Publications by authors named "Piotr Szawarski"

24 Publications

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Elevated procalcitonin concentrations in severe Covid-19 may not reflect bacterial co-infection.

Ann Clin Biochem 2021 09 18;58(5):520-527. Epub 2021 Jun 18.

Wexham Park Hospital, Frimley Health NHS Foundation Trust, Slough, UK.

Background: The variability of Covid-19 severity between patients has driven efforts to identify prognosticating laboratory markers that could aid clinical decision-making. Procalcitonin is classically used as a diagnostic marker in bacterial infections, but its role in predicting Covid-19 disease severity is emerging. We aimed to identify the association between procalcitonin and Covid-19 disease severity in a critical care setting and whether bacterial co-infection is implicated.

Methods: We retrospectively reviewed Covid-19 patients with procalcitonin concentrations measured in a critical care setting at our institution between February and September 2020. Laboratory markers including peak procalcitonin values and a range of bacterial culture results were analysed. Outcomes were the requirement and duration of invasive mechanical ventilation as well as inpatient mortality.

Results: In total, 60 patients were included; 68% required invasive mechanical ventilation and 45% died as inpatient. Univariate analysis identified higher peak procalcitonin concentrations significantly associated with both the requirement for invasive mechanical ventilation (OR: 3.2, 95% CI 1.3-9.0,  = 0.02) and inpatient mortality (OR: 2.6, 95% CI 1.1-6.6,  = 0.03). Higher peak procalcitonin concentrations was an independent predictor of mortality on multivariate analysis (OR 3.7, 95% CI 1.1-12.4,  = 0.03). There was a significant positive correlation between increased peak procalcitonin concentrations and duration on invasive mechanical ventilation. No significant difference was found between peak procalcitonin concentrations of patients with positive and negative bacterial cultures.

Conclusions: Elevated procalcitonin concentrations in Covid-19 patients are associated with respiratory failure requiring prolonged invasive mechanical ventilation and inpatient mortality. This association may be independent of bacterial co-infection.
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http://dx.doi.org/10.1177/00045632211022380DOI Listing
September 2021

Politicisation of ivermectin raises concerns about how we communicate with the public.

BMJ 2021 05 19;373:n1258. Epub 2021 May 19.

Thames Valley Deanery, Oxford, UK.

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http://dx.doi.org/10.1136/bmj.n1258DOI Listing
May 2021

Human factors and ergonomics to improve performance in intensive care units during the COVID-19 pandemic.

Anaesthesiol Intensive Ther 2021 ;53(3):265-270

International Fluid Academy, Lovenjoel, Belgium.

The COVID-19 pandemic has tested the very elements of human factors and ergonomics (HFE) to their maximum. HFE is an established scientific discipline that studies the interrelationship between humans, equipment, and the work environment. HFE includes situation awareness, decision making, communication, team working, leadership, managing stress, and coping with fatigue, empathy, and resilience. The main objective of HF is to optimise the interaction of humans with their work environment and technical equipment in order to maximise patient safety and efficiency of care. This paper reviews the importance of HFE in helping intensivists and all the multidisciplinary ICU teams to deliver high-quality care to patients in crisis situations.
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http://dx.doi.org/10.5114/ait.2021.105760DOI Listing
September 2021

Medicine and the human factor.

Authors:
Piotr Szawarski

Postgrad Med J 2020 Dec 28;96(1142):784-787. Epub 2020 Oct 28.

Anaesthesia and Intensive Care Medicine, Wexham Park Hospital, Slough, UK

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http://dx.doi.org/10.1136/postgradmedj-2020-138943DOI Listing
December 2020

Classic cases revisited - Tony Nicklinson and the question of dignity.

Authors:
Piotr Szawarski

J Intensive Care Soc 2020 May 6;21(2):174-178. Epub 2019 Jun 6.

Department of Anaesthesia and Intensive Care Medicine, Frimley Health Foundation Trust, Wexham Park Hospital, Slough, UK.

Dignity is a concept we often evoke in healthcare when caring for patients and attending to their basic needs. It is a very human concept, unique perhaps. Yet, though instinctively we think we know what it means, we rarely pause to reflect on it. What does it mean? It is a concept that is hard to define and not easy to apply and yet a concept important for humanity. This article explores the roots and the uses of the term with particular reference to human rights, patient choices at the end of life and to vulnerability.
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http://dx.doi.org/10.1177/1751143719853746DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7238471PMC
May 2020

Classic cases revisited: Of hurricanes, cyanide and moral courage.

Authors:
Piotr Szawarski

J Intensive Care Soc 2020 Feb 12;21(1):2-6. Epub 2018 Jul 12.

Department of Anaesthesia and Intensive Care Medicine, Frimley Health Foundation Trust, Wexham Park Hospital, Slough, UK.

All decisions made by doctors have a moral dimension. When a moral judgement demands a different course of action to one that represents the usual practice, many doctors do struggle. The inability to embrace such decisions can represent moral negligence, as often the consequence is greater suffering for the individual in question or loss of utility for the population. On the other hand, it takes courage to make such decisions as the society fails to accept them, even though decisions made are rational and morally valid. Clinical practice that does not conform to moral judgements can result in moral distress, burn out and job-leave. Reflective practice evaluating moral dimensions of clinical decision making is an important aspect of nurturing humanity, empathy and professionalism in the therapeutic endeavour.
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http://dx.doi.org/10.1177/1751143718787755DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7137158PMC
February 2020

"Do no harm" was forgotten in death of asylum seeker.

Authors:
Piotr Szawarski

BMJ 2019 10 21;367:l6051. Epub 2019 Oct 21.

Wexham Park Hospital, Slough SL2 4HL, UK.

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http://dx.doi.org/10.1136/bmj.l6051DOI Listing
October 2019

Classic cases revisited: Mr Miura and the delusion of immortality.

Authors:
Piotr Szawarski

J Intensive Care Soc 2018 Aug 29;19(3):269-273. Epub 2018 Jan 29.

Department of Anaesthesia and Intensive Care Medicine, Frimley Health Foundation Trust, Wexham Park Hospital, Slough, UK.

Death continues to be viewed as a failure by many clinicians and society. For now however, it remains a biological certainty and to think otherwise is to delude oneself. Nevertheless, the society is becoming older and many individuals enjoy fulfilling life in spite of advancing years. The trajectory of age-related physiological deterioration varies, introducing an uncertainty as to the potential for survival when faced with critical illness. There is risk of harm associated with invasive interventions and utility of such remains uncertain in the very elderly. Changing demographic demands improved triage of the elderly patients and an evolution of the research agenda to acknowledge ageing population. There is also moral imperative to ensure avoidance of harm and cost-effectiveness in relation to intensive care unit utilisation by this patient population.
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http://dx.doi.org/10.1177/1751143718754995DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6110030PMC
August 2018

Classic cases revisited - Death of a nurse and the anatomy of error.

J Intensive Care Soc 2018 May 3;19(2):155-160. Epub 2017 Oct 3.

Frimley Health NHS Foundation Trust, Wexham Park Hospital, Slough, UK.

The tragic case of Mayra Cabrera who died as a result of wrong route drug administration is notable as it was the first time a verdict of unlawful killing was recorded against an NHS Trust. Error within medicine is a significant cause of patient morbidity and mortality. We explore the costs of error, the dynamics of error causation, the role of both the individual and institution in accountability for error, as well as transferrable lessons from other industries to reduce error.
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http://dx.doi.org/10.1177/1751143717735203DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5956681PMC
May 2018

Doctor won't see you now: changing paradigms in mountain medicine.

Postgrad Med J 2018 Mar 20;94(1109):182-184. Epub 2017 Dec 20.

UIAA Medcom, UIAA Medcom, Holsworthy, Devon, UK.

The evolution in communication and digital technologies is revolutionising the practice of medicine. A physician is now able to oversee provision of healthcare at a distance. In this paper, we argue that practice of telemedicine is an essential and evolving aspect of high altitude and expedition medicine. We acknowledge the lack of international consensus, limited legislation as well as possible reservations towards telemedical practice. Given some unique social and medical aspects of participation in remote, high altitude expeditions we propose a number of guiding principles for those involved in provision of telemedical services for such endeavours.
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http://dx.doi.org/10.1136/postgradmedj-2017-135468DOI Listing
March 2018

Classic cases revisited - Oxygen in court and the problem of therapeutic illusion.

Authors:
Piotr Szawarski

J Intensive Care Soc 2017 Aug 3;18(3):228-233. Epub 2017 Jan 3.

Wexham Park Hospital, Frimley Health NHS Foundation Trust, Wexham, Slough, UK.

Medical science attempts to inform clinical practice. Law is concerned with causality. Intersection of law and medicine at times highlights the shortcomings in the medical approach to causality. Evidence-based medicine is only as good as the process of gathering evidence and this is inherently imperfect as suggested by philosophers. There is a risk of attributing a causal relationship when there is none, which can result in a false belief about an intervention. False beliefs can become entrenched forming a dogma. An application of treatment and a subsequent observation of clinical improvement may create a therapeutic illusion of benefit. It is possible that oxygen is used in this way. We cannot safely infer based on harm associated with its deprivation that supplementation of oxygen is beneficial in all patients. Evidence of benefit of oxygen therapy versus harm is not overwhelmingly convincing. The case of oxygen serves to illustrate a potential for a wider problem in science and medicine where potentially harmful treatments are administered based on beliefs rather than evidence and on the extrapolations from population-wide observations and without considering particulars of each case. Current application of oxygen is possibly inappropriate and efforts should be made to reappraise its use.
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http://dx.doi.org/10.1177/1751143716684523DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5665127PMC
August 2017

Classic cases revisited: Oscar the cat and predicting death.

Authors:
Piotr Szawarski

J Intensive Care Soc 2016 Nov 25;17(4):341-345. Epub 2016 Apr 25.

Consultant in Intensive Care Medicine and Anaesthesia, Wexham Park Hospital, Wexham, UK.

Uncertainty, although inherent in medicine, is rarely discussed in spite of being ubiquitous. Communication of uncertainty is poor due to anxiety associated with it, yet one could argue that lack of such disclosure could undermine trust, lead to perception of deceit, alter decision making and in some cases could invalidate the consent process. Predictions concerning end of life are particularly difficult and may lead to excessive or insufficient medical interventions. Acknowledging uncertainty when prognosticating outcomes, and in particular death, may help in facilitating patient-centred care in context of a critical illness.
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http://dx.doi.org/10.1177/1751143716646123DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5624465PMC
November 2016

Fulminant high altitude blindness.

J Travel Med 2016 Jun 5;23(6). Epub 2016 Sep 5.

College of Environmental Protection, Associate Prof. in Geography, Trg mladosti 7, Velenje 3320, Slovenia.

Prolonged altitude exposure even with acclimatization continues to present a physiological challenge to all organ systems including the central nervous system. We describe a case of a 41-year-old Caucasian female climber who suffered severe visual loss that was due to possible optic nerve pathology occurring during a high altitude expedition in the Himalayas. This case is atypical of classic high altitude cerebral oedema and highlights yet another danger of prolonged sojourn at extreme altitudes.
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http://dx.doi.org/10.1093/jtm/taw057DOI Listing
June 2016

Classic cases revisited: Mr David James, futile interventions and conflict in the ICU.

Authors:
Piotr Szawarski

J Intensive Care Soc 2016 Aug 2;17(3):244-251. Epub 2016 Feb 2.

Wexham Park Hospital, Frimley Health NHS Foundation Trust, Slough, UK.

The technology so prevalent in the modern healthcare setting often creates an illusion that the biological certainty of death can somehow be evaded. Increasing number of deaths worldwide occurs in hospitals, and doctors by necessity inherit the role traditionally owned by priests, in overseeing the dying process. Unrealistic expectations concerning cure or indeed different perceptions of patient's interests on a background of deficient communication can lead to conflict. The case of David James illustrates conflict arising in the context of critical illness where further life-sustaining interventions were deemed to be futile. Futility and conflict in context of critical illness are discussed along with the legal judgements pertaining to the case of David James.
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http://dx.doi.org/10.1177/1751143716628885DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5606518PMC
August 2016

Patient-centred mountain medicine.

Postgrad Med J 2016 Aug 27;92(1090):482-3. Epub 2016 May 27.

Holsworthy, Devon, UK UIAA Medcom, Bern, Switzerland, Devon, UK.

Venturing into the mountains, doctors have accompanied expeditions to provide routine care to the teams, undertake research and occasionally take on a rescue role. The role of doctors practicing mountain medicine is evolving. Public health issues involving concepts of health and safety have become necessary with the coming of commercial and youth expeditions. Increasingly individuals with a disability or a medical diagnosis choose to ascend to high altitudes. Doctors become involved in assessment of risk and providing advice for such individuals. The field of mountain medicine is perhaps unique in that acceptance of risk is part of the ethos of climbing and adventure. The pursuit of mountaineering goals may represent the ultimate conquest of a disability. Knowledge of mountain environment is essential in facilitating mountain ascents for those who choose to undertake them, in spite of a disability or medical condition.
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http://dx.doi.org/10.1136/postgradmedj-2016-134096DOI Listing
August 2016

Classic cases revisited: Baby Theresa and the definition of death.

J Intensive Care Soc 2015 Aug 11;16(3):222-225. Epub 2015 Feb 11.

Leeds General Infirmary, Leeds, UK.

As our medical knowledge grows the criteria for the diagnosis of death continue to evolve. The criteria tend to be pragmatic, and are designed to serve the needs of the society. They are however, only a set of tools and as such they fail to address the question of what death actually is. More importantly, a question remains as to what does death mean to us, human beings. The historical case of Baby Theresa challenges the way we think about death, life and organ transplantation.
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http://dx.doi.org/10.1177/1751143715569021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5606434PMC
August 2015

Classic cases revisited: Mrs Janet Tracey, resuscitation and the importance of good communication.

Authors:
Piotr Szawarski

J Intensive Care Soc 2015 May 4;16(2):142-146. Epub 2015 Feb 4.

Consultant in Intensive Care Medicine and Anaesthesia, Wexham Park Hospital, Frimley Health NHS Foundation Trust, Wexham, UK.

The prevalence of inappropriate care, defined as actions contrary to personal and professional beliefs, is high. This is a reflection of the reluctance of the society at large to acknowledge the biological certainty that is death. The case of Mrs Janet Tracey illustrates importance of good communication at the end of life, and the difficulties associated with making of DNACPR decisions. The case brings together two bioethical perspectives on the relationship between the patient and the physician namely the rights based approach, as emphasised by the Article 8 of the European Convention on Human Rights and the bioethical principles approach ephasising autonomy. In doing so it creates a medico-legal landmark for all those involved in management of the end of life.
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http://dx.doi.org/10.1177/1751143715569020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5606485PMC
May 2015

Precedents in law for punishing gross negligence.

Authors:
Piotr Szawarski

BMJ 2013 Mar 5;346:f1359. Epub 2013 Mar 5.

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http://dx.doi.org/10.1136/bmj.f1359DOI Listing
March 2013

Pituitary apoplexy and high altitude.

Singapore Med J 2012 Aug;53(8):559; author reply 559

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August 2012

N-methyl-D-aspartate receptor antibody-mediated encephalitis.

Br J Hosp Med (Lond) 2012 Aug;73(8):472-3

Department of Intensive Care Medicine, University College London Hospital, London NW1 2BU, UK.

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http://dx.doi.org/10.12968/hmed.2012.73.8.472DOI Listing
August 2012

Spironolactone does not prevent acute mountain sickness: a prospective, double-blind, randomized, placebo-controlled trial by SPACE Trial Group (spironolactone and acetazolamide trial in the prevention of acute mountain sickness group).

Wilderness Environ Med 2011 Mar 30;22(1):15-22. Epub 2010 Oct 30.

Nepal International Clinic, Kathmandu, Nepal.

Objectives: Over the last 20 years a number of small trials have reported that spironolactone effectively prevents acute mountain sickness (AMS), but to date there have been no large randomized trials investigating the efficacy of spironolactone in prevention of AMS. Hence, a prospective, double-blind, randomized, placebo-controlled trial was conducted to evaluate the efficacy of spironolactone in the prevention of AMS.

Methods: Participants were sampled from a diverse population of western trekkers recruited at 4300 m on the Mount Everest base camp approach (Nepal side) en route to the study endpoint at 5000 m. Three hundred and eleven healthy trekkers were enrolled, and 251 completed the trial from October to November 2007. Participants were randomly assigned to receive at least 3 doses of spironolactone 50 mg BID, acetazolamide 250 mg BID, or visually matched placebo. A Lake Louise AMS Score of 3 or more, together with the presence of headache and 1 other symptom, was used to evaluate the incidence and severity of AMS. Secondary outcome measures were blood oxygen content and the incidence and severity of high altitude headache (HAH).

Results: Acetazolamide was more effective than spironolactone in preventing AMS (OR = 0.28, 95% CI 0.12-0.60, p < 0.01). Spironolactone was not significantly different from placebo in the prevention of AMS. AMS incidence for placebo was 20.3%, acetazolamide 10.5%, and spironolactone 29.4%. Oxygen saturation was also significantly increased in the acetazolamide group (83% ± 0.04) vs spironolactone group (80% ± 0.05, p < 0.01).

Conclusions: Spironolactone (50 mg BID) was ineffective in comparison to acetazolamide (250 mg BID) in the prevention of AMS in partially acclimatized western trekkers ascending to 5000 m in the Nepali Himalaya.
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http://dx.doi.org/10.1016/j.wem.2010.10.009DOI Listing
March 2011

Acetazolamide-induced myopia at altitude.

Wilderness Environ Med 2009 ;20(3):300-1

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http://dx.doi.org/10.1580/08-WEME-LE-259R1.1DOI Listing
October 2009

Antibiotics on the intensive care unit: continuous infusion or intermittent bolus?

Authors:
Piotr Szawarski

Br J Hosp Med (Lond) 2007 Oct;68(10):568

Queen Elizabeth Hospital, London.

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http://dx.doi.org/10.12968/hmed.2007.68.10.27334DOI Listing
October 2007
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