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Themes. Style. Historical Context. Critical Overview. Criticism. Sources. Further Reading. Chitra Banerjee Divakaruni. Chitra Divakaruni's . Dutta Writes a Letter. Divakaruni is an Indian who immigrated to the United States, and . Dutta Writes a Letter. In this particular case, Mrs. Dutta, an Indian widow, bows to her sense of duty and pressure from her Calcutta relatives. She decides to come and live with her son and his family in the San Francisco Bay area. Throughout the story, Mrs. Dutta tries to answer her Calcutta friend's question about whether or not she is happy in America, but she keeps putting her response letter aside. She is afraid to explore how she really feels, since this may conflict with her loyalty to her family. However, through a series of cultural conflicts, she finally gains the strength to be honest with herself about her unhappiness. When this story was published in 1. India was highly visible in the international arena for the cultural conflict among its religious groups, its nuclear weapons tests, and its ongoing border dispute with Pakistan. Dutta Writes a Letter. She lived in several Indian cities while she was growing up and then attended the University of Calcutta, where she earned her bachelor's degree in English. Her family expected that she would get married after she finished her education and spend her time raising a family in India. However, in 1. 97. United States. In 1. Dutta Writes a Letter'. Pedagogical Strategies in Discussing Chitra Banerjee Divakaruni. LAYERED FEMALE IDENTITIES IN MRS. DUTTA WRITES A LETTER. English from Wright State University in Dayton, Ohio. The next year, she married S. Murthy Divakaruni, although not in a traditional arranged marriage. In 1. 98. 5, she graduated from the University of California at Berkeley with her doctorate in English. While she was a student at Berkeley, she volunteered at a women's center, where she worked with abused women. This experience would inspire her in many ways. After school, she taught creative writing at Diablo Valley College (1. She also began writing her own poems. In 1. 98. 9, Divakaruni began teaching creative writing at Foothill College. While teaching there, she published several works. In her poetry collection Black Candle (1. India, Pakistan, and Bangladesh. The same year, she helped form Maitri, a nonprofit organization in the San Francisco Bay area that assists South Asian women facing domestic violence, emotional abuse, or family conflict. Maitri is a Sanskrit word that means friendship. Her volunteer work with other immigrant women at Maitri. This collection of short stories, which won the American Book Award in 1. Indian women who are torn between their Indian heritage and American culture. In 1. 99. 7, she published two works, her first novel, The Mistress of Spices, and a poetry collection, Leaving Yuba City: New and Selected Poems. The latter was awarded the Allen Ginsberg Poetry Prize and the Pushcart Prize. In 2. 00. 1, Divakaruni published her second collection of short stories, The Unknown Errors of Our Lives (2. Dutta Writes a Letter. Divakaruni lives and works in the San Francisco Bay area. Dutta Writes a Letter. Dutta, an old, widowed Indian woman who had moved into her son's American home two months earlier. On the first morning, she gets up too early, prompting her son, Sagar, to tell her that she is waking up his wife, Shyamoli, and that Mrs. Dutta should get up later. Dutta's habits, which she learned as an arranged wife in India, conflict with the American customs of her son's family. The next morning, Mrs. Dutta gets up later as ordered, but now she ends up being in the bathroom when her grandchildren need it, and they complain. Dutta is surprised when Shyamoli does not punish the children for being disrespectful to Mrs. As she does throughout the story, she compares this American behavior with the Indian customs that she has followed her whole life. She also thinks about the letter she received from her Calcutta friend, Mrs. Basu, who has asked if Mrs. Dutta is happy in America. Dutta is struggling to be loyal to her son's family, although she feels uncomfortable about life in America, and so she has not sent a reply to her friend yet. She starts making alu dum, a traditional Indian meal. In her mind, she writes a response to Mrs. Basu, saying that she misses India and then rebukes herself for being nostalgic. She continues making her meal, noting that Shyamoli is worried that Mrs. Dutta's food has too much cholesterol and is making them gain weight. Later in the day, Mrs. Dutta washes her clothes. She has insisted on doing her own laundry so that nobody else will have to touch her underclothes. However, she is terrified of the modern washing machine, so she secretly washes the clothes by hand. She hangs the clothes on the fence to dry, while crafting another mental response to Mrs. She remembers her departure from India, when she got rid of her house and gave away most of her possessions. When she is pulling the dry clothes off the fence, she notices the next- door neighbor and waves to her, but the neighbor ignores her. Sagar comes home early from work that day, and Mrs. Dutta is happy when he enjoys the story she tells him about his childhood. However, when Shyamoli arrives home, upset, Mrs. Dutta goes to her room to give them some privacy. She realizes that she left her unfinished response to Mrs. Basu on the kitchen table and goes to retrieve it. She overhears Shyamoli arguing with Sagar, saying that the next- door neighbor complained about Mrs. Dutta hanging her clothes over the fence. Although her sense of duty says that she should stay with her son's family, Mrs. Dutta realizes that she is an outsider and that she would be much happier back in India. She writes a response to Mrs. Basu, saying that she is coming back to India and asking Mrs. Basu to rent out her downstairs flat to Mrs. Dutta's longtime friend and neighbor in India. It is her letter that prompts Mrs. Dutta to examine whether or not she is really happy. At the end of the story, Mrs. Basu to ask if she can rent her friend's downstairs apartment, which has been recently vacated. Mrinalini Dutta. Mrinalini is Mrs. Dutta's granddaughter, who is not interested in exploring her Indian heritage. Shyamoli calls Mrinalini . Dutta's grandson, who is not interested in exploring his Indian heritage. Shyamoli calls Pradeep . Dutta is a dutiful Indian widow, who experiences cultural conflict while trying to live with her son's Americanized family. Dutta wed Sagar's father in a traditional Indian marriage when she was seventeen. Throughout her life, she has been subservient to her husband and other family members, suppressing her own desires in order to fulfill their needs. 143 USB Screw Style 144 FEATURES : USB Connectors are available at Mouser Electronics. Mouser offers inventory, pricing, & datasheets for USB Connectors. USB Connector Guide — Guide to USB Cables What are USB Connectors? Male: Female: image to. The USB-C connector has a reversible/symmetrical design and can be plugged into any USB-C device using either end. Usb connectors usb connectors mini usb connector & cable esb3,4,5 series usb connector & cable esb0 series (connector) esb1 series (cable) ieee1394 connector & cable esb6 series (connector) esb2 series (cable) u.s. Gender of connectors and fasteners. Schematic symbols for male and female connector pins. In electrical and mechanical trades and manufacturing, each half of a pair of mating connectors or fasteners is conventionally assigned the designation male or female. Extension of the analogy results in the verb to mate being used to describe the process of connecting two corresponding parts together. In some cases (notably electrical power connectors), the gender of connectors is selected according to rigid rules, to enforce a sense of one- way directionality (e. Buy Generic USB A Female to Mini USB B 5 Pin Male Adapter (SF4814): Stereo Jack Cables - Amazon.com FREE DELIVERY possible on eligible purchases.This gender distinction is implemented to enhance safety or ensure proper functionality by preventing unsafe or non- functional configurations from being set up. In terms of mathematical graph theory, an electrical power distribution network made up of plugs and sockets is a directed tree, with the directionality arrows corresponding to the female- to- male transfer of electrical power through each mated connection. This is an example where male and female connectors have been deliberately designed and assigned to physically enforce a safe network topology. In other contexts, such as plumbing, one- way flow is not enforced through connector gender assignment. Flows through piping networks can be bidirectional, as in underground water distribution networks which have designed- in redundancy. In plumbing situations where one- way flow is desired, it is implemented through other means (e. Correspondingly, a threaded nut, an alignment hole, a mounting recess, or sheet metal slot connector is considered to be female. While some mechanical designs are . To avoid unnecessary confusion, conventional definitions of fastener gender have been defined and agreed upon. Modular construction toys. This should not be surprising, since these toys feature the nearly infinite flexibility and versatility of shape that a modular interconnect architecture can enable. Mathematicians have begun to classify well- known construction sets using group theory to study the combinatoric possibilities of structures that can be built. For example, the canonical LEGO plastic blocks have . Meccano and Erector have many gendered connections, starting with the nut- and- bolt fasteners they use frequently. Stickle bricks, using interlocking plastic protrusions, are effectively genderless. Lincoln logs use a very simple form of genderless connections. Kapla or KEVA planks are extremely simple genderless systems interconnected only by gravity. Plumbing. For example: MIPT denotes Male Iron Pipe Thread; FIPT denotes Female Iron Pipe Thread. A short length of pipe having an MIP thread at both ends is sometimes called a nipple. A picture of such fittings appears in the #Genderless (hermaphroditic) connectors section of this article. Downspout. These tubes usually come in sections, joined by inserting the male end (often crimped with a special tool to slightly reduce its size) into the female end of the next section. These connections are usually not sealed or caulked, instead relying on gravity to move the rainwater from the male end and into the receiving female connection located directly below. Ductwork. Typically, the airflow through a ductwork connection is from male to female. However, since one- way flow is implemented by forced- air fans or blowers, . The flow convention is usually loosely adhered to for simplicity of design, and to reduce the number of gender changer fittings required, but exceptions are made whenever expedient. Electrical and electronic. Instead, connector gender is conventionalized and thus can be somewhat obscure to the uninitiated. For example, the female D- subminiature connector body projects outward from the mounting plane of the chassis, and this protrusion could be erroneously construed as male. The male/female distinction is more obvious with ring crimp lug connectors which are placed around a screw post, but again with spade or split ring crimp lug connectors the end alone is not obviously female. Further confusion can be caused by the term . IEEE STD 1. 00, IEEE- 3. IEEE 2. 00- 1. 97. ASME Y1. 4. 4. 4- 2. Where the relationship is equal, such as when two flexible cables are connected, each is considered a plug. Jacks use the reference designator prefix of J and plugs use the reference designator prefix of P. In this case the connector is designated a jack (J ref des) regardless of the contact gender because the housing for the contacts is in fact configured as the receptacle even though its mate (the plug) goes around the receptacle. See MIL- STD- 3. 89. It is common practice to use female connectors for jacks, so the informal gender- based usage often happens to agree with the functional description of the technical standards. However, this is not always the case; often- seen exceptions include a computer's AC Power Inlet and EIA2. DE9 Serial Port, or the male coaxial power jacks for connecting external power adapters to portable equipment. To summarize, it is considered best practice to use . These connectors were originally referred to as . For example, in Switchcraft XLR microphone or hydrophone connectors, the part numbers are denoted as follows: A3. F = Audio 3- pin Female connector; A3. M = Audio 3- pin Male connector. The terms plug, pin, and prong are also often used for . In many cases these terms are more common than male and female, especially in documentation intended for the non- specialist. These nearly synonymous terms can cause a fair amount of confusion when the designations are shortened in labels. For example, a female high- density D- subminiature connector with a size 1 shell can be named DE1. F or DE1. 5S (see accompanying pictures). Both terms mean the same thing but could be construed to be completely different items. Similarly, a male standard- density D- sub with a size 1 shell can be named DE9. M or DE9. P; a female standard- density D- sub with a size 2 shell can be named DA1. F or DA1. 5S; a male high- density D- sub with a size 3 shell can be named DB4. M or DB4. 4P; and so forth. Male and female electrical connectors. A panel- mounted IEC 6. C1. 4male connector jack designed to accept AC line power A null modem cable with a female connector on each end, both of which serve as plugs A male D- Subminiature connector which serves as a plug. The pins make this connector male; the surrounding shield does not change that. A male 5. 0 ohm BNC connectorplug. Three circular projections (including the central pin) interlock with two rings of the female jack. Female (left) and male weatherproof plugs for photovoltaic solar panels This HDMIplug is conventionally assigned to male gender Gender selection in electronic design. This is usually done because female connectors are more resistant to damage or contamination, by virtue of their concealed or recessed electrical contacts. A damaged motherboard connector can result in the scrapping of an expensive piece of electronic equipment. The risk of expensive damage is reduced by relegating the more exposed male contacts to connecting cables, which can be repaired or replaced at lower cost. With a RS2. 32 serial port, the male connector is more fragile than the female connector. This confusing reversal of the RS- 2. In the case of electrical power connections, designers do not reverse connector gender in such a casual fashion, since such misuse of AC line power connectors is unsafe and generally illegal. Fortunately, a special male IEC 6. C1. 4 connector (see Gallery above) is available which is recessed below the surface of a mounting panel, providing the desired protection from mechanical damage while conforming to safety regulations. A male plug, with fully exposed protruding contacts, is installed on the cord of (or directly onto) the device receiving the power. In the case of consumer- level AC power, connector gender is used to implicitly enforce safe use of power connectors. Because of this consideration, it is illegal under electrical code to make or use any gender changers to connect AC line power to consumer- level equipment. In low- voltage use such as for data communications, electrical shock hazard is not an issue, and male or female connectors are used based on other engineering factors such as convenience of use, cost, or ease of manufacturing. For example, the common . Power is provided by the femaleplug on the right to the malejack on the left; the exposed conductors are not hazardous due to the low voltage. See text for further explanation. As an illustrative example of some design tradeoffs in power connector selection, consider the picture to the left. A commonly seen coaxial power connector is usually set up so that power is fed from the female plug on the right into the male jack on the left (which is typically a part of the electronic device accepting the power). Although the plug is female, with a partially recessed center contact, it is still possible for casual accidental contact with a metallic object to short- circuit the power source. Depending on the design of the power adapter, it may react to a short circuit by shutting down temporarily, or instead by blowing out an internal safety fuse. In this example, the marginal reliability of the connector choice was deemed to be acceptable by the equipment designer, since the power adapter supplies low voltage that does not pose an electric shock hazard. The potential fire hazard from accidental short- circuiting is addressed by the internal safety fuse, although this requires that a failed power adapter must be completely replaced. In a different design, if the power adapter were intended to supply a voltage sufficient to cause electrical shock, the semi- exposed center contact of the female plug would be considered unacceptably hazardous, requiring a different choice of power connector. Ambiguous gender. See the discussion of Genderless connectors elsewhere in this article for more detailed information. Daily. Med - FENTANYL - fentanyl patch. Special Precautions. Fentanyl transdermal system contains a high concentration of a potent Schedule II opioid agonist, fentanyl. Schedule II opioid substances which include fentanyl, hydromorphone, methadone, morphine, oxycodone, and oxymorphone have the highest potential for abuse and associated risk of fatal overdose due to respiratory depression. Fentanyl can be abused and is subject to criminal diversion. The high content of fentanyl in the patches (fentanyl transdermal system) may be a particular target for abuse and diversion.
Back Pain Home > Fentanyl Patch 12.5 Mcg/hr. It is best to underestimate the dose initially, in order to avoid dangerous side effects. Fentanyl (Absorbed through the skin). The fentanyl skin patch. Physical dependence may lead to withdrawal side effects if treatment is stopped. Fentanyl transdermal system patches are intended for transdermal use (on intact skin) only. The fentanyl transdermal system patch should not be used if the pouch seal is broken, or the patch is cut, damaged, or changed in any way. Each fentanyl transdermal system patch may be worn continuously for 7. The next patch should be applied to a different skin site after removal of the previous transdermal system. If problems with adhesion of the fentanyl transdermal system patch occur, the edges of the patch may be taped with first aid tape. If problems with adhesion persist, the patch may be overlayed with a transparent adhesive film dressing (e. Bioclusive. A new patch may be applied to a different skin site. Fentanyl transdermal system is ONLY for use in patients who are already tolerant to opioid therapy of comparable potency. Use in non- opioid tolerant patients may lead to fatal respiratory depression. Overestimating the fentanyl transdermal system dose when converting patients from another opioid medication can result in fatal overdose with the first dose. Rosenfeld on 12 mcg fentanyl patch. Follow @HealthTap </> Embed.Due to the mean half- life of approximately 2. Patients receiving fentanyl transdermal system and any CYP3. A4 inhibitor should be carefully monitored for an extended period of time and dosage adjustments should be made if warranted (see BOX WARNING, CLINICAL PHARMACOLOGY . The dose conversion schedule described in Table C, and method of titration described below are recommended in opioid- tolerant pediatric patients over 2 years of age with chronic pain (see PRECAUTIONS . Patients who are considered opioid- tolerant are those who have been taking, for a week or longer, at least 6. Because serious or life- threatening hypoventilation could occur, fentanyl transdermal system is contraindicated: in patients who are not opioid- tolerantin the management of acute pain or in patients who require opioid analgesia for a short period of time. The most important factor to be considered in determining the appropriate dose is the extent of pre- existing opioid- tolerance (see BOX WARNING and CONTRAINDICATIONS). Initial doses should be reduced in elderly or debilitated patients (see PRECAUTIONS). Fentanyl transdermal system should be applied to intact, non- irritated, and non- irradiated skin on a flat surface such as the chest, back, flank, or upper arm. In young children and persons with cognitive impairment, adhesion should be monitored and the upper back is the preferred location to minimize the potential of inappropriate patch removal. Hair at the application site should be clipped (not shaved) prior to system application. If the site of fentanyl transdermal system application must be cleansed prior to application of the patch, do so with clear water. Do not use soaps, oils, lotions, alcohol, or any other agents that might irritate the skin or alter its characteristics. Allow the skin to dry completely prior to patch application. Fentanyl transdermal system should be applied immediately upon removal from the sealed package. Do not use if the pouch seal is broken. Do not alter the patch (e. The transdermal system should be pressed firmly in place with the palm of the hand for 3. Fentanyl transdermal system should be kept out of the reach of children. Used patches should be folded so that the adhesive side of the patch adheres to itself, then the patch should be flushed down the toilet immediately upon removal. Patients should dispose of any patches remaining from a prescription as soon as they are no longer needed. Unused patches should be removed from their pouches, folded so that the adhesive side of the patch adheres to itself, and flushed down the toilet. Dose Selection. Doses must be individualized based upon the status of each patient and should be assessed at regular intervals after fentanyl transdermal system application. Reduced doses of fentanyl transdermal system are suggested for the elderly and other groups discussed in PRECAUTIONS. Fentanyl transdermal system is ONLY for use in patients who are already tolerant to opioid therapy of comparable potency. Use in non- opioid tolerant patients may lead to fatal respiratory depression. In selecting an initial fentanyl transdermal system dose, attention should be given to 1) the daily dose, potency, and characteristics of the opioid the patient has been taking previously (e. Each patient should be maintained at the lowest dose providing acceptable pain control. Initial Fentanyl Transdermal System Dose Selection. Overestimating the fentanyl transdermal system dose when converting patients from another opioid medication can result in fatal overdose with the first dose. Due to the mean half- life of approximately 2. The efficacy of fentanyl transdermal system 1. In addition, patients who are not opioid- tolerant have experienced hypoventilation and death during use of fentanyl transdermal system. Therefore, fentanyl transdermal system should be used only in patients who are opioid- tolerant. To convert adult and pediatric patients from oral or parenteral opioids to fentanyl transdermal system, use Table C: Alternatively, for adult and pediatric patients taking opioids or doses not listed in Table C, use the following methodology: Calculate the previous 2. Convert this amount to the equianalgesic oral morphine dose using Table D. Table E displays the range of 2. Use this table to find the calculated 2. Initiate fentanyl transdermal system treatment using the recommended dose and titrate patients upwards (no more frequently than every 3 days after the initial dose or than every 6 days thereafter) until analgesic efficacy is attained. The recommended starting dose when converting from other opioids to fentanyl transdermal system is likely too low for 5. This starting dose is recommended to minimize the potential for overdosing patients with the first dose. For delivery rates in excess of 1. The majority of patients are adequately maintained with fentanyl transdermal system administered every 7. Some patients may not achieve adequate analgesia using this dosing interval and may require systems to be applied every 4. An increase in the fentanyl transdermal system dose should be evaluated before changing dosing intervals in order to maintain patients on a 7. Dosing intervals less than every 7. Because of the increase in serum fentanyl concentration over the first 2. The initial fentanyl transdermal system dose may be increased after 3 days (see DOSAGE AND ADMINISTRATION - Dose Titration). During the initial application of fentanyl transdermal system, patients should use short- acting analgesics as needed until analgesic efficacy with fentanyl transdermal system is attained. Thereafter, some patients still may require periodic supplemental doses of other short- acting analgesics for . The initial fentanyl transdermal system dose may be increased after 3 days based on the daily dose of supplemental opioid analgesics required by the patient in the second or third day of the initial application. Physicians are advised that it may take up to 6 days after increasing the dose of fentanyl transdermal system for the patient to reach equilibrium on the new dose (see graph in CLINICAL PHARMACOLOGY). Therefore, patients should wear a higher dose through two applications before any further increase in dosage is made on the basis of the average daily use of a supplemental analgesic. Appropriate dosage increments should be based on the daily dose of supplementary opioids, using the ratio of 4. Fentanyl transdermal system - 1. Discontinuation of FENTANYL TRANSDERMAL SYSTEMTo convert patients to another opioid, remove fentanyl transdermal system and titrate the dose of the new analgesic based upon the patient's report of pain until adequate analgesia has been attained. Upon system removal, 1. Opioid withdrawal symptoms (such as nausea, vomiting, diarrhea, anxiety, and shivering) are possible in some patients after conversion or dose adjustment. For patients requiring discontinuation of opioids, a gradual downward titration is recommended since it is not known at what dose level the opioid may be discontinued without producing the signs and symptoms of abrupt withdrawal. Tables C, D, and E should not be used to convert from fentanyl transdermal system to other therapies. Because the conversion to fentanyl transdermal system is conservative, use of Tables C, D, and E for conversion to other analgesic therapies can overestimate the dose of the new agent. Overdosage of the new analgesic agent is possible. Matrifen - Summary of Product Characteristics (SPC)Matrifen, 1. Transdermal patch Matrifen, 2. Transdermal patch Matrifen, 5. Transdermal patch Matrifen, 7. Transdermal patch Matrifen, 1. Transdermal patch Matrifen 1. Each transdermal patch contains 1. Matrifen 2. 5 micrograms/hour: Each transdermal patch contains 2. Matrifen 5. 0 micrograms/hour: Each transdermal patch contains 5. Matrifen 7. 5 micrograms/hour: Each transdermal patch contains 8. Matrifen 1. 00 micrograms/hour: Each transdermal patch contains 1. For the full list of excipients, see section 6. Transdermal patch. Rectangular, translucent patch on a removable protective film. The protective film is larger than the patch. Patches are marked with a coloured imprint stating the trade name and strength: Matrifen 1. Matrifen 2. 5 micrograms/hour patch: red imprint. Matrifen 5. 0 micrograms/hour patch: green imprint. Matrifen 7. 5 micrograms/hour patch: light blue imprint Matrifen 1. Adults: Severe chronic pain, which can be adequately managed only with opioid analgesics. Children: Long term management of severe chronic pain in children receiving opioid therapy from 2 years of age. Posology. Fentanyl transdermal patches release the active substance over 7. The fentanyl release rate is 1. The required fentanyl dosage is adjusted individually and should be assessed regularly after each administration. Choice of initial dosage. The dosage level of fentanyl is based upon the previous use of opioids and takes into account the possible development of tolerance, concomitant medicinal treatment, the patient's general state of health and the degree of severity of the disorder. Adults: Opioid- tolerant patients. To convert opioid- tolerant patients from oral or parenteral opioids to Matrifen refer to Equianalgesic potency conversion below. The dosage may subsequently be titrated upwards or downwards, if required, in increments of either 1. Matrifen depending on response and supplementary analgesic requirements. Opioid- naive patients. The initial dosage should not exceed 1. Clinical experience with fentanyl transdermal patch is limited in opioid- na. In the circumstances in which therapy with fentanyl transdermal patch is considered appropriate in opioid- na. Patients can then be converted to fentanyl transdermal patch. The dose may subsequently be titrated upwards or downwards, if required, in increments of 1. Special warnings and precautions for use: Opioid na. Calculate the previous 2. Convert this amount to the equianalgesic oral morphine dose using Table 1. All IM and oral doses in this chart are considered equivalent to 1. IM morphine in analgesic effect. To derive the dosage of Matrifen corresponding to the calculated 2. Table 2 or Table 3 as follows: Table 2 is for adult patients who have been stabilised on oral morphine or another immediate- release opioid over several weeks and who need opioid rotation (conversion ratio of oral morphine to transdermal fentanyl approximately equal to 1. Table 3 is for highly opioid- tolerant adult patients who have been on a stable and well- tolerated opioid regimen for a long period, and who need opioid rotation (conversion ratio of oral morphine to transdermal fentanyl approximately equal to 1. Tables 2 and 3 should not be used to switch from transdermal fentanyl to another opioid treatment. Table 1: Equianalgesic potency conversion. Name of medicinal product. Equianalgesic dosage (mg) i. Oral. Morphine. 10. Hydromorphone. 1. Methadone. 10. 20. Oxycodone. 10- 1. Levorphanol. 24. Oxymorphine. Diamorphine. 56. 0Pethidine. Codeine 2. 00. Buprenorphine. Ketobemidone. 10. Based on studies conducted with single doses, in which the i. Oral dosages are the recommended dosages when changing from parenteral to oral administration.** The efficacy ratio of 3: 1 for morphine i. Table 2: Recommended initial dose of Matrifen based upon daily oral morphine dose (for patients stabilised on oral morphine or immediate release opioid for several weeks and who need opioid rotation)Oral morphine dose per 2. Dose of Matrifen transdermal patch micrograms/hour< 4. Conversion schemes are based on clinical trials. Schemes based on other trials have been found useful in clinical practice and may be used. Table 3: Recommended starting dosage of Matrifen based upon daily oral morphine dosage (for patients on stable and well tolerated opioid therapy for long periods and who need opioid rotation) Oral morphine dose per 2. Dose of Matrifen transdermal patch micrograms/hour< 4. Previous analgesic therapy should be phased out gradually from the time of the first patch application until analgesic efficacy with Matrifen is attained. For both strong opioid- na. The dose should be titrated individually until a balance between analgesic efficacy and tolerability is attained. In patients who experience a marked decrease in the period 4. The dose 1. 2 micrograms/hour is appropriate for dose titration in the lower dosage area. If analgesia is insufficient at the end of the initial application period, the dose may be increased after 3 days, until the desired effect is obtained for each patient. Additional dose adjustment should normally be performed in 1. More than one patch may be used for dose adjustments and for doses greater than 1. Patients may require periodic supplemental doses of a short- acting analgesic for breakthrough pain. Additional or alternative methods of analgesia or alternative administration of opioids should be considered when the Matrifen dose exceeds 3. Opioid withdrawal symptoms (see section 4. Undesirable effects) have been reported when changing from long- term treatment with Morphine to transdermal fentanyl despite adequate analgesic efficacy. In case of withdrawal symptoms it is recommended to treat those with short- acting Morphine in low doses. Discontinuation of Matrifen. If discontinuation of the patch is necessary, any replacement with other opioids should be gradual, starting at a low dose and increasing slowly. This is because fentanyl levels fall gradually after the patch is removed; it takes at least 1. As a general rule, the discontinuation of opioid analgesia should be gradual, in order to prevent withdrawal symptoms (nausea, vomiting, diarrhea, anxiety and muscular tremor). Table 2 and Table 3 should not be used to convert from Matrifen to other therapies to avoid overestimating the new analgesic dose and potentially causing overdose. Use in older people. Elderly or cachectic patients should be observed carefully and the dose reduced if necessary (see section 4. Use in patients with hepatic or renal impairment. Patients with impaired hepatic or renal function should carefully be observed for symptoms of an overdosage and the dose should possibly be reduced (see section 4. Use in febrile patients. Dose adjustment may be necessary in patients during episodes of fever (see section 4. Use in paediatric population. Children aged 1. 6 years and above: follow adult dosage. Children aged 2 to 1. Matrifen should be administered only to opioid- tolerant paediatric patients (ages 2 to 1. To convert paediatric patients from oral or parenteral opioids to Matrifen, refer to “Equianalgesic potency conversion” (Table 1), and “Recommended initial Matrifen dose based upon daily oral morphine dose” (Table 4). In the paediatric studies, the required fentanyl transdermal patch dose was calculated conservatively: 3. It should be noted that this conversion schedule for children only applies to the switch from oral morphine (or its equivalent) to fentanyl patches. The conversion schedule could not be used to convert from fentanyl into other opioids, as overdose could then occur. The analgesic effect of the first dose of Matrifen patches will not be optimal within the first 2. Therefore, during the first 1. Matrifen, the patients should be given the previous regular dose of analgesics. In the next 1. 2 hours, these analgesics should be provided based on clinical need. Since peak fentanyl levels occur after 1. Matrifen therapy or up- titration of the dose (see also section 4. Special warnings and precautions for use). Dose titration and maintenance. If the analgesic effect of Matrifen is insufficient, supplementary morphine or another short- duration opioid should be administered. Depending on the additional analgesic needs and the pain status of the child, it may be decided to increase the dose. Dose adjustments should be done in 1. Method of administration. For transdermal use. Fentanyl transdermal patch should be applied to non- irritated and non- irradiated skin on a flat surface of the torso or upper arm. In young children the upper back is the preferred location to apply the patch, to minimize the potential of the child removing the patch. Hair at the application site (hairless area is preferred) should be clipped (not shaved) prior to system application. If the site requires to be cleansed prior to application of the patch, this should be done with water. Soaps, oils, lotions, alcohol or any other agent that might irritate the skin or alter its characteristics should not be used. The skin should be completely dry before application of the patch. Patches should be inspected prior to use. The transdermal patch should not be divided or cut (see section 4. Patches that are cut, divided, or damaged in any way should not be used. Since the transdermal patch is protected outwardly by a waterproof covering foil, it may also be worn when taking a short shower. The Matrifen patch should be removed from the protective pouch by first folding the notch (located close to the tip of the arrow on the pouch label) and then carefully tearing the pouch material. If scissors are used to open the pouch, this should be done close to the sealed edge so as not to damage the patch inside. Fentanyl transdermal patch is to be attached as soon as the pack has been opened and avoid touching the adhesive side of the patch. Following removal of the protective layer, the transdermal patch should be pressed firmly in place with the palm of the hand for approximately 3. |
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September 2017
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