Scientific Letter
Are anti-TNF-α agents really useful in systemic vasculitis? Experience in polyarteritis nodosa
¿Son realmente útiles los anti-TNFα en vasculitis sistémicas? Experiencia en panarteritis nodosa
E. Núñez Cuadrosa,
, R. Galindo Zavalaa, G. Díaz Cordovés-Regoa, A. Vera Casañob, A.L. Urda Cardonac
Corresponding author
a Unidad de Reumatología pediátrica, Unidad de Gestión Clínica de Pediatría, Hospital Materno-Infantil, Hospital Regional Universitario de Málaga, Málaga, Spain
b Unidad de Dermatología pediátrica, Hospital Materno-Infantil, Hospital Regional Universitario de Málaga, Málaga, Spain
c Unidad de Gestión Clínica de Pediatría, Hospital Materno-Infantil, Hospital Regional Universitario de Málaga, Málaga, Spain
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"apellidos" => "Urda Cardona" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Unidad de Reumatología pediátrica, Unidad de Gestión Clínica de Pediatría, Hospital Materno-Infantil, Hospital Regional Universitario de Málaga, Málaga, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Unidad de Dermatología pediátrica, Hospital Materno-Infantil, Hospital Regional Universitario de Málaga, Málaga, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Unidad de Gestión Clínica de Pediatría, Hospital Materno-Infantil, Hospital Regional Universitario de Málaga, Málaga, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "¿Son realmente útiles los anti-TNFα en vasculitis sistémicas? Experiencia en panarteritis nodosa" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 758 "Ancho" => 1399 "Tamanyo" => 144499 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Superior mesenteric artery (SMA) arteritis assessed by ultrasound (case 2). (A) Sagittal view: hyperechoic halo around the SMA due to thickening of its wall. 1: liver parenchyma; 2: spleno-portal axis; 3: inferior vena cava; 4: aorta; 5: SMA. (B) Coronal view: 2<span class="elsevierStyleHsp" style=""></span>mm thickening of SMA from its origin in the aorta to its bifurcation (4.3<span class="elsevierStyleHsp" style=""></span>cm).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Polyarteritis nodosa (PAN) is a rare vasculitis that affects small and medium vessels. Its clinical manifestations are varied, ranging from mild skin changes to multisystemic forms.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> New diagnostic criteria were established in 2008,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> with diagnosis requiring histopathological abnormalities (necrotising vasculitis) or angiographic abnormalities (aneurism, stenosis or occlusion) with at least one of the following:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1.</span><p id="par0010" class="elsevierStylePara elsevierViewall">Skin involvement: <span class="elsevierStyleItalic">livedo reticularis</span>, subcutaneous nodules, cutaneous infarction with ulcerations or minor ischaemic changes.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2.</span><p id="par0015" class="elsevierStylePara elsevierViewall">Myalgia.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3.</span><p id="par0020" class="elsevierStylePara elsevierViewall">Arterial hypertension (AHT): arterial systolic/diastolic pressure above 95th percentile for height.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4.</span><p id="par0025" class="elsevierStylePara elsevierViewall">Peripheral sensitive neuropathy or mononeuritis multiplex of motor nerves.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5.</span><p id="par0030" class="elsevierStylePara elsevierViewall">Renal involvement: proteinuria, haematuria or kidney function impairment.</p></li></ul></p><p id="par0035" class="elsevierStylePara elsevierViewall">Regarding the treatment randomised controlled clinical trials have not been conducted in the paediatric population. Conventional treatment includes systemic corticosteroids and cyclophosphamide for induction therapy and azathioprine for maintenance, but the literature has reported cases of patients refractory to treatment that have had good outcomes with mycophenolate, infliximab or rituximab.</p><p id="par0040" class="elsevierStylePara elsevierViewall">We describe the cases of two girls suffering from refractory PAN that were treated with infliximab.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Case 1</span><p id="par0045" class="elsevierStylePara elsevierViewall">Girl aged 6 years with a 15-day history of artralgia, ankle arthritis and purpuric lesions (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A–C). Laboratory findings included anaemia and thrombocytosis (haemoglobin [Hb], 11<span class="elsevierStyleHsp" style=""></span>g/L; platelets, 495<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>/L); C reactive protein (CRP), 236<span class="elsevierStyleHsp" style=""></span>mg/L; erythrocyte sedimentation rate (ESR), 88<span class="elsevierStyleHsp" style=""></span>mm; and tested negative for anti-neutrophil cytoplasmic antibodies (ANCAs). The skin biopsy results were compatible with PAN. The patient's condition worsened, as she developed fever, arthritis in knees and elbows, subcutaneous nodules (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>D) and arterial hypertension, without renal involvement. Although her skin symptoms improved with prednisone and subcutaneous methotrexate in doses of 15<span class="elsevierStyleHsp" style=""></span>mg/m<span class="elsevierStyleSup">2</span>/week, after 10 weeks the rest of the symptoms remained. She was treated consecutively with monthly immunoglobulin therapy, subcutaneous etanercept (0.8<span class="elsevierStyleHsp" style=""></span>mg/kg/week), intravenous cyclophosphamide (500<span class="elsevierStyleHsp" style=""></span>mg/m<span class="elsevierStyleSup">2</span>/month) and oral azathioprine (2<span class="elsevierStyleHsp" style=""></span>mg/kg/day). Each treatment regimen was maintained for two months and well tolerated by the patient, and discontinued due to ineffectiveness. After one year, treatment with infliximab was initiated (dosage, 5<span class="elsevierStyleHsp" style=""></span>mg/kg at weeks 0, 2 and 6 and subsequently every 8 weeks), with a decrease in the Paediatric Vasculitis Assessment Score (PVAS) from 8 to 0 in one month, which allowed the discontinuation of prednisone at 4 months. From this point, the patient remained asymptomatic and without adverse effects attributable to the treatment. Treatment with infliximab was discontinued after three years.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Case 2</span><p id="par0050" class="elsevierStylePara elsevierViewall">A 5-year-old girl of Moroccan descent, presenting with fever and abdominal pain of one month's duration, whey-faced, anaemia (Hb: 8.1<span class="elsevierStyleHsp" style=""></span>g/L), thrombocytosis (platelets, 582<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>/L); CRP, 178<span class="elsevierStyleHsp" style=""></span>mg/L; ESR, 101<span class="elsevierStyleHsp" style=""></span>mm; the patient tested negative for ANCAs. Abdominal ultrasound showed a thickening of the superior mesenteric artery wall with a normal but narrowed lumen compatible with arteritis (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>), confirmed by computed tomography angiography. The screening for infectious diseases was negative and other vascular diseases were ruled out. The symptoms resolved spontaneously in one week. Four months later, the patient had a similar episode, familial Mediterranean fever was excluded and treatment with prednisone was initiated. Six months later the patient developed painful erythematous nodules in the lower limbs, the biopsy of which confirmed the presence of necrotising vasculitis. Although subcutaneous methotrexate was added to the regimen (15<span class="elsevierStyleHsp" style=""></span>mg/m<span class="elsevierStyleSup">2</span>/week), the patient had two more episodes within 12 months, so treatment with oral azathioprine was initiated (2<span class="elsevierStyleHsp" style=""></span>mg/kg/week), to which the patient responded favourably and without adverse effects. After eight months without prednisone, she had several flares of disease, so therapy was switched to intravenous infliximab (5<span class="elsevierStyleHsp" style=""></span>mg/kg) given at weeks 0, 2, 6 and subsequently every 8 weeks. The PVAS decreased from 5 to 0 in one month. At present, after 24 months of treatment, the patient has only experienced post-infusion headaches and two mild episodes that resolved with prednisone.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Polyarteritis nodosa is rare in childhood, and its incidence peaks at 10 years. The most common sites of involvement are the skin, joints, peripheral nerves, gastrointestinal tract and kidneys.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> Gastrointestinal involvement, while reported in 23–60% of patients<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> in isolation or at presentation (case 2), is rare.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Diagnosis requires compatible biopsy results,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> so it can be delayed in patients with lesions that are hard to access (case 2). Angiography is an alternative option in these patients, although it was not performed in the case presented here.</p><p id="par0065" class="elsevierStylePara elsevierViewall">The lack of clinical trials and the variability of clinical manifestations make it difficult to choose a treatment. While anti-TNFα agents have revolutionised the treatment of various autoimmune diseases, their efficacy in the treatment of vasculitis has not been demonstrated.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> The largest case series in the paediatric age group corresponds to a study by Eleftheriou et al.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a> that comprised 25 patients with vasculitis (11 with PAN). Of the PAN patients, 8 received infliximab, and their mean vasculitis activity score decreased from 8 to 3. The PVAS<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a> scale has been recently validated for the routine assessment of disease outcome and response to treatment.</p><p id="par0070" class="elsevierStylePara elsevierViewall">A new autoinflammatory syndrome caused by a PAN-like vasculopathy has been recently described that is characterised by early infarctions and caused by mutations in the gene which encodes adenosine deaminase 2 (ADA2), in which treatment with anti-TNF agents was shown to be effective. Specific genetic testing has yet to be performed in our two patients to rule out this disease, which would account for their excellent response to infliximab.</p><p id="par0075" class="elsevierStylePara elsevierViewall">The prognosis of PAN depends on the degree of visceral involvement, but overall it is better in children than in adults, with mortality ranging between 1.1% and 10%.</p><p id="par0080" class="elsevierStylePara elsevierViewall">To conclude, while there is little data on the efficacy of infliximab in children, and multicentre studies still need to be conducted, infliximab can be used as an alternative therapy in refractory cases.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Case 1" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Case 2" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Núñez Cuadros E, Galindo Zavala R, Díaz Cordovés-Rego G, Vera Casaño V, Urda Cardona AL. ¿Son realmente útiles los anti-tnfα en vasculitis sistémicas? Experiencia en panarteritis nodosa. An Pediatr (Barc). 2015;83:350–352.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1135 "Ancho" => 1500 "Tamanyo" => 174869 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Skin lesions in case 1. (A) Painful swelling in left ankle with purpuric lesions in the anterior surface. (B) <span class="elsevierStyleItalic">Livedo reticularis</span> with haemorrhagic suffusion in the external lateral surface of the right ankle. (C) Isolated purpuric lesions in the buttocks. (D) Skin nodule in the fifth finger of the right hand.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 758 "Ancho" => 1399 "Tamanyo" => 144499 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Superior mesenteric artery (SMA) arteritis assessed by ultrasound (case 2). (A) Sagittal view: hyperechoic halo around the SMA due to thickening of its wall. 1: liver parenchyma; 2: spleno-portal axis; 3: inferior vena cava; 4: aorta; 5: SMA. (B) Coronal view: 2<span class="elsevierStyleHsp" style=""></span>mm thickening of SMA from its origin in the aorta to its bifurcation (4.3<span class="elsevierStyleHsp" style=""></span>cm).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Diagnosis and classification of polyarteritis nodosa" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "J. Hernández-Rodríguez" 1 => "M.A. Alba" 2 => "S. Prieto-González" 3 => "M.C. Cid" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jaut.2014.01.029" "Revista" => array:6 [ "tituloSerie" => "J Autoimmun" "fecha" => "2014" "volumen" => "48" "paginaInicial" => "84" "paginaFinal" => "89" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24485157" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0040" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "EULAR/PRINTO/PRES criteria for Henoch–Schönlein purpura, childhood polyarteritis nodosa, childhood Wegener granulomatosis and childhood Takayasu arteritis: Ankara 2008 part II: final classification criteria" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "S. Ozen" 1 => "A. Pistorio" 2 => "S.M. Iusan" 3 => "A. Bakkaloglu" 4 => "T. Herlin" 5 => "R.P. Brik" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/ard.2009.116657" "Revista" => array:6 [ "tituloSerie" => "Ann Rheum Dis" "fecha" => "2010" "volumen" => "69" "paginaInicial" => "798" "paginaFinal" => "806" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20413568" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0045" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Abdominal manifestations of polyarteritis nodosa demonstrated with CT" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "I. Adaletli" 1 => "S. Ozpeynici Kurungoglu" 2 => "L. Sever" 3 => "N. Arisoy" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00247-009-1466-4" "Revista" => array:6 [ "tituloSerie" => "Pediatr Radiol" "fecha" => "2010" "volumen" => "40" "paginaInicial" => "766" "paginaFinal" => "769" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20151119" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0050" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Anti TNF-alpha therapy and systemic vasculitis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "P.A. Jarrot" 1 => "G. Kaplanski" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "Mediators Inflamm" "fecha" => "2014" "volumen" => "27" "paginaInicial" => "493593" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0055" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Biologic therapy in primary systemic vasculitis of the young" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "D. Eleftheriou" 1 => "M. Melo" 2 => "S.D. Marks" 3 => "K. Tullus" 4 => "J. Sills" 5 => "G. Cleary" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Rheumatology (Oxf)" "fecha" => "2009" "volumen" => "48" "paginaInicial" => "978" "paginaFinal" => "986" ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0060" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Disease activity in paediatric vasculitis: development of a generic assessment tool – PVAS" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "P. Dolezalova" 1 => "P.A. Brogan" 2 => "S. Özen" 3 => "S. Benseler" 4 => "J. Anton" 5 => "J. Brunner" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "Pediatr Rheumatol Online J" "fecha" => "2011" "volumen" => "9" "paginaInicial" => "P92" ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:3 [ "titulo" => "Acknowledgments" "texto" => "<p id="par0085" class="elsevierStylePara elsevierViewall">The authors thanked Dr. Purificación Moreno, who was in charge of the initial followup of these patients.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/23412879/0000008300000005/v1_201512040119/S2341287915002008/v1_201512040119/en/main.assets" "Apartado" => array:4 [ "identificador" => "38181" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Scientific letters" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23412879/0000008300000005/v1_201512040119/S2341287915002008/v1_201512040119/en/main.pdf?idApp=UINPBA00005H&text.app=https://analesdepediatria.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341287915002008?idApp=UINPBA00005H" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 2 | 11 | 13 |
| 2024 October | 47 | 39 | 86 |
| 2024 September | 48 | 31 | 79 |
| 2024 August | 57 | 68 | 125 |
| 2024 July | 57 | 25 | 82 |
| 2024 June | 69 | 34 | 103 |
| 2024 May | 62 | 29 | 91 |
| 2024 April | 72 | 38 | 110 |
| 2024 March | 81 | 22 | 103 |
| 2024 February | 97 | 28 | 125 |
| 2024 January | 87 | 35 | 122 |
| 2023 December | 80 | 19 | 99 |
| 2023 November | 82 | 45 | 127 |
| 2023 October | 84 | 52 | 136 |
| 2023 September | 84 | 25 | 109 |
| 2023 August | 83 | 19 | 102 |
| 2023 July | 102 | 33 | 135 |
| 2023 June | 92 | 30 | 122 |
| 2023 May | 128 | 34 | 162 |
| 2023 April | 46 | 20 | 66 |
| 2023 March | 92 | 24 | 116 |
| 2023 February | 77 | 14 | 91 |
| 2023 January | 72 | 27 | 99 |
| 2022 December | 63 | 47 | 110 |
| 2022 November | 88 | 35 | 123 |
| 2022 October | 95 | 46 | 141 |
| 2022 September | 92 | 37 | 129 |
| 2022 August | 90 | 59 | 149 |
| 2022 July | 95 | 44 | 139 |
| 2022 June | 58 | 38 | 96 |
| 2022 May | 83 | 37 | 120 |
| 2022 April | 77 | 37 | 114 |
| 2022 March | 112 | 59 | 171 |
| 2022 February | 84 | 33 | 117 |
| 2022 January | 117 | 54 | 171 |
| 2021 December | 87 | 40 | 127 |
| 2021 November | 83 | 60 | 143 |
| 2021 October | 100 | 64 | 164 |
| 2021 September | 54 | 40 | 94 |
| 2021 August | 57 | 34 | 91 |
| 2021 July | 59 | 34 | 93 |
| 2021 June | 58 | 33 | 91 |
| 2021 May | 96 | 33 | 129 |
| 2021 April | 157 | 61 | 218 |
| 2021 March | 77 | 25 | 102 |
| 2021 February | 57 | 27 | 84 |
| 2021 January | 57 | 18 | 75 |
| 2020 December | 56 | 22 | 78 |
| 2020 November | 83 | 22 | 105 |
| 2020 October | 83 | 14 | 97 |
| 2020 September | 66 | 32 | 98 |
| 2020 August | 53 | 30 | 83 |
| 2020 July | 77 | 44 | 121 |
| 2020 June | 60 | 28 | 88 |
| 2020 May | 75 | 24 | 99 |
| 2020 April | 46 | 21 | 67 |
| 2020 March | 52 | 22 | 74 |
| 2020 February | 91 | 9 | 100 |
| 2020 January | 64 | 18 | 82 |
| 2019 December | 61 | 30 | 91 |
| 2019 November | 55 | 17 | 72 |
| 2019 October | 34 | 20 | 54 |
| 2019 September | 52 | 14 | 66 |
| 2019 August | 54 | 17 | 71 |
| 2019 July | 50 | 24 | 74 |
| 2019 June | 53 | 21 | 74 |
| 2019 May | 83 | 35 | 118 |
| 2019 April | 120 | 77 | 197 |
| 2019 March | 59 | 19 | 78 |
| 2019 February | 52 | 13 | 65 |
| 2019 January | 59 | 19 | 78 |
| 2018 December | 61 | 34 | 95 |
| 2018 November | 137 | 34 | 171 |
| 2018 October | 144 | 17 | 161 |
| 2018 September | 68 | 15 | 83 |
| 2018 August | 2 | 0 | 2 |
| 2018 July | 1 | 0 | 1 |
| 2018 June | 2 | 0 | 2 |
| 2018 May | 7 | 0 | 7 |
| 2018 April | 62 | 0 | 62 |
| 2018 March | 40 | 0 | 40 |
| 2018 February | 18 | 0 | 18 |
| 2018 January | 37 | 0 | 37 |
| 2017 December | 41 | 0 | 41 |
| 2017 November | 19 | 0 | 19 |
| 2017 October | 48 | 0 | 48 |
| 2017 September | 23 | 0 | 23 |
| 2017 August | 31 | 0 | 31 |
| 2017 July | 29 | 0 | 29 |
| 2017 June | 23 | 11 | 34 |
| 2017 May | 64 | 10 | 74 |
| 2017 April | 19 | 4 | 23 |
| 2017 March | 21 | 4 | 25 |
| 2017 February | 26 | 5 | 31 |
| 2017 January | 9 | 8 | 17 |
| 2016 December | 25 | 10 | 35 |
| 2016 November | 26 | 13 | 39 |
| 2016 October | 40 | 5 | 45 |
| 2016 September | 80 | 3 | 83 |
| 2016 August | 38 | 4 | 42 |
| 2016 July | 15 | 6 | 21 |
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