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Ken Thompson, who was a colleague of Stroustrup at Bell Labs, gives his assessment: It certainly has its good points. But by and large I think it's a bad language. It does a lot of things half well and it's just a garbage heap of ideas that are mutually exclusive. Everybody I know, whether it's personal or corporate, selects a subset and these subsets are different. So it's not a good language to transport an algorithm—to say, "I wrote it; here, take it." It's way too big, way too complex. And it's obviously built by a committee.
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The symptoms of COVID‑19 are variable but often include fever, cough, headache, fatigue, breathing difficulties, loss of smell, and loss of taste. Symptoms may begin one to fourteen days after exposure to the virus. At least a third of people who are infected do not develop noticeable symptoms. Of those who develop symptoms noticeable enough to be classified as patients, most (81%) develop mild to moderate symptoms (up to mild pneumonia), while 14% develop severe symptoms (dyspnea, hypoxia, or more than 50% lung involvement on imaging), and 5% develop critical symptoms (respiratory failure, shock, or multiorgan dysfunction). Older people are at a higher risk of developing severe symptoms. Some people continue to experience a range of effects (long COVID) for months after recovery, and damage to organs has been observed. Multi-year studies are underway to further investigate the long-term effects of the disease.
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During the initial outbreak in Wuhan, the virus and disease were commonly referred to as "coronavirus" and "Wuhan coronavirus", with the disease sometimes called "Wuhan pneumonia". In the past, many diseases have been named after geographical locations, such as the Spanish flu, Middle East respiratory syndrome, and Zika virus. In January 2020, the World Health Organization (WHO) recommended 2019-nCoV and 2019-nCoV acute respiratory disease as interim names for the virus and disease per 2015 guidance and international guidelines against using geographical locations or groups of people in disease and virus names to prevent social stigma. The official names COVID‑19 and SARS-CoV-2 were issued by the WHO on 11 February 2020 with COVID-19 being shorthand for "coronavirus disease 2019". The WHO additionally uses "the COVID‑19 virus" and "the virus responsible for COVID‑19" in public communications.
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SARS-CoV-2 is closely related to the original SARS-CoV. It is thought to have an animal (zoonotic) origin. Genetic analysis has revealed that the coronavirus genetically clusters with the genus "Betacoronavirus", in subgenus "Sarbecovirus" (lineage B) together with two bat-derived strains. It is 96% identical at the whole genome level to other bat coronavirus samples (BatCov RaTG13). The structural proteins of SARS-CoV-2 include membrane glycoprotein (M), envelope protein (E), nucleocapsid protein (N), and the spike protein (S). The M protein of SARS-CoV-2 is about 98% similar to the M protein of bat SARS-CoV, maintains around 98% homology with pangolin SARS-CoV, and has 90% homology with the M protein of SARS-CoV; whereas, the similarity is only around 38% with the M protein of MERS-CoV.
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The many thousands of SARS-CoV-2 variants are grouped into either clades or lineages. The WHO, in collaboration with partners, expert networks, national authorities, institutions and researchers, have established nomenclature systems for naming and tracking SARS-CoV-2 genetic lineages by GISAID, Nextstrain and Pango. The expert group convened by the WHO recommended the labelling of variants using letters of the Greek alphabet, for example, Alpha, Beta, Delta, and Gamma, giving the justification that they "will be easier and more practical to discussed by non-scientific audiences." Nextstrain divides the variants into five clades (19A, 19B, 20A, 20B, and 20C), while GISAID divides them into seven (L, O, V, S, G, GH, and GR). The Pango tool groups variants into lineages, with many circulating lineages being classed under the B.1 lineage.
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The SARS-CoV-2 virus can infect a wide range of cells and systems of the body. COVID‑19 is most known for affecting the upper respiratory tract (sinuses, nose, and throat) and the lower respiratory tract (windpipe and lungs). The lungs are the organs most affected by COVID‑19 because the virus accesses host cells via the receptor for the enzyme angiotensin-converting enzyme 2 (ACE2), which is most abundant on the surface of type II alveolar cells of the lungs. The virus uses a special surface glycoprotein called a "spike" to connect to the ACE2 receptor and enter the host cell.
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One common symptom, loss of smell, results from infection of the support cells of the olfactory epithelium, with subsequent damage to the olfactory neurons. The involvement of both the central and peripheral nervous system in COVID‑19 has been reported in many medical publications. It is clear that many people with COVID-19 exhibit neurological or mental health issues. The virus is not detected in the central nervous system (CNS) of the majority of COVID-19 patients with neurological issues. However, SARS-CoV-2 has been detected at low levels in the brains of those who have died from COVID‑19, but these results need to be confirmed. While virus has been detected in cerebrospinal fluid of autopsies, the exact mechanism by which it invades the CNS remains unclear and may first involve invasion of peripheral nerves given the low levels of ACE2 in the brain. The virus may also enter the bloodstream from the lungs and cross the blood–brain barrier to gain access to the CNS, possibly within an infected white blood cell.
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A high incidence of thrombosis and venous thromboembolism occurs in people transferred to intensive care units with COVID‑19 infections, and may be related to poor prognosis. Blood vessel dysfunction and clot formation (as suggested by high D-dimer levels caused by blood clots) may have a significant role in mortality, incidences of clots leading to pulmonary embolisms, and ischaemic events within the brain found as complications leading to death in people infected with COVID‑19. Infection may initiate a chain of vasoconstrictive responses within the body, including pulmonary vasoconstriction a possible mechanism in which oxygenation decreases during pneumonia. Furthermore, damage of arterioles and capillaries was found in brain tissue samples of people who died from COVID‑19.
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Although SARS-CoV-2 has a tropism for ACE2-expressing epithelial cells of the respiratory tract, people with severe COVID‑19 have symptoms of systemic hyperinflammation. Clinical laboratory findings of elevated IL2, IL7, IL6, granulocyte-macrophage colony-stimulating factor (GMCSF), interferon gamma-induced protein10 (IP10), monocyte chemoattractant protein1 (MCP1), macrophage inflammatory protein 1alpha (MIP1alpha), and tumour necrosis factor (TNFα) indicative of cytokine release syndrome (CRS) suggest an underlying immunopathology.
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Multiple viral and host factors affect the pathogenesis of the virus. The S-protein, otherwise known as the spike protein, is the viral component that attaches to the host receptor via the ACE2 receptors. It includes two subunits: S1 and S2. S1 determines the virus-host range and cellular tropism via the receptor-binding domain. S2 mediates the membrane fusion of the virus to its potential cell host via the H1 and HR2, which are heptad repeat regions. Studies have shown that S1 domain induced IgG and IgA antibody levels at a much higher capacity. It is the focus spike proteins expression that are involved in many effective COVID‑19 vaccines.
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A cytokine storm is due to an acute hyperinflammatory response that is responsible for clinical illness in an array of diseases but in COVID‑19, it is related to worse prognosis and increased fatality. The storm causes acute respiratory distress syndrome, blood clotting events such as strokes, myocardial infarction, encephalitis, acute kidney injury, and vasculitis. The production of IL-1, IL-2, IL-6, TNF-alpha, and interferon-gamma, all crucial components of normal immune responses, inadvertently become the causes of a cytokine storm. The cells of the central nervous system, the microglia, neurons, and astrocytes, are also involved in the release of pro-inflammatory cytokines affecting the nervous system, and effects of cytokine storms toward the CNS are not uncommon.
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In addition to the above, other clinical studies have proved that SARS-CoV-2 can affect the period of pregnancy in different ways. On the one hand, there is little evidence of its impact up to 12 weeks gestation. On the other hand, COVID-19 infection may cause increased rates of unfavourable outcomes in the course of the pregnancy. Some examples of these could be foetal growth restriction, preterm birth, and perinatal mortality, which refers to the foetal death past 22 or 28 completed weeks of pregnancy as well as the death among live-born children up to seven completed days of life.
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The University of Oxford's CEBM has pointed to mounting evidence that "a good proportion of 'new' mild cases and people re-testing positives after quarantine or discharge from hospital are not infectious, but are simply clearing harmless virus particles which their immune system has efficiently dealt with" and have called for "an international effort to standardize and periodically calibrate testing" In September 2020, the UK government issued "guidance for procedures to be implemented in laboratories to provide assurance of positive SARS-CoV-2 RNA results during periods of low prevalence, when there is a reduction in the predictive value of positive test results".
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Chest CT scans may be helpful to diagnose COVID‑19 in individuals with a high clinical suspicion of infection but are not recommended for routine screening. Bilateral multilobar ground-glass opacities with a peripheral, asymmetric, and posterior distribution are common in early infection. Subpleural dominance, crazy paving (lobular septal thickening with variable alveolar filling), and consolidation may appear as the disease progresses. Characteristic imaging features on chest radiographs and computed tomography (CT) of people who are symptomatic include asymmetric peripheral ground-glass opacities without pleural effusions.
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The first COVID‑19 vaccine was granted regulatory approval on 2December 2020 by the UK medicines regulator MHRA. It was evaluated for emergency use authorization (EUA) status by the US FDA, and in several other countries. Initially, the US National Institutes of Health guidelines do not recommend any medication for prevention of COVID‑19, before or after exposure to the SARS-CoV-2 virus, outside the setting of a clinical trial. Without a vaccine, other prophylactic measures, or effective treatments, a key part of managing COVID‑19 is trying to decrease and delay the epidemic peak, known as "flattening the curve". This is done by slowing the infection rate to decrease the risk of health services being overwhelmed, allowing for better treatment of active cases, and delaying additional cases until effective treatments or a vaccine become available.
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The WHO and the US CDC recommend individuals wear non-medical face coverings in public settings where there is an increased risk of transmission and where social distancing measures are difficult to maintain. This recommendation is meant to reduce the spread of the disease by asymptomatic and pre-symptomatic individuals and is complementary to established preventive measures such as social distancing. Face coverings limit the volume and travel distance of expiratory droplets dispersed when talking, breathing, and coughing. A face covering without vents or holes will also filter out particles containing the virus from inhaled and exhaled air, reducing the chances of infection. However, if the mask includes an exhalation valve, a wearer that is infected (and possibly asymptomatic) may transmit the virus through the valve. Many countries and local jurisdictions encourage or mandate the use of face masks or cloth face coverings by members of the public to limit the spread of the virus.
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Thorough hand hygiene after any cough or sneeze is required. The WHO also recommends that individuals wash hands often with soap and water for at least twenty seconds, especially after going to the toilet or when hands are visibly dirty, before eating and after blowing one's nose. When soap and water are not available, the CDC recommends using an alcohol-based hand sanitiser with at least 60% alcohol. For areas where commercial hand sanitisers are not readily available, the WHO provides two formulations for local production. In these formulations, the antimicrobial activity arises from ethanol or isopropanol. Hydrogen peroxide is used to help eliminate bacterial spores in the alcohol; it is "not an active substance for hand antisepsis." Glycerol is added as a humectant.
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After being expelled from the body, coronaviruses can survive on surfaces for hours to days. If a person touches the dirty surface, they may deposit the virus at the eyes, nose, or mouth where it can enter the body and cause infection. Evidence indicates that contact with infected surfaces is not the main driver of COVID‑19, leading to recommendations for optimised disinfection procedures to avoid issues such as the increase of antimicrobial resistance through the use of inappropriate cleaning products and processes. Deep cleaning and other surface sanitation has been criticised as hygiene theatre, giving a false sense of security against something primarily spread through the air.
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On many surfaces, including glass, some types of plastic, stainless steel, and skin, the virus can remain infective for several days indoors at room temperature, or even about a week under ideal conditions. On some surfaces, including cotton fabric and copper, the virus usually dies after a few hours. The virus dies faster on porous surfaces than on non-porous surfaces due to capillary action within pores and faster aerosol droplet evaporation. However, of the many surfaces tested, two with the longest survival times are N95 respirator masks and surgical masks, both of which are considered porous surfaces.
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The CDC says that in most situations, cleaning surfaces with soap or detergent, not disinfecting, is enough to reduce risk of transmission. The CDC recommends that if a COVID‑19 case is suspected or confirmed at a facility such as an office or day care, all areas such as offices, bathrooms, common areas, shared electronic equipment like tablets, touch screens, keyboards, remote controls, and ATMs used by the ill persons should be disinfected. Surfaces may be decontaminated with 62–71 per cent ethanol, 50–100 per cent isopropanol, 0.1 per cent sodium hypochlorite, 0.5 per cent hydrogen peroxide, 0.2–7.5 per cent povidone-iodine, or 50–200 ppm hypochlorous acid. Other solutions, such as benzalkonium chloride and chlorhexidine gluconate, are less effective. Ultraviolet germicidal irradiation may also be used, although popular devices require exposure and may deteriorate some materials over time. A datasheet comprising the authorised substances to disinfection in the food industry (including suspension or surface tested, kind of surface, use dilution, disinfectant and inocuylum volumes) can be seen in the supplementary material of.
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The severity of COVID‑19 varies. The disease may take a mild course with few or no symptoms, resembling other common upper respiratory diseases such as the common cold. In 3–4% of cases (7.4% for those over age 65) symptoms are severe enough to cause hospitalisation. Mild cases typically recover within two weeks, while those with severe or critical diseases may take three to six weeks to recover. Among those who have died, the time from symptom onset to death has ranged from two to eight weeks. The Italian Istituto Superiore di Sanità reported that the median time between the onset of symptoms and death was twelve days, with seven being hospitalised. However, people transferred to an ICU had a median time of ten days between hospitalisation and death. Abnormal sodium levels during hospitalization with COVID-19 are associated with poor prognoses: high sodium with a greater risk of death, and low sodium with an increased chance of needing ventilator support. Prolonged prothrombin time and elevated C-reactive protein levels on admission to the hospital are associated with severe course of COVID‑19 and with a transfer to ICU.
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Some early studies suggest 10% to 20% of people with COVID‑19 will experience symptoms lasting longer than a month. A majority of those who were admitted to hospital with severe disease report long-term problems including fatigue and shortness of breath. On 30 October 2020, WHO chief Tedros Adhanom warned that "to a significant number of people, the COVID virus poses a range of serious long-term effects." He has described the vast spectrum of COVID‑19 symptoms that fluctuate over time as "really concerning". They range from fatigue, a cough and shortness of breath, to inflammation and injury of major organsincluding the lungs and heart, and also neurological and psychologic effects. Symptoms often overlap and can affect any system in the body. Infected people have reported cyclical bouts of fatigue, headaches, months of complete exhaustion, mood swings, and other symptoms. Tedros therefore concluded that a strategy of achieving herd immunity by infection, rather than vaccination, is "morally unconscionable and unfeasible".
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Genetics plays an important role in the ability to fight off Covid. For instance, those that do not produce detectable type I interferons or produce auto-antibodies against these may get much sicker from COVID‑19. Genetic screening is able to detect interferon effector genes. Some genetic variants are risk factors in specific populations. For instance, and allele of the DOCK2 gene (dedicator of cytokinesis 2 gene) is a common risk factor in Asian populations but much less common in Europe. The mutation leads to lower expression of DOCK2 especially in younger patients with severe Covid. In fact, many other genes and genetic variants have been found that determine the outcome of SARS-CoV-2 infections.
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While very young children have experienced lower rates of infection, older children have a rate of infection that is similar to the population as a whole. Children are likely to have milder symptoms and are at lower risk of severe disease than adults. The CDC reports that in the US roughly a third of hospitalised children were admitted to the ICU, while a European multinational study of hospitalised children from June 2020, found that about 8% of children admitted to a hospital needed intensive care. Four of the 582 children (0.7%) in the European study died, but the actual mortality rate may be "substantially lower" since milder cases that did not seek medical help were not included in the study.
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The immune response by humans to SARS-CoV-2 virus occurs as a combination of the cell-mediated immunity and antibody production, just as with most other infections. B cells interact with T cells and begin dividing before selection into the plasma cell, partly on the basis of their affinity for antigen. Since SARS-CoV-2 has been in the human population only since December 2019, it remains unknown if the immunity is long-lasting in people who recover from the disease. The presence of neutralising antibodies in blood strongly correlates with protection from infection, but the level of neutralising antibody declines with time. Those with asymptomatic or mild disease had undetectable levels of neutralising antibody two months after infection. In another study, the level of neutralising antibodies fell four-fold one to four months after the onset of symptoms. However, the lack of antibodies in the blood does not mean antibodies will not be rapidly produced upon reexposure to SARS-CoV-2. Memory B cells specific for the spike and nucleocapsid proteins of SARS-CoV-2 last for at least six months after the appearance of symptoms.
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A December 2020 systematic review and meta-analysis estimated that population IFR during the first wave of the pandemic was about 0.5% to 1% in many locations (including France, Netherlands, New Zealand, and Portugal), 1% to 2% in other locations (Australia, England, Lithuania, and Spain), and exceeded 2% in Italy. That study also found that most of these differences in IFR reflected corresponding differences in the age composition of the population and age-specific infection rates; in particular, the metaregression estimate of IFR is very low for children and younger adults (e.g., 0.002% at age 10 and 0.01% at age 25) but increases progressively to 0.4% at age 55, 1.4% at age 65, 4.6% at age 75, and 15% at age 85. These results were also highlighted in a December 2020 report issued by the WHO.
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At an early stage of the pandemic, the World Health Organization reported estimates of IFR between 0.3% and 1%. On 2July, The WHO's chief scientist reported that the average IFR estimate presented at a two-day WHO expert forum was about 0.6%. In August, the WHO found that studies incorporating data from broad serology testing in Europe showed IFR estimates converging at approximately 0.5–1%. Firm lower limits of IFRs have been established in a number of locations such as New York City and Bergamo in Italy since the IFR cannot be less than the population fatality rate. (After sufficient time however, people can get reinfected). As of 10 July, in New York City, with a population of 8.4 million, 23,377 individuals (18,758 confirmed and 4,619 probable) have died with COVID‑19 (0.3% of the population). Antibody testing in New York City suggested an IFR of ≈0.9%, and ≈1.4%. In Bergamo province, 0.6% of the population has died. In September 2020, the U.S. Centers for Disease Control and Prevention (CDC) reported preliminary estimates of age-specific IFRs for public health planning purposes.
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The Chinese Center for Disease Control and Prevention reported the death rate was 2.8% for men and 1.7% for women. Later reviews in June 2020 indicated that there is no significant difference in susceptibility or in CFR between genders. One review acknowledges the different mortality rates in Chinese men, suggesting that it may be attributable to lifestyle choices such as smoking and drinking alcohol rather than genetic factors. Smoking, which in some countries like China is mainly a male activity, is a habit that contributes to increasing significantly the case fatality rates among men. Sex-based immunological differences, lesser prevalence of smoking in women and men developing co-morbid conditions such as hypertension at a younger age than women could have contributed to the higher mortality in men. In Europe as of February 2020, 57% of the infected people were men and 72% of those died with COVID‑19 were men. As of April 2020, the US government is not tracking sex-related data of COVID‑19 infections. Research has shown that viral illnesses like Ebola, HIV, influenza and SARS affect men and women differently.
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In the US, a greater proportion of deaths due to COVID‑19 have occurred among African Americans and other minority groups. Structural factors that prevent them from practising social distancing include their concentration in crowded substandard housing and in "essential" occupations such as retail grocery workers, public transit employees, health-care workers and custodial staff. Greater prevalence of lacking health insurance and care of underlying conditions such as diabetes, hypertension, and heart disease also increase their risk of death. Similar issues affect Native American and Latino communities. On the one hand, in the Dominican Republic there is a clear example of both gender and ethnic inequality. In this Latin American territory, there is great inequality and precariousness that especially affects Dominican women, with greater emphasis on those of Haitian descent. According to a US health policy non-profit, 34% of American Indian and Alaska Native People (AIAN) non-elderly adults are at risk of serious illness compared to 21% of white non-elderly adults. The source attributes it to disproportionately high rates of many health conditions that may put them at higher risk as well as living conditions like lack of access to clean water.
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Leaders have called for efforts to research and address the disparities. In the UK, a greater proportion of deaths due to COVID‑19 have occurred in those of a Black, Asian, and other ethnic minority background. More severe impacts upon patients including the relative incidence of the necessity of hospitalisation requirements, and vulnerability to the disease has been associated via DNA analysis to be expressed in genetic variants at chromosomal region 3, features that are associated with European Neanderthal heritage. That structure imposes greater risks that those affected will develop a more severe form of the disease. The findings are from Professor Svante Pääbo and researchers he leads at the Max Planck Institute for Evolutionary Anthropology and the Karolinska Institutet. This admixture of modern human and Neanderthal genes is estimated to have occurred roughly between 50,000 and 60,000 years ago in Southern Europe.
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Biological factors (immune response) and the general behaviour (habits) can strongly determine the consequences of COVID‑19. Most of those who die of COVID‑19 have pre-existing (underlying) conditions, including hypertension, diabetes mellitus, and cardiovascular disease. According to March data from the United States, 89% of those hospitalised had preexisting conditions. The Italian Istituto Superiore di Sanità reported that out of 8.8% of deaths where medical charts were available, 96.1% of people had at least one comorbidity with the average person having 3.4 diseases. According to this report the most common comorbidities are hypertension (66% of deaths), type 2 diabetes (29.8% of deaths), ischaemic heart disease (27.6% of deaths), atrial fibrillation (23.1% of deaths) and chronic renal failure (20.2% of deaths).
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The virus is thought to be of natural animal origin, most likely through spillover infection. A joint-study conducted in early 2021 by the People's Republic of China and the World Health Organization indicated that the virus descended from a coronavirus that infects wild bats, and likely spread to humans through an intermediary wildlife host. There are several theories about where the index case originated and investigations into the origin of the pandemic are ongoing. According to articles published in July 2022 in Science, virus transmission into humans occurred through two spillover events in November 2019 and was likely due to live wildlife trade on the Huanan wet market in the city of Wuhan (Hubei, China). Doubts about the conclusions have mostly centred on the precise site of spillover. Earlier phylogenetics estimated that SARS-CoV-2 arose in October or November 2019. A phylogenetic algorithm analysis suggested that the virus may have been circulating in Guangdong before Wuhan. U.S intelligence agencies and other scientists have found that the virus may have been unintentionally leaked from a laboratory such as the Wuhan Institute of Virology, but that it was not developed as a biological weapon and is unlikely to have been genetically engineered.
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The first confirmed human infections were in Wuhan. A study of the first 41 cases of confirmed COVID‑19, published in January 2020 in "The Lancet", reported the earliest date of onset of symptoms as 1December 2019. Official publications from the WHO reported the earliest onset of symptoms as 8December 2019. Human-to-human transmission was confirmed by the WHO and Chinese authorities by 20 January 2020. According to official Chinese sources, these were mostly linked to the Huanan Seafood Wholesale Market, which also sold live animals. In May 2020, George Gao, the director of the CDC, said animal samples collected from the seafood market had tested negative for the virus, indicating that the market was the site of an early superspreading event, but that it was not the site of the initial outbreak. Traces of the virus have been found in wastewater samples that were collected in Milan and Turin, Italy, on 18 December 2019.
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By December 2019, the spread of infection was almost entirely driven by human-to-human transmission. The number of COVID-19 cases in Hubei gradually increased, reaching sixty by 20 December, and at least 266 by 31 December. On 24 December, Wuhan Central Hospital sent a bronchoalveolar lavage fluid (BAL) sample from an unresolved clinical case to sequencing company Vision Medicals. On 27 and 28 December, Vision Medicals informed the Wuhan Central Hospital and the Chinese CDC of the results of the test, showing a new coronavirus. A pneumonia cluster of unknown cause was observed on 26 December and treated by the doctor Zhang Jixian in Hubei Provincial Hospital, who informed the Wuhan Jianghan CDC on 27 December. On 30 December, a test report addressed to Wuhan Central Hospital, from company CapitalBio Medlab, stated an erroneous positive result for SARS, causing a group of doctors at Wuhan Central Hospital to alert their colleagues and relevant hospital authorities of the result. The Wuhan Municipal Health Commission issued a notice to various medical institutions on "the treatment of pneumonia of unknown cause" that same evening. Eight of these doctors, including Li Wenliang (punished on 3January), were later admonished by the police for spreading false rumours and another, Ai Fen, was reprimanded by her superiors for raising the alarm.
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During the early stages of the outbreak, the number of cases doubled approximately every seven and a half days. In early and mid-January 2020, the virus spread to other Chinese provinces, helped by the Chinese New Year migration and Wuhan being a transport hub and major rail interchange. On 20 January, China reported nearly 140 new cases in one day, including two people in Beijing and one in Shenzhen. Later official data shows 6,174 people had already developed symptoms by then, and more may have been infected. A report in "The Lancet" on 24 January indicated human transmission, strongly recommended personal protective equipment for health workers, and said testing for the virus was essential due to its "pandemic potential". On 30 January, the WHO declared COVID-19 a Public Health Emergency of International Concern. By this time, the outbreak spread by a factor of 100 to 200 times.
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RT-PCR testing of untreated wastewater samples from Brazil and Italy have suggested detection of SARS-CoV-2 as early as November and December 2019, respectively, but the methods of such sewage studies have not been optimised, many have not been peer-reviewed, details are often missing, and there is a risk of false positives due to contamination or if only one gene target is detected. A September 2020 review journal article said, "The possibility that the COVID‑19 infection had already spread to Europe at the end of last year is now indicated by abundant, even if partially circumstantial, evidence," including pneumonia case numbers and radiology in France and Italy in November and December.
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Modelling research has been conducted with several objectives, including predictions of the dynamics of transmission, diagnosis and prognosis of infection, estimation of the impact of interventions, or allocation of resources. Modelling studies are mostly based on compartmental models in epidemiology, estimating the number of infected people over time under given conditions. Several other types of models have been developed and used during the COVID‑19 including computational fluid dynamics models to study the flow physics of COVID‑19, retrofits of crowd movement models to study occupant exposure, mobility-data based models to investigate transmission, or the use of macroeconomic models to assess the economic impact of the pandemic. Further, conceptual frameworks from crisis management research have been applied to better understand the effects of COVID‑19 on organisations worldwide.
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In June, initial results from the randomised RECOVERY Trial in the United Kingdom showed that dexamethasone reduced mortality by one third for people who are critically ill on ventilators and one fifth for those receiving supplemental oxygen. Because this is a well-tested and widely available treatment, it was welcomed by the WHO, which is in the process of updating treatment guidelines to include dexamethasone and other steroids. Based on those preliminary results, dexamethasone treatment has been recommended by the NIH for patients with COVID‑19 who are mechanically ventilated or who require supplemental oxygen but not in patients with COVID‑19 who do not require supplemental oxygen.
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A cytokine storm can be a complication in the later stages of severe COVID‑19. A cytokine storm is a potentially deadly immune reaction where a large amount of pro-inflammatory cytokines and chemokines are released too quickly. A cytokine storm can lead to ARDS and multiple organ failure. Data collected from Jin Yin-tan Hospital in Wuhan, China indicates that patients who had more severe responses to COVID‑19 had greater amounts of pro-inflammatory cytokines and chemokines in their system than patients who had milder responses. These high levels of pro-inflammatory cytokines and chemokines indicate presence of a cytokine storm.
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Tocilizumab has been included in treatment guidelines by China's National Health Commission after a small study was completed. It is undergoing a PhaseII non-randomised trial at the national level in Italy after showing positive results in people with severe disease. Combined with a serum ferritin blood test to identify a cytokine storm (also called cytokine storm syndrome, not to be confused with cytokine release syndrome), it is meant to counter such developments, which are thought to be the cause of death in some affected people. The interleukin-6 receptor (IL-6R) antagonist was approved by the FDA to undergo a PhaseIII clinical trial assessing its effectiveness on COVID‑19 based on retrospective case studies for the treatment of steroid-refractory cytokine release syndrome induced by a different cause, CAR T cell therapy, in 2017. There is no randomised, controlled evidence that tocilizumab is an efficacious treatment for CRS. Prophylactic tocilizumab has been shown to increase serum IL-6 levels by saturating the IL-6R, driving IL-6 across the blood–brain barrier, and exacerbating neurotoxicity while having no effect on the incidence of CRS.
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Transferring purified and concentrated antibodies produced by the immune systems of those who have recovered from COVID‑19 to people who need them is being investigated as a non-vaccine method of passive immunisation. Viral neutralisation is the anticipated mechanism of action by which passive antibody therapy can mediate defence against SARS-CoV-2. The spike protein of SARS-CoV-2 is the primary target for neutralising antibodies. As of 8August 2020, eight neutralising antibodies targeting the spike protein of SARS-CoV-2 have entered clinical studies. It has been proposed that selection of broad-neutralising antibodies against SARS-CoV-2 and SARS-CoV might be useful for treating not only COVID‑19 but also future SARS-related CoV infections. Other mechanisms, however, such as antibody-dependant cellular cytotoxicity or phagocytosis, may be possible. Other forms of passive antibody therapy, for example, using manufactured monoclonal antibodies, are in development.
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The use of passive antibodies to treat people with active COVID‑19 is also being studied. This involves the production of convalescent serum, which consists of the liquid portion of the blood from people who recovered from the infection and contains antibodies specific to this virus, which is then administered to active patients. This strategy was tried for SARS with inconclusive results. An updated Cochrane review in May 2021 found high certainty evidence that, for the treatment of people with moderate to severe COVID‑19, convalescent plasma did not reduce mortality or bring about symptom improvement. There continues to be uncertainty about the safety of convalescent plasma administration to people with COVID‑19 and differing outcomes measured in different studies limits their use in determining efficacy.
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Sexual intercourse (or coitus or copulation) is a sexual activity typically involving the insertion and thrusting of the penis into the vagina for sexual pleasure or reproduction. This is also known as vaginal intercourse or vaginal sex. Other forms of penetrative sexual intercourse include anal sex (penetration of the anus by the penis), oral sex (penetration of the mouth by the penis or oral penetration of the female genitalia), fingering (sexual penetration by the fingers) and penetration by use of a dildo (especially a strap-on dildo). These activities involve physical intimacy between two or more individuals and are usually used among humans solely for physical or emotional pleasure and can contribute to human bonding.
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There are different views on what constitutes sexual intercourse or other sexual activity, which can impact on views on sexual health. Although "sexual intercourse", particularly the term "coitus," generally denotes penile–vaginal penetration and the possibility of creating offspring, it also commonly denotes penetrative oral sex and penile–anal sex, especially the latter. It usually encompasses sexual penetration, while non-penetrative sex has been labeled "outercourse", but non-penetrative sex may also be considered sexual intercourse. "Sex", often a shorthand for "sexual intercourse", can mean any form of sexual activity. Because people can be at risk of contracting sexually transmitted infections during these activities, safer sex practices are recommended by health professionals to reduce transmission risk.
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Reproductive sexual intercourse between non-human animals is more often called "copulation", and sperm may be introduced into the female's reproductive tract in non-vaginal ways among the animals, such as by cloacal copulation. For most non-human mammals, mating and copulation occur at the point of estrus (the most fertile period of time in the female's reproductive cycle), which increases the chances of successful impregnation. However, bonobos, dolphins and chimpanzees are known to engage in sexual intercourse regardless of whether the female is in estrus, and to engage in sex acts with same-sex partners. Like humans engaging in sexual activity primarily for pleasure, this behavior in these animals is also presumed to be for pleasure, and a contributing factor to strengthening their social bonds.
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"Sexual intercourse" may be called "coitus", "copulation", "coition", or "intercourse". "Coitus" is derived from the Latin word "coitio" or "coire", meaning "a coming together or joining together" or "to go together", and is known under different ancient Latin names for a variety of sexual activities, but usually denotes penile–vaginal penetration. This is often called "vaginal intercourse" or "vaginal sex." "Vaginal sex," and less often "vaginal intercourse", may also denote any vaginal sexual activity, particularly if penetrative, including sexual activity between lesbian couples. "Copulation", by contrast, more often denotes the mating process, especially for non-human animals; it can mean a variety of sexual activities between opposite-sex or same-sex pairings, but generally means the sexually reproductive act of transferring sperm from a male to a female or sexual procreation between a man and a woman.
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Although "sex" and "having sex" also most commonly denote penile–vaginal intercourse, "sex" can be significantly broad in its meaning and may cover any penetrative or non-penetrative sexual activity between two or more people. The World Health Organization (WHO) states that non-English languages and cultures use different words for sexual activity, "with slightly different meanings". Various vulgarisms, slang, and euphemisms are used for sexual intercourse or other sexual activity, such as "fuck", "shag", and the phrase "sleep together". The laws of some countries use the euphemism "carnal knowledge". Penetration of the vagina by the erect penis is additionally known as "intromission", or by the Latin name "immissio penis" (Latin for "insertion of the penis"). The age of first sexual intercourse is called "sexarche".
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Vaginal, anal and oral sex are recognized as sexual intercourse more often than other sexual behaviors. Sexual activity that does not involve penile-vaginal sex or other sexual penetration might be used to retain virginity (sometimes called "technical virginity)" or labeled "outercourse". One reason virginity loss is often based on penile–vaginal intercourse is because heterosexual couples may engage in anal or oral sex as a way of being sexually active while maintaining that they are virgins since they have not engaged in the reproductive act of coitus. Some gay men consider frotting or oral sex as a way of maintaining their virginities, with penile-anal penetration used as sexual intercourse and for virginity loss, while other gay men may consider frotting or oral sex as their main forms of sexual activity. Lesbians may categorize oral sex or fingering as sexual intercourse and subsequently an act of virginity loss, or tribadism as a primary form of sexual activity.
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Researchers commonly use "sexual intercourse" to denote penile–vaginal intercourse while using specific words, such as "anal sex" or "oral sex", for other sexual behaviors. Scholars Richard M. Lerner and Laurence Steinberg state that researchers also "rarely disclose" how they conceptualize sex "or even whether they resolved potential discrepancies" in conceptualizations of sex. Lerner and Steinberg attribute researchers' focus on penile–vaginal sex to "the larger culture's preoccupation with this form of sexual activity," and have expressed concern that the "widespread, unquestioned equation of penile–vaginal intercourse with sex reflects a failure to examine systematically 'whether the respondent's understanding of the question [about sexual activity] matches what the researcher had in mind'". This focus can also relegate other forms of mutual sexual activity to foreplay or contribute to them not being regarded as "real sex", and limits the meaning of rape. It may also be that conceptually conflating sexual activity with vaginal intercourse and sexual function hinders and limits information about sexual behavior that non-heterosexual people may be engaging in, or information about heterosexuals who may be engaging in non–vaginal sexual activity.
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Studies regarding the meaning of sexual intercourse sometimes conflict. While most consider penile–vaginal intercourse to be sex, whether anal or oral intercourse are considered sex is more debatable, with oral sex ranking lowest. The Centers for Disease Control and Prevention (CDC) stated that "although there are only limited national data about how often adolescents engage in oral sex, some data suggest that many adolescents who engage in oral sex do not consider it to be 'sex'; therefore they may use oral sex as an option to experience sex while still, in their minds, remaining abstinent". Upton et al. stated, "It is possible that individuals who engage in oral sex, but do not consider it as 'sex', may not associate the acts with the potential health risks they can bring." In other cases, condom use is a factor, with some men stating that sexual activity involving the protection of a condom is not "real sex" or "the real thing". This view is common among men in Africa, where sexual activity involving the protection of a condom is often associated with emasculation because condoms prevent direct penile–to–skin genital contact.
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Natural human reproduction involves penile–vaginal penetration, during which semen, containing male gametes known as sperm cells or spermatozoa, is expelled via ejaculation through the penis into the vagina. The sperm passes through the vaginal vault, cervix and into the uterus, and then into the fallopian tubes. Millions of sperm are present in each ejaculation to increase the chances of fertilization (see sperm competition), but only one reaching an egg or ovum is sufficient to achieve fertilization. When a fertile ovum from the female is present in the fallopian tubes, the male gamete joins with the ovum, resulting in fertilization and the formation of a new embryo. When a fertilized ovum reaches the uterus, it becomes implanted in the lining of the uterus (the endometrium) and a pregnancy begins.
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When a sperm donor has sexual intercourse with a woman who is not his partner and for the sole purpose of impregnating the woman, this may be known as natural insemination, as opposed to artificial insemination. Artificial insemination is a form of assisted reproductive technology, which are methods used to achieve pregnancy by artificial or partially artificial means. For artificial insemination, sperm donors may donate their sperm through a sperm bank, and the insemination is performed with the express intention of attempting to impregnate the female; to this extent, its purpose is the medical equivalent of sexual intercourse. Reproductive methods also extend to gay and lesbian couples. For gay male pairings, there is the option of surrogate pregnancy; for lesbian couples, there is donor insemination in addition to choosing surrogate pregnancy.
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There are a variety of safe sex methods that are practiced by heterosexual and same-sex couples, including non-penetrative sex acts, and heterosexual couples may use oral or anal sex (or both) as a means of birth control. However, pregnancy can still occur with anal sex or other forms of sexual activity if the penis is near the vagina (such as during intercrural sex or other genital-genital rubbing) and its sperm is deposited near the vagina's entrance and travels along the vagina's lubricating fluids; the risk of pregnancy can also occur without the penis being near the vagina because sperm may be transported to the vaginal opening by the vagina coming in contact with fingers or other non-genital body parts that have come in contact with semen.
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Safe sex is a relevant harm reduction philosophy and condoms are used as a form of safe sex and contraception. Condoms are widely recommended for the prevention of sexually transmitted infections (STIs). According to reports by the National Institutes of Health (NIH) and World Health Organization (WHO), correct and consistent use of latex condoms reduces the risk of HIV/AIDS transmission by approximately 85–99% relative to risk when unprotected. Condoms are rarely used for oral sex and there is significantly less research on behaviors with regard to condom use for anal and oral sex. The most effective way to avoid sexually transmitted infections is to abstain from sexual intercourse, especially vaginal, anal, and oral sexual intercourse.
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Decisions and options concerning birth control can be affected by cultural reasons, such as religion, gender roles or folklore. In the predominantly Catholic countries Ireland, Italy and the Philippines, fertility awareness and the rhythm method are emphasized while disapproval is expressed with regard to other contraceptive methods. Worldwide, sterilization is a more common birth control method, and use of the intrauterine device (IUD) is the most common and effective way of reversible contraception. Conception and contraception are additionally a life-and-death situation in developing countries, where one in three women give birth before age 20; however, 90% of unsafe abortions in these countries could be prevented by effective contraception use.
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Regarding oral or anal intercourse, the CDC stated in 2009, "Studies indicate that oral sex is commonly practiced by sexually active male-female and same-gender couples of various ages, including adolescents." Oral sex is significantly more common than anal sex. The 2010 NSSHB study reported that vaginal intercourse was practiced more than insertive anal intercourse among men, but that 13% to 15% of men aged 25 to 49 practiced insertive anal intercourse. Receptive anal intercourse was infrequent among men, with approximately 7% of men aged 14 to 94 years old having said that they were a receptive partner during anal intercourse. The study said that fewer women reported engaging in anal sex than other partnered sexual behaviors. It was estimated that 10% to 14% of women aged 18 to 39 years old practiced anal sex in the past 90 days, and that most of the women who engage in anal sex said they practiced it once a month or a few times a year.
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In the third group, age of men and women at sexual initiation was more closely matched; there were two sub-groups, however. In non-Latin, Catholic countries (Poland and Lithuania are mentioned), age at sexual initiation was higher, suggesting later marriage and reciprocal valuing of male and female virginity. The same pattern of late marriage and reciprocal valuing of virginity was reflected in Singapore and Sri Lanka. The study considered China and Vietnam to also fall into this group, though data were not available. In northern and eastern European countries, age at sexual initiation was lower, with both men and women involved in sexual intercourse before any union formation; the study listed Switzerland, Germany and the Czech Republic as members of this group.
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Concerning United States data, tabulations by the National Center for Health Statistics report that the age of first sexual intercourse was 17.1 years for both males and females in 2010. The CDC stated that 45.5 percent of girls and 45.7 percent of boys had engaged in sexual activity by 19 in 2002; in 2011, reporting their research from 2006 to 2010, they stated that 43% of American unmarried teenage girls and 42% of American unmarried teenage boys have ever engaged in sexual intercourse. The CDC also reports that American girls will most likely lose their virginity to a boy who is 1 to 3 years older than they are. Between 1988 and 2002, the percentage of people in the U.S. who had sexual intercourse between the ages of 15 to 19 fell from 60 to 46 percent for never-married males, and from 51 to 46 percent for never-married females.
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In humans, sexual intercourse and sexual activity in general have been reported as having health benefits as varied as increased immunity by increasing the body's production of antibodies and subsequent lower blood pressure, and decreased risk of prostate cancer. Sexual intimacy and orgasms increase levels of the hormone oxytocin (also known as "the love hormone"), which can help people bond and build trust. Oxytocin is believed to have a more significant impact on women than on men, which may be why women associate sexual attraction or sexual activity with romance and love more than men do. A long-term study of 3,500 people between ages 18 and 102 by clinical neuropsychologist David Weeks indicated that, based on impartial ratings of the subjects' photographs, sex on a regular basis is associated with people looking significantly chronologically younger. However this does not imply causality.
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There are 19 million new cases of sexually transmitted infections every year in the U.S., and, in 2005, the World Health Organization (WHO) estimated that 448 million people aged 15–49 were infected per year with curable STIs (such as syphilis, gonorrhea and chlamydia). Some STIs can cause a genital ulcer; even if they do not, they increase the risk of both acquiring and passing on HIV up to ten-fold. Hepatitis B can also be transmitted through sexual contact. Globally, there are about 257 million chronic carriers of hepatitis B. HIV is one of the world's leading infectious killers; in 2010, approximately 30 million people were estimated to have died because of it since the beginning of the epidemic. Of the 2.7 million new HIV infections estimated to occur worldwide in 2010, 1.9 million (70%) were in Africa. The World Health Organization also stated that the "estimated 1.2 million Africans who died of HIV-related illnesses in 2010 comprised 69% of the global total of 1.8 million deaths attributable to the epidemic." It is diagnosed by blood tests, and while no cure has been found, it can be controlled by management through antiretroviral drugs for the disease, and patients can enjoy healthy and productive lives.
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In cases where infection is suspected, early medical intervention is highly beneficial in all cases. The CDC stated "the risk of HIV transmission from an infected partner through oral sex is much less than the risk of HIV transmission from anal or vaginal sex," but that "measuring the exact risk of HIV transmission as a result of oral sex is very difficult" and that this is "because most sexually active individuals practice oral sex in addition to other forms of sex, such as vaginal or anal sex, when transmission occurs, it is difficult to determine whether it occurred as a result of oral sex or other more risky sexual activities". They added that "several co-factors may increase the risk of HIV transmission through oral sex"; this includes ulcers, bleeding gums, genital sores, and the presence of other STIs.
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In 2005, the World Health Organization estimated that 123 million women become pregnant worldwide each year, and around 87 million of those pregnancies or 70.7% are unintentional. Approximately 46 million pregnancies per year reportedly end in induced abortion. Approximately 6 million U.S. women become pregnant per year. Out of known pregnancies, two-thirds result in live births and roughly 25% in abortions; the remainder end in miscarriage. However, many more women become pregnant and miscarry without even realizing it, instead mistaking the miscarriage for an unusually heavy menstruation. The U.S. teenage pregnancy rate fell by 27 percent between 1990 and 2000, from 116.3 pregnancies per 1,000 girls aged 15–19 to 84.5. This data includes live births, abortions, and fetal losses. Almost 1 million American teenage women, 10% of all women aged 15–19 and 19% of those who report having had intercourse, become pregnant each year.
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Sexual activity can increase the expression of a gene transcription factor called ΔFosB (delta FosB) in the brain's reward center; consequently excessively frequent engagement in sexual activity on a regular (daily) basis can lead to the overexpression of ΔFosB, inducing an addiction to sexual activity. Sexual addiction or hypersexuality is often considered an impulse control disorder or a behavioral addiction. It has been linked to atypical levels of dopamine, a neurotransmitter. This behavior is characterized by a fixation on sexual intercourse and disinhibition. It was proposed that this 'addictive behavior' be classified in DSM-5 as an impulsive–compulsive behavioral disorder. Addiction to sexual intercourse is thought to be genetically linked. Those having an addiction to sexual intercourse have a higher response to visual sexual cues in the brain. Those seeking treatment will typically see a physician for pharmacological management and therapy. One form of hypersexuality is Kleine–Levin syndrome. It is manifested by hypersomnia and hypersexuality and remains relatively rare.
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Sexual intercourse, when involving a male participant, often ends when the male has ejaculated, and thus the partner might not have time to reach orgasm. In addition, premature ejaculation (PE) is common, and women often require a substantially longer duration of stimulation with a sexual partner than men do before reaching an orgasm. Scholars, such as Weiten et al., state that "many couples are locked into the idea that orgasms should be achieved only through intercourse [penile-vaginal sex]," that "the word "foreplay" suggests that any other form of sexual stimulation is merely preparation for the 'main event'" and that "because women reach orgasm through intercourse less consistently than men," they are likelier than men to fake an orgasm to satisfy their sexual partners.
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In 1991, scholars from the Kinsey Institute stated, "The truth is that the time between penetration and ejaculation varies not only from man to man, but from one time to the next for the same man." They added that the appropriate length for sexual intercourse is the length of time it takes for both partners to be mutually satisfied, emphasizing that Kinsey "found that 75 percent of men ejaculated within two minutes of penetration. But he didn't ask if the men or their partners considered two minutes mutually satisfying" and "more recent research reports slightly longer times for intercourse". A 2008 survey of Canadian and American sex therapists stated that the average time for heterosexual intercourse (coitus) was 7 minutes and that 1 to 2 minutes was too short, 3 to 7 minutes was adequate and 7 to 13 minutes desirable, while 10 to 30 minutes was too long.
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Anorgasmia is regular difficulty reaching orgasm after ample sexual stimulation, causing personal distress. This is significantly more common in women than in men, which has been attributed to the lack of sex education with regard to women's bodies, especially in sex-negative cultures, such as clitoral stimulation usually being key for women to orgasm. The physical structure of coitus favors penile stimulation over clitoral stimulation; the location of the clitoris then usually necessitates manual or oral stimulation in order for the woman to achieve orgasm. Approximately 25% of women report difficulties with orgasm, 10% of women have never had an orgasm, and 40% or 40–50% have either complained about sexual dissatisfaction or experienced difficulty becoming sexually aroused at some point in their lives.
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Vaginismus is involuntary tensing of the pelvic floor musculature, making coitus, or any form of penetration of the vagina, distressing, painful and sometimes impossible for women. It is a conditioned reflex of the pubococcygeus muscle, and is sometimes referred to as the "PC muscle." Vaginismus can be hard to overcome because if a woman expects to experience pain during sexual intercourse, this can cause a muscle spasm, which results in painful sexual intercourse. Treatment of vaginismus often includes both psychological and behavioral techniques, including the use of vaginal dilators. Additionally, the use of Botox as a medical treatment for vaginismus has been tested and administered. Painful or uncomfortable sexual intercourse may also be categorized as dyspareunia.
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Approximately 40% of males reportedly have some form of erectile dysfunction (ED) or impotence, at least occasionally. Premature ejaculation has been reported to be more common than erectile dysfunction, although some estimates suggest otherwise. Due to various meanings of the disorder, estimates for the prevalence of premature ejaculation vary significantly more than for erectile dysfunction. For example, the Mayo Clinic states, "Estimates vary, but as many as 1 out of 3 men may be affected by [premature ejaculation] at some time." Further, "Masters and Johnson speculated that premature ejaculation is the most common sexual dysfunction, even though more men seek therapy for erectile difficulties" and that this is because "although an estimated 15 percent to 20 percent of men experience difficulty controlling rapid ejaculation, most do not consider it a problem requiring help, and many women have difficulty expressing their sexual needs". The American Urological Association (AUA) estimates that premature ejaculation could affect 21 percent of men in the United States.
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For those whose impotence is caused by medical conditions, prescription drugs such as Viagra, Cialis, and Levitra are available. However, doctors caution against the unnecessary use of these drugs because they are accompanied by serious risks such as increased chance of heart attack. The selective serotonin reuptake inhibitor (SSRI) and antidepressant drug dapoxetine has been used to treat premature ejaculation. In clinical trials, those with PE who took dapoxetine experienced sexual intercourse three to four times longer before orgasm than without the drug. Another ejaculation-related disorder is delayed ejaculation, which can be caused as an unwanted side effect of antidepressant medications such as fluvoxamine; however, all SSRIs have ejaculation-delaying effects, and fluvoxamine has the least ejaculation-delaying effects.
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Obstacles that those with disabilities face with regard to engaging in sexual intercourse include pain, depression, fatigue, negative body image, stiffness, functional impairment, anxiety, reduced libido, hormonal imbalance, and drug treatment or side effects. Sexual functioning has been regularly identified as a neglected area of the quality of life in patients with rheumatoid arthritis. For those that must take opioids for pain control, sexual intercourse can become more difficult. Having a stroke can also largely impact on the ability to engage in sexual intercourse. Although disability-related pain, including as a result of cancer, and mobility impairment can hamper sexual intercourse, in many cases, the most significant impediments to sexual intercourse for individuals with a disability are psychological. In particular, people who have a disability can find sexual intercourse daunting due to issues involving their self-concept as a sexual being, or a partner's discomfort or perceived discomfort. Temporary difficulties can arise with alcohol and sex, as alcohol can initially increase interest through disinhibition but decrease capacity with greater intake; however, disinhibition can vary depending on the culture.
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People with mental disabilities also are subject to challenges in participating in sexual intercourse. Women with intellectual disabilities (ID) are often presented with situations that prevent sexual intercourse. This can include the lack of a knowledgeable healthcare provider trained and experienced in counseling those with ID on sexual intercourse. Those with ID may have hesitations regarding the discussion of the topic of sex, a lack of sexual knowledge and limited opportunities for sex education. In addition there are other barriers such as a higher prevalence of sexual abuse and assault. These crimes often remain underreported. There remains a lack of "dialogue around this population's human right to consensual sexual expression, undertreatment of menstrual disorders, and legal and systemic barriers". Women with ID may lack sexual health care and sex education. They may not recognize sexual abuse. Consensual sexual intercourse is not always an option for some. Those with ID may have limited knowledge and access to contraception, screening for sexually transmitted infections and cervical cancer.
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Sexual dissatisfaction due to the lack of sexual intercourse is associated with increased risk of divorce and relationship dissolution, especially for men. Some research, however, indicates that general dissatisfaction with marriage for men results if their wives flirted with, erotically kissed or became romantically or sexually involved with another man (infidelity), and that this is especially the case for men with a lower emotional and composite marital satisfaction. Other studies report that the lack of sexual intercourse does not significantly result in divorce, though it is commonly one of the various contributors to it. According to the 2010 National Survey of Sexual Health and Behavior (NSSHB), men whose most recent sexual encounter was with a relationship partner reported greater arousal, greater pleasure, fewer problems with erectile function, orgasm, and less pain during the event than men whose last sexual encounter was with a non-relationship partner.
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Adolescents commonly use sexual intercourse for relational and recreational purposes, which may negatively or positively impact their lives. For example, while teenage pregnancy may be welcomed in some cultures, it is also commonly disparaged, and research suggests that the earlier onset of puberty for children puts pressure on children and teenagers to act like adults before they are emotionally or cognitively ready. Some studies have concluded that engaging in sexual intercourse leaves adolescents, especially girls, with higher levels of stress and depression, and that girls may be likelier to engage in sexual risk (such as sexual intercourse without the use of a condom), but it may be that further research is needed in these areas. In some countries, such as the United States, sex education and abstinence-only sex education curricula are available to educate adolescents about sexual activity; these programs are controversial, as debate exists as to whether teaching children and adolescents about sexual intercourse or other sexual activity should only be left up to parents or other caregivers.
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Some studies from the 1970s through 1990s suggested an association between self-esteem and sexual intercourse among adolescents, while other studies, from the 1980s and 1990s, reported that the research generally indicates little or no relationship between self-esteem and sexual activity among adolescents. By the 1990s, the evidence mostly supported the latter, and further research has supported little or no relationship between self-esteem and sexual activity among adolescents. Scholar Lisa Arai stated, "The idea that early sexual activity and pregnancy is linked to low self-esteem became fashionable in the latter half of the 20th century, particularly in the US," adding that, "Yet, in a systematic review of the relationship between self-esteem and teenagers' sexual behaviours, attitudes and intentions (which analyzed findings from 38 publications) 62% of behavioral findings and 72% of the attitudinal findings exhibited no statistically significant associations (Goodson et al, 2006)." Studies that do find a link suggest that non-virgin boys have higher self-esteem than virgin boys and that girls who have low self-esteem and poor self-image are more prone to risk-taking behaviors, such as unprotected sex and multiple sexual partners.
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Robert Francoeur et al. stated that "prior to the 1970s, rape definitions of sex often included only penile-vaginal sexual intercourse." Authors Pamela J. Kalbfleisch and Michael J. Cody stated that this made it so that if "sex means penile-vaginal intercourse, then rape means forced penile-vaginal intercourse, and other sexual behaviors – such as fondling a person's genitals without her or his consent, forced oral sex, and same-sex coercion – are not considered rape"; they stated that "although some other forms of forced sexual contact are included within the legal category of sodomy (e.g., anal penetration and oral-genital contact), many unwanted sexual contacts have no legal grounding as rape in some states". Ken Plumber argued that the legal meaning "of rape in most countries is unlawful sexual intercourse which means the penis must penetrate the vagina" and that "other forms of sexual violence towards women such as forced oral sex or anal intercourse, or the insertion of other objects into the vagina, constitute the 'less serious' crime of sexual assault".
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Over time, the meaning of rape broadened in some parts of the world to include many types of sexual penetration, including anal intercourse, fellatio, cunnilingus, and penetration of the genitals or rectum by an inanimate object. Until 2012, the Federal Bureau of Investigation (FBI) still considered rape a crime solely committed by men against women. In 2012, they changed the meaning from "The carnal knowledge of a female forcibly and against her will" to "The penetration, no matter how slight, of the vagina or anus with any body part or object, or oral penetration by a sex organ of another person, without the consent of the victim." The meaning does not change federal or state criminal codes or impact charging and prosecution on the federal, state or local level, but instead assures that rape will be more accurately reported nationwide. In some instances, penetration is not required for the act to be categorized as rape.
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In most societies around the world, the concept of incest exists and is criminalized. James Roffee, a senior lecturer in criminology at Monash University, addressed potential harm associated with familial sexual activity, such as resulting children born with deficiencies. However, the law is more concerned with protecting the rights of people who are potentially subjected to such abuse. This is why familial sexual relationships are criminalized, even if all parties are consensual. There are laws prohibiting all kinds of sexual activity between relatives, not necessarily penetrative sex. These laws refer to grandparents, parents, children, siblings, aunts and uncles. There are differences between states in terms of the severity of punishments and what they consider to be a relative, including biological parents, step-parents, adoptive parents and half-siblings.
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Sexual intercourse has traditionally been considered an essential part of a marriage, with many religious customs requiring consummation of the marriage and citing marriage as the most appropriate union for sexual reproduction (procreation). In such cases, a failure for any reason to consummate the marriage would be considered a ground for annulment (which does not require a divorce process). Sexual relations between marriage partners have been a "marital right" in various societies and religions, both historically and in modern times, especially with regard to a husband's rights to his wife. Until the late 20th century, there was usually a marital exemption in rape laws which precluded a husband from being prosecuted under the rape law for forced sex with his wife. Author Oshisanya, 'lai Oshitokunbo stated, "As the legal status of women has changed, the concept of a married man's or woman's marital right to sexual intercourse has become less widely held."
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There are various legal positions regarding the meaning and legality of sexual intercourse between persons of the same sex or gender. For example, in the 2003 New Hampshire Supreme Court case Blanchflower v. Blanchflower, it was held that female same-sex sexual relations, and same-sex sexual practices in general, did not constitute sexual intercourse, based on a 1961 entry in "Webster's Third New International Dictionary" that categorizes sexual intercourse as coitus; and thereby an accused wife in a divorce case was found not guilty of adultery. Some countries consider same-sex sexual behavior an offense punishable by imprisonment or execution; this is the case, for example, in Islamic countries, including LGBT issues in Iran.
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For primitive insects, the male deposits spermatozoa on the substrate, sometimes stored within a special structure; courtship involves inducing the female to take up the sperm package into her genital opening, but there is no actual copulation. In groups that have reproduction similar to spiders, such as dragonflies, males extrude sperm into secondary copulatory structures removed from their genital opening, which are then used to inseminate the female. In dragonflies, it is a set of modified sternites on the second abdominal segment. In advanced groups of insects, the male uses its aedeagus, a structure formed from the terminal segments of the abdomen, to deposit sperm directly (though sometimes in a capsule called a "spermatophore") into the female's reproductive tract.
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The bachelor of arts (BA) degree is an undergraduate postsecondary degree that puts a focus on liberal arts and studies. In comparison, a bachelor of science (BS) has a greater focus on science, math, and engineering. The bachelor of arts degree is a type of baccalaureate degree. A bachelor of arts degree is usually completed in four years because it requires four years of full-time coursework to earn. However, just as with other degrees, some may require a longer time period. This is due to factors such as the student's ability, motivation, and access to financial assistance to earn the degree. Just like other baccalaureate degrees, a bachelor of arts is traditionally offered only at public and private four-year universities and colleges. A bachelor of arts, just like other bachelor's degrees is an admission requirement for graduate and professional school. Beginning in the 1990s, community colleges started to confer their own baccalaureate degrees. In addition to the standard BA degrees, there are career-specific bachelor of arts degrees, including bachelor of arts in administration, bachelor of arts in interdisciplinary studies, and regents bachelor of arts.
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In Germany, university-level education usually happens in either a "Universität" (plural: "Universitäten") or a "Fachhochschule" (plural: "Fachhochschulen"); both can be referred to as a "Hochschule", which is the generic term in Germany for all institutions awarding academic degrees. Fachhochschule is often translated as "University of Applied Sciences". "Universitäten" place greater emphasis on fundamental science and background in theory, while "Fachhochschulen" are generally designed with a focus on teaching professional skills. Degrees earned at "Universitäten" and "Fachhochschulen" are legally equivalent.
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In the Netherlands, the BA and Master of Arts (MA) degrees were introduced in 2002. Until then, a single program led to the "doctorandus" degree (abbreviated drs.), which comprised the same course load as the bachelor's and master's programs combined. The title "doctorandus" was used in almost all fields of study; other titles were used for legal studies ("meester", Dutch for master, abbreviated "Mr.") and engineering ("ingenieur", abbreviated ir. for academic masters level or ing. for higher vocational bachelors level). Those who had already started the "doctorandus" program could, on completing it, opt for the "doctorandus" degree (entitling them to use "drs." in front of their name) or could use the master's degree (postnominal letters) in accordance with the new standard. When attaining a master level/graduate degree, it is still customary to use either drs. pre-nominally or MA/MSc post-nominally at the discretion of the holder.
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In the United Kingdom (excluding Scotland) and Ireland, the first degree course normally lasts three years, but nomenclature varies: 19th-century and later universities usually distinguish between arts and sciences subjects by awarding either a BA or BSc degree. However, some older or ancient universities, such as Oxford, Cambridge and Dublin traditionally award BAs to undergraduates having completed the final examinations, e.g., Part II Tripos (Cambridge), Final Honour Schools (Oxford), Moderatorship (Dublin), in most subjects including the sciences. Some new plate glass universities established in the 1960s, such as York and Lancaster originally followed the practice of Oxford and Cambridge by awarding BAs in all subjects, but have since changed to awarding BSc degrees in science subjects. At Oxford, Cambridge, and Dublin the degree of MA can be claimed, usually twenty-one terms after matriculation. For many centuries, the bachelor's degree was an intermediate step and was awarded for much of the work carried out in later times at secondary schools. The names of the final secondary school exams in France and Spain (and increasingly in the UK—the International Baccalaureate) come from this: le Baccalauréat and el "Bachillerato", respectively.
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A bachelor of arts is entitled to the designation BA for an ordinary/pass degree and BA (Hons) for an honours degree. Students who completed an honours BA sometimes style themselves by '(Hon)' or '(Hons)' after the degree abbreviation in parentheses. An honours degree is always awarded in one of four classes depending upon the marks gained in the final assessments and examinations. The top students are awarded a first-class degree, followed by an upper second-class degree (usually referred to as a 2:1), a lower second-class degree (usually referred to as a 2:2), and those with the lowest marks gain a third-class degree. An ordinary or unclassified degree (which does not give the graduate the right to add '(Hons)') may be awarded if a student has completed the full honours degree course but has not obtained the total required passes sufficient to merit a third-class honours degree. Typically these degrees lack the final year requirement of a dissertation.
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In colleges and universities in Australia, New Zealand, Nepal, and South Africa, the BA degree can be taken over three years of full-time study. Students must pursue at least one major area of study and units from that subject are usually studied in each year, though sometimes students may choose to complete upper-level classes in the same year and as a result, can leave space for elective subjects from a different field. At some universities, students may choose to pursue a second major; alternatively, the remainder of the degree is taken up with a minor area of study (in the first two years) and other individual or stream-based subjects. Honours is an additional year of study after the BA degree, that combines aspects of undergraduate study with those of postgraduate research. Entry to the honours program is usually highly selective.
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Network nodes can validate transactions, add them to their copy of the ledger, and then broadcast these ledger additions to other nodes. To achieve independent verification of the chain of ownership, each network node stores its own copy of the blockchain. At varying intervals of time averaging to every 10 minutes, a new group of accepted transactions, called a block, is created, added to the blockchain, and quickly published to all nodes, without requiring central oversight. This allows bitcoin software to determine when a particular bitcoin was spent, which is needed to prevent double-spending. A conventional ledger records the transfers of actual bills or promissory notes that exist apart from it, but the blockchain is the only place where bitcoins can be said to exist in the form of unspent outputs of transactions.
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Transactions are defined using a Forth-like scripting language. Transactions consist of one or more "inputs" and one or more "outputs". When a user sends bitcoins, the user designates each address and the amount of bitcoin being sent to that address in an output. To prevent double spending, each input must refer to a previous unspent output in the blockchain. The use of multiple inputs corresponds to the use of multiple coins in a cash transaction. Since transactions can have multiple outputs, users can send bitcoins to multiple recipients in one transaction. As in a cash transaction, the sum of inputs (coins used to pay) can exceed the intended sum of payments. In such a case, an additional output is used, returning the change back to the payer. Any input "satoshis" not accounted for in the transaction outputs become the transaction fee.
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In the blockchain, bitcoins are registered to bitcoin addresses. Creating a bitcoin address requires nothing more than picking a random valid private key and computing the corresponding bitcoin address. This computation can be done in a split second. But the reverse, computing the private key of a given bitcoin address, is practically unfeasible. Users can tell others or make public a bitcoin address without compromising its corresponding private key. Moreover, the number of valid private keys is so vast that it is extremely unlikely someone will compute a key pair that is already in use and has funds. The vast number of valid private keys makes it unfeasible that brute force could be used to compromise a private key. To be able to spend their bitcoins, the owner must know the corresponding private key and digitally sign the transaction. The network verifies the signature using the public key; the private key is never revealed.
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To be accepted by the rest of the network, a new block must contain a "proof-of-work" (PoW). The PoW requires miners to find a number called a "nonce" (a number used just once), such that when the block content is hashed along with the nonce, the result is numerically smaller than the network's "difficulty target". This proof is easy for any node in the network to verify, but extremely time-consuming to generate, as for a secure cryptographic hash, miners must try many different nonce values (usually the sequence of tested values is the ascending natural numbers: 0, 1, 2, 3, ...) before a result happens to be less than the difficulty target. Because the difficulty target is extremely small compared to a typical SHA-256 hash, block hashes have many leading zeros as can be seen in this example block hash:
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By adjusting this difficulty target, the amount of work needed to generate a block can be changed. Every 2,016 blocks (approximately 14 days given roughly 10 minutes per block), nodes deterministically adjust the difficulty target based on the recent rate of block generation, with the aim of keeping the average time between new blocks at ten minutes. In this way the system automatically adapts to the total amount of mining power on the network. , it takes on average 122 sextillion (122 thousand billion billion) attempts to generate a block hash smaller than the difficulty target. Computations of this magnitude are extremely expensive and utilize specialized hardware.
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The successful miner finding the new block is allowed by the rest of the network to collect for themselves all transaction fees from transactions they included in the block, as well as a predetermined reward of newly created bitcoins. , this reward is currently ₿6.25 in newly created bitcoins per block. To claim this reward, a special transaction called a "coinbase" is included in the block, with the miner as the payee. All bitcoins in existence have been created through this type of transaction. The bitcoin protocol specifies that the reward for adding a block will be reduced by half every 210,000 blocks (approximately every four years). Eventually, the reward will round down to zero, and the limit of ₿21 million is expected to be reached 2140 at current rates; the record keeping will then be rewarded by transaction fees only.
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Conversely, researchers have pointed out a "trend towards centralization". Although bitcoin can be sent directly from user to user, in practice intermediaries are widely used. Bitcoin miners join large mining pools to minimize the variance of their income. Because transactions on the network are confirmed by miners, decentralization of the network requires that no single miner or mining pool obtains 51% of the hashing power, which would allow them to double-spend coins, prevent certain transactions from being verified and prevent other miners from earning income. just six mining pools controlled 75% of overall bitcoin hashing power. In 2014 mining pool Ghash.io obtained 51% hashing power which raised significant controversies about the safety of the network. The pool has voluntarily capped its hashing power at 39.99% and requested other pools to act responsibly for the benefit of the whole network. Around the year 2017, over 70% of the hashing power and 90% of transactions were operating from China.
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Bitcoin is pseudonymous, meaning that funds are not tied to real-world entities but rather bitcoin addresses. Owners of bitcoin addresses are not explicitly identified, but all transactions on the blockchain are public. In addition, transactions can be linked to individuals and companies through "idioms of use" (e.g., transactions that spend coins from multiple inputs indicate that the inputs may have a common owner) and corroborating public transaction data with known information on owners of certain addresses. Additionally, bitcoin exchanges, where bitcoins are traded for traditional currencies, may be required by law to collect personal information. To heighten financial privacy, a new bitcoin address can be generated for each transaction.
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The first wallet program, simply named "Bitcoin", and sometimes referred to as the "Satoshi client", was released in 2009 by Satoshi Nakamoto as open-source software. In version 0.5 the client moved from the wxWidgets user interface toolkit to Qt, and the whole bundle was referred to as "Bitcoin-Qt". After the release of version 0.9, the software bundle was renamed "Bitcoin Core" to distinguish itself from the underlying network. Bitcoin Core is, perhaps, the best known implementation or client. Alternative clients (forks of Bitcoin Core) exist, such as Bitcoin XT, Bitcoin Unlimited, and Parity Bitcoin.
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Physical wallets can also take the form of metal token coins with a private key accessible under a security hologram in a recess struck on the reverse side. The security hologram self-destructs when removed from the token, showing that the private key has been accessed. Originally, these tokens were struck in brass and other base metals, but later used precious metals as bitcoin grew in value and popularity. Coins with stored face value as high as ₿1,000 have been struck in gold. The British Museum's coin collection includes four specimens from the earliest series of funded bitcoin tokens; one is currently on display in the museum's money gallery. In 2013, a Utah manufacturer of these tokens was ordered by the Financial Crimes Enforcement Network (FinCEN) to register as a money services business before producing any more funded bitcoin tokens.
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The receiver of the first bitcoin transaction was Hal Finney, who had created the first reusable proof-of-work system (RPoW) in 2004. Finney downloaded the bitcoin software on its release date, and on 12 January 2009 received ten bitcoins from Nakamoto. Other early cypherpunk supporters were creators of bitcoin predecessors: Wei Dai, creator of b-money, and Nick Szabo, creator of bit gold. In 2010, the first known commercial transaction using bitcoin occurred when programmer Laszlo Hanyecz bought two Papa John's pizzas for ₿10,000 from Jeremy Sturdivant.
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On 1 November 2011, the reference implementation Bitcoin-Qt version 0.5.0 was released. It introduced a front end that used the Qt user interface toolkit. The software previously used Berkeley DB for database management. Developers switched to LevelDB in release 0.8 in order to reduce blockchain synchronization time. The update to this release resulted in a minor blockchain fork on 11 March 2013. The fork was resolved shortly afterwards. Seeding nodes through IRC was discontinued in version 0.8.2. From version 0.9.0 the software was renamed to Bitcoin Core. Transaction fees were reduced again by a factor of ten as a means to encourage microtransactions. Although Bitcoin Core does not use OpenSSL for the operation of the network, the software did use OpenSSL for remote procedure calls. Version 0.9.1 was released to remove the network's vulnerability to the Heartbleed bug.
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In March 2013 the blockchain temporarily split into two independent chains with different rules due to a bug in version 0.8 of the bitcoin software. The two blockchains operated simultaneously for six hours, each with its own version of the transaction history from the moment of the split. Normal operation was restored when the majority of the network downgraded to version 0.7 of the bitcoin software, selecting the backwards-compatible version of the blockchain. As a result, this blockchain became the longest chain and could be accepted by all participants, regardless of their bitcoin software version. During the split, the Mt. Gox exchange briefly halted bitcoin deposits and the price dropped by 23% to $37 before recovering to the previous level of approximately $48 in the following hours.
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On 15 May 2013, US authorities seized accounts associated with Mt. Gox after discovering it had not registered as a money transmitter with FinCEN in the US. On 23 June 2013, the US Drug Enforcement Administration listed ₿11.02 as a seized asset in a United States Department of Justice seizure notice pursuant to 21 U.S.C. § 881. This marked the first time a government agency had seized bitcoin. The FBI seized about ₿30,000 in October 2013 from the dark web website Silk Road, following the arrest of Ross William Ulbricht. These bitcoins were sold at blind auction by the United States Marshals Service to venture capital investor Tim Draper. Bitcoin's price rose to $755 on 19 November and crashed by 50% to $378 the same day. On 30 November 2013, the price reached $1,163 before starting a long-term crash, declining by 87% to $152 in January 2015.
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