What's In A Name?
by Donna Castellone, MS, MT(ASCP)S • November 06, 2023
It has been well established that coagulation testing is complex. Compounding that is the confusing way that coagulation tests are named. When a laboratory test name is ambiguous it can lead to wrong ordering, missed interpretations which will impact diagnosis to the patient. Standardization is very important. The more complicated a test is the more likely it will be subject to naming issues.1 Problems in testing appear to have two root causes: the multiplicity of names and abbreviations for a test and the complexity of the nomenclature itself, including the absence of standardization.2
Coagulation tests are a prime opportunity for inappropriate testing and harms associated with inappropriate use of tests, misinterpretation as well as increased costs. Harm to patients include increased risk of exposure to blood products, additional investigations and referrals, as well as delays to patient care.3 For example in coagulation testing, the lupus anticoagulant is inappropriate, in particular since it is not a test for an anticoagulant but is actually a procoagulant and primarily found in patients who do not have systemic lupus erythematosus (SLE).2
Laboratories are federally required to use Logical Observation Identifiers Names and Codes (LOINC) to every test, but it doesn't have to actually be used for anything. The system itself has flaws and tests with different reference ranges can have the same code. Coagulation testing is among the categories that are problematic.1
FACTOR ASSAYS- ROMAN NUMERALS??
Prior to the 13th century, the Europeans used Roman numerals to do arithmetic. Trading was done using Roman numbers and calculations were fairly elaborate and used fingers or a mechanical abacus. The use of Hindu-Arabic numbers was done by the influence of Leonardo of Pisa, or more commonly known as Fibonacci in about 1202. He learned the mathematics developed by both Indian and Arabic mathematicians. He completed the first general purpose arithmetic book in the West, Liber abbaci, so that ordinary people could understand math.4
The International Committee for the Nomenclature of Blood Clotting Factors was established in 1954 to develop terminology in the coagulation field. At that time most factors were referred to in literature by multiple and unrelated names, with up to 14 terms being used for one of them. Most factors were named after the person who discovered them. Four years of deliberation resulted in the recommendation that Roman numerals be used to designate factors which defined each as distinct entity.
Factor I-IX were approved in 1957 and Factor X in 1959 and Factors XI and XII in 1961.5
The following criteria was used to determine a distinct entity for factors:
"(1) A factor in question should be considered to be distinct from other known coagulation factors on the basis of several physico-chemical properties, such as stability on storage, adsorbability by various agents, heat inactivation, stability to variations in pH, separability by conventional plasma fractionation methods, together with electrophoretic, chromatographic, and centrifugal techniques;5
"(2) the existence of pathologic states associated with abnormalities in the clotting mechanism, referable to abnormal activities of the entity in question;"5
"(3) availability of adequate assay methods."5
To date, therefore, the recommendations of the Committee are that the following terms be used for the designated blood clotting factors.
Factor I (Fibrinogen)
Factor II (Prothrombin)
Factor III (Thromboplastin)
Factor IV (Calcium)
Factor V (Ac-Globulin, proaccelerin, labile factor)
Factor VII (Proconvertin, Spca)
Factor VIII (Antihemophilic Factor)
Factor IX (Plasma throboplastin componeint-PTC)
Factor X (Stuart-Prower Factor)
Factor XI (Plasma thromoboplastin antecedent-PTA)
Factor XII (Hageman Factor)
DISCUSSION:
This brings us to the question regarding factor assays. Do we continue to use Roman numerals or do we switch to the Hindu-Arabic numerals? I took part in lively email discussion regarding this topic. The following arguments were delivered pro and con for changing or keeping Roman numerals.
CONS USING ROMAN NUMERALS:
Order errors from clinicians
Legibility issues for paper requestions.
Support interpretations of results.
People are not comfortable with Roman numerals, in particular new graduates.
PRO FOR KEEPING ROMAN NUMERALS:
Tradition, when you start to mix Roman and Arabic is F II or Factor 2? Or Factor XI or FII? Also, the 'parental' administration of 'parenteral' agents as another example of mixed context.
Accuracy, scientific standards, literature, and clarity.
How will data be retrieved from scientific databases in the future if this is adopted in manuscripts.
Roman numerals are considered as Unbiased numbering in science. In other parts of the world, Arabic numbers are called Western or European numbers.(Arabic numbers are different).
The HUGO Gene Nomenclature Committee (HGNC), the gene names are in Arabic numerals. Example: Approved symbol: F5, Approved name: coagulation factor V; Approved symbol: F8, Approved name: coagulation factor VIII. Arabic numerals for the factor genetic test results. Mixing both the factor activity results and the genetic test results can be confusing for physicians.
SOLUTIONS:
Should be able with your LIS to configure a test and mnemonic that would utilize both Roman and Arabic numerals, in which orders could be generated with searches for either, and the final report could be figured with tests reported as Roman numerals. However, when tests are mapped to the LIS the results can be 1:1 FVIII= F8 or one to many FVIII=F8, FAC8, 8 activity level, many to one or many to many, further complicating the testing process.2
Ordering coagulation tests are not prioritized training for residents. Studies have demonstrated that when properly trained and tested, scores testing knowledge went from 67% to 91% showing improvement with educational intervention.3
A solution is to have a laboratory-provider relationship when naming tests to address inconsistencies. Up to 10% of laboratory testing is lost or not understood properly, since they have called it one name, but in actuality it was tested under the correct name.1
CONCLUSION:
Can you guess my take on this? I am on team keep the Roman Numerals. As was stated in the email discussion, the Superbowl uses Roman Numerals, people have no trouble following that. I bet if Starbucks incorporated Roman Numerals, this generation would have no trouble at all using them. The original committee who developed the use of Roman numerals did state that there can be dangers in the solidification of concept and the desirability for change if new evidence warrants. A statement in the discussion was, "While I prefer the classical Roman numerals, I do see the advantage of using Arabic numerals. It's a new age, I guess."
References:
- Paxton, Anne, Many knots to untangle in lab test names, CAP Today, September 2023,
- Passiment E, Meisel JL, Fontanesi J, Fritsma G, Aleryani S, Marques M. Decoding laboratory test names: a major challenge to appropriate patient care. J Gen Intern Med. 2013 Mar;28(3):453-8.
- Nadia Gabarin, Martina Trinkaus, Rita Selby, Nicola Goldberg, Hina Hanif, Michelle Sholzberg, Coagulation test understanding and ordering by medical trainees: Novel teaching approach,Research and Practice in Thrombosis and Haemostasis, Volume 6, Issue 4,2022.
- Devlin, K, The Man of Numbers: Fibonacci's Arithmetic Revolution [Excerpt] Scientific American, March 8, 2013.
- Wright IS. Special report: the nomenclature of blood clotting factors. Can Med Assoc J. 1962;86:373–374.
- The FRITZMA FACTOR, https://fritsmafactor.com/arabic-numerals/, September, 8 2023.