Embracing the Prepositional Power of Because of and Due to

Jennifer Clare Ball, MA, JAMA Network

The recent acceptance of due to as a prepositional phrase by the AMA Manual of Style (Chapter 11.1, Correct and Preferred Usage of Common Words and Phrases) is a noteworthy development with substantial implications for professional writers and editors.1

The previous recommendation against its use in this way had sparked debate among grammarians and language enthusiasts, some of whom argued that it should only be used as an adjective phrase modifying a noun.

The relaxation of grammar rules, such as the new guidance on because of vs due to, can positively and negatively affect language depending on the context in which it is used. While it can increase flexibility for writers and make the language more accessible to nonnative speakers, it may also reduce clarity and consistency in some cases. Thus, the creation of official guidance in the AMA Manual of Style is crucial.

The etymology of because of and due to is also worth exploring.2 Because was modeled on the French par cause and has been used with the word of since the late 14th century.

On the other hand, due is from old French deu, past participle of devoir, meaning “to owe.” Due to came about in the early 15th century as “deserved by, merited by,” and its use as a prepositional phrase dates back to 1897.

Current guidance now indicates that because of, caused by, due to, and owing to are acceptable to use as prepositions without restriction.

To illustrate the use of due to in medical writing, below are examples from various JAMA Network articles in which the phrase can now be used interchangeably with because of as a prepositional phrase.

The acceptance of due to as a prepositional phrase by the AMA Manual of Style is a notable milestone in the ongoing debate over its use. It provides greater flexibility for writers and editors while ensuring consistency and clarity in medical writing and other communication formats that follow AMA style.

  • The AMA Manual of Style now accepts “due to” as a prepositional phrase, which impacts authors and medical editors.
  • The debate over “due to” was sparked by its previous disallowance in many instances; some argued for its limited role.
  • Relaxed grammar rules can enhance flexibility and accessibility, but may compromise clarity; this highlights the significance of AMA accepting this change.

References

  1. Frey T, Young RK. Correct and preferred usage. In: Christiansen S, Iverson C, Flanagin A, et al. AMA Manual of Style: A Guide for Authors and Editors. 11th ed. Oxford University Press; 2020. Accessed February 17, 2023. https://doi.org/10.1093/jama/9780190246556.003.0011
  2. Online etymology dictionary. Accessed February 17, 2023. https://www.etymonline.com/
  3. Srinivas M, Wong NS, Wallace R, et al. Sexually transmitted infection rates and closure of family planning clinics because of abortion restrictions in iowa. JAMA Netw Open. 2022;5(10):e2239063. Published October 3, 2022. doi:10.1001/jamanetworkopen.2022.39063
  4. Martinez FJ, Han MK, Lopez C, et al. Discriminative accuracy of the CAPTURE tool for identifying chronic obstructive pulmonary disease in US primary care settings. JAMA. 2023;329(6):490-501. doi:10.1001/jama.2023.0128
  5. Wang J, Lee CC, Kesselheim AS, Rome BN. Estimated Medicaid spending on original and citrate-free adalimumab from 2014 through 2021. JAMA Intern Med. 2023;183(3):275-276. doi:10.1001/jamainternmed.2022.6299

September 5, 2023.

Do Changes Actually Create Change?

Amanda Ehrhardt, MA, JAMA Network

Part of the purpose of the AMA Style Insider is to report on changes made in the AMA Manual of Style that aim to improve not only the editing process but also advance ethics and equity in medical publishing. Changes are not made arbitrarily but as a result of many experts building consensus on what represents best practices, and they’re made to create a widespread standard.

However, the manual can only release these standards to the world–what requires more follow up is whether the changes are actually implemented in publishing and how successful they are in creating new standards.

This year, in JAMA Network Open, several JAMA Network editors and staff published a cross-sectional study1 that examined race and ethnicity reporting across 3 JAMA Network journals before (January to March 2019 and May to July 2021) and after (January to March 2022) the implementation of the Updated Guidance on the Reporting of Race and Ethnicity in Medical and Science Journals2 in August 2021 (which was based on revisions made to 11.12.3 of the style guide).

Among the key takeaways were that the number of articles that reported race and ethnicity information for study participants increased by 10.4% from 2019 to 2022, more articles reported participants’ age or sex and gender, and the number of articles that defined categories included in the term “other” increased 58.1% from 2019 to 2022.

Additionally, the number of articles that listed racial and ethnic group categories by alphabetical order increased by 75.9% between 2021 and 2022, and there was a 24.1% increase in the number of articles that defined how race and ethnicity were determined.

Although this study had limitations (which are clearly stated in the article) and more improvement is needed, these results seem encouraging that AMA Style Manual updates are not made just to alter the day-to-day of editors across medical publishing, but to potentially create real and lasting change.

References

  1. Flanagin A, Cintron MY, Christiansen SL, et al. Comparison of reporting race and ethnicity in medical journals before and after implementation of reporting guidance, 2019-2022. JAMA Netw Open. 2023(6):e231706. doi:10.1001/jamanetworkopen.2023.1706
  2. Flanagin A, Frey T, Christiansen SL, et al. Updated guidance on the reporting of race and ethnicity in medical and science journals. JAMA. 2021;326(7):621-627. doi:10.1001/jama.2021.13304

September 5, 2023.

The AMA Garden of Hyphens

Timothy Gray, PhD, JAMA Network

If your professional life requires adherence to AMA style, you may have gotten lost in the weeds styling hyphenated compounds in titles. No capitalization after a hyphen if a prefix or a suffix, if both parts are considered a single word (requiring a field trip to Merriam-Webster), if the compound is temporary, or if the parts do not carry equal weight.

I have long wondered how parts of a compound carry weight, which isn’t to say that I don’t like the idea. As a practical suggestion, though, it lacks a little, uh, practicality.

If you think of a compound as an entity on its own, any word that may carry weight because of its particular part of speech loses that identity (and drops the weight!) when it gets pulled into that magical realm of a hyphenated compound (all adjectives all the time). So “Short-term Effects” and “Full-time Coverage” have always read as weird to me, especially if they have appeared near “Early-Onset Disease.”

How fitting, then, that the AMA Manual of Style has finally addressed the weed problem with hyphenation. No need to kill them. We can just get them out of our way. Let the weeds live happy lives in some other organization’s style manual.

The new guidance in 10.2.2 reads “In titles, subtitles, and text headings, capitalize both parts of a hyphenated compound.” Hence, “Short-Term Effects” and “Full-Time Coverage.” Take a look in the online manual for more information and other new style guidance.

Now when you review capitalization in titles with hyphenated compounds to align with AMA style, you needn’t make excursions to other sources. You can stay in the AMA garden without getting lost in the weeds.

Published August 1, 2023.

New Mpox Name for Monkeypox Disease

Stacy L. Christiansen, MA, Managing Editor, JAMA

The recent outbreak of monkeypox disease (caused by the monkeypox virus), like COVID-19 and other pathogens before it, raised concern about disease names, particularly those that could negatively affect particular nations, populations, or animals.

The naming of diseases (and in this case, renaming) falls to the World Health Organization (WHO). After reports from individuals and countries raised concerns about the term “monkeypox” being racist or stigmatizing, the WHO met with concerned parties and invited public comment to rename the disease.1

The result is “mpox.”

The AMA Manual of Style will add the term “mpox” to the viruses section in the Nomenclature chapter (14.14) as well as information about the renamed clade I and clade II (formerly Central African and West African, respectively).2

We recommend dual reporting, such as mpox (monkeypox), at first mention to ease adoption of the new terminology. Other organizations, such as the Centers for Disease Control and Prevention3 and AP Stylebook,4 have also announced their adoption of the updated terminology.

The monkeypox virus name has not yet been changed. The International Committee on the Taxonomy of Viruses is responsible for that terminology,1 and when new nomenclature is announced we will update the Manual accordingly.

References

  1. World Health Organization. WHO recommends new name for monkeypox disease. Accessed December 1, 2022. https://www.who.int/news/item/28-11-2022-who-recommends-new-name-for-monkeypox-disease
  2. World Helath Organization. Monkeypox: experts give virus variants new names. Accessed December 1, 2022. https://www.who.int/news/item/12-08-2022-monkeypox–experts-give-virus-variants-new-names
  3. US Centers for Disease Control and Prevention. Monkeypox. Updated November 30, 2022. Accessed December 1, 2022. https://www.cdc.gov/poxvirus/monkeypox/index.html
  4. The Associated Press. mpox. AP Stylebook. November 30, 2022. Accessed December 1, 2022. https://www.apstylebook.com/ap_stylebook/mpox

A Short Update on Long COVID

Stacy L. Christiansen, MA, Managing Editor, JAMA

After infection with SARS-CoV-2, some people develop long-term effects. This condition has been termed post-COVID conditions (PCCs), post-COVID syndrome, postacute sequelae of SARS-CoV-2 infection (PASC), and in common parlance, long COVID.1

Which term to use will depend on the content and the intended audience. The ICD-10 code principally uses the term post COVID-19 condition.2,3

In the JAMA Network journals, we prefer post–COVID-19 condition (PCC), with allowance of long COVID for colloquial use (eg, in narrative or patient-focused content). Note that “long” is lowercase.

Avoid jargon terms, such as “long haulers,” in clinical or scientific content. The online style manual will be updated to include this terminology in chapter 11.1, Correct and Preferred Usage of Common Words and Phrases.

References

  1. US Centers for Disease Control and Prevention. Long COVID or post-COVID conditions. Updated September 1, 2022. Accessed October 28, 2022. https://www.cdc.gov/coronavirus/2019-ncov/long-term-effects/index.html
  2. US Centers for Medicare & Medicaid Services. Post COVID-19 condition: ICD-10-CM official guidelines for coding and reporting. Updated April 1, 2022. Accessed October 14, 2022. https://www.cms.gov/files/document/fy-2022-icd-10-cm-coding-guidelines-updated-02012022.pdf
  3. World Health Organization. Coronavirus disease (COVID-19): post COVID-19 condition. Accessed October 14, 2022. https://www.who.int/news-room/questions-and-answers/item/coronavirus-disease-(covid-19)-post-covid-19-condition

Pregnancy Language Update

Iris Y. Lo, BA, JAMA Network

The AMA Manual of Style will soon offer guidance on inclusive language when referring to people who are pregnant or people with the capacity for pregnancy.

This wording has more general use and can include individuals who were assigned female at birth, transgender men, nonbinary individuals, gender-nonconforming individuals, and gender-fluid individuals–basically anyone who is physically able to become pregnant.

This language should be used when study investigators have not explicitly asked participants to self-identify their gender. In studies in which participants have all identified as women, it is appropriate to use terms like pregnant women.

However, if study participants have not completley self-reported their gender as women, terms such as pregnant participants, pregnant individuals, and pregnant patients are more accurate. In these cases, birthing parent rather than mother is a more accurate term and should be used for the same reasons.

The JAMA Network has internally started to follow this guidance, joining many other scientific journals, such as Nature, and medical associations and societies, such as the Society for Maternal-Fetal Medicine. The US Preventive Services Task Force also uses this type of language.

Style vs Substance—Is There Room for Both?

Peter J. Olson, ELS, JAMA Network

There’s a scene in the film Pirates of the Caribbean: The Curse of the Black Pearl in which the heroine, Elizabeth, is taken captive by the infamous Captain Barbosa aboard his ship. In an attempt to negotiate her release, she invokes the Pirates Code, a set of rules to which she knows Barbosa is beholden. Barbosa initially appears to comply, then abruptly reneges. When Elizabeth protests his disregard for the Code, Barbosa defends his decision with a snide retort:

“The Code is more what you’d call guidelines than actual rules.”

His deviousness aside, the Captain has a point. As humans, we have an innate tendency to create rules with the intent of establishing order and certainty, yet those rules are occasionally subject to exceptions, inapplicability, and multiple interpretations. Try as we might, it’s virtually impossible to anticipate every possible scenario and account for it, which means there will be times when the rules we make for ourselves simply do not apply—and editorial style rules are no exception.

The question is: does style always supersede substance?

The AMA Manual of Style is a renowned and authoritative reference manual, and for good reason. It’s a meticulously crafted, oft-updated repository of linguistic and stylistic information steeped in authentic medical language and policy, and the guidance within its pages is critical to physicians, authors, and editors alike.

In that sense, the argument could be made that when it comes to the AMA Manual, style is substance. However, as editors, we at times find ourselves in scenarios in which adhering to a particular style point is akin to the proverbial placement of a square peg in a round hole. The gadget doesn’t quite fit into the device, and the results can be ugly. It’s those circumstances in which the absence of a peg may be preferable to the sight of a horribly splintered one.

What’s more, rules are almost always subject to change, and depending on the impetus behind an amendment, it can take the purveyors of a style manual weeks, months, even years to discuss and formulate a responsible and sustainable update before disseminating it to the manual’s users.

Take the topic of race and ethnicity language (Chapter 11.12.3), which continues to evolve at an unprecedentedly rapid pace—enough so that the requisite section in the AMA Manual was updated less than a year after the release of the 11th edition.1 Language and terms that may have been deemed acceptable just months previously may shift suddenly, and the intuitive and attentive editor may need to set aside current style guidelines to align with cultural and/or societal trends.

That said, style deviations should be made only after careful consideration of the potential ramifications, especially those involving reader perception. In other words: if you’re going to deviate from style, you’d better have a really good explanation ready.

Authors are often quick to point out style infractions in previously published material, either to defend their own infringements or to object to style-adherent edits (“If this author got to do it, why can’t I?”), and trivial or inexplicable noncompliance can undermine the authority of your style manual as well as your publication. If you can’t justify a style detour that goes beyond “I just thought it sounded better that way,” you probably shouldn’t take it.

Fictional though he may be, I expect that Captain Barbosa fully honors the Pirates Code—he is a pirate, after all. Yet even he knows to adapt the rules when necessary to achieve his goals. This is not to suggest that editors should swashbuckle their way through a manuscript, playing fast and loose with the style rules they’ve sworn to uphold. Those rules are there for a reason, and they wouldn’t exist if they didn’t almost always apply.

However, absolutism is fraught with its own perils, and the astute editor must be mindful of those rare situations in which a rule may need to be bent—or perhaps broken—for the greater good. And although there’s no single, comprehensive answer to the question of whether and when to sacrifice style for substance, if preserving the integrity of a publication is given precedence, the answers will at least be easier to identify.

Reference

  1. Frey T, Young RK. Race and ethnicity. In: Christiansen SL, Iverson C, Flanagin A, et al, eds. AMA Manual of Style: a Guide for Authors and Editors. 11th ed. Oxford University Press; 2020:545-547.

Icons at the JAMA Network

Nancy Essex, Director, Brand Design, JAMA Network

Good things in small packages: JAMA Network visual abstract icons

Serena Williams. The Nike swoosh. The bald eagle.

What comes to mind when you think of the word “icon”? A tennis superstar, a ubiquitous consumer brand logo, a nation’s official symbol?

You’d be right, of course. When we use the word icon around JAMA Network lately, it usually suggests those adorable line drawings on our visual abstracts that represent some of your favorite things, like catheters, IV bags, and dermatitis.





(If you’re not familiar with visual abstracts, please visit this overview page. It’s ok, we’ll be here when you get back.)

What is an icon?

An icon can be defined as an emblem or symbol, a pictorial representation of a thing. We are all familiar with software icons, like the envelope, trash can, and folder. Icons are also important in wayfinding and signage–can you imagine being in an airport in a country whose language you don’t speak, trying to find the bathroom without them?

Icons need to be general enough so we don’t have to create a new one for each visual abstract. For instance, a torn meniscus and osteoarthritis of the knee could be represented by a single knee icon.

Of course, those conditions are completely different, but in the context of our visual abstracts, a simple knee icon is often all that’s needed to communicate the basic idea of knee condition.

Details make the design, but not too many details

Icons are an important part of the visual vocabulary used in visual abstracts. To keep everything consistent, we developed the following criteria to guide icon development:

  • Simplicity
    • When it comes to icons, the simpler the better. The viewer should almost be able to sight-read an icon, and so icons must be recognizable with as little detail as possible. Plus, they are small to begin with, so too much detail would make them unreadable blobs when viewed in context on Twitter, for instance.
  • Scale and size
    • Icons are created on a 72px square field— that’s just 1 square inch— to represent interventions, population, and conditions, and on a 32px square field for settings and locations. They are always used in the same size and never scaled up or down.
  • Line quality
    • Icons use a consistent 2px line weight throughout. On a few unavoidable occasions, a narrower line weight can be added for a necessary detail. A rounded end cap is used for the ends of lines to keep everything looking friendly.
  • Angles and corners
    • Because we never know which icons will be used side by side, it’s important to use harmonious and consistent angles and corner radii. This helps to maintain the organized and structured look of the visual abstract layout.
  • Monochromatic color palette
    • Color is kept to black line only. White and tan are used when possible to create an illusion of solidity, and after many requests, light gray has recently been approved for use to add another level of differentiation.
Some do’s and don’ts for visual abstract icons.

We strictly uphold these requirements for a few practical and aesthetic reasons: consistency, brand alignment, efficiency, and, importantly, visual elegance and sophistication.

The JAMA Network icon library has grown to include nearly 300 icons, from acne to radiography, and many things in between.

As you can imagine, it takes many talented people to complete a visual abstract. Manuscript editors, visual abstract editors, managing editors, production graphics, editorial graphics, designers, marketers, social media managers, administrators, and more—we all play a part.

An example of a published JAMA Network visual abstract. For guidance on how to prepare figures for use in visual abstracts, please consult chapter 4.2.10 of the AMA Manual of Style.

Hawaiian Diacritics

Miriam Cintron, BA, JAMA Network

https://decolonialatlas.wordpress.com/2015/06/03/the-hawaiian-islands/

The islands of Hawaiʻi and its people have a culture rich in history, traditions, and the Native Hawaiian language.

Sadly, use of the Native Hawaiian language began to decline in 1896, when it was banned from schools just 3 years after the Hawaiian monarchy was overthrown.1 Without being taught in schools, the Native Hawaiian language became dangerously close to being completely forgotten. By the early 1980s, fewer than 50 children spoke the language.2

A resurgence in cultural pride and identity in the 1970s led to the resurgence of many Native Hawaiian cultural traditions, including the language.

With this in mind, the AMA Manual of Style strives to be accurate, fair, and respectful in reflecting the identities of individuals and groups. The Manual is adding 2 diacritical marks used in Native Hawaiian to the Accent Marks (Diacritics) section (chapter 12.2).

The okina (ʻ) is a glottal stop and the kahakō is a macron (ā) that lengthens and adds stress to the marked vowel.

The marks are used throughout the language, including in many of the names of the main Hawaiian islands (eg, Hawaiʻi, Kahoʻolawe, Kauaʻi, Lānaʻi, Molokaʻi, Niʻihau, and Oʻahu).

Note that Hawaiʻi has 2 official languages according to the state constitution: English and Hawaiian.3 “Hawaiian” is considered an English word, so it doesn’t take the okina.

  1. Hawaii State Department of Education. History of Hawaiian education. Accessed January 19, 2022. https://www.hawaiipublicschools.org/TeachingAndLearning/StudentLearning/HawaiianEducation/Pages/History-of-the-Hawaiian-Education-program.aspx
  2. The Hawaiian Islands. The Hawaiian language. Accessed January 19, 2022. https://www.gohawaii.com/hawaiian-culture/hawaiian-language-guide
  3. The Constitution of the State of Hawaii. Article XV. Accessed January 22, 2022. https://lrb.hawaii.gov/constitution#articlexv

It’s All About Access

Amanda Ehrhardt, MA, JAMA Network

Let’s take a little jaunt through time to before the pandemic days (remember those?) and look at one of the most downloaded and cited articles in the history of the JAMA Network. Perhaps you’ll recognize the title (or, more likely, the author).

As you move toward the reference section of this article by our former president, you may notice that something looks a bit different about the first citation.

It’s subtle, but according to the newest edition of the AMA Manual of Style, 3.15.3, the location of the published and access dates now comes before the URL in electronic references, and there is no longer a period after the URL.

If President Obama’s article were published today, that reference would look like this:

  1. Centers for Medicare & Medicaid Services. National Health Expenditure Data: NHE tables. Published December 3, 2015. Accessed June 14, 2016. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical.html

Just as access to health care is important, so is the access date in articles!