Ultrafast control of the LnF+/LnO+ ratio from Ln(hfac)3.

The photo-induced dissociative ionization of lanthanide complexes Ln(hfac)3 (Ln = Pr, Er, Yb) is studied using ultrafast shaped laser pulses in a time-of-flight (TOF) mass spectrometry setup. Various fluorine and Ln-containing mass fragments were observed, which can be interpreted by the photo-fragmentation mechanistic pathway involving C-C bond rotation processes proposed previously. A set of experiments used pulse shaping guided by closed-loop feedback control to identify pulses that optimize the ratio of LnF+/LnO+. In agreement with previous studies in which very little LnO+ was observed, broad pulses were found to maximize the LnF+/LnO+ ratio, which involves metal-ligand bond-breaking followed by bond rotation and bond rearrangement. In contrast, a transform limited (TL) pulse favored the formation of LnO+. Finally, the recently developed experimental control pulse slicing (CPS) technique was applied to elucidate the dynamics induced by fields that either maximize or minimize the LnF+/LnO+ ratio, which also indicates that longer laser pulses facilitate LnF+ formation during the C-C bond rotation dissociative-ionization process.

Individualized care for patients with intersex (differences of sex development): Diagnosis and treatment of aphallia.

This review discusses issues and concerns in the management of aphallia, updating status of a post-pubertal individual who required further surgery after having initial surgery for aphallia as an infant. Through this case, which discusses an 18-year-old young adult who had penile agenesis, who desired further phalloplasty involving glanuloplasty and implantation of an erectile device, we highlight the importance of periodic evaluation and close follow up. Surgery during infancy or early childhood to create a penis is important for gender development in a boy, especially if there were functional testes during fetal life, even if this surgery would only be the first stage. There is a strong probability of subsequent surgery after initial phalloplasty before puberty, even with the use of currently refined techniques. Here we discuss the changing techniques that document the ongoing, continued refinement of these procedures, highlighting that further outcome data are needed to identify ways to further optimize current techniques.

Safety and outcomes analysis: transcatheter implantation of autologous angiogenic cell precursors for the treatment of cardiomyopathy.

BACKGROUND: Stem cell transplantation is an emerging therapy for severe cardiomyopathy, proffering stem cell recruitment, anti-apoptosis, and proangiogenic capabilities. Angiogenic cell precursors (ACP-01) are autologous, lineage-specific, cells derived from a multipotent progenitor cell population, with strong potential to effectively engraft, form blood vessels, and support tissue survival and regeneration. METHODS: This IRB approved outcome analysis reports upon 74 consecutive patients who failed medical management for severe cardiomyopathy, and were selected to undergo transcatheter intramyocardial or intracoronary implantation of ACP-01. Serious adverse events (SAEs) were reported. Cell analysis was conducted for each treatment. The left ventricular ejection fraction (LVEF) was measured by multi-gated acquisition scan (MUGA) or echocardiogram at 4 months ± 1.9 months and 12 months ± 5.5 months. Patients reported quality of life statements at 6 months (± 5.6 months). RESULTS: Fifty-four of 74 patients met requirements for inclusion (48 males and five females; age 68.1 ± 11.3 years). The mean treatment cell number of 57 × 106 ACP-01 included 7.7 × 106 CD34 + and 21 × 106 CD31 + cells with 97.6% viability. SAEs included one death (previously unrecognized silent MI), ventricular tachycardia (n = 2) requiring cardioversion, and respiratory infection (n = 2). LVEF in the ischemic subgroup (n = 41) improved by 4.7% ± 9.7 from pre-procedure to the first follow-up (4 months ± 1.9 months) (p < 0.004) and by 7.2% ± 10.9 at final follow-up (n = 25) at average 12 months (p < 0.004). The non-ischemic dilated cardiomyopathy subgroup (n = 8) improved by 7.5% ± 6.0 at the first follow-up (p < 0.017) and by 12.2% ± 6.4 at final follow-up (p < 0.003, n = 6). Overall improvement in LVEF from pre-procedure to post-procedure was significant (Fisher's exact test p < 0.004). LVEF improvement was most marked in the patients with the most severe cardiomyopathy (LVEF < 20%) improving from a mean 14.6% ± 3.4% pre-procedurally to 28.4% ± 8% at final follow-up. Quality of life statements reflected improvement in 33/50 (66%), no change in 14/50 (28%), and worse in 3/50 (6%). CONCLUSION: Transcatheter implantation of ACP-01 for cardiomyopathy is safe and improves LVEF in the setting of ischemic and non-ischemic cardiomyopathy. The results warrant further investigation in a prospective, blinded, and controlled clinical study. TRIAL REGISTRATION: IRB from Genetic Alliance #APC01-001, approval date July 25, 2022. Cardiomyopathy is common and associated with high mortality. Stem cell transplantation is an emerging therapy. Angiogenic cell precursors (ACP-01) are lineage-specific endothelial progenitors, with strong potential for migration, engraftment, angiogenesis, and support of tissue survival and regeneration. A retrospective outcomes analysis of 53 patients with ischemic and non-ischemic dilated cardiomyopathy undergoing transcatheter implantation of ACP-01 demonstrated improvements in the left ventricular ejection fraction of 7.2% ± 10.9 (p < 0.004) and 12.2% ± 6.4, respectively, at 12 months (± 5) follow-up. Quality of life statements reflected improvement in 33/50 (66%) patients.

Molecular characterization of Burkholderia mallei strains isolated from horses in Brazil (2014-2017).

Glanders is an infectious zoonosis caused by Burkholderia (B.) mallei that mainly affects equids. The objective of this work was to provide additional knowledge on the diversity of the strains circulating in Brazil. Six Burkholderia mallei isolates obtained during necropsies of glanderous horses between 2014 and 2017 in two different states (Pernambuco and Alagoas) were analyzed by polymerase chain reaction-high-resolution melting (PCR-HRM). While four strains (9902 RSC, BM_campo 1, BM_campo 3 and UFAL2) clustered in the L3B2 branch, which already includes the Brazilian 16-2438_BM#8 strain, two strains (BM_campo 2.1 and BM_campo 2.2) clustered within the L3B3sB3 branch, which mostly includes older isolates, from Europe and the Middle East. Whole genome sequencing of two of these strains (UFAL2 and BM_campo 2.1), belonging to different branches, confirmed the HRM typing results and refined the links between the strains, including the description of the L3B3Sb3Gp1SbGp1 genotype, never reported so far for contemporary strains. These results suggest different glanders introduction events in Brazil, including a potential link with strains of European origin, related to colonization or trade.

Neo-phalloplasty in children and adolescents for acquired penile loss.

INTRODUCTION: From 2000 to 2019, the De Castro's neo-phalloplasty was used in 47 patients with congenital and acquired penile loss. PURPOSE: Herein, the technical aspects of penile reconstruction and the outcomes in 17 children and adolescents treated for total or sub-total acquired penile loss are reported. MATERIAL AND METHODS: The median age at the time of injury was 3 months (range: 2 days-15 years). Twelve patients were born with normal penis but suffered injuries (11) or underwent surgical resection of the penis (1). The remaining 5, affected by bladder exstrophy (2) or cloacal exstrophy (3), had penile loss due to surgical complications. RESULTS: The median age at the time of surgery was 5 years (range: 2-20 years). The median length of the procedure was 5 h (range 4-8 h). Skin expander were inserted in preparation of phalloplasty in 9 patients. Corpora-cavernosa remnants were found and incorporated in the neophallus in 12 patients. In 7 patients, urethral remnants were also incorporated into the repair, placing the meatus at the tip of the neophallus. In the remaining patients the urethra was left in the acquired position after penile loss creating a perineal (2), scrotal (3), peno-scrotal (3), or posterior penile (1) urethrostomy. The first patient of this series was the only patient to receive simultaneously phalloplasty and total urethroplasty, with failure of urethral reconstruction. The median follow-up was 2 years (range 1-11 years). The overall complication rate was about 47%. All of the complications were late and required surgical revision. The results were assessed regarding overall functionality (voiding, erection/erogenous areas, masturbation/sexual intercourse) and aesthetic outcome using subjective and objective parameters. Psychological evaluation for both patient and parents was performed in 4 cases. DISCUSSION: There are no specific guidelines for treating significant penile injuries in the pediatric population. We do not think secondary severe penile impairments should wait until adult age for repair. In this specific subgroup of patients technical aspects differ from phalloplasty done for congenital aphallia, due to the possible presence of corpora-cavernosa/urethral remnants and the feasibility to perform a "functional phalloplasty" with very encouraging results. CONCLUSION: The De Castro's neo-phalloplasty remains one of the few techniques available for total penile reconstruction in pediatric age group. Data demonstrate that this technique for acquired aphallia is feasible and reproducible, however, it is a challenging procedure with a high complication rate and likelihood of revisions.

A salvage procedure for redo penile prosthesis implantation in phalloplasty (De castro technique) for congenital aphallia.

INTRODUCTION: We present a different salvage procedure for penile prosthesis implantation in a De Castro neophallus. METHODS: A patient with congenital aphallia had been operated at the age of 11. Ten years later he had two non successful attempts of prosthesis implantation. Surgery consisted of adapting the implants into the aortic graft and folding it in the middle over the cylinders to reinforce its strength. RESULTS: Patient had a successful postoperative course and has now 6 months of follow-up. DISCUSSION: In a systematic review of penile prosthetic outcomes and complications in gender-affirming surgery, most of the prostheses were inflatable (83.6%) and single-cylinder (61.0%). At a mean follow-up of 3.0 years: 36.2% of prosthesis complications, 60.0% of patients had their original implant present and 83.9% reported achieving penetration. We decided to use vascular grafts as a scaffold because of former non successful attempts. CONCLUSION: The use of vascular prosthesis as a device to implant the penile prosthesis seems to be a safe and effective alternative in an attempt to offer erectile function to the neophallus in case of congenital aphallia.

Ultrafast Photofragmentation of Ln(hfac)3 with a Proposed Mechanism for forming High Mass Fluorinated Products.

The photo-induced dissociative-ionization of lanthanide complexes Ln(hfac)3 (Ln = Pr, Er, Yb) is studied using intense ultrafast transform limited (TL) and linearly chirped laser pulses in a time-of-flight (TOF) mass spectrometry setup. Various fluorine and Ln-containing high-mass fragments were observed in this experiment, including the molecular parent ion, which have not been seen with previous studies relying on relatively long-duration laser pulses (i.e., ns or longer). These new high-mass observations provide important formerly missing information for deducing a set of photo-fragmentation mechanistic pathways for Ln(hfac)3. An overall ultrafast control mechanism is proposed by combining insights from earlier studies and the fragments observed in this research to result in three main distinct photo-fragmentation processes: (a) ligand-metal charge transfer, (b) CF3 elimination, and (c) C-C bond rotation processes. We conclude that ultrafast dissociative-ionization could be a promising technique for generating high-mass fragments for potential use in material science applications.

Gaining Mechanistic Insight with Control Pulse Slicing: Application to the Dissociative Ionization of CH2BrI.

In quantum control experiments with shaped femtosecond laser pulses, adaptive feedback control is often used to identify pulse shapes that can optimally steer the quantum system toward the desired outcome. However, gaining mechanistic information can pose a challenge due to the varied structural features of the control pulses and/or the often complex nature of the associated simulations of the experiments. In this article, we introduce control pulse slicing (CPS) as an easy-to-implement experimental analysis tool that can be employed directly in the laboratory without the need for modeling, to gain mechanistic insights about control experiments, regardless of whether the pulse is optimal or chosen by other means. As an illustration, we apply CPS to dissociative ionization of CH2BrI with mass spectral detection, where two pulses with similar intensities are investigated, with each capable of distinctively controlling the ratio of Br+/CH2Br+. These two control pulses were, respectively, first identified with closed loop and open loop procedures, and then the multispecies experimental data was analyzed with CPS. By comparing the dynamical evolution of the observed multiple fragment ion yields upon slicing scans of the two distinct pulses, we were able to reveal insights about the control mechanism for manipulating the objective ratio. In addition, we also identified the relationship between the temporal structures of the control pulses and the associated key reaction pathways involved in ionic as well as neutral electronic states, in spite of the signals only directly being from the ionic species. The CPS technique is not limited to controlled fragmentation mass spectrometry, and it may be applied to gain mechanistic insights in any control experiment, reflected in the nature of the recorded signal.

Neophalloplasty in boys with aphallia: A systematic review.

OBJECTIVE: Aphallia is a rare penile congenital abnormality. The aim of this systematic review was to assess all available literature on neophalloplasty in infancy with an interest in technical alternatives and clinical outcome. MATERIALS AND METHODS: We performed a Pubmed search using the terms: neophalloplasty, neophallus, and phalloplasty, and selected articles that presented technical alternatives for penile construction in cases of penile dysgenesis, especially aphallia in children and/or adolescents. RESULTS: A total of 319 articles were identified in the initial search. Among the different techniques presented in 19 papers collected, we categorized reconstructive procedures into two groups: microsurgical and non-microsurgical techniques. Among the microsurgical techniques, procedures such as the osteocutaneous fibular flap (n = 18), the myocutaneous latissimus dorsi flap (n = 24), and the radial forearm free flap (n = 293) were reported. Among the non-microsurgical techniques, we found a wider range of technical options (6 in total). Most were based on groin, abdominal, and scrotal flaps. Long-term reports on the functionability of the neophallus and psychological aspects of the patients are lacking. CONCLUSION: In assessing recent literature, it seems rational that neophalloplasty should be regarded as the preferred strategy for boys born with aphallia, in opposition to female gender assignment.

Soroprevalência de Maedi-visna em rebanhos ovinos do estado do Maranhão, Brasil

Apesar de ter sido relatada em vários Estados, não há informação sobre o Vírus da Maedi Visna (MVV) no Maranhão, e com o crescimento de sua ovinocultura, aumenta o fluxo de animais de outras regiões. Com isso objetivou-se determinar a soroprevalência do MVV em rebanhos ovinos das três principais mesorregiões produtoras do Estado do Maranhão, através da pesquisadas de 1.495 amostras sanguíneas de ovinos, com idade superior a seis meses, pertencentes a 83 rebanhos de 23 municípios das mesorregiões Cento, Leste e Norte. O diagnóstico sorológico da infecção pelo vírus MVV foi realizado por meio do teste de imunodifusão em gel de ágar (micro-IDGA). Constatou-se uma prevalência geral de 0,7% (IC95%:0,4-1,3%) de ovinos soropositivos e prevalências nas mesorregiões Centro, Leste e Norte de 0,5% (IC95%:0,1-1,4%), 0,7% (IC95%:0,2-1,8%) e 1% (IC95%:0,3-2,4%) respectivamente. Em relação à variável sexo, não foi observado diferença significativa (P>0,05) entre machos (0,5%, IC95%:0-2,7%) e fêmeas (0,8%, IC95%:0,4-1,4%), assim como quanto a genética comparando ovinos de raças puras (1,5%, IC95%: 0,4-8,1%), mestiços (1%, IC95%:0,4-2,0%) e SRD (0,3%, IC95%:0,04-1,1%). A análise quanto a idade não demonstrou diferença significante (P>0,05). Conclui-se que a infecção pelo MVV está presente em ovinos das mesorregiões estudadas, sendo este o primeiro registro desta enfermidade no Estado do M

Manipulating quantum pathways on the fly.

The expectation value of a quantum system observable can be written as a sum over interfering pathway amplitudes. In this Letter, we demonstrate for the fist time adaptive manipulation of quantum pathways using the Hamiltonian encoding-observable decoding (HE-OD) technique. The principles of HE-OD are illustrated for population transfer in atomic rubidium using shaped femtosecond laser pulses. The ability to manipulate multiple pathway amplitudes is of fundamental importance in all quantum control applications.

Production of Equine Infectious Anemia Virus (EIAV) antigen in Pichia pastoris.

Equine Infectious Anemia (EIA) is a persistent lentivirus infection of horses which causes a chronic clinical condition with worldwide importance in veterinary medicine. The p26 protein is usually prepared for use as an antigen in serological tests for EIA diagnosis since it is a well-conserved gene sequence and very immunogenic. In view of the ability of yeast to make post-translational modifications of proteins, this study was carried out to allow Pichia pastoris to be used for the expression of a synthetic codon-optimized EIAV p26 gene. The gene was cloned into pPICZαA vector after appropriate enzymatic digestion. P. pastoris clones transformed with the pPICZαAp26 construction were induced to produce the recombinant p26 protein (rp26) under the regulation of alcohol oxidase 1 promoter by adding methanol to the culture medium. The p26 gene expression was detected by RT-PCR and the production of rp26 was confirmed by dot blotting, Western blotting, ELISA and AGID. The P. pastoris expression system was capable of producing a functional EIAV p26 protein that can be used directly in the functionality tests without requiring laborious purification or recovery steps. This is the first reported study of EIAV p26 protein production in yeast cells.

Phalloplasty and urethroplasty in a boy with penile agenesis.

OBJECTIVE: New concepts in ambiguous genitalia have questioned the strategy of female gender reassignment in cases of penile agenesis. Hence, we present a video of the construction of a phallus according to the De Castro technique as an alternative approach for this devastating condition. METHODS: A 12-year-old boy with congenital penile agenesis and posterior urethra emerging in the distal rectum was selected. An ASTRA approach was used and a phallus was constructed with a skin flap from the abdominal wall, tubularized to produce a phallic appearance. A buccal mucosa graft was tubularized to create the new urethra. RESULTS: Immediate outcome was excellent. Partial dehiscence of the dorsal urethral sutures occurred and the patient started voiding through a scrotal urethrostomy at 9 months postoperatively. Phalloplasty provided an adequate male appearance with a good cosmetic aspect. CONCLUSION: The technique is a feasible alternative. A procedure in 2 stages by first creating the neourethra at a later date might be an interesting option to try to avoid the urethral complications observed. Long-term follow-up is however necessary to confirm the initial results.

Surgical treatment of high urogenital sinuses using the anterior sagittal transrectal approach: a useful strategy to optimize exposure and outcomes.

PURPOSE: Surgical management of the high urogenital sinus remains challenging. The anterior sagittal transrectal approach provides optimal exposure, facilitates vaginal dissection and separation from the urethra, and allows reconstruction of the bladder neck musculature. In this study we report our initial experience with this technique. MATERIALS AND METHODS: We performed a retrospective review of a 6-year multi-institutional experience treating patients with a urogenital sinus anomaly using the anterior sagittal transrectal approach without preoperative colostomy or prolonged postoperative fasting. Variables analyzed included patient age, associated malformations, the need for additional procedures and surgical outcomes. RESULTS: A total of 23 children with a mean age of 2.3 years (range 3 months to 17 years) who underwent surgery between 2003 and 2010 were included in the study. Mean followup was 3.4 years (range 14 months to 7 years). All children had a high urogenital sinus with (16) or without (7) congenital adrenal hyperplasia. There were 3 isolated cases treated with additional procedures. Only 1 anterior sagittal transrectal approach related complication was encountered when a perineal infection developed in a child and required temporary diverting colostomy without compromising the repair. There were no postoperative urethrovaginal fistulas. All toilet trained patients were continent for feces and most were voiding normally per urethra (21), except for 2 with associated urological malformations. There were 15 patients who underwent followup examination under anesthesia, and demonstrated separate urethral and vaginal openings. CONCLUSIONS: The anterior sagittal transrectal approach provides excellent exposure for the management of a high urogenital sinus, facilitating the separation of urogenital structures. Good outcomes in terms of urinary/fecal continence as well as the absence of urethrovaginal fistulas were achieved in the majority of cases, supporting its consideration for the surgical management of this congenital abnormality.

Retrograde ureteral access after cross-trigonal ureteral reimplantation: A straightforward technique.

PURPOSE: Retrograde ureteral access after cross-trigonal ureteral reimplantation can be challenging. We present our experience with percutaneous retrograde ureteral catheterization, status post cross-trigonal ureteral reimplantation. MATERIALS AND METHODS: We evaluated all patients who underwent attempted percutaneous retrograde ureteral catheterization after cross-trigonal ureteral reimplantation. All clinical data, radiographic images and operative reports were reviewed. Ureteral access was obtained by percutaneously entering the bladder with an intravenous needle/catheter under cystoscopic guidance. The needle was then removed leaving the catheter in place. The ureteral orifice was then accessed through the intravenous catheter by a ureteral access wire and/or ureteral catheter under cystoscopic guidance. RESULTS: From 1978 to 2008, 13 patients (11 boys and 2 girls) with a history of cross-trigonal ureteral reimplantation underwent percutaneous retrograde ureteral catheterization. The procedure was unilateral in 12 patients and bilateral in one. Indications for the procedure included: retrograde pyelography and double-J stent insertion for ureteropelvic junction or ureterovesical junction obstruction (10); removal of migrated stent (2); and treatment of a ureteral stone (1). The procedure was performed successfully in all patients and without complications. CONCLUSIONS: Percutaneous retrograde ureteral catheterization is a safe, straightforward, and effective modality for obtaining retrograde ureteral access in children, status post cross-trigonal ureteral reimplantation.

Latex allergy in a patient with Kabuki syndrome. Case report.

BACKGROUND AND OBJECTIVES: The knowledge of anesthesiologists of specific aspects of patients with rare syndromes is a growing need since those patients are increasingly taken to the operating room. The objective of this report was to describe a case of latex allergy in a patient with Kabuki Syndrome, whose aspects have not been completely explained, alerting anesthesiologists for the possibility of this association. CASE REPORT: This is an 11 years old patient with the diagnosis of Kabuki syndrome, admitted for removal of soft tissue lesions. She had a history of allergic reactions after small surgeries. Since she needed to undergo another procedure, after the pre-anesthetic evaluation the patient was referred to an allergist who confirmed, after skin tests, that the patient had latex allergy. She was taken to the operating room for removal of those lesions under general anesthesia. All precautions were taken to avoid new clinical manifestations. Intercurrences were not observed during the procedure and the patient was discharged on the same day without any complications, which reinforced the diagnosis. CONCLUSIONS: Kabuki syndrome seems to have a relatively benign course. However, it has many aspects that remain to be cleared and, therefore, the possibility of its association with other condition that might be important for the anesthesiologist exists. The objective of this report was to alert for the risk of its association with latex allergy. For such, during the pre-anesthetic evaluation, a good anamnesis with analysis of predisposing factors other than the syndrome itself should be stimulated.

Histological evaluation of an alternative method of neophalloplasty based on two lower abdominal skin flaps and simultaneous buccal mucosa graft in the ventral surface of the neophallus (two-stage urethroplasty): experimental study in rabbits.

OBJECTIVE: To evaluate, in an experimental study in rabbits, a new model of neophalloplasty based on two lower abdominal skin flaps and ventral buccal mucosa graft for planned two-stage urethroplasty procedure. MATERIAL AND METHODS: Sixteen rabbits were operated and divided into four equal groups which were sacrificed at 2, 4, 8 and 12 weeks. The inflammatory pattern, presence of sub-epithelial fibrosis and epithelial changes in the grafted area were evaluated histologically. RESULTS: There were no deaths and no dehiscence of the wound was seen. One animal in the 2-week group developed an ulcer in the grafted area. We found minimal contracture of the neophallus, but this was not statistically significant between groups. Buccal mucosa graft showed good uptake in all groups, with vascular support from subcutaneous tissue of the flaps. The grafted area developed epithelial metaplasia, showing a decrease in cell layers with time, with disappearance of the sub-epithelial papillae and appearance of stratum granulosum and keratinization of the epithelial graft surface. A decrease in sub-epithelial fibrosis with replacement of immature by mature (eosinophilic) collagen was found. In the later groups was also observed an important decrease in inflammatory response, and the chorion of the grafted area presented a dilated capillary network, indicating that the process of neoangiogenesis was effective. CONCLUSION: Buccal mucosa displayed histological integration in the abdominal flaps with epithelial metaplasia in all groups. The surgical aspect of the neophallus was cosmetically acceptable, with minimal contracture.

Seroprevalence of caprine arthritis-encephalitis virus in goats in the Cariri region, Paraiba state, Brazil.

The seroprevalence of caprine arthritis-encephalitis virus (CAEV) in the Cariri Region of Paraíba State, Brazil, was determined in 60 goat herds using the agar gel immunodiffusion test. The overall seroprevalence was 8.2%, with seropositivity in 21/60 (35%) herds and 13/15 (86.6%) municipalities. Bucks had a significantly higher frequency of infection (28.3%) than does (5.9%), and bucks that originated in other states had a significantly higher frequency of infection (76.5%) than those from Paraíba State (9.3%).

Implementation of the Surviving Sepsis Campaign guidelines for severe sepsis and septic shock: we could go faster.

PURPOSE: The aim of this study is to evaluate the feasibility of applying sepsis bundles in the intensive care unit (ICU) and their effect on outcomes. METHODS: In this prospective, observational study in a 31-bed capacity department of intensive care, we measured the time taken to perform sepsis bundle interventions in 69 consecutive patients with severe sepsis or septic shock. RESULTS: Compliance with the 6-hour bundle was obtained in 44 (72%) of 61 patients; these patients had a lower mortality rate (16% vs 41%, P = .04) and shorter ICU stay (median [range], 5 [3-10] vs 9 [6-19] days, P = .01) than other patients. Compliance with the 24-hour bundle was obtained in 30 (67%) of 44 eligible patients. The mortality rate and duration of ICU stay were not significantly lower in the 24-hour compliant as compared with the noncompliant group (23% vs 33% and 6 [4-11] vs 9 [6-25] days, respectively; P value is not significant). Patients who complied with the 24-hour sepsis bundle after only 12 hours had a lower mortality rate (10% vs 39%, P = .036) and shorter stay (6 [4-10] vs 9 [6-25] days, P = .055) than those who were compliant after 24 hours. CONCLUSIONS: Correct application of the sepsis bundles was associated with reduced mortality and length of ICU stay. Earlier implementation of the 24-hour management bundle could result in better outcomes.