nomenclature

Odds and Ends

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Amanda Ehrhardt, MA, JAMA Network

Earlier this year, several small updates were made to the AMA Manual of Style that clarified some lingering questions that had left some editors potentially perplexed (or perhaps possibly puzzled!).

To Repeat or Not to Repeat?

The debate between the use of repeat vs repeated is no longer an existential crisis worthy of a Danish prince. Chapter 11.1 has been updated to indicate that these terms can be used interchangeably (just like Rosencranz and Guildenstern).

Game, Dataset, Match

One author serves up data in a data set. Another author swings their racket, sending data across the court in a dataset. So who won?

According to Chapter 11.3, author 2 can celebrate with strawberries and cream: dataset is now the preferred spelling.

A Sensitive Matter

To differentiate high-sensitivity troponin T from contemporary assays, it is now being reported in ng/L, which has been updated accordingly in chapter 17.5.

So please add these changes to the Homerian catalog already in your editor’s mind, as we know the evolution of style changes is always an odyssey!

July 12, 2024

Language to Discuss Suicide

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Miriam Cintron, BA, JAMA

Although often regularly used in the past, the term committed suicide may imply that the act of suicide is criminal or morally wrong.1

Likewise, referring to a suicide attempt as a “success” or “failure” implies that “the person who died by suicide has accomplished or not accomplished (a failure) the act of suicide”1 or that death was a favorable outcome.2

Factual and judgment-free language is preferred.1 Language that is careful not to stigmatize suicide, suicidal behavior, or mental health issues3 should always be used. For that reason, terms such as died by suicide or suicide attempt should be used. Such terms contribute to destigmatizing suicide.2

The term suicide should also not be used out of context (eg, “political suicide”) because this may desensitize readers to the term2 or seem insensitive.

Person-first language, which aligns with existing AMA Manual of Style guidelines (chapter 11.12.6), should be used (eg, “person who attempted suicide” instead of “suicide attempter” or “person with suicidal ideation” instead of “suicidal person”).

Avoid:

  • Committed or completed suicide
  • Unsuccessful or successful suicide attempt
  • Failed suicide attempt
  • Suicide epidemic
  • Killed themself
  • Took their own life
  • Ended their life

Preferred:

  • Died by suicide
  • Death by suicide
  • Suicide death
  • Suicide attempt
  • Fatal suicide behavior
  • Person with suicidal ideation

The term “intentional self-harm” should not be used interchangeably with “suicide attempts.”

References

  1. Suicide Prevention Alliance. Changing how we view suicide prevention: suicide language. Accessed March 11, 2024. https://www.suicidepreventionalliance.org/about-suicide/suicide-language/
  2. World Health Organization. Preventing suicide: a resource for media professionals: update 2023. Accessed March 11, 2024. https://iris.who.int/bitstream/handle/10665/372691/9789240076846-eng.pdf
  3. International Association for Suicide Prevention. The language of suicide. Accessed March 11, 2024. https://www.iasp.info/languageguidelines/

May 31, 2024

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.

New Mpox Name for Monkeypox Disease

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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

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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

Pregnancy Language Update

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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.

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

Updates to Reporting Black and White as Racial Categories

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Everyone in the business of communication has a responsibility to use and promote the use of clear and accurate language, with words that reflect the world around us. As evidenced by perpetual updates to style manuals, dictionaries, and other resources, nomenclature is never a static enterprise.

Specifying the race or ethnicity of an individual can provide information about the generalizability of the results of a specific study. Because many individuals may have mixed heritage, a racial or ethnic distinction should not be considered absolute, and ideally it should be based on a person’s self-designation.

In the JAMA Network journals, we ask authors to provide an explanation of who classified individuals’ race, ethnicity, or both, the classifications used, and whether the options were defined by the investigator or the participant. In addition, the reasons that race/ethnicity were assessed in the study also should be described (eg, in the Methods section and/or in table footnotes).1

We have received a number of queries about the presentation of racial and ethnic terms in the AMA Manual of Style, in particular the manual’s style current preference for using lowercase for the term black. The 11th edition specifies capitalizing racial and ethnic terms that derive from geographic nouns such as Asian, Alaska Native, and Latina (chapter 10.3.2, Capitalization, Proper Nouns, Sociocultural Designations), but the terms black and white have been lowercased as racial designators (because they are not derived from proper nouns).

However, ongoing and recent events spurred us to reconsider this style recommendation. The manual’s committee met several times, conducted research, and sought input on this issue from multiple sources. We deem this issue too important to wait for change.

In weighing the options (keep black and white lowercase, capitalize just Black, or capitalize both Black and White), we reviewed usage recommendations in a variety of sources, including other style manuals (Chicago Manual of Style,2APA style,3 and the AP Stylebook4), writing by an array of scholars, and guidance on diversity from academic and government sources, such as the US National Institutes of Health.5

The committee has concluded that we will now capitalize both Black and White, which aligns with the capitalization preference applied to other racial/ethnic categories. We acknowledge that there may be instances in which a particular context may merit exception to this guidance, for example, in cases for which capitalization could be perceived as inflammatory or otherwise inappropriate.

The online style manual will be updated to reflect this change, including the section on race/ethnicity in the Usage chapter  (chapter 11.12.3, Usage, Inclusive Language, Race/Ethnicity) and the aforementioned entry in the Capitalization chapter.

There are additional language issues to consider, including use of “other” as a category and abbreviating racial and ethnic terms. The nonspecific “other” is sometimes used for comparison in data analysis but may also be a “convenience” grouping/label that should be avoided, unless it was a prespecified formal category in a database or research instrument.

In such case, the categories included in “other” should be defined and reported. Authors and researchers are advised to be as specific as possible when reporting on racial/ethnic categories (even if these comprise a small percentage of participants).

Example (not recommended): “The study included 200 White individuals, 100 Black individuals, and 100 of other race/ethnicity.”

In this situation, an editor should ask the author for further explanation, considering that the racial/ethnic background of a quarter of the study is not provided.

Example (preferred): “The study included 200 White individuals, 100 Black individuals, and 100 of other race/ethnicity, which included Chinese, Japanese, Korean, and Native Hawaiian/Pacific Islander and those who reported multiple categories.”

Racial and ethnic terms also should not be abbreviated unless necessary for space constraints (eg, in tables and figures with clear expansion in explanatory footnotes or legends).

The manual’s committee will continue to explore changing trends in usage of other racial and ethnic terms as well, such as Latinx. As with all changes to the style manual, we welcome input from readers. The update to the manual online will be implemented as soon as possible, and the JAMA Network journals will begin to use Black and White as we edit new content.–Stacy Christiansen and Tracy Frey, for the AMA Manual of Style committee

References:

1. Instructions for Authors. JAMA. Updated April 13, 2020. Accessed June 19, 2020.  https://jamanetwork.com/journals/jama/pages/instructions-for-authors#SecReportingRace/Ethnicity

2. Black and White: a matter of capitalization. CMOS Shop Talk. Posted June 22, 2020. Accessed June 22, 2020. https://cmosshoptalk.com/2020/06/22/black-and-white-a-matter-of-capitalization/

3. APA Style. Racial and ethnic identity. Accessed June 20, 2020. https://apastyle.apa.org/style-grammar-guidelines/bias-free-language/racial-ethnic-minorities

4. AP Stylebook. Race-related coverage. Accessed June 22, 2020. https://www.apstylebook.com/race-related-coverage

5. Racial and ethnic categories and definitions for NIH diversity programs and for other reporting purposes. National Institutes of Health. Released April 8, 2015. Accessed June 20, 2020. https://grants.nih.gov/grants/guide/notice-files/not-od-15-089.html

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

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