abbreviations

New Abbreviations for Liver Diseases

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Timothy Gray, PhD, JAMA Network

The designation “nonalcoholic fatty liver disease (NAFLD)” is no longer accepted across JAMA and the JAMA Network journals, except to reflect the language used in data collection for a study (or search terms for a review).

The directive is based on the recommendations of the American Association for the Study of Liver Diseases and the European Association for the Study of the Liver, as well as the Latin American Association for the Study of the Liver.

In collaboration with hepatologists, gastroenterologists, pediatricians, endocrinologists, hepatopathologists, public health and obesity experts, colleagues from industry, regulatory agencies, and patient advocacy organizations, a consensus was developed via the Delphi process for a change in nomenclature.1

The term chosen to replace NAFLD is “metabolic dysfunction–associated steatotic liver disease (MASLD).” In the previous designation, the term nonalcoholic may have been confusing for patients and physicians. The word fatty also has stigmatizing and negative connotations.

The same committee process resulted in another designation change that will be implemented across JAMA and the JAMA Network journals. The designation “nonalcoholic steatohepatitis (NASH)” is now called “metabolic dysfunction–associated steatohepatitis (MASH)” to avoid trivializing the diseases or confusing patients with the possible connotations of the term nonalcoholic.2

It is hoped that these updates will clarify what the diseases are instead of what they are not.

The AMA Manual of Style has added these abbreviations and expansions to the list of clinical terms in chapter 13.11.

References

  1. Rinella ME, Lazarus JV, Ratziu V, et al. A multisociety Delphi consensus statement on new fatty liver disease nomenclature. Hepatology. 2023;78:1966-1986.
  2. Eskridge W, Cryer DR, Schattenberg JM, et al. Metabolic dysfunction–associated steatotic liver disease and metabolic dysfunction–associated steatohepatitis: the patient and physician perspective. J Clin Med. 2023;12(19):6216.

May 24, 2024.

A Short Update on Long COVID

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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

Updated Guidance on Reporting Race and Ethnicity: Let’s Start With the Why

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Kim Penelton Campbell, BS, JAMA Network

I have used many adjectives to describe myself, but I’ve never referred to myself as other. When teachers called my name during morning attendance, I responded by saying “Here.” I never said, “Invisible.”

In medical literature, the failure to fairly and respectfully recognize and include individuals of all races and ethnicities can severely adversely affect patients’ lives and the quality of care they receive. It can misinform clinicians. It can compromise the credibility of a journal.

This means that race and ethnicity data should be reported in a way that encourages fairness, equity, consistency, and clarity in medical and science journals.1

Changing the b in Black and the w in White to uppercase lettering when describing race is not about mere political correctness—these changes are part of a conscientious movement toward equitable delivery of health care services to all people.

The objective of this post is to emphasize that updated guidance about the reporting of race and ethnicity is important, not because the AMA Manual of Style says so, but because inattentiveness to these changes can contribute to unconscious bias and ultimately affect how patients are treated or unintentionally mistreated.

Bias, when unintentional, is not mitigated—it remains bias all the same. Unintentional bias can occur simply because the writer or editor is removed from the patient’s life experience. When the writer or editor is unaware, they may not recognize how insensitive wording can affect the reader.

Example: “Adherence to the prescribed medication was higher among White patients than among Blacks.”

Consequence: Does this mean that if you are White you are a patient but if you are Black you are nothing? What is a Black?

When a person is called a Black instead of a Black patient or a patient who is Black, the wording detracts from that person’s humanity.

Likewise, use of lowercase lettering for Black and White, as well as referring to people as minorities instead of as members of a racial or ethnic minority group, also diminishes their humanity. Stating race or ethnicity in noun form can be interpreted pejoratively and is akin to labeling patients by their disease (eg, the blind, schizophrenics, epileptics) instead of putting the individual first (eg, a person with schizophrenia).2 Other things that can be interpreted pejoratively and should be avoided are using the term mixed race, which can carry negative connotations, instead of multiracial or multiethnic, merging race and ethnicity with a virgule (ie, race/ethnicity) rather than recognizing the numerous subcategories within race and ethnicity with the term race and ethnicity, and using abbreviations for racial and ethnic terms. Although the writer or manuscript editor may not have intended to negatively portray a group of people, the potential effect on readers remains unchanged.

  • To potential authors, the absence of a single word can indicate that a journal is insensitive to the health care needs of a population of patients.
  • To clinicians with the same racial or ethnic background as the one negatively represented, this can promote the inference that the journal has no diversity on its editorial board or staff.
  • To a practicing physician, this language can translate to offensive or insensitive communication when speaking with a patient or a patient’s family member.
  • To a patient, this wording can indicate that the medical community views individuals from their racial or ethnic group as nonpersons—unseen, unconsidered, and uncared for.
  • For all of these individuals, this can deepen a sense of mistrust.

Language that excludes a racial or ethnic group can subtly influence a medical trainee to “unsee” the humanity in people who are from a different background. If their research and educational sources are written or edited without intercultural competence, the medical trainee may unintentionally miscommunicate or make incorrect assumptions about patients from other backgrounds. This breach can interfere with a clinician’s understanding of the patient and, in response, impede the patient’s trust in the clinician.

Among some patients from communities that have been medically underserved or ignored, information about medical mistreatment can transcend generations. Past miscommunication can lead to mistrust, which can then lead to fear.

A family may never forget that Grandma never came home from the hospital and that no clinician took the time to explain why. Although this family was made to feel invisible because of miscommunication, it is quite possible that the clinician intended no disrespect and had no knowledge of how the family was affected. A patient with a historic burden of oppression can potentially interpret disrespectful communication as an initial step down the road to medical abuse.

My godfather once expressed such fear. He was Black, the clinicians were White, and he had grown up in Mississippi during the 1940s. Although I asked, he refused to ever repeat details of what was said by these physicians many years ago. But decades later, when I was a teenager and a novice driver, my godmother phoned and urgently asked that I come to their home immediately to rush him to our local VA hospital.

On my arrival, she exclaimed, “I think he had a heart attack while gardening in the back yard!” I said, “I’ll call 911. The ambulance will get him there faster.” Then, she stopped me. She pleaded that I drive him there myself. As I rushed to his aid, she continued by telling me that he would die of fear if an ambulance came to their home. She told me that I must speak for him when we arrived, remain by his side, and do everything in my power to keep him calm.

He cried like a baby during the entire ride. He was afraid. He was humiliated about expressing fear in my presence. I did not know what to say. I just kept driving. My heart was broken.

This brief story is an example of deep-seated fear that some Black people experience in a health care setting, a fear that can only begin to be abated with a conscientious effort to ensure that language humanizes Black patients and patients from all racial and ethnic backgrounds.

How does one address suboptimal reporting on race and ethnicity?

  • First, follow the guidelines.
  • Second, write and edit with a raised antenna. Look for what is unsaid in addition to what is written on the page.
  • Try to interpret as if you are a person from a racial or ethnic group unlike your own. Think about how you would you feel as the subject or nonsubject of the article.
  • Consider how wording can be misinterpreted.
  • Consider how inattentiveness to detail can affect the health, safety, or life of someone who is misrepresented.
  • Edit responsibly, but without fear of respectfully questioning the author.

Remember: no one is invisible, and no one is other.

“Not everything that is faced can be changed, but nothing can be changed unless it is faced.”3

James Baldwin

References

  1. Flanagin A, Frey T, Christiansen SL; AMA Manual of Style Committee. Updated guidance on the reporting of race and ethnicity in medical science journals. JAMA. 2021;326(7):621-627. doi:10.1001/jama.2021.13304
  2. Christiansen SL, Iverson C, Flanagin A, et al, eds. Correct and preferred usage. In: AMA Manual of Style: a Guide for Authors and Editors. 11th ed. Oxford University Press; 2020:547-548.
  3. Baldwin J. As much truth as one can bear. New York Times. January 14, 1962: Book review 1, 38. https://www.nytimes.com/1962/01/14/archives/as-much-truth-as-one-can-bear-to-speak-out-about-the-world-as-it-is.html

IQR You Serious?!

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Amanda Ehrhardt, MA, JAMA Network

Compared with navigating the treacherous waters of causal language, or throwing down the proverbial gauntlet against the terms renal and mutation, upholding AMA Manual of Style rules regarding abbreviations and when to expand them may seem like Not That Big of a Deal. If you had to plot the interquartile range for feelings surrounding this task, it may go something like this:

The median response toward expanding an abbreviation was “Meh” (interquartile range, “Yuck!” to “Yay!”).

However, one of the beautiful things about style rules is that they evolve and adapt with changes in cultural and societal outlooks and the editing process, and they occasionally throw you a colorful floatie while you’re swimming in copy.

That interquartile range that I’ve mentioned several times now? Well, check out the Common Abbreviations and Expansions table in the updated version of 13.11.

That’s right, it’s IQR! From beginning to end! No expansion necessary anymore!

So perhaps we should reassess that statement from the beginning?

The median response to learning that IQR no longer needs to be expanded was “Woohoo!” (IQR, “Cool.” to “Best thing ever!”).

Mxed Messages

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H Ford, they/them/theirs, Manuscript Editor, JAMA Network

There is a particular type of online pedant whose view of the English language has the effect of invalidating strangers’ sexual and gender identities. Much physical and digital ink has been spilled discussing the validity of the singular “they” when referring to a single gender-unknown subject of discussion and as an intentional personal pronoun.

I will not relitigate this issue here, but it should suffice that the AMA Manual of Style (sections 11.12.2 and 7.2.3.2, specifically) concurs with the Chicago Manual of Style, the AP Stylebook, and historical use (eg, Shakespeare and Emily Dickinson) in permitting the singular they.

Now with that said, let’s talk about respecting our queer friends, family, colleagues, and authors by using the honorific Mx! According to Merriam-Webster, the first use of the gender-neutral honorific Mx was in the 1970s, but its widespread use has only gained momentum within the past 5 to 10 years.

It can be helpful to compare Mx with Ms, another relatively recently developed honorific. Although the very first publication of the honorific Ms was in a 1901 article and was likely more focused on expediency of the address than the linguistic and sociopolitical ramifications of defining a woman by her social status, most people’s understanding of Ms is rooted in Gloria Steinem’s eponymous magazine (https://www.nytimes.com/2009/10/25/magazine/25FOB-onlanguage-t.html).

Mx is an honorific that affords the same respect to nonbinary and gender-nonconforming people that has traditionally been given to gender-conforming individuals who do not hold advanced degrees. As awareness grows of the existence of gender identities outside the male/female binary, more people every day feel comfortable publicly identifying as nonbinary, genderqueer, and agender.

The widespread use of Mx signals acknowledgment of and respect toward these individuals. Yet there is a broader application of the honorific Mx that we haven’t fully considered, one that is as practical as it is gender inclusive. Just as the title Ms allowed us to ask why a woman’s marital status affected how she was addressed, Mx should allow us to ask why a person’s gender should matter to any respectful form of address.

For these reasons, JAMA Network now offers Mx as a salutation for submissions to all of its journals!

As editors and writers, we occupy a unique position in the process of the legitimization of nascent linguistic terms. Let’s use that power for good!

Abbreviating the Pandemic

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If you’ve followed AMA style for at least the last several years, you may remember this big (welcome) announcement:

The companion abbreviation “AIDS” was given expansion-exempt status even before this with the 2007 publication of the 10th edition. It took some time for HIV to catch up.

Why did we decide that these 2 abbreviations no longer needed expansion? For one, they are ubiquitous, instantly recognizable (at least to English-reading audiences), and are long and cumbersome to write out in full.

After more than a year of publishing coronavirus-related content (JAMA’s first article was published in January 2020 by Fauci and colleagues), the AMA Manual committee has determined that COVID-19 and SARS-CoV-2 meet those same criteria to forgo expansion: ubiquity, familiarity, and cumbersome expansions.

  • Before: Protection against coronavirus disease 2019 (COVID-19) is mediated in large part by an immune response directed against the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spike protein.
  • After: Protection against COVID-19 is mediated in large part by an immune response directed against the SARS-CoV-2 spike protein.

While we all hope to soon have this pandemic in our collective rearview mirror, it is not likely that we will forget coronavirus disease 2019 or severe acute respiratory syndrome coronavirus 2.–Stacy Christiansen, Chair, AMA Manual of Style

Nephrology Nuance

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When you’re in quarantine, you have to look for little things to spark joy in your life. I’ve found myself getting excited when I edit an article for which new AMA style guide updates come into play. Recently, while editing an article focusing on patients with end-stage kidney disease, I had the chance to refresh my knowledge on the new guidelines in the 11th edition of the AMA Manual of Style regarding nephrology nomenclature (14.18).

In accordance with the international efforts put forth by KDIGO (Kidney Disease: Improving Global Outcomes), which focus on making terminology more patient-friendly, precise, and universal, the 11th edition has updated the nomenclature used to describe kidney function and disease.

Updates on language choice include:

Kidney vs renal: Select the more patient-friendly term (ie, kidney). Also, avoid using both terms in parallel, as this could lead to confusion over different abbreviations for the same condition (eg, RRT [renal replacement therapy] and KRT [kidney replacement therapy]).

Kidney failure vs end-stage renal disease: Kidney failure is the preferred term except when referring to eligibility for medical care under US legislation or other regulations. Patients with kidney failure should be further described by the presence or absence of therapy by dialysis, transplant, or conservative care and by symptom severity.

Decreased glomerular filtration rate: Use this instead of decreased kidney function. Kidneys execute various functions, not just glomerular filtration, so precision in terminology is preferred.

The final recommendations and a complete glossary of related terms will be available in the near future and used to inform an update to this chapter in the manual online. –Suzanne Walker

Exhibit A

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There are times when authors question whether they really need copyediting; occasionally, when edits are especially light and authorial moods particularly dark, I even wonder if the idea of skipping it might even be right. But I am never swayed long, because to copyeditors, it is usually clear how tricky English can be, even in its smallest and seemingly simple parts.

Consider exhibit A: a.

English offers 2 indefinite articles, a and an, and the 11th edition of the AMA Manual of Style includes a simple-but-not-easy rule of when to use them: the a goes before consonant sounds and the an before vowel sounds. The hard part is that the sounds, not the written letters, are the deciding factor.

Because English is nonphonetic, words that start with written consonants (such as h) might begin with a vowel sound (as with hour), and those starting with a vowel may be said as an initial consonant sound (as with one). The only way to know the correct article to use is to know how each word is said aloud.

Medical writing further complicates this with prodigious abbreviations. Exactly half of the letters in the English alphabet, including 8 consonants, are said with initial vowel sounds; for example, an N is pronounced “en” and thus must follow an an when it occurs in acronyms such as NSAID. (The other 7 such consonants are F, H, L, M, R, S, and X.)

Making things even worse, acronyms that are pronounced as words (eg, LASIK) must be matched with the indefinite article that goes with their initial sound (in LASIK, “la-,” which means an a should be used), not the sound that matches the spoken letter (the “el” sound of L, which would go with an an). This means it is essential to know which acronym is said as a word and which as a mere cluster of letters.

It is a relief that nearly all of the letter names that start with consonant sounds (B, C, D, G, J, K, P, Q, T, W, Y, and Z) are for actual consonants, making the a their default article—except that, of course, Y is a consonant (said “ya”) and a vowel (“ee”) with a rather inexplicable spoken name (“why”), and…. well, you get the picture. The complexity never ceases.

Anyone can get this stuff wrong, even native English speakers. For authors using English as a foreign language, including those who largely write in rather than speak the language (and therefore do not sound it out much) and those whose native languages do not include indefinite articles (eg, Japanese, Hindi, Polish, many more)—this might be pretty hard to manage. For everyone, there are copyeditors. We hope to handle this and all the rules in our 1200-page style manual, from a to z.–M. Sophia Newman

Birthplaces and Social and Economic Descriptions of Countries

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There are more examples of bias-free language in the new edition of the AMA Manual of Style, including 2 new entries in the Correct and Preferred Usage chapter, one discussing the birthplace of study participants and the other describing countries in terms of their economic and social factors.

The first new entry discusses not using the term foreign-born. We see this descriptor all the time in studies describing participants who aren’t from the country where the study was conducted but this term may be considered derogatory and should be avoided.

The easiest solution is to say that the person was born outside the country of interest or born abroad. For example, for a study that took place in the United States, use “non–US born participants” or “participants born outside the United States.” Also, it’s preferred to use US or United States vs American or America for clarity.

The second new entry is a little trickier and refers to adjectives used to describe a nation, region, or group in which most of the population lives on far less money—with far fewer basic public services—than the population in wealthy countries.

There is no universal, agreed-on criterion for describing a country in terms of its economic or human “development” and which countries fit these different categories, although there are different reference points, such as a nation’s gross domestic product per capita or the limited nation’s Human Development Index (HDI) compared with that of other nations.

The appropriate term should be based on context and respectfully reflect a specific country’s economic and social situations. The AMA Manual of Style suggests limited-income, low-income, resource-limited, resource-poor, and transitional.

Avoid the terms first world/third world and developed/developing. The term third world is pejorative and archaic, and while developing might seem like an acceptable alternative, it too can be considered pejorative and insensitive to the many complexities of metrics used to measure economic, political, resource, and social factors.

Best practice is to avoid such general terms and use specific terms that reflect what is being compared, such as low-income or high-income for an article comparing countries based on measures such as gross national product per capita.–Tracy Frey

Variants for Mutation

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Other than in reference to the Teenage Mutant Ninja Turtles, the anthropomorphic crime-fighting turtles who love pizza, there are few instances in which the term mutation, or any form of the word, has a positive connotation.

Because of this negative connotation and the confusion regarding the definitions of the terms mutation and polymorphism across disciplines, the Human Genome Variation Society recommends avoiding these terms.

The 11th edition of the AMA Manual of Style reinforces this recommendation, as well as the suggestion to instead use the terms sequence variant, sequence variation, alteration, or allelic variant.

In light of this recommendation, the term single-nucleotide variation (SNV) is more frequently being used than single-nucleotide polymorphism (SNP). To aid readers’ understanding during this transition, it is suggested that SNV be used at first mention, with SNP included in parentheses as follows: “…SNV (formerly SNP).” This should help authors and readers adjust to the recommended language.–Nicole FioRito