The technology of polychrome glazed ceramics in Ifriqiya: new data from the site of Chimtou

Ifriqiya (roughly Tunisia and eastern Algeria) is believed to have played a significant role in the diffusion of ceramic glazed technologies into other regions of the Western Mediterranean. However, due to limited analysis on North African glazed ceramics, its role in technology transfer remains poorly understood. This paper uses SEM-EDS and petrographic analyses to understand the technology employed in the production of Tunisian ceramics through the study of 30 polychrome glazed ceramics from a medieval settlement at the site of Chimtou (ancient Simitthus), Tunisia, dated to the late ninth-twelfth century. The results show that these are lead-rich glazes with varying contents of alkalis, coloured with copper, iron and manganese oxide and applied over a calcareous body. Opaque glazes were obtained using cassiterite crystals as opacifier or by adding crushed quartz. The use of lead stannate as a colourant and opacifier in one light yellow glaze raises questions about the mechanisms of introduction of tin opacification technology in North Africa. Scrap metal seems to have been used as a source of lead for the glazes; while iron slag was probably used as a source of iron to colour the glaze in one sample, pointing to a cross-craft interaction between glazemaking and metallurgy.

Supplementary information

The online version contains supplementary material available at 10.1007/s12520-024-01974-x.

1103 AN EVALUATION OF A GERIATRICIAN-LED ACUTE MEDICAL ADMISSION UNIT AT MORRISTON HOSPITAL, SWANSEA

Introduction

The medical intake at Morriston Hospital is accepted on two units; Rapid Assessment Unit (RAU) and Acute Medical Assessment Unit. Both were acute physician-led until July 2021

Method

(Phase 1). From July 2021, RAU became geriatrician-led (Phase 2). This evaluation concerns the performance of RAU.

Phase 1 (Acute Physician-Led Unit) Between 01/08/2020-30/06/2021, there were 3102 admissions with a median length of stay (LOS) of 2 days on RAU. 37.2% of patients were discharged directly from the unit. (SBUHB data). A detailed analysis of 496 patients consecutively assessed between November 2020–January 2021 showed a median LOS on RAU of 1, 28.8% were discharged directly from RAU. Overall health board (HB) median LOS for the cohort was 7. In over 70 years, median LOS on RAU was 1, overall HB LOS 9.

Phase 2 (Geriatrician-Led Unit) 1237 patients were assessed July-December 2021, with a median LOS of 2 days. 42.8% of patients were discharged from RAU. (SBUHB data). A detailed analysis of 566 patients consecutively assessed between September-November 2021 showed a median LOS on RAU of 2, 41.7% discharged directly from RAU. Overall HB median LOS for the entire cohort was 5. For the > 70 years, median LOS on RAU was 2, overall HB LOS was 7. Patient flow through assessment areas is dependent on the function of downstream medical wards. Mean LOS within medicine at Morriston increased 1.5 days between Phase 1 and Phase 2.

Results

Acute geriatricians have delivered the 72hr LOS standard that SBUHB has set for assessment areas. The unit has achieved a reduction in overall LOS for the cohort of patients evaluated (p<.01), especially for the > 70 years (p=.007).

Conclusion

This data supported a change in practice; RAU has taken a frailty specific intake since January 2022.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

1061 AN EMERGENCY FRAILTY UNIT AS AN INTERVENTION TO PREVENT INPATIENT FALLS IN THE EMERGENCY DEPARTMENT

Introduction

There is evidence that dedicated units that provide comprehensive geriatric assessment can reduce inpatient falls and other iatrogenic harm1. The Emergency Department (ED) in Morriston Hospital has 90,000 attendances a year. 4,000 patients >65 years presented with falls. Between January 2018–November 2021, ED reported 207 incidents of falls via the Health Board Datix System.

Intervention

Phase 1 In April 2018, the Older Person’s Assessment Service (OPAS) (Geriatrician led Multidisciplinary team) began a liaison service to ED, taking referrals from the medical and ED teams for patients presented with frailty syndromes. Phase 2 In June 2020, OPAS was allocated a dedicated Emergency Frailty Unit within the Emergency Department footprint, allowing patients to be assessed rapidly by a specialist team and nursed in a specialist environment.

Results

Between June 2020–November 2021, the service saw 1,317 new patients. The average age of an OPAS patient was 83 years and had a Rockwood Clinical Frailty Scale Score of >5. 73% of patients presented with falls as a primary presenting complaint. Between June 2020–November 2021, there was one reported fall within the unit. The mean incident reported of inpatient falls in ED in phase 2 (M = 5.50, SD = 2.66) is statistically significantly higher than phase 1 (M = 3.96, SD = 1.87), t(42) = −2.26, p = 0.03. The service did not show any impact on the incidence of inpatient falls in ED.

Conclusion

The unit was an effective intervention to prevent falls for the patients it assessed within the unit but had no impact on inpatient falls within the main ED. The impact of this service is difficult to determine given the low reported falls in ED. 1. Fox MT, Persaud M, Maimets I et al. J Am Geriatr Soc, 2012, 60:2237–2,245.

1028 OLDER PERSON’S ASSESSMENT SERVICE (OPAS): DELIVERING COMPREHENSIVE GERIATRIC ASSESSMENT (CGA) IN THE EMERGENCY DEPARTMENT (ED)

Introduction

Innovative models of service delivery are required to provide Comprehensive Geriatric Assessment for older patients presenting to the Emergency Department with frailty syndromes.

Method

In 2018, the Older Person’s Assessment Service began a liaison service to the ED, taking referrals from the medical and ED teams for patients who presented with frailty syndromes (falls, cognitive impairment, care dependence, polypharmacy). The service saw 437 patients April–August 2018. 76% of the patients assessed were discharged by utilising available community services, rapid access outpatient follow up and inpatient reablement off the acute site. The service was estimated to avoid 50–80 admissions per month to medicine (saving 17–23 beds a year) and was commissioned as a permanent service. Phase 2 In 2020, a dedicated unit within ED was allocated to OPAS, enabling the acceptance of patients directly from triage and from the Ambulance Service by direct referral. This provided rapid access to specialist assessment, continued access to Elderly Care services, avoided exposure to coronavirus related admissions and the risks of nosocomial infection associated with admission. The service operates from 8 am-4 pm on weekdays.

Results

Between June 2020 and October 2021, the service saw 1,173 new patients. 988 patients (84.5%) were discharged off the acute site on the day of assessment. 68 (5.79%) patients were admitted to other facilities run by the Health Board (e.g Inpatient Reablement). The average age of an OPAS patient was 83 yrs and had a CFS > 5. Readmission rate at 14 days was 4% (47).Of the 253 patients who were admitted to an inpatient setting, 13.5% (35) contracted nosocomial covid-19.

Conclusion

The service has been supported and funded to expand into extended weekday hours as a result of this success and there are plans for future 7 day working.

A Randomized, double-blind, dose ranging clinical trial of intravenous FDY-5301 in acute STEMI patients undergoing primary PCI

BACKGROUND

Ischemia-reperfusion injury remains a major clinical problem in patients with ST-elevation myocardial infarction (STEMI), leading to myocardial damage despite early reperfusion by primary percutaneous coronary intervention (PPCI). There are no effective therapies to limit ischemia-reperfusion injury, which is caused by multiple pathways activated by rapid tissue reoxygenation and the generation of reactive oxygen species (ROS). FDY-5301 contains sodium iodide, a ubiquitous inorganic halide and elemental reducing agent that can act as a catalytic anti-peroxidant. We tested the feasibility, safety and potential utility of FDY-5301 as a treatment to limit ischemia-reperfusion injury, in patients with first-time STEMI undergoing emergency PPCI.

METHODS

STEMI patients (n = 120, median 62 years) presenting within 12 h of chest pain onset were randomized at 20 PPCI centers, in a double blind Phase 2 clinical trial, to receive FDY-5301 (0.5, 1.0 or 2.0 mg/kg) or placebo prior to reperfusion, to evaluate the feasibility endpoints. Participants underwent continuous ECG monitoring for 14 days after PPCI to address pre-specified cardiac arrhythmia safety end points and cardiac magnetic resonance imaging (MRI) at 72 h and at 3 months to assess exploratory efficacy end points.

RESULTS

Intravenous FDY-5301 was delivered before re-opening of the infarct-related artery in 97% participants and increased plasma iodide levels ~1000-fold within 2 min. There was no significant increase in the primary safety end point of incidence of cardiac arrhythmias of concern. MRI at 3 months revealed median final infarct sizes in placebo vs. 2.0 mg/kg FDY-5301-treated patients of 14.9% vs. 8.5%, and LV ejection fractions of 53.9% vs. 63.2%, respectively, although the study was not powered to detect statistical significance. In patients receiving FDY-5301, there was a significant reduction in the levels of MPO, MMP2 and NTproBNP after PPCI, but no reduction with placebo.

CONCLUSIONS

Intravenous FDY-5301, delivered immediately prior to PPCI in acute STEMI, is feasible, safe, and shows potential efficacy. A larger trial is justified to test the effects of FDY-5301 on acute ischemia-reperfusion injury and clinical outcomes.

CLINICAL TRIAL REGISTRATION

CT.govNCT03470441; EudraCT 2017-000047-41.

Prisoner rehabilitation through animal-assisted activities in Argentina: the Huellas de Esperanza Prison Dog Programme

One of the most traumatic events that a person can ever experience in their lifetime is being detained. The prison dog programmes are the most successful prison rehabilitation programmes in the United States of America and consist of detainees training service dogs for other people to assist with different types of disability. It is a typical win-win system: inmates win as they connect with their deepest feelings of affection and solidarity while acquiring a concrete skill for their future release; people with disabilities win because they receive a dog to support their day-to-day activities; the dogs win (especially adopted street dogs) because their lot in life is improved; institutions win because they are enabled to meet their objective more fully; and society wins because they gain a concrete tool to aid the social rehabilitation of detainees. This article describes the operation and achievements of Huellas de Esperanza (Traces of Hope), the Argentine prison dog programme, which has been implemented by the Federal Penitentiary Service since 2010 using State resources. A total of 85 inmates have participated in the programme, which has delivered more than a dozen assistance dogs to people with disabilities and many more dogs to elderly people to provide them with affection and companionship. The article also describes the programme methodology and the way it has decreased prison unrest and led to a low reoffending rate among programme participants.

An exploratory service-based study of Deliberate Self-Harm (DSH) in Ireland: 'A hidden population'?

The aim of this study was to investigate the nature and extent of deliberate self-harm (DSH) amongst those attending national crisis centres in Ireland, and to assess clients' views of the service. A secondary analysis was undertaken of a large data set of clients presenting with DSH (n=823). Clients were predominantly female, under 25 and with self-cutting widely reported (73%). DSH co-occurred with suicidal ideation (SI) (42%) and/or a suicide attempt (SA) (35%). Males were significantly more likely to present with more severe problems, and to use more dramatic methods of DSH; more severe presenting issues were also significantly associated with a history of having friends who engage in DSH. The treatment completion rate was 36%. Clients reported overwhelmingly positive views about the service. This is the first study in Ireland to provide insights into a 'hidden population' of people who engage in DSH. A need for greater awareness of DSH and its links to suicidal ideation/behaviour is indicated.

The effect of deep muscle relaxation on the force required during Latissimus Dorsi dissection for breast reconstructive surgery: results of a prospective, double-blinded observational pilot study

BACKGROUND

The use of neuromuscular blocking agents has previously been suggested to facilitate the dissection of the latissimus dorsi muscle during breast reconstructive surgery. The aim of this study was to quantify the influence of deep muscle relaxation on the force required to lift the latissimus dorsi muscle during flap preparation.

METHODS

After ethics approval and written informed consent 15 patients scheduled for elective breast reconstruction with a latissimus dorsi pedicled flap (muscle flap, not myocutaneous flap) under general anaesthesia were prospectively included. Midway through the muscle dissection a sterile cotton tape was slung around the mid portion of the muscle and connected with a sterile strain gauge stably positioned just above the patient. Thereafter, the muscle was lifted by moving the strain gauge vertically upwards until a muscle tension similar to that created manually during muscle dissection was achieved. The force (N) and distance required to tension the muscle were recorded and the tension released. In a randomized and blinded crossover design either rocuronium (0.6 mg.kg-1) or normal saline were given intravenously, and the tension protocol was repeated 2 min after each drug administration.

RESULTS

Muscle relaxation significantly reduced the force for flap tensioning (median [percentiles] - 22 [-32/-13] %; P = 0.011) in 10/15 patients. However, in the remaining 5 patients no significant effect was measured. Normal saline had no effect on the measured force.

CONCLUSIONS

Deep muscle relaxation significantly reduces the force required to manually elevate the latissimus dorsi muscle during its dissection in the majority of but not all patients.

TRIAL REGISTRATION

The study was retrospectively registered on [17.6.2014] with the Australian and New Zealand Clinical Trials Registry. ACTRN12614000637640.

Prebiotic-supplemented partially hydrolysed cow's milk formula for the prevention of eczema in high-risk infants: a randomized controlled trial

Background

Prevention guidelines for infants at high risk of allergic disease recommend hydrolysed formula if formula is introduced before 6 months, but evidence is mixed. Adding specific oligosaccharides may improve outcomes.

Objective

To evaluate whether partially hydrolysed whey formula containing oligosaccharides (0.8 g/100 ml) (pHF‐OS) can prevent eczema in high‐risk infants [ISRCTN65195597].

Methods

We conducted a parallel‐group, multicentre, randomized double‐blind controlled trial of pHF‐OS vs standard cow's milk formula. Infants with a family history of allergic disease were randomized (stratified by centre/maternal allergy) to active (n = 432) or control (n = 431) formula until 6 months of age if formula was introduced before 18 weeks. Primary outcome was cumulative incidence of eczema by 12 months in infants randomized at 0–4 weeks (375 pHF‐OS, 383 control). Secondary outcomes were cumulative incidence of eczema by 12 or 18 months in all infants randomized, immune markers at 6 months and adverse events.

Results

Eczema occurred by 12 months in 84/293 (28.7%) infants allocated to pHF‐OS at 0‐4 weeks of age, vs 93/324 (28.7%) control (OR 0.98 95% CI 0.68, 1.40; P = 0.90), and 107/347 (30.8%) pHF‐OS vs 112/370 (30.3%) control in all infants randomized (OR 0.99 95% CI 0.71, 1.37; P = 0.94). pHF‐OS did not change most immune markers including total/specific IgE; however, pHF‐OS reduced cow's milk‐specific IgG1 (P < 0.0001) and increased regulatory T‐cell and plasmacytoid dendritic cell percentages. There was no group difference in adverse events.

Conclusion

pHF‐OS does not prevent eczema in the first year in high‐risk infants. The immunological changes found require confirmation in a separate cohort.

N-terminal pro-B-type natriuretic peptide is better than TIMI risk score at predicting death after acute myocardial infarction

BACKGROUND

The TIMI risk score is a well-validated scoring system used to predict mortality in patients following an ST-segment elevation myocardial infarction (STEMI). N-terminal pro-B-type natriuretic peptide (NTproBNP) has also been found to be useful in predicting mortality following STEMI.

OBJECTIVE

To investigate the utility of the TIMI score and NTproBNP levels at predicting risk of death in patients with acute myocardial infarction (AMI).

METHODS

473 patients (352 men, mean (SD) age 63.7 (12.3) years) with AMI were studied. Blood was drawn within 24 hours after the onset of chest pain and the plasma concentration of NTproBNP was determined using an in-house non-competitive immunoassay. Patients' TIMI risk score was measured and patients stratified into low- (0 to 2), intermediate- (3-7) and high-risk (>8) groups.

RESULTS

Mortality was 8.9% and was related to higher TIMI risk scores (p = 0.029 for trend). Higher NTproBNP levels were also related to increased mortality (median (range) fmol/ml, survivors 700.2 (0.3-11485.3) vs dead 5781.3 (1.4-10835.9), p<0.001). In a multivariate binary logistic regression model, independent predictors of mortality were NTproBNP levels in the first 24 hours (odds ratio (OR) = 4.21, 95% CI 1.96 to 9.07, p<0.001) together with drug treatments. The receiver operating curve for NTproBNP in the first 24 hours yielded an area under the curve (AUC) of 0.79 (95% CI 0.70 to 0.88), p<0.001, for TIMI risk score the AUC was 0.67 (95% CI 0.58 to 0.76), p = 0.001.

CONCLUSION

In the first 24 hours following an AMI, NTproBNP is better than the TIMI risk score at predicting mortality. A simple NTproBNP blood test is more easily applicable and is more accurate than a clinical risk score.

154 UNDERNUTRITION DURING THE PERICONCEPTIONAL PERIOD IN EWES AFFECTS THE BLOOD PRESSURE AND WEIGHT OF THEIR NEONATAL LAMBS

Evidence from epidemiological and experimental studies has shown that maternal undernutrition during pregnancy can alter fetal growth and development and is associated with increased risk of hypertension and cardiovascular disease in the offspring. However, there is a paucity of data examining the effect of undernutrition during the periconceptual period on offspring health. Therefore, we investigated the impact of ewe undernutrition during the periconceptional period on lamb birth weight and blood pressure. Crossbred ewes (n = 166) were individually penned and randomly allocated to 1 of 2 treatments and fed either 0.7 (restricted) or 1.1 (control) maintenance energy requirements from 28 days prior until 7 days post-mating. After Day 7, ewes in both treatments were managed similarly until parturition. Following parturition, lamb gender, birth weight, and blood pressure were recorded. Lamb weight and blood pressure were subsequently measured at 4 and 10 weeks of age. Restricted ewes lost 2.6 � 0.2 kg over the treatment period compared with control ewes which gained 1.7 � 0.58 kg (P &lt; 0.01). There was no treatment effect on lamb birth weight in either singleton or twin gestations. However, at 4 and 10 weeks of age singleton lambs born to nutritionally restricted ewes were heavier than those born to control ewes (males, n = 17: 19.4 � 0.1 vs. 16.4 � 0.1 kg; females, n = 16: 34.9 � 1.0 vs. 30.9 � 1.6 kg, P &lt; 0.05). Blood pressure, measured within the first 24 h of life, was higher (P &lt; 0.05) in singleton lambs born to nutritionally restricted mothers compared to controls (males: systolic 126 � 11 vs. 94 � 5; diastolic 99 � 12 vs. 58 � 5; mean 112 � 11 vs. 77 � 5 mmHg; P &lt; 0.05; females: systolic 126 � 11 vs. 94 � 5; diastolic 99 � 12 vs. 58 � 5; mean 112 � 11 vs. 77 � 5 mmHg; P &lt; 0.05). This difference was no longer apparent at 4 or 10 weeks of age. Mean blood pressures of twin lambs at birth and 4 weeks of age were numerically greater in the restricted than in the control treatment but were significantly different only among male twin groups at 4 weeks of age (diastolic 77 � 4 vs. 94 � 4; mean 96 � 4 vs. 110 � 3 mmHg; P &lt; 0.01). Maternal undernutrition during the periconceptional period was associated with increased offspring weight at 4 and 10 weeks of age in singletons, as well as alterations in offspring cardiovascular function in both singletons and twins. These findings suggest that maternal nutrition at the time of conception influences offspring health. Exact mechanisms remain to be elucidated but may involve genetic modification. This research was funded by IRCSET and University College Dublin.

Assessment of an electronic daily diary in patients with overactive bladder

OBJECTIVE

To assess the effectiveness of a portable electronic diary as a data collection device for overactive bladder symptoms, and to evaluate its level of patient acceptability compared with a conventional paper-based voiding diary.

PATIENTS AND METHODS

Patients were identified through USA and UK hospital incontinence clinics. Patients were trained in the use of paper and electronic diaries before randomization, to complete either diary for 7 days. The diaries were then collected and, after a further training session, patients completed the other diary type for 7 days.

RESULTS

In all, 35 patients were recruited into the trial; overall, patients using the paper diaries (35) and electronic diaries (33) recorded similar data for the median number of incontinent episodes per week (8.2 and 7.0, respectively) and for the median number of significant leaks per day (0.4 and 0.5, respectively). However, the number of daily micturitions was slightly lower for the electronic than for the paper diary (7.3 vs 8.5, respectively). The frequency of urgency recorded in the electronic diary was higher than that recorded in the paper diary (5.8 vs 4.7). As 94% of patients found the electronic diary easy to use, and the electronic diary reflects real-time data entries, the electronic diary data may provide a more accurate reflection of patient symptoms.

CONCLUSION

We confirmed that the electronic diary is a novel method of collecting clinically relevant symptom data from patients with an overactive bladder. In addition, the ease-of-use ratings support the use of the electronic diary as a superior alternative to paper diaries, providing real-time data which can be rapidly analysed, and thus allowing a speedy review of data during ongoing clinical studies.

ACE-Asia intercomparison of a thermal-optical method for the determination of particle-phase organic and elemental carbon

A laboratory intercomparison of organic carbon (OC) and elemental carbon (EC) measurements of atmospheric particulate matter samples collected on quartz filters was conducted among eight participants of the ACE-Asia field experiment The intercomparison took place in two stages: the first round of the intercomparison was conducted when filter samples collected during the ACE-Asia experiment were being analyzed for OC and EC, and the second round was conducted after the ACE-Asia experiment and included selected samples from the ACE-Asia experiment Each participant operated ECOC analyzers from the same manufacturer and utilized the same analysis protocol for their measurements. The precision of OC measurements of quartz fiber filters was a function of the filter's carbon loading but was found to be in the range of 4-13% for OC loadings of 1.0-25 microg of C cm(-2). For measurements of EC, the precision was found to be in the range of 6-21% for EC loadings in the range of 0.7-8.4 microg of C cm(-2). It was demonstrated for three ambient samples, four source samples, and three complex mixtures of organic compounds that the relative amount of total evolved carbon allocated as OC and EC (i.e., the ECOC split) is sensitive to the temperature program used for analysis, and the magnitude of the sensitivity is dependent on the types of aerosol particles collected. The fraction of elemental carbon measured in wood smoke and an extract of organic compounds from a wood smoke sample were sensitive to the temperature program used for the ECOC analysis. The ECOC split for the three ambient samples and a coal fly ash sample showed moderate sensitivity to temperature program, while a carbon black sample and a sample of secondary organic aerosol were measured to have the same split of OC and EC with all temperature programs that were examined.

Strategic management of non-point source pollution from sewage sludge

In the UK, the recycling of sewage sludge to land is expected to double by 2006 but the security of this route is threatened by environmental concerns and health scares. Strategic investment is needed to ensure sustainable and secure sludge recycling outlets. At present, the security of this landbank for sludge recycling is determined by legislation relating to nutrient rather than potentially toxic elements (PTEs) applications to land--especially the environmental risk linked to soil phosphorus (P) saturation. We believe that not all land has an equal risk of contributing nutrients derived from applications to land to receiving waters. We are currently investigating whether it is possible to minimise nutrient loss by applying sludge to land outside Critical Source Areas (CSAs) regardless of soil P Index status. Research is underway to develop a predictive and spatially-sensitive, semi-distributed model of critical thresholds for sludge application that goes beyond traditional "end-of-pipe" or "edge-of-field" modelling, to include hydrological flow paths and delivery mechanisms to receiving waters from non-point sources at the catchment scale.