Cradles of industry and occupational medicine in the modern world: Milan 1906 -- Annus Mirabilis.

BACKGROUND: The example examined is Milan, Italy's main industrial city, where the great International Exhibition was held in 1906. This was the culmination of a period of accelerated industrial growth that modern-day historiography considers to be when Italy's first real industrial revolution began. The twenty-five years between the National Industrial Exhibition of 1881, which was also held in Milan, and the 1906 Exhibition truly reflected a period which was crucial for this transformation to take of. Alongside industry, which was then going through a phase of reorganization and development, Milanese civil society was increasingly turning its interest and attention to what was called the "social question". In an atmosphere of debate and exchange of ideas and experience with Turin, another major industrial city of the north and the birthplace of the Italian engineering and automobile industries, social organizations, political parties and trade unions began to be established thus heralding the Italian approach towards twentieth-century welfare. RESULTS: This is the context in which the first International Congress on Occupational Diseases was held in Milan from 9 to 14 June 1906 within the framework of the International Exhibition. The success achieved with this initiative. organized by Luigi Devoto and Malachia De Cristoforis, which was to continue with the founding of the International Permanent Commission on Occupational Health, showed that the time was ripe for a new subject to appear on the scene--the occupational health physician--who from then on was to play an important role in the promotion of workers' health. CONCLUSIONS: The article outlines the main features of the Italian industrial transformation at the turn of the new century with special attention focused on Milan, the capital of industry in Italy. It also describes the impact on public opinion caused by the events surrounding the epic construction of the transalpine railway tunnels which began in 1856 with the Mont Cenis tunnel, then the tragic enterprise of the St. Gotthard tunnel in 1883, ending in 1906 with the inauguration of the Simplon tunnel. The Milan congress is examined as well as the developments which, from then on, began increasingly to give physicians specialised in occupational diseases a higher profile in events of an international nature in the defence of workers' health but also in the interests of economic development.

Uncertainty, imprecision, and the precautionary principle in climate change assessment.

Statistical decision theory can provide useful support for climate change decisions made under conditions of uncertainty. However, the probability distributions used to calculate expected costs in decision theory are themselves subject to uncertainty, disagreement, or ambiguity in their specification. This imprecision can be described using sets of probability measures, from which upper and lower bounds on expectations can be calculated. However, many representations, or classes, of probability measures are possible. We describe six of the more useful classes and demonstrate how each may be used to represent climate change uncertainties. When expected costs are specified by bounds, rather than precise values, the conventional decision criterion of minimum expected cost is insufficient to reach a unique decision. Alternative criteria are required, and the criterion of minimum upper expected cost may be desirable because it is consistent with the precautionary principle. Using simple climate and economics models as an example, we determine the carbon dioxide emissions levels that have minimum upper expected cost for each of the selected classes. There can be wide differences in these emissions levels and their associated costs, emphasizing the need for care when selecting an appropriate class.

The utility and cost-effectiveness of D-dimer measurements in the diagnosis of deep vein thrombosis.

BACKGROUND AND OBJECTIVE: The potential utility of D-dimer measurements for the diagnosis of deep vein thrombosis became evident soon after the development of reliable commercial assays. The purpose of this review is to outline some critical aspects affecting cost-effectiveness of D-dimer measurements in the diagnosis of deep vein thrombosis (DVT). METHODS: The authors have been working in this field contributing original papers whose data have been used for this study. In addition, the material analyzed in this article includes papers published in the journals covered by the Science Citation Index and Medline. RESULTS: D-dimer levels are very sensitive to the process of fibrin formation/dissolution occurring with ongoing thrombosis. However, they may not be highly specific for venous thromboembolism as they are influenced by the presence of comorbid conditions potentially elevating plasma D-dimer (cancer, surgery, infectious diseases). In addition, commercially available ELISA assays, although quantitative and reproducible, cannot be used under emergency conditions because they are time-consuming and suited for batch-processing of plasma samples. Recently, new assays have been introduced which permit fast and quantitative D-dimer estimations in individual patients. We have evaluated the utility of two new rapid assays (LPIA D-dimer. Mitsubishi, and VIDAS D-DIMER, bio-Merieux) in combination with compression real-time-B-mode ultrasonography for the detection of deep vein thrombosis in asymptomatic patients following elective hip replacement and in patients with clinically suspected deep vein thrombosis. In both settings, we identified cut-off values with optimal sensitivity which allow exclusion of deep vein thrombosis in a considerable percentage of patients, with substantial sparing of economic resources. In fact, based on a cost-effectiveness analysis, a diagnostic algorithm combining D-dimers measurement and compression ultrasonography would result in cost-savings ranging from 5% to 55% in patients with high or low clinical pretest probability respectively. However, the specificity of D-dimer measurements for deep vein thrombosis was much higher in symptomatic than in asymptomatic patients. Choice of the cut-off value proved to be dependent on the method as well as on the patient populations studied. CONCLUSIONS: The cost-effectiveness of D-dimers measurement in the diagnosis of asymptomatic DVT remains questionable. Conversely, our data strongly support the utility of D-dimers determinations in the diagnosis of symptomatic DVT. In terms of sparing economic resources, the introduction in the clinical laboratory of the rapid quantitative assays would be highly convenient, because they avoid a source of bias in the interpretation of D-dimers results, are easy to perform and do not require dedicated personnel or instrumentation. Prospective management studies validating the utility of D-dimer measurement in the diagnosis of deep vein thrombosis are urgently needed.