Embolization of porto-systemic shunt as treatment for recurrent hepatic encephalopathy
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"documento" => "article" "crossmark" => 0 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "fla" "cita" => "Ann Hepatol. 2014;13:548-54" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 97 "formatos" => array:3 [ "EPUB" => 17 "HTML" => 47 "PDF" => 33 ] ] "en" => array:11 [ "idiomaDefecto" => true "titulo" => "Heparin-induced thrombocytopenia testing is over-utilized in cirrhosis & correlates with poor clinical outcomes" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "548" "paginaFinal" => "554" ] ] "contieneResumen" => array:1 [ "en" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "f0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 350 "Ancho" => 494 "Tamanyo" => 21338 ] ] "descripcion" => array:1 [ "en" => "<p id="sp0005" class="elsevierStyleSimplePara elsevierViewall">Study subject flow and cohort definition.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Karlyn Martin, Leila Kia, Neehar D. Parikh, Laura Kulik, Brandon McMahon" "autores" => array:5 [ 0 => array:2 [ "nombre" => "Karlyn" "apellidos" => "Martin" ] 1 => array:2 [ "nombre" => "Leila" "apellidos" => "Kia" ] 2 => array:2 [ "nombre" => "Neehar D." "apellidos" => "Parikh" ] 3 => array:2 [ "nombre" => "Laura" "apellidos" => "Kulik" ] 4 => array:2 [ "nombre" => "Brandon" "apellidos" => "McMahon" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1665268119312554?idApp=UINPBA00004N" "url" => "/16652681/0000001300000005/v1_201906141004/S1665268119312554/v1_201906141004/en/main.assets" ] "en" => array:14 [ "idiomaDefecto" => true "titulo" => "Embolization of porto-systemic shunt as treatment for recurrent hepatic encephalopathy" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "555" "paginaFinal" => "557" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Hugh Leonard, James O’Beirne, Dominic Yu, Emmanuel Tsochatzis" "autores" => array:4 [ 0 => array:3 [ "nombre" => "Hugh" "apellidos" => "Leonard" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "aff0005" ] ] ] 1 => array:3 [ "nombre" => "James" "apellidos" => "O’Beirne" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Dominic" "apellidos" => "Yu" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">**</span>" "identificador" => "aff0010" ] ] ] 3 => array:4 [ "nombre" => "Emmanuel" "apellidos" => "Tsochatzis" "email" => array:1 [ 0 => "tsochatzis@ucl.ac.uk" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Sheila Sherlock Liver Unit and UCL Institute of Liver and Digestive Health, Royal Free Hospital and UCL, London, UK" "etiqueta" => "*" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Radiology, Royal Free Hospital, London, UK" "etiqueta" => "**" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "*" "correspondencia" => "Correspondence and reprint request:" ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "f0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 464 "Ancho" => 504 "Tamanyo" => 17278 ] ] "descripcion" => array:1 [ "en" => "<p id="sp0015" class="elsevierStyleSimplePara elsevierViewall">Successful occlusion of the umbilical vein after deployment of 2 Amplatzer Vascular Plugs (arrows).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="s0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0005">Clinical Presentation</span><p id="p0005" class="elsevierStylePara elsevierViewall">A 72-year-old female with a history of autoimmune hepatitis-related cirrhosis, osteoporosis, and hypertension was admitted with recurrent episodes of confusion and drowsiness over the course of two years. On each occasion, the patient demonstrated fluctuating confusion with drowsiness and was disorientated to time and place. A marked liver flap was present on examination with no other features of hepatic decompensation. These episodes were associated with raised serum ammonia levels, normal neuroimaging findings and no features to suggest a precipitating illness. They became more frequent, severe and longer in duration in early 2014, prompting three hospital admissions in 2 months despite being on optimal medical therapy of rifaximin, twicedaily enemas and maximally tolerated lactulose.</p><p id="p0010" class="elsevierStylePara elsevierViewall">Most recently she was admitted with a two-day history of increasing confusion, wandering around the house, and drowsiness. There were no features of jaundice, ascites, gastro-intestinal bleeding or sepsis. She was opening her bowels two to three times per day. Examination demonstrated marked confusion (abbreviated mental test score 4/10), drowsiness with a Glasgow Coma Score of 13/15 and a marked liver flap. There was no focal neurology, and the remainder of the examination was unremarkable except for 2cm splenomegaly. Initial blood tests demonstrated bilirubin: 19 μmol/L, ALT 54 IU/L, AST 50 IU/L, ALP 90 IU/L, albumin 33g/L, creatinine 63 umol/L, sodium 139 mmol/L, PT 12.8, CRP 2 mg/L and serum ammonia of 93 μmol/L. Oesophagoduodenoscopy (OGD) showed one small varix (grade 1) with no evidence of red signs or recent bleeding, while an electroencephalogram demonstrated slow waves suggestive of cerebral dysfunction, but no epileptiform activity. Despite an increase in laxatives, the patient’s confusion persisted with no appreciable change in her liver function tests, or her ammonia level. Given this patient’s otherwise good liver function, with a MELD score of 8 and unexplained, recurrent encephalopathy, a triple phase computed tomography (CT) of her liver liver was conducted to investigate for a large spontaneous porto-systemic shunt (SPSS)<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> which could account for her symptoms.</p></span><span id="s0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0010">Images</span><p id="p0015" class="elsevierStylePara elsevierViewall">The CT demonstrated a large left portosystemic shunt. Since she was not a transplant candidate due to her age, she subsequently underwent embolisation of the shunt via a trans-jugular approach. A venogram performed from the main portal vein during the procedure confirmed the presence of a large recanalised umbilical vein, which was subsequently embolised. Portal venous pressure before embolisation was 26 mmHg, rising to 31 mmHg following embolisation. Details are shown in <a class="elsevierStyleCrossRefs" href="#f0005">figures 1</a>–<a class="elsevierStyleCrossRef" href="#f0015"><span class="elsevierStyleSup">3</span></a>.</p><elsevierMultimedia ident="f0005"></elsevierMultimedia><elsevierMultimedia ident="f0010"></elsevierMultimedia><elsevierMultimedia ident="f0015"></elsevierMultimedia><p id="p0020" class="elsevierStylePara elsevierViewall">Over the following 3 days there was marked improvement in the patient’s confusion, with resolution of her asterixis. An OGD was performed prior to discharge, which demonstrated no aggravation of her oesophageal varix or new gastric varices. The patient remains well 2 months after the procedure, with minimal confusion and no complications.</p></span><span id="s0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0015">Discussion</span><p id="p0025" class="elsevierStylePara elsevierViewall">Hepatic encephalopathy (HE) is a complex neuropsychiatric syndrome seen frequently in patients with advanced cirrhosis and is usually triggered by a precipitating event such as gastro-intestinal bleeding or sepsis. In some patients, HE can present and persist in the absence of such events. In this latter group of patients, large SPSS are found at a high rate<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> and are believed to contribute to the encephalopathic process by the portal flow steal mechanism.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>,<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Recurrent or persistent encephalopathy in the setting of early cirrhosis and no clear precipitant should prompt investigation for such shunts. Embolization of these shunts has been explored as a therapeutic intervention to manage encephalopathy in selected patients with persistent HE which is resistant to maximal medical therapy.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Concerns have been raised regarding the aggravation of portal hypertension and subsequent increased risk of variceal haemorrhages following this procedure.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> In a multicentre retrospective cohort study of 37 patients undergoing SPSS embolization with mean follow-up of 697 ± 157 days, 48.6% of patients had no further episodes of HE, while the frequency and severity of HE was significantly reduced in the remainder.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Regarding the safety of the procedure, one patient had capsular bleeding requiring surgical intervention and two patients developed de novo oesophageal varices during follow up. The authors concluded that a MELD cut-off of 11 was safe for embolization of porto-systemic shunts. A recent retrospective case-control study of 34 patients compared SPSS embolization against best medical therapy.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> This demonstrated significant improvements in both patient survival (100% <span class="elsevierStyleItalic">vs.</span> 60%) and HE-free survival (19% <span class="elsevierStyleItalic">vs.</span> 70%) at 2 years of follow-up in patients with MELD < 15 without hepatocellular carcinoma. Post-procedure, three patients developed de novo, or had progression of their oesophageal varices with no subsequent bleeds.</p></span><span id="s0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0020">Conclusion</span><p id="p0030" class="elsevierStylePara elsevierViewall">In patients with Child A or early B cirrhosis who are otherwise stable, unexplained recurrent encephalopathy should prompt investigations for porto-systemic shunts. In selected patients with no options for liver transplantation and preserved liver function, embolization of such shunts is safe and effective. Patients should be followed up and screened post-embolization for development of portal hypertension, more specifically for oesophageal and gastric varices.</p></span><span id="s0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0025">Abbreviations</span><p id="p0035" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="l0005"><li class="elsevierStyleListItem" id="u0005"><span class="elsevierStyleLabel">•</span><p id="p0040" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">ALP:</span> alkaline phosphatise.</p></li><li class="elsevierStyleListItem" id="u0010"><span class="elsevierStyleLabel">•</span><p id="p0045" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">ALT:</span> alanine aminotransferase.</p></li><li class="elsevierStyleListItem" id="u0015"><span class="elsevierStyleLabel">•</span><p id="p0050" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">AST:</span> aspartate aminotransferase.</p></li><li class="elsevierStyleListItem" id="u0020"><span class="elsevierStyleLabel">•</span><p id="p0055" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">CRP:</span> C-reactive protein.</p></li><li class="elsevierStyleListItem" id="u0025"><span class="elsevierStyleLabel">•</span><p id="p0060" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">CT:</span> computed tomography</p></li><li class="elsevierStyleListItem" id="u0030"><span class="elsevierStyleLabel">•</span><p id="p0065" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">HE:</span> hepatic encephalopathy.</p></li><li class="elsevierStyleListItem" id="u0035"><span class="elsevierStyleLabel">•</span><p id="p0070" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">MELD:</span> Model for End-stage Liver Disease</p></li><li class="elsevierStyleListItem" id="u0040"><span class="elsevierStyleLabel">•</span><p id="p0075" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">OGD:</span> oesophagoduodenoscopy.</p></li><li class="elsevierStyleListItem" id="u0045"><span class="elsevierStyleLabel">•</span><p id="p0080" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">PT:</span> prothrombin time</p></li><li class="elsevierStyleListItem" id="u0050"><span class="elsevierStyleLabel">•</span><p id="p0085" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">SPSS:</span> spontaneous portosystemic shunt</p></li><li class="elsevierStyleListItem" id="u0055"><span class="elsevierStyleLabel">•</span><p id="p0090" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">UKELD:</span> United Kingdom Model for End-stage Liver Disease</p></li></ul></p></span><span id="s0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0030">Financial Support</span><p id="p0095" class="elsevierStylePara elsevierViewall">No financial support was received for this manuscript</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:7 [ 0 => array:2 [ "identificador" => "s0005" "titulo" => "Clinical Presentation" ] 1 => array:2 [ "identificador" => "s0010" "titulo" => "Images" ] 2 => array:2 [ "identificador" => "s0015" "titulo" => "Discussion" ] 3 => array:2 [ "identificador" => "s0020" "titulo" => "Conclusion" ] 4 => array:2 [ "identificador" => "s0025" "titulo" => "Abbreviations" ] 5 => array:2 [ "identificador" => "s0030" "titulo" => "Financial Support" ] 6 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-05-29" "fechaAceptado" => "2014-05-29" "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "f0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 420 "Ancho" => 504 "Tamanyo" => 26148 ] ] "descripcion" => array:1 [ "en" => "<p id="sp0005" class="elsevierStyleSimplePara elsevierViewall">Coronal CT demonstrating a large recanalised umbilical vein (arrows).</p>" ] ] 1 => array:7 [ "identificador" => "f0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 508 "Ancho" => 504 "Tamanyo" => 12443 ] ] "descripcion" => array:1 [ "en" => "<p id="sp0010" class="elsevierStyleSimplePara elsevierViewall">Portal venogram showing a catheter in the main portal vein, sheath in left portal vein and the large umbilical vein (arrow).</p>" ] ] 2 => array:7 [ "identificador" => "f0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 464 "Ancho" => 504 "Tamanyo" => 17278 ] ] "descripcion" => array:1 [ "en" => "<p id="sp0015" class="elsevierStyleSimplePara elsevierViewall">Successful occlusion of the umbilical vein after deployment of 2 Amplatzer Vascular Plugs (arrows).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bs0010" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1." "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Hepatobiliary and pancreatic: spontaneous splenorenal shunts in portal hypertension" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "Tsochatzis E." 1 => "Venerito M." 2 => "Papatheodoridis G.V." 3 => "Archiman-dritis A.J." 4 => "Mönkemüller K." 5 => "Malfertheiner P." ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1440-1746.2006.04555.x" "Revista" => array:5 [ "tituloSerie" => "J Gastroenterol Hepatol" "fecha" => "2006" "volumen" => "21" "paginaInicial" => "1214" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16824079" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2." "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "High prevalence of spontaneous portal-systemic shunts in persistent hepatic encephalopathy: a case-control study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:7 [ 0 => "Riggio O." 1 => "Efrati C." 2 => "Catalano C." 3 => "Pediconi F." 4 => "Mecarelli O." 5 => "Accornero N." 6 => "Nicolao F." ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/hep.20905" "Revista" => array:6 [ "tituloSerie" => "Hepatology" "fecha" => "2005" "volumen" => "42" "paginaInicial" => "1158" "paginaFinal" => "1165" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16250033" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3." "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "New assessment of hepatic encephalopathy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "Codoba J." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "J Hepatology" "fecha" => "2011" "volumen" => "54" "paginaInicial" => "1030" "paginaFinal" => "1040" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4." "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Liver cirrhosis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "Tsochatzis E.A." 1 => "Bosch J." 2 => "Burroughs A.K." ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/S0140-6736(14)60121-5" "Revista" => array:6 [ "tituloSerie" => "Lancet" "fecha" => "2014" "volumen" => "383" "paginaInicial" => "1749" "paginaFinal" => "1761" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24480518" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5." "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Effect of spontaneous portosystemic shunts on hemorrhage from esophagogastric varices" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "Hsieh J.S." 1 => "Wang J.Y." 2 => "Huang C.J." 3 => "Chen F.M." 4 => "Huang T.J." ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00268-003-7068-7" "Revista" => array:6 [ "tituloSerie" => "World J Surg" "fecha" => "2004" "volumen" => "28" "paginaInicial" => "23" "paginaFinal" => "28" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14648045" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6." "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Embolization of Large Spontaneous Portosystemic Shunts for Refractory Hepatic Encephalopathy: A Multicenter Survey on Safety and Efficacy" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:7 [ 0 => "Laleman W." 1 => "Simon-Talero M." 2 => "Maleux G." 3 => "Perez M." 4 => "Ameloot K." 5 => "Soriano G." 6 => "Villalba J." ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/hep.26314" "Revista" => array:7 [ "tituloSerie" => "Hepatology" "fecha" => "2013" "volumen" => "57" "numero" => "6" "paginaInicial" => "2448" "paginaFinal" => "2457" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23401201" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7." 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 7 | 0 | 7 |
| 2024 October | 33 | 9 | 42 |
| 2024 September | 53 | 11 | 64 |
| 2024 August | 34 | 8 | 42 |
| 2024 July | 60 | 2 | 62 |
| 2024 June | 58 | 8 | 66 |
| 2024 May | 46 | 4 | 50 |
| 2024 April | 30 | 3 | 33 |
| 2024 March | 29 | 7 | 36 |
| 2024 February | 44 | 7 | 51 |
| 2024 January | 72 | 12 | 84 |
| 2023 December | 61 | 9 | 70 |
| 2023 November | 75 | 11 | 86 |
| 2023 October | 81 | 12 | 93 |
| 2023 September | 56 | 2 | 58 |
| 2023 August | 43 | 8 | 51 |
| 2023 July | 37 | 5 | 42 |
| 2023 June | 56 | 4 | 60 |
| 2023 May | 68 | 7 | 75 |
| 2023 April | 75 | 4 | 79 |
| 2023 March | 64 | 3 | 67 |
| 2023 February | 44 | 6 | 50 |
| 2023 January | 25 | 6 | 31 |
| 2022 December | 46 | 15 | 61 |
| 2022 November | 44 | 8 | 52 |
| 2022 October | 50 | 6 | 56 |
| 2022 September | 32 | 9 | 41 |
| 2022 August | 45 | 13 | 58 |
| 2022 July | 30 | 10 | 40 |
| 2022 June | 30 | 7 | 37 |
| 2022 May | 30 | 10 | 40 |
| 2022 April | 32 | 9 | 41 |
| 2022 March | 33 | 8 | 41 |
| 2022 February | 47 | 5 | 52 |
| 2022 January | 70 | 11 | 81 |
| 2021 December | 57 | 8 | 65 |
| 2021 November | 46 | 4 | 50 |
| 2021 October | 34 | 12 | 46 |
| 2021 September | 30 | 8 | 38 |
| 2021 August | 43 | 4 | 47 |
| 2021 July | 18 | 8 | 26 |
| 2021 June | 15 | 9 | 24 |
| 2021 May | 54 | 9 | 63 |
| 2021 April | 62 | 18 | 80 |
| 2021 March | 41 | 10 | 51 |
| 2021 February | 32 | 3 | 35 |
| 2021 January | 33 | 5 | 38 |
| 2020 December | 32 | 19 | 51 |
| 2020 November | 13 | 5 | 18 |
| 2020 October | 19 | 5 | 24 |
| 2020 September | 19 | 5 | 24 |
| 2020 August | 21 | 7 | 28 |
| 2020 July | 12 | 2 | 14 |
| 2020 June | 13 | 3 | 16 |
| 2020 May | 9 | 6 | 15 |
| 2020 April | 5 | 2 | 7 |
| 2020 March | 4 | 5 | 9 |
| 2020 February | 8 | 1 | 9 |
| 2020 January | 3 | 3 | 6 |
| 2019 December | 6 | 13 | 19 |
| 2019 November | 4 | 2 | 6 |
| 2019 October | 2 | 4 | 6 |
| 2019 September | 6 | 2 | 8 |
| 2019 August | 1 | 1 | 2 |
| 2019 July | 3 | 5 | 8 |
| 2019 June | 2 | 5 | 7 |
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