The remuneration system for online medical consultations in Japan has undergone significant changes over the past few years. While the global pandemic of the novel COVID-19 unintentionally acted as a driving force, it is estimated that online consultations have become a significant trend in daily medical practice even in the post-COVID-19 era when COVID-19 has been classified as a category 5 infectious disease. Just as our lifestyle shifted dramatically with the transition from pagers to mobile phones and further to smartphones, the wave of digitization, which had been somewhat lagging in the medical industry compared to other sectors, is now spreading in the medical field, leading to significant transformations in the way medical services are provided.　However, it is evident from survey results that a large number of medical practitioners still do not regularly utilize online medical consultations. This seems to be due to several reasons, including concerns over information management security risks, ambiguous positioning within the framework of medical and physician laws, and the inability to claim medical reimbursement in many cases.　In this paper, we aim to organize and reconfirm these issues and examine the desirable integration of online medical consultations and remote collaboration in regional healthcare in Japan.

　Limb salvage is difficult to complete at a single facility, and treatment is often carried out in cooperation with multiple facilities. It is rare for multiple facilities to have a doctor specializing in limb salvage, so collaboration is essential. This time, we explored the possibility of early intervention by using remote medical collaboration software “Ashi Care Navi”. We describe our experience and considerations for this use.

　As the increase of diabetic foot ulcers（DFU）is considered to be a global challenge, multiple guidelines on DFU strongly recommend the use of off-loading devices. However, it has been shown that the use of such devices is not sufficient across the United States. Although there are several cross-sectional studies on the use of off-loading devices in the U.S., there are still no reports on the use of such devices at a facility level along with insurance coverage information. Therefore, we conducted this study to clarify:（1）the process of providing off-loading devices;（2）types of devices dispensed;（3）insurance coverage for each;（4）frequency of using off-loading devices in an outpatient clinic affiliated with podiatric school in the U.S. The results suggest that in the U.S.:（1）the insurance system is set to promote the use of more evidence-based off-loading devices;（2）convenience, efficiency, and cost of clinic management affect the choice of device;（3）a detailed educational program including insurance coverage information as well as a system considering the convenience and efficiency of clinic management are needed to promote the use of off-loading devices.

　Purpose: This study aimed to evaluate the characteristics of patients with disuse edema, lower extremity arterial disease（LEAD）, or heart failure using bioelectrical impedance analysis（BIA）. We also aimed to evaluate the relationship between disuse edema and drug-induced edema.　Methods: Patients with disuse edema（n=17）, LEAD（n=25）, heart failure（n=48）, or drug-induced edema（n=16）underwent BIA to measure body fat mass, muscle mass, body fat percentage, and extracellular water to total body water ratio（ECW/TBW）. Blood samples were collected to evaluate variables such as CONUT score.　Results: Patients with disuse edema had a significantly higher body mass index, body fat percentage, and body fat mass. Patients with drug-induced edema had a significantly higher ECW/TBW than those with disuse edema. Multivariate analysis revealed that older age and higher CONUT score were independent risk factors for an ECW/TBW\_mls2265\/0.4.　Conclusion: Patients with disuse edema tended to be more obese than those with LEAD or heart failure. Patients with drug-induced edema have similar characteristics to those with disuse edema, but they are more edematous. High ECW/TBW, which is a marker of edema, is a risk factor for nutritional disorders in older people.

　Maintenance dialysis patients are known to have a high prevalence of peripheral arterial disease（PAD）. Skin perfusion pressure（SPP）, a method to evaluate blood flow in the lower extremities, is used to diagnose PAD, but it is difficult to test all patients. On the other hand, autonomic neuropathy is associated with arteriosclerosis and can be measured by the coefficient of variation of R-R intervals（CVRR）measured by electrocardiography. We conducted a cross-sectional study of the association between CVRR and SPP in maintenance hemodialysis patients. The subjects were maintenance hemodialysis patients（n=65）attending our hospital. ROC analysis was performed for CVRR and complications of foot lesions, such as ulcers, and the cutoff value for CVRR was set at 1.42. The subjects were classified into a normal CVRR group（CVRR \u00002265 1.42）and a low CVRR group（CVRR < 1.42）. The SPP of the low CVRR group（51.9 mmHg）was significantly lower than that of the normal CVRR group（73.1 mmHg）（p < 0.001）. These findings suggest that CVRR is associated with SPP and that CVRR may be useful as an additional indicator for the diagnosis of PAD.

　Aortic mural thrombus is an uncommon cause of peripheral arterial thromboembolism. We present three cases of lower extremity thromboembolism due to aortic mural thrombus. All cases were treated with anticoagulant therapy. Endovascular therapy with a stent graft was performed in one case. Thromboembolism recurred in one case due to the interruption of anticoagulant therapy. The treatment of aortic mural thrombus is controversial. Recently, endovascular therapy with a stent graft has been reported. In all cases, thromboembolism did not recur during anticoagulant therapy. Endovascular or surgical therapy is recommended when thromboembolism recurs, or thrombi grow with anticoagulant therapy.

　The purposes of this study were to investigate the implementation of foot care by nurses in cardiovascular surgery, and examine future issues of foot care in surgery. A mailed questionnaire survey was administered to nurses on cardiovascular surgery wards at two university hospitals. In total, 30 valid responses were received（response rate: 66%）. Regarding the implementation of foot care, “observation of foot condition” and “moisturizing” were implemented by more than 80% of the respondents. There were no significant differences between two groups divided by the implementation rate, or between two groups with less or more than 5 years of experience. Regarding the content of observation, “skin tone,” “presence or absence of wounds,” and “presence or absence of edema” accounted for more than 90%, while “corns and calluses,” “signs of infection,” “peripheral hemodynamics, and “foot shape” were less than 10% of the total. Regarding the actual state of foot care among cardiovascular surgery nurses, it was clear that although the implementation rate of foot “observation” was high, it was mainly an observation item related to the postoperative period of the lower extremities, and limited observation or foot care focused on lifestyle-related foot problems associated with the fall risk was performed.

 Foot care guidance suitable for elderly dialysis patients is necessary. It has been reported that the act of touching one’s own feet is an important factor in preventive self-care of foot lesions in diabetic patients. A survey was performed, aimed to clarify the relationship between the act of touching one’s own feet and foot troubles in elderly dialysis patients.
 A questionnaire survey was conducted involving dialysis patients aged 65 or over concerning the act of touching one’s own feet. Regarding the current status of foot trouble,12 items were extracted from the foot care check sheet based on: circulation, perception, nails, and skin condition. A total of 74 patients were analyzed, 56 people performed the act of touching one’s own feet. Although there was a tendency toward some associations between the act of touching one’s own feet and foot trouble items, there was no significant correlation. The effectiveness of moisturizing care was shown as one of the methods of touching one’s own feet in those with dry skin. It was suggested that the act of touching one’s own feet promotes moisturizing care and leads to the prevention of dry skin in elderly dialysis patients.

　Our hospital is located in Shinjo City, Yamagata prefecture, in Japan where there are few health care workers who specialize in the treatment of disorders of the feet. Our hospital focuses on a system for community diabetes as well as foot care medical treatment and recuperation support. We hold foot care seminars, lectures, practical skill demonstrations, and case study sessions. In our hospital, patients’ feet are inspected by a nurse and electrocardiography is performed at the same time for patients with suspected tinea unguium. In cases with positive findings by direct microscopic inspection, we prescribe efinaconazole or fosravuconazole. We also trim the thickened nails with a water jet grinder. These continuous efforts have resulted in community-based foot care that receives many consultations from nearby medical and welfare facilities. Even at general medical clinics, foot care can be performed as part of primary health care.