1

Call to order and role call

@Jim Case

This meeting is being recorded to ensure that important discussion points are not missed in the minutes.  The recording will be available to the SNOMED International community.  Joining the meeting by accepting the Zoom prompt declares that you have no objection to your comments being recorded

2

Conflicts of interest and agenda review

@Jim Case

None recorded

3

Update on "Abnormality of X"

@Jim Case 

Discussion page at Re: Proper terming of "Abnormality of X (body structure)".

After reviewing HPO content that generated this issue, SNOMED will be looking to add these concepts as "Structural abnormality of X" for precision for HPO terms that refer to morphology. If the abnormality is also modeled as a congenital disorder, the FSN will include the word "congenital" in the FSN (e.g. "Congenital structural abnormality of bone"). For those HPO concepts that group both functional and structural abnormalities, they will be left in that form, e.g. HPO - Abnormality of the gastrointestinal tract has subtypes "Abnormal gastrointestinal tract morphology" and "Functional abnormality of the gastrointestinal tract".  Early testing of approaches for these grouper concepts has exposed an issue with the Functional disorder hierarchy and will need to be addressed in later tasks.

The focus for this issue is the terming for HPO concepts that represent structural abnormalities.

Discussion:

Seeking consensus for the terming approach. Do we need to add structural to the acquired concepts as well?  There are around 400+ of these already in SNOMED.  There are a large number of inconsistencies in the HPO terming.  Consider an alternative as morphological anomaly?  Would adding these now result in changes in naming down the road.  What do we we do with the concepts that appear as duplicates when added to the International release.  

There are inconsistencies within the terming of these concepts in the International release as well.  Need clearer guidance.  There are also inconsistencies in the use of anomaly, malformation and deformation.  

The meaning of "abnormal" in a clinical sense is a deviation from normal and may not be definable at a level other than abnormal.  The vagueness makes it difficult to resolve.  The downstream impact argues against adding the HPO terms at this time until the issues in the International release are resolved.  

Additional comments from @Monique van Berkum (Unlicensed) :

Open

Decision:

Hold off adding this content until clear editorial guidance is developed that can be applied to both international content and HPO.

3

Bypass graft and shunt modeling proposal update

@Victor Medina 

The analysis paper: Review of 48537004 |Bypass graft (procedure)| v0.2.0 is attached to this agenda. 

Previous discussion resulted in suggested edits to the following revised 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 reconstruction, using a biological or synthetic graft, of a
  structural defect to allow for a tension-free anastomosis.

• ANASTOMOSIS. Surgical procedure to create a connection between two tubular or hollow anatomic structures.

It was also proposed that the concepts 360021005 |Bypass - action (qualifier value)| and 424208002 |Shunt - action (qualifier value)| would be inactivated.  However, upon further testing, there were situations where the use of these two concepts were useful.  Alternative solutions are provided.

Discussion:

Decision:

Based on discussion, a review of the proposed model by SI to ensure that all of the proposed RGs are needed to express the meaning of bypass and shunt procedures is needed.  A task that provides examples and the results of the application of the proposed model will be made available to the EAG members to review and provide comments.  A decision to keep or inactivate the unidirectional shunt grouper terms will be made following review of the proposed modeling.

4

Endoscopy and endoscopic procedures

@Victor Medina 

An analysis document "Endoscopy, endoscopic procedure and related procedures" is attached for discussion.  The consistent distinction between an endoscopy and an endoscopic procedure is inconsistently represented as the initial distinction was made based on whether a procedure other than visualization was performed.  This is a difficult distinction to make as it is unknown when an endoscopy is performed whether an additional procedure will be added (such as a biopsy).  The proposal seeks to eliminate this false distinction as well as propose other modeling changes for this hierarchy.

Discussion:

The history of the distinction between Ednoscopy and Endoscopic procedure was presented.  As the new editorial guidance for this area of the terminology now requires the addition of an inspection RG, as opposed to being implicit for endoscopic procedure may make the need for the current distinction between endoscopy and endoscopic procedure mot, as all endoscopic procedures will contain an inspection RG.  The more constrained use of USING ACCESS DEVICE will be discussed.

Decision:

5

 Replacement procedures

@Victor Medina 

@Jim Case 

An analysis document "Review of the replacement procedure hierarchy" is attached for discussion.  The issues related to the use of a single concept "Replacement - action" to model replacement procedures are discussed an alternative modeling constructs proposed. Consistent use of the Procedure site attributes for Replacement procedures is also discussed. 

Discussion:

Continued to a future call

Decision:

6

Conversion procedures

@Victor Medina 

@Jim Case 

Conversion procedures primarily in the orthopedic space have been historically represented as two separate concepts: i.e. "Conversion from X" and "Conversion to X".  This mimics the approach taken in OPCS4 and was done ostensibly to prevent a large combinatorial explosion of terms that represented both aspects of a conversion procedure.  Recently SNOMED International has received requests for combined conversion procedures (e.g. Conversion from X to Y").  There are currently:

39 "conversion from" orthopedic concepts

44 "conversion to" orthopedic concepts

There are also conversion procedures related to laparoscopy where a procedure is converted from laparoscopic to open, as well as other procedures unrelated to the orthopedic domain.

The question to be answered is whether SNOMED should continue to represent orthopedic conversions using two concepts or whether we would allow combined conversion procedures?

The affected concepts are listed in the attached worksheet.

The number of combined concepts would not be a cross product of conversion from and conversion to concepts (i.e. 39 x 44 = 1716) as many are site specific.  For knee, for example it would be 4 x 6 = 24 combined concepts; for hip it would be 6 x 6 = 36 combined concepts, etc.

Discussion:

Continued to a future call

Decision:

Cellulitis

@Jim Case 

Cellulitis is most commonly caused by a bacterial infection; however, there are cases where it can be caused by fungal infections or even non-infectious causes.  The majority of definitions of cellulitis refer to it as a result of a bacterial infection as that is by far the most common clinical presentation.  SNOMED currently has 234 concepts under 128045006 |Cellulitis (disorder)| including a subconcept of 402929007 |Bacterial cellulitis (disorder)|.  Most concepts just state "cellulitis of X" resulting in the lack of subsumption under "Bacterial infectious disease".  It has been noted in the literature that the use of the term "cellulitis" in cases other than bacterial infections is a misnomer.  In many cases the causative agent is unable to be identified, so the disease is diagnosed on clinical signs and response to therapy.  Given the rarity of non-bacterial cellulitis conditions:

• Should SI infer that the common clinical usage of cellulitis as a bacterial infection is the meaning of "Cellulitis of X" concepts? 

• If so, would renaming and remodeling be considered a substantive change requiring inactivation and replacement?  

• If the FSN is changed to "Bacterial cellulitis of X", can the PT of "Cellulitis of X" be retained?

It is proposed that the current top level concept 128045006 |Cellulitis (disorder)| be retained in order to group the non-bacterial types under a common header.

References:

https://jamanetwork.com/journals/jama/article-abstract/2533510 "Cellulitis is a bacterial infection of the skin, presenting with poorly demarcated erythema, edema, warmth, and tenderness."

https://www.njmonline.nl/cntpdf.php?t=i&id=210#page=6 "Cellulitis is a bacterial skin and soft tissue infection which occurs when the physical skin barrier, the immune system and/or the circulatory system are impaired."

https://www.medical.theclinics.com/article/S0025-7125(21)00047-X/abstract "Cellulitis is a skin infection typically precipitated by entry of bacteria through a breach in the skin barrier"

https://www.clinicalkey.com/#!/content/clinical_overview/67-s2.0-7dabbf3c-ea31-4472-8aea-72dc2b003cab"Cellulitis is a spreading, acute bacterial skin infection of the dermal and subcutaneous tissue that presents clinically with skin erythema, calor, induration, and tenderness"

https://pmc.ncbi.nlm.nih.gov/articles/PMC5466351/ Fungal orbital cellulitis

https://pmc.ncbi.nlm.nih.gov/articles/PMC10058517/ Aseptic orbital cellulitis

Discussion:

Continued to a future call. Comments from EAG members below indicate a preference for maintaining the distinction between cellulitis of unspecified cause (whether bacterial or not) as there are many instances in which the offending organism is not identified.  This would be consistent with the open world view that the absence of a statement in an ontology does not imply that the statement is false in the real world (i.e. not bacterial).  This would leave the subhierarchy of 402929007 |Bacterial cellulitis (disorder)| as only subsuming concepts where the specific bacteria or bacterial class is specified in the FSN .

The problematic concept 130021000119100 |Cellulitis of nasal mucous membrane (disorder)|, which is modeled with a finding site that is not consistent with the text definition on 128045006 |Cellulitis (disorder)|, is being investigated as a potential erroneous concept as no authoritative references related to this concept have as yet been located.

10

AOB

EAG

11

Next meeting

@Jim Case