Lifecycle management in pharmaceutical analysis: How to establish an efficient and relevant continued performance monitoring program

It is the objective of a systematic and holistic Quality-by-Design approach to demonstrate and ensure that an analytical procedure is fit for its intended purpose over its entire lifecycle. Such a lifecycle approach, as proposed for a new USP General Information Chapter includes the three stages Procedure Design and Development, Procedure Performance Qualification, and Continued Procedure Performance Verification, in alignment to manufacturing process validation. A decisive component of this approach is the Analytical Target Profile, which defines the performance requirements for the measurement of a Quality Attribute as the target for selection, development and optimization of the respective analytical procedures. Although the most benefit can be gained by a comprehensive Quality-by-Design approach establishing the Analytical Target Profile in the very beginning of a drug development project, it may also be established retrospectively for analytical procedures long in routine use, in order to facilitate future lifecycle activities such as continual improvements, transfers, monitoring and periodic performance evaluations. In contrast to the first two stages of the analytical lifecycle with usually limited amount of data, the Continued Procedure Performance Verification stage offers the possibility to utilize a much more reliable data base to collect, analyze, and evaluate data that relate to analytical procedure performance. This monitoring program should be aligned as far as possible with other quality systems already in place and may include performance indicators such as Conformity (i.e. out-of specification test results with analytical root-cause), Validity (i.e. failure to meet method acceptance criteria, e.g. system suitability tests), and (numerical) analytical performance parameters (e.g. ranges for replicate determinations, control sample results, etc). In addition to the monitoring of analytical control parameters by means of control charts, average (pooled) performance parameters can be calculated. Over time, a large number of data can be included and thus the reliability of these estimates is increased tremendously. Such reliable estimates for the true performance parameters, e.g. repeatability or intermediate precision are essential to identify systematic effects (also called special cause variation) with good confidence. The intent of the analytical procedure performance evaluation is to identify substandard performance, identify root cause through investigations, and determine when additional activities are required to improve it. Examples are provided for the monitoring and evaluation of performance parameters for the compendial drug substance Furosemide and for biopharmaceutical applications.

Case Report: Monoclonal Gammopathy of Undetermined Significance is Associated with Loa loa Infection

A 63-year-old woman who migrated from Nigeria to the United States was found to have an elevated total serum protein, anemia, and eosinophilia. Serum protein electrophoresis (SPEP) and serum protein immunofixation electrophoresis (SPIFE) demonstrated monoclonal immunoglobulin G (IgG) κ restricted bands (IgG 3,820 mg/dL; κ/λ ratio 4.47), indicative of monoclonal gammopathy of unknown significance (MGUS). A rapid diagnostic test (RDT) for malaria was positive for Plasmodium falciparum (BinaxNOW^®; Alere Scarborough Inc., Scarborough, ME). Giemsa-stained blood smears were negative for malarial parasites, however, Loa loa microfilariae were identified. Reverse transcription polymerase chain reaction for P. falciparum, Plasmodium ovale, Plasmodium malariae, and Plasmodium vivax yielded a negative result. She was treated for loiasis with diethylcarbamazine and received no malaria medication. Treatment resulted in a resolution of the microfilaremia and eosinophilia, a negative RDT for malaria, and marked reduction in the monoclonal gammopathy. This is the first reported human case of MGUS associated with loiasis and its resolution after antiparasitic treatment.

Recently listed Stockholm convention POPs: Analytical methodology, occurrence in food and dietary exposure

In recent years, the Stockholm Convention has listed an additional set of persistent organic pollutants (POPs) for elimination or restricted use/release. Data on the occurrence of these contaminants in food is scarce. Validated analytical methodology was developed to investigate the occurrence of hexachlorobutadiene (HCBD), pentachlorobenzene (PCBz), hexachlorobenzene (HCB) pentachlorophenol (PCP) and polychlorinated naphthalenes (PCNs) in 120 retail foods and 19 total diet study samples. The foods covered the range of commonly consumed dietary items including dairy products, eggs (hen and other species), poultry, meat, fish, vegetables, etc. HCBD showed a low frequency of detection, whereas PCBz, HCB and PCNs occurred in most samples (ranges: <0.01 to 0.19 μg/kg; <0.01 to 3.16 μg/kg and 0.1 to 166 ng ΣPCNs/kg respectively). PCP (<0.01 to 1.9 μg/kg) was detected more frequently in meat products, offal and eggs. Fish, shellfish, eggs from all species, animal fats, meat, offal and meat products showed higher contamination levels, which is normal when investigating lipophilic POPs. These levels of occurrence are similar to more recently reported literature levels but perhaps lower, relative to historic data. This is not unexpected, given the restrictions/limitations on these chemicals within the UK and Western Europe. The estimated human exposure to population groups through dietary intake is correspondingly low and based on current toxicological knowledge, the levels in the examined samples do not suggest a cause for health concern. The data also provide a current baseline for HCBD, PCBz and PCP, and update existing data for PCN and HCB occurrence in foods.

Outcomes and outcome measures used in evaluation of communication training in oncology - a systematic literature review, an expert workshop, and recommendations for future research

BACKGROUND

Communication between health care provider and patients in oncology presents challenges. Communication skills training have been frequently developed to address those. Given the complexity of communication training, the choice of outcomes and outcome measures to assess its effectiveness is important. The aim of this paper is to 1) perform a systematic review on outcomes and outcome measures used in evaluations of communication training, 2) discuss specific challenges and 3) provide recommendations for the selection of outcomes in future studies.

METHODS

To identify studies and reviews reporting on the evaluation of communication training for health care professionals in oncology, we searched seven databases (Ovid MEDLINE, CENTRAL, CINAHL, EMBASE, PsychINFO, PsychARTICLES and Web of Science). We extracted outcomes assessed and the respective assessment methods. We held a two-day workshop with experts (n = 16) in communication theory, development and evaluation of generic or cancer-specific communication training and/or outcome measure development to identify and address challenges in the evaluation of communication training in oncology. After the workshop, participants contributed to the development of recommendations addressing those challenges.

RESULTS

Out of 2181 references, we included 96 publications (33 RCTs, 2 RCT protocols, 4 controlled trials, 36 uncontrolled studies, 21 reviews) in the review. Most frequently used outcomes were participants' training evaluation, their communication confidence, observed communication skills and patients' overall satisfaction and anxiety. Outcomes were assessed using questionnaires for participants (57.3%), patients (36.0%) and observations of real (34.7%) and simulated (30.7%) patient encounters. Outcomes and outcome measures varied widely across studies. Experts agreed that outcomes need to be precisely defined and linked with explicit learning objectives of the training. Furthermore, outcomes should be assessed as broadly as possible on different levels (health care professional, patient and interaction level).

CONCLUSIONS

Measuring the effects of training programmes aimed at improving health care professionals' communication skills presents considerable challenges. Outcomes as well as outcome measures differ widely across studies. We recommended to link outcome assessment to specific learning objectives and to assess outcomes as broadly as possible.

Quality Assessment of the Preanalytical Workflow in Liquid Biobanking: Taurine as a Serum-Specific Quality Indicator for Preanalytical Process Variations

The scientific impact of translational biomedical research largely depends on the availability of high-quality biomaterials. However, evidence-based and robust quality indicators (QIs) covering the most relevant preanalytical variations are still lacking. The aim of this study was to identify and validate a QI suitable for assessing time-to-centrifugation (TTC) delays in human liquid biospecimens originating from both healthy and diseased individuals. Serum and plasma samples with varying TTCs were analyzed by liquid chromatography coupled to tandem mass spectrometry (LC-MS/MS) in a pilot cohort of healthy individuals to identify a suitable QI candidate. Taurine (TAU), as a TTC QI candidate, was validated in healthy individuals and patients with rheumatologic and cardiologic diseases, considering the (1) preanalytical handling temperature, (2) platelet count, and (3) postcentrifugation delay. For discrimination of high TTC (TTC >60 minutes) from low TTC serum specimens, a probability calculation tool was developed (Triple-T-cutoff-model). TTC-dependent changes in healthy individuals were observed for amino acids, particularly TAU. Validation of the TAU levels in an independent cohort of healthy individuals revealed a time-dependent increase in serum, but not in plasma, for a TTC delay of 30-240 minutes. TAU increases were dependent on the handling temperature and platelet count and volume. By contrast, no changes in TAU concentrations were observed for additional postcentrifugation delays. Validation of TAU and the Triple-T-cutoff-model, in rheumatologic/cardiologic patient collectives, allowed the discrimination of samples with TTC ≤60 min/>60 min with estimated AUROC (area under the receiver operating characteristic curve) values of 89% [78%-100%]/86% [71%-100%] and 91% [79%-100%]/84% [68%-100%], respectively. Considering the preanalytical handling temperature and platelet count and volume, TAU and the Triple-T-cutoff-model represent reliable QIs for TTC >60 minutes in serum samples from healthy individuals and selected rheumatologic/cardiologic patients. However, further studies in larger patient collectives with various diseases are needed to assess the robustness and potential of the QIs presented in this article as biobanking quality assurance/quality control tools to support high-quality biomedical research.

Zen and the Art of Making a Bayesian Espresso

In this issue of Neuron, Konovalov and Krajbich (2018) argue that a Bayesian inference is employed when learning new sequences and identify distinct brain networks that track the uncertainty of both the current state and the underlying pattern structure.

The potential of recycled materials used in agriculture to contaminate food through uptake by livestock

The potential for contaminant uptake from recycled materials used in livestock farming, to animal tissues and organs, was investigated in three practical modular studies involving broiler chickens, laying chickens and pigs. Six types of commercially available recycled materials were used either as bedding material for chickens or as fertilizer for cropland that later housed outdoor reared pigs. The contaminants studied included regulated contaminants e.g. polychlorinated dibenzo-p-dioxins and dibenzofurans (PCDD/Fs, dioxins) and polychlorinated biphenyls (PCBs), but related contaminants such as polybrominated diphenylethers (PBDEs), hexabrominated cyclododecane (HBCDD), polychlorinated naphthalenes (PCNs), polybrominated dioxins (PBDD/Fs) and perfluoroalkyl substances (PFAS) were also investigated. Contaminant occurrence in the recycled materials was verified prior to the studies and the relationship to tissue and egg concentrations in market ready animals was investigated using a weights of evidence approach. Contaminant uptake to animal tissues and eggs was observed in all the studies but the extent varied depending on the species and the recycled material. PCBs, PBDEs, PCDD/Fs, PCNs and PFAS showed the highest potential to transfer, with laying chickens showing the most pronounced effects. PBDD/Fs showed low concentrations in the recycled materials, making it difficult to evaluate potential transfer. Higher resulting occurrence levels in laying chickens relative to broilers suggests that period of contact with the materials may influence the extent of uptake in chickens. Bio-transfer factors (BTFs) estimated for PCDD/F and PCBs showed a greater magnitude for chicken muscle tissue relative to pigs with the highest values observed for PCBs in laying chickens. There were no significant differences between BTFs for the different chicken tissues which contrasted with the high BTF values for pigs liver relative to muscle. The study raises further questions which require investigation such as the effects of repeated or yearly application of recycled materials as fertilizers, and the batch homogeneity/consistency of available recycled materials.

Survey of antimicrobial susceptibility of bacterial pathogens isolated from dogs and cats with respiratory tract infections in Europe: ComPath results

AIMS

To present antimicrobial susceptibilities for bacteria from dogs and cats with respiratory tract infection (RTI) across Europe in 2013-2014 and compare with data from 2008-2010.

METHODS AND RESULTS

Minimal inhibitory concentrations were determined for 464 isolates following Clinical and Laboratory Standards Institute standards using antibiotics approved for RTI treatment. Where possible, susceptibility was calculated using predominantly human-derived breakpoints whilst some antibiotics had no breakpoints. The main pathogen from dogs was Staphylococcus pseudintermedius which was > 90% susceptible to fluoroquinolones and oxacillin (92·5%; six isolates confirmed mecA-positive) and 53·8, 80·0 and 88·8% susceptible to tetracycline, penicillin and trimethoprim/sulfamethoxazole. Streptococci, Escherichia coli, Bordetella bronchiseptica, Staphylococcus aureus and Pseudomonas aeruginosa were also present in dog RTI. Streptococci were fully susceptible to penicillin, ampicillin and pradofloxacin. None were enrofloxacin-resistant but 31·4% had intermediate susceptibility. The least active agent against streptococci was tetracycline (51·4% susceptible). For E. coli, 90·9% were amoxicillin/clavulanic acid-susceptible; susceptibility to other compounds ranged from 63·6 to 81·8%. There are no breakpoints for B. bronchiseptica and Ps. aeruginosa. For Staph. aureus, penicillin susceptibility was low (34·8%); for other compounds 87·0-100%. The main RTI pathogen from cats was Pasteurella multocida, where only pradofloxacin has breakpoints (100% susceptible). Susceptibility of coagulase-negative staphylococci ranged from 66·7% (penicillin) to 97·2% (pradofloxacin). Streptococci from cats were 100% susceptible to all antibiotics except enrofloxacin and tetracycline (both 65·2% susceptible).

CONCLUSIONS

Overall, antimicrobial resistance was low to medium in RTI in dogs and cats, although susceptibility varied widely among pathogens studied.

SIGNIFICANCE AND IMPACT OF THE STUDY

Responsible use of antibiotics is crucial to maintain susceptibility and continued resistance monitoring is important to support this goal. These findings support the need for the setting of RTI-specific breakpoints for pathogens of dogs and cats.

Real-time forecasting of pesticide concentrations in soil

Forecasting pesticide residues in soils in real time is essential for agronomic purposes, to manage phytotoxic effects, and in catchments to manage surface and ground water quality. This has not been possible in the past due to both modelling and measurement constraints. Here, the analytical transient probability distribution (pdf) of pesticide concentrations is derived. The pdf results from the random ways in which rain events occur after pesticide application. First-order degradation kinetics and linear equilibrium sorption are assumed. The analytical pdfs allow understanding of the relative contributions that climate (mean storm depth and mean rainfall event frequency) and chemical (sorption and degradation) properties have on the variability of soil concentrations into the future. We demonstrated the two uncertain reaction parameters can be constrained using Bayesian methods. An approach to a Bayesian informed forecast is then presented. With the use of new rapid tests capable of providing quantitative measurements of soil concentrations in the field, real-time forecasting of future pesticide concentrations now looks possible for the first time. Such an approach offers new means to manage crops, soils and water quality, and may be extended to other classes of pesticides for ecological risk assessment purposes.

A Simple Method to Estimate Entropy and Free Energy of Atmospheric Gases from Their Action

A convenient practical model for accurately estimating the total entropy (ΣS_i) of atmospheric gases based on physical action is proposed. This realistic approach is fully consistent with statistical mechanics, but reinterprets its partition functions as measures of translational, rotational, and vibrational action or quantum states, to estimate the entropy. With all kinds of molecular action expressed as logarithmic functions, the total heat required for warming a chemical system from 0 K (ΣS_iT) to a given temperature and pressure can be computed, yielding results identical with published experimental third law values of entropy. All thermodynamic properties of gases including entropy, enthalpy, Gibbs energy, and Helmholtz energy are directly estimated using simple algorithms based on simple molecular and physical properties, without resource to tables of standard values; both free energies are measures of quantum field states and of minimal statistical degeneracy, decreasing with temperature and declining density. We propose that this more realistic approach has heuristic value for thermodynamic computation of atmospheric profiles, based on steady state heat flows equilibrating with gravity. Potentially, this application of an action principle can provide better understanding of emergent properties of many natural or evolving complex systems, including modelling of predictions for global warming.

Reduced memory-related ongoing oscillatory activity in healthy older adults

Age-related impairments in episodic memory have been linked to alterations in encoding-induced neural activity. In young individuals, even prestimulus activity has been shown to influence the encoding of an upcoming stimulus, with ongoing theta and beta oscillations being predictive of subsequent recognition. The present study investigated if these memory-related ongoing oscillations are also affected by aging. In an EEG experiment, healthy older and young individuals performed an encoding task with a subsequent recognition test on picture and word stimuli. The group of younger participants showed an increased oscillatory activity in the lower frequency range (ranging from 3 to 17 Hz) in the pre- and post-stimulus period compared with the older adults. Only in young participants, ongoing beta power during encoding was related to later memory in both stimulus categories, whereas in older participants, this effect was diminished. Interestingly, there was no general age-related decrease in recognition performance. These results indicate that ongoing low beta oscillations might constitute a functional indicator of cognitive aging that reveals itself even before a strong decline in behavioral performance is noticeable, and that could be a potential target for neuromodulatory interventions.

In Vitro and In Vivo Activity of a Novel Antisense Peptide Nucleic Acid Compound Against Multidrug-Resistant Acinetobacter baumannii

Multidrug-resistant (MDR) Acinetobacter baumannii is a difficult pathogen due to its propensity to develop resistance to antibiotics. Antisense nucleic acid analogs have been proposed as a potential alternative anti-infective approach. We developed a peptide nucleic acid (PNA) compound that targets the essential Acinetobacter gene carA. The PNA oligomer was conjugated to the cell-penetrating peptide (RXR)₄XB. In vitro testing of the PNA conjugate against four clinical strains of MDR-A. baumannii in minimal medium demonstrated that all four strains were inhibited at a concentration of 1.25 μM. In vivo testing of the PNA conjugate was done using a Galleria mellonella model of sepsis caused by one of the clinical strains. Preliminary testing of a variety of inocula demonstrated that an inoculum of 1 × 10⁶ cfu was lethal to the majority of caterpillars by day 3, but not within 24 hours. The PNA compound was administered 30 minutes after an inoculum of 1 × 10⁶ cfu at doses estimated to produce concentrations of ∼5 and 20 μM. The PNA compound had no effect at the lower dose. However, the higher dose reduced mortality from 5/28 (18%) to 0/28 (0%) at day 1 (p = 0.051) and from 19/28 (68%) to 9/28 (32%) at day 6 (p = 0.015). Antisense therapy is a novel approach to dealing with difficult MDR pathogens that could circumvent the problem of progressive resistance to available antibiotics. Further studies need to be done with additional strains and more complex in vivo model systems.

P97 Utility of computer technology in management of non-syndromic craniosynostosis- is it cost effective?

Objectives

To discuss the utility of Computer technology for non-syndromic craniosynostosis (Metopic craniosynostosis) in the form of 3D printed models that could be utilised intraoperatively to aid fronto-orbital remodelling.

Design

Prospective study form 2015–2017.

Subjects

Paediatric non-syndromic metopic craniosynostosis cohort.

Methods

We present a series of 7 patients with non-syndromic metopic craniosynostosis operated on by the craniofacial team Edinburgh over a three year period. The Edinburgh Craniofacial service is supported by the Managed Service Network (MSN) for Neurosurgery, Scotland as a part of nationally delivered Craniofacial service. We utilised 3D printing models of the orbital bar to plan a fronto-orbital advancement technique. The models were then subsequently sterilised and used intra operatively. 3D printer utility is available to us as a part of the NHS Lothian craniomaxillofacial and plastics surgery service.

Results

No intra-operative or post operative complications were noted in our series. All patients undergo standardised pre and post operative 3D CT and photography follow up to objectively measure the outcome.

Conclusions

The utility of Computer technology is a useful and safe adjunct for non-syndromic craniosynostosis, particularly metopic craniosynostosis. A careful pre-operative planning and 3D printed model is helpful to achieve the desired bespoke surgical outcome and to reduce operative time. Post operative 3D CT and 3D photography were utilised to objectively measure the outcome. No extra costs were incurred to our service. We believe that this could be incorporated in preoperative planning as an essential tool.

Which Matters More in Incidental Category Learning: Edge-Based Versus Surface-Based Features

Although many researches have shown that edge-based information is more important than surface-based information in object recognition, it remains unclear whether edge-based features play a more crucial role than surface-based features in category learning. To address this issue, a modified prototype distortion task was adopted in the present study, in which each category was defined by a rule or a similarity about either the edge-based features (i.e., contours or shapes) or the corresponding surface-based features (i.e., color and textures). The results of Experiments 1 and 2 showed that when the category was defined by a rule, the performance was significantly better in the edge-based condition than in the surface-based condition in the testing phase, and increasing the defined dimensions enhanced rather than reduced performance in the edge-based condition but not in the surface-based condition. The results of Experiment 3 showed that when each category was defined by a similarity, there was also a larger learning effect when the category was defined by edge-based dimensions than by surface-based dimensions in the testing phase. The current study is the first to provide convergent evidence that the edge-based information matters more than surface-based information in incidental category learning.

Isolated Tear of the Pectoralis Minor Tendon in a Professional American Football Quarterback: A Case Report

CASE

A 27-year-old right-hand-dominant National Football League (NFL) quarterback injured his right shoulder after falling with the elbow flexed and the shoulder flexed and slightly abducted. He noted an immediate onset of right anterior shoulder pain, but was able to continue playing and throwing without notable deficit. Magnetic resonance imaging of the chest revealed an isolated tear of the pectoralis minor tendon. The patient received nonoperative local treatment and was able to start as quarterback at the next game.

CONCLUSION

An isolated pectoralis minor tear in the dominant arm of a professional throwing athlete may be successfully treated with nonoperative local treatment and shoulder strengthening and stabilization exercises, allowing an early return to competition.

[Empirical health services research in emergency and acute medicine : Preliminary results of concomitant monitoring of patient recruitment and sample quality]

BACKGROUND

Up until now, research data on the implementation of empirical health services research in emergency departments in Germany are scarce.

STUDY AIM

A monitoring instrument applied in a multicenter prospective cohort study in emergency departments (EDs) is described and discussed regarding requirements for the control and supervision of data collection.

MATERIALS AND METHODS

Patients with cardiac diseases, respiratory tract infections, and hip fractures were recruited in eight EDs located in a central district of Berlin. Enrolment figures and nonresponder reasons were analyzed through descriptive statistics. Potential sample bias was examined in terms of response rates as well as the distribution of age and sex in the group of participants and nonresponders. Qualitative content analysis was applied to data from routine supervisory and feedback meetings with study nurses.

RESULTS

Within the first 8 months of data collection, 61.1% of the aimed 1104 patients were recruited. Most frequently stated nonresponder reasons were the dense work and care processes in EDs (41.9%) and patients' disease burden (24.7%). Moreover, qualitative results revealed problems with identifying potentially eligible participants and difficulties because of missing research infrastructure in study centers. The response rate of 50.7% and approximately equal distribution of age and sex in participants and nonresponders do not indicate sample biases.

DISCUSSION

The monitoring instrument has proven to be suited for empirical research in EDs and revealed optimization potential. We recommend using qualitative and quantitative data systematically.

Implicit acoustic sequence learning recruits the hippocampus

The exclusive role of the medial temporal lobe in explicit memory has been questioned by several studies reporting medial temporal lobe involvement during implicit learning. Prior studies have demonstrated that hippocampal engagement is present during the implicit learning of perceptual associations, however, it is absent during learning response-related associations. Therefore, it was hypothesized that the function of the medial temporal lobe during implicit learning is related to the extraction of perceptual associations in general. While in most implicit learning tasks visual stimuli were used, the aim of the current functional magnetic resonance imaging (fMRI) study was to detect whether activations within medial temporal lobe structures are also found during implicit learning of auditory associations. In a modified version of the classical serial reaction time task, participants reacted to the presentation of five different tones. Unbeknownst to the participants, the tones were presented with an underlying sequential regularity that could be learned. To avoid an influence of response learning on acoustic associative learning, response buttons were remapped in every trial. After learning, two different tests were used to measure participants' conscious knowledge about the underlying sequence in order to assess the amount of implicit memory and to exclude participants with explicit knowledge acquired during learning. fMRI results revealed hippocampal activations for implicit learning of the acoustic sequence. When detecting a relation between implicit learning of acoustic associations and hippocampal activations, this study indicated a relation between hippocampal activations and memory formation of perceptual-based relational representation regardless of explicit knowledge. Thus, present findings suggest a general functional role for the formation of sequenced perceptual associations independent of the involvement of awareness.

General population normative data for the EORTC QLQ-C30 health-related quality of life questionnaire based on 15,386 persons across 13 European countries, Canada and the Unites States

OBJECTIVE

The European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 health-related quality of life questionnaire is one of the most widely used cancer-specific health-related quality of life questionnaires worldwide. General population norm data can facilitate the interpretation of QLQ-C30 data obtained from cancer patients. This study aimed at systematically collecting norm data from the general population to develop European QLQ-C30 norm scores and to generate comparable norm data for individual countries in Europe and North America.

METHODS

We collected QLQ-C30 data from the general population across 11 European Union (EU) countries, Russia, Turkey, Canada and United States (n ≥ 1000/country). Representative samples were stratified by sex and age groups (18-39, 40-49, 50-59, 60-69 and ≥ 70 years). After applying weights based on the United Nations population distribution statistics, we calculated QLQ-C30 domain scores to generate a 'European QLQ-C30 Norm' based on the EU countries. Further, we calculated QLQ-C30 norm scores for all 15 individual countries.

RESULTS

A total of 15,386 respondents completed the online survey. For the EU sample, most QLQ-C30 domains showed differences by sex/age, with men scoring somewhat better health than women, while age effects varied across domains. Substantially larger differences were seen in inter-country comparisons, with Austrian and Dutch respondents reporting consistently better health compared with British and Polish respondents.

CONCLUSIONS

This study is the first to systematically collect EORTC QLQ-C30 general population norm data across Europe and North America applying a consistent data collection method across 15 countries. These new norm data facilitate valid intra-country as well as inter-country comparisons and QLQ-C30 score interpretation.