Tuesday, 30 March 2021

We are all in the gutter, but some of us are looking at the stars. - Oscar Wilde X FRIGHTMOVE

 

Diego Vallmitjana lenticularis
Altocumulus lenticularis clouds ARGNTNA



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Moral outrage makes people seem more attractive, new research finds.

Moral outrage can take many forms, including protesting against injustice, supporting political action and helping victims get recompense.


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CONTENTMENT IS PEM - PLSR ENGAGEMENT MEANING


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FOCUS IS THE ULTIMATE TOOL FOR ACADEMIC EXCEELLENCE


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FLOW X FOCUS= SUCCESS


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HOLLYWOOD -CNMA 

NY- STOCK EX

HARVARD- KNWLDGE


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ALTRUISM KARMA PROSCIAL COMPASSN - SPIRTUALITY

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MEANING IS SECULAR WAY OF SPIRITUALITY


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KARMA YOGA X MEDITATION X BHAKTI YOGA IMPROVES PSYCHOL RESILIENCE

SELF ENQUIRY 

4 SOURCES OF MEANING IN LYF

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How Can Consciousness Have Multiple Experiences at Once?

https://www.ted.com/talks/donald_hoffman_do_we_see_reality_as_it_is?utm_campaign=tedspread&utm_medium=referral&utm_source=tedcomshare




















POE-LON , LOK , LOIP X B GHI X GKW

 

uluru waterfalls oz 


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GHI X GKW

We do have the potential to awaken, but we must do the hard work of distinguishing when we are motivated by greed, hatred, and delusion, and when we are motivated by their opposites—generosity, kindness, and wisdom.

—Lynn Kelly, “First Thought, Worst Thought”


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kipling 

"Words are, of course, the most powerful drug used by mankind.

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SHELLEY-
"The very winds whispered in soothing accents, and maternal Nature bade me weep no more."

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"Ultimately the bond of all companionship, whether in marriage or in friendship, is conversation."

-- Oscar Wilde



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VAN GOGH

“Normality is a paved road: it’s comfortable to walk, but no flowers grow on it.”


If I am worth anything later, I am worth something now. For wheat is wheat, even if people think it is a grass in the beginning.”


“Your profession is not what brings home your weekly paycheck, your profession is what you’re put here on earth to do, with such passion and such intensity that it becomes spiritual in calling.”



Sunday, 28 March 2021

Observation of an observer | Episode 2 - Part 2




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BP ema Chodron:

“The way to dissolve our resistance to life is to meet it face to face. When we feel resentment because the room is too hot, we could meet the heat and feel its fieriness and its heaviness. When we feel resentment because the room is too cold, we could meet the cold and feel its iciness and its bite. When we want to complain about the rain, we could feel its wetness instead. When we worry because the wind is shaking our windows, we could meet the wind and hear its sound. Cutting our expectations for a cure is a gift we can give ourselves. There is no cure for hot and cold. They will go on forever. After we have died, the ebb and flow will still continue. Like the tides of the sea, like day and night—this is the nature of things. Being able to appreciate, being able to look closely, being able to open our minds—this is the core of maitri [loving-kindness].”


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Saudade: a Portuguese word that means "a deep emotional state of nostalgic or profound melancholic longing for an absent something or someone that one cares for and/or loves. Moreover, it often carries a repressed knowledge that the object of longing might never be had again. It is the recollection of feelings, experiences, places, or events that once brought excitement, pleasure, and well-being, which now trigger the senses and make one experience the pain of separation from those joyous sensations."



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“I choose to live by choice, not by chance.”

 — Miyamoto Musashi



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Saturday, 27 March 2021

HBD MTHR 83 X HBD SSTR 53 X HPPY HOLI

 









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B

OBSERVING MIND SAW BOTH THOUGHTS

I continued to sit, I was able to watch aversion operating in the mind. On the one hand, the mind was straining to hear what my teacher was saying. On the other hand, a group of children were making noise just outside the meditation hall. I wanted them to stop, and I saw the mind complaining about the noise and complaining that I couldn’t hear my teacher’s talk



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DTHING AND NIGHTING WITH MANTRA JAPA

TO DTH GRACEFULLY


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মৃত্যুকালে আমাদের শুধুমাত্র কৃষ্ণের কাছে প্রার্থনা করতে হবে-"কৃষ্ণ,দয়া করে আমাকে তোমার প্রতি পূর্ণ শরণাগতি দাও।এতদিন ধরে আমি কেবলই তোমার শরণাগত হতে চাইছিলাম।এখন সময় এসেছে প্রকৃতই তোমার শরণাগত হবার।এখন তুমি ছাড়া কোন আশা নেই,অন্য কোন আশ্রয় নেই।"

~শ্রীল ভক্তিচারু স্বামী গুরুমহারাজ,শ্রীমদ্ভাগবত ২,১০,৪২,উজ্জয়িনী,২৭শে মার্চ,২০০৮


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"Let Thy will be done"
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When I started on spritual path I suppose that only good would happen to me; but I found that many difficult experience also came. Then I reasoned; "Because I love God so deeply, I have expected too much from Him. From now on I will say, 'Lord, let Thy will be done.' " Severe trials came. But I held to the thought, "Let Thy will be done." I wanted to accept whatever He sent my way. And He always showed me how to be victorious in every test.
Sri Sri Paramahansa Yogananda.
Man's Eternal Quest. P. 145.
[ How to be more likable ]


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Friday, 26 March 2021

SPIELBERG X HITCHCOCK XRAY X KUROSAWA X ORSON WELLES X CHAPLIN X MARTIN SCORSESE 7 DIRECTORS

 





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'When things go wrong, don't go with them.


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"A lot of times people look at the negative side of what they feel they can't do. I always look on the positive side of what I can do."


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POE - THEODICY -   NB BLIND WATCHMAKER

LAW OF KARMA 

LAW OF NATURE 

LAW OF IMPERMANENCE 


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BETTER COMPANY WITH A WALL X HVN - YORKSHR DALES ON A SUMMER DAY X SC MEETS REALITY ABSOLUTE ASYMPTOTICALLY X SENCHA BEANS -SENTIENT BEINGS

 



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And I couldn't think of an example. But that's my answer there in good old Fight Club fashion: you are not your thoughts. Not your thoughts of how good you are or how rubbish your are. Not any of them. Not even these thoughts of not being your thought

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OSG  KAKA SHOSHUR FROM SHYAMNAGAR

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Seeds for a Boundless Life by Zenkei Blanche Hartman. It's a nice and simple book. In it she recommends smiling...not a big inane grin, but a small smile.

Now, I've heard people recommend this before and have always run a mile from that advice: Zen, for me, is all about being exactly how you are right now, not forcing yourself to feel something you're not. But, Hartman is lovely, so I'm giving it a go.

A very small smile whenever I remember. And it does something, that's for sure. 



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Ryokan's Hut

My hut lies in the middle of a dense forest;
Every year the green ivy grows longer.
No news of the affairs of men,
Only the occasional sound of a woodpecker.
The sun shines and I mend my robe;
When the moon comes out I read Buddhist poems.
I have nothing to report, my friends.
If you want to find the meaning, stop chasing after
so many things.

– Ryokan



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I'm reading this book on reflection in Buddhism and the author talks about people not liking doing nothing or just not having the time to sit and do nothing. Literally nothing. I don't have that problem: I've been doing zazen regularly for over 10 years and inevitably my way of thinking has changed and I have developed a habit of doing nothing! Some of my happiest times, moods and moments are when I'm sitting zazen and so I associate doing nothing with being happy. The bits inbetween exciting events are great too. 


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Sitting with my back straight, eyes pointing downwards, ears ringing. Sitting within a space where the universe flows through you. No effort, just a gradual and natural focusing without any object.



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By Ven. Tenzin Tsepal

Many months ago, when Venerable Chodron asked for a volunteer to produce a series of 10-minute talks on “Working with Jealousy,” I put my hand up. The talks would be posted on Insight Timer, where we’ve been posting meditations led by Venerable Chodron and other Sravasti Abbey monastics for a couple of years now.

I’m glad I volunteered. Through preparing these talks, I have learned so much by looking into jealousy’s characteristics, some of its causes, its disadvantages, and its antidotes. I’d like to share some highlights.

Identifying Jealousy

Socrates said, “Jealousy is the ulcer of the soul.” We may think we know ourselves pretty well, but often we’re unaware of our thoughts and emotions and how they impact us, especially with jealousy. We may be so caught up in obsessing about the person we’re jealous of that we’re blind to what’s happening in our own mind.

Once we start to notice it, though, it can be easy to over-identify with jealousy: “Oh, I’m such a jealous person.” But our mind is constantly changing; states of mind come and go all day long. We’re not jealous 100% of the time. Notice how different it is to think, “Oh, jealousy is arising in my mind. I’m experiencing jealous thoughts and feelings.”

It’s hard to admit that we’re jealous because, at its core, jealousy arises from the painful belief that we are just not good enough. But admitting to jealousy can bring a sense of relief. It’s important to cultivate self-acceptance in meditation as an important step in overcoming the jealous mind.

To overcome jealous thoughts, we need a method and a goal. One short-term goal might be to have strong confidence in our own self-worth so that we can easily rejoice in the happiness, good fortune, and opportunity of others without any jealous feelings getting in our way.

The Disadvantages of Jealousy

One method we can use to let go of jealousy is to convince ourselves beyond the shadow of a doubt that jealousy is not in our best interest, and to know just how harmful and damaging it is. Then we’ll naturally move away from it.

Once we know the disadvantages of jealousy inside and out, that will motivate us to make the changes and inner transformation we’re looking for. Think about what happens to you physically when you feel jealous. What happens emotionally? How does it impact your relationships? What happens spiritually when we indulge in jealousy?

The First Dalai Lama was definitely on to the disadvantages of jealousy. In his verses on “Requesting Protection from the Eight Dangers” that are part of the Green Tara sadhana we use at Sravasti Abbey, he writes:

Lurking in its dark pit of ignorance,
Unable to bear the wealth and excellence of others,
It swiftly injects them with its cruel poison,
The snake of jealousy — please protect us from this danger!

Jealousy necessarily involves attachment, so it’s an afflicted and distorted point of view. We’re exaggerating the happiness we’d have from getting the object of our attachment, and convinced that we can’t be happy as long as someone else has something we want.

That “something” could be love, respect, admiration or affection from a particular person. It could be social standing, status, praise, followers on social media, or more tangible possessions like money, clothes, cars, diamond rings, and so on. With attachment, there is clinging.

Jealousy is also associated with anger or hostility—because we resent that someone else has what we want—whether that’s the attention of our boy/girlfriend, or some possession or quality that we want for ourselves.

We can’t bear that they have it and we don’t, which often leads to thoughts of wanting to deprive them of having the thing we want or destroying their happiness.

The Comparing Mind

Another thing that fuels our jealousy is the comparing mind. It seems pretty natural to compare ourselves with others. In the past, we might have compared ourselves to people around us in similar situations—those in our family or neighborhood, our classmates, and friends.

But in the age of social media, we can now compare ourselves to people from all over the world—famous movie stars, international super-models, world-class athletes, Ivy League entrepreneurs, and billionaires. No wonder we feel so inadequate and jealous!

Comparing ourselves with others starts early. Maybe we felt jealous of older siblings when they got to do things we couldn’t do, or jealous of a younger sibling who got special treatment from Mom and Dad or got away with anything. Mine did!

One of my first memories of jealousy is of my older sister having ice skates when I only had rubber boots to skid around in. “It was not fair!”

Venerable Chodron reminds us that those are some of the first words we first learned as kids. “It’s not fair! She got to stay up later than me!” “She got to sleep over at her friend’s house, and I didn’t. It’s not fair!”

We grow up with this mentality of “It’s not fair,” which we carry into adulthood, and even to the monastery. “Why does Venerable praise so-and-so, but not me?” “Why does so-and-so get to travel with Venerable, but not me? It’s not fair!”

Comparison can easily turn into jealousy, which can quickly turn into self-pity. “Why does everybody like them, but not me?” “Even if I try, I’ll never be as good as them. It’s not fair!”

Turning Self-Pity Around

Jealousy creates the conditions for self-pity to arise, and self-pity is so irresistible! It’s captivating, even addictive because it thinks, “Oh, poor me!” And once again, I’m the center of the universe.

“Oh, they’re better looking than me.” “They’re more talented than me.” “They’re more popular than me.” “They’re more skilled than me.” “People notice them. They don’t notice me.” We can spend our whole life creating a story like that in our mind.

It’s important to recognize that self-pity doesn’t help us, and in fact, keeps us stuck. It can be a little embarrassing to admit that we throw pity parties for ourselves, but recognition allows us to change and to do something about it.

Many different kinds of thoughts lie behind jealousy, so it’s very good to notice what those thoughts are. This is where a daily mindfulness practice can really help—whether it’s just five minutes or half an hour.

Meditation helps us to monitor our mind for what we’re thinking, doing and saying throughout the day. Then, we have a better chance at catching unskillful or destructive thoughts like self-pity that are lurking below our conscious awareness and influencing our behavior.

Every minute devoted to self-pity is 60 seconds devoted to misery instead of creating causes for the happiness we want! For example, we can practice gratitude instead.

It’s impossible to feel grateful and indulge in self-pity at the same time, so recognize all the things you have to be grateful for—everything from being alive to the fresh air we breathe and clean water we drink. Or get out and help others. It’s hard to feel sorry for yourself when you’re busy helping those who are less fortunate.


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NOT GETTING ENVY -JLSY 

The First Dalai Lama was definitely on to the disadvantages of jealousy. In his verses on “Requesting Protection from the Eight Dangers” that are part of the Green Tara sadhana we use at Sravasti Abbey, he writes:

Lurking in its dark pit of ignorance,
Unable to bear the wealth and excellence of others,
It swiftly injects them with its cruel poison,
The snake of jealousy — please protect us from this danger!

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We’ll have a much more precise statement about our ignorance but nothing more x DNB CABS DO NOT BE CRRD AWAY BY SITNS

 



KALACHAKRA MANDALA - WHOLENESS OF BEING







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We’ll have a much more precise statement about our ignorance but nothing more


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Just measure things better and hope something will turn up


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There’s a limit to how much more we’ll ever be able to learn about the Universe


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We’re no closer to answering the big questions about dark matter, dark energy and the origins of the Universe


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Philippians 4:6-7. "Be anxious for nothing, but in everything by prayer and supplication with thanksgiving, let your requests be made known unto God. And the peace of God, which passes all understanding, shall keep your hearts and minds through Christ Jesus."


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BHAKTI YOGA


 Psalm 46:1 reminds us, “God is our refuge and strength, always ready to help in times of trouble.”


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DRUIDS V ROMANS

DRUIDS MYSTICAL KNWLDGE

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Famous poet Lain S. Thomas reminded us to not let the pain of a situation make you hopeless. "Do not let negativity wear off on you. Do not let the bitterness steal your sweetness. Even though others may disagree with you, take pride in the fact that you still know the world to be a beautiful place.


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Life will go on with you or without you. It's harsh, but this is true no matter how much we want it to bend to our will. You can surrender to the devastation and avoid the trials, or accept that life has ups and downs. This doesn't mean you have to approve of it or understand it. Like the situation in Las Vegas, the merciless assassination of people is unacceptable, but we can't go back in time, so we properly grieve. Over time when we don't work through our pain, we can become resentful and indignant towards God, ourselves and others. Then it could manifest into depression. If you're having difficulty with managing anger, think of an alternative approach to the situation to help you manage it better. This can be seeing a therapist or logging your thoughts on paper when you need it.



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GRF FEAR LV

Kay Redfield Jamison, wrote, “Grief is so human and it hits everyone at one point or another, at least, in their lives. If you love, you will grieve, and that's just given.”



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DISRAELI Silence is the mother of truth."


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P Lateral neck pain as a symptom of severe sinusitis

 

Lateral neck pain as a symptom of severe sinusitis: A case report

CLDP SCORE

 

Development of a severity scale to assess chronic lung disease after extremely preterm birth

First published: 17 March 2021
 

Abstract

Objective

Chronic lung disease of prematurity (CLDP) is a frequent complication of prematurity. We aimed to identify what clinicians believe are the most important factors determining the severity of CLDP in extremely preterm infants (<28 weeks gestational age) after discharge from the neonatal intensive care unit (NICU) through 12 months corrected age (CA), and to evaluate how these factors should be weighted for scoring, to develop a CLDP severity scale.

Study design

Clinicians completed a three‐round online survey utilizing Delphi methodology. Clinicians rated the importance of various factors used to evaluate the severity of CLDP, from 0 (not at all important) to 10 (very important) for the period between discharge home from the NICU and 12 months CA. Fourteen factors were considered in Round 1; 13 in Rounds 2 and 3. The relative importance of factors was explored via a set of 16 single‐profile tasks (i.e., hypothetical patient profiles with varying CLDP severity levels).

Results

Overall, 91 clinicians from 11 countries who were experienced in treating prematurity‐related lung diseases completed Round 1; 88 completed Rounds 2 and 3. Based on Round 3, the most important factors in determining CLDP severity were mechanical ventilation (mean absolute importance rating, 8.89), supplemental oxygen ≥2 L/min (8.49), rehospitalizations (7.65), and supplemental oxygen <2 L/min (7.56). Single‐profile tasks showed that supplemental oxygen had the greatest impact on profile classification.

Conclusion

The most important factors for clinicians assigning CLDP severity during infancy were mechanical ventilation, supplemental oxygen ≥2 L/min, and respiratory‐related rehospitalizations.

1 INTRODUCTION

Bronchopulmonary dysplasia (BPD) is diagnosed at 36 weeks postmenstrual age (PMA) and is a frequent complication of extremely premature birth (<28 weeks gestational age). The reported global incidence of BPD is 10%–89%.1 Across regions, reported estimates range from 18%–89% in North America, 10%–73% in Europe, 30%–62% in Oceania, and 18%–82% in Asia.1-3 BPD is associated with high healthcare costs and an increased risk of mortality and rehospitalization among preterm infants during the first year of life.45 BPD is also a leading cause of chronic lung disease of prematurity (CLDP),6 which can manifest in patients with or without a prior diagnosis of BPD (using current criteria). No new drugs for the prevention and treatment of BPD have been approved in recent decades.7 Recombinant human insulin‐like growth factor 1 complexed with its binding protein (rhIGF‐1/rhIGFBP‐3) is currently under investigation for the prevention of complications of prematurity among extremely preterm infants. A 2019 phase 2 trial evaluating rhIGF‐1/rhIGFBP‐3 supplementation in extremely preterm infants reported substantial reductions in the incidence of severe BPD.8 A phase 2b trial is currently ongoing to evaluate if rhIGF‐1/rhIGFBP‐3 can reduce the burden of CLDP in extremely preterm infants (NCT03253263).

Currently, the assessment of long‐term pulmonary morbidity is associated with the diagnosis of BPD and is driven by the amount of respiratory support (e.g., the requirement for oxygen, continuous positive airway pressure [CPAP], and mechanical ventilation) administered at 36 weeks PMA or at the time of discharge from the neonatal intensive care unit (NICU).9-11 This approach focuses on short‐term, rather than long‐term, morbidity and is heavily impacted by variations in NICU respiratory support practices.10 In addition, infants who do not meet the diagnostic criteria for BPD may at a later date exhibit clinically important respiratory disease.12 For these reasons, at least in part, the US Food and Drug Administration now requires a long‐term assessment of these infants when determining the effectiveness of respiratory interventions.13 BPD as currently defined is considered an imperfect biomarker for long‐term pulmonary outcomes14 and is not accepted as an endpoint for regulatory decision making.

Based on a survey of North American academic health science center‐based pulmonologists, Gage et al.15 developed a chronic lung disease severity score, which assessed CLDP severity in very low birth weight infants at 4–9 months corrected age (CA). The objective of the current study was to build on the work of Gage et al. by identifying additional important factors believed by physicians to be measured for the severity of CLDP during the months following extremely preterm birth and to evaluate how these factors should be weighted for scoring in a CLDP severity scale (CLDPSS). The CLDPSS is being used as a secondary outcome measure in the global phase 2b clinical trial, being conducted by Takeda, which is evaluating if rhIGF‐1/rhIGFBP‐3 can decrease the morbidity of CLDP through 12 months CA (NCT03253263).

2 MATERIALS AND METHODS

2.1 Participants

Three Delphi rounds were conducted; participants on the panels were required to have (1) a general medical license/registration; (2) board certification, or equivalent, in neonatology, pediatric pulmonology, and/or pediatrics; (3) ≥2 years’ post‐fellowship/residency experience treating prematurity‐related chronic lung disease (i.e., CLDP); (4) currently treating at least two premature infants with CLDP per year in the outpatient setting; and (5) fluency in English. Clinicians were recruited by a third‐party market research vendor (Global Perspectives; Norwich, United Kingdom), via online physician research panels. Potentially eligible participants were emailed a secure link to complete an initial screening questionnaire to determine eligibility. In addition to the screening questions, potential participants were directed to an online “consent” screen, which included study information and participant requirements, with an option to opt in to participate in the study. Eligible participants could then proceed to complete Round 1 of the survey. Survey respondents who completed all three rounds of the survey received $300 in honoraria. IRB approval was not required because this was a non‐interventional study.

2.2 Variables

In the Round 1 survey, to reach a consensus on the importance of different variables in the determination of CLDP severity at 1 year CA, clinicians considered a comprehensive set of prespecified factors related to the severity of chronic lung disease during infancy. The factors selected for assessment were based on the previous work by Gage et al.15 and were supplemented with factors identified by four clinical experts (HMO'B, RS, RMW, and MH).

Fourteen factors were evaluated in Round 1 of the survey; 13 factors were evaluated in Rounds 2 and 3. Intermittent administration of pulmonary vasodilator was removed following Round 1, based on clinical expert feedback (Table 1). The factors considered in the Delphi Rounds included the use of home mechanical ventilation, including bilevel positive airway pressure (BiPAP) and nasal intermittent positive pressure ventilation (NIPPV); supplemental oxygen (thresholds of <2 L/min or ≥2 L/min, the latter of which includes CPAP); respiratory‐related rehospitalizations after NICU discharge; respiratory‐related emergency department (ED) visits without hospitalization; and use of pulmonary medications (i.e., bronchodilators, corticosteroids [inhaled and systemic], diuretics, and pulmonary vasodilators [intermittent administration only included in Round 1]).

Table 1. Factors considered in the Delphi survey
Home mechanical ventilation, including BiPAP and NIPPV
Supplemental oxygen via nasal cannula at ≥2 L/min, including CPAP
Supplemental oxygen via nasal cannula at <2 L/min
Respiratory‐related rehospitalization after NICU discharge
Respiratory‐related ED visits without hospitalization
Daily (≥3 days/week) administration of a bronchodilator
Daily (≥3 days/week) administration of inhaled corticosteroid
Daily (≥3 days/week) administration of diuretic
Daily (every day) administration of pulmonary vasodilatora
Intermittent administration of a bronchodilator
Intermittent administration of inhaled corticosteroid
Intermittent administration of systemic corticosteroid
Intermittent administration of diuretic
Intermittent administration of pulmonary vasodilatora
  • Abbreviations: BiPAP, bilevel positive airway pressure; CPAP, continuous positive airway pressure; ED, emergency department; NICU, neonatal intensive care unit; NIPPV, nasal intermittent positive pressure ventilation.
  • a Included in Round 1, but not included in Rounds 2 and 3, based on feedback from clinical expert consultants.

2.3 Iterative surveys

2.3.1 Delphi survey

This study used a modified three‐round online Delphi survey, designed to explore the most important and relevant factors in determining the severity of lung disease among extremely preterm infants after discharge from the NICU. The Delphi approach was adopted because it represents an established method of obtaining an expert opinion and evaluating the degree of consensus on a given topic.16 The Delphi method is a structured communication technique that involves participants (in this case, selected clinicians) who answer a questionnaire anonymously in an iterative manner after being provided with a summary of group responses.16

In Round 1 of the Delphi survey, clinicians rated the importance of respiratory‐related factors used to evaluate the severity of CLDP, from 0 (not at all important) to 10 (very important) for the period between discharge home from the NICU and 12 months CA. Clinicians also ranked the relative importance of factors (i.e., relative to others) in determining severity. Clinicians had the opportunity to identify and rate additional attributes (not already included) via free‐text responses. To facilitate response, clinicians were first asked to select and rank‐order the five most important factors, then to select and rank‐order the next five most important, and so on. In Rounds 2 and 3, clinicians were presented with anonymized aggregate results from the previous round and were given the opportunity to accept or change their prior response. A fourth Delphi round was not required because sufficient consensus was achieved in Round 3.

2.3.2 Discrete choice experiment

We also conducted an exploratory discrete choice experiment (DCE) to explore the relative importance and weighting of attributes included in the survey. A DCE is a methodology used to elicit preferences and evaluate the relative importance of aspects related to health outcomes among participants (in this case, selected clinicians).17 In a DCE, participants are presented with a series of hypothetical clinical profiles that are composed of a fixed set of treatment characteristics, which are presented using systematically varied levels for each treatment characteristic. Participants are then asked to make a choice for each hypothetical profile.

In the current study, the DCE was conducted through a set of 16 single‐profile choice tasks based on hypothetical patient profiles with varying CLDP severity levels, representative of an infant born extremely preterm aged 12 months CA who had been diagnosed with BPD at 36 weeks PMA. Clinicians were presented with eight respiratory‐related treatment attributes with a possible two to four levels each (Table S1). Clinicians were then asked to rate the severity of CLDP in relation to the infant profiles, based solely on recent respiratory treatment utilization presented in the profile (see Table S2, for example).

A D‐efficient experimental design was generated in Ngene 1.1.2 (ChoiceMetrics) to systematically vary the attribute levels and generate 12 single‐profile choice tasks. A D‐efficient design is commonly used to maximize the statistical efficiency in measuring the main effects.17 Clinical expert input was used to ensure that these profiles were clinically possible. Four additional choice tasks, developed by a clinical expert (HMO'B), were included within the survey to assess internal validity. The DCE was conducted in full in Round 2; however, in Round 3, only the four choice tasks developed by the clinical expert (HMO'B) were included.

2.4 Data analysis

Analyses were performed using SAS version 9.4 (SAS Institute Inc) or R version 3.3.3 or higher (R Core Team).

Following each round, descriptive analyses were conducted for each survey question. If ≥75% of clinicians indicated that an attribute had no importance (i.e., a rating of 0; overall, at discharge, or at 12 months CA), it was excluded from future survey rounds. In Round 1, each attribute included the percentage of “no importance” ratings and the mean, standard deviation, and interquartile range (IQR) of the importance ratings. For absolute importance ratings (or weight; on a scale from 0 to 10), a higher score indicated greater importance. For relative importance rankings, a lower score (e.g., a ranking of 1) indicated greater importance; relative rankings were therefore adjusted such that a higher score indicated greater importance. Overall importance scores were calculated by multiplying the absolute importance ratings by the adjusted relative importance rankings.

The first 12 experimental design–generated DCE choice tasks were analyzed descriptively and via multinomial logistic regression. The final four clinical expert–generated DCE choice tasks were analyzed by examining choice frequencies for each severity indication. The results are presented as relative risk ratios and predicted probabilities, which represent the effect of each attribute level on severity classification, independently from the other attributes.

The outcome variable was modeled as a choice among the four severity classifications (asymptomatic/minimal, mild, moderate, or severe), with the asymptomatic/minimal classification as the baseline category. The independent, predictive variables were the attribute levels included in the choice profiles, treated as dummy variables. For each attribute, the least severe indication was treated as the reference category. Relative risk ratios were estimated to show how each attribute level affected the choice of severity indication. Predicted probabilities were calculated to explore the predicted probability of selecting each severity indication at each level of the different attributes, holding the other attributes at their means or, alternatively, at the lowest (least severe) levels. In Rounds 2 and 3, the severity assessments for the four additional clinician‐generated profiles were summarized descriptively.

2.5 Consensus

In Rounds 2 and 3 of the survey, the between‐clinician consensus was assessed by examining the IQR of the importance ratings and rankings.16 Based on a 2012 review, an IQR <2 was considered good consensus when assessing responses to a scale of 0–10.16 After Round 3 of the survey, an analysis of variance (ANOVA) for repeated measures with equal variance, including a test of homogeneity of variance, was run for all remaining factors. We studied the consensus between Round 2 and 3 responses using ANOVA. A separate test was performed for each factor. The ANOVA included the absolute importance rating values for the factor as the dependent variable and clinicians as the independent variable. An F value ≥4 for the clinician variable indicated that the between‐clinician variability was substantially larger than the within‐clinician variability.

2.6 Weighting and scoring

The importance scores of attributes included in the final survey round were used to develop the final attribute weights on an integer scale of 0–100. We identified the factors associated with the most severe chronic lung disease; these mutually exclusive “worst” factors were set to correspond to a total score of 100 and included home mechanical ventilation, at least one respiratory‐related rehospitalization, at least one respiratory‐related ED visit without hospitalization, daily pulmonary vasodilator use, daily diuretic use, daily bronchodilator use, intermittent systemic corticosteroid use, and daily inhaled corticosteroid use (Table S3). The absence of any factors was set to correspond to a total score of 0.

3 RESULTS

3.1 Participant characteristics

A total of 91 participants (51 pediatric pulmonologists, 20 pediatricians, and 20 neonatologists) completed Round 1 of the CLDP severity survey; 88 of these participants completed Rounds 2 and 3. Participants resided in 11 countries across North America, Europe, Asia, and South America (Table 2). They had a mean of 16 years’ post‐fellowship/residency experience in caring for premature infants with CLDP and treated a mean of ~32 premature infants with CLDP in an outpatient setting per year. When asked if they had co‐authored peer‐reviewed publications, spoken at conferences, or acted as a principal investigator in a neonatal clinical trial pertaining to CLDP, 35.2% answered yes.

Table 2. Characteristics of CLDP survey participants
CharacteristicRound 1 (N = 91)Rounds 2 and 3 (N = 88)
Clinician type, n (%)a
Pediatric pulmonologist51 (56.0)50 (56.8)
Pediatrician20 (22.0)19 (21.6)
Neonatologist20 (22.0)19 (21.6)
Country of practice, n (%)
United States22 (24.2)22 (25.0)
Canada15 (16.5)14 (15.9)
Germany10 (11.0)9 (10.2)
United Kingdom9 (9.9)9 (10.2)
Italy9 (9.9)8 (9.1)
Spain8 (8.8)8 (9.1)
South Korea5 (5.5)5 (5.7)
France4 (4.4)4 (4.5)
Japan4 (4.4)4 (4.5)
Brazil3 (3.3)3 (3.4)
Mexico2 (2.2)2 (2.3)
Years of experience, mean (SD)b15.6 (7.3)15.6 (7.4)
Patients treated per yearc
Median (Q1–Q3)30.0 (10.0–50.0)27.5 (10.0–50.0)
Range3.0–95.03.0–95.0
  • Abbreviations: CLDP, chronic lung disease of prematurity; SD, standard deviation; Q, quarter.
  • a Some participants had multiple specialties.
  • b Years of experience in caring for premature infants with CLDP.
  • c Premature infants with CLDP treated per year on an outpatient basis.

3.2 Delphi survey

3.2.1 Round 1

In the first‐round survey, the most important factors, in terms of mean absolute importance (on a scale from 0 [not at all important] to 10 [very important]), were determined to be home mechanical ventilation (8.38), supplemental oxygen at ≥2 L/min (8.14), rehospitalizations (7.97), and ED visits without hospitalization (7.82) (Figure 1). The factors ranked most important relative to the others were home mechanical ventilation (3.48), supplemental oxygen ≥2 L/min (3.70), rehospitalizations (5.38), and supplemental oxygen <2 L/min (7.07) (Figure S1).

image
Mean absolute importance of factors in evaluating CLDP severity. Each factor was rated individually on a scale of 0 (not at all important) to 10 (very important) and is presented in order of the Round 3 results (most to least important). CLDP, chronic lung disease of prematurity; ED, emergency department [Color figure can be viewed at wileyonlinelibrary.com]

All attributes were identified to be of at least some importance (i.e., score >0) by ≥25% of the clinician sample. Therefore, no predefined factors were removed in the subsequent round of the survey, except for PRN use of pulmonary vasodilators, which was considered clinically infeasible and removed following clarification by the clinical expert consultants. Likewise, when grouping the free‐text responses, no responses were endorsed by more than 25% of the sample. Following an additional review of the free‐text responses by the clinical expert consultants, it was decided that no responses warranted the inclusion of additional attributes in the Round 2 survey, and the free‐text option was removed in subsequent rounds of the survey.

3.2.2 Round 2

In the second‐round survey, the most important factors in terms of mean absolute importance were home mechanical ventilation (8.60), supplemental oxygen at ≥2 L/min (8.47), rehospitalizations (7.76), and supplemental oxygen at <2 L/min (7.63) (Figure 1). The same four factors were ranked most important relative to the others.

When assessing the IQR of the absolute importance ratings for each factor, most factors had an IQR of 1.00, with a maximum of 2.00, indicating that there was fairly good consensus in the absolute importance ratings across the sample (both overall and within clinician groups).

3.2.3 Round 3

In Round 3, the factors ranked most important in terms of mean absolute importance were home mechanical ventilation (8.89), supplemental oxygen ≥2 L/min (8.49), rehospitalizations (7.65), and supplemental oxygen <2 L/min (7.56); the same four factors were also ranked most important in terms of relative importance to the others (Figures 1 and S1). When assessing the IQR of the absolute importance ratings for each factor, all factors had an IQR of 1.00, with the exception of home mechanical ventilation, which had an IQR of 2.00, indicating good consensus in the absolute importance ratings across the sample. ANOVA results comparing the Rounds 2 and 3 absolute importance ratings showed no statistically significant differences in ratings between rounds, except for mechanical ventilation (F = 4.42; p = .0385) (Table 3). Combined IQR and ANOVA results indicated that good consensus was achieved after the Round 3 survey.

Table 3. ANOVA results comparing Rounds 2 and 3 absolute importance ratings among clinicians (N = 88)
AttributeAbsolute importance ratinga, mean (SD)F valuep value
Round 2Round 3
Home mechanical ventilation8.60 (1.62)8.89 (1.22)4.42.0385*
Supplemental oxygen ≥ 2 L/min8.47 (1.47)8.49 (1.49)0.03.8630
Supplemental oxygen <2 L/min7.63 (1.41)7.56 (1.13)0.23.6337
Respiratory‐related rehospitalizations7.76 (1.31)7.65 (1.04)0.70.4045
Daily administration of pulmonary vasodilator7.40 (1.26)7.34 (1.20)0.17.6783
ED visits without hospitalization7.36 (1.32)7.24 (1.17)0.80.3737
Daily administration of diuretics6.50 (1.40)6.43 (1.10)0.26.6123
Intermittent administration of systemic corticosteroid6.83 (1.34)6.73 (1.08)0.47.4969
Daily administration of inhaled corticosteroid6.70 (1.20)6.67 (1.24)0.05.8190
Daily administration of a bronchodilator6.60 (1.22)6.51 (1.12)0.45.5051
Intermittent administration of diuretics5.58 (1.43)5.70 (1.07)0.67.4141
Intermittent administration of a bronchodilator5.76 (1.11)5.55 (1.32)3.11.0815
Intermittent administration of inhaled corticosteroid5.48 (1.61)5.56 (1.36)0.20.6573
  • Abbreviations: ANOVA, analysis of variance; ED, emergency department.
  • a As rated on a scale from 0 (not at all important) to 10 (very important).
  • Statistically significant at α = .05 level.

3.3 Discrete choice experiment findings

The exploratory DCE results from Round 2 showed that supplemental oxygen had the largest influence on profile classification. If a profile described the need for “mechanical ventilation” rather than the reference level of “no supplemental oxygen,” the predicted probability that it would be classified as asymptomatic/minimal lung disease decreased from 0.30 to 0.06, and the predicted probability that it would be classified as severe lung disease increased from 0 to 0.28 (Figure 2). If a profile described the need for daily pulmonary vasodilator use rather than the reference level of “none,” the predicted probability that it would be classified as asymptomatic/minimal lung disease decreased from 0.30 to 0.17, and the predicted probability that it would be classified as moderate lung disease increased from 0.15 to 0.24. Overall, the results of the exploratory DCE supported the Delphi findings on the importance of factors.

image
Predicted probability of choosing asymptomatic/minimal versus mild, moderate, or severe lung disease for each attribute level, holding all other attributes at their lowest level. BiPAP, bilevel positive airway pressure; CPAP, continuous positive airway pressure; ED, emergency department; NIPPV, nasal intermittent positive pressure ventilation; suppl, supplemental [Color figure can be viewed at wileyonlinelibrary.com]

3.4 CLDPSS instrument scoring

Based on the Round 3 mean overall importance values for each factor (Figure 3), the factor weights were calculated. For each variable, the worst level was selected (e.g., mechanical ventilation for the supplemental oxygen variable), and the sum of these important values was calculated and then rescaled to 100; the individual final importance values were then rescaled down to the final weights for each factor (Table S3). These were home mechanical ventilation, 23.4; at least one respiratory‐related rehospitalization, 15.1; daily pulmonary vasodilator use, 13.6; at least one ED visit without hospitalization, 12.2; daily use of diuretics, 9.3; intermittent use of systemic corticosteroids, 9.2; daily use of inhaled corticosteroids, 8.8; and daily use of a bronchodilator, 8.4.

image
Mean overall importance of factors in evaluating CLDP severity. Calculated as the product of absolute importance rating and adjusted relative importance rank (i.e., ranking values adjusted such that “1 = least important”); therefore, higher values indicate greater relative importance; presented in order of the Round 3 results (most to least important). CLDP, chronic lung disease of prematurity; ED, emergency department [Color figure can be viewed at wileyonlinelibrary.com]

4 DISCUSSION

We solicited the opinions of a diverse group of physicians to explore their real‐world impressions as to what defines different severities of CLDP at 12 months CA, based on a set of prespecified respiratory‐related factors. Findings from this Delphi consensus‐building study reveal that the most important factors for clinicians in assessing CLDP severity from NICU discharge through 12 months CA included home mechanical ventilation, supplemental oxygen at ≥2 L/min, respiratory‐related rehospitalization, and supplemental oxygen at <2 L/min. However, clinicians did not characterize as unimportant any of the 13 prespecified factors discussed in the Delphi survey.

The current study built on work previously conducted by Gage et al.15 and includes additional questions on systemic corticosteroid use and pulmonary vasodilator therapy. Further, while Gage et al. confined their Delphi‐based survey to pediatric pulmonologists at North American academic health science centers, we sought greater generalizability in the current study by including pediatricians and neonatologists, in addition to pediatric pulmonologists, and by surveying a global sample of physicians from 11 countries across North America, Europe, Asia, and South America. This approach acknowledged the wide variations in neonatology clinical practice. For example, in countries other than the United States, some infants might be treated by a pediatrician, as opposed to a subspecialist (i.e., pediatric pulmonologist).

The results of this study informed the weighting and scoring of factors in the CLDPSS, a novel instrument to measure the severity of CLDP after discharge from the NICU through 12 months CA. The CLDPSS is a continuous outcome measure that is more discriminating and informative than any dichotomous measure, and it is easily measured with clinical data that are typically available until 1 year CA. This is important, given that the Prematurity and Respiratory Outcomes Program study found that many infants with severe BPD at 36 weeks PMA reported no respiratory morbidity at 1 year CA, while other infants who did not have a BPD diagnosis at 36 weeks PMA did have morbidity at 1 year CA.12

CLDPSS data can be collected directly from caregivers for assessment of CLDP in clinical trials of premature infants with respiratory issues. Further, the scale is brief, resulting in less respondent (caregiver) or clinician burden, and can aid in routine monitoring of preterm infants with respiratory issues. The CLDPSS will provide standardized assessments of long‐term pulmonary outcomes that may be useful in interventional neonatal studies. Data may be comparable across real‐world clinical practices and may aid in benchmarking of outcomes in this population. If these data can determine factors during the NICU stay that correlate with long‐term pulmonary morbidity better than a diagnosis of BPD at 36 or 40 weeks PMA, the CLDPSS will be an important addition to long‐term care.

The CLDPSS development phase (clinician feedback) is complete. The reliability and validity of the CLDPSS scale will be evaluated via a prospective study assessing clinimetric properties, using patient data in routine clinical care settings.

The Delphi approach allowed the differentiation of the importance of specific factors among a diverse group of clinicians in multiple countries. The finding that the daily use of pulmonary vasodilators was only moderately important (i.e., not among the four most important factors) to the surveyed physicians was surprising. Previous studies have shown that when BPD‐associated pulmonary hypertension is severe enough to require daily pulmonary vasodilators, it is associated with severe BPD with increased morbidity and mortality through 1 year CA.1819 Further support for this association comes from a 2020 retrospective study of very preterm infants with severe BPD, where investigators found that a diagnosis of pulmonary hypertension was a primary predictor of mortality.20 The ranking of vasodilators outside the four most important factors here could be due, at least in part, to the three granular levels of supplemental oxygen use (mechanical ventilation, ≥2 L/min, and <2 L/min). If these factors were grouped as one supplemental oxygen variable, pulmonary vasodilator use would be the third most important variable (behind supplemental oxygen and rehospitalizations). However, we believe that grouping the three levels of supplemental oxygen had a minor effect only on the ranking of pulmonary vasodilators, and the finding is more likely explained by the diversity of surveyed clinicians in the current study.

We do not have an understanding of the factors that drove the clinicians’ importance ratings/rankings in the current study, but it is possible that the frequency with which treatment is used in clinical practice may have had an impact. This could explain why the final weights for the pulmonary vasodilator variable were not as high as expected when compared with the other variables. It is possible that clinical practice changes resulting from the emerging literature on the management of infants with BPD/pulmonary hypertension is variable across centers and geographical locations. Additional differences among respondents that could account for our findings include years of experience, the degree of patient severity they usually manage, and their formal training or clinical specialty (e.g., pulmonology, pediatrics, neonatology).

Our study has some limitations. We provided clinical scenarios at one point in time (i.e., as in a cross‐sectional study), so we cannot be certain how our approach will perform in the same child over time. We did not provide physiologic measurements of respiratory (e.g., infant pulmonary function testing, hypoxic oxygen challenge, lung clearance index) or cardiovascular (e.g., pulmonary artery pressures) function, so we do not know how sensitive the predictors will be to changes in the patient's physiologic status over time.

Furthermore, clinicians were recruited via online research panels, which could potentially introduce sample bias. Clinicians had different specializations, were from different countries, and were not necessarily academically active in this area of research; therefore, they might have assigned different importance to factors due to differences in clinical practice—for example, approaches to ventilatory support, whether it be supplemental oxygen, positive airway pressure, and so forth. Lastly, we speculate that pediatric pulmonologists see more severe cases than pediatricians do, while neonatologists are typically only involved in early NICU care and not when the child is 1 year CA.

In conclusion, we identified factors important for clinicians in assessing CLDP severity after NICU discharge through 12 months CA following extremely preterm birth to develop a weighted CLDPSS. The CLDPSS adds granularity to previous instruments in terms of supplemental oxygen; respiratory‐related ED visits; and administration of vasodilators, systemic corticosteroids, and intermittent diuretics. The CLDPSS will enable the standardized assessment of long‐term pulmonary morbidity in neonatal trials and clinical practice.

ACKNOWLEDGMENTS

Under direction of the authors, Rosalind Bonomally, MSc, employee of Excel Medical Affairs, provided writing assistance for this manuscript. Editorial assistance in formatting, proof reading, and copy editing was also provided by Excel Medical Affairs. Shire, a Takeda company, provided funding to Excel Medical Affairs for support in editing this manuscript. The interpretation of the data was made by the authors independently. This study was funded by Takeda.