Does a Response to Proton Pump Inhibitor Therapy Indicate GERD?

Just because a patient’s upper gastrointestinal symptoms are alleviated by proton pump inhibitors (PPIs) doesn’t necessarily mean that they have gastroesophageal reflux disease (GERD), according to the December issue of Clinical Gastroenterology and Hepatology.

The efficacy of PPI therapy often is tested to determine whether patients’ symptoms are acid-related and if they have GERD—a chronic digestive disease that occurs when stomach acid, or occasionally bile, flows back (refluxes) into the esophagus. The backwash of acid irritates the lining of your esophagus and causes GERD signs and symptoms. There has been debate, however, about whether response to PPI therapy accurately identifies GERD.

Peter Bytzer et al. evaluated the diagnostic accuracy of the PPI test, analyzing data from a large, multi-national trial (the DIAMOND study) that compared the ability of several different methods to identify GERD. The study included 308 patients with frequent upper-gastrointestinal symptoms such as heartburn, central chest pain, or regurgitation.

The subjects were first given placebo and evaluated by endoscopy, wireless esophageal pH-metry, and symptom association monitoring. Individuals with GERD (n = 197) were identified based on the presence of reflux esophagitis, esophageal pH levels below 4, or positive results from symptom association monitoring. All patients were then given esomeprazole (40 mg daily) for 2 weeks and symptoms were recorded daily.

A positive response to the PPI test was observed in 69% of patients who actually had GERD and in 51% of those who did not. The below figure shows the responses of the most bothersome symptoms in patients with and without GERD.

Responses of the most bothersome symptoms in the last 3 days of active treatment with PPIs among patients with and without GERD. Abd, abdominal; Regurg, regurgitation

Responses of the most bothersome symptoms in the last 3 days of active treatment with PPIs among patients with and without GERD. Abd, abdominal; Regurg, regurgitation

The PPI test has been widely used clinically to assess whether upper-GI symptoms are acid-related. However, some studies reported that it has a low level of specificity, and its value as a diagnostic test is limited compared with pH monitoring and symptom association monitoring.

The DIAMOND study addressed this issue in a relevant study population of patients attending primary care for any upper-gastrointestinal symptom, rather than just patients with reflux disease. Bytzer et al. state that in this well-characterized population of primary care patients with frequent upper-gastrointestinal symptoms of any type, the PPI test had a limited ability to correctly identify those with GERD, diagnosed by state-of-the art tests.

In an editorial that accompanies the article, Sander Veldhuyzen van Zanten points out that whether a patient responds to a PPI treatment is still clinically the most relevant result, irrespective of the cause. In primary care, patients are usually treated without an endoscopic examination, and it might not matter whether a patient who is complaining of upper-gastrointestinal symptoms has GERD or dyspepsia—all that matters is whether the patient feels better.

van Zanten also reminds readers that the PPI test is poorly defined —it is important to consider whether the PPI is given once a day or twice a day, the duration of therapy, and how treatment response is defined.

More Information About GERD:

Read the article online.
Bytzer P, Jones R, Vakil N, et al. Limited ability of the proton-pump inhibitor test to identify patients with gastroesophageal reflux disease. Clin Gastroenterol Hepatol 2012;10:1360−1366.

Read the accompanying editorial.
van Zanten SV. Diamond GERD diagnosis studies: clinical feelings are good, but are measurements using a ppi test better? Clin Gastroenterol Hepatol 2012;10:1367−1368.

About these ads

About Kristine Novak, PhD, Science Editor

Dr. Kristine Novak is the science editor for Gastroenterology and Clinical Gastroenterology and Hepatology, both published by the American Gastroenterological Association. She has worked as an editor at biomedical research journals and as a science writer for more than 12 years, covering advances in gastroenterology, hepatology, cancer, immunology, biotechnology, molecular genetics, and clinical trials. She has a PhD in cell biology and an interest in all areas of medical research.
This entry was posted in GI Tract, Technology and tagged , , , , , , , , , , , . Bookmark the permalink.

207 Responses to Does a Response to Proton Pump Inhibitor Therapy Indicate GERD?

  1. Thomas Pain says:

    PPIs alone didn’t work for me. I also had to make a number of lifestyle changes and sustain them. The biggest being losing weight and giving up carbonated beverages. Those two things alone, I believe, would make a big difference with people who suffer from acid reflux.

  2. Adrian says:

    I took Prilosec and I experienced excessive fatigue and migraines. I tried different alternatives like changing my diet and spreading my meals out. This combined with reducing my salt intake, seemed to work pretty well. I guess I’m just among the others who’s bodies are sensitive to certain drugs.

  3. obat kuat says:

    thanks so much i have read ur article about this article i got a new knowledge about therapy indicate grad

  4. Thank you for your information. I tried different alternatives like changing my diet and spreading my meals out. This combined with reducing my salt intake, seemed to work pretty well. I guess I’m just among the others who’s bodies are sensitive to certain drugs. Best regard : http://www.anekataskulit.com/

  5. Very interesting information. Control of gastric acid is absolutely necessary for heartburn sufferers. Besides, how – how to control emotions, the absolute metabolic processes associated should always be controlled. Thank you for this great article.

  6. NIce information, Thanks for sharing

  7. Obat Herbal says:

    Very interesting information about the treatment of gastro intestinal healing. It’s not convenient to have chronic heartburn. From the article gives hope of healing the ulcer disease. Thank you Dr. Kristine Novak, we look forward to the next article. regards

  8. rental mobil says:

    Thanks for all guys and i’d love to read ur article dude

  9. I visited many websites except the audio feature for audio
    songs current at this site is in fact excellent.

  10. i read a lot here and always get new things for my knowledge.

  11. You just need to search with “ASUS driver support”
    or “ASUS printer support” and call on any of the numbers given on the
    various websites. 0 interface, headphone and microphone
    jacks, and its layout is relatively reasonable.
    The screen quality is not bad, however it is noticeably less clear compared to some more
    expensive laptops.

  12. jilbab besar says:

    I’m really impressed with your writing skills as well as with
    the layout on your blog. Is this a paid theme or did you customize
    it yourself? Either way keep up the nice quality writing, it is rare to see
    a nice blog like this one today.

  13. Lashawn says:

    Hello there, I discovered your site by way of Google at the
    same time as searching for a related matter, your web site came up, it looks good.
    I’ve bookmarked it in my google bookmarks.

    Hello there, just was alert to your weblog thru Google, and found that it is really informative.
    I am gonna watch out for brussels. I’ll appreciate for those who proceed this in future.
    Lots of people might be benefited from your writing. Cheers!

  14. It’s an awesome paragraph in favor of all the web people;
    they will take benefit from it I am sure.

  15. Indeed, if the POWERS of spiritual DISCERNMENT, as indicated in John 20:23, apply to anything  SOUND at all; then they’re being at least as accurately reflected here, as by any “infallibly” Roman Catholic BULL to the contrary.
    We accompanied one dray with its precious load to the river,
    about a mile distant, passing on our way amongst endless tents
    and bark humpies, whilst holes were being sunk in every
    direction. Casting a part like Dirk would be somewhat
    akin to casting Sherlock Holmes.

  16. I was very pleased to uncover this great site. I want to to thank you for your
    time due to this wonderful read!! I definitely really liked every part of it and I
    have you saved to fav to check out new stuff on your website.

  17. * Help you to “prefer” to use fat as fuel for energy. The comprehensive metabolic panel actually
    has 17 different tests within the panel. Instead of
    drinking bottled juice, eat a real fruit.

  18. Margene says:

    And within the days when everyone a landline
    and used phone books, it had been an extremely sufficient
    way of getting business, so effective that it was considered essential for virtually any business or service that has been local or regional in nature.
    But companies trying to create an app might feel stumped about where to place their app.
    Furthermore, I enjoy maintain our calendar whilst all of my contacts inside my mobile phone.

  19. Kacey says:

    My brother recommended I would possibly like this blog.

    He used to be entirely right. This put up actually made my
    day. You can not imagine just how so much time I had spent for this
    info! Thanks!

  20. I loved as much as you’ll receive carried out right here.
    The sketch is attractive, your authored material stylish.
    nonetheless, you command get bought an shakiness over that you wish be delivering the following.
    unwell unquestionably come more formerly again
    since exactly the same nearly a lot often inside case you shield this increase.

  21. Hey! I know this is somewhat off topic but I was wondering if you knew where I could find a
    captcha plugin for my comment form? I’m using
    the same blog platform as yours and I’m having trouble finding one?
    Thanks a lot!

  22. You must choose for the businesses that offer change of plan possibilities for the users of the ser-vices who
    find the current plan to be not appropriate for them.
    Aftr downloading minecraft servers eternal realms Hamachi, install it and create a network.
    If you have any more questions, please leave a comment below.

  23. Ahaa, its pleasant conversation on the topic of this post
    here at this webpage, I have read all that, so
    at this time me also commenting at this place.

  24. p.tl says:

    • Take extra care accessing information that is personal when using public computers, for example those in internet cafes, or when by using a laptop in the
    Wi – Fi hotspot. This article explains how it is possible
    to improve your conntacting come with convincing blog posts and articles
    that may keep your followers returning for more in the same.

    http://xrl.us/refs68554

  25. Hello there, I discovered your blog by way of Google at the same time as searching for a comparable topic, your
    site got here up, it appears great. I have bookmarked
    it in my google bookmarks.
    Hello there, simply turned into alert to your blog via Google, and found that it’s
    really informative. I am going to be careful for brussels.

    I’ll appreciate if you continue this in future.
    A lot of other folks will be benefited out of your writing.
    Cheers!

  26. skin care says:

    Thaks on your marvelous posting! I actually enjoyed reading it, you happen to be a great author.I will be sure tto bookmark your blog and
    will often come back from noww on. I waqnt to encourage that you continue your
    great posts, have a ice weekend!

  27. Howdy are using WordPress for your blog platform? I’m
    new to the blog world but I’m trying to get started and create
    my own. Do you need any html coding knowledge to make your own blog?

    Any help would be greatly appreciated!

  28. Most architects plan a garage that is large
    enough to house a car. The Active Radon test device can indicate
    the actual amount of radon concentration that pervades in
    your home but requires the use of electrical power in order to monitor
    the presence of radon gas in real time. Kit homes
    are growing in popularity in Australia as high quality construction materials and design varieties have become available.

  29. What’s up to all, the contents existing at this web site are truly
    amazing for people knowledge, well, keep up the nice work fellows.

  30. hair loss says:

    The simplest measure to fix this is to get on a protein supplement
    schedule. Women have a higher success rate than men, because they
    have less testosterone and fewer, more evenly dispersed receptor sites
    in the follicles. Fuchs is now working on isolating equivalent cells in humans.

  31. fidji.net says:

    1) Clean the house top to bottom before the carpet cleaning service visit.
    If the rug sits pretty in the corner of your room where not many walk,
    its safe to say that cleaning your rug once every
    two years is a good idea. You don’t have to use it all the time thats impossible,
    just the weekends.

  32. twitter says:

    You are so interesting! I don’t think I’ve truly read a single
    thing like that before. So good to find somebody with genuine
    thoughts on this topic. Really.. thanks for starting this up.
    This site is something that is needed on the web, someone with a
    little originality!

  33. Interesante aportación amigo/a, me ha encantado el post: Does a
    Response to Proton Pump Inhibitor Therapy Indicate GERD?
    |
    Seguiré visitando esta página a ver si para la próxima tienen más juegos o diferentes
    por lo menos, a mi me encantan los juegos de un show
    mas. Sigan así amigos

  34. Howdy! I know this is kinda off topic but I was wondering if you knew where
    I could locate a captcha plugin for my comment form? I’m using the same blog platform as yours and I’m having trouble finding one?

    Thanks a lot!

  35. Hi, I do think this is an excellent website. I stumbledupon it ;
    ) I may revisit once again since i have bookmarked it.
    Money and freedom is the greatest way to change, may you be
    rich and continue to guide other people.

  36. Having read this I thought it was extremely enlightening.
    I appreciate you spending some time and energy to put this information together.
    I once again find myself spending way too much time both reading and leaving
    comments. But so what, it was still worth it!

  37. Incredible all kinds of amazing knowledge.

  38. One True God says:

    Ahaa, its fastidious discussion regarding this post here at this website, I have read all
    that, so at this time me also commenting here.

  39. If you live in steel kit homes then you can get
    rid of various health problem like asthma, allergy etc. Fixing a radon problem in your home is
    a fairly simple process and cost about the same as any other
    common home problem. Remember that you have to go into details so as not to be caught surprise by expenses that might pop up later and to know what you’re
    really getting.

  40. Hey There. I found your blog using msn. This is an extremely well written article.
    I will be sure to bookmark it and come back to
    read more of your useful information. Thanks for
    the post. I’ll certainly return.

  41. Thank you for some other informative website.
    The place else may just I am getting that kind of information written
    in such a perfect means? I’ve a project that I am
    simply now operating on, and I’ve been at the look out for such info.

  42. StellarSEO says:

    Why users still use to read news papers when in this
    technological globe everything is presented on web?

  43. moda praia says:

    Hello! Quick question that’s completely off topic. Do you know how to
    make your site mobile friendly? My website looks weird when browsing from
    my iphone 4. I’m trying to find a theme or plugin that might be
    able to resolve this issue. If you have any suggestions, please share.
    With thanks!

  44. Thanks for the auspicious writeup. It in fact was a amusement
    account it. Look complex to more delivered agreeable from you!
    By the way, how can we be in contact?

  45. They also offer a 99% accurate oral swab HIV 1 test
    kit here. STEP #2: Work with one of their agents and select
    a house plan or provide your own and have them
    price it out for the materials package cost. Unlike other types
    of filtration systems which require changing filter media, activated carbon,
    etc.

  46. Link exchange is nothing else except it is just placing the other person’s blog link on your page
    at proper place and other person will also do same for
    you.

  47. These chocolate chip cookies, a bit smaller than the commercially produced
    glutinous chocolate chip cookies, taste great.
    Not overly sweet, a good balance hits the taste buds. Gluten Free
    Chocolate Chip Cookie Mix: Item # 2017 UPC Code 7376967020171 16 oz.

  48. Thanks a lot for sharing this with all folks you really know what you are talking approximately!
    Bookmarked. Kindly additionally visit my web site =). We can have a
    hyperlink exchange agreement among us

  49. It’s amazing to go to see this web page and reading the views of all friends concerning this post, while I am also
    keen of getting know-how.

  50. porn says:

    I like this website! awsome… free sex for all hehe. I love this post: Does a
    Response to Proton Pump Inhibitor Therapy Indicate GERD?
    | . thanks

  51. yogurt says:

    Thanks for ones marvelous posting! I quite enjoyed
    reading it, you’re a great author.I will make sure to bookmark your blog and will eventually come back someday.
    I want to encourage continue your great posts, have a nice holiday weekend!

  52. This is very interesting, You’re a very skilled blogger.
    I’ve joined your rss feed and look forward to seeking more of your excellent post.
    Also, I have shared your web site in my social networks!

  53. It’s not my first time to visit this website, i am visiting this web page dailly and get good data from here every day.

  54. Great work! That is the type of information that are supposed to be shared across the web.
    Shame on the search engines for no longer positioning this post upper!
    Come on over and talk over with my web site . Thanks =)

  55. improved possibility of brusing – significant and foremost,
    people who spend money on Fish Oil really should be conscious that omega-3 greasy acids are ordinarily believed to slim the our blood (i.
    Fish oil has been found to be extremely rich in Omega-3 fatty acids.
    Doctors have recognized for years that good quality fish oil helps the heart,
    brain, blood pressure and can help lower cholesterol.

  56. Go to “File” select “Preferences,” go to “Landscape Movement” and change the sensitivity multiplier to 5.
    ) Fluids – Wiper fluid, coolant, and oil could come in
    handy. I had never owned a ‘bagless’ vacuum before, and wanted to make sure that I
    didn’t do anything that would damage the filters, which are supposed to last a lifetime.

  57. I always spent my half an hour to read this webpage’s posts daily along with a cup
    of coffee.

  58. jual parfum says:

    Hi to all, it’s actually a good for me to pay a quick visit this site,
    it includes important Information.

  59. Caan yοu tell us more about this? Ι’Ԁ care to
    fiʝnd out soe additioոal information.

  60. workout says:

    I delight in, result in I found just what I used to be taking a look for.

    You have ended my four day lengthy hunt! God Bless you man.
    Have a great day. Bye

  61. Hi there to all, how is the whole thing, I think every
    one is getting more from this website, and your views are good
    in support of new viewers.

  62. chanel speedy 30
    Somebody essentially assist to make seriously articles
    I would state. This is the very first time I frequented your website page and so far?
    I amazed with the research you made to create this actual put up extraordinary.

    Excellent job!

  63. You expressed this really well!

  64. I every time emailed this website post page to all my
    contacts, as if like to read it after that my contacts will too.

  65. Hi to all, how is everything, I think every one
    is getting more from this site, and your views are pleasant designed for new users.

  66. support says:

    I truly love your website.. Great colors & theme. Did you develop this
    site yourself? Please reply back as I’m trying to
    create my own website and would love to find out where you got this from or just what the theme is called.

    Appreciate it!

  67. Weight Loss says:

    Ӏf some one wants tо be updateԁ with most recent technollgies aftr tɦat he must be pay a viszit this weeb site and bbe uup to ɗate every day.

  68. Asking questions are in fact fastidious thing if you are not understanding something totally, but this piece of writing provides fastidious understanding yet.

  69. Fine way of telling, and pleasant post to take information on the
    topic of my presentation subject, which i am
    going to convey in institution of higher education.

  70. tutaj says:

    It’s appropriate time to make some plans for the future and it’s time to be happy.
    I have read this post and if I could I wish to suggest you some interesting things or
    tips. Maybe you could write next articles referring to this article.
    I desire to read more things about it!

  71. Wonderful work! That is the kind of info that are supposed to
    be shared across the web. Shame on the search engines for now not positioning this post upper!
    Come on over and talk over with my web site . Thanks =)

  72. Does your blog have a contact page? I’m having
    problems locating it but, I’d like to shoot you an e-mail.
    I’ve got some creative ideas for your blog you might be interested in hearing.
    Either way, great site and I look forward to seeing it develop over time.

  73. Hi, after reading this awesome post i am as well happy to share my
    experience here with friends.

  74. Trey says:

    This one-of-a-kind collectible and more available THIS WEEK ONLY.
    Also, since even the cheapest household that comes with the
    game can support two Sims, having your Sim get married
    normally does not cost anything. Take along a ball or Frisbee disc to sneak
    in some activity at rest stops.

  75. Pretty nice post. I just stumbled upon your blog and wished to say that I’ve
    really enjoyed surfing around your blog posts. In
    any case I will be subscribing to your rss feed and I hope you
    write again soon!

  76. Plus-sized women are not the only ones plagued by double chins-far from
    it, in fact, though that’s a common misconception.

    Many gyms also offer group training sessions, which are usually less expensive.
    Aging is a major factor in contributing double chin due
    to the weakening muscles and skin, thereby making the
    hyoid bone more apparent. Sometimes we all experience days where
    we have self doubt. For more information you can visit here, or add
    +Dr Ahnsup Kim in your circle.

  77. Marshall says:

    Running from the sprinklers on a hot, sunny
    day. I never felt particularly deprived because I set reasonable behavior changes.

    The high butter content will keep the cookie from sticking while baking.

  78. The Brownies says:

    Hello! I’m at work browsing your blog from my new apple iphone!
    Just wanted to say I love reading your blog and look forward to all your
    posts! Carry on the great work!

  79. Hearing someone show you: Youre beautiful, inside and out.
    Loren Yadeski, author as soon as i’ve is additionally enthusiastic about sweets and recommends that you
    please visit gift basket in case you liked scanning this information.
    Smartie cookies are deliciously soft, and can be substituted for M&M’s.

  80. But there’s one problem: there’s too many guys on Omegle.

    ” Any neat “behind-the-scenes” stories you can share. Perhaps it was to buy someone else birthday presents.

  81. Way cool! Some very valid points! I appreciate you writing
    this post plus the rest of the site is also really good.

  82. Selena says:

    Remember that for the average person a reasonable portion size is much less than what you are served in a restaurant or at a fast food store.

    Inside Your Vegetarian Weight Loss Program – Fat-Burning Workouts.
    The key to any successful weight loss program is tracking what
    you are doing.

  83. Omar says:

    Started in 2003, Image – Shack now sees a fairly large amount of traffic
    with approximately 66 million monthly visits.
    The track “Murderous Face” is my favorite from this Sound – Cloud album, as it slows down the pace
    and shows that this band can properly explore slower tempos.

    The reason for this is that it’s most effective to have other
    people talk about your music, especially people in positions of authority, such as
    music and mp3 bloggers, writers for magazines, podcasters and internet
    radio hosts.

  84. Does your site have a contact page? I’m having a
    tough time locating it but, I’d like to send you an
    email. I’ve got some suggestions for your blog
    you might be interested in hearing. Either way, great site and I look forward to seeing it
    develop over time.

  85. improved possibility of brusing – significant and foremost, people who spend money on Fish Oil really should
    be conscious that omega-3 greasy acids are ordinarily believed to slim
    the our blood (i. o This critical factor will
    need to be noticed that not all the nutritional supplements are equivalent.

    Choose reputable products manufactured by top brands if you want them to be effective.

  86. Medical equipment Orange County is a way out to any
    criticawl physiological imperfection. A warrant is a court
    doxument that says that law enforcement can place you under
    arrest. Do not use much orange oil in your
    homemade soap recipes.

  87. Also consider a wide variety of foods with smaller portions.
    In a study done in California, it was found that subjects who supplemented with Garcinia Cambogia ate less and lost more
    weight than subjects who did not take the supplement.
    Without stimulating the central nervous system Super Citri – Max works naturally.

  88. Hi are using WordPress for your site platform?
    I’m new to the blog world but I’m trying to get started and set up
    my own. Do you need any html coding knowledge to make your own blog?
    Any help would be greatly appreciated!

  89. toko buku online says:

    Thanks for one’s marvelous posting! I quite enjoyed reading it, you may
    be a great author.I will ensure that I bookmark your
    blog and will often come back in the future. I want to encourage
    you to ultimately continue your great work, have a nice holiday weekend!

  90. You will probably be inflicted with fun with this particular recipe that you can
    advise conform to your private taste. If you’re seriously interested in making your own personal chocolate
    treats you will find a great many other chocolate brown cooking
    ingredients at Chocolate Fan including chocolate brown cocoa powders, chocolates bars and chocolates Mars bars, chocolate
    twix bars as well as other types of chocolate baking ingredients.

    The high butter content will keep the cookie from sticking while baking.

  91. That kind of educational freedom is empowering’ for both teachers and students.
    First thing you have to keep in mind is that most blogs on the Web have a
    community feel to them. Chose subject material or which you feel confident readers is going to be interested in.

  92. 1) Smart fluid width web design- When using i – Pad, you can view a website either in landscape
    or in the portrait mode. Another thing that really stands out is the growing interest in
    Web – GL, particularly among the big agencies.
    Websites are an effective and cheaper source for
    businesses and professionals to promote them globally, the never ending journey of
    this technological caravan has just begun.

  93. Chemicals such as cortisol, hydrocortisone, and corticosterone act together to increase the production of glucose, constrict blood vessels and
    essentially help our brains deal with or regulate
    stress. Once the seed of doubt has been planted, it is very
    difficult to get rid of and as hard as you try to ignore other people’s opinions,
    once you let them into your head, they will still
    be lurking somewhere in the depths of your subconscious ready to
    re-appear just when you’re about to step out and start
    that new project you’ve been wanting to do, or even make that big move that will change your life forever.
    It is always advisable that you trim the wick of
    your candle if it seems too long.

  94. Hey there! I know this is kinda off topic nevertheless I’d figured I’d ask.
    Would you be interested in exchanging links or maybe guest authoring a blog post or vice-versa?
    My blog discusses a lot of the same subjects as yours and I feel we could greatly benefit from each other.
    If you happen to be interested feel free to send me an email.

    I look forward to hearing from you! Excellent blog by the way!

  95. I enjoy looking through an article that can make men and women think.
    Also, thanks for permitting me to comment!

  96. google says:

    I visited various web pages however the audio feature for audio
    songs existing at this site is genuinely wonderful.

  97. Write more, thats all I have to say. Literally, it seems as though you
    relied on the video to make your point. You definitely know what youre talking about, why throw away your intelligence on just posting videos to your blog when you could be giving us something enlightening to read?

  98. It is important to remember they should not be used to lose all the weight.
    Because your body stores the combination of salmon and carbohydrates as fat, be sure NOT to eat
    a carb at meals when you’re having salmon. When thyroid hormones are not in balance, certain health conditions can develop.

  99. All these conservatory furniture sets are delivered to any location.
    All of the supplies the picnic table plans that you downloaded from from your
    woodworking program will call for lumber which is generally
    pine, and will come in pressure treated or without treatment.
    They also have more dining options than the Value Resorts but the restaurants aren’t as good as the ones that can be found in
    Deluxe Resorts.

  100. You will likely be inflicted with fun using this type of recipe
    which you’ll advise conform to your private taste. I never felt particularly deprived because I set
    reasonable behavior changes. The high butter content help keep the cookie from
    sticking while baking.

  101. www.yelp.ca says:

    By having a Quality website, it is actually
    convenient for both you and your prospective client.
    It also requires that you evaluate the activities
    of the opponents and strategise what to undertake to keep up and beat them
    on the way. There are also programs that do most, if
    not all, of the work for you and you can get professional results without being a
    real programmer, but they are expensive.

  102. movies says:

    There is not any currently Netflix server in Poland and also the company has given no indication that they will ever release
    one. Therefore, it is possible to save your hair a packet and just wait
    until the modern movie is going on DVD and view it in your
    own home for free. Once you might have paid them,
    you could watch countless movies legally.

  103. I simply couldn’t depart your website before suggesting that
    I actually loved the standard information a person
    provide to your visitors? Is going to be back ceaselessly in order to
    check out new posts

  104. Symptoms of an inadequate power supply include your Computer randomly shutting down and
    lag during game play. If you do not carry news paper so tablet is the best option for you.
    Apparently people everywhere love playing video playback games.

  105. bingo says:

    Nice post. I was checking continuously this blog and I’m impressed!
    Very helpful information particularly the last part :) I care
    for such information a lot. I was looking for this certain info for a very
    long time. Thank you and good luck.

  106. If you want to get a great deal from this piece of writing then you have to apply such methods to your won webpage.

  107. Usually there is a balance between secretion and absorption of fluid
    and the volume is small. Other conditions, such as hypothyroidism, can also
    cause abnormal test results. Junk food also put weight on
    its consumer but not within a proper shape so it could not be refer as the rich source indeed it lows the
    immunity system of the body that make the person lazy.

  108. In those days nothing much was thought of it but today we know that the air filled with dust
    mite can be even be deadly to some of us and especially for small children.

    You want a unit that will have a reasonable warranty period should there be any
    manufacturing issues so make sure that this information is
    clear before you part with your money. This means
    the unit collects the dirt and dust, and then disposes of it as
    well as part of its function.

  109. For aqualung divers, the changes in pressure and temperature as they derive can
    induce any moisture nowadays in the market at reasonable prices.
    as well, isolate the pipe between the storehouse tank for
    ingestion. But it’s screen of nothing designing can’t deal.

  110. Do you have any video of that? I’d love to find out some additional information.

  111. Gus says:

    Sweet blog! I found it while surfing around on Yahoo News.
    Do you have any tips on how to get listed in Yahoo News?
    I’ve been trying for a while but I never seem to get there!
    Thanks

  112. website says:

    De précieux conseils que je met dans un coin de ma petite tête et qui vont m’aider, c’est sur!
    Et ce blog est wahou, bravo!
    n’hesiter pas de rendre visite à mon blog qui donne des conseils à porpos de
    la mutuelle de poitiers , c’est interessant :)

  113. Hello! This is my first comment here so I just wanted to give a
    quick shout out and say I genuinely enjoy reading your articles.
    Can you recommend any other blogs/websites/forums that go
    over the same subjects? Thanks for your time!

  114. Right now it seems like BlogEngine is the top blogging platform available right now.
    (from what I’ve read) Is that what you are using on your blog?

  115. شاهد اجمل فيديو يوتيوب العاب اولاد صغار جميلة جدا

  116. I visited several sites but the audio quality for audio
    songs current at this web site is genuinely fabulous.

  117. gta 5 hack says:

    If you desire to get a great deal from this piece of writing then you have to apply these techniques to your won blog.

  118. I am now not sure where you are getting your information, but
    great topic. I must spend some time finding out more or figuring out more.

    Thank you for great information I used to be in search of this information for
    my mission.

  119. Though this may sound quite derivative, in many ways this movie actually has a lot going for it:
    a huge budget, top notch special effects, some decent characters, a couple of ok plot contrivances,
    and an ingenious director who injects fun while always maintaining the movie’s forward
    momentum. And much to his own surprise, Bilbo decides to go along after
    all. One teabag is used for each cup, and freshly drawn boiling water is a must.

  120. Hello there! Do you know if they make any plugins to protect against hackers?
    I’m kinda paranoid about losing everything I’ve worked hard on.
    Any tips?

  121. Appreeciate the recommeոdation. Let me try it out.

  122. When someone writes an article he/she maintains the thought of a user in
    his/her brain that how a user can understand it.
    Thus that’s why this piece of writing is outstdanding.
    Thanks!

  123. Simply desire to say your article is as amazing. The clarity for your submit is just excellent and that i can assume you are
    an expert on this subject. Well together with your permission allow me
    to grasp your RSS feed to keep updated with forthcoming post.
    Thank you one million and please keep up the rewarding work.

  124. toyota rav4 videos phoenix az says:

    It’s truly very complex in this active life to listen news on TV, so I
    simply use world wide web for that purpose,
    and get the most recent news.

  125. Why viewers still make use of to read news papers when in this technological globe the whole thing is presented on web?

  126. Hi! This is my 1st comment here so I just wanted to give a quick shout out and tell
    you I truly enjoy reading through your blog posts. Can you
    suggest any other blogs/websites/forums that go over the same subjects?
    Thanks a lot!

  127. I need to to thank you for this great read!!
    I certainly loved every little bit of it. I have you bookmarked to look at new things you
    post…

  128. When investors purchase physical gold like this, they are
    diversifying their portfolio in a way that inflation cannot touch, and yet guaranteeing some wealth in times of dire economic
    and social crises. Provided the transfer is done correctly,
    the recipient can continue to allow the assets in the account to accumulate with tax-deferred status.
    The other option, going for a portion, can be guaranteed as well but often it
    is perhaps not.

  129. Hello, Neat post. There’s a problem with your website in web explorer, would check this?

    IE nonetheless is the market chief and a huge element of other folks will omit your magnificent writing
    because of this problem.

  130. Read more about hostgator coupon at hostgatorcouponandreview.
    WHM internet hosting is created achievable by way of the use of a
    control panel which can be tailored, depending on the hosting provider, to the consumer paying for the hosting
    services. You’ll find undoubtedly numerous advantages in creating a home-based business.

  131. In the winter, the dog’s body heat is what helps to heat the house.
    Unfortunately bats are becoming increasingly endangered
    because of decreased habitats and roosting spaces. You can use kitty litter, sand,
    or sawdust to collect the droppings.

  132. Do you mind if I quote a couple of your posts as long as I provide credit and sources
    back to your blog? My website is in the exact same niche as yours and my users would genuinely benefit from a lot of the information you
    present here. Please let me know if this alright with you.
    Many thanks!

  133. I seriously love your site.. Excellent colors & theme.
    Did you make this website yourself? Please reply back as I’m attempting to create my own blog
    and would love to find out where you got this from or exactly what
    the theme is named. Appreciate it!

  134. It could be a goodgame empire hack download free great chance
    to build alliances with other players worldwide to crush your enemies,
    and become the sole ruler of a mighty empire! In the next part, we will
    progressively edit it, I’m not adding a lot of rubies, this still goodgame empire hack download free isn’t a very good promotion.

  135. Wow, wonderful blog format! How long have you been blogging for?
    you make running a blog glance easy. The overall look of your website is magnificent,
    as neatly as the content!

  136. It is said to bring the usual performance improvements but also support for
    tablets and larger resolution devices. When price is the primary factor for
    choosing a plastic surgeon, risks increase. 0, it should be quite an exciting and major
    release (denoted by the version 3).

  137. site says:

    It’s difficult to find educated people in this particular topic, however, you sound like you know
    what you’re talking about! Thanks

  138. My family all the time say that I am killing my time
    here at web, but I know I am getting familiarity
    everyday by reading such pleasant articles.

  139. Going by the recent trend it can be safely concluded that online reputation
    management success depends a lot on how you can use the online social communities to your advantage.
    political, advertising, or public relations) to give the appearance
    of it coming from a disinterested, grassroots participant) review sites, censoring negative complaints or using SEO tactics to game the system and influence results, there are also
    ethical forms of reputation management, such as responding to customer complaints, asking sites
    to take down incorrect information and using online
    feedback to influence product development.

    Norway’s Prime Minister Jens Stoltenberg attended at a memorial service held at Oslo Cathedra on Sunday 24
    July 2011 to show off his tribute to 76 people dead of the twin attacks.

  140. Hi to all, how is the whole thing, I think every one is getting more from
    this web page, and your views are good for new viewers.

  141. Quyen says:

    It is truly a great and helpful piece of info. I’m happy that
    you just shared this useful information with us. Please stay us informed like
    this. Thank you for sharing.

  142. Shonda says:

    I’ve read several excellent stuff here. Definitely price bookmarking for revisiting.
    I surprise how so much attempt you put to create such a magnificent informative site.

  143. Attractive section of content. I just stumbled upon your blog and in accession capital to assert that I get actually enjoyed account your blog posts.
    Any way I’ll be subscribing to your feeds and even I achievement you
    access consistently rapidly.

  144. Throne of the Phantom King works particularly
    well if you pick a remote mountain range a few days travel from the nearest city.
    show that Jesus was and is in control; He is Lord indeed.
    His unmarried and solitary life is meaningless and empty.

  145. I’m really enjoying the design and layout of your site.

    It’s a very easy on the eyes which makes it much more enjoyable for me
    to come here and visit more often. Did you hire out a designer to create
    your theme? Fantastic work!

  146. This is very attention-grabbing, You’re a very skilled blogger.
    I’ve joined your feed and look forward to in search of more of your fantastic post.
    Also, I’ve shared your site in my social networks

  147. jeux gratui says:

    I really like your blog.. very nice colors & theme.

    Did you create this website yourself or did you hire someone
    to do it for you? Plz respond as I’m looking to construct my own blog
    and would like to find out where u got this from. kudos

  148. I do not even know how I ended up here, however I thought this post was once
    great. I do not understand who you might be but certainly you
    are going to a well-known blogger if you happen to are not already.
    Cheers!

  149. Hello, yeah this post is actually pleasant and I have
    learned lot of things from it concerning blogging.
    thanks.

  150. Hi there to every one, it’s really a pleasant for
    me to go to see this website, it consists of important Information.

  151. Marketing strategies using the Internet have been around for
    some time. So it is important that the consumers are targeted
    using well-planned promotions in this stage of the decision making process, as this is when
    the actual purchase decision takes place. articles online that may have put you off keyword use altogether.

  152. Thanks for sharing your info. I really appreciate your efforts and I will be waiting for
    your further post thanks once again.

  153. è fa finisce con sazietà frutta mattino individuo dei più elevata di Attualmente di
    rinunciare perfezionismo,

  154. Useful info. Fortunate me I discovered your site by chance, and I am surprised why
    this twist of fate did not came about in advance! I bookmarked it.

  155. Hello, yup this paragraph is truly good and I have learned lot of things
    from it concerning blogging. thanks.

  156. Hello! I’ve been reading your blog for some time now and finally got the courage to go
    ahead and give you a shout out from Porter Texas!
    Just wanted to mention keep up the good job!

  157. I really like reading through a post that will make men and women think.

    Also, many thanks for allowing me to comment!

  158. valentine 1 says:

    Thank уou fօr the gߋod writeup. Ӏt іn fɑct
    ԝas a amusement account іt. Look advanced to far
    added agreeable from yߋu! Вy the ѡay, how can wе communicate?

  159. I just like the helpful info you supply to your articles.
    I’ll bookmark your weblog and check once more right here regularly.
    I am quite certain I’ll be told plenty of new stuff right here!
    Best of luck for the following!

  160. susu glutera says:

    Great post. I was checking continuously this blog and I
    am impressed! Very useful information specially the last part :) I care for such info much. I was seeking
    this particular info for a long time. Thank you and good luck.

  161. esq watches says:

    Incredible! This blog looks exactly like my old one!
    It’s on a completely different subject but it has pretty much the same page layout and
    design. Excellent choice of colors!

  162. I blog quite often and I truly thank you for your information.
    This great article has really peaked my interest.
    I will take a note of your blog and keep checking for new information about once a week.

    I subscribed to your RSS feed too.

  163. Every weekend i used to visit this web site, because i wish for enjoyment,
    as this this web site conations really fastidious funny information too.

  164. webpage says:

    I like the valuable info you provide in your articles.
    I’ll bookmark your weblog and check again here regularly.

    I’m quite certain I will learn many new stuff right here!
    Best of luck for the next!

  165. staircases says:

    Normally I do not learn article on blogs, however I wish to say that
    this write-up very compelled me to take a look at and do so!
    Your writing style has been amazed me. Thank you, quite great article.

  166. great put up, very informative. I ponder why the other specialists of this sector don’t understand this.
    You should continue your writing. I am sure, you have a huge readers’ base already!

  167. Also for those of us that are on vegan diets you will also find some fantastic vegetarian diet recipes
    in the Dukan Diet. Salads and sandwiches with lean protein such as chicken,
    turkey or fish are the best for your lunch menu. The Potato Museum’s mission is to
    educate the world about the potato.

  168. Hey There. I discovered your blog the usage of msn.
    This is a really smartly written article. I will be sure to bookmark
    it and come back to learn extra of your useful info.
    Thank you for the post. I will definitely comeback.

  169. This is one of the reasons why capsicum has secured its place well
    in herbal diet pills. Besides the unbeatable weight reduction quality, it can also help in inhibiting other types of diseases that cause bacteria.
    The first week of Day – Z saw more than 400,000 copies of the game sold and
    downloaded with the game handling up to 40,000 users signed in at the same time.

  170. Paul Newman is always great to watch on Netflix?
    While the free trial offer. And it’s not just because they trespassed into forbidden
    territory or because they’re testing tthe laws
    of gravity. Director: Stevan free netflix account MenaR-Rated85 mins________________________________________________________________________70.
    Noow movie buffs can just loog in to your Netfliix instant viewjng list.
    It supports 1080p HD video, and also to rebut a claim made by Reed Hundt.
    To take a look at what Netflix has to pay for your online
    movie rentsl service.

  171. Wow, incredible blog layout! How long have you been
    blogging for? you make blogging look easy. The overall
    look of your website is wonderful, as well as
    the content!

  172. That is very fascinating, You are a very skilled
    blogger. I have joined your feed and stay up for looking for extra
    of your wonderful post. Additionally, I have shared your web site in my social networks

  173. webpage says:

    Hi, I think your website might be having browser compatibility issues.
    When I look at your blog site in Ie, it looks fine but when opening in Internet Explorer,
    it has some overlapping. I just wanted to give you a quick heads up!

    Other then that, fantastic blog!

  174. You should be a part of a contest for one of the most useful sites online.
    I’m going to recommend this blog!

  175. anal toys says:

    When I originally commented I clicked the “Notify me when new comments are added” checkbox and now each time a comment is added I get four emails with the same comment.
    Is there any way you can remove people from that service?
    Cheers!

  176. Appreciatе the recοmmendation. Let mе try it out.

  177. Hay Day by Supercell is free to download from the App store to your i – Phone
    or i – Pad. My husband is so tired of hearing about this subject.
    For example, if you buy the 30 000 coin silo, you will
    gain 302 xp and the added benefit of making your farm more beautiful.

  178. Its like you read my thoughts! You appear to understand a lot
    about this, like you wrote the e-book in it
    or something. I believe that you can do with some p.c.

    to drive the message house a bit, however other than that, that
    is magnificent blog. A fantastic read. I’ll definitely be back.

  179. Great post. I was checking constantly this weblog and I’m impressed!
    Extremely helpful info particularly the ultimate section :) I care for such information a lot.
    I used to be looking for this certain information for a very long time.

    Thank you and good luck.

  180. acne says:

    May I simply say what a comfort to uncover somebody who truly understands
    what they’re discussing online. You certainly understand how to bring a problem
    to light and make it important. More and more people ought to read this and understand this side
    of your story. I was surprised that you are not
    more popular given that you certainly have the gift.

  181. Indeed, about two-hundred years of modern democracy have done more than the past few thousand to completely confirm perhaps even its grossest incapacity
    for anything else, as well as its strongest instinct to murder anybody who dares tell it as much.
    In the past 20 years, he has made over 2000 presentations that have included more than 10,000 hours
    of coaching and HR consulting. I put all my attention in
    producing these original mobile series, because I knew I wanted to
    further pursue digital content and that led me to the experience at Go – TV.

  182. Hello superb blog! Does running a blog like this take a great deal of work?
    I have virtually no knowledge of computer programming however
    I was hoping to start my own blog in the near future.
    Anyhow, if you have any ideas or techniques for new blog owners
    please share. I understand this is off topic
    however I just wanted to ask. Thank you!

  183. insurance says:

    I think that is among the most vital information for me.
    And i’m glad studying your article. But should commentary on few general things, The website style is
    ideal, the articles is truly excellent : D. Just right job, cheers

  184. Jeannette says:

    Wow! This blog looks just like my old one! It’s on a entirely different
    topic but it has pretty much the same layout and design.

    Wonderful choice of colors!

  185. whjoah tis blog is great i really likje studying your posts.

    Stay up the good work! You realize, a lot of people are hunting
    round for this info, you can help them greatly.

  186. Just want to say your article iss as astonishing.
    The clearness in your post is simply spectacular aand i can assume you are ann expert on this subject.
    Fine with your permission let me to grab your feed to keep updated with forthcoming post.
    Thanks a million and please keep up the rewardig work.

  187. Your methpd of telling the whoile thing in his
    post is really nice, all be able to without difficulty
    understand it, Thanks a lot.

  188. Hello, just wanted to say, I liked this blog post. It was funny.
    Keep on posting!

  189. Write more, thats all I have to say. Literally, it seems as though you relied on
    the video to make your point. You obviously know what youre talking about, why throw away your intelligence on just
    posting videos to your weblog when you could be giving us something enlightening to read?

  190. The influenza virus or flu can cause serious complications, and certain people groups have a higher risk of experiencing
    health complicati. Instead of the giant towering metal antennas of
    yesterday, you can get even better performance
    with a smaller digital antenna that mounts on the side of
    your house. One such myth is that anyone can easily install a metal roof.

  191. I wanted to thank you for this fantastic read!!

    I certainly loved every bit of it. I have got you saved as a favorite to check out
    new things you post…

  192. jual obat pelangsing says:

    Hi! I could have sworn I’ve been to this web site before but after going through
    some of the posts I realized it’s new to me. Regardless, I’m certainly delighted I found it
    and I’ll be bookmarking it and checking back often!

  193. Happy Wheels says:

    Hurrah! After all I got a weblog from where I know how to in fact take useful data regarding my study and knowledge.

  194. Thanks for finally writing about >Does a Response to Proton Pump Inhibitor Therapy Indicate GERD?

    | <Liked it!

  195. I seldom comment, but after browsing a ton of comments on Does a
    Response to Proton Pump Inhibitor Therapy Indicate GERD?

    |. I do have some questions for you if it’s okay. Is it simply me or does it appear like some of the responses come across like they are left by brain dead individuals? :-P And, if you are writing at other online sites, I would like to keep up
    with you. Would you make a list of every one of your
    social community pages like your linkedin profile, Facebook page or
    twitter feed?

  196. I am in fact glad to read this weblog posts which
    consists of lots of valuable facts, thanks for providing
    these kinds of statistics.

  197. Piece of writing writing is also a fun, if you know then you can write or else it is
    difficult to write.

  198. Very good information. Lucky me I discovered your blog by chance (stumbleupon).

    I’ve bookmarked it for later!

  199. newzevents says:

    Your method of describing everything in this article is in fact fastidious, every one can simply be aware of it,
    Thanks a lot.

  200. Oսtstanding quest there. What occurred after?
    Good luck!

  201. Hello there, You’ve done a great job. I’ll certainly digg
    it and personally suggest to my friends. I’m
    confident they will be benefited from this site.

  202. Informative article, exactly what I wanted to
    find.

  203. When this happens you will need to crawl into your attic and
    try to find what is causing your ceiling to become wet.
    This is one thing illegitimate companies do not provide.
    So how do we rate wood as being the best natural green building materials, lets
    look at how they fare against these criteria:.

  204. Thanks for shariոg youг thoughts about skin carе yuma az.
    Regards

  205. You can sell only the number units shown. For now, Gold could only be harvested one time before the land has to
    be palatable for the dog.With this positive feedback in mind, if farmville 2 cheat yur crops are going tto be really
    important to togally dedicate your efforts to unearth the might secretys tat all top
    players on Farmville.

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s