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On the demand side substance abuse is tackled through poverty reduction strategies buy viagra extra dosage 200mg on line erectile dysfunction pills amazon, advocacy discount viagra extra dosage amex erectile dysfunction 16 years old, education and communication cheap viagra extra dosage american express erectile dysfunction pills otc, fostering socio-economic development and advancing anti-substance abuse social policies. On the supply side the key intervention areas include controlling production, sale, marketing and distribution of harmful substances. It also includes law enforcement and where necessary taking legal action against supplies of illegal substances. Harm reduction is based on treatment, aftercare and reintegration of those dependent on substances. The South African Drug prevention Master Plan employs the supply and demand framework. Figure 11: Supply and Demand Framework Demand Reduction Supply Reduction Harm Reduction Poverty Reduction Controlling the production, manufacture, sale, distribution and trafficking of drugsprecursor Treatment materials and manufacturing facilities, Advocacy Controlling the distribution of and access to raw drugs and precursor materials Aftercare Education and Communication Seizing and destroying precursor materials, raw materials and products, refineddrugs, production, manufacturing and distribution facilities, and resources; Development Re-integration of substance dependents with society. Taking legal action on the use, abuse, production, Social Policy Application manufacture, marketing, distribution and trafficking of precursor materials, raw materials and products, refined drugs, manufacturing and distribution and facilities, and resources. The main drawback of the Supply and Demand framework is that it places intervention programmes in silos, with limited vertical and horizontal interactions. In reality, substance abuse is multifaceted challenge that requires a multidimensional and integrated set of intervention strategies. Figure 12 provides a pictorial view of the Bronfenbrenner socio-ecological framework. The framework implies that a substance abuser is affected by different types of environmental systems. The nested structures of these environmental systems begin with the individual domain, moving outwards to the microsystem, the mesosystem and finally, the exosystem. Applications of this framework can be found in Mason, Cheung, & Walker, (2004) for substance use; Yu, Stiffman, & Freedenthal, (2005) on tobacco use; and Marsden, Boys, 16 Farrell, Stillwell, Hutchings, et al. The ecological model takes a holistic view to the problem and demonstrates that factors driving drug abuse are interrelated and intervention strategies or programmes for combating the scourge should be integrated. The next paragraphs review literature on the determinants of substance abuse following the Bronfenbrenner’s socio-ecological model. Steinman and Zimmerman (2004) observe that behaviours such as low religious involvement, short-term goals in life, depressive symptoms and a poor sense of wellbeing and low self-esteem make the youth succumb to substance abuse. Evidence also points to the fact that youth are also prone to drug abuse because of their vulnerability (Mohasoa, 2010). Youth become vulnerable because they are in a phase of substantial experimentation, they are unemployed, have no income, and are poor, among other things (Kadalie & Thomas, 2013; Parry et al. Interviews with respondents, Rocha-Silva reported that youths use drugs 17 to gain confidence in dealing with people and stressful situations surrounding them. Mohasoa (2010) also reports that youth use substances because they are overwhelmed by the challenges in their own lives or families, and society at large. For example, stressors in their own lives could be cold weather which may lead them to taking solvents in order to escape the misery associated with the stressful environment. Microsystem The microsystem envelopes the individual domain and represents one’s immediate environment. It focusses, inter alia, on the household and family influences, neighbourhood, school, and peer pressures. Many studies have singled out the family as the most significant determinant of substance abuse by the youth at the microsystem level. In a study of learners in the Western Cape, Peltzer and Ramlagan (2009) found a strong link between risky drinking behaviours and lack of parental and peer support, school truancy, and mental distress. Pretorius (2003), observe that exposure to alcohol in the family causes risk behaviours such as rebelliousness and having friends who drink (Pretorius 2010). In addition, literature shows that youths that have parents who drink heavily, and/or are tolerant of alcohol use, as well as having close acquaintances who drink, places youth at risk for heavy drinking. Youths tend to imitate the behaviours of their parents, guardians or other influential people and quantitative and qualitative evidence suggests that those with adequate role models are less likely to indulge in substance abuse (Morojele et al. Conversely, youth with inadequate role models (role models who drink or do drugs) consider it acceptable (Brook et al 2006 and Onya, 2005). On the other hand, a nurturing home environment, encompassing family supervision and monitoring, together with open communication lines between parents and children, has been empirically determined to be strongly associated with low substance abuse (Meghdadpour et al. Meghdadpour et al found that in South Africa, family supervision is likely to reduce male youths being drunk by 23% and lowers their chance of using illegal drugs by 38%. Therefore to combat drug and alcohol abuse emphasis should be placed on strategies that address “parental drinking, low parental monitoring, low parental bonding, poor parent-child communication, poor school performance, low school commitment, peer norms, peer drinking, peer influence, peer delinquency” South African empirical studies indicate that peer pressure is one of the most significant and most consistent predictor of substance use among youth (Brook et al. Peers encourage their uninitiated peers to use drugs, and more often drug or alcohol use is celebrated with those taking illegal substance held in high regard. Youth will then want to be accepted by their peers in these substance abuse networks at all costs. According to Bility (1999) peer pressure is rampant in youth gang networks and other marginalised groups such as street children. Evidence also indicates that youth prefer to discuss issues with their peers more than they would with their family members, teachers, or medical doctors (Hoberg, 2003). They value opinions or support of their peers more than any other social structures at their disposal (Hoberg, 2003). The pressure to be recognised and accepted by peers and gain meaningful participation inadvertedly increases vulnerability of the youth (Ungar, 2006:7 18 It is important to note that peer pressure and inadequate parental role modelling discussed above reinforce each other. When there are no good parental role models for the youth, peers become role models and the outcomes may not be desirable. Another area that has been variously cited as key to drug/alcohol abuse prevention in the microsystem is the school. The schools is part of the immediate environment of the learner or youth and quantitative and qualitative evidence shows that some of the influences of alcohol and drug abuse are found within the school environment. This study noted that when alcohol is close to the school it can easily be brought into the school. The school also lends itself to being a space for illegal substance when some learners are demotivated, have low academic aspirations or their performance is below par. Flisherv at al, (2003) have found a direct relationship between drug abuse with learners’ poor performance, absenteeism and repetition of a grade. Mesosystem The mesosystem is simple a system of microsystems and how they interact. It involves linkages between an individual and family, family and school, peer group and family, or between family and church. The primary risk factor is when microsystems are not interacting well leaving children exposed to pressures that will see them succumb to substance use. A good example is that if the family does not interact with peers of their children, such children will be exposed to peer pressure. The main message implied by the mesosystem is that substance abuse prevention programmes should be multidimensional and integrated. Exosystem At the exosystem level, the focus is on access and availability of illegal substances that the youth may succumb to. The risk factors considered under the exosystem consists, inter alia, of the legislative, social and economy wide environment that inhibits/delays the onset of drug or alcohol abuse.

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Saturate a thick gauze bandage or cotton pad with fresh urine discount viagra extra dosage american express erectile dysfunction treatment dublin, place it over the wound or bum and secure it with additional gauze buy discount viagra extra dosage erectile dysfunction treatment injection therapy; cover with plastic or soft towel to prevent leakage cheap 200mg viagra extra dosage with mastercard erectile dysfunction jet lag. Reapply fresh urine with clean medidne dropper directly onto the existing inside compress. Urine is also known to prevent scarring, so keep the urine pack applied as long or as often as possible until healing is complete. The pain is quickly relieved and the burn or wound heals rapidly without scarring. Eye And Nose Drops There are reports from people who have used urme drops for both eye and nose drops, for relief of eye itching or inflammation, or for nasal congestion. In both cases, make certain that you are using fresh, clear, normal urine only and that the acidity factor of the urine is normal (see previous section on Monitoring Your pH in this chapter). A compress of fresh normal urine is also excellent for external eye inflammations such as styles. As the research studies indicate, oral or injected urea has been shown to be extremely effective and safe in treating cases where excess fluid production is a problem (see pgs. Using urea in conjunction with natural urine therapy can be discussed with your doctor, once he or she has been made aware of the research findings relating to urea and urine therapy. Oral urine therapy also allows for slower application and absorption which can decrease any possible de-toxifying symptoms. Gradual introduction of urine therapy, or any medical therapy is always important, but even more so if you have a history of poor nutrition or chronic, serious illnesses which weaken the body and 205 promote poisons and toxins in the system. Introducing a new therapy too rapidly places a strain on an ah-eady weakened system and can cause a sudden release of toxins that may make you feel ill unnecessarily. As clinical studies have demonstrated, oral urine or urea can be fust as effective for non-emergency cases as injected urine. However, if your situation is extremely severe, urine injections can definitely be of benefit. As several of the dinical studies showed, urea, even in large doses, has been found to be harmless to the body, Researchers, (Urea - New Use of An Old Agent), reported that they safely administered urea daily to several patients for a period ranging from several day» to weeks, and in some cases, even several months, without any side effects, in doses ranging from 100 mg. Uric acid, usually thought to be a toxic waste product of the body, has been found by researchers to actually be a natural body defense against cancer and aging, allowing us to 206 live much longer than other mammals (Omni Magazine article, 1982). Most people think that uric add causes gout, but strictly speaking, it is not the uric add alone that causes the gout, but rather an overall, ongoing and chronic overaridity in the body which can be caused by many different factors including improper, overly-arid diet, kidney, liver and adrenal disorders, obesity, diabetes, chronic stress, undereating (anorexia), etc. Normally, the amount of uric add contained in urine is not a problem during urine therapy, because the body will excrete the amount it does not need. If you fed that you have a problem with chronic, ongoing overacidity (see section on Monitoring Arid/Alkaline Levels in this chapter), make certain that you decrease or eliminate meat while using urine therapy. Also, improve your diet by eating more alkaline foods, and decreasing arid foods before and after you start on urine therapy. Monitor your add/alkaline level with pH strips to determine when your pH has returned to a normal or more balanced condition. In cases of chronic addosis (over-acidity), do not do extended urine fasts or ingest large quantities over long periods of time. Use oral drops to begin; start with 1-2 drops once a day, and gradually increase to 5-10 drops two to four times a day, for one to three weeks, depending on your need. Monitor your pH levels and your symptoms (see symptoms of addosis in this chapter). You can also dilute the urine in water, or use a homeopathic preparation of your urine. The amount of time needed to achieve results with urine therapy is different for every person and each condition. Many people have found that chronic, long-standing complaints require a longer period of time to heal, while others experience rapid resuite. In general, do not use large amounts of urine infernally for more 207 than two to three weeks at a time. A maintenance dose for many people is one to two ounces of morning urine per day, although even 2-5 drops of morning urine per day or every oiher day could be considered a good maintenance dose, especially for those with acidosis or weak kidneys. There are several excellent urine testing kits that have been developed in the last few years that can be used at home and can save you an amazing amount of time and money. Now you can perform many of the same urine tests at home that your doctor performs in hia office. Also, these tests are particularly helpful when using urine therapy because you can monitor your own health progress easily and inexpensively. The booklet also explains how to interpret your urine color and appearance which are important additional indicators of health conditions. Many of the research tests on urine recycling have been undertaken with animals, and vetermarians have used urine therapy for treatment by catherizing the arumal and administering oral urine drops with reportedly good results. Urine home test strips are available to test for these conditions and many others: o Kidney and Urinary Tract Infections o Diabetes o Blood in the urine o Pregnancy o Ovulation 208 o Liver Function You can purchase these strips in drug- stores or they are available by catalog Summary Remember to begin your treatment slowly with a few oral drops and increase the amount to a well-tolerated dosage. Do not use the therapy while ingesting heavy amounts of nicotine, caffeine or while using recreational drugs or therapeutic drugs than small amounts. If you do decide to use it, however, use only very small amounts (3-5 drops 1x day. Drink as much water as you feel thirsty for, and keep weli-hydrated, but do not force-drink large amounts oi fluid during the therapy. Daily maintenance doses vary from a few drops to one to two ounces of morning urine, depending on your sensitivity and preference. Start with small amounts and work up to larger amounts gradually for internal use. Do Not combine urine therapy with a starvation diet (or fasting) unless you have been using the therapy for at least two months. Beginning in 1983, the school moved in-stages to the new branch campus in Kubang Kerian, Kelantan. The Health Campus is fully equipped with up-to-date teaching, research and patient care facilities. One of the unique features of the School of Medical Sciences is its integrated organ-system and problem-based curriculum. The course aims to produce dedicated medical practitioners who will be able to provide leadership in the health care team at all levels as well as excel in continuing medical education. More specifically, the student upon graduation, should be able to:- (a) Understand the scientific basis of medicine and its application to patient care. This ‘spiral’ concept enables the school to implement the philosophy of both horizontal and vertical integration of subjects/disciplines. The Medical School in formulating the new curriculum, studied the various problems in established medical faculties parri passu with new developments in medical education. The study of behavioural sciences and exposure to the clinical environment are also incorporated.

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Liver function tests buy generic viagra extra dosage line best erectile dysfunction pills treatment, inflamed gallbladder moves downwards and impinges blood cultures buy viagra extra dosage 130 mg without a prescription erectile dysfunction solutions pump, inflammatory markers and amylase on the fingers) cheap viagra extra dosage amex impotence under 30. Management r Patients with asymptomatic gallstones are usually Macroscopy managed conservatively. Cholesterol stones are yellow to green in colour with r Patients with impacted stones or acute cholecystitis arough surface, typically rounded, faceted and large require adequate analgesia and antibiotics to prevent Chapter 5: Disorders of the gallbladder 217 or treat cholangitis. It may be performed as an Surgical resection is often not feasible due to local spread emergency (severe or complicated acute cholangi- and metastases. Sometimes aggressive segmental resec- tis), early elective (during initial admission for acute tion of the liver and regional lymph nodes is carried out. In acute cholecystitis 90% of patients settle with conser- vative management within 4–5 days. Ascending cholan- Carcinoma of the bile ducts gitishasamortalityofupto20%inseverecasesrequiring emergency decompression. Carcinoma of the gallbladder is rare, but almost always associated with gallstones. The tumour can arise anywhere in the biliary sys- Aetiology/pathophysiology tem and may be multifocal. It causes obstruction and Unknown, but associated with gallstones and chronic hence dilatation of the proximal ducts. Histologically 90% of tumours are adeno- carcinomas and 10% are squamous carcinomas. Clinical features The usual presentation is progressive obstructive jaun- Clinical features dice. Other symptoms include vague epigastric or right Patients may have a history of gallstone disease. A mass is often palpable in the right upper empyema presenting with biliary colic and a non-tender quadrant. Direct invasion of local structures, especially the liver, is almost invari- Macroscopy/microscopy ableatpresentation. Spreadviathelymphaticsandblood The carcinoma commonly appears as a sclerotic stricture occurs early. The islets of Langerhans are islands of endocrine cells scattered throughout the pancreas. They are clustered Investigations around a capillary network into which they secrete their r Ultrasound may show dilated intrahepatic ducts and hormones. Management Acute pancreatitis Curative treatment is only attempted if the tumour is localised and the patient is fit for radical resection. Definition r Carcinoma of the common bile duct is treated by the Acute inflammation of the pancreas with variable in- Whipple’s operation (see page 221). Incidence The remaining biliary tree is anastomosed to a Roux Almost 5–25 per 100,000 per year and rising. Palliative treatments include insertion of a stent or anas- Age tomosis of a Roux loop of jejunum to a biliary duct in More common >40 years. The prognosis is better for patients with carcinoma of Aetiology the common bile duct who are suitable for a Whipple’s Biliary tract disease (80%), especially cholelithiasis, gall- operation. Alcoholism is the second most common cause (20% in the United Disorders of the pancreas Kingdom). Causes are as follows: r Obstruction: Gallstones, biliary sludge, carcinoma of the pancreas. Introduction to the pancreas r Drugs/toxins: Alcohol, azathioprine, steroids, diuret- The pancreas has two important functions: the produc- ics. Proteolysis Chapter 5: Disorders of the pancreas 219 due to proteases, fat necrosis due to lipases and phos- Table5. Translocation of gut pancreatitis bacteria can result in local infection and septicaemia. Within 48 hours of admission Shock may result from the release of bradykinin and Age >55 years prostaglandins, or secondary to sepsis. Haemorrhage may cause Grey– Turner’s sign, which is bruising around the left loin and/or Cullen’s sign, bruising around the umbilicus. The pancreas appears oedematous with grey-white Other investigations are required to assess the sever- necrotic patches. Bacterial infection leads to inflamma- ity and to monitor for complications: full blood count, tion and pus formation. Healing results in fibrosis with clotting screen, urea and electrolytes, liver function tests, calcification. Complications In the most severe cases there is systemic organ failure: Management r Cardiovascularsystem:Shock(hypotension,tachycar- The early management depends on the severity of the dia, arrhythmias). Patients require careful fluid balance zymes walled off by compressed tissue), pancreatic using central venous pressure monitoring and uri- abscesses (which may contain gas indicating infection nary catheterisation to allow accurate urine output withgas-formingbacteria)andduodenalobstruction. Prophylactic Investigations broad-spectrumantibioticsaregiventoreducetherisk When supportive clinical features are present the diag- of infective complications. Ascites and persistent obstructive jaundice with conservative management require laparoscopic may occur. Prognosis Investigations Pancreatitis is a serious condition: overall mortality is Serum amylase fluctuates, but may be moderately raised 10%. Endoscopic retrograde cholangiopancreatography mayshowscarringoftheductalsystemandevenstonesin the pancreatic duct. Magnetic resonance cholangiopan- Chronic pancreatitis creatography is increasingly being used. Definition Chronic pancreatitis is an inflammatory condition that Management results in irreversible morphological change and impair- Precipitating factors especially alcohol need to be re- ment of exocrine and endocrine function. Adequate analgesia is required, thoracoscopic splanchnicectomymayberequiredinrefractorypainnot Age associated with main pancreatic duct dilatation. Surgical M > F techniques include sphincteromy or sphincteroplasty, partial pancreatectomy or opening the pancreatic duct Aetiology/pathophysiology along its length and anastomosing it with the duodenum Two patterns of chronic pancreatitis are seen, a chronic or jejunum. Total pancreatectomy can be carried out, relapsing course with recurring acute pancreatitis and with replacement oral pancreatic enzymes and insulin. Risk factors includealcoholabuse,hereditarypancreatitis,ductalob- Tumours of the pancreas struction (e. Hy- percalcaemia, hyperlipidaemia and congenital pancre- Definition atic malformations are recognised associations. Clinical features Incidence Patients may present with an acute episode of pancre- 10 per 100,000 per annum and rising. Late com- plications include impaired glucose tolerance, diabetes Age mellitus and malabsorption (steatorrhoea) associated Mainly >60 years. Chapter 5: Disorders of the pancreas 221 Sex Complications 2M : 1F The main routes of spread are local causing obstruc- tive jaundice or invasion of the duodenum, lymphatic to Geography adjacent lymph nodes which drain into the coeliac and In many Western countries it is the fourth commonest superior mesenteric lymph nodes and haematogenous cause of cancer death in males and in females, the sixth. Aetiology There appears to be some familial clustering and hence Investigations it is suggested that genetic susceptibility may play an There are no useful tumour markers or pancreatic func- important role. Specific inherited risks include famil- tion tests for diagnosis, which must be histological. Mosttumoursdevelop intheheadofthepancreasandthesetendtopresentearly ducts and may also be used for intervention.

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Similarly purchase viagra extra dosage 200 mg without prescription impotence leaflets, the prevalence of cancer in this population is so low that the likelihood a positive test would be cancer is very low and there will be many more false positives than true positives buy viagra extra dosage without prescription erectile dysfunction pills philippines. The screening test must be a good one and must accurately detect disease in the population of people who are in the presymptomatic phase of disease purchase cheap viagra extra dosage online erectile dysfunction at the age of 25. It should also reliably exclude disease in the population without disease or have high specificity. Of the two, we want the sensitivity to be perfect or almost perfect so that we can identify all patients with the disease. We’d like the specificity to be extremely high so that only a few peo- ple without disease are mislabeled leading to a high positive predictive value. This usually means that a reasonable confirmatory test must be available that will more accurately discriminate between those people with a positive screen- ing test who do and don’t have the disease. It should be relatively comfortable, not very painful, should not cause serious side effects, and also be reasonably priced. A screening test may be unacceptable if it produces too many false positives since those people will be falsely labeled as having the disease, a circumstance which could lead to psychological trauma, anxiety, insurance or employment discrimination, or social conflicts. Several studies have found significant increases in anxiety that interferes with life activities in persons who were falsely labeled as having disease on a screening test. This is an especially serious issue with genetic tests in which a positive test does not mean the disease will express itself, but only that a person has the gene for the disease. For screening tests, most people will tolerate only a low level of discomfort either from the test procedure itself or from the paperwork involved in getting the test done. People would much rather have their blood pressure taken to screen for hypertension than have a colonoscopy to look for early signs of colon cancer. Finally, people are more willing to have a test performed to detect disease when they are symptomatic than when they are well. If the test is too complex such as screening colonoscopy for colon cancer, most people would not be willing to have it done. A test that is very uncomfortable such as a digital rectal exam for prostate or rectal cancer, may be refused by a large proportion of patients. Both examples also require more complex logistics such as individual examin- ing rooms and sedation for the colonoscopy than a screening test such as blood pressure measurement. Screening tests must also be well advertised so that peo- ple will know why and how to have the test done. Pitfalls in the screening process Simply diagnosing the disease at an earlier stage is not helpful unless the progno- sis is better if treatment is begun at that earlier stage of the illness. The treatment must be acceptable and more effective before people will be willing to accept treatment at an asymptomatic stage of illness. Why should someone take a drug for hypertension if they have no signs or symptoms of the disease when that drug can cause significant side effects and must be taken for a lifetime? During the 1960s and 1970s, some lung cancers were detected at an earlier stage by routine screening chest x-rays. However, immediate treatment of these cancers did not result in increased survival and caused increased patient suffer- ing due to serious side effects of the surgery and chemotherapeutic drugs. There- fore, even though cancers were detected at an earlier stage, mortality was the same. The validity of a screening test can be determined from the evidence in the literature. Screening tests must balance the need to learn something about a patient, the diagnostic yield, with the ability to actively and effectively intervene in the disease process at an earlier stage. Lead-time bias results in over- optimistic results of the screening test in the clinical study. The patients seem to live longer but this is only because their disease is detected earlier. In this case, the total time from onset of illness to death is the same in the group of patients who were screened and treated early compared with the unscreened group. The lead time is the time from diagnosis of disease by screening test to the appear- ance of symptoms. The time from appearance of symptoms to death is the same whether the disease was detected by the screening test or not. The total life span of the screened patient is no different from that of the unscreened patient. The time between early diagnosis with the screening test and appearance of symp- toms, the lead time, will now be spent undergoing treatment (Fig. This Screening tests 315 Onset of Fig. Onset of Asymptomatic Death Symptoms disease No screening Survival Time Screened but early treatment not effective Apparent Survival Time (lead-time bias) Screened and early treatment is effective (No lead- time bias, time Prolonged Survival Time effectiveness) could be very uncomfortable due to the side effects of treatment or even dan- gerous if treatment can result in serious morbidity or death of the patient. Patients are not randomized and the spectrum of disease may be very different in the screened group when compared to the unscreened group. A disease that is indolent and slowly progressive is more likely to be detected than one that is rapidly progressive and quickly fatal. Patients with aggressive cancers are more likely to die shortly after their cancer is detected. Those with slow-growing indo- lent tumors are more likely to be cured of their disease after screening and will live a long time until they die of other causes. There are some whose disease is too early to detect and who will be missed by screening. Without screening, his or her disease will be detected when it becomes symptomatic, which will be at a later stage. This problem can be reduced in large population studies by effective randomization that ensures a similar spec- trum of disease in screened and unscreened patients. Compliance bias occurs because in general, patients who are compliant with therapy do better than those who are not regardless of the therapy. Compliant patients may have other characteristics such as being more health-conscious in their lifestyle choices, which lead to better outcomes. Studies of screening tests often compare a group of people who are in a screening program with people in the population who are not in the screening program. Therefore, the screened group is more likely to be composed of people who are more compliant or health-conscious, since they took advantage of the screening test in the first place. This will make it more likely that the screened group will do better since they may be the healthier patients in general. This bias can be avoided if patients in these studies are randomized before being put through the screening test. One way to test for this bias is to 316 Essential Evidence-Based Medicine Fig. Screening Performed Onset Detectable Symptomatic Death Rapidly progressive - Curable Not curable detected too late; no survival benef t Slowly progressive - Detected in curable symptomatic phase; survival benefit Very slowly growing tumor (missed) - not detected; patient reassured, no actual survival benefit, but, survival appears longer have two groups of patients, one that is randomized to receive the screening test or not and the other group that has a choice of whether to get screened or not. Effectiveness of screening Another problem with screening tests revolves around their overall effectiveness. For example, consider the use of mammograms for the early detection of breast cancer in young women.