Informações:
Falhas:
ID
29434
Descrição
Long term follow-up, Visit 6 Month 30, Serious adverse events Study ID: 101695 Ext. Mth30 Clinical Study ID: 101695 Study Title: Long-term study of immune response persistence of GSK Biologicals' 2-dose thiomersal-free Engerix™-B and 3-dose preservative-free Engerix™-B vaccines in subjects aged 11-15 yrs Patient Level Data: Study Listed on ClinicalStudyDataRequest.com Clinicaltrials.gov Identifier: NCT00343915 Sponsor: GlaxoSmithKline Collaborators: N/A Phase: Phase 3 Study Recruitment Status: Completed Generic Name: Hepatitis B Vaccine, Recombinant Trade Name: BIO HBV; Engerix-B Study Indication: Hepatitis B
Palavras-chave
Versões (1)
- 24/03/2018 24/03/2018 -
Titular dos direitos
GlaxoSmithKline (GSK)
Transferido a
24 de março de 2018
DOI
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Licença
Creative Commons BY-NC 3.0
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GSK Biologicals' 2-dose thiomersal-free Engerix™-B and 3-dose preservative-free Engerix™-B vaccines Study ID: 101695 NCT00343915
Long term follow-up, Visit 6 Month 30, Serious adverse events
- StudyEvent: ODM
Similar models
Long term follow-up, Visit 6 Month 30, Serious adverse events
- StudyEvent: ODM
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de dados
Alias
CL Item
Initial report (1)
CL Item
Additional info (2)
CL Item
Additional info (3)
CL Item
Additional info (4)
Initials
Item
Initials:
text
C2986440 (UMLS CUI [1])
Date of birth
Item
Date of birth:
date
C0421451 (UMLS CUI [1])
CL Item
Male (1)
CL Item
Female (2)
Adverse event diagnosis
Item
Adverse Event (please print clearly) Diagnosis (or signs and symptoms if not known)
text
C0877248 (UMLS CUI [1])
Start date/time
Item
Date and time started: (Adverse event first symptoms)
datetime
C0808070 (UMLS CUI [1])
C1301880 (UMLS CUI [2])
C1301880 (UMLS CUI [2])
End date/time
Item
Date and time stopped: (If ongoing please leave blank)
datetime
C2826793 (UMLS CUI [1])
CL Item
1 (1)
CL Item
2 (2)
CL Item
3 (3)
Item
Specify criteria for considering this as a Serious Adverse Event. (mark all that apply).
integer
C1519255 (UMLS CUI [1])
Code List
Specify criteria for considering this as a Serious Adverse Event. (mark all that apply).
CL Item
Result in death (1)
CL Item
Life threatening (2)
CL Item
Result in persistent or significant disability/incapacity (3)
CL Item
Requires in-patient hospitalization. (4)
CL Item
Prolongation of existing hospitalization (5)
CL Item
Congenital anomaly / birth defect in the offspring of a study subject. (6)
CL Item
“Medically important” event (7)
Autopsy
Item
Autopsy?
boolean
C0004398 (UMLS CUI [1])
Hospitalization
Item
Hospitalization Admission date
boolean
C0011008 (UMLS CUI [1,1])
C0019993 (UMLS CUI [1,2])
C0019993 (UMLS CUI [1,2])
Hospitalization
Item
Hospitalization Discharge date
date
C0011008 (UMLS CUI [1,1])
C0019993 (UMLS CUI [1,2])
C0019993 (UMLS CUI [1,2])
Prolongation of Hospitalization
Item
Prolongation of Hospitalization: Discharge date
date
C0745041 (UMLS CUI [1,1])
C2361123 (UMLS CUI [1,2])
C2361123 (UMLS CUI [1,2])
Cancer
Item
Other events (not SAE) to be reported in the same way: Cancer
boolean
C0006826 (UMLS CUI [1])
Vaccine contribution
Item
In your opinion, did the vaccine possibly contribute to the SAE:
boolean
C1519255 (UMLS CUI [1,1])
C1880177 (UMLS CUI [1,2])
C0042210 (UMLS CUI [1,3])
C1880177 (UMLS CUI [1,2])
C0042210 (UMLS CUI [1,3])
Item
Other possible contributors: (mark all that apply)
integer
C0085978 (UMLS CUI [1,1])
C1519255 (UMLS CUI [1,2])
C1519255 (UMLS CUI [1,2])
CL Item
Medical history (record in section 15) (1)
(Comment:en)
CL Item
Other medication (record in section 14) (2)
(Comment:en)
CL Item
Protocol required procedure (3)
(Comment:en)
CL Item
Other procedure (4)
(Comment:en)
CL Item
Lack of efficacy (5)
(Comment:en)
CL Item
Erroneous administration (6)
(Comment:en)
CL Item
Other, specify: _________________ (record additional information in section 19) (7)
(Comment:en)
CL Item
Recovered (1)
CL Item
Recovered with sequelae (2)
CL Item
Ongoing (3)
CL Item
Died (4)
CL Item
None (1)
CL Item
Vaccination course postponed (2)
CL Item
Vaccination course stopped (3)
Item
Events after further vaccination
integer
C0042196 (UMLS CUI [1,1])
C0700325 (UMLS CUI [1,2])
C0877248 (UMLS CUI [1,3])
C0700325 (UMLS CUI [1,2])
C0877248 (UMLS CUI [1,3])
CL Item
Event reappeared (1)
CL Item
Event did not reappear (2)
CL Item
Unknown at this time (3)
CL Item
Not applicable (4)
Subject withdrawal
Item
Was subject withdrawn due to this specific SAE?
boolean
C0422727 (UMLS CUI [1])
C1710677 (UMLS CUI [2,1])
C1519255 (UMLS CUI [2,2])
C1710677 (UMLS CUI [2,1])
C1519255 (UMLS CUI [2,2])
Vaccine
Item
Vaccine (specify mixed or separate)
text
C0042210 (UMLS CUI [1])
Dose No
Item
Dose No
integer
C3174092 (UMLS CUI [1,1])
C0449788 (UMLS CUI [1,2])
C0042210 (UMLS CUI [1,3])
C0449788 (UMLS CUI [1,2])
C0042210 (UMLS CUI [1,3])
Lot No
Item
Lot No
integer
C2826710 (UMLS CUI [1,1])
C0042210 (UMLS CUI [1,2])
C0042210 (UMLS CUI [1,2])
Route / Site
Item
Route / Site
text
C1515974 (UMLS CUI [1,1])
C0042210 (UMLS CUI [1,2])
C0013153 (UMLS CUI [2,1])
C0042210 (UMLS CUI [2,2])
C0042210 (UMLS CUI [1,2])
C0013153 (UMLS CUI [2,1])
C0042210 (UMLS CUI [2,2])
Date
Item
Date
date
C0011008 (UMLS CUI [1,1])
C0042196 (UMLS CUI [1,2])
C0042196 (UMLS CUI [1,2])
Item Group
Concomitant medication / vaccination that could have contributed to this SAE
C2347852 (UMLS CUI-1)
C1519255 (UMLS CUI-2)
C1519255 (UMLS CUI-2)
Drug / vaccine
Item
Drug / vaccine
text
C2347852 (UMLS CUI [1])
Dosage
Item
Dosage
text
C0178602 (UMLS CUI [1])
Frequency
Item
Frequency
text
C3476109 (UMLS CUI [1])
Route
Item
Route
text
C0013153 (UMLS CUI [1])
Start date
Item
Start date
date
C0808070 (UMLS CUI [1])
End date
Item
End date
date
C0806020 (UMLS CUI [1])
Item Group
Relevant intercurrent illness & medical history that could have contributed to this SAE (Including allergies)
C3640977 (UMLS CUI-1)
Condition
Item
Condition:
text
C0012634 (UMLS CUI [1])
Presence of disease
Item
Still present?
boolean
C0012634 (UMLS CUI [1,1])
C0150312 (UMLS CUI [1,2])
C0150312 (UMLS CUI [1,2])
Item Group
Drug(s) used to treat this SAE
C0013227 (UMLS CUI-1)
C0087111 (UMLS CUI-2)
C1519255 (UMLS CUI-3)
C0087111 (UMLS CUI-2)
C1519255 (UMLS CUI-3)
Drug
Item
Drug
text
C2347852 (UMLS CUI [1])
Dosage
Item
Dosage
text
C0178602 (UMLS CUI [1])
Frequency
Item
Frequency
text
C3476109 (UMLS CUI [1])
Start date
Item
Start date
date
C0808070 (UMLS CUI [1])
End date
Item
End date
date
C0806020 (UMLS CUI [1])
Surgical treatment for SAE
Item
Surgical treatment for this SAE (please specify)
text
C0543467 (UMLS CUI [1,1])
C1519255 (UMLS CUI [1,2])
C1519255 (UMLS CUI [1,2])
Item Group
SAE administative information
C1519255 (UMLS CUI-1)
C0684224 (UMLS CUI-2)
C0684224 (UMLS CUI-2)
Description of SAE
Item
Description (provide a brief narrative description of the SAE including relevant diagnostic findings, lab data & evolution of the events etc…)
text
C1519255 (UMLS CUI [1,1])
C0678257 (UMLS CUI [1,2])
C0678257 (UMLS CUI [1,2])
Comments
Item
Comments (provide further comments concerning the case)
text
C0947611 (UMLS CUI [1])
Investigator signature
Item
Investigator signature
text
C2346576 (UMLS CUI [1])
Date
Item
Date
date
C0011008 (UMLS CUI [1])
Investigator name
Item
Please PRINT name:
text
C2826892 (UMLS CUI [1])
Clinical Development Manager: Signature
Item
Clinical Development Manager: Signature
text
C1519316 (UMLS CUI [1,1])
C0681803 (UMLS CUI [1,2])
C0681803 (UMLS CUI [1,2])
Clinical Development Manager: Name
Item
Clinical Development Manager: Please PRINT name
text
C0027365 (UMLS CUI [1,1])
C0681803 (UMLS CUI [1,2])
C0681803 (UMLS CUI [1,2])
Date
Item
Date
date
C0011008 (UMLS CUI [1])
AEGIS Number
Item
AEGIS Number:
integer
C0600091 (UMLS CUI [1,1])
C0679918 (UMLS CUI [1,2])
C0679918 (UMLS CUI [1,2])