usage

One for All

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Timothy Gray, PhD, JAMA Network

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If you’re eating candy, it’s “3 Musketeers.”

If you’re reading about the friends of d’Artagnan, it’s The Three Musketeers.

Given that JAMA Network publications are technical instead of literary (A Piece of My Mind and Poetry notwithstanding), we would fall on the candy side of the divide between using numerals and using words (whether candy is technical is a discussion for another day).

The online abstract to Chapter 18.0 in the AMA Manual of Style, Numbers and Percentages, raises “the difficult question of when to use numerals and when to use words, and how to combine the two.” Note the tidy example of spelling a number as a noun. This difficulty is a factor in what I see as numeral inflation in the form of encroaching “1” use.

One of the most obvious places for numeral use is in identifying study populations.

For example, take this hypothetical Delphi consensus group: 5 physicians, 4 nurse practitioners, 3 patient advocates, 2 patient caregivers, and 1 health system leader.

One of the most obvious places for spelled number use is in idiomatic phrasing or in parts of speech. Section 18.2.3, Accepted Usage, advises using words “in circumstances in which use of the numeral would place an unintended emphasis on precise quantity.” When a number appears in text, what is the cutoff point between intended and unintended emphasis?

The manual suggests that “common sense” plays a role in editorial judgment, but one person’s “common sense” is another person’s “thanks anyway.”

As examples of avoiding unintended emphasis on quantity, the style manual lists “one-time variables,” “in one recent case,” and “has become one of the dominant topics.” However, in current publications you will find encroaching “1” use in various “1-time” constructions, the phrase “in 1 recent analysis,” and the wording “has become 1 of the leading reasons.”

How about these uses of encroaching 1?

  • “At least 1 moderate event.”
  • “In 1 large health system.”
  • “More than 1 time zone.”

Numeral use would seem to be justified by the idea that a moderate event, a large heath system, and a time zone are being counted.

Section 18.2.2 advises that we should spell “one” used as a pronoun or a noun, and these 1s are part of a noun phrase as the object of the prepositions “at least,” “in,” and “more than.”

I am “all for one.” It can be a relief to have an automatic edit to make in the name of upholding style, but many of us are not “one for all”—even in cases sanctioned by Accepted Usage. Not every “one” that seems countable should be “1,” and I offer this observation not to get editors into the weeds (an occupational hazard) but rather to help them avoid reflexive editing.

December 9, 2024

Can JAMA Network Authors Use Generative Artificial Intelligence to Create Content?

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Jennifer Sakhnovsky, MA, JAMA Network

The short answer is yes, but with a caveat: transparency is key. It is no secret that generative artificial intelligence (AI) models can create various types of content, including text, images, audio, and video. However, people’s feelings about using these tools in scientific research are mixed, with some academics showing concern and others embracing the new technology.

Regardless of personal opinion, people are using these tools—a 2023 Nature survey of more than 1600 scientists reported that nearly 30% reported using generative AI tools to assist with writing manuscripts.1 As 2023 began, many research articles already listed the generative AI tool ChatGPT as an author.2 By October of the same year, 87 of the 100 highest-ranked scientific journals saw the need to publish online guidance for authors on generative AI use for content creation at their publications.3

JAMA and the specialty journals in the JAMA Network were among those that provided online guidance, encouraging authors, reviewers, and editors to be transparent, responsible, and follow AI best practices in medical and scientific publishing. Importantly, the guidelines noted that “nonhuman artificial intelligence, language models, machine learning, or similar technologies do not qualify for authorship.”4 More information on ethical and legal considerations can be found in chapter 5.1.12 of the AMA Manual of Style.

If authors choose to use AI tools to create content or assist with manuscript creation, they must disclose such use in the Methods or Acknowledgements section of the article. The following example, found in chapter 3.15.13 of the AMA Manual of Style, can be used as an acknowledgment for an article that uses generative AI:

“The authors acknowledge using ChatGPT (GPT-3.5, OpenAI) for text editing to improve the fluency of the English language in the preparation of this manuscript on September 15, 2023. The authors affirm that the original intent and meaning of the content remain unaltered during editing and that ChatGPT had no involvement in shaping the intellectual content of this work. The authors assume full responsibility for upholding the integrity of the content presented in this manuscript.“

As presented in this example, the following information must be included in the disclosure of AI use for content generation:

  • Name of the AI software platform, program, or tool;
  • Version and extension numbers;
  • Manufacturer;
  • Date(s) of use; and
  • A brief description of how the AI was used and on what portions of the manuscript or content.

In addition to the above considerations, authors should provide the following additional information if AI was used in the study:

  • Prompt(s) used, their sequence, and any revisions;
  • Institutional review board/ethics review, approval, waiver, or exemption;
  • Methods or analyses included to address and manage AI-related bias and inaccuracy of AI-generated content; and
  • Adherence to a relevant reporting guideline if followed.

These guidelines emphasize accountability and human oversight when AI is used in medical publishing. To assist authors with adhering to new policies regarding AI, the JAMA Network’s automated manuscript submission system asks all authors whether AI was used for content creation.5 If AI tools were used to generate creative content (noncreative content, such as basic grammar and spelling checks, does not need to be disclosed), authors must provide specific information about their use and take responsibility for the integrity of the AI tools’ outputs.

JAMA Network authors are also asked to be aware of inputting identifiable patient information into an AI model, as well as potential copyright and intellectual property concerns. Limitations of AI tools should be included in an article’s Discussion section, including potential inaccuracies or biases, and, ideally, how these have been managed by the authors.

The JAMA Network also encourages authors to consult relevant EQUATOR guidelines (https://www.equator-network.org) depending on the type of study and AI use,4 including the following:

  • Reporting guidelines for clinical trial reports for interventions involving artificial intelligence (CONSORT-AI);
  • Guidelines for clinical trial protocols for interventions involving artificial intelligence (SPIRIT-AI);
  • Minimum information about clinical artificial intelligence modeling (MI-CLAIM);
  • Checklist for Artificial Intelligence in Medical Imaging (CLAIM);
  • MINimum Information for Medical AI Reporting (MINIMAR) for developing reporting standards for AI in health care; and
  • Updated guidance for reporting clinical prediction models that use regression or machine learning methods (TRIPOD-AI).

At the time of writing this blog post, several reporting guidelines are under development by the EQUATOR Network, including the following:

As AI tools continue to gain momentum and develop rapidly, editorial leaders of scientific journals are wise to guide the responsible use of such tools. This guidance may—and likely will—evolve over time. Like other publishers, the JAMA Network has moved expediently to publish AI usage guidelines. As is true for the journal’s other style rules, authors who publish in JAMA and the JAMA Network specialty journals will be guided to follow these guidelines into the future.

References

  1. Van Noorden R, Perkel JM. AI and science: what 1,600 researchers think. Nature. 2023;621(7980):672-675. doi:10.1038/d41586-023-02980-0
  2. Mazzoleni S, Ambrosino N. How artificial intelligence is changing scientific publishing—unrequested advice for young researchers II. Pulmonology. 2024;30(5):413-415. doi:10.1016/j.pulmoe.2024.04.011
  3. Ganjavi C, Eppler MB, Pekcan A, et al. Publishers’ and journals’ instructions to authors on use of generative artificial intelligence in academic and scientific publishing: bibliometric analysis. BMJ. 2024;384:e077192. doi:10.1136/bmj-2023-077192
  4. Flanagin A, Bibbins-Domingo K, Berkwits M, Christiansen SL. Nonhuman “authors” and implications for the integrity of scientific publication and medical knowledge. JAMA. 2023;329(8):637-639. doi: 10.1001/jama.2023.1344
  5. Flanagin A, Kendall-Taylor J, Bibbins-Domingo K. Guidance for authors, peer reviewers, and editors on use of AI, language models, and chatbots. JAMA. 2023;330(8):702-703. doi:10.1001/jama.2023.12500

November 27, 2024

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

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.

Embracing the Prepositional Power of Because of and Due to

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Jennifer Clare Ball, MA, JAMA Network

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

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

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

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

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

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

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

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

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

References

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

October 5, 2023.

Do Changes Actually Create Change?

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Amanda Ehrhardt, MA, JAMA Network

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

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

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

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

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

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

References

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

September 5, 2023.

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.

Style vs Substance—Is There Room for Both?

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Peter J. Olson, ELS, JAMA Network

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

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

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

The question is: does style always supersede substance?

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

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

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

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

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

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

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

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

Reference

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