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left untreated&#44; it may lead to dehydration&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">1&#44;2</span></a> Oral rehydration therapy &#40;ORT&#41; is the most suitable treatment for children with AGE&#44; but it is challenging in the presence of persistent&#47;refractory emesis&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">2</span></a> Guidelines state that ORT in children has a high chance of failure in the setting of persistent vomiting&#44; and support the use of intravenous &#40;IV&#41; rehydration in this context&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">3&#44;4</span></a> However a recent publication showed that ORT is efficacious even in children with vomiting in a high percentage of cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">3&#44;4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">When pharmacological intervention is used for persistent nausea and vomiting&#44; it can prevent severe complications due to dehydration&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">2&#44;5</span></a> Bromopride&#44; metoclopramide&#44; and ondansetron have been used in clinical practice in these situations&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">6&#44;7</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Bromopride has been used since the 1970s&#59; its use has been fully incorporated by pediatricians since then&#46; The recommendation of bromopride remains a reference as a therapeutic resource for various diseases in gastroenterology textbooks and published reviews on prokinetics&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">8</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Metoclopramide is an anti-emetic widely used in the treatment of vomiting in children&#44; with good results&#46; A study comparing the therapeutic effectiveness of intravenous metoclopramide &#40;72&#37;&#41; and ondansetron &#40;81&#37;&#41; showed that both are effective in stopping vomiting&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">9</span></a> Some studies found that metoclopramide was associated with adverse effects&#44; such as sedation&#44; agitation&#44; or extrapyramidal reaction&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">2&#44;5&#44;8&#44;10</span></a> However&#44; such adverse effects could be secondary to the dosing used&#59; this remains to be clarified&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Ondansetron has been widely used as an anti-emetic in cases of vomiting associated with chemotherapy&#44; radiotherapy&#44; and surgical interventions&#46; Recent studies have shown that the prescription of ondansetron is rising in pediatric emergency departments for treating AGE-associated vomiting&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">3&#44;7&#44;11&#44;12</span></a> It has been shown in a recent meta-analysis that ondansetron compared with placebo increased the chance for vomiting cessation up to one hour after drug administration&#44; but there was no difference between the groups after four&#44; 24&#44; and 48<span class="elsevierStyleHsp" style=""></span>h&#46; Treatment with ondansetron compared with placebo reduced the risk of failure of oral rehydration therapy and reduced the risk of hospitalization&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">4</span></a> A study conducted in the United States and Canada with ondansetron found that 86&#37; of physicians recommended its use&#44; considering its effectiveness effective in improving ORT success and its reasonable cost&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">13</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Still&#44; more evidence is needed concerning the safety and efficacy of antiemetic use for vomiting in children&#46; The aim of this study was to assess the effectiveness of a single intramuscular dose of bromopride&#44; metoclopramide&#44; and ondansetron to treat acute onset vomiting in a pediatric emergency department&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Trial design</span><p id="par0040" class="elsevierStylePara elsevierViewall">Controlled clinical trial phase IV&#44; randomized in three parallel groups&#44; to assess the therapeutic effectiveness of ondansetron&#44; bromopride&#44; and metoclopramide in treating vomiting&#46; Patients were randomized in sequential blocks as they became eligible to participate in the study&#44; and similar distribution in each treatment group was ensured&#46; The assignment was made as 1&#58;1&#58;1 for each medication in blocks of fifteen children&#44; including five from each group&#46; The sequential block randomization was not predictable by treating clinicians&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Changes in trial design</span><p id="par0045" class="elsevierStylePara elsevierViewall">There were no changes in the study design throughout its duration&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Study setting</span><p id="par0050" class="elsevierStylePara elsevierViewall">The study was conducted in the Pediatric Emergency Department &#40;PedER&#41; of Hospital Universit&#225;rio de Santa Maria &#40;HUSM&#41;&#44; in southern Brazil&#44; between August 2013 and June 2014&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Eligibility criteria for participants</span><p id="par0055" class="elsevierStylePara elsevierViewall">Inclusion criteria were as follows&#58; children 1&#8211;12 years of age&#44; admitted to the PedER with two or more episodes of vomiting in the previous 24<span class="elsevierStyleHsp" style=""></span>h&#44; and considered to need intramuscular anti-emetic medication by the attending physician&#46; The study did not consider the severity or details of the vomiting&#44; but only the attending physician&#39;s decision to use anti-emetic medication&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Exclusion criteria were as follows&#58; &#40;a&#41; use of anti-emetic medications in the previous 24<span class="elsevierStyleHsp" style=""></span>h&#59; &#40;b&#41; children with known allergy to bromopride&#44; metoclopramide&#44; and&#47;or ondansetron&#59; &#40;c&#41; severe dehydration&#44; vomiting due to sedation&#44; anesthesia&#44; or chemotherapy&#59; &#40;d&#41; pregnant and&#47;or breast-feeding teenagers&#59; &#40;e&#41; children with heart disease&#44; advanced renal disease&#44; urinary tract infection&#44; epilepsy&#44; intestinal obstruction&#44; appendicitis&#44; meningitis&#44; diabetes mellitus&#44; malnutrition&#44; pneumonia&#44; or brain tumor&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Interventions</span><p id="par0065" class="elsevierStylePara elsevierViewall">Once subjects were identified as meeting eligibility criteria&#44; they were approached for recruitment&#46; Immediately following recruitment&#44; patients were randomized to a treatment group&#46; The three treatment groups were&#58; group A&#44; bromopride &#40;0&#46;15<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#44; maximum 10<span class="elsevierStyleHsp" style=""></span>mg&#41;&#59; group B&#44; metoclopramide &#40;0&#46;15<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#44; maximum 10<span class="elsevierStyleHsp" style=""></span>mg&#41;&#59; group C&#44; ondansetron&#44; &#40;0&#46;15<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#44; maximum 8<span class="elsevierStyleHsp" style=""></span>mg&#41;&#46; They were all administered as a single intramuscular dose&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Children remained under observation in the PedER until discharged by the attending physician&#46; At the time of discharge&#44; a survey was given to parents or legal guardians to ascertain details on the evolution of symptoms in the 24<span class="elsevierStyleHsp" style=""></span>h following the treatment&#46; Children whose vomiting did not improve 60<span class="elsevierStyleHsp" style=""></span>min following the intervention were prescribed other medications by the attending physician&#44; as they deemed appropriate &#40;typically either intravenous fluid or other anti-emetics&#41;&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">All assessments within the 24<span class="elsevierStyleHsp" style=""></span>h period of data collection &#40;<span class="elsevierStyleItalic">i&#46;e&#46;</span>&#44; response to treatment at one&#44; six&#44; and 24<span class="elsevierStyleHsp" style=""></span>h post treatment&#41; were made by members of the research team&#44; who were blinded to the intervention&#46; Following discharge&#44; information was collected by phone calls to the caregivers by members of the research team&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Outcomes</span><p id="par0080" class="elsevierStylePara elsevierViewall">Variables were assessed for the three drugs&#44; at 60<span class="elsevierStyleHsp" style=""></span>min&#44; six hours&#44; and 24<span class="elsevierStyleHsp" style=""></span>h after intervention with IM medication&#46; At 60<span class="elsevierStyleHsp" style=""></span>min&#44; data was obtained regarding the number of children in whom vomiting ceased&#44; acceptance of oral fluids and amount &#40;mL&#41;&#44; need for intravenous rehydration&#44; and side effects&#46; After receiving the medication&#44; children were restrained from receiving any oral fluid for 30<span class="elsevierStyleHsp" style=""></span>min&#59; then&#44; children were allowed to drink 300<span class="elsevierStyleHsp" style=""></span>mL of either oral rehydration solution or tap water&#44; given in small amounts using a 10<span class="elsevierStyleHsp" style=""></span>mL syringe by their accompanying parents&#44; to avoid stimulating the emetic reflex as much as possible&#46; The amount of fluids taken orally was measured one hour after initiating its administration&#46; After full oral fluid intake was tolerated&#44; light solid food intake was advised at discharge from the PedER&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Six hours post anti-emetic medication&#44; the number of children that ceased vomiting was recorded&#44; as well as whether they had been discharged home or remained in the PedER&#46; Side effects were also recorded&#44; such as diarrhea&#44; somnolence&#44; or others&#46; Information collected 24<span class="elsevierStyleHsp" style=""></span>h post anti-emetic medication included the number or children that ceased vomiting&#44; returns to PedER due to vomiting or side effects&#44; and side effects at any point in time &#8211; like diarrhea&#44; somnolence&#44; or others&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">The sample size was calculated based on previous studies&#44; considering the vomit cessation rate at 24<span class="elsevierStyleHsp" style=""></span>h&#44;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">14</span></a> using the expected values for each medication under study&#58; 60&#37; &#40;ondansetron&#41;&#44; 45&#37; &#40;bromopride&#41;&#44; and 30&#37; &#40;metoclopramide&#41;&#46; The estimated sample was 48 subjects per group &#40;144 children&#41;&#46; Estimating attrition of 20&#37;&#44; the final sample size was set at 180 patients&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Continuous variables were expressed as means and standard deviation &#40;SD&#41; or medians with interquartile ranges&#44; depending on their distribution&#46; Similarly&#44; Student&#39;s <span class="elsevierStyleItalic">t</span>-test or the Kruskal&#8211;Wallis test was used when appropriate&#46; The categorical variables were expressed by percentage and compared by Pearson&#39;s chi-squared test or Fisher&#39;s exact test&#46; Data was analyzed using&#160;SPSS software &#40;IBM Corp&#46; Released 2011&#46; IBM SPSS Statistics for Windows&#44; Version 20&#46;0&#46; NY&#44; USA&#41;&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">The study was approved by the institutional Review Board &#40;CAAE&#58; 12188513&#46;9&#46;0000&#46;5336&#41;&#44; and all parents or legal guardians agreed to participate by signing an informed consent&#46; Clinical Trial registration number&#58; RBR-5ky3ks&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Results</span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Participant flow</span><p id="par0105" class="elsevierStylePara elsevierViewall">One hundred and eighty children were selected and randomized to receive treatment for vomiting in the PedER &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Losses and exclusions</span><p id="par0110" class="elsevierStylePara elsevierViewall">Five children were excluded &#40;four from the bromopride group and one from the ondansetron group&#41; due to the prescription of a different antiemetic drug by the attending physician&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Baseline data</span><p id="par0115" class="elsevierStylePara elsevierViewall">No significant differences were observed between study groups in terms of sex&#44; age&#44; weight&#44; and number of episodes of vomiting before administering the study drug &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Numbers analyzed</span><p id="par0120" class="elsevierStylePara elsevierViewall">175 children completed the study&#44; distributed as follows&#58; group A &#40;bromopride&#41;&#44; 59&#59; group B &#40;metoclopramide&#41;&#44; 58&#44; and group C &#40;ondansetron&#41;&#44; 58&#46; There were no losses in the follow up&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Outcomes</span><p id="par0125" class="elsevierStylePara elsevierViewall">Of all study participants&#44; only five children &#40;2&#46;9&#37;&#41; vomited in the first hour after receiving medication&#46; Two &#40;3&#46;4&#37;&#41; belonged to group A&#44; and three &#40;5&#46;2&#37;&#41; to group B&#44; with no significant difference between groups &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0130" class="elsevierStylePara elsevierViewall">At 24<span class="elsevierStyleHsp" style=""></span>h&#44; the anti-emetic effect&#44; in terms of number of children having stopped vomiting&#44; was statistically superior in group C compared to groups A and B &#40;96&#46;6&#37; <span class="elsevierStyleItalic">vs</span>&#46; 67&#46;8&#37; and 67&#46;2&#37;&#44; respectively &#91;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#93;&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Oral fluid intake &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#44; evaluated 30<span class="elsevierStyleHsp" style=""></span>min after receiving medication&#44; was statistically better &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;050&#41; for group C &#40;200<span class="elsevierStyleHsp" style=""></span>mL&#41;&#44; compared to groups A &#40;150<span class="elsevierStyleHsp" style=""></span>mL&#41; and B &#40;100<span class="elsevierStyleHsp" style=""></span>mL&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0140" class="elsevierStylePara elsevierViewall">Intravenous &#40;IV&#41; rehydration was given to 11 children&#44; five from the bromopride group and six from the metoclopramide group &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;658&#41;&#46; No patients needed IV rehydration in the ondansetron group &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;033&#41;&#46; Seven children returned to the PedER due to vomiting &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Side effects</span><p id="par0145" class="elsevierStylePara elsevierViewall">At 60<span class="elsevierStyleHsp" style=""></span>min post-treatment&#44; the group that showed fewest adverse effects was Group C &#40;24&#46;1&#37;&#41;&#44; while groups A and B reported twice as many adverse events&#59; 44&#46;8&#37; and 46&#46;5&#37;&#44; respectively &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;020&#41;&#46; The most common side effect was somnolence in all three groups&#59; however&#44; this was less prevalent in Group C than Groups A and B &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; At 24<span class="elsevierStyleHsp" style=""></span>h&#44; Group C showed less side effects than Groups A and B&#44; but this was not statistically significant &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;752&#41;&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">There were no statistical differences in diarrhea episodes after using the anti-emetics in any of the medication groups&#46;</p></span></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Discussion</span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Interpretation</span><p id="par0155" class="elsevierStylePara elsevierViewall">The results showed that bromopride&#44; metoclopramide&#44; and ondansetron are effective anti-emetic medications for treating vomiting in children&#44; with relatively benign safety profiles&#46; Of the three drugs we tested&#44; ondansetron demonstrated to have the best therapeutic profile in terms of effectiveness and amount of oral fluids accepted after the administration of the drug&#59; it was also associated with a lower frequency of side effects&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">15</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">The scientific literature supports the use of anti-emetics for treating persistent vomiting&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">7</span></a> A study conducted in the USA revealed that most emergency pediatricians prescribe anti-emetics to treat vomiting&#44; considering that it is distressing and unpleasant to children and caregivers&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">13</span></a> A study conducted in Italy had similar results&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">16</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">Apart from their efficacy&#44; clinicians will often use medications based on their safety profile&#46; Ondansetron has been shown to be effective in preventing vomiting&#44; allowing oral rehydration and limiting IV rehydration use for patients with AGE&#44; while having relatively few side effects&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">4&#44;7</span></a> Several studies have compared the effectiveness of ondansetron to placebo&#44; and have shown that ondansetron is more effective in treating vomiting&#44; reducing admission rates&#59; however&#44; some studies report diarrhea with the use of ondansetron&#44; probably due to its prokinetic effect&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">11&#44;12&#44;17</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">According to different authors&#44; six hours after the administration of anti-emetic medication may be the most suitable time period to assess its effectiveness&#46; There appears to be benefits from using ondansetron in comparison to bromopride and metoclopramide&#46; In the present study&#44; ondansetron was more effective six &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;023&#41; and 24<span class="elsevierStyleHsp" style=""></span>h &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; after administration in reducing the incidence of vomiting&#44; compared to the other drugs&#46; It showed a low rate of side effects&#44; was more successful in oral rehydration&#44; prevented IV rehydration&#44; and prevented hospital admission &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; Bromopride and metoclopramide were considered effective but caused adverse effects&#44; mainly in the first hour after medication&#44; such as somnolence&#44; which may increase the observation time and hospital costs&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Cubeddu et al&#46; compared the therapeutic effectiveness of ondansetron&#44; metoclopramide&#44; and a placebo in control of vomiting&#44; 24<span class="elsevierStyleHsp" style=""></span>h after receiving anti-emetics&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">14</span></a> Ondansetron was more effective in controlling vomiting compared to metoclopramide and the placebo&#46; The limitation of this study was the small sample size&#46; A study conducted by Al-Ansari et al&#46; evaluated the time to vomiting cessation during episodes of AGE and revealed that both ondansetron and metoclopramide were equally effective in this context&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">9</span></a> Some authors concerned about side effects from anti-emetics&#44; like diarrhea or dystonic reaction&#44; have described that metoclopramide can cause extrapyramidal symptoms and sedation in children&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">2&#44;7&#44;10</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">The present study investigated whether the anti-emetic medications studied were associated with the development of diarrhea&#46; Neither drug was shown to cause significant diarrhea in the cohort studied&#46; Al-Ansari et al&#46;&#44; also failed to show an association between anti emetic use and diarrhea&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">9</span></a> Cubeddu et al&#46; had previously suggested that diarrhea may be related to the use of metoclopramide&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">14</span></a> Although the prokinetic effect of metoclopramide could contribute to this side effect&#44; one would expect ondansetron to cause similar symptoms given its mechanism of action&#46; A study mentions that the increased incidence of diarrhea can be considered as resulting from toxin retention&#44; which could have been eliminated by vomiting&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">6</span></a></p><p id="par0185" class="elsevierStylePara elsevierViewall">To the authors&#8217; knowledge&#44; this is the only study that has compared the therapeutic effectiveness of bromopride&#44; metoclopramide&#44; and ondansetron in the treatment of acute onset vomiting in a pediatric cohort treated at the emergency department&#46;</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Limitations</span><p id="par0190" class="elsevierStylePara elsevierViewall">The main limitation of the present study is that the clinicians caring for the children in the emergency department&#44; as well as parents and caregivers&#44; were not blinded to the intervention&#46; However&#44; randomization of the medication minimized this potential bias&#46; In addition&#44; there was no placebo arm&#59; however&#44; these children were treated as per routine clinical practice that includes the use of anti-emetic medications&#46; Specific diagnosis was not included in the eligibility criteria&#59; however&#44; vomiting without a definitive diagnosis is a common complaint in pediatric emergency departments&#44; and randomization controlled this potential bias&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">In conclusion&#44; it was found that bromopride&#44; metoclopramide&#44; and ondansetron are effective anti-emetic medications for treating vomiting in children&#44; hence preventing dehydration&#44; use of IV fluids&#44; and hospitalization&#46; Ondansetron was superior to the other two agents studied in achieving emesis control and also had fewer side effects&#46;</p></span></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Registration number&#58; RBR-5ky3ks</span><p id="par0200" class="elsevierStylePara elsevierViewall">Name of trial registry&#58; Randomized clinical trial&#44; comparing the therapeutic effectiveness of intramuscular bromopride&#44; metoclopramide&#44; and ondansetron in the treatment of vomiting&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">Protocol&#58; The Brazilian Clinical Trials Registry&#47;clinicaltrials&#46;gov&#46; Identifier&#58; RBR-5ky3ks&#46;</p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Funding</span><p id="par0210" class="elsevierStylePara elsevierViewall">The study received funding from HUSM&#46;</p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Conflicts of interest</span><p id="par0215" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest&#46;</p></span></span>"
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              "identificador" => "sec0035"
              "titulo" => "Interventions"
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            5 => array:2 [
              "identificador" => "sec0040"
              "titulo" => "Outcomes"
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        6 => array:3 [
          "identificador" => "sec0045"
          "titulo" => "Results"
          "secciones" => array:6 [
            0 => array:2 [
              "identificador" => "sec0050"
              "titulo" => "Participant flow"
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            1 => array:2 [
              "identificador" => "sec0055"
              "titulo" => "Losses and exclusions"
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            2 => array:2 [
              "identificador" => "sec0060"
              "titulo" => "Baseline data"
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            3 => array:2 [
              "identificador" => "sec0065"
              "titulo" => "Numbers analyzed"
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              "titulo" => "Interpretation"
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            1 => array:2 [
              "identificador" => "sec0090"
              "titulo" => "Limitations"
            ]
          ]
        ]
        8 => array:2 [
          "identificador" => "sec0095"
          "titulo" => "Registration number&#58; RBR-5ky3ks"
        ]
        9 => array:2 [
          "identificador" => "sec0100"
          "titulo" => "Funding"
        ]
        10 => array:2 [
          "identificador" => "sec0105"
          "titulo" => "Conflicts of interest"
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        11 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2016-10-31"
    "fechaAceptado" => "2017-02-15"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1284283"
          "palabras" => array:3 [
            0 => "Clinical trial"
            1 => "Antiemetics"
            2 => "Vomiting"
          ]
        ]
      ]
      "pt" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palavras-chave"
          "identificador" => "xpalclavsec1284284"
          "palabras" => array:3 [
            0 => "Ensaio cl&#237;nico"
            1 => "Antiem&#233;ticos"
            2 => "V&#244;mito"
          ]
        ]
      ]
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    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To compare the effectiveness of a single intramuscular dose of bromopride&#44; metoclopramide&#44; or ondansetron for treating vomiting&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Randomized controlled trial including children 1&#8211;12 years of age presenting with acute vomiting at the pediatric emergency department&#46; Outcomes&#58; Number of children that stopped vomiting at one&#44; six&#44; and 24<span class="elsevierStyleHsp" style=""></span>h following treatment&#59; episodes of diarrhea&#59; acceptance of oral liquids&#59; intravenous rehydration&#59; return to hospital and side effects&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">There were 175 children who completed the study&#46; Within the first hour after treatment&#44; all drugs were equally effective&#44; with ondansetron preventing vomiting in 100&#37;&#44; bromopride in 96&#46;6&#37;&#44; and metoclopramide in 94&#46;8&#37; of children &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;288&#41;&#46; Within six hours&#44; ondansetron was successful in preventing vomiting in 98&#46;3&#37; of children&#44; compared to bromopride and metoclopramide&#44; which were successful in 91&#46;5&#37; and 84&#46;4&#37; of patients&#44; respectively &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;023&#41;&#46; Within 24<span class="elsevierStyleHsp" style=""></span>h&#44; ondansetron was superior to both other agents&#44; as it remained efficacious in reducing vomiting in 96&#46;6&#37; of children&#44; as opposed to 67&#46;8&#37; and 67&#46;2&#37; with bromopride and metoclopramide&#44; respectively &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; The ondansetron group showed better acceptance of oral liquids &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41; when compared to the bromopride and metoclopramide&#46; The ondansetron group did not show any side effects in 75&#46;9&#37; of cases&#44; compared to 54&#46;2&#37; and 53&#46;5&#37; in the bromopride and metoclopramide groups&#44; respectively&#46; Somnolence was the most common side effect&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">A single dose of ondansetron is superior to bromopride and metoclopramide in preventing vomiting six hours and 24<span class="elsevierStyleHsp" style=""></span>h following treatment&#46; Oral fluid intake after receiving medication was statistically better with Ondansetronwhile also having less side effects compared to the other two agents&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Objective"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Methods"
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          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
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          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusions"
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      ]
      "pt" => array:3 [
        "titulo" => "Resumo"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Para comparar a efic&#225;cia de uma &#250;nica dose intramuscular de bromoprida&#44; metoclopramida ou ondansetrona no tratamento de v&#244;mito&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Ensaio controlado randomizado incluindo crian&#231;as de 1 a 12 anos de idade que apresentam v&#244;mito agudo no departamento de emerg&#234;ncia pedi&#225;trica&#46; Desfechos&#58; N&#250;mero de crian&#231;as que pararam de vomitar 1&#44; 6 e 24 horas ap&#243;s o tratamento&#59; epis&#243;dios de diarreia&#59; aceita&#231;&#227;o de l&#237;quidos orais&#59; reidrata&#231;&#227;o intravenosa&#44; retorno ao hospital e efeitos colaterais&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">175 crian&#231;as conclu&#237;ram o estudo&#46; Na primeira hora ap&#243;s o tratamento&#44; todos os medicamentos foram igualmente eficazes&#44; sendo que a ondansetrona preveniu v&#244;mito em 100&#37;&#44; a bromoprida em 96&#44;6&#37; e metoclopramida em 94&#44;8&#37; das crian&#231;as &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;288&#41;&#46; Em 6 horas&#44; a ondansetrona mostrou sucesso na preven&#231;&#227;o do v&#244;mito em 98&#44;3&#37; das crian&#231;as&#44; em compara&#231;&#227;o &#224; bromoprida e &#224; metoclopramida&#44; que mostraram sucesso em 91&#44;5&#37; e 84&#44;4&#37; dos pacientes&#44; respectivamente &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;023&#41;&#46; Em 24 horas&#44; a ondansetrona foi superior aos dois outros agentes&#44; pois ela continuou eficaz na redu&#231;&#227;o do v&#244;mito em 96&#44;6&#37; das crian&#231;as&#44; diferente de 67&#44;8&#37; e 67&#44;2&#37; com bromoprida e metoclopramida&#44; respectivamente &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46; O grupo de ondansetrona mostrou melhor aceita&#231;&#227;o de l&#237;quidos orais &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41; em compara&#231;&#227;o a bromoprida e metoclopramida&#46; O grupo de ondansetrona n&#227;o mostrou efeitos colaterais em 75&#44;9&#37; dos casos&#44; em compara&#231;&#227;o a 54&#44;2&#37; e 53&#44;5&#37; dos grupos de bromoprida e metoclopramida&#46; O efeito colateral mais comum foi sonol&#234;ncia&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclus&#245;es</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Uma &#250;nica dose de ondansetrona &#233; superior a bromoprida e metoclopramida no tratamento de v&#244;mito 6 horas e 24 horas ap&#243;s o tratamento&#46; A ingest&#227;o de flu&#237;dos orais ap&#243;s receber medica&#231;&#227;o foi estatisticamente melhor com ondansetrona&#44; ao mesmo tempo em que tamb&#233;m apresentando menos efeitos colaterais em compara&#231;&#227;o aos outros dois agentes&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Objetivo"
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          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "M&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
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          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclus&#245;es"
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    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0055">Please cite this article as&#58; Epifanio M&#44; Portela JL&#44; Piva JP&#44; Ferreira CH&#44; Icaza EE&#44; Mattiello R&#46; Bromopride&#44; metoclopramide&#44; or ondansetron for the treatment of vomiting in the pediatric emergency department&#58; a randomized controlled trial&#46; J Pediatr &#40;Rio J&#41;&#46; 2018&#59;94&#58;62&#8211;8&#46;</p>"
      ]
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        "figura" => array:1 [
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        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">CONSORT flowchart of enrollment&#44; treatment&#44; and follow-up&#46;</p>"
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        "etiqueta" => "Table 1"
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          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">IQR&#44; interquartile range&#59; <span class="elsevierStyleItalic">n</span>&#44; number of patients&#46;</p>"
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                  \t\t\t\t">Vomits &#40;24<span class="elsevierStyleHsp" style=""></span>h&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Median &#40;IQR&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">5&#46;0 &#40;3&#46;0&#8211;7&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">5&#46;0 &#40;3&#46;0&#8211;8&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">5&#46;0 &#40;3&#46;0&#8211;7&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;505<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Kruskal&#8211;Wallis test&#58;</p>"
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Baseline characteristics of children treated for vomiting with bromopride&#44; metoclopramide&#44; and ondansetron intramuscular&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
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                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Bromopride &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>59&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Metoclopramide &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>58&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Ondansetron &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>58&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Vomit &#40;60<span class="elsevierStyleHsp" style=""></span>min&#41;&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;3&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;5&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;288&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Vomit &#40;6<span class="elsevierStyleHsp" style=""></span>h&#41;&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">5 &#40;8&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9 &#40;15&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">1 &#40;1&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;023<a class="elsevierStyleCrossRefs" href="#tblfn0015"><span class="elsevierStyleSup">a&#44;b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Vomit &#40;24<span class="elsevierStyleHsp" style=""></span>h&#41;&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">19 &#40;32&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">19 &#40;32&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;3&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;001<a class="elsevierStyleCrossRefs" href="#tblfn0015"><span class="elsevierStyleSup">a&#44;c</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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              "identificador" => "tblfn0015"
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            1 => array:3 [
              "identificador" => "tblfn0020"
              "etiqueta" => "b"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0020">Metoclopramide <span class="elsevierStyleItalic">vs&#46;</span> bromopride and ondansetron&#46;</p>"
            ]
            2 => array:3 [
              "identificador" => "tblfn0025"
              "etiqueta" => "c"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0025">Ondansetron <span class="elsevierStyleItalic">vs&#46;</span> metoclopramide and bromopride&#46;</p>"
            ]
          ]
        ]
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          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Comparison between bromopride&#44; metoclopramide and ondansetron groups at 60<span class="elsevierStyleHsp" style=""></span>min&#44; six hours&#44; and 24<span class="elsevierStyleHsp" style=""></span>h after medicating&#46;</p>"
        ]
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Bromopride &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>59&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Metoclopramide &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>58&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Ondansetron &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>58&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Amount of liquid &#40;mL&#41; &#8211; Median &#40;interquartile range&#41;</span><a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">150&#46;0 &#40;50&#46;0&#8211;200&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">100&#46;0 &#40;100&#46;0&#8211;200&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">200 &#40;100&#46;0&#8211;200&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;050<a class="elsevierStyleCrossRefs" href="#tblfn0035"><span class="elsevierStyleSup">b&#44;c</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">IV Rehydration&#44; &#40;yes&#41;&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;8&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 &#40;10&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;033<a class="elsevierStyleCrossRefs" href="#tblfn0045"><span class="elsevierStyleSup">d&#44;e</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Return to the PedER&#44; &#40;yes&#41;&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;5&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;5&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;1&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;637<a class="elsevierStyleCrossRef" href="#tblfn0045"><span class="elsevierStyleSup">d</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Side effects &#40;60</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">min&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">32 &#40;54&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">31 &#40;53&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">44 &#40;75&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;020<a class="elsevierStyleCrossRefs" href="#tblfn0045"><span class="elsevierStyleSup">d&#44;e</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Somnolence&#44; &#40;yes&#41;&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26 &#40;44&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26 &#40;44&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12 &#40;20&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;034<a class="elsevierStyleCrossRefs" href="#tblfn0045"><span class="elsevierStyleSup">d&#44;e</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Diarrhea&#44; &#40;yes&#41;&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0 &#40;0&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;1&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Other&#44; &#40;yes&#41;&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;1&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;1&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;1&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Side effects &#40;24</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">h&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>None&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">38 &#40;64&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">35 &#40;63&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">40 &#40;69&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;752<a class="elsevierStyleCrossRef" href="#tblfn0045"><span class="elsevierStyleSup">d</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Somnolence&#44;&#40;yes&#41;&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10 &#40;16&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11 &#40;20&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 &#40;12&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Diarrhea&#44; &#40;yes&#41;&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;5&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;9&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;5&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Other&#44; &#40;yes&#41;&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8 &#40;13&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4 &#40;7&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8 &#40;13&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0050">Ondansetron <span class="elsevierStyleItalic">vs&#46;</span> metoclopramide and bromopride&#46;</p>"
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          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Secondary outcome measures comparing different medications&#46;</p>"
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                0 => array:2 [
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                      "titulo" => "Acute diarrhea in adults and children&#58; a global perspective"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "M&#46; Farthing"
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                    0 => array:2 [
                      "titulo" => "European Society for Pediatric Gastroenterology&#44; Hepatology&#44; and Nutrition&#47;European Society for Pediatric Infectious Diseases evidence-based guidelines for the management of acute gastroenteritis in children in Europe&#58; update 2014"
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                          "etal" => false
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                            4 => "R&#46; Shamir"
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