Antibiotic Linked to Intestinal Disorder in Infants
The September, 2001, issue of the Journal of Pediatrics reports that giving infants the antibiotic erythromycin, especially within the first two weeks of life, can increase their chances of developing an intestinal disorder that likely will require surgery.
The disorder, called infantile hypertrophic pyloric stenosis (IHPS), occurs when the tube leading from the stomach to the small intestine (the pyloris) becomes enlarged, blocking the stomach’s outlet. This results in projectile vomiting, dehydration and weight loss. IHPS is the most common cause of abdominal surgery in infancy.
The researchers also found that there may be a link between IHPS and a mother using the antibiotic during the last 10 weeks of pregnancy as well.
The study also saw some evidence that two related antibiotics, azithromycin and clarithromycin, may also be linked to IHPS.
“For a community to be whole and healthy, it must be based on people’s love and concern for each other.”
– Millard Fuller
Antibiotics for Otitis Media NOT RECOMMENDED
A group of eight international researchers from Britain, the Netherlands and the United States reported their review of the scientific literature on the use of antimicrobials for the treatment of otitis media. While the researchers were multinational, the study was funded by the Agency for Health Care Policy and Research (AHCPR) within the U.S. Department of Health and Human Services.
The paper compares the discriminating use of antimicrobials for acute ear infection in the Netherlands and Iceland, versus the abundant prescription policies of antibiotics in the U.S. and Britain.
According to the authors, otitis media is the “most common reason for outpatient antimicrobial use” in the U.S. Approximately 30 percent of children under age three receive microbial treatment for acute ear ache each year.
The Netherlands, by comparison, does not include antimicrobial use in their initial routine treatment of otitis media symptoms. The authors report that “this policy is associated with decreased emergence of resistance among organisms commonly found in otitis media.”
The paper asks and answers some important questions:
“Does Treatment Improve Outcomes?
“Nevertheless, since results are mixed and no study found large differences between placebo and antimicrobial groups, we conclude that the benefit of routine antimicrobial use for otitis media, judged be either short or long-termed outcomes, is unproven. “Does Treatment Prevent Complications?
“Although preventing mastoiditis and meningitis is a rationale for antimicrobial treatment, little evidence exists that routine treatment is effective for this purpose.
“Do Children at High Risk Benefit from Antimicrobials?
“‘No study has addressed whether antimicrobial treatment decreases the refluency of these in all or some of those with known risk factors.
“What is the Optimal Type and Duration of Administration?
In the nine country study, antimicrobials did not improve outcome at two months, and no differences in rates of recovery were found for either antimicrobial type or duration.
No Compelling Evidence
“After addressing these four questions, we conclude that existing research offers no compelling evidence that children with acute otitis media routinely given antimicrobials have a shorter duration of symptoms, fewer recurrences, or better long-term outcomes than those who do not receive them.
“What Is the Effect on Antimicrobial Resistance?
“Antimicrobial use in children with otitis media results in the emergence of resistant organisms in those children and in the community. Although the organisms that cause otitis media are similar across countries, the Netherlands has a. lower prevalence of resistant strains than other European countries.
“What Needs to Be done?
“Research – Placebo studies indicate that more than 80 percent of children.with acute otitis media recover without antimicrobials.
“Prevention of acute otitis media – Sufficient information exists to support aggressive encouragement of breast feeding and avoidance of tobacco smoke. There is insufficient evidence of effectiveness to recommend pneumococcal vaccine.
“Treatment of acute otitis media – Clinicians should immediately reconsider the routine use of antimicrobials for children with otitis media and consider treating symptoms with analgesics and observation for lack of improvement. ”
It is hard to believe that these drugs have been prescribed for decades without needed supporting research. Even more concerning is the warning given by the authors in the first sentence of the paper:
“Increasing worldwide resistance OJ bacteria to antimicrobial drugs h causing a crises manifested by higher morbidity, mortality and costs.2″
While much of this will not be considered news to the chiropractic community, or to many medical doctors, one hopes the medical pediatric community will begin to reconsider the routine prescription of antiobiotics for otitis media
1. Froom J, Culpepper L, Jacobs M et at. Antimicrobials for acute otitis media? A review from the International Primary Care Network. BMJ 1997:315;98 102. .
2. Neu HG. The crises of antibiotic resistance. Science 1992:257;1036-8.
Study says doctors are over-prescribing antibiotics
CHICAGO – Doctors wrote 12 million antibiotic prescriptions in a single year for colds, bronchitis and other respiratory infections against which the drugs are almost always useless a study found.
Such indiscriminate use of antibiotics has contributed to the emergence of drug-resistant bacteria in the United States, the researchers said.
More than 90 percent of upper respiratory infections, including bronchitis and colds, are caused by a virus and are therefore impervious to antibiotics, researchers stated in the Journal of the American Medical Association.”
In 1992, doctors prescribed antibiotics to two-thirds of bronchitis sufferers who visited them in their offices and half of common-cold sufferers and patients with other upper respiratory infections, the researchers found.
That amounted to 12 million prescriptions, or one in every five antibiotic prescriptions written for adults that year, the researchers said.
Antibiotic overuse continuing problem
The Associated Press reports that doctors continue to write 12 million antibiotic prescriptions yearly for virus-caused colds, bronchitis and upper respiratory infections even though they know that the antibiotics have no effect on viral illnesses.
The September 17, 1997 issue of the Journal of the American Medical Association says that this kind of indiscriminate use of antibiotics is one of the main reasons for the emergence of drug-resistant bacteria.
While more than 90 percent of upper respiratory infections, bronchitis and colds are caused by viruses and therefore unaffected by antibiotics, doctors continue to prescribe the drugs. Studies have shown that doctors may give in to patients expectations for antibiotics even though they know the drugs will not help.
Lead author of the study, Dr. Ralph Gonzales of the University of Colorado Health Sciences Center, says “Every time we use an antibiotic, we run the risk of promoting antibiotic resistance, or drug resistance by bacteria.”
Antibiotic overuse: doctors blame parental pressure
The February 1999 issue of the journal Pediatrics reports on a study that finds parental pressure is the main reason doctors give when pressed for reasons why they prescribe antibiotics to children in inappropriate situations.
610 pediatricians, all members of the American Academy of Pediatrics from around the country were surveyed. One in three of the surveyed doctors said they often or occasionally prescribed antibiotics they believed to be unnecessary to appease the parents.
Antibiotic overuse is a major health problem. in 1980, 4.2 million prescriptions were written for amoxicillin, most commonly used for ear infections. By 1992, the number of prescriptions increased by 194% to 12.4 million. The use of cephalosporin antibiotics grew 687% during that same time.
The problem with antibiotic overuse, the researchers note, is that doctors continue to prescribe antibiotics for viral problems such as colds and flu that they know the drugs are ineffective against.
UK report: Antibiotics overused, not working
A February, 2002 report by industrial analysts Datamonitor, shows that as antibiotics are being overused in the United Kingdom their effectiveness is decreasing. This has the effect of accelerating the development of antibiotic resistant strains.
Despite many years of warnings, doctors continue to prescribe antibiotics for even minor infections such as respiratory tract infections. In the UK, the report says, doctors rely on two types of antibiotics, penicillins and macrolides. As these drugs become more and more useless due to bacterial resistance, stronger and more expensive drugs are needed and the cycle continues.
The report says that currently, 15% of patients taking antibiotics have to have another round of treatment with another antibiotic because the first one proved ineffective.
Why do doctors keep writing antibiotic prescriptions even though they are aware of the problem? Apparently doctors are too busy to take the time to explain why antibiotic use may be dangerous. “For a time-stretched GP, it is, instead, far easier to take one minute off to print a prescription,” the report says. “Doctors find that they simply do not have the time to explain why antibiotic treatment could actually do more harm than good.”
Commentary: The doctor’s too busy to explain? What nonsense. Your doctor’s responsibility is to make sure you know what’s going on with your health. If you ever have a doctor dismiss one of your questions with an “I’m too busy,” or “It’s too complicated-you wouldn’t understand, just trust me” attitude, get up and run out of that office. No matter who they are or how good they are, if they won’t explain things to you, you don’t need them.
Use Antibiotics Wisely – by Dr. John Macaulay
In order to have antibiotics that are effective in treating severe infections, care must be taken to use such drugs properly. Both patients and physicians should be aware of the dangers of over-prescribing antibiotics.
Physicians prescribe 6.5 million antibiotics each year for pediatric patients with upper respiratory infections, even though nearly all such prescriptions were inappropriate. Statistics from the Centers for Disease Control (CDC) show that at least 25’0 of streptococcus pneumonia bacteria are resistant to penicillin today, but only 5’0 were resistant just five years ago. Nearly all of the bacteria that cause human infections are now resistant to the best choice for treatment of a particular infection.
In a round of viral upper respiratory infection that swept throughout upstate New York, a high percentage of the people infected went to their physician and received an antibiotic. Those who did not consult their doctor probably recovered in the same length of time without an antibiotic.
Keep in mind that antibiotics have no beneficial effect on viral infections. It’s a fact that 85’0 of all upper respiratory infections, including sore throats, sinusitis, bronchitis and ear inflammations, are caused by viruses.
Casualties of the War on Germs
Antibiotics can disrupt the vaginal flora, making the patient more susceptible to vaginal infections such as that due to the yeast Candida albicans.
“Candida albicans infection, often associated with antibiotic-induced alterations in microbial flora, may cause defects in cellular immunity.”
While no one can argue the fact that antibiotics have saved lives, many authorities believe that doctors’ efforts to “eradicate microbes at all costs” represent an undeclared war that is not without a price. In fact, some suggest there are numerous circumstances in which the risks of antibiotics outweigh the benefits.
Antibiotics continue to be prescribed for conditions that do not even warrant their use.
This heavy prescribing of antibiotics is not without costs in both dollars and human suffering. Perhaps the worst tragedy is that many doctors consider much of the antibiotic prescribing medically unnecessary or worse-harmful! Consider the views expressed by leaders in the fields of infectious diseases and medical consumerism, much of which has been published in medical textbooks and peerreviewed medical journals:
“After Congressional hearings and numerous academic studies on this issue, it has become the general consensus that 40 to 60 percent of all antibiotics in this country are misprescribed.”
“Pharyngitis and tonsillitis. . . are among the worst-treated of all illnesses, primarily because of the overprescription of antibiotics.”
“In 1983, more than 51 percent of the more than 3 million patients who saw doctors for treatmen of the common cold were unnecessarily given a prescription for an antibiotic.”8 Antibiotics do nothing for the common cold because the condition is viral in nature.
“It is no accident that the most allergic generation in history has been raised on antibiotics. Several times a week I see a new patient whose allergies appeared or became much worse after a course of antibiotics.”
“Researchers are questioning whether the routine use of antibiotics is a contributing factor to frequently occurring acute otitis media [middle ear infection] and persistent middle ear fluid-conditions that were rare before the advent of antimicrobial therapy.”
“Recurrence rates [of middle ear fluid] were significantly higher in the antibiotic-treated group than in the placebo group.” Children receiving amoxicillin for chronic middle ear infection experienced two to six times the rate of recurrence.
Antibiotics used to treat upper respiratory infections have been shown to cause urinary tract infections.
The latest issue of the British Medical Journal includes a study(1) that will be cheered by chiropractors, and painful to pediatricians. Most will recognize this as another case of scientific research finally catching up with chiropractic philosophy.
How satisfying it is to finally read in a press release that “antibiotics are not the best treatment for middle ear infections and doctors should stop routinely prescribing drugs for them.”2 The scientists from Britain, Netherlands and the United States who examined all of the relevant studies are now basically saying what chiropractic has been saying for years.
Imagine the drug companies finally being cut off from their multi-billion-dollar annual income streams, and concerned parents no longer buying virtually worthless drugs.
What will the MDs do now, prescribe aspirin or insert tubes?
Who needs an office call to learn that the wonder drug doesn’t work?
How much faith can mothers have in a profession that has used useless drugs to create antibiotic-resistant organisms for their now antibiotic-immune children to face in later life?
In 1994, the Agency for Health Care Policy and Research released their guidelines, Managing Otitis Media with Effusion in Young Children (please see “Otitis Media Guidelines Leave Door Open for Chiropractic” in the September 23, 1994 issue). Antibiotics were their first recommended form of treatment, but the list of potential harmful side-effects (and the percentage of children they affect) is enough to wake up any parent:
– Nausea, vomiting and diarrhea (in 2- 32 % of children) depending on dose and antibiotic used;
– Cutaneous reactions, less than or equal to 5%;
– Numerous rare organ side-effects, including very rare fatalities
Doing some simple math, depending on the dose and antibiotic, a child has as much as a 37 percent chance of experiencing a harmful side-effect from a drug not considered to have any real value for acute ear infections.
So who’s going to tell the parents? Who’s going to tell the truth about what the drug companies and their MD accomplices have perpetrated on many of the children of the Western world? YOU WILL
Don’t hold your breath waiting for pediatrician confessions or drug company apologies. If parents are going to hear the truth, they’ll have to hear it from you.
Fortunately, the paper presented in the British Medical Journal is straightforward and easy to read. It is as if the authors wrote it for the patient audience.
We contacted the British Medical Journal, purchased reprints of the paper, and paid to have them shipped to us for distribution to the chiropractic profession. We’re offering them to you at our cost.
This paper is a must read for all your patients, particularly those with small children. Many of them will want to share this information with their friends and family. Some may even want to have some serious discussions with their MDs.
It would not be surprising for MDs to continue to prescribe antibiotics for ear infections in the face of this report. This is your opportunity to demonstrate your concern and your professionalism.
You may order by credit card (Visa, Mastercard, American Express, Discover) with a choice of four methods:
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News the Doctor Felt You Should Know:”Warning Sought for Antibiotic Prescriptions”
From the November 2000 issue of The Nation’s Health published by the American Public
Health Association comes an article entitled as above.
The article references a move on the part of the Food and Drug Administration seeking to add labels to antibiotic prescriptions that would caution physicians to prescribe them only when needed for patients to use them as directed.
According to FDA Commissioner Jane Henney, M.D., “Antibiotic resistance is a serious and growing public health concern in the United States and the world. When we avoid the unnecessary use of antibiotics we help preserve their effectiveness.”
Under the FDA proposal the New labeling to physicians would include the following:
– only prescribe antibiotic when a bacterial infection exists
– use the antibiotic designed to address the organism involved
– if tests show a different organism to be involved, modify the antibiotic being used
A 1992 study demonstrated that 21% of antibiotic prescriptions were written to address viral infections, for which they are ineffective. Lest you think this is a US problem, in China, 62% of antibiotic use was for the wrong organism, again applications for which they are ineffective. I don’t want you to think the Chinese are out in left field, the World Health Organization estimates that 50% of antibiotic use in the US and Canada is inappropriate.
Antibiotics and Immune Suppression
One irony of antibiotic use is that while they are intended to “bolster” the immune response by killing bacteria, they may in some cases have a suppressive effect on immunity. Evidence for this comes from two basic sources: studies of the effect of antibiotics on the activity of white blood cells, and the outcome of infections treated with antibiotics.
In an article published in The American Journal of Medicine in 1982, Drs. William Hauser and Jack Remington of Stanford University School of Medicine reported on the ability of some antibiotics to alter the immune response.Tetracycline was shown to inhibit the abililty of white cells to engulf and destroy bacteria (phagocytosis) and to delay the ability of white cells to move to the site of infection. Sulfonamides inhibited the microbiocidal activity of white cells. Trimethoprim-sulfamethoxazole inhibited antibody production. Similar action of numerous antibiotics was reported (26).
Antibiotics have also been shown to increase the likelihood of repeat infections. In one report, children with strep throat who were given antibiotics recovered from the initial infection in short order. However, they experienced a rate of recurrent infections two to eight time higher than those not recriving antibiotics. This was especially true if antibiotics were given in the first two days of illness.
Similar findings have been reported with antibiotics used to treat ear infections. A study published in 1974 showed that children with actual earaches who received antibiotics with in the first few days of illness experienced up to 2.9 percent recurrent infections than those in whom antibiotic use was delayed (7 or more days) or avoided. (28). This study was met with some skepticism and seemed to have little impact on medical practice. A 1991 article published in the Journal of the American Medical Association has renewed the debate raised by the 1974 study. It showed that children with chronic earaches who received antibiotics experienced two to six times more recurrent middle ear effusion than those receiving placebo. (29).
Such evidence seems to suggest that antibiotics may in some cases limit the body’s ability to recognize and destroy invading bacteria. It appears that when antibiotic treatment is delayed, children are able to develop natural immunity, thereby insulating them from future episodes. Early antibiotic therapy may inhibit the initial immune response, which may increase the likelihood of repeat infections.
One in five taking Cipro experience side effects
The November 9, 2001 issue of the CDC’s Morbidity and Mortality Weekly Report finds that one in five (20%) of people taking the antibiotic Cipro after presumed exposure to anthrax are experiencing adverse reactions to the drug.
Dr. Julie Gerberding, acting deputy director of the CDC’s National Center for Infectious Diseases, says that percentage of side effects was expected. “We have had no surprises,” she said. “These adverse events are no different from what we typically see with ciprofloxacin and doxycycline.”
With approximately 32,000 people taking antibiotics to prevent anthrax since October 8, 2001 and more expected, thousands of people are expected to experience Cipro’s side effects including nausea, vomiting, dizziness, convulsions, rashes, itching, swelling of the face, neck or throat, breathing problems, ruptured tendons, heart rhythm irregularities and psychiatric illness.
Inappropriate Rx for common cold is harmful, expensive
Government health insurance programs may be spending millions of dollars in futile treatments for the common cold.
Reseachers at the University of Kentucky in Lexington found their state’s Medicaid program spends $1.62 million treating colds with the antibiotics, which don’t work because colds and other upper respiratory tract infections are caused by viruses, not bacteria. Inappropriate antibiotics accounted for 23 percent of the total cost of outpatient care.
The unnecessary antibiotics may actually be harmful, as the overuse of the drugs is thought to contribute to bacteria’s growing antibiotic resistance, the researchers said.
The finding was not all that surprising, they write in the current issue of Archive of Family Medicine. This and other studies have found that more that half of all cold sufferers get prescriptions for antibiotics.
Conflict of Interest Taints Antibiotic Research
Antibiotics may not be the best way to treat ear infections. A 1991 double-blind study from the University of Pittsburgh and reported in the Journal of the American Medical Association found that children treated with amoxicillin didn’t recover any faster than children treated with a placebo, and were even more likely to have their infections recur.
These results contradict a 1987 analysis of the same data, which appeared in the New England Journal of Medicine and supported amoxicillin treatment. the Journal of the American Medical Association decided to publish this alternative report after reviewing evidence showing
1. that the authors of the original report omitted data that did not support amoxicillin,
2. that amoxicillin’s manufacturer paid $260,000 in honoraria to the scientist responsible for the pro-amoxicillin report, and
3. that the manufacturer paid $3.5 million in research grants to the research center where the study was performed.
More antibiotics in the news
Government links antibiotic to severe illness in newborns (AP). In a report that shocked pediatricians, the government said a common antibiotic used to treat whooping cough in newborns caused serious stomach problems in babies at a Tennessee hospital.
Doctors said the report from the Center for Disease and Prevention is the first time that erythromycin has been strongly linked to pyloric stenosis, an illness among newborns that blocks digestion and causes projectile vomiting. The illness must be treated with surgery.
“Wow!” said Dr. William Kanto, director of the children’s hospital at Medical College of Georgia in Augusta. “I think it’s going to make everybody pause whenever they decide to give erythromycin to a newborn. The CDC said doctors and parents need to be aware of the potentially serious side effect of the antibiotic.
But the agency said that doesn’t mean doctors should stop prescribing it for whooping cough, which puts most infected babies in the hospital and can be fatal. Newborns are sometimes also given erythromycin to treat chlamydia infections transmitted from their mothers during birth.
An eye ointment to prevent blinding gonorrhea infections also contains the antibiotic.
Dr. Warner responds: Here is another reason to check all newborns for vertebral subluxation.
Report raises concerns of human harm from antibiotics-fed – chickens (AP). A government report suggests up to 5,000 Americans might have suffered longer lasting food poisoning last year because they caught an antibiotic-resistant strain from eating chicken.
The report, being debated at an FDA meeting with food safety and veterinary experts, is the first attempt to predict human health risk if antibiotic use in animals lets drug-resistant germs wind up in the meat people eat.
Many public health experts say on the farm drugs worsen the already serious problem of antibiotics losing their power to fight infections. But the animal drug industry insists there is no serious risk to consumers.
Dr. Warner responds: The problems with antibiotics used in raising animals for food is enormous and it will be many years before we can even measure the devastating effects on humans and our planet.
When the “Cure” is Worse Than the Cause
Antibiotic resistant “super-bugs” are evolving at an alarming rate, according to a just-published study in the New England Journal of Medicine. Soon, say experts, many infections will be untreatable altogether. As prevention specialists, Drs. Pam and Steve Jarboe are concerned about the misuse and overuse of antibiotic medication in the community. Drs. Jarboe encourage patients to familiarize themselves with all information about antibiotic and to share it with friends and family – it may one day save their lives.
When infection-causing bacteria are killed with antibiotic medications, not all of the bacteria die. The extra-hardy bacteria that survive reproduce – creating indestructible legions of super-bugs. These strains trigger serious, untreatable, infections. New, stronger, antibiotics are then created to annihilate the super-bugs, perpetuating the vicious cycle.
What’s even more frightening is that drug technology cannot possibly keep up with the super-bugs. “It takes seven to 10 years to develop a new antibiotic and bacteria just a few months or years to develop resistance to it,” explains Dr. Pharm Schentag, one of the developers of The Resistance Web, a Web site dedicated to tracking antibiotic resistance trends.
Super-bugs evolve due to the misuse and overuse of antibiotic drugs. Quite often, antibiotics are prescribed for viral conditions that do not respond to antibiotic treatment – or are given indiscriminately to children whose conditions don’t warrant medication, in order to ease parents’ anxiety.
Antibiotics and drug-resistant bacteria may also sneak into a person’s system through the foods he or she eats. “Factory farming” frequently involves dosing animals with excessive amounts of antibiotics. These drugs are present in dairy goods and other products. In addition, meat from antibiotic-fed livestock may be infected with resistant bacteria, which triggers food poisoning – some cases of which are fatal.
The study, upon which the New England Journal of Medicine article was based, was conducted by the Active Bacterial Core Surveillance team – a program of the United State’s Centers for Disease Control and Prevention in Atlanta, Georgia. Dr. Cynthia G. Whitney led the 14member research team.
Researchers focused on antibiotic resistance to Streptococcus pneumoniae bacteria. Streptococcus pneumoniae is the main culprit behind middle ear infection, pneumonia, meningitis and several other common conditions. The research team pooled data from 12,045 samples taken from patients with Streptococcus pneumoniae diseases between 1995 and 1998.
And the answers were…
Findings revealed that 24 percent of the bacteria in the samples were resistant to penicillin. And, resistance to at least three different types of antibiotics among patients with Streptococcus pneumoniae infection jumped from 9 percent in 1995 to 14 percent in 1998.
The study concluded that “Multidrug-resistant pneumococci are common and are increasing.”
All of this means what?
The results of the study show that super-bugs are evolving at a frenzied rate. If the explosion of antibiotic-resistant bacteria remains unchecked, more and more resistant bacteria will emerge, triggering diseases that are impossible to fight.
Despite the widespread use of antibiotics, the rate of Streptococcus pneumoniae infections is rocketing. For instance, cases of bacterial pneumonia more than doubled in children under the age of four – and in seniors aged 70 to 79 years between 1993 and 1997.
An editorial accompanying the report pointed out that “Each year in the United States, 160 million prescriptions are written for antibiotics and 22.7 million kg (25,000 tons) of antibiotics are prescribed.”
“In a population of 275 million, this degree of use in terms of exposure is equivalent to nearly 30 prescriptions per 100 persons per year and to 4.1 kg (9 lb) of antibiotics per 100 persons per year. This enormous level of use of antibiotics has great potential for selecting for or enhancing the growth of resistant strains. Probably half of all such uses are inappropriate, as is represented by the needless treatment of viral upper respiratory tract infections, bronchitis, and pharyngitis.”
The editorial also highlighted the influence of antibiotic resistance in nosocomial infections (infections that patients pick up during a hospital stay, which.they did not have prior to hospitalization). Nosocomial infections of the bloodstream are the eighth leading cause of death in the United States. The three leading causes of these infections are resistant bacteria.
“The antibiotic era is barely 60 years old, yet the inappropriate use of these drugs threatens our ability to cope with infections,” noted the authors of the editorial.
How may patients obtain a copy of the article?
The article, Increasing Prevalence of Multidrug-Resistant Streptococcus pneumoniae in the United States, which appeared in the December 28, 2000 issue of The New England Journal of Medicine (N Engl J Med 2000;343:1917-24), may be viewed for no cost at the journal’s Web site at www.nejm.org. Most chiropractic school and medical school libraries also carry the journal.