ID

33832

Beschrijving

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

Trefwoorden

  1. 02-01-19 02-01-19 -
Houder van rechten

GSK group of companies

Geüploaded op

2 januari 2019

DOI

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Licentie

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
Beschrijving

Administrative data

Site
Beschrijving

Site

Datatype

text

Subject
Beschrijving

Subject

Datatype

text

Visit Name
Beschrijving

Visit Name

Datatype

text

Status
Beschrijving

Status

Datatype

text

Document Number
Beschrijving

Document Number

Datatype

text

(Serious) Hypoglycaemic Events
Beschrijving

(Serious) Hypoglycaemic Events

Has the subject experiences any protocol defined hypoglycaemic events?
Beschrijving

any protocol defined hypoglycaemic events?

Datatype

boolean

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

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

Datatype

text

Serious Adverse Events
Beschrijving

Serious Adverse Events

AE/SAE Reference Number
Beschrijving

AE/SAE Reference Number

Datatype

integer

Start date of Event
Beschrijving

Start date of Event

Datatype

date

Start Time of Event
Beschrijving

Start Time of Event

Datatype

time

End date of Event
Beschrijving

End date of Event

Datatype

date

End time of Event
Beschrijving

End time of Event

Datatype

time

Blood Glucose Test Result at Time of Event
Beschrijving

Blood Glucose Test Result at Time of Event

Datatype

text

Unit
Beschrijving

Unit

Datatype

text

Frequency
Beschrijving

Frequency

Datatype

text

Severity of hypoglycaemic event
Beschrijving

per ADA group guidelines

Datatype

text

If Severe, check all that apply:
Beschrijving

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

Datatype

text

Record the number of hospitalization days
Beschrijving

number of hospitalization days

Datatype

integer

Enter the most severe intervention methods
Beschrijving

Intervention

Datatype

text

Action Taken with Background or Anti-Hyperglycaemic Medications section
Beschrijving

if Yes, please update Anti-Hyperglycaemic Medications page

Datatype

text

Injection Site Reaction
Beschrijving

Injection Site Reaction

AE/SAE Number
Beschrijving

AE/SAE Number

Datatype

integer

Date of Injection
Beschrijving

Date of Injection

Datatype

date

Date of Reaction
Beschrijving

Date of Reaction

Datatype

date

Size of skin reaction - length
Beschrijving

maximum

Datatype

integer

Maateenheden
  • mm
mm
Size of skin reaction - width
Beschrijving

maximum

Datatype

integer

Maateenheden
  • mm
mm
Location of Injection
Beschrijving

Location of Injection

Datatype

text

If Other, specify
Beschrijving

If Other, specify

Datatype

text

Was the local reaction within 24 hrs of dose?
Beschrijving

timeframe of local reaction

Datatype

boolean

Redness / Erythema
Beschrijving

Redness / Erythema

Datatype

text

Itching / Pruritis
Beschrijving

Itching / Pruritis

Datatype

text

Raised
Beschrijving

Raised

Datatype

text

Warmth
Beschrijving

Warmth

Datatype

text

Other symptoms
Beschrijving

Other symptoms

Datatype

text

Specify Other symptoms
Beschrijving

Specify Other symptoms

Datatype

text

Was treatment given for this local reaction?
Beschrijving

Was treatment given for this local reaction?

Datatype

boolean

Was the serum sample obtained?
Beschrijving

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

Datatype

boolean

If Yes, please provide date
Beschrijving

If Yes, please provide date

Datatype

date

Pancreatitis
Beschrijving

Pancreatitis

AE/SAE Number
Beschrijving

AE/SAE Number

Datatype

integer

Date of Onset
Beschrijving

Date of Onset

Datatype

date

Was alcohol consumed on a regular basis?
Beschrijving

Alcohol

Datatype

text

Average number of units consumed daily
Beschrijving

Average number of units consumed daily

Datatype

integer

Is there a family history of Pancreatitis?
Beschrijving

Family History of Pancreatitis

Datatype

boolean

Grandmother (maternal)
Beschrijving

Grandmother (maternal)

Datatype

text

Grandfather (maternal)
Beschrijving

Grandfather (maternal)

Datatype

text

Grandmother (paternal)
Beschrijving

Grandmother (paternal)

Datatype

text

Grandfather (paternal)
Beschrijving

Grandfather (paternal)

Datatype

text

Mother
Beschrijving

Mother

Datatype

text

Father
Beschrijving

Father

Datatype

text

Sibling 1
Beschrijving

Sibling 1

Datatype

text

specify
Beschrijving

specify

Datatype

text

Sibling 2
Beschrijving

Sibling 2

Datatype

text

specify
Beschrijving

specify

Datatype

text

Other
Beschrijving

Other

Datatype

text

specify
Beschrijving

specify

Datatype

text

Recent Trauma / Vascular Invasive Procedures or Surgery
Beschrijving

Recent Trauma / Vascular Invasive Procedures or Surgery

Datatype

text

Date of Procedure
Beschrijving

Date of Procedure

Datatype

date

Recent Trauma / Vascular Invasive Procedures or Surgery
Beschrijving

Recent Trauma / Vascular Invasive Procedures or Surgery

Datatype

text

Date of Procedure
Beschrijving

Date of Procedure

Datatype

date

Recent Trauma / Vascular Invasive Procedures or Surgery
Beschrijving

Recent Trauma / Vascular Invasive Procedures or Surgery

Datatype

text

Date of Procedure
Beschrijving

Date of Procedure

Datatype

date

Symptoms of Gastrointestinal Illness Associated with Pancreatitis
Beschrijving

Symptoms of Gastrointestinal Illness Associated with Pancreatitis

Check below all that apply
Beschrijving

Check below all that apply

Datatype

text

Pain in the Epigastrium
Beschrijving

Pain in the Epigastrium

Date of Onset
Beschrijving

Date of Onset

Datatype

date

Ongoing?
Beschrijving

Ongoing?

Datatype

boolean

Date of Resolution
Beschrijving

Date of Resolution

Datatype

date

Pain in the Periumbical Region
Beschrijving

Pain in the Periumbical Region

Date of Onset
Beschrijving

Date of Onset

Datatype

date

Ongoing?
Beschrijving

Ongoing?

Datatype

boolean

Date of Resolution
Beschrijving

Date of Resolution

Datatype

date

Pain in the Right Upper Quadrant
Beschrijving

Pain in the Right Upper Quadrant

Date of Onset
Beschrijving

Date of Onset

Datatype

date

Ongoing?
Beschrijving

Ongoing?

Datatype

boolean

Date of Resolution
Beschrijving

Date of Resolution

Datatype

date

Pain in the Left Upper Quadrant
Beschrijving

Pain in the Left Upper Quadrant

Date of Onset
Beschrijving

Date of Onset

Datatype

date

Ongoing?
Beschrijving

Ongoing?

Datatype

boolean

Date of Resolution
Beschrijving

Date of Resolution

Datatype

date

Pain in the Left Lower Quadrant
Beschrijving

Pain in the Left Lower Quadrant

Date of Onset
Beschrijving

Date of Onset

Datatype

date

Ongoing?
Beschrijving

Ongoing?

Datatype

boolean

Date of Resolution
Beschrijving

Date of Resolution

Datatype

date

Pain in the Right Lower Quadrant
Beschrijving

Pain in the Right Lower Quadrant

Date of Onset
Beschrijving

Date of Onset

Datatype

date

Ongoing?
Beschrijving

Ongoing?

Datatype

boolean

Date of Resolution
Beschrijving

Date of Resolution

Datatype

date

Pain in the Right Flank
Beschrijving

Pain in the Right Flank

Date of Onset
Beschrijving

Date of Onset

Datatype

date

Ongoing?
Beschrijving

Ongoing?

Datatype

boolean

Date of Resolution
Beschrijving

Date of Resolution

Datatype

date

Pain in the Left Flank
Beschrijving

Pain in the Left Flank

Date of Onset
Beschrijving

Date of Onset

Datatype

date

Ongoing?
Beschrijving

Ongoing?

Datatype

boolean

Date of Resolution
Beschrijving

Date of Resolution

Datatype

date

Pain in the Back
Beschrijving

Pain in the Back

Date of Onset
Beschrijving

Date of Onset

Datatype

date

Ongoing?
Beschrijving

Ongoing?

Datatype

boolean

Date of Resolution
Beschrijving

Date of Resolution

Datatype

date

Other Symptoms
Beschrijving

Other Symptoms

Specify symptom
Beschrijving

Specify symptom

Datatype

text

Date of Onset
Beschrijving

Date of Onset

Datatype

date

Ongoing?
Beschrijving

Ongoing?

Datatype

boolean

Date of Resolution
Beschrijving

Date of Resolution

Datatype

date

Nausea
Beschrijving

Nausea

Date of Onset
Beschrijving

Date of Onset

Datatype

date

Ongoing?
Beschrijving

Ongoing?

Datatype

boolean

Date of Resolution
Beschrijving

Date of Resolution

Datatype

date

Vomiting
Beschrijving

Vomiting

Date of Onset
Beschrijving

Date of Onset

Datatype

date

Ongoing?
Beschrijving

Ongoing?

Datatype

boolean

Date of Resolution
Beschrijving

Date of Resolution

Datatype

date

Fever
Beschrijving

Fever

Temperature
Beschrijving

Temperature

Datatype

float

Maateenheden
  • °C
°C
Date of Onset
Beschrijving

Date of Onset

Datatype

date

Ongoing?
Beschrijving

Ongoing?

Datatype

boolean

Date of Resolution
Beschrijving

Date of Resolution

Datatype

date

Biochemistry
Beschrijving

Biochemistry

Record lab results in corresponding categories below
Beschrijving

Record lab results in corresponding categories below

Datatype

text

Alkaline phosphatase
Beschrijving

Alkaline phosphatase

Was lab test performed?
Beschrijving

Was lab test performed?

Datatype

boolean

Lab Test Result
Beschrijving

Lab Test Result

Datatype

text

Lab Unit
Beschrijving

Lab Unit

Datatype

text

Other lab unit, specify
Beschrijving

Other lab unit, specify

Datatype

text

Lab LLN
Beschrijving

Lab LLN

Datatype

text

Lab ULN
Beschrijving

Lab ULN

Datatype

text

Total bilirubin
Beschrijving

Total bilirubin

Was lab test performed?
Beschrijving

Was lab test performed?

Datatype

boolean

Lab Test Result
Beschrijving

Lab Test Result

Datatype

text

Lab Unit
Beschrijving

Lab Unit

Datatype

text

Other lab unit, specify
Beschrijving

Other lab unit, specify

Datatype

text

Lab LLN
Beschrijving

Lab LLN

Datatype

text

Lab ULN
Beschrijving

Lab ULN

Datatype

text

Direct bilirubin
Beschrijving

Direct bilirubin

Was lab test performed?
Beschrijving

Was lab test performed?

Datatype

boolean

Lab Test Result
Beschrijving

Lab Test Result

Datatype

text

Lab Unit
Beschrijving

Lab Unit

Datatype

text

Other lab unit, specify
Beschrijving

Other lab unit, specify

Datatype

text

Lab LLN
Beschrijving

Lab LLN

Datatype

text

Lab ULN
Beschrijving

Lab ULN

Datatype

text

Creatinine
Beschrijving

Creatinine

Was lab test performed?
Beschrijving

Was lab test performed?

Datatype

boolean

Lab Test Result
Beschrijving

Lab Test Result

Datatype

text

Lab Unit
Beschrijving

Lab Unit

Datatype

text

Other lab unit, specify
Beschrijving

Other lab unit, specify

Datatype

text

Lab LLN
Beschrijving

Lab LLN

Datatype

text

Lab ULN
Beschrijving

Lab ULN

Datatype

text

Other lab test
Beschrijving

Other lab test

Specify test
Beschrijving

Specify test

Datatype

text

Lab Test Result
Beschrijving

Lab Test Result

Datatype

text

Lab Unit
Beschrijving

Lab Unit

Datatype

text

Other lab unit, specify
Beschrijving

Other lab unit, specify

Datatype

text

Lab LLN
Beschrijving

Lab LLN

Datatype

text

Lab ULN
Beschrijving

Lab ULN

Datatype

text

Were additional Lab-Results Biochemistry evaluations performed?
Beschrijving

Were additional Lab-Results Biochemistry evaluations performed?

Datatype

boolean

Diagnostic Studies - Pancreatitis
Beschrijving

Diagnostic Studies - Pancreatitis

Was Abdominal Ultrasound performed?
Beschrijving

Was Abdominal Ultrasound performed?

Datatype

boolean

Date of abdominal ultrasound
Beschrijving

Date of abdominal ultrasound

Datatype

date

If Yes, record the result
Beschrijving

If Yes, record the result

Datatype

text

Are there any evidence of cholelithiasis?
Beschrijving

Are there any evidence of cholelithiasis?

Datatype

text

Was an additional Abdominal Ultrasound performed?
Beschrijving

Was an additional Abdominal Ultrasound performed?

Datatype

boolean

Abdominal CT Scan
Beschrijving

Abdominal CT Scan

Was an abdominal CT Scan performed?
Beschrijving

Was an abdominal CT Scan performed?

Datatype

boolean

If Yes, Date of Abdominal CT
Beschrijving

If Yes, Date of Abdominal CT

Datatype

date

Record overall results
Beschrijving

Record overall results

Datatype

text

If Abnormal, what are the diagnostic findings?
Beschrijving

If Abnormal, what are the diagnostic findings?

Datatype

text

Specify other
Beschrijving

Specify other

Datatype

text

Was an additional Abdominal CT Scan performed?
Beschrijving

Was an additional Abdominal CT Scan performed?

Datatype

boolean

MRI
Beschrijving

MRI

Was MRI performed?
Beschrijving

Was MRI performed?

Datatype

boolean

Date of MRI
Beschrijving

Date of MRI

Datatype

date

Results of MRI
Beschrijving

Results of MRI

Datatype

text

If Abnormal, what was the diagnostic finding?
Beschrijving

check all that apply

Datatype

integer

Was additional MRI performed?
Beschrijving

Was additional MRI performed?

Datatype

boolean

New Thyroid Nodules
Beschrijving

New Thyroid Nodules

Date of evaluation at which new nodule appeared
Beschrijving

Date of evaluation at which new nodule appeared

Datatype

date

AE/SAE Reference Number
Beschrijving

AE/SAE Reference Number

Datatype

integer

Type
Beschrijving

Type

Datatype

text

Location
Beschrijving

Location

Datatype

text

Bidimensional Measurement
Beschrijving

Bidimensional Measurement

length
Beschrijving

length

Datatype

float

Maateenheden
  • cm
cm
width
Beschrijving

width

Datatype

float

Maateenheden
  • cm
cm
Thyroid Nodules AE Details
Beschrijving

Thyroid Nodules AE Details

Was an action taken?
Beschrijving

Was an action taken?

Datatype

boolean

If Yes, please check all that apply
Beschrijving

If Yes, please check all that apply

Datatype

text

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

check only one

Datatype

text

If Malignant, thyroid cancer, check all that apply
Beschrijving

If Malignant, thyroid cancer, check all that apply

Datatype

text

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

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

Datatype

boolean

If Yes, please provide details:
Beschrijving

If Yes, please provide details:

Datatype

text

Thyroid function tests
Beschrijving

Thyroid function tests

Record the details below
Beschrijving

Record the details below

Datatype

boolean

Free T4
Beschrijving

Free T4

Result
Beschrijving

Result

Datatype

text

Unit
Beschrijving

Unit

Datatype

text

LLN
Beschrijving

LLN

Datatype

text

ULN
Beschrijving

ULN

Datatype

text

T4
Beschrijving

T4

Result
Beschrijving

Result

Datatype

text

Unit
Beschrijving

Unit

Datatype

text

LLN
Beschrijving

LLN

Datatype

text

ULN
Beschrijving

ULN

Datatype

text

TSH
Beschrijving

TSH

Result
Beschrijving

Result

Datatype

text

Unit
Beschrijving

Unit

Datatype

text

LLN
Beschrijving

LLN

Datatype

text

ULN
Beschrijving

ULN

Datatype

text

Free T3
Beschrijving

Free T3

Result
Beschrijving

Result

Datatype

text

Unit
Beschrijving

Unit

Datatype

text

LLN
Beschrijving

LLN

Datatype

text

ULN
Beschrijving

ULN

Datatype

text

T3 Uptake
Beschrijving

T3 Uptake

Result
Beschrijving

Result

Datatype

text

Unit
Beschrijving

Unit

Datatype

text

LLN
Beschrijving

LLN

Datatype

text

ULN
Beschrijving

ULN

Datatype

text

Similar models

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

Name
Type
Description | Question | Decode (Coded Value)
Datatype
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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