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Informations:
Erreur:
ID
16384
Description
DOCUMENTED PATHOGENS (Use this table for guidance on the pathogens of interest) Bacteria: S. pneumoniae, Other gram positive (i.e.: other streptococci, staphylococci, listeria …),Haemophilus influenzae, Other gram negative (i.e.: E. coli klebsiella, proteus, serratia, pseudomonas …), Legionella sp, Mycobacteria sp, other.... Fungi: Candida sp, Aspergillus sp, Pneumocystis carinii, other... Parasites: Toxoplasma gondii, other Viruses: HSV, VZV, EBV, CMV, HHV-6, RSV, Other respiratory virus (influenza, parainfluenza,Adenovirus, HBV, HCV, HIV,Papovavirus, Parvovirus, other
Mots-clés
Versions (4)
- 14/07/2016 14/07/2016 -
- 21/08/2016 21/08/2016 -
- 13/04/2021 13/04/2021 - Dr. rer. medic Philipp Neuhaus
- 20/09/2021 20/09/2021 -
Téléchargé le
14 juillet 2016
DOI
Pour une demande vous connecter.
Licence
Creative Commons BY-NC 3.0
Modèle Commentaires :
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EBMT Allograft
19pp EBMT Allograft 18Allo.
- StudyEvent: ODM
Similar models
19pp EBMT Allograft 18Allo.
- StudyEvent: ODM
Name
Type
Description | Question | Decode (Coded Value)
Type de données
Alias
CL Item
Negative (Negative )
CL Item
Positive (Positive )
CL Item
Not evaluated (Not evaluated )
CL Item
Unknown (Unknown)
CL Item
Negative (Negative )
CL Item
Positive (Positive )
CL Item
Not evaluated (Not evaluated )
CL Item
Unknown (Unknown)
CL Item
Negative (Negative )
CL Item
Positive (Positive )
CL Item
Not evaluated (Not evaluated )
CL Item
Unknown (Unknown)
CL Item
Negative (Negative )
CL Item
Positive (Positive )
CL Item
Not evaluated (Not evaluated )
CL Item
Unknown (Unknown)
CL Item
Negative (Negative )
CL Item
Positive (Positive )
CL Item
Not evaluated (Not evaluated )
CL Item
Unknown (Unknown)
CL Item
Negative (Negative )
CL Item
Positive (Positive )
CL Item
Not evaluated (Not evaluated )
CL Item
Unknown (Unknown)
CL Item
Negative (Negative )
CL Item
Positive (Positive )
CL Item
Not evaluated (Not evaluated )
CL Item
Unknown (Unknown)
CL Item
Negative (Negative )
CL Item
Positive (Positive )
CL Item
Not evaluated (Not evaluated )
CL Item
Unknown (Unknown)
CL Item
Negative (Negative )
CL Item
Positive (Positive )
CL Item
Not evaluated (Not evaluated )
CL Item
Unknown (Unknown)
CL Item
Negative (Negative)
CL Item
Positive (Positive)
CL Item
Not evaluated (Not evaluated )
CL Item
Unknown (Unknown)
CL Item
Negative (Negative)
CL Item
Positive (Positive)
CL Item
Not evaluated (Not evaluated )
CL Item
Unknown (Unknown)
CL Item
Negative (Negative )
CL Item
Positive (Positive )
CL Item
Not evaluated (Not evaluated )
CL Item
Unknown (Unknown)
CL Item
Negative (Negative )
CL Item
Positive (Positive )
CL Item
Not evaluated (Not evaluated )
CL Item
Unknown (Unknown)
CL Item
Negative (Negative )
CL Item
Positive (Positive )
CL Item
Specify (Specify)
Item Group
PRE-TRANSPLANT HISTORY OF DOCUMENTED INVASIVE FUNGAL INFECTION SINCE INITIAL DIAGNOSIS
Item
PRE-TRANSPLANT HISTORY OF DOCUMENTED INVASIVE FUNGAL INFECTION SINCE INITIAL DIAGNOSIS
text
Code List
PRE-TRANSPLANT HISTORY OF DOCUMENTED INVASIVE FUNGAL INFECTION SINCE INITIAL DIAGNOSIS
CL Item
No (No)
CL Item
Yes (Yes)
CL Item
Unknown (Unknown)
CL Item
Yes (Yes )
CL Item
No (No)
CL Item
Unknown (Unknown)
CL Item
Yes (Yes)
CL Item
No (No)
CL Item
Unknown (Unknown)
CL Item
Yes (Yes )
CL Item
No (No )
CL Item
Unknown (Unknown)
Other
Item
Other
boolean
Other
Item
if yes, please specify
text
CL Item
Karnofsky (Karnofsky)
CL Item
Lansky (Lansky)
CL Item
Not evaluated (Not evaluated)
CL Item
Unknown (Unknown)
CL Item
100 (Normal, NED) (1)
CL Item
90 (Normal activity) (2)
CL Item
80 (Normal with effort) (3)
CL Item
70 (Cares for self) (4)
CL Item
60 (Requires occasional assistance) (5)
CL Item
50 (Requires assistance) (6)
CL Item
40 (Disabled) (7)
CL Item
30 (Severely disabled) (8)
CL Item
20 (Very sick) (9)
CL Item
10 (Moribund) (10)
CL Item
Not evaluated (11)
CL Item
Unknown (12)
Weight
Item
Weight
float
C0005910 (UMLS CUI [1])
Height
Item
Height
float
C0005890 (UMLS CUI [1])
Multiple donors
Item
Multiple donors
boolean
Number of donors or different stem cell products of same donor or cord blood units
Item
Number of donors or different stem cell products of same donor or cord blood units Make as many copies of the DONOR and HISTOCOMPATIBILITY sections as there are donors. Complete all of them and include them all in your report. For each donor Indicate in all pages their number in the infusion order and their Donor ID if known
float
Item
SOURCE OF STEM CELLS FOR THIS DONOR/PRODUCT Tick only one. If same donor has donated stem cells from more than one source, fill the information under a separate donor form
text
Code List
SOURCE OF STEM CELLS FOR THIS DONOR/PRODUCT Tick only one. If same donor has donated stem cells from more than one source, fill the information under a separate donor form
CL Item
Bone marrow (Bone marrow)
CL Item
Peripheral blood (Peripheral blood)
CL Item
Cord blood (Cord blood)
Identification of Donor or Cord Blood Unit given by the centre
Item
Identification of Donor or Cord Blood Unit given by the centre (can be the family relation if a related donor; if unrelated donor use the ID provided by the Donor Registry)
text
Number in the infusion order
Item
Number in the infusion order (if multiple donors or stem cell products)
text
CL Item
Not applicable (Not applicable)
CL Item
HLA-identical sibling (may include non-monozygotic twin) (HLA-identical sibling (may include non-monozygotic twin))
CL Item
Syngeneic (monozygotic twin) (Syngeneic (monozygotic twin))
CL Item
HLA-matched other relative (HLA-matched other relative)
CL Item
HLA-mismatched relative:Degree of allele mismatch (HLA-mismatched relative:Degree of allele mismatch)
CL Item
1 HLA antigen mismatch ALLMISRL (1 HLA antigen mismatch ALLMISRL)
CL Item
> 2 HLA antigen mismatch (> 2 HLA antigen mismatch)
CL Item
Unrelated donor (Unrelated donor)
Name of the Donor registry
Item
Name of the Donor registry
text
BMDW / WMDA code for the donor registry (up to 4 characters)
Item
BMDW / WMDA code for the donor registry (up to 4 characters) (This information can be found in http://www.bmdw.org under “Participating Registries”)
text
Identification of Donor or Cord Blood Unit given by the donor registry
Item
Identification of Donor or Cord Blood Unit given by the donor registry
text
Name of the Cord blood bank
Item
Name of the Cord blood bank
text
Eurocord code for the cord blood bank
Item
Eurocord code for the cord blood bank
text
Identification of Cord Blood Unit given by the cord blood bank
Item
Identification of Cord Blood Unit given by the cord blood bank
text
CL Item
match (0)
CL Item
one mismatch (1)
CL Item
2 mismatches (2)
CL Item
not evaluated (N/E)
CL Item
match (0)
CL Item
one mismatch (1)
CL Item
2 mismatches (2)
CL Item
not evaluated (N/E)
CL Item
match (0)
CL Item
one mismatch (1)
CL Item
2 mismatches (2)
CL Item
not evaluated (N/E)
CL Item
match (0)
CL Item
one mismatch (1)
CL Item
2 mismatches (2)
CL Item
not evaluated (N/E)
CL Item
match (0)
CL Item
one mismatch (1)
CL Item
2 mismatches (2)
CL Item
not evaluated (N/E)
CL Item
match (0)
CL Item
one mismatch (1)
CL Item
2 mismatches (2)
CL Item
not evaluated (N/E)
CL Item
match (0)
CL Item
one mismatch (1)
CL Item
2 mismatches (2)
CL Item
not evaluated (N/E)
CL Item
match (0)
CL Item
one mismatch (1)
CL Item
2 mismatches (2)
CL Item
not evaluated (N/E)
CL Item
match (0)
CL Item
one mismatch (1)
CL Item
2 mismatches (2)
CL Item
not evaluated (N/E)
CL Item
match (0)
CL Item
one mismatch (1)
CL Item
2 mismatches (2)
CL Item
not evaluated (N/E)
CL Item
match (0)
CL Item
one mismatch (1)
CL Item
2 mismatches (2)
CL Item
not evaluated (N/E)
CL Item
match (0)
CL Item
one mismatch (1)
CL Item
2 mismatches (2)
CL Item
not evaluated (N/E)
CL Item
A (A)
CL Item
B (B)
CL Item
AB (AB)
CL Item
O (O)
Date of birth
Item
Date of birth
date
C0421451 (UMLS CUI [1])
CL Item
Male (1)
CL Item
Female (2)
Item Group
STATUS OF THE DONOR OR CORD BLOOD UNIT BEFORE HSCT
CL Item
Negative (Negative )
CL Item
Positive (Positive )
CL Item
Not evaluated (Not evaluated )
CL Item
Unknown (Unknown)
CL Item
Negative (Negative )
CL Item
Positive (Positive )
CL Item
Not evaluated (Not evaluated )
CL Item
Unknown (Unknown)
CL Item
Negative (Negative )
CL Item
Positive (Positive )
CL Item
Not evaluated (Not evaluated )
CL Item
Unknown (Unknown)
CL Item
Negative (Negative )
CL Item
Positive (Positive )
CL Item
Not evaluated (Not evaluated )
CL Item
Unknown (Unknown)
CL Item
Negative (Negative )
CL Item
Positive (Positive )
CL Item
Not evaluated (Not evaluated )
CL Item
Unknown (Unknown)
CL Item
Negative (Negative )
CL Item
Positive (Positive )
CL Item
Not evaluated (Not evaluated )
CL Item
Unknown (Unknown)
CL Item
Negative (Negative )
CL Item
Positive (Positive )
CL Item
Not evaluated (Not evaluated )
CL Item
Unknown (Unknown)
CL Item
Negative (Negative )
CL Item
Positive (Positive )
CL Item
Not evaluated (Not evaluated )
CL Item
Unknown (Unknown)
CL Item
Negative (Negative )
CL Item
Positive (Positive )
CL Item
Not evaluated (Not evaluated )
CL Item
Unknown (Unknown)
CL Item
Negative (Negative)
CL Item
Positive (Positive)
CL Item
Not evaluated (Not evaluated )
CL Item
Unknown (Unknown)
CL Item
Negative (Negative)
CL Item
Positive (Positive)
CL Item
Not evaluated (Not evaluated )
CL Item
Unknown (Unknown)
CL Item
Negative (Negative )
CL Item
Positive (Positive )
CL Item
Not evaluated (Not evaluated )
CL Item
Unknown (Unknown)
CL Item
Negative (Negative )
CL Item
Positive (Positive )
CL Item
Not evaluated (Not evaluated )
CL Item
Unknown (Unknown)
CL Item
Negative (Negative )
CL Item
Positive (Positive )
CL Item
Specify (Specify)
Date of harvest or cord blood collection
Item
Date of harvest or cord blood collection
date
CL Item
No (No)
CL Item
Yes (Yes)
CL Item
Unknown (Unknown)
GROWTH FACTORS ADMINISTERED TO THE DONOR
Item
If Yes, please specify
text
Laboratory / Hospital
Item
Laboratory / Hospital
text
Unit
Item
Unit
text
Contact number
Item
Contact number (telephone/fax)
text
Technique Used
Item
Technique Used
text
Serology (antigenic) HLA typing done
Item
Serology (antigenic) HLA typing done
boolean
DNA (Allelic/molecular) HLA typing done
Item
DNA (Allelic/molecular) HLA typing done
boolean
CL Item
A (A)
CL Item
B (B)
CL Item
C (C)
CL Item
DRB1 (DRB1)
CL Item
DQB1 (DQB1)
CL Item
DPB1 (DPB1)
HLA string
Item
HLA string
text
NMDP code
Item
NMDP code
text
NMDP code
Item
NMDP code
boolean
NMDP code
Item
NMDP code
boolean
CL Item
No (No)
CL Item
Yes (Yes)
CL Item
A (A)
CL Item
B (B)
CL Item
C (C)
CL Item
DRB1 (DRB1)
CL Item
DQB1 (DQB1)
CL Item
DPB1 (DPB1)
CL Item
Not evaluated (Not evaluated)
CL Item
Not evaluated (Not evaluated)
Identification of donor or Cord Blood Unit given by the centre
Item
IF MULTIPLE DONORS Identification of donor or Cord Blood Unit given by the centre (please, use same ID as in the preceding sheets)
text
Number in the infusion order
Item
Number in the infusion order (if applicable)
text
C0237753 (UMLS CUI [1])
Item
GRAFT MANIPULATION EX-VIVO (INCLUDING T-CELL DEPLETION)
text
Code List
GRAFT MANIPULATION EX-VIVO (INCLUDING T-CELL DEPLETION)
CL Item
No (No)
CL Item
Yes (Yes)
CL Item
No (No )
CL Item
Yes (Yes)
CL Item
Unknown (Unknown)
CL Item
T-cell depletion by MoAB (do not enter "Campath in bag" here) (T-cell depletion by MoAB (do not enter "Campath in bag" here) )
CL Item
B-cell depletion by MoAB (B-cell depletion by MoAB )
CL Item
NK cell depletion by MoAB (NK cell depletion by MoAB )
CL Item
Elutriation (Elutriation )
CL Item
Other (Other)
CL Item
No (No)
CL Item
Yes: Monoclonal antibodies (Yes: Monoclonal antibodies)
CL Item
unknown (unknown)
CL Item
No (No)
CL Item
Yes (Yes)
CL Item
Unknown (Unknown)
CL Item
CD 34+ (CD 34+ )
CL Item
Other (Other)
Monoclonal antibodies
Item
if other, please specify
text
CL Item
No (No)
CL Item
Yes (Yes)
CL Item
Unknown (Unknown)
CL Item
No (No)
CL Item
Yes (Yes)
CL Item
Unknown (Unknown)
Identification of donor or Cord Blood Unit given by the centre
Item
IF MULTIPLE DONORS: Identification of donor or Cord Blood Unit given by the centre (please, use same ID as in the preceding sheets)
text
Number in the infusion order
Item
Number in the infusion order (if applicable)
text
C0237753 (UMLS CUI [1])
CL Item
Intravenous (IV) (Intravenous (IV))
CL Item
intrabone / intramedullary (intrabone / intramedullary)
CL Item
Other, specify (Other, specify)
CL Item
unknown (unknown)
Route of infusion
Item
If other, please specify
text
CL Item
DMSO (DMSO)
CL Item
Wash (Rubinstein/New York) (Wash (Rubinstein/New York))
CL Item
Other, specify (Other, specify)
Infusion method
Item
if other, please specify
text
Item
Tests performed after thawing of an aliquot on
text
Code List
Tests performed after thawing of an aliquot on
CL Item
Contiguous segment (Contiguous segment )
CL Item
Reference bag (Reference bag )
CL Item
unknown (unknown)
CL Item
7-AAD (7-AAD)
CL Item
Acridine orange-ethidium iodide (Acridine orange-ethidium iodide)
CL Item
Tryptan blue (Tryptan blue)
CL Item
Other, specify (Other, specify)
CL Item
Acridine orange-ethidium bromide (Acridine orange-ethidium bromide)
CL Item
unknown (unknown)
Method used
Item
if other, please specify
text
Viability of all cells
Item
Viability of all cells
float
Viability of CD34+ cells
Item
Viability of CD34+ cells
float
Item Group
CELLS INFUSED FROM THIS DONOR AND STEM CELL SOURCE COMBINATION
Bone Marrow
Item
Total number of cells actually infused Nucleated cells (/kg*)
float
CL Item
Not evaluated (Not evaluated )
CL Item
unknown (unknown)
Bone Marrow
Item
Total number of cells actually infused CD 34+ (cells/kg*)
float
CL Item
Not evaluated (Not evaluated )
CL Item
unknown (unknown)
Bone Marrow
Item
Total number of cells actually infused T-cells (CD 3+) (cells/kg*)
float
CL Item
Not evaluated (Not evaluated )
CL Item
unknown (unknown)
Peripheral Blood
Item
Total number of cells actually infused Nucleated cells (/kg*)
float
CL Item
Not evaluated (Not evaluated )
CL Item
unknown (unknown)
Peripheral Blood
Item
Total number of cells actually infused CD 34+ (cells/kg*)
float
CL Item
Not evaluated (Not evaluated )
CL Item
unknown (unknown)
Peripheral Blood
Item
Total number of cells actually infused T-cells (CD 3+) (cells/kg*)
float
CL Item
Not evaluated (Not evaluated )
CL Item
unknown (unknown)
Cord Blood
Item
Total number of cellsactually infused Nucleated cells (/kg*)
float
CL Item
Not evaluated (Not evaluated )
CL Item
unknown (unknown)
Cord Blood
Item
Total number of cellsactually infused CD 34+ (cells/kg*)
float
CL Item
Not evaluated (Not evaluated )
CL Item
unknown (unknown)
Cord Blood
Item
Total number of cells actually infused T-cells (CD 3+) (cells/kg*)
float
CL Item
Not evaluated (Not evaluated )
CL Item
unknown (unknown)
Chronological number of HSCT for this patient
Item
Chronological number of HSCT for this patient
integer
CL Item
No (No )
CL Item
Yes (Yes )
CL Item
Previous HSCT(s) autologous (Previous HSCT(s) autologous)
Date of previous HSCT
Item
Date of previous HSCT
date
CL Item
Allo (Allo)
CL Item
Auto (Auto)
CL Item
Relapse/progression after previous HSCT (Relapse/progression after previous HSCT)
CL Item
Graft failure after allo BMT (Graft failure after allo BMT)
CL Item
Other (Other)
Reason for this transplant
Item
if other, please specify
text
Item
HSCT part of a multiple sequential graft protocol
text
Code List
HSCT part of a multiple sequential graft protocol
CL Item
No (No)
CL Item
Yes (Yes)
CL Item
Unknown (Unknown)
Type of multiple graft protocol
Item
Type of multiple graft protocol
text
Graft number in the protocol
Item
Graft number in the protocol
integer
total number of HSCTs in the program
Item
total number of HSCTs in the program
integer
PREPARATIVE (CONDITIONING) REGIMEN GIVEN
Item
PREPARATIVE (CONDITIONING) REGIMEN GIVEN
boolean
CL Item
No (No)
CL Item
Yes (Yes)
CL Item
Unknown (Unknown)
CL Item
Age of recipient (Age of recipient)
CL Item
Comorbid conditions (Comorbid conditions)
CL Item
Prior HSCT (Prior HSCT)
CL Item
Protocol driven (Protocol driven)
CL Item
Other, specify (Other, specify)
Reason not myeloablative
Item
Age of recipient
boolean
Reason not myeloablative
Item
Comorbid conditions
boolean
Reason not myeloablative
Item
Prior HSCT
boolean
Reason not myeloablative
Item
Protocol driven
boolean
Reason not myeloablative
Item
If other additional reason, please specify
text
Item
Drugs (include any active agent be it chemo, monoclonal antibody, polyclonal antibody, serotherapy, etc.) NOTE: ONLY AGENTS GIVEN BEFORE THE DATE OF THE 1ST CELL INFUSION (DAY 0) SHOULD BE LISTED HERE
text
Code List
Drugs (include any active agent be it chemo, monoclonal antibody, polyclonal antibody, serotherapy, etc.) NOTE: ONLY AGENTS GIVEN BEFORE THE DATE OF THE 1ST CELL INFUSION (DAY 0) SHOULD BE LISTED HERE
CL Item
No (No)
CL Item
Yes (Yes)
CL Item
Unknown (Unknown)
NAME OF DRUG
Item
NAME OF DRUG
text
PRESCRIBED CUMULATIVE DOSE AS PER PROTOCOL (DAILY DOSE BY NUMBER OF DAYS)
Item
PRESCRIBED CUMULATIVE DOSE AS PER PROTOCOL (DAILY DOSE BY NUMBER OF DAYS)
text
CL Item
No (1)
CL Item
Yes (2)
CL Item
Unknown (3)
CL Item
mg (1)
CL Item
mg/m2 (2)
CL Item
mg/Kg (3)
CL Item
* (4)
CL Item
mCi (1)
CL Item
mBq (2)
ADDITIONAL DRUG INFORMATION
Item
If the dose units you need are not listed, please write them on the side For Busulphan
text
CL Item
Oral (Oral )
CL Item
IV (IV )
CL Item
Both (Both)
CL Item
Horse (Horse )
CL Item
Rabbit (Rabbit )
CL Item
Other, specify (Other, specify)
Animal origin
Item
if other, please specify
text
CL Item
No (No )
CL Item
Yes (Yes )
CL Item
Unknown (Unknown)
Total dose (Gy)
Item
Total dose (Gy)
float
Number of fractions
Item
Number of fractions
float
radiation days
Item
radiation days
integer
CL Item
No (No)
CL Item
Yes (Yes)
CL Item
Unknown (Unknown)
Total dose (Gy)
Item
Total dose (Gy)
float
CL Item
No (No )
CL Item
Yes (Yes )
CL Item
Unknown (Unknown)
Item Group
TREATMENT DURING THE IMMEDIATE POST-TRANSPLANT PERIOD
Item
GROWTH FACTORS (CYTOKINES) (excluding growth factors administered for engraftment failure)
text
Code List
GROWTH FACTORS (CYTOKINES) (excluding growth factors administered for engraftment failure)
CL Item
No (No)
CL Item
Yes (Yes)
CL Item
nknown (nknown)
GROWTH FACTORS (CYTOKINES)
Item
If yes, please specify
text
Date started
Item
Date started
date
CL Item
No (No)
CL Item
Yes (Yes)
CL Item
Unknown (Unknown)
Date of first infusion
Item
Date of first infusion (can be the same as HSCT date)
date
CL Item
Donor lymphocyte infusion (DLI) (only lymphocytes from same donor(s) as HSCT) (Donor lymphocyte infusion (DLI) (only lymphocytes from same donor(s) as HSCT))
CL Item
Mesenchymal cells (Mesenchymal cells)
CL Item
Other (Other)
CL Item
Unknown (Unknown)
CELLULAR THERAPY
Item
if other, please specify
text
Nucleated cells (/kg*)
Item
Nucleated cells (/kg*)
float
CL Item
Not evaluated (Not evaluated)
CL Item
unknown (unknown)
CD 34+ (cells/kg*)
Item
CD 34+ (cells/kg*)
float
CL Item
Not evaluated (1)
CL Item
unknown (2)
CD 3+ (cells/kg*)
Item
CD 3+ (cells/kg*)
float
CL Item
Not evaluated (1)
CL Item
unknown (2)
All cells (cells/kg*)
Item
All cells (cells/kg*) (non DLI only)
float
CL Item
Not evaluated (Not evaluated)
CL Item
unknown (unknown)
Chronological number of this cell therapy for this patient
Item
Chronological number of this cell therapy for this patient
integer
CL Item
Planned/protocol (Planned/protocol )
CL Item
Treatment for disease (Treatment for disease)
CL Item
Loss/decreased chimaerism (Loss/decreased chimaerism )
CL Item
Mixed chimaerism (Mixed chimaerism)
CL Item
Treatment of GvHD (Treatment of GvHD )
CL Item
Treatment viral infection (Treatment viral infection)
CL Item
Treatment PTLD, EBV lymphoma (Treatment PTLD, EBV lymphoma)
CL Item
Other (Other)
Indication
Item
Indication if other, please specify
text
Number of infusions within 10 weeks
Item
Number of infusions within 10 weeks count only infusions that are part of same regimen and given for the same indication
integer
Item
GVHD PREVENTION IN THE RECIPIENT (THERAPEUTIC IMMUNOSUPPRESSION)
integer
Code List
GVHD PREVENTION IN THE RECIPIENT (THERAPEUTIC IMMUNOSUPPRESSION)
CL Item
No (1)
CL Item
Yes (2)
CL Item
Unknown (3)
CL Item
Cyclosporine (Cyclosporine)
CL Item
Methotrexate (Methotrexate)
CL Item
ATG/ALG (if started after day 0) (ATG/ALG (if started after day 0))
CL Item
Corticosteroids (if started after day 0) (Corticosteroids (if started after day 0))
CL Item
Mycophenolate (Mycophenolate)
CL Item
Tacrolimus (Tacrolimus)
CL Item
Monoclonal antibodies, specify (Monoclonal antibodies, specify)
CL Item
Extra-corporeal photopheresis (ECP) (Extra-corporeal photopheresis (ECP))
CL Item
Other (Other)
Drugs
Item
If Monoclonal antibodies, specify
text
Drugs
Item
If Other, please specify
text
CL Item
Yes (Yes)
CL Item
No reconstitution (No reconstitution)
CL Item
Lost graft (Lost graft)
CL Item
Yes (Yes)
CL Item
No (No)
CL Item
Never below this level (Never below this level)
Date Neutrophils > 0.5 x 109/l
Item
Date Neutrophils > 0.5 x 109/l
date
CL Item
Yes (1)
CL Item
No (2)
CL Item
Never below this level (3)
Date Platelets > 20 x 109/l
Item
Date Platelets > 20 x 109/l
date
CL Item
Yes (Yes)
CL Item
No (No)
CL Item
Never below this level (Never below this level)
Date Platelets > 50 x 109/l
Item
Date Platelets > 50 x 109/l
date
Date last assessment
Item
Date last assessment
date
Date of graft failure
Item
Date of graft failure
date
CL Item
Full (donor >95 %) (Full (donor >95 %) )
CL Item
Mixed (partial) (Mixed (partial))
CL Item
Autologous reconstitution (recipient >95 %) (Autologous reconstitution (recipient >95 %) )
CL Item
Aplasia (Aplasia)
CL Item
Not evaluated (Not evaluated)
Item Group
DATE(S) AND RESULTS OF ALL TESTS DONE FOR ALL DONORS
undefined item
Item
text
Date of test
Item
Date of test
date
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-cell
Item
Cell type on which test was performed
float
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])
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])
C1522609 (UMLS CUI [1,2])
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)
CL Item
No (1)
CL Item
Growth factors GRFAIGRF (2)
CL Item
Subsequent transplant (please complete a new transplant form) (3)
CL Item
AUTOgraft (must have prior conditioning) (4)
CL Item
ALLOgraft (5)
CL Item
Autologous PBSC re-infusion (no preparative treatment or conditioning) (6)
CL Item
Autologous BM re-infusion (no preparative treatment or conditioning) (7)
CL Item
Other (8)
CL Item
grade 0 (Absent) (1)
CL Item
grade I (2)
CL Item
grade II (3)
CL Item
grade III (4)
CL Item
grade IV (5)
CL Item
Not evaluated (6)
Date of onset
Item
Date of onset
date
C0574845 (UMLS CUI [1])
Item
Stage skin
integer
C0856825 (UMLS CUI [1,1])
C1306673 (UMLS CUI [1,2])
C1306673 (UMLS CUI [1,3])
C1306673 (UMLS CUI [1,2])
C1306673 (UMLS CUI [1,3])
CL Item
0 (1)
CL Item
1 (2)
CL Item
2 (3)
CL Item
3 (4)
CL Item
4 (5)
CL Item
Not evaluated (6)
CL Item
unknown (7)
Item
Stage liver
integer
C0856825 (UMLS CUI [1,1])
C1306673 (UMLS CUI [1,2])
C0023884 (UMLS CUI [1,3])
C1306673 (UMLS CUI [1,2])
C0023884 (UMLS CUI [1,3])
CL Item
0 (1)
CL Item
1 (2)
CL Item
2 (3)
CL Item
3 (4)
CL Item
4 (5)
CL Item
Not evaluated (6)
CL Item
unknown (7)
Item
Stage gut
integer
C0856825 (UMLS CUI [1,1])
C1306673 (UMLS CUI [1,2])
C0021853 (UMLS CUI [1,3])
C1306673 (UMLS CUI [1,2])
C0021853 (UMLS CUI [1,3])
CL Item
0 (1)
CL Item
1 (2)
CL Item
2 (3)
CL Item
3 (4)
CL Item
4 (5)
CL Item
Not evaluated (6)
CL Item
unknown (7)
CL Item
No (1)
CL Item
Yes (2)
aGvHD Date of resolution
Item
Date of resolution
date
C0856825 (UMLS CUI [1,1])
C1514893 (UMLS CUI [1,2])
C0011008 (UMLS CUI [1,3])
C1514893 (UMLS CUI [1,2])
C0011008 (UMLS CUI [1,3])
Treatment
Item
Treatment
boolean
CL Item
Corticosteroids (Corticosteroids)
CL Item
ATG/ALG (ATG/ALG)
CL Item
MoAB (MoAB)
CL Item
Other (Other)
INFECTION RELATED COMPLICATIONS
Item
INFECTION RELATED COMPLICATIONS
boolean
Bacteraemia/ fungemia / viremia / parasites
Item
Pathogen Use the list of pathogens listed after this table for guidance. Use “unknown” if necessary.
text
Bacteraemia/ fungemia / viremia / parasites
Item
Date Provide different dates for different episodes of the same complication if applicable.
date
Septic shock
Item
Pathogen Use the list of pathogens listed after this table for guidance. Use “unknown” if necessary.
text
Septic shock
Item
Date Provide different dates for different episodes of the same complication if applicable.
date
ARDS
Item
Pathogen Use the list of pathogens listed after this table for guidance. Use “unknown” if necessary.
text
ARDS
Item
Date Provide different dates for different episodes of the same complication if applicable
date
Multiorgan failure due to infection
Item
Pathogen Use the list of pathogens listed after this table for guidance. Use “unknown” if necessary.
text
Multiorgan failure due to infection
Item
Date Provide different dates for different episodes of the same complication if applicable.
date
Pneumonia
Item
Pathogen Use the list of pathogens listed after this table for guidance. Use “unknown” if necessary.
text
Pneumonia
Item
Date Provide different dates for different episodes of the same complication if applicable.
date
Hepatitis
Item
Pathogen Use the list of pathogens listed after this table for guidance. Use “unknown” if necessary.
text
Hepatitis
Item
Date Provide different dates for different episodes of the same complication if applicable.
date
CNS infection
Item
Pathogen Use the list of pathogens listed after this table for guidance. Use “unknown” if necessary.
text
CNS infection
Item
Date Provide different dates for different episodes of the same complication if applicable.
date
Gut infection
Item
Pathogen Use the list of pathogens listed after this table for guidance. Use “unknown” if necessary.
text
Gut infection
Item
Date Provide different dates for different episodes of the same complication if applicable.
date
Skin infection
Item
Pathogen Use the list of pathogens listed after this table for guidance. Use “unknown” if necessary.
text
Skin infection
Item
Date Provide different dates for different episodes of the same complication if applicable.
date
Cystitis
Item
Pathogen Use the list of pathogens listed after this table for guidance. Use “unknown” if necessary.
text
Cystitis
Item
Date Provide different dates for different episodes of the same complication if applicable.
date
Retinitis
Item
Pathogen Use the list of pathogens listed after this table for guidance. Use “unknown” if necessary.
text
Retinitis
Item
Date Provide different dates for different episodes of the same complication if applicable.
date
Other
Item
Pathogen Use the list of pathogens listed after this table for guidance.
text
Other
Item
Date Provide different dates for different episodes of the same complication if applicable.
date
Item
NON INFECTION RELATED COMPLICATIONS
integer
C0009566 (UMLS CUI [1])
CL Item
No complications (1)
CL Item
Yes (2)
Item
Specify: Idiopathic pneumonia syndrome
text
C1504431 (UMLS CUI [1])
CL Item
Yes (Yes)
CL Item
No (No )
CL Item
Unknown (Unknown)
CL Item
Yes (Yes)
CL Item
No (No )
CL Item
Unknown (Unknown)
Item
Specify: Haemorrhagic cystitis, non infectious
text
C0085692 (UMLS CUI [1])
CL Item
Yes (Yes )
CL Item
No (No )
CL Item
Unknown (Unknown)
CL Item
Yes (Yes)
CL Item
No (No)
CL Item
Unknown (Unknown)
CL Item
Yes (1)
CL Item
No (2)
CL Item
Unknown (3)
Item
Specify: HSCT-associated microangiopathy
text
C0155765 (UMLS CUI [1])
CL Item
Yes (Yes)
CL Item
No (No)
CL Item
Unknown (Unknown)
Item
Specify: Renal failure requiring dialysis
text
C0035078 (UMLS CUI [1])
CL Item
Yes (Yes)
CL Item
No (No)
CL Item
Unknown (Unknown)
Item
Specify: Haemolytic anaemia due to blood group
text
C0002878 (UMLS CUI [1])
CL Item
Yes (Yes)
CL Item
No (No)
CL Item
Unknown (Unknown)
Other type of infection
Item
Other type of infection
boolean
Date Idiopathic pneumonia syndrome
Item
Idiopathic pneumonia syndrome
date
Date VOD
Item
Date VOD
date
Date Haemorrhagic cystitis, non infectious
Item
Date Haemorrhagic cystitis, non infectious
date
Date ARDS, non infectious
Item
Date ARDS, non infectious
date
Date Multiorgan failure, non infectious
Item
Date Multiorgan failure, non infectious
date
Date HSCT-associated microangiopathy
Item
Date HSCT-associated microangiopathy
date
Date Renal failure requiring dialysis
Item
Date Renal failure requiring dialysis
date
Date Haemolytic anaemia due to blood group
Item
DAte Haemolytic anaemia due to blood group
date
Date of other Type
Item
Date of other Type
date
C2316983 (UMLS CUI [1,1])
C0220886 (UMLS CUI [1,2])
C0220886 (UMLS CUI [1,2])
LastContactDate
Item
Date of Last Contact
date
C0011008 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
C1705415 (UMLS CUI [1,3])
C1517741 (UMLS CUI [1,4])
C0011008 (UMLS CUI [1,2])
C1705415 (UMLS CUI [1,3])
C1517741 (UMLS CUI [1,4])
CL Item
No (1)
CL Item
Yes, First Episode (2)
CL Item
Yes, Recurrence (3)
Date of Onset
Item
Onset
date
C0574845 (UMLS CUI [1])
CL Item
limited (1)
CL Item
Extensive (2)
CL Item
not evaluated (3)
CL Item
Skin (1)
CL Item
Gut (2)
CL Item
Liver (3)
CL Item
Mouth (4)
CL Item
Eyes (5)
CL Item
Lung (6)
CL Item
Other, specify (7)
CL Item
Unknown (8)
Item
Relapse or progression
integer
C0035020 (UMLS CUI [1,1])
C1704632 (UMLS CUI [1,2])
C1704632 (UMLS CUI [1,2])
CL Item
Previously reported (1)
CL Item
No (2)
CL Item
yes (3)
CL Item
Continuous progression since transplant (4)
CL Item
Unknown (5)
If yes, date diagnosed
Item
RELAPSE OR PROGRESSION
date
Item
Cinical/haematological relapse or progression
integer
C0018939 (UMLS CUI [1,1])
C0205210 (UMLS CUI [1,2])
C0205210 (UMLS CUI [1,2])
CL Item
No (1)
CL Item
Yes (2)
CL Item
Not evaluated (3)
Cinical/haematological relapse or progression
Item
Date assessed
date
Cinical/haematological relapse or progression
Item
Date first seen
date
Item
Cytogenetic relapse or progression
integer
C0010802 (UMLS CUI [1])
CL Item
No (1)
CL Item
Yes (2)
CL Item
Not evaluated (3)
Cytogenetic relapse or progression
Item
Date assessed
date
Cytogenetic relapse or progression
Item
Date first seen
date
Item
Molecular relapse or progression
integer
C0026376 (UMLS CUI [1])
CL Item
No (1)
CL Item
Yes (2)
CL Item
Not evaluated (3)
Molecular relapse or progression
Item
Date assessed
date
Molecular relapse or progression
Item
Date first seen
date
Item
Clinical/haematological
integer
C0018939 (UMLS CUI [1,1])
C0205210 (UMLS CUI [1,2])
C0205210 (UMLS CUI [1,2])
CL Item
No (1)
CL Item
Yes (2)
CL Item
Not evaluated (3)
Date of Evaluation
Item
Last date evaluated/Last date assessed
date
C2985720 (UMLS CUI [1])
CL Item
No (1)
CL Item
Yes: Considered disease relapse/progression No (2)
CL Item
Yes: Considered disease relapse/progression Yes (3)
CL Item
Yes: Considered disease relapse/progression Not evaluated (4)
Last date assessed
Item
Last date assessed
date
CL Item
No (No)
CL Item
yes (yes)
CL Item
No Considered disease relapse/progression (No Considered disease relapse/progression)
CL Item
Yes Considered disease relapse/progression (Yes Considered disease relapse/progression)
CL Item
Not evaluated (Not evaluated)
CL Item
alive (0)
CL Item
dead (1)
CL Item
Karnofsky (Karnofsky)
CL Item
Lansky (Lansky)
CL Item
Not evaluated (Not evaluated)
CL Item
Unknown (Unknown)
CL Item
100 (Normal, NED) (1)
CL Item
10 (Moribund) (10)
CL Item
Not evaluated (11)
CL Item
Unknown (12)
CL Item
90 (Normal activity) (2)
CL Item
80 (Normal with effort) (3)
CL Item
70 (Cares for self) (4)
CL Item
60 (Requires occasional assistance) (5)
CL Item
50 (Requires assistance) (6)
CL Item
40 (Disabled) (7)
CL Item
30 (Severely disabled) (8)
CL Item
20 (Very sick) (9)
CL Item
Relapse or progression (1)
CL Item
Secondary malignancy (including lymphoproliferative disease) (2)
CL Item
Transplantation related cause (3)
CL Item
Unknown (4)
CL Item
Other (5)
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])
C0018133 (UMLS CUI [1,2])
Code List
If dead and HSCT related cause of death, specify (check as many as apppropriate): GvHD
CL Item
No (No )
CL Item
Unknown (Unknown)
CL Item
Yes (Yes)
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])
C0206061 (UMLS CUI [1,2])
Code List
If dead and HSCT related cause of death, specify (check as many as apppropriate): Interstitial Pneumonitis
CL Item
No (No )
CL Item
Unknown (Unknown)
CL Item
Yes (Yes)
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])
C0919924 (UMLS CUI [1,2])
Code List
If dead and HSCT related cause of death, specify (check as many as apppropriate): Pulmonary toxicity
CL Item
No (No )
CL Item
Unknown (Unknown)
CL Item
Yes (Yes)
CL Item
bacterial (1)
CL Item
viral (2)
CL Item
fungal (3)
CL Item
parasitic (4)
CL Item
unknown (5)
Item
Rejection / poor graft function
integer
C0018129 (UMLS CUI [1])
CL Item
Yes (1)
CL Item
No (2)
CL Item
Unknown (3)
Item
Veno-Occlusive disease (VOD)
integer
C0007465 (UMLS CUI [1,1])
C0948441 (UMLS CUI [1,2])
C0948441 (UMLS CUI [1,2])
CL Item
Yes (1)
CL Item
No (2)
CL Item
Unknown (3)
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])
C0019080 (UMLS CUI [1,2])
Code List
If dead and HSCT related cause of death, specify (check as many as apppropriate): Haemorrhage
CL Item
No (No )
CL Item
Unknown (Unknown)
CL Item
Yes (Yes)
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])
C0876994 (UMLS CUI [1,2])
Code List
If dead and HSCT related cause of death, specify (check as many as apppropriate): Cardiac toxicity
CL Item
No (No )
CL Item
Unknown (Unknown)
CL Item
Yes (Yes)
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])
C3160947 (UMLS CUI [1,2])
Code List
If dead and HSCT related cause of death, specify (check as many as apppropriate): Central nervous system toxicity
CL Item
No (No )
CL Item
Unknown (Unknown)
CL Item
Yes (Yes)
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])
C1142499 (UMLS CUI [1,2])
Code List
If dead and HSCT related cause of death, specify (check as many as apppropriate): Gastro intestinal toxicity
CL Item
No (No )
CL Item
Unknown (Unknown)
CL Item
Yes (Yes)
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])
C1167791 (UMLS CUI [1,2])
Code List
If dead and HSCT related cause of death, specify (check as many as apppropriate): Skin toxicity
CL Item
No (No )
CL Item
Unknown (Unknown)
CL Item
Yes (Yes)
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])
C0035078 (UMLS CUI [1,2])
Code List
If dead and HSCT related cause of death, specify (check as many as apppropriate): Renal failure
CL Item
No (No )
CL Item
Unknown (Unknown)
CL Item
Yes (Yes)
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])
C0026766 (UMLS CUI [1,2])
Code List
If dead and HSCT related cause of death, specify (check as many as apppropriate): Multiple organ failure
CL Item
No (No )
CL Item
Unknown (Unknown)
CL Item
Yes (Yes)
Other transplantation related
Item
Other transplantation related
boolean
COMMENTS
Item
COMMENTS
text
IDENTIFICATION & SIGNATURE
Item
IDENTIFICATION & SIGNATURE
text
CL Item
Hispanic or Latino (1)
CL Item
Not Hispanic or Latino (2)
CL Item
White (1)
CL Item
Black (2)
CL Item
Asian (3)
CL Item
American Indian or Alaska Native (4)
CL Item
Native Hawaiian or Pacific Native (5)
CL Item
Other (6)
COMORBID CONDITIONS
Item
Was there any clinically significant co-existing disease or organ impairment at time of patient assessment prior to preparative (conditioning) regimen?
boolean
Item
Treated at any time point in the patient's past history, excluding nonmelanoma skin cancer
text
Code List
Treated at any time point in the patient's past history, excluding nonmelanoma skin cancer
CL Item
No (No)
CL Item
Yes (Yes)
CL Item
Not evaluated (Not evaluated)
CL Item
No (No )
CL Item
Yes (Yes)
CL Item
Not evaluated (Not evaluated)
CL Item
No (No)
CL Item
Yes (Yes)
CL Item
Not evaluated (Not evaluated)
CL Item
No (No )
CL Item
Yes (Yes)
CL Item
Not evaluated (Not evaluated)
Item
Serum crratinine > 2 mg/dL or >177 μmol/L, on dialysis, or prior renal transplantation
text
Code List
Serum crratinine > 2 mg/dL or >177 μmol/L, on dialysis, or prior renal transplantation
CL Item
No (No)
CL Item
Yes (Yes)
CL Item
Not evaluated (Not evaluated)
Item
Chronic hepatitis, bilirubine between Upper Limit Normal (ULN) and 1.5 x the ULN, or AST/ALT between ULN and 2.5 × ULN
text
Code List
Chronic hepatitis, bilirubine between Upper Limit Normal (ULN) and 1.5 x the ULN, or AST/ALT between ULN and 2.5 × ULN
CL Item
No (No)
CL Item
Yes (Yes)
CL Item
Not evaluated (Not evaluated)
Item
Liver cirrhosis, bilirubine greater than 1.5 × ULN, or AST/ALT greater than 2.5 × ULN
text
Code List
Liver cirrhosis, bilirubine greater than 1.5 × ULN, or AST/ALT greater than 2.5 × ULN
CL Item
No (No)
CL Item
Yes (Yes )
CL Item
Not evaluated (Not evaluated)
Item
Atrial fibrillation or flutter, sick sinus syndrome, or ventricular arrhythmias
text
Code List
Atrial fibrillation or flutter, sick sinus syndrome, or ventricular arrhythmias
CL Item
No (No)
CL Item
Yes (Yes)
CL Item
Not evaluated (Not evaluated)
Item
Coronary artery disease, congestive heart failure, myocardial infarction, or EF ≤ 50%
text
Code List
Coronary artery disease, congestive heart failure, myocardial infarction, or EF ≤ 50%
CL Item
No (No)
CL Item
yes (yes)
CL Item
Not evaluated (Not evaluated)
CL Item
No (No)
CL Item
Yes (Yes)
CL Item
Not evaluated (Not evaluated)
CL Item
No (No)
CL Item
Yes (Yes)
CL Item
Not evaluated (Not evaluated)
CL Item
No (No)
CL Item
Yes (Yes)
CL Item
Not evaluated (Not evaluated)
CL Item
No (No)
CL Item
Yes (Yes)
CL Item
Not evaluated (Not evaluated)
CL Item
No (No)
CL Item
Yes (Yes)
CL Item
Not evaluated (Not evaluated)
CL Item
No (No)
CL Item
Yes (Yes)
CL Item
Not evaluated (Not evaluated)
CL Item
No (No)
CL Item
Yes (Yes)
CL Item
Not evaluated (Not evaluated)
other comorbidity
Item
other comorbidity, please specify
text