Age-related mortality in blunt traumatic hemorrhagic shock: the killers and the life savers.

BACKGROUND: There are sparse data on the association between age and mortality in hemorrhagic shock (HS). We examined this association in this study. MATERIALS AND METHODS: The Glue Grant database was analyzed. Patients aged ≥16 y with blunt traumatic HS were stratified into eight age groups (16-24, 25-34, 35-44, 45-54, 55-64, 65-74, 75-84, and ≥85 y) to identify the mortality inflection point. Subsequently, patients were restratified into young age (16-44 y), middle age (45-64 y), and elderly (≥65 y). Multivariate analysis was used to determine predictors of mortality by group. RESULTS: A total of 1976 patients were included, with mortality of 16%. Mortality by initial age group is as follows: 16-24 (13.0%), 25-34 (11.9%), 35-44 (11.9%), 45-54 (15.6%), 55-64 (15.7%), 65-74 (20.3%), 75-84 (38.2%), and ≥85 y (51.6%), delineating 65 y as the mortality inflection point. Overall, 55% were young, 30% middle age, and 15% elderly. Predictors of mortality in the young include multiple-organ dysfunction score (MODS; odds ratio [OR]: 1.93, confidence interval [CI]: 1.62-2.30), emergency room lactate (OR: 1.14, CI: 1.02-1.27), injury severity score (OR: 1.06, CI: 1.03-1.09), and cardiac arrest (OR: 10.60, CI: 3.05-36.86). Predictors of mortality in the middle age include MODS (OR: 1.38, CI: 1.24-1.53), cardiac arrest (OR: 12.24, CI: 5.38-27.81), craniotomy (OR: 5.62, CI: 1.93-16.37), and thoracotomy (OR: 2.76, CI: 1.28-5.98). In the elderly, predictors of mortality were age (OR: 1.07, CI: 1.02-1.13), MODS (OR: 1.47, CI: 1.26-1.72), laparotomy (OR: 2.04, CI: 1.02-4.08), and cardiac arrest (OR: 11.61, CI: 4.35-30.98). Open fixation of nonfemoral fractures was protective against mortality in all age groups. CONCLUSIONS: In blunt HS, mortality parallels increasing age, with the inflection point at 65 y. MODS and cardiac arrest uniformly predict mortality across all age groups. Craniotomy and thoracotomy are associated with mortality in the middle age, whereas laparotomy is associated with mortality in the elderly.

Abdominal compartment syndrome in traumatic hemorrhagic shock: is there a fluid resuscitation inflection point associated with increased risk?

BACKGROUND: The volume of fluid administered during trauma resuscitation correlates with the risk of abdominal compartment syndrome (ACS). The exact volume at which this risk rises is uncertain. We established the inflection point for ACS risk during shock resuscitation. METHODS: Using the Glue Grant database, patients aged ≥16 years with ACS were compared with those without ACS (no-ACS). Stepwise analysis of the sum or difference of the mean total fluid volume (TV)/kg, TV and/or body weight, (µ) and standard deviations (σ) vs % ACS at each point was used to determine the fluid inflection point. RESULTS: A total of 1,976 patients were included, of which 122 (6.2%) had ACS. Compared with no-ACS, ACS patients had a higher emergency room lactate (5.8 ± 3.0 vs 4.5 ± 2.8, P < .001), international normalized ratio (1.8 ± 1.5 vs 1.4 ± .8, P < .001), and mortality (37.7% vs 14.6%, P < .001). ACS group received a higher TV/kg (498 ± 268 mL/kg vs 293 ± 171 mL/kg, P < .001) than no-ACS. The % ACS increased exponentially with the sum of µ and incremental σ, with the sharpest increase occurring at TV and/or body weight = µ + 3σ or 1,302 mL/kg. CONCLUSIONS: There is a dramatic rise in ACS risk after 1,302 mL/kg of fluid is administered. This plot could serve as a guide in limiting the ACS risk during resuscitation.

Trauma associated splenic artery aneurysms: an analysis of the National Trauma Data Bank.

BACKGROUND: Trauma associated splenic artery aneurysm (SAA) is potentially life threatening and infrequently studied. We evaluated the subject using a large trauma database. METHODS: The National Trauma Data Bank (2002 to 2006) was queried. All patients aged greater than or equal to 18 years with a primary diagnosis of SAA (International Classification of Diseases: Ninth Revision code 442.83) were identified. Data on demographics, injury severity, pre-existing comorbidities, surgical interventions, complications, and mortality were analyzed. RESULTS: One hundred twenty-four patients were included with a mean age of 40 ± 13 years and 72% were male. Mean Injury Severity Score was 24 ± 12. All patients suffered blunt trauma, and 5% of the patients (n = 6) had systolic blood pressure less than 90 mm Hg on arrival. The most frequent interventions were surgical ligation of aneurysm (45%), bronchoscopy (35%), endovascular procedures (27%), splenectomy (27%), and thoracostomy tube (25%). About 1.7% developed pulmonary collapse. Mean length of stay was 13 days and mortality was 1.6%. CONCLUSIONS: Trauma associated SAA has low mortality and most patients require surgical intervention. Pulmonary dysfunction and invasive pulmonary procedures are frequent despite low rate of chest injuries possibly due to anatomic proximity of lung and spleen.

Body mass index in blunt trauma patients with hemorrhagic shock: opposite ends of the body mass index spectrum portend poor outcome.

BACKGROUND: There are controversial data on the relationship between trauma and body mass index. We investigated this relationship in traumatic hemorrhagic shock. METHODS: The "Glue Grant" database was analyzed, stratifying patients into underweight, normal weight (NW), overweight, Class I obesity, Class II obesity, and Class III obesity. Predictors of mortality and surgical interventions were statistically determined. RESULTS: One thousand nine hundred seventy-six patients were included with no difference in injury severity between groups. Marshall's score was elevated in overweight (5.3 ± 2.7, P = .016), Class I obesity (5.8 ± 2.7, P < .001), Class II obesity (5.9 ± 2.8, P < .001), and Class III obesity (6.3 ± 3.0, P < .001) compared with NW (4.8 ± 2.6). Underweight had higher lactate (4.8 ± 4.2 vs 3.3 ± 2.5, P = .04), were 4 times more likely to die (odds ratio 3.87, confidence interval 2.22 to 6.72), and were more likely to undergo a laparotomy (odds ratio 2.06, confidence interval 1.31 to 3.26) than NW. CONCLUSION: Early assessment of body mass index, with active management of complications in each class, may reduce mortality in traumatic hemorrhagic shock.

Associated injuries in traumatic sternal fractures: a review of the National Trauma Data Bank.

Sternal fractures occur infrequently with blunt force trauma. The demographics and epidemiology of associated injuries have not been well characterized from a national trauma database. The National Trauma Data Bank was queried for patients with closed sternal fractures. The demographics were analyzed by age, gender, mechanism and indicators of anatomic and physiologic injuries. Types of commonly associated injuries were also determined. A total of 23,985 records were analyzed. Males accounted for 68.3 per cent and whites 70.9 per cent. Motor vehicle crash was the leading mechanism. More than 56 per cent had severe injuries based on Injury Severity Score (greater than 15) and 17 per cent with Glasgow Coma Score 8 or less. Crude mortality was 7.9 per cent. The majority (57.8%) and approximately one-third (33.7%) of the patients had rib fractures and lung contusions, respectively, 22.0 per cent with closed pneumothorax, 21.6 per cent had a closed thoracic vertebra fracture, 16.9 per cent with lumbar spine fracture, 3.9 per cent with concussion, and blunt cardiac injury in 3.6 per cent. Sternal fractures are usually associated with severe blunt trauma. Lung contusion remains the leading associated injury followed by vertebral spine fractures. Cardiac injuries are less frequent and vascular injuries less so. Mechanism of injury and presence of sternal fractures should alert providers to these potential associated injuries.

Disparities in trauma care: are fewer diagnostic tests conducted for uninsured patients with pelvic fracture?

BACKGROUND: Research from other medical specialties suggests that uninsured patients experience treatment delays, receive fewer diagnostic tests, and have reduced health literacy when compared with their insured counterparts. We hypothesized that these disparities in interventions would not be present among patients experiencing trauma. Our objective was to examine differences in diagnostic and therapeutic procedures administered to patients undergoing trauma with pelvic fractures using a national database. METHODS: A retrospective analysis was conducted using the National Trauma Data Bank (NTDB), 2002 to 2006. Patients aged 18 to 64 years who experienced blunt injuries with pelvic fractures were analyzed. Patients who were dead on arrival, those with an injury severity score (ISS) less than 9, those with traumatic brain injury, and patients with burns were excluded. The likelihood of the uninsured receiving select diagnostic and therapeutic procedures was compared with the same likelihood in the insured. Multivariate analysis for mortality was conducted, adjusting for age, sex, race, ISS, presence of shock, Glasgow Coma Scale (GCS) motor score, and mechanism of injury. RESULTS: Twenty-one thousand patients met the inclusion criteria: 82% of these patients were insured and 18% were uninsured. There was no clinical difference in ISSs (21 vs 20), but the uninsured were more likely to present in shock (P < .001). The mortality rate in the uninsured was 11.6% vs 5.0% in the insured (P < .001). The uninsured were less likely to receive vascular ultrasonography (P = .01) and computed tomography (CT) of the abdomen (P < .005). There was no difference in the rates of CT of the thorax and abdominal ultrasonography, but the uninsured were more likely to receive radiographs. There was no difference in exploratory laparotomy and fracture reduction, but uninsured patients were less likely to receive transfusions, central venous pressure (CVP) monitoring, or arterial catheterization for embolization. Insurance-based disparities were less evident in level 1 trauma centers. CONCLUSIONS: Uninsured patients with pelvic fractures get fewer diagnostic procedures compared with their insured counterparts; this disparity is much greater for more invasive and resource-intensive tests and is less apparent in level 1 trauma centers. Differences in care that patients receive after trauma may be 1 of the mechanisms that leads to insurance disparities in outcomes after trauma.

Pneumoperitoneum 48 days after laparoscopic hysterectomy.

BACKGROUND AND OBJECTIVES: Postoperative pneumoperitoneum following laparoscopic surgery is self-limited, typically resolving within days. METHODS: We analyzed the case of a 48-y-old woman who presented with acute abdominal pain 48 d after a total laparoscopic hysterectomy. Imaging studies revealed free air under the diaphragm suggesting a perforated viscus. RESULTS: An exploratory laparotomy was performed, but no perforations or organic traumas were found intraoperatively. To the best of our knowledge, this is the longest period of time reported for persistent pneumoperitoneum after laparoscopic surgery. CONCLUSION: Absent clinical findings, introduction of atmospheric air into the abdominal cavity during the original laparoscopic surgery was the most likely cause and is supported by the literature. Pneumoperitoneum observed up to 48 d status post laparoscopic hysterectomy, in the absence of peritoneal signs, fever, leukocytosis, or hemodynamic instability, may be considered for expectant management and serial inspection for clinical change.

Living on a prayer: religious affiliation and trauma outcomes.

Research has shown that religious affiliation is associated with reduced all cause mortality. The aim of this study was to determine if religious affiliation predicts trauma-specific mortality and length of stay. Patients admitted to our urban Level I trauma center in 2008 were examined; the main study categorization was based on endorsement of a specific religious affiliation during a standard intake procedure. Bivariate and multivariate analysis was performed with in-hospital mortality and length of stay as the outcomes of interest, adjusting for demographic and injury severity characteristics. A total of 2303 patients were included in the study. Forty-six per cent endorsed a religious affiliation. Patients with a religious affiliation were more likely to be female, Hispanic, and older than those who reported no affiliation (P < 0.001). There was no difference in length of hospital stay. On bivariate analysis those without religious affiliation were more likely to die (P = 0.01), but this difference disappeared after adjusting for covariates. Although we could not identify a statistical association between religious affiliation and mortality on multivariate analysis, there was an association with injury severity suggesting religious patients were less severely injured.

T4b breast masses: a retrospective review of 12 cases presenting to a metropolitan tertiary care center.

INTRODUCTION: Due to increased awareness of breast cancer resulting in early detection, there is a decreased incidence nationwide of late-stage breast cancer, including that which presents with skin involvement (T4b). METHODS: A retrospective analysis of a 10-month period from August 2007 to May 2008 at Howard University Hospital (HUH), Washington, DC, revealed 12 patients diagnosed with T4b breast cancer and compared to similarly staged patients in the Surveillance, Epidemiology, and End Results (SEER) database. Finally, a logistic regression for the likelihood of T4b diagnosis was performed patients in the SEER database. RESULTS: HUH patients with T4b tumors were more likely than SEER patients to present with predictors of poor clinical outcome, including high-grade histology (100% vs 59.4%, p = .04) and estrogen receptor- (75% vs 30.3%, p = .001) and progesterone receptor- negative (91.7% vs 43.9%, p = .001) status. Conversely, HUH patients were younger (57.8 y vs 66.3 y, p = .03) and had smaller tumors (11.1 cm vs 28.2 cm, p = .02) than SEER patients with similarly staged tumors. Older patients (OR, 2.36; 95% CI, 1.50-2.00; p < .001; 60-80 y), African American patients (OR, 1.63; 95% CI, 1.26-2.11; p < .001), and patients with high-grade (OR, 5.51; 95% CI, 3.88-6.52; p < .001) tumors were more likely to be diagnosed with T4b tumors, whereas patients who lived in an area with increased median household income (OR, 0.99; 95% CI, 0.99-0.99; p = .001) were less likely to be diagnosed with a T4b lesion. CONCLUSION: While much research has focused on the socioeconomic causes for the development of T4b tumors, both patient and tumor biologic conditions cannot be eliminated as causative agents.

Early-stage gallbladder cancer in the Surveillance, Epidemiology, and End Results database: effect of extended surgical resection.

HYPOTHESIS: Extended surgical resection (ESR) may improve survival in patients with early-stage primary gallbladder cancer. DESIGN: Retrospective analysis of findings in the Surveillance, Epidemiology, and End Results (SEER) database. SETTING: Academic research. PATIENTS: Individuals with potentially surgically curable gallbladder cancer (Tis, T1, or T2) who underwent a surgical procedure. MAIN OUTCOME MEASURES: Overall survival, number of lymph nodes (LNs) excised, and results of simple cholecystectomy vs ESR. RESULTS: We identified 3209 patients with early-stage gallbladder cancer (11.7% Tis, 30.1% T1, and 58.2% T2). On multivariate analysis, decreased survival was noted among patients older than 60 years (hazard ratio, 1.57; 95% confidence interval, 1.30-1.90), among patients with more advanced cancer (1.99; 1.46-2.70 for T1; 3.29; 2.45-4.43 for T2), and among patients with disease-positive LNs (1.65; 1.39-1.95 for regional; 2.58; 1.54-4.34 for distant) (P < .001 for all), while increased survival was observed among female patients (0.82; 0.70-0.96; P = .02) and among patients undergoing ESR (0.59; 0.45-0.78; P < .001). The survival advantage of ESR was seen only in patients with T2 lesions (0.49; 0.35-0.68; P < .001). Lymph node excision data were available for a subset of 2507 patients, of whom 68.2% had no LN excised, 28.2% had 1 to 4 LNs excised, and 3.6% had 5 or more LNs excised. On multivariate analysis, patients with 1 to 4 LNs excised had a survival benefit over those with no LN excised (HR, 0.55; 95% CI, 0.46-0.66; P < .001), and patients with 5 or more LNs excised had a survival benefit over patients with 1 to 4 LNs removed (0.63; 0.40-0.96; P = .03). Lymph node excision improved survival in patients with T2 lesions (0.42; 0.33-0.53; P < .001 for patients with 1-4 LNs excised). CONCLUSION: Extended surgical resection, LN excision, or both may improve survival in certain patients with incidentally discovered gallbladder cancer.

Negative appendectomy: a 10-year review of a nationally representative sample.

BACKGROUND: Appendectomy remains one of the most common emergency surgical procedures encountered throughout the United States. With improvements in diagnostic techniques, the efficiency of diagnosis has increased over the years. However, the entity of negative appendectomies still poses a dilemma because these are associated with unnecessary risks and costs to both patients and institutions. This study was conducted to show current statistics and trends in negative appendectomy rates in the United States. METHODS: A retrospective analysis was conducted using data from the National Inpatient Sample from 1998 to 2007. Adult patients (>18 y) having undergone appendectomies were identified by the appropriate International Classification of Diseases 9th revision codes. Patients with incidental appendectomy and those with appendiceal pathologies, also identified by relevant International Classification of Diseases 9th revision codes, were excluded. The remaining patients represent those who underwent an appendectomy without appendiceal disease. The patients then were stratified according to sex, women were classified further into younger (18-45 y) and older (>45 y) based on child-bearing age. The primary diagnoses subsequently were categorized by sex to identify the most common conditions mistaken for appendiceal disease in the 2 groups. RESULTS: Between 1998 and 2007, there were 475,651 cases of appendectomy that were isolated. Of these, 56,252 were negative appendectomies (11.83%). There was a consistent decrease in the negative appendectomy rates from 14.7% in 1998 to 8.47% in 2007. Women accounted for 71.6% of cases of negative appendectomy, and men accounted for 28.4%. The mortality rate was 1.07%, men were associated with a higher rate of mortality (1.93% vs .74%; P < .001). Ovarian cyst was the most common diagnosis mistaken for appendicitis in younger women, whereas malignant disease of the ovary was the most common condition mistaken for appendiceal disease in women ages 45 and older. The most common misdiagnosis in men was diverticulitis of the colon. CONCLUSIONS: There has been a consistent decline in the rates of negative appendectomy. This trend may be attributed to better diagnostics. Gynecologic conditions involving the ovary are the most common to be misdiagnosed as appendiceal disease in women.

Treatment outcomes of injured children at adult level 1 trauma centers: are there benefits from added specialized care?

BACKGROUND: Accidental traumatic injury is the leading cause of morbidity and mortality in children. The authors hypothesized that no mortality difference should exist between children seen at ATC (adult trauma centers) versus ATC with added qualifications in pediatrics (ATC-AQ). METHODS: The National Trauma Data Bank, version 7.1, was analyzed for patients aged <18 years seen at level 1 trauma centers. Bivariate analysis compared patients by ATC versus ATC-AQ using demographic and injury characteristics. Multivariate analysis adjusting for injury and demographic factors was then performed. RESULTS: A total sample of 53,702 children was analyzed, with an overall mortality of 3.9%. The adjusted odds of mortality was 20% lower for children seen at ATC-AQ (odds ratio, .80; 95% confidence interval, .68-.94). Children aged 3 to 12 years, those with injury severity scores > 25, and those with Glasgow Coma Scale scores < 8 all had significant reductions in the odds of death at ATC-AQ. CONCLUSIONS: Improved overall survival is associated with pediatric trauma patients treated at ATC-AQ.

Does the pattern of injury in elderly pedestrian trauma mirror that of the younger pedestrian?

BACKGROUND: Walking is the primary mode of transportation for people aged 65 y and over; hence pedestrian injuries are a substantial source of morbidity and mortality among elderly patients in the United States. This study is aimed at evaluating the pattern of injury in the elderly pedestrians and how it differs from younger patients. METHODS: Retrospective analysis of the National Trauma Data Bank (2002-2006) was performed, with inclusion criteria defined as pedestrian injuries based on ICD-9 codes, excluding age < 15 y. The following age categories in years were created: 15-24 (reference group), 25-34, 35-44, 45-54, 55-64, 65-74, 75-84, and 85-89. The injury prevalence was compared, and multivariate regression for mortality was conducted adjusting for demographic and injury characteristics. RESULTS: A total of 79,307 patients were analyzed. Superficial injuries were the most common at 29.1%, with lower extremity fractures and intracranial injuries following at 25.1% and 21.4% respectively. The very elderly (75-84 and 85-89) had significantly higher rates of fractures of the pelvis(16.2% and 16.8% versus 8.1% in the youngest group), upper (19.3% and 18.4% versus 9.8%), lower extremities (31.1% and 31.9% versus 22.5%) and intracranial injuries (25.5% and 28.7% versus 22.4%), but sustained lower rates of hepatic (2.3% and 1.7% versus 3.0%) injuries, with no difference seen in pancreatic, splenic, and genitourinary injuries. On multivariate analysis, very elderly patients were six to eight times more likely to die (OR 6.24 and 8.27, P < 0.001). CONCLUSION: Elderly patients have higher rates of fractures and intracranial injuries with an extremely worse mortality after pedestrian trauma.

Insurance status is a potent predictor of outcomes in both blunt and penetrating trauma.

BACKGROUND: Patients with penetrating injuries are known to have worse outcomes than those with blunt trauma. We hypothesize that within each injury mechanism there should be no outcome difference between insured and uninsured patients. METHODS: The National Trauma Data Bank version 7 was analyzed. Patients aged 65 years and older and burn patients were excluded. The insurance status was categorized as insured (private, government/military, or Medicaid) and uninsured. Multivariate analysis adjusted for insurance status, mechanism of injury, age, race, sex, injury severity score, shock, head injury, extremity injury, teaching hospital status, and year. RESULTS: A total of 1,203,243 patients were analyzed, with a mortality rate of 3.7%. The death rate was significantly higher in penetrating trauma patients versus blunt trauma patients (7.9% vs 3.0%; P < .001), and higher in the uninsured (5.3% vs 3.2%; P < .001). On multivariate analysis, uninsured patients had an increased odds of death than insured patients, in both penetrating and blunt trauma patients. Penetrating trauma patients with insurance still had a greater risk of death than blunt trauma patients without insurance. CONCLUSIONS: Insurance status is a potent predictor of outcome in both penetrating and blunt trauma.

Ureteral trauma: patterns and mechanisms of injury of an uncommon condition.

BACKGROUND: Traumatic ureteral injuries are uncommon, thus large series are lacking. METHODS: We performed a retrospective analysis of the National Trauma Data Bank (2002-2006). RESULTS: Of the 22,706 genitourinary injuries, 582 ureteral injury patients were identified (38.5% blunt, 61.5% penetrating). Patients were 84% male, 38% white, and 37% black (mean age, 31 y). Blunt trauma patients had a median Injury Severity Score of 21.5 versus 16.0 for penetrating injury (P < .001). Mortality rates were 9% blunt, and 6% penetrating (P = .166). Penetrating trauma patients had a higher incidence of bowel injuries (small bowel, 46%; large bowel, 44%) and vascular injuries (38%), whereas blunt trauma patients had a higher incidence of bony pelvic injuries (20%) (P < .001). CONCLUSIONS: Ureteral injuries are uncommon, seen in approximately 3 per 10,000 trauma admissions, and occur more in penetrating than in blunt trauma. The most common associated injury for blunt ureteral trauma is pelvic bone fracture, whereas penetrating ureteral trauma patients have more hollow viscus and vascular injuries.

Treatment and survival outcome for molecular breast cancer subtypes in black women.

OBJECTIVE: To analyze whether the local-regional surgical treatments (breast-conserving therapy, mastectomy) resulted in different overall survival, distant metastasis-free survival, and locoregional recurrence-free survival rates for the various molecular breast cancer subtypes. SUMMARY BACKGROUND DATA: Molecular gene expression profiling has been proposed as a new classification and prognostication system for breast cancer. Current recommendation for local-regional treatment of breast cancer is based on traditional clinicopathologic variables. METHODS: Retrospective analysis of 372 breast cancer cases with assessable immunohistochemical data for ER, PR, and Her-2/neu receptor status, diagnosed from 1998 to 2005. Molecular subtypes analyzed were luminal A, luminal B, basal like, and Her-2/neu. RESULTS: No substantial difference was noted in overall survival, and locoregional recurrence rate between the local-regional treatment modalities as a function of the molecular breast cancer subtypes. The basal cell-like subtype was an independent predictor of a poorer overall survival (hazard ratio [HR] = 2.52, 95% confidence interval [CI] 1.28-4.97, P < 0.01) and a shorter distant metastasis-free survival time (HR = 3.61, 95% CI 1.27-10.2, P < 0.01), and showed a tendency toward statistical significance as an independent predictor of locoregional recurrence (HR = 3.57, 95% CI 0.93-13.6, P = 0.06). CONCLUSIONS: The basal cell-like subtype is associated with a worse prognosis, a higher incidence of distant metastasis, and may be more prone to local recurrence when managed with breast-conserving therapy.

Basal cell-like (triple-negative) breast cancer, a predictor of distant metastasis in African American women.

BACKGROUND: The aim of this study was to evaluate the prognostic significance of the basal cell-like molecular breast cancer subtype with respect to locoregional recurrence and distant metastasis in African American women treated for breast cancer. METHODS: A retrospective analysis was performed of the tumor registry database for all African American women diagnosed and treated for breast cancer from 1998 to 2005 who had assessable data for all 3 markers: estrogen, progesterone, and Her-2/neu. RESULTS: A total of 372 patients were included in our study sample. Of these, 22 (6.1%) had locoregional recurrence, 35 (9.8%) had distant metastasis, and 301 (84.1%) had no evidence of breast tumor recurrence. The median follow-up time was 36 months. Compared with the other molecular subtypes the basal cell-like subtype showed a statistically significant association to distant metastasis: 15 (42.9%) vs 13 (37.1%), 4 (11.4%), and 3 (8.6%) (P < .001), respectively, for luminal A, Her-2/neu, and luminal B subtypes. The basal cell-like subtype was an independent predictor of distant metastasis (odds ratio, 5.8; 95% confidence interval, 1.5-22.0, P = .009). The molecular subtypes showed no statistically significant difference with respect to locoregional treatment administered and tumor stage at time of diagnosis. CONCLUSIONS: The basal cell-like molecular breast cancer subtype is an independent predictor of distant metastasis in African American women.