ID

21015

Description

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

Keywords

Versions (2)
  1. 2/22/17 2/22/17 -
  2. 4/3/17 4/3/17 -
Uploaded on

April 3, 2017

DOI

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License

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

English

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

1 forms  
Hospitalization Report Form
Description

Hospitalization Report Form

1. Date of admission (dd mon yy)
Description

Date of admission

Data type

date

Alias
UMLS CUI [1]
C1302393
2. Date of discharge (dd mon yy)
Description

Date of Discharge

Data type

date

Alias
UMLS CUI [1]
C2361123
3. Did the patient spend any days at the Intensive Care Unit (ICU) during the hospitalization?
Description

intensive care unit

Data type

boolean

Alias
UMLS CUI [1,1]
C0021708
UMLS CUI [1,2]
C0030673
If yes, number of days.
Description

Number of days

Data type

float

Alias
UMLS CUI [1,1]
C0809949
UMLS CUI [1,2]
C0021708
UMLS CUI [1,3]
C0439228
UMLS CUI [1,4]
C0750480
4. Was the reason for admission an outcome event?
Description

Reason for admission

Data type

boolean

Alias
UMLS CUI [1,1]
C0392360
UMLS CUI [1,2]
C0809949
If yes, please indicate which outcome event and complete the respective outcome event form. NOTE: there is no outcome event form for TTP or neutropenia
Description

Outcome Event

Data type

integer

Alias
UMLS CUI [1,1]
C1547647
UMLS CUI [1,2]
C0441471
If NO, please indicate reason for admission and complete the Serious Adverse event form.
Description

Reason for admission

Data type

integer

Alias
UMLS CUI [1]
C0681841
Specify "Other"
Description

Specification

Data type

text

Alias
UMLS CUI [1]
C2348235
5. Did the patients experience outcome events during hospitalization? If yes, please complete respective Outcome Event Forms.
Description

Outcome events during hospitalization

Data type

boolean

Alias
UMLS CUI [1,1]
C1705586
UMLS CUI [1,2]
C0019993
6. Were any of the following procedures performed?
Description

Performed Procedures

Data type

boolean

Alias
UMLS CUI [1]
C0087111
If yes, please indicate which:
Description

Indication

Data type

integer

Alias
UMLS CUI [1]
C3146298
Specify "Other"
Description

Specification

Data type

text

Alias
UMLS CUI [1]
C2348235
7. What was the patients discharge destination?
Description

Discharge of Destination

Data type

integer

Alias
UMLS CUI [1,1]
C0079220
UMLS CUI [1,2]
C0586514
Specify "Other destination"
Description

Specification

Data type

text

Alias
UMLS CUI [1,1]
C0079220
UMLS CUI [1,2]
C2348235
Invenstigator´s Declaration
Description

Invenstigator´s Declaration

8. 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.
Description

Invenstigator´s Declaration

Data type

text

Investigator´s signature
Description

Investigator´s signature

Data type

text

Alias
UMLS CUI [1]
C2346576
Date of Signature
Description

Date of Signature

Data type

date

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

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

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Hospitalization Report Form
Date of admission
Item
1. Date of admission (dd mon yy)
date
C1302393 (UMLS CUI [1])
Date of Discharge
Item
2. Date of discharge (dd mon yy)
date
C2361123 (UMLS CUI [1])
intensive care unit
Item
3. Did the patient spend any days at the Intensive Care Unit (ICU) during the hospitalization?
boolean
C0021708 (UMLS CUI [1,1])
C0030673 (UMLS CUI [1,2])
Number of days
Item
If yes, number of days.
float
C0809949 (UMLS CUI [1,1])
C0021708 (UMLS CUI [1,2])
C0439228 (UMLS CUI [1,3])
C0750480 (UMLS CUI [1,4])
Reason for admission
Item
4. Was the reason for admission an outcome event?
boolean
C0392360 (UMLS CUI [1,1])
C0809949 (UMLS CUI [1,2])
Item
If yes, please indicate which outcome event and complete the respective outcome event form. NOTE: there is no outcome event form for TTP or neutropenia
integer
C1547647 (UMLS CUI [1,1])
C0441471 (UMLS CUI [1,2])
Outcome Event
Code List
If yes, please indicate which outcome event and complete the respective outcome event form. NOTE: there is no outcome event form for TTP or neutropenia
CL Item
Stroke (1)
CL Item
Myocardial infarction (2)
CL Item
Congestive Heart Failure (3)
CL Item
ODVE (4)
CL Item
Hemorrhagic event (5)
CL Item
TTP (6)
CL Item
Neutropenia (7)
CL Item
Severe Neutropenia (8)
CL Item
Diabetes (9)
Item
If NO, please indicate reason for admission and complete the Serious Adverse event form.
integer
C0681841 (UMLS CUI [1])
Reason for admission
Code List
If NO, please indicate reason for admission and complete the Serious Adverse event form.
CL Item
Cancer (1)
CL Item
Fracture (2)
CL Item
Unstable Angina (3)
CL Item
Genito-urinary (4)
CL Item
Pulmonary (5)
CL Item
Injury (6)
CL Item
Psychiatric (7)
CL Item
Gastrointestinal (8)
CL Item
Other (9)
Specification
Item
Specify "Other"
text
C2348235 (UMLS CUI [1])
Outcome events during hospitalization
Item
5. Did the patients experience outcome events during hospitalization? If yes, please complete respective Outcome Event Forms.
boolean
C1705586 (UMLS CUI [1,1])
C0019993 (UMLS CUI [1,2])
Performed Procedures
Item
6. Were any of the following procedures performed?
boolean
C0087111 (UMLS CUI [1])
Item
If yes, please indicate which:
integer
C3146298 (UMLS CUI [1])
Indication
Code List
If yes, please indicate which:
CL Item
Coronary angiography (1)
CL Item
PTCA (2)
CL Item
Temporary Pacemaker (3)
CL Item
Carotid stenting (4)
CL Item
CABG (5)
CL Item
Carotid endarterectomy (6)
CL Item
Permanent Pacemaker insertion (7)
CL Item
Other procedures (8)
Specification
Item
Specify "Other"
text
C2348235 (UMLS CUI [1])
Item
7. What was the patients discharge destination?
integer
C0079220 (UMLS CUI [1,1])
C0586514 (UMLS CUI [1,2])
Discharge of Destination
Code List
7. What was the patients discharge destination?
CL Item
Home (1)
CL Item
Assisted living (2)
CL Item
Not applicable (3)
CL Item
Rehabilitation Centre (4)
CL Item
Nursing Home (5)
CL Item
Other destination (6)
Specification
Item
Specify "Other destination"
text
C0079220 (UMLS CUI [1,1])
C2348235 (UMLS CUI [1,2])
Item Group
Invenstigator´s Declaration
Invenstigator´s Declaration
Item
8. 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])
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