ID
16853
Beskrivning
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
Länk
Nyckelord
Versioner (3)
- 2016-07-21 2016-07-21 -
- 2016-08-10 2016-08-10 -
- 2021-09-17 2021-09-17 -
Uppladdad den
10 augusti 2016
DOI
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Licens
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
Beskrivning
Patient
Beskrivning
Unique Identification Code (UIC)
Datatyp
text
Alias
- UMLS CUI [1]
- C2348585
Beskrivning
Hospital Unique Patient Number or Code
Datatyp
text
Alias
- UMLS CUI [1]
- C1827636
Beskrivning
Initials
Datatyp
text
Alias
- UMLS CUI [1]
- C2986440
Beskrivning
Date of birth
Datatyp
date
Alias
- UMLS CUI [1]
- C0421451
Beskrivning
Sex
Datatyp
integer
Alias
- UMLS CUI [1]
- C0079399
Beskrivning
ABO Group
Datatyp
integer
Alias
- UMLS CUI [1]
- C0000778
Beskrivning
Rh factor
Datatyp
integer
Alias
- UMLS CUI [1]
- C0035403
Beskrivning
Disease
Beskrivning
Date of diagnosis
Datatyp
date
Alias
- UMLS CUI [1]
- C2316983
Beskrivning
Primary Disease Diagnosis
Datatyp
integer
Alias
- UMLS CUI [1]
- C0277554
Beskrivning
SYSTEMIC LUPUS ERITHEMATOSUS (SLE)
Beskrivning
Name of Referring Physician
Datatyp
integer
Alias
- UMLS CUI [1]
- C1709880
Beskrivning
Address
Datatyp
integer
Alias
- UMLS CUI [1]
- C0421449
Beskrivning
Fax
Datatyp
integer
Alias
- UMLS CUI [1]
- C1549619
Beskrivning
Datatyp
integer
Alias
- UMLS CUI [1]
- C0013849
Beskrivning
INITIAL DIAGNOSIS
Beskrivning
DIAGNOSTIC CRITERIA FOR SYSTEMIC LUPUS ERYTHEMATOSUS
Beskrivning
Fixed erythema, flat or raised, over the malar eminences, tending to spare the nasolabial folds
Datatyp
integer
Alias
- UMLS CUI [1]
- C3805720
Beskrivning
Erythematous raised patches with adherent keratotic scaling and follicular plugging; atrophic scarring may occur in older lesions
Datatyp
integer
Alias
- UMLS CUI [1]
- C3805721
Beskrivning
Skin rash as a result of unusual reaction to sunlight, by patient history or physician observation
Datatyp
integer
Alias
- UMLS CUI [1]
- C0349506
Beskrivning
Oral or nasopharyngeal ulceration, usually painless, observed by a physician
Datatyp
integer
Alias
- UMLS CUI [1]
- C0149745
Beskrivning
Non-erosive arthritis involving two or more peripheral joints, characterized by tenderness, swelling or effusion
Datatyp
integer
Alias
- UMLS CUI [1]
- C0003864
Beskrivning
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
Datatyp
integer
Alias
- UMLS CUI [1]
- C0036749
Beskrivning
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
Datatyp
integer
Alias
- UMLS CUI [1]
- C0022658
Beskrivning
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
Datatyp
integer
Alias
- UMLS CUI [1]
- C0027765
Beskrivning
a) Hemolytic anemia – with reticulocytosis ~OR~ b) Thrombocytopenia – <100,000/mm 3 platelets in the absence of offending drugs
Datatyp
integer
Alias
- UMLS CUI [1]
- C0018939
Beskrivning
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
Datatyp
integer
Alias
- UMLS CUI [1]
- C0021053
Beskrivning
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.
Datatyp
integer
Alias
- UMLS CUI [1]
- C0003243
Beskrivning
FIRST LINE THERAPIES
Beskrivning
Date started
Datatyp
date
Alias
- UMLS CUI [1]
- C3173309
Beskrivning
(including antibodies, GF, hormones, etc.)
Datatyp
text
Alias
- UMLS CUI [1]
- C0002844
Beskrivning
(including antibodies, GF, hormones, etc.)
Datatyp
integer
Alias
- UMLS CUI [1]
- C0003374
Beskrivning
Azathioprin
Datatyp
integer
Alias
- UMLS CUI [1]
- C0004482
Beskrivning
Corticosteroids
Datatyp
integer
Alias
- UMLS CUI [1]
- C0001617
Beskrivning
Cyclophosphamide
Datatyp
integer
Alias
- UMLS CUI [1]
- C0010583
Beskrivning
Cyclosporine
Datatyp
integer
Alias
- UMLS CUI [1]
- C0010592
Beskrivning
Mycophenolate mofetil
Datatyp
integer
Alias
- UMLS CUI [1]
- C0209368
Beskrivning
Intravenous immune globulin (IVIG)
Datatyp
integer
Alias
- UMLS CUI [1]
- C0085297
Beskrivning
Other drugs
Datatyp
integer
Alias
- UMLS CUI [1]
- C2729346
Beskrivning
Lymphocytopheresis
Datatyp
integer
Alias
- UMLS CUI [1]
- C0024226
Beskrivning
Plasmapheresis
Datatyp
integer
Alias
- UMLS CUI [1]
- C0032134
Beskrivning
Other drugs
Datatyp
boolean
Alias
- UMLS CUI [1]
- C2729346
Beskrivning
DATE OF HSCT
Beskrivning
STATUS OF DISEASE AT MOBILISATION
Beskrivning
Was lupus nephritis present at anytime prior to mobilisation?
Datatyp
integer
Alias
- UMLS CUI [1]
- C0024143
Beskrivning
Renal biopsy
Datatyp
integer
Alias
- UMLS CUI [1]
- C0194073
Beskrivning
date of most recent renal biopsy
Datatyp
date
Alias
- UMLS CUI [1,1]
- C0194073
- UMLS CUI [1,2]
- C2963433
Beskrivning
Grade Histology
Datatyp
integer
Alias
- UMLS CUI [1]
- C1317415
Beskrivning
Grade Histology
Datatyp
text
Alias
- UMLS CUI [1,1]
- C1317415
- UMLS CUI [1,2]
- C0205394
Beskrivning
SLEDAI (Systemic Lupus Erythematosus Disease Activity Index) score
Beskrivning
Recent onset (last 10 days). Exclude metabolic, infectious or drug cause, or seizure due to past irreversible CNS damage.
Datatyp
integer
Alias
- UMLS CUI [1]
- C0036572
Beskrivning
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.
Datatyp
integer
Alias
- UMLS CUI [1]
- C0033975
Beskrivning
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.
Datatyp
integer
Alias
- UMLS CUI [1]
- C0029221
Beskrivning
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.
Datatyp
integer
Alias
- UMLS CUI [1]
- C0547030
Beskrivning
New onset of sensory or motor neuropathy involving cranial nerves. Include vertigo due to lupus.
Datatyp
integer
Alias
- UMLS CUI [1]
- C0010266
Beskrivning
Severe, persistent headache: may be migrainous, but must be nonresponsive to narcotic analgesia.
Datatyp
integer
Alias
- UMLS CUI [1]
- C3898566
Beskrivning
New onset of cerebrovascular accident(s). Exclude arteriosclerosis or hypertensive causes.
Datatyp
integer
Alias
- UMLS CUI [1]
- C0038454
Beskrivning
Ulceration, gangrene, tender finger nodules, periungual infarction, splinter hemorrhages or biopsy or angiogram proof of vasculitis.
Datatyp
integer
Alias
- UMLS CUI [1]
- C0042384
Beskrivning
More than 2 joints with pain and signs of inflammation (i.e., tenderness, swelling or effusion).
Datatyp
integer
Alias
- UMLS CUI [1]
- C0003864
Beskrivning
Proximal muscle aching/weakness, associated with elevated creatine phosphokinase/aldolase or electromyogram changes or a biopsy showing myositis.
Datatyp
integer
Alias
- UMLS CUI [1]
- C0027121
Beskrivning
Heme-granular or red blood cell casts.
Datatyp
integer
Alias
- UMLS CUI [1]
- C4048266
Beskrivning
>5 red blood cells/high power field. Exclude stone, infection or other cause.
Datatyp
integer
Alias
- UMLS CUI [1]
- C0018965
Beskrivning
>0.5 gm/24 hours. New onset or recent increase of >0.5 gm/24 hours
Datatyp
integer
Alias
- UMLS CUI [1]
- C0033687
Beskrivning
>5 white blood cells/high power field. Exclude infection
Datatyp
integer
Alias
- UMLS CUI [1]
- C0034359
Beskrivning
Ongoing inflammatory lupus rash
Datatyp
integer
Alias
- UMLS CUI [1]
- C0015230
Beskrivning
Ongoing abnormal, patchy or diffuse loss of hair due to active lupus.
Datatyp
integer
Alias
- UMLS CUI [1]
- C0002171
Beskrivning
Ongoing oral or nasal ulcerations due to active lupus
Datatyp
integer
Alias
- UMLS CUI [1]
- C0236053
Beskrivning
Classic and severe pleuritic chest pain or pleural rub or effusion or new pleural thickening due to lupus.
Datatyp
integer
Alias
- UMLS CUI [1]
- C0032231
Beskrivning
Classic and severe pericardial pain or rub or effusion or electrocardiogram confirmation.
Datatyp
integer
Alias
- UMLS CUI [1]
- C1963211
Beskrivning
Low complement
Datatyp
integer
Alias
- UMLS CUI [1]
- C3897137
Beskrivning
>25% binding by Farr assay or above normal range for testing laboratory.
Datatyp
integer
Alias
- UMLS CUI [1]
- C1148673
Beskrivning
Fever
Datatyp
integer
Alias
- UMLS CUI [1]
- C1556366
Beskrivning
<100,000 platelets/mm 3 (x 10 9 /L).
Datatyp
integer
Alias
- UMLS CUI [1]
- C0040034
Beskrivning
<3,000 white blood cells/mm 3 (x 10 9 /L). Exclude drug causes.
Datatyp
integer
Alias
- UMLS CUI [1]
- C0023530
Beskrivning
LABORATORY VALUES
Beskrivning
Haemoglobin
Datatyp
float
Måttenheter
- g/dL
Alias
- UMLS CUI [1]
- C0019046
Beskrivning
ESR
Datatyp
integer
Måttenheter
- mm/hr
Alias
- UMLS CUI [1]
- C1176468
Beskrivning
Erythrocyte sedimentation rate
Datatyp
integer
Alias
- UMLS CUI [1]
- C1176468
Beskrivning
platelets
Datatyp
integer
Måttenheter
- x10^9 /l
Alias
- UMLS CUI [1]
- C0005821
Beskrivning
WBC
Datatyp
float
Måttenheter
- x10^9/l
Alias
- UMLS CUI [1]
- C0023508
Beskrivning
Serumcreatinine
Datatyp
float
Alias
- UMLS CUI [1]
- C0201976
Beskrivning
Creatinine Clearance
Datatyp
float
Måttenheter
- mL/min
Alias
- UMLS CUI [1]
- C0373595
Beskrivning
Total urinary protein excretion (mg/24 h)
Datatyp
float
Alias
- UMLS CUI [1]
- C3897352
Beskrivning
CH50 Complement reduced
Datatyp
integer
Alias
- UMLS CUI [1]
- C0369025
Beskrivning
Complement component reduced
Datatyp
integer
Alias
- UMLS CUI [1]
- C0009506
Beskrivning
Antibodies studied
Datatyp
integer
Alias
- UMLS CUI [1]
- C0003241
Beskrivning
anti-dsDNA
Datatyp
integer
Alias
- UMLS CUI [1]
- C2746079
Beskrivning
anti-cardiolipin IgG
Datatyp
integer
Alias
- UMLS CUI [1]
- C0368842
Beskrivning
anti-cardiolipin IgM
Datatyp
integer
Alias
- UMLS CUI [1]
- C0368843
Beskrivning
antinuclear antibody (ANA) test
Datatyp
integer
Alias
- UMLS CUI [1]
- C0003243
Beskrivning
anti-Sm
Datatyp
integer
Alias
- UMLS CUI [1]
- C0241910
Beskrivning
anti-SSA (anti-Ro)
Datatyp
integer
Alias
- UMLS CUI [1]
- C0075128
Beskrivning
anti-SSB (anti-La)
Datatyp
integer
Alias
- UMLS CUI [1]
- C1168480
Beskrivning
lupus-anticoagulant
Datatyp
integer
Alias
- UMLS CUI [1]
- C1142517
Beskrivning
PATIENT’S SELF ASSESSMENT PRIOR TO MOBILISATION
Beskrivning
SF-36 Health Survey
Datatyp
integer
Alias
- UMLS CUI [1]
- C3640521
Beskrivning
Physical Functioning
Datatyp
float
Alias
- UMLS CUI [1]
- C0516981
Beskrivning
Role Functioning-Physical
Datatyp
float
Alias
- UMLS CUI [1]
- C0516981
Beskrivning
Role Functioning-Emotional
Datatyp
float
Alias
- UMLS CUI [1]
- C0013987
Beskrivning
Social Functioning
Datatyp
float
Alias
- UMLS CUI [1]
- C2585826
Beskrivning
Bodily Pain
Datatyp
float
Alias
- UMLS CUI [1]
- C3890602
Beskrivning
Mental Health
Datatyp
float
Alias
- UMLS CUI [1]
- C0025353
Beskrivning
Vitality
Datatyp
float
Alias
- UMLS CUI [1]
- C0424589
Beskrivning
General Health
Datatyp
float
Alias
- UMLS CUI [1]
- C0516984
Beskrivning
HEALTH ASSESSMENT QUESTIONNAIRE (HAQ)
Beskrivning
Health Assessment Questionnaire
Datatyp
integer
Alias
- UMLS CUI [1]
- C0451208
Beskrivning
health score
Datatyp
float
Alias
- UMLS CUI [1]
- C2960025
Beskrivning
Worst possible score
Datatyp
float
Alias
- UMLS CUI [1,1]
- C0449820
- UMLS CUI [1,2]
- C1522166
Beskrivning
Best possible score
Datatyp
float
Alias
- UMLS CUI [1,1]
- C0449820
- UMLS CUI [1,2]
- C1299381
Beskrivning
STATUS OF DISEASE AT HSCT
Beskrivning
Was lupus nephritis present at anytime prior to HSCT?
Datatyp
integer
Alias
- UMLS CUI [1]
- C0024143
Beskrivning
Was lupus nephritis present at anytime prior to HSCT?
Datatyp
date
Alias
- UMLS CUI [1]
- C0194073
Beskrivning
Grade Histology
Datatyp
integer
Alias
- UMLS CUI [1]
- C1317415
Beskrivning
Renal biopsy done?
Datatyp
text
Alias
- UMLS CUI [1]
- C0194073
Beskrivning
ADDITIONAL TREATMENT POST-HSCT
Beskrivning
FORMS TO BE FILLED IN
Similar models
Systemic lupus erythematosus EBMT General Information Form
- StudyEvent: ODM
C0011008 (UMLS CUI [1,2])
C2963433 (UMLS CUI [1,2])
C0205394 (UMLS CUI [1,2])
C1522166 (UMLS CUI [1,2])
C1299381 (UMLS CUI [1,2])
C0040739 (UMLS CUI [1,2])