Editorial
Pediatric sarcopenia: exploring a new concept in children with chronic liver disease
Sarcopenia pediátrica: explorando um novo conceito em crianças com doença hepática crônica
Manuela Merli
Sapienza University of Rome, Department of Translational and Precision Medicine, Gastroenterology and Hepatology Unit, Rome, Italy
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"cabecera" => "<span class="elsevierStyleTextfn">Original article</span>" "titulo" => "Sarcopenia in children and adolescents with chronic liver disease" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "pt" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "439" "paginaFinal" => "446" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Sarcopenia em crianças e adolescentes com doença hepática crônica" ] ] "contieneResumen" => array:2 [ "en" => true "pt" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Ionar Figueredo Bonfim Rezende, Maria Ester P. Conceição-Machado, Viviane Sahade Souza, Elisana M. dos Santos, Luciana R. Silva" "autores" => array:5 [ 0 => array:2 [ "nombre" => "Ionar Figueredo Bonfim" "apellidos" => "Rezende" ] 1 => array:2 [ "nombre" => "Maria Ester P." "apellidos" => "Conceição-Machado" ] 2 => array:2 [ "nombre" => "Viviane Sahade" "apellidos" => "Souza" ] 3 => array:2 [ "nombre" => "Elisana M. dos" "apellidos" => "Santos" ] 4 => array:2 [ "nombre" => "Luciana R." "apellidos" => "Silva" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "pt" => array:9 [ "pii" => "S2255553619300928" "doi" => "10.1016/j.jpedp.2019.05.011" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "pt" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2255553619300928?idApp=UINPBA000049" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0021755718310878?idApp=UINPBA000049" "url" => "/00217557/0000009600000004/v3_202008280702/S0021755718310878/v3_202008280702/en/main.assets" ] ] "en" => array:14 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial</span>" "titulo" => "Pediatric sarcopenia: exploring a new concept in children with chronic liver disease" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "406" "paginaFinal" => "408" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Manuela Merli" "autores" => array:1 [ 0 => array:3 [ "nombre" => "Manuela" "apellidos" => "Merli" "email" => array:1 [ 0 => "Manuela.merli@uniroma1.it" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Sapienza University of Rome, Department of Translational and Precision Medicine, Gastroenterology and Hepatology Unit, Rome, Italy" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Sarcopenia pediátrica: explorando um novo conceito em crianças com doença hepática crônica" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The association between chronic liver disease (CLD) and malnutrition, both in adults and pediatric patients, has been known for a long time.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> Multiple studies have also clearly demonstrated that an impaired nutritional status can be detrimental on the outcome of these patients, increasing their vulnerability to complications and reducing their life expectancy.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3•6</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In the last decades, it has been suggested that muscle wasting should be considered the main component of malnutrition in CLD.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> The reduction in muscle mass is nowadays better defined as sarcopenia. Sarcopenia was initially described as a physiologic process during aging, but chronic diseases may considerably anticipate this event (secondary sarcopenia). The definition of sarcopenia includes both a decrease in muscle mass and reduced muscle function<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>; however, up to now, a large number of studies have mainly focused on the measurement of muscle mass, disregarding the evaluation of muscle function. This could depend on the idea that measurement of muscle mass could be more objective and easier to perform than functional evaluations, the latter also being more time consuming. In adult CLD patients, total muscle area at L3 in a computed tomography (CT) or magnetic resonance imaging (MRI) is considered the gold standard for the diagnosis of sarcopenia<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> and is utilized in the majority of the studies. CT and MRI are usually available in these patients for other clinical indication (before liver transplantation or to study hepatic focal lesions). The importance of focusing on muscle function to confirm sarcopenia and the need to provide clear cut-off points (for age, gender, and ethnicity) to identify patients with muscle impairment have been recently recommended by the revised European consensus on the definition and diagnosis of sarcopenia.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Different mechanism may participate in causing sarcopenia in CLD.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Calorie and protein intake are usually lower than those required due to low appetite, dyspepsia, and erroneous medical prescriptions, malabsorption may be present due to portal hypertension, and energy metabolism may be moderately increased during complications. Furthermore, because liver glycogen stores are depleted due to liver fibrosis, energy metabolism in these patients shows a rapid transition to a “fasting pattern‿ inducing protein catabolism to supply gluconeogenesis. Protein synthesis is also impaired in the muscle of patients with CLD for multiple reasons, such as low testosterone levels, mainly in males, reduced amino acid availability, and chronic hyperammonemia causing increased myostatin levels. For these reasons, patients with advanced liver disease undergo a progressive reduction in muscle mass, which is clearly evident either at anthropometry (arm muscle circumference) or at imaging analysis (CT or MRI). In adult patients with advanced liver disease, sarcopenia is associated with complications such as encephalopathy, infections, or refractory ascites, is a predictor of mortality in the waiting list for liver transplantation, and increases hospital length of stay and hospital costs post-transplant.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,11</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The interest in sarcopenia in children with CLD has only recently been recognized in the pediatric literature<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> and few studies have evaluated the impact of sarcopenia on clinical outcomes in this population. With regard to the presence of reduced muscle mass, this has been measured either by dual-energy X-ray absorptiometry (DEXA), CT, MRI, or bioelectric impedance analysis (BIA). All these methods require cooperation to stay motionless during measurements, which makes these techniques challenging in infants and young children. Furthermore, radiation exposure restricts the use of CT, if not included in clinical staging, and MRI, which is radiation free, is even more expensive. DEXA may represent a useful alternative; however, there is controversy regarding whether all-body skeletal muscle mass and appendicular lean mass perform equally well as markers of sarcopenia. Finally, age- and gender-matched normative data are not always available in healthy children, and the absence of uniform diagnostic criteria has become the main barrier in stating the presence of sarcopenia in children.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The peculiarity of assessing body composition in children is that they are growing individuals. This causes variability between males and females, and according to the child's age. A crucial event is the pubertal growth, which may also be delayed by malnutrition or the underlying disease. During puberty, females are known to gain more fat mass, while in males the increase in fat-free mass is predominant. This may obviously hamper the correct evaluation of sarcopenia.</p><p id="par0030" class="elsevierStylePara elsevierViewall">As mentioned earlier, the assessment of muscle function is crucial for the assessment of sarcopenia since muscle strength is not linearly related to muscle mass. However, this measurement is also frequently missing in studies assessing sarcopenia in children.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Appropriate muscle function tests need to consider the development of coordination, or stability and the competence in purposeful movements in small infants. Motor function assessment scales, taking into consideration muscle strength for the evaluation of sarcopenia, have not been developed for early childhood, and a standardized assessment of muscle function for the diagnosis of sarcopenia is currently lacking in young pediatric patients. In older children or adolescents strength test utilized in adults can also be adopted (hand-grip [HG] test or six-minute walk test); however, normative values in children are not always available and measurements are therefore difficult to evaluate in an objective way.</p><p id="par0040" class="elsevierStylePara elsevierViewall">In this issue of the <span class="elsevierStyleItalic">Jornal of Pediatria</span>, Rendeze et al.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> report descriptive data from children who were pediatric patients with CLD followed at the clinical treatment outpatient clinics, and transplanted patients from the Department of Gastroenterology and Pediatric Hepatology at the Universidade Federal de Bahia (Brazil). There were 85 patients included (64.7% females, mean age 11.7<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>3.4 years, 50% in the pubertal stage) affected by various liver diseases, with biliary atresia and autoimmune hepatitis representing the most frequent etiologies. There were 28 children with a diagnosis of cirrhosis, which was Child-Pugh score A in 82.1%. Sarcopenia was diagnosed based on the simultaneous presence of muscle mass and muscle strength insufficiency. Muscle mass was analyzed by DEXA and muscle strength by HG test. The authors fixed the cutoff for these parameters at the median value obtained in the study population. The diagnosis of sarcopenia was made in 40% of patients. Muscle mass was influenced by gender (higher in males) and age group (<10 <span class="elsevierStyleItalic">vs</span>. >10 or <14 <span class="elsevierStyleItalic">vs</span>. >14 years), but not by BMI or other parameters including body weight.</p><p id="par0045" class="elsevierStylePara elsevierViewall">This study valuably participates in exploring the paradigm of sarcopenia in children with CLD.</p><p id="par0050" class="elsevierStylePara elsevierViewall">CLD is a relevant condition in pediatric patients, which may occur even in the first year of life for some genetic diseases, such as biliary atresia or Alagille syndrome. These patients may develop liver insufficiency and need early liver transplantation, and both malnutrition and sarcopenia may compromise their clinical outcome, as is the case in adult patients. In spite of this, few studies have been dedicated to this issue.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Only three retrospective studies have been published on sarcopenia in children, two in patients with CLD and one in patients after liver transplantation<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14•16</span></a> (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). All these studies underlined that basic nutritional parameters, such as BMI or anthropometry, could underestimate the presence of sarcopenia in children. Mager et al.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> reported that the presence of sarcopenia in liver-transplanted children was associated with some relevant clinical outcomes (growth retardation, length of hospitalization, and rate of re-admission).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">The study by Rendeze et al.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> is the first examining both muscle mass and muscle function in children with CLD, as recommended by the recent EWGSO consensus.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> It is worth noting that although the patients enrolled were less severe (cirrhosis less than 30% compensated • the large majority Child-Pugh class A, followed as outpatients), the authors reported a prevalence of sarcopenia as high as 40%. These results demonstrate the difficulties in comparing different series when methods of assessment and diagnosis are not standardized. Indeed, the study by Rendeze et al.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> utilized an internal comparison for the diagnosis of sarcopenia so that the patients were considered sarcopenic when they were above the median values for appendicular skeletal muscle (ASM) in the enrolled population. The result is that different series may have different cutoffs, which hampers generalization of the results. It is important to emphasize that sarcopenia needs to be evaluated in children with CLD and that future research is needed to improve methods and diagnostic criteria considering the possible confounding factors. The good news is that this process has started.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0065" class="elsevierStylePara elsevierViewall">The author declares no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Merli M. Pediatric sarcopenia: exploring a new concept in children with chronic liver disease. J Pediatr (Rio J). 2020;96:406–8.</p>" ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">See paper by Rezende et al. in pages 439–46.</p>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">ESLD, end-stage liver disease., CT, computed tomography, DEXA, dual-energy X-Ray absorptiometry.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Author/Year \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Patients/number/gender \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Age \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Method of diagnosis \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Evaluation \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Clinical outcome \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mangus 2017<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ESLD/35/ females 60%Age- and sex-matched healthy controls/35. \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mean 7.8 (range 0•17) yrs. \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CT L 2-L3Psoas muscle area/height.No assessment of muscle function. \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Comparison with matched controls. \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">23% sarcopenia in ESLD <span class="elsevierStyleItalic">vs</span>. controls. Female gender: more fat and less muscle.Age 13•17 yrs, higher prevalence of sarcopenia. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Lurz 2018<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ESLD/23/ females 60%Age- and sex-matched healthy controls/46 \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mean 0.9 (range 0.5•3.7) yrs. \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CT L 3-L4Psoas muscle area/height.No assessment of muscle function. \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Comparison with matched controls. \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Psoas muscle area significantly decreased in ESLD children. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mager 2018<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1•8 yrsPost-liver transplantation/41/ females 58%. \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.5•17 years \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">DEXANo assessment of muscle function. \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Skeletal muscle mass <span class="elsevierStyleItalic">z</span>-score<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>2. \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sarcopenia in 40% of post liver transplant children. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2367314.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Studies on sarcopenia in pediatric patients with chronic liver disease.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:16 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Nutrition in end-stage liver disease: principles and practice" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "A. 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| 2024 November | 6 | 5 | 11 |
| 2024 October | 41 | 26 | 67 |
| 2024 September | 37 | 26 | 63 |
| 2024 August | 52 | 36 | 88 |
| 2024 July | 39 | 44 | 83 |
| 2024 June | 21 | 23 | 44 |
| 2024 May | 25 | 13 | 38 |
| 2024 April | 40 | 28 | 68 |
| 2024 March | 19 | 15 | 34 |
| 2024 February | 29 | 39 | 68 |
| 2024 January | 31 | 23 | 54 |
| 2023 December | 24 | 21 | 45 |
| 2023 November | 33 | 35 | 68 |
| 2023 October | 24 | 36 | 60 |
| 2023 September | 35 | 38 | 73 |
| 2023 August | 28 | 18 | 46 |
| 2023 July | 29 | 14 | 43 |
| 2023 June | 17 | 15 | 32 |
| 2023 May | 40 | 14 | 54 |
| 2023 April | 32 | 22 | 54 |
| 2023 March | 31 | 19 | 50 |
| 2023 February | 23 | 14 | 37 |
| 2023 January | 21 | 20 | 41 |
| 2022 December | 40 | 26 | 66 |
| 2022 November | 31 | 28 | 59 |
| 2022 October | 45 | 34 | 79 |
| 2022 September | 42 | 37 | 79 |
| 2022 August | 39 | 31 | 70 |
| 2022 July | 32 | 35 | 67 |
| 2022 June | 46 | 31 | 77 |
| 2022 May | 38 | 35 | 73 |
| 2022 April | 52 | 35 | 87 |
| 2022 March | 41 | 39 | 80 |
| 2022 February | 60 | 37 | 97 |
| 2022 January | 64 | 23 | 87 |
| 2021 December | 33 | 24 | 57 |
| 2021 November | 28 | 13 | 41 |
| 2021 October | 42 | 20 | 62 |
| 2021 September | 25 | 15 | 40 |
| 2021 August | 21 | 10 | 31 |
| 2021 July | 45 | 11 | 56 |
| 2021 June | 33 | 13 | 46 |
| 2021 May | 44 | 15 | 59 |
| 2021 April | 92 | 23 | 115 |
| 2021 March | 83 | 19 | 102 |
| 2021 February | 41 | 16 | 57 |
| 2021 January | 36 | 5 | 41 |
| 2020 December | 45 | 12 | 57 |
| 2020 November | 41 | 24 | 65 |
| 2020 October | 44 | 14 | 58 |
| 2020 September | 65 | 40 | 105 |
| 2020 August | 57 | 31 | 88 |
| 2020 July | 13 | 7 | 20 |
| 2020 June | 25 | 21 | 46 |
| 2020 May | 33 | 26 | 59 |
| 2020 April | 16 | 15 | 31 |
| 2020 March | 17 | 5 | 22 |
| 2020 February | 27 | 7 | 34 |
| 2020 January | 32 | 29 | 61 |
| 2019 December | 18 | 14 | 32 |
| 2019 November | 14 | 5 | 19 |
| 2019 October | 14 | 14 | 28 |
Show all
