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  1. 1. Clinical Trial
  2. 2. Routine Documentation
  3. 3. Registry/Cohort Study
  4. 4. Quality Assurance
  5. 5. Data Standard
  6. 6. Patient-Reported Outcome
  7. 7. Medical Specialty
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REGIMS Multiple Sclerosis Immunotherapy Registry Version 2016 - Baseline Main Sheet

- 9/20/21 - 9 forms, 25 itemgroups, 116 items, 2 languages
Itemgroups: Ein-Ausschlusskriterien,Patientendaten,Krankheitsspezifische Angaben,EDSS-Score vor 12 Monaten,Heutige Scores der Funktionssysteme,Frühere verlaufsmodifizierende MS-Therapien,Aktuelle MS-Therapie,WeitereErkrankungen,Herz- / Kreislauferkrankungen,Stoffwechselerkrankungen,Infektionserkrankungen,Gastrointestinale Erkrankungen,Neurologische / Psychiatrische Erkrankungen,Allergien,Urogenitale Erkrankungen,Autoimmunerkrankungen,Blutbild / Labor,Allgemeine Symptome,Operation,Krebserkrankungen,Welche Therapien wurden aufgrund der Krebserkrankung durchgeführt?,Andere Erkrankung,Keine Vorerkrankungen aus diesen obigen Krankheitsgruppen/Erkrankungen bekannt,Schwangerschaft,Biologisches Material (z.B. Blut)
REGIMS is a registry of the administration, adverse events and benefit of immunotherapeutic agents in patients with Multiple Sclerosis. REGIMS is a project from the Institute of Epidemiology and Social Medicine of the University of Muenster, publication granted by Prof. Dr. Berger. For further information (in German), please view http://campus.uni-muenster.de/index.php?id=6075 or http://www.kompetenznetz-multiplesklerose.de/aktuelle-studien/regims. REGIMS ist ein Immuntherapieregister zur Verbesserung der Arzneimittelsicherheit in der Multiple Sklerose Therapie innerhalb des krankheitsbezogenen Kompetenznetzes MS. Das primäre Ziel von REGIMS ist die Erfassung der Häufigkeit, Charakteristika und Auswirkungen von Nebenwirkungen aktueller und neuer Immuntherapien in der klinischen Routinebehandlung der MS. Sekundäre Ziele sind die Auswertung von Faktoren, die a) mit Nebenwirkungen und b) mit guter Therapie-Adhärenz assoziiert sind. Optional können bei Zustimmung der Patienten Blutproben für die Biobank des KKNMS gesammelt werden. Patienten mit Multipler Sklerose (MS) weisen trotz des chronischen Verlaufs eine große Heterogenität klinischer Symptome, in Befunden der Bildgebung sowie pathophysiologischen Prozessen auf. Faktoren, die zur individuellen Krankheitsprognose beitragen sind kaum bekannt, jedoch hat die Einführung neuer Substanzen die Therapiemöglichkeiten der MS in den letzten Jahren deutlich erweitert. Die Anwendung sogenannter Immuntherapeutika (inklusive der neuen Substanzklasse der Biologika) bietet in der MS-Therapie eine Reihe von Chancen, birgt aber auch Risiken.

Baseline Pregnancy Part 1

25 itemgroups 116 items

Follow Up Main Sheet

25 itemgroups 116 items

Follow Up Medication Change

25 itemgroups 116 items

Quality assurance Follow-up Heart Transplant (AQUA) - Quality assurance Follow-up Liver Transplant (AQUA)

- 9/27/19 - 1 form, 2 itemgroups, 16 items, 2 languages
Itemgroups: Follow-up(auszufüllen nach 1, 2 und 3 Jahren),Überlebensstatus des Empfängers
Documentation form for quality assurance in German Health Care by the Institute for Applied Quality Improvement and Research in Health Care (Aqua), https://www.aqua-institut.de/en/home. Internal Aqua form version: HTXFU Specification 2015 V02

NCI Standard Adverse Event/Serious Adverse Event CTCAE v3 Template - 2748814v1.0 - NCI Standard Adverse Event/Serious Adverse Event CTCAE v3 Template

- 4/13/21 - 1 form, 4 itemgroups, 28 items, 1 language
Itemgroups: Mandatory Adverse Event Questions,Conditional Adverse Event Questions,Optional Adverse Event Questions,Optional Serious Adverse Event Questions
The collection of CDEs used in the Adverse Events/Serious Adverse Events module. Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=4D0BC7DD-57DD-63BE-E044-0003BA3F9857

Breast Cancer Adverse Event NCT00382070 - rade 2 and 3 Adverse Event Report Breast Cancer NCT00382070 NSABP B-42

- 9/20/21 - 1 form, 2 itemgroups, 9 items, 1 language
Itemgroups: Header,Adverse event
NSABP Protocol B-42 - Grade 2 and 3 Adverse Event (AE) Report Form Worksheet Letrozole in Treating Postmenopausal Women Who Have Received Hormone Therapy for Hormone Receptor-Positive Breast Cancer NCT00382070 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=17ADF05F-DB75-341D-E044-0003BA3F9857

CDASH Adverse Event - Adverse Event

- 3/9/20 - 1 form, 2 itemgroups, 18 items, 2 languages
Itemgroups: General information,Details Adverse Event
translated and modified from CDASH Adverse Event 2011-10-24 http://www.cdisc.org/

REGIMS - SUE Report

- 9/27/21 - 1 form, 10 itemgroups, 43 items, 2 languages
Itemgroups: SUE,Patientenangaben,SUE: Beschreibung,SUE: Behandlung,SUE: Ausgang,SUE: MS-Medikation,SUE: Begleitmedikation,SUE: Relevante Vorerkrankung / Sypmtome,Ergebnisse der relevanten Diagnostischen Untersuchungen,Kontaktdaten des Berichterstatters
Schwerwiegendes unerwünschtes Ereignis (SUE) in der Therapie SUE Berichtsformular Bitte ausfüllen und faxen oder senden an: Westfälische Wilhelms-Universität Münster, Institut für Epidemiologie und Sozialmedizin, Albert-Schweitzer-Campus 1, Gebäude 03, 48149 Münster Fax: (0251) 83-55300, E-Mail: regims@uni-muenster.de http://epi.uni-muenster.de

Effect of GSK958108 on ejaculatory latency time (ELT); NCT00861484 - Logs/Repeats

- 9/27/21 - 1 form, 12 itemgroups, 130 items, 1 language
Itemgroups: Date of visit, Assessment Date,Adverse Event; Concomitant Agent; Evaluation, Repeat,Liver, Adverse Event,Non-serious Adverse Event,Serious Adverse Event,Concomitant Agent,Laboratory Procedures,Urinalysis,Vital signs,12 lead ECG,12 lead ECG, Abnormality, Repeat,Pharmacokinetic aspect, Blood, Repeat
Study ID: 111155 Clinical Study ID: 111155 Study Title: A double blind, parallel group, placebo controlled study to evaluate the effect of a single oral dose of GSK958108 on ejaculatory latency time (ELT) in male patients suffering from premature ejaculation. Patient Level Data: Study Listed on ClinicalStudyDataRequest.com Clinicaltrials.gov Identifier: NCT00861484 Sponsor: GlaxoSmithKline Collaborators: N/A Phase: Phase 1 Study Recruitment Status: Completed Generic Name: GSK958108 , Placebo Trade Name: N/A Study Indication: Premature Ejaculation

Endpoint Hospitalisation for heart failure GSK study Chronic Coronary Heart Disease NCT00799903

- 9/20/21 - 1 form, 3 itemgroups, 43 items, 1 language
Itemgroups: Investigator section,CEC Section,CEC Status
Study ID: 100601 Clinical Study ID: LPL100601 Study Title: LPL100601, A Clinical Outcomes Study of Darapladib versus Placebo in Subjects with Chronic Coronary Heart Disease to Compare the Incidence of Major Adverse Cardiovascular Events (MACE) Patient Level Data: Study Listed on ClinicalStudyDataRequest.com Clinicaltrials.gov Identifier: NCT00799903 Sponsor: GlaxoSmithKline Collaborators: N/A Phase: phase 3 Study Recruitment Status: Completed Generic Name: darapladib Trade Name: darapladib Study Indication: Atherosclerosis Study part: Endpoint Hospitalisation for heart failure - Repeating form (Scheduled visits)

Safety, tolerance and preliminary pharmacokinetics of single ascending intravenous doses of halofantrine [SK&F 102886] in healthy male volunteers. - Administration, demographics, inclusion criteria, exclusion criteria, infusion details, ecg, alcohol/drug screening, baseline/advers events

- 9/20/21 - 1 form, 14 itemgroups, 86 items, 1 language
Itemgroups: Administration,Demographic Details,Volunteer Inclusion Criteria,Volunteer Exclusion Criteria,Infusion Details,ECG-Arrhythmia,Electrocardiography,Electrocardiography,Alcohol Screening (Blow test),Drug Screening (Urine),Baseline Events,Baseline Events,Adverse Events,Adverse Events
https://www.gsk-clinicalstudyregister.com/study/102886/003?search=study&study_ids=102886#csr Study ID : 102886/003 Clinical Study ID : 102886/003 Study Title :Safety, tolerance and preliminary pharmacokinetics of single ascending intravenous doses of halofantrine [SK&F 102886] in healthy male volunteers. Clinicaltrials.gov Identifier : Sponsor : GlaxoSmithKline Collaborators :N/A Phase :N/A Study Recruitment Status :Completed Generic Name :halofantrine Trade Name :Halfan Study Indication Malaria

GSK1034702 after Repeat Doses in Healthy Subjects; NCT00950586 - Logs and Repeats

- 9/20/21 - 1 form, 16 itemgroups, 156 items, 1 language
Itemgroups: Date of visit, Assessment Date,Adverse Event; Concomitant Agent; Evaluation, Repeat,Liver, Adverse Event,Non-serious Adverse Event,Serious Adverse Event,Concomitant Agent,Laboratory Procedures,Vital signs,Pharmacokinetic aspect, Blood, Repeat,Pulmonary function tests, Repeat,Holter Electrocardiography, Repeat,Holter Electrocardiography, Abnormality, Repeat,Telemetry, Repeat,Telemetry, Abnormality, Repeat,12 lead ECG, Abnormality, Repeat,12 lead ECG
Study ID: 110792 Clinical Study ID: 110792 Study Title: A placebo-controlled, single-blind, randomised study to investigate the safety, tolerability, pharmacokinetics and drug interaction of GSK1034702 after repeat doses in healthy subjects Patient Level Data: Study Listed on ClinicalStudyDataRequest.com Clinicaltrials.gov Identifier: NCT00950586 Sponsor: GlaxoSmithKline Collaborators: N/A Phase: Phase 1 Study Recruitment Status: Completed Generic Name: Dextromethorphan, Placebo Trade Name: N/A Study Indication: Cognitive Disorders

PART B - Period 1 - Day 1 - Ropinirole and the effect of food in early stage Parkinson’s disease subjects 101468/164

- 9/20/21 - 1 form, 18 itemgroups, 90 items, 1 language
Itemgroups: Note,Inclusion Criteria,Exclusion Criteria,Physical examination,Pregnancy test,Alcohol test,Urine drug screening,orthostatic blood pressure / Pulse - Predose,Concomitant medication,Adverse event,Patient diary,Randomization,High fat breakfast,Study Drug Dosing,Orthostatic blood pressure / pulse measurement - post dose,Adverse Event - post dosing,Pharmacokinetic sampling post dosing,Discharge
PART B - Period 1 - Day 1 - Ropinirole and the effect of food in early stage Parkinson’s disease subjects 101468/164 Study ID: 101468/164 Clinical Study ID: 101468/164 Study Title: An open-label, randomised, two part study to investigate the relative bioavailability of Ropinirole new and standard, marketed formulations and the effect of food on the pharmacokinetics of Ropinirole new formulation in early stage Parkinson’s disease subjects Patient Level Data: Study Listed on ClinicalStudyDataRequest.com Clinicaltrials.gov Identifier: Sponsor: GlaxoSmithKline Collaborators: N/A Phase: phase 1 Study Recruitment Status: Completed Generic Name: ropinirole Trade Name: Modutab,ZIPEREVE,ZEPREVE,REPREVE,ADARTREL,REQUIP,Zygara; Zygara,ZIPEREVE,ZEPREVE,Requip Depot,REQUIP,REPREVE,Modutab,ADARTREL Study Indication: Restless Legs Syndrome

Immune Persistence of GSK Biologicals' Combined Hepatitis A / Hepatitis B Vaccine in Healthy Adult Volunteers NCT00289718 - Long-Term Follow Up (Year 12, Visit 1) - Informed Consent; Demographics; General medical history/ Physical examination; Laboratory Tests; Blood sample conclusion; Vaccine Administration; Unsolicited Adverse Events; Solicited Adverse Events - Local and General Symptoms

- 9/20/21 - 1 form, 12 itemgroups, 101 items, 1 language
Itemgroups: Administration,Demographics,General Medical History / Physical Examination,Medical Condition,Laboratory Tests,HCG Urine Pregnancy Test,Blood Sample Conclusion,Vaccine Administration,Vaccine Administration,Unsolicited Adverse Events,Solicited Adverse Events - Local Symptoms,Solicited Adverse Events - General Symptoms
Study ID: 100556 (Y11) Clinical Study ID: 100556 Study Title: Long-Term Persistence Follow-up Study to Evaluate the Immune Persistence of GSK Biologicals' Combined Hepatitis A / Hepatitis B Vaccine in Healthy Adult Volunteers Patient Level Data: Study Listed on ClinicalStudyDataRequest.com Clinicaltrials.gov Identifier: NCT00289718 Sponsor: GlaxoSmithKline Phase: phase 3 Study Recruitment Status: Completed Generic Name: Hepatitis A (Inactivated), Hepatitis B (Recombinant) Vaccine Trade Name: Twinrix Study Indication: Hepatitis A; Hepatitis B

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