Selingan Asik : Kata2 Mutiara dalam Spongebob Squarepants

1."pengetahuan tidak dapat menggantikan persahabatan. Aku (Patrick) lebih suka jadi idiot daripada kehilanganmu (Spongebob)"

2. spongebob: Apa yg biasanya kau lakukan saat aku pergi?
patrick : menunggumu kembali..

3. Saat sponge bob menjadi kaya dan melupakan patrick juga tmn2 spongebob yang kaya pergi dari spongebob, spongebob memohon kepada patrick, dan patrick berkata:
"kalau uang bisa membuatku melupakan sahabat terbaikku, maka aku lebih memilih untuk tidak punya uang sama sekali"

4. Saat patrick di fitnah mencuri jaring ubur2 nya spongebob,patrick berkata:
" Tak apa kawan.. aku mungkin hanya bintang laut yang jelek.. lebih baik aku pergi dari bikini bottom.. ini, ambil saja barang2ku.. tapi aku tak pernah mengambil jaring mu kawan.."
(Patrick dituduh nyolong jaring dan dia sabar aja)

5. Patrick berteriak : "AKU JELEK DAN AKU BANGGA!!!"

6. Kalau kamu memberitahukan rahasia kepada seseorang, maka itu namanya bkn rahasia lagi.

7. pas spongebob mau masuk anggota jelly spotter.. terakhirnya patrick bilang:
"pemujaan yang berlebihan itu tidak sehat.."


8. waktu itu ortu Patrick mau datang jenguk anaknya. Tapi Patrick takut dikatain bodoh sama ortunya. Demi Patrick, SpongeBob bela2in akting jadi orang bego biar ortu Patrick ga ngatain anaknya bego. Trus Patrick bilang ke SpongeBob:
"TEMAN ADALAH KEKUATAN"

9. waktu patrick dianggap ada keturunan raja terus mulai ngambil barang2 milik orang lain, terus dia berkata:
"hidup itu memang tidak adil, jadi biasakanlah dirimu"...

10. waktu sponge bob mau les nyetir buat dapetin sim..
"seharusnya kau belajar berjalan dulu nak, baru lah kau bisa berlari.."

11. waktu episode yg si spongebob nyari spatula baru, terus dia dapet spatula yg emas (klo ga salah), tapi si spatula emasnya ga nurut sama si spongebob akhirnya dia balik pk spatula nya yg lama.si spongebob ngomong:
"Ternyata semua yg berkilau itu belum tentu emas"

Coffee Drink may protect against Risk for Liver Cancer

July 1, 2008 — Higher coffee consumption was associated with lower liver cancer risk but higher levels of gamma-glutamyltransferase (GGT) may increase risk for this disease, according to the results of a study reported in the July issue of Hepatology.

"Only three Japanese prospective studies have suggested an inverse association between coffee drinking and liver cancer risk," write Gang Hu, from the Department of Public Health, University of Helsinki in Finland, and colleagues. "No prospective studies on the association between ... GGT and liver cancer risk have been reported. We aimed to determine the single and joint associations of coffee consumption and serum GGT with the risk of primary liver cancer."

The study cohort consisted of 60,323 Finns who were 25 to 74 years of age and free of any cancer at enrollment. Median follow-up was 19.3 years (interquartile range, 9.3 - 29.2 years). Incident liver cancer was diagnosed in 128 participants during follow-up. Hazard ratios for liver cancer risk as a function of coffee consumption were multivariable-adjusted for age, sex, alcohol consumption, education, smoking, diabetes and chronic liver disease at baseline and during follow-up, body mass index was assessed.

Adjusted hazard ratios of liver cancer in participants who drank 0 to 1, 2 to 3, 4 to 5, 6 to 7, and more than 8 cups of coffee daily were 1.00, 0.66, 0.44, 0.38, and 0.32, respectively (P for trend = .003), and further adjustment for serum GGT in subgroup analysis affected the results only slightly. For the highest vs the lowest quartile of serum GGT, the multivariable-adjusted and coffee-adjusted hazard ratio of liver cancer was 3.13 (95% confidence interval, 1.22 - 8.07).

Stratification by baseline factors did not abolish the multivariable-adjusted inverse association between coffee consumption and liver cancer risk; these factors included age younger than 50 years and 50 years and older, current smoker/never smoked/ever smoked, alcohol drinker/never drinker, obese/nonobese, and the highest/lowest 3 quartiles of serum GGT. Risk was increased nearly 9-fold for the combination of very low coffee consumption and high level of serum GGT.

"Coffee drinking has an inverse and graded association with the risk of liver cancer," the study authors write. "High serum GGT is associated with an increased risk of liver cancer."

Limitations of this study include use of self-reported data on coffee intake only at baseline; lack of data about other main sources of caffeine; no data on history of either hepatitis B virus or hepatitis C virus infections at baseline; use of only a dichotomized measure of alcohol consumption in the whole sample; and inability to completely exclude the effects of residual confounding due to measurement error.

"The biological mechanisms behind the association of coffee consumption with the risk of liver cancer are not understood at present," the study authors conclude. "It would be interesting to find out whether the modification of coffee drinking would modify the risk of liver cancer in people positive for either HBV [hepatitis B virus] or HCV [hepatitis C virus] infection."

In an accompanying editorial, Carlo La Vecchia, from Universitá degli Studi di Milano in Milan, Italy, notes the difficulties in translating the inverse relation between coffee drinking and liver cancer risk into potential implications for preventing liver cancer by increasing coffee consumption.

"Together with avoidance of lung cancer through tobacco control, primary liver cancer is the other common neoplasm which is most largely avoidable, through HBV vaccination, control of HCV transmission, and reduction of alcohol drinking," Dr. La Vecchia writes. "These three measures can, in principle, avoid more than 90% of primary liver cancers worldwide. Whether coffee drinking has an additional role in liver cancer prevention remains open to discussion, but in any case any such role would be limited — if not negligible — as compared to that achievable through control of HBV, HCV, and alcohol consumption, which are the major recognized risk factors for liver cancer."

The Finnish Academy and Special Research Funds of the Social Welfare and Health Board, City of Oulu, supported this study. The authors have disclosed no relevant financial relationships.

The Italian Association for Cancer Research and the Italian League Against Cancer supported this work.

Hepatology. 2008;48:7-9, 129-136.

Clinical Context

According to the current authors, liver cancer is the third most common cause of death from cancer worldwide. The incidence rate is high in western and central Africa and southeastern and eastern Asia and low in most developed countries except Japan, and hepatitis B and C virus infections have been identified as causative factors in more than 75% of cases. However, according to the current authors, coffee consumption has been found to be inversely related to risk for primary liver cancer, whereas GGT levels has been linked to increased risk. Finns drink coffee daily and have a higher per capita consumption of coffee (11.4 kg/year) than others such as the Japanese (3.2 kg/year) and Americans (4.1 kg/year). The prevalence of primary liver cancer and of hepatitis B and C virus infection is low in the Finnish population, making it a good setting to test the hypothesis that coffee consumption protects against primary liver cancer.

This is a population-based prospective cohort study to examine the association between coffee consumption and GGT level and risk for primary liver cancer during 19 years of follow-up in the Finn population.

Study Highlights

• 7 independent surveys were conducted in 6 geographic areas of Finland between 1972 and 2002, and a randomly selected sample was drawn during 2 of the years, and stratified by area, sex, and age, according to the World Health Organization MONICA [MONItoring trends and determinants of CArdiovascular disease] protocol.
• Subjects included were those 25 to 64 years of age and 65 to 74 years with a total sample size of 62,015.
• After excluding those with any history of cancer and incomplete data, 29,286 men and 31,037 women were analyzed and observed.
• Participants completed a questionnaire at baseline for medical history, lifestyle, and demographics.
• Smoking was categorized as never, ex-smoker, and current smoker; diabetes was documented from disease registers, and participants were asked "How many cups of coffee do you drink daily?".
• 1 cup of coffee in Finland is 1 dL.
• Alcohol consumption was categorized as abstainers and users and also into 4 subgroups of consumption.
• Body mass index was calculated.
• GGT was determined from venous blood using a kinetic method.
• All cancers were identified using the Finnish Cancer Registry, and survey cohorts were followed with computer-based registry linkage to 2006.
• Primary liver cancer included all types of cancer, such as hepatocellular carcinoma, cholangiocarcinoma, and adenocarcinoma.
• Mean age was 45 years, mean body mass index was 26 kg/m², 60% to 72% were alcohol drinkers, 24% to 60% were current smokers, 7% had incident diabetes during follow-up, and less than 0.4% had chronic liver disease.
• Median coffee consumption was 5.0 cups, and only 6.9% reported no coffee consumption and 3.3% reported 1 cup a day.
• Coffee consumption was positively associated with body mass index and smoking and inversely related to education and serum GGT.
• After excluding those with chronic liver disease, the multivariate adjusted hazard ratios during the first 2 years of follow-up for liver cancer for those who drank 0 to 1, 2 to 3, 4 to 5, 6 to 7, and 8 or more cups daily were 1.00, 0.66, 0.43, 0.42, and 0.35, respectively (P for trend .013).
• For the entire cohort for a median follow-up of 19.3 years, the adjusted hazard ratios for 0 to 1, 2 to 3, 4 to 5, 5 to 6, 6 to 7 and 8 or more cups daily were 1.00, 0.66, 0.44, 0.38, and 0.32 (P for trend .003).
• When analysis was restricted to 1982 to 2002 (n = 37,842) for a median of 14.3 years of follow-up, the multivariate and GGT adjusted odds of liver cancer for 0 to 1, 2 to 3, 4 to 5, 6 to 7 and 8 or more cups daily were 1.00, 0.53, 0.41, 0.29, and 0.22 respectively (P for trend .018).
• A significant positive association was found for serum GGT and liver cancer risk, with a hazard ratio of 3.13 for the highest vs the lowest quartile of GGT, excluding those with chronic liver disease or those who died from any cause did not change this association.
• No interactions were found for age group, smoking, body mass index, and alcohol consumption.
• The association did not change for filtered vs pot-boiled coffee.
• Those who drank the least coffee (0-1 cups daily) and in the highest quartile of serum GGT level had a 9.2 times increased risk for liver cancer.
• There was no significant interaction between coffee intake and GGT level for the risk for liver cancer.
• The authors concluded that coffee consumption and serum GGT were independently associated with liver cancer risk.

Pearls for Practice

• Coffee consumption is associated with reduced risk for primary liver cancer in the Finnish population.
• Serum GGT level is associated with increased risk for primary liver cancer in the Finnish population.

Berikut ini adalah fakta unik yang menarik sekaligus menggelitik yang ada di dunia ini.

1. Jerapah dan tikus bisa bertahan hidup lebih lama tanpa air dari pada unta.
2. Perut memproduksi lapisan lendir setiap dua minggu agar perut tidak mencerna organnya sendiri.
3. Semut dapat mengangkat beban 50 kali tubuhnya.
4. Lidah jerapah panjangnya sekitar 50 cm.
5. Mulut menghasilkan 1 liter ludah setiap hari.
6. Tanpa dicampur ludah di dalam mulut, kita tidak akan merasakan rasa makanan
7. Kita bernafas kira-kira 23.000 kali setiap hari.
8. Rata-rata kita bicara 5.000 kata tiap hari (walaupun 80% nya kita bicara pada diri sendiri).
9. Seumur hidup kita meminum air sebanyak kurang lebih 75.000 liter.
10. Pria kehilangan 40 helai rambut tiap hari. wanita 70 helai.
11. Sehelai rambut di kepala kita mempunyai masa tumbuh 2 sampai 6 tahun sebelum diganti dengan rambut baru
12. Unta punya 3 kelopak mata.
13. Otot yang bekerja paling cepat ditubuh kita adalah otot dikelopak mata yang membuat kita berkedip. kita bisa berkedip 5kali dalam sedetik.
14. Seseorang masih akan sadar selama 8 detik setelah dipenggal.
15. Coklat dapat membunuh anjing,karena langsung mempengaruhi jantung dan susunan syarafnya.
16. Kuku jari tangan tumbuh 4 kali lebih cepat daripada kuku kaki.
17. Hampir semua lipstik mengandung sisik ikan.
18. Kita sebenarnya melihat dengan otak. mata hanya berupa kamera yang mengirim data ke otak. 1/4 bagian dari otak digunakan untuk mengatur kerja mata.
19. Kalajengking bisa dibunuh dengan menyiramnya dengan cuka,mereka akan murka dan menyengat dirinya sendiri.
20. Saat kita bersin selalu dalam keadaan mata terpejam.
21. Jika bersin terlalu keras dapat meretakkan tulang iga. JIka mencoba menahan bersin, bisa mengalami pecah pembuluh nadi di kepala dan leher trus mati . jika memaksa mata terbuka saat bersin, bola mata bisa meloncat keluar.
22. Anak-anak mempunyai 20 gigi awal. Orang dewasa punya 32.
23. Karena langkanya logam, piala Oscars yang dibagikan pada perang dunia ke II terbuat dari kayu.
24. Ada 318.979.564. 000 kemungkinan kombinasi pembukaan pertama pada catur.
25. Ada lebih dari 300 bakteri pembentuk karang gigi.
26. Macan adalah anggota terbesar dalam keluarga kucing.
27. Pohon kelapa membunuh 150 orang tiap tahun. Lebih banyak daripada hiu.
28. Daerah kutub kehilangan matahari selama 186 hari dalam setahun.
29. Butuh 10 tahun bagi Leonardo Da Vinci untuk melukis Mona Lisa.Lukisan itu tidak ditandai dan di beri tanggal. Leonardo dan Mona mempunya susunan tulang yang persis sama dan menurut sinar X, ada 3 versi lukisan dibawah lukisan itu.
30. Rata-rata hujan jatuh dengan kecepatan 7 mil per jam.
31. Gerakan Bruce Lee sangat cepat sehingga mereka harus melambatkan film agar kita bisa melihat semua gerakannya.
32. Satu kilo dari berat badan kita mengandung 7000 kalori.
33. Bayi lahir setiap 7 detik.
34. Saat Titanic karam, 2.228 orang ada di dalamnya. Hanya 706 yang selamat.
35. Di Amerika, seseorang didiagnosa menderita AIDS tiap 10 menit. Di Afrika, seseorang meninggal karena AIDS tipa 10 menit.
36. Sampai usia 6 bulan, bayi bisa menelan dan bernapas secara bersamaan. Orang dewasa tidak bisa.
37. Tiap tahun bulan menjauh 3.82 cm dari bumi.
38. Saat kita bertahan hidup dan tidak ada bahan makanan, sabuk kulit dan sepatu keds adalah makanan terbaik untuk dimakan karena mengandung cukup gizi untuk hidup sementara.
39. Dalam satu tetes air mengandung 50 juta bakteri.
40. Suara yang kita dengar dari dalam kerang bukan suara ombak laut, tapi suara aliran darah dalam kepala kita.
41. Secara fisik, babi tidak bisa melihat ke langit.
42. Gajah satu-satunya hewan yang tidak bisa meloncat.
43. Kita tidak bisa menjilat siku kita sendiri.
44. Siput bisa tidur selama 3 tahun.
45. Kita berulang tahun bersama 9 juta orang dari seluruh dunia.
46. Tikus beranakpinak sangat cepat dan dalam waktu 18 bulan, dua tikus dapat memiliki lebih dari 1 juta keturunan.
47. Kupu-kupu melihat dengan 12.000 mata.
48. Ayam yang sudah terpenggal lehernya masih mampu lari sepanjang lapangan bola sebelum benar-benar mati.
49. Kecoak bisa hidup 9 hari tanpa kepala, dan akan mati karena kelaparan.
50. Umur dari capung adalah 24 jam.
51. Daya ingat ikan hanya 3 detik.
52. Ubur-ubur terdiri dari 95% air.
53. Kucing tidak bisa merasakan rasa manis.
54. Kentut sapi termasuk penyebab utama global warming.
55. Buaya tidak bisa menjulurkan lidah.
56. 80% dari seluruh binatang di dunia adalah serangga.
57. Kacang adalah salah satu bahan untuk membuat dinamit.
58. Eropa adalah benua tanpa padang pasir.
59. Tanduk badak terbuat dari rambutnya yang mengeras.
60. Kuda Nil kentut lewat mulut.
61. 25% dari tulang manusia ada di kaki.
62. Bola mata kita beratnya sekitar 28 gram.
63. Beberapa jenis cacing pita akan memakan dirinya sendiri jika kelaparan.
64. Ikan hiu kebal terhadap kanker.
65. Rat-rata orang bergerak 40 kali dalam tidurnya.
66. Partikel debu didalam rumah sebagian besar berasal dari sel kulit mati.
67. Nyamuk lebih suka anak-anak daripada orang dewasa.
68. Ganymede adalah bulan planet Jupiter, merupakan bulan terbesar di tata surya kita, lebih besar dari planet Merkurius.
69. Anak baru lahir memiliki 350 tulang. Mereka menyatu atau menghilang sampai menjadi 206 pada usia 5 tahun.
70. Dito Nama yang sangat populer hahaha ini sbagai bonus aja ,ga sah di baca biar genap 70

Semoga bisa dijadikan pengetahuan

FAKTA UNIK YANG MENARIK DAN LUCU

Berikut ini adalah fakta unik yang menarik sekaligus menggelitik yang ada di dunia ini.

1. Jerapah dan tikus bisa bertahan hidup lebih lama tanpa air dari pada unta.
2. Perut memproduksi lapisan lendir setiap dua minggu agar perut tidak mencerna organnya sendiri.
3. Semut dapat mengangkat beban 50 kali tubuhnya.
4. Lidah jerapah panjangnya sekitar 50 cm.
5. Mulut menghasilkan 1 liter ludah setiap hari.
6. Tanpa dicampur ludah di dalam mulut, kita tidak akan merasakan rasa makanan
7. Kita bernafas kira-kira 23.000 kali setiap hari.
8. Rata-rata kita bicara 5.000 kata tiap hari (walaupun 80% nya kita bicara pada diri sendiri).
9. Seumur hidup kita meminum air sebanyak kurang lebih 75.000 liter.
10. Pria kehilangan 40 helai rambut tiap hari. wanita 70 helai.
11. Sehelai rambut di kepala kita mempunyai masa tumbuh 2 sampai 6 tahun sebelum diganti dengan rambut baru
12. Unta punya 3 kelopak mata.
13. Otot yang bekerja paling cepat ditubuh kita adalah otot dikelopak mata yang membuat kita berkedip. kita bisa berkedip 5kali dalam sedetik.
14. Seseorang masih akan sadar selama 8 detik setelah dipenggal.
15. Coklat dapat membunuh anjing,karena langsung mempengaruhi jantung dan susunan syarafnya.
16. Kuku jari tangan tumbuh 4 kali lebih cepat daripada kuku kaki.
17. Hampir semua lipstik mengandung sisik ikan.
18. Kita sebenarnya melihat dengan otak. mata hanya berupa kamera yang mengirim data ke otak. 1/4 bagian dari otak digunakan untuk mengatur kerja mata.
19. Kalajengking bisa dibunuh dengan menyiramnya dengan cuka,mereka akan murka dan menyengat dirinya sendiri.
20. Saat kita bersin selalu dalam keadaan mata terpejam.
21. Jika bersin terlalu keras dapat meretakkan tulang iga. JIka mencoba menahan bersin, bisa mengalami pecah pembuluh nadi di kepala dan leher trus mati . jika memaksa mata terbuka saat bersin, bola mata bisa meloncat keluar.
22. Anak-anak mempunyai 20 gigi awal. Orang dewasa punya 32.
23. Karena langkanya logam, piala Oscars yang dibagikan pada perang dunia ke II terbuat dari kayu.
24. Ada 318.979.564. 000 kemungkinan kombinasi pembukaan pertama pada catur.
25. Ada lebih dari 300 bakteri pembentuk karang gigi.
26. Macan adalah anggota terbesar dalam keluarga kucing.
27. Pohon kelapa membunuh 150 orang tiap tahun. Lebih banyak daripada hiu.
28. Daerah kutub kehilangan matahari selama 186 hari dalam setahun.
29. Butuh 10 tahun bagi Leonardo Da Vinci untuk melukis Mona Lisa.Lukisan itu tidak ditandai dan di beri tanggal. Leonardo dan Mona mempunya susunan tulang yang persis sama dan menurut sinar X, ada 3 versi lukisan dibawah lukisan itu.
30. Rata-rata hujan jatuh dengan kecepatan 7 mil per jam.
31. Gerakan Bruce Lee sangat cepat sehingga mereka harus melambatkan film agar kita bisa melihat semua gerakannya.
32. Satu kilo dari berat badan kita mengandung 7000 kalori.
33. Bayi lahir setiap 7 detik.
34. Saat Titanic karam, 2.228 orang ada di dalamnya. Hanya 706 yang selamat.
35. Di Amerika, seseorang didiagnosa menderita AIDS tiap 10 menit. Di Afrika, seseorang meninggal karena AIDS tipa 10 menit.
36. Sampai usia 6 bulan, bayi bisa menelan dan bernapas secara bersamaan. Orang dewasa tidak bisa.
37. Tiap tahun bulan menjauh 3.82 cm dari bumi.
38. Saat kita bertahan hidup dan tidak ada bahan makanan, sabuk kulit dan sepatu keds adalah makanan terbaik untuk dimakan karena mengandung cukup gizi untuk hidup sementara.
39. Dalam satu tetes air mengandung 50 juta bakteri.
40. Suara yang kita dengar dari dalam kerang bukan suara ombak laut, tapi suara aliran darah dalam kepala kita.
41. Secara fisik, babi tidak bisa melihat ke langit.
42. Gajah satu-satunya hewan yang tidak bisa meloncat.
43. Kita tidak bisa menjilat siku kita sendiri.
44. Siput bisa tidur selama 3 tahun.
45. Kita berulang tahun bersama 9 juta orang dari seluruh dunia.
46. Tikus beranakpinak sangat cepat dan dalam waktu 18 bulan, dua tikus dapat memiliki lebih dari 1 juta keturunan.
47. Kupu-kupu melihat dengan 12.000 mata.
48. Ayam yang sudah terpenggal lehernya masih mampu lari sepanjang lapangan bola sebelum benar-benar mati.
49. Kecoak bisa hidup 9 hari tanpa kepala, dan akan mati karena kelaparan.
50. Umur dari capung adalah 24 jam.
51. Daya ingat ikan hanya 3 detik.
52. Ubur-ubur terdiri dari 95% air.
53. Kucing tidak bisa merasakan rasa manis.
54. Kentut sapi termasuk penyebab utama global warming.
55. Buaya tidak bisa menjulurkan lidah.
56. 80% dari seluruh binatang di dunia adalah serangga.
57. Kacang adalah salah satu bahan untuk membuat dinamit.
58. Eropa adalah benua tanpa padang pasir.
59. Tanduk badak terbuat dari rambutnya yang mengeras.
60. Kuda Nil kentut lewat mulut.
61. 25% dari tulang manusia ada di kaki.
62. Bola mata kita beratnya sekitar 28 gram.
63. Beberapa jenis cacing pita akan memakan dirinya sendiri jika kelaparan.
64. Ikan hiu kebal terhadap kanker.
65. Rat-rata orang bergerak 40 kali dalam tidurnya.
66. Partikel debu didalam rumah sebagian besar berasal dari sel kulit mati.
67. Nyamuk lebih suka anak-anak daripada orang dewasa.
68. Ganymede adalah bulan planet Jupiter, merupakan bulan terbesar di tata surya kita, lebih besar dari planet Merkurius.
69. Anak baru lahir memiliki 350 tulang. Mereka menyatu atau menghilang sampai menjadi 206 pada usia 5 tahun.
70. Dito Nama yang sangat populer hahaha ini sbagai bonus aja ,ga sah di baca biar genap 70

Semoga bisa dijadikan pengetahuan

Knapa Kita Ngorok ?

Why Do We Snore?
• When we sleep our breathing and heart rate slows and our muscles relax. This loss of muscle tone causes the soft palate and other tissue in the mouth, nose and throat to become limp and flaccid, reverberating in the air flow and making the sound that we commonly recognise as snoring.
• The problems associated with snoring may exist even when we are awake, though improved muscle tone during waking hours is usually enough to prevent us from snoring.
• Snoring is not easily cured, though it is something that can be successfully controlled. Helps Stop Snoring is helping millions of people to benefit from improved sleep, whilst also reducing the strain that the problem can often place on relationships

The Causes Of Snoring

• As a rule, snoring is aggravated by either a restriction of the nasal airways or a relaxing of the soft tissue in the throat.
• Factors that relax the soft tissue lining at the back of the throat can add to the problem. Air passing through the restricted passages will cause the soft tissue to vibrate producing an even heavier reverberating sound.
• Smoking is one activity that has been linked to aggravation of the snoring condition. Smoking is one of several factors that encourage the body to produce excess mucus, which can contribute to the restriction of the airways.
• Excessive consumption of dairy products and common allergies, such as hayfever, are further mucus stimulants - each raising the incidence or level of snoring in sufferers.
• Other factors that affect breathing such as non-allergic ailments like colds and flu can also have a restricting effect on the airways, although these are more difficult to deal with.
• Alcohol is a well-known relaxant and which can cause a softening of the tissue in the throat, which will nearly always lead to a noticeable effect on a snorer.
• Finally obesity can have an effect. Over eating leads to an enlargement of the tissue in the neck which, when lying down, can compress and restrict the airway and thus raising the likelihood of snoring.

Inflammatory Bowel Disease

 Overview

The term inflammatory bowel disease (IBD) covers a group of disorders in which the intestines become inflamed (red and swollen), probably as a result of an immune reaction of the body against its own intestinal tissue.

Two major types of IBD are described: ulcerative colitis (UC) and Crohn's disease (CD). As the name suggests, ulcerative colitis is limited to the colon (large intestine). Although Crohn's disease can involve any part of the gastrointestinal tract from the mouth to the anus, it most commonly affects the small intestine and/or the colon.

Both ulcerative colitis and Crohn's disease usually run a waxing and waning course in the intensity and severity of illness. When there is severe inflammation, the disease is considered to be in an active stage, and the person experiences a flare-up of the condition. When the degree of inflammation is less (or absent), the person usually is without symptoms, and the disease is considered to be in remission.

Causes

Researchers do not yet know what causes inflammatory bowel disease. Therefore, IBD is called an idiopathic disease (disease with an unknown cause).
An unknown factor/agent (or a combination of factors) triggers the body’s immune system to produce an inflammatory reaction in the intestinal tract that continues without control. As a result of the inflammatory reaction, the intestinal wall is damaged leading to bloody diarrhea and abdominal pain.
Genetic, infectious, immunologic, and psychological factors have all been implicated in influencing the development of IBD.
There is a genetic predisposition (or perhaps susceptibility) to the development of IBD. However, the triggering factor for activation of the body’s immune system has yet to be identified. Factors that can turn on the body’s immune system include an infectious agent (as yet unidentified), an immune response to an antigen (eg, protein from cow milk), or an autoimmune process. As the intestines are always exposed to things that can cause immune reactions, more recent thinking is that there is a failure of the body to turn off normal immune responses.

Symptoms

Because inflammatory bowel disease is a chronic disease (lasting a long time), you will go through periods in which the disease flares up and causes symptoms. These periods are followed by remission, in which symptoms disappear or decrease and good health returns.

Symptoms may range from mild to severe and generally depend upon the part of the intestinal tract involved. They include the following:

• Abdominal cramps and pain
• Bloody diarrhea
• Severe urgency to have a bowel movement
• Fever
• Loss of appetite
• Weight loss
• Anemia (due to blood loss)

Intestinal complications of inflammatory bowel disease include the following:

• Profuse bleeding from the ulcers
• Perforation (rupture) of the bowel
• Strictures and obstruction: In persons with Crohn's disease, strictures often are inflammatory and frequently resolve with medical treatment. Fixed or fibrotic (scarring) strictures may require endoscopic or surgical intervention to relieve the obstruction. In ulcerative colitis, colonic strictures should be presumed to be malignant (cancerous).
• Fistulae (abnormal passage) and perianal disease: These are more common in persons with Crohn's disease. They may not respond to vigorous medical treatment. Surgical intervention often is required, and there is a high risk of recurrence.
• Toxic megacolon (acute nonobstructive dilation of the colon): This is a life-threatening complication of ulcerative colitis and requires urgent surgical intervention. It is fortunately relatively rare.
• Malignancy: The risk of colon cancer in ulcerative colitis begins to rise significantly above that of the general population after approximately 8-10 years of diagnosis. The risk of cancer in Crohn's disease may equal that of ulcerative colitis if the entire colon is involved. The risk of small intestine malignancy is increased in Crohn's disease.

Extraintestinal complications

• Extraintestinal involvement of IBD refers to complications involving organs other than the intestines. These affect only a small percentage of people with IBD.
• Persons with IBD may have arthritis, skin conditions, inflammation of the eye, liver and kidney disorders, and bone loss. Of all the extraintestinal complications, arthritis is the most common. Joint, eye, and skin complications often occur together.

Exams and Tests

Your health care provider makes the diagnosis of inflammatory bowel disease based on your symptoms and various exams and tests.
 
Stool examination

• A stool examination is done to eliminate the possibility of bacterial, viral, or parasitic causes of diarrhea.

• A fecal occult blood test is used to examine stool for traces of blood that cannot be seen with the naked eye.

Complete blood count

• An increase in the white blood cell count suggests the presence of inflammation in the body. 
• If you have severe bleeding, the red blood cell count may decrease and hemoglobin level may fall (anemia).

Both the above tests are not diagnostic of IBD, as they may be abnormal in many other diseases.
 
Barium x-ray

• Upper gastrointestinal (GI) tract: This exam uses x-rays to find abnormalities in the upper GI tract (esophagus, stomach, duodenum, sometimes the small intestine). For this test, you are required to swallow barium (a chalky white substance). When barium is swallowed, it coats the inside of the intestinal tract, which can be documented on x-rays. If you have Crohn's disease, abnormalities will be seen on barium x-rays.
• Lower gastrointestinal (GI) tract: In this exam, barium is given in an enema that is retained in the colon while x-rays are taken. Abnormalities will be noted in the rectum and colon in persons with Crohn's disease and ulcerative colitis.

Sigmoidoscopy: In this procedure, your health care provider uses a sigmoidoscope (a narrow, flexible tube with a lens and a light source) to visualize the last one-third of the large intestine, which includes the rectum and the sigmoid colon. The sigmoidoscope is inserted through the anus and the intestinal wall is examined for ulcers, inflammation, and bleeding. During this procedure, your health care provider may take samples (biopsies) of the lining of the intestine.

Colonoscopy: A colonoscopy is an examination similar to a sigmoidoscopy, but with this procedure, the entire colon can be examined.

Upper endoscopy: If you have upper GI symptoms (nausea, vomiting), an endoscope (narrow, flexible tube with a light source) is used to examine the esophagus, stomach, and the duodenum. The endoscope is inserted through the mouth, and the stomach and duodenum are examined for ulceration. Ulceration occurs in the stomach and duodenum in 5-10% of persons with Crohn's disease.

Treatment

Self-Care at Home

It is important to eat a healthy diet. Depending on your symptoms, your health care provider may ask you to decrease the amount of fiber or dairy products in your diet.

Diet has little or no influence on the inflammatory activity in ulcerative colitis. However, diet may influence symptoms. For this reason, people with inflammatory bowel disease often are placed on a variety of diet interventions, especially low-residue diets. Evidence does not support a low-residue diet as beneficial in treating the inflammation of ulcerative colitis, though it might decrease the frequency of bowel movements.

Unlike ulcerative colitis, diet can influence inflammatory activity in Crohn's disease. Nothing by mouth (NPO status) can hasten reduction of inflammation, as might the use of a liquid diet or a predigested formula.

When you become extremely upset, your symptoms may get worse. Therefore, it is important that you learn to manage the stress in your life.

Medical Treatment

The goal of medical treatment is to suppress the abnormal inflammatory response. This allows the intestinal tissue to heal, thereby relieving the symptoms of diarrhea and abdominal pain. Once the symptoms are under control, medical treatment is used to decrease the frequency of flare-ups and to maintain remission.

A stepwise approach to the use of medications for inflammatory bowel disease may be taken. With this approach, the most benign (least harmful) drugs or drugs taken for a short period of time are used first. If they fail to provide relief, drugs from a higher step are used.

The aminosalicylates and symptomatic agents are step I drugs under this scheme. Antibiotics are a step IA; they are particularly used in persons with Crohn's disease who have perianal disease or an inflammatory mass.

Corticosteroids constitute step II drugs to be used if the step I drugs fail to provide adequate control of the IBD. They tend to provide rapid relief of symptoms as well as a significant decrease in inflammation.

The immune modifying agents are step III drugs to be used if corticosteroids fail or are required for prolonged periods. These agents are not used in acute flare-ups because the time from initiation of treatment to the onset of significant action may be as long as 2-3 months. Infliximab is a step IIIA drug to be used in persons with Crohn's disease. As of this writing, the medications approved by the US FDA for the treatment of Crohn's disease are prednisone, budesonide, and infliximab.

The experimental agents are step IV drugs to be used only after failure of the previous steps and only by health care providers familiar with their use.

Note that drugs from all steps may be used additively; in general, the goal is to wean off the corticosteroids as soon as possible to prevent long-term side effects. There may be different opinions regarding the use of certain agents in this stepwise approach.

Medications

Different groups of drugs are used for the treatment of persons with inflammatory bowel disease. These include aminosalicylates, corticosteroids, immune modifiers, anti-tumor necrosis factor (TNF) agents, and antibiotics.

Aminosalicylates

• Aminosalicylates are aspirinlike anti-inflammatory drugs. There are 5 aminosalicylate preparations available for use in the US: sulfasalazine (Azulfidine), mesalamine (Asacol, Pentasa), olsalazine (Dipentum), and balsalazide (Colazal).
• These drugs can be given either orally or rectally (enema, suppository formulations). They are useful both for treating flare-ups of the IBD and the maintenance of remission.

Corticosteroids

• Corticosteroids are rapid-acting anti-inflammatory agents. The indication for use in IBD is for acute flare-ups of the disease only. There is no role for corticosteroids in the maintenance of remission.
• Corticosteroids may be administered by a variety of routes, depending upon the location and severity of disease; they may be administered intravenously (methylprednisolone, hydrocortisone) in the hospital, orally (prednisone, prednisolone, budesonide, dexamethasone), or rectally (enema, suppository, foam preparations).
• Corticosteroids tend to provide rapid relief of symptoms as well as a significant decrease in inflammation, but their side effects limit their use (particularly longer-term use). The consensus for treatment with corticosteroids is that they should be tapered as soon as possible.

Immune modifiers

• Immune modifiers include 6-mercaptopurine (6-MP, Purinethol) and azathioprine (Imuran). Immune modifiers may work by causing a reduction in the lymphocyte count (a type of white blood cell). Their onset of action is relatively slow (typically 2-3 months).
• They are used in selected persons with IBD when aminosalicylates and corticosteroids are either ineffective or only partially effective. They are useful in reducing or eliminating some persons' dependence on corticosteroids.
• Immune modifiers may also be helpful in maintaining remission in some persons with refractory ulcerative colitis (persons who do not respond to standard medications).
• They are also used as primary treatment of fistulae and the maintenance of remission in persons who cannot tolerate aminosalicylates.
• If you are taking immune modifiers, your blood cell count will be monitored on a regular basis because the immune modifiers can cause a significant reduction in the number of white blood cells, predisposing you to serious infections.

Anti-TNF agent

• Infliximab (Remicade) is an anti-TNF agent. TNF is produced by white blood cells and is believed to be responsible for promoting the tissue damage noted in persons with Crohn's disease. Infliximab acts by binding to TNF, thereby inhibiting its effects on the tissues. 
• It is approved by the FDA for the treatment of persons with moderate-to-severe Crohn's disease who have had an inadequate response to standard medications. In such persons, a response rate of 80% and a remission rate of 50% have been reported.
• Infliximab is also used for the treatment of fistulae, a complication of Crohn's disease. Closure of fistulae has been reported in 68% of persons treated with infliximab.
• Infliximab must be given intravenously. It is very expensive, so insurance coverage may play a factor in the decision to use this drug.

Antibiotics

• Metronidazole and ciprofloxacin are the most commonly used antibiotics in persons with IBD.
• Antibiotics are used sparingly in persons with ulcerative colitis because they have an increased risk of developing antibiotic-associated pseudomembranous colitis (a type of infectious diarrhea).
• In persons with Crohn's disease, antibiotics are used for the treatment of complications (perianal disease, fistulae, inflammatory mass).

Symptomatic treatments: You may be given antidiarrheal agents, antispasmodics, and acid suppressants for symptomatic relief.

Experimental agents

• Drugs used in Crohn's disease include methotrexate, thalidomide, and interleukin-11.
• Drugs used in ulcerative colitis include cyclosporine A, nicotine patch, butyrate enema, and heparin.

Surgery

Surgical treatment in persons with inflammatory bowel disease varies, depending upon the disease. Ulcerative colitis is a surgically curable disease because the disease is limited to the colon. However, surgical resection is not curative in persons with Crohn's disease. On the contrary, excessive surgical intervention in persons with Crohn's disease can lead to more problems. Situations arise in Crohn's disease in which surgery without resection can be used. This is done to halt function of the colon in order possibly to allow for healing of the disease distal to the site where surgery is done.

Ulcerative colitis

• In about 25-30% of persons with ulcerative colitis, medical treatment is not completely successful. In such persons and in persons with dysplasia (changes in the cells that are considered a precursor to cancer), surgery may be considered. Unlike Crohn's disease, which can recur after surgery, ulcerative colitis is cured after colectomy (surgical removal of the colon).
• The surgical options for persons with ulcerative colitis depend on a number of factors: the extent of the disease, the person's age, and his overall health. The first option involves the removal of the entire colon and rectum (proctocolectomy) with the creation of an opening on the abdomen through which feces is emptied into a pouch (ileostomy). This pouch is attached to the skin with an adhesive.
• The other most commonly used option is a technically demanding surgery and is generally a multistage procedure. The surgeon removes the colon, creates an internal ileal pouch from the small intestine, attaches it to the anal sphincter muscle (ileoanal anastomosis), and creates a temporary ileostomy. After the ileoanal anastomosis heals, the ileostomy is closed and the passage of the feces through the anus is reestablished.

Crohn's disease 

• Even though surgery is not curative in persons with Crohn's disease, approximately 75% of persons will require surgery at some point of time (especially for complications). The most simple surgery for Crohn's disease is the segmental resection, in which a segment of intestine with active disease or a stricture (narrowing) is removed and the remaining bowel is reanastomosed (two ends of healthy bowel are joined together).
• In persons with a very short stricture, instead of removal of that part of the intestine, a bowel-sparing stricturoplasty (repair) can be performed.
• Ileorectal or ileocolonic anastomosis is an option is some persons who have lower small intestine or upper colon disease.
• In persons with severe perianal fistulae, diverting ileostomy/colostomy is a surgical option. In this procedure, the function is halted for the distal colon and a temporary ileostomy or colostomy is created. The rectum, for which function is halted, is allowed to heal, and the ileostomy/colostomy is then reversed.

Next Steps

Follow-up

Persons with inflammatory bowel disease are prone to the development of malignancy (cancer). In Crohn's disease, there is a higher rate of small intestinal malignancy. Persons with involvement of the whole colon, particularly ulcerative colitis, are at a higher risk of developing colonic malignancy after 8-10 years of the onset of the disease. For cancer prevention, surveillance colonoscopy every 1-2 years after 8 years of disease is recommended.
Use of corticosteroids may lead to debilitating illness, particularly after long-term use. You should consider trying more aggressive therapies rather than remaining on corticosteroids because of the potential for side effects with these drugs.
If you are taking steroids, you should undergo a yearly ophthalmologic examination because of the risk of development of cataract.
Persons with IBD have a reduction in bone density, either from decreased calcium absorption (because of the underlying disease process) or because of corticosteroid use. Crippling osteoporosis can be a very serious complication. If you have significantly low bone density, you will be administered bisphosphonates and calcium supplements.

Prevention

No known dietary or lifestyle change prevents the development of inflammatory bowel disease.
Dietary manipulation may help symptoms in persons with ulcerative colitis, and it actually may help reduce inflammation in Crohn's disease. However, there is no evidence that consuming or avoiding any particular food item causes or avoids flare-ups of IBD.
Smoking cessation is the only lifestyle change that may benefit persons with Crohn's disease. Smoking has been linked to increases in the number and severity of flare-ups of Crohn's disease. Smoking cessation occasionally is sufficient to make a person with refractory (not responding to treatment) Crohn's disease go into remission.

Outlook

The typical course of the inflammatory bowel diseases (for the vast majority of persons) includes periods of remission interspersed with occasional flare-ups.

Ulcerative colitis

• A person with ulcerative colitis has a 50% probability of having another flare-up during the next 2 years. However, a very broad range of experiences exists; some persons may only have 1 flare-up over 25 years (as many as 10%); others may have almost constant flare-ups (much less common).
• Persons with ulcerative colitis limited to the rectum and sigmoid at the time of diagnosis have a greater than 50% chance of progressing to more extensive disease and a 12% rate of colectomy over 25 years.
• More than 70% of persons presenting with proctitis (inflammation of the rectum) alone continue to have disease limited to the rectum over 20 years. Most who develop more extensive disease do so within 5 years of diagnosis.
• Among persons with ulcerative colitis involving the entire colon, 60% eventually require colectomy, whereas very few persons with proctitis do.
• Most of the surgical intervention is required in the first year of disease; the annual colectomy rate after the first year is 1% for all persons with ulcerative colitis. Surgical resection for persons with ulcerative colitis is considered curative for the disease.

Crohn's disease

• The course of Crohn's disease is much more variable than that of ulcerative colitis. The clinical activity of Crohn's disease is independent of the anatomic location and extent of the disease.
• A person in remission has a 42% likelihood of being free of relapse for 2 years and only a 12% likelihood of being free of relapse for 10 years.
• Over a 4-year period, approximately 25% of persons remain in remission, 25% have frequent flare-ups, and 50% have a course that fluctuates between periods of flare-ups and remissions.
• Surgery for Crohn's disease generally is performed for the complications (stricture, stenosis, obstruction, fistula, bleeding) rather than for the inflammatory disease itself.
• After operation, there is a high frequency of recurrence of Crohn's disease, generally in a pattern mimicking the original disease pattern, often on one or both sides of the surgical anastomosis.
• Approximately 33% of persons with Crohn's disease who require surgery, require surgery again within 5 years, and 66% require surgery again within 15 years.
• Endoscopic evidence for recurrent inflammation is present in 93% of persons 1 year after surgery for Crohn's disease.
• Surgery is an important treatment option for Crohn's disease, but you should be aware that it is not curative and that disease recurrence after surgery is the rule.

·         Multimedia

·         Media file 1: Stricture, terminal ileum - colonoscopy. Narrowed segment visible upon intubation of the lower small intestine with colonoscope. Relatively little active inflammation is present, indicating this is a cicatrix (scar) stricture.

Media type:  Photo

Media file 2: Enteroenteric (bowel-to-bowel) fistula - small bowel series x-ray films. The narrow-appearing segments filled out relatively normally on subsequent films. Note that barium is just starting to enter the cecum in the right lower quadrant (reader's left), but that barium has also started to enter the sigmoid colon toward the bottom of the picture, thus indicating the presence of a fistula (hole) from small bowel to sigmoid colon.

Media type:  X-RAY

Media file 3: Severe advanced pyoderma gangrenosum (a rare skin complication of inflammatory bowel disease) is present on the left ankle.

Media type:  Photo

Media file 4: Severe colitis - colonoscopy. The mucosa is grossly denuded, with active bleeding noted. This patient had her colon resected very shortly after this view was obtained.

Media type:  Photo

Media file 5: Toxic megacolon, a rare complication of ulcerative colitis that almost always requires surgical removal of the colon. Courtesy of Dr Pauline Chu.

Media type:  X-RAY

Media file 6: Episcleritis, inflammation of a portion of the eye in conjunction with inflammatory bowel disease. Courtesy of Dr. David Sevel.

Media type:  Photo

Media file 7: Double-contrast barium enema examination in Crohn's colitis demonstrates numerous aphthous ulcers (the tiny spots on the lining of the intestine).

Media type:  X-RAY