Agenda 21 Militar numa Unidade do Exército Português: contributos para um desenvolvimento sustentável através da liderança participativa

Dissertação apresentada na Faculdade de Ciências e Tecnologia da Universidade Nova de Lisboa para obtenção do grau de Mestre em Gestão e Políticas AmbientaisNo seguimento da Cimeira da Terra em 1992 foram realizados vários esforços com vista a promover a sustentabilidade ao nível local. O conceito “Pensar global, agir local” levou a que os objectivos da Agenda 21 fossem transpostos para pequenas comunidades, surgindo por todo o Mundo diversos projectos de implementação da Agenda 21 Local. Em Portugal, o número de municípios e de escolas que implementaram Agendas 21 ainda é (infelizmente) muito reduzido. Avaliar e estudar a sua aplicabilidade ao sector da Defesa, designadamente ao Exército Português e desenvolver um modelo conceptual, que se optou designar por “Agenda 21 Militar” (A21M), constitui, para além de um grande desafio, uma possibilidade de adaptar um instrumento de gestão participada, sendo um contributo para o desenvolvimento sustentável nas Forças Armadas. O trabalho caracteriza os antecedentes e a evolução das questões ambientais na Defesa Nacional e no Exército Português, através da análise de directivas, legislação e documentação, identificando as várias “estruturas ambientais” e as suas capacidades de comunicação e partilha de informação ambiental. Devido à especificidade da instituição militar, fortemente hierarquizada, são analisados os estilos de liderança e a forma como se podem relacionar com os processos de gestão participada de uma Agenda 21 Local. São abordadas as formas permitem aumentar e facilitar a troca de informação ambiental entre as diferentes estruturas com responsabilidades ambientais no seio da Defesa Nacional e também com as comunidades envolventes. Julga-se que o modelo em estudo permitirá uma melhor conciliação entre a gestão ambiental e o cumprimento da Missão do Exército, rumo ao Desenvolvimento Sustentável, através da integração de metodologias participativas, do envolvimento e da co-responsabilização dos vários actores

Association between Serum Interleukin-6 Concentrations and Mortality in Older Adults: The Rancho Bernardo Study

Background: Interleukin-6 (IL-6) may have a protective role in acute liver disease but a detrimental effect in chronic liver disease. It is unknown whether IL-6 is associated with risk of liver-related mortality in humans. Aims: To determine if IL-6 is associated with an increased risk of all-cause, cardiovascular disease (CVD), cancer, and liverrelated mortality. Methods: A prospective cohort study included 1843 participants who attended a research visit in 1984–87. Multiple covariates were ascertained including serum IL-6. Multivariable-adjusted Cox proportional hazards regression analyses were used to examine the association between serum IL-6 as a continuous (log transformed) variable with all-cause, CVD, cancer, and liver-related mortality. Patients with prevalent CVD, cancer and liver disease were excluded for cause-specific mortality. Results: The mean (6 standard deviation) age and body-mass-index (BMI) of participants was 68 (610.6) years and 25 (63.7) Kg/m 2, respectively. During the 25,802 person-years of follow-up, the cumulative all-cause, CVD, cancer, and liverrelated mortality were 53.1 % (N = 978), 25.5%, 11.3%, and 1.3%, respectively. The median (6IQR) length of follow-up was 15.3610.6 years. In multivariable analyses, adjusted for age, sex, alcohol, BMI, diabetes, hypertension, total cholesterol, HDL, and smoking, one-SD increment in log-transformed serum IL-6 was associated with increased risk of all-cause, CVD, cancer, and liver-related mortality, with hazard ratios of 1.48 (95 % CI, 1.33–1.64), 1.38 (95 % CI, 1.16–1.65), 1.35 (95 % CI, 1.02–1.79)

Alanine aminotransferase decreases with age: the Rancho Bernardo Study.

Serum alanine aminotransferase (ALT) is a marker of liver injury. The 2005 American Gastroenterology Association Future Trends Committee report states that serum ALT levels remain constant with age. This study examines the association between serum ALT and age in a community-dwelling cohort in the United States.A cross-sectional study of 2,364 (54% female) participants aged 30-93 years from the Rancho Bernardo Study cohort who attended a research clinic visit in 1984-87. Demographic, metabolic co-variates, ALT, bilirubin, gamma glutamyl transferase (GGT), albumin, and adiposity signaling biomarkers (leptin, IL-6, adiponectin, ghrelin) were measured. Participants were divided into four-groups based upon age quartile, and multivariable-adjusted least squares of means (LSM) were examined (p for trend <0.05).ALT decreased with increasing age, with mean ALT levels (IU/L) of 23, 21, 20, and 17 for those between quartile ages 30-62, 63-71, 72-77, and 78-93 years (p<0.0001). Trends of decreasing LSM ALT with age and the decreasing prevalence of categorically defined elevated serum ALT with age remained robust after adjusting for sex, alcohol use, metabolic syndrome components, and biomarkers of adiposity (p-value <0.0001), and was not materially changed after adjusting for bilirubin, GGT, and albumin.ALT levels decrease with age in both men and women independent of metabolic syndrome components, adiposity signaling biomarkers, and other commonly used liver function tests. Further studies are needed to understand the mechanisms responsible for a decline in ALT with age, and to establish the optimal cut-point of normal ALT in the elderly

The impact of genetic risk on liver fibrosis in non‐alcoholic fatty liver disease as assessed by magnetic resonance elastography

BackgroundVariants in multiple genetic loci modify the risk of non-alcoholic fatty liver disease (NAFLD) and cirrhosis but there are limited data on the quantitative impact of variant copies on liver fibrosis.AimTo investigate the effect of PNPLA3, TM6SF2, MBOAT7, GCKR and HSD17B13 genotype on liver fibrosis assessed by magnetic resonance elastography (MRE), a reproducible, accurate, continuous biomarker of liver fibrosis.MethodsThis is a cross-sectional analysis derived from a well-characterised cohort at risk for NAFLD who underwent genotyping and MRE assessment. Liver stiffness (LS) was estimated using MRE and advanced fibrosis was defined as liver stiffness ≥3.63&nbsp;kilopascals (kPa). Univariable and multivariable linear and logistic regression analysis, were used to assess the association between genotype and MRE.ResultsTwo hundred sixty-four patients (63% women) with a mean age 53 (±17)&nbsp;years, and 31% Hispanic ethnicity with genotyping and MRE were included. The odds of advanced fibrosis were 3.1 (95% CI: 1.1-8.9, P&nbsp;=&nbsp;0.04) for CG and 6.5 (95% CI: 2.2-18.9, P&nbsp;&lt;&nbsp;0.01) for GG compared to CC PNPLA3 genotype. Each PNPLA3 risk variant copy was associated with 0.40&nbsp;kPa (95% CI: 0.19-0.61, P&nbsp;&lt;&nbsp;0.01) increase in LS on MRE in analysis adjusted for age, sex and BMI and there was significant genotype-age interaction (P&nbsp;&lt;&nbsp;0.01). Conversely, the protective TA allele in HSD17B13 was associated with a -0.41&nbsp;kPa (95% CI: -0.76 to -0.05, P&nbsp;=&nbsp;0.03) decrease in liver stiffness on MRE multivariable analysis.ConclusionKnowledge of PNPLA3 and HSD17B13 genotype may assist in the non-invasive risk stratification of NAFLD with closer monitoring recommended for those with high genetic risk

Increased severity of liver fat content and liver fibrosis in non-alcoholic fatty liver disease correlate with epicardial fat volume in type 2 diabetes: A prospective study.

OBJECTIVES:To determine whether severity of non-alcoholic fatty liver disease (NAFLD) and liver fibrosis quantitatively assessed in individuals with diabetes mellitus (DM)-2 correlate with increased coronary heart disease (CHD) risk using non-invasive markers. METHODS:We conducted a single-centre, prospective, cross-sectional study in 100 consecutive diabetic individuals without known CHD recruited between March 2013 and September 2014. History, physical examination, serum markers, cardiac computed tomography (CT), magnetic resonance (MR) imaging-estimated proton density fat fraction (PDFF) and MR elastography (MRE) were obtained for 95 participants. Written informed consent was provided. Institutional review board approved this study. Spearman rank correlation was performed to assess for correlations. Multiple linear regression model determined independent predictors of epicardial adipose tissue (EAT) volume. RESULTS:A p value &lt; 0.05 determined statistical significance. The EAT volume was higher in the NAFLD group, defined as MR-imaging PDFF ≥ 5 %, compared to the non-NAFLD group (126.5 ml (IQR 80.9) versus 85.4 ml (IQR 44.7), p=0.002). MR imaging-PDFF correlated with EAT (r=0.42, p &lt; 0.0001). MR imaging-PDFF and liver fibrosis were independently associated with EAT. CONCLUSIONS:Higher liver fat content and liver fibrosis may portend worse cardiovascular risk in diabetics. KEY POINTS:• EAT volume is higher in diabetic individuals with NAFLD. • Liver fat content is positively correlated with EAT. • Liver fat content and liver fibrosis were independently associated with EAT. • Higher liver fat content and fibrosis may adversely affect cardiovascular risk

Geographic Variability in Liver Disease-Related Mortality Rates in the United States.

PURPOSE:Liver disease is an important cause of morbidity and mortality in the United States. Geographic variations in the burden of chronic liver disease may have significant impact on public health policies but have not been explored at the national level. The objective of this study is to examine interstate variability in liver disease mortality in the United States. METHODS:We compared liver disease mortality from the 2010 National Vital Statistics Report on a state level. States in each quartile of liver disease mortality were compared with regard to viral hepatitis death rates, alcohol consumption, obesity, ethnic and racial composition, and household income. Race, ethnicity, and median household income data were derived from the 2010 US Census. Alcohol consumption and obesity data were obtained from the 2010 Behavioral Risk Factor Surveillance System Survey. RESULTS AND CONCLUSION:We found significant interstate variability in liver disease mortality, ranging from 6.4 to 17.0 per 100,000. The South and the West carry some of the highest rates of liver disease mortality. In addition to viral hepatitis death rates, there is a strong correlation between higher percentage of Hispanic population and a state's liver disease mortality rate (r&nbsp;=&nbsp;0.538, P&nbsp;&lt;&nbsp;.001). Lower household income (r&nbsp;=&nbsp;0.405, P&nbsp;=&nbsp;.003) was also associated with the higher liver disease mortality. While there was a trend between higher obesity rates and higher liver disease mortality, the correlation was not strong and there was no clear association between alcohol consumption and liver disease mortality rates

Prognostic utility of magnetic resonance elastography and MEFIB index in predicting liver-related outcomes and mortality in individuals at risk of and with nonalcoholic fatty liver disease

BackgroundMagnetic resonance elastography (MRE) is an accurate biomarker of liver fibrosis; however, limited data characterize its association with outcomes. We aimed to evaluate the association between liver stiffness (LS) on MRE and liver-related outcomes.MethodsThis is a longitudinal, retrospective analysis of subjects at risk of NAFLD who had MRE assessment. LS was estimated using MRE, and liver fat was assessed using magnetic resonance imaging proton density fat fraction. Univariable and multivariable survival and regression analyses were used to assess the association between LS on MRE and liver-related outcomes including a cumulative primary outcome of hepatic decompensation, hepatocellular carcinoma (HCC), or death.ResultsIn all, 265 patients (68% women) with a mean age of 50 (±18) years and 44% Hispanic ethnicity and 45.3% with NAFLD were included. A total of 76 liver-related events or death occurred, and there was 453 person-years of follow-up time in 97 patients with available follow-up. Each 1-kPa increase in LS was associated with 2.20-fold (95% CI: 1.70-2.84, p &lt; 0.001) increased odds of prevalent hepatic decompensation or HCC. A positive MEFIB index, a combination of MRE ⩾ 3.3 kPa and FIB-4 ⩾ 1.6, had a strong association with the primary outcome compared with those without, HR = 21.8 (95% CI: 4.28-111.4, p &lt; 0.001). The MEFIB index had a sensitivity of 75% and specificity of 90%, and a negative score was associated with 98% negative predictive value for incident liver-related events or death.ConclusionLS assessed by MRE is associated with hepatic decompensation and death, and the MEFIB combination of MRE with FIB-4 may have high negative predictive value for liver-related events

Increased severity of liver fat content and liver fibrosis in non-alcoholic fatty liver disease correlate with epicardial fat volume in type 2 diabetes: A prospective study.

OBJECTIVES:To determine whether severity of non-alcoholic fatty liver disease (NAFLD) and liver fibrosis quantitatively assessed in individuals with diabetes mellitus (DM)-2 correlate with increased coronary heart disease (CHD) risk using non-invasive markers. METHODS:We conducted a single-centre, prospective, cross-sectional study in 100 consecutive diabetic individuals without known CHD recruited between March 2013 and September 2014. History, physical examination, serum markers, cardiac computed tomography (CT), magnetic resonance (MR) imaging-estimated proton density fat fraction (PDFF) and MR elastography (MRE) were obtained for 95 participants. Written informed consent was provided. Institutional review board approved this study. Spearman rank correlation was performed to assess for correlations. Multiple linear regression model determined independent predictors of epicardial adipose tissue (EAT) volume. RESULTS:A p value &lt; 0.05 determined statistical significance. The EAT volume was higher in the NAFLD group, defined as MR-imaging PDFF ≥ 5 %, compared to the non-NAFLD group (126.5 ml (IQR 80.9) versus 85.4 ml (IQR 44.7), p=0.002). MR imaging-PDFF correlated with EAT (r=0.42, p &lt; 0.0001). MR imaging-PDFF and liver fibrosis were independently associated with EAT. CONCLUSIONS:Higher liver fat content and liver fibrosis may portend worse cardiovascular risk in diabetics. KEY POINTS:• EAT volume is higher in diabetic individuals with NAFLD. • Liver fat content is positively correlated with EAT. • Liver fat content and liver fibrosis were independently associated with EAT. • Higher liver fat content and fibrosis may adversely affect cardiovascular risk