Specialized regulatory T cell stifles antibody production centers: Discovery has potential implications for cancer, autoimmune disease

ScienceDaily (July 25, 2011) — A regulatory T cell that expresses three specific genes shuts down the mass production of antibodies launched by the immune system to attack invaders, a team led by scientists at The University of Texas MD Anderson Cancer Center reported online in the journal Nature Medicine.See Also:Health & MedicineLymphomaImmune SystemStem CellsBrain TumorCancerLung CancerReferenceNatural killer cellT cellLymph nodeHeat shock protein

"Regulatory T cells prevent unwanted or exaggerated immune system responses, but the mechanism by which they accomplish this has been unclear," said paper senior author Chen Dong, Ph.D., professor in MD Anderson's Department of Immunology and director of the Center for Inflammation and Cancer.

"We've identified a molecular pathway that creates a specialized regulatory T cell, which suppresses the reaction of structures called germinal centers. This is where immune system T cells and B cells interact to swiftly produce large quantities of antibodies," Dong said.

The discovery of the germinal center off-switch, which comes two years after Dong and colleagues identified the mechanisms underlying a helper T cell that activates the centers, has potential implications for cancer and autoimmune diseases.

"In some types of cancer, the presence of many regulatory T cells is associated with poor prognosis," Dong said. "The theory is those cells suppress an immune system response in the tumor's microenvironment that otherwise might have attacked the cancer."

However, in B cell lymphomas, overproliferation and mutation of B cells are the problems, Dong said. Hitting the regulatory T cell off-switch might help against lymphomas and autoimmune diseases, while blocking it could permit an immune response against other cancers.

Antibody production central

Germinal centers are found in the lymph nodes and the spleen. They serve as gathering points for B and T cell lymphocytes, infection-fighting white blood cells.

When the adaptive immune system detects an invading bacterium or virus, B cells present a piece of the invader, an antigen, to T cells. The antigen converts a naïve T cell to a helper T cell that secretes cytokines, which help the B cells expand and differentiate into specialized antibodies to destroy the intruder.

"Germinal centers have mostly B cells with a few helper T cells to regulate them. The B cells mutate to make high-affinity antibodies and memory B cells for long-term immunity. The cell population in the germinal center structures replicates in an average of several hours, one of the fastest rates of cell replication known in mammals," Dong said.

Tracking down specialized T cell

In the Nature Medicine paper, Dong and colleagues found that a subgroup of regulatory T cells that expresses two genes, Bcl-6 and CXCR5, moves into germinal centers in both mice and humans, where they have access to B cells.

(Bcl-6 produces a protein called a transcription factor, which moves into the cell nucleus to regulate other genes. CXCR5 is a receptor protein for a signaling molecule called CXCL13.)

They also found that the Bcl-6/CXCR5 T cells aren't produced in the thymus, with other T cells, but are generated by regulatory T cell precursor cells that express Foxp3, another transcription factor.

Knocking out the regulatory T cells that express all three proteins in mice resulted in increased germinal center production of antibodies. They named this key T cell the T follicular regulatory cell, or Tfr.

In a 2009 paper in the journal Science, the researchers found that naïve T cells that expressed Bcl-6 and CXCR5 also gathered in the B cell zone of germinal centers. Expression of Bcl6 converted the T cell into a T follicular helper (Tfh) cell that launches antibody production in the germinal centers.

With Tfr turning germinal centers off and Tfh turning them on, we could potentially regulate antibody production, Dong noted. Increasing Tfr production could be a new approach to treating autoimmune inflammatory disorders, such as lupus and rheumatoid arthritis.

The team's research was funded by grants from the National Institutes of Health, the Leukemia and Lymphoma Society, MD Anderson, the American Heart Association, Doris Duke Charitable Foundation Clinical Scientist Development Award and the China Ministry of Science and Technology Protein Science Key Research Project.

Co-authors with Dong are first author Yeonseok Chung, Ph.D., Shinya Tanaka, Ph.D., Roza Nurieva, Ph.D., Gustavo Martinez, Yi-Hong Wang and Joseph Reynolds, Ph.D., of MD Anderson's Department of Immunology and the Center for Cancer Immunology; Chung also is with The University of Texas Health Science Center at Houston Institute of Molecular Medicine; Seema Rawal and Sattva Neelapu, M.D., of MD Anderson's Department of Lymphoma and Myeloma, also of the Center for Cancer Immunology; and Ziao-hui Zhou, M.D., Hui-min Fan, M.D., and Zhong-ming Liu, M.D., of Shanghai Dong Fang Hospital, Shanghai, China.

Email or share this story:

New software protects water utilities from terrorist attacks and contaminants

ScienceDaily (July 25, 2011) — Americans are used to drinking from the kitchen tap without fear of harm, even though water utilities might be vulnerable to terrorist attacks or natural contaminants.See Also:Matter & EnergyNature of WaterNuclear EnergyComputers & MathSoftwareHackingScience & SocietyResource ShortageEnvironmental PoliciesReferenceSecurity engineeringPumiceComputer securityComputer software

Now, thanks to CANARY Event Detection Software -- an open-source software developed by Sandia National Laboratories in partnership with the Environmental Protection Agency (EPA) -- public water systems can be protected through enhanced detection of such threats.

"People are excited about it because it's free and because we've shown that it works really well. We would love to have more utilities using it," said Regan Murray, acting associate division director of the EPA's Water Infrastructure Protection Division at the National Homeland Security Research Center.

The software tells utility operators within minutes whether something is wrong with their water, giving them time to warn and protect the public. And it's improving water quality by giving utility managers more comprehensive real-time data about changes in their water.

CANARY is being used in Cincinnati and Singapore, and Philadelphia is testing the software system. A number of other U.S. utilities also are evaluating CANARY for future use.

Sean McKenna, the Sandia researcher who led the team that developed CANARY, said people began to pay attention to the security of the nation's water systems after 9/11.

McKenna and Murray said CANARY could have lessened the impact of the nation's largest public water contamination. In 1993, a cryptosporidiosis outbreak in Milwaukee hastened the deaths of dozens of citizens, made more than 400,000 residents ill and cost more than $96 million in medical expenses and lost productivity, according to reports about the tragedy.

"If you don't have a detection system, the way you find out about these things is when people get sick," Murray said.

Sandia, a national security laboratory, had worked on water security before the 9/11 attacks. So when the EPA was looking for help early in the last decade to better monitor water utilities, they contacted Sandia.

A Sandia-developed, risk-assessment methodology for water focused on physical security of the utility infrastructure, but did not address detection and assessment of the impact of contamination within the water itself. CANARY was designed to meet that need for better assessment, McKenna said.

CANARY, which runs on a desktop computer, can be customized for individual water utilities, working with existing sensors and software, McKenna said.

While some utilities monitor their water using real-time sensors, many still send operators out once a week to take samples, said David Hart, the lead Sandia software developer for CANARY.

Compared to weekly samples, CANARY works at lightning speed.

"From the start of an event -- when a contaminant reaches the first sensor -- to an event alarm would be 20-40 minutes, depending on how the utility has CANARY configured," McKenna said.

The challenge for any contamination detection system is reducing the number of false alarms and making data meaningful amidst a "noisy" background of information caused by the environment and the utility infrastructure itself.

CANARY researchers used specially designed numerical algorithms to analyze data coming from multiple sensors and differentiate between natural variability and unusual patterns that indicate a problem. For example, the Multivariate-Nearest Neighbor algorithm groups data into clusters based on time and distance, explained Kate Klise, a numerical analyst at Sandia. When new data is received, CANARY decides whether it's close enough to a known cluster to be considered normal or whether it's far enough away to be deemed anomalous. In the latter case, CANARY alerts the utility operator, Klise said.

The computer program uses a moving 1.5- to two-day window of past data to detect abnormal events by comparing predicted water characteristics with current observations. But a single outlier won't trigger the alarm, which helps to avoid costly and inefficient false alarms. CANARY aggregates information over multiple 2- to 5-minute time steps to build evidence that water quality has undergone a significant change, McKenna said.

"We've taken techniques from different fields and put those together in a way they haven't been put together before; certainly the application of those techniques to water quality monitoring hasn't been done before," McKenna said.

CANARY also provides information about gradual changes in the water, McKenna said.

One unintended benefit of the software is that when utility operators better understood the data being sent by their sensors, they could make changes to the management of the water systems to improve its overall quality, McKenna said.

"What we found from utilities we work with is that a better managed system is more secure, and a more secure system is better managed," McKenna said.

Harry Seah, director of the Technology and Water Quality Office at the Public Utilities Board (PUB), Singapore's national water authority, wrote in a letter supporting CANARY that the software provided a "quantum leap" in the utility's practice.

In the past, Seah wrote, the utility depended on preset limits of three water characteristics to determine water quality.

"With the implementation of CANARY, relative changes in the patterns of these three parameters can be used to uncover water quality events, even if each individual parameter lies within the alarm limits," Seah wrote. "This dramatically improves PUB's ability to respond to water quality changes, and allows PUB to arrest poor quality water before

Making biological images sharper, deeper and faster

ScienceDaily (July 25, 2011) — For modern biologists, the ability to capture high-quality, three-dimensional (3D) images of living tissues or organisms over time is necessary to answer problems in areas ranging from genomics to neurobiology and developmental biology. The better the image, the more detailed the information that can be drawn from it. Looking to improve upon current methods of imaging, researchers from the California Institute of Technology (Caltech) have developed a novel approach that could redefine optical imaging of live biological samples by simultaneously achieving high resolution, high penetration depth (for seeing deep inside 3D samples), and high imaging speed.See Also:Plants & AnimalsDevelopmental BiologyBiotechnologyBiologyMatter & EnergyOpticsBiochemistryMedical TechnologyReferenceConfocal laser scanning microscopySpectroscopyInfraredElectron microscope

The imaging technique is explained in a paper in the advance online publication of the journal Nature Methods, released on July 14. It will also appear in an upcoming print version of the journal.

"Before our work, the state-of-the-art imaging techniques typically excelled in only one of three key parameters: resolution, depth, or speed. With our technique, it's possible to do well in all three and, critically, without killing, damaging, or adversely affecting the live biological samples," says biologist Scott Fraser, director of the Biological Imaging Center at Caltech's Beckman Institute and senior author of the study.

The research team achieved this imaging hat trick by first employing an unconventional imaging method called light-sheet microscopy, where a thin, flat sheet of light is used to illuminate a biological sample from the side, creating a single illuminated optical section through the sample. The light given off by the sample is then captured with a camera oriented perpendicularly to the light sheet, harvesting data from the entire illuminated plane at once. This allows millions of image pixels to be captured simultaneously, reducing the light intensity that needs to be used for each pixel. This not only enables fast imaging speed but also decreases the light-induced damage to the living samples, which the teams demonstrated using the embryos of fruit fly and zebrafish.

To achieve sharper image resolution with light-sheet microscopy deep inside the biological samples, the team used a process called two-photon excitation for the illumination. This process has been used previously to allow deeper imaging of biological samples; however, it usually is used to collect the image one pixel at a time by focusing the exciting light to a single small spot.

"The conceptual leap for us was to realize that two-photon excitation could also be carried out in sheet-illumination mode," says Thai Truong, a postdoctoral fellow in Fraser's laboratory and first author of the paper. This novel side-illumination with a two-photon illumination is the topic of a pending patent.

"With this approach, we believe that we can make a contribution to advancing biological imaging in a meaningful way," continues Truong, who did his Ph.D. training in physics. "We did not want to develop a fanciful optical imaging technique that excels only in one niche area, or that places constraints on the sample so severe that the applications will be limited. With a balanced high performance in resolution, depth, and speed, all achieved without photo-damage, two-photon light-sheet microscopy should be applicable to a wide variety of in vivo imaging applications." He credits this emphasis on wide applicability to the interdisciplinary nature of the team, which includes two biologists, two physicists, and one electrical engineer.

"We believe the performance of this imaging technique will open up many applications in life sciences and biomedical research -- wherever it is useful to observe, non-invasively, dynamic biological process in 3D and with cellular or subcellular resolution," says Willy Supatto, co-author of the paper and a former postdoctoral fellow in Fraser's laboratory (now at the Centre National de la Recherche Scientifique, in France).

One example of such an application would be to construct 3D movies of the entire embryonic development of an organism, covering the entire embryo in space and time. These movies could capture what individual cells are doing, as well as important genes' spatiotemporal expression patterns -- elucidating the activation of those genes within specific tissues at specific times during development.

"The goal is to create 'digital embryos,' providing insights into how embryos are built, which is critical not only for basic understanding of how biology works but also for future medical applications such as robotic surgery, tissue engineering, or stem-cell therapy," says Fraser. The team's first attempt at this can be seen in the accompanying movie, in which the cell divisions and movements that built the entire fruit fly embryo were captured without perturbing its development: http://www.youtube.com/watch?v

Global bioterrorism threat analyzed for world animal health office

ScienceDaily (July 25, 2011) — Around the globe, many nations are realizing that the potential for bioterrorism isn't just about the U.S., officials say.See Also:Plants & AnimalsAgriculture and FoodZoologyBehavioral ScienceScience & SocietyWorld DevelopmentPublic HealthScientific ConductReferenceTularemiaAnthraxBiological warfareRicin

And because an intentional introduction of bacteria, a virus or a toxin could happen anywhere, the World Organization for Animal Health is issuing a paper aimed at prevention.

"Any emerging country that is beginning to think about maintaining international trade needs to be aware of the potential for bioterrorism," said Dr. Neville Clarke, special assistant to the Texas A&M University System's vice chancellor of agriculture.

Clarke is lead author of "Bioterrorism: intentional introduction of animal disease," which appears in the animal health organization's journal Scientific and Technical Review this month.

Preventing bioterrorism worldwide

Around the globe, many nations are realizing that the potential for bioterrorism isn't just about the U.S., officials say.

First off, bioterrorism is not new.

The intentional introduction of animal disease dates to the Middle Ages when "diseased carcasses and bodies were catapulted over enemy walls in attempts to induce sickness in humans or animals," Clarke wrote with co-author Jennifer L. Rinderknecht, Texas AgriLife Research assistant.

Throughout time, similar practices ensued until 1975, when more than 160 countries at the Biological and Toxic Weapons Convention agreed to prohibit biological warfare programs, the article noted.

But, the authors say, evidence around the world indicates that the "development of biological agents continues in some countries."

Clarke said that those farthest away from being prepared are the developing nations such as in Sub-Saharan Africa and Indonesia. He said the article would be helpful for nations that are wanting to protect their markets as they grow globally.

The article discusses potential perpetrators and their methods, priority diseases, modern biology, trade and regulatory restraints as listed by the World Organization for Animal Health, which is headquartered in Paris and known as OIE for Office International des Epizooties.

Clarke pointed to the live animal and fresh meat restrictions on imports from Brazil that are in place because there are still pockets of Foot-and-Mouth Disease in that South American country.

"That impairs their ability to export to the U.S.," he said. "Trade restriction is one of the most important underlying issues that face countries. That makes bioterrorism everyone's business."

While the article deals specifically with intentional introductions, Clarke said the "clean up and control is same" for either type event.

"The only difference is in attribution," he said. "If an act is intentional, then the focus goes to finding out who did it."

Email or share this story:

Antibiotic appears more effective than cranberry capsules for preventing urinary tract infections

ScienceDaily (July 25, 2011) — In premenopausal women who have repeated urinary tract infections (UTIs), the antibiotic trimethoprim-sulfamethoxazole (TMP-SMX) appeared more effective than cranberry capsules for preventing recurrent infections, at the risk of contributing to antibiotic resistance, according to a report in the July 25 issue of Archives of Internal Medicine, one of the JAMA/Archives journals.See Also:Health & MedicineDiabetesInfectious DiseasesWomen's HealthPlants & AnimalsBacteriaMicrobes and MoreFoodReferenceUrinary tract infectionCranberryClinical trialDouble blind

Urinary tract infections are common in women, affecting nearly half at some point in their lives, according to background information in the article. The authors note that up to 30 percent of women develop recurrent UTIs (rUTIs), a condition for which a low-dose antibiotic is frequently used as a preventive measure. "However, this may lead to drug resistance not only of the causative microorganisms but also of the indigenous flora," write the authors. Studies of cranberries and cranberry products have shown some effectiveness in preventing rUTIs, but these trials have not compared those interventions directly with TMP-SMX, the standard antibiotic used in these cases.

Mariëlle A.J. Beerepoot, M.D., from the Academic Medical Center, Amsterdam, and colleagues conducted a double-blind noninferiority trial of cranberry capsules and TMP-SMX. The 221 participants were premenopausal adult women who had reported at least three symptomatic UTIs in the previous year. They were randomized to take either TMP-SMX (480 mg at night, plus one placebo capsule twice daily) or cranberry capsules (500 mg twice daily, plus one placebo tablet at night) for 12 months. Researchers assessed participants' clinical status once a month (and for three months after stopping the study medication) via urine and feces samples and a questionnaire; participants also submitted urine samples when they experienced UTI-like symptoms.

At 12 months, the average number of clinical recurrences was 1.8 in the TMP-SMX group and 4.0 in the cranberry capsules group. Recurrence occurred, on average, after eight months in the drug group and after four months in the cranberry capsules group. Antibiotic resistance rates tripled in the pathogens found in patients in the TMP-SMX group, although three months after the drug was discontinued, resistance rates returned to the levels they had been at when the study began.

The antibiotic used in this study appeared to be more effective at preventing rUTIs than cranberry capsules, but the researchers noted that achieving this result also seemed to increase the rate of antibiotic resistance. "From clinical practice and during the recruitment phase of this study, we learned that many women are afraid of contracting drug-resistant bacteria using long-term antibiotic prophylaxis and preferred either no or nonantibiotic prophylaxis," they report. "In those women, cranberry prophylaxis may be a useful alternative despite its lower effectiveness."

This study was supported by a grant from the Netherlands Organization for Health Research and Development. The authors received the cranberry and placebo capsules from Springfield Nutraceuticals BV, Oud Beijerland, the Netherlands.

Commentary: Cranberries as Antibiotics?

An accompanying commentary by Bill J. Gurley, Ph.D., from the University of Arkansas for Medical Sciences, Little Rock, evaluates the results obtained by Beerepoot and colleagues in the context of nonpharmacologic remedies. Botanical dietary supplements are not intended to be used to treat, cure or prevent disease, he writes, but "most U.S. consumers, however, have expectations of health benefits from the dietary supplements they consume." Nevertheless, supplements such as cranberry capsules may not demonstrate optimal efficacy due to issues with poor water solubility and the type of metabolism that occurs.

Dr. Gurley notes that the report by Beerepoot and colleagues has two important features. Given that one month into the study, antibiotic resistance for Escherichia coli was higher than 85 percent in the TMP-SMX group but less than 30 percent in the cranberry capsule group, "such a marked reduction in antibiotic resistance certainly favors the therapeutic potential of cranberry as a natural UTI preventative." Further, Gurley points out that TMP-SMX showed superior efficacy to cranberry capsules, but that the low rate of bioavailability of bacteria-fighting chemicals in the dosage used of the latter may have affected the study's results. "Because optimal doses have not been established for many botanicals, clinical efficacy trials have often yielded negative or inconclusive results," Gurley points out. He mentions an ongoing dose-ranging study for cranberry that may provide more information on this supplement's effectiveness.

Email or share this story:

Evolution of human generosity

ScienceDaily (July 25, 2011) — Imagine you're dining at a restaurant in a city you're visiting for the first -- and, most likely the last -- time. Chances are slim to none that you'll ever see your server again, so if you wanted to shave a few dollars off your tab by not leaving a tip, you could do so. And yet, if you're like most people, you will leave the tip anyway, and not give it another thought.See Also:Mind & BrainSocial PsychologyPsychologyRelationshipsScience & SocietyEconomicsUrbanizationWorld DevelopmentLiving WellReferenceCooperationExperimental economicsGame theoryAltruism

These commonplace acts of generosity -- where no future return is likely -- have long posed a scientific puzzle to evolutionary biologists and economists. In acting generously, the donor incurs a cost to benefit someone else. But choosing to incur a cost with no prospect of a compensating benefit is seen as maladaptive by biologists and irrational by economists. If traditional theories in these fields are true, such behaviors should have been weeded out long ago by evolution or by self-interest. According to these theories, human nature is fundamentally self-serving, with any "excess" generosity the result of social pressure or cultural conformity.

Recently, however, a team of scientists at UC Santa Barbara conducted a series of computer simulations designed to test whether it was really true that evolution would select against generosity in situations where there is no future payoff. Their work surprisingly shows that generosity -- acting to help others in the absence of foreseeable gains -- emerges naturally from the evolution of cooperation. This means that human generosity is likely to rest on more than social pressure, and is instead built in to human nature.

Their findings appear in the current issue of the Proceedings of the National Academy of Sciences.

"When past researchers carefully measured people's choices, they found that people all over the world were more generous than the reigning theories of economics and biology predicted they should be," said Max M. Krasnow, a postdoctoral scholar at UCSB's Center for Evolutionary Psychology, and one of the paper's lead authors. "Even when people believe the interaction to be one-time only, they are often generous to the person they are interacting with."

"Our simulations explain that the reason people are more generous than economic and biological theory would predict is due to the inherent uncertainty of social life," added Andrew Delton, also a postdoctoral scholar at the Center for Evolutionary Psychology and the paper's other lead author. "Specifically, you can never know for certain whether an interaction you are having right now will be one-time only -- like interacting with a server in a distant city -- or continue on indefinitely -- like interacting with a server at your favorite hometown diner."

Krasnow and Delton co-authored the paper with Leda Cosmides, professor of psychology and co-director of the Center for Evolutionary Psychology; and John Tooby, professor of anthropology and also co-director of the Center for Evolutionary Psychology.

"There are two errors a cooperating animal can make, and one is more costly than the other," noted Cosmides. "Believing that you will never meet this individual again, you might choose to benefit yourself at his expense -- only to find out later that the relationship could have been open-ended. If you make this error, you lose out on all the benefits you might have had from a long-term, perhaps life-long, cooperative relationship. This is an extraordinarily costly error to make. The other error is to mistakenly assume that you will have additional interactions with the other individual and therefore cooperate with him, only to find out later that it wasn't necessary. Although you were 'unnecessarily' nice in that one interaction, the cost of this error is relatively small. Without knowing why, the mind is skewed to be generous to make sure we find and cement all those valuable, long-term relationships."

The simulations, which are mathematical tools for studying how natural selection would have shaped our ancestors' decision making, show that, over a wide range of conditions, natural selection favors treating others as if the relationship will continue -- even when it is rational to believe the interaction is one-time only. "Although it's impossible to know the true state of the world with complete certainty, our simulated people were designed to use the 'gold-standard' for rational reasoning -- a process called Bayesian updating -- to make the best possible guesses about whether their interactions will continue or not," Krasnow noted.

Delton continued: "Nonetheless, even though their beliefs were as accurate as possible, our simulated people evolved to the point where they essentially ignored their beliefs and cooperated with others regardless. This happens even when almost 90 percent of the interactions in their social world are actually one-time rather than indefinitely continued."

According to Tooby, economic models of rationality and evolutionary models of fitness maximization both predict that humans should be designed to be selfish in one-time only situations. Yet, experimental work -- and everyday experience -- shows that humans are often surprisingly generous.

"So one of the outstanding problems in the behavioral sciences was why natural selection had not weeded out this pleasing but apparently self-handicapping behavioral tendency," Tooby said. "The paper shows how this feature of human behavior emerges logically out of the dynamics of cooperation, once an overlooked aspect of the problem -- the inherent uncertainty of social life -- is taken into account. People who help only when they can see a gain do worse than those who are motivated to be generous without always looking ahead to see what they might get in return."

Email or share this story:

New data-based strategies and treatment models can improve diabetes care for older African-Americans

ScienceDaily (July 25, 2011) — Better data are needed to evaluate access to care by minority groups at increased risk for diabetes, such as older African Americans, and to assess the benefits of new community-based treatment strategies, including greater use of health information technology and access to multilevel diabetes education teams, according to a report in Population Health Management, a peer-reviewed journal published by Mary Ann Liebert, Inc.See Also:Health & MedicineDiabetesHealth PolicyDiseases and ConditionsMental Health ResearchToday's HealthcareElder CareReferenceAthletic trainingDiabetes mellitus type 2Palliative careDiabetic diet

Older adults of racial or ethnic minority descent tend to have a higher incidence of diabetes than whites, and these populations often have less access to quality health care. Karen Fitzner, PhD, American Association of Diabetes Educators (Chicago, IL), David Dietz, MSW, MHSA, U.S. Department of Health and Human Services (Rockville, MD), and Ernest Moy, MD, MPH, Agency for Healthcare Research and Quality (Rockville, MD) identify the gaps in care for underserved older adults and describe how better use of health information technology and multilevel diabetes education teams can help fill those gaps and improve health outcomes for older African Americans with diabetes.

The authors focus on treatment models that incorporate advances in information technology such as telehealth and geo-mapping for improved data sharing, Diabetes Self-Management Education and Training (DSME/T) programs, national collaboratives, and a multilevel diabetes education team approach that relies on less-skilled team members such as community health workers, supervised and supported by a multidisciplinary team of professional health care providers to facilitate community-based diabetes care, education, and prevention.

Email or share this story: