ID

13632

Beskrivning

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

Nyckelord

Versioner (1)
  1. 2016-02-22 2016-02-22 -
Uppladdad den

22 februari 2016

DOI

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

Engelsk

CABACS Case Report Form [Medical History]

1 Formulär  
Medical history
Beskrivning

Medical history

Date of screening for trial
Beskrivning

Date of screening

Datatyp

date

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

Patient Study ID

Datatyp

integer

Alias
UMLS CUI [1]
C2348585
Month of birth
Beskrivning

Month of birth

Datatyp

integer

Alias
UMLS CUI [1]
C0439231
Year of birth
Beskrivning

Year of birth

Datatyp

integer

Alias
UMLS CUI [1]
C2826771
Gender
Beskrivning

Gender

Datatyp

integer

Alias
UMLS CUI [1]
C0079399
Body Height
Beskrivning

Body Height

Datatyp

integer

Måttenheter
  • cm
Alias
UMLS CUI [1]
C0005890
cm
Body Weight
Beskrivning

Body Weight

Datatyp

float

Måttenheter
  • kg
Alias
UMLS CUI [1]
C0005910
kg
Hypertensive disease
Beskrivning

Hypertension

Datatyp

boolean

Alias
UMLS CUI [1]
C0020538
Hyperlipidemia
Beskrivning

Hyperlipidemia

Datatyp

boolean

Alias
UMLS CUI [1]
C0020473
Smoking status
Beskrivning

Substance use disorder

Datatyp

text

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

Former smoker

Datatyp

text

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

Anatomical position of carotid stenosis

Datatyp

text

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

Prior carotid TEA

Datatyp

text

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

Prior carotid TEA

Datatyp

integer

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

Comorbidities

Datatyp

boolean

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

Comorbidities

Datatyp

text

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

Start date

Datatyp

integer

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

Ongoing

Datatyp

boolean

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

Date of completion

Datatyp

date

Alias
UMLS CUI [1]
C0011008
Signature by Investigator
Beskrivning

Signature

Datatyp

text

Alias
UMLS CUI [1]
C1519316
Name of Investigator
Beskrivning

Name of Investigator

Datatyp

text

Alias
UMLS CUI [1]
C0008961
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Similar models

CABACS Case Report Form [Medical History]

1 Formulär
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
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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