HIV-1 evades virus-specific IgG2 and IgA responses by targeting systemic and intestinal B cells via long-range intercellular conduits.

Contact-dependent communication between immune cells generates protection but also facilitates viral spread. Here we found that macrophages formed long-range actin-propelled conduits in response to negative factor (Nef), a human immunodeficiency virus type 1 (HIV-1) protein with immunosuppressive functions. Conduits attenuated immunoglobulin G2 (IgG2) and IgA class switching in systemic and intestinal lymphoid follicles by shuttling Nef from infected macrophages to B cells through a guanine-exchange factor-dependent pathway involving the amino-terminal anchor, central core and carboxy-terminal flexible loop of Nef. By showing stronger virus-specific IgG2 and IgA responses in patients with Nef-deficient virions, our data suggest that HIV-1 exploits intercellular 'highways' as a 'Trojan horse' to deliver Nef to B cells and evade humoral immunity systemically and at mucosal sites of entry.

Increased longevity in HIV: caring for older HIV-infected adults.

The demographics of the HIV-infected population in the United States have shifted in a way that few would have predicted 30 years ago when the tide of sick and dying patients largely consisted of young men. Effective ART has allowed those infected to live long, productive lives and to grow old with their disease. With the increase in life expectancy afforded by HIV treatment, the cause of death among HIV-infected individuals is far more likely to be from an HIV-associated non-AIDS condition. Nonetheless, HIV seems to accelerate the aging process, and care providers involved in the treatment of older patients with HIV need to be aware that their patients are at increased risk of developing various common disorders, compared to uninfected same-age patients. Clinicians need to remain vigilant to the possibility of a new diagnosis of HIV among their older patients. Awareness of current or distant risk, frank discussions of sexual practices, and willingness to offer routine testing are crucial to making this diagnosis, with the recognition that longevity for patients with HIV is directly linked to how soon they enter care. HIV infection adds another challenge to the management of older patients; geriatricians and HIV specialists need to coordinate their efforts to provide patients with comprehensive multidisciplinary care. Older patients with HIV also have social and psychological needs that extend beyond the medical office. Maintaining independence, acknowledging limitations, reducing risk of adverse events such as falls or medication errors, and supporting self-acceptance and awareness are only a few of the many areas where care providers outside the medical office can be important for patients' ongoing well-being. Accessing family support, community outreach, church affiliation, or other outpatient support networks can be useful for patients. The remarkable change in prognosis brought about by effective ART in the mid-1990s has meant that HIV is now, for many, a manageable chronic illness. Clinicians and other care providers are changing their approach and goals of care as patients with HIV grow old.

Pneumocystis pneumonia in a person with a low CD4 count after stopping antiretroviral therapy.

Pneumocystis pneumonia has been previously described in this column. Here presented is a case of a patient who had done well for more than 9 years but whose condition deteriorated when he withdrew from medical care for nearly 2 years.

Nurse-patient advocacy and the right to die.

This article examines the implications of the U.S. Supreme Court's decision to uphold Oregon's Death with Dignity Act, as well as three crucial cases, on nursing practice: Terri Schiavo, Karen Quinlan, and Nancy Cruzan. In addition, an individual example is provided to demonstrate how nurses can advocate for patients at the end of life, and specific suggestions are offered.

Writing approaches of nursing students.

Over the past 20years, research has focused on the writing processes of college students, however, despite recent support for writing as a tool of reflection in nursing education, little is known about how it is that nursing students go about writing papers and assignments as part of their professional education. In order to determine the writing processes of nursing students, the Inventory of Processes in College Composition, a self-response questionnaire, was administered to 169 nursing students. Results support the independence of the writing approaches that nursing students use and similarity to the writing approaches of a general college student population.