title: Spanish language in the United States

text: Spanish in the US shows mixing and dialect leveling between different varieties of Spanish in large cities with Hispanics of different origins. For example, Salvadorans in Houston show a shift towards lowered rates of /s/ reduction, due to contact with the larger number of Mexican speakers and the low prestige of Salvadoran Spanish.


title: Spanish language in the United States

text: Los Angeles has its own vernacular Spanish variety, the result of dialect leveling between speakers of different, mainly central Mexican varieties. The children of Salvadoran parents who grow up in Los Angeles typically grow up speaking this variety. Other cities may have their own vernacular Spanish varieties as well.


title: Spanish language in the United States

text: Voseo, the use of the second person pronoun instead of or alongside the more widespread , is widespread among Honduran and Salvadoran immigrants to the US. The children of these immigrants tend to accommodate to more widespread use of , although at the same time they maintain occasional use of as a symbol of Central American identity. Second-generation Salvadoran-Americans often engage in verbal voseo, using voseo-related verb forms alongside due to linguistic insecurity in contact situations. On the other hand, third-generation Salvadoran-Americans have begun using pronominal voseo, with being used alongside the verb forms associated with .


title: Spanish language in the United States

text: Many standard American English words are of Spanish etymology, or originate from third languages but entered English via Spanish.


title: Spanish language in the United States

text: Spanish in the US often has some phonological influence from English. For example, bilinguals who grew up in the Mesilla Valley in southern New Mexico most often pronounce as a tap instead of a trilled when it comes at the beginning of a word or after a consonant. Even in word-medial position is frequently pronounced as a tap. The use of a trill is even less frequent in northern New Mexico, where contact with monolingual Mexican Spanish is lesser.


title: Spanish language in the United States

text: Although Mexican Spanish generally pronounces as a velar fricative, Chicano Spanish often realizes it as a glottal , like English's h sound. In addition, may occasionally be realized as a fricative in initial position.


title: Spanish language in the United States

text: The vowel system of Spanish speakers in the US may also be affected by English influence. For example, can be fronted.


title: Spanish language in the United States

text: Much of the variation in US Spanish pronunciation reflects the differences between other Spanish dialects and varieties:


title: Spanish language in the United States

text: The vocabulary and grammar of US Spanish reflect English influence, accelerated change, and the Latin American roots of most US Spanish.


title: Spanish language in the United States

text: One example of English influence is that the usage of Spanish words by American bilinguals shows a convergence of semantics between English and Spanish cognates. For example, the Spanish words "atender" ("to pay attention to") and "éxito" ("success") have acquired a similar semantic range in American Spanish to the English words "attend" and "exit." In some cases, loanwords from English turn existing Spanish words into homonyms: "coche" has come to acquire the additional meaning of "coach" in the United States, it retains its older meaning of "car."


title: Spanish language in the United States

text: Spanish-speakers are the fastest growing linguistic group in the United States. Continued immigration and the prevalent Spanish-language mass media (such as Univisión, Telemundo, and Azteca América) support Spanish-speakers. Moreover, the North American Free Trade Agreement makes many American manufacturers use multilingual product labeling in English, French, and Spanish, three of the four official languages of the Organization of American States (the other is Portuguese).


title: Spanish language in the United States

text: Besides the businesses that always have catered to Hispanophone immigrants, a small but increasing number of mainstream American retailers now advertise bilingually in Spanish-speaking areas and offer bilingual customer services. One common indicator of such businesses is "Se Habla Español", which means "Spanish Is Spoken".


title: Spanish language in the United States

text: The annual State of the Union Address and other presidential speeches are translated into Spanish, following the precedent set by Bill Clinton's administration. Moreover, non-Hispanic American origin politicians fluent in Spanish speak in Spanish to Hispanic-majority constituencies. There are 500 Spanish newspapers, 152 magazines, and 205 publishers in the United States. Magazine and local television advertising expenditures for the Hispanic market have increased substantially from 1999 to 2003, with growth of 58 percent and 43 percent, respectively.


title: Spanish language in the United States

text: Historically, immigrants' languages tend to disappear or to be reduced by generational assimilation. Spanish disappeared in several countries and US territories during the 20th century, notably in the Philippines and in the Pacific Island countries of Guam, Micronesia, Palau, the Northern Marianas islands, and the Marshall Islands.


title: Spanish language in the United States

text: The English-only movement seeks to establish English as the sole official language of the United States. Generally, they exert political public pressure upon Hispanophone immigrants to learn English and speak it publicly. As universities, business, and the professions use English, there is much social pressure to learn English for upward socio-economic mobility.


title: Spanish language in the United States

text: Generally, Hispanics (13.4% of the 2002 US population) are bilingual to a degree. A Simmons Market Research survey recorded that 19 percent of Hispanics speak only Spanish, 9 percent speak only English, 55 percent have limited English proficiency, and 17 percent are fully English-Spanish bilingual.


title: Spanish language in the United States

text: Intergenerational transmission of Spanish is a more accurate indicator of Spanish's future in the United States than raw statistical numbers of Hispanophone immigrants. Although Hispanics hold varying English proficiency levels, almost all second-generation Hispanics speak English, but about 50 percent speak Spanish at home. Two thirds of third-generation Mexican Americans speak only English at home. Calvin Veltman undertook in 1988, for the National Center for Education Statistics and for the Hispanic Policy Development Project, the most complete study of Anglicization by Hispanophone immigrants. Veltman's language shift studies document abandonment of Spanish at rates of 40 percent for immigrants who arrived in the US before the age of 14, and 70 percent for immigrants who arrived before the age of 10. The complete set of the studies' demographic projections postulates the near-complete assimilation of a given Hispanophone immigrant cohort within two generations. Although his study based itself upon a large 1976 sample from the Bureau of the Census, which has not been repeated, data from the 1990 census tend to confirm the great Anglicization of the Hispanic population.


title: Spanish language in the United States

text: American literature in Spanish dates back to 1610 when a Spanish explorer Gaspar Pérez de Villagrá first published his epic poem "History of New Mexico". However, it was not until the late 20th century that Spanish, Spanglish, and bilingual poetry, plays, novels, and essays were readily available on the market through independent, trade, and commercial publishing houses and theaters. Cultural theorist Christopher González identifies Latina/o authors—such as Oscar “Zeta” Acosta, Gloria Anzaldúa, Piri Thomas, Gilbert Hernandez, Sandra Cisneros, and Junot Díaz—as having written innovative works that created new audiences for Hispanic Literature in the United States.


title: ICD-11

text: The ICD-11 is the eleventh revision of the International Classification of Diseases (ICD). It replaces the ICD-10 as the global standard for recording health information and causes of death. The ICD is developed and annually updated by the World Health Organization (WHO). Development of the ICD-11 started in 2007 and spanned over a decade of work, involving over 300 specialists from 55 countries divided into 30 work groups, with an additional 10,000 proposals from people all over the world. Following an alpha version in May 2011 and a beta draft in May 2012, a stable version of the ICD-11 was released on 18 June 2018, and officially endorsed by all WHO members during the 72nd World Health Assembly on 25 May 2019.


title: ICD-11

text: The ICD-11 is a large ontology consisting of about 85,000 entities, also called classes or nodes. An entity can be anything that is relevant to health care. It usually represents a disease or a pathogen, but it can also be an isolated symptom or (developmental) anomaly of the body. There are also classes for reasons for contact with health services, social circumstances of the patient, and external causes of injury or death. The ICD-11 is part of the WHO-FIC, a family of medical classifications. The WHO-FIC contains the Foundation Component, which comprises all entities of all classifications endorsed by the WHO. The Foundation is the common core from which all classifications are derived. For example, the ICD-O is a derivative classification optimized for use in oncology. The primary derivative of the Foundation is called the ICD-11 MMS, and it is this system that is commonly referred to as simply "the ICD-11". MMS stands for Mortality and Morbidity Statistics. The ICD-11 is distributed under a Creative Commons BY-ND license.


title: ICD-11

text: The ICD-11 officially came into effect on 1 January 2022. On 11 February, the WHO claimed that 35 countries were using the ICD-11. In the United States, an expected implementation year of 2025 has been given, but if a clinical modification is determined to be needed (similar to the ICD-10-CM), ICD-11 implementation might not begin until 2027.


title: ICD-11

text: The ICD-11 MMS can be viewed online on the WHO's website. Aside from this, the site offers two maintenance platforms: the ICD-11 Maintenance Platform, and the WHO-FIC Foundation Maintenance Platform. Users can submit evidence-based suggestions for the improvement of the WHO-FIC, i.e. the ICD-11, the ICF, and the ICHI.


title: ICD-11

text: The WHO Family of International Classifications (WHO-FIC), also called the WHO Family, is a suit of classifications used to describe various aspects of the health care system in a consistent manner, with a standardised terminology. The abbreviation is variously written with or without a hyphen ("WHO-FIC" or "WHOFIC"). The WHO-FIC consists of four components: the WHO-FIC Foundation, the Reference Classifications, the Derived Classifications, and the Related Classifications. The WHO-FIC Foundation, also called the Foundation Component, represents the entire WHO-FIC universe. It is a collection of over hundred thousand entities, also called classes or nodes. Entities are anything relevant to health care. They are used to describe diseases, disorders, body parts, bodily functions, reasons for visit, medical procedures, microbes, causes of death, social circumstances of the patient, and much more.


title: ICD-11

text: The Foundation Component is a multidimensional collection of entities. An entity can have multiple parents and child nodes. For example, pneumonia can be categorized as a lung infection, but also as a bacterial or viral infection (i.e. by site or by etiology). Thus, the node Pneumonia (entity id: ) has two parents: Lung infections (entity id: ) and Certain infectious or parasitic diseases (entity id: ). The Pneumonia node in turn has various children, including Bacterial pneumonia (entity id: ) and Viral pneumonia (entity id: ).


title: ICD-11

text: The Foundation Component is the common core on which all Reference and Derived Classifications are based. The WHO-FIC contains three Reference Classifications: the ICD-11 MMS (see below), the ICF, and the ICHI. Derived Classifications are based on the three Reference Classifications, and are usually tailored for a particular specialty. For example, the ICD-O is a Derived Classification used in oncology. Each node of the Foundation has a unique entity id, which remains the same in all Reference and Derived Classifications, guaranteeing consistency. Related Classifications are complementary, and cover specialty areas not covered elsewhere in the WHO-FIC. For example, the International Classification of Nursing Practice (ICNP), draws on terms from the Foundation Component, but also uses terms specific for nursing not found in the Foundation.


title: ICD-11

text: A classification can be represented as a tabular list, which is a "flat" hierarchical tree of categories. In this tree, all entities can only have a single parent, and therefore must be mutually exclusive of each other. Such a classification is also called a linearization.


title: ICD-11

text: The ICD-11 MMS is the main Reference Classification of the WHO-FIC, and the primary linearization of the Foundation Component. The ICD-11 MMS is commonly referred to as simply "the ICD-11". The "MMS" was added to differentiate the ICD-11 entities in the Foundation from those in the Classification. The ICD-11 MMS does not contain all classes from the Foundation ICD-11, and also adds some classes from the ICF. MMS stands for Mortality and Morbidity Statistics. The abbreviation is variously written with or without a hyphen between 11 and MMS ("ICD-11 MMS" or "ICD-11-MMS").


title: ICD-11

text: The ICD-11 MMS consists of approximately 85,000 entities. Entities can be chapters, blocks or categories. A chapter is a top level entity of the hierarchy; the MMS contains 28 of them (see Chapters section below). A block is used to group related categories or blocks together. A category can be anything that is relevant to health care. Every category has a unique, alphanumeric code called an ICD-11 code, or just ICD code. Chapters and blocks never have ICD-11 codes, and therefore cannot be diagnosed. An ICD-11 code is not the same as an entity id.


title: ICD-11

text: The ICD-11 MMS takes the form of a "flat" hierarchical tree. As aforementioned, the entities in this linearization can only have a single parent, and therefore must be mutually exclusive of each other. To make up for this limitation, the hierarchy of the MMS contains gray nodes. These nodes appear as children in the hierarchy, but actually have a different parent node. They originally belong to a different block or chapter, but are also listed elsewhere because of overlap. For example, Pneumonia () has two parents in the Foundation: "Lung infections" (site) and "Certain infectious or parasitic diseases" (etiology). In the MMS, Pneumonia is categorized in the "Lung infections", with a gray node in "Certain infectious or parasitic diseases". The same goes for injuries, poisonings, neoplasms, and developmental anomalies, which can occur in almost any part of the body. They each have their own chapters, but their categories also have gray nodes in the chapters of the organs they affect. For instance, the blood cancers, including all forms of leukemia, are in the "Neoplasms" chapter, but they are also displayed as gray nodes in the chapter "Diseases of the blood or blood-forming organs".


title: ICD-11

text: The ICD-11 MMS also contains residual categories, or residual nodes. These are the "Other specified" and "Unspecified" categories, miscellaneous classes which can be used to code conditions that do not fit with any of the more specific MMS entities. In the ICD-11 Browser, residual nodes are displayed in a maroon color. Residual categories are not in the Foundation, and therefore are the only classes with derivative entity IDs: their IDs are the same as their parent nodes, with "/mms/otherspecified" or "/mms/unspecified" tagged at the end. Their ICD codes always end with Y for "Other specified" categories, or Z for "Unspecified" categories (e.g. and ).


title: ICD-11

text: The ICD-11, both the ICD-11 Foundation and the MMS, can be accessed using a multilingual REST API. Documentation on the ICD API and some additional tools for integration into third-party applications can be found at the ICD API home page.


title: ICD-11

text: The WHO has released a map that can be used to link and convert ICD-10 terms to those of the ICD-11. It can be downloaded from the ICD-11 MMS browser. In 2017, SNOMED International announced plans to release a SNOMED CT to ICD-11 MMS map.


title: ICD-11

text: The ICD-11 Foundation, and consequently the MMS, are updated annually, similarly to the ICD-10. , five versions of the ICD-11 have been released.


title: ICD-11

text: Below is a list of all chapters of the ICD-11 MMS, the primary linearization of the Foundation Component.


title: ICD-11

text: Unlike the ICD-10 codes, the ICD-11 MMS codes never contain the letters I or O, to prevent confusion with the numbers 1 and 0.


title: ICD-11

text: The ICD-11 MMS features a more flexible coding structure. In the ICD-10, every code starts with a letter, indicating the chapter. This is followed by a two digit number (e.g. ), creating 99 slots per chapter, excluding subcategories and blocks. This proved enough for most chapters, but four are so voluminous that they span two letters: chapter 1 (A00–B99), chapter 2 (C00.0–D48.9), chapter 19 (S00–T98), and chapter 20 (V01–Y98). In the ICD-11 MMS, there is a single first character for every chapter. The codes of the first nine chapters begin with the numbers 1 to 9, while the next nineteen chapters start with the letters A to X. The letters I and O are not used, to prevent confusion with the numbers 1 and 0. The chapter character is then followed by a letter, a number, and a fourth character that starts as a number (0-9, e.g. ) and may then continue as a letter (A-Z, e.g. ). The WHO opted for a forced number as the third character to prevent the spelling of "undesirable words". In the ICD-10, each entity within a chapter either has a code (e.g. ) or a code range (e.g. ). The latter is a block. In the ICD-11 MMS, blocks never have codes, and not every entity necessarily has a code, although each entity does have a unique id.


title: ICD-11

text: In the ICD-10, the next level of the hierarchy is indicated in the code by a dot and a single number (e.g. ). This is the lowest available level in the ICD-10 hierarchy, causing an artificial limitation of 10 subcategories per code (.0 to .9). In the ICD-11 MMS, this limitation no longer exists: after 0–9, the list may continue with A-Z (e.g. – ). Then, following the first character after the dot, a second character may be used in the next level of the hierarchy (e.g. – ). This level is currently the lowest appearing in the MMS. The large amount of unused coding space in the MMS allows for updates to be made without having to change the other categories, ensuring that codes remain stable.


title: ICD-11

text: The ICD-11 features five new chapters. The third chapter of the ICD-10, "Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism", has been split in two: "Diseases of the blood or blood-forming organs" (chapter 3) and "Diseases of the immune system" (chapter 4). The other new chapters are "Sleep-wake disorders" (chapter 7), "Conditions related to sexual health" (chapter 17, see section), and "Supplementary Chapter Traditional Medicine Conditions - Module I" (chapter 26, see section).


title: ICD-11

text: The following mental disorders have been newly added to the ICD-11, but were already included in the American ICD-10-CM adaption: Binge eating disorder (ICD-11: ; ICD-10-CM: ), Bipolar type II disorder (ICD-11: ; ICD-10-CM: ), Body dysmorphic disorder (ICD-11: ; ICD-10-CM: ), Excoriation disorder (ICD-11: ; ICD-10-CM: ), Frotteuristic disorder (ICD-11: ; ICD-10-CM: ), Hoarding disorder (ICD-11: ; ICD-10-CM: ), and Intermittent explosive disorder (ICD-11: ; ICD-10-CM: ).


title: ICD-11

text: The following mental disorders have been newly added to the ICD-11, and are not in the ICD-10-CM: Avoidant/restrictive food intake disorder (), Body integrity dysphoria (), Catatonia (), Complex post-traumatic stress disorder (), Gaming disorder (), Olfactory reference disorder (), and Prolonged grief disorder ().


title: ICD-11

text: Aside from the updates made for the ICD-11, the WHO has developed an ICD-11 subset of the "Clinical descriptions and diagnostic guidelines" (CDDG), although it has not yet been published. A book of the same name was released in 1992 for the ICD-10, which was also known as the "Blue Book". It contains expanded definitions and diagnostic criteria for the mental disorders, whereas the ICD-10/-11 mental disorders chapters contain only short summaries. The ICD chapters are meant as a quick reference point, whereas the CDDG is meant for extensive diagnosing by health care professionals. To differentiate the old and the new version, the newest revision is called the ICD-11 CDDG. The WHO described the development of the ICD-11 CDDG as "the most global, multilingual, multidisciplinary and participative revision process ever implemented for a classification of mental disorders", involving nearly 15,000 clinicians from 155 countries. , the WHO has not made the ICD-11 CDDG publicly available.


title: ICD-11

text: The personality disorder (PD) section has been completely revamped. All distinct PDs have been merged into one: Personality disorder (), which can be coded as Mild (), Moderate (), Severe (), or severity unspecified (). There is also an additional category called Personality difficulty (), which can be used to describe personality traits that are problematic, but do not rise to the level of a PD. A personality disorder or difficulty can be specified by one or more Prominent personality traits or patterns (). The ICD-11 uses five trait domains: (1) Negative affectivity (); (2) Detachment (), (3) Dissociality (), (4) Disinhibition (), and (5) Anankastia (). Listed directly underneath is Borderline pattern (), a category similar to Borderline personality disorder. This is not a trait in itself, but a combination of the five traits in certain severity.


title: ICD-11

text: Described as a clinical equivalent to the Big Five model, the five-trait system addresses several problems of the old category-based system. Of the ten PDs in the ICD-10, two were used with a disproportionate high frequency: Emotionally unstable personality disorder, borderline type () and Dissocial (antisocial) personality disorder (). Many categories overlapped, and individuals with severe disorders often met the requirements for multiple PDs, which Reed et al. (2019) described as "artificial comorbidity". PD was therefore reconceptualized in terms of a general dimension of severity, focusing on five negative personality traits which a person can have to various degrees.


title: ICD-11

text: There was considerable debate regarding this new dimensional model, with many believing that categorical diagnosing should not be abandoned. In particular, there was disagreement about the status of Borderline personality disorder. Reed (2018) wrote: "Some research suggests that borderline PD is not an independently valid category, but rather a heterogeneous marker for PD severity. Other researchers view borderline PD as a valid and distinct clinical entity, and claim that 50 years of research support the validity of the category. Many – though by no means all – clinicians appear to be aligned with the latter position. In the absence of more definitive data, there seemed to be little hope of accommodating these opposing views. However, the WHO took seriously the concerns being expressed that access to services for patients with borderline PD, which has increasingly been achieved in some countries based on arguments of treatment efficacy, might be seriously undermined." Thus, the WHO believed the inclusion of a Borderline pattern category to be a "pragmatic compromise".


title: ICD-11

text: The Alternative DSM-5 Model for Personality Disorders (AMPD) included near the end of the DSM-5 is similar to the PD-system of the ICD-11, although much larger and more comprehensive. It was considered for inclusion in the ICD-11, but the WHO decided against it because it was considered "too complicated for implementation in most clinical settings around the world", since an explicit aim of the WHO was to develop a simple and efficient method that could also be used in low-resource settings.


title: ICD-11

text: Gaming disorder () has been newly added to the ICD-11, and placed in the group "Disorders due to addictive behaviours", alongside Gambling disorder (). The latter was called Pathological gambling () in the ICD-10. Aside from Gaming disorder, the ICD-11 also features Hazardous gaming (), an ancillary category that can be used to identify problematic gaming which does not rise to the level of a disorder.


title: ICD-11

text: Although a majority of scholars supported the inclusion of Gaming disorder (GD), a significant number did not. Aarseth et al. (2017) stated that the evidence base which this decision relied upon is of low quality, that the diagnostic criteria of gaming disorder are rooted in substance use and gambling disorder even though they are not the same, that no consensus exist on the definition and assessment of GD, and that a pre-defined category would lock research in a confirmatory approach. Rooij et al. (2017) questioned if what was called "gaming disorder" is in fact a coping strategy for underlying problems, such as depression, social anxiety, or ADHD. They also asserted moral panic, fueled by sensational media stories, and stated that the category could be stigmatizing people who are simply engaging in a very immersive hobby. Bean et al. (2017) wrote that the GD category caters to false stereotypes of gamers as physically unfit and socially awkward, and that most gamers have no problems balancing their expected social roles outside games with those inside.


title: ICD-11

text: In support of the GD category, Lee et al. (2017) agreed that there were major limitations of the existing research, but that this actually necessitates a standardized set of criteria, which would benefit studies more than self-developed instruments for evaluating problematic gaming. Saunders et al. (2017) argued that gaming addiction should be in the ICD-11 just as much as gambling addiction and substance addiction, citing functional neuroimaging studies which show similar brain regions being activated, and psychological studies which show similar antecedents (risk factors). Király and Demetrovics (2017) did not believe that a GD category would lock research into a confirmatory approach, noting that the ICD is regularly revised and characterized by permanent change. They wrote that moral panic around gamers does indeed exist, but that this is not caused by a formal diagnosis. Rumpf et al. (2018) noted that stigmatization is a risk not specific to GD alone. They agreed that GD could be a coping strategy for an underlying disorder, but that in this debate, "comorbidity is more often the rule than the exception". For example, a person can have an alcohol dependence due to PTSD. In clinical practice, "both" disorders need to be diagnosed and treated. Rumpf et al. also warned that the lack of a GD category might jeopardize insurance reimbursement of treatments.


title: ICD-11

text: The DSM-5 (2013) features a similar category called Internet Gaming Disorder (IGD). However, due to the controversy over its definition and inclusion, it is not included in its main body of mental diagnoses, but in the additional chapter "Conditions for Further Study". Disorders in this chapter are meant to encourage research and are not intended to be officially diagnosed.


title: ICD-11

text: In May 2019, a number of media incorrectly reported that burn-out was newly added to the ICD-11. In reality, burn-out is also in the ICD-10 (), albeit with a short, one-sentence definition only. The ICD-11 features a longer summary, and specifically notes that the category should only be used in an occupational context. Furthermore, it should only be applied when mood disorders (), Disorders specifically associated with stress (), and Anxiety or fear-related disorders () have been ruled out.


title: ICD-11

text: As with the ICD-10, burn-out is not in the mental disorders chapter, but in the chapter "Factors influencing health status or contact with health services", where it is coded . In response to media attention over its inclusion, the WHO emphasized that the ICD-11 does not define burn-out as a mental disorder or a disease, but as an occupational phenomenon that undermines a person's well-being in the workplace.


title: ICD-11

text: Conditions related to sexual health is a new chapter in the ICD-11. The WHO decided to put the sexual disorders in a separate chapter due to "the outdated mind/body split". A number of ICD-10 categories, including sex disorders, were based on a Cartesian separation of "organic" (physical) and "non-organic" (mental) conditions. As such, the sexual dysfunctions that were considered non-organic were included in the mental disorder chapter, while those that were considered organic were for the most part listed in the chapter on diseases of the genitourinary system. In the ICD-11, the brain and the body are seen as an integrate whole, with sexual dysfunctions considered to involve an interaction between physical and psychological factors. Thus, the organic/non-organic distinction was abolished.


title: ICD-11

text: Regarding general sexual dysfunction, the ICD-10 has three main categories: Lack or loss of sexual desire (), Sexual aversion and lack of sexual enjoyment (), and Failure of genital response (). The ICD-11 replaces these with two main categories: Hypoactive sexual desire dysfunction () and Sexual arousal dysfunction (). The latter has two subcategories: Female sexual arousal dysfunction () and Male erectile dysfunction (). The difference between Hypoactive sexual desire dysfunction and Sexual arousal dysfunction is that in the former, there is a reduced or absent desire for sexual activity. In the latter, there is insufficient physical and emotional response to sexual activity, even though there still is a "desire" to engage in satisfying sex. The WHO acknowledged that there is an overlap between desire and arousal, but they are not the same. Management should focus on their distinct features.


title: ICD-11

text: The ICD-10 contains the categories Vaginismus (), Nonorganic vaginismus (), Dyspareunia (), and Nonorganic dyspareunia (). As the WHO aimed to steer away from the aforementioned "outdated mind/body split", the organic and nonorganic disorders were merged. Vaginismus has been reclassified as sexual pain-penetration disorder (). Dyspareunia () has been retained. A related condition is Vulvodynia, which is in the ICD-9 (), but not in the ICD-10. It has been re-added to the ICD-11 ().


title: ICD-11

text: Sexual dysfunctions and Sexual pain-penetration disorder can be coded alongside a temporal qualifier, "lifelong" or "acquired", and a situational qualifier, "general" or "situational". Furthermore, the ICD-11 offers five aetiological qualifiers, or "Associated with..." categories, to further specify the diagnosis. For example, a woman who experiences sexual problems due to adverse effects of an SSRI antidepressant may be diagnosed with "Female sexual arousal dysfunction, acquired, generalised" () combined with "Associated with use of psychoactive substance or medication" ().


title: ICD-11

text: Excessive sexual drive () from the ICD-10 has been reclassified as Compulsive sexual behaviour disorder (CSBD, ) and listed under Impulse control disorders. The WHO was unwilling to overpathologize sexual behaviour, stating that having a high sexual drive is not necessarily a disorder, so long as these people do not exhibit impaired control over their behavior, significant distress, or impairment in functioning. Kraus et al. (2018) noted that several people self-identify as "sex addicts", but on closer examination do not actually exhibit the clinical characteristics of a sexual disorder, although they may have other mental health problems, such as anxiety or depression. Experiencing shame and guilt about sex is not a reliable indicator of a sex disorder, Kraus et al. stated.


title: ICD-11

text: There was debate on whether CSBD should be considered a (behavioral) addiction. It has been claimed that neuroimaging shows overlap between compulsive sexual behavior and substance-use disorder through common neurotransmitter systems. Nonetheless, it was ultimately decided to place the disorder in the Impulse control disorders group. Kraus et al. wrote that, for the ICD-11, "a relatively conservative position has been recommended, recognizing that we do not yet have definitive information on whether the processes involved in the development and maintenance of [CSBD] are equivalent to those observed in substance use disorders, gambling and gaming".


title: ICD-11

text: Paraphilic disorders, called Disorders of sexual preference in the ICD-10, have remained in the mental disorders chapter, although they have gray nodes in the sexual health chapter. The ICD-10 categories Fetishism () and Fetishistic transvestism () were removed because, if they don't cause distress or harm, they are not considered mental disorders. Frotteuristic disorder () has been newly added.


title: ICD-11

text: Transgenderism and gender dysphoria are called Gender incongruence in the ICD-11. In the ICD-10, the group Gender identity disorders () consisted of three main categories: Transsexualism (), Dual-role transvestism (), and Gender identity disorder of childhood (). In the ICD-11, Dual-role transvestism was deleted due to a lack of public health or clinical relevance. Transsexualism was renamed Gender incongruence of adolescence or adulthood (), and Gender identity disorder of childhood was renamed Gender incongruence of childhood ().


title: ICD-11

text: In the ICD-10, the Gender identity disorders were placed in the mental disorders chapter, following what was customary at the time. Throughout the 20th century, both the ICD and the DSM approached transgender health from a psychopathological position, as transgender identity presents a discrepancy between someone's assigned sex and their gender identity. Since this may cause mental distress, it was consequently considered a mental disorder, with distress or discomfort being a core diagnostic feature. In the 2000s and 2010s, this notion became increasingly challenged, as the idea of viewing transgender people as having a mental disorder was believed by some to be stigmatizing. It has been suggested that distress and dysfunction among transgender people should be more appropriately viewed as the result of social rejection, discrimination, and violence toward individuals with gender variant appearance and behavior. Studies have shown transgender people to be at higher risk of developing mental health problems than other populations, but that health services aimed at transgender people are often insufficient or nonexistent. Since an official ICD code is usually needed to gain access to and reimbursement for therapy, the WHO found it ill-advised to remove transgender health from the ICD-11 altogether. It was therefore decided to transpose the concept from the mental disorders chapter to the new sexual health chapter.


title: ICD-11

text: The group related to coding antimicrobial resistance has been significantly expanded: compare in the ICD-10 to in the ICD-11. Also, the ICD-11 codes are more closely in line with the WHO's Global Antimicrobial Resistance Surveillance System (GLASS). Launched in October 2015, this project aims to track the worldwide immunity of malicious microbes (viruses, bacteria, fungi, and protozoa) against medication.


title: ICD-11

text: "Supplementary Chapter Traditional Medicine Conditions - Module I" is an additional chapter in the ICD-11. It consists of concepts that are commonly referred to as Traditional Chinese Medicine (TCM), although the WHO prefers to use the more general and neutral sounding term Traditional Medicine (TM). Many of the traditional therapies and medicines that originally came from China also have long histories of usage and development in Japan (Kampo), Korea (TKM), and Vietnam (TVM). Medical procedures that can be labeled as "traditional" continue to be used all over the world, and are an integral part of health services in some countries. A 2008 survey by the WHO found that "[i]n some Asian and African countries, 80% of the population depend on traditional medicine for primary health care". Also, "[i]n many developed countries, 70% to 80% of the population has used some form of alternative or complementary medicine (e.g. acupuncture)".


title: ICD-11

text: From approximately 2003 to 2007, a group of experts from various countries developed the WHO International Standard Terminologies on Traditional Medicine in the Western Pacific Region, or simply IST. In the following years, based on this nomenclature, the group created the International Classification of Traditional Medicine, or ICTM. , Module I, also called TM1, is the only module of the ICTM to have been released. Morris, Gomes, & Allen (2012) have stated that Module II will cover Ayurveda, that Module III will cover homeopathy, and that Module IV will cover "other TM systems with independent diagnostic conditions in a similar fashion". However, these modules have yet to be made public, and Singh & Rastogi (2018) noted that this "keeps the speculations open for what actually is encompassing under the current domain [of the ICTM]".


title: ICD-11

text: The decision to include T(C)M in the ICD-11 has been criticized, because it is often alleged to be pseudoscience. Editorials by "Nature" and "Scientific American" admitted that some TM techniques and herbs have shown effectiveness or potential, but that others are pointless, or even outright harmful. They wrote that the inclusion of the TM-chapter is at odds with the scientific, evidence-based methods usually employed by the WHO. Both editorials accused the government of China of pushing the WHO to incorporate TCM, a global, billion-dollar market in which China plays a leading role. The WHO has stated that the categories of TM1 "do not refer to – or endorse – any form of treatment", and that their inclusion is primarily intended for statistical purposes. The TM1 codes are recommended to be used in conjunction with the Western Medicine concepts of ICD-11 chapters 1-25.


title: Buried penis

text: Buried penis (also known as hidden penis or retractile penis) is a congenital or acquired condition in which the penis is partially or completely hidden below the surface of the skin. A buried penis can lead to urinary difficulties, poor hygiene, infection, and inhibition of normal sexual function.


title: Buried penis

text: Buried penis is different than micropenis, which is an abnormally small, normally structured penis with a stretched penile length of less than 2.5 standard deviations below the mean for age or stage of sexual development of the patient.


title: Buried penis

text: Buried penis was first described by Edward Lawrence Keyes in 1919 as the apparent absence of the penis due to the penis being buried beneath the skin of the abdomen, thigh, or scrotum. Further research was done by Maurice Campbell in 1951, when he reported on the penis being buried beneath subcutaneous fat of the scrotum, perineum, hypogastrium, and thigh.


title: Buried penis

text: Congenital causes can include the maldevelopment of the penile shaft with a lack of attachments of the shaft skin to the penile shaft. While rare, it can include an abnormally large pubic fat pad and firm tissue that pulls the penis inward.


title: Buried penis

text: While not every obese male has the buried penis condition, 87% of men that received surgical treatment for buried penis were reported to be obese. Significant overlying abdominal fat can also create an environment that encourages bacterial and fungal growth. Obesity can also increase the likelihood of the development of type II diabetes mellitus, which is characterized by increase susceptibility to infections, making it difficult to successfully and promptly manage the buried penis condition. Such recurring infections can also lead to scar contracture, which can cause the prepubic skin to shift over the shaft and glans, thus invaginating the shaft's skin and leading to a buried penis.


title: Buried penis

text: While an uncommon cause, penoscrotal lymphodema causes a deformity of the shaft and scrotum, resulting in a buried penis.


title: Buried penis

text: In some cases of circumcision, too much foreskin is removed or the suture line constricts, causing cicatricial scarring, which can trap the penis in the remaining foreskin or push the penis into the suprapubic area and lead to a buried penis.


title: Buried penis

text: BXO is a chronic inflammatory dermatological process that causes sclerosis of the glans, shaft, prepuce, or urethra. This can result in a cicatrix of the distal penis and its entrapment.


title: Buried penis

text: Dysgenic dartos is a condition characterized by a lack of dorsal support together with the hypermobility of the ventral skin and the lack of proper attachment between the dartos and the penis. This can enable the penis to "telescope" into the scrotum, thus creating a buried penis.


title: Buried penis

text: The condition may resolve itself without any intervention in very young children; however, patients may eventually need definitive reconstructive surgery. Urgent surgery may be necessary if infection is present. Congenitial buried penis can be corrected surgically in childhood by anchoring the corpora cavernosa to dartos bundles at the penile base. While weight loss may be of help to morbidly obese children and adults, it usually does not resolve the problem completely.


title: Buried penis

text: Surgical options could include the detachment of the ligaments connecting the base of the penis to the pubic bone; the performance of skin grafts to cover areas of the penis requiring additional skin; liposuction using catheters to suck out fat cells under the skin from the area around the penis; an abdominoplasty in which excess fat and skin from the region are removed; an escutheonectomy in which the pad of fat just above the pubic area is removed; or a panniculectomy in which the panniculus, excess tissue, and skin that hangs over the genitals and thighs are removed. In a video demonstrating the use of a panniculectomy in the repair of adult buried penis, Dr. Bryan Voelzke and his colleagues emphasized the need to tack the suprapubic fat pad to the periosteum of the symphysis pubis as well as the importance of not pulling down the peno-scrotal junction and peno-abdominal junction just in order to further expose the penis.


title: Buried penis

text: King IC, Tahir A, Ramanathan C, and Siddiqui H developed a modified treatment algorithm employing a single surgical technique consisting primarily of scar release and the mobilization of the skin of the penis.


title: Buried penis

text: An article published in August 2019 by Dr. James J. Elist reported that a procedure involving the insertion of a subcutaneous soft silicone penile implant was successful in reversing the condition of adult acquired buried penis.


title: Salvatore Schillaci

text: Salvatore Schillaci (; born 1 December 1964), commonly referred to by his nickname Totò, is an Italian former professional footballer, who played as a striker. During his club career, he played for Messina (1982–1989), Juventus (1989–1992), Internazionale (1992–1994) and Júbilo Iwata (1994–1997).


title: Salvatore Schillaci

text: At the international level he was the surprise star of the 1990 FIFA World Cup, as he helped Italy to a third-place finish on home soil. Coming on as substitute in Italy's first game, Schillaci went on to score six goals throughout the World Cup, claiming the Golden Boot as the leading goalscorer, and received the Golden Ball as player of the tournament ahead of established stars Lothar Matthäus and Diego Maradona, who came second and third respectively. That year he also placed second in the 1990 Ballon d'Or, behind Matthäus.


title: Salvatore Schillaci

text: Born in Palermo, Italy, from a poor family, Schillaci started to play for an amateur team of his native city, "Amat Palermo". He then signed in 1982 for the Sicilian club Messina, where he played until 1989 and showed his goal-scoring abilities, most notably winning the Serie B top-scorer Award during the 1988–89 Serie B season, with 23 goals. He then joined Turin club Juventus, and made his debut in Serie A on 27 August 1989. Juventus, the "Old Lady" of Italian football, was at the time suffering from the breakup of the wonder team which dominated Italian football in the 1980s, under manager Giovanni Trapattoni; Schillaci's arrival coincided with a return to form under the direction of former legendary Juventus goalkeeper Dino Zoff. He featured prominently for the Turinese club that season, scoring 15 league goals and 21 in all competitions in a very positive year, which ended with Juventus winning both the 1989–90 Coppa Italia and the UEFA Cup titles. Due to his clever, inventive, and aggressive attacking style, he was then selected by head coach of Italy, Azeglio Vicini, to play in the 1990 FIFA World Cup, to be hosted by Italy itself, despite being a novice in the arena of national team competitions.


title: Salvatore Schillaci

text: After the end of the 1990 World Cup, Schillaci played one more year for Juventus, alongside his Italy attacking team-mate Roberto Baggio, before joining Internazionale. Schillaci ultimately fell short of the expectations of the Inter fans, as well as those of Juventus, mainly because of the physical troubles which he suffered after the 1990 campaign. In 1994, he joined Japanese club Júbilo Iwata, becoming the first Italian player to play in the J.League, and he won the J.League Division 1 title with the club in 1997. He retired in 1999.


title: Salvatore Schillaci

text: After making one over-age appearance for the Italy Under-21 side, under Cesare Maldini, Schillaci made his senior international debut for Italy under manager Azeglio Vicini, on 31 March 1990, in a 1–0 friendly away win over Switzerland, in Basel. He was subsequently called up for Italy's squad for the 1990 FIFA World Cup, to be played on home soil.


title: Salvatore Schillaci

text: At the 1990 World Cup, Schillaci replaced Andrea Carnevale during Italy's first match against Austria. He scored the decisive goal as the match ended with a 1–0 win for Italy. Against the USA, Schillaci again made an appearance as a substitute, but he started the next match, against Czechoslovakia, alongside Roberto Baggio. Italy won 2–0, with Baggio and Schillaci both scoring. Schillaci started alongside Baggio in Italy's next two matches of the knock-out stages, also opening the scoring in the round of 16 and quarter-finals, against Uruguay and the Republic of Ireland respectively, and set up Aldo Serena's goal against Uruguay.


title: Salvatore Schillaci

text: For the semi-final match against defending champions Argentina, Gianluca Vialli replaced Baggio in the starting line-up, whereas Schillaci kept his place in the team. The match ended 1–1, with Schillaci scoring his fifth goal of the tournament, but Italy were eliminated after a penalty shoot-out, in which he controversially refused to take a penalty, stating injury as the reason for his choice.


title: Salvatore Schillaci

text: After setting up Baggio's opening goal, Schillaci scored the winning goal in Italy's 2–1 win in the third-place match against England from a penalty, and won the Golden Boot, with six goals, as well as the Golden Ball Award for the best player of the tournament. Overall, he scored seven goals in sixteen caps for Italy between 1990 and 1991, scoring his only other goal for Italy in a 2–1 defeat away against Norway, in 1991, in an UEFA Euro 1992 qualifying match.


title: Salvatore Schillaci

text: Schillaci was a small, quick, agile, and mobile striker, with an eye for the goal, and solid technique. A prolific, reliable, and opportunistic goalscorer, Schillaci was known in particular for his anticipation, reactions, and his excellent positional sense, which, along with his acceleration, enabled him to make attacking runs to beat opponents to the ball in the area, giving him the reputation for frequently being "in the right place at the right time". He was capable of finishing well both inside and outside the area, as well as from volleys, with powerful strikes, and was capable of scoring with his head as well as with his feet, despite not being particularly imposing in the air; he was also accurate on set pieces and effective on penalties. Although he was primarily known for his selfish and instinctive style of play, he was also capable of linking-up with and playing off of his team-mates, despite not being a particularly notable passer. Due to his goalscoring exploits, his former Messina manager Francesco Scoglio described him by saying he had "never seen a player who wanted to score as much as him."


title: Salvatore Schillaci

text: Schillaci retired in 1999. Today he lives back in his native Palermo, where he owns a youth academy of football.


title: Salvatore Schillaci

text: He appeared as a guest on "Craig Doyle Live" during UEFA Euro 2012. Former South African national team captain Steven Pienaar is nicknamed "Schillo" after Schillaci.


The United States Court of Appeals for the Seventh Circuit (in case citations, 7th Cir.) is the U.S. federal court with appellate jurisdiction over the courts in the following districts:


title: United States Court of Appeals for the Seventh Circuit

text: The court is based at the Dirksen Federal Building in Chicago and is composed of eleven appellate judges. It is one of 13 United States courts of appeals.


text: The court offers a relatively unique internet presence that includes wiki and RSS feeds of opinions and oral arguments. It is also notable for having one of the most prominent law and economics scholars, Judge Frank H. Easterbrook, on its court. Richard Posner, another prominent law and economics scholar, also served on this court until his retirement in 2017. Three judges from the Seventh Circuit, Sherman Minton, John Paul Stevens, and Amy Coney Barrett, have been appointed as Associate Justices of the Supreme Court.


title: The Inklings

text: The Inklings were an informal literary discussion group associated with J. R. R. Tolkien and C. S. Lewis at the University of Oxford for nearly two decades between the early 1930s and late 1949. The Inklings were literary enthusiasts who praised the value of narrative in fiction and encouraged the writing of fantasy. The best-known, apart from Tolkien and Lewis, were Charles Williams, and (although a Londoner) Owen Barfield.


title: The Inklings

text: "Properly speaking," wrote Warren Lewis, "the Inklings was neither a club nor a literary society, though it partook of the nature of both. There were no rules, officers, agendas, or formal elections." As was typical for university groups in their time and place, the Inklings were all male.


title: The Inklings

text: Readings and discussions of the members' unfinished works were the principal purposes of meetings. Tolkien's "The Lord of the Rings", Lewis's "Out of the Silent Planet", and Williams's "All Hallows' Eve" were among the novels first read to the Inklings. Tolkien's fictional Notion Club (see "Sauron Defeated") was based on the Inklings. Meetings were not all serious; the Inklings amused themselves by having competitions to see who could read the notoriously bad prose of Amanda McKittrick Ros for the longest without laughing.


title: The Inklings

text: The name was associated originally with a society of Oxford University's University College, initiated by the then undergraduate Edward Tangye Lean around 1931, for the purpose of reading aloud unfinished compositions. The society consisted of students and dons, among them Tolkien and Lewis. When Lean left Oxford in 1933, the society ended, and Tolkien and Lewis transferred its name to their group at Magdalen College. On the association between the two 'Inklings' societies, Tolkien later said "although our habit was to read aloud compositions of various kinds (and lengths!), this association and its habit would in fact have come into being at that time, whether the original short-lived club had ever existed or not."


title: The Inklings

text: Until late 1949, Inklings readings and discussions were usually held on Thursday evenings in C. S. Lewis's rooms at Magdalen. The Inklings and friends were also known to gather informally on Tuesdays at midday at a local public house, The Eagle and Child, familiarly and alliteratively known in the Oxford community as The Bird and Baby, or simply The Bird. The publican, Charlie Blagrove, let Lewis and friends use his private parlour for privacy; the wall and door separating it from the public bar were removed in 1962. During the war years, beer shortages occasionally rendered the Eagle and Child unable to open and the group instead met at other pubs, including the White Horse and the Kings Arms. Later pub meetings were at The Lamb and Flag across the street, and in earlier years the Inklings also met irregularly in yet other pubs, but The Eagle and Child is the best known.


title: The Inklings

text: The Marion E. Wade Center, located at Wheaton College, Illinois, is devoted to the work of seven British authors including four Inklings. Overall, the Wade Center has more than 11,000 volumes including first editions and critical works. Other holdings on the seven foremost authors (G. K. Chesterton, George MacDonald, and Inklings Owen Barfield, C. S. Lewis, J. R. R. Tolkien, Dorothy L. Sayers and Charles Williams) include letters, manuscripts, audio and video tapes, artwork, dissertations, periodicals, photographs, and related materials. Wheaton also has a creative writing critique group inspired by the Inklings called "WhInklings".


title: The Inklings

text: The Mythopoeic Society is a literary organization devoted to the study of mythopoeic literature, particularly the works of J. R. R. Tolkien, C. S. Lewis, and Charles Williams, founded by Glen GoodKnight in 1967 and incorporated as a non-profit organization in 1971.


title: The Inklings

text: In "Swan Song" (1947) by Edmund Crispin a discussion takes place between Professor Gervase Fen and others in the front parlour of the Eagle and Child.


title: The Inklings

text: "The Late Scholar" (2013) by Jill Paton Walsh is a sequel, set in 1951, to the Lord Peter Wimsey novels of Dorothy L. Sayers. Wimsey, now 17th Duke of Denver, is investigating a mystery in the fictional St Severin's College, Oxford with his friend Charles Parker, now an assistant chief constable.


title: The Inklings

text: Three of the founding members of the Inklings – Tolkien, Lewis, and Williams – are the main characters of James A. Owen's fantasy series, "The Chronicles of the Imaginarium Geographica". (Warren Lewis and Hugo Dyson are recurring minor characters throughout the series.) The existence and founding of the organization are also alluded to in the third novel, "The Indigo King". (The timeline of the books is different from the historical timeline at points, but these are dealt with part way through the series by the explanation that the books take place in a history alternative to our own.)


title: Marian Gold

text: Marian Gold (born Hartwig Schierbaum; 26 May 1954) is a German singer-songwriter who gained fame as the lead singer of the German synth-pop recording act Alphaville, but also has recorded as a solo artist. He is known for his tenor multi-octave vocal range.


title: Marian Gold

text: Born in Herford, West Germany, Gold became part of the Berlin art collective the Nelson Community, where he formed the band Chinchilla Green in the late 1970s, which also included future Alphaville colleague Bernhard Lloyd.


title: Marian Gold

text: In 1982, he joined Lloyd and Frank Mertens in the band Forever Young, which soon became Alphaville. He sang lead vocals on Alphaville's 1980s pop singles, including "Forever Young", "Big in Japan", "Sounds Like a Melody", "Dance with Me" and "Jerusalem".


title: Marian Gold

text: As of 2022, he is the last remaining member of the band, whose latest album "Eternally Yours" was released in 2022.


title: Marian Gold

text: Gold's first solo album, "So Long Celeste", was released in 1992. Included on the album were cover versions of "The Shape of Things to Come" (originally by the Headboys) and "One Step Behind You" (by Furniture).


title: IC3PEAK

text: IC3PEAK is a Russian electronic music band created by Anastasia Kreslina and Nikolay Kostilev. They achieved worldwide notoriety because of the political undertones in their music criticizing the Russian government, which led to attempts of censorship of their music in 2019. Their effects in mainstream media led to outpouring support throughout the West, and in Russia.


title: IC3PEAK

text: From the very beginning of the project the distinctive features of IC3PEAK's work were a mixture of musical genres, a simultaneous emphasis on both audio and visual components, and lyrics that dealt with taboo topics such as death. Both artists characterize the initial period of their work as “audiovisual terrorism”. In 2014, they released the EP "Substances", their first project. The entire EP was written in English. The visual design was done by Anastasia and Nikolai themselves.


title: IC3PEAK

text: Shortly after, the video for the song "Ether" was presented to the public, being the first video work of IC3PEAK.


title: IC3PEAK

text: From the first days of its existence the project gained popularity outside of Russia. In 2014, after the release of their second EP "Vacuum", IC3PEAK performed at their first overseas concerts in European cities such as Bordeaux, Paris, Riga, Prague, and Helsinki. Two years later, in 2016, the project performed in South America. During their stay in Brazil, the duo partially filmed their music video for the song "Go With The Flow". To this day, the IC3PEAK project continues to successfully tour abroad.


title: IC3PEAK

text: On November third, 2017, IC3PEAK released their first album in Russian — "Sladkaya zhizn" (“Sweet life”) and the music video for the song “Grustnaya suka” ("Sad Bitch") which quickly became a hit. The video currently has over 57 million views on YouTube.


title: IC3PEAK

text: In the duo's earlier work their vocals performed the role of an ”instrument”. However, in Russian-language texts the semantic component prevails and references to Russian folk art are emphasized. Flowing with their increased popularity in their homeland, the duo released another Russian-language longplay named "Skazka” (“Fairy Tale") on September 28, 2018. It included new videos made for the compositions "Skazka” and ”Smerti bolshe net” ("Death No More"). The video for the song "Smerti bolshe net" is IC3PEAK's most viewed music video - at this time it has more than 100 million views on YouTube.


title: IC3PEAK

text: The second Russian-language album by IC3PEAK named "Sladkaya zhizn" and, in particular, the video for the song “Smerti bolshe net” had wide political resonance. Some conservative public figures protested the video as an insult to law enforcement structures and to the Russian authorities. They also claimed the video contained calls to suicide, which, according to the authorities, could have an impact on the duo's underage fans.


title: IC3PEAK

text: The Russian security forces began to target IC3PEAK's next planned tour. According to IC3PEAK, people calling themselves representatives of the security forces made threatening calls to concert venues throughout Russia, forcing them to refuse to host the duo's concerts. The performance in Novosibirsk on 1 December 2018 became the peak of that confrontation. On that day, the participants of the IC3PEAK project and the local concert organizers were detained while exiting the train at Novosibirsk Central Railway Station. After a series of threats, interrogations and 3 hours of detention, the police, under public pressure (which included Western media), were forced to release the artists without drawing up protocols. The concert took place at an alternative venue. After a series of canceled concerts, a number of musicians and public figures around the world expressed their active support for IC3PEAK and their opposition to art censorship in Russia.


title: IC3PEAK

text: Throughout its existence, the members of the IC3PEAK project have been producing visual design and video content by themselves.


title: IC3PEAK

text: Anastasia and Nikolay write scripts, direct, edit and process their videos, take photographs and create cover art for releases by themselves.


title: IC3PEAK

text: Anastasia and Nikolai keep an extremely private lifestyle and rarely appear in public. It is not known for certain who they are to each other - in interviews, the musicians avoid giving a direct answer to this question. They also mention that they live in a wooden hut, away from city life, and this helps them to fully concentrate on their creative work process.


title: Renal cell carcinoma

text: Renal cell carcinoma (RCC) is a kidney cancer that originates in the lining of the proximal convoluted tubule, a part of the very small tubes in the kidney that transport primary urine. RCC is the most common type of kidney cancer in adults, responsible for approximately 90–95% of cases. RCC occurrence shows a male predominance over women with a ratio of 1.5:1. RCC most commonly occurs between 6th and 7th decade of life.


title: Renal cell carcinoma

text: Initial treatment is most commonly either partial or complete removal of the affected kidney(s). Where the cancer has not metastasised (spread to other organs) or burrowed deeper into the tissues of the kidney, the five-year survival rate is 65–90%, but this is lowered considerably when the cancer has spread.


title: Renal cell carcinoma

text: The body is remarkably good at hiding the symptoms and as a result people with RCC often have advanced disease by the time it is discovered. The initial symptoms of RCC often include blood in the urine (occurring in 40% of affected persons at the time they first seek medical attention), flank pain (40%), a mass in the abdomen or flank (25%), weight loss (33%), fever (20%), high blood pressure (20%), night sweats and generally feeling unwell. When RCC metastasises, it most commonly spreads to the lymph nodes, lungs, liver, adrenal glands, brain or bones. Immunotherapy and targeted therapy have improved the outlook for metastatic RCC.


title: Renal cell carcinoma

text: RCC is also associated with a number of paraneoplastic syndromes (PNS) which are conditions caused by either the hormones produced by the tumour or by the body's attack on the tumour and are present in about 20% of those with RCC. These syndromes most commonly affect tissues which have not been invaded by the cancer. The most common PNSs seen in people with RCC are: high blood calcium levels, high red blood cell count, high platelet count and secondary amyloidosis.


title: Renal cell carcinoma

text: Historically, medical practitioners expected a person to present with three findings. This classic triad is 1: haematuria, which is when there is blood present in the urine, 2: flank pain, which is pain on the side of the body between the hip and ribs, and 3: an abdominal mass, similar to bloating but larger. It is now known that this classic triad of symptoms only occurs in 10–15% of cases, and is usually indicative that the renal cell carcinoma (RCC) is in an advanced stage. Today, RCC is often asymptomatic (meaning few to no symptoms) and is generally detected incidentally when a person is being examined for other ailments.


title: Renal cell carcinoma

text: Other signs and symptom may include haematuria; loin pain; abdominal mass; malaise, which is a general feeling of unwellness; weight loss and/or loss of appetite; anaemia resulting from depression of erythropoietin; erythrocytosis (increased production of red blood cells) due to increased erythropoietin secretion; varicocele, which is seen in males as an enlargement of the pampiniform plexus of veins draining the testis (more often the left testis) hypertension (high blood pressure) resulting from secretion of renin by the tumour; hypercalcemia, which is elevation of calcium levels in the blood; sleep disturbance or night sweats; recurrent fevers; and chronic fatigue.


title: Renal cell carcinoma

text: The greatest risk factors for RCC are lifestyle-related; smoking, obesity and hypertension (high blood pressure) have been estimated to account for up to 50% of cases.


title: Renal cell carcinoma

text: Occupational exposure to some chemicals such as asbestos, cadmium, lead, chlorinated solvents, petrochemicals and PAH (polycyclic aromatic hydrocarbon) has been examined by multiple studies with inconclusive results.


title: Renal cell carcinoma

text: Another suspected risk factor is the long term use of non-steroidal anti-inflammatory drugs (NSAIDS).


title: Renal cell carcinoma

text: Finally, studies have found that women who have had a hysterectomy are at more than double the risk of developing RCC than those who have not. Moderate alcohol consumption, on the other hand, has been shown to have a protective effect.


title: Renal cell carcinoma

text: Hereditary factors have a minor impact on individual susceptibility with immediate relatives of people with RCC having a two to fourfold increased risk of developing the condition. Other genetically linked conditions also increase the risk of RCC, including hereditary papillary renal carcinoma, hereditary leiomyomatosis, Birt–Hogg–Dube syndrome, hyperparathyroidism-jaw tumor syndrome, familial papillary thyroid carcinoma, von Hippel–Lindau disease and sickle cell disease.


title: Renal cell carcinoma

text: The most significant disease affecting risk however is not genetically linked – patients with acquired cystic disease of the kidney requiring dialysis are 30 times more likely than the general population to develop RCC.


title: Renal cell carcinoma

text: The tumour arises from the cells of the proximal renal tubular epithelium. It is considered an adenocarcinoma. There are two subtypes: sporadic (that is, non-hereditary) and hereditary. Both such subtypes are associated with mutations in the short-arm of chromosome 3, with the implicated genes being either tumour suppressor genes (VHL and TSC) or oncogenes (like c-Met).


title: Renal cell carcinoma

text: The first steps taken to diagnose this condition are consideration of the signs and symptoms, and a medical history (the detailed medical review of past health state) to evaluate any risk factors. Based on the symptoms presented, a range of biochemical tests (using blood and/or urine samples) may also be considered as part of the screening process to provide sufficient quantitative analysis of any differences in electrolytes, kidney and liver function, and blood clotting times. Upon physical examination, palpation of the abdomen may reveal the presence of a mass or an organ enlargement.


title: Renal cell carcinoma

text: Although this disease lacks characterization in the early stages of tumor development, considerations based on diverse clinical manifestations, as well as resistance to radiation and chemotherapy are important. The main diagnostic tools for detecting renal cell carcinoma are ultrasound, computed tomography (CT) scanning and magnetic resonance imaging (MRI) of the kidneys.


title: Renal cell carcinoma

text: Renal cell carcinoma (RCC) is not a single entity, but rather a collection of different types of tumours, each derived from the various parts of the nephron (epithelium or renal tubules) and possessing distinct genetic characteristics, histological features, and, to some extent, clinical phenotypes.


title: Renal cell carcinoma

text: Array-based karyotyping can be used to identify characteristic chromosomal aberrations in renal tumors with challenging morphology. Array-based karyotyping performs well on paraffin embedded tumours and is amenable to routine clinical use. See also Virtual Karyotype for CLIA certified laboratories offering array-based karyotyping of solid tumours.


title: Renal cell carcinoma

text: The 2004 World Health Organization (WHO) classification of genitourinary tumours recognizes over 40 subtypes of renal neoplasms. Since the publication of the latest iteration of the WHO classification in 2004, several novel renal tumour subtypes have been described:


title: Renal cell carcinoma

text: Laboratory tests are generally conducted when the patient presents with signs and symptoms that may be characteristic of kidney impairment. They are not primarily used to diagnose kidney cancer, due to its asymptomatic nature and are generally found incidentally during tests for other illnesses such as gallbladder disease. In other words, these cancers are not detected usually because they do not cause pain or discomfort when they are discovered. Laboratory analysis can provide an assessment on the overall health of the patient and can provide information in determining the staging and degree of metastasis to other parts of the body (if a renal lesion has been identified) before treatment is given.


title: Renal cell carcinoma

text: The presence of blood in urine is a common presumptive sign of renal cell carcinoma. The haemoglobin of the blood causes the urine to be rusty, brown or red in colour. Alternatively, urinalysis can test for sugar, protein and bacteria which can also serve as indicators for cancer. A complete blood cell count can also provide additional information regarding the severity and spreading of the cancer.


title: Renal cell carcinoma

text: The CBC provides a quantified measure of the different cells in the whole blood sample from the patient. Such cells examined for in this test include red blood cells (erythrocytes), white blood cells (leukocytes) and platelets (thrombocytes). A common sign of renal cell carcinoma is anaemia whereby the patient exhibits deficiency in red blood cells. CBC tests are vital as a screening tool for examination the health of patient prior to surgery. Inconsistencies with platelet counts are also common amongst these cancer patients and further coagulation tests, including erythrocyte sedimentation rate (ESR), prothrombin time (PT), activated partial thromboplastin time (APTT) should be considered.


title: Renal cell carcinoma

text: Blood chemistry tests are conducted if renal cell carcinoma is suspected as cancer has the potential to elevate levels of particular chemicals in blood. For example, liver enzymes such as aspartate aminotransferase (AST) and alanine aminotransferase (ALT) are found to be at abnormally high levels. The staging of the cancer can also be determined by abnormal elevated levels of calcium, which suggests that the cancer may have metastasised to the bones. In this case, a doctor should be prompted for a CT scan. Blood chemistry tests also assess the overall function of the kidneys and can allow the doctor to decide upon further radiological tests.


title: Renal cell carcinoma

text: The characteristic appearance of renal cell carcinoma (RCC) is a solid renal lesion which disturbs the renal contour. It will frequently have an irregular or lobulated margin and may be seen as a lump on the lower pelvic or abdomen region. Traditionally, 85 to 90% of solid renal masses will turn out to be RCC but cystic renal masses may also be due to RCC. However, the advances of diagnostic modalities are able to incidentally diagnose a great proportion of patients with renal lesions that may appear to be small in size and of benign state. Ten percent of RCC will contain calcifications, and some contain macroscopic fat (likely due to invasion and encasement of the perirenal fat).


title: Renal cell carcinoma

text: Deciding on the benign or malignant nature of the renal mass on the basis of its localized size is an issue as renal cell carcinoma may also be cystic. As there are several benign cystic renal lesions (simple renal cyst, haemorrhagic renal cyst, multilocular cystic nephroma, polycystic kidney disease), it may occasionally be difficult for the radiologist to differentiate a benign cystic lesion from a malignant one. The Bosniak classification system for cystic renal lesions classifies them into groups that are benign and those that need surgical resection, based on specific imaging features.


title: Renal cell carcinoma

text: The main imaging tests performed in order to identify renal cell carcinoma are pelvic and abdominal CT scans, ultrasound tests of the kidneys (ultrasonography), MRI scans, intravenous pyelogram (IVP) or renal angiography. Among these main diagnostic tests, other radiologic tests such as excretory urography, positron-emission tomography (PET) scanning, ultrasonography, arteriography, venography, and bone scanning can also be used to aid in the evaluation of staging renal masses and to differentiate non-malignant tumours from malignant tumours.


title: Renal cell carcinoma

text: Contrast-enhanced computed tomography (CT) scanning is routinely used to determine the stage of the renal cell carcinoma in the abdominal and pelvic regions. CT scans have the potential to distinguish solid masses from cystic masses and may provide information on the localization, stage or spread of the cancer to other organs of the patient. Key parts of the human body which are examined for metastatic involvement of renal cell carcinoma may include the renal vein, lymph node and the involvement of the inferior vena cava. According to a study conducted by Sauk et al., multidetector CT imaging characteristics have applications in diagnosing patients with clear renal cell carcinoma by depicting the differences of these cells at the cytogenic level.


title: Renal cell carcinoma

text: Ultrasonographic examination can be useful in evaluating questionable asymptomatic kidney tumours and cystic renal lesions if computed tomography imaging is inconclusive. This safe and non-invasive radiologic procedure uses high frequency sound waves to generate an interior image of the body on a computer monitor. The image generated by the ultrasound can help diagnose renal cell carcinoma based on the differences of sound reflections on the surface of organs and the abnormal tissue masses. Essentially, ultrasound tests can determine whether the composition of the kidney mass is mainly solid or filled with fluid.


title: Renal cell carcinoma

text: A percutaneous biopsy can be performed by a radiologist using ultrasound or computed tomography to guide sampling of the tumour for the purpose of diagnosis by pathology. However this is not routinely performed because when the typical imaging features of renal cell carcinoma are present, the possibility of an incorrectly negative result together with the risk of a medical complication to the patient may make it unfavourable from a risk-benefit perspective. However, biopsy tests for molecular analysis to distinguish benign from malignant renal tumours is of investigative interest.


title: Renal cell carcinoma

text: Magnetic resonance imaging (MRI) scans provide an image of the soft tissues in the body using radio waves and strong magnets. MRI can be used instead of CT if the patient exhibits an allergy to the contrast media administered for the test. Sometimes prior to the MRI scan, an intravenous injection of a contrasting material called gadolinium is given to allow for a more detailed image. Patients on dialysis or those who have renal insufficiency should avoid this contrasting material as it may induce a rare, yet severe, side effect known as nephrogenic systemic fibrosis. A bone scan or brain imaging is not routinely performed unless signs or symptoms suggest potential metastatic involvement of these areas.


title: Renal cell carcinoma

text: MRI scans should also be considered to evaluate tumour extension which has grown in major blood vessels, including the vena cava, in the abdomen. MRI can be used to observe the possible spread of cancer to the brain or spinal cord should the patient present symptoms that suggest this might be the case.


title: Renal cell carcinoma

text: Intravenous pyelogram (IVP) is a useful procedure in detecting the presence of abnormal renal mass in the urinary tract. This procedure involves the injection of a contrasting dye into the arm of the patient. The dye travels from the blood stream and into the kidneys which in time, passes into the kidneys and bladder. This test is not necessary if a CT or MRI scan has been conducted.


title: Renal cell carcinoma

text: Renal angiography uses the same principle as IVP, as this type of X-ray also uses a contrasting dye. This radiologic test is important in diagnosing renal cell carcinoma as an aid for examining blood vessels in the kidneys. This diagnostic test relies on the contrasting agent which is injected in the renal artery to be absorbed by the cancerous cells. The contrasting dye provides a clearer outline of abnormally-oriented blood vessels believed to be involved with the tumour. This is imperative for surgeons as it allows the patient's blood vessels to be mapped prior to operation.


title: Renal cell carcinoma

text: The staging of renal cell carcinoma is the most important factor in predicting its prognosis. Staging can follow the TNM staging system, where the size and extent of the tumour (T), involvement of lymph nodes (N) and metastases (M) are classified separately. Also, it can use overall stage grouping into stage I–IV, with the 1997 revision of AJCC described below:


title: Renal cell carcinoma

text: At diagnosis, 30% of renal cell carcinomas have spread to the ipsilateral renal vein, and 5–10% have continued into the inferior vena cava.


title: Renal cell carcinoma

text: The gross and microscopic appearance of renal cell carcinomas is highly variable. The renal cell carcinoma may present reddened areas where blood vessels have bled, and cysts containing watery fluids. The body of the tumour shows large blood vessels that have walls composed of cancerous cells.


title: Renal cell carcinoma

text: Gross examination often shows a yellowish, multilobulated tumor in the renal cortex, which frequently contains zones of necrosis, haemorrhage and scarring. In a microscopic context, there are four major histologic subtypes of renal cell cancer: clear cell (conventional RCC, 75%), papillary (15%), chromophobic (5%), and collecting duct (2%). Sarcomatoid changes (morphology and patterns of IHC that mimic sarcoma, spindle cells) can be observed within any RCC subtype and are associated with more aggressive clinical course and worse prognosis. Under light microscopy, these tumour cells can exhibit papillae, tubules or nests, and are quite large, atypical, and polygonal.


title: Renal cell carcinoma

text: Recent studies have brought attention to the close association of the type of cancerous cells to the aggressiveness of the condition. Some studies suggest that these cancerous cells accumulate glycogen and lipids, their cytoplasm appear "clear", the nuclei remain in the middle of the cells, and the cellular membrane is evident. Some cells may be smaller, with eosinophilic cytoplasm, resembling normal tubular cells. The stroma is reduced, but well vascularised. The tumour compresses the surrounding parenchyma, producing a pseudocapsule.


title: Renal cell carcinoma

text: The most common cell type exhibited by renal cell carcinoma is the clear cell, which is named by the dissolving of the cells' high lipid content in the cytoplasm. The clear cells are thought to be the least likely to spread and usually respond more favourably to treatment. However, most of the tumours contain a mixture of cells. The most aggressive stage of renal cancer is believed to be the one in which the tumour is mixed, containing both clear and granular cells.


title: Renal cell carcinoma

text: The recommended histologic grading schema for RCC is the Fuhrman system (1982), which is an assessment based on the microscopic morphology of a neoplasm with haematoxylin and eosin (H&E staining). This system categorises renal cell carcinoma with grades 1, 2, 3, 4 based on nuclear characteristics. The details of the Fuhrman grading system for RCC are shown below:


title: Renal cell carcinoma

text: Nuclear grade is believed to be one of the most imperative prognostic factors in patients with renal cell carcinoma. However, a study by Delahunt et al. (2007) has shown that the Fuhrman grading is ideal for clear cell carcinoma but may not be appropriate for chromophobe renal cell carcinomas and that the staging of cancer (accomplished by CT scan) is a more favourable predictor of the prognosis of this disease. In relation to renal cancer staging, the Heidelberg classification system of renal tumours was introduced in 1976 as a means of more completely correlating the histopathological features with the identified genetic defects.


title: Renal cell carcinoma

text: The type of treatment depends on multiple factors and the individual, some of which include the stage of renal cell carcinoma (organs and parts of the body affected/unaffected), type of renal cell carcinoma, pre-existing or comorbid conditions and overall health and age of the person.


title: Renal cell carcinoma

text: Every form of treatment has both risks and benefits; a health care professional will provide the best options that suit the individual circumstances.


title: Renal cell carcinoma

text: If it has spread outside of the kidneys, often into the lymph nodes, the lungs or the main vein of the kidney, then multiple therapies are used including surgery and medications. RCC is resistant to chemotherapy and radiotherapy in most cases but does respond well to immunotherapy with interleukin-2 or interferon-alpha, biologic, or targeted therapy. In early-stage cases, cryotherapy and surgery are the preferred options.


title: Renal cell carcinoma

text: Active surveillance or "watchful waiting" is becoming more common as small renal masses or tumours are being detected and also within the older generation when surgery is not always suitable. Active surveillance involves completing various diagnostic procedures, tests and imaging to monitor the progression of the RCC before embarking on a more high risk treatment option like surgery. In the elderly, patients with co-morbidities, and in poor surgical candidates, this is especially useful.


title: Renal cell carcinoma

text: The recommended treatment for renal cell cancer may be nephrectomy or partial nephrectomy, surgical removal of all or part of the kidney. This may include some of the surrounding organs or tissues or lymph nodes. If cancer is only in the kidneys, which is about 60% of cases, it can be cured roughly 90% of the time with surgery.


title: Renal cell carcinoma

text: Small renal tumors (< 4 cm) are treated increasingly by partial nephrectomy when possible. Most of these small renal masses manifest indolent biological behavior with excellent prognosis. Nephron-sparing partial nephrectomy is used when the tumor is small (less than 4 cm in diameter) or when the patient has other medical concerns such as diabetes or hypertension. The partial nephrectomy involves the removal of the affected tissue only, sparing the rest of the kidney, Gerota's fascia and the regional lymph nodes. This allows for more renal preservation as compared to the radical nephrectomy, and this can have positive long-term health benefits. Larger and more complex tumors can also be treated with partial nephrectomy by surgeons with a lot of kidney surgery experience.


title: Renal cell carcinoma

text: Surgical nephrectomy may be "radical" if the procedure removes the entire affected kidney including Gerota's fascia, the adrenal gland which is on the same side as the affected kidney, and the regional retroperitoneal lymph nodes, all at the same time. This method, although severe, is effective. But it is not always appropriate, as it is a major surgery that contains the risk of complication both during and after the surgery and can have a longer recovery time. It is important to note that the other kidney must be fully functional, and this technique is most often used when there is a large tumour present in only one kidney.


title: Renal cell carcinoma

text: In cases where the tumor has spread into the renal vein, inferior vena cava, and possibly the right atrium, this portion of the tumor can be surgically removed, as well. When the tumor involved the inferior vena cava, it is important to classify which parts of the vena cava are involved and to plan accordingly, as sometimes complete resection will involve an incision into the chest with increased morbidity. For this reason, Dr. Gaetano Ciancio adapted liver mobilization techniques from liver transplant to address retrohepatic or even suprahepatic inferior vena caval thrombus associated with renal tumors. With this technique, the whole abdominal inferior vena cava is able to be mobilized. This facilitates milking of the tumor down below the major hepatic veins by the surgeon's fingers, bypassing the need for a thoracoabdominal incision or cardiopulmonary bypass. In cases of known metastases, surgical resection of the kidney ("cytoreductive nephrectomy") may improve survival, as well as resection of a solitary metastatic lesion. Kidneys are sometimes embolized prior to surgery to minimize blood loss.


title: Renal cell carcinoma

text: Surgery is increasingly performed via laparoscopic techniques. Commonly referred to as key hole surgery, this surgery does not have the large incisions seen in a classically performed radical or partial nephrectomy, but still successfully removes either all or part of the kidney. Laparoscopic surgery is associated with shorter stays in the hospital and quicker recovery time but there are still risks associated with the surgical procedure. These have the advantage of being less of a burden for the patient and the disease-free survival is comparable to that of open surgery. For small exophytic lesions that do not extensively involve the major vessels or urinary collecting system, a partial nephrectomy (also referred to as "nephron sparing surgery") can be performed. This may involve temporarily stopping blood flow to the kidney while the mass is removed as well as renal cooling with an ice slush. Mannitol can also be administered to help limit damage to the kidney. This is usually done through an open incision although smaller lesions can be done laparoscopically with or without robotic assistance.


title: Renal cell carcinoma

text: Laparoscopic cryotherapy can also be done on smaller lesions. Typically a biopsy is taken at the time of treatment. Intraoperative ultrasound may be used to help guide placement of the freezing probes. Two freeze/thaw cycles are then performed to kill the tumor cells. As the tumor is not removed followup is more complicated (see below) and overall disease-free rates are not as good as those obtained with surgical removal.


title: Renal cell carcinoma

text: Surgery for metastatic disease: If metastatic disease is present surgical treatment may still a viable option. Radical and partial nephrectomy can still occur, and in some cases, if the metastasis is small this can also be surgically removed. This depends on what stage of growth and how far the disease has spread.


title: Renal cell carcinoma

text: Percutaneous ablation therapies use image-guidance by radiologists to treat localized tumors if a surgical procedure is not a good option. Although the use of laparoscopic surgical techniques for complete nephrectomies has reduced some of the risks associated with surgery, surgery of any sort in some cases will still not be feasible. For example, the elderly, people who already have severe renal dysfunction, or people who have several comorbidities, surgery of any sort is not warranted.


title: Renal cell carcinoma

text: A probe is placed through the skin and into the tumor using real-time imaging of both the probe tip and the tumor by computed tomography, ultrasound, or even magnetic resonance imaging guidance, and then destroying the tumor with heat (radiofrequency ablation) or cold (cryotherapy). These modalities are at a disadvantage compared to traditional surgery in that pathologic confirmation of complete tumor destruction is not possible. Therefore, long-term follow-up is crucial to assess completeness of tumour ablation. Ideally, percutaneous ablation is restricted to tumours smaller than 3.5 cm and to guide the treatment. However, there are some cases where ablation can be used on tumors that are larger.


title: Renal cell carcinoma

text: The two main types of ablation techniques that are used for renal cell carcinoma are radio frequency ablation and cryoablation.


title: Renal cell carcinoma

text: Radio frequency ablation uses an electrode probe which is inserted into the affected tissue, to send radio frequencies to the tissue to generate heat through the friction of water molecules. The heat destroys the tumor tissue. Cell death will generally occur within minutes of being exposed to temperatures above 50 °C.


title: Renal cell carcinoma

text: Cryoablation also involves the insertion of a probe into the affected area, however, cold is used to kill the tumor instead of heat. The probe is cooled with chemical fluids which are very cold. The freezing temperatures cause the tumor cells to die by causing osmotic dehydration, which pulls the water out of the cell destroying the enzyme, organelles, cell membrane and freezing the cytoplasm.


title: Renal cell carcinoma

text: Cancers often grow in an unbridled fashion because they are able to evade the immune system. Immunotherapy is a method that activates the person's immune system and uses it to their own advantage. It was developed after observing that in some cases there was spontaneous regression. Immunotherapy capitalises on this phenomenon and aims to build up a person's immune response to cancer cells.


title: Renal cell carcinoma

text: Other targeted therapy medications inhibit growth factors that have been shown to promote the growth and spread of tumours. Most of these medications were approved within the past ten years. These treatments are:


title: Renal cell carcinoma

text: For patients with metastatic cancer, sunitinib probably results in more progression of the cancer than pembrolizumab, axitinib and avelumab. In comparison to pembrolizumab and axitinib, it probably results in more death, but it may slightly reduce serious unwanted effects. When compared with combinations of immunotherapy (nivolumab and ipilimumab), sunitinib may lead to more progression and serious effects. There may be little to no difference in progression, survival and serious effects between pazopanib and sunitib.


title: Renal cell carcinoma

text: Activity has also been reported for ipilimumab but it is not an approved medication for renal cancer.


title: Renal cell carcinoma

text: More medications are expected to become available in the near future as several clinical trials are currently being conducted for new targeted treatments, including: atezolizumab, varlilumab, durvalumab, avelumab, LAG525, MBG453, TRC105, and savolitinib.


title: Renal cell carcinoma

text: Chemotherapy and radiotherapy are not as successful in the case of RCC. RCC is resistant in most cases but there is about a 4–5% success rate, but this is often short-lived with more tumours and growths developing later.


title: Renal cell carcinoma

text: Adjuvant therapy, which refers to therapy given after a primary surgery, has not been found to be beneficial in renal cell cancer. Conversely, neoadjuvant therapy is administered before the intended primary or main treatment. In some cases neoadjuvant therapy has been shown to decrease the size and stage of the RCC to then allow it to be surgically removed. This is a new form of treatment and the effectiveness of this approach is still being assessed in clinical trials.


title: Renal cell carcinoma

text: Metastatic renal cell carcinoma (mRCC) is the spread of the primary renal cell carcinoma from the kidney to other organs. 25–30% of people have this metastatic spread by the time they are diagnosed with renal cell carcinoma. This high proportion is explained by the fact that clinical signs are generally mild until the disease progresses to a more severe state. The most common sites for metastasis are the lymph nodes, lung, bones, liver and brain. How this spread affects the staging of the disease and hence prognosis is discussed in the "Diagnosis" and "Prognosis" sections.


title: Renal cell carcinoma

text: MRCC has a poor prognosis compared to other cancers although average survival times have increased in the last few years due to treatment advances. Average survival time in 2008 for the metastatic form of the disease was under a year and by 2013 this improved to an average of 22 months. Despite this improvement the five-year survival rate for mRCC remains under 10% and 20–25% of patients remain unresponsive to all treatments and in these cases, the disease has a rapid progression.


title: Renal cell carcinoma

text: The available treatments for RCC discussed in the "Treatment" section are also relevant for the metastatic form of the disease. Options include interleukin-2 which is a standard therapy for advanced renal cell carcinoma. From 2007 to 2013, seven new treatments have been approved specifically for mRCC (sunitinib, temsirolimus, bevacizumab, sorafenib, everolimus, pazopanib and axitinib). These new treatments are based on the fact that renal cell carcinomas are very vascular tumors – they contain a large number of blood vessels. The drugs aim to inhibit the growth of new blood vessels in the tumors, hence slowing growth and in some cases reducing the size of the tumors.


title: Renal cell carcinoma

text: Radiotherapy and chemotherapy are more commonly used in the metastatic form of RCC to target the secondary tumors in the bones, liver, brain and other organs. While not curative, these treatments do provide relief for symptoms associated with the spread of tumors.


title: Renal cell carcinoma

text: The prognosis is influenced by several factors, including tumour size, degree of invasion and metastasis, histologic type, and nuclear grade. Staging is the most important factor in the outcome of renal cell cancer. The following numbers are based on patients first diagnosed in 2001 and 2002 by the National Cancer Data Base:


title: Renal cell carcinoma

text: A Korean study estimated a disease-specific overall five-year survival rate of 85%. Taken as a whole, if the disease is limited to the kidney, only 20–30% develop metastatic disease after nephrectomy. More specific subsets show a five-year survival rate of around 90–95% for tumors less than 4 cm. For larger tumors confined to the kidney without venous invasion, survival is still relatively good at 80–85%. For tumors that extend through the renal capsule and out of the local fascial investments, the survivability reduces to near 60%. Factors as general health and fitness or the severity of their symptoms impact the survival rates. For instance, younger people (among 20–40 years old) have a better outcome despite having more symptoms at presentation, possibly due to lower rates spread of cancer to the lymph nodes (stage III).


title: Renal cell carcinoma

text: Histological grade is related to the aggressiveness of the cancer, and it is classified in 4 grades, with 1 having the best prognosis (five-year survival over 89%), and 4 with the worst prognosis (46% of five-year survival).


title: Renal cell carcinoma

text: Some people have the renal cell cancer detected before they have symptoms (incidentally) because of the CT scan (Computed Tomography Imaging) or ultrasound. Incidentally diagnosed renal cell cancer (no symptoms) differs in outlook from those diagnosed after presenting symptoms of renal cell carcinoma or metastasis. The five-year survival rate was higher for incidental than for symptomatic tumours: 85.3% versus 62.5%. Incidental lesions were significantly lower stage than those that cause symptoms, since 62.1% patients with incidental renal cell carcinoma were observed with Stage I lesions, against 23% were found with symptomatic renal cell carcinoma.


title: Renal cell carcinoma

text: If it has metastasized to the lymph nodes, the five-year survival is around 5% to 15%. For metastatic renal cell carcinoma, factors which may present a poor prognosis include a low Karnofsky performance-status score (a standard way of measuring functional impairment in patients with cancer), a low haemoglobin level, a high level of serum lactate dehydrogenase, and a high corrected level of serum calcium. For non-metastatic cases, the Leibovich scoring algorithm may be used to predict post-operative disease progression.


title: Renal cell carcinoma

text: Renal cell carcinoma is one of the cancers most strongly associated with paraneoplastic syndromes, most often due to ectopic hormone production by the tumour. The treatment for these complications of RCC is generally limited beyond treating the underlying cancer.


title: Renal cell carcinoma

text: The incidence of the disease varies according to geographic, demographic and, to a lesser extent, hereditary factors. There are some known risk factors, however the significance of other potential risk factors remains more controversial. The incidence of the cancer has been increasing in frequency worldwide at a rate of approximately 2–3% per decade until the last few years where the number of new cases has stabilised.


title: Renal cell carcinoma

text: The incidence of RCC varies between sexes, ages, races and geographic location around the world. Men have a higher incidence than women (approximately 1.6:1) and the vast majority are diagnosed after 65 years of age. Asians reportedly have a significantly lower incidence of RCC than whites and while African countries have the lowest reported incidences, African Americans have the highest incidence of the population in the United States. Developed countries have a higher incidence than developing countries, with the highest rates found in North America, Europe and Australia / New Zealand.