Scientific letters
Laparoscopic diaphragmatic plication for paralysis posterior to trauma. Case report
F. Reyna-Sepúlveda, F. Vásquez-Fernández, Á. Rodríguez-Briseño
, C. Montero-Cantú, G.E. Muñoz-Maldonado
Corresponding author
qxangelrdz@gmail.com
Corresponding author at: Servicio de Cirugía General, Hospital Universitario “Dr. José Eleuterio González”, Av. Francisco I. Madero s/n y Gonzalitos Col. Mitras Centro, C.P. 64460, Monterrey, N.L., Mexico. Tel.: +52 81 83 46 78 00.
Corresponding author at: Servicio de Cirugía General, Hospital Universitario “Dr. José Eleuterio González”, Av. Francisco I. Madero s/n y Gonzalitos Col. Mitras Centro, C.P. 64460, Monterrey, N.L., Mexico. Tel.: +52 81 83 46 78 00.
General Surgery Department at the “Dr. José Eleuterio González”, University Hospital of the Autonomous University of Nuevo León, Mexico
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"apellidos" => "Villarreal-Cavazos" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1665579616300618?idApp=UINPBA00004N" "url" => "/16655796/0000001800000071/v1_201608180032/S1665579616300618/v1_201608180032/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S1665579616300527" "issn" => "16655796" "doi" => "10.1016/j.rmu.2016.03.005" "estado" => "S300" "fechaPublicacion" => "2016-04-01" "aid" => "66" "copyright" => "Universidad Autónoma de Nuevo León" "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "crp" "cita" => "Medicina Universitaria. 2016;18:91-4" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 1491 "formatos" => array:3 [ "EPUB" => 58 "HTML" => 1112 "PDF" => 321 ] ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Scientific letter</span>" "titulo" => "Management of firearm facial fractures at the “Dr. José Eleuterio González”: University Hospital Case Report" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "91" "paginaFinal" => "94" ] ] "contieneResumen" => array:1 [ "en" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 815 "Ancho" => 1600 "Tamanyo" => 227361 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">(A) Three-dimensional reconstruction of the left profile, where the displacement of the maxilla and the alveolar jaw segment can be seen, resulting in poor dental occlusion for the patient. (B) Post-surgical image, showing an adequate fragment reduction and dental occlusion.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "I.Z. González-Vargas, M. García-Pérez, Y. Castro-Govea, C.E. Franco-Vazquez, A. Juárez-López de Nava, J.I. Fonseca-Sada" "autores" => array:6 [ 0 => array:2 [ "nombre" => "I.Z." "apellidos" => "González-Vargas" ] 1 => array:2 [ "nombre" => "M." "apellidos" => "García-Pérez" ] 2 => array:2 [ "nombre" => "Y." "apellidos" => "Castro-Govea" ] 3 => array:2 [ "nombre" => "C.E." "apellidos" => "Franco-Vazquez" ] 4 => array:2 [ "nombre" => "A." "apellidos" => "Juárez-López de Nava" ] 5 => array:2 [ "nombre" => "J.I." "apellidos" => "Fonseca-Sada" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1665579616300527?idApp=UINPBA00004N" "url" => "/16655796/0000001800000071/v1_201608180032/S1665579616300527/v1_201608180032/en/main.assets" ] "en" => array:18 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Scientific letters</span>" "titulo" => "Laparoscopic diaphragmatic plication for paralysis posterior to trauma. Case report" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "95" "paginaFinal" => "97" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "F. Reyna-Sepúlveda, F. Vásquez-Fernández, Á. Rodríguez-Briseño, C. Montero-Cantú, G.E. Muñoz-Maldonado" "autores" => array:5 [ 0 => array:2 [ "nombre" => "F." "apellidos" => "Reyna-Sepúlveda" ] 1 => array:2 [ "nombre" => "F." "apellidos" => "Vásquez-Fernández" ] 2 => array:4 [ "nombre" => "Á." "apellidos" => "Rodríguez-Briseño" "email" => array:1 [ 0 => "qxangelrdz@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 3 => array:2 [ "nombre" => "C." "apellidos" => "Montero-Cantú" ] 4 => array:2 [ "nombre" => "G.E." "apellidos" => "Muñoz-Maldonado" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "General Surgery Department at the “Dr. José Eleuterio González”, University Hospital of the Autonomous University of Nuevo León, Mexico" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author at: Servicio de Cirugía General, Hospital Universitario “Dr. José Eleuterio González”, Av. Francisco I. Madero s/n y Gonzalitos Col. Mitras Centro, C.P. 64460, Monterrey, N.L., Mexico. Tel.: +52 81 83 46 78 00." ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 806 "Ancho" => 990 "Tamanyo" => 59197 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Post-op thoracic X-ray.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Background</span><p id="par0005" class="elsevierStylePara elsevierViewall">Diaphragmatic paralysis (DP) is a pathology characterized by the relaxation and elevation and of an atrophic, aplastic and inactive diaphragm followed by a phrenic or spinal cord injury.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">1</span></a> A report by Christensen et al. showed 38 cases out of 107,778 individuals from Denmark with a radiographic report of hemidiaphragm elevation. The real prevalence of this pathology remains unknown.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Diaphragmatic paralysis, which involves the phrenic nerve, has an etiology linked to injuries to the spinal cord at a radicular level, at the conduct or in the peripheral nerve. At a cervical level, it may be caused by trauma or an iatrogenic injury during neck surgery. Mediastinal-level involvement is caused by mediastinal tumors, tuberculosis or trauma. When DP does not involve the phrenic nerve, thoracoabdominal trauma or an adjacent disease, such as sub-phrenic abscesses, atelectasis or pleural infection might be the cause.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The etiology often remains without explanation. A study by Pielher et al.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">2</span></a> proved that the cause could not be identified in 57.5% of cases. Neoplasia and surgery are responsible in 33% of the cases.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Clinical case</span><p id="par0020" class="elsevierStylePara elsevierViewall">A 50-year-old male patient without significant family history, personal history of type 2 diabetes and arterial hypertension both under adequate control. Surgical history of an appendectomy 28 years ago. A year before being consultation, the patient was admitted to the emergency room after being involved in a car accident where he suffered trauma to the left hemithorax. With an unstable thorax and pulmonary contusion which progressed to respiratory insufficiency requiring intubation, the patient was moved to the intensive care unit. The patient was discharged after 2 weeks without additional surgical management.</p><p id="par0025" class="elsevierStylePara elsevierViewall">During the next eight months the patient presented progressive dyspnea, which was exacerbated by moderate to mild efforts; therefore, he went in for a medical assessment. The thoracic X-ray showed elevation of the left hemidiaphragm (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) and the computer axial tomography (CAT) scan reported elevation of left hemidiaphragm and basal atelectasis, excluding associated pathologies (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). A fluoroscopy was conducted under clinical suspicion (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>) confirming persistent elevation during breathing.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">A St. George respiratory questionnaire (SGRQ)<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">3</span></a> was conducted in order to assess the impact on his everyday life, producing an average of 57, with a symptomatology scale of 54, activities 70 and impact 48. Pulmonary function tests showed a severe restrictive process with a forced expiratory volume in the first second (FEV1) of 43 with 1.56<span class="elsevierStyleHsp" style=""></span>L real and 3.5 theoretical, additionally a forced vital capacity (FVC) of 43 with 1.9<span class="elsevierStyleHsp" style=""></span>L real and 4.4 theoretical. Preoperative arterial saturation was 92%.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Surgery was performed, 3 ports were introduced into the abdominal cavity: an umbilical, with a 30 degree camera, and two other 5<span class="elsevierStyleHsp" style=""></span>mm ports. Diaphragmatic plication was done with intermittent non-absorbable 2–0 suture from medial to lateral direction. The process was repeated, ending with a double suture line. Operative time was 93<span class="elsevierStyleHsp" style=""></span>minutes.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The patient was released on the third postoperative day. He was afebrile, tolerating oral diet and without dyspnea. Basal saturation was 97%, with a thoracic X-ray with radiological improvements (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>). The SGRQ was repeated 3 months later resulting in a reduction of 14 points (29%), patient referred symptomatic improvement.</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Discussion</span><p id="par0045" class="elsevierStylePara elsevierViewall">The consequences of diaphragmatic elevation can be respiratory, causing hypoxemia and diminishing the relation of ventilation and perfusion. Other consequences can be digestive, with a rise of the abdominal organs, resulting in rare cases like Chilaiditi syndrome<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">4–6</span></a> for the left side and gastroesophageal reflux for the right. Diaphragmatic plication is a corrective surgery, from a functional and morphological point of view.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The procedure can be performed by laparoscopic or thoracoscopic approach. Huttl et al.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">7</span></a> recently described the superior benefits of laparoscopy in comparison to the thoracoscopic approach.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">8</span></a> Our patient improved dramatically in our clinic according to the SGRQ, thanks to the improved perfusion of the affected basal pulmonary section.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The majority of the comparative results of these procedures are similar. Others have demonstrated the usefulness of the thoracoscopic approach,<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">9–11</span></a> while at the same time documenting that the disadvantages of this approach are selective intubation, reduced work space, an 8–10% risk of an abdominal organ injury because of no direct line of sight (5% with a laparoscopic approach) and greater postoperative pain (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusions</span><p id="par0060" class="elsevierStylePara elsevierViewall">There is an important relevance in this topic to include this management as part of the therapeutic arsenal, and having no standardized treatment and anecdotal case reports need more cases to define it.</p><p id="par0065" class="elsevierStylePara elsevierViewall">The laparoscopic approach is definitively associated with reduced hospitalization time. More cases should be reported. This is the approach of choice in our institution.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conflict of interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:8 [ 0 => array:3 [ "identificador" => "xres719242" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Clinical case" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Discussion" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec724472" "titulo" => "Keyword" ] 2 => array:2 [ "identificador" => "sec0005" "titulo" => "Background" ] 3 => array:2 [ "identificador" => "sec0010" "titulo" => "Clinical case" ] 4 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 5 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusions" ] 6 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of interest" ] 7 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-02-16" "fechaAceptado" => "2016-05-16" "PalabrasClave" => array:1 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keyword" "identificador" => "xpalclavsec724472" "palabras" => array:1 [ 0 => "Laparoscopic diaphragmatic plicature" ] ] ] ] "tieneResumen" => true "resumen" => array:1 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Diaphragmatic paralysis is a pathology characterized by the elevation of a plastic and inactive atrophic diaphragm, followed by an injury to the spinal column or to the phrenic nerve. Because it involves the phrenic nerve, it is often associated with an injury at its exit in the spinal cord at the radicular level, at the conduct or in the peripheral nerve.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Clinical case</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A 50-year-old male patient with a history of thoracic trauma and diagnosis of unstable thorax is admitted for progressive dyspnea in the following 8 months. Diaphragmatic paralysis is diagnosed and a laparoscopic diaphragmatic plicature is performed. Patient improved his clinical status by 29%.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Discussion</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The consequences of the elevation of a hemidiaphragm can be respiratory, causing hypoxemia and decreases in the ventilation–perfusion ratio. This procedure is considered a corrective surgery from the morphological and functional point of view.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Our patient's clinical status improved according to the Saint George respiratory questionnaire, thanks to an improved perfusion of the basal lung expansion. Laparoscopic diaphragmatic plicature is a safe procedure associated with a minimal hospital stay, and more cases need to be reported. This is the procedure of choice in our institution.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Clinical case" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Discussion" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 783 "Ancho" => 990 "Tamanyo" => 66628 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Pre-op thoracic X-ray. Elevated left hemidiaphragm.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 772 "Ancho" => 989 "Tamanyo" => 66606 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Computed axial tomography. Abnormal content in the thorax.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 808 "Ancho" => 990 "Tamanyo" => 52485 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Fluoroscopy. The gastric chamber is observed no evidence of herniation.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 806 "Ancho" => 990 "Tamanyo" => 59197 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Post-op thoracic X-ray.</p>" ] ] 4 => 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:1 [ "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">Thoracoscopic approach \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">Laparoscopic approach \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">Advantages \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• Low morbimortality \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• Does not use selective ventilation<br>• Less surgical and hospital stay time \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">Disadvantages \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• Limited workspace<br>• Risk of injury to intra-abdominal structures \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• The right side is difficult to approach<br>• Risk of causing pleural effusion or pneumothorax. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1182422.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Advantages and disadvantages of the thoracoscopic and laparoscopic approaches to diaphragmatic plication.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:11 [ 0 => array:3 [ "identificador" => "bib0060" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Idiopathic diaphragmatic paralysis; a report of eight cases" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "E.A. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 7 | 0 | 7 |
| 2024 October | 20 | 1 | 21 |
| 2024 September | 49 | 6 | 55 |
| 2024 August | 33 | 4 | 37 |
| 2024 July | 40 | 10 | 50 |
| 2024 June | 54 | 4 | 58 |
| 2024 May | 39 | 4 | 43 |
| 2024 April | 30 | 7 | 37 |
| 2024 March | 33 | 3 | 36 |
| 2024 February | 70 | 4 | 74 |
| 2024 January | 66 | 3 | 69 |
| 2023 December | 68 | 7 | 75 |
| 2023 November | 73 | 10 | 83 |
| 2023 October | 102 | 13 | 115 |
| 2023 September | 45 | 1 | 46 |
| 2023 August | 49 | 6 | 55 |
| 2023 July | 52 | 14 | 66 |
| 2023 June | 49 | 5 | 54 |
| 2023 May | 49 | 9 | 58 |
| 2023 April | 37 | 2 | 39 |
| 2023 March | 49 | 8 | 57 |
| 2023 February | 38 | 5 | 43 |
| 2023 January | 35 | 10 | 45 |
| 2022 December | 38 | 4 | 42 |
| 2022 November | 57 | 8 | 65 |
| 2022 October | 29 | 8 | 37 |
| 2022 September | 26 | 8 | 34 |
| 2022 August | 39 | 21 | 60 |
| 2022 July | 16 | 8 | 24 |
| 2022 June | 23 | 7 | 30 |
| 2022 May | 18 | 13 | 31 |
| 2022 April | 21 | 7 | 28 |
| 2022 March | 30 | 9 | 39 |
| 2022 February | 27 | 8 | 35 |
| 2022 January | 36 | 5 | 41 |
| 2021 December | 22 | 7 | 29 |
| 2021 November | 29 | 11 | 40 |
| 2021 October | 32 | 12 | 44 |
| 2021 September | 18 | 14 | 32 |
| 2021 August | 20 | 8 | 28 |
| 2021 July | 20 | 5 | 25 |
| 2021 June | 21 | 8 | 29 |
| 2021 May | 18 | 7 | 25 |
| 2021 April | 44 | 12 | 56 |
| 2021 March | 41 | 7 | 48 |
| 2021 February | 17 | 11 | 28 |
| 2021 January | 15 | 7 | 22 |
| 2020 December | 14 | 5 | 19 |
| 2020 November | 14 | 7 | 21 |
| 2020 October | 11 | 5 | 16 |
| 2020 September | 15 | 9 | 24 |
| 2020 August | 30 | 8 | 38 |
| 2020 July | 16 | 7 | 23 |
| 2020 June | 19 | 4 | 23 |
| 2020 May | 24 | 6 | 30 |
| 2020 April | 14 | 1 | 15 |
| 2020 March | 19 | 5 | 24 |
| 2020 February | 21 | 3 | 24 |
| 2020 January | 16 | 3 | 19 |
| 2019 December | 23 | 11 | 34 |
| 2019 November | 9 | 8 | 17 |
| 2019 October | 22 | 2 | 24 |
| 2019 September | 20 | 9 | 29 |
| 2019 August | 15 | 5 | 20 |
| 2019 July | 23 | 10 | 33 |
| 2019 June | 25 | 18 | 43 |
| 2019 May | 65 | 40 | 105 |
| 2019 April | 32 | 10 | 42 |
| 2019 March | 9 | 10 | 19 |
| 2019 February | 7 | 6 | 13 |
| 2019 January | 7 | 2 | 9 |
| 2018 December | 9 | 1 | 10 |
| 2018 November | 13 | 2 | 15 |
| 2018 October | 9 | 7 | 16 |
| 2018 September | 6 | 3 | 9 |
| 2018 August | 2 | 0 | 2 |
| 2018 July | 3 | 1 | 4 |
| 2018 June | 2 | 0 | 2 |
| 2018 May | 1 | 1 | 2 |
| 2018 April | 4 | 0 | 4 |
| 2018 March | 3 | 1 | 4 |
| 2018 February | 7 | 0 | 7 |
| 2018 January | 2 | 0 | 2 |
| 2017 December | 5 | 0 | 5 |
| 2017 November | 7 | 0 | 7 |
| 2017 October | 9 | 1 | 10 |
| 2017 September | 7 | 1 | 8 |
| 2017 August | 10 | 1 | 11 |
| 2017 July | 9 | 2 | 11 |
| 2017 June | 17 | 1 | 18 |
| 2017 May | 28 | 4 | 32 |
| 2017 April | 14 | 3 | 17 |
| 2017 March | 21 | 3 | 24 |
| 2017 February | 17 | 5 | 22 |
| 2017 January | 14 | 0 | 14 |
| 2016 December | 24 | 5 | 29 |
| 2016 November | 27 | 9 | 36 |
| 2016 October | 45 | 7 | 52 |
| 2016 September | 28 | 8 | 36 |
| 2016 August | 26 | 7 | 33 |
| 2016 July | 0 | 1 | 1 |
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