WALES Research Articles

Reply

Sir: Thank you for the opportunity to reply to the letter by Dr. Acartürk. We reported in the March 2010 issue of Plastic and Reconstructive Surgery a case of banking a hemiabdominal deep inferior epigastric perforator (DIEP) flap for “high-risk patients.”1 We sought to describe this as a unique and original technique for preserving a perforator flap while awaiting oncologic clearance of a tumor that was being primarily reconstructed at a single recipient site. The title of the article and the indication for the procedure certainly demonstrated this, and clearly differed from the planned staging of a bilateral breast reconstruction, in which two separate defects were reconstructed, as reported by Dr. Acartürk.2 Although Dr. Acartürk's case was reported in 2008, we performed our reported case in November of 2004, with the original photograph and dates from the camera shown in Figure 1. We have actually performed a series of these procedures since 1999, with the first procedure performed in February of 1999 and the original photograph and date from the camera of the first such procedure shown in Figure 2 (this is a 12-month follow-up photograph). However, where the concern appears to have arisen is the time between Dr. Acartürk's 2008 publication and our March of 2010 publication. We would like to point out that in fact we wrote our article before Dr. Acartürk's publication (in early 2008), and our article was submitted, accepted, and has been in press since 2008. He also claims that we referenced a 2009 article in our article—we certainly did not, and there is no mention of this reference in our article,3 given that our submission was well before that. There were certainly no “intentional” omissions from the literature, and a thorough literature review was indeed performed at the time of initial writing, before Dr. Acartürk's case was published or presented.Fig. 1.: Original photograph of the published case example of a “surplus,” banked DIEP flap performed in November of 2004, in which chest wall reconstruction with a right-sided hemiabdominal DIEP flap was performed for locally advanced lymphangiosarcoma, and closure of the abdominal wall was performed with a left DIEP advancement flap for subsequent use in the case of local recurrence.Fig. 2.: Original photograph of our first case of a “surplus,” banked DIEP flap performed in February of 1999 for unilateral breast reconstruction, demonstrating the 12-month postoperative results.This must of course be taken in the context of the Plastic and Reconstructive Surgery Viewpoints section, which offers the ability to provide broad access to many ideas and techniques by limiting submissions to five references and 500 words, but which in turn can serve to limit the extent of literature review. However, given the nature of the different case reports in the current discussion, this is not highly relevant here. In addition, the dates of submission and acceptance are not listed in the Viewpoints section, which can confound the interpretation of dates. Finally, in terms of Dr. Acartürk's presentation of the case report at the European Federation of Societies for Microsurgery meeting, the presentation was not seen by any of the authors, and again the article was written well before this. We commend Dr. Acartürk for his earliest publication of such a technique, one which we have clearly found useful ourselves for some time, in a range of different clinical settings. Rafael Acosta, M.D. Department of Plastic Surgery Uppsala Clinic Hospital Uppsala, Sweden Warren M. Rozen, M.B.B.S., B.Med.Sc., P.G.Dip.Surg.Anat., Ph.D. Brockhoff Reconstructive Plastic Surgery Research Unit Department of Anatomy and Cell Biology University of Melbourne Parkville, Victoria, Australia Iain S. Whitaker, B.A.(Hons.), M.A.(Cantab.), M.R.C.S. Department of Plastic, Reconstructive, and Burns Surgery Welsh National Plastic Surgery Unit Morriston Hospital Swansea, United Kingdom

Alun Roberts, The Welsh National School of Medicine 1893–1931: the Cardiff years, Cardiff, University of Wales Press, 2008, pp. xxiv, 389, illus., £55.00 (hardback 978-0-7083-2174-4).

Welsh medical education has been poorly served by historians, something which was partly rectified in the three volumes on the history of Welsh universities published by Williams and Morgan in the 1990s. While Alun Roberts claims that these gave proper treatment to the history of the medical school, Williams suggested that the Welsh School of Medicine deserved a separate history. Roberts, a former registrar of the school and a trained historian, took up the challenge. The Cardiff Medical School, as it was originally known, was established in 1893, ten years after the creation of the University College of South Wales and Monmouthshire. Arguments put forward in support of this included the economic, linguistic and moral advantages of providing medical education for Welsh students at home. In the early years the school offered pre-clinical training only. It was shaped by advice from Sir Donald MacAlister, principal of Glasgow University and chairman of the GMC, and Sir William Osler, with the latter advocating a clinical unit structure modelled on that adopted at Johns Hopkins. While this led to Rockefeller Foundation support in the 1920s, it also exacerbated tensions within the medical and university communities. One of the strengths of the book is the way in which it analyses these clashes. As the Western Mail observed in 1927, “Complication follows complication in the efforts to lift the Welsh National School of Medicine from the arena of controversy.” As happened elsewhere, there were bitter disputes over the threat to private practice posed by part-time academic appointments, and the struggle for clinical control between professors and hospital clinicians. The 1920s were also marked by constitutional wrangles between the school and local hospital managers. A further complication came with the territorial disputes between Cardiff and North Wales, and the debates as to what constituted a national school. Roberts tackles all of these issues with clarity and balance. At the same time, he never loses sight of the individuals for whom the school was established. Chapter 9 examines the family, educational and social backgrounds of the students and outlines the subsequent careers of sixty of the sixty-four who graduated between 1916 and 1931. One of the most interesting statistics is the fact that only 3 per cent of the students were domiciled in North Wales; rather than journey to Cardiff, it seems that they preferred to study in Liverpool. Alun Roberts has written an unashamedly old-fashioned narrative history, a “biography of an institution” as he describes it in the preface—and it is none the worse for that. He writes clearly and sustains the story with meticulous footnotes, though at times the essential clarity of the text is swamped by detail. Extended biographical sketches often interrupt the flow of the narrative but do flesh out what is clearly intended as a tribute to Welsh medicine. While much of the information is useful, there are times when a good copy editor might have tempered Roberts’ enthusiasm. Did we really need to know of (Sir) Ewen Maclean, appointed “professor extraordinary” of obstetrics in 1921, that “[h]is nephew in due course achieved notoriety as the spy Donald Maclean”? Despite such minor cavils, this is a worthwhile contribution to the historiography of medical education in Britain.

A pragmatic randomised controlled trial of the Welsh National Exercise Referral Scheme: protocol for trial and integrated economic and process evaluation

BackgroundThe benefits to health of a physically active lifestyle are well established and there is evidence that a sedentary lifestyle plays a significant role in the onset and progression of chronic disease. Despite a recognised need for effective public health interventions encouraging sedentary people with a medical condition to become more active, there are few rigorous evaluations of their effectiveness. Following NICE guidance, the Welsh national exercise referral scheme was implemented within the context of a pragmatic randomised controlled trial.Methods/DesignThe randomised controlled trial, with nested economic and process evaluations, recruited 2,104 inactive men and women aged 16+ with coronary heart disease (CHD) risk factors and/or mild to moderate depression, anxiety or stress. Participants were recruited from 12 local health boards in Wales and referred directly by health professionals working in a range of health care settings. Consenting participants were randomised to either a 16 week tailored exercise programme run by qualified exercise professionals at community sports centres (intervention), or received an information booklet on physical activity (control). A range of validated measures assessing physical activity, mental health, psycho-social processes and health economics were administered at 6 and 12 months, with the primary 12 month outcome measure being 7 day Physical Activity Recall. The process evaluation explored factors determining the effectiveness or otherwise of the scheme, whilst the economic evaluation determined the relative cost-effectiveness of the scheme in terms of public spending.DiscussionEvaluation of such a large scale national public health intervention presents methodological challenges in terms of trial design and implementation. This study was facilitated by early collaboration with social research and policy colleagues to develop a rigorous design which included an innovative approach to patient referral and trial recruitment, a comprehensive process evaluation examining intervention delivery and an integrated economic evaluation. This will allow a unique insight into the feasibility, effectiveness and cost effectiveness of a national exercise referral scheme for participants with CHD risk factors or mild to moderate anxiety, depression, or stress and provides a potential model for future policy evaluations.Trial registrationCurrent Controlled Trials ISRCTN47680448

John Bryn Thomas Griffiths

After a period in the Royal Air Force, John Bryn Thomas Griffiths studied medicine at the Welsh National School of Medicine in Cardiff and then worked at Cardiff Royal Infirmary...

Book review: Julios, C. 2008: Contemporary British identity: English language, migrants and public discourse. Aldershot: Ashgate. 210 pp. £55/ US$99.95 cloth. ISBN: 978 0 7546 7158 9. Jones, R. and Fowler, C. 2008: Placing the nation: Aberystwyth and the reproduction of Welsh nationalism. Cardiff: University of Wales Press. 224 pp. £16.99/US$35 paper. ISBN: 978 0 7083 2137 9

Book review: Julios, C. 2008: Contemporary British identity: English language, migrants and public discourse. Aldershot: Ashgate. 210 pp. £55/ US$99.95 cloth. ISBN: 978 0 7546 7158 9. Jones, R. and Fowler, C. 2008: Placing the nation: Aberystwyth and the reproduction of Welsh nationalism. Cardiff: University of Wales Press. 224 pp. £16.99/US$35 paper. ISBN: 978 0 7083 2137 9

JOHN KERRIGAN, Archipelagic English: Literature, History and Politics 1603-1707.

ONE suspects that some readers may view this book as, at least in part, a politically partisan work designed to promote Celtic nationalism. And indeed, on one level such an impression would be understandable. Though the author claims it is ‘not a manual for devolutionary politicians’ (87), it seems at least tacitly, and in places explicitly, sympathetic with the respective nationalist agendas in Wales, Scotland, and Northern Ireland. Evidence for this is signalled, for example, in the author's stated aim to ‘strip away modern Anglocentric and Victorian imperial paradigms’ (2), and in his consistently employing terminology sceptical or hostile to the union—‘the so-called British Isles’ (21). And perhaps at times, particularly in relation to recent history, Kerrigan can frame his analysis within uncharacteristically narrow parameters: the resurgence of Irish, Welsh, and Scottish nationalism in the 1980s, for instance, takes place ‘against a background of harsh and assertively English Thatcherite government from Whitehall’ (22), with no further evidence or context offered.

Hot, banal and everyday nationalism: Bilingual road signs in Wales

The paper focuses on Billig's (Billig, M. (1995). Banal nationalism. London: Sage) notion of banal nationalism. While Billig's work is to be commended for demonstrating the way in which nationalism is an endemic political ideology in all states – and not merely an extreme or hot political ideology that is based upon “blood and belonging” (Ignatieff, M. (1993). Blood and belonging: Journeys into the new nationalism. London: BBC Books) – we suggest that his work tends, perhaps unwittingly, to reinforce an unwarranted separation of the banal and hot processes that reproduce nationalism. Some empirical work has implicitly and explicitly begun to question the distinction between banal and hotter forms of nationalism. We argue that one way in which such an agenda can be furthered is through a promotion of the idea of everyday nationalism, which combines banal and hot elements in more complex and contingent ways. We elaborate on the benefits of adopting such an approach through an empirical discussion of the campaign in favour of bilingual road signs in Wales between 1967 and 1975. We focus, first, on how monolingual English road signs were constructed by Welsh nationalists as part of an everyday landscape of oppression and, second, on the everyday politics of road signs within the spaces of government. We conclude the paper by reaffirming the need to move beyond notions of banal and hot nationalism and to focus on the everyday contexts within which nationalism is reproduced.

Synthesis and reactivity of a Ru(i) dimer devoid of π-acid ligands

Zinc reduction of [(Cym)RuCl(2)](2) gives [(Cym)RuCl](2), (Cym = 1,4-Me(i)PrC(6)H(4)), whose reactivity is evaluated. This Ru(I) dimer with two bridging chlorides shows no reactivity towards H(2), N(2), N(2)O or methyl triflate, but does add HCl to form (Cym)(2)Ru(2)HCl(3). Attempts to form a monomeric monovalent ruthenium complex with dppm, Ph(2)PCH(2)PPh(2), gives disproportionation to (Cym)RuCl(2)(eta(1)-dppm) and (Cym)Ru(eta(2)-dppm). With terpyridyl, the analogous disproportionation behavior is observed, to form Ru(terpy)(2)(2+) and a zero valent product, which decomposed before it could be isolated. The molecular orbitals, from a DFT calculation, of [(Cym)RuCl](2) show the LUMO to be in a sterically crowded region of the molecule, and thus helps to account for the reactivity targeted for small and more nucleophilic reagents, while the HOMO is accessible to reaction with HCl.

Janina Elizabeth Hopkin

Janina Elizabeth Hopkin qualified with full honours from the Welsh National School of Medicine with a distinguished collection of distinctions and academic prizes, and went on to complete a masters...

Placing the Nation: Aberystwyth and the Reproduction of Welsh Nationalism by Rhys Jones and Carwyn Fowler

Placing the Nation: Aberystwyth and the Reproduction of Welsh Nationalism by Rhys Jones and Carwyn Fowler

Relocating nationalism: on the geographies of reproducing nations

The paper examines the distinction that has been made in studies of nationalism between national elites and the ordinary members of nations. While the distinction is useful as a way of beginning to conceptualise the mechanisms through which nations and nationalisms are reproduced, it can also reify a boundary between national elites and the mass membership of the nation that is, in actual fact, blurred and unstable in character. Through case studies of nationalist campaigns relating to education and linguistic rights in the town of Aberystwyth in West Wales, the paper argues that a focus on the places in which national ideologies are produced, circulated and consumed can enable us to question the distinction that is made between the national elites and ordinary members of the nation. As well as illustrating the poly‐vocal production of Welsh nationalism, the empirical research also suggests the need to re‐examine the social and spatial contexts within which nationalism is reproduced.

A study of the attitudes and perceived barriers to undertaking clinical governance activities of dietitians in a Welsh National Health Service trust

Previous studies of National Health Service (NHS) employees have identified barriers to undertaking clinical governance activities. Little of this research has investigated dietitians; however, where dietitians were included, generally positive attitudes towards research and evidence-based practice were reported alongside the identified barriers. A quantitative, whole population census was undertaken via a questionnaire distributed to 54 dietitians employed by Gwent Healthcare NHS Trust. Dietitians reported positive attitudes towards clinical governance; however, barriers to undertaking clinical governance activities were identified. The main barriers included lack of time, inadequate funding, the view that direct patient care should always be prioritised over clinical governance activities and inadequate research and critical evaluation skills. Findings were similar to those reported in previous studies of NHS staff. Where comparison was possible, all of the barriers identified were reported at lower levels than in previous studies. As the study was purely quantitative in nature, no understanding was gained regarding the nature of identified barriers or what factors influenced the dietitians' attitudes and perceptions. For further in-depth analysis of these factors, a qualitative study is recommended. As the study comprised a whole population census, the findings cannot be generalized to the dietetic profession as a whole, or to other staff groups within or outside of the study Trust.

Museums, Nations, Identities: Wales and its National Museums

A recent request by a Welsh MP that Wales be represented in the Union Jack1 illustrates a new confidence in the idea of Welshness, and the prompt concession by the Culture Minister to consider this change indicates the importance of Welsh national identity in British politics today. Mason's study of Welsh national museums is thus a timely addition to the literature on Wales and nationhood, and makes an important contribution to our understanding not only of Welsh nationalism made explicit within museums but also to the whole concept of nationalism within the UK. This book goes beyond the consideration of the cultural discourse around one set of practices – the establishment and maintenance of national museums in Wales – and examines a range of interesting issues about the nation and culture in general. Mason examines the macro-level of governmental and media debates and the micro-level of institutional collecting policies,...

Finding the Lost Children of Craig-y-nos

Craig-y-nos Castle (meaning ‘Rock of the Night’) lays claim to be the most haunted castle in Wales. Perched on the edge of the Brecon Beacons National Park, it was the estate of Adelina Patti, the world famous opera singer, from 1878 until her death in 1919. Within the castle grounds, Patti built an ornate theatre where she sang for audiences of up to 150 guests including British and European Royalty. The Patti Theatre is now a Grade 1 listed opera house and headquarters of the Opera School Wales. On Patti’s death, her third husband, Baron Rolf Cederstrom, sold the estate to the King Edward VII Welsh National Memorial Association, established in 1910, to combat tuberculosis in Wales. As the Adelina Patti Hospital, it served for 40 years as a sanatorium for children and young women, at a time when the incidence and death rate of TB in the industrial areas of south Wales were higher than anywhere else in Britain. TB claimed the lives of 12 young men and 17 young women a year in every Welsh community of 6000 people.

Biobrane: A Versatile Tool in the Armamentarium of the Reconstructive and Burns Surgeon

Sir: Biobrane is becoming increasingly popular in the management of superficial and moderate-depth partial-thickness burns. When used appropriately, it has been shown to reduce pain levels, healing time, inpatient stay, and nursing requirements when compared with traditional dressings. We would like to draw the attention of the reconstructive community to the versatility of Biobrane above and beyond these well-known indications. Biobrane is a biosynthetic wound dressing first developed by Woodruff in 1979. It has many of the “ideal” properties highlighted by Pruitt and Levine in 1984.1 There is a great deal of literature available outlining the successful use of Biobrane in the management of partial-thickness burns in pediatric patients. There is also evidence for its use in the treatment of partial- and full-thickness burns in the adult, particularly in large burns and those involving joints and the hand. Various application modifications have been published to overcome coverage of difficult areas (e.g., use of the Biobrane glove to dress the foot and the Biobrane “jacket” to dress the torso). In addition to covering the burn wound, it is also used in the management of split-thickness skin graft donor sites, in both burned and nonburned patients. Its use in stenting split-thickness skin grafts has also been advocated. The use of Biobrane has been reported to cover the axillary defect following surgical excision for hidradenitis suppurativa.2 This single-stage procedure, with no donor-site morbidity, exhibited the ability to use Biobrane in colonized tissues. The limitations included a longer healing time and increased cost of dressing. Biobrane has also been used successfully after laser resurfacing of the face.3 It was well tolerated, minimized pain and drainage, decreased erythema, reduced healing time, and simplified nursing care. Similarly, Biobrane has been used as a dressing after mechanical dermabrasion. This study showed that Biobrane reduced erythema and healing time by up to 50 percent when compared with air-exposed wounds. The use of Biobrane has been reported in the successful treatment of serious skin conditions, such as toxic epidermal necrolysis4 and paraneoplastic pemphigus. Biobrane was applied to the extensive areas of erosion to assist in pain management and to provide a temporary barrier function. The treatment of serious skin conditions such as toxic epidermal necrolysis and pemphigus with Biobrane is an area that warrants further evaluation, as it may contribute to the overall treatment and comfort of these patients. Chronic wounds such as large venous ulcers have also been managed successfully using Biobrane. There are several case reports concerning the use of Biobrane in the contemporary literature. The skin substitute was used in the treatment of a life-threatening esophageal fistula by covering an expandable metallic stent and in the management of subcutaneous colostomy perforation. Biobrane has also been used in the successful management of sternotomy wounds that were not closed immediately due to massive intraoperative edema formation. Adverse affects following the use of Biobrane are uncommon, but surgeons should be aware of the possibility of contact dermatitis, hypersensitivity, and hypertrophic scarring.5 We believe that Biobrane is a highly versatile tool that should be in the armamentarium of all reconstructive and burns surgeons. Further randomized controlled trials assessing its use in a variety of conditions are warranted. Iain S. Whitaker, M.R.C.S. The Welsh Plastic Surgery and Burns Unit The Morriston Hospital Swansea, United Kingdom Paul Mallinson, M.B.Ch.B. Pinderfield's Hospital Wakefield, United Kingdom Peter J. Drew, F.R.C.S.(Edin.), F.R.C.S.(Eng.), F.R.C.S.Plast. Department of Burns and Plastic Surgery The Welsh National Plastic Surgery and Burns Unit The Morriston Hospital Swansea, United Kingdom DISCLOSURE None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this communication.

Derek John Llewellyn

Derek John Llewellyn is best known for the establishment of vocational training for general practice in Wales. In the late 1960s and early 1970s he travelled the length and breadth...

William Benjamin Clee

Born in Merthyr Tydfil, William Benjamin Clee became Student of the Borough and represented Afon Taf School on BBC’s Top of the Form , before entering the Welsh National School...

William Anthony Jerrett

William Anthony Jerrett (“Bill”) was born and educated in Cardiff. He was a keen sportsman in cricket and rugby, both in school and while a medical student at the Welsh...

‘Nurses make a difference’ in wales

‘Nurses make a difference’ in wales

Gernika in Context

36 Historically Speaking September/October 2007 of Antoine Roquentin replicates in many ways the life of Jean-Paul Sartre. Thus we can fill in many of the gaps in Roquentin's life with what we know about his creator. Sartre was born and raised in Paris, he attended the Ecole normale supérieure, where he studied more literature than history, which explains his limitations as a historian. He did do his military service, it turns out. He taught high school in Le Havre, while living in hotels, which goes a long way toward explaining his depression. He benefited from an inheritance, which gave him his chance to travel. He learned about Husserl from reading about him, not from staring at chestnut trees. And he had a running relationship with Simone de Beauvoir, almost as sadomasochistic as Roquentin's relationship with Anny. But this is no excuse for what Sartre does not tell us in his novel. The universe may be disorderly, but this is no reason to take it out on us. Nature may be indifferent, but this is no reason to be insensitive. And, indeed, if we want to identify the most pungent odor seeping out from the pages of Sartre's Nausea, it is the odor of obliviousness. During the time that he was writing it, he had a chance to see the fascists and the Nazis first hand. During the time that he was completing it, Mussolini was invading Abyssinia and Hitler was remilitarizing the Rhineland. My mother, who never agonized over chestnut trees, took one look at Mussolini and decided that he was bad news, and that is one reason that I am here speaking to you today. But neither Antoine Roquentin nor Jean-Paul Sartre, in their absorption with themselves, had the sensitivity, nay the elementary common sense, to predict that the next time the trolley car parked at the Grands Bassins, it was not only heading for the slaughterhouse. It was moving right on to Dachau. Paul Sennino isprofessor of history at the University of California, Santa Barbara. He haspublished widely on 17th-century Europe, including Louis XIV and the Origins of the Dutch War (Cambridge University Press, 1988). Gernika in Context Rob Stradling I ^^ uring the early weeks of ^B 1937 a controversial trial ^^ was proceeding at the Old Bailey. The case involved mass murder , and evoked widespread attention. Yet its details were hardly the usual gory diet of the popular press. Three men were in the dock, accused of damage to Crown property—an act described by the judge as "most dangerous and wicked." The unlikely terrorists were a university lecturer, a Nonconformist minister, and a schoolteacher. They were also, respectively , the president (Saunders Lewis) and two senior officials (Valentine and Williams) of the Welsh Nationalist Party, Plaid Genedlaethol Cymru. But the Crown—prosecuting agency as well as alleged victim— stood counter-accused by Lewis of a crime of unimaginably greater dimensions : no less than planning the massacre of noncombatant civilians by bombing action from the air in a future war. Even before September 1936, when the three saboteurs set fire to an RAF training school for pilots being built at Penyberth in north Wales, Lewis had accused the British government of pursuing a policy of defense rearmament which was tantamount to "baby-murdering." Certainly, when the bombing of Gernika occurred on April 26, 1937, the British government's response to the threat of massed bombing raids on British cities was already under way. A potential aggressor had to be deterred (as it were, Plan A); or failing that, retaliated against (Plan B). Because of Langston Hughes, Mikhail Koltsov, Ernest Hemingway, Nicolas Guillen, Madrid, 1937. Yale Collection ofAmerican Literature, Belnecke Rare Book and Manuscript Library. the Penyberth trial—among other things—people were becoming aware of the practical and ethical implications of air warfare. As Orwell was soon to argue, the only way of winning a war in which the enemy dropped bombs on your mother was to drop bigger bombs on his mother. Plan B was exactly what the Allies were to carry out in World War II, and its existential logic underpins the whole policy of nuclear deterrence. Indeed, the...