Nancy R Fefferman, M.D.

The efficacy of digital fluoroscopic image capture in the evaluation of vesicoureteral reflux in children
Fefferman, Nancy R; Sabach, Amy S; Rivera, Rafael; Milla, Sarah; Pinkney, Lynne P; Strubel, Naomi A; Babb, James
2009 Nov;39(11):1179-1187, Pediatric radiology
BACKGROUND: In accordance with ALARA, minimizing radiation exposure associated with voiding cystourethrograms (VCUG) is of critical importance. Advances in fluoroscopic technology might help achieve this goal. OBJECTIVE: To determine the efficacy of fluoroscopic image capture compared to conventional digital radiographic spot (DRS) images in voiding cystourethrograms (VCUG) for the evaluation of vesicoureteral reflux (VUR) in children. MATERIALS AND METHODS: The study was a retrospective review of 65 VCUG examinations (130 kidney/ureter units). Each examination consisted of fluoroscopically captured spot (FCS) images and the corresponding DRS images. Each set of images was evaluated by three pediatric radiologists for the diagnosis of VUR for a total of 390 kidney/ureter units reviewed. Using the DRS image set as the reference standard, the efficacy of the FCS images for diagnosing reflux was determined. RESULTS: The diagnostic accuracy of the FCS images in terms of the binary characterization of reflux as negative or positive was 97.2% (379/390). The sensitivity of the FCS images was 92.6% (88/95); the specificity of the FCS images was 98.6% (291/295). CONCLUSION: Fluoroscopically captured images are adequate in documenting absence of VUR on VCUG examinations, obviating the need for radiographic spot images and resulting in reduction in radiation exposure
— id: 106491, year: 2009, vol: 39, page: 1179, stat: Journal Article,

Ultrasound of pediatric abdominal and scrotal emergencies
Amodio J.; Fefferman N.
2007 ;36(12):22-23, Applied radiology
— id: 75441, year: 2007, vol: 36, page: 22, stat: Journal Article,

Splenic infarction due to concomitant hereditary spherocytosis and sickle cell trait
Dulman, Robin Yates; Buchanan, George R; Ginsburg, Howard; Fefferman, Nancy R; Greco, M Alba; Borys, Dariusz; Blei, Francine
2007 Dec;42(12):2129-2131, Journal of pediatric surgery
Concomitant hereditary spherocytosis and sickle cell trait, although extremely rare, could potentially lead to splenic sequestration or infarction. We report here the first case of splenic infarction in a child with hereditary spherocytosis and sickle cell trait while flying on a commercial aircraft. The presence of hypoxia, hemoconcentrated erythrocytes, and sickle hemoglobin created the perfect environment for clinical sequelae
— id: 75677, year: 2007, vol: 42, page: 2129, stat: Journal Article,

The relationship between alpha angle and resistive index of the femoral epiphysis in the normal and abnormal infant hip
Amodio, John; Rivera, Rafael; Pinkney, Lynne; Strubel, Naomi; Fefferman, Nancy
2006 Aug;36(8):841-844, Pediatric radiology
BACKGROUND: The arterial vascularity of the hip has been investigated in normal infants using duplex Doppler sonography. This study addressed the differences in hip vascularity in infants with respect to gender and acetabular morphology. OBJECTIVE: To determine whether there is a relationship between the resistive index of the vessels of the femoral chondroepiphysis and the alpha angle in normal infant hips and in those with developmental dysplasia of the hip. MATERIALS AND METHODS: We studied 76 hips (38 patients) with gray-scale and power Doppler US. The patients were referred because of a possible abnormal clinical hip examination or had risk factors for developmental dysplasia of the hip. The infants ranged in age from 1 day to 6 weeks. There were 13 boys and 25 girls. Gray-scale images were initially performed in the coronal and transverse planes to evaluate acetabular morphology, alpha angle and position of the femoral chondroepiphysis relative to the acetabulum. The hips were then examined with power Doppler US, in both sagittal and transverse planes, to identify arterial vessels within the femoral epiphysis. Resistive indices were then recorded from the spectral analysis in each vessel identified. Each examination was performed by one of five pediatric radiologists. Mixed model regression was used to assess the relationship between resistive index and alpha angle, age and gender. RESULTS: Of the 76 hips, 34 had an alpha angle of 60 degrees or greater and were classified as normal, 26 had an alpha angle between 50 degrees and 59 degrees and were classified as immature, and 13 had an alpha angle of less than 50 degrees and were either subluxed or dislocated at the time of examination. At least two vessels were documented in each femoral epiphysis except in three hips, in which no vessels could be documented because of technical factors. There was a statistically significant linear relationship between the alpha angle and resistive index, such that the resistive index tended to rise with increasing alpha angle (P=0.0022). In addition, female infants had a significantly higher average resistive index than the average resistive index in male infants with the same alpha angle (P=0.0005). CONCLUSION: There is a direct linear relationship between alpha angle and resistive index in the infant hip. Female infants have a higher average resistive index than male infants. We believe that these results might serve as a model for predicting an infant hip at risk of ischemia. In addition, the fact that lower resistive indices of the femoral epiphysis are associated with acetabular dysplasia might help explain the documented low incidence of avascular necrosis in untreated hip dysplasia
— id: 71139, year: 2006, vol: 36, page: 841, stat: Journal Article,

Splenic infarction due to concomitant hereditary spherocytosis and sickle cell trait
Yates, R; Buchanan, GR; Ginsburg, H; Fefferman, N; Greco, MA; Borys, D; Blei, F
2006 NOV 16 ;108(11):8B-9B, Blood
— id: 71216, year: 2006, vol: 108, page: 8B, stat: Journal Article,

Metanephric adenoma in an 8-year-old child: case report and review of the literature
Amodio, John B; Shapiro, Ellen; Pinkney, Lynne; Rivera, Rafael; Strubel, Naomi; Douglas, Diah; Fefferman, Nancy
2005 May;40(5):e25-e28, Journal of pediatric surgery
Metanephric adenoma (MA) is a renal tumor that is rarely found in children. We present a case of MA that was incidentally discovered in an 8-year-old child on computed tomography. We also review the literature regarding this lesion in the pediatric population. There are certain imaging features of MA that may suggest the diagnosis preoperatively. Metanephric adenoma is often hyperechoic on sonography, hyperdense on noncontrast computed tomography scans, and of low signal intensity on T1- and T2-weighted magnetic resonance images. Nephron sparring surgery has been performed in several cases. However, the distinction of MA from other metanephric lesions as well as from Wilms' tumor and papillary renal cell carcinoma may not be readily apparent at the time of surgery
— id: 56145, year: 2005, vol: 40, page: e25, stat: Journal Article,

Tuberculous splenic abscess in a neonate with thrombocytopenia
Amodio, John; Biskup, Darius; Rivera, Rafael; Shah, Shetal; Fefferman, Nancy
2005 Sep;35(9):887-890, Pediatric radiology
We present a case of a premature neonate who presented with anemia and persistent thrombocytopenia. The patient was ultimately diagnosed with disseminated tuberculosis. Initial sonographic evaluation of the abdomen revealed a heterogeneous but predominately hypoechoic spleen; there was subsequent evolution of a splenic abscess. The patient was treated medically with anti-tubercular drugs. Follow-up post-treatment sonograms of the spleen showed diminution of the abscess and the evolution of multiple calcifications compatible with calcified granulomas. This case is an unusual presentation of tuberculosis in an infant with splenic abscess associated with thrombocytopenia and anemia
— id: 56147, year: 2005, vol: 35, page: 887, stat: Journal Article,

Spontaneous development of bilateral subdural hematomas in an infant with benign infantile hydrocephalus: color Doppler assessment of vessels traversing extra-axial spaces
Amodio, John; Spektor, Vadim; Pramanik, Bidyut; Rivera, Rafael; Pinkney, Lynne; Fefferman, Nancy
2005 Nov;35(11):1113-1117, Pediatric radiology
We present an infant with macrocrania, who initially demonstrated prominent extra-axial fluid collections on sonography of the brain, compatible with benign infantile hydrocephalus (BIH). Because of increasing macrocrania, a follow-up sonogram of the brain was performed; it revealed progressive enlargement of the extra-axial spaces, which now had echogenic debris. Color Doppler US showed bridging veins traversing these extra-axial spaces, so it was initially thought that these spaces were subarachnoid in nature (positive cortical vein sign). However, an arachnoid membrane was identified superior to the cortex, and there was compression of true cortical vessels beneath this dural membrane. An MRI of the brain showed the extra-axial spaces to represent bilateral subdural hematomas. The pathogenesis of spontaneous development of the subdural hematomas, in the setting of BIH, is discussed. We also emphasize that visualizing traversing bridging veins through extra-axial spaces does not necessarily imply that these spaces are subarachnoid in origin
— id: 56146, year: 2005, vol: 35, page: 1113, stat: Journal Article,

Primary bacterial peritonitis in otherwise healthy children: imaging findings
Dann, Phoebe H; Amodio, John B; Rivera, Rafael; Fefferman, Nancy R
2005 Feb;35(2):198-201, Pediatric radiology
We report the imaging findings of two recent cases of primary bacterial peritonitis in otherwise healthy children with a clinical presentation mimicking acute appendicitis. Primary bacterial peritonitis is rare in the absence of underlying systemic disease. Although it has been described in the pediatric literature, the imaging findings have not been described in the radiological literature to the best of our knowledge. With imaging playing an increasing role in the evaluation of appendicitis in children, it is important for the radiologist to be familiar with this inflammatory process
— id: 56030, year: 2005, vol: 35, page: 198, stat: Journal Article,

Appendicitis in children: low-dose CT with a phantom-based simulation technique--initial observations
Fefferman, Nancy R; Bomsztyk, Elan; Yim, Angela M; Rivera, Rafael; Amodio, John B; Pinkney, Lynne P; Strubel, Naomi A; Noz, Marilyn E; Rusinek, Henry
2005 Nov;237(2):641-646, Radiology
PURPOSE: To retrospectively determine the accuracy of low-dose (20-mAs) computed tomography (CT) in the diagnosis of acute appendicitis in children by using a technique that enables the simulation of human CT scans acquired at a lower tube current given the image acquired at a standard dose. MATERIALS AND METHODS: Institutional review board approval was obtained, informed consent was not required, and the study was HIPAA compliant. The authors reviewed 100 standard-dose pediatric abdominal-pelvic CT scans (50 positive and 50 negative scans) obtained in 100 patients and corresponding simulated low-dose (20-mAs) scans. The standard-dose scans were obtained for evaluation in patients suspected of having appendicitis. Scans were reviewed in randomized order by four experienced pediatric radiologists. The patients with positive findings included 21 girls (mean age, 9.2 years) and 29 boys (mean age, 8.4 years). The patients with negative findings included 28 girls (mean age, 9.2 years) and 22 boys (mean age, 8.4 years). Simulation was achieved by adding noise patterns from repeated 20-mAs scans of a pediatric pelvis phantom to the original scans obtained with a standard tube current. Observers recorded their confidence in the diagnosis of appendicitis by using a six-point scale. Dose-related changes were analyzed with generalized estimating equations and the nonparametric sign test. RESULTS: There was a statistically significant (P < .001, sign test) decrease in both sensitivity and accuracy with a lower tube current, from 91.5% with the original tube current to 77% with the lower tube current. A low dose was the only statistically significant (P < .001) risk factor for a false-negative result. The specificity was unchanged at 94% for both the images obtained with the original tube current and the simulated low-dose images. The overall accuracy decreased from 92% with the original dose to 86% with the low dose. CONCLUSION: Preliminary findings indicate that it is feasible to optimize the CT dose used to evaluate appendicitis in children by using phantom-based computer simulations
— id: 62345, year: 2005, vol: 237, page: 641, stat: Journal Article,

Imaging evaluation of chest wall disorders in children
Fefferman, Nancy R; Pinkney, Lynne P
2005 Mar;43(2):355-370, Radiologic clinics of North America
This article discusses the imaging evaluation of chest wall disorders in children
— id: 51098, year: 2005, vol: 43, page: 355, stat: Journal Article,

Idiopathic intraparenchymal hematoma of the liver in a neonate
Amodio, John; Fefferman, Nancy; Rivera, Rafael; Pinkney, Lynne; Strubel, Naomi
2004 Apr;34(4):358-361, Pediatric radiology
Hepatic hematomas in newborn infants are not frequently detected clinically, but are often found at perinatal autopsies. These hematomas of the liver are usually subcapsular in location. A variety of etiologies for such hematomas has been implicated, such as trauma, sepsis, and coagulopathies. We present a neonate who presented with jaundice and abdominal distention. Initial imaging studies revealed a large intraparenchymal lesion of the liver, which was at first thought to be suspicious for neoplasm; however, MRI showed the lesion to be hemorrhagic and follow-up sonographic studies showed total resolution of this lesion, compatible with hematoma. The intraparenchymal location and the idiopathic nature of this lesion distinguish this case from others previously reported
— id: 42147, year: 2004, vol: 34, page: 358, stat: Journal Article,

Thymoma in children: report of two cases and review of literature
Dhall, Girish; Ginsburg, Howard B; Bodenstein, Lawrence; Fefferman, Nancy R; Greco, M Alba; Chang, Mary W; Gardner, Sharon
2004 Oct;26(10):681-685, Journal of pediatric hematology/oncology
Thymoma is an uncommon tumor of childhood. Stage of the tumor is an independent prognostic factor for survival. Surgery is the treatment of choice for stage I and stage II tumors. Chemotherapy is reserved for patients with refractory or metastatic disease. Thymomas are moderately radiosensitive. However, radiation therapy is not an attractive option for children due to its side-effects on developing organs. The authors describe 2 children with completely encapsulated thymoma who were successfully treated with surgery alone. Both patients remain free of disease 3 years after surgery. One of the patients also has nevus sebaceous. The authors also discuss the possible association between the two disease entities
— id: 95965, year: 2004, vol: 26, page: 681, stat: Journal Article,

Risk of serious bacterial infection in young febrile infants with respiratory syncytial virus infections
Levine, Deborah A; Platt, Shari L; Dayan, Peter S; Macias, Charles G; Zorc, Joseph J; Krief, William; Schor, Jeffrey; Bank, David; Fefferman, Nancy; Shaw, Kathy N; Kuppermann, Nathan
2004 Jun;113(6):1728-1734, Pediatrics
BACKGROUND: The evaluation of young febrile infants is controversial, in part because it is unclear whether clinical evidence of a viral infection significantly reduces the risk of serious bacterial infections (SBIs). Specifically, it remains unclear whether the risk of SBI is altered in a meaningful way in the presence of respiratory syncytial virus (RSV) infections. OBJECTIVE: The objective of this study was to determine the risk of SBI in young febrile infants who are infected with RSV compared with those without RSV infections. METHODS: We conducted a 3-year multicenter, prospective, cross-sectional study. All febrile (> or =38 degrees C) infants who were < or =60 days of age and presented to any of 8 pediatric emergency departments from October through March 1998-2001 were eligible. General clinical appearance was evaluated using the Yale Observational Scale. We determined RSV status by antigen testing of nasopharyngeal secretions. We defined bronchiolitis as either wheezing alone or chest retractions in association with an upper respiratory infection. We evaluated infants with blood, urine, cerebrospinal fluid, and stool cultures. Urinary tract infection (UTI) was defined by single pathogen growth of > or =5 x 10(4) cfu/mL, or > or =10(4) cfu/mL in association with a positive urinalysis in a catheterized specimen, or > or = 10(3) cfu/mL in a suprapubic aspirate. Bacteremia, bacterial meningitis, and bacterial enteritis were defined by growth of a known bacterial pathogen. SBI was defined as any of the above-mentioned 4 bacterial infections. RESULTS: We enrolled 1248 patients, including 269 (22%) with RSV infections. The overall SBI status could be determined in 1169 (94%) of the 1248 patients, and the rate of SBIs was 11.4% (133 of 1169; 95% confidence interval [CI]: 9.6%-13.3%). The rate of SBIs in the RSV-positive infants was 7.0% (17 of 244; 95% CI: 4.1%-10.9%) compared with 12.5% (116 of 925; 95% CI: 10.5%-14.8%) in the RSV-negative infants (risk difference: 5.5%; 95% CI: 1.7%-9.4%). The rate of UTI in the RSV-positive infants was 5.4% (14 of 261; 95% CI: 3.0%-8.8%) compared with 10.1% (98 of 966; 95% CI: 8.3%-12.2%) in the RSV-negative infants (risk difference: 4.7%; 95% CI: 1.4%-8.1%). The RSV-positive infants had a lower rate of bacteremia than the RSV-negative infants (1.1% vs 2.3%; risk difference: 1.2%; 95% CI: -0.4% to 2.7%). No RSV-positive infant had bacterial meningitis (0 of 251; 95% CI: 0%-1.2%); however, the differences between the 2 groups with regard to bacteremia and bacterial meningitis did not achieve statistical significance. CONCLUSIONS: Febrile infants who are < or =60 days of age and have RSV infections are at significantly lower risk of SBI than febrile infants without RSV infection. Nevertheless, the rate of SBIs, particularly as a result of UTI, remains appreciable in febrile RSV-positive infants
— id: 43782, year: 2004, vol: 113, page: 1728, stat: Journal Article,

Assessment of vasculature using combined MRI and MR angiography
Roche, Kevin J; Rivera, Rafael; Argilla, Michael; Fefferman, Nancy R; Pinkney, Lynne P; Rusinek, Henry; Genieser, Nancy B
2004 Apr;182(4):861-866, American journal of roentgenology
OBJECTIVE: The purpose of this study was to compare combined cine gradient-recalled echo MRI and MR angiography with conventional angiography in the evaluation of the pulmonary vascular supply in patients with pulmonary atresia, ventricular septal defect, and major aortopulmonary collateral arteries. MATERIALS AND METHODS: Eleven patients who underwent both MRI and conventional angiography were retrospectively reviewed. Contiguous 2D cine gradient-recalled echo images (TR range/TE, 30-80/4.8; flip angle, 20 degrees or 30 degrees ) and 3D MR angiographic images (TR range/TE range, 3.8-5.0/1.3-2.0; acquisition time, 13-32 sec) using gadopentetate meglumine (0.1-0.2 mmol/kg) were obtained. The presence, size, and course of the pulmonary arteries (main, right, left) and major aortopulmonary collateral arteries (>/= 5 mm) were determined. Presence of minor collateral arteries (< 5 mm) was also noted. Results were compared with findings at conventional angiography. RESULTS: MRI showed all main (n = 4) and branch (n = 17) pulmonary arteries found at conventional angiography and showed the pulmonary confluence in five of six cases. MRI showed all major aortic collaterals (n = 22) with a highly significant correlation between MRI and conventional angiography measurements (r = 0.84, p < 0.001 [95% confidence interval, -0.35 to 0.40]). One coronary artery collateral was not shown on MRI examination. At MRI, 12 of 14 major and four of seven minor brachiocephalic artery collaterals were shown. MRI showed more minor aortic collaterals than angiography (22 vs 18 vessels, respectively). CONCLUSION: Combined cine gradient-recalled echo MRI and MR angiography is a reliable method for imaging pulmonary vascular supply in patients with these disorders. Additional prospective studies comparing MRI and conventional angiography may determine whether routine preoperative conventional angiography is required
— id: 43783, year: 2004, vol: 182, page: 861, stat: Journal Article,

Sclerosing stromal tumor of the ovary in a premenarchal female
Fefferman, Nancy R; Pinkney, Lynne P; Rivera, Rafael; Popiolek, Dorota; Hummel-Levine, Pascale; Cosme, Jaqueline
2003 Jan;33(1):56-58, Pediatric radiology
Sclerosing stromal tumor (SST) is a rare benign ovarian neoplasm of stromal origin with less than 100 cases reported in the literature. Unlike the other stromal tumors, thecomas and fibromas, which tend to occur in the fifth and sixth decades, sclerosing stromal tumors predominantly affect females in the second and third decades. Computed tomography (CT), magnetic resonance imaging (MRI), and ultrasound findings have been described, but have not been reported previously in the pediatric literature. We present a case of SST of the ovary in a 10-year-old premenarchal female, the youngest patient to our knowledge reported in the literature, and describe the ultrasound and CT findings with pathologic correlation
— id: 33063, year: 2003, vol: 33, page: 56, stat: Journal Article,

Suspected appendicitis in children: focused CT technique for evaluation
Fefferman NR; Roche KJ; Pinkney LP; Ambrosino MM; Genieser NB
2001 Sep;220(3):691-695, Radiology
PURPOSE: To determine the accuracy of a focused computed tomographic (CT) technique with oral and intravenous contrast materials for the diagnosis of appendicitis. MATERIALS AND METHODS: Ninety-three abdominal-pelvic contrast material-enhanced CT scans obtained during 6 years in 54 girls and 39 boys (age range, 1-18 years) with right lower quadrant pain were retrospectively reviewed. The detected abnormal findings were recorded as being in the region above the upper pole of the right kidney, between the upper pole of the right kidney and the lower pole of the right kidney (RLP), or below the iliac crest. Sensitivity, specificity, and positive and negative predictive values were calculated. chi(2) analysis was performed to determine whether there were significant differences among patient groups according to region of detected disease. RESULTS: Fifty-five scans were abnormal: 38 showed appendicitis; and 17, other diseases. No scans, except two that showed pneumonia, had key findings above the RLP. Nineteen scans showed key findings between the RLP and the iliac crest. Thirty-three scans had diagnostic findings only below the iliac crest. The sensitivity (97%), specificity (93%), positive predictive value (90%), and negative predictive value (98%) of interpretation with all images for the diagnosis of appendicitis were the same as those of interpretation with only the focused images. CONCLUSION: CT performed to diagnose appendicitis can be limited to the region below the RLP
— id: 26676, year: 2001, vol: 220, page: 691, stat: Journal Article,

Pneumocystis carinii infection presenting as an intra-abdominal cystic mass in a child with acquired immunodeficiency syndrome
Hagmann S; Merali S; Sitnitskaya Y; Fefferman N; Pollack H
2001 Oct 15;33(8):1424-1426, Clinical infectious diseases
We describe the case of a pediatric patient with acquired immunodeficiency syndrome (AIDS) with an unusual large, fluid-filled intra-abdominal cystic lesion in which Pneumocystis carinii trophozoites were identified. Extrapulmonary P. carinii infection should be considered in the differential diagnosis of an intra-abdominal cystic mass in a child with AIDS
— id: 26617, year: 2001, vol: 33, page: 1424, stat: Journal Article,

Short rib-polydactyly syndrome: more evidence of a continuous spectrum
Sarafoglou K; Funai EF; Fefferman N; Zajac L; Geneiser N; Paidas MJ; Greco A; Wallerstein R
1999 Aug;56(2):145-148, Clinical genetics
We report a fetus with radiological features of the four established types of short rib-polydactyly syndrome (SRPS). The phenotype of this fetus supports the previously suggested hypothesis that the different subtypes of the short rib and polydactyly syndrome are not single entities, but rather, part of a continuous spectrum with variable expressivity
— id: 8644, year: 1999, vol: 56, page: 145, stat: Journal Article,

Monitoring of girls undergoing medical therapy for isosexual precocious puberty
Ambrosino MM; Hernanz-Schulman M; Genieser NB; Sklar CA; Fefferman NR; David R
1994 Jul;13(7):501-508, Journal of ultrasound in medicine
We evaluated the use of sonography in monitoring the efficacy of suppressive therapy with a gonadotropin releasing hormone analogue in girls being treated for isosexual precocious puberty. Ten girls 5 to 9 years of age underwent serial sonography and hormonal stimulation tests on the same day. Sonographic trends of decreasing ovarian volume and uterine length indicated early suppression even when absolute values were above threshold. Changes in ovarian volume were the most sensitive predictor of pituitary-gonadal suppression. Sonography is a sensitive and accurate method of monitoring medical therapy; ovarian volume and analysis of interval change are the most sensitive barometers of change
— id: 6566, year: 1994, vol: 13, page: 501, stat: Journal Article,