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  • GlobalSurg 3: PLEASE COMPLETE THIS FORM WITH THE DATA … · Underweight (BMI < 18.5) Normal weight (BMI 18.5 to 24.9) Overweight (BMI 25 to 30) Obese (BMI >30) Performance
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PATIENT (Form 1) Patient ID: _____________________________________ Method of identification __________________________ Age: ____________ (years) Sex: M / F / Unknown BMI: _____________ Weight loss ≥10%: _____________ Performance status: 0 / 1 / 2 / 3 / 4 / Unknown ASA: 1 / 2 / 3 / 4 / 5 / Unknown Smoking: No, never / Stopped >6 wks / Yes / Unknown Diabetes: No / Diet / Medication / Insulin / Unknown HIV tested: No / Yes, Negative / Yes, Positive Presentation: Symptomatic / Screening / Incidentally / Unknown Date of first consult: ____ / ____ / ____ (DD/MM/YY) Who did the patient first consult? _____________________________________________ Distance from home to hospital: _______________ km DISEASE & NEOADJUVANT TREATMENT (Form 2) Cancer type (circle): Breast / Gastric / Colorectal STAGING All patients Ultrasound scan: 0/1/2 /3/9 CT: 0/1/2 /3/9 MRI: 0/1/2 /3/9 Gastric or Colorectal cancer only Endoscopy/colonoscopy: 0/1/2 /3/9 Endoscopy/colonoscopy biopsy: 0/1/2 /3/9 Endoscopic/transanal ultrasound 0/1/2 /3/9 Staging laparoscopy: 0/1/2 /3/9 Breast cancer only Mammogram: 0/1/2 /3/9 Fine needle aspiration: 0/1/2 /3/9 Core biopsy: 0/1/2 /3/9 Open biopsy : 0/1/2 /3/9 Receptor status on pre-op biopsy: ER: 0/1/2 /3/9 PR: 0/1/2 /3/9 HER2: 0/1/2 /3/9 Ki-67: 0/1/2 /3/9 All patients Clinical TNM: T1/T2 /T3/T4 | N0/N1/N2/N3 | M0/M1 Essential TNM (Gastric / Colon): M+ / R+ / A / L Essential TNM (Breast): M+ / R2 / R1/ A / L2 / L1 Neoadjuvant therapy:_____________________________ GlobalSurg 3: Quality and outcomes in global cancer surgery Short Data Collection Form globalsurg.org/gs3 PLEASE COMPLETE THIS FORM WITH THE DATA DICTIONARY FOR REFERENCE OPERATION (Form 3) Admission date: ____ / ____ / ____ (DD/MM/YY) ____:____ (24H) Knife to skin: ____ / ____ / ____ (DD/MM/YY) ____:____ (24H) Urgency: Elective / Emergency Intent of operation: Palliative / Curative Checklist used?: No, not available / No, available / Yes / Unknown Primary operation: _______________________________ Breast cancer only Sentinel lymph node biopsy: _______________________ Axillary lymph node dissection: _____________________ Resection margins checked at surgery: _______________ Reconstruction: _________________________________ Gastric or Colorectal cancer only Operative approach: _____________________________ Site: __________________________________________ Anastomosis: ___________________________________ Obstruction: ____________ Perforation: _____________ Gastric cancer only D2 lymphadenectomy: ____________________________ Colorectal cancer only Stoma formed: (if yes, what type) ___________________ 0. No, not available in this hospital 1. No, not indicated 2. No, indicated and available, but patient not able to pay 3. Yes 9. Unknown 0. No, not available in this hospital 1. No, but available in this hospital 2. Yes, NEGATIVE result 3. Yes, POSTIIVE result 9. Unknown Note to users: This form is patient-identifiable information and should be kept in a secure location, then destroyed appropriately once data uploaded onto REDCap

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Page 1: GlobalSurg 3: PLEASE COMPLETE THIS FORM WITH THE DATA … · Underweight (BMI < 18.5) Normal weight (BMI 18.5 to 24.9) Overweight (BMI 25 to 30) Obese (BMI >30) Performance

PATIENT(Form1)PatientID:_____________________________________Methodofidentification__________________________Age:____________(years)Sex:M/F/UnknownBMI:_____________Weightloss≥10%:_____________Performancestatus: 0/1/2/3/4/UnknownASA: 1/2/3/4/5/UnknownSmoking:No,never/Stopped>6wks/Yes/UnknownDiabetes:No/Diet/Medication/Insulin/UnknownHIVtested: No/Yes,Negative/Yes,PositivePresentation:Symptomatic/Screening/Incidentally/UnknownDateoffirstconsult:____/____/____(DD/MM/YY)Whodidthepatientfirstconsult?_____________________________________________Distancefromhometohospital:_______________km

DISEASE&NEOADJUVANTTREATMENT(Form2)

Cancertype(circle): Breast/Gastric/ColorectalSTAGINGAllpatientsUltrasoundscan: 0/1/2/3/9CT: 0/1/2/3/9MRI: 0/1/2/3/9GastricorColorectalcanceronlyEndoscopy/colonoscopy: 0/1/2/3/9Endoscopy/colonoscopybiopsy: 0/1/2/3/9Endoscopic/transanalultrasound 0/1/2/3/9Staginglaparoscopy: 0/1/2/3/9BreastcanceronlyMammogram: 0/1/2/3/9Fineneedleaspiration: 0/1/2/3/9Corebiopsy: 0/1/2/3/9Openbiopsy: 0/1/2/3/9Receptorstatusonpre-opbiopsy:ER: 0/1/2/3/9PR: 0/1/2/3/9 HER2: 0/1/2/3/9 Ki-67: 0/1/2/3/9 AllpatientsClinicalTNM:T1/T2/T3/T4|N0/N1/N2/N3|M0/M1EssentialTNM(Gastric/Colon):M+/R+/A/LEssentialTNM(Breast): M+/R2/R1/A/L2/L1Neoadjuvanttherapy:_____________________________

GlobalSurg3:Qualityandoutcomesinglobalcancersurgery

ShortDataCollectionForm

globalsurg.org/gs3

PLEASECOMPLETETHISFORMWITHTHEDATADICTIONARYFORREFERENCE

OPERATION(Form3)Admissiondate:____/____/____(DD/MM/YY)____:____(24H)Knifetoskin:____/____/____(DD/MM/YY)____:____(24H)Urgency: Elective/EmergencyIntentofoperation: Palliative/CurativeChecklistused?:

No,notavailable/No,available/Yes/UnknownPrimaryoperation:_______________________________BreastcanceronlySentinellymphnodebiopsy:_______________________Axillarylymphnodedissection:_____________________Resectionmarginscheckedatsurgery:_______________Reconstruction:_________________________________GastricorColorectalcanceronlyOperativeapproach:_____________________________Site:__________________________________________Anastomosis:___________________________________Obstruction:____________Perforation:_____________GastriccanceronlyD2lymphadenectomy:____________________________ColorectalcanceronlyStomaformed:(ifyes,whattype)___________________

0.No,notavailableinthishospital1.No,notindicated2.No,indicatedandavailable,butpatientnotabletopay3.Yes9.Unknown

0.No,notavailableinthishospital1.No,butavailableinthishospital2.Yes,NEGATIVEresult3.Yes,POSTIIVEresult9.Unknown

Notetousers:Thisformispatient-identifiableinformationandshouldbekeptinasecurelocation,thendestroyedappropriatelyoncedatauploadedontoREDCap

Page 2: GlobalSurg 3: PLEASE COMPLETE THIS FORM WITH THE DATA … · Underweight (BMI < 18.5) Normal weight (BMI 18.5 to 24.9) Overweight (BMI 25 to 30) Obese (BMI >30) Performance

PATHOLOGY(Form4)AllpatientsMostvalidbasisforcancerdiagnosis:_______________________________________________Histology:______________________________________Sizeofinvasivetumour:_________________________cmPathologicalTstage(pT):T1/T2/T3/T4(a/b/c/d)/TisLymphnodesPathologicalNstage(pN):N0/N1/N2NumberINVOLVEDinspecimen:____________________TOTALnumberinspecimen:_______________________Histologicalgrade: 1/2/3/4Lymphaticorvascularinvasion:No/Yes/UnknownGastricorColorectalcanceronlyResectionmargin: R0/R1/R2ColorectalcanceronlyPerineuralinvasion: No/Yes/UnknownCircumferentialresectionmargin:_______________mmBreastcanceronlyMargin:_______________________________________Receptorstatusonpathologicalspecimen:ER: 0/1/2/3/9PR: 0/1/2/3/9 Ki-67: 0/1/2/3/9BreastandgastriccanceronlyHER2: 0/1/2/3/9

OUTCOMES&ADJUVANTTREATMENT(Form5)

FOLLOW-UPLengthofstay:_________days(firstdayaftersurgery=1)30-dayfollow-upmethod:________________________30-daymortality: Alive/Died/UnknownDateofdeath:______/______/_______(DD/MM/YY)COMPLICATIONSMinorcomplication(CD1):No/Yes/UnknownMinorcomplication(CD2):No/Yes/UnknownReintervention(unplanned)(CD3):No/Yes(noGA)/Yes(GA)/UnknownCriticalcareadmission(unplanned)(CD4):No/Yes(singleorgan)/Yes(multiorgan)/UnknownHospitalre-admission(unplanned):No/Yes/UnknownSPECIFICCOMPLICATIONSSSI: 0/1/2/3/4/5/9Post-opbleed:

0/1/2/3/4/5/9BreastcanceronlyPost-opseroma:

0/1/2/3/4/5/9GastricorColorectalcanceronlyAnastomoticleak: 0/1/2/3/4/5/9Intra-abdominalabscess: 0/1/2/3/4/5/9

AllpatientsAdjuvanttreatmentplanned:______________________

NotesDonotuse“Unknown”,pleasefindout!MostvalidbasisofcancerdiagnosisClinicalonlyImagingExploratorysurgery/endoscopynohistologyTumourspecificmarkersCytologyHistologyofmetastasis/secondaryHistologyofprimary/biopsyEssentialTNMBreast Gastric/Colorectal

0.No,notavailableinthishospital1.No,butavailableinthishospital2.Yes,NEGATIVEresult3.Yes,POSTIIVEresult9.Unknown

0,No1,Yes,ClavienDindo12,Yes,ClavienDindo23,Yes,ClavienDindo34,Yes,ClavienDindo45,Yes,ClavienDindo59,Unknown

BMI:Weight(kg)/height2(metres)Underweight(BMI<18.5)Normalweight(BMI18.5to24.9)Overweight(BMI25to30)Obese(BMI>30)

Performancestatus0,Fullyactive1,Restrictedinstrenuousactivityonly2,Ambulatory&capableofallselfcare3,Capableofonlylimitedselfcare4,Completelydisabled9,Unknown

ASA1,normal/healthy2,mildsystemicdisease3,severesystemicdisease4,severesystemicdisease,constantthreattolife5,notexpectedtosurvivewithouttheoperation9,Unknown

Whodidpatientfirstconsult?Localclinic:familydoctorLocalclinic:nurseLocalclinic:specialistdoctorHospital:out-patientclinicHospital:in-patientOther/nonmedicalhealerUnknown

30-dayfollow-upmethodStillinpatientClinicreviewTelephonereviewCommunity/homereviewDischargedbefore30daysandnotcontactedagain

Notetousers:Thisformispatient-identifiableinformationandshouldbekeptinasecurelocation,thendestroyedappropriatelyoncedatauploadedontoREDCap


目 錄 - country.org.tw · BMI(Body Mass Index，身體質量指數) = 體重（公斤）／身高2（公尺2） 正常範圍 18.5≦BMI﹤24 體重過重 24≦BMI﹤27 輕度肥胖

GlobalSurg Collaborative NIHR Unit on Global …...GlobalSurg 3 全球癌症外科手術品質與結果：國際性前瞻性佇列研究 GlobalSurg Collaborative NIHR Unit on Global

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Home Page - Dr Alice Boyes › Next-Magazine-Body-Image.pdf · 2.89 (1 -7m x 17m) = 22.5. A BMI below 18.5 indicates you are underweight. For NZ Europeans a BMI over 25 is classed

2016-2017 for Wellness...2016-2017 Rewards for Wellness Details for upcoming programs BMI ranges Classification Less than 18.5 Underweight 18.5 – 24.9 Healthy weight 25.0 – 29.9

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Internal validity, dimensionality and performance of the ... · (BMI between 18.5-24.9); overweight (BMI between 25.0-29.9); obese (BMI ≥ 30)8,9. 3. Procedures The BSQ was adapted

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lindice di massa corporea (Body Mass Index -BMI) esprime ... - 1... · Indice di massa corporea Sottopeso < 18.5 Normale 18.5 – 24.9 Sovrappeso 25 – 29.9 Obesità > 30 •

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SBEW POWER PRESS-FRONT BACKimg.tradeindia.com/fm/249033/1048946.pdf · 2015. 8. 6. · Motor power kW 5.5 7.5 11 11 15 15 18.5 18.5 18.5 18.5 18.5 Volume of oil tank Lts 180 260 320

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Barnsley Clinical Commissioning Group … › CCG Downloads › strategies...has suffered trauma to the breast during or after development and has a BMI within the range 18.5 - 27

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