Mapping mental health inequalities: The intersecting effects of gender, race, class, and ethnicity on ADHD diagnosis.

While the effects of social stratification by gender, race, class, and ethnicity on health inequalities are well-documented, our understanding of the intersecting consequences of these social dimensions on diagnosis remains limited. This is particularly the case in studies of mental health, where "paradoxical" patterns of stratification have been identified. Using a Bayesian multi-level random-effects Poisson model and a nationally representative random sample of 138,009 households from the National Survey of Children's Health, this study updates and extends the literature on mental health inequalities through an intersectional investigation of one of the most commonly diagnosed psychiatric conditions of childhood/adolescence: attention-deficit hyperactivity disorder (ADHD). Findings indicate that gender, race, class, and ethnicity combine in mutually constitutive ways to explain between-group variation in ADHD diagnosis. Observed effects underscore the importance and feasibility of an intersectional, multi-level modelling approach and data mapping technique to advance our understanding of social subgroups more/less likely to be diagnosed with mental health conditions.

The Effect of Medical Home on Shared Decision-Making for Caregivers of Children with Emotional, Developmental, or Behavioral Health Conditions.

INTRODUCTION: Known as the "pinnacle of patient-centered care," shared decision-making (SDM) is the process that enables and encourages the health care provider, the patient, and/or their caregiver (parent or guardian) to participate collaboratively in medical decisions. Prior research indicates that children with emotional, developmental, or behavioral health conditions (EDB) are less likely to attain SDM than children with other special health care needs (SHCNs). This study investigates whether the presence of a medical home reduces disparities in SDM among children with EDB when compared to children with other SHCNs and the general pediatric population. METHODS: Using the 2016 National Survey of Children's Health, we conducted weighted descriptive statistics to investigate the prevalence of medical home and SDM for children with (1) EDB, (2) other SHCNs, and (3) no SHCNs. We then employed a nested multivariate logistic regression model to examine whether the presence of a medical home reduced the disparity between children with EDB and their counterparts. RESULTS: Nationally, 21% of children with EDB (n = 647,274), 14.0% of children with other SHCNs (n = 1,086,068), and 13% of children with no SHCNs (n = 883,969) did not attain caregiver-reported SDM in medical care. In each of the health condition groups, the presence of a medical home significantly improved the odds of SDM (p < 0.001). Presence of a medical home also reduced the disparities observed in caregiver-reported SDM among children with EDB as compared to those with other SHCNs and no SHCNs. DISCUSSION: Ongoing investment in medical homes may reduce disparities in SDM experienced by children with EDB.

The Impact of an Electronic Medication Administration Record (eMAR) and Computerized Physician Order Entry (CPOE) on Nurse Extender and Unit Clerk Staffing.

OBJECTIVE: The aim of this study is to describe the impact of the introduction of health information technology (HIT) on the utilization and payroll costs of nurse extenders and unit clerks in medicine and surgery units in a large regional health system. BACKGROUND: Long-term policy goals of HIT implementation are reported to include system-level reductions in labor costs, achieved through improved efficiency. METHODS: Using a retrospective cohort model, we analyzed how hours worked per patient day and staffing costs per patient day varied with the implementation of HIT over time at 2 different hospitals within a health system. RESULTS: Implementation of electronic medication administration records was not associated with significant changes in staffing or labor costs. Both labor hours and costs associated with nurse extenders and unit clerks were significantly reduced after the subsequent addition of computerized provider order entry. Simultaneously, units that did not implement any HIT experienced a significant increase in both labor hours and costs. CONCLUSION: Health information technology implementation in the inpatient setting is associated with significant savings in labor hours and costs in non-registered nursing roles.

Hourly rounding and patient falls: what factors boost success?

BACKGROUND: Falls are a persistent problem in all healthcare settings, with rates in acute care hospitals ranging from 1.3 to 8.9 falls per 1,000 inpatient days, about 30% resulting in serious injury. METHODS: A 30-day prospective pilot study was conducted on two units with pre- and postimplementation evaluation to determine the impact of patient-centered proactive hourly rounding on patient falls as part of a Lean Six Sigma process improvement project. Nurse leaders and a staff champion from Unit 1 were involved in the process from the start of the implementation period, while Unit 2 was introduced to the project for training shortly before the intervention began. RESULTS: On Unit 1, where staff and leadership were engaged in the project from the outset, the 1-year baseline mean fall rate was 3.9 falls/1,000 patient days. The pilot period fall rate of 1.3 falls/1,000 patient days was significantly lower than the baseline fall rate (P = 0.006). On Unit 2, where there was no run-in period, the 1-year baseline mean fall rate was 2.6 falls/1,000 patient days, which fell, but not significantly, to 2.5 falls/1,000 patient days during the pilot period (P = 0.799). DISCUSSION: Engaging an interdisciplinary team, including leadership and unit champions, to complete a Lean Six Sigma process improvement project and implement a patient-centered proactive hourly rounding program was associated with a significant reduction in the fall rate in Unit 1. Implementation of the same program in Unit 2 without engaging leadership or front-line staff in program design did not impact its fall rate. CONCLUSIONS: The active involvement of leadership and front-line staff in program design and as unit champions during the project run-in period was critical to significantly reducing inpatient fall rates and call bell use in an adult medical unit.

"Pills Don't Teach Skills": ADHD Coaching, Identity Work, and the Push toward the Liminal Medicalization of ADHD.

Despite physicians' near monopoly over medicalization historically, various stakeholder groups shape an increasingly complex process today. This study examines a relatively new initiative, "health coaching," within the context of the changing nature of medicalization. Utilizing 51 in-depth interviews with attention deficit hyperactivity disorder (ADHD) coaches, participant observation from seven ADHD symposia, and ADHD coach publications, I examine coaching's emergence as a partial challenge to medicalization. Findings reveal a field comprised mainly of individuals personally affected by ADHD whose dissatisfaction with institutionalized framings and practices underpins a push for liminal medicalization. Members move between medical and nonmedical discourses to frame ADHD as a paradox of pathology and gift. Additionally, they leverage and commodify personal experience alongside institutional and alternative knowledge into an adjunct or substitute to medication and potential challenge to therapy-one aimed at "self-actualization" versus "treatment." Such efforts highlight (de)medicalization's dimensionality, simultaneous medicalization and demedicalization, and a lay-driven enterprise's role in such processes.

Globalization and cognitive enhancement: emerging social and ethical challenges for ADHD clinicians.

Globalization of ADHD and the rise of cognitive enhancement have raised fresh concerns about the validity of ADHD diagnosis and the ethics of stimulant drug treatment. We review the literature on these two emerging phenomena, with a focus on the corresponding social, scientific and ethical debates over the universality of ADHD and the use of stimulant drug treatments in a global population of children and adolescents. Drawing on this literature, we reflect on the importance of ethically informed, ecologically sensitive clinical practices in relation to ADHD diagnosis and treatment.

Management of the ptotic or hypertrophic breast in immediate autologous breast reconstruction: a comparison between the wise and vertical reduction patterns for mastectomy.

BACKGROUND: The Wise pattern can be used in mastectomies to address the excess skin in the ptotic or hypertrophic breast; however, limitations include mastectomy flap necrosis (MFN) and poor shape. The vertical pattern can potentially reduce the amount of MFN with improved aesthetic results. This study compares the Wise and vertical mastectomy patterns in immediate, autologous breast reconstruction. METHODS: Thirty-three patients with grade 2 or 3 ptosis who elected to undergo immediate, autologous breast reconstruction were prospectively recruited into 2 nonrandomized cohorts. Of total, 17 patients (26 reconstructions) had Wise pattern and 16 (28 reconstructions) had vertical pattern. All patients were followed for MFN, time for wound healing, and postoperative complications. Patient and surgeon surveys rated the aesthetics of the reconstructions. RESULTS: The 2 groups did not differ in age, body mass index, smoking, or breast measurements. The Wise group had significantly larger areas of MFN, higher number of postoperative visits, and longer wound-healing periods, compared with the vertical group (P < 0.05). There was no difference in time to adjuvant therapy or additional procedures. Patient surveys rated both incisions with equal satisfaction, except for symmetry that rated better in the Wise group. Surgeon surveys showed better scores for the vertical incision. CONCLUSIONS: The Wise pattern is associated with significantly more MFN and prolonged wound care. Despite this complication, patients rate their breast reconstructions favorably, regardless of the type of incision. Both the Wise and vertical patterns can be safely used in skin-sparing mastectomies with immediate, autologous breast reconstruction with good aesthetic outcomes. The authors recommend the vertical pattern because of less MFN and surgeon-preferred aesthetics.

Negotiating health-related uncertainties: biomedical and religious sources of information and support.

This article explores how people experience health-related uncertainties and how they look to biomedical and religious sources of information in response. Data were gathered in a larger project focused on spirituality in everyday life. Respondents were not asked any direct questions about their health or health care, but almost all of the 95 participants brought up the topics in response to other questions. About one-third spoke of being uncertain about some aspect of their health or healthcare. We explore the health-related topics about which people were uncertain and how they looked to biomedical and religious sources of information, most often seeing the religious as a support for the biomedical. We outline the range of ways they experienced God in this process pointing to the multiple complex ways they make sense of health-related uncertainties.

Deserving but not entitled: The social construction of autism spectrum disorder in federal policy.

Public policies play an influential role in shaping public opinion about health conditions, who is affected by them, and potential pathways for identification and intervention. This study draws upon a social constructionist perspective of policy design and disability to examine how autism spectrum disorder (ASD) has been framed in United States federal legislation. Qualitative content analysis of autism legislation passed between 1973 and 2019 indicates that policies reinforced ASD as a largely medicalized, neurobiological condition of childhood; this was reflected in both the policy aims, sources of knowledge and groups prioritized to address ASD; and the symbolic or material resources committed (or not committed) by enacted federal legislation to specific constituencies. Policy aims of early ASD legislation were symbolic in nature, focusing predominantly on framing children with ASD as a group worthy of public recognition. More recent legislation, in contrast, conferred material resources - albeit in targeted ways. Funding for surveillance and medical research on causation, early detection, treatment, and health professional training were prioritized with little attention to either service delivery needs of individuals with ASD and their families, supports over the lifecourse, or the social factors influencing ASD.

Breast cancer surgery trend changes since the introduction of BRCA1/2 mutation screening: a retrospective cohort analysis of 158 mutation carriers treated at a single institution.

BACKGROUND: Bilateral mastectomy in women diagnosed with unilateral breast cancer is on the rise in the USA. One contributing factor is increased awareness of contralateral breast cancer risk. Positive testing for deleterious mutation in BRCA1/2 is a concrete measure of this contributing factor. We hypothesize that breast cancer surgery trend change is temporally associated with the introduction of BRCA1/2 genetic testing around 1996. METHODS: Our study cohort included 158 BRCA1 or BRCA2 mutation carriers diagnosed with unilateral breast cancer between 1963 and 2009. Mutation carriers with ovarian cancer or bilateral breast cancer were excluded. Breast surgery and breast reconstruction surgery trends were analyzed according to year of breast cancer diagnosis or when bilateral mastectomy was performed, respectively. RESULTS: Surgery trends changed significantly over time. We observed a significant drop in the rate of unilateral mastectomy (P < 0.001) after the period 1996-2000, and the rate of bilateral mastectomy appears to be on the rise, up to 30.3% between 2006 and 2009. Breast reconstruction trends also changed significantly over time, with a significant rise in the rate of free flap reconstruction to 58.8% between 2006 and 2009. CONCLUSIONS: Our results demonstrated a significant decrease in unilateral mastectomy with a rise in bilateral mastectomy after the period 1996-2000, a period which encompassed the year when genetic testing of the two BRCA1/2 genes became commercially available, hence supporting our hypothesis.

Longitudinal evaluation of the concordance and prognostic value of lymphovascular invasion in transurethral resection and radical cystectomy specimens.

OBJECTIVE: To evaluate the concordance transurethral resection of bladder tumour (TURBT) and radical cystectomy (RC) specimens with regard to the presence of lymphovascular invasion (LVI). Additionally, to evaluate the prognostic value of LVI in the prediction of lymph node metastases, overall survival, disease-specific survival and recurrence-free survival following RC. PATIENTS AND METHODS: The records of 487 patients who underwent RC at our institution between 1987 and 2008 were retrospectively reviewed and evaluated for the presence or absence of LVI as determined by pathological evaluation. The presence or absence of LVI was then evaluated on previous transrectal resection specimens of this cohort of patients undergoing RC. Cox regression and Kaplan-Meier analysis were undertaken to evaluate the contribution of LVI to various outcomes. RESULTS: Of 474 patients with complete LVI data, 60 (12.3%) were found to have LVI at TURBT compared to 161 (33.1%) at RC. Although the presence of LVI at TURBT was more significantly associated with the presence of LVI at RC, only 42.9% of patients in whom LVI was documented at TURBT were found to harbour LVI at RC. The risk of nodal disease was higher in those patients with LVI at TURBT than in those with no evidence of LVI at TURBT (48.3% vs 25.0%, P < 0.001). Additionally, LVI at TURBT was associated with an increasing risk of pathological upstaging and the receipt of adjuvant chemotherapy. Survival analysis showed a significant decrement in overall and recurrence-free survival among those with LVI at TURBT compared to those with no evidence of LVI. CONCLUSIONS: Lymphovascular invasion at TURBT provides useful prognostic information that should be incorporated into clinical decision-making, particularly with regard to cystectomy for nonmuscle-invasive carcinoma and the administration of neoadjuvant chemotherapy.

Behavioral and perceived stressor effects on urinary catecholamine excretion in adult Samoans.

OBJECTIVES: The effects of perceptions and behaviors related to culturally patterned socioeconomic obligations on catecholamine excretion rates were studied in a cross-sectional sample of Samoan adults. METHODS: A total of 378 participants, ages 29-62 years, from 9 villages throughout Samoa, provided timed overnight urine specimens, and self-reported perceptions and behaviors associated with contributions to one's family, aiga, and chief, matai, and communal gift exchanges, fa'alavelave. Urinary norepinephrine and epinephrine excretion rates were measured by high performance liquid chromatography with electrochemical detection. Age (≤40 vs. >40 years) and gender-specific regression models were estimated to detect associations with catecholamine excretion. RESULTS: Young women who contribute more to their matai, who consider fa'alavelave to be a financial strain, and who view their contribution to their matai to be "just right," had significantly higher residence-adjusted norepinephrine excretion. Young women who contribute more to their matai, who consider fa'alavelave to be a financial strain, and who consider their contribution to their aiga not to be a burden, had higher epinephrine excretion. Older men who contribute more to their aiga and who perceive their contribution to their aiga to be "just right" had increased residence-adjusted epinephrine excretion. CONCLUSIONS: Individual-level perceptions and behaviors related to traditional socioeconomic obligations are a significant correlate of increased overnight catecholamine excretion rates. Higher excretion rates may be attributed to psychosocial stress arousal associated with a discordance between personal desires for upward social mobility, and family and community-based socioeconomic obligations. Changes in patterns of individual-level psychosocial stress arousal may contribute to cardiovascular disease risk in modernizing Samoans.

Ecological and sociodemographic effects on urinary catecholamine excretion in adult Samoans.

BACKGROUND: Ecological and sociodemographic correlates of stress may contribute to cardiovascular disease risk in modernizing Samoans. AIM: The effects of peri-urban vs rural residence, education, occupation, caffeine intake and cigarette consumption on urinary catecholamine excretion were studied in Samoan adults. SUBJECTS AND METHODS: Five hundred and seven participants, aged 29-69 years, were randomly selected from nine villages throughout Samoa. Sociodemographic and lifestyle factors were assessed by questionnaire. Epinephrine and norepinephrine excretion rates were measured by high performance liquid chromatography with electrochemical detection in overnight urine samples. Age ( ≤ 40 vs >40 years) and gender-specific regression models were estimated to detect associations with BMI-adjusted catecholamine excretion. RESULTS: Norepinephrine was significantly higher in peri-urban young men and older women. Epinephrine was significantly higher in peri-urban older men. Adjustment for caffeine attenuated the relationship between residence and norepinephrine in young women. CONCLUSION: General residential exposure to modernization in urban villages is a significant correlate of increased overnight catecholamine excretion rates and is consistent with past studies. Caffeine consumption in younger women plays a complex role in stress-related catecholamine excretion. Further studies of individual level attitudinal and behavioural factors in Samoans are needed to understand psychosocial stress, physiologic arousal and health.

Evaluating the use of a barbed suture for skin closure during autologous breast reconstruction.

This study compared the use of barbed suture to a traditional skin closure method for incision closure in free flap breast reconstruction. A retrospective study compared the two closure methods in consecutive series of patients undergoing autologous breast reconstruction between January 2007 and January 2009. Outcomes included total duration of operation and wound complications. We also performed a cost analysis. Use of the barbed suture significantly decreased operative time for unilateral cases by an average of 45 minutes (405 versus 360 minutes, P = 0.02). For bilateral cases, the mean operative time was decreased by an average of 10 minutes (510 versus 500 minutes, P = 0.44). There were more episodes of delayed wound healing in the bilateral barbed suture group (33/46 [72%] versus 15/31 [48%], P = 0.04). No statistical difference was noted between the two groups with regard to dehiscence, infection, or suture extrusion. Use of the barbed suture was, however, more cost-effective. The use of a barbed suture in the closure of abdominal and breast incisions in free flap breast reconstruction may expedite wound closure and reduce the cost of the procedure but may increase wound complications.

Defining pathological variables to predict biochemical failure in patients with positive surgical margins at radical prostatectomy: implications for adjuvant radiotherapy.

OBJECTIVE: To evaluate the utility of estimated tumour volume, number of positive surgical margins (PSMs), and margin location for predicting biochemical failure in patients with PSM, in an attempt to better risk-stratify the heterogeneous group of patients at high risk of biochemical failure after radical prostatectomy (RP) for prostate cancer. PATIENTS AND METHODS: We reviewed our database of 2410 patients who had RP, and isolated 423 with PSMs who had a prostate-specific antigen (PSA) nadir at undetectable levels. Kaplan-Meier curves were used for univariate survival analysis, with the log-rank test used to examine differences between survival curves. Multivariate Cox regression analysis was used to assess the independent main effect of estimated tumour volume, number of PSMs and margin location on biochemical-free survival. RESULTS: Increasing estimated tumour volume was directly associated with increasing risk of biochemical failure in patients with PSMs (P = 0.041). Patients with more than one PSM were at greater risk of biochemical failure than those with one PSM (P = 0.001). Margin location had no effect on biochemical-free survival in patients with PSMs. When incorporated into a multivariate Cox regression model including age, preoperative PSA level and pathological Gleason score, estimated tumour volume and number of PSMs remained independent predictors of biochemical recurrence. CONCLUSIONS: Coupled with other variables before and after RP, both estimated tumour volume and number of PSMs might serve to further discriminate those patients most likely to benefit from immediate adjuvant radiotherapy after RP.

Impact of adjuvant chemotherapy on patients with lymph node metastasis at the time of radical cystectomy.

INTRODUCTION: Radical cystectomy (RC) remains the gold standard treatment for patients with muscle-invasive bladder cancer. Unfortunately, a significant proportion of patients will have lymph node involvement at the time of RC. We set out to determine the impact of adjuvant cisplatin-based chemotherapy (AC) in a cohort of lymph node positive patients following RC. PATIENTS AND METHODS: We reviewed our RC database and isolated patients with lymph node positive disease at the time of RC. Univariate and multivariable analysis was performed to identify predictors of poor outcome in patients receiving AC. Overall survival (OS), disease specific survival (DSS) and recurrence free survival (RFS) were calculated for those patients who received AC compared to those who did not. RESULTS: Of the 316 patients, we identified 85 patients with metastatic lymph node involvement at the time of RC. Fifty-five (65%) of these patients received AC. Median follow up was 46 months. On multivariable analysis lymph node positive patients receiving AC had significantly improved OS, DSS and RFS compared to patients who did not receive AC (p = 0.031, p = 0.028, p = 0.004). The delivery of AC conferred the greatest recurrence-free, disease-specific, and overall survival advantages to those with lymph node densities (LND) of < 20% with (p = 0.016, p = 0.011, p = 0.007, respectively). CONCLUSION: AC administered to patients with known lymph node metastasis conferred a significant survival advantage compared to observation. Furthermore, a LND of < 20% predicts of a more favorable response to AC. Further studies in larger patient populations are warranted to reveal the exact impact of AC in this subset of patients.

Resident and RN perceptions of the impact of a medical emergency team on education and patient safety in an academic medical center.

OBJECTIVE: To assess the perceptions of residents and RNs about the effects of a medical emergency team on patient safety and their own educational experiences. DESIGN: Survey-based study. SETTING: A single academic medical center. PARTICIPANTS: In 2007, 1 yr after the introduction of a medical emergency team, a Web-based survey was administered to 141 internal medicine and general surgery residents and 497 RNs in a single academic medical center. Residents' and RNs' beliefs about the effects of the medical emergency team on patient safety and education were measured using 12 Likert scale items. Group differences were assessed using Mann-Whitney U test and Kruskal-Wallis test. RESULTS: The overall response rate was 79% (67% for residents and 83% for RNs). Residents and RNs agreed that the medical emergency team improved patient safety, but RNs held this belief more strongly than did residents. Residents neither agreed nor disagreed with the notion that the creation of the medical emergency team decreased their opportunities to obtain critical care skills or education, whereas RNs disagreed with this statement. Relative to surgical residents, medical residents were more involved in activation of the medical emergency team and believed more strongly that the team improved patient safety. Residents and RNs who perceived that they were involved in the call activation had more positive attitudes toward the team. CONCLUSION: Residents and RNs believe that a medical emergency team improves patient safety in the hospital without compromising educational experiences or skills. Frequency of involvement in the events and the decision to activate the team correlated with more positive attitudes.

Factors associated with mortality and brain injury after falls from the standing position.

BACKGROUND: Trauma centers are increasingly tasked with evaluating patients who have sustained low-acuity mechanisms of injury, such as fall from standing (FFS). Previous studies have shown that low-level falls are associated with a high incidence of injury in certain patient groups. The purpose of the current study was to assess risk factors associated with brain injury and death after fall from the standing position only. MATERIALS: A retrospective analysis was performed on all patients who presented with FFS as the mechanism of injury from 2000 to 2005. Demographic variables, past medical history, use of warfarin, blood-alcohol level, initial vital signs, injuries, disposition, and mortality outcome were recorded. Data were analyzed to determine risk factors associated with brain injury, need for intensive care unit (ICU) admission, need for emergency operation, and mortality. RESULTS: A total of 808 patients were identified. Risk factors associated with brain injury, the need for ICU admission, and death included: Injury Severity Score, age >or=60 years, blood-alcohol level greater than 80 mg/dL, warfarin use, systolic blood pressure <100 mm Hg, and Glasgow Coma Scale

Invisible work and changing roles: Health information technology implementation and reorganization of work practices for the inpatient nursing team.

Hospitals have invested heavily in health information technology (HIT) which has been promoted as an integral component of quality, safe, and efficient health-care delivery. Research on the expanding use of such technology, however, has shown that user/technology interactions are shaped through practices of use that can yield far from normative, even unexpected outcomes. Drawing upon focus group and interview data from an inpatient, two-hospital health system in the United States, this paper considers the perceived impact of HIT implementation on work practices and roles for nurse managers and unit clerks. We find that HIT implementation generated significant reconfigurations of work practices at the expense of nurse/patient interaction. Following such changes, nursing leadership described re-prioritizing patient care and interaction - perceived to them as essential to the patient experience and unit functioning - through realignments in staffing that prioritized more versatile staff and task delegation of largely invisible, articulation work to unit clerks. Despite maintaining an integral role as "gatekeeper" and the "face on the floor," unit clerks experienced significant reconfigurations of their work and some concomitant uncertainty about their role. We consider the implications of our findings for literature on the socio-materiality of HIT, with particular attention to literature on work practices, roles, and the visibility of work within organizational power hierarchies.

Method of primary tumor detection as a risk factor for local and distant recurrence after breast-conservation treatment for early-stage breast cancer.

BACKGROUND: Recent studies have shown that breast cancer detected by screening has a more favorable prognosis than interval breast cancer. To further understand the biologic significance of this finding, we investigated the association of disease recurrence, local and distant, with the method of detection of the primary breast cancer in a cohort of 1686 women treated with breast conservation. PATIENTS AND METHODS: The charts of 1686 women with primarily stage I or II invasive breast cancer treated by breast conservation between 1977 and 2002 were reviewed. The median length of follow-up was 6 years. Univariate and multivariate analyses using binary logistic regression were performed for 2 subgroups: (1) those with local recurrence versus those without; and (2) those with distant metastasis versus those without distant metastasis. RESULTS: Our data confirmed several of the well-known risk factors for local and distant recurrence. In addition, we found that individuals with breast cancer detected on physical examination alone have a significantly higher risk for local recurrence compared with patients with cancer detected on mammogram alone, independent of tumor size (odds ratio [OR], 2.369; 95% CI, 1.235-4.547; P = .01). We also found a similar correlation for risk of distant metastasis in these 2 groups of women (OR, 2.201; 95% CI, 1.211-3.998; P = .01). CONCLUSION: Breast cancers that are palpable might represent an aggressive biologic subtype with an increased risk of local and distant recurrence. Risk stratification might need to include this clinical feature in addition to conventional prognostic factors.