Adductor canal block (ACB) with additional nerve blocks (ANBs) is reported to provide adequate analgesia and enhanced functional rehabilitation in total knee arthroplasty (TKA). The present study aims to evaluate whether ANBs are superior to multiple-site infiltration analgesia (MIA) in patients undergoing TKA under ACB.We enrolled 530 patients undergoing primary TKA from 2015 to 2019 at our institution in this retrospective cohort study. Patients were divided into two groups: Group A was treated with ANBs + ACB; Group B was treated with MIA + ACB. Primary outcomes were pain scores and morphine consumption. Functional recovery was the secondary outcome. Other outcomes included satisfaction score, cost-effectiveness, adverse events, and length of hospital stay (LOS).Pain scores at rest and morphine consumption were slightly lower in the ANBs + ACB group than in the MIA + ACB group. No significant difference was found in functional recovery, post-operative complications or LOS between the groups. Meanwhile, the cost of analgesic intervention in the MIA + ACB group was less than that in the ANBs + ACB group.The present study suggests that ANBs do not provide superior pain relief compared to MIA for patients undergoing TKA under ACB.https://www.chictr.org.cn/showproj.aspx?proj=121745.Chinese Clinical Trial Registry, ChiCTR2100043227. Registered 9 February 2021,  Total knee arthroplasty (TKA) is currently the most effective treatment for alleviating persistent pain in patients with end-stage knee arthritis . HoweverThe American Society of Anesthesiologists (ASA) recommends multimodal analgesia strategy for acute pain in place of the extensive use of opioids, which has been connected with complications such as nausea, vomiting, sedation and respiratory depression . MultimoMIA, which is widely accepted, is achieved by injecting a mixture of local anaesthetics, epinephrine, corticosteroids, anti-inflammatory drugs and opioids into the articular cavity , 11. WheSince little is known about whether ANBs + ACB is superior to MIA + ACB, this study aims to determine whether ANBs + ACB is superior to MIA + ACB by comparing patients’ post-operative pain, functional rehabilitation, cost-effectiveness and complications during TKA for the two approaches.This study was designed as a retrospective cohort study. The protocol was approved by the institutional review board of the authors’ affiliated institutions. Informed consent was obtained from each patient.From January 2015 to November 2019, patients in our department who were undergoing primary unilateral TKA were eligible for recruitment. They were adults older than 18 years with a body mass index (BMI) of 18–35 kg/m2 and an American Society of Anesthesiologists physical status classification of I–III.The exclusion criteria were: (1) knee flexion deformity ≥ 30°, varus–valgus deformity ≥ 30°; (2) allergy to morphine, local anaesthetics or other drugs used in this study; (3) chronic opioid consumption for more than 3 months prior to surgery; (4) diagnosis of traumatic arthritis, rheumatoid arthritis, septic arthritis or prior knee surgery; (5) mental illness or cognitive impairment making communication or comprehension difficult; and (6) thrombolytic events .Patients were admitted by one medical team in our institution, and we divided them into 2 groups. The only difference between the groups was the nerve block approach. The ANBs + ACB group was treated with ACB combined with ANBs (iPACK/LFCNB/ONB + LFCNB/iPACK + LFCNB), and the other group was treated with ACB and MIA.All patients’ basic characteristics were recorded preoperatively: age, sex, BMI, and surgery side, pain scores, quadricep strength, ASA status, and range of motion and Knee Society Score (KSS). Loxoprofen  was taken as pre-emptive analgesia.One senior surgeon performed the TKA procedures after general anaesthesia was applied. A medial parapatellar approach was adopted by making an anterior midline skin incision. The surgeon inserted prostheses (DePuy PFC and Stryker Triathlon) with cementing techniques. Patients were given 1 g of tranexamic acid intravenously during the surgery.An experienced anaesthetist finished nerve blocks via a high-frequency linear array ultrasonic transducer, injecting an anaesthetic cocktail (0.2% ropivacaine and 2.0 μg/ml epinephrine) into the nerve region. ACB and additional nerve blocks were performed by single-shot injections preoperatively, while MIA was implemented by the surgeon during the surgery.ACB: After scanning the middle of the thigh to locate the adductor canal, the anaesthetist embedded a 22-gauge, 100-mm needle in a lateral-to-medial plane. Three millilitres of isotonic saline was injected to ensure the target position of the saphenous nerve and the nerve to the vastus medialis. Then, 20 ml of the anaesthetic cocktail was injected.iPACK: Under ultrasound guidance, the popliteal artery and the capsule of the knee were identified by using an in-plane approach to the intercondylar fossa. Twenty millilitres of the anaesthetic cocktail could be injected into the space provided the needle was in the correct place, which was confirmed by 3 ml of isotonic saline.LFCNB: The ultrasonic transducer helped detect the lateral femoral cutaneous nerve along the inguinal crease deep in the fascia lata. Then, the anaesthetist inserted 10 ml of medication around the nerve.ONB: A 22-gauge, 100-mm needle oriented the obturator nerve after finding the fascial planes of the pectineus and adductor muscles through ultrasonic guidance. Five millilitres of the cocktail was injected between the pectineus and adductor brevis muscles, and another 5 ml was injected between the adductor brevis and adductor magnus muscles.MIA: Patients were given the same cocktail  periarticularly via a multisite technique during the operation. Twenty millilitres of cocktail for each infiltration site was injected into the posterior aspect of the capsule (prior to placement of the prosthesis), medial and lateral collateral ligaments (prior to component implantation) and quadriceps and retinacular tissues (after implantation).All patients received ice compression but no analgesia pump when they returned to the ward. Loxoprofen  and prolonged-release oxycodone hydrochloride tablets  were prescribed to manage post-operative pain. Morphine hydrochloride (10 mg) was injected subcutaneously only if patients were unable to bear pain. To avoid venous thromboembolism (VTE), every patient was administered enoxaparin (0.2 ml) 12 h after surgery and then 0.4 ml every 24 h afterwards until discharge. After leaving the hospital, rivaroxaban  was taken orally for two weeks to continue VTE prophylaxis. Patients received lower extremity strength training when they were capable of moving their lower limbs. Before discharge, patients were expected to walk with walking aids.Primary outcomes were pain scores measured by the visual analogue scale   and morpThe secondary outcome was functional recovery of the knee, including range of motion, quadricep strength, daily ambulatory distance and KSS function score during hospitalization and follow-up. Moreover, the length of hospital stay was defined as the time from the end of surgery to discharge, and a patient’s satisfaction score  was also recorded at 48 h post-operatively. In our hospital, the cost of equipment and supply to provide nerve block is 195 CNY each position. Ropivacaine (100 mg) costs 45.78 CNY and epinephrine (1 mg) costs 4.8 CNY. Any occurrences of complications composed of nausea, vomiting, falls, infection, calf paraesthesia, venous thrombosis, or cerebrovascular and cardiovascular events or wound adverse events  were documented in detail. Patient mortality and readmission rate were counted at the 6-month follow-up.p < 0.05 were considered significant.Statistical data were calculated using SPSS 25.0 . Quantitative variables are represented as the mean ± standard deviation (SD), and qualitative variables are represented as the number and percentage (%). Differences in continuous data between groups were analysed by Student’s t-test or Mann–Whitney U test, after confirming their distribution types . Chi-squared and Fisher’s exact tests were used to analyse categorical data. Differences of A total of 530 patients undergoing primary unilateral TKA were divided into two groups depending on analgesic strategies. Of these, 290 patients were treated with ACB and ANBs, while the other 240 patients were assigned to the ACB and MIA group. With regard to the patients who were treated with ANBs + ACB, various additional nerve block proposals were made, and 110 patients received ACB + iPACK, 80 received ACB + LFCNB, 50 received ACB + ONB + LFCNB and 50 received ACB + iPACK + LFCNB.p = 0.09; POD2: 2.8 vs. 3.0, p = 0.18; at discharge: 2.0 vs. 2.1, p = 0.13), respectively. Morphine consumption during hospitalization between the groups was slightly lower in the ANBs + ACB group , although there was no significant difference. Patients in the ANBs + ACB and MIA + ACB groups had similar VAS scores with activity  (Table As shown in Table p > 0.05). Patients in the ANBs + ACB group stayed in the hospital for 66.4 ± 8.6 h post-operatively, and those in the MIA + ACB group stayed for 65.5 ± 7.5 h (p > 0.05). There was no significant difference in the KSS or patient satisfaction scores between the two groups (p > 0.05). However, the average cost of analgesic intervention in the MIA + ACB group was significantly lower than that in the ANBs + ACB group  , and they were treated with metoclopramide dihydrochloride injections to alleviate the symptoms. Differences in the incidence of falls after surgery, wound complications and any venous thrombotic events were not significant (p > 0.05). Four patients in the ANBs + ACB group and 1 patient in the MIA + ACB group experienced slight calf paraesthesia (p > 0.05). In addition, no other adverse events were found, such as infection, readmission, cerebrovascular events, cardiovascular events or 6-month mortality  we had used in TKA; some of these nerve blocks have been introduced in previous studies , 14, 17.The cost-effectiveness of analgesic interventions was taken into consideration. Corman et al.  reportedOur study has some limitations. First, the study was retrospective which meant that we collected data reliant on our medical records. Thus, we may have overlooked the existence of some undocumented outcome indicators, such as adverse events. PNB-related complications could require longer follow-up to determine. Although this was the first study to assess the efficacy of ACB when combined with ANBs or MIA in TKA to our knowledge, in terms of study design, a prospective study with a standard protocol should be created to increase evidence. Second, there was a lack of measurement of systemic toxicity, such as serum levels, although we did not observe serious local anaesthetic intoxication. Finally, we only counted the difference between ANBs + ACB and MIA + ACB, and the subfractions of ANBs were not considered.ANBs + ACB and MIA + ACB are both effective approaches to alleviate pain and speed functional recovery after TKA. However, ACB with ANBs is not superior to the MIA + ACB approach in alleviating pain or speeding recovery; further, ANBs + ACB is more costly and technically difficult. Additional studies should explore better ways to manage pain and maximize functional recovery for patients.


To investigate the epidemiological characteristics of major intra‐articular fractures.This retrospective study enrolled patients with major intra‐articular fractures who were treated in the Third Hospital of Hebei Medical University from January 2015 to December 2019. A total of 11,084 patients  meeting the inclusion and exclusion criteria were included. The distribution characteristics of intra‐articular fractures involving shoulder, elbow, wrist, hip, knee, ankle, and subtalar joints were identified.The potential associations between fractures and various other factors, such as age, gender, sites, were explored.There were 74 cases (0.67%) of shoulder fractures, 1,941 cases (17.51%) of elbow fractures, 1,155 cases (10.42%) of wrist fractures, 520 cases (4.69%) of hip fractures, 3,118 cases (28.13%) of knee fractures, 2,156 cases (19.45%) of ankle fractures, and 2,120 cases (19.13%) of subtalar fractures. The overall male‐to‐female ratio was 1.96:1. The highest proportion age group of major intra‐articular fractures included the ages 45–54 years. For males, the highest proportion age group was 45–54 years, for females, it was 55–64 years. The knee joint fracture was the most common type, accounting for 28.13%. For male and female patients, knee fractures accounted for 26.19% and 31.93%, respectively, with a male to female ratio of 1.13:1. The proportion of shoulder fractures was the smallest among this investigation, accounting for 0.67%. For male and female patients, shoulder fractures accounted for 0.44% and 1.12%, respectively, with a male to female ratio of 0.76:1. The age group with the highest proportion of shoulder joint fractures was ≥65 year olds (41.89%), with a male to female ratio of 0.76:1. The age group with the highest risk of elbow, wrist, hip, knee, ankle, and subtalar joint fracture was 5–14 year olds (33.59%) with a male to female ratio of 3.29:1, 5–14 year olds (23.98%) with a male to female ratio of 6.91:1, 45–54 year olds (26.92%) with a male to female ratio of 5.67:1, 45–54 year olds (24.60%) with a male to female ratio of 1.68:1, 25–34 year olds (20.36%) with a male to female ratio of 2.30:1, 45–54 year olds (27.41%) with a male to female ratio of 9.02:1, respectively. The most common site of intra‐articular fractures in different age groups was corresponding as follows: 0–4 year olds (elbow), 5–14 year olds (elbow), 15–24 year olds (ankle), 25–34 year olds , 35–44 year olds , 45–54 year olds (knee), 55–64 year olds (knee), 65–74 year olds (knee), and ≥75 year olds (knee).The current study revealed the age‐ and gender‐specific epidemiological characteristics of major intra‐articular fractures, providing a basis for clinical evaluation and practices. The current study revealed the age‐ and gender‐specific epidemiological characteristics of 11,084 major intra‐articular fractures, providing a basis for clinical evaluation and practices. Intra‐articular fracture refers to a fracture involving the articular surface, which belongs to a common type of fracture in clinical practice. It is mostly caused by high‐energy injuries or falling injuries, and the treatment requires a high standard of expertise; otherwise, improper handling often creates functional obstacles of different levels. At present, most studies focus on conservative or surgical treatment, and there remains a lack of large‐sample epidemiological investigation; furthermore, a substantial proportion of epidemiological studies focus on a specific location (e.g. knee joint fracture), rather than investigating the epidemiological characteristics of major intra‐articular fractures in the whole body.As early as 1832, Astley CooperStudies have shown that age and gender are closely related to intra‐articular fractures at specific sitesPatients with major intra‐articular fractures of the limbs were selected to be included in this study.Patients were sourced through the picture archiving and communication systems (PACS) and the medical record inquiry systems of the Third Hospital of Hebei Medical University from January 2015 to December 2019.Inclusion criteria were as follows: (i) shoulder joint: humeral head, humeral anatomic neck and glenoid; (ii) elbow joint: humeral intercondylar, internal and external condyle of humerus, capitellum, radius head, ulan olecranon, coronal process; (iii) wrist joint: distal radial articular surface; (iv) hip joint: femoral head, acetabulum; (v) knee joint: femoral intercondylar, Hoffo fracture, tibial plateau, patella; (vi) ankle joint: medial malleolus, lateral malleolus, posterior malleolus; (vii) subtalar joint: calcaneus and talus.Exclusion criteria: (i) patients with pathological fractures; (ii)patients with old fractures.The medical records of enrolled patients were retrieved using the medical record inquiry system. The demographic characteristics of patients and detailed information on major intra‐articular fractures were recorded. The preoperative radiographs, computed tomography (CT), and magnetic resonance imaging (MRI) of the intra‐articular fractures were collected with the use of the picture archiving and communication systems. The X‐ray films, CT, and MRI scans of the intra‐articular fractures were reviewed by five orthopaedic surgeons with more than 10 years of experience. Intra‐articular fractures are divided into shoulder intra‐articular fractures, elbow intra‐articular fractures, wrist intra‐articular fractures, hip intra‐articular fractures, knee intra‐articular fractures, ankle intra‐articular, and subtalar intra‐articular fractures according to the fracture site. If there was any disagreement in the diagnosis of intra‐articular fractures, a final decision would be made through discussion, with consensus achieved by at least three surgeons.There were nine groups stratified by age: 0–4 years, 5–14 years, 15–24 years, 25–34 years, 35–44 years, 45–54 years, 55–64 years, 65–74 years, and ≥ 75 years.An intra‐articular fracture is a fracture that crosses a joint surface, so all the patients we included met the definition of intra‐articular fracture. Preoperative X‐ray, CT, and MRI were used for auxiliary diagnosis of intra‐articular fractures. Intra‐articular fractures in seven major sites of the human body were selected for analysis and each intra‐articular fracture included the following fracture type:Intra‐articular fractures of shoulder include humeral head, humeral anatomic neck and glenoid.Intra‐articular fractures of elbow include humeral intercondylar, internal and external condyle of humerus, capitellum, radius head, ulan olecranon, coronal process.Intra‐articular fractures of wrist include distal radial articular surface.Intra‐articular fractures of hip include femoral head, acetabulum.Intra‐articular fractures of knee include femoral intercondylar, Hoffo fracture, tibial plateau, patella.Intra‐articular fractures of ankle include medial malleolus, lateral malleolus, posterior malleolus.Intra‐articular fractures of subtalar joint include calcaneus and talus.P‐value of <0.05 was considered significant. Descriptive data were presented as numbers. The number of major intra‐articular fractures and composition ratios in each year were analyzed. The distribution of male and female patients in different age groups and the distribution of intra‐articular fractures in different age groups were all accessed. The Kolmogorov–Smirnov test was used to check whether results were in accordance with the normal distribution. The compositions of intra‐articular fractures in different years were analyzed by Analysis of Variance (ANOVA) test, and the comparison between pairs was performed by Student‐Newman‐Keuls Q test (SNK‐Q test) or Least Significant Difference test (LSD test). The compositions of intra‐articular fractures in different genders over 5 five years were compared by Pearson chi‐square test.All the analyses were performed with the use of SPSS 22.0 . A P > 0.05), and there was a significant difference in the composition of intra‐articular fractures between men and women . The proportion of intra‐articular fractures in each year and in different genders is shown in Tables A total of 11,084 patients with major joint fractures were identified over the 5‐year period, accounting for 17.08% (11084/64885) of the total fractures at the whole skeleton sites in the same period, including 7338 males and 3746 females. The overall male‐to‐female ratio was 1.96:1. The highest proportion age group was 45–54 years 20.49%), the male and female patients were 45–54 years (20.89%) and 55~64 years (23.63%), respectively. There were 74 cases (0.67%) of shoulder fractures, 1,941 cases (17.51%) of elbow fractures, 1,155 cases (10.42%) of wrist fractures, 520 cases (4.69%) of hip fractures, 3,118 cases (28.13%) of knee fractures, 2,156 cases (19.45%) of ankle fractures, and 2,120 cases (19.13%) of subtalar fractures. From 2015 to 2019, the numbers of patients with intra‐articular fractures was 1992, 2039, 2118, 2474, and 2461, showing an increasing trend year by year. There was no significant difference in the composition of intra‐articular fractures over the 5 years , with a male to female ratio of 0.76:1. The peak incidence occurred at 5–14 years of age (33.59%) in elbow fractures, with a male to female ratio of 3.29:1. For other joints, such as wrist, hip, knee, ankle, and subtalar joint, the age groups with the highest proportion of fractures were 5–14 years (23.98%), 45–54 years (26.92%), 45–54 years (24.60%), 25–34 years (20.36%), 45–54 years (27.41%), respectively, and the male‐to‐female ratio was 6.91:1, 5.67:1, 1.68:1, 2.30:1, and 9.02:1, respectively.P = 0.000), as shown in Table The most common intra‐articular fracture sites in different age groups were: 0–4 years ; 5–14 years ; 15–24 years ; 25–34 years ; 35–44 years ; 45–54 years ; 55–64 years ; 65–74 years ; ≥75 years . There were significant differences in the composition of intra‐articular fractures among different age groups  and the male‐to‐female ratio was 0.76:1, which was the only age group where the number of female patients exceeded that of male patients. The reason may be that osteoporosis of females was more severe in older women than in older menThe age group at risk of elbow and wrist joint fractures was 5–14 year olds, and males were significantly more prone to these fractures than females, which was related to the lively and active character of boys in this age groupThe age group with the highest proportion of hip, knee, and subtalar joint fractures was 45–54 year olds, with more males than females experiencing these fractures. Obviously, this age group includes first‐home owners. Therefore, it is necessary to strengthen the protection of lower limb joints in this age group. This study also showed that peak incidences of ankle fractures occurred at 25–34 years, especially in men, suggesting that attention should be paid to the protection of ankle joints in young men who engage in more construction and transportation activities. Similar to previous studies, LiuThe elbow fractures were the most common in 0–4 year olds and 5–14 year olds, which may be related to more activity patterns and high incidences of humeral condyle and olecranonBy dividing patients into age groups, we defined the most common intra‐articular fracture sites in each age group, which would be helpful to institute preventive and protective measures in order to reduce the incidence of intra‐articular fractures and avoid complications such as deformity, dysfunction, and pain. Finally, the burden on both families and society will be reduced.Several limitations of this study should be noted. First, because it was a retrospective study, recall bias is inevitable. Second, the cases were only from a single center and other factors such as mechanism of injury, occupation, classification of fractures were not taken into account. Therefore, the next step is to expand the sample size through a multi‐center study and consider more related factors.The most common fracture site among major intra‐articular fractures is in the knee, while the least common major intra‐articular fracture site is the shoulder. Male patients are more likely to experience these fractures than females. At 0–4 years and 5–14 years, the most common intra‐articular fractures occur in the elbow. However, ankle fractures, subtalar fractures, and knee fractures are most common in 15–24 year olds, 25–44 year olds, and >45 year olds, respectively. Targeted preventive measures can be formulated according to the above characteristics.Yingze Zhang conceived the idea for the study; Weiguang Zhao designed the study. Yanbin Zhu, Jiangtao MA, Xiaoli Yan collected the relevant data. Yanbin Zhu and Jiangtao Ma prepared the tables and figures. Weiguang Zhao performed the statistical analyses. All the authors interpreted the data and contributed to preparation of the manuscript.


CA19–9 is one of the most widely used tumor markers in biliary-pancreatic diseases. The measured value may not factually reflect the genuine CA19–9 level secreted by tumor, which affected by biliary obstruction. There is an urgent need of developing a correction formula of CA19–9 in biliary obstructive patients to guide clinical practice and avoid making improper clinical decision.Clinical characteristics were collected among patients undergoing biliary drainage in our hospital between January 2014 and January 2019. By comparing the malignant and benign patients statistically, dynamic change trend of CA19–9 levels after biliary drainage was obtained. The correction formulas of CA19–9 were generated by means of linear regression.p = 0.109). The drop proportion of the average CA19–9 level in the malignant patients  was much lower than that in the benign patients  (p = 0.014). The correction formula, CA19–9True = 0.63 × CA19–9Measured - 20.3 , was generated based on the linear relation between CA19–9 after drainage and CA19–9 before drainage in malignant patients, which had similar diagnostic value with true CA19–9 value.121 patients, including 102 malignant and 19 benign patients, were enrolled in this study. The baseline CA19–9 level of malignant patients is much higher than that of benign patients. Total bilirubin (TB) level was found to be not related with CA19–9 value (Quantitative correction formulas of CA19–9 considering the effect of biliary decompression was first proposed in this study, aiming to provide a more accurate CA19–9 level to make more accurate clinical decision and avoid making improper therapeutic schedule.The online version contains supplementary material available at 10.1186/s12885-021-08204-w. Cancer antigen 19–9 (CA19–9), chemically named monosialoganglioside, was first isolated from a mouse immunized with a colorectal carcinoma cell line . Out of Through the ages, extremely high level of serum CA19–9 has been considered as a factor of unresectability of pancreatic cancer by surgeons –12. In 2Between January 2014 and January 2019, 1618 patients underwent endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepaticcholangial drainage (PTCD) to decompress the obstructed common bile duct in Peking Union Medical College Hospital. Patients with confirmed clinical diagnoses verified by radiological or pathological findings were selected. Patients with high serum total bilirubin (>34.2 μmol/L), whose CA19–9 levels were measured before and within 1 month after the decompression operation, were screened. Patients with primary diseases except periampullary and pancreaticobiliary lesions and other possible situations causing elevated serum CA19–9 level, such as teratoma, heart failure, ovarian cyst and hashimoto thyroids, were excluded.Patients’ demographic information, imaging data, pathological result, date and type of performed operation, diagnosis and serological results  were collected. The CA19–9 and total bilirubin were measured by the Laboratory Medicine on standardized platforms .P value less than 0.05 was considered statistically significant. All statistical analyses were carried out using IBM SPSS statistics 25.0.Numerical variables were expressed by means of median and interquartile range (IQR). The Comparison between serum levels in the 2 groups of patients was obtained by means of the Mann–Whitney U test. Spearman rank correlation was conducted to evaluate the relevance between CA19–9 and other common laboratory variables. The correction formula was obtained by linear regression between CA19–9 and total bilirubin levels. Two-tailed Among the 121 patients enrolled in our study, 102 (84%) patients were found to have malignant diseases and the rest 19 (16%) patients are benign. The sex ratios  of the malignant and benign groups are 1.27 and 8.5, with the average age of each group are 63 and 60 years.p = 0.176), CEA (p = 0.074) and CA125 (p = 0.486) levels than that of benign patients, however without statistic significance.The serum CA19–9 level of malignant patients is much higher than that of benign patients  U/mL, benign group 267.7 (141.9–639.9) U/mL) (Table p = 0.044) and neutrophil percentage (p = 0.016) had statistic differences between the two groups, conforming to the anemia and infection status of cancer patients, with common enzymes related to liver and bile duct having no significant differences between the two groups of patients. In terms of relevance, TB value was found surprisingly to be not related with CA19–9 value . CA19–9 value was verified to be more correlated with the severity of biliary infection, with white blood cell count  and neutrophil percentage  having strong relevance with CA19–9.To further explore the differences of laboratory results between malignant and benign patients and potential relationship between CA19–9 and these indicators, liver function and blood routine results of malignant and benign patients were collected Table . Red bloAfter biliary decompression, the variation trend of CA19–9 in benign and malignant patients was portrayed intuitively on basis of the CA19–9 value before and after PTCD or ERCP in malignant and benign patients , indicating the effect of biliary decompression in both groups was the same (Table p = 0.014). Not surprisingly, the post-operative average CA19–9 level in the benign patients nearly returned to the normality in 1 week. The difference confirmed the fact that the rise of CA19–9 levels in benign lesions was mainly caused by biliary obstruction, which meant the left CA19–9 in malignant lesions was truly secreted by tumors. The drop ratio of CEA (p = 0.306) and CA125 (p = 0.051) in the two groups had no obvious differences.In a quantified view, the drop ratio of the average TB in both malignant  and benign  was similar , log (CA19–9 before drainage) and log (CA19–9 after drainage)  in malignant patients. As for benign patients, CA19–9 difference and Log (CA19–9 difference) were found to be linearly related with TB before drainage , CA19–9 before drainage  and Log (CA19–9 before drainage)  respectively.With the aim of obtaining the genuine CA19–9 level excluding the affect of biliary obstruction, we tried to fit the pre-operative baseline CA19–9 and TB, and the post-operative CA19–9 or the CA19–9 difference Table . As the CA19–9True = 0.63 × CA19–9Measured- 20.3  , was obtained  with a dissatisfactory diagnostic value. As for CA19–9 after biliary drainage and CA19–9 by correction formulas, the AUC were 0.699 (p = 0.006) and 0.695 (p = 0.007) respectively, which indicated that corrected CA19–9 value by our formulas obtained similar diagnostic efficacy with true CA19–9 value.We then portrayed Receiver Operating Characteristic (ROC) curves of CA19–9 before biliary drainage, CA19–9 after biliary drainage and CA19–9 by correction formulas in distinguishing benign and malignant lesions Fig. . The areCA19–9, as a classical tumor marker, play a significant role in the clinical management of pancreaticobiliary tumor since it was first found in 1982 by John L. Magnani [The NCCN guidelines for pancreatic adenocarcinoma in version 1.2019 cited two studies to illustrate the relationship between CA19–9 and biliary obstruction. D.V. Mann collected 31 jaundiced patients with high CA19–9 levels and found that relief of jaundice was associated with a fall in CA19–9 level in all benign cases and in nine of the 15 with malignancy and in benign jaundiced cases, a positive correlation was observed between bilirubin and CA19–9 elevation . D. MarrEven though the relationship between CA19–9 and biliary obstruction has been found for nearly 20 years, the internal mechanism that why and how obstructed bile duct can raise the CA19–9 value is still vague. Some hypotheses mainly concentrated on the carrier of CA19–9 from local to the circulation. Mucin4 (MUC4), MUC5AC and bile globular membrane (BGM) are highly specific tumor-associated proteins, which are two carrier proteins of CA19–9 in bile tract , 17. TheKrasG12D oncogene to produce aggressive pancreatic cancer. The newfound potential role of CA19–9 in the course of carcinogenesis and aggression promotion in pancreatic cancer provided a more forceful explanation of the extremely high level of CA19–9 in malignant patients. Nevertheless, the true machanism and quantitative relation between TB or bile duct pressure and CA19–9 still needed more investigation.Notably and recently, D.D.Engle and colleagues found that CA19–9 expression in mice resulted in rapid and severe pancreatitis with hyperactivation of epidermal growth factor receptor (EGFR) signaling [Through the ages, extremely high level of serum CA19–9 has been considered as a factor of unresectability of PDAC by surgeons –12. In 2The more that preoperative CA19–9 increased, the lower were tumor resectability and survival rates. Resectability and 5-year survival varied from 80 to 38% and from 27 to 0% for CA19–9<37 versus ≥4000 U/mL, respectively. The R0 resection rate was as low as 15% in all patients with CA19–9 levels ≥1000 U/mL. CA19–9 increased with the stage of the disease and was highest in AJCC stage IV. Patients with an early postoperative CA19–9 increase had a dismal prognosis . These pThe sensibility and specificity of CA19–9 are both nearly 80% as reported. Considering the above-mentioned confounding factors, we cannot help wondering the question, if CA19–9 is the best tumor marker for biliary and pancreatic tumors. More recently discovered tumor markers, such as exosomes, circulating tumor cells and circulating tumor DNA, are being explored in the management of pancreatic cancer.Pancreatic cancer cell-derived exosomes play critical roles in tumorigenesis and tumor development, and their numerous differentially expressed and functional contents make exosomes promising screening tools. For example, glypican-1 (GPC1), a membrane-anchored protein overexpressed in several tumor types , is re-eThese new-found tumor biomarkers showed promising potential in diagnosis, stage evaluation, therapeutic response evaluation, recurrence monitoring and prognosis prediction. However, the relative low homogeneity of these studies, immature and costly testing methods limit the spread and application of these biomarkers. There remains a giant gap between the rising biomarkers and CA19–9, and therefore, deeper digging of the essence of CA19–9 is still helpful for making clinical decision.Although correction formulas with good diagnostic value were obtained in our study, several limitations still existed objectively. First, the sample size was not big enough which may restricted the accuracy of correction formula. On account of the sample size, the enrolled cases were too few to allow us to obtain a satisfactory regression result in each cancer type. Second, our study was carried out retrospectively and the CA19–9 value after biliary drainage was measured in a similar time quantum after ERCP or PTCD, not the same time point, which would cause bias. In the future, prospective study of large samples will be performed to verify the accuracy of our correction formulas and assess their values in other vital issues of pancreatic caner, such as resectability evaluation. Linear relation of CA19–9 before and after biliary decompression in each cancer type will be calculated as well on basis of the increased sample volume.Classic tumor markers like CA19–9 played and will keep playing an important role in managing kinds of neoplasms. Quantitative correction formulas of CA19–9 considering the effect of biliary decompression was first proposed in this study, helping surgeons obtain genuine CA19–9 value secreted by tumors to effectively make accurate clinical decision such as resectablity evaluation. Using these formulas, surgeons can have a preliminary estimation of the true value CA19–9 value and tumor load of the patients to avoid making improper therapeutic schedule.Additional file 1: Supplementary Fig. 1 Linear regression of CA19–9 before and after biliary drainage in each cancer type. (A) Pancreatic cancer. (B) Periampullary cancer. (C) Bile duct cancer. (D) Other types of cancer.


Real‐world data for patients with positive colorectal cancer (CRC) screening stool‐tests demonstrate that adenoma detection rates are lower when endoscopists are blinded to the stool‐test results. This suggests adenoma sensitivity may be lower for screening colonoscopy than for follow‐up to a known positive stool‐based test. Previous CRC microsimulation models assume identical sensitivities between screening and follow‐up colonoscopies after positive stool‐tests. The Colorectal Cancer and Adenoma Incidence and Mortality Microsimulation Model (CRC‐AIM) was used to explore the impact on screening outcomes when assuming different adenoma sensitivity between screening and combined follow‐up/surveillance colonoscopies.Modeled screening strategies included colonoscopy every 10 years, triennial multitarget stool DNA (mt‐sDNA), or annual fecal immunochemical test (FIT) from 50 to 75 years. Outcomes were reported per 1000 individuals without diagnosed CRC at age 40. Base‐case adenoma sensitivity values were identical for screening and follow‐up/surveillance colonoscopies. Ranges of adenoma sensitivity values for colonoscopy performance were developed using different slopes of odds ratio adjustments and were designated as small, medium, or large impact scenarios.As the differences in adenoma sensitivity for screening versus follow‐up/surveillance colonoscopies became greater, life‐years gained (LYG) and reductions in CRC‐related incidence and mortality versus no screening increased for mt‐sDNA and FIT and decreased for screening colonoscopy. The LYG relative to screening colonoscopy reached >90% with FIT in the base‐case scenario and with mt‐sDNA in a “medium impact” scenario.Assuming identical adenoma sensitivities for screening and follow‐up/surveillance colonoscopies underestimate the potential benefits of stool‐based screening strategies. Application of more realistic, indication‐associated estimates for adenoma sensitivity at screening versus follow‐up/surveillance colonoscopy provides a more accurate simulation of the CRC screening benefits from primary stool‐based screening strategies. Future CRC screening microsimulation models should consider incorporating a range of different sensitivities between screening and follow‐up/surveillance colonoscopies. The invThe specificity, reach, complications, and sensitivity of CRC detection by disease stage for colonoscopy, FIT, and mt‐sDNA are provided in Table 2.3Intervals for screening used in the model were colonoscopy every 10 years, FIT every 1 year, and mt‐sDNA every 3 years. The average‐risk screening period was modeled between 50 and 75 years of age. These intervals and the age range were selected since they are “strong” recommendations from USPSTF and the ACS.2.4Simulated outcomes included the numbers of stool tests, complications from colonoscopies, CRC cases, CRC deaths, and life‐years with CRC, as well as the number of life‐years gained (LYG) and reduction in CRC‐related incidence and mortality compared with no CRC screening. Number of colonoscopies was used as an indicator of related resource use, costs, and complications. By virtue of simulated model outputs, AMR (proportion of missed adenomas per colonoscopy) and ADR  were able to be calculated. Adenoma miss rates have been estimated by tandem colonoscopies in research settings and may be as high as 47.9%.The weighted mean AMR was calculated using the cross‐sectional AMR per colonoscopy. The ADR for FIT and mt‐sDNA was calculated for the first follow‐up colonoscopy. The percentage of LYG relative to colonoscopy was determined for mt‐sDNA and FIT; strategies with LYG within 90% are considered to have comparable effectiveness to colonoscopy.2.5Two sensitivity analyses were conducted. In the primary analysis, it was assumed that for each scenario (except the base‐case scenario 1) the follow‐up/surveillance colonoscopy after a positive mt‐sDNA or FIT had a greater sensitivity than a screening colonoscopy based on the data published by Johnson et al.,For the second sensitivity analysis, the goal was to use the most up‐to‐date evidence of screening modality performance. The primary analysis was replicated using newer dataThe test performance characteristics for FIT and mt‐sDNA used in the primary analysis were derived from the data generated in a cross‐sectional study .All other modeling aspects in the sensitivity analyses were the same as the primary analyses.33.1For the base‐case scenario scenario 1), the LYG was higher for colonoscopy every 10 years (351.9) compared with triennial mt‐sDNA 299.5) and annual FIT , the weighted mean AMR for colonoscopy every 10 years (21.3%) was greater than that of triennial mt‐sDNA (18.9%) and annual FIT . For the base‐case scenario (scenario 1), the ADR was 30.3% for triennial mt‐sDNA and 31.7% for annual FIT Table . As the 3.4In the first sensitivity analysis that assumed the sensitivity of a follow‐up colonoscopy after positive FIT was the same as a screening colonoscopy, the pattern of changes in CRC‐related outcomes, AMR, and ADR for FIT over the spectrum of adenoma sensitivity scenarios reversed from that of the primary analysis Figures  and S5. 4The results of this CRC‐AIM microsimulation study demonstrate the impact of differences in adenoma sensitivity for screening colonoscopy and follow‐up/surveillance colonoscopy after a positive stool‐based test with respect to multiple CRC outcomes, including AMR and ADR. Within the range of simulated scenarios, when assuming identical adenoma sensitivities regardless of colonoscopy indication, the screening strategy of colonoscopy every 10 years yielded increases in LYG, reductions in CRC incidence and mortality, and higher AMR compared with triennial mt‐sDNA and annual FIT. When real‐world data were applied to the adenoma sensitivity inputs,Notably, although the blinded versus unblinded endoscopist study by Johnson et al.AMR is, in part, a reflection of the sensitivity of a colonoscopy whereas ADR is an established indicator of the colonoscopy quality. In the current model, the estimated AMR for screening colonoscopies ranged from 21% in the base‐case adenoma sensitivity scenario to 53% in the highest impact adenoma sensitivity scenario. In contrast, the AMR for colonoscopy after a positive stool‐based test decreased from 19% in the base‐case scenario to 5% in the highest impact scenario. Although these predicted AMRs span a broad range, they are in line with those published from tandem colonoscopies in clinical trials, which in one review ranged from 47.9% to 5.1%.At present, it remains unknown which of the adenoma sensitivity scenarios is most representative of real‐world clinical practice in diverse settings. In the Johnson et al.A limitation of the current analysis is there is little published data on the adenoma sensitivity of surveillance colonoscopy after a positive stool‐test compared with screening colonoscopy. Therefore, it was assumed that surveillance colonoscopy adenoma sensitivity was identical to follow‐up colonoscopy sensitivity for our modeled scenarios. Similar to previous models, the current analysis using the CRC‐AIM model is limited in that it does not account for serrated polyps which may account for up to 30% of CRC.5Application of more realistic, indication‐associated estimates for adenoma sensitivity at screening versus follow‐up/surveillance colonoscopy provides a more accurate simulation of the CRC screening benefits from primary stool‐based screening strategies. Future CRC screening microsimulation models should consider incorporating a range of different sensitivities between screening and follow‐up/surveillance colonoscopies.6The study sponsor contributed to the study design, data analysis, and data interpretation. All authors made the decision to submit the manuscript.7This modeling study did not involve human subjects or animals. Ethics committee approval was not required.D.A. Fisher is a consultant for Exact Sciences and Guardant Health. L. Saoud, M. Matney, A.B. Ozbay, and M. Parton are employees of Exact Sciences Corporation. K. Hassmiller Lich has nothing to disclose. A.M. Fendrick has been a consultant for AbbVie, Amgen, Centivo, Community Oncology Association, Covered California, EmblemHealth, Exact Sciences, Freedman Health, GRAIL, Harvard University, Health & Wellness Innovations, Health at Scale Technologies, MedZed, Penguin Pay, Risalto, Sempre Health, the State of Minnesota, U.S. Department of Defense, Virginia Center for Health Innovation, Wellth, and Zansors; has received research support from the Agency for Healthcare Research and Quality, Gary and Mary West Health Policy Center, Arnold Ventures, National Pharmaceutical Council, Patient‐Centered Outcomes Research Institute, Pharmaceutical Research and Manufacturers of America, the Robert Wood Johnson Foundation, the State of Michigan, and the Centers for Medicare and Medicaid Services. B.J. Borah has nothing to disclose. P.J. Limburg serves as Chief Medical Officer for Screening at Exact Sciences through a contracted services agreement with Mayo Clinic. Dr. Limburg and Mayo Clinic have contractual rights to receive royalties through this agreement.Deborah Fisher: conceptualization and writing – review and editing. Laila Saoud: methodology, data curation, formal analysis, investigation, software, visualization, and writing – review and editing. Kristen Hassmiller Lich: conceptualization and writing – review and editing. A. Mark Fendrick: methodology and writing – review and editing. A. Burak Ozbay: conceptualization, methodology, supervision, visualization, and writing – review and editing of the manuscript. Bijan J. Borah: conceptualization and writing – review and editing. Michael Matney: resources, software, and writing – review and editing. Marcus Parton: conceptualization, methodology, funding, and writing – review and editing. Paul J. Limburg: conceptualization, methodology, and writing – review and editing.https://www.exactsciences.com/. The funding agreement ensured the authors’ independence in designing the study, interpreting the data, writing, and publishing the report.Financial support for this study was provided by a contract with Exact Sciences Corporation. Fig S1Click here for additional data file.Fig S2Click here for additional data file.Fig S3Click here for additional data file.Supplementary MaterialClick here for additional data file.


Obstructive sleep apnea (OSA) is often accompanied by other complications, especially hypertension.The purpose of this study is to compare the application value of six tools in the screening of OSA in patients with hypertension. Compared with other questionnaires, we hypothesized that Berlin performed better in screening hypertensive patients suspected of OSA.In this study, we collected the basic data and polysomnography (PSG) data of patients diagnosed with hypertension who underwent PSG at the Sleep Medicine Center of the First Affiliated Hospital of Guangzhou Medical University from April 2012 to March 2021. The sensitivity, specificity, positive predictive value, negative predictive value, area under the curv (AUC) and diagnostic odds ratio (DOR) of the six screening tools were then calculated, and their correlation with the sleep apnea hypopnea index (AHI) analyzed.There were 303 males  out of 398 hypertension patients suspected of OSA. The area under the curve of the Berlin questionnaire's receiver operating characteristic (ROC) curve reached 0.753 (95%CI: 0.707–0.794). When the AHI was 5, 15 and 30 times/h as the cut‐off points, the sensitivity and negative predictive value of Berlin were the highest at 0.947 and 0.630, 0.970 and 0.851, and 0.988 and 0.957 respectively, while the specificity and positive predictive value of the Epworth Sleepiness Scale (ESS) were the highest at 0.696 and 0.729, 0.750 and 0.887, and 0.674 and 0.575 respectively. The DOR value of the Berlin questionnaire could reach 18.333 when the AHI cut‐off point was 30 times/h. Berlin had the largest rank correlation coefficient with AHI at 0.466.The Berlin questionnaire can be considered a priority for the screening and stratifying of hypertensive patients suspected of OSA. AHIapnea hypopnea indexAUCarea under the curveBMIbody mass indexCIconfident intervalDORdiagnostic odds ratioDPdiastolic pressureESSEpworth Sleepiness ScaleHRheart rateMean‐NOXmean nocturnal oxygen saturationMin‐NOXminimum nocturnal oxygen saturationNCneck circumferenceNPVnegative predictive valueOSAobstructive sleep apneaPPVpositive predictive valuePSGpolysomnographyROCreceiver operating curveSDBsleep disordered breathingSPsystolic pressureWCwrist circumference1Obstructive sleep apnea (OSA) is a kind of disease in which partial or complete upper airway obstruction occurs repeatedly during sleep, causing a series of clinical manifestations.At present, the gold standard for diagnosing OSA is polysomnography (PSG) at night, but this is expensive, time‐consuming and limited to areas with good medical care, which will cause delays in the diagnosis and treatment of a large number of patients with suspected OSA.22.1This study collected data on patients diagnosed with hypertension who underwent PSG examination at the Sleep Medicine Center of the First Affiliated Hospital of Guangzhou Medical University from April 2012 to March 2021. If a patient had a clear history of hypertension or was taking antihypertensive drugs, or they had systolic blood pressure ≥ 140 mmHg or diastolic blood pressure ≥ 90 mmHg before and after monitoring, they were considered hypertensive. This study was approved by the medical ethics committee of the hospital (Ethics Number: 201705), and eligible patients were selected according to the inclusion and exclusion criteria. Inclusion criteria: (a) Patients who first came to the sleep respiratory center for PSG monitoring due to complaints of snoring, lethargy, high blood pressure or apnea; (b) Patients diagnosed with hypertension; (c) Patients aged between 18 and 80 years old (including 18 and 80 years old); (d) Patients who had autonomous behavioral ability and cognitive ability, had completed six scales in the sleep laboratory and agreed to sign the informed consent; (e) Patients with total sleep time > 4 h. Exclusion criteria: (a) Patients with coronary heart disease, diabetes, kidney disease, chronic lung disease, or cerebrovascular disease; (b) Patients with a history of brain tumors or epilepsy; (c) Patients with various mental and psychological diseases who were taking sedative and sleeping pills; (d) Patients with severe organ failure; (e) OSA patients who had received treatment; (f) Patients with incomplete answers on the scale; (g) Patients with sleep apnea hypopnea syndrome with predominantly central or mixed events.2.2In our study, we collected general information such as the patients' name, age, gender, occupation, education, smoking, drinking, height, weight, neck circumference, waist circumference, blood pressure, and so on. The patient and family members filled in the ESS, STOP, STOP‐Bang and Berlin scales together, and the sleep technician verified the items on the scales to ensure their reliability, then took back the completed questionnaires. The researchers then refined the NoSAS and No‐Apnea scores based on the general data.2.32 is 3 points, BMI ≥30 kg/m2 is 5 points; ③ Snoring is 2 points; ④ Age ≥ 55 years old is 4 points; ⑤ Male is 2 points. If the NoSAS score ≥ 8 points, it indicates that the patient is at high risk of OSA.NOSASNo‐ApneaESSSTOP2], A (age > 50 years old), N (neck circumference > 40 cm), G . Answer with “yes” or “no”; “yes” is 1 point, “no” is 0 points. If the STOP‐Bang score is ≥3 points, it indicates that the patient is at high risk of OSA.STOP‐BangBerlin2.4PSG monitoring was mainly used to diagnose sleep disordered breathing. Recording indicators include electroencephalogram, electrooculogram, mandibular electromyography, oral and nasal airflow and respiratory movement, electrocardiogram, blood oxygen saturation, snoring, limb movement, body position and other parameters. We used an Alice 5 polysomnograph made by the Philips Wellcome Company to record continuously and synchronously for at least 7 h. After automatic analysis, the original parameters were manually reviewed and corrected, and finally interpreted and analyzed by trained sleep physicians. Sleep apnea hypopnea index (AHI) refers to the number of apnea and hypopnea events per hour of sleep. Patients with AHI ≥5 times/h and obstructive apneas as the main respiratory event were judged to have OSA in the following disease grades: normal group (AHI < 5 times/h), mild OSA group (5 ≤ AHI < 15 times/h), moderate OSA group (15 ≤ AHI < 30 times/h), severe OSA group (AHI ≥30 times/h).2.5p value for comparing the area under the ROC curve of single and multiple indicators. The correlation between the six scales and AHI was analyzed using the bivariate correlation method. Pearson correlation analysis was used for the normal distribution data, and Spearman correlation analysis was used for the non‐normal distribution data. p < .05 was defined as statistically significant.SPSS 26.0 statistical software was used for analysis. The measurement data of normal distribution were expressed as mean ± SD, the measurement data of skewed distribution was expressed as median   and the count data was expressed as frequency. For the measurement data, a one‐way analysis of variance test was used for normal distribution, a multi‐group independent sample rank test  (w) multiple comparison) was used for skewed distribution data, and a chi‐square test or Fisher's exact probability method was used to count the data. The diagnostic results of the scales and PSG were calculated in the form of a four‐grid table for the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LR+), and negative likelihood ratio (LR‐) of each scale, and reported with respective 95% confidence intervals (CI). The ROC curve was analyzed using MedCalc software to evaluate the diagnostic value of the five scales for OSA, and calculate the 33.1p < .001) with the disease predominantly affecting males, but there was no statistically significant difference for smoking and drinking. The average age of these patients was (51.8 ± 12.5) years old, average systolic blood pressure was (149.2 ± 17.6) mmHg, average diastolic blood pressure was (95.9 ± 11.6) mmHg, average heart rate was (79.4 ± 12.2) beats/min, average body mass index was (27.6 ± 3.8) kg/m2, average neck circumference was (39.4 ± 3.8) cm and average waist circumference was (98.6 ± 10.7) cm. There were no statistically significant differences in age, systolic blood pressure or diastolic blood pressure, but differences in heart rate, body mass index, neck circumference and waist circumference were statistically significant (p < .001). The medians of NoSAS, No‐Apnea, ESS, STOP, STOP‐Bang, Berlin, AHI, lowest nocturnal oxygen saturation, and mean nocturnal oxygen saturation were respectively 11  points, 4  points, 8  points, 3  points, 5  points, 2  points, 19.7 times/h, , 80%  and 94% , with statistically significant differences (p < .001). In the post test, except for drinking, age, systolic blood pressure and diastolic blood pressure, there were significant differences among the severe OSA group and normal group, and the mild OSA group and moderate OSA group respectively (p < .005) , 152 were smokers  and 105 cases were drinkers . Among them, the gender difference was statistically significant (3.2p < .001). When AHI was 20, 25, and 30 times/h as the cut‐off point, the predictive value of STOP‐Bang was significantly better than those of the other five scales with statistically significant difference (p < .005) , so it needs to be further verified in other environments.5In conclusion, for screening hypertensive patients suspected of OSA, although there are many test contents in Berlin, relatively speaking, it is still better than the other five screening tools, and can be considered a priority for the screening and stratification of hypertensive patients suspected of OSA. The screening of STOP‐Bang is better than that of STOP, NoSAS and ESS, and it can also be used to screen for hypertensive patients suspected of OSA. NoSAS is simple to use but requires further certification as a new screening tool. Finally, ESS is not effective and no‐apnea may not be suitable in screening for hypertensive patients suspected of OSA.The authors declare no conflicts of interest.


Numerous studies have shown the effects of rapid eye movement sleep deprivation (REM‐SD) on behavior and brain structures. The impact of REM‐SD on learning and memory, thus neurogenesis, has been reported in previous studies. Royal jelly (RJ) is known as the wealthiest biological nutrient with various physiological properties. This study aimed to study the possible effect of RJ on neurogenesis of the rat hippocampus neonates following exposure of mother to REM‐SD during pregnancy.n = 3): group 1, no treatment; group 2, REM‐SD; groups 3, 4, and 5, REM‐SD +RJ. The former group received 72 h REM‐SD during pregnancy , and the latter group received REM‐SD + RJ . At week 4, the rat neonates of all groups were sacrificed (n = 6 each group). Their brains were fixed, removed, and prepared for Nissl and Hoechst 33342 staining. By using real time polymerase chain reaction methode the brain‐derived neurotrophic factor BDNF gene expression was studied (RT‐PCR), brain‐derived neurotrophic factor (BDNF) gene expression was studied. The results were analyzed statistically, and the Pv  < .05 was considered significant.Thirty neonate rats from 15 pregnant Wistar rats were used. To induce REM‐SD, the flowerpot method was used. The pregnant rats were divided into five groups  on neurogenesis following early exposure to rapid eye movement sleep deprivation (REM‐SD) in rat neonates, the present study designed to study the effect of Royal Jelly. We believe that RJ has a dual role via brain‐derived neurotrophic factor (BDNF) following REM‐SD; increasing the expression of BDNF in the hippocampus stimulates cell proliferation and differentiation and inhibits apoptosis. Sleep follows a circadian rhythm that consists of two phases; rapid eye movement (REM) and non‐REM sleep. REM sleep is a unique physiological phase that occurs intermittently during sleep and is expressed in higher‐order mammals, including humans. Many researchers have shown the neuronal structures and circuits that are involved in REM sleep regulation. It is shown that many neurological, neurodegenerative diseases and several psychosomatic illnesses are associated with sleep disorders, mainly loss of REM sleep. Prolonged REM‐SD may lead to death. REM‐SD leads to many biochemical and cellular changes. It is shown that REM‐SD affects intracellular calcium, membrane permeability, and protein expression at the cellular and molecular levels, including enzymes, hormones, and neurotransmitters. From the research point of view, SD is accepted as an experimental method to investigate the neural bases of sleep phenomena.Regarding this, the effects of REM‐SD on learning and memory tasks were reported by many researchers. The hippocampus is well known for its role in memory processing, consolidating short‐term memory information into long‐term memory, and neurogenesis , a secretion of honeybee hypopharyngeal and mandibular glands, is a nutrient consisting of water, various protein, monosaccharide, fatty acid, and hydroxy‐2‐decanoic acid. Its main proteins (MRJPs) consist of a family of nine proteins from MRJP1 , MRJP2, MRJP3, MRJP4, and MRJP5 in a gel secreted by worker bees, of which MRJP1 is the most abundant one. These five proteins contain 83% to 90% of the total royal jelly proteins , Hoechst3334, and cDNA synthesis kit—Gene All—from Sigma‐Aldrich Co.2.2n = 3): group 1; the pregnant animals with no intervention , group 2; the pregnant animals received 72 h of REM‐SD (positive control group), and group 3, 4, and 5; the pregnant animals that received the same REM‐SD and different doses of RJ . Animals of the first group had no intervention and were kept in normal conditions, and their neonates were considered as negative controls. The second group received 72 h REM‐SD during pregnancy , and their kids were the positive control group, and the last groups received REM‐SD  + RJ  and their neonates were the trial animals. One week after delivery, the rat neonates of all groups, as the study groups, were sacrificed and prepared for subsequent studies. To study neuronal density and cell count, apoptosis, and expression of BDNF, Nissl staining, Hoechst staining, and real time polymerase chain reaction methode the brain‐derived neurotrophic factor BDNF gene expression was studied (RT‐PCR) were respectively used.In this study, 30 rat neonates from pregnant Wistar rats were used. The animals were purchased from the Animal Care Center of Iran University of Medical Sciences (IUMS). During the experiment, the pregnant rats during pregnancy had free access to water and food and were kept under standard dark‐light cycle 12:12, room temperature, and humidity. Animal Ethical Committee of NRC/IUMS approved all procedures used in this study. After pregnancy confirmation by observing vaginal plug, the 15 pregnant rats were randomly divided into five study groups  mixture.Immediately, the animals were perfused and fixed by aldehyde solutions transcardially. Their brain was removed and kept in graded sucrose solution as the cryoprotective agent, by using a freezing microtome (Leica 3000 Germany) and coronal sections of 10 μm were prepared. Nissl staining was done as mentioned in our previous studies . All works are performed under a laminar hood and on ice. Quantitative analysis of the extracted RNA using adsorption was performed at OD 260/280 by nanodrop. To make complementary DNA molecules, cDNA synthesis kit—Gene All—Cat. No. 601‐005 made in South Korea were used. The ingredients were first combined in a tube according to the kit instructions. For this purpose, 2 μg of sample RNA was mixed with 1 μl of random hexamer primer, 1 μl of dNTPs, and RNAse‐free water was added until the total volume reached 14 μl. The materials were centrifuged inside the tube for a short time to ensure that they were mixed. They were then incubated at 65°C for 1 min. To measure the expression levels of BDNF mRNA, the quantitative Real time‐PCR method was used using Premix SYBR Green II. The reaction mixture at final volume was 20 μl. Primers were designed based on BDNF and GAPDH genes in NBCI Gene Bank as Housekeeping gene was considered  statistical software using One Way ANOVA and Tukey test, the 33.1RJ restore the number of living cells in the hippocampus of rat neonates with maternal REM‐SD.p < .001)  was significantly lower than the negative control group. In the neonates whose mother received RJ at doses of 25, 50, and 100 mg/kg, the number of neurons was significantly higher than the positive group (REM‐SD) animals that showed the possible protective role of RJ. Our data also showed that the effect of RJ was dose‐dependent, that is, the higher dose of RJ led to the high number of lived neurons  Figure .3.2Apoptosis significantly decreased in the hippocampus of rat neonates with maternal REM‐SD.p < .001) of apoptotic cells in the hippocampus of the neonates from mothers with REM‐SD +RJ compared to the positive control group (REM‐SD). The effect of royal jelly was dose‐dependent at doses of 25, 50, and 100 mg/kg . Administration of royal jelly with different doses causes a significant increase (p < .001) in BDNF expression in the hippocampus of the neonates of the REM‐SD + RJ mothers compared to neonates from the positive control group (REM‐SD). All doses of RJ led to a significant increase in BDNF expression in a dose‐dependent manner.Real‐time PCR data Figure  showed t4In this study, the effect of royal jelly was investigated on neuronal survival, apoptosis, and the BDNF expression in the hippocampus of the rat neonates with maternal short‐term REM‐SD. Our data at first showed that REM‐SD caused apoptosis and a decrease in BDNF expression in the hippocampus. Much research has been done since Klitman and Aserinsky first identified rapid eye movement sleep (REMS) in 1953. Since then, REM‐SD is supposed as a research strategy to study the neural bases of sleep. Many researchers have shown the structures involved in REM sleep regulation and the effects of REM‐SD on certain structures of the brain. Many reports show the REM‐SD at different times, either short or long term, has dramatic cellular and molecular effects on brain structures. Sakai  reportedUsing RJ in REM‐SD + RJ, the level of BDNF expression increased, and the number of apoptotic cells significantly decreased. The question is how RJ could insert this effect. Many studies have examined the impact of specific protective agents on the impact of REM‐SD.Alquraan et al.  studied Regarding the action mechanism of RJ on apoptosis and subsequent cell proliferation and differentiation, You et al. showed RJ could inhibit apoptosis via activating the cAMP/PKA/CREB/BDNF pathway in an AD mouse model Mueller, . Accordi5Based on our findings, RJ acts as a neuroprotective agent that could compensate for the effects of REM‐SD on learning and memory via restoring neurogenesis. Although we know that the exact mechanisms of RJ action on neurogenesis and subsequent learning and memory needs more research, we believe that RJ could be a promising medicine for certain neurodegenerative and neurological disorders such as AD with sleep disturbances origin. Easy access to royal jelly and its low cost are important advantages that reduce the cost of treating some neurodegenerative diseases. Accordingly, we suggest strongly for more research on the effects of RJ and its action mechanisms on different neurodegenerative diseases.The authors declare no conflict of interest.M. Farhadi, S. B. Jameie, and V. Pirhajati: Study design; budget planning; methodology. A. Khodaverdiloo and Jameie Melikasadat: Methodology; methods and microscopic study and reports. S. B. Jameie and M. Farhadi: Manuscript preparation. Jameie Melikasadat and S. B. Jameie: Editing of the manuscript. Jameie Melikasadat: Data analysis.https://publons.com/publon/10.1002/brb3.2423The peer review history for this article is available at


Apodemus spp. mice and bank voles (Myodes glareolus) on 5 forest sites with differing disturbance history. The study sites, located in a forest dominated by European beech (Fagus sylvatica), Norway spruce (Picea abies), and silver fir , consisted of two primeval forest sites with small canopy gaps, two sites with larger gaps , and a managed forest stand with closed canopy as a control. Hierarchical Bayesian N‐mixture models revealed a strong influence of seed rain on small rodent abundance, which were site‐specific for M. glareolus but not for Apodemus spp. Following years of moderate or low seed crop, M. glareolus avoided open habitat patches but colonized those habitats in large numbers after full mast events, suggesting that spillover events also occur in unmanaged forests, but not in all small rodents. The species‐ and site‐specific characteristics of local density responding to food availability have potentially long‐lasting effects on forest gap regeneration dynamics and should be addressed in future studies.Mast seeding, the synchronized interannual variation in seed production of trees, is a well‐known bottom‐up driver for population densities of granivorous forest rodents. Such demographic effects also affect habitat preferences of the animals: After large seed production events, reduced habitat selectivity can lead to spillover from forest patches into adjacent alpine meadows or clear‐cuts, as has been reported for human‐impacted forests. In unmanaged, primeval forests, however, gaps created by natural disturbances are typical elements, yet it is unclear whether the same spillover dynamics occur under natural conditions. To determine whether annual variation in seed production drives spillover effects in naturally formed gaps, we used 14 years of small mammal trapping data combined with seed trap data to estimate population densities of  We present novel hierarchical Bayesian N‐mixture models of unique count data from 14 years of small mammal live trapping investigating functional responses of dominant rodent taxa to different habitat types and mast seeding, including sites of natural disturbance events and sites in the largest remaining primeval forest of the Alps. For example, Carey and Johnson  found thApodemus spp. and Myodes glareolus densities across sites with differing disturbance history, including frequent small‐scale and rare medium‐scale natural disturbances on primeval or old‐growth forest patches, as well as managed forest without natural disturbances. To do so, we used hierarchical Bayesian N‐mixture models to estimate temporal changes in rodent abundance for each of the sites, as a function of seed rain. Because abiotic conditions are known to affect the detection probability of the target species  and silver fir  as the other common species. The disturbance history of the area is well documented, and the disturbance regime is characterized by frequently occurring low severity disturbances and less frequent medium‐scale disturbance events  is located within the northern Limestone Alps of Lower Austria, Austria. The climate of the region is submaritime with long winter periods and short cool summers. Annual precipitation  shows a bimodal pattern, reaching one maximum during the vegetation period and another one at wintertime. The protected area of the WAD covers 3,500 ha in total from which approximately 300 ha is declared as a strictly protected area , the primeval forest Rothwald, which has never been logged  and two sites located in a basin in ~4‐km linear distance to the summit Dürrenstein  of approx. 240 ha; PFs is characterized by old individuals of P. abies established rapidly in the middle parts, while the avalanche runout zone is characterized by a high amount of coarse woody debris and gravel. Eleven years after the disturbance event, open grassland occupied around half of the site  of 10.1 ha size with a length of over 1,000 m and a width of up to 120 m. e Brenn, .A windthrow area (WTs) of 10 ha size , which was formed in 1990 in an old‐growth forest stand close to PFs. The area was not cleared from logs and provides a heterogeneous habitat with dense thickets intermixed with patches of grassland.The study sites on the basin represented the following two disturbance scenarios:A primeval forest site with frequent small‐scale disturbance history (PFb) of approx. 60 ha; it is characterized by a high amount of deadwood and densely mixed regeneration and a higher ground vegetation cover compared with PFb.P. abies, intermixed with F. sylvatica and A. alba. Ground vegetation is dominated by Vaccinium myrtillus, which is less common at all other sites. The managed forest (MFb) is adjacent to PFb and other beech‐dominated forest stands.A managed forest site without occurrence of natural disturbances (MFb); MFb is dominated by The study sites in the We monitored seed rain on the plots PFs and PFb, representing the slope and the basin, respectively. Small mammal live trapping was done on all five study sites .To estimate the abundance of small mammals, we conducted live trapping between 2004 and 2019. Trapping sessions were carried out between May and October with one to three sessions each year. The duration of a trapping session varied between 2 and 5 consecutive trap nights , as their seed rain was positively correlated . Seed rain was monitored at the plots PFs (representing the slope) and PFb (representing the basin) in 100 × 100 m plots using geostatistical grid designs with 81 seed traps in 2003 and from 2006 to 2018  algorithm  had reached the reproductive age  and seed rain of F. sylvatica could potentially occur due to the presence of parent trees. In contrast, the interaction between seed rain of conifers and mammal sites was not included as dispersal distances of conifer seeds are considerably larger compared with F. sylvatica .The abundance of each rodent taxon at session  Kutter, , potentipij is detection probability at session i and trap night j. α0 represents the intercept, and α1 to α5 are slope coefficients for the night of the session, the mean temperature between 19:00 and 06:00 CET of the preceding night, a quadratic term of the mean temperature, the sum of precipitation of the previous day, and an interaction between precipitation and temperature, respectively. We added a quadratic term of the mean temperature as we expected extreme temperatures (very hot and very cold) to have a negative effect on the detection probability because small mammals might adapt foraging behavior according to their thermal neutral zone . The number of conifer seeds was higher than average in 2003, 2011, 2015, and 2018 both on the slope and in the basin. Masting of F. sylvatica was above average in 2003, 2007 (basin plot only), 2011, 2014, and 2016 (slope plot only).Seed production of the three dominant tree species varied strongly between study years, with overall mean values of 3.2Nightly estimates of mean temperature differed only slightly among sites. For example, the primeval forest at the slope PFs was on average 0.35°C ± 0.17 colder than PFb, and 0.26°C ± 0.18 colder than AV. Furthermore, we found that WTs mean nightly temperatures during the summer months were highly correlated with data from the nearby weather station Appendix  supporti3.3Apodemus spp. and 2,195 M. glareolus captures. Capture numbers were highly variable between years for both taxa , Muscardinus avellanarius (n = 37), Sorex araneus (n = 79), Sorex minutus (n = 81), Sorex alpinus (n = 69), and Sorex sp. . Furthermore, we recorded rare captures of Microtus agrestis (n = 11), Microtus subterraneus (n = 12), and Crocidura suaveolens (n = 1). Mustela sp. and Vipera berus occurred at WTs and AVs only, where the latter was seen coincidentally and did not enter the traps.In 455 trap nights, we recorded 2,385 3.4C^‐values of 1.08 in Apodemus spp. and 1.09 in M. glareolus. Bayesian p‐values based on a chi‐squared discrepancy measure were .18 for Apodemus spp. and .15 for M. glareolus, indicating acceptable fit of the models to the data.Both N‐mixture models showed only slight overdispersion with 3.5Apodemus spp., detection probability increased with increasing precipitation and over consecutive nights within a session  and the managed forest stand without natural disturbances (MF). However, in years with high overall density following bumper crops of seeds, the species even occupied open sites  in large numbers, exceeding local densities in their commonly preferred habitat. Corresponding to our hypothesis, the observation of spillover effects in M. glareolus applies both for the avalanche patch on the primeval forest site (AVs) and for the windthrow patch (WTs) on a formerly old‐growth forest site. However, our results do not indicate site‐specific responses to seed rain for Apodemus spp.. These main findings are in line with other studies on M. glareolus on forest sites with adjacent open habitats, although the open patches in these studies were not created by natural disturbances but stemmed from human intervention ; data curation ; formal analysis (lead); investigation ; methodology (lead); project administration ; software (lead); supervision (supporting); validation (lead); visualization (lead); writing–original draft (lead); writing–review and editing . Mario Pesendorfer: Conceptualization (supporting); data curation (supporting); formal analysis (supporting); investigation (supporting); methodology (supporting); supervision ; validation (supporting); visualization (supporting); writing–original draft (supporting); writing–review and editing . Georg Gratzer: Conceptualization (lead); data curation ; funding acquisition (lead); investigation (lead); project administration (lead); resources (lead); supervision ; validation ; writing–original draft (supporting); writing–review and editing . Ursula Nopp‐Mayr: Conceptualization (lead); data curation ; funding acquisition ; investigation (lead); project administration ; resources (lead); supervision ; validation ; writing–original draft (supporting); writing–review and editing .Supplementary MaterialClick here for additional data file.


Thamnophis sirtalis tetrataenia) to fit an integrated growth–survival model. Growth models showed that females reach longer asymptotic lengths than males and that the magnitude of sexual size dimorphism differed among populations. The capture probability and availability of San Francisco gartersnakes for capture increased with snout–vent length. The survival rate of female snakes exhibits a nonlinear relationship with snout–vent length (SVL), with survival flat between 300 mm and 550 mm SVL before decreasing for females between 550 mm and 700 mm SVL. For male snakes, survival decreased for adult males >550 mm SVL. The survival rates of the smallest and largest San Francisco gartersnakes were highly uncertain because recapture rates were very low for these sizes. By integrating growth and survival models and using penalized splines, we found support for size‐dependent survival in San Francisco gartersnakes. Our results have applications for devising management activities for this endangered subspecies, and our methods could be applied broadly to the study of size‐dependent demography among animals.Estimates of demographic rates for animal populations and individuals have many applications for ecological and conservation research. In many animals, survival is size‐dependent, but estimating the form of the size–survival relationship presents challenges. For elusive species with low recapture rates, individuals’ size will be unknown at many points in time. Integrating growth and capture–mark–recapture models in a Bayesian framework empowers researchers to impute missing size data, with uncertainty, and include size as a covariate of survival, capture probability, and presence on‐site. If there is no theoretical expectation for the shape of the size–survival relationship, spline functions can allow for fitting flexible, data‐driven estimates. We use long‐term capture–mark–recapture data from the endangered San Francisco gartersnake  exhibit size‐dependent survival by integrating growth and capture–mark–recapture models. We found that both capture probability and survival are size‐dependent in this species, with individuals of intermediate size having the highest survival rate. Integrating growth models into models of survival has the potential to reveal insights into species demography.We investigated whether San Francisco gartersnakes ( Capture probabilities for this species are low  that occurs in San Mateo and northwestern Santa Cruz counties in California, USA, and is listed as endangered under the federal Endangered Species Act , California red‐legged frogs (Rana draytonii), and Pacific newts (Taricha spp.). San Francisco gartersnake populations have become more isolated as urbanization in the species’ range has altered wetlands and surrounding upland habitats , bulrushes (Schoenoplectus spp.), cattails (Typha spp.), and willows , which provided foraging habitat for San Francisco gartersnakes. Drought from 2012 to 2015 caused the two permanent water bodies to dry in the late summer of 2014. Upland habitat was primarily coastal scrub and grazed grassland, with Douglas‐fir (Pseudotsuga menziesii) forest at higher elevations. Native amphibian prey species for San Francisco gartersnakes at Site C included Pacific newts, Sierran treefrogs, and California red‐legged frogs.Site C was an open‐space preserve in coastal southern San Mateo County  that was off‐limits for recreation but subject to cattle grazing during the 20th century until 1998, and again from 2015 to 2020. Site C is regularly covered in coastal fog  co‐occurred up until 2015; the bullfrogs were culled by site management between 2014 and 2015  that was a private cattle ranch until 2008. Diurnal temperature at Site I ranged between 9 and 30°C  during our sampling. Since 2008, the site has been managed to limit public access and enhance habitat for sensitive wildlife species. Management activities at Site I include controlling vegetation by removing invasive weeds and reintroducing grazing in 2015 to keep vegetation at an early‐successional stage. Aquatic habitat at Site I comprised three ephemeral wetlands and one permanent lake. As in Site C, the permanent lake at Site I dried in the late summer of 2014 for the first time in decades. The vegetation in aquatic and upland habitat at Site I was comparable to that at Site C, with the addition of mixed evergreen forest at higher elevations. Native amphibian prey taxa at Site I were similar to Site C, but invasive American bullfrogs  of all captured snakes. We determined snake sex by cloacal probing and marked snakes by branding ventral scales with a unique code  is drawn from a normal distribution centered on iEL,t with random variation around the expected size at time t (tε) that encompasses both measurement error and individual variation around expected size  growth model based on Armstrong and Brooks  to snake k Wang, , we foll k Wang,  and subsEquation .(2)Li,k) as a function of sex (fixed effect) and random effects of individual (i), site (s), and year (t) (Equation We modeled log(Equation .(3)logfµ is the mean value of k for a female snake, mβ is the effect of maleness on k, im is a binary indicator of whether an individual is male (1) or not (0), and sexα,s, tζ, and iι are site (by sex), year, and individual random effects, respectively.The variable ia) as a function of sex and site  sampling in JAGS Plummer,  accessed2.4ϕ), probability of being available for capture (γ), and daily recapture probability (p) at each site, while accounting for variation due to individual size. Our robust‐design model conditioned on initial capture and is a multistate version of a Cormack–Jolly–Seber model  each composed of multiple secondary periods (j) separated by small temporal intervals; populations are assumed closed between secondary periods , while populations are assumed to be open  during the larger intervals between primary periods , availability (γ), and capture probability (p). The key innovation in the model of Riecke et al. , relative humidity, and day of year on p, where the covariate matrix is W, and the vector of coefficients is pδ  on capture probability to be linear functions because our two‐month sampling period did not cover the full seasonal variation in weather at our study sites. Although we believe that using linear functions was a reasonable assumption for this short time period, it is likely that some of these covariates might have more complex relationships with capture probability when evaluated over a wider range of values .We included potential effects of snake SVL on nes Eqs. ,6. Givennes Eqs. , and basEquation . In equaG = 5 knots  and fit spline functions (degree = 3) to each knot + represents max, and d is the degree of the spline. The splines are penalized because each b is drawn from a normal distribution (N) with a shared standard deviation parameter (bσ), making each b parameter analogous to a random effect , we used a shared spline function, f(x) among sites and both sexes. In other words, although the intercept could differ among sexes and sites, we assumed that the size–survival function would be the same for each site‐sex group, likewise for the size–capture probability function. We also assumed a shared slope among sites and sexes for the size–availability functions. We made the assumption of shared shape of size effects among sites because most of our CMR data came from Site C, and we lacked sufficient data to estimate independent functions for snakes from Site I. We tested for potential correlation among annual growth and survival rates by using a covariance matrix to define annual random effects for these parameters , and data to reproduce occupancy analyses area are available at Rose et al. (https://doi.org/10.5066/P9SC36I8).We ran the robust‐design model using Markov chain Monte Carlo (MCMC) sampling in JAGS Plummer,  accesseda Figure . The Bay33.1n = 91 individuals), followed by Site I (41), Site N (20), Site S (7), and Site P (4). Of the 163 San Francisco gartersnakes with growth data, 148 were caught twice and 15 were caught three times, resulting in 178 growth increments. The average interval between captures was 507.0 days (SD = 284.7), and the majority of growth measurements (126/178) were taken in consecutive years, with a further 41 growth increments separated by 2 years, and 11 increments separated by 3 or more years (max = 6 years). Most recaptured snakes (154/163) were >300 mm SVL at first capture, so minimal data were available to estimate growth of neonates.We captured 1090 individual San Francisco gartersnakes at the five study sites. The largest captured male measured 635 mm SVL, and the largest female measured 825 mm SVL. Of these 1090 San Francisco gartersnakes, 163 individuals  were captured and measured more than once, and data from these snakes were used to estimate San Francisco gartersnake growth. Most of the growth data came from Site C  captured at Site C and Site I. At Site C, 603 snakes  were captured a total of 829 times (including multiple captures within the same year). Of the 603 snakes captured at Site C, 510 were captured in only one year, 84 were captured in two years, and 9 were captured in 3 years. At Site I, 142 snakes  were captured a total of 262 times. Of the 142 snakes captured at Site I, 101 were captured in only one year, 35 were captured in two years, and 6 were captured in 3 years.p) was positively related to air temperature, and negatively related to relative humidity and day of year. Capture probability was lower if there was precipitation in the 24 h before trap‐checking than if there was no precipitation , but the difference between female snakes at the two sites was smaller . At Site I, mean p was higher for male snakes than for female snakes ; at Site C, the two sexes had nearly equal mean values for p , given average survey conditions and 52 days of sampling (the average survey period per year), was 0.48 (0.20–0.88) and 0.59 (0.29–0.94) for female and male snakes, respectively, at Site I, and 0.39 (0.21–0.69) for female and 0.40 (0.23–0.68) male snakes at Site C.Daily recapture probability (ϕ) at Site C exhibited a flat relationship with snake SVL for individuals between 300 mm to 550 mm, followed by a decline in survival for snakes between 550 mm and 700 mm SVL . At Site I, patterns for the posterior mean were similar, but sample sizes were smaller and uncertainty in ϕ was greater for all sizes. Mean annual survival for a snake of average SVL (463 mm) was higher for females than for males at Site C  and survival within our sample .Annual apparent survival  increased linearly with snake SVL  than females , there was a pattern of nearly equal survival for snakes between 300 and 550 mm SVL, and a decrease in survival for female snakes as SVL increased from 550 mm to 700 mm. Whether survival further decreased or plateaued for the largest San Francisco gartersnakes was unclear due to our small sample of snakes >700 mm SVL. Reduced survival for larger female San Francisco gartersnakes could be a sign of senescence  in Canada, with females from eastern populations reaching sexual maturity at a smaller size and producing larger litters of smaller neonates compared with western populations , and potentially greater uncertainty in the response variable where data are sparse. Overall, our recapture rates of San Francisco gartersnakes were low, with only 18% of snakes recaptured in at least one year following their initial capture and marking. This led to high uncertainty in our survival estimates, particularly for the youngest, smallest snakes and the largest snakes, which were rarely recaptured. For elusive snake species, complex statistical models alone cannot resolve the issue of low capture rates Steen, . IncreasReducing uncertainty in our estimates of survival for the smallest and largest San Francisco gartersnakes could require a combination of increased sampling effort, greater duration of sampling within a year, and complementary approaches to studying the demography of these snakes. For reptiles, early life stages are notoriously difficult to capture and recapture ; Data curation ; Formal analysis (lead); Methodology ; Software (lead); Writing – original draft (lead); Writing – review & editing . Richard Kim: Data curation ; Formal analysis (supporting); Investigation ; Methodology ; Software (supporting); Writing – original draft (supporting); Writing – review & editing . Elliot J Schoenig: Conceptualization (supporting); Data curation ; Investigation ; Writing – review & editing (supporting). Patrick C Lien: Conceptualization (supporting); Data curation ; Investigation ; Writing – review & editing (supporting). Brian J. Halstead: Conceptualization ; Formal analysis (supporting); Funding acquisition (lead); Methodology ; Project administration (lead); Supervision (lead); Writing – review & editing .Fig S1Click here for additional data file.Fig S2Click here for additional data file.Fig S3Click here for additional data file.Fig S4Click here for additional data file.Fig S5Click here for additional data file.Fig S6Click here for additional data file.Supplementary MaterialClick here for additional data file.