Summer 2021 (Volume 31, Number 2)

Acronyms Gone Wild

By Philip A. Baer, MDCM, FRCPC, FACR

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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 (, not to be confused with the California Rheumatology Alliance ( or the Canada 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 Arthritis” registry.

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 Study Group.”

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. 2003; 30(4):255-7.

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
Editor-in-chief, CRAJ
Scarborough, Ontario

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