A best evidence topic was written according to a structured protocol. The clinical question investigated was: is low serum albumin associated with postoperative complications in patients undergoing cardiac surgery? There were 62 papers retrieved using the reported search strategy. Of these, 12 publications embodied the best evidence to answer this clinical question. The authors, journal, date and country of the publication, patient group investigated, study design, relevant outcomes and results of these papers were tabulated. This paper includes a total of 12 589 patients, and of the papers reviewed, 4 were level 3 and 8 level 4. Each of the publications reviewed and compared either all or some of the following postoperative complications: mortality, postoperative bleeding requiring reoperation, prolonged hospital stay and ventilatory support, infection, liver dysfunction, delirium and acute kidney injury (AKI). Of the studies that examined postoperative mortality, all except for three established a significant multivariate association with low preoperative albumin level. Some scepticism is required in accepting other results that were only present in univariate analysis. While three studies examined multiple levels of serum albumin, most dichotomized the serum albumin levels into normal and abnormal groups. This led to differing classifications of hypoalbuminaemia, ranging from less than 2.5 to 4.0 g/dl. The available evidence, however, suggests that low preoperative serum albumin level in patients undergoing cardiac surgery is associated with the following: (i) increased risk of mortality after surgery and (ii) greater incidence of postoperative morbidity. While the evidence supports the use of preoperative albumin in assessing post-cardiac surgery complications, a specific level of albumin considered to be abnormal cannot be concluded from this review.

A best evidence topic was written according to a structured protocol. The question addressed was: in patients undergoing oesophagectomy for oesophageal malignancy, is low serum albumin associated with postoperative complications? Altogether, 87 papers were found using the reported search, of which 16 demonstrated the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. This paper includes 2 level 2 papers, 12 level 3 papers and 2 level 4 papers. All the papers compared either all or some of the following postoperative complications: mortality, morbidity, anastomotic leak, respiratory and non-respiratory complications, and length of hospital stay. Eleven of the 16 papers found an association between low serum albumin and postoperative complications. Of these, one study showed that low serum albumin combined with low fibrinogen levels (FA score) was predictive of postoperative recurrence of oesophageal cancer. Another study showed that when combined with white cell count and C-reactive protein (CRP, NUn score), serum albumin had a high diagnostic accuracy for major complications after postoperative day 3. The largest study compared the in-hospital mortality in 7227 patients who underwent oesophageal surgery for malignancy. The percentage of in-hospital mortality was associated with low serum albumin (<15.0 vs >35.0 g/l, 21.0 vs 11.3%, P <0.001). Five of the 16 papers found no significant association between low serum albumin and postoperative complications. Of these papers, one showed that low serum albumin was not an independent risk factor, while four others found no association between low serum albumin with respiratory complications, anastomotic leak and postoperative mortality. Instead, these studies found other factors responsible for postoperative complications such as: CRP, smoking, disease duration, malnutrition and low T-cell levels. Taken together, while low serum albumin is associated with postoperative complications, opinion regarding the prognostic value of low serum albumin and nutritional support remains conflicted. Because of the confounding factors encountered in these studies, the clinician should consider the finding of low serum albumin in patients, together with disease and surgical factors to provide optimal care for these patients.

A best evidence topic was written according to a structured protocol. The question addressed was: does preoperative statin therapy prevent postoperative atrial fibrillation (AF) in patients undergoing cardiac surgery? There were 445 papers found using the reported search. From these, 12 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. This paper includes three systematic reviews with meta-analysis, five randomized controlled trials and four retrospective studies. All the papers compared either all or some of the following postoperative complications: mortality, morbidity, AF, length of hospital stay (intensive care unit and hospital) and inflammatory markers. The largest study in this paper includes a systematic review of 91 491 patients that showed a reduction in postoperative AF with preoperative statin therapy (OR = 0.71, 95% CI 0.61-0.82, P <0.0001). However, the durations (3 days to 2 months preoperatively), doses and types of preoperative statin differed between these papers. Although the majority of studies (10 of 12) support the use of statins preoperatively, 2 studies found no association between preoperative statin therapy and the reduction of postoperative AF. In conclusion, the available evidence suggests that preoperative statin therapy in patients undergoing elective cardiac surgery is associated with the following: (1) a lower incidence and risk of developing postoperative AF, (2) reduced stroke, (3) a shorter hospital stay and (4) reduced levels of inflammatory markers postoperatively. However, while the evidence supports the use of statins preoperatively, the optimal duration, dose and type of statin cannot be concluded from this review.

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UST discontinuation occurred in 2 (1.7%), 13 (10.8%) and 33 (27.5%) patients by 3, 6 & 12 months. Reasons included (n): primary non-response (23), loss of response (9), sub-optimal response (4) and side effects (4). Adverse events occurred in 23 (19%) patients, including 12 patients requiring surgical intervention for progressive disease.Concomitant IM were prescribed in 56 (47%) patients at baseline and continued in 47 (39%) and 38 (32%) at 6 and 12 months, respectively. Concomitant use did not impact outcomes at any timepoint, nor affect median treatment persistence with UST. Prior anti-TNF exposure was a negative predictor of clinical remission at one year, OR 0.32 (95% CI 0.12-0.81, p£0.02), but there was no association with disease location, phenotype, presence of perianal disease or those with a smoking history. Conclusions Ustekinumab is effective in the treatment of moderate-severe CD in a treatment refractory RW cohort. In keeping with trial data, prior anti-TNF exposure was a negative predictor of remission and concomitant IM use did not alter clinical or biological outcomes.