ID

21014

Beschrijving

The purpose of the trial is to determine if extended-release dipyridamole + aspirin [Aggrenox, Asasa ntin] is superior to clopidogrel [Plavix], and if telmisartan [Micardis, Gliosartan, Kinzal, Kinzalm ono, Predxal, Pritor, Samertan, Telmisartan] is superior to placebo, in the presence of background antihypertensive therapy, in prevention of a second stroke in patients who have recently suffered a stroke and therefore are at high risk of suffering another one. Source & Descriptions: https://clinicaltrials.gov/ct2/show/NCT00153062?term=NCT00153062&rank=1

Link

https://clinicaltrials.gov/ct2/show/NCT00153062?term=NCT00153062&rank=1

Trefwoorden

Versies (2)
  1. 22-02-17 22-02-17 -
  2. 03-04-17 03-04-17 -
Geüploaded op

3 april 2017

DOI

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Licentie

Creative Commons BY 4.0
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Death Report Form PRoFESS - Prevention Regimen For Effectively Avoiding Second Strokes NCT00153062

Engels

Death Report Form PRoFESS - Prevention Regimen For Effectively Avoiding Second Strokes NCT00153062

1 Formulieren  
Death Report Form
Beschrijving

Death Report Form

Alias
UMLS CUI-1
C0011065
UMLS CUI-2
C1516308
1. Date of death (dd mon yy)
Beschrijving

Date of death

Datatype

date

Alias
UMLS CUI [1]
C1148348
2. Was the patient on study medication within the 7 days prior to the event?
Beschrijving

Study Medication

Datatype

boolean

Alias
UMLS CUI [1]
C0013227
If NO, which medication was the patient was not taking (please indicate all that apply):
Beschrijving

if NO

Datatype

integer

Alias
UMLS CUI [1,1]
C0030705
UMLS CUI [1,2]
C0457432
3. What was the cause of death (please indicate one)?
Beschrijving

Cause of death

Datatype

integer

Alias
UMLS CUI [1]
C0007465
Cancer Specification
Beschrijving

Cancer Specification

Datatype

integer

Alias
UMLS CUI [1]
C0178759
Specify "Other Non Vascular Causes"
Beschrijving

Other Non Vascular Causes

Datatype

text

Alias
UMLS CUI [1,1]
C3262234
UMLS CUI [1,2]
C2348235
4. Did the patient die in hospital? If yes, complete Hospitalization Report Form
Beschrijving

Death in Hospital

Datatype

boolean

Alias
UMLS CUI [1]
C0277608
Please remember to fax Supporting Documentation clearly identified with the patient number
Beschrijving

Please remember to fax Supporting Documentation clearly identified with the patient number

5. Please indicate which supporting documentation has been supplied:
Beschrijving

Supporting Documentation

Datatype

integer

Alias
UMLS CUI [1]
C0678257
Invenstigator´s Declaration
Beschrijving

Invenstigator´s Declaration

Alias
UMLS CUI-1
C0008961
Invenstigator´s Declaration By signing and dating this page, I declare that I have reviewed for accuracy all case report form pages for this patient; the information contained on these pages accurately reflects the medical record including the results of tests and evaluations performed in the dates specified.
Beschrijving

Invenstigator´s Declaration

Datatype

text

Investigator´s signature
Beschrijving

Investigator´s signature

Datatype

text

Alias
UMLS CUI [1]
C2346576
Date of Signature
Beschrijving

Date of Signature

Datatype

date

Alias
UMLS CUI [1,1]
C0011008
UMLS CUI [1,2]
C1519316
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Similar models

Death Report Form PRoFESS - Prevention Regimen For Effectively Avoiding Second Strokes NCT00153062

1 Formulieren
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
Item Group
Death Report Form
C0011065 (UMLS CUI-1)
C1516308 (UMLS CUI-2)
Date of death
Item
1. Date of death (dd mon yy)
date
C1148348 (UMLS CUI [1])
Study Medication
Item
2. Was the patient on study medication within the 7 days prior to the event?
boolean
C0013227 (UMLS CUI [1])
Item
If NO, which medication was the patient was not taking (please indicate all that apply):
integer
C0030705 (UMLS CUI [1,1])
C0457432 (UMLS CUI [1,2])
if NO
Code List
If NO, which medication was the patient was not taking (please indicate all that apply):
CL Item
Bottle A (1)
CL Item
Bottle B (2)
CL Item
Blister card C (3)
CL Item
Blister card D (4)
Item
3. What was the cause of death (please indicate one)?
integer
C0007465 (UMLS CUI [1])
Cause of death
Code List
3. What was the cause of death (please indicate one)?
CL Item
Ischemic Stroke (Complete Stroke report form) (1)
CL Item
Hemorrhagic Stroke (Complete Stroke report form and Hemorrhagic Events Report Form) (2)
CL Item
Stroke of Uncertain Cause (Complete Stroke report form) (3)
CL Item
Myocardial Infarction (Complete MI report form) (4)
CL Item
Hemorrhage (excluding intracranial bleeding) (Complete Hemorrhagic Events report form) (5)
CL Item
Other Vascular Causes (Complete Other Designated Vascular Events Report form) (6)
CL Item
Asystole (7)
CL Item
Congestive Heart failure (8)
CL Item
Ventricular Tachycardia (9)
CL Item
Ventricular fibrillation (10)
CL Item
Pneumonia (11)
CL Item
Other Infection (12)
CL Item
Cancer (please specify site below) (13)
CL Item
Trauma (14)
CL Item
Other Non Vascular Causes (15)
Item
Cancer Specification
integer
C0178759 (UMLS CUI [1])
Cancer Specification
Code List
Cancer Specification
CL Item
Lung (1)
CL Item
Breast (2)
CL Item
Gastrointestinal (3)
CL Item
Prostate (4)
CL Item
Brain (5)
CL Item
Skin (6)
CL Item
Multi site (7)
CL Item
Genito-urinary (8)
CL Item
Other Sites (9)
Other Non Vascular Causes
Item
Specify "Other Non Vascular Causes"
text
C3262234 (UMLS CUI [1,1])
C2348235 (UMLS CUI [1,2])
Death in Hospital
Item
4. Did the patient die in hospital? If yes, complete Hospitalization Report Form
boolean
C0277608 (UMLS CUI [1])
Item Group
Please remember to fax Supporting Documentation clearly identified with the patient number
Item
5. Please indicate which supporting documentation has been supplied:
integer
C0678257 (UMLS CUI [1])
Supporting Documentation
Code List
5. Please indicate which supporting documentation has been supplied:
CL Item
Death certificate (1)
CL Item
Emergency Room report (2)
CL Item
Autopsy report (3)
CL Item
Other (4)
Item Group
Invenstigator´s Declaration
C0008961 (UMLS CUI-1)
Invenstigator´s Declaration
Item
Invenstigator´s Declaration By signing and dating this page, I declare that I have reviewed for accuracy all case report form pages for this patient; the information contained on these pages accurately reflects the medical record including the results of tests and evaluations performed in the dates specified.
text
Investigator´s signature
Item
Investigator´s signature
text
C2346576 (UMLS CUI [1])
Date of Signature
Item
Date of Signature
date
C0011008 (UMLS CUI [1,1])
C1519316 (UMLS CUI [1,2])
Terug naar het begin van de pagina 

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