ID

44355

Descripción

Study ID: 101468/194 Clinical Study ID: 101468/194 Study Title: A 12 Week, Double-Blind, Placebo-Controlled, Parallel Group Study to Assess the Efficacy and Safety of Ropinirole in Patients 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: requip Study Indication: Restless Legs Syndrome

Palabras clave

Versiones (2)
  1. 5/3/19 5/3/19 -
  2. 20/9/21 20/9/21 -
Titular de derechos de autor

GlaxoSmithKline

Subido en

20 de septiembre de 2021

DOI

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Licencia

Creative Commons BY-NC 3.0
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Ropinirole in Patients with Restless Legs Syndrome (Study ID: 101468/194)

Inglés

Screening

1 formularios  
  1. StudyEvent: ODM
    1. Screening
Administrative data
Descripción

Administrative data

Alias
UMLS CUI-1
C1320722
Centre Number
Descripción

Study Coordinating Center, Identification number

Tipo de datos

integer

Alias
UMLS CUI [1,1]
C2825181
UMLS CUI [1,2]
C1300638
Patient Number
Descripción

Clinical Trial Subject Unique Identifier

Tipo de datos

integer

Alias
UMLS CUI [1]
C2348585
Patient Initials
Descripción

Person Initials

Tipo de datos

text

Alias
UMLS CUI [1]
C2986440
Visit Date
Descripción

Date of visit

Tipo de datos

date

Alias
UMLS CUI [1]
C1320303
RLS Screen History
Descripción

RLS Screen History

Alias
UMLS CUI-1
C0035258
UMLS CUI-2
C0220908
UMLS CUI-3
C0262926
How old was the patient at the onset of RLS?
Descripción

Restless Legs Syndrome, Age of Onset

Tipo de datos

integer

Unidades de medida
  • years
Alias
UMLS CUI [1,1]
C0035258
UMLS CUI [1,2]
C0206132
years
Did the patient start any new medication near the time of their first onset of RLS symptoms that may have caused RLS?
Descripción

Restless Legs Syndrome, Pharmaceutical Preparations, Relationships

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C0035258
UMLS CUI [1,2]
C0013227
UMLS CUI [1,3]
C0439849
If ’Yes’ please specify medication(s)
Descripción

Restless Legs Syndrome, Pharmaceutical Preparations, Relationships

Tipo de datos

text

Alias
UMLS CUI [1,1]
C0035258
UMLS CUI [1,2]
C0013227
UMLS CUI [1,3]
C0439849
If female, did RLS symptoms develop during pregnancy?
Descripción

Restless Legs Syndrome, During, Pregnancy

Tipo de datos

text

Alias
UMLS CUI [1,1]
C0035258
UMLS CUI [1,2]
C0347984
UMLS CUI [1,3]
C0032961
Has the patient ever had PLMS (Periodic Limb Movements during Sleep)?
Descripción

Limb movement, Sleep

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C0596840
UMLS CUI [1,2]
C0037313
How old was the patient at the onset of PLMS?
Descripción

Limb movement, Sleep, Age of Onset

Tipo de datos

integer

Unidades de medida
  • years
Alias
UMLS CUI [1,1]
C0596840
UMLS CUI [1,2]
C0037313
UMLS CUI [1,3]
C0206132
years
Does the patient drink alcohol?
Descripción

Alcohol consumption

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0001948
Units/week
Descripción

Alcohol consumption, alcohol units/week

Tipo de datos

integer

Unidades de medida
  • Units/week
Alias
UMLS CUI [1,1]
C0001948
UMLS CUI [1,2]
C0560579
Units/week
Does the patient drink caffeine (coffee, tea, caffeinated drinks)?
Descripción

Caffeine consumption

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0948365
Cups/day
Descripción

Caffeine consumption, cups of coffee consumed per day (___cups/day)

Tipo de datos

integer

Unidades de medida
  • cups/day
Alias
UMLS CUI [1,1]
C0948365
UMLS CUI [1,2]
C2164136
cups/day
Does the patient have any sleep disorder as defined by DSM IV?
Descripción

f ’Yes’ please record on the Significant Medical/Surgical History and Physical Examination page.

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0851578
Has any first degree relative (mother/father, brother/sister, son/daughter) of the patient ever been diagnosed with or had symptoms of RLS?
Descripción

Restless Legs Syndrome, Family History

Tipo de datos

text

Alias
UMLS CUI [1,1]
C0035258
UMLS CUI [1,2]
C0241889
Has any first degree relative (mother/father, brother/sister, son/daughter) of the patient ever been diagnosed with or had symptoms of PLMS?
Descripción

Limb movement, Sleep, Family History

Tipo de datos

text

Alias
UMLS CUI [1,1]
C0596840
UMLS CUI [1,2]
C0037313
UMLS CUI [1,3]
C0241889
Are the patient’s current symptoms mainly present ...
Descripción

Restless Legs Syndrome; Symptoms; Temporal periods of day

Tipo de datos

text

Alias
UMLS CUI [1,1]
C0035258
UMLS CUI [1,2]
C1457887
UMLS CUI [1,3]
C0439548
RLS Diagnostic Criteria
Descripción

RLS Diagnostic Criteria

Alias
UMLS CUI-1
C0035258
UMLS CUI-2
C0679228
The International RLS Study Group Criteria* defines RLS patients as having a desire to move the limbs usually associated with paresthesias or dysesthesias.
Descripción

Restless Legs Syndrome, limb movement, desire; Restless Legs Syndrome, Paresthesia; Restless Legs Syndrome, Dysesthesia

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C0035258
UMLS CUI [1,2]
C0596840
UMLS CUI [1,3]
C0871633
UMLS CUI [2,1]
C0035258
UMLS CUI [2,2]
C0030554
UMLS CUI [3,1]
C0035258
UMLS CUI [3,2]
C0392699
The International RLS Study Group Criteria* defines RLS patients as having motor restlessness (during wakefulness does the patient move the limbs in attempt to relieve the discomfort).
Descripción

Restless Legs Syndrome, Motor Restlessness

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C0035258
UMLS CUI [1,2]
C0700075
The International RLS Study Group Criteria* defines RLS patients as having symptoms worse or exclusively present at rest with at least partial and temporal relief by activity
Descripción

Restless Legs Syndrome, Symptoms, Rest; Restless Legs Syndrom, Physical activity, Feeling relief

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C0035258
UMLS CUI [1,2]
C1457887
UMLS CUI [1,3]
C0035253
UMLS CUI [2,1]
C0035258
UMLS CUI [2,2]
C0026606
UMLS CUI [2,3]
C0564405
The International RLS Study Group Criteria* defines RLS patients as having symptoms worse in the evening or night.
Descripción

Restless Legs Syndrome, Symptoms, Temporal periods of day

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C0035258
UMLS CUI [1,2]
C1457887
UMLS CUI [1,3]
C0439548
Demography
Descripción

Demography

Alias
UMLS CUI-1
C0011298
Date of Birth
Descripción

Patient date of birth

Tipo de datos

date

Alias
UMLS CUI [1]
C0421451
Gender
Descripción

Gender

Tipo de datos

text

Alias
UMLS CUI [1]
C0079399
Race
Descripción

Racial group

Tipo de datos

text

Alias
UMLS CUI [1]
C0034510
Vital Signs
Descripción

Vital Signs

Alias
UMLS CUI-1
C0518766
Height (without shoes)
Descripción

Body Height

Tipo de datos

text

Alias
UMLS CUI [1]
C0005890
Height (without shoes)
Descripción

Body Height

Tipo de datos

float

Alias
UMLS CUI [1]
C0005890
Weight (without shoes)
Descripción

Body Weight

Tipo de datos

text

Alias
UMLS CUI [1]
C0005910
Weight (without shoes)
Descripción

Body Weight

Tipo de datos

float

Alias
UMLS CUI [1]
C0005910
Pulse (after 5 minutes sitting)
Descripción

Heart rate

Tipo de datos

integer

Unidades de medida
  • bpm
Alias
UMLS CUI [1]
C0018810
bpm
Sitting Blood Pressure (after 5 minutes sitting) - Systolic
Descripción

Systolic pressure, Sitting position

Tipo de datos

integer

Unidades de medida
  • mmHg
Alias
UMLS CUI [1,1]
C0871470
UMLS CUI [1,2]
C0277814
mmHg
Sitting Blood Pressure (after 5 minutes sitting) - Diastolic
Descripción

Diastolic blood pressure, Sitting position

Tipo de datos

integer

Unidades de medida
  • mmHg
Alias
UMLS CUI [1,1]
C0428883
UMLS CUI [1,2]
C0277814
mmHg
Orthostatic Vital Signs
Descripción

Orthostatic Vital Signs

Alias
UMLS CUI-1
C1827287
After 10 minutes semi-supine - Time Vitals Taken
Descripción

Semi-erect; Vital Signs Time

Tipo de datos

time

Alias
UMLS CUI [1,1]
C0522019
UMLS CUI [1,2]
C2826762
After 10 minutes semi-supine - Blood Pressure (systolic)
Descripción

Semi-erect; Systolic Pressure

Tipo de datos

integer

Unidades de medida
  • mmHg
Alias
UMLS CUI [1,1]
C0522019
UMLS CUI [1,2]
C0871470
mmHg
After 10 minutes semi-supine - Blood Pressure (diastolic)
Descripción

Semi-erect; Diastolic blood pressure

Tipo de datos

integer

Unidades de medida
  • mmHg
Alias
UMLS CUI [1,1]
C0522019
UMLS CUI [1,2]
C0428883
mmHg
After 10 minutes semi-supine - Pulse
Descripción

Semi-erect; Heart rate

Tipo de datos

integer

Unidades de medida
  • bpm
Alias
UMLS CUI [1,1]
C0522019
UMLS CUI [1,2]
C0018810
bpm
After erect for 1 minute - Time Vitals Taken
Descripción

Erect, Vital Signs Time

Tipo de datos

time

Alias
UMLS CUI [1,1]
C0522014
UMLS CUI [1,2]
C2826762
After erect for 1 minute - Blood Pressure (systolic)
Descripción

Erect, Systolic Pressure

Tipo de datos

integer

Unidades de medida
  • mmHg
Alias
UMLS CUI [1,1]
C0522014
UMLS CUI [1,2]
C0871470
mmHg
After erect for 1 minute - Blood Pressure (diastolic)
Descripción

Erect, Diastolic blood pressure

Tipo de datos

integer

Unidades de medida
  • mmHg
Alias
UMLS CUI [1,1]
C0522014
UMLS CUI [1,2]
C0428883
mmHg
After erect for 1 minute - Pulse
Descripción

Erect, Heart rate

Tipo de datos

integer

Unidades de medida
  • bpm
Alias
UMLS CUI [1,1]
C0522014
UMLS CUI [1,2]
C0018810
bpm
Electrocardiogram (12 Lead)
Descripción

Electrocardiogram (12 Lead)

Alias
UMLS CUI-1
C0430456
Date of ECG
Descripción

12 lead ECG, Date in time

Tipo de datos

date

Alias
UMLS CUI [1,1]
C0430456
UMLS CUI [1,2]
C0011008
Were any clinically significant abnormalities detected?
Descripción

If ’Yes’, please record details on the Significant Medical/Surgical History and Physical Examination or Baseline Signs and Symptoms/SAE pages and repeat prior to baseline.

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C0430456
UMLS CUI [1,2]
C1704258
Physical Examination
Descripción

Physical Examination

Alias
UMLS CUI-1
C0031809
Laboratory Evaluation
Descripción

Laboratory Evaluation

Alias
UMLS CUI-1
C0022885
UMLS CUI-2
C0220825
Date of blood sample
Descripción

Collection of blood specimen for laboratory procedure, Date in time

Tipo de datos

date

Alias
UMLS CUI [1,1]
C0005834
UMLS CUI [1,2]
C0011008
Please affix the Quest Diagnostics Laboratory label here.
Descripción

Laboratory Procedures, Laboratory specimen identification label

Tipo de datos

text

Alias
UMLS CUI [1,1]
C0022885
UMLS CUI [1,2]
C4273937
Were any clinically significant abnormalities detected?
Descripción

If ’Yes’, please record details on the Significant Medical/Surgical History and Physical Examination or Baseline Signs and Symptoms/SAE pages and repeat prior to baseline.

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C0022885
UMLS CUI [1,2]
C1704258
Urine Dipstick
Descripción

Urine Dipstick

Alias
UMLS CUI-1
C0430370
What was the result of the urine dipstick performed at this visit?
Descripción

If ’Positive’, please record details on the Significant Medical/Surgical History and Physical Examination or Baseline Signs and Symptoms/SAE pages and send a sample to Quest Diagnostics for further evaluation.

Tipo de datos

text

Alias
UMLS CUI [1,1]
C0430370
UMLS CUI [1,2]
C0456984
Pregnancy Dipstick
Descripción

Pregnancy Dipstick

Alias
UMLS CUI-1
C0430056
Is the patient a female of child-bearing potential?
Descripción

Childbearing Potential

Tipo de datos

boolean

Alias
UMLS CUI [1]
C3831118
If ’Yes’, please perform a pregnancy dipstick test and record result below.
Descripción

If ’Positive’, please record details on the Significant Medical/ Surgical History and Physical Examination and exclude the patient.

Tipo de datos

text

Alias
UMLS CUI [1,1]
C0430056
UMLS CUI [1,2]
C0456984
Significant Medical/Surgical History and Physical Examination
Descripción

Significant Medical/Surgical History and Physical Examination

Alias
UMLS CUI-1
C0262926
UMLS CUI-2
C0489540
UMLS CUI-3
C0031809
Is the patient suffering from or has he/she ever suffered from any significant medical or surgical condition?
Descripción

f 'Yes' , please list below one diagnosis per line. (Please print clearly)

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C0262926
UMLS CUI [1,2]
C0489540
Diagnosis (Only in the absence of a diagnosis, record the signs and symptoms on separate lines.)
Descripción

Medical History, Diagnosis; History of surgical procedures, Diagnosis

Tipo de datos

text

Alias
UMLS CUI [1,1]
C0262926
UMLS CUI [1,2]
C0011900
UMLS CUI [2,1]
C1948041
UMLS CUI [2,2]
C0011900
Year of first diagnosis (if known)
Descripción

Medical History, Diagnosis, Year; History of surgical procedures, Diagnosis, Year

Tipo de datos

integer

Alias
UMLS CUI [1,1]
C0262926
UMLS CUI [1,2]
C0011900
UMLS CUI [1,3]
C0439234
UMLS CUI [2,1]
C1948041
UMLS CUI [2,2]
C0011900
UMLS CUI [2,3]
C0439234
Past / Ongoing
Descripción

Medical History, Diagnosis, Current, Past; History of surgical procedures, Diagnosis, Current, Past

Tipo de datos

integer

Alias
UMLS CUI [1,1]
C0262926
UMLS CUI [1,2]
C0011900
UMLS CUI [1,3]
C0521116
UMLS CUI [1,4]
C1444637
UMLS CUI [2,1]
C1948041
UMLS CUI [2,2]
C0011900
UMLS CUI [2,3]
C0521116
UMLS CUI [2,4]
C1444637
Prior and Concomitant Medication
Descripción

Prior and Concomitant Medication

Alias
UMLS CUI-1
C2826257
UMLS CUI-3
C2347852
Has the patient taken any medication (excluding any pharmacotherapy medication for treatment of RLS) in the 3 months prior to study entry?
Descripción

If ‘Yes’, please record details below (Please print clearly)

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0013227
Drug Name (Trade Name Preferred)
Descripción

Pharmaceutical Preparations, Medication name

Tipo de datos

text

Alias
UMLS CUI [1,1]
C0013227
UMLS CUI [1,2]
C2360065
Total Daily Dose
Descripción

Pharmaceutical Preparations, Daily Dose, Total

Tipo de datos

text

Alias
UMLS CUI [1,1]
C0013227
UMLS CUI [1,2]
C2348070
UMLS CUI [1,3]
C0439810
Medical Illness/ Diagnosis (or symptom in absence of diagnosis)
Descripción

Pharmaceutical Preparations, Disease

Tipo de datos

text

Alias
UMLS CUI [1,1]
C0013227
UMLS CUI [1,2]
C0012634
Start Date (be as precise as possible)
Descripción

Pharmaceutical Preparation, Start Date

Tipo de datos

date

Alias
UMLS CUI [1,1]
C0013227
UMLS CUI [1,2]
C0808070
End Date
Descripción

Pharmaceutical Preparation, End Date

Tipo de datos

date

Alias
UMLS CUI [1,1]
C0013227
UMLS CUI [1,2]
C0806020
Continuing
Descripción

Pharmaceutical Preparations, Continuous

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C0013227
UMLS CUI [1,2]
C0549178
RLS Pharmacotherapy History
Descripción

RLS Pharmacotherapy History

Alias
UMLS CUI-1
C0035258
UMLS CUI-2
C0013227
UMLS CUI-3
C0262926
Has the patient taken any pharmacotherapy medication for treatment of RLS?
Descripción

If ‘Yes’, please record details below (Please print clearly)

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C0035258
UMLS CUI [1,2]
C0013227
UMLS CUI [1,3]
C0262926
Drug Name (Trade Name Preferred)
Descripción

Restless Legs Syndrome, Pharmaceutical Preparations, Medication name

Tipo de datos

text

Alias
UMLS CUI [1,1]
C0035258
UMLS CUI [1,2]
C0013227
UMLS CUI [1,3]
C2360065
Start Date (be as precise as possible)
Descripción

Restless Legs Syndrome, Pharmaceutical Preparations, Start Date

Tipo de datos

date

Alias
UMLS CUI [1,1]
C0035258
UMLS CUI [1,2]
C0013227
UMLS CUI [1,3]
C0808070
End Date
Descripción

Restless Legs Syndrome, Pharmaceutical Preparations, End Date

Tipo de datos

date

Alias
UMLS CUI [1,1]
C0035258
UMLS CUI [1,2]
C0013227
UMLS CUI [1,3]
C0806020
Continuing
Descripción

Restless Legs Syndrome, Pharmaceutical Preparations, Continuous

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C0035258
UMLS CUI [1,2]
C0013227
UMLS CUI [1,3]
C0549178
Did the patient respond to the treatment? (mark one)
Descripción

Restless Legs Syndrome, Drug Treatment and Response to Therapy

Tipo de datos

text

Alias
UMLS CUI [1,1]
C0035258
UMLS CUI [1,2]
C0150839
Did the patient tolerate the treatment? (mark one)
Descripción

Restless Legs Syndrome, Pharmaceutical Preparations, Physical tolerance to drug

Tipo de datos

text

Alias
UMLS CUI [1,1]
C0035258
UMLS CUI [1,2]
C0013227
UMLS CUI [1,3]
C0556444
Screening Inclusion/Exclusion Criteria
Descripción

Screening Inclusion/Exclusion Criteria

Alias
UMLS CUI-1
C0013893
Inclusion - Patients diagnosed with RLS using IRLSSG diagnostic criteria with a history of a minimum of 15 nights of RLS symptoms during the previous month. In the case of a patient currently receiving medication for the treatment of RLS, the investigator should use his/her best clinical judgement to assess whether that patient would have suffered from a minimum of 15 nights with RLS symptoms if they had not been taking any medication.
Descripción

Restless Legs Syndrome, Diagnosis

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C0035258
UMLS CUI [1,2]
C0011900
Inclusion - Patient is ≥ 18 years old and < 80 years of age.
Descripción

Age

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0001779
Inclusion - Patient has given written informed consent prior to any specific study procedures.
Descripción

Informed Consent

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0021430
Exclusion - Patient is suffering from RLS symptoms which require treatment during the daytime (daytime defined as 10.00 until 18.00).
Descripción

Restless Legs Syndrome, Daytime

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C0035258
UMLS CUI [1,2]
C0332169
Exclusion - Patient suffers from a primary sleep disorder other than RLS that may significantly affect the symptoms of RLS (e.g. narcolepsy, sleep terror disorder, sleepwalking disorder, breathing related sleep disorder).
Descripción

Primary Sleep Disorders

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0236991
Exclusion - Patient is suffering from a movement disorder (e.g. Parkinson's Disease, dyskinesias or dystonias).
Descripción

Movement Disorders

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0026650
Exclusion - Patient has medical conditions with symptoms which could affect assessments of efficacy (e.g. diabetes, peripheral neuropathy, rheumatoid arthritis, fibromyalgia syndrome, etc.).
Descripción

Disease

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0012634
Exclusion - Patient has exhibited intolerance to ropinirole or any other dopamine agonist
Descripción

Ropinirole, Intolerance to substance; Dopamine Agonists, Intolerance to substance

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C0244821
UMLS CUI [1,2]
C1744706
UMLS CUI [2,1]
C0178601
UMLS CUI [2,2]
C1744706
Exclusion - Patient meets DSM-IV criteria for substance abuse (alcohol or drugs) or substance dependence within 6 months prior to Screening.
Descripción

Substance Use Disorders; Substance Dependence

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0038586
UMLS CUI [2]
C0038580
Exclusion - Patient is a woman, of child-bearing potential and is not practising a clinically accepted method of contraception such as oral contraception, surgical sterilisation, IUD, diaphragm in conjunction with spermicidal foam and condom on the male partner, or systemic contraception (i.e., Norplant).
Descripción

Female, Childbearing Potential, Contraceptive methods

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C0086287
UMLS CUI [1,2]
C3831118
UMLS CUI [1,3]
C0700589
Exclusion - Patient is a woman who has a positive pregnancy test or is lactating.
Descripción

Female, Pregnancy; Female, Breast Feeding

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C0086287
UMLS CUI [1,2]
C0032961
UMLS CUI [2,1]
C0086287
UMLS CUI [2,2]
C0006147
Exclusion - Patient has clinically significant or unstable medical conditions which in the opinion of the investigator would render the patient unsuitable for the study (e.g., symptomatic orthostatic hypotension, severe cardiovascular disease, hepatic or renal failure, etc.).
Descripción

Disease

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0012634
Exclusion - Patient who, in the opinion of the Investigator, would be non-compliant with the visit schedule or other study procedures.
Descripción

Non-Compliance

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0457432
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Similar models

Screening

1 formularios
  1. StudyEvent: ODM
    1. Screening
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
Alias
Item Group
Administrative data
C1320722 (UMLS CUI-1)
Study Coordinating Center, Identification number
Item
Centre Number
integer
C2825181 (UMLS CUI [1,1])
C1300638 (UMLS CUI [1,2])
Clinical Trial Subject Unique Identifier
Item
Patient Number
integer
C2348585 (UMLS CUI [1])
Person Initials
Item
Patient Initials
text
C2986440 (UMLS CUI [1])
Date of visit
Item
Visit Date
date
C1320303 (UMLS CUI [1])
Item Group
RLS Screen History
C0035258 (UMLS CUI-1)
C0220908 (UMLS CUI-2)
C0262926 (UMLS CUI-3)
Restless Legs Syndrome, Age of Onset
Item
How old was the patient at the onset of RLS?
integer
C0035258 (UMLS CUI [1,1])
C0206132 (UMLS CUI [1,2])
Restless Legs Syndrome, Pharmaceutical Preparations, Relationships
Item
Did the patient start any new medication near the time of their first onset of RLS symptoms that may have caused RLS?
boolean
C0035258 (UMLS CUI [1,1])
C0013227 (UMLS CUI [1,2])
C0439849 (UMLS CUI [1,3])
Restless Legs Syndrome, Pharmaceutical Preparations, Relationships
Item
If ’Yes’ please specify medication(s)
text
C0035258 (UMLS CUI [1,1])
C0013227 (UMLS CUI [1,2])
C0439849 (UMLS CUI [1,3])
Item
If female, did RLS symptoms develop during pregnancy?
text
C0035258 (UMLS CUI [1,1])
C0347984 (UMLS CUI [1,2])
C0032961 (UMLS CUI [1,3])
Restless Legs Syndrome, During, Pregnancy
Code List
If female, did RLS symptoms develop during pregnancy?
CL Item
No (1)
CL Item
Yes (2)
CL Item
Not applicable (3)
Limb movement, Sleep
Item
Has the patient ever had PLMS (Periodic Limb Movements during Sleep)?
boolean
C0596840 (UMLS CUI [1,1])
C0037313 (UMLS CUI [1,2])
Limb movement, Sleep, Age of Onset
Item
How old was the patient at the onset of PLMS?
integer
C0596840 (UMLS CUI [1,1])
C0037313 (UMLS CUI [1,2])
C0206132 (UMLS CUI [1,3])
Alcohol consumption
Item
Does the patient drink alcohol?
boolean
C0001948 (UMLS CUI [1])
Alcohol consumption, alcohol units/week
Item
Units/week
integer
C0001948 (UMLS CUI [1,1])
C0560579 (UMLS CUI [1,2])
Caffeine consumption
Item
Does the patient drink caffeine (coffee, tea, caffeinated drinks)?
boolean
C0948365 (UMLS CUI [1])
Caffeine consumption, cups of coffee consumed per day (___cups/day)
Item
Cups/day
integer
C0948365 (UMLS CUI [1,1])
C2164136 (UMLS CUI [1,2])
Sleep Disorders
Item
Does the patient have any sleep disorder as defined by DSM IV?
boolean
C0851578 (UMLS CUI [1])
Item
Has any first degree relative (mother/father, brother/sister, son/daughter) of the patient ever been diagnosed with or had symptoms of RLS?
text
C0035258 (UMLS CUI [1,1])
C0241889 (UMLS CUI [1,2])
Restless Legs Syndrome, Family History
Code List
Has any first degree relative (mother/father, brother/sister, son/daughter) of the patient ever been diagnosed with or had symptoms of RLS?
CL Item
No  (1)
CL Item
Yes (2)
CL Item
Unknown (3)
Item
Has any first degree relative (mother/father, brother/sister, son/daughter) of the patient ever been diagnosed with or had symptoms of PLMS?
text
C0596840 (UMLS CUI [1,1])
C0037313 (UMLS CUI [1,2])
C0241889 (UMLS CUI [1,3])
Restless Legs Syndrome, Family History
Code List
Has any first degree relative (mother/father, brother/sister, son/daughter) of the patient ever been diagnosed with or had symptoms of PLMS?
CL Item
No  (1)
CL Item
Yes (2)
CL Item
Unknown (3)
Item
Are the patient’s current symptoms mainly present ...
text
C0035258 (UMLS CUI [1,1])
C1457887 (UMLS CUI [1,2])
C0439548 (UMLS CUI [1,3])
Restless Legs Syndrome; Symptoms; Temporal periods of day
Code List
Are the patient’s current symptoms mainly present ...
CL Item
At nightime only (1)
CL Item
In evening and nightime (2)
CL Item
Daytime, evening and nightime (3)
Item Group
RLS Diagnostic Criteria
C0035258 (UMLS CUI-1)
C0679228 (UMLS CUI-2)
Restless Legs Syndrome, limb movement, desire; Restless Legs Syndrome, Paresthesia; Restless Legs Syndrome, Dysesthesia
Item
The International RLS Study Group Criteria* defines RLS patients as having a desire to move the limbs usually associated with paresthesias or dysesthesias.
boolean
C0035258 (UMLS CUI [1,1])
C0596840 (UMLS CUI [1,2])
C0871633 (UMLS CUI [1,3])
C0035258 (UMLS CUI [2,1])
C0030554 (UMLS CUI [2,2])
C0035258 (UMLS CUI [3,1])
C0392699 (UMLS CUI [3,2])
Restless Legs Syndrome, Motor Restlessness
Item
The International RLS Study Group Criteria* defines RLS patients as having motor restlessness (during wakefulness does the patient move the limbs in attempt to relieve the discomfort).
boolean
C0035258 (UMLS CUI [1,1])
C0700075 (UMLS CUI [1,2])
Restless Legs Syndrome, Symptoms, Rest; Restless Legs Syndrom, Physical activity, Feeling relief
Item
The International RLS Study Group Criteria* defines RLS patients as having symptoms worse or exclusively present at rest with at least partial and temporal relief by activity
boolean
C0035258 (UMLS CUI [1,1])
C1457887 (UMLS CUI [1,2])
C0035253 (UMLS CUI [1,3])
C0035258 (UMLS CUI [2,1])
C0026606 (UMLS CUI [2,2])
C0564405 (UMLS CUI [2,3])
Restless Legs Syndrome, Symptoms, Temporal periods of day
Item
The International RLS Study Group Criteria* defines RLS patients as having symptoms worse in the evening or night.
boolean
C0035258 (UMLS CUI [1,1])
C1457887 (UMLS CUI [1,2])
C0439548 (UMLS CUI [1,3])
Item Group
Demography
C0011298 (UMLS CUI-1)
Patient date of birth
Item
Date of Birth
date
C0421451 (UMLS CUI [1])
Item
Gender
text
C0079399 (UMLS CUI [1])
undefined item
Code List
Gender
CL Item
Male (1)
CL Item
Female (2)
Item
Race
text
C0034510 (UMLS CUI [1])
Racial group
Code List
Race
CL Item
White  (1)
CL Item
Black (2)
CL Item
Oriental (3)
CL Item
Other, specify: (4)
Item Group
Vital Signs
C0518766 (UMLS CUI-1)
Item
Height (without shoes)
text
C0005890 (UMLS CUI [1])
Body Height
Code List
Height (without shoes)
CL Item
cm (1)
CL Item
in (2)
Body Height
Item
Height (without shoes)
float
C0005890 (UMLS CUI [1])
Item
Weight (without shoes)
text
C0005910 (UMLS CUI [1])
Body Weight
Code List
Weight (without shoes)
CL Item
kg (1)
CL Item
lbs (2)
Body Weight
Item
Weight (without shoes)
float
C0005910 (UMLS CUI [1])
Heart rate
Item
Pulse (after 5 minutes sitting)
integer
C0018810 (UMLS CUI [1])
Systolic pressure, Sitting position
Item
Sitting Blood Pressure (after 5 minutes sitting) - Systolic
integer
C0871470 (UMLS CUI [1,1])
C0277814 (UMLS CUI [1,2])
Diastolic blood pressure, Sitting position
Item
Sitting Blood Pressure (after 5 minutes sitting) - Diastolic
integer
C0428883 (UMLS CUI [1,1])
C0277814 (UMLS CUI [1,2])
Item Group
Orthostatic Vital Signs
C1827287 (UMLS CUI-1)
Semi-erect; Vital Signs Time
Item
After 10 minutes semi-supine - Time Vitals Taken
time
C0522019 (UMLS CUI [1,1])
C2826762 (UMLS CUI [1,2])
Semi-erect; Systolic Pressure
Item
After 10 minutes semi-supine - Blood Pressure (systolic)
integer
C0522019 (UMLS CUI [1,1])
C0871470 (UMLS CUI [1,2])
Semi-erect; Diastolic blood pressure
Item
After 10 minutes semi-supine - Blood Pressure (diastolic)
integer
C0522019 (UMLS CUI [1,1])
C0428883 (UMLS CUI [1,2])
Semi-erect; Heart rate
Item
After 10 minutes semi-supine - Pulse
integer
C0522019 (UMLS CUI [1,1])
C0018810 (UMLS CUI [1,2])
Erect, Vital Signs Time
Item
After erect for 1 minute - Time Vitals Taken
time
C0522014 (UMLS CUI [1,1])
C2826762 (UMLS CUI [1,2])
Erect, Systolic Pressure
Item
After erect for 1 minute - Blood Pressure (systolic)
integer
C0522014 (UMLS CUI [1,1])
C0871470 (UMLS CUI [1,2])
Erect, Diastolic blood pressure
Item
After erect for 1 minute - Blood Pressure (diastolic)
integer
C0522014 (UMLS CUI [1,1])
C0428883 (UMLS CUI [1,2])
Erect, Heart rate
Item
After erect for 1 minute - Pulse
integer
C0522014 (UMLS CUI [1,1])
C0018810 (UMLS CUI [1,2])
Item Group
Electrocardiogram (12 Lead)
C0430456 (UMLS CUI-1)
12 lead ECG, Date in time
Item
Date of ECG
date
C0430456 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
12 lead ECG, Abnormality
Item
Were any clinically significant abnormalities detected?
boolean
C0430456 (UMLS CUI [1,1])
C1704258 (UMLS CUI [1,2])
Item Group
Physical Examination
C0031809 (UMLS CUI-1)
Item Group
Laboratory Evaluation
C0022885 (UMLS CUI-1)
C0220825 (UMLS CUI-2)
Collection of blood specimen for laboratory procedure, Date in time
Item
Date of blood sample
date
C0005834 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Laboratory Procedures, Laboratory specimen identification label
Item
Please affix the Quest Diagnostics Laboratory label here.
text
C0022885 (UMLS CUI [1,1])
C4273937 (UMLS CUI [1,2])
Laboratory Procedures, Abnormality
Item
Were any clinically significant abnormalities detected?
boolean
C0022885 (UMLS CUI [1,1])
C1704258 (UMLS CUI [1,2])
Item Group
Urine Dipstick
C0430370 (UMLS CUI-1)
Item
What was the result of the urine dipstick performed at this visit?
text
C0430370 (UMLS CUI [1,1])
C0456984 (UMLS CUI [1,2])
Urine dipstick test, Test Result
Code List
What was the result of the urine dipstick performed at this visit?
CL Item
Negative (1)
CL Item
Positive (2)
Item Group
Pregnancy Dipstick
C0430056 (UMLS CUI-1)
Childbearing Potential
Item
Is the patient a female of child-bearing potential?
boolean
C3831118 (UMLS CUI [1])
Item
If ’Yes’, please perform a pregnancy dipstick test and record result below.
text
C0430056 (UMLS CUI [1,1])
C0456984 (UMLS CUI [1,2])
Urine pregnancy test, Test Result
Code List
If ’Yes’, please perform a pregnancy dipstick test and record result below.
CL Item
Negative (1)
CL Item
Positive (2)
Item Group
Significant Medical/Surgical History and Physical Examination
C0262926 (UMLS CUI-1)
C0489540 (UMLS CUI-2)
C0031809 (UMLS CUI-3)
Medical History, History of surgical procedures
Item
Is the patient suffering from or has he/she ever suffered from any significant medical or surgical condition?
boolean
C0262926 (UMLS CUI [1,1])
C0489540 (UMLS CUI [1,2])
Medical History, Diagnosis; History of surgical procedures, Diagnosis
Item
Diagnosis (Only in the absence of a diagnosis, record the signs and symptoms on separate lines.)
text
C0262926 (UMLS CUI [1,1])
C0011900 (UMLS CUI [1,2])
C1948041 (UMLS CUI [2,1])
C0011900 (UMLS CUI [2,2])
Medical History, Diagnosis, Year; History of surgical procedures, Diagnosis, Year
Item
Year of first diagnosis (if known)
integer
C0262926 (UMLS CUI [1,1])
C0011900 (UMLS CUI [1,2])
C0439234 (UMLS CUI [1,3])
C1948041 (UMLS CUI [2,1])
C0011900 (UMLS CUI [2,2])
C0439234 (UMLS CUI [2,3])
Item
Past / Ongoing
integer
C0262926 (UMLS CUI [1,1])
C0011900 (UMLS CUI [1,2])
C0521116 (UMLS CUI [1,3])
C1444637 (UMLS CUI [1,4])
C1948041 (UMLS CUI [2,1])
C0011900 (UMLS CUI [2,2])
C0521116 (UMLS CUI [2,3])
C1444637 (UMLS CUI [2,4])
Medical History, Diagnosis, Current, Past; History of surgical procedures, Diagnosis, Current, Past
Code List
Past / Ongoing
CL Item
Past (1)
CL Item
Ongoing (2)
Item Group
Prior and Concomitant Medication
C2826257 (UMLS CUI-1)
C2347852 (UMLS CUI-3)
Pharmaceutical Preparations
Item
Has the patient taken any medication (excluding any pharmacotherapy medication for treatment of RLS) in the 3 months prior to study entry?
boolean
C0013227 (UMLS CUI [1])
Pharmaceutical Preparations, Medication name
Item
Drug Name (Trade Name Preferred)
text
C0013227 (UMLS CUI [1,1])
C2360065 (UMLS CUI [1,2])
Pharmaceutical Preparations, Daily Dose, Total
Item
Total Daily Dose
text
C0013227 (UMLS CUI [1,1])
C2348070 (UMLS CUI [1,2])
C0439810 (UMLS CUI [1,3])
Pharmaceutical Preparations, Disease
Item
Medical Illness/ Diagnosis (or symptom in absence of diagnosis)
text
C0013227 (UMLS CUI [1,1])
C0012634 (UMLS CUI [1,2])
Pharmaceutical Preparation, Start Date
Item
Start Date (be as precise as possible)
date
C0013227 (UMLS CUI [1,1])
C0808070 (UMLS CUI [1,2])
Pharmaceutical Preparation, End Date
Item
End Date
date
C0013227 (UMLS CUI [1,1])
C0806020 (UMLS CUI [1,2])
Pharmaceutical Preparations, Continuous
Item
Continuing
boolean
C0013227 (UMLS CUI [1,1])
C0549178 (UMLS CUI [1,2])
Item Group
RLS Pharmacotherapy History
C0035258 (UMLS CUI-1)
C0013227 (UMLS CUI-2)
C0262926 (UMLS CUI-3)
Restless Legs Syndrome, Pharmaceutical Preparations, Medical History
Item
Has the patient taken any pharmacotherapy medication for treatment of RLS?
boolean
C0035258 (UMLS CUI [1,1])
C0013227 (UMLS CUI [1,2])
C0262926 (UMLS CUI [1,3])
Restless Legs Syndrome, Pharmaceutical Preparations, Medication name
Item
Drug Name (Trade Name Preferred)
text
C0035258 (UMLS CUI [1,1])
C0013227 (UMLS CUI [1,2])
C2360065 (UMLS CUI [1,3])
Restless Legs Syndrome, Pharmaceutical Preparations, Start Date
Item
Start Date (be as precise as possible)
date
C0035258 (UMLS CUI [1,1])
C0013227 (UMLS CUI [1,2])
C0808070 (UMLS CUI [1,3])
Restless Legs Syndrome, Pharmaceutical Preparations, End Date
Item
End Date
date
C0035258 (UMLS CUI [1,1])
C0013227 (UMLS CUI [1,2])
C0806020 (UMLS CUI [1,3])
Restless Legs Syndrome, Pharmaceutical Preparations, Continuous
Item
Continuing
boolean
C0035258 (UMLS CUI [1,1])
C0013227 (UMLS CUI [1,2])
C0549178 (UMLS CUI [1,3])
Item
Did the patient respond to the treatment? (mark one)
text
C0035258 (UMLS CUI [1,1])
C0150839 (UMLS CUI [1,2])
Restless Legs Syndrome, Drug Treatment and Response to Therapy
Code List
Did the patient respond to the treatment? (mark one)
CL Item
Yes (1)
CL Item
No (2)
CL Item
Unknown (3)
Item
Did the patient tolerate the treatment? (mark one)
text
C0035258 (UMLS CUI [1,1])
C0013227 (UMLS CUI [1,2])
C0556444 (UMLS CUI [1,3])
Restless Legs Syndrome, Drug Treatment and Response to Therapy
Code List
Did the patient tolerate the treatment? (mark one)
CL Item
Yes (1)
CL Item
No (2)
CL Item
Unknown (3)
Item Group
Screening Inclusion/Exclusion Criteria
C0013893 (UMLS CUI-1)
Restless Legs Syndrome, Diagnosis
Item
Inclusion - Patients diagnosed with RLS using IRLSSG diagnostic criteria with a history of a minimum of 15 nights of RLS symptoms during the previous month. In the case of a patient currently receiving medication for the treatment of RLS, the investigator should use his/her best clinical judgement to assess whether that patient would have suffered from a minimum of 15 nights with RLS symptoms if they had not been taking any medication.
boolean
C0035258 (UMLS CUI [1,1])
C0011900 (UMLS CUI [1,2])
Age
Item
Inclusion - Patient is ≥ 18 years old and < 80 years of age.
boolean
C0001779 (UMLS CUI [1])
Informed Consent
Item
Inclusion - Patient has given written informed consent prior to any specific study procedures.
boolean
C0021430 (UMLS CUI [1])
Restless Legs Syndrome, Daytime
Item
Exclusion - Patient is suffering from RLS symptoms which require treatment during the daytime (daytime defined as 10.00 until 18.00).
boolean
C0035258 (UMLS CUI [1,1])
C0332169 (UMLS CUI [1,2])
Primary Sleep Disorders
Item
Exclusion - Patient suffers from a primary sleep disorder other than RLS that may significantly affect the symptoms of RLS (e.g. narcolepsy, sleep terror disorder, sleepwalking disorder, breathing related sleep disorder).
boolean
C0236991 (UMLS CUI [1])
Movement Disorders
Item
Exclusion - Patient is suffering from a movement disorder (e.g. Parkinson's Disease, dyskinesias or dystonias).
boolean
C0026650 (UMLS CUI [1])
Disease
Item
Exclusion - Patient has medical conditions with symptoms which could affect assessments of efficacy (e.g. diabetes, peripheral neuropathy, rheumatoid arthritis, fibromyalgia syndrome, etc.).
boolean
C0012634 (UMLS CUI [1])
Ropinirole, Intolerance to substance; Dopamine Agonists, Intolerance to substance
Item
Exclusion - Patient has exhibited intolerance to ropinirole or any other dopamine agonist
boolean
C0244821 (UMLS CUI [1,1])
C1744706 (UMLS CUI [1,2])
C0178601 (UMLS CUI [2,1])
C1744706 (UMLS CUI [2,2])
Substance Use Disorders; Substance Dependence
Item
Exclusion - Patient meets DSM-IV criteria for substance abuse (alcohol or drugs) or substance dependence within 6 months prior to Screening.
boolean
C0038586 (UMLS CUI [1])
C0038580 (UMLS CUI [2])
Female, Childbearing Potential, Contraceptive methods
Item
Exclusion - Patient is a woman, of child-bearing potential and is not practising a clinically accepted method of contraception such as oral contraception, surgical sterilisation, IUD, diaphragm in conjunction with spermicidal foam and condom on the male partner, or systemic contraception (i.e., Norplant).
boolean
C0086287 (UMLS CUI [1,1])
C3831118 (UMLS CUI [1,2])
C0700589 (UMLS CUI [1,3])
Female, Pregnancy; Female, Breast Feeding
Item
Exclusion - Patient is a woman who has a positive pregnancy test or is lactating.
boolean
C0086287 (UMLS CUI [1,1])
C0032961 (UMLS CUI [1,2])
C0086287 (UMLS CUI [2,1])
C0006147 (UMLS CUI [2,2])
Disease
Item
Exclusion - Patient has clinically significant or unstable medical conditions which in the opinion of the investigator would render the patient unsuitable for the study (e.g., symptomatic orthostatic hypotension, severe cardiovascular disease, hepatic or renal failure, etc.).
boolean
C0012634 (UMLS CUI [1])
Non-Compliance
Item
Exclusion - Patient who, in the opinion of the Investigator, would be non-compliant with the visit schedule or other study procedures.
boolean
C0457432 (UMLS CUI [1])
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