Informações:
Falhas:
ID
23863
Descrição
Study part: Pregnancy Notification Form (Subject) Week 36/ Early Withdrawal Visit.A Phase 2 Multicenter, Double-blind, Placebo-controlled, Study to to Evaluate the Corticosteroid- sparing effects of Mepolizumab in Subjects with Hypereosinophilic Syndromes (HES) and Evaluate Efficacy and Safety of Mepolizumab in Controlling the Clinical Signs and Symptoms of subjects with HES Patient Level Data: Study Listed on ClinicalStudyDataRequest.com. Sponsor: GlaxoSmithKline. Study ID: 100185, Clinical Study ID:MHE100185.
Palavras-chave
Versões (1)
- 15/07/2017 15/07/2017 -
Titular dos direitos
GlaxoSmithKline
Transferido a
15 de julho de 2017
DOI
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Licença
Creative Commons BY-NC 3.0
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Pregnancy Notification Form (Subject) Week 36 Mepolizumab HES NCT00086658
Pregnancy Notification Form (Subject) Week 36
- StudyEvent: ODM
Similar models
Pregnancy Notification Form (Subject) Week 36
- StudyEvent: ODM
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de dados
Alias
Item Group
MOTHER’S RELEVANT MEDICAL/FAMILY HISTORY
C0241889 (UMLS CUI-1)
C0026591 (UMLS CUI-2)
C0026591 (UMLS CUI-2)
Subject ID
Item
Subject ID
text
C2348585 (UMLS CUI [1])
Centre Number
Item
Centre Number
integer
C0600091 (UMLS CUI [1,1])
C0019994 (UMLS CUI [1,2])
C0019994 (UMLS CUI [1,2])
Randomisation Number
Item
Randomisation Number
integer
C0449788 (UMLS CUI [1,1])
C0034656 (UMLS CUI [1,2])
C0034656 (UMLS CUI [1,2])
date of birth mother
Item
Mother’s date of birth
date
C0421451 (UMLS CUI [1,1])
C0026591 (UMLS CUI [1,2])
C0026591 (UMLS CUI [1,2])
Date of last menstrual period
Item
Date of last menstrual period
date
C0425932 (UMLS CUI [1])
Estimated date of delivery
Item
Estimated date of delivery
date
C1287845 (UMLS CUI [1])
method of contraception
Item
Was the mother using a method of contraception?
boolean
C0700589 (UMLS CUI [1])
method of contraception
Item
If Yes, specify
text
C0700589 (UMLS CUI [1])
CL Item
Normal (includes use of fertility drugs) (Normal (includes use of fertility drugs))
CL Item
IVF (in vitro fertilisation) (IVF (in vitro fertilisation))
C0015915 (UMLS CUI-1)
laboratory tests
Item
Relevant laboratory tests and procedures (e.g., ultrasound, amniocentesis and chorionic villi sampling,including dates of tests and procedures).
text
C0022885 (UMLS CUI [1])
Number of previous pregnancies Pre-term
Item
Number of previous pregnancies-Pre-term
integer
C0422807 (UMLS CUI [1,1])
C1547235 (UMLS CUI [1,2])
C1547235 (UMLS CUI [1,2])
Number of previous pregnancies Full-term
Item
Number of previous pregnancies-Full-term
integer
C0422807 (UMLS CUI [1,1])
C3814420 (UMLS CUI [1,2])
C3814420 (UMLS CUI [1,2])
Normal births
Item
Normal births
integer
C3665337 (UMLS CUI [1])
Stillbirths
Item
Stillbirths
integer
C0595939 (UMLS CUI [1])
Children born with defects
Item
Children born with defects
integer
C0000768 (UMLS CUI [1,1])
C2229974 (UMLS CUI [1,2])
C2229974 (UMLS CUI [1,2])
Spontaneous abortion
Item
Spontaneous abortion
integer
C0000786 (UMLS CUI [1])
Elective abortion
Item
Elective abortion
integer
C0269439 (UMLS CUI [1])
Other
Item
If other, please specify
text
C0205394 (UMLS CUI [1])
Children born with defects
Item
Record details of children born with defects
text
C0000768 (UMLS CUI [1,1])
C2229974 (UMLS CUI [1,2])
C2229974 (UMLS CUI [1,2])
pregnancy outcome
Item
Are there any additional factors that may have an impact on the outcome of this pregnancy?
text
C0032972 (UMLS CUI [1])
pregnancy outcome
Item
If Yes, specify
text
C0032972 (UMLS CUI [1])
Item Group
FATHER’S RELEVANT MEDICAL/FAMILY HISTORY
C0241889 (UMLS CUI-1)
C0015671 (UMLS CUI-2)
C0015671 (UMLS CUI-2)
Family history father substance use disorder
Item
FATHER’S RELEVANT MEDICAL/FAMILY HISTORY (Include habitual exposures such as alcohol/substance abuse, chronic illnesses, familial birth defects/genetic/chromosomal disorders and medication use)
text
C0241889 (UMLS CUI [1,1])
C0015671 (UMLS CUI [1,2])
C0038586 (UMLS CUI [1,3])
C0015671 (UMLS CUI [1,2])
C0038586 (UMLS CUI [1,3])
Drug Name
Item
Drug Name
text
C0013227 (UMLS CUI [1])
Route
Item
Route of Admin. or Formulation
text
C0013153 (UMLS CUI [1])
Total Daily Dose
Item
Total Daily Dose
text
C2348070 (UMLS CUI [1])
Units
Item
Units
text
C1519795 (UMLS CUI [1])
Started Pre-Study
Item
Started Pre-Study
boolean
C0013227 (UMLS CUI [1,1])
C0451613 (UMLS CUI [1,2])
C0451613 (UMLS CUI [1,2])
Start Date
Item
Start Date
date
C0808070 (UMLS CUI [1])
Stop Date
Item
Stop Date
date
C0806020 (UMLS CUI [1])
Ongoing Medication
Item
Ongoing Medication
boolean
C2826666 (UMLS CUI [1])
Reason for Medication
Item
Reason for Medication
text
C0392360 (UMLS CUI [1,1])
C0013227 (UMLS CUI [1,2])
C0013227 (UMLS CUI [1,2])
withdrawn from the study
Item
Was the subject withdrawn from the study as a result of this pregnancy?
boolean
C0422727 (UMLS CUI [1])
Item Group
REPORTING INVESTIGATOR INFORMATION
C1955348 (UMLS CUI-1)
C0008961 (UMLS CUI-2)
C0008961 (UMLS CUI-2)
Name
Item
Name
text
C0008961 (UMLS CUI [1])
Title
Item
Title
text
C3888414 (UMLS CUI [1])
Speciality
Item
Speciality
text
C0037778 (UMLS CUI [1,1])
C0008961 (UMLS CUI [1,2])
C0008961 (UMLS CUI [1,2])
Address
Item
Address
text
C1442065 (UMLS CUI [1])
City
Item
City or State/Province
text
C0008848 (UMLS CUI [1])
Country
Item
Country
text
C0454664 (UMLS CUI [1])
Zip Code
Item
Post or Zip Code
integer
C0421454 (UMLS CUI [1])
Telephone No
Item
Telephone No
integer
C1515258 (UMLS CUI [1])
Fax No
Item
Fax No
integer
C1549619 (UMLS CUI [1])
Investigator signature
Item
Investigator’s signature
text
C2346576 (UMLS CUI [1])
Investigator name
Item
Investigator’s name
text
C2826892 (UMLS CUI [1])
Date
Item
Date
date
C0011008 (UMLS CUI [1])
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