ID

33832

Beskrivning

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

Nyckelord

  1. 2019-01-02 2019-01-02 -
Rättsinnehavare

GSK group of companies

Uppladdad den

2 januari 2019

DOI

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Licens

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
Beskrivning

Administrative data

Site
Beskrivning

Site

Datatyp

text

Subject
Beskrivning

Subject

Datatyp

text

Visit Name
Beskrivning

Visit Name

Datatyp

text

Status
Beskrivning

Status

Datatyp

text

Document Number
Beskrivning

Document Number

Datatyp

text

(Serious) Hypoglycaemic Events
Beskrivning

(Serious) Hypoglycaemic Events

Has the subject experiences any protocol defined hypoglycaemic events?
Beskrivning

any protocol defined hypoglycaemic events?

Datatyp

boolean

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

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

Datatyp

text

Serious Adverse Events
Beskrivning

Serious Adverse Events

AE/SAE Reference Number
Beskrivning

AE/SAE Reference Number

Datatyp

integer

Start date of Event
Beskrivning

Start date of Event

Datatyp

date

Start Time of Event
Beskrivning

Start Time of Event

Datatyp

time

End date of Event
Beskrivning

End date of Event

Datatyp

date

End time of Event
Beskrivning

End time of Event

Datatyp

time

Blood Glucose Test Result at Time of Event
Beskrivning

Blood Glucose Test Result at Time of Event

Datatyp

text

Unit
Beskrivning

Unit

Datatyp

text

Frequency
Beskrivning

Frequency

Datatyp

text

Severity of hypoglycaemic event
Beskrivning

per ADA group guidelines

Datatyp

text

If Severe, check all that apply:
Beskrivning

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

Datatyp

text

Record the number of hospitalization days
Beskrivning

number of hospitalization days

Datatyp

integer

Enter the most severe intervention methods
Beskrivning

Intervention

Datatyp

text

Action Taken with Background or Anti-Hyperglycaemic Medications section
Beskrivning

if Yes, please update Anti-Hyperglycaemic Medications page

Datatyp

text

Injection Site Reaction
Beskrivning

Injection Site Reaction

AE/SAE Number
Beskrivning

AE/SAE Number

Datatyp

integer

Date of Injection
Beskrivning

Date of Injection

Datatyp

date

Date of Reaction
Beskrivning

Date of Reaction

Datatyp

date

Size of skin reaction - length
Beskrivning

maximum

Datatyp

integer

Måttenheter
  • mm
mm
Size of skin reaction - width
Beskrivning

maximum

Datatyp

integer

Måttenheter
  • mm
mm
Location of Injection
Beskrivning

Location of Injection

Datatyp

text

If Other, specify
Beskrivning

If Other, specify

Datatyp

text

Was the local reaction within 24 hrs of dose?
Beskrivning

timeframe of local reaction

Datatyp

boolean

Redness / Erythema
Beskrivning

Redness / Erythema

Datatyp

text

Itching / Pruritis
Beskrivning

Itching / Pruritis

Datatyp

text

Raised
Beskrivning

Raised

Datatyp

text

Warmth
Beskrivning

Warmth

Datatyp

text

Other symptoms
Beskrivning

Other symptoms

Datatyp

text

Specify Other symptoms
Beskrivning

Specify Other symptoms

Datatyp

text

Was treatment given for this local reaction?
Beskrivning

Was treatment given for this local reaction?

Datatyp

boolean

Was the serum sample obtained?
Beskrivning

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

Datatyp

boolean

If Yes, please provide date
Beskrivning

If Yes, please provide date

Datatyp

date

Pancreatitis
Beskrivning

Pancreatitis

AE/SAE Number
Beskrivning

AE/SAE Number

Datatyp

integer

Date of Onset
Beskrivning

Date of Onset

Datatyp

date

Was alcohol consumed on a regular basis?
Beskrivning

Alcohol

Datatyp

text

Average number of units consumed daily
Beskrivning

Average number of units consumed daily

Datatyp

integer

Is there a family history of Pancreatitis?
Beskrivning

Family History of Pancreatitis

Datatyp

boolean

Grandmother (maternal)
Beskrivning

Grandmother (maternal)

Datatyp

text

Grandfather (maternal)
Beskrivning

Grandfather (maternal)

Datatyp

text

Grandmother (paternal)
Beskrivning

Grandmother (paternal)

Datatyp

text

Grandfather (paternal)
Beskrivning

Grandfather (paternal)

Datatyp

text

Mother
Beskrivning

Mother

Datatyp

text

Father
Beskrivning

Father

Datatyp

text

Sibling 1
Beskrivning

Sibling 1

Datatyp

text

specify
Beskrivning

specify

Datatyp

text

Sibling 2
Beskrivning

Sibling 2

Datatyp

text

specify
Beskrivning

specify

Datatyp

text

Other
Beskrivning

Other

Datatyp

text

specify
Beskrivning

specify

Datatyp

text

Recent Trauma / Vascular Invasive Procedures or Surgery
Beskrivning

Recent Trauma / Vascular Invasive Procedures or Surgery

Datatyp

text

Date of Procedure
Beskrivning

Date of Procedure

Datatyp

date

Recent Trauma / Vascular Invasive Procedures or Surgery
Beskrivning

Recent Trauma / Vascular Invasive Procedures or Surgery

Datatyp

text

Date of Procedure
Beskrivning

Date of Procedure

Datatyp

date

Recent Trauma / Vascular Invasive Procedures or Surgery
Beskrivning

Recent Trauma / Vascular Invasive Procedures or Surgery

Datatyp

text

Date of Procedure
Beskrivning

Date of Procedure

Datatyp

date

Symptoms of Gastrointestinal Illness Associated with Pancreatitis
Beskrivning

Symptoms of Gastrointestinal Illness Associated with Pancreatitis

Check below all that apply
Beskrivning

Check below all that apply

Datatyp

text

Pain in the Epigastrium
Beskrivning

Pain in the Epigastrium

Date of Onset
Beskrivning

Date of Onset

Datatyp

date

Ongoing?
Beskrivning

Ongoing?

Datatyp

boolean

Date of Resolution
Beskrivning

Date of Resolution

Datatyp

date

Pain in the Periumbical Region
Beskrivning

Pain in the Periumbical Region

Date of Onset
Beskrivning

Date of Onset

Datatyp

date

Ongoing?
Beskrivning

Ongoing?

Datatyp

boolean

Date of Resolution
Beskrivning

Date of Resolution

Datatyp

date

Pain in the Right Upper Quadrant
Beskrivning

Pain in the Right Upper Quadrant

Date of Onset
Beskrivning

Date of Onset

Datatyp

date

Ongoing?
Beskrivning

Ongoing?

Datatyp

boolean

Date of Resolution
Beskrivning

Date of Resolution

Datatyp

date

Pain in the Left Upper Quadrant
Beskrivning

Pain in the Left Upper Quadrant

Date of Onset
Beskrivning

Date of Onset

Datatyp

date

Ongoing?
Beskrivning

Ongoing?

Datatyp

boolean

Date of Resolution
Beskrivning

Date of Resolution

Datatyp

date

Pain in the Left Lower Quadrant
Beskrivning

Pain in the Left Lower Quadrant

Date of Onset
Beskrivning

Date of Onset

Datatyp

date

Ongoing?
Beskrivning

Ongoing?

Datatyp

boolean

Date of Resolution
Beskrivning

Date of Resolution

Datatyp

date

Pain in the Right Lower Quadrant
Beskrivning

Pain in the Right Lower Quadrant

Date of Onset
Beskrivning

Date of Onset

Datatyp

date

Ongoing?
Beskrivning

Ongoing?

Datatyp

boolean

Date of Resolution
Beskrivning

Date of Resolution

Datatyp

date

Pain in the Right Flank
Beskrivning

Pain in the Right Flank

Date of Onset
Beskrivning

Date of Onset

Datatyp

date

Ongoing?
Beskrivning

Ongoing?

Datatyp

boolean

Date of Resolution
Beskrivning

Date of Resolution

Datatyp

date

Pain in the Left Flank
Beskrivning

Pain in the Left Flank

Date of Onset
Beskrivning

Date of Onset

Datatyp

date

Ongoing?
Beskrivning

Ongoing?

Datatyp

boolean

Date of Resolution
Beskrivning

Date of Resolution

Datatyp

date

Pain in the Back
Beskrivning

Pain in the Back

Date of Onset
Beskrivning

Date of Onset

Datatyp

date

Ongoing?
Beskrivning

Ongoing?

Datatyp

boolean

Date of Resolution
Beskrivning

Date of Resolution

Datatyp

date

Other Symptoms
Beskrivning

Other Symptoms

Specify symptom
Beskrivning

Specify symptom

Datatyp

text

Date of Onset
Beskrivning

Date of Onset

Datatyp

date

Ongoing?
Beskrivning

Ongoing?

Datatyp

boolean

Date of Resolution
Beskrivning

Date of Resolution

Datatyp

date

Nausea
Beskrivning

Nausea

Date of Onset
Beskrivning

Date of Onset

Datatyp

date

Ongoing?
Beskrivning

Ongoing?

Datatyp

boolean

Date of Resolution
Beskrivning

Date of Resolution

Datatyp

date

Vomiting
Beskrivning

Vomiting

Date of Onset
Beskrivning

Date of Onset

Datatyp

date

Ongoing?
Beskrivning

Ongoing?

Datatyp

boolean

Date of Resolution
Beskrivning

Date of Resolution

Datatyp

date

Fever
Beskrivning

Fever

Temperature
Beskrivning

Temperature

Datatyp

float

Måttenheter
  • °C
°C
Date of Onset
Beskrivning

Date of Onset

Datatyp

date

Ongoing?
Beskrivning

Ongoing?

Datatyp

boolean

Date of Resolution
Beskrivning

Date of Resolution

Datatyp

date

Biochemistry
Beskrivning

Biochemistry

Record lab results in corresponding categories below
Beskrivning

Record lab results in corresponding categories below

Datatyp

text

Alkaline phosphatase
Beskrivning

Alkaline phosphatase

Was lab test performed?
Beskrivning

Was lab test performed?

Datatyp

boolean

Lab Test Result
Beskrivning

Lab Test Result

Datatyp

text

Lab Unit
Beskrivning

Lab Unit

Datatyp

text

Other lab unit, specify
Beskrivning

Other lab unit, specify

Datatyp

text

Lab LLN
Beskrivning

Lab LLN

Datatyp

text

Lab ULN
Beskrivning

Lab ULN

Datatyp

text

Total bilirubin
Beskrivning

Total bilirubin

Was lab test performed?
Beskrivning

Was lab test performed?

Datatyp

boolean

Lab Test Result
Beskrivning

Lab Test Result

Datatyp

text

Lab Unit
Beskrivning

Lab Unit

Datatyp

text

Other lab unit, specify
Beskrivning

Other lab unit, specify

Datatyp

text

Lab LLN
Beskrivning

Lab LLN

Datatyp

text

Lab ULN
Beskrivning

Lab ULN

Datatyp

text

Direct bilirubin
Beskrivning

Direct bilirubin

Was lab test performed?
Beskrivning

Was lab test performed?

Datatyp

boolean

Lab Test Result
Beskrivning

Lab Test Result

Datatyp

text

Lab Unit
Beskrivning

Lab Unit

Datatyp

text

Other lab unit, specify
Beskrivning

Other lab unit, specify

Datatyp

text

Lab LLN
Beskrivning

Lab LLN

Datatyp

text

Lab ULN
Beskrivning

Lab ULN

Datatyp

text

Creatinine
Beskrivning

Creatinine

Was lab test performed?
Beskrivning

Was lab test performed?

Datatyp

boolean

Lab Test Result
Beskrivning

Lab Test Result

Datatyp

text

Lab Unit
Beskrivning

Lab Unit

Datatyp

text

Other lab unit, specify
Beskrivning

Other lab unit, specify

Datatyp

text

Lab LLN
Beskrivning

Lab LLN

Datatyp

text

Lab ULN
Beskrivning

Lab ULN

Datatyp

text

Other lab test
Beskrivning

Other lab test

Specify test
Beskrivning

Specify test

Datatyp

text

Lab Test Result
Beskrivning

Lab Test Result

Datatyp

text

Lab Unit
Beskrivning

Lab Unit

Datatyp

text

Other lab unit, specify
Beskrivning

Other lab unit, specify

Datatyp

text

Lab LLN
Beskrivning

Lab LLN

Datatyp

text

Lab ULN
Beskrivning

Lab ULN

Datatyp

text

Were additional Lab-Results Biochemistry evaluations performed?
Beskrivning

Were additional Lab-Results Biochemistry evaluations performed?

Datatyp

boolean

Diagnostic Studies - Pancreatitis
Beskrivning

Diagnostic Studies - Pancreatitis

Was Abdominal Ultrasound performed?
Beskrivning

Was Abdominal Ultrasound performed?

Datatyp

boolean

Date of abdominal ultrasound
Beskrivning

Date of abdominal ultrasound

Datatyp

date

If Yes, record the result
Beskrivning

If Yes, record the result

Datatyp

text

Are there any evidence of cholelithiasis?
Beskrivning

Are there any evidence of cholelithiasis?

Datatyp

text

Was an additional Abdominal Ultrasound performed?
Beskrivning

Was an additional Abdominal Ultrasound performed?

Datatyp

boolean

Abdominal CT Scan
Beskrivning

Abdominal CT Scan

Was an abdominal CT Scan performed?
Beskrivning

Was an abdominal CT Scan performed?

Datatyp

boolean

If Yes, Date of Abdominal CT
Beskrivning

If Yes, Date of Abdominal CT

Datatyp

date

Record overall results
Beskrivning

Record overall results

Datatyp

text

If Abnormal, what are the diagnostic findings?
Beskrivning

If Abnormal, what are the diagnostic findings?

Datatyp

text

Specify other
Beskrivning

Specify other

Datatyp

text

Was an additional Abdominal CT Scan performed?
Beskrivning

Was an additional Abdominal CT Scan performed?

Datatyp

boolean

MRI
Beskrivning

MRI

Was MRI performed?
Beskrivning

Was MRI performed?

Datatyp

boolean

Date of MRI
Beskrivning

Date of MRI

Datatyp

date

Results of MRI
Beskrivning

Results of MRI

Datatyp

text

If Abnormal, what was the diagnostic finding?
Beskrivning

check all that apply

Datatyp

integer

Was additional MRI performed?
Beskrivning

Was additional MRI performed?

Datatyp

boolean

New Thyroid Nodules
Beskrivning

New Thyroid Nodules

Date of evaluation at which new nodule appeared
Beskrivning

Date of evaluation at which new nodule appeared

Datatyp

date

AE/SAE Reference Number
Beskrivning

AE/SAE Reference Number

Datatyp

integer

Type
Beskrivning

Type

Datatyp

text

Location
Beskrivning

Location

Datatyp

text

Bidimensional Measurement
Beskrivning

Bidimensional Measurement

length
Beskrivning

length

Datatyp

float

Måttenheter
  • cm
cm
width
Beskrivning

width

Datatyp

float

Måttenheter
  • cm
cm
Thyroid Nodules AE Details
Beskrivning

Thyroid Nodules AE Details

Was an action taken?
Beskrivning

Was an action taken?

Datatyp

boolean

If Yes, please check all that apply
Beskrivning

If Yes, please check all that apply

Datatyp

text

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

check only one

Datatyp

text

If Malignant, thyroid cancer, check all that apply
Beskrivning

If Malignant, thyroid cancer, check all that apply

Datatyp

text

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

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

Datatyp

boolean

If Yes, please provide details:
Beskrivning

If Yes, please provide details:

Datatyp

text

Thyroid function tests
Beskrivning

Thyroid function tests

Record the details below
Beskrivning

Record the details below

Datatyp

boolean

Free T4
Beskrivning

Free T4

Result
Beskrivning

Result

Datatyp

text

Unit
Beskrivning

Unit

Datatyp

text

LLN
Beskrivning

LLN

Datatyp

text

ULN
Beskrivning

ULN

Datatyp

text

T4
Beskrivning

T4

Result
Beskrivning

Result

Datatyp

text

Unit
Beskrivning

Unit

Datatyp

text

LLN
Beskrivning

LLN

Datatyp

text

ULN
Beskrivning

ULN

Datatyp

text

TSH
Beskrivning

TSH

Result
Beskrivning

Result

Datatyp

text

Unit
Beskrivning

Unit

Datatyp

text

LLN
Beskrivning

LLN

Datatyp

text

ULN
Beskrivning

ULN

Datatyp

text

Free T3
Beskrivning

Free T3

Result
Beskrivning

Result

Datatyp

text

Unit
Beskrivning

Unit

Datatyp

text

LLN
Beskrivning

LLN

Datatyp

text

ULN
Beskrivning

ULN

Datatyp

text

T3 Uptake
Beskrivning

T3 Uptake

Result
Beskrivning

Result

Datatyp

text

Unit
Beskrivning

Unit

Datatyp

text

LLN
Beskrivning

LLN

Datatyp

text

ULN
Beskrivning

ULN

Datatyp

text

Similar models

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

Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
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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