RESUMO
The U.S. Air Force conducts vector and arbovirus surveillance worldwide. We report on two Rhabdoviridae detected at Holloman Air Force Base in Otero County, New Mexico including the nearly complete 11-kb genome of Merida virus, which was not previously known from the USA, and aâ¯novel virus tentatively named Dillard's Draw virus. Merida virus was previously only known from Mexico. Dillard's Draw virus represents aâ¯novel arbovirus most closely related to an avian pathogen from Australia and shares some genetic similarity to Durham virus from the eastern United States.
Assuntos
Culex/virologia , Mosquitos Vetores/virologia , Rhabdoviridae/isolamento & purificação , Animais , Feminino , Masculino , México , New Mexico , Filogenia , Rhabdoviridae/classificação , Rhabdoviridae/genéticaRESUMO
Vitiligo is a relatively common disorder that is characterized by depigmented patches of skin. Multiple studies characterize the overwhelming psychological burden that is experienced by many patients around the globe. This review examines personal patient stories and the impacts of age, culture, sex, race, and ethnicity in relationship to altered self-esteem and quality of life in patients who live with vitiligo.
RESUMO
Bovine herpesvirus-1 (BoHV-1) causes significant disease in cattle. Control programs in North America incorporate vaccination with modified live viral (MLV) or killed (KV) vaccine. BoHV-1 strains are isolated from diseased animals or fetuses after vaccination. There are markers for differentiating MLV from field strains using whole-genome sequencing and analysis identifying single nucleotide polymorphisms (SNPs). Using multiple primer sets and sequencing of products permits association of BoHV-1 isolates with vaccines. To determine association between vaccine virus and strains isolated from clinical cases following vaccination, we analyzed 12 BoHV-1 isolates from animals with various clinical syndromes; 9 corresponded to BoHV-1.1 respiratory group. The remaining three corresponded to BoHV-1.2b, typically found in genital tracts of cattle. Four BoHV-1 isolates were identical to a vaccine strain; three were from post-vaccination abortion episodes with typical herpetic lesions whose dams had received MLV vaccine during pregnancy, and one from a heifer given a related MLV vaccine; Sequences of two respiratory isolates perfectly matched mutations characterizing RLB106 strain, a temperature sensitive mutant used in intranasal and parenteral vaccines. The last three respiratory strains clearly appeared related to a group of MLV vaccines. Previously the MLV vaccines were grouped into four groups based on SNPs patterns. In contrast with above-mentioned isolates that closely matched SNP patterns of their respective MLV vaccine virus, these 3 strains both lacked some and possessed a number of additional mutations compared to a group of MLV vaccine viral genome. Finding BoHV-1.2b in respiratory cases indicates focus should be given BoHV-1.2b as an emerging virus or a virus not recognized nor fully characterized in BRD.
Assuntos
Doenças dos Bovinos/prevenção & controle , Doenças dos Bovinos/virologia , Variação Genética , Infecções por Herpesviridae/veterinária , Infecções por Herpesviridae/virologia , Herpesvirus Bovino 1/classificação , Herpesvirus Bovino 1/genética , Vacinas contra Herpesvirus/imunologia , Animais , Bovinos , DNA Viral/química , DNA Viral/genética , Feminino , Genótipo , Infecções por Herpesviridae/patologia , Herpesvirus Bovino 1/isolamento & purificação , Mutação , América do Norte , Polimorfismo de Nucleotídeo Único , Gravidez , Análise de Sequência de DNARESUMO
The inaugural issue of Pathologia Veterinaria in 1964 contained the first detailed account of lesions in aborted fetuses following natural, experimental, and postvaccinal infection with bovine herpesvirus 1 (BoHV-1). The article, written by pathologists Kennedy and Richards, described diagnostic gross and histologic features in 13 bovine fetuses. The authors provided clinical and epidemiologic features of 1 postvaccination outbreak, including the absence of clinical signs in infected dams and the propensity for abortions to occur after 6 months' gestation. Subsequent field and experimental studies corroborated and expanded these observations. As a result of this and later reports, veterinarians became alert to the association between infectious bovine rhinotracheitis and abortion, including the risks of exposing pregnant cattle to live vaccinal BoHV-1. Methods were developed to corroborate a morphologic diagnosis of herpetic abortion in cattle, including immunofluorescence, immunohistochemistry, and polymerase chain reaction methods. Outbreaks of postvaccinal BoHV-1 abortion in the United States began to be reported with apparently increased frequency in the early 2000s. This coincided with licensure in 2003 of modified live BoHV-1 vaccines intended for use in pregnant cattle, which are now sold by 3 manufacturers. Ten recent herd episodes of postvaccinal BoHV-1 abortion are reported. All 10 BoHV-1 isolates had single-nucleotide polymorphism (SNPs) profiles previously identified in a group of BoHV-1 isolates that contains vaccine strains, based on a BoHV-1 SNP classification system. They lacked SNP features typical of those in characterized field-type strains of BoHV-1.
Assuntos
Aborto Animal/epidemiologia , Surtos de Doenças/veterinária , Herpesvirus Bovino 1/imunologia , Doença Iatrogênica/veterinária , Rinotraqueíte Infecciosa Bovina/prevenção & controle , Vacinas Virais/efeitos adversos , Feto Abortado/patologia , Feto Abortado/virologia , Aborto Animal/virologia , Animais , Bovinos , Surtos de Doenças/estatística & dados numéricos , Monitoramento Epidemiológico , Feminino , Herpesvirus Bovino 1/genética , Doença Iatrogênica/epidemiologia , Rinotraqueíte Infecciosa Bovina/virologia , Polimorfismo de Nucleotídeo Único/genética , Gravidez , Vacinação/efeitos adversos , Vacinação/veterinária , Vacinas Atenuadas/efeitos adversos , Vacinas Atenuadas/imunologia , Vacinas Virais/imunologiaRESUMO
The serum collectin mannose-binding lectin (MBL) plays a major role in innate immunity by activation of the lectin complement pathway or by acting as an opsonin. The serum levels of human and animal MBL are associated with susceptibility to a wide range of infections, and the variation of MBL in serum is genetically determined. In the chicken, 14 single nucleotide polymorphisms (SNPs) have so far been found in the MBL promoter region. In this study, the transcription activity of a 670-bp promoter region covering all 14 SNPs from the four MBL promoter alleles A1 to A4 was assessed using a dual-luciferase assay. Of the analysed alleles, A1 showed the highest transcription activity although this allele is frequently found in chickens with low MBL mRNA expression.
Assuntos
Alelos , Galinhas/genética , Lectina de Ligação a Manose/genética , Regiões Promotoras Genéticas , Transcrição Gênica , Animais , Expressão Gênica , Ordem dos Genes , Genes Reporter , Lectina de Ligação a Manose/sangue , Polimorfismo de Nucleotídeo ÚnicoRESUMO
The overarching goal of this in situ study was to investigate the integrated impact(s) that metal/metalloid contamination might have on the overall health and performance of the ecologically important aquatic macrophyte, Vallisneria neotropicalis. Morphological (i.e., shoot growth-based endpoints) and photo-physiological (i.e., photosynthetic activity measured as chlorophyll a fluorescence and oxygen exchange) variables, along with aboveground tissue metal/metalloid concentrations, were measured in natural populations of V. neotropicalis that differed with respect to their anthropogenic pressure. With the exception of an overall negative effect on growth, our results suggest that there were no detrimental effects of low/moderate contamination of V. neotropicalis by trace elements (i.e., arsenic As and mercury Hg; 1.04-2.77 µg g(-1) dry wt. and 3.76-15.18 ng g(-1) dry wt., respectively) on the photosynthetic physiological performance of this species. V. neotropicalis appears to tolerate low/moderate levels of trace element contamination with little impact on plant health and performance.
Assuntos
Magnoliopsida/efeitos dos fármacos , Metais/toxicidade , Poluentes Químicos da Água/toxicidade , Clorofila/química , Clorofila A , Fluorescência , Magnoliopsida/metabolismo , Magnoliopsida/fisiologia , FotossínteseRESUMO
Culicoides sonorensis is the primary vector of bluetongue and epizootic hemorrhagic disease viruses in North America. Bluetongue disease is one of the most economically important arthropod-borne diseases of sheep in North America, because it causes significant morbidity and mortality and can lead to local quarantines and international trade restrictions. Long-lasting repellent pesticides could be applied to sheep as they are moved down from mountain pastures to protect them from biting midges until the 1st frost. We tested long-lasting pesticides on sheep as repellents against C. sonorensis. Both Python ear tags with 10% zeta-cypermethrin (9.8 g/tag) synergized with 20% piperonyl butoxide (PBO) and a 12-ml low-volume spray application of ready-to-use sheep insecticide (Y-TEX) with 2.5% permethrin and 2.5% PBO in an oil-based formulation were repellent to C. sonorensis for at least 3-5 wk after a single application.
Assuntos
Ceratopogonidae/efeitos dos fármacos , Comportamento Alimentar/efeitos dos fármacos , Repelentes de Insetos/farmacologia , Butóxido de Piperonila/farmacologia , Piretrinas/farmacologia , Animais , Inseticidas/farmacologia , Permetrina/farmacologia , Ovinos , Fatores de TempoRESUMO
Human leukocyte antigen B-*15:180 is a B*08/B*15 recombinant allele similar to B*15:29 with substitutions positions at 97, 292, 538, 539.
Assuntos
Alelos , Antígenos HLA-B/genética , Proteínas Recombinantes/genética , Sequência de Bases , Antígeno HLA-B15 , Humanos , Dados de Sequência Molecular , Alinhamento de SequênciaRESUMO
Posture, ventilation, and acid-base balance using auricular venous blood values (pH, lactate, base excess [BE], HCO(3)(-), PO(2), SO(2), and PCO(2)), oxygen saturation of hemoglobin (SpO(2)), and end-tidal carbon dioxide (P(ET)CO(2)) were compared between sternal (STE) and lateral (LAT) recumbency in free-ranging black rhinoceros (Diceros bicornis bicornis) receiving oxygen insufflation. Data are reported as median, minimum, and maximum (median [minimum, maximum]). Thirty-six desert-adapted black rhinoceros (20 male, 16 female; age 8 [1.5, 33] yr) were immobilized in Namibia in March and April of 2008, from a helicopter, by remote intramuscular injection with etorphine HCl, azaperone, and hyaluronidase. Time from darting to recumbency was 6.0 (3, 15.5) min. Data were organized into two sampling periods: sample period 1 (P1, collected within 0-20 min postdarting; 13 [6.5, 19] min) and sample period 2 (P2, collected between 20-40 min postdarting; 32 [22.3, 39] min). All animals were acidemic (pH 7.24 [7.07, 7.32]) and hypoxemic (PO(2) 51 [38, 95.2]; SO(2) 78 [64, 96] mmHg) after capture. Lactate at P1 was 7.2 (3.2, 16.8) mmol/l and decreased (P=0.01) to 4.6 (1.2, 10.9) mmol/l at P2. At P2, lactate was less (P=0.06) in LAT 3.5 (1.2, 8.6) mmol/l than in STE posture 7.4 (3.1, 10.9) mmol/l. In P2, PO(2), SO(2), and SpO(2) were higher (P=0.02, 0.10, and 0.01, respectively) in STE than in LAT. End-tidal carbon dioxide in LAT was 38 (26, 47) mmHg and increased (P<0.001) rapidly to 48 (37, 55) mmHg when animals were moved into STE; no corresponding change in PCO(2) was observed. These preliminary findings suggest that STE posture in recumbent black rhinoceros reduces dead-space ventilation and improves oxygenation. Lateral posture was associated with lower blood lactate, quicker lactate recovery, or both. It is possible that the posture of recumbent rhinoceros after capture affects lactate accumulation and clearance, or both, and procedures should consider positioning in order to enhance perfusion.
Assuntos
Equilíbrio Ácido-Base/fisiologia , Hipnóticos e Sedativos/administração & dosagem , Ácido Láctico/sangue , Oxigênio/metabolismo , Perissodáctilos/fisiologia , Postura , Animais , Animais Selvagens , Azaperona/administração & dosagem , Azaperona/efeitos adversos , Gasometria/veterinária , Capnografia/veterinária , Etorfina/administração & dosagem , Etorfina/efeitos adversos , Feminino , Hialuronoglucosaminidase/administração & dosagem , Hialuronoglucosaminidase/efeitos adversos , Hipnóticos e Sedativos/efeitos adversos , Hipóxia/prevenção & controle , Hipóxia/veterinária , Imobilização/veterinária , Masculino , Namíbia , Perissodáctilos/sangue , Respiração/efeitos dos fármacosRESUMO
Differential expression of heat shock genes can modulate protein folding and stress-related cell death. There have been no comparisons of their levels of expression in animals and humans. Levels of expression of heat shock 70 genes in human brain were compared to levels in non-stressed and heat-stressed brain of rat. Levels of hsp70 proteins in human brain were 43-fold higher than in non-stressed rat brain and 14-fold higher than highest induced levels in brains of heat-shocked rats. Levels of constitutively synthesized hsc70 proteins were approximately 1.5-fold higher in human than in rat. Higher levels of hsp70 proteins in human brain may serve to protect brain cells against stress-related death or dysfunction throughout the lifespan.
Assuntos
Envelhecimento/metabolismo , Encéfalo/metabolismo , Proteínas de Choque Térmico HSP70/metabolismo , Estresse Fisiológico/metabolismo , Idoso , Idoso de 80 Anos ou mais , Animais , Cadáver , Humanos , Técnicas In Vitro , Masculino , Camundongos , Pessoa de Meia-Idade , Ratos , Ratos Sprague-Dawley , Especificidade da Espécie , Distribuição TecidualRESUMO
The recent publication of the chicken genome sequence along with the extensive single nucleotide polymorphism and physical map open exciting avenues for defining gene function and for understanding the genotypic basis of phenotypic variation in the chicken. The number of genes identified on the sequence map is growing rapidly. Genetically uniform lines and crosses derived from them will allow identification of gene function and gene interactions that contribute to traits such as immunity, disease resistance, growth, production, and behavior. Selected, inbred, and congenic lines will continue to be essential in defining the genetics of many traits. Although dwindling under budgetary pressures, a number of well characterized lines and genetic strains remain. If preserved, these can be used to address questions regarding newly mapped candidate genes defining their importance in a variety of problems in basic, biomedical, and applied avian biology. If lost, years of breeding and selection will be required to replace them.
Assuntos
Galinhas/genética , Genoma/genética , Animais , Cruzamento , Mapeamento Cromossômico , Conservação dos Recursos Naturais , Cruzamentos Genéticos , Ligação Genética , Pesquisa em Genética/economia , Variação Genética , Genótipo , Endogamia , Fenótipo , Doenças das Aves Domésticas/genética , Seleção Genética , Análise de Sequência de DNARESUMO
Killer Ig-like receptor (KIR) is a major cluster of the natural killer cell receptors and may play a role in the outcome of hematopoietic cell transplants. A total of 65 AML cases transplanted with T-replete hematopoietic cells from unrelated donors were retrospectively KIR-genotyped by a multiplex PCR method of our own design. The KIR gene frequency and genotype patterns in these 130 samples were consistent with the data in the literature. Based upon overall inhibitory and activating KIR genes in both donors and patients, we developed an algorithm to calculate a compatibility score for each transplant case as plus, zero or minus. Significantly higher incidence (18/20, 90%) of acute (a) GVHD (grade II-IV) was found in the transplant cases with plus scores than that (25/45, 56%) in the cases with zero or minus scores (P < 0.01). When the scores are sorted in the opposite way, fewer cases (13/26, 50%) of aGVHD were found in the transplants with minus scores than that (30/39, 77%) in the transplants with zero or plus scores (P < 0.05). The difference of aGVHD prevalence between the plus score and minus score groups is highly significant (P < 0.01). KIR genotype compatibility calculated by this algorithm may predict aGVHD incidence and be helpful in choosing donors.
Assuntos
Doença Enxerto-Hospedeiro/etiologia , Transplante de Células-Tronco Hematopoéticas/efeitos adversos , Histocompatibilidade , Leucemia Mieloide/terapia , Receptores Imunológicos/genética , Receptores Imunológicos/imunologia , Doença Aguda , Adolescente , Adulto , Algoritmos , Criança , Pré-Escolar , Feminino , Frequência do Gene , Genótipo , Doença Enxerto-Hospedeiro/genética , Humanos , Lactente , Leucemia Mieloide/complicações , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prevalência , Receptores KIR , Estudos RetrospectivosRESUMO
The human striatum has been implicated in processing reward-related information. More recently, activity in the striatum, particularly the caudate nucleus, has been observed when a contingency between behavior and reward exists, suggesting a role for the caudate in reinforcement-based learning. Using a gambling paradigm, in which affective feedback (reward and punishment) followed simple, random guesses on a trial by trial basis, we sought to investigate the role of the caudate nucleus as reward-related learning progressed. Participants were instructed to make a guess regarding the value of a presented card (if the value of the card was higher or lower than 5). They were told that five different cues would be presented prior to making a guess, and that each cue indicated the probability that the card would be high or low. The goal was to learn the contingencies and maximize the reward attained. Accuracy, as measured by participant's choices, improved throughout the experiment for cues that strongly predicted reward, while no change was observed for unpredictable cues. Event-related fMRI revealed that activity in the caudate nucleus was more robust during the early phases of learning, irrespective of contingencies, suggesting involvement of this region during the initial stages of trial and error learning. Further, the reward feedback signal in the caudate nucleus for well-learned cues decreased as learning progressed, suggesting an evolving adaptation of reward feedback expectancy as a behavior-outcome contingency becomes more predictable.
Assuntos
Encéfalo/fisiologia , Jogo de Azar/psicologia , Aprendizagem/fisiologia , Imageamento por Ressonância Magnética , Recompensa , Adulto , Sinais (Psicologia) , Retroalimentação Psicológica , Feminino , Humanos , Interpretação de Imagem Assistida por Computador , Masculino , Neostriado/fisiologiaRESUMO
Killer-cell immunoglobulin-like receptors (KIRs) on natural killer (NK) cells recognize groups of HLA class I alleles. Recent work suggests that KIR genotype may affect the outcome of hematopoietic stem-cell transplants and that prospective KIR typing maybe of benefit in future matching of donors and recipients. A simple and informative KIR genotyping method was developed using a multiplex polymerase chain reaction-sequence-specific primer strategy. This method contains four multiplex reactions for detecting all functional KIR genes, including some 2DS4 variants that harbor a common deletion. Primer pairs were designed to provide short amplicons (108-565 bp) that can be analyzed by agarose gel electrophoreses or by automated electrophoretic systems. This method was evaluated in a blinded survey with the NK/KIR Phase II QC Panel (a total of 16 cell lines) from the 14th International Histocompatibility Workshop (IHWS), and the results are 100% concordant with the consensus genotype. Results in further KIR genotyping of 20 reference cell lines from the 10th IHWS were consistent with previously published genotypes, matching those of one study in instances where different genotypes have been previously reported. The genotypes obtained in this study may be helpful to other labs developing KIR genotyping methods in resolving typing discrepancies and in detecting common deletion variants of 2DS4. This method can save labor and reagent costs. It provides good results from partially degraded template DNA due to short amplicons in this method. It is convenient to use in both clinical and research laboratories.
Assuntos
DNA/genética , Células Matadoras Naturais/imunologia , Receptores Imunológicos/imunologia , Genótipo , Humanos , Reação em Cadeia da Polimerase , Receptores Imunológicos/genética , Receptores KIRRESUMO
Evidence for the importance of major histocompatibility complex (MHC) genotype in immunological fitness of chickens continues to accumulate. The MHC B haplotypes contribute resistance to Marek's and other diseases of economic importance. The Rfp-Y, a second cluster of MHC genes in the chicken, may also contribute to disease resistance. Nevertheless, the MHC B and Rfp-Y haplotypes segregating in broiler chickens are poorly documented. The Camperos, free-range broiler chickens developed in Argentina, provide an opportunity to evaluate MHC diversity in a genetically diverse broiler stock. Camperos are derived by cross-breeding parental stocks maintained essentially without selection since their founding. We analysed 51 DNA samples from the Camperos and their parental lines for MHC B and Rfp-Y variability by restriction fragment pattern (rfp) and SSCP typing methods for B-G, B-F (class Ia), B-Lbeta (class II) and Y-F (class Ib) diversity. We found evidence for 38 B-G genotypes. The Camperos B-G patterns were not shared with White Leghorn controls, nor were any of a limited number of Camperos B-G gene sequences identical to published B-G sequences. The SSCP assays provided evidence for the presence of at least 28 B-F and 29 B-Lbeta genotypes. When considered together B-F, B-L, and B-G patterns provide evidence for 40 Camperos B genotypes. We found even greater Rfp-Y diversity. The Rfp-Y class I-specific probe, 163/164f, revealed 44 different rfps among the 51 samples. We conclude that substantial MHC B and Rfp-Y diversity exists within broiler chickens that might be drawn upon in selecting for desirable immunological traits.
Assuntos
Galinhas/imunologia , Variação Genética , Genótipo , Complexo Principal de Histocompatibilidade/genética , Animais , Southern Blotting , Galinhas/genéticaRESUMO
Alteration of metabolism has been suggested as a major limiting factor to long-term space flight. In humans and primates, a negative energy balance has been reported. The metabolic response of rats to space flight has been suggested to result in a negative energy balance. We hypothesized that rats flown in space would maintain energy balance as indicated by maintenance of caloric intake and body mass gain. Further, the metabolism of the rat would be similar to that of laboratory-reared animals. We studied the results from 15 space flights lasting 4 to 19 d. There was no difference in average body weight (206 +/- 13.9 versus 206 +/- 14.8 g), body weight gain (5.8 +/- 0.48 versus 5.9 +/- 0.56 g/d), caloric intake (309 +/- 21.0 versus 309 +/- 20.1 kcal/kg of body mass per day), or water intake (200 +/- 8.6 versus 199 +/- 9.3 mL/kg of body mass per day) between flight and ground control animals. Compared with standard laboratory animals of similar body mass, no differences were noted. The observations suggested that the negative balance observed in humans and non-human primates may be due to other factors in the space-flight environment.
Assuntos
Peso Corporal , Ingestão de Líquidos/fisiologia , Ingestão de Alimentos/fisiologia , Ingestão de Energia/fisiologia , Voo Espacial , Adaptação Fisiológica , Animais , Astronautas , Feminino , Humanos , Masculino , Modelos Animais , Necessidades Nutricionais , Ratos , Ratos Endogâmicos F344 , Ratos Endogâmicos SHR , Ausência de PesoRESUMO
We have developed a DNA-based method for defining MHC B system genotypes in chickens. Genotyping by this method requires neither prior determination of allele-specific differences in nucleotide sequence nor the preparation of haplotype-specific alloantisera. Allelic differences at chicken B-F (class I) and B-L (class II) loci are detected in PCR single-strand conformation polymorphism (SSCP) assays. PCR primer pairs were designed to hybridize specifically with conserved sequences surrounding hypervariable regions within the two class I and two class I loci of the B-complex and used to generate DNA fragments that are heat- and formamide-denatured and then analyzed on nondenaturing polyacrylamide gels. PCR primer pairs were tested for the capacity to produce SSCP patterns allowing the seven B haplotypes in the MHC B congenic lines, and seven B haplotypes known to be segregating in two commercial broiler breeder lines to be distinguished. Primer pairs were further evaluated for their capacity to reveal the segregation of B haplotypes in a fully pedigreed family and in a closed population. Concordance was found between SSCP patterns and previously assigned MHC types. B-F and B-L SSCP patterns segregated in linkage as expected for these closely linked loci. We conclude that this method is valuable for defining MHC B haplotypes and for detecting potential recombinant haplotypes especially when used in combination with B-G (class IV) typing by restriction fragment pattern.
Assuntos
Galinhas/genética , Complexo Principal de Histocompatibilidade/genética , Polimorfismo Conformacional de Fita Simples , Animais , Desoxirribonucleases de Sítio Específico do Tipo II/metabolismo , Genótipo , Haplótipos , Reação em Cadeia da Polimerase , Alinhamento de SequênciaRESUMO
Effective pain management in the terminally ill patient requires an understanding of pain control strategies. Ongoing assessment of pain is crucial and can be accomplished using various forms and scales. It is also important to determine if the pain is nociceptive (somatic or visceral pain) or neuropathic (continuous dysesthesias or chronic lancinating or paroxysmal pain). Nociceptive pain can usually be controlled with nonsteroidal antiinflammatory drugs or corticosteroids, whereas neuropathic pain responds to tricyclic antidepressants or anticonvulsants. Relief of breakthrough pain requires the administration of an immediate-release analgesic medication. If a significant amount of medication for breakthrough pain is already being given, the baseline dose of sustained-release analgesic medication should be increased. If pain does not respond to one analgesic medication, physicians should use an equianalgesic dose chart when changing the medication or route of administration. Opioid rotation can be used if pain can no longer be controlled on a specific regimen. The impact of unresolved psychosocial or spiritual issues on pain management may need to be addressed.