CL Item
Negative (Negative )
CL Item
Positive (Positive )
CL Item
Not evaluated (Not evaluated )
CL Item
Unknown (Unknown)
Item
HIV ANTIGENS (if testing applicable)
text
Code List
HIV ANTIGENS (if testing applicable)
CL Item
Negative (Negative )
CL Item
Positive (Positive )
CL Item
Not evaluated (Not evaluated )
CL Item
Unknown (Unknown)
CL Item
Negative (Negative )
CL Item
Positive (Positive )
CL Item
Not evaluated (Not evaluated )
CL Item
Unknown (Unknown)
CL Item
Negative (Negative )
CL Item
Positive (Positive )
CL Item
Not evaluated (Not evaluated )
CL Item
Unknown (Unknown)
CL Item
Negative (Negative )
CL Item
Positive (Positive )
CL Item
Not evaluated (Not evaluated )
CL Item
Unknown (Unknown)
Item
HBVs ANTIGENS (if testing applicable)
text
Code List
HBVs ANTIGENS (if testing applicable)
CL Item
Negative (Negative )
CL Item
Positive (Positive )
CL Item
Not evaluated (Not evaluated )
CL Item
Unknown (Unknown)
CL Item
Negative (Negative )
CL Item
Positive (Positive )
CL Item
Not evaluated (Not evaluated )
CL Item
Unknown (Unknown)
CL Item
Negative (Negative )
CL Item
Positive (Positive )
CL Item
Not evaluated (Not evaluated )
CL Item
Unknown (Unknown)
Item
HBVe ANTIGENS (if testing applicable)
text
Code List
HBVe ANTIGENS (if testing applicable)
CL Item
Negative (Negative )
CL Item
Positive (Positive )
CL Item
Not evaluated (Not evaluated )
CL Item
Unknown (Unknown)
CL Item
Negative (Negative)
CL Item
Positive (Positive)
CL Item
Not evaluated (Not evaluated )
CL Item
Unknown (Unknown)
Item
HCV ANTIGENS (if testing applicable)
text
Code List
HCV ANTIGENS (if testing applicable)
CL Item
Negative (Negative)
CL Item
Positive (Positive)
CL Item
Not evaluated (Not evaluated )
CL Item
Unknown (Unknown)
CL Item
Negative (Negative )
CL Item
Positive (Positive )
CL Item
Not evaluated (Not evaluated )
CL Item
Unknown (Unknown)
CL Item
Negative (Negative )
CL Item
Positive (Positive )
CL Item
Not evaluated (Not evaluated )
CL Item
Unknown (Unknown)
Item
if other Antibodies in the patient
text
Code List
if other Antibodies in the patient
CL Item
Negative (Negative )
CL Item
Positive (Positive )
CL Item
Specify (Specify)
Item
PRE-TRANSPLANT HISTORY OF DOCUMENTED INVASIVE FUNGAL INFECTION SINCE INITIAL DIAGNOSIS
text
Code List
PRE-TRANSPLANT HISTORY OF DOCUMENTED INVASIVE FUNGAL INFECTION SINCE INITIAL DIAGNOSIS
CL Item
Unknown (Unknown)
CL Item
Unknown (Unknown)
CL Item
Unknown (Unknown)
Item
Pneumocystis carinii
text
Code List
Pneumocystis carinii
CL Item
Unknown (Unknown)
Other
Item
if yes, please specify
text
Multiple donors
Item
Multiple donors
boolean
Number of donors or different stem cell products of same donor or cord blood units
Item
Number of donors or different stem cell products of same donor or cord blood units Make as many copies of the DONOR and HISTOCOMPATIBILITY sections as there are donors. Complete all of them and include them all in your report. For each donor Indicate in all pages their number in the infusion order and their Donor ID if known
float
Item
SOURCE OF STEM CELLS FOR THIS DONOR/PRODUCT Tick only one. If same donor has donated stem cells from more than one source, fill the information under a separate donor form
text
Code List
SOURCE OF STEM CELLS FOR THIS DONOR/PRODUCT Tick only one. If same donor has donated stem cells from more than one source, fill the information under a separate donor form
CL Item
Bone marrow (Bone marrow)
CL Item
Peripheral blood (Peripheral blood)
CL Item
Cord blood (Cord blood)
Identification of Donor or Cord Blood Unit given by the centre
Item
Identification of Donor or Cord Blood Unit given by the centre (can be the family relation if a related donor; if unrelated donor use the ID provided by the Donor Registry)
text
Number in the infusion order
Item
Number in the infusion order (if multiple donors or stem cell products)
text
Item
Number in the infusion order
text
Code List
Number in the infusion order
CL Item
Not applicable (Not applicable)
Item
HLA MATCH TYPE (DONOR RELATION WITH PATIENT)
text
Code List
HLA MATCH TYPE (DONOR RELATION WITH PATIENT)
CL Item
HLA-identical sibling (may include non-monozygotic twin) (HLA-identical sibling (may include non-monozygotic twin))
CL Item
Syngeneic (monozygotic twin) (Syngeneic (monozygotic twin))
CL Item
HLA-matched other relative (HLA-matched other relative)
CL Item
HLA-mismatched relative:Degree of allele mismatch (HLA-mismatched relative:Degree of allele mismatch)
CL Item
1 HLA antigen mismatch ALLMISRL (1 HLA antigen mismatch ALLMISRL)
CL Item
> 2 HLA antigen mismatch (> 2 HLA antigen mismatch)
CL Item
Unrelated donor (Unrelated donor)
Name of the Donor registry
Item
Name of the Donor registry
text
BMDW / WMDA code for the donor registry (up to 4 characters)
Item
BMDW / WMDA code for the donor registry (up to 4 characters) (This information can be found in http://www.bmdw.org under “Participating Registries”)
text
Identification of Donor or Cord Blood Unit given by the donor registry
Item
Identification of Donor or Cord Blood Unit given by the donor registry
text
Name of the Cord blood bank
Item
Name of the Cord blood bank
text
Eurocord code for the cord blood bank
Item
Eurocord code for the cord blood bank
text
Identification of Cord Blood Unit given by the cord blood bank
Item
Identification of Cord Blood Unit given by the cord blood bank
text
CL Item
Negative (Negative )
CL Item
Positive (Positive )
CL Item
Not evaluated (Not evaluated )
CL Item
Unknown (Unknown)
Item
HIV ANTIGENS (if testing applicable)
text
Code List
HIV ANTIGENS (if testing applicable)
CL Item
Negative (Negative )
CL Item
Positive (Positive )
CL Item
Not evaluated (Not evaluated )
CL Item
Unknown (Unknown)
CL Item
Negative (Negative )
CL Item
Positive (Positive )
CL Item
Not evaluated (Not evaluated )
CL Item
Unknown (Unknown)
CL Item
Negative (Negative )
CL Item
Positive (Positive )
CL Item
Not evaluated (Not evaluated )
CL Item
Unknown (Unknown)
CL Item
Negative (Negative )
CL Item
Positive (Positive )
CL Item
Not evaluated (Not evaluated )
CL Item
Unknown (Unknown)
Item
HBVs ANTIGENS (if testing applicable)
text
Code List
HBVs ANTIGENS (if testing applicable)
CL Item
Negative (Negative )
CL Item
Positive (Positive )
CL Item
Not evaluated (Not evaluated )
CL Item
Unknown (Unknown)
CL Item
Negative (Negative )
CL Item
Positive (Positive )
CL Item
Not evaluated (Not evaluated )
CL Item
Unknown (Unknown)
CL Item
Negative (Negative )
CL Item
Positive (Positive )
CL Item
Not evaluated (Not evaluated )
CL Item
Unknown (Unknown)
Item
HBVe ANTIGENS (if testing applicable)
text
Code List
HBVe ANTIGENS (if testing applicable)
CL Item
Negative (Negative )
CL Item
Positive (Positive )
CL Item
Not evaluated (Not evaluated )
CL Item
Unknown (Unknown)
CL Item
Negative (Negative)
CL Item
Positive (Positive)
CL Item
Not evaluated (Not evaluated )
CL Item
Unknown (Unknown)
Item
HCV ANTIGENS (if testing applicable)
text
Code List
HCV ANTIGENS (if testing applicable)
CL Item
Negative (Negative)
CL Item
Positive (Positive)
CL Item
Not evaluated (Not evaluated )
CL Item
Unknown (Unknown)
CL Item
Negative (Negative )
CL Item
Positive (Positive )
CL Item
Not evaluated (Not evaluated )
CL Item
Unknown (Unknown)
CL Item
Negative (Negative )
CL Item
Positive (Positive )
CL Item
Not evaluated (Not evaluated )
CL Item
Unknown (Unknown)
Item
if other Antibodies in the patient
text
Code List
if other Antibodies in the patient
CL Item
Negative (Negative )
CL Item
Positive (Positive )
CL Item
Specify (Specify)
Date of harvest or cord blood collection
Item
Date of harvest or cord blood collection
date
Item
GROWTH FACTORS ADMINISTERED TO THE DONOR
text
Code List
GROWTH FACTORS ADMINISTERED TO THE DONOR
CL Item
Unknown (Unknown)
GROWTH FACTORS ADMINISTERED TO THE DONOR
Item
If Yes, please specify
text
Laboratory / Hospital
Item
Laboratory / Hospital
text
Contact number
Item
Contact number (telephone/fax)
text
Technique Used
Item
Technique Used
text
Serology (antigenic) HLA typing done
Item
Serology (antigenic) HLA typing done
boolean
DNA (Allelic/molecular) HLA typing done
Item
DNA (Allelic/molecular) HLA typing done
boolean
Item
DNA (Allelic/molecular) HLA typing done
text
Code List
DNA (Allelic/molecular) HLA typing done
HLA string
Item
HLA string
text
NMDP code
Item
NMDP code
text
NMDP code
Item
NMDP code
boolean
NMDP code
Item
NMDP code
boolean
Item
Serology (antigenic) HLA typing done
text
Code List
Serology (antigenic) HLA typing done
CL Item
Not evaluated (Not evaluated)
CL Item
Not evaluated (Not evaluated)
Identification of donor or Cord Blood Unit given by the centre
Item
IF MULTIPLE DONORS Identification of donor or Cord Blood Unit given by the centre (please, use same ID as in the preceding sheets)
text
Number in the infusion order
Item
Number in the infusion order (if applicable)
text
C0237753 (UMLS CUI [1])
Item
GRAFT MANIPULATION EX-VIVO (INCLUDING T-CELL DEPLETION)
text
Code List
GRAFT MANIPULATION EX-VIVO (INCLUDING T-CELL DEPLETION)
Item
NEGATIVE SELECTION
text
Code List
NEGATIVE SELECTION
CL Item
Unknown (Unknown)
Item
if negative selection
text
Code List
if negative selection
CL Item
T-cell depletion by MoAB (do not enter "Campath in bag" here) (T-cell depletion by MoAB (do not enter "Campath in bag" here) )
CL Item
B-cell depletion by MoAB (B-cell depletion by MoAB )
CL Item
NK cell depletion by MoAB (NK cell depletion by MoAB )
CL Item
Elutriation (Elutriation )
Item
if positive selection
text
Code List
if positive selection
CL Item
Yes: Monoclonal antibodies (Yes: Monoclonal antibodies)
CL Item
unknown (unknown)
Item
Monoclonal antibodies
text
Code List
Monoclonal antibodies
CL Item
Unknown (Unknown)
Monoclonal antibodies
Item
if other, please specify
text
CL Item
Unknown (Unknown)
Item
GENE MANIPULATION (gene transfer/transduction)
text
Code List
GENE MANIPULATION (gene transfer/transduction)
CL Item
Unknown (Unknown)
Identification of donor or Cord Blood Unit given by the centre
Item
IF MULTIPLE DONORS: Identification of donor or Cord Blood Unit given by the centre (please, use same ID as in the preceding sheets)
text
Number in the infusion order
Item
Number in the infusion order (if applicable)
text
C0237753 (UMLS CUI [1])
Item
CELL INFUSION METHOD Fill in for Cord Blood HSCT only
text
Code List
CELL INFUSION METHOD Fill in for Cord Blood HSCT only
CL Item
Intravenous (IV) (Intravenous (IV))
CL Item
intrabone / intramedullary (intrabone / intramedullary)
CL Item
Other, specify (Other, specify)
CL Item
unknown (unknown)
Route of infusion
Item
If other, please specify
text
Item
Infusion method
text
Code List
Infusion method
CL Item
Wash (Rubinstein/New York) (Wash (Rubinstein/New York))
CL Item
Other, specify (Other, specify)
Infusion method
Item
if other, please specify
text
Item
Tests performed after thawing of an aliquot on
text
Code List
Tests performed after thawing of an aliquot on
CL Item
Contiguous segment (Contiguous segment )
CL Item
Reference bag (Reference bag )
CL Item
unknown (unknown)
CL Item
Acridine orange-ethidium iodide (Acridine orange-ethidium iodide)
CL Item
Tryptan blue (Tryptan blue)
CL Item
Other, specify (Other, specify)
CL Item
Acridine orange-ethidium bromide (Acridine orange-ethidium bromide)
CL Item
unknown (unknown)
Method used
Item
if other, please specify
text
Viability of all cells
Item
Viability of all cells
float
Viability of CD34+ cells
Item
Viability of CD34+ cells
float
Bone Marrow
Item
Total number of cells actually infused Nucleated cells (/kg*)
float
Item
Total number of cells actually infused Nucleated cells (/kg*)
text
Code List
Total number of cells actually infused Nucleated cells (/kg*)
CL Item
Not evaluated (Not evaluated )
CL Item
unknown (unknown)
Bone Marrow
Item
Total number of cells actually infused CD 34+ (cells/kg*)
float
Item
Total number of cells actually infused CD 34+ (cells/kg*)
text
Code List
Total number of cells actually infused CD 34+ (cells/kg*)
CL Item
Not evaluated (Not evaluated )
CL Item
unknown (unknown)
Bone Marrow
Item
Total number of cells actually infused T-cells (CD 3+) (cells/kg*)
float
Item
Total number of cells actually infused T-cells (CD 3+) (cells/kg*)
text
Code List
Total number of cells actually infused T-cells (CD 3+) (cells/kg*)
CL Item
Not evaluated (Not evaluated )
CL Item
unknown (unknown)
Peripheral Blood
Item
Total number of cells actually infused Nucleated cells (/kg*)
float
Item
Total number of cells actually infused Nucleated cells (/kg*)
text
Code List
Total number of cells actually infused Nucleated cells (/kg*)
CL Item
Not evaluated (Not evaluated )
CL Item
unknown (unknown)
Peripheral Blood
Item
Total number of cells actually infused CD 34+ (cells/kg*)
float
Item
Total number of cells actually infused CD 34+ (cells/kg*)
text
Code List
Total number of cells actually infused CD 34+ (cells/kg*)
CL Item
Not evaluated (Not evaluated )
CL Item
unknown (unknown)
Peripheral Blood
Item
Total number of cells actually infused T-cells (CD 3+) (cells/kg*)
float
Item
Total number of cells actually infused T-cells (CD 3+) (cells/kg*)
text
Code List
Total number of cells actually infused T-cells (CD 3+) (cells/kg*)
CL Item
Not evaluated (Not evaluated )
CL Item
unknown (unknown)
Cord Blood
Item
Total number of cellsactually infused Nucleated cells (/kg*)
float
Item
Total number of cellsactually infused Nucleated cells (/kg*)
text
Code List
Total number of cellsactually infused Nucleated cells (/kg*)
CL Item
Not evaluated (Not evaluated )
CL Item
unknown (unknown)
Cord Blood
Item
Total number of cellsactually infused CD 34+ (cells/kg*)
float
Item
Total number of cellsactually infused CD 34+ (cells/kg*)
text
Code List
Total number of cellsactually infused CD 34+ (cells/kg*)
CL Item
Not evaluated (Not evaluated )
CL Item
unknown (unknown)
Cord Blood
Item
Total number of cells actually infused T-cells (CD 3+) (cells/kg*)
float
Item
Total number of cells actually infused T-cells (CD 3+) (cells/kg*)
text
Code List
Total number of cells actually infused T-cells (CD 3+) (cells/kg*)
CL Item
Not evaluated (Not evaluated )
CL Item
unknown (unknown)
Chronological number of HSCT for this patient
Item
Chronological number of HSCT for this patient
integer
CL Item
Previous HSCT(s) autologous (Previous HSCT(s) autologous)
Date of previous HSCT
Item
Date of previous HSCT
date
Item
Type of previous HSCT
text
Code List
Type of previous HSCT
Item
Reason for this transplant
text
Code List
Reason for this transplant
CL Item
Relapse/progression after previous HSCT (Relapse/progression after previous HSCT)
CL Item
Graft failure after allo BMT (Graft failure after allo BMT)
Reason for this transplant
Item
if other, please specify
text
Item
HSCT part of a multiple sequential graft protocol
text
Code List
HSCT part of a multiple sequential graft protocol
CL Item
Unknown (Unknown)
Type of multiple graft protocol
Item
Type of multiple graft protocol
text
Graft number in the protocol
Item
Graft number in the protocol
integer
total number of HSCTs in the program
Item
total number of HSCTs in the program
integer
PREPARATIVE (CONDITIONING) REGIMEN GIVEN
Item
PREPARATIVE (CONDITIONING) REGIMEN GIVEN
boolean
Item
Was regimen intended to be myeloablative
text
Code List
Was regimen intended to be myeloablative
CL Item
Unknown (Unknown)
Item
Main reason (tick only one)
text
Code List
Main reason (tick only one)
CL Item
Age of recipient (Age of recipient)
CL Item
Comorbid conditions (Comorbid conditions)
CL Item
Prior HSCT (Prior HSCT)
CL Item
Protocol driven (Protocol driven)
CL Item
Other, specify (Other, specify)
Reason not myeloablative
Item
Age of recipient
boolean
Reason not myeloablative
Item
Comorbid conditions
boolean
Reason not myeloablative
Item
Prior HSCT
boolean
Reason not myeloablative
Item
Protocol driven
boolean
Reason not myeloablative
Item
If other additional reason, please specify
text
Item
Drugs (include any active agent be it chemo, monoclonal antibody, polyclonal antibody, serotherapy, etc.) NOTE: ONLY AGENTS GIVEN BEFORE THE DATE OF THE 1ST CELL INFUSION (DAY 0) SHOULD BE LISTED HERE
text
Code List
Drugs (include any active agent be it chemo, monoclonal antibody, polyclonal antibody, serotherapy, etc.) NOTE: ONLY AGENTS GIVEN BEFORE THE DATE OF THE 1ST CELL INFUSION (DAY 0) SHOULD BE LISTED HERE
CL Item
Unknown (Unknown)
NAME OF DRUG
Item
NAME OF DRUG
text
PRESCRIBED CUMULATIVE DOSE AS PER PROTOCOL (DAILY DOSE BY NUMBER OF DAYS)
Item
PRESCRIBED CUMULATIVE DOSE AS PER PROTOCOL (DAILY DOSE BY NUMBER OF DAYS)
text
Item
IF MONOCLONAL ANTIBODY, RADIO LABELLED?
integer
Code List
IF MONOCLONAL ANTIBODY, RADIO LABELLED?
Item
UNITS IF NOT RADIO LABELLED*
integer
Code List
UNITS IF NOT RADIO LABELLED*
Item
UNITS IF RADIO LABELLED
integer
Code List
UNITS IF RADIO LABELLED
ADDITIONAL DRUG INFORMATION
Item
If the dose units you need are not listed, please write them on the side For Busulphan
text
Item
Route of administration
text
Code List
Route of administration
Item
Animal origin For ALG, ATG (ALS, ATS):
text
Code List
Animal origin For ALG, ATG (ALS, ATS):
CL Item
Other, specify (Other, specify)
Animal origin
Item
if other, please specify
text
Item
TBI (If yes, complete TBI Form)
text
Code List
TBI (If yes, complete TBI Form)
CL Item
Unknown (Unknown)
Total dose (Gy)
Item
Total dose (Gy)
float
Number of fractions
Item
Number of fractions
float
radiation days
Item
radiation days
integer
Item
TLI / TNI / TAI
text
Code List
TLI / TNI / TAI
CL Item
Unknown (Unknown)
Total dose (Gy)
Item
Total dose (Gy)
float
Item
Local radiotherapy
text
Code List
Local radiotherapy
CL Item
Unknown (Unknown)
Item
GROWTH FACTORS (CYTOKINES) (excluding growth factors administered for engraftment failure)
text
Code List
GROWTH FACTORS (CYTOKINES) (excluding growth factors administered for engraftment failure)
GROWTH FACTORS (CYTOKINES)
Item
If yes, please specify
text
Date started
Item
Date started
date
Item
CELLULAR THERAPY
text
Code List
CELLULAR THERAPY
CL Item
Unknown (Unknown)
Date of first infusion
Item
Date of first infusion (can be the same as HSCT date)
date
Item
CELLULAR THERAPY if yes
integer
Code List
CELLULAR THERAPY if yes
CL Item
Donor lymphocyte infusion (DLI) (only lymphocytes from same donor(s) as HSCT) (Donor lymphocyte infusion (DLI) (only lymphocytes from same donor(s) as HSCT))
CL Item
Mesenchymal cells (Mesenchymal cells)
CL Item
Unknown (Unknown)
CELLULAR THERAPY
Item
if other, please specify
text
All cells (cells/kg*)
Item
All cells (cells/kg*) (non DLI only)
float
Item
All cells (cells/kg*) (non DLI only)
integer
Code List
All cells (cells/kg*) (non DLI only)
CL Item
Not evaluated (Not evaluated)
CL Item
unknown (unknown)
Chronological number of this cell therapy for this patient
Item
Chronological number of this cell therapy for this patient
integer
Item
Indication (check all that apply)
text
Code List
Indication (check all that apply)
CL Item
Planned/protocol (Planned/protocol )
CL Item
Treatment for disease (Treatment for disease)
CL Item
Loss/decreased chimaerism (Loss/decreased chimaerism )
CL Item
Mixed chimaerism (Mixed chimaerism)
CL Item
Treatment of GvHD (Treatment of GvHD )
CL Item
Treatment viral infection (Treatment viral infection)
CL Item
Treatment PTLD, EBV lymphoma (Treatment PTLD, EBV lymphoma)
Indication
Item
Indication if other, please specify
text
Number of infusions within 10 weeks
Item
Number of infusions within 10 weeks count only infusions that are part of same regimen and given for the same indication
integer
Item
GVHD PREVENTION IN THE RECIPIENT (THERAPEUTIC IMMUNOSUPPRESSION)
integer
Code List
GVHD PREVENTION IN THE RECIPIENT (THERAPEUTIC IMMUNOSUPPRESSION)
CL Item
Cyclosporine (Cyclosporine)
CL Item
Methotrexate (Methotrexate)
CL Item
ATG/ALG (if started after day 0) (ATG/ALG (if started after day 0))
CL Item
Corticosteroids (if started after day 0) (Corticosteroids (if started after day 0))
CL Item
Mycophenolate (Mycophenolate)
CL Item
Tacrolimus (Tacrolimus)
CL Item
Monoclonal antibodies, specify (Monoclonal antibodies, specify)
CL Item
Extra-corporeal photopheresis (ECP) (Extra-corporeal photopheresis (ECP))
Drugs
Item
If Monoclonal antibodies, specify
text
Drugs
Item
If Other, please specify
text
Item
GRAFT PERFORMANCE Haemopoietic reconstitution (Engraftment)
text
Code List
GRAFT PERFORMANCE Haemopoietic reconstitution (Engraftment)
CL Item
No reconstitution (No reconstitution)
CL Item
Lost graft (Lost graft)
Item
Neutrophils > 0.5 x 109/l reached?
text
Code List
Neutrophils > 0.5 x 109/l reached?
CL Item
Never below this level (Never below this level)
Date Neutrophils > 0.5 x 109/l
Item
Date Neutrophils > 0.5 x 109/l
date
Item
Platelets > 20 x 109/l reached?
integer
Code List
Platelets > 20 x 109/l reached?
CL Item
Never below this level (3)
Date Platelets > 20 x 109/l
Item
Date Platelets > 20 x 109/l
date
Item
Platelets > 50 x 109/l reached?
text
Code List
Platelets > 50 x 109/l reached?
CL Item
Never below this level (Never below this level)
Date Platelets > 50 x 109/l
Item
Date Platelets > 50 x 109/l
date
Date last assessment
Item
Date last assessment
date
Date of graft failure
Item
Date of graft failure
date
Item
Overall chimaerism
text
Code List
Overall chimaerism
CL Item
Full (donor >95 %) (Full (donor >95 %) )
CL Item
Mixed (partial) (Mixed (partial))
CL Item
Autologous reconstitution (recipient >95 %) (Autologous reconstitution (recipient >95 %) )
CL Item
Aplasia (Aplasia)
CL Item
Not evaluated (Not evaluated)
Date of test
Item
Date of test
date
Identification
Item
Identification of donor or Cord Blood Unit given by the centre
text
C1718162 (UMLS CUI [1])
Number in the infusion order
Item
Number in the infusion order (if applicable)
text
C0237753 (UMLS CUI [1])
Bone marrow
Item
Cell type on which test was performed (% Donor Cells): BM
float
C0005953 (UMLS CUI [1])
PB mononuclear cells (PBMC)
Item
Cell type on which test was performed (% Donor cells): PB mononuclear cells (PBMC)
float
C1321301 (UMLS CUI [1])
T-cell
Item
Cell type on which test was performed
float
B-Cells
Item
Cell type on which test was performed (% Donor cells): B-Cells
float
C0004561 (UMLS CUI [1])
Red blood cells
Item
Cell type on which test was performed (% Donor cells): Red blood cells
float
C0014772 (UMLS CUI [1])
Monocytes
Item
Cell type on which test was performed (% Donor cells): Monocytes
float
C0026473 (UMLS CUI [1])
PMNs (neutrophils)
Item
Cell type on which test was performed (% Donor cells): PMNs (neutrophils)
float
C0200633 (UMLS CUI [1])
Lymphocytes, NOS
Item
Cell type on which test was performed (% Donor cells): Lymphocytes, NOS
float
C0024264 (UMLS CUI [1])
Myeloid cells, NOS
Item
Cell type on which test was performed (% Donor cells): Myeloid cells, NOS
float
C0887899 (UMLS CUI [1])
Other cell type - value
Item
Cell type on which test was performed (% Donor cells): Other
float
C0449475 (UMLS CUI [1,1])
C1522609 (UMLS CUI [1,2])
Item
Test used
integer
C0022885 (UMLS CUI [1])
CL Item
Molecular (Molecular)
CL Item
Cytogenetic (Cytogenetic)
CL Item
ABO group (ABO group)
CL Item
unknown (unknown)
Item
TREATMENT FOR FAILURE (If engraftment failure)
integer
Code List
TREATMENT FOR FAILURE (If engraftment failure)
CL Item
Growth factors GRFAIGRF (2)
CL Item
Subsequent transplant (please complete a new transplant form) (3)
CL Item
AUTOgraft (must have prior conditioning) (4)
CL Item
Autologous PBSC re-infusion (no preparative treatment or conditioning) (6)
CL Item
Autologous BM re-infusion (no preparative treatment or conditioning) (7)
Item
Maximum grade ACUTE GRAFT VERSUS HOST DISEASE (AGVHD)
integer
Code List
Maximum grade ACUTE GRAFT VERSUS HOST DISEASE (AGVHD)
CL Item
grade 0 (Absent) (1)
CL Item
Not evaluated (6)
Date of onset
Item
Date of onset
date
C0574845 (UMLS CUI [1])
Item
Stage skin
integer
C0856825 (UMLS CUI [1,1])
C1306673 (UMLS CUI [1,2])
C1306673 (UMLS CUI [1,3])
CL Item
Not evaluated (6)
Item
Stage liver
integer
C0856825 (UMLS CUI [1,1])
C1306673 (UMLS CUI [1,2])
C0023884 (UMLS CUI [1,3])
CL Item
Not evaluated (6)
Item
Stage gut
integer
C0856825 (UMLS CUI [1,1])
C1306673 (UMLS CUI [1,2])
C0021853 (UMLS CUI [1,3])
CL Item
Not evaluated (6)
Item
Resolution
integer
C0856825 (UMLS CUI [1,1])
C1514893 (UMLS CUI [1,2])
aGvHD Date of resolution
Item
Date of resolution
date
C0856825 (UMLS CUI [1,1])
C1514893 (UMLS CUI [1,2])
C0011008 (UMLS CUI [1,3])
Treatment
Item
Treatment
boolean
Item
Treatment, if yes
text
Code List
Treatment, if yes
CL Item
Corticosteroids (Corticosteroids)
CL Item
ATG/ALG (ATG/ALG)
INFECTION RELATED COMPLICATIONS
Item
INFECTION RELATED COMPLICATIONS
boolean
Bacteraemia/ fungemia / viremia / parasites
Item
Pathogen Use the list of pathogens listed after this table for guidance. Use “unknown” if necessary.
text
Bacteraemia/ fungemia / viremia / parasites
Item
Date Provide different dates for different episodes of the same complication if applicable.
date
Septic shock
Item
Pathogen Use the list of pathogens listed after this table for guidance. Use “unknown” if necessary.
text
Septic shock
Item
Date Provide different dates for different episodes of the same complication if applicable.
date
ARDS
Item
Pathogen Use the list of pathogens listed after this table for guidance. Use “unknown” if necessary.
text
ARDS
Item
Date Provide different dates for different episodes of the same complication if applicable
date
Multiorgan failure due to infection
Item
Pathogen Use the list of pathogens listed after this table for guidance. Use “unknown” if necessary.
text
Multiorgan failure due to infection
Item
Date Provide different dates for different episodes of the same complication if applicable.
date
Pneumonia
Item
Pathogen Use the list of pathogens listed after this table for guidance. Use “unknown” if necessary.
text
Pneumonia
Item
Date Provide different dates for different episodes of the same complication if applicable.
date
Hepatitis
Item
Pathogen Use the list of pathogens listed after this table for guidance. Use “unknown” if necessary.
text
Hepatitis
Item
Date Provide different dates for different episodes of the same complication if applicable.
date
CNS infection
Item
Pathogen Use the list of pathogens listed after this table for guidance. Use “unknown” if necessary.
text
CNS infection
Item
Date Provide different dates for different episodes of the same complication if applicable.
date
Gut infection
Item
Pathogen Use the list of pathogens listed after this table for guidance. Use “unknown” if necessary.
text
Gut infection
Item
Date Provide different dates for different episodes of the same complication if applicable.
date
Skin infection
Item
Pathogen Use the list of pathogens listed after this table for guidance. Use “unknown” if necessary.
text
Skin infection
Item
Date Provide different dates for different episodes of the same complication if applicable.
date
Cystitis
Item
Pathogen Use the list of pathogens listed after this table for guidance. Use “unknown” if necessary.
text
Cystitis
Item
Date Provide different dates for different episodes of the same complication if applicable.
date
Retinitis
Item
Pathogen Use the list of pathogens listed after this table for guidance. Use “unknown” if necessary.
text
Retinitis
Item
Date Provide different dates for different episodes of the same complication if applicable.
date
Other
Item
Pathogen Use the list of pathogens listed after this table for guidance.
text
Other
Item
Date Provide different dates for different episodes of the same complication if applicable.
date
Item
NON INFECTION RELATED COMPLICATIONS
integer
C0009566 (UMLS CUI [1])
Code List
NON INFECTION RELATED COMPLICATIONS
CL Item
No complications (1)
Item
Specify: Idiopathic pneumonia syndrome
text
C1504431 (UMLS CUI [1])
Code List
Specify: Idiopathic pneumonia syndrome
CL Item
Unknown (Unknown)
Item
Specify: VOD
text
C0948441 (UMLS CUI [1])
CL Item
Unknown (Unknown)
Item
Specify: Haemorrhagic cystitis, non infectious
text
C0085692 (UMLS CUI [1])
Code List
Specify: Haemorrhagic cystitis, non infectious
CL Item
Unknown (Unknown)
Item
Specify: ARDS, non infectious
text
C0035222 (UMLS CUI [1])
Code List
Specify: ARDS, non infectious
CL Item
Unknown (Unknown)
Item
Multiorgan failure, non infectious
integer
Code List
Multiorgan failure, non infectious
Item
Specify: HSCT-associated microangiopathy
text
C0155765 (UMLS CUI [1])
Code List
Specify: HSCT-associated microangiopathy
CL Item
Unknown (Unknown)
Item
Specify: Renal failure requiring dialysis
text
C0035078 (UMLS CUI [1])
Code List
Specify: Renal failure requiring dialysis
CL Item
Unknown (Unknown)
Item
Specify: Haemolytic anaemia due to blood group
text
C0002878 (UMLS CUI [1])
Code List
Specify: Haemolytic anaemia due to blood group
CL Item
Unknown (Unknown)
Other type of infection
Item
Other type of infection
boolean
Date Idiopathic pneumonia syndrome
Item
Idiopathic pneumonia syndrome
date
Date VOD
Item
Date VOD
date
Date Haemorrhagic cystitis, non infectious
Item
Date Haemorrhagic cystitis, non infectious
date
Date ARDS, non infectious
Item
Date ARDS, non infectious
date
Date Multiorgan failure, non infectious
Item
Date Multiorgan failure, non infectious
date
Date HSCT-associated microangiopathy
Item
Date HSCT-associated microangiopathy
date
Date Renal failure requiring dialysis
Item
Date Renal failure requiring dialysis
date
Date Haemolytic anaemia due to blood group
Item
DAte Haemolytic anaemia due to blood group
date
Date of other Type
Item
Date of other Type
date
C2316983 (UMLS CUI [1,1])
C0220886 (UMLS CUI [1,2])
LastContactDate
Item
Date of Last Contact
date
C0011008 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
C1705415 (UMLS CUI [1,3])
C1517741 (UMLS CUI [1,4])
Item
Presence of cGVHD
integer
C0867389 (UMLS CUI [1])
Code List
Presence of cGVHD
CL Item
Yes, First Episode (2)
CL Item
Yes, Recurrence (3)
Date of Onset
Item
Onset
date
C0574845 (UMLS CUI [1])
Item
cGvHD grade
integer
C0867389 (UMLS CUI [1,1])
C0441800 (UMLS CUI [1,2])
CL Item
not evaluated (3)
Item
Organs affected
integer
C0449642 (UMLS CUI [1])
Code List
Organs affected
CL Item
Other, specify (7)
Item
Relapse or progression
integer
C0035020 (UMLS CUI [1,1])
C1704632 (UMLS CUI [1,2])
Code List
Relapse or progression
CL Item
Previously reported (1)
CL Item
Continuous progression since transplant (4)
If yes, date diagnosed
Item
RELAPSE OR PROGRESSION
date
Item
Cinical/haematological relapse or progression
integer
C0018939 (UMLS CUI [1,1])
C0205210 (UMLS CUI [1,2])
Code List
Cinical/haematological relapse or progression
CL Item
Not evaluated (3)
Cinical/haematological relapse or progression
Item
Date assessed
date
Cinical/haematological relapse or progression
Item
Date first seen
date
Item
Cytogenetic relapse or progression
integer
C0010802 (UMLS CUI [1])
Code List
Cytogenetic relapse or progression
CL Item
Not evaluated (3)
Cytogenetic relapse or progression
Item
Date assessed
date
Cytogenetic relapse or progression
Item
Date first seen
date
Item
Molecular relapse or progression
integer
C0026376 (UMLS CUI [1])
Code List
Molecular relapse or progression
CL Item
Not evaluated (3)
Molecular relapse or progression
Item
Date assessed
date
Molecular relapse or progression
Item
Date first seen
date
Item
Clinical/haematological
integer
C0018939 (UMLS CUI [1,1])
C0205210 (UMLS CUI [1,2])
Code List
Clinical/haematological
CL Item
Not evaluated (3)
Date of Evaluation
Item
Last date evaluated/Last date assessed
date
C2985720 (UMLS CUI [1])
Item
Cytogenetic/FISH
integer
C0010802 (UMLS CUI [1,1])
C0162789 (UMLS CUI [1,2])
Code List
Cytogenetic/FISH
CL Item
Yes: Considered disease relapse/progression No (2)
CL Item
Yes: Considered disease relapse/progression Yes (3)
CL Item
Yes: Considered disease relapse/progression Not evaluated (4)
Last date assessed
Item
Last date assessed
date
Item
Molecular
text
C0026376 (UMLS CUI [1])
CL Item
No Considered disease relapse/progression (No Considered disease relapse/progression)
CL Item
Yes Considered disease relapse/progression (Yes Considered disease relapse/progression)
CL Item
Not evaluated (Not evaluated)
Item
Survival Status
integer
C1148433 (UMLS CUI [1])
Code List
Survival Status
Item
If alive: Type of score used:
text
C1518965 (UMLS CUI [1])
Code List
If alive: Type of score used:
CL Item
Karnofsky (Karnofsky)
CL Item
Not evaluated (Not evaluated)
CL Item
Unknown (Unknown)
Item
Score
integer
C1518965 (UMLS CUI [1])
CL Item
100 (Normal, NED) (1)
CL Item
10 (Moribund) (10)
CL Item
Not evaluated (11)
CL Item
90 (Normal activity) (2)
CL Item
80 (Normal with effort) (3)
CL Item
70 (Cares for self) (4)
CL Item
60 (Requires occasional assistance) (5)
CL Item
50 (Requires assistance) (6)
CL Item
40 (Disabled) (7)
CL Item
30 (Severely disabled) (8)
CL Item
20 (Very sick) (9)
Item
Cause of death (if dead)
integer
C0007465 (UMLS CUI [1])
Code List
Cause of death (if dead)
CL Item
Relapse or progression (1)
CL Item
Secondary malignancy (including lymphoproliferative disease) (2)
CL Item
Transplantation related cause (3)
Item
If dead and HSCT related cause of death, specify (check as many as apppropriate): GvHD
text
C0007465 (UMLS CUI [1,1])
C0018133 (UMLS CUI [1,2])
Code List
If dead and HSCT related cause of death, specify (check as many as apppropriate): GvHD
CL Item
Unknown (Unknown)
Item
If dead and HSCT related cause of death, specify (check as many as apppropriate): Interstitial Pneumonitis
text
C0007465 (UMLS CUI [1,1])
C0206061 (UMLS CUI [1,2])
Code List
If dead and HSCT related cause of death, specify (check as many as apppropriate): Interstitial Pneumonitis
CL Item
Unknown (Unknown)
Item
If dead and HSCT related cause of death, specify (check as many as apppropriate): Pulmonary toxicity
text
C0007465 (UMLS CUI [1,1])
C0919924 (UMLS CUI [1,2])
Code List
If dead and HSCT related cause of death, specify (check as many as apppropriate): Pulmonary toxicity
CL Item
Unknown (Unknown)
Item
Infection:
integer
C0009450 (UMLS CUI [1])
Item
Rejection / poor graft function
integer
C0018129 (UMLS CUI [1])
Code List
Rejection / poor graft function
Item
Veno-Occlusive disease (VOD)
integer
C0007465 (UMLS CUI [1,1])
C0948441 (UMLS CUI [1,2])
Code List
Veno-Occlusive disease (VOD)
Item
If dead and HSCT related cause of death, specify (check as many as apppropriate): Haemorrhage
text
C0007465 (UMLS CUI [1,1])
C0019080 (UMLS CUI [1,2])
Code List
If dead and HSCT related cause of death, specify (check as many as apppropriate): Haemorrhage
CL Item
Unknown (Unknown)
Item
If dead and HSCT related cause of death, specify (check as many as apppropriate): Cardiac toxicity
text
C0007465 (UMLS CUI [1,1])
C0876994 (UMLS CUI [1,2])
Code List
If dead and HSCT related cause of death, specify (check as many as apppropriate): Cardiac toxicity
CL Item
Unknown (Unknown)
Item
If dead and HSCT related cause of death, specify (check as many as apppropriate): Central nervous system toxicity
text
C0007465 (UMLS CUI [1,1])
C3160947 (UMLS CUI [1,2])
Code List
If dead and HSCT related cause of death, specify (check as many as apppropriate): Central nervous system toxicity
CL Item
Unknown (Unknown)
Item
If dead and HSCT related cause of death, specify (check as many as apppropriate): Gastro intestinal toxicity
text
C0007465 (UMLS CUI [1,1])
C1142499 (UMLS CUI [1,2])
Code List
If dead and HSCT related cause of death, specify (check as many as apppropriate): Gastro intestinal toxicity
CL Item
Unknown (Unknown)
Item
If dead and HSCT related cause of death, specify (check as many as apppropriate): Skin toxicity
text
C0007465 (UMLS CUI [1,1])
C1167791 (UMLS CUI [1,2])
Code List
If dead and HSCT related cause of death, specify (check as many as apppropriate): Skin toxicity
CL Item
Unknown (Unknown)
Item
If dead and HSCT related cause of death, specify (check as many as apppropriate): Renal failure
text
C0007465 (UMLS CUI [1,1])
C0035078 (UMLS CUI [1,2])
Code List
If dead and HSCT related cause of death, specify (check as many as apppropriate): Renal failure
CL Item
Unknown (Unknown)
Item
If dead and HSCT related cause of death, specify (check as many as apppropriate): Multiple organ failure
text
C0007465 (UMLS CUI [1,1])
C0026766 (UMLS CUI [1,2])
Code List
If dead and HSCT related cause of death, specify (check as many as apppropriate): Multiple organ failure
CL Item
Unknown (Unknown)
Other transplantation related
Item
Other transplantation related
boolean
COMMENTS
Item
COMMENTS
text
IDENTIFICATION & SIGNATURE
Item
IDENTIFICATION & SIGNATURE
text
Item
Ethnicity
text
C0015031 (UMLS CUI [1])
CL Item
Hispanic or Latino (1)
CL Item
Not Hispanic or Latino (2)
Item
Race
text
C0034510 (UMLS CUI [1])
CL Item
American Indian or Alaska Native (4)
CL Item
Native Hawaiian or Pacific Native (5)
COMORBID CONDITIONS
Item
Was there any clinically significant co-existing disease or organ impairment at time of patient assessment prior to preparative (conditioning) regimen?
boolean
Item
Treated at any time point in the patient's past history, excluding nonmelanoma skin cancer
text
Code List
Treated at any time point in the patient's past history, excluding nonmelanoma skin cancer
CL Item
Not evaluated (Not evaluated)
Item
Crohn's disease or ulcerative colitis
text
Code List
Crohn's disease or ulcerative colitis
CL Item
Not evaluated (Not evaluated)
Item
Requiring continuation of antimicrobial treatment after day 0
text
Code List
Requiring continuation of antimicrobial treatment after day 0
CL Item
Not evaluated (Not evaluated)
Item
Requiring treatment with insulin or oral hypoglycemics but not diet alone
text
Code List
Requiring treatment with insulin or oral hypoglycemics but not diet alone
CL Item
Not evaluated (Not evaluated)
Item
Serum crratinine > 2 mg/dL or >177 μmol/L, on dialysis, or prior renal transplantation
text
Code List
Serum crratinine > 2 mg/dL or >177 μmol/L, on dialysis, or prior renal transplantation
CL Item
Not evaluated (Not evaluated)
Item
Chronic hepatitis, bilirubine between Upper Limit Normal (ULN) and 1.5 x the ULN, or AST/ALT between ULN and 2.5 × ULN
text
Code List
Chronic hepatitis, bilirubine between Upper Limit Normal (ULN) and 1.5 x the ULN, or AST/ALT between ULN and 2.5 × ULN
CL Item
Not evaluated (Not evaluated)
Item
Liver cirrhosis, bilirubine greater than 1.5 × ULN, or AST/ALT greater than 2.5 × ULN
text
Code List
Liver cirrhosis, bilirubine greater than 1.5 × ULN, or AST/ALT greater than 2.5 × ULN
CL Item
Not evaluated (Not evaluated)
Item
Atrial fibrillation or flutter, sick sinus syndrome, or ventricular arrhythmias
text
Code List
Atrial fibrillation or flutter, sick sinus syndrome, or ventricular arrhythmias
CL Item
Not evaluated (Not evaluated)
Item
Coronary artery disease, congestive heart failure, myocardial infarction, or EF ≤ 50%
text
Code List
Coronary artery disease, congestive heart failure, myocardial infarction, or EF ≤ 50%
CL Item
Not evaluated (Not evaluated)
Item
Transient ischemic attack or cerebrovascular accident
text
Code List
Transient ischemic attack or cerebrovascular accident
CL Item
Not evaluated (Not evaluated)
Item
Except mitral valve prolapse
text
Code List
Except mitral valve prolapse
CL Item
Not evaluated (Not evaluated)
Item
DLco and/or FEV1 66-80% or dyspnea on slight activity
text
Code List
DLco and/or FEV1 66-80% or dyspnea on slight activity
CL Item
Not evaluated (Not evaluated)
Item
DLco and/or FEV1 ≤ 65% or dyspnea at rest or requiring oxygen
text
Code List
DLco and/or FEV1 ≤ 65% or dyspnea at rest or requiring oxygen
CL Item
Not evaluated (Not evaluated)
Item
Patients with a body mass index > 35 kg/m2
text
Code List
Patients with a body mass index > 35 kg/m2
CL Item
Not evaluated (Not evaluated)
Item
Requiring treatment
text
Code List
Requiring treatment
CL Item
Not evaluated (Not evaluated)
Item
Depression or anxiety requiring psychiatric consult or treatment
text
Code List
Depression or anxiety requiring psychiatric consult or treatment
CL Item
Not evaluated (Not evaluated)
other comorbidity
Item
other comorbidity, please specify
text