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Background: Pressure injuries are a ubiquitous, yet largely preventable, hospital acquired complication commonly seen in critically ill patients in the intensive care unit. Objectives: The objectives of this study were to implement targeted evidence-based pressure injury prevention strategies and evaluate their effect through measurement of patient pressure injury observations. Methods: A prospective multiphased design was used in the intensive care unit of an Australian tertiary referral hospital using three study periods (period 1, weeks 1–18; period 2, weeks 19–28; and period 3, weeks 29–52). The interventions included staff-focused interventions and patient-focused interventions, with the latter defined in a work unit guideline. Weekly visual observations of critically ill patients' skin integrity were conducted by trained research nurses over 52 weeks from November 2015 to November 2016. The primary outcome measure was a pressure injury of any stage, identified at the weekly observation, and the effect of the intervention was evaluated through logistic regression. Reporting rigour has been demonstrated using the Standards for Quality Improvement Reporting Excellence checklist. Results: Over the whole study, 15.4% (95% confidence interval [CI] = 12.6, 18.2%, 97/631) of patients developed a pressure injury, with the majority of these injuries (73.2%, 95% CI = 64.4%, 82.0%, 71/97) caused by medical devices. After adjustment for covariates known to influence hospital-acquired pressure injury development, pressure injury rates for period 3 compared with period 1 were reduced (odds ratio = 0.41, 95% CI = 0.20–0.97, p = 0.0126). Conclusions: We found the use of defined pressure injury prevention strategies targeted at both staff and patients reduced pressure injury prevalence.

The belief that weather influences people’s health has been prevalent for millennia. Recent studies on the relationship between weather and pain for those who suffer from chronic pain remain indeterminate, with some studies finding strong effects and others finding no effects; most studies face limitations to their study design or dataset size. To address these limitations, a U.K.-wide smartphone study Cloudy with a Chance of Pain was conducted over 15 months with 10,584 citizen scientists who suffer from chronic pain, producing the largest dataset both in duration and number of participants. Compared to other similar citizen-science studies, our retention of participants was substantially better, with 15% still entering data nearly every day after 200 days. Analysis of the dataset using synoptic climatology and compositing revealed the daily weather associated with a prevalence of high pain and low pain across the population. Specifically, our results indicate that the top 10% of days with a high percentage of participants (about 20%) experiencing a pain event (represented here by a +1 change or greater in their pain level on a 5-point scale; referred to as a high-pain day) were associated with below-normal pressure, above-normal humidity, higher precipitation rate, and stronger wind. In contrast, the bottom 10% of days with a small percentage of participants (about 10%) experiencing a pain event (a low-pain day) were associated with above-normal pressure, below-normal humidity, lower precipitation rate, and weaker wind. Thus, these synoptic weather patterns support the beliefs of many participants who said that low pressure—and its accompanying weather—was associated with a pain event.

Prior to the start of the COVID-19 pandemic, Woodlands Hospice Wellbeing and Support Centre ran several regular groups plus nurse-led clinics for patients well enough to attend the hospice. When the pandemic started it was clear that this would no longer be an option as most of the patients were in the shielding category. Clearly the needs of these patients would not go away but the community palliative care and district nursing services could not be expected to take on the role that the hospice had previously played, as they also faced increased demand due to the pandemic. Out of necessity and working towards a new city-wide integrated palliative care model, a decision was made to move to a system of triage coordinators and regular nurse led telephone clinics to monitor these patients. The nursing team underwent an education programme to enhance their triage and symptom management skills and they had ready access to the medical team for support if there were problems. Consultations are carried out by telephone or video consultation as well as face-to-face where needed. The nursing team gradually took over the surveillance role of the medical clinics to free capacity for urgent medical appointments so patients could be assessed by the doctors when problems arise or when symptoms are more complex. The triage coordinator now looks at all referrals coming into the hospice and assesses the patient’s needs to ensure the patient is linked into the most appropriate services. All this integrated working has reduced the time from referral to comprehensive specialist nursing assessment in the hospice from two weeks to within five working days. The working relationships with all teams has become closer and more effective, and patients are still able to access services despite the restrictions that the pandemic has brought.

OBJECTIVES To report longitudinal prevalence rates of device-related pressure injuries in critically ill adult patients in the intensive care unit and to explore the patient characteristics associated with the development of device related pressure injuries. RESEARCH DESIGN A prospective observational design where observations of patients' skin integrity were conducted on one day each week for 52 weeks. SETTING The study was conducted in the 36-bed ICU of a major metropolitan tertiary referral hospital in Queensland, Australia. The sample included all patients aged 18 years or older admitted to the intensive care unit before midnight on the day preceding the observation, with a medical device in situ. MAIN OUTCOME MEASURES The primary outcome measure was device related pressure injuries identified at the weekly observations and defined as a pressure injury found on the skin or mucous membrane with a history of medical device in use at the location of the injury. Patient demographic and clinical characteristics were recorded. RESULTS Over the study period, 11.3% (71/631) of patients developed at least one hospital-acquired DRPI. The most common devices associated with injury were nasogastric/nasojejunal tubes (41%) and endotracheal tubes (27%). Significant predictors of device related pressure injuries were the total number of devices (OR 1.230, 95% CI 1.09-1.38, p

Medical device-related pressure injuries are the most common cause of pressure injuries within the intensive care unit, in particular those caused by nasogastric tubes and endotracheal tubes. There are several known methods, which can alleviate the pressure of these devices on the skin surface to reduce the rate of these injuries. To determine the feasibility of conducting a larger, adequately powered trial testing, several clinically effective interventions to reduce the incidence of medical device-related pressure injuries caused by these devices. Patients were recruited into both study arms and received one of three different methods of skin protection for both arms. Outcome measures included fidelity to the processes of care protocol, recruitment potential, and the number of medical device-related pressure injuries. Recruitment (n = 87) was slower than expected with less than 10% of screened potential patients available for enrolment. Fidelity to the process of care for each subgroup was variable with better adherence in the nasogastric tube arm compared to the endotracheal tube arm. This feasibility study has revealed concerns about the intervention designs and effectiveness as well as challenges for the adherence of the nursing staff to the protocol.

Social "difficulties" associated with ASD may be a product of neurotypical-autistic differences in emotion expression and recognition. Research suggests that neurotypical and autistic individuals exhibit expressive differences, with autistic individuals displaying less frequent expressions that are rated lower in quality by non-autistic raters. Autistic individuals have difficulties recognizing neurotypical facial expressions; neurotypical individuals have difficulties recognizing autistic expressions. However, findings are mixed. Task-related factors (e.g., intensity of stimuli) and participant characteristics (e.g., age, IQ, comorbid diagnoses) may contribute to the mixed findings. The authors conclude by highlighting important areas for future research and the clinical implications of the discussed findings.

Background Chronic pain is a common and disabling health problem and those affected may need support with their activities of daily living (ADLs). However currently there are no data quantifying how much social care support people with chronic pain need. Methods Between June-July 2019, previous participants of the Cloudy with a Chance of Pain study were invited to take part in an online survey, adapted from a validated Personal Social Services Research Unit interview survey. It collected data on whether participants with chronic pain needed help with ADLs, how frequently help was needed and who provided it (formal/informal social care). Additional data was collected on demographics, employment status, pain diagnosis, and comorbidities. Descriptive statistics described the burden of social care need and multivariable logistic regression identified factors associated with social care need. Results There were 981 respondents; 791 (81%) were female, median age 59 years (Table 1). In the last month 527 (61%) respondents reported needing help with ADLs. Over three-quarters of help was provided informally by family and friends (408 (77%)). For 309 (59%) respondents, help was needed at least daily. In the multivariable logistic regression model, needing help was lower with older age, (OR (95% CI) 0.96 (0.94-0.98), but higher in female gender (OR (95% CI) 1.96(1.27-3.01), fibromyalgia (OR (95% CI) 2.75 (2.53-5.54)), osteoarthritis (OR (95% CI) 1.56 (1.11-2.19)) and multi-morbidity OR (95% CI) 2.13 (1.51-3.01)). Compared to full-time work, respondents who were retired or unable to work were also significantly more likely to need help with ADLs, respective OR (95% CI) 2.16 (1.21-3.84) and 6.98 (3.72-13.08). Conclusion A high proportion of people with chronic pain needed support with ADLs; for more than half, on a daily or more frequent basis. Interestingly, younger patients were more likely to need help which may reflect responder bias. Most support was provided informally, and this could be for a number of reasons. For example, lack of awareness/not meeting eligibility/unable to afford formal social care, or preference to be cared for by familiar persons. This should be explored in future research. These results demonstrate the burden of social care may be significantly greater than government and social care organisations are aware, with important implications for policy and planning. Disclosures J.H. Humphreys None. K. Dempsey None. O. Phelan None. L. Boothman None. L. Cook None. W.G. Dixon None.

Background Wearables provide opportunities for frequent health data collection and symptom monitoring. The feasibility of using consumer cellular smartwatches to provide information both on symptoms and contemporary sensor data has not yet been investigated. Objective This study aimed to investigate the feasibility and acceptability of using cellular smartwatches to capture multiple patient-reported outcomes per day alongside continuous physical activity data over a 3-month period in people living with knee osteoarthritis (OA). Methods For the KOALAP (Knee OsteoArthritis: Linking Activity and Pain) study, a novel cellular smartwatch app for health data collection was developed. Participants (age ≥50 years; self-diagnosed knee OA) received a smartwatch (Huawei Watch 2) with the KOALAP app. When worn, the watch collected sensor data and prompted participants to self-report outcomes multiple times per day. Participants were invited for a baseline and follow-up interview to discuss their motivations and experiences. Engagement with the watch was measured using daily watch wear time and the percentage completion of watch questions. Interview transcripts were analyzed using grounded thematic analysis. Results A total of 26 people participated in the study. Good use and engagement were observed over 3 months: most participants wore the watch on 75% (68/90) of days or more, for a median of 11 hours. The number of active participants declined over the study duration, especially in the final week. Among participants who remained active, neither watch time nor question completion percentage declined over time. Participants were mainly motivated to learn about their symptoms and enjoyed the self-tracking aspects of the watch. Barriers to full engagement were battery life limitations, technical problems, and unfulfilled expectations of the watch. Participants reported that they would have liked to report symptoms more than 4 or 5 times per day. Conclusions This study shows that capture of patient-reported outcomes multiple times per day with linked sensor data from a smartwatch is feasible over at least a 3-month period. International Registered Report Identifier (IRRID) RR2-10.2196/10238

Background Hospital-acquired pressure injury is associated with increased morbidity and mortality and considered to be largely preventable. Pressure injury prevalence is regarded as a marker of health care quality. Objective To compare the state-wide prevalence, severity and location of pressure injuries of intensive care unit patients compared to patients in non-intensive care wards. Method The study employed a secondary data analysis design to extract and analyse de-identified pressure injury data from all Queensland Health hospitals with level I–III intensive care facilities that participated in Queensland Bedside Audits between 2012–2014. The sample included all adult ICU and non-ICU patients that provided consent for the Queensland Bedside Audits, excluding those in mental health units. Results Excluding Stage I, overall hospital-acquired pressure injury prevalence from 2012 to 2014 was 11% for intensive care patients and 3% for non-intensive care patients. Intensive care patients were 3.8 times more likely (RR 2.7–5.4, 95% CI) than non-intensive care patients to develop a pressure injury whilst in hospital. The sacrum/coccyx was the most common site of hospital-acquired pressure injury in all patients (intensive care patients 22%; non-intensive care patients 35%) however, mucosal pressure injury proportion was significantly higher in intensive care patients (22%) than in non-intensive care patients (2%). Stage II HAPI prevalence was the most common stage reported, 53% for intensive care patients compared to 63% for non-intensive care patients. Conclusion There are significant differences in hospital-acquired pressure injury prevalence by stage and location between intensive care and non-intensive care patients reflecting the possible impact of critical illness on the development of skin injury. This has implications for resource funding for pressure injury prevention and the imposition of government initiated financial penalties for hospital-acquired pressure injury. For future comparisons to be effective between intensive care units, benchmarking partners should share similar characteristics and relevant targets.

Patients with chronic pain commonly believe their pain is related to the weather. Scientific evidence to support their beliefs is inconclusive, in part due to difficulties in getting a large dataset of patients frequently recording their pain symptoms during a variety of weather conditions. Smartphones allow the opportunity to collect data to overcome these difficulties. Our study Cloudy with a Chance of Pain analysed daily data from 2658 patients collected over a 15-month period. The analysis demonstrated significant yet modest relationships between pain and relative humidity, pressure and wind speed, with correlations remaining even when accounting for mood and physical activity. This research highlights how citizen-science experiments can collect large datasets on real-world populations to address long-standing health questions. These results will act as a starting point for a future system for patients to better manage their health through pain forecasts.

Purpose: The purpose of this study was to provide longitudinal prevalence rates of incontinence-associated dermatitis (IAD) in patients in an intensive care unit (ICU) and to identify patient characteristics associated with IAD development. Design: Prospective observational. Subjects and Setting: The sample comprised 351 patients aged 18 years and older in a major metropolitan public hospital ICU in Queensland, Australia. Methods: All consenting, eligible participants at risk of developing IAD underwent weekly skin inspections to determine the presence of IAD. Data were collected weekly for 52 consecutive weeks. Descriptive statistics described the study sample and logistic regression analysis was used to identify patient characteristics associated with development of IAD. Results: The weekly IAD prevalence ranged between 0% and 70%, with IAD developing in 17% (n = 59/351) of ICU patients. The odds of IAD developing increased statistically significantly with increasing age (odds ratio [OR]: 1.029, 95% confidence interval [CI]: 1.005-1.054, P =.016), time in the ICU (OR = 1.104; 95% CI: 1.063-1.147, P

Objective Assessment of safety culture in health care is of particular relevance in the complex intensive care setting, where the effects of human error can have catastrophic consequences. The aim of this review was to examine the literature on safety culture in intensive care units (ICUs) and specifically, to explore the state of knowledge regarding safety culture in the context of Australian ICUs. Methods A search was conducted of key databases for studies published in English between January 2008 and December 2017 using terms ‘safety culture’, ‘safety climate’, ‘safety attitude’, ‘intensive care’, ‘ICU’ and ‘critical care’. Studies were included if they presented original research, utilised the teamwork and safety climate factors of a quantitative survey tool to assess safety culture, the sample population included participants working in an adult intensive care, and the findings were reported in the context of intensive care. Results Of the 36 studies identified, two were conducted in Australia. The studies demonstrate a rapid expansion in safety culture assessment globally. Three levels of safety culture application in intensive care were identified, including safety culture assessment, effect of an intervention on safety culture, and evaluation of the association between safety culture and structural, process and outcomes measures. The use of targeted safety culture domains is emerging. Common findings included variation in perceptions of safety culture between ICUs, unit and hospital management, and professional groups. Conclusion Though the assessment of safety culture in ICUs has been an area of prolific research internationally over the past ten years, the Australian context is limited and could be advanced through further research, including the effect on safety culture of interventions, and to establish the association between safety culture and patient safety outcomes. Longitudinal studies to demonstrate sustained intervention effects on safety culture should be considered.

BACKGROUND The Knee OsteoArthritis, Linking Activity and Pain (KOALAP) study is the first to test the feasibility of using consumer-grade cellular smartwatches for health care research. OBJECTIVE The overall aim was to investigate the feasibility of using consumer-grade cellular smartwatches as a novel tool to capture data on pain (multiple times a day) and physical activity (continuously) in patients with knee osteoarthritis. Additionally, KOALAP aimed to investigate smartwatch sensor data quality and assess whether engagement, acceptability, and user experience are sufficient for future large-scale observational and interventional studies. METHODS A total of 26 participants with self-diagnosed knee osteoarthritis were recruited in September 2017. All participants were aged 50 years or over and either lived in or were willing to travel to the Greater Manchester area. Participants received a smartwatch (Huawei Watch 2) with a bespoke app that collected patient-reported outcomes via questionnaires and continuous watch sensor data. All data were collected daily for 90 days. Additional data were collected through interviews (at baseline and follow-up) and baseline and end-of-study questionnaires. This study underwent full review by the University of Manchester Research Ethics Committee (#0165) and University Information Governance (#IGRR000060). For qualitative data analysis, a system-level security policy was developed in collaboration with the University Information Governance Office. Additionally, the project underwent an internal review process at Google, including separate reviews of accessibility, product engineering, privacy, security, legal, and protection regulation compliance. RESULTS Participants were recruited in September 2017. Data collection via the watches was completed in January 2018. Collection of qualitative data through patient interviews is still ongoing. Data analysis will commence when all data are collected; results are expected in 2019. CONCLUSIONS KOALAP is the first health study to use consumer cellular smartwatches to collect self-reported symptoms alongside sensor data for musculoskeletal disorders. The results of this study will be used to inform the design of future mobile health studies. Results for feasibility and participant motivations will inform future researchers whether or under which conditions cellular smartwatches are a useful tool to collect patient-reported outcomes alongside passively measured patient behavior. The exploration of associations between self-reported symptoms at different moments will contribute to our understanding of whether it may be valuable to collect symptom data more frequently. Sensor data–quality measurements will indicate whether cellular smartwatch usage is feasible for obtaining sensor data. Methods for data-quality assessment and data-processing methods may be reusable, although generalizability to other clinical areas should be further investigated. INTERNATIONAL REGISTERED REPOR DERR1-10.2196/10238

Background Skin integrity management is often a low clinical priority in the intensive care environment, possibly resulting in high pressure injury (PI) prevalence. This article reports the results of the first phase of a multiphased project, “Translating evidence-based pressure injury prevention strategies to the intensive care environment (SUSTAIN study)”. The SUSTAIN study used a research translation framework to guide the assessment of research uptake, development, and monitoring of translational strategies to reduce PIs. Objective The objective was to assess the enablers and barriers to research translation of evidence-based skin integrity management in one Australian tertiary referral intensive care unit (ICU). Methods This exploratory study was conducted in an Australian metropolitan tertiary ICU on a sample of 204 registered nurses. Data were collected using (i) a descriptive cross-sectional cohort survey of barriers, enablers, and attitudes to PI prevention, (ii) a cross-sectional survey of PI knowledge, and (iii) focus groups to understand the local contextual factors impacting registered nurses' PI prevention practice. Results Participants reported a moderate to high ability to rise above barriers in PI prevention, a positive attitude towards PI prevention, and considered this a priority in their care of patients. High patient acuity emerged as a barrier to implementing timely PI prevention strategies. In the knowledge, test participants with postgraduate qualifications answered more statements correctly. Focus group data revealed four themes: (i) team ICU, (ii) processes of care, (iii) education for consistency, and (iv) the patient. Conclusions It is essential that evidence-based PI prevention strategies are provided in the intensive care environment. Our findings indicate that despite positive attitudes and sound knowledge levels, high patient acuity is a significant barrier to evidence implementation.

Background The authors9 service has child protection guidance listing locally agreed ‘markers’ of potential abuse and exploitation to aid identification of vulnerable young people. Objectives To review whether staff are identifying markers of sexual abuse and exploitation, and to review documentation relating to assessment of Fraser criteria in under-14s (young people) attending sexual health clinics in Gwent, South Wales, UK. Methods Analysis of case notes of 242 young people who made 598 visits to a sexual health clinic between 1 January and 31 December 2003. Results A total of 81 references to a marker of potential abuse or exploitation were recorded at 8% of visits and for 11% of young people. For 72 references a marker was present and for nine was absent. There was no reference to a marker being present or absent for any young males or for 81% of females. Increasing attendance was associated with increasing prevalence of recorded markers. All young people with three or more markers identified as present were referred onwards compared with 53% of those with one or two markers present. Referral did not deter future attendance. Reference to Fraser guidance assessment was recorded at 35% of visits or for 64% of young people and fully demonstrated at 7% of visits or for 16% of young people. There was no recorded assessment for 18% of females and 60% of males. Conclusions The authors9 service is not recording sufficient information to help identify young people (particularly males) at risk of abuse or exploitation or to demonstrate the service9s compliance with Fraser guidance.

Objectives To determine the gender, sexual history and reason(s) for visit for under-14s (young people) attending the authors9 sexual health clinics. Methods Analysis of case notes of 242 young people who made a total of 598 visits to a sexual health clinic in Gwent, South Wales, UK between 1 January and 31 December 2003. Results Of the 242 young people studied, 41% were male and males were responsible for 42% of visits. There was no written record relating to 7% of the total visits. Median age at both first registration and first heterosexual intercourse (when recorded) was 12 years for males and 13 years for females. Some 57% of females and 30% of males were already sexually active at first registration. Details relating to a young person9s partner and their experience of sex (e.g. willingness, autonomy and consensual nature of sex) were infrequently recorded, especially for males. 96% of males requested condoms and 99% received them, whilst 72% of females requested condoms and/or hormonal contraception and 86% received them. 35% of females were seen for the consequences of sex (i.e. pregnancy testing, emergency contraception, screening and/or treatment of sexually transmitted infections and unplanned pregnancies). 80% of these subsequently received condoms and/or hormonal contraception. The majority of young people saw a nurse exclusively (96% males, 71% females). Conclusions Of the young clients seen, 41% are male. Sexual history details are infrequently recorded, particularly for males. The majority of young people accessing the authors9 service are taking action to protect their sexual health and most will see a nurse exclusively.

International guidelines for pressure injury prevention (PIP) apply equally to all general and specialty nursing areas. However, intensive care unit (ICU) patients are a unique population due to their severity of illness. Not only are these patients susceptible to pressure injuries (PIs) over bony prominences, they are at increased risk for medical device-related pressure injuries from chemical restraint, physical restrictions, and the many invasive procedures they undergo. The juxtaposition of urgent life-saving interventions with the adherence to best practice PIP guidelines poses problems for nursing staff who constantly juggle these priorities. In our ICU these challenges were highlighted during the weekly skin integrity nursing rounds and from analysis of the integument-related patient incident reports. To develop an evidence-based, clinical guideline that integrates PIP strategies into a tertiary intensive care context as a strategy to reduce PI prevalence. A survey of nurses’ perceptions of barriers, enablers and attitudes towards pressure injury prevention and skin integrity care was conducted in combination with focus groups. The need for an ICU-specific guideline was identified. Collaboration with the ICU nursing leadership and medical team, hospital skin integrity service and quality and safety unit, resulted in the development of a clinical guideline with simplification of the PI risk assessment categories, clarification of PIP strategies in ICU and documentation recommendations to improve consistency and minimise skin disruptions. An ongoing reduction in the prevalence and incidence of PIs in the ICU occurred that was evidenced by weekly PIP prevalence audits from 16% to 9% over 6 months and other reporting measures. Implementation of a standardised, evidence-based approach to PIP and skin integrity optimisation with expert collaboration and explicit interpretation in an intensive care context should be considered in order to achieve sustained PI reduction.

Background The anticipated increase in uptake of intrauterine system (IUS) fittings is slower than predicted by the National Institute for Health and Clinical Excellence (NICE). There is evidence to suggest that this is because of a high perceived cost of providing this contraceptive method. Whereas studies to date have all guessed at these costs, we calculated the actual costs of providing the IUS. Methods We tracked the notes of 283 women who had an IUS fitted in our community sexual and reproductive health service for 5 years. We recorded duration of use, measured the actual cost of all appointments and interventions over the lifespan of the device, and compared our findings with NICE predicted costs. Results With 70% complete follow-up, the average duration of use of the IUS was 3.44 years compared to NICE9s prediction of 3.32. The average annual cost of providing an IUS for contraception in community clinics was £54.55 per woman; this compares with £70.49 modelled by NICE for provision in primary care. Most (80%) of the cost is incurred in the first year. The cost of managing problems is small. Conclusions Providing the IUS for contraception was 23% cheaper in the present study than that predicted by NICE and cheaper than providing combined oral contraception in our service. Fitting IUSs in community clinics may be cheaper than in primary care. Streamlining the patient pathway will reduce costs further. Restricting access to the IUS because of initial cost is a false economy.

clients In reference to the letters from Drs Barber and Waters1 and Dr Matiluko2 published in the January 2008 issue of the Journal on Implanon® failure and antiretroviral therapy, we were dismayed to see obsolete advice on the management of overweight clients discussed. The letter from Tristan Barber1 states that: “earlier replacement of Implanon at 2 years is consistent with current advice”. He quotes Member Enquiry #1072. We have read this response and the Clinical Effectiveness Unit (CEU) replied that although the summary of Product Characteristics suggests considering the earlier replacement of Implanon in heavier women, the FFPRHC Guidance is that women weighing over 70 kg should not be treated any differently to other women.3 Likewise Member Enquiry #10374 also states that weight does not have an effect on the efficacy of Implanon. Dr Matiluko in his reply2 suggests that women resuming bleeding after a period of amenorrhoea on Implanon should seek advice about earlier replacement. The CEU recommends following the UKMEC Selected Practice Recommendations for Contraceptive Use, namely that women developing bleeding should be investigated if clinically indicated and that the serum concentrations of Implanon remain sufficient to inhibit ovulation throughout the 3 years and a return to bleeding does not demonstrate a return to fertility.5 It would be a shame if women over 70 kg were subject to an unnecessary change of Implanon at 2 years because of these letters, and it will also impact on an already overstretched drug budget.