Letter to the Editor
The transfer of neuropaediatrics to adult medicine
La transferencia de neuropediatría a medicina de adultos
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Marked, unilateral, low uptake of the right striatum.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "F. Pérez Errazquin, M.J. Gomez Heredia" "autores" => array:2 [ 0 => array:2 [ "nombre" => "F." "apellidos" => "Pérez Errazquin" ] 1 => array:2 [ "nombre" => "M.J." "apellidos" => "Gomez Heredia" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173580812000399?idApp=UINPBA00004N" "url" => "/21735808/0000002700000003/v1_201305151325/S2173580812000399/v1_201305151325/en/main.assets" ] "en" => array:14 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "The transfer of neuropaediatrics to adult medicine" "tieneTextoCompleto" => true "saludo" => "Sir," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "183" "paginaFinal" => "185" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "J. López Pisón, L. Monge Galindo, R. Pérez Delgado, M. Lafuente Hidalgo, P. Abenia Uson, M.C. García Jiménez, J.L. Peña Segura" "autores" => array:7 [ 0 => array:4 [ "nombre" => "J." "apellidos" => "López Pisón" "email" => array:1 [ 0 => "jlopezpi@salud.aragon.es" ] "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" => "L." "apellidos" => "Monge Galindo" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "R." 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"apellidos" => "Peña Segura" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Sección de Neuropediatría, Hospital Universitario Miguel Servet, Zaragoza, Spain" "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Instituto Aragonés de Ciencias de la Salud, Zaragoza, Spain" "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Sección de Metabolismo, Hospital Universitario Miguel Servet, Zaragoza, Spain" "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "La transferencia de neuropediatría a medicina de adultos" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Neuropaediatricians manage patients from the neonatal period through adolescence and youth. Whenever their patients are not discharged, sooner or later they must be transferred to adult physicians: family physicians, neurologists, neurosurgeons or other specialists.</p><p id="par0010" class="elsevierStylePara elsevierViewall">This transfer is necessary because neuropaediatricians are experts in children and adolescents but not in adults. Moreover, it is inappropriate for adults to be treated in paediatric wards.</p><p id="par0015" class="elsevierStylePara elsevierViewall">However, this transfer can be traumatic because, in some cases, a relationship has existed for many years. This includes both the way of working and the affection established between neuropaediatricians and patients and their families, who must adapt to new environments and new professionals. Furthermore, neurologists are not always prepared to deal with some neuropaediatric diseases.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The issue of transfers was raised for the first time in the United States, at a convention which took place in 1984, as a result of the significant increase in survival in children with chronic and disabling conditions during the 1970s and 1980s. Subsequently, there have been 2 other conventions in 1989 and 2001.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">A search in PubMed, dated February 13th, 2011, for reviews containing the terms “<span class="elsevierStyleItalic">pediatric to adult transition</span>”, returned 130 articles (of which only 8 were from the 20th century) related to cystic fibrosis, cancer, transplants, congenital heart disease, diabetes mellitus, inflammatory bowel disease, chronic kidney disease, growth hormone deficiency and neurological and neurosurgical pathology.</p><p id="par0030" class="elsevierStylePara elsevierViewall">In total, 12 articles made reference to neurological problems concerning unspecified neurological diseases,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> miopathies,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> hydrocephalus,<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> CNS tumours,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> attention deficit hyperactivity disorder (ADHD),<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> neurosurgical pathology,<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7–9</span></a> brain trauma,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> phacomatosis and genetically determined tumours,<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> spina bifida<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12,13</span></a> and cerebral palsy.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> In addition, 1 review made reference to inborn errors of metabolism,<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> many of which have a neurological effect. Until recently, their diagnosis and follow-up corresponded to paediatricians, but, at present, adult services (especially neurology and internal medicine) must also adapt to them.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">All the articles agree that very little progress has been made and highlight a number of barriers for a successful transition: lack of coordination between paediatric and adult units, problems related to parents, family and patient resistance, lack of planning and lack of institutional support.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Neuropaediatricians deal with:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">–</span><p id="par0045" class="elsevierStylePara elsevierViewall">Problems of low fragility and high prevalence, such as headaches, some non-epileptic paroxysmal disorders, some epilepsies and ADHD.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">–</span><p id="par0050" class="elsevierStylePara elsevierViewall">Problems of high fragility (taken into account separately, although together they represent a large number of patients), lower prevalence, and with a high personal, family and social impact, such as pathological psychomotor retardation (including autism spectrum disorders and mental retardation), cerebral palsy, tumoural pathology, metabolic diseases, neuromuscular unit diseases, spinal disorders including myelomeningocele, refractory epilepsy and neurocutaneous syndromes. Over 8% of our patients suffer rare diseases (with an established diagnosis) and over 8% suffer epilepsies, of which over 20% are refractory.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p></li></ul></p><p id="par0055" class="elsevierStylePara elsevierViewall">We reviewed our experience at Hospital Miguel Servet in Zaragoza for a period of 20 years, from May 1990 to November 2010.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16–18</span></a> The paediatric neurology database contained 13<span class="elsevierStyleHsp" style=""></span>268 patients from that period, of which 855 (6.4%) were over 14 years of age at the time of last modification: 361 were aged 14 years, 170 were aged 15 years, 103 were aged 16 years, 86 were aged 17 years, 72 were aged 18 years and 62 were aged 19 to 28 years. Of these 855 patients, 274 (32%) continued to be managed by the neuropaediatric unit, 11 (1.2%) died, 353 (41.2%) were discharged (that is, transferred to the care of their family doctor) and 151 (17.6%) were transferred to adult neurology units.</p><p id="par0060" class="elsevierStylePara elsevierViewall">The pathologies suffered by patients who were transferred to adult neurology units were 108 cases of epilepsy and 22 neuromuscular unit diseases (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). The diagnoses of the 353 children who were discharged and, therefore, transferred to their family doctors, included 35 cases of mental retardation, 26 cases of cerebral palsy, 18 cases of ADHD, 6 cases of type 1 neurofibromatosis and 2 cases of autism spectrum disorders.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">The neurology and neuropaediatric services and the managers responsible should make an effort to improve the transfer through a transition process, which could be established through different approaches. There are some pathologies which can and should be managed by paediatricians and primary care physicians, others which should be transferred to neurosurgery and, perhaps, psychiatry services, and yet others which should be transferred to neurology services.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Currently, there is no dispute about the need for experts in 2 age groups: neuropaediatricians and neurologists. The figure of an expert in the transition age group (and, therefore, “expert in transition”) could also be very useful.</p><p id="par0075" class="elsevierStylePara elsevierViewall">An “expert in transition” would be a prime tool to implement communication and teamwork between neuropaediatricians, neurologists and neurosurgeons. All have much to learn from each other and communication should be fostered through joint meetings and the use of information and communication technology (especially e-mail).</p><p id="par0080" class="elsevierStylePara elsevierViewall">The keys to a successful transition are:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">–</span><p id="par0085" class="elsevierStylePara elsevierViewall">The transfer should be announced previously.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">–</span><p id="par0090" class="elsevierStylePara elsevierViewall">There should be a perception of continuity by users, of being part of the same team, with the same criteria and work methodology.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">–</span><p id="par0095" class="elsevierStylePara elsevierViewall">Planning.</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">–</span><p id="par0100" class="elsevierStylePara elsevierViewall">Institutional support.</p></li></ul></p><p id="par0105" class="elsevierStylePara elsevierViewall">Neurology services in Spain generally have more neurologists than neuropaediatric units. Neuropaediatricians are too few to share the burden of healthcare and permanent update in very diverse fields (many of them complex and with continuous advances). Neurology services could share a neurologist with neuropaediatric units (“part-time donation”), ideally one suitable as a neuropaediatrician after 2 years of training at a neuropaediatric unit. This neurologist–neuropaediatrician could alternate between healthcare, teaching, neurology research and management, neuropaediatric and “transition” duties.</p><p id="par0110" class="elsevierStylePara elsevierViewall">In conclusion, neuropaediatric patients should be transferred to adult physicians between the ages of 14 and 18 years, ideally through a transition process led by a neurologist–neuropaediatrician. This professional would rapidly become an expert in such transitions and a key figure in the communication between neurology and neuropaediatric units, as well as in the training of neurologists for problems which they are not used to, including neurocutaneous syndromes, mental retardation, autism spectrum disorders, childhood cerebral palsy, ADHD and metabolic diseases. Ultimately, quality and continuity of care would improve to the benefit of patients, their families and professionals, who would be satisfied by the improvement of their service.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: López Pisón J, et al. La transferencia de neuropediatría a medicina de adultos. Neurología. 2012;27:183–5.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">SMA: spinal muscular atrophy.</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=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Total patients transferred to adult neurology</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">151 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Epilepsies</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">108 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Partial symptomatic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">54 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Generalised idiopathic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">22 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Cryptogenic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Partial cryptogenic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Epileptic encephalopathy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Neuromuscular unit diseases</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">22 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Sensorimotor hereditary neuropathies \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Dystrophinopathies \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Other muscular dystrophies \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Type II SMA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Friedreich ataxia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Congenital muscular dystrophy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab264819.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Diagnoses of the 151 patients transferred from a neuropaediatric unit to an adult neurology service.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:18 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 5 | 0 | 5 |
| 2024 October | 9 | 1 | 10 |
| 2024 September | 12 | 3 | 15 |
| 2024 August | 15 | 8 | 23 |
| 2024 July | 14 | 3 | 17 |
| 2024 June | 9 | 7 | 16 |
| 2024 May | 9 | 10 | 19 |
| 2024 April | 34 | 3 | 37 |
| 2024 March | 18 | 9 | 27 |
| 2024 February | 15 | 7 | 22 |
| 2024 January | 8 | 3 | 11 |
| 2023 December | 16 | 4 | 20 |
| 2023 November | 25 | 4 | 29 |
| 2023 October | 25 | 7 | 32 |
| 2023 September | 13 | 3 | 16 |
| 2023 August | 15 | 5 | 20 |
| 2023 July | 17 | 7 | 24 |
| 2023 June | 6 | 4 | 10 |
| 2023 May | 35 | 3 | 38 |
| 2023 April | 17 | 8 | 25 |
| 2023 March | 47 | 5 | 52 |
| 2023 February | 27 | 6 | 33 |
| 2023 January | 13 | 8 | 21 |
| 2022 December | 14 | 8 | 22 |
| 2022 November | 30 | 8 | 38 |
| 2022 October | 18 | 8 | 26 |
| 2022 September | 11 | 6 | 17 |
| 2022 August | 21 | 7 | 28 |
| 2022 July | 9 | 8 | 17 |
| 2022 June | 7 | 10 | 17 |
| 2022 May | 20 | 7 | 27 |
| 2022 April | 20 | 13 | 33 |
| 2022 March | 12 | 9 | 21 |
| 2022 February | 10 | 8 | 18 |
| 2022 January | 12 | 5 | 17 |
| 2021 December | 14 | 13 | 27 |
| 2021 November | 14 | 8 | 22 |
| 2021 October | 10 | 5 | 15 |
| 2021 September | 9 | 11 | 20 |
| 2021 August | 8 | 7 | 15 |
| 2021 July | 9 | 6 | 15 |
| 2021 June | 20 | 10 | 30 |
| 2021 May | 16 | 5 | 21 |
| 2021 April | 31 | 11 | 42 |
| 2021 March | 14 | 3 | 17 |
| 2021 February | 11 | 7 | 18 |
| 2021 January | 11 | 10 | 21 |
| 2020 December | 11 | 6 | 17 |
| 2020 November | 9 | 8 | 17 |
| 2020 October | 8 | 6 | 14 |
| 2020 September | 13 | 11 | 24 |
| 2020 August | 10 | 5 | 15 |
| 2020 July | 6 | 7 | 13 |
| 2020 June | 10 | 3 | 13 |
| 2020 May | 20 | 11 | 31 |
| 2020 April | 13 | 0 | 13 |
| 2020 March | 9 | 4 | 13 |
| 2020 February | 9 | 3 | 12 |
| 2020 January | 11 | 2 | 13 |
| 2019 December | 21 | 5 | 26 |
| 2019 November | 3 | 2 | 5 |
| 2019 October | 7 | 1 | 8 |
| 2019 September | 16 | 3 | 19 |
| 2019 August | 6 | 7 | 13 |
| 2019 July | 12 | 15 | 27 |
| 2019 June | 25 | 10 | 35 |
| 2019 May | 89 | 0 | 89 |
| 2019 April | 9 | 2 | 11 |
| 2019 March | 6 | 6 | 12 |
| 2019 February | 8 | 1 | 9 |
| 2019 January | 4 | 8 | 12 |
| 2018 December | 4 | 4 | 8 |
| 2018 November | 4 | 1 | 5 |
| 2018 October | 13 | 8 | 21 |
| 2018 September | 5 | 5 | 10 |
| 2018 August | 3 | 1 | 4 |
| 2018 July | 4 | 1 | 5 |
| 2018 June | 7 | 2 | 9 |
| 2018 May | 8 | 2 | 10 |
| 2018 April | 14 | 1 | 15 |
| 2018 March | 3 | 1 | 4 |
| 2018 February | 4 | 0 | 4 |
| 2018 January | 10 | 0 | 10 |
| 2017 December | 5 | 0 | 5 |
| 2017 November | 7 | 1 | 8 |
| 2017 October | 11 | 4 | 15 |
| 2017 September | 12 | 1 | 13 |
| 2017 August | 11 | 3 | 14 |
| 2017 July | 6 | 1 | 7 |
| 2017 June | 11 | 1 | 12 |
| 2017 May | 3 | 6 | 9 |
| 2017 April | 9 | 1 | 10 |
| 2017 March | 13 | 30 | 43 |
| 2017 February | 12 | 2 | 14 |
| 2017 January | 19 | 2 | 21 |
| 2016 December | 10 | 3 | 13 |
| 2016 November | 7 | 1 | 8 |
| 2016 October | 24 | 4 | 28 |
| 2016 September | 5 | 8 | 13 |
| 2016 August | 15 | 4 | 19 |
| 2016 July | 15 | 1 | 16 |
| 2016 June | 20 | 8 | 28 |
| 2016 May | 25 | 17 | 42 |
| 2016 April | 25 | 15 | 40 |
| 2016 March | 31 | 25 | 56 |
| 2016 February | 22 | 19 | 41 |
| 2016 January | 20 | 12 | 32 |
| 2015 December | 13 | 15 | 28 |
| 2015 November | 14 | 14 | 28 |
| 2015 October | 17 | 15 | 32 |
| 2015 September | 14 | 11 | 25 |
| 2015 August | 14 | 8 | 22 |
| 2015 July | 6 | 4 | 10 |
| 2015 June | 5 | 0 | 5 |
| 2015 May | 12 | 6 | 18 |
| 2015 April | 11 | 13 | 24 |
| 2015 March | 30 | 10 | 40 |
| 2015 February | 16 | 5 | 21 |
| 2015 January | 29 | 7 | 36 |
| 2014 December | 41 | 10 | 51 |
| 2014 November | 26 | 2 | 28 |
| 2014 October | 24 | 4 | 28 |
| 2014 September | 30 | 1 | 31 |
| 2014 August | 34 | 4 | 38 |
| 2014 July | 28 | 2 | 30 |
| 2014 June | 13 | 1 | 14 |
| 2014 May | 16 | 2 | 18 |
| 2014 April | 9 | 0 | 9 |
| 2014 March | 19 | 6 | 25 |
| 2014 February | 15 | 2 | 17 |
| 2014 January | 12 | 1 | 13 |
| 2013 December | 16 | 5 | 21 |
| 2013 November | 20 | 5 | 25 |
| 2013 October | 26 | 1 | 27 |
| 2013 September | 38 | 5 | 43 |
| 2013 August | 27 | 2 | 29 |
| 2013 July | 15 | 2 | 17 |
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