Suchergebnisse

En el norte de la Patagonia argentina, más precisamente en el Alto Valle , se ha desarrollado un sistema urbano-rural en el cual una ciudad ha sobresalido del resto en las últimas décadas, la ciudad de Neuquén. En torno a ella se ha manifestado un proceso de conurbación cuyo centro está conformado por esta ciudad, capital de la provincia de Neuquén, y la ciudad de Cipolletti centro de mayor relevancia de la provincia de Río Negro perteneciente a este bloque. Ambas se presentan como una unidad urbana a partir de la cual se han evidenciado importantes procesos de expansión urbana. Esta conurbación presenta una gran concentración de servicios, capital, tecnologías, transportes e infraestructura en general y un peso y densidad poblacional muy superior al del resto de las áreas urbanas del Alto Valle. Esa dinámica poblacional y económica trajo aparejados inconvenientes para esta zona. Los más notables son los conflictos sociales ante una elevada presión sobre el uso de suelo, la pérdida de tierra agrícola ante la expansión urbana y la especulación del negocio inmobiliario, así como el asentamiento de personas en áreas de riesgo y problemas de circulación de las personas. Ante este contexto la presente tesis tiene como objetivo principal analizar características territoriales, demográficas, ambientales y de movilidad urbana de dicha conurbación con el propósito de ofrecer aportes orientados a la formulación de propuestas de ordenamiento territorial. En consecuencia, la investigación intenta dar un panorama general del desarrollo del área urbana de la conurbación para identificar disfuncionalidades o conflictos que atentan contra un desarrollo urbano armónico. Algunas preguntas que surgen desde el inicio de la investigación han permitido guiar el camino en esta tarea: ¿Qué cambios afectaron a la conurbación en torno a la ciudad de Neuquén? ¿De qué manera la afectaron? ¿Cuál es la magnitud de los problemas generados? ¿Cuáles son las nuevas características de esta área urbana y sus tendencias futuras? ¿Cómo abordar y explicar esas problemáticas generadas? ¿Cuáles serían las propuestas más óptimas para resolver estas dificultades? El desarrollo de la investigación se ha segmentado en 10 capítulos, el primero de ellos se presenta como una introducción a todo el documento, el capitulo 2 desarrolla los principales conceptos de la ciencia geográfica que serán tenidos en cuenta en adelante, los mismos parten de considerar a la geografía como una ciencia social centrada en el estudio del espacio geográfico y sus tiempos. A partir de este nivel conceptual se orientan las reflexiones que involucran conceptos como el de región que permitirá entender de manera más apropiada la dinámica de la conurbación neuquina, para luego avanzar sobre conceptos e ideas empíricas cercanas al proceso de urbanización, a los modelos de las plantas urbanas, a la movilidad urbana y a los problemas ambientales. El tercer capítulo detalla la metodología utilizada para la indagación y búsqueda de resultados. No es sólo una enumeración de actividades, sino que se explica de manera asociada al marco teórico y a ciertos conceptos clave, el cómo será la investigación en cuanto a técnicas y procedimientos. En el capítulo 4 se analiza de manera un tanto detallada las condiciones del medio natural que influyen en el asentamiento urbano del área de estudio. Es decir que este apartado no es una descripción exhaustiva del marco natural, es una búsqueda de los condicionantes que permiten o dificultan el surgimiento de áreas urbanas. Así se trabaja principalmente sobre las geoformas o unidades geomorfológicas atendiendo a los procesos naturales que se manifiestan en cada una de ellas y cómo influyen en la actualidad en el desarrollo urbano y en la vida de las personas que habitan la ciudad. El capítulo 5 realiza una auténtica periodización urbana de la zona del Alto Valle, ya que la mayoría de las que podemos encontrar en los textos referidos a la zona están en sintonía económica o determinadas a partir de cortes arbitrarios, sin debidas evaluaciones teórico metodológicas. El capítulo 6 se encuentra muy en sintonía con la concepción de región, a esta altura de la investigación ya se hace necesario identificar algunos límites de la conurbación en torno a la ciudad de Neuquén. Se trata de establecer algunas precisiones en torno a estos aspectos dejando en claro que esos límites no son rígidos y que están identificados en función de los objetivos de esta investigación. Es así que el análisis se basará en algunas variables y luego en capítulos posteriores se avanzará en profundidad sobre otras. En primer lugar, y haciendo honor a la disciplina, se analiza la situación desde el punto de vista espacial (relacionada con la expansión de las áreas urbanas, particularmente sobre áreas agrícolas), para posteriormente trabajar sobre la variable poblacional y finalmente la funcional. En el capítulo 7 se intenta comparar y aplicar diversos indicadores de flujos vehiculares al ámbito de la conurbación neuquina comentando las potencialidades y falencias de cada uno. Tales indicadores son parte de un conjunto más amplio de información base que, tratada debidamente, nos ayuda a comprender como son las características de la movilidad espacial de las personas en este espacio urbano. Los resultados de la aplicación de los indicadores nombrados manifiestan un incremento de los flujos vehiculares en torno a los tramos de rutas más cercanos a la ciudad de Neuquén y a la vez expresan una cierta centralidad de esta ciudad en todo el conjunto de la conurbación. Esto repercute en la generación de problemas en cuanto a cuestiones viales y de transporte de las personas; cuestiones que deben ser tenidas en cuenta por parte de los decisores políticos a la hora de implementar acciones para un mejor ordenamiento territorial. El recorrido realizado en los apartados anteriores hizo posible la identificación de diferentes problemas ambientales que fueron trabajados en el capítulo 8. Algunos de éstos repetidos en los diferentes municipios, otros puntuales y específicos y otros que afectan de manera integral al sistema. Se destacan así los inconvenientes generados a partir de la instalación de viviendas en áreas de riesgo y la contaminación ambiental generada por efluentes, residuos sólidos urbanos y los generados a partir de la actividad petrolera. El capítulo 9 plantea como resultado del recorrido de la investigación algunas posibles acciones a realizar para la mitigación o solución de los principales inconvenientes detectados en la conurbación. Algunas de estas acciones están referidas a problemas teóricos o metodológicos en el entendimiento de los problemas por parte de las autoridades de gobierno, como el abordaje parcializado de los problemas ya sea en forma espacial o temática. Otras acciones propuestas son más directas como la de limitar la expansión urbana y favorecer una mayor densidad de uso del suelo urbano de algunos sectores. Otro tipo de propuestas hacen mención a las funciones o funcionamiento de la conurbación proponiendo nuevas centralidades, una mejora en la circulación a partir de esto, además de sugerir una diversificación y fortalecimiento de ciertos tipos de movilidad urbana. Por último el capítulo 10, arriba a unas conclusiones o reflexiones finales de la investigación que dejan ciertas certezas pero que también abren la puerta a nuevos temas y nuevas formas de estudiar esta conurbación en torno a la ciudad de Neuquén. ; In the north of the Patagonia Argentina, more precisely in the Alto Valle , a rural-urban system has developed, in which Neuquén city has outstood from the rest during the last decades. Around it, a conurbation process has occurred, whose center is comprised by Neuquén city, which is the capital city of Neuquén province, and Cipolletti city, the most important city in Río Negro province. Both cities are presented as an urban unit from which important processes of urban expansion have been evidenced. This conurbation presents a great concentration of services, capital, technologies, transport and infrastructure in general; and has a much higher population density and proportion compared to those of other urban areas of the Alto Valle. This economic and population dynamic brought with it several drawbacks in the area, of which the most notable are the social conflicts due to a high pressure over land use, the loss of agricultural land due to urban expansion, the speculation of the property business, the settlement of people in risk areas and, problems with the circulation of people. In this context, the present thesis aims at analyzing the territorial, demographic, environmental and urban mobility characteristics of such conurbation, with the purpose of offering contributions aimed at the formulation of land-use zoning proposals. In consequence, the research attempts to bring an overview of the development of the urban area of the conurbation to identify dysfunctions or conflicts threating harmonious urban development. The following questions arising from the beginning of the study have allowed framing it within such objectives: Which changes affected conurbation around the city of Neuquén, and in which ways? What is the magnitude of the generated problems? What are the new characteristics of this urban area, and its future trends? How to address and explain the generated issues? Which would be the most adequate proposals for resolving these issues? The investigation has been divided in 10 chapters, of which the first is an introduction of the whole document. Chapter 2 develops the main concepts of geographic science that are taken up in the text, on the basis of geography as a social science centered in the study of the geographic space and its times. From this conceptual level the reflections involving concepts such as region are oriented, which allows a more appropriate understanding of the conurbation dynamic in Neuquén, to then move forward over concepts and empirical ideas that are close to the urbanization process, urban plant models, urban mobility and environmental problems. The third chapter details the methodology used for the inquiry and search of results. The chapter is not only an enumeration of activities, but it rather explains the techniques and proceedings of the research associated to the theoretical framework and certain key concepts. In chapter 4, the environmental conditions influencing the urban settlements in the study area are analyzed in detail. Instead of an exhaustive description of the natural framework, this chapter aims at identifying the conditioning factors that allow or hamper the emergence of urban areas. Thus, it is mainly focused on the geoforms or geomorphological units, with emphasis on the natural processes that arise in each unit, and their present influence over urban development and livelihoods of the inhabitants. Chapter 5 performs an actual urban periodization of the area of Alto Valle, since most of those available in the literature of the area are in tune with the economy or determined from arbitrary cuts, with no theoretical-methodological evaluations. Chapter 6 is much in tune with the conception of region, and at this stage of the research emerged theneed to identify the boundaries of the conurbation around Neuquén city. Efforts are put in establishing certain precisions with regard to these aspects, making it clear that these boundaries are not rigid and that they are identified based on the objectives of this research. Thus, the analysis is based in certain variables, while the following chapters will move towards other variables. Firstly, and living up to the field, the situation is analyzed from a spatial point of view (related with the expansion of urban areas, particularly over agricultural areas), to posteriorly focus on the population variable, and finally on the functional variable. Chapter 7 aims at comparing and applying several indicators of traffic flow to the scope of the conurbation in Neuquén, discussing the potential and flaws of each one. Such indicators are part of a wider set of base-information that, if properly treated, can help us understand the spatial mobility characteristics of people in this urban space. The results of the application of the mentioned indicators show an increase in the traffic flow around the legs of the route that are closer to Neuquén city; and also denote a certain centrality of the city in the whole conurbation ensemble. This has direct impact on problems related to roads and the transportation of people; issues which must be taken into account by policymakers when implementing actions for a better land-use planning. The process described above allowed for the identification of different environmental issues that were treated in chapter 8. Some of these were generalized in several municipalities, others were more specific and punctual, and others affected the system as a whole. Some of the most important were drawbacks generated from the installation of housing in risk areas and environmental contamination generated by effluents, solid urban waste and waste generated by oil activity. Chapter 9 proposes certain actions to be taken for the mitigation or solution of the main drawbacks detected in the conurbation, as a result of the whole research. Some of these actions refer to theoretical or methodological problems in the understanding of the whole issue by government authorities, such as their biased approach, either spatial or thematic, of such problems. Other proposed actions are more direct, such as the suggestion of limiting urban expansion and favoring a higher density of urban use of land in certain sectors. Other type of proposals make reference to the functions or functioning of the conurbation, suggesting new centralities and a consequent improvement in the circulation; and a diversification and strengthening of other types of urban mobility. Finally, chapter 10 addresses the conclusions and final thoughts of this research, identifying several certainties but also gateways towards new themes, and ways of tackling this conurbation around Neuquén city. ; . ; Facultad de Humanidades y Ciencias de la Educación

Purpose: studying of life quality indicators at elderly patients with osteoarthritis using international EuroQol questionnaire for evaluate of efficiency of sanatorium treatment.Materials and methods. 72 patients have been included in study at the age from 60 till 78 years, mean age was 67,6±8,7 years. Patients have been divided by method of randomization on two groups. Patients of one of groups in addition passed rehabilitation in sanatorium conditions for 18–21 days. Assessment of life quality related to health was conducted with use of international questionnaire EuroQol-5D-European Quality of Life instrument (EQ-5D).Results. At all patients with osteoarthritis health problems of varying degree have been revealed. In 12 months according to the questionnaire, reliable positive dynamics of life quality was observed at patients passing sanatorium treatment at the expense of improvement of ability to movement, reduce pain and discomfort and increase daily activity.Conclusions. Having of sanatorium stage of rehabilitation in complex treatment of osteoarthritis allows affect quality of life and keep remission for a longer period in comparison with outpatient treatment.KEY WORDS: quality of life, sanatorium treatments, osteoarthritis.Osteoarthritis (OA) is one of the most common disorders of the muscle-skeletal system, especially in the elderly age group ( in every third elderly person, reaching 70% among those who have over 65 years). During the natural aging occurs involutional changes in the connective tissue, especially in the tendons, ligaments, cartilage, bone tissue, in the walls of blood vessels, muscles [2]. Thus aging of body contributes to the accumulation of diseases. During the examination in elderly and senile patients were diagnosed from three to five different diseases. Modern elderly person is - a unique clinical phenomenon from the point of view on availability and the combination of its diverse in character and course of diseases that are competing for their prognostic significance and impact on quality of life. OA attributed to diseases with high comorbidity, and founded that patients with OA have a significantly higher risk of comorbid conditions than patients who do not suffering from OA [4].Clinical experience and numerous publications data suggest that OA is often associated with subsequent somatic disorders: hypertension, coronary heart disease, obesity, diabetes, lung diseases (chronic obstructive pulmonary disease) and gastro- intestinal tract diseases. The greatest burden on society observed in cases of combination OA and osteodeficiency (osteopenia, osteoporosis (OP)), which significantly decreses the quality of life [5].Quality of life - integrated description of physical, psychological, emotional and social functioning of a person based on its subjective perception. Assessment of quality of life at modern stage have more increasing strong position in medicine, reflecting on the one hand, the presence of new medical technologies that do not affect the life expectancy, but significantly improve its quality, and from the other hand - expanding activity of the patient, increasing of its role in choice of methods of diagnostic and treatment [9].When selecting the questionnaires it is important to consider that to be used in a clinical studying suitable only those that give results of the evaluation quality of life in a form of a single summary score from 0 to 1.0. These includes a generic questionnaire EQ-5D (EuroQol) [8]. This general questionnaire is easy to fill , widely used in different countries and gives during the processing of collected data single score to measure the quality of life, represented by values between 0 and 1, which also provides the possibility of its using in clinical trials. This questionnaire is widely used in various clinical situations , including in assessing the quality of life patients with rheumatic diseases [7].The aging process is controversial, because on the background of regression processes - atrophy, degradation, etc., develops progressive trends of creating the new compensatory-adaptive mechanisms to maintain homeostasis in an aging body, which, however, does not fully offset the growing phenomena of degradation [2]. It should be noted that the adaptive capacity of the aging body is reduced, the possibility of development various diseases increases. In this context, particularly important in cases of illness in the elderly patient is the role of sanogenetic mechanisms, their stimulation and support. A special interest belongs to the sanatorium stage of rehabilitation, whose mission is the prevention of disease progression, stimulation of compensatory capacity of the muscle-skeletal system and the possible restoration of joint function.Spa treatment has a special place in the treatment and preventive care of elderly patients , as a stage in the system of rehabilitation of many chronic diseases. Multi-disciplinary nature of medical rehabilitation in spa conditions, a wide range of rehabilitation methods can embrace patients of all age groups with the most common diseases [1].Compared with medication treatment, natural and artificial physical factors, when they are properly used, characterized by the absence of allergies, lower incidence and severity of side effects, the ability of positively influencing on the number of pathological processes and the whole body, thus helping to improve the quality of life and are important in the prevention of premature aging [2]. In the resort conditions further rehabilitation is indicated for patients with initial stages of OA, disabled (groups I and II), patients with resistant synovitis and comorbidity with the possibility of self-servicing (including general contraindications for a spa treatment) [3].The aim of the study. To investigate the quality of life in elderly patients with osteoarthritis using international EuroQol questionnaire to evaluate the effectiveness of spa treatment.Materials and methods. In study were included 72 patients aged from 60 to 78 years, middle age was 67,6 ± 8,7 years. Among the patients predominates women - 88.4 %. I radiographic stage of osteoarthritis by J.H. Kellgren-Lawrence [ 6] was diagnosed in 23,3 % of patients , II stage - in 76,7 %. In the view of modern geriatric approaches applying of the physical factors in patients with OA who were in the spa rehabilitation stage in the appointment of balneotherapeutic procedures we gave preference to ultrasonic inhalation of mineral waters and baths , from physiotherapy usually prescribed magnetic-lazer therapy, interferential therapy, patients also performed massage and physical rehabilitation . In order to prevent climate-adaptational and reaclimate-adaptational reactions and optimization process of climate-adaptation were included into the treatment complex ( based on established risk factors) adaptogens and treatment procedures that have adaptogenic action ( phytoaeroionisation , singlet-oxygen therapy). In the process of rehabilitation treatment in sanatorium conditions , we have selected the most effective combination of different methods of rehabilitation , which caused the most significant treatment effectiveness : a combination of balneotherapy , physiotherapy and exercise therapy. To improve continuity during medical rehabilitation, at discharging from the sanatorium patients were given written (in the form of special attractions ) recommendatitons about further treatment, lifestyle, physical activity, diet etc.By the method of randomization, patients were divided into two groups. A marked difference for the main source of clinical and functional parameters between the groups were not observed. The control group consisted of 14 patients of the same age without joint pathology. Treatment regimens differed between the studying groups the presence in one of the groups sanatorium stage of rehabilitation. In the first group (n=34) patients received Structum 500 mg 2 times a day ( within 6 months of the year ) and courses of NSAID, including mainly patients treated with meloxicam ( at a dose of 7,5 mg/d) or nimesulide (in dose of 100-200 mg/d) for 7-10 days during worcening. The patients of the second group (n=38) during the 18-21 day were on spa treatment ( once a year ), in the scheme of rehabilitation were: sitting hydrogen sulfide baths, a concentration of 80 mg/L for 10 minutes at a temperature of 360C , the course of 8 procedures every other day or ultrasonic inhalation by hydrogen sulfide water, period of 5 minutes; blue clay applications every other day at 260C temperature; interferential therapy and magnet-lazer therapy on the affected joints to 8 treatments alternately every other day ; pneumomassage ; classes of physical rehabilitation therapy, aromatherapy , singlet -oxygen therapy . After the sanatorium stage of rehabilitation patients are taking drugs containing chondroitin sulfate (within 6 months of the year), at worcening of NSAIDs.Assessment quality of life related to health , was conducted using an international EuroQol-5D-European Quality of Life instrument (EQ-5D), which consists of two parts. At first part the patient self- assessed his condition by 5 parameters: mobility, self-care , usual activities, pain and discomfort , anxiety and depression. In each variant patients could give three possible answers : No problem - 1 , there is some problem - 2, much of the problem - 3. In the second part of the questionnaire , patients assessed their health on a scale from 0 to 100 on the VAS, the so-called thermometer , where 0 means the worst condition , 100 - the best state of health of the patient. This part of the questionnaire is a quantitative assessment of general health.Statistical analysis of the results was done in the department of statistical system research at SHEE "Ternopil State Medical University by I. Y. Gorbachevsky Ministry of Health of Ukraine" in the software package Statsoft STATISTIC. To determine the reliability of the differences in the change of certain indicators were used parametric and non-parametric methods: criterion Wilkoksona, two-sided Fisher's criterion. A significant differences were considered when the degree of probability of error-free prognosis is (p) 95% (p <0.05). Results and discussion. General description of the health status of patients studied with OA according to EQ-5D questionnaire is given in the table.In all patients with osteoarthritis were found health problems of different severity degrees. Mostly suffers ability to travel and daily activity . This data confirms that the OA in the elderly age reduces quality of life. After 12 months, according to questionnaire, health status was different in two groups . Reliable positive trend was in patients from the second group 57,9 % (p < 0,05), as a result of improving the ability to travel in space , reducing pain and discomfort and increasing of daily activity.According to the second part of the questionnaire EQ-5D, at baseline, most patients had reduced general health assessment : the first group to 51,91 ± 1,07 ( median for «thermometer» EQ 52 points ) in the second group to 50,65 ± 1,17 ( median 48,5 points) in comparison with the best state of possible health. 12 months after the sanatorium stage of rehabilitation of patients with repeated testing were produced the following results : The average index quality of life on the " thermometer " EQ-5D questionnaire in the first group of patients was 54,76 ± 1,23 ( median - 56 points), the second group was 69,28 ± 0,89 ( median - 70 points), reliability differences is high : p < 0,001.In the category quality of life most of all patients reacted on the presence of sanatorium stage of rehabilitation in the category " movement in space " ( GPA retesting 1,60 ± 0,08, p < 0,001), " daily activity " ( GPA retesting 1 68 ± 0,07, p < 0,001), " pain / discomfort " ( GPA retesting 1,92 ± 0,08, p < 0,001), " anxiety / depression ( GPA retesting 1 52 ± 0,08, p < 0,05).Thus, the data suggested that in elderly patients with OA who were once a year on a spa treatment and took over 6 months structure-modification drugs significantly upgraded quality of life during 12 months.Conclusions1. Based on the analysis were founded that elderly patients with OA who underwent rehabilitation treatment in sanatorium- health resorts have continued improving quality of life in comparison with patients who were treated only in outpatient conditions.2. Availability sanatorium stage of rehabilitation in the treatment of elderly patients with OA contributes more complex influence on the human organism.3. Multi-disciplinary nature of medical rehabilitation in spa conditions , a wide range of used restorative treatment methods can affect the quality of life and maintain remission for more longer period in comparison with outpatient treatment.4. Monitoring the quality of life can not only control the functional state of the organism in the elderly aged people at various stages of treatment , but also to properly evaluate the effectiveness of treatment , and, if necessary, to carry out the correction of rehabilitation activities .Perspectives for future research. Aimed at studying the impact of rehabilitative and preventive measures on the quality of life in elderly patients with osteoarthritis at other stages of rehabilitation. Further work in this direction is reasonable and economically justified.REFERENCES1. Golyachenko A.O., Martynyuk V.I., Bakalyuk T.G. Medical rehabilitation in the spa conditions // Journal of research. - 2007 . - № 4. - P. 8-9.2. Kazymyrko V.K., KovalenkoV.N., Flehontova V.V. Involutional osteoarthritis and osteoporosis. - Donetsk: Publisher Zaslavsky A.J., 2011. - 724 p.3. Kovalenko V.N., Bortkiewicz A.P. Osteoarthritis . Practical guidance . - K.: Moryon , 2005. - 592 p.4. Mendel O.I., Naumov A.V., Alekseeva L.I. et al Osteoarthritis as a factor of risk in cardio-vascular catastrophes // Ukrainian Journal of Rheumatology . - 2010 . - № 3. - P. 68-73.5. Povoroznyuk V.V. Osteoarthritis // Art of treatments. - 2004 . - № 3. - P.16 -23.6 . Altman R., Asch E., Bloch D. et al. The American College of Rheumatology criteria for the classification and reporting of osteoarthritis of the knee // Arthritis Rheum. - 1986 . - № 29. - P. 1039-1049 .7 . Harrison M.J., Davies L.M., Bansback N.J. et al. The comparative responsiveness of the EQ-5D and SF-6D to change in patients with inflammatory arthritis // Qual Life Res. - 2009 . - № 18. - P. 1195-1205.8 . Herdman M., Gudex C., Lloyd A., et al. Development and preliminary testing of the new five-level version of EQ-5D (EQ-5D-5L) // Qual Life Res. - 2011 . - № 20 . - P. 1727-1736.9 . Langley P., Muller-Schwefe G., Nicolaou A., Liedgens H., Pergolizzi J., Varrassi G. The societal impact of pain in the European Union: health-related quality of life and healthcare resource utilization // J. Med Econ. - 2010 . - № 1. - P. 571-581. ; Мета: вивчення показників якості життя у хворих похилого віку на остеоартроз з використанням міжнародного запитальника EuroQol для оцінки ефективності санаторно-курортного лікування.Матеріали і методи. У дослідження було включено 72 пацієнти віком від 60 до 78 років, середній вік склав 67,6±8,7 року. Методом рандомізації пацієнтів було розподілено на дві групи. Пацієнти однієї з груп додатково проходили реабілітацію в умовах санаторію протягом 18-21 дня. Оцінка якості життя, пов'язаного зі здоров'ям, проводилась з використанням міжнародного запитальника EuroQol-5D-European Quality of Life instrument (EQ-5D).Результати. У всіх хворих на остеоартроз виявлено проблеми зі здоров'ям різного ступеня. Через 12 місяців за даними запитальника достовірна позитивна динаміка якості життя спостерігалася у пацієнтів, що проходили санаторно-куротне лікування, за рахунок покращення здатності до пересування, зменшення болю і дискомфорту та збільшення повсякденної активності.Висновки. Наявність санаторно-курортного етапу реабілітації у комплексному лікуванні остеоартрозу дозволяє вплинути на якість життя та зберегти ремісію на більш тривалий термін порівняно з амбулаторним лікуванням.КЛЮЧОВІ СЛОВА: якість життя, санаторно-курортне лікування, остеоартроз.

Purpose: studying of life quality indicators at elderly patients with osteoarthritis using international EuroQol questionnaire for evaluate of efficiency of sanatorium treatment.Materials and methods. 72 patients have been included in study at the age from 60 till 78 years, mean age was 67,6±8,7 years. Patients have been divided by method of randomization on two groups. Patients of one of groups in addition passed rehabilitation in sanatorium conditions for 18–21 days. Assessment of life quality related to health was conducted with use of international questionnaire EuroQol-5D-European Quality of Life instrument (EQ-5D).Results. At all patients with osteoarthritis health problems of varying degree have been revealed. In 12 months according to the questionnaire, reliable positive dynamics of life quality was observed at patients passing sanatorium treatment at the expense of improvement of ability to movement, reduce pain and discomfort and increase daily activity.Conclusions. Having of sanatorium stage of rehabilitation in complex treatment of osteoarthritis allows affect quality of life and keep remission for a longer period in comparison with outpatient treatment.KEY WORDS: quality of life, sanatorium treatments, osteoarthritis.Osteoarthritis (OA) is one of the most common disorders of the muscle-skeletal system, especially in the elderly age group ( in every third elderly person, reaching 70% among those who have over 65 years). During the natural aging occurs involutional changes in the connective tissue, especially in the tendons, ligaments, cartilage, bone tissue, in the walls of blood vessels, muscles [2]. Thus aging of body contributes to the accumulation of diseases. During the examination in elderly and senile patients were diagnosed from three to five different diseases. Modern elderly person is - a unique clinical phenomenon from the point of view on availability and the combination of its diverse in character and course of diseases that are competing for their prognostic significance and impact on quality of life. OA attributed to diseases with high comorbidity, and founded that patients with OA have a significantly higher risk of comorbid conditions than patients who do not suffering from OA [4].Clinical experience and numerous publications data suggest that OA is often associated with subsequent somatic disorders: hypertension, coronary heart disease, obesity, diabetes, lung diseases (chronic obstructive pulmonary disease) and gastro- intestinal tract diseases. The greatest burden on society observed in cases of combination OA and osteodeficiency (osteopenia, osteoporosis (OP)), which significantly decreses the quality of life [5].Quality of life - integrated description of physical, psychological, emotional and social functioning of a person based on its subjective perception. Assessment of quality of life at modern stage have more increasing strong position in medicine, reflecting on the one hand, the presence of new medical technologies that do not affect the life expectancy, but significantly improve its quality, and from the other hand - expanding activity of the patient, increasing of its role in choice of methods of diagnostic and treatment [9].When selecting the questionnaires it is important to consider that to be used in a clinical studying suitable only those that give results of the evaluation quality of life in a form of a single summary score from 0 to 1.0. These includes a generic questionnaire EQ-5D (EuroQol) [8]. This general questionnaire is easy to fill , widely used in different countries and gives during the processing of collected data single score to measure the quality of life, represented by values between 0 and 1, which also provides the possibility of its using in clinical trials. This questionnaire is widely used in various clinical situations , including in assessing the quality of life patients with rheumatic diseases [7].The aging process is controversial, because on the background of regression processes - atrophy, degradation, etc., develops progressive trends of creating the new compensatory-adaptive mechanisms to maintain homeostasis in an aging body, which, however, does not fully offset the growing phenomena of degradation [2]. It should be noted that the adaptive capacity of the aging body is reduced, the possibility of development various diseases increases. In this context, particularly important in cases of illness in the elderly patient is the role of sanogenetic mechanisms, their stimulation and support. A special interest belongs to the sanatorium stage of rehabilitation, whose mission is the prevention of disease progression, stimulation of compensatory capacity of the muscle-skeletal system and the possible restoration of joint function.Spa treatment has a special place in the treatment and preventive care of elderly patients , as a stage in the system of rehabilitation of many chronic diseases. Multi-disciplinary nature of medical rehabilitation in spa conditions, a wide range of rehabilitation methods can embrace patients of all age groups with the most common diseases [1].Compared with medication treatment, natural and artificial physical factors, when they are properly used, characterized by the absence of allergies, lower incidence and severity of side effects, the ability of positively influencing on the number of pathological processes and the whole body, thus helping to improve the quality of life and are important in the prevention of premature aging [2]. In the resort conditions further rehabilitation is indicated for patients with initial stages of OA, disabled (groups I and II), patients with resistant synovitis and comorbidity with the possibility of self-servicing (including general contraindications for a spa treatment) [3].The aim of the study. To investigate the quality of life in elderly patients with osteoarthritis using international EuroQol questionnaire to evaluate the effectiveness of spa treatment.Materials and methods. In study were included 72 patients aged from 60 to 78 years, middle age was 67,6 ± 8,7 years. Among the patients predominates women - 88.4 %. I radiographic stage of osteoarthritis by J.H. Kellgren-Lawrence [ 6] was diagnosed in 23,3 % of patients , II stage - in 76,7 %. In the view of modern geriatric approaches applying of the physical factors in patients with OA who were in the spa rehabilitation stage in the appointment of balneotherapeutic procedures we gave preference to ultrasonic inhalation of mineral waters and baths , from physiotherapy usually prescribed magnetic-lazer therapy, interferential therapy, patients also performed massage and physical rehabilitation . In order to prevent climate-adaptational and reaclimate-adaptational reactions and optimization process of climate-adaptation were included into the treatment complex ( based on established risk factors) adaptogens and treatment procedures that have adaptogenic action ( phytoaeroionisation , singlet-oxygen therapy). In the process of rehabilitation treatment in sanatorium conditions , we have selected the most effective combination of different methods of rehabilitation , which caused the most significant treatment effectiveness : a combination of balneotherapy , physiotherapy and exercise therapy. To improve continuity during medical rehabilitation, at discharging from the sanatorium patients were given written (in the form of special attractions ) recommendatitons about further treatment, lifestyle, physical activity, diet etc.By the method of randomization, patients were divided into two groups. A marked difference for the main source of clinical and functional parameters between the groups were not observed. The control group consisted of 14 patients of the same age without joint pathology. Treatment regimens differed between the studying groups the presence in one of the groups sanatorium stage of rehabilitation. In the first group (n=34) patients received Structum 500 mg 2 times a day ( within 6 months of the year ) and courses of NSAID, including mainly patients treated with meloxicam ( at a dose of 7,5 mg/d) or nimesulide (in dose of 100-200 mg/d) for 7-10 days during worcening. The patients of the second group (n=38) during the 18-21 day were on spa treatment ( once a year ), in the scheme of rehabilitation were: sitting hydrogen sulfide baths, a concentration of 80 mg/L for 10 minutes at a temperature of 360C , the course of 8 procedures every other day or ultrasonic inhalation by hydrogen sulfide water, period of 5 minutes; blue clay applications every other day at 260C temperature; interferential therapy and magnet-lazer therapy on the affected joints to 8 treatments alternately every other day ; pneumomassage ; classes of physical rehabilitation therapy, aromatherapy , singlet -oxygen therapy . After the sanatorium stage of rehabilitation patients are taking drugs containing chondroitin sulfate (within 6 months of the year), at worcening of NSAIDs.Assessment quality of life related to health , was conducted using an international EuroQol-5D-European Quality of Life instrument (EQ-5D), which consists of two parts. At first part the patient self- assessed his condition by 5 parameters: mobility, self-care , usual activities, pain and discomfort , anxiety and depression. In each variant patients could give three possible answers : No problem - 1 , there is some problem - 2, much of the problem - 3. In the second part of the questionnaire , patients assessed their health on a scale from 0 to 100 on the VAS, the so-called thermometer , where 0 means the worst condition , 100 - the best state of health of the patient. This part of the questionnaire is a quantitative assessment of general health.Statistical analysis of the results was done in the department of statistical system research at SHEE "Ternopil State Medical University by I. Y. Gorbachevsky Ministry of Health of Ukraine" in the software package Statsoft STATISTIC. To determine the reliability of the differences in the change of certain indicators were used parametric and non-parametric methods: criterion Wilkoksona, two-sided Fisher's criterion. A significant differences were considered when the degree of probability of error-free prognosis is (p) 95% (p <0.05). Results and discussion. General description of the health status of patients studied with OA according to EQ-5D questionnaire is given in the table.In all patients with osteoarthritis were found health problems of different severity degrees. Mostly suffers ability to travel and daily activity . This data confirms that the OA in the elderly age reduces quality of life. After 12 months, according to questionnaire, health status was different in two groups . Reliable positive trend was in patients from the second group 57,9 % (p < 0,05), as a result of improving the ability to travel in space , reducing pain and discomfort and increasing of daily activity.According to the second part of the questionnaire EQ-5D, at baseline, most patients had reduced general health assessment : the first group to 51,91 ± 1,07 ( median for «thermometer» EQ 52 points ) in the second group to 50,65 ± 1,17 ( median 48,5 points) in comparison with the best state of possible health. 12 months after the sanatorium stage of rehabilitation of patients with repeated testing were produced the following results : The average index quality of life on the " thermometer " EQ-5D questionnaire in the first group of patients was 54,76 ± 1,23 ( median - 56 points), the second group was 69,28 ± 0,89 ( median - 70 points), reliability differences is high : p < 0,001.In the category quality of life most of all patients reacted on the presence of sanatorium stage of rehabilitation in the category " movement in space " ( GPA retesting 1,60 ± 0,08, p < 0,001), " daily activity " ( GPA retesting 1 68 ± 0,07, p < 0,001), " pain / discomfort " ( GPA retesting 1,92 ± 0,08, p < 0,001), " anxiety / depression ( GPA retesting 1 52 ± 0,08, p < 0,05).Thus, the data suggested that in elderly patients with OA who were once a year on a spa treatment and took over 6 months structure-modification drugs significantly upgraded quality of life during 12 months.Conclusions1. Based on the analysis were founded that elderly patients with OA who underwent rehabilitation treatment in sanatorium- health resorts have continued improving quality of life in comparison with patients who were treated only in outpatient conditions.2. Availability sanatorium stage of rehabilitation in the treatment of elderly patients with OA contributes more complex influence on the human organism.3. Multi-disciplinary nature of medical rehabilitation in spa conditions , a wide range of used restorative treatment methods can affect the quality of life and maintain remission for more longer period in comparison with outpatient treatment.4. Monitoring the quality of life can not only control the functional state of the organism in the elderly aged people at various stages of treatment , but also to properly evaluate the effectiveness of treatment , and, if necessary, to carry out the correction of rehabilitation activities .Perspectives for future research. Aimed at studying the impact of rehabilitative and preventive measures on the quality of life in elderly patients with osteoarthritis at other stages of rehabilitation. Further work in this direction is reasonable and economically justified.REFERENCES1. Golyachenko A.O., Martynyuk V.I., Bakalyuk T.G. Medical rehabilitation in the spa conditions // Journal of research. - 2007 . - № 4. - P. 8-9.2. Kazymyrko V.K., KovalenkoV.N., Flehontova V.V. Involutional osteoarthritis and osteoporosis. - Donetsk: Publisher Zaslavsky A.J., 2011. - 724 p.3. Kovalenko V.N., Bortkiewicz A.P. Osteoarthritis . Practical guidance . - K.: Moryon , 2005. - 592 p.4. Mendel O.I., Naumov A.V., Alekseeva L.I. et al Osteoarthritis as a factor of risk in cardio-vascular catastrophes // Ukrainian Journal of Rheumatology . - 2010 . - № 3. - P. 68-73.5. Povoroznyuk V.V. Osteoarthritis // Art of treatments. - 2004 . - № 3. - P.16 -23.6 . Altman R., Asch E., Bloch D. et al. The American College of Rheumatology criteria for the classification and reporting of osteoarthritis of the knee // Arthritis Rheum. - 1986 . - № 29. - P. 1039-1049 .7 . Harrison M.J., Davies L.M., Bansback N.J. et al. The comparative responsiveness of the EQ-5D and SF-6D to change in patients with inflammatory arthritis // Qual Life Res. - 2009 . - № 18. - P. 1195-1205.8 . Herdman M., Gudex C., Lloyd A., et al. Development and preliminary testing of the new five-level version of EQ-5D (EQ-5D-5L) // Qual Life Res. - 2011 . - № 20 . - P. 1727-1736.9 . Langley P., Muller-Schwefe G., Nicolaou A., Liedgens H., Pergolizzi J., Varrassi G. The societal impact of pain in the European Union: health-related quality of life and healthcare resource utilization // J. Med Econ. - 2010 . - № 1. - P. 571-581. ; Мета: вивчення показників якості життя у хворих похилого віку на остеоартроз з використанням міжнародного запитальника EuroQol для оцінки ефективності санаторно-курортного лікування.Матеріали і методи. У дослідження було включено 72 пацієнти віком від 60 до 78 років, середній вік склав 67,6±8,7 року. Методом рандомізації пацієнтів було розподілено на дві групи. Пацієнти однієї з груп додатково проходили реабілітацію в умовах санаторію протягом 18-21 дня. Оцінка якості життя, пов'язаного зі здоров'ям, проводилась з використанням міжнародного запитальника EuroQol-5D-European Quality of Life instrument (EQ-5D).Результати. У всіх хворих на остеоартроз виявлено проблеми зі здоров'ям різного ступеня. Через 12 місяців за даними запитальника достовірна позитивна динаміка якості життя спостерігалася у пацієнтів, що проходили санаторно-куротне лікування, за рахунок покращення здатності до пересування, зменшення болю і дискомфорту та збільшення повсякденної активності.Висновки. Наявність санаторно-курортного етапу реабілітації у комплексному лікуванні остеоартрозу дозволяє вплинути на якість життя та зберегти ремісію на більш тривалий термін порівняно з амбулаторним лікуванням.КЛЮЧОВІ СЛОВА: якість життя, санаторно-курортне лікування, остеоартроз.

Aerosols play a key role in air quality (health aspects) and climate. In this thesis atmospheric chemistry transport models are used to study the uncertainties in aerosol modelling and to evaluate the effects of emission reduction scenarios on air quality. Uncertainties in: the emissions of gas and aerosol species in the inventories, in meteorological parameters, in the impact of orography on meteorology, all contribute to the uncertainties in gas and aerosol modelling and require high priority in order to estimate better the gas and aerosol concentrations for scientific research and policy making. The overall objectives of this thesis are to identify and quantify a few key uncertainties related to gas and aerosol regional and global scale modelling. These are: I. The impact of using two different emission inventories on gas and aerosol calculated concentrations. II. The role of the temporal and vertical distribution of emissions on gas and aerosol calculations. III. The impact of model resolution on aerosol calculations. IV. The impact of using two different meteorological driver models on gas and aerosol calculations. V. The impact of emission reduction scenarios on calculated air quality. VI. Strategies to evaluate model results with atmospheric measurements. In Chapter 1 an introduction to aerosols and aerosol modelling is given. In the following chapters, the subjects regarding the uncertainties in aerosol modelling are described. The first and the second subject of this thesis, the sensitivity in aerosol modelling to two different emission inventories, injection altitude and temporal variations of anthropogenic emissions, is described in chapter 2. We use the two-way nested global transport chemistry model TM5 focusing on Europe in June and December 2000. Two widely used emission inventories were available for this study. The EMEP inventory is a policy relevant European scale inventory which contains reported emissions by the member countries (http://www/emep.int), with more detailed information on the vertical, temporal and spatial distribution of the emissions. The AEROCOM inventory (Dentener et al., 2006) is a compilation of global scale aerosol and precursor emissions for the year 2000, and was used in the IPCC AR5 assessment report. The simulations of gas, aerosol concentrations and aerosol optical depth (AOD) with the two emission inventories are compared with EMEP gas and aerosol surface based measurements, AERONET sun photometer retrievals and MODIS satellite data. We evaluated the impact of the EMEP and AEROCOM emission inventories on aerosol concentrations and aerosol optical depth (AOD) in Europe for June and December 2000. There are substantial differences between annual emissions included in the two inventories. It also appears that differences are found in the vertical distribution of the SO2 and NOx emissions. Despite these differences, for most aerosol species and aerosol precursor gases TM5 simulates the spatial and temporal distribution over Europe relatively well when compared to observations. Spatial correlations, based on monthly mean surface concentrations, are often quite high (> 0.7) and many EMEP measurement stations show high temporal correlation with the simulations using EMEP and AEROCOM. However, from the comparison with surface observations, we conclude that the AEROCOM inventory overestimates the emissions of aerosol precursor gases SO2 and NOx and NH3 emissions, especially in June. Furthermore, a lack in seasonal varia tion in the AEROCOM inventory and uncertainty in the vertical distribution of emissions (SO2 and NOx), contributes to disagreement of model and surface observations. For NH3 it seems that the inclusion of recent abatement measures in the EMEP inventory indeed leads to a better agreement with measured concentrations. The large differences in surface concentrations between the simulations are not equally reflected in corresponding differences in computed column aerosol and AOD. Model AOD computations using the AEROCOM and EMEP emission inventories reveal good agreement with surface based AERONET sun photometer observations and AOD retrieved from MODIS. Spatial patterns over Europe of AOD differ due to the varying contributions of mineral dust and inorganic aerosol, as observed by satellite and confirmed by model simulations. An evaluation of the impact on aerosol of the temporal distribution (daily, weekly and seasonal) of emissions reveals that the concentrations of most aerosol components are not strongly influenced by introduction of a high temporal resolution of emissions. The exception is aerosol nitrate and its precursor gases NOx, and NH3. However, seasonal temporal variation of the emissions do play an important role for all gas and aerosol calculations, and need to be included to accurately calculate aerosol concentrations and it's influence on air quality and climate change. The third subject of this thesis is to study the model resolution dependency on aerosol calculations, see chapter 3. For this work the mesoscale Transport of Atmospheric Pollutants Model (TAPOM) is used. Firstly, we evaluated the TAPOM performance in calculated aerosol surface concentrations and aerosol optical depth (AOD) values for the greater Milan area in Italy during June 2001. Secondly, we used the model to study scale issues in aerosol modelling at three horizontal resolutions (5x5 km, 10x10 km and 20x20 km) through calculations of AOD and other aerosol properties for the same area and period. Model calculations of sulphate aerosol concentrations on a 5x5 km horizontal resolution show a reasonable agreement with measurements, i.e. within a factor 1.5 of the measurements. A comparison of aerosol optical depth calculated with the model and surface based sun photometer measurements revealed some discrepancies, which can be roughly divided in two clusters: 1. On clear, dry sky days there is a relatively good correlation between model and sun photometer AOD and satellite AOD. 2. A second group of model calculated AOD and measurements appear to be uncorrelated. The discrepancies of model results and measurements are for some days related to the underestimation of PM emissions and the lack of natural dust at the boundaries. Another reason could be related to the presence of cirrus clouds appearing as AOD in the measurements. Model calculations at 5x5 and 10x10 km horizontal resolution show a good internal agreement, whereas a model version using 20x20 km resolution loses some details regarding the spatial distribution of AOD. Daily mean and maximum coinciding model 5x5 km AOD values with MODIS and MISR AOD agree better with the observations than the computed AOD using the 20x20 km resolution. The largest differences in aerosol calculated concentrations between the different resolutions are associated with high RH (relative humidity) conditions leading to large amounts of computed aerosol water and higher AOD values. A further scale related issue is the non-linearity of aerosol formation at especially high relative humidity. These uncertainties are expected to be even more uncertain in large scale models that use fairly simplified parameterization relating relative humidity to cloud formation. Given the uncertainties in cloud screening of the satellite products, the reliability of these satellite products is often questionable and it has turned out to be difficult to make comparisons to model results at the mesoscale (like in this study). This problem is even larger for global scale models, with resolutions higher than 100x100km and less detailed emission inventories, where local and regional information are not taken into account. This study also showed the importance of accurate model boundary conditions for realistic gas, aerosol and AOD computations in regional/urban scale air quality modelling. In chapter 4, the fourth subject of thesis is described, i.e. studying the impact of two different meteorological models (MM5 and WRF) on aerosol and O3 calculations with the chemistry transport model CHIMERE. The area and period of interest is the Po valley region (Italy) for January and June 2005. The meteorological data sets used for the study were created in the frame of the Po valley air quality Model Inter-comparison (POMI) exercise, which is coordinated by the Institute of Environment and Sustainability, JRC, Ispra, Italy (http://aqm.jrc.it/POMI/). First we evaluate for January, June and the whole year the calculated meteorological parameters by MM5 and WRF (temperature, wind speed, wind direction, relative humidity and precipitation) with observations. The analysis shows that the overall performance of both models is similar, however some small differences are still noticeable. On a yearly basis, the temperatures are mainly underestimated (less by WRF) when compared to observations and the values of relative humidity are in general overestimated (less by MM5). WRF output follows better the hourly pattern of relative humidity. We had only two stations available with wind data. The wind speed is well reproduced for Ispra monitoring site (especially by WRF) but for Mantova is largely overestimated by both models (less by MM5). Both models do not reproduce well the wind direction. The rainfall is in general overestimated, however the MM5 output shows lower rainfall values. Secondly, we analyze the impact of using MM5 and WRF on calculated PM10 and O3 concentrations. In general the model underestimates the observed PM10 concentrations with both the MM5 and WRF meteorology, from now on denoted as CHIMERE/MM5, CHIMERE/WRF respectively. The PM10 concentrations for January are a factor 1.6 higher for CHIMERE/MM5 than CHIMERE/WRF. The concentrations of gases and aerosols at ground level strongly depend on the profile of the planetary boundary layer. Therefore we examined the PBL profiles and the latent and sensible heat fluxes which are responsible for the PBL formation. The difference and the larger underestimation in PM10 concentrations by CHIMERE/WRF are related to the differences in heat fluxes and the resulting PBL heights calculated by WRF. In general the PBL height by WRF meteorology is a factor 2.8 higher at noon in January than calculated by MM5. This could result in a better vertical mixing of the aerosols than CHIMERE/MM5, causing lower aerosol concentrations at the surface. Changing the Noah LSM scheme in our WRF pre-processing for the 5-layer soil temperature model, leads to an increase of the calculated PM10 concentrations of 30% for January 2005 when compared to the simulation using Noah LSM. This study also showed that the difference in microphysics scheme has an impact on the profile of cloud liquid water (CLW) calculated by the meteorological driver and therefore on the production and removal of SO4 = aerosol. For June the differences in PM10 concentrations between the model simulations using MM5 and WRF are small. Analyzing the heat fluxes and the diurnal behaviour of the PBL height we observe small differences between the two meteorological models. In the previous chapters, three major uncertainties which contribute to modelled aerosol calculations are described. It is crucial to understand how important these sources of uncertainties contribute to the model outcome, especially when the model results are used for policy relevant studies. In the last chapter of this thesis (chapter 5) we performed a case study to evaluate the impact of emission reduction scenarios on PM2.5 and O3 calculated concentrations for the Po valley area, by using the chemistry transport model CHIMERE. Comparing calculated surface aerosol concentrations by the model for the standard case (no emission reductions) with observations for January and June 2005 shows that the monthly mean PM10 concentrations are in general underestimated by a factor 1.4. To evaluate the impact of emission reduction scenarios we reduced the emissions of NOx, PM2.5, SO2, VOC or NH3 by 50% separately for each component and for different source sectors, together with 5 additional scenarios. The 50% reduction of the emissions corresponds to the application of the current legislation for PM2.5 for Italy which should be met in 2010 in respect to the emissions of the base year 2000 (EURODELTA exercise: http://aqm.jrc.it/eurodelta/, which is carried out in the frame of the Clean Air For Europe programme, CAFE). The most effective scenarios to abate PM2.5 concentration are based on the nonindustrial combustion plants, i.e. domestic heating (SNAP2) and road traffic (SNAP7) sectors, for which the NOx and PM2.5 emissions are reduced by 50%. These scenarios reduce the monthly calculated PM2.5 concentrations for the Po valley area for January on average by 1-6µg/m3. However, these emission reduction scenarios for domestic heating and traffic do not have an effect on lowering the number of days for which the planned European limit value (Directive 2008/50/EC) of 25µg/m3 is exceeded. Only by combining the emission reductions of NOx, PM25, SO2, VOC and NH3 for domestic heating, road traffic and agriculture (SNAP10) results in a larger reduction of PM2.5 calculated concentrations over the larger area in the Lombardy region (~20%), which corresponds with the findings of a similar study performed by APAT (the Italian National Agency for environmental protection and technical services). In the APAT study more than one species was reduced for different activity sectors. Our study also showed that a more effective pollutant reduction (emissions) per tonne of pollutant reduced (concentrations) for the greater Milan area is obtained by reducing the primary PM2.5 emissions for road traffic. The most effective scenario on (secondary) PM2.5 decrease for which precursor emissions are reduced is achieved by reducing SO2 emissions by 50% for road traffic. Our study showed that during summer, the largest reductions in O3 concentrations are achieved for SNAP 7 emission reductions, when volatile organic compounds (VOCs) are reduced by 50%. It appears that around 40% of the PM2.5 concentration for Milan is caused by the emissions from surroundings of the Lombardy region as well as by longrange transport from elsewhere (as reflected as model boundary conditions). Therefore effective abatement of air pollution does need the consideration of the transboundary aspects of air pollution. Our study showed that differences may occur between measurement (ground based and space born) data sets for the same variable and time period. This complicates the use of observations for model evaluation purposes. The main conclusions of this thesis can be summarized as: • The amounts and the temporal and vertical distributions of the emissions are important for gas and aerosol calculations, especially when calculations are compared to surface measurements. • Going to a finer model resolution results in better agreement between calculated aerosol and AOD values and observations. • The PBL height and vertical mixing of the lower troposphere determine to a large extend the surface gas and aerosol concentrations. These boundary layer characteristics are strongly determined by the sensible and latent heat fluxes at the surface. • Local emission reductions result in a local improvement in air quality.Longrange transport is however also very important for reducing local pollution. • Surface and space born measurements of gas phase and aerosol components are crucial for evaluating model results. However inconsistencies in measurement data sets make it complicated for reliable comparisons with model simulations.

El Objeto de la tesis son las ciudades de Gibellina y Salemi (valle del Belice, Sicilia), destruidas, en su totalidad o en parte, por un violento terremoto en enero de 1968. El objetivo de la tesis es estudiar la relación entre permanencia y transformación en la arquitectura de la ciudad a través del análisis de un caso extremo donde una catástrofe provoca una fractura repentina en la evolución, física y social, de la historia de un lugar. El proceso de reconstrucción evidencia como estos elementos se combinan en el proyecto arquitectónico y en el uso del espacio construido para que la ciudad se mantenga viva. En los últimos 40 años Gibellina y Salemi han sido un laboratorio de la arquitectura y de las ciencias humanas, en una dimensión analizable en un único estudio; el Belice un banco de pruebas para la cultura política y arquitectónica italiana, que no tenía, entonces, herramientas legislativas para actuar al margen de la cultura de la emergencia. Gibellina y Salemi son el sujeto de una investigación histórica que sitúa la mirada en el presente y en el uso. Las dos ciudades, física y social, dialogan: la primera cambia y requiere que lo haga también la segunda. ¿Cómo la historia interrumpida puede seguir su curso? ¿Cómo la conservación y la innovación de los elementos espaciales y culturales de una comunidad garantizan su supervivencia? ¿Cómo la memoria rememorada hace avanzar hacia el futuro? Estas preguntas nacen de unas hipótesis iniciales. La primera es que la construcción de la ciudad sea un proceso continuo donde territorio y sociedad son los términos de un diálogo constante. La segunda concierne al propio mecanismo de la catástrofe el cual no puede leerse solo como acontecimiento luctuoso, sino como portador de un punto de vista nuevo, de la oportunidad de hacer las cosas de manera diferente. La memoria, para acabar, cobra un papel fundamental combinando permanencia y transformación tanto en el proyecto de arquitectura como en el uso de la ciudad. Si el análisis de un caso concreto puede aclarar los mecanismos de producción, transformación y transmisión de la arquitectura en el tiempo, podremos entender, mediante él, cómo se mantiene a lo largo de la historia la conexión entre un territorio y su cultura. La tesis reordena las etapas de la reconstrucción y propone un punto de vista diferente con respecto a mucha literatura sobre Belice, situando el análisis del texto urbano en su específico contexto histórico, geográfico y cultural, sin expresar juicios a posteriori e investigando las razones contingentes de las elecciones llevadas a cabo. La tesis se compone de tres partes según una estructura cronológica clásica. En la primera se analiza el Belice según los parámetros de construcción y resistencia. La teoría del territorio como paisaje construido y culturalizado se refiere a la tradición italiana desde Assunto hasta Natarelli. La lectura de Rossi es fundamental para entender la ciudad como artefacto que evoluciona en el tiempo. La teoría sociogenética de Muntañola relaciona proyecto, territorio y sociedad, mientras que la psicología ambiental, Pol, ayuda a comprender lo urbano desde el punto de vista del sujeto que lo habita. El análisis de la arquitectura en el tiempo se hace a partir de la teoría del tipo como estructura que, en la tradición de Quatremère de Quincy, es releída y actualizada por Caniggia y Muratori en los setenta y, más recientemente, por Martí y Moneo. Para la reflexión sobre forma, figura y símbolo nos referimos a Colquhoun y para el concepto de espacio prototípico en psicología ambiental a Valera. Fuera de la arquitectura, la topología y la teoría psicogenética de Piaget sugieren un interesante punto de vista para entender la evolución del tipo en el tiempo. Con estas bases se identifican y describen los tipos urbanos y arquitectónicos fundamentales del Belice antes 1968. La segunda parte se apoya en los estudios de Muntañola sobre la poética en arquitectura y utiliza la teoría de las catástrofes del matemático René Thom para defender la duplicidad del concepto de catástrofe: como trauma y como solución. El análisis de estos puntos de vista aplicados a la arquitectura hace reflexionar sobre como "regla" y "modelo" intervienen en el proyecto de arquitectura en un contexto de destrucción de la forma urbana y disolución del contexto social al que pertenece. El estudio de los planes para Gibellina y Salemi ha sido hecho de acuerdo con esta nueva orientación. En la tercera parte, la teoría de la memoria de Ricoeur ayuda a entender como resistencia y transformación se entrelazan en los diferentes proyectos de reconstrucción a través de los elementos de topos, tipo y uso. La relación del texto arquitectónico con su contexto histórico y social se cumple en el "habitar reflexivo". ; Oggetto della tesi sono le città di Gibellina e Salemi (valle del Belice, Sicilia), distrutte, nella loro totalità o in parte, da un violento terremoto nel gennaio del 1968. Obiettivo della tesi è indagare la relazione tra permanenza e trasformazione nell'architettura della città attraverso l'analisi di un caso estremo in cui una catastrofe opera una frattura repentina nell'evoluzione, fisica e sociale, della storia di un luogo. Il processo di ricostruzione mostra come i due elementi si combinano nel progetto architettonico e nell'uso dello spazio costruito per consentire alla città di mantenersi viva. Durante gli ultimi 40 anni Gibellina e Salemi sono state un laboratório dell'architettura e delle scienze umane, in una dimensione analizzabile in un unico studio; il Belice un banco di prova per la cultura politica e architettonica italiana priva, allora, di strumenti legislativi per operare oltre la cultura dell'emergenza. Gibellina e Salemi sono il soggetto di una ricerca storica, che situa lo sguardo nel presente e sull'uso. Le due città, fisica e sociale, dialogano: la prima si modifica e richiede che lo faccia anche la seconda. Come la storia interrotta prosegue il suo corso? Come la conservazione e il rinnovamento degli elementi spaziali e culturali di una comunità ne garantiscono la sopravvivenza? Come la memoria fa avanzare verso il futuro? Queste domande nascono da alcune ipotesi di partenza. La prima è che la costruzione della città sia un processo continuo in cui territorio e società sono i termini di un dialogo costante. La seconda riguarda il meccanismo stesso della catastrofe che non può essere letta solo come evento luttuoso, ma tale da portare con sè il germe costruttivo di un punto di vista nuovo, della opportunità di fare le cose diversamente. La memoria, infine, ha un ruolo fondamentale nel combinare permanenza e trasformazione tanto nel progetto di architettura come nell'uso della città. Se l'analisi di un caso concreto può far luce sui meccanismi di produzione, trasformazione e trasmissione dell'architettura nel tempo, potremo, per suo tramite, capire come il legame tra un territorio e la sua cultura si mantiene nella storia. La tesi riordina le tappe della ricostruzione e propone un punto di vista diverso rispetto a molta letteratura sul Belice, situando l'analisi del testo urbano all'interno del suo specifico contesto storico, geografico e culturale, senza esprimere giudizi a posteriori e indagando le ragioni contingenti delle scelte operate. La tesi si compone di tre parti secondo una struttura cronologica classica. Nella prima, si analizza il Belice secondo i parametri di costruzione e resistenza. La teoria del territorio come paesaggio costruito e culturalizzato si rifà alla tradizione italiana da R. Assunto fino a E. Natarelli. La lettura di A. Rossi è fondamentale per intendere la città come manufatto che si evolve nel tempo. La teoria sociogenetica di J. Muntañola relaziona progetto, territorio e società, mentre la psicologia ambientale, E. Pol, aiuta nella comprensione dell'urbano dal punto di vista del soggetto che lo abita. L'analisi della resistenza dell'architettura nel tempo viene a fatta a partire dalla teoria del tipo come struttura che, nella tradizione di Quatremère de Quincy, è riletta e aggiornata da G. Caniggia e S. Muratori negli anni '70 e più recentemente da C. Martì e R. Moneo. Per la riflessione su forma, figura e simbolo ci siamo riferiti ad A. Colquhoun e per il concetto di spazio prototipico in psicologia ambientale a S. Valera. Al di fuori dell'architettura, la topologia e la teoria psicogenetica di J. Piaget suggeriscono un interessante punto di vista per capire l'evoluzione del tipo nel tempo. Su queste basi si identificano e descrivono i tipi urbani ed architettonici fondamentali del Belice prima del 1968. La seconda parte si appoggia agli studi di Muntañola sulla poetica in architettura e utilizza la teoria delle catastrofi del matematico R. Thom per sostenere la duplicità del concetto di catastrofe: come trauma e come soluzione. L'analisi dei due punti di vista applicati all'architettura fa riflettere su come regola e modello intervengono nel progetto di architettura in un contesto di distruzione della forma urbana e di dissoluzione del contesto sociale di appartenenza. Lo studio dei piani per Gibellina e Salemi è fatto a partire da questo nuovo orientamento. Nella terza parte la teoria della memoria di P. Ricoeur ci aiuta a capire come resistenza e trasformazione si declinano nei diversi progetti di ricostruzione mediante i tre elementi di topos, tipo e uso. La relazione del testo architettonico con il suo contesto storico e sociale trova compimento nell'abitare riflessivo. ; This thesis explores the cities of Gibellina and Salemi (Belice Valley, Sicily), which were entirely or partially destroyed by a major earthquake in January 1968. The aim of the thesis is to study the relationship between permanence and transformation in the architecture of the city by analysing an extreme case in which a disaster causes a sudden fracture in the physical and social evolution of the history of a place. The reconstruction process shows how these elements are combined in the architectural project and use of built-up space in order to keep the city alive. In the last forty years Gibellina and Salemi have been a laboratory for architecture and human sciences on a scale that can be analysed in one study. Belice is a testbed for Italian political and architectural culture which at that time did not possess the legislative means to act outside the emergency culture. Gibellina and Salemi are the subject of historical research focusing on the present and on use. Both cities, physically and socially, maintain a dialogue: the former changes and forces the latter to do so also. How can uninterrupted history continue its course? How do the conservation and innovation of the spatial and cultural elements of a community ensure its survival? How does remembered memory lead us into the future? All of these questions are borne out of initial hypotheses. The first is that the construction of a city is a continual process in which land and society are the terms of ongoing dialogue. The second concerns the mechanism of the disaster itself, which must not be seen merely as a painful event but as the bringer of a new perspective - the chance to do things differently. Finally, memory plays a key role by bringing together permanence and transformation both in the architectural project and in the use of the city. If analysing a specific case can shed light upon the mechanisms of production, transformation and transmission of architecture in time, we shall thereby be able to understand how the connection between a land and its culture is upheld through history. This thesis reorders the reconstruction stages and proposes a fresh point of view with regard to the bulk of the literature on Belice, placing the urban text analysis within its historical, geographical and cultural context without making judgements and exploring the underlying reasons for the choices made. It is split into three parts in the classical chronological structure. Firstly, Belice is analysed in terms of construction and resistance. The theory of territory as a built and culturalized landscape refers to the Italian tradition from Assunto to Natarelli. The reading of Rossi is vital to understanding the city as an artefact that evolves over time. Josep Muntañola's theory of sociogenetics links project, territory and society, whilst Enric Pol's work on environmental psychology provides insight into the urban from the perspective of its inhabitants. My analysis of architecture over time is underpinned by the theory of the type as structure which, in the tradition of Quatremère de Quincy, was revisited and updated by Caniggia and Muratori in the 1970's and, more recently, by Martí and Moneo. I shall refer to Colquhoun on form, figure and symbol, and to Valera on the concept of prototypical space in environmental psychology. Moving beyond the architectural domain, Jean Piaget's theory of psychogenetics provides a fascinating point of view for understanding the evolution of type in time. These are the underlying principles that have been taken to identify and describe the fundamental urban and architectural types in Belice before 1968. The second section is based on Muntañola's studies on the poetic in architecture and uses mathematician René Thom's catastrophe theory to support the twofold nature of the catastrophe concept: as a trauma and as a solution. The analysis of these points of view as applied to architecture leads to a consideration of how 'rule' and 'model' intervene in the architectural project in a context of destruction of the urban form and breakdown of the social setting to which it belongs. The plans for Gibellina and Salemi have been studied in accordance with this new direction. In the third part, Ricoeur's memory theory is useful in understanding how resistance and transformation are intertwined in the various reconstruction projects through the three elements topos, types and use. The relationship between the architectural text and its historical and social setting is brought about by "reflexive inhabiting". ; Postprint (published version)

El Objeto de la tesis son las ciudades de Gibellina y Salemi (valle del Belice, Sicilia), destruidas, en su totalidad o en parte, por un violento terremoto en enero de 1968. El objetivo de la tesis es estudiar la relación entre permanencia y transformación en la arquitectura de la ciudad a través del análisis de un caso extremo donde una catástrofe provoca una fractura repentina en la evolución, física y social, de la historia de un lugar. El proceso de reconstrucción evidencia como estos elementos se combinan en el proyecto arquitectónico y en el uso del espacio construido para que la ciudad se mantenga viva. En los últimos 40 años Gibellina y Salemi han sido un laboratorio de la arquitectura y de las ciencias humanas, en una dimensión analizable en un único estudio; el Belice un banco de pruebas para la cultura política y arquitectónica italiana, que no tenía, entonces, herramientas legislativas para actuar al margen de la cultura de la emergencia. Gibellina y Salemi son el sujeto de una investigación histórica que sitúa la mirada en el presente y en el uso. Las dos ciudades, física y social, dialogan: la primera cambia y requiere que lo haga también la segunda. ¿Cómo la historia interrumpida puede seguir su curso? ¿Cómo la conservación y la innovación de los elementos espaciales y culturales de una comunidad garantizan su supervivencia? ¿Cómo la memoria rememorada hace avanzar hacia el futuro? Estas preguntas nacen de unas hipótesis iniciales. La primera es que la construcción de la ciudad sea un proceso continuo donde territorio y sociedad son los términos de un diálogo constante. La segunda concierne al propio mecanismo de la catástrofe el cual no puede leerse solo como acontecimiento luctuoso, sino como portador de un punto de vista nuevo, de la oportunidad de hacer las cosas de manera diferente. La memoria, para acabar, cobra un papel fundamental combinando permanencia y transformación tanto en el proyecto de arquitectura como en el uso de la ciudad. Si el análisis de un caso concreto puede aclarar los mecanismos de producción, transformación y transmisión de la arquitectura en el tiempo, podremos entender, mediante él, cómo se mantiene a lo largo de la historia la conexión entre un territorio y su cultura. La tesis reordena las etapas de la reconstrucción y propone un punto de vista diferente con respecto a mucha literatura sobre Belice, situando el análisis del texto urbano en su específico contexto histórico, geográfico y cultural, sin expresar juicios a posteriori e investigando las razones contingentes de las elecciones llevadas a cabo. La tesis se compone de tres partes según una estructura cronológica clásica. En la primera se analiza el Belice según los parámetros de construcción y resistencia. La teoría del territorio como paisaje construido y culturalizado se refiere a la tradición italiana desde Assunto hasta Natarelli. La lectura de Rossi es fundamental para entender la ciudad como artefacto que evoluciona en el tiempo. La teoría sociogenética de Muntañola relaciona proyecto, territorio y sociedad, mientras que la psicología ambiental, Pol, ayuda a comprender lo urbano desde el punto de vista del sujeto que lo habita. El análisis de la arquitectura en el tiempo se hace a partir de la teoría del tipo como estructura que, en la tradición de Quatremère de Quincy, es releída y actualizada por Caniggia y Muratori en los setenta y, más recientemente, por Martí y Moneo. Para la reflexión sobre forma, figura y símbolo nos referimos a Colquhoun y para el concepto de espacio prototípico en psicología ambiental a Valera. Fuera de la arquitectura, la topología y la teoría psicogenética de Piaget sugieren un interesante punto de vista para entender la evolución del tipo en el tiempo. Con estas bases se identifican y describen los tipos urbanos y arquitectónicos fundamentales del Belice antes 1968. La segunda parte se apoya en los estudios de Muntañola sobre la poética en arquitectura y utiliza la teoría de las catástrofes del matemático René Thom para defender la duplicidad del concepto de catástrofe: como trauma y como solución. El análisis de estos puntos de vista aplicados a la arquitectura hace reflexionar sobre como "regla" y "modelo" intervienen en el proyecto de arquitectura en un contexto de destrucción de la forma urbana y disolución del contexto social al que pertenece. El estudio de los planes para Gibellina y Salemi ha sido hecho de acuerdo con esta nueva orientación. En la tercera parte, la teoría de la memoria de Ricoeur ayuda a entender como resistencia y transformación se entrelazan en los diferentes proyectos de reconstrucción a través de los elementos de topos, tipo y uso. La relación del texto arquitectónico con su contexto histórico y social se cumple en el "habitar reflexivo". ; Oggetto della tesi sono le città di Gibellina e Salemi (valle del Belice, Sicilia), distrutte, nella loro totalità o in parte, da un violento terremoto nel gennaio del 1968. Obiettivo della tesi è indagare la relazione tra permanenza e trasformazione nell'architettura della città attraverso l'analisi di un caso estremo in cui una catastrofe opera una frattura repentina nell'evoluzione, fisica e sociale, della storia di un luogo. Il processo di ricostruzione mostra come i due elementi si combinano nel progetto architettonico e nell'uso dello spazio costruito per consentire alla città di mantenersi viva. Durante gli ultimi 40 anni Gibellina e Salemi sono state un laboratório dell'architettura e delle scienze umane, in una dimensione analizzabile in un unico studio; il Belice un banco di prova per la cultura politica e architettonica italiana priva, allora, di strumenti legislativi per operare oltre la cultura dell'emergenza. Gibellina e Salemi sono il soggetto di una ricerca storica, che situa lo sguardo nel presente e sull'uso. Le due città, fisica e sociale, dialogano: la prima si modifica e richiede che lo faccia anche la seconda. Come la storia interrotta prosegue il suo corso? Come la conservazione e il rinnovamento degli elementi spaziali e culturali di una comunità ne garantiscono la sopravvivenza? Come la memoria fa avanzare verso il futuro? Queste domande nascono da alcune ipotesi di partenza. La prima è che la costruzione della città sia un processo continuo in cui territorio e società sono i termini di un dialogo costante. La seconda riguarda il meccanismo stesso della catastrofe che non può essere letta solo come evento luttuoso, ma tale da portare con sè il germe costruttivo di un punto di vista nuovo, della opportunità di fare le cose diversamente. La memoria, infine, ha un ruolo fondamentale nel combinare permanenza e trasformazione tanto nel progetto di architettura come nell'uso della città. Se l'analisi di un caso concreto può far luce sui meccanismi di produzione, trasformazione e trasmissione dell'architettura nel tempo, potremo, per suo tramite, capire come il legame tra un territorio e la sua cultura si mantiene nella storia. La tesi riordina le tappe della ricostruzione e propone un punto di vista diverso rispetto a molta letteratura sul Belice, situando l'analisi del testo urbano all'interno del suo specifico contesto storico, geografico e culturale, senza esprimere giudizi a posteriori e indagando le ragioni contingenti delle scelte operate. La tesi si compone di tre parti secondo una struttura cronologica classica. Nella prima, si analizza il Belice secondo i parametri di costruzione e resistenza. La teoria del territorio come paesaggio costruito e culturalizzato si rifà alla tradizione italiana da R. Assunto fino a E. Natarelli. La lettura di A. Rossi è fondamentale per intendere la città come manufatto che si evolve nel tempo. La teoria sociogenetica di J. Muntañola relaziona progetto, territorio e società, mentre la psicologia ambientale, E. Pol, aiuta nella comprensione dell'urbano dal punto di vista del soggetto che lo abita. L'analisi della resistenza dell'architettura nel tempo viene a fatta a partire dalla teoria del tipo come struttura che, nella tradizione di Quatremère de Quincy, è riletta e aggiornata da G. Caniggia e S. Muratori negli anni '70 e più recentemente da C. Martì e R. Moneo. Per la riflessione su forma, figura e simbolo ci siamo riferiti ad A. Colquhoun e per il concetto di spazio prototipico in psicologia ambientale a S. Valera. Al di fuori dell'architettura, la topologia e la teoria psicogenetica di J. Piaget suggeriscono un interessante punto di vista per capire l'evoluzione del tipo nel tempo. Su queste basi si identificano e descrivono i tipi urbani ed architettonici fondamentali del Belice prima del 1968. La seconda parte si appoggia agli studi di Muntañola sulla poetica in architettura e utilizza la teoria delle catastrofi del matematico R. Thom per sostenere la duplicità del concetto di catastrofe: come trauma e come soluzione. L'analisi dei due punti di vista applicati all'architettura fa riflettere su come regola e modello intervengono nel progetto di architettura in un contesto di distruzione della forma urbana e di dissoluzione del contesto sociale di appartenenza. Lo studio dei piani per Gibellina e Salemi è fatto a partire da questo nuovo orientamento. Nella terza parte la teoria della memoria di P. Ricoeur ci aiuta a capire come resistenza e trasformazione si declinano nei diversi progetti di ricostruzione mediante i tre elementi di topos, tipo e uso. La relazione del testo architettonico con il suo contesto storico e sociale trova compimento nell'abitare riflessivo. ; This thesis explores the cities of Gibellina and Salemi (Belice Valley, Sicily), which were entirely or partially destroyed by a major earthquake in January 1968. The aim of the thesis is to study the relationship between permanence and transformation in the architecture of the city by analysing an extreme case in which a disaster causes a sudden fracture in the physical and social evolution of the history of a place. The reconstruction process shows how these elements are combined in the architectural project and use of built-up space in order to keep the city alive. In the last forty years Gibellina and Salemi have been a laboratory for architecture and human sciences on a scale that can be analysed in one study. Belice is a testbed for Italian political and architectural culture which at that time did not possess the legislative means to act outside the emergency culture. Gibellina and Salemi are the subject of historical research focusing on the present and on use. Both cities, physically and socially, maintain a dialogue: the former changes and forces the latter to do so also. How can uninterrupted history continue its course? How do the conservation and innovation of the spatial and cultural elements of a community ensure its survival? How does remembered memory lead us into the future? All of these questions are borne out of initial hypotheses. The first is that the construction of a city is a continual process in which land and society are the terms of ongoing dialogue. The second concerns the mechanism of the disaster itself, which must not be seen merely as a painful event but as the bringer of a new perspective - the chance to do things differently. Finally, memory plays a key role by bringing together permanence and transformation both in the architectural project and in the use of the city. If analysing a specific case can shed light upon the mechanisms of production, transformation and transmission of architecture in time, we shall thereby be able to understand how the connection between a land and its culture is upheld through history. This thesis reorders the reconstruction stages and proposes a fresh point of view with regard to the bulk of the literature on Belice, placing the urban text analysis within its historical, geographical and cultural context without making judgements and exploring the underlying reasons for the choices made. It is split into three parts in the classical chronological structure. Firstly, Belice is analysed in terms of construction and resistance. The theory of territory as a built and culturalized landscape refers to the Italian tradition from Assunto to Natarelli. The reading of Rossi is vital to understanding the city as an artefact that evolves over time. Josep Muntañola's theory of sociogenetics links project, territory and society, whilst Enric Pol's work on environmental psychology provides insight into the urban from the perspective of its inhabitants. My analysis of architecture over time is underpinned by the theory of the type as structure which, in the tradition of Quatremère de Quincy, was revisited and updated by Caniggia and Muratori in the 1970's and, more recently, by Martí and Moneo. I shall refer to Colquhoun on form, figure and symbol, and to Valera on the concept of prototypical space in environmental psychology. Moving beyond the architectural domain, Jean Piaget's theory of psychogenetics provides a fascinating point of view for understanding the evolution of type in time. These are the underlying principles that have been taken to identify and describe the fundamental urban and architectural types in Belice before 1968. The second section is based on Muntañola's studies on the poetic in architecture and uses mathematician René Thom's catastrophe theory to support the twofold nature of the catastrophe concept: as a trauma and as a solution. The analysis of these points of view as applied to architecture leads to a consideration of how 'rule' and 'model' intervene in the architectural project in a context of destruction of the urban form and breakdown of the social setting to which it belongs. The plans for Gibellina and Salemi have been studied in accordance with this new direction. In the third part, Ricoeur's memory theory is useful in understanding how resistance and transformation are intertwined in the various reconstruction projects through the three elements topos, types and use. The relationship between the architectural text and its historical and social setting is brought about by "reflexive inhabiting". ; Postprint (published version)

Building no. 02. The Regiment House has been called by many names. Although small in stature, it has a diverse history. Not only has its use and title changed many times since it was built, it has also misled some local historians into reporting it as being located at different places. Once affectionately known as "The Little Chapel at Fort Brown," it originally stood with its back to the Rio Grande and faced the parade grounds near the present Gateway International Bridge and Customs facilities. Sources noted it had "been moved from its original location to a point near the international bridge." Another account described the chapel as once being located near the Jefferson entrance and used as a school for African-American soldiers. These minor errors that crept into historical record made Building No. 2. an interesting study. There were actually two chapels; each one moved one time and still in use today. The first chapel was originally built to be used as a school and library. In 1889, plans were originally designed for it to be made of wood. However, a hurricane in 1880 may have convinced the Army that a brick building would last longer. Maps showed that building No. 2 was built between 1882 and 1884. It was used as a school until 1907. Between 1907 and 1922 its use is uncertain. From 1922 to 1941 it was used as a Post Chapel, N.C.O. "Bachelors'" Quarters, Officers' Guests Quarters, Post Office and N.C.O. Quarters, and the Chaplain's office prior to October 1941 as will be explained later. Earliest Post Engineer's records show that a single 20' x 30' ft. bedroom and 16' x 18' living room comprised the floor space with an open porch. At that time it listed a capacity for 50 persons. "The larger room was the chapel's auditorium, while the smaller room was its vestry." Later records show the building was divided with a hall to make three bedrooms and small kitchen to house a single family by 1938. It was also painted at one time. By then, the. porch was screened. In 1951, the Little Chapel at Fort Brown was remembered at the time for being a "popular place for weddings of soldiers and local girls" when it was transferred by the city of Brownsville as a museum to the Brownsville Historical Association. The BHA restored the building and opened it in 1952. The BHA was organized in 1946 and granted a charter by the state of Texas in 1947. They were granted use of the Chapel as a museum for 50 years. However, by 1958, the Stillman house at 1305 E. Washington Street was purchased by Chauncey Stillman, a great-grandson of Charles Stillman, and donated to the BHA as their permanent home. When businessmen in downtown Brownsville heard about this, they petitioned to oppose the BHA relocating there under the charge that "a museum would stifle the growth of the immediate area." The BHA restored the home and moved in by 1960. Now with the expanded Brownsville Heritage Complex, the BHA continues to organize a wide range of activities to promote local history and preserve historical records. From 1960 to 1991, Building No. 2 was used as an office for the General Services Administration (GSA) and a tool and maintenance building. Little maintenance had been done on the building and after thirty years of neglect, the building had seen better days. In 1992 when expansion of the U.S. Customs facility would require that it be removed, the "Little Chapel" was suddenly in need of a few small miracles. Mark Lund, Director of City Planning, (Heritage Officer for Brownsville at the time) had first hand experience from the initial dismantling, storage, and restoration of Building No. 2. He stated that the city had a contract with the GSA to remove (demolish) the building. When the Texas State Historical Commission became involved, the "Planning staff and Heritage Council persuaded the City Commission to intervene such that the building's demolition (disassembly) was done carefully to allow it at a future date to be possibly reassembled." The GSA was anxious to remove Building No. 2 because it delayed construction by standing in the way of a road that had to be widened for trucks to make a sharp turn from the bridge for inspection. Once the Historical Commission was satisfied assessment requirements were met, the process to demolish was approved. When the city was contracted by the GSA to demolish Building No. 2, Mr. Lund involved the Heritage Council and Planning Director Joe Galvan, who spoke with Butch Barbosa of the City Commission, to find what could be done to save the little building. Bricks were not numbered as previously believed. Instead, temporary workers were hired and instructed to carefully remove the bricks and place them on pallets to be stored for future use. The City Manager, Kirby Lellijedahl, sent Parks Department trucks to transport brick and wooden pieces, which were labeled and protected by tarps. There was no funding to immediately relocate the building. One ideal plan was to situate the building near the entrance at the Fort Brown Memorial Golf Course as a visitor's center. Until Building No. 2's fate would be known, components would be temporarily stored in Brownsville Compress warehouses free of rent for several months by compress owners. After several months, the city was asked to begin paying rent. Since the building was eligible to receive funds from the Community Development Block Grant – Community Development Funds (CBDG), approximately $1,200 was used to keep the parts in storage until it could be decided where it would be rebuilt. Around this time Los Caminos Del Rio was producing a film to highlight significant architectural buildings along both sides of the Rio Grande Valley to be aired by the Public Broadcasting System (PBS). The Dallas-based philanthropic Meadows Foundation supported this production and representatives were visiting Brownsville. After learning about Building No. 2, they advised the City to write a formal grant proposal. Once funding by the Meadows Foundation was assured, TSC got involved with the Texas Historical Commission and the City Planning Department in planning a new site for the building on the historical campus. TSC officials must have considered Building 2 as an inherent part of the historical assemblage of fort buildings and that it would be turned over to them, even though it had fallen under ownership of the GSA and later, transferred to the City. The project was entitled "Building Number Two" by the City and an Inter-Local Agreement was signed between the City and TSC under which the City would pay all costs once a $50,000 grant was secured by the Meadows Foundation. Construction was to be supervised by Heritage Officer Mark Lund and progress of the work would be reported to Michael Putegnat, TSC Executive Director. Once the job was completed, the City would "turn over title and control to TSC. Costs involved for TSC would be time and landscaping." Bricks were delivered near the parking lot on the site it would be rebuilt. This pile caused rainwater to flood the parking lot and Michael Putegnat, was pressured to correct this situation. For a short while, stagnant water became known as "Putegnat's Pond." Bricks had to be reset aside to allow for proper drainage. During reconstruction, the contractor became dissatisfied with the amount of his reimbursement when the small building proved to be a bigger challenge than he anticipated. He had stored some of the wooden pieces from the Brownsville Compress in his garage and held up construction. Mark Lund was faced with two problems: One was to hire a new contractor to complete the half-finished project with the amount of funds that were left over (most contractors would not want to bid on a halffinished job) and the second was to get the wooden pieces back. Lund had the police called in as a precautionary measure to ensure parts would be delivered. The Parks Department was used again to deliver wooden parts to the second contractor, Carroll Adams, who saw the project to the end. (His nephew, Jearel Adams, worked on the Cavalry building). Some wooden pieces had become damaged from being taken apart, stepped on, or exposed to moisture. Carroll Adams, having worked on historic building restoration jobs before and seeing Mark had been scraping pieces of interior wood trim so that they may be used again, took it upon himself to purchase wood pieces with his money to see the job be done correctly. Another obstacle to rebuilding was met below the ground on which Building No. 2 now stands. Because of its heavy 12" brick walls, a continuous concrete brick foundation had to be placed below the ground. Utility pipes obstructed digging and created problems for re-builders: Boxed openings were made in the reinforced concrete foundation. Steel pieces were placed on the top of the openings after the concrete cured. This was done to handle the loads of substantial masonry walls. The City sidewalk crew (under the direction of Santana Vallejo) built this concrete foundation. They did very well in dealing with the challenges presented by the existing utilities. The foundation design was done by the City Engineer, P. J. Garcia, P. E. The private contractor was hired to do the subsequent work… after the foundation was completed. Mark Lund also had the odious task of placing insulation from the crawl space beneath the floor of Building No. 2. Work was completed by 1993 and it now sits near the Art Annex Building No. 89. Most peculiar about this building is that there is no historical subject marker on the Little Chapel for visitors to inform them where the building was once located, what it was used for, and to memorialize the people who all worked together to save it. A second Post Chapel (Building No. 62) once stood in the area between Tandy Hall and the Lightner Student Center, next to the Post Theater. This chapel was the actual "Regimental" chapel. It had a larger capacity to hold services for a larger number of men. The large wood-frame structure with a steeple was built in 1941 and had a 350 person capacity. It measured 81'-3" long and 37' wide. The Quartermaster record lists it as a "temporary" building and classify it as a "Regimental Chapel" on the floor plan. It was dedicated on Sunday, October 26, 1941. There was a movable altar for Jewish, Catholic, or Protestant services. Before that, services were held in the service club near Building No. 2. Chaplain Stephan K. Callahan moved his office from Building No. 2 into the new chapel the following Monday. In 1947, the two chapels and other buildings at Fort Brown were declared surplus property by the War Assets Administration (WAA). An appeal was made to the WAA to secure Building No. 2 (The Little Chapel) as a museum for the BHA that had just had its first annual meeting at the Brownsville Chamber of Commerce after being chartered by the State of Texas. Immaculate Conception Church bought Building No. 62 for the St. Joseph Church on the corner of Sixth and 555 W. St. Francis. Luke Waters of Harlingen took the job of moving the building from the fort to its new site. For a job that would have normally lasted a few days or couple of weeks at the most, it actually took nearly five months. It was a burden Mr. Waters carried to the end. Waters began the task in October of 1947. To move it presented a problem because streets were only 30 feet wide. Weighing 150,000 pounds, it was moved by heavy trucks. Telephone cables were either lowered or raised to make way for the chapel. Electric lines were also cut. This upset some people who found themselves temporarily without electricity. The weather caused the greatest problems. Whenever it rained, the job would be halted, as the earth was too soft to move over without getting the load stuck in the mud, which it did at various points. The "front end" was pulled out of one of Water's trucks. Two winch trucks were damaged and cable lines broke several times. Mr. Waters also broke his arm in a fall on January 2nd. Asked if he remembered the exact route that was followed in moving, his reply was "I certainly do. I'll never forget it." After leaving Fort Brown, the building proceeded on Jefferson to East Ninth, turned north to Madison, west on Madison to Seventh, north on Seventh to Van Buren, west on Van Buren across the Southern Pacific railroad tracks to Ninth, south on Ninth to Jackson, west on Jackson between the Resaca and City Cemetery, across Palm Blvd. to West First, south across vacant lots to Jefferson, west on Jefferson to W. Seventh, south to Elizabeth, east to half-way between W. Fourth and Fifth, west again to Seventh, south on Seventh to St. Francis, and finally to its destination at W. Sixth and St. Francis. For the "wandering church" to reach its destination, brush had to be cleared on some vacant lots to move it. It finally reached its destination on February 17, 1948. Father Chateau officiated services and Father Casey was appointed first pastor in 1953. It remained a parish until 1962 when a new church was built across the street. Research material showed that historian A. A. Champion and his wife, Isabel, were members of this church. The church has been covered in brick with an addition on its west side and the steeple has been removed. It now serves as a youth center for the church. ; https://scholarworks.utrgv.edu/ftbrown/1511/thumbnail.jpg

Building no. 62. Constructed in 1941-10-10. O.q.m.g. plan no. 7033-787-1; Regiment chapel. The Regiment House has been called by many names. Although small in stature, it has a diverse history. Not only has its use and title changed many times since it was built, it has also misled some local historians into reporting it as being located at different places. Once affectionately known as "The Little Chapel at Fort Brown," it originally stood with its back to the Rio Grande and faced the parade grounds near the present Gateway International Bridge and Customs facilities. Sources noted it had "been moved from its original location to a point near the international bridge." Another account described the chapel as once being located near the Jefferson entrance and used as a school for African-American soldiers. These minor errors that crept into historical record made Building No. 2. an interesting study. There were actually two chapels; each one moved one time and still in use today. The first chapel was originally built to be used as a school and library. In 1889, plans were originally designed for it to be made of wood. However, a hurricane in 1880 may have convinced the Army that a brick building would last longer. Maps showed that building No. 2 was built between 1882 and 1884. It was used as a school until 1907. Between 1907 and 1922 its use is uncertain. From 1922 to 1941 it was used as a Post Chapel, N.C.O. "Bachelors'" Quarters, Officers' Guests Quarters, Post Office and N.C.O. Quarters, and the Chaplain's office prior to October 1941 as will be explained later. Earliest Post Engineer's records show that a single 20' x 30' ft. bedroom and 16' x 18' living room comprised the floor space with an open porch. At that time it listed a capacity for 50 persons. "The larger room was the chapel's auditorium, while the smaller room was its vestry." Later records show the building was divided with a hall to make three bedrooms and small kitchen to house a single family by 1938. It was also painted at one time. By then, the. porch was screened. In 1951, the Little Chapel at Fort Brown was remembered at the time for being a "popular place for weddings of soldiers and local girls" when it was transferred by the city of Brownsville as a museum to the Brownsville Historical Association. The BHA restored the building and opened it in 1952. The BHA was organized in 1946 and granted a charter by the state of Texas in 1947. They were granted use of the Chapel as a museum for 50 years. However, by 1958, the Stillman house at 1305 E. Washington Street was purchased by Chauncey Stillman, a great-grandson of Charles Stillman, and donated to the BHA as their permanent home. When businessmen in downtown Brownsville heard about this, they petitioned to oppose the BHA relocating there under the charge that "a museum would stifle the growth of the immediate area." The BHA restored the home and moved in by 1960. Now with the expanded Brownsville Heritage Complex, the BHA continues to organize a wide range of activities to promote local history and preserve historical records. From 1960 to 1991, Building No. 2 was used as an office for the General Services Administration (GSA) and a tool and maintenance building. Little maintenance had been done on the building and after thirty years of neglect, the building had seen better days. In 1992 when expansion of the U.S. Customs facility would require that it be removed, the "Little Chapel" was suddenly in need of a few small miracles. Mark Lund, Director of City Planning, (Heritage Officer for Brownsville at the time) had first hand experience from the initial dismantling, storage, and restoration of Building No. 2. He stated that the city had a contract with the GSA to remove (demolish) the building. When the Texas State Historical Commission became involved, the "Planning staff and Heritage Council persuaded the City Commission to intervene such that the building's demolition (disassembly) was done carefully to allow it at a future date to be possibly reassembled." The GSA was anxious to remove Building No. 2 because it delayed construction by standing in the way of a road that had to be widened for trucks to make a sharp turn from the bridge for inspection. Once the Historical Commission was satisfied assessment requirements were met, the process to demolish was approved. When the city was contracted by the GSA to demolish Building No. 2, Mr. Lund involved the Heritage Council and Planning Director Joe Galvan, who spoke with Butch Barbosa of the City Commission, to find what could be done to save the little building. Bricks were not numbered as previously believed. Instead, temporary workers were hired and instructed to carefully remove the bricks and place them on pallets to be stored for future use. The City Manager, Kirby Lellijedahl, sent Parks Department trucks to transport brick and wooden pieces, which were labeled and protected by tarps. There was no funding to immediately relocate the building. One ideal plan was to situate the building near the entrance at the Fort Brown Memorial Golf Course as a visitor's center. Until Building No. 2's fate would be known, components would be temporarily stored in Brownsville Compress warehouses free of rent for several months by compress owners. After several months, the city was asked to begin paying rent. Since the building was eligible to receive funds from the Community Development Block Grant – Community Development Funds (CBDG), approximately $1,200 was used to keep the parts in storage until it could be decided where it would be rebuilt. Around this time Los Caminos Del Rio was producing a film to highlight significant architectural buildings along both sides of the Rio Grande Valley to be aired by the Public Broadcasting System (PBS). The Dallas-based philanthropic Meadows Foundation supported this production and representatives were visiting Brownsville. After learning about Building No. 2, they advised the City to write a formal grant proposal. Once funding by the Meadows Foundation was assured, TSC got involved with the Texas Historical Commission and the City Planning Department in planning a new site for the building on the historical campus. TSC officials must have considered Building 2 as an inherent part of the historical assemblage of fort buildings and that it would be turned over to them, even though it had fallen under ownership of the GSA and later, transferred to the City. The project was entitled "Building Number Two" by the City and an Inter-Local Agreement was signed between the City and TSC under which the City would pay all costs once a $50,000 grant was secured by the Meadows Foundation. Construction was to be supervised by Heritage Officer Mark Lund and progress of the work would be reported to Michael Putegnat, TSC Executive Director. Once the job was completed, the City would "turn over title and control to TSC. Costs involved for TSC would be time and landscaping." Bricks were delivered near the parking lot on the site it would be rebuilt. This pile caused rainwater to flood the parking lot and Michael Putegnat, was pressured to correct this situation. For a short while, stagnant water became known as "Putegnat's Pond." Bricks had to be reset aside to allow for proper drainage. During reconstruction, the contractor became dissatisfied with the amount of his reimbursement when the small building proved to be a bigger challenge than he anticipated. He had stored some of the wooden pieces from the Brownsville Compress in his garage and held up construction. Mark Lund was faced with two problems: One was to hire a new contractor to complete the half-finished project with the amount of funds that were left over (most contractors would not want to bid on a halffinished job) and the second was to get the wooden pieces back. Lund had the police called in as a precautionary measure to ensure parts would be delivered. The Parks Department was used again to deliver wooden parts to the second contractor, Carroll Adams, who saw the project to the end. (His nephew, Jearel Adams, worked on the Cavalry building). Some wooden pieces had become damaged from being taken apart, stepped on, or exposed to moisture. Carroll Adams, having worked on historic building restoration jobs before and seeing Mark had been scraping pieces of interior wood trim so that they may be used again, took it upon himself to purchase wood pieces with his money to see the job be done correctly. Another obstacle to rebuilding was met below the ground on which Building No. 2 now stands. Because of its heavy 12" brick walls, a continuous concrete brick foundation had to be placed below the ground. Utility pipes obstructed digging and created problems for re-builders: Boxed openings were made in the reinforced concrete foundation. Steel pieces were placed on the top of the openings after the concrete cured. This was done to handle the loads of substantial masonry walls. The City sidewalk crew (under the direction of Santana Vallejo) built this concrete foundation. They did very well in dealing with the challenges presented by the existing utilities. The foundation design was done by the City Engineer, P. J. Garcia, P. E. The private contractor was hired to do the subsequent work… after the foundation was completed. Mark Lund also had the odious task of placing insulation from the crawl space beneath the floor of Building No. 2. Work was completed by 1993 and it now sits near the Art Annex Building No. 89. Most peculiar about this building is that there is no historical subject marker on the Little Chapel for visitors to inform them where the building was once located, what it was used for, and to memorialize the people who all worked together to save it. A second Post Chapel (Building No. 62) once stood in the area between Tandy Hall and the Lightner Student Center, next to the Post Theater. This chapel was the actual "Regimental" chapel. It had a larger capacity to hold services for a larger number of men. The large wood-frame structure with a steeple was built in 1941 and had a 350 person capacity. It measured 81'-3" long and 37' wide. The Quartermaster record lists it as a "temporary" building and classify it as a "Regimental Chapel" on the floor plan. It was dedicated on Sunday, October 26, 1941. There was a movable altar for Jewish, Catholic, or Protestant services. Before that, services were held in the service club near Building No. 2. Chaplain Stephan K. Callahan moved his office from Building No. 2 into the new chapel the following Monday. In 1947, the two chapels and other buildings at Fort Brown were declared surplus property by the War Assets Administration (WAA). An appeal was made to the WAA to secure Building No. 2 (The Little Chapel) as a museum for the BHA that had just had its first annual meeting at the Brownsville Chamber of Commerce after being chartered by the State of Texas. Immaculate Conception Church bought Building No. 62 for the St. Joseph Church on the corner of Sixth and 555 W. St. Francis. Luke Waters of Harlingen took the job of moving the building from the fort to its new site. For a job that would have normally lasted a few days or couple of weeks at the most, it actually took nearly five months. It was a burden Mr. Waters carried to the end. Waters began the task in October of 1947. To move it presented a problem because streets were only 30 feet wide. Weighing 150,000 pounds, it was moved by heavy trucks. Telephone cables were either lowered or raised to make way for the chapel. Electric lines were also cut. This upset some people who found themselves temporarily without electricity. The weather caused the greatest problems. Whenever it rained, the job would be halted, as the earth was too soft to move over without getting the load stuck in the mud, which it did at various points. The "front end" was pulled out of one of Water's trucks. Two winch trucks were damaged and cable lines broke several times. Mr. Waters also broke his arm in a fall on January 2nd. Asked if he remembered the exact route that was followed in moving, his reply was "I certainly do. I'll never forget it." After leaving Fort Brown, the building proceeded on Jefferson to East Ninth, turned north to Madison, west on Madison to Seventh, north on Seventh to Van Buren, west on Van Buren across the Southern Pacific railroad tracks to Ninth, south on Ninth to Jackson, west on Jackson between the Resaca and City Cemetery, across Palm Blvd. to West First, south across vacant lots to Jefferson, west on Jefferson to W. Seventh, south to Elizabeth, east to half-way between W. Fourth and Fifth, west again to Seventh, south on Seventh to St. Francis, and finally to its destination at W. Sixth and St. Francis. For the "wandering church" to reach its destination, brush had to be cleared on some vacant lots to move it. It finally reached its destination on February 17, 1948. Father Chateau officiated services and Father Casey was appointed first pastor in 1953. It remained a parish until 1962 when a new church was built across the street. Research material showed that historian A. A. Champion and his wife, Isabel, were members of this church. The church has been covered in brick with an addition on its west side and the steeple has been removed. It now serves as a youth center for the church. ; https://scholarworks.utrgv.edu/ftbrown/1388/thumbnail.jpg

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Machine generated contents note: Section One Introduction to Telemental Health -- 1.Introduction / Kathleen Myers -- Introduction -- The Telemental Health Imperative -- Current Trends Supporting the Broader Adoption of Telemental Health -- Organization of This Book -- References -- 2.Telemental Health as a Solution to the Widening Gap Between Supply and Demand for Mental Health Services / Michael Flaum -- Workforce Shortages in Mental Health: The Example of Psychiatry -- What Is the Current Supply of Psychiatrists in the United States? -- Rate of Growth in Psychiatrists and All Physicians Over Time -- The Psychiatry Pipeline: Trends in Residency Training -- The Aging-Out Effect -- What Is the Current Need or Demand for Psychiatrists in the United States? -- Quantifying the need for different kinds of providers of mental health services -- The Distribution of Psychiatrists: The Iowa Example -- Telepsychiatry as a Key Strategy for Closing the Gap -- Workforce Issues of Psychology Health Service Providers -- Conclusions: The Optimal Use of Telemental Health to Address Workforce Shortages -- References -- Section Two Developing a Therapeutic Space During Telemental Health -- 3.Establishing Therapeutic Rapport in Telemental Health / Dehra Glueck -- Introduction -- Review of the Literature on Rapport and Alliance -- Technological Considerations Impacting Rapport -- Establishing Therapeutic Rapport with the Patient -- Explaining Telemental Health to Patients -- Developing Rapport with Special Populations -- Establishing Therapeutic Rapport with the Referring Clinic -- Building Rapport with Staff: An Open-Door Policy -- The Importance of a Clinical Coordinator in Facilitating Rapport at the Patient Site -- Establishing Rapport with the Broader Community -- Conclusion -- References -- 4.Ethical Considerations in Providing Mental Health Services Over Videoteleconferencing / Sarah E. Velasquez -- Introduction -- Applying Ethical Principles in Telemental Health -- Principle A Beneficence and Nonmaleficence -- Principle B Fidelity and Responsibility -- Principle C Integrity -- Principle D Justice -- Principle E Respect for People's Rights and Dignity -- Concerns Specific to Research -- Emerging VTC-Related Technologies -- Home Telehealth and VTC -- Mobile Devices and VTC -- Integration of Technologies -- Conclusion -- References -- 5.Integrating Culturally Appropriate Care into Telemental Health Practice / Jay H. Shore -- Culturally Appropriate Care and Telemental Health: An Introduction -- What Is Culturally Appropriate Care? -- The Use of Telemental Health with Rural, Distant, and Underserved Populations -- The Interplay Between Culture and Telemental Health -- Prior Research Examining Telehealth with Cultural Subgroups -- American Indian Veteran Telemental Health Clinics -- Telehealth Treatment with the Elderly, Child, and Adolescent Populations -- Treatment with Linguistically Diverse Populations -- Treatment with Other Cultural Subgroups -- The Appropriateness of Telemedicine -- Understanding the Patient Culture and Community -- Community Leaders and Key Informants -- Local Outreach Workers -- Utilizing Local Information -- Incorporating the Community for Effective Telemental Health Services -- Establishing Local Partnerships and Collaborations -- Dual Relationships in Rural Areas -- Technological Considerations When Working with Diverse Populations -- Communication -- Technological Knowledge and Comfort -- Conclusion -- Case Studies -- The Use of Talking Circles in Telemental Health Group Therapy -- Using Telemental Health to Increase Access in a Medically Underserved Area -- The Use of Asynchronous Technology to Bridge Language Barriers -- References -- 6.Managing Risk and Protecting Privacy in Telemental Health: An Overview of Legal, Regulatory, and Risk-Management Issues / Jay H. Shore -- Introduction -- Legal and Regulatory Issues -- Licensure -- Malpractice -- Credentialing and Privileging -- Security and Privacy Considerations -- Data Security for Electronic Protected Health Information -- Special Considerations for Mobile Devices in TMH Care -- Other Privacy Considerations -- Clinical Practices to Manage Risk -- Informed Consent -- Safety Plans and Emergency Management -- Risk Issues in Home-Based TMH -- Conclusion -- References -- Section Three Establishing a Telemental Health Practice -- 7.Business Aspects of Telemental Health in Private Practice / Dehra Glueck -- Introduction -- Choosing a Telemedicine Group or Technology-Only Support -- Technology-Only Models -- Group-Practice Models -- Institution-Based Practice Model -- Direct-to-Consumer Model -- Deciding on the Model of Care -- Direct Care Versus Consultation -- Direct Care -- Evaluation of Patients -- Direct Care -- Ongoing Treatment of Patients -- Consultative Care -- Deciding on a Model: Strength and Needs Assessments -- Financial Feasibility -- Understanding Costs: Patient and Provider Perspective -- Impact of Patient Volume on Costs -- Impact of No-Show Appointments on Costs -- Reimbursement: Insurance -- Reimbursement: Private Payment -- Reimbursement: Contracted Time -- Practical Considerations -- Malpractice, Licensure, and Consent -- Informed Consent and Standard of Care -- Staffing -- Sharing Records -- Technology -- Selection, Use, and Technical Support -- Technology: Bandwidth -- Technical Support -- Building a Referral Base and Growing a Practice -- Lifestyle Benefits -- Conclusion -- References -- 8.Technology Options for the Provision of Mental Health Care Through Videoteleconferencing / Carolyn L. Turvey -- Introduction -- Standards-Based Versus Consumer-Grade Software -- Hardware-Based Codecs -- Software-Based Applications -- Mobile -- Dedicated, Direct Connections to VTC Equipment and End Points -- Bandwidth -- Impact of Cloud Computing -- Audio -- Microphones -- Echo Cancelation -- Video -- Video Standards -- H.264 -- Screen-in-Screen -- Camera Options and Clinical Implications -- Screen Size -- Video Issues and Troubleshooting -- Packet Loss -- Technology and Privacy -- HIPAA Compliance and Videoteleconferences -- What Behaviors Are Important to Maintain Privacy -- Security Standards -- Backup Technologies and Protocols Should VTC Equipment Fail -- Conclusion -- References -- Section Four Improving Access for Special Populations Through Telemental Health -- 9.Telemental Health in Primary Care / Caroline Bonham -- The Rationale for Collaborative and Integrative Care -- A Continuum of Collaboration -- Four Key Concepts in Collaborative Care -- Tailoring TMH to Models of Care -- TMH Consultation and Collaboration for Children, Adolescents, and Their Families -- Primary Care Sites -- School-Based Health Centers -- TMH Consultation and Collaboration for Adults -- Direct Care Models -- Consultation Care Model -- Collaborative Care Models -- Asynchronous Telepsychiatry -- Cultural Considerations -- Conclusion -- References -- 10.Geriatric Telemental Health / Terry Rabinowitz -- Introduction -- The Need for Better Geriatric Mental Health Services -- Barriers to Mental Health Care for the Elderly -- Studies on Geriatric Telemental Health Services -- Acceptability of Telemental Health Among the Elderly -- Telepsychiatry in Nursing-Home Settings -- Remote Telemonitoring and Geriatric Mental Health Care -- Suicidality -- Case Presentations: Three Examples of the Use of Telehealth with Geriatric Populations -- Telepsychiatry in Nursing-Home Settings -- Tele-DCM for Elderly Rehabilitation Patients -- Telemonitor-Based Depression Care Management in Home Care -- Conclusions -- Acknowledgment -- References -- 11.Child and Adolescent Telemental Health / L. Lee Carlisle -- Introduction -- Literature Review -- Developmental and Clinical Considerations -- The Practice of Child and Adolescent Telemental Health -- Models of Care and Clinical Practice: Primary Care -- Models of Care and Clinical Practice: Other Sites of Practice -- Optimizing the Virtual Clinical Encounter with Children and Families -- Treatment in Child and Adolescent Telemental Health -- Telepsychiatry in a Youth's System of Care -- Summary and Conclusions -- References -- 12.Rural Veterans and Telemental Health Service Delivery / Karen Kloezeman -- Introduction -- Rural Veteran Population -- Mental Health Disorders in Veterans -- Rural-Urban Health Disparities in Veterans -- Access to Care -- VA Health-Care Service Utilization -- Barriers to Access to Care -- Limitations in the Access to Care Literature -- TMH and the Department of Veterans Affairs -- Clinical Effectiveness of Psychotherapies Delivered via CVT -- Considerations Associated with CVT Delivery -- Challenges Associated with CVT Delivery -- Limitations in the CVT Literature -- Future Directions -- Conclusions -- References -- 13.Videoteleconferencing in Forensic and Correctional Practice / Robert D. Morgan -- Videoteleconferencing Health in Forensic and Correctional Practices -- The Development of Videoteleconferencing in Forensic and Correctional Settings -- Barriers to Health Care -- How Can VTC Improve Services in Criminal Justice Settings? -- Demonstrating the Effectiveness of VTC -- Challenges Facing VTC in Corrections -- The Need for Specialty Best Practice Guidelines -- Future Directions -- Spotlight on TMH and Telelaw Programs -- Summary -- References -- Section Five Assessment and Intervention -- 14.Special Considerations in Conducting Neuropsychology Assessment over Videoteleconferencing / Maria C. Grosch -- Background and Scope -- Why Teleneuropsychology? -- Limiting Factors -- Availability of Equipment -- Data Transmission Speeds -- VTC Environment -- Setting Up Teleneuropsychology Services -- Evidence for VTC-Based Diagnosis and VTC-Based Cognitive Assessment -- Consumer Satisfaction with VTC-Based Services -- Practical and Ethical Issues in Teleneuropsychology -- Mobile Teleneuropsychology Applications -- Future Directions -- Summary -- References --

Privacy Enhancing Technologies (PETs) are at the forefront of efforts to protect privacy and enable responsible data use. But what are they and how are they used? Dan Cassara, former Project Manager for the Digital Credit Observatory (DCO), provides a case study of how PETs can be used to enable better financial lending practices across countries in the third part of our series on 'How PETs Make Data Work for All.'Read parts one and two. Learn more about PETs in our Data Privacy Lab.Credit: Maksym Yemelyanov via Adobe StockAccording to GSMA's 2023 State of the Industry Report, it took 17 years for the first 800 million mobile money accounts to register globally, but just five years for the next 800 million accounts. The expansion of other digitized financial services has also accelerated, with the proportion of mobile money providers offering digital credit nearly doubling in the past two years. Though the surge of digital financial services across low- and middle-income countries (LMICs) is well documented, the implications for data protection and compliance have received less attention until recently. This blog post builds off of parts one and two in this series exploring how Privacy Enhancing Technologies (PETs) can enable more responsible data sharing for the public good.Many mobile money providers and fintechs operate in multiple markets. For example, Safaricom, which catalyzed the rise of mobile money by launching M-Pesa in 2007, recently began operating in Ethiopia, its tenth market. Because many fintechs use machine learning algorithms to predict loan repayment and create credit scores for consumers, new markets provide not just growth, but also new data to improve their models. However, new markets can also create regulatory and compliance challenges.Data Protection ChallengesRegulatory efforts to safeguard data have often included data protection laws: 71% of all nations worldwide have data protection laws, including roughly half of the countries the UN refers to as Least Developed Countries. These laws generally govern what data can be collected, how it is processed, and how it can be shared. In particular, they often limit cross-border data sharing. Kenya, the birthplace of mobile money and a hub for fintech firms in Africa, passed a Data Protection Act in 2019 that states personal data cannot be "transferred outside Kenya, unless there is proof of adequate data protection safeguards or consent from the data subject."A fintech aiming to aggregate data from customers in multiple countries to predict consumer behavior may not be able to do so because of these kinds of data sharing restrictions. As a result, it might face higher default rates and pass those costs on to consumers in the form of increased interest rates. Instead, the fintech could turn to homomorphic encryption (HE), which refers to methods for analyzing data while it is still encrypted. (Analyzing data has traditionally required that the data be decrypted, making it vulnerable to hacks and misuse.) In this way, it may comply with data sharing regulations, as underlying data is not available across borders, and still learn from the data.Using Homomorphic Encryption (HE) to Protect PrivacyTo illustrate the idea underpinning HE, consider a scenario before electronic communications where Alice wants to send a secret message to her colleague, Bob, but is worried it could be intercepted. So Alice puts the message in a box, locks it, and sends it to Bob. The message is secure, but there's a new problem once Bob receives it: he doesn't have the key. Bob puts his own lock on the box and sends it back to Alice. After she removes her lock and sends the box back to Bob, he can remove his lock and finally access the message. This approach added extra steps, but it ensured that the contents of the box were never revealed to anyone except Bob.In practice, the secret message is often a desired query or computation, like the total number of transactions that customers initiated last quarter. Suppose there are just two customers who made 4 and 7 transactions, respectively; with access to a list of customers and their transaction histories, it's a simple task to calculate that 11 transactions were made. But if the bank uses HE to protect customers' data, the analysis must incorporate a set of procedures to ensure the encryption, computation, and decryption processes return the correct answer. There are many such systems, but most rely on a set of public and private keys that are similar to the locks Alice and Bob used to lock and unlock the box — or encrypt the data and decrypt the results — but with a few important differences. First, the dataholder (the bank) has both keys. Second, some predefined operations can be performed on the data in the box without ever needing to see inside.For simplicity, let's also assume that a given encryption system and set of public keys transform the values 4 and 7 into encrypted values of 31 and 212 (the math can get complex, interested readers should consult the endnotes). When the query is attempted, instead of 4 + 7 = 11, the system, operating on encrypted data, gets 31 * 212 = 6,572 (for technical reasons, 31 and 212 are multiplied, not added; see the endnotes for more info). The encrypted value of 6,572 clearly does not equal 11, but this is expected in this encrypted space. To return to unencrypted numbers, the bank's system uses a decryption function that relies on private keys. With some hand-waving (see notes), the computer returns the correct answer of 11 to the bank, who never saw the underlying transaction histories.The Future of HEsThe processing power needed to privately analyze data using HE limited real-world applications until recent advances in computing power, but financial services applications are now growing. HE was used in combination with Multiparty Computing to enable data from non-Belgian subsidiaries of a Belgian bank to be used in its machine-learning model, even though EU privacy regulation prohibits the cross-border transfer of this data. Researchers constructed a privacy-preserving machine learning model that did not require any of the underlying data from the non-Belgian subsidiaries to be shared, and all private data remained encrypted throughout the computational process.Industry's growing reliance on big data and the increasing prevalence of data misuse has led many countries to pass data protection laws. These laws often empower people to have greater control of their data, and provide necessary safeguards. The cost is that data sharing — and the learning and innovation it can facilitate — becomes more burdensome, if not impossible. Privacy enhancing technologies like homomorphic encryption can play an important role in facilitating responsible data usage to expand access to financial services and to drive down costs, without sacrificing the data protections that people deserve.For more detail on how HE works, review this example.Homomorphic Encryption for Cross-Border Computation was originally published in CEGA on Medium, where people are continuing the conversation by highlighting and responding to this story.

One of my basic rules of skiing is that if the mountain gets in my head, my skiing turns to shit.  Well, it was one of those days.  I had an ambitious plan--to complete the White Ring, which connects Zurs to Zug to Lech to Stubenbach and then back to Zurs.  The map below is incredibly deceptive.  It makes it seem like the longest route was through Lech.  Pretty sure it was not.This sign showed thata) I was on the right path--the white ringb) the path was hard--a red diamond (see yesterday's post about Euro signs)The first leg, which seems kind of short took probably half of the time--it was quite a long, incredibly downhill set of runs.  I had read enough to know this was the most challenging section--could have been worse if the snow was more moguly or icy.  Instead, it was a mix of fresh stuff and pretty hard stuff.  It was pretty clear so visibility was not a problem.  Instead, it was mostly the deep steep and narrow traverses.  I let the mountain get in my head, so I lost my form and skied mostly in survival mode--lots of sliding and turning to keep my speed down.  It wasn't harder than trails I have done elsewhere, but it really did feel like I was doing down the mountain side, which made me nervous about my speed and control.  And it went on and on and on, and down and down.  So, I sweated a lot, my legs didn't tire, but my lungs did.  I fell maybe once or twice, mostly trying to stop.  Nothing traumatic.Near the top of the endless decline is a spotwhere one can climb to the right to get a great view. Um, no thanks.  The roundthing on the right is the RingView of the run down to Zugfrom the gondola on the opposite side.  I skied from that notchat the top all the way downAnd then I got to Zug. I sat on a spare chairlift bench and rested for about ten minutes and then took the lift to the top.  There, I was greated by a rope tow---a horizontal one to get from the lift to the top of Lech.  It was fine although different from any rope tow I had done before--and I have mostly avoided any kind of lift that involves dragging (until today x 2).  Once there, I was able to take a very long (but not as long as the map suggests) ride down from the top of Lech to nearly the bottom.  I took a break at the first sign of cafeteria where I embraced my addictions:  The strudel was pretty good.  Not life changing but definitely much needed after the exertion to get there.The luxurious heated/leather seated lift to startthe adventure had a pictogram to explain whenthe safety bar and the protective hood wouldautomatically lift. Once done with my snack, I skied to the bottom of Lech, and it is a pretty neat place.  A river runs through it, so I had to carry my skis across the bridge and over to the gondola.  It was a huge, 30 person or so, gondola.  Today was definitely my day for experiencing pretty much every kind of ski lift: 2 person chair, 4 person chair, hooded/heated/leather chair (see the pic), small gondola, huge gondola, rope town, t-bar (always so much fun--their scarcity these downs shows their evolutionary inferiority).  Anyhow, I chatted with the gondola operator since I was squeezed in next time.   Several Brits were signing various songs, which apparently is not normal.  Maybe they had a nip early in the day?  The gondola took us to the top and other side of the mountain range, and the reviews said the next run (blue, so it was easy) was scenic.  Not with the snow that was falling.  Again, I used the trick of following the neon people to stay on course.  The signs were good enough that going off the edge was not a problem, but following people would tell me where the dips were since the light was so flat, it was hard to tell what the pitch of the slope is.  Anyhow, despite the vision challenge, this was a fun run and I might do it again tomorrow, depending on the snow/visibility conditions.  My hotel has the BEST ski lockers--the things holding up the boots and mittens are air dryers.  So, my boots, helmet, and gloves should be drytomorrow.  My coat?  We shall see.At the bottom was, alas, the aforementioned t-bar.  I have little practice with them (deliberately so), but managed to do ok.  It went up higher than I was expecting.  So, then I had a nice long but not so visible blue run to the bottom of a lift I had taken yesterday, which meant I was back at Zurs.  I forgot how high up it went, so it turns out that my last run was much longer than I was expecting.  Which gave me enough time and space to have one last fall in the wettest snow.  So, I am hoping my jacket dries by tomorrow.  The good news is that the visibility problems today (unlike yesterday) were due to fresh snow.  So, the conditions should be good for my last day here.  The big question is whether I go back to Lech (by bus) and ski some terrain their or just use the accumulated local knowledge to ski Zurs.  Oh, back to the psychology of skiing, having so much time alone while doing all of this and sitting on the lifts had me thinking about and being frustrated by letting this stuff get into my head.  I didn't have that problem playing ultimate--I never really choked, as I was always pretty confident in my throws and my ability to see the field.  I did remember a notable moment long ago--the finals for my weight class in the middle school/high school inter-scholastic tourney.  I choked, losing to a guy I had beaten earlier in the season.  That was the only time that happened, as I won pretty much all of the tourneys at camp despite usually (always?) being the underdog.I think the combo of unfamiliar equipment (the rental helmet in particular didn't fit well), very mixed snow conditions, limited visibility at times, and the aforementioned steep narrow traverses all caused me to think rather than just ski.  I never did any mindfulness or meditation stuff, so I have no skills to push this stuff out.  I will try tomorrow to just focus on getting into rhythm.   Even so, I had a great time, and am enjoying this completely different ski experience.      

Where are the Ukraine partisans? After nearly two years of intense emotional investment in fueling the war aims of Kyiv, activists have seemingly fled to other battlestations in the Middle East — and at precisely the moment when the military effort needs public pressure most.
In other words, pro-Ukrainian activists — and the U.S. government — pumped up expectations for a military solution, only to leave their benefactors high and dry when the war started taking a turn for the worse and the conflict in Gaza started demanding more and more attention.
For the past five months, more than $60 billion of military and economic aid to Ukraine has been held up in Congress, with Ukrainian leadership and frontline troops as well as U.S. officials and analysts all warning the country's war effort will face a serious setback, if not outright defeat, without it. The aid has been stuck for a number of reasons, not least of which is growing GOP opposition to further assistance for the war.
Meanwhile, President Joe Biden has warned that Russian President Vladimir Putin "is banking on the United States failing to deliver for Ukraine," with the White House previously insisting that a drop in aid would "kneecap" the country's battlefield chances.
Last week, after months of wrangling, the funding suffered yet another setback when the Senate GOP voted down a border security deal that had been included in the package at Republicans' request to win their support. And while the rest of the package may be voted on in a stand-alone bill, it's unclear whether that will have any better luck — raising the very real possibility that U.S. aid to Ukraine, by far the largest single source of its military funding, completely dries up.
This state of affairs has not come about suddenly or unexpectedly. Congress has been hemming and hawing over the package for nearly six months, and technically even longer, while it's been clear since early last year that U.S. funding was due to run out in September 2023, and that Republican opposition to further assistance was growing, making the passage of further aid a likely intense political slog.
Yet aside from some angry op-eds and finger-pointing, the funding package has ultimately withered with little popular anger. MSNBC host Al Sharpton even asked one of the bill's authors if there was any effort being made to "get the public to really rise up in various states, to say to their senators that they really want to see the border issue resolved" in order to get the bill passed. But no such public uprising came.
The opposite is happening on the Gaza issue. Unlike the lukewarm pressure being put on Congress to pass Ukraine aid, the Palestinian cause is enjoying an outpouring of grass-roots activism at all levels of American society, mostly on the left, not unlike the Ukrainian cause two years ago.
Since October, pro-ceasefire protests have taken place in major U.S. cities nearly every week —even multiple times a week. At times, they've targeted specific Capitol Hill lawmakers, to the point of protesting outside their offices and even homes. A "tent city" has been set up outside Secretary of State Antony Blinken's residence in Arlington,Virginia, for 24-7 demonstrations.
In some cases the protests have been deliberately disruptive, occupying and shutting down public spaces and major roads. Activists have organized mass pressure campaigns on recalcitrant lawmakers, to the point that congressional offices are being deluged with unprecedented amounts of emails and phone calls.
Meanwhile, voters sympathetic to the Palestinians in key states have effectively threatened to withhold their votes and scuttle the president's re-election chances, while activists now regularly interrupt his campaign rallies and speeches. At least 48 cities have officially called for a ceasefire, calls that themselves were the products of intense public pressure and official opposition.
Furthermore, there have been unprecedented expressions of dissatisfaction with U.S. policy on the war from within the federal government itself, with congressional interns, fellows and staffers all engaging in their own public pressure campaigns. Even Sen. Bernie Sanders (I-Vt.) was publicly urged by more than 300 former campaign staffers to back a ceasefire.
One would think — given the intense emotion attached to Ukraine's war effort across the political spectrum these past two years, the ubiquity of Ukrainian flags in U.S. cities and social media profiles, and the widespread support for it expressed by public figures and institutions, even during non-political events — that the ongoing hold-up of aid would occasion something similar.
Instead there's been nothing of the sort. Aside from taking potshots at those questioning the transparency of efficacy of continued aid, we are largely moving toward complete radio silence on the Ukraine front.
The irony is that support for Ukraine's war effort was loudest and most intense when Kyiv appeared to be winning and when it had lockstep support from Congress. Now at the precise moment its military campaign looks shaky, when Congress is wavering on further aid, and when some grass-roots pressure is finally needed to get it over the line, it's nowhere to be found.
It's hard to say what exactly explains this phenomenon. Was it a war-fever-by-proxy that briefly revived the U.S. self-image as a virtuous global hegemon that evaporated over time? Was Ukraine's war effort the temporary recipient of emotional, financial, and military investment born of years of anti-Russian animus that has dominated domestic U.S. politics?
Was Ukraine really just the "current thing," one of a never ending series of fleeting political causes that became the subject of hyper-social media activism and public branding?
Whatever the case, what the U.S. government and its handmaidens in the foreign policy establishment did was far worse.
Channeling increasing Ukrainian discontent with its Western partners, Oleksiy Arestovych, a former adviser to President Volodymyr Zelensky, recently charged that Ukraine had "defeated the regular Russian army and thwarted their invasion plan on our own, with minimal help from the West," and that the "war could have ended with the Istanbul agreements." But, as reporting backs up, Western governments had "promised us, Ukraine, real support for waging a real, big war," encouraging Kyiv to scuttle negotiations with Moscow. Support for a large-scale war never came — and "we paid a huge price for it," Arestovych declared.
How many times have we heard calls for "total victory" and smears for those urging a negotiated resolution? In the process, these voices have not only proven to be fair-weather friends, but have helped lead Ukraine into a vastly worse position than it was in at the start of the war.
There are lessons here, many of which are becoming evident in real time. We can only hope to learn from them. But for the Ukrainian people, it's likely far too late.

As of this writing, the United States and UK have carried out nine rounds of strikes against Houthi targets in Yemen, and Washington is mulling a response to the drone attack that killed three American soldiers in Jordan on Sunday. All of this has increased fears of further escalation in the Middle East and sparked a debate in Congress over the legality and strategic rationale of the U.S. response. Last week, four Senators — Mike Lee (R-Utah), Tim Kaine (D-Va.), Todd Young (R-Ind.), and Chris Murphy (D-Conn.) — sent a letter to the president, telling him that under the Constitution, the Congress must deliberate and vote on whether to take the nation to war. Biden did not go to Congress for approval before launching the airstrikes in Yemen."We strongly condemn the repeated Houthi attacks against international cargo ships and U.S. military assets protecting those ships in the Red Sea," the letter reads. However, "while the Houthis and their backers, namely Iran, bear the responsibility for escalation, unless there is a need to repel a sudden attack the Constitution requires that the United States not engage in military action absent a favorable vote of Congress."The missive also lays out a series of questions for Biden to ensure that the American response to the situation in the Red Sea is "strategic and authorized," including whether the strikes fall into the administration's understanding of "self-defense," under which legal authorization the administration carried out the strikes, and on what date U.S. forces were "introduced into hostilities" in Yemen. Why is any of this important? RS asked Senator Lee about the letter, his response to the Jordan attacks, his concerns over a wider war with Iran, and whether other colleagues in Congress feel the same urgency to hold the administration to account.RS: Do you expect President Biden to come before Congress for authorization if the administration plans to respond to the drone attacks in Jordan?Sen. Lee: I do not know if President Biden will voluntarily ask Congress for authorization to retaliate following the drone attacks in Jordan, but he should. He is within his rights to conduct defensive strikes in cases of immediate threats to the United States and its military, but as we have already seen, the Biden administration already interprets this prerogative far too broadly in other areas of the Middle East. It is possible that retaliation is indeed the right move, but we cannot allow President Biden to sleepwalk America into an undeclared war with Iran in the process. RS: You recently sent a letter to President Biden urging him to go to Congress before pursuing further offensive U.S. military action against the Houthis. Why does the president have to go to Congress to authorize these strikes? Are there any plans to pursue a legislative vehicle that would authorize the use of force?
Sen. Lee: Every military decision made by the executive branch must be within the bounds of what the Constitution allows and consistent with the War Powers Resolution. The Constitution deliberately vested the power to make war with Congress, in Article I — keeping this power with the branch closest to the people who will bear the costs. Absent specific authority from Congress, the President reserves the power to defend the U.S. and its forces from imminent attacks. The Biden administration's pattern of engaging in offensive airstrikes without authorization and calling such actions defensive is a warped understanding of the interactions between the legislative and executive branch powers in war making. RS: The letter had four signatories, two from each party. Do you see potential for more bipartisan buy-in on this issue? If not, why not?
Sen. Lee: I have found great success in working with a serious group of members from both sides of the aisle in this space. The 2019 passage of the Yemen War Powers Resolution, which passed both chambers, was made possible by a bipartisan coalition. When the focus is kept on reasserting and restoring the role of Congress in the decision to declare war, a coalition of this kind can make history.RS: There are recent conflicting reports that the Biden administration is considering a withdrawal of troops from Syria. In the past, you have supported efforts to withdraw. Would you support a withdrawal of troops from Syria today?Sen. Lee: The first-order issue I had when U.S. troops were introduced into Syria remains the same today. Congress has never provided authorization for use of military force in Syria, nor has any administration provided a specific mission for U.S. presence that includes clear objectives and timelines on engagement. Strategic errors of this magnitude are how the United States ends up in endless wars, and it is exactly why the decision to make war was intentionally vested in the legislative branch and not in the hands of one, all-powerful but fallible executive.RS: You recently told The American Conservative that "We've been down this road before and we know it costs the U.S. blood and treasure for little gain." How concerned are you about the risk of escalation in the Middle East that could draw the U.S. in even further? What steps do you think could or should be taken to reduce these risks?
Sen. Lee: I am deeply concerned about escalation in the Middle East. For President Biden to admit that airstrikes have not changed the strategic environment in favor of U.S. interests while announcing his intention to continue them is wildly reckless policy. Beyond that, it doesn't seem the administration is concerned about how any of this affects the strategic landscape broadly for the United States. Both the 2018 and 2022 National Defense Strategies acknowledge that we cannot effectively engage in active military campaigns in two theaters at once, even by proxy, and yet the Biden administration seems perfectly content to ignore its own acknowledged limits. RS: Do you support the repeal of the 1991 and 2002 authorizations for the use of military force in Iraq? Do you expect that efforts to repeal these AUMFs will succeed this year?
Sen. Lee: Keeping outdated AUMFs on the books creates an unnecessary risk of misuse. The 1991 and 2002 AUMFs should have been repealed years ago and I joined a number of my colleagues in cosponsoring bipartisan legislation to do this. The repeals passed the Senate last year and I continue to encourage my colleagues in the House to take action to complete the repeal. I also believe that Congress needs to begin a serious debate on the merits of maintaining the 2001 AUMF, which has become the fallback "authorization" cited for most military action in the Middle East.

 I am not an international law specialist nor have I extensively studied the Israel-Palestine conflict, but I have written extensively about irredentism--the effort to enlarge one's country to include territories that are considered to be one's own by history and by blood.  So, when I see pictures like this, I get engaged:The river to the sea, used by either side, is an inherently irredentist phrase: that the lands between the Mediterranean and the Jordan River belong to just one side of this means seeking to get all of the territory of the other.  Palestianians and their supporters have been saying this, and so have Israelis and their allies.  Irredentism does not have to be this maximalist--Russia has claimed just a chunk of Ukraine.  But these claims and efforts are inherently violent--that any effort to change one's boundaries to include territories governed by others will produce war because no country (or quasi-state) surrenders inhabited territory without a fight.  Not Ukraine, not Taiwan, not Israel, and not Palestine.The thing is: all territory has been occupied by multiple groups, so there will always be competing claims pretty much everywhere on the planet except perhaps Antarctica.  Stuart Kaufman illustrated this nicely at the start of his book on Modern Hatreds:So, if irredentist claims are possible everywhere, then why isn't there violence everywhere?  Despite the news suggesting otherwise, ethnic violence, including irredentism, is rare.  Ethnic conflicts do end, people do find a way forward without fighting. Remember that the key grievance between Germany and France for ... at least three wars ... was Alsace-Lorraine.  Yet that is not an issue these days.  It is rare because irredentism is usually very self-destructive.  It didn't work out so well for Nazi Germany and not so well for 1990s Armenia, Croatia, or Serbia.  It has worked out well for China (Tibet), but Taiwan would be another story entirely.  Bill Ayres and I compared the irredentisms that occurred in the 1990s (the aforementioned Armenia, Croatia, and Serbia) and those that did not--Hungary, Romania, and Russia.  We confirmed that irredentism is very costly and self-destructive, but some countries do it anyway--when it benefits the politicians in power.  What is good for the politicians may not be good for the public, which produced our title: For Kin or Country.  Helping the kin abroad is often very bad for the country as war is bad.  Russia is paying a pretty high price for its irredentist campaign against Ukraine, but, thus far, Putin hasn't paid a price himself.  So, when I see what is going on in Israel and Palestine, my bias is to watch the strategies politicians use to stay in power and see how that intersects with the nationalism of the country. Politics is in part about shaping the nationalism, defining the us, the them, and whether the them can be tolerated.  A central irony we found is that the nationalisms that were more willing to include the thems, the others, in the state, the more able they are to engage in irredentism since any successful expansion will generally lead to more thems as well as us's in the larger state.  Indeed, why do folks often oppose irredentism--a successful campaign would produce the equivalent of a massive wave of immigration, upsetting the balance of domestic politics.  For example, a Greater Albania including Kosovo would likely weaken those who currently hold power in Albania since there are a lot of Kosovars.  And, yes, this gets to a key dynamic that the Hungarian case revealed--shades of identity, of us-ness.  That for Hungarians in Hungary, they identify with the Hungarians outside of Hungary (due to the Treaty of Trianon in 1920) but only up to a point.  Those Hungarians didn't experience post-1956 Hungary, so they don't have the same experiences and thus are not seen as quite the same.  So, Hungarians in Hungary want the Hungarians outside of Hungary to do well but to stay put--they don't want to share power or their welfare state with them.  Anyhow, irredentism varies over time and over targets based on who matters to the politicians in power.  Somalia's irredentism from 1960 to 1990 varied depending on who was in power and whose clans they needed for support.  So, Somalia sometimes targeted all three neighbors, despite that being profoundly unwise, because the clans with ties to those in Djibouti, Kenya, and Ethiopia all mattered in the domestic political game. At other times, only those in Ethiopia matters (1976-1977).  Back to Israel and Palestine: the irredentist efforts of Hamas (it aims to eliminate Israel and govern the entire space) and of Netanyahu (his coalition includes many parties that seek to incorporate the occupied territories, hence the support for the crazed settlers)* reinforce each other, giving each set of politicians more support from those who fear the other.  Not unlike Milosevic and Tudjman being each other's best allies as Tudjman could get Croats to support him because of the threat posed by Milosevic, and Milosevic could do the same to get Serbs to support him.  Have Hamas and Netanyahu delivered on other public policy issues?  No, they are utter failures, but they are hard to replace when the enemy is at the gates.  The coverage of this war has been quite clear that Netanyahu empowered Hamas to weaken the Palestinian Authority and perhaps also to keep the Israeli public focused on this than his own corruption.So, what is good for the politicians--war--is bad for the public, but the publics go along with it because they don't see any alternatives.  That people on both sides are talking about claiming territory from the river to the sea is understandable and horrifying, given what it requires--lots more bloodshed.

It empowers the worst leaders. It requires incredible leadership by alternative politicians to push in another direction. But until that happens, there won't be peace. BUT if that were to happen, you could have peace.

Alas, extremists have killed or marginalized the peacekmakers. So, things are going to be grim. We did cover this a bit in the book when we survey the world's irredentist hotspots including Ireland, Kashmir, Taiwan, etc.Anyhow, the focus should be on the politicians and their incentives. Irredentism is not inevitable, it can be sidelined.  But it can be really hard to stop once it gets started because of the media it generates, the fear it generates, and how the two sides can reinforce each other's worst instincts. *Yes, killing the two state solution is a key part of an irredentist strategy.  Never really thought about that before, but two state solution inherently recognizes limits on expansion, so one must do away with that if one wants to add the desired territories.