ID

12442

Beskrivning

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.

Nyckelord

Versioner (1)
  1. 2015-11-19 2015-11-19 - Julian Varghese
Uppladdad den

19 november 2015

DOI

För en begäran logga in.

Licens

Creative Commons BY-NC 3.0
Modellkommentarer :

Här kan du kommentera modellen. Med hjälp av pratbubblor i Item-grupperna och Item kan du lägga in specifika kommentarer.

Tillbaka till modellkommentarer
Itemgroup-kommentar för :

Item-kommentar för :

Du måste vara inloggad för att kunna ladda ner formulär. Var vänlig logga in eller registrera dig utan kostnad.

Treatment Form Hyperthermia treatment Study

Engelsk

Treatment Form Day 1 to 4

1 Formulär  
Patient Identification
Beskrivning

Patient Identification

Hyper-PEI-UPN
Beskrivning

Hyper-PEI-UPN

Datatyp

text

Date
Beskrivning

Date

Datatyp

date

Alias
UMLS CUI [1]
C0011008
Body weight
Beskrivning

Weight

Datatyp

float

Måttenheter
  • kg
Alias
UMLS CUI [1]
C0005910
kg
Height
Beskrivning

Height

Datatyp

float

Måttenheter
  • cm
Alias
UMLS CUI [1]
C0005890
cm
BSA
Beskrivning

Body surface

Datatyp

float

Måttenheter
  • m²
Alias
UMLS CUI [1]
C0005902
m²
Technical Specifications
Beskrivning

Technical Specifications

Maximum Output
Beskrivning

Maximum Output

Datatyp

text

Måttenheter
  • Watt
Alias
UMLS CUI [1,1]
C0020548
UMLS CUI [1,2]
C1709366
Watt
Frequency
Beskrivning

Frequency

Datatyp

text

Måttenheter
  • MHz
Alias
UMLS CUI [1,1]
C0020548
UMLS CUI [1,2]
C2826655
MHz
Focus
Beskrivning

Focus

Datatyp

text

Process of Hyperthermia
Beskrivning

Process of Hyperthermia

Organ
Beskrivning

Cave: complete AE/SAE Form if need be

Datatyp

text

Alias
UMLS CUI [1]
C0807185
Tumor Probe
Beskrivning

Tumor Probe

Datatyp

text

Alias
UMLS CUI [1]
C3882401
Urinary Bladder
Beskrivning

Bladder

Datatyp

text

Alias
UMLS CUI [1]
C0005682
Rectum
Beskrivning

Rectum

Datatyp

text

Alias
UMLS CUI [1]
C0034896
Vagina
Beskrivning

Vagina

Datatyp

text

Alias
UMLS CUI [1]
C0042232
Skin
Beskrivning

Note any abnormality

Datatyp

text

Alias
UMLS CUI [1]
C1123023
Vital signs
Beskrivning

Vital signs

Pulse
Beskrivning

Pulse Rate

Datatyp

integer

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

Oxygen saturation

Datatyp

text

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

Blood Pressure

Datatyp

integer

Alias
UMLS CUI [1]
C0005823
Chemotherapy
Beskrivning

Chemotherapy

Cycle Number
Beskrivning

Cycle

Datatyp

integer

Alias
UMLS CUI [1]
C2045829
Day of Treatment
Beskrivning

Day of Treatment

Datatyp

text

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

Medication

Datatyp

text

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

40mg/m²

Datatyp

float

Måttenheter
  • mg
Alias
UMLS CUI [1]
C0008838
mg
Total amount of Carboplatin administerd
Beskrivning

400mg/m²

Datatyp

float

Måttenheter
  • mg
Alias
UMLS CUI [1]
C0079083
mg
Total amount of Etoposide administered
Beskrivning

100mg/m²

Datatyp

float

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

600mg/m²

Datatyp

float

Måttenheter
  • mg
Alias
UMLS CUI [1]
C0000294
mg
Total amount of Ifosfamide administered
Beskrivning

1800mg/m²

Datatyp

float

Måttenheter
  • mg
Alias
UMLS CUI [1]
C0020823
mg
Total amount of Cyclophosphamide administered
Beskrivning

600mg/m²

Datatyp

float

Måttenheter
  • mg
Alias
UMLS CUI [1]
C0010583
mg
Total amount of Mesna administered
Beskrivning

1800mg/m²

Datatyp

float

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

Sedation

Datatyp

float

Måttenheter
  • mg
Alias
UMLS CUI [1]
C0344106
mg
Any other Medication administered
Beskrivning

Other Medication

Datatyp

text

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

Correctness of information confirmed

Date
Beskrivning

Date

Datatyp

date

Alias
UMLS CUI [1]
C0011008
Treating Physician
Beskrivning

Physician

Datatyp

text

Alias
UMLS CUI [1]
C1710470
Signature
Beskrivning

Responsible Person Signature

Datatyp

text

Alias
UMLS CUI [1]
C1550483
Chemotherapy
Beskrivning

Chemotherapy

Cycle number
Beskrivning

Cycle

Datatyp

integer

Alias
UMLS CUI [1]
C2045829
Day of Treatment
Beskrivning

Day of Treatment

Datatyp

text

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

Medication

Datatyp

text

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

100mg/m²

Datatyp

float

Måttenheter
  • mg
Alias
UMLS CUI [1]
C0015133
mg
Total amount of Ifosfamide administered
Beskrivning

1800mg/m²

Datatyp

float

Måttenheter
  • mg
Alias
UMLS CUI [1]
C0020823
mg
Total amount of Cyclophosphamide administered
Beskrivning

600mg/m²

Datatyp

float

Måttenheter
  • mg
Alias
UMLS CUI [1]
C0010583
mg
Total amount of Mesna administered
Beskrivning

1800mg/m²

Datatyp

float

Måttenheter
  • mg
Alias
UMLS CUI [1]
C0000294
mg
Any other medication administered
Beskrivning

Other Medication

Datatyp

text

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

Correctness of information confirmed

Date
Beskrivning

Date

Datatyp

date

Alias
UMLS CUI [1]
C0011008
Treating Physician
Beskrivning

Physician

Datatyp

text

Alias
UMLS CUI [1]
C1710470
Signature
Beskrivning

Responsible Person Signature

Datatyp

text

Alias
UMLS CUI [1]
C1550483
Tillbaka till toppen

Similar models

Treatment Form Day 1 to 4

1 Formulär
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
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])
Tillbaka till toppen 

Kontakt

Använd detta formulär för feedback, frågor och förslag på förbättringar.

Fält markerade med * är obligatoriska.

Hjälp

Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

Watch Tutorial