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Summary: Background: Encephalitis is a worldwide public health issue, with a substantially high burden among children in southeast Asia. We aimed to determine the causes of encephalitis in children admitted to hospitals across the Greater Mekong region by implementing a comprehensive state-of-the-art diagnostic procedure harmonised across all centres, and identifying clinical characteristics related to patients’ conditions. Methods: In this multicentre, observational, prospective study of childhood encephalitis, four referral hospitals in Cambodia, Vietnam, Laos, and Myanmar recruited children (aged 28 days to 16 years) who presented with altered mental status lasting more than 24 h and two of the following minor criteria: fever (within the 72 h before or after presentation), one or more generalised or partial seizures (excluding febrile seizures), a new-onset focal neurological deficit, cerebrospinal fluid (CSF) white blood cell count of 5 per mL or higher, or brain imaging (CT or MRI) suggestive of lesions of encephalitis. Comprehensive diagnostic procedures were harmonised across all centres, with first-line testing was done on samples taken at inclusion and results delivered within 24 h of inclusion for main treatable causes of disease and second-line testing was done thereafter for mostly non-treatable causes. An independent expert medical panel reviewed the charts and attribution of causes of all the included children. Using multivariate analyses, we assessed risk factors associated with unfavourable outcomes (ie, severe neurological sequelae and death) at discharge using data from baseline and day 2 after inclusion. This study is registered with ClinicalTrials.gov, NCT04089436, and is now complete. Findings: Between July 28, 2014, and Dec 31, 2017, 664 children with encephalitis were enrolled. Median age was 4·3 years (1·8–8·8), 295 (44%) children were female, and 369 (56%) were male. A confirmed or probable cause of encephalitis was identified in 425 (64%) patients: 216 (33%) of 664 cases were due to Japanese encephalitis virus, 27 (4%) were due to dengue virus, 26 (4%) were due to influenza virus, 24 (4%) were due to herpes simplex virus 1, 18 (3%) were due to Mycobacterium tuberculosis, 17 (3%) were due to Streptococcus pneumoniae, 17 (3%) were due to enterovirus A71, 74 (9%) were due to other pathogens, and six (1%) were due to autoimmune encephalitis. Diagnosis was made within 24 h of admission to hospital for 83 (13%) of 664 children. 119 (18%) children had treatable conditions and 276 (42%) had conditions that could have been preventable by vaccination. At time of discharge, 153 (23%) of 664 children had severe neurological sequelae and 83 (13%) had died. In multivariate analyses, risk factors for unfavourable outcome were diagnosis of M tuberculosis infection upon admission (odds ratio 3·23 [95% CI 1·04–10·03]), coma on day 2 (2·90 [1·78–4·72]), supplementary oxygen requirement (1·89 [1·25–2·86]), and more than 1 week duration between symptom onset and admission to hospital (3·03 [1·68–5·48]). At 1 year after inclusion, of 432 children who were discharged alive from hospital with follow-up data, 24 (5%) had died, 129 (30%) had neurological sequelae, and 279 (65%) had completely recovered. Interpretation: In southeast Asia, most causes of childhood encephalitis are either preventable or treatable, with Japanese encephalitis virus being the most common cause. We provide crucial information that could guide public health policy to improve diagnostic, vaccination, and early therapeutic guidelines on childhood encephalitis in the Greater Mekong region. Funding: Institut Pasteur, Institut Pasteur International Network, Fondation Merieux, Aviesan Sud, INSERM, Wellcome Trust, Institut de Recherche pour le Développement (IRD), and Fondation Total.

This paper explores the lived philosophy of Ishmael in Herman Melville’s epic, Moby-Dick, particularly as it contrasts with Captain Ahab. Furthermore, this paper examines how Ahab’s narcissism ushers him towards death, while Ishmael’s collectivism guides him towards life. While Ahab is obsessed with himself and his goal of killing Moby Dick, which leads to his own demise, Ishmael is focused on exploring people and their respective philosophies in order to express the infinite spiritual aspects of human life. Ishmael learns from his mistakes, listens to the perspectives of others, and searches for spirituality through various religious and secular means. The form of the novel mirrors its narrator’s wide and wandering curiosity, as Ishamel shares with the reader both the narrative story of the Pequod and worldly facts about the sperm whale. The novel’s form enhances Ishamel’s actions within the story, revealing a nuanced philosophy that values human connection and curiosity. While some scholars have made claims that Ishmael’s narrative style reflects his confusion or ambiguity, this paper argues that it is actually evidence of a life-sustaining philosophy, one which eventually saves Ishmael from being swallowed by the whirlpool caused by Ahab’s pride.

Tennessee Williams’s A Cat on a Hot Tin Roof centers Brick Pollitt; he is filled with disgust because he feels that he is a truthful man surrounded by liars and schemers. Each character has a different concept of truth and morality, Brick's being the most rigid in definition, and it is this rigidity that causes Brick’s personal crisis. By exploring Satrean existentialism, the foundations of Brick’s crisis are revealed as rooted in an inability to act in alignment with his preconceived identity. Intersecting this personal crisis is America’s idealized conception of childhood homoeroticism as well as Alfred Kinsey’s study Sexual Behavior in the Human Male, both of which inform Brick’s relationship with his late best friend. Brick rejects the social world instead of accepting complication, but is still asked to participate in his family structure. His wife and his father simultaneously uphold and subvert the strict structures of the American South; they find ways to accept complication in their own lives, especially when finding themselves in a socially marginalized position. While Brick’s privilege has protected him from facing the painful yet necessary complexities of being alive, Maggie and Big Daddy accept truth as subjective and make space for human complexity.