Editorial
Paediatric rheumatology: The importance of anamnesis and physical examination
Reumatología pediátrica: la importancia de la anamnesis y la exploración
J. de Inocencio Arocena
Unidad de Reumatología Pediátrica, Hospital Universitario 12 de Octubre, Madrid, Spain
Read
14324
Timeswas read the article
2728
Total PDF
11596
Total HTML
Share statistics
array:23 [ "pii" => "S2341287916000132" "issn" => "23412879" "doi" => "10.1016/j.anpede.2016.01.001" "estado" => "S300" "fechaPublicacion" => "2016-03-01" "aid" => "2032" "copyright" => "Asociación Española de Pediatría" "copyrightAnyo" => "2015" "documento" => "article" "crossmark" => 1 "subdocumento" => "sco" "cita" => "An Pediatr (Barc). 2016;84:131-2" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 2024 "formatos" => array:3 [ "EPUB" => 132 "HTML" => 1328 "PDF" => 564 ] ] "Traduccion" => array:1 [ "es" => array:19 [ "pii" => "S1695403316000023" "issn" => "16954033" "doi" => "10.1016/j.anpedi.2016.01.001" "estado" => "S300" "fechaPublicacion" => "2016-03-01" "aid" => "2032" "copyright" => "Asociación Española de Pediatría" "documento" => "article" "crossmark" => 1 "subdocumento" => "sco" "cita" => "An Pediatr (Barc). 2016;84:131-2" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 3608 "formatos" => array:3 [ "EPUB" => 107 "HTML" => 2587 "PDF" => 914 ] ] "es" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial</span>" "titulo" => "Reumatología pediátrica: la importancia de la anamnesis y la exploración" "tienePdf" => "es" "tieneTextoCompleto" => "es" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "131" "paginaFinal" => "132" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Paediatric rheumatology: The importance of anamnesis and physical examination" ] ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J. de Inocencio Arocena" "autores" => array:1 [ 0 => array:2 [ "nombre" => "J." "apellidos" => "de Inocencio Arocena" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2341287916000132" "doi" => "10.1016/j.anpede.2016.01.001" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341287916000132?idApp=UINPBA00005H" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1695403316000023?idApp=UINPBA00005H" "url" => "/16954033/0000008400000003/v1_201602260010/S1695403316000023/v1_201602260010/es/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S2341287916000077" "issn" => "23412879" "doi" => "10.1016/j.anpede.2015.06.016" "estado" => "S300" "fechaPublicacion" => "2016-03-01" "aid" => "1895" "copyright" => "Asociación Española de Pediatría" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "An Pediatr (Barc). 2016;84:133-8" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 1531 "formatos" => array:3 [ "EPUB" => 108 "HTML" => 1047 "PDF" => 376 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original Article</span>" "titulo" => "Food habits of the school population from La Mancha-Centro Health Area (Ciudad Real)" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "133" "paginaFinal" => "138" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Patrón dietético de la población escolar del Área La Mancha-Centro (Ciudad Real)" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1612 "Ancho" => 1474 "Tamanyo" => 98251 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Percentage of children that consumed protein-rich foods from animal sources throughout the day.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "A. González-González, M.P. Falero-Gallego, O. Redondo-González, A. Muñoz-Serrano" "autores" => array:4 [ 0 => array:2 [ "nombre" => "A." "apellidos" => "González-González" ] 1 => array:2 [ "nombre" => "M.P." "apellidos" => "Falero-Gallego" ] 2 => array:2 [ "nombre" => "O." "apellidos" => "Redondo-González" ] 3 => array:2 [ "nombre" => "A." "apellidos" => "Muñoz-Serrano" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S1695403315002362" "doi" => "10.1016/j.anpedi.2015.06.001" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1695403315002362?idApp=UINPBA00005H" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341287916000077?idApp=UINPBA00005H" "url" => "/23412879/0000008400000003/v1_201602260011/S2341287916000077/v1_201602260011/en/main.assets" ] "en" => array:14 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial</span>" "titulo" => "Paediatric rheumatology: The importance of anamnesis and physical examination" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "131" "paginaFinal" => "132" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "J. de Inocencio Arocena" "autores" => array:1 [ 0 => array:3 [ "nombre" => "J." "apellidos" => "de Inocencio Arocena" "email" => array:1 [ 0 => "jaime.inocencio@salud.madrid.org" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Unidad de Reumatología Pediátrica, Hospital Universitario 12 de Octubre, Madrid, Spain" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Reumatología pediátrica: la importancia de la anamnesis y la exploración" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Paediatric rheumatology (PR) is the medical speciality that focuses on inflammatory and non-inflammatory conditions of the musculoskeletal system in children and adolescents. It is one of the most recent paediatric specialities, and this may explain why it is still not as well known as it should to families and to many paediatricians. It would be difficult otherwise to explain the observation that whereas children with non-surgical heart, respiratory or kidney conditions are referred to the appropriate paediatric specialist, rather than to a cardiovascular, thoracic or urological surgeon, respectively, children with non-surgical, non-orthopaedic and non-traumatic conditions of the musculoskeletal system are commonly referred to an orthopaedic surgeon, even if paediatric rheumatology units are available in their area.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Paediatric rheumatology may be young, but it is well past puberty. An editorial published in 2014 discussed its origins,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> placing them in the 1950s, both in the USA and in Europe. The speciality was officially recognised in the US in 1992, with the first accreditation examination in paediatric rheumatology, the Subboard of Pediatric Rheumatology, conducted by the American Board of Pediatrics. The United Kingdom followed a similar process, and the Royal College of Paediatrics and Child Health recognised the speciality in 1996. As for Spain, the paediatric rheumatology section of the Spanish Association of Paediatrics was founded in 1995 and the Sociedad Española de Reumatología Pediátrica (Spanish Paediatric Rheumatology Society) in 1998.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The low priority given to teaching the musculoskeletal system compared with other organs and systems in undergraduate<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> and postgraduate courses also does not help to divulge PR. This inadequate training in musculoskeletal medicine could explain why examination of the locomotor system is rarely recorded in the clinical history of paediatric patients who are hospitalised<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> or assessed in the emergency services. Indeed, in emergency reports on patients receiving attention for non-traumatic limp or limb pain it is not uncommon to find an exhaustive assessment of their level of consciousness, capillary refill or absence of meningeal signs, while the exploration of their musculoskeletal system, often incomplete, is based on descriptions such as “there does not seem to be <span class="elsevierStyleItalic">much</span> pain”, “knee <span class="elsevierStyleItalic">somewhat</span> swollen” or “<span class="elsevierStyleItalic">apparently</span> without limitation of motion”. Such vague terms indicate the lack of confidence of the person conducting the assessment when examining the musculoskeletal system or, being more optimistic, their uncertainty about how to record such an examination.</p><p id="par0020" class="elsevierStylePara elsevierViewall">An additional difficulty in rheumatology is that the response pattern of the joint to insults is limited: either it is inflamed or it swells or not. Therefore full anamnesis and physical examination, important in all areas of medicine, are crucial in rheumatology. A monoarthritis of the ankle is a monoarthritis, but it can have many possible causes. Taking a good medical history can provide clues to its aetiology, even before confirming that the ankle is swollen.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The type of pain pattern, “inflammatory” when the pain increases at rest (morning stiffness) and improves with activity, or “mechanical” when the opposite is true, is as important as the date of onset, clinical course or functional limitations. A history of low-grade fever, macular rash and joint pain will raise suspicions of a viral infection, intense pain accompanied by fever and functional limitation will suggest a septic arthritis, history of a direct trauma will point towards a fracture or traumatic arthritis, the appearance of a purpuric rash on the lower extremities in a child without fever will guide us towards Schönlein–Henoch purpura, and so on. In this same clinical context a personal history of juvenile idiopathic arthritis, bleeding disorder or primary immunodeficiency changes the spectrum of possible aetiologies.</p><p id="par0030" class="elsevierStylePara elsevierViewall">It is also important to take the family history. Although there is not usually any history of rheumatic diseases in the family, with the exception of systemic lupus erythematosus or HLA-B27-associated diseases (spondyloarthropathies or inflammatory bowel disease), it is common for family members to have been diagnosed with other autoimmune diseases (thyroiditis, psoriasis, vitiligo).</p><p id="par0035" class="elsevierStylePara elsevierViewall">The information obtained in the medical history is supplemented by the examination, which must be complete and systematic, including the skin, skin appendages and mucous membranes, cardiopulmonary auscultation and assessment of enlarged organs and glands. Only after performing the complete general examination should one proceed to examine the joints.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The examination of the joints, crucial in rheumatology, is what finally confirms both the diagnostic impression suggested by the medical history (presence of arthritis or other findings) and the type (oligoarthritis or polyarthritis). This calls for technical skill and training that a large number of paediatricians, for various reasons, have not received, which explains the interest aroused by the practical joint examination workshops organised by various paediatric societies.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The limited expression of articular disease in paediatrics makes it essential to examine all the joints, because (1) paediatric inflammatory diseases tend to be asymmetrical and joint range of motion varies with age and sex, and therefore the best reference is the mobility of the contralateral joint; (2) inflammatory arthritis, unlike septic arthritis, does not usually associate pain or other external signs of inflammation (heat, redness), not being uncommon that subclinical arthritis alter the differential diagnosis (oligoarthritis versus monoarthritis); (3) the presence of referred pain; (4) the articular pattern of the disease (symmetrical or asymmetrical, involving large or small joints) may suggest the diagnosis; and (5) some findings are pathognomonic, including the dactylitis characteristic of psoriatic arthritis or the tarsitis characteristic of spondyloarthropathies/enthesitis-related arthritis.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Paediatric rheumatology is a recognised speciality in many countries, with clearly defined (1) which inflammatory and non-inflammatory conditions are within its scope; (2) what theoretical and practical training the professionals who practise it should receive; (3) what its specific techniques are, including arthrocentesis and joint injections, capillaroscopy and musculoskeletal ultrasound; and (4) which criteria must be met by the units where care is delivered.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Despite the fact that paediatric rheumatology fulfils the criteria for a <span class="elsevierStyleItalic">specific training area</span>, children with rheumatic diseases are still frequently cared for by physicians who, at best, have received minimal training in paediatric rheumatology or have spent a short-term elective in a specialised unit, but who, for organisational reasons, have had to undertake the treatment of these children. This situation is not confined to Spain, and it gave rise to an editorial in the Pediatric <span class="elsevierStyleItalic">Rheumatology</span> online journal which highlighted the unsuitability of both paediatricians and rheumatologists without specific training to practise this speciality.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">In Spain there are paediatric rheumatology units with properly trained staff who have the capacity and experience needed to treat patients with these conditions. In 2016 it is no longer acceptable for physicians without specific training, whether paediatricians or rheumatologists, to take on the task of treating these patients on a more or less occasional basis, at their own wish or on the instructions of their superiors. This was the standard scenario when paediatric specialities began to be developed in the 1970s, but it is far from being the appropriate model forty years later. As the above-mentioned editorial concluded,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> our patients deserve better.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-12-23" "fechaAceptado" => "2016-01-04" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: de Inocencio Arocena J. Reumatología pediátrica: la importancia de la anamnesis y la exploración. An Pediatr (Barc). 2016;84:131–132.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Reumatología pediátrica. Breve historia y situación de la especialidad en España" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "J. De Inocencio Arocena" 1 => "J. Antón López" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "Acta Rheumatol" "fecha" => "2014" "volumen" => "1" "paginaInicial" => "1" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0035" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The inadequacy of musculoskeletal knowledge in graduating medical students in the United Kingdom" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "S.S. Al-Nammari" 1 => "I. Pengas" 2 => "V. Asopa" 3 => "A. Jawad" 4 => "M. Rafferty" 5 => "M. Ramachandran" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "J Bone Jt Surg Am" "fecha" => "2015" "volumen" => "97" "paginaInicial" => "e36" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0040" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A disjointed effort: paediatric musculoskeletal examination" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "I. Gill" 1 => "F. Sharif" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/archdischild.2011.301180" "Revista" => array:6 [ "tituloSerie" => "Arch Dis Child" "fecha" => "2012" "volumen" => "97" "paginaInicial" => "641" "paginaFinal" => "643" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22307987" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0045" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "pGALS – paediatric Gait Arms Legs and Spine: a simple examination of the musculoskeletal system" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "H.E. Foster" 1 => "S. Jandial" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1186/1546-0096-11-44" "Revista" => array:5 [ "tituloSerie" => "Pediatr Rheumatol Online J" "fecha" => "2013" "volumen" => "11" "paginaInicial" => "44" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24219838" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Why should pediatric rheumatology be recognized as a separate subspecialty: an open letter to medical councils and government agencies" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "C.H. Spencer" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "Pediatr Rheumatol Online J" "fecha" => "2007" "volumen" => "21" "paginaInicial" => "21" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23412879/0000008400000003/v1_201602260011/S2341287916000132/v1_201602260011/en/main.assets" "Apartado" => array:4 [ "identificador" => "25501" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Editorial" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/23412879/0000008400000003/v1_201602260011/S2341287916000132/v1_201602260011/en/main.pdf?idApp=UINPBA00005H&text.app=https://analesdepediatria.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341287916000132?idApp=UINPBA00005H" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 68 | 16 | 84 |
| 2024 October | 515 | 43 | 558 |
| 2024 September | 460 | 53 | 513 |
| 2024 August | 378 | 83 | 461 |
| 2024 July | 457 | 36 | 493 |
| 2024 June | 300 | 34 | 334 |
| 2024 May | 268 | 45 | 313 |
| 2024 April | 289 | 40 | 329 |
| 2024 March | 289 | 47 | 336 |
| 2024 February | 273 | 46 | 319 |
| 2024 January | 463 | 32 | 495 |
| 2023 December | 277 | 17 | 294 |
| 2023 November | 293 | 43 | 336 |
| 2023 October | 371 | 39 | 410 |
| 2023 September | 284 | 30 | 314 |
| 2023 August | 269 | 28 | 297 |
| 2023 July | 292 | 42 | 334 |
| 2023 June | 259 | 44 | 303 |
| 2023 May | 263 | 23 | 286 |
| 2023 April | 167 | 24 | 191 |
| 2023 March | 212 | 32 | 244 |
| 2023 February | 198 | 15 | 213 |
| 2023 January | 147 | 30 | 177 |
| 2022 December | 160 | 24 | 184 |
| 2022 November | 241 | 39 | 280 |
| 2022 October | 218 | 52 | 270 |
| 2022 September | 274 | 36 | 310 |
| 2022 August | 154 | 48 | 202 |
| 2022 July | 113 | 40 | 153 |
| 2022 June | 77 | 26 | 103 |
| 2022 May | 108 | 60 | 168 |
| 2022 April | 113 | 44 | 157 |
| 2022 March | 113 | 46 | 159 |
| 2022 February | 103 | 31 | 134 |
| 2022 January | 108 | 49 | 157 |
| 2021 December | 118 | 53 | 171 |
| 2021 November | 110 | 67 | 177 |
| 2021 October | 121 | 66 | 187 |
| 2021 September | 97 | 40 | 137 |
| 2021 August | 84 | 40 | 124 |
| 2021 July | 81 | 40 | 121 |
| 2021 June | 80 | 53 | 133 |
| 2021 May | 85 | 42 | 127 |
| 2021 April | 147 | 90 | 237 |
| 2021 March | 143 | 49 | 192 |
| 2021 February | 71 | 18 | 89 |
| 2021 January | 73 | 28 | 101 |
| 2020 December | 60 | 19 | 79 |
| 2020 November | 45 | 17 | 62 |
| 2020 October | 54 | 35 | 89 |
| 2020 September | 42 | 25 | 67 |
| 2020 August | 56 | 17 | 73 |
| 2020 July | 45 | 17 | 62 |
| 2020 June | 35 | 21 | 56 |
| 2020 May | 52 | 19 | 71 |
| 2020 April | 28 | 25 | 53 |
| 2020 March | 47 | 34 | 81 |
| 2020 February | 53 | 17 | 70 |
| 2020 January | 38 | 21 | 59 |
| 2019 December | 60 | 31 | 91 |
| 2019 November | 45 | 16 | 61 |
| 2019 October | 58 | 19 | 77 |
| 2019 September | 27 | 18 | 45 |
| 2019 August | 31 | 30 | 61 |
| 2019 July | 19 | 23 | 42 |
| 2019 June | 43 | 34 | 77 |
| 2019 May | 66 | 54 | 120 |
| 2019 April | 87 | 27 | 114 |
| 2019 March | 45 | 19 | 64 |
| 2019 February | 41 | 23 | 64 |
| 2019 January | 29 | 16 | 45 |
| 2018 December | 38 | 25 | 63 |
| 2018 November | 50 | 37 | 87 |
| 2018 October | 83 | 23 | 106 |
| 2018 September | 45 | 21 | 66 |
| 2018 August | 2 | 0 | 2 |
| 2018 July | 2 | 0 | 2 |
| 2018 June | 3 | 0 | 3 |
| 2018 May | 2 | 0 | 2 |
| 2018 April | 35 | 0 | 35 |
| 2018 March | 27 | 0 | 27 |
| 2018 February | 10 | 0 | 10 |
| 2018 January | 22 | 0 | 22 |
| 2017 December | 14 | 0 | 14 |
| 2017 November | 13 | 0 | 13 |
| 2017 October | 14 | 0 | 14 |
| 2017 September | 18 | 0 | 18 |
| 2017 August | 17 | 0 | 17 |
| 2017 July | 17 | 0 | 17 |
| 2017 June | 30 | 15 | 45 |
| 2017 May | 33 | 15 | 48 |
| 2017 April | 31 | 23 | 54 |
| 2017 March | 17 | 10 | 27 |
| 2017 February | 13 | 9 | 22 |
| 2017 January | 7 | 5 | 12 |
| 2016 December | 32 | 12 | 44 |
| 2016 November | 27 | 10 | 37 |
| 2016 October | 28 | 9 | 37 |
| 2016 September | 32 | 7 | 39 |
| 2016 August | 33 | 4 | 37 |
| 2016 July | 8 | 3 | 11 |
| 2016 June | 1 | 0 | 1 |
| 2016 March | 2 | 0 | 2 |
Show all
