text:
import React from 'react';
import { shallow } from 'enzyme';
import { assert } from 'chai';

import TreeNode from '../src/js/TreeNode';

const baseProps = {
    checked: 0,
    disabled: false,
    expandDisabled: false,
    expanded: false,
    lang: {
        collapseAll: 'Collapse',
        expandAll: 'Expand',
        toggle: 'Toggle',
    },
    icons: {
        check: ,
        uncheck: ,
        halfCheck: ,
        expandClose: ,
        expandOpen: ,
        parentClose: ,
        parentOpen: ,
        leaf: ,
    },
    isLeaf: true,
    isParent: false,
    label: 'Jupiter',
    optimisticToggle: true,
    showNodeIcon: true,
    treeId: 'id',
    value: 'jupiter',
    onCheck: () => {},
    onExpand: () => {},
};

describe('<TreeNode />', () => {
    describe('component', () => {
        it('should render the rct-node container', () => {
            const wrapper = shallow(
                <TreeNode {...baseProps} />,
            );

            assert.isTrue(wrapper.find('.rct-node').exists());
        });

        it('should render a label associated with a checkbox', () => {
            const wrapper = shallow(
                <TreeNode {...baseProps} treeId="planets" value="jupiter" />,
            );

            assert.equal('planets-jupiter', wrapper.find('label').prop('htmlFor'));
            assert.equal('planets-jupiter', wrapper.find('label NativeCheckbox').prop('id'));
        });

        it('should render a label associated with a checkbox given integer value', () => {
            const wrapper = shallow(
                <TreeNode {...baseProps} treeId="planets" value={0} />,
            );

            assert.equal('planets-0', wrapper.find('label').prop('htmlFor'));
            assert.equal('planets-0', wrapper.find('label NativeCheckbox').prop('id'));
        });

        it('should render a label associated with a checkbox given float value', () => {
            const wrapper = shallow(
                <TreeNode {...baseProps} treeId="planets" value={0.25} />,
            );

            assert.equal('planets-0.25', wrapper.find('label').prop('htmlFor'));
            assert.equal('planets-0.25', wrapper.find('label NativeCheckbox').prop('id'));
        });
    });

    describe('checked', () => {
        it('should render icons associated with each check state', () => {
            const iconMap = {
                0: ,
                1: ,
                2: ,
            };

            Object.keys(iconMap).forEach((state) => {
                const wrapper = shallow(
                    <TreeNode {...baseProps} checked={parseInt(state, 10)} />,
                );

                assert.isTrue(wrapper.contains(iconMap[state]));
            });
        });

        it('should render an unchecked input element when not set to 1', () => {
            const wrapper1 = shallow(
                <TreeNode {...baseProps} checked={0} />,
            );
            const wrapper2 = shallow(
                <TreeNode {...baseProps} checked={2} />,
            );

            assert.isFalse(wrapper1.find('NativeCheckbox').prop('checked'));
            assert.isFalse(wrapper2.find('NativeCheckbox').prop('checked'));
        });

        it('should render a checked input element when set to 1', () => {
            const wrapper = shallow(
                <TreeNode {...baseProps} checked={1} />,
            );

            assert.isTrue(wrapper.find('NativeCheckbox').prop('checked'));
        });
    });

    describe('className', () => {
        it('should append the supplied className to
 of the node', () => {
            const wrapper = shallow(
                <TreeNode {...baseProps} className="my-test-class" />,
            );

            assert.isTrue(wrapper.find('.my-test-class').exists());
        });
    });

    describe('disabled', () => {
        it('should disable the hidden <input> element', () => {
            const wrapper = shallow(
                <TreeNode {...baseProps} disabled />,
            );

            assert.isTrue(wrapper.find('NativeCheckbox[disabled]').exists());
        });
    });

    describe('expandDisabled', () => {
        it('should disable the expand <button>', () => {
            const wrapper = shallow(
                <TreeNode {...baseProps} expandDisabled isLeaf={false} />,
            );

            assert.isTrue(wrapper.find('Button.rct-collapse-btn[disabled]').exists());
        });
    });

    describe('expanded', () => {
        it('should render children when set to true', () => {
            const wrapper = shallow(
                <TreeNode {...baseProps} expanded isLeaf={false}>
                    <TreeNode {...baseProps} label="Europa" value="europa" />
                </TreeNode>,
            );

            assert.equal('europa', wrapper.find(TreeNode).prop('value'));
        });

        it('should not render children when set to false', () => {
            const wrapper = shallow(
                <TreeNode {...baseProps} expanded={false} isLeaf={false}>
                    <TreeNode {...baseProps} />
                </TreeNode>,
            );

            assert.isFalse(wrapper.find(TreeNode).exists());
        });

        it('should render expanded icons when set to true', () => {
            const wrapper = shallow(
                <TreeNode {...baseProps} expanded isLeaf={false} />,
            );

            assert.isTrue(wrapper.contains());
            assert.isTrue(wrapper.contains());
        });

        it('should render collapsed icons when set to false', () => {
            const wrapper = shallow(
                <TreeNode {...baseProps} expanded={false} isLeaf={false} />,
            );

            assert.isTrue(wrapper.contains());
            assert.isTrue(wrapper.contains());
        });

        it('should append the `rct-node-expanded` class to the node when set to true', () => {
            const wrapper = shallow(
                <TreeNode {...baseProps} expanded isLeaf={false} />,
            );

            assert.isTrue(wrapper.find('li').hasClass('rct-node-expanded'));
        });

        it('should append the `rct-node-collapsed` class to the node when set to true', () => {
            const wrapper = shallow(
                <TreeNode {...baseProps} expanded={false} isLeaf={false} />,
            );

            assert.isTrue(wrapper.find('li').hasClass('rct-node-collapsed'));
        });

        it('should not append any expanded/collapsed classes to the node when a leaf', () => {
            const wrapper = shallow(
                <TreeNode {...baseProps} expanded isLeaf />,
            );

            assert.isFalse(wrapper.find('li').hasClass('rct-node-expanded'));
            assert.isFalse(wrapper.find('li').hasClass('rct-node-collapsed'));
        });
    });

    describe('icon', () => {
        it('should replace the node\'s icons with the supplied value', () => {
            const wrapper = shallow(
                <TreeNode {...baseProps} icon={} />,
            );

            assert.isTrue(wrapper.contains(

                ,
            ));
        });
    });

    describe('icons', () => {
        it('should replace the default set of icons with the provided values', () => {
            const wrapper = shallow(
                <TreeNode {...baseProps} icons={{ uncheck:  }} />,
            );

            assert.isTrue(wrapper.find('.rct-checkbox').contains(
                ,
            ));
        });
    });

    describe('label', () => {
        it('should render the node\'s label', () => {
            const wrapper = shallow(
                <TreeNode {...baseProps} label="Europa" value="europa" />,
            );

            assert.isTrue(wrapper.contains(

                    Europa
                ,
            ));
        });
    });

    describe('showCheckbox', () => {
        it('should render a checkbox for the node when true', () => {
            const wrapper = shallow(
                <TreeNode {...baseProps} />,
            );

            assert.isTrue(wrapper.find('.rct-checkbox').contains(
                ,
            ));
        });

        it('should not render a checkbox or label for the node when false', () => {
            const wrapper = shallow(
                <TreeNode {...baseProps} showCheckbox={false} />,
            );

            assert.isFalse(wrapper.find('label').exists());
            assert.isFalse(wrapper.find('.rct-checkbox').exists());
            assert.isTrue(wrapper.find('.rct-bare-label').exists());
        });
    });

    describe('showNodeIcon', () => {
        it('should render the node icon when true', () => {
            const wrapper = shallow(
                <TreeNode {...baseProps} />,
            );

            assert.isTrue(wrapper.contains(

                ,
            ));
        });

        it('should not render the node icon when false', () => {
            const wrapper = shallow(
                <TreeNode {...baseProps} showNodeIcon={false} />,
            );

            assert.isFalse(wrapper.contains(

                ,
            ));
        });
    });

    describe('title', () => {
        it('should add the `title` property to the label when set', () => {
            const wrapper = shallow(
                <TreeNode {...baseProps} title="Some extra text" />,
            );

            assert.equal('Some extra text', wrapper.find('label').prop('title'));
        });

        it('should add the `title` property to the bare label when set on a checkbox-less node', () => {
            const wrapper = shallow(
                <TreeNode {...baseProps} showCheckbox={false} title="Some extra text" />,
            );

            assert.equal('Some extra text', wrapper.find('.rct-bare-label').prop('title'));
        });
    });

    describe('onCheck', () => {
        it('should pass the current node\'s value', () => {
            let actual = {};

            const wrapper = shallow(
                <TreeNode
                    {...baseProps}
                    value="jupiter"
                    onCheck={(node) => {
                        actual = node;
                    }}
                />,
            );

            wrapper.find('NativeCheckbox').simulate('click');

            assert.equal('jupiter', actual.value);
        });

        it('should toggle an unchecked node to checked', () => {
            let actual = {};

            const wrapper = shallow(
                <TreeNode
                    {...baseProps}
                    checked={0}
                    value="jupiter"
                    onCheck={(node) => {
                        actual = node;
                    }}
                />,
            );

            wrapper.find('NativeCheckbox').simulate('click');

            assert.isTrue(actual.checked);
        });

        it('should toggle a checked node to unchecked', () => {
            let actual = {};

            const wrapper = shallow(
                <TreeNode
                    {...baseProps}
                    checked={1}
                    value="jupiter"
                    onCheck={(node) => {
                        actual = node;
                    }}
                />,
            );

            wrapper.find('NativeCheckbox').simulate('click');

            assert.isFalse(actual.checked);
        });

        it('should toggle a partially-checked node to checked', () => {
            let actual = {};

            const wrapper = shallow(
                <TreeNode
                    {...baseProps}
                    checked={2}
                    value="jupiter"
                    onCheck={(node) => {
                        actual = node;
                    }}
                />,
            );

            wrapper.find('NativeCheckbox').simulate('click');

            assert.isTrue(actual.checked);
        });

        it('should trigger on key press', () => {
            let actual = {};

            const wrapper = shallow(
                <TreeNode
                    {...baseProps}
                    checked={2}
                    value="jupiter"
                    onCheck={(node) => {
                        actual = node;
                    }}
                />,
            );

            wrapper.find('.rct-checkbox').simulate('keyup', { keyCode: 32 });

            assert.isTrue(actual.checked);
        });

        describe('optimisticToggle', () => {
            it('should toggle a partially-checked node to unchecked', () => {
                let actual = {};

                const wrapper = shallow(
                    <TreeNode
                        {...baseProps}
                        checked={2}
                        optimisticToggle={false}
                        value="jupiter"
                        onCheck={(node) => {
                            actual = node;
                        }}
                    />,
                );

                wrapper.find('NativeCheckbox').simulate('click');

                assert.isFalse(actual.checked);
            });
        });
    });

    describe('onExpand', () => {
        it('should negate the expanded property and pass the current node\'s value', () => {
            let actual = {};

            const wrapper = shallow(
                <TreeNode
                    {...baseProps}
                    expanded
                    isLeaf={false}
                    value="jupiter"
                    onExpand={(node) => {
                        actual = node;
                    }}
                />,
            );

            wrapper.find('.rct-collapse').simulate('click');

            assert.deepEqual({ value: 'jupiter', expanded: false }, actual);
        });
    });

    describe('onClick', () => {
        it('should render the label inside of the DOM label when null', () => {
            const wrapper = shallow(
                <TreeNode
                    {...baseProps}
                    value="jupiter"
                    onClick={null}
                />,
            );

            assert.isTrue(wrapper.find('label .rct-title').exists());
        });

        it('should render the label outside of the DOM label when NOT null', () => {
            const wrapper = shallow(
                <TreeNode
                    {...baseProps}
                    value="jupiter"
                    onClick={() => {}}
                />,
            );

            assert.isFalse(wrapper.find('label .rct-title').exists());
        });

        it('should pass the current node\'s value', () => {
            let actual = {};

            const wrapper = shallow(
                <TreeNode
                    {...baseProps}
                    value="jupiter"
                    onClick={(node) => {
                        actual = node;
                    }}
                />,
            );

            wrapper.find('.rct-node-clickable').simulate('click');

            assert.equal('jupiter', actual.value);
        });

        it('should get the unchecked node as unchecked', () => {
            let actual = {};

            const wrapper = shallow(
                <TreeNode
                    {...baseProps}
                    checked={0}
                    value="jupiter"
                    onClick={(node) => {
                        actual = node;
                    }}
                />,
            );

            wrapper.find('.rct-node-clickable').simulate('click');

            assert.isFalse(actual.checked);
        });

        it('should get the checked node as checked', () => {
            let actual = {};

            const wrapper = shallow(
                <TreeNode
                    {...baseProps}
                    checked={1}
                    value="jupiter"
                    onClick={(node) => {
                        actual = node;
                    }}
                />,
            );

            wrapper.find('.rct-node-clickable').simulate('click');

            assert.isTrue(actual.checked);
        });

        it('should get the partially-checked node as checked', () => {
            let actual = {};

            const wrapper = shallow(
                <TreeNode
                    {...baseProps}
                    checked={2}
                    value="jupiter"
                    onClick={(node) => {
                        actual = node;
                    }}
                />,
            );

            wrapper.find('.rct-node-clickable').simulate('click');

            assert.isTrue(actual.checked);
        });
    });
});

redpajama_set_name: RedPajamaGithub


I've been wearing the Moto 360 watch for the last two weeks, trying it over a range of activities. The idea of being able to handle notifications more quickly without the hassle and distraction potential of getting out my phone was the main draw, and it is good at this. Any notification that shows up on your phone also shows up on the watch, but a watch notification is more intrusive than a silent phone notification so I turned off watch notifications for a few apps like email that were too much. In the case of email, I also felt like the watch wasn't well suited for long messages I might need to respond to. It was at it's best when communicating things I could handle with a glance, and email isn't like that.
For notifications, something vibrating on your wrist is a lot more noticeable than in your pocket. I don't like having my phone make noise because I don't want to bother the people around me and don't like having to remember to turn it off when I go into places where ringing would be embarrassing, but I do sometimes miss texts and pings with my phone in my pocket on vibrate. On my wrist I didn't miss any, which was really nice.
I was initially worried about the battery, with people saying that they were only getting ~13hr out of it, but I was finishing most days with over 50% charge left. To be fair, though, I was a relatively light user: ambient mode off, no custom watch face, not that many notifications. Motorola also just pushed out an update that people are saying improved their battery life a lot, so I wouldn't worry about this. I did run out of charge once, at the end of a day when I spent three hours in the car with navigation running and stayed up four hours later than usual.
I was also worried about the watch's appearance, that it might be too large and bulky, but mostly it just looks like a watch. A few people asked if it was one of those new smartwatch things, but overall people didn't seem to notice it.
Voice control was a bit of a disappointment. On my phone I can say something like "set an alarm for one hour and fifteen minutes: hang up laundry" but the watch instead wants me to say "set an alarm" and then use my finger to select the time. In general voice interaction with the watch is broken up into stages, where you say something, get a prompt, say something else. This may be because when the phone misinterprets you there's a keyoard to fix the part it didn't get while the watch doesn't have this, but the phone does well enough at understanding me and asking for clarification when it needs it that I was hoping the watch would simply act as another microphone and display for the same tool.
The charging display at night is really nice. You set the phone down in its cradle, and it looks like a little digital bedside table clock. Well designed, useful, and readable with my glasses off, unlike the clock on the other side of the room.
The watch has a step counter and heart-rate monitor, and I had initially thought I didn't care about these features. After a few days, though, I noticed that it was getting me to walk more and think more about getting exercise. On the other hand, it did inform me that I had reached my step goal and heart activity goal while I was playing the piano for a dance last night, so it's not completely accurate.
One missing feature that would be really helpful is a screen lock. Normally when you touch the screen it turns on and starts interpreting input, but if you're contra dancing or playing with an infant there are a lot more accidental touches than intentional ones. Several times my baby managed to get the phone into a weird state, sometimes without me even noticing she had turned it on. Requiring a button push or accelerometer gesture to turn on the screen would be helpful in these cases.
The key issue for me, however, turned out to be wrist irritation. I haven't worn a watch on my wrist for years, and from when I first put this one on it bothered the bottom of the back of my hand. I thought I would get used to it, but after two weeks it's getting worse if anything, so I'm going to stop wearing it.  In general I have bad wrists and am sensitive about things pushing on the tendons on the back of my hand, and now that I think about this I vaguely remember this was why I stopped wearing a watch before.  If it wasn't annoying my wrist, though, I would keep wearing the Moto 360, and I'm sad to be ending this experiment early.
 I had switched from a wrist watch to a pocket watch, and then to a carabiner that hung from my belt, held my keys, and had an integrated digitial watch.


The JFSC has been focusing heavily on Suspicious Activity Reports ("SARs") recently. This is understandable. SARs are a crucial part of the regulatory framework. If regulated businesses are properly reporting suspicions of criminal conduct then the law enforcement agencies receive vital ammunition for cleaning up the finance industry and investigating crime without lifting a finger. The regulator can step back and leave reporting to businesses, as long as they can be trusted to make SARs when they should.
"The JFSC is afforded access to SARs and they are crucial in protecting investors from suffering financial losses and safeguarding the integrity of our finance industry. They form a critical part of what is often a complex jigsaw puzzle of information and timely reporting is key. Our Supervisors will be keen to ensure that SARs are submitted to JFCU as soon as is reasonably practicable. The reason for any delay should be clearly documented.
JFSC staff have seen for themselves how SAR intelligence makes a huge difference and enables the regulator to prevent financial crime working closely with the Joint Financial Crimes Unit. Very often the person submitting the SAR may not appreciate the key role they are playing in contributing to piecing together the jigsaw puzzle. I can only say that in some cases if we had not received a particular SAR we might not have been able to have protected some very vulnerable members of our society."
SARs are something the JFSC can measure. It knows how many SARs each business makes. It takes a keen interest in how many internal SARs are externalised, and how quickly internal SARs are evaluated by the MLRO.
Though there are no specific targets in the AML Handbook, the JFSC will look at the ratio of internal SARs being externalised, and the time taken to evaluate internal SARs. MLRO's can expect to be asked to explain any time delays in the evaluation process and any decision not to submit an internal SAR to JFCU. A high percentage of internal SARs that are not submitted to JFCU may be indicative of a dysfunctional AML function within a business.
Some businesses appear to be working towards a target of 75% of internal SARs externalised, or 30 days to evaluate an internal SAR. However these are not targets approved by the JFSC, and meeting these measures may well not in itself be sufficient to demonstrate full compliance. What is adequate to comply with the regulatory requirements will of course vary from business to business and case to case. Barry Faudemer, who is also the JFSC's MLRO, comments "In some cases a SAR should be submitted immediately for example to prevent financial loss or assist the authorities with a terrorism investigation. I usually process internal SARs submitted to me by JFSC staff and place them in the hands of JFCU within 48 hours. Setting any benchmark for the volume of SARs externalised is dependent on many factors including the type and scale of business together with the risk appetite of the firm."
The requirement as to timing is to make a SAR as soon as is reasonably practicable. Some SARs are so obviously reportable and urgent that they should be externalised immediately, and in such cases waiting without good reason would constitute a breach for failing to report in good time.
However taking several weeks may be a reasonable timeframe in more complex cases, giving time to investigate the case, and some cases may reasonably take even longer to investigate properly. It is important to avoid falling into the trap of waiting to secure firm evidence of money laundering before submitting a SAR. Only a suspicion of money laundering is required to activate the requirement to submit a SAR.
Monitoring the percentage of SARs externalised can only be a rough guide to the general effectiveness of the SAR procedures in a business. If staff are very cautious then many internal SARs may be made which the MLRO properly decides not to externalise. If staff have poor AML awareness or the culture is hostile to reporting, so only a few internal SARs are made, but each one plainly needs externalising, there is still a problem. Plainly a lot depends on the quality of the training and culture in the business, and the competency of the MLROs and their decision making.
As for measuring SAR reporting, how many SARs should each business be making? Will the JFSC consider a business to be higher risk if it is making "too many" SARs (indicating that it must have too much risky business), or if it is making "too few" SARs (indicating that its staff must be failing to report suspicions adequately)? We can expect the JFSC to apply a risk based approach to this. I posed these questions to Barry Faudemer, and his response was this: "I cannot recall a case in recent times where a business has submitted too many SARs and caused alarm to the JFSC. Enforcement have however received referrals and conducted investigations into instances where a business has failed to file a SAR with JFCU. This usually leads to the identification of wider AML weaknesses within a business requiring enforcement action to remedy the shortfall".
The important thing is ensure that your SAR reporting system is working properly. If the staff know when to report something, they are encouraged to do so, and the MLRO competently and promptly evaluates it, and externalises where appropriate without obstruction from the business, then the system is working. Simply saying you have the procedures will not be enough. Expect the JFSC to require clear proof that your SAR procedures are effective.


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Unleashes the energy of a Seal spell to judge an enemy, giving each attack a chance to restore 2% of the attacker's base mana. Refer to individual Seals for additional Judgement effect. Only one Judgement per Paladin can be active at any one time.
Attacks and spells used against you have a chance of restoring some of the attacker's mana.
Judgement of Wisdom is a Paladin ability that places a [Judgment] on the enemy target, causing attackers to restore their mana. It replaced the Judgement effect of [Seal of Wisdom].
As with all Judgements, your miss chance with Judgement of Wisdom is the same as your miss chance with a melee attack.
The amount restored is 2% of the attacker's base mana.
As with [Judgement of Light], the effect can be triggered by both physical attacks and offensive spells against the target.
[Seals of the Pure] increases damage.
[Enlightened Judgements] increases the range by 15/30 yards.
With [Judgements of the Pure], this also increases your casting and melee haste by 3/6/9/12/15% for 1 min.
[Benediction] reduces the mana cost by 2/4/6/8/10%.
Improved Judgements decreases the cooldown by 1/2 sec.
With [Heart of the Crusader] this will also increase the critical strike chance of all attacks made against that target by an additional 1/2/3%.
[Glyph of Judgement] increases the damage by 10%.
Patch 4.0.1 (2010-10-12): Removed. There is now only one Judgement.
Patch 3.0.8 (2009-01-20): Now returns a percentage of base mana instead of a percentage of max mana.
This page was last edited on 20 October 2018, at 16:48.


text:
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redpajama_set_name: RedPajamaCommonCrawl


text:
Mechel and BELAZ a joint venture ElgaBelAvto
JSC "Mechel" and of "BelAZ" to announce the signing of the Agreement on the establishment of a joint Russian-Belarusian company OAO "ElgaBelAvto" for the maintenance and repair of mining haul trucks, "BELAZ" in the Republic of Sakha (Yakutia). The company will be located at the site of HC "JAkutugol" is also planned to set up a branch at the Elga section.
It is assumed that "ElgaBelAvto" will be able to fully meet the needs of service of two major coal mines HC "JAkutugol" — Neruyngri and Elgin (more than 140 units of mining equipment in the medium term).
Total investment in the project is estimated at USD 9.5 million by 2018. It is planned to create more than 330 jobs. According to the agreement, "ElgaBelAvto" will start in late 2013 — early 2014. In the future, the joint venture will be able to serve and other consumer appliances brand "BELAZ" in the Republic of Sakha (Yakutia) and the surrounding regions.
"BELAZ" — our reliable partner of many years and, today, mining machinery manufactured in Belarus works on all mining operations "Mechel". Creation of a joint service center will allow HC "JAkutugol" reduce the cost of maintenance of equipment and a logistical base for large-scale production increase by HK "JAkutugol" and Elga coal deposit, "- commented Vice President, Business Operations of" Mechel "Michael Urvantsev.
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text:
Vilsack to China: Get up to speed on GMOs
by Grant Gerlock, NET News/Harvest Public Media
U.S. Ag Secretary Tom Vilsack says he will talk to Chinese regulators about their slow pace in evaluating biotech traits. (Photo by Grant Gerlock, Harvest Public Media)
Grant Gerlock, NET News/Harvest Public Media
Agriculture Secretary Tom Vilsack will travel to China this week to ask Chinese regulators to get on the same page as the U.S. when it comes to evaluating genetically modified crops.
It's a trade visit that happens every year, but this time there is added interest for American farmers. China has rejected 5 loads of corn from the U.S. in recent weeks. The corn contained an insect-resistant trait from the seed company Syngenta that's approved in the U.S. and several major export markets like Mexico and Japan. But the seed variety is not approved for sale in China.
China was the top market for farm exports from the U.S. last year, but Vilsack says the country's slow approach to regulating biotech crops is a regular point of friction.
"China's leadership has embraced biotechnology, and there seems to be disconnect at the regulatory level," Vilsack said.
The problem, he said, is timing.
"China basically does not start its regulatory process on new (biotech) events until a country like America or Brazil or Argentina has finished their work," Vilsack said.
As a result, whole shipments of grain that show a trace of an unapproved trait may be blocked. Even if that seed variety is commonly grown on U.S. farms.
Vilsack will ask Chinese regulators to start the process when the U.S. does, even if it takes longer to complete. Syngenta has reportedly resubmitted an application to have its trait approved in China.
The secretary of agriculture will travel with Secretary of Commerce Penny Pritzker and U.S. Trade Representative Michael Froman who also hope to address issues of intellectual property rights and market access in China. They were preceded in the last month by visits from Vice President Joe Biden and EPA Administrator Gina McCarthy.
The parade of American officials comes as the U.S. and Asia-Pacific nations try to wrap up a major Trans-Pacific Partnership (TPP) trade agreement. Agriculture, from corn to catfish farming, are caught up in the negotiations.
Corn lawsuits underscore Chinese influence on Midwest farmers
Farmers ready to grow biotech wheat face consumer scrutiny
Generic seeds could have a short life span
Monsanto, world's largest seed company, sets off a corporate 'feeding frenzy'
USDA Official Asks Frustrated Farmers For Patience With China Trade Dispute


Topic How will the payoneer escrow fee work?
How will the payoneer escrow fee work?
- How will the payooner escrow fee work?
- Can i collect the fee on my marketplace on each sell?
Thanks for those who help me.


i totally forgot how to do overlays, lol, thank you!
what happens is the character starts to faint, but then stands up at the very end and doesn't stay down. If you could help that would be great!
You'll have to create a choice and have your readers pick which skin color overlay fits them.
What comes after that part?
maybe someone could help me with that and say what I have done incorrectly??
[NAME], where have you been?
Here we have the mean of all bosses out there. I don't really like her but what other choice do I have.
You are late for work!
Here we have Ace, you won't be able to change his name but you can change the way he look's.
What skin color would you like?
What eyebrow shape would you like?
What color should your eyebrows be?
What face shape would you like?
What eye shape would you like?
What mouth shape would you like?
What color lips would you like?
What natural lip color would you like?
What lip color would you like?
Which hair styles would you like to browse?
What short hair style would you like?
What hip hairstyle do you want?
What longer hair style do you have?
What hair color would you like?
Are you sure this is the look for you?


The 2019 March GAMSAT landed violently upon us, and just as quickly, left. Students hoping to get into medical school are, across Australia, now recovering and nervously awaiting results! For those of you who might look to take the GAMSAT in the future, I would like you to start thinking about how you might answer the essay-type questions (Section 2). I personally encourage my students to write essays as soon as possible, read books as frequently as humanly possible, and start getting used to writing both creative and writing essay in a variety of GAMSAT essay topics. With this blog post, I want to very specifically break down the GAMSAT essay questions, and how you go about answering section 2. Generally, students who are sitting the GAMSAT have a very strong background in science, and so the essay section is a scary proposition that causes a great deal of stress. In this blog, I want to look at what we might find in this daunting section, and then the initial steps to take to defeat it!
(2) Empathy through describing emotions between characters and social relations in a story (a vital skill as a doctor!).
What follows is an example approach of mine when looking at stimuli provided in section 2, where I will look at the quotes, tease out the themes that are presented, and then structure my essay response.
Initially, you need to identify the theme. This is not a restrictive exercise. You should view this as an exercise in expanding the possibilities of what you can write about here! I always make a mind-map of themes that could appear from the quotes – I will go through each quote and identify the various themes from each. Have a go at this! From the quotes above, I have discerned themes of choice, evil, morality, the notion of good, apathy, animals, cruelty, monsters, anger, and others. You can then pick a topic of discussion for your argumentative or creative writing task within ANY of these themes. You don't need to quote the stimuli again, you don't need to explicitly refer to any one of them, but only need to generally address the themes that come out of the stimuli.
When you pick your general approach/thesis, you will then need to plan out your GAMSAT essay topics, based on the particular style of writing you are going to go forward with. This is obviously highly dependent on the various styles that you could choose and will not be covered here – this requires a more in-depth discussion with an expert tutor, such as during a GradReady class. The major points to take away here is that your analysis of the theme should be an expansive project, which opens up the opportunities of what you can write in the GAMSAT – before you even write full essays, I would recommend simply practicing finding themes and writing essays plans over and over again when you start your GAMSAT essay questions study. Find more tips on how to ace the GAMSAT section 2 in our article GAMSAT Section 2 Essay Tips.
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THE SIXTH DAY OF NOVEMBER IN THE YEAR OF GRACE TWO THOUSAND AND SIXTEEN.
Mom (no doubt, like many of yours) is a model of the Christian life as Peter describes it–a life of serving others with the gifts God has entrusted to us, in the strength God provides and to God's glory (1 Peter 4:10-11). For all such saints we give thanks to God and seek to imitate them as they imitate Christ. The inner character of such a person is seen in the following excerpt from one of Mom's recent emails.
[Second son Henry and third son Robert also live in Limestone County, Ala., where Mom now lives] Last evening as Robert was bringing me home (how I do treasure the one-on-one times with him and Henry to and from church services on alternate Sundays — their families in separate cars for convenience) I told him that I felt perhaps one reason the Lord was allowing me these extra years was so I could learn more every day of the exciting truths in His Word that seem to keep unfolding as I read, hear and meditate, and that I can talk about with him and Henry. Not to mention the joy and privilege of living near enough for regular times with each set of families and progeny.
During a visit earlier this year with the three Rollings sisters (Judy, Patricia and Martha) they asked how I kept busy. Among other things, I told them about the manuscript of my book, A BRIEF STUDY OF REVELATION, which I compiled and used in ladies' class in Tupelo, Miss. [before moving to Athens, Alabama last year]. Last Saturday morning, I decided to read the study all the way through and to concentrate particularly on the text and comments of worship and joyfulness of the heavenly scenes and promises, more or less skimming through (though not oblivious to) the rest. Finished about 10:30 that night being thrilled all the way.


The Social Threat have a new release, Even Honest Talk Is Cheap, coming out next Tuesday, March 11. They join The Antidote for a talk about the new EP the following night, Wednesday March 12 at 9pm EST. For a taste of what to expect, The Social Threat have a video for "Strong and Free" from Even Honest Talk Is Cheap.


While our church family takes three weeks for all classes to focus on sharing Jesus without fear, we seize this time to focus on the causes for early church growth as a means of introducing our church-wide evangelism emphasis.
The early church did not grow by chance. Nor did it grow by silence of the believers. The church grew, as the church does today, by the work of the Holy Spirit in bringing the good news of our salvation to the hearts and minds of the unbeliever. The Holy Spirit bears witness to Jesus Christ, the incarnate God, who gave his life as a ransom for sinners. Before Jesus died, he spoke to his Apostles the words of John 14-16, in which he prophesied and promised the Holy Spirit would come. Jesus was specific that the Spirit would bear witness to him. "The Spirit of truth who goes out from the Father, he will testify about me" (Jn 15:26).
That is indeed the work of the Holy Spirit, to "convict the world of guilt in regard to sin and righteousness and judgment" (Jn 16:8). The Spirit brings "glory" to Jesus "by taking what is mine [Jesus] and making it known to you" (Jn 16:14).
The growth of the church, then, is the story of the Holy Spirit working among humanity. We are remiss, however, if we leave out a key to the work of the Holy Spirit. The key is found in the very same passages. In John 15, after Jesus said the Spirit "will testify about me," Jesus immediately adds, "and you also must testify" (Jn 15:27). In other words, evangelism is the work of the Holy Spirit; witnessing is the work of the Holy Spirit, but the Holy Spirit does this work through followers of Christ.
This truth is seen throughout our New Testament. Jesus gave the parting instructions to his disciples to "go and make disciples of all nations" (Mt. 28:19).
Paul would put it this way: in the church, we are all parts of the "body" of Christ (1 Cor. 12). In this body, we all have a manifestation or gift of the Holy Spirit. That gift, though, is for the church, the "common good" (12:7). As the body of Christ, we do the works of Christ. We are his hands, his feet, and his mouth. Not all have the same gift, and not all have the same role in God's evangelism. But all have a gifting for the common good. All have this from God. A natural part of living a truthful life is recognition of God as our source and meaning. Therefore, it is only right and natural that we should openly speak of who gives us meaning and purpose, and of whom we rely on for our today and tomorrow.
This was the experience of the early church. Some were actual missionaries, sent out to take the good news to foreign people. These were, however, not the majority of the Christians. Far more were called to live lives that proclaimed the good news in every day ways to every day people.
The thrust of the early Christians' evangelism was a natural outflow of a changed life dependent upon God. The church was not out to grab converts! The church was following the instructions of the Messiah, telling the good news as God gave the chance and opportunity. This was not an in-your-face accept it or roast-in-hell lifestyle. To the contrary, it was one of love and compassion. The proclamation of the good news was a natural outflow of obedience to Christ as a witness. It was sowing of seed. The church's role was not to get the conversions. That was and is the role of the Holy Spirit. The Holy Spirit convicts hearts and minds; the church merely delivers the message.
Jesus recognized, and the early church understood, that each follower of Christ is a witness to some degree or another. In a real sense, it is merely a question of what kind of witness the believer will be. Will the believer be a light that shines from a hill at night? Or, will the witness be one of shame and silence about the Lord?
The early church grew from a handful of low status, little influence, uneducated, Jewish fishermen in a back-water country of the Roman Empire into a huge economic and social institution that went from end to end of the Roman Empire by 200 A.D. How did the church do this? How did God do this? What was it that made Christianity not just flourish, but grow with an unbelievable speed? That is our focus this week.
Was it Paul? Maybe Peter? Was it a group of people, say the 12 apostles? Who had the "gift of evangelism?" Who were the ones that brought such growth?
It certainly was NOT the attraction of the church in society's eyes--for this was not a time where it was socially acceptable to be a Christian. As we have already studied, those who put their faith in Jesus were frequently targeted not just for persecution, but also even for death. In fact, as we saw in our "Martyr" lesson, the word martyr itself is an English version of the Greek word meaning "witness." Yet in spite of this persecution, at the hand of the state as well as individuals, more and more came to faith. People overcame their fears of speaking about the most important thing in their lives -- Jesus.
It certainly was NOT a big publicity campaign! Publicity was dangerous! It could cause persecution and death.
It certainly was NOT big, beautiful church buildings. The earliest church met in homes. Gradually, many of these homes were expanded into the earliest church buildings, but those buildings were extremely limited and inconspicuous for the first 300 years of the church.
It was actually the simple words and deeds of ordinary Christians used by God in extraordinary ways that brought about the amazing growth of the church. As Christians spoke, more and more came to faith, and as those words were accompanied with actions, the results were astonishing.
How did the early Christians overcome fear issues and share their faith at a time of great persecution? We have a window into their thoughts and actions through writings of the early church fathers as well as secular writings that commented on the early believers. Let us consider how the early Christians stood out in their passion, prayer, partnership, power, and preparation.
The early Christians had an absolute conviction that Jesus Christ conquered death, both in his own body and for those who believed in him. Without this confidence, early Christianity would make no sense for anyone. As Paul wrote in 1 Corinthians, "If Christ has not been raised, your faith is futile" and "we are to be pitied more than all men" (1 Cor. 15:17, 19).
Paul is quick to add, "but Christ has been raised from the dead, the first fruits of those who have fallen asleep" (1 Cor. 15:20). And this conviction, of which Paul and hundreds of others were eyewitnesses, moved Paul to live "in victory" (1 Cor. 15:57). With deep conviction and passion, Paul could urge others to "stand firm" and "let nothing move you" because our God has conquered death and removed its sting, setting men free from sin's grip. Paul and others would "always give [themselves] fully to the work of the Lord, because" that "labor is not in vain."
Paul had passion, and the early church had nothing less! Countless Christians would give their very lives for their convictions. We spent several weeks looking at some of the martyrs of the early church. The effect of the martyrdoms was huge on evangelism. In the early third century, Tertullian would write that the blood of the martyrs was the seed of the church. Tertullian put into words the effect of the passion and conviction of Christians among the world. As the lost saw that people would willingly and peaceably give up their lives for a simple belief and trust in Jesus, they were drawn to Him also.
And, this is no surprise. Many of the lost live in fear of death. Many live in guilt and distress over life. Many go through the motions of life without purpose or direction. When they see someone who has passion in his life, a passion that brings peace in life and death, it is noticed!
This was not a hidden passion. The early church persecution in Asia Minor in the second century caused Christians to come out in mass and march before a provincial governor's home to protest the injustice and show the depth of their faith. With actions like these, we see a passion that clearly overcame any fears about speaking out! The point of these actions and passion was not to get more "converts." Although the church was ecstatic when even one would come to faith, the church saw this as the Holy Spirit's work. The role of the Christian was to be real and faithful; speaking and living as God gave the opportunity, and trusting God with the consequences.
The early church was composed of people of prayer. No doubt this had a profound effect on their walk. No doubt it aided their overcoming of any fear issues associated with living or sharing their faith.
The Didache, which we covered several months ago, was an early church training manual for new Christians. In it, we saw that the early Christians would pause at least three times a day to recite the Lord's Prayer. This prayer was not some magical formula that merely needed vocalizing. Rather, it was said as a true petition before a listening God. While we say it in King James formal English, the original prayer was very ordinary every day-speak. We say, "Our Father, who art in heaven, hallowed be thy name. Thy kingdom come; thy will be done in heaven as it is on earth. Give us this day, our daily bread and forgive us our debts (trespasses); as we forgive our debtors (those who trespass against us). And lead us not into temptation, but deliver us from evil. For thine is the kingdom and the power and the glory forever, amen."
For them, they would reflect and pray three times a day. "Our heavenly Father. You are holy in your person and your actions. We pray that your church will grow on earth and that it will finally be united with you in heaven. Please make sure we have the things we need today, including not just food, but forgiveness for our sins. Knowing your forgiveness, we also forgive those who have wronged us. Father, please protect us spiritually. We live for you. You are all powerful. You alone are worthy of our praise. Amen."
Now, saying that prayer with conviction and thought three times a day will help conquer any fear or obstacle that Satan might use to inhibit our growth!
As mentioned above, the early church did not see conversion of the masses as their responsibility. They saw it as the work of God, and the role of man was to partner with God in that work. This was done in part with words, but even more so with deeds. The actions of the early Christians were profoundly different from actions of the lost. That difference was because of partnership with God.
Around 180 A.D., one of Christianity's most vocal critics was a pagan writer named Celsus. Celsus was quick to point out the uniqueness of the Christian fellowship. There was a social bonding among the Christians that differed greatly from normal life.
"Social bonding" is almost too weak a description for the actions of the early church that drew attention. Christians had charity for each other in measures not seen in the world. Tertullian reported on the pagan comment, "See how these Christians love one another." Jesus foretold this love as the way in which Christians would be recognized. Jesus told his followers, "A new command I give you: Love one another...By this all men will know that you are my disciples, if you love one another" (Jn 13:34-35).
And, Jesus was right! Church historian Henry Chadwick writes, "The practical application of charity [love] was probably the single most potent cause of Christian success." 1 Chadwick then points out multiple areas where the Christians' love was stunning in its actions.
Christians took care of the poor. In a time and in a society where there was no governmental assistance or social security for those in need, the church stepped up and provided the care. The poor, the widows, and the orphans all had help from followers of Christ.
In fact, the primary responsibility for the early church treasury was to provide for the poor. Chadwick cites that by the year 251, the records indicate that the church at Rome had grown so much it supported its "bishop, 46 presbyters, 7 deacons, subdeacons, 42 acolytes, and 52 exorcists, readers and doorkeepers" along with "1500 widows and needy persons, all of whom were `fed by the grace and kindness of the Lord'" (Id. at 58, 59).
This is even more stunning when we remember that the church was an illegal institution subject to the death penalty.
The church did not grow, and people did not overcome fear, merely from these good deeds. The early Christians had power! Great power! Now, this was not a power in the social or governmental structures of the world, nor are we talking about great personal, physical strength. This was not even great miracle working power. This was the greatest power of all - the power of the gospel.
For the early church had in the gospel, an answer to those hurting. There was a real solace in God, Christ and the Holy Spirit, a balm for human pain. For those without purpose, there was divine direction in the gospel. For those without security or peace, there was a peace that passed understanding. There was a confidence of eternity with God.
For those plumbing the depths of human philosophy for happiness or contentment, there was a solid answer. More than merely feeling happy, a deep joy was present. Christianity had the power of giving the outcast a home. Women, who were trampled by society, had equal standing before God in his kingdom. Slaves likewise were treated as equals, for indeed they were! In Christ, there was neither male nor female, neither slave nor free. All were of the same Spirit and set for the same destiny.
This power was tremendous in its effects. Consider how it is today...true answers of peace, meaning, joy, forgiveness, holiness, and eternal security...who wouldn't readily embrace that? That is the power of the gospel message, and there is no greater power on earth today.
In his first epistle, Peter wrote that the Christians were to "always be ready to make a defense to everyone who asks you to give an account for the hope that is in you, yet with gentleness and reverence" (1 Pet. 3:15). That involves preparation!
The church got that preparation meeting together regularly, studying together, and living lives consistent with their teaching. We have seen over the last 14 lessons the study and the fellowship that saw the church grow rapidly. In fact, most of the writings we have studied and used thus far in this class are themselves "preparation" writings. These were documents and letters to help people understand not only the faith we share but also the practical ramifications of that faith.
The early church prepared and fought for the truth of their faith everywhere heresy and unbelief raised its head. Early Christians even wrote the Emperor himself in pleas for understanding and in defense of their faith. We saw this in our class on the early apologists.
So, where does this leave us as we start a three-week emphasis on sharing our faith? We can easily see, I hope, how these same five factors apply to us. With the overriding recognition that God is the evangelist, the Holy Spirit the converter, we can boldly (yet with "gentleness" and "reverence") never fear to speak about who we are and why we are the way we are.
Passion. We should have the passion of the early church. We worship a true redeemer. We have answers to life's problems, and we have eternal destiny. We have purpose. We have secure love. That is worth being passionate about!
Prayer. We need to "pray without ceasing" (1 Thes. 5:17). With a constant dialogue with God, we should be ever watchful for God's opportunities for us to speak or show the love of God to those around us.
Partnership. We are God's hands and feet. We must show the love that he has given us. That is the key that Jesus selected as the means by which people will know we are His. Jesus is present on earth, but we are his body, so what people see in us, is the vision of Jesus they will have.
Power. When we see those hurting, guilty, listless, anxious and worried, lonely, we must remember we hold the gospel message with power to meet their needs! And the gospel meets those needs like nothing else! That is the beauty of God's work and we can bring that to those in need! associated with harsh judgmentalism, with "holier than thou" attitudes, and with political parties rather than the faith of loving creatures basking in the life given by a loving God. Actions must accompany our words to overcome this stereotyping!
Preparation. Not a bad word - preparation is fun! It is study, it is fellowship, and it is more! It is growing before God ourselves. It is learning the power we set out above firsthand!
As we walk in these areas, we will see God use us as never before! Come back next week as Scott helps us "prepare!"
Chadwick, The Early Church, (Dorset Press, 1967).


text:
Does pulse oximeter use impact health outcomes? A systematic review
http://orcid.org/0000-0002-3183-0010Abigail J Enoch1,
Mike English2,3,
Sasha Shepperd1
1Nuffield Department of Population Health, University of Oxford, Oxford, UK
2KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
3Nuffield Department of Medicine, University of Oxford, Oxford, UK
Correspondence to Abigail J Enoch, Nuffield Department of Population Health, Richard Doll Building, Old Road Campus, Headington, Oxford OX3 7LF, UK; abigail.enoch{at}seh.ox.ac.uk
Objective Do newborns, children and adolescents up to 19 years have lower mortality rates, lower morbidity and shorter length of stay in health facilities where pulse oximeters are used to inform diagnosis and treatment (excluding surgical care) compared with health facilities where pulse oximeters are not used?
Design Studies were obtained for this systematic literature review by systematically searching the Database of Abstracts of Reviews of Effects, Cochrane, Medion, PubMed, Web of Science, Embase, Global Health, CINAHL, WHO Global Health Library, international health organisation and NGO websites, and study references.
Patients Children 0–19 years presenting for the first time to hospitals, emergency departments or primary care facilities.
Interventions Included studies compared outcomes where pulse oximeters were used for diagnosis and/or management, with outcomes where pulse oximeters were not used. Main outcome measures: mortality, morbidity, length of stay, and treatment and management changes.
Results The evidence is low quality and hypoxaemia definitions varied across studies, but the evidence suggests pulse oximeter use with children can reduce mortality rates (when combined with improved oxygen administration) and length of emergency department stay, increase admission of children with previously unrecognised hypoxaemia, and change physicians' decisions on illness severity, diagnosis and treatment. Pulse oximeter use generally increased resource utilisation.
Conclusions As international organisations are investing in programmes to increase pulse oximeter use in low-income settings, more research is needed on the optimal use of pulse oximeters (eg, appropriate oxygen saturation thresholds), and how pulse oximeter use affects referral and admission rates, length of stay, resource utilisation and health outcomes.
Outcomes research
Paediatric Practice
This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/
What is already known on this topic
Hypoxaemia is a common complication of pneumonia, bronchiolitis, asthma and sepsis and is associated with increased risk of death in children.
Pulse oximeters are a low-cost intervention that could help reduce child mortality by more effectively diagnosing and monitoring children with hypoxaemia.
Pulse oximeters are often not available or not used in low-income settings, but several international projects aim to increase their availability and use.
What this study adds
The evidence, while low quality, suggests pulse oximeter use may improve children's mortality rates, morbidity measurement, hospital length of stay and admission of hypoxic children.
In the included studies, pulse oximeters were often important for physician's clinical decision-making about children's treatment and management, and their use generally increased resource utilisation.
More research is needed on optimal thresholds to use for hypoxaemia definitions, and on how pulse oximeter use affects resource utilisation and impacts health outcomes.
In newborns, children and adolescents hypoxaemia is associated with increased risk of death, and is a common complication of bronchiolitis, pneumonia, asthma and other serious conditions (eg, sepsis).1–4 Pulse oximetry is a low-cost intervention that could reduce child mortality, in line with Millennium Development Goal 4, by enabling early detection of hypoxaemia and improving accurate diagnosis, thereby increasing the chance of prompt, effective treatment.
Despite the potential to improve health outcomes, pulse oximeters are often not available, particularly in low-income settings. For example, only 38% of Nigerian tertiary hospitals and 3 of 22 Kenyan hospitals providing physician internship training had pulse oximeters in 2011 and 2012, respectively.5 ,6 To promote access, pulse oximeters have been designed for low-income settings, for example, Lifebox, a low-cost, robust, portable, battery-operated oximeter.7 Other designs deliver pulse oximeter results to smartphones, using their spread to remote areas.8 Initiatives supporting pulse oximeter uptake include the WHO's Global Pulse Oximetry Project, Lifebox donations, and the BMJ Christmas Appeal.7 ,9 ,10
Evidence suggests that pulse oximeters identify 20–30% additional hypoxic children compared with using clinical signs alone, for example, grunting and depressed consciousness, which can be imprecise.1 ,11 However, evidence of an association between hypoxaemia and mortality is not necessarily evidence that pulse oximetry implementation improves outcomes, particularly taking a broad health system perspective, when health worker actions, characteristics of children and health facilities, and additional resources, all interact to impact outcomes.
In the complex world of health systems, pulse oximetry could lead to improved health outcomes and system efficiencies, and reduced resource use, by helping health workers promptly diagnose children and initiate treatment, and by improving diagnostic accuracy, thereby preventing unnecessary admissions and treatments. Alternatively, pulse oximetry could lead to unnecessary admissions, treatment, referrals, and/or discharge delays, if thresholds for admission, referral or intervention are inappropriate.
As pulse oximetry availability increases at primary and community care levels in low-income countries, understanding the health system implications is increasingly important, particularly how pulse oximetry impacts resource utilisation. In high-income countries, guidance for routine screening with pulse oximetry is inconsistent, with some suggesting it is unhelpful.12–17 Debate also remains about optimum hypoxaemia definitions, especially at altitude.2 ,18–22
We therefore reviewed the evidence on how pulse oximetry introduction impacts health and service use outcomes.
We addressed the question "Do newborns, children and adolescents aged up to 19 years have lower mortality rates, lower morbidity, and shorter length of stay where pulse oximeters are used to inform diagnosis and treatment (excluding operative surgical care) compared with where pulse oximeters are not used?" Our secondary research question was, "What proportion of newborns, children and adolescents are given oxygen therapy where pulse oximeters are used compared with where pulse oximeters are not used."
Studies were included if they recruited newborns, children and/or adolescents aged up to 19 years, presenting for the first time to a hospital, emergency department (ED), or primary care facility, regardless of setting. Studies assessing pulse oximeters in screening healthy newborns before discharge, or monitoring, for example, during surgery were excluded.
We included studies with at least one intervention group in which a pulse oximeter reading was taken and at least one control group in which pulse oximetry was not used. We included studies reporting mortality, morbidity (illness severity, ie, pneumonia severity scores, disability at discharge) and length of stay. Descriptive studies were excluded.
We systematically searched the Database of Abstracts of Reviews of Effects, Cochrane, Medion, PubMed, Web of Science, Embase, Global Health, CINAHL and WHO Global Health Library, with no language restrictions (Search terms—see online supplementary appendix I). Study references were checked. Websites of non-governmental organisations, health organisations and development organisations were searched for unpublished reports using 'pulse oximeter' and 'pulse oximetry'. Topic experts were contacted for additional materials.
Studies that were not relevant based on title/abstract were excluded. We read the remaining studies' full texts and excluded those not fulfilling the inclusion criteria. All full texts were read by a second person, and if inclusion was uncertain, a third. We extracted data using a tailored Cochrane data collection form and assessed risk of bias using the Cochrane ACROBAT tool.23 ,24
We intended to calculate risk ratios, mean differences and CI's, and if possible pool data within subgroups and conduct a meta-analysis. However, due to the small number of studies and the study design/outcome variability this was not possible. Instead we narratively describe the evidence using a structured approach while drawing insights where possible, a standard strategy in such situations.
We found 7992 reports after removing duplicates and screened all titles and abstracts, and the full texts of 17 potentially relevant studies. Five studies,25–29 all uncontrolled before-after studies (without independent comparison groups), were included (see figure 1).
Flow chart showing the study selection process. See online supplementary appendix II for the Characteristics of Included Studies table and online supplementary appendix III for the Characteristics of Excluded Studies table.
Risk of bias
Table 1 demonstrates each study's risk of bias.
Risk of bias ratings for each domain for each study
Only five eligible studies were included, all uncontrolled before-after studies at high risk of bias; our confidence in the effect estimates is therefore limited with a high level of uncertainty.
Mortality rates
Duke et al,27 reported that mortality rates for children with pneumonia at five Papua New Guinea hospitals decreased by 35% after services were reorganised and pulse oximeters, oxygen concentrators and training were introduced. It is not possible to determine how much of this mortality improvement was due to pulse oximetry versus the provision of training, oxygen systems and other changes.
Three studies assessed whether pulse oximeters influence physicians' clinical decision-making. Paediatric physicians assessed children presenting to an ED and decided their treatment before and after obtaining their pulse oximeter results.25 ,28 ,29 Studies defined hypoxaemia differently and their physicians used different oxygen saturation (SaO2) thresholds to indicate necessary treatment. No independent controls were included, which increased the risk of bias, as did the study designs' accentuation of pulse oximeters' value in the clinical process by presenting oximeter results to physicians after their initial evaluations.
No studies directly measured morbidity; however, two examined whether pulse oximeters facilitate morbidity measurement (illness severity scores and diagnosis). Anderson et al,25 asked physicians to record illness severity assessments, on a 5-point scale, for ill children presenting to the paediatric ward, excluding those with minor orthopaedic/surgical injuries, before and after obtaining pulse oximeter results. Physicians changed 53% of children's scores; two-thirds of these scores were reduced. Physicians in Mower et al,29 changed the diagnoses in 8% of children with SaO2 <95% and 0.7% of children with SaO2 ≥95% after receiving pulse oximeter results.
Length of stay and influence on admission rates
In Choi and Claudius,26 the average time spent in a paediatric ED triage when pulse oximeters were used was 17% less than in the same ED a year previously, when pulse oximeters were not used.
Maneker et al,28 reported that 46/69 children (67%) who had low SaO2 (SaO2<92%) had not been clinically expected to have low SaO2, while 23 (33%) had been expected to have low SaO2. After obtaining pulse oximeter results, physicians admitted 13/46 (28%) of children with unexpectedly low SaO2 (who would have been discharged without pulse oximetry) and admitted 1/23 (4%) of children who expectedly had low SaO2.28 Mower et al,29 found that after receiving pulse oximeter results, physicians admitted 5 additional children of the 305 who had SaO2<95% (2%) and 5 additional children of the 1822 who had SaO2≥95% (0.3%).29
Secondary research question
Management plans changed for 19% of children in Anderson et al;25 most of these plans became less intense. In Maneker et al,28 management plans changed for 91% of children who unexpectedly had low SaO2 (SaO2<92%); 90% of these were started on oxygen therapy. Management plans also changed for 43% of children who expectedly had low SaO2; 90% of these were started on oxygen. In Mower et al,29 after receiving pulse oximeter results, physicians ordered new diagnostic tests for 20% of children with SaO2<95% and for 0.5% of children with SaO2≥95%; they ordered new treatments for 11% of children with SaO2<95% and for 1% of children with SaO2≥95%.
Pulse oximeters are routinely used in high-income countries, but are implemented without consistent guidelines of when/how to use them and little research on how their routine use impacts health outcomes or resources. New programmes encouraging pulse oximeter use in low-income countries should address these inadequacies in the evidence base and promote evidence-based decision-making.
Only five studies, all before-after studies at high risk of bias, were identified. Potential dissimilarities in patient/location characteristics existed between time periods in two studies;26 ,27 there were no independent controls in three,25 ,28 ,29 and in these, physicians were perhaps more inclined to respond to pulse oximetry because results were given after, not during, initial evaluations (unlike outside study settings). In the study providing mortality data, oxygen concentrators, training and other improvements were introduced with pulse oximeters;27 while this study points to important effects of improving oxygen therapy systems, from identification to management, it provides only indirect information on possible effects of wide-scale pulse oximetry adoption, for example, primary care facilities for guiding referral. Other challenges in generalising the findings are that the studies were conducted in the USA and Papua New Guinea and none were conducted in primary care facilities. Although the data are drawn from US studies and those conducted over 15 years ago, available results have some value as they suggest how pulse oximeter introduction impacts physicians' decision-making, the key mechanism by which pulse oximetry influences practice.
Study design limitations reduce our confidence in the included studies' effect estimates. However, there is some evidence to indicate that pulse oximetry may lead to improved health outcomes, with lower mortality rates (when combined with improved/adequate oxygen administration) and reduced time in ED triage; pulse oximetry may change physicians' decisions regarding illness severity, and increase hospital admissions related to previously unrecognised hypoxaemia (note: hypoxaemia definitions varied from <92% to 95%). Routine pulse oximetry may also influence diagnostic tests and treatments used. Mower et al,29 argue that physicians generally accurately judged SaO2 clinically when very high or low, but made more management changes when moderately low.
It is unclear from the literature how pulse oximetry impacts resource utilisation, even though pulse oximetry campaigns focus on low-income settings, where cost-effectiveness is crucial.
In Maneker et al,28 and Mower et al,29 pulse oximetry increased resource use through increased admissions and oxygen therapy for children with otherwise undetected hypoxaemia. Pulse oximetry led to reduced resource utilisation in two studies: in Anderson et al25 two-thirds of children whose illness severity scores changed were then considered less severely ill, and two-thirds of children whose management plans changed were then managed less aggressively; in Choi and Claudius,26 pulse oximetry led to reduced triage time.
Pulse oximetry could facilitate quicker diagnosis, so effective treatment starts earlier and recovery likelihood increases, reducing future resource use. Oximetry can reduce resource waste by indicating when to end treatment, and by decreasing false-positives. However, in Schroeder et al,30 hospital stays were on average 1.6 days longer because of pulse oximetry as 26% of children met discharge criteria except needing oxygen according to pulse oximeters. If additional treatment was unnecessary (eg, inappropriate thresholds were used), then resources were wasted (as the authors assumed). However, if pulse oximetry enabled detection of hypoxic children who would not otherwise obtain treatment, then the additional resources were justified.
Although not discussed here, pulse oximetry also has important resource implications in outpatient facilities, where hypoxaemia prevalence in children, while lower than in hospitals, is still considerable (eg, 4–12%),2 and where pulse oximetry could facilitate timely recognition of necessary care or referral to hospital. Figure 2 illustrates the range of effects of introducing pulse oximetry.
Simple, hypothetical illustration of introducing pulse oximetry into primary care or walk-in clinical settings illustrating the trade-offs that may be apparent in terms of increased or decreased referral or admission rates based on plausible (low and high) estimates of existing rates and true prevalence of hypoxaemia. Note that in low-income countries children often have multiple acute respiratory infections (ARI) episodes per year. The estimates for the baseline (when pulse oximeters are not used) were the following: low estimate for referral rates from primary care facilities: 100 (1%); high estimate: 500 (5%); low estimate for admission from emergency department (ED): 500 (5%); high estimate: 1500 (15%). Referral and admission rates for when pulse oximeters are used were estimated by assuming an increase or decrease in primary care referrals/ED admissions of 5–50% over or below the baseline referral/admission rates. Hypoxaemia prevalence in children aged 7 days–36 months presenting to an ED with ARI has been shown to be as high as 59%31 (when hypoxaemia defined as SaO2<91%) so these high estimates for referral/admission rates are reasonable. Referral/admission rates would be higher in a population if: the true hypoxaemia prevalence in the population is higher (eg, due to high altitude, seasonal effects on bronchiolitis, predisposing environmental factors for asthma); a larger proportion of hypoxaemic children are being missed by clinical evaluation; or higher thresholds are used to define hypoxaemia. The converse of these conditions would lead to lower referral/admission rates, as would a reduction in the number of false-positives as a result of improved accuracy of hypoxaemia diagnosis over clinical signs.
Randomly assigning health facilities to pulse oximeter introduction (with training) or no pulse oximetry could provide robust data on resource use (admissions, diagnostic tools, treatments, referrals, length of stay), health outcomes (mortality, morbidity, re-presentations), and which thresholds, if any, would be most effective for treatment initiation, if studies were sufficiently large. Such pragmatic studies could be done alongside implementation programmes and could elucidate whether pulse oximetry impacts resource use and health outcomes within cost-effectiveness analyses.
If evidence suggests pulse oximetry increases resource utilisation then health workers, facility managers and public health practitioners would need to weigh cost-benefit trade-offs between using scarce resources on pulse oximetry or on other interventions. Context-specific formal cost-effectiveness analyses could be performed to help address these issues but these are rarely done when technologies are introduced into low-income countries' health systems. Such research should be independent and transparent evaluations feeding into wider, evidence-based and inclusive processes for decision-making on resource allocation within health systems.
More research is also needed on the best ways to use pulse oximeters, particularly concerning SaO2 thresholds.
In high-income settings, disease management guidelines rarely recommend SaO2 thresholds for diagnosing, evaluating or monitoring children.12 ,13 When specific SaO2 thresholds are recommended, they differ across organisations, even though WHO's 2012 Recommendations for Management of Common Childhood Conditions provide clear guidance that oxygen be administered if SaO2<90% (for children at ≤2500 m).14 ,15 Conversely, the Canadian Paediatric Society warns "it is important to recognize that setting arbitrary thresholds for oxygen therapy will influence admission rates".16 Setting thresholds is complicated because pulse oximeter results may not be considered in isolation from clinical findings, SaO2 can naturally fluctuate over a day, and studies show that 'healthy' SaO2 differs by age and altitude.20–22 ,32 A few studies have investigated whether outcomes are comparable when thresholds higher than WHO's <90% are used: Cunningham et al,33 found cough resolution time in children with bronchiolitis was equivalent when a <94% or <90% threshold was used for oxygen therapy while Lazzerini et al,34 found that hypoxaemia predicted elevated mortality risk in children with acute lower respiratory infection when a <92% or <90% hypoxaemia threshold was used. It is therefore perhaps unexpected that no studies have examined health system consequences of implementing the WHO guidance of using SaO2<90% thresholds.
In absence of clear guidelines, opinion differs on which thresholds should indicate hypoxaemia and prompt admission, referral, oxygen therapy or other treatments. When emergency physicians were surveyed, there was considerable variability in the lowest SaO2 for which they would discharge a 2-year-old with pneumonia and a 10-month-old with bronchiolitis.18 Maneker et al28 and Mower et al,29 defined low SaO2 as ≤92% and <95% respectively, thus reducing results comparability.
Threshold choice can substantially impact health system outcomes; thus in Schuh et al's35 randomised clinical trial of infants (excluded from this review because all children received pulse oximeter readings), admission rates were sensitive to small saturation differences: 41% of children in the control group were admitted within 72 h versus 25% of children whose displayed SaO2s were artificially increased by 3%.
Pulse oximeters are routinely used in high-income countries and international organisations are investing in programmes to promote pulse oximetry in low-income countries, but there is little evidence, from any region or setting, on the impact or optimal use of pulse oximeters when children present to a health facility. More research is needed on how pulse oximetry impacts health outcomes and services, how knowledge of SaO2 should be integrated with other clinical findings, whether defining 'one-size fits all' thresholds is possible or even useful, for hypoxaemia and in diagnosing/monitoring specific diseases, and how pulse oximetry affects resource utilisation. Such pragmatic research could accompany pulse oximeter implementation efforts and would provide much needed evidence.⇓
Summary of findings
The authors thank Trevor Duke for his advice and assistance with the topic and background; Nia Roberts for her advice on systematic searching methods; and Orlaith Burke for her assistance with the statistical methods.
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Data supplement 1 - Online Appendix I
Data supplement 2 - Online Appendix II
Data supplement 3 - Online Appendix III
Data supplement 4 - Online Appendix IV
Twitter Follow Abigail Enoch at @AbbyEnoch
Contributors AJE drafted the initial protocol with the assistance of SS and ME; AJE carried out the systematic review, SS and ME read through full texts of potential studies and advised on the bias assessments; AJE drafted the initial report and all authors contributed to its development and approved the final version.
Funding AJE is the recipient of a studentship jointly funded by the Medical Research Council and the Oxford Nuffield Department of Population Health; ME is supported by funds from a Wellcome Trust Senior Fellowship (#097170). SS is supported by Oxford's Nuffield Department of Population Health.
Competing interests None declared.
Provenance and peer review Not commissioned; internally peer reviewed.
Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/ This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/
Pulse oximetry: an important first step in improving health outcomes, but is of little use if there is no oxygen
Peter P Moschovis Patricia L Hibberd
Archives of Disease in Childhood 2016; 101 685-685 Published Online First: 12 Apr 2016. doi: 10.1136/archdischild-2015-310055


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