ID

16384

Description

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

Mots-clés

  1. 14/07/2016 14/07/2016 -
  2. 21/08/2016 21/08/2016 -
  3. 13/04/2021 13/04/2021 - Dr. rer. medic Philipp Neuhaus
  4. 20/09/2021 20/09/2021 -
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14 juillet 2016

DOI

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Licence

Creative Commons BY-NC 3.0

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EBMT Allograft

19pp EBMT Allograft 18Allo.

ANTIBODIES IN THE PATIENT
Description

ANTIBODIES IN THE PATIENT

HIV
Description

HIV

Type de données

text

HIV ANTIGENS (if testing applicable)
Description

HIV

Type de données

text

CMV
Description

CMV

Type de données

text

EBV
Description

EBV

Type de données

text

HBVs
Description

HBVs

Type de données

text

HBVs ANTIGENS (if testing applicable)
Description

HBVs

Type de données

text

HBVc
Description

HBVc

Type de données

text

HBVe
Description

HBVe

Type de données

text

HBVe ANTIGENS (if testing applicable)
Description

HBVe

Type de données

text

HCV
Description

HCV

Type de données

text

HCV ANTIGENS (if testing applicable)
Description

HCV

Type de données

text

HTLV.I
Description

HTLV.I

Type de données

text

Toxoplasmosis
Description

Toxoplasmosis

Type de données

text

if other Antibodies in the patient
Description

Other

Type de données

text

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

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

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

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

Type de données

text

Candida
Description

Candida

Type de données

text

Aspergillus
Description

Aspergillus

Type de données

text

Pneumocystis carinii
Description

Pneumocystis carinii

Type de données

text

Other
Description

Other

Type de données

boolean

if yes, please specify
Description

Other

Type de données

text

PERFORMANCE SCORE
Description

PERFORMANCE SCORE

Type of score used
Description

Type of score used

Type de données

text

Score
Description

Performance score

Type de données

integer

Alias
UMLS CUI [1]
C1518965
Weight
Description

Weight

Type de données

float

Unités de mesure
  • kg
Alias
UMLS CUI [1]
C0005910
kg
Height
Description

Height

Type de données

float

Unités de mesure
  • cm
Alias
UMLS CUI [1]
C0005890
cm
DONOR AND STEM CELL SOURCE
Description

DONOR AND STEM CELL SOURCE

Multiple donors
Description

Multiple donors

Type de données

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
Description

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

Type de données

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
Description

SOURCE OF STEM CELLS FOR THIS DONOR/PRODUCT

Type de données

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)
Description

Identification of Donor or Cord Blood Unit given by the centre

Type de données

text

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

Number in the infusion order

Type de données

text

Number in the infusion order
Description

Number in the infusion order

Type de données

text

HLA MATCH TYPE (DONOR RELATION WITH PATIENT)
Description

HLA MATCH TYPE

Type de données

text

Name of the Donor registry
Description

Name of the Donor registry

Type de données

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”)
Description

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

Type de données

text

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

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

Type de données

text

Name of the Cord blood bank
Description

Name of the Cord blood bank

Type de données

text

Eurocord code for the cord blood bank
Description

Eurocord code for the cord blood bank

Type de données

text

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

Identification of Cord Blood Unit given by the cord blood bank

Type de données

text

HLA MISMATCHES BETWEEN DONOR AND PATIENT
Description

HLA MISMATCHES BETWEEN DONOR AND PATIENT

Serology A
Description

Serology

Type de données

text

Serology B
Description

Serology

Type de données

text

Serology C
Description

Serology

Type de données

text

Serology DRB1
Description

Serology

Type de données

text

Serology DQB1
Description

Serology

Type de données

text

Serology DPB1
Description

Serology

Type de données

text

DNA A
Description

DNA

Type de données

text

DNA B
Description

DNA

Type de données

text

DNA C
Description

DNA

Type de données

text

DNA DRB1
Description

DNA

Type de données

text

DNA DQB1
Description

DNA

Type de données

text

DNA DPB1
Description

DNA

Type de données

text

BLOOD GROUP, DATE OF BIRTH AND SEX OF DONOR
Description

BLOOD GROUP, DATE OF BIRTH AND SEX OF DONOR

ABO group
Description

ABO group

Type de données

text

Date of birth
Description

Date of birth

Type de données

date

Alias
UMLS CUI [1]
C0421451
Sex
Description

Sex

Type de données

text

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

STATUS OF THE DONOR OR CORD BLOOD UNIT BEFORE HSCT

HIV
Description

HIV

Type de données

text

HIV ANTIGENS (if testing applicable)
Description

HIV

Type de données

text

CMV
Description

CMV

Type de données

text

EBV
Description

EBV

Type de données

text

HBVs
Description

HBVs

Type de données

text

HBVs ANTIGENS (if testing applicable)
Description

HBVs

Type de données

text

HBVc
Description

HBVc

Type de données

text

HBVe
Description

HBVe

Type de données

text

HBVe ANTIGENS (if testing applicable)
Description

HBVe

Type de données

text

HCV
Description

HCV

Type de données

text

HCV ANTIGENS (if testing applicable)
Description

HCV

Type de données

text

HTLV.I
Description

HTLV.I

Type de données

text

Toxoplasmosis
Description

Toxoplasmosis

Type de données

text

if other Antibodies in the patient
Description

Other

Type de données

text

Date of harvest or cord blood collection
Description

Date of harvest or cord blood collection

Type de données

date

GROWTH FACTORS ADMINISTERED TO THE DONOR
Description

GROWTH FACTORS ADMINISTERED TO THE DONOR

Type de données

text

If Yes, please specify
Description

GROWTH FACTORS ADMINISTERED TO THE DONOR

Type de données

text

HISTOCOMPATIBILITY RESULTS
Description

HISTOCOMPATIBILITY RESULTS

Laboratory / Hospital
Description

Laboratory / Hospital

Type de données

text

Unit
Description

Unit

Type de données

text

Contact number (telephone/fax)
Description

Contact number

Type de données

text

Technique Used
Description

Technique Used

Type de données

text

Serology (antigenic) HLA typing done
Description

Serology (antigenic) HLA typing done

Type de données

boolean

DNA (Allelic/molecular) HLA typing done
Description

DNA (Allelic/molecular) HLA typing done

DNA (Allelic/molecular) HLA typing done
Description

DNA (Allelic/molecular) HLA typing done

Type de données

boolean

DNA (Allelic/molecular) HLA typing done
Description

Locus

Type de données

text

HLA string
Description

HLA string

Type de données

text

NMDP code
Description

NMDP code

Type de données

text

NMDP code
Description

NMDP code

Type de données

boolean

NMDP code
Description

NMDP code

Type de données

boolean

Serology (antigenic) HLA typing done
Description

Serology (antigenic) HLA typing done

Serology (antigenic) HLA typing done
Description

Serology (antigenic) HLA typing done

Type de données

text

Serology
Description

Serology

Type de données

text

Serology
Description

Serology

Type de données

text

HLA
Description

HLA

Type de données

text

GRAFT MANIPULATION
Description

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)
Description

Identification of donor or Cord Blood Unit given by the centre

Type de données

text

Number in the infusion order (if applicable)
Description

Number in the infusion order

Type de données

text

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

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

Type de données

text

NEGATIVE SELECTION
Description

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

Type de données

text

if negative selection
Description

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

Type de données

text

if positive selection
Description

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

Type de données

text

Monoclonal antibodies
Description

Monoclonal antibodies

Type de données

text

if yes
Description

Monoclonal antibodies

Type de données

text

if other, please specify
Description

Monoclonal antibodies

Type de données

text

EXPANSION
Description

EXPANSION

Type de données

text

GENE MANIPULATION (gene transfer/transduction)
Description

GENE MANIPULATION

Type de données

text

CELL INFUSION
Description

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)
Description

Identification of donor or Cord Blood Unit given by the centre

Type de données

text

Number in the infusion order (if applicable)
Description

Number in the infusion order

Type de données

text

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

Route of infusion

Type de données

text

If other, please specify
Description

Route of infusion

Type de données

text

Infusion method
Description

Infusion method

Type de données

text

if other, please specify
Description

Infusion method

Type de données

text

CELL VIABILITY RESULTS AT HSCT CENTRE
Description

CELL VIABILITY RESULTS AT HSCT CENTRE

Tests performed after thawing of an aliquot on
Description

Tests performed after thawing of an aliquot on

Type de données

text

Method used
Description

Method used

Type de données

text

if other, please specify
Description

Method used

Type de données

text

Viability of all cells
Description

Viability of all cells

Type de données

float

Viability of CD34+ cells
Description

Viability of CD34+ cells

Type de données

float

CELLS INFUSED FROM THIS DONOR AND STEM CELL SOURCE COMBINATION
Description

CELLS INFUSED FROM THIS DONOR AND STEM CELL SOURCE COMBINATION

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

Bone Marrow

Type de données

float

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

Bone Marrow

Type de données

text

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

Bone Marrow

Type de données

float

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

Bone Marrow

Type de données

text

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

Bone Marrow

Type de données

float

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

Bone Marrow

Type de données

text

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

Peripheral Blood

Type de données

float

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

Peripheral Blood

Type de données

text

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

Peripheral Blood

Type de données

float

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

Peripheral Blood

Type de données

text

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

Peripheral Blood

Type de données

float

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

Peripheral Blood

Type de données

text

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

Cord Blood

Type de données

float

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

Cord Blood

Type de données

text

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

Cord Blood

Type de données

float

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

Cord Blood

Type de données

text

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

Cord Blood

Type de données

float

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

Cord Blood

Type de données

text

HSC TRANSPLANTATION
Description

HSC TRANSPLANTATION

Chronological number of HSCT for this patient
Description

Chronological number of HSCT for this patient

Type de données

integer

If > 1
Description

Donor the same as for previous HSCT?

Type de données

text

Date of previous HSCT
Description

Date of previous HSCT

Type de données

date

Type of previous HSCT
Description

Type of previous HSCT

Type de données

text

Reason for this transplant
Description

Reason for this transplant

Type de données

text

if other, please specify
Description

Reason for this transplant

Type de données

text

HSCT part of a multiple sequential graft protocol
Description

HSCT part of a multiple sequential graft protocol

Type de données

text

Type of multiple graft protocol
Description

Type of multiple graft protocol

Type de données

text

Graft number in the protocol
Description

Graft number in the protocol

Type de données

integer

total number of HSCTs in the program
Description

total number of HSCTs in the program

Type de données

integer

PREPARATIVE TREATMENT (conditioning)
Description

PREPARATIVE TREATMENT (conditioning)

PREPARATIVE (CONDITIONING) REGIMEN GIVEN
Description

PREPARATIVE (CONDITIONING) REGIMEN GIVEN

Type de données

boolean

Was regimen intended to be myeloablative
Description

Was regimen intended to be myeloablative

Type de données

text

Main reason (tick only one)
Description

Reason not myeloablative

Type de données

text

Age of recipient
Description

Reason not myeloablative

Type de données

boolean

Comorbid conditions
Description

Reason not myeloablative

Type de données

boolean

Prior HSCT
Description

Reason not myeloablative

Type de données

boolean

Protocol driven
Description

Reason not myeloablative

Type de données

boolean

If other additional reason, please specify
Description

Reason not myeloablative

Type de données

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
Description

Drugs

Type de données

text

Drugs
Description

Drugs

NAME OF DRUG
Description

NAME OF DRUG

Type de données

text

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

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

Type de données

text

IF MONOCLONAL ANTIBODY, RADIO LABELLED?
Description

IF MONOCLONAL ANTIBODY, RADIO LABELLED?

Type de données

integer

UNITS IF NOT RADIO LABELLED*
Description

UNITS IF NOT RADIO LABELLED*

Type de données

integer

UNITS IF RADIO LABELLED
Description

UNITS IF RADIO LABELLED

Type de données

integer

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

ADDITIONAL DRUG INFORMATION

Type de données

text

Route of administration
Description

ADDITIONAL DRUG INFORMATION

Type de données

text

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

Animal origin

Type de données

text

if other, please specify
Description

Animal origin

Type de données

text

TBI (If yes, complete TBI Form)
Description

TBI

Type de données

text

Total dose (Gy)
Description

Total dose (Gy)

Type de données

float

Number of fractions
Description

Number of fractions

Type de données

float

radiation days
Description

radiation days

Type de données

integer

TLI / TNI / TAI
Description

TLI / TNI / TAI

Type de données

text

Total dose (Gy)
Description

Total dose (Gy)

Type de données

float

Local radiotherapy
Description

Local radiotherapy

Type de données

text

TREATMENT DURING THE IMMEDIATE POST-TRANSPLANT PERIOD
Description

TREATMENT DURING THE IMMEDIATE POST-TRANSPLANT PERIOD

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

GROWTH FACTORS (CYTOKINES)

Type de données

text

If yes, please specify
Description

GROWTH FACTORS (CYTOKINES)

Type de données

text

Date started
Description

Date started

Type de données

date

CELLULAR THERAPY
Description

CELLULAR THERAPY

Type de données

text

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

Date of first infusion

Type de données

date

CELLULAR THERAPY if yes
Description

CELLULAR THERAPY

Type de données

integer

if other, please specify
Description

CELLULAR THERAPY

Type de données

text

Number of cells infused by type
Description

Number of cells infused by type

Nucleated cells (/kg*)
Description

Nucleated cells (/kg*)

Type de données

float

Nucleated cells (/kg*)
Description

Nucleated cells (/kg*)

Type de données

text

CD 34+ (cells/kg*)
Description

CD 34+ (cells/kg*)

Type de données

float

CD 34+ (cells/kg*)
Description

CD 34+ (cells/kg*)

Type de données

integer

CD 3+ (cells/kg*)
Description

CD 3+ (cells/kg*)

Type de données

float

CD 3+ (cells/kg*)
Description

CD 3+ (cells/kg*)

Type de données

integer

Total number of cells infused
Description

Total number of cells infused

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

All cells (cells/kg*)

Type de données

float

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

All cells (cells/kg*)

Type de données

integer

Chronological number of this cell therapy for this patient
Description

Chronological number of this cell therapy for this patient

Type de données

integer

Indication (check all that apply)
Description

Indication

Type de données

text

Indication if other, please specify
Description

Indication

Type de données

text

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

Number of infusions within 10 weeks

Type de données

integer

GVHD PREVENTION IN THE RECIPIENT (THERAPEUTIC IMMUNOSUPPRESSION)
Description

GVHD PREVENTION IN THE RECIPIENT (THERAPEUTIC IMMUNOSUPPRESSION)

Type de données

integer

Drugs
Description

Drugs

Type de données

text

If Monoclonal antibodies, specify
Description

Drugs

Type de données

text

If Other, please specify
Description

Drugs

Type de données

text

GRAFT PERFORMANCE
Description

GRAFT PERFORMANCE

GRAFT PERFORMANCE Haemopoietic reconstitution (Engraftment)
Description

GRAFT PERFORMANCE

Type de données

text

Neutrophils > 0.5 x 109/l reached?
Description

Neutrophils > 0.5 x 109/l reached?

Type de données

text

Date Neutrophils > 0.5 x 109/l
Description

Date Neutrophils > 0.5 x 109/l

Type de données

date

Platelets > 20 x 109/l reached?
Description

Platelets > 20 x 109/l reached?

Type de données

integer

Date Platelets > 20 x 109/l
Description

Date Platelets > 20 x 109/l

Type de données

date

Platelets > 50 x 109/l reached?
Description

Platelets > 50 x 109/l reached?

Type de données

text

Date Platelets > 50 x 109/l
Description

Date Platelets > 50 x 109/l

Type de données

date

Date last assessment
Description

Date last assessment

Type de données

date

Date of graft failure
Description

Date of graft failure

Type de données

date

Overall chimaerism
Description

HAEMOPOIETIC CHIMAERISM

Type de données

text

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

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

undefined item
Description

undefined item

Type de données

text

Date of test
Description

Date of test

Type de données

date

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

Identification

Type de données

text

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

Number in the infusion order

Type de données

text

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

Bone marrow

Type de données

float

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

PB mononuclear cells (PBMC)

Type de données

float

Unités de mesure
  • %
Alias
UMLS CUI [1]
C1321301
%
Cell type on which test was performed
Description

T-cell

Type de données

float

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

B-Cells

Type de données

float

Unités de mesure
  • %
Alias
UMLS CUI [1]
C0004561
%
Cell type on which test was performed (% Donor cells): Red blood cells
Description

Red blood cells

Type de données

float

Unités de mesure
  • %
Alias
UMLS CUI [1]
C0014772
%
Cell type on which test was performed (% Donor cells): Monocytes
Description

Monocytes

Type de données

float

Unités de mesure
  • %
Alias
UMLS CUI [1]
C0026473
%
Cell type on which test was performed (% Donor cells): PMNs (neutrophils)
Description

PMNs (neutrophils)

Type de données

float

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

Lymphocytes, NOS

Type de données

float

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

Myeloid cells, NOS

Type de données

float

Unités de mesure
  • %
Alias
UMLS CUI [1]
C0887899
%
Cell type on which test was performed (% Donor cells): Other
Description

Other cell type - value

Type de données

float

Unités de mesure
  • %
Alias
UMLS CUI [1,1]
C0449475
UMLS CUI [1,2]
C1522609
%
Test used
Description

Laboratory tests

Type de données

integer

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

TREATMENT FOR FAILURE

Type de données

integer

ACUTE GRAFT VERSUS HOST DISEASE (GvHD)
Description

ACUTE GRAFT VERSUS HOST DISEASE (GvHD)

Maximum grade ACUTE GRAFT VERSUS HOST DISEASE (AGVHD)
Description

Maximum grade

Type de données

integer

Date of onset
Description

Date of onset

Type de données

date

Alias
UMLS CUI [1]
C0574845
Stage skin
Description

aGvHD Stage Skin

Type de données

integer

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

aGvHD Stage liver

Type de données

integer

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

aGvHD stage gut

Type de données

integer

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

aGvHD Resolution

Type de données

integer

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

aGvHD Date of resolution

Type de données

date

Unités de mesure
  • yyyy/mm/dd
Alias
UMLS CUI [1,1]
C0856825
UMLS CUI [1,2]
C1514893
UMLS CUI [1,3]
C0011008
yyyy/mm/dd
Treatment
Description

Treatment

Type de données

boolean

Treatment, if yes
Description

Treatment

Type de données

text

COMPLICATIONS WITHIN THE FIRST 100 DAYS.
Description

COMPLICATIONS WITHIN THE FIRST 100 DAYS.

INFECTION RELATED COMPLICATIONS
Description

INFECTION RELATED COMPLICATIONS

Type de données

boolean

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

Bacteraemia/ fungemia / viremia / parasites

Type de données

text

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

Bacteraemia/ fungemia / viremia / parasites

Type de données

date

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

Septic shock

Type de données

text

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

Septic shock

Type de données

date

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

ARDS

Type de données

text

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

ARDS

Type de données

date

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

Multiorgan failure due to infection

Type de données

text

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

Multiorgan failure due to infection

Type de données

date

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

Pneumonia

Type de données

text

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

Pneumonia

Type de données

date

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

Hepatitis

Type de données

text

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

Hepatitis

Type de données

date

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

CNS infection

Type de données

text

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

CNS infection

Type de données

date

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

Gut infection

Type de données

text

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

Gut infection

Type de données

date

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

Skin infection

Type de données

text

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

Skin infection

Type de données

date

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

Cystitis

Type de données

text

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

Cystitis

Type de données

date

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

Retinitis

Type de données

text

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

Retinitis

Type de données

date

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

Other

Type de données

text

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

Other

Type de données

date

NON INFECTION RELATED COMPLICATIONS
Description

NON INFECTION RELATED COMPLICATIONS

Type de données

integer

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

Idiopathic pneumonia syndrome

Type de données

text

Alias
UMLS CUI [1]
C1504431
Specify: VOD
Description

VOD

Type de données

text

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

Haemorrhagic cystitis, non infectious

Type de données

text

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

ARDS, non infectious

Type de données

text

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

Multiorgan failure, non infectious

Type de données

integer

Specify: HSCT-associated microangiopathy
Description

HSCT-associated microangiopathy

Type de données

text

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

Renal failure requiring dialysis

Type de données

text

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

Haemolytic anaemia due to blood group

Type de données

text

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

Other type of infection

Type de données

boolean

Idiopathic pneumonia syndrome
Description

Date Idiopathic pneumonia syndrome

Type de données

date

Date VOD
Description

Date VOD

Type de données

date

Date Haemorrhagic cystitis, non infectious
Description

Date Haemorrhagic cystitis, non infectious

Type de données

date

Date ARDS, non infectious
Description

Date ARDS, non infectious

Type de données

date

Date Multiorgan failure, non infectious
Description

Date Multiorgan failure, non infectious

Type de données

date

Date HSCT-associated microangiopathy
Description

Date HSCT-associated microangiopathy

Type de données

date

Date Renal failure requiring dialysis
Description

Date Renal failure requiring dialysis

Type de données

date

DAte Haemolytic anaemia due to blood group
Description

Date Haemolytic anaemia due to blood group

Type de données

date

Date of other Type
Description

Date of other Type

Type de données

date

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

STATUS AT 100 DAYS

Date of Last Contact
Description

LastContactDate

Type de données

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
Description

Presence of cGVHD

Type de données

integer

Alias
UMLS CUI [1]
C0867389
Onset
Description

Date of Onset

Type de données

date

Alias
UMLS CUI [1]
C0574845
cGvHD grade
Description

cGvHD grade

Type de données

integer

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

Organs affected

Type de données

integer

Alias
UMLS CUI [1]
C0449642
Relapse or progression
Description

Relapse or progression

Type de données

integer

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

If yes, date diagnosed

Type de données

date

Method of detection
Description

Method of detection

Cinical/haematological relapse or progression
Description

Clinical/hematological

Type de données

integer

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

Cinical/haematological relapse or progression

Type de données

date

Date first seen
Description

Cinical/haematological relapse or progression

Type de données

date

Cytogenetic relapse or progression
Description

Cytogenetic relapse or progression

Type de données

integer

Alias
UMLS CUI [1]
C0010802
Date assessed
Description

Cytogenetic relapse or progression

Type de données

date

Date first seen
Description

Cytogenetic relapse or progression

Type de données

date

Molecular relapse or progression
Description

Molecular relapse or progression

Type de données

integer

Alias
UMLS CUI [1]
C0026376
Date assessed
Description

Molecular relapse or progression

Type de données

date

Date first seen
Description

Molecular relapse or progression

Type de données

date

LAST DISEASE STATUS
Description

LAST DISEASE STATUS

Clinical/haematological
Description

Clincal/Hematological evaluation

Type de données

integer

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

Date of Evaluation

Type de données

date

Unités de mesure
  • yyyy/mm/dd
Alias
UMLS CUI [1]
C2985720
yyyy/mm/dd
Cytogenetic/FISH
Description

Cytogenetics/FISH

Type de données

integer

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

Last date assessed

Type de données

date

Molecular
Description

Molecular

Type de données

text

Alias
UMLS CUI [1]
C0026376
Survival Status
Description

Survival Status

Type de données

integer

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

Performance Score

Type de données

text

Alias
UMLS CUI [1]
C1518965
Score
Description

Performance score

Type de données

integer

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

Cause of death

Type de données

integer

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

GvHD

Type de données

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
Description

Interstitial Pneumonitis

Type de données

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
Description

Pulmonary toxicity

Type de données

text

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

Infection

Type de données

integer

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

Rejection / poor graft function

Type de données

integer

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

Veno-Occlusive disease (VOD)

Type de données

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
Description

Haemorrhage

Type de données

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
Description

Cardiac toxicity

Type de données

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
Description

Central nervous system toxicity

Type de données

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
Description

Gastro intestinal toxicity

Type de données

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
Description

Skin toxicity

Type de données

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
Description

Renal failure

Type de données

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
Description

Multiple organ failure

Type de données

text

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

Other transplantation related

Type de données

boolean

COMMENTS
Description

COMMENTS

Type de données

text

IDENTIFICATION & SIGNATURE
Description

IDENTIFICATION & SIGNATURE

Type de données

text

ADDITIONAL NOTES IF APPLICABLE
Description

ADDITIONAL NOTES IF APPLICABLE

ALLOGRAFT APPENDIX
Description

ALLOGRAFT APPENDIX

Ethnicity
Description

Ethnicity

Type de données

text

Alias
UMLS CUI [1]
C0015031
Race
Description

Race

Type de données

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?
Description

COMORBID CONDITIONS

Type de données

boolean

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

Solid tumor, previously present

Type de données

text

Crohn's disease or ulcerative colitis
Description

Inflammatory bowel disease

Type de données

text

Requiring continuation of antimicrobial treatment after day 0
Description

Infection

Type de données

text

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

Diabetes

Type de données

text

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

Renal: moderate/severe

Type de données

text

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

Hepatic: mild

Type de données

text

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

Hepatic: moderate/severe

Type de données

text

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

Arrhythmia

Type de données

text

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

Cardiac

Type de données

text

Transient ischemic attack or cerebrovascular accident
Description

Cerebrovascular disease

Type de données

text

Except mitral valve prolapse
Description

Heart valve disease

Type de données

text

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

Pulmonary: moderate

Type de données

text

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

Pulmonary: severe

Type de données

text

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

Obesity

Type de données

text

Requiring treatment
Description

Peptic ulcer

Type de données

text

Depression or anxiety requiring psychiatric consult or treatment
Description

Psychiatric disturbance

Type de données

text

other comorbidity, please specify
Description

other comorbidity

Type de données

text

Similar models

19pp EBMT Allograft 18Allo.

Name
Type
Description | Question | Decode (Coded Value)
Type de données
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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