Multicenter Assessment of Cryoanalgesia Use in Minimally Invasive Repair of Pectus Excavatum: A 20-center Retrospective Cohort Study.

OBJECTIVE: To assess the clinical implications of cryoanalgesia for pain management in children undergoing minimally invasive repair of pectus excavatum (MIRPE). BACKGROUND: MIRPE entails significant pain management challenges, often requiring high postoperative opioid use. Cryoanalgesia, which blocks pain signals by temporarily ablating intercostal nerves, has been recently utilized as an analgesic adjunct. We hypothesized that the use of cryoanalgesia during MIRPE would decrease postoperative opioid use and length of stay (LOS). MATERIALS AND METHODS: A multicenter retrospective cohort study of 20 US children's hospitals was conducted of children (age below 18 years) undergoing MIRPE from January 1, 2014, to August 1, 2019. Differences in total postoperative, inpatient, oral morphine equivalents per kilogram, and 30-day LOS between patients who received cryoanalgesia versus those who did not were assessed using bivariate and multivariable analysis. P value <0.05 is considered significant. RESULTS: Of 898 patients, 136 (15%) received cryoanalgesia. Groups were similar by age, sex, body mass index, comorbidities, and Haller index. Receipt of cryoanalgesia was associated with lower oral morphine equivalents per kilogram (risk ratio=0.43, 95% confidence interval: 0.33-0.57) and a shorter LOS (risk ratio=0.66, 95% confidence interval: 0.50-0.87). Complications were similar between groups (29.8% vs 22.1, P =0.07), including a similar rate of emergency department visit, readmission, and/or reoperation. CONCLUSIONS: Use of cryoanalgesia during MIRPE appears to be effective in lowering postoperative opioid requirements and LOS without increasing complication rates. With the exception of preoperative gabapentin, other adjuncts appear to increase and/or be ineffective at reducing opioid utilization. Cryoanalgesia should be considered for patients undergoing this surgery.

Upper Gastrointestinal Series in the Workup for Pediatric Gastrostomy Placement: Does it Delay Care?

INTRODUCTION: Upper gastrointestinal (UGI) series is often part of the workup prior to the placement of gastrostomy tubes in children. Prior studies have suggested UGI to be limited in utility and an extra financial burden. The goal of this study was to investigate the utility and cost of UGI studies. METHODS: A retrospective, case control study of patients aged < 18 y receiving gastrostomy tubes at a free-standing children's hospital between 2012 and 2017. Total costs were obtained from the Pediatric Health Information System. RESULTS: Six hundred eighty five patients underwent gastrostomy placement during the study period. UGI was obtained in 90.8% of patients; 23.6% of studies were abnormal. The most common abnormal findings were reflux (13.8%) and abnormal anatomy (5.8%). The median time to obtain a UGI was 0.82 d (interquartile range 0.22-1.05). Obtaining a UGI was associated with delayed care in 104 patients (15.2%). If a delay was encountered, median time was 2.47 d (interquartile range 1.86-2.99). Ladd's procedures were performed in 12 patients (1.7%) found to have malrotation on UGI. None of the 63 patients who did not undergo UGI required a Ladd's procedure. Patients that had a UGI did not experience an increase in overall length of stay (14.3 versus 15.6 d, excluding intensive care unit patients), operative time (34 versus 39 min), or a change in rate of operative complications (11.5% versus 14.3%). In addition, UGI did not have a significant impact on total adjusted costs ($49,844 versus $83,438 without UGI, P = 0.12) but did slightly increase total adjusted costs per day ($2212 versus $1999 without UGI, P = 0.01). CONCLUSIONS: UGI prior to gastrostomy placement in children rarely identified abnormal findings that changed the operative plan, was associated with delayed care in 15% of patients, and was associated with slightly increased costs per day. Further analyses to identify subsets of children that may benefit from routine UGI are warranted.

Providers' Perceptions Versus Practices Inform Pediatric Colorectal Enhanced Recovery After Surgery Implementation.

INTRODUCTION: There are many barriers to the implementation of an enhanced recovery after surgery (ERAS) pathway. The aim of this study was to compare surgeon and anesthesia perceptions with current practices prior to the initiation of an ERAS protocol in pediatric colorectal patients and to use that information to inform ERAS implementation. METHODS: This was a mixed method single institution study of barriers to implementation of an ERAS pathway at a free-standing children's hospital. Anesthesiologists and surgeons at a free-standing children's hospital were surveyed regarding current practices of ERAS components. A retrospective chart review was performed of 5- to 18-y-old patients undergoing colorectal procedures between 2013 and 2017, followed by the initiation of an ERAS pathway, and a prospective chart review for 18 mo postimplementation. RESULTS: The response rate was 100% (n = 7) for surgeons and 60% (n = 9) for anesthesiologists. Preoperative nonopioid analgesics and regional anesthesia were rarely used. Intraoperatively, 54.7% of patients had a fluid balance of <10 cc/kg/h and normothermia was achieved in only 38.7%. Mechanical bowel prep was frequently utilized (48%). Median nil per os time was significantly longer than required at 12 h. Postoperatively, 42.9% of surgeons reported that patients could have clears on postoperative day zero, 28.6% on postoperative day one, and 28.6% after flatus. In reality, 53.3% of patients were started on clears after flatus, with a median time of 2 d. Most surgeons (85.7%) expected patients to get out of bed once awake from anesthesia; however, median time that patients were out of bed was postoperative day one. While most surgeons reported frequent use of acetaminophen and/or ketorolac, only 69.3% received any nonopioid analgesic postoperatively, with only 41.3% receiving two or more nonopioid analgesics. Nonopioid analgesia showed the highest rates of improvement from retrospective to prospective: preoperative use of analgesics increased from 5.3% to 41.2% (P < 0.0001), postoperative use of acetaminophen increased by 27.4% (P = 0.5), Toradol by 45.5% (P = 0.11), and gabapentin by 86.7% (P < 0.0001). Postoperative nausea/vomiting prophylaxis with >1 class of antiemetic increased from 8% to 47.1% (P < 0.001). The length of stay was unchanged (5.7 versus 4.4 d, P = 0.14). CONCLUSIONS: For the successful implementation of an ERAS protocol, perceptions versus reality must be assessed to determine current practices and identify barriers to implementation.

A survey of surgical management of the sentinel node positive melanoma patient in the post-MSLT2 era.

BACKGROUND: The evidence-based management of melanoma patients with a positive sentinel lymph node biopsy (SLNB) has undergone a dramatic shift following publication of practice-changing surgical trials demonstrating no melanoma-specific survival advantage for completion lymph node dissection (CLND) in this scenario. We aimed to survey how surgeons' clinical practice had shifted in response to new evidence from these trials, and at a time when there was starting to become available systemic adjuvant treatments for AJCC Stage III melanoma patients. METHODS: A web-based survey consisting of practice-based questions and hypothetical clinical scenarios about current melanoma practice with regard to positive sentinel node biopsy was developed and sent to the surgical members of a Melanoma and Skin Cancer (MASC) Trials group in December 2018. Responses were analysed using descriptive statistics. RESULTS: There were 212 invitations sent and 65 respondents (31%). Respondents were from 17 countries, 94% of whom practice in specialist melanoma centres or at referral centres. Of these 97% were familiar with the MSLT2 and DeCOG-SLT clinical trials. At survey, 5% of respondents reported routinely recommending CLND and 55% recommend CLND in selected cases. Respondents were most likely to recommend CLND when multiple SLNs were positive. Important factors for surgical decision-making mentioned included size of SLN deposit, number of positive SLNs and likely compliance with the recommended surveillance regimen. CONCLUSION: In line with rapid adoption of published evidence, surgical management of Stage III melanoma has altered significantly, with few surgeons within the cohort now performing routine CLNDs after positive SLNB.

A practical guide on the use of imiquimod cream to treat lentigo maligna.

Lentigo maligna (LM) is a common in situ melanoma subtype arising on chronically sun-damaged skin and mostly affects the head and neck region. Localisation in cosmetically sensitive areas, difficulty to obtain wide resection margins and advanced patient age/comorbidities have encouraged investigation of less invasive therapeutic strategies than surgery in managing complex cases of LM. Radiotherapy and imiquimod have emerged as alternative treatment options in this context. The treatment of LM with imiquimod cream can be challenging due to the nature of the disease including its often large size, variegated appearance, involvement of adnexal structures, poorly defined peripheral edge and frequent localisation close to sensitive structures such as the eyes and lips, and elderly patients with multiple comorbidities. Prolonged and unpredictable inflammatory reaction and side effects and compliance with a patient-delivered therapy can also be challenging. In the literature to date, studies evaluating the use of imiquimod to treat LM have utilised varying methodologies and provided short follow-up and these limitations have impaired the development of clear guidelines for dosage and management of side effects. Based on our multidisciplinary experience and review of the literature, we propose practical clinical strategies for the use of imiquimod for treating LM, detailing optimal administration procedures in various clinical scenarios and long-term management, with the aim of facilitating optimal patient outcomes.

The uptake of evidence-informed guidelines for reporting suicide into media codes of practice and policies in Australia.

ISSUE ADDRESSED: Despite different models and frameworks for effective suicide prevention, a universal intervention that is consistently highlighted is the need for responsible and safe media reporting of suicide. This is based on evidence of an association between media reporting of suicide and subsequent suicidal behaviour. This study examines the extent to which media-led policies and codes of practice in Australia have integrated and aligned with evidence-informed recommendations about reporting suicide. METHODS: An online search of Australian media agency websites was used to identify codes of practice or similar guidance for news reporting. Content analysis was conducted on all identified documents, assessing alignment with 16 key recommendations from the Mindframe media guidelines for reporting on suicide. RESULTS: A total of 17 documents across 12 media agencies were identified. Ten of the 12 agencies provided specific advice about the reporting of suicide, with all agencies that issue codes of practice or editorial policies including between two and 10 recommendations aligned with the Mindframe guidelines. CONCLUSIONS: While the results of this study are positive, significant variation between media agencies shows that there are opportunities to enhance adoption and implementation of evidence-informed guidance for media professionals in Australia. SO WHAT?: With over 3000 people dying by suicide and over 60 000 people attempting suicide each year in Australia, the prevention of suicide remains a key public health priority requiring a multi-sector and health-in-all-policies approach. This study reveals that there is a strong platform for ongoing collaboration with the Australian media to ensure safe and sensitive coverage of suicide.

Correction to: 1 Versus 2-cm Excision Margins for pT2-pT4 Primary Cutaneous Melanoma (MelMarT): A Feasibility Study.

In the original article John F. Thompson was inadvertently omitted as an author. The author list is updated as shown in this correction.

1 Versus 2-cm Excision Margins for pT2-pT4 Primary Cutaneous Melanoma (MelMarT): A Feasibility Study.

BACKGROUND: There is a lack of consensus regarding optimal surgical excision margins for primary cutaneous melanoma > 1 mm in Breslow thickness (BT). A narrower surgical margin is expected to be associated with lower morbidity, improved quality of life (QoL), and reduced cost. We report the results of a pilot international study (MelMarT) comparing a 1 versus 2-cm surgical margin for patients with primary melanoma > 1 mm in BT. METHODS: This phase III, multicentre trial [NCT02385214] administered by the Australia & New Zealand Medical Trials Group (ANZMTG 03.12) randomised patients with a primary cutaneous melanoma > 1 mm in BT to a 1 versus 2-cm wide excision margin to be performed with sentinel lymph node biopsy. Surgical closure technique was at the discretion of the treating surgeon. Patients' QoL was measured (FACT-M questionnaire) at baseline, 3, 6, and 12 months after randomisation. RESULTS: Between January 2015 and June 2016, 400 patients were randomised from 17 centres in 5 countries. A total of 377 patients were available for analysis. Primary melanomas were located on the trunk (56.9%), extremities (35.6%), and head and neck (7.4%). More patients in the 2-cm margin group required reconstruction (34.9 vs. 13.6%; p < 0.0001). There was an increased wound necrosis rate in the 2-cm arm (0.5 vs. 3.6%; p = 0.036). After 12 months' follow-up, no differences were noted in QoL between groups. DISCUSSION: This pilot study demonstrates the feasibility of a large international RCT to provide a definitive answer to the optimal excision margin for patients with intermediate- to high-risk primary cutaneous melanoma.

Impact of a multimedia teaching tool on parental anxiety and knowledge during the informed consent process.

PURPOSE: Before performing a surgical procedure, informed consent (IC) is obtained. Parents may exhibit anxiety and/or a desire for more knowledge during the IC process for their child. The purpose of this study was to measure the impact of a multimedia intervention (MMI) versus conventional discussion on parental understanding and anxiety during the IC process for infants undergoing surgery for hypertrophic pyloric stenosis. METHODS: A time-interrupted series design was employed over a 9-month period. In the first phase, conventional discussion for IC was performed. In the second phase, a MMI was utilized. In both phases, anxiety scores and post-consent knowledge tests were collected. RESULTS: 31 participants were included in the study, 17 in the conventional consent and 14 in the MMI phase. Parental anxiety around the IC discussion was measured. There was a significant decrease in anxiety noted with use of the MMI (p = 0.046) but no significant difference in knowledge (p = 0.84). CONCLUSION: The MMI significantly reduced parental anxiety during the IC process. Providers may consider applying this type of MMI to other surgical procedures. Securing IC in a manner that improves knowledge and decreases anxiety may improve long-term understanding and parental satisfaction with the health care process.

Pyloric stenosis: an enigma more than a century after the first successful treatment.

Despite hypertrophic pyloric stenosis (HPS) being one of the most frequently treated pediatric surgical conditions, its etiology remains incompletely understood. We review the diagnosis and treatment of this condition with an emphasis on the evolution of surgical techniques that led to laparoscopic pyloromyotomy, the most frequently performed technique for HPS today. In addition, we review key developments in the understanding of HPS etiology and treatment, including the postulated etiology of work-induced hypertrophy of the pylorus, its association with prokinetic macrolide antibiotics, and the emerging role of atropine sulfate as a medical treatment for HPS or a rescue treatment for incomplete myotomy.

Debate: adjuvant whole brain radiotherapy or not? More data is the wiser choice.

Every year 170,000 patients are diagnosed with brain metastases (BMs) in the United States. Traditionally, adjuvant whole brain radiotherapy (AWBRT) has been offered following local therapy with neurosurgery (NSx) and/or stereotactic radiosurgery (SRS) to BMs. The aim is to increase intracranial control, thereby decreasing symptoms from intracranial progression and a neurological death. There is a rapidly evolving change in the radiation treatment of BMs happening around the world. AWBRT is now being passed over in favour of repeat scanning at regular intervals and more local therapies as more BMs appear radiologically, BMs that may never become symptomatic. This change has happened after the American Society for Radiation Oncology (ASTRO) in Item 5 of its "Choosing Wisely 2014" list recommended: "Don't routinely add adjuvant whole brain radiation therapy to SRS for limited brain metastases". The guidelines are supposed to be based on the highest evidence to hand at the time. This article debates that the randomised controlled trials (RCTs) published prior to this recommendation consistently showed AWBRT significantly increases intracranial control, and avoids a neurological death, what it is meant to do. It also points out that, despite the enormity of the problem, only 774 patients in total had been randomised over more than three decades. These trials were heterogeneous in many respects. This data can, at best, be regarded as preliminary. In particular, there are no single histology AWBRT trials yet completed. A phase two trial investigating hippocampal avoiding AWBRT (HAWBRT) showed significantly less NCF decline compared to historical controls. We now need more randomised data to confirm the benefit of adjuvant HAWBRT. However, the ASTRO Guideline has particularly impacted accrual to trials investigating this, especially the international ANZMTG 01.07 WBRTMel trial. This is an RCT investigating AWBRT following local treatment in patients with one to three BMs from melanoma. WBRTMel has accrued 196 of a required 220 to date but accrual has slowed. HAWBRT may now never be tested in a randomised setting. Encouraging more data in AWBRT is the wiser choice.

A multidisciplinary approach to providing care to adolescents with spinal cord trauma resulting from all-terrain vehicle accidents.

All-terrain vehicle accidents that affect the spine can lead to complex injuries in adolescents. This requires that many subspecialties work together on a multidisciplinary team to improve patient outcomes. Our case presentation will examine the multidisciplinary approach to care required for an 11-year-old adolescent involved in an all-terrain vehicle accident that resulted in traumatic spinal cord injury.

Examining the quality of news media reporting of complex mental illness in relation to violent crime in Australia.

PURPOSE: News reporting on mental illness can perpetuate stigma. An understanding of the current picture of such reporting is important to identify areas for improvement. This study investigated the quality of Australian news media coverage of complex mental illness in the context of crime and violence over a 2-year period, prior to the release of new media guidelines. METHODS: This research utilised a systematic search of Australian news articles that were published between July 2018 and July 2020 and reported on mental illness in relation to violent crime. Researchers developed a Mental Illness and Crime Reporting Quality Framework to determine quality scores for news articles according to 11 relevant factors in media guidelines. An additional 11 characteristics of articles were extracted for further descriptive analysis. RESULTS: One-hundred and twenty-eight Australian news articles met inclusion criteria. The average quality score was 50 (SD = 13.91) out of a possible maximum score of 100 (range 11-78). Strengths and weaknesses were identified as some criteria were consistently met, and other criteria were met rarely or not at all. There were emerging trends between quality scores and article characteristics, including publication source, though these analyses were not statistically significant. CONCLUSION: The findings indicate that Australian news coverage of complex mental illness and violent crime met half of the criteria of reporting guidelines that minimises risk of perpetuating or reinforcing stigma. This demonstrates significant opportunity to improve the overall quality of media reporting on crime and mental illness. Future research should evaluate the impact of the guidelines on the quality of news reporting after their implementation by utilising a similar methodology, using these findings as a baseline measure.

Media reporting on alcohol and other drugs in Australia and the Mindframe guidelines: Baseline data.

INTRODUCTION: The aim of this study was to generate a baseline database of print media reporting on alcohol and other drug (AOD) issues prior to the release of the Mindframe guidelines in March 2019. Specifically, to: (i) describe the content associated with media entries that focus on AOD use in Australian news media; (ii) determine how the media entries compare to several domains associated with recently developed Mindframe guidelines for publicly reporting on AOD; and (iii) identify content factors associated with different scores. METHODS: Media entries between July 2016 and June 2017 were searched for key AOD-related terms using the Australian and New Zealand Newsstream database. Two coding schemes were developed to rate a stratified sample of 50% of the media entries against the Mindframe guidelines. Associations between content and total comparison scores were determined using linear regression models. RESULTS: Detailed coding of the 2007 articles identified as relevant for the current study indicated that a majority (67%) were focused on one of three substances: alcohol, cannabis or methamphetamine. Most of the entries were either law enforcement (22%) or criminal justice related (19%). Entries that focused on methamphetamine scored significantly lower than entries on alcohol when compared to the Mindframe guidelines, similarly entries focused on crime/justice-related topics scored significantly lower than entries focused on positive outcomes. DISCUSSION AND CONCLUSIONS: A disproportionate number of print media entries, particularly those related methamphetamine use, focused on crime or justice-related topics, potentially further contributing to stigma, and emphasising the legal consequences of AOD use.

Ultrasound is safe and highly specific for confirmation of proper gastrostomy tube replacement in pediatric patients.

BACKGROUND: Gastrostomy tube (GT) dislodgement is a common cause of Pediatric Emergency Department (PED) visits. Postoperative patients and those who require stoma dilation are more likely to have complications during emergent replacement. Although incorrect replacement can cause significant morbidity overall, the occurrence is infrequent. Contrast injection of the GT is considered the standard for confirming proper placement. Case reports in both pediatric and adult patients suggest that ultrasound can be used to confirm proper replacement. The objective of the present study was to assess the utility of ultrasound to confirm GT placement in pediatric patients most at risk for complications from incorrect replacement. METHODS: This is a non-randomized cohort pilot trial to determine the sensitivity and specificity of ultrasound to confirm proper replacement of a GT in a Pediatric Emergency Department. RESULTS: We enrolled 55 pediatric subjects, of which 50 had ultrasound imaging after GT replacement in the PED prior to contrast injection. Ultrasound was found to have 96% sensitivity and 100% specificity for confirming GT placement. CONCLUSIONS: Ultrasound is a safe and reliable confirmatory study to confirm GT placement in pediatric patients, especially those at highest risk of complications from incorrect placement. LEVEL OF EVIDENCE: II.

Journey to a new era: An innovative academic-practice partnership.

Successful academic-clinical partnerships are mutually beneficial for academic nursing and clinical organizations, supporting the long-term success of nursing programs while simultaneously improving patient outcomes. Advocated by the American Association of Colleges of Nursing in their 2016 report, Advancing Healthcare Transformation: New Era for Academic Nursing, this position paper provides six actions for transforming academic nursing. However, developing sustainable academic-practice models has proven challenging despite this roadmap, as research has not substantiated their benefits. This article describes an innovative academic-practice model that transitioned advanced practice registered nurses practicing at Le Bonheur Children's Hospital to full-time faculty, with a continued primary clinical practice role, in the College of Nursing at the University of Tennessee Health Science Center. We present the origin, development, and implementation of this academic-practice partnership model, offering recommendations for its replication by other universities and clinical agencies on this journey. Creating a sustainable model requires a shared vision, buy-in at all levels, frequent and transparent communication, planning that considers the individual policies of the partnering agencies, and persistence despite leadership changes. Two years into the partnership and remaining intact despite critical leadership changes within the clinical agency, the next phase of the relationship will permit us to document the model's impact on academic and clinical outcomes.

Cost Analysis of Adjuvant Whole-Brain Radiotherapy Treatment Versus No Whole-Brain Radiotherapy After Stereotactic Radiosurgery and/or Surgery Among Adults with One to Three Melanoma Brain Metastases: Results from a Randomized Trial.

PURPOSE: We aimed to compare Australian health system costs at 12 months for adjuvant whole-brain radiotherapy (WBRT) treatment after stereotactic radiosurgery (SRS) and/or surgery versus observation among adults with one to three melanoma brain metastases. We hypothesized that treatment with adjuvant WBRT and subsequent healthcare would be more expensive than SRS/surgery alone. METHODS: The analysis was conducted alongside a multicentre, randomized phase III trial. A bespoke cost questionnaire was used to measure healthcare use, including hospitalizations, specialist and primary care visits, imaging, and medicines over 12 months. Mean per-patient costs were calculated based on the quantity of resources used and unit costs, reported in Australian dollars ($AU), year 2018 values. Skewness of cost data was determined using normality tests and censor-adjusted costs reported using the Kaplan-Meier sample average method. The analysis of difference in mean costs at each 2-month time point and at 12 months was performed and checked using Kruskal-Wallis, generalized linear models with gamma distribution and log link, modified Park test, ordinary least squares, and non-parametric bootstrapping. RESULTS: In total, 89 patients with similar characteristics at baseline were included in the cost analysis (n = 43 WBRT; n = 46 observation). Hospitalization cost was the main cost, ranging from 63 to 89% of total healthcare costs. The unadjusted 12-monthly cost for WBRT was $AU71,138 ± standard deviation 41,475 and for observation $AU69,848 ± 33,233; p = 0.7426. The censor-adjusted 12-monthly cost for WBRT was $AU90,277 ± 36,274 and $AU82,080 ± 34,411 for observation. There was no significant difference in 2-monthly costs between groups (p > 0.30 for all models). CONCLUSIONS: Most costs were related to inpatient hospitalizations associated with disease recurrence. Adding WBRT after local SRS/surgery for patients with one to three melanoma brain metastases did not significantly increase health system costs during the first 12 months. TRIAL REGISTRATION: ACTRN12607000512426, prospectively registered 14 September 2007.

Phase I/II trial of concurrent extracranial palliative radiation therapy with Dabrafenib and Trametinib in metastatic BRAF V600E/K mutation-positive cutaneous Melanoma.

BACKGROUND: Concurrent treatment with BRAF inhibitors and palliative radiation therapy (RT) could be associated with increased toxicity, especially skin toxicity. Current Eastern Cooperative Oncology Group (ECOG) consensus guideline recommend ceasing BRAF inhibitors during RT. There is a lack of data regarding concurrent RT with combined BRAF and MEK inhibitors. This single-arm phase I/II trial was designed to assess the safety and tolerability of palliative RT with concurrent Dabrafenib and Trametinib in patients with BRAF-mutant metastatic melanoma. MATERIALS AND METHODS: Patients received Dabrafenib and Trametinib before and during palliative RT to soft tissue, nodal or bony metastases. The RT dose was escalated stepwise during the study period. Toxicity data including clinical photographs of the irradiated area was collected for up to 12 months following completion of RT. RESULTS: Between June 2016 to October 2019, ten patients were enrolled before the study was stopped early due to low accrual rate. Six patients were treated at level 1 (20 Gy in 5 fractions, any location) and 4 patients at level 2a (30 Gy in 10 fractions with no abdominal viscera exposed). All alive patients completed one year of post-RT follow-up. Of the 82 adverse events (AEs) documented, the majority (90%) were grade 1 and 2. Eight grade 3 events (10%) occurred in five patients, only one was treatment-related (grade 3 fever due to Dabrafenib and Trametinib). No patients experienced grade 3 or 4 RT related toxicities, including skin toxicities. One serious AE was documented in relation to a grade 3 fever due to Dabrafenib and Trametinib requiring hospitalisation. CONCLUSIONS: The lack of grade 3 and 4 RT-related toxicities in our study suggests that Dabrafenib and Trametinib may be continued concurrently during fractionated non-visceral palliative RT to extracranial sites.