Conflicts of interest

Approval of minutes from Bratislava

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Current editorial guidance on the use of the Pathological Process Value = 257552002 Inflammation (qualifier value)

The current editorial guidance on the use of this process value eventually resulted in the need to distinguish between process and structure in the Morphologic abnormality hierarchy. E.g. 23583003 |Inflammation (morphologic abnormality)| vs. 409774005 |Inflammatory morphology (morphologic abnormality)|.

There is a tracker item: IHTSDO-558

Common pattern in classifications such as ICD.

One potential modeling pattern proposed is the use of the Situation model with one "known present" relationship group and one "known absent" relationship group.

The problem with specific negation is that it is silent about other clinical aspects that may be of significance.

What is the purpose of calling out one specific clinical manifestation?

Comments solicited from, CMAG.

We received a comment from a dutch lexographer:

Dear fellow terminologist(s),

I am the Dutch medical linguist currently in charge of checking translations of SNOMED terms into Dutch (as for the Netherlands, not for Belgium) on morphosyntactical rules. In 2015 I translated the IHTSDO translation guidelines into Dutch as an assignment by Nictiz, the Dutch release centre.

It occurs to me that in compound adjectives in many SNOMED terms, the dash has been left out:
– pacing induced cardiomyopathy = ‘a sentence in past tense stating that …’?
§ where I expect: pacing-induced cardiomyopathy = cardiomyopathy induced by pacing
– left sided atrium connecting to both ventricles > ‘lefties sitting next to…’?
§ where I expect: left-sided atrium

This will unintentionally render a collocation into a sentence, as in many cases the past participle is a homograph of the verb in past tense. In most cases however, the term will be interpreted correctly anyhow.

Why does SNOMED not follow commonly taught spelling rules in English? I do know that in informal American English this compounding dash has become somewhat uncommon. Likewise, the adverbial suffix ‑ly was abolished in the USA already a while ago. Possibly this dash will join its fate. Must SNOMED anticipate this? I feel that a mere spelling inaccuracy should not be a reason for terminologists to embrace it.

Likewise, the ISO 704 norm for terminology instructs that a term should not be capitalized without a reason. In Dutch we will spell stomach and not Stomach. As a lexicographer I come across this irrational, somewhat ‘American’ typesetting custom in a very few, mostly obsolete medical glossaries only. Has SNOMED International never considered running some semi-conditional routine for replacing an initial letter in upper case where not required with the letter in lower case?

Has SNOMED International been spending any thoughts on these two orthographical matters? I hope that you will be willing to share your thoughts on this with me. It will be interesting to be able to learn from each other’s expertise and practice!

Currently we have many concepts in the specimen hierarchy that include “from patient”as well as those that do not include it as an ancestor.  Since the subject of record is the default for specimens, we would like to retire these apparent duplicates, but then we run into the problem of specimens derived from other sources such as donors or normal control patients. 

They cannot be subtypes if the intended meaning is “subject of record”..or can they, since the context is implied?  How do we structure the specimen hierarchy to account for this? 

What are the analytical implications of having different sources for specimens as subtypes of one another?

The "soft" default of specimens originating from the patient is where the problem lies. Currently, the organization of the values for SPECIMEN SOURCE causes some specimens from patients to not classify under the grouper term "Specimen from patient".

Suggestion to make a more general term "Patient from specimen or donor", but that would only address two of the SPECIMEN SOURCE types.

KCA mentioned the many issues with the "soft default'. For the most part, these specimens are used as coming from the patient. However, does the FSN then need to be changed to reflect that these are from the patient? Does the PT need to reflect explicitly that it comes from the patient?

Should every Specimen have the SPECIMEN SOURCE explicitly defined? Often this context comes from where the concept is used within the record. The history of these terms may provide some of the reasoning as to why these terms were created. For example, the restrictions in where codes could be used in earlier versions of HL7 v2 (i.e. prior to v2.5) meant there was not place to provide additional information around the specimen. KCA suggested that these then be segregated into a module so that they can eventually be segregated away from the core.

Non-patient oriented specimens are the major issue now and many of the use cases still use the older transport structure, meaning they need pre-coordinated content.

What are the requirements for the addition of these terms and what is the major function of the core to address these requirements? More modern transport mechanisms such as FHIR, do not need this level of pre-coordination.

Comments from IMO indicated that most users of the terminology are not sufficiently sophisticated to use either terminology or model based post-coordination.

The long-standing practice of using unspecified Specimens provides substantial challenges to revising this to make it explicit as it would result in a large number of changes that may impact implementers.

A prosthesis can be infected (e.g. vegetation on a prosthetic heart valve). The need to associate a procedure with these would be unnecessary and in many cases incorrect. The use of a DUE TO relationship is not appropriate.

Currently, the involved concepts inherit ASSOCIATED WITH = Procedure from the parent "Complication associated with device", which should not have this relationship.

There are also timing aspects that are not represented in these terms, which make them more vague.

The associated problem is the need for a definition of what is meant by "infected device". If we view the presence of the device as just another acquired body structure, then these may not be complications. The timing of the infection in relation to a procedure, may be the reason to classify something as a Complication of a procedure (i.e. within a certain number of days).

The two approaches are "close to reality", which is multi-dimensional and challenging to determine, or "simplified model" that just describes what is certain. The determination of whether something is a complication or not is often unknown. Some testing will need to be done to see the impact of applying a simplified model. If it does not meet the needs from a classification standpoint, then a more complex model will be needed.

This argues for the use of ASSOCIATED WITH as the relationship for devices.

For the procedures such as "Removal of prosthesis due to infection" the possibility of the use of HAS FOCUS.

There are guidelines on the evaluation of patients prior to implantation, where pre-existing infection would cause abortion of the procedure.

Clarification on the current understanding of Complications can be found here.

• There are existing "Acquired X (morphologic abnormality)" concepts, but these are very much analogous to the "Congenital X" morphologies that we are trying hard to get rid of. 
• "Acquired" and "Congenital" are not morphologies, but timeframes.  We do not have a way of denoting "All periods of life after birth" like we do for "Congenital".  If we did, then we could create a fully defined concept grouper of "Acquired disorder", which would subsume all concepts that had any OCCURRENCE value later than "At birth", but then it would require that all acquired disorders have a valid OCCURRENCE relationship.
• This approach might also open the door that all disorders that are not specifically “Congenital” have an OCCURRENCE relationship stating that it is required, which seems to be “overmodeling”.  While we can use the "Acquired deformity" morphology concepts currently, due to the lack of many useful subtypes of "Acquired X" morphologies, it would only be a partial solution. 
• The HoT is not in favor of recreating the problem in "Acquired" concepts that would mimic the type of concepts we are trying to inactivate in the Congenital space.  However, the current guidance related to “Congenital” is not totally correct, because there are many conditions that can ONLY be congenital, even if the FSN does not state it (For example, aplasias or supernumerary structures).   So the guidance does need to be updated.
• One potential solution is to create a primitive grouper of "Acquired disorder" and then using that as the proximal primitive parent, adding the necessary relationships to make acquired disorders defined.  It is a kludge, but it would allow for full definition.

There are 690 "Acquired X" disorders in SNOMED CT. The vast majority are primitive.

There are three alternatives to discuss:

• Create an intermediate primitive grouper - "Acquired disorder" that would allow subtypes to be fully defined under. These would also classify under the appropriate parent term related to the disorder.
• Create a "period of life" subtype that included all periods except "fetal, congenital, and neonatal(?) (substantial testing of impacts would be needed)
• Create a set of "Acquired X (morphologic abnormalities)" to support definition of acquired disorders.

This demonstrates a need to support disjointness, which will hopefully be supported by the concept model in the near future. There are challenges with using period of life as a way to classify these. What is the use case to make the distinction between congenital and acquired. Used the example of "anodontia".

There is also the distinction between hereditary and "congenital", which are often conflated in disease naming. Hereditary diseases often manifest later in life. Would these be considered "acquired"? What do we mean when we say "acquired"?

Could limit the use of the period of life grouper for only those disease where the FSN specifies "acquired". Would diseases that manifest later in life but are actually genetic be incorrectly classified under acquired disorder (if that were created)? Would there be an advantage of having this top level grouper?

The challenge is how to represent the acquisition of the trait as opposed to the clinical manifestation of the trait.

Suggested that a new qualifier value of "Post-natal" be created to aggregate the periods of life that would be used to define "Acquired" conditions.

2017-11-03: A related tracker exists: PCP-71. The work related to this item will be linked to that tracker.

The Oxford comma is a comma added after the penultimate term in a list, e.g. For example "Disorder of head, neck, and shoulders". The purpose if its use is to make explicit the fact that the terms are part of a list. The editorial guide is silent about its use, but the example provided does not use the Oxford comma.

There are currently 347 FSNs in SNOMED CT that use the Oxford comma. Most of these are terms obtained from other terminology, such as ICD and nursing. There are 2500 FSNs that contain comma delimited lists, but do not use the Oxford comma.

Question:

Should SNOMED CT be consistent in the use of this grammar mark or maintain fidelity to the original source of the terms that do use it?

KCA expressed support for the Oxford comma. The question being whether there should be a retroactive application to FSNs. It does not change the meaning so would not be considered as a requirement for inactivation and replacement.

JRO was not in favor of using the Oxford comma where it does not add value. The challenge is to provide editorial guidance on what the conditions are that require its use or non-use.

Placement of "conditions" and "predispositions" as clinical findings as opposed to disorders. - BGO

Device disorder vs. device failure