Nontraumatic vs. Spontaneous injury
We have noticed an inconsistency in our review of nontraumatic vs. spontaneous injury. In some cases we make a distinction between them:
1296953008 |Nontraumatic rupture of extensor tendon of left hand (disorder)|
321371000119100 |Spontaneous rupture of extensor tendon of left hand (disorder)|
whereas in other cases we treat them as synonymous:
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In determining the meaning of nontraumatic vs. spontaneous, we have found that nontraumatic means injury not caused by an external force and could occur with or without premonitory signs or symptoms, whereas "spontaneous" injuries usually refer to acute injuries without premonitory signs or symptoms.
The primary question is whether in general clinical practice this distinction has value, and if so, 1) should SNOMED explicitly separate out concepts where spontaneous injury is expressed as a synonym for nontraumatic and 2) should SNOMED create nontraumatic injury concepts as parents to spontaneous injuries where a nontraumatic parent does not currently exist?
Comments
The original application of this was to address issues with structural inconsistencies in the injury hierarchy in the QI project and while we did address the difference in the ed guide superficially, based on the FSN, I agree that the guidelines are not clear as to why the distinction is being made. Addition of the specific characteristics of spontaneous, vs. nontraumatic might make this clearer. From a clinical perspective, I think nontraumatic would most often be used, as it subsumes spontaneous injury, but then spontaneous injury concepts would be available when the distinction is desired. Not trying to bias the discussion regarding the direction of travel, just providing my opinion.
From @Feikje Hielkema (Unlicensed)
I have had a look through our translations and translation guidelines. For the most part, we have translated these terms literally, copying the English inconsistency and occasionally introducing some more inconsistency ourselves - as one does.
Spontaneous appears to be a negative concept, that you use when there is no external cause. In non-injury concepts, this excludes for instance infectious causes; in injury concepts, it is less clear what such causes might be. If there are no other identifiable causes for an injury other than a trauma the distinction between spontaneous and non-traumatic is moot and in those cases the terms are used interchangeably.
The Netherlands has an explicit guideline that says to translate spontaneous haemorrhage or non-traumatic haemorrhage both as PTN niet-traumatische hemorragie SYN spontane bloeding. I.e. the guideline specifically recommends non-traumatic haemorrhage and sponteneous haemorrhage as synonymous.
Non-traumatic rupture has usually been translated in the same manner: PTN niet-traumatisch, SYN spontaan. However, when searching through SNOMED's concepts concerning spontaneous rupture, I believe I saw some exceptions in cases where an iatrogenic event is another likely cause:
Prolonged spontaneous rupture of membranes - The other usual cause for ruptured membranes is iatrogenic and deliberate, I would hope a traumatic cause is quite rare; to distinguish between non-traumatic and traumatic would be quite confusing with respect to ruptured membranes.
Spontaneous rupture of esophagus (Boerhaave syndrom) https://www.ncbi.nlm.nih.gov/books/NBK430808/ Boerhaave syndrome is usually not truly spontaneous, but this term helps distinguish it from iatrogenic perforation. Vomiting is the most common cause, but any activity that increases intraesophageal pressure can result in this syndrome.
An injury with iatrogenic cause is certainly not spontaneous. But I am not sure: does iatrogenic count as traumatic, or as non-traumatic? Or neither?
All this I'm afraid is not particularly helpful in resolving on a course of action. I think there are many concepts, e.g. the haemorrhages, where spontaneous injury comes down to the same thing as non-traumatic injury and thus would make a proper synonym. But those are exceptions to the more general rule that a spontaneous disorder is more specific than a non-traumatic disorder; I fear we would have to identify the exceptions by examining them case by case. On the bright side, only 41 descendants of < 1119219007 |Nontraumatic injury (disorder)| have 'spontaneous' in a description. To answer Jim's original questions:
1) should SNOMED explicitly separate out concepts where spontaneous injury is expressed as a synonym for nontraumatic
Only if there is a usecase for that spontaneous injury as a separate concept. Please leave those haemorrhages as they are.
and 2) should SNOMED create nontraumatic injury concepts as parents to spontaneous injuries where a nontraumatic parent does not currently exist?
If it is a concept where spontaneous is in effect synonymous with non-traumatic, you would be better off changing the FSN or replacing it. Concepts such as 1088181000119100 |Spontaneous rupture of tympanic membrane of left ear co-occurrent and due to recurrent acute suppurative otitis media (disorder)| do refer to the more specific spontaneous and non-traumatic would I think just confuse. I have not managed to find a concept where an additional non-traumatic variant would be helpful.
Feikje,
Thanks for the comments. From what you have said, in many cases, the distinction between nontraumatic and spontaneous does not provide much added benefit. ICD-11 classifies iatrogenic injuries as traumatic (e.g. Iatrogenic pneumothorax is a subtype of Traumatic pneumothorax) as they refer to external causes. It is interesting that in the case of 1088181000119100 |Spontaneous rupture of tympanic membrane of left ear co-occurrent and due to recurrent acute suppurative otitis media (disorder), this concept does not comply with our understanding of spontaneous referring to a lack of premonitory signs. It is mapped to an ICD-10 complex map that references the residual class H72.9 Perforation of tympanic membrane, unspecified (with an index term of "Rupture, ruptured eardrum, nontraumatic). Nor is it modeled with a DUE TO = Spontaneous event. So there is an implied synonymy between nontraumatic and spontaneous in this concept.
It is still not clear whether the distinction provides benefit, but additional questions remain:
If they can be considered synonymous, what should the FSN and PT be? "Spontaneous" is used as commonly in clinical parlance as "Nontraumatic".
Does SNOMED CT "Need" to be consistent in this regard (i.e. terming)?
Should separate concepts that distinguish spontaneous and nontraumatic for the same condition be combined as a single concept?
From @Jeff Pierson (Unlicensed)
Great discussion. Attached is an analysis, which may or may not be helpful.
Jim, I agree with Monique that having clear definitions should help us to determine if there is synonymy and how to move forward.
Also, all things being equal, I think “nontraumatic” is better as an FSN because “spontaneous” is harder to pin down.
From @Monique van Berkum (Unlicensed)
Perhaps this has already been decided? I haven’t thought about it enough to know whether I agree, but the Editorial guidance below seems to imply that “Spontaneous injury” is distinct from |Non-traumatic injury|. 789750003 |Spontaneous event (event)| was added to SNOMED in 2020 and is used with DUE To 112 times in the stated view. Not all uses are for concepts that descend from |Non-traumatic injury|.
Even if these terms are used in clinical practice, I don’t think that most clinicians would appreciate the distinction between non-traumatic and spontaneous based the latter not having premonitory signs or symptoms. The guidance below implies that “Spontaneous injury” means injury with no underlying mechanism. If this distinction is maintained for injuries going forward, the difference between “Spontaneous injury” and |Non-traumatic injury| would need to be more clearly articulated.