10 Tips for an Amazing Valentines Day

Valentines Day, also known as Saint Valentines Day, is a holiday which is celebrated each year on February 14^th.  Valentines Day is the traditional day in which lovers express their love for each other by sending each other Valentines cards, flowers, or candy.  The holiday is named after two Christian martyrs named Valentine.  They became associated with romantic love and the day came to be. 

Today, most people associate Valentines Day with the exchange of love notes and other symbols of their love.  If you are looking for some ways to show your love this Valentines Day, here are some tips to get you started:

Tip #1 – One of the best things you can do on Valentines Day is to write your lover a love note.  Don’t send an electronic greeting or purchase a card, spend the time to write an actual, traditional love note to someone you care about.  Your love note does not need to be long; however, it needs to be handwritten with some thought having gone into it.

Tip #2 – If you have zero writing skills, then instead of an all out love note, you can write down a list of the things you love about your lover.  A simple “I love you because…” list can go a long way to showing someone how you care about them. 

Tip #3 – Place your love note on your lover’s pillow or if you will not see each other in the morning then you can have it delivered to them with some flowers or candy. 

Tip #4 – If you want to add some creativity to your Valentines Day gift then you can create a scavenger hunt which your lover will have to follow around your house to find their gift.  You can leave clues around the house which all lead your lover to find the next clue, and then ultimately to find your gift to them. 

Tip #5 – If you have a variety of gifts for your lover then you can start at the front door and run a string from one gift to another.  By doing this, your lover has to follow the string to get to their next gift.  You can use inexpensive kite string from the dollar store to string your gifts together. 

Tip #6 – Rather than going out and fighting the crowds on Valentines Day, you can celebrate it at home by cooking for your lover, or you and your lover can cook a meal for each other, together.  Cooking at home can be both romantic and a lot more fun than going out and paying for an expensive meal out. 

Tip #7 – If you are looking for a non-traditional gift to give to your lover this Valentines Day, consider making some coupons for them that they can redeem for a variety of things throughout the year.  You can make them for simple things like washing their car, or for more sensual gifts.  Thanks to home computers and cool paper, you can make some really great coupons or gift certificates in the comfort of your own home. 

Tip #8 – If you are single this Valentines Day, there are many fun ways which you can spend the day or evening with friends.  On fun way to spend the evening is to have a “Valentines Day Sucks” party with your other single friends.  Each friend brings a romantic comedy movie and their favorite junk food to the event.  You spend the evening making fun of sappy movies and eating as much junk food as you want, just for one evening.

Tip #9 – Another fun way to spend Valentines Day if you do not have a lover to share it with, is to go to a very expensive restaurant with a friend and order the foods you have always wanted to try – including desert.  Take a long evening to enjoy the food and company of a good friend. 

Tip #10 – If you will not be seeing your lover until a day or two after the big holiday, you can wait to purchase your flowers or candy until the later date and save a ton of cash. 

Fire Safety and Insurance

Insurance is one of the things which are not thought about until when asked for. If you own a house, the whole responsibility is on you. But if you are living in a rented apartment, and there is fire due to a burning pan left by your neighbor unattended, it will be your responsibility again because you didn’t buy a renter’s insurance. Therefore, everyone is prone to danger; no matter if the fire is due to human err of a natural disaster. 

Renter’s insurance dose not cost more than a pizza deliver in a month. Majority of the renter’s insurance plans cover fire damages too. Discussions can be made with the insurance agents and insurance plans can be selected which covers the needs. Some insurance plans even cover really valuable objects such as your wedding rings. When buying a fire insurance policy it is necessary to think more than the house value. Suppose if the cost of the house is $200,000 and the insurance only covers the structure cost, then it would easily take more than this amount  to rebuild the house in case of any disaster. This estimate included everything from rebuilding the house to possessions like jewelry to flatware. It is important that owners and renters make an inventories of the objects they posses in their homes. It would be very smart to take pictures of the contents of your home and store it in a sage or a lock box in order to achieve peace of mind. When you go through the process of claims, many questions such as “How many dishes were there in the flatware?” will arise, which will be very difficult to answer then. 

Insurance companies will reduce the periodical premium to be paid if there are no bushes or flammable materials surrounding the house. In case of fire, the bushes or the flammable materials engulf the house and burns it down earlier than otherwise. Clearing these materials also helps to create defensible space for the firefighters. Although bushes provides a beautiful view, they also risks the life the inhabitants of the house.

If the insurance is claimed in case of accident, on one hand it will help to restore the damages but on the other hand this process will increase the periodical premium. So in every case, prevention is better than cure. Firstly install smoke detectors in the house, especially in kitchen and rooms in which the family sleeps. They should be checked every month and must be replaced if they are older than ten years. The oil burner should be checked periodically by a professional. Do not leave electric appliances such as dishwashers, washing machine, and heaters on when not at home or when you go to bed. Every floor of the home must be equipped with at least one fire extinguisher. 

House should have two exits so that if one of them is blocked, the other one can be used. It is better to have a fire safety plan before hand and let the whole family know about it. If there is a pet in the house, the plan should also include the pet. Be careful while burning candles because they produce lots of soot which can damage the ceilings, floors and walls. It can also damage the personal belongings. They should be burned in a safe place away from curtains, loose furniture fabric, people, children and pets. According to a research done by the Consumer Product Safety Commissions in 2001, fires caused by candles were due to existence of a combustible substance within close proximity of the candle. Another major reason for candle fire is tipping of candle by pets or children or knocking over by the wind. Extra care must be taken when burning gel candles as they burn longer than the wax candles, thus increasing the risk.

People usually are seen wondering whether they turned off the stove burner or not. People should make it a habit to double check electrical appliances and other instruments which can lead to fire, before leaving the house or before going to sleep.

Arisan Back Link

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cara ini bisa dipraktekkan siapa saja, intinya semua peserta ARISAN BACKLINK membuat posting yang disertakan daftar 10 link peserta lainnya, merubah urutannya dengan cara menaikkan 1 level keatas ( urutan nomor 1 hilang ) dan merubah daftar urut ke 10 dengan blog anda.
dengan kata lain, anda hanya meng-copy artikel ini dan mengedit daftar linknya saja seperti langkah diatas.

jika semuanya menjalankan yang sama, efeknya akan sangat luar biasa. daftar link yang harus anda pasang adalah :

1. download
2. funny video
3. seo
4. antivirus
5. ferdian
6. adsense tips
7. pemandu wisata
8. info artis
9. Therapy Article
10. Healthy Bloging

sebelum anda letakkan link diatas, anda harus menghapus peserta nomor 1 dari daftar. maka semua peserta posisinya menjadi naik 1 level. ( yang sebelumnya ada pada nomor 2 menjadi nomor 1, yang sebelumnya ada pada nomor 3 menjadi nomor 2, dan seterusnya. Kemudian masukkan link anda sendiri di bagian paling bawah (nomor 10).
bila setiap peserta berhasil mengajak 5 orang saja, maka jumlah backlink yang akan didapat adalah seperti berikut :

Ketika posisi link anda 10, jumlah backlink = 1

Posisi 9, jumlah backlink = 5

Posisi 8, jumlah backlink = 25

Posisi 7, jumlah backlink = 125

Posisi 6, jumlah backlink = 625

Posisi 5, jumlah backlink = 3,125

Posisi 4, jumlah backlink = 15,625

Posisi 3, jumlah backlink = 78,125

Posisi 2, jumlah backlink = 390,625

Posisi 1, jumlah backlink = 1,953,125


copy paste artikel ini lalu sarankan ke blogger yang lainnya!

terima kasih atas kunjungannya :) dukung terus

CAUSE OF OBESITY

Obesity is a serious problem. It happened because there is too much fat on human body. Basically fat that consumed were store into fat cell in case that body need more energy after calories from carbohydrate used up. And now lots of people eat lots of fat and rarely do significant physic activities while physic activities can burn the fat calories. This condition disturbs the balance of calories-in and out and it may bring bad diseases like diabetes, heart attack, stroke, arthritis, and maybe cancers. So this is why Obesity is a serious problem.

There are some causes of obesity, such as, consuming too many calories, consume something too much is not a good idea, hold your appetite for a while by drink water of eat vegetable. The next cause is sedentary lifestyle, people in this century waste lots of time by sit to watch TV, doing some papers, play video game, and far away from physic activities. Less sleeping time can twice the possibility of obesity, how come? By awake all night long, your body will produce lots of Ghrelin hormone that can stimulates your appetite and reduce Leptin hormone that can hold down your appetite. The last cause is medication treatment you may have, some medicine make your body needs to consume more calories than usual.

Carpal Tunnel Syndrome

Most of us follow a similar routine each day. From waking up in the morning until going to bed, many activities are the same from day to day. And many of us dosen’t understand what our body need actually. This includes work, whether it's sitting in front of a computer or operating machinery. And mostly,we just think about how we can work for my company but didn’t think about our healthy condition.

Repetition is a part of life, but it can occasionally bring about health problems. One such example that has shown to be related to work life is carpal tunnel syndrome (CTS). The repetitive motions involved in the tasks of computer users, assembly line workers, cashiers, and hairdressers put these individuals at greater risk. Other common causes include infections or growths, osteoarthritis, fluid build-up, and pregnancy.

But how do you know if you might have carpal tunnel syndrome? Below are a few key indicators:

• Numbness is one of the first signs of carpal tunnel syndrome. You may experience tingling sensation in your thumb or fingers, and any activities that require you to bend or flex your wrist will make the numbness worse. The numbness may subside only to reappear again, but if CTS worsens, the numbness will become more constant. Activities that may cause numbness include driving, writing, holding objects, combing your hair or simply sleeping in an uncomfortable position.
• Another common sign of carpal tunnel syndrome is a loss in strength and muscle. For example, you may begin to see your grip weakening, whether you're holding a book or carrying a bag. This is caused by increased pressure on the median nerve. Enduring cases of CTS will cause the muscles of your thumb to decrease in size over time.
• In correlation with a decrease in strength is the increase in dropped objects. This is a frequent complaint of those with carpal tunnel syndrome. Something as simple as carrying a box into your garage may become a challenge. Because of the numbness in your thumbs and fingers, you may not notice an object slipping from your grip. For many individuals experiencing CTS, this can be a frightening and eye-opening experience.
• Though not as common as other symptoms, pain is still an indicator of carpal tunnel syndrome. Many times, the unrelenting numbness in your fingers can cause an aching sensation which may spread through your shoulders and neck. Severe cases of CTS may be accompanied by a burning pain in the wrist and hand.

Our routines become a part of us and the lives we build. However, in some instances, the repetitions that are part of every day may cause health issues. If your daily routine results in carpal tunnel syndrome, knowing the symptoms can help you identify the condition and seek treatment more quickly for a faster recovery.

Kitchi Joyce is the Director of Administrative Services for Southern Orthopaedics Specialists, a full service Atlanta orthopedic practice specializing in orthopaedic surgery and sports medicine. Southern Orthopaedics Specialists has multiple locations around the Atlanta Metro area where doctors, physicians and medical staff patients live and perform at the peak of their physical ability. Decades of experience, education and research means that all your needs for orthopedic doctors in Atlanta are covered, from cartilage restoration to spine care and sports medicine.

Valentine's Day.

St Valentine's Day has roots in several different legends that have found their way to us through the ages. One of the earliest popular symbols of the Valentine's day is Cupid, the Roman god of love, who is represented by the image of a young boy with bow and arrow. Several theories surround the history of Valentine's Day.

Was There a Real Valentine?

Three hundred years after the death of Jesus Christ, the Roman emperors still demanded that everyone believe in the Roman gods. Valentine, a Christian priest, had been thrown in prison for his teachings. On February 14, Valentine was beheaded, not only because he was a Christian, but also because he had performed a miracle. He supposedly cured the jailer's daughter of her blindness. The night before he was executed, he wrote the jailer's daughter a farewell letter, signing it "From Your Valentine." Another legend tells us that this same Valentine, well-loved by all, received notes to his jail cell from children and friends who missed him.

Bishop Valentine?

Another Valentine was an Italian bishop who lived at about the same time, AD 200. He was imprisoned because he secretly married couples, contrary to the laws of the Roman emperor. Some legends say he was burned at the stake.

Feast of Lupercalia

The ancient Romans celebrated the feast of Lupercalia, a spring festival, on the 15th of February, held in honor of a goddess. Young men randomly chose the name of a young girl to escort to the festivities. With the introduction of Christianity, the holiday moved to the 14th of February. The Christians had come to celebrate February 14 as the saint day that celebrated the several early Christian martyrs named Valentine.

The custom of choosing a sweetheart on this date spread through Europe in the Middle Ages, and then to the early American colonies. Throughout the ages, people also believed that birds picked their mates on February 14! In AD 496 Sain Pope Gelasius I declared February 14 as "Valentine's Day". Although it's not an official holiday, most Americans observe this day.

Whatever the odd mixture of origins, St Valentine's Day is now a day for sweethearts. It is the day that you show your friend or loved one that you care. You can send candy to someone you think is special. Or you can send roses, the flower of love. Most people send "valentine" a greeting card named after the notes that St Valentine received in jail.

Kindle DX Wireless Reading Device

The 9.7 inch screen means you get 2.5 times the screen area you would from a 6 inch Kindle 3 or 6 inch Nook. It makes a pretty big difference with PDFs and newspapers and websites and is quite pleasurable even when reading. It also becomes your ideal eReader if you need or like rather large font size and still want lots of words on every page.

The other thing that makes it unique is the $379 price which is closer to the iPad than to eReaders. This balances out a lot of the positives and firmly cements it as an awkward caught-in-the-middle device. If the Kindle 3 and Nook are for people who love to read the Kindle DX 2 is for people who love to read and love it more than the next 5 things combined.

Slim: Just over 1/3 of an inch, as thin as most magazines Carry Your Library: Holds up to 3,500 books, periodicals, and documents Beautiful Large Display: 9.7" diagonal e-ink screen reads like real paper; boasts 16 shades of gray for clear text and sharp images Auto-Rotating Screen: Display auto-rotates from portrait to landscape as you turn the device so you can view full-width maps, graphs, tables, and Web pages Built-In PDF Reader: Native PDF support allows you to carry and read all of your personal and professional documents on the go Wireless: 3G wireless lets you download books right from your Kindle DX, anytime, anywhere; no monthly fees, no annual contracts, and no hunting for Wi-Fi hotspots Books In Under 60 Seconds: You get free wireless delivery of books in less than 60 seconds; no PC required Long Battery Life: Read for days without recharging Read-to-Me: With the text-to-speech feature, Kindle DX can read newspapers, magazines, blogs, and books out loud to you, unless the book's rights holder made the feature unavailable Big Selection, Low Prices: Over 400,000 books, newspapers, magazines, and blogs; New York Times Best Sellers and New Releases are only $9.99, unless marked otherwise More Than Books: U.S. and international newspapers including the New York Times and Wall Street Journal, magazines including The New Yorker and Time, plus popular blogs, all auto-delivered wirelessly

 

Protect your Kindle DX for two full years -- Adds an additional year and more comprehensive protection than the one-year manufacturer's warranty, including coverage for accidental drops and damage (limited to one incident). This helps avoid the inconvenience and costs associated with a broken device. The warranty stays with the device even if it is gifted or sold to another party.

The Kindle DX Extended Warranty is offered and sold by an experienced service management company, Service Net Retail Solutions, LLC ("Service Net"). If your Kindle DX experiences a covered failure during the plan's term, Service Net will replace your unit at no additional cost. Service Net will even cover shipping costs for both the defective and replacement unit.

What is Covered

• Two years of coverage for failures due to normal operation of device
• Two years of coverage (limited to a single claim) for accidental drops or damage

How it Works

• Purchase 2-year Extended Warranty plan for your qualifying Kindle DX (you will receive an information packet in the mail)
• Contact Service Net customer service at (877) 441-3836 if your Kindle DX fails

• Receive a replacement Kindle DX and return your damaged device to Service Net

Technical Details

Display: 9.7" diagonal E Ink® electronic paper display, 1200 x 824 pixel resolution at 150 ppi, 16-level gray scale.
Size (in inches): 10.4" x 7.2" x 0.38".
Weight: 18.9 ounces.
System requirements: None, because it doesn't require a computer.
Storage: 4GB internal (approximately 3.3GB available for user content).
Battery Life: Read on a single charge for up to 4 days with wireless on. Turn wireless off and read for up to two weeks. Battery life will vary based on wireless usage, such as shopping the Kindle Store and downloading content. In low coverage areas or in 1xRTT only coverage, wireless usage will consume battery power more quickly.
Charge Time: Fully charges in approximately 4 hours and supports charging from your computer via the included USB 2.0 cable.
Connectivity: EVDO modem with fallback to 1xRTT; utilizes Amazon Whispernet to provide U.S wireless coverage via Sprint's 3G high-speed data network (check wireless coverage). See Wireless Terms and Conditions.
USB Port: USB 2.0 (micro-USB connector) for connection to the Kindle DX power adapter or optionally to connect to a PC or Macintosh computer.
Audio: 3.5mm stereo audio jack, built-in stereo speakers.
Content Formats Supported: Kindle (AZW), PDF, TXT, Audible (formats 4, Audible Enhanced (AAX)), MP3, unprotected MOBI, PRC natively; HTML, DOC, RTF, JPEG, GIF, PNG, BMP through conversion.
Included Accessories: Power adapter, USB 2.0 cable, battery. Leather book cover sold separately.
Documentation: Quick Start Guide (included in box) [PDF]; Kindle DX User's Guide (pre-installed on device) [PDF].
Warranty and Service: 1 year limited warranty and service included. Optional 2 year Extended Warranty sold separately.

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Video You Smile Mp3-Justin Bieber

Video You Smile Mp3-Justin Bieber

For the Lyrics and Mp3 Version click here 

 

Lyric You Smile Mp3-Justin Bieber

Lyric You Smile Mp3-Justin Bieber 

 For download Mp3 version

 Oh
Yeah
Mmmm

I’d wait on you forever and a day
Hand and foot
Your world is my world
Yeah
Ain’t no way you’re ever gon’ get
Any less than you should
Cause baby
You smile I smile (oh)
Cause whenever
You smile I smile
Hey hey hey

Your lips, my biggest weakness
Shouldn’t have let you know
I’m always gonna do what they say (hey)

If you need me
I’ll come running
From a thousand miles away
When you smile I smile (oh whoa)
You smile I smile
Hey

Baby take my open heart and all it offers
Cause this is as unconditional as it’ll ever get
You ain’t seen nothing yet
I won’t ever hesitate to give you more
Cause baby (hey)
You smile I smile (whoa)
You smile I smile
Hey hey hey
You smile I smile
I smile I smile I smile
You smile I smile
Make me smile baby

Baby you won’t ever work for nothing
You are my ins and my means now
With you there’s no in between
I’m all in
Cause my cards are on the table
And I’m willing and I’m able
But I fold to your wish
Cause it’s my command
Hey hey hey

You smile I smile (whoa)
You smile I smile
Hey hey hey
You smile I smile
I smile I smile I smile
You smile I smile
Oh

Lirik & Mp3 Ingin Putus saja - GAC

Ingin Putus saja - GAC 

For Download Mp3 Version

 

Dan terulang lagi kau sakiti aku yang tlah percaya (percaya)

Dan akhirnya kini hatiku tak ada sedikit pun rasa (yang tersisa)

Daripada lama-lama ku jadi gila (ja ja ja jadi gila)

Baiknya cepat-cepat berpisah

Janganlah kau salah aku bukan putus asa

Tapi ingin putus saja karena tak cinta

Sudah tak bisa denganmu

Tak cuma sekali sering kita putus cuma sehari (terus kembali)

Berkali kau janji mau berubah malah semakin parah (bikin marah)

Daripada lama-lama ku jadi gila (jadi gila)

Baiknya cepat-cepat berpisah

Janganlah kau salah aku bukan putus asa

Tapi ingin putus saja karena tak cinta

Sudah tak bisa denganmu

Janganlah kau salah aku bukan putus asa

Tapi ingin putus saja karena tak cinta

Sudah tak bisa denganmu

Bukan putus asa, cuma ingin putus saja

Ingin putus saja

Janganlah kau salah aku bukan putus asa

Tapi ingin putus saja karena tak cinta

Sudah tak bisa denganmu

Janganlah kau salah aku bukan putus asa

Tapi ingin putus saja karena tak cinta

Sudah tak bisa denganmu

Bona Paputungan - Markus Mp3

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Bona Paputungan-Markus mp3

Hipotiroidisme

HIPOTIROIDISME

I.                   PENDAHULUAN 

Hipotiroid (hiposekresi hormon tiroid) adalah status metabolik yang diakibatkan oleh kehilangan hormon tiroid. Hipotiroid dimana gagalnya kelenjar tiroid untuk mensekresi hormon tiroid yang adekuat jumlahnya, yang disebabkan oleh gangguan pada salah satu tingkat dari aksis hipotalamus-hipofisis-tiroid-”end organ”, dengan akibat terjadinya defisiensi hormon tiroid, ataupun gangguan respon jaringan terhadap hormon tiroid.

Klasifikasi :

1.      Hipotiroid Primer : lebih mengacu kepada disfungsi kelenjar tiroid itu sendiri.

1)      Goiter : Tiroiditis Hashimoto, fase penyembuhan setelah tiroiditis, defisiensi yodium.

2)      Non-goiter : destruksi pembedahan, kondisi setelah pemberian yodium radioaktif atau radiasi eksternal, agenesis, amiodaron

3)      Sekunder : kegagalan hipotalamus (↓ TRH, TSH yang berubah-ubah, ↓ T4 bebas) atau kegagalan pituitari (↓ TSH, ↓ T4 bebas).

4)      Hipotiroidisme tersier, jika sepenuhnya disebabkan oleh hipofisis.

2.      Usia awitan hipotiroid dibedakan menjadi tiga, yaitu :

1)      Hipotiroidisme dewasa atau maksidema

2)      Hipertiroidisme juvenilis, timbul sesudah usia 1 atau 2 tahun

3.      Hipotiroidisme kongenital atau kreatinin disebabkan oleh kekurangan hormon tiroid sebelum atau segera sesudah lahir.

 

II.               INSIDEN 

a.       Frekuensi

-          Amerika Serikat

Survei Kesehatan dan Penguji Gizi Nasional (NHANES 1999-2002) dari 4.392 individu/penduduk AS dilaporkan hipotiroidisme (didefinisikan sebagai tingkat TSH> 4.5 mIU / L) dalam 3,7% dari population hipotiroid. Lebih sering terjadi pada wanita dengan tubuh kecil ukuran saat lahir dan indeks massa tubuh rendah selama masa kanak-kanak.

-           Internasional

Di seluruh dunia, Kekurangan yodium sebagai penyebab hipotiroidisme pada umumnya. pada penelitian, prevalensi yang dilaporkan yaitu 2-5% dan terus meningkat menjadi 15% pada usia 75 tahun.

b.      Mortalitas / Morbiditas

Di negara maju, kematian yang disebabkan oleh hipotiroidisme jarang terjadi.

c.       Ras

NHANES 1999-2002 melaporkan bahwa prevalensi hipotiroidisme (termasuk subklinis) lebih banyak pada ras kulit putih (5,1%) dan cenderung memiliki nilai THS yang rendah.

d.      Jenis kelamin

Komunitas studi menggunakan kriteria yang sedikit berbeda untuk menentukan hipotiroidisme, karena itu, rasio perempuan dan laki-laki bervariasi. Umumnya, penyakit tiroid jauh lebih umum pada wanita dari pada laki-laki, dengan laporan prevalensi 2-8 kali lebih tinggi pada wanita.

e.       Usia

Frekuensi hipotiroidisme, gondok, dan nodul tiroid meningkat berdasarkan usia. Hypothyroidism adalah yang paling umum pada populasi lanjut usia, dengan 2% sampai sebanyak 20% dari kelompok umur yang lebih tua memiliki beberapa bentuk hipotiroidisme. Pada Studi Framingham ditemukan hipotiroidisme (TSH> 10 mIU / L) pada 5,9% wanita dan 2,4% pria lebih tua dari 60 years. Dalam NHANES 1999-2002, kemungkinan mendapatkan hypothyroidism adalah 5 kali lebih besar pada orang berusia 80 tahun dan lebih tua dari pada orang berusia 12-49 tahun.

III.            EPIDEMIOLOGI 

Prevalensi Hipotiroid kongenital diperkirakan 1 dari 4000 kelahiran, 1 dari 2000 orang pada ras Timur, 1 dari 5500 pada ras eropa dan 1 dari 32000 pada ras afrika, insiden meningkat pada sindrom down 1:140. 95 % kelainan ini bersifat sporadik dan 5% nya terkait genetik, yang biasanya pada dishormonogenesis. Perbandingan perempuan dan laki-laki adalah 2:1 dan terkait tipe HLA spesifik

IV.             ETIOLOGI

Hormon Tiroid

Hormon tiroid dihasilkan oleh kelenjar tiroid. Kelenjar ini terletak di bagian bawah leher, di bawah jakun. Kelenjar tersebut membungkus di sekitar pipa udara (trakea) dan memiliki bentuk yang mirip dengan kupu-kupu - yang dibentuk oleh dua sayap (lobes) serta dilengkapi dengan bagian tengah (isthmus). Kelenjar tiroid menggunakan yodium (umumnya tersedia pada diet dalam makanan seperti seafood, roti, dan garam) untuk menghasilkan hormon tiroid. Dua hormon tiroid yang paling penting adalah tiroksin (T4) dan triiodothyronine (T3), yang mencakup 99% dan 1% dari hormon tiroid ada dalam darah masing-masing. Namun, hormon dengan aktivitas yang paling biologis T3. Setelah dilepaskan dari kelenjar tiroid ke dalam darah, sejumlah besar T4 diubah menjadi T3 - hormon aktif yang mempengaruhi metabolisme sel.

 

Gambar 1. Glandula tiroidea, tempat produksi hormon tiroid^. 

Regulasi hormon tiroid - Rantai komando

Tiroid itu sendiri diatur oleh kelenjar lain yang terletak di otak, yang disebut hipofisis. Pada gilirannya, pituitari diatur sebagian oleh tiroid (melalui efek "umpan balik" dari hormon tiroid pada kelenjar pituitari) dan oleh kelenjar lain yang disebut hipotalamus. Hipotalamus melepaskan hormon yang disebut thyrotropin releasing hormon (TRH), yang mengirimkan sinyal ke pituitari untuk melepaskan thyroid stimulating hormon (TSH). Pada gilirannya, TSH mengirimkan sinyal ke tiroid untuk melepas hormon tiroid. Jika gangguan terjadi pada salah satu tingkat ini, cacat dalam produksi hormon tiroid dapat menyebabkan kekurangan hormon tiroid (hipotiroidisme).

Hypothalamus - TRH

Pituitary- TSH

Thyroid- T4 and T3

Tingkat produksi hormon tiroid dikendalikan oleh kelenjar pituitari. Jika ada cukup jumlah hormon tiroid yang beredar dalam tubuh untuk memungkinkan untuk fungsi normal, pelepasan TSH ditingkatkan oleh kelenjar pituitary dalam upaya untuk lebih merangsang produksi hormon tiroid. Sebaliknya, bila ada kelebihan jumlah sirkulasi hormon tiroid, kadar TSH menurun sebagai upaya hipofisis untuk mengurangi produksi hormon tiroid.

Gambar 2. Kelenjar Pituitary di Otak yang bekerja meregulasi hormon tiroid.

Pada bayi yang lahir tanpa kelenjar tiroid atau dengan kelenjar yang tidak berfungsi dengan baik mungkin memiliki beberapa tanda dan gejala hipotiroid. Ketika bayi baru lahir memiliki masalah dengan kelenjat tiroid (hipotiroid), maka akan menimbulkan gejala dan tanda sebagai berikut :

Ø  Kulit dan putih mata menguning (penyakit kuning).

Ø  Sering tersedak.

Ø  Lidah besar dan menonjol.

Ø  Wajah bengkak.

Ø  Sembelit

Ø  kantuk yang berlebihan

Ø  Pertumbuhan terlambat, sehingga bertubuh pendek

Ø  Tertunda perkembangan gigi permanen

Ø  Tertunda pubertas

V.                ANATOMI

Kelenjar tiroid ( kelenjar gondok) adalah salah satu dari kelenjar endokrin terbesar pada tubuh manusia. Terletak di leher, tepat dibawah jakun, dengan diameter sekitar 5 cm. Kedua bagian tiroid dihubungkan oleh ismus, sehingga bentuknya menyerupai huruf H atau dasi kupu-kupu.

Dalam keadaan normal, kelenjar tiroid berukuran kecil, dengan berat hanya 2-4 gram posisinya dileher depan bagian tengah dan tidak teraba. Sehingga pada leher orang normal tidak tampak tonjolan atau massa yang mengganggu pemandangan seperti apa yang kita lihat pada penderita gondok. Fungsi kelenjar tiroid yaitu mengatur metabolisme tubuh, sehingga segala sesuatunya berjalan lancar dan normal didalam tubuh seseorang.

  Gambar 1. Kelenjar endokrin utama pada pria dan wanita. 

VI.             PATOFISIOLOGI 

Kelenjar tiroid bekerja di bawah pengaruh kelenjar hipofisis, tempat diproduksi hormon tireotropik. Hormon ini mengatur produksi hormon tiroid yaitu tiroksin (T4) dan triiodo-tironin (T3). Kedua hormon tersebut dibentuk dari monoido-tirosin dan diiodo-tirosin. Untuk itu diperlukan jodium. T3 dan T4 diperlukan dalam proses metabolic di dalam badan, lebih-lebih pada pemakaian oksigen. Selain itu ia merangsang sintesis protein dan mempengaruhi metabolism karbohidrat, lemak dan vitamin. Hormon ini juga diperlukan utnuk mengolah karoten menjadi vitamin A. untuk pertumbuhan badan, hormon ini sangat dibutuhkan, tetapi harus bekerja sama dengan growth hormon.

VII.         PENYEBAB 

Ada banyak alasan mengapa sel-sel di kelenjar tiroid tidak dapat membuat hormon tiroid yang cukup. Berikut adalah penyebab utama hipotiroid :

      Penyakit autoimun. Salah satu penyakit autoimun yang menyebabkan hipotiroid adalah tiroiditis Hashimoto. Penyakit autoimun terjadi ketika sistem kekebalan tubuh menghasilkan antibodi yang menyerang jaringan tubuh sendiri. Para ilmuwan berpendapat virus dan bakteri menjadi pemicu respon autoimun, sementara yang lain percaya cacat genetik menjadi penyebab proses autoimun.

      Pengobatan untuk hipertiroidisme. Dalam beberapa kasus orang yang sedang menjalani pengobatan hipertiroid untuk mengurangi dan menormalkan fungsi tiroid dapat mengakibatkan hipotiroid permanen.

      Terapi radiasi. Radiasi yang digunakan untuk mengobati kanker kepala dan leher dapat mempengaruhi kelenjar tiroid yang dapat mengakibatkan hipotiroid.

      Operasi tiroid. pengangkatan semua atau sebagian kelenjar tiroid dapat mengurangi atau menghentikan produksi hormon tiroksin.

      Obat tertentu. Sejumlah obat dapat berkontribusi terjadinya hipotiroid. Salah satu obat tersebut adalah lithium, yang digunakan untuk mengobati gangguan jiwa tertentu.

Selain faktor di atas, hipotiroid dapat terjadi karena salah satu dari faktor berikut yang sangat jarang terjadi :

      Penyakit bawaan. Sekitar 1 dari 3.000 bayi di Amerika Serikat akan lahir dengan kelenjar tiroid rusak atau tidak ada kelenjar tiroid sama sekali. Hal itu disebabkan karena kelenjar tiroid tidak berkembang secara normal.

      Gangguan hipofisis. Kegagalan kelenjar hipofisis untuk menghasilkan TSH yang cukup dapat menyebabkan hipotiroid yang biasanya disebabkan karena tumor jinak dari kelenjar hipofisis.

      Kehamilan . Beberapa wanita mengalami hipotiroid selama atau setelah kehamilan (hipotiroidisme pasca-melahirkan), disebabkan karena mereka sering menghasilkan antibodi ke kelenjar tiroid mereka sendiri. Jika hipotiroid tidak diobati dapat meningkatkan risiko keguguran, kelahiran prematur dan preeclampsia.

      Defisiensi yodium. Yodium sangat penting untuk produksi hormon tiroid. Di beberapa bagian dunia, defisiensi yodium adalah umum, tetapi penambahan yodium ke garam meja telah hampir menghilangkan masalah ini di Amerika Serikat.

VIII.      GEJALA 

Gejala-gejala hipotiroid adalah seringkali tak kentara. Tidak spesifik (yang berarti mereka dapat meniru gejala-gejala dari banyak kondisi-kondisi lain) dan seringkali dihubungkan pada penuaan. Pasien-pasien dengan hipotiroid ringan mungkin tidak mempunyai tanda-tanda atau gejala-gejala. Gejala-gejala umumnya menjadi lebih nyata ketika kondisinya memburuk dan mayoritas dari keluhan-keluhan ini berhubungan dengan suatu perlambatan metabolisme tubuh. Gejala-gejala umum dibawah ini:

Ø  Kelelahan

Ø  Depresi

Ø  Kenaikkan berat badan yang sedang

Ø  Ketidaktoleranan dingin

Ø  Ngantuk yang berlebihan

Ø  Rambut yang kering dan kasar

Ø  Sembelit

Ø  Kulit kering

Ø  Kejang-kejang otot

Ø  Tingkat-tingkat kolesterol yag meningkat

Ø  Konsentrasi menurun

Ø  Sakit-sakit dan nyeri-nyeri yang samar-samar

Ø  Kaki-kaki yang bengkak

Ketika penyakit menjadi lebih berat, mungkin ada bengkak-bengak sekeliling mata-mata, suatu denyut jantung yang melambat, suatu penurunan temperatur tubuh, dan gagal jantung. Dalam bentuknya yang amat besar, hipotiroid yang berat mungkin menjurus pada suatu koma yang mengancam nyawa (myxedema coma). Pada seorang yang mempunyai hipotiroid yang berat, suatu myxedema coma cenderung dipicu oleh penyakit-penyakit berat, operasi, stres, atau luka trauma. Kondisi ini memerlukan opname (masuk rumah sakit) dan perawatan segera dengan hormon-hormon tiroid yang diberikan melalui suntikan. Didiagnosis secara benar, hipotiroid dapat dengan mudah dan sepenuhnya dirawat dengan penggantian hormon tiroid. Pada sisi lain, hipotiroid yang tidak dirawat dapat menjurus pada suatu pembesaran jantung (cardiomyopathy), gagal jantung yang memburuk, dan suatu akumulasi cairan sekitar paru-paru (pleural effusion).

^IX.                 DIAGNOSA 

Untuk mendiagnosa hipotiroid maka harus dilakukan pemeriksaan fisik dan melakukan tes laboratorium. Pemeriksaan fisik yang mungkin akan ditemukan pada penderita hipotiroid antara lain adalah lelah atau lesu, memiliki kulit kering, sembelit dan suara serak, atau memiliki masalah tiroid sebelumnya atau gondok. Dari hasil tes darah didapatkan kadar hormon tiroksin yang rendah kadar TSH yang tinggi yang menunjukkan kelenjar tiroid yang kurang akitf.

X.                DIAGNOSA BANDING 

a.       Mongolisme

Sering disertai hipotiroid kongenital, sehingga perlu dilakukan pemeriksaan faal tiroid secara rutin.

·         Epikantus (+)

·         Makroglosi (+)

·         Miksedema (-)

·         Retardasi motorik dan mental

·         ”Kariotyping”, Trisomi 21

b.      Sebab-sebab hipotiroid :

-          Sebab-sebab bawaan (kongenital) :

·         Disgenetik kelenjar tiroid: ektopik, agenesis, aplasi atau hipoplasi.

·         Dishormonogenesis.

·         ’Hypothalamic-pituitary hypothyroidism’.

·         Bersifat sementara :

Ø  Induksi obat-obatan.

Ø  Antibodi maternal.

Ø  Idiopatik.

·         Ibu mendapat

Ø  Bahan goitrogen.

Ø  Pengobatan yodium radio-aktif.

-           Sebab-sebab yang didapat (”acquired”):

·         Tiroiditis limfositik menahun.

·         Bahan-bahan goitrogen (yodium, tiourasil, dsb).

·         Tiroidektomi.

·         Penyakit infiltratif (sistinosis, histiositosis-X).

·         Defisiensi yodium (gondok endemik).

·          “Euthyroid sick syndrome”.

·         Hipopituitarisme

XI.             PENATALAKSANAAN 

1.      Pada pengobatan hipotiroidisme yang perlu diperhatikan adalah dosis awal dan cara menaikkan dosis tiroksin. Tujuan pengobatan hipotiroidisme adalah :

a)      Meringankan keluhan dan gejala

b)      Menormalkan metabolism

c)      Menormalkan TSH (bukan mensupresi)

d)     Membuat T3 (dan T4) normal

e)      Menghindarkan komplikasi dan resiko

Beberapa prinsip dapat digunakan dalam melaksanakan substitusi, yaitu  makin berat hipotiroidisme makin rendah dosis awal dan makin landai  peningkatan dosis, dan geriatri dengan angina pektoris, CHF, gangguan irama, dosis harus hati-hati.

Prinsip substitusi adalah mengganti kekurangan produksi hoemon tiroid endogen pasien. Indikator kecukupan optimal sel ialah kadar TSH normal. Dosis supresi tidak dianjurkan, sebab ada risiko gangguan jantung dan densitas mineral. Tersedia L-tiroksin (T4), L-triodotironin (T3) maupun pulvus tiroid. Pulvus tidak digunakan lagi karena efeknya sulit diramalkan. T3 tidak digunakan sebagai substitusi karena waktu paruhnya pendek hingga perlu diberikan beberapa kali sehari. Obat oral terbaik adalah T4
Tiroksin dianjurkan diminum pagi hari dalam keadaan perut kosong dan tidak bersama bahan lain yang mengganggu serapan dari usus. Contohnya pada penyakit sindrom malabsorbsi, short bowel syndrome, sirosis, obat (sukralfat, aluminium hidroksida, kolestiramin, sulfas ferosus, kalsium karbonat).

2.      Makanan yang adekuat dengan cukup kalori dan protein

3.      Vitamin dan mineral

XII.         KOMPLIKASI 

·         Koma miksedema

Koma miksedema adalah situasi yang mengancam nyawa yang ditandai oleh eksaserbasi (perburukan) semua gejala hipotiroidisme termasuk hipotermi tanpa menggigil, hipotensi, hipoglikemia, hipoventilasi, dan penurunan kesadaran hingga koma. Dalam keadaan darurat (misalnya koma miksedema), hormon tiroid bisa diberikan secara intravena.

·         Gangguan pertumbuhan dan perkembangan (Kretinisme)

Jika hipotiroidisme yang berat sudah terjadi sewaktu hidup fetal, maka kita akan mendapatkan penderita yang cebol dan mungkin imbesil. Pada waktu lahir tidak ditemukan kelainan tetapi pada umur 2-3 bulan sudah bisa timbul gejala lidah tebal dan jarak antara ke dua mata lebih besar dari biasanya. Pada waktu ini kulit kasar dan warnanya agak kekuningan. Kepala anak besar, mukanya bulat dan raut mukanya (ekspresi) seperti orang bodoh sedangkan hidungnya besar dan pesek, bibirnya tebal, mulutnya selalu terbuka dan juga lidah yang tebal dikeluarkan. Pertumbuhan tulang juga terlambat. Sedangkan keadaan psikis berbeda-beda biasanya antara agak cerdik dan sama sekali imbesil.

·         Kematian dapat terjadi apabila tidak diberikan HT dan stabilisasi semua gejala dengan segera.

XIII.      PROGNOSIS 

Makin muda dimulai pemberian hormon tiroid, makin baik prognosisnya. Kalau terapi dimulai sesudah umur 1 tahun, biasanya tidak akan tercapai IQ yang normal. Pertumbuhan badan dapat baik. Pada hipotiroidisme didapat dengan pengobatan yang baik, prognosisnya akan lebih baik.