The Qualification Examination for Specialists and Instructors in the Japanese Society of Neuroendovascular Therapy: History and Current Status

Abstract

Neuroendovascular therapy is a key treatment for cerebrovascular disorders, driven by advancements in devices and techniques. The Japanese Society for Neuroendovascular Therapy (JSNET) established a certification system in 1997 to ensure operator competence and minimize complications, with the first examination in 2002. JSNET offers 2 main certifications: specialist and instructor. Specialists perform basic procedures, while instructors lead in practice, education, and research. In 2020, the mechanical thrombectomy practitioner qualification was added to promote mechanical thrombectomy. Applicants must have a JSNET membership, relevant certifications, training, and documented experience. The certification process includes rigorous written and practical examinations that now employ non-fluoroscopic models. Certification renewal every 5 years requires conference participation and a continuing education program. Public awareness and integration into stroke center designations have grown. Over 2200 specialists, including more than 500 instructors, have been certified, significantly advancing neuroendovascular therapy in Japan. JSNET aims to continue improving certification and education to maintain high standards.

Introduction

Neuroendovascular therapy has become the first choice for the treatment of cerebrovascular disorders due to improvements in devices and treatment techniques, as well as the accumulation of clinical evidence regarding its efficacy. Historically, this therapy began around the 1950s and had already started to rapidly spread by the 1990s. Consequently, the Japanese society for neuroendovascular therapy (JSNET) began developing a specialist certification system in 1997, based on the belief that “the basic skills of the operator should be ensured by the society to avoid unnecessary complications caused by inappropriate techniques or inexperienced practitioners.” This system was approved by the board in 2000, and the first specialist examination was held in 2002. The details of the development of this system and the first specialist examination were reported by Taki et al. in 2002,¹⁾ and 6 years after its inception, the situation was reported by Hyogo et al. in 2008.²⁾ More than 20 years have passed since the first examination, and 23 examinations have been conducted to date. During this period, the number of examinees has significantly increased, and the style of the examinations has also evolved. In this article, we introduce the changes and the current situation of this system.

JSNET Specialist Certification System

Definitions of each qualification

From the outset, our society has established 2 types of specialists: the specialist and the instructor. A Specialist is defined as “a physician with sufficient knowledge of neuroendovascular therapy and the ability to perform basic neuroendovascular procedures as an operator.” This certification is recognized as a subspecialty specialist in the 4 basic fields (internal medicine, neurosurgery, radiology, and emergency medicine) and is officially acknowledged by the Ministry of Health, Labor and Welfare. An instructor is defined as “a physician with sufficient knowledge and skills in neuroendovascular therapy who can play a leading role in clinical practice, education, and research.” This qualification is positioned above the neuroendovascular therapy specialist.

Additionally, from 2020, a new qualification called the mechanical thrombectomy practitioner was established to promote the widespread use of mechanical thrombectomy. This qualification is certified by 3 societies: the Japan Stroke Society, the Japan Neurosurgical Society, and JSNET. It is defined as “a physician with basic knowledge and diagnostic ability related to acute ischemic stroke, capable of determining the indication for mechanical thrombectomy and performing the procedure as an operator.” JSNET is responsible for the certification process.

Specialist Certification System (Table 1)

Neuroendovascular therapy specialist

Application requirements: the following conditions must be met to apply:

Basic qualifications: applicants for the neuroendovascular therapy specialist qualification must be regular members of JSNET and hold specialist certifications in neurosurgery, internal medicine, radiology, or emergency medicine. Additionally, they must have experience as an operator in more than 200 cerebrovascular and spinal angiographies.

Neuroendovascular therapy training: applicants must have received more than 1 year of neuroendovascular therapy training at a training facility. Physicians who cannot secure an environment for training at a training facility can substitute by observing 30 cases performed by an instructor.

Neuroendovascular therapy experience: JSNET requires the documentation of 1 operator and 1 or 2 assistants for each treatment case. Applicants must have participated as an operator or first/second assistant in more than 100 cases involving specialists (including instructors) as the treating physician, with experience as the operator in at least 20 of those cases. Additionally, applicants must have participated in at least 10 aneurysm embolizations, 15 revascularization procedures, and more than 5 treatments of arteriovenous malformations (AVM) or dural arteriovenous fistulas (dAVF).

Certification requirement: certification is granted by passing the specialist examination detailed in Specialist Examination section.

Table 1 Summary of definitions and requirements of specialists, instructors, and mechanical thrombectomy practitioners on the JSNET

	Specialist	Instructor	Mechanical thrombectomy practitionar
Accrediting organization	JSNET	JSNET	JSS/JNS/JSNET
Announcement	Possible	Impossible	Impossible
Certification method	Board examination	Document review	Document review
Basic qualification	Board certifiication (JNS, The Japanese Society of Internal Medicine, Japan Radiological Society, Japanese Association for Acute Medicine)	Board certified specialist of JSNET	Board certifiication (JNS, The Japanese Society of Internal Medicine, Japan Radiological Society, Japanese Association for Acute Medicine)
Membership	JSNET membership (more than 4 years)	JSNET membership (more than 4 years)	JSNET membership
Training	1 year at a training facility	No additional preriod	Not required
Experience: cerebral angiography	More than 200 cases	No additional requirements	More than 200 cases
Experience: neuroendovascular therapy	100 cases	200 cases	100 cases
1st operator	20 cases	200 cases	20 cases
Assistant	1st or 2nd assistant	Not required	Not required
Number of cases  (minimum  requirements)	Aneurysm:10, AVM/dAVF: 5, Vascular reconstruction: 15	Aneurysm:40, AVM: 5, dAVF: 10, vascular reconstruction: 30, tumor: 10	Mechanical thrombectomy 15
Academic activities	Not required	Conference presentation: 10, paper presentation (1st author, peer-reviewed): 3	Not required
Certification period	5 years	5 years	5 years

AVM, arteriovenous malformations; dAVF, dural arteriovenous fistulas; JSNET, The Japanese Society for NeuroEndovascular Therapy; JSS, The Japan Stroke Society; JNS, The Japan Neurosurgical Society

Instructor

Application requirements: the following conditions must be met to apply:

Qualifications: applicants must hold the neuroendovascular therapy specialist qualification.

Academic experience: applicants must have published at least 3 peer-reviewed papers as the first author directly related to neuroendovascular therapy and have made more than 10 conference presentations as the lead presenter.

Neuroendovascular therapy experience: applicants must have experience as an operator in more than 200 neuroendovascular therapy cases, including at least 40 aneurysm embolizations, 20 revascularizations, 5 cerebral or spinal AVMs, 10 dAVFs, and 10 tumor cases.

Certification requirement: certification is granted by passing a strict review of the application documents by the specialist and instructor certification committee.

Mechanical thrombectomy practitioner

Application requirements: the following conditions must be met to apply:

Qualifications: applicants for the mechanical thrombectomy practitioner qualification must be regular members of JSNET and hold specialist certifications in neurosurgery, internal medicine, radiology, or emergency medicine. Additionally, they must have experience as an operator in more than 200 cerebrovascular and spinal angiographies.

Training: applicants for the mechanical thrombectomy practitioner qualification are not required to have neuroendovascular therapy training at a training facility.

Neuroendovascular therapy experience: applicants must have participated in more than 100 neuroendovascular therapy cases, including at least 40 aneurysm embolizations, 20 revascularizations, 5 cerebral or spinal AVMs, 10 dAVFs, and 10 tumor cases.

Certification requirement: certification is granted by passing a strict review of the application documents by the specialist and instructor certification committee and approval by the 3 societies.

Training facilities

Training facilities must meet the following conditions:

1) Perform at least 30 cases of neuroendovascular therapy annually.

2) Have at least 1 full-time instructor on staff.

3) Regularly conduct educational conferences.

4) Complete regular reporting.

Currently, 286 facilities nationwide are accredited.

Specialist Examination

Written examination

The written examination consists of 150 multiple-choice questions. It evaluates knowledge related to neuroendovascular therapy, including neuroanatomy, neurophysiology, neuropathology, neuropharmacology, basic radiology, instruments and devices, as well as standard handling, diagnosis, and treatment strategies. The questions include image-based questions (covering aneurysms, cerebral and spinal AVMs, dAVFs, neuro-oncology of the brain and spinal cord, trauma, cerebrovascular disorders, etc.). After the written examination, each question is analyzed by a computer, and questions deemed inappropriate for evaluation (e.g., extremely difficult) or with low discrimination coefficients are excluded from the evaluation.

Oral and practical examinations

Oral examination: each applicant is evaluated by 2 examiners using actual case information, including medical imaging. This examination assesses the applicant’s knowledge in areas such as imaging interpretation, equipment, and treatment strategies for actual cases including cerebral aneurysms, dural arteriovenous fistulas, and cerebral ischemic diseases.

Practical examination: the method of this examination has evolved since its inception in 2002. Initially, 2 examiners visited each facility to evaluate actual treatments, but concerns arose that the examination might affect treatment outcomes. From 2006 to 2014, the examination utilized an animal model. From 2015 to 2023, it used a vascular model under fluoroscopy. Starting in 2024, to avoid radiation exposure to applicants and examiners, the examination was changed to use a non-fluoroscopic vascular model. This practical examination evaluates the use of devices such as microcatheters, microguidewires, and coils.

Examination Statistics

The number of certified specialists by basic discipline and overall pass rates for the specialist examinations from 2000 to 2023 were shown (Table 2). It can be observed that the number of certified neurosurgeons and internists has been increasing year by year. Also, the proportion of internists among successful candidates for specialist and instructor certifications is increasing. On the other hand, the pass rate has been decreasing compared to the beginning of the system, dropping below 50% in 2019–2020. Since 2021, the pass rate has slightly increased. As of July 1, 2024, there were 2427 certified specialists, of which 557 were instructors. Regarding the age groups for obtaining specialist and instructor certifications, there was no significant difference in the age of acquisition for supervising physicians. However, the age for specialists has become younger, shifting from around 40 years old to before 35 years old. The breakdown of specialists by basic discipline is as follows: 2181 neurosurgeons (89.9%), 196 internists (8.1%), 44 radiologists (1.8%), and 6 acute care physicians (0.2%). The breakdown of instructors is as follows: 527 neurosurgeons (94.6%), 17 internists (3.1%), 12 radiologists (2.2%), and 1 acute care physician (0.2%) (Fig. 1).

Table 2 Annual trend of the number of certified specialists and instructors by their background on board examination of JSNET

Year	Specialist							Instructor
	Neurosurgery, n (%)	Internal medicine, n (%)	Radiology, n (%)	Acute care, n (%)	Total	Pass rate (%)	Age of successful applicants	Neurosurgery, n (%)	Internal medicine, n (%)	Radiology, n (%)	Acute care, n (%)	Total	Age of successful applicants
2000	13 (92.9)	0 (0)	1 (7.1)	0 (0)	14	Not required	Not required	13 (92.9)	0 (0)	1 (7.1)	0 (0)	14	Not required
2001	32 (94.1)	0 (0)	2 (5.9)	0 (0)	34	70.8	Not required	32 (94.1)	0 (0)	2 (5.9)	0 (0)	34	42.2
2002	103 (94.5)	0 (0)	6 (5.5)	0 (0)	109	70.9	41.1	8 (100)	0 (0)	0 (0)	0 (0)	8	43.4
2003	48 (87.3)	0 (0)	7 (12.7)	0 (0)	55	68.8	40.7	7 (87.5)	0 (0)	1 (12.5)	0 (0)	8	43.4
2004	38 (97.4)	1 (2.6)	0 (0)	0 (0)	39	70.9	40.5	11 (91.7)	0 (0)	1 (8.3)	0 (0)	12	43.4
2005	70 (97.2)	1 (1.4)	1 (1.4)	0 (0)	72	73.1	39.5	3 (100)	0 (0)	0 (0)	0 (0)	3	39.3
2006	57 (89.1)	2 (3.1)	5 (7.8)	0 (0)	64	74.4	39.4	7 (100)	0 (0)	0 (0)	0 (0)	7	44.7
2007	50 (89.3)	4 (7.1)	2 (3.6)	0 (0)	56	70.4	39.1	18 (94.7)	0 (0)	1 (5.3)	0 (0)	19	42.2
2008	58 (96.7)	2 (3.3)	0 (0)	0 (0)	60	57.7	37.3	18 (94.7)	0 (0)	1 (5.3)	0 (0)	19	42.0
2009	54 (94.7)	2 (3.5)	1 (1.8)	0 (0)	57	46.4	38.2	9 (90.0)	1 (10.0)	0 (0)	0 (0)	10	41.8
2010	68 (94.4)	3 (4.2)	1 (1.4)	0 (0)	72	57.1	38.0	9 (100)	0 (0)	0 (0)	0 (0)	9	44.2
2011	68 (91.9)	5 (6.8)	1 (1.4)	0 (0)	74	58.1	37.7	30 (100)	0 (0)	0 (0)	0 (0)	30	43.0
2012	61 (88.4)	5 (7.2)	2 (2.9)	1 (1.4)	69	54.5	37.6	19 (86.4)	2 (9.1)	1 (4.5)	0 (0)	22	44.4
2013	78 (80.4)	17 (17.5)	2 (2.1)	0 (0)	97	64.5	38.5	22 (95.7)	0 (0)	1 (4.3)	0 (0)	23	43.7
2014	94 (86.2)	11 (10.1)	4 (3.7)	0 (0)	109	66.0	38.1	24 (96.0)	0 (0)	1 (4.0)	0 (0)	25	41.7
2015	88 (91.7)	8 (8.3)	0 (0)	0 (0)	96	58.5	37.4	17 (100)	0 (0)	0 (0)	0 (0)	17	42.6
2016	87 (91.6)	7 (7.4)	1 (1.1)	0 (0)	95	59.7	36.3	24 (88.9)	3 (11.1)	0 (0)	0 (0)	27	43.8
2017	102 (85.0)	16 (13.3)	0 (0)	2 (1.7)	120	58.5	36.5	31 (93.9)	2 (6.1)	0 (0)	0 (0)	33	41.7
2018	105 (86.1)	16 (13.1)	1 (0.8)	0 (0)	122	52.8	36.6	34 (94.4)	1 (2.8)	1 (2.8)	0 (0)	36	42.6
2019	112 (88.2)	11 (8.7)	4 (3.1)	0 (0)	127	47.7	35.8	36 (97.3)	0 (0)	0 (0)	1 (2.7)	37	42.8
2020	134 (90.5)	14 (9.5)	0 (0)	0 (0)	148	47.4	36.0	32 (91.4)	2 (5.7)	1 (2.9)	0 (0)	35	43.1
2021	158 (88.3)	19 (10.6)	1 (0.6)	1 (0.6)	179	56.3	36.5	40 (97.6)	1 (2.4)	0 (0)	0 (0)	41	41.8
2022	165 (91.2)	15 (8.3)	1 (0.6)	0 (0)	181	60.7	35.6	37 (92.5)	3 (7.5)	0 (0)	0 (0)	40	42.2
2023	142 (89.3)	16 (10.1)	1 (0.6)	0 (0)	159	52.3	35.6	46 (95.8)	2 (4.2)	0 (0)	0 (0)	48	42.1
2024	196 (89.5)	21 (9.6)	0 (0)	2 (0.9)	219	69.7	36.4
Total	2181 (89.9)	196 (8.1)	44 (1.8)	6 (0.2)	2427	61.1	37.3	527 (94.6)	17 (3.1)	12 (2.2)	1 (0.2)	557	42.6

JSNET, The Japanese Society for NeuroEndovascular Therapy

Fig. 1 Graphs showing proportions of backgrounds of certified specialists, instructors, and practitioners of mechanical thrombectomy. incl., including

Certification Renewal (Table 3)

The certification period for specialists, instructors, and mechanical thrombectomy practitioners is 5 years. Therefore, certification must be renewed every 5 years. However, if an instructor certification is obtained, the Specialist certification is simultaneously renewed. Similarly, if a mechanical thrombectomy practitioner obtains a neuroendovascular therapy specialist certification, only the renewal procedure for the neuroendovascular therapy specialist is required. Membership in JSNET is mandatory for all certifications. Additionally, specialists and instructors must attend the academic conference 3 times within 5 years, while mechanical thrombectomy practitioners must attend at least once within 5 years. Participation in a continuing education program (CEP) once every 5 years is also required for all certifications. Furthermore, specialists must report 50 procedures (including supervision), instructors must report 100 procedures, and mechanical thrombectomy practitioners must report the number of thrombectomy procedures performed over 5 years. The renewal of all certifications is determined by the specialist and instructor certification committee based on the submitted documentation.

Table 3 Summary of requirements on certification renewal for specialists, instructors, and mechanical thrombectomy practitioners

	Specialist	Instructor	Mechanical thrombectomy practitioner
Certification renewal	Every 5 years	Every 5 years	Every 5 years
Membership	JSNET* membership (full payment of membership fees)	JSNET* membership (full payment of membership fees)	JSNET* membership (full payment of membership fees)
Participation in the annual JSNET meeting	At least 3 times in 5 years	At least 3 times in 5 years	At least once in 5 years
Continuing education program	At least once in 5 years	At least once in 5 years	At least once in 5 years
Experience	50 cases of neuroendovascular treatment (including supervision)	100 cases of neuroendovascular treatment (including supervision)	Engagement in mechanical thrombectomy (including supervision)

*JSNET, The Japanese Society of NeuroEndovascular Therapy

Public Awareness of Specialist Certification

In May 2006, the JSNET became a specified nonprofit corporation, gaining the qualification to apply for the advertisement of specialists from the Ministry of Health, Labor and Welfare. This was approved in February 2008, allowing neuroendovascular therapy specialists to publicly advertise their certification on websites and other platforms. However, instructors and mechanical thrombectomy practitioners are not included in the scope of this advertisement.

In 2019, the Japan Stroke Society began certifying stroke centers. Primary stroke centers, which can administer intravenous tissue plasminogen activator (t-PA) therapy on a 24/7 basis, were certified nationwide. Subsequently, facilities capable of performing mechanical thrombectomy on a 24/7 basis were certified as core facilities of primary stroke centers. The conditions for certification included having “at least 3 neuroendovascular therapy specialists and mechanical thrombectomy practitioners.” As a result, these specialists and practitioners have become essential in the stroke care system in Japan.

Discussion

The specialist certification system has become a mature system over more than 20 years with significant contributions from many involved parties, certifying numerous specialists and instructors. Additionally, since 2020, the certification of mechanical thrombectomy practitioners has also begun. These specialist certifications have been integrated into the certification requirements for stroke centers, increasing their societal importance. With the development and dissemination of neuroendovascular therapy, the importance of this examination system is expected to grow further.

On the other hand, there are issues to be considered regarding this examination system. For example, the implementation of the examinations requires considerable effort. First, the creation of questions for both the written and oral practical exams involves many new questions being prepared annually by the specialist and instructor certification committee, which requires a significant amount of time for selection and modification. Moreover, the exams require a total of 4 days, including 1 day for the written exam and 3 days for the oral practical exams, placing a heavy burden on society members and examiners, leading to calls for simplification and shortening of the examination period. In practice, the oral practical exam has evolved from the initial method where 2 examiners visited the applicant’s facility to evaluate actual treatments, to using an animal model, then a vascular model under fluoroscopy, and, more recently, a non-fluoroscopic vascular model, thus reducing the burden (including radiation exposure) on examiners and applicants. In the future, further integration of IT technologies, such as simulators for practical exams and online formats for written and oral exams, may be considered.

Regarding the pass rates, there have been temporal changes. Compared to the early 2000s, the pass rates have gradually decreased, dropping below 50% during 2019–2021. This decrease is thought to be due to the increasing number of applicants with fewer experience. As neuroendovascular therapy becomes more widespread nationwide, more facilities with fewer treatment cases have emerged, making it a future challenge to ensure the quality of treatment by applicants and specialists. Given that this treatment is often performed during the acute phase of cerebrovascular disorders, there is a societal need to distribute neuroendovascular therapy specialists nationwide. To address this need, the evaluation criteria have been reviewed, resulting in a slight increase in pass rates since 2022. However, fundamentally, it is necessary to enhance the educational system based on the original idea of ensuring the basic skills of operators to avoid unnecessary complications caused by inappropriate techniques or inexperienced practitioners. One such initiative is the curriculum training system, which outlines the content applicants should learn during their training and ensures a certain level of experience at training facilities nationwide. Although the curriculum has already been published and training logs issued, it has not yet been fully implemented. Improvements are needed for standardizing the training and objective evaluation of achievements.

As previously mentioned, more than 2427 specialists, including 557 instructors, have been certified to date. Due to the established efficacy of procedures such as coil embolization, thrombectomy, and carotid artery stenting, the required number of neurointerventional physicians is rapidly changing over time, making it challenging to provide an accurate estimate of the necessary workforce. However, since the establishment of this certification system, the effectiveness of endovascular treatments such as ruptured cerebral aneurysm embolization, thrombectomy, and carotid artery stenting has been confirmed through randomized controlled trials and recommended in national guidelines. Particularly, since thrombectomy needs to be performed as soon as possible after onset, there is an urgent need to distribute physicians who can perform this treatment nationwide, leading to the initiation of the mechanical thrombectomy practitioner certification. On the other hand, Japan is facing a severe aging and declining population, making it challenging to predict the appropriate number of specialists in an ever-changing situation. Discussions on whether to limit the number of practitioners based on experience and quality have not yet begun.

The CEP plays a role regarding continuing education for certified specialists. In addition to practical experience, attending the CEP helps maintain and improve the quality of specialists by keeping them updated with the progress in this field, where innovations in devices and techniques are active. Although the convenience of taking the CEP has been improved by allowing DVD purchases, since 2020, on-demand distribution has started, and DVD production has been discontinued. It is expected that the provision of educational content and information online will continue to develop.

Conclusion

This article introduced the history, certification requirements, and examination process of the JSNET specialist certification system. More than 2200 specialists have been certified under this system, significantly contributing to cerebrovascular disorder care in Japan. JSNET plans to continue working to ensure the provision of better neuroendovascular therapy nationwide through further improvements in the specialist certification system.

Acknowledgments

We would like to express my gratitude to Dr. Nobuyuki Sakai (currently at Shimizu Hospital, former President of JSNET) and Dr. Naoya Kuwayama (currently at Toyama Red Cross Hospital, former Chair of the JSNET Specialist Certification Committee) for their provision of materials and advice in preparing this manuscript. I also thank Chiaki Sato, Masako Motohashi, and Akiko Mizusawa (JSNET Office) for their support.

Disclosure Statement

Shinichi Yoshimura received lecture fees from Stryker, Medtronic, Johnson & Johnson, Kaneka Medics and Terumo, and research funding from Terumo and Asahi Intecc.

Masaru Hirohata has no conflict of interest.

Kenji Sugiu received lecture fees from Medtronic Japan, Terumo, and Kaneka Medix.

Akira Ishii received lecture fees from Medtronic, Terumo, Stryker, and Kaneka, and research funding from Fuji Film ltd.

Yukiko Enomoto received lecture fees from Medtronic, Dai-ichi Sankyo, and Otsuka Pharmaceutical, and research funding from Medtronic, ZACROS, and Sysmex.

Toshiyuki Fujinaka received lecture fees from Medtronic and Stryker.

Hitoshi Hasegawa received lecture fees from Medtronic and Terumo.

Toshio Higashi received lecture fee from Medtronic.

Hirotoshi Imamura received lecture fees from Medtronic, Stryker, Terumo, Daiichi Sankyo, Johnson & Johnson, and Asahi Intecc.

Takashi Izumi received technical training fee from Medtronic and research funding from Kaneka Medics.

Hiro Kiyosue received honoraria for an advisory role from Phillips Healthcare, and holds a patent on Medikit and research funding from Japan Society for the Promotion of Science.

Yasushi Matsumoto received lecture fees from Medtronic Japan, holds a patent on Sumitomo Bakelite, and received honoraria for chair courses from Kaneka medics, Nipro, Medtronic Japan, Terumo, and Stryker Japan.

Hidenori Oishi received a lecture fees from Medtronic, Stryker, Kaneka Medix, Terumo, and Century Medical, and received research funding to the endowed chair of his departments from Medtronic, Stryker, Kaneka Medix, and Terumo.

Tetsu Satow received lecture fees from Medtronic and Kaneka Medics and research funding from Canon Medical Systems.

Michihiro Tanaka has no conflict of interest.

Tomoyuki Tsumoto received lecture fees from Terumo and Kaneka Medics.

Wataro Tsuruta received lecture fees from Medtronic.

Hiroshi Yamagami received lecture fees from Boston Scientific Japan.

Yuji Matsumaru holds shares in Epsilon Medical, received lecture fees from Terumo, Medtronic, Kaneka, Daiichi Sankyo, and Epsilon Medical, and research funding from the Japan Agency for Medical Research and Development.

Shigeru Miyachi received lecture fees from Kaneka Medics and Daiichi-Sankyo, and fees for promotional materials from Japan Medtronic and Kaneka Medics.

References

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