ID

13823

Beskrivning

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

Länk

http://www.ebmt.org/

Nyckelord

Versioner (4)
  1. 2016-02-15 2016-02-15 -
  2. 2016-02-28 2016-02-28 -
  3. 2016-03-06 2016-03-06 -
  4. 2016-03-08 2016-03-08 - Julian Varghese
Uppladdad den

8 mars 2016

DOI

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Licens

Creative Commons BY-NC-ND 3.0
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Follow up EBMT MDS

Engelsk

Follow up EBMT MDS

1 Formulär  
  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
Beskrivning

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)
Beskrivning

Unique Identification Code (UIC)

Datatyp

text

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

Date of this report

Datatyp

date

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

National/ international study/trial

Datatyp

text

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

Name of national/ international study/trial

Datatyp

text

Alias
UMLS CUI [1]
C2348560
Hospital Unique Patient Number
Beskrivning

Hospital Unique Patient Number

Datatyp

text

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

Initials

Datatyp

text

Alias
UMLS CUI [1]
C2986440
Date of birth
Beskrivning

Date of birth

Datatyp

date

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

Date of last HSCT for this patient

Datatyp

date

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

Patient last seen

Date of last contact or death
Beskrivning

Date of last contact or death

Datatyp

date

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

Graft versus Host Disease (GvHD) since last report

Acute Graft versus Host Disease (aGvHD) - Maximum grade
Beskrivning

Maximum grade

Datatyp

text

Alias
UMLS CUI [1]
C0441799
If present, specify:
Beskrivning

Specification

Datatyp

text

Alias
UMLS CUI [1,1]
C0856825
UMLS CUI [1,2]
C2348235
If present, specify reason:
Beskrivning

Reason

Datatyp

text

Alias
UMLS CUI [1,1]
C0856825
UMLS CUI [1,2]
C0392360
If yes, specify date of onset of this episode (if new or recurrent and applicable)
Beskrivning

date of onset of this episode

Datatyp

date

Alias
UMLS CUI [1]
C0574845
If yes, specify stage skin:
Beskrivning

Skin involvement

Datatyp

text

Alias
UMLS CUI [1,1]
C1123023
UMLS CUI [1,2]
C1314939
If yes, specify stage liver:
Beskrivning

Liver involvement

Datatyp

text

Alias
UMLS CUI [1,1]
C1123023
UMLS CUI [1,2]
C0023884
If yes, specify stage gut:
Beskrivning

Gut involvement

Datatyp

text

Alias
UMLS CUI [1,1]
C1123023
UMLS CUI [1,2]
C0021853
Resolution
Beskrivning

Resolution

Datatyp

boolean

Alias
UMLS CUI [1,1]
C0856825
UMLS CUI [1,2]
C1514893
If resolution, specify date:
Beskrivning

Date of Resolution

Datatyp

date

Alias
UMLS CUI [1]
C0011008
Presence of cGvHD
Beskrivning

Chronic Graft versus Host Disease (cGvHD)

Datatyp

text

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

Specification

Datatyp

text

Alias
UMLS CUI [1,1]
C0867389
UMLS CUI [1,2]
C2348235
If yes, specify date of onset:
Beskrivning

Date of onset

Datatyp

date

Alias
UMLS CUI [1,1]
C0867389
UMLS CUI [1,2]
C0574845
If present continuously since last reported episode, specify cGvHD grade:
Beskrivning

Grading

Datatyp

text

Alias
UMLS CUI [1,1]
C0867389
UMLS CUI [1,2]
C0441799
If present continuously since last reported episode, specify which organs are affected:
Beskrivning

Affected sites

Datatyp

text

Alias
UMLS CUI [1,1]
C0867389
UMLS CUI [1,2]
C0449642
If present continuously since last reported episode, specify others:
Beskrivning

Specification

Datatyp

text

Alias
UMLS CUI [1,1]
C0867389
UMLS CUI [1,2]
C2348235
If resolved, specify date of resolution:
Beskrivning

Date of resolution

Datatyp

date

Alias
UMLS CUI [1,1]
C0867389
UMLS CUI [1,2]
C0011008
UMLS CUI [1,3]
C1514893
Other Complications since last report (please use the document "Definitions of infectious diseases and complications after stem cell transplantation" to fill these items.)
Beskrivning

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
Beskrivning

Infection related complications

Datatyp

boolean

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

bacteriaemia/ fungemia/ viremia/ parasites

Datatyp

text

Alias
UMLS CUI [1]
C0004610
UMLS CUI [2]
C0085082
UMLS CUI [3]
C0042749
UMLS CUI [4]
C0030498
If other, specify (general):
Beskrivning

Specification

Datatyp

text

Alias
UMLS CUI [1,1]
C0009450
UMLS CUI [1,2]
C0009566
UMLS CUI [1,3]
C2348235
Specify the date of the episode (General)
Beskrivning

date of the episode

Datatyp

date

Alias
UMLS CUI [1]
C0011008
Systemic Symptoms of Infections
Beskrivning

Systemic Symptoms of Infections

Datatyp

text

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

Type of Systemic Infections

Datatyp

text

Alias
UMLS CUI [1,1]
C2039684
UMLS CUI [1,2]
C0004610
UMLS CUI [2,1]
C2039684
UMLS CUI [2,2]
C0085082
UMLS CUI [3,1]
C2039684
UMLS CUI [3,2]
C0042749
UMLS CUI [4,1]
C2039684
UMLS CUI [4,2]
C0030498
Systemic symptoms of infection: if other, specify:
Beskrivning

Specification of other systemic infections

Datatyp

text

Alias
UMLS CUI [1,1]
C2039684
UMLS CUI [1,2]
C0009450
UMLS CUI [1,3]
C2348235
Systemic symptoms of infection: Specify the date of the episode
Beskrivning

Systemic infection: date of the episode

Datatyp

date

Alias
UMLS CUI [1,1]
C2039684
UMLS CUI [1,2]
C0009450
UMLS CUI [1,3]
C0011008
Endorgan diseases
Beskrivning

Endorgan diseases

Datatyp

text

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

Type of endorgan diseases

Datatyp

text

Alias
UMLS CUI [1,1]
C0349410
UMLS CUI [1,2]
C0004610
UMLS CUI [2,1]
C0349410
UMLS CUI [2,2]
C0085082
UMLS CUI [3,1]
C0349410
UMLS CUI [3,2]
C0042749
UMLS CUI [4,1]
C0349410
UMLS CUI [4,2]
C0030498
Endorgan diseases: If other, specify:
Beskrivning

Infection related complications

Datatyp

text

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

Endorgan diseases: date of the episode

Datatyp

date

Alias
UMLS CUI [1,1]
C0349410
UMLS CUI [1,2]
C0009450
UMLS CUI [1,3]
C0011008
Non infection related complications
Beskrivning

Non infection related complications

Datatyp

boolean

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

Idiopathic pneumonia syndrome

Datatyp

text

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

Date of onset: Idiopathic pneumonia syndrome

Datatyp

date

Alias
UMLS CUI [1,1]
C1504431
UMLS CUI [1,2]
C0574845
Specify: VOD
Beskrivning

VOD

Datatyp

text

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

Date of onset: VOD

Datatyp

date

Alias
UMLS CUI [1,1]
C0948441
UMLS CUI [1,2]
C0574845
Specify: Cataract
Beskrivning

Cataract

Datatyp

text

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

Date of onset: Cataract

Datatyp

date

Alias
UMLS CUI [1,1]
C0086543
UMLS CUI [1,2]
C0574845
Specify: Haemorrhagic cystitis, non infectious
Beskrivning

Haemorrhagic cystitis, non infectious

Datatyp

text

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

Date of onset: Haemorrhagic cystitis, non infectious

Datatyp

date

Alias
UMLS CUI [1,1]
C0085692
UMLS CUI [1,2]
C0574845
Specify: ARDS, non infectious
Beskrivning

ARDS, non infectious

Datatyp

text

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

Date of onset: ARDS, non infectious

Datatyp

date

Alias
UMLS CUI [1,1]
C0035222
UMLS CUI [1,2]
C0574845
Specify: Multiorgan-failre, non infectious
Beskrivning

Multiorgan-failre, non infectious

Datatyp

text

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

Date of onset: Multiorgan-failre, non infectious

Datatyp

date

Alias
UMLS CUI [1,1]
C0026766
UMLS CUI [1,2]
C0574845
Specify: HSCT-associated microangiopathy
Beskrivning

HSCT-associated microangiopathy

Datatyp

text

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

Date of onset: HSCT-associated microangiopathy

Datatyp

date

Alias
UMLS CUI [1,1]
C0155765
UMLS CUI [1,2]
C0574845
Specify: Renal failure requiring dialysis
Beskrivning

Renal failure requiring dialysis

Datatyp

text

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

Date of onset: Renal failure requiring dialysis

Datatyp

date

Alias
UMLS CUI [1,1]
C0035078
UMLS CUI [1,2]
C0574845
Specify: Haemolytic anaemia due to blood group
Beskrivning

Haemolytic anaemia due to blood group

Datatyp

text

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

Date of onset: Haemolytic anaemia due to blood group

Datatyp

date

Alias
UMLS CUI [1,1]
C0002878
UMLS CUI [1,2]
C0574845
Specify: Aseptic bone necrosis
Beskrivning

Aseptic bone necrosis

Datatyp

text

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

Date of onset: Aseptic bone necrosis

Datatyp

date

Alias
UMLS CUI [1,1]
C0158452
UMLS CUI [1,2]
C0574845
Specify: Other
Beskrivning

Specification - other

Datatyp

text

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

Date of onset

Datatyp

date

Alias
UMLS CUI [1]
C0574845
Graft loss
Beskrivning

Graft loss

Datatyp

text

Alias
UMLS CUI [1]
C0877042
Overall chimaerism
Beskrivning

Overall chimaerism

Datatyp

text

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

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.)
Beskrivning

Date of test

Datatyp

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.)
Beskrivning

Identification

Datatyp

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.)
Beskrivning

Number in the infusion order

Datatyp

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.)
Beskrivning

Bone marrow

Datatyp

float

Måttenheter
  • %
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.)
Beskrivning

PB mononuclear cells (PBMC)

Datatyp

float

Måttenheter
  • %
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.)
Beskrivning

T-Cells

Datatyp

float

Måttenheter
  • %
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.)
Beskrivning

B-Cells

Datatyp

float

Måttenheter
  • %
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.)
Beskrivning

Red blood cells

Datatyp

float

Måttenheter
  • %
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.)
Beskrivning

Monocytes

Datatyp

float

Måttenheter
  • %
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.)
Beskrivning

PMNs (neutrophils)

Datatyp

float

Måttenheter
  • %
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.)
Beskrivning

Lymphocytes, NOS

Datatyp

float

Måttenheter
  • %
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.)
Beskrivning

Myeloid cells, NOS

Datatyp

float

Måttenheter
  • %
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.)
Beskrivning

Specification of other cell type

Datatyp

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.)
Beskrivning

Other cell type - value

Datatyp

float

Måttenheter
  • %
Alias
UMLS CUI [1,1]
C0449475
UMLS CUI [1,2]
C1522609
%
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.)
Beskrivning

Labarotory tests

Datatyp

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.)
Beskrivning

Specification other labaratory tests

Datatyp

text

Alias
UMLS CUI [1,1]
C0022885
UMLS CUI [1,2]
C2348235
Secondary Malignancy, Lymphoproliferative or Myeloproliferative disorder
Beskrivning

Secondary Malignancy, Lymphoproliferative or Myeloproliferative disorder

Secondary Malignancy, Lymphoproliferative or Myeloproliferative disorder diagnosed
Beskrivning

Secondary Malignancy, Lymphoproliferative or Myeloproliferative disorder

Datatyp

text

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

Date of diagnosis

Datatyp

date

Alias
UMLS CUI [1]
C2316983
If yes, specify the diagnosis
Beskrivning

Specification of the diagnosis

Datatyp

text

Alias
UMLS CUI [1]
C0011900
If other, specify:
Beskrivning

Specification of other diagnosis

Datatyp

text

Alias
UMLS CUI [1,1]
C0011900
UMLS CUI [1,2]
C2348235
Additional therapies since last follow up
Beskrivning

Additional therapies since last follow up

Treatment given since last report
Beskrivning

Additional treatment

Datatyp

text

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

start date

Datatyp

date

Alias
UMLS CUI [1]
C0808070
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.
Beskrivning

Additional treatment - Cellular therapy

Datatyp

text

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

Disease response

Datatyp

text

Alias
UMLS CUI [1]
C1704632
If yes, specify the cell type
Beskrivning

cell type

Datatyp

text

Alias
UMLS CUI [1]
C0449475
If yes, specify the cell type: If cell type other, specify:
Beskrivning

Specification: other cell type

Datatyp

text

Alias
UMLS CUI [1,1]
C0449475
UMLS CUI [1,2]
C2348235
If DLI, specify the number of cells infused by type: Nucleated cells
Beskrivning

Nucleated cells

Datatyp

text

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

Number of infused Nucleated cells

Datatyp

float

Måttenheter
  • 10^8/kg
Alias
UMLS CUI [1,1]
C1180059
UMLS CUI [1,2]
C0237753
10^8/kg
If DLI, specify the number of cells infused by type: CD 34+
Beskrivning

CD 34+

Datatyp

text

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

Number of infused CD 34+

Datatyp

float

Måttenheter
  • (10^6/kg)
Alias
UMLS CUI [1,1]
C3538723
UMLS CUI [1,2]
C0237753
(10^6/kg)
If DLI, specify the number of cells infused by type: CD 3+
Beskrivning

CD 3+

Datatyp

text

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

Number of infused CD 3+

Datatyp

float

Måttenheter
  • (10^6/kg)
Alias
UMLS CUI [1,1]
C3542405
UMLS CUI [1,2]
C0237753
(10^6/kg)
If non DLI, specify total number of cells infused:
Beskrivning

All cells

Datatyp

text

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

Total number of cells infused

Datatyp

float

Måttenheter
  • (10^6/kg)
Alias
UMLS CUI [1,1]
C0007584
UMLS CUI [1,2]
C0237753
(10^6/kg)
Chronological number of this cell therapy for this patient
Beskrivning

Chronological number

Datatyp

float

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

Indication

Datatyp

text

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

Specification of other indication

Datatyp

text

Alias
UMLS CUI [1,1]
C3146298
UMLS CUI [1,2]
C0302189
UMLS CUI [1,3]
C2348235
Number of Infusions (within 10 weeks) (count only infusions that are part of same regimen and given for the same indication)
Beskrivning

Number of Infusions

Datatyp

float

Alias
UMLS CUI [1,1]
C2348184
UMLS CUI [1,2]
C1289919
Acute Graft versus Host Disease (after this infusion but before any further infusion/ transplant) Maximum grade:
Beskrivning

Acute Graft versus Host Disease

Datatyp

text

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

Other additional treatment

Datatyp

boolean

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

Specification of other additional treatment

Datatyp

text

Alias
UMLS CUI [1,1]
C1706712
UMLS CUI [1,2]
C2348235
First evidence of relapse or progression since last HSCT
Beskrivning

First evidence of relapse or progression since last HSCT

Relapse or Progression
Beskrivning

Relapse or Progression

Datatyp

text

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

date of diagnosis

Datatyp

date

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

Last disease and pateint status

last disease status
Beskrivning

Last Disease Status

Datatyp

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?
Beskrivning

Conception

Datatyp

text

Alias
UMLS CUI [1]
C0032961
Survival status
Beskrivning

Survival Status

Datatyp

text

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

Performance Score

Datatyp

text

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

Performance Score value

Datatyp

text

Alias
UMLS CUI [1,1]
C1518965
UMLS CUI [1,2]
C1522609
If dead, specify cause of death:
Beskrivning

Cause of Death

Datatyp

text

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

GvHD

Datatyp

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
Beskrivning

Interstitial Pneumonitis

Datatyp

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
Beskrivning

Pulmonary toxicity

Datatyp

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
Beskrivning

Infection

Datatyp

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:
Beskrivning

Specification of Infection

Datatyp

text

Alias
UMLS CUI [1,1]
C0007465
UMLS CUI [1,2]
C0009450
UMLS CUI [1,3]
C2348235
If dead and HSCT related cause of death, specify (check as many as apppropriate): Rejection/ Poor graft function
Beskrivning

Rejection/ Poor graft function

Datatyp

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)
Beskrivning

Veno-Occlusive disease (VOD)

Datatyp

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
Beskrivning

Haemorrhage

Datatyp

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
Beskrivning

Cardiac toxicity

Datatyp

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
Beskrivning

Central nervous system toxicity

Datatyp

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
Beskrivning

Gastro intestinal toxicity

Datatyp

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
Beskrivning

Skin toxicity

Datatyp

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
Beskrivning

Renal failure

Datatyp

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
Beskrivning

Multiple organ failure

Datatyp

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
Beskrivning

Other Cause of Death

Datatyp

text

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

Specification of other Cause of Death

Datatyp

text

Alias
UMLS CUI [1,1]
C0007465
UMLS CUI [1,2]
C2348235
If other, specify:
Beskrivning

Other Cause of Death

Datatyp

text

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

Additional notes if applicable

Comments:
Beskrivning

Comments

Datatyp

text

Alias
UMLS CUI [1]
C0947611
Identification and Signature
Beskrivning

Identification and Signature

Identification
Beskrivning

Identification

Datatyp

text

Alias
UMLS CUI [1]
C0205396
Signature
Beskrivning

Signature

Datatyp

text

Alias
UMLS CUI [1]
C1519316
Tillbaka till toppen

Similar models

Follow up EBMT MDS

1 Formulär
  1. StudyEvent: ODM
    1. Follow up EBMT MDS
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
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)
Name of national/ international study/trial
Item
If yes, specify:
text
C2348560 (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) - Maximum grade
text
C0441799 (UMLS CUI [1])
Acute Graft versus Host Disease (aGvHD)
Code List
Acute Graft versus Host Disease (aGvHD) - Maximum grade
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 [1,1])
C2348235 (UMLS CUI [1,2])
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 [1,1])
C0392360 (UMLS CUI [1,2])
undefined item
Code List
If present, specify reason:
CL Item
Tapering (Tapering)
CL Item
DLI (DLI)
CL Item
Unexplained (Unexplained)
date of onset of this episode
Item
If yes, specify date of onset of this episode (if new or recurrent and applicable)
date
C0574845 (UMLS CUI [1])
Item
If yes, specify stage skin:
text
C1123023 (UMLS CUI [1,1])
C1314939 (UMLS CUI [1,2])
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
C1123023 (UMLS CUI [1,1])
C0023884 (UMLS CUI [1,2])
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
C1123023 (UMLS CUI [1,1])
C0021853 (UMLS CUI [1,2])
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)
Resolution
Item
Resolution
boolean
C0856825 (UMLS CUI [1,1])
C1514893 (UMLS CUI [1,2])
Date of Resolution
Item
If resolution, specify date:
date
C0011008 (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 [1,1])
C2348235 (UMLS CUI [1,2])
undefined item
Code List
If yes, specify:
CL Item
First episode (First episode)
CL Item
Recurrence (Recurrence)
Date of onset
Item
If yes, specify date of onset:
date
C0867389 (UMLS CUI [1,1])
C0574845 (UMLS CUI [1,2])
Item
If present continuously since last reported episode, specify cGvHD grade:
text
C0867389 (UMLS CUI [1,1])
C0441799 (UMLS CUI [1,2])
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 [1,1])
C0449642 (UMLS CUI [1,2])
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)
Specification
Item
If present continuously since last reported episode, specify others:
text
C0867389 (UMLS CUI [1,1])
C2348235 (UMLS CUI [1,2])
Date of resolution
Item
If resolved, specify date of resolution:
date
C0867389 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
C1514893 (UMLS CUI [1,3])
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
C0004610 (UMLS CUI [1])
C0085082 (UMLS CUI [2])
C0042749 (UMLS CUI [3])
C0030498 (UMLS CUI [4])
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)
Specification
Item
If other, specify (general):
text
C0009450 (UMLS CUI [1,1])
C0009566 (UMLS CUI [1,2])
C2348235 (UMLS CUI [1,3])
date of the episode
Item
Specify the date of the episode (General)
date
C0011008 (UMLS CUI [1])
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])
C0004610 (UMLS CUI [1,2])
C2039684 (UMLS CUI [2,1])
C0085082 (UMLS CUI [2,2])
C2039684 (UMLS CUI [3,1])
C0042749 (UMLS CUI [3,2])
C2039684 (UMLS CUI [4,1])
C0030498 (UMLS CUI [4,2])
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)
Specification of other systemic infections
Item
Systemic symptoms of infection: if other, specify:
text
C2039684 (UMLS CUI [1,1])
C0009450 (UMLS CUI [1,2])
C2348235 (UMLS CUI [1,3])
Systemic infection: date of the episode
Item
Systemic symptoms of infection: Specify the date of the episode
date
C2039684 (UMLS CUI [1,1])
C0009450 (UMLS CUI [1,2])
C0011008 (UMLS CUI [1,3])
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])
C0004610 (UMLS CUI [1,2])
C0349410 (UMLS CUI [2,1])
C0085082 (UMLS CUI [2,2])
C0349410 (UMLS CUI [3,1])
C0042749 (UMLS CUI [3,2])
C0349410 (UMLS CUI [4,1])
C0030498 (UMLS CUI [4,2])
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])
Endorgan diseases: date of the episode
Item
Endorgan diseases: Specify the date of the episode
date
C0349410 (UMLS CUI [1,1])
C0009450 (UMLS CUI [1,2])
C0011008 (UMLS CUI [1,3])
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)
Date of onset: Idiopathic pneumonia syndrome
Item
If yes, specify: Idiopathic pneumonia syndrome Date of onset
date
C1504431 (UMLS CUI [1,1])
C0574845 (UMLS CUI [1,2])
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)
Date of onset: VOD
Item
If yes, specify: VOD Date of onset
date
C0948441 (UMLS CUI [1,1])
C0574845 (UMLS CUI [1,2])
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)
Date of onset: Cataract
Item
If yes, specify: Cataract Date of onset
date
C0086543 (UMLS CUI [1,1])
C0574845 (UMLS CUI [1,2])
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)
Date of onset: Haemorrhagic cystitis, non infectious
Item
If yes, specify: Haemorrhagic cystitis, non infectious Date of onset
date
C0085692 (UMLS CUI [1,1])
C0574845 (UMLS CUI [1,2])
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)
Date of onset: ARDS, non infectious
Item
If yes, specify: ARDS, non infectious Date of onset
date
C0035222 (UMLS CUI [1,1])
C0574845 (UMLS CUI [1,2])
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)
Date of onset: Multiorgan-failre, non infectious
Item
If yes, specify: Multiorgan-failre, non infectious Date of onset
date
C0026766 (UMLS CUI [1,1])
C0574845 (UMLS CUI [1,2])
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)
Date of onset: HSCT-associated microangiopathy
Item
If yes, specify: HSCT-associated microangiopathy Date of onset
date
C0155765 (UMLS CUI [1,1])
C0574845 (UMLS CUI [1,2])
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)
Date of onset: Renal failure requiring dialysis
Item
If yes, specify: Renal failure requiring dialysis Date of onset
date
C0035078 (UMLS CUI [1,1])
C0574845 (UMLS CUI [1,2])
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)
Date of onset: Haemolytic anaemia due to blood group
Item
If yes, specify: Haemolytic anaemia due to blood group Date of onset
date
C0002878 (UMLS CUI [1,1])
C0574845 (UMLS CUI [1,2])
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)
Date of onset: Aseptic bone necrosis
Item
If yes, specify: Aseptic bone necrosis Date of onset
date
C0158452 (UMLS CUI [1,1])
C0574845 (UMLS CUI [1,2])
Specification - other
Item
Specify: Other
text
C0009566 (UMLS CUI [1])
Date of onset
Item
If other: Date of onset
date
C0574845 (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
Date of test
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])
Identification
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])
Number in the infusion order
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])
Bone marrow
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])
PB mononuclear cells (PBMC)
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])
T-Cells
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])
B-Cells
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])
Red blood cells
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])
Monocytes
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])
PMNs (neutrophils)
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])
Lymphocytes, NOS
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])
Myeloid cells, NOS
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])
Specification of other cell type
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])
Other cell type - value
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 [1,1])
C1522609 (UMLS CUI [1,2])
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)
Specification other labaratory tests
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 [1,1])
C2348235 (UMLS CUI [1,2])
Item Group
Secondary Malignancy, Lymphoproliferative or Myeloproliferative disorder
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)
Date of diagnosis
Item
If yes, specify date of diagnosis
date
C2316983 (UMLS CUI [1])
Item
If yes, specify the diagnosis
text
C0011900 (UMLS CUI [1])
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)
Specification of other diagnosis
Item
If other, specify:
text
C0011900 (UMLS CUI [1,1])
C2348235 (UMLS CUI [1,2])
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)
start date
Item
If yes, specify the start date
date
C0808070 (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
C1704632 (UMLS CUI [1])
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
C0449475 (UMLS CUI [1])
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)
Specification: other cell type
Item
If yes, specify the cell type: If cell type other, specify:
text
C0449475 (UMLS CUI [1,1])
C2348235 (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)
Number of infused Nucleated cells
Item
If DLI, specify the number of cells infused by type: Nucleated cells (10^8/kg)
float
C1180059 (UMLS CUI [1,1])
C0237753 (UMLS CUI [1,2])
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)
Number of infused CD 34+
Item
If DLI, specify the number of cells infused by type: CD 34+ (10^6/kg)
float
C3538723 (UMLS CUI [1,1])
C0237753 (UMLS CUI [1,2])
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)
Number of infused CD 3+
Item
If DLI, specify the number of cells infused by type: CD 3+ (10^6/kg)
float
C3542405 (UMLS CUI [1,1])
C0237753 (UMLS CUI [1,2])
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)
Total number of cells infused
Item
If non DLI, specify the total number of cells infused (10^6/kg)
float
C0007584 (UMLS CUI [1,1])
C0237753 (UMLS CUI [1,2])
Chronological number
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)
Specification of other indication
Item
Indication: If other, specify:
text
C3146298 (UMLS CUI [1,1])
C0302189 (UMLS CUI [1,2])
C2348235 (UMLS CUI [1,3])
Number of Infusions
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 [1,1])
C1289919 (UMLS CUI [1,2])
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)
Other additional treatment
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 [1,1])
C2348235 (UMLS CUI [1,2])
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)
date of diagnosis
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 [1,1])
C1522609 (UMLS CUI [1,2])
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])
C2348235 (UMLS CUI [1,3])
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)
Specification of other 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 [1,1])
C2348235 (UMLS CUI [1,2])
Other 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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