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The present study aimed know the degree of internal speech with ages ( 6.7 , 9 and 11.12 years .And the significance of the statistical differences in the degree of internal speech depending on the variables of age, sex, and to achieve the goals of research, after reviewing the literature and previous studies have been prepared in the search tool according to the theory of Vygotsky and formed the search tool from a series of questions (14 ) Q & important task of the library and the task of the book and after each task asks the child a set of questions about thinking and internal speech has been provided some of the questions at the beginning of training on activities that can be performed by human activities that can not do and used the feedback with some of the questions , while questions about the internal speech was without feedback, the researchers extracted the psychometric properties of the instrument was extraction of validity and reliability has reached ( 80.0 ) , (88.0 ) on the sequence , results showed that the modern interior is composed at the age of 7 years. , and pointed out the results of analysis of variance duo to the presence of traces of life in the evolution of internal speech any that modern interior takes a path evolutionary . results indicated no differences in the internal speech variable according to sex and that the children's knowledge of internal speech evolve progress in age, the study came out a set of recommendations and proposals

Objectives: The aim of this study was to assess potential cost-effectiveness of using a prostate cancer specific functional imaging technology capable of identifying residual localized disease versus small volume metastatic disease for asymptomatic men with low but detectable prostate specific antigen (PSA) elevation following radical prostatectomy.Methods: Markov modeling was used to estimate the incremental impact on healthcare system costs (2012 USD) and quality-adjusted life-years (QALYs) of two alternative strategies: (i) using the new diagnostic to guide therapy versus (ii) current usual care—using a combination of computed tomography, magnetic resonance imaging, and bone scan to guide therapy. Costs were based on estimates from literature and Medicare reimbursement. Prostate cancer progression, survival, utilities, and background risk of all-cause mortality were obtained from literature. Base-case diagnostic sensitivity (75 percent), specificity (90 percent), and cost (USD 2,500) were provided by our industry partner GE Healthcare.Results: The new diagnostic strategy provided an average gain of 1.83 (95 percent uncertainty interval [UI]: 1.24–2.64) QALYs with added costs of USD 15,595 (95 percent UI: USD -6,330–44,402) over 35 years. The resulting incremental cost-effectiveness ratio was USD 8,516/QALY (95 percent UI: USD -2,947–22,372). Results were most influenced by the utility discounting rate and test performance characteristics; however, the new diagnostic provided clinical benefits over a wide range of sensitivity and specificity.Conclusion: This analysis suggests a diagnostic technology capable of identifying whether men with biochemical recurrence after radical prostatectomy have localized versus metastatic disease would be a cost-effective alternative to current standard work-up. The results support additional investment in development and validation of such a diagnostic.

Because benign biopsies resulting from false-positive mammographic findings are a known harm of breast cancer screening, physicians and test manufacturers are searching for ways to reduce their frequency. The aim of this study was to estimate potential costs and consequences associated with using an adjunct diagnostic test for triaging women with suspicious mammographic findings before biopsy.A decision model was developed to compare the use of an adjunct test before biopsy to the current standard of care for suspicious mammographic findings. The decision analysis was performed from the perspective of a national health payer, with a 1-year time horizon among women representative of the US screening population aged 40 to 79 years. Three primary outcomes were assessed: (1) incremental costs, (2) number of benign biopsies avoided, and (3) number of missed opportunities for diagnosing cancer per million women screened. Input parameters were obtained from the medical literature and expert opinion. Sensitivity analyses were performed to evaluate the effects of uncertainty in parameter estimates.The base-case analysis demonstrated that the use of an adjunct diagnostic test with 95% sensitivity, 75% specificity, and a cost of $1,000 would eliminate 8,127 unnecessary breast biopsies per million women screened. However, this would cost the US health care system an additional $6,462,977 and result in 255 missed opportunities for diagnosing cancer per million women screened.The addition of an adjunct test for triaging women for breast biopsy after abnormal findings on screening mammography would likely eliminate many unnecessary biopsies but also increase overall health care costs. This exploratory analysis highlights the fact that mammography remains a relatively inexpensive and effective breast cancer screening and diagnostic modality.

Purpose Because benign biopsies resulting from false-positive mammographic findings are a known harm of breast cancer screening, physicians and test manufacturers are searching for ways to reduce their frequency. The aim of this study was to estimate potential costs and consequences associated with using an adjunct diagnostic test for triaging women with suspicious mammographic findings before biopsy. Methods A decision model was developed to compare the use of an adjunct test before biopsy to the current standard of care for suspicious mammographic findings. The decision analysis was performed from the perspective of a national health payer, with a 1-year time horizon among women representative of the US screening population aged 40 to 79 years. Three primary outcomes were assessed: (1) incremental costs, (2) number of benign biopsies avoided, and (3) number of missed opportunities for diagnosing cancer per million women screened. Input parameters were obtained from the medical literature and expert opinion. Sensitivity analyses were performed to evaluate the effects of uncertainty in parameter estimates. Results The base-case analysis demonstrated that the use of an adjunct diagnostic test with 95% sensitivity, 75% specificity, and a cost of $1,000 would eliminate 8,127 unnecessary breast biopsies per million women screened. However, this would cost the US health care system an additional $6,462,977 and result in 255 missed opportunities for diagnosing cancer per million women screened. Conclusions The addition of an adjunct test for triaging women for breast biopsy after abnormal findings on screening mammography would likely eliminate many unnecessary biopsies but also increase overall health care costs. This exploratory analysis highlights the fact that mammography remains a relatively inexpensive and effective breast cancer screening and diagnostic modality.

To evaluate the cost effectiveness of genetic screening for the apolipoprotein (APOE) e4 allele in combination with preventive donepezil treatment in comparison with the standard of care for amnestic mild cognitive impairment (AMCI) patients in Canada. We performed a cost-effectiveness analysis using a Markov model with a societal perspective and a time horizon of 30 years. For each strategy, we calculated quality-adjusted life-years (QALYs), using utilities from the literature. Costs were also based on the literature and, when appropriate, Ontario sources. One-way and probabilistic sensitivity analyses were performed. Expected value of perfect information (EVPI) analysis was conducted to explore the value of future research. The base case results in our exploratory study suggest that the combination of genetic testing and preventive donepezil treatment resulted in a gain of 0.027 QALYs and an incremental cost of $1,015 (in 2009 Canadian dollars [Can$]), compared with the standard of care. The incremental cost-effectiveness ratio (ICER) for the base case was Can$38,016 per QALY. The ICER was sensitive to the effectiveness of donepezil in slowing the rate of progression to Alzheimer’s disease (AD), utility in AMCI patients, and AD and donepezil treatment costs. EVPI analysis showed that additional information on these parameters would be of value. Using presently available clinical evidence, this exploratory study illustrates that genetic testing combined with preventive donepezil treatment for AMCI patients may be economically attractive. Since our results were based on a secondary post hoc analysis, our study alone is insufficient to warrant recommending APOE genotyping in AMCI patients. Future research on the effectiveness of preventive donepezil as a targeted therapy is recommended.

To review economic evaluations of genetic interventions published between 2004 and 2009 and assess the quality of the identified studies, we searched for economic evaluations of genetic testing and interventions published between 2004 and 2009. Studies that met inclusion criteria were reviewed and their quality then assessed using a validated instrument—the Quality of Health Economic Studies. Of 54 articles identified, 26 met study criteria and were included in the review. These studies span a number of clinical indications, genetic tests, and interventions, but the majority (92%) focuses on genetic interventions for preventive screening and increasing treatment efficacy. The mean quality score for the reviewed studies was 89.8. Comparison of the quality of different study types revealed that cost-utility studies and studies that used a combined decision tree and Markov model had the highest mean quality scores. Clear statements regarding bias, funding source, and study perspective were commonly lacking in the reviewed studies. Although the reviewed studies were of fairly high quality, we found Quality of Health Economic Studies methodology for grading the quality of economic evaluations challenging and observed no statistically significant improvement in quality of studies between the periods of 1995–2004 and 2004–2009.

229 Background: Asymptomatic men with low but detectable PSA elevation following radical prostatectomy, often receive costly, burdensome, and potentially damaging salvage radiation therapy with uncertain benefit. A new prostate cancer specific functional imaging technology capable of identifying residual localized disease vs. small volume metastatic disease, to more accurately guide therapy decisions, could be of benefit. As a guide to diagnostic development efforts, the objective of this study was to assess the potential cost-effectiveness of using a novel diagnostic in this way. Methods: A Markov model was built to reflect the life-time natural history of prostate cancer recurrence. The model was used to estimate the incremental impact on costs (US healthcare system perspective) and quality adjusted life years (QALYs) of two alternative strategies: 1) using the new diagnostic to guide therapy vs. 2) usual care - using a combination of CT, MRI and bone scan to guide therapy. Costs were based on estimates from the literature, Medicare reimbursement and expert opinion. Prostate cancer progression, survival, and utilities plus the background risk of all-cause mortality, were obtained from the literature. Base-case diagnostic sensitivity, specificity, and cost were 75%, 90%, and $2,500. Results: The new diagnostic strategy provided an average per patient gain of 1.83 (95% UI: 1.41 - 2.5) QALYs and added cost of $15,600 (95% UI: -$7,000 - 48,800) with an incremental cost-effectiveness ratio of $8,500/QALY (95% UI: -$4,100 - 22,900). Results were most influenced by utility parameters and test performance characteristics however; the new diagnostic provided clinical benefits over a wide range of specificity and sensitivity. Conclusions: This analysis suggests that a diagnostic technology capable of identifying whether men with biochemical recurrence after radical prostatectomy have localized vs. metastatic disease would be cost-effective by reducing the costs and quality-of-life burden associated with non-beneficial radiation therapy. These results support additional investment in the development and validation of such a diagnostic.

6077 Background: When added to first-line chemotherapy for metastatic colorectal cancer, bevacizumab provides a moderate survival increase, but is associated with significant adverse events and high cost. As only a minority of patients respond to antiangiogenic therapy, a diagnostic that identifies potential responders ex ante could potentially change the benefit to risk profile of bevacizumab and likely improve cost-effectiveness. Since efforts to identify a predictive test have so far been unsuccessful, a novel strategy may be to measure tumor response after bevacizumab treatment initiation using an in vivo biomarker test to guide decisions on whether patients should continue treatment. The objective is to estimate the cost-effectiveness of biomarker-directed use of bevacizumab in first-line treatment of metastatic colorectal cancer compared to standard care. Methods: The analysis takes the perspective of the US healthcare system. A decision model was built to estimate the incremental effect of adding bevacizumab to IFL, FOLFIRI, 5FU/LV and FOLOFOX/XELOX regimens. Survival data, estimated through a meta-analysis of four clinical trials, combined with utilities from the literature were used to calculate quality-adjusted life years (QALYs). Costs were based on Medicare reimbursement and expert opinion. Assumed performance characteristics of the biomarker technology (sensitivity, specificity – provided by our industry partner) were 75% and 95% 10 days after commencement of bevacizumab. Results: The biomarker-directed bevacizumab strategy dominated usual care, providing both an average per patient gain of 0.015 QALYs and a cost-savings of $21,038. The cost-effectiveness of the biomarker technology was most influenced by the cost of the test and colorectal cancer utilities. Variations in biomarker specificity and sensitivity changed the magnitude of cost-savings and benefit gain but did not change the overall result of dominance. Conclusions: Modeling predicts that a validated marker which could identify responders to bevacizumab will save money and improve quality-adjusted life years. The results support additional investment in identifying such a diagnostic.