ID

637

Description

ADVL0212- Review Form (Dr. Chin) FR901228 in Treating Children With Refractory or Recurrent Solid Tumors or Leukemia Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=C0F2E959-BAAB-54D8-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=C0F2E959-BAAB-54D8-E034-0003BA12F5E7

Keywords

  1. 8/26/12 8/26/12 -
  2. 5/22/15 5/22/15 -
  3. 6/3/15 6/3/15 - Julian Varghese
Uploaded on

August 26, 2012

DOI

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License

Creative Commons BY-NC 3.0 Legacy

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Brain and Central Nervous System Tumors NCT00053963 Treatment - ADVL0212- Review Form (Dr. Chin) - 2172492v3.0

No Instruction available.

  1. StudyEvent: ADVL0212- Review Form (Dr. Chin)
    1. No Instruction available.
Unnamed1
Description

Unnamed1

Date of ECG
Description

DateofECG

Data type

text

Did patient experience any of the following: SVT, atrial fibrillation, or atrial flutter?
Description

Didpatientexperienceanyofthefollowing:SVT,atrialfibrillation,oratrialflutter?

Data type

text

check all that apply
Description

checkallthatapply

Data type

text

Did patient experience prolonged QTc compared to baseline?
Description

DidpatientexperienceprolongedQTccomparedtobaseline?

Data type

text

check all that apply
Description

checkallthatapply

Data type

text

Was there a T wave inversion in leads II, III, AVF (inferior leads) or V4, V5, and V6 (lateral leads)?
Description

WasthereaTwaveinversioninleadsII,III,AVF(inferiorleads)orV4,V5,andV6(lateralleads)?

Data type

text

Was ST segment at the J-point greater than or equal to 2 mm below baseline in leads II, II AVF (inferior leads), V4, V5, V6 (lateral leads)?
Description

WasSTsegmentattheJ-pointgreaterthanorequalto2mmbelowbaselineinleadsII,IIAVF(inferiorleads),V4,V5,V6(lateralleads)?

Data type

text

Did patient experience ventricular arrhythmia?
Description

Didpatientexperienceventriculararrhythmia?

Data type

text

Ccrr Module For Advl0212- Review Form (dr. Chin)
Description

Ccrr Module For Advl0212- Review Form (dr. Chin)

Similar models

No Instruction available.

  1. StudyEvent: ADVL0212- Review Form (Dr. Chin)
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Unnamed1
DateofECG
Item
Date of ECG
text
Item
Did patient experience any of the following: SVT, atrial fibrillation, or atrial flutter?
text
Code List
Did patient experience any of the following: SVT, atrial fibrillation, or atrial flutter?
CL Item
Yes (Yes)
CL Item
No (No)
Item
check all that apply
text
Code List
check all that apply
CL Item
SVT (SVT)
CL Item
Atrial fibrillation (Atrial fibrillation)
CL Item
Atrial flutter (Atrial flutter)
Item
Did patient experience prolonged QTc compared to baseline?
text
Code List
Did patient experience prolonged QTc compared to baseline?
CL Item
Yes (Yes)
CL Item
No (No)
Item
check all that apply
text
Code List
check all that apply
CL Item
To greater than or equal to 480 msec (To greater than or equal to 480 msec)
CL Item
Increase of greater than or equal to 50 msec (Increase of greater than or equal to 50 msec)
CL Item
Increase by 15 % (Increase by 15 %)
Item
Was there a T wave inversion in leads II, III, AVF (inferior leads) or V4, V5, and V6 (lateral leads)?
text
Code List
Was there a T wave inversion in leads II, III, AVF (inferior leads) or V4, V5, and V6 (lateral leads)?
CL Item
Yes (Yes)
CL Item
No (No)
Item
Was ST segment at the J-point greater than or equal to 2 mm below baseline in leads II, II AVF (inferior leads), V4, V5, V6 (lateral leads)?
text
Code List
Was ST segment at the J-point greater than or equal to 2 mm below baseline in leads II, II AVF (inferior leads), V4, V5, V6 (lateral leads)?
CL Item
Yes (Yes)
CL Item
No (No)
Item
Did patient experience ventricular arrhythmia?
text
Code List
Did patient experience ventricular arrhythmia?
CL Item
Yes, change in VT (Yes, change in VT)
CL Item
Yes, change in VF (Yes, change in VF)
CL Item
Yes, change in both VT and VF (Yes, change in both VT and VF)
CL Item
No (No)
Item Group
Ccrr Module For Advl0212- Review Form (dr. Chin)

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