ID

16384

Beschreibung

DOCUMENTED PATHOGENS (Use this table for guidance on the pathogens of interest) Bacteria: S. pneumoniae, Other gram positive (i.e.: other streptococci, staphylococci, listeria …),Haemophilus influenzae, Other gram negative (i.e.: E. coli klebsiella, proteus, serratia, pseudomonas …), Legionella sp, Mycobacteria sp, other.... Fungi: Candida sp, Aspergillus sp, Pneumocystis carinii, other... Parasites: Toxoplasma gondii, other Viruses: HSV, VZV, EBV, CMV, HHV-6, RSV, Other respiratory virus (influenza, parainfluenza,Adenovirus, HBV, HCV, HIV,Papovavirus, Parvovirus, other

Stichworte

  1. 14.07.16 14.07.16 -
  2. 21.08.16 21.08.16 -
  3. 13.04.21 13.04.21 - Dr. rer. medic Philipp Neuhaus
  4. 20.09.21 20.09.21 -
Hochgeladen am

14. Juli 2016

DOI

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EBMT Allograft

19pp EBMT Allograft 18Allo.

ANTIBODIES IN THE PATIENT
Beschreibung

ANTIBODIES IN THE PATIENT

HIV
Beschreibung

HIV

Datentyp

text

HIV ANTIGENS (if testing applicable)
Beschreibung

HIV

Datentyp

text

CMV
Beschreibung

CMV

Datentyp

text

EBV
Beschreibung

EBV

Datentyp

text

HBVs
Beschreibung

HBVs

Datentyp

text

HBVs ANTIGENS (if testing applicable)
Beschreibung

HBVs

Datentyp

text

HBVc
Beschreibung

HBVc

Datentyp

text

HBVe
Beschreibung

HBVe

Datentyp

text

HBVe ANTIGENS (if testing applicable)
Beschreibung

HBVe

Datentyp

text

HCV
Beschreibung

HCV

Datentyp

text

HCV ANTIGENS (if testing applicable)
Beschreibung

HCV

Datentyp

text

HTLV.I
Beschreibung

HTLV.I

Datentyp

text

Toxoplasmosis
Beschreibung

Toxoplasmosis

Datentyp

text

if other Antibodies in the patient
Beschreibung

Other

Datentyp

text

PRE-TRANSPLANT HISTORY OF DOCUMENTED INVASIVE FUNGAL INFECTION SINCE INITIAL DIAGNOSIS
Beschreibung

PRE-TRANSPLANT HISTORY OF DOCUMENTED INVASIVE FUNGAL INFECTION SINCE INITIAL DIAGNOSIS

PRE-TRANSPLANT HISTORY OF DOCUMENTED INVASIVE FUNGAL INFECTION SINCE INITIAL DIAGNOSIS
Beschreibung

PRE-TRANSPLANT HISTORY OF DOCUMENTED INVASIVE FUNGAL INFECTION SINCE INITIAL DIAGNOSIS

Datentyp

text

Candida
Beschreibung

Candida

Datentyp

text

Aspergillus
Beschreibung

Aspergillus

Datentyp

text

Pneumocystis carinii
Beschreibung

Pneumocystis carinii

Datentyp

text

Other
Beschreibung

Other

Datentyp

boolean

if yes, please specify
Beschreibung

Other

Datentyp

text

PERFORMANCE SCORE
Beschreibung

PERFORMANCE SCORE

Type of score used
Beschreibung

Type of score used

Datentyp

text

Score
Beschreibung

Performance score

Datentyp

integer

Alias
UMLS CUI [1]
C1518965
Weight
Beschreibung

Weight

Datentyp

float

Maßeinheiten
  • kg
Alias
UMLS CUI [1]
C0005910
kg
Height
Beschreibung

Height

Datentyp

float

Maßeinheiten
  • cm
Alias
UMLS CUI [1]
C0005890
cm
DONOR AND STEM CELL SOURCE
Beschreibung

DONOR AND STEM CELL SOURCE

Multiple donors
Beschreibung

Multiple donors

Datentyp

boolean

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
Beschreibung

Number of donors or different stem cell products of same donor or cord blood units

Datentyp

float

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
Beschreibung

SOURCE OF STEM CELLS FOR THIS DONOR/PRODUCT

Datentyp

text

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)
Beschreibung

Identification of Donor or Cord Blood Unit given by the centre

Datentyp

text

Number in the infusion order (if multiple donors or stem cell products)
Beschreibung

Number in the infusion order

Datentyp

text

Number in the infusion order
Beschreibung

Number in the infusion order

Datentyp

text

HLA MATCH TYPE (DONOR RELATION WITH PATIENT)
Beschreibung

HLA MATCH TYPE

Datentyp

text

Name of the Donor registry
Beschreibung

Name of the Donor registry

Datentyp

text

BMDW / WMDA code for the donor registry (up to 4 characters) (This information can be found in http://www.bmdw.org under “Participating Registries”)
Beschreibung

BMDW / WMDA code for the donor registry (up to 4 characters)

Datentyp

text

Identification of Donor or Cord Blood Unit given by the donor registry
Beschreibung

Identification of Donor or Cord Blood Unit given by the donor registry

Datentyp

text

Name of the Cord blood bank
Beschreibung

Name of the Cord blood bank

Datentyp

text

Eurocord code for the cord blood bank
Beschreibung

Eurocord code for the cord blood bank

Datentyp

text

Identification of Cord Blood Unit given by the cord blood bank
Beschreibung

Identification of Cord Blood Unit given by the cord blood bank

Datentyp

text

HLA MISMATCHES BETWEEN DONOR AND PATIENT
Beschreibung

HLA MISMATCHES BETWEEN DONOR AND PATIENT

Serology A
Beschreibung

Serology

Datentyp

text

Serology B
Beschreibung

Serology

Datentyp

text

Serology C
Beschreibung

Serology

Datentyp

text

Serology DRB1
Beschreibung

Serology

Datentyp

text

Serology DQB1
Beschreibung

Serology

Datentyp

text

Serology DPB1
Beschreibung

Serology

Datentyp

text

DNA A
Beschreibung

DNA

Datentyp

text

DNA B
Beschreibung

DNA

Datentyp

text

DNA C
Beschreibung

DNA

Datentyp

text

DNA DRB1
Beschreibung

DNA

Datentyp

text

DNA DQB1
Beschreibung

DNA

Datentyp

text

DNA DPB1
Beschreibung

DNA

Datentyp

text

BLOOD GROUP, DATE OF BIRTH AND SEX OF DONOR
Beschreibung

BLOOD GROUP, DATE OF BIRTH AND SEX OF DONOR

ABO group
Beschreibung

ABO group

Datentyp

text

Date of birth
Beschreibung

Date of birth

Datentyp

date

Alias
UMLS CUI [1]
C0421451
Sex
Beschreibung

Sex

Datentyp

text

Alias
UMLS CUI [1]
C0079399
STATUS OF THE DONOR OR CORD BLOOD UNIT BEFORE HSCT
Beschreibung

STATUS OF THE DONOR OR CORD BLOOD UNIT BEFORE HSCT

HIV
Beschreibung

HIV

Datentyp

text

HIV ANTIGENS (if testing applicable)
Beschreibung

HIV

Datentyp

text

CMV
Beschreibung

CMV

Datentyp

text

EBV
Beschreibung

EBV

Datentyp

text

HBVs
Beschreibung

HBVs

Datentyp

text

HBVs ANTIGENS (if testing applicable)
Beschreibung

HBVs

Datentyp

text

HBVc
Beschreibung

HBVc

Datentyp

text

HBVe
Beschreibung

HBVe

Datentyp

text

HBVe ANTIGENS (if testing applicable)
Beschreibung

HBVe

Datentyp

text

HCV
Beschreibung

HCV

Datentyp

text

HCV ANTIGENS (if testing applicable)
Beschreibung

HCV

Datentyp

text

HTLV.I
Beschreibung

HTLV.I

Datentyp

text

Toxoplasmosis
Beschreibung

Toxoplasmosis

Datentyp

text

if other Antibodies in the patient
Beschreibung

Other

Datentyp

text

Date of harvest or cord blood collection
Beschreibung

Date of harvest or cord blood collection

Datentyp

date

GROWTH FACTORS ADMINISTERED TO THE DONOR
Beschreibung

GROWTH FACTORS ADMINISTERED TO THE DONOR

Datentyp

text

If Yes, please specify
Beschreibung

GROWTH FACTORS ADMINISTERED TO THE DONOR

Datentyp

text

HISTOCOMPATIBILITY RESULTS
Beschreibung

HISTOCOMPATIBILITY RESULTS

Laboratory / Hospital
Beschreibung

Laboratory / Hospital

Datentyp

text

Unit
Beschreibung

Unit

Datentyp

text

Contact number (telephone/fax)
Beschreibung

Contact number

Datentyp

text

Technique Used
Beschreibung

Technique Used

Datentyp

text

Serology (antigenic) HLA typing done
Beschreibung

Serology (antigenic) HLA typing done

Datentyp

boolean

DNA (Allelic/molecular) HLA typing done
Beschreibung

DNA (Allelic/molecular) HLA typing done

DNA (Allelic/molecular) HLA typing done
Beschreibung

DNA (Allelic/molecular) HLA typing done

Datentyp

boolean

DNA (Allelic/molecular) HLA typing done
Beschreibung

Locus

Datentyp

text

HLA string
Beschreibung

HLA string

Datentyp

text

NMDP code
Beschreibung

NMDP code

Datentyp

text

NMDP code
Beschreibung

NMDP code

Datentyp

boolean

NMDP code
Beschreibung

NMDP code

Datentyp

boolean

Serology (antigenic) HLA typing done
Beschreibung

Serology (antigenic) HLA typing done

Serology (antigenic) HLA typing done
Beschreibung

Serology (antigenic) HLA typing done

Datentyp

text

Serology
Beschreibung

Serology

Datentyp

text

Serology
Beschreibung

Serology

Datentyp

text

HLA
Beschreibung

HLA

Datentyp

text

GRAFT MANIPULATION
Beschreibung

GRAFT MANIPULATION

IF MULTIPLE DONORS Identification of donor or Cord Blood Unit given by the centre (please, use same ID as in the preceding sheets)
Beschreibung

Identification of donor or Cord Blood Unit given by the centre

Datentyp

text

Number in the infusion order (if applicable)
Beschreibung

Number in the infusion order

Datentyp

text

Alias
UMLS CUI [1]
C0237753
GRAFT MANIPULATION EX-VIVO (INCLUDING T-CELL DEPLETION)
Beschreibung

GRAFT MANIPULATION EX-VIVO (INCLUDING T-CELL DEPLETION)

Datentyp

text

NEGATIVE SELECTION
Beschreibung

GRAFT MANIPULATION EX-VIVO (INCLUDING T-CELL DEPLETION)

Datentyp

text

if negative selection
Beschreibung

GRAFT MANIPULATION EX-VIVO (INCLUDING T-CELL DEPLETION)

Datentyp

text

if positive selection
Beschreibung

GRAFT MANIPULATION EX-VIVO (INCLUDING T-CELL DEPLETION)

Datentyp

text

Monoclonal antibodies
Beschreibung

Monoclonal antibodies

Datentyp

text

if yes
Beschreibung

Monoclonal antibodies

Datentyp

text

if other, please specify
Beschreibung

Monoclonal antibodies

Datentyp

text

EXPANSION
Beschreibung

EXPANSION

Datentyp

text

GENE MANIPULATION (gene transfer/transduction)
Beschreibung

GENE MANIPULATION

Datentyp

text

CELL INFUSION
Beschreibung

CELL INFUSION

IF MULTIPLE DONORS: Identification of donor or Cord Blood Unit given by the centre (please, use same ID as in the preceding sheets)
Beschreibung

Identification of donor or Cord Blood Unit given by the centre

Datentyp

text

Number in the infusion order (if applicable)
Beschreibung

Number in the infusion order

Datentyp

text

Alias
UMLS CUI [1]
C0237753
CELL INFUSION METHOD Fill in for Cord Blood HSCT only
Beschreibung

Route of infusion

Datentyp

text

If other, please specify
Beschreibung

Route of infusion

Datentyp

text

Infusion method
Beschreibung

Infusion method

Datentyp

text

if other, please specify
Beschreibung

Infusion method

Datentyp

text

CELL VIABILITY RESULTS AT HSCT CENTRE
Beschreibung

CELL VIABILITY RESULTS AT HSCT CENTRE

Tests performed after thawing of an aliquot on
Beschreibung

Tests performed after thawing of an aliquot on

Datentyp

text

Method used
Beschreibung

Method used

Datentyp

text

if other, please specify
Beschreibung

Method used

Datentyp

text

Viability of all cells
Beschreibung

Viability of all cells

Datentyp

float

Viability of CD34+ cells
Beschreibung

Viability of CD34+ cells

Datentyp

float

CELLS INFUSED FROM THIS DONOR AND STEM CELL SOURCE COMBINATION
Beschreibung

CELLS INFUSED FROM THIS DONOR AND STEM CELL SOURCE COMBINATION

Total number of cells actually infused Nucleated cells (/kg*)
Beschreibung

Bone Marrow

Datentyp

float

Total number of cells actually infused Nucleated cells (/kg*)
Beschreibung

Bone Marrow

Datentyp

text

Total number of cells actually infused CD 34+ (cells/kg*)
Beschreibung

Bone Marrow

Datentyp

float

Total number of cells actually infused CD 34+ (cells/kg*)
Beschreibung

Bone Marrow

Datentyp

text

Total number of cells actually infused T-cells (CD 3+) (cells/kg*)
Beschreibung

Bone Marrow

Datentyp

float

Total number of cells actually infused T-cells (CD 3+) (cells/kg*)
Beschreibung

Bone Marrow

Datentyp

text

Total number of cells actually infused Nucleated cells (/kg*)
Beschreibung

Peripheral Blood

Datentyp

float

Total number of cells actually infused Nucleated cells (/kg*)
Beschreibung

Peripheral Blood

Datentyp

text

Total number of cells actually infused CD 34+ (cells/kg*)
Beschreibung

Peripheral Blood

Datentyp

float

Total number of cells actually infused CD 34+ (cells/kg*)
Beschreibung

Peripheral Blood

Datentyp

text

Total number of cells actually infused T-cells (CD 3+) (cells/kg*)
Beschreibung

Peripheral Blood

Datentyp

float

Total number of cells actually infused T-cells (CD 3+) (cells/kg*)
Beschreibung

Peripheral Blood

Datentyp

text

Total number of cellsactually infused Nucleated cells (/kg*)
Beschreibung

Cord Blood

Datentyp

float

Total number of cellsactually infused Nucleated cells (/kg*)
Beschreibung

Cord Blood

Datentyp

text

Total number of cellsactually infused CD 34+ (cells/kg*)
Beschreibung

Cord Blood

Datentyp

float

Total number of cellsactually infused CD 34+ (cells/kg*)
Beschreibung

Cord Blood

Datentyp

text

Total number of cells actually infused T-cells (CD 3+) (cells/kg*)
Beschreibung

Cord Blood

Datentyp

float

Total number of cells actually infused T-cells (CD 3+) (cells/kg*)
Beschreibung

Cord Blood

Datentyp

text

HSC TRANSPLANTATION
Beschreibung

HSC TRANSPLANTATION

Chronological number of HSCT for this patient
Beschreibung

Chronological number of HSCT for this patient

Datentyp

integer

If > 1
Beschreibung

Donor the same as for previous HSCT?

Datentyp

text

Date of previous HSCT
Beschreibung

Date of previous HSCT

Datentyp

date

Type of previous HSCT
Beschreibung

Type of previous HSCT

Datentyp

text

Reason for this transplant
Beschreibung

Reason for this transplant

Datentyp

text

if other, please specify
Beschreibung

Reason for this transplant

Datentyp

text

HSCT part of a multiple sequential graft protocol
Beschreibung

HSCT part of a multiple sequential graft protocol

Datentyp

text

Type of multiple graft protocol
Beschreibung

Type of multiple graft protocol

Datentyp

text

Graft number in the protocol
Beschreibung

Graft number in the protocol

Datentyp

integer

total number of HSCTs in the program
Beschreibung

total number of HSCTs in the program

Datentyp

integer

PREPARATIVE TREATMENT (conditioning)
Beschreibung

PREPARATIVE TREATMENT (conditioning)

PREPARATIVE (CONDITIONING) REGIMEN GIVEN
Beschreibung

PREPARATIVE (CONDITIONING) REGIMEN GIVEN

Datentyp

boolean

Was regimen intended to be myeloablative
Beschreibung

Was regimen intended to be myeloablative

Datentyp

text

Main reason (tick only one)
Beschreibung

Reason not myeloablative

Datentyp

text

Age of recipient
Beschreibung

Reason not myeloablative

Datentyp

boolean

Comorbid conditions
Beschreibung

Reason not myeloablative

Datentyp

boolean

Prior HSCT
Beschreibung

Reason not myeloablative

Datentyp

boolean

Protocol driven
Beschreibung

Reason not myeloablative

Datentyp

boolean

If other additional reason, please specify
Beschreibung

Reason not myeloablative

Datentyp

text

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
Beschreibung

Drugs

Datentyp

text

Drugs
Beschreibung

Drugs

NAME OF DRUG
Beschreibung

NAME OF DRUG

Datentyp

text

PRESCRIBED CUMULATIVE DOSE AS PER PROTOCOL (DAILY DOSE BY NUMBER OF DAYS)
Beschreibung

PRESCRIBED CUMULATIVE DOSE AS PER PROTOCOL (DAILY DOSE BY NUMBER OF DAYS)

Datentyp

text

IF MONOCLONAL ANTIBODY, RADIO LABELLED?
Beschreibung

IF MONOCLONAL ANTIBODY, RADIO LABELLED?

Datentyp

integer

UNITS IF NOT RADIO LABELLED*
Beschreibung

UNITS IF NOT RADIO LABELLED*

Datentyp

integer

UNITS IF RADIO LABELLED
Beschreibung

UNITS IF RADIO LABELLED

Datentyp

integer

If the dose units you need are not listed, please write them on the side For Busulphan
Beschreibung

ADDITIONAL DRUG INFORMATION

Datentyp

text

Route of administration
Beschreibung

ADDITIONAL DRUG INFORMATION

Datentyp

text

Animal origin For ALG, ATG (ALS, ATS):
Beschreibung

Animal origin

Datentyp

text

if other, please specify
Beschreibung

Animal origin

Datentyp

text

TBI (If yes, complete TBI Form)
Beschreibung

TBI

Datentyp

text

Total dose (Gy)
Beschreibung

Total dose (Gy)

Datentyp

float

Number of fractions
Beschreibung

Number of fractions

Datentyp

float

radiation days
Beschreibung

radiation days

Datentyp

integer

TLI / TNI / TAI
Beschreibung

TLI / TNI / TAI

Datentyp

text

Total dose (Gy)
Beschreibung

Total dose (Gy)

Datentyp

float

Local radiotherapy
Beschreibung

Local radiotherapy

Datentyp

text

TREATMENT DURING THE IMMEDIATE POST-TRANSPLANT PERIOD
Beschreibung

TREATMENT DURING THE IMMEDIATE POST-TRANSPLANT PERIOD

GROWTH FACTORS (CYTOKINES) (excluding growth factors administered for engraftment failure)
Beschreibung

GROWTH FACTORS (CYTOKINES)

Datentyp

text

If yes, please specify
Beschreibung

GROWTH FACTORS (CYTOKINES)

Datentyp

text

Date started
Beschreibung

Date started

Datentyp

date

CELLULAR THERAPY
Beschreibung

CELLULAR THERAPY

Datentyp

text

Date of first infusion (can be the same as HSCT date)
Beschreibung

Date of first infusion

Datentyp

date

CELLULAR THERAPY if yes
Beschreibung

CELLULAR THERAPY

Datentyp

integer

if other, please specify
Beschreibung

CELLULAR THERAPY

Datentyp

text

Number of cells infused by type
Beschreibung

Number of cells infused by type

Nucleated cells (/kg*)
Beschreibung

Nucleated cells (/kg*)

Datentyp

float

Nucleated cells (/kg*)
Beschreibung

Nucleated cells (/kg*)

Datentyp

text

CD 34+ (cells/kg*)
Beschreibung

CD 34+ (cells/kg*)

Datentyp

float

CD 34+ (cells/kg*)
Beschreibung

CD 34+ (cells/kg*)

Datentyp

integer

CD 3+ (cells/kg*)
Beschreibung

CD 3+ (cells/kg*)

Datentyp

float

CD 3+ (cells/kg*)
Beschreibung

CD 3+ (cells/kg*)

Datentyp

integer

Total number of cells infused
Beschreibung

Total number of cells infused

All cells (cells/kg*) (non DLI only)
Beschreibung

All cells (cells/kg*)

Datentyp

float

All cells (cells/kg*) (non DLI only)
Beschreibung

All cells (cells/kg*)

Datentyp

integer

Chronological number of this cell therapy for this patient
Beschreibung

Chronological number of this cell therapy for this patient

Datentyp

integer

Indication (check all that apply)
Beschreibung

Indication

Datentyp

text

Indication if other, please specify
Beschreibung

Indication

Datentyp

text

Number of infusions within 10 weeks count only infusions that are part of same regimen and given for the same indication
Beschreibung

Number of infusions within 10 weeks

Datentyp

integer

GVHD PREVENTION IN THE RECIPIENT (THERAPEUTIC IMMUNOSUPPRESSION)
Beschreibung

GVHD PREVENTION IN THE RECIPIENT (THERAPEUTIC IMMUNOSUPPRESSION)

Datentyp

integer

Drugs
Beschreibung

Drugs

Datentyp

text

If Monoclonal antibodies, specify
Beschreibung

Drugs

Datentyp

text

If Other, please specify
Beschreibung

Drugs

Datentyp

text

GRAFT PERFORMANCE
Beschreibung

GRAFT PERFORMANCE

GRAFT PERFORMANCE Haemopoietic reconstitution (Engraftment)
Beschreibung

GRAFT PERFORMANCE

Datentyp

text

Neutrophils > 0.5 x 109/l reached?
Beschreibung

Neutrophils > 0.5 x 109/l reached?

Datentyp

text

Date Neutrophils > 0.5 x 109/l
Beschreibung

Date Neutrophils > 0.5 x 109/l

Datentyp

date

Platelets > 20 x 109/l reached?
Beschreibung

Platelets > 20 x 109/l reached?

Datentyp

integer

Date Platelets > 20 x 109/l
Beschreibung

Date Platelets > 20 x 109/l

Datentyp

date

Platelets > 50 x 109/l reached?
Beschreibung

Platelets > 50 x 109/l reached?

Datentyp

text

Date Platelets > 50 x 109/l
Beschreibung

Date Platelets > 50 x 109/l

Datentyp

date

Date last assessment
Beschreibung

Date last assessment

Datentyp

date

Date of graft failure
Beschreibung

Date of graft failure

Datentyp

date

Overall chimaerism
Beschreibung

HAEMOPOIETIC CHIMAERISM

Datentyp

text

DATE(S) AND RESULTS OF ALL TESTS DONE FOR ALL DONORS
Beschreibung

DATE(S) AND RESULTS OF ALL TESTS DONE FOR ALL DONORS

undefined item
Beschreibung

undefined item

Datentyp

text

Date of test
Beschreibung

Date of test

Datentyp

date

Identification of donor or Cord Blood Unit given by the centre
Beschreibung

Identification

Datentyp

text

Alias
UMLS CUI [1]
C1718162
Number in the infusion order (if applicable)
Beschreibung

Number in the infusion order

Datentyp

text

Alias
UMLS CUI [1]
C0237753
Cell type on which test was performed (% Donor Cells): BM
Beschreibung

Bone marrow

Datentyp

float

Maßeinheiten
  • %
Alias
UMLS CUI [1]
C0005953
%
Cell type on which test was performed (% Donor cells): PB mononuclear cells (PBMC)
Beschreibung

PB mononuclear cells (PBMC)

Datentyp

float

Maßeinheiten
  • %
Alias
UMLS CUI [1]
C1321301
%
Cell type on which test was performed
Beschreibung

T-cell

Datentyp

float

Cell type on which test was performed (% Donor cells): B-Cells
Beschreibung

B-Cells

Datentyp

float

Maßeinheiten
  • %
Alias
UMLS CUI [1]
C0004561
%
Cell type on which test was performed (% Donor cells): Red blood cells
Beschreibung

Red blood cells

Datentyp

float

Maßeinheiten
  • %
Alias
UMLS CUI [1]
C0014772
%
Cell type on which test was performed (% Donor cells): Monocytes
Beschreibung

Monocytes

Datentyp

float

Maßeinheiten
  • %
Alias
UMLS CUI [1]
C0026473
%
Cell type on which test was performed (% Donor cells): PMNs (neutrophils)
Beschreibung

PMNs (neutrophils)

Datentyp

float

Maßeinheiten
  • %
Alias
UMLS CUI [1]
C0200633
%
Cell type on which test was performed (% Donor cells): Lymphocytes, NOS
Beschreibung

Lymphocytes, NOS

Datentyp

float

Maßeinheiten
  • %
Alias
UMLS CUI [1]
C0024264
%
Cell type on which test was performed (% Donor cells): Myeloid cells, NOS
Beschreibung

Myeloid cells, NOS

Datentyp

float

Maßeinheiten
  • %
Alias
UMLS CUI [1]
C0887899
%
Cell type on which test was performed (% Donor cells): Other
Beschreibung

Other cell type - value

Datentyp

float

Maßeinheiten
  • %
Alias
UMLS CUI [1,1]
C0449475
UMLS CUI [1,2]
C1522609
%
Test used
Beschreibung

Laboratory tests

Datentyp

integer

Alias
UMLS CUI [1]
C0022885
TREATMENT FOR FAILURE (If engraftment failure)
Beschreibung

TREATMENT FOR FAILURE

Datentyp

integer

ACUTE GRAFT VERSUS HOST DISEASE (GvHD)
Beschreibung

ACUTE GRAFT VERSUS HOST DISEASE (GvHD)

Maximum grade ACUTE GRAFT VERSUS HOST DISEASE (AGVHD)
Beschreibung

Maximum grade

Datentyp

integer

Date of onset
Beschreibung

Date of onset

Datentyp

date

Alias
UMLS CUI [1]
C0574845
Stage skin
Beschreibung

aGvHD Stage Skin

Datentyp

integer

Alias
UMLS CUI [1,1]
C0856825
UMLS CUI [1,2]
C1306673
UMLS CUI [1,3]
C1306673
Stage liver
Beschreibung

aGvHD Stage liver

Datentyp

integer

Alias
UMLS CUI [1,1]
C0856825
UMLS CUI [1,2]
C1306673
UMLS CUI [1,3]
C0023884
Stage gut
Beschreibung

aGvHD stage gut

Datentyp

integer

Alias
UMLS CUI [1,1]
C0856825
UMLS CUI [1,2]
C1306673
UMLS CUI [1,3]
C0021853
Resolution
Beschreibung

aGvHD Resolution

Datentyp

integer

Alias
UMLS CUI [1,1]
C0856825
UMLS CUI [1,2]
C1514893
Date of resolution
Beschreibung

aGvHD Date of resolution

Datentyp

date

Maßeinheiten
  • yyyy/mm/dd
Alias
UMLS CUI [1,1]
C0856825
UMLS CUI [1,2]
C1514893
UMLS CUI [1,3]
C0011008
yyyy/mm/dd
Treatment
Beschreibung

Treatment

Datentyp

boolean

Treatment, if yes
Beschreibung

Treatment

Datentyp

text

COMPLICATIONS WITHIN THE FIRST 100 DAYS.
Beschreibung

COMPLICATIONS WITHIN THE FIRST 100 DAYS.

INFECTION RELATED COMPLICATIONS
Beschreibung

INFECTION RELATED COMPLICATIONS

Datentyp

boolean

Pathogen Use the list of pathogens listed after this table for guidance. Use “unknown” if necessary.
Beschreibung

Bacteraemia/ fungemia / viremia / parasites

Datentyp

text

Date Provide different dates for different episodes of the same complication if applicable.
Beschreibung

Bacteraemia/ fungemia / viremia / parasites

Datentyp

date

Pathogen Use the list of pathogens listed after this table for guidance. Use “unknown” if necessary.
Beschreibung

Septic shock

Datentyp

text

Date Provide different dates for different episodes of the same complication if applicable.
Beschreibung

Septic shock

Datentyp

date

Pathogen Use the list of pathogens listed after this table for guidance. Use “unknown” if necessary.
Beschreibung

ARDS

Datentyp

text

Date Provide different dates for different episodes of the same complication if applicable
Beschreibung

ARDS

Datentyp

date

Pathogen Use the list of pathogens listed after this table for guidance. Use “unknown” if necessary.
Beschreibung

Multiorgan failure due to infection

Datentyp

text

Date Provide different dates for different episodes of the same complication if applicable.
Beschreibung

Multiorgan failure due to infection

Datentyp

date

Pathogen Use the list of pathogens listed after this table for guidance. Use “unknown” if necessary.
Beschreibung

Pneumonia

Datentyp

text

Date Provide different dates for different episodes of the same complication if applicable.
Beschreibung

Pneumonia

Datentyp

date

Pathogen Use the list of pathogens listed after this table for guidance. Use “unknown” if necessary.
Beschreibung

Hepatitis

Datentyp

text

Date Provide different dates for different episodes of the same complication if applicable.
Beschreibung

Hepatitis

Datentyp

date

Pathogen Use the list of pathogens listed after this table for guidance. Use “unknown” if necessary.
Beschreibung

CNS infection

Datentyp

text

Date Provide different dates for different episodes of the same complication if applicable.
Beschreibung

CNS infection

Datentyp

date

Pathogen Use the list of pathogens listed after this table for guidance. Use “unknown” if necessary.
Beschreibung

Gut infection

Datentyp

text

Date Provide different dates for different episodes of the same complication if applicable.
Beschreibung

Gut infection

Datentyp

date

Pathogen Use the list of pathogens listed after this table for guidance. Use “unknown” if necessary.
Beschreibung

Skin infection

Datentyp

text

Date Provide different dates for different episodes of the same complication if applicable.
Beschreibung

Skin infection

Datentyp

date

Pathogen Use the list of pathogens listed after this table for guidance. Use “unknown” if necessary.
Beschreibung

Cystitis

Datentyp

text

Date Provide different dates for different episodes of the same complication if applicable.
Beschreibung

Cystitis

Datentyp

date

Pathogen Use the list of pathogens listed after this table for guidance. Use “unknown” if necessary.
Beschreibung

Retinitis

Datentyp

text

Date Provide different dates for different episodes of the same complication if applicable.
Beschreibung

Retinitis

Datentyp

date

Pathogen Use the list of pathogens listed after this table for guidance.
Beschreibung

Other

Datentyp

text

Date Provide different dates for different episodes of the same complication if applicable.
Beschreibung

Other

Datentyp

date

NON INFECTION RELATED COMPLICATIONS
Beschreibung

NON INFECTION RELATED COMPLICATIONS

Datentyp

integer

Alias
UMLS CUI [1]
C0009566
Specify: Idiopathic pneumonia syndrome
Beschreibung

Idiopathic pneumonia syndrome

Datentyp

text

Alias
UMLS CUI [1]
C1504431
Specify: VOD
Beschreibung

VOD

Datentyp

text

Alias
UMLS CUI [1]
C0948441
Specify: Haemorrhagic cystitis, non infectious
Beschreibung

Haemorrhagic cystitis, non infectious

Datentyp

text

Alias
UMLS CUI [1]
C0085692
Specify: ARDS, non infectious
Beschreibung

ARDS, non infectious

Datentyp

text

Alias
UMLS CUI [1]
C0035222
Multiorgan failure, non infectious
Beschreibung

Multiorgan failure, non infectious

Datentyp

integer

Specify: HSCT-associated microangiopathy
Beschreibung

HSCT-associated microangiopathy

Datentyp

text

Alias
UMLS CUI [1]
C0155765
Specify: Renal failure requiring dialysis
Beschreibung

Renal failure requiring dialysis

Datentyp

text

Alias
UMLS CUI [1]
C0035078
Specify: Haemolytic anaemia due to blood group
Beschreibung

Haemolytic anaemia due to blood group

Datentyp

text

Alias
UMLS CUI [1]
C0002878
Other type of infection
Beschreibung

Other type of infection

Datentyp

boolean

Idiopathic pneumonia syndrome
Beschreibung

Date Idiopathic pneumonia syndrome

Datentyp

date

Date VOD
Beschreibung

Date VOD

Datentyp

date

Date Haemorrhagic cystitis, non infectious
Beschreibung

Date Haemorrhagic cystitis, non infectious

Datentyp

date

Date ARDS, non infectious
Beschreibung

Date ARDS, non infectious

Datentyp

date

Date Multiorgan failure, non infectious
Beschreibung

Date Multiorgan failure, non infectious

Datentyp

date

Date HSCT-associated microangiopathy
Beschreibung

Date HSCT-associated microangiopathy

Datentyp

date

Date Renal failure requiring dialysis
Beschreibung

Date Renal failure requiring dialysis

Datentyp

date

DAte Haemolytic anaemia due to blood group
Beschreibung

Date Haemolytic anaemia due to blood group

Datentyp

date

Date of other Type
Beschreibung

Date of other Type

Datentyp

date

Alias
UMLS CUI [1,1]
C2316983
UMLS CUI [1,2]
C0220886
STATUS AT 100 DAYS
Beschreibung

STATUS AT 100 DAYS

Date of Last Contact
Beschreibung

LastContactDate

Datentyp

date

Alias
UMLS CUI [1,1]
C0011008
UMLS CUI [1,2]
C0011008
UMLS CUI [1,3]
C1705415
UMLS CUI [1,4]
C1517741
Presence of cGVHD
Beschreibung

Presence of cGVHD

Datentyp

integer

Alias
UMLS CUI [1]
C0867389
Onset
Beschreibung

Date of Onset

Datentyp

date

Alias
UMLS CUI [1]
C0574845
cGvHD grade
Beschreibung

cGvHD grade

Datentyp

integer

Alias
UMLS CUI [1,1]
C0867389
UMLS CUI [1,2]
C0441800
Organs affected
Beschreibung

Organs affected

Datentyp

integer

Alias
UMLS CUI [1]
C0449642
Relapse or progression
Beschreibung

Relapse or progression

Datentyp

integer

Alias
UMLS CUI [1,1]
C0035020
UMLS CUI [1,2]
C1704632
RELAPSE OR PROGRESSION
Beschreibung

If yes, date diagnosed

Datentyp

date

Method of detection
Beschreibung

Method of detection

Cinical/haematological relapse or progression
Beschreibung

Clinical/hematological

Datentyp

integer

Alias
UMLS CUI [1,1]
C0018939
UMLS CUI [1,2]
C0205210
Date assessed
Beschreibung

Cinical/haematological relapse or progression

Datentyp

date

Date first seen
Beschreibung

Cinical/haematological relapse or progression

Datentyp

date

Cytogenetic relapse or progression
Beschreibung

Cytogenetic relapse or progression

Datentyp

integer

Alias
UMLS CUI [1]
C0010802
Date assessed
Beschreibung

Cytogenetic relapse or progression

Datentyp

date

Date first seen
Beschreibung

Cytogenetic relapse or progression

Datentyp

date

Molecular relapse or progression
Beschreibung

Molecular relapse or progression

Datentyp

integer

Alias
UMLS CUI [1]
C0026376
Date assessed
Beschreibung

Molecular relapse or progression

Datentyp

date

Date first seen
Beschreibung

Molecular relapse or progression

Datentyp

date

LAST DISEASE STATUS
Beschreibung

LAST DISEASE STATUS

Clinical/haematological
Beschreibung

Clincal/Hematological evaluation

Datentyp

integer

Alias
UMLS CUI [1,1]
C0018939
UMLS CUI [1,2]
C0205210
Last date evaluated/Last date assessed
Beschreibung

Date of Evaluation

Datentyp

date

Maßeinheiten
  • yyyy/mm/dd
Alias
UMLS CUI [1]
C2985720
yyyy/mm/dd
Cytogenetic/FISH
Beschreibung

Cytogenetics/FISH

Datentyp

integer

Alias
UMLS CUI [1,1]
C0010802
UMLS CUI [1,2]
C0162789
Last date assessed
Beschreibung

Last date assessed

Datentyp

date

Molecular
Beschreibung

Molecular

Datentyp

text

Alias
UMLS CUI [1]
C0026376
Survival Status
Beschreibung

Survival Status

Datentyp

integer

Alias
UMLS CUI [1]
C1148433
If alive: Type of score used:
Beschreibung

Performance Score

Datentyp

text

Alias
UMLS CUI [1]
C1518965
Score
Beschreibung

Performance score

Datentyp

integer

Alias
UMLS CUI [1]
C1518965
Cause of death (if dead)
Beschreibung

Cause of death

Datentyp

integer

Alias
UMLS CUI [1]
C0007465
If dead and HSCT related cause of death, specify (check as many as apppropriate): GvHD
Beschreibung

GvHD

Datentyp

text

Alias
UMLS CUI [1,1]
C0007465
UMLS CUI [1,2]
C0018133
If dead and HSCT related cause of death, specify (check as many as apppropriate): Interstitial Pneumonitis
Beschreibung

Interstitial Pneumonitis

Datentyp

text

Alias
UMLS CUI [1,1]
C0007465
UMLS CUI [1,2]
C0206061
If dead and HSCT related cause of death, specify (check as many as apppropriate): Pulmonary toxicity
Beschreibung

Pulmonary toxicity

Datentyp

text

Alias
UMLS CUI [1,1]
C0007465
UMLS CUI [1,2]
C0919924
Infection:
Beschreibung

Infection

Datentyp

integer

Alias
UMLS CUI [1]
C0009450
Rejection / poor graft function
Beschreibung

Rejection / poor graft function

Datentyp

integer

Alias
UMLS CUI [1]
C0018129
Veno-Occlusive disease (VOD)
Beschreibung

Veno-Occlusive disease (VOD)

Datentyp

integer

Alias
UMLS CUI [1,1]
C0007465
UMLS CUI [1,2]
C0948441
If dead and HSCT related cause of death, specify (check as many as apppropriate): Haemorrhage
Beschreibung

Haemorrhage

Datentyp

text

Alias
UMLS CUI [1,1]
C0007465
UMLS CUI [1,2]
C0019080
If dead and HSCT related cause of death, specify (check as many as apppropriate): Cardiac toxicity
Beschreibung

Cardiac toxicity

Datentyp

text

Alias
UMLS CUI [1,1]
C0007465
UMLS CUI [1,2]
C0876994
If dead and HSCT related cause of death, specify (check as many as apppropriate): Central nervous system toxicity
Beschreibung

Central nervous system toxicity

Datentyp

text

Alias
UMLS CUI [1,1]
C0007465
UMLS CUI [1,2]
C3160947
If dead and HSCT related cause of death, specify (check as many as apppropriate): Gastro intestinal toxicity
Beschreibung

Gastro intestinal toxicity

Datentyp

text

Alias
UMLS CUI [1,1]
C0007465
UMLS CUI [1,2]
C1142499
If dead and HSCT related cause of death, specify (check as many as apppropriate): Skin toxicity
Beschreibung

Skin toxicity

Datentyp

text

Alias
UMLS CUI [1,1]
C0007465
UMLS CUI [1,2]
C1167791
If dead and HSCT related cause of death, specify (check as many as apppropriate): Renal failure
Beschreibung

Renal failure

Datentyp

text

Alias
UMLS CUI [1,1]
C0007465
UMLS CUI [1,2]
C0035078
If dead and HSCT related cause of death, specify (check as many as apppropriate): Multiple organ failure
Beschreibung

Multiple organ failure

Datentyp

text

Alias
UMLS CUI [1,1]
C0007465
UMLS CUI [1,2]
C0026766
Other transplantation related
Beschreibung

Other transplantation related

Datentyp

boolean

COMMENTS
Beschreibung

COMMENTS

Datentyp

text

IDENTIFICATION & SIGNATURE
Beschreibung

IDENTIFICATION & SIGNATURE

Datentyp

text

ADDITIONAL NOTES IF APPLICABLE
Beschreibung

ADDITIONAL NOTES IF APPLICABLE

ALLOGRAFT APPENDIX
Beschreibung

ALLOGRAFT APPENDIX

Ethnicity
Beschreibung

Ethnicity

Datentyp

text

Alias
UMLS CUI [1]
C0015031
Race
Beschreibung

Race

Datentyp

text

Alias
UMLS CUI [1]
C0034510
Was there any clinically significant co-existing disease or organ impairment at time of patient assessment prior to preparative (conditioning) regimen?
Beschreibung

COMORBID CONDITIONS

Datentyp

boolean

Treated at any time point in the patient's past history, excluding nonmelanoma skin cancer
Beschreibung

Solid tumor, previously present

Datentyp

text

Crohn's disease or ulcerative colitis
Beschreibung

Inflammatory bowel disease

Datentyp

text

Requiring continuation of antimicrobial treatment after day 0
Beschreibung

Infection

Datentyp

text

Requiring treatment with insulin or oral hypoglycemics but not diet alone
Beschreibung

Diabetes

Datentyp

text

Serum crratinine > 2 mg/dL or >177 μmol/L, on dialysis, or prior renal transplantation
Beschreibung

Renal: moderate/severe

Datentyp

text

Chronic hepatitis, bilirubine between Upper Limit Normal (ULN) and 1.5 x the ULN, or AST/ALT between ULN and 2.5 × ULN
Beschreibung

Hepatic: mild

Datentyp

text

Liver cirrhosis, bilirubine greater than 1.5 × ULN, or AST/ALT greater than 2.5 × ULN
Beschreibung

Hepatic: moderate/severe

Datentyp

text

Atrial fibrillation or flutter, sick sinus syndrome, or ventricular arrhythmias
Beschreibung

Arrhythmia

Datentyp

text

Coronary artery disease, congestive heart failure, myocardial infarction, or EF ≤ 50%
Beschreibung

Cardiac

Datentyp

text

Transient ischemic attack or cerebrovascular accident
Beschreibung

Cerebrovascular disease

Datentyp

text

Except mitral valve prolapse
Beschreibung

Heart valve disease

Datentyp

text

DLco and/or FEV1 66-80% or dyspnea on slight activity
Beschreibung

Pulmonary: moderate

Datentyp

text

DLco and/or FEV1 ≤ 65% or dyspnea at rest or requiring oxygen
Beschreibung

Pulmonary: severe

Datentyp

text

Patients with a body mass index > 35 kg/m2
Beschreibung

Obesity

Datentyp

text

Requiring treatment
Beschreibung

Peptic ulcer

Datentyp

text

Depression or anxiety requiring psychiatric consult or treatment
Beschreibung

Psychiatric disturbance

Datentyp

text

other comorbidity, please specify
Beschreibung

other comorbidity

Datentyp

text

Ähnliche Modelle

19pp EBMT Allograft 18Allo.

Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Item Group
ANTIBODIES IN THE PATIENT
Item
HIV
text
Code List
HIV
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)
Item
CMV
text
Code List
CMV
CL Item
Negative  (Negative )
CL Item
Positive  (Positive )
CL Item
Not evaluated  (Not evaluated )
CL Item
Unknown (Unknown)
Item
EBV
text
Code List
EBV
CL Item
Negative  (Negative )
CL Item
Positive  (Positive )
CL Item
Not evaluated  (Not evaluated )
CL Item
Unknown (Unknown)
Item
HBVs
text
Code List
HBVs
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)
Item
HBVc
text
Code List
HBVc
CL Item
Negative  (Negative )
CL Item
Positive  (Positive )
CL Item
Not evaluated  (Not evaluated )
CL Item
Unknown (Unknown)
Item
HBVe
text
Code List
HBVe
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)
Item
HCV
text
Code List
HCV
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)
Item
HTLV.I
text
Code List
HTLV.I
CL Item
Negative  (Negative )
CL Item
Positive  (Positive )
CL Item
Not evaluated  (Not evaluated )
CL Item
Unknown (Unknown)
Item
Toxoplasmosis
text
Code List
Toxoplasmosis
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 Group
PRE-TRANSPLANT HISTORY OF DOCUMENTED INVASIVE FUNGAL INFECTION SINCE INITIAL DIAGNOSIS
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
No (No)
CL Item
Yes (Yes)
CL Item
Unknown (Unknown)
Item
Candida
text
Code List
Candida
CL Item
Yes  (Yes )
CL Item
No (No)
CL Item
Unknown (Unknown)
Item
Aspergillus
text
Code List
Aspergillus
CL Item
Yes (Yes)
CL Item
No (No)
CL Item
Unknown (Unknown)
Item
Pneumocystis carinii
text
Code List
Pneumocystis carinii
CL Item
Yes  (Yes )
CL Item
No  (No )
CL Item
Unknown (Unknown)
Other
Item
Other
boolean
Other
Item
if yes, please specify
text
Item Group
PERFORMANCE SCORE
Item
Type of score used
text
Code List
Type of score used
CL Item
Karnofsky (Karnofsky)
CL Item
Lansky (Lansky)
CL Item
Not evaluated (Not evaluated)
CL Item
Unknown (Unknown)
Item
Score
integer
C1518965 (UMLS CUI [1])
Code List
Score
CL Item
100 (Normal, NED) (1)
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)
CL Item
10 (Moribund) (10)
CL Item
Not evaluated (11)
CL Item
Unknown (12)
Weight
Item
Weight
float
C0005910 (UMLS CUI [1])
Height
Item
Height
float
C0005890 (UMLS CUI [1])
Item Group
DONOR AND STEM CELL SOURCE
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
Item Group
HLA MISMATCHES BETWEEN DONOR AND PATIENT
Item
Serology A
text
Code List
Serology A
CL Item
match (0)
CL Item
one mismatch (1)
CL Item
2 mismatches (2)
CL Item
not evaluated (N/E)
Item
Serology B
text
Code List
Serology B
CL Item
match (0)
CL Item
one mismatch (1)
CL Item
2 mismatches (2)
CL Item
not evaluated (N/E)
Item
Serology C
text
Code List
Serology C
CL Item
match (0)
CL Item
one mismatch (1)
CL Item
2 mismatches (2)
CL Item
not evaluated (N/E)
Item
Serology DRB1
text
Code List
Serology DRB1
CL Item
match  (0)
CL Item
one mismatch (1)
CL Item
2 mismatches  (2)
CL Item
not evaluated (N/E)
Item
Serology DQB1
text
Code List
Serology DQB1
CL Item
match  (0)
CL Item
one mismatch (1)
CL Item
2 mismatches  (2)
CL Item
not evaluated (N/E)
Item
Serology DPB1
text
Code List
Serology DPB1
CL Item
match  (0)
CL Item
one mismatch (1)
CL Item
2 mismatches  (2)
CL Item
not evaluated (N/E)
Item
DNA A
text
Code List
DNA A
CL Item
match  (0)
CL Item
one mismatch (1)
CL Item
2 mismatches  (2)
CL Item
not evaluated (N/E)
Item
DNA B
text
Code List
DNA B
CL Item
match  (0)
CL Item
one mismatch (1)
CL Item
2 mismatches  (2)
CL Item
not evaluated (N/E)
Item
DNA C
text
Code List
DNA C
CL Item
match  (0)
CL Item
one mismatch (1)
CL Item
2 mismatches  (2)
CL Item
not evaluated (N/E)
Item
DNA DRB1
text
Code List
DNA DRB1
CL Item
match  (0)
CL Item
one mismatch (1)
CL Item
2 mismatches  (2)
CL Item
not evaluated (N/E)
Item
DNA DQB1
text
Code List
DNA DQB1
CL Item
match  (0)
CL Item
one mismatch (1)
CL Item
2 mismatches  (2)
CL Item
not evaluated (N/E)
Item
DNA DPB1
text
Code List
DNA DPB1
CL Item
match  (0)
CL Item
one mismatch (1)
CL Item
2 mismatches  (2)
CL Item
not evaluated (N/E)
Item Group
BLOOD GROUP, DATE OF BIRTH AND SEX OF DONOR
Item
ABO group
text
Code List
ABO group
CL Item
A (A)
CL Item
B (B)
CL Item
AB (AB)
CL Item
O (O)
Date of birth
Item
Date of birth
date
C0421451 (UMLS CUI [1])
Item
Sex
text
C0079399 (UMLS CUI [1])
Code List
Sex
CL Item
Male (1)
CL Item
Female (2)
Item Group
STATUS OF THE DONOR OR CORD BLOOD UNIT BEFORE HSCT
Item
HIV
text
Code List
HIV
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)
Item
CMV
text
Code List
CMV
CL Item
Negative  (Negative )
CL Item
Positive  (Positive )
CL Item
Not evaluated  (Not evaluated )
CL Item
Unknown (Unknown)
Item
EBV
text
Code List
EBV
CL Item
Negative  (Negative )
CL Item
Positive  (Positive )
CL Item
Not evaluated  (Not evaluated )
CL Item
Unknown (Unknown)
Item
HBVs
text
Code List
HBVs
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)
Item
HBVc
text
Code List
HBVc
CL Item
Negative  (Negative )
CL Item
Positive  (Positive )
CL Item
Not evaluated  (Not evaluated )
CL Item
Unknown (Unknown)
Item
HBVe
text
Code List
HBVe
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)
Item
HCV
text
Code List
HCV
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)
Item
HTLV.I
text
Code List
HTLV.I
CL Item
Negative  (Negative )
CL Item
Positive  (Positive )
CL Item
Not evaluated  (Not evaluated )
CL Item
Unknown (Unknown)
Item
Toxoplasmosis
text
Code List
Toxoplasmosis
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
No (No)
CL Item
Yes (Yes)
CL Item
Unknown (Unknown)
GROWTH FACTORS ADMINISTERED TO THE DONOR
Item
If Yes, please specify
text
Item Group
HISTOCOMPATIBILITY RESULTS
Laboratory / Hospital
Item
Laboratory / Hospital
text
Unit
Item
Unit
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
Item Group
DNA (Allelic/molecular) HLA typing done
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
CL Item
A (A)
CL Item
B (B)
CL Item
C (C)
CL Item
DRB1 (DRB1)
CL Item
DQB1 (DQB1)
CL Item
DPB1 (DPB1)
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 Group
Serology (antigenic) HLA typing done
Item
Serology (antigenic) HLA typing done
text
Code List
Serology (antigenic) HLA typing done
CL Item
No (No)
CL Item
Yes (Yes)
Item
Serology
text
Code List
Serology
CL Item
A (A)
CL Item
B (B)
CL Item
C (C)
CL Item
DRB1 (DRB1)
CL Item
DQB1 (DQB1)
CL Item
DPB1 (DPB1)
Item
Serology
text
Code List
Serology
CL Item
Not evaluated (Not evaluated)
Item
HLA
text
Code List
HLA
CL Item
Not evaluated (Not evaluated)
Item Group
GRAFT MANIPULATION
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)
CL Item
No (No)
CL Item
Yes (Yes)
CL Item
No  (No )
CL Item
Yes (Yes)
CL Item
Unknown (Unknown)
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 )
CL Item
Other (Other)
CL Item
No (No)
CL Item
Yes: Monoclonal antibodies (Yes: Monoclonal antibodies)
CL Item
unknown (unknown)
Item
Monoclonal antibodies
text
Code List
Monoclonal antibodies
CL Item
No (No)
CL Item
Yes (Yes)
CL Item
Unknown (Unknown)
Item
if yes
text
Code List
if yes
CL Item
CD 34+  (CD 34+ )
CL Item
Other (Other)
Monoclonal antibodies
Item
if other, please specify
text
Item
EXPANSION
text
Code List
EXPANSION
CL Item
No (No)
CL Item
Yes (Yes)
CL Item
Unknown (Unknown)
Item
GENE MANIPULATION (gene transfer/transduction)
text
Code List
GENE MANIPULATION (gene transfer/transduction)
CL Item
No (No)
CL Item
Yes (Yes)
CL Item
Unknown (Unknown)
Item Group
CELL INFUSION
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
DMSO (DMSO)
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 Group
CELL VIABILITY RESULTS AT HSCT CENTRE
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)
Item
Method used
text
Code List
Method used
CL Item
7-AAD (7-AAD)
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
Item Group
CELLS INFUSED FROM THIS DONOR AND STEM CELL SOURCE COMBINATION
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)
Item Group
HSC TRANSPLANTATION
Chronological number of HSCT for this patient
Item
Chronological number of HSCT for this patient
integer
CL Item
No  (No )
CL Item
Yes  (Yes )
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
CL Item
Allo (Allo)
CL Item
Auto (Auto)
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)
CL Item
Other (Other)
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
No (No)
CL Item
Yes (Yes)
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
Item Group
PREPARATIVE TREATMENT (conditioning)
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
No (No)
CL Item
Yes (Yes)
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
No (No)
CL Item
Yes (Yes)
CL Item
Unknown (Unknown)
Item Group
Drugs
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?
CL Item
No (1)
CL Item
Yes (2)
CL Item
Unknown (3)
Item
UNITS IF NOT RADIO LABELLED*
integer
Code List
UNITS IF NOT RADIO LABELLED*
CL Item
mg (1)
CL Item
mg/m2 (2)
CL Item
mg/Kg (3)
CL Item
* (4)
Item
UNITS IF RADIO LABELLED
integer
Code List
UNITS IF RADIO LABELLED
CL Item
mCi (1)
CL Item
mBq (2)
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
CL Item
Oral  (Oral )
CL Item
IV  (IV )
CL Item
Both (Both)
Item
Animal origin For ALG, ATG (ALS, ATS):
text
Code List
Animal origin For ALG, ATG (ALS, ATS):
CL Item
Horse  (Horse )
CL Item
Rabbit  (Rabbit )
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
No  (No )
CL Item
Yes  (Yes )
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
No (No)
CL Item
Yes (Yes)
CL Item
Unknown (Unknown)
Total dose (Gy)
Item
Total dose (Gy)
float
Item
Local radiotherapy
text
Code List
Local radiotherapy
CL Item
No  (No )
CL Item
Yes  (Yes )
CL Item
Unknown (Unknown)
Item Group
TREATMENT DURING THE IMMEDIATE POST-TRANSPLANT PERIOD
Item
GROWTH FACTORS (CYTOKINES) (excluding growth factors administered for engraftment failure)
text
Code List
GROWTH FACTORS (CYTOKINES) (excluding growth factors administered for engraftment failure)
CL Item
No (No)
CL Item
Yes (Yes)
CL Item
nknown (nknown)
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
No (No)
CL Item
Yes (Yes)
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
Other (Other)
CL Item
Unknown (Unknown)
CELLULAR THERAPY
Item
if other, please specify
text
Item Group
Number of cells infused by type
Nucleated cells (/kg*)
Item
Nucleated cells (/kg*)
float
Item
Nucleated cells (/kg*)
text
Code List
Nucleated cells (/kg*)
CL Item
Not evaluated (Not evaluated)
CL Item
unknown (unknown)
CD 34+ (cells/kg*)
Item
CD 34+ (cells/kg*)
float
Item
CD 34+ (cells/kg*)
integer
Code List
CD 34+ (cells/kg*)
CL Item
Not evaluated (1)
CL Item
unknown (2)
CD 3+ (cells/kg*)
Item
CD 3+ (cells/kg*)
float
Item
CD 3+ (cells/kg*)
integer
Code List
CD 3+ (cells/kg*)
CL Item
Not evaluated (1)
CL Item
unknown (2)
Item Group
Total number of cells infused
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)
CL Item
Other (Other)
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
No (1)
CL Item
Yes (2)
CL Item
Unknown (3)
Item
Drugs
text
Code List
Drugs
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))
CL Item
Other (Other)
Drugs
Item
If Monoclonal antibodies, specify
text
Drugs
Item
If Other, please specify
text
Item Group
GRAFT PERFORMANCE
Item
GRAFT PERFORMANCE Haemopoietic reconstitution (Engraftment)
text
Code List
GRAFT PERFORMANCE Haemopoietic reconstitution (Engraftment)
CL Item
Yes (Yes)
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
Yes (Yes)
CL Item
No (No)
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
Yes (1)
CL Item
No (2)
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
Yes (Yes)
CL Item
No (No)
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)
Item Group
DATE(S) AND RESULTS OF ALL TESTS DONE FOR ALL DONORS
undefined item
Item
text
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])
Code List
Test used
CL Item
FISH (FISH)
CL Item
Molecular (Molecular)
CL Item
Cytogenetic (Cytogenetic)
CL Item
ABO group (ABO group)
CL Item
Other (Other)
CL Item
unknown (unknown)
Item
TREATMENT FOR FAILURE (If engraftment failure)
integer
Code List
TREATMENT FOR FAILURE (If engraftment failure)
CL Item
No (1)
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
ALLOgraft (5)
CL Item
Autologous PBSC re-infusion (no preparative treatment or conditioning) (6)
CL Item
Autologous BM re-infusion (no preparative treatment or conditioning) (7)
CL Item
Other (8)
Item Group
ACUTE GRAFT VERSUS HOST DISEASE (GvHD)
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
grade I  (2)
CL Item
grade II  (3)
CL Item
grade III  (4)
CL Item
grade IV  (5)
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])
Code List
Stage skin
CL Item
0 (1)
CL Item
1 (2)
CL Item
2 (3)
CL Item
3 (4)
CL Item
4 (5)
CL Item
Not evaluated (6)
CL Item
unknown (7)
Item
Stage liver
integer
C0856825 (UMLS CUI [1,1])
C1306673 (UMLS CUI [1,2])
C0023884 (UMLS CUI [1,3])
Code List
Stage liver
CL Item
0 (1)
CL Item
1 (2)
CL Item
2 (3)
CL Item
3 (4)
CL Item
4 (5)
CL Item
Not evaluated (6)
CL Item
unknown (7)
Item
Stage gut
integer
C0856825 (UMLS CUI [1,1])
C1306673 (UMLS CUI [1,2])
C0021853 (UMLS CUI [1,3])
Code List
Stage gut
CL Item
0 (1)
CL Item
1 (2)
CL Item
2 (3)
CL Item
3 (4)
CL Item
4 (5)
CL Item
Not evaluated (6)
CL Item
unknown (7)
Item
Resolution
integer
C0856825 (UMLS CUI [1,1])
C1514893 (UMLS CUI [1,2])
Code List
Resolution
CL Item
No  (1)
CL Item
Yes (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)
CL Item
MoAB (MoAB)
CL Item
Other (Other)
Item Group
COMPLICATIONS WITHIN THE FIRST 100 DAYS.
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)
CL Item
Yes (2)
Item
Specify: Idiopathic pneumonia syndrome
text
C1504431 (UMLS CUI [1])
Code List
Specify: Idiopathic pneumonia syndrome
CL Item
Yes (Yes)
CL Item
No  (No )
CL Item
Unknown (Unknown)
Item
Specify: VOD
text
C0948441 (UMLS CUI [1])
Code List
Specify: VOD
CL Item
Yes (Yes)
CL Item
No  (No )
CL Item
Unknown (Unknown)
Item
Specify: Haemorrhagic cystitis, non infectious
text
C0085692 (UMLS CUI [1])
Code List
Specify: Haemorrhagic cystitis, non infectious
CL Item
Yes  (Yes )
CL Item
No  (No )
CL Item
Unknown (Unknown)
Item
Specify: ARDS, non infectious
text
C0035222 (UMLS CUI [1])
Code List
Specify: ARDS, non infectious
CL Item
Yes (Yes)
CL Item
No (No)
CL Item
Unknown (Unknown)
Item
Multiorgan failure, non infectious
integer
Code List
Multiorgan failure, non infectious
CL Item
Yes (1)
CL Item
No (2)
CL Item
Unknown (3)
Item
Specify: HSCT-associated microangiopathy
text
C0155765 (UMLS CUI [1])
Code List
Specify: HSCT-associated microangiopathy
CL Item
Yes (Yes)
CL Item
No (No)
CL Item
Unknown (Unknown)
Item
Specify: Renal failure requiring dialysis
text
C0035078 (UMLS CUI [1])
Code List
Specify: Renal failure requiring dialysis
CL Item
Yes (Yes)
CL Item
No (No)
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
Yes (Yes)
CL Item
No (No)
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])
Item Group
STATUS AT 100 DAYS
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
No (1)
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])
Code List
cGvHD grade
CL Item
limited (1)
CL Item
Extensive (2)
CL Item
not evaluated (3)
Item
Organs affected
integer
C0449642 (UMLS CUI [1])
Code List
Organs affected
CL Item
Skin (1)
CL Item
Gut (2)
CL Item
Liver (3)
CL Item
Mouth (4)
CL Item
Eyes (5)
CL Item
Lung (6)
CL Item
Other, specify (7)
CL Item
Unknown (8)
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
No (2)
CL Item
yes (3)
CL Item
Continuous progression since transplant (4)
CL Item
Unknown (5)
If yes, date diagnosed
Item
RELAPSE OR PROGRESSION
date
Item Group
Method of detection
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
No (1)
CL Item
Yes (2)
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
No (1)
CL Item
Yes (2)
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
No (1)
CL Item
Yes (2)
CL Item
Not evaluated (3)
Molecular relapse or progression
Item
Date assessed
date
Molecular relapse or progression
Item
Date first seen
date
Item Group
LAST DISEASE STATUS
Item
Clinical/haematological
integer
C0018939 (UMLS CUI [1,1])
C0205210 (UMLS CUI [1,2])
Code List
Clinical/haematological
CL Item
No (1)
CL Item
Yes (2)
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
No (1)
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])
Code List
Molecular
CL Item
No (No)
CL Item
yes (yes)
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
CL Item
alive (0)
CL Item
dead (1)
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
Lansky (Lansky)
CL Item
Not evaluated (Not evaluated)
CL Item
Unknown (Unknown)
Item
Score
integer
C1518965 (UMLS CUI [1])
Code List
Score
CL Item
100 (Normal, NED) (1)
CL Item
10 (Moribund) (10)
CL Item
Not evaluated (11)
CL Item
Unknown (12)
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)
CL Item
Unknown (4)
CL Item
Other (5)
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
No  (No )
CL Item
Unknown (Unknown)
CL Item
Yes (Yes)
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
No  (No )
CL Item
Unknown (Unknown)
CL Item
Yes (Yes)
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
No  (No )
CL Item
Unknown (Unknown)
CL Item
Yes (Yes)
Item
Infection:
integer
C0009450 (UMLS CUI [1])
Code List
Infection:
CL Item
bacterial  (1)
CL Item
viral  (2)
CL Item
fungal  (3)
CL Item
parasitic  (4)
CL Item
unknown (5)
Item
Rejection / poor graft function
integer
C0018129 (UMLS CUI [1])
Code List
Rejection / poor graft function
CL Item
Yes (1)
CL Item
No (2)
CL Item
Unknown (3)
Item
Veno-Occlusive disease (VOD)
integer
C0007465 (UMLS CUI [1,1])
C0948441 (UMLS CUI [1,2])
Code List
Veno-Occlusive disease (VOD)
CL Item
Yes (1)
CL Item
No (2)
CL Item
Unknown (3)
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
No  (No )
CL Item
Unknown (Unknown)
CL Item
Yes (Yes)
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
No  (No )
CL Item
Unknown (Unknown)
CL Item
Yes (Yes)
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
No  (No )
CL Item
Unknown (Unknown)
CL Item
Yes (Yes)
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
No  (No )
CL Item
Unknown (Unknown)
CL Item
Yes (Yes)
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
No  (No )
CL Item
Unknown (Unknown)
CL Item
Yes (Yes)
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
No  (No )
CL Item
Unknown (Unknown)
CL Item
Yes (Yes)
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
No  (No )
CL Item
Unknown (Unknown)
CL Item
Yes (Yes)
Other transplantation related
Item
Other transplantation related
boolean
COMMENTS
Item
COMMENTS
text
IDENTIFICATION & SIGNATURE
Item
IDENTIFICATION & SIGNATURE
text
Item Group
ADDITIONAL NOTES IF APPLICABLE
Item Group
ALLOGRAFT APPENDIX
Item
Ethnicity
text
C0015031 (UMLS CUI [1])
Code List
Ethnicity
CL Item
Hispanic or Latino (1)
CL Item
Not Hispanic or Latino (2)
Item
Race
text
C0034510 (UMLS CUI [1])
Code List
Race
CL Item
White (1)
CL Item
Black (2)
CL Item
Asian (3)
CL Item
American Indian or Alaska Native (4)
CL Item
Native Hawaiian or Pacific Native (5)
CL Item
Other (6)
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
No (No)
CL Item
Yes (Yes)
CL Item
Not evaluated (Not evaluated)
Item
Crohn's disease or ulcerative colitis
text
Code List
Crohn's disease or ulcerative colitis
CL Item
No  (No )
CL Item
Yes (Yes)
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
No (No)
CL Item
Yes (Yes)
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
No  (No )
CL Item
Yes (Yes)
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
No (No)
CL Item
Yes (Yes)
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
No (No)
CL Item
Yes (Yes)
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
No (No)
CL Item
Yes  (Yes )
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
No (No)
CL Item
Yes (Yes)
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
No (No)
CL Item
yes (yes)
CL Item
Not evaluated (Not evaluated)
Item
Transient ischemic attack or cerebrovascular accident
text
Code List
Transient ischemic attack or cerebrovascular accident
CL Item
No (No)
CL Item
Yes (Yes)
CL Item
Not evaluated (Not evaluated)
Item
Except mitral valve prolapse
text
Code List
Except mitral valve prolapse
CL Item
No (No)
CL Item
Yes (Yes)
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
No (No)
CL Item
Yes (Yes)
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
No (No)
CL Item
Yes (Yes)
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
No (No)
CL Item
Yes (Yes)
CL Item
Not evaluated (Not evaluated)
Item
Requiring treatment
text
Code List
Requiring treatment
CL Item
No (No)
CL Item
Yes (Yes)
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
No (No)
CL Item
Yes (Yes)
CL Item
Not evaluated (Not evaluated)
other comorbidity
Item
other comorbidity, please specify
text

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