text:
Acute pancreatitis

Acute pancreatitis (AP) is a sudden inflammation of the pancreas. Causes, in order of frequency, include: a gallstone impacted in the common bile duct beyond the point where the pancreatic duct joins it; heavy alcohol use; systemic disease; trauma; and, in children, mumps. Acute pancreatitis may be a single event; it may be recurrent; or it may progress to chronic pancreatitis and/or pancreatic failure (the term pancreatic dysfunction includes cases of acute or chronic pancreatitis where the pancreas is measurably damaged, even if it has not failed).

Mild cases are usually successfully treated with conservative measures: hospitalization, pain control, nothing by mouth, intravenous (IV) nutritional support, and intravenous fluid rehydration. Severe cases often require admission to an intensive care unit to monitor and manage complications of the disease. Complications are associated with a high mortality, even with optimal management. For people with this condition, the pancreas will begin to secrete active enzymes such as trypsin, chymotrypsin and carboxypeptidase, instead of their inactive forms. Damage to the pancreatic ducts can occur as a result of this. Damage to the liver, gallbladder, and spleen can result in severe cases of pancreatitis.

Common
Although these are common symptoms, frequently they are not all present; and epigastric pain may be the only symptom.
 * severe epigastric pain (upper abdominal pain) radiating to the back in 50% of cases
 * nausea
 * vomiting
 * loss of appetite
 * fever
 * chills (shivering)
 * hemodynamic instability, including shock
 * tachycardia (rapid heartbeat)
 * respiratory distress
 * peritonitis
 * hiccup

Uncommon
The following are associated with severe disease:
 * Grey-Turner's sign (hemorrhagic discoloration of the flanks)
 * Cullen's sign (hemorrhagic discoloration of the umbilicus)
 * Pleural effusions (fluid in the bases of the pleural cavity)
 * Grünwald sign (appearance of ecchymosis, large bruise, around the umbilicus due to local toxic lesion of the vessels)
 * Körte's sign (pain or resistance in the zone where the head of pancreas is located (in epigastrium, 6–7 cm above the umbilicus))
 * Kamenchik's sign (pain with pressure under the xiphoid process)
 * Mayo-Robson's sign (pain while pressing at the top of the angle lateral to the erector spinae muscles and below the left 12th rib (left costovertebral angle (CVA))
 * Mayo-Robson's point – a point on border of inner 2/3 with the external 1/3 of the line that represents the bisection of the left upper abdominal quadrant, where tenderness on pressure exists in disease of the pancreas. At this point the tail of pancreas is projected on the abdominal wall.

Complications
Locoregional complications include pancreatic pseudocyst (most common, occurring in up to 25% of all cases, typically after 4–6 weeks) and phlegmon/abscess formation, splenic artery pseudoaneurysms, hemorrhage from erosions into splenic artery and vein, thrombosis of the splenic vein, superior mesenteric vein and portal veins (in descending order of frequency), duodenal obstruction, common bile duct obstruction, progression to chronic pancreatitis, pancreatic ascites, pleural effusion, sterile/infected pancreatic necrosis.

Systemic complications include acute respiratory distress syndrome (ARDS), multiple organ dysfunction syndrome, disseminated intravascular coagulation (DIC), hypocalcemia (from fat saponification), hyperglycemia and insulin dependent diabetes mellitus (from pancreatic insulin-producing beta cell damage), malabsorption due to exocrine failure
 * Metabolic
 * Hypocalcemia, hyperglycemia, hypertriglyceridemia
 * Respiratory
 * Hypoxemia, atelectasis, effusion, pneumonitis, acute respiratory distress syndrome
 * Renal
 * Renal artery or vein thrombosis
 * Kidney failure
 * Circulatory
 * Arrhythmias
 * Hypovolemia and shock
 * Myocardial infarction
 * Pericardial effusion
 * Vascular thrombosis
 * Gastrointestinal
 * Gastrointestinal hemorrhage from stress ulceration
 * Gastric varices (secondary to splenic vein thrombosis)
 * Gastrointestinal obstruction
 *  Hepatobiliary
 * Jaundice
 * Portal vein thrombosis
 * Neurologic
 * Psychosis or encephalopathy (confusion, delusion and coma)
 * Cerebral Embolism
 * Blindness (angiopathic retinopathy with hemorrhage)
 * Hematologic
 * Anemia
 * Disseminated intravascular coagulation
 * Leucocytosis
 * Dermatologic
 * Painful subcutaneous fat necrosis
 * Miscellaneous
 * Subcutaneous fat necrosis
 * Arthalgia

Most common

 * Biliary pancreatitis due to gallstones or constriction of ampulla of Vater in 40% of cases
 * Alcohol in 30% of cases
 * Idiopathic in 15–25% of cases
 * Metabolic disorders: hereditary pancreatitis, hypercalcemia, elevated triglycerides, malnutrition
 * Post-endoscopic retrograde cholangiopancreatography
 * Abdominal trauma
 * Penetrating ulcers
 * Carcinoma of the head of pancreas, and other cancer
 * Drugs: diuretics (e.g., thiazides, furosemide), gliptins (e.g., vildagliptin, sitagliptin, saxagliptin, linagliptin), tetracycline, sulfonamides, estrogens, azathioprine and mercaptopurine, pentamidine, salicylates, steroids, sodium valproate
 * Infections: mumps, viral hepatitis, coxsackie B virus, cytomegalovirus, Mycoplasma pneumoniae, Ascaris
 * Structural abnormalities: choledochocele, pancreas divisum
 * Radiotherapy
 * Autoimmune pancreatitis
 * Severe hypertriglyceridemia

Less common

 * Scorpion venom
 * Chinese liver fluke
 * Ischemia from bypass surgery
 * Heart valve surgery
 * Fat necrosis
 * Pregnancy
 * Infections other than mumps, including varicella zoster
 * Hyperparathyroidism
 * Valproic acid
 * Cystic fibrosis
 * Anorexia or bulimia
 * Codeine phosphate reaction

Pathogenesis
Acute pancreatitis occurs when there is abnormal activation of digestive enzymes within the pancreas. This occurs through inappropriate activation of inactive enzyme precursors called zymogens (or proenzymes) inside the pancreas, most notably trypsinogen. Normally, trypsinogen is converted to its active form (trypsin) in the first part of the small intestine (duodenum), where the enzyme assists in the digestion of proteins. During an episode of acute pancreatitis, trypsinogen comes into contact with lysosomal enzymes (specifically cathepsin), which activate trypsinogen to trypsin. The active form trypsin then leads to further activation of other molecules of trypsinogen. The activation of these digestive enzymes lead to inflammation, edema, vascular injury, and even cellular death. The death of pancreatic cells occurs via two main mechanisms: apoptosis, which is physiologically controlled, and necrosis, which is less organized and more damaging. The balance between these two mechanisms of cellular death is mediated by caspases which regulate apoptosis and have important anti-necrosis functions during pancreatitis: preventing trypsinogen activation, preventing ATP depletion through inhibiting polyADP-ribose polymerase, and by inhibiting the inhibitors of apoptosis (IAPs). If, however, the caspases are depleted due to either chronic ethanol exposure or through a severe insult then necrosis can predominate.

Pathophysiology
The two types of acute pancreatitis are mild and severe, which are defined based on whether the predominant response to cell injury is inflammation (mild) or necrosis (severe). In mild pancreatitis, there is inflammation and edema of the pancreas. In severe pancreatitis, there is necrosis of the pancreas, and nearby organs may become injured.

As part of the initial injury there is an extensive inflammatory response due to pancreatic cells synthesizing and secreting inflammatory mediators: primarily TNF-alpha and IL-1. A hallmark of acute pancreatitis is a manifestation of the inflammatory response, namely the recruitment of neutrophils to the pancreas. The inflammatory response leads to the secondary manifestations of pancreatitis: hypovolemia from capillary permeability, acute respiratory distress syndrome, disseminated intravascular coagulations, renal failure, cardiovascular failure, and gastrointestinal hemorrhage.

Histopathology
The acute pancreatitis (acute hemorrhagic pancreatic necrosis) is characterized by acute inflammation and necrosis of pancreas parenchyma, focal enzymic necrosis of pancreatic fat and vessel necrosis (hemorrhage). These are produced by intrapancreatic activation of pancreatic enzymes. Lipase activation produces the necrosis of fat tissue in pancreatic interstitium and peripancreatic spaces as well as vessel damage. Necrotic fat cells appear as shadows, contours of cells, lacking the nucleus, pink, finely granular cytoplasm. It is possible to find calcium precipitates (hematoxylinophilic). Digestion of vascular walls results in thrombosis and hemorrhage. Inflammatory infiltrate is rich in neutrophils. Due to the pancreas lacking a capsule, the inflammation and necrosis can extend to include fascial layers in the immediate vicinity of the pancreas.

Diagnosis
Acute pancreatitis is diagnosed using clinical history and physical examination, based on the presence of at least 2 of 3 criteria: abdominal pain, elevated serum lipase or amylase, and abdominal imaging findings consistent with acute pancreatitis. Additional blood studies are used to identify organ failure, offer prognostic information, and determine if fluid resuscitation is adequate and whether endoscopic retrograde cholangiopancreatography is necessary.
 * Blood investigations – complete blood count, kidney function tests, liver function, serum calcium, serum amylase and lipase
 * Imaging – A triple phase abdominal CT and abdominal ultrasound are together considered the gold standard for the evaluation of acute pancreatitis. Other modalities including the abdominal x-ray lack sensitivity and are not recommended. An important caveat is that imaging during the first 12 hours may be falsely reassuring as the inflammatory and necrotic process usually requires 48 hours to fully manifest.

Differential diagnosis
The differential diagnosis includes:
 * Perforated peptic ulcer
 * Biliary colic
 * Acute cholecystitis
 * Pneumonia
 * Pleuritic pain
 * Myocardial infarction

Biochemical

 * Elevated serum amylase and lipase levels, in combination with severe abdominal pain, often trigger the initial diagnosis of acute pancreatitis. However, they have no role in assessing disease severity.
 * Serum lipase rises 4 to 8 hours from the onset of symptoms and normalizes within 7 to 14 days after treatment.
 * Serum amylase may be normal (in 10% of cases) for cases of acute or chronic pancreatitis (depleted acinar cell mass) and hypertriglyceridemia.
 * Reasons for false positive elevated serum amylase include salivary gland disease (elevated salivary amylase), bowel obstruction, infarction, cholecystitis, and a perforated ulcer.
 * If the lipase level is about 2.5 to 3 times that of amylase, it is an indication of pancreatitis due to alcohol.
 * Decreased serum calcium
 * Glycosuria

Regarding selection on these tests, two practice guidelines state:

 * "It is usually not necessary to measure both serum amylase and lipase. Serum lipase may be preferable because it remains normal in some nonpancreatic conditions that increase serum amylase including macroamylasemia, parotitis, and some carcinomas. In general, serum lipase is thought to be more sensitive and specific than serum amylase in the diagnosis of acute pancreatitis"

 * "Although amylase is widely available and provides acceptable accuracy of diagnosis, where lipase is available it is preferred for the diagnosis of acute pancreatitis (recommendation grade A)"

Most, but not all individual studies support the superiority of the lipase. In support of the superiority of the lipase: Without support for the superiority of the lipase:
 * In one large study, there were no patients with pancreatitis who had an elevated amylase with a normal lipase. Another study found that the amylase could add diagnostic value to the lipase, but only if the results of the two tests were combined with a discriminant function equation.
 * In one large study, there were no patients with pancreatitis who had an elevated amylase with a normal lipase. Another study found that the amylase could add diagnostic value to the lipase, but only if the results of the two tests were combined with a discriminant function equation.

While often quoted lipase levels of 3 or more times the upper-limit of normal is diagnostic of pancreatitis, there are also other differential diagnosis to be considered relating to this rise.

Computed tomography
Regarding the need for computed tomography, practice guidelines state:

CT is an important common initial assessment tool for acute pancreatitis. Imaging is indicated during the initial presentation if:
 * the diagnosis of acute pancreatitis is uncertain
 * there is abdominal distension and tenderness, fever >102 F (38,9 C), or leukocytosis
 * there is a Ranson score > 3 or APACHE score > 8
 * there is no improvement after 72 hours of conservative medical therapy
 * there has been an acute change in status: fever, pain, or shock

CT is recommended as a delayed assessment tool in the following situations:
 * acute change in status
 * to determine therapeutic response after surgery or interventional radiologic procedure
 * before discharge in patients with severe acute pancreatitis

Abdominal CT should not be performed before the first 12 hours of onset of symptoms as early CT (<12 hours) may result in equivocal or normal findings.

CT findings can be classified into the following categories for easy recall:
 * Intrapancreatic – diffuse or segmental enlargement, edema, gas bubbles, pancreatic pseudocysts and phlegmons/abscesses (which present 4 to 6 wks after initial onset)
 * Peripancreatic / extrapancreatic – irregular pancreatic outline, obliterated peripancreatic fat, retroperitoneal edema, fluid in the lessar sac, fluid in the left anterior pararenal space
 * Locoregional – Gerota's fascia sign (thickening of inflamed Gerota's fascia, which becomes visible), pancreatic ascites, pleural effusion (seen on basal cuts of the pleural cavity), adynamic ileus, etc.

The principal value of CT imaging to the treating clinician is the capacity to identify devitalised areas of the pancreas which have become necrotic due to ischaemia. Pancreatic necrosis can be reliably identified by intravenous contrast-enhanced CT imaging, and is of value if infection occurs and surgical or percutaneous debridement is indicated.

Magnetic resonance imaging
While computed tomography is considered the gold standard in diagnostic imaging for acute pancreatitis, magnetic resonance imaging (MRI) has become increasingly valuable as a tool for the visualization of the pancreas, particularly of pancreatic fluid collections and necrotized debris. Additional utility of MRI includes its indication for imaging of patients with an allergy to CT's contrast material, and an overall greater sensitivity to hemorrhage, vascular complications, pseudoaneurysms, and venous thrombosis.

Another advantage of MRI is its utilization of magnetic resonance cholangiopancreatography (MRCP) sequences. MRCP provides useful information regarding the etiology of acute pancreatitis, i.e., the presence of tiny biliary stones (choledocholithiasis or cholelithiasis) and duct anomalies. Clinical trials indicate that MRCP can be as effective a diagnostic tool for acute pancreatitis with biliary etiology as endoscopic retrograde cholangiopancreatography, but with the benefits of being less invasive and causing fewer complications.

Ultrasound
On abdominal ultrasonography, the finding of a hypoechoic and bulky pancreas is regarded as diagnostic of acute pancreatitis.

Treatment
Initial management of a patient with acute pancreatitis consists of supportive care with fluid resuscitation, pain control, nothing by mouth, and nutritional support.

Fluid replacement
Currently, following the findings of the WATERFALL clinical trial, moderate hydration at a rate of 1.5 ml/kg per hour of isotonic crystalloid solution (e.g. normal saline or lactated Ringer's solution), preceded by one or more boluses of 10 mL/kg in case of hypovolaemia, is recommended in acute pancreatitis.

Fluid requirements should be reassessed at frequent intervals in the first six hours of admission and for the next 24 to 48 hours. The rate of fluid resuscitation should be adjusted based on clinical assessment, hematocrit and blood urea nitrogen (BUN) values.

In the initial stages (within the first 12 to 24 hours) of acute pancreatitis, fluid replacement has been associated with a reduction in morbidity and mortality.

Pain control
Abdominal pain is often the predominant symptom in patients with acute pancreatitis and should be treated with analgesics.

Opioids are safe and effective at providing pain control in patients with acute pancreatitis. Adequate pain control requires the use of intravenous opiates, usually in the form of a patient-controlled analgesia pump. Hydromorphone or fentanyl (intravenous) may be used for pain relief in acute pancreatitis. Fentanyl is being increasingly used due to its better safety profile, especially in renal impairment. As with other opiates, fentanyl can depress respiratory function. It can be given both as a bolus as well as constant infusion. Meperidine has been historically favored over morphine because of the belief that morphine caused an increase in sphincter of Oddi pressure. However, no clinical studies suggest that morphine can aggravate or cause pancreatitis or cholecystitis. In addition, meperidine has a short half-life and repeated doses can lead to accumulation of the metabolite normeperidine, which causes neuromuscular side effects and, rarely, seizures.

Bowel rest
In the management of acute pancreatitis, the treatment is to stop feeding the patient, giving them nothing by mouth, giving intravenous fluids to prevent dehydration, and sufficient pain control. As the pancreas is stimulated to secrete enzymes by the presence of food in the stomach, having no food pass through the system allows the pancreas to rest. Approximately 20% of patients have a relapse of pain during acute pancreatitis. Approximately 75% of relapses occur within 48 hours of oral refeeding.

The incidence of relapse after oral refeeding may be reduced by post-pyloric enteral rather than parenteral feeding prior to oral refeeding. IMRIE scoring is also useful.

Nutritional support
Recently, there has been a shift in the management paradigm from total parenteral nutrition (TPN) to early, post-pyloric enteral feeding (in which a feeding tube is endoscopically or radiographically introduced to the third portion of the duodenum). The advantage of enteral feeding is that it is more physiological, prevents gut mucosal atrophy, and is free from the side effects of TPN (such as fungemia). The additional advantages of post-pyloric feeding are the inverse relationship of pancreatic exocrine secretions and distance of nutrient delivery from the pylorus, as well as reduced risk of aspiration.

Disadvantages of a naso-enteric feeding tube include increased risk of sinusitis (especially if the tube remains in place greater than two weeks) and a still-present risk of accidentally intubating the trachea even in intubated patients (contrary to popular belief, the endotracheal tube cuff alone is not always sufficient to prevent NG tube entry into the trachea).

Oxygen
Oxygen may be provided in some patients (about 30%) if Pao2 levels fall below 70mm of Hg.

Antibiotics
Up to 20 percent of people with acute pancreatitis develop an infection outside the pancreas such as bloodstream infections, pneumonia, or urinary tract infections. These infections are associated with an increase in mortality. When an infection is suspected, antibiotics should be started while the source of the infection is being determined. However, if cultures are negative and no source of infection is identified, antibiotics should be discontinued.

Preventative antibiotics are not recommended in people with acute pancreatitis, regardless of the type (interstitial or necrotizing) or disease severity (mild, moderately severe, or severe)

Endoscopic retrograde cholangiopancreatography
In 30% of those with acute pancreatitis, no cause is identified. Endoscopic retrograde cholangiopancreatography (ERCP) with empirical biliary sphincterotomy has an equal chance of causing complications and treating the underlying cause, therefore, is not recommended for treating acute pancreatitis. If a gallstone is detected, ERCP, performed within 24 to 72 hours of presentation with successful removal of the stone, is known to reduce morbidity and mortality. The indications for early ERCP are:
 * Clinical deterioration or lack of improvement after 24 hours
 * Detection of common bile duct stones or dilated intrahepatic or extrahepatic ducts on abdominal CT

The risks of ERCP are that it may worsen pancreatitis, it may introduce an infection to otherwise sterile pancreatitis, and bleeding.

Surgery
Surgery is indicated for (i) infected pancreatic necrosis and (ii) diagnostic uncertainty and (iii) complications. The most common cause of death in acute pancreatitis is secondary infection. Infection is diagnosed based on 2 criteria
 * Gas bubbles on CT scan (present in 20 to 50% of infected necrosis)
 * Positive bacterial culture on FNA (fine needle aspiration, usually CT or US guided) of the pancreas.

Surgical options for infected necrosis include:
 * Minimally invasive management – necrosectomy through small incision in skin (left flank) or abdomen
 * Conventional management – necrosectomy with simple drainage
 * Closed management – necrosectomy with closed continuous postoperative lavage
 * Open management – necrosectomy with planned staged reoperations at definite intervals (up to 20+ reoperations in some cases)

Other measures

 * Pancreatic enzyme inhibitors are proven not to work.
 * The use of octreotide has been shown not to improve outcomes.

Classification by severity: prognostic scoring systems
Acute pancreatitis patients recover in majority of cases. Some may develop abscess, pseudocyst or duodenal obstruction. In 5 percent cases, it may result in acute respiratory distress syndrome (ARDS), disseminated intravascular coagulation DIC. Acute pancreatitis can be further divided into mild and severe pancreatitis.

Mostly the Ranson Criteria are used to determine severity of acute pancreatitis. In severe pancreatitis serious amounts of necrosis determine the further clinical outcome. About 20% of the acute pancreatitis are severe with a mortality of about 20%. This is an important classification as severe pancreatitis will need intensive care therapy whereas mild pancreatitis can be treated on the common ward.

Necrosis will be followed by a systemic inflammatory response syndrome (SIRS) and will determine the immediate clinical course. The further clinical course is then determined by bacterial infection. SIRS is the cause of bacterial (Gram negative) translocation from the patients colon.

There are several ways to help distinguish between these two forms. One is the above-mentioned Ranson Score.

In predicting the prognosis, there are several scoring indices that have been used as predictors of survival. Two such scoring systems are the Ranson criteria and APACHE II (Acute Physiology and Chronic Health Evaluation) indices. Most, but not all studies report that the Apache score may be more accurate. In the negative study of the APACHE-II, the APACHE-II 24-hour score was used rather than the 48-hour score. In addition, all patients in the study received an ultrasound twice which may have influenced allocation of co-interventions. Regardless, only the APACHE-II can be fully calculated upon admission. As the APACHE-II is more cumbersome to calculate, presumably patients whose only laboratory abnormality is an elevated lipase or amylase do not need assessment with the APACHE-II; however, this approach is not studied. The APACHE-II score can be calculated at www.sfar.org.

Practice guidelines state:
 * 2006: "The two tests that are most helpful at admission in distinguishing mild from severe acute pancreatitis are APACHE-II score and serum hematocrit. It is recommended that APACHE-II scores be generated during the first 3 days of hospitalization and thereafter as needed to help in this distinction. It is also recommended that serum hematocrit be obtained at admission, 12 h after admission, and 24 h after admission to help gauge adequacy of fluid resuscitation."

 * 2005: "Immediate assessment should include clinical evaluation, particularly of any cardiovascular, respiratory, and renal compromise, body mass index, chest x ray, and APACHE II score"

Ranson score
The Ranson score is used to predict the severity of acute pancreatitis. They were introduced in 1974.

At admission

 * age in years > 55 years
 * white blood cell count > 16000 cells/mm3
 * blood glucose > 11.1 mmol/L (> 200 mg/dL)
 * serum AST > 250 IU/L
 * serum LDH > 350 IU/L

At 48 hours
The criteria for point assignment is that a certain breakpoint be met at any time during that 48 hour period, so that in some situations it can be calculated shortly after admission. It is applicable to both gallstone and alcoholic pancreatitis.
 * Calcium (serum calcium < 2.0 mmol/L (< 8.0 mg/dL)
 * Hematocrit fall >10%
 * Oxygen (hypoxemia PO2 < 60 mmHg)
 * BUN increased by 1.8 or more mmol/L (5 or more mg/dL) after IV fluid hydration
 * Base deficit (negative base excess) > 4 mEq/L
 * Sequestration of fluids > 6 L

Alternatively, pancreatitis can be diagnosed by meeting any of the following:[2]

Alternative Ranson score
Ranson's score of ≥ 8 Organ failure Substantial pancreatic necrosis (at least 30% glandular necrosis according to contrast-enhanced CT)

Interpretation If the score ≥ 3, severe pancreatitis likely. If the score < 3, severe pancreatitis is unlikely Or

Score 0 to 2 : 2% mortality Score 3 to 4 : 15% mortality Score 5 to 6 : 40% mortality Score 7 to 8 : 100% mortality

APACHE II score
"Acute Physiology And Chronic Health Evaluation" (APACHE II) score > 8 points predicts 11% to 18% mortality
 * Hemorrhagic peritoneal fluid
 * Obesity
 * Indicators of organ failure
 * Hypotension (SBP <90 mmHG) or tachycardia > 130 beat/min
 * PO2 <60 mmHg
 * Oliguria (<50 mL/h) or increasing BUN and creatinine
 * Serum calcium < 1.90 mmol/L (<8.0 mg/dL) or serum albumin <33 g/L (<3.2.g/dL)>

Balthazar score
Developed in the early 1990s by Emil J. Balthazar et al., the Computed Tomography Severity Index (CTSI) is a grading system used to determine the severity of acute pancreatitis. The numerical CTSI has a maximum of ten points, and is the sum of the Balthazar grade points and pancreatic necrosis grade points:

Balthazar grade

Necrosis score

CTSI's staging of acute pancreatitis severity has been shown by a number of studies to provide more accurate assessment than APACHE II, Ranson, and C-reactive protein (CRP) level. However, a few studies indicate that CTSI is not significantly associated with the prognosis of hospitalization in patients with pancreatic necrosis, nor is it an accurate predictor of AP severity.

Glasgow score
The Glasgow score is valid for both gallstone and alcohol induced pancreatitis, whereas the Ranson score is only for alcohol induced pancreatitis. If a patient scores 3 or more it indicates severe pancreatitis and the patient should be considered for transfer to ITU. It is scored through the mnemonic, PANCREAS:
 * P – PaO2 <8kPa
 * A – Age >55-years-old
 * N – Neutrophilia: WCC >15x10(9)/L
 * C – Calcium <2 mmol/L
 * R – Renal function: Urea >16 mmol/L
 * E – Enzymes: LDH >600iu/L; AST >200iu/L
 * A – Albumin <32g/L (serum)
 * S – Sugar: blood glucose >10 mmol/L

BISAP score
Predicts mortality risk in pancreatitis with fewer variables than Ranson's criteria. Data should be taken from the first 24 hours of the patient's evaluation.
 * BUN >25 mg/dL (8.9 mmol/L)
 * Abnormal mental status with a Glasgow coma score <15
 * Evidence of SIRS (systemic inflammatory response syndrome)
 * Patient age >60 years old
 * Imaging study reveals pleural effusion

Patients with a score of zero had a mortality of less than one percent, whereas patients with a score of five had a mortality rate of 22 percent. In the validation cohort, the BISAP score had similar test performance characteristics for predicting mortality as the APACHE II score. As is a problem with many of the other scoring systems, the BISAP has not been validated for predicting outcomes such as length of hospital stay, need for ICU care, or need for intervention.

Epidemiology
In the United States, the annual incidence is 18 cases of acute pancreatitis per 100,000 population, and it accounts for 220,000 hospitalizations in the US. In a European cross-sectional study, incidence of acute pancreatitis increased from 12.4 to 15.9 per 100,000 annually from 1985 to 1995; however, mortality remained stable as a result of better outcomes. Another study showed a lower incidence of 9.8 per 100,000 but a similar worsening trend (increasing from 4.9 in 1963–74) over time.

In Western countries, the most common cause is alcohol, accounting for 65 percent of acute pancreatitis cases in the US, 20 percent of cases in Sweden, and 5 percent of those in the United Kingdom. In Eastern countries, gallstones are the most common cause of acute pancreatitis. The causes of acute pancreatitis also varies across age groups, with trauma and systemic disease (such as infection) being more common in children. Mumps is a more common cause in adolescents and young adults than in other age groups.

title: Acute pancreatitis


text:
Guatapará

Guatapará is a municipality in the state of São Paulo in Brazil. The population is 7,709 (2020 est.) in an area of 414 km². The elevation is 512 m.

Media
In telecommunications, the city was served by Centrais Telefônicas de Ribeirão Preto. In December 2000, this company was acquired by Telefónica, which adopted the Vivo brand in 2012. The company is currently an operator of cell phones, fixed lines, internet (fiber optics/4G) and television (satellite and cable).

license: Creative Commons - Attribution Share-Alike - https://creativecommons.org/licenses/by-sa/4.0/

title: Guatapará


text:
Wikipedia:UK Wikipedians' notice board/UKCOTW/Removed

This page contains nominations from the main UK collaboration of the week page which have been removed due to lack of votes or because they're unsuitable nominations. Successful nominations are listed at the history page.

Tourism in Wales (1 vote in 1 week)
Nominated October 1, needs three votes by October 8

Support
 * 1) Graham  ☺ | Talk 22:19, 1 Oct 2004 (UTC)

Comments
 * Kinda scary that there is as yet no page here.-- Graham ☺ | Talk 22:19, 1 Oct 2004 (UTC)
 * I don't think this is the best choice if the aim is to get a featured article. None of the "tourism in..." pages I looked at were very inspiring. They are often just extended lists. Angela. 23:53, Oct 1, 2004 (UTC)

Reason for removal
 * Withdrawn by nominator -- Graham ☺ | Talk 22:27, 2 Oct 2004 (UTC)

Football in Scotland (1 vote in 1 week)
Nominated October 1, needs three votes by October 8

Support
 * 1) Graham  ☺ | Talk 22:19, 1 Oct 2004 (UTC)

Comments
 * I'm sure something can be said on this subject.-- Graham ☺ | Talk 22:19, 1 Oct 2004 (UTC)
 * We already have a lot of articles on Scottish Football. I'm not sure what another one would have to add. For example: Scottish Football Association, Scotland national football team, Scotland football hall of fame, Scottish Cup and SAFA. Angela. 23:53, Oct 1, 2004 (UTC)

Reason for removal
 * Withdrawn by nominator -- Graham ☺ | Talk 22:27, 2 Oct 2004 (UTC)

Politics of Wales (1 vote in 1 week)

 * Nominated 2 October, needs three votes by 9 October

Support
 * 1) [[User:Neutrality|Neutrality (talk)]] 00:09, Oct 2, 2004 (UTC)

Comments
 * A large hole in UK coverage, I feel. [[User:Neutrality|Neutrality (talk)]] 00:09, Oct 2, 2004 (UTC)

Reason for removal
 * Not enough votes. -- Graham ☺ | Talk 21:32, 9 Oct 2004 (UTC)

Empire Windrush (1 vote in 1 week)

 * Nominated 5 October, needs three votes by 12 October

Support
 * 1) ALoan (Talk) 17:29, 5 Oct 2004 (UTC)

Comments
 * An unsuccessful Collaboration of the week candidate for two weeks in July, gaining 5 votes, but still an important topic in the history of multicultural Britain with a tiny stubby article. -- ALoan (Talk) 17:29, 5 Oct 2004 (UTC)
 * It's a ship... I don't really know what more you could write about it. -- Graham  ☺ | Talk 23:04, 8 Oct 2004 (UTC)

Reason for removal
 * Not enough votes. -- Graham ☺ | Talk 23:18, 12 Oct 2004 (UTC)

St. George's Day (2 votes in 1 week)

 * Nominated 6 October, needs three votes by 13 October

Support
 * 1) violet/riga (t) 21:15, 6 Oct 2004 (UTC)
 * 2) User:NeilTarrant (t) 11:18, 9 Oct 2004 (UTC)

Comments
 * Could do with at least something written about it! The Saint George article itself seems quite good, but surely Englands day (and the campaigns to boost it's recognition) are noteworthy? violet/riga (t) 21:15, 6 Oct 2004 (UTC)
 * Sounds like a good idea, but note that England isn't the only area over which St. George holds sainthood (Genoa, Georgia, Anatolia...) --NeilTarrant 11:18, 9 Oct 2004 (UTC)
 * Surely the article should be at St George's Day (no dot) Warofdreams 19:38, 11 Oct 2004 (UTC)
 * Should have redirects from both... St. (note dot) is becoming an accepted abbreviation for Saint.--NeilTarrant 23:39, 11 Oct 2004 (UTC)

Reason for removal
 * Not enough votes. -- Graham ☺ | Talk 23:20, 13 Oct 2004 (UTC)

Lorraine Kelly (5 votes in 2 week)

 * Nominated 2 October, needs six votes by 16 October

Support
 * 1) Graham ☺ | Talk 22:26, 2 Oct 2004 (UTC)
 * 2) Derek Ross | Talk 04:53, 2004 Oct 3 (UTC)
 * 3) Theresa Knott  (The torn steak) 10:38, 4 Oct 2004 (UTC)
 * 4) Dmn / [[User talk:Dmn|Դմն ]] 15:54, 8 Oct 2004 (UTC)
 * 5) Silverfish 00:37, 16 Oct 2004 (UTC)

Comments
 * It is a crime that the goddess of daytime TV has no article... -- Graham ☺ | Talk 22:26, 2 Oct 2004 (UTC)

Reason for removal
 * Not enough votes. -- Graham ☺ | Talk 17:24, 17 Oct 2004 (UTC)

Toby jug (2 votes in 1 week)
Nominated 11 October, needs three votes by 18 October

Support
 * 1) Graham ☺ | Talk 11:18, 11 Oct 2004 (UTC)
 * 2) Silverfish 00:42, 16 Oct 2004 (UTC)

Comments
 * Just thought this'd be an interesting one to do together. -- Graham ☺ | Talk 11:18, 11 Oct 2004 (UTC)

Reason for removal
 * Not enough votes. (removed by Steinsky 01:37, 19 Oct 2004)

Boulton and Watt (2 votes in 1 week)
Nominated 14 October, needs three votes by 21 October

Support
 * 1) Jerry 09:44, 14 Oct 2004 (UTC)
 * 2) [[User:Noisy|Noisy | Talk]] 22:46, 15 Oct 2004 (UTC)

Comments
 * Although there are separate articles on Boulton and Watt (see links from the current stub) their collaboration, arguably the most significant of the industrial revolution, deserves a decent article. There are lots of other existing articles which could be linked to this article.

Reason for removal
 * Not enough votes. -- ALoan (Talk) 16:32, 21 Oct 2004 (UTC)

Canterbury, Kent (7 votes in 3 weeks)
(Originally nominated as Canterbury, England)
 * Nominated 1 October, needs nine votes by 22 October

Support
 * 1) Graham  ☺ | Talk 22:07, 1 Oct 2004 (UTC)
 * 2) Angela. 23:53, Oct 1, 2004 (UTC)
 * 3) Keith Edkins 06:29, 4 Oct 2004 (UTC)
 * 4) Theresa Knott (The torn steak) 10:38, 4 Oct 2004 (UTC)
 * 5) CheekyMonkey 20:00, 4 Oct 2004 (UTC)
 * 6) AlexG 17:58, 8 Oct 2004 (UTC)
 * 7) Picapica 21:43, 10 Oct 2004 (UTC)

Comments
 * Page recently went through WP:COTW but was withdrawn for lack of votes. -- Graham ☺ | Talk 22:07, 1 Oct 2004 (UTC)
 * Do we have anybody who lives there and can fill in on the current culture - stuff that isn't in books? --Keith Edkins 06:29, 4 Oct 2004 (UTC)
 * I live in Canterbury, not sure what I could add about culture that isn't already written down in books though. CheekyMonkey 20:00, 4 Oct 2004 (UTC)
 * Unfortunately my internet access will be little to non-existant in the next 10 days. And just hours before Canterbury might be chosen as current UKCOTW - bleah. CheekyMonkey 17:58, 17 Oct 2004 (UTC)
 * I wonder if Canterbury, Kent would be a better name for it than Canterbury, England? -- 217.41.241.203 11:55, 4 Oct 2004 (UTC)
 * Agreed, 'C, Kent' is closer to WP standard. --Steinsky 19:14, 6 Oct 2004 (UTC)
 * Why does the vote target keep moving higher and later every time we get to it? Is this vandalism?--Keith Edkins 21:20, 8 Oct 2004 (UTC)
 * No it's following the standard practice used at WP:COTW. On 10th October the article with the highest number of votes gets selected; in the meantime setting a target number of votes for it to achieve means that articles are not listed here indefinitely.  The reason the target has been raised to nine is because the six votes have already been achieved.  If you think this practice is silly let me know and I'll revert the targets back to one week on each candidate. -- Graham  ☺ | Talk 21:43, 8 Oct 2004 (UTC)
 * I guess I can live with it, although it's very confusing that all the articles are being judged on different days of the week. On a point of etiquette, is it considered bad manners to work on articles listed on this page before they do, or don't, get voted in?--Keith Edkins 15:15, 9 Oct 2004 (UTC)
 * It is confusing a lot of people so I might change it to be honest. No it's not considered bad etiquette at all, but please leave us something to do when it is the collaboration! -- Graham  ☺ | Talk 21:27, 9 Oct 2004 (UTC)

Reason for removal
 * Not enough votes. -- Graham ☺ | Talk 17:43, 24 Oct 2004 (UTC)

British Virgin Islands (3 vote in 2 weeks)

 * Nominated October 9, needs six votes by October 23

Support
 * 1) [[User:Neutrality|Neutrality (talk)]] 22:45, Oct 8, 2004 (UTC)
 * 2) Ambi 09:49, 15 Oct 2004 (UTC)
 * 3) Silverfish 00:39, 16 Oct 2004 (UTC)

Comments
 * Pathetic. [[User:Neutrality|Neutrality (talk)]] 22:45, Oct 8, 2004 (UTC)

Reason for removal
 * Not enough votes. -- Graham ☺ | Talk 17:43, 24 Oct 2004 (UTC)

Children in Need (3 votes in 2 weeks)
Nominated October 16, needs six votes by October 30

Support
 * 1) Graham ☺ | Talk 15:49, 16 Oct 2004 (UTC)
 * 2) Joe D 16:26, 16 Oct 2004 (UTC)
 * 3) No[[User_talk:norm|rm]] 00:09, 19 Oct 2004 (UTC)

Comments
 * Only just created today. -- Graham ☺ | Talk 15:50, 16 Oct 2004 (UTC)

Reason for removal
 * Not enough votes. -- Graham ☺ | Talk 02:06, 1 Nov 2004 (UTC)

Culture of England (1 vote in 1 week)
Nominated 31 October, needs three votes by 7 November

Support
 * 1) Graham ☺ | Talk 02:08, 1 Nov 2004 (UTC)

Comments
 * Something to get our teeth into. -- Graham ☺ | Talk 02:08, 1 Nov 2004 (UTC)
 * This is UKCOTW - what about Culture of the United Kingdom, which is not brilliant, or Culture of Wales, Culture of Scotland, or Culture of Northern Ireland? Shouldn't we start with UK and work down? -- ALoan (Talk) 14:51, 1 Nov 2004 (UTC)
 * If you think we should do one of the others first then nominate it. My own feeling is though that if I nominated Culture of the United Kingdom at WP:COTW it would be rejected for not being a stub - should we have the same guideline here or is nominating an article that long ok? -- Graham  ☺ | Talk 15:13, 1 Nov 2004 (UTC)
 * I knew you'd say that and I may just do so :) I think the rule ought to be roughly the same as WP:COTW, although, given the traffic here, we could afford to be a bit less rigid and (I'll say this quietly, and don't quote me) the rule in WP:COTW is really intended to put the frighteners on people to stop them nominating something that is clearly inappropriate, and is more honoured in the breach than the observance anyway: nominated articles rarely get rejected out of hand unless they are clearly not stubby .   Culture of the United Kingdom is not really a stub, I suppose, particularly by reference to the 1,000 character limit, but it nowhere near a full treatment - one section of overview, a table of bank holidays, and a list of links.  By way of comparison, British military history is also quite long in terms of characters, but it is almost content-free. -- ALoan (Talk) 15:33, 1 Nov 2004 (UTC)
 * Thanks for calling me predicatble, I'll take that as a compliment. What you raise here is a very good point, and I'm on the verge of bending the rules myself, seeing how few articles we have in nominations at the moment, and that is dragging one or two of the more popular ones back out of /Removed and keeping them here semi-permanently, i.e. doing away with the three votes per week thing, or reducing it, or just clearing away the ones that are just inappropriate.  I am intereste in what other people think of this, though it might be advisable bringing it up in talk rather than here. -- Graham  ☺ | Talk 15:44, 1 Nov 2004 (UTC)
 * I think we should keep the N-votes-per-week rule for two reasons (i) to prevent the list of nominations getting stale, and (ii) because listing articles on a page like this usually has the effect of encouraging people to work on them even if they are not selected as the Collaboration of the Week. Perhaps the number of votes required should be reduced to 2 per week?  In any event, there is no objection to re-nominating previous unsuccessful candidates if they still meet the criteria - I've been known to do it on WP:COTW myself, and some of my nominees here (including British military history, IIRC) came from there too. -- ALoan (Talk) 16:15, 1 Nov 2004 (UTC)

Reason for removal
 * Not enough votes. -- Joe D (t) 11:40, 8 Nov 2004 (UTC) [and ALoan (Talk) 11:45, 8 Nov 2004 (UTC)]

Religion in the United Kingdom (4 votes in 2 weeks)
Nominated 25 October, needs six votes by 8 November

Support
 * 1) ALoan (Talk) 12:41, 25 Oct 2004 (UTC)
 * 2) Joe D (t) 15:18, 25 Oct 2004 (UTC)
 * 3) [[User:Neutrality|Neutrality (hopefully!)]] 19:29, Oct 26, 2004 (UTC)
 * 4) Graham ☺ | Talk 22:10, 1 Nov 2004 (UTC)

Comments
 * Ridiculous that this is a red link. -- ALoan (Talk) 12:41, 25 Oct 2004 (UTC)

Reason for removal
 * Not enough votes. -- ALoan (Talk) 17:30, 8 Nov 2004 (UTC)

Glasgow patter (2 votes in 1 week)
Nominated 1 November, needs three votes by 8 November

Support
 * 1) Joe D (t) 13:34, 1 Nov 2004 (UTC)
 * 2) ALoan (Talk) 14:51, 1 Nov 2004 (UTC)

Comments
 * I'm not from Glasgow or anywhere near there, but this was mentioned in the VFD for Glasgow slang. I think we should merge them, there must be lots to say about the history?  Joe D (t) 13:34, 1 Nov 2004 (UTC)

Reason for removal
 * Not enough votes. -- ALoan (Talk) 17:30, 8 Nov 2004 (UTC)

Traffic warden (2 votes in 1 week)
Nominated 8 November, needs three votes by 15 November

Support
 * 1) ALoan (Talk) 17:38, 8 Nov 2004 (UTC)
 * 2) Graham ☺ | Talk 00:27, 10 Nov 2004 (UTC)

Comments
 * A red link at the moment - from The Beetles's Lovely Rita, to black and yellow uniforms, to parking tickets: much to be said. Nothing at parking attendant or parking ticket, although parking meter and meter maid exist. -- ALoan (Talk) 17:38, 8 Nov 2004 (UTC)
 * I redirected it to meter maid for the moment, though it could proviede an interesting project. -- Graham ☺ | Talk 00:27, 10 Nov 2004 (UTC)

Reason for removal: Note enough votes. -- Graham ☺ | Talk 12:48, 16 Nov 2004 (UTC)

Albert Square (2 votes in 1 week)
Nominated 8 November, needs three votes by 15 November

Support
 * 1) ALoan (Talk) 17:38, 8 Nov 2004 (UTC)
 * 2) Graham ☺ | Talk 00:30, 10 Nov 2004 (UTC)

Comments
 * Quite a short stub: is there much enthusiasm for popular culture out there?  EastEnders is a bit longer, but mostly cast list. -- ALoan (Talk) 17:38, 8 Nov 2004 (UTC)
 * I added the cast list from the BBC website, though I don't know how many in the 'present' section are actually current cast members. I've been going through (slowly) creating pages for those that I can find lots of info on, but there's a fair few for whom this is their only acting experience.  Still with Christopher Parker attempting suicide today, I've got something to add to at least one article...  Would EastEnders make a better nomination, or not? -- Graham  ☺ | Talk 00:30, 10 Nov 2004 (UTC)

Reason for removal Not enough votes. -- Graham ☺ | Talk 12:48, 16 Nov 2004 (UTC) -

Bedfordshire (4 votes in 3 weeks)
Nominated November 15, needs six votes by November 29

Support
 * 1) Graham ☺ | Talk 01:50, 15 Nov 2004 (UTC)
 * 2) Keith Edkins 08:53, 15 Nov 2004 (UTC)
 * 3) Warofdreams 12:38, 16 Nov 2004 (UTC)
 * 4) Joe D (t) 00:08, 29 Nov 2004 (UTC)

Comments
 * I'm intrigued as to what we can make of this as a community: a relatively short sample of the UK county articles. My own efforts at Buckinghamshire and others efforts at other counties have produced interesting results, I'd be fascinated to see how, for example, the Geology of, Geography of and History of links go and just how far one of these pages can expand. -- Graham  ☺ | Talk 01:50, 15 Nov 2004 (UTC)

Reason for removal
 * Not enough votes -- Graham ☺ | Talk 18:42, 5 Dec 2004 (UTC)

Drover (1 vote in 1 week)
Nominated 28 November, needs three votes by 5 December

Support
 * 1) violet/riga (t) 12:34, 28 Nov 2004 (UTC)

Comments
 * Just made this tiny stub. Quite a tradition in Wales I believe and the external links at the article should help it be expanded quite easily. violet/riga (t) 12:34, 28 Nov 2004 (UTC)

Reason for removal
 * Not enough votes -- Graham ☺ | Talk 20:45, 9 Dec 2004 (UTC)

Template:Former British colonies (1 vote in 1 week)

 * Nominated January 25, 2005; needs three votes by February 1, 2005

Support: Comments:
 * 1) Instantnood — 12:30, 25 Jan 2005 (UTC)
 * It needs people to help expand the list.
 * Does a template really qualify as a COTW? McMullen 15:08, 25 Jan 2005 (UTC)
 * Please note that this is currently on WP:TFD and, in my opinion, doesn't qualify as a COTW or even an acceptable template (category or list maybe). violet/riga (t) 23:21, 25 Jan 2005 (UTC)
 * This is not a stub. It shouldn't be considered here.  To expand the list, please check out British Empire. -- PFHLai 03:36, 2005 Jan 26 (UTC)

Reason for removal
 * Not eligible. -- Francs2000 | Talk 02:53, 3 Feb 2005 (UTC)

Thames House (MI5 headquarters)
Nominated 27 January, needs three votes by 3 February

Support
 * 1) Grunners 20:22, 27 Jan 2005 (UTC)
 * 2) Francs2000 | Talk 20:52, 27 Jan 2005 (UTC)
 * 3) PopUpPirate 15:09, Mar 5, 2005 (UTC)

Comments
 * Began this brief article, which is nothing compared to the article on the MI6 headquarters. Unfortuantly I know little about it other than its location. Grunners 20:22, 27 Jan 2005 (UTC)

Reason for removal

Time expired.

The Duke of Edinburgh's Award
Nominated 3 February, needs three votes by 10 February

Support
 * 1) Grunners 02:45, 3 Feb 2005 (UTC)
 * 2) (though it's official name according to  is The Duke of Edinburgh's Award) -- Francs2000 | Talk  02:51, 3 Feb 2005 (UTC)

Comments
 * Hugely popular organisation, and not even a stub! Grunners 02:45, 3 Feb 2005 (UTC)

Reason for removal

Time expired.

-


text: Category:Elections in Pakistan

title: Category:Elections in Pakistan


text:
Quartz Compositor

Quartz Compositor is the display server (and at the same time the compositing window manager) in macOS. It is responsible for presenting and maintaining rasterized, rendered graphics from the rest of the Core Graphics framework and other renderers in the Quartz technologies family.

Overview
The bitmap output from Quartz 2D, OpenGL, Core Image, QuickTime, or other process is written to a specific memory location, or backing store. The Compositor then reads the data from the backing stores and assembles each into one image for the display, writing that image to the frame buffer memory of the graphics card. Quartz Compositor only accepts raster data, and is the only process that can directly access the graphics frame buffer.

In managing individual windows, Quartz Compositor accepts a bitmap image of the window's contents from its renderer, along with its position. The choice of the renderer is up to the individual application, although most use Quartz 2D. Quartz Compositor then acts as a "visual mixing board," by adding the given window to the whole scene for the display.

In its role as window manager, Quartz Compositor also has an event queue which receives events, such as key strokes and mouse clicks. The Quartz Compositor takes the events from the queue, determines which process owns the window where the event occurred, and passes the event on to the process.

Quartz Extreme
Mac OS X v10.2 introduced Quartz Extreme: graphics processor (GPU) acceleration for the Quartz Compositor. With Quartz Extreme, far fewer central processing unit (CPU) cycles are needed for scene composition. Instead, the Quartz Compositor encapsulates each rendered backing store in an OpenGL texture map or surface. It then directs the GPU to compose the surfaces and maps to provide the final image, which is delivered to the frame buffer.

Quartz Extreme only uses OpenGL commands, and requires a graphics card connected to an AGP 2X or faster bus (including AGP 4X, 8X, and PCI Express), supporting textures and maps of arbitrary size, since many of the renderers have no size limitation (Quartz 2D for example). In Mac OS X Tiger, it is automatically enabled on Mac systems with one of the following types of graphics cards:
 * AMD (ATI) Radeon, AGP-based, 16 MB VRAM minimum, or better
 * NVIDIA GeForce2 MX, 16 MB VRAM minimum, or better

As of OS X El Capitan, Quartz Extreme is enabled on all supported Macs.

QuartzGL
QuartzGL (called Quartz 2D Extreme when it was introduced in Mac OS X Tiger) is GPU acceleration for the Quartz 2D API. With QuartzGL enabled, all Quartz drawing commands are translated to OpenGL commands and executed on the GPU. This differs from Quartz Extreme, which still executes Quartz drawing commands on the CPU but performs final composition using the GPU.

As of OS X Mountain Lion, QuartzGL is still not enabled by default. However, it is possible to enable it using the Quartz Debug application included in the Apple Developer Tools. QuartzGL will be disabled once again upon quitting the Quartz Debug utility. A workaround is to force quit the Quartz Debug application, which will leave QuartzGL enabled system-wide.

All graphics cards capable of supporting Core Image also support QuartzGL.

title: Quartz Compositor


text: Category:Elections in Syria

title: Category:Elections in Syria


text:
Wikipedia:Articles for deletion/Cranberry Elementary School

Cranberry Elementary School
Unnotable elementary school. Substub. [[User:Neutrality|Neutrality (talk)]] 22:33, Oct 2, 2004 (UTC)
 * Delete. Non-notable elementary school.   — Gwalla | Talk 00:07, 3 Oct 2004 (UTC)
 * Delete -- Nothing of note User:MartinSpamer
 * Delete. RickK 04:30, Oct 3, 2004 (UTC)
 * Delete. Non-notable. --*drew 04:34, 3 Oct 2004 (UTC)
 * Delete. The article is so short as to be of no use. Average Earthman 15:05, 3 Oct 2004 (UTC)
 * Delete. Notability not demonstrated in article. [[User:Dpbsmith|Dpbsmith (talk)]] 20:42, 3 Oct 2004 (UTC)
 * Delete. Trollstub.  Postdlf 06:24, 4 Oct 2004 (UTC)
 * Keep and expand. Notable school. anthony (see warning) 21:46, 6 Oct 2004 (UTC)
 * Can you do us a favor and expand this? Mandel 09:09, Oct 10, 2004 (UTC)
 * Sure, as soon as the VfD notice gets taken off. I'm not working on something just so it can get deleted, after all. anthony (see warning) 16:45, 10 Oct 2004 (UTC)
 * Why don't you summarize your points as to what makes it notable? Tell us why you think this particular school substub can be expanded into a real article.  Postdlf 17:17, 10 Oct 2004 (UTC)
 * Delete: Just a school. Geogre 02:24, 8 Oct 2004 (UTC)


text: Category:Elections in Tajikistan

title: Category:Elections in Tajikistan


text:
Wikipedia:Articles for deletion/Miyayke Elementary School

Miyayke Elementary School
Unnotable elementary school. Substub. [[User:Neutrality|Neutrality (talk)]] 22:34, Oct 2, 2004 (UTC)
 * Delete. Non-notable school.   — Gwalla | Talk 00:07, 3 Oct 2004 (UTC)
 * Delete -- Nothing of note User:MartinSpamer
 * Delete. Unnecessary inclusion. --*drew 04:35, 3 Oct 2004 (UTC)
 * Delete. Non-notable.  RickK 04:38, Oct 3, 2004 (UTC)
 * Delete. And this differs from thousands of other elementary schools in what way exactly? Average Earthman 15:05, 3 Oct 2004 (UTC)
 * Delete. Notability not demonstrated in article. [[User:Dpbsmith|Dpbsmith (talk)]] 20:43, 3 Oct 2004 (UTC)
 * Delete. Trollstub.  Postdlf 06:25, 4 Oct 2004 (UTC)
 * Keep and expand. Notable school. anthony (see warning) 21:47, 6 Oct 2004 (UTC)
 * Keep. I hope authors will tell us the location (prefecture, city) and interesting information about the school. Also, should the spelling be "Miyake" (that is, delete the second "y")? Fg2 01:20, Oct 8, 2004 (UTC)
 * Delete: Just a school. Whether it's exotic or not, it's mundane in its own context. Geogre 02:25, 8 Oct 2004 (UTC)


text: Category:Elections in Yemen

title: Category:Elections in Yemen


text:
Wikipedia:Articles for deletion/Arbor Heights Elementary

Arbor Heights Elementary
Unnotable elementary school. Substub. [[User:Neutrality|Neutrality (talk)]] 22:35, Oct 2, 2004 (UTC)
 * Delete. Created by a troll looking to cause trouble.  RickK 04:22, Oct 3, 2004 (UTC)
 * Delete. Antandrus 04:23, 3 Oct 2004 (UTC)
 * Delete Non-notable. jni 14:00, 3 Oct 2004 (UTC)
 * Delete. Nothing to indicate notability. Average Earthman 15:06, 3 Oct 2004 (UTC)
 * Delete. Notability not demonstrated in article. [[User:Dpbsmith|Dpbsmith (talk)]] 20:43, 3 Oct 2004 (UTC)
 * Delete. Non-notable elementary school.   — Gwalla | Talk 17:45, 4 Oct 2004 (UTC)
 * Delete. Not notable. Stupid school articles. Argh. --Improv 21:33, 4 Oct 2004 (UTC)
 * Keep. Completely notable school. anthony (see warning) 21:48, 6 Oct 2004 (UTC)
 * Delete: Just a school. Glad the trees are on a height. Geogre 02:26, 8 Oct 2004 (UTC)
 * Keep. Just a school. Intrigue 17:34, 8 Oct 2004 (UTC)
 * Delete: even if it was notable, current article doesn't help in any way in saying that. Mozzerati 20:35, 2004 Oct 8 (UTC)
 * Keep. It clearly needs to be finished (and maybe even started a little), but it should still be kept.--TheGrza 21:42, Oct 8, 2004 (UTC)
 * Delete: As far as I know, it isn't notable for anything. There are dozens of elementary schools in every moderately sized town, and thousands across the United States.  If there's anything special about it, I don't know what it is.   •  →  Iñgólemo  ←•  22:29, 2004 Oct 8 (UTC)
 * Why does there have to be something special about it for it to be notable? anthony (see warning) 03:22, 9 Oct 2004 (UTC)


text: Category:Elections in Uzbekistan

title: Category:Elections in Uzbekistan


text:
Volksgemeinschaft

Volksgemeinschaft is a German expression meaning "people's community",  "folk community", "national community", or "racial community", depending on the translation of its component term Volk (cognate with the English word "folk"). This expression originally became popular during World War I as Germans rallied in support of the war, and many experienced "relief that at one fell swoop all social and political divisions could be solved in the great national equation". The idea of a Volksgemeinschaft was rooted in the notion of uniting people across class divides to achieve a national purpose, and the hope that national unity would "obliterate all conflicts - between employers and employees, town and countryside, producers and consumers, industry and craft".

After Germany's defeat in World War I, the concept of Volksgemeinschaft remained popular especially on the right wing of German politics, in opposition to the class struggle advocated by Marxist parties like the Social Democrats and the Communists. The German Conservative Party became the German National People's Party and the National Liberal Party reorganized itself into the German People's Party, with the new names intended partly as references to Volksgemeinschaft.

The concept was notoriously embraced by the newly founded Nazi Party in the 1920s, and eventually became strongly associated with Nazism after Adolf Hitler's rise to power. In the Nazi vision of Volksgemeinschaft, society would continue to be organized into classes (based upon talent, property, or profession), but there would be no class conflict, because a common national consciousness would inspire the different economic and social classes to live together harmoniously and work for the nation. There was also an important racial aspect to the Nazi Volksgemeinschaft: only "people of Aryan blood" could be members.

Development
The word "Volksgemeinschaft" was probably first used in Gottlob August Tittel's 1791 translation of a text written by John Locke, synthesising the expression "in any [particular] place, generally". Among 19th century scholars who used the word "Volksgemeinschaft" were Friedrich Schleiermacher, Friedrich Carl von Savigny, Carl Theodor Welcker, Johann Caspar Bluntschli, Hermann Schulze, Wilhelm Dilthey, and Wilhelm Wundt. Most influential was perhaps Ferdinand Tönnies' theory in his work Gemeinschaft und Gesellschaft ("Community and Society") of 1887. Decades later, in 1932, Tönnies joined the Social Democratic Party of Germany to oppose the rise of Nazism and protest against their use of his concept. He had his honorary professorship removed when Adolf Hitler came to power.

In 1914, at the beginning of World War I, the Emperor Wilhelm II proclaimed before the Reichstag the Burgfrieden ("peace in the castle" or "truce in the castle", a kind of "unity within a besieged castle" for the duration of the conflict), announcing that henceforward all of the regional differences between the different states of the Reich; between rich, middle class and poor; between Roman Catholics and Protestants; and between rural and urban no longer existed and the German people were all one for the duration of the war. During the war, many Germans longed to have the sense of unity that the Burgfrieden inspired continue after the war, and it was during this period that many ideas started to circulate about how to convert the wartime Burgfrieden into a peacetime Volksgemeinschaft.

In the aftermath of World War I, the idea of Volksgemeinschaft was used to interpret economic catastrophes and hardship facing Germans during the Weimar Republic era as a common experience of the German nation and to argue for German unity to bring about renewal to end the crisis. It was invoked by the Jewish social anarchists Gustav Landauer (who was killed for his participation in the Bavarian Soviet Republic) and Erich Mühsam (who died in Oranienburg concentration camp) in articulating their vision of a peaceful, non-coercive mutualist society. However, it was subsequently adopted by the Nazi Party to justify actions against Jews, profiteers, Marxists, and the Allies of World War I, whom the Nazis accused of obstructing German national regeneration, causing national disintegration in 1918 and Germany's defeat in World War I.

There is an ongoing debate among historians as to whether a Volksgemeinschaft was or was not successfully established between 1933 and 1945. This is a notably controversial topic of debate for ethical and political reasons, and is made difficult by the ambiguous language employed by Hitler and the Nazis when talking about the Volksgemeinschaft.

Nazi Volksgemeinschaft
In the aftermath of the November Revolution of 1918 that marked the end of the German Empire and the beginning of the Weimar Republic, there was strong animosity amongst many Germans towards the Weimar Republic and the social democrats who sponsored its creation. This was combined with anxiety in the 1930s and with the severe economic crisis in Germany and abroad, in which many Germans faced unemployment. This situation resulted in increasing popularity for the Nazi Party, including amongst workers, small business owners, and others who desired a government that would resolve the economic crisis. While ascending to power, Hitler promised to restore faith in the Volk and to bring wholeness while accusing other politicians of tearing at German unity.

Upon rising to power in 1933, the Nazis sought to gain support of various elements of society. Their concept of Volksgemeinschaft was racially unified and organized hierarchically. This involved a mystical unity, a form of racial soul uniting all Germans, including those living abroad. Nevertheless, this soul was regarded as related to the land, in the doctrine of "blood and soil". Indeed, one reason for "blood and soil" was the belief that landowner and peasant lived in an organic harmony. Aryan Germans who had sexual relations with non-Germanics were excluded from the people's community.

The Nazis solidified support amongst nationalists and conservatives by presenting themselves as allied with President Paul von Hindenburg, who was considered a war hero of World War I in Germany. On 21 March 1933, special celebrations were held to mark the re-opening of the Reichstag following the Reichstag fire, and the Nazis called this event Potsdam Day. Potsdam Day was used to celebrate military tradition, the Hohenzollern dynasty of Prussia, the sacrifices of World War I and the "hero of Tannenberg," President Hindenburg. The image of Hitler and Hindenburg shaking hands was reproduced on thousands of postcards, representing "the union of the new and old Germany," a way for the Nazis to portray themselves as connected to the aristocratic traditions of the past.

Having organized Potsdam Day to gain conservative support, the Nazis sought to gain the support of workers by declaring May Day, a day celebrated by organized labour, to be a paid holiday named the "Day of National Work" and held celebrations on 1 May 1933 to honour German workers. The regime believed that the only way to avoid a repeat of the disaster of 1918 was to secure workers' support for the German government. The regime also insisted through propaganda that all Germans take part in the May Day celebrations, not just workers, in the hope that this would help break down class hostility between workers and burghers. Songs in praise of labour and workers were played by state radio throughout May Day 1933, as well as an airshow in Berlin and fireworks. The Nazis added strongly nationalist themes to the celebrations, and Hitler spoke of workers as patriots who had built Germany's industrial strength and had honourably served in the war, while claiming that they had been oppressed under economic liberalism. Hitler praised the virtues of labor, and was quoted in the Völkischer Beobachter as declaring that "I only acknowledge one nobility—that of labour." The event proved convincing, as the next day the Berliner Morgenpost, a newspaper which had been associated with the political left in the past, praised the regime's May Day celebrations. At the same time, however, the Nazis sought to destroy independent working class organizations, seeing them as incompatible with the trans-class unity of the Volksgemeinschaft. On 2 May 1933, one day after the celebrations, the trade union movement was banned, and "stormtroopers sealed off and took over the operations of the socialist Free Trade Unions and incorporated them into what became the German Labor Front".

The Nazis continued social welfare policies initiated by the governments of the Weimar Republic and mobilized volunteers to assist those impoverished, "racially-worthy" Germans through the National Socialist People's Welfare organization. This organization oversaw charitable activities, and became the largest civic organization in Nazi Germany. Successful efforts were made to get middle-class women involved in social work assisting large families. The Winter Relief campaigns acted as a ritual to generate public feeling. These efforts also served to reinforce the racial ideology of the Nazis and the idea that the Volksgemeinschaft was a racial community, because Jews and other non-Aryans were excluded from social welfare benefits, as were Germans who opposed Nazism or who were deemed "unfit" for other reasons.

The Volksgemeinschaft was intended to create a sense of uniformity amongst its members; Fritz Reinhardt, state secretary for the finance ministry, introduced numerous tax breaks for lower and middle class Germans, narrowed pension gaps between blue and white collar workers, and lowered the entrance standards for civil service exams. The ubiquitous uniforms within Nazi organisations were intended to suppress visible class differences in dress and create an image of unity. Between 1933 and 1939, upward mobility was twice as likely as between 1927 and 1933. The Second World War assisted in this, as social status and class did not affect whether one received Reich services. Wartime rationing was implemented in an egalitarian manner, which greatly pleased the working class – a secret wartime report by the Social Democrats stated that "the working classes thoroughly welcome the fact that 'the better off' have, in practical terms, ceased to be that."

Nevertheless, in many ways the Nazi Volksgemeinschaft served only as a symbolic unity, while real differences of status and wealth continued to dominate daily life. The Nazis disparaged sophisticated forms of address such as gnädige Frau ("gracious lady") and the associated practice of kissing a lady's hand, but Hitler was routinely shown engaging in that same practice in press photographs. Old titles of nobility were shunned, but the Nazi Party hierarchy created numerous new titles. Elegant evening dress and other public displays of wealth were sometimes derided and sometimes encouraged. The Nazi Party claimed to administer justice impartially to all ethnic Germans regardless of their social origins, and Nazi propaganda emphasized instances where upper class individuals were found guilty by the courts as evidence of this, but at the same time the Nazi Party provided many opportunities for corruption and vested interests among its members. On one occasion the arrest of a Reichsbank director was widely publicized by the Nazi press, while his subsequent release was never mentioned.

In propaganda
Nazis gave a great deal of prominence to this new "folk community" in their propaganda, depicting the events of 1933 as a Volkwerdung, or a people becoming itself. The Volk were not just a people; a mystical soul united them, and propaganda continually portrayed individuals as part of a great whole, worth dying for. A common Nazi mantra declared that ethnic Germans must put "collective need ahead of individual greed" and oppose class conflict, materialism, and profiteering in order to ensure the survival of the Volk—a widespread sentiment in this era. To exemplify and encourage such views, when the Hitlerjugend and Bund Deutscher Mädel collected donations for Winterhilfswerk (Winter Relief), totals were not reported for any individuals, only what the branch raised. The Winterhilfswerk campaigns themselves acted as a ritual to generate public feeling. Organisations and institutions such as Hitlerjugend, Bund Deutscher Mädel, Winterhilfswerk, but also the Reich Labour Service and, above all, the Nazi party were portrayed as exemplifications and concrete manifestations of the "Volksgemeinschaft".

Hitler declared that he knew nothing of bourgeois or proletarian, only Germans. Volksgemeinschaft was portrayed as overcoming distinctions of party and social class. The commonality this created across classes was among the great appeals of Nazism.

After the failure of the Beer Hall Putsch, Hitler, in the trial, omitted his usual pre-putsch anti-Semitism and centered his defense on his selfless devotion to the good of the Volk and the need for bold action to save them. The Versailles settlement had betrayed Germany, which they had tried to save. Thereafter, his speeches concentrated on his boundless devotion to the Volk, though not entirely eliminating the anti-Semitism. Even once in power, his immediate speeches spoke of serving Germany. While the Reichstag fire was used to justify anti-Communist and anti-Semitic violence, Hitler himself spoke on a new life, honor, and unity in Germany. Similarly, the Night of the Long Knives was justified as a peril to the people so great that only decisive action would save them. Goebbels described Hitler after that event as suffering "tragic loneliness" and as a Siegfried forced to shed blood to preserve Germany.

Devotion to this Volk is common in Nazi propaganda. An account, for instance, of a SA brawl depicted its leader as uncouth and therefore a simple, strong, and honest man of the people. Sturmabteilung speakers were used, in part, for the appeal of their folksy manner. One element of Horst Wessel's life that was fictionalized out of the movie Hans Westmar was the willful provoking of violent conflicts with Communists; Westmar preaches class reconciliation, and his death unifies students and workers. These ideas were also propagandized to the Sturmabteilung, whose violent, rebellious and confrontational past had to be transformed into a community organization to be useful in a Germany where Nazis held official power.

This unity was what justified Nazi propaganda; its pejorative connotation had sprung solely from its selfish use, and the Nazis' honorable goal, the unity of the German people, made it honorable for them.

It also justified the one-party state as all that was needed in a society with a united will, where Hitler implemented the will of the Volk more directly than in a democracy. Attacks on Great Britain as a plutocracy also emphasized how the German, being able to participate in his Volk, is freer than the Briton.

In his pamphlet State, Volk and Movement, Carl Schmitt praised the expulsion of Jews from political life without ever using the term "Jew" and using "non-Aryan" only rarely, by praising the homogeneity of the people and the Volksgemeinschaft ensuing; merely Gleichschaltung was not sufficient, but Nazi principles must continue to make the German people pure. Even Carl Jung's "collective unconscious" was preferred to Freudian concepts because of its communal element.

The Volksgemeinschaft was also depicted in films on the home-front during World War II, with the war uniting all levels of society, as in the two most popular films of the Nazi era, Die grosse Liebe and Wunschkonzert. The Request Concert radio show, on which the latter film was based, achieved great popularity by broadcasting music claimed to be requested by men in the armed forces. Attempts to get women of "better classes" to take factory jobs were presented as breaking down class barriers and so helping create a true people's community. Failure to support the war was an anti-social act; this propaganda managed to bring arms production to a peak in 1944.

Categories of Germans
Nazi legal theory divided all Germans into two categories, namely the Volksgenossen ("National Comrades") who belonged to the Volksgemeinschaft and the Gemeinschaftsfremde ("Community Aliens") who did not. In addition to the duties and responsibilities shared by those in the community, the National Comrades were expected to build and create a "Volksgeist" ("Volk spirit") that would encompass the best aspects of the German people. As such, community aliens could not belong, since they were deemed an undermining element in the very foundations of the "Volksgemeinschaft".

The modern German historian Detlev Peukert wrote the following about the purpose of Nazi social policy:

The goal was an utopian Volksgemeinschaft, totally under police surveillance, in which any attempt at nonconformist behaviour, or even any hint or intention of such behaviour, would be visited with terror.

Criminals, if deemed unable to be part of the people's community, were severely punished, even executed for crimes that did not provide for the death penalty, such as doubling the sentence the prosecution asked for when a defendant had not helped put out a fire, thus showing a disregard for the life of his "Volksgenossen" and community. In support of this, Peukert quoted two articles from the projected "Law for the Treatment of Community Aliens" of 1944, which though never implemented owing to bureaucratic quarrels showed the intentions of Nazi social policy:

"Article I.

Community Aliens (Gemeinschaftsfremde)

1.

"Community Aliens" are such persons who:

1, Show themselves, in their personality or in the conduct of their life, and especially in light of any unusual deficiency of mind or character, unable to comply by their own efforts with the minimum requirements of the national community.

2.(a) owing to work-shyness or slovenliness, lead a worthless, unthrifty or disorderly life and are thereby a burden or danger to the community:

Or

Display a habit of, or inclination towards beggary or vagrancy, idling at work, larceny, swindling or other less seriously offences, or engage in excessive drunkenness, or for any such reasons are in breach of their obligation to support themselves.

Or

(b) through persistent ill-temper or quarrelsomeness disturb the peace of the community;

3. show themselves, in their personality or the conduct of their life, mentally disposed towards the commission of serious offences (community-hostile criminals [gemeinschaftsfeindliche Verbrecher]) and criminals by inclination [Neigungsverbrecher]).

Article II

Police Measures Against Community Aliens

2.

1. Community aliens should be subject towards police supervision.

2. If supervisory measures are insufficient, the police shall transfer the community aliens to the Gau (or Land) welfare authorities.

3. If, in the case of any community alien persons, a stricter degree of custody is required than is possible within the institutions of the Gau (or Land) welfare authorities, the police shall place them in a police camp.""

Children and youth

In their desire to establish a total state, the Nazis understood the importance of “selling” their ideology to the youth. To accomplish this, Hitler established Nazi youth groups. Young boys from 6–10 years old participated in the Pimpfen, similar to the cub scouts. Boys from 10–14 years old participated in the Deutsches Jungvolk, and boys 14–18 years old participated in the Hitler Jugend (Hitler Youth). The two older groups fostered military values and virtues, such as duty, obedience, honor, courage, strength, and ruthlessness. Uniforms and regular military drills were supplemented by ceremonies honoring the war dead. Most importantly, the Hitler Youth did their utmost to indoctrinate the youth of Germany with the ideological values of Nazism. Youth leaders bore into the youth a sense of fervent patriotism and utter devotion to Hitler, including military training so as to be ready to join the Wehrmacht. By 1939, when membership in the Hitler Youth became compulsory, each new member of the Jungvolk was required to take an oath to the Führer swearing total allegiance.

Young girls were also a part of the Hitler Youth in Nazi Germany. Girls from 10 to 14 years old were members of the Jungmädelbund, while girls fourteen to eighteen belonged to the Bund Deutscher Mädel. Hitler youth girls were instructed in the principles of service, regimentation, obedience, and discipline. Girls were taught to be dutiful wives and mothers. Members of the Bund Deutscher Mädel were educated in the skills needed for domestic chores, nursing, and hygiene.

In the early years of the Nazi regime, bonfires were made of school children's differently colored caps as symbolic of the abolition of class differences. But by the end of the 1930s, most Hitler Youth officials were recruited from wealthier families, and the use of differently colored sashes had returned to schools.

Daily life in Nazi Germany was manipulated from the beginning of Nazi rule. Propaganda dominated popular culture and entertainment. Finally, Hitler and the party realized the possibilities of controlling Germany's youth as a means of continuing the Reich as they wanted the generation of Germans to follow to be dedicated to the strengthening and preservation of the German Volk and of the "Greater German Reich".

title: Volksgemeinschaft


text:
William Thomas White

Sir William Thomas White, GCMG, PC (UK), PC (Can) (November 13, 1866 – February 11, 1955), was a Canadian politician and Cabinet minister. He served as minister of finance from 1911 to 1919 under Prime Minister Robert Borden. As finance minister, White introduced the income tax to help fund Canada's World War I efforts.

Early life
White worked as a reporter for the Toronto Evening Telegram in 1890, and subsequently worked for Toronto's Assessment Department. He received a Bachelor of Arts degree from the University of Toronto in 1895, and a law degree from Osgoode Law School in 1899.

White did not practice law after his graduation, but instead worked as a Managing Director for the National Trust Company, Ltd., becoming its Vice-President in 1911. National Trust was incorporated in 1898 by Senator George Albertus Cox and Edward Rogers Wood. National Trust Company, Ltd. became part of Bank of Nova Scotia as Scotia Trust in 1997.

Political career and finance minister
White was initially a Liberal party member, but his views diverged from the party's policies on some key matters. He was a supporter of British imperialism, and joined Clifford Sifton and other Liberals in signing an anti - reciprocity manifesto in 1911.

Although he had few allies in the Conservative Party, White was respected by party leader Robert Borden, who recognized that White's presence would bring some disaffected Liberals to the party. After winning the general election of 1911, Borden appointed White as his Minister of Finance. White did not hold a seat in the House of Commons of Canada at the time, and in fact had never campaigned for public office before. Nevertheless, he was elected by acclamation in a by-election in the eastern Ontario riding of Leeds, after another Conservative Member of Parliament (MP) was convinced to resign.

White was responsible for managing Canada's finances during World War I. His approach was conservative, and he was reluctant to interfere with private enterprise or even to raise taxes in the early period of the war. Although he eventually made some interventions (including fixed profit margins and regulated food supplies), he continued to reject fundamental changes in the nation's finances. One exception was the introduction in 1917 of an income tax of 4% on all income of single men over $2,000; for Canadians with annual incomes of more than $6,000, the tax rate ranged from 2 to 25 per cent. Though it was intended as a temporary war measure and despite White's recommendation that "a year or two after the war is over, the measure should be reviewed by the minister of finance of the day, with a view of judging whether it is suitable to the conditions which then prevail," income tax became a permanent feature of Canadian life.

In the 1916 New Year Honours, White was knighted a Knight Commander of the Order of St Michael and St George (KCMG).

In 1919, he approved the use of naval warships to suppress post-war labour radicalism in British Columbia. White served as Finance Minister until August 1, 1919. From February 20 to May 23 of 1919, he also served as Acting Prime Minister while Borden was in Europe attending the Paris Peace Conference. Several members of Borden's Unionist government (a wartime coalition of the Conservative Party and some Liberals) called on White to replace Borden as Prime Minister in 1920, but he declined.

In the 1920 New Year Honours, as a reward for his service as Acting Prime Minister, White was appointed to the Imperial Privy Council, allowing him to use the honorific "The Right Honourable". He remained a Member of Parliament until the 1921 election when he retired from politics. Later in the year, he published a pamphlet entitled The Story of Canada's War Finances, defending his management of the wartime economy.

Later life
White did not consider himself as a "career politician". His tenure as Finance Minister was very stressful, and he seems to have welcomed the opportunity to leave political life after the war's end. There is no indication that he entertained a return to politics in later years.

In 1933, he served as a member of the Royal Commission on Banking and Currency. He opposed the creation of the Bank of Canada.

In the King's 1935 Birthday Honours, he was promoted within the Order of St Michael and St George to a Knight Grand Cross (GCMG) "For public services in the Dominion of Canada."

Archives
There is a Sir William Thomas White fonds at Library and Archives Canada.

title: William Thomas White


text:
Chronic pancreatitis

Chronic pancreatitis is a long-standing inflammation of the pancreas that alters the organ's normal structure and functions. It can present as episodes of acute inflammation in a previously injured pancreas, or as chronic damage with persistent pain or malabsorption. It is a disease process characterized by irreversible damage to the pancreas as distinct from reversible changes in acute pancreatitis. Tobacco smoke and alcohol misuse are two of the most frequently implicated causes, and the two risk factors are thought to have a synergistic effect with regards to the development of chronic pancreatitis. Chronic pancreatitis is a risk factor for the development of pancreatic cancer.

Signs and symptoms

 * Upper abdominal pain: Upper abdominal pain which increases after drinking or eating, lessens when fasting or sitting and leaning forward. Some people may not suffer pain.
 * Nausea and vomiting
 * Steatorrhea: Frequent, oily, foul-smelling bowel movements. Damage to the pancreas reduces the production of pancreatic enzymes that aid digestion, which can result in malnutrition. Fats and nutrients are not absorbed properly, leading to loose, greasy stool known as steatorrhea.
 * Weight loss even when eating habits and amounts are normal.
 * Type 3c diabetes (pancreatogenic diabetes): Chronic pancreatitis can affect the ability of the pancreatic islets to produce insulin to regulate glucose levels, leading to diabetes type 3c. Symptoms of diabetes type 3c are due to elevated sugar and may include increased hunger and thirst, frequent urination, weight loss, fatigue, and blurry vision.

There have been three symptom profiles described in those with chronic pancreatitis. Type A involves intermittent, severe symptom flare-ups with or without objective pancreatitis amongst a background of symptom-free periods. The type A symptom profile is usually more common early in the course of chronic pancreatitis. Type B chronic pancreatitis involves chronic pain accompanied by intermittent severe attacks. And, the type C symptom profile of chronic pancreatitis involves chronic, long-term, severe pain without interspersed acute flare-ups or symptom exacerbations.

Causes
Among the causes of chronic pancreatitis are the following: • Alcohol

• Autoimmune disorders

• Intraductal obstruction

• Idiopathic pancreatitis

• Tumors

• Ischemia

• Calcific stones

Chronic alcohol misuse and smoking are well-established risk factors for the development of chronic pancreatitis, and the two are thought to have a synergistic effect with regard to disease development. Alcohol use is present in 42–77% of those who have chronic pancreatitis, and tobacco use is present in greater than 60% of those with chronic pancreatitis. Genetic mutations are thought to be responsible for 10% of cases. This includes mutations of the cystic fibrosis transmembrane conductance regulator (CFTR), serine protease inhibitor Kazal-type 1 (SPINK1), and the chymotrypsin C (CTRC) proteins. 28% of cases of chronic pancreatitis are idiopathic (of an unknown cause). In a small group of patients, chronic pancreatitis has been shown to be hereditary. Hereditary pancreatitis, which causes 1% of chronic pancreatitis, involves a mutation of the Trypsin 1 gene that is inherited in an autosomal dominant fashion. Almost all patients with cystic fibrosis have established chronic pancreatitis, usually from birth. Cystic fibrosis gene mutations have also been identified in patients with chronic pancreatitis but in whom there were no other manifestations of cystic fibrosis. Obstruction of the pancreatic duct because of either a benign or malignant process may result in chronic pancreatitis.

Pathophysiology
The mechanism of chronic pancreatitis viewed from a genetic standpoint indicates early onset of severe epigastric pain beginning in childhood. It is an autosomal dominant disease; chronic pancreatitis disease is identified in the cationic trypsinogen gene PRSS1, and mutation, R122H. R122H is the most common mutation for hereditary chronic pancreatitis with replacement of arginine with histidine at amino acid position 122 of the trypsinogen protein. There are, of course, other mechanisms – alcohol, malnutrition, smoking – each exhibiting its own effect on the pancreas.

Diagnosis
The diagnosis of chronic pancreatitis is made based on the history and characteristics of symptoms combined with findings on radiologic imaging. Serum amylase and lipase may be moderately elevated in cases of chronic pancreatitis.

Symptoms of diarrhea, with oily, bulky, and foul-smelling stools indicated steatorrhea or fat malabsorption due to exocrine pancreatic insufficiency. Exocrine pancreatic insufficiency can be confirmed by also checking a fecal elastase level, with low levels specifying exocrine pancreatic insufficiency. A quantitative fecal fat test can also be done to quantify the fat levels in the stool and confirm the presence of exocrine pancreatic insufficiency.

When chronic pancreatitis is caused by genetic factors, elevations in ESR, IgG4, rheumatoid factor, ANA and anti-smooth muscle antibody may be detected.

Computed tomography, magnetic resonance cholangiopancreatography (MRCP), and endoscopic ultrasound (EUS) all have similar sensitivity and specificity for diagnosing chronic pancreatitis. MRCP is particularly utilized for its sensitivity in imaging the pancreatic ducts and bile ducts for associated changes such as stones or strictures. A biopsy of the pancreas is not required for the diagnosis. On imaging, pancreatic and bile duct dilatation, atrophy of the pancreas, multiple calcifications of the pancreas, and enlargement of pancreatic glands can be found.

On MRI scan, there is a low T1 signal due to inflammation, fibrosis, focal lesions, and calcifications. In those who are given a contrast agent, there would be a higher T1 signal with late gadolinium enhancement due to compression from the fibrotic areas. The overall thickness of the pancreas will be reduced.

Treatment
The different treatment options for the management of chronic pancreatitis are medical measures, therapeutic endoscopy, and surgery. Treatment is directed, when possible, to the underlying cause, and to relieve pain and malabsorption. Insulin dependent diabetes mellitus may occur and need long-term insulin therapy. The abdominal pain can be very severe and require high doses of analgesics, sometimes including opiates. Medications such as pregabalin, gabapentin, tricyclic antidepressants and serotonin–norepinephrine reuptake inhibitors (SNRIs) are commonly used to treat pain in chronic pancreatitis. Alcohol cessation is important to manage pain and slow the calcific process, possibly reducing the future risk of flare-ups. Antioxidants may help, but it is unclear if the benefits are meaningful.

Endoscopic treatments, including removal of stones in the pancreatic duct, and dilation of strictures may be done. Extracorporeal shockwave lithotripsy can also be done, in which external acoustic waves are administered to break the stones. This may be combined with endoscopic retrograde cholangiopancreatography to collect larger stones.

Behavioral treatments such as cognitive behavioral therapy including resilience training, stress management, chronic pain rehabilitation programs and addiction treatment may also be used as adjunct treatments.

Pancreatic enzymes
Pancreatic enzyme replacement is often effective in treating the malabsorption and steatorrhea associated with chronic pancreatitis. Treatment of CP consists of the administration of a solution of pancreatic enzymes with meals. Some patients do have pain reduction with enzyme replacement, and since they are relatively safe, giving enzyme replacement to a chronic pancreatitis patient is an acceptable step in treatment for most patients. Treatment may be more likely to be successful in those without the involvement of large ducts and those with idiopathic pancreatitis.

Surgery
Surgery to treat chronic pancreatitis tends to be divided into two areas – resectional and drainage procedures. Among the reasons to opt for surgery is if there is a pseudocyst, fistula, ascites, or a fixed obstruction. The Puestow procedure (anastomosis of the pancreatic duct to the jejunum to allow drainage of the obstructed duct), pancreaticoduodenectomy (partial pancreatic resection), or total pancreatectomy with or without autologous islet cell transplantation (removal of the whole pancreas, which is usually reserved for cases refractory to other surgical and medical interventions) may be used for treatment of chronic pancreatitis.

Epidemiology
The annual incidence of chronic pancreatitis is 5 to 12 per 100,000 persons, the prevalence is 50 per 100,000 persons. It has been reported that the pancreas is able to absorb radioactive cesium (Cs-134 and Cs-137) in great quantities from environmental contamination, causing chronic pancreatitis and probably pancreatic cancer with damage of pancreatic islets with Type 3c (pancreatogenic) diabetes.

title: Chronic pancreatitis


text:
Talk:NBC Nightly News

A Commons file used on this page has been nominated for speedy deletion
The following Wikimedia Commons file used on this page has been nominated for speedy deletion: You can see the reason for deletion at the file description page linked above. —Community Tech bot (talk) 09:36, 13 June 2019 (UTC)
 * Nightlynewslogo2019.png

Weekend anchor listing
An anon IP has been inserting additional people into the list of former weekend anchors, and adding details like "some Saturdays." I'm not sure any of this is verifiable. JTRH (talk) 13:18, 26 January 2021 (UTC)

Image overlapping text
Could someone please fix the NBC logo image under the Weekend edition section where it overlaps the text? I would do it if I knew how. Ghost writer's cat (talk) 04:46, 13 November 2023 (UTC)

Irrelevant Talk subject?
How does that Talk entry "Marijuana usage while pregnant" relate to this page? Seems like it should be deleted. Ghost writer's cat (talk) 04:49, 13 November 2023 (UTC)

title: Talk:NBC Nightly News


text:
List of political parties in the Maldives

Political parties in the Maldives were legalized when the Maldivian parliament voted unanimously for the creation of a multi-party system on 2 June 2005. This came after decades of authoritarian rule. Prior to this ruling, political parties had not been not allowed under the Maldivian legal system.

Political Party Bill
On March 12, 2013, President Waheed ratified a new 'Political Party Bill', replacing the guidelines established in 2005, when a multi-party system was created in the country. The bill saw the raising of the minimum number of members required to register a political party from 3000 to 10,000. With the ratification of the bill, all political parties which did not have 10,000 members registered were dissolved.

The following is a list of parties dissolved under the new law:


text:
Juan Antonio Samaranch Salisachs

Juan Antonio Samaranch Salisachs (born 1 November 1959) is a Spanish sports executive and financial analyst who currently serves as the vice president of the International Olympic Committee (IOC). He is the son of former IOC president Juan Antonio Samaranch.

Early life
Samaranch was born on 1 November 1959 in Barcelona, Spain, the only son of María Teresa Salisachs and Juan Antonio Samaranch. He has one sister, María Teresa. His father was Minister of Sports under Franco from 1967 to 1971 and president of the IOC from 1980 to 2001. The family spent some time living in Moscow, Soviet Union while Samaranch the elder served as a diplomat following the restoration of democracy in Spain.

Samaranch attended University of Barcelona, where he studied industrial engineering, and earned his MBA from New York University (NYU) in 1986. He previously served as the regional leader for NYU's Stern School of Business alumni group in Spain.

Career
Before earning his MBA, Samaranch worked as a perfume salesman for International Flavors & Fragrances for two and a half years. After graduating from NYU in 1986, he worked for three years as an associate at First Boston Corporation in New York, then served as a partner and as the vice president of corporate finance for S. G. Warburg & Co. in London. In 1991, he co-founded GBS Finanzas. In 1996, he became vice president of the Union Internationale de Pentathlon Moderne (UIPM) and in 2001, the same year his father retired, was elected as a member of the IOC. He served on the Organizing Committees for the 2006 Winter Olympics in Turin, Italy and the 2014 Winter Olympics in Sochi, Russia. In 2015, Samaranch was appointed president of the Summit Shopping, Tourism and Economy committee, which focused on increasing the "number of quality visitors and tourists in Spain and Madrid." He was elected vice president of the IOC in 2016, where he served on the Oswald Commission, which made decisions about Russian athletes following the Summer Olympics doping scandal. He finished his four year term as VP of IOC in 2020.

Samaranch established the Samaranch Foundation in Beijing, China in 2012 in honor of his late father. The organization "aims to promote sport in China" and encourages good relations between China and Spain. Initial funding came from the Samaranch family, IOC, Chinese Olympic Committee, Beijing Olympic City Development Association, Spanish government, Barcelona's government, Anta Sports, Samsung China, Tibet Spring, China Post, Beijing Tourism Group, Taishan Sports, and La Caixa.

In February 2013, the IOC voted to eliminate one sport from the Olympics. Although many experts predicted that the pentathlon would be removed due to its low popularity.Despite having a larger athlete and fan base,wrestling due the doping cases was removed instead. This rule was about to start at the 2020 Summer Olympics. Samaranch was largely regarded as a major player in the decision, in part because of his conflict of interest with the UIPM, which would be damaged with the elimination of the pentathlon. By September, wrestling had been reinstated on grounds of its long history at the Olympics.

In 2019, Samaranch received an honorary doctorate from Handong Global University in South Korea. As of 2022, Samaranch had been reelected as the IOC vice president, was on the IOC's Board of Directors, was a member of the Spanish Olympic Committee, and was chairman of the Organizing Committee for Beijing 2022.

In 2020, Samaranch was firm in his belief that the Olympics should continue regardless of the COVID-19 pandemic, albeit with necessary restrictions and precautions, even if the vaccine did not become available before the event. Historically, Samaranch has supported the candidacy of Madrid as the host of the 2016 Summer Olympics as well as Beijing for the 2022 Winter Olympics despite experts' assertions that it would be the "most unsustainable games of all time" due to the amount of artificial snow needed. He was also a major proponent of holding the 2030 Winter Olympics in Barcelona-Pyrenees but the bid was officially pulled in June 2022 due to a lack of agreement between the governments of Aragon and Catalonia.

Personal life
Samaranch is married to Italian socialite Cristina Bigelli and together they have four children: Juan, Alessia, Matteo, and Allegra. Alessia is married to French financier Hadrien Forterre. Samaranch speaks Spanish, Catalan, Italian, French, and English. He and his family live in Madrid.

title: Juan Antonio Samaranch Salisachs


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