ID

13632

Beschreibung

Coronary Artery Bypass graft surgery in patients with Asymptomatic Carotid Stenosis. A randomized controlled clinical trial. Short title: "CABACS" DRKS Number:DRKS00000521 IRSCTN Number:ISRCTN13486906 Phase:Therapeutic confirmatory(Phase III) Head of clinical trial: Prof. Dr. med. Christian Weimar University Duisburg-Essen Phone: 0201/723-6503 Fax: 0201/723-6948 e-mail: christian.weimar@uk-essen.de University Hospital Essen Hospital for Neurology Hufelandstr. 55 45122 Essen Trial coordinator: Dr. med. Stephan Knipp Phone: 0201/723-4915 Fax: 0201/723-5451 e-mail: stephan.knipp@uk-essen.de University Duisburg-Essen University Hospital Essen Hospital for thoracic- and cardiovascular surgery Hufelandstr. 55 45122 Essen Data Management: Anja Marr Phone: 0201/92239-257 Fax: 0201/92239-333 o. 0201/723-5933 e-mail: anja.marr@uk-essen.de University Hospital Essen Center for clinical trials Essen c/o IMIBE Hufelandstr. 55 45122 Essen Monitoring: Dipl.-Biol. Konstantinos Bilbilis Phone: 0201/92239-252 Fax: 0201/92239-310 e-mail: konstantinos.bilbilis@uk-essen.de University Hospital Essen Center for clinical trials Essen c/o IMIBE Hufelandstr. 55 45122 Essen

Stichworte

Versionen (1)
  1. 22.02.16 22.02.16 -
Hochgeladen am

22. Februar 2016

DOI

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Lizenz

Creative Commons BY-NC 3.0
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Medical History Coronary Artery Bypass graft surgery in patients with Asymptomatic Carotid Stenosis DRKS00000521

Englisch

CABACS Case Report Form [Medical History]

1 Formulare  
Medical history
Beschreibung

Medical history

Date of screening for trial
Beschreibung

Date of screening

Datentyp

date

Alias
UMLS CUI [1,1]
C0011008
UMLS CUI [1,2]
C1710477
Patient ID
Beschreibung

Patient Study ID

Datentyp

integer

Alias
UMLS CUI [1]
C2348585
Month of birth
Beschreibung

Month of birth

Datentyp

integer

Alias
UMLS CUI [1]
C0439231
Year of birth
Beschreibung

Year of birth

Datentyp

integer

Alias
UMLS CUI [1]
C2826771
Gender
Beschreibung

Gender

Datentyp

integer

Alias
UMLS CUI [1]
C0079399
Body Height
Beschreibung

Body Height

Datentyp

integer

Maßeinheiten
  • cm
Alias
UMLS CUI [1]
C0005890
cm
Body Weight
Beschreibung

Body Weight

Datentyp

float

Maßeinheiten
  • kg
Alias
UMLS CUI [1]
C0005910
kg
Hypertensive disease
Beschreibung

Hypertension

Datentyp

boolean

Alias
UMLS CUI [1]
C0020538
Hyperlipidemia
Beschreibung

Hyperlipidemia

Datentyp

boolean

Alias
UMLS CUI [1]
C0020473
Smoking status
Beschreibung

Substance use disorder

Datentyp

text

Alias
UMLS CUI [1]
C0038586
If you are a former smoker, when did you quit smoking?
Beschreibung

Former smoker

Datentyp

text

Alias
UMLS CUI [1]
C0337671
Anatomical position of carotid stenosis
Beschreibung

Anatomical position of carotid stenosis

Datentyp

text

Alias
UMLS CUI [1,1]
C0007282
UMLS CUI [1,2]
C0277809
Prior carotid TEA
Beschreibung

Prior carotid TEA

Datentyp

text

Alias
UMLS CUI [1,1]
C0162363
UMLS CUI [1,2]
C0007272
Prior carotid TEA:please give the year of the procedure
Beschreibung

Prior carotid TEA

Datentyp

integer

Alias
UMLS CUI [1]
C0007272
Are there any other relevant comorbidities? Please specify below
Beschreibung

Comorbidities

Datentyp

boolean

Alias
UMLS CUI [1]
C0009488
Please specify comorbidities by ICD-Code or Diagnosis
Beschreibung

Comorbidities

Datentyp

text

Alias
UMLS CUI [1]
C0009488
Please give the year, the comorbidity was first diagnosed
Beschreibung

Start date

Datentyp

integer

Alias
UMLS CUI [1]
C0011008
Is the symptom/comorbidity persistent?
Beschreibung

Ongoing

Datentyp

boolean

Alias
UMLS CUI [1]
C0549178
Date of completion of this form
Beschreibung

Date of completion

Datentyp

date

Alias
UMLS CUI [1]
C0011008
Signature by Investigator
Beschreibung

Signature

Datentyp

text

Alias
UMLS CUI [1]
C1519316
Name of Investigator
Beschreibung

Name of Investigator

Datentyp

text

Alias
UMLS CUI [1]
C0008961
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Ähnliche Modelle

CABACS Case Report Form [Medical History]

1 Formulare
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Item Group
Medical history
Date of screening
Item
Date of screening for trial
date
C0011008 (UMLS CUI [1,1])
C1710477 (UMLS CUI [1,2])
Patient Study ID
Item
Patient ID
integer
C2348585 (UMLS CUI [1])
Month of birth
Item
Month of birth
integer
C0439231 (UMLS CUI [1])
Year of birth
Item
Year of birth
integer
C2826771 (UMLS CUI [1])
Item
Gender
integer
C0079399 (UMLS CUI [1])
Gender
Code List
Gender
CL Item
male (1)
CL Item
female (2)
Body Height
Item
Body Height
integer
C0005890 (UMLS CUI [1])
Body Weight
Item
Body Weight
float
C0005910 (UMLS CUI [1])
Hypertension
Item
Hypertensive disease
boolean
C0020538 (UMLS CUI [1])
Hyperlipidemia
Item
Hyperlipidemia
boolean
C0020473 (UMLS CUI [1])
Item
Smoking status
text
C0038586 (UMLS CUI [1])
Substance use disorder
Code List
Smoking status
CL Item
Never (1)
CL Item
Quit smoking (2)
CL Item
smoker (3)
Item
If you are a former smoker, when did you quit smoking?
text
C0337671 (UMLS CUI [1])
Former smoker
Code List
If you are a former smoker, when did you quit smoking?
CL Item
≥ 5 years (1)
CL Item
< 5 years (2)
Item
Anatomical position of carotid stenosis
text
C0007282 (UMLS CUI [1,1])
C0277809 (UMLS CUI [1,2])
Anatomical position of carotid stenosis
Code List
Anatomical position of carotid stenosis
CL Item
ACC right (1)
CL Item
ACC left (2)
CL Item
ACI right (3)
CL Item
ACI left (4)
Item
Prior carotid TEA
text
C0162363 (UMLS CUI [1,1])
C0007272 (UMLS CUI [1,2])
Prior carotid TEA
Code List
Prior carotid TEA
CL Item
No (1)
CL Item
right side (2)
CL Item
left side (3)
Prior carotid TEA
Item
Prior carotid TEA:please give the year of the procedure
integer
C0007272 (UMLS CUI [1])
Comorbidities
Item
Are there any other relevant comorbidities? Please specify below
boolean
C0009488 (UMLS CUI [1])
Comorbidities
Item
Please specify comorbidities by ICD-Code or Diagnosis
text
C0009488 (UMLS CUI [1])
Start date
Item
Please give the year, the comorbidity was first diagnosed
integer
C0011008 (UMLS CUI [1])
Ongoing
Item
Is the symptom/comorbidity persistent?
boolean
C0549178 (UMLS CUI [1])
Date of completion
Item
Date of completion of this form
date
C0011008 (UMLS CUI [1])
Signature
Item
Signature by Investigator
text
C1519316 (UMLS CUI [1])
Name of Investigator
Item
Name of Investigator
text
C0008961 (UMLS CUI [1])
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