Summer 2021 (Volume 31, Number 2)
Acronyms Gone Wild
By Philip A. Baer, MDCM, FRCPC, FACR
The theme of the recently completed CRA 2021 Annual
Scientific Meeting was “CRA.” What does that mean?
Well, the first CRA is our own Canadian Rheumatology
Association (www.rheum.ca), not to be confused with
the California Rheumatology Alliance (www.calrheum.org)
or the Canada Revenue Agency (www.canada.ca/en/revenue-agency), which at times has taken unwanted interest in our
CRA. If you do clinical trials, you may also be familiar with
the job title Clinical Research Associate, also abbreviated
CRA. The second CRA cleverly stands for Collaboration,
Resilience and Advancement.
My other affiliations include the OMA, which is the
Ontario Medical Association, not the now frequently used
acronym OMA to represent non-TNF inhibitor biologics,
which have “Other Mechanisms of Action.” I also belong
to the Ontario Rheumatology Association (ORA), which
shares that acronym with the French “Orencia in Rheumatoid
How can we keep all these acronyms straight? Enter the
world of clinical trial acronyms and you will get even more
confused. We have two AMBITION trials in rheumatology:
“Actemra versus Methotrexate double-Blind Investigative
Trial in mONotherapy,” and “A study of first-line aMBrIsentan
and Tadalafil combinatION therapy in subjects with
pulmonary arterial hypertension.” Both are examples of
the Tolstoy manoeuvre, on which more later.
Similarly, I recall the MORE trial: “Multiple Outcomes for
Raloxifene Evaluation,” and another MORE trial which I was
a principal investigator for: “a multi-center, double-blind,
randomized, parallel-group trial to compare the efficacy
and safety of three doses of MelOxicam (7.5, 15, and 22.5
mg) and placebo in patients With RhEumatoid arthritis.”
The SELECT clinical trial program is also familiar to
rheumatologists, covering multiple trials of upadacitinib.
An earlier SELECT trial was the Safety and Efficacy Large-scale
Evaluation of COX-inhibiting Therapies trial in osteoarthritis,
comparing meloxicam to piroxicam.
Duplicate trial acronyms abound, often with only one
of the pair relating to rheumatology. A recent journal club
reviewed findings of the Multicenter Osteoarthritis Study
(MOST), not to be confused with the Mode Selection Trial
in Sinus-Node Dysfunction (MOST) in cardiology.
Speaking of cardiology, it leads the list in percentage
of trials with acronyms, including 16 using the acronym
HEART. Other popular trial acronyms are IMPACT and
SMART, used 16 and 13 times respectively.
I recommend reading two excellent papers on acronyms,
both available free online, and both with rheumatology
angles explored. In 2003,
Drs. Fred and Cheng published Acronymesis.1 The term indicates that improper
use of acronyms has become a nemesis. Failure to define
acronyms, duplication of acronyms as above, and coercive
acronyms are all covered. The latter refers to trial names
such as CURE, MIRACLE and SAVE, which may falsely entice
patients to participate. Reference is made to trials with
positive-sounding acronyms that had negative results, including
IMPROVED and PROMISE.
The Tolstoy manoeuvre is referenced, but not by name.
This refers to using random letters in a trial’s name, not
the first or second letters in a word, to build a catchy acronym.
Both AMBITION trials are guilty, as were RENAISSANCE
(Randomized Etanercept North American Strategy
to Study AntagoNism of CytokinEs) and RENEWAL (Randomized
EtaNErcept Worldwide evALuation).
More recently, the Christmas 2014 issue of the British Medical Journal (BMJ) featured a Danish group’s research
paper, entitled “SearCh for humourIstic and Extravagant
acroNyms and Thoroughly Inappropriate names For Important
Clinical trials (SCIENTIFIC): qualitative and
quantitative systematic study.”2 This semi-serious study reviewed
a number of RCTs in different specialties, including
rheumatology. Acronyms were assessed for positive and negative
features using the aptly named BEAUTY and CHEATING
criteria: (BEAUTY, Boosting Elegant Acronyms Using
a Tally Yardstick) and negative (CHEATING, obsCure and
awkHward usE of lettArs Trying to spell somethING). They
also included a list of honourable and dishonourable mentions
that did not obtain a particularly high or low score
but still deserved to be highlighted.
Results indicated that 8.1% of 1,404 RA RCTs published
between 2000 and 2012 used acronyms in their titles.
5.8% of RA trial acronyms were considered “cool.” The
top-scoring acronym was PREDICTIVE, a diabetes trial.
No RA trial made the top 25. However, a Canadian rheumatology
trial topped the list of 25 worst acronyms. This
was the METGO study of 2005: “a 48-week, randomized,
double-blind, double-observer, placebo-controlled multicenter
trial of combination METhotrexate and intramuscular
GOld therapy in rheumatoid arthritis.”3 This study
was run out of UBC and the Arthritis Research Centre. Named
authors included Allen Lehman, John Esdaile, Alice
Klinkhoff, Eric Grant, Avril Fitzgerald, and Janice Canvin.
The other investigators hid under the cloak of the “METGO
One RA study, which I confess I had never heard of despite
the fact it was published both in A&R 2011 and ARD 2012, made the honourable mentions list: “Treating to
target matrix metalloproteinase 3 normalisation together
with disease activity score below 2.6 yields better effects
than each alone in rheumatoid arthritis patients: treating
to twin targets; the T-4 study.” We also had an entry on the
dishonourable mentions list: the “Abatacept study to Determine
the effectiveness in preventing the development of
rheumatoid arthritis in RA patients with Undifferentiated
inflammatory arthritis and to evaluate Safety and Tolerability
(ADJUST).” This study was also cited as an example
of a failed Tolstoy manoeuvre, as the letter J is not present
anywhere in the title!
For now, in the world of virtual meetings, everything
happens in your home or office on your computer screen.
When we return to in-person meetings, remember not to
confuse any of the CRA acronyms, or you could end up in
Los Angeles when you should be in Quebec City.
1. Herbert L Fred, Tsung O Cheng. Acronymesis: The Exploding Misuse of Acronyms. Tex Heart Inst J.
2. Pottegård A, et al. SearCh for humourIstic and Extravagant acroNyms and Thoroughly. BMJ (Clinical
research ed). 2014; 349:g7092. doi: 10.1136/bmj.g7092.
3. Lehman AJ, et al. A 48‐week, randomized, double‐blind, double‐observer, placebo‐controlled multicenter
trial of combination methotrexate and intramuscular gold therapy in rheumatoid arthritis:
Results of the METGO study. Arthritis Rheum. 2005; 52:1360‐70.
Philip A. Baer, MDCM, FRCPC, FACR