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Referral to secondary care is indicated for severe or rapidly progressive neurological symptoms, diagnostic uncertainty, suspected bone marrow failure, or in pregnancy or paediatric cases

Interestingly, Ammonia (a neurotoxic by-product) can impair the nervous system even at low levels and it has been associated with anxiety disorderspotentially serving as a biomarker (Duan et al., 2015)

Cremer H, Lozachmeur JM

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