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AURORA, COLO. – Do you ask your patients about their sexual health? Many providers do not broach the topic – whether because they lack the time, feel awkward, or their patients have other, more pressing concerns to discuss.
Yet nearly half of women experience some form of sexual dysfunction, such as low sex drive, pain during sex (dyspareunia), or trouble reaching orgasm. When dysfunction is paired with significant distress, the condition is called hypoactive sexual desire disorder (HSDD).
At the annual meeting of the Society of General Internal Medicine, experts said patients want to talk about these problems, but they need their physicians to be ready for the conversation.
Hannah Abumusa, MD, clinical instructor of medicine at the University of Pittsburgh Medical Center, recommended implementing the “5As” framework.
- Ask. Start by asking patients if they would be comfortable with you posing a few questions about their sexual health.
- Advise. Make sure your patient knows many women struggle with the problem they have raised.
- Assess. Ask a set of standardized assessment questions.
- Assist. Tell your patient about treatment options.
- Arrange. Arrange a follow-up visit to see if treatment has been effective.
Kathryn Leyens, MD, admitted she does not discuss sexual health enough with her patients, although she believes the topic is important.
“If it’s brought up, I’m comfortable talking about it,” said Dr. Leyens, a clinical assistant professor of medicine at the University of Pittsburgh. “But I think it’s something that I could initiate more often.”
The 5As framework offers a helpful way to initiate those conversations, she said.
Medications might be to blame
Holly Thomas, MD, an assistant professor of medicine at the University of Pittsburgh, first conducts a medication review when discussing low sexual desire with her patients.
“There are definitely medications that we commonly use in primary care that can have negative effects on sexual function,” Dr. Thomas said. “But we’re not always the best at talking with patients about these things, and I think sometimes patients get the message that they should deprioritize their sex lives to their medication needs.”
For example, sexual dysfunction is a common side effect of antidepressants, with paroxetine, fluvoxamine, sertraline, and fluoxetine carrying the highest frequency of this reported effect. Beta-blockers are also known to cause sexual dysfunction in women.
Pharmacologic options
Once clinicians conduct a medication review, they can discuss treatment options with patients, which can range from prescription drugs to therapy.
Several medications have been shown in clinical trials to increase sexual desire in women. Flibanserin (Addyi), a once-daily pill, boosted libido in about half of women who used the drug in studies leading to its approvalby the Food and Drug Administration in 2015.
The most common adverse effects reported in clinical trials included dizziness, syncope, and somnolence, which occurred in roughly 12% of users. The FDA recommends people avoid alcohol 2 hours before and after taking the drug.
Bremelanotide (Vyleesi) is an on-demand medication, like sildenafil for men, which in trials led to modest increases in desire among 25% of women who took the drug. About 40% of users reported experiencing nausea. Hyperpigmentation can also be a side effect, which in rare cases can be permanent, Dr. Thomas said. Patients can use a maximum of eight doses per month of the drug.
Testosterone serves as an off-label treatment, as the FDA has not approved the hormone for women. Adverse effects can include acne and weight gain. Data on the safety of its use past 2 years are scarce.
“But up until then, there’s pretty strong evidence for the efficacy and safety of testosterone for treatment of hypoactive sexual desire disorder in women,” Dr. Thomas said.
Hormone replacement therapy is another potential treatment option, which could include estrogen plus progesterone.
“It’s not FDA approved for HSDD, but if you’re using it for other menopausal symptoms, it’s likely to improve sexual function with small- to moderate-effect sizes,” she said.
Bupropion (multiple brands) is a cost-effective option also prescribed for depression, Dr. Thomas said. A recently published systematic review provided further data to support the efficacy of the drug.
“That’s something that a lot of us are very familiar with and maybe more comfortable prescribing if we’re less familiar with some of the newer options,” she said.
Nonpharmacologic interventions
Dr. Thomas encouraged clinicians to consider nonpharmacologic approaches, too, such as referring patients to sex therapists.
“There’s something called ‘sensate focus,’ which is a type of sex therapy that’s been around for decades, but it’s still very effective,” Dr. Thomas said.
Cognitive-behavioral therapy (CBT) is another option, she said. A systematic review published in 2022 showed CBT was an effective tool for treating HSDD, although Dr. Thomas noted the evidence is limited.
A newer treatment gaining traction is mindfulness meditation, often provided by therapists, which focuses on present moment and nonjudgmental bodily awareness. Dr. Thomas recommended referring patients to educational literature such as “Better Sex Through Mindfulness: How Women Can Cultivate Desire” by Lori Brotto (Vancouver: Greystone Books, 2018). The book also comes with a workbook.
“This has actually been shown in multiple trials to be effective for the treatment of low sexual desire with moderate to large effect sizes,” she said.
Dr. Abumusa, Dr. Leyens, and Dr. Thomas reported no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
AURORA, COLO. – Do you ask your patients about their sexual health? Many providers do not broach the topic – whether because they lack the time, feel awkward, or their patients have other, more pressing concerns to discuss.
Yet nearly half of women experience some form of sexual dysfunction, such as low sex drive, pain during sex (dyspareunia), or trouble reaching orgasm. When dysfunction is paired with significant distress, the condition is called hypoactive sexual desire disorder (HSDD).
At the annual meeting of the Society of General Internal Medicine, experts said patients want to talk about these problems, but they need their physicians to be ready for the conversation.
Hannah Abumusa, MD, clinical instructor of medicine at the University of Pittsburgh Medical Center, recommended implementing the “5As” framework.
- Ask. Start by asking patients if they would be comfortable with you posing a few questions about their sexual health.
- Advise. Make sure your patient knows many women struggle with the problem they have raised.
- Assess. Ask a set of standardized assessment questions.
- Assist. Tell your patient about treatment options.
- Arrange. Arrange a follow-up visit to see if treatment has been effective.
Kathryn Leyens, MD, admitted she does not discuss sexual health enough with her patients, although she believes the topic is important.
“If it’s brought up, I’m comfortable talking about it,” said Dr. Leyens, a clinical assistant professor of medicine at the University of Pittsburgh. “But I think it’s something that I could initiate more often.”
The 5As framework offers a helpful way to initiate those conversations, she said.
Medications might be to blame
Holly Thomas, MD, an assistant professor of medicine at the University of Pittsburgh, first conducts a medication review when discussing low sexual desire with her patients.
“There are definitely medications that we commonly use in primary care that can have negative effects on sexual function,” Dr. Thomas said. “But we’re not always the best at talking with patients about these things, and I think sometimes patients get the message that they should deprioritize their sex lives to their medication needs.”
For example, sexual dysfunction is a common side effect of antidepressants, with paroxetine, fluvoxamine, sertraline, and fluoxetine carrying the highest frequency of this reported effect. Beta-blockers are also known to cause sexual dysfunction in women.
Pharmacologic options
Once clinicians conduct a medication review, they can discuss treatment options with patients, which can range from prescription drugs to therapy.
Several medications have been shown in clinical trials to increase sexual desire in women. Flibanserin (Addyi), a once-daily pill, boosted libido in about half of women who used the drug in studies leading to its approvalby the Food and Drug Administration in 2015.
The most common adverse effects reported in clinical trials included dizziness, syncope, and somnolence, which occurred in roughly 12% of users. The FDA recommends people avoid alcohol 2 hours before and after taking the drug.
Bremelanotide (Vyleesi) is an on-demand medication, like sildenafil for men, which in trials led to modest increases in desire among 25% of women who took the drug. About 40% of users reported experiencing nausea. Hyperpigmentation can also be a side effect, which in rare cases can be permanent, Dr. Thomas said. Patients can use a maximum of eight doses per month of the drug.
Testosterone serves as an off-label treatment, as the FDA has not approved the hormone for women. Adverse effects can include acne and weight gain. Data on the safety of its use past 2 years are scarce.
“But up until then, there’s pretty strong evidence for the efficacy and safety of testosterone for treatment of hypoactive sexual desire disorder in women,” Dr. Thomas said.
Hormone replacement therapy is another potential treatment option, which could include estrogen plus progesterone.
“It’s not FDA approved for HSDD, but if you’re using it for other menopausal symptoms, it’s likely to improve sexual function with small- to moderate-effect sizes,” she said.
Bupropion (multiple brands) is a cost-effective option also prescribed for depression, Dr. Thomas said. A recently published systematic review provided further data to support the efficacy of the drug.
“That’s something that a lot of us are very familiar with and maybe more comfortable prescribing if we’re less familiar with some of the newer options,” she said.
Nonpharmacologic interventions
Dr. Thomas encouraged clinicians to consider nonpharmacologic approaches, too, such as referring patients to sex therapists.
“There’s something called ‘sensate focus,’ which is a type of sex therapy that’s been around for decades, but it’s still very effective,” Dr. Thomas said.
Cognitive-behavioral therapy (CBT) is another option, she said. A systematic review published in 2022 showed CBT was an effective tool for treating HSDD, although Dr. Thomas noted the evidence is limited.
A newer treatment gaining traction is mindfulness meditation, often provided by therapists, which focuses on present moment and nonjudgmental bodily awareness. Dr. Thomas recommended referring patients to educational literature such as “Better Sex Through Mindfulness: How Women Can Cultivate Desire” by Lori Brotto (Vancouver: Greystone Books, 2018). The book also comes with a workbook.
“This has actually been shown in multiple trials to be effective for the treatment of low sexual desire with moderate to large effect sizes,” she said.
Dr. Abumusa, Dr. Leyens, and Dr. Thomas reported no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
AURORA, COLO. – Do you ask your patients about their sexual health? Many providers do not broach the topic – whether because they lack the time, feel awkward, or their patients have other, more pressing concerns to discuss.
Yet nearly half of women experience some form of sexual dysfunction, such as low sex drive, pain during sex (dyspareunia), or trouble reaching orgasm. When dysfunction is paired with significant distress, the condition is called hypoactive sexual desire disorder (HSDD).
At the annual meeting of the Society of General Internal Medicine, experts said patients want to talk about these problems, but they need their physicians to be ready for the conversation.
Hannah Abumusa, MD, clinical instructor of medicine at the University of Pittsburgh Medical Center, recommended implementing the “5As” framework.
- Ask. Start by asking patients if they would be comfortable with you posing a few questions about their sexual health.
- Advise. Make sure your patient knows many women struggle with the problem they have raised.
- Assess. Ask a set of standardized assessment questions.
- Assist. Tell your patient about treatment options.
- Arrange. Arrange a follow-up visit to see if treatment has been effective.
Kathryn Leyens, MD, admitted she does not discuss sexual health enough with her patients, although she believes the topic is important.
“If it’s brought up, I’m comfortable talking about it,” said Dr. Leyens, a clinical assistant professor of medicine at the University of Pittsburgh. “But I think it’s something that I could initiate more often.”
The 5As framework offers a helpful way to initiate those conversations, she said.
Medications might be to blame
Holly Thomas, MD, an assistant professor of medicine at the University of Pittsburgh, first conducts a medication review when discussing low sexual desire with her patients.
“There are definitely medications that we commonly use in primary care that can have negative effects on sexual function,” Dr. Thomas said. “But we’re not always the best at talking with patients about these things, and I think sometimes patients get the message that they should deprioritize their sex lives to their medication needs.”
For example, sexual dysfunction is a common side effect of antidepressants, with paroxetine, fluvoxamine, sertraline, and fluoxetine carrying the highest frequency of this reported effect. Beta-blockers are also known to cause sexual dysfunction in women.
Pharmacologic options
Once clinicians conduct a medication review, they can discuss treatment options with patients, which can range from prescription drugs to therapy.
Several medications have been shown in clinical trials to increase sexual desire in women. Flibanserin (Addyi), a once-daily pill, boosted libido in about half of women who used the drug in studies leading to its approvalby the Food and Drug Administration in 2015.
The most common adverse effects reported in clinical trials included dizziness, syncope, and somnolence, which occurred in roughly 12% of users. The FDA recommends people avoid alcohol 2 hours before and after taking the drug.
Bremelanotide (Vyleesi) is an on-demand medication, like sildenafil for men, which in trials led to modest increases in desire among 25% of women who took the drug. About 40% of users reported experiencing nausea. Hyperpigmentation can also be a side effect, which in rare cases can be permanent, Dr. Thomas said. Patients can use a maximum of eight doses per month of the drug.
Testosterone serves as an off-label treatment, as the FDA has not approved the hormone for women. Adverse effects can include acne and weight gain. Data on the safety of its use past 2 years are scarce.
“But up until then, there’s pretty strong evidence for the efficacy and safety of testosterone for treatment of hypoactive sexual desire disorder in women,” Dr. Thomas said.
Hormone replacement therapy is another potential treatment option, which could include estrogen plus progesterone.
“It’s not FDA approved for HSDD, but if you’re using it for other menopausal symptoms, it’s likely to improve sexual function with small- to moderate-effect sizes,” she said.
Bupropion (multiple brands) is a cost-effective option also prescribed for depression, Dr. Thomas said. A recently published systematic review provided further data to support the efficacy of the drug.
“That’s something that a lot of us are very familiar with and maybe more comfortable prescribing if we’re less familiar with some of the newer options,” she said.
Nonpharmacologic interventions
Dr. Thomas encouraged clinicians to consider nonpharmacologic approaches, too, such as referring patients to sex therapists.
“There’s something called ‘sensate focus,’ which is a type of sex therapy that’s been around for decades, but it’s still very effective,” Dr. Thomas said.
Cognitive-behavioral therapy (CBT) is another option, she said. A systematic review published in 2022 showed CBT was an effective tool for treating HSDD, although Dr. Thomas noted the evidence is limited.
A newer treatment gaining traction is mindfulness meditation, often provided by therapists, which focuses on present moment and nonjudgmental bodily awareness. Dr. Thomas recommended referring patients to educational literature such as “Better Sex Through Mindfulness: How Women Can Cultivate Desire” by Lori Brotto (Vancouver: Greystone Books, 2018). The book also comes with a workbook.
“This has actually been shown in multiple trials to be effective for the treatment of low sexual desire with moderate to large effect sizes,” she said.
Dr. Abumusa, Dr. Leyens, and Dr. Thomas reported no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
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<root generator="drupal.xsl" gversion="1.7"> <header> <fileName>163533</fileName> <TBEID>0C04A3A9.SIG</TBEID> <TBUniqueIdentifier>MD_0C04A3A9</TBUniqueIdentifier> <newsOrJournal>News</newsOrJournal> <publisherName>Frontline Medical Communications</publisherName> <storyname/> <articleType>2</articleType> <TBLocation>QC Done-All Pubs</TBLocation> <QCDate>20230519T132249</QCDate> <firstPublished>20230519T133424</firstPublished> <LastPublished>20230519T133424</LastPublished> <pubStatus qcode="stat:"/> <embargoDate/> <killDate/> <CMSDate>20230519T133424</CMSDate> <articleSource>AT SGIM 2023</articleSource> <facebookInfo/> <meetingNumber>3017-23</meetingNumber> <byline>Kelly Ragan</byline> <bylineText>KELLY RAGAN</bylineText> <bylineFull>KELLY RAGAN</bylineFull> <bylineTitleText/> <USOrGlobal/> <wireDocType/> <newsDocType/> <journalDocType/> <linkLabel/> <pageRange/> <citation/> <quizID/> <indexIssueDate/> <itemClass qcode="ninat:text"/> <provider qcode="provider:imng"> <name>IMNG Medical Media</name> <rightsInfo> <copyrightHolder> <name>Frontline Medical News</name> </copyrightHolder> <copyrightNotice>Copyright (c) 2015 Frontline Medical News, a Frontline Medical Communications Inc. company. All rights reserved. This material may not be published, broadcast, copied, or otherwise reproduced or distributed without the prior written permission of Frontline Medical Communications Inc.</copyrightNotice> </rightsInfo> </provider> <abstract/> <metaDescription>AURORA, COLO. – Do you ask your patients about their sexual health? Many providers do not broach the topic – whether because they lack the time, feel awkward, o</metaDescription> <articlePDF/> <teaserImage/> <title>Unveiling sexual dysfunction: Clinicians can do more</title> <deck/> <disclaimer/> <AuthorList/> <articleURL/> <doi/> <pubMedID/> <publishXMLStatus/> <publishXMLVersion>1</publishXMLVersion> <useEISSN>0</useEISSN> <urgency/> <pubPubdateYear/> <pubPubdateMonth/> <pubPubdateDay/> <pubVolume/> <pubNumber/> <wireChannels/> <primaryCMSID/> <CMSIDs/> <keywords/> <seeAlsos/> <publications_g> <publicationData> <publicationCode>fp</publicationCode> <pubIssueName/> <pubArticleType/> <pubTopics/> <pubCategories/> <pubSections/> </publicationData> <publicationData> <publicationCode>im</publicationCode> <pubIssueName/> <pubArticleType/> <pubTopics/> <pubCategories/> <pubSections/> </publicationData> <publicationData> <publicationCode>ob</publicationCode> <pubIssueName/> <pubArticleType/> <pubTopics/> <pubCategories/> <pubSections/> </publicationData> </publications_g> <publications> <term canonical="true">15</term> <term>21</term> <term>23</term> </publications> <sections> <term>53</term> <term canonical="true">39313</term> </sections> <topics> <term canonical="true">322</term> <term>246</term> <term>50741</term> <term>294</term> </topics> <links/> </header> <itemSet> <newsItem> <itemMeta> <itemRole>Main</itemRole> <itemClass>text</itemClass> <title>Unveiling sexual dysfunction: Clinicians can do more</title> <deck/> </itemMeta> <itemContent> <p><span class="dateline">AURORA, COLO</span>. – Do you ask your patients about their sexual health? Many providers do not broach the topic – whether because they lack the time, feel awkward, or their patients have other, more pressing concerns to discuss.</p> <p>Yet <span class="Hyperlink">nearly half of women</span> experience some form of <span class="Hyperlink">sexual dysfunction</span>, such as low sex drive, pain during sex (dyspareunia), or trouble reaching orgasm. When <span class="Hyperlink">dysfunction is paired with significant distress</span>, the condition is called hypoactive sexual desire disorder (HSDD).<br/><br/>At the annual meeting of the Society of General Internal Medicine, experts said patients want to talk about these problems, but they need their physicians to be ready for the conversation.<br/><br/>Hannah Abumusa, MD, clinical instructor of medicine at the University of Pittsburgh Medical Center, recommended implementing the “5As” framework.</p> <ul class="body"> <li>Ask. Start by asking patients if they would be comfortable with you posing a few questions about their sexual health.</li> <li>Advise. Make sure your patient knows many women struggle with the problem they have raised.</li> <li>Assess. Ask a set of standardized assessment questions.</li> <li>Assist. Tell your patient about treatment options.</li> <li>Arrange. Arrange a follow-up visit to see if treatment has been effective.</li> </ul> <p>Kathryn Leyens, MD, admitted she does not discuss sexual health enough with her patients, although she believes the topic is important.<br/><br/>“If it’s brought up, I’m comfortable talking about it,” said Dr. Leyens, a clinical assistant professor of medicine at the University of Pittsburgh. “But I think it’s something that I could initiate more often.”<br/><br/>The 5As framework offers a helpful way to initiate those conversations, she said.<br/><br/></p> <h2>Medications might be to blame</h2> <p>Holly Thomas, MD, an assistant professor of medicine at the University of Pittsburgh, first conducts a medication review when discussing low sexual desire with her patients.</p> <p>“There are definitely medications that we commonly use in primary care that can have negative effects on sexual function,” Dr. Thomas said. “But we’re not always the best at talking with patients about these things, and I think sometimes patients get the message that they should deprioritize their sex lives to their medication needs.”<br/><br/>For example, <span class="Hyperlink"><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3108697/">sexual dysfunction is a common side effect of antidepressants</a></span>, with <span class="Hyperlink">paroxetine</span>, <span class="Hyperlink">fluvoxamine</span>, <span class="Hyperlink">sertraline</span>, and <span class="Hyperlink">fluoxetine</span> carrying the highest frequency of this reported effect. <span class="Hyperlink"><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9143081/">Beta-blockers</a></span> are also known to cause sexual dysfunction in women. <br/><br/></p> <h2>Pharmacologic options</h2> <p>Once clinicians conduct a medication review, they can discuss treatment options with patients, which can range from prescription drugs to therapy. </p> <p>Several medications have been shown in clinical trials to increase sexual desire in women. <span class="Hyperlink">Flibanserin (Addyi), a once-daily pill</span>, boosted libido in about half of women who used the drug in studies leading to <span class="Hyperlink">its approval</span>by the Food and Drug Administration in 2015. <br/><br/>The most common adverse effects <span class="Hyperlink">reported in clinical trials included</span> dizziness, <span class="Hyperlink">syncope</span>, and somnolence, which occurred in roughly 12% of users. The FDA recommends people avoid alcohol 2 hours before and after taking the drug.<br/><br/><span class="Hyperlink">Bremelanotide</span> (Vyleesi) is an on-demand medication, like <span class="Hyperlink">sildenafil</span> for men, which in trials led to modest increases in desire among 25% of women who took the drug. <span class="Hyperlink">About 40% of users reported experiencing nausea.</span> Hyperpigmentation can also be a side effect, which in rare cases can be permanent, Dr. Thomas said. Patients can use a maximum of eight doses per month of the drug.<br/><br/><span class="Hyperlink">Testosterone</span> serves as an off-label treatment, <span class="Hyperlink"><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9331845/">as the FDA has not approved</a></span> the hormone for women. Adverse effects can include <span class="Hyperlink">acne</span> and weight gain. Data on the <span class="Hyperlink"><a href="https://bjgp.org/content/70/693/203">safety of its use</a></span> past 2 years are scarce. <br/><br/>“But up until then, there’s pretty strong evidence for the efficacy and safety of testosterone for treatment of hypoactive sexual desire disorder in women,” Dr. Thomas said.<br/><br/><span class="Hyperlink">Hormone replacement therapy</span> is another potential treatment option, which could include <span class="Hyperlink">estrogen</span> plus progesterone.<br/><br/>“It’s not FDA approved for HSDD, but if you’re using it for other menopausal symptoms, it’s likely to improve sexual function with small- to moderate-effect sizes,” she said.<br/><br/><span class="Hyperlink">Bupropion</span> (multiple brands) is a cost-effective option also prescribed for <span class="Hyperlink">depression</span>, Dr. Thomas said. <span class="Hyperlink"><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9886814/">A recently published</a></span> systematic review provided further data to support the efficacy of the drug. <br/><br/>“That’s something that a lot of us are very familiar with and maybe more comfortable prescribing if we’re less familiar with some of the newer options,” she said.<br/><br/></p> <h2>Nonpharmacologic interventions</h2> <p>Dr. Thomas encouraged clinicians to consider nonpharmacologic approaches, too, such as referring patients to sex therapists.</p> <p>“There’s something called ‘sensate focus,’ which is a type of sex therapy that’s been around for decades, but it’s still very effective,” Dr. Thomas said.<br/><br/>Cognitive-behavioral therapy (CBT) is another option, she said. A <span class="Hyperlink"><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9334335/">systematic review published in 2022</a></span> showed CBT was an effective tool for treating HSDD, although Dr. Thomas noted the evidence is limited.<br/><br/>A newer treatment gaining traction is mindfulness meditation, often provided by therapists, which focuses on present moment and nonjudgmental bodily awareness. Dr. Thomas recommended referring patients to educational literature such as “<span class="Hyperlink"><a href="https://www.amazon.com/Better-Sex-Through-Mindfulness-Cultivate/dp/1771642351">Better Sex Through Mindfulness: How Women Can Cultivate Desire</a>” </span>by Lori Brotto (Vancouver: Greystone Books, 2018). The book also comes with a workbook.<br/><br/>“This has actually been shown in multiple trials to be effective for the treatment of low sexual desire with moderate to large effect sizes,” she said.<br/><br/>Dr. Abumusa, Dr. Leyens, and Dr. Thomas reported no relevant financial relationships.</p> <p> <em>A version of this article originally appeared on <span class="Hyperlink"><a href="https://www.medscape.com/viewarticle/992105">Medscape.com</a></span>.</em> </p> </itemContent> </newsItem> <newsItem> <itemMeta> <itemRole>teaser</itemRole> <itemClass>text</itemClass> <title/> <deck/> </itemMeta> <itemContent> <ul class="body"> <li>Start by asking patients if they would be comfortable with you posing a few questions about their sexual health.</li> </ul> </itemContent> </newsItem> </itemSet></root>
AT SGIM 2023