ID

13889

Beschrijving

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

Link

http://www.ebmt.org/

Trefwoorden

Versies (1)
  1. 13-03-16 13-03-16 -
Geüploaded op

13 maart 2016

DOI

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Licentie

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

Engels

Follow up EBMT CLL

1 Formulieren  
  1. StudyEvent: ODM
    1. Follow up EBMT CLL
Follow Up
Beschrijving

Follow Up

Unique Identification Code (UIC) (if known)
Beschrijving

Unique Identification Code (UIC)

Datatype

text

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

Date of this report

Datatype

date

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

Study/ Trial

Datatype

text

Alias
UMLS CUI [1]
C2348568
If yes, specify Name of study/ trial
Beschrijving

Study Name

Datatype

text

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

Hospital Unique Patient Number

Datatype

text

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

Initials

Datatype

text

Alias
UMLS CUI [1]
C2986440
Date of birth
Beschrijving

Date of birth

Datatype

date

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

Date of last HSCT for this patient

Datatype

date

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

Patient last seen

Date of last contact or death
Beschrijving

Date of last contact or death

Datatype

date

Alias
UMLS CUI [1]
C0805839
UMLS CUI [2]
C1148348
Acute Graft versus Host Disease (aGvHD) since last report
Beschrijving

Acute Graft versus Host Disease (aGvHD) since last report

Acute Graft versus Host Disease Maximum grade
Beschrijving

Grading aGvHD

Datatype

text

Alias
UMLS CUI [1,1]
C0856825
UMLS CUI [1,2]
C0441799
If present, specify:
Beschrijving

Specification aGvHD

Datatype

text

Alias
UMLS CUI [1,1]
C0856825
UMLS CUI [1,2]
C2348235
Reason for aGvHD
Beschrijving

Reason for aGvHD

Datatype

text

Alias
UMLS CUI [1,1]
C0392360
UMLS CUI [1,2]
C0856825
Date of onset of this episode (if new or recurrent) (if applicable)
Beschrijving

Date of onset

Datatype

date

Alias
UMLS CUI [1]
C0574845
aGvHD: Stage skin
Beschrijving

Stage skin

Datatype

text

Alias
UMLS CUI [1,1]
C0856825
UMLS CUI [1,2]
C0037274
aGvHD: Stage skin If evaluatd, specify:
Beschrijving

Stage skin: grading

Datatype

text

Alias
UMLS CUI [1,1]
C0856825
UMLS CUI [1,2]
C0037274
UMLS CUI [1,3]
C0441799
aGvHD Stage liver
Beschrijving

Stage liver

Datatype

text

Alias
UMLS CUI [1,1]
C0856825
UMLS CUI [1,2]
C0023895
aGvHD Stage liver If evaluated, specify:
Beschrijving

Stage liver: grading

Datatype

text

Alias
UMLS CUI [1,1]
C0856825
UMLS CUI [1,2]
C0023895
UMLS CUI [1,3]
C0441799
aGvHD Stage gut
Beschrijving

Stage gut

Datatype

text

Alias
UMLS CUI [1,1]
C0856825
UMLS CUI [1,2]
C0017178
aGvHD Stage gut If evaluated, specify:
Beschrijving

Stage gut: grading

Datatype

text

Alias
UMLS CUI [1,1]
C0856825
UMLS CUI [1,2]
C0017178
UMLS CUI [1,3]
C0441799
aGvHD Resolution
Beschrijving

Resolution

Datatype

boolean

Alias
UMLS CUI [1,1]
C0856825
UMLS CUI [1,2]
C1514893
If yes, specify the date of resolution
Beschrijving

Date of resolution

Datatype

date

Alias
UMLS CUI [1,1]
C0011008
UMLS CUI [1,2]
C1514893
Chronic Graft versus Host Disease (cGvHD) since last report
Beschrijving

Chronic Graft versus Host Disease (cGvHD) since last report

Presence of cGvHD
Beschrijving

Chronic Graft versus Host Disease

Datatype

text

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

Specification cGvHD

Datatype

text

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

Date of onset of cGvHD

Datatype

date

Alias
UMLS CUI [1,1]
C0574845
UMLS CUI [1,2]
C0867389
If present continously since last report, specify cGvHD gade:
Beschrijving

cGvHD grade

Datatype

text

Alias
UMLS CUI [1,1]
C0867389
UMLS CUI [1,2]
C0441799
If present continously since last reported episode, speicfy affected organs:
Beschrijving

Affected organs

Datatype

text

Alias
UMLS CUI [1,1]
C0867389
UMLS CUI [1,2]
C0392760
UMLS CUI [1,3]
C0178784
If present continously since last reported episode, speicfy affected organs: If other, specify:
Beschrijving

Affected organs - specification

Datatype

text

Alias
UMLS CUI [1,1]
C0867389
UMLS CUI [1,2]
C0392760
UMLS CUI [1,3]
C0178784
UMLS CUI [1,4]
C2348235
If resolved, specify the date of resolution:
Beschrijving

Date of Resolution

Datatype

date

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

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
Beschrijving

Infection related complications

Datatype

boolean

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

Bacteriaemia/ fungemia/ viremia/ parasites

Datatype

text

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

Specification

Datatype

text

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

Date of the episode

Datatype

date

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

Systemic Symptoms of Infections

Datatype

text

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

Type of Systemic Infections

Datatype

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:
Beschrijving

Specification of other systemic infections

Datatype

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
Beschrijving

Systemic infection: date of the episode

Datatype

date

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

Endorgan diseases

Datatype

text

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

Type of endorgan diseases

Datatype

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:
Beschrijving

Infection related complications

Datatype

text

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

Endorgan diseases: date of the episode

Datatype

date

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

Non infection related complications

Datatype

boolean

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

Idiopathic pneumonia syndrome

Datatype

text

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

Date of onset: Idiopathic pneumonia syndrome

Datatype

date

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

VOD

Datatype

text

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

Date of onset: VOD

Datatype

date

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

Cataract

Datatype

text

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

Date of onset: Cataract

Datatype

date

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

Haemorrhagic cystitis, non infectious

Datatype

text

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

Date of onset: Haemorrhagic cystitis, non infectious

Datatype

date

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

ARDS, non infectious

Datatype

text

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

Date of onset: ARDS, non infectious

Datatype

date

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

Multiorgan-failure, non infectious

Datatype

text

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

Date of onset: Multiorgan-failure, non infectious

Datatype

date

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

HSCT-associated microangiopathy

Datatype

text

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

Date of onset: HSCT-associated microangiopathy

Datatype

date

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

Renal failure requiring dialysis

Datatype

text

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

Date of onset: Renal failure requiring dialysis

Datatype

date

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

Haemolytic anaemia due to blood group

Datatype

text

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

Date of onset: Haemolytic anaemia due to blood group

Datatype

date

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

Aseptic bone necrosis

Datatype

text

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

Date of onset: Aseptic bone necrosis

Datatype

date

Alias
UMLS CUI [1,1]
C0158452
UMLS CUI [1,2]
C0574845
If other, specify:
Beschrijving

Specification - other

Datatype

text

Alias
UMLS CUI [1,1]
C0200867
UMLS CUI [1,2]
C2348235
If other: Date of onset
Beschrijving

Date of onset

Datatype

date

Alias
UMLS CUI [1]
C0574845
Graft Assessment and Haemopoietic chimaerism
Beschrijving

Graft Assessment and Haemopoietic chimaerism

Graft loss
Beschrijving

Graft loss

Datatype

text

Alias
UMLS CUI [1]
C0877042
Overall chimaerism
Beschrijving

Overall chimaerism

Datatype

text

Alias
UMLS CUI [1]
C0333678
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.
Beschrijving

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 of test
Beschrijving

Date of test

Datatype

date

Alias
UMLS CUI [1]
C2826247
Identification of donor or Cord Blood Unit given by the centre
Beschrijving

Identification

Datatype

text

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

Number in the infusion order

Datatype

text

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

Bone marrow

Datatype

float

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

PB mononuclear cells (PBMC)

Datatype

float

Maateenheden
  • %
Alias
UMLS CUI [1]
C1321301
%
Cell type on which test was performed (% Donor cells): T-Cells
Beschrijving

T-Cells

Datatype

float

Maateenheden
  • %
Alias
UMLS CUI [1]
C0039194
%
Cell type on which test was performed (% Donor cells): B-Cells
Beschrijving

B-Cells

Datatype

float

Maateenheden
  • %
Alias
UMLS CUI [1]
C0004561
%
Cell type on which test was performed (% Donor cells): Red blood cells
Beschrijving

Red blood cells

Datatype

float

Maateenheden
  • %
Alias
UMLS CUI [1]
C0014772
%
Cell type on which test was performed (% Donor cells): Monocytes
Beschrijving

Monocytes

Datatype

float

Maateenheden
  • %
Alias
UMLS CUI [1]
C0026473
%
Cell type on which test was performed (% Donor cells): PMNs (neutrophils)
Beschrijving

PMNs (neutrophils)

Datatype

float

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

Lymphocytes, NOS

Datatype

float

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

Myeloid cells, NOS

Datatype

float

Maateenheden
  • %
Alias
UMLS CUI [1]
C0887899
%
Cell type on which test was performed: Other, specify:
Beschrijving

Specification of other cell type

Datatype

text

Alias
UMLS CUI [1]
C0449475
Cell type on which test was performed (% Donor cells): Other
Beschrijving

Other cell type - value

Datatype

float

Maateenheden
  • %
Alias
UMLS CUI [1,1]
C0449475
UMLS CUI [1,2]
C1522609
%
Test used:
Beschrijving

Laboratory tests

Datatype

text

Alias
UMLS CUI [1]
C0022885
Test used: If other, specify:
Beschrijving

Specification other labaratory tests

Datatype

text

Alias
UMLS CUI [1,1]
C0022885
UMLS CUI [1,2]
C2348235
Other complications since last report - secondary malignancy, lymphoproliferative or myeloproliferative disorder diagnosed
Beschrijving

Other complications since last report - secondary malignancy, lymphoproliferative or myeloproliferative disorder diagnosed

Secondary Malignancy, Lymphoproliferative or Myeloproliferative disorder diagnosed
Beschrijving

Secondary Malignancy, Lymphoproliferative or Myeloproliferative disorder

Datatype

text

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

Date of diagnosis

Datatype

date

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

Specification of the diagnosis

Datatype

text

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

Specification of other diagnosis

Datatype

text

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

Additional therapies since last follow up

Treatment given since last report
Beschrijving

Additional treatment

Datatype

text

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

Start date

Datatype

date

Alias
UMLS CUI [1]
C0808070
One cell therapy regimen is defined as any number of insufiosn given within 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.
Beschrijving

One cell therapy regimen is defined as any number of insufiosn given within 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.

If additional treatment is given, specify for cellular therapy:
Beschrijving

Cellular therapy

Datatype

text

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

Disease status

Datatype

text

Alias
UMLS CUI [1]
C0699749
If yes, specify the cell type
Beschrijving

Cell type

Datatype

text

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

Specification: other cell type

Datatype

text

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

Nucleated cells

Datatype

text

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

Number of infused Nucleated cells

Datatype

float

Maateenheden
  • 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+
Beschrijving

CD 34+

Datatype

text

Alias
UMLS CUI [1]
C3538723
Number of infused CD34+ cells
Beschrijving

Number of infused CD34+ cells

Datatype

float

Alias
UMLS CUI [1,1]
C3538723
UMLS CUI [1,2]
C0237753
If DLI, specify the number of cells infused by type: CD 3+
Beschrijving

CD 3+

Datatype

text

Alias
UMLS CUI [1]
C3542405
Number of infused CD3+ cells
Beschrijving

Number of infused CD3+ cells

Datatype

float

Alias
UMLS CUI [1,1]
C3542405
UMLS CUI [1,2]
C0237753
If non DLI, specify total number of cells infused:
Beschrijving

All cells

Datatype

text

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

Total number of cells infused

Datatype

float

Maateenheden
  • (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
Beschrijving

Chronological number

Datatype

float

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

Indication

Datatype

text

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

Specification of other indication

Datatype

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)
Beschrijving

Number of Infusions

Datatype

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:
Beschrijving

Acute Graft versus Host Disease

Datatype

text

Alias
UMLS CUI [1]
C0856825
Apart from donor cell infusion or other type of cell therapy
Beschrijving

Apart from donor cell infusion or other type of cell therapy

Disease treatment
Beschrijving

Disease treatment

Datatype

boolean

Alias
UMLS CUI [1]
C0087111
If yes, specify:
Beschrijving

Disease treatment specifiation

Datatype

text

Alias
UMLS CUI [1]
C2348235
First evidence of relapse or progression since last HSCT
Beschrijving

First evidence of relapse or progression since last HSCT

Relapse or Progression
Beschrijving

Relapse or Progression

Datatype

text

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

Date of diagnosis

Datatype

date

Alias
UMLS CUI [1]
C2316983
Clinical/ haematological relapse or progression
Beschrijving

Clinical/ haematological relapse or progression

Datatype

text

Alias
UMLS CUI [1,1]
C0205210
UMLS CUI [1,2]
C0277556
UMLS CUI [2,1]
C0205210
UMLS CUI [2,2]
C0242656
UMLS CUI [3,1]
C0018943
UMLS CUI [3,2]
C0277556
UMLS CUI [4,1]
C0018943
UMLS CUI [4,2]
C0242656
If Clinical/ haematological relapse or progression "No", specify Date of assessment:
Beschrijving

Date of assessment

Datatype

date

Alias
UMLS CUI [1]
C2985720
If Clinical/ haematological relapse or progression "Yes", specify date first seen:
Beschrijving

Date of initial diagnosis

Datatype

date

Alias
UMLS CUI [1,1]
C2316983
UMLS CUI [1,2]
C0205265
If Clinical/ haematological relapse or progression "Yes", specify affected site:
Beschrijving

Site

Datatype

text

Alias
UMLS CUI [1]
C1515974
Clinical/ haematological relapse or progression
Beschrijving

MRD relapse or progression

Datatype

text

Alias
UMLS CUI [1,1]
C1511791
UMLS CUI [1,2]
C0277556
UMLS CUI [2,1]
C1511791
UMLS CUI [2,2]
C0242656
If MRD relapse or progression "No", specify Date of assessment:
Beschrijving

Date of assessment

Datatype

date

Alias
UMLS CUI [1]
C2985720
If MRD relapse or progression "Yes", specify date first seen:
Beschrijving

Date of initial diagnosis

Datatype

date

Alias
UMLS CUI [1,1]
C2316983
UMLS CUI [1,2]
C0205265
If MRD relapse or progression "Yes", specify affected site:
Beschrijving

Site

Datatype

text

Alias
UMLS CUI [1]
C1515974
If MRD relapse or progression "Yes", specify sensitivity of MRD assay: Known?
Beschrijving

Sensitivity of MRD assay

Datatype

boolean

Alias
UMLS CUI [1,1]
C1511791
UMLS CUI [1,2]
C0036667
If MRD relapse or progression "Yes", specify sensitivity of MRD assay: If known, specify:
Beschrijving

Sensitivity of MRD assay specification

Datatype

text

Alias
UMLS CUI [1,1]
C1511791
UMLS CUI [1,2]
C0036667
UMLS CUI [1,3]
C2348235
Last Disease status
Beschrijving

Last Disease status

Last Disease Status
Beschrijving

Disease response

Datatype

text

Alias
UMLS CUI [1]
C1704632
Only to be completed when patient is in Haematological Complete Remission
Beschrijving

Only to be completed when patient is in Haematological Complete Remission

Residual Disease Status Minimal residual disease investigated by: Immunophenotyping
Beschrijving

Immunophenotyping

Datatype

text

Alias
UMLS CUI [1]
C0079611
Residual Disease Status Minimal residual disease investigated by: Molecular Biology
Beschrijving

Molecular Biology

Datatype

text

Alias
UMLS CUI [1]
C0026376
Please indicate sensitivity of MRD assay: Known?
Beschrijving

Sensitivity of MRD assay

Datatype

boolean

Alias
UMLS CUI [1,1]
C1511791
UMLS CUI [1,2]
C0036667
Please indicate the sensitivity of MRD assay: If known, specify:
Beschrijving

Sensitivitiy of MRD assay specification

Datatype

text

Alias
UMLS CUI [1,1]
C1511791
UMLS CUI [1,2]
C0036667
UMLS CUI [1,3]
C2348235
Last Disease status - Conception
Beschrijving

Last Disease status - Conception

Has patient or partner become pregnant after this HSCT?
Beschrijving

Conception

Datatype

text

Alias
UMLS CUI [1]
C0032961
Last Disease status - Survival status
Beschrijving

Last Disease status - Survival status

Survival status
Beschrijving

Survival Status

Datatype

text

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

Performance Score

Datatype

text

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

Performance Score value

Datatype

text

Alias
UMLS CUI [1,1]
C1518965
UMLS CUI [1,2]
C1522609
Last Disease status - Cause of death (if dead)
Beschrijving

Last Disease status - Cause of death (if dead)

If dead, specify cause of death:
Beschrijving

Cause of Death

Datatype

text

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

Cause of death: GvHD

Datatype

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
Beschrijving

Cause of death: Interstitial Pneumonitis

Datatype

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
Beschrijving

Cause of death: Pulmonary toxicity

Datatype

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
Beschrijving

Cause of death: Infection

Datatype

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:
Beschrijving

Cause of death: Specification of Infection

Datatype

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
Beschrijving

Cause of death: Rejection/ Poor graft function

Datatype

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)
Beschrijving

Cause of death: no-Occlusive disease (VOD)

Datatype

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
Beschrijving

Cause of death: Haemorrhage

Datatype

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
Beschrijving

Cause of death: Cardiac toxicity

Datatype

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
Beschrijving

Cause of death: Central nervous system toxicity

Datatype

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
Beschrijving

Cause of death: Gastro intestinal toxicity

Datatype

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
Beschrijving

Cause of death: Skin toxicity

Datatype

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
Beschrijving

Cause of death: Renal failure

Datatype

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
Beschrijving

Cause of death: Multiple organ failure

Datatype

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
Beschrijving

Other Cause of Death

Datatype

text

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

Specification of other Cause of Death

Datatype

text

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

Other Cause of Death

Datatype

text

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

Additional notes if applicable

Comments:
Beschrijving

Comments

Datatype

text

Alias
UMLS CUI [1]
C0947611
Identification and Signature
Beschrijving

Identification and Signature

Identification
Beschrijving

Identification

Datatype

text

Alias
UMLS CUI [1]
C0205396
Signature
Beschrijving

Signature

Datatype

text

Alias
UMLS CUI [1]
C1519316
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Similar models

Follow up EBMT CLL

1 Formulieren
  1. StudyEvent: ODM
    1. Follow up EBMT CLL
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
Item Group
Follow Up
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])
Study/ Trial
Code List
Patient following national/ international study/ trial
CL Item
No (No)
CL Item
Yes (Yes)
CL Item
Unknown (Unknown)
Study Name
Item
If yes, specify Name of study/ trial
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
Acute Graft versus Host Disease (aGvHD) since last report
Item
Acute Graft versus Host Disease Maximum grade
text
C0856825 (UMLS CUI [1,1])
C0441799 (UMLS CUI [1,2])
Grading aGvHD
Code List
Acute Graft versus Host Disease Maximum grade
CL Item
grade 0 (Absent) (grade 0 (Absent))
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)
Item
If present, specify:
text
C0856825 (UMLS CUI [1,1])
C2348235 (UMLS CUI [1,2])
Specification aGvHD
Code List
If present, specify:
CL Item
New onset (New onset)
CL Item
Recurrent (Recurrent)
CL Item
Persistent (Persistent)
Item
Reason for aGvHD
text
C0392360 (UMLS CUI [1,1])
C0856825 (UMLS CUI [1,2])
Reason for aGvHD
Code List
Reason for aGvHD
CL Item
Tapering (Tapering)
CL Item
DLI (DLI)
CL Item
Unexplained (Unexplained)
Date of onset
Item
Date of onset of this episode (if new or recurrent) (if applicable)
date
C0574845 (UMLS CUI [1])
Item
aGvHD: Stage skin
text
C0856825 (UMLS CUI [1,1])
C0037274 (UMLS CUI [1,2])
Stage skin
Code List
aGvHD: Stage skin
CL Item
Evaluated (Evaluated)
CL Item
Not evaluated (Not evaluated)
CL Item
Unknown (Unknown)
Item
aGvHD: Stage skin If evaluatd, specify:
text
C0856825 (UMLS CUI [1,1])
C0037274 (UMLS CUI [1,2])
C0441799 (UMLS CUI [1,3])
Stage skin: grading
Code List
aGvHD: Stage skin If evaluatd, specify:
CL Item
1 (1)
CL Item
2 (2)
CL Item
3 (3)
CL Item
4 (4)
Item
aGvHD Stage liver
text
C0856825 (UMLS CUI [1,1])
C0023895 (UMLS CUI [1,2])
Stage liver
Code List
aGvHD Stage liver
CL Item
Evaluated (Evaluated)
CL Item
Not evaluated (Not evaluated)
CL Item
Unknown (Unknown)
Item
aGvHD Stage liver If evaluated, specify:
text
C0856825 (UMLS CUI [1,1])
C0023895 (UMLS CUI [1,2])
C0441799 (UMLS CUI [1,3])
Stage liver: grading
Code List
aGvHD Stage liver If evaluated, specify:
CL Item
1 (1)
CL Item
2 (2)
CL Item
3 (3)
CL Item
4 (4)
Item
aGvHD Stage gut
text
C0856825 (UMLS CUI [1,1])
C0017178 (UMLS CUI [1,2])
Stage gut
Code List
aGvHD Stage gut
CL Item
Evaluated (Evaluated)
CL Item
Not evaluated (Not evaluated)
CL Item
Unknown (Unknown)
Item
aGvHD Stage gut If evaluated, specify:
text
C0856825 (UMLS CUI [1,1])
C0017178 (UMLS CUI [1,2])
C0441799 (UMLS CUI [1,3])
Stage gut: grading
Code List
aGvHD Stage gut If evaluated, specify:
CL Item
1 (1)
CL Item
2 (2)
CL Item
3 (3)
CL Item
4 (4)
Resolution
Item
aGvHD Resolution
boolean
C0856825 (UMLS CUI [1,1])
C1514893 (UMLS CUI [1,2])
Date of resolution
Item
If yes, specify the date of resolution
date
C0011008 (UMLS CUI [1,1])
C1514893 (UMLS CUI [1,2])
Item Group
Chronic Graft versus Host Disease (cGvHD) since last report
Item
Presence of cGvHD
text
C0867389 (UMLS CUI [1])
Chronic Graft versus Host Disease
Code List
Presence of cGvHD
CL Item
No (No)
CL Item
Yes (Yes)
CL Item
Present continously since last reported episode (Present continously since last reported episode)
CL Item
Resolved (Resolved)
Item
If yes, specify:
text
C0867389 (UMLS CUI [1,1])
C2348235 (UMLS CUI [1,2])
Specification cGvHD
Code List
If yes, specify:
CL Item
First episode (First episode)
CL Item
Recurrence (Recurrence)
Date of onset of cGvHD
Item
If yes, specify Date of onset:
date
C0574845 (UMLS CUI [1,1])
C0867389 (UMLS CUI [1,2])
Item
If present continously since last report, specify cGvHD gade:
text
C0867389 (UMLS CUI [1,1])
C0441799 (UMLS CUI [1,2])
cGvHD grade
Code List
If present continously since last report, specify cGvHD gade:
CL Item
Limited (Limited)
CL Item
Extensive (Extensive)
Item
If present continously since last reported episode, speicfy affected organs:
text
C0867389 (UMLS CUI [1,1])
C0392760 (UMLS CUI [1,2])
C0178784 (UMLS CUI [1,3])
Affected organs
Code List
If present continously since last reported episode, speicfy affected organs:
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)
Affected organs - specification
Item
If present continously since last reported episode, speicfy affected organs: If other, specify:
text
C0867389 (UMLS CUI [1,1])
C0392760 (UMLS CUI [1,2])
C0178784 (UMLS CUI [1,3])
C2348235 (UMLS CUI [1,4])
Date of Resolution
Item
If resolved, specify the date of resolution:
date
C1514893 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
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])
Bacteriaemia/ fungemia/ viremia/ parasites
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])
Systemic Symptoms of Infections
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])
Type of Systemic Infections
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])
Endorgan diseases
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])
Type of endorgan diseases
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
Specify: Idiopathic pneumonia syndrome
text
C1504431 (UMLS CUI [1])
Idiopathic pneumonia syndrome
Code List
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])
VOD
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])
Cataract
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])
Haemorrhagic cystitis, non infectious
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])
ARDS, non infectious
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-failure, non infectious
text
C0026766 (UMLS CUI [1])
Multiorgan-failre, non infectious
Code List
Specify: Multiorgan-failure, non infectious
CL Item
Yes (Yes)
CL Item
No  (No )
CL Item
Unknown (Unknown)
Date of onset: Multiorgan-failure, non infectious
Item
If yes, specify: Multiorgan-failure, 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])
HSCT-associated microangiopathy
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])
Renal failure requiring dialysis
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])
Haemolytic anaemia due to blood group
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])
Aseptic bone necrosis
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
If other, specify:
text
C0200867 (UMLS CUI [1,1])
C2348235 (UMLS CUI [1,2])
Date of onset
Item
If other: Date of onset
date
C0574845 (UMLS CUI [1])
Item
Graft loss
text
C0877042 (UMLS CUI [1])
Graft loss
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])
Overall chimaerism
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
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 of test
Item
Date of test
date
C2826247 (UMLS CUI [1])
Identification
Item
Identification of donor or Cord Blood Unit given by the centre
text
C1718162 (UMLS CUI [1])
Number in the infusion order
Item
Number in the infusion order (if applicable)
text
C0237753 (UMLS CUI [1])
Bone marrow
Item
Cell type on which test was performed (% Donor Cells): BM
float
C0005953 (UMLS CUI [1])
PB mononuclear cells (PBMC)
Item
Cell type on which test was performed (% Donor cells): PB mononuclear cells (PBMC)
float
C1321301 (UMLS CUI [1])
T-Cells
Item
Cell type on which test was performed (% Donor cells): T-Cells
float
C0039194 (UMLS CUI [1])
B-Cells
Item
Cell type on which test was performed (% Donor cells): B-Cells
float
C0004561 (UMLS CUI [1])
Red blood cells
Item
Cell type on which test was performed (% Donor cells): Red blood cells
float
C0014772 (UMLS CUI [1])
Monocytes
Item
Cell type on which test was performed (% Donor cells): Monocytes
float
C0026473 (UMLS CUI [1])
PMNs (neutrophils)
Item
Cell type on which test was performed (% Donor cells): PMNs (neutrophils)
float
C0200633 (UMLS CUI [1])
Lymphocytes, NOS
Item
Cell type on which test was performed (% Donor cells): Lymphocytes, NOS
float
C0024264 (UMLS CUI [1])
Myeloid cells, NOS
Item
Cell type on which test was performed (% Donor cells): Myeloid cells, NOS
float
C0887899 (UMLS CUI [1])
Specification of other cell type
Item
Cell type on which test was performed: Other, specify:
text
C0449475 (UMLS CUI [1])
Other cell type - value
Item
Cell type on which test was performed (% Donor cells): Other
float
C0449475 (UMLS CUI [1,1])
C1522609 (UMLS CUI [1,2])
Item
Test used:
text
C0022885 (UMLS CUI [1])
Laboratory tests
Code List
Test used:
CL Item
FISH (FISH)
CL Item
Molecular (Molecular)
CL Item
Cytogenetic (Cytogenetic)
CL Item
ABO group (ABO group)
CL Item
Other (Other)
CL Item
unknown (unknown)
Specification other labaratory tests
Item
Test used: If other, specify:
text
C0022885 (UMLS CUI [1,1])
C2348235 (UMLS CUI [1,2])
Item Group
Other complications since last report - secondary malignancy, lymphoproliferative or myeloproliferative disorder diagnosed
Item
Secondary Malignancy, Lymphoproliferative or Myeloproliferative disorder diagnosed
text
C3266877 (UMLS CUI [1,1])
C0024314 (UMLS CUI [1,2])
C0027022 (UMLS CUI [1,3])
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])
Specification of the diagnosis
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 Group
One cell therapy regimen is defined as any number of insufiosn given within 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.
Item
If additional treatment is given, specify for cellular therapy:
text
C1706712 (UMLS CUI [1,1])
C0302189 (UMLS CUI [1,2])
Cellular therapy
Code List
If additional treatment is given, specify for cellular therapy:
CL Item
No  (No)
CL Item
Yes  (Yes)
CL Item
Unknown (Unknown)
Item
If yes, specify the disease status before this cellular therapy
text
C0699749 (UMLS CUI [1])
Disease status
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])
Cell type
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])
Nucleated cells
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])
CD 34+
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 CD34+ cells
Item
Number of infused CD34+ cells
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])
CD 3+
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 CD3+ cells
Item
Number of infused CD3+ cells
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])
All cells
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])
Indication
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])
Acute Graft versus Host Disease
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)
Item Group
Apart from donor cell infusion or other type of cell therapy
Disease treatment
Item
Disease treatment
boolean
C0087111 (UMLS CUI [1])
Item
If yes, specify:
text
C2348235 (UMLS CUI [1])
Disease treatment specifiation
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
Unknown (Unknown)
CL Item
Continous progression since HSCT (Continous progression since HSCT)
Date of diagnosis
Item
If yes, specify date of diagnosis
date
C2316983 (UMLS CUI [1])
Item
Clinical/ haematological relapse or progression
text
C0205210 (UMLS CUI [1,1])
C0277556 (UMLS CUI [1,2])
C0205210 (UMLS CUI [2,1])
C0242656 (UMLS CUI [2,2])
C0018943 (UMLS CUI [3,1])
C0277556 (UMLS CUI [3,2])
C0018943 (UMLS CUI [4,1])
C0242656 (UMLS CUI [4,2])
Clinical/ haematological relapse or progression
Code List
Clinical/ haematological relapse or progression
CL Item
No (No)
CL Item
Yes (Yes)
CL Item
Not evaluated (Not evaluated)
Date of assessment
Item
If Clinical/ haematological relapse or progression "No", specify Date of assessment:
date
C2985720 (UMLS CUI [1])
Date of initial diagnosis
Item
If Clinical/ haematological relapse or progression "Yes", specify date first seen:
date
C2316983 (UMLS CUI [1,1])
C0205265 (UMLS CUI [1,2])
Item
If Clinical/ haematological relapse or progression "Yes", specify affected site:
text
C1515974 (UMLS CUI [1])
Site
Code List
If Clinical/ haematological relapse or progression "Yes", specify affected site:
CL Item
marrow (marrow)
CL Item
blood (blood)
CL Item
extramedullary (extramedullary)
Item
Clinical/ haematological relapse or progression
text
C1511791 (UMLS CUI [1,1])
C0277556 (UMLS CUI [1,2])
C1511791 (UMLS CUI [2,1])
C0242656 (UMLS CUI [2,2])
MRD relapse or progression
Code List
Clinical/ haematological relapse or progression
CL Item
No (No)
CL Item
Yes (Yes)
CL Item
Not evaluated (Not evaluated)
Date of assessment
Item
If MRD relapse or progression "No", specify Date of assessment:
date
C2985720 (UMLS CUI [1])
Date of initial diagnosis
Item
If MRD relapse or progression "Yes", specify date first seen:
date
C2316983 (UMLS CUI [1,1])
C0205265 (UMLS CUI [1,2])
Item
If MRD relapse or progression "Yes", specify affected site:
text
C1515974 (UMLS CUI [1])
Site
Code List
If MRD relapse or progression "Yes", specify affected site:
CL Item
marrow  (marrow)
CL Item
blood  (blood)
CL Item
extramedullary (extramedullary)
Sensitivity of MRD assay
Item
If MRD relapse or progression "Yes", specify sensitivity of MRD assay: Known?
boolean
C1511791 (UMLS CUI [1,1])
C0036667 (UMLS CUI [1,2])
Sensitivity of MRD assay specification
Item
If MRD relapse or progression "Yes", specify sensitivity of MRD assay: If known, specify:
text
C1511791 (UMLS CUI [1,1])
C0036667 (UMLS CUI [1,2])
C2348235 (UMLS CUI [1,3])
Item Group
Last Disease status
Item
Last Disease Status
text
C1704632 (UMLS CUI [1])
Clinical/ haematological disease stage
Code List
Last Disease Status
CL Item
Complete Remission (Complete Remission)
CL Item
Stable disease (Stable disease)
CL Item
Relapse (Relapse)
CL Item
Progression (Progression)
Item Group
Only to be completed when patient is in Haematological Complete Remission
Item
Residual Disease Status Minimal residual disease investigated by: Immunophenotyping
text
C0079611 (UMLS CUI [1])
Immunophenotyping
Code List
Residual Disease Status Minimal residual disease investigated by: Immunophenotyping
CL Item
Negative (Negative)
CL Item
Positive (Positive)
CL Item
Not evaluated (Not evaluated)
CL Item
Unknown (Unknown)
Item
Residual Disease Status Minimal residual disease investigated by: Molecular Biology
text
C0026376 (UMLS CUI [1])
Molecular Biology
Code List
Residual Disease Status Minimal residual disease investigated by: Molecular Biology
CL Item
Negative (Negative)
CL Item
Positive (Positive)
CL Item
Not evaluated (Not evaluated)
CL Item
Unknown (Unknown)
Sensitivity of MRD assay
Item
Please indicate sensitivity of MRD assay: Known?
boolean
C1511791 (UMLS CUI [1,1])
C0036667 (UMLS CUI [1,2])
Sensitivitiy of MRD assay specification
Item
Please indicate the sensitivity of MRD assay: If known, specify:
text
C1511791 (UMLS CUI [1,1])
C0036667 (UMLS CUI [1,2])
C2348235 (UMLS CUI [1,3])
Item Group
Last Disease status - Conception
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 Group
Last Disease status - Survival status
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])
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])
Performance Score value
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 Group
Last Disease status - Cause of death (if dead)
Item
If dead, specify cause of death:
text
C0007465 (UMLS CUI [1])
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])
Cause of death: GvHD
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])
Cause of death: Interstitial Pneumonitis
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])
Cause of death: Pulmonary toxicity
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])
Cause of death: Infection
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])
Cause of death: Specification of Infection
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])
Cause of death: Rejection/ Poor graft function
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])
Cause of death: no-Occlusive disease (VOD)
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])
Cause of death: Haemorrhage
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])
Cause of death: Cardiac toxicity
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])
Cause of death: Central nervous system toxicity
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])
Cause of death: Gastro intestinal toxicity
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])
Cause of death: Skin toxicity
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])
Cause of death: Renal failure
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])
Cause of death: Multiple organ failure
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])
Other 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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