Sharpening Occam’s Razor – A Diagnostic Dilemma

Payal Sen, MD¹

Uddalak Majumdar, MD²

Patrick Rendon, MD¹

Ali Imran Saeed, MD¹

Akshay Sood, MD¹

¹University of New Mexico

Albuquerque, NM US

²Cleveland Clinic Foundation

Cleveland, OH USA

Abstract

Objective: Physicians often search for Occam’s Razor, that is, to have a single diagnosis explain all clinical manifestations in an individual patient. Herein, we describe a case which was significant for a dual clinical diagnosis, thus proving that Occam’s razor may not always hold true. 

Case Summary: A 22-year-old Caucasian man presented with 4 days history of fever, and dry cough. Chest x-ray revealed a right middle lobe pneumonia. Mycoplasma IgM antibody titer was significantly elevated (>1:320), using the rapid diagnosis enzyme-immunoassay (EIA) test, and clinical course was complicated by rhabdomyolysis. He was treated with oral azithromycin for 5 days. The patient however returned to the ER in 2 weeks with similar symptoms and repeat chest x-ray revealed a persistent right middle lobe infiltrate. Endobronchial biopsy revealed necrotizing granulomatous inflammation which stained positive for Histoplasma capsulatum. Serum complement fixation antibody test for Histoplasma demonstrated an elevated titer of 1:64. The patient was diagnosed to have an ‘atypical pneumonia due to sub-acute Histoplasma capsulatum and acute Mycoplasma Pneumoniae infections, complicated by rhabdomyolysis.’

Discussion: This case is unusual because the patient had an acute community-acquired atypical pneumonia from Mycoplasma pneumoniae, complicated by rhabdomyolysis, and also had subacute Histoplasma pneumonia. Physicians often search for Occam’s Razor. However, following Hickam’s dictum, we made the unusual diagnosis of concomitant lung infection in an immunocompetent host with Mycoplasma pneumoniae and Histoplasma capsulatum. 

Conclusion: This was an immunocompetent patient who ran a complex, protracted, and unusual course of community acquired pneumonia. Often, the pursuit of additional or alternative diagnoses may require repeated and multiple invasive diagnostic sampling. Occam’s razor may not always hold true.

Introduction

Occam's razor proposes that the simplest explanation is usually the correct one. However, in the science of medicine, simple solutions may be elusive. Often there is an incredibly complex constellation of symptoms co-occurring with one another, thereby confounding the scientific community. We described the diagnostic conundrums in managing our patient who ran a complex protracted course of community acquired pneumonia.

Case

A 22-year-old Caucasian male college student with no significant past medical history, initially presented to the University hospital in New Mexico, United States, with 4 days’ history of fever, dry cough, and dyspnea. He had recently returned from a family vacation in Illinois and had spent several weeks fishing on the Mississippi river. Review of systems was negative for chest pain, headache, fever, chills, or night sweats. He denied any sick contacts. He did not smoke and did not use recreational drugs. His grandfather, who had been a heavy cigar smoker, had died of lung cancer.

His vital signs were significant for a body temperature of 100.6° Fahrenheit, respiratory rate of 32 breaths per minute, pulse rate of 94 bpm, blood pressure of 130/82 millimeters of mercury, and pulse oximetry of 90 percent on room air. Physical examination demonstrated that he was in mild respiratory distress. Chest auscultation revealed decreased breath sounds over the right mid to lower lung field. The rest of his physical examination was otherwise unremarkable. 

His laboratory tests revealed a normal complete blood count with a hematocrit of 40.5%, white blood cell count of 8,200 cells per microliter, and platelet count of 263,000 per microliter.  His electrolyte levels showed a serum sodium of 136 mEq per liter, potassium of 3.4 mEq per liter, chloride of 100 mEq per liter, bicarbonate of 21 mEq per liter, blood urea nitrogen of 15 mg/dL and creatinine of 0.9 mg/dL. His blood glucose was normal at 98 mg/dL. His urine analysis revealed 3+ blood without red blood cells. His liver function tests demonstrated an elevated aspartate aminotransferase at 244 units per liter, elevated alanine aminotransferase at 72 units per liter, with normal total bilirubin, albumin, and alkaline phosphatase levels. His serum creatinine kinase (CK) was highly elevated at 26,000 units per liter (normal reference range 39-308 units per liter). His arterial blood gas at rest on room air at an elevation of 5500 feet above sea level showed acute respiratory alkalosis with a normal alveolar arterial gradient with a pH of 7.57, PaCO2 of 28 mmHg, PaO2 of 77 mmHg, and bicarbonate of 22 mEq per liter.  His mycoplasma IgM antibody titer was significantly elevated (> 1:320) using the rapid diagnosis enzyme-immunoassay (EIA) test. Anti-mycoplasma pneumoniae IgA was also elevated. The urinary legionella and pneumococcal antigen levels, sputum culture, blood cultures, and urine toxicology screen were negative. Chest radiograph revealed a right middle and lower lobe pneumonia (Figure 1). 

Figure 1. CXR revealed right mid and lower lobe pneumonia.

The patient was diagnosed with sepsis secondary to Mycoplasma pneumoniae infection of the lungs, with the added complication of rhabdomyolysis. He was treated with intravenous followed by oral azithromycin 500 mg daily for 5 days and given intense hydration therapy. Within 48 hours, his low-grade fever subsided, CK decreased to 1000 units per liter, and the patient felt better. He was then discharged on Day 3 of hospitalization.

The patient however returned to the emergency department 2 weeks after discharge with persistent cough, chest discomfort, and loss of wellbeing. Repeat chest radiograph revealed a persistent right lower lobe infiltrate. Computed tomography (CT) scan of the chest revealed a right lower lobe consolidation with surrounding nodular opacities with a possible endobronchial lesion in the right lower lobe (Figure 2).

Figure 2. Panel A: Coronal view of thoracic CT scan showing right lateral basilar segment consolidation. Panel B: Axial view showing consolidation in the right lower lobe with surrounding nodular opacities.

He underwent bronchoscopy which revealed a mass-like endobronchial lesion in the lateral basilar segmental bronchus of the right lower lobe (Figure 3).

Figure 3. Bronchoscopy revealing a mass-like endobronchial lesion in a lateral segmental bronchus of the right lower lobe.

Endobronchial biopsy revealed necrotizing granulomatous inflammation and stained positive for the yeast form of Histoplasma capsulatum.  Serum complement fixation antibody test for Histoplasma demonstrated an elevated titer of 1:64. Acid fast bacilli were not seen on smear or culture and cytology and histopathology tests did not reveal malignancy.

The patient was diagnosed with an atypical pneumonia due to sub-acute Histoplasma capsulatum and acute Mycoplasma Pneumoniae infections, complicated by rhabdomyolysis. The mycoplasma infection and rhabdomyolysis had already been treated and resolved. For the subacute pulmonary histoplasmosis, the patient was treated with 10 weeks of oral itraconazole. Post treatment clinic follow-up revealed resolution of symptoms and radiological abnormalities.

Discussion

Mycoplasma pneumoniae is a common causative pathogen for community-acquired pneumonia in both children and adults (1).  Apart from respiratory tract symptoms, it is associated with a variety of extra-pulmonary manifestations (2). Recognizing this association can lead to timely diagnosis and treatment of both the mycoplasma infection and its complications. In this case report, we also want to highlight the fact that infection with endemic mycoses can often be mistaken for community acquired pneumonias, and thus having a high index of suspicion for fungal infection is very important, even in immunocompetent patients (3), to prevent a delay in treatment. Physicians often search for Occam’s Razor, i.e., to have a single diagnosis explain all clinical manifestations in an individual patient. This case is significant because of a dual clinical diagnosis, thus proving that Occam’s razor may not always hold true in an individual patient.

Mycoplasma infection can cause several unusual extra-pulmonary manifestations such as hemolytic anemia, immune thrombocytopenic purpura, transverse myelitis, Guillain-Barre syndrome, acute hepatitis and arthritis (4). Another lesser known complication of mycoplasma infection is rhabdomyolysis (5). Rhabdomyolysis is a syndrome caused by injury to the skeletal muscles, thereby resulting in leakage of myoglobin into blood (6). The classic triad of mycoplasma infection consists of myalgias, pigmenturia, and generalized muscle weakness, but this classic triad is seen in less than 10 percent of infected patients (7). Acute renal failure due to acute tubular necrosis as a result of mechanical obstruction by myoglobin is the most common complication, in particular if the serum CK level is >16,000 IU/l, which may be as high as 100,000 IU/l (8). In addition to mycoplasma infection, more common causes of rhabdomyolysis are trauma, immobilization, and recreational drug and alcohol use (9). 

Other organisms known to cause rhabdomyolysis are Influenza A and B virus, Coxsackie virus, Epstein-Barr virus, Primary Human Immunodeficiency virus, Legionella species, Staphylococcus aureus, and Streptococcus pyogenes (9). With respect to Mycoplasma pneumoniae infection, a possible mechanism for rhabdomyolysis is the induction of inflammatory cytokines, such as tumor necrosis factor-alfa (TNF-α) and interleukin-1 (IL-1), which may cause proteolysis of skeletal muscles (10). 

The rapid and reliable diagnosis of Mycoplasma pneumoniae (Mp) enables the correct and prompt use of antibiotics. Methods for identifying Mp infection include culture, molecular detection of pathogen specific antigen or nucleic acid, and serological analysis (11). Each of these methods has its pros and cons. Culture is the definitive method for diagnosis and is critical for monitoring trends in epidemiology but is slow and requires specialized media and trained personnel (11). Although molecular methods for nucleic acid or antigen detection have emerged as the primary techniques for identification of MP pneumoniae in surveillance programs, adoption of these methods is still lagging behind in USA.

Serologic analysis can prove to be problematic due to poor sensitivity and specificity, and the inability to characterize the specific Mp strain. Having said that, most physicians in the United States continue to rely on serological testing in concordance with the IDSA guidelines (11). It is well known that a single serologic test is of limited value in the early diagnosis of mycoplasma pneumoniae since there are often no IgM antibodies in the early stage of infection, and these IgM antibodies may persist long after the infection (12). However, if these IgM antibodies are present along with anti-Mycoplasma pneumoniae IgA, it is usually indicative of recent primary mycoplasma pneumoniae infection (13). A single high Mp-specific antibody titer (> 1:320) has been regarded as a diagnostic marker of mycoplasma pneumoniae, although it is present in only about 30 percent of the patients (12). Since our hospital relies on serological testing, we tested for the specific Mycoplasma pneumoniae IgM and IgA, both of which were positive. The MP-specific antibody titer was also greater than 1:320, thus signifying it indeed was early MP infection.

Symptoms of Mp infection generally resolve within 3–4 weeks after disease onset but can be shortened with antibiotic therapy; macrolides and doxycycline are the mainstay of this treatment (14). The mainstay for the prevention of pigment-induced acute kidney injury is the correction of volume depletion, prevention of intratubular cast formation, and the treatment of the underlying cause of rhabdomyolysis (4). This is done by aggressive fluid resuscitation resulting in increased renal blood flow and thus increasing the urinary flow with consequential wash out of partially obstructing tubular casts (4). Physicians will be served well to watch out for mycoplasma associated rhabdomyolysis in patients with atypical pneumonia and manifestations like myalgia, elevated aminotransferase levels, and myoglobinuria. 

Moving on to the second teaching point, endemic mycoses like coccidioidomycosis, histoplasmosis, and blastomycosis are often overlooked causes for community acquired pneumonia, particularly when immunocompetent patients travel out of the endemic zones (15). Often, testing is not even performed until the patient has failed to improve on antibacterial therapy. Delays in recognition, diagnosis and proper treatment may lead to disastrous outcomes (3). Performance of fungal antigen testing on bronchial washings or lavage fluid may improve the sensitivity for diagnosis over microscopic examination and the speed of diagnosis over culture even though isolation of the fungus by culture remains the gold standard method for definitive diagnosis (16). In this case, our patient was previously treated as mycoplasma pneumonia, thus leading to prolonged symptom course from histoplasmosis.

This case is unusual because the patient had an acute community-acquired atypical pneumonia from Mycoplasma pneumoniae, complicated by rhabdomyolysis, and also had subacute Histoplasma pneumonia. Physicians often search for Occam’s Razor, a principle from philosophy that when presented with competing hypothetical answers to a problem, one should select the one that makes the fewest assumptions.  Countering

Occam’s Razor, Dr. John Hickam said “Patients can have as many diseases as they damn well please!” (17). Following Hickam’s dictum, we made the unusual diagnosis of concomitant lung infection in an immunocompetent host with Mycoplasma pneumoniae and Histoplasma capsulatum.

Conclusion

With this case report, the authors wish to highlight two important teaching points. The first being that rhabdomyolysis is a serious but treatable extrapulmonary complication of Mycoplasma pneumoniae infection of the lungs. Having a high index of suspicion can limit treatment delay for rhabdomyolysis caused by mycoplasma infection and will therefore limit consequential morbidity like renal insufficiency. The second point that the authors wish to emphasize is that endemic fungal infection can often be mistaken for bacterial and viral community-acquired pneumonia in an immunocompetent host, particularly when they present with symptoms outside the endemic zone, thus delaying timely management. Hence one should have a high suspicion for fungal infection in immunocompetent hosts with unusual presentations such as history of travel to endemic zone, chronicity of symptoms, lack of response to therapy for community-acquired pneumonia, nodular lung lesions, and endobronchial abnormalities.

References

1. Hardy RD, Jafri HS, Olsen K, Hatfield J, Iglehart J, Rogers BB, Patel P, et al. Mycoplasma pneumoniae induces chronic respiratory infection, airway hyperreactivity, and pulmonary inflammation: a murine model of infection-associated chronic reactive airway disease. Infect Immun. 2002 Feb;70(2):649-54. [CrossRef] [PubMed]
2. Kawai Y, Miyashita N, Kato T, Okimoto N, Narita M. Extra-pulmonary manifestations associated with Mycoplasma pneumoniae pneumonia in adults. Eur J Intern Med. 2016 Apr;29:e9-e10. [CrossRef] [PubMed]
3. Hage CA, Knox KS, Wheat LJ. Endemic mycoses: overlooked causes of community acquired pneumonia. Respir Med. 2012 Jun;106(6):769-76. [CrossRef] [PubMed]
4. Gosselt A, Olijhoek J, Wierema T. Severe asymptomatic rhabdomyolysis complicating a mycoplasma pneumonia. BMJ Case Rep. 2017 Jul 26;2017. pii: bcr-2016-217752. [CrossRef] [PubMed]
5. Khan FY, Sayed H. Rhabdomyolysis associated with Mycoplasma pneumoniae pneumonia. Hong Kong Med J. 2012 Jun;18(3):247-9. [PubMed]
6. Zimmerman JL, Shen MC. Rhabdomyolysis. Chest. 2013 Sep;144(3):1058-65. [CrossRef] [PubMed]
7. Zutt R, van der Kooi AJ, Linthorst GE, Wanders RJ, de Visser M. Rhabdomyolysis: review of the literature. Neuromuscul Disord. 2014 Aug;24(8):651-9. [CrossRef] [PubMed]
8. Allison SJ. Acute kidney injury: Macrophage extracellular traps in rhabdomyolysis-induced AKI. Nat Rev Nephrol. 2018 Mar;14(3):141. [CrossRef] [PubMed]
9. Bosch X, Poch E, Grau JM. Rhabdomyolysis and acute kidney injury. N Engl J Med. 2009 Jul 2;361(1):62-72. [CrossRef] [PubMed]
10. Giannoglou GD, Chatzizisis YS, Misirli G. The syndrome of rhabdomyolysis: Pathophysiology and diagnosis. Eur J Intern Med. 2007 Mar;18(2):90-100. [CrossRef] [PubMed]
11. Diaz MH, Winchell JM. The evolution of advanced molecular diagnostics for the detection and characterization of Mycoplasma pneumoniae. Front Microbiol. 2016 Mar 8;7:232. [CrossRef] [PubMed]
12. Lee SC, Youn YS, Rhim JW, Kang JH, Lee KY. Early serologic diagnosis of Mycoplasma pneumoniae pneumonia: An observational study on changes in titers of specific-igm antibodies and cold agglutinins. Medicine. 2016 May;95(19):e3605. [CrossRef] [PubMed]
13. Lee WJ, Huang EY, Tsai CM, Kuo KC, Huang YC, Hsieh KS, et al. Role of serum Mycoplasma pneumoniae IgA, IgM, and IgG in the diagnosis of mycoplasma pneumoniae-related pneumonia in school-age children and adolescents. Clin Vaccine Immunol. 2017 Jan 5;24(1). pii: e00471-16. [CrossRef] [PubMed]
14. Novacco M, Sugiarto S, Willi B, Baumann J, Spiri AM, Oestmann A, Riond B, et al. Consecutive antibiotic treatment with doxycycline and marbofloxacin clears bacteremia in Mycoplasma haemofelis-infected cats. Vet Microbiol. 2018 Apr;217:112-120. [CrossRef] [PubMed]
15. Valdivia L, Nix D, Wright M, Lindberg E, Fagan T, Lieberman D, Stoffer T, et al. Coccidioidomycosis as a common cause of community-acquired pneumonia. Send to Emerg Infect Dis. 2006 Jun;12(6):958-62. [CrossRef] [PubMed]
16. Wheat LJ. Approach to the diagnosis of the endemic mycoses. Clin Chest Med. 2009 Jun;30(2):379-89. [CrossRef] [PubMed]
17. Gupta N, Aragaki A, Wikenheiser-Brokamp KA, Benzaquen S, Panos RJ. Occam's razor or Hickam's dictum? J Bronchology Interv Pulmonol. 2012 Jul;19(3):216-9. [CrossRef] [PubMed]

Cite as: Sen P, Majumdar U, Rendon P, Saeed AI, Sood A. Sharpening Occam's razor-a diagnostic dilemma. Southwest J Pulm Crit Care. 2018;16(6):324-31. doi: https://doi.org/10.13175/swjpcc061-18 PDF 

June 2018 Pulmonary Case of the Month

Lewis J. Wesselius, MD

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ USA

History of Present Illness

The patient is a 53-year-old man who presented in January 2018 for a second opinion on interstitial lung disease first diagnosed in 2011. He lives in Los Angeles and had one year of increasing dyspnea on exertion prior to diagnosis. He had an outside surgical lung biopsy and was treated with prednisone, then started on azathioprine and the prednisone tapered. He was followed regularly and had limited progression over next 7 years.  However, recently he had increasing shortness of breath.

Past Medical History, Social History, Family History

He has no significant past medical history. He is a nonsmoker and denies any significant occupational exposures.

Physical Examination

Physical examination was unremarkable without rales or clubbing.

Which of the following should be obtained at this time? (Click on the correct answer to proceed to the second of five pages)

1. Prior chest x-rays, CT scans, pulmonary function testing and lung biopsy
2. Repeat CT scan, pulmonary function testing
3. Rheumatological serologies
4. 1 and 3
5. All of the above

Cite as: Wesselius LJ. June 2018 pulmonary case of the month. Southwest J Pulm Crit Care. 2018;16(6):296-303. doi: https://doi.org/10.13175/swjpcc063-18 PDF 

May 2018 Pulmonary Case of the Month

Kenneth K. Sakata, MD

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ USA

History of Present Illness

A 70-year-old man was referred because of new anemia and a heme-positive stool. Esophagogastroduodenoscopy (EGD) was performed which revealed gastritis. Ascites developed and a chest x-ray noted a left pleural effusion. He was managed with weekly high-volume thoracentesis and paracentesis. He was referred to pulmonary medicine.

Past Medical History, Social History and Family History

He has a history of coronary artery disease having undergone coronary bypass grafting in 2016. He also has type 2 diabetes mellitus managed by diet and recently diagnosed orthostasis. He smokes about ½ pack of cigarettes per day but does not drink alcohol. He denies any inhalational exposures. He is Native American and works as a judge. There is no family history of any similar disorders.

Physical Examination

• No acute distress
• Slight bruise to left eye
• No lymphadenopathy
• Decreased breath sounds on left
• Protuberant distended abdomen
• Significant left leg edema
• Discoloration of a few nails

A point of contact ultrasound is performed (Figure 1).

Figure 1. Image from the point of contact ultrasound.

What should be done next? (Click on the correct answer to proceed to the second of seven pages)

1. Needle biopsy of pleural mass
2. Thoracentesis
3. Thoracic surgery consultation for video-assisted thorascopic surgery (VATS)
4. 1 and 3
5. All of the above

Cite as: Sakata KK. May 2018 pulmonary case of the month. Southwest J Pulm Crit Care. 2018;16(5):237-44. doi: https://doi.org/10.13175/swjpcc059-18 PDF 

Tobacco Company Campaign Contributions and Congressional Support of Tobacco Legislation

Richard A. Robbins, MD

Phoenix Pulmonary and Critical Care Research and Education Foundation

Gilbert, AZ USA

Abstract

Although it is widely held that campaign contributions influence Congressional support for legislation, the impact of these contributions is unclear. Three bills involving tobacco regulation were introduced into the 2017-8 Congress and were co-sponsored in both the House of Representatives and Senate. One was pro-tobacco (HR564/S294-Traditional Cigar Manufacturing and Small Business Jobs Preservation Act of 2017) and two were anti-tobacco (HR4273/S2100-Tobacco to 21 Act, HR2878/S1341-Children Don't Belong on Tobacco Farms Act). The association between tobacco political action committee (PAC) campaign contributions with sponsorship of these bills was examined. Tobacco PAC contributions to sponsors of pro-tobacco HR564/S294 were significantly larger [$18218, 95% confidence interval (CI) $15077-$21359, p<0.01] than to non-sponsors ($8730, 95% CI, $6959-$10501). Sponsors of the anti-tobacco HR4273/S2100 received significantly smaller contributions ($2114, 95% CI $0-$4833, p<0.01) than non-sponsors ($12048, 95% CI, $10289-$13707). Similarly, sponsors of the anti-tobacco HR2878/S1341 also received significantly smaller contributions ($2500, 95% CI $0-$5284, p<0.01) than non-sponsors ($12097, 95% CI $10429-$13765). These data demonstrate a significant correlation between campaign contributions and legislative support of pro- and anti-tobacco legislation.

Introduction

Previously, it has been shown tobacco contributions influence state legislators in terms of tobacco control policy-making and support by Southwest US Members of Congress of The Traditional Cigar Manufacturing and Small Business Jobs Preservation Act of 2015 (HR 662/S 441, aka the "Cigar Bill") (1,2). Although it is widely held that campaign contributions influence elected legislators, Powell (3) notes "political scientists have had great difficulty determining whether and how much influence contributions have on the legislative process". Studies have been inconsistent, with some demonstrating a linkage between campaign contributions and influence while others do not, suggesting that there are other influences in addition to contributions. Powell (3) has pointed out that the influence of donations is likely to occur early in the legislative process, such as during sponsorship for legislation or by directing that funds should be spent on a specific project (earmarks).

During the current 115^th Congress, the pro-tobacco “The Traditional Cigar Manufacturing and Small Business Jobs Preservation Act” was reintroduced (HR564/S294) (4). In addition, two anti-tobacco bills were introduced (HR4273/S2100 and HR2878/S1341) (4). Tobacco PAC contributions were examined for their association with sponsorship of these bills.

Methods

Tobacco Bills

The website Congress.Gov (4) was searched with the key word tobacco. Three bills were identified that had reached sufficient maturity to be introduced into the House of Representatives and the Senate and had co-sponsors listed in both the House and Senate. One was the pro-tobacco (HR564/S294-Traditional Cigar Manufacturing and Small Business Jobs Preservation Act of 2017) and two were anti-tobacco (HR4273/S2100-Tobacco to 21 Act, HR2878/S1341-Children Don't Belong on Tobacco Farms Act) (Table 1).

Table 1. Tobacco related legislation introduced during the 115^th session of Congress.

Sponsors and cosponsors were identified as listed on Congress.Gov.

Campaign Contributions

Tobacco company political action committee (PAC) contributions to members of Congress were obtained from the Campaign for Tobacco-Free Kids website (5). Contributions from the years listed (2006-18) were summed and no effort was made to separate recent from more past contributions.

Statistics

The relationship between sponsorship of the tobacco-related bills and tobacco PAC campaign contributions was done by Fisher's exact test using a 2X2 contingency table. Amounts of campaign contributions were expressed as means with 95% confidence intervals. The Mann-Whitney U test was used to calculate comparisons of the amounts of campaign contributions.

Results

Tobacco PAC Contributions

Sixty-five percent of the members of Congress have received a tobacco PAC contribution since 2006 (Appendix 1). The average reported was $11,637. Ten members received over $80,000, of which the largest was to Sen. Richard Burr (R-NC)($124,022); all but three were from what is referred to as the deep South. Over $6 million was donated in total; 82% of the donations went to Republicans.

Traditional Cigar Manufacturing and Small Business Jobs Preservation Act of 2017 (HR564/S294)

Ninety-four percent of the members of Congress who cosponsored the pro-tobacco "Traditional Cigar Manufacturing and Small Business Jobs Preservation Act of 2017 (aka Cigar Bill)" had received tobacco PAC campaign contributions (Appendix 2). In contrast, 53% of who were not cosponsors had received contributions (p<0.01 by Fisher's Exact Test). Furthermore, the amount of contributions was larger for those who had cosponsored the bill larger ($18218, 95% CI $15077-$21359) than non-sponsors ($8730, 95% CI, $6959-$10501, p<0.01 by Mann-Whitney U test).

Tobacco to 21 Act (HR4273/S2100)

Eighty-two percent of the members of Congress who cosponsored the anti-tobacco " Tobacco to 21 Act" had not received tobacco PAC campaign contributions (Appendix 3). In contrast, 35% of who were not cosponsors had not received contributions (p<0.01 by Fisher's Exact Test). Furthermore, the amount of contributions was smaller for those who had cosponsored the bill ($2114, 95% CI $0-$4833) than non-sponsors ($12048, 95% CI, $10289-$13707, p<0.01 by Mann-Whitney U test).

Children Don't Belong on Tobacco Farms Act (HR2878/S1341) 

Data were similar with the anti-tobacco “Children Don't Belong on Tobacco Farms Act”. Seventy-eight percent of the members of Congress who sponsored the bill had not received tobacco PAC campaign contributions (Appendix 4). Thirty-five percent of the members of Congress who had not cosponsored the bill did not receive contributions (p<0.01 by Fisher's Exact Test). Furthermore, the amount of contributions was smaller for those who had cosponsored the bill ($2500, 95% CI $0-$5284) than non-sponsors ($12097, 95% CI $10429-$13765), p<0.01 by Mann-Whitney U test).

Discussion

This manuscript shows an association between tobacco PAC campaign contributions and sponsorship of both pro- and anti-tobacco legislation. More members of Congress who supported the pro-tobacco “Traditional Cigar Manufacturing and Small Business Jobs Preservation Act of 2017” had received tobacco PAC campaign contributions and the contributions were larger compared to those not sponsoring the legislation. The data was the opposite for the anti-tobacco “Tobacco to 21 Act” and “Children Don't Belong on Tobacco Farms Act”. The percentage of the members of Congress who had not received tobacco PAC contributions was higher for those who sponsored the legislation compared to those who did not. Taken together these data suggest an influence of campaign contributions on the sponsoring of tobacco legislation in the US Congress.

The data in this manuscript confirms and extends the previous observations that tobacco contributions to state legislators and Southwest Members of Congress influence support of tobacco legislation (1,2).  The Southwest US is not a major tobacco growing or manufacturing region (7). Furthermore, tobacco consumption tends to be low in Southwest US (7). The Southwest is a good area to study the influence of campaign contributions because of the lack of confounding influences from a constituency that makes a living by tobacco growing or manufacturing or has a high prevalence of smokers. Reexamination of the correlation between tobacco PAC contributions and Congressional sponsorship of the "Cigar Bill" shows similar results with the data in 2016 (1, Appendix 1). The present study shows that association occurred in Congress as a whole and extended to anti-smoking legislation.

The title of HR564/S294 is deceiving. The “Traditional Cigar Manufacturing and Small Business Jobs Preservation Act” is titled to conjure up images of small businesses hand-rolling premium cigars. However, many of the cigars affected by the legislation are not the large, thick, and expensive ones manufactured with fine tobacco but rather small, thin, cheap cigars that are often flavored (8).

There is no doubt that smoking tobacco is harmful including cigars where the risk can be as high as or exceed those of cigarette smoking (9). Cigarette consumption in the United States is decreasing, compelling US tobacco companies to search for new markets (10). The cigar market, especially the flavored cigar market, represents one strategy to increase tobacco consumption and profits. Flavored cigar use is increasing in US middle and high school students (11). Therefore, tobacco companies support of the "Cigar Bill" is not surprising. By removing regulation, the tobacco companies can increase advertising to children and grow the candy-flavored cigar market (8).

The amount of money donated by the tobacco PACs is quite large and would seem to exceed anything that anti-tobacco smoking organizations could muster. Sixty-five percent of the members of Congress have received contributions totaling over 6 million dollars since 2006. The influence of these contributions may make regulation of tobacco quite difficult.

This manuscript has several limitations. Receiving tobacco PAC contributions and sponsoring pro-tobacco legislation does not necessarily represent cause and effect. It seems likely that tobacco companies would be more likely to support legislators that they perceive as sympathetic. It also seems likely that the tobacco PACs would be less likely to donate to supporters of anti-tobacco legislation.

References

1. Monardi F, Glantz SA. Are tobacco industry campaign contributions influencing state legislative behavior? Am J Public Health. 1998 Jun;88(6):918-23. [CrossRef] [PubMed]
2. Robbins RA. Tobacco company campaign contributions and congressional support of the cigar bill. Southwest J Pulm Crit Care. 2016;13(4):187-90. [CrossRef]
3. Powell LW. The influence of campaign contributions on legislative policy. The Forum: A Journal of Applied Research in Contemporary Politics 2013;11(3):339-55. [CrossRef]
4. Congress.gov. Available at: https://www.congress.gov/ (accessed 3/26/18).
5. Campaign for Tobacco-Free Kids. Tobacco company political action committee (PAC) contributions to Federal candidates. Available at: https://www.tobaccofreekids.org/what-we-do/us/tobacco-campaign-contributions  (accessed 3/26/18).
6. Statistica. Statistics and facts about the tobacco industry. Available at: http://www.statista.com/topics/1593/tobacco/ (accessed 3/26/18).
7. Campaign for tobacco-free kids. Key state-specific tobacco-related data & rankings. Available at: https://www.tobaccofreekids.org/assets/factsheets/0176.pdf (accessed 3/26/18).
8. American Thoracic Society. ATS Joins Letter Opposing Cigar Exemption. October, 2017. Available at: https://news.thoracic.org/washington-letter/2017/ats-joins-letter-opposing-cigar-exemption.php (accessed 3/26/18).
9. Chang CM, Corey CG, Rostron BL, Apelberg BJ. Systematic review of cigar smoking and all cause and smoking related mortality. BMC Public Health. 2015 Apr 24;15:390. [CrossRef] [PubMed]
10. Centers for Disease Control. Current Cigarette Smoking Among Adults in the United States. Available at: https://www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/index.htm (accessed 3/26/18).
11. King BA, Tynan MA, Dube SR, Arrazola R. Flavored-little-cigar and flavored-cigarette use among U.S. middle and high school students. J Adolesc Health. 2014 Jan;54(1):40-6. [CrossRef] [PubMed]

Cite as: Robbins RA. Tobacco company campaign contributions and congressional support of tobacco legislation. Southwest J Pulm Crit Care. 2018;16(4):232-6. doi: https://doi.org/10.13175/swjpcc053-18 PDF 

Social Media: A Novel Engagement Tool for Miners in Rural New Mexico

Shreya Wigh¹

William Cotton Jarrell, CMSP³

Elizabeth Kocher, MPH¹

Roger Karr²

Xin Wang, MS¹

Akshay Sood, MD, MPH^1,2

¹University of New Mexico Health Sciences Center School of Medicine

Albuquerque, NM, USA

²Miners Colfax Medical Center

Raton, NM, USA

³Peabody New Mexico Services

Grants, NM, USA

Abstract

Background: New Mexico miners usually live in rural areas. As compared to urban areas, rural areas in the United States demonstrate a lower use of the Internet and lower adoption of new technologies such as the smartphone and social media. Our study objective was to examine the use of these technologies among miners in rural New Mexico. Our long-term goal is to utilize these technologies to increase our program’s engagement with miners to provide medical screening and education services. Methods: We anonymously surveyed 212 miners at two town hall meetings in rural New Mexico communities, predominantly Hispanic and American Indian, in 2017. We then compiled that data in a Research Electronic Data Capture (REDCap) database and performed a statistical analysis using Statistical Analysis Software (SAS). IRB approval was obtained. Results: 60.8% of the 212 surveyed miners reported using social media. Among social media users, 88.4% reported using Facebook.  Most miners expressed willingness to use social media to keep in contact with other miners (51.2% overall) or to receive information about our miners’ program services (53.9% overall); and social media users were more likely to do so than non-users (p<0.001 for both analyses). Additionally, 79.7% of miners who owned a smartphone utilized it for texting. Conclusions: A majority of miners in rural New Mexico report use of social media and express willingness to use social media to network with other miners and with our program. The adoption of these communication technologies by rural New Mexico miners in our study is comparable or superior to that reported by rural Americans overall. It is possible to utilize this newer technology to increase program engagement with miners.

Introduction

New Mexico miners usually live in rural and medically underserved areas and suffer from multiple chronic diseases, particularly dust related lung diseases or pneumoconiosis. Rural counties in northern New Mexico have among the highest mortality rates for silicosis and pneumoconiosis, including coal workers’ pneumoconiosis, in the United States (1). To address this challenge, Miners’ Colfax Medical Center and the University of New Mexico have partnered in a federally funded medical screening program for rural miners.  As compared to urban areas, those who live in rural areas reportedly have a lower use of the Internet and are less willing to adopt new communication technologies such as the smartphone and social media (2). We have previously published that the primary source of information about miners’ health related activities for attendees at our miners’ health screening programs are traditional routes of communication such as a relative, friend, and community newspaper or flyer (3). Traditional media is, however, a one-way communication system that doesn’t create program engagement or work towards promoting word-of-mouth - the hallmark of social media (4). Our programs could utilize social media to promote awareness, encourage miner engagement, and increase the spread of accurate health messaging among New Mexico miners. Serving older, less educated, poorer, racial/ethnic minority, miners living in geographically remote and medically underserved rural areas of New Mexico may however affect the use and effectiveness of this communication tool.

The objective of our study was to examine the use of Internet-based smartphone and social media technology among miners in rural New Mexico. We hypothesized a low usage rate of these novel communication technologies among rural miners in New Mexico. Our long-term goal is to use these technologies to increase bidirectional engagement with miners with our federally funded Black Lung and Radiation Exposure Screening and Education Programs that currently provide medical screening, health care, and education services to coal and uranium miners in New Mexico.

Methods

Study design: This is a cross sectional survey of 212 miners, mostly coal miners, at two town hall meetings held in rural and medically underserved communities of Grants and Socorro, New Mexico, in 2017. These communities are predominantly American Indian and Hispanic respectively. The town hall meetings were held in conjunction with mobile health screening clinics for miners.

Survey creation: We created a survey on the use of the smartphone and social media, which asked construct-specific questions with either Yes/No responses or multiple choices. Examples of questions included whether miners would be willing to use social media to stay in touch with the mining community and if they had access to a computer with internet. The questions were formatted for an eighth-grade vocabulary, since our previous studies have shown that 57.2% of New Mexico miners do not complete high school education (3).

Survey administration: The paper copy of the survey was given to miners to fill out during the town hall meeting by the mine safety officer, on a voluntary and anonymous basis.

Analytic and database strategy: We compiled the survey data into a Research Electronic Data Capture (REDCap) database. We compared characteristics between social media users with social media non-users. Statistical analysis included an analysis of frequency distributions and Chi-square test, using Statistical Analysis Software (SAS 13.0, Cary, NC). A p-value less than 0.05 was considered statistically significant. We obtained human Institutional Review Board (IRB) approval for research exempt status (HRPO 14-058). The study was sponsored by Health Resource Services and Administration (HRSA) and Patient Centered Outcomes Research Institute (PCORI).

Results

60.8% of the 212 miners surveyed reported using social media. Among the social media users, 88.4% reported using Facebook, 27.9% reported using Instagram, and 26.4% reported using Snapchat.  Social media users reported utilizing the technology for an average of 47.9 ± 134.3 (SD) minutes daily, for approximately 6.0 ± 4.4 (SD) years. Most miners expressed willingness to use social media to keep in contact with other miners (51.2% overall) or to receive information about our miners’ program services (53.9% overall); and social media users were more likely to do so than non-users (p<0.001 for both analyses, Table 1).

Table 1. Difference in characteristics between self-reported social media users and nonusers, among rural miners in New Mexico.

86.3% of the miners surveyed also reported possessing a smart phone (93.8% versus 74.7% of the social media users and non-users respectively; p<0.001). 79.7% of miners owning a smartphone utilized it for texting (91.5% versus 61.5% of social media users versus nonusers respectively; p<0.001).

94.3% of rural miners reported having access to the Internet. Social media users were more likely to report having Internet access via computer or via phone than non-users (p = 0.08 and <0.001 respectively, Table 1). 24.0% of all miners however reported poor Internet connection as a challenge, and as compared to nonusers, social media users were more likely to report this challenge (p=0.01). 13.2% of all miners complained of the high expense of the Internet and the social media user status did not predict this characteristic (p=0.67). There was also no difference between the two groups with respect to the reported difficulty in navigating social media sites (p=0.32).

Discussion

Based on our results, we conclude that the majority of miners in rural New Mexico use Internet-based smartphone and social media technologies and are willing to use social media to network with other miners or programs that deliver health services to miners. We found that Facebook was the most popular social media site. The adoption of these communication technologies by rural New Mexico miners in our study is comparable or superior to that reported by rural Americans overall. This suggests that it is possible to use smartphone texting and social media technology to increase bidirectional program engagement with miners in rural New Mexico.

In 2017, the proportion of US population with a social media profile was variably estimated at 69-81% (5-7). Rural Americans in the US were approximately 8% less likely to use social media than urban Americans (2). The market leader in social media was Facebook, used by 68% and 79% of all and online American adults respectively (7). In our study, 60.8% of the rural miners reported using social media and 53.8% reported using Facebook, which is comparable to that reported in other US rural communities. In 2017, the proportion of American adults who owned a smartphone was 83%, 78%, and 65% for urban, suburban, and rural locations respectively (8). In comparison, 86.3% of rural miners in our study reported possessing a smartphone, indicating a higher level of smartphone possession than that reported by rural Americans overall. In 2017-2018, 89% of all American adults used the Internet (9). In an earlier survey from November 2016, 81% of rural Americans used the Internet, as compared to 89% of urban Americans (10). 63% of rural Americans had a broadband Internet connection at home, 10 percentage points less likely than Americans overall (10). In comparison, 94.3% of rural New Mexico miners in our study reported having access to the Internet, indicating a higher level of Internet access than that reported by rural Americans overall. Contrary to our initial hypothesis, we found that rural New Mexico miners in our study reported adoption of newer communication technologies at a level that was comparable or superior to that reported by rural Americans overall.

Racial/ethnic and health status-related disparities exist with respect to Internet access in the U.S. (9). However, among those with Internet access, these characteristics do not affect their social media use (11). New Internet-based technologies including smartphone and social media, may be changing the communication pattern throughout the U.S. and the world but this change has not been well studied, particularly in rural areas (11).  Potential overarching benefits of social media for health communication are (1) increased interactions with others, (2) more available, shared, and tailored information, (3) increased accessibility and widening access to health information, (4) peer/social/emotional support, (5) public health surveillance, and (6) potential to influence health policy (12). Our findings indicate that social media can similarly be used for health communication purposes among rural miners in New Mexico. Our HRSA-funded miners’ health and benefits programs in New Mexico have established a social media platform to provide rural miners with information on our clinical programs, research, education and other interventions as well as to provide opportunities for bidirectional engagement between the program and miners as well as among miners themselves. Our program has also launched a social media literacy campaign for miners, with the help of a rural mine safety officer.

Currently there is a limited amount of literature evaluating the use of social media for sustained engagement of diverse communities in health promotion (13,14). For instance, the Youth Voices Research Group has reported creating novel opportunities to engage young people to explore health topics ranging from tobacco use, food security, mental health, and navigation of health services, by combining social organizing with arts-informed methods for creative expression, using information technology (14). Creating opportunities for engagement alone is however insufficient. The information exchanged needs to be monitored for quality and reliability, users’ confidentiality and privacy need to be maintained (12), and its impact evaluated. Use of social media in health promotion in underserved populations, such as indigenous populations in Australia, is associated with limited evidence of benefit (15). Online social network health behavior interventions are reported to have small effect sizes, often statistically nonsignificant, with high participant attrition and low fidelity (16). It is therefore necessary for our program to critically evaluate the role and effectiveness of these new technologies in health promotion and health care for our population of rural miners.

The strength of our study includes inclusion of miners from rural and predominantly Hispanic and American Indian communities. Limitations of our study include small sample size and lack of information on individual demographic characteristics. Although our study was limited to New Mexico, our findings may be generalizable to other rural and medically underserved areas of the United States outside of New Mexico.

Conclusions

Most miners in rural New Mexico have Internet access, use smartphones and social media, and are willing to use social media to network with other miners or programs that deliver health services to miners. Rural New Mexico miners in our study report adoption of newer communication technologies at a level that is comparable or superior to that reported by rural Americans overall. This study provides preliminary information on a potential and novel way in which rural mining communities and miners’ health and benefits programs can engage with each other to promote miners’ health by assisting in clinical programs, research, education and other interventions. Miners’ program may consider interactive blogging, photograph elicitation, and video documentaries, alongside real-world social media projects, to promote this engagement. Potential barriers in rural miners include low social media literacy and poor Internet connection. Low social media literacy can however be addressed by targeted education of miners. Emerging areas of research include evaluating the effectiveness of the use of smartphones and social networking platforms such as Facebook, in building effective interventions for health promotion and providing healthcare for miners in rural communities.

Acknowledgments

SW, WCJ, EK, RK, KW, AS made substantial contributions to the conception or design of the work; SW, WCJ, EK, RK, KW, AS made substantial contributions to the acquisition, analysis, or interpretation of data for the work. SW, WCJ, EK, RK, KW, AS made substantial contribution towards drafting the work or revising it critically for important intellectual content. SW, WCJ, EK, RK, KW, AS provided the final approval of the version to be published. SW, WCJ, EK, RK, KW, AS agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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Cite as: Wigh S, Jarrell WC, Kocher E, Karr R, Wang X, Sood A. Social media: A novel engagement tool for miners in rural New Mexico. Southwest J Pulm Crit Care. 2018;16(4):206-11. doi: https://doi.org/10.13175/swjpcc017-18 PDF