Effective Surface Passivation of InP Nanowires by Atomic-Layer-Deposited Al2O3 with POx Interlayer.

III/V semiconductor nanostructures have significant potential in device applications, but effective surface passivation is critical due to their large surface-to-volume ratio. For InP such passivation has proven particularly difficult, with substantial depassivation generally observed following dielectric deposition on InP surfaces. We present a novel approach based on passivation with a phosphorus-rich interfacial oxide deposited using a low-temperature process, which is critical to avoid P-desorption. For this purpose we have chosen a POx layer deposited in a plasma-assisted atomic layer deposition (ALD) system at room temperature. Since POx is known to be hygroscopic and therefore unstable in atmosphere, we encapsulate this layer with a thin ALD Al2O3 capping layer to form a POx/Al2O3 stack. This passivation scheme is capable of improving the photoluminescence (PL) efficiency of our state-of-the-art wurtzite (WZ) InP nanowires by a factor of ∼20 at low excitation. If we apply the rate equation analysis advocated by some authors, we derive a PL internal quantum efficiency (IQE) of 75% for our passivated wires at high excitation. Our results indicate that it is more reliable to calculate the IQE as the ratio of the integrated PL intensity at room temperature to that at 10 K. By this means we derive an IQE of 27% for the passivated wires at high excitation (>10 kW cm-2), which constitutes an unprecedented level of performance for undoped InP nanowires. This conclusion is supported by time-resolved PL decay lifetimes, which are also shown to be significantly higher than previously reported for similar wires. The passivation scheme displays excellent long-term stability (>7 months) and is additionally shown to substantially improve the thermal stability of InP surfaces (>300 °C), significantly expanding the temperature window for device processing. Such effective surface passivation is a key enabling technology for InP nanowire devices such as nanolasers and solar cells.

Ultralow Surface Recombination Velocity in Passivated InGaAs/InP Nanopillars.

The III-V semiconductor InGaAs is a key material for photonics because it provides optical emission and absorption in the 1.55 µm telecommunication wavelength window. However, InGaAs suffers from pronounced nonradiative effects associated with its surface states, which affect the performance of nanophotonic devices for optical interconnects, namely nanolasers and nanodetectors. This work reports the strong suppression of surface recombination of undoped InGaAs/InP nanostructured semiconductor pillars using a combination of ammonium sulfide, (NH4)2S, chemical treatment and silicon oxide, SiOx, coating. An 80-fold enhancement in the photoluminescence (PL) intensity of submicrometer pillars at a wavelength of 1550 nm is observed as compared with the unpassivated nanopillars. The PL decay time of ∼0.3 µm wide square nanopillars is dramatically increased from ∼100 ps to ∼25 ns after sulfur treatment and SiOx coating. The extremely long lifetimes reported here, to our knowledge the highest reported to date for undoped InGaAs nanostructures, are associated with a record-low surface recombination velocity of ∼260 cm/s. We also conclusively show that the SiOx capping layer plays an active role in the passivation. These results are crucial for the future development of high-performance nanoscale optoelectronic devices for applications in energy-efficient data optical links, single-photon sensing, and photovoltaics.

Multivariate logistic regression for predicting total culturable virus presence at the intake of a potable-water treatment plant: novel application of the atypical coliform/total coliform ratio.

Predicting the presence of enteric viruses in surface waters is a complex modeling problem. Multiple water quality parameters that indicate the presence of human fecal material, the load of fecal material, and the amount of time fecal material has been in the environment are needed. This paper presents the results of a multiyear study of raw-water quality at the inlet of a potable-water plant that related 17 physical, chemical, and biological indices to the presence of enteric viruses as indicated by cytopathic changes in cell cultures. It was found that several simple, multivariate logistic regression models that could reliably identify observations of the presence or absence of total culturable virus could be fitted. The best models developed combined a fecal age indicator (the atypical coliform [AC]/total coliform [TC] ratio), the detectable presence of a human-associated sterol (epicoprostanol) to indicate the fecal source, and one of several fecal load indicators (the levels of Giardia species cysts, coliform bacteria, and coprostanol). The best fit to the data was found when the AC/TC ratio, the presence of epicoprostanol, and the density of fecal coliform bacteria were input into a simple, multivariate logistic regression equation, resulting in 84.5% and 78.6% accuracies for the identification of the presence and absence of total culturable virus, respectively. The AC/TC ratio was the most influential input variable in all of the models generated, but producing the best prediction required additional input related to the fecal source and the fecal load. The potential for replacing microbial indicators of fecal load with levels of coprostanol was proposed and evaluated by multivariate logistic regression modeling for the presence and absence of virus.

Immune modulator studies in primates: the utility of flow cytometry and immunohistochemistry in the identification and characterization of immunotoxicity.

Exposure to natural environmental products, biopharmaceuticals, or investigational adjuvants has the potential to negatively impact the immune system, resulting in either up- or downregulation of immune function (immunomodulation). Many current protocols for primate toxicologic testing call for the evaluation of changes in immune cell number (peripheral blood or tissue), alterations in the weights of immune system organs (lymph nodes, spleen, thymus), and/or increases in the overall incidence of infections or neoplasms; these data are relied upon to suggest altered immune function. However, these are informative only when clear differences in frequency and/or severity of effects can be distinguished across control and dosed groups. In the absence of such distinct morphologic or clinical pathologic changes, the identification of potential immunomodulatory effects can present a much greater challenge. Additional evaluations may be needed to detect altered immune system integrity; these are based on in vivo assessments in primates of cellular or humoral responsiveness. Immunomodulatory effects can be characterized by in vitro or in vivo immune function tests: these tests require prestudy planning to integrate assessments into ongoing toxicology programs. These methods also involve specialized training and equipment, particularly if the intent is to evaluate parameters in a GLP laboratory setting. In primate toxicology, the added costs required to perform a complete functional analysis of the immune system can be substantial, but may be warranted depending on the clinical development plans. Two analytical methods that are easily incorporated into the standard toxicology profile in primates are flow cytometry and immunohistochemistry. Flow cytometry (FC) is used to assess changes in the relative distribution of immune cell marker expression, and where marker expression is known to fluctuate with the state of cell activation, can also provide information on functional attributes of immune cells. Immunohistochemistry (IHC) provides a means to evaluate similar characteristics of immune cells within tissue sections. Used together, FC and IHC can aid in the identification of changes in immune system that may not be apparent by traditional testing procedures (such as H&E staining), thus aiding in the characterization of immune system alterations. This presentation focused on the utility of flow cytometry and immunohistochemistry in a standard primate toxicology evaluation, with representative examples showing the benefits of these technologies in the diagnosis of potential immunomodulatory effects.

Overview status of preclinical safety assessment for immunomodulatory biopharmaceuticals.

Scientists from academia, industry, FDA, European and Japanese regulatory groups met to discuss key considerations that are central to the safe and expeditious development of novel biologic agents that are thought to act by modulation of the host immune system. In the presentations and case studies, particular attention was given to the current clinical experience with immunosuppressant agents. Many new biologic agents (such as humanized monoclonal antibodies) have been developed to interact in a highly specific manner with their target. However, their pharmacologic properties may be more complex than originally appreciated, impacting on clinical trial designs. The goal of preclinical safety assessment should be to provide some assurance that patients will be protected from any unacceptable risks by defining "safe" and "active" doses. For immunomodulatory molecules, particular attention is paid to defining potential for increased risks of lymphoproliferative disorders, opportunistic infections, and immune impairment. To address these issues, a wide variety of preclinical studies, mainly in non-human primates, have been performed for the purpose of assessing the potential risk of drug-induced, human immunotoxicity. Case studies presented at this symposium showed the feasibility of assessing humoral and cell-mediated aspects of the immune system, using antigen and neoantigen challenges, immunohistochemical, and flow cytometric (FACS) methods. In some cases, homologous forms of the biologic agent and "humanized" transgenic models have been used to assess potential clinical risks. These data have been useful in providing some assurance that severe adverse effects would not be induced in patients. Despite these limitations, it is important that industry sponsors provide information to regulatory authorities, the clinical investigator, and patients that provides the best feasible basis for risk assessment, safe clinical trial design, informed consent, and eventually, appropriate labeling. It is recognized that existing preclinical models often have significant limitations. Consequently, the sponsor's and regulatory authority's experienced judgement has determined whether or not the purported benefits of the novel therapeutic agent are balanced by the potential short- and long-term risks. In this field of development, preclinical models often need to reflect recent technology innovations; therefore, these models are not always "validated" in a conventional sense. Experience to date suggests that improved methods and approaches are needed as these agents are developed for use in lower or moderate risk patient populations. Consequently, there is an increased need for an industry/regulatory partnership in order to achieve progress in these risk assessment areas.

Regulatory decision strategy for entry of a novel biological therapeutic with a clinically unmonitorable toxicity into clinical trials: pre-IND meetings and a case example.

The following material was derived from a synthesis of case histories taken from investigational new drug (IND) applications and drug sponsors' experiences, utilizing fictionalized data to avoid any resemblance to any proprietary information; any such resemblance is accidental. These examples are used as an instructional scenario to illustrate appropriate handling of a difficult toxicology issue. In this scenario, a drug caused a toxicity in animals that was detected only by histopathologic analysis; if it were to develop in patients, no conventional clinical methods could be identified to monitor for it. It is not unusual for a firm to cancel clinical development plans for a lead drug candidate that causes such a toxicity, especially if such a drug is intended for use as a chronic therapeutic in a population of patients with a chronic disease. This case synthesis was inspired by a Food and Drug Administration (FDA) agreement to allow such a product to proceed into clinical trials after substantive pre-IND discussions and agreement on well-considered toxicology program designs. The scientists most closely involved in the strategy development included the sponsor's toxicologist, veterinary toxicologic pathologist, and pharmacokineticist, as well as the FDA's reviewing pharmacologist. The basis of this decision was thorough toxicity characterization (1-month studies in 2 species); correlating toxicities with a particular cumulative area under the curve (AUC) in both species; identification of the most sensitive species (the species that showed the lower AUC correlating with toxicity); allometric assessment of clearance of the drug in 3 nonhuman species; construction of a model of human kinetics (based on extrapolation from animal kinetics); and finally, estimation of clinical safety factors (ratios of the human estimated cumulative AUC at the proposed clinical doses, over the animal cumulative AUC that correlated with the no adverse effect levels). Industry and FDA scientists negotiated a joint assessment of risk and benefit in patients, resulting in the FDA permitting such a compound to enter into clinical trials for a serious autoimmune disease. Such constructive, early communication starts with the pre-IND meeting, and the conduct and planning for this meeting can be very important in establishing smooth scientific and regulatory groundwork for the future of a drug under IND investigation.

Neurobehavioral and pregnancy effects of prenatal zidovudine exposure in Sprague-Dawley rats: preliminary findings.

In 1994, the Public Health Service made prenatal zidovudine (ZDV, AZT) the standard of care to prevent mother-to-child transmission of HIV. The current study was undertaken to determine if prenatal exposure to ZDV has an impact on pregnancy outcomes, birth anomalies, or offspring behavior in an animal model using Sprague-Dawley (SD) rats. Thirty-one virgin female SD rats were mated and randomly assigned to receive either ZDV at 150 mg/kg/day or vehicle via gastric intubation for 22 days starting on gestation day (G) 1. On G 22, teratologic examination of 12 litters showed no gross structural malformations. There were no significant differences between the groups for maternal food and water consumption or maternal weight gain across pregnancy. However, ZDV treatment significantly reduced litter size and increased birth weights for both male and female pups. One developmental milestone, pinna detachment, occurred significantly earlier in the ZDV-exposed male pups compared to the vehicle-intubated male controls. On day 21-22 of life, pups in each litter were injected with one of four doses of amphetamine and were observed for behavioral activity in a photobeam-based activity monitor for 1 h. Overall amphetamine increased activity and decreased thigmotaxis or wall-hugging behavior. ZDV treatment increased the locomotor response to amphetamine in females only and dampened the action of amphetamine to decrease thigmotaxis in both genders. Further studies are warranted to determine the threshold dose at which these changes occur, the duration of the effects, as well as the neurochemical system(s) responsible for the altered amphetamine responses.

Cyclic AMP-mediated desensitization of D1 dopamine receptor-coupled adenylyl cyclase in NS20Y neuroblastoma cells.

Cyclic AMP-mediated desensitization of D1 dopamine receptor-coupled adenylyl cyclase was investigated using NS20Y neuroblastoma cells. Pretreatment of the cells for 24 h with 8-(4-chlorophenylthio)-adenosine-3':5'-cyclic monophosphate (CPT-cAMP), a membrane-permeable analog of cAMP, resulted in an approximately 90% reduction of the maximum dopamine-stimulated adenylyl cyclase activity. In addition, there was a twofold reduction in the potency of dopamine for stimulating cAMP production that was not dependent on the concentration of Mg2+ in the assay. These effects of CPT-cAMP pretreatment were time dependent, showing a t1/2 of about 3 h and a maximum reduction after about 8 h. Receptor-binding activity, as measured using the D1-selective antagonist [3H]SCH-23390, also declined following CPT-cAMP pretreatment with a t1/2 of about 5 h and a maximum reduction of about 70% after 20 h. Saturation analysis indicated that the loss in radioligand binding was due to a reduction in maximum binding capacity (Bmax) with no alteration in receptor affinity (KD). The EC50 of CPT-cAMP for producing enzyme desensitization and D1 receptor downregulation was determined to be about 30 microM with a maximal response occurring at 1 mM. These regulatory effects of CPT-cAMP were pharmacologically specific as other analogs of cAMP, such as dibutryl-cAMP, 8-bromo-cAMP, and Sp-cAMPS, were capable of inducing D1 receptor desensitization and downregulation, whereas treatment of the cells with the cAMP antagonist Rp-cAMPS had no effect. Conversely, Rp-cAMPS was capable of blocking the regulatory effects of CPT-cAMP but was apparently without effect in blocking dopamine-induced desensitization.(ABSTRACT TRUNCATED AT 250 WORDS)

Regulatory considerations for oligonucleotide drugs: updated recommendations for pharmacology and toxicology studies.

This article describes pharmacology and toxicity studies for oligonucleotide drugs that are recommended for inclusion in the initial Investigational New Drug Application (IND), a first request to use an investigational drug in clinical trials. Recent observations of non-sequence-dependent cardiovascular toxicity and deaths in monkeys following intravenous infusions of phosphorothioates have raised a potential safety concern for oligonucleotide drugs. This concern should be considered by drug sponsors in designing pre-IND nonclinical development programs and Phase I clinical protocols. Pre-IND conduct of pharmacodynamic cardiovascular screening is highly recommended for defining safe clinical dosing regimens for phosphorothioate (and, possibly, other charged-backbone) oligomers. Additionally, drug sponsors are encouraged to (1) conduct research into-the mechanisms responsible for this dose-limiting toxicity, (2) institute liberal publication policies for research conducted under industrial sponsorship, and (3) communicate with reviewing divisions at FDA for updated guidance in this field when planning pre-IND safety studies. Recommendations for nonclinical studies during development of oligonucleotides will be modified as new information regarding the biological properties of oligonucleotides becomes available.

High-frequency jet ventilation in children with the adult respiratory distress syndrome complicated by pulmonary barotrauma.

High-frequency jet ventilation (HFJV) was used in 29 children with severe ARDS complicated by pulmonary barotrauma (PBT). Treatment with HFJV was begun when PBT was progressing over a 24-h period while receiving conventional ventilation (CV). The mean (+/- SD) age was 0.95 +/- 1.21 years (range, 0.03-4 years). The most common diagnosis was viral pneumonia (n = 17); other diagnoses included aspiration pneumonitis (n = 4), bacterial pneumonia (n = 3), multiple trauma (n = 2), and near-drowning (n = 3). The Bunnell Life-Pulse ventilator was used at a rate of 240/min or 300/min, with inspiratory time of 0.02 sec. Twenty children survived (69%). Survivors and nonsurvivors had equal disease severity prior to HFJV as assessed by ventilator settings, alveolar-to-arterial oxygen tension gradient, oxygenation index, and blood gas values. Survivors had spent significantly less time on conventional ventilation prior to HFJV than nonsurvivors, with a mean (+/- SD) of 3.7 +/- 2.1 days vs 9.6 +/- 4.5 days, respectively (P < 0.05). Survivors underwent an average of 4.4 +/- 3.9 days of HFJV, which supported adequate gas exchange with lower airway pressures, and produced resolution or significant improvement in airleak on chest radiograph. In conclusion, we speculate that the application of HFJV early in the course of severe hypoxemic respiratory failure complicated by airleak, allows the reduction of airway pressures, thereby minimizing pulmonary barotrauma and allowing the lung to recover from the underlying insult. Further controlled evaluation of HFJV in this high risk group of patients is warranted.

Regulatory considerations for evaluating the pharmacology and toxicology of antisense drugs.

This article focuses on pharmacology and toxicology data that should be included in an Investigational New Drug Application (IND), a request to use an investigational drug in clinical trials. In general, pharmacology and toxicology testing programs for antisense compounds are held to the same regulatory standards applied to other new therapeutic classes. Biological properties of oligonucleotide therapeutics are mentioned where they may pertain to clinical safety issues. Nonclinical data submitted to the IND should characterize the pharmacology, disposition, and toxicology of a new drug; these data form the basis for clinical risk assessment. Concomitant evaluation of pharmacokinetics allows for better interpretation of in vivo studies and increased accuracy of dose extrapolation to humans. Recommendations for nonclinical drug development will be modified as new information regarding the biological properties of oligonucleotides becomes available.

Elevated lead levels in a patient with sickle cell disease and inappropriate secretion of antidiuretic hormone.

A five-year-old girl with known sickle cell disease presented with severe hyponatremia and findings compatible with syndrome of inappropriate secretion of antidiuretic hormone (SIADH). She was found to have lead levels in the Class III category. By exclusion, we postulated that the SIADH was in some way related to the high lead levels, since this was the only abnormality the patient exhibited. The toxic lead levels and the elevated vasopressin levels rapidly responded to dimercaprol and calcium EDTA chelation therapy.

N-(p-isothiocyanatophenethyl)spiperone, a selective and irreversible antagonist of D2 dopamine receptors in brain.

N-ethoxycarbonyl-2-ethoxy-1,2-dihydroquinoline (EEDQ), an irreversible and nonselective protein-modifying reagent, has been used extensively in studies involving inactivation of receptors. Here, we present N-(p-isothiocyanatophenethyl)spiperone (NIPS), a novel and highly selective irreversible inactivator of D2 but not D1 receptors. In in vitro studies, NIPS exhibited an apparent Ki of 10 nM for [3H]methylspiperone binding to D2 receptors in rat striatum. Preincubation of the striatal membranes with NIPS followed by extensive washing resulted in up to an 80% reduction of the D2 receptor maximum binding (Bmax). Coincubation with the D2 receptor antagonist domperidone could protect against this reduction. NIPS was additionally shown to irreversibly inactivate D2 receptor binding activity in cultured cells expressing the D2 receptor protein. In in vivo administration studies, using [3H]SCH 23390 and [3H]spiperone to assay D1 and D2 receptors in vitro, 24 hr after injection (s.c.) with 5 to 40 mg/kg of NIPS D2 receptor, Bmax was decreased by 58 to 76%, without a change in D2 receptor affinity. In contrast, there was no effect on D1 receptor Bmax or affinity. There was also a small (24%) reduction in frontal cortex 5-hydroxytryptamine2 receptors by 20 mg/kg of NIPS. However, there was no effect on alpha-1 or alpha-2 adrenergic receptors in the frontal cortex, or on muscarinic cholinergic or 5-hydroxytryptamine1A receptors in the hippocampus. After single doses of either 20 mg/kg of NIPS or 10 mg/kg of EEDQ, the D2 receptor recovery rate was much slower after NIPS (half-time of receptor recovery = 170 hr) than after EEDQ (half-time of receptor recovery = 76.7 hr).(ABSTRACT TRUNCATED AT 250 WORDS)

Agonist-induced desensitization of D2 dopamine receptors in human Y-79 retinoblastoma cells.

Y-79 human retinoblastoma cells can be induced to express significant quantities of functional D2 dopamine receptors after attachment and differentiation with sodium butyrate. In membranes prepared from differentiated Y-79 cells, the D2 dopaminergic antagonist [3H] methylspiperone exhibits a KD of 77 pm and a Bmax of 60 fmol/mg of protein, whereas the antagonist [125I]iodosulpride reveals a KD of 0.77 nM and a Bmax of 40 fmol/mg of protein. Dopamine also induces a pharmacologically specific, pertussis toxin-sensitive, dose-dependent inhibition of forskolin-stimulated adenylyl cyclase activity, with an EC50 of 2 microM and a maximal response at 100 microM (approximately 50% enzyme inhibition). Pretreatment of the cells with dopamine results in a diminution in the subsequent ability of dopamine to inhibit adenylyl cyclase activity. This effect is time dependent, reaching maximal desensitization after approximately 24 hr. The dopamine dose-response curve for inducing desensitization exhibits an EC50 of approximately 2-3 microM and a maximal response at approximately 0.1-1 mM, similar to that for inhibiting adenylyl cyclase activity. After maximal desensitization, the EC50 for dopamine-induced inhibition of adenylyl cyclase activity is increased greater than 20 fold (lower affinity) and the maximum inhibition is decreased to approximately 15%, representing an approximately 70% desensitization. The agonist-induced desensitization is pharmacologically specific, inasmuch as preincubation of the cells with the dopaminergic agonists epinine and (+-)-2-amino-6,7-dihydroxy-1,2,3,4-tetrahydronaphthalene or the D2-selective agonist N-0434 also results in desensitization of dopamine-induced inhibition of enzyme activity, whereas preincubation with the D1-selective agonist SKF-38393 or with the nondopaminergic agonists isoproterenol and serotonin results in little or no desensitization. Preincubation of the cells with dopamine also promotes a time-dependent increase (approximately 3-fold) in the KD for [3H]methylspiperone, with no change in its Bmax. In contrast, after dopamine preincubation, the KD for [125I]iodosulpride is unchanged, whereas its Bmax is reduced by approximately 50% upon maximum desensitization. In addition, agonist pretreatment promotes a functional uncoupling of the D2 receptor, as suggested by a loss of high affinity agonist binding observed in radioligand competition binding assays after desensitization. Upon removal of agonist, the cellular D2 receptor binding activity and functional response recover to control levels within a 24-hr period. These results suggest that prolonged exposure of cells to dopaminergic agonists initiates a desensitization process involving a functional uncoupling of the D2 dopamine receptor as well as a loss of its ligand binding activity.

Complete recovery from severe metabolic acidosis associated with isoniazid poisoning in a young boy.

Isoniazid (INH) poisoning is a known cause of metabolic acidosis and seizures. The following case report describes a 14-year-old boy with an INH overdose who suffered profound metabolic acidosis (pH of 6.69) and who completely recovered with no obvious sequelae.

Prognostic variables in osteosarcoma: a multi-institutional study.

This is a report of a multi-institutional study of all patients with osteosarcoma who were seen at 13 comprehensive cancer centers from July 1, 1977, to December 31, 1982. Follow-up extended to 9 years; a minimum of 3 years was obtained for greater than 90% of the patients. All patients with osteosarcoma were considered, but only those with tissue confirmation who had had at least part of their first course of treatment at one of the 13 institutions were included. There were 543 patients. In a search for prognostic indicators, 38 patient characteristics, three treatment categories, and an institutional variable were studied. A combination of nine of these constituted the best indicator of survival. They were morphology (two parts), site of primary cancer (two parts), spread of tumor, grade and size of tumor, duration of symptoms, weight loss of greater than 4.5 kg (10 lb), swelling at primary site, and lytic appearance. Unexpectedly, treatment was not one of the indicators of survival. A prognostic score was developed in which the coefficients were obtained from the Cox regression (step-down) method. Each patient had a score (S) and an observed survival time that together provided the expected risk of death for that patient. Although this was not a randomized study, treatments were compared before and after adjusting for characteristics identified as prognostic. Three treatments differed little: surgery alone, surgery plus chemotherapy and/or radiotherapy, and chemotherapy and/or radiotherapy followed in 1-4 months by surgery. Patients with amputations and those with resections had similar death rates, but the observed progression rates differed widely. However, when the rates were adjusted for prognostic characteristics, the difference disappeared. Complete surgery (if osteosarcoma existed within surgical margins) was no better than incomplete surgery (if osteosarcoma existed beyond surgical margins) with respect to death but, as would be expected, complete surgery was much better with respect to disease progression.

Familial cancer in an oncology clinic.

Knowledge of cancer genetics provides the physician with a powerful tool for the recognition of patients who might profit from highly targeted cancer surveillance/management programs. Family history was evaluated by registered nurses on 565 consecutively ascertained patients with verified cancer from Creighton's Oncology Clinic. This initial assessment yielded 199 (35.5%) families with two more family members with cancer (all sites) within an informative nuclear component, which constituted parents, grandparents, aunts/uncles, siblings, and children. One or more of the operational criteria for cancer familiality, namely vertical transmission of cancer, bilaterality, and/or multiple primaries, early age of onset, and three or more site specific cancers, were found on physician review in 171 (30.5%) of the families. This group was referred for comprehensive cancer genetic evaluation consisting of pedigree extension and tumor verification through all second degree, and when possible, third degree relatives. It was determined that approximately 4% of the total clinic population demonstrated findings compatible with hereditary cancer syndromes. Its universal extension in clinical practice is advocated because of the potential yield from meticulous surveillance for cancer of highly targeted organs in such high-risk kindreds, as well as the economy and general case of obtaining detailed family history by registered nurses. The physician is able, therefore, to devote his primary effort toward pedigree analysis and syndrome identification.