ID

35556

Beschreibung

Study ID: 101468/192 Clinical Study ID: 101468/192 Study Title:A 52 Week Open-Label Extension Study of the Long-Term Safety of Ropinirole in Subjects Suffering from Restless Legs Syndrome (RLS) Patient Level Data: Study Listed on ClinicalStudyDataRequest.com Clinicaltrials.gov Identifier: Sponsor: GlaxoSmithKline Collaborators: N/A Phase: phase 3 Study Recruitment Status: Completed Generic Name: ropinirole Trade Name: Modutab,ZIPEREVE,ZEPREVE,REPREVE,ADARTREL,REQUIP,Zygara; Zygara,ZIPEREVE,ZEPREVE,Requip Depot,REQUIP,REPREVE,Modutab,ADARTREL Study Indication : Restless Legs Syndrome The study consists of 16 visits which are devided in 3 study books: Book 1: Screening (+Baseline), Day 2, Week 1, Week 2 , Week 3 , Week 4, Week 5, Week 6, Week 7, Week 8 Book 2: Week 12, Week 24, Week 36, Week 48, Week 52, Follow-up Book 3: Early withdrawal and Follow-up Each follow-up Visit takes place 7 +/- 3 days after last dose This document contains the signs and symptoms form. It has to be filled in for screening (baseline).

Stichworte

Versionen (1)
  1. 08.03.19 08.03.19 -
Rechteinhaber

GlaxoSmithKline

Hochgeladen am

8. März 2019

DOI

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Creative Commons BY-NC 3.0
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Long-Term Safety of Ropinirole in Subjects Suffering from Restless Legs Syndrome (RLS), 101468/192

Englisch

Signs And Symptoms

1 Formulare  
  1. StudyEvent: ODM
    1. Signs And Symptoms
Administrative data
Beschreibung

Administrative data

Alias
UMLS CUI-1
C1320722
Centre Number
Beschreibung

Centre Number

Datentyp

integer

Alias
UMLS CUI [1,1]
C0600091
UMLS CUI [1,2]
C0019994
Patient Initials
Beschreibung

Patient Initials

Datentyp

text

Alias
UMLS CUI [1]
C2986440
Patient Number
Beschreibung

Patient Number

Datentyp

text

Alias
UMLS CUI [1]
C2348585
Visit Date
Beschreibung

day month year

Datentyp

date

Alias
UMLS CUI [1]
C1320303
Signs and symptoms
Beschreibung

Signs and symptoms

Alias
UMLS CUI-1
C0037088
Did baseline events occur during the module?
Beschreibung

serious baseline event is any untoward medical occurrence that, at any dose : A - results in death. B - is life threatening.. C - requires hospitalisation or prolongation of existing hospitalisation. D - results in disability/incapacity, or E - is a congenital anomaly/birth defect. F - other

Datentyp

text

Alias
UMLS CUI [1,1]
C1442488
UMLS CUI [1,2]
C0877248
Onset Date
Beschreibung

day month year

Datentyp

date

Alias
UMLS CUI [1]
C0574845
Onset Time
Beschreibung

00:00-23:59

Datentyp

time

Alias
UMLS CUI [1]
C0449244
End Date
Beschreibung

day month year

Datentyp

date

Alias
UMLS CUI [1]
C0806020
End Time
Beschreibung

00:00-23:59

Datentyp

time

Alias
UMLS CUI [1]
C1522314
Outcome
Beschreibung

If patient died, STOP: go to SAE section and follow instructions given there

Datentyp

integer

Alias
UMLS CUI [1]
C1705586
Experience Course
Beschreibung

Experience Course

Datentyp

integer

Alias
UMLS CUI [1,1]
C0877248
UMLS CUI [1,2]
C0750729
No. of episodes
Beschreibung

Number of episodes

Datentyp

integer

Alias
UMLS CUI [1,1]
C0877248
UMLS CUI [1,2]
C4086638
Intensity (maximum)
Beschreibung

MILD: An event which is easily tolerated MODERATE: An event which is sufficiently discomforting to interfere with daily activities SEVERE: An event which prevents normal everyday activities

Datentyp

integer

Alias
UMLS CUI [1]
C1710066
Relationship to Investigational Drug
Beschreibung

RELATED: There is a direct cause and effect relationship between the event and the study procedures POSSIBLY RELATED: A direct cause and effect relationship between the study procedures and the event has not been demonstrated but is possible or likely PROBABLY UNRELATED: Cause and effect relationship between the study procedures and the event has not been demonstrated, is improbable but not impossible UNRELATED: The event is definitely not related to the study procedures

Datentyp

integer

Alias
UMLS CUI [1,1]
C1518404
UMLS CUI [1,2]
C0013230
UMLS CUI [1,3]
C0439849
Corrective Therapy
Beschreibung

If ‘Yes’, record details in the Concomitant Medication section and/or Healthcare Resource Utilisation form if appropriate

Datentyp

text

Alias
UMLS CUI [1,1]
C0877248
UMLS CUI [1,2]
C0087111
Was patient withdrawn due to this specific AE?
Beschreibung

patient withdrawn due to this specific AE

Datentyp

text

Alias
UMLS CUI [1,1]
C0422727
UMLS CUI [1,2]
C1518404
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Ähnliche Modelle

Signs And Symptoms

1 Formulare
  1. StudyEvent: ODM
    1. Signs And Symptoms
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Item Group
Administrative data
C1320722 (UMLS CUI-1)
Centre Number
Item
Centre Number
integer
C0600091 (UMLS CUI [1,1])
C0019994 (UMLS CUI [1,2])
Patient Initials
Item
Patient Initials
text
C2986440 (UMLS CUI [1])
Patient Number
Item
Patient Number
text
C2348585 (UMLS CUI [1])
Visit Date
Item
Visit Date
date
C1320303 (UMLS CUI [1])
Item Group
Signs and symptoms
C0037088 (UMLS CUI-1)
Baseline events
Item
Did baseline events occur during the module?
text
C1442488 (UMLS CUI [1,1])
C0877248 (UMLS CUI [1,2])
Onset Date
Item
Onset Date
date
C0574845 (UMLS CUI [1])
Onset Time
Item
Onset Time
time
C0449244 (UMLS CUI [1])
End Date
Item
End Date
date
C0806020 (UMLS CUI [1])
End Time
Item
End Time
time
C1522314 (UMLS CUI [1])
Item
Outcome
integer
C1705586 (UMLS CUI [1])
Outcome
Code List
Outcome
CL Item
Resolved (1)
CL Item
Ongoing (2)
CL Item
Died (3)
Item
Experience Course
integer
C0877248 (UMLS CUI [1,1])
C0750729 (UMLS CUI [1,2])
Experience Course
Code List
Experience Course
CL Item
Intermittent (1)
CL Item
Constant (2)
Number of episodes
Item
No. of episodes
integer
C0877248 (UMLS CUI [1,1])
C4086638 (UMLS CUI [1,2])
Item
Intensity (maximum)
integer
C1710066 (UMLS CUI [1])
Intensity
Code List
Intensity (maximum)
CL Item
Mild (1)
CL Item
Moderate (2)
CL Item
Severe (3)
Item
Relationship to Investigational Drug
integer
C1518404 (UMLS CUI [1,1])
C0013230 (UMLS CUI [1,2])
C0439849 (UMLS CUI [1,3])
Relationship to Investigational Drug
Code List
Relationship to Investigational Drug
CL Item
Related (1)
CL Item
Possibly related (2)
CL Item
Probably unrelated  (3)
CL Item
Unrelated (4)
Item
Corrective Therapy
text
C0877248 (UMLS CUI [1,1])
C0087111 (UMLS CUI [1,2])
Corrective Therapy
Code List
Corrective Therapy
CL Item
Yes (Y)
CL Item
No (N)
Item
Was patient withdrawn due to this specific AE?
text
C0422727 (UMLS CUI [1,1])
C1518404 (UMLS CUI [1,2])
patient withdrawn due to this specific AE
Code List
Was patient withdrawn due to this specific AE?
CL Item
Yes (Y)
CL Item
No (N)
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