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In-patient versus out-patient withdrawal programmes for medication overuse headache: a 2 year randomized trial generic ropinirole 1 mg otc treatment plant. A Randomized cheap ropinirole online medications and mothers milk 2016, Double-blind Comparison of Single Dose Prochlorperazine Versus Acetaminophen ropinirole 0.5 mg overnight delivery medicine quetiapine, Aspirin order ropinirole 0.25mg mastercard kapous treatment, and Caffeine for the Treatment of Acute Migraine in the Emergency Department. Randomized trial of sumatriptan and naproxen sodium combination in adolescent migraine. Acupuncture versus valproic acid in the prophylaxis of migraine without aura: a prospective controlled study. Pilot study of amitriptyline in the prophylactic treatment of medication-overuse headache: a 1-year follow-up. Assessment of the efficacy and safety profiles of aspirin and acetominophen with codeine: results from 2 randomized, controlled trials in individuals with tension-type headache and postoperative dental pain. Improvement of migraine symptoms with a proprietary supplement containing riboflzvin, magnesium and Q10: a randomized, placebo-controlled, double-blind, multicenter trial. Results of a multicenter, double-blind, randomized, parallel-group, placebo-controlled, single-dose study comparing the fixed combination of acetaminophen, acetylsalicylic acid, and caffeine with ibuprofen for acute treatment of patients with severe migraine. Triptans in prevention of menstrual migraine: a systematic review with meta-analysis. Economic and outcomes assessment of magnetic resonance imaging in the evaluation of headache. An open labeled randomized controlled trial of pregabalin versus amitriptyline in chronic low backache. Topiramate plus nortriptyline in the preventive treatment of migraine: a controlled study for nonresponders. Flunarizine versus topiramate for chronic migraine prophylaxis: a randomized trial. Comparison ketoprofen, ibuprofen and naproxen sodium in the treatment of tension-type headache. Comparative efficacy of ibuprofen arginine and β-cyclodextrin piroxicam as treatment for tension-type headache. A randomized, one-year clinical trial comparing the efficacy of topiramate, flunarizine, and a combination of flunarazine and topiramate in migraine prophylaxis. Solubilized ibuprofen: evaluation of onset, relief, and safety of a novel formulation in the treatment of episodic tension-type headache. Efficacy and safety of acetaminophen and naproxen in the treatment of tension-type headache. Przeklasa-Muszynska A, Skrzypiec K, Kocot-Kepska M, Dobrogowski J, Wiatr M, Mika J. Prednisone for the treatment of withdrawal headache in patients with medication overuse headache: a randomzied, double-blind, placebo-controlled study. Effectiveness of Vitamin B2 versus Sodium Valproate in Migraine Prophylaxis: a randomzied clinical t rial. Naratriptan in the preventive treatment of refractory chronic migraine: a review of 27 cases. Amitriptyline and aerobic exercise or amitriptyline alone in the treatment of chronic migraine: a randomzied comparative study. Migraine prevention with a supraorbital transcutaneous stimulator: a randomized controlled trial. Naratriptan in the preventive treatment of refractory transformed migraine: a prospective pilot study. Efficacy of Enalapril in Migraine Prophylaxis: A Randomized, Double-blind, Placebo-controlled trial. Aspirin in episodic tension-type headache; placebo-controlled dose-ranging comparison with paracetamol. Celecoxib vs prednisone for the treatment of withdrawal headache in patients with medication overuse headache: a randomized, double-blind clinical trial. Tarighat Esfanjani A, Mahdavi R, Ebrahimi Mameghani M, Talebi M, Nikniaz Z, Safaiyan A. The effects of magnesium, L-carnitine, and concurrent magnesium-L-carnitine supplementation in migraine prophylaxis. Clinical experience with transcutaneous supraorbital nerve stimulation in patients with refractory migraine or with migraine and intolerance to topiramate: a prospective exploratory clinical study. Consistency of response to sumatriptan/naproxen sodium in a randomized placebo-controlled, cross over study for the acute treatment of migraine in adolescence. Comparison of efficacy and safety of topiramate with gabapentin in migraine prophylaxis: randomized open label control trial. This edition of the guideline was approved for publication by the Guideline Oversight Group in April 2018. Team the Headache Guideline development team included representatives from the following specialties: Adolescent Medicine, Family Practice, Neurology, Nursing Operations, Obstetrics/Gynecology, Pharmacy, Residency, and Urgent Care. Team members listed above have disclosed that their participation on the Migraine and Tension Headache Guideline team includes no promotion of any commercial products or services, and that they have no relationships with commercial entities to report. In many cases, you can treat headaches at home with over-the-counter painkillers and lifestyle changes, such as getting more rest and drinking enough fuids. Tension headaches Tension headaches are the most common type of headache and are what we think of as normal, “everyday” headaches. They feel like a constant ache that affects both sides of the head, as though a tight band is stretched around it. A tension headache normally won’t be severe enough to prevent you doing everyday activities. The exact cause is unclear, but tension headaches have been linked to things such as stress, poor posture, skipping meals and dehydration. Tension headaches can usually be treated with ordinary painkillers such as paracetamol and ibuprofen. Lifestyle changes, such as getting regular sleep, reducing stress and staying well hydrated, may also help. They’re usually felt as a severe, throbbing pain at the front or side of the head. Some people also have other symptoms, such as nausea or vomiting (feeling or being sick) and increased sensitivity to light or sound. Migraines tend to be more severe than tension headaches and can stop you carrying out your normal daily activities. They usually last at least a couple of hours, and some people fnd they need to stay in bed for days at a time. Cluster headaches Cluster headaches are a rare type of headache that occur in clusters for a month or two at a time around the same time of year. They’re very painful, causing intense pain around one eye, and often occur with other symptoms, such as a watering or red eye and a blocked or runny nose. Painkillers Many people who have migraines fnd that over-the-counter painkillers, such as paracetamol, aspirin and ibuprofen, can help to reduce their symptoms. They tend to be most effective if taken at the frst signs of a migraine attack, as this gives them time to absorb into your bloodstream and ease your symptoms.
Toxic nodule: This is a solitary hyperactive nodule which may be part of a generalized nodularity or a true toxic adenoma buy 0.5mg ropinirole amex conventional medicine. It is autonomous and its hypertrophy and hyperplasia are not due to thyroid stimulating antibodies order ropinirole 0.25mg amex medicine 0025-7974. Diagnosis of thyrotoxicosis • Most cases are easily diagnosed by the clinical picture order on line ropinirole treatment yellow jacket sting. This helps to determine the functional activity relative to the surrounding gland according to isotope uptake order ropinirole overnight ad medicine. Treatment of thyrotoxicosis Treatment of thyrotoxicosis includes specific and non-specific measures. The specific measures are • the use of antithyroid drugs • surgery • radioiodine the nonspecific measures which include rest and sedation are not commonly recommended. But it should be clear that antithyroid drugs cannot cure a toxic nodule since the overactive thyroid tissue is autonomous and recurrence of the hyperthyroidism is certain when the drug is discontinued. Surgery: Surgery cures thyrotoxicosis by reducing the mass of overactive tissue below critical mass. Preoperatively, the patient must be prepared with antithyroid drugs so that the patient becomes euthyroid. Post-operative complications • Hemorrhage a tension hematoma may develop deep to the cervical fascia – which is potentially life threatening • Respiratory obstruction can occur due to laryngeal edema or secondary to tension hematoma. It occurs if a thyrotoxic patient has been inadequately prepared for thyroidectomy. Neoplasms of the thyroid Classification of thyroid neoplasm Benign: follicular adenoma Malignant: Primary Follicular epithelial: follicular, papillary, anaplastic Para follicular epithelium: medullary Lymphoid cells: lymphoma Secondary -M etastatic Local infiltrations 130 Benign tumors Follicular adenomas present as clinically solitary nodules and the distinction between a follicular carcinoma and an adenoma can only be made by histological examination. Malignant Tumors Clinical feature: the commonest presenting symptom is • thyroid swelling • Enlarged cervical lymph node may be the presentation of papillary carcinomas. Prognosis: Prognosis is influenced by histological type, age, extra thyroid spread, and size of tumor. With regard to age, males of more than 40 years of age and females over 50 years have worse prognosis. Local infiltration is an early feature of these tumors with spread by lymphatics and blood stream. They are extremely lethal tumors with death occurring in most cases within months. Many lesions present in advanced stages with tracheal obstruction and require urgent tracheal decompression. Radiotherapy should be given in all cases and may provide a worth while period of palliation. Compare and contrast papillary and follicular thyroid carcinoma with respect to root of metastasis, overall mortality and location of recurrence? This is due to lack of screening facilities, low index of suspicion among health professionals, poverty and lack of knowledge. Benign conditions of the breast are important because of the discomfort they produce and frequent confusion with neoplastic disease. Anatomy nd • the protuberant part of the human breast is generally described as overlying the 2 th to 6 ribs, • It extends from the lateral border of the sternum to the anterior axillary line, between th th clavicle and to the 7 and 8 ribs below. The nipple contains smooth muscle fibers arranged concentrically and longitudinally. These could be secondary to either benign disease conditions, or fatal carcinomas. Students should be familiar with some of differentiating mechanisms between malignant and benign breast lumps. Breast cysts This is a rare condition which may occur in the last decade of reproductive life due to a non integrated involution of stroma and epithelium. If there is residual lump after aspiration, if fluid is blood stained, or if cyst recurs, local excision for histological diagnosis is advisable. Fibroadenoma Usually occurs during 15-25 years of age and arises from hyperplasia of a single lobule. Most fibroadenomas can be excised through periareolar incision with good cosmetic result. Phyllodes Tumor • Are benign tumors • Usually occur in women over 40 years but can appear in younger woman. Ductectasia/ periductal mastitis Definition: This is dilatation of the breast ducts associated with periductal inflammation. Pathogenesis: Dilatation of lactiferous ducts that will be subsequently filled with a stagnant brown or green secretion. The fluid sets up an irritant reaction in surrounding tissue leading to periductal mastitis, even abscess or fistula formation. When the diagnosis of carcinoma is in doubt There are cases where one cannot be sure whether the particular lump in the breast is area of mammary dysplasia, benign tumor or an early carcinoma. If there is doubt on clinical, cytological or radiological examination, it is essential to obtain a tissue diagnosis. Bacterial mastitis is the commonest variety of mastitis and nearly always commences acutely. It is associated with lactation in the majority of cases 136 Cause Most cases are caused by staphylococcus aureus. Clinical presentation o Pain o Swelling o Redness o Tenderness and hotness of the affected side. Complication: breast abscess If acute infection of breast doesn’t resolve with in 48 hours, or if after emptied of milk there is an area of tense induration, the inflammation has resulted in an abscess. Unlike majority of localized infections; fluctuation is a late sign so incision must not be delayed. Drainage of breast abscess Under general or local anesthesia, incision is sited in a radial direction over the affected segment. Every part of abscess is palpated against the point of hemostat and its jaw opened, all loculi that can be felt are entered. Finally the hemostat having been removed, a finger is introduced and any remaining septa are disrupted. The wound may then be lightly packed with gauze or drain inserted to allow dependent drainage. Carcinoma of the Breast Breast cancer is the commonest cause of death in middle-aged women in western countries. Risk factors • Geographical it occurs commonly in the western world accounting for 3-5 percent of deaths but is rare tumor in Far East like Japan. Pathology: Breast cancer may arise from the epithelium of the duct system starting from the nipple to the end of lactiferous ducts which is in the lobule. It may be entirely in situ (with out breaching basement membrane) or may be invasive. The degree of differentiation of a tumor is usually described by three grades well differentiated, moderately or poorly differentiated. It tends to involve the skin and to penetrate the pectoral muscles, and even the chest wall.
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Based on embryological origin order 2mg ropinirole with visa symptoms hypothyroidism, the lining of the mucous membrane of the anal canal can be divided in two parts ropinirole 0.5 mg without prescription treatment 1 degree av block, the upper part generic 0.25 mg ropinirole with mastercard medications qhs, derived from the hindgut endoderm and the lower part buy discount ropinirole medicine engineering, derived from the ectoderm of the proctodeum. Note that the pectinate (dentate) line separates the upper from the lower anal canal. The upper part is lined by columnar epithelium, has anal columns, anal valves and anal crypts. The lower part has stratified epithelium (progressively merging with the perianal epidermis at the anus), no anal columns and associated structures. The anal canal has two sphincters, an involuntary internal sphincter and a voluntary external sphincter. Note that the puborectalis (part of the levator ani) blends with the deep part of the external sphincter. Recall that the puborectalis muscle forms a sling passing at the junction of the rectum and the anal canal. The external sphincter can be divided in three parts: a subcutaneous part found at the lowest aspect of the anal canal, a superficial part attached posteriorly to the coccyx and anteriorly to the perianal body, and the deep part, located at the upper end of the anal canal. Note that the internal and the 3 parts of the external sphincter form together an anorectal ring that can be found on rectal examination. The blood supply to the upper part of the anal canal is by the superior rectal artery (branch of the inferior mesenteric artery). The blood supply to the lower portion of the anal canal is by the inferior rectal artery (branch of the internal pudendal artery). The venous return of the upper portion of the anal canal is by the superior rectal vein draining into the inferior mesenteric vein and then into the portal vein. The venous drainage of the lower part of the anal canal is by the inferior rectal vein draining into the internal iliac vein and then the inferior vena cava. Recall that any significant increase in blood pressure in the portal-systemic anastomosis due to liver disease can lead to internal or external hemorrhoids. In terms of sensory innervation, note that the mucous membrane of the upper part of the anal canal is innervated by sensory fibers ascending through the right and left hypogastric plexuses. The lower portion of the anal canal is innervated by sensory fibers ascending through the inferior rectal nerves (branches of the pudendal nerve). In terms of motor innervation, the muscle fibers of the internal sphincter receive sympathetic innervation from the hypogastric plexuses whereas the voluntary external sphincter is innervated by the inferior rectal nerve. The lymphatic drainage of the upper part of the anal canal is in the pararectal nodes and then in the inferior mesenteric nodes. The urinary bladder is found immediately posterior to the pubic symphysis in both male and female. The bladder has a strong muscular wall and is able to receive about 500 ml of urine. This muscular wall is composed of three layers of smooth muscle collectively known as the detrusor muscle. Note that although located in the pelvis, the bladder can be palpated through the anterior abdominal wall, immediately above the pubic symphysis, when completely full. Classically, the bladder is described as having a pyramidal shape, has an apex (connected to the umbilicus by the median umbilical ligament, a remnant of the urachus), a base (triangular posterior surface), and a neck (inferiorly). Note that the neck opens in the urethra (prostatic urethra in male) and that at the neck, the circular muscular fibers thickened to form the sphincter vesicae. This sphincter, under autonomic control, regulates the release of urine from the bladder. Observe also that the neck is anchored to the walls of the pelvis by the pubovesical ligaments in female and puboprostatic ligament in male. The inside of the bladder muscular wall is covered by a mucous membrane forming folds in the empty bladder. The smooth portion of the mucous membrane found below a line passing between the two ureteric orifices on the posterior wall is called the trigone. In this area, the mucous membrane do not form folds, even in the empty bladder, due to the fact the membrane is tightly adherent to the underlying muscular layer. The superior surface and the upper part of the posterior surface of the bladder is covered by peritoneum. Note that in female, the neck of the bladder (inferiorly) rests on the upper surface of the urogenital diaphragm whereas in male the neck of the bladder lies on the upper surface of the prostate. Laterally, in both the male and the female, the inferolateral surfaces are related anteriorly to the retropubic fat pads and posteriorly to the obturator internus above and the levator ani below. Note that in males, the two vas deferens and the two seminal vesicles can be found on the inferior aspect of the posterior surface of the bladder, superior to the prostate (see later in this lecture). The superior and inferior vesical arteries (branches of the internal iliac arteries) provide blood supply to the bladder in both males and females. In both males and females, the venous drainage is by the vesical venous plexus draining into the internal iliac vein through the superior and inferior vesical veins. Note that in males, the vesical venous plexus communicates with the prostatic venous plexus. In terms of innervation, the bladder is under the control of the inferior hypogastric plexuses. The sympathetic fibers originate from the first and second lumbar ganglion, synapse in the inferior hypogastric plexuses and end in the bladder. They inhibit contraction of the detrusor and stimulate the closure of the sphincter vesicae. The parasympathetic fibers pass through the pelvic splanchnic nerves (S2-4), and also synapse in the inferior hypogastric plexuses before innervating the bladder. They stimulate contraction of the muscular wall and inhibit the action of the sphincter vesicae. Most of the afferent (sensory) fibers are believed to reach the central nervous system through the pelvic splanchnic nerves, with only st a few passing through the sympathetic fibers (1 nd and 2 lumbar splanchnic). This muscle, innervated by the perineal branch of the pudendal nerve, compresses the urethra to stop the flow of urine out of the bladder. In male, as already discussed, the urethra is divided in 3 parts, the prostatic, membranous and penile urethra. Beginning at the neck of the bladder, it passes through the prostate and then becomes the membranous urethra. The prostatic urethra is the widest and most dilatable portion of the entire urethra. Observe on each side of this crest the prostatic groove with the openings of the prostatic gland. Note also a small depression on the urethral crest, the prostatic utricle, with on its edges the openings of the two ejaculatory ducts (see later in this lecture). The prostate is a male fibromuscular organ located around the urethra, below the bladder and above the urogenital diaphragm. The prostate has a fibrous capsule covered externally by a fibrous sheath (part of the visceral pelvic fascia), a base (superiorly against the neck of the bladder), and an apex (lying inferiorly against the urogenital diaphragm). The anterior surface of the prostate is related to the extraperitoneal fat located in the retropubic space (posterior to the symphysis pubis). Recall that antero-laterally, the prostate is anchored through the puboprostatic ligament.
Also buy 1mg ropinirole free shipping medicine 72, the bacterium that causes leprosy directly Selenium Styrene Sulfur dioxide 15 Tetrachlorobiphenyl Thallium Toluene damages myelin sheating purchase ropinirole 2mg otc medications affected by grapefruit. Zinc Zinc pyridinethione Hexachlorophene is a good bacterio-static anti-biotic 7-6 Volatile organic solvents affect permeability of cell against Staphylococcus Aureus order ropinirole in india medications major depression. Blood-brain barrier alterations (glue sniffing 0.5 mg ropinirole with mastercard medicine effects, microwaves) and aldehydes, and solvents found in quick-drying glues. Astrocyte alterations (brain’s cleaners disabled) However, repeated use of any of these may result in damage so 7. According to some sources, the average adult loses 85,000 Polyneuropathy can involve more than one mechanism, in the brain cells per day, but only regenerates 50. There are about same way that more than one organ can be intoxicated by a 100 billions cells in the adult brain. At the anatomical level, neuropathy can be New brain cells are produced by exercise, estrogen, stimulating peripheral or central. A graphic loss of central 22 environments, high social status, electroconvulsive therapy , neurons can be seen in Alzheimer’s disease stroke and other injuries and antidepressants. It appears that (bottom), where the temporal lobes formerly filled with neurons providing memory and language are cannabinoids promote neurogenesis, and produce anxiolytic 16 now empty ventricles. Fewer cells are produced as a consequence of aging, spikes in stress hormones, sleep deprivation, barren 7. In mammals, a severed nerve in an arm or leg regrows and re Developing brains may be more susceptible to chemicals. A similar injury in the Common anesthetics administered to children (midazolam, spinal cord or within the brain will not be repaired, resulting in nitrous oxide and isoflurane) induce apoptosis in baby rat permanent disability and paralysis. Poor regeneration in the models, which leads to lasting memory and learning deficits. Many acute exposures with low molecular weight compounds Anoxia can result from these agents, as well as excessive produce reversible effects in nervous tissue. Mn contamination of water at dangerous levels gives it For example, toluene potentiates the toxicity of all other a nasty smell. There is great conflict and discussion over the Unborn children transplacentally exposed to methyl existence of the syndrome. Histology of the brain tissue after their death shows absence of myelin and astrocytes (“infantile” There are differences between myelination in the peripheral brains without normal maturation). Effects are the Schwann cell, which wraps itself around a portion of the developmental delays, distractability, short-term neuronal axon in much the same fashion as a window roller memory and planning skills impairment. The nucleus of the Schwann cell resides on the outer used as insulation for transformers and now taint most surface of the rolled myelin layers. These effects in the children are side by side, provide the myelin for one neuron. Damage to a single Schwann cell can result in its with the best test batteries, each victim presenting one or a few 2,3 death, with a gap of nonmyelinated axon surrounded by debris. Victims often present at a relatively young age the neuron conducts pulses rapidly down to the point of the with serious neurological sequelae from excessive exposure to damage, but pulses slow down over the defect, resulting in the solvents by inhalation, and are forced to retire from their work. The effects are fatigue, sleplessness, produce a plethora of sheaths around several adjacent axons, headaches, irritability and nausea as well as memory and rather than just on one axon. Unlike peripheral myelinopathy which tends to be relatively specific or localized in effect, a centrally located the mechanisms by which solvents induce such effects is myelinopathy may appear quite diffuse. Solvent Myelinopathy with conduction, as well as causing damage to Schwann or the short-term alcohol-like symptoms of solvent neurotoxicity oligodendroglial cells and subsequent alterations in myelinated are headache, dizziness, sleepiness, agitation, euphoria and pathways. Hexacarbon-Induced the chronic symptoms are premature aging, memory impairment, mild depression and anxiety. Polyneuropathy-Axonopathy the solvents are typically chlorinated hydrocarbons, alcohols, n-hexane and methyl-butylketone cause classical peripheral esters and ketones. Benzene is both a neurotoxin and a the associated pathology, first detected in humans, was taken carcinogen. Scientists 7-9 returned to the human situation with recommendations for appearance of a bird nest. Nutrients are no longer transported modification of glue formulations, which produced fewer to the distal end. The neuropathy, reported among workers in the shoe industry, was always most severe in the early springtime, following a winter of closed doors and windows (poor ventilation). These swellings cause disruption of the microtubule and neurofilament system responsible for the transport of nutrients to the distal part of the axon from the cell body, with eventual death and disintegration of the nerve endings. The central-peripheral distal Gradual onset of distal paresthesia axonopathy, so named by neurologists because it affects Muscle weakness distal (hands, feet) distal axons of both the central and peripheral nervous systems, No ataxia or muscle spasticity is caused by a reactive metabolite, 2,5-hexanedione, found to Symmetrical dysfunction (hands, feet) cyclize during further biotransformation to form a 5-membered Loss of sensation “stocking and glove” ring (imidazole) that interacts with protein structures to disrupt Persistent muscular weakness neural organization and cause the tangles. The complete Atrophy of musculature mechanism has not been entirely identified, and interest has declined with the banning of n-hexane and methyl-butylketone Experiments in animal models revealed that not only were the and the substitution of other volatile ketones. In the paranodal swellings tangles of microtubules and filaments were observed, giving the 7-10 This is seen in tunnel workers who inject an acrylamide resin F7. Formation using a pressurized lance into soil and rock to create an of axonopathies impervious, water-proof layer to prevent leaking. Metals Neurotoxicity the term "heavy metal" describes a class of agents in the Humans take a periodic table possessing certain chemical similarities, long time to including a divalent positive ion. Cadmium, cobalt, lead, bio-transform magnesium, manganese, mercury, nickel, and vanadium are and excrete a toxicologically important and all are neurotoxic. Adults elimination in the urine A millenium ago, body concentrations of lead were typically occurring one-hundredth to one-thousandth of post-industrial levels. When such workers were removed cardiovascular and kidney diseases, decreased fertility, 25 from exposure, the condition was not alleviated, but continued hypertension and cancer. Blood lead levels ranging from as to worsen for approximately 14 days, after which recovery little as 20 to 29 µg/dL are associated with a 39 % increase in began slowly. Overexposure to inorganic lead continues among workers in battery manufacturing, mining of lead and zinc ores, and 7-11 painting and paper-hanging. Work-related lead exposure remains a problem, and above 5 µg/dL and 90 % are above 1 µg/dL. Children recently been found in relation to Polycyclic Aromatic Lead is especially toxic to the central nervous system, affecting 21 Hydrocarbons (from combustion of fossil fuels). Behavioral disorders such as attention deficit disorder have also been For every 5 µg/dl increase in a child’s average blood-lead level 28 attributed to lead exposure. In children, 20 to 25 mg/100 ml (ages 5 and 6), there is a 25 percent increase in the number of 29 can cause irreversible brain damage. Studies of lead in city children initially drove the lowering of acceptable lead concentrations in the blood to 10 µg/dl. Within the range 1-10 µg/dL, for each µg/dL increase in adhesion molecules causes a mis-wiring of the central nervous blood lead level in children, there is a 0. Above 10 µg/dL, each µg/dL increase only corresponds to a This is a major concern for young children who absorb lead Acute lead poisoning kills children much more efficiently than adults, and who may come into in the state of Zamfara, Nigeria contact with higher levels than adults. A total of 163 children out of 355 cases from several remote villages have died of lead poisoning.