The Percolating Proofreader

Editor’s Note: Here begins an occasional series by one of The JAMA Network’s favorite overcaffeinated proofreaders, David Antos. He has a deep affection for parts of speech, punctuation, and widows and orphans. (See what I did there?)

Twice in the past week I’ve done the unthinkable, which, however, I found my mind was eventually willing to grasp, as if the unthinkable could be thought through without losing its privileged status of noble ignorance. Less like a raccoon’s grasping a crayfish than a raccoon’s washing pastry till it dissolves, my mind was the beneficiary of an organic shampooing so dense and luxurious that I got a little smarter right there in the shower. No blinding insight in my trickle-down acuity, but a soft perception that there was meaning to be had in twice forgetting to close a parenthetical expression, which is the horror I’d committed.

Do you call parens open/close or opening/closing? Or left/right? I tend toward overexpression, so you can imagine I favor the suffix, but, to keep this clean and tidy, like my hair, let’s do open/close, even though “close” reminds me of “clothes,” which I was bereft of in the shower though in polite society am usually not. Which is the point my shampooed mind was shoring into, that society becomes impolite when punctuation falters. In 2 emails I’d sent that week I’d properly initiated a parenthetical expression that, when gotten to the end of, nakedly submitted itself to the rest of the sentence without so much as a stitch of close. Well, actually, the 2nd email contained a couple bracketed morsels at its conclusion, and the close paren was likely forgotten in the heat of bracketing. No excuse that, but a circumstance lending a ray of thought to the unthinkable. I’d also preemptively included in each of those emails the assertion that, in the interests of sending them in a timely fashion, I was not going back to proofread before hitting the button of no return. I had my out, yet when, after sending, I did proofread, I felt guilt, shame, inner filth, as if I were Michelangelo’s socks when he finally crept down the Sistine Chapel’s ladder. I’d poured my soul into words and left out the close parens, rendering that soul holier than the aforementioned socks. And not in a good way.

Later, I washed my hair and, as a person does when feeling hair and contemplating sin, reflected on the week that was and the week that will never be. I thought of the close parens that were not allowed to see the light of another’s eyes and of the violent omissions recounted in the week’s headlines, and it began not to seem out of place to think that faulty punctuation is at the heart of a world gone wrong. Not that a sloppy email is to blame for unthinkable atrocities, but the sense of purpose, order, and unblinking inclusion punctuation provides mirrors the sense of moral rectitude we only occasionally achieve in our dealings with each other. Punctuation is never evil, just misplaced or missing, and as I stepped out of the shower I cheerfully anticipated my next trip on public transportation, for I would no longer regard the other commuters as merely people but as pieces of punctuation, possibly shoveled into a seat of crumbs or wedged pielike into each other, but innately good, even angelic. —David Antos

Ch-ch-ch-changes

To pass the time between stylebook editions, the JAMA Network staff keep an in-house file of little tips, tricks, guidelines, and style changes that have occurred since the last time the manual was published. Here is a small peek inside that file—2 things from this past summer.

The terms multivariable and multivariate are not synonymous, as the entries in the Glossary of Statistical Terms suggest (Chapter 20.9, page 881 in the print). To be accurate, multivariable refers to multiple predictors (independent variables) for a single outcome (dependent variable). Multivariate refers to 1 or more independent variables for multiple outcomes. (This update was implemented June 1, 2014.)

Cross-section, as a verb or adjective should be capped in titles as Cross-section; cross section as a noun should be capped in titles as Cross Section. (This update was implemented August 4, 2014).—Brenda Gregoline, with help from John McFadden

Questions From Users of the Manual

Q: I can’t find anywhere in the AMA Manual of Style guidance on having back-to-back sets of parentheses in running text. Here is an example:

 The mean duration of surgery for the computerized-navigation group was 52.6 minutes longer than that of the control group, resulting in a statistically significant difference (P < .05) (Table 1).

I would prefer to see something like this:

The mean duration of surgery for the computerized-navigation group was 52.6 minutes longer than that of the control group, resulting in a statistically significant difference (P < .05; Table 1).

But does the manual have a preference?

A: Short answer: The style manual does not include anything about a pref on use of back-to-back parens, so this is something to think about including in the Punctuation chapter for the 11th edition. (Also, as you’ll see from the few examples below, because we don’t have a policy on this, it has not been handled consistently in our publications.)

Longer answer: Although our first response to your specific example was that we liked the avoidance of back-to-back parens and would favor (as you do) the inclusion of both items in a single set of parens, or would find either version OK, on further thought we decided that this answer was too easy and that often both sets of parens should be retained. Reasons: (1) Although in the example provided it makes sense to combine and use the semicolon, in more complicated sentences it might not be the best choice. (2) Table and Figure citations might be easier to find if not combined with other info.

Below are a few examples from The JAMA Network Journals that might illustrate where combining the information in parens might not be as desirable as keeping the parenthetical items separate.

A significantly higher incidence of SSHL was noted in the HIV group compared with the control group, with an incidence rate ratio (IRR) of 2.17 (95% CI, 1.07-4.40), particularly for the male participants, who had an IRR of 2.23 (1.06-4.69) (Table 2).

Here, keeping the table citation separate makes it clear that the table citation relates to BOTH values given in the sentence, not just the second one. Note that in our journals the first citation of a table or figure is set in different type (here, heavy boldface) to make it stand out.

In this example, where info was combined, it would probably have been better to also have kept the table citation separate as it applied to both bits of info in the sentence:

Mean mandible defect lengths were similar for patients undergoing FFF and LSBF reconstruction (7.8 and 7.7 cm, respectively); STFFs were used to reconstruct significantly shorter defects (mean, 6.0 cm, P<.001, Table 1).

And in this example, which does not include a table or figure citation, similar logic would also probably have made retention of back-to-back parens a better choice since the hazard ratio and P value apply to both, not just the second “n”:

Significantly more patients (n=174) withdrew from the placebo group compared with the chelation group (n=115; hazard ratio, 0.66; P=.001).

Splitting or lumping parentheses should depend more on content than strictly on style.—Cheryl Iverson, MA

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

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

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

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

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

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

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

I dutifully changed it:

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

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

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

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

The diagnosis and initial treatment/diagnostic planning were recorded.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Right and Almost Right

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

aesthetic (secondary variant: esthetic)

breastfeeding (Webster’s: breast-feeding)

cutoff (as noun or adjective)

cut off (as verb)

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

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

phosphorus (as noun)

phosphorous (as adjective)

sulfur (secondary variant: sulphur)

supersede (secondary variant: supercede)

Just Plain Wrong

accommodate (not accomodate)

ancillary (not ancilary)

arrhythmia (not arhythmia)

brussels sprouts (not brussel sprouts)

cholecystectomy (not cholecysectomy)

consensus (not concensus)

cribriform (not cribiform)

desiccate (not dessicate)

diphtheria (not diptheria)

dyspnea (not dysnea)

embarrass (not embarass)

erythematosus (not erythematosis)

Escherichia (not Echerichia)

fluorescent (not florescent)

fluorouracil (not flourouracil)

Haemophilus (not Hemophilus)

harass (not harrass)

hematopoietic (not hematopoetic)

Legionella pneumophila (not Legionella pneumophilia)

levothyroxine (not levothyroxin)

millennium (not millenium)

minuscule (not miniscule)

Neisseria gonorrhoeae (not Neisseria gonorrhea)

ophthalmology (not opthalmology)

Papanicolaou (not Papanicolou)

pertussis (not pertussus)

pruritus (not pruritis)

sagittal (not saggital)

sinusitis (not sinusitus)

sphygmomanometer (not sphygomamometer)

sulfide (not sulphide)

syphilis (not syphillis)

unwieldy (not unwieldly)

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

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

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

end point (not endpoint)

health care (not healthcare)

policy maker (not policymaker)

under way (not underway)

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

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

Questions From Users of the Manual

Q:    If a person has multiple advanced degrees, should the medical degree always be listed first, eg, MD, PhD?

A:   We would advise following the author’s preference as far as the order in which degrees are listed.

Q:   I know that journal names are typically italicized in their expanded form, eg, Journal of the American Medical Association. Should the abbreviation also be italic, eg, JAMA?

A:   Yes. The same policy applies to book titles and their expansions. See, for example, International Classification of Diseases, Ninth Revision and ICD-9 in the list in 14.11.

Q:   On page 500, in the list of journal abbreviations, is there a reason that the journal Transplantation is spelled out in full as Transplantation and yet other journals whose titles include that word abbreviate it as Transplant?

A:    Yes, there is a reason. See the sentence on page 479 advising that “Single-word journal titles are not abbreviated.”

Q:    The AMA Manual of Style says that tables should be able to stand independently and not require explanation from the text. Could you clarify “stand independently”? Our publication has taken this rule to an extreme, often adding lengthy definitions of terms already provided in the text. One recent example added 15 footnotes to a single table!

A:   As with so many things editorial, this requires judgment.  We were thinking about things like this:

  • Expansion of any abbreviations, given in the text, provided again in a single footnote to the table.
  • Explanation of things that might not be apparent from the tables (eg, what the various groups are if they are only identified as “group 1, group 2, etc” in the table).
  • Explanation of how to convert units from conventional to SI (or the reverse), if this is important in your publication/to your audience.
  • Explanation of some statistical method that would likely not be familiar to your readers without some information—the bare bones, not a lengthy explanation. If a lengthy explanation is necesssary, simply refer the reader to the relevant section or subsection of the text.
  • Explanation of a phrase used for shorthand in a table stub or column head that might not be clear if all you were looking at was the table (eg, if a column head is “Unstable Vital Signs,” explain in a footnote the specific items and values that this refers to).

It truly is a question of judgment and I suspect that 15 footnotes in a single table is taking it too far.—Cheryl Iverson, MA

Questions From Users of the Manual

Q:    When a bulleted list is introduced by a brief comment, eg, “The principal signs and symptoms of rheumatoid arthritis are as follows,” and all of the items in the bulleted list are from the same source, does a citation need to be placed at the end of each bulleted item or is it sufficient to place the citation at the end of the brief introductory comment?

A:    We would recommend placing the citation within the text that introduces the bulleted list if all the items in the list came from the same source.  If the items came from multiple sources, then placing the appropriate citation at the end of each item would be necessary.

Q:    In this example, would you hyphenate “well child”?

  • He was taken for a well-child [or well child] checkup.

A:    Yes, we would hyphenate in this case.

Q:    The Manual says nothing about how to treat reference citations in the abstract.  Should such citations simply be deleted from the abstract and from the reference list or should complete bibliographic details about the reference be inserted in the abstract parenthetically?

A:    You are quite right that the Manual does not mention how to treat references in the abstract as we never include reference citations (either as superscript numbers or within parentheses in the text) in the abstract (see 2.3, fourth bullet, re not citing references in an abstract).  If an author has included references in an abstract, it doesn’t seem advisable to delete the references altogether.  Discuss with the author trying to include the references early on in the manuscript itself.  It seems unlikely that an author would consider a reference important enough to include in the abstract and then not cite it in the text.

Q:   I don’t see anything in the Manual about how to style “e-mail,” ie, with or without a hyphen.  Help, please.

A:   Although the Manual doesn’t specifically address this point, it does include guidance on capping (see 10.7) and, in that section, it’s clear that the Manual recommends a hyphen in “e-mail.”  If you use the Manual online, for questions like this the “quick search” box is invaluable.  Just type the term you are looking for into the search box and the results should guide you.  If you had begun with “email,” you would have gotten no results, which would—I hope—have tipped you off to try “e-mail,” which produces 3 pages of results.—Cheryl Iverson, MA

Quiz Bowl: Units of Measure

Welcome, participants, to the AMA Manual of Style Quiz Bowl. Every month at http://www.amamanualofstyle.com/, we offer subscribers a quiz on different aspects of the manual that help participants master AMA style and improve their editing skills. Previous quizzes have covered topics as varied as correct and preferred usage, genetics, tables, figures, and ethics, as well as numerous other subjects. In this blog, we will offer a sample question from each month’s quiz to whet your appetite. This month’s quiz is on Units of Measure: Format, Style, and Punctuation. So, here goes.

Edit the following sentence based on your understanding of section 18.3 of the AMA Manual of Style.

A total of 50 mg of etanercept were administered subcutaneously twice weekly for 12 weeks.

Well, how did you do? Did you identify the problem? Here’s the answer (use your mouse to highlight the text box):

A total of 50 mg of etanercept was administered subcutaneously twice weekly for 12 weeks.

Units of measure are treated as collective singular (not plural) nouns and require a singular verb (§18.3.3, Subject-Verb Agreement, p 791 in print).

So, did you enjoy this tidbit? If you are not sated, subscribe to the AMA Manual of Style online and take the full quiz.—Laura King, MA, ELS

Questions From Users of the Manual

Q:  Do you recommend end point or endpoint?  I have folks dying on their grammatical swords over this and thought you might have an opinion.

A:  We follow Dorland’s and use end point.  Replying quickly so as little blood as possible is shed.

Q:  I failed to find guidance in the Manual on correct use of the apostrophe with plural compound nouns, eg, the possessive of mothers-in-law.  What would you advise?

A:  You are quite right that we don’t include any examples that address this specifically and it would be helpful to do so.  (A thought for the next edition—or an annotation for section 8.7.3 if you are an online subscriber.)  I would recommend mothers-in-law’s, as in mothers-in-law’s first meeting.  The Chicago Manual of Style also recommends this (section 7.23):  my sons-in-law’s addresses.

Q:  Where is the style going on the treatment of Web site?  We use Web site but are seeing it more and more frequently as website, or web site, or Website.

A:  JAMA and the Archives Journals are still sticking with Web site, but the new edition of the Chicago Manual of Style is recommending website.  So, it appears that things are, indeed, shifting but we have not shifted yet!

Q:  We’re having a debate about the order of footnotes in a table.  Are they ordered left to right, top to bottom?  Or are they ordered by where they fall in terms of the table components (eg, title, column heading, row heading, field) and then left to right, top to bottom?

A:  There’s a great example in the Manual on on page 93 (Table 10).  In that table, which has a raft of footnotes, you’ll see that the order is basically from top to bottom and, within that, from left to right…as we expect readers would move through a table as they were reading it.  That said, there is nothing sacred about this and a publication could certainly establish a different policy (eg, with the table body, priority could be given to footnotes attached to table stubs, so that if you had footnotes a and b in stubs high up in the table and then footnotes c, d, and e in rows below this but NOT in the table stubs, and then footnote f in a later stub, you might decide to make the stub footnotes a through c [renaming f to c] and then the footnotes within the body of the table d through f. )—Cheryl Iverson, MA