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Use of Ambient AI Scribes to Reduce Administrative Burden and Professional Burnout

Author/s: 
Kristine D. Olson, Daniella Meeker, Matt Troup

Importance: While in short supply and high demand, ambulatory care clinicians spend more time on administrative tasks and documentation in the electronic health record than on direct patient care, which has been associated with burnout, intention to leave, and reduced quality of care.

Objective: To examine whether ambient AI scribes are associated with reducing clinician administrative burden and burnout.

Design, setting, and participants: This quality improvement study used preintervention and 30-day postintervention surveys to evaluate the use of the same ambient AI platform for clinical note documentation among ambulatory care physicians and advanced practice practitioners of 6 academic and community-based health care systems across the US. Clinicians were recruited by the health systems' digital health leaders; participation was voluntary. The study was conducted between February 1 and October 31, 2024.

Exposure: Use of an ambient AI scribe for 30 days.

Main outcomes and measures: The primary outcome was change in self-reported burnout, estimated using hierarchical logistic regression. Secondary outcomes of burnout evaluated were changes in note-related cognitive task load, focused attention on patients, patient understandability of notes, ability to add patients to the clinic schedule if urgently needed, and time spent documenting after hours. Outcome measures were linearly transformed to 10-point scales to ease interpretation and comparison. Differences between preintervention and postintervention scores were determined using paired t tests.

Results: Of the 451 clinicians enrolled, 272 completed the preintervention and postintervention surveys (60.3% completion rate), and 263 with direct patient care in ambulatory clinics (mean [SD] years in practice, 15.1 [9.3]; 141 female [53.6%]) were included in the analysis. The sample included 131 primary care practitioners (49.7%), 232 attending physicians (88.2%), and 168 academic faculty (63.9%). After 30 days with the ambient AI scribe, the proportion of participants experiencing burnout decreased significantly from 51.9% to 38.8% (odds ratio, 0.26; 95% CI, 0.13-0.54). On 10-point scales, the ambient AI scribe was associated with significant improvements in secondary outcomes of burnout (mean [SE] difference, 0.47 [0.12] points), note-related cognitive task load (mean [SE] difference, 2.64 [0.13] points), ability to provide undivided attention (mean [SE] difference, 2.05 [0.18] points), patient understandability of their care plans from reading the notes (mean [SE] difference, -0.44 [0.17] points), ability to add patients to the clinic schedule if urgently needed (mean [SE] difference, 0.51 [0.24] points), and time spent documenting after hours (mean [SE] difference, 0.90 [0.19] hours).

Conclusions and relevance: This multicenter quality improvement study found that use of an ambient AI scribe platform was associated with a significant reduction in burnout, cognitive task load, and time spent documenting, as well as the perception that it could improve patient access to care and increase attention on patient concerns in an ambulatory environment. These findings suggest that AI may help reduce administrative burdens for clinicians and allow more time for meaningful work and professional well-being.

Keywords 
burnout burnout, professional ambulatory care ambient AI

Online Unsupervised Tai Chi Intervention for Knee Pain and Function in People With Knee Osteoarthritis: The RETREAT Randomized Clinical Trial

Author/s: 
Shiyi Julia Zhu, Rana S Hinman, Rachel K Nelligan, Peixuan Li, Anurika P De Silva, Jenny Harrison, Alexander J Kimp, Kim L Bennell

Importance: Tai chi is a type of exercise recommended for knee osteoarthritis, but access to in-person tai chi can be limited.

Objective: To evaluate the effects of an unsupervised multimodal online tai chi intervention on knee pain and function for people with knee osteoarthritis.

Design, setting, and participants: The RETREAT study was a 2-group superiority randomized clinical trial enrolling participants who met clinical criteria for knee osteoarthritis in Australian communities from August 2023 and November 2024.

Interventions: Participants in the control group received access to a purpose-built website containing information about osteoarthritis and exercise benefits. Participants in the intervention group received the My Joint Tai Chi intervention comprising access to the same website plus tai chi information, a 12-week unsupervised video-based Yang-style tai chi program, and encouragement to use an app to facilitate program adherence.

Main outcomes and measures: Changes in knee pain during walking (Numeric Rating Scale; range 0-10 with higher scores indicating greater pain) and difficulty with physical function (Western Ontario and McMaster Universities Osteoarthritis Index; range 0-68 with higher scores indicating greater dysfunction) during 12 weeks. Secondary outcomes included another knee pain measure, sport and recreation function, quality of life, physical and mental well-being, fear of movement, self-efficacy, balance confidence, positive activated affect, sleep quality, global improvement, and oral medication use.

Results: Of 2106 patients screened, 178 met inclusion criteria and were randomized, 89 (mean [SD] age, 61.0 [8.7] years; 66 female [74%] and 23 [26%] male participants) to the control group and 89 (mean [SD] age, 62.1 [7.3] years; 59 [66%] female and 30 male [34%] participants) to the tai chi intervention. Of the total, 170 (96%) completed both of the primary outcomes at 12 weeks. The tai chi group reported greater improvements in knee pain (control, -1.3; tai chi, -2.7; mean difference, -1.4 [95% CI, -2.1 to -0.7] units; P < .001) and function (control, -6.9; tai chi, -12.0; mean difference, -5.6 [95% CI, -9.0 to -2.3] units; P < .001) compared to the control group. More participants in the tai chi than in the control group achieved a minimal clinically important difference in pain (73% vs 47%; risk difference, 0.3; 95% CI, 0.1 to 0.4; P < .001) and function (72% vs 52%; risk difference, 0.2; 95% CI, 0.1 to 0.3; P = .007). Between-group differences for most secondary outcomes favored tai chi, including another knee pain measure, sport and recreation function, quality of life, physical and mental well-being, global improvement, pain self-efficacy, and balance confidence. No associated serious adverse events were reported.

Conclusions and relevance: This randomized clinical trial found that this unsupervised multimodal online tai chi intervention improved knee pain and function compared with the control at 12 weeks. This free-to-access web-based intervention offers an effective, safe, accessible, and scalable option for guideline-recommended osteoarthritis exercise.

Keywords 
Knee osteoarthritis kinesiophobia Tai Chi

Superficial Vein Thrombosis: A Review

Author/s: 
Gregory Piazza, Darsiya Krishnathasan, Nada Hamade

Importance: Superficial vein thrombosis (SuVT) is characterized by thrombus in the superficial veins, typically in the lower or upper extremities, and has an estimated annual incidence of 64 to 131 per 100 000 person-years. Approximately 10% of patients with SuVT progress to deep vein thrombosis (DVT) or pulmonary embolism (PE).

Observations: Endothelial injury (caused by infection or intravenous devices), venous stasis (such as from chronic venous insufficiency or prolonged immobility), and hypercoagulability (due to cancer or pregnancy) are pathophysiologic factors associated with SuVT. Clinical risk factors for lower extremity SuVT are similar to those of DVT and PE and include pregnancy, varicose veins, and active cancer. The incidence of SuVT is greater in females than males (78-167 compared with 49-116 per 100 000 person-years). In contrast with lower extremity SuVT, upper extremity SuVT is primarily caused by indwelling intravenous catheters. Patients typically present with a tender, red, palpable cord under the skin in the upper or lower extremity. D-dimer testing has a sensitivity of approximately 48% to 74.3% and, therefore, is not reliable for excluding SuVT. Approximately 25% of patients with lower extremity SuVT present with concomitant DVT, likely because risk factors for SuVT and DVT are similar and because SuVT can extend into deep veins. In people without classic symptoms and signs of SuVT, ultrasonography can establish the presence and extent of the thrombus. Management may include elastic compression stockings and nonsteroidal anti-inflammatory drugs. For patients with SuVTs that are at least 5 cm long or those with persistent or worsening symptoms despite several days of conservative therapy, treatment includes anticoagulation with fondaparinux 2.5 mg. Alternative anticoagulation treatment includes rivaroxaban 10 mg once daily and low-molecular-weight heparins (eg, enoxaparin 40 mg once daily), which may reduce subsequent venous thromboembolic events. SuVT located within 3 cm of a deep vein should be treated with therapeutic doses of anticoagulation such as direct oral anticoagulants.

Conclusions and relevance: SuVT typically presents as a tender, painful, palpable cord under the skin. Management may include elastic compression stockings, nonsteroidal anti-inflammatory drugs, and systemic anticoagulation with fondaparinux 2.5 mg or rivaroxaban 10 mg. SuVTs within 3 cm of a deep vein should be treated with therapeutic dose anticoagulation.

Keywords 
surgery vascular surgery Venous Thromboembolism Cardiology anticoagulants

Cannabidiol and Liver Enzyme Level Elevations in Healthy Adults: A Randomized Clinical Trial

Author/s: 
Jeffry Florian, Pablo Salcedo, Keith Burkhart, Aanchal Shah, Lakshmi Manasa S Chekka, Dro Keshishi, Vikram Patel, ShanChao Yang, Melanie Fein, Ryan DePalma, Murali Matta, David G Strauss, Rodney Rouse

Importance The wide use of unregulated cannabidiol (CBD) products among consumers raises safety concerns. Most research on CBD has studied the relatively high doses used by patients taking prescription CBD. However, limited safety data are available at lower doses.

Objective To study the effects of 4-weeks of twice-daily CBD use on the liver and endocrine hormones using a dose within the range consumers are taking with unregulated CBD products.

Design, Setting, and Participants This randomized double-blinded placebo-controlled trial from January to August 2024, using per protocol analysis, included healthy adults recruited from a clinical pharmacology unit (Spaulding Clinical Research in West Bend, Wisconsin).

Interventions Healthy participants were randomized to CBD, 5 mg/kg/d (2.5 mg/kg/d twice daily), or placebo for 28 days with weekly laboratory assessments.

Main Outcomes and Measures The primary end point was the percentage of participants with an alanine aminotransferase or aspartate aminotransferase level elevation greater than 3 times the upper limit of normal during the study.

Results In 201 healthy participants (median age, 36 years [IQR, 30-43 years]; 89 women [44%]), 8 participants (5.6%; 95% CI, 1.8%-9.3%) in the CBD group and 0 participants (0%; 95% CI, 0%-7.6%) in the placebo group had liver enzyme level elevation greater than 3 times the upper limit of normal. Seven participants met withdrawal criteria for potential drug-induced liver injury, detected at day 21 in 2 participants and day 28 in 5 participants. No differences in change from baseline were observed between the CBD and placebo groups for total testosterone and inhibin B in male participants or thyrotropin, total triiodothyronine, and free thyroxine in all participants.

Conclusions and Relevance In this study, the incidence of elevated alanine aminotransferase or aspartate aminotransferase coupled with the finding of increased eosinophilia, underscores the need for further investigation on the long-term effects of CBD use, its impact on various populations, and the safety of lower doses commonly used by consumers.

Trial Registration ClinicalTrials.gov Identifier: NCT06192589

Keywords 
cannabidiol aspartate aminotransferases alanine transaminase Double-Blind Method liver cannabinoids

Testosterone Treatment in Middle-Aged and Older Men with Hypogonadism

Author/s: 
Shalender Bhasin, Peter J Snyder

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In clinical trials involving middle-aged and older men with hypogonadism, testosterone treatment led to improved sexual activity and libido, correction of anemia, and modestly improved energy, mood, and walking ability. (The following key points also refer to findings from clinical trials involving this patient population.)
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Testosterone treatment did not improve cognition in men without a previously diagnosed cognitive disorder and did not prevent progression to diabetes in men with prediabetes or improve glycemic control in those with diabetes.
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Testosterone treatment did not increase the risk of major cardiovascular events among men with preexisting cardiovascular disease.
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Testosterone treatment did not increase the risk of prostate cancer or acute urinary retention and did not worsen lower urinary tract symptoms.
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Testosterone treatment was associated with an increased risk of clinical fractures and pulmonary embolism.
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The decision to administer testosterone treatment in a man with hypogonadism should be based on the severity of the hypogonadism and an assessment of the potential benefits and risks of treatment.

Keywords 
testosterone hypogonadism Libido anemia pulmonary embolism

Long-Term Anticoagulation Discontinuation After Catheter Ablation for Atrial Fibrillation: The ALONE-AF Randomized Clinical Trial

Author/s: 
Daehoon Kim, MD, Jaemin Shim, MD, Eue-Keun Choi, MD

Importance: Data from randomized clinical trials on a long-term anticoagulation strategy for patients after catheter-based ablation for atrial fibrillation (AF) are lacking.

Objective: To evaluate whether discontinuing oral anticoagulant therapy provides superior clinical outcomes compared with continuing oral anticoagulant therapy in patients without documented atrial arrhythmia recurrence after catheter ablation for AF.

Design, setting, and participants: A randomized clinical trial including 840 adult patients (aged 19-80 years) who were enrolled and randomized from July 28, 2020, to March 9, 2023, at 18 hospitals in South Korea. Enrolled patients had at least 1 non-sex-related stroke risk factor (determined using the CHA2DS2-VASc score [range, 0-9]) and no documented recurrence of atrial arrhythmia for at least 1 year after catheter ablation for AF. The CHA2DS2-VASc score is used as an assessment of stroke risk among patients with AF (calculated using point values for congestive heart failure, hypertension, ≥75 years of age, diabetes, stroke or transient ischemic attack, vascular disease, between 65 and 74 years of age, and sex category). The date of final follow-up was June 4, 2025.

Interventions: The patients were randomly assigned in a 1:1 ratio to discontinue oral anticoagulant therapy (n = 417) or continue oral anticoagulant therapy (with direct oral anticoagulants; n = 423).

Main outcomes and measures: The primary outcome was the first occurrence of a composite of stroke, systemic embolism, and major bleeding at 2 years. Individual components of the primary outcome (such as ischemic stroke and major bleeding) were assessed as secondary outcomes.

Results: Of the 840 adults randomized, the mean age was 64 (SD, 8) years, 24.9% were women, the mean CHA2DS2-VASc score was 2.1 (SD, 1.0), and 67.6% had paroxysmal AF. At 2 years, the primary outcome occurred in 1 patient (0.3%) in the discontinue oral anticoagulant therapy group vs 8 patients (2.2%) in the continue oral anticoagulant therapy group (absolute difference, -1.9 percentage points [95% CI, -3.5 to -0.3]; P = .02). The 2-year cumulative incidence of ischemic stroke was 0.3% in the discontinue oral anticoagulant therapy group vs 0.8% in the continue oral anticoagulant therapy group (absolute difference, -0.5 percentage points [95% CI, -1.6 to 0.6]). Major bleeding occurred in 0 patients in the discontinue oral anticoagulant therapy group vs 5 patients (1.4%) in the continue oral anticoagulant therapy group (absolute difference, -1.4 percentage points [95% CI, -2.6 to -0.2]).

Conclusions and relevance: Among patients without documented atrial arrhythmia recurrence after catheter ablation for AF, discontinuing oral anticoagulant therapy resulted in a lower risk for the composite outcome of stroke, systemic embolism, and major bleeding vs continuing direct oral anticoagulant therapy.

Trial registration: ClinicalTrials.gov Identifier: NCT04432220.

Keywords 
clinical pharmacy and pharmacology Oral Anticoagulation Cardiology atrial fibrillation Rhythm Disorders

Prostatitis: A Review

Author/s: 
Benjamin J Borgert, Eric M Wallen, Minh N Pham

Importance Prostatitis is defined as infection, inflammation, or pain of the prostate gland and affects approximately 9.3% of men in their lifetime.

Observations Acute bacterial prostatitis consists of a urinary tract infection (UTI) that includes infection of the prostate, typically associated with fever or chills and caused by gram-negative bacteria, such as Escherichia coli, Klebsiella, or Pseudomonas, in 80% to 97% of cases. First-line therapy for acute prostatitis is broad-spectrum intravenous or oral antibiotics, such as intravenous piperacillin-tazobactam, ceftriaxone, or oral ciprofloxacin, which has a 92% to 97% success rate when prescribed for 2 to 4 weeks for people with febrile UTI and acute prostatitis. Chronic bacterial prostatitis is defined as a persistent bacterial infection of the prostate, typically presenting as recurrent UTIs from the same strain. Up to 74% of chronic bacterial prostatitis diagnoses are due to gram-negative organisms, such as E coli. First-line therapy for chronic bacterial prostatitis is a minimum 4-week course of levofloxacin or ciprofloxacin. Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) presents as pelvic pain or discomfort for at least 3 months and is associated with urinary symptoms, such as urinary frequency. CP/CPPS is diagnosed when evaluation, including history and physical examination, urine culture, and postvoid residual measurement, does not identify other causes for the symptoms, such as infection, cancer, urinary obstruction, or urinary retention. The National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) measures symptom severity (scale of 0-43), with a 6-point change considered clinically meaningful. First-line oral therapy for CP/CPPS with urinary symptoms is α-blockers (eg, tamsulosin, alfuzosin; ΔNIH-CPSI score difference vs placebo = −10.8 to −4.8). Other oral therapies are associated with modest changes in NIH-CPSI score compared with placebo, including anti-inflammatory drugs (eg, ibuprofen; ΔNIH-CPSI score difference = −2.5 to −1.7), pregabalin (ΔNIH-CPSI score difference = −2.4), and pollen extract (ΔNIH-CPSI score difference = −2.49).

Conclusions and Relevance Prostatitis includes acute bacterial prostatitis, chronic bacterial prostatitis, and CP/CPPS, each of which is diagnosed and treated differently. First-line treatments are broad-spectrum antibiotics for acute bacterial prostatitis (such as piperacillin-tazobactam, ceftriaxone, or ciprofloxacin), at least 4 weeks of fluoroquinolones for chronic bacterial prostatitis, and α-blockers for CP/CPPS with urinary symptoms.

Keywords 
Urology Infectious diseases Reproductive Health prostate Prostatitis

Approach to lubricant use for sexual activity

Author/s: 
Ryleigh Vanderschee, Sanja Kostov

Objective: To present health care providers with an inclusive, evidence-based framework to identify patients who may benefit from lubricant use during sexual activity, and assist patients in selecting a lubricant tailored to their specific needs.

Sources of information: A MEDLINE, PubMed, Google Scholar, and Google search was performed for white and grey literature published from 2003 to 2024. Interdisciplinary experts in sexual health also conducted an iterative review.

Main message: Lubricant use during sexual activity has numerous benefits, minimal harms, and can play a role in managing many common sexual health concerns encountered in primary care. However, counselling on lubricant use can be challenging due to a lack of accessible, evidence-based clinical tools. Consequently, clinicians are often hesitant to discuss lubricant use and can only offer anecdotal advice. Lubricant use is especially beneficial for patients using condoms or experiencing dryness, pain (eg, dyspareunia), or dysfunction during sex. There are 3 main types of lubricants available: oil-, silicone-, and water-based products. For patients who use condoms or who experience recurrent vaginal infections or irritation, silicone- or water-based lubricants are recommended, which are free of harmful ingredients and are within recommended osmolality and pH ranges.

Conclusion: Lubricant use during sexual activity can enhance sexual well-being across diverse patient populations. This review summarizes evidence and provides practical tools to help clinicians integrate counselling on lubricant use into routine sexual health discussions.

Keywords 
Lubricant Sexual Health sexual behavior

What Is Prostate Cancer?

Author/s: 
Rebecca Voelker, MSJ

Prostate cancer is a common malignancy in older men. Prostate cancer typically affects older men (average age at diagnosis is 67 years) and is more common among Black men than White men.1 More than half of prostate cancer risk is due to genetic factors. Prostate cancer is the second most common cause of cancer in men worldwide, with about 1.5 million cases diagnosed in 2021. In the US, 3.4 million men were living with prostate cancer in 2021.

Keywords 
Patient Information jama Patient Information Reproductive Health oncology prostate cancer

Addictive Screen Use Trajectories and Suicidal Behaviors, Suicidal Ideation, and Mental Health in US Youths

Author/s: 
Yunyu Xiao, PhD, Yuan Meng, PhD, Timothy T. Brown, PhD

Importance: Increasing child and adolescent use of social media, video games, and mobile phones has raised concerns about potential links to youth mental health problems. Prior research has largely focused on total screen time rather than longitudinal addictive use trajectories.

Objectives: To identify trajectories of addictive use of social media, mobile phones, and video games and to examine their associations with suicidal behaviors and ideation and mental health outcomes among youths.

Design, setting, and participants: Cohort study analyzing data from baseline through year 4 follow-up in the Adolescent Brain Cognitive Development Study (2016-2022), with population-based samples from 21 US sites.

Exposures: Addictive use of social media, mobile phones, and video games using validated child-reported measures from year 2, year 3, and year 4 follow-up surveys.

Main outcomes and measures: Suicidal behaviors and ideation assessed using child- and parent-reported information via the Kiddie Schedule for Affective Disorders and Schizophrenia. Internalizing and externalizing symptoms were assessed using the parent-reported Child Behavior Checklist.

Results: The analytic sample (n = 4285) had a mean age of 10.0 (SD, 0.6) years; 47.9% were female; and 9.9% were Black, 19.4% Hispanic, and 58.7% White. Latent class linear mixed models identified 3 addictive use trajectories for social media and mobile phones and 2 for video games. Nearly one-third of participants had an increasing addictive use trajectory for social media or mobile phones beginning at age 11 years. In adjusted models, increasing addictive use trajectories were associated with higher risks of suicide-related outcomes than low addictive use trajectories (eg, increasing addictive use of social media had a risk ratio of 2.14 [95% CI, 1.61-2.85] for suicidal behaviors). High addictive use trajectories for all screen types were associated with suicide-related outcomes (eg, high-peaking addictive use of social media had a risk ratio of 2.39 [95% CI, 1.66-3.43] for suicidal behaviors). The high video game addictive use trajectory showed the largest relative difference in internalizing symptoms (T score difference, 2.03 [95% CI, 1.45-2.61]), and the increasing social media addictive use trajectory for externalizing symptoms (T score difference, 1.05 [95% CI, 0.54-1.56]), compared with low addictive use trajectories. Total screen time at baseline was not associated with outcomes.

Conclusions and relevance: High or increasing trajectories of addictive use of social media, mobile phones, or video games were common in early adolescents. Both high and increasing addictive screen use trajectories were associated with suicidal behaviors and ideation and worse mental health.

Keywords 
adolescent addictive behavior mental health Cohort Studies cell phone child behavior suicide video games screen time social media
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