Objective: Funnel plots (plots of effect estimates against sample size) may be useful to detect bias in meta-analyses that were later contradicted by large trials. We examined whether a simple test of asymmetry of funnel plots predicts discordance of results when meta-analyses are compared to large trials, and we assessed the prevalence of bias in published meta-analyses. Design: Medline search to identify pairs consisting of a meta-analysis and a single large trial (concordance of results was assumed if effects were in the same direction and the meta-analytic estimate was within 30% of the trial); analysis of funnel plots from 37 meta-analyses identified from a hand search of four leading general medicine journals 1993-6 and 38 meta-analyses from the second 1996 issue of the Cochrane Database of Systematic Reviews. Main outcome measure: Degree of funnel plot asymmetry as measured by the intercept from regression of standard normal deviates against precision. Results: In the eight pairs of meta-analysis and large trial that were identified (five from cardiovascular medicine, one from diabetic medicine, one from geriatric medicine, one from perinatal medicine) there were four concordant and four discordant pairs. In all cases discordance was due to meta-analyses showing larger effects. Funnel plot asymmetry was present in three out of four discordant pairs but in none of concordant pairs. In 14 (38%) journal meta-analyses and 5 (13%) Cochrane reviews, funnel plot asymmetry indicated that there was bias. Conclusions: A simple analysis of funnel plots provides a useful test for the likely presence of bias in meta-analyses, but as the capacity to detect bias will be limited when meta-analyses are based on a limited number of small trials the results from such analyses should be treated with considerable caution.

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Preventive home visitation programs appear to be effective, provided the interventions are based on multidimensional geriatric assessment and include multiple follow-up home visits and target persons at lower risk for death. Benefits on survival were seen in young-old rather than old-old populations.

The association between corticosteroid therapy and subsequent infections was calculated by pooling data from 71 controlled clinical trials. The overall rate of infectious complications was 12.7010 in the 2,111 patients randomly allocated to systemic corticosteroids and 8.0070 in the 2,087 controls (relative risk [RR], 1.6; 95% confidence interval reI], 1.3-1.9; P < .001). The risk of infection was particularly high in patients with neurologic diseases (RR, 2.8; 95% CI, 1.9-4.3; P< .001) and less pronounced in patients with intestinal (RR, 1.4; 95% CI, 1.1-1.7; P = .02), hepatic (RR, 1.4; 95% CI, 0.9-2.3; P = .25), and renal (RR> 1; P = .03) diseases. The rate was not increased in patients given a daily dose of <10 mg or a cumulative dose of <700 mg of prednisone. With increasing doses the rate of occurrence of infectious complications increased in patients given corticosteroids as well as in patients given placebo, a finding suggesting that not only the corticosteroid but also the underlying disease state account for the steroid-associated infectious complications observed in clinical practice.Corticosteroids in pharmacologic doses are commonly used to inhibit the immunologic network [1, 2]. As a consequence one might expect that the resistance to a wide variety of bacterial, viral, protozoal, and fungal agents is depressed, as was clearly demonstrated by numerous investigations in animals [3][4][5]. The effect of corticosteroids on the rate of infection was shown to depend upon many variables, including the dosage of the steroid and the resistance of the animal. These observations in animals were in accordance with the clinical impression of an increased rate of infections in patients treated with glucocorticoids.Toxicologic studies in animals allow in many but not all instances for the prediction of potential adverse effects of a drug in humans and for the establishment of the underlying mechanism for such unwanted effects. However, such studies cannot provide a quantitative estimate of the rate of occurrence of a given adverse effect in humans. This might also be true for corticosteroids. For instance, a large number of the investigations dealing with the enhance-

These data suggest that this intervention can reduce disabilities among elderly people at low risk but not among those at high risk for functional impairment, and that these effects are likely related to the home visitor's performance in conducting the visits.

Using a survey questionnaire design, we investigated the incidence, site, and nature of jogging injuries among all participants of a popular 16 km race. The response rate was 83.6%. Of 4,358 male joggers, 45.8% had sustained jogging injuries during the 1 year study period, 14.2% had required medical care, and 2.3% had missed work because of jogging injuries. Occurrence of jogging injuries was independently associated with higher weekly mileage (P less than 0.001), history of previous running injuries (P less than 0.001), and competitive training motivation (P = 0.03). Higher mileage was also associated with more frequent medical consultations due entirely to jogging-related injuries. In 33 to 44 year olds (N = 1,757), the number of years of running was inversely related to incidence of injuries (P = 0.02). Injuries were not significantly related to race running speed, training surface, characteristics of running shoes, or relative weight. Achillodynia and calf muscle symptoms were the two most common overuse injuries and occurred significantly more often among older runners with increased weekly mileage. We conclude that jogging injuries are frequent, that the number of firmly established etiologic factors is low, and that, in recommending jogging, moderation should be the watchword.

Study objective: To describe mortality inequalities related to education and housing tenure in 11 European populations and to describe the age pattern of relative and absolute socioeconomic inequalities in mortality in the elderly European population. Design and Methods: Data from mortality registries linked with population census data of 11 countries and regions of Europe were acquired for the beginning of the 1990s. Indicators of socioeconomic status were educational level and housing tenure. The study determined mortality rate ratios, relative indices of inequality (RII), and mortality rate differences. The age range was 30 to 90+ years. Analyses were performed on the pooled European data, including all populations, and on the data of populations separately. Data were included from Finland, Norway, Denmark, England and Wales, Belgium, France, Austria, Switzerland, Barcelona, Madrid, and Turin. Main results: In Europe (populations pooled) relative inequalities in mortality decreased with increasing age, but persisted. Absolute educational mortality differences increased until the ages 90+. In some of the populations, relative inequalities among older women were as large as those among middle aged women. The decline of relative educational inequalities was largest in Norway (men and women) and Austria (men). Relative educational inequalities did not decrease, or hardly decreased with age in England and Wales (men), Belgium, Switzerland, Austria, and Turin (women). Conclusions: Socioeconomic inequalities in mortality among older men and women were found to persist in each country, sometimes of similar magnitude as those among the middle aged. Mortality inequalities among older populations are an important public health problem in Europe.

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