Editorial
The nuances of age as an outcome predictor
Las sutilezas de la edad como predictor del resultado clínico
T.L. Higgins
Corresponding author
Vice Chair - Clinical Affairs, Department of Medicine, Baystate Medical Center, Springfield, Massachusetts, USA. Professor of Medicine, Surgery & Anesthesiology, Tufts University School of Medicine, Boston, Massachusetts, USA
M.J. Brennan
Interim Chief, Division of Geriatrics, Palliative Care and Postacute Medicine, Department of Medicine, Baystate Medical Center, Associate Professor of Medicine, Tufts University School of Medicine, Boston, Massachusetts, USA
Read
888
Timeswas read the article
529
Total PDF
359
Total HTML
Share statistics
array:23 [ "pii" => "S001425651300372X" "issn" => "00142565" "doi" => "10.1016/j.rce.2013.11.006" "estado" => "S300" "fechaPublicacion" => "2014-03-01" "aid" => "864" "copyright" => "Elsevier España, S.L.. All rights reserved" "copyrightAnyo" => "2013" "documento" => "simple-article" "crossmark" => 0 "subdocumento" => "edi" "cita" => "Rev Clin Esp. 2014;214:85-6" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 757 "formatos" => array:2 [ "HTML" => 355 "PDF" => 402 ] ] "itemSiguiente" => array:19 [ "pii" => "S0014256513002841" "issn" => "00142565" "doi" => "10.1016/j.rce.2013.08.011" "estado" => "S300" "fechaPublicacion" => "2014-03-01" "aid" => "834" "copyright" => "Elsevier España, S.L." "documento" => "simple-article" "crossmark" => 0 "subdocumento" => "crp" "cita" => "Rev Clin Esp. 2014;214:87-93" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 1543 "formatos" => array:2 [ "HTML" => 1198 "PDF" => 345 ] ] "es" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Actualización Clínica</span>" "titulo" => "Carcinoma anal e infección por el virus de la inmunodeficiencia humana: ¿es la hora del cribado?" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "87" "paginaFinal" => "93" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Anal carcinoma and HIV infection: Is it time for screening?" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1182 "Ancho" => 1662 "Tamanyo" => 153785 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Algoritmo de actuación en el cribado del carcinoma anal.</p> <p id="spar1025" class="elsevierStyleSimplePara elsevierViewall">Fuente: Palefsky et al<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a>.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "P. Herranz-Pinto, E. Sendagorta-Cudós, J.I. Bernardino-de la Serna, J.M. Peña-Sánchez de Rivera" "autores" => array:4 [ 0 => array:2 [ "nombre" => "P." "apellidos" => "Herranz-Pinto" ] 1 => array:2 [ "nombre" => "E." "apellidos" => "Sendagorta-Cudós" ] 2 => array:2 [ "nombre" => "J.I." "apellidos" => "Bernardino-de la Serna" ] 3 => array:2 [ "nombre" => "J.M." "apellidos" => "Peña-Sánchez de Rivera" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2254887414000125" "doi" => "10.1016/j.rceng.2013.08.001" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2254887414000125?idApp=WRCEE" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0014256513002841?idApp=WRCEE" "url" => "/00142565/0000021400000002/v2_201404030127/S0014256513002841/v2_201404030127/es/main.assets" ] "itemAnterior" => array:18 [ "pii" => "S0014256514000198" "issn" => "00142565" "doi" => "10.1016/j.rce.2014.01.013" "estado" => "S300" "fechaPublicacion" => "2014-03-01" "aid" => "905" "copyright" => "Elsevier España, S.L." "documento" => "simple-article" "crossmark" => 0 "subdocumento" => "edi" "cita" => "Rev Clin Esp. 2014;214:83-4" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 603 "formatos" => array:2 [ "HTML" => 346 "PDF" => 257 ] ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial</span>" "titulo" => "The gender gap in academic leadership" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "83" "paginaFinal" => "84" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "La brecha de género en el liderazgo académico" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Elaine M. Hylek" "autores" => array:1 [ 0 => array:2 [ "nombre" => "Elaine M." "apellidos" => "Hylek" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0014256514000198?idApp=WRCEE" "url" => "/00142565/0000021400000002/v2_201404030127/S0014256514000198/v2_201404030127/en/main.assets" ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial</span>" "titulo" => "The nuances of age as an outcome predictor" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "85" "paginaFinal" => "86" ] ] "autores" => array:2 [ 0 => array:4 [ "autoresLista" => "T.L. Higgins" "autores" => array:1 [ 0 => array:4 [ "nombre" => "T.L." "apellidos" => "Higgins" "email" => array:1 [ 0 => "thomas.higgins@baystatehealth.org" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Vice Chair - Clinical Affairs, Department of Medicine, Baystate Medical Center, Springfield, Massachusetts, USA. Professor of Medicine, Surgery & Anesthesiology, Tufts University School of Medicine, Boston, Massachusetts, USA" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] 1 => array:3 [ "autoresLista" => "M.J. Brennan" "autores" => array:1 [ 0 => array:2 [ "nombre" => "M.J." "apellidos" => "Brennan" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Interim Chief, Division of Geriatrics, Palliative Care and Postacute Medicine, Department of Medicine, Baystate Medical Center, Associate Professor of Medicine, Tufts University School of Medicine, Boston, Massachusetts, USA" "identificador" => "aff0010" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Las sutilezas de la edad como predictor del resultado clínico" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Old people die. Young people tend to survive. Our observation of the world around us leads us to this conclusion even before medical training. The influence of age on outcome is quantified in benchmarking tools such as Acute Physiology and Chronic Health Evaluation (APACHE),<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> the Mortality Probability Models (MPM)<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> and the Simplified Acute Physiology Score (SAPS).<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">However, age is not the most important predictor of outcome; a more nuanced approach considers the interactions between chronologic age, physiologic age and comorbidities.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> While mortality increases with the passage of time, risk differs significantly by patient subset and even the oldest ICU patients may fare well if other risk factors are absent.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> In the present study,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> the authors have shown that geriatric patients in the ICU are more likely to die and require tracheostomies and renal replacement therapy but they do not necessarily have longer lengths of stay. It remains unclear to what extent this finding reflects selection bias in ICU admissions or shifts in goals of care over time. In addition, elders are an extremely heterogeneous group and it is likely desirable to focus on smaller subsets of patients rather than the terciles of age examined in this study. Geriatricians typically consider those under 75 the “young old” and those over 85 years the “old old”.</p><p id="par0015" class="elsevierStylePara elsevierViewall">This report adds to the literature by examining a subset of patients hospitalized for 14 or more days in intensive care and tracks outcomes to one year post hospitalization. The authors are quite correct that admissions of elders to critical care will continue to increase; we agree that a careful approach to triage decisions should not be based on age alone but must consider the severity of illness, comorbidities, and the patient's previous functional state. In short, the best assessment of prognosis from all available sources as well as patient preferences must inform decisions about ICU admissions.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The influence of age on outcome is not linear, and the inflection point at which risk becomes exponential varies by patient. It is possible to see a poorly controlled 45-year-old diabetic with less physiologic reserve than a robust nonagenarian. There is no question that physiologic reserve shrinks over time; this is termed “homeostenosis” in the geriatrics literature. It is why we seldom see world class athletes in the later decades of life. In essence, a 20-year old dances in a gymnasium and even extreme excursions are unlikely to result in a collision with a wall while the nonagenarian dances in a closet. The rate at which the room shrinks, however, is entirely variable and influenced by genetic factors, declining reserves in major organ systems (pulmonary, renal), damage to the infrastructure (vasculopathy from diabetes) and perhaps changes over time within the populations of mitochondria.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> The situation is further complicated by a host of lifestyle choices such as the extent of physical activity, personality structure and even the richness of the patient's social network.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Age is associated with physiologic decay, but real age and chronologic age are not identical. Unfortunately most databases lack adequate markers of frailty which might elucidate functional and physiologic reserves. Cognitive impairment, diminished activity levels, poor nutrition, and similar measures of preexisting vulnerabilities are rarely tracked, but may be far more useful than chronologic age in predicting outcomes. The challenge for future researchers will be to incorporate geriatric-specific predictors into outcome analysis. This work has begun for medicine and some surgical specialties, an example being Min et al's study of older adults admitted with trauma.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Those authors showed that the Vulnerable Elders Survey (VES 13) improved prediction of morbidity and mortality when added to existing risk stratification tools.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Finally, mortality is not the only outcome of interest; the authors acknowledge this by examining length of stay, and interventions such as tracheotomies and renal replacement therapy. Future investigation should also examine “geriatrics” outcomes such as functional decline, cognitive impairment, increased dependence and institutionalization following critical illness. Better defining the full range of outcomes meaningful to patients and their loved ones is vitally important. The financial and human “costs” of achieving those results must also be clarified. The latter include not only interventions such as tracheostomies but also multiple other “geriatrics” outcomes such as delirium, pressure ulcers, falls, incontinence and the onset of frailty and all that implies. Knowledge of expected outcomes and the likely price required to achieve them will help clinicians guide therapeutic choices for critically ill elders and their struggling families.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Acute Physiology and Chronic Health Evaluation (APACHE) IV: hospital mortality assessment for today's critically ill patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "J.E. Zimmerman" 1 => "A.A. Kramer" 2 => "McNair" 3 => "F.M. Malila" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/01.CCM.0000215112.84523.F0" "Revista" => array:6 [ "tituloSerie" => "Crit Care Med" "fecha" => "2006" "volumen" => "34" "paginaInicial" => "1297" "paginaFinal" => "1310" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16540951" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Assessing contemporary intensive care unit outcomes: an updated Mortality Probability Admission Model (MPM0-III)" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "T.L. Higgins" 1 => "D. Teres" 2 => "W.S. Copes" 3 => "B.H. Nathanson" 4 => "M. Stark" 5 => "A.A. Kramer" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/01.CCM.0000257337.63529.9F" "Revista" => array:6 [ "tituloSerie" => "Crit Care Med" "fecha" => "2007" "volumen" => "35" "paginaInicial" => "827" "paginaFinal" => "835" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17255863" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Saps 3 – from evaluation of the patient to evaluation of the intensive care unit. Part 2: development of a prognostic model for hospital mortality at ICU admission" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "G. Iapichino" 1 => "D. Edbrooke" 2 => "M. Capuzzo" 3 => "J.R. Le Gall" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Intern Care Med" "fecha" => "2005" "volumen" => "31" "paginaInicial" => "1345" "paginaFinal" => "1355" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Do elderly patients fare well in the ICU?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "B.H. Nathanson" 1 => "T.L. Higgins" 2 => "M.J. Brennan" 3 => "A.A. Kramer" 4 => "M. Stark" 5 => "D. Teres" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1378/chest.10-1233" "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "2011" "volumen" => "139" "paginaInicial" => "825" "paginaFinal" => "831" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21071528" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Frailty, fitness and late-life mortality in relation to chronological and biological age" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "A.B. Mitnitski" 1 => "J.E. Graham" 2 => "J. Mogilner" 3 => "K. Rockwood" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1186/1471-2318-2-1" "Revista" => array:3 [ "tituloSerie" => "BMC Geriatr" "fecha" => "2002" "volumen" => "2" ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Influence of age on length of stay and on the mortality of patients who remain for an extended period in intensive care units" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "L. Santana-Cabrera" 1 => "R. Lorenzo-Torrent" 2 => "M. Sánchez-Palacios" 3 => "J. Josefa Delia Martín Santana" 4 => "J.R. Juan Ramón Hernández Hernández" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:2 [ "tituloSerie" => "Rev Clin Esp" "fecha" => "2014" ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Larsson: mitochondrial dysfunction as a cause of ageing" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "A. Trifunovic" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1365-2796.2007.01905.x" "Revista" => array:6 [ "tituloSerie" => "J. Intern. Med." "fecha" => "2008" "volumen" => "263" "paginaInicial" => "167" "paginaFinal" => "178" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18226094" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0040" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The Vulnerable Elders Survey-13 predicts hospital complications and mortality in older adults with traumatic injury: a pilot study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "L. Min" 1 => "N. Ubhayakar" 2 => "D. Saliba" 3 => "L. Kelley-Quon" 4 => "E. Morley" 5 => "J. Hiatt" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1532-5415.2011.03493.x" "Revista" => array:6 [ "tituloSerie" => "J Am Geriatr Soc" "fecha" => "2011" "volumen" => "59" "paginaInicial" => "1471" "paginaFinal" => "1476" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21718276" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/00142565/0000021400000002/v2_201404030127/S001425651300372X/v2_201404030127/en/main.assets" "Apartado" => array:4 [ "identificador" => "1020" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Editoriales" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/00142565/0000021400000002/v2_201404030127/S001425651300372X/v2_201404030127/en/main.pdf?idApp=WRCEE&text.app=https://revclinesp.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S001425651300372X?idApp=WRCEE" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 0 | 6 | 6 |
| 2024 September | 0 | 1 | 1 |
| 2024 July | 0 | 1 | 1 |
| 2024 June | 0 | 2 | 2 |
| 2024 May | 0 | 2 | 2 |
| 2024 April | 0 | 3 | 3 |
| 2024 March | 0 | 3 | 3 |
| 2023 December | 0 | 4 | 4 |
| 2023 November | 0 | 2 | 2 |
| 2023 October | 0 | 14 | 14 |
| 2023 August | 0 | 4 | 4 |
| 2023 July | 0 | 2 | 2 |
| 2023 May | 0 | 2 | 2 |
| 2023 March | 4 | 4 | 8 |
| 2023 February | 0 | 6 | 6 |
| 2022 December | 0 | 5 | 5 |
| 2022 November | 0 | 1 | 1 |
| 2022 October | 0 | 5 | 5 |
| 2022 September | 0 | 10 | 10 |
| 2022 August | 0 | 1 | 1 |
| 2022 July | 0 | 1 | 1 |
| 2022 June | 0 | 1 | 1 |
| 2022 May | 0 | 1 | 1 |
| 2022 February | 0 | 1 | 1 |
| 2021 December | 0 | 3 | 3 |
| 2021 October | 0 | 1 | 1 |
| 2021 August | 0 | 2 | 2 |
| 2021 July | 0 | 2 | 2 |
| 2021 June | 0 | 1 | 1 |
| 2021 May | 0 | 5 | 5 |
| 2021 April | 0 | 5 | 5 |
| 2021 March | 0 | 2 | 2 |
| 2021 February | 0 | 2 | 2 |
| 2020 December | 0 | 3 | 3 |
| 2020 November | 0 | 8 | 8 |
| 2020 August | 0 | 4 | 4 |
| 2020 July | 0 | 1 | 1 |
| 2020 June | 0 | 1 | 1 |
| 2020 May | 0 | 3 | 3 |
| 2020 April | 0 | 1 | 1 |
| 2020 March | 0 | 1 | 1 |
| 2020 January | 0 | 3 | 3 |
| 2019 December | 0 | 2 | 2 |
| 2019 November | 0 | 1 | 1 |
| 2019 October | 0 | 3 | 3 |
| 2019 September | 0 | 2 | 2 |
| 2019 August | 0 | 6 | 6 |
| 2019 July | 0 | 2 | 2 |
| 2019 June | 1 | 11 | 12 |
| 2019 May | 0 | 11 | 11 |
| 2019 April | 0 | 5 | 5 |
| 2019 March | 0 | 2 | 2 |
| 2019 February | 0 | 4 | 4 |
| 2019 January | 0 | 2 | 2 |
| 2018 December | 0 | 5 | 5 |
| 2018 November | 0 | 9 | 9 |
| 2018 August | 0 | 2 | 2 |
| 2018 June | 0 | 2 | 2 |
| 2018 May | 0 | 1 | 1 |
| 2018 February | 44 | 6 | 50 |
| 2018 January | 24 | 13 | 37 |
| 2017 December | 34 | 11 | 45 |
| 2017 November | 23 | 11 | 34 |
| 2017 October | 11 | 9 | 20 |
| 2017 September | 12 | 10 | 22 |
| 2017 August | 8 | 13 | 21 |
| 2017 July | 7 | 10 | 17 |
| 2017 June | 19 | 10 | 29 |
| 2017 May | 13 | 16 | 29 |
| 2017 April | 11 | 22 | 33 |
| 2017 March | 13 | 97 | 110 |
| 2017 February | 14 | 12 | 26 |
| 2017 January | 16 | 12 | 28 |
| 2016 December | 14 | 12 | 26 |
| 2016 November | 11 | 12 | 23 |
| 2016 October | 23 | 16 | 39 |
| 2016 September | 13 | 3 | 16 |
| 2016 August | 27 | 6 | 33 |
| 2016 July | 16 | 7 | 23 |
| 2016 June | 0 | 13 | 13 |
| 2016 May | 1 | 4 | 5 |
| 2016 February | 0 | 1 | 1 |
| 2016 January | 0 | 3 | 3 |
Show all
