Inglés

Protocol IA-CPM AIEOP-BFM ALL 2009 NCT01117441

1 formularios  
Patient Information
Descripción

Patient Information

Alias
UMLS CUI-1
C1955348
Stud.-Nr. (Pat.-ID)
Descripción

Patient ID

Tipo de datos

text

Alias
UMLS CUI [1]
C2348585
Patient date of birth
Descripción

Patient birthday

Tipo de datos

date

Alias
UMLS CUI [1]
C0421451
Body weight
Descripción

Weight

Tipo de datos

float

Unidades de medida
  • kg
Alias
UMLS CUI [1]
C0005910
kg
Body height
Descripción

Height

Tipo de datos

float

Unidades de medida
  • cm
Alias
UMLS CUI [1]
C0005890
cm
Body surface
Descripción

Body surface

Tipo de datos

float

Unidades de medida
  • mˆ2
Alias
UMLS CUI [1]
C0005902
mˆ2
Chemotherapy Regimen
Descripción

Chemotherapy Regimen

Alias
UMLS CUI-1
C0392920
Prednisone administration form
Descripción

Prednisone: administration form

Tipo de datos

text

Alias
UMLS CUI [1,1]
C0032952
UMLS CUI [1,2]
C0013153
Prednisone dosage 60 mg/mˆ2/d
Descripción

Prednisone: dosage

Tipo de datos

float

Unidades de medida
  • mg
Alias
UMLS CUI [1,1]
C0032952
UMLS CUI [1,2]
C0178602
mg
Prednisone Date of administration
Descripción

Prednisone: date of administration

Tipo de datos

date

Alias
UMLS CUI [1,1]
C0032952
UMLS CUI [1,2]
C2584899
VCR administration form i.v.
Descripción

VCR: administration form

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C0042679
UMLS CUI [1,2]
C1522726
VCR dosage 1,5 mg/mˆ2/ED (max. 2 mg/ED)
Descripción

VCR: dosage

Tipo de datos

float

Unidades de medida
  • mg
Alias
UMLS CUI [1,1]
C0042679
UMLS CUI [1,2]
C0178602
mg
VCR Date of administration
Descripción

VCR: date of administration

Tipo de datos

date

Alias
UMLS CUI [1,1]
C0042679
UMLS CUI [1,2]
C2584899
DNR administration form p.i. (1h)
Descripción

DNR: administration form

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C0011015
UMLS CUI [1,2]
C1827465
DNR dosage 30 mg/mˆ2/d
Descripción

DNR: dosage

Tipo de datos

float

Unidades de medida
  • mg
Alias
UMLS CUI [1,1]
C0011015
UMLS CUI [1,2]
C0178602
mg
DNR Date of administration
Descripción

DNR: date of administration

Tipo de datos

date

Alias
UMLS CUI [1,1]
C0011015
UMLS CUI [1,2]
C2584899
Cyclophosphamide administration form p.i.
Descripción

CPM: administration form

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C0010583
UMLS CUI [1,2]
C1827465
Cyclophosphamide 1000 mg/mˆ2/ED
Descripción

CPM: dosage

Tipo de datos

float

Unidades de medida
  • mg
Alias
UMLS CUI [1,1]
C0010583
UMLS CUI [1,2]
C0178602
mg
Cyclophosphamide Date of administration
Descripción

CPM: date of administration

Tipo de datos

date

Alias
UMLS CUI [1,1]
C0010583
UMLS CUI [1,2]
C2584899
MTX administration form i.th
Descripción

MTX: administration form

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C0025677
UMLS CUI [1,2]
C0677897
MTX dosage (Age-dependent: 1 - < 2 y/o: 8 mg 2 - < 3y/o: 10 mg >= 3 y/o: 12 mg
Descripción

MTX: dosage

Tipo de datos

float

Unidades de medida
  • mg
Alias
UMLS CUI [1,1]
C0025677
UMLS CUI [1,2]
C0178602
mg
MTX Date of administration (while MTX infusion)
Descripción

MTX: date of administration

Tipo de datos

date

Alias
UMLS CUI [1,1]
C0025677
UMLS CUI [1,2]
C2584899
If CNS status CNS2 or CNS3, extra MTX dose (i.th., on day 19 and 26): Date of administration
Descripción

MTX and CNS status: date of administration

Tipo de datos

date

Alias
UMLS CUI [1,1]
C0025677
UMLS CUI [1,2]
C0449389
UMLS CUI [1,3]
C2584899
PEG-L-ASP administration form p.i. (2h)
Descripción

PEG-L-ASP: administration form

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C0071568
UMLS CUI [1,2]
C1827465
PEG-L-ASP dosage 2500 mg/mˆ2/ED (ONCASPAR: 3750 E/ED)
Descripción

PEG-L-ASP: dosage

Tipo de datos

float

Unidades de medida
  • E
Alias
UMLS CUI [1,1]
C0071568
UMLS CUI [1,2]
C0178602
E
PEG-L-ASP (If Randomisation in Group HR-ASP+, continue PEG-L-ASP therapy 14 days after dose on day 26) Date of administration
Descripción

PEG-L-ASP: date of administration

Tipo de datos

date

Alias
UMLS CUI [1,1]
C0071568
UMLS CUI [1,2]
C2584899
PEG-L-ASP/ Erwinase
Descripción

PEG-L-ASP/ Erwinase

Alias
UMLS CUI-1
C0071568
UMLS CUI-3
C0591457
Change from PEG-L-ASP to Erwinase in this element
Descripción

Change from PEG-L-ASP to Erwinase

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C0580105
UMLS CUI [1,2]
C0071568
UMLS CUI [1,3]
C0591457
If "yes", specify: Erwinase: date of first administration
Descripción

Erwinase: date of first administration

Tipo de datos

date

Alias
UMLS CUI [1,1]
C0591457
UMLS CUI [1,2]
C2584899
UMLS CUI [1,3]
C0205435
If "yes", specify: Erwinase: date of last administration
Descripción

Erwinase: date of last administration

Tipo de datos

date

Alias
UMLS CUI [1,1]
C0591457
UMLS CUI [1,2]
C2584899
UMLS CUI [1,3]
C1517741
If "yes", specify: Numbers of Erwinase doses
Descripción

Numbers of Erwinase doses

Tipo de datos

float

Alias
UMLS CUI [1,1]
C0591457
UMLS CUI [1,2]
C0237753
If "yes", specify: Reason for change to erwinase: Hypersensitivity
Descripción

Reason for drug change: Hypersensitivity

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C0591457
UMLS CUI [1,2]
C0392747
UMLS CUI [2]
C0020517
If "yes", specify: Reason for change to erwinase: Date of allergic reaction
Descripción

Reason for drug change: date of hypersensitivity

Tipo de datos

date

Alias
UMLS CUI [1,1]
C0591457
UMLS CUI [1,2]
C0392747
UMLS CUI [2,1]
C0020517
UMLS CUI [2,2]
C0011008
If "yes", specify: Reason for change to erwinase: Other reason
Descripción

Reason for drug change: Other reason

Tipo de datos

text

Alias
UMLS CUI [1,1]
C0591457
UMLS CUI [1,2]
C0392747
UMLS CUI [2]
C3840932
Identification and Signature
Descripción

Identification and Signature

Alias
UMLS CUI-1
C0205396
UMLS CUI-3
C1519316
Date and signature of the doctor who calculated and created chemotherapy regimen
Descripción

Chemotherapy creator: signature

Tipo de datos

text

Alias
UMLS CUI [1,1]
C0392920
UMLS CUI [1,2]
C1707531
UMLS CUI [2]
C1519316
Date and signature of the person who administered chemotherapy
Descripción

Chemotherapy administration: signature

Tipo de datos

text

Alias
UMLS CUI [1,1]
C0392920
UMLS CUI [1,2]
C1533734
UMLS CUI [2]
C1519316
Volver a la parte superior de la página

Similar models

Protocol IA-CPM AIEOP-BFM ALL 2009 NCT01117441

1 formularios
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
Alias
Item Group
Patient Information
C1955348 (UMLS CUI-1)
Patient ID
Item
Stud.-Nr. (Pat.-ID)
text
C2348585 (UMLS CUI [1])
Patient birthday
Item
Patient date of birth
date
C0421451 (UMLS CUI [1])
Weight
Item
Body weight
float
C0005910 (UMLS CUI [1])
Height
Item
Body height
float
C0005890 (UMLS CUI [1])
Body surface
Item
Body surface
float
C0005902 (UMLS CUI [1])
Item Group
Chemotherapy Regimen
C0392920 (UMLS CUI-1)
Item
Prednisone administration form
text
C0032952 (UMLS CUI [1,1])
C0013153 (UMLS CUI [1,2])
Dexamethasone: administration form
Code List
Prednisone administration form
CL Item
p.o (p.o)
CL Item
i.v. (i.v.)
Prednisone: dosage
Item
Prednisone dosage 60 mg/mˆ2/d
float
C0032952 (UMLS CUI [1,1])
C0178602 (UMLS CUI [1,2])
Prednisone: date of administration
Item
Prednisone Date of administration
date
C0032952 (UMLS CUI [1,1])
C2584899 (UMLS CUI [1,2])
VCR: administration form
Item
VCR administration form i.v.
boolean
C0042679 (UMLS CUI [1,1])
C1522726 (UMLS CUI [1,2])
VCR: dosage
Item
VCR dosage 1,5 mg/mˆ2/ED (max. 2 mg/ED)
float
C0042679 (UMLS CUI [1,1])
C0178602 (UMLS CUI [1,2])
VCR: date of administration
Item
VCR Date of administration
date
C0042679 (UMLS CUI [1,1])
C2584899 (UMLS CUI [1,2])
DNR: administration form
Item
DNR administration form p.i. (1h)
boolean
C0011015 (UMLS CUI [1,1])
C1827465 (UMLS CUI [1,2])
DNR: dosage
Item
DNR dosage 30 mg/mˆ2/d
float
C0011015 (UMLS CUI [1,1])
C0178602 (UMLS CUI [1,2])
DNR: date of administration
Item
DNR Date of administration
date
C0011015 (UMLS CUI [1,1])
C2584899 (UMLS CUI [1,2])
CPM: administration form
Item
Cyclophosphamide administration form p.i.
boolean
C0010583 (UMLS CUI [1,1])
C1827465 (UMLS CUI [1,2])
CPM: dosage
Item
Cyclophosphamide 1000 mg/mˆ2/ED
float
C0010583 (UMLS CUI [1,1])
C0178602 (UMLS CUI [1,2])
CPM: date of administration
Item
Cyclophosphamide Date of administration
date
C0010583 (UMLS CUI [1,1])
C2584899 (UMLS CUI [1,2])
MTX: administration form
Item
MTX administration form i.th
boolean
C0025677 (UMLS CUI [1,1])
C0677897 (UMLS CUI [1,2])
MTX: dosage
Item
MTX dosage (Age-dependent: 1 - < 2 y/o: 8 mg 2 - < 3y/o: 10 mg >= 3 y/o: 12 mg
float
C0025677 (UMLS CUI [1,1])
C0178602 (UMLS CUI [1,2])
MTX: date of administration
Item
MTX Date of administration (while MTX infusion)
date
C0025677 (UMLS CUI [1,1])
C2584899 (UMLS CUI [1,2])
MTX and CNS status: date of administration
Item
If CNS status CNS2 or CNS3, extra MTX dose (i.th., on day 19 and 26): Date of administration
date
C0025677 (UMLS CUI [1,1])
C0449389 (UMLS CUI [1,2])
C2584899 (UMLS CUI [1,3])
PEG-L-ASP: administration form
Item
PEG-L-ASP administration form p.i. (2h)
boolean
C0071568 (UMLS CUI [1,1])
C1827465 (UMLS CUI [1,2])
PEG-L-ASP: dosage
Item
PEG-L-ASP dosage 2500 mg/mˆ2/ED (ONCASPAR: 3750 E/ED)
float
C0071568 (UMLS CUI [1,1])
C0178602 (UMLS CUI [1,2])
PEG-L-ASP: date of administration
Item
PEG-L-ASP (If Randomisation in Group HR-ASP+, continue PEG-L-ASP therapy 14 days after dose on day 26) Date of administration
date
C0071568 (UMLS CUI [1,1])
C2584899 (UMLS CUI [1,2])
Item Group
PEG-L-ASP/ Erwinase
C0071568 (UMLS CUI-1)
C0591457 (UMLS CUI-3)
Change from PEG-L-ASP to Erwinase
Item
Change from PEG-L-ASP to Erwinase in this element
boolean
C0580105 (UMLS CUI [1,1])
C0071568 (UMLS CUI [1,2])
C0591457 (UMLS CUI [1,3])
Erwinase: date of first administration
Item
If "yes", specify: Erwinase: date of first administration
date
C0591457 (UMLS CUI [1,1])
C2584899 (UMLS CUI [1,2])
C0205435 (UMLS CUI [1,3])
Erwinase: date of last administration
Item
If "yes", specify: Erwinase: date of last administration
date
C0591457 (UMLS CUI [1,1])
C2584899 (UMLS CUI [1,2])
C1517741 (UMLS CUI [1,3])
Numbers of Erwinase doses
Item
If "yes", specify: Numbers of Erwinase doses
float
C0591457 (UMLS CUI [1,1])
C0237753 (UMLS CUI [1,2])
Reason for drug change: Hypersensitivity
Item
If "yes", specify: Reason for change to erwinase: Hypersensitivity
boolean
C0591457 (UMLS CUI [1,1])
C0392747 (UMLS CUI [1,2])
C0020517 (UMLS CUI [2])
Reason for drug change: date of hypersensitivity
Item
If "yes", specify: Reason for change to erwinase: Date of allergic reaction
date
C0591457 (UMLS CUI [1,1])
C0392747 (UMLS CUI [1,2])
C0020517 (UMLS CUI [2,1])
C0011008 (UMLS CUI [2,2])
Reason for drug change: Other reason
Item
If "yes", specify: Reason for change to erwinase: Other reason
text
C0591457 (UMLS CUI [1,1])
C0392747 (UMLS CUI [1,2])
C3840932 (UMLS CUI [2])
Item Group
Identification and Signature
C0205396 (UMLS CUI-1)
C1519316 (UMLS CUI-3)
Chemotherapy creator: signature
Item
Date and signature of the doctor who calculated and created chemotherapy regimen
text
C0392920 (UMLS CUI [1,1])
C1707531 (UMLS CUI [1,2])
C1519316 (UMLS CUI [2])
Chemotherapy administration: signature
Item
Date and signature of the person who administered chemotherapy
text
C0392920 (UMLS CUI [1,1])
C1533734 (UMLS CUI [1,2])
C1519316 (UMLS CUI [2])
Volver a la parte superior de la página