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1. Contact address (person who provides information. This information will be treated confidentially)?
Title
Mr.
Mrs.
Professor.
Associate professor
MD
MD/PHD
PHD
Name
*
First
Last
Address
Address Line 1
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State / Province / Region
Postal Code
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Telephone 1
*
Telephone 2
Email
*
2. What is the source of your information about human xenotransplantation practices?
Publication
Congress
Advertisement
Others
Could you please send a copy of your source of information to our office located at Sichuan Provincial people's hospital? (see Contact addresses)
If other, please specify
3. What is the therapeutic purpose of this xenotransplantation treatment?
a. Acute liver failure
b. Other end-stage liver diseases
c. Chronic cardiac failure
d. Chronic renal failure
e. Diabetes
f. Burns
g. Impotency
h. Neurological degenerative disorders
i. Others degenerative disorder
j. Other treatments
If other,please specify
4. Where and when is this human xenotransplantation practice taking place?
Country
Timing
Comment
5. Is this treatment part of a clinical trial?
*
Yes
No
Item #1 Yes
Item #1 No
6. What is the animal source of the xenotransplantation product?
i. Pig
ii. Non-human primate
iii. Rat
iv. Mouse
v. Others
If other,please specify
7. Source animals
*
Yes
No
Do you have information about source animals?
Do you have information about source animals? Yes
Do you have information about source animals? No
8. Testing of safety
*
Yes
No
Do you have information about testing of safety?
Do you have information about testing of safety? Yes
Do you have information about testing of safety? No
9. What type of cells was transplanted?
*
Hepatocytes
Islets of langerhans
Fetal islet like cell clusters
Purkinje cells
Neural precursors cells
Embryonic stem cells
Mesenchymal stem cells
Fetal sheep cells
Cells: Hepatocytes
Cells: Islets of langerhans
Cells: Fetal islet like cell clusters
Cells: Purkinje cells
Cells: Neural precursors cells
Cells: Embryonic stem cells
Cells: Mesenchymal stem cells
Cells: Fetal sheep cells
What type of tissues was transplanted?
*
Skin
Cardiac valves
Cells: Skin
Cells: Cardiac valves
What type of organs was transplanted?
*
Liver
Heart
Kidney
Pancreas
Lung
Small intestine
Cornea
Cells: Liver
Cells: Heart
Cells: Kidney
Cells: Pancreas
Cells: Lung
Cells: Small intestine
Cells: Cornea
If other,please specify
10. What type of exposure to xenogeneic cells was involved?
Yes
No
Solid-organ xenotransplantation:
Solid-organ xenotransplantation: Yes
Solid-organ xenotransplantation: No
Cellular xenotransplantation:
Cellular xenotransplantation: Yes
Cellular xenotransplantation: No
Tissue xenotransplantation:
Tissue xenotransplantation: Yes
Tissue xenotransplantation: No
Human cells exposed to xenogeneic Feeder cell:
Human cells exposed to xenogeneic Feeder cell: Yes
Human cells exposed to xenogeneic Feeder cell: No
Extracorporeal perfusion:
Extracorporeal perfusion: Yes
Extracorporeal perfusion: No
Encapsulation:
Encapsulation: Yes
Encapsulation: No
Other bioartificial isolation device:
Other bioartificial isolation device: Yes
Other bioartificial isolation device: No
If other,please specify
11. Transplant recipient
Yes
No
Do you have information about transplant recipients?
How are the transplant recipients being monitored for infections?
Which microbial agents have been tested in transplant recipients?
Has this microbiological testing been done by a registered laboratory?
Yes
No
if yes, which?
if not, by whom?
What testing methods were used?
Serological or culture assay testing
Immunohistopathology
Immunofluorescence
Radioimmunoassay
ELISA
PCR
Others
If other,please specify
What samples are taken and how often?
For how long will they continue to be taken?
For how long will they be stored?
How often is the patient seen for follow-up?
How long are the patients followed?
Location of the clinical follow-up examination:
Yes
No
In the same clinic?
if yes, which?
if no, where?
12. Have results been presented at a scientific congress?
Yes
No
if yes, where?
13. Have results been published in a scientific journal?
Yes
No
If yes, where? Could you please give the reference?
14. Is this human clinical trial performed with governmental and/or institutional oversight and supervision?
Yes
No
if yes, which?
15. Was the trial approved by a public health authorities(ministry of health, governmental agency...)?
Yes
No
if yes, which?
16.Was the trial overseen by a public health authorities(ministry of health, governmental agency...)?
Yes
No
if yes, which?
17. Comment
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