560 1St Ave
New York NY 10016
Medical School: New York University School Of Medicine - 1991
Accepts Medicare: Yes
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License #: 197256
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The challenging ultrasound diagnosis of perforated appendicitis in children: constellations of sonographic findings improve specificity. - Pediatric radiology
Rapid and accurate diagnosis of appendicitis, particularly with respect to the presence or absence of perforation, is essential in guiding appropriate management. Although many studies have explored sonographic findings associated with acute appendicitis, few investigations discuss specific signs that can reliably differentiate perforated appendicitis from acute appendicitis prior to abscess formation.The purpose of our study was to identify sonographic findings that improve the specificity of US in the diagnosis of perforated appendicitis. Our assessment of hepatic periportal echogenicity, detailed analysis of intraperitoneal fluid, and formulation of select constellations of sonographic findings expands upon the literature addressing this important diagnostic challenge.We retrospectively reviewed 116 abdominal US examinations for evaluation of abdominal pain in children ages 2 to 18Â years from January 2008 to September 2011 at a university hospital pediatric radiology department. The study group consisted of surgical and pathology proven acute appendicitis (nâ€‰=â€‰51) and perforated appendicitis (nâ€‰=â€‰22) US exams. US exams without a sonographic diagnosis of appendicitis (nâ€‰=â€‰43) confirmed by follow-up verbal communication were included in the study population as the control group. After de-identification, the US exams were independently reviewed on a PACS workstation by four pediatric radiologists blinded to diagnosis and all clinical information. We recorded the presence of normal or abnormal appendix, appendicolith, appendiceal wall vascularity, thick-walled bowel, dilated bowel, right lower quadrant (RLQ) echogenic fat, increased hepatic periportal echogenicity, bladder debris and abscess or loculated fluid. We also recorded the characteristics of intraperitoneal fluid, indicating the relative quantity (number of abdominal regions) and quality of the fluid (simple fluid or complex fluid). We used logistic regression for correlated data to evaluate the association of diagnosis with the presence versus absence of each US finding. We conducted multivariable analysis to identify constellations of sonographic findings that were predictive of perforated appendicitis.The individual US findings of abscess/loculated fluid, appendicolith, dilated bowel and increased hepatic periportal echogenicity were significantly associated with perforated appendicitis when compared with acute appendicitis (Pâ€‰<â€‰0.01). The sonographic observation of increased hepatic periportal echogenicity demonstrated a statistically significant association with perforated appendicitis compared with acute appendicitis (Pâ€‰<â€‰0.01). The presence of complex fluid yielded a specificity of 87.7% for perforated appendicitis compared with the acute appendicitis group. The US findings of â‰¥2 regions or â‰¥3 regions with fluid had specificity of 87.3% and 99.0%, respectively, for perforated appendicitis compared with the acute appendicitis group. Select combinations of sonographic findings yielded high specificity in the diagnosis of perforated appendicitis compared with acute appendicitis. These constellations yielded higher specificity than that of each individual finding in isolation. The constellation of dilated bowel, RLQ echogenic fat, and complex fluid had the highest specificity (99.5%) for perforated appendicitis (Pâ€‰<â€‰0.01).Our study demonstrates that identification of select constellations of findings using abdominal sonography, in addition to focused US examination of the right lower quadrant, can improve sonographic diagnosis of perforated appendicitis in the pediatric population.
Relative distribution of pertinent findings on portable neonatal abdominal radiographs: can we shield the gonads? - Pediatric radiology
Shielding of the gonads is a dose-saving strategy in pediatric radiography and its use is the law in New York and the majority of other states. However, routine use of gonadal shields is controversial because of concerns that important diagnostic information can be obscured.The purpose of this study was to assess the frequency and spatial distribution of key findings on portable neonatal abdominal radiographs.We reviewed the 2,544 portable neonatal intensive care unit anteroposterior abdominal radiographs performed in 2010 at a university medical center, of which 962 were inadequately shielded. These 962 radiographs were reviewed by pairs of pediatric radiologists for the presence of findings in different regions, including bowel abnormalities, pneumatosis, free air, inguinal hernias, osseous abnormalities, and catheter/tube tips.The fewest pertinent findings were present below the level of the sacrosciatic notches (nâ€‰=â€‰181, 18.8%). Of the 853 abnormalities below the level of the iliac crests in our cohort, six were isolated to these regions, whereas others had concomitant abnormalities more superiorly. Of 35 radiographs with pneumatosis or suspected pneumatosis in the pelvis, 33 had pneumatosis in more superior regions. Suspected free air was never isolated to the pelvis. Osseous abnormalities were only present in the pelvis below the sacrosciatic notch, and 37.5% of lower extremity catheters terminated below the level of the sacrosciatic notches.Pertinent findings on neonatal intensive care unit abdominal radiographs are rarely isolated to the pelvic regions.
Managing radiation exposure in children--reexamining the role of ultrasound in the diagnosis of appendicitis. - Journal of pediatric surgery
To assess the efficacy and accuracy of ultrasonography (US) and selective computed tomography (CT) in the diagnosis of acute appendicitis in children.A retrospective review of all ultrasound evaluations for appendicitis from July 1, 2003, to June 30, 2010, was conducted at two urban pediatric centers. Beginning in 2003, a multi-disciplinary diagnostic protocol was implemented to reduce radiation exposure employing US as the initial imaging modality followed by CT for non-diagnostic US studies in patients with an equivocal clinical presentation. The imaging, operative findings, and pathology of 802 patients (365 females, 437 males, age less than 18 years) with suspected appendicitis were reviewed. The sensitivity, specificity, predictive value, and negative appendectomy rate of the protocol were analyzed. A telephone survey was conducted of patients discharged without a diagnosis of appendicitis to evaluate the missed appendicitis rate.Of the 601 pediatric appendectomies performed, a total of 275 (46%) were diagnosed by protocol. The selective protocol had a sensitivity of 94.2%, specificity of 97.5%, positive predictive value of 95.2%, and negative predictive value of 97.0%. The negative appendectomy rate was 1.82%, and the missed appendicitis rate was 0%. No patient discharged after only ultrasound evaluation without undergoing surgery reported missed appendicitis on the survey (41.7% response rate). Protocol use increased from 6.7% to 88.3%. US was the sole imaging modality in 630 of all 802 patients (78.6%).US followed by selective CT for the diagnosis of acute appendicitis is useful and accurate. This has important implications in the reduction of childhood radiation exposure.Copyright Â© 2012. Published by Elsevier Inc.
The efficacy of digital fluoroscopic image capture in the evaluation of vesicoureteral reflux in children. - Pediatric radiology
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.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.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.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).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.
Splenic infarction due to concomitant hereditary spherocytosis and sickle cell trait. - 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.
The relationship between alpha angle and resistive index of the femoral epiphysis in the normal and abnormal infant hip. - Pediatric radiology
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.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.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.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).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.
Appendicitis in children: low-dose CT with a phantom-based simulation technique--initial observations. - Radiology
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.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.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.Preliminary findings indicate that it is feasible to optimize the CT dose used to evaluate appendicitis in children by using phantom-based computer simulations.
Metanephric adenoma in an 8-year-old child: case report and review of the literature. - 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.
Spontaneous development of bilateral subdural hematomas in an infant with benign infantile hydrocephalus: color Doppler assessment of vessels traversing extra-axial spaces. - 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.
Tuberculous splenic abscess in a neonate with thrombocytopenia. - 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 predominantly 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.
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