Four years have passed since the new postgraduate clinical training become obligatory. A negative influence of this training system has been actualized in the from of an "uneven distribution of doctors and collapse of the community health". It is actually an educational system near the desk theory though the Ministry of Health, Labour and Welfare evaluated this system as going well only based on the results of a questionnaire for trainee doctors. In the past, medical education was mainly carried out by the university hospitals in Japan, and this has achieved one of the best medical treatment levels in the world so far. It is thought that a doctor's postgraduate clinical education can be most efficiently doing in the university hospital, and keep the quality of medical care high. In this paper, this new postgraduate clinical training system is verified, and the role that the university hospital should play in accomplishing an ideal clinical training program is considered.

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The Japanese Board of Medical Specialties requests that medical societies, including the Japan Neurosurgical Society, reform their medical specialties systems in order to guarantee the quality of medical specialties. The standardization of training institutes, training guidelines and requalification processes is an essential part of the reformation. In addition, determing how many the Japan Neurosurgical Society certified neurosurgeons should be stationed to practice neurosurgery throughout the country is required.

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Does the new Regime support systematic improvement? Dramatic change has taken place in both the political and economical environment in Japan during the last 5 years, and comparable change has also occurred in the medical & clinical service and educational systems. New clinical training curricula have brought revolutionary changes in medical education and the clinical research system. These circumstances have induced a dilemma for the medical office in the University (so-called Ikyoku). Although there has been some stagnancy in the way of ongoing Ancien Regime, I believe that opportunities for great future developments are being provided. Future work is needed to establish and validate their value.

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Acknowledging the disintegration of healthcare in Japan, this paper clarifies the fundamental causes of this situation and presents the direction that Japanese healthcare should take in the future. The time taken for patients to be transported to a medical facility after a 119 emergency call has been received (national average) increased from 24.4 minutes in 1996 to 32.0 minutes in 2006. The number of medical institutions with childbirth facilities decreased from 3,991 in 1996 to 2,933 in 2005. Japan must raise its total health expenditures by approximately 10% to bring the current level in line with the OECD's average total health expenditure as a percentage of GDP. Between fiscal 2002 and 2006, national treasury funding of social security expenses was cut year-on-year by 3.3 trillion yen. Of this, treasury funding of healthcare expenses decreased by 8 trillion yen, and if this situation were to continue for 10 years, the decrease would be approximately 31 trillion yen-equivalent to the total national health expenditures for one year. Securing resources of funding for social security is the responsibility of the national government. It is imperative that medical professionals unite in taking action to protect social security, and healthcare in particular.

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Refusal of blood transfusion due to religious belief such as with Jehovah's Witnesses, has brought about many clinical conflicts. To guarantee one's right of autonomy is important and so, in ordinary cases where patients themselves demand transfusionless treatment, physicians understand without much confusion and therefore, whether the doctors accept this request or not, can discuss the matter to the point. However, it may be difficult to resolve if the patient, who is not a believer, is unconscious and the patient's relatives request transfusionless treatment according to their own belief. We here show our own recently experienced case of a deep-coma due to acute cerebellar hemorrhage in a 67-year-old man, and consider the matters around his transfusion refusal and patient autonomy. We also discuss the recently released Japanese guideline for dealing with transfusion refusal cases due to religious reasons.

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In Japan, there is no legal assurance for living wills or advanced directives, therefore, it is always a matter of argument in stopping medically useless life-supporting interventions or adopting a DNR-order when it is strongly requested by the patient through his/her autonomy. Since individualism is not the prevailing attitude but totalitarianism is still a voice in Japanese society, the paternalistic attitude of seniors to juniors becomes the keynote in families and society at large even when a judgment is required for a medical decision. Surrogate opinion cannot always represent the thoughts of the patient. In Japan, even dying with dignity is hard to guarantee, and moreover, choosing euthanasia with autonomy and its legal endorsement will be too difficult. We physicians should consider more deeply the autonomy and preference of the last terminally ill patients when they come to stages.

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Recently, intracranial arterial dissection has recently been considered to be one of the main causes of brain infarction in young adults. Intracranial arterial dissection, excepting the vertebrobasilar, artery is still rare and its natural history remains unclear. We retrospectively analyzed the clinical manifestations, serial radiological changes, treatments, and outcomes in patients with non-hemorrhagic intracranial arterial dissection, excepting the vertebrobasilar artery. Patients were 6 males and 3 females, and the mean age was 53.1 years. Six of the 9 patients (67%) presented with hemiparesis, 2 (22%) with headache, 1 (11%) with sensory disturbance, and 1 (11%) with dizziness. NIHSS on admission were 0-10. The site of the dissection involved 1 internal carotid artery (C4 portion), 3 anterior cerebral arteries (A2 portion), 2 middle cerebral arteries M1 portion, 1 middle cerebral artery M2 portion, and 2 posterior cerebral arteries (P2 portion). Initial angiography or MR angiography revealed string sign in 7 (78%) and pearl and string sign in 2 (22 %) of the patients. Serial angiographic changes were observed in 7 patients. Four regressions, 3 progressions, and 2 stables were detected. Regression after progression was observed in 2 cases and progression after regression was observed in 1 patient. Six out of 9 patients underwent anti-thrombotic therapy in the acute stage, and all patients received an anti-platelet agent as chronic stage treatment. Modified Rankin Scales at 3 months after onset were 0-2. Our results suggest that anti-thrombotic therapy in patients with non-hemorrhagic arterial dissection results in good clinical outcome, however, the indication and selection of anti-thrombotic therapy should be considered carefully in order to avoid hemorrhagic complications.

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Idiopathic thrombocytopenic purpura (ITP) is the most common autoimmune disease in women of childbearing age group. Although maternal antiplatelet antibodies might cross the placenta, they usually do not cause severe bleeding disturbances in the fetus. Occurrence of fetal intracranial hemorrhage is extremely uncommon. We report a case of a fetus developed intracranial hemorrhage at 34 weeks of gestational age, possibly secondary to maternal ITP. The hemorrhage was intra and periventricular, with the development of posthemorrhagic hydrocephalus. Cesarean section was performed at 35 weeks of gestation because of progression of hydrocephalus. In order to control hydrocephalus, Ommaya's reservoir was placed in the right anterior horn three days after birth, considering the poor general condition of the infant girl. Her level of consciousness suddenly decreased the following day. CT scan showed recurrence of intraventricular hemorrhage. She underwent platelet transfusion and repeated aspiration of bloody cerebrospinal fluid from the reservoir. Following this, her platelet count normalized gradually. Ventriculoperitoneal shunt was carried out successfully 2 months after birth. Thereafter she did not experience any hemorrhagic episodes. The problem of ITP of the mother in relation to pregnancy and its effects on the fetus and the newborn infant are discussed in the present report.

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