
Patients often see their symptoms like bleeding and fatigue get better after a platelet transfusion. At LIV Hospital, we know how important this treatment is. It helps those with low platelet counts.
Platelet transfusions are key for treating low platelet counts from different causes. With a targeted transfusion strategy, patients face fewer complications and better results.
We know getting a transfusion can worry patients. Our medical team is here to give top-notch care. We make sure patients get the best treatment with as little risk as possible.
Key Takeaways
- Platelet transfusions can significantly improve symptoms like bleeding and fatigue.
- Targeted transfusion strategies minimize complications and enhance patient outcomes.
- Comprehensive care is provided to patients undergoing transfusions.
- Our medical team is committed to delivering world-class healthcare services.
- Platelet transfusions are crucial for treating central thrombocytopenia.
The Critical Role of Platelets in Human Health

Platelets are key to stopping bleeding when we get hurt. They are tiny, colorless parts of our blood that help form clots. This is vital for our health, keeping us from bleeding too much when injured.
What are platelets and their primary functions?
Platelets are made in the bone marrow and move through our blood. Their main job is to clump together at injuries to stop bleeding. This is called primary hemostasis. They also help with healing wounds and fighting off infections.
A normal platelet count is between 150,000 and 450,000 per microliter of blood. If this number is off, it can mean health problems. For example, too few platelets, or thrombocytopenia, can make us bleed more easily. Too many, or thrombocytosis, can cause unwanted clots.
Normal platelet count ranges across different demographics
Platelet counts can differ based on age, sex, and ethnicity. For instance, women usually have more platelets than men. Counts also change as we get older. Knowing these differences helps doctors diagnose and treat platelet-related issues.
|
Demographic |
Normal Platelet Count Range (per μL) |
|---|---|
|
Adult Men |
150,000 – 400,000 |
|
Adult Women |
150,000 – 450,000 |
|
Children |
150,000 – 450,000 (varies with age) |
While the normal range is 150,000 to 450,000 platelets per microliter, there’s a lot of variation. Doctors take these differences into account when looking at platelet counts. This helps them decide the best treatment for patients with abnormal counts.
Causes and Consequences of Low Platelet Count

Thrombocytopenia, or low platelet count, can come from many medical treatments and diseases. It means there are not enough platelets in the blood. This can make it easier to bleed and bruise.
Chemotherapy-induced Thrombocytopenia
Chemotherapy often leads to thrombocytopenia. It stops the bone marrow from making platelets. This drop in platelets can cause bleeding problems.
We keep an eye on platelet counts during chemotherapy. We adjust treatment plans as needed. Sometimes, we give platelet transfusions to stop or treat bleeding.
Hematological Malignancies Affecting Platelet Production
Hematological malignancies, like leukemia and lymphoma, can harm platelet production. These cancers fill the bone marrow, making it hard to produce platelets and other blood cells.
Thrombocytopenia in these patients is serious. It raises the risk of bleeding and may need frequent transfusions. We treat the cancer and support blood cell production to manage this.
Other Medical Conditions Leading to Thrombocytopenia
Other conditions, like autoimmune diseases, infections, and some medications, can also cause thrombocytopenia. Treating the root cause is key to managing thrombocytopenia.
|
Cause |
Description |
Consequence |
|---|---|---|
|
Chemotherapy |
Suppresses bone marrow activity |
Increased risk of bleeding |
|
Hematological Malignancies |
Infiltrates bone marrow, disrupting blood cell production |
Thrombocytopenia, anemia, and increased infection risk |
|
Autoimmune Diseases |
Immune system attacks platelets |
Thrombocytopenia and potential for bleeding |
Knowing why and how low platelet count happens is crucial for good care. By tackling the cause and managing the condition well, we can help patients live better lives.
Recognizing Symptoms of Critically Low Platelet Levels
It’s key to know the signs of low platelet levels to get help fast. When platelets are very low, people might feel a lot of symptoms. These can be different for everyone.
Bleeding Manifestations and Their Severity
Bleeding is a big worry with low platelets. Bleeding manifestations can be mild or very serious. Symptoms include:
- Petechiae, which are small, pinpoint spots on the skin
- Purpura, or purple bruises
- Nosebleeds or bleeding gums
- Prolonged bleeding after injuries or surgical procedures
Severe cases can lead to big bleeding problems. These can be life-threatening and need urgent care.
Fatigue and Its Relationship to Platelet Function
Fatigue is common in people with low platelets. The link between fatigue and platelets is complex. But, it’s thought that the body’s fight against low platelets can make you tired. Also, the reasons for low platelets, like chemotherapy, can add to feeling tired.
When Symptoms Indicate a Medical Emergency
Knowing when to call for a medical emergency is crucial. Severe bleeding, like heavy nosebleeds or vomiting blood, is an emergency. Patients should watch for these signs and get help right away to avoid serious issues.
By knowing these symptoms, patients and doctors can better manage low platelets. This helps improve health outcomes.
Blood Transfusion Fundamentals: The Platelet Component
The platelet component is key in blood transfusion therapy. It’s vital to understand its basics. Blood transfusions save lives, and platelets are crucial for patients with many health issues.
Different Components of Blood Used in Transfusions
Blood has several parts, each with its own role in transfusions. Red blood cells carry oxygen, plasma has clotting factors, and platelets help with blood clotting.
Healthcare providers need to know about these parts. They help decide what to transfuse based on the patient’s needs.
Unique Aspects of Platelet Transfusions
Platelet transfusions are special. They have a short shelf life, lasting 3 to 5 days. They’re also used for patients with low platelets or those at risk of bleeding.
The success of platelet transfusions depends on many things. This includes the patient’s condition, any antibodies, and the quality of the platelets. Compatibility testing is very important.
Single Donor vs. Pooled Platelet Products
Platelet products can come from one donor or many. Single donor platelets are from one person, reducing risks. Pooled platelet products come from many, but are more available.
Choosing between single donor and pooled platelets depends on the patient’s needs and what’s available. We’ll look at this more in later sections.
Step-by-Step: The Platelet Transfusion Procedure
Administering a platelet transfusion needs careful attention. It starts with preparing the patient and ends with checking how they did after. We’ll walk you through each step that healthcare providers take to make sure the treatment is safe and works well.
Patient Preparation and Consent
First, we make sure the patient is ready. We get their consent, explain the procedure, its benefits, and risks. We also check their medical history for any past reactions or allergies.
We watch the patient’s vital signs and do a physical check. We make sure lab tests, like blood type and cross-matching, are done. This ensures the donor platelets match the patient’s blood.
Compatibility Testing and Matching
Compatibility testing is key. We do ABO and RhD typing to match the platelets with the patient’s blood type. We also cross-match to check for antibodies against the donor platelets.
In some cases, we use leukoreduced or irradiated platelets to lower the risk of bad reactions. This testing helps avoid complications and ensures the best results for the patient.
Administration Techniques and Duration
After confirming compatibility, we start the transfusion. The platelets are given through a sterile set, and it takes 30 to 60 minutes.
We keep an eye on the patient’s vital signs during the transfusion. We watch for any bad reactions, like fever or chills. We adjust the transfusion rate based on how the patient is doing.
Post-Transfusion Assessment
After the transfusion, we check how the patient did. We look at vital signs, watch for bad reactions, and check their health.
We also do lab tests, like a CBC, to see if the transfusion worked. This helps us plan future treatments and make any needed changes.
2025 Evidence-Based Guidelines for Platelet Transfusions
The 2025 guidelines for platelet transfusions are a big step forward in transfusion medicine. Our knowledge of platelet biology and transfusion medicine keeps growing. This means the advice for doctors has changed too. We’ll look at the latest guidelines from groups like the AABB and the ICTMG.
AABB Recommendations for Restrictive Transfusion Approaches
The AABB leads in setting up restrictive transfusion approaches. They aim to cut down on unnecessary transfusions while keeping patients safe. A study on PubMed shows these strategies can lower the risk of bad effects from transfusions.
The AABB says to give platelets when counts drop to 10,000/μL for patients not at risk of bleeding. Studies show this method works just as well as giving more transfusions to prevent bleeding.
|
Organization |
Recommended Threshold |
Patient Population |
|---|---|---|
|
AABB |
10,000/μL |
Non-bleeding patients without additional risk factors |
|
ICTMG |
10,000-20,000/μL |
Patients with hematologic malignancies or undergoing chemotherapy |
ICTMG Guidelines on Platelet Transfusion Thresholds
The ICTMG also has guidelines for when to give platelet transfusions. They suggest a range of 10,000 to 20,000/μL, based on the patient’s condition and situation.
For patients with cancer or those getting chemotherapy, the ICTMG recommends 10,000 to 20,000/μL. This lets doctors make decisions based on each patient’s risk and needs.
Clinical Trials Supporting the 10,000/μL Threshold
Many studies have looked into the best platelet transfusion threshold. They all show that 10,000/μL is safe and effective for many patients. This threshold helps avoid too much allogenic blood while keeping bleeding risks low.
A key study was done by the Platelet Dose study group. They found that a dose of 1.1 × 1011 per square meter body surface area keeps platelet counts above 10,000/μL for most patients.
In short, the 2025 guidelines for platelet transfusions push for more restrictive transfusion practices. They aim to reduce unnecessary transfusions and improve patient care. By following these guidelines, doctors can give their patients the best care possible.
When Do Patients Truly Need Platelet Transfusions?
It’s key for doctors to know when to give platelet transfusions. These transfusions help patients with low platelet counts or those bleeding a lot. The decision to give platelets depends on the patient’s platelet count, health, and risk of bleeding.
Prophylactic Transfusions for Non-Bleeding Patients
Doctors give platelet transfusions to prevent bleeding in patients not bleeding. This is crucial for those getting chemotherapy or undergoing stem cell transplants. It helps keep their platelet count high to avoid spontaneous bleeding.
Guidelines suggest giving transfusions when the platelet count drops below 10,000/μL. But, the right count can vary based on the patient’s health and other risks.
Therapeutic Transfusions for Active Bleeding
Platelet transfusions are given to stop bleeding in patients with active bleeding. This is especially true for those who have had surgery or trauma. The goal is to control bleeding and keep the patient stable.
Doctors decide on transfusions based on how severe the bleeding is, the patient’s platelet count, and other lab results. They also look at the cause of bleeding and the patient’s overall health.
Special Clinical Scenarios Requiring Higher Thresholds
Some situations need higher platelet counts for safety. For example, patients having major surgery or those with bleeding in the brain might need higher counts. This is to reduce the risk of bleeding during or after surgery.
|
Clinical Scenario |
Recommended Platelet Count Threshold |
|---|---|
|
Prophylaxis for non-bleeding patients |
10,000/μL |
|
Major surgery |
50,000/μL |
|
Central nervous system bleeding |
100,000/μL |
Understanding these details helps doctors make better decisions about platelet transfusions. They can weigh the benefits against the risks and complications.
Patient Experience: Sensations During and After Transfusion
For many patients, a platelet transfusion is a crucial medical intervention that brings significant relief. As we guide patients through this process, understanding their experiences and sensations during and after the transfusion is essential.
Common Physical Sensations During the Procedure
Patients may experience various physical sensations during a platelet transfusion. These can range from a feeling of coldness due to the rapid infusion of blood products to mild discomfort at the needle site. We ensure that patients are comfortable and informed throughout the procedure.
Some patients might feel a slight tingling sensation or a metallic taste in their mouth, although these sensations are typically mild and temporary. Our medical team is trained to monitor patients closely and address any concerns promptly.
Immediate Symptom Improvements Reported by Patients
Many patients report an improvement in their symptoms shortly after the transfusion. This can include reduced fatigue, decreased bruising, and a decrease in bleeding episodes. The rate at which patients experience these improvements can vary based on their individual condition and response to the transfusion.
To illustrate the potential benefits, consider the following table, which summarizes patient-reported outcomes after platelet transfusions:
|
Symptom |
Pre-Transfusion |
Post-Transfusion |
|---|---|---|
|
Fatigue |
Severe |
Mild |
|
Bleeding Episodes |
Frequent |
Rare |
|
Bruising |
Extensive |
Minimal |
Timeline for Experiencing Benefits
The timeline for experiencing the benefits of a platelet transfusion can vary. Some patients may notice improvements within a few hours, while others may take a few days to feel the full effects. Our healthcare team works closely with patients to monitor their progress and adjust treatment plans as necessary.
By understanding the patient experience during and after platelet transfusion, we can better support those undergoing this critical medical intervention. Our goal is to provide compassionate, high-quality care that addresses the unique needs of each patient.
Measuring Transfusion Success: Clinical and Laboratory Markers
Measuring the success of a platelet transfusion is complex. It involves looking at many clinical and laboratory markers. This way, we can truly see how well the transfusion worked and make better care plans.
Post-transfusion Platelet Count Increments
One key lab marker is the post-transfusion platelet count increment. It shows how much the patient’s platelet count went up after the transfusion. A big increase usually means the transfusion was a success.
“The corrected count increment (CCI) is a valuable metric that takes into account the patient’s body surface area and the number of platelets transfused,” says a leading hematologist. “It provides a more accurate assessment of transfusion efficacy.”
Clinical Improvement Assessment Methods
Seeing how the patient feels is also important. We check for:
- Less bleeding
- Improvement in the patient’s overall health
- If more transfusions are needed
These checks help us know if the transfusion did what it was meant to do.
Quality of Life Measurements Following Transfusion
How the patient feels after the transfusion is also key. We look at:
- How the patient feels about their energy and overall health
- How well they can do daily tasks
- Any bad side effects
By looking at these, we get a full picture of how the transfusion affected the patient’s life.
In short, checking if a transfusion worked involves looking at lab results and how the patient feels. By using all these tools, we make sure our patients get the best care and have the best results.
Understanding Risks and Complications of Platelet Transfusions
It’s key to know the risks of platelet transfusions for better patient care. These transfusions are vital for treating low platelet counts and stopping bleeding. But, they also have risks that doctors need to handle well.
Acute Transfusion Reactions: Types and Management
Acute transfusion reactions can happen during or right after a transfusion. They can be mild or severe, like allergic reactions or hemolytic reactions. Quick action and the right treatment are crucial. This might mean stopping the transfusion, giving medicine, or more in serious cases.
Transfusion-Related Acute Lung Injury (TRALI)
TRALI is a serious issue that causes lung problems. It’s a big reason for deaths linked to transfusions. Symptoms include trouble breathing, low oxygen levels, and lung problems seen on X-rays. Treatment focuses on supporting the lungs, like using oxygen and a ventilator. To prevent it, doctors use special screening and donor selection.
Infectious Disease Transmission: Current Rates
The chance of getting sick from platelet transfusions is very low today. This is because of better screening and testing of donors. Thanks to strict testing, the risk is almost zero for viruses like HIV and hepatitis.
Long-term Complications of Multiple Transfusions
Getting many platelet transfusions can lead to long-term problems. These include making the immune system react to blood, iron overload, and graft-versus-host disease. These issues can make future transfusions less effective. Doctors use special blood products and treatments to reduce these risks.
Knowing about these risks helps doctors manage transfusions better. This way, they can reduce bad outcomes and improve care for patients.
Optimal Dosing Strategies: Balancing Benefits and Risks
Finding the right dose for platelet transfusions is key. It’s about getting the most benefit while avoiding risks. Each patient reacts differently, and the situation matters a lot.
Standard Dose vs. High-Dose Platelet Transfusions
Platelet transfusions come in different sizes. Standard doses are based on the patient’s weight and guidelines. High-dose transfusions use more platelets for certain situations.
Choosing between standard and high doses depends on many things. These include the patient’s health, if they’re bleeding, and the chance of bad reactions. We’ll look into these factors to see how they affect dosing.
Research Findings on Dose-Response Relationships
Many studies have looked into how platelet transfusions work. They found that more platelets don’t always mean better results. Sometimes, more platelets just don’t add up to better health.
One important discovery is that the relationship between dose and effect isn’t always straightforward. After a certain point, more platelets don’t bring as much benefit. This has led to more careful and specific transfusion guidelines.
Why Higher Doses Don’t Always Improve Outcomes
There are several reasons why more platelets don’t always help. Higher doses can lead to more side effects, like TRALI. Also, after a certain count, more platelets might not make a big difference in stopping bleeding.
The patient’s condition also plays a big role. Patients with certain cancers or those getting chemotherapy might react differently to transfusions. This is compared to others with low platelet counts for other reasons.
In summary, finding the best dose for platelet transfusions is complex. It needs a deep understanding of the patient, the situation, and the risks and benefits of different doses. By carefully balancing these, doctors can make transfusions safer and more effective.
Global Perspectives: International Platelet Transfusion Practices
Platelet transfusion practices vary worldwide. This is due to differences in healthcare systems, blood donation rates, and clinical guidelines. It shows that the way platelet transfusions are handled is not the same everywhere.
United States Transfusion Rates and Practices
In the United States, platelet transfusions follow guidelines from the AABB. These guidelines help decide when to give platelets. They consider the patient’s health, platelet count, and if they are bleeding.
Key aspects of US practices include:
- Restrictive transfusion strategies to minimize unnecessary transfusions
- Use of platelet count thresholds to guide transfusion decisions
- Emphasis on patient safety and minimizing transfusion-related complications
European Approaches to Platelet Transfusion
European countries have their own guidelines for platelet transfusions. These guidelines vary slightly between countries. The European Society for Blood Transfusion and the European Hematology Association help set these standards.
|
Country |
Platelet Transfusion Threshold |
Guiding Organization |
|---|---|---|
|
UK |
10 x 10^9/L |
British Committee for Standards in Haematology |
|
France |
20 x 10^9/L (higher in bleeding patients) |
French Society of Blood Transfusion |
|
Germany |
10 x 10^9/L |
German Medical Association |
Resource-Limited Settings: Adaptations and Challenges
In places with limited resources, platelet transfusions face big challenges. These include a lack of platelet products, unclear guidelines, and limited healthcare resources.
Adaptations in these settings often involve:
- Prioritizing patients with the most critical need for transfusion
- Implementing cost-effective strategies for platelet production and distribution
- Developing local guidelines tailored to the available resources and prevalent conditions
Looking at how platelet transfusions are done around the world shows the importance of working together. Healthcare professionals worldwide need to share knowledge to improve patient care.
LIV Hospital’s Multidisciplinary Approach to Transfusion Medicine
At LIV Hospital, we’re changing transfusion medicine with a team effort. Our experts work together to meet each patient’s needs. This approach sets a new standard in patient care.
International Leadership in Hematology Care
LIV Hospital is known worldwide for its top-notch hematology care. Our hematologists and transfusion medicine specialists work together to create the best treatment plans. A leading expert says, “Combining hematology care with transfusion medicine is key to better patient results.”
“The future of transfusion medicine lies in its ability to be both highly specialized and deeply personalized.”
We lead in hematology care thanks to our research, education, and practice. We always keep up with the latest in transfusion medicine. This ensures our patients get the best care.
Integration of Academic Protocols with Patient Care
At LIV Hospital, we mix academic research with patient care. Our patients get the newest research and clinical trials turned into real treatments. Our method means every patient gets care that’s backed by evidence and tailored to them.
By blending research with clinical skills, we offer new treatments that help patients more. This mix is what makes our healthcare world-class.
Personalized Transfusion Medicine Approaches
Personalization is key in our transfusion medicine services. We know every patient is different, needing a care plan just for them. Our team works closely with patients and their families to create plans that fit their needs.
Our goal is to treat the medical condition and also improve our patients’ lives. As we grow in the field, our focus on personalized care never wavers.
Special Patient Populations and Tailored Approaches
Special patient groups face unique challenges with platelet transfusions. This calls for special strategies. For example, kids, pregnant women, older adults, and those getting stem cell transplants need careful planning for the best results.
Pediatric Platelet Transfusion Considerations
Kids have different needs for platelet transfusions. Their small size and growing bodies mean we must be precise with the amount and how we give it. It’s crucial to consider the child’s weight, age, and health when figuring out the right transfusion plan.
A leading hematologist says, “The key to successful pediatric platelet transfusion lies in precise dosing and careful monitoring.”
“Pediatric transfusion medicine is a nuanced field that requires a deep understanding of the patient’s unique needs and circumstances.”
Pregnant Patients with Thrombocytopenia
Pregnancy makes managing low platelet counts harder. Close monitoring of platelet counts is essential, especially in the third trimester. This is to prevent bleeding risks during delivery.
Pregnant women with low platelet counts need a team effort. Obstetricians, hematologists, and anesthesiologists work together to keep both mom and baby safe.
Elderly Patients and Comorbidity Factors
Elderly patients often have other health issues that make platelet transfusions tricky. Cardiovascular disease, renal impairment, and other chronic conditions must be considered when deciding if and when to give platelet transfusions.
Stem Cell Transplant Recipients
Patients getting stem cell transplants need careful platelet count management. The timing and dose of platelet transfusions are critical to help them through the transplant period.
By tailoring our approach to each patient’s needs, we can make platelet transfusions more effective. This improves care for all patients.
Conclusion: Optimizing Platelet Transfusion Outcomes
Improving platelet transfusion results needs a detailed plan. This plan should follow the latest guidelines and practices. We’ve talked about how platelets are vital for our health, the reasons for low platelet counts, and the basics of blood transfusions.
Healthcare experts play a key role in making transfusions safer and more effective. They must follow the best practices in transfusion medicine. New guidelines recommend careful transfusion use, especially for certain patients. For more on these guidelines, check out NYSORA’s educational resource.
It’s crucial to tailor transfusions to each patient’s needs. This includes kids, pregnant women, and the elderly. By doing so, we can better care for our patients and improve transfusion medicine.
FAQ
What is a platelet transfusion, and how does it help patients?
A platelet transfusion is a medical process. It moves platelets into a patient’s blood to stop bleeding. This helps patients by lowering the risk of bleeding and improving their health.
What are the primary functions of platelets in the human body?
Platelets are key in blood clotting. They help stop bleeding when a blood vessel is hurt. They form a plug at the injury site, sealing the vessel.
What is considered a normal platelet count, and how does it vary across different demographics?
A normal platelet count is between 150,000 and 450,000 per microliter of blood. Counts can slightly vary by age and demographics. But big changes might mean a health issue.
What are the causes and consequences of low platelet count (thrombocytopenia)?
Thrombocytopenia can come from many things like chemotherapy or certain drugs. It can cause mild bruising to serious bleeding, depending on how low the count is.
How is a platelet transfusion performed, and what are the key steps involved?
The transfusion process includes preparing the patient, checking for compatibility, giving the platelets, and monitoring after. Each step is tailored to the patient’s needs and the healthcare team’s protocols.
What are the evidence-based guidelines for platelet transfusions, and which organizations recommend them?
Groups like the AABB and ICTMG give guidelines for platelet transfusions. They suggest using transfusions wisely and setting specific count levels for different situations.
When do patients truly need platelet transfusions, and what are the indications for prophylactic versus therapeutic transfusions?
Patients might need transfusions to prevent or stop bleeding. The decision depends on their platelet count, health, and bleeding risk.
What can patients expect during and after a platelet transfusion in terms of physical sensations and symptom improvements?
During the transfusion, patients might feel some mild sensations. After, they might see better symptoms like less bleeding or bruising. How fast this happens can vary.
How is the success of a platelet transfusion measured, and what are the key clinical and laboratory markers?
The success of a transfusion is checked through clinical and lab tests. These include the platelet count after transfusion, bleeding symptoms, and quality of life.
What are the risks and complications associated with platelet transfusions, and how are they managed?
Platelet transfusions can have risks like allergic reactions or infections. Managing these risks involves watching the patient closely, screening blood products well, and following guidelines.
How do global perspectives influence platelet transfusion practices, and what are the differences between regions?
Platelet transfusion practices vary worldwide. They are shaped by local guidelines, blood product availability, and healthcare systems. For example, the U.S. might differ from Europe or low-resource areas.
What is LIV Hospital’s approach to transfusion medicine, and how does it integrate academic protocols with patient care?
LIV Hospital combines international leadership in hematology with personalized care. It uses academic protocols to improve transfusion outcomes for patients.
Are there special considerations for certain patient populations, such as pediatric or pregnant patients, when it comes to platelet transfusions?
Yes, patients like kids, pregnant women, and the elderly need special care with platelet transfusions. Their unique health needs are considered.
What is the significance of optimal dosing strategies for platelet transfusions, and how do standard doses compare to high-dose transfusions?
Optimal dosing aims to balance transfusion benefits and risks. Research and guidelines suggest standard doses for most patients. High-dose transfusions are reserved for specific cases.
How does autologous blood transfusion differ from traditional platelet transfusions?
Autologous blood transfusion uses the patient’s own blood before surgery. It reduces risks of allogenic blood transfusions like reactions and infections.
What role do blood banks play in the process of platelet transfusion?
Blood banks are key for collecting, testing, and storing platelets. They make sure platelets are safe and match the recipient’s blood type, supporting effective transfusions.
References
- JAMA Network. Evidence-Based Medical Insight. Retrieved from https://jamanetwork.com/journals/jama/article-abstract/28347034