text:
An instrument for performing delicate surgery on man is provided with a continuous wave laser source specially associated with a binocular surgical microscope. The laser source emits electromagnetic radiation at wavelengths, preferably in the visible light range but also in the near visible infrared and ultraviolet ranges, which are absorbed selectively by different types of human tissue or tissue substructures. The source is mounted on a portable base remote from the operating area, and the radiation from the laser is communicated through a flexible fiber optic conductor to the binocular surgical operating microscope which is mounted on an articulating arm extending from the base so that the microscope may be freely positioned adjacent to the patient at the operating area. The laser beam is directed onto the tissue of the patient in a path coaxial with the viewing axis of the microscope to a point in the microscope's field of view. Controls on the microscope give the surgeon complete control of the laser beam. These include a focusing telescope for control of the laser spot size and angle of convergence of the beam, a joy stick control for moving the fiber optic tip to cause a corresponding movement in the focused laser beam on the tissue within the field of view of the microscope to allow the surgeon to precisely prescribe an incision or effect localized irradiation on that area of the patient. Transillumination of the tissues in the area of interest on the patient is possible by the direct laser beam emitted at a low-nonhazardous power level or by a second laser system which may be operated independently of the main high power surgical laser and is delivered by a hand-held sterile probe.
Claims available in
Description (OCR text may contain errors)
United States Patent [1 1 Goldman et a1.
Nov. 6, 1973 Appl. N6; 239,976
U.S. Cl 128/2 R, l28/303.l, 128/395 A6lb 5/00 Field of Search 128/303.l, 395, 2 R;
[56] References Cited UNITEDSTATES PATENTS 3,703,176 11/1972 Vassiliadis et a1. 128/395 3,315,680 4/1967 Silbertrust et a1. 128/395 3,096,767 7/1963 Gresser et al 128/395 3,348,547 10/1967 Kavanagh 128/395 Primary ExaminerLawrence W. Trapp Altorney.lames S. Hight et al.
[ ABSTRACT An instrument for performing delicate surgery on man is provided with a continuous wave laser source specially associated with a binocular surgical microscope.
The laser source emits electromagnetic radiation at wavelengths, preferably in the visible light range but also in the near visible infrared and ultraviolet ranges, which are absorbed selectively by different types of human tissue or tissue substructures. The source is mounted on a portable base remote from the operating area, and the radiation from the laser is communicated through a flexible fiber optic conductor to the binocular surgical operating microscope which is mounted on an articulating arm extending from the base so that the microscope may be freely positioned adjacent to the patient at the operating area. The laser beam is directed onto the tissue of the patient in a path coaxial with the viewing axis of the microscope to a point in the microscopes field of view. Controls on the microscope give the surgeon complete control of the laser beam. These include a focusing telescope for control of the laser spot size and angle of convergence of the beam, a joy stick control for moving the fiber optic tip to cause a corresponding movement in the focused laser beam on the tissue within the field of view of the microscope to allow the surgeon to precisely prescribe an incision or effect localized irradiation on that area of the patient. Transillumination of the tissues in the area of interest on the patient is possible by the direct laser beam emitted at a low-nonhazardous power level or by a second laser system which may be operated independently of the main high power surgical laser and is delivered by a hand-held sterile probe.
25 Claims, 2 Drawing Figures INSTRUMENT FOR PERFORMING LASER MICRO-SURGERY AND DIAGNOSTIC TRANSILLUMINATION OF LHVENG HUMAN TlSSUlE The present invention relates to the use of lasers in performing delicate, bloodless micro-surgery on living human tissue.
The development of the laser has prompted extensive research over the last decade into their possible uses in medicine. The ability of the laser to emit highly controllable electromagnetic radiation of high power has led many to hope that it may provide for a surgeon a powerful tool in operating on human living tissue. The unique characteristics of laser radiation which have inspired these hopes reside in the great precision which can be obtained in focusing the radiation beam for performing delicate micro-surgery and in its ability to cauterize small bleeding vessels, thus making possible bloodless surgery. Until the present time, however, no device or method has been proposed to make effective use of laser in the near-ultraviolet, visible, and nearinfrared spectral regions so that a surgeon may realize its advantages in performing micro-surgery on man.
It is the principal objective of the present invention to provide a practical method and apparatus through which the advantages of lasers may be efficiently and effectively employed by a surgeon to extend his means in performing micro-surgery on man beyond those which are presently available.
The present invention provides a novel combination of features to satisfy certain considerations which are highly important to the surgeon.
One of these considerations is that the devices employed present compact operating units which will occupy a minimum amount of space in the operating area, andthat such a device be capable of fast and efficient use and be capable of simple, rapid and precise control by the surgeon. Further, the device must be sufficiently portable to serve several operating rooms and be capable of being quickly brought to a patient and to the operating area so that it may provide general utility when a surgeon decides that its particular advantages as a cutting tool and coagulating are desired. Furthermore, for micro-surgery, the device must be provided with adequate viewing magnification preferably of the type giving depth perception such as standard binocular operating microscopes. Also, the safety of both the surgeon and the patient must be insured, particularly in protecting the eyes of the surgeon from the high intensity laser light. Finally, the device should allow for control of the effects of the surgical procedure on the patient to the extent that only that tissue or tissue substructure which must necessarily be irradiated in the course of the operation is involved.
Another important factor considered by the present invention is the absorption characteristic of the tissue or tissue substructure upon which the operation is to be performed. It is necessary, in order for a sufficient and controllable reaction to take place' in a tissue, that the tissue effectively absorb a critical amount of the laser radiation. Thus, the absorption properties of the tissue or tissue substructure determine those radiation wavelengths and intensities which are desirable if microsurgery is to be possible. Some radiation of present laser devices, for example, in the far infrared spectrum (10,000 nanometers), is readily and uniformly absorbable by almost all living human tissue and tissue substructures. But as an additional consideration, it is highly preferable that the particular part of the tissue or tissue substructure desired to be effected in the surgical procedure, and only that part, absorb the radiation.
To achieve this result, the present invention incorporates a continuous wave or high pulse rate frequency (prf) laser source which emits electromagnetic radiation in the visible or near visible spectral ranges. It has been found that radiation having a wavelength in this range is more readily absorbed by some types of tissue and tissue substructures than others. By selecting the proper radiation wavelength for the particular operation to be performed, the surgeon may very precisely restrict the primary effects of the irradiation to only the tissue or tissue substructures of interest, thus, minimizing the extent of damage to surrounding and underlying tissue. Also, it is possible to some degree to cause effects in some tissue substructures (blood vessels, pigmented tumors, etc.) which are part of a given tissue layer if the absorption of these substructures is considerably above that of the layer through which surgery is to be performed. In the visible light spectral range, the selective absorption effect can sometimes be enhanced by the technique of staining the tissues with various vital dyes. This involves the injection, ingestion, or surface painting of a substance into or on a patient which substance will collect in certain types of tissue and render them more capable of absorbing certain wavelengths of radiation. This is quite often possible where cancerous tissue is involved.
It has been shown that selective absorption processes occur in human tissue with radiation in an approximate wavelength range from 200 or 300 nanometers to something in excess of 2,000 nanometers, or from the near ultraviolet spectral region to the near infrared spectral region. A detailed discussion of the selective absorption properties of living tissue are discussed at length in the book entitled Lasers In Medicine by Leon Goldman, M. D., and R. James Rockwell, Jr., Gordon and Breach Science Publishers, Inc., N.Y., 1971, and particularly, in Chapter VII therein. A choice of selectively absorbable wavelengths of energy makes it possible for the surgeon to cause effects only on the precise tissue or tissue substructure of interest, and thus to avoid doing unwanted damage to surrounding tissue which is less absorbant to that particular frequency.
To further achieve the consideration set forth above, the present invention provides for the completely flexible communication of a high power laser beam from a remote but portable source to a compact surgical operating microscope mounted so as to be freely positionable to the operating area. Means are provided for causing the beam to be projected toward the patient from the microscope in a path coaxial with the viewing optics of the microscope. This allows the laser beam to be automatically directed on the tissue upon which the operation is to be performed and to remain in the viewing field of the microscope as the surgeon positions the microscope optics to view the surgical area. In this way the surgeon need perform only the initial operation of positioning the microscope which will be an operation with which the surgeon will be generally familiar. Once the microscope is focused and in place, the surgeon is able to precisely control the size, focus and location of the laser spot on the tissue by controls conveniently positioned on the microscope. For this purpose, the device of the present invention is provided with a small, compact focusing telescope mounted on the microscope and through which the laser beam is directed. This telescope is provided with a focusing control readily accessible to the surgeon so that he may control the size and convergence or divergence of the spot on the patient by focusing the laser beam.
The initial positioning of the laser beam may be obtained by operating the laser source at a low power level so as to direct this beam on the tissue for purposes of safely viewing. This low irradiance power level will be bright enough for the surgeon to see but not suffi ciently intense to cause a reaction of the tissue. Alternatively, and according to one aspect of the present invention, the aiming of the spot may be accomplished through use of one or more of the low power level emissions of a laser at frequencies which are not the principal emissions of the laser emissions where one such low level emission of sufficient intensity to be rendered visible exists. To do this, a filter may be employed to block the main band of energy from the laser. A separate low power laser of a different frequency in the visible spectrum may also be used. The initial aiming of the spot visually is made possible by employing a laser frequency which is in the visible spectral range.
Once the spot has been initially focused and positioned at the proper point within the field of view of the microscope, the surgeon can energize the high intensity laser and move the spot to prescribe an incision on the patient. The spot is so moved by a joy stick control mounted on the microscope which moves the tip of the fiber optic in relation to the objective lens of the telescope.
Also, provided are an external exposure control of the average laser power and a separate exposure control of the exposure time.
The arrangement of the device of the present invention effectively provides the surgeon with complete safety from the laserradiation and particularly from the danger to his eyes while viewing the operating area. This is accomplished by a special filter in the viewing microscope which reduces the transmitted radiation at the principal frequency or frequencies of the surgical laser to non-hazardous levels.
Furthermore, the compact device of the present invention provides a minimum number of controls which must be handled by the surgeon during the operation, and thus provides a device which can be easily sterilized to maintain the required operating room environment. The bulk of the electronic portion of the laser device is maintained at sufficient distance from the operating area to prevent contamination of the operating area, and is set upon a sufficiently portable base so that the device can be moved from operating room to operating room providing enhanced utility as an operating tool for a surgeon.
Additionally, it is contemplated that visible laser radiation may be used as a diagnostic aid to the surgeon. This is done by transillumination of the tissue by passing a laser beam of the proper visible wavelength therethrough. This will allow the surgeon to locate and delineate subsurface growths or other types of tissue abnormalities. The selective absorption features discussed above in connection with the surgical use of the laser may greatly enhance the effectiveness of this feature. This procedure may be effected by use of the low power emission from the surgical laser or, ultimately, from a second laser of independent control and independent frequency.
None of the prior art devices which have been thus far proposed incorporating lasers for use in medicine have been effective to provide the features set forth above. A discussion of these prior art devices may be found in the book, Lasers In Medicine cited above and in the publications cited in the extensive bibliographies contained therein.
The prior art uses of lasers in connection with clinical medicine generally fall into three classes: ophthalmology, dermatology, and experimental surgery. These areas and the equipment used therein are discussed briefly in an article entitled Designs and Functions Of Laser Systems For Biomedical Applications," by R. James Rockwell, Jr., Annals Of The New York Academy Of Sciences, Volume 168, Article 3, Pages 459-471, Feb. 10, 1970.
The ophthalmological uses involve perhaps the most extensive, practical medical application of lasers to date. In this field, lasers are used for operations on the retina of the eye. The most frequent uses are the attaching detached retinas through laser photocoagulation to form lesions of scar tissue, and the sealing of blood vessels and destroying proliferative vascular growths in retinal diseases such as diabetic retinopathy. In these applications, a laser beam is focused on the retina and, by short exposures of radiation, produce a pinpoint thermal coagulation lesion on the retina or retinal substructure. Typical devices for use in such operations are disclosed in U. S. Pat. of Gresser No. 3,096,767, Silbertrust et al. No. 3,315,680, and Kavanagh No. 3,348,547, and in the article by F. A. IEsperance, Jr., E. F. Labuda, and A. M. Johnson, Photocoagulation Delivery Systems For Continuous-wave Lasers, British Journal of Ophthamology, Vol. 53, No. 5, pages 310-322, May, 1969.
Most of these devices employ a laser, either a pulsed ruby laser or an argon-ion laser, in combination with either a monocular indirect afocal viewing telescope or slit lamp binocular microscope which allows the eye surgeon to view the operation which he is performing. These devices would not be effective in performing micro-surgical techniques under standard operating room procedures and are generally incapable of performing knife-like incisions in micro-surgery. Generally, these devices operate to cause a very minimal thermal reaction in the retinal tissues at a single spot of 50 to 300 micron size. Accordingly, the devices which have been developed for this use are relatively inflexible and too cumbersome for use in an operating room. Most of these devices are large and stationary and require that the patient be positioned relative to the laser equipment. Some of these devices, while having some portability, have a laser generator inflexibly associated with the viewing optics, thus requiring it to be moved in bulk to the patient. These cannot be easily positioned in a surgical area and are provided with no means by which a scan of the beam across the tissue can be achieved to make knife-like incisions. Other devices, which provide portable optical units remote from the laser generator, doe not provide means for positioning the viewing opticsand then moving the beam within the field of the optics to prescribe a delicate incision. Thus, these devices would fail to satisfy many of those considerations discussed above with relation to the requirements of a practical laser in micro-surgical application on man. Specifically, these devices could not be positioned for quick efficient use by a surgeon in a general operating room. They do not present a device'which can be employed quickly and efficiently so that a surgeon may view a surgical area and fixed into position relative to the area and then allow a laser beam to be precisely and accurately manipulated within the area while viewing so as to perform knife-like incisions. Furthermore, the absence of the laser frequencies which are selectively absorbed in tissues or tissue substructures would further fail to satisfy another important consideration for practical surgical use.
in the field of dermatology, laser devices have been used to remove foreign pigments from the skin such as tattoos and to treat certain vascular disorders (angiomas, etc.) and remove various pigmented skin lesions and tumors such as melanoma. These laser devices have employed visible light for this purpose. The requirement for flexible delivery of the laser energy has generally involved movement of the entire laser source with respect to the area of skin to be treated. Normally, dermatologic treatments have employed pulsed lasers, although continuous wave lasers have been used to some limited extent. For most dermatologic applications, the laser beam is usually directed over a relatively large area of skin of from two to three square centimeters. These applications usually do not require surgical use wherein fine knife-like incisions are made in living tissue.
With respect to the experimental gross surgical applications, high-powered (50-300 watt) continuous wave lasers have been used for massive surgical cutting procedures. Typically, these lasers have been focused onto tissues with spot sizes of approximately one millimeter diameter and caused to move relative thereto at a uniform speed across the surface thereof to produce a continuous cut. For this purpose, infrared frequency lasers, such as the CO laser, have been used. These lasers emit in the far infrared spectral region at a 10,600 nanometer wavelength. Such radiation is not selectively absorbed by human tissues or tissue substructures, but is strongly and uniformly absorbed by all components of living tissue so that selective cutting of the tissue is not possible. A further disadvantage of such radiation has been that it requires special infrared lenses, normal optical glass being opaque to radiation of this wavelength. Furthermore, since the focal spot is invisible, only the resulting tissue reaction can be seen by the surgeon making it more difficult to precisely direct the beam. Attempts have not been made prior to the present invention to incorporate this type of surgical device into an optical viewing system such as the binocular microscope employed by the present invention and thus, no prior proposal has been made to provide suitable means to manipulate the operating laser beam with respect to the field of vision of such optical system and to overcome the delicate control problems involved in performing surgery on man.
None of these prior art devices is capable of producing satisfactory results in a practical and highly flexible instrument which can be efficiently used by a surgeon for micro-surgery on living human tissue or tissue substructures, and particularly, none provides means for generating high power continuous wave or high pulse rate frequency laser energy which can be selectively absorbed in tissues or tissue substructure and directing it in a beam in a precise manner on living tissues within the field of view of an operating microscope so that the laser may be used as a knife or perform other surgical procedures.
Also with the present invention, delicate control of the instrument makes it possible for the first time to use a surgical microscope for illumination and recognition of early pre-invasive cancer, and particularly, in the case of cancer of the cervix, and also, for the precise laser treatment of the actual areas of pre-invasive cancer. The present invention will thus provide an adjunct in the cancer control program where the PAP or cytological smears are performed, to find the precise source of the pathological PAP smear.
These objects and advantages of the present invention discussed above and others will be more readily apparant from the following detailed description of the drawings illustrating the apparatus embodying principals of the present invention, and setting forth the method of the present invention in connection with the discussion of the use and operation of the apparatus illustrated and described.
FIG. 1 is a perspective view of a surgical laser embodying principals of the present invention.
FIG. 2 is an elevational diagram of the device of FIG. 1.
Referring to FIG. 1, there is illustrated a laser device 10 ofself-contained design specifically intended for use in precision surgery with magnifying optics. This device 10 is designed for efficient and convenient use by a surgeon in performing surgery on man. The device 10 includes a laser generator unit 11 which contains the laser source. This device 11 is illustrated in one preferred form mounted on a portable floor standing unit 12 having a wheeled base 13, but this unit may also be mounted in or hanging from the ceiling above the operating area or in the base of the operating table 15. A conventional surgical binocular operating microscope 20 of the type commonly used in delicate micro surgery is provided. The microscope 20, through the motion of the articulating arm 21, can be moved by the surgeon 18 to any position in close proximity to the patient 17 upon the table 14 and in such position the microscope can remain during'the course of the operation or until further moved by the surgeon 18. The laser beam from the laser unit 11 is communicated through a flexible fiber optic 23 into a path coaxial with the viewing axis of the microscope 20. The optical arrangement of the components can better be understood by reference to the diagrams of FIG. 2.
Referring to FIG. 2, a cross-sectional diagram of a conventional operating microscope 20 is illustrated having associated therewith a laser beam communicating device 31. The microscope 20 is a conventional microscope including a pair of eyepieces 32, internal optics 33 for directing light from an objective lens 34 or pair of objective lenses, toward the eyepieces 32, and internal focusing elements 35 which can be operated so as to focus the microscope through the operation of a focusing control knob illustrated diagrammatically at 36. When focused, the microscope will present a magnified field to the surgeon 18 of an area 37 of the tissue 38 of the patient 17. A filter shutter 39 is connected into the microscope 20 to be moved into the optical path upon the operation of the surgical laser at high operating power to protect the eyes of the surgeon.
The laser beam path 41 is illustrated as emanating from a point 42 near the center of the objective lens 34 and coaxial with the optical path of the objective lens 34. This path 41 will direct the beam onto a spot on the area 36 within the viewing optical field of the objective 34. The laser beam directing device 31 includes a pair of dichroic filters or mirrors 44, a focusing telescope 45, the fiber optic rod 23, all connected in a series from a laser source 50 contained within the unit 11. The source 50 emits coherent light along the fiber optic conductor 23 to a point 51 which falls within the focal length 52 of an objective lens 53 of the focusing telescope 45 which serves to collimate the beam exiting the fiber optic 23. The beam passing through the telescope 45 is directed by the mirrors 44 along the path 41. The laser beam can be focused by adjusting the control 57 of the telescope 45 which controls the focusing optics 58 of the telescope 45. This adjustment causes a change in the convergence of the laser beam and thereby regulates the size of the spot impinging upon a point 60 of the area 37 at the focal plane of the microscope 20. In this manner, the surgeon can control the diameter of the operating beam from the laser which he is using for surgery and thus minimize the amount of tissue destroyed by the incision. The beam diameter which is most effective for most micro-surgical purposes of this type is roughly in the range from 30 to 1000 microns in diameter.
The point 51 is defined by the end of the fiber optic 23. This end is mounted by suitable mounts 62 such as a slidable plate or block, so that it can move in a plane perpendicular to the axis of the telescope objective lens 53. This movable mounting 62 allows the point 51 to be moved through the control of a control lever 64 which is attached at a univeral pivot point 65 to the structural case of the microscope 20. By motion of the control 64, the laser beam source is moved in the focal plane of the objective lens 53 so as to cause a movement of the spot 60 on the area 37. This allows the surgeon to control the point of impingence of the beam and to thus prescribe the path of the beam on the tissue to define the incision which is being made by the laser beam. This is done while the microscope remains focused and in place.
The fiber optic 23 may only be made from certain high efficiency fibers. One type now available is a special tapered fiber described in a recently published West German patent application in the name of Gunther Nath. Another suitable type of fiber is that manufactured by Nipon Electric of Japan and sold under the name Selfoc. It is also of quartz and is believed to have a parabolic index of refraction across its cross-section to serve as a waveguide and conserve beam coherence.
The laser source 50 may be any one ofa number of conventionally known laser sources, and it is anticipated that many other suitable sources will be developed in the near future which are effective for this purpose. The source may be of the type designed to generate energy at a discrete frequency or, and perferably, a tunable source so that selective absorption may be best realized. This laser source generates essentially continuous wave laser energy which will emit a beam having a wavelength of visible or near visible light. Various laser sources and the wavelengths of radiation that they emit are listed in the tables on pages 62-64 of Lasers In Medicine cited above. Of these sources, those classified as quarsi-CW" lasers emit pulses of high pulse rate frequency which may be essentially continuous wave energy for the purposes of the present invention. Not all of those sources listed are presently available in devices which generate sufficient power for surgical use. In order to obtain selective absorption of the energy by tissue, this light should be in the range from 200 to- 3,000 nanometers in wavelength. It has been found that selective absorption does occur with wavelengths in this range and especially with wavelengths from 300 to 1,000 nanometers. Selective absorption occurs throughout the visible range of 400 to 700 nanometers and into the near infrared range where it is very pronounced at 1,000 nanometers where minimum absorption occurs in unpigmented tissues. This 1,000 nanometers may be ideally suited for some uses. Selective absorption is also significant at 2,200 nanometers. However, in the far infrared range of approximately 10,000 nanometers, no selectivity is achieved in that all tissue tends to uniformly absorb radiation of this wavelength. This data is discussed in the text relating to table 7-l and FIG. 7-2 on pages 168 and 169 respectively of Lasers In Medicine cited above.
A suitable laser source 50 for micro-surgical uses should be capable of emissions in the range of from approximately 0.5 to 10 watts, average power. In order that cutting may be effected, this must be focused to an irradiance ranging from 0.1 to something in the order of 50 kilowatts per square centimeters.
Remote controls for the laser source 50 are provided at the operating area. These include an average power level control and an exposure time control in the form of foot pedals 81 and 82 respectively.
Aiming of the laser can be achieved by a low level secondary emission from the laser 50 (as discussed above) for which is provided a filter 83 selectively controllable by a switch 84 positioned on the microscope 20. Alternatively, an independent laser white light source may be used connected into the system in the manner of the laser source of FIG. 2.
For purposes of transillumination of the tissue to aid the surgeon in locating the precise area at which the surgery is to be made, a separate laser generator is preferably provided. This is illustrated in FIG. 2 as the generator 70 which is also contained in the laser unit 11. This laser 70 is generally of a lower intensity than that used for the surgical laser source 50. It is possible, however, that a single laser source be used for both surgery and transillumination and that it be operated for transillumination at either a lower intensity or in a manner which will more widely distribute the beam so as to provide an irradiance which provides a satisfactory visual effect but which does not cause tissue injury. This may be done through focusing of the telescope 45. When the separate transillumination laser source 70 is used, and a separate laser source is generally prefered, the emission from the source 70 may be utilized in one of two ways. In one way, the beam may be communicated through the optics provided for the surgical laser source 50 by directing the beam along a path 71 and into the fiber optic 23 through the use of a dichroic filter 72. Alternatively, the beam from the source 70 may be directed along a separate path through a separate fiber optic 74 to a probe 75 which may be separately held by the surgeon. Both paths may be selectively incorporated into a single unit by incorporation of a fifty percent reflective mirror 77, or a moveable mirror, or a polarization sensitive optical switch such as a Pockells cell. This cell would operate to allow the beam to pass directly through it under normal conditions to the fiber 74, or it can operate as a dichroic mirror to direct the beam along the path 71 when a specific electrical potential is applied to the cell.
The book Lasers In Medicine cited above and particularly the specific sections referred to in the specification above are expressly incorporated by reference into this application.
Through the use of the apparatus described above, the unique micro-surgical procedure which the present invention has sought to provide is achieved. Through this method, the unique characteristics of the laser can now be used in performing delicate bloodless microsurgery on man.
In performing such surgery, the surgeon utilizes his surgical microscope to magnify the area of tissue of the patient on which a micro-surgical operationis to be performed. He does so by positioning the microscope, which is freely moveable through its articulating arm mounts 21 adjacent the surgical area. Through a focusing control 36 on the microscope, the surgeon focuses the microscope on the tissue to present to him a field of view which includes the tissues or tissue substructures upon which the desired surgery is to be performed.
The surgeon then may employ the diagnostic functions of the device to locate and evaluate the surgical area. To do so he engages the transillumination laser source 70, preferably controlled through a switch conviently positioned, for example, on the probe 75, and directs the probe 75 toward the patient causing the transilluminating radiation to pass through and illuminate the tissue and substructure. The transilluminating radiation may be visible or near visible and rendered visible through the use of special materials in the optics of the microscope or through a substance such as a fluorescent stain applied to the tissue. The selective absorption of the radiation will enhance the contrast within the tissue and substructure parts. Through the use of a tunable laser, whether continuous or discrete frequency type, the surgeon may also obtain information regarding the relative absorption properties of the tissue and substructures by changing the frequency and observing the changes in contrast among the tissues and substructures. Normally, the surgeon will select his surgical frequency from his previous experiences and clinical data previously acquired.
Once the area is located and the proper frequency selected, the surgeon focuses and aims the surgical laser. He does so either by directing a separate aiming light source through the telescope 45 or by operating the laser source 50 at low power or by the use of one of the secondary emissions of the source 50 with the principal emission blocked by the filter 83. Focusing is achieved by adjustment of the knob 57 on the telescope 45 to control the laser beam conveyance and the spot size on the tissue. By operation of the lever 64, the fiber optic 23 is moved to cause a corresponding movement of the spot on the tissue to position the spot to the point Where the surgical operation is to begin. The surgical laser beam, as well as the aiming radiation is transmitted into a path coaxial with the axis of the viewing optics to allow precise positioning of the spot. This is done with the microscope 20 stationary presenting a fixed viewing field. At this time the surgeon activates the filter 39 in the microscope to shield his eyes from the intense radiation.
The surgeon then sets the exposer time control through foot pedal 82, and the power level control through foot pedal 81. He then energizes the source 50 to high surgical power level or, depending on the embodiment of the device used, may deactivate the filter 83 through switch 84 on the microscope. The surgical power then begins and lasts until the preset exposure time lapses or until he manually terminates the laser emission.
To perform micro-surgery involving delicate knifelike incisions, the surgeon moves the spot on the tissue through the lever 64 while the surgical laser 50 is energized and while his microscope 20 is fixed on the viewing field. The lever 64, presents a high mechanical advantage particularly with the specific relationship of the moveable fiber optic tip 51 to the telescope objective lens 53. This allows very precise and delicate movement of the cutting beam of a degree heretofore unrealized in micro-surgery.
From the above discussion of the invention it will be apparent that not only is a unique method and apparatus presented which will provide a new and powerful tool for the surgeon in performing delicate bloodless microsurgery, but also that it provides a means by which the advantages of the laser may provide for future further extension of the art of surgery on man.
What is claimed is:
1. A surgical instrument for making knife-like incisions on living human tissue or tissue substructures comprising:
a base positioned remote from an operating area;
a laser source mounted at said base;
said laser source being operable to emit essentially continuous wave electromagnetic radiation having a wavelength within a spectral range including near ultraviolet visible and near infrared radiation;
a binocular microscope;
means for mounting said microscope for free move ment adjacent said operating area;
laser beam focusing optics mounted on said microscope;
a flexible fiber optic conductor connected between said source and said focusing optics to transmit the output of said source to said focusing optics;
means for communicating said laser beam from said focusing optics along a path coaxial with the viewing axis of said microscope toward a patient at said operating area; and
controls positioned at the operating area for operation by a surgeon while viewing through said mic roscope, said controls including a. a first control for focusing said microscope on a portion of tissue of a patient at said operating area,
b. a second control for focusing said focusing optics to control the size of the spot formed by said laser beam on said tissue, and
c. a third control for moving said spot on said tissue in the field of view of said microscope.
2. The instrument of claim 1 wherein:
the spectral range of said laser emission includes only the visible range.
3. The instrument of claim 1 wherein:
said radiation has a wavelength within the spectral range of from 200 to 3,000 nanometers.
said third control includes a lever mounted on said microscope for moving said end of said fiber optic conductor.
8. The instrument of claim 1 wherein:
said laser source is operable to emit relatively low power level secondary emissions in the visible spectral range; and
said instrument further includes filter means for se-,
lectively blocking the primary emission from said source;
whereby said laser is capable of being aimed by said low power emission without causing a reaction on said tissue.
9. The instrument of claim 1 wherein:
said microscope mounting means includes an articulating arm connected to said base.
10. The instrument of claim 1 wherein:
said base is a portable wheeled floor standing base.
1 l. The instrument of claim 1 further comprising:
means for generating electromagnetic radiation for diagnostic transillumination including a laser source operable to emit electromagnetic radiation within a spectral range including visible radiation and radiation within the near ultraviolet and near infrared spectra] ranges which can be rendered visible; and
means for directing said transilluminating radiation onto and through said tissue or tissue substructures for transillumination thereof.
12. The instrument of claim 11 wherein;
said transilluminating laser source includes a second laser source distinct from said first recited laser source.
13. The instrument of claim 11 further comprising:
means for communicating said transilluminating radiation through said focusing optics.
14. The instrument of claim 11 further comprising:
means, including a light probe, and a second fiber optic conductor distinct from said first recited fiber optic conductor for directing said visible light onto said tissue.
l5. The instrument of claim 14 wherein:
said transilluminating laser source includes a second laser source distinct from said first recited laser source; and
said instrument further comprises means for communicating said transilluminating radiation through said focusing optics and means for alternatively directing said light from said second source through said second fiber optic conductor and said probe.
16. The instrument of claim 1 wherein:
said controls are mounted on said microscope.
17. The instrument of claim 1 where said controls further include:
surgery on living human tissue or tissue substructure comprising:
a laser source mounted remote from an operating area;
said laser source being operable to emit essentially continuous wave electromagnetic radiation having a wavelength within a spectral range in which it is differently absorbed by different tissue or tissue substructure;
a surgical microscope;
means for mounting said microscope for free movement adjacent said operating area;
laser beam focusing optics mounted on said microscope;
a conductor of said radiation connected between said source and said focusing optics to transmit the output of said source to said focusing optics;
means for communicating said laser beam from said focusing optics toward a patient at said operating area; and
controls mounted on said microscope including a. a first control for focusing said microscope on a portion of tissue of a patient at said operating area,
b. a second control for focusing said focusing optics to control the size of the spot formed by said laser beam on said tissue, and
c. a third control for moving said spot on said tissue in the field of view of said microscope.
20. A laser instrument comprising:
a laser operable to generate a beam of electromagnetic radiation at its output;
a focusing telescope for controlling the coherence of said beam, said telescope having an objective lens;
a flexible fiber optic conductor extending from said laser output to said telescope to transmit said beam from said laser to said telescope;
the exit end of said conductor being mounted for movement in a plane intersecting the optical axis of said telescope and within the focus of said objective lens; and
a control for moving said exit end in said plane.
21. The instrument of claim 20 wherein:
said control includes a universally pivoted lever.
22. A method of aiming and operating a laser instrument which comprises:
a. a laser operable to generate a beam of electromagnetic radiation at its output, said radiation including a principal emission at a first frequency and at least one secondary emission at a second frequency different from said first frequency, the power level of said principal emission being sufficient to cause a given effect on a target when directed thereon, and the power level of said secondary emission being insufficient to cause said effect but being capable of being rendered visible where directed upon said target b. means for controllably directing said beam from said laser output to said target, and
c. a selectively actuable filter for blocking said principal emission, said filter being positioned between said laser output and said target, said method comprising the steps of:
operating said laser and actuating said filter to generate a beam toward said target containing said secondary emission but absent said principal emission; and, concurrent therewith,
controlling said directing means to direct said beam onto a desired spot on said target; then deactuating said filter and operating said laser to generate a beam toward said target containing said principal emission to cause said given effect on said target.
23. A method of performing micro-surgery on living human tissues or tissue substructures comprising the steps of:
viewing under magnification and along a given viewing axis an area on a patient which includes the tissue or tissue substructure upon which said microsurgery is desired;
generating a laser beam of electromagnetic radiation at a selected frequency which is highly absorbed by said desired tissue of substructure and which is less highly absorbed by adjacent tissue, said frequency being within a spectral range including near ultraviolet, visible, and near infrared radiation;
directing said laser beam onto said area;
focusing said beam to a given spot size on said area;
while maintaining said viewing area fixed, moving said beam to a selected point on said desired tissue; and
then generating said laser beam at a power level sufficient to cause reaction in said desired tissue or tissue substructure. I
24. The method of claim 24 further comprising the steps of:
generating a transilluminating laser beam of electromagnetic radiation within the spectral range of near ultraviolet, visible, and near infrared radiation and at a power density insufficient to cause reaction on said tissue or tissue substructure; and
passing said transilluminating laser beam through tissue at said viewed area to locate said desired tissue.
25. The method of claim 25 further comprising the step of:
varying the frequency of said transilluminating laser while observing the contrast of the area under magnification to determine said selected frequency.
UNITED STATES PATENT OFFICE I CERTIFICATE OF CORRECTION Patent No, 3,769,963 Dated November 6, 1973 Inventor(s) Leon Goldman and R. James Rockwell, Jr.
It is certified that error appears in the above-identified patent and that said Letters Patent are hereby corrected as shown below:
Column 4, line 64, "doe" should be do Column 7, line 35, "univeral" should be universal Column 14, line ll, second "24" should be 23 Column 14, line 20, second "25' should be 24 Signed and sealed this 19th day of March 1974.
(SEAL) Attest:
EDWARD M. FLETCHER,JR. I c. MARSHALL DANN Attestlng Officer Commissioner of Patents FORM PO-IOSO (10 69)
Patent Citations
Referenced by
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text:
The CSOM Training Curricula site features several training curricula for probation and parole agencies and other stakeholders across the country who share responsibility for sex offender management.
Improving Restitution Management in Community Corrections
With funding from the Office for Victims of Crime, this American Probation and Parole Association 1-day training seminar focuses on improving the management of restitution in community corrections. The goal of this training is to provide community corrections and court services agencies and personnel with strategies they can implement to improve enforcement and collection of restitution and improve their ability to communicate with victims of crime about restitution issues.
National Institute of Corrections (NIC): Training
NIC provides management and specialty training for staff of state and local corrections throughout the U.S. and its commonwealths and territories. NIC also offers live satellite and video opportunities, including the following videos from NIC's Community Services Division which address topics in offender employment and employment retention:
National Parole Resource Center (NPRC)
Funded in part by the Bureau of Justice Assistance, NPRC is a national initiative that underscores the critical role that paroling authorities play in the American criminal justice system. NPRC serves as a source of information, training, and technical assistance for paroling authorities and the supervision agencies that they oversee and with whom they collaborate.
National Reentry Resource Center
Sponsored by the Bureau of Justice Assistance, the National Reentry Resource Center provides education, training, and technical assistance to states, tribes, territories, local governments, service providers, nonprofit organizations, and corrections agencies working on prisoner reentry.
Promising Victim-Related Practices in Probation & Parole
Supported through the Office for Victims of Crime, this American Probation and Parole Association training provides instruction to front-line probation and parole officers and first-line supervisors on: the impact of crime on victims; the role of community corrections in providing victim services; effectively communicating with crime victims; incorporating victim input into the community supervision process; providing effective victim notification; and enhancing restitution collection and management.
Also see the NCJRS Justice Events Calendar, a database of conferences, trainings and other events which are searchable based on topic, geographical location or dates.
Links from the NCJRS Web site to non-Federal sites do not constitute an endorsement by NCJRS or its sponsors. NCJRS is not responsible for the content or privacy policy of any off-site pages that are referenced, nor does NCJRS guarantee the accuracy, completeness, timeliness, or correct sequencing of information. NCJRS is also not responsible for the use of, or results obtained from the use of, the information. It is the responsibility of the user to evaluate the content and usefulness of information obtained from non-Federal sites.

subset: commoncrawl


text:
Viewers: in countries Watching now:
Learn how to speed up time and create compelling visual effects with time-lapse photography. Join Rich Harrington in the field as he captures nature's patterns at Red Rock Canyon in southwestern Nevada, and shows how to frame your scene and choose the proper camera settings. He'll show you how to capture great images, whether you're using a DSLR camera and a motorized slider or just a smartphone you have handy. Then join him back in the studio to transform your still footage into a storytelling time-lapse video, using tools like Photoshop, Premiere Pro, and Final Cut Pro.
This course was created and produced by Rich Harrington. We are honored to host this content in our library.
Rich: Once you know your delivery size, it's time to think about acquisition. What are you going to be shooting in the camera? The choices that you have in your camera are going to vary depending upon manufacturer, and the bigger choice is, if you're shooting RAW versus JPEG. But remember, most cameras offer different sizes of recording. For example, on a Canon camera, you can choose from different size RAW on a lot of them. Nikon doesn't tend to do that as much. Are you going to be shooting RAW and JPEG? I tend to shoot the largest frame possible, because I find that memory cards are pretty cheap. You can always go in to your camera and adjust the quality settings. So notice there as I step through, RAW versus Basic. Here RAW, or the different sizes, normal or fine quality, and in fact, using the other dial, I could chose from small, medium, or large. Now, generally speaking, that small, medium and large is only available when you are shooting.
In a JPEG or RAW plus JPEG format. The good news is is just about any DSLR, Micro 4 3rds or modern camera is going to hold up really well. You're going to shoot with the maximum image size that you have available. As such, make sure you have plenty of storage. You don't want to be in a situation where you're running out of card space, so having high capacity memory cards, is really going to come in handy. Use the maximum quality that your camera shoots. And I strongly encourage you to shoot RAW. Which, of course, will consume easily ten times more space on the card, but, that'll give you greater flexibility. Don't worry, we'll explore the raw versus jpeg argument in greater depth later. I just want to make sure that you take advantage of the maximum quality, your camera can record.
So you get the best looking time-lapse.
There are currently no FAQs about Creating Time-Lapse Video.
Access exercise files from a button right under the course name.
Search within course videos and transcripts, and jump right to the results.
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Click on text in the transcript to jump to that spot in the video. As the video plays, the relevant spot in the transcript will be highlighted.


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The future of currency in Canada
Jeremy Hobson
Interview by
Apr 12, 2012 Canada just recently announced plans to phase out the penny, and now it's looking to bring it back -- in digital form.
As politics shift in Myanmar, so do economics
Stacey Vanek Smith
Interview by
Apr 2, 2012 Myanmar's foreign minister announced that historic elections in the country have gone smoothly, including apparent victories by pro-Democracy candidates. Also this morning, Myanmar's central bank floated the country's currency for the first time.
Rethinking the humble parking lot
Kai Ryssdal
Interview by
Mar 14, 2012 MIT professor Eran Ben-Joseph has a minor obsession: Parking lots. He wants to design and use them better.
The problem with cash
Kai Ryssdal
Interview by
Feb 15, 2012 In his new book, "The End of Money," David Wolman explains why he advocates for the elimination of cash.
Saving money on making money
Kai Ryssdal
Feb 13, 2012 In his new budget released today, President Obama said he wants Congress to let the Treasury Department use cheaper materials to mint our coins.
Economists: RMB internationalization good for U.S., global economy
Jing Zhao
Feb 7, 2012 Many fear that China's RMB is going to overtake the U.S. dollar as the world's most important currency. But some say the U.S. should encourage China to progress with the RMB internationalization.
Japan to agree on currency deal with India
Steve Chiotakis
Interview by
Dec 27, 2011 After signing similar deals with China and Korea, this third move shows that Japan might be on its way back to prominence.
China, Japan make currency deal
Andrew Wood
Dec 26, 2011 China and Japan announce plans to allow businesses to swap currency without dealing in U.S. dollars
Podcast: Extreme weather, much ado about mutton, and more shopping madness
Adriene Hill
Hosted By
Dec 26, 2011 An increase in extreme weather in 2011 has lead to one of the most expensive years for insurance claims. It's also turning out to be a record year for sheep rustlers on the lamb in the English countryside, where a record number of sheep have gone missing this year. Plus, China and Japan make a currency deal, Detroit girds for possible state takeover, and more top headlines from around the globe on this day after Christmas.
U.S. dollar strengthens against the euro
Scott Tong
Interview with
Dec 14, 2011 The U.S. dollar hits an 11 month high against the euro as questions remain about the ability to solve the debt crisis in Europe.


text:
Happy Christmas to everyone and all the best in the New Year.
Vincent Brady (TEX)
Printable View
Happy Christmas to everyone and all the best in the New Year.
Vincent Brady (TEX)
Thanks Tex. A Happy Christmas to all!
Thank you, and a joyous season to you, family and friends!
Merry Christmas to all.
My wishes for world peace goes out to all, as well as for the climate and environment to get better.
Hope you all can spend the christmas in a analouge harmony and be happy for all the great produckts still availible for making great prints in the end!
Hope you have a happy Christmas & NY too Vincent.
God, it was cold today wasn't it?
I had my Hassie with the zone plate fitted and went out to photograph a
group of hardy ( i.e. mental) souls who took part in the first ever Winter Frostie Swimming Race held at Skerries.
It snowed just before the race and was 0 degrees out of the water and not much different in it either I believe. Should also mention that the finish point was on an exposed headland so with a breeze blowing the wind-chill made it feel more like -2.
Still I got some really nice pics (have just devved the negs which are hanging up to dry).
Even though it was freezing cold it was nice and bright (f65 @ 1/30 second for fuji 400asa at ei 320)
All true artist suffer for their art, looks like you are well on the way George.
Happy Christmas
Happy Christmas APUG and to you Tex. I'll raise a glass to your health in twenty ten.
Season's greetings to you all, hope you receive lots of nice photo gear as presents :)
happy x-mass to all!


text:
Otten, LJ; Rugg, MD; (2004) Interpreting event-related brain potentials. In: Handy, TC, (ed.) Event-Related Potentials: A Methods Handbook. (3 - 16). MIT Press: Cambridge.
Full text not available from this repository.
|Book chapter
|Interpreting event-related brain potentials.
|UCL classification:
|UCL > School of Life and Medical Sciences > Faculty of Brain Sciences > Psychology and Language Sciences (Division of) > Institute of Cognitive Neuroscience
UCL > School of Life and Medical Sciences > Faculty of Life Sciences
Archive Staff Only: edit this record


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You can now invite anyone to meet at your favorite Starbucks.
Limited-time feature
22 year old man | Naval Anacostia Annex, DC, USA | Seeking women 18-21 within 30 miles of Washington, DC
Go ahead and shoot me an email!!!
Hello, my name is Josh. I am in the Navy Ceremonial Guard, If you dont know what that is google search it. My hometown is very close by in Hollywood MD. I may be kinda young but I have a lot going for me right now. Im mature for my age, A lot of girls seem to want that in a guy. Im really tall also so it would be nice to meet someone who is my height or close to it. I dont really have much more to say about my self. I'd much rather just talk to someone rather than writing on here about myself. So If your interested send me a message!
Coffee and conversation , Cooking , Dining out , Hobbies and crafts , Movies/Videos , Museums and art , Music and concerts , Exploring new areas , Nightclubs/Dancing , Playing cards , Playing sports , Shopping/Antiques , Travel/Sightseeing , Video games , Watching sports
Auto racing / Motorcross, Billiards / Pool, Bowling, Cycling, Football, Golf, Other types of exercise, Running, Swimming, Tennis / Racquet sports, Walking / Hiking, Weights / Machines
I exercise 3-4 times per week.
I like Dogs
I love dogs, I use to have two dogs when I was younger.
Middle of the Road
Well im kind of new to this area but I like to walk around the National Mall and visit some of the museums.
My favorite things in life are my career, my car, my money and my health. I like racket ball, running, video games, motorcycles, funny people, good times, free stuff, new clothes/shoes, expensive electronics, stuff like that.
I like to do whatever for fun. I love going to the movies. Whenever some of my friends invite me to go some place I usually tag along no matter how ridiculous it sounds. For outdoors kinda stuff I like to go running and jetski!
The last thing I read was my W-2 and my lump of tax returns. Oh yeah!
Z{{Cta}} {{#if HasMoreInfo}} ?{{CtaSecondary}} {{/if}}
|What he is looking for
|6'3" (190cms)
|5'5" (165cms) to 6'5" (195cms)
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|No preference
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Active Duty Military. In the Untied States Navy Honor Guard.
|$25,001 to $35,000
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- Home
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See below for Sylosis concert tickets. Check 2015 tour dates, gigs and concerts information. Buy Sylosis tickets in confidence with Live Nation.
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Indian River County athletic directors targeting hazing
INDIAN RIVER COUNTY - Athletic directors here plan to step up discussions about hazing, driving home the point that it's not to be tolerated.
And those who see hazing occur will be expected to tell someone or risk facing penalties themselves.
In the coming months, the topic will be discussed in mandatory videos, discussions, handouts and forms to be signed. Athletic directors have already started talking with coaches. They plan to continue the conversation closer to the start of sports seasons.
After investigating a hazing incident involving a Sebastian River High School baseball player this spring, district officials recommended additional anti-hazing training for coaches and players. SRHS Athletic Director Michael Stutzke said he brought up the subject at a June coach's meeting and showed an anti-hazing video from the National Federation of State High School Associations.
"That was the first step," Stutzke said.
After rosters have been determined at the start of every sports season, players also will see a video, he said. Parents meetings also will discuss hazing, he said.
Vero Beach High School Athletic Director Tim Tharp said he plans to implement training sessions as well. The topic will be covered with coaches during a fall luncheon, he said. The school also is looking at an online coaching certification program that includes an ethics course, he said.
Training will be handled sport by sport, coach by coach, he said. Sessions will take place every sports season to make sure everyone is clear on the policy, he said.
"It's going to be high on everybody's priority list," he said.
Stutzke said SRHS students already know first-hand the consequences of hazing because of what happened this spring.
"I think it's important the subject be discussed openly, honestly," Stutzke said.
An anti-hazing policy has always been in place at SRHS, Stutzke said. Now, the school plans to add to the policy, he said.
Students will be trained on how to recognize hazing and what to do if it happens, not just to them but to a teammate, he said. Students also need to know to report it to administrators, because those who observe and don't say anything could face penalties, he said.
"Not only is hazing illegal, to not report it is unacceptable," Stutzke said.
Stutzke said after what the school and students have been through as part of the investigation, he has serious doubts as to whether another hazing incident ever happens again there.
"We hope that it never happens again," Stutzke said.
•Hazing is defined as any humiliating or dangerous activity — regardless of the student's willingness to participate — expected of a student to belong to a group.
•About 48 percent of students belonging to groups reported being subjected to hazing activities, according to a study by Alfred University in western New York. About 43 percent reported being subjected to humiliating activities, and 30 percent reported performing potentially illegal acts as part of their initiation.
National Federation of State High School
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|Plug your Board - The RockMan EXE Zone
|Tweet Topic Started: Nov 23 2011, 07:38 AM (394 Views)
|Nov 23 2011, 07:38 AM Post #1
This is my melody and it's just the raver's fantasy
I included our board in ZetaBoards Anniversary. Anyone who have an account at Support Board can discuss our board, and maybe we will win something.
My entry is there: http://if.invisionfree.com/topic/5129685/findpost/8339321
The RockMan EXE Zone - As title says, it is a board about Rockman.
Nemomon - Admin. But I hid my username from Admin list.
My board generally is about RockMan EXE games and Ryuusei no RockMan, and RockMan Zero. We like all other RockMan series too, yet we are mostly about GBA and NDS games.
|1 user reading this topic (1 Guest and 0 Anonymous)
|« Previous Topic · News & Site Updates · Next Topic »


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Plan a literary pilgrimage with this guide to storied travel destinations around the world.
Bath Travel Guide
Articles about Bath
By Caroline Hallemann
By Wayne Curtis
Cheers to these small towns for great Main Streets, where you can admire architecture, sample the local flavor, and find a lost America.
By Heather Smith MacIsaac
Summer in Maine is like the best of fall everywhere else. Sunny days start off crisp; against an enameled-blue sky, the evergreens look that much deeper. By midday the air softens and the scent of pine, sprinkled with salt from the coast, rises....
By Eve M. Kahn
The thermal waters of Bath, England, have attracted travelers for at least 10 millennia. Over the past few years, the development of the historic Georgian baths into Thermae Bath Spa, a high-end facility designed by Sir Nicholas Grimshaw, has been...


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FG Wilson offers customer support on a global scale. This is achieved through our strong sales team, which includes employees based at the company headquarters in Larne, employees in our worldwide sales offices and individual dealers located in over 150 countries throughout the world.
Our global sales offices and Dealers develop technical literature suited to their specific markets.
We believe our success is firmly rooted in the strength of our Dealer network. The relationship we have with our Dealers is nurtured in our Global conferences held around the world, where our Dealers can have face-to-face discussions with managers from all areas of our company.


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Delaware Small Cap Core Fund seeks long-term capital appreciation.
The Fund invests in stocks of small companies believed to have a combination of attractive valuations, growth prospects, and strong cash flows.
Institutional Class shares are only available to certain investors. See the prospectus for more information.
The performance quoted represents past performance and does not guarantee future results. Investment return and principal value of an investment will fluctuate so that shares, when redeemed, may be worth more or less than their original cost. Current performance may be lower or higher than the performance quoted.
Total returns may reflect waivers and/or expense reimbursements by the manager and/or distributor for some or all of the periods shown. Performance would have been lower without such waivers and reimbursements.
Returns for less than one year are not annualized.
Prior to Aug. 1, 2005, the Fund had not engaged in a broad distribution effort of its shares and had been subject to limited redemption requests. 12b-1 fees were waived for this period. Had 12b-1 fees been applied, performance would have been lower. Expense waivers were in effect for the periods shown. Performance would have been lower if waivers did not apply.
Index performance returns do not reflect any management fees, transaction costs, or expenses. Indices are unmanaged and one cannot invest directly in an index.
Portfolio holdings are as of the date noted below and are subject to change at any time. Holdings may not be representative of current or future investments and may not include the entire investment portfolio. Holdings information is made available to the public 30 calendar days after the most recent month-end.
Holdings data is for informational purposes only, and is not intended as a recommendation, offer, or solicitation for the purchase or sale of any specific security. By accessing the portfolio holdings, you agree not to reproduce, distribute or disseminate the portfolio holdings, in whole or part. In no event shall the Delaware Family of Funds or its affiliates have any liability relating to the use of the portfolio holdings.
Unlike the Fund's regulatory filings, the portfolio data and its presentation in this document is not required to conform to Generally Accepted Accounting Principles (GAAP) and Securities and Exchange Commission (SEC) presentation requirements. Therefore, it may differ from that provided in the complete portfolio of investments in the annual and semiannual report to shareholders filed with the SEC on Form N-CSR, and the complete portfolio of investments filed in the first and third quarter on Form N-Q.
*Cash balance includes other assets and liabilities.
Portfolio holdings are as of the date noted below and are subject to change at any time. Holdings may not be representative of current or future investments and may not include the entire investment portfolio. Holdings information is made available to the public 30 calendar days after the most recent quarter-end.
Holdings are as of the date indicated and subject to change.
1If a Fund makes a distribution from any source other than net income, it is required to provide shareholders with a notice disclosing the source of such distribution (each a "Notice"). The amounts and sources of distributions reported above and in each Notice are only estimates and are not provided for tax reporting purposes. Each Fund will send each shareholder a Form 1099 DIV for the calendar year that will provide definitive information on how to report the Fund's distributions for federal income tax purposes. The information in the table above will not be updated to reflect any subsequent recharacterization of dividends and distributions. Click here to see recent Notices pertaining to the Fund (if any).
2Information on return of capital distributions (if any) is only provided from June 1, 2014 onward.
3Includes both short- and long-term capital gains.
Senior Vice President, Chief Investment Officer — Core Equity
Start date on the Fund: November 2004
Years of industry experience: 32
(View bio)
Francis X. Morris joined Delaware Investments in 1997 as a vice president and portfolio manager, and is currently the chief investment officer for Core Equity investments. He is also a member of the firm's asset allocation committee, which is responsible for building and managing multi-asset class portfolios. In addition, Morris serves as a Trustee for the Delaware Management Holdings, Inc. (Delaware Investments) 401(k) and Retirement Plan. Prior to joining the firm, Morris was vice president and director of equity research at PNC Asset Management. He received a bachelor's degree from Providence College and holds an MBA from Widener University. He is currently a member of the Business Advisory Council of the Providence College School of Business. Morris is a past president of the CFA Society of Philadelphia and is a member of the CFA Institute. He is a former officer of the National Association of Petroleum Investment Analysts.
Vice President, Senior Portfolio Manager
Years of industry experience: 26
Christopher S. Adams is a senior portfolio manager on the firm's Core Equity team. He also performs analysis and research to support the portfolio management function. From 1995 to 1998, he was the firm's vice president, strategic planning. Prior to joining Delaware Investments in 1995 as assistant vice president of strategic planning, Adams had approximately 10 years of experience in the financial services industry in the U.S. and U.K., including positions with Coopers & Lybrand, The Sumitomo Bank, Bank of America, and Lloyds Bank. Adams holds both bachelor's and master's degrees in history and economics from Oxford University, England, and received an MBA with dual concentrations in finance and insurance/risk management from The Wharton School of the University of Pennsylvania. He is a past president of the CFA Society of Philadelphia.
Years of industry experience: 22
Michael S. Morris, who joined Delaware Investments in 1999 as assistant vice president and senior analyst, is currently a senior portfolio manager on the firm's Core Equity team. He also performs analysis and research to support the portfolio management function. Prior to joining the firm, he worked as a senior equity analyst at Newbold's Asset Management, covering financial stocks. Morris began his investment career in 1993 at Ohio Casualty. He earned his bachelor's degree in finance from Indiana University and an MBA from The Wharton School of the University of Pennsylvania. He is a former member of the Bank and Financial Analysts Association.
Years of industry experience: 28
Donald G. Padilla is currently a senior portfolio manager on the firm's Core Equity team. He also performs analysis and research to support the portfolio management function. Padilla joined Delaware Investments in 1994 as assistant controller in the firm's treasury function, responsible for managing corporate cash investments, developing financial models, and overseeing the financial operations of the Lincoln Life 401(k) annuities segment. Prior to joining Delaware Investments, he held various positions at The Vanguard Group. Padilla holds a bachelor's degree in accounting from Lehigh University, and he is a member of the CFA Society of Philadelphia.
The table below describes the fees and expenses that you may pay if you buy and hold shares of the Fund.
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Delaware Small Cap Core Fund (Institutional Class shares and Class A shares at net asset value) posted positive returns but failed to keep pace with its benchmark, the Russell 2000® Index, during the first quarter of 2015. The main detractor from performance was stock selection in the business services, technology, and communications services sectors. On the positive side, stock selection in the basic materials, energy, and consumer discretionary sectors contributed to relative performance.
One of the stocks that detracted from performance during the quarter was RigNet, a provider of fully-managed voice and data networks for the oil and gas industry. During the quarter, shares of RigNet fell 30%, which was mainly a result of the company's exposure to the energy sector. We continue to own this stock as we believe the company's unique business model should allow it to respond well to any stabilization and recovery in the energy markets.
Acorda Therapeutics is a biotechnology company that specializes in therapies for neurological diseases, particularly multiple sclerosis (MS). The stock fell approximately 20% during the quarter amid news that a hedge fund filed an inter partes review (IPR) to challenge Acorda's patent for its MS drug, Ampyra, putting pressure on the stock. An IPR process begins with a third party filing a petition with the U.S. Patent and Trademark Office and does not invalidate the company's patents in any way. We continue to own the stock as we believe that, although the challenge adds volatility to the stock in the short term, it should ultimately fail. We are positive on the company's new drug pipeline, which includes a number of therapies in various phases of clinical trials.
Coupons.com is a leading digital promotions platform that connects retailers and consumers across a variety of digital channels. Shares declined nearly 35% during the quarter as the company reported slower-than-expected revenue and transaction growth for the fourth quarter of 2014. We maintained the Fund's position in the stock — we believe that Coupons.com's scale and advanced technology platform should enable the company to capture significant market share, leading to improved top-line growth and margin expansion.
Among the stocks that contributed to the Fund's performance during the quarter was ICON PLC, a contract research organization that provides outsourced development services to the pharmaceutical, biotechnology, and medical device industries. The stock rose nearly 40% during the quarter on the back of a strong earnings beat. In addition, the company issued 2015 guidance that was substantially above consensus estimates. We continue to see further upside in the stock which we anticipate will be driven by business execution and continued margin expansion.
Biotechnology company Ligand Pharmaceuticals develops programs that lead to licensing deals or acquire royalty revenue-generating assets with biotechnology and pharmaceutical companies. The stock rose 45% during the quarter on positive news from partner Amgen that reported successful trial data in early March for its drug Kyprolis (which can be used in the treatment of multiple myeloma). Ligand receives a royalty from Amgen for the company's sales of Kyprolis. We continue to favor shares of Ligand based on its diversified business model, multiple drug development partnerships, and what we see as an attractive pipeline of potential new drugs.
After an increase of nearly 40% during the fourth quarter of 2014, shares of NPS Pharmaceuticals, a biopharmaceutical company, rose almost 30% during the first quarter as the company agreed to be acquired by Shire. The all-cash tender offer was announced in early January and we closed out the Fund's position in NPS Pharmaceuticals in late February. The addition of NPS's products should strengthen Shire's rare diseases portfolio.
In our view, small-cap stocks remain a good way to leverage the strength of the U.S. economy as small-cap companies generally derive a higher percentage of sales from the United States than mid- or large-cap companies. We ended the quarter with the forward price-to-earnings ratio back at cycle highs. However, looking at small-caps relative to large-caps suggests that small-caps are currently cheaper.
We continue to keep a close eye on economic indicators as we believe improving conditions in the U.S. should provide tailwinds to the earnings growth of small-caps. We believe the U.S. Federal Reserve will begin to raise rates once the economy is strong enough to stand on its own. This should come after the Fed is comfortable with inflation and employment, which we are in agreement with.
We have maintained the Fund's overweight to the basic materials and capital goods sectors, which we believe should perform well at this point in the cycle. The Fund is overweight in the finance sector, specifically regional banks, which could benefit from net interest margin relief when rates increase. Small-cap banks are already experiencing positive loan growth trends relative to their large-cap peers. The Fund is underweight the yield sensitive sectors like real estate investment trusts (REITs) and utilities, which do not look attractive to us in this environment.
2015 is off to a solid start with respect to merger-and-acquisition activity, particularly in the healthcare sector where we have already had one takeout in the portfolio. We expect this activity to continue across multiple sectors in the portfolio as the credit markets remain favorable. Our research continues to favor companies with what we view as strong balance sheets and cash flow, sustainable competitive advantages, and high-quality management teams, which we believe have the potential to outperform over the cycle.
The price-to-earnings ratio is a valuation ratio of a company's current share price compared to its earnings per share.
The views expressed represent the Manager's assessment of the Fund and market environment as of the date indicated, and should not be considered a recommendation to buy, hold, or sell any security, and should not be relied on as research or investment advice. Information is as of the date indicated and subject to change.
Document must be used in its entirety.
All third-party marks cited are the property of their respective owners.
Russell Investment Group is the source and owner of the trademarks, service marks, and copyrights related to the Russell Indexes. Russell® is a trademark of Russell Investment Group.
Carefully consider the Fund's investment objectives, risk factors, charges, and expenses before investing. This and other information can be found in the Fund's prospectus and its summary prospectus, which may be obtained by clicking the prospectus link located in the right-hand sidebar or calling 800 362-7500. Investors should read the prospectus and the summary prospectus carefully before investing.
Investing involves risk, including the possible loss of principal.
Narrowly focused investments may exhibit higher volatility than investments in multiple industry sectors.
Investments in small and/or medium-sized companies typically exhibit greater risk and higher volatility than larger, more established companies.
REIT investments are subject to many of the risks associated with direct real estate ownership, including changes in economic conditions, credit risk, and interest rate fluctuations.
International investments entail risks not ordinarily associated with U.S. investments including fluctuation in currency values, differences in accounting principles, or economic or political instability in other nations.
Investing in emerging markets can be riskier than investing in established foreign markets due to increased volatility and lower trading volume.
The Funds are distributed by Delaware Distributors L.P., an affiliate of Delaware Management Holdings, Inc., and Macquarie Group Limited.
Not FDIC Insured | No Bank Guarantee | May Lose Value
$877.4 million all share classes
(View Morningstar disclosure)
Past performance is not a guarantee of future results. Morningstar proprietary ratings reflect historical risk-adjusted performance as of 05/31/2015. For each fund with at least a three-year history, Morningstar calculates a Morningstar RatingTM based on a Morningstar Risk-adjusted Return measure that accounts for variation in a fund's monthly performance (including the effects of sales charges, loads, and redemption fees), placing more emphasis on downward variations and rewarding consistent performance.
The top 10% of funds in each category receive 5 stars, the next 22.5% receive 4 stars, the next 35% receive 3 stars, the next 22.5% receive 2 stars, and the bottom 10% receive 1 star. (Each share class is counted as a fraction of one fund within this scale and rated separately, which may cause slight variations in the distribution percentages.) The Overall Morningstar Rating for a fund is derived from a weighted average of the performance figures associated with its three-, five-, and ten-year (if applicable) Morningstar Rating metrics.
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Lipper fund data for all time periods shown are as of the date shown. Although a Fund may outperform peers when compared to Lipper peer groups, the returns for that period may still be negative. Rankings shown are provided by Lipper, Inc., a leading independent analysis service. Rankings and performance for other time periods are available from Lipper.
Past performance is no guarantee of future results.
The Fund offers other share classes, and their performance and rankings may be lower than those of the class shown.
Lipper rankings reflect a fund's historical total return performance, excluding sales charges as applicable, relative to peers as of the above date. The ratings are subject to change every month and are based on equal-rated average of percentile ranks for the total return metrics over 1-, 3-, 5-, and 10-year periods, if applicable. Lipper rankings are not intended to predict future results, and Lipper does not guarantee the accuracy of this information.
Expense waivers may have been in effect for some or all of the periods shown. Performance would have been lower if waivers did not apply or if sales charges were included. Lipper rankings may have been lower if waivers did not apply or if sales charges were included.
Russell 2000® Index (view definition)
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text:
Could the oral drug Nystatin cause death? How do you know if you are allergic to it?
- Posted:
- 2 Sep 2009 by brittanygdv
- Topics:
- oral thrush, nystatin
Answers (1)
3 Sep 2009
Nystatin is highly unlikely to cause death unless you have a severe allergic reaction and don't get medical help immediately.
Symptoms of an allergic reaction are rash, itching, difficulty breathing; tightness in chest, closing of your throat; swelling of your lips, tongue, or face; or hives.
Other side effects that you may experience are mouth irritation, nausea or stomach upset, vomiting, or diarrhea.
Since nystatin is not absorbed by your body, drug interactions are not expected.
Further Information
- Nystatin Information for Consumers
- Nystatin Information for Healthcare Professionals (includes dosage details)
- Side Effects of Nystatin (detailed)
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text: May E. Callis, nee Medin, 80, of Day, Fla., passed away Aug. 2, 2013. She was born May 5, 1933 to Lief and Agnes Medin. She was a woman of strong faith who was a devoted mother and grandmother. She was an excellent cook, loved the outdoors and loved listening to the birds sing. Her [...]...Read More


text: SUNY Potsdam Institutional Repository (SPIRe) provides a secure and searchable digital archive to showcase and preserve the intellectual and creative accomplishments of our College. This initiative takes advantage of the SUNY Digital Repository using the open source system DSpace, and operates under the leadership of the College Libraries. SPIRe provides opportunity for College departments and offices and individual faculty members to make their research and creative endeavors, including significant work of students, available to a broader audience. SPIRe also enhances the College community's understanding of digital access and preservation issues.


text:
Latest news
- 1
Showing 1 - 4 of 4
Up close with the new Renault Twingo
The Twingo is back! We swan around the French Riviera in the base car, then tear things up a little in the more Top Gearish turbo version
Facelifted Renaultsport Twingo
The Renaultsport and Gordini Twingo's styling is brought up to speed
The TG Nan Prix
Four of Britain's least expensive cars. One Stig. No optional extras. Will any survive?


text:
Originally written on Fox Sports Houston | Last updated 2/28/12
Usually it's a contending team, lacking other options, that considers transforming a starter to a closer. Other times, a team will overspend on the free-agent market for a reliable closer, hoping he's the difference between staying home and making the playoffs. The idea is that, in a division race, every lead is precious. Stability at the back of the bullpen is huge for a team on the cusp. Bad teams worry about their closer lastly. Except, that is, for the Houston Astros, who this week announced that veteran starter Brett Myers is now the club's closer. Citing an abundance of starters and a lack of reliable relievers on the roster, the Astros decided they need Myers to move to the bullpen. Why is a team that could very well lose 100 games or more worried about a closer? More important, why are the Astros taking a guy who has chewed up well over 200 innings in each of the past two seasons and hiding him in the bullpen? How many significant leads do the Astros expect to have? Oh, a...
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41 year old man | Round Rock, TX, USA | Seeking women 30-45 within 10 miles
Active within 5 days
Lets kill the day out having fun! Movies, mudding, going out to eat, grabbing beers, shooting the sh%t.
These pictures are the most recent I have. I have lost 25 lbs in the past 3 months, but have no recent pics of me without the weight. I am not a selfie pic taking kind of guy. My skinny clothes are even getting too big for me. I have been working on getting my life straightened out since my wife left me. I am not going to tell you I am 100% back on track, because I am not. I have my own apartment now and I am enjoying it very much. I am an honest, wear my heart on my sleeve, can't lie without easily being found out, hard working, dedicated, (friends say I am the life of the party), I don't feel that way, beer drinking, die hard Cubs fan, that loves hard rock, and hair bands. I am looking for someone who doesn't judge me for who I am, and who would enjoy my sense of humor (Sophomore like). Likes middle of the day calls to go hang out and blow the day off and be in the moment. Wether we go to a BBQ joint in Llano, go see a live music show, play pool, or you make the call for a day doing something I have never done. I am open to new experiences. I have not done much traveling because I was married early and had kids. I have the means to travel now and I am wide open to it. I have a great schedule for it also. If you are looking for a workout nut, I am not your guy. I have been eating better and I do like to go walking 3-4 miles ever day I have off to clear my head and listen to my music. I would like you be laid back, non judgmental, understand that my kids and job come first, but that isn't to say you will be excluded. I want you to try to be as healthy as you can, everyone has their vices and I am trying to kick mine. Maybe we can do that together? I have friends that I would like you to get to know. They are pretty much just like me. If you have questions message me, and I will tell you anything you want to know about me.
Camping , Cooking , Dining out , Fishing/Hunting , Movies/Videos , Music and concerts , Video games , Watching sports
Walking / Hiking
I exercise 1-2 times per week.
Flix, Alamo Draft House, Juniors, Brass Tap, Innbetween bar, Louisiana Longhorn Cafe, Longhorn Steak House… you get the idea.
Steaks, beer, baseball (especially the Cubs), Game of Thrones, Raising Arizona, mudding
Movies, watching baseball, going out to eat, drinking beer, karaoke, hiking, I like to work on classic cars. Although I am not very good at it. I have fun spending time with my 2 kids still living at home 18 & 15. Watching my favorite bands.
I don't read for fun much, I have a lot of work related reading I have to do.
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|What he is looking for
|5'11" (180cms)
|5'0" (152cms) to 6'0" (182cms)
|Body type:
|About average
|No preference
|No preference
|Light brown
|No preference
|No Way, Occasionally, Daily, Cigar aficionado, Yes, but trying to quit
|Social Drinker
|Never, Social Drinker, Regularly, Moderately
|Political / Govt / Civil Service / Military
|Administrative / Secretarial, Artistic / Creative / Performance, Executive / Management, Financial / Accounting / Real Estate, Labor / Construction, Legal, Medical / Dental / Veterinary / Fitness, Political / Govt / Civil Service / Military, Retail / Food services, Retired, Sales / Marketing, Self-Employed / Entrepreneur, Student, Education / Teacher / Professor, Technical / Science / Computers / Engineering, Travel / Hospitality / Transportation, Other profession, Nonprofit / Volunteer / Activist, Law enforcement / Security / Military, Fashion / Model / Beauty, Architecture / Interior design
|$75,001 to $100,000
|$35,001 to $50,000, $50,001 to $75,000, $75,001 to $100,000, $100,001 to $150,000, $150,001+
|Never Married, Widow / Widower, Currently Separated, Divorced
|Have kids:
|Yes, and they sometimes live at home (2)
|Yes, and they sometimes live at home, No, Yes, and they live away from home, Yes, and they live at home
|Wants kids:
|Not sure
|Definitely, Someday, Not sure, Probably not, No, No, but it's OK if my partner has kids
|White / Caucasian
|No preference
|Spiritual but not religious
|No preference
|Some college
|No preference


text:
The recent news about migraines is enough to give anyone a headache. An experimental drug therapy may prevent migraines by disrupting the pathways, though it could be years before the medication is in development, and scientists don't know the long-term effects of this drug. But the key to treating migraines might not be in your medicine cabinet—it could be in your fridge.
Migraines are much worse than the usual type of headache. Migraine sufferers experience a debilitating, throbbing pain with sensitivity to light and sound, often accompanied by nausea.
Certain foods have been known to trigger migraines, including dairy, caffeine, chocolate, alcohol, citrus, meat, tomatoes, onions, corn, and even apples.
Generally, safe foods include rice, cooked green/orange/yellow vegetables, and cooked fruits that aren't citrus.
A recent study by Physicians Committee researchers shows that a plant-based diet, followed by an elimination diet may reduce migraine pain. An elimination diet helps to identify any food-based triggers. The basic process of an elimination diet is removing all types of trigger foods for two weeks while stocking up on foods from the safe list. After two weeks, reintroduce the potential trigger foods one at a time to see if there is any negative reaction.
For more information about trigger foods and how to reduce migraine pain naturally, check out the Physicians Committee's guide to the Migraine Diet: http://www.pcrm.org/health/health-topics/a-natural-approach-to-migraines
Here are several migraine-safe recipes to get you started:
Fruited Breakfast Quinoa
Rice Pasta with Creamy Zucchini Pesto
Summer Squash with Basil
Braised Kale or Collard Greens
Black-Eyed Peas with Sweet Potatoes and Greens
Roasted Sweet Potato Wedges
Carob Fondue


text:
BUENA VISTA, Colo. — A 13-year-old girl said her father shielded her as boulders crashed down on them on a Colorado hiking trail -- an action that authorities say probably saved her life even as her father and four other family members were killed.
Rescuers dug Gracie Johnson out of the rubble after Monday's slide, and she was airlifted to a Denver-area hospital with a broken leg, the Chaffee County Sheriff's Department said Tuesday.
"She told me at the last second when the boulders were coming down on top of them that he covered her up and protected her, which I believe it saved her life," said sheriff's Deputy Nick Tolsma.
Gracie's parents and sister from nearby Buena Vista were killed, as were two of her cousins from Missouri.
The sheriff's department identified the dead as Dwayne Johnson, 46, and Dawna Johnson, 45, Gracie's parents; and her 18-year-old sister, Kiowa-Rain Johnson.
The other victims were identified as Baigen Walker, 10, and Paris Walkup, 22, both of Birch Tree, Mo. They were nephews of Dwayne and Dawna Johnson.
All five bodies were recovered Tuesday afternoon and identified by a family member, Sheriff Pete Palmer said. Palmer said the coroner will make the final, formal identification.
Dwayne and Dawna Johnson were coaches in Buena Vista schools, were well known in the town and very active in community events, the sheriff's department said.
Family friend Mike Carr of Buena Vista said Dwayne Johnson was quick to help others.
"Probably his only regret is that he didn't jump in front of his whole family. He's just that type of guy," Carr said. "He probably did that without one bit of hesitation."
Monday's slide sent 100-ton boulders onto a popular viewing area that overlooks Agnes Vaille falls below 14,197-foot Mount Princeton in south-central Colorado.
The massive slide left a gash the size of a football field in the mountainside, Undersheriff John Spezze said.
What triggered it wasn't immediately known, though Spezze said the area had heavy summer rain and a recent snowfall.
Rain or melting snow can make slides more likely by weakening a steep slope and making the rocks and soil heavier, said Jerry Higgins, an associate professor of geological engineering at the Colorado School of Mines in Golden.