sepsis.

Genetic Counselors (GCs) hold the dual responsibility to engage in patient-centered psychosocial counseling and to recognize when a patient's needs require referral to another healthcare professional (HCP). While previous work has shown that GCs use a variety of patient factors to determine when they could benefit from additional supportive services, we sought to better understand how GCs determine whether to refer a patient to another HCP or engage in more complex psychosocial counseling. Utilizing a multimethods approach, we used two sets of surveys to learn about our participants but ultimately prioritized the qualitative data from in-depth semistructured interviews with 15 participants (N = 15). Initial data collection and analysis relied on constructivist interpretive frameworks of grounded theory, which supported learning directly from participants while maintaining our ability to delve into issues raised by the participants. An iterative process of coding, reviewing, memoing, and testing resulted in the development of several conceptual models of possible theories. Through continued review of the data and guided by an interpretivism paradigm, we elected to honor the breadth of information shared by participants, abandoning our initial goal of defining a single theory to instead define three core conceptual categories related to GCs' consideration of providing psychosocial counseling or referring: (1) For GCs, it's personal! GC beliefs in themselves, their personal identities, and their conceptualization of the role of a "GC" influence their engagement in psychosocial assessment and support; (2) Training matters, but experience is key; and (3) Referrals occur when GCs are aware of and trust that another HCP/resource will be a good fit for a patient's need and that a patient can actually access it. These findings suggest that GC confidence in managing patient care evolves with experience and highlight the value of ongoing skill development for all practitioners.