Respiratory health 1

Track 8
Saturday, October 28, 2023
2:00 PM - 3:15 PM
Meeting Room C2.6


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Prof Chris van Weel
Past President WONCA, Emeritus Professor Family Medicine
WONCA, Radboud University Nijmegen, Netherlands



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Prof Amanda Barnard
Professor of Rural Health
Australian National University

Building a diagnostic picture of asthma in primary care: Development of a novel ‘jigsaw puzzle’ approach

2:00 PM - 2:15 PM


Introduction: Asthma remains both under- and over-diagnosed globally. There is an identified an educational need for simple tools to diagnose asthma in the absence of a single objective test. New teaching and learning tools are required.

Aims: To describe the process of defining the format and content of teaching and learning tools to facilitate and improve the quality of asthma diagnosis by students , early stage clinicians and other primary care pracitioners using a jigsaw puzzle metaphor.

Methods:A half-day “jigsaw“ workshop of primary care academics and clinicians in low, middle and high income countries with an asthma diagnosis interest was convened. Four working groups in two rounds negotiated and prioritised jigsaw pieces describing: reason for presentation, symptoms, predisposing factors and tests/investigations most relevant when building a clinical picture of asthma. In the third round a single comprehensive jigsaw puzzle was formed through debate about relative importance of jigsaw pieces over time (

Resource content: Building the puzzle begins with establishing the reason/s the person has presented in primary care followed by an exploration of their respiratory symptoms. A personal and family history is important and continuity of care is crucial as more than one encounter is often needed to build the diagnostic puzzle. Objective tests should be considered where available e.g. a simple test of airway reversibility using peak flow pre- and post- administration of a short-acting bronchodilator, serial peak flow monitoring, microspirometry or spirometry. Other tests such as blood eosinophil levels or FeNO may be considered.

Conclusions: This project identified a new teaching and learning strategy, the asthma jigsaw puzzle, applicable to many teaching situations. The creation of context-specific development process and a tool enables learners to visualize the clinical picture and decide on the likelihood of an asthma diagnosis before taking action.


1 Novel approaches to "old" challenges are needed
2 Creative and collaborative processes can produce new tools
3 Asthma jigsaw puzzle process can be utilized in many education setting


Professor Amanda Barnard is an experienced medical educator , academic and rural clinician, who established and directed the Rural Clinical School of the Australian National University. She has particular interests in gender equity, family violence, rural medical education and respiratory illness in primary care. She is past chair of the Wonca Working Party on Women and Family Medicine, and currently on its Executive. She is on the Boards of the International Primary Care Respiratory Group and the National Asthma Council.
Ms Fiona Gardiner
Neurology Medical Science Liaison
Eisai Australia Pty Ltd

Effect of lemborexant on total sleep time in subjects with comorbid insomnia disorder and mild obstructive sleep apnoea

2:15 PM - 2:30 PM


Obstructive sleep apnoea (OSA) and insomnia are frequently co-existing disorders, known as COMISA. Treatment is challenging because some sleep-promoting drugs may impact pre-existing respiratory conditions. The impact of lemborexant (LEM), a competitive-dual-orexin-receptor-antagonist with demonstrated respiratory safety in patients with mild-to-severe OSA, was assessed for total-sleep-time (TST) in subjects with comorbid insomnia disorder/mild OSA.

In Study E2006-G000-304 (Study 304; NCT02783729), subjects age ≥55y with insomnia disorder were randomized (5:5:5:4) to receive LEM 10mg (LEM10) or 5mg (LEM5), zolpidem tartrate extended-release 6.25 mg (ZOL), or placebo (PBO) for 1 month. Objective TST (oTST) was assessed during Nights (N)1/2 and N29/30 of treatment using polysomnography; subjective TST (sTST) was assessed during the first (first7N) and last 7 (last7N) nights of treatment using sleep diaries. Change-from-baseline (CFB) was analysed using mixed-effect-model-repeated-measurement; CFB mean is reported as least-square-mean visit estimates. This post-hoc analysis included subjects with both insomnia disorder and mild OSA (apnoea-hypopnoea-index ≥5 to <15 events/h of sleep).

Of 1006 subjects with insomnia, 410 (40.8%) had mild OSA. Improvement (increase) in oTST (minutes) from baseline was larger and significantly different versus PBO for LEM10/LEM5/ZOL on N1/2 (LEM10/LEM5/ZOL/PBO: 76.2/62.5/53.2/14.3; P<0.0001) and N29/30 (67.6/61.4/41.3/20.6; P≤0.0002), and for LEM10/LEM5 versus ZOL on N1/2 (P≤0.0464) and N29/30 (P<0.0001). Improvement (increase) in sTST (minutes) from baseline was larger and significantly different for LEM10 versus PBO during the first7N (LEM10/LEM5/ZOL/PBO: 59.7/43.0/47.7/33.1; P=0.0061) and last7N (74.7/57.2/65.3/41.6; P=0.0025) of treatment and for ZOL versus PBO (P=0.0287) on last7N of treatment. There were no new safety signals in the mild-OSA subpopulation.

LEM significantly improves objective/subjective TST versus PBO and objective TST versus ZOL in older patients with insomnia disorder and mild OSA. As LEM does not adversely impact the apnoea-hypopnoea-index in patients with mild-to-severe OSA, it may be a safe treatment option for COMISA.

Support: Eisai Inc.


1. Familiarity with the clinical entity known as “COMISA”
2. Appreciation of the impact of lemborexant on objective and subjective total sleep time in patients with comorbid insomnia disorder and OSA (COMISA) of mild severity OSA.
3. Awareness of the overall safety of lemborexant in patients with COMISA whose OSA was of mild severity.


Fiona Gardiner is a Medical Science Liaison at Eisai Australia Pty Ltd and medical lead for the insomnia portfolio. She has worked as a clinical research scientist at the University of Melbourne, Austin Health and has worked in industry covering multiple therapeutic areas, including oncology neurology, neonatology, and metabolic rare disease.
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A/Prof Gritt Overbeck
University of Copenhagen

Implementing CRP POCT test for respiratory tract infections in children in Kyrgyzstan – studying enablers and barriers to implementation

2:30 PM - 2:35 PM


Introduction: Inappropriate prescriptions of antibiotics to children are common in primary care in Central Asia. “Currently, a cluster randomised trial is investigating this possible reduction through the implementation of point-of-care CRP-testing in primary care clinics in rural areas of the Kyrgyz Republic.”
Introducing point-of-care CRP-testing is a process consisting of several interacting educational and behavioural components, and the success depends on the acceptance and coordinated efforts of the involved health professionals.
Aim: We aim to evaluate how primary care professionals accept the new test technology
Method: Qualitative interviews with 20 general practitioners, feldshers and practice nurses before and during the implementation period.
Results: Data collection, parallel to the roll out of the randomised trial, is still ongoing but will finish in spring 2023. Initial results, point towards barriers to change prescription style so that this is based on CPR-test results relate to practical conditions, e.g. having sufficient amount of test kits, professionals’ difference in educational level and their view of themselves as evidence-based practitioners.


Opportunities and challenges when implementing new technologies in rural primary care


Susanne Reventlow is specialist in general practice, Master in social anthropology and has a medical doctorate on a thesis on risk perception and osteoporosis in women aged 60-70. She is professor and head of the Research Unit for General Practice in Copenhagen and in Region Zealand, both of which belong to the Centre for General Practice. She has worked for years as a general practitioner and at the same time has been involved in professional activities. Special research areas are chronic disease - especially chronic disease with multimorbidity -, patient perspectives, patient involvement and communication, risk and prevention, children and families, as well as research methodology. Interdisciplinary research is also a major interest; is involved in several national and international collaborations and projects, she is part of a research project in Kirgizstan.