Ann Intern Med 1 May 2007 Vol 146

Giant cell arteritis is not a diagnosis we make readily in general practice, though in theory it can be made on clinical grounds without the necessity of a temporal artery biopsy (see the US definition). We don’t know what causes it but we do know that TNF-alpha is involved, so this European study used infliximab to block it and hoped to show that this might allow patients to be weaned off corticosteroids. Not so, however, and the infliximab group had more infections, some of them nasty.

By contrast, we diagnose polymyalgia rheumatica all the time, on the basis of history, elevated ESR and response to steroids. It’s a gratifying diagnosis in that the patient feels so much better within a day or two, but dispiriting because again we don’t know the cause and we know that the patient may have to remain on steroids for a very long time. Might we use infliximab at the outset to douse the effect of TNF and bring lasting benefit? This study provides no evidence to support that strategy and some (again) to suggest that it is unsafe.

I don’t know of any epic to come out of Norfolk, though it is likely that many were sung in the mead-halls of that county from the time of its colonisation by Saxons in the mid-fifth-century. EPIC-Norfolk was set up 1500 years later as a sort of mega-Framingham cohort study to study the determinants of health in the English fens. The novel cardiovascular risk factor in this section of the mighty epic is the apolipoprotein B/apolipoprotein –A1 ratio: yes, highly significant in itself but no, not a useful addition to the risk factors we already measure. Take it away, it’s boring: we want the one about Beowulf and the monsters.