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Comment on “A randomized trial of the effects of antibiotic prophylaxis on epidural-related fever in labor”
Comentario sobre “Estudio aleatorio sobre el efecto de la profilaxis antibiótica en la fiebre epidural durante el trabajo de parto”
Eduardo Kattan, Hector J. Lacassie
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lacassie@med.puc.cl
Corresponding author at: Dpto. Anestesiología, Hospital Clínico UC, Marcoleta 367, 3er piso, Santiago, Chile.
Corresponding author at: Dpto. Anestesiología, Hospital Clínico UC, Marcoleta 367, 3er piso, Santiago, Chile.
Anesthesiology Division, Faculty of Medicine, Pontificia Universidad Católica de Chile, Chile
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Lacassie" "autores" => array:2 [ 0 => array:2 [ "nombre" => "Eduardo" "apellidos" => "Kattan" ] 1 => array:4 [ "nombre" => "Hector J." "apellidos" => "Lacassie" "email" => array:1 [ 0 => "lacassie@med.puc.cl" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Anesthesiology Division, Faculty of Medicine, Pontificia Universidad Católica de Chile, Chile" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author at:</span> Dpto. Anestesiología, Hospital Clínico UC, Marcoleta 367, 3er piso, Santiago, Chile." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Comentario sobre “Estudio aleatorio sobre el efecto de la profilaxis antibiótica en la fiebre epidural durante el trabajo de parto”" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">This work presents a critical analysis of the article by Sharma et al.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Neuraxial analgesia is the method of choice for pain management during labor.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> Some recent reports have suggested a link between epidural analgesia (EA) and the development of maternal fever.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> Possible etiologies include: increased metabolic expenditure, decreased heat loss due to lack of hyperventilation as a result of pain relief, thermoregulatory changes induced by epidural analgesia, direct effects of local anesthetics on the central nervous system, paralysis of the sudoriferous glands which reduce heat loss, non-infectious inflammatory processes and intrapartum infection, among others.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The consequences of maternal fever during labor include an increase in neonatal evaluations for sepsis, use of maternal and neonatal antibiotics and prolonged hospital stays.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a> Microorganisms that are usually isolated in an infectious process such as chorioamnionitis include aerobic and anaerobic agents.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a></p><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective of the study</span><p id="par0020" class="elsevierStylePara elsevierViewall">To evaluate the relationship between EA used in labor, the presence of intrapartum fever and the possible role of an infectious component.</p></span></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Study design</span><p id="par0025" class="elsevierStylePara elsevierViewall">A prospective randomized, unicentric and double-blind clinical study was designed. Previous to authorization from the Ethics Committee, 400 late-term pregnant women were recruited who were classified as ASA I-II with the fetus in cephalic presentation, in the first stage of spontaneous labor and who requested EA. Exclusion criteria are not described.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Patients were randomly distributed into two groups. One group received 2<span class="elsevierStyleHsp" style=""></span>g of cefoxitin intravenously, the other saline solution, repeating the dosage every 6<span class="elsevierStyleHsp" style=""></span>h. The epidural injection was then administered. 0.25% of bupivacaine was administered in successive 3<span class="elsevierStyleHsp" style=""></span>ml doses and a continuous EA was maintained to obtain a T10 sensitivity level.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Obstetrical management included the artificial rupture of membranes, oxytocic acceleration and pelvic examination every 2<span class="elsevierStyleHsp" style=""></span>h. Temperature was measured with a tympanic thermometer. If the patients presented with fever, ampicillin and gentamicin were administered in doses to treat chorioamnionitis until the fever was absent for 24<span class="elsevierStyleHsp" style=""></span>h. In the neonates of mothers with fever or when sepsis was suspected (at the discretion of the neonatologist), a sepsis examination was conducted and antibiotics were administered for 48<span class="elsevierStyleHsp" style=""></span>h.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The placentas were evaluated by a pathologist blinded to the randomized study. The presence of neutrophilic infiltration and chorioamnionitis were evaluated along with the severity and presence of funisitis (inflammation and neutrophilic infiltration of the umbilical cord).</p><p id="par0045" class="elsevierStylePara elsevierViewall">The primary outcome was maternal fever (>38<span class="elsevierStyleHsp" style=""></span>°C tympanic temperature). The secondary outcomes were characteristics of labor, placental histopathology and neonatal results. Standardized statistical testing was conducted and the randomization sequence was kept hidden. The study was conducted with no intention to treat and was financed by departmental funding.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="par0050" class="elsevierStylePara elsevierViewall">The groups were similar in their initial variables, though there was a significantly higher representation of the Afro-American ethnicity in the placebo group. All 400 patients completed the study, but only 305 placentas (75.5%) were analyzed pathologically. There was no difference in the incidence of fever among the groups (38% and 40% (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>not significant (ns))). The number of pelvic examinations (a risk factor for chorioamnionitis) was similar, and 15% required a cesarean section. The duration times were similar for the first and second stages of labor, time from analgesia until delivery, rupture of membranes, and the number of patients with labor >10<span class="elsevierStyleHsp" style=""></span>h (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>ns).</p><p id="par0055" class="elsevierStylePara elsevierViewall">In the histopathology, the use of cefoxitin did not have an effect on the incidence of neutrophilic infiltration (45% vs 48%, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>ns). Upon subdividing the patients in fever vs. no fever groups, the first group presented with increased placental neutrophilic infiltration (46% vs. 23%, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001Q), chorioamnionitis and funisitis.</p><p id="par0060" class="elsevierStylePara elsevierViewall">In neonates there was no difference in weight, temperature, Apgar score, umbilical arterial gases, nor admissions to the intensive care unit (ICU). The analysis of the subgroup of patients with fever vs those without fever, the former presented with significantly more neonates with an Apgar score<span class="elsevierStyleHsp" style=""></span>≤<span class="elsevierStyleHsp" style=""></span>7 after 1<span class="elsevierStyleHsp" style=""></span>min (14% versus 8%, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.013), a difference which was lost after 5<span class="elsevierStyleHsp" style=""></span>min. There was no difference in umbilical cord blood gases nor in admission to the ICU.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Reviewers’ commentary</span><p id="par0065" class="elsevierStylePara elsevierViewall">This study presents a low risk of bias since it was prospective, unicentric and randomized with a hidden randomization sequence for patients and physicians, including blind outcome assessment. It should be highlighted that exclusion criteria are not mentioned and an explanation is provided for why 98 placentas were not available, which could have changed the results since 25% of samples were not included.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Approximately 40% of the pregnant women who requested EA presented with fever, a figure that did not vary with the use of antibiotics. The histopathological and neonatal results were not affected either. In other words, the fever is unlikely to be caused by infection. However, by subdividing the groups according to the presence of infection, the fever group had a higher level of neutrophilic infiltration, an increase in histological chorioamnionitis and a higher incidence of Apgar under 7 in the first minute, which is to be expected in patients with infection. This analysis of the subgroup does not answer the original question of the study, but is rather a clinical finding that must be reported.</p><p id="par0075" class="elsevierStylePara elsevierViewall">There are some limitations. Firstly, with the choice of antibiotic, cefoxitin is a second-generation cephalosporin with anti-Gram-positive, Gram-negative and anaerobic bacteriostatic activity and is not active against <span class="elsevierStyleItalic">Chlamydia trachomatis</span>,<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> which could explain the lack of response to treatment. Secondly, it is worth noting the high rate of maternal fever (up to 40%), even when compared to previous results of the same group.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> This could be explained on the one hand by the tympanic method of measurement which could increase the rate of false positives, or on the other hand by non-strict diagnostic criteria. Whichever it may be, these rates are higher than usual in our practice, which raises the possibility of the incidences reported being due to the Hawthorne effect (a psychological factor involved in human research in which subjects of the study modify their behavior or modify the variable that is measured because they know they are part of a study, rather than being secondary to the manipulation of the studied variable),<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a> however, it could really be of the reported magnitude. Given this, it would have been interesting to use other study methods to conclude more robust results. For example, the microbacterial culture of placenta samples or the determination of serum inflammatory markers such as interleukins<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a> could be used to evaluate changes in connection with the administration of prophylactic antibiotics.</p><p id="par0080" class="elsevierStylePara elsevierViewall">It seems necessary to explore other physiopathological alternatives that explain the cause of fever and then propose the appropriate treatment options, such as the potential protective effect of magnesium sulfate for fever during labor,<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a> or the use of epidural dexamethasone associated with analgesia in labor.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a> However, further studies of high methodological quality are needed before recommending their routine use.</p><p id="par0085" class="elsevierStylePara elsevierViewall">In conclusion, in first-time pregnant women in late-term spontaneous labor, fever associated with EA presents an inflammatory component (proven by the presence of placental inflammation), which was not reduced with the administration of prophylactic antibiotics, which makes the infectious etiology unlikely.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conflict of interest</span><p id="par0090" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Funding</span><p id="par0095" class="elsevierStylePara elsevierViewall">The author did not received funding for this article.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:7 [ 0 => array:3 [ "identificador" => "sec0005" "titulo" => "Introduction" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0010" "titulo" => "Objective of the study" ] ] ] 1 => array:2 [ "identificador" => "sec0015" "titulo" => "Study design" ] 2 => array:2 [ "identificador" => "sec0020" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "sec0025" "titulo" => "Reviewers’ commentary" ] 4 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflict of interest" ] 5 => array:2 [ "identificador" => "sec0035" "titulo" => "Funding" ] 6 => 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: Kattan E, Lacassie HJ. Comentario sobre “Estudio aleatorio sobre el efecto de la profilaxis antibiótica en la fiebre epidural durante el trabajo de parto”. Rev Colomb Anestesiol. 2016;44:134–136.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0050" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A randomized trial of the effects of antibiotic prophylaxis on epidural-related fever in labor" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "S.K. Sharma" 1 => "B.B. Rogers" 2 => "J.M. Alexander" 3 => "D.D. McIntire" 4 => "K.J. Leveno" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1213/ANE.0b013e3182a5d539" "Revista" => array:6 [ "tituloSerie" => "Anesth Analg" "fecha" => "2014" "volumen" => "118" "paginaInicial" => "604" "paginaFinal" => "610" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24299929" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0055" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Epidural versus non-epidural or no analgesia in labour" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M. Anim-Somuah" 1 => "R.M. Smyth" 2 => "L. Jones" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:3 [ "tituloSerie" => "Cochrane Database Syst Rev" "fecha" => "2011" "paginaInicial" => "CD000331" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0060" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Epidural analgesia during labor and maternal fever" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "J. Philip" 1 => "J.M. Alexander" 2 => "S.K. Sharma" 3 => "K.J. Leveno" 4 => "D.D. McIntire" 5 => "J. Wiley" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Anesthesiology" "fecha" => "1999" "volumen" => "90" "paginaInicial" => "1271" "paginaFinal" => "1275" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10319772" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0065" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Intrapartum maternal fever and neonatal outcome" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "E. Lieberman" 1 => "J. Lang" 2 => "D.K. Richardson" 3 => "F.D. Frigoletto" 4 => "L.J. Heffner" 5 => "A. Cohen" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:7 [ "tituloSerie" => "Pediatrics" "fecha" => "2000" "volumen" => "105" "numero" => "1 Pt 1" "paginaInicial" => "8" "paginaFinal" => "13" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10617697" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0070" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Outcome of microbial invasion of amniotic cavity in the preterm premature rupture of membranes" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S.A. Ovalle" 1 => "M.R. Gomez" 2 => "T.M. Martinez" 3 => "W.E. Kakarieka" 4 => "G.A. Fuentes" 5 => "M.C. Aspillaga" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "/S0034-98872005000100007" "Revista" => array:6 [ "tituloSerie" => "Rev Med Chil" "fecha" => "2005" "volumen" => "133" "paginaInicial" => "51" "paginaFinal" => "61" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15768150" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0075" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ampicillin/sulbactam vs. cefoxitin for the treatment of pelvic inflammatory disease" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "J.G. Jemsek" 1 => "F. Harrison" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1155/S1064744997000562" "Revista" => array:6 [ "tituloSerie" => "Infect Dis Obstet Gynecol" "fecha" => "1997" "volumen" => "5" "paginaInicial" => "319" "paginaFinal" => "325" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18476179" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0080" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The Hawthorne effect: a randomised, controlled trial" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "R. McCarney" 1 => "J. Warner" 2 => "S. Iliffe" 3 => "R. van Haselen" 4 => "M. Griffin" 5 => "P. Fisher" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1186/1471-2288-7-30" "Revista" => array:5 [ "tituloSerie" => "BMC Med Res Methodol" "fecha" => "2007" "volumen" => "7" "paginaInicial" => "30" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17608932" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0085" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Association between the administration of intrapartum magnesium and the incidence of intrapartum fever" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "E. Lange" 1 => "C. Wong" 2 => "S. Segal" 3 => "C. Pancaro" 4 => "P. Toledo" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "LibroEditado" => array:3 [ "titulo" => "Society of Obstetric Anesthesia 47th annual meeting" "conferencia" => "May 13–17, 2015; Colorado Springs, Colorado" "serieFecha" => "2015" ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0090" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Influence of epidural dexamethasone on maternal temperature and serum cytokine concentration after labor epidural analgesia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "L.Z. Wang" 1 => "X.X. Hu" 2 => "X. Liu" 3 => "P. Qian" 4 => "J.M. Ge" 5 => "B.L. Tang" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ijgo.2010.10.026" "Revista" => array:6 [ "tituloSerie" => "Int J Gynaecol Obstet" "fecha" => "2011" "volumen" => "113" "paginaInicial" => "40" "paginaFinal" => "43" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21306709" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/22562087/0000004400000002/v1_201604260026/S2256208716000122/v1_201604260026/en/main.assets" "Apartado" => array:4 [ "identificador" => "42470" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Brief Academy" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/22562087/0000004400000002/v1_201604260026/S2256208716000122/v1_201604260026/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2256208716000122?idApp=UINPBA00004N" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 3 | 0 | 3 |
| 2024 October | 8 | 1 | 9 |
| 2024 September | 5 | 2 | 7 |
| 2024 August | 19 | 2 | 21 |
| 2024 July | 9 | 8 | 17 |
| 2024 June | 10 | 0 | 10 |
| 2024 May | 7 | 9 | 16 |
| 2024 April | 9 | 1 | 10 |
| 2024 March | 7 | 6 | 13 |
| 2024 February | 13 | 2 | 15 |
| 2024 January | 11 | 4 | 15 |
| 2023 December | 8 | 2 | 10 |
| 2023 November | 5 | 12 | 17 |
| 2023 October | 8 | 10 | 18 |
| 2023 September | 11 | 47 | 58 |
| 2023 August | 6 | 4 | 10 |
| 2023 July | 3 | 6 | 9 |
| 2023 June | 2 | 1 | 3 |
| 2023 May | 7 | 3 | 10 |
| 2023 April | 4 | 1 | 5 |
| 2023 March | 1 | 2 | 3 |
| 2023 February | 2 | 2 | 4 |
| 2023 January | 4 | 3 | 7 |
| 2022 December | 9 | 3 | 12 |
| 2022 November | 8 | 3 | 11 |
| 2022 October | 6 | 8 | 14 |
| 2022 September | 5 | 4 | 9 |
| 2022 August | 9 | 6 | 15 |
| 2022 July | 7 | 7 | 14 |
| 2022 June | 4 | 8 | 12 |
| 2022 May | 7 | 5 | 12 |
| 2022 April | 9 | 7 | 16 |
| 2022 March | 10 | 10 | 20 |
| 2022 February | 6 | 4 | 10 |
| 2022 January | 4 | 2 | 6 |
| 2021 December | 7 | 8 | 15 |
| 2021 November | 7 | 6 | 13 |
| 2021 October | 6 | 13 | 19 |
| 2021 September | 5 | 4 | 9 |
| 2021 August | 3 | 4 | 7 |
| 2021 July | 14 | 8 | 22 |
| 2021 June | 4 | 7 | 11 |
| 2021 May | 5 | 6 | 11 |
| 2021 April | 17 | 14 | 31 |
| 2021 March | 7 | 3 | 10 |
| 2021 February | 4 | 12 | 16 |
| 2021 January | 6 | 9 | 15 |
| 2020 December | 6 | 8 | 14 |
| 2020 November | 4 | 6 | 10 |
| 2020 October | 1 | 5 | 6 |
| 2020 September | 4 | 8 | 12 |
| 2020 August | 3 | 10 | 13 |
| 2020 July | 7 | 11 | 18 |
| 2020 June | 5 | 6 | 11 |
| 2020 May | 5 | 4 | 9 |
| 2020 April | 1 | 1 | 2 |
| 2020 March | 5 | 3 | 8 |
| 2020 February | 5 | 1 | 6 |
| 2020 January | 5 | 5 | 10 |
| 2019 December | 5 | 8 | 13 |
| 2019 November | 3 | 3 | 6 |
| 2019 September | 2 | 3 | 5 |
| 2019 July | 3 | 5 | 8 |
| 2019 June | 2 | 1 | 3 |
| 2019 May | 1 | 17 | 18 |
| 2018 September | 1 | 0 | 1 |
| 2018 June | 1 | 0 | 1 |
| 2018 May | 19 | 6 | 25 |
| 2018 April | 37 | 6 | 43 |
| 2018 March | 14 | 7 | 21 |
| 2018 February | 16 | 5 | 21 |
| 2018 January | 18 | 5 | 23 |
| 2017 December | 12 | 6 | 18 |
| 2017 November | 12 | 4 | 16 |
| 2017 October | 14 | 9 | 23 |
| 2017 September | 13 | 6 | 19 |
| 2017 August | 10 | 7 | 17 |
| 2017 July | 14 | 1 | 15 |
| 2017 June | 15 | 7 | 22 |
| 2017 May | 26 | 10 | 36 |
| 2017 April | 36 | 12 | 48 |
| 2017 March | 21 | 7 | 28 |
| 2017 February | 10 | 2 | 12 |
| 2017 January | 10 | 6 | 16 |
| 2016 December | 32 | 14 | 46 |
| 2016 November | 20 | 15 | 35 |
| 2016 October | 18 | 13 | 31 |
| 2016 September | 14 | 6 | 20 |
| 2016 August | 26 | 6 | 32 |
| 2016 July | 9 | 8 | 17 |
| 2016 June | 1 | 0 | 1 |
| 2016 May | 4 | 33 | 37 |
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