***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: OBJECTIVES : The lower esophageal sphincter ( LES ) , surrounded by diaphragmatic muscle , prevents gastroesophageal reflux . When these structures become incompetent , gastric contents may cause gastroesophageal reflux disease ( GERD ) . For treatment , lifestyle interventions are always recommended . We hypothesized that by actively training the crura of the diaphragm as part of the LES using breathing training exercises , GERD can be positively influenced . METHODS : A prospect i ve r and omized controlled study was performed . Patients with non-erosive GERD or healed esophagitis without large hernia and /or previous surgery were included . Patients were r and omized and allocated either to active breathing training program or to a control group .  Quality of life ( QoL ) , pH-metry , and on-dem and proton pump inhibitor ( PPI ) usage were assessed at baseline and after 4 weeks of training . For long-term follow-up , all patients were invited to continue active breathing training and were further assessed regarding QoL and PPI usage after 9 months . Paired and unpaired t-test was used for statistical analysis . RESULTS : Nineteen patients with non-erosive GERD or healed esophagitis were r and omized into two groups ( 10 training group and 9 control group ) . There was no difference in baseline patient characteristics between the groups and all patients finished the study . There was a significant decrease in time with a pH<4.0 in the training group ( 9.1±1.3 vs. 4.7±0.9 % ; P<0.05 ) , but there was no change in the control group . QoL scores improved significantly in the training group ( 13.4±1.98 before and 10.8±1.86 after training ; P<0.01 ) , but no changes in QoL were seen in the control group . At long-term follow-up at 9 months , patients who continued breathing exercise ( 11/19 ) showed a significant decrease in QoL scores and PPI usage ( 15.1±2.2 vs. 9.7±1.6 ; 98±34 vs. 25±12 mg/week , respectively ; P<0.05 ) , whereas patients who did not train had no long-term effect . CONCLUSIONS : We show that actively training the diaphragm by breathing exercise can improve GERD as assessed by pH-metry , QoL scores and PPI usage . This non-pharmacological lifestyle intervention could help to reduce the disease burden of GERD Background The risk for acidic reflux is mainly determined by the position of the gastric acid pocket . It was hypothesised that compounds affecting proximal stomach tone might reduce gastro-oesophageal reflux by changing the acid pocket position . Objective To study the effect of azithromycin ( Azi ) on acid pocket position and acid exposure in patients with gastro-oesophageal reflux disease ( GORD ) . Methods Nineteen patients with GORD were included , of whom seven had a large hiatal hernia ( ≥3 cm ) ( L-HH ) and 12 had a small or no hiatal hernia ( S-HH ) . Patients were r and omised to Azi 250 mg/day or placebo during 3 days in a crossover manner . On each study day , reflux episodes were detected using concurrent high-resolution manometry and pH-impedance monitoring after a st and ardised meal . The acid pocket was visualised using scintigraphy , and its position was determined relative to the diaphragm . Results Azi reduced the number of acid reflux events ( placebo 8.0±2.2 vs Azi 5.6±1.8 , p<0.01 ) and postpr and ial acid exposure ( placebo 10.5±3.8 % vs Azi 5.9±2.5 % , p<0.05 ) in all patients without affecting the total number of reflux episodes . Acid reflux occurred mainly when the acid pocket was located above , or at the level of , the diaphragm , rather than below the diaphragm . Treatment with Azi reduced hiatal hernia size and result ed in a more distal position of the acid pocket compared with placebo ( below the diaphragm 39 % vs 29 % , p=0.03 ) . Azi reduced the rate of acid reflux episodes in patients with S-HH ( 38 % to 17 % ) to a greater extent than in patients with L-HH ( 69 % to 62 % , p=0.04 ) . Conclusion Azi reduces acid reflux episodes and oesophageal acid exposure . This effect was associated with a smaller hiatal hernia size and a more distal position of the acid pocket , further indicating the importance of the acid pocket in the pathogenesis of GORD . clinical trial registration http://www.trialregister.nl/trialreg/admin/ rct view.asp?TC=1970 NTR1970 The crural diaphragm ( CD ) is an essential component of the esophagogastric junction ( EGJ ) , and inspiratory exercises may modify its function . This study 's goal is to verify if inspiratory muscle training ( IMT ) improves EGJ motility and gastroesophageal reflux ( GER ) .  Twelve GER disease [ GERD ; 7 males , 20 - 47 yr , 9 esophagitis , and 3 nonerosive reflex disease ( NERD ) ] and 7 healthy volunteers ( 3 males , 20 - 41 yr ) performed esophageal pH monitoring , manometry , and heart rate variability ( HRV ) studies . A 6-cm sleeve catheter measured average EGJ pressure during resting , peak inspiratory EGJ pressures during  sinus arrhythmia maneuver ( SAM ) and inhalations under 17- , 35- , and 70-cmH2O loads ( TH maneuvers ) , and along 1 h after a meal . GERD patients entered a 5-days-a-week IMT program . One author scored heartburn and regurgitation before and after IMT . IMT increased average EGJ pressure ( 19.7 ± 2.4 vs. 29.5 ± 2.1 mmHg ; P < 0.001 ) and inspiratory EGJ pressure during SAM ( 89.6 ± 7.6 vs. 125.6 ± 13.3 mmHg ; P = 0.001 ) and during TH maneuvers . The EGJ-pressure gain across 35- and 70-cmH2O loads was lower for GERD volunteers . The number and cumulative duration of the transient lower esophageal sphincter relaxations decreased after IMT . Proximal progression of GER decreased after IMT but not the distal acid exposure . Low-frequency power increased after IMT and the higher its increment the lower the increment of supine acid exposure . IMT decreased heartburn and regurgitation scores . In conclusion , IMT  improved EGJ pressure , reduced GER proximal progression , and reduced GERD symptoms . Some GERD patients have a CD failure , and IMT may prove beneficial as a GERD add-on treatment OBJECTIVES The prevalence of gastroesophageal reflux disease ( GERD ) in patients with laryngopharyngeal disorders is probably greater than realized . STUDY DESIGN Prospect i ve study . METHODS To investigate the incidence of gastroenterological diseases including GERD in patients complaining of nonspecific laryngopharyngeal symptoms , laryngological examinations and gastroenterological evaluation with esophagogastroduodenoscopy were performed in 30 patients who refused to undergo 24-hour pH monitoring . Therapeutic intervention by behavioural and dietary modifications , antireflux medication , and eradication of Helicobacter pylori were assessed for changes in laryngeal findings and relief of symptoms . RESULTS Posterior laryngitis was present in 26 patients and in 19 of them was accompanied by erythema and edema of the interarytenoid region . Gastroenterological diseases such as GERD ( 43 % ) , hiatal hernia ( 43 % ) , and Helicobacter pylori-positive antrum gastritis ( 23 % ) were confirmed in 22 ( 73 % ) cases by esophagogastroduodenoscopy and histological examination of biopsy specimens . Medical antireflux treatment and eradication of Helicobacter pylori result ed in a remarkably therapeutic success rate of 90 % because there was resolution of laryngopharyngeal symptoms and laryngeal findings in 20 of 22 patients with gastroenterological diseases for the mean follow-up period of 8 months . CONCLUSIONS Laryngopharyngeal symptoms can be predictors of gastroesophageal diseases and GERD because the most frequent underlying cause is supposed to be associated with posterior laryngitis . Medical antireflux treatment is effective for relief of symptoms and mucosal healing of posterior laryngitis The treatment of gastroesophageal reflux disease may be clinical or surgical . The clinical consists basically of the use of drugs ; however , there are new techniques to complement this treatment , osteopathic intervention in the diaphragmatic muscle is one these . The objective of the study is to compare pressure values in the examination of esophageal manometry of the lower esophageal sphincter ( LES ) before and immediately after osteopathic intervention in the diaphragm muscle . Thirty-eight patients with gastroesophageal reflux disease - 16 su bmi tted to sham technique and 22 su bmi tted osteopathic technique - were r and omly selected . The average respiratory pressure ( ARP ) and the maximum expiratory pressure ( MEP ) of the LES were measured by manometry before and after osteopathic technique at the point of highest pressure . Statistical analysis was performed using the Student 's t-test and Mann-Whitney , and magnitude of the technique proposed was measured using the Cohen 's index . Statistically significant difference in the osteopathic technique was found in three out of four in relation to the group of patients who performed the sham technique for the following measures of LES pressure : ARP with P= 0.027 . The MEP had no statistical difference ( P= 0.146 ) . The values of Cohen d for the same measures were : ARP with d= 0.80 and MEP d= 0.52 . Osteopathic manipulative technique produces a positive increment in the LES region soon after its performance BACKGROUND Proton pump inhibitors ( PPIs ) are a major breakthrough in the medical management of  gastroesophageal reflux disease ( GERD ) . In several patients with non erosive reflux disease symptoms ( NERD ) the response to PPIs is partial or limited and symptoms relief needs the administration of additional medications . AIM The aim of this study was to evaluate the effect of a new medical device , based on an oral fixed combination of hyaluronic acid and chondroitin-sulphate ( HA+CS ) , in a bioadhesive carrier , in adults with symptoms of non erosive gastroesophageal reflux and with a low response to PPIs . PATIENTS AND METHODS Twenty patients who had experienced heartburn and /or acid regurgitation for at least 3 days during a 7 day run-in period , without endoscopic mucosal breaks , were r and omized in a double blind crossover study to receive four daily doses of a fixed oral combination of HA+CS and placebo for 14 days . Relief of cardinal symptoms of GERD was evaluated at the end of each period . RESULTS A significant greater Sum of Symptoms Intensity Difference , compared to placebo , was observed after HA+CS treatment ( -2.7 vs 0.5 - p < 0.01 ) , being both heartburn ( -1.6 vs 0.5 - p < 0.03 ) and acid regurgitation ( -1.1 vs 0.1 - p < 0.03 ) significantly improved by the medical device . A speed of action ≤ 30 min was significantly more frequently reported by patients during HA+CS administration than with placebo ( 60 % vs 30 % - p = 0.05 ) . Total disappearance of symptoms was observed in 50 % of the patients compared to 10 % during placebo administration ( p = 0.01 between group comparison ) . CONCLUSIONS A fixed combination of HA+CS has demonstrated to be effective in gastroesophageal reflux control , with a rapid onset of action 
    Output:
    
Among the non-surgical , non-pharmacological treatment modalities , the breathing training on diaphragm could play an important role in selected patients to manage the symptoms of GERD