Object: Cerebrospinal fluid (CSF) shunting can improve symptoms of elderly patients idiopathic normal pressure hydrocephalus (iNPH). However, adjunctive means for confirming the diagnosis remain unavailable. We have previously reported specific increase of leucine-rich alpha-2-glycoprotein (LRG) in iNPH CSF, and present study investigates its potential clinical applications.
Methods: We performed CSF tap test (TT) on 90 patients and shunting in 52 patients (mean age 73.5 years), evaluating symptom improvement and higher cerebral functions-MMSE and Frontal Assessment Battery (FAB) before and twelve months after shunting. LRG and tau protein concentrations in TT CSF were simultaneously measured using ELIZA. Then we compared the predictive value of these concentrations with TT results regarding successful shunting outcomes.
Findings: Positive combinations of TT and LRG concentrations of 67ng/mL or higher, gave 81.6% sensitivity and 78.6% specificity. Therefore we used LRG (67ng/mL) and tau (200pg/mL) cutoff values, LRG≥67ng/ml and tau<200pg/ml, 31 of 34 patients (91.2%) had a positive TT and all operated 22 patients were shunt responders. Dementia MMSE and FAB scores in them increased from a baseline of 22.05 to 25.65 and 11.38 to 13.08respectively.
Conclusions: A combination of positive TT and biomarkers quantification such as LRG and tau protein, can reliably predict shunting outcome in iNPH patients.

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Recent studies have identified mutations in the genes encoding TDP-43 and FUS/TLS in patients with amyotrophic lateral sclerosis (ALS). Both TDP-43 and FUS/TLS display all the characteristics of a heterogeneous nuclear ribonucleoprotein, which regulates various aspects of RNA processing. In addition, TDP-43 is partly cleared from the nuclei of neurons containing cytoplasmic aggregates, suggesting loss of normal TDP-43 function in the nucleus, leading to defects or alterations in RNA metabolism, plays, at least in part, a causative role in the pathogenesis of ALS.
TDP-43 has been reported to be involved in the Drosha complex required for the biogenesis of microRNAs. The high expression level of microRNAs and the exclusive expression of certain microRNAs in the central nervous system highlights their biological importance at all stages of neural development as well as in differentiated neurons. In addition, the altered expression of certain microRNAs has been implicated in the pathogenesis of neurodegenerative diseases. Therefore, elucidation of the role of TDP-43 in microRNA biogenesis as a component of the Drosha complex is indispensable to understanding pathophysiology of ALS. In addition, the identification of TDP-43-regulated microRNAs associated with motor neuron death is expected to further contribute to the development of novel therapeutic strategies for ALS treatment.

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Spinocerebellar ataxia type 31 (SCA31) is a relatively common degenerative ataxia in Japan. We recently discovered SCA31 mutation as a complex pentanucleotide repeat containing (TAAAA)_n, (TAGAA)_n, and (TGGAA)_n. The size of this repeat ranged from 2.8 to 3.5 kilo-base pairs (kb). Among these repeats, (TGGAA)_n repeat appears crucial for SCA31 pathogenesis. The length of this complex repeat inversely correlated with ages of onset in patients. The mutation lies in an intron shared by two different genes, BEAN (brain expressed, associated with NEDD4) and TK2 (thymidine kinase 2), which are transcribed in opposite directions. Thus, the complex pentanucleotide sequence is predicted to be transcribed in both directions, but not necessarily translated into proteins. In situ hybridization analysis in patients' Purkinje cells demonstrated that pentanucleotide repeats transcribed in BEAN direction form RNA aggregates ("RNA foci"). We further found that splicing factors, SFRS1 and SFRS9, binds to (UGGAA)_n, the transcript of (TGGAA)_n in vitro. These findings may imply that SCA31 conforms to pathogenic mechanisms underlying non-coding repeat disorders, such as myotonic dystrophies (DM1 & DM2), and that SFRS1 and SFRS9 are involved in SCA31 pathogenesis.

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Chronification of migraine headaches is one of the most urgent issues. Chronic migraine (CM) and medication overuse headache (MOH) are defined in international classification of headache disorders II (ICHD-II). Appendix criteria of CM and MOH were submitted and will take over the original criteria. I described a case of CM and a case of MOH. Here I pointed out some practical issues in diagnosis of CM or MOH.
1) It is not easy to define the association of headache worsening and the beginning of medication overuse in many cases. 2) Some patients cannot discontinue the overused drugs; therefore, the diagnosis of CM nor MOH cannot be completed. 3) Some patients are not released from their headache even after the discontinuation of drug. In these cases, there are two possibilities. As a result of CM, the patient had simply overused the ineffective medications. From another point of view, MOH caused irreversible brain changes and MOH do not disappear after the detoxification. 4) In a practical management, we often prescribe preventive medications simultaneously at the beginning of detoxification. In these cases, it is unclear which one of the detoxification or the preventive medication contributes the improvement of headache.
The chronification of migraine is regarded as chronification of acute mechanism of migraine, i.e., inflammation of the trigeminovascular system and sensitization of the brain. Apart from medication overuse, there have been reported some new risk factors for migraine chronification, including frequent headache, female sex, obesity, low income, low education, stress by life events, depression, snoring, sleep disorders, and past history of neck or head injury. Chronification of migraine severely disturbs the quality of patient's life. More attention should be paid and the further and extensive studies are urgently necessary.

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Both electrophysiological studies such as magnetoencephalography (MEG) and hemodynamic studies such as functional magnetic resonance imaging (fMRI) are intensively being used to elucidate underlying mechanisms of human pain and itch perception. MEG following A-delta (first pain) and C fiber stimulation (second pain) were similar except for a longer latency for the latter. At first, primary somatosensory cortex (SI) contralateral to the stimulation is activated and then secondary somatosensory cortex (SII), insula, amygdala and anterior cingulate cortex (ACC) in the bilateral hemispheres are activated sequentially. As for findings using fMRI, the stimulation of both C and A-delta fibers activated the bilateral thalamus, bilateral SII, right (ipsilateral) middle insula, and bilateral Brodmann's area (BA) 24/32, with the majority of activity found in the posterior portion of the ACC. However, magnitude of activity in the BA32/8/6, including ACC and pre-supplementary motor area (pre-SMA), and the bilateral anterior insula was significantly stronger following the stimulation of C nociceptors than A-delta nociceptors. Findings following itch stimulation were similar to those following pain stimulation, but the precuneus may be itch selective brain region. This unique finding was confirmed by both MEG and fMRI studies.

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The disgust emotion is elicited by a variety of stimuli ranging from rotten food to immoral persons. When we encounter such disgusting stimuli, whether they are physical or social, we commonly experience rejection responses by the body such as nausea and revolt. In fact, since the time of Darwin, it has been argued that disgust has its origins in a rejection response to offensive food, and that the sensations of tastes and odors play a crucial role in the experience of disgust. This view predicts that the insula is closely related to disgust because it serves both gustatory and visceral motor functions including the control of vomiting. Indeed, the insula is activated by a broad range of disgust-related stimuli such as disgusted facial expressions, unpleasant odors, pictures of rotten food, and unfair acts. However, increasing evidence indicates that the insula plays an important role in the experience of not only unpleasant but also pleasant bodily feelings. In brief, the insula seems to be involved in the conscious perception of emotional bodily feelings in general, or somatic markers, and assist in our decisions as to approach vs. avoidance.

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The viral transneuronal labeling method using pseudorabies virus (PRV) is an ideal technique for identifying the central sites that regulate the sympathetic nervous system. Regions were identified in limbic system such as extended amygdaloid complex, lateral septum, infralimbic, insular, ventromedial temporal cortical regions, as well as in several hypothalamic and brain stem nuclei. Emotional stress causes rapid and transient expression of immediate early genes (IEGs) such as c-Fos in the brain, and the monitoring of IEGs has enabled the visualization of the neurocircuitry of stress. By a comparison of the data from the separate PRV and c-Fos neuroanatomical labeling techniques, the central sites which regulate emotional stress-induced sympathoadrenal activation can be deduced. Estrogen receptors are expressed in the brain, where estrogen modulates central nervous function and autonomic nervous function. Estrogen attenuated the stress-induced c-Fos expression in medial amygdaloid nucleus, paraventricular hypothalamic nucleus; these same regions contain central sympathetic neurons and neurons with immunoreactive estrogen receptors.

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The neural substrates of moral judgments have recently been advocated to consist of widely distributed brain networks including the orbitofrontal cortex (OFC), anterior temporal lobe and superior temporal gyrus. Moral judgments could be regarded as a conflict between the top-down rational/logical processes and the bottom-up irrational/emotional processes. Individuals with OFC damage are usually difficult to inhibit emotionally-driven outrages, thereby demonstrating severe impairment of moral judgments despite their well-preserved moral knowledge. Individuals with OFC damage frequently present with anti-social less moral behaviors. However, clinical observation indicates that some OFC patients may show "hypermoral" tendency in the sense that they are too strict to overlook other person's offense. Two representative cases with OFC damage were reported, both presented with extreme rage against others' offensive behaviors. To further elucidate the "hypermorality" of OFC patients, an experiment was performed in which patients with OFC damage and healthy control participants were asked to determine punishments for other's fictitious crimes that varied in perpetrator responsibility and crime severity. Individuals with OFC damage punished more strictly than healthy controls those persons for mitigating circumstances. The results are consistent with clinical observation of OFC patients' highly rigid and inflexible behaviors against third person's offense.

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Brodmann's brain maps, assembled in 1909, are still in use, but understanding of their animal-human homology is uncertain. Furthermore, in 1909, Brodmann did not identify human Area 12 (BA12); a location now important to understanding of frontotemporal lobar degeneration (FTLD) and emotional function. We found Brodmann did identify human BA12 in later maps (1910 and 1914), not in the 1909 monograph. Because of its current link with FTLD, BA 12's translation from animal (1909) to human (1910 and 1914) is not only an historical puzzle. It impacts how Brodmann's areas, based on comparative animal-human cyto-architecture, are widely used in current research as functional loci in human brain. If Brodmann's maps are of current value, then an accurate rather than a generic Brodmann number is in order.

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In the 1990s, the concept of frontotemporal lobar degeneration (FTLD) was proposed as a clinicopathological entity preferentially involving the frontotemporal lobes, and recent pathological findings have suggested a linkage of FTLD with ALS. FTLD includes frontotemporal dementia (FTD), reflecting behavioral changes, and progressive non-fluent aphasia (PNFA) and semantic dementia (SD) as language disorders. Although language problems appear to have become of interest relatively recently, an historical Japanese account (1893) written by Watanabe described aphasia in bulbar-onset ALS. This report is entitled "A patient who manifested cortical motor aphasia concurrently with bulbar palsy and progressive muscular atrophy", and is the first case report of aphasia published in Japan. Thus, language problems in ALS may have been overlooked for many years.
We have reported that ALS patients frequently show omission and paragraphia of kana letters, and syntactic errors in writing, and that these observations differ across patients. We also showed double dissociation between errors in kana and kanji characters in some patients, with preferential involvement of the frontotemporal lobes and frontal- and temporal-lobe predominance for kana and kanji, respectively. We also showed that the writing errors can appear as agraphia without aphasia.

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Frontotemporal lobar degeneration with TDP-43-positive inclusions (FTLD-TDP) and Pick's disease are common pathological substrates in FTLD patients. Because most Japanese FTLD-TDP patients lack a family history, characterizing clinical features in sporadic FTLD-TDP is important to infer the underlying pathologies in FTLD patients. Our recent study suggested that these two diseases tended to show different clinical pictures. Early impairment of semantic memory was frequent in sporadic FTLD-TDP, but very rare in Pick's disease. In contrast, early impairment of speech output, including non-fluent aphasia and speech apraxia, was more frequent in Pick's disease. Asymmetric motor disturbances (e.g., pyramidal signs, parkinsonism, and contracture) were frequent in sporadic FTLD-TDP, but rare in Pick's disease. The most common first syndrome in FTLD-TDP was semantic dementia (39%), but that in Pick's disease was frontotemporal dementia (64%). Pathologically, consistent with clinical features, the temporal cortex, striatum, globus pallidus, substantia nigra, and pyramidal tract were more severely degenerated in sporadic FTLD-TDP. These findings suggest that the early impairment of semantic memory and asymmetric motor disturbances in sporadic FTLD patients predict FTLD-TDP rather than Pick's disease, while initial behavioral symptoms or non-fluent aphasia without subsequent asymmetric motor disturbances predict Pick's disease rather than FTLD-TDP.

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Frontotemporal lobar degeneration (FTLD) and amyotrophic lateral sclerosis (ALS) often coexist in the same patients: FTLD/MND. However, it is unclear whether FTLD/MND can be distinguished from ALS or FTLD. TAR DNA binding protein 43KDa (TDP-43) has been identified as the major component of the ubiquitin-positive inclusion bodies in ALS, FTLD, and FTLD/MND. On the basis of this finding, a new concept of neurodegenerative disorders, namely TDP-43 proteinopathy, has been proposed for these disorders. In ALS, more than 30 mutations of the TDP-43 gene have been identified. The clinical features and neuropathological findings of ALS with TDP-43 mutation are identical to those of sporadic ALS. Therefore, TDP-43 plays a primary role in the pathogenesis of ALS. In contrast, only few patients with FTLD phenotype have TDP-43 mutations. Therefore, we have speculated that TDP-43 does not play a primary role in the pathogenesis of FTLD. The analysis of distribution of TDP-43 inclusion bodies in ALS patients revealed that ALS has two subtypes: (1) limited in the motor neuron system and (2) extended into the frontotemporal lobe. Additionally, causative genes of familial FTLD/MND have not been mapped to TDP-43. These results suggest that FTLD/MND is a disease distinct from FTLD and ALS.

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In March 2009 we sent out the questionnaire to the 4,478 board certified neurologist to ask about the palliative care in ALS. 1,495 anonymous responses (33%) have been returned.
21% of the respondents prescribe morphine, which shows a drastic increase from the 14% in the 2007 survey. However, 77% of them had only less than 5 patients, 47% of them studied and trained themselves. It illustrates that most of the neurologists are not well experienced with morphine, and that they are isolated in practice. However, 47% of the respondents answer that they would prescribe morphine whether or not the national insurance pays.
As for the withdrawal of the permanent ventilation, 21% of the respondents were asked by their patients to turn off the ventilation. While 24% of the respondents believe that the withdrawal right not should be promoted, 46% believe that such right should be granted if the decision made by the patient and/or his/her family members can explicitly be recognized. The result illustrates that the physicians are also divided.
It may be the time to lay the foundation for the Japanese ALS physicians to discuss openly and candidly together to deal with the wants and wishes of their patients.

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In Japanese context, there has been a controversy concerning the withdrawal of life-support, i.e. respiratory system, from ALS patients when, along of the progress of the disease, they have become not able to express themselves at all to people around them, i.e. when they are in so called 'totally locked in state (TLS)'. Basing himself on the system of clinical ethics he has been developing in accord with Japanese culture, the author (1) reconstitutes the logic of justifying the withdrawal in dispute, (2) examines objections against officially recognizing such withdrawal, and (3) proposes an appropriate process of decision making which he hopes to be acceptable to both sides in the controversy.

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ICT（Information and Communication Technology）の進歩は目覚ましい．ICTの進歩でインターネットをかいし，PC，iPod，iPad，携帯など情報端末を利用した学習環境は大きく変化している．この技術を幅広く利用した神経内科領域での教育教材開発や利用環境の整備が望まれる．神経内科の教育対象には，不随意運動，表情，歩行など一度眼にしていると診断が容易なものが少なくない．頻繁に遭遇するものからまれにしか遭遇しないものまで，その学習の対象は幅が広い．まれなものを有効にICTを利用してまんべんなく学習できれば，教育効率もよい．神経内科領域の救急対応教育には，シミュレータを利用して一応の知識を習得させ，技術レベルを確保する様にできる．多くの研修医，専門医にICTをもちいて救急教材を提供することが必要である．これらの教材整備やシミュレーション教育の教材は，新たな作成ばかりでなく，各施設の手持ちの教材，動的画像，地方会での発表物などを，学会主導で集中管理して，学会員すべてが自由にお互いに利用可能にすることで，有効な学習ができる．この環境整備，電子アーカイブ作りが望まれる．これらの利用には，著作権，個人情報保護，肖像権などをふくめた法的問題のクリアーが必要である．学会が主導してこれらの条件をクリアーし，情報時代に合った，法を順守した教材処理，教材集積とその利用を可能にすることが望ましい．会員全員が利用できるe-learning環境，そのシステム構築が望まれる．

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Recently, there have been many drastic changes in the educational technology for the medical fields in Japan. The educational style has shifted from the classical, which weighs knowledge, to the American, which weighs skill or performance. These trends would come from theoretical transition in pedagogics, bringing out the tremendous progress in the instructional designs, which effectively facilitated the information and communication technology (ICT). On the contrary, Neurology, as a pedagogic, is more characteristic both in the quality and the quantity of knowledge, rather than skill or performance. It has resulted in occurring many discrepancies among the educational parts of Neurology, that may be one of reasons for medical students or postgraduate trainees, having been growing up in full of ICT, had some against images of difficulty in learning this subject. So it might be more necessary for us that we should hurry to create the authentic context in the educational design of Neurology, then construct the stepwise off-the-job training system honestly along with it, on which we should aim to increase familiarity of learning neurological diseases or skills for these younger people, the future neurologists. And the important tip is that we can utilize "games", the products of ICT, without any hesitation.

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Progress in basic neurosciences and advances in technology in the last decades have contributed to clarification of neural mechanisms in behavior or cognition in health and disease. They have elaborated diagnosis and treatment of nervous diseases remarkably.
Needs in neurologists in both primary and specific medical services are rapidly increasing, with aging society and progresses in medical care in Japan.
Attraction of neurology for students and junior residents is a great concern of Japanese Society of Neurology.
In the undergraduate education, recent achievement in basic neurosciences including neurogenetics, molecular cytology, physio-pathology and imaging technique should be taught comprehensively.
In the early postgraduate course for two years, neurology is either elective or obligatory depending on the curriculum of training institutions. Work at the stroke care unit is strongly recommended in the course of emergency service, which is mandatory.
Experiences in acute infectious diseases, in various stages of neurodegenerative diseases, in collaboration with other specialist doctors for systemic diseases including metabolic or collagen diseases, in collaboration with other medical personnel in care of dementia are all included in advanced stages of postgraduate education before board examination.
In summary, studies for practical services as well as clinical researches, teaching of symptoms and signs based on neural functions, and socio-economical issues for chronic nervous diseases in aged society are important in the education in neurology.

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Establishment of an economic foundation for clinical neurologists is essential for the advancement of neurology in Japan. However, this concept sometimes seems to slip easily from the minds of neurologists in academia. This has been true in the history of the Japanese Society of Neurology for half a century.
Japan has a system of public health insurance for all people, but there are many problems related to medical pay that need to be discussed, especially for doctors seeing patients. Almost all Japanese doctors have been worried about the low medical pay in the Japanese health insurance system. We have made various approaches to the Ministry of Health, Labor and Welfare to solve these economic problems, but our hard work for the improvement of our economic situation has often been unsuccessful.
The Japanese Society of Neurotherapeutics took a step toward dealing with this problem with a symposium to discuss medical payments in 2002, and it has contributed to progress in the economic and financial systems for health insurance from the standpoint of clinical neurology.
We Japanese neurologists need to make greater efforts to improve our poor economic situation, following the success of Japanese surgeons in their diligent work with the Ministry of Health, Labor and Welfare to improve critical conditions in the field of surgery.

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Appropriate assessments for medical techniques of clinical diagnostic examination have been one of long-standing issues in social insurance system in Japan. Assessments of those in the surgical fields in which the most of assessments are evaluated by surgical operations including related materials as well as surgeons' techniques, is rather easy to evaluate quantitatively. Comparing with this, medical fields including neurology, quantitative assessments of medical techniques either diagnostic or treatment is not so easy. In order to evaluate the burden in each technique in the medical fields, several research and surveillance have been performed. In terms of 'duration' of the medical techniques, there have been several date in favor of long duration techniques are evaluated as to be worth to cost higher. However, these data were criticized for the reasons of ignorance of patients' opinion such as satisfaction to the diagnosis and treatments. However, in neurological fields, "the neurological examination techniques" which has a consensus of taking long duration in each patient, was able to be evaluated as an independent item in medical social insurance system in 2008, albeit it is not as technique but as laboratory examination. Towards establishment of the economical basis for medical care, Japanese Neurological Association should have another identity of artisans' union as well as academic union.

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The Social Insurance Union of Societies Related to Internal Medicine and the Social Insurance Union of Societies Related to Surgical Medicine have pushed for revisions of the medical service fee against the Medical Economics Division of Insurance Department, Ministry of Health, Labor and Welfare. About neurological diseases, Japanese Society of Neurology, Japanese Society of Neurological Therapeutics, Japanese Society of Clinical Neurolphysiology, and Japanese Society of Child Neurology are involved in this movement. The examination fee of the electrical encephalography and the nerve conduction study was accepted. I review the process of the comprehensive medicine, and the revision of DPC (Diagnosis Procedure Combination) and medical service fee.

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価値（value）があるものは，一般的に報酬が高くなるのが世の常である．経済学に「使用価値」や「交換価値」などという概念があるが，診察・処方などの内科系診療技術が有する価値は，どのように考えるのが妥当であろうか．また，不可逆的な特性を有する生命・健康が対象となるなか，受益者と負担者が一部ことなる国民皆保険制度のもと，大なり小なり公共資本の投入が求められる医療市場において，その価値に見合う対価の水準はどのように検討すべきであろうか．本講演では，複雑かつ困難なテーマであることを認識しつつも，社会の幸福（well-being）の最大化を目的に，神経内科診療の価値の考え方と公的医療制度における評価方法について検討を試みた．

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The increase in the aging population, the drastic change to a new system for postgraduate clinical training, and the lack of medical doctors have all become objects of national concern. Medical divide and melt down of the medical system brought stress especially to rural areas. Other types of stress are also found in urban University hospitals where doctors are forced to accomplish tons of paper work, while struggling on research, education, and clinical work.
In this symposium, I would like to show some background and reasons for the shortage of the doctors in Japan. I also present our daily clinical practice and approach for new residents. I will also discuss the future improvement of our medical system especially in the field of Neurology. We need to show strong leadership and appeal to our comrades with medical ethics, one's dignity or self-esteem as a doctor.

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The population and the area of Aomori prefecture are 1,380 thousands and 9,644km2, respectively. Aomori prefecture geographically and economically forms an independent medical district. However, only 29 neurological specialists attended work in Aomori Prefecture. The numbers of neurological specialists per 100,000 people and per 100km² were 2.1 and 0.3 in Aomori, respectively, whereas those of Tokyo metropolitan area were 5.9 and 34.9, and their nationwide averages were 3.6 and 1.2, respectively. Although Aomori prefecture is divided into six medical service areas, neurologists were eccentrically-located in three cities; Aomori, Hirosaki and Hachinohe. No neurologists give full-time service in three of the six areas. The percentage of people having medical care certificate for six specified neurological disorders (multiple sclerosis, myasthenia gravis, amyotrophic lateral sclerosis, spinocerebellar degeneration, Parkinson disease and related disorders, and multisystem atrophy) in Aomori was comparable to the nationwide average. However, the number of patients with the certificate of multiple sclerosis and myasthenia gravis in areas with neurologist's service were 11.4 and 12.0 per 100,000 people, respectively, whereas those of area without full-time neurologist's service were 9.9 and 9.2, (significant lower). The patients living in the area without neurologist's service received medical care by neurologists less frequently when compared to those living in area with neurologist's service. Forty-five percent of the patients living in the area without neurologist's service went out of their living areas to see neurologists regularly. Thus, neurologists in Aomori prefecture are under strain to provide medical services. People in Aomori prefecture do not receive sufficient neurological services, especially in the area where no neurologists attend work. In addition, patients living in area without neurologist's service bear greater burden to go to hospital.

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In Chiba, the number of doctors and hospital beds remain quite insufficient for the current population. The number of neurologists is also insufficient. However, the situation differs between urban regions and rural districts. In rural districts, few neurologists provide medical care for patients living in a large area. On the other hand, in urban regions, the number of neurologists is insufficient because they have to take care of too many patients, most of whom can be dealt with by family doctors. Therefore, we need to take measures to reduce burden on neurologists. It is important to clarify the role of each hospital employee, thereby allowing neurologists to devote themselves to their main duties. The establishment of clinical pathways is one helpful way to promote a team approach in medical care, while trying to improve the efficiency of duties and thus improve the overall medical quality. It is also important to improve the understanding of local residents through education and information programs. By promoting regional medical liaison, we can increase effective medical care that is performed by family doctors.

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What is required to provide high quality medical service to anybody, anytime and anywhere? We have investigated health care in neurology as provided by national health insurance in Aomori, Akita and Iwate prefectures compared to health care in Tokyo. We have conducted hearing surveillance to patients and doctors. Most of the patients have to drive to hospital for more than 100 kms as there is no licensed neurologist in their neighborhood and public transportation is poor. There are only a few medical facilities that can satisfy their needs even in prefectural cities. Neurologists who work alone at general hospitals face difficulties as they cannot consult with other neurologist about diagnosis and treatment and have rare opportunity to attend academic conferences. A licensed neurologist at northern Tohoku district has to be in charge of a half of Tokyo 23 districts area and twice as many people as Tokyo. We have concluded that medical divide due to the more or less of quantity of selection exists between northern Tohoku and Tokyo. How do we cure this medical divide? Creating a new framework of patients transporting system, increasing the number of doctors who work at general hospitals and opening satellite clinics at regional towns should be considered.

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