CLL-TIM

CLL-TIM Data Input Form

How to Use

Please fill in any patient data available for CLL-TIM to make its prediction. CLL-TIM is designed to work with missing values, so you are not required to enter all the requested patient information. For confident predictions, inputting patient data prior to CLL-diagnosis at several time-points, for laboratory tests and blood cultures, is recommended.

Note: Once you input data and receive CLL-TIM's prediction, you may make additional changes to some of the parameters and invoke CLL-TIM to predict again.

Diagnosis Date

Date of CLL Diagnosis

Date of Prediction (Set at 3 to 12 months post diagnosis)

Patient Details

Patient ID

Gender

Age

BaseLine

Binet Stage

IGHV mutational status

ECOG Status

Familial CLL

Beta-2 -microglubulin > 4.0 (mg/L)

CD38-expression >=30%

ZAP-70 expression >=20%

Please do not use Döhner's FISH hierarchy for entering values

del(13q)

tri(12)

del(11q)

del(17p)

Routine Lab Test Variables

Do you have any routine lab test information on Patient? Yes No

	Lab Test Date	Beta-2-microglobulin (mg/L)	Haemoglobin (mmol/L)	Erythrocyte Count (RBC) (10⁹/L)	Mean Cell Haemoglobin (MCH) (10¹²/L)	Mean Cell Volume, Erythrocyte count (10¹²/L)	Mean Cell Haemoglobin concentration (MCHC) (mmol/L)	Hematocrit (%)	Leukocytes (WBC) (10⁹/L)	Absolute Neutrophile Count (10⁹/L)	Eosinophilocytes (10⁹/L)	Basophilocytes (10⁹/L)	Absolute Lymphocyte Count (ALC) (10⁹/L)	Myeloid Immature Cells (10⁹/L)	Myelocytes (10⁹/L)	Metamyelocytes (10⁹/L)	Promyelocytes (10⁹/L)	Blast Cells (10⁹/L)	Smudge Cells (10⁹/L)	Platelet Count (10⁹/L)	Amylase (U/L)	Alkaline Phosphatase (U/L)	Creatinine (µmol/L)	eGFR (mL/min)	Albumine (g/L)	Sodium (mmol/L)	Transferrin (µmol/L)	Lactate Dehydrogenase (U/L)	C-Reactive Protein (CRP) (mg/L)	Uric Acid (mmol/L)	Prostate Specific Antigen (μg/L)	Glucose (mmol/L)	Creatinine Kinase (U/L)	International Normalized Ratio

Bloodculture

Do you have any blood culture information on Patient? Yes No

Pathology

Do you have any pathology information on Patient? Yes No