Table 3. Adjudication survey Pain . No.... | American Society of Hematology

Table 3.

Adjudication survey

Pain
No. of severe pain events and/or hospitalizations for acute VOP events per year for the last 2 y? ______
Prescribed hydroxyurea therapy? Yes ___ No ___ a. Baseline laboratory tests before starting hydroxyurea: Hb Hb F MCV Platelets If yes, current hydroxyurea dose and for how long at this dose: _____ Hb Hb F MCV Platelets Does the treating hematologist believe the patient has been adherent to their hydroxyurea therapy? What is the local definition of maximum tolerated dose of hydroxyurea (MTD HU)? Did the patient meet the local definition of MTD HU? Yes ____ No____ Specify any side effects: ________
Prescribed other therapies to decrease VOEs? a. L-glutamine: Yes ___ No____ If yes, when started: ______ Maximum dose used: _____ Any side effects at MTD? Yes ____ No_____ If yes, provide details: _____ Crizanlizumab: Yes____ No____ If yes, when started: ____ Maximum dose used: ____ Any side effects of MTD? Yes___ No___ If yes, provide details: ____ Chronic blood transfusions: Yes___ No___ If yes, when started, length of time on transfusions: _____
Has the possibility of pain associated with the following been evaluated? a. Menstrual cycle: Yes ___ No___ NA___ Traumatic event or stress (eg, divorce, trauma, and domestic violence) as precipitating pain been discussed with the: Patient alone? Yes___ No___ Parent alone? Yes___ No___ AVN or spinal compression fracture? Yes___ No___ Not evaluated___ If yes to any of the above, have they been addressed or still ongoing? ______
History of asthma? Yes___ No___ a. Did the first episode of ACS occur before 4 y of age? Yes___ No___ Evidence of optimal asthma medical care (eg, controller medication that matches asthma severity) _______ Referral to an asthma specialist? Yes___ No___
Has the treating hematologist attending provided a statement that the patient has been prescribed disease-modifying therapy for SCD, asthma, or both and despite evidence of adherence continues to have acute VOEs? Yes___ No___
Priapism (Only report episodes happening at least 4 h)
No. of priapism events per week/month for the last 12 mo managed at home? _____ No. of hospitalizations for priapism events per year for last 2 y? ____ Length of each priapism episode documented in the medical record?

Pain
No. of severe pain events and/or hospitalizations for acute VOP events per year for the last 2 y? ______
Prescribed hydroxyurea therapy? Yes ___ No ___ a. Baseline laboratory tests before starting hydroxyurea: Hb Hb F MCV Platelets If yes, current hydroxyurea dose and for how long at this dose: _____ Hb Hb F MCV Platelets Does the treating hematologist believe the patient has been adherent to their hydroxyurea therapy? What is the local definition of maximum tolerated dose of hydroxyurea (MTD HU)? Did the patient meet the local definition of MTD HU? Yes ____ No____ Specify any side effects: ________
Prescribed other therapies to decrease VOEs? a. L-glutamine: Yes ___ No____ If yes, when started: ______ Maximum dose used: _____ Any side effects at MTD? Yes ____ No_____ If yes, provide details: _____ Crizanlizumab: Yes____ No____ If yes, when started: ____ Maximum dose used: ____ Any side effects of MTD? Yes___ No___ If yes, provide details: ____ Chronic blood transfusions: Yes___ No___ If yes, when started, length of time on transfusions: _____
Has the possibility of pain associated with the following been evaluated? a. Menstrual cycle: Yes ___ No___ NA___ Traumatic event or stress (eg, divorce, trauma, and domestic violence) as precipitating pain been discussed with the: Patient alone? Yes___ No___ Parent alone? Yes___ No___ AVN or spinal compression fracture? Yes___ No___ Not evaluated___ If yes to any of the above, have they been addressed or still ongoing? ______
History of asthma? Yes___ No___ a. Did the first episode of ACS occur before 4 y of age? Yes___ No___ Evidence of optimal asthma medical care (eg, controller medication that matches asthma severity) _______ Referral to an asthma specialist? Yes___ No___
Has the treating hematologist attending provided a statement that the patient has been prescribed disease-modifying therapy for SCD, asthma, or both and despite evidence of adherence continues to have acute VOEs? Yes___ No___
Priapism (Only report episodes happening at least 4 h)
No. of priapism events per week/month for the last 12 mo managed at home? _____ No. of hospitalizations for priapism events per year for last 2 y? ____ Length of each priapism episode documented in the medical record?

The survey was completed by enrolling institutions and reviewed by the adjudication committee.

AVN, avascular necrosis; Hb F, hemoglobin F; MCV, mean corpuscular volume; NA, not applicable; VOE, vaso occlusive event.