Questions From Users of the Manual

Q: I am writing a manuscript in which I want to include the dates that a list of products were first marketed. The database from which I got the information is a subscriber-only database. This seems to be the only place that has the information I want to use. Are such subscriber-only databases allowable to include in a reference list?

A: This question was one we had to address when working on the chapter on reference citation style and the answer we decided on was YES, these may be included in a reference list. (We did not address it specifically for a subscriber-only database, but this question also arises with reference to journal articles that are password-protected/available only to subscribers.) The rationale was 2-fold. First, if there is another place that the information can be obtained that is not behind a “wall,” then of course you might want to consider using that reference instead of the one that is not easily available to all. But, as you indicated in your case, sometimes there is no “free” site for the information you want to reference, and it’s important to acknowledge your source—even if access to it is limited. Second, thinking back to the days before people were citing much online material (and those days were not that long ago, were they?), reference lists frequently cited books that might be out of print or other sources that might not allow easy access. This doesn’t seem a reason not to include the material, even though it might be an annoyance to online readers to find that the source is not freely available, so YES.

Q: How would you cite a webinar?

A: I would extrapolate from the style recommended for citing an audio presentation:

Christiansen S. Medical copyediting with AMA style [webinar]. December 15, 2011.  http://www.copyediting.com.  Accessed April 6, 2012.

Q: In section 14.12, you state “Use the abbreviation [of units of time] only in a virgule construction and in tables and line art.” Does this mandate the use or merely allow the use of these abbreviations in these instances?

A: The answer is short. It does not mandate so much as allow, although units of measure are almost always abbreviated in column heads and stubs in tables and on axes in line art in our journals because of space considerations.—Cheryl Iverson, MA

 

Quiz Bowl: Anatomy

Quiz Bowl is back! After a much need summer hiatus (much needed on my part, not sure how you guys feel about the matter), the games continue with a quiz on anatomy. Hmmm, maybe I should rephrase that. Make that with a quiz on anatomy terms. Hmmm, that’s medical terms, not the kind you see scribbled on the bathroom wall. Now that that’s cleared up, let’s get to the question.

Edit the following sentence to conform to the AMA Manual of Style guidelines on anatomical terms (§11.6, Anatomy, p 410 in print).

The investigators examined catheter-induced lesions of the right heart.

Any ideas? Consider the term right heart. Here’s the answer (use your mouse to highlight the text box):

The investigators examined catheter-induced lesions of the right side of the heart

Although some animals have more than 1 heart (the octopus, the earthworm, the cockroach), people only have 1 heart. Authors often err in referring to anatomical regions or structures as the “right heart,” “left chest,” “left neck,” and “right brain.” The terms right and left imply 2 different structures. Generally these terms can be corrected by inserting a phrase such as “part of the” or “side of the.”

Want to learn more? Take the full Anatomy Quiz on the AMA Manual of Style online. See you next month!—Laura King, MA, ELS

URLs Gone Bad: Fixing Broken Links

Link rot is a term that describes the tendency of URLs to fail over time because the page has been deleted or moved. Because of the lag between writing and publication, link rot can be a problem even before content is posted, so all URLs should be checked for dead links.

URL-Checking Software

A number of tools exist that check and verify URLs. Well-written URL-checking software can report dead links and some redirected (forwarded) links. Even if a URL appears to work and is not obviously broken, however, the content of the page may have changed, and it may no longer be what the author intended to cite. Because of this issue and others explained below, it’s not possible to detect all bad links automatically. Therefore, a copy editor should check all URLs manually at least once during the publication process, verifying that the content of the page matches the citation context.

The Link Works, but Is the Content Right?

The content of a web page can change at any time. For example, many government agencies report statistics regularly, archiving or deleting the old report once the new one becomes available. Here’s a reference from the Administration on Aging:

Department of Health and Human Services. A profile of older Americans: 2007. http://www.aoa.gov/AoARoot/Aging_Statistics/Profile/index.aspx. Accessed April 7, 2012.

This URL is valid, but the title on the page is now “A Profile of Older Americans: 2011.” As you scroll down the page there are links to previous profiles, including the 2007 version cited by the author, which now has a new URL:

http://www.aoa.gov/AoAroot/Aging_Statistics/Profile/2007/index.aspx

In this case no change is really needed; the URL is still valid, and the report the author referenced is available from this same page. If there’s any doubt about whether the content of the URL is what the author meant to cite, he or she should review and verify changed URLs (assuming time permits).

Broken Link? Google It

Here’s a sentence from an author-submitted manuscript that includes a broken URL:

To search for gene network pathways, we searched BioCarta, KEGG, and Reactome pathways and available software programs (https://www.affymetrix.com/products/software/compatible/pathway.affx).

A good tool to investigate and repair a broken link is Google. Search the title or a detailed description, in this case “Affymetrix compatible gene network pathways software.” The first result of this search,

http://www.affymetrix.com/partners_programs/genechip_compatible/genechip_compatible.affx

looks promising, and, if you click on the Pathway tab on this page, the heading is “Pathway/Network Analysis,” indicating that this new URL fits the citation context well.

It’s Really Broken: Keep the URL but Kill the Hyperlink

If a title or detailed description search fails to find a match for a source with a broken URL, ask the author to provide another source or another way to access the same source. If there’s not time to consult the author or if the author replies that there is no other way to access the reference, leave the URL in place to indicate how the author accessed the source, but remove the hyperlink.

Here’s an example from another author-submitted reference list, with the URL in place but the hyperlink removed:

Kittler H. Dermatoscopy: introduction of a new algorithmic method based on pattern analysis for diagnosis of pigmented skin lesions. Dermatopathol Practical Conceptual. 2007;13(1). http://www.derm101.com/dynaweb/resources/milestones/49057/@Generic__BookView/49067;cs=chapview.wv;ts=chaptoc.tv;chap=dpc1301a03. Accessed February 15, 2010.

A detailed title search doesn’t help in this case. There are no obvious errors in the URL. Also, entering the author’s name in the site search box provided at the home page, http://www.derm101.com/, produces this result: “The term ‘kittler’ was not found.”

Typos in URLs

Copy editors must also be alert for typos, especially errors in punctuation. These are common, and some of them, like the first example below, can be spotted and repaired before checking the reference:

Bad URL: http://www.hospitalcompare.hhs.gov/Hospital/Search/Welcomeasp

Good URL: http://www.hospitalcompare.hhs.gov/Hospital/Search/Welcome.asp

Bad URL: http://www.plosmedicine.org/article/info:doi/10.1371/journal-pmed.0050120

Good URL: http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.0050120

Bad URL: https://www.cdc.gov/nchs/nhanes.htm

Good URL: http://www.cdc.gov/nchs/nhanes.htm

Redirected URLs

If, when you attempt to verify a URL, the landing page has a URL different than the one you tested, the URL has been redirected, or forwarded. Redirection is used most often to allow URLs to be updated without breaking the old URLs. The cited URL jumps automatically to the updated URL. To identify redirected URLs, check the browser address window. Here are 2 examples:

Cited URL: http://wwwn.cdc.gov/travel/yellowbookch4-hepb.aspx Redirected to: http://wwwnc.cdc.gov/travel/yellowbook/2012/chapter-3-infectious-diseases-related-to-travel/hepatitis-b.htm

The Rule: When URLs are redirected, it’s preferable to cite the destination URL, both because redirection is sometimes temporary and because redirection sometimes fails.

The Exception to the Rule: Another tye of redirection is the use of vanity URLs to promote a product or a brand. For example, the vanity URL http://jama.com redirects to http://jama.jamanetwork.com/journal.aspx. Unlike updated URL redirects, vanity URLs should be left intact.

More Information

See §3.15, Electronic References in the AMA Manual of Style (pp 64-67 in print) for more information about the correct format for URLs in electronic references.—Paul Frank

Questions From Users of the Manual

Q: How can a user of your online manual tell if use of a particular word (such as namely) is discouraged?

A:  The first place to look might be chapter 11, Correct and Preferred Usage. But the word you used as an example is not included therein. Or you could try a search in the online manual for the word in question. But that too produces nothing helpful, most likely because we have no “official” policy on this word. Next you might consult a good usage book or the usage notes in the American Heritage Dictionary. Finding nothing anywhere, you could decide on a policy for your publication or the document you are working on, if this seems appropriate or desirable.

Q:  Several questions about the citation of abstracts in a reference list.

  • Section 3.11.9 (Abstracts and Other Material Taken From Another Source) states on page 50 that for abstracts published in the society proceedings of a journal, “the name of the society before which the paper was read need not be included” and that “if a[n abstract] number is included, it is placed in brackets along with the ‘abstract’ designation.” What is not made clear is whether including an “abstract” designation is mandatory or voluntary.   

Should an “abstract” designation be included in the citation to an abstract published in the society proceedings of a journal if neither the society’s name nor an abstract number is being provided? In other words, using example 3 of the book as a base, which of the following would be correct?  

  •  . . . Lemli-Opitz syndrome. Invest Ophthalmol Vis Sci. 2001;42(suppl):S627.  (the reference is not identified as being an abstract)

        or

  • . . . Lemli-Opitz syndrome [abstract]. Invest Ophthalmol Vis Sci. 2001;42(suppl):S627.  (the reference is identified as being an abstract)

If the “[abstract]” designation is not mandatory, is it AMA style to delete it when an author includes it (without an accompanying society name or abstract number) in such a reference?

Also, if an abstract is given an abstract number in the place where it is published, is it considered mandatory or voluntary for its number to be included in the reference citation? The text in the manual says “if a number is included” but the meaning of this is possibly ambiguous (included by the journal in which it was published; or voluntarily included by the author who submits the manuscript as a matter of the submitting author’s preference? It seems most likely that it is the latter, but I’m not certain). 

A:  In order:

  • The if  is meant to signify that the designation as an abstract should be included if it is provided.
  • The second version you provided would be preferred. It’s a nice service to readers to let them know that what is referenced is an abstract.
  • Absolutely not. We would never delete it. It too provides a service to readers, helping them to find the abstract referred to, should they be so inclined.
  • You interpreted the manual correctly—the latter is what is intended.—Cheryl Iverson, MA

Anticipate, Expect

Although the use of anticipate and expect as synonyms is now largely accepted,1 at least in casual communications, the careful writer will do well to note that some authorities still hold that there is a subtle difference between them.1-3

Although both words refer to a person’s attitude toward a future event, they differ in what they convey about that attitude. For example, some observers hold that the difference between the words relates to the level of certainty toward the future event (ie, anticipate implies that a person is certain that the event will take place, whereas expect implies only that a person predicts that the event will take place3). However, this weak distinction is easily blurred, and in practice it seems that it is not often upheld. A stronger and more often upheld distinction maintains that anticipate is the stronger of the two words, connoting that some action has been taken to prepare for the foreseen event.2,3 This sense possibly arose from an early (late 1500s) use, “To seize or take possession of beforehand.”4 Although that use is now obsolete, by the early 1600s anticipate was being used to suggest simply “to take action beforehand,” a meaning still current.4 Bernstein points out that such action “Need not be taken so literally as to mean the performance of an overt act; it may simply connote an advance accommodation of the mind or the senses, even involuntarily, to the coming event.”2

In any case, if anticipate suggests the taking of some sort of action to prepare for an expected event, it seems clear that one should perhaps not use it when wishing to convey only simple expectation. Interestingly enough, even those who consider anticipate and expect synonyms do not extend the same acceptance to the synonymous use of unanticipated and unexpected.1

The misuse of anticipate in place of expect likely arose from the tendency common among writers and speakers to use larger words.5(pp22-23) It also is an example of what Garner terms “slipshod extension”5(pp22-23)—“the mistaken stretching of a word beyond its accepted meanings, the mistake lying in a misunderstanding of the true sense.”5(pp307-308) Garner further maintains that the use of anticipate in the sense of “to await eagerly” is also incorrect and points out that such use is also likely the result of slipshod extension.5(pp22-23)

The bottom line:

● Referring to a person’s attitude toward a future event? Using anticipate and expect interchangeably is likely acceptable in casual communications, but in more formal contexts one should take care to observe the subtle differences between them.

● Referring to the simple expectation of a foreseen event? Use expect.

● Referring to a state of taking action—whether that action be either concrete, mental, or emotional—in preparation for a foreseen event? Use anticipate.—Phil Sefton, ELS

1. Anticipate. The Free Dictionary website. http://www.thefreedictionary.com/p/anticipate. Accessed June 8, 2012.

2. Anticipate, expect. In: Bernstein TM. The Careful Writer: A Modern Guide to English Usage. New York, NY: Athaneum; 1985:44-45.

3. Anticipate or Expect: What’s Next? Grammatically Correct website. http://www.uhv.edu/ac/newsletters/writing/grammartip2008.05.28.htm. Accessed June 8, 2012.

4. The Compact Oxford English Dictionary. 2nd ed. Oxford, England: Oxford University Press; 1991: 58.

5. Anticipate. In: Garner BA. The Oxford Dictionary of American Usage and Style. New York, NY: Oxford University Press; 2000.

Is It an Either/Or or a 50-50 Proposition?

The usual suspects stand 7½ inches high in a stack next to my computer. They moderate my dogma against what I think lazy or muddled use of punctuation or language by nicely telling me that I am wrong or, worse, that I have become woefully out of date.

No, I don’t wear a string of pearls, hang my reading glasses around my neck, stuff a tissue in the sleeve of my cardigan sweater, or wear my hair swept up in a bun, though my gray strands have thickened to streaks that I fear will dominate my hair soon enough. But I do become cranky about usage trends that render the language imprecise.

My problem is the slash or virgule. It seems to pop up everywhere, from a syllabus for a graduate class to a book assigned in another class. On the syllabus, the assessment subsection head includes “Exam/Term Paper and Class Participation.” Good, I thought, I will be able to pick whether to take the exam or write a paper. But no, as I read on I see there is no choice. The exam is to be written as an essay. Should that expression then be considered a compound modifier of a compound word and expressed with an en dash instead of a slash—“examination–term paper”? The book, on the other hand, discusses a collaborative “Harvard/MIT” study. Clearly, this should have been a hyphen rather than a slash.

But most frequently, I find excessive use of the virgule in the medical research articles I edit. Its prevalence in these articles always surprises me because by nature the virgule is ambiguous while science writing aims at precision—to the point of putting readers to sleep: no active verbs, few identifiable subjects, only statements that remain within the bounds of the data, and no causation, just associations.

So am I justified in being annoyed at what I consider an over-reliance on the slash? As a reader, I favor words and punctuation that make ideas clear. And while I am scrupulous about taking out an and/or construction, as is the mandate of our style manual, by stretching “red and/or white” to “red, white, or both,” I consider my irritation justified when confronted with extending its use to what was submitted in a table footnote for an article I recently edited:

            Rescue was defined as any pharmacological/electrical/surgical intervention for the termination/prevention of AF [atrial fibrillation]/flutter…

I dutifully changed it:

            Rescue was defined as any pharmacological, electrical, or surgical intervention for the termination or prevention of AF [atrial fibrillation] or flutter…

Although I was correct in determining that the slashes suggested an alternative, I could have guessed they meant a series.

Before checking the books, I confirm that the symbol of the virgule, which comes from the Latin virgula, “a little bough, twig; a rod, staff,”1 is defined as a slash in Merriam-Webster’s Collegiate Dictionary.2 Clearly, it looks like what it means, a visual mnemonic perhaps? My understanding of the punctuation mark is that the virgule can mean and or it can mean or, or as my poet-husband suggests, it classically means and/or.

So now to the stack. First up, the AMA Manual of Style,3 which in the introductory paragraph of the Forward Slash (Virgule, Solidus) section says that the virgule “is used to represent per, and, or or and to divide material (eg, numerators and denominator in fractions; month, day, and year in dates [only in tables and figures]; lines of poetry).” Then comes the first major discussion under the section, which says that the slash expresses equivalency “[w]hen 2 terms are of equal weight in an expression and and is implied” and provides the following example:

The diagnosis and initial treatment/diagnostic planning were recorded.

With this definition in mind, how do my above examples stand up to the test? MIT would probably not quibble with being viewed as equivalent to Harvard, but I still think in this case they are functioning, in their capacity as the generators of a study, as a compound modifier and should be hyphenated, even though and is implied. I think the same goes for my “exam/essay” example because and is not implied. They are a single concept as the major assessment for the class. And for my table footnote, while they represent equivalent interventions, the word and is not implied, but the expression “termination/prevention” could have been left alone as equivalent ideas. However, I think changing “AF/flutter” to “AF or flutter” was correct because I don’t think the experience is equivalent. (However, I am told by one of our medical editors that AF/flutter is so constructed because a patient’s heart rhythms may vacillate between the 2 states so that treatment and outcome are similar, thereby, demonstrating another example of the virgule serving as a visual reality.)

Fowler’s Modern English Usage4 and The Elements of Style5 are silent on the matter. The Associated Press Stylebook6 allows its use only to describe “phrases such as 24/7 or 9/11” and advises writers and editors to “otherwise confine its use to special situations, as with fractions or denoting the ends of a line in quoted poetry.”

The Chicago Manual of Style7 says, “A slash most commonly signifies alternatives. In certain contexts it is a convenient (if somewhat) informal shorthand for or. It is also used for alternative spellings or names. Where one or more of the terms separated by slashes is an open compound, a space before and after the slash can be helpful.” Although coming at it from the alternative angle rather than equivalent angle, I think my editing still stands. Nevertheless, I think the Chicago Manual captures the spirit of the slash in response to the speed brought on by the age of the Internet and people like my boss, who said, “I like it. It’s fast.”

As for me, the confusion of meaning slows me down. I vote for words.—Beverly Stewart, MSJ

1. University of Notre Dame. Latin dictionary and grammar aid Web page. http://www.nd.edu/~archives/latin.htm. Accessed July 16, 2012.

2. Virgule. Merriam-Webster’s Collegiate Dictionary. 11th ed. Springfield, MA; Merriam-Webster Inc; 2003:1397.

3. Iverson C, Christiansen S, Flanagin A, et al. AMA Manual of Style: A Guide for Authors and Editors. 10th ed. New York, NY: Oxford University Press; 2007.

4. Burchfield RW. Fowler’s Modern English Usage. 3rd rev ed. New York, NY: Oxford University Press; 2004.

5. Strunk W, White EB. The Elements of Style. 4th ed. New York, NY: Longman; 2000.

6. Goldstein N, ed. The Associated Press Stylebook and Briefing on Media Law. New York, NY: Basic Books; 2007.

7. The Chicago Manual of Style. 16th ed. Chicago, IL: University of Chicago Press; 2010.

Questions From Users of the Manual

Q: Does your style require parenthetical page numbers after the superscript citation of the reference number on all references or just direct quotations?

A: The manual does not “require” page numbers with any in-text citations. If an author wishes to cite different page numbers from a single reference source at different places in the text, the page number or page numbers may be included in the superscript citation and the source appears only once in the reference list. The superscript may include more than a single page number and/or citation of more than a single reference, and all spaces are closed up.

  • These patients showed no sign of protective sphincteric adduction.3(p21),9
  • Westman5(pp3,5) reported 8 cases in which vomiting occurred.

An author may also wish to use such a reference to an exact page after citing a quotation, directing the reader to the page on which the quotation appears. See section 3.6  for more details on this point.

Q: When a reference is cited in the text and the author is named as part of the citation, how should a 2-author citation be mentioned? Or a citation involving 3 or more authors?

A: We recommend the following:

  • Doe and Roe8 reported on the survey.
  • Doe et al10 reported on the survey.

Of course it is also acceptable to cite a reference and not give an author’s name (or authors’ names) in the text, or to use “and colleagues” or “and associates” or similar phrases rather than “et al.”  See the examples below and section 3.7 for more on this.

  • Several investigators13-16 corroborated these findings.
  • Friedman and colleagues11 reported on this at the 2011 American Heart Association meeting.—Cheryl Iverson, MA

 

Right, Almost Right, and Just Plain Wrong: Spelling (and Spacing) Variations

It is now the work of years for children to learn to spell; and after all, the business is rarely accomplished. A few men, who are bred to some business that requires constant exercise in writing, finally learn to spell most words without hesitation; but most people remain, all their lives, imperfect masters of spelling, and liable to make mistakes, whenever they take up a pen to write a short note. Nay, many people, even of education and fashion, never attempt to write a letter, without frequently consulting a dictionary.—Noah Webster1

The primary nonmedical/nonscientific dictionary used at JAMA and the Archives Journals is Merriam-Webster’s Collegiate Dictionary, and the medical/scientific dictionary of record is Dorland’s Illustrated Medical Dictionary. In the list given below, we show the preferred spelling of frequently misspelled scientific and nonscientific words as indicated by Webster’s and Dorland’s.

Whereas Webster’s shows equal or secondary variants in the entry “head,” Dorland’s uses a single term for the entry head but lists cross-references for variant spellings at the end of the entry for the preferred term. But note that Webster’s also often includes variant spellings in its entries (eg, aesthetic and esthetic). These “equal variants” are indicated by or. If they are given in alphabetical order, “they occur with equal or nearly equal frequency.” If they are given out of alphabetical order, but still joined by or, the first is slightly more common than the second. If they are joined by also, the word given second “occurs appreciably less often” than the first and is considered a “secondary variant.”

The front matter of Webster’s also notes: “Other spelling variants may be flagged with var with some further brief explanation, for example, metre … chiefly Brit var of meter.” Exception: Variant spellings that appear in direct, written (eg, published) quotations should not be changed to US variants.

To maintain consistency within their journals, the editors of JAMA and the Archives Journals prefer the first spelling of the entry of any given word.

Right and Almost Right

acknowledgment (equal variant, out of alphabetical order: acknowledgement)

aesthetic (secondary variant: esthetic)

breastfeeding (Webster’s: breast-feeding)

cutoff (as noun or adjective)

cut off (as verb)

distention (as given in Dorland’s; equal variant in Webster’s: distension)

judgment (equal variant, out of alphabetical order: judgement)

phosphorus (as noun)

phosphorous (as adjective)

sulfur (secondary variant: sulphur)

supersede (secondary variant: supercede)

Just Plain Wrong

accommodate (not accomodate)

ancillary (not ancilary)

arrhythmia (not arhythmia)

brussels sprouts (not brussel sprouts)

cholecystectomy (not cholecysectomy)

consensus (not concensus)

cribriform (not cribiform)

desiccate (not dessicate)

diphtheria (not diptheria)

dyspnea (not dysnea)

embarrass (not embarass)

erythematosus (not erythematosis)

Escherichia (not Echerichia)

fluorescent (not florescent)

fluorouracil (not flourouracil)

Haemophilus (not Hemophilus)

harass (not harrass)

hematopoietic (not hematopoetic)

Legionella pneumophila (not Legionella pneumophilia)

levothyroxine (not levothyroxin)

millennium (not millenium)

minuscule (not miniscule)

Neisseria gonorrhoeae (not Neisseria gonorrhea)

ophthalmology (not opthalmology)

Papanicolaou (not Papanicolou)

pertussis (not pertussus)

pruritus (not pruritis)

sagittal (not saggital)

sinusitis (not sinusitus)

sphygmomanometer (not sphygomamometer)

sulfide (not sulphide)

syphilis (not syphillis)

unwieldy (not unwieldly)

Now, this is nice and neat. But what if the 2 principal dictionaries (medical and nonmedical) differ on the preferred spelling of a word? Which to follow? We make such decisions on a case-by-case basis. For example, anti-inflammatory in Webster’s was chosen instead of antiinflammatory in Dorland’s because the former was considered to be expressed more clearly with a hyphen between the 2 i’s. Similarly, workup (as a noun, meaning a thorough evaluation to arrive at a diagnosis) was chosen over work-up. (But: Use work up as a verb!)

Spacing and punctuation (to hyphenate or not to hyphenate) add further questions of variation. These too are decided on a case-by-case basis. Below is a small sample of some of these decisions.

cost-effective, cost-effectiveness (not cost effective, cost effectiveness)

end point (not endpoint)

health care (not healthcare)

policy maker (not policymaker)

under way (not underway)

A final word to the wise: Until spell-checkers include a read-my-mind function, do not rely on them for solving spelling problems!—Roxanne K. Young, ELS

1. Webster N. An essay on the necessity, advantages, and practicality of reforming the mode of spelling and of rendering the orthography of words correspondent to pronunciation. In: Dissertations on the English Language: With Notes, Historical and Critical, to Which Is Added, by Way of Appendix, an Essay on a Reformed Mode of Spelling, With Dr. Franklin’s Arguments on That Subject. Boston, MA: 1789.

Questions From Users of the Manual

Q: We do not find anything in the manual on how to treat “24/7.” Would you recommend spelling it out?

A: You are right. We don’t address this. But Webster’s 11th does. Both “24-7” and “24/7” are offered as equal variants. I think the latter is more common and would prefer that, without spelling it out.

Q: I understand that human genes are set all caps and italic, with the protein products set all caps and roman. But what to do with proto-oncogenes? Do the examples in section 15.6.2 indicate that, if the c- prefix is used, the lowercase (retroviral) form of the 3-letter oncogene is always used, regardless of whether we’re dealing with humans or mice? I am often presented with c-KIT, c-Kit, and c-kit in one document and would appreciate a clear explanation.

A: For oncogenes, it would always be c-kit and then, based on page 633 of the style manual, KIT for the human gene homologue and Kit for the mouse gene homologue.

Q: To follow your reference style, if “et al” is used, is a period used after “al”? And should the reference number be set as a superscript?

A: To answer your second question first, yes, the reference number should be set as a superscript if you follow the style set forth in the AMA Manual. And unless “et al” ends the sentence, “al” would not be followed by a period (even though it is an abbreviation).—Cheryl Iverson, MA

Bucking the “Trend” and Approaching “Approaching Significance”

I believe we are on an irreversible trend toward more freedom and democracy – but that could change.

—Dan Quayle

In general usage, the concept of trend implies movement. Not only is this implied in its definitions, but the word can be traced to its Middle High German root of trendel, which is a disk or spinning top.1

In scientific writing, when is a trend not a trend? When it is not referring to comparisons of findings across an ordered series of categories or across periods of time. However, this and related terms are often misused in manuscripts and articles.

Most studies are constructed as hypothesis testing. Because an individual study only provides a point estimate of the truth, the researchers must determine before conducting the study an acceptable cutoff for the probability that a finding of an association is due to chance (the α value, most commonly but not universally set at .05 in clinical studies). This creates a dichotomous situation in interpreting the result: the study either does or does not meet this criterion. If the criterion is met, the finding is described as “statistically significant”; if it is not met, the finding is described as “not statistically significant.”

There are many limitations to this approach. Where the α level is set is arbitrary; therefore, in general all findings should be expressed as the study’s point estimate and confidence interval, rather than just the study estimate and the P value. Despite the limitations, if a researcher designs a study on the basis of hypothesis testing, it is not appropriate to change the rules after the results are available, and the results should be interpreted accordingly. The entire study design (such as calculation of the sample size and study power – the ability of a study to detect an actual difference or effect, if one truly exists) is dependent on setting the rules in advance and adhering to them.

If a study does not meet the significance criterion (for example, if the α level was set as < .05, and the P value for the finding was .08), authors sometimes describe the findings as “trending toward significance,” “having a trend toward significance,” “approaching significance,” “borderline significant,” or “nearly significant.” None of these terms is correct. Results do not trend toward significant—they either are or are not statistically significant based on the prespecified study assumptions. Similarly, the results do not include any movement and so cannot “approach” significance; and because of the dichotomous definition, “nearly significant” is no more meaningful than “nearly pregnant.”

When a finding does not meet statistical significance, there are generally 2 possible explanations: (1) There is no real association. (2) There might be an association, but the study was underpowered to detect it, usually because there were not enough participants or outcome events. A finding that does not meet statistical significance may still be clinically important and warrant further consideration.

However, when authors use terms such as trend or approaching significance, they are hedging the interpretation. In effect, they are treating the findings as if the association were statistically significant, or as if it might have been if the study had just gone a little differently. This is not justified. (Lang and Secic2 make the fascinating observation that “Curiously, P values never seem to ‘trend’ away from significance.”)

A proper use of the term trend refers to the results of one of the specific statistical tests for trend, the purpose of which is to estimate the likelihood that differences across 3 or more groups move (increase or decrease) in a meaningful direction more than would be expected by chance. For example, if a population of persons is ranked by evenly divided quintiles based on serum cholesterol level (from lowest to highest), and the risk of subsequent myocardial infarction is measured in each group, the researcher may want to determine whether risk increases in a linear way across the groups. Statistical tests that might be used for analyzing trends include the χ2 test for trend and the Cochran-Armitage test.

Similarly, a researcher may want to test for a directional movement in the values of data over time, such as a month-to-month decrease in prescriptions of a medication following publication of an article describing major adverse effects. A number of analytic approaches can be used for this, including time series and other regression models.

Instead of using these terms, the options are:

1. Delete the reported finding if it is not clinically important or a primary outcome. OR

2. Report the finding with its P value. Describe the result as “not statistically significant,” or “a statistically nonsignificant reduction/increase,” and provide the confidence interval so that the reader can judge whether insufficient power is a likely reason for the lack of statistical significance.

If the finding is considered clinically important, authors should discuss why they believe the results did not achieve statistical significance and provide support for this argument (for example, explaining how the study was underpowered). However, this type of discussion is an interpretation of the finding and should take place in the “Discussion” (or “Comment”) section, not in the “Results” section.

Bottom line:

1. The term trend should only be used when reporting the results of statistical tests for trend.

2. Other uses of trend or approaching significance should be removed and replaced with a simple statement of the findings and the phrase not statistically significant (or the equivalent). Confidence intervals, along with point estimates, should be provided whenever possible.—Robert M. Golub, MD

1. Mish FC, ed in chief. Merriam-Webster’s Collegiate Dictionary. 11th ed. Springfield, MA: Merriam-Webster Inc; 2003.

2. Lang TA, Secic M. How to Report Statistics in Medicine: Annotated Guidelines for Authors, Editors, and Publishers. 2nd ed. Philadelphia, PA: American College of Physicans; 2006:56, 58.