Jim Case

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Jim Case

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Jim Case 

SNOMED currently has extensive editorial guidance on terming patterns for disease combinations that involve the distinction of causal and temporal relationships between conditions.  One scenario that has not been adequately addressed is the representation of variably present clinical manifestations of a syndrome.  Syndromes often have multiple associated clinical manifestations that are variably present during the disease process or progression.  It is important to be able to specifically call out these conditions as being extant at the time of recording, i.e. they are not definitional for the syndrome in general, but are definitional at the time of clinical presentation.  An example is Bechet's disease, for which the pathognomic clinical presentation is oral ulcers, but other inflammatory conditions can occur with the disease (e.g. skin rashes, uveitis, arthritis, etc.).   

Current editorial guidance (Disorder Combination Modeling) suggests the use of "X with Y" as the FSN terming pattern.  Prior discussions have suggested that the use of terms such as "X with Y" and "X in Y" are too vague to represent the association of the condition with the syndrome.  The use of "X due to Y" has also been considered inappropriate as the condition is not caused by the syndrome, but is a variably present component of the syndrome.

• Jim Case to provide a list of affected concepts

Jim Case 

Exacerbations of a specific disease are currently mostly primitive concepts that are subtypes of the associated disease and variably assigned a CLINICAL COURSE  of "Acute on chronic" or "Sudden onset and/or short duration".  In developing a model for exacerbations, many external definitions do not specify that an exacerbation of a chronic disease is a subtype of the disease, but simply a finding associated with the underlying disease, i.e. an acute worsening of an already present condition, while others look at exacerbations as part of the clinical course of a disease.  We have looked at two different models for representing exacerbations:

1. Create new clinical course concepts: Exacerbation, Mild exacerbation, Moderate exacerbation, severe exacerbation as subtypes of 255212004 |Acute-on-chronic (qualifier value)|, with the following definitions:
   1. 255212004 |Acute-on-chronic (qualifier value)| - An acute (sudden onset) event superimposed on a pre-existing chronic condition. This be either a sudden worsening of a chronic condition itself (an exacerbation) or the development of a new, separate acute illness on top of a chronic disease.
   2. Exacerbation - A sudden worsening of symptoms or an increase in the severity of a chronic disease above what would be expected.
   3. These new clinical course concepts were added to concepts that explicitly stated "Exacerbation" in the FSN.
   4. Example:
2. Create a new primitive grouper concept - "Exacerbation of disease", modeled as an acute condition that would be used as the parent to all exacerbation concepts.  The relationship to the underlying chronic disease would be handled through an ASSOCIATED WITH relationship.  
   1. Example:

In the first approach, Exacerbations would classify as subtypes of the underlying disease.

In the second approach, the exacerbations would classify as a subtype of "Exacerbation of disease" and an "Acute disease".   

Given the historical position of exacerbations as subtypes of the underlying chronic disease, SNOMED would like advice on which pattern of modeling would be  most appropriate, i.e. retain the exacerbations as subtypes of the chronic disorder or be more in line with external definitions related to a finding related to a chronic disease

Monica Harry 

Angioplasty

Having completed extensive analysis, review and discussion, it has been agreed that removal of duplicate angioplasty concepts is in order; (details of discussions and consultation can be found here and on this EAG meeting page ):2024-06-03 SNOMED Editorial Advisory Group Conference Call

https://docs.google.com/spreadsheets/d/1s-CR8nBPOe-LuPdsJSqJSpUMp0uBKFuExTuPlSHCetE/edit?usp=sharing

100 concepts have been inactivated and can be reviewed here:

https://docs.google.com/spreadsheets/d/1s-CR8nBPOe-LuPdsJSqJSpUMp0uBKFuExTuPlSHCetE/edit?usp=sharingand 

Additionally, based on the procedure as demonstrated in the video linked here: https://www.nhs.uk/conditions/coronary-angioplasty/what-happens: https://www.nhs.uk/conditions/coronary-angioplasty/what-happens/

An FSN of:

Percutaneous Transluminal angioplasty of X blood vessel using [imaging] guidance with contrast has been added to those concepts understood to be procedures carried out in this same way. 

Discussion:

This also covers open endarterectomy as well as the percutaneous angioplasty concepts.  EAG members will look at the proposed inactivations to ensure the meaning are maintained.  In general the proposed changes are accepatble.  Details to follow.

Decision:

Nicola Ingram 

An updated Briefing note for transplantation procedures of both solid organs and tissues is provided.  An updated status report is also included below.

Discussion: Please read the short update document for today's EAG  attached for details (including numbers involved and inactivations). Excluded transplant procedure areas are described.

Here is a summary of the model:

Solid organ transplant procedures:

260686004 |Method (attribute)| = 410820007 |Surgical transplantation - action (qualifier value)|

405813007 |Procedure site - Direct (attribute)| = << 24486003 |Structure of transplant (body structure)|

363701004 |Direct substance (attribute)| = << 422285003 |Transplant solid organ (substance)|

For glands and viscera if required a new subtype of 24486003 |Structure of transplant (body structure)| was created. If no specific graft substances existed 261571005 |Tissue graft - material (substance)| was utilised (or 15879007 |Autograft (substance)|, similarly for allograft etc). See 119911006 |Salivary gland transplantation (procedure)| illustration on EAG update document. Any feedback comments?

The majority of tissue transplant procedure concepts (eg. nerves, muscle, tendon ,skin),  were inactivated as duplicate to the grafting procedure where this existed, or a new grafting procedure created. The transplant procedure was aded as a synonym to the grafting procedure and a normal body structure used as the procedure site plus a direct substance relationship as described above for glands and viscera.

Questions to be sent to Nicola Ingram and Jim Case for discussion and clarification at a future EAG call.

Decision:

• Jim Case to request view access to the TS browser for the EAG members to allow them to look at the remodeling impacts.

Victor Medina 

Jim Case 

At the March 2024 EAG call, the group asked for an impact analysis of the change from Surgical approach to a more general Procedure approach.  The results of that analysis were presented at the April 2024 meeting.  At the April face-to-face meeting a list of non-surgical procedures that might benefit from this change was requested and is attached (download to view as spreadsheet).  

Discussion:

Decision:

2024-04-16: Request to distribute list of non-surgical procedures affected by this change

2024-08-19:

• Victor Medina to distribute a list of non-surgical procedures affected by the proposed change

Jim Case 

Current and prior editorial policy for modeling of Events (<<272379006 |Event (event)|) stated that while the allowed attributes for events closely aligned with the Clinical finding concept model, editorial policy for using these attributes to model events were still under development.  However, one restriction has been applied and that is: "The Event hierarchy should not precoordinate periods of life/occurrence within the event concept."  It has been brought to our attention that there are a number of event concepts that do reference periods of life in which the event occurred.  Examples:

• 418189009 |Child abuse (event)|
• 242571000 |Accident due to neglect of child (event)|
• 12399091000119108 |Adult abuse (event)|
• 70055007 |Unexpected sudden death of adult (event)|
• 160957000 |Sudden infant death (event)|

A few of these have been modeled using the OCCURRENCE attribute in spite of the editorial guidance.  A member request has asked that we look at this policy as modeling of other concepts is being affected due to this restriction on modeling of events.  

Q: As  the OCCURRENCE attribute is currently an allowed attribute for EVENTS, should there be any restrictions on the use of these attributes.  If they should not be used, should the MRCM be modified to remove them from the allowed attributes set?

Discussion:

Decision:

Victor Medina 

Jim Case 

As requested from the EAG, a list of definitions has been developed that will guide content authors in the correct modeling of concepts related to bypass, bypass graft, shunt, etc.:

Proposal for definition of concepts under 48537004 |Bypass graft (procedure)|.
Proposal for Definitions.

• CONSTRUCTION OF BYPASS. Surgical creation of a passage to carry contents
  around a part of a structure in its normal route and back to a structure in its
  normal route.
• CONSTRUCTION OF BYPASS USING GRAFT. Surgical creation of a passage, using a
  biological or synthetic material, to carry contents around a part of a structure in its
  normal route and back to a structure in its normal route.
• CONSTRUCTION OF SHUNT. Surgical creation of a passage allowing contents to
  move from one structure to another, not following its normal route.
• CONSTRUCTION OF SHUNT USING GRAFT (SYN: INTERPOSITION SHUNT). Surgical
  creation of a passage using a biological or synthetic material, allowing contents to
  move from one structure to another, not following its normal route.
• INTERPOSITION GRAFT. A surgical repair, using a biological or synthetic graft, of a
  structural defect that does not allow tension-free anastomosis.
• ANASTOMOSIS. Surgical procedure to create a cross-connection between
  channels, tubes, fibers, or other parts of a network.

Discussion:

Decision:

2024-03-11 Comments will be added to the document by the EAG members. 

2024-04-16: Proposed definitions will be revised based on input and resubmitted to the EAG for review.  

2024-08-19:

• Victor Medina to revise definitions based on input from the EAG

Jim Case 

September 23, 2024