ID

16066

Beschrijving

ODM form derived from 15pp EBMT Multiple Sclerosis 13MS please refer to: http://www.ebmt.org/Contents/Data-Management/Registrystructure/MED-ABdatacollectionforms/Pages/MED-AB-data-collection-forms.aspx

Link

http://www.ebmt.org/Contents/Data-Management/Registrystructure/MED-ABdatacollectionforms/Pages/MED-AB-data-collection-forms.aspx

Trefwoorden

Versies (2)
  1. 11-04-16 11-04-16 -
  2. 27-06-16 27-06-16 -
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27 juni 2016

DOI

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Licentie

Creative Commons BY-NC 3.0
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EBMT Multiple Sclerosis Form General Information

Engels

15pp EBMT Multiple Sclerosis Form General Information

1 Formulieren  
GENERAL INFORMATION Team
Beschrijving

GENERAL INFORMATION Team

EBMT Centre Identification Code (CIC)
Beschrijving

EBMT Centre Identification Code (CIC)

Datatype

text

Alias
UMLS CUI [1]
C2348585
Hospital
Beschrijving

Klinik

Datatype

text

Alias
UMLS CUI [1]
C0019994
Unit
Beschrijving

Unit

Datatype

text

Alias
UMLS CUI [1]
C0019988
Name of contact person
Beschrijving

Contact person

Datatype

text

Alias
UMLS CUI [1]
C0337611
Telephone
Beschrijving

Patient phone number

Datatype

text

Alias
UMLS CUI [1]
C1515258
Fax
Beschrijving

Fax

Datatype

integer

Alias
UMLS CUI [1]
C1549619
E-mail
Beschrijving

E-mail

Datatype

text

Alias
UMLS CUI [1]
C0013849
Date of this report
Beschrijving

Date of this report

Datatype

date

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

Patient in Trial

Datatype

integer

Alias
UMLS CUI [1]
C1997894
Name of study / trial
Beschrijving

Name of study / trial

Datatype

text

Alias
UMLS CUI [1]
C2348560
PATIENT
Beschrijving

PATIENT

To be entered only if patient previously reported
Beschrijving

Unique Identification Code (UIC)

Datatype

text

Alias
UMLS CUI [1]
C2348585
Hospital Unique Patient Number or Code
Beschrijving

Hospital Unique Patient Number or Code

Datatype

text

Alias
UMLS CUI [1]
C1827636
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
Sex
Beschrijving

Sex

Datatype

text

Alias
UMLS CUI [1]
C0079399
ABO Group
Beschrijving

ABO Group

Datatype

integer

Alias
UMLS CUI [1]
C0000778
Rh factor
Beschrijving

Rh factor

Datatype

integer

Alias
UMLS CUI [1]
C0035403
DISEASE
Beschrijving

DISEASE

Date of Diagnosis
Beschrijving

Date of Diagnosis

Datatype

date

Alias
UMLS CUI [1]
C2316983
Primary Disease Diagnosis
Beschrijving

Check the disease for which this transplant was performed

Datatype

integer

Alias
UMLS CUI [1]
C0277554
If other primary disease diagnosis, specify:
Beschrijving

Primary Disease Diagnosis

Datatype

integer

Alias
UMLS CUI [1,1]
C0277554
UMLS CUI [1,2]
C2348235
MULTIPLE SCLEROSIS
Beschrijving

MULTIPLE SCLEROSIS

Neurologist Name
Beschrijving

Neurologist Name

Datatype

text

Alias
UMLS CUI [1]
C0237426
Address
Beschrijving

Address

Datatype

text

Alias
UMLS CUI [1]
C0376649
Fax
Beschrijving

Fax

Datatype

integer

Alias
UMLS CUI [1]
C1549619
Email
Beschrijving

Email

Datatype

integer

Alias
UMLS CUI [1]
C0013849
INITIAL DIAGNOSIS
Beschrijving

INITIAL DIAGNOSIS

Previous HSCT registration
Beschrijving

has the information requested in this section been submitted with a previous HSCT registration?

Datatype

text

Alias
UMLS CUI [1,1]
C1514821
UMLS CUI [1,2]
C0472699
Did the patient meet the Poser criteria fo clinically-definite Multiple Sclerosis?
Beschrijving

(Two attacks and clinical evidence of two separate lesions OR Two attacks; clinical evidence of one lesion and paraclinical evidence of another, separate lesion)

Datatype

integer

Alias
UMLS CUI [1]
C0026769
Did the patient meet the criteria for laboratory-supported Multiple Sclerosis?
Beschrijving

DIAGNOSTIC CRITERIA laboratory-supported Multiple Sclerosis

Datatype

integer

Alias
UMLS CUI [1,1]
C0026769
UMLS CUI [1,2]
C1254595
FIRST LINE THERAPIES
Beschrijving

FIRST LINE THERAPIES

First line therapy
Beschrijving

First line therapy

Datatype

integer

Alias
UMLS CUI [1]
C1708063
First line therapy start date
Beschrijving

First line therapy start date

Datatype

date

Alias
UMLS CUI [1,1]
C1708063
UMLS CUI [1,2]
C3173308
Drugs
Beschrijving

Drugs

Datatype

integer

Alias
UMLS CUI [1,1]
C1708063
UMLS CUI [1,2]
C0013227
if Drugs were administered, mark appropriate box
Beschrijving

Drugs

Datatype

integer

Alias
UMLS CUI [1]
C0013216
Total lymph node (TLI) Irradiation (radiotherapy) Site
Beschrijving

Total lymph node (TLI) Irradiation (radiotherapy) Site

Datatype

integer

Alias
UMLS CUI [1,1]
C0024204
UMLS CUI [1,2]
C1522449
Irradiation Craniospinal
Beschrijving

Irradiation Craniospinal

Datatype

integer

Alias
UMLS CUI [1]
C3494227
Lymphocytopheresis
Beschrijving

Other modality

Datatype

integer

Alias
UMLS CUI [1]
C0024226
Plasmapheresis
Beschrijving

Other modality

Datatype

integer

Alias
UMLS CUI [1]
C0032134
Other, specify modality
Beschrijving

Other, specify modality

Datatype

integer

Alias
UMLS CUI [1,1]
C0695347
UMLS CUI [1,2]
C1521902
DATE OF HSCT
Beschrijving

DATE OF HSCT

Date of HSCT
Beschrijving

Date of HSCT

Datatype

date

Alias
UMLS CUI [1,1]
C2584899
TRANSPLANT TYPE
Beschrijving

TRANSPLANT TYPE

Datatype

integer

Alias
UMLS CUI [1]
C3840412
Autologous: Mobilised
Beschrijving

if Transplat type

Datatype

boolean

Alias
UMLS CUI [1]
C0439859
Date of Autologous: Mobilised
Beschrijving

Date of Autologous: Mobilised

Datatype

date

Alias
UMLS CUI [1,1]
C0439859
UMLS CUI [1,2]
C2584899
STATUS OF DISEASE AT MOBILISATION
Beschrijving

STATUS OF DISEASE AT MOBILISATION

Scripps neurological rating scale Score
Beschrijving

CLINICAL EVALUATION

Datatype

integer

Alias
UMLS CUI [1]
C0451180
Kurtzke functional systems overall score
Beschrijving

CLINICAL EVALUATION

Datatype

integer

Alias
UMLS CUI [1]
C3826987
Kurtzke Expanded Disability Status
Beschrijving

Kurtzke Expanded Disability Status

Datatype

integer

Alias
UMLS CUI [1]
C0451246
Composite Scale Score
Beschrijving

CLINICAL EVALUATION

Datatype

integer

Alias
UMLS CUI [1]
C4066222
MRI BRAIN SCAN
Beschrijving

MRI BRAIN SCAN

Datatype

integer

Alias
UMLS CUI [1]
C0412675
Date of most recent MRI scan of brain
Beschrijving

Date of most recent MRI scan of brain

Datatype

date

Alias
UMLS CUI [1,1]
C0412675
UMLS CUI [1,2]
C0011008
Gadolinium-enhancing lesions present results
Beschrijving

Gadolinium-enhancing lesions present Results

Datatype

text

Alias
UMLS CUI [1]
C1333400
If Gadolinium-enhancing lesions present
Beschrijving

Gadolinium-enhancing lesions present Number

Datatype

integer

Alias
UMLS CUI [1]
C1333400
STATUS OF DISEASE AT HSCT
Beschrijving

STATUS OF DISEASE AT HSCT

DISEASE COURSE
Beschrijving

Indicate the disease course between diagnosis and mobilisation/HSCT

Datatype

integer

Alias
UMLS CUI [1]
C0449259
If DISEASE COURSE not evaluable please explain
Beschrijving

If DISEASE COURSE not evaluable please explain

Datatype

text

Alias
UMLS CUI [1]
C0449259
Did the patient progress during the 2-years prior to mobilisation/HSCT?
Beschrijving

Did the patient progress during the 2-years prior to mobilisation/HSCT?

Datatype

text

Alias
UMLS CUI [1]
C0242656
If the patient progress during the 2-years prior to mobilisation/HSCT? Number of relapses/progressions
Beschrijving

If the patient progress during the 2-years prior to mobilisation/HSCT? Number of relapses/progressions

Datatype

integer

Alias
UMLS CUI [1]
C0035020
Scripps neurological rating scale
Beschrijving

CLINICAL EVALUATION

Datatype

integer

Alias
UMLS CUI [1]
C0451180
Kurtzke functional systems Overall score
Beschrijving

CLINICAL EVALUATION

Datatype

text

Alias
UMLS CUI [1]
C3826987
Kurtzke Expanded Disability Status Scale (EDSS)
Beschrijving

CLINICAL EVALUATION

Datatype

integer

Alias
UMLS CUI [1]
C0451246
Composite Scale Score
Beschrijving

CLINICAL EVALUATION

Datatype

integer

Alias
UMLS CUI [1]
C4066222
MRI BRAIN SCAN DONE
Beschrijving

MRI BRAIN SCAN DONE

Datatype

text

Alias
UMLS CUI [1]
C0412675
If MRI BRAIN SCAN DONE Date of most recent MRI scan of brain:
Beschrijving

Date of most recent MRI scan of brain

Datatype

date

Alias
UMLS CUI [1]
C0412675
Date of most recent MRI scan of brain:
Beschrijving

Date of most recent MRI scan of brain:

Datatype

integer

Alias
UMLS CUI [1,1]
C0412675
UMLS CUI [1,2]
C0011008
Gadolinium-enhancing lesions present
Beschrijving

Gadolinium-enhancing lesions present

Datatype

integer

Alias
UMLS CUI [1]
C1333400
ADDITIONAL TREATMENT POST-HSCT
Beschrijving

ADDITIONAL TREATMENT POST-HSCT

ADDITIONAL TREATMENT FOR MULTIPLE SCLERORIS
Beschrijving

Did patient receive additional treatment post-HSCT?

Datatype

boolean

Alias
UMLS CUI [1]
C1706712
Date started if patient receive additional treatment post-HSCT
Beschrijving

Date started if patient receive additional treatment post-HSCT

Datatype

date

Alias
UMLS CUI [1,1]
C1706712
UMLS CUI [1,2]
C0808070
Overall main reason
Beschrijving

Overall main reason

Datatype

integer

Alias
UMLS CUI [1,1]
C1706712
UMLS CUI [1,2]
C1443309
If other, please specify:
Beschrijving

Overall main reason

Datatype

integer

Alias
UMLS CUI [1,1]
C1706712
UMLS CUI [1,2]
C1443309
UMLS CUI [1,3]
C1521902
Drugs administered?
Beschrijving

Drugs administered?

Datatype

integer

Alias
UMLS CUI [1]
C0812987
If drugs administered: Please mark
Beschrijving

If drugs administered: Please mark

Datatype

integer

Alias
UMLS CUI [1]
C0013216
Irradiation (radiotherapy) Total lymph node (TLI)
Beschrijving

Site

Datatype

integer

Alias
UMLS CUI [1,1]
C0024204
UMLS CUI [1,2]
C1522449
Irradiation (radiotherapy) Craniospinal
Beschrijving

Irradiation (radiotherapy)

Datatype

integer

Alias
UMLS CUI [1]
C3494227
Other modality Lymphocytopheresis
Beschrijving

Other modality Lymphocytopheresis

Datatype

integer

Alias
UMLS CUI [1]
C0024226
Other modality Plasmapheresis
Beschrijving

Other modality Plasmapheresis

Datatype

integer

Alias
UMLS CUI [1]
C0032134
If other modality please specify
Beschrijving

Other modality

Datatype

text

Alias
UMLS CUI [1,1]
C0695347
UMLS CUI [1,2]
C1521902
STATUS AT 100 DAYS POST-HSCT
Beschrijving

STATUS AT 100 DAYS POST-HSCT

DATE OF EVALUATION
Beschrijving

DATE OF EVALUATION

Datatype

date

Alias
UMLS CUI [1]
C2985720
CLINICAL EVALUATION Scripps neurological rating scale
Beschrijving

Score

Datatype

float

Alias
UMLS CUI [1]
C0451180
CLINICAL EVALUATION Kurtzke functional systems
Beschrijving

Overall score

Datatype

float

Alias
UMLS CUI [1]
C3826987
CLINICAL EVALUATION Kurtzke Expanded Disability Status
Beschrijving

Scale (EDSS)

Datatype

float

Alias
UMLS CUI [1]
C0451246
CLINICAL EVALUATION Composite Scale
Beschrijving

Score

Datatype

float

Alias
UMLS CUI [1]
C4066222
MRI BRAIN SCAN DONE
Beschrijving

MRI BRAIN SCAN DONE

Datatype

text

Alias
UMLS CUI [1]
C0412675
Results Results MRI
Beschrijving

Are new lesions present on the MRI?

Datatype

integer

Alias
UMLS CUI [1,1]
C0024485
UMLS CUI [1,2]
C1274040
FORMS TO BE FILLED IN
Beschrijving

FORMS TO BE FILLED IN

Type of Transplant
Beschrijving

Type of Transplant

Datatype

text

Alias
UMLS CUI [1,1]
C0559189
UMLS CUI [1,2]
C0040739
If Other Type of Transplant please specify
Beschrijving

TYPE OF TRANSPLANT

Datatype

text

Alias
UMLS CUI [1,1]
C0559189
UMLS CUI [1,2]
C0040739
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Similar models

15pp EBMT Multiple Sclerosis Form General Information

1 Formulieren
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
Item Group
GENERAL INFORMATION Team
EBMT Centre Identification Code (CIC)
Item
EBMT Centre Identification Code (CIC)
text
C2348585 (UMLS CUI [1])
Klinik
Item
Hospital
text
C0019994 (UMLS CUI [1])
Unit
Item
Unit
text
C0019988 (UMLS CUI [1])
Contact person
Item
Name of contact person
text
C0337611 (UMLS CUI [1])
Patient phone number
Item
Telephone
text
C1515258 (UMLS CUI [1])
Fax
Item
Fax
integer
C1549619 (UMLS CUI [1])
E-mail
Item
E-mail
text
C0013849 (UMLS CUI [1])
Date of this report
Item
Date of this report
date
C1302584 (UMLS CUI [1])
Item
Patient following national / international study / trial
integer
C1997894 (UMLS CUI [1])
Patient in Trial
Code List
Patient following national / international study / trial
CL Item
No (1)
CL Item
Yes (2)
CL Item
Not evaluated (3)
CL Item
Unknown (4)
Name of study / trial
Item
Name of study / trial
text
C2348560 (UMLS CUI [1])
Item Group
PATIENT
Unique Identification Code (UIC)
Item
To be entered only if patient previously reported
text
C2348585 (UMLS CUI [1])
Hospital Unique Patient Number or Code
Item
Hospital Unique Patient Number or Code
text
C1827636 (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])
Item
Sex
text
C0079399 (UMLS CUI [1])
Sex
Code List
Sex
CL Item
Male (1)
CL Item
Female (2)
ABO Group
Item
ABO Group
integer
C0000778 (UMLS CUI [1])
Item
Rh factor
integer
C0035403 (UMLS CUI [1])
Rh factor
Code List
Rh factor
CL Item
Absent (1)
CL Item
Present (2)
CL Item
Not evaluated (3)
Item Group
DISEASE
Date of Diagnosis
Item
Date of Diagnosis
date
C2316983 (UMLS CUI [1])
Item
Primary Disease Diagnosis
integer
C0277554 (UMLS CUI [1])
Primary Disease Diagnosis
Code List
Primary Disease Diagnosis
CL Item
Acute Leukaemia (Acute Leukaemia)
C0085669 (UMLS CUI-1)
CL Item
Acute Myelogenous Leukaemia (AML) (Acute Myelogenous Leukaemia (AML))
C0023467 (UMLS CUI-1)
CL Item
Acute Lymphoblastic Leukaemia (ALL) (Acute Lymphoblastic Leukaemia (ALL))
C0023449 (UMLS CUI-1)
CL Item
Secondary Acute Leukaemia (do not use if transformed from MDS/MPN) (Secondary Acute Leukaemia (do not use if transformed from MDS/MPN))
C0856053 (UMLS CUI-1)
CL Item
Chronic Leukaemia (Chronic Leukaemia)
C0856053 (UMLS CUI-1)
CL Item
Chronic Myeloid Leukaemia (CML) (Chronic Myeloid Leukaemia (CML))
C0023473 (UMLS CUI-1)
CL Item
Chronic Lymphocytic Leukaemia (Chronic Lymphocytic Leukaemia)
C0023434 (UMLS CUI-1)
CL Item
Lymphoma (Lymphoma)
C0024299 (UMLS CUI-1)
CL Item
Non Hodgkin (Non Hodgkin)
C0024305 (UMLS CUI-1)
CL Item
Myeloma/ Plasma cell disorder (Myeloma/ Plasma cell disorder)
C0026764 (UMLS CUI-1)
CL Item
Solid Tumour (Solid Tumour)
C0006826 (UMLS CUI-1)
CL Item
Myelodysplastic syndromes (Myelodysplastic syndromes)
C0280450 (UMLS CUI-1)
CL Item
MDS (MDS)
C3463824 (UMLS CUI-1)
CL Item
MD/ MPN (MD/ MPN)
C1292778 (UMLS CUI-1)
CL Item
Myeloproliferative neoplasm (Myeloproliferative neoplasm)
C1333046 (UMLS CUI-1)
CL Item
Bone marrow failure including Aplastic anaemia (Bone marrow failure including Aplastic anaemia)
C0002874 (UMLS CUI-1)
CL Item
Inherited disorders (Inherited disorders)
C0019247 (UMLS CUI-1)
CL Item
Primary immune deficiencies (Primary immune deficiencies)
C0398686 (UMLS CUI-1)
CL Item
Metabolic disorders (Metabolic disorders)
C0025517 (UMLS CUI-1)
CL Item
Histiocytic disorders (Histiocytic disorders)
C0398597 (UMLS CUI-1)
CL Item
Autoimmune disease (Autoimmune disease)
C0004364 (UMLS CUI-1)
CL Item
Juvenile Idiopathic Arthritis (Juvenile Idiopathic Arthritis)
C1444841 (UMLS CUI-1)
CL Item
Multiple Sclerosis (Multiple Sclerosis)
C0026769 (UMLS CUI-1)
CL Item
Systemic Lupus (Systemic Lupus)
C0024141 (UMLS CUI-1)
CL Item
Systemic Sclerosis (Systemic Sclerosis)
C0036421 (UMLS CUI-1)
CL Item
Hemoglobinopathies (Haemoglobinopathiy)
C0019045 (UMLS CUI-1)
CL Item
Other diagnosis (Other diagnosis)
C0205394 (UMLS CUI-1)
CL Item
Hodgkin´s Disease (Hodgkin´s Disease)
C0019829 (UMLS CUI-1)
Primary Disease Diagnosis
Item
If other primary disease diagnosis, specify:
integer
C0277554 (UMLS CUI [1,1])
C2348235 (UMLS CUI [1,2])
Item Group
MULTIPLE SCLEROSIS
Neurologist Name
Item
Neurologist Name
text
C0237426 (UMLS CUI [1])
Address
Item
Address
text
C0376649 (UMLS CUI [1])
Fax
Item
Fax
integer
C1549619 (UMLS CUI [1])
Email
Item
Email
integer
C0013849 (UMLS CUI [1])
Item Group
INITIAL DIAGNOSIS
Item
Previous HSCT registration
text
C1514821 (UMLS CUI [1,1])
C0472699 (UMLS CUI [1,2])
Previous HSCT registration
Code List
Previous HSCT registration
CL Item
Yes: go to `Pre-HSCT treatment` (Yes: go to `Pre-HSCT treatment`)
CL Item
No: Proceed with this section (No: Proceed with this section)
Item
Did the patient meet the Poser criteria fo clinically-definite Multiple Sclerosis?
integer
C0026769 (UMLS CUI [1])
DIAGNOSTIC CRITERIA
Code List
Did the patient meet the Poser criteria fo clinically-definite Multiple Sclerosis?
CL Item
no (1)
CL Item
yes (2)
CL Item
unknown (3)
Item
Did the patient meet the criteria for laboratory-supported Multiple Sclerosis?
integer
C0026769 (UMLS CUI [1,1])
C1254595 (UMLS CUI [1,2])
DIAGNOSTIC CRITERIA
Code List
Did the patient meet the criteria for laboratory-supported Multiple Sclerosis?
CL Item
no (1)
CL Item
yes (2)
CL Item
unknown (3)
Item Group
FIRST LINE THERAPIES
Item
First line therapy
integer
C1708063 (UMLS CUI [1])
THERAPIES
Code List
First line therapy
CL Item
no Proceed to ”Date of HSCT” (1)
CL Item
yes (2)
First line therapy start date
Item
First line therapy start date
date
C1708063 (UMLS CUI [1,1])
C3173308 (UMLS CUI [1,2])
Item
Drugs
integer
C1708063 (UMLS CUI [1,1])
C0013227 (UMLS CUI [1,2])
Drugs
Code List
Drugs
CL Item
no (1)
CL Item
yes (2)
CL Item
unknown (3)
Item
if Drugs were administered, mark appropriate box
integer
C0013216 (UMLS CUI [1])
Drugs
Code List
if Drugs were administered, mark appropriate box
CL Item
Cyclophosphamide (1)
C0010583 (UMLS CUI-1)
CL Item
Mitoxantrone (2)
C0026259 (UMLS CUI-1)
CL Item
Anti-lymphocyte antibodies/globulins (ALG) (3)
C0003369 (UMLS CUI-1)
CL Item
Corticosteroids (4)
C0001617 (UMLS CUI-1)
CL Item
Chronic low dose  (5)
C1708745 (UMLS CUI-1)
C0001617 (UMLS CUI-2)
CL Item
Pulse high dose (6)
C0001617 (UMLS CUI-1)
C1708745 (UMLS CUI-2)
CL Item
Azathioprine (7)
C0004482 (UMLS CUI-1)
CL Item
Cop-I (8)
C0528008 (UMLS CUI-1)
CL Item
alphainterferon (9)
C0002199 (UMLS CUI-1)
CL Item
beta interferon (10)
C0015980 (UMLS CUI-1)
Item
Total lymph node (TLI) Irradiation (radiotherapy) Site
integer
C0024204 (UMLS CUI [1,1])
C1522449 (UMLS CUI [1,2])
Total lymph node (TLI)
Code List
Total lymph node (TLI) Irradiation (radiotherapy) Site
CL Item
no (1)
CL Item
yes (2)
CL Item
unknown (3)
Item
Irradiation Craniospinal
integer
C3494227 (UMLS CUI [1])
Craniospinal
Code List
Irradiation Craniospinal
CL Item
no (1)
CL Item
yes (2)
CL Item
unknown (3)
Item
Lymphocytopheresis
integer
C0024226 (UMLS CUI [1])
Lymphocytopheresis
Code List
Lymphocytopheresis
CL Item
no (1)
CL Item
yes (2)
CL Item
unknown (3)
Item
Plasmapheresis
integer
C0032134 (UMLS CUI [1])
Plasmapheresis
Code List
Plasmapheresis
CL Item
no (1)
CL Item
yes (2)
CL Item
unknown (3)
Other, specify modality
Item
Other, specify modality
integer
C0695347 (UMLS CUI [1,1])
C1521902 (UMLS CUI [1,2])
Item Group
DATE OF HSCT
Date of HSCT
Item
Date of HSCT
date
C2584899 (UMLS CUI [1,1])
Item
TRANSPLANT TYPE
integer
C3840412 (UMLS CUI [1])
TRANSPLANT TYPE
Code List
TRANSPLANT TYPE
CL Item
Allogeneic (1)
CL Item
Autologous: Mobilised (2)
Autologous: Mobilised
Item
Autologous: Mobilised
boolean
C0439859 (UMLS CUI [1])
Date of Autologous: Mobilised
Item
Date of Autologous: Mobilised
date
C0439859 (UMLS CUI [1,1])
C2584899 (UMLS CUI [1,2])
Item Group
STATUS OF DISEASE AT MOBILISATION
Scripps neurological rating scale
Item
Scripps neurological rating scale Score
integer
C0451180 (UMLS CUI [1])
Kurtzke functional systems
Item
Kurtzke functional systems overall score
integer
C3826987 (UMLS CUI [1])
Item
Kurtzke Expanded Disability Status
integer
C0451246 (UMLS CUI [1])
Kurtze Expanded Disability Status
Code List
Kurtzke Expanded Disability Status
CL Item
Unknown (1)
CL Item
Not evaluated (2)
Composite Scale Score
Item
Composite Scale Score
integer
C4066222 (UMLS CUI [1])
Item
MRI BRAIN SCAN
integer
C0412675 (UMLS CUI [1])
MRI BRAIN SCAN DONE
Code List
MRI BRAIN SCAN
CL Item
Not done prior to mobilisation (Not done prior to mobilisation)
CL Item
Yes (Yes)
CL Item
Date unknown (Date unknown)
Date of most recent MRI scan of brain
Item
Date of most recent MRI scan of brain
date
C0412675 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Item
Gadolinium-enhancing lesions present results
text
C1333400 (UMLS CUI [1])
Gadolinium-enhancing lesions present Results
Code List
Gadolinium-enhancing lesions present results
CL Item
Number (Number)
CL Item
None (None)
CL Item
Not evaluated (Not evaluated)
CL Item
Unknown (Unknown)
Gadolinium-enhancing lesions present Number
Item
If Gadolinium-enhancing lesions present
integer
C1333400 (UMLS CUI [1])
Item Group
STATUS OF DISEASE AT HSCT
Item
DISEASE COURSE
integer
C0449259 (UMLS CUI [1])
DISEASE COURSE
Code List
DISEASE COURSE
CL Item
Progressive relapsing (malignant) (Progressive relapsing (malignant))
CL Item
Primary progressive (Primary progressive)
CL Item
Secondary progressive (may have had previous Relapsing/Remitting) (Secondary progressive (may have had previous Relapsing/Remitting))
CL Item
Relapsing/Remitting (Relapsing/Remitting)
CL Item
Not evaluable, explain (Not evaluable, explain)
If DISEASE COURSE not evaluable please explain
Item
If DISEASE COURSE not evaluable please explain
text
C0449259 (UMLS CUI [1])
Item
Did the patient progress during the 2-years prior to mobilisation/HSCT?
text
C0242656 (UMLS CUI [1])
Did the patient progress during the 2-years prior to mobilisation/HSCT?
Code List
Did the patient progress during the 2-years prior to mobilisation/HSCT?
CL Item
no  (no )
CL Item
yes (yes)
CL Item
unknown (unknown)
If the patient progress during the 2-years prior to mobilisation/HSCT? Number of relapses/progressions
Item
If the patient progress during the 2-years prior to mobilisation/HSCT? Number of relapses/progressions
integer
C0035020 (UMLS CUI [1])
Item
Scripps neurological rating scale
integer
C0451180 (UMLS CUI [1])
Scripps neurological rating scale
Code List
Scripps neurological rating scale
CL Item
Unknown (1)
CL Item
Not evaluated (2)
Kurtzke functional systems
Item
Kurtzke functional systems Overall score
text
C3826987 (UMLS CUI [1])
Kurtzke Expanded Disability Status
Item
Kurtzke Expanded Disability Status Scale (EDSS)
integer
C0451246 (UMLS CUI [1])
Composite Scale
Item
Composite Scale Score
integer
C4066222 (UMLS CUI [1])
Item
MRI BRAIN SCAN DONE
text
C0412675 (UMLS CUI [1])
MRI BRAIN SCAN DONE
Code List
MRI BRAIN SCAN DONE
CL Item
Not done prior to HSCT (Not done prior to HSCT)
CL Item
Yes: (Yes:)
Date of most recent MRI scan of brain
Item
If MRI BRAIN SCAN DONE Date of most recent MRI scan of brain:
date
C0412675 (UMLS CUI [1])
Item
Date of most recent MRI scan of brain:
integer
C0412675 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Date of most recent MRI scan of brain:
Code List
Date of most recent MRI scan of brain:
CL Item
Date unknown (1)
Gadolinium-enhancing lesions present
Item
Gadolinium-enhancing lesions present
integer
C1333400 (UMLS CUI [1])
Item Group
ADDITIONAL TREATMENT POST-HSCT
ADDITIONAL TREATMENT FOR MULTIPLE SCLERORIS
Item
ADDITIONAL TREATMENT FOR MULTIPLE SCLERORIS
boolean
C1706712 (UMLS CUI [1])
Date started if patient receive additional treatment post-HSCT
Item
Date started if patient receive additional treatment post-HSCT
date
C1706712 (UMLS CUI [1,1])
C0808070 (UMLS CUI [1,2])
Item
Overall main reason
integer
C1706712 (UMLS CUI [1,1])
C1443309 (UMLS CUI [1,2])
Overall main reason
Code List
Overall main reason
CL Item
Relapse/progression (1)
CL Item
Continued from pre-HSCT (2)
CL Item
unknow (3)
CL Item
Planned per protocol (4)
CL Item
Other, specify (5)
Overall main reason
Item
If other, please specify:
integer
C1706712 (UMLS CUI [1,1])
C1443309 (UMLS CUI [1,2])
C1521902 (UMLS CUI [1,3])
Item
Drugs administered?
integer
C0812987 (UMLS CUI [1])
Drugs
Code List
Drugs administered?
CL Item
No (No)
CL Item
Yes (Yes)
CL Item
Unknown (Unknown)
Item
If drugs administered: Please mark
integer
C0013216 (UMLS CUI [1])
Drugs
Code List
If drugs administered: Please mark
CL Item
Cyclophosphamide (1)
C0010583 (UMLS CUI-1)
CL Item
Mitoxantrone (2)
C0026259 (UMLS CUI-1)
CL Item
Anti-lymphocyte antibodies (3)
C0003369 (UMLS CUI-1)
CL Item
Corticosteroids (4)
C0001617 (UMLS CUI-1)
CL Item
low dose (5)
C0001617 (UMLS CUI-1)
C1708745 (UMLS CUI-2)
CL Item
high dose (6)
C2065041 (UMLS CUI-1)
C0444956 (UMLS CUI-2)
CL Item
Azathioprine (7)
C0004482 (UMLS CUI-1)
CL Item
CopI (8)
C0887887 (UMLS CUI-1)
CL Item
Alpha-interferon (9)
C0002199 (UMLS CUI-1)
CL Item
Beta-interferon (10)
C0015980 (UMLS CUI-1)
Item
Irradiation (radiotherapy) Total lymph node (TLI)
integer
C0024204 (UMLS CUI [1,1])
C1522449 (UMLS CUI [1,2])
Irradiation (radiotherapy)
Code List
Irradiation (radiotherapy) Total lymph node (TLI)
CL Item
no (no)
CL Item
yes (yes)
CL Item
unknown (unknown)
Item
Irradiation (radiotherapy) Craniospinal
integer
C3494227 (UMLS CUI [1])
Irradiation (radiotherapy)
Code List
Irradiation (radiotherapy) Craniospinal
CL Item
no  (1)
CL Item
yes (2)
CL Item
unknown (3)
Item
Other modality Lymphocytopheresis
integer
C0024226 (UMLS CUI [1])
Other modality Lymphocytopheresis
Code List
Other modality Lymphocytopheresis
CL Item
no (1)
CL Item
yes (2)
CL Item
unknown (3)
Item
Other modality Plasmapheresis
integer
C0032134 (UMLS CUI [1])
Other modality Plasmapheresis
Code List
Other modality Plasmapheresis
CL Item
no  (1)
CL Item
yes (2)
CL Item
unknown (3)
Other modality
Item
If other modality please specify
text
C0695347 (UMLS CUI [1,1])
C1521902 (UMLS CUI [1,2])
Item Group
STATUS AT 100 DAYS POST-HSCT
DATE OF EVALUATION
Item
DATE OF EVALUATION
date
C2985720 (UMLS CUI [1])
CLINICAL EVALUATION Scripps neurological rating scale
Item
CLINICAL EVALUATION Scripps neurological rating scale
float
C0451180 (UMLS CUI [1])
CLINICAL EVALUATION Kurtzke functional systems
Item
CLINICAL EVALUATION Kurtzke functional systems
float
C3826987 (UMLS CUI [1])
CLINICAL EVALUATION Kurtzke Expanded Disability Status
Item
CLINICAL EVALUATION Kurtzke Expanded Disability Status
float
C0451246 (UMLS CUI [1])
CLINICAL EVALUATION Composite Scale
Item
CLINICAL EVALUATION Composite Scale
float
C4066222 (UMLS CUI [1])
Item
MRI BRAIN SCAN DONE
text
C0412675 (UMLS CUI [1])
MRI BRAIN SCAN DONE
Code List
MRI BRAIN SCAN DONE
CL Item
Not done within 100 days from HSCT (Not done within 100 days from HSCT)
CL Item
Yes (Yes)
CL Item
Date unknown (Date unknown)
Item
Results Results MRI
integer
C0024485 (UMLS CUI [1,1])
C1274040 (UMLS CUI [1,2])
Results
Code List
Results Results MRI
CL Item
No (1)
CL Item
Yes, Indicate new lesions present (2)
CL Item
Unknown (3)
Item Group
FORMS TO BE FILLED IN
Item
Type of Transplant
text
C0559189 (UMLS CUI [1,1])
C0040739 (UMLS CUI [1,2])
Type of Transplant
Code List
Type of Transplant
CL Item
AUTOgraft (proceed to Autograft form) (AUTOgraft (proceed to Autograft form))
CL Item
ALLOgraft or Syngeneic graft (proceed to Allograft form) (ALLOgraft or Syngeneic graft (proceed to Allograft form))
CL Item
Other (contact the EBMT Central Registry for instructions) (Other (contact the EBMT Central Registry for instructions))
TYPE OF TRANSPLANT
Item
If Other Type of Transplant please specify
text
C0559189 (UMLS CUI [1,1])
C0040739 (UMLS CUI [1,2])
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