0 Ratings
ID

42769

Description

European survey on the assessment of deep molecular REsponse in chronic phase CML patients after at least two years of therapy with tyrosine KinAse inhibitors - major component of the Path to Cure Pillar of EUTOS III. ODM derived from: http://www.eutos.org/content/path_to_cure/eureka/index_eng.html

Link

http://www.eutos.org/content/path_to_cure/eureka/index_eng.html

Keywords

Versions (2)
  1. 12/7/15 12/7/15 -
  2. 9/17/21 9/17/21 -
Uploaded on

September 17, 2021

DOI

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License

Creative Commons BY-NC 3.0
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    Molecular Monitoring Survey EUREKA

    English

    Case Report Form (CRF)

    1 forms  
    1. StudyEvent: ODM
      1. Case Report Form (CRF)
    Blood Sample Collection
    Description

    Blood Sample Collection

    Date of sample
    Description

    Date of sample

    Data type

    date

    Alias
    UMLS CUI [1]
    C0460065
    Physician Information
    Description

    Physician Information

    Name
    Description

    Name

    Data type

    text

    Alias
    UMLS CUI [1]
    C0421448
    Affiliation
    Description

    Affiliation

    Data type

    integer

    Alias
    UMLS CUI [1]
    C0029239
    City
    Description

    City

    Data type

    integer

    Alias
    UMLS CUI [1]
    C0008848
    Country
    Description

    Country

    Data type

    integer

    Alias
    UMLS CUI [1]
    C0454664
    Patient Information
    Description

    Patient Information

    Initials
    Description

    first name / last name

    Data type

    integer

    Alias
    UMLS CUI [1]
    C2986440
    Date of Birth
    Description

    Month Year

    Data type

    integer

    Alias
    UMLS CUI [1]
    C0421451
    Sex
    Description

    Sex

    Data type

    integer

    Alias
    UMLS CUI [1]
    C0079399
    Ethnicity
    Description

    Ethnic Group

    Data type

    integer

    Alias
    UMLS CUI [1]
    C0015031
    Date of informed consent
    Description

    Date of informed consent

    Data type

    date

    Alias
    UMLS CUI [1]
    C2985782
    Type of BCR-ABL transcript at diagnosis
    Description

    Type of BCR-ABL transcript at diagnosis

    Data type

    integer

    Alias
    UMLS CUI [1]
    C0004891
    Eutos Score (at diagnosis)
    Description

    Eutos Score (at diagnosis)

    Data type

    integer

    Alias
    UMLS CUI [1]
    C0449820
    Sokal Score (at diagnosis)
    Description

    Sokal Score (at diagnosis)

    Data type

    integer

    Alias
    UMLS CUI [1]
    C0449820
    Euro (Hasford) Score (at diagnosis)
    Description

    Euro (Hasford) Score (at diagnosis)

    Data type

    integer

    Alias
    UMLS CUI [1]
    C0449820
    CML Diagnosis, Treatment
    Description

    CML Diagnosis, Treatment

    CML Diagnosis
    Description

    CML Diagnosis

    Data type

    date

    Alias
    UMLS CUI [1]
    C0279899
    First line TKI
    Description

    Start Stop Onging

    Data type

    integer

    Alias
    UMLS CUI [1,1]
    C0879484
    UMLS CUI [1,2]
    C1708063
    Second line TKI
    Description

    Reason for regimen change (to second line): drug resistance intolerance

    Data type

    integer

    Alias
    UMLS CUI [1,1]
    C0879484
    UMLS CUI [1,2]
    C1710038
    Third line TKI
    Description

    Reason for regimen change (to third line): drug resistance intolerance

    Data type

    integer

    Alias
    UMLS CUI [1,1]
    C2986605
    UMLS CUI [1,2]
    C0879484
    Current treatment
    Description

    Current treatment

    Data type

    integer

    Measurement units
    • mg/day
    Alias
    UMLS CUI [1]
    C1522541
    Most recent molecular result from the local lab
    Description

    Judgement of molecular result from the local lab

    Data type

    integer

    Alias
    UMLS CUI [1,1]
    C1521991
    UMLS CUI [1,2]
    C0587081
    Date & Signature
    Description

    Date & Signature

    Date
    Description

    Date

    Data type

    date

    Alias
    UMLS CUI [1]
    C0011008
    Sign./Physician Stamp
    Description

    Sign./Physician Stamp

    Data type

    integer

    Alias
    UMLS CUI [1]
    C1519316
    Addresses of reference laboratories
    Description

    Addresses of reference laboratories

    How to send samples
    Description

    Data to be sent from the referring physician to the laboratory Required: 20-30 mlperipheral blood (EDTA). Please favour days from monday to thursday for sending the samples in.

    Data type

    integer

    Alias
    UMLS CUI [1,1]
    C0229664
    UMLS CUI [1,2]
    C2919842
    Universitätsklinikum Jena
    Description

    Medizinische Universitäts-Laboratorien Hämatologisch-onkologisches Speziallabor Postfach 100236 07702 Jena

    Data type

    integer

    Alias
    UMLS CUI [1,1]
    C0000872
    UMLS CUI [1,2]
    C1442065
    Universitätsklinikum Leipzig
    Description

    Wissenschaftliches Labor III. Medizinische Klinik Universitätsmedizin Mannheim Pettenkoferstr. 22 68169 Mannheim

    Data type

    integer

    Alias
    UMLS CUI [1,1]
    C0000872
    UMLS CUI [1,2]
    C1442065
    Universtitätsklinik Mannheim
    Description

    Wissenschaftliches Labor III. Medizinische Klinik Universitätsmedizin Mannheim Pettenkoferstr. 22 68169 Mannheim

    Data type

    integer

    Alias
    UMLS CUI [1,1]
    C0000872
    UMLS CUI [1,2]
    C1442065
    Universitätsklinikum Schleswig-Holstein, Campus Kiel
    Description

    Labor für Hämatologische Spezialdiagnostik II. Medizinische Klinik Universitätsklinikum Schleswig-Holstein, Campus Kiel Im Städtischen Krankenhaus Chemnitzstrasse 33 24116 Kiel

    Data type

    integer

    Alias
    UMLS CUI [1,1]
    C0000872
    UMLS CUI [1,2]
    C1442065
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    Similar models

    Case Report Form (CRF)

    1 forms
    1. StudyEvent: ODM
      1. Case Report Form (CRF)
    Name
    Type
    Description | Question | Decode (Coded Value)
    Data type
    Alias
    Item Group
    Blood Sample Collection
    Date of sample
    Item
    Date of sample
    date
    C0460065 (UMLS CUI [1])
    Item Group
    Physician Information
    Name
    Item
    Name
    text
    C0421448 (UMLS CUI [1])
    Item
    Affiliation
    integer
    C0029239 (UMLS CUI [1])
    Affiliation
    Code List
    Affiliation
    CL Item
    academic (1)
    C0000872 (UMLS CUI-1)
    CL Item
    regional hospital (2)
    C0034971 (UMLS CUI-1)
    CL Item
    office based hematologist (3)
    C0278598 (UMLS CUI-1)
    City
    Item
    City
    integer
    C0008848 (UMLS CUI [1])
    Country
    Item
    Country
    integer
    C0454664 (UMLS CUI [1])
    Item Group
    Patient Information
    Initialen
    Item
    Initials
    integer
    C2986440 (UMLS CUI [1])
    Date of Birth
    Item
    Date of Birth
    integer
    C0421451 (UMLS CUI [1])
    Item
    Sex
    integer
    C0079399 (UMLS CUI [1])
    Sex
    Code List
    Sex
    CL Item
    Male (1)
    C1706180 (UMLS CUI-1)
    CL Item
    Female (2)
    C0086287 (UMLS CUI-1)
    Item
    Ethnicity
    integer
    C0015031 (UMLS CUI [1])
    Ethnic Group
    Code List
    Ethnicity
    CL Item
    Caucasian (1)
    C0007457 (UMLS CUI-1)
    CL Item
    Black (2)
    C0005680 (UMLS CUI-1)
    CL Item
    Hispanic (3)
    C0086409 (UMLS CUI-1)
    CL Item
    Oriental/Asian (4)
    C0078988 (UMLS CUI-1)
    CL Item
    Other (5)
    C0205394 (UMLS CUI-1)
    Date of informed consent
    Item
    Date of informed consent
    date
    C2985782 (UMLS CUI [1])
    Item
    Type of BCR-ABL transcript at diagnosis
    integer
    C0004891 (UMLS CUI [1])
    Type of BCR-ABL transcript at diagnosis
    Code List
    Type of BCR-ABL transcript at diagnosis
    CL Item
    b2a2 (e13a2) (1)
    C1955180 (UMLS CUI-1)
    CL Item
    b3a2 (e14a2) (2)
    C1955181 (UMLS CUI-1)
    CL Item
    b2a2 + b3a2 (e13a2 + e14a2) (3)
    C2709110 (UMLS CUI-1)
    CL Item
    e1a2 (4)
    C2963376 (UMLS CUI-1)
    CL Item
    b2a3 (e13a3) (5)
    CL Item
    b3a3 (e14a3) (6)
    CL Item
    e6a2 (7)
    C0029006 (UMLS CUI-1)
    CL Item
    e19a2 (8)
    C2707995 (UMLS CUI-1)
    CL Item
    unknown (9)
    C0439673 (UMLS CUI-1)
    CL Item
    Other (10)
    C0205394 (UMLS CUI-1)
    Item
    Eutos Score (at diagnosis)
    integer
    C0449820 (UMLS CUI [1])
    Eutos Score (at diagnosis)
    Code List
    Eutos Score (at diagnosis)
    CL Item
    high (1)
    C1561957 (UMLS CUI-1)
    CL Item
    low (2)
    C0205251 (UMLS CUI-1)
    Item
    Sokal Score (at diagnosis)
    integer
    C0449820 (UMLS CUI [1])
    Sokal Score (at diagnosis)
    Code List
    Sokal Score (at diagnosis)
    CL Item
    low (low)
    C0205251 (UMLS CUI-1)
    CL Item
    intermediate (intermediate)
    C0205103 (UMLS CUI-1)
    CL Item
    high (high)
    C0205250 (UMLS CUI-1)
    Item
    Euro (Hasford) Score (at diagnosis)
    integer
    C0449820 (UMLS CUI [1])
    Euro (Hasford) Score (at diagnosis)
    Code List
    Euro (Hasford) Score (at diagnosis)
    CL Item
    low (1)
    C0205251 (UMLS CUI-1)
    CL Item
    intermediate (2)
    C0205103 (UMLS CUI-1)
    CL Item
    high (3)
    C0205250 (UMLS CUI-1)
    Item Group
    CML Diagnosis, Treatment
    CML Diagnosis
    Item
    CML Diagnosis
    date
    C0279899 (UMLS CUI [1])
    Item
    First line TKI
    integer
    C0879484 (UMLS CUI [1,1])
    C1708063 (UMLS CUI [1,2])
    First line TKI
    Code List
    First line TKI
    CL Item
    Imatinib (1)
    C0935989 (UMLS CUI-1)
    CL Item
    Nilotinib (2)
    C1721377 (UMLS CUI-1)
    CL Item
    Dasatinib  (3)
    C1455147 (UMLS CUI-1)
    CL Item
    Bosutinib  (4)
    C1831731 (UMLS CUI-1)
    CL Item
    Ponatinib (5)
    C2987417 (UMLS CUI-1)
    Item
    Second line TKI
    integer
    C0879484 (UMLS CUI [1,1])
    C1710038 (UMLS CUI [1,2])
    Second line TKI
    Code List
    Second line TKI
    CL Item
    Imatinib (1)
    CL Item
    Nilotinib (2)
    CL Item
    Dasatinib (3)
    CL Item
    Bosutinib (4)
    CL Item
    Ponatinib (5)
    Item
    Third line TKI
    integer
    C2986605 (UMLS CUI [1,1])
    C0879484 (UMLS CUI [1,2])
    Third line TKI
    Code List
    Third line TKI
    CL Item
    Imatinib (1)
    C0935989 (UMLS CUI-1)
    CL Item
    Nilotinib  (2)
    C1721377 (UMLS CUI-1)
    CL Item
    Dasatinib  (3)
    C1455147 (UMLS CUI-1)
    CL Item
    Bosutinib  (4)
    C1831731 (UMLS CUI-1)
    CL Item
    Ponatinib (5)
    C2987417 (UMLS CUI-1)
    Item
    Current treatment
    integer
    C1522541 (UMLS CUI [1])
    Current treatment
    Code List
    Current treatment
    CL Item
    Imatinib  (1)
    C0935989 (UMLS CUI-1)
    CL Item
    Nilotinib (2)
    C1721377 (UMLS CUI-1)
    CL Item
    Dasatinib (3)
    C1455147 (UMLS CUI-1)
    CL Item
    Bosutinib (4)
    C1831731 (UMLS CUI-1)
    CL Item
    Ponatinib (5)
    C2987417 (UMLS CUI-1)
    CL Item
    Other (6)
    C0205394 (UMLS CUI-1)
    Item
    Most recent molecular result from the local lab
    integer
    C1521991 (UMLS CUI [1,1])
    C0587081 (UMLS CUI [1,2])
    Most recent molecular result from the local lab
    Code List
    Most recent molecular result from the local lab
    CL Item
    No MMR (1)
    CL Item
    MMR (2)
    CL Item
    MR4 (3)
    CL Item
    MR4.5 (4)
    CL Item
    MR5 (5)
    CL Item
    CMR (6)
    C0654223 (UMLS CUI-1)
    Item Group
    Date & Signature
    Date
    Item
    Date
    date
    C0011008 (UMLS CUI [1])
    Sign./Physician Stamp
    Item
    Sign./Physician Stamp
    integer
    C1519316 (UMLS CUI [1])
    Item Group
    Addresses of reference laboratories
    How to send samples
    Item
    How to send samples
    integer
    C0229664 (UMLS CUI [1,1])
    C2919842 (UMLS CUI [1,2])
    Universitätsklinikum Jena
    Item
    Universitätsklinikum Jena
    integer
    C0000872 (UMLS CUI [1,1])
    C1442065 (UMLS CUI [1,2])
    Item
    Universitätsklinikum Leipzig
    integer
    C0000872 (UMLS CUI [1,1])
    C1442065 (UMLS CUI [1,2])
    Universitätsklinikum Leipzig
    Code List
    Universitätsklinikum Leipzig
    Item
    Universtitätsklinik Mannheim
    integer
    C0000872 (UMLS CUI [1,1])
    C1442065 (UMLS CUI [1,2])
    Universtitätsklinik Mannheim
    Code List
    Universtitätsklinik Mannheim
    Universitätsklinikum Schleswig-Holstein, Campus Kiel
    Item
    Universitätsklinikum Schleswig-Holstein, Campus Kiel
    integer
    C0000872 (UMLS CUI [1,1])
    C1442065 (UMLS CUI [1,2])
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