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Clinical and prognostic features among children with acute encephalitis syndrome in Nepal; a retrospective study
Ajit Rayamajhi1,2,3,
Imran Ansari2,4,
Elizabeth Ledger3,
Krishna P Bista1,
Daniel E Impoinvil3,5,
Sam Nightingale3,
Rajendra Kumar BC6,
Chandeshwor Mahaseth1,2,
Tom Solomon3 &
Michael J Griffiths3
Acute encephalitis syndrome (AES) is commonly seen among hospitalized Nepali children. Japanese Encephalitis (JE) accounts for approximately one-quarter of cases. Although poor prognostic features for JE have been identified, and guide management, relatively little is reported on the remaining three-quarters of AES cases.
Children with AES (n = 225) were identified through admission records from two hospitals in Kathmandu between 2006 and 2008. Patients without available lumbar puncture results (n = 40) or with bacterial or plasmodium infection (n = 40) were analysed separately. The remaining AES patients with suspected viral aetiology were classified, based on positive IgM antibody in serum or cerebral spinal fluid, as JE (n = 42) or AES of unknown viral aetiology (n = 103); this latter group was sub-classified into Non-JE (n = 44) or JE status unknown (n = 59). Bad outcome was defined as death or neurological sequelae at discharge.
AES patients of suspected viral aetiology more frequently had a bad outcome than those with bacterial or plasmodium infection (31% versus 13%; P = 0.039). JE patients more frequently had a bad outcome than those with AES of unknown viral aetiology (48% versus 24%; P = 0.01). Bad outcome was independently associated in both JE and suspected viral aetiology groups with a longer duration of fever pre-admission (P = 0.007; P = 0.002 respectively) and greater impairment of consciousness (P = 0.02; P < 0.001). A higher proportion of JE patients presented with a focal neurological deficit compared to patients of unknown viral aetiology (13/40 versus 11/103; P = 0.005). JE patients weighed less (P = 0.03) and exhibited a higher respiratory rate (P = 0.003) compared to Non-JE patients.
Nepali children with AES of suspected viral aetiology or with JE frequently suffered a bad outcome. Despite no specific treatment, patients who experienced a shorter duration of fever before hospital admission more frequently recovered completely. Prompt referral may allow AES patients to receive potentially life-saving supportive management. Previous studies have indicated supportive management, such as fluid provision, is associated with better outcome in JE. The lower weight and higher respiratory rate among JE patients may reflect multiple clinical complications, including dehydration. The findings suggest a more systematic investigation of the influence of supportive management on outcome in AES is warranted.
Acute encephalitis syndrome (AES) is a constellation of clinical signs and/or symptoms, i.e. acute fever, with an acute change in mental status and/or new onset of seizures [1]. These clinical signs suggest the patient has acute inflammation of the brain and are used by clinicians to identify patients with acute encephalitis. Viruses are regarded as the most important cause of the acute encephalitis syndrome worldwide. However, the syndrome can be associated with a range of pathogens, including acute bacterial or parasitic infection. Where population based studies have been undertaken, the incidence ranges between 3.5 and 7.4 cases per 100,000 patient-years [2]. Acute encephalitis can be associated with severe complications, including impaired consciousness, seizures, limb paresis or death [3].
In Asia, the major identified cause of acute encephalitis is Japanese Encephalitis (JE) virus. JE affects over 50,000 people annually, leading to 8-30% mortality and 50-60% disability, with children bearing the brunt of the disease burden [1, 4–6]. JE is associated with considerable mortality and morbidity among Nepali children [3]. Consequently, the Ministry of Health and Population of Nepal, supported by the office of Infection Prevention Division, World Health Organisation (WHO), has integrated JE surveillance with Acute Flaccid Paralysis, Neonatal Tetanus and Measles in its National surveillance network since 2004 [7]. Over 23,000 cases of AES and 2500 cases of JE have been reported by the WHO surveillance network since 2004 (personal communication: Mr Tika Sedai, Data Manager, Programme for Immunization Preventable Diseases, WHO, Kathmandu, Nepal).
In Nepal, like many countries throughout Asia, test results for JE are often not available until weeks after the patient presents to the health care centre, because they are performed in a centralized government facility. Consequently, health care workers attempt to distinguish JE from other causes of AES based on the patient's clinical features, so that they can focus attention on known complications, such as seizures, and avoid unnecessary treatments, such as antibiotics. However, this approach can be inaccurate, leading to sub-optimal or inappropriate management. There have been several publications relating admission clinical parameters to outcome among JE cases, and the identification of poor prognostic indicators has helped focus attention on treatable complications of infection [8–10]. However, relatively little work has been done identifying prognostic features among the Non-JE AES patients. We therefore decided to investigate for diagnostic and prognostic features that distinguish between JE and other causes of AES, in a retrospective review of all children with AES at two hospitals in Kathmandu, Nepal.
The hospital records of all children, aged 1 - 14 years, presenting either to Kanti Children's Hospital, Maharajgunj, Kathmandu, Nepal or Patan Hospital, Lalitpur, Nepal, from January 2006 to January 2008 were screened for a history consistent with acute encephalitis syndrome (AES).
Kanti Children's Hospital is a busy tertiary level referral centre. It has 300 beds and provides health care services to 300-400 children per day. Patan Hospital is a general hospital situated at the southern end of Kathmandu. It has 450 beds and provides health services to around 1,000 people per day, predominantly adults.
The hospital notes were examined by qualified paediatricians employed within the respective hospitals. Relevant clinical features and laboratory parameters present at admission were recorded in a standardized proforma. Each proforma was designated a unique study number. Study data were transcribed from the proforma to the study database. The study number was used to access the data for all future data analyses.
The study was approved by the Instituitional Review Committee of Kanti Children's Hospital and Patan Hospital, Kathmandu, ethical committee of the Nepal Health Research Council, Kathmandu and the Ethical Review Committee of the Liverpool School of Tropical Medicine, Liverpool, UK.
Acute encephalitis syndrome (AES) and Japanese encephalitis (JE) case definitions
The classification of AES was based on the World Health Organization's (WHO) definition [1]. The results of the JE testing, undertaken as part of the JE surveillance programme, were related to the identified cases. The AES cases, based on the results of their microbiological and serological tests, were classified as AES of suspected viral aetiology (Confirmed JE, Non-JE and JE Status unknown) and AES of non-viral aetiology (AES-bacterial or parasitic aetiology). The clinical features within each class were examined. Cases definitions were as follows:
AES: Fever or recent history of fever with change in mental status (including confusion, disorientation, coma, or inability to talk) and/or new onset of seizures (excluding simple febrile seizures). Other early clinical findings could include an increase in irritability, somnolence or abnormal behaviour greater than that seen with usual febrile illness [1, 3].
AES of suspected viral aetiology: was defined by fulfilling the definition for AES (above) and having a discharge diagnosis of suspected viral encephalitis or menigo-encephalitis, supported by a CSF cell count < 1000 cells/mm3 with a lymphocyte predominance and no positive identification of non-viral pathogens (e.g. bacteria or parasites) in the CSF or blood [3, 11].
Confirmed JE: A suspected case which is shown to have IgM antibodies (≥ 40 units) specific to JE virus in a single (CSF and/or serum) sample (or a rise in titres among paired samples) as detected by IgM-capture ELISA (see testing below).
Non-JE: A suspected viral case which is shown to have an absence of IgM antibodies specific to JE virus based on a negative test for a single sample collected after the ninth day of illness or no change in titres in paired samples collected at least seven days apart.
JE Status unknown: A suspected viral case which was either not tested for anti-JE IgM antibodies or had samples tested that were collected too early in illness course to confidently rule out JE (as defined above).
AES of unknown viral aetiology: A suspected viral case which was not confirmed as JE; this group included both of the categories described above, i.e. Non-JE, and JE Status unknown.
AES of non-viral aetiology: was defined by fulfilling the definition for AES (above) and either; (a) having a documented discharge diagnosis of suspected bacterial meningitis or meningo-encephaltis, supported by a CSF cell count > 1000 cells/mm3 or a pleocytosis with a polymorph predominance and a raised CSF protein (> 0.45 g/L) [3, 11]; or (b) having a positive identification of non-viral pathogen in CSF or blood. A positive identification of a non-viral pathogen was fulfilled by a positive Gram stain or bacterial culture from CSF; a positive bacterial culture from blood; a positive Widal test for Samonella typhi[1, 4]; or observation of asexual Plasmodium falciparum parasites in peripheral blood smears [4, 6].
Other clinical definitions
Outcome at discharge was classified as good or bad. Good outcome was defined as being alive with no impairment of consciousness or neurological sequelae. Bad outcome was defined by death or neurological sequelae at discharge. Patients that self-discharged or were referred to another hospital prior to discharge were excluded from outcome analysis.
Neurological sequelae were defined by the presence of one or more of the following at discharge; impaired consciousness, weakness (monoparesis hemiparesis, quadriparesis), focal or generalized abnormal limb tone (hypertonia, hypotonia), focal or generalized abnormal limb reflexes (hypereflexia, hyporeflexia), diagnosis of new onset or recurrent seizures or new or recurrent extra pyramidal movement disorders [5].
JE diagnostic test
JE virus exposure was tested by MAC-ELISA (IgM antibody capture-Enzyme Linked Immunosorbent Assay). The ELISA plates were supplied by the Armed Forces Research Institute of Medical Sciences (AFRIMS), Bangkok, Thailand [12]. ELISA measurements were undertaken following the protocol supplied by AFRIMS. Diluted patient sera (1:100) or CSF (1:10) were added to the plates. Absorbance of experimental, positive and negative control samples were measured in duplicate in 96-well plates using a micro-titre plate reader (HumaReader Single Plus, Human GmbH, Wiesbaden, Germany). Single experimental patient samples with a mean absorbance ≥ 40 units (following subtraction of the absorbance for the negative controls) were considered positive. External quality assurance was undertaken by AFRIMS [12].
The acquired data for all AES patients was initially validated, coded and entered in SPSS Statistics software version 17.0 (IBM-SPSS, New York) for analysis. Differences between clinical groups were compared using Student independent samples t-tests (for Normally distributed data), Mann-Whitney U-tests (for non-Normally distributed data) and Fisher Exact tests (for categorical data/proportions). All clinical feature variables (with the exception of all duration and numbers of episodes variables apart from duration of fever) were entered into a forward stepwise multiple logistic regression model to identify variables independently associated with bad outcome or JE positive status; multiple imputation methods (10 iterations) were used to overcome problems of missing observations and collinearity statistics were examined to ensure independence of the predictor variables. The median age and numbers of AES cases were mapped using ArcGIS version 9.3 (Esri Ltd., California) software to show their distribution in the different districts across Nepal in order to identify any spatial patterns in infection dynamics. Statistical significance was set at the conventional 5% level for all analyses.
A total of 225 children with acute encephalitis syndrome (AES) were admitted to the two hospitals between January 1st, 2006 and January 1st, 2008. Forty (18%) of these patients did not have any lumbar puncture (LP) results available in their notes. These patients were analysed separately.
Of the remaining 185 AES patients, 40 (22%) were diagnosed with either bacterial (n = 39) or Plasmodium falciparum infection (n = 1). Eight of these patients also had elevated anti-JE virus titres (≥ 40 units) on serum IgM testing during acute illness. Since bacterial co-infection can change clinical features and influence patient outcome, these patients were analysed separately (Figure 1).
Flow diagram of Acute Encephalitis Syndrome patients based on aetiological classification. 225 children with Acute Encephalitis Syndrome (AES) were identified. To analyse AES of different aetiologies only patients where LP results were available were taken forward (n = 185). Patients with non-viral aetiologies were analysed separately (n = 40). The remaining AES patients were classified as JE (n = 42) or AES of unknown viral aetiology (n = 103) based on presence or absence of high anti-JE virus immunoglobulin titres. AES of unknown viral aetiology was further sub-classified into Non-JE (n = 44) and JE Status Unknown (n = 59) based on presence or absence of low or negative anti-JE virus immunoglobulin titres.
One hundred and forty five AES patients (145/185;78%) were considered to have AES of suspected viral aetiology. Forty-two of these patients (23%) were confirmed as JE. Among the other 103 patients, 44 tested negative to JE using samples collected after the ninth day of their illness and therefore were classified as Non-JE. For the remaining 59 patients JE status was unknown (Figure 1).
The majority of JE positive patients, 41/50 (82%), were identified by serum testing positive for anti-JEV IgM antibodies, with 31/41 (79%) identified by a single serum sample. The other serum samples tested positive in paired samples. The remaining 9 patients were diagnosed by testing positive for anti-JEV IgM antibodies in the CSF.
The majority of the non-viral AES patients were diagnosed with suspected bacterial meningitis based on a raised cell count with a polymorph predominance and raised protein in the CSF. The commonest identified cause of infection was gram stain positive bacteria in CSF.
Patients presented to Kanti Children's (n = 208) or Patan hospital (n = 17) from a wide range of outlying districts from Kathmandu including the hill and mountain districts. There were no marked differences in geographic distribution for the number of cases or age at presentation among the different sub-groups of suspected viral AES patients (Figure 2). Route of presentation to hospital was documented in 175 AES patients. Self-referral was the commonest route of presentation, reported by 96/175 (55%) of AES patients.
Map of residence district for Acute Encephalitis Syndrome patients of suspected viral aetiology. Panel A, All AES patients of suspected viral aetiology; Panel B, JE patients; Increasing depth of shading within a district indicates a higher number of AES patients were admitted from this district. Unshaded districts indicate no patients were admitted from this district. Increasing circle diameter within a district indicates AES patients of an older (median) age were admitted. Kathmandu is labelled on the map.
Patient outcome
Outcome at discharge was recorded for 183/185 patients where LP results were available and 38/40 patients without LP results. Among the patients without LP results, seventeen (45%) had a bad outcome; 10 (26%) died and a further 7 (18%) had neurological sequelae at discharge.
Among the AES patients with non-viral infection, 38/40 (95%) had an outcome at discharge recorded. Five (13%) had a bad outcome; 2 died and a further 3 had neurological sequelae at discharge. All 8 patients with bacterial and JE co-infection exhibited complete recovery at discharge. The one patient with P.falciparum infection recovered completely.
Among the AES patients with suspected viral infection, 45/145 (31%) had a bad outcome; 8 died and 37 had neurological sequelae at discharge. Among the sub-set of confirmed JE patients 20/42 (48%) had a bad outcome; 4 died and 16 had neurological sequelae (Table 1).
Table 1 Patient outcome for 6 aetiological categories of Acute Encephalitis Syndrome.
A significantly higher proportion of patients without LP results died compared to those where LP results were available (10/38 [26%] versus 10/183 [5%]; P < 0.001). Similarly, the proportion of patients with bad outcome were higher among patients without LP results (17/38 [45%] versus 51/183 [28%]; P = 0.053). Exclusion of the patients without LP results may have influenced outcome within the AES groups. To help address this issue, an additional analysis was undertaken, whereby patients without LP results were classified into AES categories based on their hospital discharge diagnosis supported by their JE serological results. The patients contributed to all AES groups. Each AES category exhibited a higher rate of bad outcome. There were no significant changes in the proportion of patients with bad outcome between groups (Table 1).
A significantly higher proportion of patients with AES of suspected viral aetiology had a bad outcome compared to AES patients with a non-viral infection (45/145 [31%] versus 5/38 [13%]; P = 0.039). A significantly higher proportion of JE patients exhibited a bad outcome compared to AES patients of unknown viral aetiology (20/42 [48%] versus 25/103 [24%]; P = 0.01). A similar trend was observed when JE patients were compared to Non-JE patients, with a higher proportion of JE patients exhibiting a bad outcome (20/42 [48%] versus 12/44 [27%]); P = 0.07; Table 1).
Prognostic features associated with bad outcome at discharge
Multiple parameters were associated with bad outcome at discharge for both AES cases of suspected viral aetiology (n = 145) and confirmed JE (n = 42) (Table 2). In both groups, bad outcome was associated with a longer duration of fever prior to admission, a lower Glasgow coma score, a focal neurological deficit, older patient age and higher weight at admission.
Table 2 Clinical features for JE and AES patients of suspected viral aetiology by outcome
To identify whether these features were independently associated with bad outcome, these variables were entered into a forward stepwise logistic regression model separately for each patient group. For the larger group, all AES of suspected viral aetiology, fever duration (P = 0.002), GCS (P < 0.001), and focal neurological deficit (P = 0.001) were retained in the model for outcome. In JE, fever duration (p = 0.007) and GCS (p = 0.020) were again independently associated with bad outcome (but not focal neurological deficit) together with age (P = 0.011).
To assess whether length of time from onset of illness to hospital admission was a prognostic marker for bad outcome, we used length of reported fever prior to admission as a proxy marker. We selected a threshold of 7 days of fever prior to admission (Figure 3). We found fever duration over 7 days was associated with a bad outcome. Fever duration was reported in 142/145 (98%) of patients with AES of suspected viral aetiology. Thirty-two patients reported fever duration of more than 7 days prior to admission. Of these, 19 had bad outcome and 13 had good outcome. The remaining 110 patients reported a fever duration under 7 days, of which 23 had bad outcome and 87 had good outcome (19/32 [59%] versus 23/110 [20%]; P < 0.001). This indicates that AES patients who present with a prolonged fever prior to hospital admission have an increased risk of having a bad outcome at discharge (Relative Risk = 2.8 [95% confidence interval: 1.6 - 4.4]).
Fever duration prior to admission organised by outcome among AES patients of suspected viral aetiology. Panel A, All AES patients of suspected viral aetiology; Panel B, JE patients, X-axis; fever duration (1-14 days), Y-axis; Number of patients that presented to hospital at each day of fever duration (1-24), Solid bar shading; number of patients who exhibited a bad outcome at discharge, Hatched bar shading; number of patients who exhibited a good outcome at discharge.
Among the JE patients, a reported fever duration of more than 7 days prior to admission was again linked to a significantly higher rate of bad outcome compared to those who presented with a shorter duration of fever (9/11 [82%] versus 11/31[36%]; P = 0.013). Among patients with AES of non-viral aetiology, prolonged duration of fever prior to admission was also linked to a higher rate of bad outcome (2/6 [33%] versus 3/22 [14%]; P = 0.28).
Of the treatments given to AES patients of suspected viral aetiology, mannitol and phenytoin were more frequently prescribed among those with a bad outcome compared to those with a good outcome; 27/61 (44%) versus 19/119 (16%), P < 0.001 for mannitol; 23/61 (38%) versus 12/119 (10%), P < 0.001 for phenytoin, in bad and good outcome patients respectively.
Clinical features that distinguish between confirmed JE and AES of suspected non-JE viral aetiology
Confirmed JE cases were compared to AES cases of unknown viral aetiology (Non-JE and JE status unknown). As the latter group also contained patients that did not have a confirmed negative test for JE, a further analysis was undertaken comparing JE against Non-JE cases.
The rates of many clinical features and laboratory parameters were similar on admission between confirmed JE, confirmed Non-JE and JE-status unknown (Tables 3 and 4). Importantly, the rates of many recorded neurological features were comparable between the patient groups. There were no significant differences in prevalence of an altered sensorium at admission, depth or duration of coma, frequency, duration or type of seizures between patient groups. However, there was a significantly higher prevalence of patients presenting with focal neurological deficits at admission among confirmed JE patients compared to AES cases of unknown viral aetiology (13/40 versus 11/103; P = 0.005; Relative Risk = 3.0 [95% confidence interval: 1.4-6.7]). Among AES patients of suspected viral aetiology, presence of a focal neurological deficit at admission had a positive predictive value of 32% (sensitivity 54%) for JE. Absence of a focal neurological deficit at admission had a negative predictive value of 89% (specificity 77%) for the patient not having JE.
Table 3 Clinical features at admission for 5 categories of Acute Encephalitis Syndrome
Table 4 Laboratory parameters at admission for 5 categories of Acute Encephalitis Syndrome
JE patients presented with a lower body weight (15.25 versus 20 Kg; P = 0.031), and a higher respiratory rate (30 versus 28 breaths per minute; P = 0.003) compared to confirmed non-JE patients. With the caveat that serum urea, creatinine and electrolytes were measured in only 25 AES patients of suspected viral aetiology, there was a trend for higher serum urea (15 versus 8.9 mmol/L; P = 0.27), sodium (137 versus 133 mmol/L; P = 0.09) and potassium (4.3 versus 3.9 mmol/L; P = 0.21) among JE compared to Non-JE patients (Table 4[13]). These parameters again showed a non-significant trend for higher median values among JE patients compared to AES patients of unknown viral aetiology (Table 4).
Both weight and respiratory rate, which were significantly different among JE patients compared to Non-JE patients, are in part dependent on patient age. To further dissect the influence of these parameters, age, weight and respiratory rate were entered into a stepwise logistic regression model. Only raised respiratory rate (P = 0.011) was retained.
Admission patterns also differed between JE and Non-JE patients. JE patients demonstrated a clear peak in hospital admissions rates in the months immediately following the rainy seasons each year (August and September in 2006-2007). Non-JE patients didn't demonstrate any clear seasonal variation in hospital admission rates (Figure 4).
Monthly admission numbers for Acute Encephalitis Syndrome (AES) patients of suspected viral aetiology. X-axis; month of admission, Yaxis; Number of patients admitted to hospital each month, Solid bar shading; number of JE patients, Hatched bar shading; number of Non-JE patients, Dotted bar shading; number of patients where JE Status unknown.
This study demonstrates that patients with AES of suspected viral aetiology, either where JE was confirmed or where viral aetiology remained unknown, were significantly more likely to have a bad outcome compared to AES patients with bacterial or malaria infection.
Appropriately, JE surveillance is a health priority in Nepal. However, public health and clinical teams should be aware that patients with AES of unknown viral aetiology also have a high risk of morbidity and mortality. Furthermore, since there are up to 3 times more Nepali children with AES of unknown viral aetiology than proven JE, a bad outcome among the former group impacts on a larger number of children Therefore, identification and optimizing management of patients with AES should also be a priority.
The lower frequency of bad outcome among the AES patients with bacterial or malaria infection is likely to reflect the availability and effective use of antibiotics and anti-malaria treatment to reduce morbidity among these patients.
AES patients without LP results exhibited a significantly higher rate of death. The finding is likely to reflect lumbar punctures being undertaken less frequently on children who were critically ill. The finding highlights that restricting analyses to patients where LP results are available can lead to an underestimation of the frequency of death and bad outcome linked to AES.
Interestingly, the study has identified that the number of days of fever (reflecting number of days of illness) the patient experienced prior to hospital admission is a prognostic indicator of bad outcome in both patients with AES of unknown viral aetiology and JE. When analysis was applied to AES patients of bacterial aetiology no significant association was identified. Antibiotic use in the community may reduce fever duration prior to hospital admission in patients with bacterial infection and may confound the association between fever duration and bad outcome. In contrast, antibiotics would have limited impact on fever duration during viral infection.
Shorter duration of illness (or fever) prior to admission has previously been associated with good outcome among children for a range of diseases [8]. What is striking about our finding is that there is no specific treatment for JE or AES of suspected viral aetiology, yet attending hospital earlier in the illness course appears to be of benefit. The findings would suggest that hospital admission and the supportive management received there improves outcome.
Patients with impaired consciousness are often unable to drink themselves. Consequently, dehydration and metabolic acidosis may complicate AES [14]. Dehydration and acidosis would fit the significantly lower body weight and higher respiratory rate observed among JE compared to Non-JE patients. A previous prospective survey of JE management identified that fluid supplementation was associated with a positive influence on outcome [15]. Although appropriate fluid provision is a delicate balance when managing brain injury [16, 17], one possible explanation of the positive influence of hospital admission may be that patients receive fluid support in hospital during the illness.
Given the commonest reported mode of presentation was self-referral, the focus on hastening patient attendance would lie with improving patient awareness of the features of AES and encouraging families to attend hospital promptly. Further research is needed to understand the factors that underlie families' health-seeking behaviours when a child is ill.
As shown previously, a low Glasgow coma scale (GCS) and/or a focal neurological deficit at hospital admission were independent clinical markers of bad outcome among children with AES [18]. JE patients frequently exhibit raised intra-cranial pressure, brain herniation syndromes [5] and focal brain lesions on neuro-imaging studies [19], explaining the preponderance of focal neurolgical deficits in this group.
In line with previous reports, mannitol was prescribed significantly more frequently among AES patients who exhibited a bad outcome [15]. Interestingly, a randomized clinical trial of mannitol among children with raised raised ICP secondary to cerebral malaria (another cause of non-traumatic brain injury) did not identify any beneficial effect [20]. A similar study would help clarify whether mannitol is a useful supportive treatment in AES [21].
JE patients exhibited an increased respiratory rate compared to Non-JE patients. Furthermore, JE patients who exhibited a high respiratory rate were associated with a good outcome, while those with a lower respiratory rate were associated with a bad outcome. This pattern can be observed during evolution of many complications, including metabolic acidosis, pneumonia, acute flaccid paralysis (involving the inter-costal muscles) or brain damage, where there may be an intial compensatory rise in respiratory rate followed by a fall when the body decompensates.
Tachypnea is also a feature of the severe brain injury syndrome - paroxysmal autonomic instability with dystonia (PAID)[22]. Patients with this brain injury syndrome exhibit intermittent agitation, diaphoresis, hyperthermia, hypertension, tachycardia, tachypnea, and extensor posturing. All of these signs overlap with features reported in both JE and AES. PAID may exist among AES patients.
As a descriptive analysis this study cannot distinguish cause from consequence. Consequently although several clinical features and interventions appear linked with outcome, this study is unable to determine whether these parameters are causal. Similarly, as a retrospective study it is limited by the breadth and quality of information available in the hospital notes. More detailed information on acid-base status would help discriminate between respiratory and metabolic causes of tachypnea. Similarly, more systematic measurement of urea and electrolytes and additional indicators of fluid balance would help assess the influence of fluid support on outcome. Based on their discharge diagnosis, the AES patients without LP contributed to all AES groups. However, a prospective study with a more systematic investigation of pathogen aetiology is warranted to confirm these findings.
Nepali children with AES of suspected viral aetiology, either where JE is confirmed or where the aetiology remains unknown, exhibit a high rate of death and morbidity.
One of the more striking findings from the study was the association between long duration of fever prior to admission and bad outcome. If patients with AES of suspected viral aetiology, including those with confirmed JE, attend hospital early they are more likely to make a full recovery. Despite no specific treatment for JE or for patients with AES of suspected viral aetiology, the current management in Nepal can limit the development of neurological sequelae. The findings imply that family members, primary and community health care workers should be aware of AES and seek early referral for appropriate and potentially life-saving, supportive management.
Despite many comparable neurological features between JE patients and patients with AES of unknown viral aetiology, significantly more JE patients exhibited a bad outcome. This, in part, may reflect the higher proportion of JE patients that presented with a focal neurological deficit at hospital admission.
Further research is needed to understand the factors that underlie bad outcome in AES and JE, including a more systematic investigation of the influence of supportive measures.
AES:
Acute Encephalitis Syndrome
AFRIMS:
Armed Forces Research Institute of Medical Sciences
CNS:
CSF:
cerebral spinal fluid
GCS:
Glasgow Coma Scale
ICP:
Intra-cranial pressure
LP:
MAC-ELISA:
IgM antibody capture-Enzyme Linked Immunosorbent Assay
PAID:
paroxysmal autonomic instability with dystonia
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Klein SK, Hom DL, Anderson MR, Latrizza AT, Toltzis P: Predictive factors of short-term neurologic outcome in children with encephalitis. Pediatr Neurol. 1994, 11 (4): 308-312. 10.1016/0887-8994(94)90007-8.
Dung NM, Turtle L, Chong WK, Mai NT, Thao TT, Thuy TT, Kneen R, Phu NH, Wills B, Farrar J, et al: An evaluation of the usefulness of neuroimaging for the diagnosis of Japanese encephalitis. J Neurol. 2009
Namutangula B, Ndeezi G, Byarugaba JS, Tumwine JK: Mannitol as adjunct therapy for childhood cerebral malaria in Uganda: a randomized clinical trial. Malar J. 2007, 6: 138-10.1186/1475-2875-6-138.
Kumar G, Kalita J, Misra UK: Raised intracranial pressure in acute viral encephalitis. Clin Neurol Neurosurg. 2009, 111 (5): 399-406. 10.1016/j.clineuro.2009.03.004.
Blackman JA, Patrick PD, Buck ML, Rust RS: Paroxysmal autonomic instability with dystonia after brain injury. Arch Neurol. 2004, 61 (3): 321-328. 10.1001/archneur.61.3.321.
We would like to thank all the medical staff at Kanti Children's Hospital and Patan Hospital for their support. We thank Dr Geeta Shakya, National Public Health Laboratory, Kathmandu, Nepal, Dr William Schluter and Dr Sukdeo Neupane, WHO, Kathmandu, Nepal for helping in the confirmatory testing for JE. We also thank Dr Brian Faragher, Senior Lecturer in Medical Statistics, Liverpool School of Tropical Medicine for his statistical support. TS holds an MRC Senior Clinical fellowship. MJG is a NIHR funded clinical lecturer. These funding sponsors had no role in study design, data collection, data analysis, data interpretation, or writing of the report.
Department of Paediatrics, Kanti Children's Hospital, Maharajgunj, Kathmandu, Nepal
Ajit Rayamajhi, Krishna P Bista & Chandeshwor Mahaseth
Department of Pediatrics, National Academy of Medical Sciences, Kathmandu, Nepal
Ajit Rayamajhi, Imran Ansari & Chandeshwor Mahaseth
Brain Infections Group, Department of Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, University of Liverpool, UK
Ajit Rayamajhi, Elizabeth Ledger, Daniel E Impoinvil, Sam Nightingale, Tom Solomon & Michael J Griffiths
Department of Paediatrics, Patan Academy of Health Sciences, Patan Hospital, Lalitpur, Kathmandu, Nepal
Imran Ansari
LUCINDA Group, Department of Epidemiology and Population Studies, Institute of Infection and Global Health University of Liverpool, UK
Daniel E Impoinvil
Nepal Health Research Council, Ram Shah Path, Kathmandu, Nepal
Rajendra Kumar BC
Ajit Rayamajhi
Elizabeth Ledger
Krishna P Bista
Sam Nightingale
Chandeshwor Mahaseth
Tom Solomon
Michael J Griffiths
Correspondence to Ajit Rayamajhi.
AR, TS and MJG conceived and designed the study. AR, IA, KPB, EL and SN acquired and undertook initial analysis of the data. AR, DI, RKBC, CM and MJG interpreted the data. AR, TS and MJG wrote the manuscript. All authors read and approved the final manuscript.
Rayamajhi, A., Ansari, I., Ledger, E. et al. Clinical and prognostic features among children with acute encephalitis syndrome in Nepal; a retrospective study. BMC Infect Dis 11, 294 (2011). https://doi.org/10.1186/1471-2334-11-294
Japanese Encephalitis Virus
Focal Neurological Deficit
Viral Aetiology


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text:
Looking for Life
Nobody's found signs of alien life yet. So why do they keep on looking?
Extra-terrestrial life. What images just popped into your mind? Little green men? ET, the gnarly but ultimately friendly alien? My own mind bombards me with characters from my beloved Marvel comic books: Aesir, Kree, Skrull, Chitauri, Celestials, Watchers —
Okay. I'll stop.
My point is that extraterrestrial life is widely considered to be a thing of fantasy, a plot device associated with the likes of Arthur C. Clarke or Isaac Asimov. Someone who claims to have seen a UFO, or some other such indicator of alien life, is generally believed to be about as nutty as a fruitcake.
Of course, if that someone happens to be a professional scientist, then the situation is somewhat different.
In 1967, Jocelyn Bell, then a graduate student trying to wrap up her astronomy PhD, noticed a strange signal coming through her radio telescope. It repeated about every 1.3 seconds and kept time better than atomic clock — which uses the vibrations of an element like caesium as a timekeeper and is very, very regular.
Most signals picked up from deep space are quite chaotic, and don't follow a fixed pattern. They also usually radiate across a wider frequency, as opposed to the very specific one this signal occupied.
Whatever this signal was, it didn't look natural.
That's why her supervisor, Antony Hewish, along with a few other scientists, named the signal LGM-1, where LGM stands for Little Green Men. They thought they had stumbled upon the first signals from an alien civilisation.
A little investigation on Bell's part proved differently. What she had found turned out to be a pulsar, the radio waves from a dying neutron star 5.5 million years ago.
Hewish recieved the Nobel Prize in 1974 for the discovery. Bell did not.
As recently as 2016, scientists studying the dimming patterns of a star thought they might have found evidence that there were giant structures built on its surface. At that time, nothing else explained the phenomenon as well as aliens did. Or so they thought.
It turned out to be dust.
These are just some examples of incidents where scientists think they've found aliens, until they find that they haven't. It's certainly happened more often than you might expect.
So why do they keep looking?
There are approximately 100 thousand million stars in our universe. Here's what that number looks like:
10,000,000,000,000,000,000,000.
Mind boggling, right? To put it in perspective, that's 10,000 stars for every grain of sand on planet Earth.
That's a lot of potential for life.
We could even narrow it down to only the stars that are similar to our sun — with similar size, light, and temperature. A conservative estimate tells us that's about 5% of all stars, which still leaves us with 500 billion, billion suns.
That's…still a lot of potential for life.
In 1930, Clyde Tombaugh discovered a small, icy body orbiting beyond Neptune. He had been searching for a body that was supposedly causing small shifts in the orbits of Uranus and Neptune, at the prediction of Percival Lovell. The body he found was not the one he had been looking for after all — it was the wrong size and wrong orbit — but it was an important discovery nonetheless.
He had discovered Pluto.
Until 2003, Pluto was thought to be it — the edge of our solar system and the last planet orbiting out sun — when another planet, larger than Pluto and possessing a moon of it's own, was found.
Further investigation showed that Pluto was not quite as isolated as we'd previously thought, but was, instead, one among a vast series of bodies in what we now know as the Kuiper Belt.
It was kicked off the planet list by the Planet Definition Committee in 2006, formed to take a call on what might happen if we found more objects like, or even larger than, Pluto.
A likely possibility.
People don't often appreciate just how far astronomy has come in the last few decades.
Until the 1990s, no one was able to say for sure that there were planets outside our solar system.
Then, in 1992, two astronomers at the Arecibo observatory detected what they were pretty sure was two faraway planets, orbiting a pulsar of the kind Jocelyn Bell found. Within three years, a planet had been found orbiting a star similar to our Sun. And then 2009 saw the launch of the Kepler Space Telescope, sending back so much data that computers were busy processing it long after the spacecraft had ceased its observations.
Today, scientists estimate that one in every five bodies that appear as stars that look like our sun, could be an Earth-like planet.
That means that there are a hundred billion, billion Earth-like planets.
That's one billion potentially habitable planets for every dollar that Jeff Bezos is worth.
Ever heard that cockroaches could survive a nuclear apocalypse?
Well…they can't. Not exactly, at least. However, they can withstand high amounts of radiation, up to a point. And they're not the only ones.
Amoeba, wasps, and water bears (the microscopic kind — and they're actually very cute) can all handle higher amounts of radiation. And scientists are finding life forms in increasingly extreme conditions.
Radioactive waste, boiling water near underwater volcanoes, hot tar, Antarctic ice, and gold mines several miles deep are just some of the unlikely habitats we've found so far.
What does this mean for our search for life?
Basically, that we can broaden some of our parameters. All these discoveries have shown us one thing: life doesn't require very specific conditions to survive, or even thrive.
So how many planets can we expect to find with life on it?
Even if we say that one out of every thousand Earth-like planets has given rise to life, that leaves us with a hundred quadrillion possible planets.
And even if one in every thousand of those planets has birthed intelligent life — that is, life that's able to produce radio signals such as LGM-1 — that still gives us a hundred potential planets for every dollar that Apple is worth.
Given these ridiculous numbers — and a probability of extraterrestrial life that's, well, astronomically high — it's time we stopped asking why people still search for aliens. A better question to ask might be:
Why haven't we found them yet?
Have something to say? At Snipette, we encourage questions, comments, corrections and clarifications — even if they are something that can be easily Googled! You can also sign up for our weekly email updates.
Written by Manasa Kashi

redpajama_set_name: RedPajamaCommonCrawl


text:
A few harsh facts of life on an independent Scotland's EU membership
Of all the weeks for Willie Rennie not to have a question at FMQs, this was probably the worst. While Johann Lamont and, particularly, Ruth Davidson gave Salmond just enough wiggle room over the bizarre EU legal advice issue, Willie had displayed a much more forensic approach on Tuesday. Here's the latter part of the exchange.
This is a very serious matter, Presiding Officer, because the First Minister has not cleared up the issue. He said,
"Everything that we have said is consistent with the legal advice we have received."
He said "received", and the context was that he was talking about the law officers. The First Minister has not cleared up the matter. I urge him to come forward and clarify exactly what he said, because he has not done so, so far.
The Presiding Officer: First Minister, if you wish, you can make a further brief comment.
The First Minister: I admit that Willie Rennie did not add some of the descriptions that other people have used, but it is not a good idea for him to miss out the phrases
"in terms of the debate"
"Well you could read that in the documents that we've put forward, which argue the position that we'd be successful."
As I have pointed out, all the documents that I have listed were underpinned by legal advice from our law officers. That is different from the specific legal advice on a specific matter that the Deputy First Minister announced to members this afternoon. Any fair-minded person—I am aware that that excludes a number of people—would consider that the matter has been well and truly cleared up by the full transcript of the interview.
I think what Willie has successfully done is to show that Salmond and the SNP have gone out of their way to create the impression that there was some legal basis, based on current legal advice from proper Government law officers. While Salmond can dissect the actual words he used to get himself off the hook, there's no doubt that the ordinary Scot, watching that interview in March, would have thought they had that advice. That is the crucial point. Whether the Ministerial Code has been breached is pretty much irrelevant. It is more of an irritation that Salmond was prepared to blow our hard earned taxes taking the Information Commissioner to court so he could keep the lack of legal advice secret. If this sort of situation arises again, I could recommend that he picks up the phone and speaks to Eilish Angiolini or Frank Mulholland and asks them nicely for their permission to reveal the truth.
Labour have handled this really badly. Their own record, of course, on legal advice, is not exactly squeaky perfect. I'm sure we can all remember dramas over the Iraq War, after all. By using the "lie" word in this instance, they've given Salmond something to throw back at them. This needs to be about the overall strategy of the SNP and the fact that they tried to create an impression of something that was not the case and give themselves enough space to suggest that other people might have misunderstood them. It's pretty sleekit, when you come to think about it, and has left a massive hole in Salmond's credibility. People must not be allowed to forget this.
Ultimately, though, the question of the terms of an independent Scotland's entry into the EU owes as much to realpolitik as the letter of the law. How do we know? Well, it's been looked into before. David Clark was Robin Cook's Special Adviser between 1997 and 2001 and he has written on his blog, Shifting Grounds, about the advice on the issue that was obtained then.
In summary, Scotland would have no automatic right to be admitted to the European Union as a successor state, although it is possible that it could be negotiated. The price, however, might be substantial?
First, there is no existing procedure for handling a breakaway from an EU member state. The Council of Ministers would therefore need to improvise one according to its own design.
Second, an independent Scotland could either be considered a successor state, inheriting the United Kingdom's rights and status, or a new applicant, but would have no automatic right to the former. A political decision would have to be taken by the Council of Ministers acting unanimously.
So, one veto and we're scuppered.
Clark's analysis of the likely negotiating process makes it sound a bit like trying to herd 27 cats each with its own unique cocktail of sour grapes and self interest. He argues that an independent Scotland would not be negotiating from a position of strength.
I personally have no doubt that Scotland would be allowed to join the EU. But I also have no doubt that the price would be a high one. Spain would be the first country to object to Scotland automatically inheriting the UK's rights and status. It would be determined to prove that separatism doesn't pay in order to deter its own secessionist movements in Catalonia and the Basque country. Other countries, similarly concerned to avoid any precedent that might compromise their own integrity, would be certain to support the Spanish position.
They would also be joined by a larger group of countries that have long resented the UK's opt outs and budget rebate and would relish the opportunity to deny them to Scotland. Like a new applicant, they would insist on Scotland accepting the full range of EU obligations on things like the single currency, border controls and budget contributions.
You will have to read the article yourself to see his rather surprising conclusion. Even if Alex Salmond were prepared to sell out to that extent, keeping his party and a fair chunk of those who support independence behind him would be a challenge. Of course, he wouldn't have to declare his hand until after the vote, but I'm sure that won't stop people asking him the question before then.
Labels: Alex Salmond, david clark, EU, legal advice, Scotland, SNP
Richard T said...
My take on this was that the SNP Government had taken legal advice and their reluctance to release it was because it didn't back up their position. In common with many others, perhaps lazily, I did not assume that no advice had been sought. I was clearly giving the government more credit than it was due as I could not believe they would be so stupid as to pretend they had advice when in truth they did not.
Could nemesis at last be catching up with Salmond's hubris?
Richard, it had never occurred to me either that they hadn't sought the legal advice. The whole thing is just incredible.
Alex Salmond has a massive hole in his credibility now.
Richard Thomson said...
In a spirit of fairness and consistency, will Michael Moore now publish the legal advice held - if any - by the Scotland Office on the same topic?
http://tinyurl.com/bowwuso
I can fully understand why the Westminster Government has decided not to publish whether it does or doesn't hold any advice, in line with the approach taken by the Scottish Government. Nevertheless, their stance doesn't do a great deal for the credibility of Mr Rennie on this matter, does it?
I'd be tempted to say that it leaves a great big hole in Mr Rennie's credibility, but that would assume that he had started out with some to begin with.
Munguin said...
Would the Lib Dems ever lead people to believe something in order to gain some ethereal advantage (such as get people to vote for them)? Well yes of course they do! Bu,t like their cohorts, the Tories, they simply adopt the "tell a blatant lie about it" angle to con the people and then renege on it later on. If that goes down like a lead balloon then: issue a cringing apology that you ever made the promise in the first place and not that you broke. Sound familiar Caron?
And the reason that Willie Rennie never got to ask a question is because he is simply another back bench MSP, like all the rest and is not entitled to ask a question every week. Perhaps if Willie and the rest of the Lib Dems had left themselves some "wriggle room" when they signed pledges all over the place then they might not have lost the confidence of the entire UK electorate and now be facing oblivion. It also does not help if both the leader of the Labour and Conservative parties wish to spend most of the half hour available attempting to score political points and reading out lengthy and pointless manifestos intended to make themselves look more intelligent than Alex and always failing to do so. I wonder why?
Dubbieside said...
After the tuition fees pledges that were signed by the lost deposit party none of them have any credibility.
cynicalHighlander said...
Scottish independence: Law officers 'approved EU documents'
Law officers read and approved official documents claiming an independent Scotland would remain in the EU, the Scottish government has confirmed.
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When I was a boy, the concept of a music video was completely foreign to me. I was dimly aware they existed on MTV but such programming never made it into my house. Then one fateful day in a hotel room on vacation with my cousins, I was finally introduced to the wonders of Rob Thomas getting hit by a car during the video for Bent and Scott Stapp walking Meaningfully between falling meteorites with his arms wide open during the video for With Arms Wide Open. Oh yeah. The experience was magical. It was not until much later when music videos became available for viewing on youtube that the magic began to fade and I began to discover one of the most colossal wastes of money imaginable in the entertainment industry.
What boggles me about music videos is that 90% of them are terrible. I don't mean to be too negative here, but this is a serious problem. You've seen plenty of music videos like this, right? The lead singer emotes at the camera. People around them dance. Don't forget to include a model who is almost acting and/or almost wearing clothes. Concoct some sort of story loosely connected with the song, edit it like a Jason Bourne movie and there you go. A gargantuan amount of money has been spent over the years on producing short form films that are not worth watching twice, if they're worth watching at all.
But every once in a while, a music video can be pure gold. When done well, a music video not only entertains but actually enhances the lyric and sound of a song. It can add new depth and insight. Or it can be innovative in its use of dance, physical performance, animation, or it could just blow your mind with cool-lookin' stuff. Here are four categories of music video that tend to leave the mind at least a little blown.
This approach to music-video-making is almost guaranteed to be a cut above the rest, mostly because an elaborately staged one-take film like this requires a great deal of fore-thought, planning, rehearsal and originality. OK Go has done quite a few of these but none so epic and Guinness-worthy as Needing/Getting. Check it out below along with Jack Johnson's reverse spin on this process. Also, if you're in the mood for more of these, check out a couple fun ones from Feist and Ingrid Michaelson.
Music and dance are the fraternal twins of art. And the only thing better than getting your own groove on to your favorite jam is watching someone else do it way better than you (that's how I feel anyway). Michael Jackson's Thriller is the seminal example of a music video that entertains with innovative dance, but I also like the following examples from Janelle Monae and Fatboy Slim.
Steering away from more mainstream pop and into the realm of indie and alternative, the appeal of music is often in unique sounds, timbres, textures, and instrumentation. One of my favorite approaches to music videos involves taking those unique sound ideas and combining them with creative, artful visuals, as in the Niki & the Dove example below. Another similar approach is to use innovative animation or film techniques to create something that presents you with a nonstop series of wows, like the wonderful video for Coldplay's Strawberry Swing.
My personal favorite approach is when the video tells a story that expands upon the themes of the song. I've seen a lot of story videos that depict the lyric of the song literally and, to me, that's like painting a picture of an apple and writing the word Apple on it. It might not be bad, but it's not very moving. What's better is to strip the song down to its basic themes and expand on them. Take The Only Exception, by Paramore. Essentially the lyric of the song gives us the history of Hayley's love life, beginning with her parents' divorce, meandering through years of self-imposed loneliness and safety, then ending with the ability of one man (the only exception) to make the risk finally worth it. The video, rather than telling a linear story like that, uses a sitcom-style set to give us an abstract representation of Hayley's compartmentalized mind. I love the beautiful ending in which her man has benignly infiltrated every safe and lonely place in her head and we return to reality. Very well done.
I also love the Kimbra video below for its combination of unique dance style, symbolic storytelling, and interesting visuals (kids playing house rather convincingly with a mannequin man who's not really a mannequin. And who doesn't like to watch things light on fire, right?). Both the Kimbra and the Paramore examples also do a great job of accompanying the narrative structure and flow of the song. Great songs often have a big climactic hit as the bridge falls back into the final chorus and whether the set bursts into flames or a blinding light shines through the doorway or the Foo Fighters do this thing, it's a satisfying moment when the music video follows suit.
I want more of this stuff. I wish the music industry would invest a little more in making their music videos live up to the potential of the medium, rather than making shallow fluff. I guess that's also what I want from Hollywood, music itself, and the world in general so there you go. Hit me up in the comments below. Please share with me your favorite music videos and why you love them.


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Introducing The Hangover Brunch: A Fundraiser for Theater Bartlesville. A late morning brunch hosted by Andy Dossett, Emily Allen-Worrell, and Troy Martin. Enjoy a breakfast taco bar, bagel bar with all the fixings, a sweets bar, mimosa bar, bloody mary bar, coffee bar, basically any bar you could think of! Come wearing your best set of PJs as we give away an award for Best Pajamas. Enjoy free trivia for prizes, a silent auction, and a major raffle as we raffle off a trip to LAS VEGAS! Tickets for this event are $50/single ticket or a table of 8 for $375. Included in your ticket price is trivia, food, non-alcoholic drinks and two alcoholic drink vouchers.
Join us for the most fun you'll have on a Saturday "morning", May 11th from 10 am to 12 pm at the Bartlesville Community Center.


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ITEM: MY LITTLE PONY TWILIGHT SPARKLES DOLL. WE WILL WORK TO RESOLVE ANY ISSUES YOU HAVE.
Join them as you try to knock that pesky piggy off his perch and win back the palace.
Includes right spin Energy layer, D01L Forge Disc, and TA06L Performance Tip. Valtryek V2 Attack Type. Play virtually with the Beyblade Burst app!
New Hasbro Beyblade Legends BB-59 Burn Fireblaze 135MS. New Hasbro Legends Beyblade BB-70 Galaxy Pegasus W105R2F. Includes 5-piece Legends top, Ripcord Launcher, collector card, assembly instructions and tool.
FIREFUSE DARKHELM top's Defense Spike PERFORMANCE TIP is designed to maximize defense and stamina.
New 2018 Hasbro Beyblade Burst Evolution SwitchStrike Green Fafnir F3 DR34/TS01 Starter Pack. New Hasbro Beyblade Burst Ifritor I2. Starter Pack.
I have 3 types of cases currently. Choose which 3 cases you want. This is very important. Most collectors like to have sealed cases if possible. First blader to reach 3 points wins. Here is a collector/dealers dream.
Can "burst" into pieces (burst rates vary). First blader to reach 3 points wins. Scan code on Beyblade Burst SwitchStrike top Energy Layer to unleash the top and mix and match with other components in the Beyblade Burst app.
Includes: Chamber Challenge Vault and 5 Power Tokens.
Top can "burst" into pieces, resulting in 2 points for the player left standing (Burst rates vary). First player to earn 3 points wins! Collect, customize, and compete. Play in the app with these creations.
And Pirate Orochi 145D For Stamina. Pirate Orochi Top Has A Tough Defense Performance Tip Part. Hasbro Beyblade Shogun Steel. Pirate Orochi/Guardian Leviathan. Features Guardian Leviathan A230JSB For Defense.
Shoeshine (crystal). Blind bag wave 4, bag #23.
For sale is one Obi-Wan Kenobi Force Action Lightsaber toy. I have many other Lightsabers for sale right now, as well as other Star Wars toys!
Subject to availability. Includes Beyblade Burst: Energy Layer (1), Forge Disc (1), Performance Tip (1), launcher (1), and instructions.
My Little Pony Equestria Girls Extra Long Hair Rainbow Dash 9" Doll & Accessories. Equestria Girls. My Little Pony. Rainbow Dash 9" Doll & Accessories. Includes: Doll, Brush, 3 Clip on Hair Extensions, 6 Barrett's.
LOTS of styles for children and adults! Very good condition, nothing broken. Sold as is.
Used Condition. Coins are showing wear and discoloration as is condition. Everything shown in the pictures comes with this set. More pictures upon request just ask!
Have an epic battle with the new Burst series beys from Hasbro! • Hasbro Authentic product.
• Beyblade Burst SwitchStrike Legend Spryzen S3 D30 TB06 right/left spin top.
Hasbro COPS N' CROOKS DRAGSTER C.O.P.S. 1989 89 Star Comics Series 2. Condition is New. Shipped with USPS Priority Mail.
• Dark color version with stamina flugel driver and spring layer. Have an epic battle with the new Burst series beys from Hasbro! • Compatible with Burst series beys and launchers only. • Hasbro authentic.
I think everyone knows the great detail that 4DE put into their ponies, including series accurate double-sided CUTIE MARKS, embroidered eyes (not STICKERS like lesser pony plush) and the ability to be "FREE STANDING", no 'prop' or 'doll stand' needed!
The My Little Pony Equestria Girls Minis School Dance Flash Sentry doll is ready to rock and fun to pose! Pretend to play for a cheering crowd with this mini dolls articulated arms and legs and the guitar accessory.
For sale are two 2009 Obi-Wan Kenobi Lightsaber toys. No batteries included for either Lightsaber, each requires 3x AAA. I have many Lightsabers and other Star Wars toys for sale currently.
Real Bakushin Susanow (Susanoo) Metal Takara / Hasbro Beyblade - USA SELLER!
Have an epic battle with this rare bey Bakushin Susanow 90WF (wide Flat tip). • Hasbro Authentic beyblade! • Decals included. • Special color version.
This has a bend or a roll forward at top as can be seen in close-up photos. Item in the photos is the item you will receive.
BeyBlade Stunt Stadium. Model: Pegasus.
This is a must-have for any Pokémon collector. This is new in box and ready to be played with.
Item is new and sealed. No broken seals. Just top notch quality and service at no extra cost! WILD MANE LEONE. W-05 Power.
Ride the rails with Beyblade Burst Slingshock tech! Bladers can keep the Performance Tip in Battle Ring Mode to defend their position in the Beystadium, or convert it to Slingshock Mode to ride the rails and amp up the battle.
Equestria Girls Minis. School Cafeteria Set. My Little Pony.