ID
16853
Descripción
ODM form derived from 119pp EBMT SLE 16SLE please refer to: http://www.ebmt.org/Contents/Data-Management/Registrystructure/MED-ABdatacollectionforms/Pages/MED-AB-data-collection-forms.aspx
Link
Palabras clave
Versiones (3)
- 21/7/16 21/7/16 -
- 10/8/16 10/8/16 -
- 17/9/21 17/9/21 -
Subido en
10 de agosto de 2016
DOI
Para solicitar uno, por favor iniciar sesión.
Licencia
Creative Commons BY-NC 3.0
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Systemic lupus erythematosus EBMT General Information Form
Systemic lupus erythematosus EBMT General Information Form
- StudyEvent: ODM
Descripción
Patient
Descripción
Unique Identification Code (UIC)
Tipo de datos
text
Alias
- UMLS CUI [1]
- C2348585
Descripción
Hospital Unique Patient Number or Code
Tipo de datos
text
Alias
- UMLS CUI [1]
- C1827636
Descripción
Initials
Tipo de datos
text
Alias
- UMLS CUI [1]
- C2986440
Descripción
Date of birth
Tipo de datos
date
Alias
- UMLS CUI [1]
- C0421451
Descripción
Sex
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C0079399
Descripción
ABO Group
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C0000778
Descripción
Rh factor
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C0035403
Descripción
Disease
Descripción
Date of diagnosis
Tipo de datos
date
Alias
- UMLS CUI [1]
- C2316983
Descripción
Primary Disease Diagnosis
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C0277554
Descripción
SYSTEMIC LUPUS ERITHEMATOSUS (SLE)
Descripción
Name of Referring Physician
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C1709880
Descripción
Address
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C0421449
Descripción
Fax
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C1549619
Descripción
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C0013849
Descripción
INITIAL DIAGNOSIS
Descripción
DIAGNOSTIC CRITERIA FOR SYSTEMIC LUPUS ERYTHEMATOSUS
Descripción
Fixed erythema, flat or raised, over the malar eminences, tending to spare the nasolabial folds
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C3805720
Descripción
Erythematous raised patches with adherent keratotic scaling and follicular plugging; atrophic scarring may occur in older lesions
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C3805721
Descripción
Skin rash as a result of unusual reaction to sunlight, by patient history or physician observation
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C0349506
Descripción
Oral or nasopharyngeal ulceration, usually painless, observed by a physician
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C0149745
Descripción
Non-erosive arthritis involving two or more peripheral joints, characterized by tenderness, swelling or effusion
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C0003864
Descripción
a) Pleuritis – convincing history of pleuritic pain or rub heard by a physician or evidence of pleural effusion ~OR~ b) Pericarditis – documented by ECG or rub or evidence of pericardial effusion
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C0036749
Descripción
a) Persistent proteinuria >0.5 grams per day or >3+ on urine dipsCheck if quantitation not performed ~OR~ b) Cellular casts – may be red cell, hemoglobulin, granular, tubular or mixed
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C0022658
Descripción
a) Seizures – in the absence of offending drugs or known metabolic derangements; e.g., uremia, ketoacidosis or electrolyte imbalance ~OR~ b) Psychosis – in the absence of offending drugs or known metabolic derangements, e.g., uremia, ketoacidosis or electrolyte imbalance
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C0027765
Descripción
a) Hemolytic anemia – with reticulocytosis ~OR~ b) Thrombocytopenia – <100,000/mm 3 platelets in the absence of offending drugs
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C0018939
Descripción
a) Anti-DNA: antibody to native DNA in abnormal titer ~OR~ b) Anti-Sm: presence of antibody to Sm nuclear antigen ~OR~ c) Positive finding of antiphospholipid antibodies based on (1) an abnormal serum level of IgG or IgM anticardiolipin antibodies, (2) a positive test result for lupus anticoagulant using a standard method, or (3) a false positive serologic test for Syphilis known to be positive for at least 6 months and confirmed by Treponema pallidum immobilisation or fluorescent treponemal antibody absorption test ~OR d) False positive serologic test for syphilis known to be positive for at least 6 months and confirmed by Treponema pallidum immobilisation or fluorescent treponemal antibody absorption test
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C0021053
Descripción
An abnormal titer of antinuclear antibody by immunofluorescence or an equivalent assay at any point in time and in the absence of drugs known to be associated with “drug-induced lupus” syndrome.
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C0003243
Descripción
FIRST LINE THERAPIES
Descripción
Date started
Tipo de datos
date
Alias
- UMLS CUI [1]
- C3173309
Descripción
(including antibodies, GF, hormones, etc.)
Tipo de datos
text
Alias
- UMLS CUI [1]
- C0002844
Descripción
(including antibodies, GF, hormones, etc.)
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C0003374
Descripción
Azathioprin
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C0004482
Descripción
Corticosteroids
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C0001617
Descripción
Cyclophosphamide
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C0010583
Descripción
Cyclosporine
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C0010592
Descripción
Mycophenolate mofetil
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C0209368
Descripción
Intravenous immune globulin (IVIG)
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C0085297
Descripción
Other drugs
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C2729346
Descripción
Lymphocytopheresis
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C0024226
Descripción
Plasmapheresis
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C0032134
Descripción
Other drugs
Tipo de datos
boolean
Alias
- UMLS CUI [1]
- C2729346
Descripción
DATE OF HSCT
Descripción
STATUS OF DISEASE AT MOBILISATION
Descripción
Was lupus nephritis present at anytime prior to mobilisation?
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C0024143
Descripción
Renal biopsy
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C0194073
Descripción
date of most recent renal biopsy
Tipo de datos
date
Alias
- UMLS CUI [1,1]
- C0194073
- UMLS CUI [1,2]
- C2963433
Descripción
Grade Histology
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C1317415
Descripción
Grade Histology
Tipo de datos
text
Alias
- UMLS CUI [1,1]
- C1317415
- UMLS CUI [1,2]
- C0205394
Descripción
SLEDAI (Systemic Lupus Erythematosus Disease Activity Index) score
Descripción
Recent onset (last 10 days). Exclude metabolic, infectious or drug cause, or seizure due to past irreversible CNS damage.
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C0036572
Descripción
Altered ability to function in normal activity due to severe disturbance in the perception of reality. Include hallucinations, incoherence, marked loose associations, impoverished thought content, marked illogical thinking, bizarre, disorganized or catatonic behavior. Exclude uremia and drug causes.
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C0033975
Descripción
Altered mental function with impaired orientation, memory or other intellectual function, with rapid onset and fluctuating clinical features. Include clouding of consciousness with reduced capacity to focus and inability to sustain attention to environment, plus at least 2 of the following: perceptual disturbance, incoherent speech, insomnia or daytime drowsiness or increased or decreased psychomotor activity. Exclude metabolic, infectious or drug causes.
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C0029221
Descripción
Retinal and eye changes of SLE. Include cytoid bodies, retinal hemorrhages, serous exudate or hemorrhages in the choroid, optic neuritis, scleritis or episcleritis. Exclude hypertension, infection or drug causes.
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C0547030
Descripción
New onset of sensory or motor neuropathy involving cranial nerves. Include vertigo due to lupus.
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C0010266
Descripción
Severe, persistent headache: may be migrainous, but must be nonresponsive to narcotic analgesia.
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C3898566
Descripción
New onset of cerebrovascular accident(s). Exclude arteriosclerosis or hypertensive causes.
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C0038454
Descripción
Ulceration, gangrene, tender finger nodules, periungual infarction, splinter hemorrhages or biopsy or angiogram proof of vasculitis.
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C0042384
Descripción
More than 2 joints with pain and signs of inflammation (i.e., tenderness, swelling or effusion).
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C0003864
Descripción
Proximal muscle aching/weakness, associated with elevated creatine phosphokinase/aldolase or electromyogram changes or a biopsy showing myositis.
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C0027121
Descripción
Heme-granular or red blood cell casts.
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C4048266
Descripción
>5 red blood cells/high power field. Exclude stone, infection or other cause.
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C0018965
Descripción
>0.5 gm/24 hours. New onset or recent increase of >0.5 gm/24 hours
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C0033687
Descripción
>5 white blood cells/high power field. Exclude infection
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C0034359
Descripción
Ongoing inflammatory lupus rash
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C0015230
Descripción
Ongoing abnormal, patchy or diffuse loss of hair due to active lupus.
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C0002171
Descripción
Ongoing oral or nasal ulcerations due to active lupus
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C0236053
Descripción
Classic and severe pleuritic chest pain or pleural rub or effusion or new pleural thickening due to lupus.
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C0032231
Descripción
Classic and severe pericardial pain or rub or effusion or electrocardiogram confirmation.
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C1963211
Descripción
Low complement
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C3897137
Descripción
>25% binding by Farr assay or above normal range for testing laboratory.
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C1148673
Descripción
Fever
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C1556366
Descripción
<100,000 platelets/mm 3 (x 10 9 /L).
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C0040034
Descripción
<3,000 white blood cells/mm 3 (x 10 9 /L). Exclude drug causes.
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C0023530
Descripción
LABORATORY VALUES
Descripción
Haemoglobin
Tipo de datos
float
Unidades de medida
- g/dL
Alias
- UMLS CUI [1]
- C0019046
Descripción
ESR
Tipo de datos
integer
Unidades de medida
- mm/hr
Alias
- UMLS CUI [1]
- C1176468
Descripción
Erythrocyte sedimentation rate
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C1176468
Descripción
platelets
Tipo de datos
integer
Unidades de medida
- x10^9 /l
Alias
- UMLS CUI [1]
- C0005821
Descripción
WBC
Tipo de datos
float
Unidades de medida
- x10^9/l
Alias
- UMLS CUI [1]
- C0023508
Descripción
Serumcreatinine
Tipo de datos
float
Alias
- UMLS CUI [1]
- C0201976
Descripción
Creatinine Clearance
Tipo de datos
float
Unidades de medida
- mL/min
Alias
- UMLS CUI [1]
- C0373595
Descripción
Total urinary protein excretion (mg/24 h)
Tipo de datos
float
Alias
- UMLS CUI [1]
- C3897352
Descripción
CH50 Complement reduced
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C0369025
Descripción
Complement component reduced
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C0009506
Descripción
Antibodies studied
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C0003241
Descripción
anti-dsDNA
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C2746079
Descripción
anti-cardiolipin IgG
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C0368842
Descripción
anti-cardiolipin IgM
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C0368843
Descripción
antinuclear antibody (ANA) test
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C0003243
Descripción
anti-Sm
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C0241910
Descripción
anti-SSA (anti-Ro)
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C0075128
Descripción
anti-SSB (anti-La)
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C1168480
Descripción
lupus-anticoagulant
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C1142517
Descripción
PATIENT’S SELF ASSESSMENT PRIOR TO MOBILISATION
Descripción
SF-36 Health Survey
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C3640521
Descripción
Physical Functioning
Tipo de datos
float
Alias
- UMLS CUI [1]
- C0516981
Descripción
Role Functioning-Physical
Tipo de datos
float
Alias
- UMLS CUI [1]
- C0516981
Descripción
Role Functioning-Emotional
Tipo de datos
float
Alias
- UMLS CUI [1]
- C0013987
Descripción
Social Functioning
Tipo de datos
float
Alias
- UMLS CUI [1]
- C2585826
Descripción
Bodily Pain
Tipo de datos
float
Alias
- UMLS CUI [1]
- C3890602
Descripción
Mental Health
Tipo de datos
float
Alias
- UMLS CUI [1]
- C0025353
Descripción
Vitality
Tipo de datos
float
Alias
- UMLS CUI [1]
- C0424589
Descripción
General Health
Tipo de datos
float
Alias
- UMLS CUI [1]
- C0516984
Descripción
HEALTH ASSESSMENT QUESTIONNAIRE (HAQ)
Descripción
Health Assessment Questionnaire
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C0451208
Descripción
health score
Tipo de datos
float
Alias
- UMLS CUI [1]
- C2960025
Descripción
Worst possible score
Tipo de datos
float
Alias
- UMLS CUI [1,1]
- C0449820
- UMLS CUI [1,2]
- C1522166
Descripción
Best possible score
Tipo de datos
float
Alias
- UMLS CUI [1,1]
- C0449820
- UMLS CUI [1,2]
- C1299381
Descripción
STATUS OF DISEASE AT HSCT
Descripción
Was lupus nephritis present at anytime prior to HSCT?
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C0024143
Descripción
Was lupus nephritis present at anytime prior to HSCT?
Tipo de datos
date
Alias
- UMLS CUI [1]
- C0194073
Descripción
Grade Histology
Tipo de datos
integer
Alias
- UMLS CUI [1]
- C1317415
Descripción
Renal biopsy done?
Tipo de datos
text
Alias
- UMLS CUI [1]
- C0194073
Descripción
ADDITIONAL TREATMENT POST-HSCT
Descripción
FORMS TO BE FILLED IN
Similar models
Systemic lupus erythematosus EBMT General Information Form
- StudyEvent: ODM
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C2963433 (UMLS CUI [1,2])
C0205394 (UMLS CUI [1,2])
C1522166 (UMLS CUI [1,2])
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