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Research Roundup
November 18, 2008, Volume 55, No. 13

Skin Color Affects Detection of Rape Injuries

Researchers in the Penn School of Nursing found that victims of sexual assault with dark skin are less likely than those with light skin to have their injuries identified, documented and treated, leaving them disadvantaged in the health-care and criminal-justice systems, according to a new study published in the November issue of The American Journal of Emergency Medicine.

According to the National Crime Victimization Survey, cases of rape/assault of darker-skinned women occur more often but tend to go unreported, when compared with cases involving white women, in part because women do not report sexual victimization when there is “lack of [physical] proof” that an incident occurred.

“This finding is novel and important with respect both to clinical assessments and the decisions made within the criminal justice process,” said Dr. Marilyn Sommers, the principal investigator of the study and Lillian S. Brunner Professor of Medical-Surgical Nursing.

Dr. Sommers’ study, in which 120 volunteers underwent a forensic examination after consensual sexual intercourse, found that:

• 55 percent of the sample suffered at least one post-sex external genital injury, such as a tear, abrasion, redness or swelling, with injuries identified 68 percent of the time in white women, but only 43 percent of the time in women with darker skin. Significant disparities were only evident for external genitalia.

• Nearly three times the number of injuries to the external genitalia were identified in white women.

• In this study, Penn researchers developed a computerized model that is able to predict the extent of external genitalia injury in an assault case, regardless of a victim’s skin color.

“The findings from this study have clinical ramifications for those performing forensic sexual assault exams,” Dr. Sommers said. “Practitioners need to increase their vigilance when examining individuals with dark skin to ensure all injuries are identified, treated and documented.”

Doctor-Patient Communication Key to Drug Adherence

Patients who report receiving written and verbal instructions on the proper way to take the blood thinner Warfarin are significantly less likely to suffer the serious gastrointestinal and brain bleeding problems that are associated with misuse of the drug, according to new research from Penn’s School of Medicine. The study, published in the October issue of the Journal of General Internal Medicine, also shows that patients who see only one physician and fill their prescription at a single pharmacy are less apt to experience serious bleeding events.

Lead author Dr. Joshua P. Metlay, associate professor in Penn’s division of general internal medicine and a senior scholar in the Center for Clinical Epidemiology and Biostatistics, found that patients who reported receiving medication instructions from a physician and a nurse plus a pharmacy worker were 60 percent less likely to experience a serious bleeding problem over the following two years. Since the serious side effects of Warfarin use are often linked to hospitalizations, the Penn researchers theorize that improved patient communication—which can help clarify questions about dosing, other drugs to avoid while taking Warfarin, and early symptoms of bleeding problems—could prevent a substantial number of injuries and resulting hospitalizations.

Dr. Metlay’s team, in collaboration with the Pennsylvania Pharmaceutical Assistance Contract for the Elderly (PACE), studied 2,346 older adults taking Warfarin for problems including heart rhythm abnormalities, deep vein thrombosis, stroke, heart valve replacements and pulmonary embolism. Using data provided by the Pennsylvania Healthcare Cost Containment Council, the researchers identified hospitalizations that were tied to Warfarin-related bleeding events among the patients in the study.

The findings also indicate that the way patients receive instruction about their medicine matters. Compared to receiving no instructions beyond those printed on the prescription bottle, patients who said they had been given written information or written information plus verbal instructions were less apt to suffer bleeding events. Reports of verbal instruction alone, however, were not associated with a decreased risk of bleeding problems compared to patients who received no instructions. The Penn researchers said the findings underscore previous studies showing that thorough, honest communication between health care providers and patients is an important contributor to compliance with recommended therapies.

Since only 55 percent of participants in the study reported receiving any type of medication instructions from a doctor or nurse, Dr. Metlay and his colleagues say the impact on bleeding events among Warfarin users could be slashed further if similar communication models were adopted more widely by physicians and pharmacists. New regulations requiring that all patients filling Warfarin prescriptions receive a Medication Guide could help, and since pharmacists are now able to be reimbursed for time spent providing medication counseling to Medicare recipients, the authors are hopeful more patients will get helpful information about this drug.

Stem Cells that Could Regenerate Injured Liver Tissue

A novel protein marker has been found that identifies rare adult liver stem cells, whose ability to regenerate injured liver tissue has the potential for cell-replacement therapy. For the first time, researchers at Penn’s School of Medicine led by Dr. Linda Greenbaum, assistant professor of medicine in the division of gastroenterology, have demonstrated that cells expressing the marker can differentiate into both liver cells and cells that line the bile duct.

In the future, this marker will allow for the isolation and expansion of these stem cells, which could then be used to help patients whose livers can no longer repair their own tissue. About 17,000 Americans are currently on a waiting list for a liver transplant, according to the American Liver Foundation. The findings appear online this month in the journal Hepatology.

“In a healthy liver, proliferation of mature liver and bile-duct lining cells is sufficient to maintain the necessary size and function of the organ,” explains Dr. Greenbaum. “This even works when the liver is confronted with mild and acute injury, but the situation changes when injury to the liver is chronic and severe.”

For chronic injury, the liver uses a back-up system that stimulates stem cells to proliferate and eventually differentiate into new liver cells. Dr. Greenbaum and colleagues found that these dual-potential stem cells can be identified and potentially isolated from other liver cells because they uniquely express the protein Foxl1. The team showed that in two mice models of liver injury, stem cells and their descendents were marked by the expression of Foxl1. The researchers propose to use this marker to isolate the Foxl1-bearing stem cells and transplant them back into damaged livers to restore function.

“At this point, we haven’t identified the molecular targets that are regulated by Foxl1 in the liver stem cell,” said Dr. Greenbaum. The researchers also do not yet know what signals activate the expression of Fox Foxl1 and how exactly it is related to liver function. But, they finally have a molecular handle on identifying liver stem cells, which have remained elusive to scientists.

“This work has significant implications for cell-replacement therapies of chronic liver disease in the future,” said Dr. Greenbaum.

$1 Billion Wasted? Fault With Anti-Drug Campaign

A five-year, $1 billion anti-drug advertising campaign by the US Government was ineffective, and may have actually done more harm than good. That was the finding from a long-term examination of the National Youth Anti-Drug Media Campaign. Dr. Robert C. Hornik, the Wilbur Schramm Professor of Communication and Health Policy at the Annenberg School for Communication, was scientific director and lead author for the evaluation study. Major findings of the evaluation will be reported in the December issue of the American Journal of Public Health.

“The evidence does not support a claim that the campaign produced anti-marijuana effects,” wrote the authors. Dr. Hornik was the lead author, along with, among others, Dr. Lela Jacobsohn, also from the Annenberg School.

The evaluation found that the target audience did recall the advertisements. Overall, 94 percent of youths reported general exposure to one or more anti-drug messages per month, with a median frequency of about two or three ads per week. However the message did not get through.

“There is little evidence for a contemporaneous association between exposure to anti-drug advertising and any of the outcomes … Nonusers who reported more exposure to anti-drug messages were no more likely to express anti-drug beliefs than were youths who were less exposed,” said the authors. Additionally, the Congressionally-mandated evaluation showed the 12.5 to 18 year old youths who reported seeing the advertisements more often were actually more likely to intend to use drugs at a later date.

The anti-drug advertising campaign was supervised by the White House Office of National Drug Control Policy. Overall management was conducted by the advertising firm Ogilvy and Mather. Advertising messages promoted resistance skills, education and positive alternatives, and negative consequences of drug use. The target audiences were non- and occasional drug users. One of the more recognizable elements in the campaign advertisements was a youth brand phrase: “____: My Anti-Drug,” (with something like “Soccer” filling in the blank). Congress mandated the evaluation to evaluate the effectiveness of the campaign.

More than 8,000 youths aged 9 to 18 and more than 6,000 of their parents were interviewed up to four times between 1999 and 2004. The analyses were based on three types of measures—recalled exposure to anti-drug messages aired by the campaign and other sources; cognitions and behavior related to marijuana, as outcomes; and individual and household characteristics. These associations reported in the study were adjusted for other possible influences on youth exposure to advertising.




Almanac - November 18, 2008, Volume 55, No. 13