ID

12442

Beschrijving

Hyper-PEI-protocol:a programme with regional deep hyperthermia(RHT)in combination with PEI-chemotherapy.The Hyper-PEI protocol is offered in place of the intensive standard chemotherapy for high-risk patie nts with malignant, extracranial tumors. Patients have a measurable relapsed tumor,or a primary tumor that did not respond sufficiently to treatment according to standard protocols. Responsible MD: PD Dr. med. R Wessalowski, Clinic for pediatric oncology,haematology and immunology UKD, Moorenstr. 5, 40225 Dusseldorf Purpose of this form is to document Hyperthermia treatment.This form has to be filled in by the Hyperthermia-Specialists of UKD.

Trefwoorden

Versies (1)
  1. 19-11-15 19-11-15 - Julian Varghese
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19 november 2015

DOI

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Creative Commons BY-NC 3.0
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Treatment Form Hyperthermia treatment Study

Engels

Treatment Form Day 1 to 4

1 Formulieren  
Patient Identification
Beschrijving

Patient Identification

Hyper-PEI-UPN
Beschrijving

Hyper-PEI-UPN

Datatype

text

Date
Beschrijving

Date

Datatype

date

Alias
UMLS CUI [1]
C0011008
Body weight
Beschrijving

Weight

Datatype

float

Maateenheden
  • kg
Alias
UMLS CUI [1]
C0005910
kg
Height
Beschrijving

Height

Datatype

float

Maateenheden
  • cm
Alias
UMLS CUI [1]
C0005890
cm
BSA
Beschrijving

Body surface

Datatype

float

Maateenheden
  • m²
Alias
UMLS CUI [1]
C0005902
m²
Technical Specifications
Beschrijving

Technical Specifications

Maximum Output
Beschrijving

Maximum Output

Datatype

text

Maateenheden
  • Watt
Alias
UMLS CUI [1,1]
C0020548
UMLS CUI [1,2]
C1709366
Watt
Frequency
Beschrijving

Frequency

Datatype

text

Maateenheden
  • MHz
Alias
UMLS CUI [1,1]
C0020548
UMLS CUI [1,2]
C2826655
MHz
Focus
Beschrijving

Focus

Datatype

text

Process of Hyperthermia
Beschrijving

Process of Hyperthermia

Organ
Beschrijving

Cave: complete AE/SAE Form if need be

Datatype

text

Alias
UMLS CUI [1]
C0807185
Tumor Probe
Beschrijving

Tumor Probe

Datatype

text

Alias
UMLS CUI [1]
C3882401
Urinary Bladder
Beschrijving

Bladder

Datatype

text

Alias
UMLS CUI [1]
C0005682
Rectum
Beschrijving

Rectum

Datatype

text

Alias
UMLS CUI [1]
C0034896
Vagina
Beschrijving

Vagina

Datatype

text

Alias
UMLS CUI [1]
C0042232
Skin
Beschrijving

Note any abnormality

Datatype

text

Alias
UMLS CUI [1]
C1123023
Vital signs
Beschrijving

Vital signs

Pulse
Beschrijving

Pulse Rate

Datatype

integer

Maateenheden
  • beats/min
Alias
UMLS CUI [1]
C0232117
Oxygen saturation (SaO2):
Beschrijving

Oxygen saturation

Datatype

text

Alias
UMLS CUI [1]
C0523807
Blood pressure (RR)
Beschrijving

Blood Pressure

Datatype

integer

Alias
UMLS CUI [1]
C0005823
Chemotherapy
Beschrijving

Chemotherapy

Cycle Number
Beschrijving

Cycle

Datatype

integer

Alias
UMLS CUI [1]
C2045829
Day of Treatment
Beschrijving

Day of Treatment

Datatype

text

Alias
UMLS CUI [1]
C3468389
Total amount of medication given
Beschrijving

Medication

Datatype

text

Alias
UMLS CUI [1]
C3174092
Total amount of cisplatin administered this reporting period
Beschrijving

40mg/m²

Datatype

float

Maateenheden
  • mg
Alias
UMLS CUI [1]
C0008838
mg
Total amount of Carboplatin administerd
Beschrijving

400mg/m²

Datatype

float

Maateenheden
  • mg
Alias
UMLS CUI [1]
C0079083
mg
Total amount of Etoposide administered
Beschrijving

100mg/m²

Datatype

float

Maateenheden
  • mg
Alias
UMLS CUI [1]
C0015133
mg
Total amount of Mesna-Bolus administered
Beschrijving

600mg/m²

Datatype

float

Maateenheden
  • mg
Alias
UMLS CUI [1]
C0000294
mg
Total amount of Ifosfamide administered
Beschrijving

1800mg/m²

Datatype

float

Maateenheden
  • mg
Alias
UMLS CUI [1]
C0020823
mg
Total amount of Cyclophosphamide administered
Beschrijving

600mg/m²

Datatype

float

Maateenheden
  • mg
Alias
UMLS CUI [1]
C0010583
mg
Total amount of Mesna administered
Beschrijving

1800mg/m²

Datatype

float

Maateenheden
  • mg
Alias
UMLS CUI [1]
C0000294
mg
Total amount of medication given for sedation
Beschrijving

Sedation

Datatype

float

Maateenheden
  • mg
Alias
UMLS CUI [1]
C0344106
mg
Any other Medication administered
Beschrijving

Other Medication

Datatype

text

Alias
UMLS CUI [1]
C0013227
Correctness of information confirmed
Beschrijving

Correctness of information confirmed

Date
Beschrijving

Date

Datatype

date

Alias
UMLS CUI [1]
C0011008
Treating Physician
Beschrijving

Physician

Datatype

text

Alias
UMLS CUI [1]
C1710470
Signature
Beschrijving

Responsible Person Signature

Datatype

text

Alias
UMLS CUI [1]
C1550483
Chemotherapy
Beschrijving

Chemotherapy

Cycle number
Beschrijving

Cycle

Datatype

integer

Alias
UMLS CUI [1]
C2045829
Day of Treatment
Beschrijving

Day of Treatment

Datatype

text

Alias
UMLS CUI [1]
C3468389
Total amount of medication administered
Beschrijving

Medication

Datatype

text

Alias
UMLS CUI [1]
C3174092
Total amount of Etoposide administered
Beschrijving

100mg/m²

Datatype

float

Maateenheden
  • mg
Alias
UMLS CUI [1]
C0015133
mg
Total amount of Ifosfamide administered
Beschrijving

1800mg/m²

Datatype

float

Maateenheden
  • mg
Alias
UMLS CUI [1]
C0020823
mg
Total amount of Cyclophosphamide administered
Beschrijving

600mg/m²

Datatype

float

Maateenheden
  • mg
Alias
UMLS CUI [1]
C0010583
mg
Total amount of Mesna administered
Beschrijving

1800mg/m²

Datatype

float

Maateenheden
  • mg
Alias
UMLS CUI [1]
C0000294
mg
Any other medication administered
Beschrijving

Other Medication

Datatype

text

Alias
UMLS CUI [1]
C0013227
Correctness of information confirmed
Beschrijving

Correctness of information confirmed

Date
Beschrijving

Date

Datatype

date

Alias
UMLS CUI [1]
C0011008
Treating Physician
Beschrijving

Physician

Datatype

text

Alias
UMLS CUI [1]
C1710470
Signature
Beschrijving

Responsible Person Signature

Datatype

text

Alias
UMLS CUI [1]
C1550483
Terug naar het begin van de pagina

Similar models

Treatment Form Day 1 to 4

1 Formulieren
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
Item Group
Patient Identification
Hyper-PEI-UPN
Item
Hyper-PEI-UPN
text
Date
Item
Date
date
C0011008 (UMLS CUI [1])
Weight
Item
Body weight
float
C0005910 (UMLS CUI [1])
Height
Item
Height
float
C0005890 (UMLS CUI [1])
Body surface
Item
BSA
float
C0005902 (UMLS CUI [1])
Item Group
Technical Specifications
Maximum Output
Item
Maximum Output
text
C0020548 (UMLS CUI [1,1])
C1709366 (UMLS CUI [1,2])
Frequency
Item
Frequency
text
C0020548 (UMLS CUI [1,1])
C2826655 (UMLS CUI [1,2])
Item
Focus
text
Focus
Code List
Focus
CL Item
_ , Y=_ (X)
Item Group
Process of Hyperthermia
Item
Organ
text
C0807185 (UMLS CUI [1])
Organ
Code List
Organ
CL Item
T max °C , 2=T min °C , 3=T90 °C , 4=T50 °C , 5=T20 °C , 6=CEMT90 min (1)
Item
Tumor Probe
text
C3882401 (UMLS CUI [1])
Tumor Probe
Code List
Tumor Probe
CL Item
T max °C , 2=T min °C , 3=T90 °C , 4=T50 °C , 5=T20 °C , 6=CEMT90 min (1)
Item
Urinary Bladder
text
C0005682 (UMLS CUI [1])
Bladder
Code List
Urinary Bladder
CL Item
T max °C , 2=T min °C , 3=T90 °C , 4=T50 °C , 5=T20 °C , 6=CEMT90 min (1)
Item
Rectum
text
C0034896 (UMLS CUI [1])
Rectum
Code List
Rectum
CL Item
T max °C , 2=T min °C , 3=T90 °C , 4=T50 °C , 5=T20 °C , 6=CEMT90 min (1)
Item
Vagina
text
C0042232 (UMLS CUI [1])
Vagina
Code List
Vagina
CL Item
T max °C , 2=T min °C , 3=T90 °C , 4=T50 °C , 5=T20 °C , 6=CEMT90 min (1)
Item
Skin
text
C1123023 (UMLS CUI [1])
SKIN
Code List
Skin
CL Item
T max °C , 2=T min °C , 3=T90 °C , 4=T50 °C , 5=T20 °C , 6=CEMT90 min (1)
Item Group
Vital signs
Item
Pulse
integer
C0232117 (UMLS CUI [1])
Pulse Rate
Code List
Pulse
CL Item
Start warm up , 2=10min , 3=Start Hyperthermia , 4=15min , 5=30min , 6=45min , 7=60min (1)
Item
Oxygen saturation (SaO2):
text
C0523807 (UMLS CUI [1])
Oxygen saturation
Code List
Oxygen saturation (SaO2):
CL Item
Start warm up , 2=10min , 3=Start Hyperthermia , 4=15min , 5=30min , 6=45min , 7=60min (1)
Item
Blood pressure (RR)
integer
C0005823 (UMLS CUI [1])
Blood Pressure
Code List
Blood pressure (RR)
CL Item
Start warm up , 2=10min , 3=Start Hyperthermia , 4=15min , 5=30min , 6=45min , 7=60min (1)
Item Group
Chemotherapy
Cycle
Item
Cycle Number
integer
C2045829 (UMLS CUI [1])
Item
Day of Treatment
text
C3468389 (UMLS CUI [1])
Day of Treatment
Code List
Day of Treatment
CL Item
Day 1 , 2=Day 4 (1)
Medication
Item
Total amount of medication given
text
C3174092 (UMLS CUI [1])
Cisplatin
Item
Total amount of cisplatin administered this reporting period
float
C0008838 (UMLS CUI [1])
Carboplatin
Item
Total amount of Carboplatin administerd
float
C0079083 (UMLS CUI [1])
Etoposide
Item
Total amount of Etoposide administered
float
C0015133 (UMLS CUI [1])
Mesna-Bolus
Item
Total amount of Mesna-Bolus administered
float
C0000294 (UMLS CUI [1])
Ifosfamide
Item
Total amount of Ifosfamide administered
float
C0020823 (UMLS CUI [1])
Cyclophosphamide
Item
Total amount of Cyclophosphamide administered
float
C0010583 (UMLS CUI [1])
Mesna
Item
Total amount of Mesna administered
float
C0000294 (UMLS CUI [1])
Sedation
Item
Total amount of medication given for sedation
float
C0344106 (UMLS CUI [1])
Other Medication
Item
Any other Medication administered
text
C0013227 (UMLS CUI [1])
Item Group
Correctness of information confirmed
Date
Item
Date
date
C0011008 (UMLS CUI [1])
Physician
Item
Treating Physician
text
C1710470 (UMLS CUI [1])
Responsible Person Signature
Item
Signature
text
C1550483 (UMLS CUI [1])
Item Group
Chemotherapy
Cycle
Item
Cycle number
integer
C2045829 (UMLS CUI [1])
Item
Day of Treatment
text
C3468389 (UMLS CUI [1])
Day of Treatment
Code List
Day of Treatment
CL Item
Day 2 , 2=Day 3 (1)
Medication
Item
Total amount of medication administered
text
C3174092 (UMLS CUI [1])
Etoposide
Item
Total amount of Etoposide administered
float
C0015133 (UMLS CUI [1])
Ifosfamide
Item
Total amount of Ifosfamide administered
float
C0020823 (UMLS CUI [1])
Cyclophosphamide
Item
Total amount of Cyclophosphamide administered
float
C0010583 (UMLS CUI [1])
Mesna
Item
Total amount of Mesna administered
float
C0000294 (UMLS CUI [1])
Other Medication
Item
Any other medication administered
text
C0013227 (UMLS CUI [1])
Item Group
Correctness of information confirmed
Date
Item
Date
date
C0011008 (UMLS CUI [1])
Physician
Item
Treating Physician
text
C1710470 (UMLS CUI [1])
Responsible Person Signature
Item
Signature
text
C1550483 (UMLS CUI [1])
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