Use of a paediatric advice line for parents of infants recruited to a randomised controlled trial.

BACKGROUND: This study aims to describe the use of a paediatric advice line (PAL) provided to parents whose infants were recruited to a large randomised controlled trial (RCT), including the number and types of medical concerns addressed, seasonal variability and call outcomes. Additionally, sociodemographic characteristics of the parents and children of those parents who used the PAL are compared with those who did not. METHODS: Prospective cohort of 1246 children nested in the Melbourne Infant Study: BCG for Allergy and Infection Reduction (MIS BAIR) RCT. All MIS BAIR participants were offered access to the PAL. Data were collected over the initial 2 years of a 5-year follow-up. Data were analysed using χ2 tests, and ORs were calculated using multiple logistic regression. RESULTS: The PAL was used by 230 (18.5%) participants, who made a total of 586 calls during the 2-year study period. The reasons for calling the PAL were dermatological (24%); gastrointestinal (18%); disturbances in feeding, sleeping and crying (14%); respiratory (7%); and developmental/neurological (6%). Analysis revealed that those who used the PAL were more likely to be first-time parents (OR 1.4, 95% CI 1.1 to 1.9) and mothers who hold a university degree (OR 3.3, 95% CI 1.3 to 8.4). PAL costs were minimal and comprised 15 clinicians with paediatric experience. CONCLUSIONS: A cost-effective PAL service for clinical trial participants was used appropriately by parents for relatively minor concerns and may have a role in trials to promote participant engagement and reduce demand for other health services.

Effects of two firefighting chemical formulations, Phos-Chek LC95W and BlazeTamer380, on striped marsh frog (Limodynastes peronii) tadpole survival, growth, development and behaviour.

Global wildfire events are projected to become more frequent and severe due to the continual threat of climate change, resulting in increasing demand for effective fire mitigation methods. Firefighting chemicals (FFCs), including retardants, foams and water enhancers, are often used to prevent the spread of wildfires. However, the impact of FFCs on wildlife and ecosystems is poorly understood. We investigated the effects of two common FFC formulations, Phos-Chek LC95W and BlazeTamer380, on tadpole survival, growth, development and swimming behaviour. Tadpoles of the striped marsh frog (Limnodynastes peronii) were exposed to two concentrations of either Phos-Chek (0.25 and 1 g/L) or BlazeTamer (0.05 and 0.2 g/L) for 16 days. The highest concentration of Phos-Chek was lethal to tadpoles, with mortalities gradually increasing over time and only 8% of animals surviving to day 16. Both FFCs influenced the growth and development of tadpoles, though effects were more severe in tadpoles exposed to the Phos-Chek formulation. Phos-Chek was found to completely stop tadpole growth and development over the 16-day exposure, whereas BlazeTamer significantly delayed growth and development in comparison to controls. Nevertheless, treatments had no apparent effect on tadpole movement patterns and swimming activity. Greater toxicity caused by the Phos-Chek treatment likely relates to the increased ammonia and altered water quality parameters. Runoff or accidental application of commonly used FFCs into small waterways may therefore have important ramifications for aquatic biota.

Discordance Between Diagnosis Tools for Assessing Eczema in Infants: A Challenge for Intervention Trials.

BACKGROUND: There is no standardized definition for infant eczema, and various tools have been used across studies, precluding direct comparison. OBJECTIVE: The aim of the study was to assess and to compare the accuracy of diagnostic tools for infant eczema using the extensive data collected in Melbourne Infant Study: BCG for Allergy and Infection Reduction (MIS BAIR), an eczema prevention trial. METHODS: Eczema incidence was assessed by 3 questionnaire-based measures: modified UK diagnostic tool, parent-reported medically diagnosed eczema, and parent-reported use of topical corticosteroids. Agreement between the definitions was quantified using κ coefficient. Eczema severity was assessed by 3-monthly Patient-Oriented Eczema Measure (POEM) scores and a SCORing Atopic Dermatitis (SCORAD) clinical assessment at a 12-month visit (ClinicalTrial.gov: NCT01906853). RESULTS: Among the 538 participants fulfilling at least 1 of the 3 questionnaire-based eczema definitions, only 197 participants (37%) met all 3 definitions. Agreement between the definitions was poor with κ coefficients ranging from -0.11 to 0.62. The most frequently reported symptoms were generally dry skin (483/538, 90%) and pruritus (400/538, 74%). The face (352/538, 65%) and the trunk (306/538, 57%) were more frequently affected than the creases (257/538, 48%). Participants fulfilling all 3 questionnaire-based definitions of eczema were more likely to have higher severity scores and earlier onset of symptoms. CONCLUSIONS: There is poor agreement between currently available tools for assessing infant eczema.

Prevention of infant eczema by neonatal Bacillus Calmette-Guérin vaccination: The MIS BAIR randomized controlled trial.

BACKGROUND: Bacille Calmette-Guérin (BCG) vaccine could play a role in counteracting the rising prevalence of atopic diseases, through its beneficial off-target effects. We aimed to determine whether neonatal BCG vaccination reduces the incidence of eczema in infants. METHODS: Randomized controlled trial with 1272 infants allocated to receive BCG-Denmark or no BCG at birth. The primary outcome was the 12-month incidence of eczema based on 3-monthly questionnaires. Eczema was also assessed at a 12-month clinic visit. ClinicalTrial.gov: NCT01906853. RESULTS: The 12-month eczema incidence was 32.2% in the BCG group compared with 36.6% in the control group (adjusted risk difference (aRD) -4.3%, 95% CI -9.9% to 1.3%, multiple imputation model). In addition, comparing infants in the BCG group with the control group, 15.7% vs. 19.2% had eczema lesions at the 12-month visit (aRD -3.5%, 95% CI -8.0% to 1.0%); 35.7% vs. 39.0% reported using topical steroids (aRD -3.3, 95% CI -9.2 to 2.7); and 7.3% vs. 10.2% had severe eczema scores (aRD -3.0%, 95% CI -8.8% to 2.7%). In 344 high-risk infants (two atopic parents), the 12-month eczema incidence was 35.3% in the BCG group compared with 46.8% in the control group (aRD -11.5%, 95% CI -21.9% to -1.2%; number needed to treat 8.7, 95% CI 4.6 to 83.3). CONCLUSION: There is insufficient evidence to recommend neonatal BCG vaccination in all infants for the prevention of eczema in the first year of life; however, a modest beneficial effect was observed among high-risk infants. A single dose of BCG-Denmark soon after birth could reduce the incidence of eczema in infants with two atopic parents.

Neonatal Bacille Calmette-Guérin Vaccination and Infections in the First Year of Life: The MIS BAIR Randomized Controlled Trial.

BACKGROUND: Bacille Calmette-Guérin (BCG) vaccination has beneficial off-target effects that may include protecting against non-mycobacterial infectious diseases. We aimed to determine whether neonatal BCG vaccination reduces lower respiratory tract infections (LRTI) in infants in the Melbourne Infant Study: BCG for Allergy and Infection Reduction (MIS BAIR) trial. METHODS: In this investigator-blinded trial, neonates in Australia were randomized to receive BCG-Denmark vaccination or no BCG at birth. Episodes of LRTI were determined by symptoms reported in parent-completed, 3-month questionnaires over the first year of life. Data were analyzed by intention-to-treat using binary regression. RESULTS: A total of 1272 neonates were randomized to the BCG vaccination (n = 637) or control (n = 635) group. The proportion of participants with an episode of LRTI in the first year of life among BCG-vaccinated infants was 54.8% compared to 58.0% in the control group, resulting in a risk difference of -3.2 (95% confidence interval, -9.0 to 2.6) after multiple imputation. There was no interaction observed between the primary outcome and sex, maternal BCG, or the other prespecified effect modifiers. CONCLUSIONS: Based on the findings of this trial, there is insufficient evidence to support the use of neonatal BCG vaccination to prevent LRTI in the first year of life in high-income settings.

Testing and implementing video consulting for outpatient appointments: using quality improvement system thinking and codesign principles.

Increasing demand for outpatient appointments (OPA) is a global challenge for healthcare providers. Non-attendance rates are high, not least because of the challenges of attending hospital OPAs due to transport difficulties, cost, poor health, caring and work responsibilities. Digital solutions may help ameliorate these challenges. This project aimed to implement codesigned outpatient video consultations across National Health Service (NHS) Highland using system-wide quality improvement approaches to implementation, involving patients, carers, clinical and non-clinical staff, national and local strategic leads. System mapping; an intensive codesign process involving extensive stakeholder engagement and real-time testing; Plan, Do, Study, Act cycles; and collection of clinician and patient feedback were used to optimise the service. Standardised processes were developed and implemented, which made video consulting easy to use for patients, embedded video into routine health service systems for clinicians and non-clinical staff, and automated much of the administrative burden. All clinicians and staff are using the system and both groups identified benefits in terms of travel time and costs saved. Transferable lessons for other services are identified, providing a practical blueprint for others to adapt and use in their own contexts to help implement and sustain video consultation services now and in the future.

Putting the social back into sociotechnical: Case studies of co-design in digital health.

OBJECTIVE: We sought to examine co-design in 3 contrasting case studies of technology-supported change in health care and explain its role in influencing project success. MATERIALS AND METHODS: Longitudinal case studies of a seizure detection and reporting technology for epilepsy (Southern England, 2018-2019), a telehealth service for heart failure (7 UK sites, 2016-2018), and a remote video consultation service (Scotland-wide, 2019-2020). We carried out interviews with 158 participants and collected more than 200 pages of field notes from observations. Within- and cross-case analysis was informed by sociotechnical theory. RESULTS: In the epilepsy case, co-design prioritized patient-facing features and focused closely around a specific clinic, which led to challenges with sustainability and mainstreaming. In the heart failure case, patient-focused co-design produced an accessible and usable patient portal but resulted in variation in uptake between clinical sites. Successful scale-up of video consultations was explained by a co-design process involving not only the technical interface, but also careful reshaping of work practices. DISCUSSION: A shift is needed from co-designing with technology users to co-designing with patients as service users, and with healthcare staff as professionals. Good co-design needs to involve users, including those who engage with the technology-supported service bothdirectly and indirectly. It requires sensitivity to emergence and unpredictability in complex systems. Healthcare staff need to be supported to accommodate iterative change in the service. Adequate resourcing and infrastructures for systems-focused co-design are essential. CONCLUSIONS: If co-design focuses narrowly on the technology, opportunities will be missed to coevolve technologies alongside clinical practices and organizational routines.

Near Me at Home: codesigning the use of video consultations for outpatient appointments in patients' homes.

Reforming the delivery of outpatient appointments (OPA) was high on the healthcare policy agenda prior to COVID-19. The current pandemic exacerbates the financial and associated resource limitations of OPA. Videoconsulting provides a safe method of real-time contact for some remotely residing patients with hospital-based clinicians. One factor in failing to move from introduction of service change to its general adoption may be lack of patient and public involvement. This project, based in the largest Island in the Inner Hebrides of Scotland, aimed to codesign the use of the NHS Near Me video consulting platform for OPA to take place in the patient's home. A codesign model was used as a framework. This included: step 1-presenting a process flow map of the current system of using Near Me to public participants and establishing their ideas on various steps in the process, step 2-conducting numerous Plan, Do, Study, Act (PDSA) tests and creating a current process flow diagram based on learning and step 3-conducting telephone interviews and thematic analysis of transcripts (n=7) to explore participants' perceptions of being involved in the codesign process. Twenty-five adaptations were made to the Near Me at Home video appointment process from participants' PDSA testing. Four themes were identified from thematic analysis of participants' feedback of the codesign process, namely: altruistic motivation, valuing community voices, the usefulness of the PDSA cycles and the power of 'word of mouth'. By codesigning the use of Near Me with people living in a remote area of Scotland, multiple adaptations were made to the processes to suit the context in which Near Me at Home will be used. Learning from testing and adapting with the public will likely be useful for others embarking on codesign approaches to improve spread and sustainability of quality improvement projects.

Implementing a non-steroidal anti-inflammatory drugs communication bundle in remote and rural pharmacies and dispensing practices.

Non-steroidal anti-inflammatory drugs (NSAIDs) are associated with more emergency hospital admissions due to adverse drug reactions than any other class of medicine. One way to tackle this is to ensure that patients understand how to take their NSAIDs in the safest way possible. The aim of this project was to ensure that key safety information is given to every patient, every time an NSAID is sold or dispensed. The project started as part of the Scottish Patient Safety Programme's Pharmacy in Primary Care Collaborative. An NSAIDs bundle was developed, tested and implemented using the Model for Improvement as a framework, including multiple Plan, Do, Study, Act cycles. The bundle, and associated improvement package, was developed during phase I of the project and tested by seven teams (five pharmacies and two dispensing practices). Phase II tested the spread of the defined improvement package across an additional five community pharmacies and eight dispensing general practitioner practices. The project has resulted in the development of a simple package to improve communication with patients about NSAIDs, which should enable patients to take NSAIDs safely. Three key safety messages were developed, typical for a care bundle approach, and simple tools were employed to ensure every patient received these three key messages every time. The project aim of 95% compliance with the NSAIDs bundle within the seven initial sites by December 2015 was achieved (when an exclusion was applied). The spread of the defined improvement package to a further 13 sites was achieved by December 2016. By December 2017, all 81 community pharmacies in National Health Service (NHS) Highland had agreed to implement the NSAIDs bundle. In June 2018, a national NSAIDs bundle, based on the NHS Highland work, was introduced in community pharmacies across Scotland. We also believe that the approach could be replicated for other high-risk medicines.

Evaluating pharmacist input into the pharmaceutical care of patients in dispensing medical practices in remote and rural areas of Scotland.

Background: The Highlands and the Western Isles are the two most remote and rural areas of Scotland, with many medical practices in areas where pharmacies would not be viable. Recent regulations state that that dispensing medical practices in these areas must receive pharmacist support for patients who would benefit. Objective: This study aimed to evaluate pilot services, which centred on the provision of patient centred pharmaceutical care. Methods: A realist type evaluation was conducted by an independent research team comprising collecting quantitative data around what occurred during the consultation followed by interviews with purposive samples of staff (n = 14) and patients (n = 18). Results: A total of 873 medicines related issues were identified in 473 patients reviewed, with the main issue being 'inappropriate dose, frequency, duration'. Just under half (39.7%) of issues were managed by the pharmacist without any medical input. Interviews indicated a high level of appreciation, although there was an increase in workload for some staff. While the need for telephone based pharmacist consultations for some patients was understood, there was a preference for face to face. All were supportive of continuing and extending the service. Conclusion: The clinical pharmacist service was both needed and valued highly by staff and patients. In Scotland, this aligns with the Government vision and action plan, 'Prescription for Excellence', that by 2023 all patient facing pharmacists will be independent prescribers with those in remote and rural areas entitled to 'equity of access to such expertise'.

Using a choice experiment and birder preferences to guide bird-conservation funding.

Conservation of biodiversity, including birds, continues to challenge natural-area managers. Stated-preference methods (e.g., choice experiment [CE]) are increasingly used to provide data for valuation of natural ecosystems. We used a CE to calculate birders' willingness to pay for different levels of bioecological attributes (threatened species, endemic species, and diversity) of birding sites with hypothetical entry fees. The CE was delivered at popular birding and avitourism sites in Australia and the United Kingdom. Latent-class modeling results revealed heterogeneous preferences among birders and correspondingly variable willingness to pay. Four clear groups were apparent: quantity-driven birders, special-birds seekers, confused respondents, and price-is-no-object birders. Quantity-driven birders were attracted to sites that deliver high levels of diversity and endemic species for which they were willing to pay $135 and $66 to visit, respectively, above what they were willing to pay to visit a site with low levels of diversity and few endemic and threatened species . Special-bird seekers valued threatened species and high levels of endemic species most (willingness to pay $45 and $46, respectively). Confused respondents' preferences were difficult to determine, but they were the most sensitive to the hypothetical entry fees, unlike the price-is-no-object birders, who were not at all sensitive to cost. Our findings demonstrate that birders are amenable to paying for their preferred birding experience. These payments could provide an alternative source of funding in some avitourism sites on both public and private land. Such alternative revenue streams should be explored and given full consideration in increasingly competitive conservation-financing environments.

Net Effects of Ecotourism on Threatened Species Survival.

Many threatened species rely on ecotourism for conservation funding, but simultaneously suffer direct ecological impacts from ecotourism. For a range of IUCN-Redlisted terrestrial and marine bird and mammal species worldwide, we use population viability analyses to calculate the net effects of ecotourism on expected time to extinction, in the presence of other anthropogenic threats such as poaching, primary industries and habitat loss. Species for which these calculations are currently possible, for one or more subpopulations, include: orangutan, hoolock gibbon, golden lion tamarin, cheetah, African wild dog, New Zealand sealion, great green macaw, Egyptian vulture, and African penguin. For some but not all of these species, tourism can extend expected survival time, i.e., benefits outweigh impacts. Precise outcomes depend strongly on population parameters and starting sizes, predation, and ecotourism scale and mechanisms. Tourism does not currently overcome other major conservation threats associated with natural resource extractive industries. Similar calculations for other threatened species are currently limited by lack of basic population data.

Avitourism and Australian Important Bird and Biodiversity Areas.

Formal protected areas will not provide adequate protection to conserve all biodiversity, and are not always designated using systematic or strategic criteria. Using a systematic process, the Important Bird and Biodiversity Area (IBA) network was designed to highlight areas of conservation significance for birds (i.e. IBA trigger species), and more recently general biodiversity. Land use activities that take place in IBAs are diverse, including consumptive and non-consumptive activities. Avitourism in Australia, generally a non-consumptive activity, is reliant on the IBA network and the birds IBAs aim to protect. However, companies tend not to mention IBAs in their marketing. Furthermore, avitourism, like other nature-based tourism has the potential to be both a threatening process as well as a conservation tool. We aimed to assess the current use of IBAs among Australian-based avitour companies' marketing, giving some indication of which IBAs are visited by avitourists on organised tours. We reviewed online avitour itineraries, recorded sites featuring in descriptions of avitours and which IBA trigger species are used to sell those tours. Of the 209 avitours reviewed, Queensland is the most featured state (n = 59 tours), and 73% feature at least one IBA. Daintree (n = 22) and Bruny Island (n = 17) IBAs are the most popular, nationally. Trigger species represent 34% (n = 254 out of 747) of species used in avitour descriptions. The most popular trigger species' are wetland species including; Brolga (n = 37), Black-necked Stork (n = 30) and Magpie Goose (n = 27). Opportunities exist to increase collaboration between avitour companies and IBA stakeholders. Our results can provide guidance for managing sustainability of the avitourism industry at sites that feature heavily in avitour descriptions and enhance potential cooperation between avitour companies, IBA stakeholders and bird conservation organisations.

Promoting Safer Use of High-Risk Pharmacotherapy: Impact of Pharmacist-Led Targeted Medication Reviews.

BACKGROUND: Adverse drug reactions are a recognised cause of hospital admissions. A small group of medicines carry a higher risk of adverse outcomes and are more frequently involved in hospital admissions than other medicines. These 'high-risk medicines' have been identified in previous research. However, it is less clear how to reduce the risks associated with these known high-risk medicines, or which high-risk medicines should be prioritised when implementing risk reduction interventions. Previous research has questioned the efficacy of pharmacist-led medication reviews in reducing hospital admissions and drug-related morbidity and mortality. OBJECTIVES: In this study, we aimed to identify high-risk medicines through medication review to reduce iatrogenic disease; to determine a short list of high-risk medicines to target in medication reviews to achieve the greatest impact on reducing iatrogenic disease and patient harm; and to determine whether pharmacist-conducted medication reviews of high-risk medicines are safe and effective. METHODS: A prospective cohort study was undertaken in 16 general practices in one Scottish health board. All patients prescribed a high-risk medicine were identified and received a medication review from a pharmacist (3643 patients from a total population of 38,399). The pharmacist decided whether it was appropriate to continue the high-risk medicine, or if the medicine should be stopped or amended. The pharmacist made recommendations to the patient's general practitioner (GP) for medicines to be stopped or amended, which the GP could choose to accept or not. Patient outcomes for all of the pharmacist's recommendations were identified 1 year later to determine the effectiveness of the recommendations. RESULTS: High-risk medicines were prescribed to 3643 patients from a total population of 38,399 patients. The pharmacist made 440 recommendations for GPs to stop or amend high-risk medicines. GPs accepted 214 recommendations and rejected 226, giving an acceptance rate of 49 %. The 440 recommendations were then followed up 1 year later. The risk of having an adverse outcome was significantly reduced when the pharmacist's recommendation to stop or amend a high-risk medicine was followed compared with rejecting the pharmacist's recommendation and continuing the high-risk medicine unchanged (p < 0.001). A total of 22 adverse outcomes occurred when the pharmacist's advice was rejected. Of these, 21 would have been prevented if the pharmacist's recommendation had been followed and three resulted in hospital admission. CONCLUSIONS: This study demonstrated that medication reviews for high-risk medicines are safe and effective, with results achieved within 1 year of the initial review. It identified six high-risk medicines that could form the basis of targeted medication reviews in order to reduce iatrogenic disease. It also demonstrated that pharmacists are safe and effective at delivering medication reviews.

Tourism and the conservation of critically endangered frogs.

Protected areas are critical for the conservation of many threatened species. Despite this, many protected areas are acutely underfunded, which reduces their effectiveness significantly. Tourism is one mechanism to promote and fund conservation in protected areas, but there are few studies analyzing its tangible conservation outcomes for threatened species. This study uses the 415 IUCN critically endangered frog species to evaluate the contribution of protected area tourism revenue to conservation. Contributions were calculated for each species as the proportion of geographic range inside protected areas multiplied by the proportion of protected area revenues derived from tourism. Geographic ranges were determined from IUCN Extent of Occurrence maps. Almost 60% (239) of critically endangered frog species occur in protected areas. Higher proportions of total range are protected in Nearctic, Australasian and Afrotopical regions. Tourism contributions to protected area budgets ranged from 5-100%. These financial contributions are highest for developing countries in the Afrotropical, Indomalayan and Neotropical regions. Data for both geographic range and budget are available for 201 critically endangered frog species with proportional contributions from tourism to species protection ranging from 0.8-99%. Tourism's financial contributions to critically endangered frog species protection are highest in the Afrotropical region. This study uses a coarse measure but at the global scale it demonstrates that tourism has significant potential to contribute to global frog conservation efforts.

Conservation and management of the endangered Fiji sago palm, Metroxylon vitiense, in Fiji.

Recovery planning is a key component of many threatened species conservation initiatives and can be a powerful awareness raising tool. One of the largest impediments to conservation efforts in the Pacific region however, is the lack of ecological data and its subsequent effects on the development of feasible and useful recovery plans for threatened species. Without these plans, the understaffed, underfunded and often technically ill-equipped conservation agencies face huge difficulties in planning, prioritizing and conducting conservation activities to adequately protect biodiversity. The Fiji sago palm, Metroxylon vitiense, is an endemic endangered palm species whose survival is heavily dependent on a feasible species recovery plan. It is geographically restricted and threatened by habitat destruction and overexploitation for thatch for the tourism industry and palm heart consumption by local consumers. Despite its threatened status, M. vitiense is not currently protected by national or international legislation. Recent field surveys and extensive stakeholder consultation have resulted in the production of a species recovery plan highlighting the importance of the species and advocating sustainable harvesting rather than complete bans to promote conservation. This article summarizes the recovery plan and its current effects on the status of M. vitiense in Fiji. We also discuss the role of different stakeholders in the conservation of M. vitiense, including the absence of significant behavioral changes by the largest consumer - the tourism industry, and the importance of recovery plans for biodiversity conservation in the Pacific.

Comparison of a score-based approach with risk-based ranking of in-use agricultural pesticides in Canada to aquatic receptors.

The purpose of this paper is to present a new risk-based approach developed by Environment Canada for ranking pesticides and their potential risk to aquatic life. These rankings are compared to those generated using a more traditional score-based approach. Two hundred and twelve active ingredients registered in Canada for use in agricultural field crops were included in this assessment. For each major aquatic taxon assessed (fish, insects, crustaceans, algae, and macrophytes), risk was calculated by dividing the 96-h estimated environmental concentration (modeled using parameters such as the application rate and method as well as physicochemical properties) by HC5 values (obtained through calculations of species sensitivity distribution-based toxicity endpoints). The traditional approach assigned scores based on toxicity endpoints in standard test species as well as physicochemical properties associated with the potential for aquatic contamination. A number of similarities were observed between the rankings but also notable differences. Only 22 active ingredients were common to the top 50 ranking positions from both approaches. The main reasons that accounted for the discrepancies between both rankings were the choice of toxicity endpoints, whether based on single or multiple species; the taxonomic breadth of retained data; the use of scores versus risk quotients; and the choices made in situations where multiple data points were available. We conclude that a risk-based approach that considers a broad representation of species toxicity data and estimates of runoff and drift concentration in receiving aquatic systems (even from generic application scenarios) is a more realistic representation of potential toxicological effects and a superior method of ranking products for the risk they pose to the aquatic environment.