--in that the technology to accurately read skin biopsies for neurological situations is not available everywhere, and is rather expensive. Only the most well-funded hospital/research systems with extensive neurological institutes tend to have them--Hopkins, Cornell-Columbia, Massachusetts General, Jack Miller, Washington University/St. Louis. And, the systems listed here are major research centers that, especially in the cases of Hopkins and Cornell-Columbia, actually did the pioneering research on using skin biopsy to determine intraepidermal small-fiber density and condition.

Then, too, the pathologists experienced in reading the samples are small in number as well, and tend, obviously, to be attached tot he same facilities.

The use of this technique is only around 20-25 years old, and has become more widespread in the last decade, with places like Hopkins running programs in which they will accept samples taken from almost anywhere and analyze them. But, I can understand how people outside urban centers may have a hard time getting this type of analysis done. The real tragedy is still too many neurologists THEMSELVES not KNOWING about this proecdure--with supposed continuing medical education, that's inexcusable.