Amputation and prosthetics of the lower extremity: The 2020 Dutch evidence-based multidisciplinary guideline

BACKGROUND

Lower-limb amputations are rare but debilitating events in the lives of affected persons. Treatment of persons with amputation inherently involves many different health care professions at different stages leading to and after an amputation. There are prevailing clinical questions within the work field related to different facets of care including peri/postoperative aspects, prosthetic components, rehabilitation treatment, and health care processes.

OBJECTIVES

To provide an up-to-date multidisciplinary evidence-based guideline for health care professionals involved in the treatment of persons with lower-limb amputation in the Netherlands.

METHODS

Identification of key questions in a focus group, systematic review of the evidence (up to March 2019, using Embase and MEDLINE databases), and weighing considerations, culminating in clinical recommendations.

RESULTS

Twelve key questions were formulated. Recommendations of two key questions were upheld in line with the previous 2012 guideline. Ten systematic literature searches were performed, leading to the inclusion of 59 studies.

CONCLUSION

A summary of evidence-based conclusions, considerations, and recommendations of the 2020 guideline is presented.

Expression patterns of Hoxb genes in the Xenopus embryo suggest roles in anteroposterior specification of the hindbrain and in dorsoventral patterning of the mesoderm

Hox genes are thought to participate in patterning the anteroposterior (a-p) axis during vertebrate embryogenesis. In this investigation, the spatial expression of six Hoxb genes was analyzed in early embryos of Xenopus laevis by in situ hybridization. Hoxb gene expression was first detected in late gastrulae/early neurulae, by which stage, the characteristic spatially colinear Hoxb gene expression sequence was already apparent. Dissection experiments indicated that the establishment of these localized expression patterns coincides with the acquisition of anteroposterior positional information along the main body axis. The Hoxb genes continued to be expressed in similar domains along the anteroposterior axis at all developmental stages examined, although there were some changes in expression at the cellular level. Interestingly, the 3' genes, Hoxb-1, Hoxb-3, and Hoxb-4 were expressed in very restricted domains in the future hindbrain, while Hoxb-5, Hoxb-7, and Hoxb-9 transcripts were present along the entire presumptive spinal cord. It was thus notable that the 5' Hoxb genes exhibited different types of expression domain than the 3' Hoxb genes. These observations suggest that there may be different mechanisms regulating the expression of the 3' and 5' Hoxb genes. Expression of all of the Hoxb genes analyzed, except Hoxb-4, was predominantly detectable in the central nervous system or in neural crest-derived structures. Hoxb-4 mRNA was detected in the central nervous system, but interestingly, the major expression site for this gene was the somites. The other Hoxb genes tested failed to show significant expression in the somitic mesoderm, although transcripts from genes 5' from Hoxb-4 were detected in other mesodermal tissues. In the vertebrate trunk, anteroposterior patterning of the CNS is thought to be regulated by the somites. The results obtained here for Xenopus embryos did not explicitly support the idea of a Hoxb code for the somites, although we cannot rule this out. Instead, interestingly, the data were consistent with a role for Hoxb genes in dorsoventral patterning of the mesoderm.

Overexpression of a cellular retinoic acid binding protein (xCRABP) causes anteroposterior defects in developing Xenopus embryos

We have isolated the first Xenopus laevis cDNA coding for a cellular retinoic acid binding protein (xCRABP). xCRABP contains a single open reading frame, coding for an approximately 15 × 10(3) M(r) protein. Northern blot analysis shows that this cDNA hybridizes to a mRNA that is expressed both maternally and zygotically and which already reaches maximal expression during gastrulation (much earlier than previously described CRABP genes from other species). In situ hybridisation showed that at the onset of gastrulation, xCRABP mRNA is localised at the dorsal side of the embryo, in the ectoderm and in invaginating mesoderm. xCRABP expression then rapidly resolves into two domains; a neural domain, which becomes localised in the anterior hindbrain, and a posterior domain in neuroectoderm and mesoderm. These two domains were already evident by the mid-gastrula stage. We investigated the function of xCRABP by injecting fertilized eggs with an excess of sense xCRABP mRNA and examined the effects on development. We observed embryos with clear antero-posterior defects, many of which resembled the effects of treating Xenopus gastrulae with all-trans retinoic acid. Notably, the heart was deleted, anterior brain structures and the tail were reduced, and segmentation of the hindbrain was inhibited. The effects of injecting xCRABP transcripts are compatible with the idea that xCRABP overexpression modulates the action of an endogenous retinoid, thereby regulating the expression of retinoid target genes, such as Hox genes. In support of this, we showed that the expression of two Xenopus Hoxb genes, Hoxb-9 and Hoxb-4, is strongly enhanced by xCRABP over-expression. These results suggest that xCRABP expression may help to specify the anteroposterior axis during the early development of Xenopus laevis.

Purification and characterization of a novel tetradecapeptide that modulates oesophagus motility in Lymnaea stagnalis

The isolated oesophagus of Lymnaea stagnalis was used as a bioassay preparation to identify peptides that modulate the activity of the oesophagus. Several modulatory messengers were detected from the oesophageal extract. One of these, having an excitatory action, was further purified from both the oesophagus and the central nervous system through high performance gel permeation chromatography followed by serial reversed phase high performance liquid chromatography. The purified peptide was chemically characterized through amino acid sequencing and mass spectrometry as GFRANSASRVAHGY-NH2.