Neonatal hyperammonemia is a disorder of ammonia metabolism that occurs in the neonatal period. It is a clinical syndrome characterized by abnormal accumulation of ammonia in the blood and dysfunction of the central nervous system. Due to its low incidence and lack of specificity in clinical manifestations, it is easy to cause misdiagnosis and missed diagnosis. In order to further standardize the diagnosis and treatment of neonatal hyperammonemia, the Youth Commission, Subspecialty Group of Neonatology, Society of Pediatrics, Chinese Medical Association formulated the expert consensus based on clinical evidence in China and overseas and combined with clinical practice experience,and put forward 18 recommendations for the diagnosis and treatment of neonatal hyperaminemia.
新生儿高氨血症是一种发生于新生儿期的氨代谢紊乱，以血液中氨的异常积累、中枢神经系统功能障碍为主要表现的临床综合征。由于其发病率较低，且临床表现缺乏特异性，易造成误诊、漏诊。为进一步规范新生儿高氨血症的诊断与治疗，中华医学会儿科学分会新生儿学组青年委员会基于国内外临床证据，结合临床实践经验，制定了该专家共识，对新生儿高氨血症的诊断和治疗提出了18条推荐意见。.

Six tropical freshwater species were used to assess the toxicity of mine waters from a uranium mine adjacent to a World Heritage area in northern Australia. Key contaminants of potential concern for the mine were U, Mg, Mn, and total ammonia nitrogen (TAN). Direct toxicity assessments were carried out to assess whether the established site-specific guideline values for individual contaminants would be protective with the contaminants occurring as mixtures. Metal speciation was calculated for contaminants to determine which were the major contributors of toxicity, with 84 to 96% of Mg predicted in the free-ion form as Mg2+ , and 76 to 92% of Mn predicted as Mn2+ . Uranium, Al, and Cu were predicted to be strongly bound to fulvic acid. Uranium, Mg, Mn, and Cu were incorporated into concentration addition or independent action mixture toxicity models to compare the observed toxicity in each of the waters with predicted toxicity. For >90% of the data, mine-water toxicity was less than predicted by the concentration addition model. Instances where toxicity was greater than predicted were accompanied by exceedances of individual metal guideline values in all but one case (i.e., a Mg concentration within 10% of the guideline value). This indicates that existing individual water quality guideline values for U, Mg, Mn, and TAN would adequately protect ecosystems downstream of the mine. Environ Toxicol Chem 2021;40:2334-2346. © 2021 Commonwealth of Australia. Environmental Toxicology and Chemistry © 2021 SETAC.

Management of hepatic encephalopathy (HE) remains challenging from a medical and psychosocial perspective. Members of the International Society for Hepatic Encephalopathy and Nitrogen Metabolism recognized 5 key unresolved questions in HE management focused on (i) driving, (ii) ammonia levels in clinical practice, (iii) testing strategies for covert or minimal HE, (iv) therapeutic options, and (v) nutrition and patient-reported outcomes. The consensus document addresses these topical issues with a succinct review of the literature and statements that critically evaluate the current science and practice, laying the groundwork for future investigations.

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In 2012, we published guidelines summarizing and evaluating late 2011 evidence for diagnosis and therapy of urea cycle disorders (UCDs). With 1:35 000 estimated incidence, UCDs cause hyperammonemia of neonatal (~50%) or late onset that can lead to intellectual disability or death, even while effective therapies do exist. In the 7 years that have elapsed since the first guideline was published, abundant novel information has accumulated, experience on newborn screening for some UCDs has widened, a novel hyperammonemia-causing genetic disorder has been reported, glycerol phenylbutyrate has been introduced as a treatment, and novel promising therapeutic avenues (including gene therapy) have been opened. Several factors including the impact of the first edition of these guidelines (frequently read and quoted) may have increased awareness among health professionals and patient families. However, under-recognition and delayed diagnosis of UCDs still appear widespread. It was therefore necessary to revise the original guidelines to ensure an up-to-date frame of reference for professionals and patients as well as for awareness campaigns. This was accomplished by keeping the original spirit of providing a trans-European consensus based on robust evidence (scored with GRADE methodology), involving professionals on UCDs from nine countries in preparing this consensus. We believe this revised guideline, which has been reviewed by several societies that are involved in the management of UCDs, will have a positive impact on the outcomes of patients by establishing common standards, and spreading and harmonizing good practices. It may also promote the identification of knowledge voids to be filled by future research.

Freshwater mussels play key roles in aquatic ecosystems, but are experiencing a global decline. Although studies have reported high acute sensitivity of mussels to some contaminants, chronic toxicity data are lacking for deriving high-reliability water quality guideline values. Ammonia is a contaminant of potential concern in some catchments of tropical northern Australia, where freshwater mussels are important ecological and cultural components. The extremely soft waters (hardness < 5 mg/L) of these environments can result in increased toxicity of many contaminants including ammonia, and regionally relevant tropical guideline values are needed to adequately protect these unique ecosystems. An optimized 14-d toxicity test protocol was used to assess the chronic toxicity of ammonia for 2 species, the lotic Velesunio sp. and the lentic Velesunio angasi. Ammonia exposures were conducted at pH 6.0 and 27 ± 0.5 °C to represent local environmental conditions, using shell length growth rate as the endpoint. Chronic toxicity estimates indicated high sensitivity to ammonia, with mean median effect concentrations (in total ammonia nitrogen) being 7.0 mg/L for V. angasi from the semi-urbanized Lake Bennett, 9.2 mg/L for V. angasi from Sandy Billabong, and 11.3 mg/L for Velesunio sp. from Gulungul Creek. When the 10% effect concentration values were compared with other chronic ammonia data (normalized to pH 7.0 and 20 °C), Velesunio spp. were found to be more sensitive than 8 of 16 other temperate and 7 of 9 tropical invertebrate and fish species. These chronic toxicity estimates will be used to further inform regionally relevant and site-specific guideline values. Environ Toxicol Chem 2019;38:841-851. © 2019 Commonwealth of Australia. Published by Wiley Periodicals Inc. on behalf of SETAC.

BACKGROUND: Hyperammonemia is a life-threatening event that can occur at any age. If treated, the early symptoms in all age groups could be reversible. If untreated, hyperammonemia could be toxic and cause irreversible brain damage to the developing brain.
OBJECTIVE: There are major challenges that worsen the outcome of hyperammonemic individuals in the Middle East. These include: lack of awareness among emergency department physicians about proper management of hyperammonemia, strained communication between physicians at primary, secondary, and tertiary hospitals, and shortage of the medications used in the acute management of hyperammonemia. Therefore, the urge to develop regional guidelines is extremely obvious.
METHODS: We searched PubMed and Embase databases to include published materials from 2011 to 2014 that were not covered by the European guidelines, which was published in 2012. We followed the process of a Delphi conference and involved one preliminary meeting and two follow-up meetings with email exchanges between the Middle East Hyperammonemia and Urea Cycle Disorders Scientific Group regarding each draft of the manuscript.
CONCLUSIONS: We have developed consensus guidelines based on the highest available level of evidence. The aim of these guidelines is to homogenize and harmonize the treatment protocols used for patients with acute hyperammonemia, and to provide a resource to not only metabolic physicians, but also physicians who may come in contact with individuals with acute hyperammonemia.
CONCLUSIONS: These suggested guidelines aim to ease the challenges faced by physicians dealing with acute hyperammonemia in the region. In addition, guidelines have demonstrated useful collaboration between experts in the region, and provides information that will hopefully improve the outcomes of patients with acute hyperammonemia.

Unionised ammonia (NH3) is highly toxic to freshwater organisms. Yet, most of the available toxicity data on NH3 were predominantly generated from temperate regions, while toxicity data on NH3 derived from tropical species were limited. To address this issue, we first conducted standard acute toxicity tests on NH3 using ten tropical freshwater species. Subsequently, we constructed a tropical species sensitivity distribution (SSD) using these newly generated toxicity data and available tropical toxicity data of NH3, which was then compared with the corresponding temperate SSD constructed from documented temperate acute toxicity data. Our results showed that tropical species were generally more sensitive to NH3 than their temperate counterparts. Based on the ratio between temperate and tropical hazardous concentration 10% values, we recommend an extrapolation factor of four to be applied when surrogate temperate toxicity data or temperate water quality guidelines of NH3 are used for protecting tropical freshwater ecosystems.

The lack of Australian species data has pragmatically led to the use of toxicological data from the Northern Hemisphere to develop water-quality guidelines. However, it is unknown whether Australian species and ecosystems are equally as sensitive and if an uncertainty factor is warranted for Australian guideline setting. In the present study, it is hypothesized that an uncertainty factor is not required. This was tested by generating species sensitivity distributions by 2 parametric methods using marine Northern Hemisphere and Australian/New Zealand data. Sufficient acute data were found for only 3 compounds: 4-chlorophenol, phenol, and ammonia. For ammonia and 4-chlorophenol, the 95% species protection levels generated with Australian and Northern Hemisphere data were essentially the same. For phenol, protection levels derived from Australian data were approximately 10-fold higher. Therefore, the derived benchmark concentration from Northern Hemisphere data should be protective. It is tentatively concluded that there is no need for an uncertainty factor when deriving water-quality guidelines for marine Australian ecosystems using Northern Hemisphere data. It is, however, noted that this is based on only 3 compounds.

This study examined the acute median lethal concentration (LC(50)) and the non-lethal threshold concentration (LC(01)) of ammonia in male and female Wistar rats nose-only exposed at exposure durations of either 1 or 4 h. Additional attributes characterizing the acute toxicity of inhaled ammonia were determined during a post-exposure period of 2 weeks. The objective of this study is to further refine the methodology applied to derive Emergency Response Planning Guideline (ERPG) values on potent sensory irritants in a controlled rat bioassay. In the more susceptible male rats the 1- and 4-h LC(50) (LC(01)) were 12,303 (10,067) and 4923 (4028) mg/m(3), respectively. At sublethal exposure levels the ventilation of rats was about one third of normal breathing. This change in ventilation and inhalation dosimetry was adjusted for Cxt-dependent lethal endpoints whereas sensory irritation-related phenomena were C-dependently adjusted. In summary, the outcome of this study shows that C- and C × t-dependent causes of toxicity need to be appreciated when extrapolating across species with species-specific inhalation dosimetry. It also appears to be indispensable that each exposure metric must be disentangled when translating C × t-dependent lethality and reflexively-induced, sensation-based C-dependent point of departures. For one hour exposure periods, these PODs were derived to be 1500 and 500 ppm, respectively.