Unbiased Estimation of Odds Ratio by Using Negative Binomial Plans

The use of the negative binomial distribution in both the numerator and denominator in prospective studies leads to an unbiased estimate of the odds ratio and an exact expression for its variance. Sample sizes that minimize the variance of odds ratio estimates are specified. The variance of the odds ratio estimate is shown to be close to the Cramér-Rao lower bound.     

Ovarian structures and uterine environment are associated with phenotypic and genetic merit for performance in lactating dairy cows

The objective of this study was to estimate the association between detailed reproductive phenotypes for cows categorized as divergent for phenotypic and genetic performance. The hypothesis was that higher yielding animals, either phenotypically or genetically, would have compromised ovarian and uterine reproductive performance. Detailed reproductive traits including multiple ovulations, cystic ovarian structures, corpus luteum (CL) presence, and uterine environment were available on 9675 ultrasound records from 8174 dairy lactating cows, calved between 10 and 70 days. Cows were categorized, within parity, into low, average, or high for each of the performance traits. There was a greater likelihood of multiple ovulations in cows with greater phenotypic yields (odds ratio: 1.53–1.81) and greater genetic merit for yield (odds ratio: 1.31–1.59) relative to lower performing contemporaries. After adjustment for genetic merit, a similar trend of increased odds (odds ratio: 1.29–1.87) of multiple ovulations in higher yielding cows was observed compared with the lowest yielding category. There was no association between either phenotypic milk composition or genetic merit for milk composition with the likelihood of multiple ovulations. The likelihood of cystic ovarian structures was highest in cows with greatest phenotypic milk yields (odds ratio: 2.75–3.24), greater genetic merit for milk yield (odds ratio: 1.30–1.51), and even after adjustment for genetic merit there was a greater likelihood of cystic ovarian structures in cows with the highest milk yields (odds ratio: 2.71–2.95), compared with cows in the lowest category for each of the milk traits. Cows with average phenotypic milk yields were more likely to have a CL, compared with the lowest yielding category (odds ratio: 1.20–1.23), and these associations remained after adjustment for genetic merit of the trait. The likelihood of CL presence was highest in cows with the lowest genetic merit for milk. Lower fat:protein ratio was associated with an increased likelihood of CL presence compared with cows with greater fat:protein ratio and cows with the highest phenotypic milk composition were more likely to have a CL compared with cows in the lowest composition category. Genetic predisposition to higher somatic cell score was associated with a reduced risk of multiple ovulations (odds ratio: 0.69; 95% CI: 0.55–0.87) but an increased likelihood of CL presence (odds ratio: 2.66; 95% CI: 2.09–3.37) and poorer uterine health score (odds ratio: 1.36; 95% CI: 1.20–1.55). There was a lower likelihood of multiple ovulations, cystic ovarian structures, and poorer uterine health and an increased likelihood of CL presence in cows with superior genetic merit for reproductive performance and survival.     

Sow-level risk factors for stillbirth of piglets in organic sow herds

In Danish organic pig production, one-third of total born piglets die before weaning, and stillbirth has previously crudely been estimated to account for 27% of the total preweaning mortality. The objective of this study was to evaluate season, litter size, parity and body condition of the sow as risk factors for stillbirth in nine commercial Danish organic pig herds. The study was conducted over a 1-year period, and the data included registrations on 5170 farrowings with 82 906 total born piglets. The average number of total born piglets per litter was 16.0, and the number of stillborn piglets per litter was 1.1. A significant effect of season was seen with an odds ratio for stillbirth of 1.15 during summer (May to August) compared with the remaining part of the year. A non-linear effect of litter size was seen where an increase in litter size from 11 to 16 resulted in an odds ratio of stillbirth of 1.11. An increase in litter size from 16 to 21 resulted in an odds ratio of stillbirth of 1.45. A significant interaction between body condition and parity was present. In first parity sows, an increase in body condition score from 2 (thin) to 3 (moderate) and from 3 to 4 (fat) increased the probability of stillbirth with an odds ratio of 1.23 and 1.36, respectively. In sows with parity above 4, an increase in body condition score from 2 to 3 and from 3 to 4 decreases the probability of stillbirth with an odds ratio of 0.68 and 0.79, respectively. In conclusion, increasing litter size and being born during the summer months of May to August were found to be risk factors for stillbirth. Furthermore, an interaction between body condition and parity showed that thin sows with parity above 4 had a substantially increased risk of stillbirth compared with normal and fat sows with parity above 4. In contrast, for parity 1 sows risk of stillbirth was increased in fat sows.     

Prospective seroepidemiological study of role of human papillomavirus in non-cervical anogenital cancers.

OBJECTIVE: To evaluate the association between infection with the major oncogenic types of human papillomavirus and the risk of developing non-cervical anogenital cancers in a cohort followed up prospectively. DESIGN: Data from two large serum banks to which about 700,000 people had donated serum samples were followed up for a mean of 8 years. People who developed non-cervical anogenital cancers during follow up were identified by registry linkage with the nationwide cancer registries in Finland and Norway. Within this cohort a nested case-control study was conducted based on the serological diagnosis of infection with human papillomavirus types 16, 18, and 33. SUBJECTS: 81 cases and 240 controls matched for sex, age, and storage time of serum samples. MAIN OUTCOME MEASURES: Odds ratios of developing non-cervical anogenital cancers in presence of IgG antibodies to specific micro-organisms. RESULTS: Subjects seropositive for human papillomavirus type 16 had an increased risk of developing non-cervical anogenital cancers (odds ratio 3.1 (95% confidence interval 1.4 to 6.9)). Subjects seropositive for type 33 also had an increased risk (odds ratio 2.8 (1.0 to 8.3)) but not significantly after adjustment for infection with type 16. Seropositivity for human papillomavirus type 16 was associated with an increased risk of developing vulvar and vaginal cancers (odds ratio 4.5 (1.1 to 22)) and a strongly increased risk of developing preinvasive vulvar and vaginal lesions (odds ratio infinity (3.8 to infinity)). Seropositivity for human papillomavirus type 18 increased the risk of developing preinvasive lesions (odds ratio 12 (1.2 to 590)). High, but non-significant odds ratios for types 16 and 33 were seen for penile cancers. CONCLUSIONS: This study provides prospective seroepidemiological evidence that infection with human papillomavirus type 16 confers an increased risk of developing non-cervical genital cancers, particularly vulvar and vaginal cancers.     

Factors affecting nutritional status in female adults in Dhaka slums, Bangladesh

This study looks at women from the slums in Mohammadpur, Dhaka, Bangladesh, where 54 percent of women's BMI was less than 18.5. Fifty percent of the Dhaka slum population lived below the poverty line. Logistic regression showed that women with income above 1,500 taka per capita were 1.78 times more likely to have a higher BMI (odds ratio 1.7863; CI = 0.671-3.639). Women with their own savings were 1.89 times more likely to have higher BMI (odds ratio 1.879; CI = 0.01163-1.6431). Women were 4.5 times more likely to have a higher BMI when food expenditure per capita above 559 taka per month (odds ratio 4.55; CI = 1.0302-8.0799). Women were 1.82 times more likely to have higher BMI when there was a break even situation in financial status (odds ratio 1.8212; CI = -015709-3.6285). Female headed households were 3.3 times more likely to have a higher BMI compared to women living in male headed households (odds ratio 3.2966; CI = 0.33711-6.25620). Women who work 15-23 days per month were 2.3 times more likely to have a higher BMI (odds ratio 2.33; CI = 0.1133-4.5600). Women who are the budget manager are 1.12 times more likely to have a higher BMI (odds ratio 1.125; CI = 0.29296-2.0966). Where as a husband who beats his wife is 1.83 more likely to have a poorer BMI (odds ratio 1.8312; CI = -3.72596-0.17508). Women who have no marriage documents and women who take days off due to illness less than 11 days per month were more likely to have a poorer BMI (odds ratio 0.5567; CI = -0.049339-2.8379; odds ratio 0.7569; CI = 0.183167-2.0002). Women's nutritional status and well being can influence their ability to provide for themselves and their families and the demonstration of a relationship between measures of women's autonomy and control in the household and women's nutritional status is an important indication of the importance of these sociological constructs. Women's participation in work outside the home may be a factor increasing their autonomy. The identification of relationships between women's autonomy and control and their physical well being should provide further leverage for policy change that will enable women to escape some traditional roles and to contribute as more equal partners with men in the future of Bangladeshi society.     

Blowfly strike in England and Wales: the relationship between prevalence and farm and management factors

Abstract. In order to develop and evaluate control strategies for blowfly strike, a greater understanding of the epidemiology is essential. A postal survey of sheep farmers yielded information about ten farm and management factors and their relationship to blowfly strike prevalence. The risk of a farm reporting at least one case of blowfly strike increased as flock size and stocking density increased (adjusted odds ratio of 1.13 for an increase in flock size of 100 sheep and 1.38 for an increase in stocking density of ten sheep per hectare). As farm altitude increased, the risk of blowfly strike decreased (adjusted odds ratio 0.67 for an increase in farm altitude of 100 m). The risk of high strike prevalence (more than 2% of sheep struck) decreased as both farm altitude and flock size increased. High strike prevalence was also associated with on-farm sheep carcase disposal (odds ratio 1.35). Farmers in the south-west of England were more likely to report at least one case of blowfly strike and high strike prevalence compared to all other regions.     

The use of random controls in genetic association studies

BACKGROUND: The optimal control sample would be ethnically-matched and at minimal risk of developing the disease. Alternatively, one could collect random individuals from the population or select individuals to reduce the number of at-risk individuals in the sample. The effect of randomly selected individuals in a control sample on the statistical power and the odds ratio estimate was investigated. METHODS: Case and control genotype distributions were simulated using standard genetic models with an additional term representing the proportion of unidentified cases in the control sample. Power and odds ratio were calculated from the genotype distributions generated under different sampling scenarios using established methods. RESULTS: Random sampling of controls resulted in a loss in power and a reduction in the odds ratio estimate to a degree that is determined by the proportion of random sampling and the prevalence of the disease. Random sampling resulted in a 19% loss in power for a disease having prevalence of 0.20, compared to a control sample that contained no at-risk individuals. Having random controls results in a decrease in the odds ratio estimate. CONCLUSIONS: Investigators planning case-control genetic association studies should be aware of the statistical costs of different ascertainment approaches.     

Optimal approximate conversions of odds ratios and hazard ratios to risk ratios

Odds ratios approximate risk ratios when the outcome under consideration is rare but can diverge substantially from risk ratios when the outcome is common. In this paper, we derive optimal analytic conversions of odds ratios and hazard ratios to risk ratios that are minimax for the bias ratio when outcome probabilities are specified to fall in any fixed interval. The results for hazard ratios are derived under a proportional hazard assumption for the exposure. For outcome probabilities specified to lie in symmetric intervals centered around 0.5, it is shown that the square-root transformation of the odds ratio is the optimal minimax conversion for the risk ratio. General results for any nonsymmetric interval are given both for odds ratio and for hazard ratio conversions. The results are principally useful when odds ratios or hazard ratios are reported in papers, and the reader does not have access to the data or to information about the overall outcome prevalence.     

Describing Ordinal Odds Ratios for Stratified r × c Tables

For an r × ctable with ordinal responses, odds ratios are commonly used to describe the relationship between the row and column variables. This article shows two types of ordinal odds ratios where local‐global odds ratios are used to compare several groups on a c‐category ordinal response and a global odds ratio is used to measure the global association between a pair of ordinal responses. When there is a stratification factor, we consider Mantel‐Haenszel (MH) type estimators of these odds ratios to summarize the association from several strata. Like the ordinary MH estimator of the common odds ratio for several 2 × 2 contingency tables, the estimators are used when the association is not expected to vary drastically among the strata. Also, the estimators are consistent under the ordinary asymptotic framework in which the number of strata is fixed and also under sparse asymptotics in which the number of strata grows with the sample size. Compared to the maximum likelihood estimators, simulations find that the MH type estimators perform better especially when each stratum has few observations. This article provides variances and covariances formulae for the local‐global odds ratios estimators and applies the bootstrap method to obtain a standard error for the global odds ratio estimator. At the end, we discuss possible ways of testing the homogeneity assumption.     

Case-control study of sudden infant death syndrome in Scotland, 1992-5.

OBJECTIVE: To investigate the relation between routine infant care practices and the sudden infant death syndrome in Scotland. METHODS: National study of 201 infants dying of the sudden infant death syndrome (cases) and 276 controls by means of home interviews comparing methods of infant care and socioeconomic factors. RESULTS: Sleeping prone (odds ratio 6.96 (95% confidence interval 1.51 to 31.97) and drug treatment in the previous week (odds ratio 2.33 (1.10 to 4.94)) were more common in the cases than controls on multivariate analysis. Smoking was confirmed as a significant risk factor (odds ratio for mother and father both smoking 5.19 (2.26 to 11.91)). The risk increased with the number of parents smoking (P < 0.0001), with the number of cigarettes smoked by mother or father (P = 0.0001), and with bed sharing (P < 0.005). A new finding was an increased risk of dying of the syndrome for infants who slept at night on a mattress previously used by another infant or adult (odds ratio 2.51 (1.39 to 4.52)). However, this increased risk was not established for mattresses totally covered by polyvinyl chloride. CONCLUSIONS: Sleeping prone and parental smoking are confirmed as modifiable risk factors for the sudden infant death syndrome. Sleeping on an old mattress may be important but needs confirmation before recommendations can be made.     

Effectiveness of helmets in skiers and snowboarders: case-control and case crossover study

Objective To determine the effect of helmets on the risk of head and neck injuries in skiers and snowboarders.Design Matched case-control and case crossover study.Setting 19 ski areas in Quebec, Canada, November 2001 to April 2002.Participants 1082 skiers and snowboarders (cases) with head and neck injuries reported by the ski patrol and 3295 skiers and snowboarders (controls) with non-head or non-neck injuries matched to cases at each hill.Main outcome measures Estimates of matched odds ratios for the effect of helmet use on the risk of any head or neck injury and for people requiring evacuation by ambulance.Results The adjusted odds ratio for helmet use in participants with any head injury was 0.71 (95% confidence interval 0.55 to 0.92), indicating a 29% reduction in the risk of head injury. For participants who required evacuation by ambulance for head injuries, the adjusted odds ratio for helmet use was 0.44 (0.24 to 0.81). Similar results occurred with the case crossover design (odds ratio 0.43, 0.09 to 1.83). The adjusted odds ratio for helmet use for participants with any neck injury was 0.62 (0.33 to 1.19) and for participants who required evacuation by ambulance for neck injuries it was 1.29 (0.41 to 4.04).Conclusions Helmets protect skiers and snowboarders against head injuries. We cannot rule out the possibility of an increased risk of neck injury with helmet use, but the estimates on which this assumption is based are imprecise.     

Case-control study of migraine and risk of ischaemic stroke in young women.

OBJECTIVE--To determine whether migraine is a risk factor for ischaemic stroke in young women. DESIGN--A case-control study. SETTING--Five hospitals in Paris and suburbs. SUBJECTS--72 women aged under 45 with ischaemic stroke and 173 controls randomly selected from women hospitalised in the same centres. MAIN OUTCOME MEASURES--Ischaemic stroke confirmed by cerebral computerised tomography or magnetic resonance imaging; history of headache recorded with structured interview, and diagnosis of migraine assessed by reproducibility study. RESULTS--Ischaemic stroke was strongly associated with migraine, both migraine without aura (odds ratio 3.0 (95% confidence interval 1.5 to 5.8)) and migraine with aura (odds ratio 6.2 (2.1 to 18.0)). The risk of ischaemic stroke was substantially increased for migrainous women who were using oral contraceptives (odds ratio 13.9) or who were heavy smokers (> or = 20 cigarettes/day) (odds ratio 10.2). CONCLUSIONS--These results indicate an independent association between migraine and the risk of ischaemic stroke in young women. Although the absolute risk of ischaemic stroke in young women with migraine is low, the reduction of known risk factors for stroke, in particular smoking and use of oral contraceptives, should be considered in this group.     

Estimation of Relative Risk Under Variable Multiple Matching

When disease incidence is low, the odds ratio, which closely approximates relative risk, is estimated optimally in a closed form using a variable matching ratio in a retrospective design. The model also enables one to assess the homogeneity of the odds ratio from the same one matched sample. Analogous procedures are shown to hold for the prospective design.     

Association of a variant in exon 31 of the sulfonylurea receptor 1 (SUR1) gene with type 2 diabetes mellitus in French Caucasians

The sulfonylurea receptor (SUR1) of the pancreatic beta-cell ATP-sensitive potassium channel plays a key role in glucose-induced insulin secretion. The A-allele of a single nucleotide polymorphism (SNP) in exon 31 of the SUR1 gene (AGG-->AGA; Arg1273Arg) has previously been shown to be associated with hyperinsulinemia in nondiabetic Mexican-American subjects. Here, we have investigated the association of this SNP with type 2 diabetes mellitus (T2DM) in French Caucasian subjects. We have observed an increased frequency of the A allele (37.1% vs 27.6%, P=0.0048; odds ratio 1.54), of the AA genotype (15.7% vs 9.8%; P=0.025), and of the combined AA/AG genotypes (58.5% vs 45.5%, P=0.0098; odds ratio 1.69) in patients compared with controls. This association is stronger in the subgroup of patients with age of diagnosis of diabetes equal to or less than 45 years: A allele 43.2% (P=0.0003 compared with controls; odds ratio 1.99), AA genotype 21.4% (P=0.0032), and combined AA/AG genotypes 65.1% (P=0.0022; odds ratio 2.23). Unexpectedly, the G allele is strongly associated with arterial hypertension in obese diabetic subjects (GG vs AA odds ratio 19.97). In conclusion, we have observed an association of an SNP in exon 31 of the SUR1 gene with T2DM. These data reinforce the hypothesis that insulin secretion defects in T2DM might be at least partially related to allelic variations in the SUR1 gene.     

Corticosteroids in acute traumatic brain injury: systematic review of randomised controlled trials.

OBJECTIVE: To quantify the effectiveness and safety of corticosteroids in the treatment of acute traumatic brain injury. DESIGN: Systematic review of randomised controlled trials of corticosteroids in acute traumatic brain injury. Summary odds ratios were estimated as an inverse variance weighted average of the odds ratios for each study. SETTING: Randomised trials available by March 1996. SUBJECTS: The included trials with outcome data comprised 2073 randomised participants. RESULTS: The effect of corticosteroids on the risk of death was reported in 13 included trials. The pooled odds ratio for the 13 trials was 0.91 (95% confidence interval 0.74 to 1.12). Pooled absolute risk reduction was 1.8% (-2.5% to 5.7%). For the 10 trials that reported death or disability the pooled odds ratio was 0.90 (0.72 to 1.11). For infections of any type the pooled odds ratio was 0.92 (0.69 to 1.23) and for the seven trials reporting gastrointestinal bleeding it was 1.05 (0.44 to 2.52). With only those trials with the best quality of concealment of allocation, the pooled odds ratio estimates for death and death or disability became closer to unity. CONCLUSIONS: This systematic review of randomised controlled trials of corticosteroids in acute traumatic brain injury shows that there remains considerable uncertainty over their effects. Neither moderate benefits nor moderate harmful effects can be excluded. The widely practicable nature of the drugs and the importance of the health problem suggest that large simple trials are feasible and worth while to establish whether there are any benefits from use of corticosteroids in this setting.     

Risk of Fatal Bleeding in Episodes of Major Bleeding with New Oral Anticoagulants and Vitamin K Antagonists: A Systematic Review and Meta-Analysis

Background

The reversibility of new/novel oral anticoagulants (NOAC) is not well understood, whereas the reversal strategies for bleeding associated with vitamin k antagonists (VKA), such as warfarin, is well established. It is unknown whether outcomes are different between bleeds occurring with NOAC compared to VKA use.

Objectives

This systematic review and meta-analysis of randomized controlled trials determines the relative odds of fatal bleeding given that a patient suffered a major bleed while on NOAC versus VKA therapy.

Search Methods

Data on major and fatal bleeding events was sought from randomized controlled trials of NOAC agents compared to VKAs.

Main Results

20 trials were included in the meta-analysis. From which, 4056 first-time, major bleeding events were reported and included in the primary analysis. The summary odds ratio for the conditional odds of fatal bleeding given that a major bleeding event occurred was 0.65 [0.52, 0.81] favoring the NOAC agents (p = 0.0001). The reduced odds of fatal bleeding with NOACs was not demonstrated after controlling for bleeding location. Given that an intracranial bleeding event occurred, the summary odds ratio for the conditional odds of fatal bleeding was 0.96 [0.70, 1.32]. For extracranial bleeding events, the summary odds ratio was also statistically insignificant at 0.945 [0.66, 1.35].

Author’s Conclusions

The odds ratio calculated in this meta-analysis showed a reduced odds of death in major bleeding associated with NOAC use. This risk reduction was due to a disproportionate amount of intracranial bleeding in the VKA arms. For any given bleeding site, there was no evidence of a significant difference in fatal outcomes from bleeds associated with NOAC versus VKA use.

Protocol Registration

Protocol registered on PROSPERO under CRD42014013294.     

Odds ratio based multifactor-dimensionality reduction method for detecting gene-gene interactions

MOTIVATION: The identification and characterization of genes that increase the susceptibility to common complex multifactorial diseases is a challenging task in genetic association studies. The multifactor dimensionality reduction (MDR) method has been proposed and implemented by Ritchie et al. (2001) to identify the combinations of multilocus genotypes and discrete environmental factors that are associated with a particular disease. However, the original MDR method classifies the combination of multilocus genotypes into high-risk and low-risk groups in an ad hoc manner based on a simple comparison of the ratios of the number of cases and controls. Hence, the MDR approach is prone to false positive and negative errors when the ratio of the number of cases and controls in a combination of genotypes is similar to that in the entire data, or when both the number of cases and controls is small. Hence, we propose the odds ratio based multifactor dimensionality reduction (OR MDR) method that uses the odds ratio as a new quantitative measure of disease risk. RESULTS: While the original MDR method provides a simple binary measure of risk, the OR MDR method provides not only the odds ratio as a quantitative measure of risk but also the ordering of the multilocus combinations from the highest risk to lowest risk groups. Furthermore, the OR MDR method provides a confidence interval for the odds ratio for each multilocus combination, which is extremely informative in judging its importance as a risk factor. The proposed OR MDR method is illustrated using the dataset obtained from the CDC Chronic Fatigue Syndrome Research Group. AVAILABILITY: The program written in R is available.     

Estimation of log‐odds ratio from group testing data using Firth correction

We consider the estimation of the prevalence of a rare disease, and the log‐odds ratio for two specified groups of individuals from group testing data. For a low‐prevalence disease, the maximum likelihood estimate of the log‐odds ratio is severely biased. However, Firth correction to the score function leads to a considerable improvement of the estimator. Also, for a low‐prevalence disease, if the diagnostic test is imperfect, the group testing is found to yield more precise estimate of the log‐odds ratio than the individual testing.     

Saline-filled breast implant safety and efficacy: a multicenter retrospective review

Our center undertook an industry-funded, outcomes-based, multicenter, retrospective review to evaluate the safety and efficacy of saline-filled breast implants. Our review was part of a pre-market approval review process mandated by the U.S. Food and Drug Administration. The design of our review was modeled on a Plastic Surgery Educational Foundation outcomes study previously conducted by our center. For this study, several significant changes were made to our previous protocol, including improved patient tracking, stronger biostatistical support, and a mandatory 10-year minimum patient follow-up period. Physician-reported and patient-reported data on 450 patients with 882 saline-filled breast implants placed between January 1, 1980, and June 30, 1986, were obtained. Mean patient follow-up period was 13.0 years. Most implants (93.9 percent) were placed for breast augmentation. Seventy-four percent were placed in a submammary position; 25.6 percent, subpectorally; and 0.2 percent, subcutaneously. The overall complication rate was 20.2 percent. Reoperation for capsular contracture or implant deflation was necessary in 104 of 450 patients (23.1 percent). Deflation occurred in 73 implants (8.3 percent) and was underreported according to the physicians' record review alone. This deflation rate is higher than the 5.5 percent previously reported by our center. However, 26 of these 73 deflations (35.6 percent) occurred in a single cohort of patients at one center using Surgitek saline implants. If this cohort is excluded, the deflation rate drops to 5.8 percent, a figure more consistent with data published in the literature and found in our previous study. Of the 73 deflations, spontaneous deflation was reported for 50 (74.6 percent), and the remainder were iatrogenic. Actuarial survival of the non-Surgitek implants was 98.4 percent to 99.8 percent at 5 years and 96.9 percent to 98.9 percent at 10 years (95 percent confidence interval). Risk factors for implant deflation included the use of Surgitek saline-filled implants (odds ratio = 17.5, p < 0.01), use of Heyer-Schulte and Mentor model 1800 implants (odds ratio = 3.0, p < 0.01), and implant size greater than 450 cc (odds ratio = 1.01, p < 0.02). Risk factors for capsular contracture included submammary implant position (odds ratio = 2.05, p = 0.03) and implant size greater than 450 cc (odds ratio = 1.01, p < 0.01). Overall, satisfaction was high: 93 percent of patients were "satisfied" or "very satisfied" with their implants. As in our earlier study, risk factors for patient dissatisfaction were reconstruction after mastectomy (odds ratio = 7.6, p = 0.011), significant breast firmness (odds ratio = 6.2, p < 0.001), and patient desire for smaller implants (odds ratio = 3.0, p = 0.020). In conclusion, our review provides additional outcomes-based evidence that saline-filled breast implants remain a safe, effective alternative to silicone gel-filled models.