Questionnaire for data collection – Human Xenotransplant

1. Contact address(Person who provides information. This information will be treated confidentially)?

Title

Name *

前一页

后一页

Address

Address Line 1

City

State / Province / Region

Postal Code

Country

Institution

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 University Hospital Geneva? (see Contact addresses)

If other,please specify

3. What is the therapeutic purpose of this xenotransplantation treatment?

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?

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?

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