Scientific Letter
Primary lymphoedema outside the neonatal period
Linfedema primario fuera del periodo neonatal
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"estefania.barral@salud.madrid.org" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "María" "apellidos" => "Soriano-Ramos" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Maria Rosa" "apellidos" => "Pavo García" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "Lucía" "apellidos" => "Llorente Otones" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 4 => array:3 [ "nombre" => "Jaime" "apellidos" => "de Inocencio Arocena" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Centro de Salud García Noblejas, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Unidad de Reumatología Pediátrica, Hospital Universitario 12 de Octubre, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Hospital de Fuenlabrada, Fuenlabrada, Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Linfedema primario fuera del periodo neonatal" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1898 "Ancho" => 702 "Tamanyo" => 125357 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Lymphoscintigraphy image (anterior view) showing delayed lymph drainage in the left lower extremity, with persisting radioactive tracer activity at the level of the popliteal lymph nodes (arrow), compatible with primary lymphoedema.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Primary lymphoedema is a rare disease, usually with onset in prepubertal girls, and its prevalence ranges between 1/6000 and 1/100<span class="elsevierStyleHsp" style=""></span>000 in the population.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">It is caused by abnormal angiogenesis during embryonic development, usually due to mutations in genes responsible for it.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> In up to 80% of cases it manifests in the lower extremities, although it can involve the upper extremities, face and genitals. Focal lymphatic abnormalities lead to an accumulation of lymph that, when sustained, stimulates fibrosis and produces a localised, chronic and progressive oedema. In the early stages, the oedema is not associated with pain, warmth, erythema or functional impairment.</p><p id="par0015" class="elsevierStylePara elsevierViewall">In 1934, Allen classified primary lymphoedema based on the age of onset into congenital, praecox and tarda.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> Recently, Connell et al.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> proposed a new classification that took into account the different clinical presentations and known mutations, giving rise to a complex diagnostic algorithm that encompassed 26 possible diagnoses.</p><p id="par0020" class="elsevierStylePara elsevierViewall">We present the cases of six patients with primary lymphoedema diagnosed in our centre, whose clinical and demographic characteristics are summarised in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. Most of the patients were female, and the age of onset ranged between 5 and 12 years (median, 10.5). None of the patients had associated malformations or a relevant personal history. Fifty percent had a family history of lymphoedema. The time elapsed from the onset of symptoms to diagnosis ranged between 3 months and 4.3 years (median, 9 months). Patients were referred to a specialist to rule out arthritis as the cause of the swelling of the hand or dorsum of the foot. None of the patients reported arthralgia, morning stiffness or functional impairment, and, as is characteristic of lymphoedema, the swelling improved with night rest and worsened with standing. Physical examination found soft tissue oedema in all patients, with no abnormalities in the joints. The results of the blood panel (blood counts, acute phase reactants, TSH, albumin, total protein) and the routine urinalysis were also normal.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Most of the patients had been assessed previously in other departments of the hospital (traumatology, plastic surgery, dermatology, emergency), and underwent different imaging tests (conventional ultrasound, Doppler ultrasound, MRI) that revealed the presence of oedema in the subcutaneous tissue.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The gold standard for the diagnosis of lymphoedema is lymphoscintigraphy, which assesses the velocity of the migration of a radioactive tracer through the lymphatic vessels. The tracer is injected in the dermis of an interdigital web space and tracked by a scintillation camera. This is a minimally invasive and reproducible test that can be performed in children. In patients with primary lymphoedema, this method detects absent or delayed tracer migration<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). In a study conducted in 107 patients with primary lymphoedema, Kinmonth et al. presented the structural abnormalities that could be detected by lymphoscintigraphy and classified them into three categories: aplasia (absence of lymphatic vessels), hypoplasia (small number or size of lymphatic vessels) and hyperplasia (tortuous lymphatic vessels).<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> All our patients presented this type of abnormalities in the lymphatic system, and were classified according to the scheme proposed by Connell et al.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> Other imaging techniques that have been used in more recent studies but have not been widely introduced in clinical practice include indocyanine green lymphography,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> which exposes the patient to radiation, and magnetic resonance lymphangiography using gadobenate dimeglumine as the contrast agent,<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a> which does not involve exposure to radiation and can obtain dynamic sequences, both of which are as efficacious as lymphoscintigraphy in detecting abnormalities in lymph circulation.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">The management of primary lymphoedema is mainly conservative, with the first line treatment consisting of manual lymph drainage or compression therapy. Avoidance of prolonged standing, the use compression stockings, and regular physical activity combined with adequate skin care usually suffice in most cases.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> These measures were implemented in all of our patients and succeeded in controlling the lymphoedema. The prognosis of lymphoedema is good, as the disease stabilises in half of the patients (57%),<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a> although surgical measures are available for the most severe cases.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Swelling of the extremities in the paediatric age group requires a broad differential diagnosis including traumatic injury, cellulitis, arthritis, venous insufficiency, deep vein thrombosis and primary lymphoedema.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> Knowledge of this condition and its characteristics—painless swelling in the extremities that changes with posture and is not associated with articular pain or limited range of motion—can prevent diagnostic delays as well as unnecessary referrals and diagnostic tests.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Barral Mena E, Soriano-Ramos M, Pavo García MR, Llorente Otones L, de Inocencio Arocena J. Linfedema primario fuera del periodo neonatal. An Pediatr (Barc). 2016;85:47–49.</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" => 1898 "Ancho" => 702 "Tamanyo" => 125357 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Lymphoscintigraphy image (anterior view) showing delayed lymph drainage in the left lower extremity, with persisting radioactive tracer activity at the level of the popliteal lymph nodes (arrow), compatible with primary lymphoedema.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">FH: family history; F: female; (R): right; (L): left; LE: lower extremity; UE: upper extremity; APRs: acute phase reactants; MRI: magnetic resonance imaging; SCT: subcutaneous tissue; TSH: thyroid-stimulating hormone; M: male.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sex \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Family/personal history \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Age of onset (years) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Time to diagnosis (months) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Lymphoedema location \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Blood tests (WBC, APRs, TSH, proteins) and urinalysis \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Lymphoscintigraphy \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Other imaging tests \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Final diagnosis based on Connell et al.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> classification \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Left foot and ankle \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Normal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Delayed tracer elimination in (L)LE \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Ultrasound and MRI showing SCT oedema \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Unilateral late onset primary lymphoedema \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">52 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Left foot \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Normal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Delayed tracer elimination in (L)LE \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Normal X-ray, MRI showing SCT oedema \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Unilateral late onset primary lymphoedema \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">FH of mother with lymphoedema of the LEs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Feet and ankles \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Normal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Delayed tracer elimination in (L)LE \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Normal abdominal ultrasound \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Primary lymphoedema (Meige disease) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Left foot and ankle \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Normal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Absent visualisation of lymph drainage in (L)LE due to lymphatic system aplasia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Normal X-ray, normal Doppler ultrasound, conventional ultrasound showing SCT oedema \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Unilateral late onset primary lymphoedema \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">FH of aunt and first-degree female cousin on the mother's side with oedema of the LEs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Right foot and left hand \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Normal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Hypoplasia and lymphatic vascular insufficiency in (L)LE and (R)LE lymph node chains \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Ultrasound showing SCT oedema \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Late onset multisegmental lymphoedema \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">FH of mother and maternal first-degree female cousin with oedema of the LEs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Right arm and forearm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Normal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Increased diameter of lymphatic vessels in (R)LE \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">MRI showing SCT oedema \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Late onset multisegmental lymphoedema \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1112138.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Demographic, clinical and diagnostic characteristics of patients with a primary lymphoedema diagnosis.</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" => "Primary lymphedema: clinical features and management in 138 pediatric patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "C.C. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 10 | 9 | 19 |
| 2024 October | 45 | 37 | 82 |
| 2024 September | 55 | 36 | 91 |
| 2024 August | 63 | 69 | 132 |
| 2024 July | 45 | 31 | 76 |
| 2024 June | 47 | 29 | 76 |
| 2024 May | 52 | 47 | 99 |
| 2024 April | 41 | 33 | 74 |
| 2024 March | 35 | 22 | 57 |
| 2024 February | 41 | 32 | 73 |
| 2024 January | 45 | 28 | 73 |
| 2023 December | 30 | 26 | 56 |
| 2023 November | 41 | 25 | 66 |
| 2023 October | 47 | 34 | 81 |
| 2023 September | 28 | 17 | 45 |
| 2023 August | 35 | 21 | 56 |
| 2023 July | 43 | 32 | 75 |
| 2023 June | 41 | 23 | 64 |
| 2023 May | 44 | 21 | 65 |
| 2023 April | 38 | 16 | 54 |
| 2023 March | 50 | 22 | 72 |
| 2023 February | 42 | 14 | 56 |
| 2023 January | 16 | 23 | 39 |
| 2022 December | 54 | 22 | 76 |
| 2022 November | 54 | 45 | 99 |
| 2022 October | 56 | 58 | 114 |
| 2022 September | 34 | 28 | 62 |
| 2022 August | 32 | 38 | 70 |
| 2022 July | 24 | 43 | 67 |
| 2022 June | 30 | 37 | 67 |
| 2022 May | 21 | 25 | 46 |
| 2022 April | 41 | 30 | 71 |
| 2022 March | 60 | 35 | 95 |
| 2022 February | 35 | 26 | 61 |
| 2022 January | 51 | 24 | 75 |
| 2021 December | 50 | 35 | 85 |
| 2021 November | 39 | 47 | 86 |
| 2021 October | 64 | 78 | 142 |
| 2021 September | 43 | 54 | 97 |
| 2021 August | 39 | 40 | 79 |
| 2021 July | 36 | 17 | 53 |
| 2021 June | 42 | 34 | 76 |
| 2021 May | 44 | 37 | 81 |
| 2021 April | 72 | 42 | 114 |
| 2021 March | 50 | 45 | 95 |
| 2021 February | 47 | 12 | 59 |
| 2021 January | 51 | 22 | 73 |
| 2020 December | 43 | 23 | 66 |
| 2020 November | 42 | 17 | 59 |
| 2020 October | 32 | 19 | 51 |
| 2020 September | 45 | 23 | 68 |
| 2020 August | 26 | 8 | 34 |
| 2020 July | 25 | 18 | 43 |
| 2020 June | 42 | 16 | 58 |
| 2020 May | 45 | 14 | 59 |
| 2020 April | 32 | 13 | 45 |
| 2020 March | 34 | 18 | 52 |
| 2020 February | 28 | 10 | 38 |
| 2020 January | 24 | 19 | 43 |
| 2019 December | 50 | 28 | 78 |
| 2019 November | 28 | 22 | 50 |
| 2019 October | 40 | 10 | 50 |
| 2019 September | 34 | 15 | 49 |
| 2019 August | 24 | 15 | 39 |
| 2019 July | 34 | 25 | 59 |
| 2019 June | 33 | 17 | 50 |
| 2019 May | 40 | 33 | 73 |
| 2019 April | 30 | 27 | 57 |
| 2019 March | 23 | 11 | 34 |
| 2019 February | 22 | 10 | 32 |
| 2019 January | 27 | 18 | 45 |
| 2018 December | 29 | 16 | 45 |
| 2018 November | 75 | 26 | 101 |
| 2018 October | 81 | 21 | 102 |
| 2018 September | 41 | 11 | 52 |
| 2018 July | 7 | 0 | 7 |
| 2018 June | 7 | 0 | 7 |
| 2018 May | 39 | 0 | 39 |
| 2018 April | 38 | 0 | 38 |
| 2018 March | 37 | 0 | 37 |
| 2018 February | 20 | 0 | 20 |
| 2018 January | 98 | 0 | 98 |
| 2017 December | 51 | 0 | 51 |
| 2017 November | 10 | 0 | 10 |
| 2017 October | 15 | 0 | 15 |
| 2017 September | 15 | 0 | 15 |
| 2017 August | 6 | 0 | 6 |
| 2017 July | 15 | 0 | 15 |
| 2017 June | 17 | 7 | 24 |
| 2017 May | 19 | 5 | 24 |
| 2017 April | 19 | 7 | 26 |
| 2017 March | 5 | 2 | 7 |
| 2017 February | 8 | 5 | 13 |
| 2017 January | 9 | 0 | 9 |
| 2016 December | 24 | 20 | 44 |
| 2016 November | 26 | 28 | 54 |
| 2016 October | 23 | 16 | 39 |
| 2016 September | 37 | 5 | 42 |
| 2016 August | 27 | 3 | 30 |
| 2016 July | 31 | 16 | 47 |
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