Medical Staff Pulse Newsletter

Pharmacy Focus

Pfizer withdraws Mylotarg® from market

On June 21, Pfizer announced the voluntary withdrawal of the drug Mylotarg® (gemtuzumab ozogamicin) from the U.S market. 

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Imaging Case of the Month for July

A 68-year-old female with dyspnea on exertion underwent a CT coronary angiogram as part of her workup. 

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Meetings and Events

Interdisciplinary Diabetes Conference, July 13

Argentina: Land of Pampas, Gauchos, Tango, Polo and Soccer, July 20

Sand N' Snore, July 16

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PEG Rarely Indicated for Palliative Care

New form can assist in evaluation

By Andrew Ippoliti, M.D., and Daniel Fink, M.D.
A gastrostomy tube is placed directly into the stomach to allow enteral nutrition without the discomfort, potential for dislodgement, and mechanical complications of a long-term nasogastric tube. With the development of flexible fiber optic endoscopy in the past few decades, percutaneous enterogastrostomy (PEG) has become the preferred technique for gastrostomy tube placement.

PEGs are frequently inserted in patients unable to swallow or swallow safely. Physicians and patient’s families often believe that enteral feeding via PEG prevents aspiration, maintains nutritional status, prevent decubitus ulcers and prolongs life. While no randomized trial has been done, the medical literature unfortunately shows that PEGs do not prevent aspiration, do not maintain nutritional status, do not prevent decubitus ulcers, and actually increase mortality.

PEGs are frequently inserted in elderly patients after disabling neurologic events, but PEG insertion is rarely if ever indicated as part of end of life care. The fluid and nutritional needs of a patient with advanced dementia are low, and may be met by peripheral intravenous hydration with glucose solutions. Extended care facilities will accept patients with nasogastric feeding tubes when there is limited life expectancy, although even these tubes are probably not indicated as part of end of life care.

Physicians should focus their discussions with families on patient preferences, goals and values. The lack of efficacy of PEGs in preventing complications or reducing mortality – indeed, the fact that PEGs increase mortality – should be explained to patients and families.

Members of the Center for Healthcare Ethics, Chaplaincy, and Palliative Care Services are available to assist in these discussions. References to literature regarding mortality rates in PEG patients may be obtained from the Division of Gastroenterology.

As part of efforts to improve patient care and reduce unnecessary utilization of PEGs, attending physicians and consulting gastroenterologists will be required to complete a PEG Evaluation Form before the procedure will be performed at Cedars-Sinai.

PEG Evaluation Form

Please send questions about the form or the appropriate criteria for PEG insertion to Dr. Ippoliti, director of Administration and Clinical Affairs for the Division of Digestive Diseases, at Andrew.Ippoliti@cshs.org.