Physiology of dinosaurs – Wikipedia

Note: In this article "dinosaur" means "non-avian dinosaur," since most experts regard birds as an advanced group of dinosaurs.

The physiology of dinosaurs has historically been a controversial subject, particularly thermoregulation. Recently, many new lines of evidence have been brought to bear on dinosaur physiology generally, including not only metabolic systems and thermoregulation, but on respiratory and cardiovascular systems as well.

During the early years of dinosaur paleontology, it was widely considered that they were sluggish, cumbersome, and sprawling cold-blooded lizards. However, with the discovery of much more complete skeletons in western United States, starting in the 1870s, scientists could make more informed interpretations of dinosaur biology and physiology. Edward Drinker Cope, opponent of Othniel Charles Marsh in the Bone Wars, propounded at least some dinosaurs as active and agile, as seen in the painting of two fighting "Laelaps" produced under his direction by Charles R. Knight.[1]

In parallel, the development of Darwinian evolution, and the discoveries of Archaeopteryx and Compsognathus, led Thomas Henry Huxley to propose that dinosaurs were closely related to birds.[2] Despite these considerations, the image of dinosaurs as large reptiles had already taken root,[1] and most aspects of their paleobiology were interpreted as being typically reptilian for the first half of the twentieth century.[3] Beginning in the 1960s and with the advent of the Dinosaur Renaissance, views of dinosaurs and their physiology have changed dramatically, including the discovery of feathered dinosaurs in Early Cretaceous age deposits in China, indicating that birds evolved from highly agile maniraptoran dinosaurs.

The study of dinosaurs began in the 1820s in England. Pioneers in the field, such as William Buckland, Gideon Mantell, and Richard Owen, interpreted the first, very fragmentary remains as belonging to large quadrupedal beasts.[4] Their early work can be seen today in the Crystal Palace Dinosaurs, constructed in the 1850s, which present known dinosaurs as elephantine lizard-like reptiles.[5] Despite these reptilian appearances, Owen speculated that dinosaur heart and respiratory systems were more similar to that of a mammal than a reptile.[4]

In the late 1960s, similar ideas reappeared, beginning with John Ostrom's work on Deinonychus and bird evolution.[6] His student, Bob Bakker, popularized the changing thought in a series of papers beginning with The superiority of dinosaurs in 1968.[7] In these publications, he argued strenuously that dinosaurs were warm-blooded and active animals, capable of sustained periods of high activity. In most of his writings Bakker framed his arguments as new evidence leading to a revival of ideas popular in the late 19th century, frequently referring to an ongoing dinosaur renaissance. He used a variety of anatomical and statistical arguments to defend his case,[8][9] the methodology of which was fiercely debated among scientists.[10]

These debates sparked interest in new methods for ascertaining the palaeobiology of extinct animals, such as bone histology, which have been successfully applied to determining the growth-rates of many dinosaurs.

Today, it is generally thought that many or perhaps all dinosaurs had higher metabolic rates than living reptiles, but also that the situation is more complex and varied than Bakker originally proposed. For example, while smaller dinosaurs may have been true endotherms, the larger forms could have been inertial homeotherms,[11][12] or that many dinosaurs could have had intermediate metabolic rates.[13]

The earliest dinosaurs were almost certainly predators, and shared several predatory features with their nearest non-dinosaur relatives like Lagosuchus, including: relatively large, curved, blade-like teeth in large, wide-opening jaws that closed like scissors; relatively small abdomens, as carnivores do not require large digestive systems. Later dinosaurs regarded as predators sometimes grew much larger, but retained the same set of features. Instead of chewing their food, these predators swallowed it whole.[14]

The feeding habits of ornithomimosaurs and oviraptorosaurs are a mystery: although they evolved from a predatory theropod lineage, they have small jaws and lack the blade-like teeth of typical predators, but there is no evidence of their diet or how they ate and digested it.[14]

Features of other groups of dinosaurs indicate they were herbivores. These features include:

Sauropods, which were herbivores, did not chew their food, as their teeth and jaws appear suitable only for stripping leaves off plants. Ornithischians, also herbivores, show a variety of approaches. The armored ankylosaurs and stegosaurs had small heads and weak jaws and teeth, and are thought to have fed in much the same way as sauropods. The pachycephalosaurs had small heads and weak jaws and teeth, but their lack of large digestive systems suggests a different diet, possibly fruits, seeds, or young shoots, which would have been more nutritious to them than leaves.[14]

On the other hand, ornithopods such as Hypsilophodon, Iguanodon and various hadrosaurs had horny beaks for snipping off vegetation and jaws and teeth that were well-adapted for chewing. The horned ceratopsians had similar mechanisms.[14]

It has often been suggested that at least some dinosaurs used swallowed stones, known as gastroliths, to aid digestion by grinding their food in muscular gizzards, and that this was a feature they shared with birds. In 2007 Oliver Wings reviewed references to gastroliths in scientific literature and found considerable confusion, starting with the lack of an agreed and objective definition of "gastrolith". He found that swallowed hard stones or grit can assist digestion in birds that mainly feed on grain but may not be essentialand that birds that eat insects in summer and grain in winter usually get rid of the stones and grit in summer. Gastroliths have often been described as important for sauropod dinosaurs, whose diet of vegetation required very thorough digestion, but Wings concluded that this idea was incorrect: gastroliths are found with only a small percentage of sauropod fossils; where they have been found, the amounts are too small and in many cases the stones are too soft to have been effective in grinding food; most of these gastroliths are highly polished, but gastroliths used by modern animals to grind food are roughened by wear and corroded by stomach acids; hence the sauropod gastroliths were probably swallowed accidentally. On the other hand, he concluded that gastroliths found with fossils of advanced theropod dinosaurs such as Sinornithomimus and Caudipteryx resemble those of birds, and that the use of gastroliths for grinding food may have appeared early in the group of dinosaurs from which these dinosaurs and birds both evolved.[15][16]

When laying eggs, female birds grow a special type of bone in their limbs between the hard outer bone and the marrow.[17] This medullary bone, which is rich in calcium, is used to make eggshells, and the birds that produced it absorb it when they have finished laying eggs.[18] Medullary bone has been found in fossils of the theropods Tyrannosaurus and Allosaurus and of the ornithopod Tenontosaurus.[18][19]

Because the line of dinosaurs that includes Allosaurus and Tyrannosaurus diverged from the line that led to Tenontosaurus very early in the evolution of dinosaurs, the presence of medullary bone in both groups suggests that dinosaurs in general produced medullary tissue. On the other hand, crocodilians, which are dinosaurs' second closest extant relatives after birds, do not produce medullary bone. This tissue may have first appeared in ornithodires, the Triassic archosaur group from which dinosaurs are thought to have evolved.[18]

Medullary bone has been found in specimens of sub-adult size, which suggests that dinosaurs reached sexual maturity before they were full-grown. Sexual maturity at sub-adult size is also found in reptiles and in medium- to large-sized mammals, but birds and small mammals reach sexual maturity only after they are full-grownwhich happens within their first year. Early sexual maturity is also associated with specific features of animals' life cycles: the young are born relatively well-developed rather than helpless; and the death-rate among adults is high.[18]

From about 1870 onwards scientists have generally agreed that the post-cranial skeletons of many dinosaurs contained many air-filled cavities (postcranial skeletal pneumaticity, especially in the vertebrae. Pneumatization of the skull (such as paranasal sinuses) is found in both synapsids and archosaurs, but postcranial pneumatization is found only in birds, non-avian saurischian dinosaurs, and pterosaurs.

For a long time these cavities were regarded simply as weight-saving devices, but Bakker proposed that they were connected to air sacs like those that make birds' respiratory systems the most efficient of all animals'.[9]

John Ruben et al. (1997, 1999, 2003, 2004) disputed this and suggested that dinosaurs had a "tidal" respiratory system (in and out) powered by a crocodile-like hepatic piston mechanism muscles attached mainly to the pubis pull the liver backwards, which makes the lungs expand to inhale; when these muscles relax, the lungs return to their previous size and shape, and the animal exhales. They also presented this as a reason for doubting that birds descended from dinosaurs.[20][21][22][23][24]

Critics have claimed that, without avian air sacs, modest improvements in a few aspects of a modern reptile's circulatory and respiratory systems would enable the reptile to achieve 50% to 70% of the oxygen flow of a mammal of similar size,[25] and that lack of avian air sacs would not prevent the development of endothermy.[26] Very few formal rebuttals have been published in scientific journals of Ruben et al.'s claim that dinosaurs could not have had avian-style air sacs; but one points out that the Sinosauropteryx fossil on which they based much of their argument was severely flattened and therefore it was impossible to tell whether the liver was the right shape to act as part of a hepatic piston mechanism.[27] Some recent papers simply note without further comment that Ruben et al. argued against the presence of air sacs in dinosaurs.[28]

Researchers have presented evidence and arguments for air sacs in sauropods, "prosauropods", coelurosaurs, ceratosaurs, and the theropods Aerosteon and Coelophysis.

In advanced sauropods ("neosauropods") the vertebrae of the lower back and hip regions show signs of air sacs. In early sauropods only the cervical (neck) vertebrae show these features. If the developmental sequence found in bird embryos is a guide, air sacs actually evolved before the channels in the skeleton that accommodate them in later forms.[29][30]

Evidence of air sacs has also been found in theropods. Studies indicate that fossils of coelurosaurs,[31]ceratosaurs,[28] and the theropods Coelophysis and Aerosteon exhibit evidence of air sacs. Coelophysis, from the late Triassic, is one of the earliest dinosaurs whose fossils show evidence of channels for air sacs.[30]Aerosteon, a Late Cretaceous allosaur, had the most bird-like air sacs found so far.[32]

Early sauropodomorphs, including the group traditionally called "prosauropods", may also have had air sacs. Although possible pneumatic indentations have been found in Plateosaurus and Thecodontosaurus, the indentations are very small. One study in 2007 concluded that prosauropods likely had abdominal and cervical air sacs, based on the evidence for them in sister taxa (theropods and sauropods). The study concluded that it was impossible to determine whether prosauropods had a bird-like flow-through lung, but that the air sacs were almost certainly present.[33] A further indication for the presence of air sacs and their use in lung ventilation comes from a reconstruction of the air exchange volume (the volume of air exchanged with each breath) of Plateosaurus, which when expressed as a ratio of air volume per body weight at 29ml/kg is similar to values of geese and other birds, and much higher than typical mammalian values.[34]

So far no evidence of air sacs has been found in ornithischian dinosaurs. But this does not imply that ornithischians could not have had metabolic rates comparable to those of mammals, since mammals also do not have air sacs.[35]

Three explanations have been suggested for the development of air sacs in dinosaurs:[32]

Calculations of the volumes of various parts of the sauropod Apatosaurus' respiratory system support the evidence of bird-like air sacs in sauropods:

On this basis, Apatosaurus could not have had a reptilian respiratory system, as its tidal volume would have been less than its dead-space volume, so that stale air was not expelled but was sucked back into the lungs. Likewise, a mammalian system would only provide to the lungs about 225184=41liters of fresh, oxygenated air on each breath. Apatosaurus must therefore have had either a system unknown in the modern world or one like birds', with multiple air sacs and a flow-through lung. Furthermore, an avian system would only need a lung volume of about 600liters while a mammalian one would have required about 2,950liters, which would exceed the estimated 1,700liters of space available in a 30-ton Apatosaurus chest.[36]

Dinosaur respiratory systems with bird-like air sacs may have been capable of sustaining higher activity levels than mammals of similar size and build can sustain. In addition to providing a very efficient supply of oxygen, the rapid airflow would have been an effective cooling mechanism, which is essential for animals that are active but too large to get rid of all the excess heat through their skins.[35]

The palaeontologist Peter Ward has argued that the evolution of the air sac system, which first appears in the very earliest dinosaurs, may have been in response to the very low (11%) atmospheric oxygen of the Carnian and Norian ages of the Triassic Period.[37]

Birds have spurs called "uncinate processes" on the rear edges of their ribs, and these give the chest muscles more leverage when pumping the chest to improve oxygen supply. The size of the uncinate processes is related to the bird's lifestyle and oxygen requirements: they are shortest in walking birds and longest in diving birds, which need to replenish their oxygen reserves quickly when they surface. Non-avian maniraptoran dinosaurs also had these uncinate processes, and they were proportionately as long as in modern diving birds, which indicates that maniraptorans needed a high-capacity oxygen supply.[38][39]

Plates that may have functioned the same way as uncinate processes have been observed in fossils of the ornithischian dinosaur Thescelosaurus, and have been interpreted as evidence of high oxygen consumption and therefore high metabolic rate.[40]

Nasal turbinates are convoluted structures of thin bone in the nasal cavity. In most mammals and birds these are present and lined with mucous membranes that perform two functions. They improve the sense of smell by increasing the area available to absorb airborne chemicals, and they warm and moisten inhaled air, and extract heat and moisture from exhaled air to prevent desiccation of the lungs.

John Ruben and others have argued that no evidence of nasal turbinates has been found in dinosaurs. All the dinosaurs they examined had nasal passages that were too narrow and short to accommodate nasal turbinates, so dinosaurs could not have sustained the breathing rate required for a mammal-like or bird-like metabolic rate while at rest, because their lungs would have dried out.[20][20][21][41][42] However, objections have been raised against this argument. Nasal turbinates are absent or very small in some birds (e.g. ratites, Procellariiformes and Falconiformes) and mammals (e.g. whales, anteaters, bats, elephants, and most primates), although these animals are fully endothermic and in some cases very active.[43][44][45][46] Other studies conclude that nasal turbinates are fragile and seldom found in fossils. In particular none have been found in fossil birds.[47]

In 2014 Jason Bourke and others in Anatomical Record reported finding nasal turbinates in pachycephalosaurs.[48]

In principle one would expect dinosaurs to have had two-part circulations driven by four-chambered hearts, since many would have needed high blood pressure to deliver blood to their heads, which were high off the ground, but vertebrate lungs can only tolerate fairly low blood pressure.[35] In 2000, a skeleton of Thescelosaurus, now on display at the North Carolina Museum of Natural Sciences, was described as including the remnants of a four-chambered heart and an aorta. The authors interpreted the structure of the heart as indicating an elevated metabolic rate for Thescelosaurus, not reptilian cold-bloodedness.[49] Their conclusions have been disputed; other researchers published a paper where they assert that the heart is really a concretion of entirely mineral "cement". As they note: the anatomy given for the object is incorrect, for example the alleged "aorta" is narrowest where it meets the "heart" and lacks arteries branching from it; the "heart" partially engulfs one of the ribs and has an internal structure of concentric layers in some places; and another concretion is preserved behind the right leg.[50] The original authors defended their position; they agreed that the chest did contain a type of concretion, but one that had formed around and partially preserved the more muscular portions of the heart and aorta.[51]

Regardless of the object's identity, it may have little relevance to dinosaurs' internal anatomy and metabolic rate. Both modern crocodilians and birds, the closest living relatives of dinosaurs, have four-chambered hearts, although modified in crocodilians, and so dinosaurs probably had them as well. However such hearts are not necessarily tied to metabolic rate.[52]

No dinosaur egg has been found that is larger than a basketball and embryos of large dinosaurs have been found in relatively small eggs, e.g. Maiasaura.[53] Like mammals, dinosaurs stopped growing when they reached the typical adult size of their species, while mature reptiles continued to grow slowly if they had enough food. Dinosaurs of all sizes grew faster than similarly sized modern reptiles; but the results of comparisons with similarly sized "warm-blooded" modern animals depend on their sizes:[54][55]

Tyrannosaurus rex showed a "teenage growth spurt":[56][57]

A 2008 study of one skeleton of the hadrosaur Hypacrosaurus concluded that this dinosaur grew even faster, reaching its full size at the age of about 15; the main evidence was the number and spacing of growth rings in its bones. The authors found this consistent with a life-cycle theory that prey species should grow faster than their predators if they lose a lot of juveniles to predators and the local environment provides enough resources for rapid growth.[58]

It appears that individual dinosaurs were rather short-lived, e.g. the oldest (at death) Tyrannosaurus found so far was 28 and the oldest sauropod was 38.[56] Predation was probably responsible for the high death rate of very young dinosaurs and sexual competition for the high death rate of sexually mature dinosaurs.[59]

Scientific opinion about the life-style, metabolism and temperature regulation of dinosaurs has varied over time since the discovery of dinosaurs in the mid-19th century. The activity of metabolic enzymes varies with temperature, so temperature control is vital for any organism, whether endothermic or ectothermic. Organisms can be categorized as poikilotherms (poikilo changing), which are tolerant of internal temperature fluctuations, and homeotherms (homeo same), which must maintain a constant core temperature. Animals can be further categorized as endotherms, which regulate their temperature internally, and ectotherms, which regulate temperature by the use of external heat sources.

"Warm-bloodedness" is a complex and rather ambiguous term, because it includes some or all of:

Large dinosaurs may also have maintained their temperatures by inertial homeothermy, also known as "bulk homeothermy" or "mass homeothermy". In other words, the thermal capacity of such large animals was so high that it would take two days or more for their temperatures to change significantly, and this would have smoothed out variations caused by daily temperature cycles. This smoothing effect has been observed in large turtles and crocodilians, but Plateosaurus, which weighed about 700 kilograms (1,500lb), may have been the smallest dinosaur in which it would have been effective. Inertial homeothermy would not have been possible for small species nor for the young of larger species.[35] Vegetation fermenting in the guts of large herbivores can also produce considerable heat, but this method of maintaining a high and stable temperature would not have been possible for carnivores nor for small herbivores or the young of larger herbivores.[61]

Since the internal mechanisms of extinct creatures are unknowable, most discussion focuses on homeothermy and tachymetabolism.

Assessment of metabolic rates is complicated by the distinction between the rates while resting and while active. In all modern reptiles and most mammals and birds the maximum rates during all-out activity are 10 to 20 times higher than minimum rates while at rest. However, in a few mammals these rates differ by a factor of 70. Theoretically it would be possible for a land vertebrate to have a reptilian metabolic rate at rest and a bird-like rate while working flat out. However, an animal with such a low resting rate would be unable to grow quickly. The huge herbivorous sauropods may have been on the move so constantly in search of food that their energy expenditure would have been much the same irrespective of whether their resting metabolic rates were high or low.[62]

The main possibilities are that:[35]

Dinosaurs were around for about 150 million years, so it is very likely that different groups evolved different metabolisms and thermoregulatory regimes, and that some developed different physiologies from the first dinosaurs.

If all or some dinosaurs had intermediate metabolisms, they may have had the following features:[35]

Robert Reid has suggested that such animals could be regarded as "failed endotherms". He envisaged both dinosaurs and the Triassic ancestors of mammals passing through a stage with these features. Mammals were forced to become smaller as archosaurs came to dominate ecological niches for medium to large animals. Their decreasing size made them more vulnerable to heat loss because it increased their ratios of surface area to mass, and thus forced them to increase internal heat generation and thus become full endotherms. On the other hand, dinosaurs became medium to very large animals and thus were able to retain the "intermediate" type of metabolism.[35]

Armand de Ricqls discovered Haversian canals in dinosaur bones, and argued that they were evidence of endothermy in dinosaurs. These canals are common in "warm-blooded" animals and are associated with fast growth and an active life style because they help to recycle bone to facilitate rapid growth and repair damage caused by stress or injuries.[63] Dense secondary Haversian bone, which is formed during remodeling, is found in many living endotherms as well as dinosaurs, pterosaurs and therapsids. Secondary Haversian canals are correlated with size and age, mechanical stress and nutrient turnover. The presence of secondary Haversian canals suggests comparable bone growth and lifespans in mammals and dinosaurs.[64] Bakker argued that the presence of fibrolamellar bone (produced quickly and having a fibrous, woven appearance) in dinosaur fossils was evidence of endothermy.[9]

However, as a result of other, mainly later research, bone structure is not considered a reliable indicator of metabolism in dinosaurs, mammals or reptiles:

Nevertheless, de Ricqls persevered with studies of the bone structure of dinosaurs and archosaurs. In mid-2008 he co-authored a paper that examined bone samples from a wide range of archosaurs, including early dinosaurs, and concluded that:[71]

Endotherms rely highly on aerobic metabolism and have high rates of oxygen consumption during activity and rest. The oxygen required by the tissues is carried by the blood, and consequently blood flow rates and blood pressures at the heart of warm-blooded endotherms are considerably higher than those of cold-blooded ectotherms.[72] It is possible to measure the minimum blood pressures of dinosaurs by estimating the vertical distance between the heart and the top of the head, because this column of blood must have a pressure at the bottom equal to the hydrostatic pressure derived from the density of blood and gravity. Added to this pressure is that required to move the blood through the circulatory system. It was pointed out in 1976 that, because of their height, many dinosaurs had minimum blood pressures within the endothermic range, and that they must have had four-chambered hearts to separate the high pressure circuit to the body from the low pressure circuit to the lungs.[73] It was not clear whether these dinosaurs had high blood pressure simply to support the blood column or to support the high blood flow rates required by endothermy or both.

However, recent analysis of the tiny holes in fossil leg bones of dinosaurs provides a gauge for blood flow rate and hence metabolic rate.[74] The holes are called nutrient foramina, and the nutrient artery is the major blood vessel passing through to the interior of the bone, where it branches into tiny vessels of the Haversian canal system. This system is responsible for replacing old bone with new bone, thereby repairing microbreaks that occur naturally during locomotion. Without this repair, microbreaks would build up, leading to stress fractures and ultimately catastrophic bone failure. The size of the nutrient foramen provides an index of blood flow through it, according to the Hagen-Poiseuille equation. The size is also related to the body size of animal, of course, so this effect is removed by analysis of allometry. Blood flow index of the nutrient foramen of the femurs in living mammals increases in direct proportion to the animals' maximum metabolic rates, as measured during maximum sustained locomotion. Mammalian blood flow index is about 10 times greater than in ectothermic reptiles. Ten species of fossil dinosaurs from five taxonomic groups reveal indices even higher than in mammals, when body size is accounted for, indicating that they were highly active, aerobic animals. Thus high blood flow rate, high blood pressure, a four-chambered heart and sustained aerobic metabolism are all consistent with endothermy.

Dinosaurs grew from small eggs to several tons in weight relatively quickly. A natural interpretation of this is that dinosaurs converted food into body weight very quickly, which requires a fairly fast metabolism both to forage actively and to assimilate the food quickly.[75] Developing bone found in juveniles is distinctly porous, which has been linked to vascularization and bone deposition rate, all suggesting growth rates close to those observed in modern birds.

But a preliminary study of the relationship between adult size, growth rate, and body temperature concluded that larger dinosaurs had higher body temperatures than smaller ones had; Apatosaurus, the largest dinosaur in the sample, was estimated to have a body temperature exceeding 41C (106F), whereas smaller dinosaurs were estimated to have body temperatures around 25C (77F)[76] for comparison, normal human body temperature is about 37C (99F).[77]Sund-Levander, Mrtha; Forsberg, Christina; Wahren, Lis Karin (2002). "Normal oral, rectal, tympanic and axillary body temperature in adult men and women: a systematic literature review". Scandinavian Journal of Caring Sciences. 16 (2): 122128. doi:10.1046/j.1471-6712.2002.00069.x. PMID12000664. Based on these estimations, the study concluded that large dinosaurs were inertial homeotherms (their temperatures were stabilized by their sheer bulk) and that dinosaurs were ectothermic (in colloquial terms, "cold-blooded", because they did not generate as much heat as mammals when not moving or digesting food).[76] These results are consistent with the relationship between dinosaurs' sizes and growth rates (described above).[54][55] Studies of the sauropodomorph Massospondylus and early theropod Syntarsus (Megapnosaurus) reveal growth rates of 3kg/year and 17kg/year, respectively, much slower than those estimated of Maiasaura and observed in modern birds.[64]

The ratio of the isotopes 16O and 18O in bone depends on the temperature the bone formed at: the higher the temperature, the more 16O. Barrick and Showers (1999) analyzed the isotope ratios in two theropods that lived in temperate regions with seasonal variation in temperature, Tyrannosaurus (USA) and Giganotosaurus (Argentina):[78]

Barrick and Showers concluded that both dinosaurs were endothermic but at lower metabolic levels than modern mammals, and that inertial homeothermy was an important part of their temperature regulation as adults. Their similar analysis of some Late Cretaceous ornithischians in 1996 concluded that these animals showed a similar pattern.[79]

However this view has been challenged. The evidence indicates homeothermy, but by itself cannot prove endothermy. Secondly, the production of bone may not have been continuous in areas near the extremities of limbs in allosaur skeketons lines of arrested growth ("LAGs"; rather like growth rings) are sparse or absent in large limb bones but common in the fingers and toes. While there is no absolute proof that LAGs are temperature-related, they could mark times when the extremities were so cool that the bones ceased to grow. If so, the data about oxygen isotope ratios would be incomplete, especially for times when the extremities were coolest. Oxygen isotope ratios may be an unreliable method of estimating temperatures if it cannot be shown that bone growth was equally continuous in all parts of the animal.[35]

Bakker argued that:[80]

This argument was criticized on several grounds and is no longer taken seriously (the following list of criticisms is far from exhaustive):[81][82]

Dinosaurs' limbs were erect and held under their bodies, rather than sprawling out to the sides like those of lizards and newts. The evidence for this is the angles of the joint surfaces and the locations of muscle and tendon attachments on the bones. Attempts to represent dinosaurs with sprawling limbs result in creatures with dislocated hips, knees, shoulders and elbows.[83]

Carrier's constraint states that air-breathing vertebrates with two lungs that flex their bodies sideways during locomotion find it difficult to move and breathe at the same time. This severely limits stamina, and forces them to spend more time resting than moving.[84]

Sprawling limbs require sideways flexing during locomotion (except for tortoises and turtles, which are very slow and whose armor keeps their bodies fairly rigid). However, despite Carrier's constraint, sprawling limbs are efficient for creatures that spend most of their time resting on their bellies and only move for a few seconds at a timebecause this arrangement minimizes the energy costs of getting up and lying down.

Erect limbs increase the costs of getting up and lying down, but avoid Carrier's constraint. This indicates that dinosaurs were active animals because natural selection would have favored the retention of sprawling limbs if dinosaurs had been sluggish and spent most of their waking time resting. An active lifestyle requires a metabolism that quickly regenerates energy supplies and breaks down waste products which cause fatigue, i.e., it requires a fairly fast metabolism and a considerable degree of homeothermy.

Additionally, an erect posture demands precise balance, the result of a rapidly functioning neuromuscular system. This suggests endothermic metabolism, because an ectothermic animal would be unable to walk or run, and thus to evade predators, when its core temperature was lowered. Other evidence for endothermy includes limb length (many dinosaurs possessed comparatively long limbs) and bipedalism, both found today only in endotherms.[85] Many bipedal dinosaurs possessed gracile leg bones with a short thigh relative to calf length. This is generally an adaptation to frequent sustained running, characteristic of endotherms which, unlike ectotherms, are capable of producing sufficient energy to stave off the onset of anaerobic metabolism in the muscle.[86]

Bakker and Ostrom both pointed out that all dinosaurs had erect hindlimbs and that all quadrupedal dinosaurs had erect forelimbs; and that among living animals only the endothermic ("warm-blooded") mammals and birds have erect limbs (Ostrom acknowledged that crocodilians' occasional "high walk" was a partial exception). Bakker claimed this was clear evidence of endothermy in dinosaurs, while Ostrom regarded it as persuasive but not conclusive.[9][87]

A 2009 study supported the hypothesis that endothermy was widespread in at least larger non-avian dinosaurs, and that It was plausibly ancestral for all dinosauriforms, based on the biomechanics of running.[88]

There is now no doubt that many theropod dinosaur species had feathers, including Shuvuuia, Sinosauropteryx and Dilong (an early tyrannosaur).[89][27][90] These have been interpreted as insulation and therefore evidence of warm-bloodedness.

But impressions of feathers have only been found in coelurosaurs (which includes the ancestors of both birds and tyrannosaurs), so at present feathers give us no information about the metabolisms of the other major dinosaur groups, e.g. coelophysids, ceratosaurs, carnosaurs, sauropods or ornithischians.

In fact the fossilised skin of Carnotaurus (an abelisaurid and therefore not a coelurosaur) shows an unfeathered, reptile-like skin with rows of bumps.[91] But an adult Carnotaurus weighed about 1 ton, and mammals of this size and larger have either very short hair or naked skins, so perhaps the skin of Carnotaurus tells us nothing about whether smaller non-coelurosaurid theropods had feathers.

Skin-impressions of Pelorosaurus and other sauropods (dinosaurs with elephantine bodies and long necks) reveal large hexagonal scales, and some sauropods, such as Saltasaurus, had bony plates in their skin.[92] The skin of ceratopsians consisted of large polygonal scales, sometimes with scattered circular plates.[93] "Mummified" remains and skin impressions of hadrosaurids reveal pebbly scales. It is unlikely that the ankylosaurids, such as Euoplocephalus, had insulation, as most of their surface area was covered in bony knobs and plates.[94] Likewise there is no evidence of insulation in the stegosaurs. Thus insulation, and the elevated metabolic rate behind evolving them, may have been limited to the theropods, or even just a subset of theropods.

Dinosaur fossils have been found in regions that were close to the poles at the relevant times, notably in southeastern Australia, Antarctica and the North Slope of Alaska. There is no evidence of major changes in the angle of the Earth's axis, so polar dinosaurs and the rest of these ecosystems would have had to cope with the same extreme variation of day length through the year that occurs at similar latitudes today (up to a full day with no darkness in summer, and a full day with no sunlight in winter).[95]

Studies of fossilized vegetation suggest that the Alaska North Slope had a maximum temperature of 13C (55F) and a minimum temperature of 2C (36F) to 8C (46F) in the last 35million years of the Cretaceous (slightly cooler than Portland, Oregon but slightly warmer than Calgary, Alberta). Even so, the Alaska North Slope has no fossils of large cold-blooded animals such as lizards and crocodilians, which were common at the same time in Alberta, Montana, and Wyoming. This suggests that at least some non-avian dinosaurs were warm-blooded.[95] It has been proposed that North American polar dinosaurs may have migrated to warmer regions as winter approached, which would allow them to inhabit Alaska during the summers even if they were cold-blooded.[96] But a round trip between there and Montana would probably have used more energy than a cold-blooded land vertebrate produces in a year; in other words the Alaskan dinosaurs would have to be warm-blooded, irrespective of whether they migrated or stayed for the winter.[97] A 2008 paper on dinosaur migration by Phil R. Bell and Eric Snively proposed that most polar dinosaurs, including theropods, sauropods, ankylosaurians, and hypsilophodonts, probably overwintered, although hadrosaurids like Edmontosaurus were probably capable of annual 2,600km (1,600mi) round trips.[98][99]

It is more difficult to determine the climate of southeastern Australia when the dinosaur fossil beds were laid down 115to105 million years ago, towards the end of the Early Cretaceous: these deposits contain evidence of permafrost, ice wedges, and hummocky ground formed by the movement of subterranean ice, which suggests mean annual temperatures ranged between 6C (21F) and 5C (41F); oxygen isotope studies of these deposits give a mean annual temperature of 1.5C (34.7F) to 2.5C (36.5F). However the diversity of fossil vegetation and the large size of some of fossil trees exceed what is found in such cold environments today, and no-one has explained how such vegetation could have survived in the cold temperatures suggested by the physical indicators for comparison Fairbanks, Alaska presently has a mean annual temperature of 2.9C (37.2F).[95] An annual migration from and to southeastern Australia would have been very difficult for fairly small dinosaurs in such as Leaellynasaura, a herbivore about 60 centimetres (2.0ft) to 90 centimetres (3.0ft) long, because seaways to the north blocked the passage to warmer latitudes.[95] Bone samples from Leaellynasaura and Timimus, an ornithomimid about 3.5 metres (11ft) long and 1.5 metres (4.9ft) high at the hip, suggested these two dinosaurs had different ways of surviving the cold, dark winters: the Timimus sample had lines of arrested growth (LAGs for short; similar to growth rings), and it may have hibernated; but the Leaellynasaura sample showed no signs of LAGs, so it may have remained active throughout the winter.[100] A 2011 study focusing on hypsilophodont and theropod bones also concluded that these dinosaurs did not hibernate through the winter, but stayed active.[101]

Some dinosaurs, e.g. Spinosaurus and Ouranosaurus, had on their backs "sails" supported by spines growing up from the vertebrae. (This was also true, incidentally, for the synapsid Dimetrodon.) Such dinosaurs could have used these sails to:

But these were a very small minority of known dinosaur species. One common interpretation of the plates on stegosaurs' backs is as heat exchangers for thermoregulation, as the plates are filled with blood vessels, which, theoretically, could absorb and dissipate heat.[102]

This might have worked for a stegosaur with large plates, such as Stegosaurus, but other stegosaurs, such as Wuerhosaurus, Tuojiangosaurus and Kentrosaurus possessed much smaller plates with a surface area of doubtful value for thermo-regulation. However, the idea of stegosaurian plates as heat exchangers has recently been questioned.[103]

Endothermy demands frequent respiration, which can result in water loss. In living birds and mammals, water loss is limited by pulling moisture out of exhaled air with mucous-covered respiratory turbinates, tissue-covered bony sheets in the nasal cavity. Several dinosaurs have olfactory turbinates, used for smell, but none have yet been identified with respiratory turbinates.[104]

Because endothermy allows refined neuromuscular control, and because brain matter requires large amounts of energy to sustain, some speculate that increased brain size indicates increased activity and, thus, endothermy. The encephalization quotient (EQ) of dinosaurs, a measure of brain size calculated using brain endocasts, varies on a spectrum from bird-like to reptile-like. Using EQ alone, coelosaurs appear to have been as active as living mammals, while theropods and ornithopods fall somewhere between mammals and reptiles, and other dinosaurs resemble reptiles.[104]

A study published by Roger Seymour in 2013 added more support to the idea that dinosaurs were endothermic. After studying saltwater crocodiles, Seymour found that even if their large sizes could provide stable and high body temperatures, the crocodiles' ectothermic metabolisms provided less endurance and only 14% of the muscle power of a similar sized mammal. Seymour reasoned that dinosaurs would have needed to be endothermic since they would have needed powerful muscles and endurance to compete with and dominate mammals throughout the Mesozoic era.[105][106]

It appears that the earliest dinosaurs had the features that form the basis for arguments for warm-blooded dinosaursespecially erect limbs. This raises the question "How did dinosaurs become warm-blooded?" The most obvious possible answers are:

Crocodilians present some puzzles if one regards dinosaurs as active animals with fairly constant body temperatures. Crocodilians evolved shortly before dinosaurs and, second to birds, are dinosaurs' closest living relatives but modern crocodilians are cold-blooded. This raises some questions:

Modern crocodilians are cold-blooded but can move with their limbs erect, and have several features normally associated with warm-bloodedness because they improve the animal's oxygen supply:

So why did natural selection favor these features, which are important for active warm-blooded creatures but of little apparent use to cold-blooded aquatic ambush predators that spend most of their time floating in water or lying on river banks?

It was suggested in the late 1980s that crocodilians were originally active, warm-blooded predators and that their archosaur ancestors were warm-blooded.[84] More recently, developmental studies indicate that crocodilian embryos develop fully four-chambered hearts firstthen develop the modifications that make their hearts function as three-chambered under water. Using the principle that ontogeny recapitulates phylogeny, the researchers concluded that the original crocodilians had fully 4-chambered hearts and were therefore warm-blooded and that later crocodilians developed the bypass as they reverted to being cold-blooded aquatic ambush predators.[111][112]

More recent research on archosaur bone structures and their implications for growth rates also suggests that early archosaurs had fairly high metabolic rates and that the Triassic ancestors of crocodilians dropped back to more typically "reptilian" metabolic rates.[71]

If this view is correct, the development of warm-bloodedness in archosaurs (reaching its peak in dinosaurs) and in mammals would have taken more similar amounts of time. It would also be consistent with the fossil evidence:

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The Department of Microbiology and Immunology provides a stimulating environment for faculty scientists and trainees who will play a leadership role in academic, government and industrial research and in international health organizations.

Advances in molecular and cell biology and genetics have opened new approaches to the basic and applied aspects of infectious diseases and host defenses. We are applying these approaches to basic aspects of receptor signaling, regulation of gene expression in both prokaryotic and eukaryotic cells and interactions between these cells, genetic manipulation of cellular functions, microbial genomics and evolution, and development of new vaccination strategies. The techniques of functional genomics, gene delivery, stem cells and transgenic/gene disruption animal models are being developed to address specific questions.

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Genetics of Kidney Cancer (Renal Cell Cancer) (PDQ)Health …

[Note: Many of the medical and scientific terms used in this summary are found in the NCI Dictionary of Genetics Terms. When a linked term is clicked, the definition will appear in a separate window.]

[Note: A concerted effort is being made within the genetics community to shift terminology used to describe genetic variation. The shift is to use the term variant rather than the term mutation to describe a difference that exists between the person or group being studied and the reference sequence. Variants can then be further classified as benign (harmless), likely benign, of uncertain significance, likely pathogenic, or pathogenic (disease causing). Throughout this summary, we will use the term pathogenic variant to describe a disease-causing mutation. Refer to the Cancer Genetics Overview summary for more information about variant classification.]

Renal cell cancer (RCC) is among the more commonly diagnosed cancers in both men and women. In the United States in 2016, about 62,700 cases of kidney cancer and renal pelvis cancer are expected to occur and lead to more than 14,240 deaths.[1] This cancer accounts for about 4% of all the adult malignancies. The male-to-female ratio is 1.5:1.[2] RCC is distinct from kidney cancer that involves the renal pelvis or renal medulla, and it only applies to cancer that forms in the lining of the kidney bed (i.e., in the renal tubules). Genetic pathogenic variants have been identified as the cause of inherited cancer risk in some RCC cancerprone families; these pathogenic variants are estimated to account for only 1% to 2% of RCC cases overall.[3] It is likely that other undiscovered genes and background genetic factors contribute to the development of familial RCC in conjunction with nongenetic risk factors. About 80% of sporadic RCC is of clear cell histopathology.[2] Nonrenal cell cancers of the kidney, including cancer of the renal pelvis or renal medulla, are not addressed in this summary.

RCC occurs in both sporadic and heritable forms. The following four major autosomal dominantly inherited RCC syndromes have been identified:

These genetic syndromes comprise the main focus of this summary. (Refer to the PDQ summary on Renal Cell Cancer Treatment and the PDQ summary on Transitional Cell Cancer of the Renal Pelvis and Ureter Treatment for more information about sporadic kidney cancer.)

The natural history of each of the RCCs varies according to the characteristic histopathology of the renal tumors that arise in the specific syndrome. Although it is useful to follow the predominant reported natural history of each syndrome, each individual affected will need to be evaluated and monitored for occasional individual variations. The individual prognosis will depend upon the characteristics of the renal tumor at the time of detection and intervention and will differ for each syndrome (VHL, HPRC, BHD, and HLRCC). Prognostic determinants at diagnosis include the stage of the RCC, whether the tumor is confined to the kidney, primary tumor size, Fuhrman nuclear grade, and multifocality.[4-6]

RCC accounts for about 4% of all adult malignancies in the United States.[7] Epidemiologic studies of RCC suggest that a family history of RCC is a risk factor for the disease. The relative risk (RR) is estimated to be 2.5 for a sibling of an RCC-affected patient.[8-10] Analysis of renal carcinomas up to the year 2000 in the Sweden Family-Cancer Database, which includes all Swedes born since 1931 and their biological parents, led to the observation that risk of RCC was particularly high in the siblings of those affected with RCC. The higher RR in siblings than in parent-child pairs suggests that a recessive gene contributes to the development of sporadic renal carcinoma.[8] Investigators in Iceland studied all patients in Iceland who developed RCC between 1955 and 1999 (1,078 cases). In addition, they used an extensive computerized database to perform a unique genealogic study that included more than 600,000 Icelandic individuals. The results revealed that nearly 60% of RCC patients in Iceland during this time period had either a first-degree relative or a second-degree relative with RCC.[9] A study that evaluated 80,309 monozygotic twin individuals and 123,382 same-sex dizygotic twin individuals in Denmark, Finland, Norway, and Sweden found an excess cancer risk in twins whose co-twin was diagnosed with cancer.[11] The estimated cumulative risks were an absolute 5% higher (95% confidence interval [CI], 4%6%) in dizygotic twins (37%; 95% CI, 36%38%) and an absolute 14% higher (95% CI, 12%16%) in monozygotic twins (46%; 95% CI, 44%48%)for twins whose co-twin also developed cancerthan that in the overall cohort (32%). Overall heritability of cancer, calculated by assessing the relative contribution of heredity versus shared environment, was estimated to be 33%. Heritability of kidney cancer was estimated to be 38% (95% CI, 21%55%), with shared environmental factors not showing a significant contribution to overall risk.

Young age at onset is also a clue to possible hereditary etiology. In contrast with sporadic RCC, which is generally diagnosed during the fifth to seventh decades of life, hereditary forms of kidney cancer are generally diagnosed at an earlier age. In a review from the National Cancer Institute of over 600 cases of hereditary kidney cancer, the median age at diagnosis was 37 years, with 70% of the cases being diagnosed at age 46 years or younger,[12] compared with a median age at diagnosis of 64 years in the overall population.[13]. Bilaterality and multifocality are common in most heritable RCC, except in HLRCC.

There is no consensus regarding whom to refer for genetic consultation for a possible hereditary kidney cancer syndrome, although the following organizations have offered guidance:

Studies of environmental and lifestyle factors contributing to the risk of RCC focus almost exclusively on sporadic (i.e., nonhereditary) RCC. Smoking, hypertension, and obesity are the major environmental and lifestyle risk factors associated with RCC.[16] In addition, workers who were reportedly exposed to the environmental carcinogen trichloroethylene developed sporadic clear cell RCC, presumably due to somatic variants in the VHL gene.[17] Dietary intake of vegetables and fruits has been inversely associated with RCC. Greater intake of red meat and milk products have been associated with increased RCC risk, although not consistently.[18]

Four major heritable renal cell cancer (RCC) syndromes (von Hippel-Lindau syndrome [VHL], hereditary leiomyomatosis and renal cell cancer [HLRCC], Birt-Hogg-Dub syndrome [BHD], and hereditary papillary renal cancer [HPRC]) with autosomal dominant inheritance are listed in Table 1, along with their susceptibility genes. These syndromes are summarized in detail in the following sections of this summary.

Autosomal dominant mode of inheritance is the pattern of transmission reported within the families affected by these major RCC syndromes. Genetic tests performed in Clinical Laboratory Improvement Amendments (CLIA)-certified laboratories are available for VHL, BHD, HLRCC, and HPRC. Genetic counseling is a prerequisite for genetic testing. (Refer to the PDQ summary on Cancer Genetics Risk Assessment and Counseling for more information.)

Von Hippel-Lindau syndrome (VHL) (OMIM) is an autosomal dominant, inherited disease with a predisposition to multiple neoplasms. Germline pathogenic variants in the VHL gene predispose individuals to specific types of both benign and malignant tumors and cysts in many organ systems. These include central nervous system (CNS) hemangioblastomas, retinal angiomas, clear cell RCCs (ccRCCs) and cysts, pheochromocytomas, cysts and neuroendocrine tumors (NETs) of the pancreas, endolymphatic sac tumors (ELSTs), and cystadenomas of the epididymis (males) and of the broad ligament (females).[1,2,13,14] A multidisciplinary approach is required for the evaluation, and in some cases the management, of individuals with VHL. Specialists involved in the care of individuals with VHL may include urologic oncology surgeons, neurosurgeons, general surgeons, ophthalmologists, endocrinologists, neurologists, medical oncologists, genetic counselors, and medical geneticists.

The VHL gene is a tumor suppressor gene located on the short arm of chromosome 3 at cytoband 3p25-26.[15] VHL pathogenic variants occur in all three exons of this gene. Most affected individuals inherit a germline pathogenic variant of VHL from an affected parent and a normal ("wild-type") VHL from their unaffected parent. VHL-associated tumors conform to Knudsons two-hit hypothesis,[16,17] in which the clonal origin or first transformed cell of the tumor occurs only after both VHL alleles in a cell are inactivated. The inherited germline pathogenic variant in VHL represents the first "hit," which is present in every cell in the body. The second hit is a somatic pathogenic variant, one that occurs in a specific tissue at some point after a person's birth. It damages the normal, or wild-type, VHL allele, creating a clonal neoplastic cell of origin, which then proliferates into a tumor mass.

The prevalence of VHL has been estimated to be 1 per 35,000 and 1 per 40,000 persons in the general population.[18,19] Thus, the number of VHL-affected individuals in the United States is estimated at between 6,000 and 7,000. Precise quantification of this number is a challenge because it requires comprehensive screening of potentially at-risk blood relatives of individuals diagnosed with VHL. Within this population, the large number of unique pathogenic variants in this small three-exon gene indicates that most family clusters have not arisen from a single founder. A founder effect was reported when a large U.S. family was compared with a family in Germany, both of whom had pheochromocytoma-predominant VHL.[20]

VHL pathogenic variants are highly penetrant and overall penetrance is greater than 90% by age 65 years.[18] Almost all carriers develop one or more types of syndrome-related neoplasms.

Each offspring of an individual with VHL has a 50% chance of inheriting the VHL pathogenic variant allele from their affected parent. The primary factors affecting the chances of developing VHL are: 1) a relative with VHL; 2) a germline pathogenic variant in the VHL gene; 3) a family member with one of the manifestations of VHL (e.g., CNS hemangioblastomas). (Refer to the Genetic diagnosis section of this summary for more information.)

There are a few highly predictive, direct genotype -phenotype correlations.[21,22]

For example, pheochromocytoma without RCC is the VHL pattern found in a large family with a single nucleotide change at position 505.[14,21,23] A similar family outside the United States was identified and found to have a common ancestor (i.e., a founder pathogenic variant).[23] However, no common ancestor was identified for several other pathogenic variants that occurred in multiple families. In general, founder pathogenic variants do not comprise a significant fraction of all VHL variants. Single nucleotide changes at position 712 and 713 are hot spots for pathogenic variants leading to pheochromocytomas.[23] Pathogenic variant types leading to clinical VHL include missense, nonsense, frameshifts, insertions, partial and complete deletions, and splice-site variants of VHL.

When a VHL diagnosis is made in an individual whose ancestors (biological parents and their kindred) do not have VHL, this may result from a de novo (new) VHL pathogenic variant in the affected individual. Patients diagnosed with VHL, who have no family history of VHL, have been estimated to comprise about 23% of VHL kindreds.[24] A new variant is by definition a postzygotic event, because it is not transmitted from a parent.

Depending on the embryogenesis stage at which the new variant occurs, there may be different somatic cell lineages carrying the variant; this influences the extent of mosaicism. Mosaicism is the presence in an individual of two or more cell lines that differ in genotype but which arise from a single zygote.[25] If the postzygotic de novo variant affects the gonadal cell line, there is a risk of transmitting a germline variant to offspring.[24]

VHL-associated polycythemia (also known as familial erythrocytosis type 2 or Chuvash polycythemia) is a rare, autosomal recessive blood disorder caused by homozygous or pathogenic variants in VHL in which affected individuals develop abnormally high numbers of red blood cells. The affected individuals have biallelic pathogenic variants in the VHL gene. The typical VHL syndromic tumors do not occur in these affected individuals.[26-28]

In sporadic RCC, other genetic lesions have been found. These include PBRM1, SETD2, and BAP1 and may have relevance in RCC arising in VHL patients. Future studies will define their significance in the hereditary patient population.[29]

The VHL gene product, pVHL, is a 213 amino acid protein that regulates hypoxia-inducible factors (HIFs), maintains a normal extracellular matrix, is involved in microtubule and centrosome regulation, and regulates the cell cycle.[30-32] These functions are described in more detail in the following paragraphs.

pVHL regulates protein levels of HIF1-alpha and HIF2-alpha in the cell by acting as an E3 ubiquitin ligase for HIF. In normoxic conditions, HIF1-alpha and HIF2-alpha are enzymatically hydroxylated. The hydroxylated HIF subunits are bound by the VHL protein complex, covalently linked to ubiquitin, and degraded by the S26 proteasome.

Under hypoxic conditions, hydroxylation does not occur; HIF1-alpha and HIF2-alpha are not bound to the VHL protein complex and are not ubiquitinated. The resulting high levels of HIF1-alpha and HIF2-alpha drive increased transcription of a variety of proteins. Loss of functional pVHL creates a pseudohypoxic state, with uncontrolled HIF1-alpha and HIF2-alpha protein levels, and resultant inappropriate transcription of HIF-dependent genes.

HIF1-alpha and HIF2-alpha possess distinct functional characteristics, and a shift towards a HIF2-alphadominant phenotype occurs in RCC. HIF1-alpha and HIF2-alpha may preferentially upregulate Myc activity.[33] Hypoxia activated factor has been shown to increase HIF2-alpha transactivation [34] and HIF1-alpha instability.[35] Preferential loss of chromosome 14q, the locus for the HIF1-alpha gene, results in decreased levels of HIF1-alpha.[36]

Emerging data point to the importance of pVHL-mediated control of the primary cilium and the cilia centrosome cycle. The nonmotile primary cilium acts as a mechanosensor, is a regulator of cell signaling, and controls cellular entry into mitosis.[37] Loss of primary ciliary function results in the loss of the cells ability to maintain planar cell polarity, which results in cyst formation.[38] Loss of pVHL results in loss of the primary cilium.[39] pVHL binds to and stabilizes microtubules [40] in a glycogen synthase 3dependent fashion.[41] Loss of pVHL or expression of variant pVHL in cells also results in unstable astral microtubules, dysregulation of the spindle assembly checkpoint, and an increase in aneuploidy.[32]

pVHL reintroduction induces cell cycle arrest and p27 upregulation after serum withdrawal in VHL null cell lines.[30] Additionally, pVHL destabilizes Skp2, and upregulates p27 in response to DNA damage.[42] Nuclear localization and intensity of p27 is inversely associated with tumor grade.[43] pVHL binds to, stabilizes, and transactivates p53 [44] in a phosphorylation-dependent fashion.[45] The importance of these findings is underscored by the findings that p53 is an important regulator of mitotic checkpoints, and loss of p53 permits aneuploid cells to survive.[46]

Functional pVHL is needed to form an extracellular fibronectin matrix.[47] Additionally, pVHL directly binds to, phosphorylates, and regulates fibronectin.[48] Collagen IV homeostasis is also regulated by pVHL. pVHL isoforms that are collagen IV bindingincompetent demonstrated a malignant phenotype.[31]

No representative VHL animal models are currently available. Vhlh gene knockout in mice did not produce RCC or hemangioblastomas.[49] Murine homologues of the R200W-induced polycythemia in mice, phenocopying Chuvash polycythemia.[50] A R167Q homologue did not generate RCC.[51] Coordinate inactivation of Vhlh and Pten resulted in a higher rate of cyst formation, but, once again, no obvious RCC was observed.[52] The discovery of several new potential tumor suppressor genes inactivated in the context of RCC, including PBRM1,[53] SETD2,[54] and BAP1 [55] provide new avenues for developing relevant animal models of at least some VHL disease manifestations.

The age at onset of VHL varies both from family to family and between members of the same family. This fact informs the guidelines for starting age and frequency of presymptomatic surveillance examinations. The youngest age at onset of specific VHL syndrome components is observed for retinal hemangioblastomas and pheochromocytomas; targeted screening is recommended in children younger than 10 years. At least one study has demonstrated that the incidence of new lesions varies depending on patient age, the underlying pathogenic variant, and the organ involved.[56] Examples of reported mean ages and age ranges of VHL clinical manifestations are summarized in Table 2.

(Refer to the Clinical diagnosis section of this summary for more information.)

Four clinical types of VHL have been described. In 1991, researchers classified VHL as type 1 (without pheochromocytoma) and type 2 (with pheochromocytoma).[19] In 1995, VHL type 2 was further subdivided into type 2A (with pheochromocytoma, but without RCC) and type 2B (with pheochromocytoma and RCC).[20] More recently, it was reported that VHL type 2C comprises patients with isolated pheochromocytoma without hemangioblastoma or RCC.[57] These specific VHL phenotypes are summarized below.

More than 55% of VHL-affected individuals develop only multiple renal cell cysts. The VHL-associated RCCs that occur are characteristically multifocal and bilateral and present as a combined cystic and solid mass.[58] Among individuals with VHL, the cumulative RCC risk has been reported as 24% to 45% overall. RCCs smaller than 3 cm in this disease tend to be low grade (Fuhrman nuclear grade 2 or 4) and minimally invasive,[59] and their rate of growth varies widely.[60] An investigation of 228 renal lesions in 28 patients who were followed up for at least 1 year showed that transition from a cyst to a solid lesion was rare.[58] Complex cystic and solid lesions contained neoplastic tissue that uniformly enlarged. These data may be used to help predict the progression of renal lesions in VHL. Figure 1 depicts bilateral renal tumors in a patient with VHL.

Enlarge

Figure 1. von Hippel-Lindau syndromeassociated renal cell cancers are characteristically multifocal and bilateral and present as a combined cystic and solid mass. Red arrow indicates a lesion with a solid and cystic component, and white arrow indicates a predominantly solid lesion.

Tumors larger than 3 cm may increase in grade as they grow, and metastasis may occur.[60,61] RCCs often remain asymptomatic for long intervals.

Patients can also develop pancreatic cysts, cystadenomas, and pancreatic NETs.[2] Pancreatic cysts and cystadenomas are not malignant, but pancreatic NETs possess malignant characteristics and are typically resected if they are 3 cm or larger (2 cm if located in the head of the pancreas).[62] A review of the natural history of pancreatic NETs shows that these tumors may demonstrate nonlinear growth characteristics.[63]

Retinal manifestations, first reported more than a century ago, were one of the first recognized aspects of VHL. Retinal hemangioblastomas (also known as capillary retinal angiomas) are one of the most frequent manifestations of VHL and are present in more than 50% of patients.[64] Retinal involvement is one of the earliest manifestations of VHL, with a mean age at onset of 35.9 years.[65] These tumors are the first manifestation of VHL in nearly 80% of affected individuals and may occur in children younger than 10 years.[65,66]

Retinal hemangioblastomas occur most frequently in the periphery of the retina but can occur in other locations such as the optic nerve, a location much more difficult to treat. Retinal hemangioblastomas appear as a bright orange spherical tumor supplied by a tortuous vascular supply. Nearly 50% of patients have bilateral retinal hemangioblastomas.[64] The median number of lesions per affected eye is approximately six.[67] Other retinal lesions in VHL can include retinal vascular hamartomas, flat vascular tumors located in the superficial aspect of the retina.[68]

Longitudinal studies are important for the understanding of the natural history of these tumors. Left untreated, retinal hemangioblastomas can be a major source of morbidity in VHL, with approximately 8% of patients [64] having blindness caused by various mechanisms, including secondary maculopathy, contributing to retinal detachment, or possibly directly causing retinal neurodegeneration.[69] Patients with symptomatic lesions generally have larger and more numerous retinal hemangioblastomas. Long-term follow-up studies demonstrate that most lesions grow slowly and that new lesions do not develop frequently.[67,70]

Hemangioblastomas are the most common disease manifestation in patients with VHL, potentially affecting more than 70% of individuals. A prospective study assessed the natural history of hemangioblastomas.[71] After a mean follow-up of 7 years, 75% of the 225 patients studied developed new lesions. Fifty-one percent of existing hemangioblastomas remained stable. The remaining lesions exhibited heterogeneous growth rates, with cerebellar and brainstem lesions growing faster than those in the spinal cord or cauda equina. Approximately 12% of hemangioblastomas developed either peritumoral or intratumoral cysts, and 6.4% were symptomatic and required treatment. Increased tumor burden or total tumor number detected was associated with male sex, longer follow-up, and genotype (all P < .01). Partial germline deletions were associated with more tumors per patient than were missense variants (P < .01). Younger patients developed more tumors per year. Hemangioblastoma growth rate was higher in men than in women (P < .01). Figures 2 and 3 depict cerebellar and spinal hemangioblastomas, respectively, in patients with VHL.

Enlarge

Figure 2. Hemangioblastomas are the most common disease manifestation in patients with von Hippel-Lindau syndrome. The left panel shows a sagittal view of brainstem and cerebellar lesions. The middle panel shows an axial view of a brainstem lesion. The right panel shows a cerebellar lesion (red arrow) with a dominant cystic component (white arrow).

Enlarge

Figure 3. Hemangioblastomas are the most common disease manifestation in patients with von Hippel-Lindau syndrome. Multiple spinal cord hemangioblastomas are shown.

The rate of pheochromocytoma formation in the VHL patient population is 25% to 30%,[72,73] with bilaterality occurring in some patients. Of patients with VHL pheochromocytomas, 44% developed disease in both adrenal glands.[74] One study reported a mean age at onset for pheochromocytoma in VHL patients of 30 years.[2] Rate of malignant transformation is very low. Levels of plasma and urine normetanephrine are typically elevated in patients with VHL disease,[75] and approximately two-thirds will experience physical manifestations.[72] Missense VHL gene pathogenic variants correlated with the risk of pheochromocytoma in patients with VHL,[72] with a low incidence of pheochromocytoma in patients with complete deletion of the VHL gene. The rate of VHL germline pathogenic variants in nonsyndromic pheochromocytomas and paragangliomas was very low in a cohort of 182 patients, with only 1 of 182 patients ultimately diagnosed with VHL disease.[76]

Paragangliomas are rare in VHL patients but can occur in the head and neck or abdomen.[77] A review of VHL patients who developed pheochromocytomas and/or paragangliomas revealed that 90% of patients manifested pheochromocytomas and 19% presented with a paraganglioma.[74]

The mean age at diagnosis of VHL-related pheochromocytomas and paragangliomas is approximately 30 years,[73,78] and patients with multiple tumors were diagnosed more than a decade earlier than patients with solitary lesions in one series (19 vs. 34 years; P < .001).[78] Diagnosis of pheochromocytoma was made in patients as young as 5 years in one cohort,[73] providing a rationale for early testing. All 21 pediatric patients with pheochromocytomas in this 273-patient cohort had elevated plasma normetanephrines.[73]

ELSTs are adenomatous tumors arising from the endolymphatic duct or sac within the posterior part of the petrous bone.[79] ELSTs are rare in the sporadic setting, but are apparent on imaging in 11% to 16% of patients with VHL. Although these tumors do not metastasize, they are locally invasive, eroding through the petrous bone and the inner ear structures.[79,80] Approximately 30% of VHL patients with ELSTs have bilateral lesions.[79,81]

ELSTs are an important cause of morbidity in VHL patients. ELSTs evident on imaging are associated with a variety of symptoms, including hearing loss (95% of patients), tinnitus (92%), vestibular symptoms (such as vertigo or disequilibrium) (62%), aural fullness (29%), and facial paresis (8%).[79,80] In approximately half of patients, symptoms (particularly hearing loss) can occur suddenly, probably as a result of acute intralabyrinthine hemorrhage.[80] Hearing loss or vestibular dysfunction in VHL patients can also present in the absence of radiologically evident ELSTs (approximately 60% of all symptomatic patients) and is believed to be a consequence of microscopic ELSTs.[79]

Hearing loss related to ELSTs is typically irreversible; serial imaging to enable early detection of ELSTs in asymptomatic patients and resection of radiologically evident lesions are important components in the management of VHL patients.[82,83] Surgical resection by retrolabyrinthine posterior petrosectomy is usually curative and can prevent onset or worsening of hearing loss and improve vestibular symptoms.[80,82]

Tumors of the broad ligament can occur in females with VHL and are known as papillary cystadenomas. These tumors are extremely rare, and fewer than 20 have been reported in the literature.[84] Papillary cystadenomas are histologically identical to epididymal cystadenomas commonly observed in males with VHL.[85] One important difference is that papillary cystadenomas are almost exclusively observed in patients with VHL, whereas epididymal cystadenomas in men can occur sporadically.[86] Therefore, any female with a broad ligament papillary cystadenoma should be referred for genetic counseling. These tumors are frequently cystic, and although they become large, they generally have a fairly indolent behavior.

More than one-third of all cases of epididymal cystadenomas reported in the literature and most cases of bilateral cystadenomas have been reported in patients with VHL disease.[87] Among symptomatic patients, the most common presentation is a painless, slow-growing scrotal swelling. The differential diagnoses of epididymal tumors include adenomatoid tumor (which is the most common tumor in this site), metastatic ccRCC, and papillary mesothelioma.[88]

One group of investigators observed that epididymal tumorigenesis in VHL disease occurred in two distinct sequential steps: maldevelopment of VHL-deficient mesonephric cells caused by developmental arrest of progenitor cells, followed by neoplastic papillary proliferation with activation/up-regulation of HIF and VEGF, associated with continuous reactive fibrovascular proliferation.[89] In a small series, histological analysis did not reveal features typically associated with malignancy, such as mitotic figures, nuclear pleomorphism, and necrosis. Lesions were strongly positive for CK7 and negative for RCC. CAIX was positive in all tumors. PAX8 was positive in most cases. These features were reminiscent of clear cell papillary RCC, a relatively benign form of RCC without known metastatic potential.[85]

The primary risk factor for VHL (or any of the hereditary forms of renal cancer under consideration) is the presence of a family member affected with the disease. Risk assessment should also consider gender and age for some specific VHL-related neoplasms. For example, pheochromocytomas may have onset in early childhood,[1] as early as 8 years of age.[90] Gender-specific VHL clinical findings include epididymal cystadenoma in males (10%26%), which are virtually pathognomonic for VHL, especially when bilateral, and are rare in the general male population. Epididymal cysts are also common in VHL, but they are reported in 23% of the general male population, making them a poor diagnostic discriminator.[1] Females have histologically similar lesions to cystadenomas that occur in the broad ligament.[1]

Each offspring of an individual with VHL has a 50% chance of inheriting the VHL variant allele from their affected parent. Diagnosis of VHL is frequently based on clinical criteria. If there is family history of VHL, then a patient with one or more specific VHL-type tumors (e.g., hemangioblastoma of the CNS or retina, pheochromocytoma, or ccRCC) may be diagnosed with VHL.

At-risk family members should be informed that genetic testing for VHL is available. A family member with a clinical diagnosis of VHL or who is showing signs and symptoms of VHL is initially offered genetic testing. Germline pathogenic variants in VHL are detected in more than 99% of families affected by VHL. Sequence analysis of all three exons detect point variants in the VHL gene (~72% of all pathogenic variants).[91] Using Southern blot analysis and/or quantitative polymerase chain reaction to detect partial or complete gene deletions will detect pathogenic variants in the remaining 28% of VHL families.[91,92] The technique has a detection rate approaching 100%.[91] Newer techniques such as array comparative genomic hybridization (array CGH) are powerful tools for identifying genomic imbalances. Anecdotal evidence exists for the utility of next-generation sequencing in cases of suspected mosaicism with a negative VHL genetic test.[93]

Genetic counseling is first provided, including discussion of the medical, economic, and psychosocial implications for the patient and their bloodline relatives. After counseling, the patient may choose to voluntarily undergo testing, after providing informed consent. Additional counseling is given at the time results are reported to the patient. When a VHL pathogenic variant is identified in a family member, their biologic relatives who then test negative for the same pathogenic variant are not carriers of the trait (i.e., they are true negatives) and are not predisposed to developing any VHL manifestations. Equally important, the children of true-negative family members are not as risk of VHL either. Clinical testing throughout their lifetime is therefore unnecessary.[13]

A germline pathogenic variant in the VHL gene is considered a genetic diagnosis. It is expected to carry a predisposition to clinical VHL and confers a 50% risk among offspring to inherit the VHL pathogenic variant. Approximately 400 unique pathogenic variants in the VHL gene have been associated with clinical VHL, and their presence verifies the disease-causing capability of the variant. The diagnostic genetic evaluation in a previously untested family generally begins with a clinically diagnosed individual. If a VHL pathogenic variant is identified, that specific pathogenic variant becomes the DNA marker for which other biological relatives may be tested. In cases where there is a clear VHL clinical diagnosis without a VHL pathogenic variant by usual testing of peripheral blood lymphocytes and without a history of VHL in the biological parents or in the parents kindreds, then either a de novo pathogenic variant or mosaicism may be the cause. The latter may be detected by performing genetic testing on other bodily tissues, such as skin fibroblasts or exfoliated buccal cells.

Diagnosis of VHL is frequently based on clinical criteria (see Table 4). If there is family history of VHL, then a previously unevaluated family member may be diagnosed clinically if they present with one or more specific VHL-related tumors (e.g., CNS or retinal hemangioblastoma, pheochromocytoma, ccRCC, or endolymphatic sac tumor). If there is no family history of VHL, then a clinical diagnosis requires that the patient have two or more CNS hemangioblastomas or one CNS hemangioblastoma and a visceral tumor or endolymphatic sac tumor. See Table 4 for more diagnostic details.[2,13,14]

Since 1998, when a cohort of 93 VHL families in whom all germline pathogenic variants were identified was reported, diagnoses have included a combined approach of clinical and genetic testing within families. The diagnostic strategy differs among individual family members. Table 4 summarizes a combined approach of genetic testing and clinical diagnosis.

Surveillance guidelines that have been suggested for various manifestations of VHL are summarized in Table 5. In general, these recommendations are based on expert opinion and consensus; most are not evidence-based. These modalities may be used for the initial clinical diagnostic testing and also for periodic surveillance of at-risk individuals for early detection of developing neoplasm. Periodic presymptomatic screening is advised for at-risk individuals. At-risk individuals are those testing positive for a VHL pathogenic variant and those individuals who choose not to be tested for a VHL pathogenic variant but have biologic relatives affected by VHL. The risk of inheriting the VHL predisposition in such persons may be as high as 50%.

Level of evidence: 5

The management of VHL has changed significantly as clinicians have learned how to best balance the risk of cancer dissemination while minimizing renal morbidity. Some of the initial surgical series focused on performing a bilateral radical nephrectomy for renal tumors followed by a renal transplantation.[94,95] Nephron-sparing surgery (NSS) for VHL was introduced in the 1980s after several groups demonstrated a low risk of cancer dissemination with a less-radical surgical approach.[96,97] In 1995, a large, multi-institutional series demonstrated how NSS could produce excellent cancer-specific survival in patients with RCC.[98] Because of multiple reports of excellent outcomes, when feasible, NSS is now considered the surgical standard of care. Over time, the technique of NSS in this population has been refined to minimize damage to the adjacent normal parenchyma. To avoid the taking of a wide margin, enucleative resection was developed and allows the tumor and pseudocapsule to be shelled off the surrounding adjacent normal parenchyma.[99]

Patients with VHL can have dozens of renal tumors; therefore, resection of all evidence of disease may not be feasible. To minimize the morbidity of multiple surgical procedures, loss of kidney function, and the risk of distant progression, a specific timing for intervention was questioned. The National Cancer Institute evaluated a specific size threshold to trigger surgical intervention. An evaluation of 52 patients treated before the largest lesion reached 3 cm demonstrated no evidence of distant metastases or need for renal replacement therapy at a median follow-up of 60 months.[60] Later series reinforced that this was an important threshold because 0 of 108 patients with tumors managed at 3 cm or smaller had evidence of distant spread.[100] For patients with tumors larger than 3 cm, a total of 27.3% (20 of 73) developed distant recurrence.[100] This threshold is now widely used to trigger surgical intervention for VHL-associated ccRCC. When surgery is performed on a patient with VHL, resection of more than a dozen renal tumors may be necessary.[101] The use of intraoperative ultrasound to identify and then remove smaller lesions may delay the need for further surgical interventions.[102]

Many patients with VHL develop new RCCs on an ongoing basis and may require further intervention. Adhesions and perinephric scarring make subsequent surgical procedures more challenging. While a radical nephrectomy could be considered, NSS is still the preferred approach, when feasible. While there may be a higher incidence of complications, repeat and salvage NSS can enable patients to maintain excellent renal functional outcomes and provide promising oncologic outcomes at intermediate follow-up.[103,104] These surgeries may be best handled at a specialized center with significant experience with this surgical approach.[105]

Level of evidence: 3di

Thermal ablative techniques utilize either heating or cooling of a mass in an effort to destroy the tumor. Cryoablation (CA) and radiofrequency ablation (RFA) were introduced into the management of small renal masses in the late 1990s.[106,107] For sporadic renal masses, both thermal ablative techniques have a nearly 90% recurrence-free survival rate, leading the American Urologic Association to consider this as a recommendation in high-risk patients with a small renal mass.[108] For patients with VHL, the clinical applications of ablative techniques are still not clearly defined, and surgery is still the most-studied intervention. Ablative techniques were first introduced into the management of VHL-associated RCC in a phase II trial investigating the effects of ablation at the time of lesion resection. In this study, 11 tumors were treated, and an intra-operative ultrasound showed complete elimination of blood flow to the tumors; on final pathology, there was evidence of treatment effect on all tumors.[109] Since this time, some centers have utilized thermal ablative techniques for primary and salvage management in patients with VHL with good success.[110] Other centers have found that techniques such as RFA have a higher failure rate and should be reserved for patients with marginal renal function.[111] Despite limited long-term data, these techniques have been increasingly utilized in the treatment of RCC in patients with VHL. A single-institution study evaluated treatment trends in RCC in 113 patients with VHL. Between 2004 and 2009, 43% of cases were managed with RFA at this center.[112]

Thermal ablation may play an increasing role in the salvage therapy setting for individuals with a high risk of morbidity from surgery. Cryoablation as salvage therapy was evaluated in a series of 14 patients to avoid the morbidity of repeat NSS. There was minimal change in renal function; at a median follow-up of 37 months, there was suspicion for lesion recurrence in only 4 of 33 tumors treated.[113] However, it must be cautioned that surgery after thermal ablation is a very challenging endeavor, with a significantly higher rate of postoperative complications due to adhesions and scarring, especially along the tract of the ablative probes.[114-116] In younger individuals who may need further surgical management in their lifetimes, clinicians must consider how a thermal ablation could impact future RCC management.[105,117]

The clinical applications of ablative techniques in VHL are still not clearly defined, and surgery is still the most-studied intervention. The available clinical evidence suggests that ablative approaches be reserved for small (3 cm), solid-enhancing renal masses in older patients with high operative risk, especially in patients facing salvage renal surgery because of a higher complication rate. Young age, tumor size larger than 4 cm, hilar tumors, and cystic lesions can be regarded as relative contraindications. Irreversible coagulopathy is widely accepted as an absolute contraindication.[118,119]

Level of evidence: 3di

A 2011 study prospectively evaluated the safety and efficacy of sunitinib in VHL patients.[120] Fifteen patients with VHL were given 50 mg of sunitinib daily for 28 days, followed by 14 days off for up to four cycles, with a primary endpoint of toxicity. Grade 3 toxicity included fatigue in five patients (33%); dose reductions were made in ten patients (75%). A significant response was observed in RCC but not in hemangioblastoma. Eighteen RCCs and 21 hemangioblastoma lesions were evaluable. Of these, six RCCs (33%) responded partially, versus none of the hemangioblastomas (P=.014). The expression of pFRS2 in hemangioblastoma tissue was also observed to be higher than in RCC, thus raising the hypothesis that treatment with fibroblast growth factor pathway-blocking agents may benefit patients with hemangioblastoma.[120] A retrospective study of 14 patients with VHL, 10 of whom had metastatic disease, demonstrated significant response in metastatic and primary RCC lesions. Eleven patients had cerebellar hemangioblastomas, and eight had spinal hemangioblastomas. No response was seen in hemangioblastomas.[121]

Case series and individual case reports have been published on an oral antiangiogenic agent, SU5416, in patients with VHL.[122-124] Modest improvement was observed in patients with retinal hemangioblastomas.[122,123] In a series of six VHL patients treated with SU5416, stabilization in CNS hemangioblastomas was observed in two patients.[124] A study of intravitreally administered antivascular endothelial growth factor therapy for a patient with retinal hemangioma yielded mixed results.[125] SU5416 is not licensed for human use.

Level of evidence: 2

Two studies suggest that pregnancy is associated with hemangioblastoma progression in patients with VHL.[126,127] One study retrospectively examined the records of 29 patients with VHL from the Netherlands who became pregnant 48 times (49 newborns) between 1966 and 2010 (40% became pregnant before 1990); imaging records were available for 31% of the pregnancies. Researchers reported that 17% of all pregnancies had VHL-related complications, including three patients who had craniospinal hemangioblastoma that significantly (P = .049) changed in progression score before and after pregnancy.[126] This study's findings are in contrast with a small, prospective investigation.[127] Until a large-scale, international, prospective investigation is conducted, all investigations suggest using a conservative approach that includes medical surveillance during pregnancy.

Morbidity and mortality in VHL vary and are influenced by the individual and the familys VHL phenotype (e.g., Type 1, 2A, 2B, or 2C). (Refer to the VHL familial phenotypes section of this summary for more information.)

In the past, metastatic RCC has caused about one-third of deaths in patients with VHL, and in some reports, it was the leading cause of death.[90,128-130] With increased surveillance of pathogenic variantpositive individuals, the RCC mortality rate is thought to have diminished.

Hemangioblastomas of the CNS, although histologically benign, are a major cause of morbidity and arise anywhere along the craniospinal axis, including the brainstem.[2] Pancreatic NETs, formerly called pancreatic islet cell tumors, in some cases, may grow rapidly and metastasize to liver and bone.[128,131] Hearing and vision may also be decreased or lost as a result of VHL tumors. Periodic screening allows early detection and may prevent advanced disease.

Currently, the renal manifestations of VHL are still generally managed surgically or with thermal ablation. There is a clear unmet need for better management strategies. These will include defining the molecular biology and genetics of kidney cancer development, which may result in the development of effective prevention or early intervention therapies. In addition, the evolving understanding of the molecular biology of established kidney cancers may provide opportunities to phenotypically normalize the cancer by modulating residual VHL function, identifying new targets, or discovering synthetic lethal strategies that can effectively eradicate RCC.

Hereditary leiomyomatosis and renal cell cancer (HLRCC) (OMIM) is characterized by the presence of one or more of the following: cutaneous leiomyomas (or leiomyomata), uterine leiomyomas (fibroids) in females, and RCC. Germline pathogenic variants in the fumarate hydratase (FH) gene are responsible for the susceptibility to HLRCC. FH encodes fumarate hydratase, the enzyme that catalyzes the conversion of fumarate to malate in the tricarboxylic acid cycle (Krebs cycle).

Historically, the predisposition to the development of cutaneous leiomyomas was referred to as multiple cutaneous leiomyomatosis. In 1973, two kindreds were described in which multiple members over three generations exhibited cutaneous leiomyomas and uterine leiomyomas and/or leiomyosarcomas inherited in an autosomal dominant pattern.[132] That report also described a woman aged 20 years with uterine leiomyosarcoma and metastatic RCC. Subsequently, the association of cutaneous and uterine leiomyomas became known as Reed syndrome. However, the clear association of cutaneous leiomyomas and RCC was not described until 2001, when a study reported two Finnish families in whom cutaneous and uterine leiomyomas and papillary type 2 RCC co-segregated.[3] The name hereditary leiomyomatosis and renal cell cancer was then assigned. The term HLRCC is preferred because it is impossible to distinguish between individuals with cutaneous leiomyomas who do or do not have an increased risk of renal cancer.

The FH gene consists of ten exons encompassing 22.15 kb of DNA. The gene is highly conserved across species. The human FH gene is located on chromosome 1q42.3-43.

HLRCC is an autosomal dominant syndrome; a single variant FH allele is sufficient to cause the disease.[133] Inherited biallelic pathogenic variants cause fumarate hydratase deficiency (FHD), a disorder characterized by rapidly progressive neonatal neurologic impairment including hypotonia, seizures, and cerebral atrophy. (Refer to the Genetically related disorders section of this summary for more information.)

Germline pathogenic variants in FH, plus somatic variants and loss of heterozygosity (LOH) in RCC, suggest that loss of function in the fumarate hydratase protein is the basis of tumor formation in HLRCC and, further, that FH functions as a tumor suppressor gene.[3,134]

Various pathogenic variants in FH have been identified in families with HLRCC. Most are missense pathogenic variants, but nonsense, frameshift, and splice-site variants have been described.[5,6,134,135] Recently, whole-gene or partial deletions have been identified.

The prevalence of HLRCC is unknown. It is estimated that more than 100 families with HLRCC have been seen at the National Institutes of Health, but it is likely that HLRCC remains an underrecognized entity (R. Srinivasan, MD, PhD, oral communication, April 2014).

Considering the three major clinical manifestations combined, the penetrance of HLRCC is considered to be very high. However, the estimated cumulative incidence of RCC varies widely, from between 2% and 7% to 15%, and perhaps as high as 32%, in families with germline FH pathogenic variants, depending on ascertainment method and the imaging modalities used.[3-6,136]

No genotype-phenotype correlations have been described. Thus, no correlation has been observed between specific FH variants and the occurrence of cutaneous lesions, uterine leiomyomas, or RCC in HLRCC.[6]

Although smaller studies have suggested the presence of different variant spectra in FHD and HLRCC,[5,134] a study that included a larger cohort of patients indicated that the variant distribution is fairly similar in these two entities.[133] The predisposition to HLRCC versus FHD likely results from a difference in gene dosage, rather than the location of the FH variant as originally suggested.[134]

Between 80% and 100% of individuals with HLRCC have identifiable, deleterious sequence alterations in FH.[5,6,137]

FHD, resulting from the inheritance of biallelic pathogenic variants in FH, is an autosomal recessive inborn error of metabolism characterized by rapidly progressive neurologic impairment including hypotonia, seizures, and cerebral atrophy. Homozygous or compound heterozygous germline pathogenic variants in FH are found in individuals with FHD.[138,139] To date, RCC has not been reported in FHD-affected individuals. Most individuals with FHD survive only a few months; very few survive to early adulthood.[140] However, a parent (heterozygous carrier) of an individual with FHD developed cutaneous leiomyomas similar to those observed in HLRCC.[134]

LOH around the FH locus has been identified in two early-onset sporadic uterine leiomyomas and a soft tissue sarcoma of the lower limb without other associated tumor characteristics of the heritable disease.[141,142] All three tumors displayed biallelic inactivation of FH. In sporadic forms of kidney cancer, there have been no somatic pathogenic variants identified in FH to date.[141]

The mechanisms by which alterations in FH lead to HLRCC are still being elucidated. Biallelic inactivation of FH has been shown to result in loss of oxidative phosphorylation and reliance on aerobic glycolysis to meet cellular energy requirements. Blockage of the Krebs cycle at FH results in increased levels of intracellular fumarate, inhibiting HIF prolyl hydroxylases. Inactivating variants of FH also appear to result in the generation of reactive oxygen species, further contributing to the stabilization of HIF.[143] This upregulation of the HIF pathway leads to a pseudohypoxic state and upregulation of a transcriptional program contributing to aggressive tumor biology.[144] Others have demonstrated upregulation of the antioxidant response pathway due to posttranslational modification of KEAP1. The resultant NRF-2 dysregulation leads to upregulation of antioxidant response elementcontrolled genes such as aldo-keto reductase family 1 member, B10 (AKR1B10), possibly contributing to the neoplastic process.[145]

The clinical characteristics of HLRCC include cutaneous leiomyomas, uterine leiomyomas (fibroids), and RCC. Affected individuals may have multiple cutaneous leiomyomas, a single skin leiomyoma, or no cutaneous lesion; an RCC that is typically solitary, or no renal tumors; and/or uterine leiomyomas. Disease severity shows significant intrafamilial and interfamilial variation.[3,5,6]

Cutaneous leiomyomas present as firm pink or reddish-brown papules and nodules distributed over the trunk and extremities and, occasionally, on the face. These lesions occur at a mean age of 25 years (age range, 1047 years) and tend to increase in size and number with age. Lesions are sensitive to light touch and/or cold temperature and are, less commonly, painful. Pain is correlated with severity of cutaneous involvement.[5] The presence of multiple cutaneous leiomyomas is associated with HLRCC until proven otherwise and should prompt a genetic workup; a solitary leiomyoma requires careful analysis of family history. (Refer to the Clinical diagnosis and Differential diagnosis sections below for more information.)

The onset of uterine leiomyomas in women with HLRCC occurs at a younger age than in women in the general population. The age at diagnosis ranges from 18 to 52 years (mean age, 30 years). Uterine leiomyomas are usually large and numerous. Most women experience symptoms including irregular or heavy menstruation and pelvic pain, thus requiring treatment at a younger age than females with leiomyomas in the general population. Women with HLRCC and uterine leiomyomas undergo hysterectomy or myomectomy for symptomatic uterine leiomyomas at a younger age (<30 years) than do women in the general population (median age, 45 years).[5,137,146,147]

The symptoms of RCC may include hematuria, lower back pain, and a palpable mass. However, a large number of individuals with RCC are asymptomatic. Furthermore, not all individuals with HLRCC present with or develop RCC. Most RCCs are unilateral and solitary; in a few individuals, they are multifocal. Approximately 10% to 32% of individuals with HLRCC who presented with multiple cutaneous leiomyomas had RCC at the time that renal imaging was performed.[5,137] The median age at detection of RCC was 37 years,[148] although some cases have been reported to occur as early as age 10 years.[149] In contrast to other hereditary renal cancer syndromes, RCCs associated with HLRCC are aggressive,[150,151] with Fuhrman nuclear grade 3 or 4 in many cases and 9 of 13 individuals dying from metastatic disease within 5 years of diagnosis.[5] Figure 4 depicts RCCs in a patient with HLRCC.

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Eye Specialists of Mid-Florida, P.A.

Education:

Bachelor of Science

Ashland College Ashland, OH 1970

Doctor of Medicine

University of Florida Gainesville, FL 1976

Doctor of Philosophy (Biochemistry)

University of Florida Gainesville, FL 1976

Internship

University of Florida Gainesville, FL 6/76 6/77

Ophthalmology Residency

University of Florida

Gainesville, FL 6/77 6/80

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Organizational Behavior and Human Decision Processes …

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Test the joint effects of subconscious and conscious goals during skill acquisition.

Subconscious achievement goals increase time devoted to skill acquisition.

Subconscious achievement goals increase task performance.

Subconscious underachievement goals cause individuals to abandon goal pursuit.

Difficult conscious goals moderate these effects.

A hierarchical information structure (HIS) organizes information by categories.

A flat information structure (FIS) is an information set without categories.

Scholars have advocated HIS due to its efficiency benefits.

For creativity, HIS is detrimental because it reduces cognitive flexibility.

FIS increases creativity because it enhances flexible uses of information.

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Human behavior – Wikipedia

Human behavior refers to the array of every physical action and observable emotion associated with individuals, as well as the human race as a whole. While specific traits of one's personality and temperament may be more consistent, other behaviors will change as one moves from birth through adulthood. In addition to being dictated by age and genetics, behavior, driven in part by thoughts and feelings, is an insight into individual psyche, revealing among other things attitudes and values. Social behavior, a subset of human behavior, study the considerable influence of social interaction and culture. Additional influences include ethics, encircling, authority, rapport, hypnosis, persuasion and coercion.

The behavior of humans (and other organisms or even mechanisms) falls within a range with some behavior being common, some unusual, some acceptable, and some outside acceptable limits. In sociology, behavior in general includes actions having no meaning, being not directed at other people, and thus all basic human actions. Behavior in this general sense should not be mistaken with social behavior, which is a more advanced social action, specifically directed at other people. The acceptability of behavior depends heavily upon social norms and is regulated by various means of social control. Human behavior is studied by the specialized academic disciplines of psychiatry, psychology, social work, sociology, economics, and anthropology.

Human behavior is experienced throughout an individuals entire lifetime. It includes the way they act based on different factors such as genetics, social norms, core faith, and attitude. Behavior is impacted by certain traits each individual has. The traits vary from person to person and can produce different actions or behavior from each person. Social norms also impact behavior. Due to the inherently conformist nature of human society in general, humans are pressured into following certain rules and displaying certain behaviors in society, which conditions the way people behave. Different behaviors are deemed to be either acceptable or unacceptable in different societies and cultures. Core faith can be perceived through the religion and philosophy of that individual. It shapes the way a person thinks and this in turn results in different human behaviors. Attitude can be defined as "the degree to which the person has a favorable or unfavorable evaluation of the behavior in question."[1] One's attitude is essentially a reflection of the behavior he or she will portray in specific situations. Thus, human behavior is greatly influenced by the attitudes we use on a daily basis.

Long before Charles Darwin published his book On the Origin of Species in 1859, animal breeders knew that patterns of behavior are somehow influenced by inheritance from parents. Studies of identical twins as compared to less closely related human beings, and of children brought up in adoptive homes, have helped scientists understand the influence of genetics on human behavior. The study of human behavioral genetics is still developing steadily with new methods such as genome-wide association studies.[2]

Social norms, the often-unspoken rules of a group, shape not just our behaviors but also our attitudes. An individuals behavior varies depending on the group(s) they are a part of, a characteristic of society that allows to norms heavily impact society. Without social norms, human society would not function as it currently does; humans would have to be more abstract in their behavior, as there would not be a pre-tested 'normal' standardized lifestyle, and individuals would have to make many more choices for themselves. The institutionalization of norms is, however, inherent in human society perhaps as a direct result of the desire to be accepted by others, which leads humans to manipulate their own behavior in order to 'fit in' with others. Depending on their nature and upon one's perspective, norms can impact different sections of society both positively (e.g. eating, dressing warm in the winter) and negatively (e.g. racism, drug use).

Creativity is assumed to be present within every individual.[3] Without creative minds, we would not live in a modern world like today. Creativity pushes people past their comfort zone. For example, the Wright Brothers' invention of the first practical fixed-wing aircraft. The aircraft first took flight in 1903, and fifty years later the first passenger jet airliner was introduced. Creativity is what defines human beings. Creativity has kept people alive during harsh conditions, and it has also made certain individuals wealthy. We use creativity in our daily lives as well, such as finding a shortcut to a destination.

Another important aspect of human behavior is their core faith. This faith can be manifested in the forms of religion, philosophy, culture, and/or personal belief and often affects the way a person can behave. 80% of the United States public claims some sort of belief in a higher power, which makes religion a large importance in society.[4] It is only natural for something that plays such a large role in society to have an effect on human behavior.[5]Morals are another factor of core faith that affects the way a person behaves. Emotions connected to morals including shame, pride, and discomfort and these can change the way a person acts. Most importantly, shame and guilt have a large impact on behavior.[6] Lastly, culture highly affects human behavior. The beliefs of certain cultures are taught to children from such a young age that they are greatly affected as they grow up. These beliefs are taken into consideration throughout daily life, which leads to people from different cultures acting differently. These differences are able to alter the way different cultures and areas of the world interact and act.[7]

An attitude is an expression of favor or disfavor toward a person, place, thing, or event.[8] The interesting thing about an attitude and human beings is that it alters between each individual. Everyone has a different attitude towards different things. A main factor that determines attitude is likes and dislikes. The more one likes something or someone the more one is willing to open up and accept what they have to offer. When one doesnt like something, one is more likely to get defensive and shut down. An example of how one's attitude affects one's human behavior could be as simple as taking a child to the park or to the doctor. Children know they have fun at the park so their attitude becomes willing and positive, but when a doctor is mentioned, they shut down and become upset with the thought of pain. Attitudes can sculpt personalities and the way people view who we are. People with similar attitudes tend to stick together as interests and hobbies are common. This does not mean that people with different attitudes do not interact, the fact is they do. What it means is that specific attitudes can bring people together (e.g., religious groups). Attitudes have a lot to do with the mind which highly relates to human behavior. The way a human behaves depends a lot on how they look at the situation and what they expect to gain from it.[9] Positive attitudes are better than negative ones as negativity can bring on negative emotions that most of the time can be avoided. It is up to humans to make sure their attitudes positively reflect the behaviors they want to show. This can be done by assessing their attitudes and properly presenting them in society.

Different Types of Behaviors

There are, in fact, 5 main types of human behavior. In the article My PTSD, it mentions these 5 types of human behavior: passive, aggressive, assertive, passive-aggressive, and the alternator.[10] According to Oxford Dictionaries, to be passive is Accepting or allowing what happens or what others do, without active response or resistance: the women were portrayed as passive victims.[11] For example, a person who cant say no to anybody, are being passive.In My PTSD, also describes a person being passive as a doormat and that a passive person fears being rejected or failing others.[12] Like a person trying to fit in with the cool kids. The person does anything and everything, so long as they accept them as their own, or at least make it seem like it. To be aggressive, is to feel powerful. A person who shows passive behavior insists to have control on others. In actuality, a passive person feels helpless, fearful, and abused (My PTSD).[13] Its almost reverse psychology. My PTSD describes passive-aggressive style as all about harboring and bottling your emotions, the person is usually full of anger, yet will mask it with a smile, then when your back is turned, somehow find a way to insult you or create concern for you, without directly being able to be identified and held accountable.[14] An alternator is someone who constantly alternates between aggression and passiveness. The difference between passive-aggressive and alternator, is when passive and aggression is used. Alternator, is self-explanatory, the person alternates the between the two. Passive-aggression is when both are done in the same time. Assertiveness is none of the above. The article Assertiveness- An Introduction, puts it as standing up for your personal rights - expressing thoughts, feelings and beliefs in direct, honest and appropriate ways.[15] Its about sticking up for yourself. A key point is assertive people always respect the thoughts, feelings and beliefs of other people as well as their own (Assertiveness).[16] If you are not respectful of others opinions, then you are considered an aggressive person.

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Human behavior - Wikipedia

Department of Cell Biology

Inhibitory synapses act as the brakes in the brain, preventing it from becoming overexcited. Researchers thought they were less sophisticated than their excitatory counterparts because relatively few proteins were known to exist at these structures. But a new study by the Soderling Lab, published Sept. 9 in Science, overturns that assumption, uncovering 140 proteins that have never been mapped to inhibitory synapses. Its like these proteins were locked away in a safe for over 50 years, and we believe that our study has cracked open the safe, said the studys senior investigator Scott Soderling, an Associate Professor of Cell Biology and Neurobiology at Duke. And theres a lot of gems. In particular, 27 of these proteins have already been implicated by genome-wide association studies as having a role in autism, intellectual disability and epilepsy, Soderling said, suggesting that their mechanisms at the synapse could provide new avenues to the understanding and treatment of these disorders. You can read more about this research on Duke Today.

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Department of Cell Biology

Human sexual activity – Wikipedia

This article is about sexual practices and related social aspects. For broader aspects of sexual behaviour, see Human sexuality. "Sexual activity" and "sexual behavior" redirect here. For sexual activity among other animals, see Animal sexual behaviour.

Human sexual activity, human sexual practice or human sexual behavior is the manner in which humans experience and express their sexuality. People engage in a variety of sexual acts, ranging from activities done alone (e.g., masturbation) to acts with another person (e.g., sexual intercourse, non-penetrative sex, oral sex, etc.) in varying patterns of frequency, for a wide variety of reasons. Sexual activity normally results in sexual arousal and physiological changes in the aroused person, some of which are pronounced while others are more subtle. Sexual activity may also include conduct and activities which are intended to arouse the sexual interest of another or enhance the sex life of another, such as strategies to find or attract partners (courtship and display behavior), or personal interactions between individuals (for instance, foreplay or BDSM). Sexual activity may follow sexual arousal.

Human sexual activity has sociological, cognitive, emotional, behavioral and biological aspects; these include personal bonding, sharing emotions and the physiology of the reproductive system, sex drive, sexual intercourse and sexual behavior in all its forms.

In some cultures, sexual activity is considered acceptable only within marriage, while premarital and extramarital sex are taboo. Some sexual activities are illegal either universally or in some countries or subnational jurisdictions, while some are considered contrary to the norms of certain societies or cultures. Two examples that are criminal offenses in most jurisdictions are sexual assault and sexual activity with a person below the local age of consent.

Sexual activity can be classified in a number of ways. It can be divided into acts which involve one person, also called autoeroticism, such as masturbation, or two or more people such as vaginal sex, anal sex, oral sex or mutual masturbation. If there are more than two participants in the sex act, it may be referred to as group sex. Autoerotic sexual activity can involve use of dildos, vibrators, anal beads, and other sex toys, though these devices can also be used with a partner.

Sexual activity can be classified into the gender and sexual orientation of the participants, as well as by the relationship of the participants. For example, the relationships can be ones of marriage, intimate partners, casual sex partners or anonymous. Sexual activity can be regarded as conventional or as alternative, involving, for example, fetishism, paraphilia, or BDSM activities.[1][2] Fetishism can take many forms ranging from the desire for certain body parts, for example large breasts, armpits or foot worship. The object of desire can often be shoes, boots, lingerie, clothing, leather or rubber items. Some non-conventional autoerotic practices can be dangerous. These include erotic asphyxiation and self-bondage. The potential for injury or even death that exists while engaging in the partnered versions of these fetishes (choking and bondage, respectively) becomes drastically increased in the autoerotic case due to the isolation and lack of assistance in the event of a problem.

Sexual activity can be consensual, which means that both or all participants agree to take part and are of the age that they can consent, or it may take place under force or duress, which is often called sexual assault or rape. In different cultures and countries, various sexual activities may be lawful or illegal in regards to the age, gender, marital status or other factors of the participants, or otherwise contrary to social norms or generally accepted sexual morals.

The physiological responses during sexual stimulation are fairly similar for both men and women and there are four phases.[3]

Sexual dysfunction is the inability to react emotionally or physically to sexual stimulation in a way projected of the average healthy person; it can affect different stages in the sexual response cycles, which are desire, excitement and orgasm.[7] In the media, sexual dysfunction is often associated with men, but in actuality, it is more commonly observed in females (43 percent) than males (31 percent).[8]

Sexual activity can lower blood pressure and overall stress levels, regardless of age.[citation needed] It releases tension, elevates mood, and may create a profound sense of relaxation, especially in the postcoital period. From a biochemical perspective, sex causes the release of endorphins and increases levels of white blood cells that actually boost the immune system. A study published in the journal Biological Psychology described how men who had had sex the previous night responded better to stressful situations, it suggested that if a person is regularly sexual, theyre regularly relaxed, and when the person is relaxed, they cope better with stressful situations.[citation needed] A 2007 study published in the Archives of Sexual Behavior 36, (no. 3 (June 2007): 35768) reported that sexual behavior with a partner on one day significantly predicted lower negative mood and stress, and higher positive mood, on the following day.

People engage in sexual activity for any of a multitude of possible reasons. Although the primary evolutionary purpose of sexual activity is reproduction, research on college students suggested that people have sex for four general reasons: physical attraction, as a means to an end, to increase emotional connection, and to alleviate insecurity.[9]

Most people engage in sexual activity because of pleasure they derive from the arousal of their sexuality, especially if they can achieve orgasm. Sexual arousal can also be experienced from foreplay and flirting, and from fetish or BDSM activities,[1][10] or other erotic activities. Most commonly, people engage in sexual activity because of the sexual desire generated by a person to whom they feel sexual attraction; but they may engage in sexual activity for the physical satisfaction they achieve in the absence of attraction for another, as in the case of casual or social sex.[11] At times, a person may engage in a sexual activity solely for the sexual pleasure of their partner, such as because of an obligation they may have to the partner or because of love, sympathy or pity they may feel for the partner.

A person may engage in sexual activity for purely monetary considerations, or to obtain some advantage from either the partner or the activity. A man and woman may engage in sexual intercourse with the objective of conception. Some people engage in hate sex, which occurs between two people who strongly dislike or annoy each other. It is related to the idea that opposition between two people can heighten sexual tension, attraction and interest.[12]

It has been shown that sexual activity plays a large part in the interaction of social species. Joan Roughgarden, in her book Diversity, Gender, and Sexuality in Nature and People, postulates that this applies equally to humans as it does to other social species. She explores the purpose of sexual activity and demonstrates that there are many functions facilitated by such activity including pair bonding, group bonding, dispute resolution and reproduction.[13]

Research has found that people also engage in sexual activity for reasons associated with self-determination theory. The self-determination theory can be applied to a sexual relationship when the participants have positive feelings associated with the relationship. These participants do not feel guilty or coerced into the partnership.[14] Researchers have proposed the model of self-determined sexual motivation. The purpose of this model is to connect self-determination and sexual motivation.[15] This model has helped to explain how people are sexually motivated when involved in self-determined dating relationships. This model also links the positive outcomes, (satisfying the need for autonomy, competence, and relatedness) gained from sexual motivations.[15]

According to the completed research associated with this model, it was found that people of both sexes who engaged in sexual activity for self-determined motivation had more positive psychological well-being.[15] While engaging in sexual activity for self-determined reasons, the participants also had a higher need for fulfillment. When this need was satisfied, they felt better about themselves. This was correlated with greater closeness to their partner and higher overall satisfaction in their relationship.[15] Though both sexes engaged in sexual activity for self-determined reasons, there were some differences found between males and females. It was concluded that females had more motivation than males to engage in sexual activity for self-determined reasons.[15] Females also had higher satisfaction and relationship quality than males did from the sexual activity.[15] Overall, research concluded that psychological well-being, sexual motivation, and sexual satisfaction were all positively correlated when dating couples partook in sexual activity for self-determined reasons.[15]

The frequency of sexual activity might range from zero (sexual abstinence) to 15 or 20 times a week.[16] In the United States, the average frequency of sexual intercourse for married couples is 2 to 3 times a week.[17] It is generally recognized that postmenopausal women experience declines in frequency of sexual intercourse[18] and that average frequency of intercourse declines with age. According to the Kinsey Institute, the average frequency of sexual intercourse in the US is 112 times per year (age 1829), 86 times per year (age 3039), and 69 times per year (age 4049).[19]

The age at which adolescents tend to become sexually active varies considerably between different cultures and from time to time. (See Prevalence of virginity.) The first sexual act of a child or adolescent is sometimes referred to as the sexualization of the child, and may be considered as a milestone or a change of status, as the loss of virginity or innocence. Youth are legally free to have intercourse after they reach the age of consent.

A 1999 survey of students indicated that approximately 40% of ninth graders across the United States report having had sexual intercourse. This figure rises with each grade. Males are more sexually active than females at each of the grade levels surveyed. Sexual activity of young adolescents differs in ethnicity as well. A higher percent of African American and Hispanic adolescents are sexually active than White adolescents.[20]

Research on sexual frequency has also been conducted solely on female adolescents who engage in sexual activity. Female adolescents tended to engage in more sexual activity due to positive mood. In female teenagers, engaging in sexual activity was directly positively correlated with being older, greater sexual activity in the previous week or prior day, and more positive mood the previous day or the same day as the sexual activity occurred.[21] Decreased sexual activity was associated with prior or current day negative mood or vaginal bleeding.[21]

Although opinions differ, others[who?] suggest that sexual activity is an essential part of humans, and that teenagers need to experience sex. Sexual experiences help teenagers understand pleasure and satisfaction.[22] In relation to hedonic and eudaimonic well-being, teenagers can positively benefit from sexual activity according to one particular research study. In the United States[which?] of America, a cross-sectional study of teenagers was completed.[when?] Teenagers who had their first sexual experience at age 16 revealed a higher well-being than those who were sexually inexperienced or who were first sexually active at a later age of 17.[22] Furthermore, teenagers who had their first sexual experience at age 15 or younger, or who had many sexual partners were not negatively affected and did not have associated lower well-being.[22]

Sexual activity is a normal physiological function,[23] but like other physical activity, it comes with risks. There are four main types of risks that may arise from sexual activity: unwanted pregnancy, contracting a sexually transmitted infection (STI/STD), physical injury, and psychological injury.

Any sexual activity that involves the introduction of semen into a woman's vagina, such as during sexual intercourse, or even contact of semen with her vulva, may result in a pregnancy.[24] To reduce the risk of unintended pregnancies, some people who engage in penile-vaginal sex may use contraception, such as birth control pills, a condom, diaphragms, spermicides, hormonal contraception or sterilization.[25] The effectiveness of the various contraceptive methods in avoiding pregnancy varies considerably.

Sexual activity that involves skin-to-skin contact, exposure to an infected person's bodily fluids or mucosal membranes[26] carries the risk of contracting a sexually transmitted infection. People may not be able to detect that their sexual partner has one or more STIs, for example if they are asymptomatic (show no symptoms).[27][28] The risk of STIs can be reduced by safe sex practices, such as using condoms. Both partners may opt be tested for STIs before engaging in sex.[29] There may also be an increased risk of contracting a STI when having sex with multiple partners.

Some STIs can also be contracted by using IV drug needles after their use by an infected person, as well as through childbirth or breastfeeding.

Typically, older men and women maintaining interest in sexual interest and activity could be therapeutic; it is a way of expressing their love and care for one another. Factors such as biological and psychological factors, diseases, mental conditions, boredom with the relationship, and widowhood have been found to contribute with the common decrease in sexual interest and activity in old age. National sex surveys given in Finland in the 1990s revealed aging men had a higher incidence of sexual intercourse compared to aging women and that women were more likely to report a lack of sexual desire compared to men. Regression analysis, factors considered important to female sexual activity included: sexual desire, valuing sexuality, and a healthy partner, while high sexual self-esteem, good health, and active sexual history were important to male sexual activity. Both aging genders agreed they needed good health, good sexual functioning, positive sexual self-esteem, and a sexually skilful partner to maintain sexual desire.[30]

Heterosexuality is the romantic or sexual attraction to the opposite sex. Heterosexual sexual practices are subject to laws in many places. In some countries, mostly those where religion has a strong influence on social policy, marriage laws serve the purpose of encouraging people to have sex only within marriage. Sodomy laws were seen as discouraging same-sex sexual practices, but may affect opposite-sex sexual practices. Laws also ban adults from committing sexual abuse, committing sexual acts with anyone under an age of consent, performing sexual activities in public, and engaging in sexual activities for money (prostitution). Though these laws cover both same-sex and opposite-sex sexual activities, they may differ in regard to punishment, and may be more frequently (or exclusively) enforced on those who engage in same-sex sexual activities.[31]

Different-sex sexual practices may be monogamous, serially monogamous, or polyamorous, and, depending on the definition of sexual practice, abstinent or autoerotic (including masturbation). Additionally, different religious and political movements have tried to influence or control changes in sexual practices including courting and marriage, though in most countries changes occur at a slow rate.

Homosexuality is the romantic or sexual attraction to the same sex. People with a homosexual orientation can express their sexuality in a variety of ways, and may or may not express it in their behaviors.[32] Research indicates that many gay men and lesbians want, and succeed in having, committed and durable relationships. For example, survey data indicate that between 40% and 60% of gay men and between 45% and 80% of lesbians are currently involved in a romantic relationship.[33]

It is possible for a person whose sexual identity is mainly heterosexual to engage in sexual acts with people of the same sex. For example, mutual masturbation in the context of what may be considered normal heterosexual teen development. Gay and lesbian people who pretend to be heterosexual are often referred to as being closeted (hiding their sexuality in "the closet"). "Closet case" is a derogatory term used to refer to people who hide their sexuality. Making that orientation public can be called "coming out of the closet" in the case of voluntary disclosure or "outing" in the case of disclosure by others against the subject's wishes (or without their knowledge). Among some communities (called "men on the DL" or "down-low"), same-sex sexual behavior is sometimes viewed as solely for physical pleasure. Men who have sex with men, as well as women who have sex with women, or men on the "down-low" may engage in sex acts with members of the same sex while continuing sexual and romantic relationships with the opposite sex.

People who engage exclusively in same-sex sexual practices may not identify themselves as gay or lesbian. In sex-segregated environments, individuals may seek relationships with others of their own gender (known as situational homosexuality). In other cases, some people may experiment or explore their sexuality with same (and/or different) sex sexual activity before defining their sexual identity. Despite stereotypes and common misconceptions, there are no forms of sexual acts exclusive to same-sex sexual behavior that cannot also be found in opposite-sex sexual behavior, except those involving the meeting of the genitalia between same-sex partners tribadism (generally vulva-to-vulva rubbing, commonly known by its "scissoring" position) and frot (generally penis-to-penis rubbing).

People who have a romantic or sexual attraction to both sexes are referred to as bisexual.[34][35] People who have a distinct but not exclusive preference for one sex/gender over the other may also identify themselves as bisexual.[36] Like gay and lesbian individuals, bisexual people who pretend to be heterosexual are often referred to as being closeted.

Pansexuality (also referred to as omnisexuality)[37] may or may not be subsumed under bisexuality, with some sources stating that bisexuality encompasses sexual or romantic attraction to all gender identities.[38][39] Pansexuality is characterized by the potential for aesthetic attraction, romantic love, or sexual desire towards people without regard for their gender identity or biological sex.[40] Some pansexuals suggest that they are gender-blind; that gender and sex are insignificant or irrelevant in determining whether they will be sexually attracted to others.[41] As defined in the Oxford English Dictionary, pansexuality "encompasses all kinds of sexuality; not limited or inhibited in sexual choice with regards to gender or practice".[42]

Most people experiment with a range of sexual activities during their lives, although they tend to engage in only a few of these regularly. Some people enjoy many different sexual activities, while others avoid sexual activities altogether for religious or other reasons (see chastity, sexual abstinence, asexuality). Some prefer monogamous relationships for sex, while others may prefer many different partners throughout their lives.

Alex Comfort and others propose three potential social aspects of intercourse in humans, which are not mutually exclusive: reproductive, relational, and recreational.[43] The development of the contraceptive pill and other highly effective forms of contraception in the mid- and late 20th century has increased people's ability to segregate these three functions, which still overlap a great deal and in complex patterns. For example: A fertile couple may have intercourse while using contraception to experience sexual pleasure (recreational) and also as a means of emotional intimacy (relational), thus deepening their bonding, making their relationship more stable and more capable of sustaining children in the future (deferred reproductive). This same couple may emphasize different aspects of intercourse on different occasions, being playful during one episode of intercourse (recreational), experiencing deep emotional connection on another occasion (relational), and later, after discontinuing contraception, seeking to achieve pregnancy (reproductive, or more likely reproductive and relational).

Most world religions have sought to address the moral issues that arise from people's sexuality in society and in human interactions. Each major religion has developed moral codes covering issues of sexuality, morality, ethics etc. Though these moral codes do not address issues of sexuality directly, they seek to regulate the situations which can give rise to sexual interest and to influence people's sexual activities and practices. However, the effect of religious teaching has at times been limited. For example, though most religions disapprove of extramarital sexual relations, it has always been widely practiced. Nevertheless, these religious codes have always had a strong influence on peoples' attitudes to issues of modesty in dress, behavior, speech etc.

On the other hand, some people adopt the view that pleasure is its own justification for sexual activity. Hedonism is a school of thought which argues that pleasure is the only intrinsic good.[44]

Human sexual activity, like many other kinds of activity engaged in by humans, is generally influenced by social rules that are culturally specific and vary widely. These social rules are referred to as sexual morality (what can and can not be done by society's rules) and sexual norms (what is and is not expected).

Sexual ethics, morals, and norms relate to issues including deception/honesty, legality, fidelity and consent. Some activities, known as sex crimes in some locations, are illegal in some jurisdictions, including those conducted between (or among) consenting and competent adults (examples include sodomy law and adult-adult incest).

Some people who are in a relationship but want to hide polygamous activity (possibly of opposite sexual orientation) from their partner, may solicit consensual sexual activity with others through personal contacts, online chat rooms, or, advertising in select media.

Swinging, on the other hand, involves singles or partners in a committed relationship engaging in sexual activities with others as a recreational or social activity.[45] The increasing popularity of swinging is regarded by some as arising from the upsurge in sexual activity during the sexual revolution of the 1960s. Swinging sexual activity can take place in a sex club, also known as a swinger club (not to be confused with a strip club).[46]

Some people engage in various sexual activities as a business transaction. When this involves having sex with, or performing certain actual sexual acts for another person in exchange for money or something of value, it is called prostitution. Other aspects of the adult industry include phone sex operators, strip clubs, and pornography.

Social gender roles can influence sexual behavior as well as the reaction of individuals and communities to certain incidents; the World Health Organization states that, "Sexual violence is also more likely to occur where beliefs in male sexual entitlement are strong, where gender roles are more rigid, and in countries experiencing high rates of other types of violence."[47] Some societies, such as those where the concepts of family honor and female chastity are very strong, may practice violent control of female sexuality, through practices such as honor killings and female genital mutilation.[48][49]

The relation between gender equality and sexual expression is recognized, and promotion of equity between men and women is crucial for attaining sexual and reproductive health, as stated by the UN International Conference on Population and Development Program of Action:[50]

BDSM is a variety of erotic practices or roleplaying involving bondage, dominance and submission, sadomasochism, and other interpersonal dynamics. Given the wide range of practices, some of which may be engaged in by people who do not consider themselves as practicing BDSM, inclusion in the BDSM community or subculture is usually dependent on self-identification and shared experience. BDSM communities generally welcome anyone with a non-normative streak who identifies with the community; this may include cross-dressers, extreme body modification enthusiasts, animal players, latex or rubber aficionados, and others.

B/D, a form of BDSM, is bondage and discipline. Bondage includes the restraint of the body or mind.[51] D/S means "dominant and submissive." A dominant is someone who takes control of someone who wishes to give up control. A submissive is someone who gives up the control to a person who wishes to take control.[51] S/M (sadism and masochism) means an individual who takes pleasure in the humiliation or pain of others. Masochism means an individual who takes pleasure from their own pain and/or humiliation.[51]

Unlike the usual "power neutral" relationships and play styles commonly followed by couples, activities and relationships within a BDSM context are often characterized by the participants' taking on complementary, but unequal roles; thus, the idea of informed consent of both the partners becomes essential. Participants who exert sexual dominance over their partners are known as dominants or tops, while participants who take the passive, receiving, or obedient role are known as submissives or bottoms.

Individuals are also sometimes abbreviated when referred to in writing, so a dominant person may be referred to as a "dom" for a man or a woman. Sometimes a woman may choose to use the female specific term "Domme". Both terms are pronounced the same when spoken. Individuals who can change between top/dominant and bottom/submissive roleswhether from relationship to relationship or within a given relationshipare known as switches. The precise definition of roles and self-identification is a common subject of debate within the community.[52]

In a 2013 study, the researchers suggest that BDSM is a sexual act where they play role games, use restraint, use power exchange, use suppression and pain is sometimes involved depending on individual(s).[53] The study indicates that, in the past, BDSM has been seen as maladaptive to one's psychological health, but that this may be incorrect. According to the study, one who participates in BDSM can have greater strength socially, mentally and have greater independence than those who do not practice BDSM.[53] It states that people who participate in BDSM play actually have higher subjective well-being, and that this might be due to the fact that BDSM play requires extensive communication. Before any sexual act occurs, the partners must discuss their agreement of their relationship. They discuss how long the play will last, the intensity, their actions, what each participant needs and/or desires. The sexual acts are all consensual and pleasurable to both parties.[53]

In a 2015 study, BDSM relationships were suggested to have a higher level of connection, intimacy, trust and communication compared to individuals who do not practice BDSM.[51] The study suggests that dominants and submissives exchange control for each other's pleasure and to satisfy a need. They mention that both parties enjoys pleasing their partner in any way they can. Submissive and Dominants who participated in their research, felt that this is one of the best things about BDSM. It gives a submissive pleasure to do things in general for their dominant. Where Dominant enjoys making their encounters all about the submissive. They enjoy doing things that makes their submissive happy. Their findings suggest that submissives and dominants found BDSM play more pleasurable and fun. BDSM was also suggested to improve personal growth, romantic relationships, their sense of community, their sense of self, the dominants confidence, and help an individual cope with everyday things by giving them a psychological release.[51]

There are many laws and social customs which prohibit, or in some way affect sexual activities. These laws and customs vary from country to country, and have varied over time. They cover, for example, a prohibition to non-consensual sex, to sex outside of marriage, to sexual activity in public, besides many others. Many of these restrictions are non-controversial, but some have been the subject of public debate.

Most societies consider it a serious crime to force someone to engage in sexual acts or to engage in sexual activity with someone who does not consent. This is called sexual assault, and if sexual penetration occurs it is called rape, the most serious kind of sexual assault. The details of this distinction may vary among different legal jurisdictions. Also, what constitutes effective consent in sexual matters varies from culture to culture and is frequently debated. Laws regulating the minimum age at which a person can consent to have sex (age of consent) are frequently the subject of debate, as is adolescent sexual behavior in general. Some societies have forced marriage, where consent may not be required.

Many locales have laws that limit or prohibit same-sex sexual activity.

In the West, sex before marriage is not illegal. There are social taboos and many religions condemn pre-marital sex. In many Muslim countries, such as Saudi Arabia, Pakistan,[54] Afghanistan,[55][56][57] Iran,[57] Kuwait,[58] Maldives,[59] Morocco,[60] Oman,[61] Mauritania,[62] United Arab Emirates,[63][64] Sudan,[65] Yemen,[66] any form of sexual activity outside marriage is illegal. Those found guilty, especially women, may be forced to wed the sexual partner, publicly beaten, or stoned to death.[67] In many African and native tribes, sexual activity is not viewed as a privilege or right of a married couple, but rather as the unification of bodies and is thus not frowned upon.[68]

Other studies have analyzed the changing attitudes about sex that American adolescents have outside of marriage. Adolescents were asked how they felt about oral and vaginal sex in relation to their health, social, and emotional well-being. Overall, teenagers felt that oral sex was viewed as more socially positive amongst their demographic.[69] Results stated that teenagers believed that oral sex for dating and non-dating adolescents was less threatening to their overall values and beliefs than vaginal sex was.[69] When asked, teenagers who participated in the research viewed oral sex as more acceptable to their peers, and their personal values than vaginal sex.[69]

The laws of each jurisdiction set the minimum age at which a young person is allowed to engage in sexual activity.[70] This age of consent is typically between 14 and 18 years, but laws vary. In many jurisdictions, age of consent is a person's mental or functional age.[71][71][72][73] As a result, those above the set age of consent may still be considered unable to legally consent due to mental immaturity.[71][72][73][74][75] Many jurisdictions regard any sexual activity by an adult involving a child as child sexual abuse.

Age of consent may vary by the type of sexual act, the sex of the actors, or other restrictions such as abuse of a position of trust. Some jurisdictions also make allowances for young people engaged in sexual acts with each other.[76]

Most jurisdictions prohibit sexual activity between certain close relatives. These laws vary to some extent; such acts are called incestuous.

Non-consensual sexual activity or subjecting an unwilling person to witnessing a sexual activity are forms of sexual abuse, as well as (in many countries) certain non-consensual paraphilias such as frotteurism, telephone scatophilia (indecent phonecalls), and non-consensual exhibitionism and voyeurism (known as "indecent exposure" and "peeping tom" respectively).[77]

People sometimes exchange sex for money or access to other resources. This practice, called prostitution, takes place under many varied circumstances. The person who receives payment for sexual services is called a prostitute and the person who receives such services is known by a multitude of terms, including (and most commonly) "john." Prostitution is one of the branches of the sex industry. The legal status of prostitution varies from country to country, from being a punishable crime to a regulated profession. Estimates place the annual revenue generated from the global prostitution industry to be over $100 billion.[78] Prostitution is sometimes referred to as "the world's oldest profession".[79] Prostitution may be a voluntary individual activity or facilitated or forced by pimps.

Survival sex is a form of prostitution engaged in by people in need, usually when homeless or otherwise disadvantaged people trade sex for food, a place to sleep, or other basic needs, or for drugs.[80] The term is used by sex trade and poverty researchers and aid workers.[81][82]

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Human sexual activity - Wikipedia