[ { "slug": "tooth-loss", "name": "Tooth loss", "description": "Tooth loss can be partial (one or more teeth missing) or full (edentulous). Causes include caries, periodontal disease, trauma, and developmental absence. Treatment options range from removable dentures to fixed bridges to implant-supported prostheses; choice depends on remaining bone, neighbouring teeth, and patient preference.", "treatmentLadder": [ { "tier": "conservative", "options": [ { "name": "Removable partial denture", "summary": "An acrylic or chrome-cobalt framework appliance that replaces missing teeth and is removed for cleaning. Lowest cost option but least secure; affects taste and mastication, requires periodic relining as bone resorbs.", "sourceSlugs": [ "who-surgical-safety-checklist" ] }, { "name": "Complete denture (edentulous)", "summary": "Full upper and/or lower acrylic denture. Functional but commonly poorly tolerated, with bone resorption progressing under the denture base over years.", "sourceSlugs": [ "who-surgical-safety-checklist" ] } ] }, { "tier": "procedural", "options": [ { "name": "Fixed dental bridge", "summary": "Adjacent teeth are prepared (significant enamel reduction) to anchor a fixed prosthesis spanning the gap. Avoids the discomfort of a removable appliance but irreversibly modifies healthy neighbouring teeth.", "sourceSlugs": [ "who-surgical-safety-checklist" ] } ] }, { "tier": "surgical", "options": [ { "name": "Dental implants", "procedureSlug": "dental-implants", "summary": "Titanium or zirconia screw-form implants placed directly into the jawbone, typically restored with crowns or implant-supported bridges/dentures after osseointegration. The most durable solution; requires adequate bone volume (often confirmed by CBCT) and may require bone grafting or sinus lift in deficient sites.", "sourceSlugs": [ "who-surgical-safety-checklist" ] } ] } ], "relatedProcedureSlugs": [ "dental-implants" ], "sourceSlugs": [ "who-surgical-safety-checklist" ], "clinicalOverview": { "sourceSlugs": [ "wikipedia-tooth-loss" ], "signsAndSymptoms": "In humans the teeth support the lips and cheeks, maintain the vertical dimension of occlusion, contribute alongside the tongue and lips to the pronunciation of many sounds, preserve the height of the alveolar ridge and allow food to be cut, ground and chewed. When teeth are lost the vertical dimension of occlusion falls and the mouth tends to overclose, producing a sunken-in appearance of the cheeks and wrinkle lines at the commissures. Consonants such as s, z, d, n, l, t and th, which require tongue-to-tooth contact, and the fricatives f and v, which require lip-to-tooth contact, become difficult to enunciate. Tooth loss also carries a psychological impact, generally lowering quality of life and self-esteem, with patients often embarrassed to smile, eat and talk.", "causesAndRiskFactors": "Edentulism has multiple causes. In exceedingly rare cases the teeth never develop (anodontia), but in most cases it follows permanent tooth extraction in adulthood, which may result from dental caries, periodontal (gum) disease, trauma or other pathology of the face and mouth such as cysts or tumours. In people under 45 years of age dental caries is considered the main cause, whereas periodontal disease is the primary cause in older age groups. With age the permanent teeth are exposed to normal mechanical forces such as chewing and to abnormal forces from bruxism and traumatic injury, while plaque and bacteria affect the gums and the bone that holds the teeth in place. Bone resorption in the jaw is frequently how teeth detach in the first place, and unevenly worn or misaligned teeth are more likely to loosen or become damaged. Edentulism occurs more often in people from the lower end of the socioeconomic scale.", "epidemiology": "Edentulism affected approximately 158 million people globally as of 2010, about 2.3% of the population, and is more common in women (2.7%) than in men (1.9%). It occurs predominantly in older age, when most individuals begin to experience it, and more often in people of lower socioeconomic status. A cross-sectional analysis of European survey data found substantial variation in the mean number of retained natural teeth among people aged 50 and over, ranging from 14.3 in Estonia to 24.5 in Sweden." } }, { "slug": "cosmetic-dental-concerns", "name": "Cosmetic dental concerns", "description": "Patients seek aesthetic dental treatment for discolouration, chips, gaps, or shape irregularities. The treatment ladder runs from conservative whitening through bonding and veneers to orthodontic alignment, with the appropriate intervention depending on the underlying dental anatomy and the patient's preferences. Over-aggressive treatment that destroys healthy enamel is the most common quality concern in cosmetic dentistry.", "treatmentLadder": [ { "tier": "conservative", "options": [ { "name": "Professional whitening", "summary": "In-clinic light-activated bleaching or take-home tray bleaching. Effective for extrinsic and many intrinsic stains; does not change tooth shape. Requires periodic re-treatment.", "sourceSlugs": [ "who-surgical-safety-checklist" ] }, { "name": "Direct composite bonding", "summary": "Tooth-coloured composite resin applied directly to the tooth surface to repair small chips, close minor gaps, or reshape edges. Conservative (minimal or no enamel removal) but less durable than indirect restorations.", "sourceSlugs": [ "who-surgical-safety-checklist" ] }, { "name": "Orthodontic alignment", "summary": "Fixed appliances or aligners (e.g. Invisalign) to correct positioning. Slower than veneers but preserves natural tooth structure.", "sourceSlugs": [ "who-surgical-safety-checklist" ] } ] }, { "tier": "procedural", "options": [ { "name": "Composite veneers", "summary": "Direct-bonded composite shells with minimal or no enamel preparation. Lower cost and reversible but less stain-resistant and shorter-lived than porcelain (5-7 years vs 10-15+).", "sourceSlugs": [ "who-surgical-safety-checklist" ] }, { "name": "Porcelain veneers", "procedureSlug": "dental-veneers", "summary": "Indirect porcelain shells bonded to prepared enamel. Highly aesthetic, stain-resistant, and durable. Preparation depth and design (feldspathic minimal-prep vs e.max vs full-coverage) materially affects how much healthy tooth is removed.", "sourceSlugs": [ "who-surgical-safety-checklist" ] } ] }, { "tier": "surgical", "options": [ { "name": "Surgical crown lengthening", "summary": "Periodontal surgery to expose more tooth structure when gums are excessive or uneven. Performed when aesthetic concerns are primarily gingival.", "sourceSlugs": [ "who-surgical-safety-checklist" ] } ] } ], "relatedProcedureSlugs": [ "dental-veneers" ], "sourceSlugs": [ "who-surgical-safety-checklist" ] }, { "slug": "androgenetic-alopecia", "name": "Androgenetic alopecia", "description": "Hereditary pattern hair loss in men and women, driven by androgen sensitivity in genetically predisposed follicles. Treatment combines medical therapy to slow progression with surgical hair restoration to redistribute donor follicles. Surgical results are best in patients with stabilised pattern loss and adequate donor density; the underlying genetic process continues so combined medical-surgical management is often appropriate.", "treatmentLadder": [ { "tier": "conservative", "options": [ { "name": "Topical minoxidil", "summary": "Over-the-counter 2% or 5% solution/foam applied twice daily. Slows progression and may produce modest regrowth in early-stage disease; effect lost on stopping. First-line in both men and women.", "sourceSlugs": [ "ishrs-standards" ] }, { "name": "Oral finasteride (men)", "summary": "5-alpha reductase inhibitor 1mg daily. Effective in male pattern loss; sexual side effects in a small proportion. Requires prescription and ongoing use.", "sourceSlugs": [ "ishrs-standards" ] }, { "name": "Low-level laser therapy", "summary": "FDA-cleared device-based therapy with modest evidence; an adjunct rather than a primary therapy.", "sourceSlugs": [ "ishrs-standards" ] } ] }, { "tier": "procedural", "options": [ { "name": "Hair transplant — FUE", "procedureSlug": "hair-transplant", "summary": "Follicular Unit Extraction: individual follicular units harvested from a donor area (usually occipital scalp) using small punches and implanted into thinning recipient sites. Leaves no linear scar; longer extraction time than FUT.", "sourceSlugs": [ "ishrs-standards" ] }, { "name": "Hair transplant — DHI", "summary": "Direct Hair Implantation: an FUE variant using a Choi pen-like implanter; allows precise angle and depth control without prior site-making. Often marketed as a distinct technique.", "sourceSlugs": [ "ishrs-standards" ] }, { "name": "Hair transplant — FUT", "summary": "Follicular Unit Transplantation: a linear strip of donor scalp is excised and dissected into follicular units. Leaves a linear donor-area scar but allows higher graft yields per session.", "sourceSlugs": [ "ishrs-standards" ] } ] }, { "tier": "surgical", "options": [ { "name": "Scalp reduction (historic, rarely performed)", "summary": "Surgical excision of bald scalp with advancement of hair-bearing scalp. Largely superseded by modern transplantation techniques and rarely performed today.", "sourceSlugs": [ "ishrs-standards" ] } ] } ], "relatedProcedureSlugs": [ "hair-transplant" ], "sourceSlugs": [ "ishrs-standards" ], "clinicalOverview": { "sourceSlugs": [ "wikipedia-androgenetic-alopecia" ], "signsAndSymptoms": "Pattern hair loss is a form of non-scarring hair loss. Male-pattern hair loss begins above the temples and at the vertex of the scalp; as it progresses a rim of hair at the sides and rear of the head remains, referred to as a Hippocratic wreath, and it rarely progresses to complete baldness. In most cases a receding hairline is the first starting point, moving backwards from the front and sides of the head. Female-pattern hair loss more often causes diffuse thinning of the hair across the scalp without hairline recession and similarly rarely leads to total hair loss; the frontal hairline is typically preserved while density decreases in all areas. Severity is graded in women using the Ludwig scale.", "causesAndRiskFactors": "The cause is not fully understood but appears to result from genetic changes that make scalp hair follicles sensitive to androgenic hormones, with dihydrotestosterone (DHT) the major contributor at the dermal papillae; 5-alpha-reductase converts free testosterone into DHT and is highest in the scalp and prostate gland. Men with androgenic alopecia typically have higher 5-alpha-reductase and higher total, free and unbound testosterone and DHT. Inheritance is generally regarded as autosomal dominant, although roughly 80% of bald men have bald fathers, suggesting an important paternal route. Oxidative stress, the scalp microbiome and insulin-like growth factor activity at the dermal papillae have also been implicated. Early-onset disease in men (before age 35) is associated with metabolic syndrome and insulin resistance, whereas the cause of female-pattern hair loss remains unclear and is associated with an increased risk of polyendocrine metabolic ovarian syndrome.", "diagnosis": "In men the diagnosis can usually be established from the clinical presentation, whereas in women it typically requires a more complex diagnostic evaluation. Assessment involves excluding other causes of hair loss and identifying the typical progressive pattern of androgenic alopecia. Trichoscopy can be used for further evaluation, and a biopsy may be needed to exclude other causes, with histology demonstrating perifollicular fibrosis. The Hamilton-Norwood scale grades severity in males and the Ludwig scale is used in women.", "epidemiology": "Pattern hair loss is the most common cause of hair loss. By the age of 50 it affects about half of males and a quarter of females. Some 30-50% of men have male androgenic alopecia by age 50, with an estimated 80% hereditary predisposition. According to the American Academy of Dermatology, female androgenic alopecia affects around 30 million women in the United States; although hair loss in women normally occurs after the age of 50, it is increasingly reported at earlier ages, including in women as young as 15 or 16." } }, { "slug": "nasal-aesthetic-or-breathing", "name": "Nasal aesthetic concerns or breathing problems", "description": "Patients present with cosmetic concerns about nasal shape, with functional breathing problems (deviated septum, turbinate hypertrophy, internal valve collapse), or both. The appropriate intervention depends on whether the issue is purely cosmetic, purely functional, or combined; combined functional-aesthetic procedures (septorhinoplasty) are the most technique-sensitive and have the highest revision rates.", "treatmentLadder": [ { "tier": "conservative", "options": [ { "name": "Intranasal corticosteroid spray", "summary": "First-line for mucosal congestion and turbinate hypertrophy. Effective for many functional symptoms without surgery.", "sourceSlugs": [ "rcs-eng-rhinoplasty" ] }, { "name": "External nasal dilator strips", "summary": "Adhesive strips that mechanically open the external valve. Symptomatic relief for some patients, particularly during sleep.", "sourceSlugs": [ "rcs-eng-rhinoplasty" ] } ] }, { "tier": "procedural", "options": [ { "name": "Septoplasty", "summary": "Correction of a deviated septum without external nasal change. Endonasal approach, typically same-day discharge. Addresses functional breathing without aesthetic change.", "sourceSlugs": [ "rcs-eng-rhinoplasty" ] }, { "name": "Turbinate reduction", "summary": "Submucosal reduction or radiofrequency turbinoplasty for inferior turbinate hypertrophy.", "sourceSlugs": [ "rcs-eng-rhinoplasty" ] } ] }, { "tier": "surgical", "options": [ { "name": "Rhinoplasty (open or closed)", "procedureSlug": "rhinoplasty", "summary": "Cosmetic and/or functional reshaping of the external nose. Open approach gives better visualisation and is now standard for most contemporary practitioners; closed (endonasal) is suited to smaller refinements.", "sourceSlugs": [ "rcs-eng-rhinoplasty", "asps-practice-parameters" ] }, { "name": "Septorhinoplasty", "summary": "Combined functional septoplasty and aesthetic rhinoplasty. Most demanding rhinoplasty subtype; revision rates higher than for either component alone.", "sourceSlugs": [ "rcs-eng-rhinoplasty" ] } ] } ], "relatedProcedureSlugs": [ "rhinoplasty" ], "sourceSlugs": [ "rcs-eng-rhinoplasty" ] }, { "slug": "breast-asymmetry-volume", "name": "Breast volume or asymmetry concerns", "description": "Patients seek breast surgery for volume change (augmentation or reduction), asymmetry correction, ptosis (sagging) management, or post-mastectomy reconstruction. The appropriate procedure depends on the patient's underlying anatomy, breast volume, skin envelope, ptosis grade, and goals. Combined procedures (e.g. augmentation-mastopexy) are technique-sensitive and have higher revision rates than either component alone.", "treatmentLadder": [ { "tier": "conservative", "options": [ { "name": "External prosthesis or padded clothing", "summary": "Non-surgical option for asymmetry or post-mastectomy. Reversible with no surgical risk; not appropriate when the patient seeks permanent volume change.", "sourceSlugs": [ "asps-practice-parameters" ] }, { "name": "Lipofilling (autologous fat transfer)", "summary": "Modest volume increase using the patient's own fat. Fewer foreign-body risks than implants; volume retention is partial (typically 50-70%) so multiple sessions may be required.", "sourceSlugs": [ "asps-practice-parameters" ] } ] }, { "tier": "procedural", "options": [ { "name": "Mastopexy (breast lift) without implant", "summary": "Reshaping of breast tissue with skin envelope adjustment but no volume increase. Suitable for ptosis without volume deficit.", "sourceSlugs": [ "asps-practice-parameters" ] } ] }, { "tier": "surgical", "options": [ { "name": "Breast augmentation", "procedureSlug": "breast-augmentation", "summary": "Implant-based augmentation. Implant choice (saline vs cohesive silicone, smooth vs textured, round vs anatomic) and pocket placement (subglandular vs submuscular vs dual plane) significantly affect long-term outcomes including capsular contracture and revision risk.", "sourceSlugs": [ "asps-practice-parameters", "isaps-global-survey" ] }, { "name": "Breast reduction (reduction mammoplasty)", "summary": "Reduction in breast volume with skin envelope adjustment. Often produces meaningful relief of musculoskeletal symptoms in addition to aesthetic change.", "sourceSlugs": [ "asps-practice-parameters" ] }, { "name": "Augmentation-mastopexy (combined)", "summary": "Combined volume increase and lift in a single operation. Significantly higher revision rate than either component alone; some surgeons prefer staging.", "sourceSlugs": [ "asps-practice-parameters" ] } ] } ], "relatedProcedureSlugs": [ "breast-augmentation" ], "sourceSlugs": [ "asps-practice-parameters" ] }, { "slug": "post-pregnancy-abdominal-laxity", "name": "Post-pregnancy or post-weight-loss abdominal laxity", "description": "Loose abdominal skin and rectus muscle separation (diastasis recti) are common after significant weight loss or pregnancy. The choice between conservative rehabilitation and surgical intervention depends on the severity of the laxity, the presence of muscle separation, and whether the patient has completed family planning. Pregnancy after abdominoplasty typically reverses the surgical result.", "treatmentLadder": [ { "tier": "conservative", "options": [ { "name": "Targeted physiotherapy", "summary": "Diastasis-specific rehabilitation with a women's-health physiotherapist. Effective for many cases of mild to moderate diastasis recti when the skin envelope is healthy. First-line option in postpartum recovery.", "sourceSlugs": [ "nice-cg176-spinal-injury" ] }, { "name": "Weight stabilisation", "summary": "Achieving a stable body weight before considering surgery; pre-operative weight stability for at least six months is a near-universal recommendation.", "sourceSlugs": [ "asps-practice-parameters" ] } ] }, { "tier": "procedural", "options": [ { "name": "Mini-abdominoplasty", "summary": "Limited skin and fat resection below the umbilicus, with or without lower-abdominal muscle plication. Suitable for patients with localised lower-abdominal laxity and good upper-abdominal tone.", "sourceSlugs": [ "asps-practice-parameters" ] } ] }, { "tier": "surgical", "options": [ { "name": "Abdominoplasty (full)", "procedureSlug": "abdominoplasty", "summary": "Resection of excess skin and fat from umbilicus to pubis with rectus plication. Definitive treatment for significant skin laxity and diastasis. Substantial DVT/PE risk requires careful perioperative management.", "sourceSlugs": [ "asps-practice-parameters", "nice-ng89-venous-thromboembolism" ] }, { "name": "Extended abdominoplasty (post-massive-weight-loss)", "summary": "Wider resection with possible flank extension; commonly performed after substantial bariatric weight loss. Higher complication rate than primary abdominoplasty.", "sourceSlugs": [ "asps-practice-parameters" ] } ] } ], "relatedProcedureSlugs": [ "abdominoplasty" ], "sourceSlugs": [ "asps-practice-parameters" ], "clinicalOverview": { "sourceSlugs": [ "wikipedia-post-pregnancy-abdominal-laxity" ], "signsAndSymptoms": "A diastasis recti may appear as a ridge running down the midline of the abdomen, anywhere from the xiphoid process to the umbilicus. It becomes more prominent with straining and may disappear when the abdominal muscles are relaxed, and the medial borders of the two halves of the rectus abdominis can be palpated during contraction. Beyond the abdominal bulge it can be associated with a range of painful symptoms and complications, including urinary incontinence (leaking), pelvic pain, pain with sex, prolapse, low back pain, pelvic floor dysfunction and umbilical hernia. The condition itself has no associated morbidity or mortality.", "causesAndRiskFactors": "The separation arises from stretching of the linea alba, the connective collagen sheath formed by the aponeurosis insertions of the transverse abdominis, internal oblique and external oblique muscles; this stretching increases the distance between the right and left rectus abdominis muscles. Loose abdominal skin and rectus muscle separation of this kind are common after significant weight loss or pregnancy.", "diagnosis": "Diastasis recti is diagnosed by physical examination, measuring the distance between the rectus abdominis muscles at rest and during contraction at several levels along the linea alba; it is defined as a gap of about 2.7 cm or greater. Examination is typically performed with the subject lying on the back, knees bent at 90 degrees with feet flat and the head slightly lifted with the chin on the chest; with the muscles tensed the examiner places fingers in the presenting ridge, and a separation of two fingertips (approximately 1.5 cm) or more is the determining factor. Abdominal ultrasonography provides objective evidence and confirms that the bulge is not a hernia, and a CT scan may also visualise it; the condition must be differentiated from an epigastric or incisional hernia." } }, { "slug": "infertility", "name": "Infertility", "description": "Infertility is generally defined as inability to conceive after 12 months of regular unprotected intercourse (6 months over age 35). Causes are female-factor, male-factor, both, or unexplained. Treatment is staged from lifestyle and medical optimisation through assisted reproductive technology, with specific approaches tailored to the underlying cause.", "treatmentLadder": [ { "tier": "conservative", "options": [ { "name": "Lifestyle optimisation and timed intercourse", "summary": "Weight, smoking, alcohol, and exercise modification; ovulation tracking. Effective in some couples without further intervention.", "sourceSlugs": [ "eshre-good-practice-ivf" ] }, { "name": "Ovulation induction", "summary": "Clomifene citrate or letrozole for anovulatory women. Frequently combined with intercourse timing or IUI.", "sourceSlugs": [ "eshre-good-practice-ivf" ] }, { "name": "Surgical management of underlying conditions", "summary": "Laparoscopy for endometriosis, hysteroscopy for uterine adhesions, varicocele repair in male factor — directed at correcting an identified cause before assisted reproduction.", "sourceSlugs": [ "eshre-good-practice-ivf" ] } ] }, { "tier": "procedural", "options": [ { "name": "Intrauterine insemination (IUI)", "summary": "Concentrated sperm placed in the uterus around ovulation. Less invasive and less expensive than IVF; lower per-cycle success rate.", "sourceSlugs": [ "eshre-good-practice-ivf" ] }, { "name": "IVF / ICSI", "procedureSlug": "ivf", "summary": "In-vitro fertilisation, with or without intracytoplasmic sperm injection. The standard ART option for tubal factor, severe male factor, advanced reproductive age, and after failed IUI cycles.", "sourceSlugs": [ "eshre-good-practice-ivf", "asrm-clinic-standards" ] }, { "name": "Donor egg / sperm / embryo cycles", "summary": "Treatment using donor gametes or embryos. Legal frameworks (anonymity, recognition, parentage) vary materially between jurisdictions and have implications for the resulting child.", "sourceSlugs": [ "eshre-good-practice-ivf" ] }, { "name": "Surrogacy", "summary": "Pregnancy carried by a surrogate. Legality and enforceability vary widely across countries; cross-border surrogacy carries significant legal complexity.", "sourceSlugs": [ "eshre-good-practice-ivf" ] } ] }, { "tier": "surgical", "options": [ { "name": "Tubal microsurgery", "summary": "Microsurgical repair of fallopian-tube obstruction. Largely superseded by IVF for most indications but retained for selected cases of tubal disease.", "sourceSlugs": [ "eshre-good-practice-ivf" ] }, { "name": "Endometriosis excision", "summary": "Laparoscopic excision of endometriotic deposits to improve natural conception rates and reduce pain. May be performed before or alongside IVF.", "sourceSlugs": [ "eshre-good-practice-ivf" ] } ] } ], "relatedProcedureSlugs": [ "ivf" ], "sourceSlugs": [ "eshre-good-practice-ivf" ], "clinicalOverview": { "sourceSlugs": [ "wikipedia-infertility" ], "signsAndSymptoms": "Infertility presents as the inability to become pregnant after at least one year of regular, unprotected sexual intercourse involving a male and female partner, or after six months where the woman is over 35, has a history of endometriosis, has infrequent or irregular menses, or where a male factor is involved. It is defined by this reproductive failure rather than by symptoms of its own. The most common female-factor causes are hormonal and usually manifest as scanty or absent menstrual periods, and ovarian reserve declines with age; male-factor infertility is most commonly due to deficiencies in the semen.", "causesAndRiskFactors": "Male infertility is responsible for 20-30% of cases, female infertility for 20-35%, and combined problems in both partners for 25-40%; in 10-20% of cases no cause is found. The most common cause of female infertility is disordered ovulation, of which about 70% is due to polycystic ovarian syndrome, with other hormonal contributors including low oestrogen, imbalanced GnRH secretion and ageing, which reduces ovarian reserve; some women experience primary ovarian insufficiency before age 40. Tubal infertility accounts for 11-67% of female infertility and endometriosis for 25-40%. Male infertility is most commonly due to deficiencies in the semen. Additional recognised causes include iodine deficiency, delayed puberty and antisperm antibodies, which have been implicated in around 10-30% of infertile couples.", "diagnosis": "A doctor or women's health nurse practitioner takes a medical history and performs a physical examination of both partners, and can carry out basic tests to identify a reason for the failure to conceive. Blood tests are common and may include serologies for infections such as hepatitis B, hepatitis C, HIV, syphilis and rubella, with optional tests such as karyotypes. In women, specific tests may measure anti-Mullerian hormone to assess ovarian reserve, thyroid-stimulating hormone, prolactin and vitamin D. Semen quality is used as a surrogate measure of male fecundity. Where necessary, patients are referred to a fertility clinic for more specialised tests, and the results help determine the most appropriate treatment.", "epidemiology": "Prevalence varies with the definition used. The World Health Organization reported in 2023 that about 17.5% of people experience infertility during their lifetime, with a point prevalence of 12.6%, and rates have risen by about 4% since the 1980s, largely owing to increasing age. In the UK fertility problems affect about one in seven couples; roughly 84% who have regular unprotected intercourse conceive within a year and about 95% within two years. About 94% of women aged 35 conceive after three years of trying, compared with about 77% of women aged 38." } }, { "slug": "severe-obesity-with-comorbidity", "name": "Severe obesity with comorbidity", "description": "Patients with BMI ≥40, or ≥35 with significant comorbidity (type 2 diabetes, sleep apnoea, hypertension), may be candidates for bariatric (weight-loss) surgery. The treatment ladder runs through medical management, modern weight-loss pharmacotherapy, endoscopic procedures, and definitive surgery. Surgical options have different mechanisms and trade-offs around weight loss, reflux, and reversibility.", "treatmentLadder": [ { "tier": "conservative", "options": [ { "name": "Multidisciplinary medical weight management", "summary": "Coordinated dietetic, behavioural, and exercise support. Effective in some patients but historically modest long-term outcomes for severe obesity.", "sourceSlugs": [ "ifso-bariatric-standards" ] }, { "name": "GLP-1 receptor agonist therapy", "summary": "Semaglutide, tirzepatide, and related agents producing 15-25% body-weight reduction in many patients. Continuing evidence base; weight typically regained on cessation.", "sourceSlugs": [ "ifso-bariatric-standards" ] } ] }, { "tier": "procedural", "options": [ { "name": "Endoscopic gastric balloon", "summary": "Saline- or air-filled balloon placed endoscopically for 6 months. Modest weight loss; suitable as a bridge therapy or for patients ineligible for surgery.", "sourceSlugs": [ "ifso-bariatric-standards" ] }, { "name": "Endoscopic sleeve gastroplasty", "summary": "Endoscopic suturing to reduce stomach volume without surgical resection. Less established evidence than surgical alternatives.", "sourceSlugs": [ "ifso-bariatric-standards" ] } ] }, { "tier": "surgical", "options": [ { "name": "Sleeve gastrectomy", "procedureSlug": "gastric-sleeve", "summary": "Resection of approximately 75% of the stomach to create a tubular gastric remnant. The most commonly performed bariatric operation worldwide; durable weight loss but elevated reflux risk in some patients.", "sourceSlugs": [ "ifso-bariatric-standards", "cochrane-bariatric-surgery" ] }, { "name": "Roux-en-Y gastric bypass", "summary": "Creation of a small gastric pouch and a Roux limb of small bowel, bypassing most of the stomach and proximal small bowel. Greater weight loss than sleeve in many series; better resolution of reflux and type 2 diabetes; technically more demanding.", "sourceSlugs": [ "ifso-bariatric-standards", "cochrane-bariatric-surgery" ] }, { "name": "Mini gastric bypass (one-anastomosis)", "summary": "Single-anastomosis variant of bypass. Shorter operating time; concerns about long-term bile reflux remain debated.", "sourceSlugs": [ "ifso-bariatric-standards" ] } ] } ], "relatedProcedureSlugs": [ "gastric-sleeve" ], "sourceSlugs": [ "ifso-bariatric-standards" ], "clinicalOverview": { "sourceSlugs": [ "wikipedia-severe-obesity-with-comorbidity" ], "signsAndSymptoms": "Obesity is a condition in which excess body fat has accumulated to an extent that can have negative effects on health, and it is a major cause of disability. It is classified using body mass index, with a BMI over 30 kg/m2 defined as obese; severe obesity denotes a BMI of 40 or above, or 35 or above where a significant comorbidity is present. The clinical burden is dominated by associated disease: obesity is correlated with cardiovascular disease, type 2 diabetes, obstructive sleep apnoea, certain cancers, and osteoarthritis. In patients considered for bariatric surgery, it is this comorbidity load, alongside the degree of excess weight, that characterises the presentation rather than any single symptom.", "causesAndRiskFactors": "Obesity has individual, socioeconomic, and environmental causes. The fundamental driver is a sustained positive energy balance, where energy intake from food exceeds energy expenditure, combined with a resetting of the body's weight set point at a higher value. Excess appetite for palatable, high-calorie food, low physical activity, automation, urbanisation, and increased reliance on cars are all implicated, alongside genetic susceptibility, certain medications such as atypical antipsychotics, mental disorders, endocrine disorders, insufficient sleep, and exposure to endocrine-disrupting chemicals. At a biological level, appetite-regulating hormones such as leptin and ghrelin act on the hypothalamus; deficient leptin signalling, through leptin deficiency or resistance, leads to overfeeding and may account for some genetic and acquired forms of obesity.", "diagnosis": "Obesity is assessed using body mass index, a person's weight divided by the square of their height. A BMI over 30 kg/m2 is defined as obese and the range 25 to 30 kg/m2 as overweight, though some East Asian countries apply lower thresholds. Within this classification, severe obesity is identified at a BMI of 40 or above, or 35 or above in the presence of a significant comorbidity such as type 2 diabetes, sleep apnoea, or hypertension, which is the threshold at which bariatric surgery may be considered.", "epidemiology": "In 2022, over 1 billion people lived with obesity worldwide (879 million adults and 159 million children), and the World Health Organization formally recognised obesity as a global epidemic in 1997. The CDC reported that the prevalence of obesity among US adults aged 20 and over was 41.9% from 2017 to March 2020, with severe obesity at 9.2% over the same period. Severe obesity in the United States, Australia, and Canada is increasing faster than the overall rate of obesity. Prevalence rises with age at least up to 50 or 60 years, and globally there are more obese women than men." } }, { "slug": "knee-osteoarthritis", "name": "Knee osteoarthritis", "description": "Degenerative joint disease of the knee, characterised by progressive cartilage loss, joint-space narrowing, and pain. The treatment ladder runs from lifestyle and medical management through intra-articular injections, joint-preserving surgery, and finally joint replacement. Modern guidelines have substantially reduced the role of arthroscopy in osteoarthritis without mechanical symptoms.", "treatmentLadder": [ { "tier": "conservative", "options": [ { "name": "Weight management and physiotherapy", "summary": "First-line for all symptomatic patients. Each kilogram lost reduces knee load substantially during walking; supervised exercise improves pain and function.", "sourceSlugs": [ "aaos-knee-replacement-guideline" ] }, { "name": "Analgesia (paracetamol, NSAIDs)", "summary": "Topical NSAIDs preferred for localised pain; systemic NSAIDs effective but with cardiovascular and gastrointestinal risk profiles to consider in older patients.", "sourceSlugs": [ "aaos-knee-replacement-guideline" ] } ] }, { "tier": "procedural", "options": [ { "name": "Intra-articular corticosteroid injection", "summary": "Short-term symptomatic relief (weeks to months). Repeated injections over time are associated with cartilage loss and are not a long-term solution.", "sourceSlugs": [ "aaos-knee-replacement-guideline" ] }, { "name": "Hyaluronic acid (viscosupplementation) injection", "summary": "Limited and contested evidence; some patients report symptomatic improvement.", "sourceSlugs": [ "aaos-knee-replacement-guideline" ] }, { "name": "Knee arthroscopy", "summary": "Now of limited evidence in osteoarthritis without mechanical locking; current AAOS and NICE guidance has substantially reduced its routine indication.", "sourceSlugs": [ "aaos-knee-replacement-guideline" ] } ] }, { "tier": "surgical", "options": [ { "name": "Unicompartmental knee replacement", "summary": "Partial replacement when osteoarthritis is confined to one compartment. Faster recovery and better range of motion than total replacement, but with higher revision rates in some series.", "sourceSlugs": [ "aaos-knee-replacement-guideline" ] }, { "name": "Total knee replacement", "procedureSlug": "knee-replacement", "summary": "Definitive surgical treatment for end-stage osteoarthritis. Modern implant survivorship at 15-20 years exceeds 90% in registry data.", "sourceSlugs": [ "aaos-knee-replacement-guideline", "njr-annual-report" ] }, { "name": "High tibial osteotomy", "summary": "Realignment osteotomy to redistribute load away from the affected compartment. Selected younger active patients with isolated medial-compartment disease.", "sourceSlugs": [ "aaos-knee-replacement-guideline" ] } ] } ], "relatedProcedureSlugs": [ "knee-replacement" ], "sourceSlugs": [ "aaos-knee-replacement-guideline" ], "clinicalOverview": { "sourceSlugs": [ "wikipedia-knee-osteoarthritis" ], "signsAndSymptoms": "The knee is one of the large weight-bearing joints most commonly affected by osteoarthritis, and the main symptom is pain, causing loss of ability and often stiffness. The pain is typically made worse by prolonged activity and relieved by rest, while stiffness is most common in the morning, usually lasting less than thirty minutes but returning after periods of inactivity such as prolonged sitting. Pain when ascending or descending stairs, or getting in and out of a car or bath, is associated with osteoarthritis of the patellofemoral joint behind the kneecap, which is stressed with knee flexion. The knee may produce a crackling noise, called crepitus, when moved, and patients may report joint locking and instability. Symptoms usually progress slowly over years and, as the disease advances, gait is typically affected.", "causesAndRiskFactors": "Damage from mechanical stress with insufficient self-repair by the joint is believed to be the primary cause. Contributing sources of stress include bony misalignment, mechanical injury, excess body weight, loss of strength in the muscles supporting the knee, and impaired peripheral nerves. Risk increases with ageing, a history of joint injury, and family history, and osteoarthritis of the knees is twice as common in those with obesity. It is more prevalent among post-menopausal women, who also tend to have more severe symptoms and imaging findings than men. Occupational risk for knee osteoarthritis is raised in those who kneel or squat, who combine heavy lifting with a kneeling or squatting posture, and who work standing up. Diabetes doubles the risk of a joint replacement due to osteoarthritis. Underlying this, cartilage is progressively lost, osteophytes form at the joint margins, and the synovium becomes inflamed.", "diagnosis": "Diagnosis is made with reasonable certainty based on history and clinical examination, and X-rays may confirm it. Typical radiographic changes include joint-space narrowing, subchondral sclerosis, subchondral cyst formation, and osteophytes. The combination of knee pain and osteophytes on X-ray has good sensitivity and specificity for the diagnosis. X-rays may not correlate with physical examination findings or the degree of pain, especially early in the disease when imaging can appear relatively normal. The Kellgren-Lawrence scale, using projectional radiography, is used to grade knee osteoarthritis, and the WOMAC scale accounts for pain, stiffness, and functional limitation.", "epidemiology": "Globally, as of 2010, approximately 250 million people had osteoarthritis of the knee, about 3.6% of the world's population. Together, knee and hip osteoarthritis ranked 11th for disability globally among 291 disease conditions assessed. Osteoarthritis overall is the most common form of arthritis, affecting about 237 million people or 3.3% of the world's population as of 2015, and it becomes more common as people age." } }, { "slug": "refractive-error", "name": "Refractive error", "description": "Myopia (short-sightedness), hyperopia (long-sightedness), and astigmatism are very common refractive errors corrected by glasses, contact lenses, or surgical refractive procedures. Surgical correction is elective and depends on stable refraction, healthy corneas of adequate thickness, and absence of conditions like keratoconus that contraindicate laser surgery.", "treatmentLadder": [ { "tier": "conservative", "options": [ { "name": "Spectacles", "summary": "Reversible, no surgical risk. The default option and the appropriate baseline before considering refractive surgery.", "sourceSlugs": [ "aao-ppp-refractive" ] }, { "name": "Contact lenses", "summary": "Daily disposable, monthly, or extended-wear options. Careful hygiene reduces but does not eliminate microbial keratitis risk.", "sourceSlugs": [ "aao-ppp-refractive" ] } ] }, { "tier": "procedural", "options": [ { "name": "LASIK", "procedureSlug": "lasik", "summary": "Laser-assisted in-situ keratomileusis. Femtosecond-laser flap creation followed by excimer-laser stromal ablation. Rapid visual recovery and minimal post-operative discomfort.", "sourceSlugs": [ "aao-ppp-refractive", "cochrane-lasik-vs-prk", "escrs-refractive-guidelines" ] }, { "name": "PRK", "summary": "Photorefractive keratectomy: surface ablation without flap. Slower visual recovery and more discomfort than LASIK but suitable for thin corneas and contact-sport athletes.", "sourceSlugs": [ "aao-ppp-refractive", "cochrane-lasik-vs-prk" ] }, { "name": "SMILE", "summary": "Small-incision lenticule extraction: a stromal lenticule is created by a femtosecond laser and removed through a small incision, without a flap. Promoted as having better biomechanics than LASIK; evidence for advantages over LASIK is mixed.", "sourceSlugs": [ "escrs-refractive-guidelines" ] }, { "name": "Implantable collamer lens (ICL)", "summary": "Phakic intraocular lens for high myopia or thin corneas where laser refractive surgery is contraindicated. Lens-based, reversible.", "sourceSlugs": [ "aao-ppp-refractive" ] } ] }, { "tier": "surgical", "options": [ { "name": "Refractive lens exchange (RLE)", "summary": "Replacement of the natural lens with an intraocular lens, similar to cataract surgery but performed for refractive correction. Particularly considered in presbyopic-age patients with high refractive errors unsuitable for laser surgery.", "sourceSlugs": [ "aao-ppp-refractive" ] } ] } ], "relatedProcedureSlugs": [ "lasik" ], "sourceSlugs": [ "aao-ppp-refractive" ], "clinicalOverview": { "sourceSlugs": [ "wikipedia-refractive-error" ], "signsAndSymptoms": "Refractive error is a problem with focusing light accurately on the retina due to the shape of the eye and/or cornea. Its most common forms are near-sightedness (myopia), far-sightedness (hyperopia), and astigmatism. Near-sightedness makes distant objects appear blurry, far-sightedness makes close objects blurry, and astigmatism causes objects to appear stretched out or blurry. Other symptoms may include double vision, headaches, and eye strain. Because blurred vision can arise from many conditions not related to refractive error, the pattern of blur, together with these associated symptoms, characterises the presentation.", "causesAndRiskFactors": "The error arises from the optical geometry of the eye: near-sightedness is due to the eyeball being too long, far-sightedness to the eyeball being too short, and astigmatism to the cornea being the wrong shape. There is evidence of a genetic predisposition, and individuals whose parents have a given refractive error are more likely to have a similar one; myopia features as a symptom in many inherited disorders, including connective-tissue conditions such as Marfan, Stickler, and Knobloch syndromes. Environmental factors also correlate with myopia risk: it is more common in those with visually intensive occupations, and sustained focusing on near objects, such as reading, close screen use, or writing, has been associated with its development, as have higher socioeconomic status and education. Blepharoptosis can also induce refractive error.", "diagnosis": "Diagnosis is confirmed by an eye care professional during an eye examination. The clinician determines an objective estimate of the error using lenses of different optical powers and a retinoscope, watching the pattern of reflected light while the patient views a distant target, a procedure called retinoscopy. This is refined by subjective refraction, in which lenses of progressively higher or weaker power are compared. An automated refractor is sometimes used in place of retinoscopy, and cycloplegic agents are frequently used to determine the error more accurately, particularly in children. A pinhole occluder distinguishes refractive error from other problems, as it improves vision only when the cause is refractive.", "epidemiology": "It is estimated that at least 2 billion people worldwide have refractive errors, making them the first common cause of visual impairment. The number with uncorrected refractive error was estimated at 660 million, or 10 per 100 people, in 2013, of whom 9.5 million were blind as a result. Rates vary between regions, with about 25% of Europeans and 80% of Asians affected. Near-sightedness is the most common form, with rates of 15 to 49% among adults and 1.2 to 42% among children, while far-sightedness more commonly affects young children and the elderly." } }, { "slug": "coronary-artery-disease", "name": "Coronary artery disease", "description": "Atherosclerotic narrowing of coronary arteries causing ischaemia and angina. Treatment is staged from lifestyle and medical therapy through percutaneous coronary intervention (PCI) to coronary artery bypass grafting (CABG). The choice between PCI and CABG in multi-vessel disease requires multidisciplinary heart-team assessment per current ACC/AHA guidance.", "treatmentLadder": [ { "tier": "conservative", "options": [ { "name": "Risk-factor modification and medical therapy", "summary": "Smoking cessation, lipid lowering (statins), blood-pressure control, antiplatelet therapy (aspirin), antianginal medications (beta-blockers, calcium-channel blockers, nitrates). Foundation of all coronary disease management; often sufficient for stable angina without high-risk anatomy.", "sourceSlugs": [ "aha-cabg-guideline-2021" ] } ] }, { "tier": "procedural", "options": [ { "name": "Percutaneous coronary intervention (PCI)", "summary": "Catheter-based stent placement, with or without atherectomy. Less invasive than CABG; preferred in single-vessel disease and in many multi-vessel cases without left-main or complex multi-vessel disease.", "sourceSlugs": [ "aha-cabg-guideline-2021" ] } ] }, { "tier": "surgical", "options": [ { "name": "Coronary artery bypass graft (CABG)", "procedureSlug": "cabg", "summary": "Surgical revascularisation using internal mammary artery and saphenous vein/radial artery grafts. Superior to PCI for left-main disease, complex multi-vessel disease, and diabetic patients with multi-vessel disease per AHA/ACC guidance.", "sourceSlugs": [ "aha-cabg-guideline-2021", "sts-adult-cardiac-database" ] } ] } ], "relatedProcedureSlugs": [ "cabg" ], "sourceSlugs": [ "aha-cabg-guideline-2021" ], "clinicalOverview": { "sourceSlugs": [ "wikipedia-coronary-artery-disease" ], "signsAndSymptoms": "The most common symptom is chest pain or discomfort occurring predictably with activity, after eating, or at other set times; this is termed stable angina and reflects narrowing of the coronary arteries. Angina may also be felt as tightness, heaviness, pressure, numbness, fullness, or squeezing, can travel to the shoulder, arm, back, neck, or jaw, and occasionally resembles heartburn; it typically lasts less than a few minutes and improves with rest. Angina that changes in intensity, character, or frequency is termed unstable and may precede a myocardial infarction. Shortness of breath may occur, sometimes no symptoms are present, and in many cases the first sign is a heart attack. Signs of a heart attack include angina, shortness of breath, sweating, nausea or vomiting, and light-headedness. In females the most common symptom is shortness of breath, and symptoms often appear about ten years later than in males.", "causesAndRiskFactors": "Coronary artery disease results from atherosclerosis, a chronic inflammation of the arteries that causes them to harden and accumulate cholesterol-rich atheromatous plaques on the artery walls, narrowing the lumen and reducing blood flow to the heart muscle, which can produce ischaemia and myocardial infarction. Well-established risk factors include high blood pressure, smoking, diabetes, lack of exercise, obesity, high blood cholesterol, poor diet, depression, family history, psychological stress, and excessive alcohol consumption. About half of cases are linked to genetics, with a heritability estimated between 40% and 60%. Smoking is associated with about 36% of cases and obesity with about 20%, and smoking just one cigarette per day roughly doubles the risk; lack of exercise accounts for 7 to 12% of cases. Air pollution, both indoor and outdoor, is responsible for roughly 28% of deaths from the disease.", "diagnosis": "Diagnosis depends largely on the nature of the symptoms and on imaging. The first investigation when coronary artery disease is suspected is an electrocardiogram, used for both stable angina and acute coronary syndrome, and a chest X-ray, blood tests, and resting echocardiography may also be performed. For stable symptomatic patients, non-invasive tests are chosen according to the risk profile: computed tomography angiography is the best test to rule out disease in low-risk patients, while functional methods such as PET, SPECT nuclear stress testing, and stress echocardiography are typically better to rule it in. Exercise ECG is inferior to non-invasive imaging because of false-negative and false-positive results. Invasive coronary angiography is used when non-invasive testing is inconclusive or indicates high event risk.", "epidemiology": "In 2015, coronary artery disease affected 110 million people and resulted in 8.9 million deaths, making up 15.6% of all deaths and making it the most common cause of death globally. It may affect individuals at any age but becomes dramatically more common with age, roughly tripling with each decade of life, and males are affected more often than females. In the United States in 2010, about 20% of those over 65 had the disease. The World Health Organization has reported ischaemic heart disease as the world's biggest killer, responsible for 13% of total deaths and rising to 9.1 million deaths in 2021." } }, { "slug": "cancer", "name": "Cancer", "description": "Cancer treatment varies fundamentally by tumour type, stage, biology (including molecular profile), and patient fitness. Modern oncology is multimodal and increasingly precision-driven, combining surgery, radiotherapy, systemic therapies (chemotherapy, targeted therapy, immunotherapy, hormonal therapy), and supportive care. Continuity of care across the treatment course is critical, which makes cross-border treatment particularly difficult to coordinate.", "treatmentLadder": [ { "tier": "conservative", "options": [ { "name": "Active surveillance / watchful waiting", "summary": "For selected indolent cancers (low-risk prostate, some early thyroid and chronic lymphocytic leukaemia), structured surveillance with intervention deferred until progression. Avoids treatment morbidity in patients who may never need active treatment.", "sourceSlugs": [ "esmo-clinical-practice-guidelines" ] }, { "name": "Best supportive care", "summary": "Symptom-focused care without disease-modifying treatment, appropriate when curative or life-prolonging treatment is not feasible or not in the patient's interest.", "sourceSlugs": [ "esmo-clinical-practice-guidelines" ] } ] }, { "tier": "procedural", "options": [ { "name": "Chemotherapy", "procedureSlug": "chemotherapy", "summary": "Systemic cytotoxic anti-cancer therapy, delivered as cycles of intravenous or oral drugs. Indications, regimens, and protocols are tumour- and stage-specific.", "sourceSlugs": [ "asco-chemo-safety-standards", "esmo-clinical-practice-guidelines" ] }, { "name": "Radiotherapy", "summary": "External-beam, brachytherapy, or systemic radioisotopes. Used as primary therapy, adjuvant therapy, or palliation depending on the cancer.", "sourceSlugs": [ "esmo-clinical-practice-guidelines" ] }, { "name": "Targeted therapy and immunotherapy", "summary": "Drugs targeting specific molecular alterations (kinase inhibitors, monoclonal antibodies) or immune checkpoints (PD-1/PD-L1 inhibitors). Eligibility depends on tumour molecular profiling.", "sourceSlugs": [ "esmo-clinical-practice-guidelines" ] } ] }, { "tier": "surgical", "options": [ { "name": "Curative oncologic surgery", "summary": "Resection of localised tumour with margins, often combined with regional lymphadenectomy. Cornerstone of curative treatment for most solid tumours when surgically resectable.", "sourceSlugs": [ "esmo-clinical-practice-guidelines" ] }, { "name": "Cytoreductive (debulking) surgery", "summary": "Removal of as much tumour bulk as possible to improve response to subsequent systemic therapy; commonly used in ovarian cancer.", "sourceSlugs": [ "esmo-clinical-practice-guidelines" ] }, { "name": "Palliative surgery", "summary": "Surgery to relieve symptoms (e.g. obstruction, pain) when cure is not the aim.", "sourceSlugs": [ "esmo-clinical-practice-guidelines" ] } ] } ], "relatedProcedureSlugs": [ "chemotherapy" ], "sourceSlugs": [ "esmo-clinical-practice-guidelines" ], "clinicalOverview": { "sourceSlugs": [ "wikipedia-cancer" ], "signsAndSymptoms": "Early cancer usually produces no symptoms; signs and symptoms appear as the mass grows or ulcerates, and the findings depend on the tumour's type and location. Few symptoms are specific, so cancer can act as a great imitator. Local effects reflect the mass or its ulceration: a bronchial obstruction may cause cough or pneumonia, oesophageal narrowing may make swallowing difficult, and colorectal tumours may alter bowel habit; breast or testicular masses may be felt as lumps, and ulceration may cause haemoptysis, anaemia, rectal bleeding, haematuria, or abnormal vaginal bleeding. Systemic features include fatigue, unintentional weight loss, cachexia, persistent fever, dyspnoea, and paraneoplastic syndromes such as hypercalcaemia or hyponatraemia. Almost all cancers can metastasise, most often to the lungs, liver, brain, and bones.", "causesAndRiskFactors": "About 90 to 95 per cent of cancers are attributed to environmental and lifestyle factors and the remaining 5 to 10 per cent to inherited genetics. Major contributors to cancer death include tobacco use (25 to 30 per cent), diet and obesity (30 to 35 per cent), infections (15 to 20 per cent), and ionising and non-ionising radiation (up to 10 per cent), alongside physical inactivity and pollution. Tobacco smoke, which contains over fifty known carcinogens, causes around 90 per cent of lung cancer, and alcohol raises the risk of several cancers. Infective agents such as Helicobacter pylori, hepatitis B and C, and HPV cause roughly 16 to 18 per cent of cancers worldwide. Mechanistically, cancer is a disorder of tissue-growth regulation requiring multiple alterations to oncogenes and tumour suppressor genes.", "diagnosis": "Most cancers are first recognised through signs and symptoms or through screening, but neither provides a definitive diagnosis, which requires a pathologist to examine a tissue sample. People with suspected cancer are investigated with medical tests commonly including blood tests, X-rays, contrast CT scans, and endoscopy. The biopsy identifies the proliferating cell type, its histological grade, and genetic abnormalities, information used to assess prognosis and select treatment. Cytogenetics and immunohistochemistry provide further detail on molecular changes such as mutations, fusion genes, and numerical chromosome changes. Screening seeks to detect cancer before symptoms appear and is considered useful for cervical and colorectal cancer.", "epidemiology": "An estimated 18.1 million new cases of cancer and 9.6 million deaths occurred globally in 2018. About 20 per cent of males and 17 per cent of females develop cancer at some point, while 13 per cent of males and 9 per cent of females die from it, and cancers account for almost one in six deaths. The most significant risk factor is age: although cancer can occur at any age, most people with invasive cancer are over 65." } }, { "slug": "hernia", "name": "Hernia", "description": "Protrusion of an organ or tissue through a weakness in surrounding muscle or fascia. The most common varieties are inguinal, umbilical, incisional, and hiatal. Treatment selection depends on hernia type, size, symptoms, and the patient's surgical risk profile. Watchful waiting is appropriate for small asymptomatic inguinal hernias in older patients; surgical repair (open or laparoscopic, with or without mesh) is the definitive treatment for symptomatic hernias.", "treatmentLadder": [ { "tier": "conservative", "options": [ { "name": "Watchful waiting (small asymptomatic)", "summary": "Reasonable for small, asymptomatic inguinal hernias particularly in older patients with comorbidity. Crossover to surgical repair occurs in a minority of patients over time as symptoms develop.", "sourceSlugs": [ "nice-ta160-laparoscopic-hernia" ] }, { "name": "Truss or supportive garment", "summary": "Symptomatic relief only; does not reduce the hernia or prevent progression. Of limited modern role.", "sourceSlugs": [ "nice-ta160-laparoscopic-hernia" ] } ] }, { "tier": "procedural", "options": [ { "name": "Manual reduction (incarcerated hernia, emergency)", "summary": "Manual reduction of an incarcerated hernia by trained clinician, deferring surgery to elective scheduling. Only appropriate when reduction can be achieved without force and without signs of strangulation.", "sourceSlugs": [ "nice-ta160-laparoscopic-hernia" ] } ] }, { "tier": "surgical", "options": [ { "name": "Open hernia repair", "procedureSlug": "hernia-repair", "summary": "Single-incision repair, typically with synthetic mesh reinforcement (Lichtenstein technique for inguinal). Shorter operating time than laparoscopic; suitable under local or general anaesthesia.", "sourceSlugs": [ "nice-ta160-laparoscopic-hernia", "cochrane-laparoscopic-vs-open-hernia" ] }, { "name": "Laparoscopic hernia repair", "summary": "Minimally invasive transabdominal preperitoneal (TAPP) or totally extraperitoneal (TEP) approach with mesh placement from inside the abdominal wall. Faster return to normal activity than open repair; preferred for bilateral and recurrent inguinal hernias per NICE TA160.", "sourceSlugs": [ "nice-ta160-laparoscopic-hernia", "cochrane-laparoscopic-vs-open-hernia" ] }, { "name": "Component-separation repair (large incisional)", "summary": "Reserved for large or complex incisional hernias. Releases of the abdominal wall layers permit tension-free closure of large defects, often with biological or large-pore synthetic mesh.", "sourceSlugs": [ "nice-ta160-laparoscopic-hernia" ] } ] } ], "relatedProcedureSlugs": [ "hernia-repair" ], "sourceSlugs": [ "nice-ta160-laparoscopic-hernia" ], "clinicalOverview": { "sourceSlugs": [ "wikipedia-hernia" ], "signsAndSymptoms": "Symptoms vary with the type of hernia, and about 66 per cent of people with groin hernias have symptoms. Abdominal and groin hernias typically produce a bulge that can be seen and felt, becoming more obvious on standing or bending and sometimes coming and going, although the underlying fascial defect persists. There may be pain or discomfort in the lower abdomen, often worse with coughing, exercise, or straining, worsening through the day and easing when lying down; in men there may be scrotal pain or swelling. An irreducible or incarcerated hernia cannot be pushed back and may progress to strangulation, which is always painful with tenderness and may bring nausea, vomiting, or fever from bowel obstruction, with the bulge turning red, purple, or dark. Hiatus hernias often cause heartburn or chest pain.", "causesAndRiskFactors": "Hernias arise from a disruption or opening in the fascia that forms the abdominal wall. Conditions that raise intra-abdominal pressure can cause them or worsen existing ones, including obesity, straining during defecation or urination (from constipation or an enlarged prostate), chronic lung disease, and ascites; muscles weakened by poor nutrition, smoking, or overexertion are also more prone. Recognised risk factors include smoking, chronic obstructive pulmonary disease, obesity, pregnancy, peritoneal dialysis, collagen vascular disease, and previous open appendicectomy. Predisposition is genetic, running in certain families with apparently dominant inheritance, especially in men. Abdominal wall hernias may also follow trauma, and blunt trauma is an emergency that can be associated with solid organ and hollow viscus injuries.", "diagnosis": "Hernias can often be diagnosed from the signs and symptoms; a reducible hernia typically shows a bulge that can be seen and felt and becomes more obvious on standing. Medical imaging is occasionally used to confirm the diagnosis or exclude other causes, and it is the principal means of detecting internal, diaphragmatic, or otherwise nonpalpable hernias. Multidetector CT can show the anatomical site of the hernia sac, its contents, and any complications, and defines the abdominal wall clearly. Hiatus hernias are often diagnosed by endoscopy. Inguinal hernias, up to 75 per cent of abdominal hernias, are classified as indirect or direct by their position relative to the inferior epigastric vessels.", "epidemiology": "About 27 per cent of males and 3 per cent of females develop a groin hernia at some time in their lives. In 2013 roughly 25 million people had a hernia. Inguinal, femoral, and abdominal hernias caused about 32,500 deaths globally in 2013, down from 50,500 in 1990." } }, { "slug": "cataracts", "name": "Cataracts", "description": "Clouding of the natural lens of the eye, most commonly age-related but also occurring after trauma, with diabetes, with prolonged steroid use, or congenitally. Cataracts produce gradually worsening blurred vision, glare sensitivity, and difficulty with night driving. Treatment is overwhelmingly surgical (phacoemulsification with intraocular lens implantation); there is no effective non-surgical treatment for established cataracts.", "treatmentLadder": [ { "tier": "conservative", "options": [ { "name": "Updated spectacle prescription", "summary": "May provide modest improvement in early cataracts but does not halt progression. First-line for symptomatic patients not yet at surgical threshold.", "sourceSlugs": [ "aao-ppp-refractive" ] }, { "name": "Brighter lighting and anti-glare strategies", "summary": "Practical mitigation for early cataract symptoms; not disease-modifying.", "sourceSlugs": [ "aao-ppp-refractive" ] } ] }, { "tier": "procedural", "options": [ { "name": "Phacoemulsification with IOL implantation", "summary": "Standard cataract surgery: ultrasonic fragmentation of the cataractous lens and aspiration through a small incision, followed by implantation of an intraocular lens (monofocal, multifocal, or toric). Outpatient procedure under topical anaesthesia. The most commonly performed surgical procedure worldwide.", "sourceSlugs": [ "aao-ppp-refractive" ] }, { "name": "Femtosecond laser-assisted cataract surgery (FLACS)", "summary": "Femtosecond laser performs the corneal incision, capsulotomy, and initial lens fragmentation. Theoretical precision advantages; comparative outcome data with conventional phacoemulsification remain mixed.", "sourceSlugs": [ "aao-ppp-refractive" ] } ] }, { "tier": "surgical", "options": [ { "name": "Extracapsular cataract extraction (ECCE) — for dense/complex cataracts", "summary": "Larger-incision removal of the lens nucleus in one piece. Reserved for very dense cataracts unsuitable for phacoemulsification, or in resource-limited settings.", "sourceSlugs": [ "aao-ppp-refractive" ] } ] } ], "relatedProcedureSlugs": [ "cataract-surgery", "premium-iol" ], "sourceSlugs": [ "aao-ppp-refractive" ], "clinicalOverview": { "sourceSlugs": [ "wikipedia-cataracts" ], "signsAndSymptoms": "The signs and symptoms of cataract depend on which part of the lens is affected and how; mild lens opacity may produce no symptoms at all. As clouding worsens, symptoms include blurred vision, short-sightedness, astigmatism, difficulty with night vision, sensitivity to light, double vision in one eye, faded colours, and reduced contrast and colour vision, along with halos around lights or loss of part of the visual field. Worsening visual impairment can interfere with everyday tasks and driving, reduce physical activity and independence, and increase the risk of falls and associated injuries; reduced functioning may also contribute to mental-health difficulties.", "causesAndRiskFactors": "Cataract is most commonly age-related: lens proteins denature and degrade over time, a process accelerated by diabetes mellitus and hypertension. Formation is primarily driven by oxidative stress and lipid peroxidation, which damage lens proteins and lead to their aggregation and to the accumulation of protein clumps or yellow-brown pigment, reducing light transmission to the retina; imbalances in calcium and other ions also contribute. Risk factors include diabetes, longstanding corticosteroid use, smoking, prolonged sunlight (especially UVB) exposure, alcohol, poor nutrition, obesity, chronic kidney disease, and autoimmune disease. Cataracts may also follow blunt or penetrating trauma and ionising or non-ionising radiation, or arise congenitally through genetic and chromosomal disorders.", "diagnosis": "Cataracts are usually diagnosed through an eye examination, with ophthalmoscopy and slit-lamp examination the most effective methods. During ophthalmoscopy the pupil is dilated and the red reflex is examined for opacities in the lens, while slit-lamp examination gives further detail on the cataract's characteristics, location, and extent. Age-related cataracts are classified histologically as nuclear sclerosis (the most common type), cortical, and posterior subcapsular. They may also be graded using the Lens Opacities Classification System (LOCS III), which classifies cataracts by type and by severity on a scale from 1 to 5.", "epidemiology": "In 2020 cataracts caused 39.6 per cent of all cases of blindness and 28.3 per cent of visual impairment worldwide, and they remain the single most common cause of global blindness; age-related cataracts account for about 51 per cent of world blindness, some 20 million people. In the United States, age-related lens changes have been reported in 42 per cent of people aged 52 to 64, 60 per cent aged 65 to 74, and 91 per cent aged 75 to 85, and by age 80 more than half of Americans have cataracts." } }, { "slug": "hip-osteoarthritis", "name": "Hip osteoarthritis", "description": "Degenerative joint disease of the hip, characterised by progressive cartilage loss, joint-space narrowing, osteophyte formation, and pain. Symptoms typically include groin pain on weight-bearing, stiffness after rest, and progressive functional limitation. Treatment is staged from lifestyle and medical management through intra-articular injection and finally hip replacement for end-stage disease.", "treatmentLadder": [ { "tier": "conservative", "options": [ { "name": "Weight management and physiotherapy", "summary": "First-line for all symptomatic patients. Each kilogram lost reduces hip load substantially; supervised exercise improves pain and function in early-to-moderate disease.", "sourceSlugs": [ "aaos-knee-replacement-guideline" ] }, { "name": "Analgesia (paracetamol, NSAIDs)", "summary": "Topical NSAIDs preferred for localised symptoms; systemic NSAIDs effective but with cardiovascular and gastrointestinal risk profiles to consider in older patients.", "sourceSlugs": [ "aaos-knee-replacement-guideline" ] }, { "name": "Walking aid (cane, walker)", "summary": "A cane held in the contralateral hand reduces hip load by approximately 25%. Often deferred by patients but a meaningful intervention.", "sourceSlugs": [ "aaos-knee-replacement-guideline" ] } ] }, { "tier": "procedural", "options": [ { "name": "Intra-articular corticosteroid injection", "summary": "Short-term symptomatic relief (weeks to months). Repeated injections may accelerate joint deterioration and are not a long-term solution.", "sourceSlugs": [ "aaos-knee-replacement-guideline" ] }, { "name": "Hyaluronic acid (viscosupplementation) injection", "summary": "Less established evidence for hip than for knee; some patients report symptomatic improvement.", "sourceSlugs": [ "aaos-knee-replacement-guideline" ] } ] }, { "tier": "surgical", "options": [ { "name": "Total hip replacement", "procedureSlug": "hip-replacement", "summary": "Definitive surgical treatment for end-stage hip osteoarthritis. Modern implant survivorship at 15 years exceeds 90% in registry data.", "sourceSlugs": [ "aaos-knee-replacement-guideline", "njr-annual-report" ] }, { "name": "Hip resurfacing arthroplasty", "summary": "Bone-conserving alternative to total hip replacement; metal-on-metal bearings limit current usage to selected younger male patients due to historical concerns about metal-ion debris.", "sourceSlugs": [ "njr-annual-report" ] }, { "name": "Hip arthroscopy (for early labral pathology)", "summary": "Minimally invasive treatment of femoroacetabular impingement and labral tears in earlier disease; not appropriate for advanced osteoarthritis.", "sourceSlugs": [ "aaos-knee-replacement-guideline" ] } ] } ], "relatedProcedureSlugs": [ "hip-replacement" ], "sourceSlugs": [ "aaos-knee-replacement-guideline" ], "clinicalOverview": { "sourceSlugs": [ "wikipedia-hip-osteoarthritis" ], "signsAndSymptoms": "In the hip, as in other large weight-bearing joints, the main symptom of osteoarthritis is pain, which causes loss of function and is often accompanied by stiffness. The pain is typically made worse by prolonged activity and relieved by rest, while stiffness is most common in the morning, usually lasting less than thirty minutes after activity begins but returning after periods of inactivity such as prolonged sitting. Movement of the affected joint may produce a crackling noise known as crepitus, and a person may report joint locking or instability. The hip and knee are among the large weight-bearing joints most commonly involved, and as osteoarthritis progresses gait and other movement patterns are typically affected.", "causesAndRiskFactors": "Osteoarthritis of the hip is believed to result primarily from mechanical stress on the joint with insufficient self-repair, together with low-grade inflammation. Contributing sources of stress include congenital or pathological bone misalignment, mechanical injury, excess body weight, loss of strength in the supporting muscles, and impaired peripheral nerves. Risk rises with age, previous joint injury, and family history, and hip osteoarthritis is about twice as common in people with obesity. It is more prevalent among post-menopausal women, who tend to have more severe hip symptoms and imaging findings than men, and occupational risk is increased by manual handling, physically demanding work, and, for the hip in particular, working in bent or twisted positions. Pathologically there is progressive cartilage loss, a disorganised collagen matrix with reduced proteoglycan content, osteophyte formation at the joint margins, and changes in the subchondral bone.", "diagnosis": "Hip osteoarthritis is diagnosed with reasonable certainty from the history and clinical examination. X-rays may confirm the diagnosis, with typical changes including joint-space narrowing, subchondral sclerosis, subchondral cyst formation, and osteophytes; the combination of hip pain and osteophytes on X-ray has good sensitivity and specificity for the diagnosis. Radiographs may not correlate with the physical examination or the degree of pain, particularly early in the disease when imaging findings can be relatively normal. The Tönnis classification is used to grade osteoarthritis of the hip joint using projectional radiography features.", "epidemiology": "Hip osteoarthritis affects about 0.85 per cent of the population. Osteoarthritis overall is the most common form of arthritis, affecting about 237 million people, or 3.3 per cent of the world's population as of 2015, and becomes more common with age. More than 90 per cent of hip and knee joint replacements are performed because of osteoarthritis. In the Middle East and North Africa the prevalence of hip osteoarthritis increased roughly three-fold between 1990 and 2019, to about 1.28 million cases." } }, { "slug": "varicose-veins", "name": "Varicose veins", "description": "Enlarged, twisted superficial veins (most commonly in the legs) caused by valve dysfunction in the venous system. Symptoms range from cosmetic concerns to aching, heaviness, swelling, skin discolouration, and in severe cases venous ulceration. Modern treatment is largely outpatient, minimally invasive, with surgical stripping now rarely performed in favour of endovenous ablation or sclerotherapy.", "treatmentLadder": [ { "tier": "conservative", "options": [ { "name": "Graduated compression stockings", "summary": "Class 2 (23-32 mmHg) stockings reduce symptoms and slow progression. First-line for symptomatic patients without severe disease.", "sourceSlugs": [ "who-surgical-safety-checklist" ] }, { "name": "Lifestyle modification (weight, exercise, leg elevation)", "summary": "Reduces venous pressure and may slow symptom progression. Not disease-modifying for established varicose veins.", "sourceSlugs": [ "who-surgical-safety-checklist" ] } ] }, { "tier": "procedural", "options": [ { "name": "Endovenous laser ablation (EVLA)", "summary": "Catheter-delivered laser energy ablates the main faulty vein from the inside. Outpatient under local anaesthesia with tumescent infiltration. Now first-line for symptomatic varicose veins per modern guidelines.", "sourceSlugs": [ "who-surgical-safety-checklist" ] }, { "name": "Radiofrequency ablation (RFA)", "summary": "Similar to EVLA but using radiofrequency energy. Comparable outcomes; choice depends on operator preference and equipment availability.", "sourceSlugs": [ "who-surgical-safety-checklist" ] }, { "name": "Foam sclerotherapy", "summary": "Injection of a sclerosing foam into the vein causing it to collapse and be reabsorbed. Outpatient procedure; can treat smaller tributary veins as well as main trunks.", "sourceSlugs": [ "who-surgical-safety-checklist" ] }, { "name": "VenaSeal (cyanoacrylate glue closure)", "summary": "Catheter-delivered medical adhesive closes the faulty vein; no tumescent anaesthesia required. Increasingly used for selected cases.", "sourceSlugs": [ "who-surgical-safety-checklist" ] } ] }, { "tier": "surgical", "options": [ { "name": "Vein stripping with high ligation (historic)", "summary": "Open surgical removal of the saphenous vein. Largely superseded by endovenous techniques in modern practice; reserved for selected anatomies or where endovenous techniques have failed.", "sourceSlugs": [ "who-surgical-safety-checklist" ] } ] } ], "relatedProcedureSlugs": [], "sourceSlugs": [ "who-surgical-safety-checklist" ], "clinicalOverview": { "sourceSlugs": [ "wikipedia-varicose-veins" ], "signsAndSymptoms": "Varicose veins present as enlarged, twisted superficial veins, typically in the legs just beneath the skin, and are often only a cosmetic concern. When symptomatic, they cause aching, heavy legs, ankle swelling and night-time leg cramps, together with itching, a burning or throbbing sensation, and fatigue. Skin changes may develop near the affected veins, including a brownish-yellow discolouration, and dryness, redness and itchiness known as stasis dermatitis or venous eczema, as well as lipodermatosclerosis. Severe varicosities can lead to complications from poor circulation, notably venous ulcers near the ankle, superficial thrombophlebitis (clotting within the affected veins, which can extend into deep veins), and severe bleeding from minor trauma, of particular concern in the elderly. Restless legs syndrome commonly overlaps.", "causesAndRiskFactors": "Varicose veins have no single specific cause; the underlying problem is weak or damaged valves in the veins, with venous reflux a significant contributor. They are more common in women than in men and are strongly linked to heredity and family history. Related factors include pregnancy, obesity, menopause, ageing, prolonged standing, leg injury and abdominal straining; occasionally they result from chronic venous insufficiency. Pelvic vein reflux, including ovarian and internal iliac vein reflux, is recognised in their development and in recurrence, and affects around 14% of women with varicose veins. Incompetent perforator veins also contribute. Crossing the legs or ankles is unlikely to be a cause.", "diagnosis": "Varicose veins are typically diagnosed by examination, including observation with ultrasound. Clinical tests such as the Trendelenburg test may be used to locate the site of venous reflux and assess the saphenofemoral junction. Current practice is to investigate patients with lower-limb venous ultrasonography rather than reserving imaging for suspected deep venous insufficiency, recurrence, or saphenopopliteal involvement; a randomised controlled trial showed lower recurrence and reoperation rates with routine ultrasound at two and seven years. Severity is graded using the CEAP (Clinical, Etiological, Anatomical and Pathophysiological) classification, which ranges from telangiectasia and reticular veins through varicose veins, oedema and skin changes to healed and active venous ulcers.", "epidemiology": "Varicose veins are very common, affecting about 30% of people at some point in their lives. They become more common with age and are most common after age 50. They are more prevalent in women, who develop them about twice as often as men. A hereditary role is recognised, and the condition has also been associated with smoking, chronic constipation, and occupations requiring long periods of standing." } }, { "slug": "endometriosis", "name": "Endometriosis", "description": "A chronic gynaecological condition in which endometrial-like tissue grows outside the uterus, causing pelvic pain, painful periods, painful intercourse, and infertility. Severity ranges from minimal disease (microscopic deposits) to severe deep-infiltrating endometriosis affecting bowel or bladder. Treatment is staged from hormonal medical management through laparoscopic excision and may include fertility treatment when conception is the priority.", "treatmentLadder": [ { "tier": "conservative", "options": [ { "name": "Combined hormonal contraception", "summary": "First-line medical therapy for symptomatic endometriosis when pregnancy is not currently desired. Suppresses ovulation and menstrual flow, often substantially reducing pain.", "sourceSlugs": [ "eshre-good-practice-ivf" ] }, { "name": "Progestin-only therapy (oral or IUS)", "summary": "Alternative or second-line option; particularly useful when oestrogen is contraindicated. The levonorgestrel intrauterine system is well-evidenced for symptom control.", "sourceSlugs": [ "eshre-good-practice-ivf" ] }, { "name": "GnRH analogues", "summary": "Hormonal suppression producing a temporary menopausal state. Effective for severe symptoms but limited in duration by bone-density and other oestrogen-deficiency effects unless add-back therapy is used.", "sourceSlugs": [ "eshre-good-practice-ivf" ] } ] }, { "tier": "procedural", "options": [ { "name": "Diagnostic and operative laparoscopy", "summary": "Direct visualisation and biopsy of suspected lesions remains the diagnostic gold standard for endometriosis. Visible disease can be ablated or excised in the same procedure.", "sourceSlugs": [ "eshre-good-practice-ivf" ] }, { "name": "IVF / ICSI", "procedureSlug": "ivf", "summary": "Indicated for fertility preservation or treatment in patients with endometriosis-related infertility, often after or instead of further surgical management.", "sourceSlugs": [ "eshre-good-practice-ivf" ] } ] }, { "tier": "surgical", "options": [ { "name": "Laparoscopic excision of endometriosis", "summary": "Specialist surgical excision of endometriotic deposits with preservation of fertility where possible. Outcomes substantially better with surgeons specifically trained in advanced endometriosis surgery.", "sourceSlugs": [ "eshre-good-practice-ivf" ] }, { "name": "Hysterectomy with bilateral salpingo-oophorectomy", "summary": "Considered in patients who have completed family planning and have severe refractory symptoms. Hysterectomy alone does not always cure endometriosis if extra-uterine disease remains.", "sourceSlugs": [ "eshre-good-practice-ivf" ] } ] } ], "relatedProcedureSlugs": [ "ivf" ], "sourceSlugs": [ "eshre-good-practice-ivf" ], "clinicalOverview": { "sourceSlugs": [ "wikipedia-endometriosis" ], "signsAndSymptoms": "Endometriosis is a chronic condition in which endometrial-like tissue grows outside the uterus. Common symptoms include painful periods, chronic pelvic pain, painful sex, painful urination or bowel movements, fatigue, heavy menstrual bleeding and infertility, although some individuals have no symptoms while others experience severe, life-altering pain. The degree of pain is only weakly related to the anatomical extent of disease. Symptoms typically begin in adolescence or the early 20s and usually ease after menopause as oestrogen levels decline. Pain often follows a cyclical pattern, intensifying during menstruation, and may be accompanied by bloating, constipation, diarrhoea and nausea. Deep infiltrating disease in the bowel or bladder can cause obstruction and cyclical blood in the stool or urine.", "causesAndRiskFactors": "The cause of endometriosis is not fully understood. The leading theory for pelvic disease is retrograde menstruation, in which menstrual blood and tissue flow backward through the fallopian tubes into the peritoneal cavity; other proposed mechanisms include local transformation of peritoneal cells (coelomic metaplasia) and spread via the lymphatic or circulatory system. It is an inflammatory disease, and lesions can trigger adhesions, fibrosis and cysts. Genetics accounts for around half of the risk: a first-degree relative with the condition confers a three- to nine-fold higher risk, and around eighty genetic loci have been associated. Hormonal and immune dysfunction, and angiogenesis, are implicated. Risk factors include obstructed menstrual outflow, a first period before age 12, a menstrual cycle shorter than 28 days, low BMI, nulliparity, and exposure to endocrine-disrupting pollutants.", "diagnosis": "Endometriosis may be suspected in women with chronic pelvic pain, painful periods affecting daily life, pain during sex, cyclical bowel or urinary symptoms, or infertility. Assessment begins with a health history and physical examination, which may reveal nodularity or tenderness behind the uterus or reduced uterine mobility, though a normal examination does not exclude the disease. A presumed diagnosis can be made from symptoms combined with transvaginal ultrasound or MRI imaging, though not all lesions are visible on imaging. Laparoscopy (keyhole surgery) with biopsy remains the most accurate method and the gold standard, but practice has shifted away from requiring surgical confirmation to avoid treatment delays. There are no validated blood tests.", "epidemiology": "Endometriosis affects approximately 10% of women of reproductive age, corresponding to nearly 200 million girls and women worldwide; around 22 million had a surgically confirmed diagnosis as of 2021. It is typically diagnosed when women are in their 30s, although symptoms usually start in the early 20s or in adolescence. Up to 4% of women still have endometriosis after menopause, most commonly ovarian disease. Prevalence in trans men is comparable, at around 9%." } }, { "slug": "refractive-presbyopia", "name": "Presbyopia", "description": "Age-related loss of the lens's ability to focus on near objects, typically presenting in the 40-50 age range. Distinct from refractive errors of childhood and young adulthood (myopia, hyperopia, astigmatism). Treatment options range from reading glasses and contact lenses through to refractive lens exchange (RLE) and corneal procedures.", "treatmentLadder": [ { "tier": "conservative", "options": [ { "name": "Reading glasses or progressive lenses", "summary": "Optical correction for near vision. Lowest cost, reversible, no surgical risk. The default choice unless the patient has a specific reason to seek a surgical solution.", "sourceSlugs": [ "who-surgical-safety-checklist" ] }, { "name": "Monovision contact lenses", "summary": "One eye corrected for distance, the other for near. Most patients adapt but some experience reduced depth perception. Trial with contact lenses is the standard pre-surgical assessment.", "sourceSlugs": [ "who-surgical-safety-checklist" ] } ] }, { "tier": "procedural", "options": [ { "name": "Multifocal contact lenses", "summary": "Contact lenses incorporating multiple focal zones. Higher cost than monofocal lenses; not all patients tolerate the optical compromise.", "sourceSlugs": [ "who-surgical-safety-checklist" ] } ] }, { "tier": "surgical", "options": [ { "name": "Refractive Lens Exchange", "procedureSlug": "refractive-lens-exchange", "summary": "Clear lens extraction with implantation of a monofocal, multifocal, or extended depth-of-focus IOL. Permanent and prevents future cataract. Carries the small risks of any intraocular surgery and the optical compromises of any multifocal IOL.", "sourceSlugs": [ "who-surgical-safety-checklist" ] }, { "name": "Premium intraocular lens at cataract surgery", "procedureSlug": "premium-iol", "summary": "If presbyopia coexists with early cataract, treating both at once with a multifocal or extended depth-of-focus IOL can address both conditions in one operation. Patient suitability is the gating question.", "sourceSlugs": [ "who-surgical-safety-checklist" ] } ] } ], "relatedProcedureSlugs": [ "refractive-lens-exchange", "premium-iol" ], "sourceSlugs": [ "who-surgical-safety-checklist" ], "clinicalOverview": { "sourceSlugs": [ "wikipedia-refractive-presbyopia" ], "signsAndSymptoms": "Presbyopia is an age-related, progressive loss of the eye's ability to focus clearly on close objects. Most people notice changes in their near vision after the age of 40, which worsen until around 65. A common early sign is difficulty reading small print, prompting the person to hold reading material farther away; a cardinal complaint is \"short arms\", the inability to hold material far enough from the eyes to read clearly. Other symptoms include eye strain (soreness and tiredness of the eyes), headache, squinting and drowsiness during close-up tasks, and difficulty transitioning between near and far distances. Presbyopia generally does not affect the ability to focus on distant objects.", "causesAndRiskFactors": "Presbyopia is a normal part of ageing, and the main risk factor is being older than 40. It arises from age-related stiffening of the crystalline lens together with weakening of the ciliary muscle, so that the eye focuses light behind rather than on the retina when viewing near objects. With age the lens loses flexibility through progressive nuclear sclerosis, in which insoluble crystallin proteins aggregate and cross-link, making the lens too rigid to be reshaped for near vision by ciliary contraction. Premature presbyopia, with onset before age 40, is more likely in people with hyperopia, and is linked to certain medications (antihistamines, antidepressants, diuretics), diabetes, cardiovascular disease, multiple sclerosis, premature menopause, anaemia, prior eye or head trauma, and earlier surgery on the lens such as cataract surgery.", "diagnosis": "Presbyopia is diagnosed by a comprehensive dilated eye examination including a refraction assessment and an eye-health evaluation. In presbyopia the near point of accommodation is recessed beyond the usual reading distance, so the eye cannot focus at reading distance or closer. Slit-lamp biomicroscopy and ophthalmoscopy are used to assess the front and back of the eye and to check for co-morbidities such as cataract, glaucoma, macular degeneration or dry eye. Severity is categorised as mild (typically ages 40-45, +0.75 to +1.25 dioptres), moderate (ages 46-55, +1.5 to +2.25 dioptres) or advanced (over 55, +2.5 dioptres or more). Differential diagnoses include accommodative insufficiency and latent hyperopia.", "epidemiology": "As of 2015, the prevalence of presbyopia was 24.9%, or an estimated 1.8 billion people globally, projected to rise to 2.1 billion people by 2030. All people over 40 are at risk and become affected to some degree. Women over 40 have a higher prevalence than men, hypothesised to reflect differences in tasks performed and viewing distances rather than a physiological sex difference." } }, { "slug": "post-bariatric-skin-excess", "name": "Post-bariatric excess skin", "description": "After significant weight loss (typically more than 30 kg, often after bariatric surgery), the skin envelope does not fully retract, producing excess folds at the abdomen, arms, thighs, breasts, and back. The condition is a contributor to skin breakdown, hygiene issues, and reduced quality of life. Treatment is staged body-contouring surgery once weight is stable.", "treatmentLadder": [ { "tier": "conservative", "options": [ { "name": "Stabilise weight", "summary": "Most body-contouring surgeons require at least 12 months of stable weight before surgery, to minimise the risk of the skin envelope changing again. Compression garments and physical therapy can help in the interim.", "sourceSlugs": [ "who-surgical-safety-checklist" ] } ] }, { "tier": "procedural", "options": [ { "name": "Non-surgical skin tightening", "summary": "Radiofrequency and ultrasound devices marketed for skin tightening have limited efficacy in significant skin excess. Reasonable for mild cases; not a substitute for surgery in moderate to severe cases.", "sourceSlugs": [ "who-surgical-safety-checklist" ] } ] }, { "tier": "surgical", "options": [ { "name": "Body lift after major weight loss", "procedureSlug": "body-lift", "summary": "Staged body-contouring surgery typically beginning with the abdomen (lower body lift), followed by arms (brachioplasty), thighs (thighplasty), and chest depending on the patient's distribution. Each stage carries its own risk profile.", "sourceSlugs": [ "who-surgical-safety-checklist" ] }, { "name": "Arm lift", "procedureSlug": "arm-lift", "summary": "Excision of skin and subcutaneous tissue from the upper arm. Produces a visible scar; the trade-off is normally accepted by the patient at this stage.", "sourceSlugs": [ "who-surgical-safety-checklist" ] }, { "name": "Thigh lift", "procedureSlug": "thigh-lift", "summary": "Excision of medial thigh skin. Wound healing in this anatomical region can be slower than in other body-lift sites.", "sourceSlugs": [ "who-surgical-safety-checklist" ] } ] } ], "relatedProcedureSlugs": [ "body-lift", "arm-lift", "thigh-lift" ], "sourceSlugs": [ "who-surgical-safety-checklist" ] }, { "slug": "severe-male-pattern-baldness", "name": "Severe male pattern baldness", "description": "Advanced androgenetic alopecia in men, typically Norwood VI-VII, with extensive crown and frontal loss and a limited donor area. Distinct from earlier-stage hair loss in that the treatment goal is realistic distribution of a limited donor resource rather than full coverage. Treatment combines medical management to preserve the donor, hair-transplant surgery, and (in some cases) micropigmentation or hair systems.", "treatmentLadder": [ { "tier": "conservative", "options": [ { "name": "Topical minoxidil", "summary": "FDA-approved topical treatment with modest effect on density and good tolerability in most patients. Effect is lost on discontinuation.", "sourceSlugs": [ "who-surgical-safety-checklist" ] }, { "name": "Oral finasteride", "summary": "Prescription-only 5-alpha-reductase inhibitor. Effective at slowing progression but carries a small risk of sexual side effects that may persist; assess against the patient's priorities.", "sourceSlugs": [ "who-surgical-safety-checklist" ] } ] }, { "tier": "procedural", "options": [ { "name": "Scalp micropigmentation", "summary": "A cosmetic tattoo that mimics shaved hair. Permanent (within touch-up cycles), avoids the limits of donor area, and is often paired with shaved-head presentation in severe cases.", "sourceSlugs": [ "who-surgical-safety-checklist" ] }, { "name": "PRP for hair loss", "procedureSlug": "prp-hair-loss", "summary": "Platelet-rich plasma injections into the scalp. Evidence base for severe cases is limited; effect is gradual and requires repeat sessions.", "sourceSlugs": [ "who-surgical-safety-checklist" ] } ] }, { "tier": "surgical", "options": [ { "name": "Hair transplant (FUE)", "procedureSlug": "hair-transplant", "summary": "Follicular unit extraction from the donor area to the recipient site. Donor preservation is critical in severe cases; over-harvesting produces a visible donor depletion that cannot be reversed.", "sourceSlugs": [ "who-surgical-safety-checklist" ] }, { "name": "Sapphire FUE", "procedureSlug": "sapphire-fue", "summary": "FUE using sapphire-blade recipient channels. Marketed claim of improved healing; evidence base is mixed. Subject to the same donor-preservation constraints as standard FUE.", "sourceSlugs": [ "who-surgical-safety-checklist" ] } ] } ], "relatedProcedureSlugs": [ "hair-transplant", "sapphire-fue", "prp-hair-loss" ], "sourceSlugs": [ "who-surgical-safety-checklist" ], "clinicalOverview": { "sourceSlugs": [ "wikipedia-severe-male-pattern-baldness" ], "signsAndSymptoms": "Male-pattern hair loss is a form of non-scarring alopecia that affects the top and front of the scalp. It typically begins with a receding frontal hairline together with loss of hair over the crown and vertex, and in most cases the receding hairline is the first sign. As it progresses, a rim of hair at the sides and rear of the head remains, referred to as a \"Hippocratic wreath\", and it rarely progresses to complete baldness. This retained rim corresponds to advanced male loss, in which extensive crown and frontal loss leaves only a limited fringe of permanent hair from which any remaining coverage can be redistributed.", "causesAndRiskFactors": "Pattern hair loss is caused by a combination of male sex hormones and genetic factors, although the mechanism is not fully understood. Genetic changes make scalp hair follicles sensitive to androgens, with dihydrotestosterone (DHT) the major contributor at the dermal papillae; 5-alpha-reductase converts free testosterone to DHT and is highest in the scalp and prostate gland. Men with androgenetic alopecia typically have higher 5-alpha-reductase activity and higher free androgens, including DHT. Inheritance is strong, with around 80% of bald men having bald fathers, and insulin-like growth factor, oxidative stress and the scalp microbiome have also been implicated. Early-onset disease (before age 35) is associated with metabolic syndrome and insulin resistance, at roughly a four-fold increased frequency in younger men.", "diagnosis": "In men, the diagnosis of androgenetic alopecia can usually be established from the clinical presentation and the typical progressive pattern of hair loss. Trichoscopy can be used for further evaluation, and a biopsy may be needed to exclude other causes of hair loss, with histology demonstrating perifollicular fibrosis. Severity in males is graded using the Hamilton-Norwood scale, on which advanced male pattern baldness corresponds to the higher grades of extensive crown and frontal loss.", "epidemiology": "By the age of 50, pattern hair loss affects about half of males, and it is the most common cause of hair loss. Reported figures indicate that 30-50% of men have male androgenetic alopecia by age 50, with an estimated hereditary predisposition of around 80%. The association between androgenetic alopecia and metabolic syndrome is strongest in non-obese men." } }, { "slug": "gummy-smile", "name": "Gummy smile", "description": "Excessive gingival display on smiling, typically defined as more than 3 mm of gum visible. Causes include short upper lip, vertical maxillary excess, altered passive eruption, and hyperactive upper lip elevator muscles. Treatment depends on the underlying cause and ranges from botulinum toxin through to orthognathic surgery in severe cases.", "treatmentLadder": [ { "tier": "conservative", "options": [ { "name": "Lip-positioning exercises", "summary": "Limited evidence base. Reasonable trial in mild cases before any procedural option.", "sourceSlugs": [ "who-surgical-safety-checklist" ] } ] }, { "tier": "procedural", "options": [ { "name": "Botulinum toxin to lip elevators", "summary": "Injection of botulinum toxin into the muscles that elevate the upper lip. Effect lasts 3-6 months. The standard first-line procedural option in cases where the cause is muscular hyperactivity.", "sourceSlugs": [ "who-surgical-safety-checklist" ] }, { "name": "Gingival crown lengthening", "summary": "Gum-tissue recontouring (sometimes with bone removal) to expose more of the tooth crown. Permanent and effective where the cause is altered passive eruption.", "sourceSlugs": [ "who-surgical-safety-checklist" ] }, { "name": "Lip-repositioning surgery", "summary": "Limited mucosal resection to restrict upper-lip elevation. Reversible over time but more predictable than botulinum toxin in suitable cases.", "sourceSlugs": [ "who-surgical-safety-checklist" ] } ] }, { "tier": "surgical", "options": [ { "name": "Orthognathic jaw surgery", "procedureSlug": "jaw-surgery", "summary": "Maxillary impaction to address vertical maxillary excess. Major surgery; reserved for severe cases where the cause is skeletal and the patient's facial proportions are otherwise affected.", "sourceSlugs": [ "who-surgical-safety-checklist" ] } ] } ], "relatedProcedureSlugs": [ "jaw-surgery" ], "sourceSlugs": [ "who-surgical-safety-checklist" ] }, { "slug": "jaw-malocclusion", "name": "Jaw malocclusion", "description": "Misalignment between the upper and lower jaws — Class II (retrognathic mandible), Class III (prognathic mandible), open bite, or asymmetric — producing functional and aesthetic concerns. Treatment combines orthodontics and, in moderate to severe skeletal cases, orthognathic surgery.", "treatmentLadder": [ { "tier": "conservative", "options": [ { "name": "Orthodontics alone", "summary": "Fixed or clear-aligner orthodontics can address mild skeletal discrepancy and most dental malocclusion. Treatment time is typically 12-36 months.", "sourceSlugs": [ "who-surgical-safety-checklist" ] } ] }, { "tier": "procedural", "options": [ { "name": "Orthodontics with skeletal anchorage", "summary": "Temporary anchorage devices (mini-implants) enable orthodontic movement beyond what brackets alone achieve. Useful in borderline cases between orthodontics-only and surgery.", "sourceSlugs": [ "who-surgical-safety-checklist" ] } ] }, { "tier": "surgical", "options": [ { "name": "Orthognathic jaw surgery", "procedureSlug": "jaw-surgery", "summary": "Single-jaw (maxillary or mandibular) or double-jaw surgery, typically preceded and followed by orthodontic treatment. The standard treatment for moderate to severe skeletal malocclusion; outcomes can be marked but operative and recovery time are substantial.", "sourceSlugs": [ "who-surgical-safety-checklist" ] } ] } ], "relatedProcedureSlugs": [ "jaw-surgery" ], "sourceSlugs": [ "who-surgical-safety-checklist" ], "clinicalOverview": { "sourceSlugs": [ "wikipedia-jaw-malocclusion" ], "signsAndSymptoms": "Malocclusion is a misalignment or incorrect relation between the teeth of the upper and lower dental arches when the jaws close. It is a common finding that is not usually serious enough to require treatment, but more severe malocclusions, including those presenting as part of craniofacial anomalies, may require orthodontic and sometimes orthognathic surgical treatment. Reported consequences include tooth decay and periodontal disease arising from difficulty maintaining oral hygiene, an increased risk of trauma to anterior teeth where the overjet exceeds 3mm, difficulty chewing with anterior open bites or large increased and reverse overjet, speech impairment such as a lisp, tooth impaction, and effects on psychosocial well-being. Skeletal disharmony between the upper and lower jaws can distort facial shape and impair mastication and speech.", "causesAndRiskFactors": "The aetiology of malocclusion is multifactorial, with both genetic and environmental influences, and three causative factors are generally recognised. Skeletal factors concern the size, shape and relative positions of the upper and lower jaws; variations can arise from environmental or behavioural factors such as a childhood diet of soft, cooked food (producing smaller jaws), nocturnal mouth breathing, and cleft lip and palate. Muscle factors relate to the form and function of the muscles surrounding the teeth, influenced by habits such as finger sucking, nail biting, pacifier use and tongue thrusting. Dental factors include the size of the teeth relative to the jaw, and early loss of teeth causing spacing or crowding, abnormal eruption, hyperdontia or hypodontia.", "diagnosis": "Malocclusion is defined as any deviation of the occlusion from the ideal. Its classification, popularised by Edward Angle, is based on the relationship between the mesiobuccal cusp of the maxillary first molar and the buccal groove of the mandibular first molar; if this molar relationship is correct, the teeth can align into normal occlusion. Assessment should also take into account aesthetics and the impact on function, and where these are acceptable to the patient despite the formal definition being met, treatment may not be necessary. Severe malocclusions, which may present with skeletal disharmony between the jaws as part of craniofacial anomalies, generally require orthodontic and often orthognathic surgical evaluation.", "epidemiology": "Malocclusion is a common finding in the population, although it is not usually severe enough to require treatment. It is estimated that nearly 30% of the population has malocclusions that are categorised as severe and would definitely benefit from orthodontic treatment. Malocclusion can occur in both primary and secondary dentition." } } ]