ID

33832

Descrizione

Study ID: 107032 Clinical Study ID: GLP107032 Study Title: An open-label study to evaluate the pharmacokinetics of an oral contraceptive containing Norethindrone and Ethinyl Estradiol when co-administered with GSK716155 in healthy adult female subjects Patient Level Data: Study Listed on ClinicalStudyDataRequest.com Clinicaltrials.gov Identifier: NCT01077505 Sponsor: GlaxoSmithKline Collaborators: N/A Phase: Phase 1 Study Recruitment Status: Completed Generic Name: albiglutide Trade Name: Tanzeum,Eperzan Study Indication: Diabetes Mellitus, Type 2

Keywords

  1. 02/01/19 02/01/19 -
Titolare del copyright

GSK group of companies

Caricato su

2 gennaio 2019

DOI

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Licenza

Creative Commons BY-NC 3.0

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Pharmacokinetics of an oral contraceptive co-administered with Albiglutide in women - 107032

Various Adverse Events: Hypoglycemia, Injection Site Reaction, Pancreatitis, Thyroid Nodes

Administrative data
Descrizione

Administrative data

Site
Descrizione

Site

Tipo di dati

text

Subject
Descrizione

Subject

Tipo di dati

text

Visit Name
Descrizione

Visit Name

Tipo di dati

text

Status
Descrizione

Status

Tipo di dati

text

Document Number
Descrizione

Document Number

Tipo di dati

text

(Serious) Hypoglycaemic Events
Descrizione

(Serious) Hypoglycaemic Events

Has the subject experiences any protocol defined hypoglycaemic events?
Descrizione

any protocol defined hypoglycaemic events?

Tipo di dati

boolean

If Yes, please add Hypoglycaemic Event details on the following form.
Descrizione

If Yes, please add Hypoglycaemic Event details on the following form.

Tipo di dati

text

Serious Adverse Events
Descrizione

Serious Adverse Events

AE/SAE Reference Number
Descrizione

AE/SAE Reference Number

Tipo di dati

integer

Start date of Event
Descrizione

Start date of Event

Tipo di dati

date

Start Time of Event
Descrizione

Start Time of Event

Tipo di dati

time

End date of Event
Descrizione

End date of Event

Tipo di dati

date

End time of Event
Descrizione

End time of Event

Tipo di dati

time

Blood Glucose Test Result at Time of Event
Descrizione

Blood Glucose Test Result at Time of Event

Tipo di dati

text

Unit
Descrizione

Unit

Tipo di dati

text

Frequency
Descrizione

Frequency

Tipo di dati

text

Severity of hypoglycaemic event
Descrizione

per ADA group guidelines

Tipo di dati

text

If Severe, check all that apply:
Descrizione

at least one must be checked to fit the ADA criterion of severe

Tipo di dati

text

Record the number of hospitalization days
Descrizione

number of hospitalization days

Tipo di dati

integer

Enter the most severe intervention methods
Descrizione

Intervention

Tipo di dati

text

Action Taken with Background or Anti-Hyperglycaemic Medications section
Descrizione

if Yes, please update Anti-Hyperglycaemic Medications page

Tipo di dati

text

Injection Site Reaction
Descrizione

Injection Site Reaction

AE/SAE Number
Descrizione

AE/SAE Number

Tipo di dati

integer

Date of Injection
Descrizione

Date of Injection

Tipo di dati

date

Date of Reaction
Descrizione

Date of Reaction

Tipo di dati

date

Size of skin reaction - length
Descrizione

maximum

Tipo di dati

integer

Unità di misura
  • mm
mm
Size of skin reaction - width
Descrizione

maximum

Tipo di dati

integer

Unità di misura
  • mm
mm
Location of Injection
Descrizione

Location of Injection

Tipo di dati

text

If Other, specify
Descrizione

If Other, specify

Tipo di dati

text

Was the local reaction within 24 hrs of dose?
Descrizione

timeframe of local reaction

Tipo di dati

boolean

Redness / Erythema
Descrizione

Redness / Erythema

Tipo di dati

text

Itching / Pruritis
Descrizione

Itching / Pruritis

Tipo di dati

text

Raised
Descrizione

Raised

Tipo di dati

text

Warmth
Descrizione

Warmth

Tipo di dati

text

Other symptoms
Descrizione

Other symptoms

Tipo di dati

text

Specify Other symptoms
Descrizione

Specify Other symptoms

Tipo di dati

text

Was treatment given for this local reaction?
Descrizione

Was treatment given for this local reaction?

Tipo di dati

boolean

Was the serum sample obtained?
Descrizione

Subjects with a severe injection site reaction or a severe systemic allergic reaction must have three 1-mL serum samples obtained for immunogenicity testing.

Tipo di dati

boolean

If Yes, please provide date
Descrizione

If Yes, please provide date

Tipo di dati

date

Pancreatitis
Descrizione

Pancreatitis

AE/SAE Number
Descrizione

AE/SAE Number

Tipo di dati

integer

Date of Onset
Descrizione

Date of Onset

Tipo di dati

date

Was alcohol consumed on a regular basis?
Descrizione

Alcohol

Tipo di dati

text

Average number of units consumed daily
Descrizione

Average number of units consumed daily

Tipo di dati

integer

Is there a family history of Pancreatitis?
Descrizione

Family History of Pancreatitis

Tipo di dati

boolean

Grandmother (maternal)
Descrizione

Grandmother (maternal)

Tipo di dati

text

Grandfather (maternal)
Descrizione

Grandfather (maternal)

Tipo di dati

text

Grandmother (paternal)
Descrizione

Grandmother (paternal)

Tipo di dati

text

Grandfather (paternal)
Descrizione

Grandfather (paternal)

Tipo di dati

text

Mother
Descrizione

Mother

Tipo di dati

text

Father
Descrizione

Father

Tipo di dati

text

Sibling 1
Descrizione

Sibling 1

Tipo di dati

text

specify
Descrizione

specify

Tipo di dati

text

Sibling 2
Descrizione

Sibling 2

Tipo di dati

text

specify
Descrizione

specify

Tipo di dati

text

Other
Descrizione

Other

Tipo di dati

text

specify
Descrizione

specify

Tipo di dati

text

Recent Trauma / Vascular Invasive Procedures or Surgery
Descrizione

Recent Trauma / Vascular Invasive Procedures or Surgery

Tipo di dati

text

Date of Procedure
Descrizione

Date of Procedure

Tipo di dati

date

Recent Trauma / Vascular Invasive Procedures or Surgery
Descrizione

Recent Trauma / Vascular Invasive Procedures or Surgery

Tipo di dati

text

Date of Procedure
Descrizione

Date of Procedure

Tipo di dati

date

Recent Trauma / Vascular Invasive Procedures or Surgery
Descrizione

Recent Trauma / Vascular Invasive Procedures or Surgery

Tipo di dati

text

Date of Procedure
Descrizione

Date of Procedure

Tipo di dati

date

Symptoms of Gastrointestinal Illness Associated with Pancreatitis
Descrizione

Symptoms of Gastrointestinal Illness Associated with Pancreatitis

Check below all that apply
Descrizione

Check below all that apply

Tipo di dati

text

Pain in the Epigastrium
Descrizione

Pain in the Epigastrium

Date of Onset
Descrizione

Date of Onset

Tipo di dati

date

Ongoing?
Descrizione

Ongoing?

Tipo di dati

boolean

Date of Resolution
Descrizione

Date of Resolution

Tipo di dati

date

Pain in the Periumbical Region
Descrizione

Pain in the Periumbical Region

Date of Onset
Descrizione

Date of Onset

Tipo di dati

date

Ongoing?
Descrizione

Ongoing?

Tipo di dati

boolean

Date of Resolution
Descrizione

Date of Resolution

Tipo di dati

date

Pain in the Right Upper Quadrant
Descrizione

Pain in the Right Upper Quadrant

Date of Onset
Descrizione

Date of Onset

Tipo di dati

date

Ongoing?
Descrizione

Ongoing?

Tipo di dati

boolean

Date of Resolution
Descrizione

Date of Resolution

Tipo di dati

date

Pain in the Left Upper Quadrant
Descrizione

Pain in the Left Upper Quadrant

Date of Onset
Descrizione

Date of Onset

Tipo di dati

date

Ongoing?
Descrizione

Ongoing?

Tipo di dati

boolean

Date of Resolution
Descrizione

Date of Resolution

Tipo di dati

date

Pain in the Left Lower Quadrant
Descrizione

Pain in the Left Lower Quadrant

Date of Onset
Descrizione

Date of Onset

Tipo di dati

date

Ongoing?
Descrizione

Ongoing?

Tipo di dati

boolean

Date of Resolution
Descrizione

Date of Resolution

Tipo di dati

date

Pain in the Right Lower Quadrant
Descrizione

Pain in the Right Lower Quadrant

Date of Onset
Descrizione

Date of Onset

Tipo di dati

date

Ongoing?
Descrizione

Ongoing?

Tipo di dati

boolean

Date of Resolution
Descrizione

Date of Resolution

Tipo di dati

date

Pain in the Right Flank
Descrizione

Pain in the Right Flank

Date of Onset
Descrizione

Date of Onset

Tipo di dati

date

Ongoing?
Descrizione

Ongoing?

Tipo di dati

boolean

Date of Resolution
Descrizione

Date of Resolution

Tipo di dati

date

Pain in the Left Flank
Descrizione

Pain in the Left Flank

Date of Onset
Descrizione

Date of Onset

Tipo di dati

date

Ongoing?
Descrizione

Ongoing?

Tipo di dati

boolean

Date of Resolution
Descrizione

Date of Resolution

Tipo di dati

date

Pain in the Back
Descrizione

Pain in the Back

Date of Onset
Descrizione

Date of Onset

Tipo di dati

date

Ongoing?
Descrizione

Ongoing?

Tipo di dati

boolean

Date of Resolution
Descrizione

Date of Resolution

Tipo di dati

date

Other Symptoms
Descrizione

Other Symptoms

Specify symptom
Descrizione

Specify symptom

Tipo di dati

text

Date of Onset
Descrizione

Date of Onset

Tipo di dati

date

Ongoing?
Descrizione

Ongoing?

Tipo di dati

boolean

Date of Resolution
Descrizione

Date of Resolution

Tipo di dati

date

Nausea
Descrizione

Nausea

Date of Onset
Descrizione

Date of Onset

Tipo di dati

date

Ongoing?
Descrizione

Ongoing?

Tipo di dati

boolean

Date of Resolution
Descrizione

Date of Resolution

Tipo di dati

date

Vomiting
Descrizione

Vomiting

Date of Onset
Descrizione

Date of Onset

Tipo di dati

date

Ongoing?
Descrizione

Ongoing?

Tipo di dati

boolean

Date of Resolution
Descrizione

Date of Resolution

Tipo di dati

date

Fever
Descrizione

Fever

Temperature
Descrizione

Temperature

Tipo di dati

float

Unità di misura
  • °C
°C
Date of Onset
Descrizione

Date of Onset

Tipo di dati

date

Ongoing?
Descrizione

Ongoing?

Tipo di dati

boolean

Date of Resolution
Descrizione

Date of Resolution

Tipo di dati

date

Biochemistry
Descrizione

Biochemistry

Record lab results in corresponding categories below
Descrizione

Record lab results in corresponding categories below

Tipo di dati

text

Alkaline phosphatase
Descrizione

Alkaline phosphatase

Was lab test performed?
Descrizione

Was lab test performed?

Tipo di dati

boolean

Lab Test Result
Descrizione

Lab Test Result

Tipo di dati

text

Lab Unit
Descrizione

Lab Unit

Tipo di dati

text

Other lab unit, specify
Descrizione

Other lab unit, specify

Tipo di dati

text

Lab LLN
Descrizione

Lab LLN

Tipo di dati

text

Lab ULN
Descrizione

Lab ULN

Tipo di dati

text

Total bilirubin
Descrizione

Total bilirubin

Was lab test performed?
Descrizione

Was lab test performed?

Tipo di dati

boolean

Lab Test Result
Descrizione

Lab Test Result

Tipo di dati

text

Lab Unit
Descrizione

Lab Unit

Tipo di dati

text

Other lab unit, specify
Descrizione

Other lab unit, specify

Tipo di dati

text

Lab LLN
Descrizione

Lab LLN

Tipo di dati

text

Lab ULN
Descrizione

Lab ULN

Tipo di dati

text

Direct bilirubin
Descrizione

Direct bilirubin

Was lab test performed?
Descrizione

Was lab test performed?

Tipo di dati

boolean

Lab Test Result
Descrizione

Lab Test Result

Tipo di dati

text

Lab Unit
Descrizione

Lab Unit

Tipo di dati

text

Other lab unit, specify
Descrizione

Other lab unit, specify

Tipo di dati

text

Lab LLN
Descrizione

Lab LLN

Tipo di dati

text

Lab ULN
Descrizione

Lab ULN

Tipo di dati

text

Creatinine
Descrizione

Creatinine

Was lab test performed?
Descrizione

Was lab test performed?

Tipo di dati

boolean

Lab Test Result
Descrizione

Lab Test Result

Tipo di dati

text

Lab Unit
Descrizione

Lab Unit

Tipo di dati

text

Other lab unit, specify
Descrizione

Other lab unit, specify

Tipo di dati

text

Lab LLN
Descrizione

Lab LLN

Tipo di dati

text

Lab ULN
Descrizione

Lab ULN

Tipo di dati

text

Other lab test
Descrizione

Other lab test

Specify test
Descrizione

Specify test

Tipo di dati

text

Lab Test Result
Descrizione

Lab Test Result

Tipo di dati

text

Lab Unit
Descrizione

Lab Unit

Tipo di dati

text

Other lab unit, specify
Descrizione

Other lab unit, specify

Tipo di dati

text

Lab LLN
Descrizione

Lab LLN

Tipo di dati

text

Lab ULN
Descrizione

Lab ULN

Tipo di dati

text

Were additional Lab-Results Biochemistry evaluations performed?
Descrizione

Were additional Lab-Results Biochemistry evaluations performed?

Tipo di dati

boolean

Diagnostic Studies - Pancreatitis
Descrizione

Diagnostic Studies - Pancreatitis

Was Abdominal Ultrasound performed?
Descrizione

Was Abdominal Ultrasound performed?

Tipo di dati

boolean

Date of abdominal ultrasound
Descrizione

Date of abdominal ultrasound

Tipo di dati

date

If Yes, record the result
Descrizione

If Yes, record the result

Tipo di dati

text

Are there any evidence of cholelithiasis?
Descrizione

Are there any evidence of cholelithiasis?

Tipo di dati

text

Was an additional Abdominal Ultrasound performed?
Descrizione

Was an additional Abdominal Ultrasound performed?

Tipo di dati

boolean

Abdominal CT Scan
Descrizione

Abdominal CT Scan

Was an abdominal CT Scan performed?
Descrizione

Was an abdominal CT Scan performed?

Tipo di dati

boolean

If Yes, Date of Abdominal CT
Descrizione

If Yes, Date of Abdominal CT

Tipo di dati

date

Record overall results
Descrizione

Record overall results

Tipo di dati

text

If Abnormal, what are the diagnostic findings?
Descrizione

If Abnormal, what are the diagnostic findings?

Tipo di dati

text

Specify other
Descrizione

Specify other

Tipo di dati

text

Was an additional Abdominal CT Scan performed?
Descrizione

Was an additional Abdominal CT Scan performed?

Tipo di dati

boolean

MRI
Descrizione

MRI

Was MRI performed?
Descrizione

Was MRI performed?

Tipo di dati

boolean

Date of MRI
Descrizione

Date of MRI

Tipo di dati

date

Results of MRI
Descrizione

Results of MRI

Tipo di dati

text

If Abnormal, what was the diagnostic finding?
Descrizione

check all that apply

Tipo di dati

integer

Was additional MRI performed?
Descrizione

Was additional MRI performed?

Tipo di dati

boolean

New Thyroid Nodules
Descrizione

New Thyroid Nodules

Date of evaluation at which new nodule appeared
Descrizione

Date of evaluation at which new nodule appeared

Tipo di dati

date

AE/SAE Reference Number
Descrizione

AE/SAE Reference Number

Tipo di dati

integer

Type
Descrizione

Type

Tipo di dati

text

Location
Descrizione

Location

Tipo di dati

text

Bidimensional Measurement
Descrizione

Bidimensional Measurement

length
Descrizione

length

Tipo di dati

float

Unità di misura
  • cm
cm
width
Descrizione

width

Tipo di dati

float

Unità di misura
  • cm
cm
Thyroid Nodules AE Details
Descrizione

Thyroid Nodules AE Details

Was an action taken?
Descrizione

Was an action taken?

Tipo di dati

boolean

If Yes, please check all that apply
Descrizione

If Yes, please check all that apply

Tipo di dati

text

If Diagnostic Method was Fine Needle aspirate, please provide pathology results
Descrizione

check only one

Tipo di dati

text

If Malignant, thyroid cancer, check all that apply
Descrizione

If Malignant, thyroid cancer, check all that apply

Tipo di dati

text

Was an action taken due to fine needle aspirate pathology result?
Descrizione

Was an action taken due to fine needle aspirate pathology result?

Tipo di dati

boolean

If Yes, please provide details:
Descrizione

If Yes, please provide details:

Tipo di dati

text

Thyroid function tests
Descrizione

Thyroid function tests

Record the details below
Descrizione

Record the details below

Tipo di dati

boolean

Free T4
Descrizione

Free T4

Result
Descrizione

Result

Tipo di dati

text

Unit
Descrizione

Unit

Tipo di dati

text

LLN
Descrizione

LLN

Tipo di dati

text

ULN
Descrizione

ULN

Tipo di dati

text

T4
Descrizione

T4

Result
Descrizione

Result

Tipo di dati

text

Unit
Descrizione

Unit

Tipo di dati

text

LLN
Descrizione

LLN

Tipo di dati

text

ULN
Descrizione

ULN

Tipo di dati

text

TSH
Descrizione

TSH

Result
Descrizione

Result

Tipo di dati

text

Unit
Descrizione

Unit

Tipo di dati

text

LLN
Descrizione

LLN

Tipo di dati

text

ULN
Descrizione

ULN

Tipo di dati

text

Free T3
Descrizione

Free T3

Result
Descrizione

Result

Tipo di dati

text

Unit
Descrizione

Unit

Tipo di dati

text

LLN
Descrizione

LLN

Tipo di dati

text

ULN
Descrizione

ULN

Tipo di dati

text

T3 Uptake
Descrizione

T3 Uptake

Result
Descrizione

Result

Tipo di dati

text

Unit
Descrizione

Unit

Tipo di dati

text

LLN
Descrizione

LLN

Tipo di dati

text

ULN
Descrizione

ULN

Tipo di dati

text

Similar models

Various Adverse Events: Hypoglycemia, Injection Site Reaction, Pancreatitis, Thyroid Nodes

Name
genere
Description | Question | Decode (Coded Value)
Tipo di dati
Alias
Item Group
Administrative data
Site
Item
Site
text
Subject
Item
Subject
text
Item
Visit Name
text
Code List
Visit Name
CL Item
Hypoglycemia (1)
Status
Item
Status
text
Document Number
Item
Document Number
text
Item Group
(Serious) Hypoglycaemic Events
any protocol defined hypoglycaemic events?
Item
Has the subject experiences any protocol defined hypoglycaemic events?
boolean
If Yes, please add Hypoglycaemic Event details on the following form.
Item
If Yes, please add Hypoglycaemic Event details on the following form.
text
Item Group
Serious Adverse Events
AE/SAE Reference Number
Item
AE/SAE Reference Number
integer
Start date of Event
Item
Start date of Event
date
Start Time of Event
Item
Start Time of Event
time
End date of Event
Item
End date of Event
date
End time of Event
Item
End time of Event
time
Blood Glucose Test Result at Time of Event
Item
Blood Glucose Test Result at Time of Event
text
Item
Unit
text
Code List
Unit
CL Item
mg/dL (1)
CL Item
mmol/L (2)
Item
Frequency
text
Code List
Frequency
CL Item
Single episode (1)
CL Item
Intermittent (2)
Item
Severity of hypoglycaemic event
text
Code List
Severity of hypoglycaemic event
CL Item
Severe (1)
CL Item
Documented Symptomatic (2)
CL Item
Asymptomatic (3)
CL Item
Probable Symptomatic (4)
CL Item
Relative (5)
CL Item
Not Applicable (6)
Item
If Severe, check all that apply:
text
Code List
If Severe, check all that apply:
CL Item
Assistance provided to the subject by a non-healthcare professionals (e.g., relative or non-relative) at the location of the hypoglycemic event (1)
CL Item
Assistance provided to the subject by a healthcare professional (i.re., a nurse, physician, or emergency medical service was contacted and responded) at the location of the hypoglycemic event (2)
CL Item
Event required an unscheduled visit to the investigator (but did not require hospitalization) (3)
CL Item
Event required a visit to another healthcare professional (but did not require hospitalization) (4)
CL Item
The event required a visit to the emergency room (5)
CL Item
The subject required hospitalization (record the number of hospitalization days further) (6)
number of hospitalization days
Item
Record the number of hospitalization days
integer
Item
Enter the most severe intervention methods
text
Code List
Enter the most severe intervention methods
CL Item
None (1)
CL Item
Minor; Administered sugary drinks or sweets (2)
CL Item
Immediate; glucose drinks or supplements (3)
CL Item
Extensive; glucose injection/infusion/glucagon (4)
Item
Action Taken with Background or Anti-Hyperglycaemic Medications section
text
Code List
Action Taken with Background or Anti-Hyperglycaemic Medications section
CL Item
Yes (1)
CL Item
No (2)
CL Item
Not Applicable (3)
Item Group
Injection Site Reaction
AE/SAE Number
Item
AE/SAE Number
integer
Date of Injection
Item
Date of Injection
date
Date of Reaction
Item
Date of Reaction
date
Size of skin reaction - length
Item
Size of skin reaction - length
integer
Size of skin reaction - width
Item
Size of skin reaction - width
integer
Item
Location of Injection
text
Code List
Location of Injection
CL Item
Left abdomen (1)
CL Item
Right abdomen (2)
CL Item
Other (3)
If Other, specify
Item
If Other, specify
text
timeframe of local reaction
Item
Was the local reaction within 24 hrs of dose?
boolean
Item
Redness / Erythema
text
Code List
Redness / Erythema
CL Item
Mild (1)
CL Item
Moderate (2)
CL Item
Severe (3)
Item
Itching / Pruritis
text
Code List
Itching / Pruritis
CL Item
Mild (1)
CL Item
Moderate (2)
CL Item
Severe (3)
Item
Raised
text
Code List
Raised
CL Item
Mild (1)
CL Item
Moderate (2)
CL Item
Severe (3)
Item
Warmth
text
Code List
Warmth
CL Item
Mild (1)
CL Item
Moderate (2)
CL Item
Severe (3)
Item
Other symptoms
text
Code List
Other symptoms
CL Item
Mild (1)
CL Item
Moderate (2)
CL Item
Severe (3)
Specify Other symptoms
Item
Specify Other symptoms
text
Was treatment given for this local reaction?
Item
Was treatment given for this local reaction?
boolean
serum sample obtained?
Item
Was the serum sample obtained?
boolean
If Yes, please provide date
Item
If Yes, please provide date
date
Item Group
Pancreatitis
AE/SAE Number
Item
AE/SAE Number
integer
Date of Onset
Item
Date of Onset
date
Item
Was alcohol consumed on a regular basis?
text
Code List
Was alcohol consumed on a regular basis?
CL Item
Unknown (1)
CL Item
Yes (record the average number of units) (2)
CL Item
No (3)
Average number of units consumed daily
Item
Average number of units consumed daily
integer
Family History of Pancreatitis
Item
Is there a family history of Pancreatitis?
boolean
Item
Grandmother (maternal)
text
Code List
Grandmother (maternal)
CL Item
Unknown (1)
CL Item
Yes (2)
CL Item
No (3)
Item
Grandfather (maternal)
text
Code List
Grandfather (maternal)
CL Item
Unknown (1)
CL Item
Yes (2)
CL Item
No (3)
Item
Grandmother (paternal)
text
Code List
Grandmother (paternal)
CL Item
Unknown (1)
CL Item
Yes (2)
CL Item
No (3)
Item
Grandfather (paternal)
text
Code List
Grandfather (paternal)
CL Item
Unknown (1)
CL Item
Yes (2)
CL Item
No (3)
Item
Mother
text
Code List
Mother
CL Item
Unknown (1)
CL Item
Yes (2)
CL Item
No (3)
Item
Father
text
Code List
Father
CL Item
Unknown (1)
CL Item
Yes (2)
CL Item
No (3)
Item
Sibling 1
text
Code List
Sibling 1
CL Item
Unknown (1)
CL Item
Yes (2)
CL Item
No (3)
specify
Item
specify
text
Item
Sibling 2
text
Code List
Sibling 2
CL Item
Unknown (1)
CL Item
Yes (2)
CL Item
No (3)
specify
Item
specify
text
Item
Other
text
Code List
Other
CL Item
Unknown (1)
CL Item
Yes (2)
CL Item
No (3)
specify
Item
specify
text
Recent Trauma / Vascular Invasive Procedures or Surgery
Item
Recent Trauma / Vascular Invasive Procedures or Surgery
text
Date of Procedure
Item
Date of Procedure
date
Recent Trauma / Vascular Invasive Procedures or Surgery
Item
Recent Trauma / Vascular Invasive Procedures or Surgery
text
Date of Procedure
Item
Date of Procedure
date
Recent Trauma / Vascular Invasive Procedures or Surgery
Item
Recent Trauma / Vascular Invasive Procedures or Surgery
text
Date of Procedure
Item
Date of Procedure
date
Item Group
Symptoms of Gastrointestinal Illness Associated with Pancreatitis
Check below all that apply
Item
text
Item Group
Pain in the Epigastrium
Date of Onset
Item
Date of Onset
date
Ongoing?
Item
Ongoing?
boolean
Date of Resolution
Item
Date of Resolution
date
Item Group
Pain in the Periumbical Region
Date of Onset
Item
Date of Onset
date
Ongoing?
Item
Ongoing?
boolean
Date of Resolution
Item
Date of Resolution
date
Item Group
Pain in the Right Upper Quadrant
Date of Onset
Item
Date of Onset
date
Ongoing?
Item
Ongoing?
boolean
Date of Resolution
Item
Date of Resolution
date
Item Group
Pain in the Left Upper Quadrant
Date of Onset
Item
Date of Onset
date
Ongoing?
Item
Ongoing?
boolean
Date of Resolution
Item
Date of Resolution
date
Item Group
Pain in the Left Lower Quadrant
Date of Onset
Item
Date of Onset
date
Ongoing?
Item
Ongoing?
boolean
Date of Resolution
Item
Date of Resolution
date
Item Group
Pain in the Right Lower Quadrant
Date of Onset
Item
Date of Onset
date
Ongoing?
Item
Ongoing?
boolean
Date of Resolution
Item
Date of Resolution
date
Item Group
Pain in the Right Flank
Date of Onset
Item
Date of Onset
date
Ongoing?
Item
Ongoing?
boolean
Date of Resolution
Item
Date of Resolution
date
Item Group
Pain in the Left Flank
Date of Onset
Item
Date of Onset
date
Ongoing?
Item
Ongoing?
boolean
Date of Resolution
Item
Date of Resolution
date
Item Group
Pain in the Back
Date of Onset
Item
Date of Onset
date
Ongoing?
Item
Ongoing?
boolean
Date of Resolution
Item
Date of Resolution
date
Item Group
Other Symptoms
Item
Specify symptom
text
Code List
Specify symptom
Date of Onset
Item
Date of Onset
date
Ongoing?
Item
Ongoing?
boolean
Date of Resolution
Item
Date of Resolution
date
Item Group
Nausea
Date of Onset
Item
Date of Onset
date
Ongoing?
Item
Ongoing?
boolean
Date of Resolution
Item
Date of Resolution
date
Item Group
Vomiting
Date of Onset
Item
Date of Onset
date
Ongoing?
Item
Ongoing?
boolean
Date of Resolution
Item
Date of Resolution
date
Item Group
Fever
Temperature
Item
Temperature
float
Date of Onset
Item
Date of Onset
date
Ongoing?
Item
Ongoing?
boolean
Date of Resolution
Item
Date of Resolution
date
Item Group
Biochemistry
Record lab results in corresponding categories below
Item
Record lab results in corresponding categories below
text
Item Group
Alkaline phosphatase
Was lab test performed?
Item
Was lab test performed?
boolean
Lab Test Result
Item
Lab Test Result
text
Lab Unit
Item
Lab Unit
text
Other lab unit, specify
Item
Other lab unit, specify
text
Lab LLN
Item
Lab LLN
text
Lab ULN
Item
Lab ULN
text
Item Group
Total bilirubin
Was lab test performed?
Item
Was lab test performed?
boolean
Lab Test Result
Item
Lab Test Result
text
Lab Unit
Item
Lab Unit
text
Other lab unit, specify
Item
Other lab unit, specify
text
Lab LLN
Item
Lab LLN
text
Lab ULN
Item
Lab ULN
text
Item Group
Direct bilirubin
Was lab test performed?
Item
Was lab test performed?
boolean
Lab Test Result
Item
Lab Test Result
text
Lab Unit
Item
Lab Unit
text
Other lab unit, specify
Item
Other lab unit, specify
text
Lab LLN
Item
Lab LLN
text
Lab ULN
Item
Lab ULN
text
Item Group
Creatinine
Was lab test performed?
Item
Was lab test performed?
boolean
Lab Test Result
Item
Lab Test Result
text
Lab Unit
Item
Lab Unit
text
Other lab unit, specify
Item
Other lab unit, specify
text
Lab LLN
Item
Lab LLN
text
Lab ULN
Item
Lab ULN
text
Item Group
Other lab test
Specify test
Item
Specify test
text
Lab Test Result
Item
Lab Test Result
text
Lab Unit
Item
Lab Unit
text
Other lab unit, specify
Item
Other lab unit, specify
text
Lab LLN
Item
Lab LLN
text
Lab ULN
Item
Lab ULN
text
Were additional Lab-Results Biochemistry evaluations performed?
Item
Were additional Lab-Results Biochemistry evaluations performed?
boolean
Item Group
Diagnostic Studies - Pancreatitis
Was Abdominal Ultrasound performed?
Item
Was Abdominal Ultrasound performed?
boolean
Date of abdominal ultrasound
Item
Date of abdominal ultrasound
date
Item
If Yes, record the result
text
Code List
If Yes, record the result
CL Item
Normal (1)
CL Item
Abnormal (2)
Item
Are there any evidence of cholelithiasis?
text
Code List
Are there any evidence of cholelithiasis?
CL Item
Unknown (1)
CL Item
Yes (2)
CL Item
No (3)
Was an additional Abdominal Ultrasound performed?
Item
Was an additional Abdominal Ultrasound performed?
boolean
Item Group
Abdominal CT Scan
Was an abdominal CT Scan performed?
Item
Was an abdominal CT Scan performed?
boolean
If Yes, Date of Abdominal CT
Item
If Yes, Date of Abdominal CT
date
Item
Record overall results
text
Code List
Record overall results
CL Item
Normal (1)
CL Item
Abnormal (2)
Item
If Abnormal, what are the diagnostic findings?
text
Code List
If Abnormal, what are the diagnostic findings?
CL Item
Unknown (1)
CL Item
Cholelithiasis (2)
CL Item
Pancreatic fluid collection (3)
CL Item
Pseudocysts (4)
CL Item
Edema of the small bowel mesentery (5)
CL Item
Pancreatic necrosis (6)
CL Item
Focal edema of the pancreas (7)
CL Item
Other (8)
Specify other
Item
Specify other
text
Was an additional Abdominal CT Scan performed?
Item
Was an additional Abdominal CT Scan performed?
boolean
Item Group
MRI
Was MRI performed?
Item
Was MRI performed?
boolean
Date of MRI
Item
Date of MRI
date
Item
Results of MRI
text
Code List
Results of MRI
CL Item
Normal (1)
CL Item
Abnormal (2)
Item
If Abnormal, what was the diagnostic finding?
integer
Code List
If Abnormal, what was the diagnostic finding?
CL Item
Unknown (1)
CL Item
Cholelithiasis (2)
CL Item
Pancreatic fluid collection (3)
CL Item
Pseudocysts (4)
CL Item
Edema of the small bowel mesentery (5)
CL Item
Pancreatic necrosis (6)
CL Item
Focal edema of the pancreas (7)
CL Item
Diffuse edema of the pancreas (8)
CL Item
Other (9)
Was additional MRI performed?
Item
Was additional MRI performed?
boolean
Item Group
New Thyroid Nodules
Date of evaluation at which new nodule appeared
Item
Date of evaluation at which new nodule appeared
date
AE/SAE Reference Number
Item
AE/SAE Reference Number
integer
Item
Type
text
Code List
Type
CL Item
Solitary nodule (1)
CL Item
Multinodular (2)
Item
Location
text
Code List
Location
CL Item
Right upper lobe (1)
CL Item
Left upper lobe (2)
CL Item
Right lower lobe (3)
CL Item
Left lower lobe (4)
CL Item
Isthmus (5)
Item Group
Bidimensional Measurement
length
Item
length
float
width
Item
width
float
Item Group
Thyroid Nodules AE Details
Was an action taken?
Item
Was an action taken?
boolean
Item
If Yes, please check all that apply
text
Code List
If Yes, please check all that apply
CL Item
Ultrasound (1)
CL Item
RIU (2)
CL Item
Technetium scan (3)
CL Item
Physical exam (4)
CL Item
Fine needle aspirate (5)
CL Item
Surgery (6)
CL Item
Thyroid function tests (7)
Item
If Diagnostic Method was Fine Needle aspirate, please provide pathology results
text
Code List
If Diagnostic Method was Fine Needle aspirate, please provide pathology results
CL Item
Non-diagnostic (1)
CL Item
Benign (2)
CL Item
Malignant, thyroid cancer (3)
Item
If Malignant, thyroid cancer, check all that apply
text
Code List
If Malignant, thyroid cancer, check all that apply
CL Item
Papillary (1)
CL Item
Follicular (2)
CL Item
Metastatic (3)
CL Item
Medullary (4)
CL Item
Aplastic (5)
Was an action taken due to fine needle aspirate pathology result?
Item
Was an action taken due to fine needle aspirate pathology result?
boolean
If Yes, please provide details:
Item
If Yes, please provide details:
text
Item Group
Thyroid function tests
Record the details below
Item
Record the details below
boolean
Item Group
Free T4
Result
Item
Result
text
Unit
Item
Unit
text
LLN
Item
LLN
text
ULN
Item
ULN
text
Item Group
T4
Result
Item
Result
text
Unit
Item
Unit
text
LLN
Item
LLN
text
ULN
Item
ULN
text
Item Group
TSH
Result
Item
Result
text
Unit
Item
Unit
text
LLN
Item
LLN
text
ULN
Item
ULN
text
Item Group
Free T3
Result
Item
Result
text
Unit
Item
Unit
text
LLN
Item
LLN
text
ULN
Item
ULN
text
Item Group
T3 Uptake
Result
Item
Result
text
Unit
Item
Unit
text
LLN
Item
LLN
text
ULN
Item
ULN
text

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