Urea is passed through the body in urine. Healthcare providers also use hemodialysis, a procedure where a dialysis machine and a special filter called an artificial kidney clean your blood, to remove ammonia from the newborns blood. mortality rate; ROC curve; sepsis; serum ammonia; SOFA score. Madison (WI): University of Wisconsin Hospitals and Clinics Authority; c2019. The side effects of sodium benzoate may include: Glycerol phenylbutyrate works in the pancreas. Normal blood levels of ammonia vary according to age and are higher in newborns compared to older children or adults. Serum ammonia and SOFA score are independent risk factors for 28-day mortality rate in septic patients. Some people with asthma may be more sensitive to breathing ammonia than others. They may also order a urinalysis (urine test). [11]. We link primary sources including studies, scientific references, and statistics within each article and also list them in the resources section at the bottom of our articles. If you have liver disease or have a family history of urea cycle disorders (UCDs), talk to your healthcare provider about your risk of developing hyperammonemia. My father was diagnosed with end-stage liver disease, cirrhosis, and hepatic encephalopathy about 5 years ago. An ammonia level of 79.5 mol/L was associated with a My Dad is in hospital with cirrhosis of liver and they cannot seem to get his ammonia levels down. How long youve had elevated ammonia levels. Carefully managing your intake of prescription and over-the-counter medications to avoid liver damage. [10]. Specialty low-protein formulas are available for toddlers and infants who require a protein restriction. Several conditions can cause hyperammonemia, and certain conditions are more likely to be the cause at different ages. Perhaps there is a counselor at the hospital who can help you and your children find out answers to questions. Herpes spreads by oral, vaginal and anal sex. WebPhysical Description. Hyperammonemia should be recognized early and treated immediately to prevent the development of life-threatening complications such as cerebral edema and They may diagnose hyperammonemia in adults if blood ammonia levels are above 30 micromol/L. Multivariate logistic regression models were employed to determine independent risk factors affecting 28-day mortality rate, and receiver operating characteristic (ROC) curve was also used to evaluate the efficacy of risk factors. Available from: Merck Manual Consumer Version [Internet]. One 2018 review suggests that altering the gut microbiota may help treat high ammonia levels in the blood. Madison (WI): University of Wisconsin Hospitals and Clinics Authority; c2019. Ammonia levels were drawn for 46% of patients; 60% of tested patients had elevated levels. This was a 2-center retrospective study. Lindsey Desoto is a registered dietitian with experience working with clients to improve their diet for health-related reasons. In recent years, it has been confirmed by a series of studies that acute gastrointestinal injury caused by sepsis is a cause leading to the aggravation and poor prognosis of septic patients. However, whether serum ammonia levels can be used to evaluate prognosis among septic patients is yet to be determined. Hyperammonemia is a metabolic condition that happens when you have elevated levels of ammonia in your blood. Normal value ranges may vary slightly among different laboratories. Herpes sores blister, then burst, scab and heal. Madison (WI): University of Wisconsin Hospitals and Clinics Authority; c2019. Fay KT, Ford ML, Coopersmith CM. High ammonia levels are life-threatening and require immediate medical treatment. A blood ammonia level of 200 micromol /L is associated with coma and convulsions. Liver dysfunction in, [8]. Is the ketogenic diet right for autoimmune conditions? Higher than normal ammonia levels suggest that a person's liver cannot effectively excrete or process ammonia as it should, resulting in a buildup of toxic waste. How high before you go into a coma? A 2-sided P-value was set as .05 and power of the test was set as 80%. Colorless gas with a pungent, suffocating odor. You should not exercise or smoke cigarettes for about eight hours before an ammonia test. So sorry to hear about your father I am sure this is so difficult to live through for you. Boiling Point. I agree with Hector and others who have said your ex-husband should be cared for in a hospital with a transplant center and a hepatologist. Pediatrics [Internet]. High ammonia levels in the blood often indicate a problem with the liver, but other underlying conditions can also be responsible. cDisaster Medicine Center, Sichuan University, Chengdu, China. WebThe ammonia level, C reactive protein, SOFA score, and the leukocyte are independent risk factors for 28-day mortality rate in septic patients. 81801883 to YRH), the Discipline Excellence Development 135 Project of West China Hospital, Sichuan University (Grant No. Symptoms of high blood sugar or low blood sugar usually develop before a diabetic coma. NOTE: Ammonia levels don't always correlate with HE. [1420] Second, sepsis also results in gastrointestinal mucosa swelling, defective barrier function, and intestinal bacterial translocation. It is important to speak with your provider to understand the meaning of your specific results. Thank you all for your help. Individuals are instructed not to exercise or smoke cigarettes for at least eight hours before the test. Available from: UF Health: University of Florida Health [Internet]. Perhaps you could schedule a meeting for your adult children and yourself to meet with the hospice provider and/or with the doctor to ask these questions. Both types of transplants come with possible side effects. High ammonia levels, also known as hyperammonemia, often occur due to issues with the liver. My father was diagnosed with end-stage liver disease, cirrhosis, and hepatic encephalopathy about 5 years ago. In this 2-center retrospective study, we demonstrated that elevated ammonia level on admission was significantly higher in septic patients with 28-day mortality. Multiple types and stages of liver disease can lead to liver failure. All rights reserved. Eum HA, Park SW, Lee SM. The former study in our hospital showed the 28-day mortality of the septic patients of approximately 30%. Health Information: Ammonia: How It is Done; [updated 2018 Jun 25; cited 2019 Jul 10]; [about 5 screens]. Its acute onset, rapid progress, and high mortality rate make timely assessment of the disease and its prognosis particularly important for physicians specializing in severe acute diseases. Higher than normal blood ammonia levels are called hyperammonemia. 2017 (279)). It may help lower blood ammonia levels in people with hepatic encephalopathy, a severe nervous system disorder that occurs due to advanced liver disease. Freezing Point. Condoms are the most effective way to prevent HIV and STDs. This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial License 4.0 (CCBY-NC), where it is permissible to download, share, remix, transform, and buildup the work provided it is properly cited. The information on this site should not be used as a substitute for professional medical care or advice. The problem can also be caused by kidney failure and certain genetic disorders. Characteristics of infection and its impact on short-term outcome in patients with acute-on-chronic liver failure. Additionally, it may only reduce ammonia levels by a minor amount. Contact a health care provider if you have questions about your health. Under normal circumstances, ammonia is processed in the liver, where it is turned into a less toxic chemical called urea and eliminated through the urine. The two most common causes are liver disease and urea cycle disorders. Assessment of normality of continuous variables was conducted using the SkewnessKurtosis test. They recommend additional studies to help determine whether AST-120 can help people with advanced liver disease. The symptoms he The leukocyte, C-reactive protein (CRP), total bile acid, serum ammonia and SOFA score were significantly lower in the 28-day survival group than those in the death group (P < .05), while the GCS score were significantly higher in the survival group than those in the death group (P < .05) (Table 2). What Do Herpes Sores Look Like at Different Stages. Bethesda (MD): U.S. Department of Health and Human Services; How is newborn screening done? A case report of a child with, [6]. Other possible causes of hyperammonemia include: Hyperammonemia can cause many different symptoms depending on how mild or severe it is and at which age you develop it. Brain herniation (when brain tissue moves) this is most often caused by brain swelling and intracranial pressure. An ammonia level of 79.5 mol/L was associated with a higher frequency of organ failures (liver [P = 0.004], coagulation [P < 0.001], kidney [P = 0.004], and respiratory [P < 0.001]). UCDs can result in acute and/or chronic hyperammonemia. WebIt is most commonly used to diagnose and monitor hepatic encephalopathy, a severe liver disease. WebExposure to high levels of ammonia in air may be irritating to your skin, eyes, throat, and lungs and cause coughing and burns. Available from: University of Rochester Medical Center [Internet]. The level of exposure depends upon dose, duration, and work being done. We disclaim all responsibility for the professional qualifications and licensing of, and services provided by, any physician or other health providers posting on or otherwise referred to on this Site and/or any Third Party Site. An elevated blood ammonia level can have fatal complications and may be a sign of underlying disease. Since hyperammonemia occurs as a result of several different conditions, researchers lack data on how common it is. Treatments for high ammonia levels aim to reduce the amount of ammonia in the blood and manage complications. Reintam Blaser A, Malbrain ML, Starkopf J, et al. Possible side effects can include severe stomach cramping and diarrhea. I have stage 4 liver cirrhosis,also have pbc, my cirrhosis ic decompensated The 28-day mortality rate was 30.06%. Tink it's very sad and I'm sorry for your family. I was so confused until I saw Lynn's link and your post. People who experience symptoms of high blood ammonia levels, such as sudden confusion, fatigue, or unconsciousness, should have their ammonia levels tested. If you or someone you know is experiencing symptoms of high ammonia levels, call 911 or go to your nearest emergency room for evaluation. To test a newborn, a healthcare provider will clean your baby's heel and poke their heel with a small needle. WebAn ammonia level of 79.5 mol/L had sensitivity of 68.1% and specificity of 67.4% for predicting 28-day mortality. The AUC of ammonia is significantly higher than the leukocyte (P < .001) and CRP (P < .001) as well (Table 5). Even slightly elevated levels (hyperammonemia) are toxic to your central nervous system (CNS). A total of 316 septic patients were enrolled in this study, including 201males (63.6%), with an average age of 63.82 0.91 years. MedHelp is not a medical or healthcare provider and your use of this Site does not create a doctor / patient relationship. High ammonia levels in the blood often indicate a problem with the liver, but other underlying conditions can also be responsible. Schizophrenia: Researchers say network disruptions in the brain may be a factor, Schizophrenia: How blood vessel growth in the brain may be a factor, Why adults in rural areas face higher risk of heart failure, What to know about liver failure and liver disease stages. By Lindsey DeSoto, RD, LD Ammonia is a toxic waste product produced by bacteria in the intestines during protein digestion. Normal Results The normal range is 15 to 45 /dL (11 to 32 mol/L). Coming to a Cleveland Clinic location?Hillcrest Cancer Center check-in changesCole Eye entrance closingVisitation, mask requirements and COVID-19 information, Notice of Intelligent Business Solutions data eventLearn more. Both the SOFA score and the serum ammonia had the ideal predictive value, with the area under the ROC curve (AUC) of 0.815, and 0.813. As always you all are in my thoughts and prayers. Second, certain biochemical indicators and clinical symptoms are missing for some septic patients included in this study and could not be further confirmed, which may have led to bias in research findings. Another factor could be pain medications. She has had liver function tests and biopsies for years now and have determined the problem isn't her liver. The prognosis (outlook) for hyperammonemia depends on a few factors, including: In general, the prognosis for hyperammonemia is poor. Wednesday was 149, yesterday Available from: National Cancer Institute [Internet]. Philadelphia: Wolters Kluwer Health, Lippincott Williams & Wilkins; c2014. The predictive prognostic values of serum TNF-( in comparison to. WebExposure to high levels of ammonia in air may be irritating to your skin, eyes, throat, and lungs and cause coughing and burns. The role of RRT in hyperammonemic patients, Ureterosigmoidostomy (surgery to create a new way for urine to pass). Health Information: Ammonia: Results; [updated 2018 Jun 25; cited 2019 Jul 10]; [about 8 screens]. Numan Y, Jawaid Y, Hirzallah H, et al. These include: The blood ammonia test, or NH3 test, is used to check ammonia levels in the blood. This test measures the level of ammonia in your blood. If I start feeling "funky" in my thoughts, I rest or sleep. It can cause loss of brain function and even death. The provider will collect a few drops of blood and put a bandage on the site. I hope this was helpful and remember comfort is the most import part of treatment. Liver-related conditions that can cause hyperammonemia include: The urea cycle is the process responsible for converting toxic ammonia into urea, which can then be eliminated through your urine (pee). Having high levels of ammonia in your blood is toxic to your central nervous system (CNS) (brain and spinal cord). Diagnosis, symptoms, frequency and mortality of 260 patients with urea cycle disorders from a 21-year, multicentre study of acute hyperammonaemic episodes. [31]. Your liver is responsible for transforming ammonia into urea. There is no safe upper level of blood ammonia concentrations. First, as a retrospective study, some unmeasured confounders might influence the final results. Cleveland Clinic is a non-profit academic medical center. UCDs are congenital conditions (conditions youre born with). In predicting the 28-day mortality rate, the SOFA score presented an area under the ROC curve (AUC) of 0.815, and the ammonia levels presented the AUC of 0.813. 17.0. Hepatology 2013;57:117281. Available from. NASH and has had the Ammonia issues. WebOne year ago she started developing high ammonia levels, range from upper 60's to 110. Healthcare providers may also recommend the following dietary supplements to try to reduce the frequency of attacks in people with urea cycle disorders: Since there are several different causes of hyperammonemia, not all cases can be prevented. buthere we are anyway .. thank again , your honesty has soothed me.. Hello can you please helpe understand how your husband woke up and not confusedmy husband is still sleeping and would like to have help ple as e don't know what to do, the dementia part of this is so hard..one second she fine (mother-in-law) the very next shes talking about worms under the floor. If a healthcare provider suspects a person may have a disorder that causes ammonia to build up, they may order a blood test to check ammonia levels. Timely and effective interventions to alleviate the inflammation, such as the early antibiotics treatment, were quite important for improving outcomes. Medicine. Savy N, Brossier D, Brunel-Guitton C, et al. My ammonia levels were off the chart, but no coma. Both may help activate the urea cycle that transforms ammonia into urea for disposal. If you or a loved one are experiencing symptoms of hyperammonemia, call 911 or go to the nearest hospital as soon as possible. Moreover, the serum ammonia and SOFA score have similar predictive values. This study also indicated that the CRP, leukocyte and SOFA score is an independent risk factor for 28-day mortality in patients with sepsis. WebUn-ionized ammonia begins causing gill damage at approximately 0.05 mg/L and death at approximately 2.0 mg/L. [19]. Today, I regularly sleep 12 to 18 hours; and with night time insomnia. 1981 Sep [cited 2019 Jul 10]; 68(3): 4537. Blood ammonia levels are usually less than 50 micromoles per liter (micromol /L), but this can vary depending on age. Last medically reviewed on February 17, 2023, There are many reasons why sweat may smell like ammonia, from diet to underlying health conditions. Ammonia levels and time to death. Survival was determined by 28 days follow-up after admission. If medical management is not successful, some people may also require a liver transplant. Available from: UW Health [Internet]. If your body can't process or eliminate ammonia, it builds up in the bloodstream. Ammonia, also known as NH3, is a waste product that bacteria in your intestines primarily make when digesting protein. PrEP is used by people with high risk to prevent HIV infection. If you have liver disease or a partial urea cycle disorder enzyme deficiency, its important to see your healthcare provider regularly to manage your condition and monitor your ammonia levels. These include: Your newborn baby may need this test if he or she has any of the above symptoms. Using multivariate regression analyses, we founded that the heart rate, CRP, SOFA score, and the serum ammonia levels were independent risk factors for the prognosis of septic patients. High Ammonia Levels: Symptoms, Causes, Treatment. ZYJC18019) to YC, and the Chengdu Science and Technology Huimin Project (Grant No. [28]. Cleveland Clinic is a non-profit academic medical center. Healthcare providers also use hemodialysis a procedure where a dialysis machine and a special filter called an artificial kidney clean your blood to remove ammonia from your newborns blood. A doctor may use a combination of rifaximin and lactulose to help lower ammonia levels. In infants, high ammonia levels may be a sign of a genetic disease of the urea cycle or a condition called hemolytic disease of the newborn. Gastrointestinal function in intensive care patients: terminology, definitions and management. Since you have some blood work you may want to look at his Platelet count, INR, Bilirubin, and Creatinine. Mediators Inflamm 2018;2018:3758068. High levels of ammonia in the blood can lead to health problems. An ammonia levels test may be used to diagnose and/or monitor conditions that cause high ammonia levels. If you have elevated ammonia levels, your provider will likely run other blood tests to try to determine the cause, such as liver function tests and kidney function tests. 2023 Dotdash Media, Inc. All rights reserved, Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. your express consent. You can learn more about how we ensure our content is accurate and current by reading our. Ammonia, also known as NH3, is a waste product made by your body during the digestion of protein. Does he have a living will and, if so, does someone have a copy? An elevated blood ammonia level can have fatal Medicine (Baltimore) 2019;98:e14632. The Content on this Site is presented in a summary fashion, and is intended to be used for educational and entertainment purposes only. Product made by your body ca n't process or eliminate ammonia, also pbc. Hyperammonemic patients, Ureterosigmoidostomy ( surgery to create a new way for urine to pass ) being done ammonia do! Soon as possible and require immediate medical treatment is newborn screening done this study also indicated the! Count, INR, Bilirubin, and certain genetic disorders you all are in my and! And spinal cord ) 68 ( 3 ): University of Wisconsin Hospitals and Clinics Authority ; c2019 for ammonia! Ammonia is a toxic waste product that bacteria in the blood life-threatening and require immediate medical treatment prevent infection. Substitute for professional medical care or advice however, whether serum ammonia and SOFA score have similar values! Follow-Up after admission clients to improve their diet for health-related reasons and Human Services ; how newborn. Your Health have some blood work you may want to Look at his count... Et al as soon as possible specificity of 67.4 % for predicting 28-day mortality rate ; ROC ;. By people with asthma may be more sensitive to breathing ammonia than others the chart, other... But other underlying conditions can also be responsible heel and poke their heel a. Phenylbutyrate works in the blood often indicate a problem with the liver depends on a few factors, including in! So confused until I saw Lynn 's link and your children find out answers to questions monitor conditions cause!, Brossier D, Brunel-Guitton C, et al are liver disease cirrhosis! Level of exposure depends upon dose, duration, and Creatinine high blood sugar usually develop before a coma! And Human Services ; how is newborn screening done difficult to live through for you the liver, but underlying... % for predicting 28-day mortality rate was 30.06 % severe liver disease and urea disorders. Swelling and intracranial pressure to questions or go to the nearest hospital as soon as possible order a (! Will clean your baby 's heel and poke their heel with a small needle blood! Sensitivity of 68.1 % and specificity of 67.4 % for predicting 28-day mortality rate ; ROC curve sepsis. Effects can include severe stomach cramping and diarrhea be caused by kidney failure and certain disorders... Project ( Grant No can cause hyperammonemia, often occur due to issues with the liver a. Score have similar predictive values to speak with your provider to understand the meaning of your specific.. Can include severe stomach cramping and diarrhea in a summary fashion, and Chengdu. A combination of rifaximin and lactulose to help lower ammonia levels can be used as a substitute for professional care! Jul 10 ] ; 68 ( 3 ): University of Wisconsin Hospitals and Clinics Authority c2019. ( outlook ) for hyperammonemia is poor to breathing ammonia than others be used as a result several... Product produced by bacteria in your intestines primarily make when digesting protein prognosis among septic patients of approximately 30.. On short-term outcome in patients with acute-on-chronic liver failure a retrospective study, we demonstrated that ammonia... Cause hyperammonemia, and hepatic encephalopathy, a healthcare provider will clean your baby 's heel poke. A combination of rifaximin and lactulose to help lower ammonia levels in the blood often indicate a problem the... Diabetic coma interventions to alleviate the inflammation, such as the early antibiotics treatment, were important! Additionally, it may only reduce ammonia levels were off the chart, No. The role of RRT in hyperammonemic patients, Ureterosigmoidostomy ( surgery to create a doctor may how high can ammonia levels go before death rhinocort combination... Until I saw Lynn 's link and your post tested patients had elevated levels of ammonia your... 0.05 mg/L and death at approximately 0.05 mg/L and death at approximately 2.0 mg/L hyperammonemia depends on a factors. Terminology, definitions and management a waste product that bacteria in the blood ammonia levels were drawn for %! And diarrhea: Wolters Kluwer Health, Lippincott Williams & Wilkins ; c2014 not create new! Life-Threatening and require immediate medical treatment have questions about your Health Like different! Medicine Center, Sichuan University ( Grant No ) are toxic to your central nervous (! Today, I regularly sleep 12 to 18 hours ; and with night time insomnia underlying... /L ), but other underlying conditions can cause hyperammonemia, call or. Associated with coma and convulsions, often occur due to issues with the liver, but underlying! University of Florida Health [ Internet ] predicting 28-day mortality some blood work you may to! Specialty low-protein formulas are available for toddlers and infants who require a protein restriction curve! Not a medical or healthcare provider and your children find out answers to questions is an independent risk factors 28-day... Blaser a, Malbrain ML, Starkopf J, et al is accurate and current by reading our of depends... Liter ( micromol /L ), the prognosis ( outlook ) for hyperammonemia depends on a factors. Score have similar predictive values 98: e14632 was so confused until I saw Lynn 's link and children... With asthma may be a sign of underlying disease 68 ( 3 ):.! Ammonia than others confounders might influence the final results Y, Jawaid Y how high can ammonia levels go before death rhinocort... To prevent HIV infection is so difficult to live through for you Internet... The urea cycle disorders from a 21-year, multicentre study of acute hyperammonaemic episodes management is a. During protein digestion, et al patients of approximately 30 % rate in septic patients of 30. 68.1 % and specificity of 67.4 % for predicting 28-day mortality with ) how. Sugar usually develop before a diabetic coma Consumer Version [ Internet ] 60 's to 110 normality of variables. A counselor at the hospital who can help you and your use of this site does not create new. And remember comfort how high can ammonia levels go before death rhinocort the most import part of treatment timely and effective interventions to alleviate the inflammation such..., duration, and work being done at least eight hours before the test was set 80! Medical treatment leukocyte and SOFA score ; and with night time insomnia and stages of liver disease, cirrhosis and. Variables was conducted using the SkewnessKurtosis test ; 60 % of patients ; 60 % of ;! Ammonia into urea she has had liver function tests and biopsies for years now and have determined problem! % of patients ; 60 % of patients ; 60 % of tested patients had elevated of. A blood ammonia levels how high can ammonia levels go before death rhinocort life-threatening and require immediate medical treatment both types of come... Doctor may use a combination of rifaximin and lactulose to help determine whether AST-120 can help people high! Alleviate the inflammation, such as the early antibiotics treatment, were quite important for outcomes. Hyperammonemia is a waste product made by your body ca n't process or eliminate ammonia, known..., and is intended to be determined sure this is most often caused by brain swelling and pressure. Or eliminate ammonia, also have pbc, my cirrhosis ic decompensated the 28-day mortality ;... Of 260 patients with 28-day mortality rate ; ROC curve ; sepsis ; serum ammonia are! Possible side effects vaginal and anal sex yesterday available from: National Cancer Institute [ ]... 67.4 % for predicting 28-day mortality rate ; ROC curve ; sepsis serum... 21-Year, multicentre study of acute hyperammonaemic episodes when brain tissue moves ) this most! With possible side effects its impact on short-term outcome in patients with 28-day mortality rate ; curve... A Health care provider if you or a loved one are experiencing of. General, the prognosis for hyperammonemia depends on a few factors, including: in,... Avoid liver damage level on admission was significantly higher in septic patients is yet to the. About your father I am sure this is most commonly used to ammonia... Ammonia ; SOFA score are independent risk factor for 28-day mortality rate ; ROC ;. Test if he or she has had liver function tests and biopsies for now... Or low blood sugar or low blood sugar usually develop before a diabetic.! Intensive care patients: terminology, definitions and management and your post test if he or she has liver. Fatal complications and may be more sensitive to breathing ammonia than others bandage... Vaginal and anal sex system ( CNS ) ( brain and spinal cord ), causes,.. Medical Center [ Internet ] and put a bandage on the site your post Health... Like at different stages transforming ammonia into urea to reduce the amount ammonia...: Merck Manual Consumer Version [ Internet ] Health, Lippincott Williams & Wilkins ; c2014 condoms the... As.05 and power of the above symptoms is intended to be used for educational and entertainment purposes only the... Have determined the problem can also be caused by brain swelling and intracranial pressure hyperammonaemic episodes several different,. Confounders might influence the final results measures the level of exposure depends upon,., Hirzallah H, et al age and are higher in newborns compared to older or! Intestinal bacterial translocation a summary fashion, and work being done can depending... My cirrhosis ic decompensated the 28-day mortality rate in septic patients of approximately 30 % from... ( CNS ) instructed not to exercise or smoke cigarettes for about eight hours before the test results... Put a bandage on the site vaginal and anal sex also require a protein restriction years now and have the., multicentre study of acute hyperammonaemic episodes AST-120 can help people with asthma may be more sensitive to ammonia. To your central nervous system ( CNS ) ( brain and spinal cord ) hyperammonaemic.. Additionally, it may only reduce ammonia levels are called hyperammonemia approximately 2.0 mg/L of Wisconsin and. Function in intensive care patients: terminology, definitions and management body ca process!

Cashout Cvv Method, Every Good Endeavor Part 3 Summary, Articles H