Jim Case

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Jim Case

None recorded

Jim Case 

The EAG welcomes Dr. Jeremy Rogers back to the EAG after a hiatus and expresses their gratitude to Dr. Jeff Pierson for his service on the EAG for the last 6 years.

Jim Case 

Status of EAG discussed topics since April 2024:  Completed, In progress

• Modeling of "No known X" - Revision of Context values has not progressed.  Consensus on approach not yet reached
• Transplantation vs. grafting and Terming of Transplantation concepts - work has been completed for both solid organs and tissues
• Mechanical complication of device - Inactivation of concepts complete
• Replacement of "Surgical approach" with "Procedure approach - MRCM change and batch changes to concepts underway
• MRCM change and revision of Physical object hierarchy - Being discussed at this meeting
• Inactivation of 370115009 |Special concept (special concept)| - Pending inactivation of Navigational hierarchy
• Creation of new top level hierarchy for Generic products -  proposal in development
• Bypass graft revision proposal - document under review by the EAG, will be discussed at October meeting
• Remodeling of 1263452006 |Anesthesia and/or sedation procedure (procedure)| hierarchy - On hold pending input from the Anesthesia CRG
• USING DEVICE vs. DIRECT DEVICE use in procedures - Editorial guidance to be updated with examples
• Nontraumatic vs spontaneous injury - In process
• Proposed policy for Assessment Instruments in SNOMED CT International release - Published
• Reterming of "Percutaneous transluminal angioplasty " concepts and cleanup of hierarchy - complete, ready for review by EAG
• Naming pattern for components of clinical syndromes - proposal rejected
• Representation of Exacerbations - additional discussion needed

Nicola Ingram 

Jim Case 

At the September EAG call, it was suggested by the group that normal body structures be used instead of the transplanted body structures and that the direct substance relationship be removed unless it was necessary to sufficiently define the concept.  These changes have been made and are currently ready for review by the EAG in the TS browser (project QININ and tasks QININ-270, QININ-271).  It was also noticed that the top level concept 77465005 |Transplantation (procedure)| had lost a substantial number of subtypes following the remodeling efforts.  The EAG asked for more details on this loss of subtypes.  A worksheet detailing these changes for 89 affected concepts is attached.  (Please download before trying to review the content)

Discussion:

Feikje Hielkema-Raadsveld Daniel Karlsson 

At the November 2023 EAG call, a proposal to update the Physical object MRCM to allow for the modeling of containers was presented.  The EAG requested additional information as well as examples of the proposed modeling.  Feikje Hielkema-Raadsveld and Daniel Karlsson were provided with access to the SNOMED authoring platform to test their proposed model.  Questions that arose from this testing include:

• Should we group the attributes? We immediately ran into a problem grouping them. The MS discourages grouping attributes with the same type, but to create different role groups for each additive is very counter-intuitive. Are there other branches in SNOMED where this issue emerged, and what solution was adopted there?
• We propose a modification to our initial proposal: intended content should be specimen, not substance, to accommodate for instance container for 24 hour urine specimen
• Should we distinguish between blood collection tube and blood transfer tube? Why (not)? Our example project is working on the assumption that we drop that distinction.
• Should we distinguish between blood tube and blood container? If so, is the relevant distinction the shape or something else?
• We can model coagulation factors but not (yet) clot activators. We have left those concepts primitive, but we could model them by adding a disposition. Preferably one that can be grouped with coagulation factors. Is that worth doing? Those clot activators do pop up in every blood container branch.
• Do we want to want an attribute to dinstinguish between evacuated and non-evacuated containers, or do we keep those concepts primitive?

Discussion:

Comment from Matt Cordell 

Container modelling – “intended content should be specimen”, substance seems more accurate. If becomes a “specimen” in the container.
Consider the various blood collections – they all get whole blood put in them. but the tubes (with additives) produce different specimens, plasma, serum, whole blood, pack cells, buffy coat etc.
(Maybe there is a different attribute for input content, and contained substance?)

General comments:

Discussion on the use of substance vs. specimen.  The purpose of the model is to create models for pre-manufactured specimen specific containers.

The reason for the project is to address the need from some members to create a hierarchy of specimen containers to support European data projects and to allow for subsumption testing.  An issue that it would resolve is to allow specification of a container based on its characteristics in a FHIR model.  There are currently about 100 concepts that would be affected by this model.  This would allow for a cleanup of the container hierarchy as well.  Many of the concepts will require renaming or replacement.

What is the difference between a collection tube and a transfer tube?  May need to go back to GMDN to get definitions.  Their definitions may not be consistent with SNOMED.

Need more information on clot activators.  How to represent.  

Evacuated or non-evacuated containers.  Jim Case  stated this is an intrinsic characteristic of the container and should  be represented.

Concern expressed about the complexity of the model and its relationship to other attributes  that are already defined for devices.  Specific editorial guidance will be necessary to allow for proper and consistent use of a physical object concept model that needs to represent such a wide variety of objects.

2024-10-21

From Feikje Hielkema-Raadsveld 

• Grouping attributes: None of the Dutch clinical chemists was able to think of a container for which we'd need grouping to model it, e.g. a container that's partly evacuated or that has compartments with different additives. So it looks like we can simply not group attributes

• I found 4 findings and 30 procedures that use concepts that might be specimen containers

• E.g. < 71388002 |Procedure (procedure)|: << 405815000 |Procedure device (attribute)| = (<< 706437002 |Container (physical object)| OR << 434711009 |Specimen container| OR << 706036000 |Device for body fluid and tissue management (physical object)|)

• Most of those use the new concept cytology brush, which may not even be affected by the remodelling. So impact is very limited.

• Container vs. receptacle: I found 62 concepts with 'container' or 'receptacle' in one of the descriptions. It looks to me like 'receptacle' would work for all of them.

• Collection vs. transfer: the Dutch clinical chemists say that they can be different objects - so the naming does matter. If there is a transfer tube, a collection tube must have been used as well. However, it's the collection tube that is most relevant; they are not asking for separate concepts for transfer tubes. So we cannot rename these concepts but we could create concepts that do not specify either, or only create collection concepts.

• Evacuated and non-evacuated: there were scarcely any concepts in the Dutch list that specify whether the container is evacuated, and not that many in the X-eHealth list either. SNOMED on the other hand divdes almost all the blood tubes into those two groups. I asked the clinical chemists whether this information was important to record, and they said: The amount of vacuüm on a tube (you mean whether there is vacuüm on the tube?) can affect the amount of hemolysis. Special tubes have been developed with 'low vacuüm'. But should one exchange this kind of information? The amount of hemolysis also depends on for example the method of blood collection and the extent to which the tube is filled (the amount of rest vacuüm). 
  So this makes me rather curious why the existing SNOMED concepts all specify (non)evacuated; it does not seem to be a requirement from the clinical chemists.

• examples where compositional material matters:

  • Blood tubes can be made of glass or polyethylene (PET). Glas is supposed to preserve the liquid additive and vacuum better.

  • CSF (cerebrospinal fluid) tubes can be made of polypropylene (PP) or polystyrene (PS). Proteins tend to stick a little to PS but hardly to not at all to PP. For a substance such as CSF which contains small concentrations of proteins, using PS could lead to a negative significant effect of 'sticking proteins' . In our hospitals CSF is always collected in PP, then divided according to different material parts (PS or PP).

Decision:

Further discussion will be held at the October face-to-face meeting in Korea.

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:

Comment from Matt Cordell 

• Age-related events modeling - I’m OK with keeping occurrence for these. I think simply having “Abuse” or “Death” (for the examples loses much of the meaning). I know there’s implications the “periods of life/occurrence” range brings, but perhaps we need to accept this is the language people use.

Do we have a policy for the use of events or finding in definition of situations? 

Decision:

Agree that the removal of the restriction on the use of OCCURRENCE for events.  This should be applied to the entire event hierarchy WRT the application of OCCURRENCE.  A review of abuse modeling will be undertaken.

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.:

The relevant Briefing note is attached above.

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:

James R. Campbell  - Definition of ANASTOMOSIS: While the proposed definition is technically sound, I think it is not clinically correct.  I know of no surgical anastomoses that are constructed between fibers.  The structures involved are always tubular or channels, both with a lumen.  The purpose of the anastomosis is to connect the lumens for flow of gas or fluids between the two structures.  

There were a few comments around the definitions. What is meant by "cross-connection"? Definitions will be revised based on these comments (to be included).  Replace "cross-connection" with "connection".

Shunts and bypass will be subtypes of anastomosis.   

Why is an interposition graft considered a repair instead of a construction?  What is the difference between construction and repair?  Will be discussed in the next agenda item.  Will revise this definition based on the decisions from that item.  

How does proximal and distal anastomosis apply to non-tubular structures? Can we just use the term "repair" for these concepts?  

Jeff Pierson - I would suggest that tendon is not relevant to anastomosis.  It would be either a repair, transfer, or a graft. 

we will need to determine whether this applies to nerves well. 

There needs to be more editorial guidance with examples to correctly apply these definitions.  Can we determine whether it is beneficial to use anastomosis for all of these and adding a repair RG where needed. 

The clinical usage of the term anastomosis complicates the interpretation of its use in some domains, such as neurosurgery.  For non-tubular structures, may want to keep the term "anastomosis" in the description, but not use the term in the METHOD, and focus on the repair aspect.  This will require very specific editorial guidance for how to name and model this type of term.

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: Postponed

2024-09-23: Postponed to later meeting

2024-10-21: Definitions will be updated based on comments.  Agree that we can use proximal and distal anastomosis actions for anastomosis concepts. 

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

Changes have been made to the hierarchy and is ready for review by the EAG on the SNOMED CT Terminology server.  The SNOMED tech team will provide access to the project for review.  Comments must be sent to Monica Harry (mha@snomed.org) prior to October 31, 2024 for consideration.

Discussion:

Recognized that many of these procedures may be performed by methods other than fluoroscopy

Decision:

Request to make a working definition of what is meant by Angioplasty that can be applied to existing and future concepts.  Monica Harry will follow up with a revised BN.   An online vote will be taken from the EAG to avoid delaying moving forward with this project over the holidays.  

Guillermo Reynoso What is the plan for modeling measurement procedures?  Suggested that SI create a new model for measurement procedures. A new project group?  Project proposal?  What is the priority? Need to align with Observables.  Recommended to inactivate the existing attributes and build a new model.

There is agreement that there is a need for two hierarchies for multiple member countries, but an approach to make the measurement procedure fit for purpose has not been determined.

Also needed is a review of the international and extension drug models.  

Jim Case 

TBD