lame "Take one or two daily, as instructed", but this form of instruction is most unpopular with pharmacists, for valid reasons. Can anyone help? Morton S. Rapp, MD 39 Elliotwood Ct. Willowdale, Ont.
Reducing the infant mortality rate es, Canada could save 600 Y little lives annually if the
I have carried patients with premature rupture of the membranes at 24 weeks to term, performed cerclage at 32 weeks in the presence of advanced cervical dilatation and drained large amounts of amniotic fluid along with many other intensive measures in order to prevent preterm birth,2'3 less drastic measures4-8 can often suffice if one acts on early clues and employs preventive measures. Stefan Semchyshyn, MD 22 Old Short Hills Rd. Livingston, NJ
infant mortality rate were References brought down to that of Japan in the mid-1980s, as reported by Dr. 1. Billion dollar treatment for infant mortality. US News and World Rep 1988; Patrick J. Taylor in his Medicine Aug 8: 10 Chest column in the Nov. 1, 1990, 2. Semchyshyn S: Preventing prematurity issue of CMAJ (143: 928-929). If (I): Assessing the risk. Female Patient 1985: 10: 42-54 the US dropped its rate to half the current one, we would save 20 000 babies annually.' Is it possible? Yes. Is it likely? Maybe. To make further reductions in the infant mortality rate we must revolutionize prenatal care, reorient our approach to childbirth from one of crisis intervention to one of prevention. We in the United States have some of the best medical technology in the world as well as know-how. We transplant bone marrow, livers, hearts and lungs, and we separate Siamese twins. We can save the smallest and most disadvantaged of babies. Yet when it comes to helping our babies survive their first birthday we fall behind some 20 other nations. The reason is that, sadly, we lack enthusiasm for preventive measures. Prevention has less pizzazz, creates no headlines and is financially unrewarding despite the fact that it can save lives and large amounts of money. In my 15 years in the practice of maternal-fetal medicine I have encouraged and enlisted a committed partnership with parents that is based on pregnancy "literacy", with good results. It works, saving lives and dollars. Although 120
CAN MED ASSOC J 1991; 144 (2)
3. Idem: Preventing prematurity (II): Managing early labor. Female Patient 1986;11:30-34 4. Papiemick E: Prenatal care and the prevention of preterm delivery. Int J Gynecol Obstet 1985; 23: 427-433 5. Gonik B, Creasy RK: Premature labor: diagnosis and management. Am J Obstet Gynecol 1986; 154: 3-8 6. Yawn BP, Yawn RA: Preterm birth prevention in a rural practice. JAMA 1989; 262: 230-233 7. Hueston WJ: Prevention and treatment of preterm labor. Am Fam Physician 1989; 40: 139-146 8. Freda MC, Damus K, Anderson HF et al: The neglected first step in preterm birth prevention: evaluation of the educational intervention [abstr 174]. Presented at the 10th annual meeting of the Society of Perinatal Obstetricians, Houston, Jan 23-27, 1990
Why is screening mammography delayed?
F_ ourteen cases of breast can-
cer were diagnosed in my family practice by means of screening mammography between January 1986 and June 1990. Detection was delayed in 10 cases. In early 1988 I began to order mammography every 3 years for women over the age of 40 years, every 2 years for those over the
age of 50 years and every year for those with a personal or family history of breast cancer. Other risk factors that I considered were early menarche (before age 12), late menopause (after age 50) and nulliparity or first term pregnancy after age 30. Physician delays in ordering mammography occurred in three cases. Two of the patients had a second-degree family history of breast cancer (in an aunt and several cousins); one had seen me and three gynecologists but was not offered mammography until age 69. The third patient had a "benign" cyst drained by a surgeon; 29 months passed before follow-up mammography was performed - it showed cancer at the same site. Patient delays in accepting mammography occurred in seven cases. In some cases the procedure was delayed for several years despite obvious risk factors, usually because of fear of radiation. The most frustrating case was that of a 72-year-old woman whose mother had died of breast cancer at age 70; this patient had very large breasts that were difficult to examine, she was nulliparous, and her menopause had been delayed to age 58. Fortunately, despite the delays only 1 of the 14 patients had metastases when the diagnosis was made. All of the nine patients in whom the diagnosis was made from the first mammograms were over age 60 at the time. I am sure that the situation I have described is not unusual in primary care. Although most physicians, I hope, are convinced of the lifesaving value of screening mammography, we must be astute, persistent and even forceful to make sure that our patients comply. David Rapoport, MD, CCFP 303-4430 Bathurst St. Downsview, Ont.