Informações:
Falhas:
ID
16066
Descrição
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
Palavras-chave
Versões (2)
- 11/04/2016 11/04/2016 -
- 27/06/2016 27/06/2016 -
Transferido a
27 de junho de 2016
DOI
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Licença
Creative Commons BY-NC 3.0
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EBMT Multiple Sclerosis Form General Information
15pp EBMT Multiple Sclerosis Form General Information
- StudyEvent: ODM
Similar models
15pp EBMT Multiple Sclerosis Form General Information
- StudyEvent: ODM
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de dados
Alias
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])
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])
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])
CL Item
Male (1)
CL Item
Female (2)
ABO Group
Item
ABO Group
integer
C0000778 (UMLS CUI [1])
CL Item
Absent (1)
CL Item
Present (2)
CL Item
Not evaluated (3)
Date of Diagnosis
Item
Date of Diagnosis
date
C2316983 (UMLS CUI [1])
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])
C2348235 (UMLS CUI [1,2])
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
Previous HSCT registration
text
C1514821 (UMLS CUI [1,1])
C0472699 (UMLS CUI [1,2])
C0472699 (UMLS CUI [1,2])
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])
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])
C1254595 (UMLS CUI [1,2])
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)
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])
C3173308 (UMLS CUI [1,2])
CL Item
no (1)
CL Item
yes (2)
CL Item
unknown (3)
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)
C0001617 (UMLS CUI-2)
CL Item
Pulse high dose (6)
C0001617 (UMLS CUI-1)
C1708745 (UMLS CUI-2)
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])
C1522449 (UMLS CUI [1,2])
CL Item
no (1)
CL Item
yes (2)
CL Item
unknown (3)
CL Item
no (1)
CL Item
yes (2)
CL Item
unknown (3)
CL Item
no (1)
CL Item
yes (2)
CL Item
unknown (3)
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])
C1521902 (UMLS CUI [1,2])
Date of HSCT
Item
Date of HSCT
date
C2584899 (UMLS CUI [1,1])
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])
C2584899 (UMLS CUI [1,2])
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])
CL Item
Unknown (1)
CL Item
Not evaluated (2)
Composite Scale Score
Item
Composite Scale Score
integer
C4066222 (UMLS CUI [1])
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])
C0011008 (UMLS CUI [1,2])
Item
Gadolinium-enhancing lesions present results
text
C1333400 (UMLS CUI [1])
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])
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])
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])
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])
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])
C0011008 (UMLS CUI [1,2])
CL Item
Date unknown (1)
Gadolinium-enhancing lesions present
Item
Gadolinium-enhancing lesions present
integer
C1333400 (UMLS CUI [1])
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])
C0808070 (UMLS CUI [1,2])
Item
Overall main reason
integer
C1706712 (UMLS CUI [1,1])
C1443309 (UMLS CUI [1,2])
C1443309 (UMLS CUI [1,2])
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])
C1443309 (UMLS CUI [1,2])
C1521902 (UMLS CUI [1,3])
CL Item
No (No)
CL Item
Yes (Yes)
CL Item
Unknown (Unknown)
Item
If drugs administered: Please mark
integer
C0013216 (UMLS CUI [1])
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)
C1708745 (UMLS CUI-2)
CL Item
high dose (6)
C2065041 (UMLS CUI-1)
C0444956 (UMLS CUI-2)
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])
C1522449 (UMLS CUI [1,2])
CL Item
no (no)
CL Item
yes (yes)
CL Item
unknown (unknown)
Item
Irradiation (radiotherapy) Craniospinal
integer
C3494227 (UMLS CUI [1])
CL Item
no (1)
CL Item
yes (2)
CL Item
unknown (3)
Item
Other modality Lymphocytopheresis
integer
C0024226 (UMLS CUI [1])
CL Item
no (1)
CL Item
yes (2)
CL Item
unknown (3)
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])
C1521902 (UMLS CUI [1,2])
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])
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)
CL Item
No (1)
CL Item
Yes, Indicate new lesions present (2)
CL Item
Unknown (3)
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])
C0040739 (UMLS CUI [1,2])