[November 29, 1980. The foundation of AlaMMU, an interregional section of the Italian Society of Nephrology]. / Il ruolo delle Sezioni Interregionali SIN nel recupero della nefrologia ''dispersa'': storia dell'ALaMMU.

ALaMMU is a section of the Italian Society of Nephrology encompassing 5 regions of central Italy: Abruzzo, Lazio, Marche, Molise, and Umbria. It was founded in Rome in November 1980 by eight outstanding nephrologists including Drs Cagli, Pacchiarotti, Splendiani, Casciani, Brigante, Mioli, Albertazzi, and Cinotti. Its objective was to unify the scientific and social segments of local nephrology at a national level. This paper tells the story of ALaMMU with special emphasis on the organizational, social and scientific aspects. Certain local activities were employed to develop a complete set of medical knowledge according to the modern epistemology of the Nobel laureate in economics, Friedrich A. von Hayek. Since 1980, ALaMMU has promoted annual scientific meetings in all 5 regions and has formulated diagnostic and therapeutic protocols for the most important renal diseases. The lively activity led to the steady publication of the proceedings of the meetings, which gave young nephrologists a first platform for their scientific works. In addition, ALaMMU organized many courses covering a wide range of topics to contribute to the training of nephrologists locally.

[XIII Congresso Societa' Italiana di Cardiologia 1956, in Trieste and the birth of cardionephrology]. / Il Congresso della Società Italiana di Cardiologia del 1956 a Trieste e la nascita della cardionefrologia.

The Author comes recently across the proceedings volume of the forgotten XVIII Congress of the ''Società Italiana di Cardiologia'' held in Trieste on May 1956. The proceedings focus on the ''cardiopatia renale'', i.e. the heart lesion observed in Kidney disease, namely in acute glomerulonephritis. Later ''Cardiopatia renale'' changes into ''uremic cardiomyopathy'' but the terms seem uncorrect as they do not include the cardiac derangement in early stages of nephropathies. The diction ''cardiomyopaty'' in uremic seems more complete. The topic becomes very ''hot'' and the kidney- heart scientific culture grows more and more and culminates with the ''Cardionephrology'' term coined in 1991 at Assisi Meeting and then wide spread all over Europe.

[Use of diuretics in congestive heart failure: renal effects]. / Diuretici nello scompenso cardiaco e conseguenze renali.

Diuretics are an integral part of the management of symptomatic heart failure. Although they have been used for several decades, there is still some ambiguity and confusion regarding the outcome and the optimal way of using these common agents. There are no large-scale randomized controlled trials that have evaluated the effect of diuretics on mortality and long-term morbidity in diastolic and systolic dysfunction. Nonetheless, in short-term studies furosemide has demonstrated to reduce symptomatic congestive heart failure and hospitalization, and to improve exercise capacity in the setting of systolic dysfunction. In this review, the classes, sites of action and renal effect of diuretics are reviewed and the various indications, optimal doses and recommendations on effective use and disuse are discussed. Namely, this review addresses the effects of emerging diuretic agents such as eplerenone--a selective mineral corticoid receptor antagonist, nesiritide--a brain natriuretic peptide-recombinant, and conivaptan--a vasopressin antagonist, in attempt to provide an update on current knowledge, even though adequate clinic data are not available for all agents.

[Historical Archives of Italian Nephrology. The gout as a paradigmatic example of the ancient humoral theory of diseases]. / Archivi storici della Nefrologia Italiana. La gotta come paradigma e superamento dell'antica teoria umorale delle malattie.

Gout is one of the oldest known diseases. The term derives from the Latin "gutta", which means "a drop" This word expresses and describes, as no other term can, a method of interpreting the pathologies that have been with us for more than 2000 yrs. The theory of humoral disturbance goes back to the time of Hippocrates. This paper is a historical review of gout, with particular attention given to the interpretation of the origins of clinical, articular and renal involvement allowing us paradigmatically to sum up all the stages in the evolution of the etiopathogenetic and nosographic concepts of medicine through the ages.

Age and blood pressure changes. A 20-year follow-up study in nuns in a secluded order.

In a prospective study, 144 white nuns belonging to a secluded monastic order and 138 white control laywomen were followed for 20 years to investigate whether living for a long time in a stress-free environment influences the effect of aging on blood pressure. Silence, meditation, and isolation from society are the distinctive features of the life-style examined. At study entry, blood pressure was not dissimilar in the nuns and the control group, but it increased over time only in the controls, with a mean slope of the regression line (beta coefficient) of 0.089 in the nuns (NS) and 2.171 in the controls (p less than 0.0001) for systolic blood pressure and of 0.054 in the nuns (NS) and 0.742 in the controls (p less than 0.0001) for diastolic blood pressure. Weight and body mass index increased similarly over time in the two groups. Family history of hypertension was not dissimilar between the groups. Serum cholesterol and triglycerides, higher at study entry in the nuns, increased similarly over time in the two groups. Twenty-four-hour urinary sodium excretion, collected randomly in both groups, did not differ over time between nuns and controls. None of the women smoked or used oral contraceptives. Educational level was higher in the control group, but subgroups of 48 nuns and 52 laywomen of comparable educational level maintained the same difference in the blood pressure trend over time as in the main cohort. Parity affected the increase of systolic, but not of diastolic, blood pressure with age among the laywomen, but nuns and no-childbirth controls maintained a significantly different blood pressure trend over time.(ABSTRACT TRUNCATED AT 250 WORDS)

Options in dialysis therapy: significance of cardiovascular findings.

Most patients receiving renal replacement therapy have cardiovascular disease. The most frequent conditions are left ventricular hypertrophy and coronary artery disease. Hemodialysis is associated with a characteristic spectrum of acute complications (such as hypotension, sudden death) that can be explained by typical dialysis-induced effects on the heart. With continuous ambulatory peritoneal dialysis (CAPD) some of those cardiovascular complications are ameliorated due to slow ultra-filtration and absence of an arteriovenous fistula. It is concluded that CAPD might be the preferable option in patients with cardiovascular disease when hemodialysis can only be performed in a standardized and often aggressive manner. However, achievement of medically-defined goals appears to be more important than technique in dialysis therapy.

A link between psychosocial factors and blood pressure trend in women.

The powerful effect of psychosocial and acculturating influences on population blood pressure trends seems to be confirmed, through longitudinal observations, in the nuns in a secluded order. After initial observation had been made on culture, body form, blood pressure, diet, and other variables in 144 nuns and 138 laywomen, included as a control group, a 32-year follow-up study was undertaken. Most striking were opposite trends noted between the two groups in blood pressure trend. During the follow-up period blood pressure remained remarkably stable among the nuns. None showed a rise in diastolic blood pressure to above 90 mmHg. By contrast the control women showed the expected increase in blood pressure with age. This resulted in a gradually greater difference (Delta>30/15 mmHg) in systolic and diastolic blood pressure between the two groups, which was statistically significant. Fatal and nonfatal events were exceedingly lower in the nuns than in the control women over the follow-up period. It appears reasonable to attribute much of the difference in blood pressure to the different burden in psychosocial factor and to the preserved peaceful lifestyle of the nuns.

Plasma sulfate concentration and hyperhomocysteinemia in hemodialysis patients.

BACKGROUND: Severe hyperhomocysteinemia is common in hemodialysis patients, who also present a dramatic increase in plasma concentrations of sulfate, one of the main products of methionine and cysteine catabolism. The aim of this study was to verify the relationship between high plasma sulfate levels and cysteine or homocysteine concentrations in hemodialysis patients. METHODS: Plasma sulfate, cysteine and homocysteine concentrations and some renal efficiency parameters were determined in 18 patients with end-stage renal failure, all undergoing 4h hemodialysis three times a week. The pattern of post-dialysis rises on plasma concentrations of sulfate, cysteine and homocysteine was established. RESULTS: Plasma sulfate, cysteine and homocysteine levels were significantly higher in patients than in normal controls. Plasma sulfate concentrations positively correlated with cysteinemia (p = 0.031; r = 0.482) which, in turn correlated with homocysteinemia (p = 0.042; r = 0.460). Sulfate levels also correlated with blood creatinine (p = 0.004; r = 0.630), nitrogen (p = 0.000; r = 0.899), protein (p = 0.014; r = 0.555), and albumin (p = 0.003; r = 0.642). Post-dialysis rises in sulfate and cysteine were detected some hours before homocysteine. CONCLUSION: The results suggest that high sulfate levels, due mainly to impaired renal function, are involved in the altered metabolism of homocysteine in hemodialysis patients.

3 R study: renal outcome in renal ischemia: revascularisation or medical treatment.

Ischemic nephropathy refers to the kidney damage following stenosis or an obstructive lesion in the main kidney arteries. This disorder has been overlooked in the past and a more rational and specific use of clinical criteria, and the development of not very invasive techniques with a good diagnostic accuracy such as spiral CT angiography, NMR angiography and echo-colour-Doppler have improved our ability to identify these patients. It is therefore likely that, in the next few years, we will find ourselves treating an increasing number of patients with renovascular ischemic disorders. Transluminal angioplasty and, more recently, the use of endovascular stents, have led to a marked improvement in the treatment of stenoses and, together with vascular surgery, allow to treat almost all patients with this disorder. There is, however, a lack of prospective and controlled studies, which demonstrate the long term benefit of revascularization treatment, as compared with optimum conservative treatment in reducing cardiovascular mortality, cardiovascular events and preserving renal function. The Ischemic Nephropathy Study Group of the Italian Society of Nephrology has organized a prospective, controlled study over a period of three years, aimed at comparing the effect of revascularization versus medical therapy in 300 patients with renal artery stenosis, ranging between 50 and 90 per cent, who will be randomly assigned to the two treatments. End point will be cardiovascular mortality and morbidity and need for renal replacement therapy.

"Non-dipper" hypertensive patients and progressive renal insufficiency: a 3-year longitudinal study.

Patients with a blunted or absent nocturnal blood pressure (BP) drop may be subject to increased risk for target organ damage. In this 3-year longitudinal case-control study we tested the hypothesis that an association exists between a reduced or absent night-time fall in BP and a future decline of kidney function in renal hypertensive patients. The case subjects were 48 hypertensives with renal insufficiency, divided into two groups according to the presence (dippers: n 20) or absence (non-dippers: n 28) of a nocturnal diastolic BP decline greater than 10% of daytime values, detected by ambulatory BP monitoring. At the baseline evaluation the two groups did not differ with respect to age, sex, body weight, office systolic and diastolic BP, mean daytime ambulatory BP, creatinine clearance, 24 h proteinuria. In the ambulatory BP profiles over a 3-year follow-up the nocturnal reductions of systolic and diastolic BP in the dippers were 14% and 15%, respectively, vs 7% and 5% in the non-dippers (p = 0.002/0.003). The non-dippers had a faster rate of creatinine clearance decline than the dippers (0.37 +/- 0.26 vs 0.27 +/- 0.09 ml/min/month; p = 0.002). Urinary protein excretion increase was higher in the non-dipper group than in the dipper group (993 +/- 438 vs 691 +/- 222 mg/24 h; p = 0.009). This longitudinal study suggests that the non-dipping pattern of ambulatory BP can be associated with a faster progression of renal insufficiency in renal hypertensives and that a proper nocturnal BP control is an additional aim of antihypertensive therapy.

The spectrum of cardiovascular abnormalities in autosomal dominant polycystic kidney disease: a 10-year follow-up in a five-generation kindred.

Clinical, electrocardiographic and echocardiographic data were collected in a group of 228 patients with autosomal dominant polycystic kidney disease (PKD) and in another group of 146 unaffected members (NPKD) both comprised in a five-generation kindred followed for 10 years, in order to determine the profile and prevalence of cardiovascular derangement of the genetic disease. A family of 181 members was used as a control. The prevalence of left ventricular hypertrophy in the three groups was 24, 14 and 6% respectively (p less than 0.01); after 10 years it increased up to 35, 26 and 13% respectively (p less than 0.05). The evidence of mitral-valve prolapse was more frequent in PKD and in NPKD group (25 and 20% respectively) than in control subjects (2%) (p less than 0.0001). Mitral incompetence was found in 30, 18 and 8% of those groups respectively (p less than 0.002). The large difference in mitral involvement did not change over time. Tricuspid valve prolapse was detected in 5, 4 and 1% of the three groups, respectively (p less than 0.05). A small increase in frequency was found after 10 years only in polycystic kidney disease patients. Regurgitant aortic lesions were present in higher prevalence in PKD (19%) and NPKD (17%) members than in controls (5%) (p less than 0.001). After 10 years they were 23, 20 and 8%, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of biofiltration on cardiac arrhythmias.

The effect of biofiltration-PAN system and acetate-cuprophan hemodialysis on ventricular arrhythmias detected by long-term ECG monitoring was assessed in 12 patients with end-stage renal failure, studied according to a randomized cross-over design. Low and high risk ventricular ectopic beats were significantly (p less than 0.001) more frequent both during acetate dialysis and in the post-dialytic period than with biofiltration at any time. A significant inverse correlation was found in regression analysis (r = 0.40, p less than 0.001) between total ventricular ectopic beats and pH values in the pre-dialytic, intra-dialytic, early post-dialytic and total post-dialytic periods. The lower frequency of ectopic ventricular beats in biofiltration dialysis makes this technique more suitable for patients with dangerous and disabling arrhythmias.

[Multicenter clinical study of the antihypertensive activity of lisinopril]. / Studio clinico multicentrico sull'attività antiipertensiva del Lisinopril.

One-hundred patients suffering from slight-moderate hypertension (53 m, 47 f, aged between 18 and 78, average 49.08) have been studied in order to assess the effectiveness and tolerance of lisinopril ("Zestril", ICI-Pharma), a new ACE inhibitor in a single daily administration at doses of between 10 and 80 mg in relation to pressure values. Monotherapy with Lisinopril proved effective in 84 patients (88.4%), in 74 of whom (7.9%) pressure values were returned to normal. 11 patients (11.6%) did not respond to treatment. In most cases, the result was obtained with a dose of 20 mg in a single administration (32.6%). The incidence of side-effects was limited and in no case required the withdrawal of the drug.

[Evidence-based medicine: reality and illusions. Extension of epistemological reflexions]. / La medicina basata sulle evidenze: realtà ed illusioni. Estensione delle riflessioni epistemologiche.

Evidence-based medicine (EBM) is a cultural and methodological approach to clinical practice helping to make decisions based on clinical expertise and an intimate knowledge of the individual patient's situations, beliefs, and priorities useful for the analysis of clinical research. As such, it can be considered the scientifically grounded art of medicine, as it appears to be an emerging paradigm of scientifically based clinical care. It de-emphasizes intuition and unsystematic clinical experience as grounds for medical decision-making and stresses the rigorous and formal analysis of evidence from clinical research. EBM converts the abstract exercise of reading and appraising the literature into the pragmatic process of using the literature to benefit individual patients, while simultaneously expanding the clinician's knowledge base. On EBM grounds, clinical, practice guidelines, pathways and algorithms or instructions can be developed with the aim of solving a problem or accomplishing a task. Nonetheless in these processes the theory of EBM shows internal and external bias. Among internal bias, economic-based interest may influence the development and diffusion of research and its results. In addition "systemic review" may be incorrectly guided, the quality filters of the literature can be inappropriately applied, the choice criteria can be only based on the positive results of evidence, but according to modern epistemology, it will be helpful for clinicians to know when their uncertainty stems from gaps between positive and negative evidence. Another bias is the difficulty to convert EBM into clinical practice recommendations. EBM set movement has shown that it is nearly impossible to make recommendations that are appropriate in every situation. Epistemological approach identifies external "bias" of EBM. It is consistent with the theory of "fact" as human construction. Every human fact can historically fade and then be restored according to new paradigms. EBM is a "fact" and its theory can be changed or removed every time by relevant new or emerging evidence approaching the development of up-to-date decision-making aids and so on, irrespective of how much previous processing of the evidence has taken place. Then EBM cannot be evaluated as the scientific "totem" of the third millennium, neither as the clinical digest of medical literature. Searching for clinical evidence, in fact, requires a great awareness of both the advantages and limitations of increasing bias. Clinicians are looking for new strategies to apply to diagnostic and therapeutic pathways and for the steps where EBM could be addressed when showing the full validity.

[Historical Archives of Italian Nephrology. The history of instrumentation in nephrology. Part II: microscope and haemodialyzer]. / Archivi storici della Nefrologia Italiana. La storia della strumentazione in nefrologia Parte II: microscopio e dializzatore.

Medicine in the technological era acquired many of the characteristics that concurrently marked other fields. So, by adopting procedures based on information obtained with instruments and devices, medicine developed an approach to illness that transformed it into a special form of technology. The collective effect of instrumentation deserves consideration and offers the historian opportunities for interpreting the interaction between physician and his patients in other than scientific and technological terms. The very construction of instruments and devices depends on the Author's ideas assembled with the basic theories of the time. For instance, at the end of the nineteenth century, when medical instruments became essential, the bacterial origin of diseases revolutionised their construction and application. In this context, the invention and use of the microscope became an outstanding feature of the clinical approach by disclosing the cellular universe. The microscope had become crucial in locating some major causes of physical suffering and death in man, and was considered the pre-eminent diagnostic instrument in medicine. In the nephrological field, the microscope drew the physician into a universe of physical changes that were concealed to the naked eye. The microscope made possible the verification of some of Bright's brilliant ideas, something that helped physicians classify glomerulonephritis. Many nephrologists confessed "how few things are established in this subject (nephrology) and how many more difficulties are established, we have learned by experience with the microscope". The modesty of this claim is striking. In nephrology, as in other fields, the admission of ignorance proved to be the beginning of wisdom. This wisdom, based on the admission of ignorance and assembled through the commitment and ingenuity of the pioneers of the dialysis treatment, led to the treatment of end-stage renal disease and the guarantee of success. The technique of haemodialysis has been enriched by the new lexicon, which expresses different ways and ideas on the removal of the solute.

[Historical Archives of Italian Nephrology. Virchow's theories on atherosclerosis and related kidney disease]. / Archivi storici della Nefrologia Italiana. Le teorie sull'aterosclerosi nella scienza nefrologica.

This article concerns the development of theories about atherosclerosis and its changing manifestations, some of which, such as renal artery disease and ischemic nephropathy, have been clearly defined only in recent times. An anatomical consequence of atherosclerosis is the stenosis of the renal artery, which opens an unexpected clinical response in blood pressure (nephrovascular hypertension) and in kidney function (ischemic renal disease). Today's historian, no less than the clinician, is called on 'to demand the consideration of basic definitions and nomenclature.' It is impossible to overrate Virchow's theory of artherosclerosis and his great contribution to the concept of artery insudation and thrombosis process. But even Virchow did not expressly stress the concept of atherosclerosis as an autonomic non-inflammatory entity; he called the condition 'chronic endoarteritis deformans.' However, his hypothesis introduced some inflammatory factors that today are the basis of novel atherosclerosis theory. Although Anitschkow introduced the theory of the influence of cholesterol on atherosclerotic development, his theory has been partially contradicted by widespread epidemiological data. Currently, a re-emerging theory on the role of inflammation and infection in atherosclerosis seems to explain many clinical facts taken in small account by other theories.

[Historical archives of Italian Nephrology. A historical review of Colucci's theories on nephropathy in pregnancy]. / Archivi storici della Nefrologia Italiana. La storia della nefropatia gravidica.

BACKGROUND: A review of segments of C. Colucci's detailed 1947 report on nephropathy in pregnancy is undertaken. In his paper, Colucci underlined the prevailing theories and concepts of nephropathy in pregnancy, questioned treatment guidelines, and used a modern epistemological approach to develop appropriate therapy. His outstanding achievement of the use of flux and reflux theories in nephropathy in pregnancy, such as the neuro-hypophysis overfunction theory, was further strengthened by the great physician Nicola Pende. CONCLUSIONS: The Author underlined new perspective regarding nephropathy in pregnancy, its etiology, and the prioritization of treatment aimed at curing function rather than struggling to understand vague and sometimes undefined hemodynamic parameters.

[Historical Archives of Italian Nephrology: The role of women in the history of Medicine and Nephrology]. / Archivi storici della Nefrologia Italiana: Il ruolo della donna nella storia della Medicina e della Nefrologia.

The aim of the present survey of the history of medicine is to provide a series of succinct assessments of the role of women in the development of nephrology. The inadequate role played by women in some areas of medicine underlines the trend that considers health history as part of external history modulating the branches of science. If "external" or social history considers women's role as marginal in many segments of society, no wonder they play a marginal role in the history of medicine. Nonetheless, when women are offered the opportunity to map out new medical paths or handle new health systems they have always been excellent. Tratula, a doctor from Salerno's medical school, is just an example. Women have been excellent in nursing and popular medicine. Florence Nightingale (1823-1910), an English woman of rare ability and humanitarian enthusiasm, was the first to understand the role of women in organising nursing. In this area she had such a striking success that her method contributed to the founding of the first school of nursing in England and in the world. On the other hand, women doctors have had many difficulties in the medical area. The first modern woman to take her degree in medicine was Elisabeth Blackwell, who graduated from the Geneva Medical School of Western New York in 1849. She managed to open a private dispensary, which within a few years developed into a great hospital and training school for women. In the nephrology area a great Australian woman entered the universal history of medicine, Priscilla Kincaid-Smith. Her outstanding contribution was to improve the diagnosis and treatment of glomerulonephritis. Her positive attitude and the novelty of a woman being on the same scientific level as men, combined to secure her unique reputation in both her own country and the world. We hope that new social trends will develop in which women with scientific ideas will be able to completely express their medical ability and the tendency to eliminate the vestiges of old traditions will be reinforced through the granting of new scientific and academic opportunities. In Italian nephrology this tendency has been accelerating.

[Historical Archives of Italian Nephrology: The Cerretani and charlatans: a poor page in the history of medicine and nephrology]. / Archivi storici della Nefrologia Italiana: Cerretani e ciarlatani: ovvero alcune pagine buie della storia della medicina e della nefrologia.

Cerreto is a tiny town in the Valnerine area (Umbria) famous all over the world for the phenomenon of charlatanism derived from Cerretani inhabitants. In the Middle Ages, these people started to beg for alms on hehalf of medical and religious foundations. When their occupation ended due to religious prohibition (Council of Trent) the Cerretani shifted to Charlatanism or quackery. The Charlatans exploited the absence of institutional medicine in rural areas and the credulity and superstition of many sick people. A cynical distrust of the medical profession in urban areas helped the charlatans' activity to spread. They delivered diagnostic advice and therapeutic remedies in public squares. Renal and bladder remedies were key cures from still earlier quackeries. Some historians of medicine believe that some rural or town citizens were particulalry addicted to panaceas or placebos. Charlatans from all over the world poured into the happy hunting grounds. Quackery flourished on a grand scale until education spread throughout the population and medical services were made available to the poor. Special laws to safeguard health-care, helped undermine the charlatan healing phenomenon. Popular quackery medicine neared its end in the mid twentieth century. The history of medicine never follows a linear development such as great discoveries, political reforms, growing cultural interests. By contrast, it runs parallel to local, national and world histories. The history of medicine is largely regarded as a subdivision of the history of the world. Aspects of medicine lying outside the scientific horizon are regarded as of subsidiary importance. Does the history of the Charlatan phenomenon confirm such a statement?

[Historical archives of Italian nephrology: The history of instrumentation in nephrology. Part I: Theoretical bases]. / Archivi storici della Nefrologia Italiana: La storia della strumentazione in nefrologia Parte I: basi teoriche.

Microscopes and artificial kidneys have greatly influenced both diagnosis and therapy of renal diseases. Nonetheless, in tracing the influence of instrumentation on nephrology, as revealed by daily activity, we have to recognise the influence of science upon medical instruments. It is for this reason that, besides strictly clinical factors, the scientific factors that contributed to the development of modern nephrology have received considerable attention. Nobody can use an artificial kidney without bearing in mind the contribution of many segments of science. Each segment has a hypothesis in its historical growth, development and decline. The notion that the advancement of science was made possible by the increasing reliance measurements and other quantitative procedure is hardly a novel one. Moreover, it is rather obvious that the experimental process and the use of instrumentation played an important role in the history of nephrology. Measurements, experiments and the use of instruments were interrelated and represented many phases of the improvements made in diagnosis and therapeutics. Naturally, in the history and epistemology of nephrology instrumentation we find conceptual mistakes and erroneous approaches to the biological reality. However, according to Popper's teachings, mistakes are good for science as they give an extra kick to its growth and development. Medical instrumentation is an assembly of scientific theories; it also controls medical theories and promotes the development of new ones. In addition, it changed our approach to the patient. In the pre-physical era, medical practice was almost entirely an intellectual process based on medical theories that the patient was not expected to understand. In the period of physical examinations the physician included the sensual dimension (oral and visual process) and made direct contact with the patient. In the instrumentation period we experience the third type of examination, in which the physician went back to the position of having less contact with the patient. This separation is reminiscent of the pre-physical diagnosis.