Questions From Users of the Manual

Q: What do you recommend regarding the necessity of including state names (or province names or country names) with the names of certain well-known cities?

A: We used to have a list of cities that could stand without a state (or province or country), but we discontinued that with the ninth edition and recommend that a state or country name be included with all cities.  (What is well known to one may not be well known to another.)  For details and exceptions, see section 14.5.

Q: Do you recommend using “eg” or “e.g.”? Since this represents the shortening of 2 words, I believe “e.g.” would be correct.

A: We recommend using “eg,” closed up, with no periods. See the list of Clinical, Technical, and Other Common Terms in section 14.11. It is true that this abbreviation represents 2 words, but within the list in section 14.11 you will note that most of the abbreviations included represent at least 2 words and yet they are joined without periods. This is a fairly common practice.

Q: I can’t find anything in the Manual about “normal saline,” but I seem to remember that this term was not preferred. Help.

A: Your memory is good.  In the ninth edition of the Manual (section 15.11), we did  indicate a preference for isotonic sodium chloride solution over normal saline. However, in the current edition we dropped that preference and consider normal saline acceptable, so there is no need to change it. If an author uses isotonic sodium chloride solution, however, that too may stand.  Both terms are acceptable.—Cheryl Iverson, MA

Cheat Sheet for Abbreviations Style

Abbreviations are a convenience, a time saver, a space saver, and a way of avoiding the possibility of misspelling words. However, a price can be paid for their use. Abbreviations are sometimes not understood. They can be misread, or are interpreted incorrectly. … The person who uses an abbreviation must take responsibility for making sure that it is properly interpreted.—Neil M. Davis1

Abbreviations are used widely in medical articles, and great care should be taken to provide expansions that define these abbreviations. The AMA Manual of Style includes a straightforward rule regarding the use of abbreviations: Define abbreviations at first mention by providing the expanded term first, followed by the abbreviation in parentheses, and the abbreviation is used thereafter.

But for every rule, there are exceptions.

Some Exceptions:

• Avoid creating abbreviations for terms that are easy to spell out and do not take up a lot of space. For example, it is not advisable to abbreviate “catheter ablation” as “CA” or “immune response” as “IR.” Also, avoid using too many abbreviations in any one article.

• If a term is better known as an abbreviation, provide the abbreviation first with the definition following in parentheses. “The TUNEL (terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick-end labeling) staining assay was carried out using an apoptosis detection kit.”

• It is inelegant to begin sentences with abbreviations, unless the expansion is so unwieldy that using the abbreviation makes sense. The previous example, TUNEL, also works here. Rather than begin a sentence with the cumbersome expansion, it is acceptable to begin the sentence with the abbreviation TUNEL.

• Abbreviations should not be introduced in headings. If an abbreviation is being used for the first time in a heading, expand the abbreviation in the heading; then, at first mention in the running text after the heading, expand the abbreviation again, with the abbreviation following in parentheses. Use the abbreviation thereafter.

• Some very common abbreviations do not require expanding at first mention, such as AIDS, TNM, UV, and CD-ROM. A complete list of these abbreviations is provided in section 14.11, with those that do not require expansion denoted by an asterisk.

• The efficiency of using an abbreviation is lost if the abbreviation is used only one time, so as a rule of thumb, introduce an abbreviation only if it is used at least 2 or 3 times.

Items of Note:

• Tables, figures, and abstracts are treated as separate items from the text, so abbreviated terms must be reexpanded in each of these items.

• Use the appropriate article (a or an) before an abbreviation according to the sound following the article (eg, a UN resolution, an HMO plan).

• Use a lowercase s (and no apostrophe) when making abbreviations plural (eg, NSAIDs).—Lauren B. Fischer

1. Davis NM. MEDical ABBREViations: 28,000 Conveniences at the Expense of Communication and Safety. 13th ed. Warminster, PA: Neil M Davis Associates; 2007:1.

Questions From Users of the Manual

Q: I am a medical writer (and writer, in general) and have always questioned the use of the lowercase “b” in the word “blacks.”  The “w” in “Whites” is normally capitalized when talking about that population.  Although this question is not limited to the AMA Manual of Style, how might I go about getting it changed so that the “b” in “blacks” is also capitalized, for consistency?

A: You will have noticed that in section 11.10.2 of the manual we do not use intial caps on either “white” or “black.”  Webster’s 11th seems to follow this policy also, as you will find definitions related to both races presented without initial caps. I also checked the Chicago Manual and, in section 8.39, they indicate a similar policy. “Common designation of ethnic groups by color are usually lowercased unless a particular publisher or author prefers otherwise.” So, there does seem to be consensus among this small sampling, but it is in the direction of using initial lowercase letters rather than initial caps for these terms.

Q: Are there courses that teach proper use of the AMA Manual of Style?

A: I know of one such course. It is the Medical Writing and Editing Certificate Program that is offered by the University of Chicago Graham School. See

Q: I have been working as an APA style editor for nearly 3 years.  I would like to be able to work as an AMA style editor.  I need to learn the AMA style.  Which version of the manual do you recommend?  Is this manual available online?

A: You can visit the AMA Manual of Style Online site ( and you can see that you can purchase a book, an online subscription, or a “bundle” of both. You can also subscribe to the blog and sign up for tweets at no charge. Good luck to you!

Q: Does AMA have a preference for “versus” vs “vs”? If so, can you include the rationale behind the choice?

A: Yes, we prefer “vs” as an abbreviation for “versus” (except in the names of legal cases, where we use the conventional “v”). See the list of abbreviations (14.11) re our preference for how to abbreviate “versus” and also note that we do not require this abbreviation ever to be expanded.  Note too that the use of the lowercase italic “vee” is preferred in legal cases, per convention.  As to our rationale, we have been doing this for so long it is hard to recall exactly.  I suspect it was a combination of “vs” taking up less space than “versus” and being well recognized and understood by all/most.

Q: Is it 0.9 second or 0.9 seconds? The AMA Manual of Style doesn’t seem to address this particular question.

A: This question originally arose on the AMWA Editing-Writing Listserv. There was much good discussion and various sources were cited. After considering all the comments and polling our own staff, we come down on the side of Words Into Type and Edie Schwager’s Medical English Usage and Abusage (for print usage:  prefer the singular).  But when spoken, we prefer the advice of the Chicago Manual (section 10.68)—in general, prefer the plural.—Cheryl Iverson, MA

Questions From Users of the Manual

Q: I thought AMA supported putting no space following a symbol such as > (eg, age <18) if, in the expression, the symbol is acting more as a modifier, not as an operator (eg, 3 < 4), in which case the symbol would have a space (AMA specifies a thin space).  If I’m mistaken, I need to make a mental adjustment.

A:  This is addressed in section 21.10.  We recommend thin spaces with such symbols as greater than, less than, equals, etc.  So, a small mental adjustment might be needed as we make no distinction between the 2 uses you describe.

Q: Is it true that AMA style no longer requires an expansion of CI (confidence interval) at first mention?

A: Yes, it’s true.  As of July 27, 2011, as announced on Twitter, we are no longer requiring that CI be expanded at first mention.  This is posted on the style manual Web site in “Updates to the Manual” and soon will have a special icon within the text to indicate that this material has been updated.

Q: Does AMA have a preferred format for telephone numbers?  How about international numbers?

A:   The manual does not address this question specifically (and perhaps it should).  However, if you look in section 25.11, you will see many examples (both from the United States and elsewhere) for presentation of telephone numbers.—Cheryl Iverson, MA


Questions From Users of the Manual

Q:   If one has a list of laboratory values, does one have to keep repeating the units of measure, eg, albumin levels of 3.8 g/dL, 3.9 g/dL, and 4.0 g/dL, or is once enough, eg, albumin levels of 3.8, 3.9, and 4.0 g/dL.

A:  No, the unit of measure does not have to be repeated:  albumin levels of 3.8, 3.9, and 4.0 g/dL is fine.  The exception to this is for units of measure that are set closed up to the number or value that they follow, such as the degree sign or the percent sign.  In these cases, the unit of measure should be repeated:  38%, 45%, and 53%.

Q:   What abbreviation does JAMA/Archives prefer for adjusted odds ratio?

A:   We prefer AOR.

Q:   Is “data on file” acceptable in a bibliography or in parentheses in the text?  I don’t see this in the Manual.

A:   The phrase “data on file” is a little vague.  What a reader who’s interested in more information might really want to know is how the author of the manuscript saw the data (and how, perhaps, the interested reader might be able to see it too).  Something more granular about how the author came upon the information would be more helpful.  For example, did the author learn about the information through a personal communication (and is that personal communication the “data on file”?)?  If so, see 3.13.9 in the Manual for how to style this as an in-text references.  Is the “data on file” an internal memo at an institution and, if so, does it have a document number that could be listed in the reference list?

Q:   Would you hyphenate “quality of life” when it’s used as a noun as well as when it’s used as an adjective?

A:   We usually hyphenate as an adjective and not as a noun.—Cheryl Iverson, MA

Abbreviation Nation

Of the reference books I use while editing the Archives journals, my favorite by far is MEDical ABBREViations: 28,000 Conveniences at the Expense of Communication and Safety, 13th Edition, by Neil M. Davis. Not only does it have the most wonderfully snarky title I’ve ever seen on a reference book, but it is the Great Decoder, the book that allows me to make sense of the myriad abbreviations I run across in my daily work.

As much as we are a nation of people who speak largely in cliches and mixed metaphors (I will save my rant about the overused and incorrect “magic bullet” for another day), we are a nation of overabbreviators. The number of organizations that are known by their abbreviation are too many to quantify (NFL, AMA, NORAD). We put out APBs, send out CVs, take our OTC meds, surf our Macs and PCs, and occasionally go AWOL. But when you think about it, do these mean anything? A National Football League is a thing. An NFL is not. What about an AC? Is it an air conditioner? An alternating current? Atlantic City? Though sometimes context can tell us what an abbreviation means, just as often it cannot, and it’s my job to sort these out.

As someone who previously tried to argue that texting is a valid and efficient method of communicating, it may seem hypocritical for me to do a mental fist pump every time I read Mr Davis’ snappy title, but I do. It’s because for every abbreviation that I find easily in my AMA Manual of Style or my MED ABBREV, there are so many that I must ask authors about. This worries me, because I don’t think authors would put these in their articles if they weren’t  routinely used. And though they and their colleagues and most of the American medical community may know exactly what they mean, will readers in Zimbabwe, Thailand, or Argentina? Those readers may have their own set of metaphors, jargon, and abbreviations that makes perfect sense to them. Or they may be students who don’t come across them every day. What happens when we let them slide, or when a journal doesn’t have finicky, know-it-all editors to question them? I worry that it will make journals less accessible, and that it will make medical discourse less accessible. I hate the idea of a medical student somewhere in the world not being able to use one of our articles in his research because I didn’t feel like finding out what something means. And believe me, sometimes I don’t feel like it. But I know I must be persistent, as annoying as it feels to harass a busy professional about something that seems so trivial. And that medical student out there better appreciate it.—Roya Khatiblou, MA

Questions From Users of the Manual

Q:    If a person has multiple advanced degrees, should the medical degree always be listed first, eg, MD, PhD?

A:   We would advise following the author’s preference as far as the order in which degrees are listed.

Q:   I know that journal names are typically italicized in their expanded form, eg, Journal of the American Medical Association. Should the abbreviation also be italic, eg, JAMA?

A:   Yes. The same policy applies to book titles and their expansions. See, for example, International Classification of Diseases, Ninth Revision and ICD-9 in the list in 14.11.

Q:   On page 500, in the list of journal abbreviations, is there a reason that the journal Transplantation is spelled out in full as Transplantation and yet other journals whose titles include that word abbreviate it as Transplant?

A:    Yes, there is a reason. See the sentence on page 479 advising that “Single-word journal titles are not abbreviated.”

Q:    The AMA Manual of Style says that tables should be able to stand independently and not require explanation from the text. Could you clarify “stand independently”? Our publication has taken this rule to an extreme, often adding lengthy definitions of terms already provided in the text. One recent example added 15 footnotes to a single table!

A:   As with so many things editorial, this requires judgment.  We were thinking about things like this:

  • Expansion of any abbreviations, given in the text, provided again in a single footnote to the table.
  • Explanation of things that might not be apparent from the tables (eg, what the various groups are if they are only identified as “group 1, group 2, etc” in the table).
  • Explanation of how to convert units from conventional to SI (or the reverse), if this is important in your publication/to your audience.
  • Explanation of some statistical method that would likely not be familiar to your readers without some information—the bare bones, not a lengthy explanation. If a lengthy explanation is necesssary, simply refer the reader to the relevant section or subsection of the text.
  • Explanation of a phrase used for shorthand in a table stub or column head that might not be clear if all you were looking at was the table (eg, if a column head is “Unstable Vital Signs,” explain in a footnote the specific items and values that this refers to).

It truly is a question of judgment and I suspect that 15 footnotes in a single table is taking it too far.—Cheryl Iverson, MA

Deciphering the Alphabet Soup of Cardiac Imaging

As medical technology expands, so does the lexicon of abbreviations, commonly used but indecipherable to anyone who is not “living” in that rarified world. Frequently, in professional and commercial publications, perhaps especially during February (or “heart month”), you may see advertisements encouraging people to get one of these “heart scans.” (Don’t!) All the more valuable is a tip for navigating the lexicon of cardiac testing.

One of the latest popular scans is a noninvasive way to look at the coronary arteries: CCTA or cardiac computed tomographic angiography. This scan requires intravenous (IV) injection of a contrast agent. As it requires an IV line it is most accurately described as “semi-invasive.” Additionally, there is some hazard associated with it because the contrast agent may be damaging to the kidneys. The CCTA is a variation of the more generic CT scan, which refers to any test done using a CT scanner on any body part. A CCTA is often done on a multidetector CT (MDCT) scanner. These tests are often preceded by the term 64-slice or 128-slice, which refers to the technology of the scanner. A “heart scan” commonly refers to another type of cardiac CT scan, which can be done on either an MDCT or an EBCT (electron-beam computed tomographic) scanner, an older technology. A coronary calcium scan is noninvasive as it does not use contrast enhancement. It is used to quantify coronary artery calcium (CAC).

Other newer cardiac imaging tests are PET scans—no animals here; it stands for positron emission tomographic scans. These sophisticated scans are done using various radioactive isotopes (and, you guessed it, they have various abbreviations as well). Old standbys for medical imaging are SPECT studies, or single-photon emission computed tomography and echocardiography (no abbreviations here).

To make sense out of the soup, it’s important to include an expansion for each abbreviation at first mention. Now you can be “nourished” by the soup you consume! —Rita F. Redberg, MD, MSc