ID

26030

Beschrijving

Study ID: 100601 Clinical Study ID: LPL100601 Study Title: LPL100601, A Clinical Outcomes Study of Darapladib versus Placebo in Subjects with Chronic Coronary Heart Disease to Compare the Incidence of Major Adverse Cardiovascular Events (MACE) Patient Level Data: Study Listed on ClinicalStudyDataRequest.com Clinicaltrials.gov Identifier: NCT00799903 Sponsor: GlaxoSmithKline Collaborators: N/A Phase: phase 3 Study Recruitment Status: Completed Generic Name: darapladib Trade Name: darapladib Study Indication: Atherosclerosis Study part: Hypersensitivity Reaction Record - Repeating form (Scheduled visits)

Trefwoorden

  1. 04-10-17 04-10-17 -
  2. 16-10-17 16-10-17 -
  3. 23-10-17 23-10-17 -
  4. 01-01-18 01-01-18 -
  5. 03-01-18 03-01-18 -
Houder van rechten

GlaxoSmithKline

Geüploaded op

4 oktober 2017

DOI

Voor een aanvraag inloggen.

Licentie

Creative Commons BY-NC 3.0

Model Commentaren :

Hier kunt u commentaar leveren op het model. U kunt de tekstballonnen bij de itemgroepen en items gebruiken om er specifiek commentaar op te geven.

Itemgroep Commentaren voor :

Item Commentaren voor :

U moet ingelogd zijn om formulieren te downloaden. AUB inloggen of schrijf u gratis in.

Hypersensitivity Reaction Record GSK study Chronic Coronary Heart Disease NCT00799903

Hypersensitivity Reaction Record GSK study Chronic Coronary Heart Disease NCT00799903

1. Event number
Beschrijving

1. Event number

Event number
Beschrijving

Enter the Event Number from item 1 on the Anaphylaxis Diagnosis (ANA) form

Datatype

text

Past medical conditions: 2. Food allergies
Beschrijving

Past medical conditions: 2. Food allergies

Anaphylactic reaction to food
Beschrijving

Anaphylactic reaction to food

Datatype

integer

Angioedema
Beschrijving

Angioedema food

Datatype

integer

Urticaria
Beschrijving

Urticaria food

Datatype

integer

Past medical conditions: 3. Hymenoptera sting allergy
Beschrijving

Past medical conditions: 3. Hymenoptera sting allergy

Anaphylaxis
Beschrijving

Anaphylaxis Hymenoptera sting allergy

Datatype

integer

Angioedema
Beschrijving

Angioedema Hymenoptera sting allergy

Datatype

integer

Urticaria
Beschrijving

Urticaria Hymenoptera sting allergy

Datatype

integer

Past medical conditions: 4. Latex allergy
Beschrijving

Past medical conditions: 4. Latex allergy

Anaphylaxis
Beschrijving

Anaphylaxis Latex

Datatype

integer

Angioedema
Beschrijving

Angioedema latex

Datatype

integer

Urticaria
Beschrijving

Urticaria latex

Datatype

integer

Past medical conditions: 5. Penicillin allergy
Beschrijving

Past medical conditions: 5. Penicillin allergy

Anaphylactic reaction to drug
Beschrijving

Anaphylactic reaction penicillin

Datatype

integer

Angioedema
Beschrijving

Angioedema penicillin

Datatype

integer

Drug induced urticaria
Beschrijving

Drug induced urticaria penicillin

Datatype

integer

Past medical conditions: 6. Cephalosporin allergy
Beschrijving

Past medical conditions: 6. Cephalosporin allergy

Anaphylactic reaction to drug
Beschrijving

Anaphylactic reaction to Cephalosporin

Datatype

integer

Angioedema
Beschrijving

Angioedema Cephalosporin

Datatype

integer

Drug induced urticaria
Beschrijving

Drug induced urticaria Cephalosporin

Datatype

integer

Past medical conditions: 7. Aspirin allergy
Beschrijving

Past medical conditions: 7. Aspirin allergy

Anaphylactic reaction to drug
Beschrijving

Anaphylactic reaction to aspirin

Datatype

integer

Angioedema
Beschrijving

Angioedema aspirin

Datatype

integer

Drug induced urticaria
Beschrijving

Drug induced urticaria aspirin

Datatype

integer

Past medical conditions: 8. NSAID allergy
Beschrijving

Past medical conditions: 8. NSAID allergy

Anaphylactic reaction to drug
Beschrijving

Anaphylactic reaction to NSAID

Datatype

integer

Angioedema
Beschrijving

Angioedema NSAID

Datatype

integer

Drug induced urticaria
Beschrijving

Drug induced urticaria NSAID

Datatype

integer

Past medical conditions: 9. ACE inhibitor allergy
Beschrijving

Past medical conditions: 9. ACE inhibitor allergy

Anaphylactic reaction to drug
Beschrijving

Anaphylactic reaction to ACE inhibitor

Datatype

integer

Angioedema
Beschrijving

Angioedema ACE inhibitor

Datatype

integer

Drug induced urticaria
Beschrijving

Drug induced urticaria ACE inhibitor

Datatype

integer

Other allergies
Beschrijving

Other allergies

10.a Specific Condition
Beschrijving

Specific Condition Other allergies

Datatype

text

10.b Status
Beschrijving

This item is optional

Datatype

integer

Symptoms associated with this hypersensitivity reaction: 11. Stevens-Johnson syndrome
Beschrijving

Symptoms associated with this hypersensitivity reaction: 11. Stevens-Johnson syndrome

Symptoms
Beschrijving

Symptoms Stevens-Johnson syndrome

Datatype

text

Blisters
Beschrijving

Blisters Stevens-Johnson syndrome

Datatype

boolean

Biopsy confirmed
Beschrijving

Biopsy confirmed Stevens-Johnson syndrome

Datatype

boolean

Mucous membrane involvement
Beschrijving

Mucous membrane involvement Stevens-Johnson syndrome

Datatype

boolean

Symptom start date
Beschrijving

Stevens-Johnson syndrome Symptom start date

Datatype

date

Symptoms associated with this hypersensitivity reaction: 12. Toxic epidermal necrolysis
Beschrijving

Symptoms associated with this hypersensitivity reaction: 12. Toxic epidermal necrolysis

Symptoms
Beschrijving

Symptoms Toxic epidermal necrolysis

Datatype

text

Blisters
Beschrijving

Blisters Toxic epidermal necrolysis

Datatype

boolean

Biopsy confirmed
Beschrijving

Biopsy confirmed Toxic epidermal necrolysis

Datatype

boolean

Mucous membrane involvement
Beschrijving

Mucous membrane involvement Toxic epidermal necrolysis

Datatype

boolean

Symptom start date
Beschrijving

Symptom start date Toxic epidermal necrolysis

Datatype

date

Symptoms associated with this hypersensitivity reaction: 13. Urticaria (hives)
Beschrijving

Symptoms associated with this hypersensitivity reaction: 13. Urticaria (hives)

Symptoms
Beschrijving

Symptoms Urticaria (hives)

Datatype

text

Generalised
Beschrijving

Generalised Urticaria (hives)

Datatype

boolean

Localised
Beschrijving

Localised Urticaria (hives)

Datatype

boolean

Photosensitivity
Beschrijving

Photosensitivity Urticaria (hives)

Datatype

boolean

Other
Beschrijving

Other symptoms Urticaria (hives)

Datatype

boolean

Other, specify
Beschrijving

Other symptoms Urticaria (hives) specification

Datatype

text

Symptom start date
Beschrijving

Symptom start date Urticaria (hives)

Datatype

date

Symptoms associated with this hypersensitivity reaction: 14. Angioedema
Beschrijving

Symptoms associated with this hypersensitivity reaction: 14. Angioedema

Symptoms
Beschrijving

Symptoms Angioedema

Datatype

text

Face (including eyes, lips)
Beschrijving

Angioedema Face

Datatype

boolean

Throat (including tongue, larynx)
Beschrijving

Angioedema Throat

Datatype

boolean

Laryngeal
Beschrijving

Angioedema Laryngeal

Datatype

boolean

Dyspnoea
Beschrijving

Angioedema Dyspnoea

Datatype

boolean

Dysphagia
Beschrijving

Angioedema Dysphagia

Datatype

boolean

Required intubation
Beschrijving

Angioedema Required intubation

Datatype

boolean

Other
Beschrijving

Angioedema Other symptoms

Datatype

boolean

Other, specify
Beschrijving

Angioedema Other symptoms specification

Datatype

text

Symptom start date
Beschrijving

Symptom start date Angioedema

Datatype

date

Symptoms associated with this hypersensitivity reaction: 15. Anaphylactic/Anaphylactoid reaction
Beschrijving

Symptoms associated with this hypersensitivity reaction: 15. Anaphylactic/Anaphylactoid reaction

Symptoms
Beschrijving

Anaphylactic/Anaphylactoid reaction symptoms

Datatype

text

Dyspnoea
Beschrijving

Dyspnoea Anaphylactic/Anaphylactoid reaction

Datatype

boolean

Bronchospasm
Beschrijving

Bronchospasm Anaphylactic/Anaphylactoid reaction

Datatype

boolean

Hypotension
Beschrijving

Hypotension Anaphylactic/Anaphylactoid reaction

Datatype

boolean

Loss of consciousness
Beschrijving

Loss of consciousness Anaphylactic/Anaphylactoid reaction

Datatype

boolean

Persistent gastrointestinal symptoms (crampy abdominal pain, vomiting)
Beschrijving

Persistent gastrointestinal symptoms Anaphylactic/Anaphylactoid reaction

Datatype

boolean

Other
Beschrijving

Other symptoms Anaphylactic/Anaphylactoid reaction

Datatype

boolean

Other, specify
Beschrijving

Other symptoms specidication Anaphylactic/Anaphylactoid reaction

Datatype

text

Symptom start date
Beschrijving

Symptom start date Anaphylactic/Anaphylactoid reaction

Datatype

date

Symptoms associated with this hypersensitivity reaction: 16. Other symptoms of hypersensitivity reaction
Beschrijving

Symptoms associated with this hypersensitivity reaction: 16. Other symptoms of hypersensitivity reaction

Symptoms
Beschrijving

Symptoms Other symptoms of hypersensitivity reaction

Datatype

text

Rash
Beschrijving

Other symptoms of hypersensitivity reaction Rash

Datatype

boolean

Photosensitivity
Beschrijving

Other symptoms of hypersensitivity reaction Photosensitivity

Datatype

boolean

Other
Beschrijving

Other symptoms of hypersensitivity reaction

Datatype

boolean

Other, specify
Beschrijving

Other symptoms of hypersensitivity reaction specification

Datatype

text

Symptom start date
Beschrijving

Start date Other symptoms of hypersensitivity reaction

Datatype

date

Similar models

Hypersensitivity Reaction Record GSK study Chronic Coronary Heart Disease NCT00799903

Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
Item Group
1. Event number
Event number
Item
Event number
text
Item Group
Past medical conditions: 2. Food allergies
Item
Anaphylactic reaction to food
integer
Code List
Anaphylactic reaction to food
CL Item
Past (2)
CL Item
No medical history (3)
Item
Angioedema
integer
Code List
Angioedema
CL Item
Past (2)
CL Item
No medical history (3)
Item
Urticaria
integer
CL Item
Past (2)
CL Item
No medical history (3)
Item Group
Past medical conditions: 3. Hymenoptera sting allergy
Code List
Anaphylaxis
CL Item
Past (2)
CL Item
No medical history (3)
Code List
Angioedema
CL Item
Past (2)
CL Item
No medical history (3)
CL Item
Past (2)
CL Item
No medical history (3)
Item Group
Past medical conditions: 4. Latex allergy
Item
Anaphylaxis
integer
Code List
Anaphylaxis
CL Item
Past (2)
CL Item
No medical history (3)
Item
Angioedema
integer
Code List
Angioedema
CL Item
Past (2)
CL Item
No medical history (3)
Item
Urticaria
integer
CL Item
Past (2)
CL Item
No medical history (3)
Item Group
Past medical conditions: 5. Penicillin allergy
Item
Anaphylactic reaction to drug
integer
Code List
Anaphylactic reaction to drug
CL Item
Past (2)
CL Item
No medical history (3)
Item
Angioedema
integer
Code List
Angioedema
CL Item
Past (2)
CL Item
No medical history (3)
Item
Drug induced urticaria
integer
Code List
Drug induced urticaria
CL Item
Past (2)
CL Item
No medical history (3)
Item Group
Past medical conditions: 6. Cephalosporin allergy
Item
Anaphylactic reaction to drug
integer
Code List
Anaphylactic reaction to drug
CL Item
Past (2)
CL Item
No medical history (3)
Item
Angioedema
integer
Code List
Angioedema
CL Item
Past (2)
CL Item
No medical history (3)
Item
Drug induced urticaria
integer
Code List
Drug induced urticaria
CL Item
Past (2)
CL Item
No medical history (3)
Item Group
Past medical conditions: 7. Aspirin allergy
Item
Anaphylactic reaction to drug
integer
Code List
Anaphylactic reaction to drug
CL Item
Past (2)
CL Item
No medical history (3)
Item
Angioedema
integer
Code List
Angioedema
CL Item
Past (2)
CL Item
No medical history (3)
Item
Drug induced urticaria
integer
Code List
Drug induced urticaria
CL Item
Past (2)
CL Item
No medical history (3)
Item Group
Past medical conditions: 8. NSAID allergy
Item
Anaphylactic reaction to drug
integer
Code List
Anaphylactic reaction to drug
CL Item
Past (2)
CL Item
No medical history (3)
Item
Angioedema
integer
Code List
Angioedema
CL Item
Past (2)
CL Item
No medical history (3)
Item
Drug induced urticaria
integer
Code List
Drug induced urticaria
CL Item
Past (2)
CL Item
No medical history (3)
Item Group
Past medical conditions: 9. ACE inhibitor allergy
Item
Anaphylactic reaction to drug
integer
Code List
Anaphylactic reaction to drug
CL Item
Past (2)
CL Item
No medical history (3)
Item
Angioedema
integer
Code List
Angioedema
CL Item
Past (2)
CL Item
No medical history (3)
Item
Drug induced urticaria
integer
Code List
Drug induced urticaria
CL Item
Past (2)
CL Item
No medical history (3)
Item Group
Other allergies
Specific Condition Other allergies
Item
10.a Specific Condition
text
Item
10.b Status
integer
Code List
10.b Status
CL Item
Past (2)
Item Group
Symptoms associated with this hypersensitivity reaction: 11. Stevens-Johnson syndrome
CL Item
None (None)
CL Item
Check all that apply (Check all that apply)
Blisters Stevens-Johnson syndrome
Item
Blisters
boolean
Biopsy confirmed Stevens-Johnson syndrome
Item
Biopsy confirmed
boolean
Mucous membrane involvement Stevens-Johnson syndrome
Item
Mucous membrane involvement
boolean
Stevens-Johnson syndrome Symptom start date
Item
Symptom start date
date
Item Group
Symptoms associated with this hypersensitivity reaction: 12. Toxic epidermal necrolysis
CL Item
None (None)
CL Item
Check all that apply (Check all that apply)
Blisters Toxic epidermal necrolysis
Item
Blisters
boolean
Biopsy confirmed Toxic epidermal necrolysis
Item
Biopsy confirmed
boolean
Mucous membrane involvement Toxic epidermal necrolysis
Item
Mucous membrane involvement
boolean
Symptom start date Toxic epidermal necrolysis
Item
Symptom start date
date
Item Group
Symptoms associated with this hypersensitivity reaction: 13. Urticaria (hives)
Item
Symptoms
text
CL Item
None (None)
CL Item
Check all that apply (Check all that apply)
Generalised Urticaria (hives)
Item
Generalised
boolean
Localised Urticaria (hives)
Item
Localised
boolean
Photosensitivity Urticaria (hives)
Item
Photosensitivity
boolean
Other symptoms Urticaria (hives)
Item
Other
boolean
Other symptoms Urticaria (hives) specification
Item
Other, specify
text
Symptom start date Urticaria (hives)
Item
Symptom start date
date
Item Group
Symptoms associated with this hypersensitivity reaction: 14. Angioedema
Item
Symptoms
text
CL Item
None (None)
CL Item
Check all that apply (Check all that apply)
Angioedema Face
Item
Face (including eyes, lips)
boolean
Angioedema Throat
Item
Throat (including tongue, larynx)
boolean
Angioedema Laryngeal
Item
Laryngeal
boolean
Angioedema Dyspnoea
Item
Dyspnoea
boolean
Angioedema Dysphagia
Item
Dysphagia
boolean
Angioedema Required intubation
Item
Required intubation
boolean
Angioedema Other symptoms
Item
Other
boolean
Angioedema Other symptoms specification
Item
Other, specify
text
Symptom start date Angioedema
Item
Symptom start date
date
Item Group
Symptoms associated with this hypersensitivity reaction: 15. Anaphylactic/Anaphylactoid reaction
CL Item
None (None)
CL Item
Check all that apply (Check all that apply)
Dyspnoea Anaphylactic/Anaphylactoid reaction
Item
Dyspnoea
boolean
Bronchospasm Anaphylactic/Anaphylactoid reaction
Item
Bronchospasm
boolean
Hypotension Anaphylactic/Anaphylactoid reaction
Item
Hypotension
boolean
Loss of consciousness Anaphylactic/Anaphylactoid reaction
Item
Loss of consciousness
boolean
Persistent gastrointestinal symptoms Anaphylactic/Anaphylactoid reaction
Item
Persistent gastrointestinal symptoms (crampy abdominal pain, vomiting)
boolean
Other symptoms Anaphylactic/Anaphylactoid reaction
Item
Other
boolean
Other symptoms specidication Anaphylactic/Anaphylactoid reaction
Item
Other, specify
text
Symptom start date Anaphylactic/Anaphylactoid reaction
Item
Symptom start date
date
Item Group
Symptoms associated with this hypersensitivity reaction: 16. Other symptoms of hypersensitivity reaction
CL Item
None (None)
CL Item
Check all that apply (Check all that apply)
Other symptoms of hypersensitivity reaction Rash
Item
Rash
boolean
Other symptoms of hypersensitivity reaction Photosensitivity
Item
Photosensitivity
boolean
Other symptoms of hypersensitivity reaction
Item
Other
boolean
Other symptoms of hypersensitivity reaction specification
Item
Other, specify
text
Start date Other symptoms of hypersensitivity reaction
Item
Symptom start date
date

Gebruik dit formulier voor feedback, vragen en verbeteringsvoorstellen.

Velden gemarkeerd met een * zijn verplicht.

Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

Watch Tutorial