usage

Aegis

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“Recognizing that the genetic contribution to health disparities is likely to be relatively limited is not the only reason to question the wisdom of promoting genetic research under the aegis of health disparities.”1

“In several examples published under the aegis of the [Agency for Healthcare Research and Quality], the benefit side rests on the data from randomized controlled trials….”2

“[T]his definition and associated regulations have become de facto rules for US academic and other research institutions and are applied to any work done by their employees or under their aegis regardless of the source of funding.”3

While somewhat infrequently encountered in medical writing, aegis is occasionally used in content related to health policy, institutional oversight, or the conduct of research. It also is occasionally used to refer to a journal’s vouching for the validity of data or other findings published in its pages; when such validity is called into question, a journal may issue a full retraction or simply “withdraw aegis,” ie, issue a statement to the effect that the journal is no longer responsible for the data.4

In its original sense, aegis (Greek aigis [goatskin]) referred to the shield or protective cloak worn by Zeus or Athena in the myths of ancient Greece.5 In the centuries since, the word has by association come to be used idiomatically to indicate defense (“Feeling is the aegis of enthusiasts and fools.”6) or guidance or influence (“They made their valuable individual contributions, but under the Ellington aegis they found themselves constantly enriched musically.”6). Similarly, the word is perhaps most often used in the construction “under the aegis of” to express patronage or sponsorship (“under the aegis of the museum”) and, especially, protection (“a child whose welfare is now under the aegis of the courts”).5

All of which is perfectly comforting. However, the classical roots of the word are far less benign. Whereas aegis-like shields appear in Egyptian, Nubian, and Norse mythology and art,7,8 the most elaborate account of the origins and attributes of the aegis comes, as suggested above, from the narratives of ancient Greek mythology and literature, in which it is consistently depicted as an object possessing fearsome supernatural power.

In one such narrative, the goat deity Amaltheia suckles the infant Zeus, who then—in the curiously detached manner so frequently encountered in mythological accounts—breaks off her horns and flays her hide. From one of her horns Zeus fashions the cornucopia, or horn of plenty; from her hide, he fashions the shield or cloak that would come to be called the aegis, which he then wears, on the counsel of an oracle, into battle against the marauding Titans.9 However, in the hands of Zeus, king of the gods, the aegis is more than a protective device; when in his wrath he shakes the aegis from his perch atop Mount Olympus, thunder crashes, bolts of lightning slash the sky, and fierce storms devastate the land.10 Moreover, in the Iliad, Homer describes the device as the “tempestuous terrible aegis, shaggy [and] conspicuous… given to Zeus to the terror of mortals.”11

But the aegis is associated with deities other than Zeus. In the Iliad, for example, Zeus lends the aegis to Apollo, who wields it to push his enemies back to their ships12; in other accounts, Zeus lends the aegis to his daughter, Athena, goddess of war,12 or presents it to Athena after his conquest of the Titans.9 In the most colorful account, Zeus swallows his wife, Metis, whole—after which Athena is born from Zeus’ head, emerging fully formed and bearing the aegis and other weapons of war.13 Regardless of how Athena comes to possess the aegis, however, in her hands it becomes more formidable still. For example, in the Iliad Homer reverently describes the aegis as no mere goatskin but rather as “ageless and immortal,” worn by “bright-eyed Athene” and adorned with tassels of the purest gold12; moreover, elsewhere in the Iliad he describes the aegis as a dramatic golden cloak fashioned by Hephaistos, god of fire and metalwork,14 to resemble a scaly skin like that of a snake, linked and fringed with writhing serpents, and bearing in its center the severed head of the Gorgon Medusa, eyes rolling and scalp also bristling with serpents.11

Charming as this may be, given the provenance of the word and the fell associations that come with it, how did aegis, apart from its military associations, come to be used to express defense or protection? Perhaps more puzzling, how did it come to be used to express benevolent guidance, influence, or patronage? A possible clue is that whereas early accounts often depict Athena as cultivated, civilized, urbane, and wise, the economy of ancient Greece was bolstered by military pursuits, and in short order Athena came to be depicted as the goddess of war—although, importantly, her military might was tempered by the cultivation and divine wisdom earlier attributed to her.15 Thus, Athena is sometimes viewed as having 2 sides. The first is characterized as wrathful, tempestuous, and destructive; however, the other is characterized as divinely beneficent and endowed with the inclination and ability to grant the gifts of aid, wisdom, and protection to favored mortals.16 The power of both sides is wielded through the supernatural power of the aegis—hence Homer’s description of the device in the Iliad and its depiction in visual art as inky black or brilliant gold.11,12,16

Interestingly, however, while Athena extends divine beneficence and protection—backed by the wrathfulness also attributed to her—she does not authorize those mortals fortunate enough to come under her favor to act on her behalf. Thus, whereas in current usage aegis is correctly used to express defense, protection, guidance, influence, patronage, or sponsorship, its use to indicate “under the jurisdiction of” is considered incorrect.17 —Phil Sefton, ELS

1. Sankar P, Cho MK, Condit CM, et al. Genetic research and health disparities. JAMA. 2004;291(24):2985-2989.

2. Vandenbroucke JP, Psaty BM. Benefits and risks of drug treatments: how to combine the best evidence on benefits with the best data about adverse effects. JAMA. 2008;300(2):2417-2419.

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; 2007:157.

4. Hammerschmidt DE, Franklin M. The limits and power of peer review. Minn Med.

http://www.minnesotamedicine.com/PastIssues/PastIssues2006/June2006/CommentaryHammerschmidtJune2006/tabid/2527/Default.aspx. June 2006. Accessed February 13, 2013.

5. Aegis. Merriam-Webster’s Collegiate Dictionary. 11th ed. Springfield, MA: Merriam-Webster Inc; 2003:19.

6. Aegis. The Compact Oxford English Dictionary. 2nd ed. Oxford, England: Oxford University Press; 1991:22.

7. Aegis: in Egyptian and Nubian mythology. Museum of Learning Web site.

http://www.museumstuff.com/learn/topics/aegis::sub::In_Egyptian_And_Nubian_Mythology. Accessed February 15, 2011. 8. Aegis: in Norse mythology. Museum of Learning Web site. http://www.museumstuff.com/learn/topics/aegis::sub::In_Norse_Mythology. Accessed February 15, 2011.

9. Amaltheia. Theoi Project Web site. http://www.theoi.com/Ther/AixAmaltheia.html. Accessed February 13, 2013.

10. Zeus. Theoi Project website. http://www.theoi.com/Olympios/Zeus.html. Accessed February 13, 2013.

11. Hephaistos Works 2. Theoi Greek Mythology Web site. http://www.theoi.com/Olympios/HephaistosWorks2.html. Accessed February 13, 2013.

12. Teleporter: aegis mound. Entropia Planets Web site. http://www.entropiaplanets.com/wiki/Teleporter:Aegis_Mound. Accessed February 13, 2013.

13. Athena. Theoi Project Web site. http://www.theoi.com/Olympios/Athena.html. Accessed February 13, 2013.

14. Hephaistos. Theoi Project Web site. http://www.theoi.com/Olympios/Hephaistos.html. Accessed February 13, 2013.

15. Athena. Encyclopedia Britannica Online. http://www.britannica.com/EBchecked/topic/40681/Athena?anchor+ref85160. Accessed February 13, 2013.

16. Deacy S, Villing A. What was the colour of Athena’s aegis? J Hellenic Stud. 2009;129:111-129. http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=6779888. Accessed February 13, 2013.

17. Bernstein TM. The Careful Writer: A Modern Guide to English Usage. New York, NY: Athaneum; 1985:29.

Emergency, Emergent, Urgent

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As I was editing a manuscript on patients undergoing surgery for brain tumors, I came across the sentence, “Patients who required emergency care were admitted to the hospital and classified as needing emergent or urgent surgery.” As I reread the sentence, the terms emergency, emergent, and urgent started to swim before my eyes, each backstroking to take the place of the other. Soon I was reading, “Patients who required urgent care were admitted to the hospital and classified as needing emergency or emergent surgery.” And then, “Patients who required emergent care were admitted to the hospital and classified as needing emergency or urgent surgery.” What was going on? Was my late-night habit of perusing stylebooks and usage guides before bedtime starting to produce side effects (oops, I mean adverse effects)? Was I no longer able to delineate the difference between commonly used medical terms? I had to take action.

Diligent medical copy editor that I am, I turned to my bookshelf, which is chock full of dictionaries and grammar, usage, and editing books. Now I would be able to solve this conundrum. I would take this problem step by step, or rather word by word, and find the resolution. Here’s what I found:

Emergency

Stedman’s Medical Dictionary1 defines emergency as “an unexpected development or happening; a sudden need for action.”

Dorland’s Illustrated Medical Dictionary2 defines emergency as “an unlooked for or sudden occurrence, often dangerous, such as an accident or an urgent or pressing need.”

Merriam-Webster’s Collegiate Dictionary3 defines emergency as “an unforeseen combination of circumstances or the resulting state that calls for immediate action.”

Consensus! There’s nothing a copy editor likes better.

Resolution: An emergency is basically an unexpected event that requires immediate action.

Emergent

Dorland’s defines emergent first as “pertaining to an emergency” and second as “coming into being through consecutive stages of development, as in emergent evolution.”

Stedman’s omits the definition stemming from the term emergency and defines emergent first as “arising suddenly and unexpectedly, calling for quick judgment and prompt action” and second as “coming out; leaving a cavity or other part.”

Merriam-Webster’s defines emergent as “arising unexpectedly” or “calling for prompt action.”

This one’s a little trickier. Dorland’s relates the term emergent to emergency and Stedman’s and Webster’s simply define emergent as the adjectival form of the noun emergency. So, is there a difference between these 2 words or are they synonymous? It was time to reach deeper into my bookshelf.

I first turned to the classic text A Dictionary of Modern English Usage by H. W. Fowler.4 I knew Fowler wouldn’t let me down. Fowler’s entry on emergence and emergency reads as follows, “The two are now completely differentiated, -ce meaning emerging or coming into notice, and -cy meaning a juncture that has arisen, especially one that calls for prompt measures.”

After some additional research, I found this entry in Common Errors in English Usage by Paul Brians5: “The error of considering ‘emergent’ to be the adjectival form of ‘emergency’ is common only in medical writing, but it is becoming widespread. ‘Emergent’ properly means ‘emerging’ and normally refers to events that are just beginning—barely noticeable rather than catastrophic. ‘Emergency’ is an adjective as well as a noun, so rather than writing ‘emergent care,’ use the homely ‘emergency care.’”

Eureka! Emergent means beginning to arise and emergency means arising unexpectedly.

Resolution: Use emergent to mean emerging (as in Dorland’s section definition of “coming into being through consecutive stages of development, as in emergent evolution”) and emergency to mean an unexpected event that calls for immediate attention.

But then what about urgent?

Urgent

Neither Dorland’s nor Stedman’s defines the term urgent.

Merriam-Webster’s Collegiate Dictionary defines urgent as “calling for immediate action.”

So, can urgent and emergency be used interchangeably? The Children’s Hospital of Wisconsin website provides a list of surgery types. It groups urgent or emergency surgery and defines it as surgery “done in response to an urgent medical need, such as the correction of a life-threatening congenital heart malformation or the repair of injured internal organs after an automobile accident.”6 However, the website Trivology.com states, “There is major difference between elective, urgent, emergency surgery. In urgent surgery we can wait until the patient’s health is unwavering but it has to be performed in 1-2 days. But emergency surgery needs to be performed without any impediment otherwise there will be colossal risk to patient’s life.”7

Therefore, in medical editing, be careful of changing emergency to urgent because emergency means immediate attention is required and urgent indicates quick but not immediate action is required. There is no such thing as emergent surgery unless you mean surgery that is just beginning.

Resolution: Although emergent and urgent both indicate calls for swift action, urgent is more, well, urgent.

Well, there you have it. I guess that original sentence I was editing makes sense after all. “Patients who required emergency surgery [immediate surgery because of the unforeseen nature of the incident] were admitted to the hospital and classified as needing emergent [with a few hours] or urgent [within 24 hours] care.”— Laura King, MA, ELS (January 2013)

1. Stedman’s Medical Dictionary. 26th ed. Baltimore, MD: Williams & Wilkins; 1995.

2. Dorland’s Illustrated Medical Dictionary. 32nd ed. Philadelphia, PA: Elsevier Saunders; 2012.

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

4. Fowler HW. A Dictionary of Modern English Usage. 2nd ed. Oxford, England: Oxford University Press; 1965.

5. Brians P. Common Errors in English Usage. 2nd ed. Sherwood, OR: Williams James & Co; 2008.

6. The Children’s Hospital of Wisconsin website. Types of Surgery. http://www.chw.org/display/PPF/DocID/22082/router.asp. Accessed January 10, 2013.

7. Trivology.com. http://www.trivology.com/articles/209/what-is-elective-surgery.html. Accessed January 10, 2013.

Top 10 Mistakes Authors Make

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Publishing a style manual, particularly a lengthy, detailed manual that covers a ridiculous amount of technical material (Hello, AMA Manual of Style!), is a grueling process. In our case, it involved 10 people meeting for at least an hour every week for more than a year, where we tried not to get into arguments about grammar, usage, and the presentation of scientific data. After the meetings there would usually be flurries of e-mails about grammar, usage, and the presentation of scientific data. Then we’d all go home and dream about grammar, usage, and the presentation of scientific data. You get the picture.

My point is that the writers of style manuals are often a little, shall we say, too close to the material. In the case of the AMA Manual of Style, we are all editors as well—and it can be hard for us not to roll our eyes when we run into the same problems on manuscript after manuscript. Come on, authors: there’s a whole book on this stuff!

Which, of course, is precisely the problem. There is a whole THOUSAND-PAGE book that tries to encompass all aspects of medical editing. It’s impossible to expect authors to absorb all the information–they’re just trying to get published, and it’s our job to help them. Here, in classic top-10-list reverse order, are the top 10 editorial problems we see in our submitted and accepted manuscripts, compiled by committee and editorialized upon by me. If any authors happen to read this, maybe it will help them avoid the most common errors; if any journal website–design people read it, maybe they can grab some ideas for more explicit user interface; and if any copy editors read it, maybe they can enjoy shaking their heads in wry commiseration.

10. Missing or incomplete author forms. Most journals require authors to fill out some forms, usually involving things like copyright transfer, an assertion of responsibility for authorship, and so on. These forms are often filled out incorrectly or incompletely. Following a form’s instructions as to signatures and boxes to check can save significant amounts of time in the publication process.

9. Not explaining “behind the scenes” stuff. Values in a table don’t add up—oh, it’s because of rounding. The curve in this figure doesn’t connect the values listed in the “Results” section—oh, we used data smoothing. This kind of thing can be easily explained in a footnote, but many authors forget to do so because it seems so obvious to them.

8. Making life difficult for the copy editor. Authors and editors have the same goal: a polished, published, accurate manuscript. Sure-fire ways authors can ruin what should be a pleasant working relationship are to suggest that the copy editor is making changes in the manuscript for no reason; calling the copy editor to discuss changes without having read the edited manuscript first (this wastes oodles of time); and not reading the cover letter that comes with the edited manuscript. This last is particularly charming when the author then calls the copy editor to ask all the questions that are very nicely answered in said cover letter.

7. Common punctuation and style mistakes (not an exhaustive list). Most frequently we see authors fail to expand abbreviations; use different abbreviations for the same term throughout a manuscript; use commas like seasoning instead of like punctuation marks with actual rules of deployment; and overuse the em dash. However, I’d like to tell any authors reading this not to fret, because that’s the kind of stuff we’re paid to fix. Plus I can’t really throw stones—being a fan of the em dash myself.

6. Errors of grandiosity. Sometimes a perfectly nice and valid study will go hog-wild in the conclusion, claiming to be changing the future of scientific inquiry or heralding a sea-change in the treatment of patients everywhere. Or authors will selectively interpret results, focusing on the positive and ignoring the negative or neutral. It’s natural to want to write an elegant conclusion—it’s one of the few places in a scientific manuscript where one can really let loose with the prose—but it’s always better to err on the side of caution.

5. Wacky references. All journals have a reference citation policy, and across scientific journals it is fairly standard to give reference numbers at the point of citation, cite references in numerical order in the text (as opposed to only in tables or figures), and retain a unique number for each reference no matter how many times it’s cited. However, we still get papers with references handled in all kinds of odd ways (alphabetical, chronological, or seemingly inspired by the full moon). References that include URLs can mean big problems. Often the URL doesn’t work or the site is password-protected, subscription-only, or otherwise useless to the reader. Also aggravating: references that are just the result of the search string for the article and not the URL for the article itself.

4. Duplicate submission. In scientific publication, it is not acceptable to submit a report of original research to multiple journals at the same time. Journal editors are likely to be more disturbed by this if it looks deliberate rather than like a simple mistake (not realizing that a foreign-language journal “counts,” for example) or if the case is debatable (a small section of results was published in another paper, but the new paper adds tons of new material). Remember those forms from the 10th most common mistake? One of them asks about previous submission or publication. We need authors to be up-front about any other articles in the pipeline, even if (especially if) they’re not sure if they might constitute duplicate publication.

3. Failing to protect patient identity. Yup, there’s a form for this too! Any time a patient is identifiable, in a photograph or even in text (as in a case report), authors must have the patient’s consent. (Contrary to popular belief, the gossip-mag-style “black bars” over the eyes are not sufficient to conceal identity.) Usually we hear complaints about this, because studies are written long after patients are treated and it can be hard to track people down, but them’s the breaks. If it’s really impossible to obtain after-the-fact patient consent, editors will work with authors to crop photos, take out details, or whatever it takes to “de-identify” patients.

2. Not matching up all the data “bits.” In the abstract, 76 patients were randomized to receive the intervention, but it’s 77 in Table 1. There was a 44.5% reduction in symptoms in the medicated group in the text, but later it’s 44.7%. Sometimes this is because the abstract is written first from the overall results, while the data in a table are more precisely calculated by a statistician; or maybe the number of patients changed along the way and no one went back to revise the earlier data. Either way, it drives copy editors crazy.

1. Not reading a journal’s Instructions for Authors. These days almost all scientific journals have online submission, and almost always there is a link to something called “Information for Authors,” “Guidelines for Manuscript Submission,” or something similar. Judging by the kinds of questions editorial offices receive almost daily, authors rarely read these—but the publication process would often go so much more smoothly if they would.

We are proud of our style manual, although we realize it isn’t the last word in scientific style and format. There can never really be a “last word” because some editor will always want to have it! Anyway, without authors there wouldn’t be anything to edit, so we would never hold any “mistakes” against them. No matter how grievous a manuscript’s misstep, an editor will be there to correct it, because it’s our job. (But mostly because we can’t stop ourselves.)—Brenda Gregoline, ELS

 

Going the Distance: Further or Farther?

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A medical editor who in a manuscript meeting asks, “Should we take this manuscript farther?” sparks the idea for this discussion on the grounds that farther suggests distance and further, “quantity or degree.”1

 
Once decided, the examples of variant use jump unexpectedly forward without my having to crack a book:

• Jack Shephard, spinal surgeon and Lost castaway, pauses amid the lush tropical foliage to ask his guide to Jacob’s lighthouse, “How much further, Hurley?”2 He’s a spine surgeon, not a brain surgeon, I think smugly, feeling confirmed in my theory that fictional characters are only as smart as the people who create them.
• The writer of a blurb on the Adventure Cycle Association itinerary3 for a guided bicycle trip in the Blue Ridge Mountains gets it right when describing what’s in store for riders after they reach Mabry Mill: “Approximately five miles farther down the road, you might want to take a detour of less than a mile off the parkway for a tour and a taste at the popular Chateau Morrisette winery.”
• I am sitting at an Italian restaurant celebrating the birthdays of 2 manuscript editors. Talking about my running schedule, I say that my weekly distance “will extend further.” I pause. “That would be farther.” I smile, lift my brows, and announce that I have selected further and farther for my blog entry.

But once I crack the dictionary and English-language usage books, my smugness at knowing the difference between the two dissolves, for the words “have been used more or less interchangeably throughout most of their history,” says the 11th edition of Merriam-Webster’s Collegiate Dictionary, which allots 11 lines to a discussion of their usage differences, adding that they “are showing signs of diverging.” First, noting that they are not used differently as adverbs “whenever spatial, temporal, or metaphorical distance is involved,” the entry says they “diverge” when the meaning is not conveying distance. In that case, “further is used.” Furthermore, when used as a transitional adverb announcing that the sentence aims to advance a point, the entry says further is used, but farther is not. (However, further is usually changed to furthermore in JAMA in such instances.) Adjectivally, the usage entry continues, “Farther is taking over the meaning of distance.”

 
To put it in perspective, Webster’s Dictionary of English Usage devotes 3 columns to the discussion that begins, “About every usage commentator in the 20th century … has had something to say about farther and further… as to how they should be used or how they seem to be used.”1 This explanation comes after first noting that few of the commentators have ventured little beyond a 1906 “pronouncement”:

Farther should be used to designate longitudinal distance; further to signify quantity or degree.

Webster’s says that farther and further “are historically the same word” and concludes that their interchangeable use is after all “not surprising.” To buttress the claim that they have the same origin and that they did not stem from the word far, the Webster’s entry reports that, of the two, further is older and “appears to have originated as the comparative form of a Germanic ancestor of the English forth,” whereas “farther originated in Middle English as a variant of further that was influenced by the comparative (spelled ferre) of far (then spelled fer) which it (and further) eventually replaced.”

 
The rest of the entry provides examples of usage, noting when grammatical usage for one eclipses the use by the other. In modern English, Webster’s says that further “used in the sense ‘additional’ … has taken over…” But farther is more frequently used adjectivally when “literal or figurative distance is involved.”

 
The Chicago Manual of Style4 and The Associated Press Stylebook and Libel Manual5 echo the 1906 pronouncement and distinguish the two by distance and degree. However, swerving slightly, the seventh edition of Scientific Style and Format6 suggests that the use of farther as an adverb works for physical or nonphysical distance and suggests that further be reserved for use as a transitive verb: “His theory did little to further our knowledge of the oldest galaxies.”

 
After examining the language usage explanations of the 2 words, perhaps the commentators who have not ventured further than the 1906 pronouncement offer the best understood explanation. I could go farther, but I won’t. —Beverly Stewart, MSJ

1. Webster’s Dictionary of English Usage. Springfield, MA: Merriam-Webster Inc; 1989.
2. Lighthouse. Lost. ABC television. February 23, 2010.
3. Adventure Cycling Association. Blue Ridge Bliss: tour itinerary. http://www.adventurecycling.org/tours/tourdetail.cfm?id=175&t=EV10&p=3. Accessed September 25, 2012.
4. The Chicago Manual of Style: The Essential Guide for Writers, Editors, and Publishers. 15th ed. Chicago, IL: University of Chicago Press; 2003.
5. Goldstein N, ed. The Associated Press Stylebook and Briefing on Media Law. New York, NY: Basic Books; 2007.
6. Council of Science Editors. Scientific Style and Format: The CSE Manual for Authors, Editors, and Publishers. 7th ed. Reston, VA: Council of Science Editors in cooperation with Rockefeller University Press; 2006.

A Peek at a Trio of Homophones to Pique Your Interest and Provide Peak Enjoyment

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Grammarians who pen English usage guides do not seem piqued at the misuse of the words peek, peak, and pique. Theodore M. Bernstein notes only that piqued “takes [the] preposition at or by.” Even college-level writers’ guides make little fuss. Flipping to the usage sections of several writers’ guides, one finds a no-show for the peeks. Webster’s Dictionary of English Usage, however, writes that “[t]hese homophones have a way of being muddled by nodding writers.” Relying on former newspaper columnist and grammarian James J. Kilpatrick, who had caught misuses among the peaks in various news publications, the entry notes that peak most frequently edged out its competitors and inappropriately made its way into print. The entry ends by warning writers “to keep the meaning in mind and match it to the correct spelling.”

English usage of peek is traced to 1374 and stems from the Middle English piken, which some sources speculate comes from the Middle Dutch kieken. Peek means “to glance at quickly, or to peer at furtively, as from a place of concealment.” As a verb, it means that something is “only partially visible…[t]iny crocuses peeked through the snow.” The expression peek-a-boo is “attested from 1599,” according to the Random House Dictionary.

Peak is traced to 1520-1530, perhaps from the Middle Low German words pick and pike, according to Random House. As a noun it has several meanings, some of which point to the top of a mountain, ridge, or summit. It can also be used to describe a “projecting part of a garment,” as in the bill of a hat. Nautically, it means the “upper most corner of a fore-and-aft sail” or the “narrow part of a ship’s bow.” As an intransitive verb, it means reaching “maximum capacity, value, or activity,” as in “My running pace peaked at 10 minutes per mile.” Similarly, as an adjective, reaching peak levels demonstrates that one has maxed out.

In a less common usage, those who grow sick or thin are sometimes spoken of as having peaked or “dwindled away” or, as an adjective, being peaked (2 syllables), “being pale and wan or emaciated: sickly.”

Emotion rules pique. It stems from the Vulgar Latin verb piccare, “to pick,” and its usage in English is traced to 1525-1535. It is menacingly linked with pickax and pike. As a noun, it is defined as “a transient feeling of wounded vanity.” Or, as one might say of a woman scorned, “She’s in a fit of pique.” But a woman moves quickly on, pique being a transient emotion. As a verb it means that someone has been “aroused” to “anger or resentment.” Or, as I like to use it, aroused to the state of curiosity.

Although they sound alike and to an extent they look alike, the piques are as different as … Has your interest peaked? (Begs for a pun, doesn’t it?)—Beverly Stewart, MSJ

Around, About, Approximately

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Although each of these words is used to refer to a value that is estimated and therefore imprecise, whether it is acceptable to use them interchangeably depends in part on context and the level of accuracy being implied.

Some speakers and writers will use approximately before turning to the other two—not surprising, because people faced with a choice between words will often choose the most impressive-sounding one. And sometimes that choice happens to be correct. On the other hand, people will often, especially in casual communications, use around or about as a sort of verbal shorthand. And again, sometimes that choice happens to be correct.

So, what’s the scoop? To sort this out, it helps to recognize that authorities for the most part agree that around, about, and approximately lie on a scale from casual to formal. As it happens, around is also thought of as the most imprecise and approximately the most precise, with about falling somewhere in between. It further helps to note that around, meaning merely “with some approach to exactness,”1(p68) is not widely considered an adequate replacement for either about or approximately and thus is often accepted only in casual conversation.2 Hence, in conversation between friends, for example, many speakers will toss off a “See ya around three,” whereas in written communications, as Bernstein maintains, “‘about three o’clock’ is preferable to ‘around three o’clock.’”2

Things get a bit more complicated as one moves along the scale: not only does the choice of word depend in part on the closeness to accuracy required by different types of communication, but the differences between the implied degrees of closeness can be subtle. For example, Merriam-Webster’s defines about as “reasonably close to”1(p4) and approximately as “nearly correct or exact.”1(p61) However, it is safe to say that in nontechnical communications (which presumably often place less emphasis on precision), the use of about is not only accepted but is perhaps preferred. As Garner maintains, “When possible, use about instead of approximately, a formal word”3(p5)—where a “formal” word is defined simply as one “occupying an elevated level of diction.”3(pp153-154) On the other hand, as suggested by the above definitions, about does not emphasize a closeness to accuracy as strongly as approximately does—which helps explain why about seems fine when used to refer to estimated values that have been rounded to multiples of 5 or 10 but can seem strange when used to refer to unrounded values.4 Moreover, around and about each have multiple meanings and can be used in other senses, whereas approximately is used in a single sense only, leading some authorities to maintain that the latter is a better choice for technical communications.5

The bottom line:

● Referring to an inexact value in casual conversation? Around, about, and approximately are all acceptable, but approximately can sound a bit pretentious.

● Referring to an inexact value in nontechnical writing? About is perhaps the best choice, around being too informal and approximately being a tad too formal.

● Referring to an inexact value in medical or other technical writing? Although about may very occasionally be used if one carefully assesses the context, approximately is nearly always the best choice.—Phil Sefton, ELS

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

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

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

4. Yateendra J. About and Around and Approximately: Shades of Difference? Editage website. http://blog.editage.com/about-and-around-and-approximately-shades-of-difference. Accessed August 1, 2012.

5. Scientific English as a Foreign Language: Around, About, Approximately. Worcester Polytechnic Institute website. http://users.wpi.edu/~nab/sci_eng/97_Jun_20.html. 1997. Accessed August 1, 2012.

Questions From Users of the Manual

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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

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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.

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

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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.

Apt, Liable, Likely

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Although these words are sometimes used interchangeably, particularly in infinitive constructions (apt to fall, liable to fall, likely to fall),1,2 using them interchangeably obscures subtle yet important distinctions between them.

Of the three, it seems that apt is the one most often used in its proper sense—perhaps because, unlike liable and likely, which both stress a potential consequence and thus are often confused, apt simply stresses inherent tendency (eg, “Elmer is apt to be a bit unsteady on his feet”).3 Also, whereas liable and likely refer to consequences and thus most commonly to conditions that will become manifest in the future, apt usually refers to conditions manifest in the past or present.1 In addition, some authorities hold that apt is perhaps most commonly used when referring to persons, although it can refer to nonhuman or inanimate subjects as well.1

So far so good—but, as alluded to above, tossing liable and likely into the mix can muddy the waters a bit. Both stress degrees of potential, but liable is the weaker of the two, used to stress possibility (eg, “Because Elmer is apt to be a bit unsteady on his feet, he’s liable to fall”) rather than outright probability.1 It has sometimes been held that liable should be used only when the subject of the sentence would face unpleasant consequences from the action expressed by the verb (“Because Elmer is apt to be a bit unsteady on his feet, he’s liable to fall and break a hip”).2 Certainly, of the three words under discussion, liable is the one most often taken as indicating that a consequence might be unpleasant or disadvantageous.3

Compared with liable, likely is a stronger term, used to stress probability (eg, “Because Elmer is apt to be a bit unsteady on his feet, he’ll likely fall if the steps are icy”) rather than mere possibility.1 However, unlike apt, likely used alone stresses no particular tendency in the subject that would enhance the probability of the outcome; moreover, unlike liable, it need not suggest the potential for an unpleasant consequence (eg, “Although Elmer is apt to be a bit unsteady on his feet, he’ll likely not fall, even if the steps are icy”).2

The bottom line:

● Looking for a word that stresses inherent tendency, particularly in a person? Use apt.

● Looking for a word that stresses possibility (as opposed to probability)—especially the possibility of some unpleasant consequence? Use liable.

● Looking for a word that stresses probability (as opposed to possibility), whether the perceived consequences be good or ill? Use likely.—Phil Sefton, ELS

1. Apt, liable, likely. Merriam-Webster’s Dictionary of Synonyms. Springfield, MA; Merriam-Webster Inc; 1984:56.

2. Liable. TheFreeDictionary.com website. http://www.thefreedictionary.com/p/liable. Accessed March 8, 2012.

3. Apt, liable, likely. In: Bernstein TM. The Careful Writer: A Modern Guide to English Usage. New York, NY: Athaneum; 1985:48.