ID

13558

Description

ODM derived from HSCT forms on http://www.ebmt.org/

Link

http://www.ebmt.org/

Keywords

Versions (4)
  1. 2/15/16 2/15/16 -
  2. 2/28/16 2/28/16 -
  3. 3/6/16 3/6/16 -
  4. 3/8/16 3/8/16 - Julian Varghese
Uploaded on

February 15, 2016

DOI

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License

Creative Commons BY-NC-ND 3.0
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EBMT MDS

English

Follow up EBMT MDS

1 forms  
  1. StudyEvent: ODM
    1. Follow up EBMT MDS
Follow up - Please use this form for annual follow up only and not data at 100 days, which is already included in the first report
Description

Follow up - Please use this form for annual follow up only and not data at 100 days, which is already included in the first report

Unique Identification Code (UIC) (if known)
Description

Unique Identification Code (UIC)

Data type

text

Alias
UMLS CUI [1]
C2348585
Date of this report
Description

Date of this report

Data type

date

Alias
UMLS CUI [1]
C1302584
Patient following national/ international study/trial
Description

Patient following national/ international study/trial

Data type

text

Alias
UMLS CUI [1]
C2348568
If yes, specify:
Description

Patient following national/ international study/trial

Data type

text

Alias
UMLS CUI [1]
C2348568
Hospital Unique Patient Number
Description

Hospital Unique Patient Number

Data type

text

Alias
UMLS CUI [1]
C2348585
First name(s)_surname(s)
Description

Initials

Data type

text

Alias
UMLS CUI [1]
C2986440
Date of birth
Description

Date of birth

Data type

date

Alias
UMLS CUI [1]
C0421451
Date of last HSCT for this patient
Description

Date of last HSCT for this patient

Data type

date

Alias
UMLS CUI [1,1]
C0472699
UMLS CUI [1,2]
C0011008
Patient last seen
Description

Patient last seen

Date of last contact or death
Description

Date of last contact or death

Data type

date

Alias
UMLS CUI [1]
C0805839
UMLS CUI [2]
C1148348
Graft versus Host Disease (GvHD) since last report
Description

Graft versus Host Disease (GvHD) since last report

Acute Graft versus Host Disease (aGvHD)
Description

Maximum grade

Data type

text

Alias
UMLS CUI [1]
C0856825
If present, specify:
Description

Acute Graft versus Host Disease (aGvHD)

Data type

text

Alias
UMLS CUI [1]
C0856825
If present, specify reason:
Description

Acute Graft versus Host Disease (aGvHD)

Data type

text

Alias
UMLS CUI [1]
C0856825
If yes, specify date of onset of this episode (if new or recurrent and applicable)
Description

Acute Graft versus Host Disease (aGvHD)

Data type

date

Alias
UMLS CUI [1]
C0856825
If yes, specify stage skin:
Description

Acute Graft versus Host Disease (aGvHD)

Data type

text

Alias
UMLS CUI [1]
C0856825
If yes, specify stage liver:
Description

Acute Graft versus Host Disease (aGvHD)

Data type

text

Alias
UMLS CUI [1]
C0856825
If yes, specify stage gut:
Description

Acute Graft versus Host Disease (aGvHD)

Data type

text

Alias
UMLS CUI [1]
C0856825
Resolution
Description

Acute Graft versus Host Disease (aGvHD)

Data type

boolean

Alias
UMLS CUI [1]
C0856825
If resolution, specify date:
Description

Acute Graft versus Host Disease (aGvHD)

Data type

date

Alias
UMLS CUI [1]
C0856825
Presence of cGvHD
Description

Chronic Graft versus Host Disease (cGvHD)

Data type

text

Alias
UMLS CUI [1]
C0867389
If yes, specify:
Description

Chronic Graft versus Host Disease (cGvHD)

Data type

text

Alias
UMLS CUI [1]
C0867389
If yes, specify date of onset:
Description

Chronic Graft versus Host Disease (cGvHD)

Data type

date

Alias
UMLS CUI [1]
C0867389
If present continuously since last reported episode, specify cGvHD grade:
Description

Chronic Graft versus Host Disease (cGvHD)

Data type

text

Alias
UMLS CUI [1]
C0867389
If present continuously since last reported episode, specify which organs are affected:
Description

Chronic Graft versus Host Disease (cGvHD)

Data type

text

Alias
UMLS CUI [1]
C0867389
If present continuously since last reported episode, specify others:
Description

Chronic Graft versus Host Disease (cGvHD)

Data type

text

Alias
UMLS CUI [1]
C0867389
If resolved, specify date of resolution:
Description

Chronic Graft versus Host Disease (cGvHD)

Data type

date

Alias
UMLS CUI [1]
C0867389
Other Complications since last report (please use the document "Definitions of infectious diseases and complications after stem cell transplantation" to fill these items.)
Description

Other Complications since last report (please use the document "Definitions of infectious diseases and complications after stem cell transplantation" to fill these items.)

Infection related complications
Description

Infection related complications

Data type

boolean

Alias
UMLS CUI [1,1]
C0009450
UMLS CUI [1,2]
C0009566
If yes, specify the type (bacteriaemia/ fungemia/ viremia/ parasites) (General)
Description

Infection related complications

Data type

text

Alias
UMLS CUI [1,1]
C0009450
UMLS CUI [1,2]
C0009566
If other, specify (general):
Description

Infection related complications

Data type

text

Alias
UMLS CUI [1,1]
C0009450
UMLS CUI [1,2]
C0009566
Specify the date of the episode (General)
Description

Infection related complications

Data type

date

Alias
UMLS CUI [1,1]
C0009450
UMLS CUI [1,2]
C0009566
Systemic Symptoms of Infections
Description

Infection related complications

Data type

text

Alias
UMLS CUI [1,1]
C2039684
UMLS CUI [1,2]
C0009450
Systemic Symptoms of Infections: specify the type (bacteriaemia/ fungemia/ viremia/ parasites)
Description

Infection related complications

Data type

text

Alias
UMLS CUI [1,1]
C2039684
UMLS CUI [1,2]
C0009450
Systemic symptoms of infection: if other, specify:
Description

Infection related complications

Data type

text

Alias
UMLS CUI [1,1]
C2039684
UMLS CUI [1,2]
C0009450
Systemic symptoms of infection: Specify the date of the episode
Description

Infection related complications

Data type

date

Alias
UMLS CUI [1,1]
C2039684
UMLS CUI [1,2]
C0009450
Endorgan diseases
Description

Infection related complications

Data type

text

Alias
UMLS CUI [1,1]
C0349410
UMLS CUI [1,2]
C0009450
Endorgan disease: specify the type (bacteriaemia/ fungemia/ viremia/ parasites)
Description

Infection related symptoms

Data type

text

Alias
UMLS CUI [1,1]
C0349410
UMLS CUI [1,2]
C0009450
Endorgan diseases: If other, specify:
Description

Infection related complications

Data type

text

Alias
UMLS CUI [1,1]
C0349410
UMLS CUI [1,2]
C0009450
Endorgan diseases: Specify the date of the episode
Description

Infection related complications

Data type

date

Alias
UMLS CUI [1,1]
C0349410
UMLS CUI [1,2]
C0009450
Non infection related complications
Description

Non infection related complications

Data type

boolean

Alias
UMLS CUI [1]
C0009566
If yes, specify: Idiopathic pneumonia syndrome
Description

Non infection related complications

Data type

text

Alias
UMLS CUI [1]
C1504431
If yes, specify: Idiopathic pneumonia syndrome Date of onset
Description

Non infection related complications

Data type

date

Alias
UMLS CUI [1]
C1504431
Specify: VOD
Description

Non infection related complications

Data type

text

Alias
UMLS CUI [1]
C0948441
If yes, specify: VOD Date of onset
Description

Non infection related complications

Data type

date

Alias
UMLS CUI [1]
C0948441
Specify: Cataract
Description

Non infection related complications

Data type

text

Alias
UMLS CUI [1]
C0086543
If yes, specify: Cataract Date of onset
Description

Non infection related complications

Data type

date

Alias
UMLS CUI [1]
C0086543
Specify: Haemorrhagic cystitis, non infectious
Description

Non infection related complications

Data type

text

Alias
UMLS CUI [1]
C0085692
If yes, specify: Haemorrhagic cystitis, non infectious Date of onset
Description

Non infection related complications

Data type

date

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

Non infection related complications

Data type

text

Alias
UMLS CUI [1]
C0035222
If yes, specify: ARDS, non infectious Date of onset
Description

Non infection related complications

Data type

date

Alias
UMLS CUI [1]
C0035222
Specify: Multiorgan-failre, non infectious
Description

Non infection related complications

Data type

text

Alias
UMLS CUI [1]
C0026766
If yes, specify: Multiorgan-failre, non infectious Date of onset
Description

Non infection related complications

Data type

date

Alias
UMLS CUI [1]
C0026766
Specify: HSCT-associated microangiopathy
Description

Non infection related complications

Data type

text

Alias
UMLS CUI [1]
C0155765
If yes, specify: HSCT-associated microangiopathy Date of onset
Description

Non infection related complications

Data type

date

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

Non infection related complications

Data type

text

Alias
UMLS CUI [1]
C0035078
If yes, specify: Renal failure requiring dialysis Date of onset
Description

Non infection related complications

Data type

date

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

Non infection related complications

Data type

text

Alias
UMLS CUI [1]
C0002878
If yes, specify: Haemolytic anaemia due to blood group Date of onset
Description

Non infection related complications

Data type

date

Alias
UMLS CUI [1]
C0002878
Specify: Aseptic bone necrosis
Description

Non infection related complications

Data type

text

Alias
UMLS CUI [1]
C0158452
If yes, specify: Aseptic bone necrosis Date of onset
Description

Non infection related complications

Data type

date

Alias
UMLS CUI [1]
C0158452
Specify: Other
Description

Non infection related complications

Data type

text

Alias
UMLS CUI [1]
C0009566
If other: Date of onset
Description

Non infection related complications

Data type

date

Alias
UMLS CUI [1]
C0009566
Graft loss
Description

Graft assessment and Haemopoietic chimaerism

Data type

text

Alias
UMLS CUI [1]
C0877042
Overall chimaerism
Description

Graft assessment and Haemopoietic chimaerism

Data type

text

Alias
UMLS CUI [1]
C0333678
Graft assessment and Haemopoietic chimaerism
Description

Graft assessment and Haemopoietic chimaerism

Date of test (Indicate the date(s) and results of all tests done for all donors. Split the results by donor and by the cell type on which the test was performed if applicable. Copy this table as many times as necessary.)
Description

Graft assessment and haemopoietic chimaerism

Data type

date

Alias
UMLS CUI [1]
C2826247
Identification of donor or Cord Blood Unit given by the centre (Indicate the date(s) and results of all tests done for all donors. Split the results by donor and by the cell type on which the test was performed if applicable. Copy this table as many times as necessary.)
Description

Graft assessment and haemopoietic chimaerism

Data type

text

Alias
UMLS CUI [1]
C1718162
Number in the infusion order (if applicable) (Indicate the date(s) and results of all tests done for all donors. Split the results by donor and by the cell type on which the test was performed if applicable. Copy this table as many times as necessary.)
Description

Graft assessment and haemopoietic chimaerism

Data type

text

Alias
UMLS CUI [1]
C0237753
Cell type on which test was performed (% Donor Cells): BM (Indicate the date(s) and results of all tests done for all donors. Split the results by donor and by the cell type on which the test was performed if applicable. Copy this table as many times as necessary.)
Description

Graft assessment and haemopoietic chimaerism

Data type

float

Measurement units
  • %
Alias
UMLS CUI [1]
C0005953
%
Cell type on which test was performed (% Donor cells): PB mononuclear cells (PBMC) (Indicate the date(s) and results of all tests done for all donors. Split the results by donor and by the cell type on which the test was performed if applicable. Copy this table as many times as necessary.)
Description

Graft assessment and haemopoietic chimaerism

Data type

float

Measurement units
  • %
Alias
UMLS CUI [1]
C1321301
%
Cell type on which test was performed (% Donor cells): T-Cells (Indicate the date(s) and results of all tests done for all donors. Split the results by donor and by the cell type on which the test was performed if applicable. Copy this table as many times as necessary.)
Description

Graft assessment and haemopoietic chimaerism

Data type

float

Measurement units
  • %
Alias
UMLS CUI [1]
C0039194
%
Cell type on which test was performed (% Donor cells): B-Cells (Indicate the date(s) and results of all tests done for all donors. Split the results by donor and by the cell type on which the test was performed if applicable. Copy this table as many times as necessary.)
Description

Graft assessment and haemopoietic chimaerism

Data type

float

Measurement units
  • %
Alias
UMLS CUI [1]
C0004561
%
Cell type on which test was performed (% Donor cells): Red blood cells (Indicate the date(s) and results of all tests done for all donors. Split the results by donor and by the cell type on which the test was performed if applicable. Copy this table as many times as necessary.)
Description

Graft assessment and haemopoietic chimaerism

Data type

float

Measurement units
  • %
Alias
UMLS CUI [1]
C0014772
%
Cell type on which test was performed (% Donor cells): Monocytes (Indicate the date(s) and results of all tests done for all donors. Split the results by donor and by the cell type on which the test was performed if applicable. Copy this table as many times as necessary.)
Description

Graft assessment and haemopoietic chimaerism

Data type

float

Measurement units
  • %
Alias
UMLS CUI [1]
C0026473
%
Cell type on which test was performed (% Donor cells): PMNs (neutrophils) (Indicate the date(s) and results of all tests done for all donors. Split the results by donor and by the cell type on which the test was performed if applicable. Copy this table as many times as necessary.)
Description

Graft assessment and haemopoietic chimaerism

Data type

float

Measurement units
  • %
Alias
UMLS CUI [1]
C0200633
%
Cell type on which test was performed (% Donor cells): Lymphocytes, NOS (Indicate the date(s) and results of all tests done for all donors. Split the results by donor and by the cell type on which the test was performed if applicable. Copy this table as many times as necessary.)
Description

Graft assessment and haemopoietic chimaerism

Data type

float

Measurement units
  • %
Alias
UMLS CUI [1]
C0024264
%
Cell type on which test was performed (% Donor cells): Myeloid cells, NOS (Indicate the date(s) and results of all tests done for all donors. Split the results by donor and by the cell type on which the test was performed if applicable. Copy this table as many times as necessary.)
Description

Graft assessment and haemopoietic chimaerism

Data type

float

Measurement units
  • %
Alias
UMLS CUI [1]
C0887899
%
Cell type on which test was performed: Other, specify: (Indicate the date(s) and results of all tests done for all donors. Split the results by donor and by the cell type on which the test was performed if applicable. Copy this table as many times as necessary.)
Description

Graft assessment and haemopoietic chimaerism

Data type

text

Alias
UMLS CUI [1]
C0449475
Cell type on which test was performed (% Donor cells): Other (Indicate the date(s) and results of all tests done for all donors. Split the results by donor and by the cell type on which the test was performed if applicable. Copy this table as many times as necessary.)
Description

Graft assessment and haemopoietic chimaerism

Data type

float

Measurement units
  • %
Alias
UMLS CUI [1]
C0449475
%
Test used (Indicate the date(s) and results of all tests done for all donors. Split the results by donor and by the cell type on which the test was performed if applicable. Copy this table as many times as necessary.)
Description

Graft assessment and haemopoietic chimaerism

Data type

text

Alias
UMLS CUI [1]
C0022885
Test used: If other, specify: (Indicate the date(s) and results of all tests done for all donors. Split the results by donor and by the cell type on which the test was performed if applicable. Copy this table as many times as necessary.)
Description

Graft assessment and haemopoietic chimaerism

Data type

text

Alias
UMLS CUI [1]
C0022885
Secondary Malignancy, Lymphoproliferative or Myeloproliferative disorder diagnosed
Description

Secondary Malignancy, Lymphoproliferative or Myeloproliferative disorder

Data type

text

Alias
UMLS CUI [1]
C3266877
UMLS CUI [2]
C0024314
UMLS CUI [3]
C0027022
If yes, specify date of diagnosis
Description

Secondary Malignancy, Lymphoproliferative or Myeloproliferative disorder

Data type

date

Alias
UMLS CUI [1]
C3266877
UMLS CUI [2]
C0024314
UMLS CUI [3]
C0027022
If yes, specify the diagnosis
Description

Secondary Malignancy, Lymphoproliferative or Myeloproliferative disorder

Data type

text

Alias
UMLS CUI [1]
C3266877
UMLS CUI [2]
C0024314
UMLS CUI [3]
C0027022
If other, specify:
Description

Secondary Malignancy, Lymphoproliferative or Myeloproliferative disorder

Data type

text

Alias
UMLS CUI [1]
C3266877
UMLS CUI [2]
C0024314
UMLS CUI [3]
C0027022
Additional therapies since last follow up
Description

Additional therapies since last follow up

Treatment given since last report
Description

Additional treatment

Data type

text

Alias
UMLS CUI [1]
C1706712
If yes, specify the start date
Description

Additional treatment

Data type

date

Alias
UMLS CUI [1]
C1706712
If yes: One cell therapy regimen is defined as any number of infusions given wihtin 10 weeks for the same indication. If more than one regimen of cell therapy has been given since last report, copy this section and complete it as many times as necessary.
Description

Additional treatment - Cellular therapy

Data type

text

Alias
UMLS CUI [1,1]
C1706712
UMLS CUI [1,2]
C0302189
If yes, specify the disease status before this cellular therapy
Description

Additional treatment - Cellular therapy

Data type

text

Alias
UMLS CUI [1,1]
C1706712
UMLS CUI [1,2]
C0302189
If yes, specify the cell type
Description

Additional treatment - Cellular therapy

Data type

text

Alias
UMLS CUI [1,1]
C1706712
UMLS CUI [1,2]
C0302189
If yes, specify the cell type: If cell type other, specify:
Description

Additional treatment - Cellular therapy

Data type

text

Alias
UMLS CUI [1,1]
C1706712
UMLS CUI [1,2]
C0302189
If DLI, specify the number of cells infused by type: Nucleated cells
Description

Additional treatment - Cellular therapy

Data type

text

Alias
UMLS CUI [1]
C1180059
If DLI, specify the number of cells infused by type: Nucleated cells (10^8/kg)
Description

Additional treatment - Cellular therapy

Data type

float

Measurement units
  • 10^8/kg
Alias
UMLS CUI [1]
C1180059
10^8/kg
If DLI, specify the number of cells infused by type: CD 34+
Description

Additional treatment - Cellular therapy

Data type

text

Alias
UMLS CUI [1]
C3538723
If DLI, specify the number of cells infused by type: CD 34+ (10^6/kg)
Description

Additional treatment - Cellular therapy

Data type

float

Measurement units
  • (10^6/kg)
Alias
UMLS CUI [1]
C3538723
(10^6/kg)
If DLI, specify the number of cells infused by type: CD 3+
Description

Additional treatment - Cellular therapy

Data type

text

Alias
UMLS CUI [1]
C3542405
If DLI, specify the number of cells infused by type: CD 3+ (10^6/kg)
Description

Additional treatment - Cellular therapy

Data type

float

Measurement units
  • (10^6/kg)
Alias
UMLS CUI [1]
C3542405
(10^6/kg)
If non DLI, specify total number of cells infused:
Description

Additional treatment - Cellular therapy

Data type

text

Alias
UMLS CUI [1]
C0007584
If non DLI, specify the total number of cells infused (10^6/kg)
Description

Additional treatment - Cellular therapy

Data type

float

Measurement units
  • (10^6/kg)
Alias
UMLS CUI [1]
C0007584
(10^6/kg)
Chronological number of this cell therapy for this patient
Description

Additional treatment - Cellular therapy

Data type

float

Alias
UMLS CUI [1]
C2348184
Indication (check all that apply)
Description

Additonal treatment - Cellular therapy

Data type

text

Alias
UMLS CUI [1,1]
C3146298
UMLS CUI [1,2]
C0302189
Indication: If other, specify:
Description

Additional treatment - Cellular therapy

Data type

text

Alias
UMLS CUI [1,1]
C3146298
UMLS CUI [1,2]
C0302189
Number of Infusions (within 10 weeks) (count only infusions that are part of same regimen and given for the same indication)
Description

Additional treatment - Cellular therapy

Data type

float

Alias
UMLS CUI [1]
C2348184
Acute Graft versus Host Disease (after this infusion but before any further infusion/ transplant) Maximum grade:
Description

Additonal treatment - Cellular therapy

Data type

text

Alias
UMLS CUI [1]
C0856825
apart from donor cell infusion or other type of cell therapy:
Description

Additional treatment - Disease tratment

Data type

boolean

Alias
UMLS CUI [1]
C1706712
If yes, specify:
Description

Additional treatment - Disease treatment

Data type

text

Alias
UMLS CUI [1]
C1706712
First evidence of relapse or progression since last HSCT
Description

First evidence of relapse or progression since last HSCT

Relapse or Progression
Description

Relapse or Progression

Data type

text

Alias
UMLS CUI [1]
C0277556
UMLS CUI [2]
C0242656
If yes, specify the date of diagnosis:
Description

Relapse or Progression

Data type

date

Alias
UMLS CUI [1]
C2316983
Last disease and pateint status
Description

Last disease and pateint status

last disease status
Description

Last Disease Status

Data type

text

Alias
UMLS CUI [1,1]
C0332307
UMLS CUI [1,2]
C0012634
UMLS CUI [1,3]
C0678257
Has patient or partner become pregnant after this HSCT?
Description

Conception

Data type

text

Alias
UMLS CUI [1]
C0032961
Survival status
Description

Survival Status

Data type

text

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

Survival Status - Performance Score

Data type

text

Alias
UMLS CUI [1]
C1518965
If alive and performance score evaluated, specify:
Description

Survival Status - Performance Score

Data type

text

Alias
UMLS CUI [1]
C1518965
If dead, specify cause of death:
Description

Survival Status - Cause of Death

Data type

text

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

Survival Status - Cause of Death

Data type

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

Survival Status - Cause of Death

Data type

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

Survival Status - Cause of Death

Data type

text

Alias
UMLS CUI [1,1]
C0007465
UMLS CUI [1,2]
C0919924
If dead and HSCT related cause of death, specify (check as many as apppropriate): Infection
Description

Survival Status - Cause of Death

Data type

text

Alias
UMLS CUI [1,1]
C0007465
UMLS CUI [1,2]
C0009450
If dead and HSCT related cause of death, specify (check as many as apppropriate): If Infection, specify:
Description

Survival Status - Cause of Death

Data type

text

Alias
UMLS CUI [1,1]
C0007465
UMLS CUI [1,2]
C0009450
If dead and HSCT related cause of death, specify (check as many as apppropriate): Rejection/ Poor graft function
Description

Survival Status - Cause of Death

Data type

text

Alias
UMLS CUI [1,1]
C0007465
UMLS CUI [1,2]
C0018129
If dead and HSCT related cause of death, specify (check as many as apppropriate): Veno-Occlusive disease (VOD)
Description

Survival Status - Cause of Death

Data type

text

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

Survival Status - Cause of Death

Data type

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

Survival Status - Cause of Death

Data type

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

Survival Status - Cause of Death

Data type

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

Survival Status - Cause of Death

Data type

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

Survival Status - Cause of Death

Data type

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

Survival Status - Cause of Death

Data type

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

Survival Status - Cause of Death

Data type

text

Alias
UMLS CUI [1,1]
C0007465
UMLS CUI [1,2]
C0026766
If dead and HSCT related cause of death, specify (check as many as apppropriate): Other
Description

Survival Status - Cause of Death

Data type

text

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

Survival Status - Cause of Death

Data type

text

Alias
UMLS CUI [1]
C0007465
If other, specify:
Description

Survival Status - Cause of Death

Data type

text

Alias
UMLS CUI [1]
C0007465
Additional notes if applicable
Description

Additional notes if applicable

Comments:
Description

Comments

Data type

text

Alias
UMLS CUI [1]
C0947611
Identification and Signature
Description

Identification and Signature

Identification
Description

Identification

Data type

text

Alias
UMLS CUI [1]
C0205396
Signature
Description

Signature

Data type

text

Alias
UMLS CUI [1]
C1519316
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Similar models

Follow up EBMT MDS

1 forms
  1. StudyEvent: ODM
    1. Follow up EBMT MDS
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Follow up - Please use this form for annual follow up only and not data at 100 days, which is already included in the first report
Unique Identification Code (UIC)
Item
Unique Identification Code (UIC) (if known)
text
C2348585 (UMLS CUI [1])
Date of this report
Item
Date of this report
date
C1302584 (UMLS CUI [1])
Item
Patient following national/ international study/trial
text
C2348568 (UMLS CUI [1])
Patient following national/ international study/trial
Code List
Patient following national/ international study/trial
CL Item
No (No)
CL Item
Yes (Yes)
CL Item
Unknown (Unknown)
Patient following national/ international study/trial
Item
If yes, specify:
text
C2348568 (UMLS CUI [1])
Hospital Unique Patient Number
Item
Hospital Unique Patient Number
text
C2348585 (UMLS CUI [1])
Initials
Item
First name(s)_surname(s)
text
C2986440 (UMLS CUI [1])
Date of birth
Item
Date of birth
date
C0421451 (UMLS CUI [1])
Date of last HSCT for this patient
Item
Date of last HSCT for this patient
date
C0472699 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Item Group
Patient last seen
Date of last contact or death
Item
Date of last contact or death
date
C0805839 (UMLS CUI [1])
C1148348 (UMLS CUI [2])
Item Group
Graft versus Host Disease (GvHD) since last report
Item
Acute Graft versus Host Disease (aGvHD)
text
C0856825 (UMLS CUI [1])
Acute Graft versus Host Disease (aGvHD)
Code List
Acute Graft versus Host Disease (aGvHD)
CL Item
grade I (grade I)
CL Item
grade II (grade II)
CL Item
grade III (grade III)
CL Item
grade IV (grade IV)
CL Item
not evaluated (not evaluated)
CL Item
grade 0 (absent) (grade 0 (absent))
Item
If present, specify:
text
C0856825 (UMLS CUI [1])
Acute Graft versus Host Disease (aGvHD)
Code List
If present, specify:
CL Item
New onset (New onset)
CL Item
Recurrent (Recurrent)
CL Item
Persistent (Persistent)
Item
If present, specify reason:
text
C0856825 (UMLS CUI [1])
undefined item
Code List
If present, specify reason:
CL Item
Tapering (Tapering)
CL Item
DLI (DLI)
CL Item
Unexplained (Unexplained)
Acute Graft versus Host Disease (aGvHD)
Item
If yes, specify date of onset of this episode (if new or recurrent and applicable)
date
C0856825 (UMLS CUI [1])
Item
If yes, specify stage skin:
text
C0856825 (UMLS CUI [1])
undefined item
Code List
If yes, specify stage skin:
CL Item
0 (0)
CL Item
1 (1)
CL Item
2 (2)
CL Item
3 (3)
CL Item
4 (4)
CL Item
Not evaluated (Not evaluated)
CL Item
unknown (unknown)
Item
If yes, specify stage liver:
text
C0856825 (UMLS CUI [1])
Acute Graft versus Host Disease (aGvHD)
Code List
If yes, specify stage liver:
CL Item
0 (0)
CL Item
1 (1)
CL Item
2 (2)
CL Item
3 (3)
CL Item
4 (4)
CL Item
Not evaluated (Not evaluated)
CL Item
unknown (unknown)
Item
If yes, specify stage gut:
text
C0856825 (UMLS CUI [1])
Acute Graft versus Host Disease (aGvHD)
Code List
If yes, specify stage gut:
CL Item
0 (0)
CL Item
1 (1)
CL Item
2 (2)
CL Item
3 (3)
CL Item
4 (4)
CL Item
Not evaluated (Not evaluated)
CL Item
unknown (unknown)
Acute Graft versus Host Disease (aGvHD)
Item
Resolution
boolean
C0856825 (UMLS CUI [1])
Acute Graft versus Host Disease (aGvHD)
Item
If resolution, specify date:
date
C0856825 (UMLS CUI [1])
Item
Presence of cGvHD
text
C0867389 (UMLS CUI [1])
Chronic Graft versus Host Disease (cGvHD)
Code List
Presence of cGvHD
CL Item
No (No)
CL Item
Yes (Yes)
CL Item
Present continuously since last reported episode (Present continuously since last reported episode)
CL Item
Resolved (Resolved)
Item
If yes, specify:
text
C0867389 (UMLS CUI [1])
undefined item
Code List
If yes, specify:
CL Item
First episode (First episode)
CL Item
Recurrence (Recurrence)
Chronic Graft versus Host Disease (cGvHD)
Item
If yes, specify date of onset:
date
C0867389 (UMLS CUI [1])
Item
If present continuously since last reported episode, specify cGvHD grade:
text
C0867389 (UMLS CUI [1])
Chronic Graft versus Host Disease (cGvHD)
Code List
If present continuously since last reported episode, specify cGvHD grade:
CL Item
Limited (Limited)
CL Item
Extensive (Extensive)
Item
If present continuously since last reported episode, specify which organs are affected:
text
C0867389 (UMLS CUI [1])
Chronic Graft versus Host Disease (cGvHD)
Code List
If present continuously since last reported episode, specify which organs are affected:
CL Item
Skin (Skin)
CL Item
Gut (Gut)
CL Item
Liver (Liver)
CL Item
Mouth (Mouth)
CL Item
Eyes (Eyes)
CL Item
Lung (Lung)
CL Item
Other (Other)
CL Item
Unknown (Unknown)
Chronic Graft versus Host Disease (cGvHD)
Item
If present continuously since last reported episode, specify others:
text
C0867389 (UMLS CUI [1])
Chronic Graft versus Host Disease (cGvHD)
Item
If resolved, specify date of resolution:
date
C0867389 (UMLS CUI [1])
Item Group
Other Complications since last report (please use the document "Definitions of infectious diseases and complications after stem cell transplantation" to fill these items.)
Infection related complications
Item
Infection related complications
boolean
C0009450 (UMLS CUI [1,1])
C0009566 (UMLS CUI [1,2])
Item
If yes, specify the type (bacteriaemia/ fungemia/ viremia/ parasites) (General)
text
C0009450 (UMLS CUI [1,1])
C0009566 (UMLS CUI [1,2])
Infection related complications
Code List
If yes, specify the type (bacteriaemia/ fungemia/ viremia/ parasites) (General)
CL Item
Bacteria: (Bacteria:)
CL Item
S. pneumoniae (S. pneumoniae)
CL Item
Other gram positive (i.e. other streptococci, staphylococci, listeria,...) (Other gram positive (i.e. other streptococci, staphylococci, listeria,...))
CL Item
Haemophilus influenza (Haemophilus influenza)
CL Item
Other gram negative (i.e. E.coli, klebsiella, proteus, serratia, pseudomonas,...) (Other gram negative (i.e. E.coli, klebsiella, proteus, serratia, pseudomonas,...))
CL Item
Legionella sp (Legionella sp)
CL Item
Mycobacteria sp (Mycobacteria sp)
CL Item
Other (Other)
CL Item
Fungi: (Fungi:)
CL Item
Candida sp (Candida sp)
CL Item
Aspergillus sp (Aspergillus sp)
CL Item
Pneumocystis carinii (Pneumocystis carinii)
CL Item
Other (Other)
CL Item
Parasites: (Parasites:)
CL Item
Toxoplasma gondii (Toxoplasma gondii)
CL Item
Other (Other)
CL Item
Viruses: (Viruses:)
CL Item
HSV (HSV)
CL Item
VZV (VZV)
CL Item
EBV (EBV)
CL Item
CMV (CMV)
CL Item
HHV-6 (HHV-6)
CL Item
RSV (RSV)
CL Item
Other respiratory virus (influenza, parainfluezna, rhinovirus) (Other respiratory virus (influenza, parainfluezna, rhinovirus))
CL Item
Adenovirus (Adenovirus)
CL Item
HBV (HBV)
CL Item
HCV (HCV)
CL Item
HIV (HIV)
CL Item
Papovirus (Papovirus)
CL Item
Parovirus (Parovirus)
CL Item
Other (Other)
Infection related complications
Item
If other, specify (general):
text
C0009450 (UMLS CUI [1,1])
C0009566 (UMLS CUI [1,2])
Infection related complications
Item
Specify the date of the episode (General)
date
C0009450 (UMLS CUI [1,1])
C0009566 (UMLS CUI [1,2])
Item
Systemic Symptoms of Infections
text
C2039684 (UMLS CUI [1,1])
C0009450 (UMLS CUI [1,2])
Infection Related Complications
Code List
Systemic Symptoms of Infections
CL Item
Septic shock (Septic shock)
CL Item
ARDS (ARDS)
CL Item
Multiorgan failure due to infection (Multiorgan failure due to infection)
Item
Systemic Symptoms of Infections: specify the type (bacteriaemia/ fungemia/ viremia/ parasites)
text
C2039684 (UMLS CUI [1,1])
C0009450 (UMLS CUI [1,2])
Infection related complications
Code List
Systemic Symptoms of Infections: specify the type (bacteriaemia/ fungemia/ viremia/ parasites)
CL Item
Bacteria: (Bacteria:)
CL Item
S. pneumoniae (S. pneumoniae)
CL Item
Other gram positive (i.e. other streptococci, staphylococci, listeria,...) (Other gram positive (i.e. other streptococci, staphylococci, listeria,...))
CL Item
Haemophilus influenza (Haemophilus influenza)
CL Item
Other gram negative (i.e. E.coli, klebsiella, proteus, serratia, pseudomonas,...) (Other gram negative (i.e. E.coli, klebsiella, proteus, serratia, pseudomonas,...))
CL Item
Legionella sp (Legionella sp)
CL Item
Mycobacteria sp (Mycobacteria sp)
CL Item
Other (Other)
CL Item
Fungi: (Fungi:)
CL Item
Candida sp (Candida sp)
CL Item
Aspergillus sp (Aspergillus sp)
CL Item
Pneumocystis carinii (Pneumocystis carinii)
CL Item
Other (Other)
CL Item
Parasites: (Parasites:)
CL Item
Toxoplasma gondii (Toxoplasma gondii)
CL Item
Other (Other)
CL Item
Viruses: (Viruses:)
CL Item
HSV (HSV)
CL Item
VZV (VZV)
CL Item
EBV (EBV)
CL Item
CMV (CMV)
CL Item
HHV-6 (HHV-6)
CL Item
RSV (RSV)
CL Item
Other respiratory virus (influenza, parainfluezna, rhinovirus) (Other respiratory virus (influenza, parainfluezna, rhinovirus))
CL Item
Adenovirus (Adenovirus)
CL Item
HBV (HBV)
CL Item
HCV (HCV)
CL Item
HIV (HIV)
CL Item
Papovirus (Papovirus)
CL Item
Parovirus (Parovirus)
CL Item
Other (Other)
Infection related complications
Item
Systemic symptoms of infection: if other, specify:
text
C2039684 (UMLS CUI [1,1])
C0009450 (UMLS CUI [1,2])
Infection related complications
Item
Systemic symptoms of infection: Specify the date of the episode
date
C2039684 (UMLS CUI [1,1])
C0009450 (UMLS CUI [1,2])
Item
Endorgan diseases
text
C0349410 (UMLS CUI [1,1])
C0009450 (UMLS CUI [1,2])
Infectio related complications
Code List
Endorgan diseases
CL Item
Pneumonia (Pneumonia)
CL Item
Hepatits (Hepatits)
CL Item
CNS infection (CNS infection)
CL Item
Gut infection (Gut infection)
CL Item
Skin infection (Skin infection)
CL Item
Cystitis (Cystitis)
CL Item
Retinitis (Retinitis)
CL Item
Other (Other)
Item
Endorgan disease: specify the type (bacteriaemia/ fungemia/ viremia/ parasites)
text
C0349410 (UMLS CUI [1,1])
C0009450 (UMLS CUI [1,2])
Infection related symptoms
Code List
Endorgan disease: specify the type (bacteriaemia/ fungemia/ viremia/ parasites)
CL Item
Bacteria: (Bacteria:)
CL Item
S. pneumoniae (S. pneumoniae)
CL Item
Other gram positive (i.e. other streptococci, staphylococci, listeria,...) (Other gram positive (i.e. other streptococci, staphylococci, listeria,...))
CL Item
Haemophilus influenza (Haemophilus influenza)
CL Item
Other gram negative (i.e. E.coli, klebsiella, proteus, serratia, pseudomonas,...) (Other gram negative (i.e. E.coli, klebsiella, proteus, serratia, pseudomonas,...))
CL Item
Legionella sp (Legionella sp)
CL Item
Mycobacteria sp (Mycobacteria sp)
CL Item
Other (Other)
CL Item
Fungi: (Fungi:)
CL Item
Candida sp (Candida sp)
CL Item
Aspergillus sp (Aspergillus sp)
CL Item
Pneumocystis carinii (Pneumocystis carinii)
CL Item
Other (Other)
CL Item
Parasites: (Parasites:)
CL Item
Toxoplasma gondii (Toxoplasma gondii)
CL Item
Other (Other)
CL Item
Viruses: (Viruses:)
CL Item
HSV (HSV)
CL Item
VZV (VZV)
CL Item
EBV (EBV)
CL Item
CMV (CMV)
CL Item
HHV-6 (HHV-6)
CL Item
RSV (RSV)
CL Item
Other respiratory virus (influenza, parainfluezna, rhinovirus) (Other respiratory virus (influenza, parainfluezna, rhinovirus))
CL Item
Adenovirus (Adenovirus)
CL Item
HBV (HBV)
CL Item
HCV (HCV)
CL Item
HIV (HIV)
CL Item
Papovirus (Papovirus)
CL Item
Parovirus (Parovirus)
CL Item
Other (Other)
Infection related complications
Item
Endorgan diseases: If other, specify:
text
C0349410 (UMLS CUI [1,1])
C0009450 (UMLS CUI [1,2])
Infection related complications
Item
Endorgan diseases: Specify the date of the episode
date
C0349410 (UMLS CUI [1,1])
C0009450 (UMLS CUI [1,2])
Non infection related complications
Item
Non infection related complications
boolean
C0009566 (UMLS CUI [1])
Item
If yes, specify: Idiopathic pneumonia syndrome
text
C1504431 (UMLS CUI [1])
Non infection related complications
Code List
If yes, specify: Idiopathic pneumonia syndrome
CL Item
Yes (Yes)
CL Item
No (No)
CL Item
Unknown (Unknown)
Non infection related complications
Item
If yes, specify: Idiopathic pneumonia syndrome Date of onset
date
C1504431 (UMLS CUI [1])
Item
Specify: VOD
text
C0948441 (UMLS CUI [1])
undefined item
Code List
Specify: VOD
CL Item
Yes (Yes)
CL Item
No  (No )
CL Item
Unknown (Unknown)
Non infection related complications
Item
If yes, specify: VOD Date of onset
date
C0948441 (UMLS CUI [1])
Item
Specify: Cataract
text
C0086543 (UMLS CUI [1])
undefined item
Code List
Specify: Cataract
CL Item
Yes (Yes)
CL Item
No (No)
CL Item
Unknown (Unknown)
Non infection related complications
Item
If yes, specify: Cataract Date of onset
date
C0086543 (UMLS CUI [1])
Item
Specify: Haemorrhagic cystitis, non infectious
text
C0085692 (UMLS CUI [1])
undefined item
Code List
Specify: Haemorrhagic cystitis, non infectious
CL Item
Yes  (Yes )
CL Item
No  (No )
CL Item
Unknown (Unknown)
Non infection related complications
Item
If yes, specify: Haemorrhagic cystitis, non infectious Date of onset
date
C0085692 (UMLS CUI [1])
Item
Specify: ARDS, non infectious
text
C0035222 (UMLS CUI [1])
undefined item
Code List
Specify: ARDS, non infectious
CL Item
Yes (Yes)
CL Item
No (No)
CL Item
Unknown (Unknown)
Non infection related complications
Item
If yes, specify: ARDS, non infectious Date of onset
date
C0035222 (UMLS CUI [1])
Item
Specify: Multiorgan-failre, non infectious
text
C0026766 (UMLS CUI [1])
Non infection related complications
Code List
Specify: Multiorgan-failre, non infectious
CL Item
Yes (Yes)
CL Item
No  (No )
CL Item
Unknown (Unknown)
Non infection related complications
Item
If yes, specify: Multiorgan-failre, non infectious Date of onset
date
C0026766 (UMLS CUI [1])
Item
Specify: HSCT-associated microangiopathy
text
C0155765 (UMLS CUI [1])
Non infection related complications
Code List
Specify: HSCT-associated microangiopathy
CL Item
Yes (Yes)
CL Item
No (No)
CL Item
Unknown (Unknown)
Non infection related complications
Item
If yes, specify: HSCT-associated microangiopathy Date of onset
date
C0155765 (UMLS CUI [1])
Item
Specify: Renal failure requiring dialysis
text
C0035078 (UMLS CUI [1])
Non infection related complications
Code List
Specify: Renal failure requiring dialysis
CL Item
Yes (Yes)
CL Item
No (No)
CL Item
Unknown (Unknown)
Non infection related complications
Item
If yes, specify: Renal failure requiring dialysis Date of onset
date
C0035078 (UMLS CUI [1])
Item
Specify: Haemolytic anaemia due to blood group
text
C0002878 (UMLS CUI [1])
Non infection related complications
Code List
Specify: Haemolytic anaemia due to blood group
CL Item
Yes (Yes)
CL Item
No (No)
CL Item
Unknown (Unknown)
Non infection related complications
Item
If yes, specify: Haemolytic anaemia due to blood group Date of onset
date
C0002878 (UMLS CUI [1])
Item
Specify: Aseptic bone necrosis
text
C0158452 (UMLS CUI [1])
Non infection related complications
Code List
Specify: Aseptic bone necrosis
CL Item
Yes (Yes)
CL Item
No (No)
CL Item
Unknown (Unknown)
Non infection related complications
Item
If yes, specify: Aseptic bone necrosis Date of onset
date
C0158452 (UMLS CUI [1])
Non infection related complications
Item
Specify: Other
text
C0009566 (UMLS CUI [1])
Non infection related complications
Item
If other: Date of onset
date
C0009566 (UMLS CUI [1])
Item
Graft loss
text
C0877042 (UMLS CUI [1])
Graft assessment and Haemopoietic chimaerism
Code List
Graft loss
CL Item
No (No)
CL Item
Yes (Yes)
CL Item
Not evaluated (Not evaluated)
Item
Overall chimaerism
text
C0333678 (UMLS CUI [1])
undefined item
Code List
Overall chimaerism
CL Item
95%) (Full (donor >)
CL Item
Mixed (partial) (Mixed (partial))
CL Item
95%) (Autologuos reconstitution (recipient >)
CL Item
Aplasia (Aplasia)
CL Item
Not evaluated (Not evaluated)
Item Group
Graft assessment and Haemopoietic chimaerism
Graft assessment and haemopoietic chimaerism
Item
Date of test (Indicate the date(s) and results of all tests done for all donors. Split the results by donor and by the cell type on which the test was performed if applicable. Copy this table as many times as necessary.)
date
C2826247 (UMLS CUI [1])
Graft assessment and haemopoietic chimaerism
Item
Identification of donor or Cord Blood Unit given by the centre (Indicate the date(s) and results of all tests done for all donors. Split the results by donor and by the cell type on which the test was performed if applicable. Copy this table as many times as necessary.)
text
C1718162 (UMLS CUI [1])
Graft assessment and haemopoietic chimaerism
Item
Number in the infusion order (if applicable) (Indicate the date(s) and results of all tests done for all donors. Split the results by donor and by the cell type on which the test was performed if applicable. Copy this table as many times as necessary.)
text
C0237753 (UMLS CUI [1])
Graft assessment and haemopoietic chimaerism
Item
Cell type on which test was performed (% Donor Cells): BM (Indicate the date(s) and results of all tests done for all donors. Split the results by donor and by the cell type on which the test was performed if applicable. Copy this table as many times as necessary.)
float
C0005953 (UMLS CUI [1])
Graft assessment and haemopoietic chimaerism
Item
Cell type on which test was performed (% Donor cells): PB mononuclear cells (PBMC) (Indicate the date(s) and results of all tests done for all donors. Split the results by donor and by the cell type on which the test was performed if applicable. Copy this table as many times as necessary.)
float
C1321301 (UMLS CUI [1])
Graft assessment and haemopoietic chimaerism
Item
Cell type on which test was performed (% Donor cells): T-Cells (Indicate the date(s) and results of all tests done for all donors. Split the results by donor and by the cell type on which the test was performed if applicable. Copy this table as many times as necessary.)
float
C0039194 (UMLS CUI [1])
Graft assessment and haemopoietic chimaerism
Item
Cell type on which test was performed (% Donor cells): B-Cells (Indicate the date(s) and results of all tests done for all donors. Split the results by donor and by the cell type on which the test was performed if applicable. Copy this table as many times as necessary.)
float
C0004561 (UMLS CUI [1])
Graft assessment and haemopoietic chimaerism
Item
Cell type on which test was performed (% Donor cells): Red blood cells (Indicate the date(s) and results of all tests done for all donors. Split the results by donor and by the cell type on which the test was performed if applicable. Copy this table as many times as necessary.)
float
C0014772 (UMLS CUI [1])
Graft assessment and haemopoietic chimaerism
Item
Cell type on which test was performed (% Donor cells): Monocytes (Indicate the date(s) and results of all tests done for all donors. Split the results by donor and by the cell type on which the test was performed if applicable. Copy this table as many times as necessary.)
float
C0026473 (UMLS CUI [1])
Graft assessment and haemopoietic chimaerism
Item
Cell type on which test was performed (% Donor cells): PMNs (neutrophils) (Indicate the date(s) and results of all tests done for all donors. Split the results by donor and by the cell type on which the test was performed if applicable. Copy this table as many times as necessary.)
float
C0200633 (UMLS CUI [1])
Graft assessment and haemopoietic chimaerism
Item
Cell type on which test was performed (% Donor cells): Lymphocytes, NOS (Indicate the date(s) and results of all tests done for all donors. Split the results by donor and by the cell type on which the test was performed if applicable. Copy this table as many times as necessary.)
float
C0024264 (UMLS CUI [1])
Graft assessment and haemopoietic chimaerism
Item
Cell type on which test was performed (% Donor cells): Myeloid cells, NOS (Indicate the date(s) and results of all tests done for all donors. Split the results by donor and by the cell type on which the test was performed if applicable. Copy this table as many times as necessary.)
float
C0887899 (UMLS CUI [1])
Graft assessment and haemopoietic chimaerism
Item
Cell type on which test was performed: Other, specify: (Indicate the date(s) and results of all tests done for all donors. Split the results by donor and by the cell type on which the test was performed if applicable. Copy this table as many times as necessary.)
text
C0449475 (UMLS CUI [1])
Graft assessment and haemopoietic chimaerism
Item
Cell type on which test was performed (% Donor cells): Other (Indicate the date(s) and results of all tests done for all donors. Split the results by donor and by the cell type on which the test was performed if applicable. Copy this table as many times as necessary.)
float
C0449475 (UMLS CUI [1])
Item
Test used (Indicate the date(s) and results of all tests done for all donors. Split the results by donor and by the cell type on which the test was performed if applicable. Copy this table as many times as necessary.)
text
C0022885 (UMLS CUI [1])
Graft assessment and haemopoietic chimaerism
Code List
Test used (Indicate the date(s) and results of all tests done for all donors. Split the results by donor and by the cell type on which the test was performed if applicable. Copy this table as many times as necessary.)
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)
Graft assessment and haemopoietic chimaerism
Item
Test used: If other, specify: (Indicate the date(s) and results of all tests done for all donors. Split the results by donor and by the cell type on which the test was performed if applicable. Copy this table as many times as necessary.)
text
C0022885 (UMLS CUI [1])
Item
Secondary Malignancy, Lymphoproliferative or Myeloproliferative disorder diagnosed
text
C3266877 (UMLS CUI [1])
C0024314 (UMLS CUI [2])
C0027022 (UMLS CUI [3])
Secondary Malignancy, Lymphoproliferative or Myeloproliferative disorder
Code List
Secondary Malignancy, Lymphoproliferative or Myeloproliferative disorder diagnosed
CL Item
Previously reported (Previously reported)
CL Item
Yes (Yes)
CL Item
No at date of this follow up (No at date of this follow up)
Secondary Malignancy, Lymphoproliferative or Myeloproliferative disorder
Item
If yes, specify date of diagnosis
date
C3266877 (UMLS CUI [1])
C0024314 (UMLS CUI [2])
C0027022 (UMLS CUI [3])
Item
If yes, specify the diagnosis
text
C3266877 (UMLS CUI [1])
C0024314 (UMLS CUI [2])
C0027022 (UMLS CUI [3])
Secondary Malignancy, Lymphoproliferative or Myeloproliferative disorder
Code List
If yes, specify the diagnosis
CL Item
AML (AML)
CL Item
MDS (MDS)
CL Item
Lymphoproliferative disorder (Lymphoproliferative disorder)
CL Item
Other (Other)
Secondary Malignancy, Lymphoproliferative or Myeloproliferative disorder
Item
If other, specify:
text
C3266877 (UMLS CUI [1])
C0024314 (UMLS CUI [2])
C0027022 (UMLS CUI [3])
Item Group
Additional therapies since last follow up
Item
Treatment given since last report
text
C1706712 (UMLS CUI [1])
Additional Treatment
Code List
Treatment given since last report
CL Item
No (No)
CL Item
Yes (Yes)
CL Item
Unknown (Unknown)
Additional treatment
Item
If yes, specify the start date
date
C1706712 (UMLS CUI [1])
Item
If yes: One cell therapy regimen is defined as any number of infusions given wihtin 10 weeks for the same indication. If more than one regimen of cell therapy has been given since last report, copy this section and complete it as many times as necessary.
text
C1706712 (UMLS CUI [1,1])
C0302189 (UMLS CUI [1,2])
Additional treatment - Cellular therapy
Code List
If yes: One cell therapy regimen is defined as any number of infusions given wihtin 10 weeks for the same indication. If more than one regimen of cell therapy has been given since last report, copy this section and complete it as many times as necessary.
CL Item
No  (No )
CL Item
Yes (Yes)
CL Item
Unknown (Unknown)
Item
If yes, specify the disease status before this cellular therapy
text
C1706712 (UMLS CUI [1,1])
C0302189 (UMLS CUI [1,2])
Additional treatment - Cellular therapy
Code List
If yes, specify the disease status before this cellular therapy
CL Item
CR (CR)
CL Item
Not in CR (Not in CR)
CL Item
Not evaluated (Not evaluated)
Item
If yes, specify the cell type
text
C1706712 (UMLS CUI [1,1])
C0302189 (UMLS CUI [1,2])
Additional treatment - Cellular therapy
Code List
If yes, specify the cell type
CL Item
Donor lymphocyte infusion (DLI) (Donor lymphocyte infusion (DLI))
CL Item
Mesenchymal cells (Mesenchymal cells)
CL Item
Other (Other)
CL Item
Unknown (Unknown)
Additional treatment - Cellular therapy
Item
If yes, specify the cell type: If cell type other, specify:
text
C1706712 (UMLS CUI [1,1])
C0302189 (UMLS CUI [1,2])
Item
If DLI, specify the number of cells infused by type: Nucleated cells
text
C1180059 (UMLS CUI [1])
Additional treatment - Cellular therapy
Code List
If DLI, specify the number of cells infused by type: Nucleated cells
CL Item
Evaluated (Evaluated)
CL Item
Not evaluated (Not evaluated)
CL Item
unknown (unknown)
Additional treatment - Cellular therapy
Item
If DLI, specify the number of cells infused by type: Nucleated cells (10^8/kg)
float
C1180059 (UMLS CUI [1])
Item
If DLI, specify the number of cells infused by type: CD 34+
text
C3538723 (UMLS CUI [1])
Additional treatment - Cellular therapy
Code List
If DLI, specify the number of cells infused by type: CD 34+
CL Item
Evaluated (Evaluated)
CL Item
Not Evaluated (Not Evaluated)
CL Item
Unknown (Unknown)
Additional treatment - Cellular therapy
Item
If DLI, specify the number of cells infused by type: CD 34+ (10^6/kg)
float
C3538723 (UMLS CUI [1])
Item
If DLI, specify the number of cells infused by type: CD 3+
text
C3542405 (UMLS CUI [1])
Additional treatment - Cellular therapy
Code List
If DLI, specify the number of cells infused by type: CD 3+
CL Item
Evaluated  (Evaluated )
CL Item
Not evaluated (Not evaluated)
CL Item
Unknown (Unknown)
Additional treatment - Cellular therapy
Item
If DLI, specify the number of cells infused by type: CD 3+ (10^6/kg)
float
C3542405 (UMLS CUI [1])
Item
If non DLI, specify total number of cells infused:
text
C0007584 (UMLS CUI [1])
Additional treatment - Cellular therapy
Code List
If non DLI, specify total number of cells infused:
CL Item
Evaluated (Evaluated)
CL Item
Not Evaluated (Not Evaluated)
CL Item
Unknown (Unknown)
Additional treatment - Cellular therapy
Item
If non DLI, specify the total number of cells infused (10^6/kg)
float
C0007584 (UMLS CUI [1])
Additional treatment - Cellular therapy
Item
Chronological number of this cell therapy for this patient
float
C2348184 (UMLS CUI [1])
Item
Indication (check all that apply)
text
C3146298 (UMLS CUI [1,1])
C0302189 (UMLS CUI [1,2])
Additonal treatment - Cellular therapy
Code List
Indication (check all that apply)
CL Item
Planned/ protocol (Planned/ protocol)
CL Item
Treatment for disease (Treatment for disease)
CL Item
Prophylactic (Prophylactic)
CL Item
Mixed chimaerism (Mixed chimaerism)
CL Item
Treatment of GvHD (Treatment of GvHD)
CL Item
Treatment viral infection (Treatment viral infection)
CL Item
Loss/decreased chimaerism (Loss/decreased chimaerism)
CL Item
Treatment PTLD, EBV, lymphoma (Treatment PTLD, EBV, lymphoma)
CL Item
Other (Other)
Additional treatment - Cellular therapy
Item
Indication: If other, specify:
text
C3146298 (UMLS CUI [1,1])
C0302189 (UMLS CUI [1,2])
Additional treatment - Cellular therapy
Item
Number of Infusions (within 10 weeks) (count only infusions that are part of same regimen and given for the same indication)
float
C2348184 (UMLS CUI [1])
Item
Acute Graft versus Host Disease (after this infusion but before any further infusion/ transplant) Maximum grade:
text
C0856825 (UMLS CUI [1])
Additonal treatment - Cellular therapy
Code List
Acute Graft versus Host Disease (after this infusion but before any further infusion/ transplant) Maximum grade:
CL Item
grade 0 (absent) (grade 0 (absent))
CL Item
grade 1 (grade 1)
CL Item
grade 2 (grade 2)
CL Item
grade 3 (grade 3)
CL Item
grade 4 (grade 4)
CL Item
present, grade unknown (present, grade unknown)
Additional treatment - Disease tratment
Item
apart from donor cell infusion or other type of cell therapy:
boolean
C1706712 (UMLS CUI [1])
Item
If yes, specify:
text
C1706712 (UMLS CUI [1])
Additional treatment - Disease treatment
Code List
If yes, specify:
CL Item
Planned (planned before HSCT took place) (Planned (planned before HSCT took place))
CL Item
Not planned (for relapse/ progression or persistent disease) (Not planned (for relapse/ progression or persistent disease))
Item Group
First evidence of relapse or progression since last HSCT
Item
Relapse or Progression
text
C0277556 (UMLS CUI [1])
C0242656 (UMLS CUI [2])
Relapse or Progression
Code List
Relapse or Progression
CL Item
Previously reported (Previously reported)
CL Item
No (No)
CL Item
Yes (Yes)
CL Item
Continous progression since transplant (Continous progression since transplant)
CL Item
Unknown (Unknown)
Relapse or Progression
Item
If yes, specify the date of diagnosis:
date
C2316983 (UMLS CUI [1])
Item Group
Last disease and pateint status
Item
last disease status
text
C0332307 (UMLS CUI [1,1])
C0012634 (UMLS CUI [1,2])
C0678257 (UMLS CUI [1,3])
Last Disease Status
Code List
last disease status
CL Item
Complete Remission (Complete Remission)
CL Item
Relapse (Relapse)
CL Item
Treatment failure/ progression (Treatment failure/ progression)
Item
Has patient or partner become pregnant after this HSCT?
text
C0032961 (UMLS CUI [1])
Conception
Code List
Has patient or partner become pregnant after this HSCT?
CL Item
No (No)
CL Item
Yes (Yes)
CL Item
Unknown (Unknown)
Item
Survival status
text
C1148433 (UMLS CUI [1])
Survival Status
Code List
Survival status
CL Item
Alive (Alive)
CL Item
Dead (Dead)
Item
If alive: Type of score used:
text
C1518965 (UMLS CUI [1])
Survival Status - Performance Score
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
If alive and performance score evaluated, specify:
text
C1518965 (UMLS CUI [1])
Survival Status - Performance Score
Code List
If alive and performance score evaluated, specify:
CL Item
100 (Normal, NED) (100 (Normal, NED))
CL Item
90 (Normal activity) (90 (Normal activity))
CL Item
80 (Normal with effort) (80 (Normal with effort))
CL Item
70 (Cares for self) (70 (Cares for self))
CL Item
60 (Requires occasional assistance) (60 (Requires occasional assistance))
CL Item
50 (Requires assistance) (50 (Requires assistance))
CL Item
40 (Disabled) (40 (Disabled))
CL Item
30 (Severely disabled) (30 (Severely disabled))
CL Item
20 (Very sick) (20 (Very sick))
CL Item
10 (Moribund) (10 (Moribund))
Item
If dead, specify cause of death:
text
C0007465 (UMLS CUI [1])
Survival Status - Cause of Death
Code List
If dead, specify cause of death:
CL Item
Relapse or progression (Relapse or progression)
CL Item
Secondary malignancy (including lymphoproliferative disease) (Secondary malignancy (including lymphoproliferative disease))
CL Item
HSCT related cause  (HSCT related cause )
CL Item
Unknown  (Unknown )
CL Item
Other (Other)
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])
Survival Status - Cause of Death
Code List
If dead and HSCT related cause of death, specify (check as many as apppropriate): GvHD
CL Item
Yes (Yes)
CL Item
No  (No )
CL Item
Unknown (Unknown)
Item
If dead and HSCT related cause of death, specify (check as many as apppropriate): Interstitial Pneumonitis
text
C0007465 (UMLS CUI [1,1])
C0206061 (UMLS CUI [1,2])
Survival Status - Cause of Death
Code List
If dead and HSCT related cause of death, specify (check as many as apppropriate): Interstitial Pneumonitis
CL Item
Yes (Yes)
CL Item
No  (No )
CL Item
Unknown (Unknown)
Item
If dead and HSCT related cause of death, specify (check as many as apppropriate): Pulmonary toxicity
text
C0007465 (UMLS CUI [1,1])
C0919924 (UMLS CUI [1,2])
Survival Status - Cause of Death
Code List
If dead and HSCT related cause of death, specify (check as many as apppropriate): Pulmonary toxicity
CL Item
Yes (Yes)
CL Item
No  (No )
CL Item
Unknown (Unknown)
Item
If dead and HSCT related cause of death, specify (check as many as apppropriate): Infection
text
C0007465 (UMLS CUI [1,1])
C0009450 (UMLS CUI [1,2])
Survival Status - Cause of Death
Code List
If dead and HSCT related cause of death, specify (check as many as apppropriate): Infection
CL Item
Yes (Yes)
CL Item
No  (No )
CL Item
Unknown (Unknown)
Item
If dead and HSCT related cause of death, specify (check as many as apppropriate): If Infection, specify:
text
C0007465 (UMLS CUI [1,1])
C0009450 (UMLS CUI [1,2])
Survival Status
Code List
If dead and HSCT related cause of death, specify (check as many as apppropriate): If Infection, specify:
CL Item
Bacterial (Bacterial)
CL Item
Viral (Viral)
CL Item
Fungal (Fungal)
CL Item
Parasitic (Parasitic)
CL Item
Unknown (Unknown)
Item
If dead and HSCT related cause of death, specify (check as many as apppropriate): Rejection/ Poor graft function
text
C0007465 (UMLS CUI [1,1])
C0018129 (UMLS CUI [1,2])
Survival Status - Cause of Death
Code List
If dead and HSCT related cause of death, specify (check as many as apppropriate): Rejection/ Poor graft function
CL Item
Yes (Yes)
CL Item
No  (No )
CL Item
Unknown (Unknown)
Item
If dead and HSCT related cause of death, specify (check as many as apppropriate): Veno-Occlusive disease (VOD)
text
C0007465 (UMLS CUI [1,1])
C0948441 (UMLS CUI [1,2])
Survival Status - Cause of Death
Code List
If dead and HSCT related cause of death, specify (check as many as apppropriate): Veno-Occlusive disease (VOD)
CL Item
Yes (Yes)
CL Item
No  (No )
CL Item
Unknown (Unknown)
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])
Survival Status - Cause of Death
Code List
If dead and HSCT related cause of death, specify (check as many as apppropriate): Haemorrhage
CL Item
Yes (Yes)
CL Item
No  (No )
CL Item
Unknown (Unknown)
Item
If dead and HSCT related cause of death, specify (check as many as apppropriate): Cardiac toxicity
text
C0007465 (UMLS CUI [1,1])
C0876994 (UMLS CUI [1,2])
Survival Status - Cause of Death
Code List
If dead and HSCT related cause of death, specify (check as many as apppropriate): Cardiac toxicity
CL Item
Yes (Yes)
CL Item
No  (No )
CL Item
Unknown (Unknown)
Item
If dead and HSCT related cause of death, specify (check as many as apppropriate): Central nervous system toxicity
text
C0007465 (UMLS CUI [1,1])
C3160947 (UMLS CUI [1,2])
Survival Status - Cause of Death
Code List
If dead and HSCT related cause of death, specify (check as many as apppropriate): Central nervous system toxicity
CL Item
Yes (Yes)
CL Item
No  (No )
CL Item
Unknown (Unknown)
Item
If dead and HSCT related cause of death, specify (check as many as apppropriate): Gastro intestinal toxicity
text
C0007465 (UMLS CUI [1,1])
C1142499 (UMLS CUI [1,2])
Survival Status - Cause of Death
Code List
If dead and HSCT related cause of death, specify (check as many as apppropriate): Gastro intestinal toxicity
CL Item
Yes (Yes)
CL Item
No  (No )
CL Item
Unknown (Unknown)
Item
If dead and HSCT related cause of death, specify (check as many as apppropriate): Skin toxicity
text
C0007465 (UMLS CUI [1,1])
C1167791 (UMLS CUI [1,2])
Survival Status - Cause of Death
Code List
If dead and HSCT related cause of death, specify (check as many as apppropriate): Skin toxicity
CL Item
Yes (Yes)
CL Item
No  (No )
CL Item
Unknown (Unknown)
Item
If dead and HSCT related cause of death, specify (check as many as apppropriate): Renal failure
text
C0007465 (UMLS CUI [1,1])
C0035078 (UMLS CUI [1,2])
Surivival Status - Cause of Death
Code List
If dead and HSCT related cause of death, specify (check as many as apppropriate): Renal failure
CL Item
Yes (Yes)
CL Item
No  (No )
CL Item
Unknown (Unknown)
Item
If dead and HSCT related cause of death, specify (check as many as apppropriate): Multiple organ failure
text
C0007465 (UMLS CUI [1,1])
C0026766 (UMLS CUI [1,2])
Survival Status - Cause of Death
Code List
If dead and HSCT related cause of death, specify (check as many as apppropriate): Multiple organ failure
CL Item
Yes (Yes)
CL Item
No  (No )
CL Item
Unknown (Unknown)
Item
If dead and HSCT related cause of death, specify (check as many as apppropriate): Other
text
C0007465 (UMLS CUI [1])
Survival Status - Cause of Death
Code List
If dead and HSCT related cause of death, specify (check as many as apppropriate): Other
CL Item
Yes (Yes)
CL Item
No  (No )
CL Item
Unknown (Unknown)
Survival Status - Cause of Death
Item
If dead and HSCT related cause of death, specify (check as many as apppropriate): If other, specify:
text
C0007465 (UMLS CUI [1])
Survival Status - Cause of Death
Item
If other, specify:
text
C0007465 (UMLS CUI [1])
Item Group
Additional notes if applicable
Comments
Item
Comments:
text
C0947611 (UMLS CUI [1])
Item Group
Identification and Signature
Identification
Item
Identification
text
C0205396 (UMLS CUI [1])
Signature
Item
Signature
text
C1519316 (UMLS CUI [1])
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