gators may have been biased in assessing outcomes in
patients undergoing ultrasound guidance. Randolph et
al point out a limitation of interpreting these
variable definition of failed catheterisation
across the studies and possibly in the same study. Most
remarkably, in three of these eight trials the investigators
did not even define the primary end point of their study.
When unblinded studies give no a priori definition of
failed placement, it is possible that more attempts could
have been allowed with the ultrasound method. Bias of
doctors is even more likely in unblinded studies when
patients were quasi-randomised, particularly in view of
the preference of most operators to use the ultrasound
Another concern is the number of patients investi-
gated in the trials that compare techniques using ana-
tomical landmarks with ultrasound guided cannula-
tions. In a power analysis based on published data
Lefrant et al hoped to detect a 10% reduction in com-
plications, which were estimated to have an incidence
Therefore a study including 276 patients was
calculated to provide an 80% probability of rejecting
the null hypothesis. Therefore one should assume that
the sample size of reliable studies should substantially
exceed 100 patients. Central venous catheterisation is a
daily practice for specialists in anaesthaesia and inten-
sive care, so why is the sample size of most randomised
trials less than 80
which means less than 40 patients
per group. Focusing on randomised studies including
more than 100 patients does not show a significant dif-
ference in carotid punctures and the overall success
rate of cannulations.
Ultrasound guidance improved
the number of attempts per cannulation and successful
first attempts for catheterisation of the internal jugular
vein but not the subclavian approach.
designed trials have given firm evidence for the appli-
cation of real time two dimensional ultrasonography in
children with respect to overall success, speed, and
incidence of carotid puncture.
Observational and randomised studies give sugges-
tive evidence for the benefits of ultrasound guided cath-
eterisation for selected patients at high risk of
complications and when difficult central venous access is
Additionally, inexperienced doctors
might benefit from ultrasound guidance.
complications of central venous access, the operators
should limit the number of stabs with both the seeker
needle and the definitive needle and have a plan for
either to choose another landmark or to use
Every anaesthetist and intensive care doctor should
be able to place central venous catheters without an
ultrasound device but with a dedicated knowledge of
all methods of how to maximise the success and mini-
mise the incidence of complications. Ultrasound assist-
ance is a potential useful back up technique after failed
attempts of blind cannulation and for patients in
whom catheterisation is likely to be difficult and
complications could be serious.
Manfred Muhm professor of anaesthesiology
Department of Cardiothoracic and Vascular Anaesthesia and
Intensive Care, University of Vienna, Austria
Competing interest: None declared.
1 Rosen M,Latto P, Ng S. Percutaneous central venous catheterisation. London:
W B Saunders, 1992.
2 Legler D, Nugent M. Doppler localization of the internal jugular vein
facilitates central venous cannulation. Anesthesiology 1984;60:481-2.
3 Armstrong PF, Cullen M, Scott DHT. The “SiteRite” ultrasound
an aid to internal jugular vein cannulation. Anaesthesia
4 Gilbert TB, Seneff MG, Becker RB. Facilitation of internal jugular venous
cannulation using an audio-guided Doppler ultrasound vascular access
device: results from a prospective, dual center, randomized, crossover
clinical study. Crit Care Med 1995;23:60-5.
5 Randolph AG, Cook DJ, Gonzales CA. Ultrasound guidance for
placement of central venous catheters: a meta-analysis of the literature.
Crit Care Med 1996;24:2053-8.
6 Denys BG, Uretsky BF, Reddy PS. Ultrasound-assisted cannulation of the
internal jugular vein: a prospective comparison to the external
landmark-guided technique. Circulation 1993;87:1557-62.
7 Lefrant JY, Cuvillon P, Benezet JF, Dauzat M, Peray P, Saissi G, et al. Pulsed
Doppler ultrasonography guidance for catheterization of the subclavian
vein: a randomized study. Anesthesiology 1998;88:1195-201.
8 Bold RJ, Winchester DJ, Madary AR, Gregurich MA, Mansfield PF.
Prospective, randomized trial of Doppler-assisted subclavial vein
catheterization. Arch Surg 1998;133:1089-93.
9 Troianos CA, Jobes DR, Ellison N. Ultrasound-guided cannulation of the
internal jugular vein: a prospective, randomized study. Anesth Analg
10 Slama M, Novara A, Safavian A, Ossart M, Safar M, Fagon JY.
Improvement of internal jugular vein cannulation using an ultrasound-
guided technique. Intensive Care Med 1997;23:916-9.
11 Verghese ST, McGill WA, Patel RI, Sell JE, Midgley FM, Ruttimann UE.
Ultrasound-guided internal jugular venous cannulation in infants: a pro-
spective comparison with the traditional palpation method. Anesthesiology
12 Hatfield A, Bodenham A. Portable ultrasound for difficult central venous
access. Br J Anaesth 1999;82:822-6.
Influences of the media on suicide
Researchers, policy makers, and media personnel need to collaborate on guidelines
eporting and portrayal of suicidal behaviour in
the media may have potentially negative influ-
ences and facilitate suicidal acts by people
exposed to such stimuli. Recent systematic reviews by
others and ourselves (unpublished) have found
overwhelming evidence for such effects.
the influence of media on suicidal behaviour has been
shown for newspaper and television reports of actual
suicides, film and television portrayals of suicides, and
suicide in literature, especially suicide manuals. The
potential for “suicide sites” on the internet influencing
suicidal behaviour remains to be proved, but anecdotal
evidence of negative influences is accumulating.
The impact of the media on suicidal behaviour
seems to be most likely when a method of suicide is
especially when presented in detail
the story is reported or portrayed dramatically and
for example with photographs of the
deceased or large headlines
and when suicides of
celebrities are reported.
Younger people seem to be
most vulnerable to the influence of the media,
although limited evidence also shows an impact on
elderly people. Another factor is similarity between the
media stimulus or model and the observer in terms of
age, sex, and nationality. An important aspect of the
presentation of suicide in the media is that it usually
1374 BMJ VOLUME 325 14 DECEMBER 2002 bmj.com
oversimplifies the causes, attributing the act to single
factors such as financial disasters, broken relationships,
or failure in examinations. The most common factor
leading to suicide, mental illness, is often overlooked.
Tackling this problem is one component of
preventing suicides, and it is included in the recently
published National Suicide Prevention Strategy for
Relevant questions are, therefore, how this
should be done and whether it can be effective. One
approach has been to produce guidelines for the
media, of which there are now several.
emphasise the need to avoid dramatic reporting or
portrayal of suicide and specifying means used. Most
highlight the desirability of providing accurate facts
about causes, including due emphasis on mental health
problems. At present no clear policy exists for the
problem of “suicide sites” on the internet.
One potential drawback of guidelines is that, in iso-
lation, they may be seen as dictating what the media
can or cannot do and as threatening freedom of
speech. Firstly, for them to have credibility with
authorities in the media and with journalists they must
be based on evidence. Secondly, they should be
produced ideally as a collaboration between research-
ers, public health policy makers, and senior media per-
sonnel. Thirdly, which is perhaps most difficult, they
should be shown to work. Some limited evidence exists
of this. In an initiative in Switzerland it was shown that
collaboration between researchers and the media
resulted in a reduction of sensational and lengthy
reports of suicides in newspapers.
No attempt was
made, however, to measure the impact on suicide.
Efforts to limit the reporting of subway suicides in
Vienna through the collaboration of researchers and
journalists were followed by a reduction in the number
of suicides and suicide attempts by this method.
A further but unanswered question is whether
media portrayal of positive coping with adversity in
circumstances that might have led to suicidal acts could
provide a model that might also reduce suicidal behav-
iour. Steps in this direction are worth exploring but will
also need collaborative initiatives. Their evaluation will
present a considerable but surmountable challenge.
Possibly the most influential approach to the prob-
lem of media and suicide will be through ensuring that
training courses for careers in the media pay adequate
attention to this important topic. Similar initiatives
should be made available to those already established
in media careers. Finally, inappropriate media por-
trayal and reporting of suicidal behaviour should be
immediately highlighted. This should encourage
producers and editors to remain aware of their poten-
tially influential role in future suicides.
Keith Hawton director
Kathryn Williams researcher
Centre for Suicide Research, University Department of Psychiatry,
Warneford Hospital, Oxford OX3 7JX
Competing interests: The authors have received funding for
research from Syngenta.
1 Pirkis J, Blood RW. Suicide and the media: a critical review. Canberra: Com-
monwealth Department of Health and Aged Care, 2001.
2 Baume P, Cantor CH, Rolfe A. Cybersuicide: the role of interactive
suicide notes on the internet. Crisis 1997;18:73-9.
3 Alao AO, Yolles JC, Armenta W. Cybersuicide: the internet and suicide.
Am J Psychiatry 1999;156:1836-7.
4 Phillips DP. The influence of suggestion on suicide: substantive and theo-
retical implications of the Werther effect. Am Sociol Rev 1974;39:340-54.
5 Hawton K, Simkin S, Deeks JJ, O’Connor S, Keen A, Altman DG, et al.
Effects of a drug overdose in a television drama on presentations to hos-
pital for self poisoning: time series and questionnaire study. BMJ
6 Stack S. Celebrities and suicide: a taxonomy and analysis. Am Sociol Rev
7 Fishman G, Weimann G. Motives to commit suicide: statistical versus
mass-mediated reality. Arch Suicide Res 1997;3:199-212.
8 Department of Health. National suicide prevention strategy for England.
London: Department of Health, 2002.
9 Centers for Disease Control and Prevention, National Institute of Mental
Health, Office of the Surgeon General. Reporting on suicide: recommen-
dations for the media. Suicide Life Threat Behav 2002;32:vii-xiii.
www.afsp.org/education/recommendations/index.html (accessed 24 Oct
10 Samaritans. Media guidelines. Portrayals of suicide. Ewell: Samaritans, 2002.
www.Samaritans.org/know/media_guide.shtm (accessed 24 Oct 2002).
11 Michel K, Frey C, Wyss K, Valach L. An exercise in improving suicide
reporting in print media. Crisis 2000;21:1-10.
12 Etzersdorfer E, Sonneck G. Preventing suicide by influencing mass-media
reporting. The Viennese experience 1980-1996. Arch Suicide Res
Making progress with competing interests
Still some way to go
he BMJ and other journals are making
progress with managing the problem of
competing interests (or conflicts of interest, as
most journals call them). Today we take two further
steps forward by posting on our website the competing
interests of editors, our editorial board, and our group
interests.shtme) and by publishing a study we have
conducted that shows that readers’ reactions to
research are strongly influenced by statements of com-
We still, however, have some way to go
to the fully transparent world that is desirable.
The history of medical journals and conflict of inter-
est might be cruelly summarised as lots of rhetoric and
not much action. The International Committee of Medi-
cal Journal Editors produced a policy on conflicts of
interest as long ago as 1993,
but several studies have
shown that such conflicts are rarely declared in most
despite good evidence that most authors have
The international committee strengthened its
policy in 2001 by stating that journals should declare the
exact role of sponsors (often pharmaceutical compa-
nies) in studies and decline to publish studies where the
sponsors controlled the decision on publication.
policy too has yet to be widely implemented.
At the BMJ all authors and reviewers of original
articles, editorials, and most other material are asked to
complete competing interests forms, and declarations
of the competing interests of authors are made with
We have now instituted a system to
ensure that the role of sponsors is made clear, and any-
body submitting a rapid response is required by the
electronic system to make a statement on whether they
have competing interests. Our main means of manag-
Papers p 1391
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