Author: Jason Curtis

Tendon end separation with loading in an Achilles tendon repair model: comparison of non-absorbable vs. absorbable sutures (2017)

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Type of publication:
Journal article

Author(s):
*Carmont M.R.; Kuiper J.H.; Gravare Silbernagel K.; Karlsson J.; Nilsson-Helander K.

Citation:
Journal of Experimental Orthopaedics; Dec 2017; vol. 4 (no. 1)

Abstract:
Background: Rupture of the Achilles tendon often leads to long-term morbidity, particularly calf weakness associated with tendon elongation. Operative repair of Achilles tendon ruptures leads to reduced tendon elongation. Tendon lengthening is a key problem in the restoration of function following Achilles tendon rupture. A study was performed to determine differences in initial separation, strength and failure characteristics of differing sutures and numbers of core strands in a percutaneous Achilles tendon repair model in response to initial loading. Methods: Nineteen bovine Achilles tendons were repaired using a percutaneous/minimally invasive technique with a combination of a modified Bunnell suture proximally and a Kessler suture distally, using non-absorbable 4-strand 6-strand repairs and absorbable 8-strand sutures. Specimens were then cyclically loaded using phases of 10 cycles of 100 N, 100 cycles of 100 N, 100 cycles of 190 N consistent with early range of motion training and weight-bearing, before being loaded to failure. Results: Pre-conditioning of 10 cycles of 100 N resulted in separations of 4 mm for 6-strand, 5.9 mm for 4-strand, but 11.5 mm in 8-strand repairs, this comprised 48.5, 68.6 and 72.7% of the separation that occurred after 100 cycles of 100 N. The tendon separation after the third phase of 100 cycles of 190 N was 17.4 mm for 4-strand repairs, 16.6 mm for 6-strand repairs and 26.6 mm for 8-strand repairs. There were significant differences between the groups (p < 0.0001). Four and six strand non-absorbable repairs had significantly less separation than 8-strand absorbable repairs (p = 0.017 and p = 0.04 respectively). The mean (SEM) ultimate tensile strengths were 4-strand 464.8 N (27.4), 6-strand 543.5 N (49.6) and 8-strand 422.1 N (80.5). Regression analysis reveals no significant difference between the overall strength of the 3 repair models (p = 0.32) (4 vs. 6: p = 0.30, 4 vs. 8: p = 0.87; 6 vs. 8: p = 0.39). The most common mode of failure was pull out of the Kessler suture from the distal stump in 41.7% of specimens. Conclusion: The use of a non-absorbable suture resulted in less end-to-end separation when compared to absorbable sutures when an Achilles tendon repair model was subject to cyclical loading. Ultimate failure occurred more commonly at the distal Kessler suture end although this occurred with separations in excess of clinical failure. The effect of early movement and loading on the Achilles tendon is not fully understood and requires more research.

An unusual case of breathlessness and a dry cough (2017)

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Type of publication:
Conference abstract

Author(s):
*Iftikhar S.; *Green N.J.; *Perks W.

Citation:
American Journal of Respiratory and Critical Care Medicine; 2017; vol. 195

Abstract:
A 77 year old female presented with new onset breathlessness over the previous four weeks. The patient described symptoms of fatigue and one episode of near fainting. Previously she had been active with good exercise tolerance. There was a history of gastro-oesophageal reflux. Medication included omeprazole, zopiclone and citalopram on a regular basis. The patient was a life long smoker, smoking ten cigarettes daily. Alcohol intake was up to 20 units per week. The patient's mother had died of breast cancer and father of pulmonary emphysema. On examination, the patient looked unwell. Blood pressure was 120/60 mm Hg; pulse 120 bpm; and oxygen saturation 97% by pulse oximetry. The patient weighed 60 Kg and denied any weight loss. Cardiovascular, respiratory and abdominal examination was unremarkable. A resting ECG showed sinus tachycardia with first degree heart block. A 24 hour ECG tape and 24 hour blood pressure monitoring showed no significant abnormality. Blood results showed low haemoglobin at 96 g/dl with normal red cell morphology, platelets 675 x 109 /L, white cell count 12.9 x 109 /L (with slightly elevated neutrophils, lymphocytes, monocytes and eosinophils), ESR 88 mm/hour, serum sodium 128 mmol/L, albumin 32 g/L, alkaline phosphatase 135 u/L, AST 55 u/L, ALT 122 u/L, GGT 70 u/L, calcium 2.2 mmol/L and glucose 7.5 mmol/L. A vasculitic screen was negative. Urinalysis revealed proteinuria. A CT scan, that showed marked ground glass change and mosaic attenuation, was discussed at a weekly X-ray meeting. The diagnosis of post viral pneumonitis was made. The patient died suddenly at home two weeks later just prior to a follow up hospital appointment. Post mortem examination revealed interstitial pneumonia (UIP) with focal pulmonary fibrosis and small areas of honeycomb change (fig. 1 & 2). The heart was morphologically normal, but showed myocarditis in which the infiltrate consisted of small T lymphocytes and eosinophil polymorphs (fig. 3). We postulate an association between UIP and lymphocytic myocarditis, which has rarely been described in the literature before.

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Analysis of doctors and nurses confidence with the use of in and out urinary catheters for collection of urine samples (2017)

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Type of publication:
Conference abstract

Author(s):
*Fox H.; *Gupta M.

Citation:
Archives of Disease in Childhood; May 2017; vol. 102, Suppl. 1

Abstract:
Background NICE recommends collecting urine by a clean catch sample to diagnose urinary tract infection (UTI), but if not possible or practical, to use urinary catheters (UC) to collect urine. Despite a policy to obtain clean catch urine, we have noticed high contamination rates, especially in infants. This creates diagnostic uncertainty, leading to unnecessary investigations and overuse of antibiotics. Using a UC to obtain urine can reduce rates of contamination, but experience among staff is low in our department as UC are not commonly used for this purpose. In this survey we explore the confidence, competence and training of staff with UC for collection of urine samples. Methods A survey of medical and nursing staff was undertaken during a typical working week in October 2016. We asked about their experience, confidence and competence with insertion of UC to obtain urine samples in children. Results were analysed using Microsoft Excel. Results 30 staff completed the questionnaire including 12 nurses, 3 advanced paediatric nurse practitioners (APNP), 9 tier 1 doctors (Foundation, GP and CT1-3 paediatrics trainees) and 6 tier 2 doctors (CT4 and above). 33% of Band 5 nurses, 67% of band 6 nurses, 75% of Tier 1 paediatric trainees and none of the foundation and GP trainees have inserted a UC in children. 50% of junior doctors and 53% nurses have never received training on UC insertion in children. 7% of all nurses and 67% of all doctors feel competent with insertion of UC in boys, whereas 40% of all nurses and 53% of all doctors surveyed feel competent with insertion of UC in girls. Conclusion This survey identified that experience of UC insertion is low among nursing and junior medical staff, which is reflected in their perceived competence. This may be due to infrequent use of this procedure. Most staff identified the need for more training. Therefore we recommend using a standard operating procedure to allow structured training of junior medical and nursing staff. Considering UC more often in clinical practice will improve confidence and maintain competency of staff, and reduce the incidence of contaminated urine samples, especially in infants.

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Two decades of coeliac disease in a district general hospital in England: What has changed? (2017)

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Type of publication:
Conference abstract

Author(s):
*Singh R.; *Ayub N.

Citation:
Archives of Disease in Childhood; May 2017; vol. 102, Suppl. 1

Abstract:
Aim To determine the changes in clinical presentation of Coeliac Disease in children aged less than 16 years over a period of 20 years (January 1996 to December 2015) at a DGH in England Methods A retrospective case study of the clinical presentation of biopsy-proven Coeliac disease in children, at a DGH over a period of 20 years divided into four equal periods (1996-2000, 2001-2005, 2006-2010 and 2011-2015). Relevant information was extracted and input into an Excel database by a single researcher for further analysis. Results Coeliac Disease was diagnosed in 114 children over the study period. Twelve children were excluded from final analysis. These comprised of 05 children with insufficient information and 07 children with Insulin-Dependent Diabetes Mellitus( IDDM) diagnosed with Coeliac Disease as a result of their annual screening investigations. Twenty (20) new cases of Coeliac disease were identified during each of the study periods 1996-2000 and 2001-2005. This increased to 31 cases during the study periods of 2006-2010 and 2011-2015. Although 85% of cases were diagnosed under the age of 12 years, there was a trend towards diagnosis at an older age and increasing female representation. Anaemia (53%) and diarrhoea (49%) were the commonest and most consistent symptoms. Constipation (10%) occurred in a significant minority. However, recurrent abdominal pain (46%) was not only a major symptom after the age of 3 years but increasingly likely from 2006 onwards with 71% affected in 2011-2015. Abdominal distension (24%) remained relatively unchanged while faltering growth (27%) and small stature (8%) showed a decreasing trend. Vomiting (17%) was more likely in children under the age of 4 years. Conclusion Although Coeliac Disease is being diagnosed more frequently, there is a trend towards diagnosis at an older age with increasing female representation. Iron deficiency anaemia and diarrhoea have remained unchanged as the commonest symptoms but recurrent abdominal pain is a significant symptom, especially in the older child. Constipation is found in a significant minority but both faltering growth and small stature show a decreasing trend.

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Gefitinib and EGFR gene copy number aberrations in esophageal cancer (2017)

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Type of publication:
Conference abstract

Author(s):
Petty R.D.; Dahle-Smith A.; Stevenson D.A.J.; Osborne A.; Massie D.; Clark C.; Miedzybrodzka Z.; Murray G.I.; Dutton S.J.; Roberts C.; Chong I.Y.; Mansoor W.; Thompson J.; Harrison M.; *Chatterjee A.; Falk S.J.; Elyan S.; Garcia-Alonso A.; Fyfe D.W.; Wadsley J.; Chau I; Ferry D.R.; Miedzybrodzka Z.

Citation:
Journal of Clinical Oncology; Jul 2017; vol. 35 (no. 20); p. 2279-2287

Abstract:
Purpose The Cancer Esophagus Gefitinib trial demonstrated improved progression-free survival with the epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor gefitinib relative to placebo in patients with advanced esophageal cancer who had disease progression after chemotherapy. Rapid and durable responses were observed in a minority of patients. We hypothesized that genetic aberration of the EGFR pathway would identify patients benefitting from gefitinib. Methods A prespecified, blinded molecular analysis of Cancer Esophagus Gefitinib trial tumors was conducted to compare efficacy of gefitinib with that of placebo according to EGFR copy number gain (CNG) and EGFR, KRAS, BRAF, and PIK3CA mutation status. EGFR CNG was determined by fluorescent in situ hybridization (FISH) using prespecified criteria and EGFR FISH-positive status was defined as high polysomy or amplification. Results Biomarker data were available for 340 patients. In EGFR FISH-positive tumors (20.2%), overall survival was improved with gefitinib compared with placebo (hazard ratio [HR] for death, 0.59; 95% CI, 0.35 to 1.00; P = .05). In EGFR FISH-negative tumors, there was no difference in overall survival with gefitinib compared with placebo (HR for death, 0.90; 95% CI, 0.69 to 1.18; P = .46). Patients with EGFR amplification (7.2%) gained greatest benefit from gefitinib (HR for death, 0.21; 95% CI, 0.07 to 0.64; P = .006). There was no difference in overall survival for gefitinib versus placebo for patients with EGFR, KRAS, BRAF, and PIK3CA mutations, or for any mutation versus none. Conclusion EGFR CNG assessed by FISH appears to identify a subgroup of patients with esophageal cancer who may benefit from gefitinib as a secondline treatment. Results of this study suggest that anti- EGFR therapies should be investigated in prospective clinical trials in different settings in EGFR FISH-positive and, in particular, EGFR-amplified esophageal cancer.

VIPoma: A rare cause of life threatening diarrhoea (2017)

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Type of publication:
Conference abstract

Author(s):
*Bevis M.

Citation:
Anaesthesia; Jul 2017; vol. 72 ; p. 30

Abstract:
VIPomas are rare neuroendocrine tumours that secrete excessive vasoactive intestinal peptide causing refractory diarrhoea, hypokalaemia and metabolic acidosis. This case describes the difficulties in diagnosing a rare cause of diarrhoea on the ITU. A 76-year-old male, with a background of type 2 diabetes, presented to hospital with a 3-day history of confusion, muscle weakness, lethargy and profuse diarrhoea. The patient had been having diarrhoea for two months but colonoscopy was unremarkable. On examination the patient was dehydrated and had a heart rate of 110 min-1, otherwise no abnormality was found. Blood tests showed metabolic acidosis (pH 7.17, base excess -15.4 mmol.L-1, bicarbonate 12.9 mmol.L-1) and severe hypokalaemia (K+ 1.3 mmol.L-1). He was admitted to ITU for aggressive fluid resuscitation and electrolyte correction. The patient had large volumes of watery diarrhoea (8 l every 24 h) which was unresponsive to loperamide and codeine. Stool cultures were negative. CT of the abdomen revealed a solitary focal liver lesion and a possible focal abnormality in the pancreatic tail. A gut hormone profile was sent for analysis. Although the diagnosis was unclear, the patient was started on octreotide which slowed the diarrhoea after a few days. Histology of the liver lesion confirmed neuroendocrine tumour, and both vasoactive intestinal peptide and pancreatic polypeptide were raised in the blood, therefore a diagnosis of pancreatic VIPoma was made. Discussion VIPomas are very rare, affecting less than 1 in 1,000,000 patients each year in the UK [1]. The cause of most VIPomas is unknown; however multiple endocrine neoplasia type 1 is a risk factor [1]. VIPomas are slow growing and are often malignant. Patients often develop symptoms slowly and may have diarrhoea for years before a diagnosis is made. The diarrhoea is large-volume, has a dilute tea appearance, and is not affected by fasting. Tests for VIPoma include serum vasoactive intestinal peptide (however this needs to be processed at a specialist centre), CT, MRI and octreoscan [1, 2]. Initial treatment focuses on fluid and electrolyte replacement as untreated severe electrolyte imbalance can lead to arrhythmias, cardiovascular collapse and death. Somatostatin analogues, such as octreotide, help control the symptoms of diarrhoea; however, the main treatment is surgical [2]. In conclusion, although VIPomas are rare they should be suspected in patients that present with profuse chronic diarrhoea with no obvious cause.

Abiraterone for prostate cancer not previously treated with hormone therapy (2017)

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Type of publication:
Randomised controlled trial

Author(s):
James, Nicholas D. Ph.D.; de Bono, Johann S. Ph.D.; Spears, Melissa R. M.Sc.; Clarke, Noel W. Ch.M.; Mason, Malcolm D. F.R.C.R.; Dearnaley, David P. F.R.C.R.; Ritchie, Alastair W.S. M.D.; Amos, Claire L. Ph.D.; Gilson, Clare M.R.C.P.; Jones, Rob J. M.B., Ch.B.; Matheson, David Ph.D.; Millman, Robin; Attard, Gerhardt M.D.; Chowdhury, Simon Ph.D.; Cross, William R. F.R.C.S.; Gillessen, Silke M.D.; Parker, Christopher C. M.D.; Russell, Martin J. F.R.C.R.; Berthold, Dominik R. M.D.; Brawley, Chris M.Sc.; Adab, Fawzi F.R.C.R.; Aung, San M.R.C.P.; Birtle, Alison J. F.R.C.R.; Bowen, Jo F.R.C.R.; Brock, Susannah F.R.C.R.; Chakraborti, Prabir F.R.C.R.; Ferguson, Catherine F.R.C.R.; Gale, Joanna B.M.; Gray, Emma F.R.C.R.; Hingorani, Mohan Ph.D.; Hoskin, Peter J. F.R.C.R.; Lester, Jason F. F.R.C.R.; Malik, Zafar I. F.R.C.R.; McKinna, Fiona F.R.C.R.; McPhail, Neil F.R.C.R.; Money-Kyrle, Julian F.R.C.R.; O'Sullivan, Joe Ph.D.; Parikh, Omi F.R.C.R.; Protheroe, Andrew F.R.C.P.; Robinson, Angus F.R.C.R.; *Srihari, Narayanan N. F.R.C.R.; Thomas, Carys M.R.C.P.; Wagstaff, John Ch.B.; Wylie, James F.R.C.R.; Zarkar, Anjali F.R.C.R.; Parmar, Mahesh K.B. D.Phil.; Sydes, Matthew R. M.Sc.; the STAMPEDE Investigators

Citation:
New England Journal of Medicine; Jul 2017; vol. 377 (no. 4); p. 338-351

Abstract:
BACKGROUND: Abiraterone acetate plus prednisolone improves survival in men with relapsed prostate cancer. We assessed the effect of this combination in men starting long-term androgen-deprivation therapy (ADT), using a multigroup, multistage trial design. METHODS: We randomly assigned patients in a 1:1 ratio to receive ADT alone or ADT plus abiraterone acetate (1000 mg daily) and prednisolone (5 mg daily) (combination therapy). Local radiotherapy was mandated for patients with node-negative, nonmetastatic disease and encouraged for those with positive nodes. For patients with nonmetastatic disease with no radiotherapy planned and for patients with metastatic disease, treatment continued until radiologic, clinical, or prostatespecific
antigen (PSA) progression; otherwise, treatment was to continue for 2 years or until any type of progression, whichever came first. The primary outcome measure was overall survival. The intermediate primary outcome was failure-free survival (treatment failure was defined as radiologic, clinical, or PSA progression or death from prostate cancer). RESULTS: A total of 1917 patients underwent randomization from November 2011 through January 2014. The median age was 67 years, and the median PSA level was 53 ng per milliliter. A total of 52% of the patients had metastatic disease, 20% had node-positive or node-indeterminate nonmetastatic disease, and 28% had node-negative, nonmetastatic disease; 95% had newly diagnosed disease. The median follow-up was 40 months. There were 184 deaths in the combination group as compared with 262 in the ADT-alone group (hazard ratio, 0.63; 95% confidence interval [CI], 0.52 to 0.76; P<0.001); the hazard ratio was 0.75 in patients with nonmetastatic disease and 0.61 in those with metastatic disease. There were 248 treatment-failure events in the combination group as compared with 535 in the ADT-alone group (hazard ratio, 0.29; 95% CI, 0.25 to 0.34; P<0.001); the hazard ratio was 0.21 in patients with nonmetastatic disease and 0.31 in those with metastatic disease. Grade 3 to 5 adverse events occurred in 47% of the patients in the combination group (with nine grade 5 events) and in 33% of the patients in the ADT-alone group (with three grade 5 events). CONCLUSIONS: Among men with locally advanced or metastatic prostate cancer, ADT plus abiraterone and prednisolone was associated with significantly higher rates of overall and failure-free survival than ADT alone. (Funded by Cancer Research U.K. and others; STAMPEDE ClinicalTrials.gov number, NCT00268476, and Current Controlled Trials number, ISRCTN78818544.)

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Is routine embryo culture to day 6 beneficial? (2013)

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Type of publication:
Conference abstract

Author(s):
*Nash K.; *Gittins V.; *Hatton A.; *Binnersley S.; *Hughes G.; *Kasraie J.

Citation:
Human Fertility; 2013; vol. 16 (no. 3)

Abstract:
Introduction : Following the HFEA's 'Multiple Birth, Single Embryo Transfer Policy'in 2008, blastocyst culture has become routine practice in many clinics. In our clinic, patients unable to transfer on day 5 (D5) due to failed blastocyst development or poor quality, are cultured to day 6 (D6). Supernumerary embryos not suitable for freezing on D5 are cultured to D6 and frozen if viable. We compared biochemical and clinical pregnancy rates for D5 and D6 blastocyst transfers to determine whether routine culture to D6 is beneficial. Method: Biochemical (BPR) and Clinical (CPR) pregnancy rates were compared for D5 and D6 transfers between 01/01/09 and 31/05/12. Results were analysed using Fisher's Exact test . We distinguished D6 blastocysts that were 'true'D6 from those that might have been later developing D5 blastocysts. Results: There was no significant difference in BPR (51.7%) and CPR (41.4%) for D5 (n=203) and D6 (43.5% and 30.4%, n=23) (BPR p=0.51, CPR p=0.37). One patient definitely had a 'true'D6 blastocyst. Conclusion: Culture to D6 appears beneficial as D5 and D6 pregnancy rates are similar. However, small numbers mean the D6 group results may be unreliable. One patient out of 23 had a definate D6 blastocyst making it possible that the other 22 developed late on D5. To truly distinguish D5 and 6 blastocysts we could perform transfers later on D5, but this may be impractical, particularly with blastocysts developing after 5 pm. Alternatively time-lapse technology would allow precise timing of blastulation. With these results in mind, it is likely that our policy of culturing to and freezing blastocysts on D6 regardless of the day of transfer is beneficial and will improve cumulative pregnancy rates. The number of fresh cycles a patient requires will also be reduced, ultimately benefiting the patient through reduced risk/cost, and the clinic/NHS healthcare economy.*

Should embryos be cultured on to day 6 following embryo transfer if there are no embryos suitable for cryopreservation on (2013)

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Type of publication:
Conference abstract

Author(s):
*Hughes G.; *Binnersley S.; *Wallbutton S.; *Gittins V.; *Parry S.; *Hatton A.; *Lavender A.; *Kasraie J.

Citation:
Human Fertility; 2013; vol. 16 (no. 3)

Abstract:
Introduction : Risks and costs associated with stimulation/egg collection mean that storage of excess viable embryos and maximisation of cumulative pregnancy rates from a single egg collection are a priority for clinics.  Should we culture all embryos not suitable for cryopreservation on day 3 (D3) and day 5 (D5) onwards to allow us to assess their viability for cryopreservation over an extended period? Materials and Methods: Retrospective  analysis of the development of 457 embryos from 89 patients that were allocated for training from D3 (n=71) and D5 (n=18) transfer patients that did not meet cryopreservation criteria on D3 (6C 15% fragmentation, 70 hours post insemination/injection) or D5 ( <= 3BB (Gardner and Schoolcraft) 118 hours post insemination). The  embryos allocated were cultured at 6% CO2 to D6 and graded each day. Results: Blastulation rates for D5 transfer patients were significantly greater than D3 transfer patients (43.04% vs 26.42%, p <= 0.0005). 1.88%  of embryos from D3 patients with 0 frozen developed to <= 3BB on D5 vs 8.57% of embryos from D3 patients with 1 frozen (p <= 0.0142). 6.29% of embryos from D3 patients with 0 frozen developed <= 3BB on D6 vs 11.43% of embryos from D3 patients with 1 frozen (p=0.1498). 11.39% of embryos from D5 transfer patients developed to <= 3BB on D6. Conclusions : This small retrospective study, in suboptimal culture conditions,  appears to show it may be beneficial to routinely culture embryos not meeting our cryopreservation criteria on D3 or D5 to D6. At present our biochemical success rates (53% vs 41%, p=0.3671) and clinical success rates for D5 vs D6 transfers (43% vs 32%, p=0.658) suggest that D6 blastocysts are as viable as D5 blastocysts. Practical
and financial implications must be taken into account but this practice may reduce 'fresh'egg collections and maximise cumulative success, thereby reducing risk and cost to the healthcare economy.

Routine culture and cryopreservation of day 6 blastocysts-is it worthwhile? A National Survey (2013)

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Type of publication:
Conference abstract

Author(s):
*Hatton A.; *Gittins V.; *Binnersley S.; *Hughes G.; *Lavender A.; *Kasraie J.

Citation:
Human Fertility; 2013; vol. 16 (no. 3)

Abstract:
Introduction : Blastocyst culture is now routine, but national practice is not uniform. Extended culture to day 6 (D6) may be considered controversial due to possible associated epigenetic factors and a perceived decrease in  viability of D6 blastocysts. Conversely, cryopreservation on D6 may reduce the number of fresh egg collections required, minimising risk to patients and cost to the healthcare economy, but do the benefits outweigh the  potential risks? Method : National survey of practice, protocol and outcome. Results: 40 clinics responded 7.5% did not culture to blastocyst. 92.5% cultured to blastocyst in 5-80% of treatment cycles. 59.5% cultured to D6 if  blastocysts were unavailable for transfer on day 5(D5) and between 0 and <= 90% of patients had fresh D6 transfers. Average clinical pregnancy rates (CPRs) for fresh D5 vs D6 transfers were 44.3% vs 25.7%. All clinics culturing to blastocyst cryopreserved. 89% cultured to D6 if no cryopreservation occurred on D5. 83.5% cultured remaining embryos to D6 whether or not cryopreservation occurred on D5. Average CPRs for cryopreserved D5 vs D6 blastocysts were 31% vs 28.3%. 89% believed culturing to D6 was worthwhile. Other data (e.g. culture system, cryopreservation method, carrier, media) were also collected and analysed. Conclusions : The majority of respondents cultured to, and cryopreserved, on D6. CPRs varied greatly between  centres but were generally lower in fresh D6 vs D5 transfers. Nevertheless, results suggest that D6 transfer is worthwhile for patients without D5 blastocysts. Additionally, CPRs for cryopreserved D6 blastocysts were very similar to D5 and appeared slightly higher than fresh D6. Whilst it remains to be seen whether cryopreserved D6 blastocysts are more viable than fresh, it certainly appears that cryopreservation of D6 blastocysts is effective and beneficial to both patients and the healthcare economy by reducing risks from stimulation/ egg  collections and overall costs whilst maximising cumulative success.